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Question 1
Incorrect
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A 68-year-old man was watching TV at home and had a fit which lasted for approximately ten minutes. His wife was with him at home and reports that there was no incontinence or limb jerking. An electrocardiogram (ECG) shows left bundle branch block (LBBB). The patient denies any shortness of breath or chest pain before or after the event, and his vital signs are stable. A high-sensitivity troponin assay performed upon admission is negative. The patient is a non-smoker, suffers from well-controlled hypertension and has no significant family history. He is a retired plumber.
What is the next best investigation for this patient?Your Answer: Electroencephalogram (EEG)
Correct Answer: Computed tomography (CT) head
Explanation:Appropriate Diagnostic Tests for a Patient with New-Onset Seizure
When a patient experiences a new-onset seizure, it is important to determine if there is an underlying intracranial pathology such as a space-occupying lesion. A CT scan of the head is the most appropriate diagnostic test to guide any further neurosurgical treatment if needed.
An EEG would only be helpful during a seizure activity and confirm that a seizure was occurring. If the patient has repeated seizures, a 24-hour ambulatory EEG would be useful in the diagnosis.
A coronary angiogram would be appropriate if the main diagnosis being considered was a myocardial infarction, but in this case, the patient’s LBBB is not of new onset and is not the main concern.
A urine dipstick would not be helpful in the diagnosis of the patient’s condition as there are no signs of an ongoing urinary tract infection.
An echocardiogram would be necessary if the patient had chest symptoms or signs suggestive of cardiac tamponade, but in this case, the high-sensitivity troponin assay was negative.
In summary, a CT scan of the head is the most appropriate diagnostic test for a patient with a new-onset seizure, and other tests should be considered based on the patient’s specific symptoms and medical history.
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This question is part of the following fields:
- Neurosurgery
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Question 2
Incorrect
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An 80-year-old man is brought to the Emergency Department by his daughter after being found collapsed at home by his caregiver. He is complaining of a headache and appears confused. The patient has a history of an irregular heartbeat and takes digoxin and warfarin. On examination, there is no evidence of trauma or injury. The patient is confused with a Mini Mental score of 24/30 and is slightly drowsy but can be easily awakened. He has mild weakness in his left arm and leg, and the left plantar response is extensor. Urgent blood tests reveal a haemoglobin level of 111 g/l (normal range: 135-175 g/l), an INR of 5.7 (usual range for this patient: 2-3), and a urea level of 9.6 mmol/l (normal range: 2.5-6.5 mmol/l). An urgent CT scan is ordered. What is the most likely finding on the CT scan?
Your Answer: Right sided subarachnoid haemorrhage
Correct Answer: Right sided acute subdural haematoma
Explanation:Different Types of Intracranial Bleeding and Their Causes
Intracranial bleeding can occur in various forms, each with its own causes and symptoms. Here are some of the different types of intracranial bleeding and their associated factors:
1. Right Sided Acute Subdural Haematoma
This type of bleeding can occur in elderly patients who are on anticoagulation therapy, especially if their INR levels are higher than the therapeutic limits. The symptoms include fluctuating confusion and conscious level, and a history of trauma is not always necessary.2. Intraparenchymal Haematoma in the Right Temporal Lobe with Mass Effect
This type of bleeding is usually caused by trauma, hypertension, or an underlying neoplastic lesion. It is less common than subdural haematoma.3. Right Sided Extradural Haematoma
Extradural haematoma is associated with significant head trauma.4. Right Sided Chronic Subdural Haematoma
Chronic subdural haematoma has a longer, insidious course and is often accompanied by headache, impaired conscious level, and focal signs. Over-anticoagulation can increase the likelihood of this type of bleeding.5. Right Sided Subarachnoid Haemorrhage
Subarachnoid haemorrhage is usually caused by significant trauma or a ruptured aneurysm.Overall, the elderly are more at risk of subdural haematomas due to factors such as thinner cortical bridging veins, increased subdural space, and increased probability of falls and use of medications that alter blood clotting.
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This question is part of the following fields:
- Neurosurgery
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Question 3
Incorrect
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A 28-year-old man presents to his GP with complaints of abnormal sensations in his right hand and forearm. He reports experiencing numbness and tingling in the back of his hand, particularly around his thumb, index, and middle finger. Additionally, he has noticed weakness in his elbow and wrist. Upon examination, the GP observes reduced power in elbow and wrist extension on the right side. The patient denies any history of trauma to the arm and does not engage in extreme sports. He works as a security agent and often sleeps in a chair during his night shifts. X-rays of the right wrist, elbow, and shoulder reveal no apparent fractures. What is the most probable diagnosis for this individual?
