NL-2 Neurology

MCQ Tutorial 2019

Part 1

Neurologist P
 Anatomy
Cortical level Cortical function
Vascular

Brainstem and cerebellar Brainstem and CN

Spinal cord Spinal cord syndrome

Peripheral level Nerve (Mono,polyneuropathy)

NMJ
Myopathy
 Conditions
Stroke
Seizure
CNS infection
Headache
Dementia/Delirium
Parkinson’s disease

Spinal cord syndrome

GBS
MG
Myopathy
• A 60 years old man with T2DM and HTN presents with right hemiparesis
and mutism for 3 hours. PE : PR 90(totally irregular) BP155/90
global aphasia right facial palsy(UMN) right side motor power 2/5 CBG 95
Emergency CT brain is normal

• What is the appropriate management ?"

• A. Oral ASA+Plavix
• B. Oral warfarin
• C. IV heparin
• D. IV rtPA
• E. Mechanical thrombectomy
Acute stroke care
Loss of gray-white differentiation

Parenchymal hypodensity

Loss of insular ribbon

Obscuration of deep nuclei

Acute stroke care
 Acute stroke management

Stroke onset Choice of treatment

Within 4.5 hr

Within 6-24 hr

Within 24-48 hr

Within 72 hr -7 day
IV Alteplase (tPA)
IV Alteplase (tPA)
dosing:
• 0.9 mg/kg, max dose of 90 mg
• 10% given as a bolus over 1 minute
• Remaining given over 60 minutes
Stroke 2018;49(3):e46-e110
 tPA - Contraindications
• Time of onset > 4.5 hours
• Acute intracranial haemorrhage ,
Subarachnoid hemorrhage
• Ischemic stroke, head trauma,
intracranial/spinal surgery within 3
months
• History of intracranial haemorrhage
• BP >185/110 mmHg
• GI/genitourinary bleed within 21 days
• Coagulopathy (INR > 1.7, platelets
<100,000)
• Treatment-dose LMWH w/in 24 hours
or DOAC use within 48 hours
• Glucose <50mg/dL
• Non-compressible arterial puncture
within 7 days
Stroke 2018;49(3):e46-e110
 Symptomatic intracranial hemorrhage after t-PA

• Associated with
• Elevated plasma glucose
• High BP
• Hypodensity on CT
• Persistence of proximal arterial occlusion for
more than 2 hrs after t-PA
• Severe stroke
• Not increased in extreme age

Risk Factors of Symptomatic Intracerebral Hemorrhagen. After tPA Therapy for

Acute Stroke (Stroke. 2007;38:2275-2278.)
• A 60 years old man with T2DM and HTN presents with right hemiparesis
and mutism for 6 hours. PE : PR 90(totally irregular) BP155/90 global aph
asia right facial palsy(UMN) right side motor power 2/5 CBG 95 Emergenc
y CT brain small hypodensity

• What is the appropriate management ?"

• A. Oral ASA+Plavix
• B. Oral warfarin
• C. IV heparin
• D. IV rtPA
• E. Mechanical thrombectomy
• A 60 years old man with T2DM and HTN presents with right
hemiparesis for 6 hours. PE : PR 90(regular) BP155/90 no aphasia righ
t facial palsy(UMN) – mild, pronator drift right arm CBG 95 Emergenc
y CT brain is normal

• What is the appropriate management ?"

• A. Oral ASA+Plavix
• B. Oral warfarin
• C. IV heparin
• D. IV rtPA
• E. Mechanical thrombectomy
 Mechanical Thrombectomy
• Patients should receive mechanical thrombectomy if they meet the following
criteria:
• Pre-stroke mRS of 0-1
• > 18 years of age
• NIHSS score > 6
• Can be initiated within 6 hours of symptom onset
(may be reasonable in up to 24 hours in select patients)
• Dependent on location of the causative occlusion

