Neurology

A 69-year-old man with atrial fibrillation (not anticoagulated) develops sudden right arm weakness and aphasia 45 minutes ago. BP 168/96 mmHg, glucose 120 mg/dL, NIHSS 12. Non-contrast head CT shows no hemorrhage.

A 58-year-old woman with sudden “worst headache of my life” during exertion collapses. CT head within 2 hours shows diffuse hyperdensities in basal cisterns.

A 72-year-old man with long-standing hypertension has acute left facial droop sparing the forehead and left arm weakness. CT head: right basal ganglia hemorrhage; BP 210/110.

A 33-year-old woman has monocular painful vision loss with decreased color vision; afferent pupillary defect; MRI brain shows periventricular ovoid T2 lesions.

A 24-year-old man with fever, headache, confusion, and focal seizures. CSF: lymphocytic pleocytosis, normal glucose, elevated protein. MRI: temporal lobe hyperintensity.

A 64-year-old woman with TIA (amaurosis fugax lasting 10 minutes) has 75% right internal carotid stenosis. She is otherwise healthy.

A 42-year-old man has ascending weakness and areflexia 10 days after diarrhea. CSF: protein 140 mg/dL, 2 WBC/mm³. NIF and FVC declining.

A 55-year-old woman has fluctuating ptosis and diplopia that worsen by evening; chewing fatigue; ice pack test improves ptosis. AChR antibodies positive; chest CT shows anterior mediastinal mass.

A 30-year-old woman with episodic headaches, photophobia, and nausea has throbbing unilateral pain lasting 8–12 hours, triggered by menses. Neuro exam normal.

A 63-year-old smoker develops progressive gait instability, ataxia, and nystagmus; brain MRI unremarkable; anti-Hu antibodies positive; CT chest shows small cell lung cancer.

A 70-year-old diabetic man has sudden inability to get up from a chair; exam: proximal leg weakness, preserved reflexes, no sensory loss; CK normal; EMG shows decremental response.

A 27-year-old woman with focal seizures evolving to bilateral tonic–clonic. First event 2 weeks ago; normal neuro exam. MRI shows a left mesial temporal sclerosis.

A 45-year-old man has progressive memory loss and personality changes over 2 years; MRI shows marked hippocampal atrophy; MoCA 20/30.

A 76-year-old woman with headache and jaw claudication has ESR 88 mm/h, CRP high; temporal artery tender, vision blurring.

A 59-year-old man with HIV (CD4 70) presents with headache, fever, and confusion. CSF opening pressure very high; India ink positive.

A 29-year-old woman has acute back pain followed by bilateral leg weakness and urinary retention; sensory level at umbilicus; MRI: T6–T8 cord T2 hyperintensity.

A 50-year-old man with essential tremor has disabling action tremor of both hands, worse with stress; alcohol transiently improves symptoms.

A 68-year-old woman with shuffling gait, resting tremor, bradykinesia, and rigidity; early response to levodopa but motor fluctuations now prominent.

A 37-year-old man awakens with complete right facial paralysis including forehead; cannot close eye; no limb deficits; exam shows hyperacusis.

A 32-year-old woman develops severe unilateral orbital pain with ipsilateral lacrimation and nasal congestion nightly for 1–2 hours over 3 weeks.

A 26-year-old man has first unprovoked generalized tonic–clonic seizure. Exam normal; glucose and electrolytes normal; MRI and EEG pending.

A 73-year-old woman with progressive urinary incontinence, gait disturbance (“magnetic gait”), and cognitive slowing; MRI shows enlarged ventricles with normal sulci.

A 47-year-old man with neck pain radiating to the right arm, diminished triceps reflex, and weakness of wrist/finger extension; symptoms worsen with neck extension and rotation.

A 60-year-old alcoholic presents with confusion, ataxia, and ophthalmoplegia. He is hypoglycemic.

A 36-year-old woman has electric shock–like unilateral facial pain triggered by light touch, lasting seconds to minutes. MRI shows vascular loop near CN V.

A 71-year-old man with sudden back pain, fever, and progressive leg weakness; exam: bilateral hyperreflexia and sensory level. ESR elevated. MRI: epidural fluid collection compressing thoracic cord.

A 67-year-old woman with fluctuating cognition, visual hallucinations, and parkinsonism; marked sensitivity to antipsychotics.

A 21-year-old college student with fever, neck stiffness, photophobia, and petechial rash.

A 52-year-old woman has transient right arm weakness and aphasia resolving in 30 minutes. Diffusion MRI shows no infarct; ABCD² score is 6.

A 48-year-old man with poorly controlled diabetes has burning pain and numbness in a stocking–glove pattern; decreased vibration sense; reflexes reduced at ankles.

A 34-year-old woman with severe obesity presents with daily positional headaches, transient visual obscurations, and pulsatile tinnitus. Papilledema present; MRI/MRV normal.

