Brain tumor classification and management — MCQs

10 questions

A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

A 13-year-old boy is brought to the physician because of a 4-month history of worsening dizziness, nausea, and feeling clumsy. An MRI of the brain shows a well-demarcated, 4-cm cystic mass in the posterior fossa. The patient undergoes complete surgical resection of the mass. Pathologic examination of the surgical specimen shows parallel bundles of cells with eosinophilic, corkscrew-like processes. Which of the following is the most likely diagnosis?

A 57-year-old man is brought to the emergency department by his wife 20 minutes after having had a seizure. He has had recurrent headaches and dizziness for the past 2 weeks. An MRI of the brain shows multiple, round, well-demarcated lesions in the brain parenchyma at the junction between gray and white matter. This patient's brain lesions are most likely comprised of cells that originate from which of the following organs?

A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

A 72-year-old woman comes to the emergency department 4 hours after the sudden onset of a diffuse, dull, throbbing headache. During this time, she also reports blurred vision, nausea, and one episode of vomiting. She has a history of hypertension and type 2 diabetes mellitus. Her medications include hydrochlorothiazide, lisinopril, atorvastatin, and metformin. She has smoked 1 pack of cigarettes daily for the past 30 years and drinks 1–2 glasses of wine per day. Her temperature is 36.6 °C (97.9 °F), pulse is 90/min, respirations are 14/min, and blood pressure is 185/110 mm Hg. Fundoscopic examination shows bilateral blurring of the optic disc margins. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Urinalysis shows 2+ protein but no WBCs or RBCs. Which of the following is the most likely diagnosis?

A 31-year-old woman comes to the physician because of headaches and nausea for 2 weeks. The headaches are worse on awakening and she describes them as 7 out of 10 in intensity. During this period, she has noticed brief episodes of visual loss in both eyes lasting several seconds, especially when she suddenly stands up or bends over. She is 165 cm (5 ft 5 in) tall and weighs 98 kg (216 lb); BMI is 36 kg/m2. Vital signs are within normal limits. Examination shows a visual acuity of 20/20 in both eyes with mild peripheral vision loss. Fundoscopic examination shows bilateral optic disc swelling. An MRI of the brain shows no abnormalities. A lumbar puncture is performed; opening pressure is 310 mm H2O. Cerebrospinal fluid analysis shows a leukocyte count of 4/mm3 (75% lymphocytes), a protein concentration of 35 mg/dL, and a glucose concentration of 45 mg/dL. Which of the following is the most appropriate next step in management?

A 28-year-old woman presents with a 12-month history of headache, tinnitus, retrobulbar pain, and photopsias. She says the headaches are mild to moderate, intermittent, diffusely localized, and refractory to nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, this past week, she began to have associated dizziness and photopsia with the headaches. Physical examination reveals a body temperature of 36.5°C (97.7°F), blood pressure of 140/80 mm Hg, and a respiratory rate of 13/min and regular. BMI is 29 kg/m2. Neurological examination is significant for peripheral visual field loss in the inferior nasal quadrant, diplopia, bilateral abducens nerve palsy, and papilledema. A T1/T2 MRI of the brain did not identify extra-axial or intra-axial masses or interstitial edema, and a lumbar puncture showed an opening pressure of 27 cm H2O, with a cerebrospinal fluid analysis within the normal range. Which of the following best describes the pathogenic mechanism underlying these findings?

A 67-year-old man comes to the emergency department because of decreased vision and black spots in front of his left eye for the past 24 hours. He states that it feels as if 'a curtain is hanging over his eye.' He sees flashes of light intermittently. He has no pain or diplopia. He underwent cataract surgery on the left eye 2 weeks ago. He has hypertension and type 2 diabetes mellitus. His sister has open-angle glaucoma. Current medications include metformin, linagliptin, ramipril, and hydrochlorothiazide. Vital signs are within normal limits. Examination shows a visual acuity in the right eye of 20/25 and the ability to count fingers at 3 feet in the left eye. The pupils are equal and reactive. The corneal reflex is present. The anterior chamber shows no abnormalities. The confrontation test is normal on the right side and shows nasal and inferior defects on the left side. Cardiopulmonary examination shows no abnormalities. The patient is awaiting dilation for fundus examination. Which of the following is the most likely diagnosis?