• Should receive IV alteplase even if EVTs are being considered

Stroke 2018;49(3):e46-e110
ผผผู้ปป่วยชาย อายยุ 72 ปปี 3 ชชวชั่ โมง 30 นาทปี กป่อนมาโรงพยาบาล ขณะนชงชั่ ทานอาหาร มปีอาการอป่อนแรงแขนขาดผู้ านซผู้ ายทชนทปี ญาตติไปประคอง พอเดตินไดผู้ สชงเกตวป่ามปีปากเบปี บี้ยวดผู้ านซผู้ าย พผดไมป่ชดช จจึงนนาสป่งโรง
พยาบาล
โรคประจนาตชว : ความดชนโลหติตสผง รชบยาทปีชั่คลตินติก
PE : BP 195/107 mmHg, PR 84/min regular, RR 14/min,
CVS – normal S1S2, regular HR, no carotid bruits
Neuro – Alert, follow 2 step commands
CN – full EOM, no nystagmus, Lt. facial weakness (UMN), spastic dysarthria
Motor RT LT
Upper V/V II/II Motor drop left arm
Lower V/V IV/IV Motor drift left leg
Sensory – decreased pinprick sensation Lt. side
Cortical sign – impaired tactile neglect Lt. side, Lt. homonymous hemianopia,
normal language

CT brain พบ hypodensity lesion rt parietal lobe , EKG NSR , DTX 97

• ในผผ ผปป วยรายนนค
น วรตรวจอะไรเพพม
พ เตพมมากทนส
พ ด
ส เพพอ
พ ระบส
สาเหตส

• A. MRI brain
• B. CTA of brain and neck
• C. FBS,A1C,Lipid profile
• D. Holter monitoring
• E. Echocardiography
 Large vessel atherosclerosis
Definition Clinical
Stenosis 50% or TIA or stroke in the
occlusion of stem or same vascular territory
branch, presumably (Repeat)
atherosclerosis
Cortical impairment
VF defect
Carotid bruit or absent
of carotid pulse
Atherosclerotic risk factor:
DM, HT, dyslipidemia,
smoking
Imaging Management
Infarct in the territories Dual antiplatelet 3 mo
of large cerebral
arteries or their branch Endartelectomy
(Extracranial)
Evidence of arterial
stenosis (>50%) or Stent ?
occlusion by imaging
Control risk factor
Size > 1.5 cm
 Cardioembolic stroke
Definition Clinical Imaging Management
Ischemic stroke due to Sudden onset to Multiple strokes in Anticoagulant
an embolus arising maximal deficit different arterial - Vit K antagonist
in the heart territories - NOAC
Rapid improvement of
Haemorrhagic
symptoms transformation of an PFO Occluder
ischaemic infarct
Decreased Vulvular surgery
consciousness at onset Vascular imaging: reveals
an abrupt vessel cutoff
Underlying cardiac without significant
condition that can atherosclerotic narrowing
cause embolism of the upstream vessel
 Small vessel disease
Definition Clinical Imaging Management
Ischemic stroke cause Traditional lacunar Size of infarct in lacune is Control risk factor
from occlusion of syndrome or neurological ranging from 0.2 to 15
perforating vessel deficit that can describe mm3
by lesion of perforating
vessel Vascular imaging: no
significant atherosclerotic
No evidence of cerebral narrowing of the
cortical dysfunction upstream vessel

No VF defect

No evidence of potential
cardiac source of emboli
A 34-year-old female presented with sudden onset of severe neck pain with
occipital headache, vertigo and vomiting after she was swiming two hour
s ago. She was healthy previously
On physical examination, her temperature was 37.6 C, pulse 72 beats/min,
and blood pressure 132/78 mmHg. No remarkable positive signs were
detected by the lung, cardiac, and abdominal examinations. Neurological exa
mination revealed a right-sided slight hemiparesis with Babinski sign, no neck
stiffness, a right-sided central facial palsy and an ataxic finger-nose test as well
The MOST likely diagnosis is
• A. Cervical disc compression
• B. Multiple sclerosis
• C. Cerebellar hemorrhage
• D. Vertebral artery dissection
• E. Subarachnoid hemorrhage
 Cervicocranial Arterial Dissection
• Dissection implies a tear in the wall of a major artery,
common site VA (V1-3) >> ICA
• Common undetermined cause of stroke in the young.
• Cause neurological deficit by
• Narrowed lumen
• Embolisation from local thrombus

