Stroke of Genius
A right-handed 68-year-old suddenly develops right facial droop, right arm weakness greater than leg weakness, and expressive aphasia.
Name the vascular territory.
Left MCA
A 37-year-old man develops excruciating unilateral orbital pain with lacrimation and nasal congestion. Attacks last about 45 minutes and occur nightly. During attacks, he paces around the room rather than lying down.
Diagnosis?
Cluster headache
Bonus for 100 points: Name TWO acute treatments.
Which finding MOST strongly favors generalized tonic-clonic seizure over syncope?
A) Brief jerking
B) Urinary incontinence
C) Lateral tongue biting
D) Lightheadedness beforehand
Lateral tongue biting
A patient wakes with complete unilateral facial weakness, including inability to wrinkle the forehead or close the eye. Extremity examination and speech are normal.
Diagnosis?
Bell palsy
A patient with severe low-back pain reports new tripping over the right foot and difficulty initiating urination. What diagnosis must be excluded emergently?
Cauda equina syndrome
Which is MOST suggestive of TIA?
A) Tingling marches up arm over 10 min
B) Zig-zag lines expand across vision
C) Abrupt painless monocular vision loss for 8 min
D) Staring followed by confusion
C) Abrupt transient monocular vision loss
Who can most reasonably leave WITHOUT neuroimaging?
A) 28yo, stereotyped migraine ×8 yrs, normal exam
B) 54yo, first new unilateral headache
C) 32yo, headache with coughing
D) 41yo, headache + papilledema
28yo, stereotyped migraine ×8 yrs, normal exam does NOT need imaging
A 24-year-old has an apparently unprovoked first generalized seizure. Exam and basic laboratory evaluation are normal. He has returned to baseline. What two outpatient tests should generally be obtained as soon as practical?
EEG + brain MRI using an epilepsy protocol.
Bilateral hand tremor while drinking from cup that improves with alcohol use.
Essential tremor
A patient with diabetes and recent S. aureus bacteremia develops severe focal thoracic back pain. Temperature today is normal, and there are no neurologic deficits.
Spinal epidural abscess
A 59-year-old presents 90 minutes after sudden isolated aphasia. He can move all four extremities normally. NIHSS is only 3. CT shows no hemorrhage. His BP is 168/94. What feature matters most when deciding whether IV thrombolysis should be considered?
2026 AHA/ASA guideline emphasizes rapid thrombolysis for eligible patients with disabling deficits within 4.5 hours regardless of NIHSS score.
Migraine patient now has headache 18 days/month. Which pattern most supports medication-overuse headache?
A) Naproxen 5 d/mo
B) Sumatriptan 12 d/mo ×4 months
C) Ubrogepant 4 d/mo
D) Acetaminophen 6 d/mo
Sumatriptan 12 days/month
Medication-overuse headache involves headache ≥15 days/month plus regular overuse for >3 months
Generalized convulsions have continued for 6 minutes. Someone says, “Status isn't until 30 minutes.” Your response?
Treat NOW: convulsive status is treated at 5 minutes → benzodiazepine.
Right leg spastic weakness + loss of vibration/proprioception in RIGHT leg + loss of pain/temperature in LEFT leg.
Where is the lesion?
Right hemicord — Brown-Séquard syndrome
A 67-year-old presents with fever, severe headache, neck stiffness, confusion, and a new focal neurologic deficit. You want CSF, but because of the focal deficit, you plan head imaging before LP.
What should happen to antibiotics while you wait for CT?
Do not delay empiric antibiotics. Obtain blood cultures promptly and start empiric therapy; give dexamethasone with/before the first antibiotic dose when indicated.
An otherwise eligible patient with disabling ischemic stroke presents at 2 hours. BP is 194/116 mmHg. What BP must be achieved before IV thrombolysis?
Before IV thrombolysis: <185/110.
After IV thrombolysis: maintain <180/105.
A neurologically intact 46-year-old develops the “worst headache of my life,” reaching maximum intensity within seconds. Noncontrast head CT is negative. The CT was obtained 12 hours after symptom onset. What diagnosis remains dangerous enough that further evaluation is required?
Subarachnoid hemorrhage
Adequate IV lorazepam given; patient continues seizing. Best statement?
Fosphenytoin, valproate OR levetiracetam are reasonable
A 42-year-old develops intermittent diplopia and ptosis. She is strongest in the morning and worse by evening. Pupils are normal. Sensation is normal.
Diagnosis
Myasthenia gravis
Bonus for 100 points: a drug that can exacerbate symptoms
One week after diarrhea: symmetric ascending weakness + areflexia. Suspect GBS. Which is NOT effective?
A) IVIG
B) Plasma exchange
C) Corticosteroids
D) Respiratory monitoring
Corticosteroids
SPOT THE OUTDATED STATEMENT:
A) Alteplase acceptable within conventional window
B) Tenecteplase acceptable
C) Selected large-core strokes may benefit from EVT
D) Selected basilar occlusions may benefit from EVT
E) Tenecteplase is recommended only when thrombectomy is planned
Tenecteplase is recommended only when thrombectomy is planned
Ten days after an uncomplicated vaginal delivery, a 31-year-old develops progressive headache followed by a focal seizure. BP is 126/78. CT head is unrevealing. Examination now shows mild right arm weakness. What vascular diagnosis should jump high on your differential, and what imaging specifically evaluates it?
Cerebral venous thrombosis → CTV or MRV
A 26-year-old with epilepsy wants pregnancy within the next year. She has been seizure-free on valproate. She asks whether she should stop it tonight because she heard it causes birth defects.
Do NOT abruptly stop effective antiseizure therapy; optimize the regimen preconception, avoiding valproate when clinically feasible and choosing a safer effective alternative (lamotrigine/levetiracetam/oxcarbazepine).
A 76-year-old has progressively slowed walking with short, shuffling “magnetic” steps. Family reports urinary urgency/incontinence and cognitive decline. Strength is preserved. MRI shows ventriculomegaly out of proportion to cortical atrophy.
Large-volume lumbar puncture
A healthy 38-year-old develops sudden unilateral neck/head pain after vigorous activity. Examination shows mild ipsilateral ptosis and miosis without obvious anhidrosis. No weakness is present.
What diagnosis must be urgently excluded?
Internal carotid artery dissection