Your Answer: Cubital tunnel syndrome
Correct Answer: Radial nerve palsy
Explanation:Differentiating Radial Nerve Palsy from Other Upper Limb Pathologies
Radial nerve palsy is a condition that affects the extensors of the wrist and forearms, as well as the sensation of the back of the hands at the thumb, index, middle, and radial side of the ring finger. It is often caused by compression or injury to the radial nerve, which can occur from sleeping in an awkward position or other trauma. This condition is commonly referred to as Saturday night palsy.
It is important to differentiate radial nerve palsy from other upper limb pathologies, such as carpal tunnel syndrome, Erb’s palsy, cubital tunnel syndrome, and Klumpke’s palsy. Carpal tunnel syndrome involves compression of the median nerve at the wrist, causing tingling, numbness, and pain in the palmar side of the thumb, index, middle, and ring finger area. Erb’s palsy is an injury to the brachial plexus involving the upper roots, usually occurring during delivery and causing an adducted and internally rotated shoulder with elbow extension, pronation, and wrist flexion. Cubital tunnel syndrome involves impingement of the ulnar nerve at the elbow, causing numbness and tingling at the ulnar side of the ring finger and small finger, and potentially leading to an ulnar claw deformity. Klumpke’s palsy is an injury to the brachial plexus involving the lower roots, usually occurring during delivery and causing a claw hand and potentially Horner syndrome.
By understanding the specific symptoms and causes of each condition, healthcare professionals can accurately diagnose and treat patients with upper limb pathologies.
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This question is part of the following fields:
- Neurosurgery
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Question 4
Incorrect
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A 72-year-old man presents to the Emergency Department with a headache after being referred by his General Practitioner (GP). The GP referral letter mentions that the patient presented with a history of fluctuating consciousness levels for the past week. The wife reports that her husband had a fall about a week ago and since then, he seemed to be a different man. The patient mentions that he has been experiencing a dull headache which did not respond to regular paracetamol. He denies nausea, vomiting and photophobia.
On examination, the vital signs are stable, the patient is apyrexial and there are no rashes. The patient has a past medical history of alcohol dependence, liver cirrhosis, gout and hypertension. A computed tomography (CT) scan of the patient’s head shows a crescent-shaped area of haemorrhage with midline shift of the brain structures.
What is the best next management step for this patient?Your Answer: Nimodipine
Correct Answer: Burr hole drainage
Explanation:Treatment Options for Subdural Haemorrhage: Burr Hole Drainage, Mannitol, Nimodipine, Endovascular Coiling, and Aspirin
Subdural haemorrhage is a serious medical condition that requires prompt treatment. The most common treatment option for subdural haemorrhage is burr hole drainage, which involves removing the haematoma and relieving the compression of the brain. Mannitol is another treatment option that is used to reduce intracranial pressure if signs of intracranial pressure are present. Nimodipine is used in cases of subarachnoid haemorrhage to reduce vasospasm, which is often an acute complication of subarachnoid haemorrhage and leads to cerebral ischaemia. Endovascular coiling is a treatment for subarachnoid haemorrhage and is not indicated for subdural haemorrhage. Aspirin is contraindicated in the case of a haemorrhagic stroke or intracranial haemorrhage, as it can worsen bleeding. Therefore, it is important to rule out bleeding as the cause of the patient’s symptoms before administering aspirin.
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This question is part of the following fields:
- Neurosurgery
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Question 5
Incorrect
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An 80-year-old man comes to the Emergency Department with a progressive decline in mental status and a past medical history of worsening gait and frequent falls. An MRI scan shows enlargement of the ventricular system, suggesting hydrocephalus. What other symptom would indicate a diagnosis of normal pressure hydrocephalus?
Your Answer: Resting tremor
Correct Answer: Urinary incontinence
Explanation:Understanding Normal Pressure Hydrocephalus: Symptoms and Diagnosis
Normal pressure hydrocephalus (NPH) is a condition characterized by the enlargement of cerebral ventricles, which can lead to a classical triad of symptoms including dementia, urinary incontinence, and gait apraxia. While it is typically seen in the elderly, it is a gradual and progressive disorder that can be potentially reversible. However, it is important to note that symptoms such as loss of inhibitions and inappropriate behavior are more likely to lead to a diagnosis of frontotemporal dementia rather than NPH. Resting tremors, seizures, and hallucinations are also not typically associated with NPH. Diagnosis involves testing mental status before and after a lumbar puncture, and treatment may involve therapeutic drainage of cerebrospinal fluid or placement of a ventriculoperitoneal shunt.
