Case-based MCQ

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Case-based MCQ | #MCQ_103 •••••••••••••••••••••••••••••••••••••• Correct Answer Is C Constellation of clinical findings in this patient, including vertigo, right Horner syndrome indicated by miosis, ptosis and anhidrosis, right-sided sensorineural hearing loss, blurred vision, and numbness of the right side of the face and left side of the body is highly suggestive of right-sided vertebrobasilar stroke. The vertebral arteries arise from the subclavian arteries, and as they course cephalad in the neck, they pass through the costotransverse foramina of C6 to C2. They enter the skull through the foramen magnum and merge at the pontomedullary junction to form the basilar artery. Each vertebral artery usually gives off the posterior inferior cerebellar artery (PICA). At the top of the pons, the basilar artery divides into 2 posterior cerebral arteries (PCAs). The vertebrobasilar arterial system provides blood supply to the medulla, cerebellum, pons, midbrain, thalamus, and occipital cortex. Occlusion of large vessels in this system usually leads to major disability or death (mortality rate>85%). Because of involvement of the brainstem and cerebellum, most survivors have multisystem dysfunction such as quadriplegia or hemiplegia, ataxia, dysphagia, dysarthria, gaze abnormalities, and cranial neuropathies. Fortunately, many vertebrobasilar lesions arise from small vessels and are small and discrete. The clinical correlates of these smaller lesions consist of a variety of focal neurologic deficits, depending on their location within the brainstem. Patients with small lesions usually have a benign prognosis with reasonable functional recovery. Vertebrobasilar strokes have distinct characteristic features that differentiate them from hemispheric strokes caused by lesions of anterior or middle cerebral arteries or internal carotid artery. These features include: When cranial nerves or their nuclei are involved, the corresponding clinical signs are ipsilateral to the lesion and the corticospinal signs are crossed, involving the opposite arm and leg. Cerebellar signs (e.g. dysmetria, ataxia) are frequently observed. Involvement of the ascending sensory pathways may affect the spinothalamic pathway or the medial lemniscus (dorsal columns), resulting in dissociated sensory loss, which is loss of one sensory modality on one side and preservation of other sensory modalities in the opposite limbs (dissociative sensory loss). Dysarthria and dysphagia are typically present. Vertigo, nausea, and vomiting, along with nystagmus, represent involvement of the vestibular system and are seen in vertebrobasilar strokes. Unilateral Horner syndrome occurs with brainstem lesions. Occipital lobe lesions result in visual field loss or visuospatial deficits. Cortical deficits, such as aphasia and cognitive impairments, are absent

Case-based MCQ | #MCQ_103 •••••••••••••••••••••••••••••••••••••• A 45-year-old man presents to the Emergency Department with complaints of acute-onset vertigo, right eyelid drooping, and numbness of the lower right half of the face. He also complains of blurred vision and decreased hearing in the right ear. On examination, he has a blood pressure of 176/95 mmHg, heart rate of 94 bpm, respiratory rate of 20 breaths per minute, temperature of 36.8°C, and oxygen saturation of 96% on room air. There is right-sided miosis, ptosis and anhidrosis. He has nystagmus and ataxic movements and sensory loss of the left upper and lower limbs. Rinne and Weber tests show sensorineural deafness of the right ear. Which one of the following could be the most likely cause of this constellation of symptoms? A. Right-sided Horner syndrome. B. Left vertebral artery thrombosis. C. Right vertebral artery thrombosis. D. Obstruction of the anterior communicating artery. E. Obstruction of the posterior cerebral artery.

