A 75-year-old man with Alzheimer's dementia (MMSE 18/30) is reviewed in the memory clinic. He was started on donepezil 6 months ago with some initial improvement, but his wife reports worsening confusion, nocturnal wandering, and verbal aggression over the past 4 weeks. He has developed visual hallucinations of insects on the walls. There is no evidence of infection or other physical illness. His medications include donepezil, amlodipine, and atorvastatin. What is the most appropriate initial management of his behavioural symptoms?
Q102
A 58-year-old man presents to the Emergency Department with sudden onset severe occipital headache that he describes as 'the worst headache of his life'. The headache started 6 hours ago while he was lifting weights at the gym. He has vomited twice and is photophobic. He is alert and oriented. Neurological examination is normal. Blood pressure is 158/92 mmHg. Non-contrast CT head performed 8 hours after symptom onset shows no abnormality. What is the most appropriate next investigation?
Q103
A 32-year-old woman with a 10-year history of epilepsy controlled on levetiracetam presents to the neurology clinic. She has been seizure-free for 5 years and asks about stopping her medication. Her epilepsy began in her early twenties with generalised tonic-clonic seizures. EEG performed at diagnosis showed generalised spike-and-wave discharges. She drives and works as a primary school teacher. What is the most appropriate advice regarding antiepileptic drug withdrawal?
Q104
A 64-year-old woman presents with sudden onset vertigo, vomiting, and difficulty walking that started 4 hours ago. She has a past medical history of hypertension and hyperlipidaemia. On examination, she has nystagmus, left-sided limb ataxia, and difficulty maintaining balance. There is also reduced pain and temperature sensation on the right side of her face and left side of her body. Her blood pressure is 172/98 mmHg. What vascular territory is most likely affected?
Q105
A 79-year-old man is admitted with acute confusion. His wife reports he was well until 2 days ago when he became increasingly drowsy and confused. He has a history of benign prostatic hyperplasia and recently started taking oxybutynin. On examination, he is disoriented to time and place, appears agitated, and is picking at the bed sheets. Temperature is 37.8°C, heart rate is 102 bpm, blood pressure is 138/82 mmHg. His abbreviated mental test score is 3/10. Blood tests show: Na+ 142 mmol/L, K+ 4.1 mmol/L, urea 8.2 mmol/L, creatinine 98 μmol/L, CRP 12 mg/L. Urinalysis shows leucocytes ++, nitrites +. What is the most likely diagnosis?
Q106
A 55-year-old woman presents to her GP with episodes of severe unilateral headache occurring 2-3 times per week for the past 2 months. Each episode lasts 1-2 hours and is associated with nausea, photophobia, and phonophobia. She describes the pain as throbbing and affecting the right side of her head. She has noticed that the headaches are sometimes preceded by 20 minutes of shimmering zigzag lines in her vision. Between episodes she feels well. What is the most appropriate first-line prophylactic medication?
Q107
A 28-year-old man is brought to the Emergency Department by ambulance following a witnessed generalised tonic-clonic seizure lasting approximately 3 minutes. He has now been seizing continuously for 20 minutes despite two doses of intravenous lorazepam 4 mg given 10 minutes apart. His airway is maintained, oxygen saturation is 94% on high-flow oxygen, heart rate is 118 bpm, blood pressure is 142/88 mmHg, and blood glucose is 6.2 mmol/L. What is the most appropriate next step in management?
Q108
A 68-year-old woman presents with a 6-month history of progressive memory impairment and visual hallucinations of children playing in her garden. Her husband reports marked fluctuation in her cognition, with some days much worse than others. She has developed a shuffling gait and has had two falls. There is no significant past medical history. MMSE score is 22/30. Examination reveals mild cogwheel rigidity and bradykinesia. MRI brain shows generalised atrophy with preserved hippocampal volumes. What is the most likely diagnosis?
