| Strokes 1 | Strokes 2 | Seizures and Epilepsy 1 | Seizures and Epilepsy 2 | Disorders of the Spinal Cord |
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A- LP
-aneurysmal subarachnoid hemorrhage (SAH) is not always evident on CT scans and still needs to be excluded as a diagnosis -test has a higher yield 12 hours or longer after headache onset when erythrocyte breakdown products will produce a yellow color (xanthochromia) -sudden onset, nuchal rigidity, and pupillary dilation of the left eye. The latter finding can be seen with a posterior communicating artery aneurysm as it exerts pressure on the outer portion of the oculomotor nerve (cranial nerve III) -MRI is neither sensitive nor specific enough to definitively diagnose SAH.
A 37-year-old man is evaluated in the emergency department 12 hours after sudden onset of a global, severe headache with associated neck stiffness. The patient has a 5-year history of migraine treated with sumatriptan. He says that his current headache feels different from previous headaches and did not respond to sumatriptan.
On physical examination, temperature is normal, blood pressure is 148/72 mm Hg, heart rate 86/min and regular, respiration rate is 12/min, and oxygen saturation is 96% with the patient breathing ambient air. The patient has discomfort and appears restless. Funduscopic examination is normal. The left pupil is 2 millimeters larger than the right and poorly reactive to light. Neck stiffness is noted with passive movement. A CT scan of the head is normal. Which of the following is the most appropriate next diagnostic test? A- LP B- MRI of neck C- MRI of brain D- No further testing necessary |
C Nimodipine
-risk of vasospasm is greatest 5 to 10 days after SAH onset. Nimodipine is indicted for all nonhypotensive patients with SAH and is associated with improved neurologic outcomes and survival. - presence of vasospasm is suggested by worsening findings on neurologic examination and can be confirmed with CT angiography or catheter angiography, with the latter test having the additional benefit of providing endovascular therapy. -Glucocorticoids, such as dexamethasone, are not routinely indicated for any stroke subtype and are ineffective in reducing intracranial pressure in that setting. -nitroglycerin would be inappropriate because it can increase cerebral venous volume and intracranial pressure, which is a concern in patients with SAH. -verapamil has not been shown to improve outcomes in patients with SAH or vasospasm.
A 61-year-old woman is admitted to the ICU 1 hour after having a subarachnoid hemorrhage (SAH). An emergent CT scan of the head showed an SAH, and a cerebral angiogram revealed a 6-mm rupture of the anterior communicating artery. The patient has hypertension treated with amlodipine.
On physical examination, vital signs are stable, and oxygen saturation is 96% with the patient breathing ambient air. She is somnolent. Nuchal rigidity is present. Subhyaloid hemorrhages are seen on funduscopic examination. No motor or sensory deficits are present. Administration of which of the following medications is the most appropriate treatment? A Dexamethasone B Magnesium sulfate C Nimodipine D Nitroglycerin E Verapamil |
A Head CT
-In a patient with an unprovoked, first-time seizure, head CT is the most appropriate initial study to rapidly exclude emergent pathologic issues, typically is readily available in most emergency departments and can be performed rapidly -Levetiracetam and other antiepileptic drugs are not recommended for first-time seizures until the results of further testing, such as head CT, brain MRI, and electroencephalography (EEG), are known and the recurrence risk of seizures can be determined
A 22-year-old man is evaluated in the emergency department 40 minutes after having a first-time generalized tonic-clonic seizure. According to his mother, the patient exhibited shaking for 5 minutes. He has never had a seizure previously or any episode of jerking, staring, confusion, or memory loss. He has had no recent illness and has no history of neurologic problems. Birth and development were normal. There is no family history of seizures or epilepsy. He takes no medication and does not use illicit drugs.
On physical examination, vital signs are normal. Neurologic examination findings are unremarkable. Results of laboratory studies show a normal complete blood count and comprehensive metabolic panel and a negative urine drug screen. Which of the following is the most appropriate initial step in management? A Head CT B Intravenous levetiracetam C Intravenous lorazepam D Lumbar puncture |
B Lamotrigine
-Carbamazepine, phenytoin, and phenobarbital are all inducers of the cytochrome p450 system; these drugs increase breakdown of vitamin D, which results in increased parathyroid hormone levels, and thus cause bone loss and osteoporosis -All patients on chronic AED therapy with phenytoin, carbamazepine, phenobarbital or valproic acid should undergo initial bone densitometry testing after 5 years of therapy, regardless of age, sex, or menopausal status. -Lamotrigine does not have the potential to cause or worsen osteoporosis in patients with epilepsy.
