A 33-year-old woman attends neurology clinic following a first unprovoked generalised tonic-clonic seizure 6 weeks ago. She has fully recovered with no residual symptoms. She works as a bus driver. Her neurological examination is normal. MRI brain shows no abnormality. EEG shows occasional generalised spike-and-wave discharges. She is keen to return to work as soon as possible. According to UK DVLA regulations, what advice should be given regarding her driving?
Q42
A 76-year-old man with Alzheimer's dementia (MMSE 15/30) is brought to the memory clinic by his daughter. She reports that over the past 2 months he has developed prominent visual and auditory hallucinations, becoming convinced that people are living in his attic and stealing his belongings. He has become verbally aggressive when she tries to reassure him. He has no previous psychiatric history. He is currently taking donepezil 10 mg daily, amlodipine, and atorvastatin. Which of the following is the most appropriate initial management of his psychotic symptoms?
Q43
A 51-year-old woman with a 15-year history of relapsing-remitting multiple sclerosis presents to clinic. She has experienced increasing disability over the past 18 months with progressive worsening of mobility, spasticity, and bladder symptoms, without distinct relapses. Her current EDSS score is 6.5 (requires bilateral support to walk 20 metres). She is currently on dimethyl fumarate. MRI brain shows multiple T2 hyperintense periventricular lesions, unchanged from 12 months ago, with no new gadolinium-enhancing lesions. What does this clinical picture most likely represent?
Q44
A 44-year-old man presents to his GP with a 6-week history of headaches. He describes them as bilateral, pressing/tightening in quality, of mild to moderate intensity, occurring daily. The headaches are present on waking and persist throughout the day. They are not aggravated by routine physical activity and are not associated with nausea, photophobia, or phonophobia. He denies any visual disturbances. Over the past 3 months, he has also noticed reduced libido and has gained 8 kg in weight despite no change in diet. On examination, visual acuity is 6/6 bilaterally. Fundoscopy reveals bilateral papilloedema. What is the most appropriate next investigation?
Q45
An 81-year-old man is admitted to hospital for investigation of recurrent falls. On the second day of admission, nursing staff report that he has become acutely confused overnight, believing he is in his childhood home and that deceased relatives are visiting him. He is agitated and trying to leave the ward. He has a history of hypertension and underwent a right total hip replacement 3 days ago. His current medications include amlodipine, paracetamol, and oxycodone for post-operative pain. Observations show temperature 37.8°C, blood pressure 142/86 mmHg, heart rate 94 bpm, respiratory rate 18/min, and oxygen saturation 94% on room air. What is the most appropriate first-line pharmacological intervention for his acute agitation?
Q46
A 58-year-old woman presents to neurology clinic with a 3-month history of medication-overuse headache. She has been using a combination of paracetamol, ibuprofen, and codeine daily for chronic tension-type headache over the past 2 years. She takes analgesics on at least 20 days per month. Which of the following is the most important principle in managing medication-overuse headache?
Q47
A 29-year-old woman who is 14 weeks pregnant presents to the antenatal clinic. She has a 10-year history of generalised tonic-clonic seizures, well-controlled on sodium valproate 1000 mg twice daily. She has been seizure-free for 5 years. The pregnancy was unplanned and she has been taking folic acid 5 mg daily since finding out she was pregnant 6 weeks ago. She is very anxious about the risks to her baby. What is the most appropriate advice regarding her antiepileptic medication?
Q48
A 72-year-old man with Parkinson's disease presents with a 4-month history of progressive cognitive decline. His wife reports he has become increasingly forgetful and has experienced recurrent, detailed visual hallucinations of children playing in their living room. His symptoms fluctuate throughout the day, with periods of lucidity alternating with confusion. He has had several falls. His Parkinson's medication includes co-careldopa. On examination, he has bradykinesia, rigidity, and a shuffling gait. His MMSE is 20/30. What is the most likely underlying diagnosis?
Q49
A 41-year-old woman presents to her GP with a 3-year history of recurrent episodes characterised by a brief warning sensation in her epigastrium, followed by loss of awareness lasting 30-60 seconds. During these episodes, witnesses report that she stares blankly, makes repetitive chewing movements, and fumbles with her clothing. She is amnesic for the events. She has tried lamotrigine with partial benefit but continues to have 2-3 episodes per month. Which of the following is the most appropriate next step in her antiepileptic drug management?
