Neurological Case Studies PDF

Neuro -28-year-old woman + abdominal pain + bilateral proximal upper extremity weakness + autonomic dysfunction + decreased bowel sounds + elevated urinary porphyrin levels → Acute Intermittent Porphyria (AIP) → Urinary porphyrin level testing - - -65-year-old man + tremor in left hand +...

Neuro -28-year-old woman + abdominal pain + bilateral proximal upper extremity weakness + autonomic dysfunction + decreased bowel sounds + elevated urinary porphyrin levels → Acute Intermittent Porphyria (AIP) → Urinary porphyrin level testing - - -65-year-old man + tremor in left hand + stiffness + slowness of movements + asymmetric resting tremor + stepwise resistance to passive movement (rigidity) + bradykinesia → Parkinson disease → No additional diagnostic testing needed -67-year-old retired college professor + intermittent memory loss, misplacing objects, forgetting appointments + performs daily activities independently + family history of dementia + Mini-Mental State Examination administered → Mild cognitive impairment/dementia → High level of education (Limits validity of cognitive screening tools) -45-year-old man + excessive muscle wasting (distal, asymmetric) + fasciculations + hyperreflexia + spasticity + dysarthria + dysphagia + both upper and lower motor neuron signs → Amyotrophic Lateral Sclerosis (ALS) → Lower and upper motor neuron lesions -7-year-old boy + seizure + confusion + café-au-lait macules + axillary and inguinal freckling + family history → Neurofibromatosis Type 1 (NF1) → Optic pathway gliomas -5-year-old boy + morning headache + visual changes + café-au-lait macules and axillary freckles → Neurofibromatosis type 1 with optic pathway glioma → Brain and orbital MRI - -65-year-old man + end-stage renal disease + tingling, numbness, and burning pain in bilateral hands + symptoms worsen during hemodialysis + lateral hand involvement (first 3 digits) → Dialysis-related amyloidosis → Carpal tunnel syndrome - -76-year-old woman + new, right-sided headache + malaise + elevated ESR (55 mm/hr) + age >50 → Giant Cell Arteritis (GCA) → Start prednisone and obtain temporal artery biopsy --74-year-old woman + acute monocular vision loss in right eye + 2-month history of headaches, malaise, and fatigue + lateral scalp tenderness to palpation + swollen pale optic disc with blurred margins on funduscopy → Giant cell arteritis (GCA) → High-dose systemic glucocorticoids - -38-year-old woman + intermittent episodes of left foot weakness and numbness + diminished sensation over dorsum of the left foot + foot drop with inability to walk on left heel → Common fibular (peroneal) neuropathy → Peripheral nerve compression - -35-year-old man + motorcycle crash + bilateral lower extremity weakness + diminished bilateral pain and temperature sensation + intact proprioception, vibration, and light touch → Anterior Cord Syndrome → Anterior spinal cord injury -69-year-old man + bilateral lower extremity weakness + flaccid paralysis + intact vibratory sensation + urinary retention + recent thoracic aortic aneurysm repair → Spinal cord infarction → Anterior cord syndrome with disrupted anterior spinal artery supply - -32-year-old man + schizophrenia on risperidone + erectile dysfunction + decreased libido + bilateral breast enlargement (gynecomastia) → Hyperprolactinemia due to decreased dopamine activity in the tuberoinfundibular pathway → Decreased dopamine activity in the tuberoinfundibular pathway - -65-year-old woman + progressive difficulty walking + bilateral upper and lower extremity weakness + spastic gait + bilateral Babinski sign + tongue deviation to the left on protrusion + headaches and dizziness → Foramen magnum meningioma → Compression of brainstem at foramen magnum - -72-year-old hospitalized man + new-onset right hand paresthesia + diminished sensation in lateral palm, thumb, index finger, and long finger + recent