Case Files Neurology, Third Edition, 3rd Edition

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 DEDICATION

To my fellow Houstonians who braved the

devastating flood damage of Hurricane Harvey;
To the amazingly courageous and selfless first responders
and volunteers who went into harm’s way again and again
to rescue the children, men, women, and helpless;
To my fellow healthcare professionals, with whom I worked side by side,
to help all those who were displaced and in need of medical care;
To my fellow Texans who faced the biggest flooding disaster
to strike here—today we are submerged, but by uniting, tomorrow,
we will emerge stronger and more vibrant.
You are each my hero and inspiration.
—ECT

To my mentor and chair Stanley H. Appel—a living Giant of

Neurology who set a standard of excellence for the care and
evaluation of the neurology patient.
To my husband, Rodney, and our children,
Emmanuel, Christian, and Christopher.
To my Lord, Jesus Christ, the ultimate physician.
—EPS

To the late Dr. Frank Yatsu and my mentor and

friend Dr. Ian Butler for being excellent role models in
practicing clinical neurology.
—PM

To my amazing husband, Chris, and wonderful sons,

Hopson, Eason and Wells.
To my parents, my greatest fans, Jim and Jo Furr.
Thank you for allowing me to pursue my dreams.
—EFS

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 CONTENTS

Contributors / vii
Preface / xv
Acknowledgments / xvii
Introduction /xix
Listing of Cases / xxi

Section I
How to Approach Clinical Problems....................................................................1
Part 1. Approach to the Patient.................................................................................................. 3
Part 2. Approach to Clinical Problem-Solving....................................................................... 8
Part 3. Approach to Reading.....................................................................................................10

Section II
Clinical Cases.......................................................................................................15
Fifty-Four Case Scenarios
Movement Disorders (Cases 1-6)........................................................................................17
Trauma (Cases 7-8)...................................................................................................................63
Altered Mental Status (Cases 9-10)....................................................................................79
Stroke (Cases 11-13)................................................................................................................95
Seizures (Cases 14-17).......................................................................................................... 117
Headache (Cases 18-19)...................................................................................................... 151
Dementia (Cases 20-24)...................................................................................................... 173
Infection (Cases 25-31)........................................................................................................ 219
Cranial Nerve Disorders (Cases 32-37)........................................................................... 273
Motor Disorders (Cases 38-43).......................................................................................... 327
Pediatric Neurology (Cases 44-51).................................................................................. 379
Tumors (Cases 52-53)........................................................................................................... 441
Miscellaneous (Cases 54).................................................................................................... 459

Section III
Review Questions....................................................................................................................... 465

Index / 473

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 CONTRIBUTORS

Shivika Chandra, MD
Fourth Year Resident in Neurology
McGovern Medical School at Houston
Houston, Texas
Essential Tremor
Huntington Disease
Metastatic Brain Tumor
Parkinson Disease
Sixth Nerve Palsy

David Chiu, MD
Professor
Director, Eddy Scurlock Stroke Center
Methodist Neurological Institute
Weill-Cornell Medical College
Houston, Texas
Acute Cerebral Infarction
Stroke in Young Person

Nitish Chourasia, MD
Fourth Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Absence and Complex Partial Seizures
Stroke in a Young Patient

Shilpa Dass, MD
Third Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Amyotrophic Lateral Sclerosis (Pure Motor Weakness)
Foot Drop

John Eatman, MD
Assistant Professor
Department of Neurology and Neuromuscular Medicine
St. Luke’s Health System
Kansas City, Kansas
Ataxia, Spinocerebellar
Chronic Inflammatory Demyelinating Polyneuropathy
Dermatomyositis
Guillain-Barre Syndrome
Ptosis (Myasthenia Gravis)

