Neuro - Conditions Flashcards
A 28yo woman presents with a 5/7 Hx of numbness + tingling in her left leg which has progressed to involve both legs + abdomen. She also reports it takes a while for stream to start when she goes to urinate.
She also reports a painful loss of vision in 1 eye about 6/12 ago for which she did not seek Tx.
What is the most likely condition? How would you confirm?
Multiple sclerosis
- MRI (FLAIR sequence): shows white matter lesions
- LP: IgG oligoclonal bands in CSF
- +/- visual evoked potentials: prolonged
- TFTs, vitB12, HbA1c +/- anti-NMO Abs: rule out differentials (inc. neuromyelitis optica)
A 28yo woman is diagnosed with MS. She is not currently symptomatic other than fatigue. Which medication should she be taking?
Immunomodulators e.g. INTERFERON BETA or GLATIROMER
2nd line: NATALIZUMAB, FINGOLIMOD
A 28yo presents to hospital with a severe relapse of her MS - total loss of vision in 1eye + severe weakness. How should she be managed?
3/7 IV methylprednisolone 1g OD
or 500mg PO 5/7
A 32yo woman presents with difficulty chewing her food + double vision. She also feels weak, especially when climbing stairs. O/E there is mild bilateral ptosis + and limb weakness 4/5. Sensation + reflexes are normal.
What is the likely diagnosis and how would you investigate this woman?
Myasthenia gravis
Diagnosis:
- serum AChR Abs (if negative: anti-MuSK and anti-LRP4 Abs)
- repetitive nerve stimulation: decrease in AP amplitude
- +/- EMG
Other Ix:
4. CT/MRI chest: ?thymoma or thymic hyperplasia
Describe the management options (maintenance) for a patient diagnosed with myasthenia gravis.
Maintenance:
1st line: PYRIDOSTIGMINE PO at regular intervals
2nd line: corticosteroids
3rd line: immunomodulators e.g. azathioprine
4th line: mAbs e.g. rituximab
Also: surgical referral for thyroidectomy
A 60yo man with known myasthenia gravis presents to ED with severe worsening of his weakness. He now finds it difficult to breath and is very agitation/confused.
What is the likely diagnosis and how will you assess this man?
Myasthenic crisis
- serial spirometry: if rapid decrease of <20ml/kg may require mechanical ventilation
- blood gases: for signs of T2RF
What management options should be considered for a patient presenting with a myasthenic crisis?
- ICU care for non-invasive ventilation or mechanical ventilation
- IVIG: 60% respond after 7-10/7
- plasmapheresis
How would you differentiate between a myasthenic crisis and a cholinergic crisis?
Both can present with: weakness, SOB, confusion, drowsiness, urinary/faecal urgency
Myasthenic crisis:
- normal pupils
- tachycardia
- no bronchial secretions
- cold
- no fasiculations
Cholinergic crisis:
- miosis
- bradycardia
- bronchial secretions
- warm
- fasiculations
A 20yo girls presents with back pain + tingling in her hands + feet. Over the next few days, her symptoms rapidly progress to include lower extremity weakness such that she cannot mobilise. She is areflexic + hypotonic.
What is the likely diagnosis and how would you investigate?
Guillain-Barre syndrome.
Usually a clinical diagnosis but may do:
- LP: increased protein with normal WCC
- nerve conduction studies
- serum antiganglioside Abs
How would you manage a patient with severe guillain-barre syndrome?
- plasma exchange + IVIG
- analgesia
- +/- intubation + ventilation
A 65yo man presents with a 1yr Hx of R foot drop which has now progressed to involve more proximal leg weakness. Also reports painful muscle cramps + twitching in same area. O/E there is bilateral lower limb extremity, more on the R, diffuse fasiculations + hyper-reflexia, with a positive Babinski’s sign on the R.
What is the likely diagnosis? How would you investigate?
Motor neurone disease (amyotrophic lateral sclerosis)
Ix:
- EMG + nerve conduction studies: characteristic patterns e.g. fibrillations + fasciculations
- CT +/- MRI brain/spinal cord: to exclude other pathologies
- bloods: to exclude other pathologies e.g. vitB12, folate, HIV + Lyme disease serology, CK assay…
How would you manage a patient diagnosed with MND?
Supportive:
- dietary support e.g. NG/PEG tube
- picture-boards or IT-solutions for communication
- PPV for resp. support to improve QoL and survival
Drugs:
- RILUOZOLE (neuroprotective glutamate release inhibitor): delays onset of ventilator dependance/tracheostomy and may increase survival by 2-3/12
- BACLOFEN for muscle spasms/spasticity
- etc.
A 45yo presents with loss of sensation in his hands + feet. He also complains of shooting + burning pains in his feet and legs, worse at night. PMHx: HTN, hypercholesterolaemia, T2DM.
What is the likely diagnosis? How would you manage?
Diabetic polyneuropathy
- control blood glucose
- foot care
- analgesia e.g. amitriptyline, gabapentin
