GM: Neurology

Question 1

How do you differentiate between extradural, subdural and subarachnoid haemorrhage based on…

Presentation

Associations

Vessels involved

Answer 1

ED // SD // SA

lucid intervals between LOC // week-month Hx of neuro deficits // thunderclap headache

Fixed, dilated pupil // chronically old, alcoholic // Meningism, yellow CSF 12hrs

Middle meningeal // cortical veins // circle of willis

Question 2

What bleed is this?

Answer 2

Subdural

Crescent shape inside skull

Can be low density due to time before presentation

Question 3

What bleed is this?

Answer 3

Extradural

Lens shape

Bleed on other side also seen (Contracoup)

Question 4

What bleed is this?

Answer 4

Scalp haematoma

Outside the skull

Question 5

What bleed is this?

Answer 5

Subarachnoid haemorrhage

Bleed in the basal cisterns

Question 6

What is the treatment of

Extradural

Subdural

Subarachnoid

Answer 6

Craniotomy + evacuation

High pressure: decompressive craniotomy, burr hole if low

Subarachnoid: Coil/clipping of bleed, 21 days nimodipine

Question 7

How can you differ between migraine and tension headache clinically?

Answer 7

Migraine: Unilateral +/-aura, N+V. Worse on light

Tension: Bilateral across back of head, no assoicated symptoms

Question 8

What is the diagnostic criteria for migraines?

Answer 8

5 bouts with 2 symptoms

Question 9

How do you manage migraines

Acutely

Preventatively

Answer 9

Acute: PAINT

Prevent sickness (metoclopramide)

Aspirin

Ibuprofen

Naproxen

Triptans

Prophylaxis: PAT

Propanolol, Amitripyline/topiramate

Question 10

Headache at start and end of day causing morning sickness and blurred vision but with normal MRI indicates what?

How do you treat?

Answer 10

Idiopathic intracranial hypertension

Acetazolamide (surgical shunting)

Question 11

What is the treatment for trigeminal neuralgia? What are red flags prompting neuro review?

Answer 11

Carbamazepine

Sensory change, deafness, eye pain, <40yrs

Question 12

How do you differentiate cluster headache from paroxysmal hemicrania or SUNCT?

Answer 12

Cluster: Young men, 45-90mins, alcohol

PH: Elderly women, 10-30mins

SUNCT: Nasal stuffiness and eyelid swelling

Question 13

How do you treat cluster headache?

Answer 13

Acute: Oxygen and sumitriptain

Prophylactic: Verapamil + steroids

Question 14

What seizure features point away from epilepsy?

Answer 14

Females with FHx

Gradual onset

Pelvic thrusting

Crying post-event

No tongue biting or incontience

Question 15

Name the following seizure presentations…

Spasm in flexion/etension

body jerking

LOC, arched back

Answer 15

Clonic

Myoclonic

Tonic

Question 16

What is a tonic clonic seizure?

Answer 16

Combination of tonic (LOC, arched back) and clonic (spasm in flexion, extension) in a sequence

Question 17

What is the referral and investigations for seizures

Answer 17

Urgent referral following first seizure

MRI within 6 weeks for structural cause

EEG to confirm subtype

Question 18

What blood test can help raise suspicion of epilepsy

Answer 18

Raised serum prolactin 10-20 mins post-event

Question 19

When is drug therapy initiated in epilepsy? What is the mantra for epilepsy drug prescribing?

Answer 19

>=2 seizures and specialist assessment

One doctor, one drug, increase over 2-3 months

Question 20

What drugs are first line in

Focal

Abscence

Generalised

Answer 20

Carbamazepine/lamotrigene

Sodium valproate, ethosuximide

Sodium valproate, lamotrigene

Question 21

What are the DVLA rules for cars/motorcycles and seizures?

Answer 21

Seizure when…

Awake + LOC: After 6m (first), 12m (epilepsy)

Awake: if 12m ago

Asleep: If no awake attack for 3yrs

Question 22

What are the DVLA rules about buses and lorries for seizures

Answer 22

One off: Stop for 5 years

>1/epilepsy: Seizure and medication free for 10 years

Question 23

What are the following seizure syndromes

infant repeatedly drawing arms and legs in, developmental delay

<5yrs with absences, jerking and history of spasms

Paraesthesia on walking

Teen female with morning seizure and daytime absences

Answer 23

Infantile spasm

Lennox-Gaustaut

Benign rolandic

Juvenile myoclonic

Question 24

What anti-epileptics are safe in pregnancy and breastfeeding?

Answer 24

Pregnancy: Lamotrigene, carbamazepine

Breastfeeding: All safe

Question 25

What antiepileptic is associated with

neural tube defects

cleft palate

Weight gain

Weight loss

Steven-Johnson syndrome

Answer 25

Valproate

phenytoin

valproate

topiramate

Lamotrigene

Question 26

What is the following aphasia and is its associated anatomy?

Fluent speech, comprehension intact (aware)

Fluent speech, comprehension impaired

Speech non-fluent, Comprehension intact

Speech non-fluent, comprehension impaired

Answer 26

Question heard in ear, travels to wernicke’s (superior temporal gyrus) for comprehension. Then travels along arcuate fasciculus to broca’s ( inferior frontal gyrus) to generate speech

Conductive (comprehension and speech broken due to arcuate fasciculus)

Wernicke’s (Comprehension impaired but forming response isnt)

Broca’s (understand but cannot generate speech)

Global (all areas affected)

Question 27

How does diagnosis differ if a bitemporal hemianopia is

upper > lower

lower >upper

Answer 27

Pituitary (inferior chiasmal compression)

Craniopharyngioma (superior chiasmal)

Question 28

What investigation is performed if a headache is worse on valsalva?

Answer 28

NON-CONTRAST CT

Raised ICP until proven otherwise

Question 29

Impaired adduction of one eye, horizontal nystagmus in abducting eye suggests what?

Answer 29

INO

Seen in MS and stroke

Question 30

For status epiliepticus what is…

The definition

The management

Answer 30

1 seizure >5 mins OR >=2 seizures in 5 mins without normality between

ABCDE

1st: PR diazepam/buccal midazolam if 1ary care, IV lorazepam with further dose at 10-20 mins ONCE in 2ary

Ongoing/established: Phenytoin/phenobarbital

Unresponsive: Induce <45 mins in