A 35-year-old man is evaluated for two breakthrough focal seizures in the past week. He started having focal and generalized tonic-clonic seizures 20 years ago. The seizures previously had been well controlled by phenytoin, which he has taken since age 16 years, but he missed three doses of medication this week. He has had no recent illnesses or fevers.
On physical examination, all findings, including vital signs, are normal. Results of bone densitometry show osteoporosis (T-score of −2.8). In addition to starting the patient on alendronate, which of the following drugs should be substituted for the phenytoin? A Carbamazepine B Lamotrigine C Phenobarbital D Valproic acid |
C MRI of the lumbosacral spine
-In a patient with suspected compression of the lower spinal cord, emergent MRI of the lumbosacral spine is the most appropriate test both to localize the injury and to determine its cause. -Given the elevated INR, the most likely diagnosis is a spinal epidural hematoma compressing the lumbosacral spine -Glucocorticoids have no role in treating spinal cord compression caused by a hematoma. Several trials have shown a benefit of high-dose intravenous glucocorticoids administered within the first 8 hours of traumatic spinal cord injury and in the management of metastatic spinal cord compression. -CT myelography is useful when MRI is not feasible (as in patients with implantable devices).
A 78-year-old man is evaluated in the emergency department for a 2-day history of bilateral leg weakness and urinary retention. He has atrial fibrillation and hypertension. Medications are warfarin, lisinopril, and hydrochlorothiazide.
On physical examination, vital signs are normal. Muscle strength is 4/5 in both legs. Decreased sensation in the groin, medial buttocks, and rectal area is noted, as is decreased rectal tone. No spinal sensory level is detected in the abdomen or chest region. Gait is wide based. Results of laboratory studies show an INR level of 5.3. Which of the following is the most appropriate management? A Administration of intravenous glucocorticoids B CT myelogram C MRI of the lumbosacral spine D Radiograph of the lumbosacral spine |
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A Atorvastatin
-in ischemic stroke due to intracranial atherosclerosis, the use of high-intensity atorvastatin therapy for secondary stroke prevention is associated with a reduced long-term risk of ischemic stroke -use of atorvastatin for secondary stroke prevention is associated with a reduced long-term risk of ischemic stroke, regardless of the baseline LDL cholesterol level. -2ndary benefits- plaque stabilization, anti-inflammatory properties, and slowing the progression of carotid arterial disease. -Compared with aspirin, warfarin has an increased risk of mortality when used for prevention of recurrence in patients with stroke due to intracranial atherosclerosis. Warfarin is indicated in patients with other stroke subtypes, such as those resulting from atrial fibrillation.
A 48-year-old man is hospitalized with new-onset right hemiparesis and difficulty speaking. He was well when last seen 20 hours earlier.
On physical examination, blood pressure is 138/76 mm Hg, pulse rate is 72 and regular, and respiration rate is 12/min. The patient has aphasia. A right visual field deficit and right facial, arm, and leg weakness are noted. Decreased pinprick sensation is present on the right. Reflexes also are decreased on the right; a right plantar extensor response is noted. An electrocardiogram shows sinus rhythm. A CT scan of the head shows a hypodensity in the left frontal and parietal lobes, and a CT angiogram of the head and neck shows patent internal carotid arteries and 80% stenosis of the left middle cerebral artery. Results of laboratory studies include a serum LDL cholesterol level of 108 mg/dL (2.80 mmol/L) and a hemoglobin A1c value of 6.8%. The patient is given aspirin. Which of the following is the most appropriate next step in treatment? A Atorvastatin B Intracranial stenting C Methylphenidate D Warfarin |
D No further treatment is necessary
- After thrombolytic therapy for acute stroke, antihypertensive treatment is not necessary if blood pressure is less than 180/105 mm Hg and there are no symptoms of intracerebral hemorrhage. - Given the presence of internal carotid artery stenosis, expansion of the infarct is possible if the blood pressure is significantly lowered. -Clopidogrel is an antithrombotic agent and thus is contraindicated in this patient who has just received thrombolytic therapy. nb: nitroprusside is not the medication of first choice in patients with acute stroke because of its potential to increase intracranial pressure.
A 47-year-old man is evaluated in the emergency department 2 hours after sudden onset of right-sided face, arm, and leg weakness and numbness. He has a history of hypertension. Medications are amlodipine and hydrochlorothiazide.
