SANS Desember 2013 Flashcards
Seorang wanita 37 tahun dengan riwayat panjang epilepsi dan kejang menjalani lobectomy temporal anterior 17 tahun yang lalu. Dia melaporkan bahwa dalam kurun waktu 12 bulan terakhir dia telah bebas kejang. Hal apakah yang menjadi outcome psychososial paling mungkin dari bebas kejang sebelum 12 bulan ?
A. Hidup mandiri
B. Memiliki surat izin mengemudi yang masih berlaku
C. Pekerja tetap
D. Kemandirian finansial
B. Memiliki surat izin mengemudi yang masih berlaku
In a non-randomized, study between medically managed and surgically managed temporal lobe epilepsy, Jones et al reported driving (which is defined here as holding an active driver’s license) is the only psychosocial outcome that correlates with seizure freedom in the past 12 months. Seizure freedom did not significantly correlate with full-time employment, living independently, and financial independence. This is in contrast to research by Kellett et al. and Wheelock et al. in which correlation between seizure freedom and multiple psychosocial outcomes was reported.
Peningkatan Minnesota Multiphasic Personality Inventory (MMPI) yang mengikuti lobectomy temporal anterior memprediksi outcome manakah ?
A. Kemungkinan yang lebih besar untuk terjadinya kejang terus-menerus
B. Persentase yang lebih kecil untuk terjadinya depresi klinis
C. Persentase yang lebih besar untuk terjadinya depresi klinis
D. Kemungkinan yang lebih kecil untuk terjadinya kejang terus-menerus
A. Kemungkinan yang lebih besar untuk terjadinya kejang terus-menerus
Elevated (MMPI) after anterior temporal lobectomy predicts a higher likelihood of continued seizures. A recent observational controlled study by Jones et al1 compared psychosocial outcomes of medically intractable complex partial seizures of temporal lobe origin in patients who underwent anterior temporal lobectomy versus control patients who received medical management only.
Baseline Minnesota Multiphasic Personality Inventory (MMPI) clinical scale elevations were not associated with poorer seizure outcomes in either group. A history of anxiety, depression and treatment of these disorders was investigated at follow-up interviews at 5, 12 and 17 years years post-surgery or post-medication and there was no difference between groups in diagnosis. This finding is similar to a recent study by Adams et al2 that reported no relationship between psychiatric history and seizure outcome among individuals with mesial temporal sclerosis at post-surgical follow-up. However, the Jones et al1 study did find that surgery group participants with elevated MMPI clinical scales post-surgery were significantly more likely to experience seizures at each follow-up assessment (first follow-up p = 0.044; second follow-up p = 0.004; third follow-up p = 0.004). Devinsky et al3 reported a similar finding in which there was a significant relationship between post-surgical depressive symptoms and ongoing seizures two years post-surgery. Therefore, preoperative psychopathology does not seem to be predictive of postoperative seizures and there also seems to be no difference in development of psychopathology in patients who undergo surgery versus medical treatment only. However, among patients receiving surgery, elevated postoperative MMPI may predict higher likelihood of continued seizures in patients who have undergone anterior temporal lobectomy for medically refractory complex partial seizures of temporal lobe origin.
Berapakah persentase untuk pasien yang tetap menjalani terapi obat anti epilepsi 5 tahun setelah lobectomy temporal anterior ?
A. 40-45 % B. 50-55 % C. 60-65 % D. 30-35 % E. 20-25 %
C. 60-65 %
60-65% of patients who undergo anterior temporal lobectomy for intractable seizures remain on antiepileptic medications. In a study by Jones et al, a cohort of patients who underwent anterior temporal lobectomy and a control medically treated population for medically refractory seizures where followed up for 17 years. Jones at al. report 63%, 66%, and 62% of postoperative patients were using at least one antiepileptic drug at 5, 12 and 17years respectively. These numbers are roughly consistent with a 20% discontinuation rate for antiepileptic drugs following surgery, reported by Tellez-Zenteno et al in a meta-analysis of temporal lobectomy outcomes.
Pemeriksaan MRI manakah yang paling baik untuk mengevaluasi kelayakan anatomis untuk ETV dalam NPH pada pasien dengan triventriculomegaly ?
A. Sagittal constructive interference in steady state (CISS) B. T2-weighted coronal C. Noncontrast T1-weighted axial D. Noncontrast T1-weighted midsagittal E. Flair coronal
A. Sagittal constructive interference in steady state (CISS)
The potential determination of anatomical eligibility for ETV in NPH must be based on magnetic resonance imaging (MRI); patients with triventriculomegaly should be evaluated with a sagittal constructive interference in steady-state (CISS) MRI study, or alternatively, fast imaging using steady-state acquisition (FIESTA) sequences to determine the presence of an aqueductal web. In addition to assessing the anatomical location and characteristics of the presumed site of CSF obstruction, due attention to the premesencephalic cisternal anatomy is important.
Typical radiological findings on a midsagittal noncontrast T1-weighted MRI scan may include enlarged lateral ventricles and bowing of the corpus callosum with a normal-sized or enlarged fourth ventricle. The cerebral aqueduct may appear patent; however, a corresponding CISS or FIESTA MRI scan may reveal a distal cerebral aqueduct occlusive membrane. It has been postulated that atrophy of the brain and the consequent change in the anatomical angle between the cerebral aqueduct and the fourth ventricle prevents free flow of CSF from the third ventricle.