Extracranial VADs
- Severe neck pain
- Ischemic syndrome - Lateral medullary (Wallenberg
syndrome) , Cerebellar infarctions, Spinal cord infarctions

Intracranial VADs -> SAH

JAMA. 2001;285:2757-2762
หญติง 48 ปปี อาชปีพแมป่คผู้า มาดผู้ วยอป่อนแรงดผู้ านซผู้ ายขณะเดตินเขผู้ าหผู้ องนน บี้า PE: Lt hemiparesis, Lt
facial palsy (UMN type) CT: Rt basal ganglion hemorrhage BP 170/100 mmHg UA: alb
3+, sugar neg, sp.gr. 1.020 FBS: 109 mg%, BUN 30 Cr 1.6
ทป่านจะรชกษา hypertension ของผผผู้ปป่วยรายนปี บี้อยป่างไร

1. Nifedipine 5 mg sublingual
2. Nifedipine 5 mg oral
3. Enalapril 10 mg oral
4. Nicardipine IV drip
5. ไมป่ลดความดชนขณะนปี บี้ และตติดตามการรชกษา
Intracerebral hemorrhage

Cyrus K Dastur, and Wengui Yu Stroke Vasc Neurol 2017;svn-

2016-000047
• A 56-year·old woman is evaluated in the emergency department for sudden
onset of a severe generalized headache that began 36 hours ago and has not
responded to over-the-counter medication. The patient bas a history of hyperten
sion treated ·with lifestyle modifications. She has a 30-pack-year smoking history.
• On physical examination, blood pressure is 170/80 mm Hg, pulse rate is 96/min
and regular and respiration rate is 16/min. Nuchal rigidity is noted. Other general
examination findings are normal.
• A CT scan of the head without contrast is normal
• Which of the following is the most appropriate next diagnostic test?
• A. CT of the head with contrast
• B. Lumbar puncture
• C. Magnetic resonance angiography of the head and neck
• D. MRl of the brain Without contrast
Subarachnoid hemorrhage
Differentiate between Traumatic LP and
SAH
CSF characteristic Traumatic tap Subarachnoid
hemorrhage
ต ขต วดทสต 1 ถถง 3
สสแดงตตงแต จางลงเรรต อยๆ แดงเทาต กตนตลอด
การพบXanthochromia ตตงแต ต ต พบในระยะหลตง ต แ
พบตตงแต ต รก
แรกทสตเจาะ
การพบ Clotting blood Yes No

Graff's Textbook www.emra.org

• 37 -year-old woman is evaluated for a 1-week history of diffuse headache. She
describes the headache as constant, worse when she first awakens. She reports
no other focal neurologic symptoms. patient has a 10-pack-year history of tobacc
o use. Her only medication is estrogen oral contraceptive.
• On physical examination, temperature is normal, blood pressure is 112/78 mm
Hg, pulse rate is 62/min and regular, and respiration rate is 16/min; BMI is 37.
Bilateral papilledema is noted. The Valsalva maneuver increases the headache pa
in. All other general and neurologic examination findings are unremarkable.
• An CT of the brain without contrast is normal.
• Which of the following is the most appropriate next diagnostic test?
• A Cerebral angiography
• B Lumbar puncture
• C Magnetic resonance venography
• D Measurement of serum lupus anticoagulant level
Venous sinus thrombosis
Diagnosis and Management of Cerebral Venous
Thrombosis AHA/ASA 2016
• 40 year-old man with underlying HT, presented with asymemtrical Rt.
facial expression for 1 day PE: Incomplete Rt.eye closure, Rt. Lip drooping,
Normal neuro-otological examination Which is appropriate management?