On physical examination, blood pressure is 166/72 mm Hg, pulse rate is 82/min, and respiration rate is 12/min. Right facial weakness, dysarthria, and loss of pinprick sensation in the right arm and leg are noted. The patient can lift the right arm and leg off the bed. The National Institutes of Health Stroke Scale score is 8 (moderate stroke). A CT scan of the head without contrast shows no hemorrhage or early signs of infarct. The patient receives intravenous recombinant tissue plasminogen activator (alteplase) 3 hours after symptom onset. One hour after treatment, blood pressure is 170/86 mm Hg; other physical examination findings are unchanged. A CT angiogram shows 80% stenosis of the left internal carotid artery and no intracranial arterial occlusion. Administration of which of the following is the most appropriate next step in treatment? A Amlodipine B Clopidogrel C Intravenous nitroprusside D No further treatment is necessary |
C Focal seizures
-focal seizures with altered awareness (formerly known as complex partial seizures or focal dyscognitive seizures)--> warning” symptoms (aura, which may consist of an epigastric rising sensation or a feeling of déjà vu), last more than 30 seconds, have associated mouth or limb automatisms (semipurposeful repetitive movements), and are followed by confusion and/or exhaustion - absence seizures: more frequent (occurring multiple times per day), last less than 15 seconds, and are associated with immediate recovery -atonic seizures involve the abrupt loss of muscle tone and typically are associated with falling down and a brief loss of consciousness lasting only a few seconds -Myoclonic seizures generally consist of a single jerk of the entire body, usually last less than 1 second, and are associated with retained awareness and no postictal confusion.
A 19-year-old woman is evaluated for a 6-month history of recurrent episodes of confusion that occur approximately once monthly. Her boyfriend says she has periods of wide-eyed staring, chewing motions, and repetitive grabbing of her clothes with the right hand. The patient sometimes experiences a strange but familiar feeling before the episodes but does not remember the episodes themselves, which last approximately 45 to 60 seconds and are followed by exhaustion and sleepiness for 20 minutes.
All physical examination findings are normal. Which of the following is the most likely diagnosis? A Absence seizures B Atonic seizures C Focal seizures D Myoclonic seizures |
D Piperacillin-tazobactam
-Although evidence is limited, carbapenems, fluoroquinolones, and fourth-generation cephalosporins may lower the seizure threshold and thus should be avoided in patients with epilepsy -Cefepime and carbapenems (such as imipenem) have class III evidence of triggering seizures in patients with epilepsy. -cefepime has been known to cause encephalopathy, coma, and status epilepticus in patients with or without epilepsy, especially those with acute kidney injury. -fluoroquinolones (such as levofloxacin) and fourth-generation cephalosporins lower the seizure threshold, including in patients with epilepsy.
A 54-year-old man is evaluated in the hospital for respiratory distress. The patient has well-controlled generalized epilepsy and was admitted 5 days earlier for a cervical discectomy, laminectomy, and fusion. On hospital day 4, he developed a productive cough, chills, and dyspnea. Medications are oxycodone, levetiracetam, and docusate sodium.
On physical examination, temperature is 38.4 °C (101.1 °F), blood pressure is 125/84 mm Hg, pulse rate is 108/min, respiration rate is 22/min, and oxygen saturation with the patient breathing ambient air is 93%. Crackles are heard in the right posterior thorax on pulmonary auscultation. Results of laboratory studies show a leukocyte count of 18,400/µL (18.4 × 109/L). A chest radiograph shows a right lower lobe infiltrate. Which of the following is the most appropriate treatment? A Cefepime B Imipenem C Levofloxacin D Piperacillin-tazobactam |
A Decompressive surgery with radiation
-Spinal cord compression from metastatic disease requires emergent use of high-dose glucocorticoids (dexamethasone, 20 mg) followed by maintenance glucocorticoids and urgent surgical decompression followed by radiation. -The use of glucocorticoids in traumatic spinal cord compression is controversial. They generally are not indicated with hematoma and abscess.
A 58-year-old man is evaluated in the emergency department for a 3-week history of worsening pain in the middle back and a 2-day history of increasing leg weakness that has made ambulation difficult. He has metastatic prostate cancer treated with leuprolide.
