Neuro LONG

Question 1

MS - medication specifics

Answer 1

Fingolimod
Bradyarrythmia: monitor 6hrs (including if pause Rx for 6months)
Macular oedema (clock w/‘ecg$

Natalizumab: JC virus (especially)
- TEST first for Ab+ as ↑ risk for PML (progress multifocl leucoencephalopath)
(Natalie & john) letters MS

Ocrelizumab: only approved for Primary progressive, 6monthly infusion
P-O: primacy progrssive- send mail and goes - At post office N letter to MS

Alemtuzumab: time limited Rx, monthly bloods for 5y (despite Rx annual for 2y)

Cladribine: 2 Rxs 1 yr apart

Question 2

MS - types

Question 3

MS - Ix

Answer 3

Dissemination in time & space

MRI: inflammatory demyelination (white matter areas): need 2 of:
(i) periventricular
(ii) juxtacortical
(iii) infratentorial
(iv) SC (cervical) -
- Longitudinal extensive transverse myelitis/localised suggests NMO

CSF-specific oligoclonal bands that differs to serum (IgG typically)

BLOODS - exclude MS mimics
- Anti-Aquaporin4 (NMO) - esp bilateral optic neuritis/complete SC syndrome
- MOG-IgG
- Syphilus (treponemal Ab)
- B12
- Vasculitic screen (ANA/ENA, ESR)

JCV Ab! For natalizumab Rx & PML

Visual evked potentials

Question 4

Epilepsy
-Rx options (non pharm)
- specific hx & impact questions

Answer 4

If fail 2-3 oral Rx (ie refractory focal epilepsy), ?surgical Rx
Work up: Video EEG, neuroimaging, neuro psychology,
Suicide risk peri-op, adequate social support
Surg: temporal lobectomy, lesionectomy (if specific lesion identified), vagal nerve stimulation

Social hx - impact on driving, work, family

Potential predisposing factors:
Febrile seizures as infant
Head injury
FHx
Lifestyle: ETOH, sleep deprivaiton
Handed

Question 5

CVA syndromes & differentiates
(3)

Answer 5

1) TACI (total or partial anterior)
- motor/sensory of >2 face/arm/leg
- higher centre sx, corticol dysfxn (aphasia, neglect)
- hemianopia
- PACI: no hemianopia
2) POCI (posterior) 4 Ds + 2 Cs
- CN deficits without contralat motor/sensory
- bilat motor/sensory
- isolated visual field
- cerebellar without ipsilateral motor/sensory
- Lat medullary (PICA CVA) - vertebral artery
(i) split sensory loss face + contralat body
(ii) ipsilat cerebellar
(iii) bulbar CN
(iv) horner syndrome (ipsi)
(v) autonomic dysfxn: HR, BP
- Post cerebral art:
(i) contralat homony hemianopia + hemisensory loss
(ii) can write but not read, can’t name objects
3) LACI (lacunar)
- Motor/sensory: >2 of face, arm, leg
- Ataxic hemiparesis WITHOUT HEMIANOPIA
- Clumsy hand & dysarthria

Question 6

TACI/PACI CVA fx
Aetiology & prognosis

Answer 6

1) TACI (total or partial anterior)
- motor/sensory of >2 face/arm/leg
- higher centre sx, corticol dysfxn (aphasia, neglect)
- hemianopia

PACI: no hemianopia
Not severe enough to be TACI

Embolic typically, TACI is terrible prognosis
(60% death 1yr, <5% independent)
Region supplied: Most brain - prox M1 (complete MCA)
–> M2 (still frontal, divide superior/inferior consider quadrantinopia) –> ACA (front lobe only)

Question 7

POCI CVA fx (+ pneumonic)
Region supplied, Aetiology of CVA & prognosis

Answer 7

Region supplied
○ Brainstem (midbrain, pons, medulla)
○ Cerebellar
○ Occipital lobes
Fx: 4 Ds + 2 Cs
○ Dysarthria
○ Dysphagia
○ Diplopia
○ Dizziness
○ Crossed signs (CN w/ contral leg/arm)
○ Cerebellar signs
Fx
○ CN deficit w/ contralat motor/sensory
○ Bilateral motor/sensory
○ Isolated visual field
○ Cerebellar w/o ipsilateral motor/sensory deficit
· Insitu thrombosis
· Good prognosis

Question 8

Lacunar CVA fx
Aetiology & prognosis

Answer 8

3) LACI (25%)
○ Motor/sensory deficit involving ≥2 of: face, arm, leg (pure hemiparesis or hemisensory)
○ Ataxic hemiparesis WITHOUT hemianopia
○ Ie NO HIGHER CENTRE SIGN
○ More sml vessel than embolic
Good prognosis (60% independent)