Alireza Faridar, MD
Neuroimaging Fellow
Department of Neurology
Houston Methodist Hospital
Houston, Texas
Autism
Febrile Seizure (Seizures with Fever in Child)
New-Onset Childhood Seizure
Spinal Cord Injury, Traumatic
Tourette Syndrome

vii

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 viii CONTRIBUTORS

Stanley Fisher, MD
Associate Professor, Neurology
University of Missouri, Kansas City
Co-Director of Saint Luke’s Marion Bloch Neuroscience Institute
Kansas City, Missouri
Syncope Versus Seizure (Cardiogenic Syncope)
Tourette Syndrome

Keely M. Fitzgerald, DO
Fifth Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Cerebral Concussion
Duchenne/Becker Muscular Dystrophy

Stuart M. Fraser, MD
First Year Resident in Pediatrics
McGovern Medical School at Houston
Houston, Texas
Infections in Immunocompromised Hosts: Toxoplasmosis

Erin E. Furr-Stimming, MD
Associate Professor of Neurology
Chief of Neurology, LBJ Hospital
Director, Neurology Clerkship
Director, Huntington’s Disease Society of America Center of Excellence
McGovern Medical School at University of Texas Health Science Center (UTHealth) at Houston
Houston, Texas

Rajan Gadhia, MD
Assistant Professor, Neurology and Vascular Neurology
Methodist Neurological Institute
Weill-Cornell Medical College
Houston, Texas
Acute Cerebral Infarct
Delirium
Epidural/Subdural Hematoma
Stroke in a Young Patient
Subarachnoid Hemorrhage

Ankita Ghosh, MD
Second Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Meningioma of the Acoustic Nerve
Pediatric Headache

Paul Gidley, MD
Professor
Department of Head and Neck Surgery
The University of Texas MD Anderson Cancer Center
Houston, Texas
Facial Paralysis
Meningioma of the Acoustic Nerve
Vertigo

Vansanthi K. Gomathinayagam, MS
Fourth Year Medical Student
McGovern Medical School in Houston
Houston, Texas
Chronic Headache
Subacute Combined Degeneration of the Spinal Cord

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 CONTRIBUTORS ix

Mohammad I. Hirzallah, MD
Fourth Year Resident in Neurology
McGovern Medical School at Houston
Houston, Texas
Acute Disseminated Encephalomyelitis
Migraine Headache
Spinal Cord Injury, Traumatic
Tardive Dyskinesia

David H. Hunter, MD
Fifth Year Resident
McGovern Medical School at Houston
Houston, Texas
Alzheimer Dementia
Delirium from Head Trauma
HIV-Associated Dementia
Lewy Body Dementia
N-Methyl-D-Aspartate (NMDA) Receptor Encephalitis
Sporadic Creutzfeldt-Jakob Disease

Evan Johnson
Fourth Year Medical Student
McGovern Medical School at Houston
Houston, Texas
Adult Onset Seizure
Cardiogenic Syncope
Psychogenic Non-epileptic Seizures (Pseudoseizure)

Surabhi Kaul, MD
Third Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Autism
Tourette Syndrome

Pedro Mancias, MD
Professor
Assistant Dean, Diversity and Inclusion
Assistant Dean, Student Affairs and Admissions
Distinguished Teaching Professor
Adriana Blood Professor of Pediatrics
McGovern Medical School at University of Texas Health Science Center (UTHealth) at Houston
Houston, Texas
Dermatomyositis
Spinal Muscle Atrophy Type 1/Hypotonia in Infancy

Brooke McQueen, MD
Assistant Professor, Neurology
Department of Neurology
Houston Methodist Hospital
Houston, Texas
Benign Rolandic Epilepsy
Foot Drop
Median Nerve Mononeuropathy (Carpal Tunnel)
Psychogenic Non-epileptic Seizures (Pseudoseizure)

Ashkan Mowla, MD
Interventional Neuroradiology Fellow
UCLA
Los Angeles, California
Multiple Sclerosis
Optic Neuritis

