Answer For Question 24, Neurology

     Eccentric topic of the Week: Neurology
    Question 24 Answer:

     The correct answer is C, cerebral arteriovenous malformation

The majority of migraine headaches appear before the age of 20 years. The female to male ratio is 9:1. The appearance of "worsening migraines" at the age of 30 years in a male, should cast a doubt on the diagnosis of migraine. Cerebral AVMs and anti-phospholipid syndrome can have a headache that is "migrainous-like" and these should always be looked for if the clinical picture is atypical for migraine (as in our patient). In the general population, headache due to a cerebral AVM is an extremely uncommon cause. Headache unrelated to hemorrhage occurs in 4-14% of patients with AVM and may be the presenting symptom. The headache may be typical for migraine or may present with a less specific complaint, such as, generalized head pain. Note that families with cerebral AVMs are rare, and such pedigrees have been too small to enable linkage studies. From the few familial cases reported, the inheritance appears to be autosomal dominant. In a small minority of cases, cerebral AVMs are associated with other inherited disorders, such as the Osler-Weber-Rendu syndrome (i.e. hereditary hemorrhagic telangiectasia), Sturge-Weber disease, neurofibromatosis, and von Hippel-Lindau syndrome. These associations commonly appear in the written examination. About 10 to 58% of patients with AVM have aneurysms located in vessels remote from the AVM, within arteries feeding the AVM, or within the nidus of the AVM itself.*

‡ Hauser S, Kasper D, Braunwald E, Fauci A, Londo D. Harrison's Neurology in Clinical Medicine. New York: McGraw-Hill, 2006. 


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Question 25, Neurology

Eccentric topic of the week: Neurology

Question 25:

A 57-year-old woman presents with a 3-month history of unsteady gait, incontinence, and slow thought processing. Brain magnetic resonance imaging reveals enlarged ventricles without prominent cortical sulci; no mass lesion is seen even after contrast administration. You consider the diagnosis of normal pressure hydrocephalus but her fundoscopic examination reveals the image below. Her visual examination is unremarkable.

1) How would you explain her abnormal retinal appearance?

A. This is a normal finding in middle-aged people and it is better left ignored

B. This is an old choroiditis, and possibly has no association with her current presentation

C. There are multiple foci of malignant melanoma, and her liver should be examined

D. This is proliferative retinopathy, and her serum glucose should be tested

E. This is a partial ocular albinism, and possibly has no association with her current presentation 

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Question 24, Neurology

Eccentric topic of the week: Neurology

Question 24:

A 34-year-old man is referred by his primary care physician as a difficult-to-manage case of headaches. The patient says that he has had migraine headaches for 4 years. The attacks are increasing in frequency and becoming less responsive to therapy. His family history is negative for migraine and he does not do drugs. He drinks occasionally but denies being a heavy drinker. He is married with 3 children and lives in a two-story house. This is the patient's T1-weighted magnetic resonance image of the brain:

What is the cause of these migraine headaches?

     A. Herpes simplex encephalitis

     B. Temporal lobe oligodendroglioma

     C. Cerebral arteriovenous malformation

     D. Idiopathic

     E. Cluster headache 

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