A 22-year-old male presents after a construction accident. Emergency medical services (EMS) reports there was a crane malfunction, and the patient was hit with a metal bar. Upon arrival, the patient has a Glasgow coma scale of 6, an initial pulse of 102 beats per minute, a blood pressure of 84/48 mm Hg, and an oxygen saturation of 92%. The patient is intubated for airway protection with cervical stabilization. The rest of the primary survey shows no abnormalities. Extended Focused Assessment With Sonography for Trauma. (EFAST) is negative. What is the next most appropriate step in management prior to computed tomography (CT) imaging?

A 30-year-old male patient presents with complaints of unremitting headaches, dysphagia, shoulder pain, neck pain, stiffness, and weakness. He complains that the pains keep him up at night, and he occasionally has night sweats. On physical examination, the patient appears cachectic, with a BMI of 17.9. On auscultation of the carotid arteries, no bruits are appreciated. On imaging, a mass appears to be occluding an area on the base of the skull lateral to the foramen magnum. What is the likely location of this patient's lesion?

A 65-year-old male patient was diagnosed with tubercular spine disease and associated Frankel type D neurologic deficit six weeks ago. He was started on first-line anti-tuberculosis treatment (ATT). His image-guided biopsy revealed the growth of tubercle bacilli and good sensitivity to first-line ATT. His ESR and CRP have demonstrated an overall downward trend, and his back pain, as well as neurological status, have considerably improved. However, his MRI has shown a significant increase in the size of his abscess since the inception of chemotherapy. What is the appropriate next line of management?

A 65-year-old man presents with complaints of painless visual blurring, which has happened twice in the last day. He has a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a 30 pack-year smoking history, drinks alcohol occasionally, and has never used illicit drugs. He mentions that one day earlier, he lost his speech for a few minutes. On examination, it is determined that he has again lost vision in his left eye. What is the most appropriate next step in the management of this patient?

An 87-year old female with a history of osteoporosis sustains a ground level fall. She complains only of lower back pain. She is taken to the local hospital where a physical examination reveals only focal tenderness to the lumbar spine and no evidence of neurological deficits. Advanced imaging reveals a spinal fracture of L2 that involves only the anterior 1/2 of the vertebral body. What type of fracture is this according to the Denis classification?

A 65-year-old female was brought to the neurology clinic following sudden onset dropping of her bilateral eyelids. She has no such previous episodes. On examination, she was conscious, oriented, and had no weakness or ophthalmoplegia. However, her left pupil was dilated, and the horizontal pursuit and saccadic eye movements were affected. An urgent MRI brain was advised. Based on the clinical scenario, MRI is most likely to reveal stroke at which region?

A patient has edema and a dilated cardiomyopathy due to a dietary deficiency. What is the most likely etiology?

A 36-years-old female presents to the hospital for back pain and fever. Symptoms started four days ago and are getting progressively worse. She was seen in an urgent care center and was given pain medication and antibiotics with no improvement. She had a skin infection some three weeks ago that lasted a few days but disappeared without treatment. Otherwise, she is healthy and takes no medication. Physical exam shows enderness over the thoracic spine, numbness in both thighs and low-grade fever. Her blood count shows leukocytosis. Blood cultures are drawn. The emergency department does not have the capability for emergency MRI. Which of the following is the next best step in the management of this patient?

A 16-year-old girl who has undergone ventriculoperitoneal shunting for aqueductal stenosis 12 years ago was brought in with a history of high-grade fever, persistent vomiting, and altered sensorium. The child was drowsy with a withdrawal motor response to a painful stimulus. She had neck rigidity as well. A shunt infection was diagnosed. What would be the most rational management strategy in this case

A 47-year-old female presents to a pain clinic following the acute onset of severe neck pain radiating to her left arm for the last four days. MRI spine revealed severe left foraminal stenosis following a disc prolapse at the C5-C6 level. The pain has been refractory to pain medications. The treating clinician plans cervical traction therapy for the patient. The patient has a history of heavy smoking and is on bronchodilators for chronic obstructive pulmonary disease. There is no history suggestive of exertional dyspnea or orthopnoea. Which of the following modes of traction is most appropriate for this patient?

A 3-month-old male arrives with a sacral dimple in the midline and peripheral darkened, coarse black hair surrounding the dimple. The only notable finding on the exam is that the child's left calf is approximately 6 millimeters smaller than his right calf. Which of the following is the next best step in the management of this patient?

A 58-year-old male presents with complaints of homonymous hemianopsia of his left visual field and headaches for the past 2 months. MRI of the brain shows a lesion of the right occipital lobe, and glioma is suspected. Surgery for the resection of the tumor in the occipital lobe is planned. Which of the following is an important anatomical reference of approach from the medial surface of the occipital lobe?

