Neurology PreTest Self-Assessment and Review PDF

Neurology: PreTest™ Self-Assessment and Review, 8th Edition Cerebrovascular Disease Questions 46. A 67-year-old woman with a history of type 2 diabetes mellitus and atrial fibrillation presents to the emergency room with left...

Neurology: PreTest™ Self-Assessment and Review, 8th Edition Cerebrovascular Disease Questions 46. A 67-year-old woman with a history of type 2 diabetes mellitus and atrial fibrillation presents to the emergency room with left body weakness and slurred speech. The onset was sudden while she was brushing her teeth 1 hour ago, and she was brought immediately to the emergency room. She denies word-finding difficulties, dysesthesia, and headache. She is taking warfarin. Physical examination findings include blood pressure of 205/90 mm Hg and irregularly irregular heartbeat. There is left-side neglect with slurred speech. There is a corticospinal pattern of weakness of the left body, with the face and upper extremity being worse than the lower extremity. Routine chemistries and cell counts are normal. Her international normalized ratio (INR) is 1.8. Which of the following is the most appropriate first step in management? a. Administer tissue plasminogen activator. b. Call a vascular surgery consult for possible endarterectomy. c. Order a brain computed tomography (CT). d. Order a cerebral angiogram. e. Start heparin. 47. A 74-year-old man is diagnosed with an acute stroke. A right middle cerebral artery occlusion is demonstrated by magnetic resonance angio-gram shown below. Which of the following is the most likely cause of this patient’s present condition? a. Atherosclerosis b. Fibromuscular dysplasia c. Mitral valve prolapse d. Arterial dissection e. Meningovascular inflammation 48. A 52-year-old woman with diabetes awakens with right body weakness. Examination at the hospital indicates relatively symmetric upper motor neuron pattern of weakness involving the face, arm, and leg. There are no sensory abnormalities. Language is preserved. A stroke associated with this presentation is most likely with damage to which of the following? a. Internal capsule b. Cerebellum c. Putamen d. Caudate e. Amygdala 49. Following cardiac catheterization, a 60-year-old right-handed man acutely develops a loss of sensation involving the entire left side of his body (face, arm, and leg). Which of the following structures has most likely been damaged? a. Internal capsule b. Thalamus c. Hippocampus d. Globus pallidus e. Pons 50. A 61-year-old man with a history of hypertension has been in excellent health until he presents with vertigo and unsteadiness lasting for 2 days. He then develops nausea, vomiting, dysphagia, hoarseness, ataxia, left facial pain, and right-sided sensory loss. There is no weakness. On examination, he is alert, with a normal mental status. He vomits with head movement. There is skew deviation of the eyes, left ptosis, clumsiness of the left arm, and titubation. He has loss of pin and temperature sensation on the right arm and leg and decreased joint position sensation in the left foot. He is unable to walk. Magnetic resonance imaging (MRI) in this patient might be expected to show which of the following? a. Basilar artery tip aneurysm b. Right lateral medullary infarction c. Left lateral medullary infarction d. Left medial medullary infarction e. Right medial medullary infarction 51. A 50-year-old man had a brainstem stroke following a vertebral artery dissection secondary to an acute sports-related injury. This patient might be expected to develop dysphagia secondary to involvement of which of the following structures? a. Nucleus solitarius b. Nucleus and descending tract of cranial nerve (CN) V c. Nucleus ambiguus d. Lateral spinothalamic tract e. Inferior cerebellar peduncle 52. Occlusion of which of the following arteries typically produces Wallenberg (lateral medullary) syndrome? a. Basilar artery b. Vertebral artery c. Superior cerebellar artery d. Anterior inferior cerebellar artery (AICA) e. Anterior spinal artery 53. A 75-year-old man with a history of recent memory impairment is admitted with headache, confusion, and a left homonymous hemianopsia. He has recently had two episodes of brief unresponsiveness. There is no history of hypertension. CT scan shows a right occipital lobe hemorrhage with some subarachnoid extension of the blood. An MRI scan with gradient echo (susceptibility) sequences reveals foci of hemosiderin in the right temporal and left frontal cortex. Which of the following is the most likely cause of this patient’s symptoms and signs? a. Gliomatosis cerebri b. Multi-infarct dementia c. Mycotic aneurysm d. Amyloid angiopathy e. Undiagnosed hypertension 54. A 22-year-old male abuser of intravenous heroin has been having severe headaches during sexual intercourse. Within a few minutes of one headache, he develops right-sided weakness and becomes stuporous. His neurologic examination reveals neck stiffness as well as right arm and face weakness. An unenhanced emergency CT scan reveals a 3-to-4 cm lesion in the cortex of the left parietal lobe. The addition of contrast enhancement reveals two other smaller lesions in the right frontal lobe but does not alter the appearance of the lesion in the left parietal lobe. Which of the following diagnostic studies is most likely to establish the basis for this patient’s neurologic deficits? a. Human immunodeficiency virus (HIV) antibody testing b. Cerebrospinal fluid (CSF) examination c. Electroencephalography (EEG) d. Nerve conduction studies (NCS) e. Cardiac catheterization 55. A 52-year-old right-handed woman who has abused intravenous drugs for many years has an HIV antigen test that is positive. CD4+ T- lymphocyte