On physical examination, vital signs are normal. Muscle strength testing shows 4/5 weakness in the hip flexors. Reflexes are 3+ in both legs. An MRI of the thoracic spine shows a contrast-enhancing mass originating in the T8 vertebral body with invasion into the epidural space that causes moderate cord compression. After administration of high-dose glucocorticoids, which of the following is the most appropriate next step in management? A Decompressive surgery with radiation B Laminectomy C Radiation only D Spinal angiography |
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B Intravenous nicardipine
- BP is greater than 180 mm Hg; this means she is at high risk for hematoma expansion. -Patients who have intracerebral hemorrhage without elevated intracranial pressure whose systolic blood pressure is greater than 180 mm Hg should be treated with an intravenous antihypertensive agent, such as nicardipine, to a target blood pressure of 140 mm Hg. nb:m A recently completed trial that compared systolic blood pressure targets of 120 mm Hg and 140 mm Hg noted increased adverse renal events in the treatment arm with lower blood pressure. -Candidates for surgical evacuation of an intracerebral hematoma include those with evidence of elevated ICP or a cerebellar hemorrhage greater than 3 centimeters in size. nb: Nitroprusside is not a first-line blood pressure treatment for patients with acute hemorrhagic stroke, given its potential for increasing ICP. -There is no evidence that platelet transfusion reverses the coagulopathy associated with antiplatelet agents or prevents hematoma expansion. Platelet transfusion also carries the risk of coronary stent thrombosis, volume overload, and transfusion-related reactions.
A 71-year-old woman is evaluated in the emergency department 1 hour after acute onset of a severe headache and left-sided weakness. The patient had a myocardial infarction 3 years ago that was treated with a bare metal stent in the right coronary artery. She also has hypertension. Medications are carvedilol, atorvastatin, and aspirin.
On physical examination, blood pressure is 200/110 mm Hg, pulse rate 78/min, respiration rate is 20/min, and oxygen saturation is 98% with the patient breathing ambient air. The patient is awake and attentive to both sides and has normal language function. Funduscopic examination shows no papilledema or hemorrhage. Pupils are both 3 millimeters in size and reactive. Left facial weakness, dysarthria, and flaccid paralysis in the left arm and leg with loss of sensation are noted. An emergent noncontrast CT scan shows an acute intracerebral hemorrhage, 1 centimeter in diameter, in the right basal ganglia without intraventricular hemorrhage or midline shift. Which of the following is the most appropriate treatment? A Hematoma evacuation B Intravenous nicardipine C Intravenous nitroprusside D Platelet transfusion |
C Neurosurgical intervention
-Surgical treatment with clipping or endovascular coiling can be considered in patients with symptomatic aneurysms or aneurysms of 7 millimeters or greater in the posterior circulation (posterior communicating and basilar arteries). - Aneurysms less than 7 millimeters in diameter in the posterior circulation and less than 12 millimeters in the anterior circulation have a low risk of rupture and can be managed conservatively -high risk of subarachnoid hemorrhage (SAH): size equal to or greater than 7 millimeters, rapid growth, and a cranial nerve deficit, which in this patient is compression of the oculomotor nerve (cranial nerve III) on the right. - don't need lisinopril, BP is within the appropriate target of less than 140/80 mm Hg. -If internal carotid artery dissection were suspected, a magnetic resonance angiogram (MRA) of the neck would be an appropriate next step. It is not indicated in this patient.
A 38-year-old woman is evaluated for recent onset of visual blurriness when looking straight ahead or reading. She has a 4-mm right posterior communicating artery aneurysm that was first detected 1 year ago. She has not had any recent headaches and is otherwise well. The patient's only medication is an oral contraceptive agent.
On physical examination, blood pressure is 138/78 mm Hg; other vital signs are normal. The neck is supple. Findings from funduscopic examination are normal. On neurologic examination, the right pupil is 5-millimeters in diameter and unreactive; left lateral gaze results in diplopia. The left pupil and right lateral gaze are normal. A magnetic resonance angiogram (MRA) of the brain shows that her aneurysm has grown in size to 8 millimeters. A Lisinopril administration B MRA of the neck C Neurosurgical intervention D Repeat MRA of the brain in 6 months |
D Psychogenic nonepileptic spell/event
- Sx of psychogenic nonepileptic spells/events include variability of symptoms, closing of eyes, long duration of shaking that waxes and wanes, and lack of postictal confusion; confirmation with video electroencephalographic monitoring usually is required. - generalized tonic-clonic seizure is characterized by stereotyped movements (essentially the same from one event to the next), eyes being open, cyanosis due to cessation of breathing, a duration of 2 to 5 minutes, stiffness and falling before symptoms of shaking, shaking that initially is fast but gradually slows and stops, and postictal confusion. -Myoclonic seizures are typically very brief (<1 second) and characterized by synchronous jerking or shaking of the limbs with retained awareness and no postictal confusion afterward.
A 19-year-old man is evaluated for a 2-week history of shaking episodes sometimes associated with falling that are followed by a period of unresponsiveness. He reports having a 30-minute episode just before getting in the car to go to this appointment. Episodes have been occurring daily, sometimes as often as four times per day, and last 20 to 45 minutes. According to the patient's mother, the episodes involve limb shaking with the eyes closed, intermittent cessation of breathing, and a reddening of the face. The patient remains standing for a few seconds after the shaking starts but on occasion becomes limp and falls. He does not respond when his name is called or his arms or legs are lightly touched. The shaking, which gradually increases and decreases in intensity, typically involves both arms and sometimes the legs. He is exhausted but oriented and responsive afterward and has rapid breathing.