right brachial arterial catheter placement → Median nerve injury → Compression or laceration of the median nerve during brachial artery cannulation - -14-year-old girl + abrupt onset of hand tremors + occurs at rest and during movement + inconsistent features + ceases with distraction → Functional (psychogenic) tremor → Involuntary movement with features inconsistent with neurologic cause -64-year-old woman + 10-day history of progressive difficulty walking + bilateral leg weakness + unsteady gait + increased deep tendon reflexes + decreased pinprick sensation in legs to umbilicus + chronic back pain worse at night + percussion tenderness over lower thoracic spine → Spinal cord compression → Emergency MRI of the spine and surgical evaluation - -2-year-old girl + refractory epilepsy despite adherence to 3 antiseizure medications + negative metabolic and genetic evaluation → Drug-resistant epilepsy → Start a high-fat, low-carbohydrate ketogenic diet -36-year-old woman + acute left-sided facial droop + inability to raise left eyebrow or close left eye + loss of nasolabial fold + no facial numbness + increased sensitivity to noise + no skin or mucosal lesions → Bell palsy → Neurotrophic, virus-induced nerve inflammation - -5-year-old boy + right-sided hemiplegia + mild motor aphasia + neck pain + history of trauma with a fall and toothbrush injury in mouth → Carotid artery dissection → Traumatic injury to cervical internal carotid artery - - -46-year-old man + history of heavy alcohol use + broad-based unsteady gait + nystagmus + truncal ataxia + pendular knee reflex → Alcoholic cerebellar degeneration → Postural tremor and gait dysfunction - -48-year-old woman + diabetes mellitus + difficulty falling asleep + nighttime leg discomfort alleviated by movement + symptoms worse at night → Restless legs syndrome (RLS) → Serum iron studies to assess for iron deficiency -38-year-old woman + multiple sclerosis + nighttime leg discomfort relieved by movement + worsens at rest + "tingly" sensation + physical exam with mildly increased reflexes → Restless legs syndrome → Gabapentin - -18-year-old woman + recurrent unilateral throbbing headaches with nausea + aura symptoms (numbness, tingling) + on combined oral contraceptives for 6 months → Migraine with aura → Change contraceptive method → Reduce stroke risk by avoiding estrogen-containing contraceptives -28-year-old woman + intermittent electric shock-like sensations radiating down back (Lhermitte sign) + right-sided weakness + Babinski sign on the right + decreased sensation below C6 dermatome + prior episode of vertigo and dysarthria → Multiple sclerosis (MS) → Spinal cord demyelination -35-year-old woman with a 10-year history of multiple sclerosis (MS) + muscle spasms + stiffness in legs + spastic gait → Spasticity treatment → Tizanidine or Baclofen - -57-year-old man + progressive difficulty walking + weakness and numbness in arms and legs + upper and lower motor neuron signs (muscle atrophy in arms, Babinski sign in legs) → Cervical myelopathy → Advanced spondylosis of the cervical spine on radiography. - -79-year-old woman + recurrent falls + hyperreflexia + wide-based gait + ventriculomegaly on CT without significant atrophy → Normal pressure hydrocephalus → High-volume lumbar puncture - -14-year-old girl + progressive lower limb weakness + clumsiness + wide-based gait + decreased vibratory and position sense + cervical spinal cord atrophy + high-arched feet → Friedreich ataxia → Genetic testing to confirm diagnosis - -74-year-old man + progressive rigidity + resting tremor + bradykinesia + visuospatial dysfunction + visual hallucinations + asymmetric motor symptoms → Parkinson disease dementia → Cognitive impairment following Parkinsonism >1 year -67-year-old man + urinary retention + bilateral leg numbness + weakness of plantar flexion and dorsiflexion + diminished sensation + recent neuraxial anesthesia → Spinal epidural hematoma → MRI of the lumbosacral spine -65-year-old woman + memory loss + low energy + weight loss + poor concentration + normal MRI + MoCA score 24/30 + anhedonia → Depression-related cognitive impairment → Start escitalopram pharmacotherapy - -26-year-old woman + fever + seizure + altered behavior + hyperreflexia + CSF with lymphocytic pleocytosis, elevated protein, and erythrocytes → Herpes simplex encephalitis → HSV polymerase chain reaction for confirmation -76-year-old woman + progressive memory and language difficulties + difficulty with daily tasks + paranoia + urinary incontinence + poor memory testing performance → Alzheimer disease → Early and prominent memory deficits with progressive cognitive decline - -23-year-old man + worsening headaches + fever + right cheek erythema and swelling + bilateral proptosis + cranial nerve deficits → Cavernous sinus thrombosis → Confirmed with MRI with MR venography - -17-year-old primigravida at 29 weeks gestation + intermittent headaches + bilateral optic disc edema + high BMI + recent weight gain → Idiopathic intracranial hypertension → MRI of the brain followed by lumbar puncture - -28-year-old postpartum woman + intermittent proximal muscle weakness + difficulty holding baby + blurred vision + normal reflexes and sensation → Myasthenia gravis → Confirm with acetylcholine receptor antibody testing -55-year-old man + fluctuating bulbar weakness + worsening voice quality with prolonged speech + improvement after rest + normal cranial nerve exam → Myasthenia gravis → Acetylcholine receptor antibody assay -31-year-old woman + diplopia and neck weakness resolving with rest + positive AChR antibodies → Myasthenia gravis → CT scan of the chest to evaluate for thymoma or thymic hyperplasia. --56-year-old man + fatigable muscle weakness + episodic diplopia + normal strength and reflexes → Myasthenia gravis → Pyridostigmine. - -8-year-old boy + head tilt + right arm twitching + staring episode with impaired awareness + postictal Todd paralysis + normal interictal EEG → Focal seizure → Evaluate with EEG and brain MRI for structural abnormalities - -37-year-old man + right arm weakness + focal segmental arterial narrowing + leptomeningeal enhancement + diffuse maculopapular rash + multiple sexual partners → Meningovascular syphilis → Confirm with CSF VDRL testing - -58-year-old man + sudden-onset difficulty speaking and weakness + left middle cerebral artery territory stroke + atrial fibrillation + prior transient ischemic attack → Cardioembolic stroke → Anticoagulation to prevent recurrence → Cardiogenic emboli - - -78-year-old woman + nonsensical but fluent speech + lack of language comprehension + difficulty using objects → Wernicke aphasia → Lesion in the left temporal lobe - -20-year-old man + multiple motor and vocal tics + blinking, shoulder shrugging, throat clearing + childhood onset + worsened by stress → Tourette syndrome → Treat with VMAT2 inhibitor therapy (e.g., tetrabenazine) - -13-year-old girl + head trauma + somnolence + left lower extremity weakness + epidural hematoma on CT scan → Subfalcine herniation → Brain herniation - -50-year-old woman + acute right hemiplegia + right hemisensory loss + conjugate gaze deviation to the left + severe headache, nausea, and vomiting + history of hypertension + elevated BP (230/112 mmHg) → Putaminal hemorrhage → Intracerebral hemorrhage - - -55-year-old woman + progressive arm and leg weakness + Babinski sign + MRI with 1.7-cm homogeneously enhancing globular lesion at C2 → Spinal meningioma → Exposure to radiation therapy - -46-year-old man + severe headache + neck stiffness + subarachnoid hemorrhage + mild confusion + right-sided weakness + facial droop on the fifth day → Cerebral vasospasm → Delayed complication of subarachnoid hemorrhage - -47-year-old man + right-sided facial droop + inability to close the right eye + bilateral