ELFH: neurology 1

Question 1

syncope?

Answer 1

temporary loss of consciousness due to reduction in blood flow. Usually preceded by dizziness. Fear (reflex) cough, micturition (reducing venous return)

Question 2

arrhythmia cause dizziness and fainting?

Answer 2

reduced cardiac output thus reduced cerebral blood supply

Question 3

postural hypotension causes dizziness an fainting?

Answer 3

on rising from lying or sitting, in elderly or associated with Addison’s

Question 4

causes of dizziness and fainting?

Answer 4

syncope
arrhythmias
postural hypotension
epilepsy
hypoglycaemia
panic attacks
transient ischaemic attacks

Question 5

UMN lesion?

Answer 5

opposite side and lower half of face (can wrinkle forehead)

Weakness of the lower part of face only as the frontal muscles have a bi-cortical representation
Effect would be on the contralateral side
Patient would retain blinking and forehead wrinkling
Common in strokes

Question 6

LMN lesion?

Answer 6

same side and full side

facial nerve - bell’s palsy

Question 7

causes of LMN lesion?

Answer 7

• Disease of the anterior horn cells
• Lesions at the spinal or cranial nerve root, e.g. disc lesions, tumours
• Peripheral nerve lesions, e.g. compression, trauma and poly-neuropathy
• There may also me issues at the motor end plate, e.g. myasthenia gravis

All muscles of expression affected
On the ipsilateral side
No blinking and forehead wrinkling
Causes are cerebro-pontine angle tumour, petrous bone lesions/infections, parotid gland pathology (which may be iatrogenic), skull base lesions
Commonest is Bells Palsy

Question 8

path of sensory nerves to the brain?

Answer 8

carry info from the periphery into the brain

arrive at the back (dorsum) of the spinal cord or via the sensory based cranial nerves

to thalamus

sent to areas important in actioning the infomation e.g. cerebellum

Question 9

What symptoms would indicate sensory disturbance?

Answer 9

The main indicators of sensory nerve problems are:

Pins and needles (parasthesia)
Numbness (anaesthesia)
Pain

Question 10

peripheral nerve lesion vs central tract nerve lesion?

Answer 10

peripheral nerve damage will affect the distribution of that nerve e.g. ID

CENTRAL TRACTS: affect whole limb or area

Question 11

loss of pain and sensation on opposite side implies what?

Answer 11

Loss of pain and sensation on opposite sides implies a spinal cord lesion

Question 12

loss of pain and sensation on same side suggests the lesion is from where?

Answer 12

lesion in pons

Question 13

lesion in the cortex vs thalamic region?

Answer 13

cortex = sensory loss on one side usually with no pain

Thalamus = pain

Question 14

lesion in the pyramidal and cerebellum?

Answer 14

uncoordinated and weak movements

Question 15

what may affect the cerebellum?

Answer 15

Multiple sclerosis
Tumours
Alcohol abuse
Anticonvulsant drugs

Question 16

Cerebellar lesions will result in the following signs/symptoms which should be noticed by the clinical care providers:

Answer 16

Tremor
Clumsiness
Nystagmus
Dysarthria (difficulty speaking)
Tremor of the head (titubation)

Question 17

what nerves nuclei are found i the midbrain?

Answer 17

iii - oculomotor
iv - trochlear

Question 18

what nerves nuclei are found in the pons?

Answer 18

v
vi
vii
viii

Question 19

what nerves nuclei are found in the medulla?

Answer 19

ix
x
xi
xii

Question 20

loss of function of CNI called?

Answer 20

loss of smell = anosmia

Question 21

tests for the optic nerve?

Answer 21

Visual acuity (with a Snellen chart)
Visual field (with confrontation technique)
Fundoscopy

Question 22

what nerve constricts the pupil?

Answer 22

oculomotor - parasympathetic

Question 23

Why does the pupil dilate? pathway

Answer 23

the sympathetic efferents which have arrived via the carotid vascular system will pass through the ciliary ganglion to finish at the pupillary muscle target and cause it to dilate.

Question 24

what may cause pupils to permanently dilate?

Answer 24

• III nerve palsy
• Anticholinergic drug
• Holmes Adie pupil, absent light reflex found in young women , little significance and may indicate generally slow reflexes

Question 25

What may cause pupils to be permanently constricted?

Answer 25

- Cholinergic drugs - Horner’s syndrome, interruption of sympathetic efferents at root of neck by metastatic disease such as lung cancer (Pancoast tumour) or trauma in the neck - Argyll Robinson pupil, associated with syphilis or even diabetes - Opiates

Question 26

eye nerves?

Answer 26

iii - oculomotor iv - trochlear vi - abducens

Question 27

what could affect nerves III, IV, VI?

Answer 27

Infarction Tumours Multiple sclerosis Motor neurone disease Trauma

Question 28

What is the role of the oculomotor nerve?