All physical examination findings are normal. Which of the following is the most likely diagnosis? A Convulsive status epilepticus B Generalized tonic clonic seizure C Myoclonic seizure D Psychogenic nonepileptic spell/event |
E Valproic acid
-First-line treatment is IV lorazepam, IV diazepam, or intramuscular midazolam. -benzodiazepines should be followed by an IV AED to avoid seizure recurrence when the initial treatment wears off. Fosphenytoin is preferred over phenytoin because it can be infused more rapidly and has a lower incidence of skin necrosis (such as purple glove syndrome due to drug extravasation) -Alternative second-line therapies include IV valproic acid (especially in generalized epilepsy) or IV levetiracetam
A 21-year-old man is evaluated in the emergency department for persistent convulsive status epilepticus that began 30 minutes before his arrival. An airway has been secured, and he has received intravenous glucose, thiamine, and two doses of intravenous lorazepam. After receiving the second dose of lorazepam, he continues shaking for another 5 minutes. Medications are levetiracetam and acetaminophen; the patient is allergic to phenytoin.
On physical examination, temperature is normal, blood pressure is 155/89 mm Hg, pulse rate is 108/min, respiration rate is 16/min, and oxygen saturation with the patient breathing 6 L of oxygen via a nasal cannula is 97%. The pupils are reactive but he remains comatose. Results of a urine drug screen are negative. Which of the following is the most appropriate next step in management? A Brain MRI B Electroencephalography C Fosphenytoin D Lacosamide E Valproic acid |
D Physical therapy
-Most patients with chronic cervical and lumbar stenosis respond well to conservative measures, such as physical therapy and pain control. -This patient has chronic symptoms of cervical stenosis due to multilevel disc disease. Most patients with chronic cervical and lumbar stenosis respond well to conservative measures, such as physical therapy and pain control - symptoms of more moderate to severe disease who also have signs of myelopathy on examination, such as progressive leg weakness, spasticity, distal numbness, and bladder impairment, may require surgical intervention -A hard cervical collar most commonly is used for cervical spine stabilization after trauma, surgery, and fractures or dislocations. It would be excessive in this patient whose clinical examination and imaging findings show no true cord compression or spinal instability.
A 68-year-old woman is evaluated for a 1-year history of neck stiffness and dull, achy neck pain. She also notes intermittent difficulty with dexterity while performing fine motor tasks at the hair salon where she works. Medications are ibuprofen as needed.
On physical examination, vital signs are normal. Range of motion of the neck is limited because of pain and stiffness. Fine finger movements exhibit subtle slowness. Reflex examination findings are normal, including a plantar flexor response. Muscle strength is 5/5 throughout. Gait is normal. An MRI of the cervical spine shows multilevel cervical stenosis that is worst at C4/5 and C6/7. There is moderate deformation of the cord, but no signal change in the cord is noted. Which of the following is the most appropriate next step in management? A Gabapentin B Neck immobilization in a hard cervical collar C Neurosurgical intervention D Physical therapy |
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B Outpatient cardiac telemetry
cryptogenic stroke- there is no lacunar infarct, arterial imaging is normal, and no clear cardioembolic source of stroke (such as atrial fibrillation) is found. -prolonged outpatient rhythm monitoring may yield a new diagnosis of atrial fibrillation in almost one third of patients. accumulating data on patients with cryptogenic stroke indicate that an evaluation for AF with an outpatient rhythm monitor may yield a new diagnosis of AF in almost one third of patients: cardiac telemetry, 24-hour electrocardiographic monitoring, transtelephonic and event monitors, and implantable subcutaneous devices -clopidogrel and aspirin is associated in the long term with a higher risk of hemorrhagic complications compared with a single antiplatelet agent only. -Apixaban and similar anticoagulants have not been shown to be effective for the routine prevention of cryptogenic stroke.
A 72-year-old woman is evaluated in the emergency department 5 hours after developing difficulty speaking and facial weakness on the right. She takes no medication.
