Neurological Disease Chapter 55.Neurological Compications of Systemic Disease Chapter 55A. In Adults

Question 1

Question 55A-1:
A 65-year-old man presents with left hemiparesis and sensory toss with incomplete hemianopia. CT shows a small area of early edema in the right hemisphere with cortical and subcortical involvement in the parietal area. ECG shows new atrial fibrillation. Which is the most appropriate approach to management of anticoagulation?
A. Immediate anticoagulation
B.Repeat scan the following day and consider anticoagulation if there is no hemorrhage or the infarction is not large
C. Repeat the scan after one week and anticoagulate if there is no bleeding
D. Anticoagulate one month after the stroke, if he is neurologically stable or improving

Answer 1

Answer 55A-1: B.
Anticoagulation carries significant risk of
hemonbage in patients with cardioembolic
stroke from atrial fibrilation. Warfarin has
been shown to reduce the incidence of stroke
in these patients, although this is a long-term
effect, and not an immediate stroke. Rescan to
ensure that there has been no hemorrhagic
transformation is appropriate. If there is small
infarction clinically and on scan. then
institution of anticoagulation is appropriate.
Delay of one or more weeks should be
considered only if there has been a large
stroke. (p1074)

Question 2

Question 55A-2:
A 54-year-old female is resuscitated following out-of-hospital cardiac arrest. She is comatose initially, but arouses over several hours. She is starting to respond purposefully by the next day. One week later she loses the ground she has gained and slips back into decreased mentation, cortical blindness, then unresponsiveness. Which is the most likely cause?
A. Acute cardioembolic infarction
B. DIC with multiorgan failure
C. Late demyelinating encephalopathy
D. Aortic dissection as a late complication of resuscitation

Answer 2

Answer 55A-2: C.
Late demyelinating encephalopathy is
characterized by deterioration following an
initial phase of recovery. Patients seem
initially to be improving following
unresponsiveness, then 7-10 days later show
progressive neurologic deficits including
cognitive dysfunction. pyramidal and
extrapyraoUdalabnormalities,cortical
blindness, and possible death. The other listed
disorders are all possibilities in this setting,
but they are either less likely or there is no
evidence for them in the information given.
(p1075)

Question 3

Question 55A-3:
Which of the following statements are true concerning cognitive disturbance in patients following cardiac bypass surgery?
A. Cognitive disturbance is rare
B. Cognitive disturbance is related to hypotension or cerebral emboli
C. Cognitive disturbance recovers within one year from surgery
D. All are true

Answer 3

Answer SSA-3: B.
Cognitive disturbance after CABG is not rare,
having been detected in 53% of patients at
discharge and 42% of patients at 5 years. Most
patients do improve, although these data
suggest that long-term deficit is common. The
caus~ is thought to be either cerebral emboli
or global cerebral hypoperfusion from
hypotension during or after surgery.
Occasionally, patients will develop late
neurologic deterioration, although the reason
for this is undetermined. (p 1075)

Question 4

Question 55A-4:
A 60-year-old man presents with tremor and ataxia. Imaging studies and routine laboratory tests are normal. In eliciting the history, the patient reports taking metaclopramide, sertraline, amiodarone, and propranolol. Which of these agents are likely to contribute to the clinical presentation?
1. Propranolol
2. Amiodarone
3. Sertraline
4. Metoclopramide
Select: A = 1,2,3. B = 1.3. C = 2, 4. D=4 only. E = All

Answer 4

Answer 55A-4: C.
Amiodarone can cause ataxia and tremor and
metaclopramide can cause extrapyramidal
adverse effects which can resemble
Parkinson’s disease. The other two have the
potential for neurologic complications but are
unlikely to produce this presentation. (p 1076)

Question 5

Question 55A-5:
Which of the following statements are true regarding neurologic complications of systemic lupus erythematosus?
1. Neurologic complications are present in more than 50% of patients
2. PNS involvement of SLE is more common than central involvement
3. The most common neurologic complications ofSLE are psychiatric disorders
4. Stroke in patients with SLE is due to antiphospholipid antibodies
Select: A = 1.2,3. B = 1, 3. C = 2, 4. D =4 only. E = All