Q50
A 63-year-old woman with hypertension and type 2 diabetes presents to the Emergency Department with sudden onset right-sided weakness and dysarthria that started 90 minutes ago. CT head shows no haemorrhage. Her NIHSS score is 14. CT angiography demonstrates a left middle cerebral artery (MCA) occlusion. She has no contraindications to thrombolysis or thrombectomy. Which of the following is the most appropriate initial management?
Neurology UK Medical PG Practice Questions and MCQs
Question 41: A 33-year-old woman attends neurology clinic following a first unprovoked generalised tonic-clonic seizure 6 weeks ago. She has fully recovered with no residual symptoms. She works as a bus driver. Her neurological examination is normal. MRI brain shows no abnormality. EEG shows occasional generalised spike-and-wave discharges. She is keen to return to work as soon as possible. According to UK DVLA regulations, what advice should be given regarding her driving?
A. She can return to driving her bus immediately as she has had only one seizure
B. She must stop driving all vehicles and can return to a car licence after 6 months seizure-free, but can never hold a bus licence again
C. She must stop driving all vehicles and can return to driving a car after 12 months seizure-free, but cannot return to professional driving for 5 years (Correct Answer)
D. She must stop driving all vehicles for 12 months, after which both car and bus licences can be reinstated if seizure-free
E. She can continue driving a car but must inform DVLA and stop driving her bus permanently
Explanation: ***She must stop driving all vehicles and can return to driving a car after 12 months seizure-free, but cannot return to professional driving for 5 years***- For a **Group 1 licence** (cars), the standard off-road period after a first unprovoked generalised tonic-clonic seizure is **12 months** seizure-free.- For a **Group 2 licence** (buses/lorries), the regulations are much stricter, requiring a **5-year seizure-free period** without anti-epileptic medication. *She can return to driving her bus immediately as she has had only one seizure*- This is incorrect and dangerous; a **first unprovoked seizure** necessitates an immediate cessation of driving to ensure public safety.- Driving against medical advice or **DVLA regulations** carries legal penalties and invalidates insurance. *She must stop driving all vehicles and can return to a car licence after 6 months seizure-free, but can never hold a bus licence again*- While a reduction to **6 months** for a **car licence** is possible in very specific low-risk circumstances (e.g., normal EEG/MRI, no risk factors), it is not the standard and must be approved by the DVLA.- A **Group 2 licence** is not permanently revoked after a single event; it can be reconsidered after **5 years** seizure-free off medication. *She must stop driving all vehicles for 12 months, after which both car and bus licences can be reinstated if seizure-free*- This incorrectly applies the **Group 1 (car) timescale** to a **Group 2 (bus) licence**; professional driving involves significantly higher safety standards and longer abstinence periods.- Reinstatement of a **bus licence** requires a much longer period of **5 years** seizure-free, as opposed to the 1 year for a car. *She can continue driving a car but must inform DVLA and stop driving her bus permanently*- After any seizure, individuals must **immediately stop driving all vehicles** (both Group 1 and Group 2) and inform the DVLA.- The ban for **professional driving** is not necessarily permanent after a single unprovoked seizure if the **5-year seizure-free threshold** is met.
Question 42: A 76-year-old man with Alzheimer's dementia (MMSE 15/30) is brought to the memory clinic by his daughter. She reports that over the past 2 months he has developed prominent visual and auditory hallucinations, becoming convinced that people are living in his attic and stealing his belongings. He has become verbally aggressive when she tries to reassure him. He has no previous psychiatric history. He is currently taking donepezil 10 mg daily, amlodipine, and atorvastatin. Which of the following is the most appropriate initial management of his psychotic symptoms?
A. Add risperidone 0.5 mg twice daily
B. Review for underlying causes and optimize donepezil therapy (Correct Answer)
C. Add haloperidol 1 mg twice daily
D. Stop donepezil and commence memantine
E. Add quetiapine 25 mg twice daily
Explanation: ***Review for underlying causes and optimize donepezil therapy***
- Initial management of **Behavioral and Psychological Symptoms of Dementia (BPSD)**, including new-onset psychosis, requires a thorough review for **precipitating factors** such as infections (e.g., UTI), pain, constipation, dehydration, or medication side effects.