Q109
A 45-year-old woman with known epilepsy presents to clinic requesting preconception counselling. She has been seizure-free for 3 years on sodium valproate 1000 mg twice daily. She has previously failed treatment with carbamazepine due to poor seizure control and levetiracetam due to intolerable mood disturbance. She is keen to start trying for pregnancy. What is the most appropriate management plan?
Q110
A 72-year-old man presents to the Emergency Department with sudden onset right-sided weakness and speech difficulty that started 90 minutes ago. His blood pressure is 168/95 mmHg, heart rate is 88 bpm and irregularly irregular. He has a past medical history of hypertension and type 2 diabetes mellitus. Neurological examination reveals right-sided hemiparesis with facial droop, dysphasia, and right homonymous hemianopia. His NIHSS score is 16. Non-contrast CT head shows no evidence of haemorrhage or early ischaemic changes. What is the most appropriate immediate management?
Neurology UK Medical PG Practice Questions and MCQs
Question 101: A 75-year-old man with Alzheimer's dementia (MMSE 18/30) is reviewed in the memory clinic. He was started on donepezil 6 months ago with some initial improvement, but his wife reports worsening confusion, nocturnal wandering, and verbal aggression over the past 4 weeks. He has developed visual hallucinations of insects on the walls. There is no evidence of infection or other physical illness. His medications include donepezil, amlodipine, and atorvastatin. What is the most appropriate initial management of his behavioural symptoms?
A. Add memantine to existing donepezil therapy
B. Add low-dose risperidone 0.5 mg twice daily
C. Switch from donepezil to memantine
D. Implement non-pharmacological interventions and review in 2 weeks (Correct Answer)
E. Stop donepezil and start quetiapine 25 mg at night
Explanation: ***Implement non-pharmacological interventions and review in 2 weeks***- According to **NICE guidelines**, non-pharmacological approaches are the **first-line management** for **Behavioural and Psychological Symptoms of Dementia (BPSD)** unless there is severe distress or immediate risk of harm.- These interventions include identifying triggers, **environmental modifications**, and ensuring sensory needs are met before considering pharmacological changes.
*Add memantine to existing donepezil therapy*
- While **memantine** is indicated for moderate-to-severe Alzheimer's (MMSE < 20), it is not the initial treatment for acute **behavioural symptoms** like aggression or hallucinations.
- It is typically considered as an add-on therapy to address cognitive decline when non-pharmacological methods and primary cognitive enhancers are insufficient for the broader disease progression.
*Add low-dose risperidone 0.5 mg twice daily*
- **Antipsychotics** like risperidone should only be used as a last resort for BPSD, particularly if there is an immediate risk of harm or extreme distress, due to the significant risk of **stroke** and increased **mortality** in elderly patients with dementia.
- If used, they must be prescribed at the **lowest effective dose** for the shortest possible duration, and only after non-pharmacological options have been exhausted.
*Switch from donepezil to memantine*
- There is no clinical indication to discontinue **donepezil** solely because behavioral symptoms have emerged; cholinesterase inhibitors should generally be continued unless side effects warrant cessation.
- **Dual therapy** (cholinesterase inhibitor plus NMDA antagonist) is often preferred over switching when dementia progresses to the moderate stage, rather than stopping one for the other.
*Stop donepezil and start quetiapine 25 mg at night*
- **Quetiapine** has limited robust evidence of efficacy for BPSD and carries similar risks of **cerebrovascular events** and **increased mortality** as other antipsychotics in this population.
- Abruptly stopping **donepezil** can lead to a rapid worsening of cognitive function and potentially exacerbate behavioural instability, which is generally not recommended.
Question 102: A 58-year-old man presents to the Emergency Department with sudden onset severe occipital headache that he describes as 'the worst headache of his life'. The headache started 6 hours ago while he was lifting weights at the gym. He has vomited twice and is photophobic. He is alert and oriented. Neurological examination is normal. Blood pressure is 158/92 mmHg. Non-contrast CT head performed 8 hours after symptom onset shows no abnormality. What is the most appropriate next investigation?