A 55-year-old woman is seen after a basilar artery stroke. She has had symptomatic carotid artery stenosis for the past year and has refused to see a surgeon for correction during that time. Imaging shows a persistent, right-sided primitive artery branching proximally to the carotid canal and entering the cranium via an opening directly posterior to the carotid canal. As it enters the cranium, it terminates at the basilar artery, forming an anastomosis. This is the suspected cause of the stroke in this patient, and a surgeon plans for correction. The procedural plan is to approach through a major vessel and tie off the anomalous artery just before it enters the cranium. The surgeon makes note of the nearby structures and proceeds. The procedure is successful; however, on postoperative examination, the patient has developed dysphagia and notes numbness in her throat. Which foramen was accessed during the procedure, and which nerve was most likely injured?

A 28-year-old woman with a past medical history of Chiari malformation undergoes posterior fossa decompression in the sitting position. After the procedure, she develops new-onset leftsided facial droop and right-sided weakness. What is the most appropriate treatment for this patient's condition?

A 67-year-old African American male with metastatic rectal cancer was referred to the interventional pain physician by the oncologist because of intractable back pain. His pain is 10/10 on a high dose of fentanyl patch and oral extended release morphine. Subarachnoid neurolysis was planned. Which of the following is correct?

A 42-year-old female presents with low intermittent back pain for 6 months which worsens as she bends to pull weeds in her garden. The pain improves when she reclines in her recliner. A plain film x-ray of the lumbar spine is reported as showing "mild grade I spondylolisthesis without significant change between flexion or extension and without other significant abnormalities." What is the probability that she will fail conservative therapy and require surgical treatment?

A 44-year-old male presents with complaints of weakness in both hands that have gradually developed over the last three months. Additionally, he has mild swallowing difficulty and occasional speech slurring. On physical examination, there is marked atrophy of intrinsic hand muscles with diffusely hyperactive deep tendon reflexes and positive Babinski reflex. An electromyogram (EMG) and nerve conduction study (NCS) are ordered. These tests will most likely show which of the following?

A 24-year-old professional gymnast with no past medical history presents with lower back pain that has been present for 3 months. The patient states the pain is exacerbated when he extends his spine. Upon physical examination, placing the patient into lumbar extension exacerbates his pain. Lateral lumbar x-ray shows anterior displacement of L4 in correlation to L5. What is the most common cause of this finding?

A 25-year-old male suffers from a transient inability to perform calculations and write. After resolution, he has no residual problems. He has no other neurological disorders. Which of the following tests should be performed in this patient?

A 16-year-old girl is involved in a serious motorcycle accident. The patient exhibits a fracture-dislocation of a vertebra. The signs and symptoms include (1) bilateral loss of pain and thermal sense within the area of the fracture, (2) lower motor neuron symptoms and vasomotor paralysis in areas supplied by the injured segments on the right side, (3) loss of sensory impulses in the posterior white columns below the lesion on the right side, and (4) upper motor neuron lesion below the level of injury on the right side. The symptoms described are most suggestive of which of the following?

A 28-year-old G2P1 woman notes that fetal movements were less during this pregnancy than in prior pregnancies. At birth, the infant is floppy and has very feeble arm and leg movements. The infant cannot feed, has difficulty breathing, and has a weak cry. What is the most likely diagnosis?

A 35-year-old male patient presented with chronic, daily headaches localized to the occipital area and radiating to shoulders bilaterally. Symptoms are not responsive to analgesic medications. He reports occasional gait instability and episodes of dizziness. MRI of the brain and spine showed Chiari malformation type 2. The patient undergoes foramen magnum decompression. At the four-week follow-up visit, the patient reports left-sided shoulder weakness with dropping of the left shoulder and winging of the scapula. There is also some loss of shoulder abduction. What could be the cause of this impairment?

A 25-year-old woman admitted to the hospital suffering from pain in the pectoral and axillary region, weakness and muscle loss at the base of the thumb. An x-ray result shows that the patient has a cervical rib. What is the most likely cause of these symptoms?

A 55-year-old male with altered cognition and right-sided weakness was diagnosed with primary angiitis of the central nervous system (PACNS) following cerebral angiography and stereotactic biopsy. He was promptly started on combination therapy with oral prednisone and cyclophosphamide. During the follow-up visit, the patient had no resolution of prior symptoms and was noted to have developed new-onset blurring of vision, which was also determined to be secondary to PACNS. Which of the following is the next best step in the management of this patient?

A 45-year-old male from Colombia has a brain magnetic resonance image (MRI) performed for evaluation of chronic headaches with findings of multiple brain lesions. The lesions show are consistent with vascular lesions on susceptibility-weighted imaging (SWI) with a "popcorn" like appearance. Which of the following advice should be given to his son and daughter?

A 35-year-old man presents to the clinic for follow-up. He has presented to the emergency department twice over the past two months with recurrent episodes of left hemiparesis and left homonymous hemianopia which resolved spontaneously. His head CT and subsequent MRI showed a right deep hemisphere infarction. Subsequent CT angiogram showed complete occlusion of his right terminal internal carotid artery with a mesh of distal collaterals. His right internal carotid and middle cerebral arteries were normal. The patient has no history of hypertension, diabetes, or hyperlipidemia. He does not smoke. He does have a history of craniopharyngioma, which was resected when he was a child with good recovery. What is the next best test to determine the efficacy of treatment for him to prevent subsequent ischemic events?