Q10

A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?

Brain tumor classification and management US Medical PG Practice Questions and MCQs

Question 1: A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

A. Seizure prophylaxis and palliative pain therapy
B. Chemotherapy
C. Irradiation to the brain mass
D. Surgical resection of the mass (Correct Answer)

Explanation: ***Surgical resection of the mass*** - The presence of a **solitary cortical mass** with significant edema [1], [2] in a patient with a history of **breast cancer** [3] strongly suggests a resectable brain metastasis that is causing symptomatic cerebral edema. - **Surgical resection** offers the best chance for immediate symptom relief, pathological diagnosis, and improved prognosis in cases conducive to complete removal [1]. *Seizure prophylaxis and palliative pain therapy* - While seizure prophylaxis might be considered due to the mass effect, it is a **supportive measure** and does not address the underlying cause of the symptoms (the mass) that can be surgically removed. - **Palliative pain therapy** would also be a supportive measure only and would not achieve a definitive diagnosis or treatment of the mass. *Chemotherapy* - **Chemotherapy** for brain metastases often has limited efficacy due to the **blood-brain barrier** and is generally reserved for systemic disease or multiple, unresectable brain lesions. - Prior to initiating chemotherapy, a definitive **histopathologic diagnosis** is usually required, and surgical resection would provide tissue for this purpose. *Irradiation to the brain mass* - While **brain irradiation** (like stereotactic radiosurgery or whole-brain radiation therapy) is an option for brain metastases, especially for multiple or unresectable lesions, **surgical resection** is generally preferred for a solitary, accessible metastasis with significant mass effect. - Irradiation alone might not provide the same immediate symptomatic relief from brain edema as surgical decompression [2].

Question 2: A 13-year-old boy is brought to the physician because of a 4-month history of worsening dizziness, nausea, and feeling clumsy. An MRI of the brain shows a well-demarcated, 4-cm cystic mass in the posterior fossa. The patient undergoes complete surgical resection of the mass. Pathologic examination of the surgical specimen shows parallel bundles of cells with eosinophilic, corkscrew-like processes. Which of the following is the most likely diagnosis?

A. Pinealoma
B. Medulloblastoma
C. Pilocytic astrocytoma (Correct Answer)
D. Craniopharyngioma
E. Ependymoma

Explanation: **Pilocytic astrocytoma** - The clinical presentation of **posterior fossa symptoms** (dizziness, nausea, clumsiness) in a child, coupled with an **MRI showing a cystic mass**, is highly suggestive of pilocytic astrocytoma. - Histologically, this tumor is characterized by **Rosenthal fibers** (eosinophilic, corkscrew-like processes) and **bipolar cells arranged in parallel bundles**. *Pinealoma* - Pinealomas typically present with symptoms related to compression of the **aqueduct of Sylvius** (hydrocephalus) or the **superior colliculus** (Parinaud's syndrome), such as impaired upward gaze. - They are located in the **pineal region**, not the posterior fossa, and their histology is distinct from the described features. *Medulloblastoma* - Medulloblastomas are common **posterior fossa tumors** in children, often presenting with similar symptoms. - However, they are typically **solid, poorly demarcated** masses on imaging, and their histology reveals **small, round blue cells** with **Homer-Wright rosettes**, not Rosenthal fibers. *Craniopharyngioma* - Craniopharyngiomas are typically located in the **suprasellar region**, causing symptoms like **visual field defects** (bitemporal hemianopsia) and **endocrine dysfunction**. - While they can be cystic, their location and characteristic histology (e.g., **wet keratin**, calcifications) differentiate them from the given case. *Ependymoma* - Ependymomas commonly arise from the **ventricular system**, especially the **fourth ventricle** in children, and can cause hydrocephalus and posterior fossa symptoms. - Histologically, they are characterized by **perivascular pseudorosettes** and true rosettes, lacking the described corkscrew-like processes.