count is normal. A brain CT scan reveals several hemorrhagic lesions. NCS reveal generalized slowing in the legs, and EEG exhibits focal slowing over the left parietal lobe. Cardiac catheterization suggests aortic valve disease, and the patient’s CSF is xanthochromic. Which of the following is the probable site of injury in the central nervous system (CNS)? a. An arterial wall b. The ventricular endothelium c. The pia arachnoid d. The dura mater e. The perivenular space 56. A 35-year-old man presented to the emergency room with the acute onset of right body weakness. A diffusion-weighted MRI was positive and is in part shown below. Further imaging sequences indicated a small left frontal intraparenchymal hemorrhage. Within 1 day of admission, the patient’s right-sided weakness began to abate, and within 1 week it almost completely resolved. On the sixth day of hospitalization, the patient abruptly lost consciousness and exhibited clonic movements starting in his right side and generalizing to his left side. The movements stopped within 3 minutes, but he had residual right-sided weakness for 24 hours. A head CT scan was unchanged from admission. The most appropriate treatment to institute involves which of the following? a. Heparin b. Recombinant tissue plasminogen activator (r-TPA) c. Lamotrigine d. Levetiracetam e. Warfarin 57. A 27-year-old woman presents to the emergency room following a generalized tonic-clonic seizure that began focally in her left lower extremity. Although the seizure stopped within 1 minute, there was persistent weakness of the left lower extremity lasting several hours. Further testing revealed a small arteriovenous malformation near the motor cortex. Focal weakness lasting for 24 hours following a motor seizure is most likely attributable to which of the following? a. Intracerebral hemorrhage b. Subarachnoid hemorrhage c. Encephalitis d. Todd paralysis e. Hyponatremia 58. A 16-year-old girl with complex partial seizures and mild mental retardation has a birthmark consisting of deep red discoloration extending over her forehead and left upper eyelid. A CT scan of her brain would be likely to reveal which of the following? a. A hemangioblastoma b. A Charcot-Bouchard aneurysm c. An arteriovenous malformation d. A leptomeningeal angioma e. A fusiform aneurysm 59. A 72-year-old retired school teacher has the abrupt onset of right face and hand weakness, disturbed speech production, and a right homonymous hemianopsia. This is most likely attributable to occlusion of which of the following arteries? a. Left middle cerebral artery b. Left anterior cerebral artery c. Left vertebrobasilar artery d. Right anterior choroidal artery e. Left posterior inferior cerebellar artery (PICA) 60. A 39-year-old woman has diplopia several times a day for 6 weeks. She consults a physician when the double vision becomes unremitting and also mentions a dull pain behind her right eye. When a red glass is placed over her right eye and she is asked to look at a flashlight off to her left, she reports seeing a white light and a red light. The red light appears to her to be more to the left than the white light. Her right pupil is more dilated than her left pupil and responds less briskly to a bright light directed at it than does the left pupil. Before any further investigations can be performed, the woman develops the worst headache of her life and becomes stuporous. Her physician discovers that she has marked neck stiffness and photophobia. The physician performs a transfemoral angiogram. This radiologic study is expected to reveal that the woman has which of the following? a. An arteriovenous malformation b. An occipital astrocytoma c. A sphenoidal meningioma d. A pituitary adenoma e. A saccular aneurysm 61. A 43-year-old man presents with a left CN III deficit and headache. The ocular symptoms began with papillary dilation and then progressed to oculomotor impairment. Which of the following is the most likely site of the lesion responsible for this presentation? a. Anterior communicating artery b. Posterior communicating artery c. Anterior cerebral artery d. Brainstem white matter e. Posterior cerebral artery 62. Three days after a subarachnoid hemorrhage, a patient begins to develop neck stiffness and photophobia. This is followed by left-sided weakness and hyperreflexia. Her left plantar response is upgoing. Her physician presumes that these deficits are a delayed effect of the subarachnoid blood. Which of the following is the most appropriate treatment? a. Heparin b. Warfarin c. Nimodipine d. Phenytoin e. Carbamazepine 63. A 73-year-old man with a history of hypertension has a 10-minute episode of left-sided weakness and slurred speech. On further questioning, he relates three brief episodes in the past month of sudden impairment of vision affecting the right eye. His examination now is normal. Which of the following is the most appropriate next diagnostic test? a. Creatine phosphokinase (CPK) b. Holter monitor c. Visual evoked responses d. Carotid artery Doppler ultrasound e. Conventional cerebral angiography 64. A 72-year-old woman with coronary artery disease and a history of cardiac artery stenting began developing episodes of transient visual loss several months ago. Each episode is restricted to her left eye and comes on suddenly. She says, “All of a sudden half of my vision is black.” Each time the vision returns within 30 minutes. There have been approximately 10 of these events within the past 3 months. These symptoms are most likely related to which of the following? a. Retinal vein thrombosis b. Central retinal artery ischemia c. Posterior cerebral artery ischemia d. Middle cerebral artery ischemia e. Posterior ciliary artery ischemia 