Cerebrovascular and diseases of consciousness Flashcards
What does a proto-oncogene mutation result in?
Results in promotion of cell division
What does a tumour suppressor gene mutation result in?
Results in loss of inhibition of cell division
What does a mutation of isocitrate dehydrogenase lead to?
Excessive build-up of 2-Hydroxyglutarate
Genetic instability in glial cells and subsequent inappropriate mitosis – leading to cancer
Description of grade I brain tumour
Slow growing
Least malignant
E.g. astrocytoma, craniopharyngioma
Description of grade II brain tumour
Slowly growing
Slightly abnormal appearance
May spread to nearby tissue
Description of grade III brain tumour
Malignant
Grow into nearby structures
Tend to recur
Description of grade IV brain tumour
Most malignant
Rapidly reproduce
Necrotic core
E.g. glioblastoma
Describe a glioblastoma
Type of astrocytoma
Grade IV
Occur in cerebral hemispheres
Prognosis <1yr
Describe a meningioma
Benign
Form under the dura mater
Grade I-III
Describe a oligodendroglioma
Form in the frontal lobes of the cerebral cortex
Grade II-III
IDH-1 mutation positive
7-10 years prognosis
Describe a craniopharyngioma
Form in the sellar region from remnants of Rathke’s pouch
Grade 1
Benign
Symptoms of raised ICP
Headache Drowsiness Nausea, vomiting Papilloedema 3rd, 4th, 6th nerve palsies Dilated pupils
Describe the headache that you would get with raised ICP
Worse on waking from sleep in the morning
Pain increases by coughing, straining, bending forwards
Relieved by vomiting
Symptoms with a tumour on the cerebellum
DASHING
Dysdiadochokinesis Ataxia Slurred speech Hypotonia Intention tremor Nystagmus Gait abnormality
Diagnosis of brain tumours
CT with contrast and MRI (high grade tumours have irregular edges)
Biopsy via skull burr hole to determine cancer grade
Treatment of brain tumours
Surgery to remove mass
Chemotherapy (Temozolomide, PCV)
Radiotherapy for 6 weeks (for high grade)
Oral dexamethasone for oedema
What is the primary use of EEG?
To diagnose epilepsy using inter-ictal and ictal recordings
What does a spike and wave on an EEG show?
Epileptiform discharge
Describe the Theta wave on EEG
4-7Hz
Normal physiological rhythm – seen frontally/frontocentral
Increases in drowsiness, focussed concentrations, hyperventilation
Describe the Alpha wave on EEG
8-12Hz Occipital Blocked with mental activity, and anxiety Abnormal if seen in front Drowsiness can reduce alpha by 1hz Alpha can be slow up to 7 yrs of age
Describe the Delta wave on EEG
< 4Hz
In a normal awake routine adult should only occupy <10% of the EEG
More in babies and elderly
Describe the Beta wave on EEG
Fast, 13Hz –20 Hz
Seen in drugs, esp. benzos / diazepam
Frontally
What is the hyperventilation technique in an EEG used to induce?
Childhood absence epilepsy
5 variables that can affect an EEG
Age of px Artifacts Conscious levels Drugs Co-existent cerebral pathology
Symptoms of West’s syndrome
3-12 months of age
Epileptic spasms, hypsarrhythmia, regression
Symptoms of Juvenile myoclonic epilepsy
5-34yrs
Myoclonic jerk <1sec
In mornings
Eye closure sensitivity – in 3 secs will see generalised spike and wave
What is epilepsy?
A recurrent tendency to spontaneous, intermittent, abnormal electrical and neuronal activity in part of the brain manifesting as a transient occurrence of signs and symptoms
Pathophysiology of epilepsy?
Fast/long lasting activation of glutamate NMDA receptors
OR
Genetic mutations of GABA receptors so cannot inhibit signals
Causes of epilepsy
2/3 are idiopathic Cortical scarring Space occupying lesion Stroke Alcohol withdrawal Dementia
Symptoms of a prodrome
Lasting hours or days
Change of mood/behaviour
Symptoms of an aura
Patient is aware
Deja vu / strange smells / flashing lights / hallucinations / fear
Symptoms of the post-ictal period
Headache, confusion, myalgia, sore tongue
Todd’s paralysis
Dysphasia
Diagnostic test for epilepsy
At least 2 or more unprovoked seizures occurring > 24hrs apart
OR
One seizure AND >60% chance that further seizures in the next 10 years (predisposition on MRI – stroke, tumour, encephalomalacia or EEG)
1st line drug for generalized seizures
Sodium valporate
If pregnant / woman of childbearing age then:
Lamotrigine
Carbamazepine
Levetiracetam
1st line drug for absence seziures
Ethosuximide
1st line drug for focal seizures
Carbamazepine
Criteria for medically intractable epilepsy
Reliable diagnosis
Need to be affecting quality of life – disabling seizures
2 drugs for 2 years need to be tried first
What is the driving guidelines for epilepsy?
