A 56-year-old man presents to the Emergency Department after developing trouble talking after waking up this morning. The symptoms are consistent with expressive dysphasia and lasted about 90 minutes before resolving completely. Neurological examination is unremarkable. A diagnosis of transient ischaemic attack (TIA) is made. His past medical history includes ischaemic heart disease for which he is prescribed aspirin, simvastatin and atenolol.
Which one of the following factors is most associated with an increased risk of going on to have a stroke?
Correct Answer C: This TIA lasted greater than 60 minutes which scores 2 as part of the ABCD2 prognostic scoring system. It is therefore the most significant factor which would increase his risk of going on to have a stroke.
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
A 14-year-old male is noted to have optic atrophy on fundoscopy. Neurological exam reveals dysarthric speech and nystagmus. Knee and ankle jerks are absent but there is an extensor plantar response.
What is the likely diagnosis?
Correct Answer C: Multiple sclerosis would be unlikely at this age.
Friedreich's ataxia:
Friedreich's ataxia is the most common of the early-onset hereditary ataxias. It is an autosomal recessive, trinucleotide repeat disorder characterized by a GAA repeat in the X25 gene on chromosome 9 (frataxin). Friedreich's ataxia is unusual amongst trinucleotide repeat disorders in not demonstrating the phenomenon of anticipation.
The typical age of onset is 10-15 years old. Gait ataxia is the most common presenting feature.
Neurological features:
Other features:
A 46-year-old female presents with a burning sensation over the antero-lateral aspect of her right thigh. A diagnosis of meralgia paraesthetica is suspected.
Which nerve is most likely to be affected?
Correct Answer D: Burning thigh pain - ? meralgia paraesthetica - lateral cutaneous nerve of thigh compression.
Meralgia paraesthetica: Basics:
A 72-year-old man who is being treated for Parkinson's disease is reviewed. Which one of the following features should prompt you to consider an alternative diagnosis?
Correct Answer D: Diplopia is not common in Parkinson's disease and may suggest an alternative cause of parkinsonism such as progressive supranuclear palsy.
Parkinson's disease: features:
Parkinson's disease is a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.. This results in a classic triad of features: bradykinesia, tremor and rigidity. The symptoms of Parkinson's disease are characteristically asymmetrical.
Bradykinesia:
Tremor:
Rigidity:
Other characteristic features:
Drug-induced parkinsonism has slightly different features to Parkinson's disease:
A 52-year-old woman presents with a two week history of dizziness when she rolls over in bed. She says it feels like the room is spinning around her. Examination of her ears and cranial nerves is unremarkable.
Given the likely diagnosis of benign paroxysmal positional vertigo what is the most appropriate management?
Correct Answer D:
Benign paroxysmal positional vertigo:
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterized by the sudden onset of dizziness and vertigo triggered by changes in head position.
Features:
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:
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