A. Discharge with analgesia and GP follow-up as CT is normal
B. Lumbar puncture with spectrophotometry for xanthochromia (Correct Answer)
C. CT angiography of cerebral vessels
D. MRI brain with gadolinium contrast
E. Repeat CT head after 24 hours
Explanation: ***Lumbar puncture with spectrophotometry for xanthochromia***- In a patient with a **thunderclap headache** and a negative CT performed more than 6 hours after onset, **lumbar puncture** is mandatory to rule out subarachnoid hemorrhage (SAH).- **Xanthochromia** usually takes at least **12 hours** to develop as red blood cells break down into bilirubin; spectrophotometry is the gold standard for detection.*Discharge with analgesia and GP follow-up as CT is normal*- A normal CT scan does not exclude SAH, especially if clinical suspicion is high based on a **sudden-onset severe headache**.- Premature discharge without excluding a **sentinel bleed** carries a high risk of catastrophic re-bleeding or death.*CT angiography of cerebral vessels*- While **CT angiography** can identify vascular abnormalities like aneurysms, it is not a diagnostic tool for confirming the presence of **subarachnoid blood**.- A positive CTA without evidence of hemorrhage does not confirm SAH, and a negative CTA cannot definitively rule out a small bleed.*MRI brain with gadolinium contrast*- **MRI** is generally less sensitive than CT for detecting acute blood in the first 24 hours and is not the first-line investigation for suspected **acute SAH**.- Contrast-enhanced MRI is better suited for identifying **malignancies or infections** rather than acute subarachnoid bleeding.*Repeat CT head after 24 hours*- The sensitivity of a CT scan for SAH **decreases with time** as blood is washed away or degraded; repeating it later is unlikely to show blood if the first was clear.- **Lumbar puncture** is the definitive step when the initial CT is negative to avoid missing a diagnosis that requires urgent neurosurgical intervention.
Question 103: A 32-year-old woman with a 10-year history of epilepsy controlled on levetiracetam presents to the neurology clinic. She has been seizure-free for 5 years and asks about stopping her medication. Her epilepsy began in her early twenties with generalised tonic-clonic seizures. EEG performed at diagnosis showed generalised spike-and-wave discharges. She drives and works as a primary school teacher. What is the most appropriate advice regarding antiepileptic drug withdrawal?
A. Withdrawal can be considered; the process should take at least 2-3 months and she must inform the DVLA and stop driving during withdrawal and for 6 months after (Correct Answer)
B. Withdrawal is appropriate; she can continue driving as she has been seizure-free for 5 years
C. Withdrawal should not be considered as she has generalised epilepsy with ongoing EEG abnormalities
D. Withdrawal can be attempted; she should reduce the dose by 25% every 2 weeks and can continue driving if no seizures occur
E. She should have a repeat EEG, and withdrawal can only proceed if this is normal
Explanation: ***Withdrawal can be considered; the process should take at least 2-3 months and she must inform the DVLA and stop driving during withdrawal and for 6 months after***- NICE guidelines suggest considering **antiepileptic drug (AED) withdrawal** after **2 years or more of seizure freedom**, which this patient meets (5 years). The process should be **gradual**, typically over **2-3 months** or longer to minimize recurrence risk.- **Driving regulations (DVLA in the UK)** require patients to **inform the DVLA** and **stop driving** during the entire withdrawal period and for **6 months after** the last dose, irrespective of seizure occurrence, due to the elevated risk of provoked seizures.*Withdrawal is appropriate; she can continue driving as she has been seizure-free for 5 years*- While **seizure freedom for 5 years** makes withdrawal *appropriate to consider*, continuing to drive during withdrawal is **not permissible** under driving regulations.- The act of **reducing AEDs** significantly increases the risk of **provoked seizures**, making driving unsafe and illegal until a sustained seizure-free period after withdrawal is confirmed.