Have to be free of seizures for 1 year
If coming off medications – no driving for 6 months after withdrawing from antiepileptics
What is status epilepticus?
Convulsive seizures >30 mins or multiple seizures without recovery of consciousness
Acute causes of status epilepticus
Stroke Metabolic abnormalities Hypoxia Infections Drug overdoses
Chronic causes of status epilepticus
Low conc. of AED
Alcohol misuse
Tumour
Pathophysiology of continued status epilepticus
GABA inhibitory receptors start to internalise and are no longer available
Glutamate and NMDA receptors lead to continued excitement
Potency of benzodiazepines reduces by ___ in ____ minutes in status epilepticus
20x
30 mins
Symptoms of non-convulsive status epilepticus
Seizures activity on EEG without clinical findings of generalised convulsive status epilepticus
Wandering confused, automatisms
Acutely ill, obtunded +/- motor abnormalities
Anorexia, aphasia / mutism, amnesia, catatonia, coma, confusion, lethargy, and staring
Agitation / aggression
Automatisms, blinking, facial twitching
Delusions, echolalia, laughter, nausea/vomiting
Nystagmus/eye deviation
Psychosis
Complications of status epilepticus
Airway obstruction, hypoxia, injury Increased CNS metabolic consumption Rhabdomyolysis Renal failure – acute tubular necrosis Metabolic acidosis Hyperthermia Major organ failure Cerebral oedema
In status epilepticus if the px is fitting for >5 min what do you give them?
Benzodiazepine (lorazepam / diazepam)
In status epilepticus if the px is fitting for >10 min what do you give them?
IV PHENYTOIN 18mg/kg (max rate 50kg /min)
OR
IV LEVETIRACETAM 30mg/kg (infuse over 10 mins)
OR
IV SODIUM VALPROATE 30mg/kg (infuse over 5 mins)
OR
IV PHENOBARBITAL 10mg/kg (max rate 100mg / min)
In status epilepticus if the px is fitting for >30 min what do you give them?
Anaesthesia with paralysing drug e.g. suxamethonium and ICU admission
What are the differential diagnosis for epilepsy?
Epileptic seizure
Syncope
Psychogenic nonepileptic seizure (NEAD)
What is syncope?
Reversible loss of consciousness due to short-term inadequate blood flow to the brain - transient global cerebral hypoperfusion
Symptoms of vasovagal syncope
Pallor, sweating, nausea
They know they are going to pass out
Lack of post-ictal confusion, hearing people around you before you can respond
Causes of orthostatic hypotension
Volume depletion - haemorrhage, vomiting, diarrhoea
Autonomic failure - parkinson’s, old age
Drop in what blood pressure suggests postural hypotension?
20mmHg systolic / 10mmHg diastolic
Symptoms of NEAD
Wax/wane, pelvic thrusting, crying / screaming, thrashing, sometimes responsive, self-harm
Resemble epileptic seizures, but without ictal cerebral discharges; asynchronous movements
Unaware and unresponsive
Emotionally labile
Minimal confusion
Investigations for transient loss of consciousness
12 lead ECG
Neuroimaging
What is a stroke?
Rapid onset of neurological deficit caused by infarction. Characterised by rapidly developing signs of global disturbance lasting >24hrs or death
Risk factors for stroke?
Male Black or Asian Hypertension Past TIA Smoking Diabetes mellitus Increasing age Heart disease Alcohol Polycythaemia, thrombophilia AF Hypercholesterolaemia Combined oral contraceptive pill Vasculitis Infective endocarditis
Ischaemic causes for stroke
Thrombosis - large artery disease
Cardiac emboli
Lacunar infarct - small artery disease
Hypoperfusion - sudden drop in BP by more than 40mmHg
Causes of haemorrhagic stroke
Cerebral amyloid angiopathy (main) Trauma Aneurysm rupture Carotid artery dissection Anticoagulation
Causes for strokes in young people
Vasculitis Thrombophilia Subarachnoid haemorrhage Carotid / vertebral artery dissection Venous sinus thrombosis Recreational drugs
What is the TOAST classification for stroke?