Berapakah angka persentase terjadinya resiko mortalitas pra-operative yang berkaitan dengan endoscopic third ventriculostomy (ETV) untuk kasus diopathic normal pressure hydrocephalus (iNPH) ?
A. 3-5 %
B. 1-3 %
C. 1 %
D. 5-8 %
A. 3-5 %
The perioperative risk of mortality following ETV for iNPH is between 3-5%. In a recent study of the hospital outcomes of 652 patients treated with ETV for iNPH and 12,845 patients treated with VPS, ETV was associated with a significantly higher incidence of short-term complication (17.9% vs. 11.8%) and mortality (3.2% vs 0.5%) and than VPS. In multivariate analysis, ETV alone predicted increased mortality and increased length of stay when adjusted for other patient and hospital factors. Further long-term studies are needed to determine the overall optimal treatment in improving long-term outcome.
Dengan memperhatikan pengobatan untuk kasus idiopathic normal pressure hydrocephalus (iNPH), bagaimanakah perbandingan outcome antara ventriculoperitoneal shunt (VPS) dan endoscopic third ventriculostomy (ETV) ?
A. VPS berkaitan dengan insidensi rendah terjadinya komplikasi jangka pendek
B. VPS berkaitan dengan penambahan durasi rawat inap
C. VPS berkatian dengan angka mortalitas lebih tinggi
D. VPS berkaitan dengan outcome fungsional jangka pendek yang buruk
A. VPS berkaitan dengan insidensi rendah
VPS are associated with lower incidence of short-term complications as compared to ETV for iNPH. The optimal treatment of iNPH is unclear with small case series demonstrating that ETV may be a beneficial alternative therapy to VPS. In a recent study of the hospital outcomes of 652 patients treated with ETV for iNPH and 12,845 patients treated with VPS, ETV was associated with a significantly higher incidence of short-term complication (17.9% vs. 11.8%) and mortality (3.2% vs 0.5%) and than VPS. In multivariate analysis, ETV alone predicted increased mortality and increased length of stay when adjusted for other patient and hospital factors. Further long-term studies are needed to determine the overall optimal treatment in improving long-term outcome.
Pada pasien dengan multiple sclerosis dan neuralgia trigeminal yang refrakter terhadap pengobatan, modalitas terapi apakah yang memiliki respon bebas nyeri paling baik ?
A. Stereotactic radiosurgery
B. Percutaneous retro-gasserian glycerol rhizotomy
C. Percutaneous balloon compression
D. Microvascular decompression of trigeminal nerve
E. Percutaneous radiofrequency rhizotomy
C. Percutaneous balloon compression
Percutaneous balloon compression is reported to achieve the highest pain-free response (80% at 12 months) in a large series of multiple sclerosis patients with trigeminal neuralgia by Mohammad-Mohammadi et.al. This modality was also the most durable (50% pain-free at 30 months). Percutaneous retro-gasserian glycerol rhizotomy has the second highest pain free response (45% at 12 months). Stereotactic radiosurgery, radiofrequency rhizotomy and microvascular decompression had similar initial pain-free responses around 25-30% at 12 months. For repeat procedures, there was no significant difference between treatment modalities. Nevertheless, patients with multiple sclerosis have overall shorter responses to any trigeminal neuralgia intervention compared to incidental trigeminal neuralgia. There was no significant difference in complication rates between treatment modalities.
Berapakah persentase insidensi terjadinya neuralgia trigeminal pada pasien dengan Multiple sclerosis ?
A. 12 % B. 8 % C. 4 % D. 16 % E. 20 %
C. 4 %
The lifetime risk of trigeminal neuralgia in patients with multiple sclerosis is ~4%, according to Martinelli et.al. (2008). Various studies report an incidence of TN in MS patients to be between 1% and 6%. Nevertheless, MS has a significantly higher incidence of TN compared to the general population (0.003-0.03%).
Hal apakah yang menjadi karakteristik klinis paling umum dari neuralgia trigeminal pada pasien multiple sclerosis ?
A. Lacrimasi berlebih B. Otalgia C. Bilateral facial pain D. Atypical facial pain E Lancinating pain
E Lancinating pain
The clinical presentation of trigeminal neuralgia in multiple sclerosis patients is similar to incidental trigeminal neuralgia - typical unilateral, lancinating facial pain.
Bilateral facial pain is occurs in a minority of multiple sclerosis patients with trigeminal neuralgia. In a study by Mohammad-Mohammadi et.al., the incidence of bilateral trigeminal neuralgia at initial diagnosis in multiple sclerosis patients was 4%. Otalgia is not commonly associated with trigeminal neuralgia, and is associated with vascular compression of the nervus intermedius of the facial nerves (geniculate neuralgia). Excess lacrimation is seen in pterygopalatine neuralgia, a type of atypical facial pain. By definition, atypical facial pain is a different entity than trigeminal neuralgia. However, this can be seen in a minority multiple sclerosis patients.