parotid gland swelling + hypercalcemia + low-grade fevers + cervical lymphadenopathy → Sarcoidosis → Facial nerve palsy with extrapulmonary manifestations - -11-year-old girl + 2-day history of rapid-onset jerky, involuntary movements + worse during wakefulness + generalized hypotonia + no abnormal movements during sleep → Sydenham chorea → Antistreptolysin O titer - -42-year-old man + HIV + nonadherence to antiretroviral therapy + 3 weeks of headache, vomiting, lethargy + neck stiffness + basilar meningeal enhancement + hydrocephalus on CT → Tuberculous meningitis → Central nervous system tuberculosis - -70-year-old man + ischemic stroke 4 weeks ago + left-sided neglect (shaving only the right side of the face, filling in only the right side of a clock) + raises right arm when asked to raise the left → Right parietal cortex → Hemineglect syndrome - -63-year-old woman + progressive cognitive decline + executive dysfunction (difficulty planning) + urinary frequency + depression + asymmetric reflexes + history of hypertension and diabetes → Vascular dementia → Multi-infarct dementia - -74-year-old woman + history of ischemic stroke + bilateral nystagmus + dysmetria + wide-based gait + increased reflexes + recent trimethoprim-sulfamethoxazole use → Phenytoin toxicity → Cerebellar dysfunction -25-year-old woman + intermittent double vision + vertigo + unsteady gait + inappropriate crying/laughing + left eye abduction with horizontal nystagmus + right eye does not adduct → Internuclear ophthalmoplegia (multiple sclerosis) → Right medial longitudinal fasciculus lesion - -26-year-old woman + recurrent spontaneous eyelid closure + triggered by bright light + relieved by touching or brushing the skin around the eyes → Blepharospasm → Focal dystonia -67-year-old woman + periodic confusion + memory loss + visual hallucinations + poor sleep + bilateral hand tremors + mild bilateral rigidity + generalized cortical atrophy on MRI → Dementia with Lewy bodies → Cognitive fluctuations, visual hallucinations, and parkinsonism -72-year-old man + sudden-onset slurred speech + right-sided weakness + leftward tongue deviation + no sensory loss → Medial medullary syndrome (brainstem stroke) → Left medulla - - -65-year-old man + sudden-onset right-sided weakness + right lower facial weakness sparing the upper face + no sensory deficits + history of hypertension → Left internal capsule → Pure motor stroke (lacunar infarct) - -67-year-old man + acute pure motor hemiparesis + hypertension + normal head CT → Lacunar stroke (pure motor subtype) → Small penetrating artery lipohyalinosis -25-year-old woman + 29 weeks gestation + new-onset headache + blurry vision + bilateral frontal headache + hypertension (156/92 mmHg) + no prior chronic conditions → Preeclampsia → Severe features with visual disturbance - -45-year-old woman + progressive right-sided facial weakness over 6 weeks + incomplete eye closure + facial spasms + no forehead sparing → MRI of the head → Evaluate for cerebellopontine angle tumor (e.g., acoustic neuroma). - - -54-year-old man + recurrent falls + steppage gait (excessive hip and knee flexion, foot slaps to the floor) + negative Romberg sign → Common fibular (peroneal) neuropathy → Foot drop with dorsiflexion weakness - - -45-year-old woman + high-frequency bilateral hand tremor + worse with stress + no neurological abnormalities + started sertraline 2 months ago → Enhanced physiologic tremor → Medication-induced tremor (SSRI-related) - -9-year-old boy + new-onset seizure + right parietal lobe lesion on MRI + left-sided weakness and hyperreflexia + irritability and declining school performance → Low-grade astrocytoma → Most common pediatric brain tumor in the cerebral cortex - -55-year-old man + bulbar symptoms (dysphagia, dysarthria) + involuntary muscle twitching + pooling of secretions + hyperreflexia + Babinski sign → Amyotrophic lateral sclerosis (ALS) → Degeneration of corticospinal tract - -36-year-old woman + daily headaches + preexisting migraines + worsened by frequent analgesic use → Medication-overuse headache (MOH) → Management: Advise to stop taking analgesics. - -65-year-old woman + gait abnormalities + cognitive decline + urinary urgency → Normal pressure hydrocephalus (NPH) → Decreased cerebrospinal fluid absorption. - -26-year-old man + upward gaze deviation + rigidity + haloperidol use → Acute dystonia → Benztropine. - -44-year-old woman + headache, confusion, seizure + bilateral posterior cerebral edema + hypertension → Reversible posterior leukoencephalopathy syndrome (RPLS) → Treatment: Gradual blood pressure reduction. - -65-year-old man + unsteady gait, left-sided weakness, nausea worse in the morning + papilledema → Brain tumor → Confirm with MRI of the brain. - -27-year-old woman + acute onset left-sided facial weakness, including forehead involvement, with incomplete eye closure + no systemic symptoms → Bell palsy → No additional testing needed; treat supportively with high-dose glucocorticoids. - -65-year-old man + tremor, bradykinesia, cogwheel rigidity + early falls → Atypical Parkinsonism (rule out progressive supranuclear palsy or multiple system atrophy). Early-onset postural instability (a red flag against idiopathic Parkinson disease.) - - -56-year-old woman + progressive distal limb weakness + UMN (spasticity, hyperreflexia) + LMN signs (atrophy, fasciculations) → Amyotrophic lateral sclerosis (ALS). Treatment: riluzole or edaravone. -40-year-old man + dysphagia (difficulty swallowing liquids) + slurred nasal speech + tongue atrophy and fasciculations + pathologic jaw jerk reflex → Amyotrophic lateral sclerosis (ALS) → Next step: Electromyography (EMG). - -18-year-old + TBI + unresponsive with absent brainstem reflexes + persistent deep tendon reflexes → Brain death. Movements like deep tendon reflexes can persist due to spinal cord activity. - - -14-year-old boy + chronic back pain + worsens with activity + lower extremity weakness + hyporeflexia + subcutaneous lipoma → Tethered spinal cord syndrome. Condition often associated with spinal dysraphism and stretch-induced dysfunction. Diagnosis: MRI of spine. - - -34-year-old man + sudden-onset back pain radiating to left leg + sensory loss over dorsum of foot + weakness in foot dorsiflexion/toe extension → L5 nerve root compression. Commonly caused by herniated lumbar intervertebral discs. Diagnosis: MRI of spine. - -52-year-old man + asymmetric polyneuropathy (mononeuritis multiplex) + constitutional symptoms (malaise, fever, weight loss) + livedo reticularis + renal and gastrointestinal involvement → Polyarteritis nodosa (PAN). Diagnosis: biopsy or angiography. - -5-year-old boy + hereditary hemorrhagic telangiectasia (HHT) + acute headache, vomiting, and focal neurologic deficits (hemiparesis) → Hemorrhagic stroke due to ruptured arteriovenous malformation (AVM) → Diagnosis: head CT showing hyperdense fluid collection in the right cerebral cortex. - -6-year-old girl + wide-based gait, difficulty with heel-to-toe walking, morning headache, vomiting, and bilateral abducens nerve palsy → Medulloblastoma (posterior fossa tumor). Diagnosis: cerebellar vermis tumor causing truncal ataxia and increased intracranial pressure. - -38-year-old woman + multiple sclerosis (MS) history + new left arm weakness + and urinary urgency → Acute MS exacerbation. Treat with high-dose glucocorticoids. Alternative: plasmapheresis if unresponsive to steroids. - -64-year-old woman + diabetes + sudden-onset diplopia + ptosis + "down-and-out" eye position + intact pupillary response → Ischemic oculomotor (CN III) neuropathy → Cause: Nerve ischemia. - -65-year-old woman + history of left anterior cerebral artery embolic stroke + executive dysfunction + stepwise cognitive decline + frontal lobe damage on imaging → Vascular dementia → Cause: Cerebral