Neurology long case

Question 1

Conditions associated with stroke

Answer 1

Atherosclerosis of carotid or VBI

Hypertension

AF w/ thromboembolism

Spontaneous ICH

Bacterial endocarditis

Amphetamine abuse

Cerebral venous thrombosis

Vertebral or carotid dissection

Intracranial neoplasm

Cerebral autosomal dominant arteriopathy w/ subcortical infarcts and leucoencephalopathy (CADASIL)

Hypercoagulable state

Subclavian steal

SLE, vasculitis

Question 2

Differential diagnosis of stroke

Answer 2

Hypoglycemia

Todd’s paresis (post seizure)

Migraine

Traumatic nerve damage

Intoxication

Question 3

History for epilepsy

Answer 3

Events leading to and following seizure

Type of activity and order

Medications

Precipitants

Alcohol, illicit drugs

Previous history of ABI, neurosurgery, meningitis, intracranial tumour, stroke, haemorrhage

Insulin requirements for DM

Family history epilepsy syndromes

Depression, suicide attempts

Driving, heavy machinery use

Reproductive plans

Question 4

Management of epilepsy

Answer 4

1) Rule out secondary cause - BSL, UECs, CMP, CT-B/MRI
2) attempt to localise seizure focus - EEG, MRI-B
3) Anti-epileptics -

Generalised TC seizures - valproate, carbamazapine, phenytoin

Second-line therapy - topiramate, gabapentin, lamptrigine, levetiracetam

Absence seizures - Ethosuximide, valproate

Myoclonic seizures - valproate, lamotrigine, topiramate

Lennox-Gastaut syndrome - Felbamate

Question 5

History for Multiple Sclerosis

Answer 5

Onset, neurological deficit, disease profile

Weakness, incoordination, lancinating pain, speech impairment, sphincter disturbances, sensory loss, seizures, vertigo, gait instability

Lhermitte’s phenomenon

Current treatment

Complications - aspiration pneumonia, UTI, mechanical injuries, limb contractures, pressure areas, muscle spasms

Functional level of patient, social, occupational difficulties, support, sexual function

Mood, depression, fatigue

Family history, place of birth

Prior pregnancies

Question 6

Management of Multiple Sclerosis

Answer 6

Acute attacks - IV methylpred

Long term and preventative -

Interferon 1a or b in RRMS, 1b in SPMS

Glatiramer acetate (slow onset of action 2-3months)

Natalizumab (Tyasbri)

Management of complications

Oral baclofen or diazepam for muscle spasms

Botulinum toxin injection

Neurogenic pain - antiepileptics

Urge incontinence - self catherisation, oxybutynin

Question 7

History for Myasthenia Gravis

Answer 7

Onset, age of diagnosis, duration

Consider Lambert-Eaton - difficulty climbing stairs, shoulder girdle weakness, oromucosal dryness

Details of exacerbations - frequency and trigger factors

Degree of weakness in muscle groups - ocular, thoracic, respiratory, limb musculature

History of thyroid disease, Addison’s disease, penicillamine

Previous hospitalisations with intubation and ventilation

Complications of medications

Social supports etc

Question 8

Management of Myasthenia Gravis

Answer 8

1) diagnose MG

Tensilon SE: bradycardia, CHB, bronchospasm; requires atropine on reserve

Ice pack test

Neurophysiological tests -

CT, MRI

TFT

ECG

2) Symptom management - anticholinesterase agents - neostigmine/pyrodostigmine (overmedicating can cause weakness)
3) Immunosuppression - steroids, steroid sparing agent - azathioprine, cyclosporine
4) Thymectomy
5) IVIG or plasma exchange for rapid control of myasthenia crisis