A 72 -year-old male underwent coronary artery bypass grafting. Post-operatively he is diagnosed with ventral cord syndrome at the T6-T7 level on an MRI. What findings will a neurological exam likely show?

Midway through surgery, a patient's somatosensory evoked potentials (SEPs) have been stable and consistent. However, over the course of a few minutes, the amplitude drops to 40% of baseline, and the latency increases by 15%. It is thought to be most likely due to drops in the patient's temperature. Which measure would be most effective in reversing the observed SEP changes?

A patient presents with sudden loss of vision in his right eye that lasted 45 seconds. He also felt weakness in his left arm at the same time, but the symptoms improved rapidly. He is on metoprolol, aspirin, and atorvastatin. Work up reveals a bruit in the neck and a duplex ultrasound reveals 90% stenosis at the right carotid artery bifurcation. However, because of ongoing chest pain, it is decided to stent the lesion. It is decided to perform the carotid artery stenting under intravenous sedation. After the introduction of the lead wire into the neck, an anti-embolic protection device is inserted before angioplasty and stent deployment. Once the stent is applied, the physician is unable to retrieve the anti-embolic device. What should be the next step?

A 35-year-old male patient is undergoing endoscopic thoracic sympathectomy for benign paraganglioma near T2 of his spine. Sectioning of the rami communicantes between the sympathetic trunk and spinal nerve of T2 would result in which of the following?

A 75-year-old with a history of berry aneurysms presents to the ED because of the sudden onset of diplopia. On examination, there is a lack of ability of the right eye to adduct in the primary position (looking straight ahead). All other extraocular eye movements are normal. What would you expect to find if you performed a swinging flash light test on this patient?

A 72-year-old female with a known diagnosis of obesity hypoventilation syndrome presented to the sleep clinic with complaints of progressively worsening nocturnal choking episodes, despite using continuous positive airway pressure (CPAP). The PaCO2 and pulse oximetry levels obtained in the clinic were 40 mmHg and 80%, respectively. What should be the ideal therapeutic option for this patient at this time?

A 72-year-old white man with prostate cancer treated ten years ago with resection presents with the complaint of double vision and not being able to completely open the eyelid on the right side over the past two months. The patient denies any other focal weakness, sensory loss, difficulty breathing, eating, or coughing. Vitals are normal. The neurological exam showed restriction of right eye abduction and right side ptosis with miosis. The fundal exam is unremarkable. Miosis is not changed after cocaine eye drop to the right eye, but the left eye dilated. Basic serum blood workup and CT head are unremarkable. Which of the following structures are involved in having these symptoms?

A 20-year-old college student from Illinois was admitted for chronic headaches for the past 4 months. She has no travel history or occupational exposure to toxins or infectious agents. Her vital signs are stable. The physical exam is remarkable for lymphadenopathy, erythema nodosum, ataxia, and right facial droop without facial sparing. An MRI with gadolinium shows abnormal signal intensities in the cerebellum and brainstem. A lumbar puncture reveals elevated protein and mild pleocytosis. If a lymph node biopsy is done, what is the most likely histopathology that would be seen?

A 32-year-old female has been experiencing visual deficits over the last week. She reports that she does not believe her family history includes any major eye conditions. Her extraocular muscle function, intraocular pressure, fundoscopy results, and pupillary reflex are normal. During a confrontation visual field test, the patient demonstrates a wedge-shaped, right homonymous hemianopsia. Which of the following arteries would most likely be obstructed?

A 19-year-old male is brought to the trauma bay after being found by his roommate shortly after a suicide attempt by hanging himself in their dorm room. On arrival, the patient is hemodynamically stable and neurologically intact. He is placed in a rigid cervical collar in transport, and he is taken to the CT scanner on arrival. A non-displaced bilateral C2 pars interarticularis fracture with less than 3 mm subluxation of C2 on C3 is reported by the radiologist. The family asks about the prognosis of his injury and plan of care. What is the most appropriate response?

A 46-year-old man presents to the clinic after being referred by his palliative medicine specialist. The patient has a history of metastatic lung cancer with debilitating pain severely impacting his quality of life. Despite aggressive medical management and pain specialist intervention, his pain persists, and he reports that he is starting to experience thoughts of suicidal ideation because of his discomfort. The patient requests to be provided with information about a well-known invasive surgical procedure, which is often performed in patients with cancer with refractory somatic pain. Which of the following is the most common complication leading to mortality in patients that undergo this procedure?

A 49-year-old male presents for an initial consultation having been referred by her primary care provider for low back and bilateral radicular pain present for the past 4 months. His left sided leg pain has responded to formal physical therapy but his right sided leg pain has now worsened. A trial of NSAIDs did not alleviate his pain. He now also notices some difficulty in maintaining a normal gait for long distances. His physical exam is unremarkable except for 4/5 strength in plantarflexion of the right ankle and some subjective numbness on the dorsum of the foot. Flexion and extension standing plain films do not demonstrate any instability or listhesis. An MRI is obtained which demonstrates a left-sided far lateral disc herniation at L5/S1 as well as a right sided paracentral disc herniation at L5/S1. What is the best next step in the management of this patient?

