ITE Neurology — Questions and Answers
Question 1: A 68-year-old man with atrial fibrillation and hypertension presents 90 minutes after sudden onset right-sided weakness and aphasia. CT head is negative for hemorrhage. His INR is 1.1 (not on anticoagulation). What is the most appropriate immediate intervention?
- IV alteplase (tPA) if no contraindications (Correct answer)
- Aspirin 325 mg orally immediately
- Emergency carotid endarterectomy
- Heparin drip with target aPTT 60–80 seconds
Correct answer: IV alteplase (tPA) if no contraindications
IV tPA within 4.5 hours of ischemic stroke symptom onset is the standard of care when contraindications are absent. Aspirin is appropriate but is secondary to thrombolysis in the acute window. Carotid endarterectomy is for symptomatic carotid stenosis, not acute treatment. IV heparin is not recommended in acute ischemic stroke.
Question 2: A 22-year-old woman presents with her second unprovoked tonic-clonic seizure. MRI brain is normal. EEG shows 3 Hz spike-and-wave discharges. She is of childbearing age. Which antiepileptic drug is MOST appropriate as initial monotherapy?
- Lamotrigine (Correct answer)
- Valproate
- Phenytoin
- Carbamazepine
Correct answer: Lamotrigine
Lamotrigine is appropriate for generalized epilepsy (consistent with 3 Hz spike-wave = absence/generalized epilepsy) and carries a lower teratogenic risk compared to valproate, making it preferable for women of childbearing potential. Valproate is highly effective but is a known teratogen (neural tube defects). Phenytoin and carbamazepine can worsen absence seizures.
Question 3: A 52-year-old woman presents with sudden-onset 'thunderclap' headache that she describes as the worst headache of her life, reaching peak intensity in seconds. CT head is negative. What is the next most appropriate diagnostic step?
- Lumbar puncture for xanthochromia and RBC count (Correct answer)
- MRI brain with gadolinium
- CT angiography of the head deferred to outpatient
- Empiric sumatriptan and reassurance
Correct answer: Lumbar puncture for xanthochromia and RBC count
A thunderclap headache with normal CT requires lumbar puncture to rule out subarachnoid hemorrhage (SAH), which can be CT-negative in up to 2–5% of cases in the first 6–12 hours but positive for xanthochromia on LP. MRI is less sensitive than LP for early SAH. Delaying CTA or treating empirically without LP risks missing a potentially fatal condition.
Question 4: A 65-year-old man with type 2 diabetes presents with burning pain, numbness, and tingling in both feet in a 'stocking' distribution. Nerve conduction studies show reduced amplitude and slowed conduction velocity in distal sensory nerves bilaterally. Which of the following is MOST appropriate for neuropathic pain control?
- Duloxetine or pregabalin (Correct answer)
- Gabapentin plus opioids as first-line combination
- Amitriptyline 150 mg at bedtime
- Celecoxib 200 mg twice daily
Correct answer: Duloxetine or pregabalin
Duloxetine and pregabalin are FDA-approved first-line agents for diabetic peripheral neuropathic pain with strong evidence and favorable risk profiles. Opioids are not first-line. High-dose amitriptyline (150 mg) carries significant anticholinergic and cardiac risk; low doses may be used but are not first-line. NSAIDs do not address neuropathic pain mechanisms.
Question 5: A 72-year-old man presents with a 1-year history of resting tremor of the right hand, reduced arm swing while walking, a shuffling gait, and difficulty initiating movement. Cognitive function is intact. Which of the following is the most appropriate initial pharmacologic treatment?
- Carbidopa-levodopa (Correct answer)
- Haloperidol
- Trihexyphenidyl
- Memantine
Correct answer: Carbidopa-levodopa
Carbidopa-levodopa is the most effective symptomatic treatment for Parkinson's disease and is appropriate for an elderly patient with significant motor disability. Haloperidol is a dopamine antagonist that worsens parkinsonism. Trihexyphenidyl (anticholinergic) may be used for tremor but is poorly tolerated in the elderly due to cognitive side effects. Memantine is used for dementia, not Parkinson's motor symptoms.
Question 6: A 40-year-old woman presents with two episodes of unilateral optic neuritis over 2 years plus a history of transient bilateral leg weakness that resolved completely. MRI of the brain and spine shows periventricular white matter lesions disseminated in space and time. CSF shows oligoclonal bands. What is the most likely diagnosis?
- Relapsing-remitting multiple sclerosis (RRMS) (Correct answer)
- Neuromyelitis optica spectrum disorder (NMOSD)
- CNS vasculitis
- Acute disseminated encephalomyelitis (ADEM)
Correct answer: Relapsing-remitting multiple sclerosis (RRMS)
The presentation of relapsing neurological episodes with lesions disseminated in space and time, periventricular MRI lesions, and CSF oligoclonal bands satisfies McDonald criteria for RRMS. NMOSD typically involves longitudinally extensive spinal cord lesions and AQP4-IgG positivity. CNS vasculitis and ADEM are typically monophasic or have distinct features.
ITE Neurology
A 68-year-old man with atrial fibrillation and hypertension presents 90 minutes after sudden onset right-sided weakness and aphasia.
CT head is negative for hemorrhage.
His INR is 1.1 (not on anticoagulation).
What is the most appropriate immediate intervention?