Who Wants to be a Millionaire or AMC ( MCQ + Clinical) Exams

[Lastana]

35yo man was brought to Glold Coast Hospital .
After Scooby Doo ride Pt became suddenly unwell, dizzy, nauseated , vomitted 3 times suddenly developed Visual disturbances , L sided retroorbital headache.


PHx
Healthy

Rx
None

SX
Lives with his wife and 2 kids in Melbourne.
TOP IT Programmer
Non smoker
Non drinker

OE:
Vitals - all OK'
Heart, Chest Abdo - all OK

neuro:
- Eyes Ex:


- Mild R facial weakness
- 4/5 weakness R limbs
- Cerebellar - normal
- Sensory all normal
ECG - Sinus tachy with no other ischemic changes
ALL BLOODS - OK


Task:
- Your Dx
- what Ix will confirm Dx
- Treatment

[bestfriend]

Dx Intracranial hemorrage (subarchnoid) due to rupture Av malformation (berry's aneurysm) which makes the classic signs of increased ICT (headache, nausea, vomiting, dizziness) plus hemiparesis and pupil signs
CT brain needed
tx supportive measures, decrease intracranial tension, diuretics, mannitol, ventilation, oxygen, monitoring of vital signs ICU admission, blood pressure control,...

[Vlad I.]

А на следующий день его погонят на DSA и если ему срастется то сделают coiling там где порвалось.

[Lastana]

SAH - good suggestion.
CT head on Admission to ED - NORMAL

[bestfriend]

could be neurosyphilis (Argyl Robertson Pupil; unequal pupil) because CT is Normal

[Lastana]

could be neurosyphilis (Argyl Robertson Pupil; unequal pupil) because CT is Normal

NO!..

[Yossarian]

Good evening Lastana!
Although I am not much of a neurologist, my reasoning here is as follows:
seems that photo demonstrates the Horner's syndrome in the left eye.
Local neurological signs from the cranial nerves and limbs are on the right.
Might it be the problem in the internal carotid atery (eg. aneyrism dissection)?
We can perform CT angio to confirm.
Tx would include BP control, vitals monitoring, anticoagulants promptly, vascular surgeon consult (to decise on early intervention - stenting, grafting..)

[Lastana]

Good evening Lastana!
Although I am not much of a neurologist, my reasoning here is as follows:
seems that photo demonstrates the Horner's syndrome in the left eye.
Local neurological signs from the cranial nerves and limbs are on the right.
Might it be the problem in the internal carotid atery (eg. aneyrism dissection)?
We can perform CT angio to confirm.
Tx would include BP control, vitals monitoring, anticoagulants promptly, vascular surgeon consult (to decise on early intervention - stenting, grafting..)

Why this young healthy man has carotid dissection ?

[Yossarian]

Who knows.., atherosclerosis does not spare anybody

Surprisingly, Kodra has not shown up yet to deliver the right answer!

[Lastana]

Ok!
Lets wait !

[bestfriend]

may be he has trigeminal neuralgia, or viral infection (herpes zoster)??

[Lastana]

Kodra!!!

Im waiting for your assessment.

[olley]

Ластана, последний case на энцефалит похож.

[olley]

Test:
Presence of high level of anti-GQ1b IgG antibodies (present in 60% of patients)
MRI (revealing high-intensity abnormalities in the posterior fossa, white matter or thalami ( in 30%)
Electroencephalogram and electromyography indicative of central nervous system and predominantly axonal involvement

Management:
Immunotherapy with intravenous immunoglobulin (IVIg); Treatment with steroids and double filtration plasmapheresis

For full marks - differentiate Bickerstaff's brainstem encephalitis from Fisher Miller Syndrome. These two are overlapping.

Информация взята отсюда - http://brain.oxfordjournals.org/cont.../2279.full.pdf

[Kodra]

DIAGNOSIS

Subarachnoid haemorrhage provoked by roller coaster ride.

INVESTIGATIONS

1. Urgent CT head; if normal
2. Digital subtraction angiography; if unavailable
3. Lumbar puncture (careful with ICP), looking for RBC and xanthochromia.

TREATMENT

Treatement would depend on the SAH grading. As this patient already has neurological deficit symptoms other from facial nerve palsy (mild right limbs weakness), I suspect Hunt and Hess' grade III SAH.

1. IV access, intubation, arrange urgent neurosurgical consultation and ICU admission.
2. Monitor cardiac activity, blood pressure, end-tidal carbon dioxide (regulate pCO2 at 30-35 mmHg to avoid ICP elevation).
3. Symptoms control: labetalol if increased blood pressure; mannitol and/or furosemide for increased ICP; promethazine if vomiting persists.

Then, hopefully, a surgical procedure (clipping or coiling) will be performed - as Vlad I has already mentioned.