A 59-year-old man has sudden painless monocular vision loss described as a “curtain” over the eye; afferent pupillary defect; carotid bruit present.

A 71-year-old woman with progressive spasticity, hyperreflexia, and muscle wasting of hands; fasciculations present; sensory exam normal.

A 29-year-old man after a knife injury has loss of pain and temperature on the left starting two levels below the lesion, weakness and proprioception loss on the right below the lesion.

A 62-year-old man with chronic liver disease becomes confused and agitated after hospitalization; attention fluctuates and he has asterixis.

A 56-year-old woman presents with progressive unilateral hearing loss and imbalance. MRI shows an extra-axial mass at the cerebellopontine angle extending into the internal auditory canal.

A 40-year-old man has severe low back pain radiating to both legs, urinary retention, saddle anesthesia, and decreased anal sphincter tone.

A 19-year-old student with recurrent brief (10–20 second) episodes of blank staring, eyelid flutter, and immediate resumption of activity; hyperventilation provokes an episode in clinic.

A 47-year-old right-handed woman develops hemiparesis and aphasia post-stroke; 6 weeks later she has new seizures. MRI shows chronic MCA infarct.

A 66-year-old man presents with progressive neck stiffness and difficulty relaxing his grip; exam shows cogwheel rigidity, bradykinesia, and masked facies. He develops hallucinations on higher levodopa doses.

A 27-year-old woman has painful eye movements and acute central vision loss in the right eye. MRI spine shows longitudinally extensive transverse myelitis (≥3 vertebral segments). AQP4-IgG is positive.

A 36-year-old woman with relapsing MS has new enhancing brain lesions despite interferon-β for 1 year. JCV antibody index is high.

A 58-year-old man with acute focal status epilepticus (ongoing right face and arm twitching) for 15 minutes. Airway intact.

A 29-year-old man develops neck pain and transient right Horner syndrome after minor trauma; hours later he has left arm weakness and aphasia.

A 33-year-old woman on OCPs presents with severe headache, papilledema, and focal seizures; MRI shows venous sinus thrombosis.

A 74-year-old man has lobar intracerebral hemorrhage without hypertension. MRI shows multiple cortical microbleeds.

A 19-year-old college student has first-time generalized tonic–clonic seizure after sleep deprivation. EEG shows 3–4 Hz generalized polyspike-and-wave; history of morning myoclonic jerks.

A 66-year-old woman has stepwise lacunar strokes; now with pure motor hemiparesis. MRI shows small deep infarcts; HbA1c 9.1%, BP 168/94.

A 31-year-old man has progressive distal weakness and foot drop since adolescence; high arches (pes cavus), hammer toes; family history positive.

A 52-year-old woman with long-standing diabetes develops mononeuritis multiplex with painful asymmetric sensorimotor deficits; ESR 78 mm/h; hepatitis B negative, hepatitis C positive with cryoglobulins.

A 7-month-old infant presents with constipation, poor feeding, ptosis, and descending symmetric weakness; no fever. Parents feed home-canned puree.

A 66-year-old man has rapidly progressive ascending weakness over 8 weeks, areflexia, and sensory loss; CSF protein elevated; EMG shows demyelination.

A 45-year-old woman has proximal muscle weakness and elevated CK; skin exam shows heliotrope rash and Gottron papules.

A 24-year-old man has headaches on ≥15 days/month; uses combination analgesics daily; improvement for hours then recurrence.

A 61-year-old woman has resting tremor, rigidity, bradykinesia plus early falls, vertical gaze palsy, and poor levodopa response.

A 59-year-old man with long-term antipsychotic use develops involuntary choreoathetoid orobuccal movements.

A 42-year-old woman complains of nocturnal burning discomfort in the legs with urge to move; ferritin 18 ng/mL.

A 22-year-old woman has headaches strictly side-locked with daily moderate pain, autonomic features, and striking complete response to indomethacin.

A 68-year-old man presents with subacute gait ataxia, confusion, and visual changes after starting immune checkpoint inhibitor therapy for melanoma. CSF: oligoclonal bands negative; MRI: multifocal T2 lesions without enhancement.

A 55-year-old woman with poorly controlled HIV (CD4 80) develops progressive asymmetric cognitive deficits and motor weakness; MRI shows nonenhancing multifocal white-matter lesions without mass effect.

A 50-year-old man has severe band-like back pain then bilateral loss of pain/temperature below T8 with preserved vibration/proprioception; flaccid weakness acutely.

A 26-year-old woman has new ptosis and bulbar weakness with dyspnea; she recently started ciprofloxacin. NIF −18 cmH₂O, VC 12 mL/kg.

A 38-year-old woman develops severe rigidity, hyperthermia, autonomic instability, and elevated CK after haloperidol dose increase.

A 41-year-old man with depression on MAOI and recent SSRI addition develops agitation, tremor, clonus, hyperreflexia, and hyperthermia.