A 54-year-old female with past medical history significant for polycystic kidney disease presents to the emergency department by ambulance after developing sudden onset severe headache and neck stiffness that started 2 hours ago. On exam, the patient is awake and alert but uncomfortable due to pain. She is noted to have a Cranial nerve III palsy on the left but otherwise normal neurologic exam. Vitals are blood pressure 170/106 mmHg, pulse 100 bpm, temperature 97.6 F, respiratory rate 18/minute, oxygen saturation 100% on room air. CT scan reveals subarachnoid hemorrhage. Based on the Hunt and Hess classification system, what grade of subarachnoid hemorrhage does this patient have?

Which class of medication is indicated for the treatment of moderate to severe pain, but caution must be exercised in using them to treat post-craniotomy headaches secondary to their addictive potential, ability to cause respiratory depression, and capability of obscuring neurologic responses?

A 45-year-old patient presents to the office complaining of low back pain after heavy work on his farm. No acute trauma is reported. He does, however, state that he used to wrestle when he was young and has suffered from low back pain since high school. The patient does not report leg pain. Anterior-posterior and lateral lumbosacral X-rays reveal a Mayerding grade III spondylolisthesis at L5-S1. A lateral X-ray shows a lucency in the region of the pars interarticularis with signs of sclerosis in the borders of the defect. Which type of spondylolisthesis is the most probable type, according to Wiltse?

A 24-year-old patient was planned for operative management to remove a large intraventricular tumor with evolving obstructive hydrocephalus. Following the opening of the dura, the brain was tight, and slowly the brain started mushrooming out of the craniotomy site despite the administration of mannitol. What would be the next best step in managing this intraoperative issue?

A 78-year-old female presents to the emergency department after waking up in the morning with severe midback pain. She denies any trauma. She lives alone. On clinical examination, she is obese with a BMI of 42 and has mid-thoracic midline tenderness but is neurologically intact. A CT scan of her thoracic and lumbar spine demonstrates a fracture at T8 with a 50% loss of the anterior vertebral body with no extension in the posterior columns. There is no kyphosis or any canal compromise. The patient has persistent pain refractory to intravenous analgesics and hampering her daily activities. Which is the most reasonable next step in managing this patient?

A 57-year-old male with a past medical history significant for diabetes and chronic sinusitis is scheduled for a sphenopalatine ganglion radiofrequency ablation utilizing the infra zygomatic approach. After the radiofrequency (RFA) needle is placed in the final position, stimulation confirms proper needle positioning. On injection of a local anesthetic to anesthetize the ablation area the patient complains of liquid running into the back of his throat. What step(s) should the interventionalist take at this point?

A 17-year-old male is brought into the emergency department by paramedics after jumping off a two-story building. When found, he was unresponsive on a cement parking lot. On arrival to the emergency department, the Glasgow coma scale is 6 and the patient is immediately intubated for airway protection. On initial evaluation, there is a large area of ecchymosis behind his right ear. Which of the following sets of vital signs indicates impending brain herniation?

A 69-year-old male presents with a right hemispheric cerebral stroke. Ultrasound reveals a 90% carotid bulb stenosis. He has also had a myocardial infarction three weeks before experiencing this stroke and has a history of oxygen-dependent chronic obstructive pulmonary disease. CT scan of the chest reveals a type 3 aortic arch and severe aortic calcifications. He is recovering as expected from his stroke. What is the next best intervention?

A 27-year-old man is brought to the emergency department unconscious by ambulance after being struck by a motor vehicle while riding a bicycle. Computed tomography demonstrates a temporal bone fracture. Upon awakening, the patient is noted to have ipsilateral complete hemifacial paralysis. What is the best next step in the management of this patient?

A 62-year-old female is treated with a ventriculoperitoneal shunt for hydrocephalus. One month later, she presents with a headache, unsteadiness, and fever. She attends the emergency department and discusses the case with the on-call neurosurgical team. Following a normal set of labs, including inflammatory markers and CBC, a shunt tap is performed, and a plain CT head and shunt radiographs are requested. Which of the following is the most accurate statement about the patient's condition?

Which of the following is a rare complication in a patient with autosomal dominant polycystic kidney disease?

Following a traumatic injury to the lower arm, a patient is diagnosed with stage two peripheral nerve injury (Axonotmesis). Which of the following is true?

A 6-year-old male is brought to the clinic for evaluation. The patient has been developing progressive scoliosis. MR imaging is notable for a thoracolumbar syrinx with a low lying conus medullaris and fatty filum. Surgical correction options are discussed. Which of the following are potential risks that the patient's physician would discuss with them that could result from surgery?

A 51-year-old man is admitted to the hospital for severe traumatic brain injury. The patient is found unresponsive 48 hours after admission. Physical examination shows loss of brain stem reflexes. An apnea test is aborted because the patient develops hypoxia. A decision is made to perform an EEG to confirm brain death. Which of the following best helps decrease the likelihood of a false-positive test?