Answer 5

Answer 55A-5: B.
Neurologic complications of SLE are
common. present in up to 75% of patients.
Central complications are more comtllOn than
peripheral complications, and psychiatric
symptoms including affective disturbance and
psychosis are the most common. Focal signs
can develop due to infarction which may be
related to antiphospholipid antibody
syndrome, but may also be due to cardiac
valvular disease or cerebral vasculitis. (p 1083)

Question 6

Question 55A-6: 
A 56-year-old man presents with confusion and is found on examination to have uveitis and oral and genital ulcers. Which is the most likely diagnosis? 
A.  Sarcoidosis 
B.  Scleroderma 
C.  Behvet's disease 
D.  Lupus cerebritis 
E.  None of  these

Answer 6

Answer 55A-6: C.
Behcet’s disease is a disorder of unknown
cause which is characterized by oral and
genital ulcers plus uveitis. Neurologic
presentation may be meningitis or
meningoencephalitis, or ischemic disease
which can be arterial or venous. The ischemic
disease can involve the spinal cord, although
cerebral ischemia is more likely. (p1083)

Question 7

Question 55A-7: 
Which is the most common neurologic complication of progressive systemic sclerosis (scleroderma)? 
A.  Sensorimotor neuropathy 
B.  Meningitis 
C.  Encephalitis 
D.  Oculomotor palsy

Answer 7

Answer 55A-7: A.
Progressive systemic sclerosis (scleroderma)
affects the nervous system in about 40% of
patients. The most common neurologic
complications are distal sensorimotor
neuropathy, myopathy, myositis, trigeminal
neuropathy, or entrapment neuropathy.
(p1083)

Question 8

Question 55A-8:
A 58-year-old female with severe COPD is admitted to the ICU with respiratory decompensation. She becomes septic and develops renal and hepatic failure. Encephalopathy develops and becomes profound to the point of unresponsive. Which is the most likely diagnosis?
A. Bacterial meningitis
B. Viral encephalitis
C. Diffuse encephalopathy as a component of the sepsis syndrome
D. Hepatic encephalopathy

Answer 8

Answer 55A-8: C.
The systemic inflammatory response
syndrome is associated with increased
incidence of multiorgan failure. As part of this
syndrome, encephalopathy can develop, which
can have severai etiologies and is probably
multifactorial. Multifocal ischemic disease is
felt to be a contributing factor. The other
conditions are possible and should be
considered in the differential diagnosi$, but
are less likely. (p1084)

Question 9

Question 55A-9:
A 36-year-old female presents with an episode of transient left eye visual loss. Evaluation is normal except for positive anticardiolipin IgG antibody. Which is the implication of this finding?
A. The patient has SLE complicated by antiphospholipid antibody syndrome
B. The anticardiolipin antibody predisposes to thrombotic disorders
C. The anticardiolipin antibody is an incidental finding and has no clinical implications in the patient

Answer 9

Answer 55A-9: B.
Not all patients with antiphospholipid
antibodies, including lupus anticoagulant and
anticardiolipin antibody, have SLE, but the
presence of the antibodies does predispose to
the development of thrombotic episodes.
Patients present with ischemic conditions.
including cerebral and ocular ischemia.
(p1089)

Question 10

Question 55A-10:
A patient with bilateral facial palsy is found to have sarcoidosis on the basis of lung and involvement. Which of the following statements are true regarding management?
A. Corticosteroid administration is essential to improvement
B. Intravenous immunoglobulin is the most effective treatment
C. Radiation therapy is used for meningeal involvement
D. Neurologic symptoms may remit without treatment

Answer 10

Answer 55A-10: D.
Corticosteroid use is routine for patients with
neurologic complications of sarcoidosis,
although the long-term benefit is unproved.
Symptoms often improve without treatment,
although most physicians would treat a patient
with neurosarcoidosis. Radiation therapy is
occasionally used for a focal lesion, but would
be inappropriate for meningeal disease.
Cyclosporine therapy is also occasionally
used. (p1085-1086)