A 64-year-old man who is under investigation for parkinsonian symptoms is brought to the GP by his wife. She is concerned her husband is becoming increasingly agitated. The GP prescribes haloperidol. One week later the GP is called out to see the patient as his parkinsonian symptoms have deteriorated markedly.
What is the most likely underlying diagnosis?
Correct Answer A: Patients with Lewy body dementia are extremely sensitive to neuroleptic agents.
Lewy body dementia:
Lewy body dementia is an increasingly recognized cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas.
The relationship between Parkinson's disease and Lewy body dementia is complicated, particularly as dementia is often seen in Parkinson's disease. Also, up to 40% of patients with Alzheimer's have Lewy bodies.
Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent.
Features:
A 62-year-old man is seen in the rapid access transient ischaemic attack clinic following three episodes over the past two weeks of transient left sided weakness.
What is the most appropriate advice to give with regards to driving?
Correct Answer D: DVLA advice post multipler TIAs: cannot drive for 3 months.
DVLA: neurological disorders:
The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter.
Specific rules:
Syncope:
*Previously rule was 12 months. It is now 6 months off driving if the licence holder has undergone assessment by an appropriate specialist and no relevant abnormality has been identified on investigation, for example EEG and brain scan where indicated.
**If the tumour is a benign meningioma and there is no seizure history, license can be reconsidered 6 months after surgery if remains seizure free.
A 73-year-old woman presents with episodic confusion and headaches for the past week. She has a history of alcohol excess and a background of atrial fibrillation and type 2 diabetes mellitus. Her daughter reports that she has been having frequent spells of confusion over the past few days. Last year she was assessed for frequent falls. Her current medications include bisoprolol, metformin and warfarin. Neurological examination is unremarkable and her blood sugar is 6.7 mmol/l.
What is the most likely diagnosis?
Correct Answer E: Fluctuating confusion/consciousness? - subdural haematoma.
This patient has a number of risk factors for a subdural haematoma including old age, alcoholism and anticoagulation. Korsakoff's syndrome and Wernicke's encephalopathy do not usually cause headaches.
Head injury:
Types of traumatic brain injury:
A 34-year-old man who is known to suffer from complex partial seizures is reviewed in the neurology clinic. Hehas not been able to tolerate either carbamazepine or sodium valproate.
What is the most appropriate next line drug?
Correct Answer B:
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:
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 31-year-old woman presents with a 4 month history of headache. She has brought a headache diary which demonstrates that her symptoms are present on around 20-25 days of each month. The headache is typically unilateral and she is currently taking paracetamol 1g qds and ibuprofen 400mg tds everyday to try and relieve her symptoms. A diagnosis of medication overuse headache is suspected.
What is the most appropriate management?
Correct Answer C:
This answer may seem counterintuitive but it is line with recent guidelines from SIGN, please see the link provided.
Medication overuse headache:
Medication overuse headache is one of the most common causes of chronic daily headache. It may affect up to 1 in 50 people.
Management (from 2008 SIGN guidelines):
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