Question 3: A 57-year-old man is brought to the emergency department by his wife 20 minutes after having had a seizure. He has had recurrent headaches and dizziness for the past 2 weeks. An MRI of the brain shows multiple, round, well-demarcated lesions in the brain parenchyma at the junction between gray and white matter. This patient's brain lesions are most likely comprised of cells that originate from which of the following organs?

A. Kidney
B. Skin
C. Lung (Correct Answer)
D. Thyroid
E. Prostate

Explanation: ***Lung (Correct Answer)*** - **Lung cancer** is the most common cause of **brain metastases** in adults, accounting for approximately **50% of all cases** - The clinical presentation—seizure, headaches, dizziness, and **multiple, round, well-demarcated lesions at the gray-white matter junction**—is classic for metastatic lung cancer - Both **small cell and non-small cell lung cancers** have high propensity for hematogenous spread to the brain - The watershed areas at the gray-white junction are common sites due to lodging of tumor emboli in terminal arterioles *Kidney (Incorrect)* - **Renal cell carcinoma (RCC)** can metastasize to the brain but accounts for only **5-10% of brain metastases** - While RCC metastases can appear similar on imaging, lung cancer is statistically more likely given its higher prevalence - RCC metastases are often **highly vascular and may hemorrhage**, which is not mentioned in this case *Skin (Incorrect)* - **Melanoma** has the **highest propensity per case** to metastasize to the brain among all cancers - However, the **overall incidence of melanoma is much lower** than lung cancer, making it a less probable primary source - Melanoma brain metastases often present as **hemorrhagic lesions** and would typically have skin findings or history *Thyroid (Incorrect)* - **Thyroid cancer** rarely metastasizes to the brain (accounts for <1% of brain metastases) - Brain metastases from thyroid cancer typically occur in **advanced papillary or follicular carcinoma** or in **anaplastic thyroid cancer** - More common metastatic sites for thyroid cancer are lung and bone *Prostate (Incorrect)* - **Prostate cancer very rarely metastasizes to the brain** (<1% of cases) - Prostate cancer preferentially metastasizes to **bone (especially axial skeleton), lymph nodes, and liver** - Brain metastases from prostate cancer suggest extremely advanced, aggressive disease and are exceptionally uncommon

Question 4: A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

A. Doppler ultrasound of the carotids
B. CT head with intravenous contrast
C. MRI head without intravenous contrast
D. CT head without intravenous contrast (Correct Answer)
E. MRI head with intravenous contrast

Explanation: ***CT head without intravenous contrast*** - The sudden onset of severe headache, visual disturbances, and neurological deficits (inability to move extremities), coupled with uncontrolled severe hypertension despite initial treatment, is highly suggestive of an **intracranial pathology**, most likely a **hemorrhagic stroke**. - A **non-contrast CT scan of the head** is the **gold standard** for rapidly identifying acute intracranial hemorrhage, as it can be performed quickly and is readily available in emergency settings. *Doppler ultrasound of the carotids* - This test is primarily used to evaluate **carotid artery stenosis** due to atherosclerosis, which can lead to ischemic stroke. - While the patient has risk factors for atherosclerosis, his acute presentation with severe central neurological symptoms points more towards an acute intracranial event rather than carotid disease. *CT head with intravenous contrast* - While a contrast CT can be useful for identifying tumors, abscesses, or vascular malformations, it is **contraindicated in the initial assessment of acute stroke** if an intracranial hemorrhage is suspected. - Contrast can sometimes obscure subtle bleeds or complicate the interpretation of acute hemorrhage, and it also carries a risk of **contrast-induced nephropathy**, especially in a patient with diabetes. *MRI head without intravenous contrast* - An MRI provides superior soft tissue resolution compared to CT and is excellent for detecting ischemic strokes in later stages, as well as subtle hemorrhages, tumors, and other conditions. - However, it is **less available, takes longer to perform**, and is often not the first choice in an acute neurological emergency where time is critical, particularly when differentiating between ischemic and hemorrhagic stroke. *MRI head with intravenous contrast* - Similar to a contrast CT, an MRI with contrast is generally **not the initial imaging choice for acute stroke** due to time constraints and the need to quickly rule out hemorrhage before considering contrast administration. - Contrast agents for MRI, such as gadolinium, have their own risks, including **nephrogenic systemic fibrosis** in patients with renal impairment, which is a concern in a diabetic patient.