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 x CONTRIBUTORS

Mohammad Obadah Nakawah, MD

Assistant Professor
Neurology and Neuroimaging
Houston Methodist Hospital
Houston, Texas
Absence and Complex Partial Seizures
Adult Onset Seizure
Tardive Dyskinesia

Sherwin Oommen, MD
First Year Resident in Pediatrics
McGovern Medical School at Houston
Houston, Texas
Seizures with Fever in Child
Spinal Cord Injury, Traumatic

Henry Ossó-Rivera, MD
Fifth Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Benign Epilepsy with Centrotemporal Spikes (BECTS)
Lissencephaly

Dustin Paul, DO
Fourth Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Chronic Inflammatory Demyelinating Polyneuropathy
Median Nerve Mononeuropathy (Carpal Tunnel)

Carlos A. Pérez, MD
Third Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Guillain-Barré Syndrome
Ptosis (Myasthenia Gravis)

Milvia Pleitez, MD
Neurology Practitioner
Houston, Texas
Anisocoria
Creutzfeldt-Jacob Disease
Delirium
HIV-Associated Dementia
Infant Botulism
Infections in Immunocompromised Hosts: Toxoplasmosis
Meningitis, viral
Neurosyphilis/Tabes Dorsalis

Kavya I. Rao, MD
Second Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Vertigo, Benign Paroxysmal Positional

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 CONTRIBUTORS xi

Jenny K. Riecke
Fourth Year Medical Student
McGovern Medical School at Houston
Houston, Texas
Acute Cerebral Infarct
Multiple Sclerosis
Optic Neuritis
Pseudotumor Cerebri/Idiopathic Intracranial Hypertension
Subarachnoid Hemorrhage

Sam N. Russo, MD
First Year Resident in Pediatrics
McGovern Medical School at Houston
Houston, Texas
New Onset Childhood Seizure

Parama Sahoo, MD
Kasturba Medical College
Mangalore, India
Meningitis, viral

Sheetal Shroff, MD
Assistant Professor, Neurology
Department of Neurology
Houston Methodist Hospital
Houston, Texas
HIV-Associated Dementia
Infections in Immunocompromised Hosts: Toxoplasmosis
Meningioma of the Acoustic Nerve
Metastatic Brain Tumor
Subacute Combined Degeneration of the Spinal Cord
Tabes Dorsalis

Ericka Simpson, MD
Associate Professor
Neurology Weill-Cornell Medical College
New York, New York
Co-Director MDA Neuromuscular Clinics and Director of ALS Clinical Research Division Methodist
Neurological Institute
Program Director
The Methodist Hospital Neurology Residency and Neuromuscular Fellowship
Houston, Texas
Acute Disseminated Encephalomyelitis (EDEM)
Anisocoria
Cerebral Concussion
Creutzzfeldt-Jakob Disease
Delirium
Dystonia
HIV-Associated Dementia
Infant Botulism
Infections in Immunocompromised Hosts: Toxoplasmosis
Lissencephaly
Meningitis, viral
Pediatric Headache
Spinal Muscular Atrophy Type 1
Tabes Dorsalis

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 xii CONTRIBUTORS

Stacy Smith, MD
Neurology, Neuro-ophthalmology, Headache
Department of Neurology
Houston Methodist Hospital Systems
Houston, Texas
Anisocoria
Cerebral Concussion
Chronic Headache
Migraine Headache
Multiple Sclerosis
Optic Neuritis
Pseudotumor Cerebri/Idiopathic Intracranial Hypertension
Sixth Nerve Palsy (Ischemic Mononeuropathy)

Allison L. Toy, RN
Registered Nurse
Baylor Scott & White Hillcrest Medical Center
Waco, Texas
Primary Manuscript Reviewer

Regina Troxell, MD
Fourth Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Ataxia, Spinocerebellar
Facial Paralysis

