A 64-year-old female is reviewed in the rapid access transient ischaemic attack clinic. For the past three weeks she has been having episodes of transient loss of vision in the right eye. Carotid ultrasound reveals a 48% stenosis of her right carotid artery and an ECG shows sinus rhythm.
What is the most appropriate management of this patient?
Correct Answer E:
Antiplatelets:
Carotid artery endarterectomy is recommend if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be considered if the carotid stenosis is greater than 70% or 50%, depending on the reporting criteria used - please see below.
Transient ischaemic attack: NICE issued updated guidelines relating to stroke and transient ischaemic attack (TIA) in 2008. They advocated the use of the ABCD2 prognostic score for risk stratifying patients who've had a suspected TIA:
This gives a total score ranging from 0 to 7. People who have had a suspected TIA who are at a higher risk of stroke (that is, with an ABCD2 score of 4 or above) should have:
If the ABCD2 risk score is 3 or below:
on brain imaging:
People with crescendo TIAs (two or more episodes in a week) should be treated as being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.
NICE also published a technology appraisal in 2010 on the use of clopidogrel and dipyridamole.
Recommendations from NICE include:
With regards to carotid artery endarterectomy:
*European Carotid Surgery Trialists' Collaborative Group
**North American Symptomatic Carotid Endarterectomy Trial
Which one of the following drugs is used in the management of multiple sclerosis?
Correct Answer A:
Multiple sclerosis: management: Treatment in multiple sclerosis is focused at reducing the frequency and duration of relapses. There is no cure. High dose steroids (e.g. IV methylprednisolone) may be given for 3-5 days to shorten the length of an acute relapse. Baclofen is helpful in controlling spasticity. Hallucinations are occasionally seen on the withdrawal of baclofen
Beta-interferon has been shown to reduce the relapse rate by up to 30%. Certain criteria have to be met before it is used:
Other drugs used in the management of multiple sclerosis include:
Symptom control:
A 34-year-old man from West Africa is admitted due to confusion associated with left-sided weakness and ataxia. He is known to be HIV positive but is not on anti-retroviral treatment. The following results are obtained:
What is the most likely diagnosis?
Correct Answer C:
HIV: neurocomplications:
Generalized neurological disease: Encephalitis:
Cryptococcus:
Progressive multifocal leukoencephalopathy (PML):
AIDS dementia complex:
Focal neurological lesions: Toxoplasmosis:
Primary CNS lymphoma:
Differentiating between toxoplasmosis and lymphoma is a common clinical scenario in HIV patients. It is clearly important given the vastly different treatment strategies. The table below gives some general differences. Please see the Radiopaedia link for more details.
Tuberculosis:
Which one of the following is least characteristic of Wernicke's encephalopathy?
Correct Answer D: An inability to acquire new memories and confabulation suggests the development of Korsakoff's syndrome.
Wernicke's encephalopathy: Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics. Rarer causes include: persistent vomiting, stomach cancer, dietary deficiency. A classic triad of nystagmus, ophthalmoplegia and ataxia may occur. In Wernicke's encephalopathy petechial haemorrhages occur in a variety of structures in the brain including the mamillary bodies and ventricle walls.
Features:
Investigations:
Treatment is with urgent replacement of thiamine.
A 19-year-old female presents complaining of visual disturbance. Examination reveals a bitemporal hemianopia with predominately the lower quadrants being affected.
What is the most likely lesion?
Correct Answer B:
Bitemporal hemianopia:
Visual field defects: The main points for the exam are:
A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric. Please see the link for an excellent diagram.
Homonymous hemianopia:
Homonymous quadrantanopias*:
*this is very much the 'exam answer'. Actual studies suggest that the majority of quadrantanopias are caused by occipital lobe lesions. Please see the following link for more details: http://www.ncbi.nlm.nih.gov/pubmed/9109741
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