• A. Plasma glucose
• B. CT brain
• C. MRI brain
• D. Oral ASA gr.V
• E. Oral prednisolone
Bell’s palsy
ผผผู้ปป่วยอายยุ18 ปปี วผบหมดสตติขณะรชบประทานอาหาร 2 ชม.PTA ตตชั่นมามจึนงงพบวป่า
ตนเองมปีปชสสาวะราด มปีแผลทปีชั่ลติ บี้นตชวเอง ตรวจรป่างกายทางระบบประสาทปกตติดปี ควร
สป่งตรวจอะไร

A. FBS
B. CT brain
C. Holter monitor
D. EKG
E. EEG
 Seizure/epilepsy
Seizure Epilepsy
A disease of the brain defined by any of the
From Abnormal excessive neuronal activity in following conditions
cortex
1. At least 2 unprovoked seizures occurring
Hyperexcitable neuron more than 24 hours apart

2. One unprovoked seizure and a probability

of further seizures similar to the general
recurrence risk after two unprovoked seizures
(approx 75% or more)

Provoked or unprovoked Classification for work up etiology

Antiepileptic drug (short cause) or not Almost antiepileptic drug

• A 50-year-old man is examined in the hospital for sudden onset of tonic-
clonic movements of all four extremities that have continued for more than 5
minutes.
• On physical examination, the patient is diaphoretic and intermittently
exhibiting leftward head and eye deviation associated with asynchronous
clonic jerking of the extremities. Blood pressure is 150/90 mm Hg, pulse rate
is 120/min, md respiration rate is 22/min.
• Blood glucose level by fingerstick measurement is 70 mg/ dL ( 3. 9 mmol(L).
Results of other laboratory tests are pending.
• Which of the following is the most appropriate first line treatment?
• A. Levetiracetam
• B. Lorazepam
• C. Phenytoin
• D. Valproic acid
 Status epilepticus in adults
John P BetjemannLancet Neurol 2015; 14: 615–24
• A 23-year-old lady presented with generalized tonic-clonic seizures. She
had a history of febrile convulsion when she was a child. Her mother
noticed in these 10 years she has had intermittent loss of awareness with
abnormal hand movement lasting 13 minutes which episodes are triggere
d by sleep-deprivation. She sometimes feels that the environment surroun
ding her seems familiar, even if she visits the places for the first time.

• What is the MOST likely diagnosis?

• A. Multiple sclerosis
• B. Frontal lobe epilepsy
• C. Glioblastoma multiforme
• D. Mesial temporal sclerosis
• E. Juvenile myoclonic epilepsy
 Temporal lobe epilepsy
• Temporal lobe epilepsy
• Lateral TLE:
• Mesial TLE: more common (2/3 cases)
• Hippocampal sclerosis – secondary febrile convulsion
• Other benign or malignant tumor, viral and other infection and
parasite disease, CVD, developmental malformation, trauma.
• A 23-year-old lady presented with generalized tonic-clonic seizures. She had a
history of febrile convulsion when she was a child. Her mother noticed in these
10 years she has had intermittent loss of awareness with abnormal hand movem
ent lasting 13 minutes which episodes are triggered by sleep-deprivation. She so
metimes feels that the environment surrounding her seems familiar, even if she vi
sits the places for the first time.

• Which of the following drugs is proper for this patient?

• A. Carbamazepine
• B. Phenyltoin
• C. Valproic acid
• D. Lamotrigine
• E. Phenobarbital
 Monotherapy era
Equally or higher efficacious than polytherapy
Better tolerated
No drug interaction
Possibly better compliance
Better cost effective
Particularly desirable in
- women
- elderly
- patients with co-morbid conditions
Antiepileptic drug selection
• 65 year old thai male presented with fever, alteration of concious and
behavior changing for 6 day. On examination he was drownsiness, not
follow command, CT: low density lesion of bilateral frontotemporal. C
SF : open pressure 18, WBC 10(mono100%), RBC 50, protein 45, gluco
se 65( blood100).

• What is the most appropriate treatment?