Amit Verma, MD
Associate Professor, Neurology
Director, Clinical Neurophysiology
Methodist Neurological Institute
Weill-Cornell Medical College
Houston, Texas
Absence and Complex Partial Seizure
Adult Onset Seizure
Benign Epilepsy with Centrotemporal Spikes
New Onset Childhood Seizure
Psychogenic Non-epileptic Seizures

John J. Volpi, MD
Assistant Professor, Neurology
Co-Director, Vascular Neurology
Director, Neurosonology
Methodist Neurological Institute
Weill-Cornell Medical College
Houston, Texas
Acute Cerebral Infarct
Cardiogenic Syncope
Stroke in a Young Patient
Subarachnoid Hemorrhage

Alise O. Welsh, FNP, MSN

Nurse Practitioner, Comprehensive Epilepsy Program
Texas Children’s Hospital
Clinical Instructor, Baylor College of Medicine
Houston, Texas
Acute Spinal Cord Injury
Benign Epilepsy with Centrotemporal Spikes
Pediatric Headache
Seizures with Fever in Child
Spinal Muscular Atrophy Type 1

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 CONTRIBUTORS xiii

Andrea C. Younes, MD
Second Year Resident in Child Neurology
McGovern Medical School at Houston
Houston, Texas
Infantile Botulism

Ashiq Zaman, MD
MHA Candidate
University of Oklahoma, College of Public Health
Oklahoma City, Oklahoma
Cardiogenic Syncope
Essential Tremor
Facial Nerve Paralysis
Parkinson Disease
Vertigo, Benign Paroxysmal Positional

Pamela J. Zelnick
Fourth Year Medical Student
McGovern Medical School in Houston
Houston, Texas
Anisocoria
Tabes Dorsalis

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 PREFACE

We appreciate all the kind remarks and suggestions from the many medical
students over the past 3 years. Your positive reception has been an incredible
encouragement, especially in light of the short life of the Case Files® series. In
this third edition of Case Files®: Neurology, the basic format of the book has been
retained. Improvements were made in updating many of the chapters. The new case
includes NMDA receptor encephalitis, paraneoplastic effects, and spinal muscular
atrophy type 1; a new section of Review Questions at the end of the book has been
included. We reviewed the clinical scenarios with the intent of improving them;
however, their “real-life” presentations patterned after actual clinical experience were
accurate and instructive. The multiple choice questions have been carefully reviewed
and rewritten to ensure that they comply with the National Board and USMLE
format. Through this third edition, we hope that the reader will continue to enjoy
learning diagnosis and management through the simulated clinical cases. It certainly
is a privilege to be teachers for so many students, and it is with humility that we
present this edition.

xv

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 ACKNOWLEDGMENTS

The curriculum that evolved into the ideas for this series was inspired by two
talented and forthright students, Philbert Yau and Chuck Rosipal, who have gradu-
ated from medical school. It has been a pleasure to work with Dr. Ericka Simpson, a
brilliant, compassionate, and dedicated teacher. It has also been an amazing experience
expanding our team working with Dr. Pedro Mancias, one of the brightest clinicians
and most talented educators I have encountered anywhere in the world, and Dr. Erin
Stimming, an excellent physician, teacher, and inspiration. I am greatly indebted to
my editor, Bob Boehringer, whose exuberance, experience, and vision helped to shape
this series. Likewise, Cindy Yoo has been a dream with whom to collaborate. I appre-
ciate McGraw-Hill’s believing in the concept of teaching through clinical cases. My
“family” at McGraw-Hill has been most gracious. I appreciate the support from my
encouraging Chair Dr. Sean Blackwell and my educational Vice Dean Dr. Patricia
Butler. I appreciate my feline companion Mithril, who is now in cat heaven, who
would sit at my desk and purr encouragements while I was editing. Most of all,
I appreciate my ever-loving wife Terri; and wonderful children, Andy and his wife
Anna, Michael, Allison, and Christina for their patience, encouragement, under-
standing, and “sharing their father” with my students and writing.

Eugene C. Toy

xvii

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