A 74-year-old man comes into your office complaining of constant low back pain. He has a history of a previous spinal fusion at T12/L1. Which of the following parameters would lead you to suspect sagittal imbalance as the cause of the pain in the patient?

A 64-year-old patient with alcohol use disorder lives alone and is admitted for a left leg wound that has failed to heal. He is edentulous, has multiple ecchymoses, minute hemorrhages around hair follicles, and splinter hemorrhages in the nail beds. What should be given to the patient?

A 70- year-old male patient presents to the emergency department with recurrent dizziness and fall incidents. Right carotid auscultation revealed moderately to severe bruit. Doppler sonography elucidated 80% stenosis with peak systolic velocity: 300 cm/sec in the right internal carotid artery. What is the preferred next step in the management of the patient?

A 59-year-old female with a history of an indirect carotid cavernous fistula presents to the emergency department for worsening ocular pain and vision loss. The patient had two prior unsuccessful attempts at transvenous embolization due to increased tortuosity of the vessels. Which of the following is the most appropriate intervention for this patient?

You are consulted for management of a 63-yearold female who has been admitted for signs and symptoms suspicious of vertebral osteomyelitis. Initial blood cultures are negative, and the patient has no signs of sepsis or neurologic impairment. What are your initial recommendations regarding antibiotic therapy in the patient?

A patient has been complaining of decreased sensation in the lower extremities. Laboratory studies reveal a hemoglobin 9.8 g/dL, hematocrit 33.2%, and MCV 125 fL. Microscopic examination of peripheral blood smear shows red blood cells with macrocytosis and neutrophils with hypersegmentation of nuclei. Which of the following is the most likely deficiency?

A 17-year-old Asian male recently stopped playing guitar because of "poor playing," as reported by his band. He also reports difficulty to button, typing, and texting with his right hand. He comes to the office with right-hand thenar eminence atrophy, decreased grip strength, and decreased fine motor and object manipulation in the right hand. The power of his wrist extension is 3/5, and his supinator reflex is 2+/4. The right elbow and shoulder strength are 5/5. Left upper extremity is 5/5 on manual muscle exam. Bilateral sensory is intact. The dynamic MRI cervical spine showed anterior displacement of the cord. Which of the following is the most rational next step in managing the patient?

A 45-year-old male patient has been scheduled for clipping for an anterior communicating artery (ACOM) aneurysm. The identification and preservation of the recurrent artery of Heubner (RAH) are of paramount importance so as to minimize associated neurological sequelae. What is the most reliable cue to correctly identify the RAH intraoperatively?

Optic nerve sheath fenestration (ONSF) should be considered in which one of the following scenarios?

A 57-year-old female presents to the emergency department with a chief complaint of saddle anesthesia of the left inner thigh and paresthesias in the left lower extremity. She reports no previous episodes and denies a history of trauma. Physical examination reveals a diminished left patellar reflex. The heart and lungs are clear to auscultation, and her gait is abnormal. An MRI of the spine is most likely to reveal which abnormality?

A 12-year-old girl is brought to the hospital following the weakness of both upper and lower limbs following a trivial fall injury. She has a short and webbed neck on physical examination with restricted neck movements. There is a weak gag reflex on neurological examination. Radiological imaging revealed that her odontoid tip was above the Chamberlain line, McRae line, and Wackenheim line and was compressing on the brainstem. Which of the following best describes the commonly accepted pathophysiology of the condition in the child?

A 26-year-old Asian male presents to the emergency department (ED) because of the sudden onset of aphasia, slurring of speech, and some right facial droopiness. He reports that it lasted about 10 minutes and subsided spontaneously. He has had several similar episodes over the past 2 months. Examination in the ED reveals normal vital signs and a normal neurologic exam. A head CT is normal. A CT angiogram shows bilateral, terminal internal carotid artery occlusion with the presence of moyamoya vessels. What is the best next step in management?

A 17-year-old male presents to the emergency department with a 2-day history of fevers, headache, photophobia, and neck pain. The patient is 14 days status post craniotomy for a gunshot wound to the head. On exam, the patient is lethargic but oriented to person, place, and time. There is neck stiffness, but no focal deficit can be found. Workup is significant for a white blood cell count of 26,000 cells/microL and a lactate of 5.2 mmol/L. What should be the initial antibiotic therapy for this patient?

A 34-year-old woman presents with disorientation after she had a seizure. Her husband says that she had a low-grade fever three days ago. She has no past medical history. Vital signs show oxygen saturation of 98% on room air, respiratory rate of 20 per minute, heart rate of 110 beats per minute, blood pressure of 110/70 mmHg, and temperature of 102.9 F. On examination, she can move all four extremities spontaneously, and deep tendon reflexes are 3+ without clonus. Plantar reflexes are outgoing bilaterally. The optic disc shows early papilledema, and there is mild neck stiffness. A CT scan of the head is unremarkable. Lumbar puncture shows clear fluid with an opening pressure of 280 mm of water. Cerebrospinal fluid (CSF) analysis shows glucose 77 mg/dL and serum glucose 110 mg/dL. CSF protein 170 mg/dL. There are 100 leukocytes per microL with 85% lymphocytes. There are no red blood cells. What is the most likely causative agent for this patient's presentation?

