matter junction that LACKS mass effect and do NOT enhance following contrast administration. c- true, but rarely done in clinical practice. Although PCR for JC virus in the CSF may be diagnostic , definitive diagnosis is done by brain biopsy. d- false, results in death within 3-6 months. e- true, as with amantadine and adenine arabinoside. Unfortunately no treatment is effective. Q28: Answer: e a- true, but the disease uncommon. b- true, variable course. c- true, and finally coma. d- true, only symptomatic measures and cessation of drinking and improvement in nutrition is advised. e- false, the outcome is highly variable: patients may die, survive with dementia, or recover. Q29: Answer: e a- true, over many years . b- true, due to aluminum in the dialysate fluids and may be aggravated by aluminum containing antiacids. c- true, an aggressive picture resulting in death within 6 months. d- true, these changes are characteristically reversible by diazepam. e- false, the disease is now very rare because of removal of aluminum from dialysate fluids. Q30: Answer: e a- true, should be differentiated from alcoholic cerebellar degeneration which primarily affects gait. b- true, and may be punctuated by episodes of acute hepatic encephalopathy. c- true, some improvement following L-dopa or bromocryptin has been described. d- true, but paraparesis is rare. e- false, the CSF is almost always normal apart from raised glutamine level, although slightly raised protein may be found. Q31: Answer: d a- true, usually between the ages of 50-70 years. Prior history of head trauma is absent in 25 % of cases. b- true, and may be easily missed by CT scans because bilateral hematomas are isodense with the brain and there is no midline shift. The hematomas may be demonstrated by contrast CT scans. In few cases its demonstration requires cerebral angiography which should always be done bilaterally. MRI is also useful. c- true, other risk factors are : alcoholics, epilepsy , treatment with anticoagulations, cerebral atrophy from any cause, ventricular shunts, and longterm hemodialysis. d- false, it is the usual first feature to start with. e- true, seizures are uncommon. Q32: Answer: d a- true, after Alzheimer's disease and dementia with Lewy bodies. b- true, from occlusion of major cerebral arteries OR small penetrating arteries in the subcortical white matter , basal ganglia and thalamus respectively. c- true , for example; the number of strokes, their location and the total infarct volume required for stroke to produce dementia are still uncertain. d- false, almost all patients are hypertensive. e- true, and or with stepwise progression of deficits. Q33: Answer: c a- true, with dysarthria, dysphagia and pathological emotionality. b- true, with bilateral extensor planters. c- false, the reverse is true. d- true, also should be done in those without history of hypertension. Also look for polycythemia, thrombocytosis, and cardiogenic emboli. e- true, to prevent recurrent strokes. Control hypertension and other risk factors and treat any associated disease. Q34: Answer: c a- true, and because depression is common and is treatable, distinguishing between the 2 disorders is very important. b- true, adding to more confusion to the clinical picture. When depression is being considered, psychiatric referral should be done. c- false, prominent affections of sleep, apatite, sexual desire and weight are in favor of depression. d- true, these are in favor of depression. e- true, mood is extremely depressed in the morning hours in depression. Chapter XI / Neurology Subchapter C Q1: Answer: d a-true, those patients when seen early after the injury, would exhibit a confusional state in which they are unable to incorporate new memories (i.e. anterograde amnesia). b-true, thus without a history a trauma , it will be diagnosed as a transient global amnesia rather than a post traumatic amnestic state. c-true, covering a variable period of events prior to the trauma. The period of retrograde amnesia begins to shrink gradually, with the most remote memories the first to return. d-false, always seen following head traumas that resulted in loss of consciousness. Events occurring in the post traumatic confusional interval tend to be PERMINENTLY lost. Exceptions are islands of memory, for a lucid interval between the trauma and unconsciousness, or for a period of a fluctuating post-traumatic confusional state. e-true, the severity of the injury tends to