Acute Neuro Flashcards
A 70-year-old right-handed man is discovered by a family member to have difficulty speaking and comprehending spoken language, and an inability to raise his right arm. On examination, power is 2/5 in his right arm, 4/5 in his right leg and 5/5 in his left arm and leg. A CT head scan is performed and an ischaemic stroke is diagnosed.
What type of stroke is it?
A) Left total anterior circulation stroke B) Right anterior cerebral artery stroke C) Left middle cerebral artery stroke D) Right middle cerebral artery stroke E) Left brainstem stroke
C) Left middle cerebral artery stroke
- difficulty speaking and comprehending speech + arm paralysis/power impairment on contralateral side = left middle cerebral artery (relative sparing of lower limbs)
- left total anterior - doesn’t have homonymous hemianopia
- right anterior - symptoms on the left, weakness worse in the leg than arm
- right middle - symptoms similar but on the left
- left brainstem - cranial nerve pathology more likely
Mrs Smith, an 85-year-old woman, is brought to A & E by her
husband. When she woke up this morning her husband
noticed that Mrs Smith’s smile looked strange and that she
was unable to move her right arm. She seemed fine last
night going to bed after watching the news as normal. On
examination she had right sided hemiparesis and a positive
Babinski sign. A CT-head done at the A & E excluded a
haemorrhage.
What is the next most appropriate step in her
management?
A) Carotid doppler B) 300mg aspirin, orally C) 75 mg clopidogrel, orally D) ECG E) IV alteplase
B) 300mg aspirin, orally
- <4.5 hours = IV alteplase
- > 4.5 hours (more likely given noticed in the morning) = 300mg aspirin
- carotid doppler - doesn’t solve acute problem, looks for carotid artery stenosis
- 75mg clopidogrel, orally - given after 2 weeks of aspirin in non-AF patients for stroke prophylaxis
- ECG - important to check for AF as cause but doesn’t solve acute problem
- IV alteplase - if <4.5 hours after symptom onset
A 16-year-old boy presents to A & E after collapsing on a cricket game. According to his cricket coach, the boy was unconscious for about one minute during which time, he was moving his arms and legs around. Further review revealed that he had experienced a similar episode a month before.
What is the most appropriate drug for this patient?
A) Sodium valproate B) Carbamazepine C) Lamotrigine D) Lorazepam E) Phenytoin
A) Sodium valproate
- describes generalised epileptic seizure, sodium valproate is first-line in generalised, carbamazepine second-line
- carbamazepine - 1st line for focal seizures, 2nd for generalised after sodium valproate
- lamotrigine - 2nd line for focal seizures
- lorazepam - Mx of status epilepticus
- phenytoin - for status epilepticus if lorazepam ineffective
A 62-year-old woman presents back pain and difficulty walking. On examination there is increased tone and hyper-reflexia in both legs. She has not opened her bowels or passed urine for the previous day. She has a past medical history of breast cancer, diagnosed two years earlier.
Which is the most likely diagnosis?
A) Guillain-Barré syndrome B) Spinal cord compression C) Spondylolesthesis D) Cauda equina syndrome E) Lumbosacral radiculopathy
B) Spinal cord compression
- back pain + difficulty walking + increased tone/hyper-reflexia in legs + no pooing or peeing = voluntary + autonomic symptoms = spinal cord compression
- breast cancer Hx may indicate spinal mets compressing spinal cord
- G-B syndrome - no autonomic features
- spondylolesthesis - cause of spinal compression as forward displacement of vertebra compresses nerve roots, but here compression is more likely to be mets
- cauda equina - would not have UMN symptoms (increased tone/rigidity + hyper-reflexia)
- lumbosacral radiculopathy - wouldn’t have UMN symptoms
A 20-year-old woman presents with pins and needles in both legs. Her symptoms rapidly progress over 4 days to include lower extremity weakness to the point that she is unable to mobilise her lower extremities. She reports gastrointestinal symptoms 2 weeks ago. Lumbar puncture reveals mildly elevated protein with no cells and normal glucose.Given the most likely neurological diagnosis which organism is most likely to have caused the gastroenteritis?
A) Salmonella B) Campylobacter Jejuni C) E. Coli 0517 D) Rotavirus E) Entamoeba histolytica
B) Campylobacter Jejuni
- 30% of Guillain-Barré syndrome cases occur after gastroenteritis infection with C. jejuni
- Salmonella/entamoeba - cause bloody diarrhoea
- E. coli 0517 (I thought it was 0157) causes foodborne illnesses (raw milk and beef) causes bloody diarrhoea
- Rotavirus - commonest cause of diarrhoeal disease in infants/young children
A 21-year-old woman presents to A & E with acute onset of left-sided body twitching, lasting for 5 minutes, after a minor accident in which she hit her head. She reports 3 similar episodes in the past month, after her boyfriend broke up with her. Past-medical history includes IBS for which she takes laxatives. Physical examination, laboratory investigations and imaging studies are normal.
What is the most likely diagnosis?
A) Dissociative seizure B) Simple partial seizure C) Vasovagal episode D) Todd’s palsy E) Myoclonic seizure
A) Dissociative seizure
- prolonged duration (5 minutes is long) with Hx of abuse or emotional precipitants with NORMAL biological state (resemble epileptic seizures but have NO biological correlate)
- simple partial - duration of seizure (>1 minute), the Hx and the normal findings O/E + Ix point away from epilepsy towards a more psychosomatic cause
- vasovagal episode - no evidence of precipitating factor and vagal symptoms (sweating/dizziness/light-headedness)
- Todd’s palsy - post-ictal flaccid weakness and exam is normal
- Myoclonic seizure - like simple partial, Hx/Ex/Ix not suggestive of epilepsy