Answer 28

constrict pupil levator palpebrae superioris all other extra-ocular muscles

Question 29

lesions in oculomotor result in?

Answer 29

eye down and out and fixed dilated pupil. Subarachnoid bleed from a Berry aneurysm is also a common cause. You should also consider diabetes.

Question 30

what is the role of trchlear nerve?

Answer 30

superior oblique muscle eye down and medially

Question 31

what happens when trochlear nerve is damaged?

Answer 31

double vision when looking down

Question 32

what does the abducens nerve cause?

Answer 32

lateral rectus - lateral movement

Question 33

what occurs if abducens nerve damaged?

Answer 33

Eye turns medially in lesion due to unopposed medial rectus activity, leading to double vision.

Question 34

what does trigeminal nerve supply?

Answer 34

Through its three divisions this nerve supplies sensation to the face and scalp back to the vertex. It provides sensory information from mucous membranes of sinuses, nose, oral cavity and the teeth. In addition it has a motor root which supplies, via the mandibular division, the muscles of mastication.

Question 35

A, B, C, by what nerve?

Answer 35

Question 36

mandibular nerve of V supplies motor innervation to what?

Answer 36

muscles of mastication

Question 37

How to test trigeminal nerve?

Answer 37

- Sensory loss to the face, possibly limited to one of the territories dependent upon the site of the lesion. This can be tested with cotton wool and patient specific pins - Loss of corneal reflex - Intra-oral sensory loss - Jaw will deviate to side of the lesion and temporalis and masseter can be palpated to assess their function during clenching

Question 38

describe trigeminal neuralgia?

Answer 38

sudden, short-lived, electric-like recurrent pain found in the distribution of one of the trigeminal nerve divisions.

Question 39

who is likely to get trigeminal neuralgia?

Answer 39

It mostly occurs in the elderly but if it occurs in younger patients the clinician must consider multiple sclerosis. It may have a trigger spot or be related to a repeated function such as talking or washing the face or eating.

Question 40

tx for trigeminal neuralgia?

Answer 40

Carbamazepine or oxcarbazine are the two main drug treatments. Other drugs with some benefit include lamotrigine, phenytoin and gabapentin. If drugs fail then an increasing number of patients undergo some form of surgery. This may be peripheral nerve destruction with laser, cryotherapy or glycerol injection. Central ganglion thermocoagulation or percutaneous balloon compression. Some patients may opt for vascular decompression of the ganglion which produces very good long term results, but not without risks.

Question 41

what can you mistake trigeminal neuralgia for?

Answer 41

dental pain

Question 42

other causes of LMN lesion?

Answer 42

- Parotid tumour - Parotid surgery - Local anaethesia infiltrating into the parotid gland after giving an inferior dental block. This is normally a transient phenomenon - Sarcoidosis - Tumours of the skull base - Lesions in the pons, e.g. demyelination or infarction - Melkersson Rosenthal syndrome; (facial nerve palsy, swelling of the face and fissured tongue - Ramsay Hunt Syndrome; Herpes Zoster infection of VII ganglion (geniculate) leaves facial palsy and vesicular ulcers on the palate and ear

Question 43

clinical features of bell's palsy?

Answer 43

- Ear pain preceding the event - Stiffness and difficulty moving any muscles on the affected side including difficulty in blinking - Altered taste and hyperacusis (sensitive to sounds) on the same side - Reduced tears on ipsilateral side (greater petrosal nerve via the pterygopalatine ganglion)

Question 44

management of bells palsy?

Answer 44

- Most cases recover although some may have some re-innervation issues e.g. tears and saliva produced when eating (crocodile tears) - Treatment includes high dose steroids and a short course of aciclovir, lubrication for the eye and eye protection - Recovery may take eight weeks although 10-20% may not fully recover

Question 45

symptoms of cochlear nerve damage?

Answer 45

deafness and tinnitus.

Question 46

The majority of causes of cochlear nerve or cochlear damage are:

Answer 46

Tumours (cerebellopontine angle) Petrous bone disease Ménière's disease Drugs (gentamicin) Old age

Question 47

Problems with the vestibular portion lead to:

Answer 47

- Vertigo, the illusion of movement - Manifest to the outside world as nystagmus, an oscillation of the eyes

Question 48

what nerves are usually affected together?

Answer 48

Glossopharyngeal IX, vagus X, accessory XI and hypoglossal nerves XII originate in the medulla

Question 49

lesions of nerves IX-XII result in what?

Answer 49

bulbar palsy which is commonly a LMN lesion and manifests as: - Dysarthria - Dysphagia (choking) - Wasted and fasciculating tongue. This can also be a lesion above the nuclei (UMN), i.e. a stroke, MND or even MS, will lead to a pseudobulbar palsy in which the tongue will not be wasted or fasciculating. Each of the nerves can be damaged outside the skull and result in individual signs and symptoms.