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Figure A. Noncontrast T2-weighted magnetic resonance image (MRI)
Questions 1 to 2 refer to the following case.
A 62-year-old man presents to the emergency department (ED) for evaluation of leg weakness that started 4 hours prior to arrival. The patient states that his right leg suddenly became weak while walking and he had great difficulty being helped to a chair. He delayed seeking medical help, hoping that symptoms would improve, but they have not. Past medical history is significant for a heart attack 3 years ago, hypertension, hyperlipidemia, type 2 diabetes mellitus, and chronic neck and low back pain for the past 5 years. He has not taken any medications for the past month due to financial hardship. On examination, the patient is profoundly weak with all movements of the right leg, has mild weakness in the right arm, and has sensory loss over the entire right leg. Coordination and gait seem to be limited by his weakness. An electrocardiogram shows normal sinus rhythm.
1. What is this patient’s most likely diagnosis?
- Acute C6-C7 disk herniation
- Acute compression fracture of the L2 vertebral body
- Acute left anterior cerebral artery (ACA) stroke
- Acute left middle cerebral artery stroke
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2. Noncontrast computed tomography (CT) of the head performed within 30 minutes of arrival in the ED reveals no acute findings. Assuming that the patient’s reported medical history is complete and accurate, what is the most appropriate treatment?
- Aspirin 325 mg
- Intravenous (IV) ketorolac 30 mg
- IV alteplase 0.9 mg/kg as 10% dose bolus then infusion
- IV heparin drip with weight-based dosing to the therapeutic partial thromboplastin time goal
- Placement of a rigid cervical neck stabilization collar
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3. A 43-year-old woman presents to the ED for evaluation of weakness in both legs. She has an 18-year history of multiple sclerosis (MS), and she has had several clinical relapses. Glatiramer is her only medication. A relapse 2 years ago caused profound weakness in her legs, but after months of physical therapy, she was able to ambulate steadily with a walker. She now describes worsening weakness in her legs over the last 24 hours similar to that experienced during the relapse 2 years ago. She has new urinary incontinence, describes feeling feverish overnight, and is preoccupied with an intense ache in her left flank that has been present for the last 2 days. Magnetic resonance imaging (MRI) of the spine with and without contrast is performed (Figure). How should this patient be treated?
- Antibiotics for treatment of a urinary tract infection (UTI)
- Antibiotics for treatment of a UTI and concurrent IV methylprednisolone 250 mg every 6 hours for 3 days
- Change from glatiramer to high-dose interferon beta-1a
- IV methylprednisolone 250 mg every 6 hours for 3 days
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Figure B. T1-weighted postcontrast MRI of the thoracic spine of the patient described in question 3
Questions 4 to 5 refer to the following case.
A 62-year-old man presents to the ED for evaluation of a 1-day history of leg weakness. He reports weakness in both legs while walking, and he now needs help standing up from a seated position. Past medical history is significant for a heart attack 3 years ago, hypertension, hyperlipidemia, type 2 diabetes mellitus, and lung cancer. An evaluation 3 months ago revealed no evidence of metastatic disease. He reports chronic neck and low back pain for the past 5 years. The patient also describes increasing pain in his mid-back over the past few weeks, which is not relieved by pain medication. On examination, the patient is profoundly weak with all movements of both legs but has no weakness in his arms. He has diminished sensation from the level of the umbilicus down. Reflexes are brisk in the legs and Babinski’s sign is present in both feet. Coordination and gait seem to be limited by his weakness.
4. What is this patient’s most likely diagnosis?
- Acute C6-C7 disk herniation
- L2 vertebral body metastatic lesion causing epidural cauda equina compression
- Transverse myelitis at the T9 level of the spinal cord
- T10 vertebral body metastatic lesion causing epidural spinal cord compression
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5. What is the most appropriate next step in this patient’s management?
- CT of the spine with and without contrast
- IV dexamethasone 24 mg
- MRI of the spine with and without contrast
- Neurosurgical consultation for immediate surgical management
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6. A 62-year-old man presents to the ED for evaluation of right leg weakness. Two hours prior to arrival, the patient fell asleep in a chair with his legs crossed while watching television. When the patient awoke, he realized that his right leg had become weak. He tried walking, but it was difficult, and he had to be helped back to his chair by his wife. After 15 minutes, symptoms had not improved. He denies any pain accompanying these symptoms. Past medical history is significant for a heart attack 3 years ago, hypertension, hyperlipidemia, type 2 diabetes mellitus, low back pain for the past 5 years due to degenerative disk disease, and sciatica in the right lower extremity. He has not taken any medications for the past month due to financial hardship. On examination, he has complete inability to dorsiflex or evert the right foot but normal strength elsewhere. He has slight sensory loss over the dorsum of the right foot. Gait is affected by a right foot drop. What is the patient’s most likely diagnosis?
- Flare of right lower extremity sciatica
- L5 vertebral body compression fracture
- Lacunar infarct in the left internal capsule
- Pressure palsy (neurapraxia) of the right peroneal nerve
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