On physical examination, vital signs are normal. The patient is awake and attentive. Spontaneous speech is slow. Right-sided facial weakness and dysarthria are noted. Hemoglobin level, platelet count, and coagulation profile are within normal limits. An electrocardiogram is normal. A CT scan of the head shows an acute left frontal ischemic stroke. A carotid duplex ultrasound reveals less than 40% stenosis in both internal carotid arteries; a transcranial Doppler ultrasound is normal. A transthoracic echocardiogram shows an ejection fraction of 50% but is otherwise unremarkable. Aspirin and rosuvastatin are initiated, and the patient is admitted to the telemetry unit for 3 days, during which time she remains in sinus rhythm. Which of the following is the most appropriate next step in management? A Addition of clopidogrel B Outpatient cardiac telemetry C Substitution of apixaban for aspirin D Transesophageal echocardiography |
B CT angiography of the head
- atrial fibrillation and subtherapeutic INR make a cardioembolic stroke subtype likely - likely acute occlusion of the left intracranial internal carotid artery or middle cerebral artery. -needs large vessel occlusion on vessel imaging, which is most quickly seen with CT angiography. - patient already has received intravenous alteplase, all antithrombotics need to be held for at least 24 hours after a head CT shows no hemorrhage to prevent hemorrhagic conversion. In patients who do not receive thrombolysis, aspirin can reduce the risk of recurrent stroke within the first 2 weeks when administered within 48 hours of ischemic stroke onset. -MRI takes too long, may lengthen the duration of time before an embolectomy can be performed nb: before treatment with alteplase, the patient's blood pressure should be less than 185/110 mm Hg, use labetolol or nicardipine before alteplase Nitrates should be avoided because of their potential to increase intracranial pressure.
A 64-year-old woman is evaluated in the emergency department 45 minutes after sudden onset of right-sided weakness and the loss of the ability to speak. An emergent noncontrast CT of the head shows no hemorrhage or early signs of infarct. The patient also has hypertension and atrial fibrillation. Medications are hydrochlorothiazide and warfarin.
On physical examination, blood pressure is 158/78 mm Hg, and pulse rate is 72/min and irregularly irregular. Global aphasia, left-gaze preference, right hemiparesis, and loss of pain sensation on the right side are noted. Results of laboratory studies show an INR of 1.3. The patient receives intravenous recombinant tissue plasminogen activator (alteplase) 1 hour after symptom onset. Blood pressure is now 168/86 mm Hg, but other vital signs are unchanged, as are results of repeat neurologic examination. Which of the following is the most appropriate next step in management? A Aspirin administration B CT angiography of the head C Intravenous labetalol administration D MRI of the brain |
B Convulsive syncope
- Syncope is nontraumatic, complete transient loss of consciousness and loss of postural tone. Onset is abrupt and recovery is spontaneous, rapid, and complete. -Associated lightheadedness or chest pain may suggest syncope or cardiac disease. Syncope often presents with shaking (“convulsive syncope”) -Generalized tonic-clonic seizures have increased tone at the onset (tonic phase), followed by rhythmic, synchronous jerking of all limbs (clonic phase), typically for more than 1 minute. These seizures are followed by confusion, lethargy, and (sometimes) combativeness -Tonic seizures may involve brief loss of consciousness and falling, but there is no associated aura (prodrome or warning symptoms)
A 27-year-old woman is evaluated in the emergency department after a sudden, first-time episode of loss of consciousness while standing in line to board a tour bus. She had warning symptoms of tunnel vision and palpitations, after which she lost consciousness and fell. According to her father, who witnessed the episode, she was limp and unconscious for approximately 20 to 30 seconds, during which time she displayed intermittent twitching of all four limbs, with the limbs shaking independently at separate times. After the patient regained consciousness, she was confused about why she was on the ground but answered questions appropriately and was oriented to self and place.
All physical examination findings are normal. Which of the following is the most likely diagnosis? A Atonic seizure B Convulsive syncope C Generalized tonic-clonic seizure D Myoclonic seizure E Tonic seizure |
D Video EEG monitoring
- patient already on 2 AED, video EEG is the first step in determining candidacy for surgery by confirming that the seizures seen on video EEG match the location of abnormal findings on MRI. -Temporal lobectomy leads to seizure freedom in 60% to 70% of patients with temporal lobe epilepsy not helped by medication and is the best option for treating this patient. - vagus nerve stimulator is a palliative measure, is unlikely to result in freedom from seizures, and should be offered only if resection is not an option.
A 35-year-old man is evaluated for a 3-year history of epilepsy. Seizures typically occur twice monthly, last 2 minutes, and are characterized by staring, lip smacking, and confusion; approximately once every 6 months, the patient experiences a whole-body convulsion marked by incontinence and prolonged confusion for several hours. Treatment with oxcarbazepine and lamotrigine, although initially reducing seizure frequency, has been largely ineffective. He no longer drives or works because of the seizures. He also has migraines, which are well controlled by sumatriptan.