infarction. - -73-year-old man + increasing forgetfulness + low energy, motivation, sleep disturbance + psychomotor retardation + normal head CT scan → Major depressive disorder → Depression-related cognitive impairment -65-year-old woman + orthopnea + daytime fatigue + morning headache + amyotrophic lateral sclerosis (ALS) + respiratory muscle weakness → Noninvasive positive-pressure ventilation → Early respiratory insufficiency in ALS -68-year-old woman + rheumatoid arthritis + worsening lower extremity weakness + hyperreflexia + Hoffman sign + occipital headaches → Instability of the atlantoaxial joint → Cervical myelopathy - -60-year-old man + found unresponsive + Glasgow coma score of 7 + normal initial CT scan + suspected diffuse axonal injury → Diffuse axonal injury → Punctate hemorrhages in the white matter - - -63-year-old man + bilateral action tremor of the hands + worsens with movement + no other neurological deficits + professional illustrator with impaired performance → Essential tremor → Primidone - -27-year-old woman + headache + nausea/vomiting + papilledema + obesity + normal brain imaging → Idiopathic intracranial hypertension (IIH) → Blindness - - -46-year-old man + long-standing HIV + bilateral distal extremity numbness/pain + loss of ankle jerk reflex + normal motor strength → HIV-associated distal symmetric polyneuropathy → Gabapentin - -74-year-old man + progressive leg weakness + urinary hesitancy + saddle anesthesia + decreased rectal sphincter tone + metastatic lung cancer → Cauda equina nerve roots → Cauda equina syndrome - - -47-year-old man + neck and shoulder pain + numbness and weakness of the left upper extremity + fall onto flexed neck + anterior subluxation of C6 vertebra on CT → Cervical radiculopathy → Facet dislocation - -69-year-old man + hypophonia (soft voice) + stooped posture + slow gait + rigidity in upper limbs + olfactory dysfunction → Parkinson disease → Idiopathic Parkinson disease with bulbar symptoms - f -62-year-old man + crawling leg sensations at night + relieved by movement + stage 3 CKD + no sensory or motor deficits → Restless legs syndrome (RLS) → Alpha-2-delta calcium channel - -17-year-old boy + unusual behavior + academic decline + hepatomegaly + dysarthria + hyperreflexia → Wilson disease → Serum ceruloplasmin level - - -34-year-old woman + transient visual loss with head position changes + morning headaches + enlarged blind spots + obesity → Papilledema → Increased intracranial pressure (ICP) - -67-year-old woman + recent ischemic stroke + right-sided hemianesthesia + allodynia + hyperesthesia + mild athetosis of the right hand → Thalamic pain syndrome → Thalamus - - [a] -6-month-old boy + increasing head circumference + bulging anterior fontanelle + vomiting + intraventricular mass on MRI → Choroid plexus papilloma → Hydrocephalus due to increased cerebrospinal fluid production - -35-year-old woman + episodic right-hand weakness + prior transient lower extremity numbness + periventricular white matter plaques on MRI → Multiple sclerosis → Immune-mediated demyelinating disease → Vitamin D deficiency (risk factor) - -70-year-old man + right-sided leg weakness + urinary incontinence + Babinski sign + relative sparing of upper extremity → ACA stroke → Left anterior cerebral artery - - -38-year-old woman + worsening clumsiness + right hand dysmetria + MRI with enhancing and nonenhancing white matter lesions → Acute attack of multiple sclerosis (MS) → Initiate methylprednisolone - -LP is not required when clinical and MRI findings are definitive. -17-year-old boy + progressive muscle weakness + facial weakness + myotonia + temporal wasting + testicular atrophy → Myotonic dystrophy (CTG trinucleotide repeat expansion) → Autosomal dominant - -75-year-old woman + acute-onset confusion and agitation + worsening in the evening and night + mild dementia + recent pneumonia → Delirium management → Reduce nighttime noise and disturbances - -34-year-old man + severe traumatic brain injury + elevated intracranial pressure (ICP) + hyperventilation as intervention → Cerebral vasoconstriction → Decreased cerebral blood flow and ICP - -35-year-old man + severe traumatic brain injury + episodic hypertension, tachycardia, diaphoresis, and fever triggered by external stimuli → Paroxysmal sympathetic hyperactivity (PSH) -32-year-old woman + persistent vertigo + down-beating nystagmus + no change with head position → Obtain MRI of the brain to evaluate for central vertigo (e.g., multiple sclerosis) - -51-year-old man + smoker + multiple brain lesions + gray-white matter junction → Metastatic lung cancer. - -3-year-old girl + facial port-wine stain + seizure + homonymous hemianopia → Sturge-Weber syndrome. - - -48-year-old man + immunosuppression + headache, vomiting, fever + CSF lymphocytosis, low glucose, mildly elevated protein → Cryptococcal meningitis. - -33-year-old woman + severe, bilateral facial pain triggered by light stimuli + prior neurologic symptoms (e.g., right hand numbness) → Multiple sclerosis (MS) with trigeminal neuralgia → Demyelinating plaques in the pons. - - - -48-year-old man + acute, progressive left facial drooping involving upper and lower face + preserved sensation + auricular pain prodrome → Bell palsy (CN VII peripheral neuropathy) → high-dose glucocorticoids (prednisone). - -21-year-old man + status epilepticus lasting ≥5 minutes + unresponsiveness + minimally reactive pupils + prolonged seizure activity → Cortical necrosis (due to excitatory cytotoxicity and hypoxia from excessive neuronal firing). - -29-year-old woman + seizure-free for 5 years on phenytoin + plans for pregnancy → Slowly taper and discontinue phenytoin to minimize fetal risk (e.g., fetal hydantoin syndrome). - -68-year-old woman + left oculomotor nerve palsy (ptosis, down-and-out pupil, dilated) + right-sided hemiparesis → Left midbrain infarction (Weber syndrome). - - -68-year-old woman + burning, band-like pain in a dermatomal distribution + no rash → Postherpetic neuralgia (PHN) → treat with gabapentin or tricyclic antidepressants. - -74-year-old man + back pain + difficulty walking + hyperreflexia in lower extremities → Spinal cord compression → urgent MRI of the spine is necessary for diagnosis. - -42-year-old woman + progressive double vision and gait unsteadiness after diarrhea + ophthalmoplegia, ataxia, and areflexia → Miller Fisher Syndrome (variant of Guillain-Barré Syndrome) → Immune-mediated nerve injury -78-year-old man + quadriplegia + preserved consciousness and vertical eye movements + absent horizontal eye movements → Locked-in syndrome → basilar artery occlusion. - - -65-year-old man + numbness in medial hand + decreased grip strength + weak wrist flexion → Ulnar nerve injury at the elbow. - 40-year-old woman + daily headaches and facial pain + right-sided temporal/periorbital pain + jaw fatigue while eating + tenderness in the right masseter muscle + normal neurologic exam → Temporomandibular disorder (TMD). - -45-year-old man + progressive lower extremity weakness + bilateral blurry vision + optic neuritis + longitudinally extensive spinal cord lesions on MRI + positive aquaporin-4 autoantibodies → Neuromyelitis optica (NMO) - -68-year-old hospitalized man + fever, worsening back pain, leg weakness + prior cellulitis + midline vertebral tenderness + bilateral lower extremity weakness → Spinal epidural abscess (SEA) → MRI of the spine with contrast - - -53-year-old man + painless, transient monocular vision loss + history of multiple sclerosis + normal MRI brain + concern for ischemic event → Amaurosis fugax (retinal ischemia) → Carotid duplex ultrasonography - -40-year-old man + sudden, severe headache ("thunderclap") + photophobia + nausea/vomiting + hypertension + high-density signal on noncontrast CT in basal cisterns → Subarachnoid