- Non-pharmacological interventions are always first-line. Optimizing or ensuring adherence to current **cholinesterase inhibitor** therapy like **donepezil** should be explored before considering new psychoactive medications.
*Add risperidone 0.5 mg twice daily*
- **Risperidone**, an atypical antipsychotic, is associated with a significantly increased risk of **stroke** and **all-cause mortality** in elderly patients with dementia-related psychosis.
- It should only be considered for short-term use and at the lowest effective dose if non-pharmacological measures fail and there is a **significant risk of harm** to the patient or others.
*Add haloperidol 1 mg twice daily*
- **Haloperidol**, a typical antipsychotic, has a high risk of **extrapyramidal side effects** (e.g., parkinsonism, tardive dyskinesia), sedation, and anticholinergic effects, which can worsen cognitive function in dementia.
- It is generally not recommended for the management of BPSD due to its severe side effect profile and lack of specific licensing for this indication.
*Stop donepezil and commence memantine*
- **Abruptly stopping donepezil** can lead to a rapid decline in cognitive function and may exacerbate existing neuropsychiatric symptoms, including psychosis.
- While **memantine** can be added for moderate-to-severe Alzheimer's dementia, it is not the initial appropriate step for managing acute psychotic symptoms without investigating underlying causes.
*Add quetiapine 25 mg twice daily*
- **Quetiapine** is an atypical antipsychotic sometimes used off-label due to a lower risk of extrapyramidal symptoms; however, like other antipsychotics, it carries a **black box warning** for increased mortality in elderly patients with dementia-related psychosis.
- While it may be considered in some refractory cases, it should not be the initial management for new-onset psychosis without first identifying and addressing reversible causes.
Question 43: A 51-year-old woman with a 15-year history of relapsing-remitting multiple sclerosis presents to clinic. She has experienced increasing disability over the past 18 months with progressive worsening of mobility, spasticity, and bladder symptoms, without distinct relapses. Her current EDSS score is 6.5 (requires bilateral support to walk 20 metres). She is currently on dimethyl fumarate. MRI brain shows multiple T2 hyperintense periventricular lesions, unchanged from 12 months ago, with no new gadolinium-enhancing lesions. What does this clinical picture most likely represent?
A. Relapsing-remitting multiple sclerosis with pseudo-progression
B. Secondary progressive multiple sclerosis (Correct Answer)
C. Primary progressive multiple sclerosis
D. Relapsing-remitting multiple sclerosis with frequent relapses
E. Tumefactive multiple sclerosis
Explanation: ***Secondary progressive multiple sclerosis***- This diagnosis is characterized by a **gradual neurological deterioration** that occurs independent of relapses following an initial **relapsing-remitting course (RRMS)**.- The patient's 18-month history of worsening mobility, spasticity, bladder symptoms, and a high **EDSS score** (6.5) despite stable MRI findings (no gadolinium enhancement) are classic indicators of this transition.*Relapsing-remitting multiple sclerosis with pseudo-progression*- **Pseudo-progression** involves a temporary worsening of symptoms due to external triggers like **infection** or **heat (Uthoff's phenomenon)**, not a sustained 18-month decline.- It does not represent permanent **neurological disability** or a change in the underlying disease phenotype.*Primary progressive multiple sclerosis*- **PPMS** is defined by progressive disability from the **clinical onset** of the disease without any prior relapses or remissions.- This patient has a 15-year history of **RRMS**, which explicitly excludes a diagnosis of primary progressive disease.*Relapsing-remitting multiple sclerosis with frequent relapses*- This clinical picture describes active inflammation marked by **acute attacks** and the development of **new gadolinium-enhancing lesions** on MRI.- The case states there have been **no distinct relapses** and the MRI shows **unchanged periventricular lesions**, contradicting this option.*Tumefactive multiple sclerosis*- This rare variant presents with large, **tumor-like demyelinating lesions** (greater than 2cm) that often cause mass effect or edema.- The MRI in this patient showed **multiple periventricular lesions** typical of standard MS, not the large solitary lesions seen in **tumefactive MS**.