correlate well with the duration of confusion and with the extent of permanent retrograde and post-traumatic amnesia. Q2: Answer: e a-true, uncommonly seen in those with short periods of unconsciousness. b-true, because of selective vulnerability of the pyramidal neurons in" h1 sector of Scholz". c-true, and relative preservation of remote memory ,and thus the patient typically appear to have an isolated disorder of short term memory. d-true, and many patients exhibit a lack of concern about their environment and confabulation may be very prominent in some. e-false, a period of retrograde amnesia preceding the insult may occur. Q3: Answer: e a-true, seen as an isolated syndrome. b-true, like bibrachial paresis, cortical blindness ,or visual agnosia. c-true, fortunately a rapid one, although the deficit may persist. d-true, highly characteristic. e-false, may show hypodense areas in the basal gangilia and the cerebellar dentate nuclei. Q4:. Answer: b a-true. Posterior cerebral artery supplies the medial temporal lobes, the thalami, the occipital cortex and the upper midbrain. b-false, the posterior cerebral artery comes form the vertebro-basilar system. The amnestic syndrome results from bilateral damage to the inferio-medial temporal lobes. i.e. to both hippocampi and adjacent structures like the dorso-medial thalami. c-true, sometimes with alexia without agraphia, anomia, or sensory symptoms( like peduncular hallucinosis). d-true, like impaired papillary reflexes, vertical gaze palsy, or oculomotor nerve lesions. e-true, like many acute amnestic syndromes. Q5: Answer: b a-true, or in old people with risk factors for atheroscleosis, especially a prior ischemic event in the posterior cerebral arterial territory. b-false, fortunately , only 10% will have recurrent attacks. TGA is a primary disorder of short term memory that can last for minutes or days, typically for hours. The patient appears agitated and perplexed and may repeatedly inquire about their whereabouts, the time, and the nature of what they are experiencing. c-true, as are remote memories and registration. d-true, but usually gradually shrinks. e-true, thus accounting for the patient's repetitive questions . Q6: Answer: c a-true, and some may have a prominent agitation. b-true, the patient's obvious concern about the condition distinguishes TGA from most other organically based amnestic syndromes, but unfortunately may give rise to a suspicion that this amnesia is psychogenic. c-false, many patients are having risk factors for atherosclerotic disease and there may be a history of a prior brain ischemic event. d-true, better seen by MRI. e-true, these are compatible with cerebral edema and may be related to spreading depression (a wave of cellular depolarization accompanied by cellular swelling in the brain). Q7: Answer: e a-true, or by non-alcoholic individuals. b-true, these disorders should be looked for and excluded at all possibility. c-true, with relative preservation of remote memory and immediate recall. d-true, especially serotonin or glutamine-mediated . e-false, the disorder is self-limiting and no specific treatment is required, but reduction of ethanol intake should be counseled, and thiamin should be given to treat a possible Wernicke's encephalopathy. Q8: Answer: d a-true, and in such patients, a prior psychiatric history, additional psychiatric symptoms, or a precipitating emotional stress can often be identified. b-true, or selective to some but not OTHER events during such a period. c-true, an exceedingly RARE finding in organic amnesias. Despite such disorientation to person, orientation to place and time may well be preserved. d-false, recent memory may be LESS affected than remote memories- the REVERSE of the pattern customarily seen in organic amnesias. e-true, or examination after giving amobarbital sodium. NB: Less frequent patterns of dissociative amnesia: - Systematized amnesia: restricted to certain categories of information. - Continuous amnesia: for events for some time in the past up to and including the present. - Generalized amnesia: for everything!!! Q9: Answer: e a-true, but such a history is absent in up to 25% of patient and thus the diagnosis may be challenging. Most patients are chronic heavy alcoholics, but also may be seen in malnutrition and famines. b-true, but how thiamin deficiency produces this effect?! It is still not settled. c-true, and residual signs of a preceding Wernick'es encephalopathy like a