- Large-artery atherosclerosis
- Cardioembolism
- Small-vessel occlusion
- Stroke of other determined aetiology
- Stroke of undetermined aetiology
Symptoms of a ACA stroke
Leg weakness Truncal ataxia Incontinence Akinetic mutism Drowsiness
Symptoms of a MCA stroke
Contralateral arm and leg weakness Hemianopia Aphasia Dysphasia Facial droop
Symptoms of a PCA stroke
Contralateral homonymous hemianopia
Unilateral headache
Visual agnosia
Colour naming and discriminate problems
Symptoms of a brainstem / cerebellum infarct
Locked in syndrome Hemiparesis Facial paralysis Dysarthria and speech impairment Vertigo, nausea and vomiting Visual disturbance Altered consciousness
Symptoms of a lacunar stroke
Unilateral weakness
Pure sensory loss – thalamus
Ataxic hemiparesis – pontine lesion
Dysarthria / clumsy hand - pons, internal capsule
First line investigation for stroke
Urgent CT head / MRI (diffusion weighted imaging)
When are carotid dopplers done in stroke?
The px is relatively well after stroke
If surgery is needed
If anterior circulation affected
Describe the thrombolysis treatment for stroke
Given upto 4.5hrs post onsent of symptoms
- Tissue plasminogen activator - IV ALTERPLASE 0.9mg/kg
- Then antiplatelet therapy - CLOPIDOGREL / ASPIRIN 24hrs after thrombolysis
- Repeat CT scan after 24hrs
Contraindications for thrombolysis
Recent surgery last 3 months History of active malignancy INR >1.7 Severe liver disease Head trauma <3 months Recent MI <6 weeks NHISS score <4 Large hypodense area on MRI (>1/3 of MCA territory)
How do you treat stroke if time of onset is unknown?
ASPIRIN 300 mg daily for 2 weeks then lifelong CLOPIDOGREL 75mg
How do you reverse warfarin in haemorrhagic stroke?
Beriplex and vitamin K
When would you do a thromboectomy?
Needs to be a large vessel occulsion
6hrs for ACA, 2hrs for basilar
What is malignant MCA syndrome and how do you treat it?
Occurs when cell death causes swelling, pushing on brain and reducing GCS. Treated with decompressive hemicraniectomy
In ischaemic stroke when would you give statins? What statins would you give?
If cholesterol is >3.8
Simvastatin 40mg or storvastatin 80mg
What platelet treatment would you give to prevent further strokes?
ASPIRIN 300mg 14 days/discharge then switch to CLOPIDOGREL 75mg (long-term prophylaxis)
What should INR be when on warfarin?
2-3
What does the CHADS2VaSc score measure? List what it stands for
Measures stroke risk in patients with AF
Congestive heart failure Hypertension Age > 75yrs (2) Diabetes Prior stroke / TIA (2) Vascular disease Age 65-74 Female sex
At what score on the CHADS2VaSc risk scale would you give warfarin?
2
What does the HASBLED score measure and what does it stand for?
Risk of bleeding with anticoagulation
Hypertension Abnormal renal or liver function Stroke Bleeding Labile INRs Elderly (>65yrs) Drugs or alcohol
List three factors important in the mechanism of stroke recovery
Adaptation
Regeneration
Neuroplasticity
What is the difference between primary and secondary headache?
Primary - no underlying cause relevant to the headache
Secondary - there is an underlying cause
Clinical presentation of tension headache?
Episodic Bilateral temporal pain Pressing / tight Mild / moderate intensity Scalp muscle tenderness Not aggravated by activity No nausea / vomiting
Treatment of tension headache?
Pain medication
Tricyclic antidepressants
Stress relief; avoid triggers
Triggers of migraine?
Chocolate Hangovers Orgasms Cheese Oral contraceptives Lie-ins Alcohol Tumult (loud noise) Exercise
Clinical presentation of migraine?