*Withdrawal should not be considered as she has generalised epilepsy with ongoing EEG abnormalities*- Although **generalised epilepsy** and **spike-and-wave discharges on EEG** (even if from diagnosis) are risk factors for recurrence, they do not **absolutely contraindicate** a supervised withdrawal attempt, especially after **5 years of seizure freedom**.- The decision to withdraw is a **shared process** considering individual risk factors, lifestyle, and the patient's strong desire to stop medication.*Withdrawal can be attempted; she should reduce the dose by 25% every 2 weeks and can continue driving if no seizures occur*- A **25% reduction every 2 weeks** is often considered too rapid for most AEDs and increases the risk of **withdrawal seizures**; a more gradual taper over **2-3 months** or longer is generally recommended.- The **DVLA requirement to stop driving** during and for 6 months post-withdrawal is **mandatory**, irrespective of whether seizures occur, as the increased risk is inherent to the process.*She should have a repeat EEG, and withdrawal can only proceed if this is normal*- While a **repeat EEG** can provide additional prognostic information regarding recurrence risk, a **normal EEG is not a mandatory prerequisite** for initiating AED withdrawal.- Many patients who are clinically **seizure-free** may still have **interictal epileptiform discharges** on EEG and can successfully withdraw from medication under supervision.
Question 104: A 64-year-old woman presents with sudden onset vertigo, vomiting, and difficulty walking that started 4 hours ago. She has a past medical history of hypertension and hyperlipidaemia. On examination, she has nystagmus, left-sided limb ataxia, and difficulty maintaining balance. There is also reduced pain and temperature sensation on the right side of her face and left side of her body. Her blood pressure is 172/98 mmHg. What vascular territory is most likely affected?
A. Left posterior inferior cerebellar artery (Correct Answer)
B. Right middle cerebral artery
C. Left anterior inferior cerebellar artery
D. Basilar artery
E. Right posterior inferior cerebellar artery
Explanation: ***Left posterior inferior cerebellar artery*** - This patient presents with **Wallenberg syndrome** (lateral medullary syndrome), which results from an infarct in the territory of the **Posterior Inferior Cerebellar Artery (PICA)**. - The combination of **ipsilateral limb ataxia** (left) and **crossed sensory loss** (reduced pain/temperature on the ipsilateral face (right) and contralateral body (left)) localizes the lesion precisely to the **left lateral medulla**, supplied by the left PICA. *Right middle cerebral artery* - An MCA stroke typically presents with **contralateral hemiparesis**, hemisensory loss, and potentially **aphasia** or neglect, rather than cerebellar signs. - It does not cause the **crossed sensory deficits** or the distinct brainstem findings (vertigo, vomiting, nystagmus) seen in this case. *Left anterior inferior cerebellar artery* - **AICA** occlusion leads to **lateral pontine syndrome**, which is distinguished from PICA syndrome by the presence of **ipsilateral facial paralysis** (CN VII) and **deafness** or tinnitus (CN VIII). - Since these cranial nerve VII and VIII signs are absent, a pontine lesion is less likely than a medullary one. *Basilar artery* - **Basilar artery** occlusion usually presents with more severe, global symptoms such as **bilateral motor deficits** (quadriparesis) or a **locked-in syndrome**. - It often involves significant alterations in **level of consciousness** and lacks the specific isolated lateralizing signs of Wallenberg syndrome. *Right posterior inferior cerebellar artery* - While a PICA lesion causes Wallenberg syndrome, a **right PICA infarction** would lead to **right-sided cerebellar ataxia** and **right-sided facial sensory loss**. - Because this patient has **left-sided limb ataxia** and **left-sided body sensory loss**, the lesion must be located on the **left side** of the medulla.
