CASO CLÍNICO 1 Cambiar el ácido acetilsalicílico por el clopidogrel

Continuar con ácido acetilsalicílico

Hombre de 45 años de edad, diestro, es traído a
urgencias por presentar hemiparesia derecha con
afasia global. El cuadro inició hace 6 horas con CASO CLÍNICO 2
déficit neurológico. Se le encuentra con una TA de
210/120 mmHg, glucemia capilar de 110 mg/dL y Un hombre de 58 años de edad, diestro, es
en muy poco tiempo se presenta estuporoso. llevado a Urgencias por presentar un síndrome
Antecedentes personales patológicos de caracterizado por disartria y hemiparesia
insuficiencia renal crónica, osteodistrofia renal, izquierda de 30 min de duración. Al llegar a
hipertensión arterial y diabetes mellitus tipo 2. Urgencias se le encuentra asintomático, con TA de
140/80mmHg y glucemia capilar de 130 mg/dL.
1. ¿Qué forma de enfermedad vascular Familiar refiere antecedente de bypass coronario,
cerebral aguda es más probable que tabaquismo, hipertensión e insuficiencia de
padezca? miembros pélvicos.
Infarto cerebral
Hemorragia intracerebral 6. ¿Qué forma de enfermedad vascular
Hemorragia subaracnoidea cerebral aguda es más probable que
Trombosis venosa cerebral padezca?
Ataque isquémico transitorio
Infarto cerebral
2. ¿Qué mecanismo etiológico pudo originar Hemorragia intracerebral
este padecimiento? Hemorragia subaracnoidea
Aterotrombosis
Enfermedad de pequeño vaso
Hipertensión arterial 7. ¿Cuál es la conducta a seguir en este
Disección carotidea caso?
Dar de alta, pues se ha recuperado ad integrum
Estratificar el riesgo de recurrencia y hospitalizar en
3. ¿Cuál sería la terapéutica ideal en este consecuencia
caso? Observar en Urgencias por 6 horas y dar de alta si no
Colocación de endoprótesis (stent) urgente hay recurrencia
Drenaje del hematoma con craniectomía abierta si Bajar la presión arterial con hipotensores
cumpliera criterios sublinguales
Trombolisis intravenosa con alteplase si cumpliera
criterios
Está fuera del periodo de ventana de beneficio del 8. ¿Qué escala para estratificación de riesgo
uso de trombolisis usaría en este caso?
NIHSS
ABCD2
4. ¿Qué porcentaje de mortalidad está ICH score
asociada a este padecimiento? CHADS2
Entre 10-20%
Entre 30-40%
Superior a 60% 9. ¿Qué magnitud de riesgo le corresponde
Superior a 80% a este paciente?
Leve
Bajo
5. ¿Cuál es el tratamiento de prevención Alto
secundaria (prevención de recurrencia) No es posible calcular el riesgo
ideal para este caso?
Control estricto de la presión arterial
Agregar clopidogrel
 10.¿Qué complicación debe evitarse en este Disautonomía
caso? Neuritis óptica
Hemorragia intracerebral Encefalopatía y crisis convulsivas
Rotura aneurismática
Recurrencia en la forma de infarto cerebral
Trombosis venosa 14. ¿Qué complicación crónica (riesgo) se
puede presentar en este caso?
Epilepsia
Neuritis óptica
CASO CLÍNICO 3
Hidrocefalia
Neuropatía craneal múltiple
Una mujer de 41 años de edad, diestra, acude a
Urgencias por presentar paraparesia y retención
de orina. Ella tiene el diagnóstico de lupus
15. ¿Qué marcador serológico es un indicador
eritematoso generalizado aparentemente inactivo
de este riesgo a largo plazo?
desde hace 8 años sin antecedentes de trastornos
Anticuerpos antineuronales
visuales. En la exploración la encuentras con una
Anticuerpos anti-acuaporina 4
agudeza visual en ambos ojos de 20/20, sin
Anticuerpos SSA y SSB
trastornos con la percepción de colores ni
Anticuerpos anti-gliadina
contrastes, cuadriparesia, hiperreflexia,
Hoffmann, Trömner y Babinski, con un nivel de
hipoestesia a todas las modalidades sensitivas a
CASO CLÍNICO 4
partir del dermatoma C4.
