2005 NTUH (2)

台大題庫


45. A young 28 yrs old patient come to see you with a complaint of intermittent headache, and recently has blurred vision. She report has been on birth control pill and taking tetracycline for acne on her face. Your examination, her BMI (Body mass index) is 30, EOM (Extra-ocular-movement)-intact but papilledema on both eyes are found, no other cranial nerve abnormality, no long tract sign except increase of DTR symmetrically.  What is your likely diagnosis:
(1) Cryptococcal meningitis
(2) Pseudotumor cerebri
(3) Brain stem glioma
(4) T.B. meningitis
(5) Hydrocephalus
Ans. (2)

When thrombosis occurs in the cerebral veins and dural sinuses, the resulting venous hypertension causes hypoxia of the brain with subsequent neuronal ischemia, similar to the symptomatology of dural arteriovenous fistulas.

CVT (cerebral venous thrombosis) affects all age groups and both sexes, but with a strong preponderance in women between 20 and 40 years of age. This may reflect the fact that women in that age group are more likely to use oral contraceptives and undergo changes associated with the puerperium.

Headache is the most common and often the earliest symptom and is seen in nearly 80% of patients. Nausea, vomiting, and visual changes are other symptoms experienced by patients. Increased intracranial pressure is thought to be the underlying cause of these symptoms. Papilledema is seen in about half of those afflicted, and confusion, agitation, and other changes in mental status occur in about 25% of patients.

Case Scenario II
A 42 yrs old taxi driver, had cold symptoms 2 wks ago, then developed tingling sensation of limbs 3 days ago.  He come to our ER because of progressive weakness and could not swallow his saliva.  Your presumptive diagnosis is Gullian-Barre’s syndrome, Please answer the following question.

46. Compatible neurological findings are as following except one:
(1) no fever
(2) absence of all DTR
(3) marked impaired of deep sensations
(4) mild involvement of superficial sensations
(5) positive babinski sign
Ans. (5)

The cardinal manifestations of peripheral neuropathy (Gullian-Barre’s syndrome = AIDP) are weakness, alterations in sensation, and changes in peripheral reflexes. 

47. Compatible C.S.F. findings
(1) mild elevated opening pressure
(2) normal protein and cell count
(3) elevated albumin without pleocytosis (cell count)
(4) normal albumin but pleocytosis
(5) elevated albumin and cell counts
Ans. (3)

In GBS, CSF protein is usually normal for the first several days, then rises, sometimes reaching extraordinary levels, and remains high for several months. Pleocytosis can develop, but more than 50 cells suggests an alternative diagnosis. Increased cells are especially common in HIV-associated cases.

Myelinopathy: increased CSF protein
Axonopathy: normal CSF protein

52. 關於Venous angioma of the brain的敘述，何者為非？
(1) 大多無症狀為血管攝影之意外發現
(2) 有時會有subarachnoid hemorrhage或epileptic seizure
(3) 血管攝影檢查，典型的venous angioma arterial 或capillary phases會出現
(4) 大的draining vein常可在contrast-enhanced CT發現
Ans. (3)

Venous malformations (synonyms: developmental venous anomaly, venous angioma.) are congenital venous anomalies.Despite histologic abnormalities, venous angiomas drain normal cerebral tissue. VMs rarely cause symptoms and are often incidental findings. Contrast-enhanced imaging studies reveal a stellate mass or linear enhancement of a transcerebral vein without parenchymal abnormalities. Angiography typically shows normal findings during the arterial and capillary phase. During the venous phase, however, arcades of veins or caput medusae is visualized converging into a large venous channel.

53. 下列三個構造是位在第三腦室底進行third ventriculostomy時參考的重要結構？
(1) Tuber cinereum, lamina terminalis 和infundibular recess
(2) Tuber cinereum, anterior commissure 和infundibular recess
(3) Tuber cinereum, mammillary bodies 和infundibular recess
(4) Tuber cinereum, anterior commissure 和infundibular recess
Ans. (3)

After the third ventricle is entered, the paired mamillary bodies should be evident midway along the floor, with the basilar complex generally just anterior to them in the midline. The infundibular recess is usually evident as a pinkish orange spot on the anterior midline floor. Slightly posterior to this recess is a white rectangular transverse band of the dorsum sellae. The ideal spot for fenestration is midway between the basilar complex and the dorsum sellae in the midline.

The optic recess is seen anterior to the infundibular recess as the endoscope is swept anteriorly along the third ventricular floor. The tuber cinereum forms the floor of the third ventricle from the mamillary bodies posteriorly to the infundibular recess anteriorly. In the setting of hydrocephalus, the tuber cinereum is often thin and translucent and can provide a glimpse of the basilar apex in the interpeduncular cistern below.

54. Typical presentations of patients with cauda equina lesions include all of the following EXCEPT
(1) Sensory dissociation
(2) Asymmetric motor loss
(3) Late autonomic symptoms
(4) Absence of ankle jerk and knee jerk
(5) Numbness tends to be more localized to saddle area
Ans. (1)

Dissociated sensory loss is a pattern of neurological damage caused by a lesion to a single tract in the spinal cord which involves selective loss of fine touch and proprioception without loss of pain and temperature, or vice versa. 

Dissociated sensory loss always suggests a focal lesion within the spinal cord or brainstem.

55. 小孩子之顱骨osteolytic lesion，以單一頭皮下腫塊呈現，最可能之診斷為？
(1) 癌症轉移
(2) Hyperparathyroidism
(3) Langhans cell histiocytosis
(4) Osteoblastoma
Ans. (3)

Langerhans cell histiocytosis (LCH) refers to a group of related disorders of abnormal uncontrolled histiocyte proliferation: eosinophilic granuloma, Hand-Schüller-Christian disease, Abt-Letterer-Siwe disease, and Hashimoto-Pritzker disease. Although adult cases have been reported, LCH predominantly occurs in children and adolescents, with the mean age at incidence being 12 years.

The most common and simplest form of LCH is a solitary lytic lesion of bone designated eosinophilic granuloma, which accounts for 60% to 80% of cases. The skull is the most commonly involved bone.4-6,213,215 Patients with such solitary lesions usually exhibit localized bone pain or a palpable mass.

56. 有關Locked-in Syndrome，常是何處傷害所致？
(1) Basal ganglion
(2) Ventral pons
(3) Cerebellum
(4) Bilateral frontal lobes
Ans. (2)

One of the critical anatomic elements that maintain or, more strictly speaking, activate consciousness has been defined under the term ascending reticular activating system. This neuronal system, located in the caudal brainstem, connects to the thalamus. These synapsing fibers extend from the entry of the trigeminal nerve in the midpons to the thalamus, which in turn loops fibers to the cortex and back, thereby creating a thalamic-cortical circuitry.