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This question is part of the following fields:
- Neurosurgery
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Question 6
Incorrect
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A 52-year-old woman presents to her General Practitioner for recent onset of acute back pain. For the last three months, she has been having a burning sensation and tingling of the hands and feet. Her past medical history includes hypertension, diabetes, coronary artery disease and chronic obstructive pulmonary disease (COPD). She is on medication for her hypertension and diabetes which are well controlled. X-ray of thoracic vertebrae demonstrates punched-out lytic lesions.
Her laboratory investigation report shows the following abnormalities:
Investigations Results Normal values
Calcium 3.2 mmol/l 2.2–2.6 mmol/l
Blood urea nitrogen (BUN) 15 mmol/l 2.5–6.5 mmol/l
Creatinine 130 μmol/l 50–120 μmol/l
Haemoglobin 98 g/dl 115–155 g/l
What is the most appropriate next investigation in this patient?Your Answer: Thyroid function tests
Correct Answer: Urine analysis
Explanation:Diagnostic Tests for Peripheral Neuropathy in a Patient with Multiple Myeloma
Multiple myeloma is a neoplastic clonal expansion of plasma cells that produce monoclonal immunoglobulins. It can cause extensive skeletal damage by osteopenia and inducing osteolytic bone lesions. Peripheral neuropathy symptoms (both sensory and motor involvement can be seen) are present in this patient at the same time of the onset of bone pain. Here are some diagnostic tests that can help identify the cause of peripheral neuropathy in a patient with multiple myeloma:
24-hour urine electrophoresis test: This test could confirm the diagnosis of multiple myeloma through the identification of Bence-Jones protein, a characteristic finding in multiple myeloma.
Autoimmune antibodies: Autoimmune conditions like Sjögren syndrome, lupus and rheumatoid arthritis can give rise to symptoms of peripheral neuropathy. However, the patient’s history and clinical findings do not correlate with these conditions.
Glycosylated haemoglobin: Peripheral neuropathy is a complication of uncontrolled diabetes mellitus. However, given that it is well controlled in this patient, it is highly unlikely to be a cause of her symptoms.
Serum vitamin B12 estimation: Vitamin B12 deficiency causes peripheral neuropathy. However, it does not cause osteolytic lesions in the vertebrae, as in this patient’s case.
Thyroid function tests: Hypothyroidism, which is long-standing and often untreated, can lead to complications of peripheral neuropathy. However, hypercalcaemia found in this patient would go against this diagnosis and performing thyroid function tests would not be a correct option.
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This question is part of the following fields:
- Neurosurgery
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Question 7
Incorrect
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A 67-year-old woman is on the surgical ward after admission for neurological observations following a head injury. She had fallen on the pavement and banged her head with a moderate laceration. She suffered from no loss of consciousness but now complains of nausea and double vision. You notice that:
her eyes open to speech
she is able to obey commands
she can talk properly but appears disorientated in time and place.
What is her Glasgow Coma Scale (GCS) score?Your Answer: 15
Correct Answer: 13
Explanation:Understanding the Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a valuable tool for assessing a patient’s level of consciousness, particularly in cases of head injury. It provides a standardized language for clinicians to communicate about a patient’s condition. The GCS measures the best eye, verbal, and motor responses and calculates a total score. A fully conscious and alert patient will score 15/15, while the lowest possible score is 3/15.
The GCS score is calculated based on the patient’s eye, verbal, and motor responses. The eyes can open spontaneously, in response to speech or pain, or not at all. The verbal response can range from being oriented to being completely unresponsive. The motor response can range from obeying commands to abnormal flexion or no response at all.
It is important to note that if a patient’s GCS score is 8 or below, they will require airway protection as they will be unable to protect their own airway. This typically means intubation. It is crucial to accurately calculate the GCS score to ensure appropriate medical intervention.
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This question is part of the following fields:
- Neurosurgery
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Question 8
Incorrect
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A 70-year-old man arrives at the Emergency Department with sudden onset of dizziness and hearing loss in his right ear that occurred three hours ago. He has fallen twice since then and was assisted by his daughter to get to the hospital. He reports feeling like the room is spinning and has nausea but has not vomited. Which artery territory is most likely involved in this stroke?