Question 105: A 79-year-old man is admitted with acute confusion. His wife reports he was well until 2 days ago when he became increasingly drowsy and confused. He has a history of benign prostatic hyperplasia and recently started taking oxybutynin. On examination, he is disoriented to time and place, appears agitated, and is picking at the bed sheets. Temperature is 37.8°C, heart rate is 102 bpm, blood pressure is 138/82 mmHg. His abbreviated mental test score is 3/10. Blood tests show: Na+ 142 mmol/L, K+ 4.1 mmol/L, urea 8.2 mmol/L, creatinine 98 μmol/L, CRP 12 mg/L. Urinalysis shows leucocytes ++, nitrites +. What is the most likely diagnosis?
A. Alzheimer's disease with acute deterioration
B. Delirium secondary to urinary tract infection (Correct Answer)
C. Lewy body dementia
D. Hypoactive delirium due to anticholinergic medication
E. Uremic encephalopathy
Explanation: ***Delirium secondary to urinary tract infection***
- The patient's **acute onset** (2 days) of confusion, drowsiness, disorientation, and agitation (picking at bed sheets suggesting **hyperactive delirium**) are classic features of **delirium**.
- The urinalysis showing **leucocytes ++** and **nitrites +**, along with a low-grade fever (37.8°C) and elevated CRP, strongly indicates a **urinary tract infection (UTI)** as the precipitating cause.
*Alzheimer's disease with acute deterioration*
- **Alzheimer's disease** is characterized by a **gradual, progressive decline** in cognitive function over months to years, not a sudden onset over 2 days.
- While patients with **dementia** are more susceptible to delirium, the acute change in mental status and clear signs of infection point to delirium as the primary diagnosis.
*Lewy body dementia*
- **Lewy body dementia** typically presents with fluctuating cognition, **recurrent visual hallucinations**, and **Parkinsonian features**, which are chronic and not consistent with a 2-day acute decline.
- The presence of a clear **infection (UTI)** better explains the acute cognitive decline than a new diagnosis of Lewy body dementia.
*Hypoactive delirium due to anticholinergic medication*
- While **oxybutynin** is an anticholinergic medication and can contribute to confusion, the patient is described as **agitated** and picking at bed sheets, which are features of **hyperactive delirium**, not hypoactive.
- The strong evidence of a **UTI** (leucocytes, nitrites, fever, CRP) provides a more direct and acute cause for the delirium than medication alone.
*Uremic encephalopathy*
- **Uremic encephalopathy** is caused by severe kidney dysfunction leading to accumulation of uremic toxins, typically associated with significantly elevated **urea and creatinine** levels.
- The patient's **creatinine (98 μmol/L)** and **urea (8.2 mmol/L)** are within or only very mildly elevated from the normal range for an elderly person, making uremic encephalopathy an unlikely cause.
Question 106: A 55-year-old woman presents to her GP with episodes of severe unilateral headache occurring 2-3 times per week for the past 2 months. Each episode lasts 1-2 hours and is associated with nausea, photophobia, and phonophobia. She describes the pain as throbbing and affecting the right side of her head. She has noticed that the headaches are sometimes preceded by 20 minutes of shimmering zigzag lines in her vision. Between episodes she feels well. What is the most appropriate first-line prophylactic medication?
A. Propranolol 80 mg twice daily (Correct Answer)
B. Amitriptyline 10 mg at night, gradually increasing to 50-75 mg
C. Topiramate 25 mg daily, gradually increasing to 50-100 mg
D. Pizotifen 0.5 mg at night, gradually increasing to 1.5 mg
E. Flunarizine 10 mg at night
Explanation: ***Propranolol 80 mg twice daily***
- The clinical presentation of **unilateral throbbing headache**, nausea, and **visual aura** (shimmering zigzag lines) confirms a diagnosis of **migraine with aura**.
- NICE guidelines recommend **Propranolol** as a **first-line prophylactic** agent for patients experiencing two or more attacks per month that impact quality of life.
*Amitriptyline 10 mg at night, gradually increasing to 50-75 mg*
- While effective for **neuropathic pain** and migraine prevention, it is generally considered an **alternative** or second-line option rather than the first-line choice.