A 60-year-old woman presents with rapidly progressive cognitive decline, myoclonus, and ataxia; MRI DWI cortical ribboning; CSF 14-3-3 protein positive.

A 45-year-old man has paroxysmal lancinating pain in the occipital scalp, triggered by neck movement; tenderness over greater occipital nerve.

A 72-year-old man with urinary urgency, gait unsteadiness, and hyperreflexia; MRI shows cervical cord compression from spondylosis.

A 55-year-old man with chronic alcoholism develops paresthesias, ataxia, and loss of vibration sense; macrocytosis present.

A 38-year-old woman with new-onset psychogenic nonepileptic spells (PNES) has thrashing movements, prolonged duration, eyes closed tightly, and variable responsiveness; EEG during event shows no ictal correlate.

A 49-year-old woman has thunderclap headache; CT head normal at 10 hours; LP shows xanthochromia.

A 62-year-old man has progressive asymmetric rigidity, limb apraxia, and alien limb phenomenon; poor levodopa response.

A 48-year-old man has subacute personality change, seizures, and memory impairment. CSF: lymphocytic pleocytosis; MRI: medial temporal hyperintensities; NMDA receptor antibodies negative; LGI1 antibodies positive.

A 70-year-old man on warfarin (INR 3.2) presents with ischemic stroke symptoms within 90 minutes. Noncontrast CT shows no bleed.

A 23-year-old postpartum woman has severe headache and focal deficits 1 week after emergency cesarean section; BP elevated; MRI shows posterior parieto-occipital vasogenic edema.

A 61-year-old man with progressive behavioral disinhibition, apathy, and loss of empathy; language relatively preserved; MRI shows frontal lobe atrophy.

A 35-year-old woman with chronic migraines becomes pregnant (8 weeks). She asks about acute and preventive therapy.

A 72-year-old man has acute painless third-nerve palsy sparing the pupil; history of diabetes and hypertension.

A 28-year-old man with HIV (CD4 40) presents with fever, headaches, and focal deficits. MRI shows multiple ring-enhancing lesions with edema in basal ganglia.

A 67-year-old woman develops acute vertigo, nystagmus, and inability to sit without support; head impulse test is normal (catch-up saccade absent).

A 59-year-old man with new daily persistent headache and morning worsening has progressive personality changes; MRI shows ring-enhancing frontal mass with central necrosis and edema.

A 59-year-old man with atrial fibrillation on apixaban develops sudden left hemiplegia and neglect 70 minutes ago. BP 176/98 mmHg. CT head shows no hemorrhage; CTA shows right proximal M1 occlusion. INR 1.1.

A 72-year-old woman with sudden vertigo, diplopia, dysarthria, and ataxia presents 3 hours after onset. HINTS exam suggests central lesion; CT head is normal.

A 67-year-old man on warfarin (INR 3.0) has a 4-cm lobar intracerebral hemorrhage with mild mass effect. He is somnolent but arousable, BP 168/92 mmHg.

A 29-year-old man has generalized convulsive status epilepticus for 8 minutes on EMS arrival. After lorazepam, seizures persist.

A 63-year-old woman with metastatic breast cancer has progressive mid-back pain, leg weakness, and urinary retention. Exam: hyperreflexia, Babinski signs.

A 36-year-old woman with relapsing MS becomes pregnant unexpectedly (8 weeks). She was on fingolimod.

A 58-year-old man develops acute painful unilateral vision loss with red eye and headache. Exam: mid-dilated fixed pupil, corneal haze, very high IOP.

A 25-year-old woman has new right hemiparesis and aphasia 1 day after receiving alteplase for left MCA stroke; CT shows hemorrhagic transformation in the infarct bed.

A 41-year-old man with longstanding poorly controlled diabetes has an acute foot drop after crossing his legs for hours; weakness of ankle dorsiflexion and toe extension; sensation over dorsum of foot reduced.

A 52-year-old woman has severe unilateral orbital pain with tearing and nasal congestion lasting 20–40 minutes, 3–4 attacks/day for 2 weeks; she had identical 2-week bouts every few months with no nocturnal pattern. Indomethacin abolishes attacks.

A 68-year-old man develops acute confusion and agitation postoperatively the night of surgery. He is inattentive with fluctuating course; neuro exam otherwise nonfocal.

A 74-year-old woman with progressive symmetric distal numbness and burning pain; exam shows loss of ankle reflexes and decreased vibration in toes. A1c 10.1%. B12 normal; TSH normal.

A 45-year-old woman has recurrent severe migraine lasting >72 hours with intractable nausea/vomiting despite outpatient triptan and NSAID. Neuro exam is normal.

A 33-year-old man is declared brain-dead after catastrophic SAH. Family asks about the basis of diagnosis.

A 62-year-old woman with thunderclap headache from aneurysmal SAH is day 6 post-coiling. She develops new left hemiparesis and aphasia; CT shows no new bleed.