Question 5: A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?

A. Second opinion from a neurologist
B. Withdraw ventilation support and mark time of death
C. Electroencephalogram
D. Repeat examination in several hours
E. Apnea test (Correct Answer)

Explanation: ***Apnea test*** - The patient exhibits classic signs of **brain death**, including a **coma**, fixed and dilated pupils, and absent brainstem reflexes (corneal, gag, cough). The next step is to perform an apnea test to confirm the absence of spontaneous respiratory drive. - An apnea test confirms brain death by demonstrating the **absence of respiratory effort** despite a rising pCO2, provided that spinal cord reflexes are not mistaken for respiratory efforts. *Second opinion from a neurologist* - While consulting a neurologist is often helpful in complex neurological cases, the current clinical picture presents such clear signs of brain death that **further confirmatory testing** for brain death (like the apnea test) is more immediately indicated before seeking additional opinions on diagnosis. - A second opinion would typically be sought to confirm the diagnosis or guide management, but establishing brain death requires a specific protocol which is incomplete without the apnea test. *Withdraw ventilation support and mark time of death* - It is **premature to withdraw ventilation** before brain death is unequivocally confirmed by all necessary clinical and confirmatory tests, including the apnea test. - Withdrawing support without full confirmation could lead to ethical and legal issues, as the patient might still have residual brainstem function, however minimal. *Electroencephalogram* - An **EEG** can show absent electrical activity, supporting brain death, but it is **not a mandatory part of the core brain death criteria** in many protocols, especially when clinical signs are clear and an apnea test can be performed. - The primary diagnostic criteria for brain death usually prioritize clinical examination and the apnea test for proving irreversible cessation of all brain functions. *Repeat examination in several hours* - Repeating the examination in several hours is typically done if there are **confounding factors** (e.g., severe hypothermia, drug intoxication) that might mimic brain death, or if the initial assessment is incomplete. - In this case, there are no mentioned confounding factors, and the immediate priority is to complete the brain death protocol with an apnea test, given the current clear clinical picture.

Question 6: A 72-year-old woman comes to the emergency department 4 hours after the sudden onset of a diffuse, dull, throbbing headache. During this time, she also reports blurred vision, nausea, and one episode of vomiting. She has a history of hypertension and type 2 diabetes mellitus. Her medications include hydrochlorothiazide, lisinopril, atorvastatin, and metformin. She has smoked 1 pack of cigarettes daily for the past 30 years and drinks 1–2 glasses of wine per day. Her temperature is 36.6 °C (97.9 °F), pulse is 90/min, respirations are 14/min, and blood pressure is 185/110 mm Hg. Fundoscopic examination shows bilateral blurring of the optic disc margins. Physical and neurologic examinations show no other abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Urinalysis shows 2+ protein but no WBCs or RBCs. Which of the following is the most likely diagnosis?

