LO#1
A 45-year-old woman develops a sudden, severe headache while lifting a heavy box. She says it is "the worst headache of my life" and that it reached full intensity within 1 minute. What is the most likely diagnosis?
What is a subarachnoid hemorrhage (SAH)?
A 68-year-old man with hypertension and a carotid bruit has sudden, painless loss of vision in his right eye. He says it was "like a curtain coming down," and it went away after 10 minutes (hint - amaurosis fugax). Where is the lesion?
What is the right retina / right optic nerve (embolus from the right internal carotid artery)?
Name three functions that are characteristically preserved in alexia without agraphia.
Writing, spoken-language comprehension, and oral spelling
_______ may be seen in a healthy fundus and are typically lost early in papilledema; however, their absence alone is not diagnostic of raised intracranial pressure.
Spontaneous venous pulsations.
A 19-year-old college freshman living in a dorm has a headache, fever of 39.4°C, and neck stiffness. Exam shows a petechial rash on his legs (hint - gram-negative diplococci). What is the most likely diagnosis?
What is bacterial meningitis (Neisseria meningitidis)?
A 35-year-old woman keeps bumping into door frames on both sides. She also has milky nipple discharge and has not had a period in 6 months (hint - pituitary). Where is the lesion?
What is the optic chiasm, compressed by a pituitary adenoma (prolactinoma)?
A 60-year-old right-handed woman develops acute difficulty reading. Her speech is fluent, she comprehends spoken language normally, and she can write a grammatically correct sentence to dictation but she cannot read back what she has just written. Visual field testing shows a right homonymous hemianopia. MRI reveals an infarct in the left posterior cerebral artery territory. Which combination best explains her two major neurologic deficits?
Left occipital (primary visual) cortex damage: right homonymous hemianopia
Splenium of the corpus callosum damage: right visual cortex cannot send word-form information to the left-hemisphere language network: alexia
The left occipital lesion produces the right homonymous hemianopia and knocks out left visual cortex; the splenial lesion prevents visual word-form information from the intact right occipital cortex from crossing to the left-hemisphere language zone, giving pure alexia with spared writing.
Name three functions that are characteristically normal early in papilledema.
Visual acuity, color vision, and pupillary responses.
A 72-year-old woman has a new headache over her right temple for 3 weeks. She has pain in her jaw when chewing and tenderness of the scalp. ESR is 95 mm/h (hint - jaw claudication). What is the most likely diagnosis?
What is giant cell (temporal) arteritis?
A 70-year-old man with atrial fibrillation suddenly cannot see things on his left side in either eye. His central vision is preserved. Which artery is occluded?
What is the right posterior cerebral artery (right occipital lobe infarct)?
Writing is fully preserved in this patient. Which pathway best accounts for her retained ability to write?
A. Right occipital cortex → splenium → left angular gyrus → hand
B. Visual word form area → left primary visual cortex → corticospinal tract → hand
C. Left-hemisphere language representation → left inferior parietal cortex → premotor cortex → primary sensorimotor hand cortex → corticospinal tract → hand
D. Left lateral geniculate nucleus → optic radiation → occipital cortex → hand
E. Cerebellum → red nucleus → spinal cord → hand
What is C? Writing originates as a linguistic representation in the intact left-hemisphere language network and flows forward to premotor cortex and the corticospinal tract, a motor-output route that needs no visual input and does not cross the damaged splenium, so writing survives while reading is lost.
All of the following are characteristic features of acute papilledema EXCEPT:
A. Blurring of the optic-disc margins
B. Obscuration of vessels as they cross the swollen disc margin
C. Peripapillary hemorrhages
D. Loss of spontaneous venous pulsations
E. A relative afferent pupillary defect with early loss of central visual acuity
E
A 58-year-old man with a history of lung cancer has headaches for 2 weeks. They are worst when he wakes up, get worse when he coughs or bends over, and come with vomiting. Fundoscopy shows bilateral papilledema (hint - space-occupying lesion). What is the most likely cause?
What is increased intracranial pressure from a brain metastasis?
A 30-year-old man has a left temporal lobectomy for epilepsy. Afterward, he cannot see the upper right part of the visual field in either eye (hint - "pie in the sky"). Which structure was damaged?
What is the left Meyer loop (inferior optic radiations in the temporal lobe)?
Printed words are first processed in the primary visual cortex, then relayed to the ____, located in the ______, before being passed onward to the _____ and perisylvian language network for lexical and semantic processing
Visual word form area (VWFA)
left inferior temporo-occipital (fusiform) region
angular gyrus
A 21-year-old woman presents with a 2-month history of gradually worsening headache and bilateral vision loss. Funduscopic examination is shown. List all abnormalities in this photograph attributable to raised intracranial pressure.
Abnormalities of papilledema to identify:
Mechanical (disc) signs
Blurring/indistinct disc margins
Elevation/swelling of the optic disc with loss of the physiologic cup
Edema of the peripapillary retinal nerve fiber layer (with retinal/choroidal folds in severe cases)
Vascular signs:
Disc hyperemia
Venous dilatation and tortuosity or engorgement
Peripapillary splinter/flame hemorrhages
Cotton-wool spots (nerve-fiber-layer infarcts)
Which of the following patients has a red-flag feature that needs urgent workup?
A. A 30-year-old woman with a bilateral, band-like headache that gets worse with stress at work
B. A 25-year-old woman with a one-sided throbbing headache, light sensitivity, and zigzag lines before it starts; she has had the same headaches since high school
C. A 34-year-old man with HIV (CD4 count 80) who has a new headache, fever, and confusion
D. A 40-year-old man with stabbing pain behind one eye, tearing, and a runny nose, at the same time every night for 2 weeks
E. A 28-year-old woman with a dull headache on the weekend that goes away after her morning coffee
What is C?
1. Complete loss of vision in the right eye only
2. Loss of both temporal fields
3. Left homonymous hemianopia, no macular sparing
4. Right upper quadrant loss in both eyes
5. Left lower quadrant loss in both eyes
A. Right optic tract
B. Left temporal lobe (Meyer loop)
C. Optic chiasm
D. Right optic nerve
E. Right parietal lobe (dorsal optic radiations)
What is 1-D, 2-C, 3-A, 4-B, 5-E?
A right-handed woman has intact primary visual cortex and an intact splenium of the corpus callosum. She speaks fluently, comprehends spoken language normally, and writes a grammatically correct sentence on request. However, she can no longer recognize familiar written words at a glance and instead reads them slowly, one letter at a time, with reading time increasing as words get longer. Name the cortical region most likely damaged, and give its anatomical location
Left visual word form area (VWFA), in the posterior ventral occipitotemporal (fusiform) cortex
A 29-year-old obese woman comes to the emergency department with a 3-week history of worsening headaches and transient episodes of visual dimming lasting seconds, often when she stands or bends over. She also reports horizontal double vision. Blood pressure is 146/101 mm Hg. Visual acuity is 20/20 in both eyes with normal color vision, and the pupils are equal and briskly reactive. There is a right abduction deficit. Funduscopy shows bilateral optic disc edema with blurred margins. Humphrey 24-2 visual field testing is shown.
Humphrey visual field testing is shown below.
Which of the following best describes the visual-field abnormality in this patient?
A. Bitemporal hemianopia
B. Bilateral enlarged blind spots
C. Right homonymous hemianopia
D. Bilateral central scotomas
E. Superior altitudinal defect in the right eye
The plot shows dense defects temporal to fixation in each eye, which is enlargement of the physiologic blind spot - the most common field defect in papilledema/IIH, caused by peripapillary photoreceptor dysfunction from disc edema. This is why central acuity and color vision remain normal early