65. A thorough evaluation reveals that a 69-year-old patient has a symptomatic 90% stenosis of the right internal carotid artery at the bifurcation. Which of the following management options is most likely to prevent a future stroke? a. Warfarin b. Carotid artery angioplasty c. Carotid endarterectomy d. Extracranial-intracranial bypass e. Aspirin Questions 66 to 74 For each clinical scenario, pick the language disturbance that best explains the clinical picture. Each lettered option may be used once, more than once, or not at all. a. Broca aphasia b. Wernicke aphasia c. Transcortical sensory aphasia d. Transcortical motor aphasia e. Anomic aphasia f. Global aphasia g. Conduction aphasia h. Mixed transcortical aphasia 66. A 62-year-old man with a history of myocardial infarction awakens with a dense right-sided hemiplegia. His eyes are tonically deviated to the left, and he does not respond to threat on the right side of his visual field. He appears to be alert and responds to pain on the left side of his body. His speech is unintelligible and nonfluent, and he follows no instructions. Efforts to get him to repeat simple phrases consistently fail. 67. A 45-year-old woman with chronic atrial fibrillation discontinues warfarin treatment and abruptly develops problems with language comprehension. She is able to produce some intelligible phrases and produces sound quite fluently; however, she is unable to follow simple instructions or to repeat simple phrases. On attempting to write, she becomes very frustrated and agitated. Emergency MRI reveals a lesion of the left temporal lobe that extends into the superior temporal gyrus. 68. A 71-year-old man develops headache and slight difficulty speaking while having sexual intercourse. He has a long-standing history of hypertension, but has been on medication for more than 7 years. He makes frequent errors in finding words and follows complex commands somewhat inconsistently. The most obvious defect in his language function is his inability to repeat the simplest of phrases without making repeated errors. An emergency CT scan reveals an intracerebral hemorrhage in the left parietal lobe that appears to communicate with the lateral ventricle. 69. A 24-year-old woman abruptly loses all speech during the third trimester of an otherwise uncomplicated pregnancy. She has a history of severe migraines during which she occasionally develops a transient right hemiplegia. Her comprehension is good, and she is frustrated by her inability to speak or write. She is unable to repeat simple phrases, but she does begin to produce simple words within 5 days of the acute disturbance of language. 70. A 78-year-old man has a cardiac arrest while being treated in an emergency room for chest pain. Resuscitation is initiated immediately, but profound hypotension is observed for at least 20 minutes. A cardiac rhythm is restored, but the patient remains unconscious for the next 3 days. When he is awake, alert, and extubated, his speech is limited to repetition of words and sounds produced by those around him. He has no apparent comprehension of language and produces few sounds spontaneously. Whenever the patient is spoken to, he fairly accurately repeats what was said to him. 71. A 62-year-old man has had a left hemisphere stroke. He has impaired naming and repetition. His speech is nonfluent. Comprehension is preserved. 72. An 82-year-old man has had a slow, stepwise cognitive deterioration. A brain MRI is consistent with the diagnosis of dementia caused by multiple cerebral infarcts. Naming is impaired. Comprehension, repetition, and fluency are relatively maintained. 73. A 53-year-old woman sustains a small left frontal embolic stroke during cardiac catheterization. She has poor naming ability and is nonfluent. Comprehension and repetition are relatively preserved. 74. A 28-year-old woman is hit in the left neck while playing lacrosse. Approximately 2 hours later she begins having language difficulties. Her speech is fluent and nonsensical. She cannot understand commands, but repeats well. Cerebrovascular Disease Answers 46. The answer is c. (Ropper, pp 774-775.) This is a good history for cardioembolic stroke—sudden onset, cortical symptoms, atrial fibrillation, and subtherapeutic INR. The immediate goal should be to rule out an intracranial hemorrhage and confirm the diagnosis. Tissue plasminogen activator is the treatment for acute stroke in specific circumstances. However, it is not yet certain that this is a stroke. It may be an intracranial hemorrhage, which would be a contraindication for tissue plasminogen activator. Additionally, an elevated INR in a patient on warfarin is a contraindication for tissue plasminogen activator. Carotid endarterectomy is indicated for some cases when a transient ischemic attack or stroke is believed to be caused by carotid artery narrowing. It is not yet known what caused this patient’s event, and this procedure would rarely be done emergently. A cerebral angiogram would be indicated if there was a strong suspicion of an aneurysm or vascular malformation. There is no reason to believe one of these is causing the patient’s symptoms. Heparin may be indicated if there is not an intracranial hemorrhage. This must first be established by CT or MRI. 47. The answer is a. (Ropper, pp 773-778.) Atherosclerosis may produce cerebral infarction by a variety of mechanisms, including emboli to the brain and local occlusion of atheromatous vessels. Platelet emboli may form on ulcerated atheromatous plaques in major vessel walls and ascend to the brain. The atherosclerotic plaque involves subintimal proliferation of smooth muscle, fatty deposits in the intima, inflammatory cells, and excessive elaboration of the