A. Ischemic stroke
B. Hypertensive emergency (Correct Answer)
C. Transient ischemic attack
D. Subarachnoid hemorrhage
E. Idiopathic intracranial hypertension

Explanation: ***Hypertensive emergency*** - The patient presents with **sudden onset of severe headache**, blurred vision, nausea, and vomiting, along with **markedly elevated blood pressure (185/110 mm Hg)** which are classic symptoms of hypertensive emergency. - **Bilateral blurring of the optic disc margins (papilledema)** indicates end-organ damage to the central nervous system due to severe hypertension, further supporting this diagnosis. *Ischemic stroke* - While a cerebral infarct can cause sudden-onset headache, it typically presents with **focal neurological deficits**, which are absent in this patient. - The symptoms described are more consistent with generalized intracranial pressure elevation rather than a localized ischemic event. *Transient ischemic attack* - A TIA involves **transient neurological deficits** that resolve completely, typically within an hour, and would not usually be associated with persistent symptoms like blurred vision and papilledema. - The significant and sustained elevation in blood pressure with end-organ damage points away from a TIA. *Subarachnoid hemorrhage* - Often causes a **"thunderclap" headache** described as the worst headache of one's life, which is more severe and abrupt than the "dull, throbbing" headache mentioned. - While it can cause nausea and vomiting, the absence of meningeal signs or focal neurological deficits, and the presence of severe uncontrolled hypertension with papilledema, make subarachnoid hemorrhage less likely. *Idiopathic intracranial hypertension* - This condition typically affects young, obese women and is characterized by symptoms of **increased intracranial pressure (headache, vision changes, papilledema)**, but without an identifiable cause. - The patient's age (72 years), history of uncontrolled hypertension, and very high blood pressure suggest a secondary cause for her intracranial hypertension, specifically a hypertensive emergency.

Question 7: A 31-year-old woman comes to the physician because of headaches and nausea for 2 weeks. The headaches are worse on awakening and she describes them as 7 out of 10 in intensity. During this period, she has noticed brief episodes of visual loss in both eyes lasting several seconds, especially when she suddenly stands up or bends over. She is 165 cm (5 ft 5 in) tall and weighs 98 kg (216 lb); BMI is 36 kg/m2. Vital signs are within normal limits. Examination shows a visual acuity of 20/20 in both eyes with mild peripheral vision loss. Fundoscopic examination shows bilateral optic disc swelling. An MRI of the brain shows no abnormalities. A lumbar puncture is performed; opening pressure is 310 mm H2O. Cerebrospinal fluid analysis shows a leukocyte count of 4/mm3 (75% lymphocytes), a protein concentration of 35 mg/dL, and a glucose concentration of 45 mg/dL. Which of the following is the most appropriate next step in management?

A. Prednisone therapy
B. Optic nerve sheath fenestration
C. Acetazolamide therapy (Correct Answer)
D. Furosemide therapy
E. Ventricular shunting

Explanation: ***Acetazolamide therapy*** - This patient presents with symptoms and signs consistent with **idiopathic intracranial hypertension (IIH)**: **headaches worse on awakening**, transient visual obscurations, **papilledema** on fundoscopic exam, elevated **BMI**, normal brain MRI, and **elevated CSF opening pressure** with normal CSF content. - **Acetazolamide** is the first-line medical treatment for IIH, working as a **carbonic anhydrase inhibitor** to decrease CSF production and thus lower intracranial pressure. *Prednisone therapy* - **Prednisone** is a corticosteroid that can reduce inflammation and edema, but it is **not the first-line treatment** for IIH and its prolonged use carries significant side effects. - While it may temporarily reduce intracranial pressure, it does not address the underlying pathophysiology of **CSF overproduction** or impaired absorption in IIH as effectively as acetazolamide. *Optic nerve sheath fenestration* - **Optic nerve sheath fenestration** is a surgical procedure considered for IIH patients with **progressive vision loss despite maximal medical therapy**, or those who cannot tolerate medical therapy. - It is an **invasive procedure** and not the initial management step for this patient, who has only mild peripheral vision loss and has not yet attempted medical treatment. *Furosemide therapy* - **Furosemide** is a loop diuretic that primarily reduces systemic fluid volume and can sometimes be used as an **adjunct** in resistant cases or to potentiate acetazolamide's effect in IIH. - However, it is **less effective than acetazolamide** in directly reducing CSF production and is not considered a first-line monotherapy for IIH. *Ventricular shunting* - **Ventricular shunting** (e.g., ventriculoperitoneal shunt) is a more invasive surgical option considered for severe, refractory cases of IIH, particularly those with **intractable headaches** or **severe, progressive vision loss** that has failed other treatments. - Given that this patient has not yet received initial medical therapy, **ventricular shunting is premature** as a next step in management.