A 65-year-old patient presents with complaints of fatigue, headache, and ongoing confusion for the past eight months. His past medical history is significant for several chronic disorders, including diabetes, gout, and arthritis. He has smoked heavily all his life. CT scan reveals multiple aneurysms less than 0.5 mm in the lenticulostriate vessels of the basal ganglia. With what disease process are these aneurysms frequently associated?

A 46-year-old male presents with complaints of seeing flashing lights, floaters, and slight vision loss. On physical exam there is no trauma, visual acuity is decreased, pupillary reflexes are normal. Fundoscopic examination shows the presence of vitreous hemorrhage which is the leakage of blood into the surrounding clear vitreous, blocking light from reaching the retina. On what structure in the retina is incoming light normally focused?

The macula is also called the macula lutea for its yellowish pigmented appearance and offers the greatest visual acuity within the retina. Light is focused onto the macula which contains a high concentration of cone cells and is located temporally from the optic disc. The photoreceptor cells within the macula transmit light sensory information onto the bipolar cells and then to the ganglion cells which become the optic nerve. The symptoms presented are common in retinal detachment which results in vision loss as the macula is displaced and the photoreceptor cells degenerate from ischemia.

Lumbar puncture in a patient with suspected subarachnoid hemorrhage is most sensitive during what time period?

A 16-year-old patient underwent placement of an external ventricular drain for the management of acute hydrocephalus secondary to tubercular meningitis. Two days later he developed a high-grade fever associated with chills and rigor. He had neck stiffness on clinical examination. The CSF culture showed the growth of Pseudomonas aeruginosa sensitive to amikacin only. The treating clinician planned to start intraventricular amikacin therapy. What is the safe daily dosage of amikacin that can be administered intraventricularly in the patient?

A patient with a history of obesity, known lumbar spondylosis, and chronic low back pain presents to your clinic. She has failed conservative management of her pain, including physical therapy, weight loss, diet modification, and oral medications. You suspect her pain is due to lumbar facet arthropathy. Diagnostic L3-L5 medial branch block with lidocaine results in the patient obtaining 80% pain relief that lasts for 3 hours. What is the most appropriate next step?

A 40-year-old female presented with daily hemicranial headaches precipitated by bright light. She has a moderate disability with it. She has to take medicines every time to relieve the pain. In which grade of Migraine Disability Assessment Questionnaire (MIDAS), is this patient?

A 67-year-old widowed male has a progressive headache for two weeks. For the past three days, he has been increasingly confused during his daily telephone conversations with his daughter who lives out of town. She called emergency medical services, and the patient is taken to the hospital. The patient is mildly confused, repeating himself often, but otherwise, alert without weakness. His lab workup is unremarkable including complete blood count, complete metabolic panel, urine analysis and chest x-ray. A computed tomography (CT) scan of the head identifies a 1.4 cm right subdural hematoma with mixed density. The patient's daughter states two weeks ago the patient was very mentally sharp and never repeated himself. She states the would want definitive treatment with the lowest likelihood of recurrence. Which options provides the least likelihood of recurrence of the subdural hematoma for this patient?

A 25-year-old man is brought in following a headon motor vehicle accident. He is stable after the primary survey. On examination, he has severe mid-upper facial injuries. A head CT scan reveals complex facial fractures which are classified using the Markowitz-Manson system. Which of the following structures form the boney confluence that this system stages?

A 54-year-old female presented one year ago with chronic low back pain. Imaging at the time identified an L5-S1 left-sided annular disc tear. Six months ago, she had an acute exacerbation of the pain with pain radiating into the posterolateral left leg. New imaging identified a left L5-S1 disc herniation which was treated with microdiscectomy. She was doing well initially after surgery but now presents to the clinic with recurrent left-sided posterolateral leg pain. Current repeat imaging shows recurrent L5- S1 left-sided disc herniation, which is treated with repeat micro lumbar discectomy. Which of the following is most accurate regarding closing an annular fissure?

A 65-year-old male presented in the emergency department with the complaint of loss of sensation in both lower limbs following a firearm injury to his lower back. On examination, power is 2/5 in both lower limbs. There is a poor anal sphincter tone on the digital rectal examination (DRE). The clinician on duty is confused about making a diagnosis between conus medullaris and cauda equina syndromes. Which of the following is an important difference in the presentation of conus medullaris and cauda equina syndromes?