- It is frequently associated with **anticholinergic side effects** such as dry mouth and sedation, making it less favorable than beta-blockers initially.
*Topiramate 25 mg daily, gradually increasing to 50-100 mg*
- Though a **first-line** prophylactic option, it is often avoided as the initial choice in women of childbearing age due to its **teratogenic risk**.
- It requires cautious use due to potential **cognitive side effects** (difficulty concentrating) and the risk of **secondary glaucoma**.
*Pizotifen 0.5 mg at night, gradually increasing to 1.5 mg*
- Pizotifen is rarely used as a first-line treatment in modern practice due to limited efficacy compared to modern agents.
- It is strongly associated with undesirable side effects, most notably **significant weight gain** and marked **drowsiness**.
*Flunarizine 10 mg at night*
- This is usually reserved as a **third-line** or specialist-initiated treatment for refractory migraine cases.
- It is not routinely available in many primary care settings and carries a risk of **extrapyramidal side effects** and depression.
Question 107: A 28-year-old man is brought to the Emergency Department by ambulance following a witnessed generalised tonic-clonic seizure lasting approximately 3 minutes. He has now been seizing continuously for 20 minutes despite two doses of intravenous lorazepam 4 mg given 10 minutes apart. His airway is maintained, oxygen saturation is 94% on high-flow oxygen, heart rate is 118 bpm, blood pressure is 142/88 mmHg, and blood glucose is 6.2 mmol/L. What is the most appropriate next step in management?
A. Administer intravenous phenytoin 15-18 mg/kg at maximum rate of 50 mg/min (Correct Answer)
B. Give a third dose of intravenous lorazepam 4 mg
C. Arrange urgent transfer to intensive care for intubation
D. Administer intramuscular paraldehyde 0.4 ml/kg
E. Give intravenous levetiracetam 40 mg/kg over 5 minutes
Explanation: ***Administer intravenous phenytoin 15-18 mg/kg at maximum rate of 50 mg/min*** - This patient is in **established status epilepticus**, as the seizure has continued for 20 minutes despite two adequate doses of **benzodiazepines** (lorazepam). - **Phenytoin** is a widely accepted and effective second-line antiepileptic drug for established status epilepticus, providing sustained seizure control. *Give a third dose of intravenous lorazepam 4 mg* - Administering a third dose of **benzodiazepines** is generally not recommended as it significantly increases the risk of **respiratory depression** and sedation. - Once two doses of a **first-line agent** like lorazepam have failed, the next step is to transition to a **second-line antiepileptic drug**. *Arrange urgent transfer to intensive care for intubation* - Intubation and general anesthesia are typically reserved for **refractory status epilepticus**, which is defined as seizures continuing despite adequate doses of both first- and second-line antiepileptic drugs. - While airway management is crucial, the immediate next step is to attempt to terminate the seizure pharmacologically with a **second-line agent** before escalating to general anesthesia. *Administer intramuscular paraldehyde 0.4 ml/kg* - **Paraldehyde** is an older antiepileptic agent rarely used in current practice due to its side effects, and is considered only when **intravenous access** is impossible. - This patient has already received IV lorazepam, indicating readily available IV access, making paraldehyde an inappropriate choice. *Give intravenous levetiracetam 40 mg/kg over 5 minutes* - While **levetiracetam** is an alternative second-line antiepileptic for status epilepticus, the standard recommended loading dose is typically higher, usually **60 mg/kg**. - **Phenytoin** remains a more traditionally established first choice in many acute protocols for established convulsive status epilepticus compared to levetiracetam at this suboptimal dose.
Question 108: A 68-year-old woman presents with a 6-month history of progressive memory impairment and visual hallucinations of children playing in her garden. Her husband reports marked fluctuation in her cognition, with some days much worse than others. She has developed a shuffling gait and has had two falls. There is no significant past medical history. MMSE score is 22/30. Examination reveals mild cogwheel rigidity and bradykinesia. MRI brain shows generalised atrophy with preserved hippocampal volumes. What is the most likely diagnosis?