Your Answer:
Correct Answer: Right anterior inferior cerebellar artery
Explanation:The Relationship Between Stroke and Hearing Loss: A Look at Different Arteries
Strokes can have various effects on the body, including hearing loss and vertigo. The specific artery affected can determine the type of symptoms experienced.
The right anterior inferior cerebellar artery supplies the area of the brainstem that contains the vestibular and cochlear nuclei. Its occlusion can result in vertigo and ipsilateral hearing loss.
A superior cerebellar artery territory stroke does not result in hearing loss.
Occlusion of the right posterior inferior cerebellar artery results in Wallenberg syndrome, which includes vertigo but not hearing loss.
Branches of the right middle cerebral artery supply the auditory cortex. Unilateral hearing loss is caused by damage to the inner ear, cochlear nerve, or cochlear nuclei. Unilateral damage to the auditory tracts above the level of the brainstem nuclei does not result in hearing loss because of bilateral representation of the fibers. Although dizziness is a common finding in patients with higher cortical stroke or transient ischemic attack, a true vertigo signals significant disruption of the vestibular system at the level of the brainstem nuclei, vestibular nerve, or inner ear.
A right posterior cerebral artery territory stroke is most often associated with visual deficits and sometimes causes thalamic syndrome.
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This question is part of the following fields:
- Neurosurgery
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Question 9
Incorrect
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A 37-year-old man comes to the Emergency Department complaining of left-sided hearing loss and tinnitus that have been ongoing for three months. He also reports experiencing dizziness, which has now progressed to difficulty walking steadily. Audiometry confirms sensorineural hearing loss in his left ear, and a contrast magnetic resonance imaging scan indicates that he has a tumor with characteristics consistent with an acoustic neuroma. Which type of cell is linked to the excessive growth of an acoustic neuroma?
Your Answer:
Correct Answer: Schwann cell
Explanation:Understanding the Cells Involved in Neurological Tumors
Neurological tumors can arise from various cells in the central and peripheral nervous systems. It is important to understand the different types of cells involved in these tumors to accurately diagnose and treat them.
Schwann cells are responsible for the pathogenesis of acoustic neuromas, which are benign tumors of the vestibulocochlear nerve. These cells surround nerves in the peripheral nervous system. Symptoms of acoustic neuromas include unilateral sensorineural hearing loss, tinnitus, and vertigo.
Microglial cells are immune cells in the central nervous system, but they do not typically form neurological tumors.
Astrocytes are glial cells in the central nervous system and are responsible for the most common type of glioma, but this patient’s symptoms are consistent with a peripheral nervous system tumor of glial origin.
Ependymal cells form the epithelial lining of the ventricles in the brain and the central canal of the spinal cord. Although they can cause ependymomas, which are a type of brain tumor, the symptoms present are not consistent with this and ependymal cells are not responsible for acoustic neuromas.
Satellite cells are neuroglial cells of the peripheral nervous system, but they are unlikely to be responsible for acoustic neuromas. Over-proliferation of Schwann cells is the pathogenesis of this type of tumor.
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This question is part of the following fields:
- Neurosurgery
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Question 10
Incorrect
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A patient presents to the Emergency Department after being assaulted. She tells you that this occurred a few hours ago and she has taken several blows to the head. On examination, there is bruising around the eyes. Clear fluid can be seen discharging from her nose.
Where is the patient’s pathology likely to be?Your Answer:
Correct Answer: Cribriform plate
Explanation:Differentiating Skull Fractures and their Symptoms
Skull fractures can have varying symptoms depending on the location of the fracture. A fracture of the cribriform plate can result in periorbital ecchymosis and cerebrospinal fluid (CSF) leak from the nose. In such cases, nasogastric tubes or nasal airway adjuncts should be avoided to prevent the tube from entering the cranial cavity.
Fractures of the occiput bone and middle cranial fossa can present with similar symptoms such as bruising around the mastoid process (‘battle sign’), haemotympanum, and otorrhoea. However, an occiput fracture may also cause CSF leak from the ear.
Fractures of the frontal bone are likely to have a wound at the site of the fracture but are unlikely to cause CSF leak. Similarly, zygoma fractures are unlikely to cause CSF leak. Understanding the symptoms associated with different skull fractures can aid in their proper diagnosis and management.
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This question is part of the following fields:
- Neurosurgery
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