A 53-year-old male is being monitored in the emergency department after experiencing a tonic-clonic seizure a few hours ago. The patient is currently being treated with a combination of IV valproic acid/carbamazepine. The patient is awake and oriented and is complaining of a headache. His blood pressure is 125/75 mmHg, heart rate 95 beats/min, respiratory rate 18, and temperature 36.6 C (97.8 F). The patient's history reveals that while he was having the seizure, he slid off the edge of his bed and hit his head on the corner of his nightstand. While taking the history, the emergency care provider observes the patient struggling to keep his eyes open and remain lucid. After a few minutes, the patient loses consciousness, and a code is called. The patient's vitals at this point are blood pressure 144/52 mmHg, heart rate 48 beats/min, respiratory rate 9, and temperature 36.6 C (97.8 F). An emergent CT reveals epidural hemorrhage with associated fracture of the patient's right temporal bone. The patient is rapidly transferred to the operating room for an emergent craniotomy. What drug is may be less effective than usual when providing anesthesia care to this patient?

A 44-year-old man with a prior history of glioblastoma multiforme treated with surgical excision and radiation therapy presents with symptoms of memory loss, headaches, drowsiness, and periods of blank staring. These periods usually last 2 to 3 minutes, and he is unresponsive. The symptoms started about six months after completion of the radiation therapy. An MRI brain shows a defect in the right temporal lobe with a palisading pattern of necrosis, and there is an absence of T2 flair involving the surrounding white matter. What is the most appropriate next step in management?

A 25-year-old has had refractory migraine attacks for the last two years. The pain starts in the left temporal region and spreads to the ipsilateral hemicrania. Botulinum toxin injection in the left temporal region caused the cessation of her pain. The effect, however, lasted only for three months despite three repeated injections. It has now affected the activities of her daily living as well. Which of the following is the next best step in the management of the patient?

A 46-year-old patient presents with bilateral had pain for the past month described as a "pins and needles" sensation involving all five digits on both hands and associated decreased grip strength bilaterally. On further questioning, she admits to aching neck pain over the same period, though she cannot recall any trauma or other inciting events. On exam, she is found to have a positive Spurling test. What is the next most appropriate step in management?

A 45-year-old patient on antitubercular therapy (ATT) for pulmonary tuberculosis is brought to a peripheral hospital with a history of progressive headache for two days, followed by multiple episodes of vomiting and altered sensorium for one day. On arrival, his Glasgow Coma Scale (GCS) score is E2V2M3, with both pupils equal but sluggishly reactive. His fundoscopic examination reveals the presence of bilateral papilledema. An urgent computed tomogram (CT) scan of his brain with contrast reveals the presence of communicating hydrocephalus with thick basal exudates. He undergoes prompt external ventricular drain (EVD) placement. He shows improvement in his motor score to M5 within 24 hours. What would be the most rational next step of management for this patient?

A 14-year-old boy with a known history of KlippelFeil syndrome presents to his family practice doctor with ongoing falls and new onset weakness in the left upper extremity. What is the best imaging modality to further evaluate the symptoms?

A 70-year-old female with a history of scoliosis and prior lumbar fusion presents to the clinic complaining of chronic back pain. On physical exam, she has a crouched gait with compensatory knee flexion. She exhibits no neurologic deficits and does not complain of pain in a regional pattern. Which of the following is the mainstay of spinal alignment imaging?

A 60-year-old male has a sudden onset of extreme dizziness, nausea, and vomiting while at work. He is taken to the hospital for a stroke workup. On exam, he opens his eyes to voice, is oriented to conversation, follows commands with all extremities and has profound bilateral dysmetria of the upper and lower extremities. His blood pressure is 180/100 mmHg, heart rate of 102 bpm, and oxygen saturation of 98% on room air. Imaging reveals a cerebellar hemorrhage of the bilateral cerebellar hemispheres with 40 mL of estimated blood volume and effacement of the fourth ventricle with lateral ventricular enlargement. There does not appear to be any blood in the ventricular system. What is his 30-day mortality based on the intracerebral hemorrhage (ICH) score?

A 57-year-old woman with past medical history significant for depression and hypertension presents with intractable lower back pain with radiculopathy to her left anterior thigh and feet. Her depression and hypertension are appropriately managed by her primary care provider. However, her low back pain continues to persist despite conservative management with physical therapy, use of neuropathic medications, and lumbar fusion of L3 – L5. What is her most likely diagnosis?

A 50-year-old male patient is seen in the trauma bay after a high-speed unhelmeted motorcycle accident in which he was struck in the neck with a wire fence in a "clothes-line" injury. The patient is found on computed tomography to have fractures of his second and third cervical vertebrae with extension of the fracture at the third vertebrae through the transverse foramen. One week later, while the patient is recovering from his traumatic injuries in the intensive care unit, the patient states that he is unable to see out of either eye. What test would have been most prudent to obtain at the patient's initial presentation to diagnose this catastrophic complication?

A 65-year-old male is 3 years status post intrathecal pump placement with morphine for chronic cancer pain with good pain control. Recently he reports worsening of the pain and some weakness in his left lower extremity compared to his baseline. After interrogating his intrathecal pump, you notice a 20% difference between expected and measured residual volume in the pump. What is your immediate next step in management?

A 65-year-old female is referred to physical therapy for neck pain. She states she has been experiencing vertigo with diplopia as well as a persistent headache. Diplopia and vertigo are reproducible when she tilts her head up. What is the best next step in diagnosis?

