Educational Objective:Damage to the lateral spinothalamic tracts causes contralateral loss of pain and temperature sensationbeginning two levels below the level of the lesion.(remember thatthe spinothalamic tracts cross very early on in the spinal cord).Educational Objective:Craniopharyngiomas are benign suprasellar tumors which usually present with signs of hypopituitarism.headaches and bitemporal blindness.Craniopharyngiomas are benign tumors arising from Rathke's pouch. and are more common in children.Although they are infrequently seen in adults. craniopharyngiomas actually have a bimodal age distribution -children and 55-65 years age group.whereas sexual dysfunction is more prominent in adults. Women can present with amenorrhea.The diagnosis is made with an MRI or CT scan. and treatment iswith surgery and/or radiotherapy.Educational objective:Hypertension is a common cause of spontaneous intracranial hemorrhage with the most common sites beingthe basal ganglia. cerebellum. thalamus. and pons.Educational objective:Hypothyroidism is an important cause of reversible changes in memory and mentation. It will beaccompanied by systemic changes such as weight gain. fatigue. and constipation.Educational Objective:Oligoclonal bands are present in 85-90% of cases of multiple sclerosis. CSF pressure. protein and cell countare grossly normal.Educational Objective:Paroxysmal, lightning-like pain on the face is usually due to trigeminal neuralgia. Carbamazepine is the drugof choice.severe. intense. burning orelectric shock-like. This symptom occurs in paroxysms that last a few seconds to minutes each. but occursmany times a day. The trigger factors may vary, and the cause remains unknown. Carbamazepine is thedrug of choice.Educational Objective:Subdural hematomas are serious intracranial hemorrhages that occur due to tearing of bridging veins. Blunttrauma is the most common cause. and surgical evacuation is usually required.On non-contrast CT of the head. SOH appears as a white crescent. A midline shift may also be seen. TheCT image above shows a large right-sided subdural hematoma producing a significant mass effect andmidline shift. The ventricles on the right side are completely obliterated. Emergent neurosurgical consultationfor hematoma evacuation is necessary.SOHs are more common in older patients and alcoholics due to brain atrophy andvessel fragility.Educational objective:Hemi-sensory loss with severe dysesthesia of the affected area is typical for a thalamic stroker thalamic stroke (Dejerine-Roussy syndrome). This condition iscaused by a stroke involving ventral postero-lateral (VPL) nucleus of the thalamus. which transmits sensoryinformation from the contralateral side of the body. The classic presentation involves contralateralhemianesthesia that can be accompanied by transient hemiparesis. athetosis. or ballistic movements.Dysesthesia of the area affected by the sensory loss is characteristic. and is called thalamic painphenomenon.Educational objective:Cerebral emboli are one of the most dreaded consequences of endocarditis. They occur when pieces ofinfected valvular vegetations break off and enter the CNS circulation. Treatment is with antibiotics.Although IV drug abusers can get right-sided endocarditis, left-sided endocarditis is also verycommon! The next steps in the management of this patient are initiation of broad-spectrum antibiotics andechocardiogram to evaluate for valvular vegetations.Educational objective:Essential tremor is characterized by a tremor that is suppressed at rest and exacerbated toward the end of agoal-directed movement. Affected patients typically have difficulty holding a newspaper, writing legibly,drinking a cup of coffee, or feeding themselves.ducational objective:First line treatment for essential tremor is propranolol, especially if the patient is also hypertensive. Alternativemedications include primidone ortopiramate.Educational Objective:Vertigo is a sensation of excessive motion compared to physical reality. It is most commonly due todysfunction within the vestibular system.Vertigo resulting from vestibular dysfunction tends to be of sudden onset,interfere with walking, and cause nausea and vomiting. Typical causes of vestibulopathy include Meniere'sdisease, perilymphatic fistulas, benign positional vertigo, labyrinthitis, and acoustic neuromas.Educational objective:Guillain-Barre syndrome is characterized by ascending paralysis. antecedent history of infection. and CSFfinding of albumino-cytologic dissociation. The treatment includes IV immunoglobulin and plasmapheresis.Cranial nerve paralysis (most likely facial nerve palsy) often