Unilateral pounding/pulsating pain lasting 4-72hrs
Visual / somatosensory aura
Nausea / vomiting
Photophobia / phonophobia
Treatment of migraine
Sumatriptan
NSAIDs
Propranolol
Clinical presentation of cluster headaches?
Headache ‘clusters’ of 8-10x a day, lasts 15mins-3hrs
Shooting / stabbing around one eye / temple / forehead; can wake from sleep
Horner’s syndrome
Clinical presentation of Horner’s syndrome?
Miosis
Ptosis
Anhidrosis
Treatment of cluster headaches?
Acute attack - sumatriptan
Verapamil as first line prophylaxis
Clinical presentation of trigeminal neuraglia headaches?
Unilateral Paroxysmal attacks 1sec-2mins Severe intensity Electric shock like Precipitated by innocuous (non-harmful) stimuli
Treatment of trigeminal neuraglia headaches?
Oral carbamazepine
Surgery (microvascular decompression; gamma knife surgery)
Clinical presentation of drug overdose headache
Headache present on ≥ 15 days / month
Regular use for >3 months of 1+ drugs
What organism is most likely to cause meningitis in 1-23month old children?
Neisseria meningtides
What organism is most likely to cause meningitis in those >50years?
Strep. pneumoniae
Clinical presentation of meningitis
Sudden onset HEADACHES FEVER NUCAL RIGIDITY Confusion Vomiting Papilloedema BRUDZINSKI’S SIGN KERNIG’S SIGN Petechial rash + signs of sepsis
WBC count of 500-10,000 neutrophils would be seen in the CSF of which type of meningitis?
Bacterial meningitis
Which type of meningitis would you see normal glucose in the CSF?
Viral meningitis
How do you treat bacterial meningitis?
Oral DEXAMETHASONE 0.15mg/kg qds for 4 days if unknown or S. pneumonia
IV CEFOTAXIME or IV CEFTRIAXONE (for N. meningitis)
If > 50/immunocompromised then add IV AMOXICILLIN 2g to cover Listeria
If presenting in GP then give IM BENZYLPENICILLIN
How do you treat TB meningitis?
12 months of rifampicin, isoniazid, pyrazinamide, ethambutol
What do you add to treatment of meningitis if underlying HIV infection or cryptococcal meningitis?
Liposomal amphotericin b (AmBisome) + flucytosine for 2 weeks
What is the most common organism to cause encephalitis?
Herpes simplex virus 1 & 2
Which lobes does HSV encephalitis mainly affect?
Frontal and temporal lobes
What are the symptoms of HSV encephalitis?
Disorientation
Fever, chills, malaise
Speech disturbance
Hypo-mania, irritability
Treatment of HSV encephalitis?
Acyclovir for 14-21 days
Clinical presentation of shingles / herpes zoster?
Rash in the same dermatome
Diagnosis of shingles / herpes zoster?
Tzanck test (multinucleated giant cells in the fluid of the vesicles)
CSF HSV-1 DNA PCR (48hrs-10days)
CSF HSV antivosy from 10 days
Treatment of shingles / herpes zoster?
Acyclovir 5x daily
What is Ramsey Hunt syndrome?
Bell’s palsy and loss of hearing and rash around ear
What is amaurosis fugax?
Sudden transient loss of vision in one eye
Temporary reduction in the retinal ophthalmic or ciliary blood flow leading to temporary retinal hypoxia
What is the main cause of TIA?
Atherothromboembolism from the carotid
What imaging would you do in a TIA?
Carotid artery doppler to look for stenosis
(If significant stenosis within then endarterectomy within 2 weeks)
MRI/CT angiography to determine extent of stenosis
What does the ABCD2 score measure and what are its features?
Risk of stroke after TIA
Age > 60 yrs = 1 Blood pressure > 140/90mmHg = 1 Clinical features (Unilateral weakness = 2; Speech disturbance without weakness = 1) Duration of symptoms (symptoms lasting ≥ 1hr = 2; symptoms lasting 10-59min = 1) Diabetes = 1
Antiplatelet treatment for TIA?
Aspirin 300mg immediately
Continue clopidogrel 75mg 1x daily
Definition of traumatic brain injury
Alteration in brain function; evidence of brain pathology caused by external force
What is a contusion injury?
Bruising of the brain (large contusion = hemorrhage)
What is a contrecoup injury?