Case-based MCQ | #MCQ_102 •••••••••••••••••••••••••••••••••••••• Correct Answer Is A The sixth cranial nerve (CN-VI) palsy results in isolated weakness of abduction of the affected eye and horizontal binocular diplopia. On examination, there is an esotropia (inward deviation) that is worsened with gaze into the field of the affected lateral rectus muscle. Abduction is commonly limited on the side of the lesion. Poorly controlled diabetes is a predisposing factor. (Option B) In the right sixth cranial nerve palsy the right eye will be in an abnormal position (medially deviated), and the patient is diplopic on looking laterally to the right side. (Option C) The third cranial nerve supplies the levator palpebrae muscle of the eyelid and 4 extraocular muscles: the medial rectus, superior rectus, inferior rectus, and inferior oblique. These muscles adduct, depress, and elevate the eye. Patients with acute acquired third nerve palsy usually complain of the sudden onset of binocular horizontal, vertical, or oblique diplopia and a droopy eyelid. Pupil reflex remains intact in ischemic palsies (e.g. due to diabetes or midbrain infarcts). (Options D and E) A person with fourth nerve palsy may complain of binocular (both eyes open) vertical diplopia and/or subjective tilting of objects (torsional diplopia). The affected eye is usually extorted because the superior oblique muscle is responsible for intorsion of the eye. Objects viewed in primary position, especially in down-gaze may appear double when going down a flight of stairs so that the patient does not know which step to take first

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Case-based MCQ | #MCQ_102 •••••••••••••••••••••••••••••••••••••• Aaron,  73 years old, is a diabetic patient of yours who has presented to the clinic with sudden onset of horizontal diplopia, better when he looks at a near object and worse when looking at distance. On examination, the left eye is deviated towards medial side. Which one of the following is the most likely diagnosis? A. Left sixth cranial nerve palsy. B. Right Sixth cranial nerve palsy. C. Right third cranial nerve palsy. D. Left third cranial nerve palsy. E. Left fourth cranial nerve palsy

Case-based MCQ | #MCQ_101 •••••••••••••••••••••••••••••••••••••• Correct Answer Is D The clinical features described are consistent with left oculomotor (3rd cranial nerve [CN-3]) palsy with sparing of the pupil. The most common causes of the oculomotor nerve palsy sparing the pupil reaction is ischemia of the nerve as a result of vascular compromise due to diabetes mellitus.

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Case-based MCQ | #MCQ_101 •••••••••••••••••••••••••••••••••••••• A 45-year-old man with history of type II diabetes mellitus comes to the emergency department with diplopia and ptosis of his left eye. On examination, the left eye is deviated slightly out and down in straight-ahead gaze. Upward gaze is impaired. Pupils have normal reaction to light. Which one of the following would be the most likely underlying cause of this presentation? A. Aneurysm of the posterior communicating artery. B. Tumor. C. TB meningitis. D. Diabetes mellitus. E. Trans-tentorial brain herniation.

Case-based MCQ | #MCQ_100 •••••••••••••••••••••••••••••••••••••• Correct Answer Is C It is recommended that asymptomatic patients with carotid artery stenosis of equal to or greater than 60% and symptomatic patients with stenosis of equal to or greater than 50% undergo endarterectomy in an attempt to prevent further strokes as the most appropriate management. With a cerebrovascular event and a stenosis of 50%, this patent requires carotid endarterectomy as the most appropriate action to prevent further strokes.

Case-based MCQ | #MCQ_100 •••••••••••••••••••••••••••••••••••••• A 71-year-old man presents to the Emergency Department with weakness of the left arm and leg. His past medical history is significant for coronary angioplasty 5 years ago for which he is currently on daily low-dose aspirin. A non-contrast brain CT scan excludes cerebral hemorrhage. Doppler ultrasonography shows bilateral carotid artery stenosis of 50%. Which one of the following would be the most appropriate action to takef or long-term secondary prevention? A. Add warfarin. B. Add clopidogrel. C. Carotid endarterectomy. D. Continue the same dose of aspirin. E. Increase the dose of aspirin

Case-based MCQ | #MCQ_99 •••••••••••••••••••••••••••••••••••••• Correct Answer Is D Haloperidol is a first-generation antipsychotic that acts by inhibition of dopamine receptors in CNS. On the other hand, the pathophysiology of Parkinson disease is dopamine depletion from the basal ganglia. Consequently, haloperidol results in worsening of extrapyramidal symptoms of Parkinson disease such as bradykinesia and tremors. All antipsychotic drugs are capable of producing extrapyramidal effects in a dose-dependent fashion. Aripiprazole, clozapine and quetiapine are probably exceptions. When extrapyramidal effects develop, it is an indication that the dose of drug has exceeded the optimal therapeutic range for a given patient. In such circumstances, the next best step would be decreasing the dose of the antipsychotic.