A. Alzheimer's disease with Parkinsonian features
B. Dementia with Lewy bodies (Correct Answer)
C. Parkinson's disease with dementia
D. Vascular dementia with parkinsonism
E. Progressive supranuclear palsy
Explanation: ***Dementia with Lewy bodies***
- This patient presents with the classic triad of **fluctuating cognition**, detailed **visual hallucinations** (children playing), and spontaneous **parkinsonism** (shuffling gait, falls, cogwheel rigidity, bradykinesia).
- The **preserved hippocampal volumes** on MRI, despite generalized atrophy, is a key feature differentiating it from Alzheimer's, and the presentation fits the 'one-year rule' where cognitive symptoms occur concurrently or within a year of motor symptoms.
*Alzheimer's disease with Parkinsonian features*
- While common, **Alzheimer's disease** typically presents with early, prominent episodic memory loss and would show **hippocampal atrophy** on MRI, which is absent here.
- Vivid visual hallucinations and marked cognitive fluctuations are not characteristic early features of AD, distinguishing it from **Dementia with Lewy bodies**.
*Parkinson's disease with dementia*
- This diagnosis requires that **motor symptoms** (parkinsonism) must be present for at least **one year before** the onset of significant cognitive impairment or dementia.
- In this case, memory impairment and visual hallucinations developed concurrently or shortly after the motor symptoms, making **Dementia with Lewy bodies** more likely.
*Vascular dementia with parkinsonism*
- Characterized by a **stepwise decline** in cognition and a history of vascular risk factors or strokes, rather than the prominent daily fluctuations seen here.
- MRI would typically reveal specific **vascular lesions** like infarcts or significant white matter disease, not just generalized atrophy with preserved hippocampi.
*Progressive supranuclear palsy*
- Presents with early and prominent **falls** and axial rigidity, but a distinguishing feature is **vertical gaze palsy** (difficulty looking up or down), which is not mentioned.
- The cognitive profile in PSP is often more subcortical, and vivid visual hallucinations are not a typical primary symptom as seen in DLB.
Question 109: A 45-year-old woman with known epilepsy presents to clinic requesting preconception counselling. She has been seizure-free for 3 years on sodium valproate 1000 mg twice daily. She has previously failed treatment with carbamazepine due to poor seizure control and levetiracetam due to intolerable mood disturbance. She is keen to start trying for pregnancy. What is the most appropriate management plan?
A. Continue sodium valproate with high-dose folic acid supplementation
B. Switch to lamotrigine with gradual dose titration before conception (Correct Answer)
C. Switch to phenytoin as it has lower teratogenic risk than valproate
D. Continue current medication but ensure she uses reliable contraception
E. Reduce sodium valproate dose to minimise teratogenic risk
Explanation: ***Switch to lamotrigine with gradual dose titration before conception***- **Sodium valproate** is highly **teratogenic**, associated with a **10% risk of major congenital malformations** and up to a **40% risk of neurodevelopmental delay**; it must be avoided in women of childbearing potential unless no alternative exists.- **Lamotrigine** is a preferred first-line option in pregnancy due to its **lowest risk profile**; given she failed levetiracetam, lamotrigine is the most appropriate next step to attempt before conception.*Continue sodium valproate with high-dose folic acid supplementation*- While **5mg folic acid** is mandatory for women on antiepileptics, it does not sufficiently mitigate the significant **teratogenic and neurodevelopmental risks** unique to valproate.- Guidelines and the **Valproate Pregnancy Prevention Programme** mandate shifting to safer alternatives whenever clinically possible.*Switch to phenytoin as it has lower teratogenic risk than valproate*- **Phenytoin** is also associated with significant teratogenicity, including the **fetal hydantoin syndrome**, and is generally avoided in pregnancy.- It is not a preferred alternative when modern options like **lamotrigine** have a much better-established safety profile for the fetus.*Continue current medication but ensure she uses reliable contraception*- This option ignores the patient's explicit request for **preconception counselling** and her desire to start trying for pregnancy.- Management must focus on optimizing her medication regimen to facilitate a **safe pregnancy** rather than simply preventing one.*Reduce sodium valproate dose to minimise teratogenic risk*- Although risks are dose-dependent (higher risk >1000mg/day), there is **no established "safe" dose** of valproate that eliminates the high risk of birth defects.- For a patient who is currently stable, the priority is to transition to a drug with **lower intrinsic teratogenicity** rather than sticking with a high-risk agent.