Diffusion of the force - more diffuse injury opposite to the side of the blow
How would you define a mild traumatic brain injury?
LOC <30 min
No skull fracture
PTA <1 day
How would you define a moderate traumatic brain injury?
LOC >30 mins and <24hrs
With/out skull fracture
PTA >1day <7days
How would you define a severe traumatic brain injury?
LOC >24hrs
With contusion, haematoma, or skull fracture
PTA >7 days
When do you do a CT scan with a traumatic brain injury?
GCS < 13 at any time GCS < 15 at 2hrs post injury Basal skull fracture Seizures > 1 episode of vomiting Antegrade amnesia > 30 min No improvement in 4 hours Severe symptoms
Immediate management of traumatic brain injury
IV fluids Glucose Early CT scan If seizures - Diazepam 10 mg PR/IV If opiods - Nalaxone 0.4 mg IV If alcohol - Thiamine 100 mg IV If tricyclics - Physostigmine 1 mg IV If Benzodiazepines - Flumazenil 0.2 mg IV over 30 sec If ICP - Mannitol
Risk factors for venous sinus thrombosis?
Virchow’s triad:
Stasis of blood flow
Endothelial injury
Hypercoagulability
What sign does a CT scan show for venous sinus thrombosis?
Dense triangle sign
Clinical presentation of venous sinus thrombosis?
Isolated intracranial hypertension
Raised ICP esp. worse lying flat, visual obscuration with postural change and pulsatile tinnitus
Management of venous sinus thrombosis?
LMWH
What are some unusual causes of stroke?
Vasculitis Arterial dissection Cerebral venous sinus thrombosis Antiphospholipid antibody syndrome Cocaine use Degenerative amyloidosis (CAA) Degenerative moya moya MELAS syndrome Fabry's disease Myxoma
Name some stroke mimics
Brain tumour CNS infection Falls / trauma Hypoglycaemia Migraines Multiple sclerosis Seizure Haemorrhage Vertigo Hyponatraemia /hypercalcaemia/Wernickee’s Nonketotic hyperosmolar hyperglycaemia Paroxysmal symptoms MS Cervical Cord Neuropraxia Transient global amnesia
What system is involved in disorders of consciousness?
The ascending reticular activating system
Symptoms of a coma?
Unrousable Unresponsive >6 hours Cannot be wakened Lacks normal sleep-wake cycle No voluntary actions
How do you diagnose permanent vegetative state?
VS >6 months after nontraumatic brain damage OR
VS 12 months after traumatic brain injury
How do you assess minimally conscious state?
Purposeful behaviour
Following simple commands
Verbal / gestured yes or no
Intelligible verbalisations
How do you emerge from minimally conscious state?
Functional interactive communication on two consecutive evaluations
Functional use of two different objects on two consecutive evaluations
What is brainstem death?
Declared when brainstem reflexes, motor responses and respiratory drive are absent in a normothermic, non-drugged comatose patient with an irreversible widespread brain lesion of known cause and no contributing metabolic derangements
What are the common arteries that cause intracerebral haemorrahge?
Lenticulostriate
Thalamoperforators
Paramedian branches of the Basilar Artery
What is the main cause of lobar intracerebral haemorrahge?
Cerebral amyloid angiopathy
What is the main surgical treatment for intracerebral haemorrhage?
External ventricular drainage / ventriculostomy
Main cause of subarachnoid haemorrhage?
Berry aneurysm
Presentation of subarachnoid haemorrhage?
Thunderclap headache Nuchal rigidity Seizures Symptoms of raised ICP Kernig / Brudzinski's sign Papilloedema
What imaging would you use for a subarachnoid haemorrhage and what will it show?
CT scan
Star shaped lesion
Treatment for subarachnoid haemorrhage?
Clip artery and endovascular coiling
Calcium channel blockers
What is the main cause of a subdural haemorrhage?
Accumulation of blood in the subdural space following rupture of a bridging vein between the cortex and venous sinus
Presentation of subdural haemorrhage?
Headache Personality change Unsteadiness Seizures Coma Raised ICP symptoms
What shape would you see on CT scan for a subdural haemorrhage?
Crescent shape
Treatment for subdural haemorrhage?
IV mannitol
Drained fluid / craniotomy
What is an extradural haemorrhage?
Collection of blood between the dura mater and the bone caused by head injury
What artery is most likely to be damaged in an extradural haemorrhage?