• A. Ceftriazone
• B. Acyclovir
• C. Prednisolone
• D. Amoxiclav
• E. IRZE
 CNS infection
Meningitis
Syndrome of fever + headache +
minigismus + Inflammation of the
subarachnoid
Onset
Acute – bacteria , virus
Subacute – low virulent bacteria ,
TB , fungus
Chronic – fungus , TB , virus
Encephalitis
Inflammation of brain parenchyma + Brain
dysfunction
-Cognitive dysfunction eg. Memory disturbance
-Behavioral change eg. Hallucination, psychosis,
personality change
-Focal neurological abnormalities
-Seizures
Infection
Viral ex. HSV, enterovirus, VZV,Epstein-Barr
virus(EBV), measle subacute sclerosing
panencephilitis(Measle SSPE), rotavirus,
rabies , HHV-6
Bacterial ex. Chlamydia spp., Mycoplasma
spp., Bartonella hensalae
Other ex. TB Creutzfeldt-Jakob Disease
Other Autoimmune
 CSF profile
CSF profile Normal Bacteria Virus
(Septic) (Aseptic)
OP (cmH2O) 10-20 High Normal

Colour Clear Turbid Clear

Cells/mm3 <5 50-5000 5-500

Differential Mono PMN Mono
CSFglucose/PG ratio Normal Low Normal
(60%)

Protein(mg/dl) <45 >100-1000 50-100

 CSF profile
CSF profile Normal TB Fungus Parasite Carcinomatous

OP (cmH2O) 10-20 High Very high Usually high Normal-high

Colour Clear Yellow Clear Cloudy, Clear

/cloudy /cloudy xanthochromia

Cells/mm3 <5 25-500 5-100 >5 25-500

Differential Mono Mono Mono Eosinophil / RBC Atypical cells

CSFglucose/PG Normal (60%) <30% Normal-low Normal-low Normal-low

ratio

Protein <45 100-5000 20-500 >60 100-500

(mg/dl)
CSF Gross Appearance
• ญ 35 มนไข ผ ปวดหหวมา10วหน BT37.8 PE: stiff neck + อยปาง
อพน
พ ปกตพ CBC :wbc 12000(N70 L23 M4 Eo3) CSF:open
pressure20 wbc400(N60 L30 Eo10) glc protein ปกตพ
ถาม Treatment
• A. Acyclovir
• B. Albendazole
• C. Ceftri
• D. IRZE
• E. Prednisolone
 Eosinophilic Meningitis (EoM)
• CSF eosinophil > 10 % ( Wet smear or Wright’s stain )
• Angiostrongyliasis
• EoM : Prednisolone (1 or 2 weeks +/- albendazole) and Lumbar puncture
• Eo. Meningoencephalitis : supportive Rx.
• Gnathostomiasis
• Cutaneous : Albendazole 800 mg,21 days
• Neurological : supportive Rx. (albendazole or steroid may be beneficial)
• A 40 years old accountant has had off-and-on headache for about
5 years.It tends to occur at afternoon with mild to moderate pain. She
feels like a tight band around her head and sometimes referred to her
neck and shoulder. Using paracetamol is ineffective. Physical examina
tion is unremarkable. What is proper management?

• A. Amitryptiline
• B. Flurinazine
• C. Propanolol
• D. Tramadol
• E. Topiramate
Headache approach
• ตตตแหนนงททปท วด + ลลกษณะททท บทงถถ ง
กตรดตตเนนนโรค รนวม Secondary
ก กบตรวจรนตงกตย headache

เขขาไดขกลบเกณฑฑการววนวจฉลย ตรวจ work up

Primary headache lab & imaging

ววนวจฉลย ตว ดตามอาการ
Primary headache
Tension headache
A 68 year-old man with HT woke up because of sudden onset of severe
pulsating headache. He also had N/V. His headache is relieve upon
hospital arrival. He has never had this symptom before. PE:
BP150/90mmhg PR 78/min irregular RR 22/min BT 37°C. Alert and
good orientation. Normal neuro exam and fundoscopic. CT brain w/o
contrast is normal.

What is the best appropriate management?

A. CT brain with contrast
B. LP
C. propanolol
D. ergotamine
E. ibuprofen
End of part 1