Question 8: A 28-year-old woman presents with a 12-month history of headache, tinnitus, retrobulbar pain, and photopsias. She says the headaches are mild to moderate, intermittent, diffusely localized, and refractory to nonsteroidal anti-inflammatory drugs (NSAIDs). In addition, this past week, she began to have associated dizziness and photopsia with the headaches. Physical examination reveals a body temperature of 36.5°C (97.7°F), blood pressure of 140/80 mm Hg, and a respiratory rate of 13/min and regular. BMI is 29 kg/m2. Neurological examination is significant for peripheral visual field loss in the inferior nasal quadrant, diplopia, bilateral abducens nerve palsy, and papilledema. A T1/T2 MRI of the brain did not identify extra-axial or intra-axial masses or interstitial edema, and a lumbar puncture showed an opening pressure of 27 cm H2O, with a cerebrospinal fluid analysis within the normal range. Which of the following best describes the pathogenic mechanism underlying these findings?

A. Systemic hypertension
B. Increased cerebrospinal fluid production
C. Aqueductal stenosis
D. Arachnoid granulation adhesions
E. Elevated intracranial venous pressure (Correct Answer)

Explanation: ***Elevated intracranial venous pressure*** - The combination of **papilledema**, **abducens nerve palsy**, normal brain MRI, and normal CSF analysis with **elevated opening pressure** (27 cm H2O; normal <20-25 cm H2O) is classic for **idiopathic intracranial hypertension (IIH)**, also known as pseudotumor cerebri. - The primary pathogenic mechanism in IIH is often thought to be impaired **CSF absorption** due to elevated **intracranial venous pressure**, particularly within the dural venous sinuses, which can be exacerbated by obesity. *Systemic hypertension* - While the patient has slightly elevated blood pressure (140/80 mmHg), **systemic hypertension** rarely directly causes **papilledema** or **abducens nerve palsy** without other signs of hypertensive encephalopathy or end-organ damage, which are not described. - The elevated intracranial pressure is not directly explained by simply high systemic blood pressure, especially with normal brain imaging. *Increased cerebrospinal production* - **Increased CSF production** is a very rare cause of intracranial hypertension, typically associated with choroid plexus tumors. - The normal CSF analysis and absence of a mass on MRI make this an unlikely primary mechanism. *Aqueductal stenosis* - **Aqueductal stenosis** would lead to **obstructive hydrocephalus**, characterized by ventricular enlargement on MRI, which was not observed in this patient. - While it causes elevated ICP, the normal ventricular size rules out this specific structural obstruction. *Arachnoid granulation adhesions* - **Arachnoid granulation adhesions** could theoretically impair CSF absorption, leading to elevated intracranial pressure. - However, direct evidence of such adhesions is not typically observed on routine MRI, and the underlying cause often relates to a more systemic issue affecting CSF outflow, such as the venous drainage problem described in the correct option.

Question 9: A 67-year-old man comes to the emergency department because of decreased vision and black spots in front of his left eye for the past 24 hours. He states that it feels as if 'a curtain is hanging over his eye.' He sees flashes of light intermittently. He has no pain or diplopia. He underwent cataract surgery on the left eye 2 weeks ago. He has hypertension and type 2 diabetes mellitus. His sister has open-angle glaucoma. Current medications include metformin, linagliptin, ramipril, and hydrochlorothiazide. Vital signs are within normal limits. Examination shows a visual acuity in the right eye of 20/25 and the ability to count fingers at 3 feet in the left eye. The pupils are equal and reactive. The corneal reflex is present. The anterior chamber shows no abnormalities. The confrontation test is normal on the right side and shows nasal and inferior defects on the left side. Cardiopulmonary examination shows no abnormalities. The patient is awaiting dilation for fundus examination. Which of the following is the most likely diagnosis?