Question 44: A 44-year-old man presents to his GP with a 6-week history of headaches. He describes them as bilateral, pressing/tightening in quality, of mild to moderate intensity, occurring daily. The headaches are present on waking and persist throughout the day. They are not aggravated by routine physical activity and are not associated with nausea, photophobia, or phonophobia. He denies any visual disturbances. Over the past 3 months, he has also noticed reduced libido and has gained 8 kg in weight despite no change in diet. On examination, visual acuity is 6/6 bilaterally. Fundoscopy reveals bilateral papilloedema. What is the most appropriate next investigation?
A. MRI brain with pituitary protocol (Correct Answer)
B. CT head with contrast
C. Lumbar puncture to measure opening pressure
D. Visual field testing by perimetry
E. 24-hour urinary free cortisol
Explanation: ***MRI brain with pituitary protocol***- The patient presents with **papilloedema**, indicating **raised intracranial pressure**, combined with **endocrine dysfunction** (reduced libido, weight gain). This constellation of symptoms strongly points to a **pituitary or sellar mass lesion**.- **MRI with pituitary protocol** is the **gold standard** for high-resolution imaging of the **sella turcica** and surrounding structures, essential for diagnosing pituitary adenomas or other space-occupying lesions in this region.*CT head with contrast*- **CT scans** are significantly **less sensitive** than MRI for detailed evaluation of the **pituitary gland** and detecting small or subtle soft-tissue lesions.- While useful for acute neurological emergencies or identifying large masses, it is **suboptimal** for a dedicated pituitary assessment.*Lumbar puncture to measure opening pressure*- Performing a **lumbar puncture** is **contraindicated** as an initial investigation in a patient with **papilloedema** due to the significant risk of **brain herniation (coning)**.- Neuroimaging must always precede a lumbar puncture in cases of suspected **raised intracranial pressure** to rule out a space-occupying lesion.*Visual field testing by perimetry*- While **visual field testing** is an important part of the neurological workup for pituitary lesions (to detect **bitemporal hemianopia**), it is a **functional assessment**.- It does not identify the underlying structural cause of the symptoms, and **urgent imaging** is required to diagnose the lesion causing raised ICP and endocrine dysfunction.*24-hour urinary free cortisol*- This investigation is used to diagnose **Cushing's syndrome**, which can cause weight gain but typically does not present with **papilloedema** as a direct primary symptom.- The immediate priority is to identify the **structural lesion** responsible for both the signs of **raised intracranial pressure** and the endocrine disturbance.
Question 45: An 81-year-old man is admitted to hospital for investigation of recurrent falls. On the second day of admission, nursing staff report that he has become acutely confused overnight, believing he is in his childhood home and that deceased relatives are visiting him. He is agitated and trying to leave the ward. He has a history of hypertension and underwent a right total hip replacement 3 days ago. His current medications include amlodipine, paracetamol, and oxycodone for post-operative pain. Observations show temperature 37.8°C, blood pressure 142/86 mmHg, heart rate 94 bpm, respiratory rate 18/min, and oxygen saturation 94% on room air. What is the most appropriate first-line pharmacological intervention for his acute agitation?
A. Haloperidol 0.5 mg orally (Correct Answer)
B. Lorazepam 1 mg orally
C. Diazepam 5 mg orally
D. Quetiapine 25 mg orally
E. Risperidone 1 mg orally
Explanation: ***Haloperidol 0.5 mg orally***- This patient presents with features highly suggestive of **delirium**, characterized by acute onset of fluctuating attention, disorientation, and hallucinations, often triggered by surgery and opioid use in an elderly patient.- **Haloperidol** is the first-line pharmacological treatment for severe agitation in delirium when non-pharmacological measures are insufficient, with **0.5 mg** being an appropriate low starting dose for elderly individuals to minimize side effects.*Lorazepam 1 mg orally*- **Benzodiazepines** like lorazepam are generally **contraindicated** in delirium as they can worsen cognitive impairment, increase confusion, and precipitate paradoxical agitation in the elderly.- Their use is typically restricted to delirium caused by **alcohol withdrawal** or in cases where antipsychotics are absolutely contraindicated (e.g., severe Parkinson's disease).*Diazepam 5 mg orally*- **Diazepam** has a very **long half-life** and produces active metabolites, leading to prolonged sedation, increased risk of **falls**, and respiratory depression, particularly in elderly patients.- Similar to other benzodiazepines, it is not recommended for the routine management of **acute delirium** as it can exacerbate the underlying cognitive dysfunction.*Quetiapine 25 mg orally*- While **quetiapine** is an atypical antipsychotic that can be used in delirium, it is often considered a second-line agent or for specific situations where extrapyramidal symptoms are a major concern, and **haloperidol** is generally preferred for acute agitation.- The starting dose of **25 mg** might be relatively high for an acutely agitated elderly patient, and its sedative profile may not be ideal for clear delirium management.*Risperidone 1 mg orally*- **Risperidone** is an atypical antipsychotic, but a starting dose of **1 mg** is often considered too high for an 81-year-old patient with delirium, increasing the risk of **extrapyramidal side effects** and cerebrovascular events.- Low-dose **haloperidol** is generally preferred for its more predictable efficacy in acute agitation and the ability to start at extremely low doses to minimize adverse effects in the elderly.
