Neurology 1
A nine-year-old girl is brought to the clinic for inattentiveness. Her parents say she occasionally drops her toothbrush in the morning, doesn't pay attention in class, and doesn't pay attention when her parents are talking to her. Symptoms are present at home and school. EEG reveals 4-hertz spike and wave complexes. What is the first-line medication for her condition?
This patient likely has absence seizures. The first-line treatment for absent seizures is ethosuximide. Ethosuximide is a thalamic calcium channel blocker.
These two drugs treat both migraines and seizure disorders. Both carry increased risk of neural tube defects.
Valproate and topiramate.
19 year old boy with daytime sleepiness despite sleeping 8-9 hours a night. He occasionally collapses without losing consciousness, usually when laughing. Vital signs are unremarkable. What is the first line treatment?
Modafinil is the first line treatment for narcolepsy. It is a stimulant that increases levels of dopamine and orexin neuron activation.
This drug is used to treat both neuroleptic malignant syndrome and Parkinson's disease.
Bromocriptine, a dopamine receptor agonist.
64 yo man, intention tremor, tremor worsens through the day, no Hx alcohol consumption, negative Romberg test, no gait instability. What is the first line treatment?
This pt has essential tremor because his tremor is absent at rest (intention tremor), worse through the day due to increasing fatigue. First line treatment is propranolol. MOA is antagonism of peripheral B-2 receptors on muscle spindle fibers.
A 35 year old man presents with chief concern of fatigue. The patient says he is sleepy during the day. While exploring the patient's symptoms, the physician asks if the patient has narcolepsy. Which drug used to treat insomnia is contraindicated in patients with narcolepsy?
Suvorexant, an orexin receptor antagonist. People with narcolepsy have an orexin deficiency. Orexin is a neurotransmitter that promotes wakefulness.
A 23 yo man is brought to the ED by paramedics. His respirations are shallow and irregular. His temperature is 99.1 F, BP 182/110, HR 48. CT shows diffuse cerebral edema. After stabilization, what is the best emergency treatment?
Mannitol or hypertonic saline.
A 60-year-old woman presents to her PCP for difficulty sleeping. She says she has an uncomfortable feeling in her legs at night that goes away when she gets up and walks. The uncomfortable feeling also happens if she sits down for too long. Physical exam is normal and vital signs are normal. What is the most appropriate next step in workup of this patient?
This patient has restless leg syndrome. The most appropriate next test and workup of this condition is to check serum ferritin. Low iron levels are associated with restless leg syndrome, and correcting iron levels often remedies the condition.
A 75 yo man is found unconscious by paramedics at a park. His last known well is unknown. His vital signs are RR 8, HR 56, BP 180/110. On exam, the patient is lethargic and has upper and lower extremity weakness on the right side. The left pupil is reactive to light and the right pupil is fixed and dilated. CT results are pending. Which side of the patient is causing this herniation syndrome?
This patient has symptoms of uncal herniation (cushing's triad, ipsalateral pupil findings, ipsalateral motor findings). The ipsalateral motor findings are a false localizing sign called Kernohan's Phenomenon. The herniation is likely coming from the right side (ipsalateral to the eye and motor symptoms).
A 9 yo girl is brought to the neurology clinic for difficulty walking. Her parents say her symptoms have worsened over the past month, and she is unable to walk without holding onto furniture. She also developed nystagmus during this time. Physical exam reveals tachycardia and hypertension as well as truncal ataxia and chaotic multidirectional eye movement. There are also intermittent myoclonic jerks, even at rest. Imaging studies of the brain are non-diagnostic. What tumor is the most likely cause of this patient's symptoms?
This patient presents with opsoclonus myoclonus. Apsoclonus-myoclonus is a rare paraneoplastic syndrome, usually caused by neuroblastoma. Neuroblastomas often cause the body to create antibodies that cross-react with antigens in the cerebellum and brainstem.
An eight-year-old boy is brought to the pediatrician. Just the previous night, the boy had an episode at 3:00 a.m. where the left side of his face was twitching, the boy was drooling, and he was unable to speak. The episode lasted four minutes, after which the boy went back to sleep. On neurologic assessment, there are no focal neurologic deficits. Vital signs are normal. EEG reveals sharp biphasic waves in the centrotemporal region of the brain. What is the most appropriate long-term treatment at this time?
The best treatment is nothing. This patient most likely has benign Rolandic Seizures, also called self-limited epilepsy with centrotemporal spikes (SeLECTS). This is a common form of childhood epilepsy that causes infrequent seizures involving the face or mouth. Seizures are most common at night time and usually do not inhibit functioning. The most common treatment is observation. If seizures become frequent, pharmacologic therapy is considered with carbamazepine or levetiracetam.