horizontal nystagmus or a mild cerebellar gait ataxia might be seen. d-true, and long term memory is frequently affected as well but registration is intact. e-false, the patient is classically apathetic and lacks insight into his illness. They may attempts to reassure the physician that no impairment exists and try to explain away their obvious inability to remember. CONFABULATION IS OFTEN BUT NOT ALWAYS PRESENT. NB: All patients should receive thiamin to prevent progression of the deficits, although existing deficits are unlikely to be reversed. Q10: Answer: b a-true, seen in those who recover. Often there is a total amnesia for the period of encephalitis. b-false, confabulation may occur and the whole syndrome may exactly resemble that of alcoholic Korsakoff's. c-true, like docility, indifference, flat affect and mood, inappropriate jocularity, sexual illusions, hyperphagia, impotence, repetitive stereotyped motor activities, and the absence of goal-oriented activities. d-true, with or without secondary generalization. e-true. Q11: Answer: a a-false, it is a rare type. b-true, or compressing its floor or walls from without. c-true, may pose a diagnostic challenge. d-true, and endocrine disturbances, visual field defects and papilloedema. e-true, may include surgery, irradiation, or both. Q12: Answer: d a-true, and presents as an amnestic syndrome that may precede the full blown picture of the original lung tumor. b-true, Anti-Hu antibodies may be detected up to 6% of patients in the serum and CSF. c-true, these changes preferentially affect the gray matter of the hippocampus, cingulum, piriform cortex, inferior frontal lobes , insula, and amygdale. d-false, they are VERY COMMOMN EARLY features. e-true, and in many situations it progresses to a global dementia. NB: Complex partial seizures with or without secondary generalization may occur. Depending on the underlying tumor and their auto-antibodies, other parts of the nervous system may be involved as well and thus many other signs are seen, like pyramidal, cerebellar…etc. Q13: Answer: c a-true, but non-specific findings. b-true, but non-diagnostic. c-false, in the medial temporal lobes. d-true, anti Hu antibodies are the commonest and are usually associated with small cell lung cancer, and anti Ta antibodies in testicular cancers ; in both the prognosis is poor. e-true, or it can progress or can remit. NB: Korsakoff's syndrome should always be excluded, because cancer patients are prone for malnutrition and the resulting thiamin deficiency is easily treatable. Chapter XI / Neurology Subchapter D: Headache is a very common complaint, yet it is totally non specific. Every day, we see many patients in the neurology headache clinic (either referred from other doctors or through a self–referral), and the majorities of those patients are thinking that they are suffering from a neurological illness (mainly a brain TUMOR). Proper history taking and an efficient examination (not only neurological, but also a general medical one ) will provide a clue or clues to the underlying CAUSE of this "HEAD PAIN" in the majority of cases, at least will provide a crude reassuring evidence that we are not dealing a sinister pathology. Psychological support of the patient and good explanation about "what is going on" is very important in the management,. e.g many patients with tension type headache do not know what is "tension" headache and thus they change the physician repeatedly and non-fruitfully in an attempt to exclude a" brain tumor". In this chapter I will try to cover this VERY IMPORTANT and COMMON yet UNDER-ESTIMATED and BADLY MANAGED COMPLAINT. Few Notes to be remembered: 1-Headache is caused by: traction, displacement, inflammation, vascular spasm, or distension of the pain sensitive structures in the head and neck. 2-Isolated involvement of the boney skull, most of the dura, or most regions of the brain parenchyma does not produce pain. 3-Pain sensitive structures within the cranial vault; these include: a- Venous sinuses ( like the superior sagittal sinus). b- Anterior and middle cerebral arteries. c- Dura at the base of the skull. d- Trigeminal, glossopharyngeal, and vagus nerves. e- Proximal portion of the internal carotid artery and its branches near the circle of Willis. f- Brainstem periaquiductal gray matter. g- Sensory nuclei of the thalamus. 