A. Endophthalmitis
B. Degenerative retinoschisis
C. Hemorrhagic choroidal detachment
D. Acute angle-closure glaucoma
E. Retinal detachment (Correct Answer)

Explanation: ***Retinal detachment*** - The patient's symptoms of **decreased vision**, **black spots** (floaters), **flashes of light** (photopsia), and the sensation of a "**curtain hanging over the eye**" are classic signs of **retinal detachment**. - Recent **cataract surgery** is a significant risk factor for retinal detachment, and the visual field defects (nasal and inferior) noted in the confrontation test are consistent with the detached retina. *Degenerative retinoschisis* - While retinoschisis can cause visual field defects, it typically presents with **asymptomatic peripheral vision loss** and **does not usually cause photopsia or floaters**. - It is a **splitting of the retina**, often stable and less likely to cause a sudden, symptomatic curtain-like vision loss. *Endophthalmitis* - Endophthalmitis is a severe intraocular infection characterized by **pain**, **redness**, and significant **vision loss**, often with **hypopyon** (pus in the anterior chamber). - The patient has no pain or redness, and the anterior chamber is unremarkable, making endophthalmitis unlikely. *Hemorrhagic choroidal detachment* - This condition is often associated with **severe pain**, a **deepening of the anterior chamber**, and can occur post-operatively after intraocular surgery. - While vision loss can be profound, the absence of pain and a normal anterior chamber make this diagnosis less likely. *Acute angle-closure glaucoma* - This condition presents with **sudden, severe eye pain**, **redness**, **halos around lights**, and often **nausea and vomiting**. - The patient denies pain and redness, and the symptoms described are more consistent with retinal pathology than acute angle-closure glaucoma.

Question 10: A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?

A. Lumbar puncture
B. Decompressive craniectomy
C. Administration of levetiracetam
D. Administration of methylprednisolone
E. Surgical evacuation of the clots (Correct Answer)

Explanation: ***Surgical evacuation of the clots*** - The CT scan image shows a **biconvex (lenticular) hyperdensity** consistent with an **epidural hematoma (EDH)**, which typically results from arterial bleeding (often from the **middle meningeal artery**). This patient's **"lucid interval"** (initial loss of consciousness, regain consciousness, then deterioration) is classic for EDH. - Given the patient's neurological deterioration (left-sided weakness, pupillary changes, confusion, memory issues) and signs of increased intracranial pressure (hypertension, bradycardia - part of Cushing's triad), urgent surgical evacuation of the hematoma is indicated to relieve pressure and prevent herniation. *Lumbar puncture* - A lumbar puncture is **contraindicated** in the setting of suspected or confirmed **increased intracranial pressure (ICP)**, as it can precipitate **cerebral herniation**. - The CT scan clearly demonstrates a space-occupying lesion, making a lumbar puncture unnecessary and potentially dangerous. *Decompressive craniectomy* - While decompressive craniectomy is a neurosurgical procedure used to reduce ICP, it is generally considered when other measures have failed or in cases of **diffuse brain swelling** or large **intracerebral hematomas** not amenable to simple evacuation. - In this case of a localized epidural hematoma with a clear surgical target, direct evacuation is the primary and most effective intervention. *Administration of levetiracetam* - Levetiracetam is an **anticonvulsant** used to prevent seizures. While seizures can occur after traumatic brain injury, there is no indication that the patient is currently seizing. - Prophylactic anticonvulsants are sometimes used in severe TBI, but addressing the life-threatening hematoma takes **precedence** over seizure prophylaxis. *Administration of methylprednisolone* - **Corticosteroids** like methylprednisolone are generally **contraindicated** in traumatic brain injury (TBI) as studies have shown **worse outcomes** and increased mortality. - They are primarily used for their **anti-inflammatory effects** in conditions like spinal cord injury or vasogenic edema from tumors, not for acute head trauma with hematoma.

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