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38-year-old Caucasian female presents to your office because of sudden episodes of severe, right-sided facial pain. She describes the pain as "a knife stabbing my face." The pain lasts several seconds and is usually instigated by a meal or teeth brushing. There is no nausea or vomiting. She denies any visual changes. Her past medical history is significant for hyperlipidemia. She drinks alcohol socially and does not use tobacco. She has no family history of facial pain. Her vital signs are within normal limits, and physical examination shows no rash.

Educational objective: Trigeminal neuralgia presents with brief episodes of sudden and severe "electric shock-like" or "stabbing" pain in the distribution of CN V (particularly V2 and V3). Carbamazepine is the drug of choice.

Educational Objective: Symmetrical enlargement of the ventriculi is characteristic of communicating hydrocephalus. Communicating hydrocephalus usually occurs secondary to dysfunction or obliteration of subarachnoid villi. This dysfunction is usually a sequelae of meningeal infection (including tuberculosis meningitis) or subarachnoid/intraventricular hemorrhage.

A 64-year-old woman is evaluated for progressive gait disturbance over the last 2 years. The patient feels her feet are "stuck on the floor" and that she is unsteady while walking. She also recently began experiencing urinary urgency and has wet herself several times due to difficulty getting to the bathroom on time. The patient stopped working 6 months ago because of difficulty concentrating, and she has also lost interest in her hobbies and social activities. She has had no tremor, visual changes, headaches, nausea, or vomiting. The patient has a remote history of closed traumatic brain injury. Vital signs are within normal limits. On physical examination, lower extremity tone and deep tendon reflexes are increased. Sensation to light touch, pain, and vibration are normal. The patient's gait is slow with small steps and a wide base. CT scan of the head is shown below.

Educational objective: Normal pressure hydrocephalus presents with progressive gait difficulties, cognitive disturbances, and urinary incontinence. It is a form of communicating hydrocephalus characterized by ventriculomegaly without persistent elevations in intercranial pressure. Brain imaging reveals ventricular enlargement out of proportion to sulci enlargement.

A 55-year-old, right-handed woman is brought to the emergency department due to acute-onset headache and difficulty with vision. En route to the hospital, she becomes unconscious. Medical history is significant for hypertension. Blood pressure is 150/90 mm Hg and pulse is 90/min and regular. CT scan of the head without contrast demonstrates an acute hemorrhage in the left temporal lobe with compression of the anterior medial temporal lobe against the free margin of the tentorium cerebelli.

Educational objective: Uncal herniation is a possible complication of an expanding ipsilateral mass lesion (eg, hemorrhage, tumor). The first sign of uncal herniation is a fixed, dilated pupil on the side of the lesion. Contralateral or ipsilateral hemiparesis and contralateral homonymous hemianopsia with macular sparing may also occur.

Educational objective: Upper motor neuron lesions (ie, internal capsule stroke) cause contralateral weakness with clasp-knife spastic rigidity, hyperreflexia, and a positive Babinski sign. These lesions damage the pyramidal motor system (eg, corticospinal tracts), which runs from the precentral gyrus (primary motor cortex) through the internal capsule to the brainstem and spinal cord.