Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Correct Answer E:
Triptans: Triptans are specific 5-HT1 agonists used in the acute treatment of migraine. They are generally used second line when standard analgesics such as paracetamol and ibuprofen are ineffective.
Prescribing points:
Adverse effects:
Contraindications:
A 24-year-old man is seen in the 'First Seizure' clinic. He has been referred by the local the Emergency Department following a single episode of a witnessed seizure. Which one of the following factors would be least relevant when deciding whether to start anti-epileptic drugs after a single seizure?
Correct Answer D:
Epilepsy: treatment:
Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting antiepileptics after the first seizure if any of the following are present:
Sodium valproate is considered the first line treatment for patients with generalized seizures with carbamazepine used for partial seizures.
Generalized tonic-clonic seizures:
Absence seizures* (Petit mal):
Myoclonic seizures:
Partial seizures:
*Carbamazepine may actually exacerbate absence seizure.
**The 2007 SANAD study indicated that lamotrigine may be a more suitable first-line drug for partial seizures although this has yet to work its way through to guidelines.
A 23-year-old man is admitted following the sudden onset of an occipital headache. On examination GCS is 15/15, neurological examination is unremarkable but neck stiffness is noted. A subarachnoid haemorrhage is suspected but the CT scan is normal.
At what time should a lumbar puncture be done to exclude the diagnosis?
Correct Answer D: If the patient was acutely unwell or had an altered GCS then discussion with neurosurgery may be appropriate rather than waiting 12 hours.
Subarachnoid haemorrhage: Causes x85% are due to rupture of berry aneurysms (conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta):
Investigations:
Complications:
Management:
*The way nimodipine works in subarachnoid haemorrhage is not fully understood. It has been previously postulated that it reduces cerebral vasospasm (hence maintaining cerebral perfusion) but this has not been demonstrated in studies.
Which one of the following causes of peripheral neuropathy is most associated with demyelination?
Correct Answer C:
Peripheral neuropathy: demyelinating vs. axonal:
Demyelinating pathology:
Axonal pathology:
*May also cause a demyelinating picture.
A 19-year-old man is admitted following a generalized seizure. No past history is available as the man is currently in a postictal state. On examination it is noted that he has three patches of hypopigmented skin and fibromata under two of his finger nails.
What is the most likely diagnosis?
Correct Answer E: This man has a neurocutaneous syndrome which raises the possibility of neurofibromatosis or tuberous sclerosis. Given the areas of hypopigmentation and subungual fibromas the most likely diagnosis is tuberous sclerosis.
Tuberous sclerosis:
Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the majority of features seen in TS are neuro-cutaneous.
Cutaneous features:
Neurological features:
Also
*These of course are more commonly associated with neurofibromatosis. However a 1998 study of 106 children with TS found café-au-lait spots in 28% of patients.
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