develops.The classic presentation includes ascendingparalysis. areflexia and sensory changes 3-4 weeks after an upper respiratory tract infection orgastroenteritis. Educational Objective:Primidone is an anticonvulsant agent which can be used to treat benign essential tremors. Its administrationcan precipitate acute intermittent porphyria. which can be diagnosed by checking for urine porphobilinogen.The administration of primidone may precipitate acute intermittentporphyria. which manifests as abdominal pain. neurologic and psychiatric abnormalities (as seen in thispatient).Educational objective:Restless leg syndrome is a potentially debilitating condition characterized by the uncomfortable desire tomove ones legs at rest or at night. It can be treated with dopamine agonists.RLS is more common inmiddle aged and older patients. as well as in those with chronic kidney disease and/or iron deficiencyanemia. Educational Objective:It is important to know the function of each cranial nerve. The ophthalmic branch (V1) of the trigeminal nerve(V) controls corneal sensation. When it is damaged. patients can suffer from corneal injury withoutawareness.he ophthalmic nerve (V1). carries sensory fibers to the scalp.forehead. upper eyelid. conjunctiva. cornea. nose. and frontal sinuses. Damage to V1 results in cornealanesthesia; thus. a lesion on the eye may not be sensed if a V1 lesion is present.Educational Objective:Rupture of a saccular aneurysm is the most frequent cause of non-traumatic subarachnoid hemorrhage(SAH). Know the appearance of SAH on CT.Aneurysms are more likely to rupture when they are larger than 7 mm, and are mostfrequent in the anterior circulation on the circle of Willis.Educational Objective:Patients with Huntington's chorea usually present in their forties or fifties with chorea and/or behavioraldisturbance. Atrophy of the caudate nucleus is a characteristic feature.Choreais characterized by sudden. jerky and irregular movements of the extremities. Memory impairment is a late findinEducational objective:Tick-borne paralysis is characterized by rapidly progressive ascending paralysis. absence of fever. absenceof sensory abnormalities and normal CSF examination.Meticulous search and removal of the tick usually result in improvement within an hour and complete recoveryafter several days.Educational objective:Fronto-temporal dementia is characterized by personality changes, compulsive behaviors, and impairedmemory.Dementia with Lewy bodies (DLB) is characterized by fluctuating cognitive impairment. Bizarre,visual hallucinations may occur. Parkinsonism may also occur, but there is a poor response to dopaminergicagonist therapy.Alzheimer's disease is a progressive dementia. Its associated risk factors are: age, femalegender, positive family history, head trauma, and Down's syndrome. The typical first symptoms are subtlememory loss, language difficulties and apraxia, followed by impaired judgment and personality changes. Thetreatment is specifically targeted towards the particular symptoms, but generally includes psychosocialintervention and pharmacotherapy with donepezil or tacrine.Educational objective:NPH is thought to result from decreased CSF absorption or transient increases in intracranial pressure thatcause permanent ventricular enlargement without chronically increasing intracranial pressure. It ischaracterized clinically by dementia. gait disturbances. and incontinence.The initial increase in ventricular size may be due to either diminished CSF absorption at thearachnoid villi or obstructive hydrocephalus.Educational objective:It is important to be able to differentiate between the different types of dementia. Dementia with Lewy bodiescauses alterations in alertness. visual hallucinations. and extrapyramidal symptoms.Lewy bodies are a pathologic finding also present in Parkinsons disease. The key distinction between thesetwo conditions is the early appearance of dementia in Lewy body disease and of motor symptoms inParkinsons disease.Educational objective:Pseudotumor cerebri or idiopathic intracranial hypertension (IIH) can present as an acute. subacute. orchronic headache with associated blurry vision or visual loss. papilledema. pulsatile tinnitus. abducens nervepalsy. nausea. and vomiting. Patients with IIH are typically young obese women. Certain medications.including vitamin A and oral contraceptive pills. can also lead to IIH. Brain MRI can show an empty sella andslit-like ventricles. Because IIH is a diagnosis of exclusion. head magnetic resonance venography is requiredto exclude cerebral venous sinus thrombosis as the cause of elevated opening pressure.