Question 46: A 58-year-old woman presents to neurology clinic with a 3-month history of medication-overuse headache. She has been using a combination of paracetamol, ibuprofen, and codeine daily for chronic tension-type headache over the past 2 years. She takes analgesics on at least 20 days per month. Which of the following is the most important principle in managing medication-overuse headache?
A. Gradual reduction of analgesics over 3-6 months
B. Complete and abrupt withdrawal of all overused medications (Correct Answer)
C. Switching to stronger opioid analgesics
D. Adding a prophylactic agent while continuing current analgesics
E. Reducing analgesic frequency to 10 days per month
Explanation: ***Complete and abrupt withdrawal of all overused medications***
- The most critical step in managing **medication-overuse headache (MOH)** is the **complete and abrupt cessation** of the overused analgesic medications to break the cycle of headache frequency and drug sensitivity.
- **Abrupt withdrawal** for simple analgesics, NSAIDs, and triptans is generally more effective than gradual tapering in achieving long-term resolution and is the recommended first-line approach.
*Gradual reduction of analgesics over 3-6 months*
- This approach is generally **less effective** for MOH caused by simple analgesics and NSAIDs, as it can prolong the withdrawal phase and increase the risk of relapse.
- While gradual tapering may be considered for **opioids** or **barbiturates** to mitigate severe withdrawal symptoms, it is not the primary principle for the combination of drugs mentioned.
*Switching to stronger opioid analgesics*
- This approach is **contraindicated** as it would exacerbate the underlying problem of medication overuse, leading to increased dependency and worsening of the headache cycle.
- The management principle is to **reduce or eliminate** analgesic use, not to escalate to more potent and potentially addictive substances.
*Adding a prophylactic agent while continuing current analgesics*
- Prophylactic agents are typically introduced **after** the withdrawal phase, as their efficacy is significantly diminished or negated while the patient continues to overuse analgesics.
- The primary goal is to **break the MOH cycle** before effectively treating the underlying primary headache disorder with prophylactic medication.
*Reducing analgesic frequency to 10 days per month*
- While reducing frequency is a goal for preventing MOH, for an established case, **complete cessation** is the initial and most important step to break the medication overuse cycle.
- Merely reducing frequency may not be sufficient to resolve the MOH and could perpetuate the issue, especially with a history of use on at least 20 days per month.
Question 47: A 29-year-old woman who is 14 weeks pregnant presents to the antenatal clinic. She has a 10-year history of generalised tonic-clonic seizures, well-controlled on sodium valproate 1000 mg twice daily. She has been seizure-free for 5 years. The pregnancy was unplanned and she has been taking folic acid 5 mg daily since finding out she was pregnant 6 weeks ago. She is very anxious about the risks to her baby. What is the most appropriate advice regarding her antiepileptic medication?
A. Continue sodium valproate as benefits of seizure control outweigh risks at this stage (Correct Answer)
B. Immediately switch to lamotrigine
C. Immediately switch to levetiracetam
D. Gradually withdraw all antiepileptic medication
E. Reduce sodium valproate dose by half
Explanation: ***Continue sodium valproate as benefits of seizure control outweigh risks at this stage***
- By **14 weeks gestation**, the critical period for **organogenesis** and the primary risk for **neural tube defects** (typically 3-4 weeks post-conception) associated with valproate has largely passed, meaning a switch now will not undo previous exposure.