Middle meningeal artery
Presentation of extradural haemorrhage?
Lucid interval Severe headache Nausea Vomiting Ipsilateral pupil dilates Coma Bilateral limb weakness Breathing becomes deep and irregular
What would you see on CT scan for a extradural haemorrhage?
Hyperdense mass that is biconvex shaped and adjacent to the skull
Diagnosis of insomnia?
Difficulty falling asleep / waking up throughout the night / waking up in the early-morning and then struggling to fall asleep / hypnic phenomena
Must be present >3x a week for 3 months
Clinical presentation of narcoplexy?
CHESS
Cataplexy Hallucinations Excessive daytime sleepiness Sleep paralysis Sleep disruption
Diagnostic test and diagnostic criteria for narcoplexy
Multiple sleep latency test
At least one of:
Episodes of cataplexy
Hypocretin deficiency
Reduced REM latency
Clinical presentation of obstructive sleep apnea
At night: Breathing stopping and starting, gasping noises, loud snoring
At day: feeling very tired, headache on waking
Treatment of obstructive sleep apnea
Continuous positive airway pressure
How is HIV transmitted?
Sexual intercourse IV drug abuse Mother to child Accidental needle sticks Blood products
Which cells does HIV target?
CD4+ cells
What happens after HIV enters the body?
Acute infection - acute HIV syndrome Large spike in HIV replication Amount of virus in blood declines Latent phase (2-10yrs) (no. of virus in blood slowly increases; no. of T cells in blood decreases) AIDS
At level do the CD4+ cells need to fall below to be classified as AIDS?
200cells/mm3
Symptoms of seroconversion in HIV?
Fever Malaise Myalgia (muscle pain) Pharyngitis (sore throat) Maculopapular rash Significant weight loss
Name some AIDS defining conditions
Candidiasis oesophageal/lung (fungal infection) Extra-pulmonary cryptococcosis Cryptosporidiosis >1 month Mycobacterium TB Persistent herpes simplex (cold sores) Pneumocystis jiroveci (carinii) pneumonia Recurrent bacterial pneumonia Cytomegalovirus (CMV) Recurrent salmonella septicaemia
Invasive cervical carcinoma
Kaposi’s carcinoma
Primary CNS lymphoma
Non-Hodgkin’s lymphoma
HIV dementia/encephalopathy
HIV associated wasting
How do you diagnose HIV?
HIV viral load (RNA copies/ml) (from 2 weeks)
Detection of IgG antigen/antibody test (6 weeks)
What is highly active antiretroviral therapy for HIV?
2 NRTI + 1 NNRTI OR
2 NRTI + 1PI
Nucleoside reverse transcriptase inhibitors (NRTI)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Protease inhibitors (PI)
Clinical presentation of toxoplasmosis encephalitis
Fever, headache, altered mental status, focal neurology, seizures
Extracerebral disease – lung, eye, muscle (calcified cysts in muscles)
Clinical presentation of primary CNS lymphoma
Confusion, lethargy, memory loss, hemiparesis, aphasia, seizures
+/- Constitutional symptoms (fever/weight loss/night sweats)
Clinical presentation of tuberculous meningitis
Fever, headache, meningism, weight loss, fluctuating GCS
Clinical presentation of cryptococcal meningitis
Fever, headache, meningism, photophobia, vomiting
What is progressive multifocal leukoencephalopathy?
Severe demyelinating disease of CNS
Reactivation of John-Cunningham virus (acquired asymptomatically in childhood, then latent)
Treatment for toxoplasmosis encephalitis
Initial therapy (6 weeks) - sulfadiazine and pyrimethamine
Steroids
Maintenance therapy (prophylaxis)
Anti-retroviral therapy after 2 weeks
Diagnosis and treatment of primary CNS lymphoma
Stereotactic biopsy (diagnosis)
High dose methotrexate (every 2 weeks 8-12 weeks)
Diagnosis of cryptococcal meningitis
CSF cryptococcal antigen
Treatment of cryptococcal meningitis
Acutely - Liposomal amphotericin B + flucytosine or fluconazole (antifungal) (2 weeks)
Consolidation - fluconazole 400mg, 8 weeks
Clinical presentation of progressive multifocal leukoencephalopathy?
Altered mental state, motor deficit, ataxia, hemianopia
Subacute months – years
