Neurology in Question

Emily felt the excitement in the air as she first entered the neurology service. This was Emily's fourth year in medical university, and her first doing clinical medicine, with real patients. It was different from pulmonology and infectiology. It felt more logical than cardiology for her, but maybe it was because she had studied more neurology in her free time during COVID confinement. Emily had learned that medicine is not maths. It’s not 1 plus 1 equals 2. It was difficult for the student to fathom such a reality. Some of her classmates had more hardships communicating with patients and colleagues. It was exciting seeing new parts of everyone, of her classmates, new residents, general doctors, assistants, and professors. Emily couldn’t help but stare in awe. Her eyes weren’t the only ones filled with curiosity. The eyes of everyone who strived for the medical path there mirrored a thirst for knowledge. The classmates exchanged a conversation about the Willis Polygon. Another classmate stated, “A lesion of the third cranial nerve can lead to homolateral mydriasis.” The classmate beside her added, “A temporal brain herniation, specifically uncal herniation, can compress the third cranial nerve and cause a homolateral mydriasis as well." "It usually occurs on the side of the mass effect, although severe intracranial pressure can produce more complex patterns. Brain herniation is a medical emergency and can be fatal if untreated." "As the herniation progresses, it can compress the brainstem and affect consciousness, respiration, and cardiovascular function.” She paused. “A unilateral mydriasis is therefore a warning sign that requires urgent evaluation. In an acute setting, we first look for a dangerous intracranial cause, usually with urgent brain imaging such as a non-contrast CT." "If a third-nerve palsy is suspected, we then determine whether the cause is compression, vascular disease, an aneurysm, trauma, or another lesion.” Emily listened carefully. The service chief obliged us externs, medical students who hadn’t yet begun internship and weren’t officially treating patients, to attend the morning handover. It seemed I was the first student to attend the morning handover. I was late as there was traffic, the usual. I admit I actually woke up late, at 6:30 a.m., and rode the bus at 7 a.m. If I had woken up at 6 a.m. and ridden the bus at 6:30 a.m., I’d have reached the hospital before 8:30 a.m., when the morning handover actually began. As I sat in a chair near the round table, the doctors, including my meticulous, quiet neurology stage master, were preparing the patient folders. The strict service chief looked at me. Then the other doctors looked at me. Which made me wonder if I was an alien. My self-esteem hit rock bottom as I thought I had turned into a wiggling worm. One of the doctors, Dr. Fernand, smiled at me. "Good job.” She was the replacement for our stage master when our stage master was on vacation during our first week of studying neurology. I thought Dr. Fernand was our stage master at first. She emanated an aura of a strong personality. Luckily, the doctors’ attention shifted back to the documents. The morning handover started. One of my classmates joined the group soon after. Dr. John was one of my neurosurgery teachers. Dr James, one of my neurology teachers, was the first to present his patients. “Patient Alex Brad, 10 months old.” A mother rushed toward Dr. James, holding her baby. “I came for my baby. His head has enlarged over the past six days,” the mother said. “Do an urgent brain imaging assessment. I’m suspecting hydrocephalus.” “He has hydrocephalus,” Dr. John said after reviewing the imaging. “Hydrocephalus can occur in children and adults. In a baby, rapidly increasing head circumference is an important warning sign.” “How is it treated? Does he need surgery?” “That depends on the cause and severity. If there is acute obstructive hydrocephalus with raised intracranial pressure, he may need urgent cerebrospinal fluid diversion. A neurosurgeon will determine the appropriate procedure.” “Is it an emergency?” “It can be. If intracranial pressure becomes severely elevated, brain herniation can occur. In the most severe cases, the brainstem can become compressed, affecting consciousness, breathing, and cardiovascular function.” “What’s a brain herniation?” “It’s when part of the brain is displaced from its normal position because of increased intracranial pressure or a mass effect. If the brainstem becomes compressed, the respiratory and cardiovascular centers can be affected.” Dr. James called Dr. John’s hospital phone through the neurology service phone. “Hi. A ten-month-old baby named Alex Brad has hydrocephalus and may need neurosurgical management,” Dr. James reported. “Thanks for telling me. Tell the parents to come see me,” Dr. John ordered. “Dr. John is waiting for you in the neurosurgery hospitalization room.” “Hello, Ms. Marie. What’s your baby’s name?” “Alex Brad. He has asthma, by the way.” “What medication does he take for it?” “Ventoline, two puffs during attacks, and a high-dose inhaled corticosteroid, two puffs twice a day. He also takes tiotropium twice a day.” The baby’s face suddenly turns blue. “What’s happening to my child?!” “He’s hypoxemic. It’s a severe asthma exacerbation.” Dr. John quickly checks his oxygen saturation. “His SpO₂ is 84%. Give him oxygen and start inhaled short-acting beta₂-agonist treatment immediately.” The baby receives nebulized salbutamol, with additional treatment appropriate for a severe asthma exacerbation. His oxygen saturation gradually increases. 92%. His skin coloration returns to normal. That’s when the mother’s expression calms down. After stabilizing him, the neurosurgical team performs urgent CSF diversion to relieve the hydrocephalus and intracranial pressure. “The bulging fontanelle is gone. His eyes are wide open again.” The mother’s lips perk into a smile. “Continue his prescribed asthma treatment, including his inhaled corticosteroid. Use Ventoline during attacks according to the pediatrician’s instructions.” “Should he take tiotropium? I looked it up on Google and found it is a a long-acting beta-agonist.” “Taking tiotropium depends on the severity and control of his asthma. Tiotropium is a long-acting anticholinergic, not a long-acting beta-agonist. His pediatrician or pediatric pulmonologist should decide whether it is appropriate and adjust his treatment.”