4- Extracranial pain-sensitive structures; these include: a- Periosteum of the skull. b- Skin, subcutaneous tissues, muscles and arteries. c- Neck muscles. d-2 nd and 3 rd cranial nerves. e- Eyes, ears, paranasal sinuses, teeth, oropharynx, and mucous membrane of the nasal cavity. 5- Certain associated symptoms with headache: a- Recent weight loss: think of cancer, giant cell arteritis, depression. b- Fever and or chills: think of systemic infections ( bacterial , viral…etc.) and meningitis. c- Dyspnea: think of infective endocarditis causing a brain abscess, pulmonary encephalopathy. d- Visual disturbances: think of ocular disorders (acute glaucoma, acute iritis), migraine, or intracranial process affecting the optic nerve or visual pathways. f- Nausea and vomiting: think of migraine, post-traumatic headache, intracranial mass lesions. g- Phtophobia: think of meningitis, subarachnoid hemorrhage, and migraine. f- Myalgia: think of: viral syndromes, tension headache, giant cell arteritis. g- Ipsilateral rhinorrhoea and lacrimation: typical of cluster headache. h- Transient loss of consciousness: may accompany migraine and glossopharyngeal neuralgia. 6- Physical signs detected when examining a patient complaining of headache: a- Fever: think of systemic infections( viral, typhoid etc), CNS infections (meningitis, brain abscess etc). b- Tachycardia: think of anxious patient with tension headache, systemic infections, severe headache per se, Pheochromocytoma( ? episodic, BP, sweating etc), mass lesion with early raised intracranial pressure, medications ( like vasodilators with reflex tachycardia). c- Blood pressure, hypertensive patient: think of an acute elevation in blood pressure (?pheochromocytoma) or very blood pressure( ie malignant hypertension or hypertensive encephalopathy). Hypertension per se is a risk factor for strokes (? ICH, SAH, ischemic) but chronic uncomplicated hypertension PER SE is RARE cause of chronic headache syndromes. d- Hypoventilation: look for cyanosis and pulmonary encephalopathy ( ? examine the optic disks for papilloedema). e-Weight loss: Cachexia; think of cancer, polymyalgia rheumatica, giant cell arteritis, chronic infections. f- Skin: local infection of skin of the head and neck ( ?causing brain abscess, cavernous sinus thrombosis), vasculitic lesions( ? systemic necrotizing vasculitides, infective endocarditis, cancer associated, skin stigmata of phakomatosis ( neurofibromatosis cauing brain tumors, nevus flamus of Sturge-Weber's and intracranial AVMs, Shagreen patches in tuberous sclerosis with intracranial gliomas). g- Scalp, face, and head: scalp tenderness; think of migraine, giant cell arteritis, subdural hematoma, post-herpetic neuralgia, head trauma. Skull boney tenderness; think of multiple myoloma, metastatic cancer, head trauma, Paget's disease. Bruit over the orbit or skull; think of intracranial AVMs, carotico-cavernous fistulae, aneurysm, meningioma. Tongue laceration; think of post-ictal headache. h- Neck: Cervical muscle spasm; think of tension headache, cervical spondylosis, spine injuries, migraine headache, cervical vasculitides, meningitis. Q1- Answer: e a-true, ruptured Berry's aneurysm is responsible for up to 75% of cases. b-true, with an equal sex incidence in general. c-true, and ruptured AVMs are mainly seen in the 2dn to 4 th decades of life. d-true, but acute elevation of blood pressure (eg at orgasm) may be responsible for their rupture. e-false, responsible for only 10% of cases, with somewhat male preponderance. Q2: Answer: b a-true, they are not TRULY congenital, and found in up to 2% of autotopsy series in previously healthy people. b-false, they are multiple in 20% of cases. The aneurysms are mainly located at the major side branches at the circle of Willis. c-true, looking for adult polycystic kidneys or aortic coarctation. d-true, sometimes very large ones with multiple feeding vessels are found. e-true, "mycotic" aneurysms in bacterial endocarditis; these are responsible for 2-3 of ruptures and are mainly located at the distal middle cerebral arterial territory. Q3: Answer: d a-true, and distorts the pain sensitive structures causing severe headache. b-true, and acutely reduce the cerebral blood flow, and this together with "convulsive" effect of the rupture, are thought to be responsible for the sudden loss of consciousness at onset which seen in at least 50% of patients. c-true, sub-hyaloid preretinal hemorrhages are seen in up to 20% of cases. d-false, the subachnoid bleed is located outside the brain parynchyma. Focal cerebral signs are UNCOMMON at