Papilledema is not acontraindication to an LP unless the patient has evidence of obstructive or noncommunicating hydrocephalusand/or a space-occupying lesion with/without mass effect or midline shift. Pseudotumor cerebri causes acommunicating hydrocephalus (i.e.. pressures in the ventricular and subarachnoid spaces are equilibratedwith the lumbar cistern); therefore. an LP is considered safe. The following criteria are used for the diagnosis of IIH:1 . Presence of features of increased intracranial pressure in an alert patient2. Absence of focal neurologic signs except for sixth nerve palsy3. Normal CSF examination except for increased CSF opening pressure4. Absence of any ventricular abnormality. other than reduction in ventricular size (slit-like ventricles). andother causes of increased intracranial pressure

Educational objective:HIV and hepatitis C infection should be suspected in patients with weight loss and history of intravenous drugabuse. Patients with HIV are at risk of developing depression and dementia.It would be reasonable to perform a CT or MRI of the head if this patient's serologic work-up isnegative or if he develops focal neurologic deficits.Educational objective:Lacunar strokes are due to microatheroma and lipohyalinosis in small penetrating arteries of the brain. Theyoften affect the internal capsule and result in pure motor dysfunction. Lacunes comprise 25% of ischemicstrokes. Hypertension and diabetes are two major risk factors.Educational Objective:Several well-designed clinical trials have proven that interieron-beta decreases the frequency of relapse. andreduces disability in patients with the relapsing-remitting form of MS.Educational Objective:Cauda equina syndrome is a serious neurologic disorder characterized by saddle anesthesia. bowel andbladder dysfunction. low back pain. and a variety of lower extremity findings. The cauda equina consists ofspinal nerves before they exit the spinal canal. The etiology of CES must be identified rapidly in order topreserve neurologic function.The cauda equina is particularly sensitive to damage because thenerves have a poorly developed epineurium.An emergent MRI of the spine must be obtained when entertaining a diagnosis ofCES. In this patient. he likely has CES due to prostate cancer or a reaction to radiation therapy.Educational objective:Normal pressure hydrocephalus is characterized by the triad of gait disturbance. dementia and urinaryincontinence. Lumbar puncture reveals the normal CSF pressures. and MRI shows the enlarged ventricles.Educational objective:Steroid-induced myopathy is a well-described result of chronic corticosteroid use characterized by painlessproximal muscle weakness. It will slowly improve once the offending medication is discontinued.Themechanism of steroid myopathy is thought to be due to decreased protein synthesis. mitochondrialalterations. increased protein degradation. and electrolyte and carbohydrate metabolism disturbances.For both acute and chronic forms. the diagnosis is clinical. with no definitive diagnostictest. Muscle power improves after discontinuation of the steroids. butthe improvement can take weeks tomonths.Educational objective:In heat stroke the temperature is usually above 40.5 C (105 F). Heat stroke results from an insufficientevaporative cooling mechanism. Therefore. treatment involves induction of evaporative cooling to reversehyperthermia.Other signs and symptoms of heat stroke mayinclude altered mental status. headache. dizziness. dry skin. hypotension. tachycardia and tachypnea.Hyperthermia may also induce systemic damage including rhabdomyolysis. acute renal failure. and DIC.Educational objective:If a patient presents within 4.5 hours after the onset of an ischemic stroke. thrombolytic therapy with tPA (afterCT scan) should be started. Many trials have demonstrated improved neurological outcomes with thisapproach.The use of streptokinase in stroke patients has not shown any benefits. The drug actuallyincreases the risk of bleeding. The FDA currently recommends only tPA in the management of strokepatients.

tRIGENMIANL Aplastic anemia can occur with prolonged use; therefore. routine CBC is included in the follow-upmanagement of such patients. When medication fails to control the pain. surgical gangliolysis or suboccipitalcraniectomy for decompression of the trigeminal nerve are options.

Educational Objective:Subdural hematoma results from the rupture of bridging veins. Epidural hematoma results from the rupture ofthe middle meningeal artery. Recognize the characteristic appearances of these hematomas on CT.The condition can also occur secondarily to minor trauma if the patient is onanticoagulation therapy. especially a combination of aspirin and Coumadin (warfarin).Bleeding occurs due tothe tearing of the bridging veins between the cortex and venous sinusesSOH is more common in the elderly and alcoholics.Educational Objective:MRI is the test of choice to support the clinical diagnosis of multiple sclerosis.The typical locations of the plaques are theperiventricular regions. corpus callosum. deep white matter and basal ganglia.fundoscopy is normal.central visual field defectEducational Objective:Suspect pseudodementia in elderly patients with dementia in the setting of severe depression.Antidepressants are the treatment of choice.Pseudodementia is reversible with the treatment of depression.using antidepressant medications such as SSRisAgood distinguishing factor to remember is that patients with pseudodementia seem significantly concernedabouttheir impaired memory; whereas. patients with Alzheimer's dementia seem relatively unconcerned.