Hombre de 35 años de edad, diestro, es llevado a
11.¿Qué diagnóstico es más probable en este
Urgencias por presentar paraparesia y trastorno de
momento?
la marcha. Padeció un cuadro diarreico hace 1.5
Síndrome de neuromielitis óptica
semanas, con resolución espontánea. Al examen
Encefalomielitis diseminada aguda
físico se le encuentra con cuadriparesia, con mayor
Mielopatía / mielitis transversa
debilidad (0/5) en miembros pélvicos, en
Esclerosis concéntrica de Baló
comparación (1/5) con miembros torácicos, no eleva
las extremidades superiores, ni los hombros, tiene
hiporreflexia generalizada, la respuesta plantar es
12.Usted solicita resonancia magnética
normal y sin trastornos sensitivos.
cervical con resultados de una extensa
zona de desmielinización que abarca los
16. ¿Qué diagnóstico es más probable en este
segmentos C1-C6 y que afecta
caso?
discretamente la parte inferior de la
Mielopatía inflamatoria aguda
médula oblonga. También se solicitan la
Síndrome de Guillain-Barré
cuantificación de anticuerpos anti-
Síndrome de Millard-Gubler
acuaporina 4 en plasma, los que se
Síndrome de Foster-Kennedy
informan positivos. Los potenciales
evocados visuales son normales. En este
punto, ¿qué diagnóstico parece más
17. ¿Qué complicación aguda está en riesgo de
compatible?
presentar este paciente?
Enfermedad de Devic
Falla ventilatoria
Mielitis del espectro neuromielitis óptica (NMO)
Disautonomía
Esclerosis múltiple
Oftalmoplejía
Síndrome de Foix-Alajouanine
Hidrocefalia

13.¿Qué complicación aguda se puede

18. ¿Qué alteración en el análisis del líquido
presentar en este caso?
cerebroespinal se evidencia típicamente en
Falla ventilatoria
estos pacientes?
Bandas oligoclonales positivas
Anticuerpos antiacuaporina-4 positivos
Pleocitosis marcada
Disociación proteíno-citológica
19.¿Qué otro estudio de extensión solicitaría
en este caso?
Resonancia magnética de columna
Estudio de electroconducción nerviosa
Electromiografía
Potenciales evocados somatosensoriales
20.De los siguientes, ¿qué tratamiento
propondría en este caso?
Ciclofosfamida intravenosa en bolo
Plasmaféresis seguida de inmunoglobulina
Inmunoglobulina seguida de plasmaféresis
Plasmaféresis o inmunoglobulina intravenosa
CLINICAL CASE 5
A 50-year-old female is brought to the emergency
center after she experienced sudden onset of
severe headache which is associated with
vomiting, neck stiffness, and left-sided weakness.
Her sister noted that she complained about the
worst headache of her life before she became
progressively confused. Two weeks ago when she
returned from jogging she had a moderate
headache beside nausea and photophobia. On the
examination, her temperature is 37.6°C; heart
rate 120 bpm; respiration rate 32 bpm, and blood
pressure 180/90 mmHg. She is stuporous and
moans incoherently. Her right pupil is dilated
with papilledema and ipsilateral ptosis, and she
vomits when a light shines in her eyes. She has
her left lower droopy face and doesn’t retire her
left arm and leg to pain as fast as her right side.
Her neck is rigid. She has a history of
hypertension and tobacco use.
21.What is the most likely diagnosis?
Intracerebral hemorrhage
Subarachnoid hemorrhage
Transient ischemic attack
Cerebral venous thrombosis
22.What is the next diagnostic step?
Non-contrast CT of the head
Magnetic resonance imaging
Angio-CT of the head
Lumbar puncture
23.What is the next step after your suspicion
is confirmed?
Magnetic resonance imaging
Transcranial Doppler Ultrasound
Electroencephalogram
Cerebral angiography
24.I n c a s e o f a n e g a t i v e r e s u l t o n
noncontrast head CT for your initial
suspicion, but with a higher probability
that your suspicion is true, what would
be the next best step?
Lumbar puncture
Magnetic resonance imaging
Transcranial Doppler Ultrasound
Electroencephalogram
25.What is the name of the first headache
episode (the one before the current) the
patient suffered 2 weeks ago?
Migraneous hemorrhage
Sentinel headache
Jabs and jolts headache
Prognostic headache
CLINICAL CASE 6
A 30-year-old female presents a 1-month history
of intermittent ptosis and fatigue. She has been
working on a very exigent project in her work and
she considers that this ptosis is a manifestation of
her fatigue. However she became concerned when
she developed ptosis acutely at night a month
ago. Her 6-year old twins have pointed out to her
that she can’t keep up with them when they ride
their bicycles. She has experienced three more
ptosis episodes in the past month. All of them
have occurred while she has been working at
night and she has improved by the morning. She
was healthy until now. Her cranial nerve
examination reveals bilateral ptosis in the
primary gaze, which it gets worse when she holds
an upward gaze for 90 seconds. Her muscular
strength is normal with the exception in the
deltoid muscles bilaterally (4/5). In repetitive
tests, fatigability of right iliopsoas muscle is
elicited, which improves after 2 minutes of rest.
26.What is the most likely diagnosis?
Myasthenia gravis
Guillain-Barré syndrome
Devic’s disease
Bell’s palsy
27.What is the best test to confirm the
diagnosis?
Anti-aquaporin 4 antibodies
Anti-acetylcholine receptor antibodies
Electroconduction of the nerves
Antineural antibodies
28.What is the next step in therapy?