onset , exception are : massive hemorrhage with extension into the underlying brain parenchyma, large aneurysms in the middle cerebral artery, and ruptured AVMs. Q4: Answer: c a-true, it is classical but not invariable. b-true, total absence of headache is against the diagnosis. The headache needs not be to severe, eg mild headache is usually seen in ruptured AVMs, but should be present. c-false, at least is seen in 50% of cases at onset. Vomiting and neck stiffness are also common . d-true, and during either at rest or exertion. e-true, sentinel headache due to mild leaking or aneurysmal stretch. NB: The most significant feature of the headache is that it is NEW, milder but otherwise similar headaches may have occurred in the weeks prior to the acute event. These prior headaches are probably the result of small prodromal sentinel bleeds or aneurysmal stretch. Q5: Answer: c a-true, and usually subsides slowly over the next 2 weeks. b-true, and doubles the mortality figure. c-false, the blood pressure rises very rapidly and may reach a very high level and a hypertensive encephalopathy may a be diagnosed instead. d-true, and together with signs of meningeal irritation , a diagnosis of pyogenic meningitis is usually made. e-true, but are usually absent in the first few hours of the ictus. NB: Bilateral upgoing toes and VI cranial nerve palsy are common , BUT these do not bear any relationship to the site of the ruptured aneurysm. Acute oculomotor nerve palsy is an uncommon finding in posterior communicating artery aneurysms and localizes the ruptured site. Ruptured AVMs also may localize the ruptured site by giving focal cerebral hemispheric signs. Q6: Answer: c a-true, will be positive in 90% of cases especially in patients with impaired consciousness . It may show a subarachnoid bleed, intra-parenchymal extension, intra-venticular blood or hydrocephalus, and even cerebral infarction. It is rapid and available at many hospitals and suitable for unstable patients. However, it may not show the aneurysm itself unless it is large enough. b-true, these can not be seen by CT scans. c-false, the sensitivity of the brain CT scans falls gradually day by day after the ictus ( from 90% in the first day down to less than 40% after 5 days post ictus. d-true, also it is time consuming , not available at all centers, and has many contraindications. e-true, rises from less than 50% whithin the first 3 days to more than 80% 5 days post ictus. NB: If the initial CT scan is normal and the clinical index is high, the next step should be lumbar puncture and CSF analysis. Q7: Answer: c a-true, and usually exceeds the upper limit of the standard CSF manometers .ie above 600 mm. b-true, and may be very difficult to differentiate it from traumatic taps in certain cases and contains from 100000 to more than 1000000 RBC/ mm3. c-false, it becomes xanthochromic after 6-12 hours due to break down of RBCs and hemoglobin. d-true, but in the same proportion to red cells as in the peripheral blood. e-true. NB: Blood is highly irritant to the leptomeninges, and a "chemical" meningitis may be seen; the while cell count may be very high in the first 48 hours, and the glucose becomes low 4 to 8 days post ictus. In the absence of such a pleocytosis, the CSF glucose should be NORMAL. Q8: Answer: c a-true, like peaked or deeply inverted T wave, short PR interval, or a tall U wave. The cardiac troponins may be raised as well. These occur due to a massive catecholamine release which may damage the myocardium. b-true, to visualize the whole cerebral vasculature. The aneurysm is multiple in 20% of cases, and AVMs may have multiple feeding vessels. Angiography can be performed at the earliest time convenient for the radiology department personnel (emergency angiography at the middle of the night is rarely indicated). c-false, angiography is a prerequisite to the rational planning of surgical treatment and is therefore not necessary for patients who are not surgical candidates eg those who are deeply comatose. d-true, causes are: the aneurysm may be sealed off by a clot, the aneurysm may be very small, bleeding from a venous angioma, bleeding from a cavernous angioma, and bleeding from a spinal source. e-true, hence it is used mainly in screening purposes. Q9: [...]