Neurology Topics

Question 1

Epidural Abscess
1- clinical presentation/clues
2- predisposing conditions
3- MCC (pathogens)
4- Dx
5- Management

Answer 1

1 - Fever (not always) and back pain +/- leg weakness/loss sensation, bowel/bladder

2 - DM, alcoholism, HIV, spinal trauma/hardware, local or systemic infection

3 - S. aureus 66%. Staph Epi, E coli (UTI spread), Pseudomonas (IVDU). rarely anaerobic.

4- DX: MRI. CBC,cultures, inflamm markers, good H&P. (no routine LP, adds little to dx)

5- emergency decompressive surgery + abx

Question 2

Carotid Stenosis Diagnosis

• what tests are appropriate to dx?
• benefits/limitations of each?

Answer 2

Ultrasound - widely available. Only detects bifurcation

MRA - can’d discriminate sub-total from total occlusion. standard MRI C/I and time/cost. Usually no gadolimium needed

CTA - widely available and good resolution of entire tree. Contrast risks.

Catheter angio - best accuracy, but expensive and invasive (0.5-1% risk CVA/MI/vessel injury/retroper bleed)

Question 3

Carotid Stenosis Management

• indications?
• what entails symptomatic?
• medical vs surgical management?

Answer 3

symptomatic = cause of syncope or TIA/CVA

medical management: statins, antiplatelet, HTN tx

• initiate for symptomatic 50-69% stenosis (men may benefit more than women)
• continue aspirin after surgical intervention

CEA - symptomatic and some high-grade asymptomatic pts

• # 1 = symptomatic >70% occlusion
• CEA preferred over CAS historically

CAS (stenting) - symptomatic and some high-grade asymptomatic pts (especially cases not amenable to CEA)
- recent trial (ACT) studied pts >79yo with asymptomatic 70-99% stenosis. CAS was non-inferior to CEA in terms of stroke and death