- Maintaining **seizure freedom** is paramount during pregnancy; switching medication now carries a significant risk of **seizure recurrence**, which could lead to maternal trauma, falls, and potentially dangerous **fetal hypoxia**.
*Immediately switch to lamotrigine*
- An immediate switch to **lamotrigine** would involve a titration period during which the patient could be at risk of **breakthrough seizures**, jeopardizing both maternal and fetal well-being.
- While lamotrigine has a generally lower teratogenic risk, the most vulnerable period for valproate-related malformations has passed, making seizure stability the priority.
*Immediately switch to levetiracetam*
- Switching abruptly to **levetiracetam** could destabilize a previously well-controlled epilepsy, leading to a risk of **seizures** during pregnancy when maintaining stability is crucial.
- The primary **teratogenic risk** of sodium valproate occurs in the first trimester, so changing medication at 14 weeks offers little benefit in preventing those specific malformations and introduces new risks.
*Gradually withdraw all antiepileptic medication*
- **Withdrawing all antiepileptic medication** in a patient with a history of generalized tonic-clonic seizures carries an unacceptably high risk of **severe, uncontrolled seizures** or even **status epilepticus**.
- Uncontrolled seizures during pregnancy pose significant dangers to the fetus, including **hypoxia**, **acidosis**, and **trauma**, far outweighing any potential benefit of medication cessation at this stage.
*Reduce sodium valproate dose by half*
- Arbitrarily reducing the **sodium valproate dose by half** is likely to lead to **subtherapeutic levels** and increase the risk of **breakthrough seizures**, which are dangerous for both mother and fetus.
- The goal in pregnancy is to maintain the **lowest effective dose** that ensures seizure control; making a significant reduction without careful titration and monitoring is inappropriate and potentially harmful.
Question 48: A 72-year-old man with Parkinson's disease presents with a 4-month history of progressive cognitive decline. His wife reports he has become increasingly forgetful and has experienced recurrent, detailed visual hallucinations of children playing in their living room. His symptoms fluctuate throughout the day, with periods of lucidity alternating with confusion. He has had several falls. His Parkinson's medication includes co-careldopa. On examination, he has bradykinesia, rigidity, and a shuffling gait. His MMSE is 20/30. What is the most likely underlying diagnosis?
A. Alzheimer's dementia
B. Vascular dementia
C. Dementia with Lewy bodies (Correct Answer)
D. Parkinson's disease dementia
E. Normal pressure hydrocephalus
Explanation: ***Dementia with Lewy bodies***
- This diagnosis is characterized by the triad of **fluctuating cognition**, recurrent **detailed visual hallucinations**, and spontaneous **parkinsonism**.
- The **one-year rule** applies here; if cognitive decline occurs prior to or within one year of the onset of motor symptoms, it is classified as DLB rather than Parkinson's disease dementia.
*Alzheimer's dementia*
- Primarily presents with early and progressive **episodic memory loss**, rather than early visual hallucinations or motor symptoms.
- Lacks the **fluctuating levels of consciousness** and attention typically seen in Lewy body pathology.
*Vascular dementia*
- Typically follows a **stepwise decline** associated with focal neurological deficits or a history of strokes/vascular risk factors.
- While it can cause executive dysfunction, it does not typically feature **recurrent complex hallucinations** as a primary early symptom.
*Parkinson's disease dementia*
- In this condition, **motor symptoms** must be well-established for at least **one year** (usually much longer) before the onset of cognitive impairment.
- Though biologically similar to DLB, the **chronological sequence** of symptoms in this patient suggests DLB over PDD.
*Normal pressure hydrocephalus*
- Characterized by the classic triad of **magnetic gait** (shuffling), **urinary incontinence**, and cognitive impairment.
- It does not typically present with **complex visual hallucinations** or the specific fluctuating alertness seen in this case.
Question 49: A 41-year-old woman presents to her GP with a 3-year history of recurrent episodes characterised by a brief warning sensation in her epigastrium, followed by loss of awareness lasting 30-60 seconds. During these episodes, witnesses report that she stares blankly, makes repetitive chewing movements, and fumbles with her clothing. She is amnesic for the events. She has tried lamotrigine with partial benefit but continues to have 2-3 episodes per month. Which of the following is the most appropriate next step in her antiepileptic drug management?