Plasmapheresis
IV steroids
IV ciclofosfamide
Pyridostigmine and immunosuppression
29.In case of a negative result in serological
tests, what would be the next action to
prove your suspicion?
Lumbar puncture
Electromyography with Jolly test (repetitive
stimulation)
Electroconduction of the nerves
Electroencephalogram
30.What neoplasm is associated with this
disorder?
Hamartoma
Thymoma
Neuroblastoma
Small cell lung cancer
CLINICAL CASE 7
An 18-year-old girl who was riding on the back of
her boyfriend’s motorcycle without a helmet is
admitted on emergency room because she has a
left frontal skull fracture and multiple other
fractures. Her left pupil is abnormally dilated and
it has no response. She has 4 points in the Glasgow
coma scale. She is admitted to the intensive care
unit.
31.What is the most likely diagnosis?
Subdural hematoma
Epidural hematoma
Intracerebral hemorrhage
Diffuse axonal damage
32.What is the best test to confirm the
diagnosis?
Non-contrast CT of the head
Magnetic resonance imaging
Angio-CT of the head
To watch in the Emergency Department for 6 hours
33.What is the next step in therapy?
Craniotomy, duraplasty and evacuation of hematoma
Open craniotomy only
Intranenous thrombolysis
Ventricular derivation
34.What acute complication should be
suspected based on her anisocoria?
Subfalcine herniation
Uncal herniation
Hydrocephalus
Re-bleeding
35.Based on the GCS score, what is the
prognosis?
Excellent with complete regain of all motor
functions
Excellent with partial regain of all motor functions
Bad, with high mortality or functional complications
if she survives
Very bad, without chances to survive
CLINICAL CASE 8
A 21-year-old female arrives to the emergency
department with the complaint of right-hand
weakness. She is taking oral steroids at high doses
(1 mg/kg) because she has active systemic lupus
erythematosus, which was associated with fasting
hyperglycemia and carbohydrate intolerance. On
her clinical examination you notice a left foot
drop and an ipsilateral steppage gait. On sensory
examination you detect allodynia in right upper
and left lower extremity. No rash is noted.
36.What is the most likely diagnosis?
Guillain-Barré syndrome
Combined radiculopathy
Immune-mediated polyneuropathy
Mononeuritis multiplex
37.What is the next step to prove the
diagnosis?
Electroconduction studies
Magnetic resonance
Electromyography
Urgent nerve biopsy
38.What is the appropriate treatment at this
point?
Steroids
IV immunoglobulin
Alpha interferon
Beta interferon
39.What is the best test to confirm the
diagnosis?
Electroconduction studies
Magnetic resonance imaging
Electromyography
Nerve biopsy
40.What is the main mediating pathogenic
mechanism in this diagnosis?
A vasculitic neuropathy
Immune-mediated axonal loss
Immune-mediated peripheral nerve demyelination
Toxic peripheral nerve demyelination
CLINICAL CASE 9
A 27-year-old female was diagnosed with juvenile
myoclonic epilepsy (Janz epilepsy) since the age
of 17 years and she is on valproate therapy, with
optimal control (last seizure 7 years ago). She
married 2 years ago, now she is planning a
pregnancy, but she hasn’t got pregnant yet. She is
concerned about the teratogenicity associated
with her antiepileptic therapy.
41.What would you suggest at this moment?
Try an overlap with valproate and a drug with no
teratogenic profile, but wait the pregnancy
Withdraw antiepileptic drugs during pregnancy
and restart after delivery
Pregnancy is contraindicated, thus, contraception
should be emphasized
Reduce valproate doses but to assure that
minimum therapeutic concentrations are at rate
of 50-70 mcg/mL
42.If this woman is already pregnant and
asks for your advice, what would be the
best option?
Change valproate for another antiepileptic drug
with less teratogenicity
Withdraw antiepileptic drugs during pregnancy
and restarting after delivery
Pregnancy is contraindicated
Continue valproate but alert the woman that
seizures could reappear and the teratogenic effect
in fetus are high
43.If the patient is planning to get pregnant,
what is the best decision about
supplementation with folic acid?
Supplement with 0.4 mg folic acid per oral
Supplement with 40 mg folic acid per oral
Supplement with 8 mg folic acid per oral
Supplement with 4 mg folic acid intravenous
44.If the patient is already pregnant), what
is the best decision with respect to folic
acid supplementation?
Supplement with 0.4 mg folic acid daily per oral
Supplement with 4 mg folic acid daily per oral
Supplement with 8 mg folic acid daily per oral
Supplement with 40 mg folic acid daily per oral
45.Beside folic acid, what other vitaminic
supplementation should be indicated in
this patient in case she continues with
valproate before and during pregnancy?
Vitamin K, 10-20 mg per oral daily
Vitamin D, 100 mcg per oral daily
Vitamin E, 100 IU per oral daily
Vitamin E, 400 IU per oral daily