... in CSF absorption d-false, these are rare and may mistaken for seizures Seizures occur in 10% of cases and ONLY after damage to the underlying cerebral cortex e-true, but all of them are uncommon Q10: Answer: d a-true, remote arteries may be affected but this is uncommon and usually not that significant b-true, and peaks at day 1 0- 14 post ictus c-true, the only ways to diagnose it d-false, it is closely... eg traumatic SAH or SAH following AVM rupture e-true, much more common than re-bleeding Q10: Answer: d a-true, this includes: bed rest, mild sedation, elevation of head of bed (1 5-2 0 degrees) and analgecis b-true , as well as heparin c-true, to ensure adequate cerebral perfusion, and intravenous fluids should be used with caution to avoid over-hydration d-false , hyponatremia should be treated by oral... treated c-true d-true e-false ,up to 50% Q 14: Answer: e a-true, and relief with recumbency b-true, and comes in 1-2 days after LP and disappears within 1-2 days thereafter c-true, with traction upon pain sensitive structures at the base of the brain d-true , e.g 22 gauge or smaller, and removing only as much as fluid needed for the studies to be performed e-false , although it is self limited in the... Q15: Answer: e a-true, for unknown reasons b-true , or it may be severe and SAH-like in nature c-true , or it may be a post-LP like in nature ie mild dull occipital and increased by upright position and relieved by recumbency d-true , all but the severe types are benign The severe ones must be differentiated from SAH e-false, marked increase in the systemic blood pressure Q16: Answer: d a-true, causing... for re-bleeding and permits aggressive treatment vasospasm with volume expansion and pharmacologic elevation of blood pressure Q13: Answer: e a-true, overall , about 65% of patients will die!!! b-true, and 25% of patients will die subsequently because of the initial hemorrhage and its complications, and a further 20% will die of re-bleeding if the aneurysm was not surgically treated c-true d-true e-false... definitive surgical treatment of the ruptured aneurysm c-true d-false, anticonvulsants should be given prophylactically ( e.g pheytoin 300 mg /day) because seizures increase the risk of re-bleeding e-true, to avoid brain edema Q12: Answer: e a-true, clinical grade I, II, and III In those patients, surgery has been shown to improve the clinical outcome b-true, but current evidence support an early intervention... is not against the diagnosis e-true, and in the idiopathic variety, young woman are the usual victims with a peak incidence in the 3rd decade Q 17: Answer: e a-true, but be aware of headache free type ( we diagnosed a young male patient few days ago as having this type of psuedotumor cerebri) b-true, they are very common Abducens nerve palsy could be uni- or bilateral c-true, but moderate to severe... questions well Q23: Answer: d a-true, the incidence increases with advancing age ( 70 % above the age of 70 ), and with thepresence of underlying immune suppression (like AIDS ,steroid usage…etc) ,or malignancy( the classical one is Hodgkin's disease) b-true, it is uncommon for the pain to persist for more than a year c-true, a useful clue indicating a previous attack of herpes zoster d-FALSE, the first division... mg twice daily b-true, very effective in these cases, given as 6 0-8 0 mg / day, and follow up the patient c-true, to produce a "dural LEAK" area for the CSF to escape into the surrounding regions d-true, but unfortunately shunt complications are common e-FALSE, unilateral procedures had been shown to protect BOTH eyes Q20: Answer: d a-true, if the patient was young ,or the pain is bilateral or alternating... multiple sclerosis b-true, but in general the cause is still unknown c-true, isolated involvement of the 1st division or bilateral affection in the idiopathic variety is very RARE d-FALSE, fortunately, occurrence during sleep is RARE Prominent occurrence during sleep may be a clue towards cluster headache e-true, but long term spontaneous remission is very RARE Q21: Answer: c a-true, any abnormal . treated. c-true. d-true. e-false ,up to 50%. Q 14: Answer: e a-true, and relief with recumbency. b-true, and comes in 1-2 days after LP and disappears within 1-2 days thereafter. c-true, with. matter. g- Sensory nuclei of the thalamus. 4- Extracranial pain-sensitive structures; these include: a- Periosteum of the skull. b- Skin, subcutaneous tissues, muscles and arteries. c- Neck. of goal-oriented activities. d-true, with or without secondary generalization. e-true. Q11: Answer: a a-false, it is a rare type. b-true, or compressing its floor or walls from without. c-true,