hemorrhage (SAH) → Ruptured saccular (berry) aneurysm - -68-year-old man + gait disturbance + urinary incontinence + memory impairment + wide-based gait + ventriculomegaly on CT scan with normal sulci → Normal pressure hydrocephalus (NPH) → Large ventricles with normal sulci on CT scan of the brain - -28-year-old woman + stiffness and weakness in hands + temporal wasting + bilateral ptosis + grip myotonia + excessive sleepiness → Myotonic dystrophy (type 1) → Cytosine-thymine-guanine (CTG) trinucleotide repeat expansion - -16-year-old boy + head injury with helmet-to-helmet impact + transient disorientation + no focal neurologic deficits + normal cranial imaging → Concussion (mild traumatic brain injury) → Neuronal functional disturbance - -62-year-old woman + progressive gait unsteadiness + leg stiffness + frequent stumbles + mild wasting of hand muscles + electric shock-like sensation in the spine (Lhermitte sign) + increased reflexes in lower extremities → Cervical spondylotic myelopathy with spinal cord compression → MRI of the cervical spine -68-year-old man + COPD + cardiac arrest with pulseless electrical activity + generalized myoclonus after regaining circulation + unresponsiveness despite no sedation → Posthypoxic myoclonus → Prolonged cerebral hypoxia - -24-year-old woman + history of migraines + recent daily bifrontal headaches + morning onset + nausea/vomiting + blurry vision + concern for increased intracranial pressure → Secondary headache (evaluate for intracranial pathology) → MRI of the brain -79-year-old man + stooped posture + masked facies + monotone voice + resting tremor → Parkinson's disease → Hypokinetic gait with bradykinesia → narrow-based, small-stride gait with shuffling - -60-year-old woman + diabetes mellitus + balance problems + weakness and diminished proprioception + hyperactive knee reflex + upgoing plantar reflex (Babinski sign) → Spinal cord lesion (evaluate for mass or compression) → MRI of the spine -65-year-old man + motor vehicle collision + hyperextension injury + disproportionate weakness in upper extremities + intact lower extremity motor function + cervical spondylosis → Central cord syndrome - -52-year-old woman + unilateral, intermittent sharp facial pain triggered by brushing teeth or cold stimuli + no facial asymmetry or neurologic deficits → Trigeminal neuralgia → Vascular nerve root compression - -58-year-old woman + severe headache, nausea, blurred vision, halos around lights + dilated sluggish pupil with conjunctival injection + recent use of trihexyphenidyl → Acute angle-closure glaucoma (ACG) → Triggered by anticholinergic medication (trihexyphenidyl) - -56-year-old man + chronic burning pain in feet + symmetric distal sensory loss + loss of ankle reflexes + history of chronic alcohol use → Alcoholic neuropathy (toxic neuropathy) (Symmetric distal polyneuropathy) - -56-year-old right-handed man + nonfluent speech with preserved comprehension + right-sided weakness → Broca aphasia → Lesion in the dominant frontal lobe - -35-year-old man + recurrent severe unilateral periorbital pain + ipsilateral autonomic symptoms (rhinorrhea, ptosis, conjunctival injection) + agitation during attacks → Cluster headache → Treated acutely with 100% oxygen by face mask - - -75-year-old man + progressive bilateral hearing loss + difficulty understanding speech in noisy environments + tinnitus + Weber test midline + air conduction > bone conduction bilaterally → Presbycusis → Bilateral symmetric sensorineural hearing loss due to age-related degeneration - -56-year-old man + vertigo, ataxia, and Horner syndrome + ipsilateral loss of pain and temperature sensation on the face + contralateral loss of pain and temperature on the body → Lateral medullary (Wallenberg) syndrome → Lesion in the left medulla - - -71-year-old man + progressive memory loss and word-finding difficulty + Montreal Cognitive Assessment score