ducational Objective:Expressive aphasia results from the lesions in dominant frontal lobe. Frontallobe also contains motor cortexwhose damage results in contralateral paresis.Sensory cortex is present in the parietal lobe and damage to sensory cortex results in contralateralhemianesthesia. Damage to dominant parietal lobe also results in dysgraphia. dyscalculia and right/leftconfusion. Damage to nondominant parietal lobe causes construction apraxia. contralateral sensory neglectand anosognosia.Posterior part of dominant frontal lobe contains motor speech area of Brocaand damage to this area results in expressive aphasia in which patient can't articulate speech or writenormally but can comprehend written and spoken language.

Educational Objective:Suspect Huntington's disease in a patient with mood disturbances, dementia, chorea and a family history ofsimilar symptoms.ducational objective:The classic symptom triad of normal pressure hydrocephalus (NPH) is abnormal gait. incontinence. anddementia. NPH is treated with large volume lumbar punctures and. if successful. ventriculoperitonealshunting.Educational Objective:Hypokalemia is a common electrolyte abnormality that causes weakness. fatigue. and muscle cramps.When severe. it can lead to paralysis and arrhythmia. The ECG may show U waves. flat and broad T waves.and premature ventricular beats.Stroke does not cause muscle pain and usually has focal findings. The presentation for anischemic stroke will depend on the location of the lesion.

CN Ill (oculomotor nerve) has the following functions:1. Its somatic component innervates the inferior. superior. and medial rectus. inferior oblique and levatorpalpebrae muscles. Ptosis occurs due to paralysis of the levator palpebrae; whereas. the unopposedaction of the lateral rectus (CN VI) and superior oblique (CN IV) muscles lead to a "down and out" gaze.2. Parasympathetic fibers of CN Ill innervate the sphincter of the iris and the ciliary muscle. Paralysis ofparasympathetic fibers causes a fixed. dilated pupil and causes an inability of the lens to changeshape (loss of accommodation).Educational Objective:Diabetic mononeuropathy often involves CN Ill. Nerve damage is ischemic. and only somatic nerve fibers areaffected. Parasympathetic fibers of CN Ill retain function. Ptosis and a "down and out" gaze in conjunctionwith normal light and accommodation reflexes indicate diabetic CN Ill neuropathy.Educational Objective:The absence of forehead furrows indicates peripheral facial nerve palsy and excludes central causes.Educational objective:Normal age-related cognitive changes include tiredness. occasional forgetfulness. occasional word findingdifficulty. and trouble falling asleep. Dementia cannot be diagnosed unless there are functional impairments.Educational Objective:Pregnancy testing should be performed in women of child-bearing age (high risk of being pregnant)before starting treatment with sumatriptan.The contraindications of triptans are as follows:1 . familial hemiplegic migraine2. uncontrolled hypertension3. coronary artery disease4. Prinzmetal angina5. pregnancy6. ischemic stroke7. basilar migraine