On physical examination, vital signs are normal. All other physical examination findings, including those from a neurologic examination, are unremarkable. Results of routine outpatient electroencephalography (EEG) are normal. An MRI of the brain shows right hippocampal atrophy. Which of the following is the most appropriate next step in management? A Levetiracetam B Topiramate C Vagus nerve stimulation D Video EEG monitoring |
-E Vitamin B12
-previous chronic abuse of nitrous oxide has resulted in a functional B12 deficiency that is due to inactivation of the vitamin. -Subacute combined degeneration is a myelopathy manifesting as dysfunction of the corticospinal tracts and dorsal columns that is caused by vitamin B12 and copper deficiencies
A 52-year-old man is evaluated for a 9-month history of progressively worsening gait, ataxia, and paresthesia in the legs. He is a dentist who was recently barred from practice because of chronic illicit drug use, specifically amphetamines and nitrous oxide.
On physical examination, vital signs are normal. Decreased vibration and position sense is noted in both feet. Reflexes are 3+ in both legs. Muscle strength is 4/5 in both hips. A complete blood count is normal, as is a routine chemistry panel. A T2-weighted MRI of the thoracic spinal cord shows hyperintensity in the posterior columns and throughout the cord. There is no associated contrast enhancement. Measurement of which of the following serum levels is the most appropriate next diagnostic test? A 25-Hydroxyvitamin D B Thiamine C Vitamin A D Vitamin B6 E Vitamin B12 |
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A Carotid duplex ultrasonography
initial test of choice for evaluating ICA stenosis is duplex ultrasonography because of its wide availability, low cost, and low risk; readily available, and noninvasive imaging modality for identifying high-grade stenosis and the possible need for surgery. -CT angiography of the neck is more costly and less widely available than carotid duplex ultrasonography. Additionally, the radiation exposure makes CT angiography less desirable as an initial imaging test. -Brain MRI is not the initial test of choice because the presence or absence of a cerebral infarct will not immediately change medical management or affect the patient's stroke risk. -patients with risk factors for stroke after a TIA, transesophageal echocardiography is (TEE) is unlikely to immediately change management, is invasive, and has low yield for finding an embolic source of stroke in patients who are in sinus rhythm.
A 49-year-old-man is evaluated 1 day after having an episode of right arm weakness without pain that lasted 5 minutes. He is now asymptomatic. The patient has type 2 diabetes mellitus and dyslipidemia. Medications are aspirin, metformin, and atorvastatin.
On physical examination, blood pressure is 126/68 mm Hg, pulse rate is 86/min and regular, and respiration rate is 12/min. No carotid bruits or cardiac murmurs are heard on cardiac auscultation. All other physical examination findings are normal. An electrocardiogram shows normal sinus rhythm with no ST-segment or T-wave changes. Which of the following is the most appropriate initial imaging test? A Carotid duplex ultrasonography B CT angiography of the neck C MRI of the brain D Transesophageal echocardiography |
E No further treatment or intervention
-LDL cholesterol level adequately controlled -patient has asymptomatic internal carotid artery stenosis of 60% to 80%; the risk of stroke with best medical therapy is very low. Carotid revascularization with either endarterectomy or stenting, on the other hand, has a higher risk of adverse effects, including stroke, and its absolute risk reduction of stroke in asymptomatic patients is small, particularly among patients with stenosis of 80% or less. -Carotid revascularization should be considered in patients at low risk for perioperative cardiovascular morbidity who have greater than 80% stenosis only in the context of a clinical trial -MRA not needed b/c an additional diagnostic test is unlikely to change medical management -no clear evidence that clopidogrel is superior to aspirin for the primary prevention of stroke in the setting of asymptomatic internal carotid artery stenosis,
A 67-year-old man is evaluated for a carotid bruit detected on routine medical examination. He reports no history of previous focal neurologic symptoms or visual loss. He has type 2 diabetes mellitus and hyperlipidemia treated with metformin, moderate-intensity pravastatin, and aspirin.
