302.An 87-year-old man had been sitting on the toilet when suddenly he
fell to the left side against an adjacent wall. Fortunately his wife was in the
adjoining bedroom and had heard him hit his head against the tile wall and
found him partially wedged against the wall. His wife left him to call 911,
and then went back to him. While he was conscious, he had difficulty
speaking and had little control of his left side, though he had some move-
ment. The paramedics arrived and lifted him from his stuck position and
gave him oxygen during the ambulance ride, hooked up ECG leads, and
found normal heart rhythm and patterns. By the time he got to the emer-
gency room, he was a little more responsive and had slurred speech. A
head CT was immediately performed and was read as normal other than
slight shrinkage of the brain, typical of an 87-year old. He then reported he
had a bad headache and stiff neck. There was no papilledema, so a spinal
tap was performed since they didn’t know whether to start tissue plas-
minogen activator (TPA) treatment or not. The spinal tap was quickly per-
formed and had some blood within all four tubes collected, so TPA was not
initiated. Which of the following is the most likely diagnosis?
a. Subarachnoid hemorrhagic stroke, which had stopped by the time the CT, was
performed
b. Ischemic stroke, which had opened by the time the CT was performed
c. Subdural hematoma
d. Epidural hematoma
e. Alzheimer’s dementia
303.A patient is observed to suffer from hypoglossal hemiplegia. There is
atrophy of the tongue on the right side and deviation of the protruded
tongue to the right. In addition, the patient exhibits upper motor neuron
paralysis of the left side of the body. Deviation of the tongue toward the
right involves which of the following?
a. Left nucleus ambiguus
b. Left pyramidal tract caudal to the decussation
c. Right hypoglossal nerve
d. Right nucleus ambiguus
e. Right pyramidal tract rostral to the decussation
Head and Neck 421