A. Add carbamazepine
B. Add levetiracetam (Correct Answer)
C. Switch to sodium valproate
D. Add phenytoin
E. Switch to carbamazepine
Explanation: ***Add levetiracetam***
- This patient presents with **focal seizures with impaired awareness**, suggested by the epigastric aura, loss of awareness, and automatisms (chewing, fumbling). Given **lamotrigine** offers partial benefit, adding a second-line antiepileptic drug is the next appropriate step.
- **Levetiracetam** is a suitable choice for adjunctive therapy in focal epilepsy, particularly in women of childbearing age due to its **favorable safety profile** and minimal **drug-drug interactions**.
*Add carbamazepine*
- While effective for focal seizures, **carbamazepine** is a potent **enzyme inducer** and carries a significant risk of **drug-drug interactions**, which can complicate polytherapy.
- It can also cause notable side effects like **dizziness** and **ataxia**, and may not be the optimal adjunctive choice when other safer alternatives exist.
*Switch to sodium valproate*
- **Sodium valproate** has a high **teratogenic risk** and is generally avoided in women of childbearing potential unless absolutely necessary and other options are exhausted.
- Since lamotrigine provides partial benefit and is tolerated, switching is less appropriate than adding an adjunctive therapy.
*Add phenytoin*
- **Phenytoin** is characterized by **zero-order kinetics** and a **narrow therapeutic window**, making its dosing and monitoring challenging and increasing toxicity risk.
- Long-term use is associated with significant side effects, including **gingival hyperplasia**, **hirsutism**, and **osteomalacia**, making it a less preferred add-on option.
*Switch to carbamazepine*
- Switching from an antiepileptic drug that offers partial benefit is generally not the first approach; **adjunctive therapy** is typically preferred to optimize seizure control.
- Similar to adding it, switching to **carbamazepine** introduces concerns regarding **enzyme induction** and potential **drug interactions** with existing medications.
Question 50: A 63-year-old woman with hypertension and type 2 diabetes presents to the Emergency Department with sudden onset right-sided weakness and dysarthria that started 90 minutes ago. CT head shows no haemorrhage. Her NIHSS score is 14. CT angiography demonstrates a left middle cerebral artery (MCA) occlusion. She has no contraindications to thrombolysis or thrombectomy. Which of the following is the most appropriate initial management?
A. Mechanical thrombectomy alone
B. Intravenous alteplase alone
C. Intravenous alteplase followed by mechanical thrombectomy (Correct Answer)
D. Aspirin 300 mg immediately
E. Dual antiplatelet therapy with aspirin and clopidogrel
Explanation: ***Intravenous alteplase followed by mechanical thrombectomy*** - For patients presenting within **4.5 hours** of symptom onset with a **large vessel occlusion (LVO)**, such as the left MCA, a "bridging therapy" approach is the standard of care.- **IV alteplase** is administered immediately to potentially dissolve the clot while preparations for **mechanical thrombectomy** occur, as the combination provides the highest likelihood of functional recovery.*Mechanical thrombectomy alone* - This approach is generally reserved for patients who have absolute **contraindications to thrombolysis** (e.g., recent surgery or bleeding disorders), which this patient does not have.- Current guidelines favor initiating **IV thrombolysis** first because it may achieve early recanalization or soften the clot before the endovascular procedure.*Intravenous alteplase alone* - While effective for smaller vessels, stroke caused by LVO has a low **recanalization rate** (often <15-30%) with **IV alteplase** alone.- Patients with high **NIHSS scores** and confirmed LVO significantly benefit from adding **mechanical thrombectomy** to achieve better reperfusion results.*Aspirin 300 mg immediately* - **Aspirin** is recommended for secondary prevention but must be delayed for **24 hours** after the administration of **IV thrombolysis** to minimize the risk of hemorrhagic transformation.- It is not a substitute for reperfusion therapies in the hyperacute phase of an **ischemic stroke** with a major deficit.*Dual antiplatelet therapy with aspirin and clopidogrel* - **Dual antiplatelet therapy (DAPT)** is used for minor strokes or high-risk TIAs, but not in the presence of a **large vessel occlusion** requiring emergency reperfusion.- Similar to aspirin monotherapy, **DAPT** is contraindicated within the first 24 hours of receiving **IV alteplase** due to the significant risk of intracranial bleeding.