A 35-year-old male patient is being managed for post-meningitic hydrocephalus with the placement of an extraventricular drain (EVD). The patient gradually shows clinical improvement, and repeat CT images did not show any progression of the hydrocephalus. The patient is thus planned for EVD removal. Which of the following best describes the ideal method for the safe removal of the EVD in such patients?

A 42-year-old woman presents to the clinic to assess options for her cancer-related pain. The patient currently works as a museum curator and has a history of von Willebrand disease, hypertension, diabetes mellitus, liver failure with severe coagulopathy, and metastatic breast cancer. Her vital signs are all within normal reference ranges. She rates her pain as 6 out of 10 in her pelvis with a continuous infusion of opioids and oral gabapentin, and the pain in her right leg is making it difficult for her to work. She is interested in definitive, permanent options to palliate her pain. Which of the following is the most appropriate approach to this patient?

A 2-month-old female infant is brought in by her grandmother due to increased crying, vomiting, and decreased oral intake. As per her grandmother, the patient was in her usual state of health 2 days prior when she last saw her. Vital signs are stable, and the patient is afebrile. On physical examination, the infant is irritable with a high pitched cry. The anterior fontanelle is bulging. The rest of the physical has symmetric chest expansion, clear breath sounds, and no adventitious sounds. The abdomen is soft and non-tender. The skin is clear with no rashes or lesions. Labs and imaging are performed. The chest x-ray shows lucencies in the posterior ribs. What is the diagnosis?

A 16-year-old female is brought to the clinic for evaluation of multiple recurrent burn wounds sustained while cooking food. Her neurological examination reveals the presence of dissociative sensory loss along her bilateral upper arms and anterior part of the nape of her neck and upper chest. Further radiological workup reveals that the tip of the odontoid process, anterior arch of atlas, and clivus in unison were above the Chamberlain line but below McRae and Wackenheim lines. She also has cerebellar tonsils well below the foramen magnum. Based on these findings, which of the following is the most rational approach for managing the patient?

A 62-year-old female patient is seen in the clinic for her annual follow-up visit. She has a past medical history of hypertension, hyperlipidemia, and depression. Her current medications include aspirin, simvastatin, lisinopril, and fluoxetine. She was diagnosed with celiac disease at age 28 and follows a gluten-free diet. She notes that she has felt increasingly fatigued over the last few months. She has also noticed a new-onset of numbness and tingling in her lower extremities, as well as problems with balance. Her physical exam was significant for a noted decrease in sensation to both pinprick and light touch of her bilateral lower feet. She was also found to have a positive Romberg test. A complete blood count (CBC) reveals a decrease in hemoglobin, a decrease in hematocrit, and an increased mean corpuscular volume (MCV). The physician suspects a vitamin deficiency as the cause of this patients neurological problems. Which of the following structures is most likely affected by this patient's suspected vitamin deficiency?

A 76-year-old female presents for preoperative evaluation for carotid endarterectomy. She has well-controlled diabetes mellitus, hypertension, and hyperlipidemia. Her medications include aspirin, atorvastatin, and chlorthalidone. She has no cardiac symptoms or history. The only physical finding is a left carotid bruit. The ECG is normal except for rare premature ventricular contractions. Laboratories show normal electrolytes, hemoglobin A1c, liver function tests, renal function, and lipid profile. Which of the following is the expected risk of life-threatening complications in the patient?

A 65-year-old man with a history of bitemporal hemianopsia is undergoing a surgical evaluation. The patient describes severe thirst and seems lethargic and disoriented. MRI of the head and neck reveals a craniopharyngioma. Transsphenoidal hypophysectomy is performed without apparent complications. Two hours after surgery, he develops polyuria (375 mL/h) and hypernatremia (155 mEq/L). Which of the following is the next best step in the management of this patient?

A 58-year-old male presented twelve months ago with low back pain. Workup at the time revealed an annular disc tear at L4-L5 level without disc protrusion. He was prescribed NSAIDs as well as low-impact physical therapy. This failed to relieve his symptoms, and he underwent three rounds of transforaminal steroid injections at the affected level with temporary relief only. He presents to the clinic with continued pain and a new magnetic resonance image showing some mild T1 contrast enhancement at the annular disc tear without disc protrusion or foraminal stenosis. No relative instability is noted on dynamic flexion-extension x-rays. What is the most appropriate surgical treatment modality for this patient?

A 17-year-old obese male football lineman presents to your outpatient clinic complaining of recurrent, dull, achy low back pain which is worse with activity. You suspect spondylolysis. Which physical exam maneuver would be most useful to test for this condition?

An 80-year-old male presents to the clinic with a 10-year history of chronic pain in the lower back region when walking. Recently, he had an episode of fecal incontinence and urinary incontinence. His past medical history reveals arthritis, diabetes mellitus, hyperlipidemia, and hypertension. An MRI (magnetic resonance imaging) of the spine reveals spinal stenosis at the levels of L3 and L4. A decision is made to correct this with decompressive laminectomy. What are the layers from the outermost to the innermost penetrated by the surgeon during the procedure?