On physical examination, blood pressure is 128/64 mm Hg, pulse rate is 78/min and regular, and respiration rate is 16/min. A left carotid bruit is heard on cardiac examination. All other physical examination findings, including those from a neurologic examination, are unremarkable. Results of laboratory studies show an LDL cholesterol level of 82 mg/dL (2.12 mmol/L). The carotid ultrasound report describes a mixed-density plaque at the origin of the left internal carotid artery with stenosis estimated to be 60% to 80%. Which of the following is the most appropriate next step in management? A Carotid endarterectomy B Carotid stenting C Magnetic resonance angiography of the neck D Replacement of aspirin with clopidogrel E No further treatment or intervention |
B Levetiracetam
-In a woman with childbearing potential, levetiracetam and lamotrigine are the most appropriate treatment options because of their relatively low risk of teratogenicity. -Valproic acid is strongly associated with neural tube defects and lower IQ in offspring and should be avoided in women with childbearing potential, unless absolutely necessary. -Gabapentin and oxcarbazepine also have a relatively favorable profile in terms of lower fetal risk, but both are known to worsen generalized epilepsy and thus should be avoided in patients with JME. -Maternal topiramate use is associated with cleft lip/palate in offspring. This teratogenic drug should be avoided by women with childbearing potential
A 29-year-old woman is evaluated before attempting pregnancy. Juvenile myoclonic epilepsy was diagnosed 11 years ago, at which time she started taking valproic acid; she has had no symptoms for 10.5 years. Her only other medication is an oral contraceptive agent. She is concerned about taking her medications if she becomes pregnant.
All physical examination findings are normal, as was her most recent electroencephalogram. A plan is made to discontinue the oral contraceptive, start folic acid, and then taper the valproic acid. Which of the following is the most appropriate additional step in treatment? A Gabapentin B Levetiracetam C Oxcarbazepine D Topiramate E No additional treatment is necessary |
A Continuous (24-hour) electroencephalography
-Nonconvulsive status epilepticus should be suspected in patients with critical illness who develop altered mental status; the diagnosis is confirmed with continuous (24-hour) electroencephalography. At least 24 hours of monitoring is recommended in non-comatose patients, and at least 48 hours is recommended in comatose patients.
A 65-year-old man is evaluated in the ICU for a 24-hour history of altered mental status with a fluctuating level of consciousness. He was admitted to the hospital 5 days ago for urosepsis and acute kidney injury and developed acute respiratory distress syndrome on hospital day 3. The patient is currently intubated, mechanically ventilated, and receiving continuous hemodialysis. Medications are cefepime, norepinephrine, and fentanyl.
On physical examination, temperature is 38.4 °C (101.1 °F), blood pressure is 105/71 mm Hg, pulse rate is 108/min, and respiration rate is 12/min; FIO 2 is 0.9. The patient opens his eyes to voice but does not fixate on the examiner or follow commands. Pupils are reactive, and gag and corneal reflexes are present. All limbs move intermittently but not on command. The patient withdraws from painful stimuli in all four limbs. Intermittent twitching of the shoulders and eyelids is noted. Results of laboratory studies show a serum creatinine level of 5.4 mg/dL (477 µmol/L). Glucose, calcium, and electrolyte levels are within normal limits. A 20-minute electroencephalogram shows generalized slow activity, a nonspecific finding compatible with encephalopathy, but no evidence of seizure activity. A head CT scan is normal. Which of the following is the most appropriate next step in management? A Continuous (24-hour) electroencephalography B Intravenous fosphenytoin C Intravenous lorazepam D No treatment |
D Plasma exchange therapy
-Idiopathic TM is a monophasic inflammatory and demyelinating myelopathy affecting a portion of the spinal cord. Affected patients frequently experience a subacute onset of weakness, sensory changes, and bowel or bladder dysfunction, which is sometimes preceded by back pain or a thoracic banding sensation. -First-line treatment for this disorder is administration of high-dose intravenous glucocorticoids. The most appropriate next step is plasma exchange therapy, which has been shown to improve outcomes in patients with idiopathic transverse myelitis that is refractory to glucocorticoids.
A 19-year-old man is evaluated in the hospital after admission for subacute onset of bilateral lower extremity paraplegia, urinary incontinence, and sensory deficits. His initial treatment was a 5-day course of high-dose intravenous methylprednisolone. Four days after completion of the infusions, no clinical improvement has occurred. The patient had flu-like symptoms for several days before onset of neurologic symptoms but otherwise has been healthy.
On physical examination, vital signs are normal. Muscle strength is 0/5 in both legs and 5/5 in both arms. Reflexes are absent in the lower extremities and normal in the upper extremities. Moderate sensory loss is noted below T3 bilaterally. Cerebrospinal fluid analysis: Erythrocyte count: 2/µL (2 × 106/L) Leukocyte count: 38/µL (38 × 106/L), with a predominance of lymphocytes Glucose: Normal Protein: 62 mg/dL (620 mg/L) A T2-weighted MRI of the thoracic spine shows a hyperintense lesion in the thoracic cord at T2 with peripheral contrast enhancement. An MRI of the brain is normal. Which of the following is the most appropriate next step in treatment? A Antituberculosis drug regimen B Inpatient rehabilitation only C Intravenous immunoglobulin therapy D Plasma exchange therapy |
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