Question 110: A 72-year-old man presents to the Emergency Department with sudden onset right-sided weakness and speech difficulty that started 90 minutes ago. His blood pressure is 168/95 mmHg, heart rate is 88 bpm and irregularly irregular. He has a past medical history of hypertension and type 2 diabetes mellitus. Neurological examination reveals right-sided hemiparesis with facial droop, dysphasia, and right homonymous hemianopia. His NIHSS score is 16. Non-contrast CT head shows no evidence of haemorrhage or early ischaemic changes. What is the most appropriate immediate management?
A. Intravenous alteplase followed by mechanical thrombectomy (Correct Answer)
B. Aspirin 300 mg stat and admission to stroke unit
C. Mechanical thrombectomy alone without thrombolysis
D. Reduce blood pressure to target <140/90 mmHg before further intervention
E. CT angiography followed by deferred decision based on vessel occlusion site
Explanation: ***Intravenous alteplase followed by mechanical thrombectomy***
- The patient presents within the **4.5-hour window** for intravenous thrombolysis, and the non-contrast CT head **excludes haemorrhage**, making **alteplase** the immediate first-line treatment to improve clinical outcomes.
- An **NIHSS score of 16** and clinical features like **right homonymous hemianopia** and severe hemiparesis strongly suggest a **large vessel occlusion (LVO)**, for which **mechanical thrombectomy** in conjunction with alteplase is the standard of care to achieve reperfusion.
*Aspirin 300 mg stat and admission to stroke unit*
- **Aspirin** is crucial for secondary prevention in ischaemic stroke but is typically deferred for **24 hours after intravenous thrombolysis** to minimize the risk of haemorrhagic transformation.
- Administering aspirin alone would represent an under-treatment, as it would forgo the opportunity for **acute reperfusion therapies** (thrombolysis and thrombectomy) which are time-sensitive and more effective in reversing neurological deficits.
*Mechanical thrombectomy alone without thrombolysis*
- Current guidelines advocate for a "**bridging therapy**" approach, meaning patients eligible for both treatments should receive **intravenous alteplase** as soon as possible while preparing for mechanical thrombectomy.
- Omitting thrombolysis without specific contraindications can delay reperfusion and miss the chance for earlier clot lysis, potentially worsening patient outcomes.
*Reduce blood pressure to target <140/90 mmHg before further intervention*
- Aggressive blood pressure lowering in the acute phase of ischaemic stroke can reduce **cerebral perfusion pressure** to the **ischaemic penumbra**, potentially worsening ischaemia and infarct size.
- For patients eligible for thrombolysis, blood pressure needs to be maintained below **185/110 mmHg**; the patient's current BP of 168/95 mmHg is within the acceptable range and does not require immediate lowering prior to alteplase.
*CT angiography followed by deferred decision based on vessel occlusion site*
- While **CT angiography (CTA)** is essential to confirm a large vessel occlusion and guide mechanical thrombectomy, it should **not delay** the administration of **intravenous alteplase** in eligible patients.
- The strategy is often "**drip and ship**" or "drip and scan," where alteplase is initiated immediately after non-contrast CT rules out haemorrhage, and CTA is performed either concurrently or subsequently to plan for thrombectomy.