Educational Objective:Hemi-neglect syndrome is characterized by ignoring the left side of a space. and involves the right(non-dominant) parietal lobe.Educational Objective:The typical CT/MRI findings in high-grade astrocytoma are heterogenous and serpiginous contrastenhancement. Recognize the classic butterfly appearance of GBM.Patients with brain metastasis usually have a duration of symptoms of less than 2 months. Thesite of metastasis is the gray-white junction or watershed zones.Educational objective:Alzheimer's dementia is the most common type in the United States and is characterized by early memoryand visuospatial impairments. Gait impairment is the most prominent clinical features of NPH and appearsearly in its disease course.Subcortical and frontal features dominate the cognitive disturbance of NPH. Cortical features (e.g.aphasia. agnosia) are less common.Educational Objective:Acute vertigo (sensation of spinning of head) is often due to dysfunction of the labyrinth. Patients with BPPVhave vertigo related to head positioning. Global cerebral ischemia results in presyncope (lightheadednesswith visual blurring. not spinning) and syncope.Educational Objective:Riluzole is a glutamate inhibitor that is currently approved for use in patients with amyotrophic lateral sclerosis.Its side effects are dizziness, nausea, weight loss, elevated liver enzymes and skeletalweakness.Educational Objective:GBS can lead to respiratory muscle weakness and may occasionally result in respiratory failure. The bestway to monitor respiratory function in such cases is through serial measurements of bedside vital capacity.The risk for ventilatory failureincreases significantly when the VC falls below 15 mUkg. especially if there has been a clear downwardtrend. Educational Objective:Guillain-Barre syndrome is an acute or subacute ascending paralysis. CSF analysis reveals an elevatedprotein level with normal glucose levels, WBC, and RBC counts.Elevated WBC and RBC counts with normal protein and glucose levels can be seen with herpesencephalitis. Educational objective:Because the facial/ophthalmic venous system is valveless. uncontrolled infection of the skin can result incavernous sinus thrombosis. Red-flag symptoms include severe headache; bilateral periorbital edema; andcranial nerve Ill, IV, V, and VI deficits.Treatment includesbroad-spectrum intravenous antibiotics and prevention or reversal of cerebral herniation.As a result, unilateral symptoms (eg, headache, binocular palsies, periorbital edema, hypoesthesia, orhyperesthesia in V1N2 distribution) can rapidly become bilateral.Educational objective:Pronator drift is a relatively sensitive and specific physical exam finding for upper motor nerve damageaffecting the upper extremities. In particular, many patients with strokes will demonstrate pronator drift.Educational objective:Amaurosis fugax is the painless loss of vision from emboli, and is a warning sign for an impending stroke.Most emboli occur from the carotid bifurcation; hence, a duplex ultrasound of the neck should be performed.Cholesterol particles (Hollenhorst bodies)may be seen in the eye.Educational Objective:Suspect syringomyelia in a patient with areflexic weakness in the upper extremities and dissociatedanesthesia in a "cape" distribution. The presence of a cord cavity is the most characteristic feature. Caudaldisplacement of the fourth ventricle or cerebellar tonsils, and focal cord enlargement may occur.dissociated anesthesia (loss of pain and temperature with preserved position and vibration)Educational objective:A transient ischemic attack (TIA) is defined by focal neurologic symptoms lasting less than 24 hours due tocerebral ischemia. A head CT should always be obtained in patients with stroke symptoms to distinguishischemic from hemorrhagic etiologies. In patients with strokes or TIAs due to ischemia, if a thrombotic causeis suspected, an antiplatelet agent such as aspirin is used to prevent future events. Medications such aswarfarin are used to prevent future ischemic events due to cardiogenic emboli.

CONTROLLING HYPERTENTION IS THE SINGLE MOST IMPORTANT FACTOR IN PREVENTING STROKE.

Educational objective:The three cardinal signs of Parkinson disease are resttremor, rigidity, and bradykinesia. The presence of atleast two of these signs on physical examination is grounds for a clinical diagnosis of this disease.Educational objective:Always suspect lacunar stroke if a patient presents with a limited neurologic deficit. The typical lacunar strokescenarios are pure motor stroke, pure sensory stroke (thalamus), ataxic-hemiparesis, and dysarthria-clumsyhand syndrome. The principal cause of lacunar stroke is hypertension.Educational objective:An isolated, round, smooth-bordered, ring-enhancing intracranial lesion on contrast CT scan of the brain in animmunocompetent patient with a known extracranial bacterial infection is most likely a brain abscess. Aerobicand anaerobic streptococci and Bacteroides species (anaerobes) are the most common causativeorganisms.Educational objective:The most common site of hypertensive hemorrhages is the putamen (35%). The internal capsule that liesadjacent to the putamen is almost always involved, thereby leading to hemiparesis.The onset of symptoms is not abrupt as in subarachnoid hemorrhage or embolic stroke.Educational Objective:Amyotrophic lateral sclerosis (ALS) is characterized by the presence of both upper (spasticity, bulbarsymptoms, hyperreflexia) and lower (fasciculations) motor neuron lesions.Educational Objective:Herpes mainly affects the temporal lobe of the brain and may present acutely (