Neuro

Question 1

Stroke Patterns by Anatomy

Answer 1

Anterior Cerebral
= contralateral hemiparesis + sensory loss (lower limb worse than upper)

Middle Cerebral
= contralateral hemiparesis + sensory loss (upper limb worse than lower), contra HH, aphasia

Posterior Cerebral
= contralateral HH with macular sparing, visual agnosia

Weber’s (branches of PCA to midbrain)
= ipsilateral CN3 palsy, contra limb weakness

Posterior Inferior Cerebellar (lat medullary, Wallenberg)
= ipsilateral face pain + temp loss, contralateral limb/ torso pain + temp loss, also ataxia, nystagmus

Anterior Inferior Cerebellar (lat pontine)
= wallenbergs + ipsilateral facial paralysis and deafness

Retinal/ Ophthalmic
= amaurosis fugax

Basilar
= locked-in

Question 2

Third Nerve Palsy

Answer 2

Causes - PCA aneurysm (dilated, pain), cavernous sinus thrombosis, Weber’s, DM, vasculitis (TA, SLE), ^ICP

= down and out eye, ptosis, mydriasis if surgical

Question 3

Encephalitis

Answer 3

Cause - HSV-1 (95%, ^temporal and inferior frontal lobes)

= fever, headache, psych symptoms (mood, behaviour, cognition), seizures (^temporal, HEAD), vomiting, focal (aphasia)

Inv - LP (CSF lymphocytosis, ^protein), PCR (HSV, VZV, enteroviruses), MRI, EEG

-> IV acyclovir to all suspected

Question 4

Bell’s Palsy

Answer 4

Acute, unilateral, idiopathic facial paralysis, LMN so forehead is affected

RF - 20-40yrs, pregnant

= unilateral facial paralysis, pain behind ear may precede, altered taste, dry eyes, hyperacusis

-> PO pred <72hrs of onset, may add antiviral, artificial tears and lubricants to prevent exposure keratopathy

Prog - if no better at 3wks then refer urgently to ENT, most better in 3-4m, 15% have weakness if not treated

Question 5

Meningitis: Causes

Answer 5

0-3m: Group B strep, E.coli, listeria

3m-6yrs - Neisseria meningitidis, strep pnuem, Hib

6-60yrs - Neisseria meningitidis, strep pnuem

> 60yrs - Strep pneum, Nm, listeria

IS - Listeria

Viral: more common, less severe
- enterovirus (coxsackie, echo), mumps, HSV, CMV, HIV, measles

Question 6

Meningitis

Answer 6

= headache, fever, n+v, photophobia, seizures, drowsy, neck stiffness, purpuric rash if meningococcal sepsis

Inv - FBC, CRP, blood cultures, glucose, ABG, LP (not if sepsis/ signs of ^ICP)

-> notifiable, pre-hospital give IM benpen, in hospital 3m-50yrs give IV cefotaxime, + IV amoxicillin to infants/ older, IV dex may v neuro comp (contra if sepsis, IC, <3m)

Contacts <7d -> ciprofloxacin or rifampicin, vacc

Question 7

Meningitis: Complications

Answer 7

Comp - SN hearing loss, seizures, focal deficit, sepsis, IC abscess, hydrocephalus, brain herniation

Meningococcal septicaemia: risk of Waterhouse Friedrichsen syndrome (adrenal haemorrhage causing insufficiency)

Question 8

Meningitis: CSF

Answer 8

Bacterial - cloudy, vv glucose, ^protein, 10-5000 polymorphs

Viral - clear/ cloudy, v glucose, norm/^protein, 15-1000 lymphocytes

TB - cloudy/ fibrin web, vv glucose, ^protein, 30-300 lymphocytes

Fungal - cloudy, vv glucose, ^protein, 20-200 lymphocytes

Question 9

Aphasia

Answer 9

Wernicke’s: superior temporal gyrus lesion (inf left MCA)
= receptive, fluent but makes no sense, word salad, impaired comprehension

Broca’s: inferior frontal gyrus lesion (superior left MCA)
= expressive, non-fluent speech and impaired repetition, normal comprehension

Conduction: arcuate fasciculus lesion (connects B+W)
= fluent but poor repetition, normal comprehension

Global: all 3 areas affected
= expressive and receptive aphasia, may communicate using gestures

Question 10

Multiple Sclerosis

Answer 10

Chronic cell-mediated AI demyelination of the CNS

RF - 3F:M, 20-40yrs, tropics, smoking, low vit D, EBV

Types
Relapsing-remitting: ^common, 1-2m attack then remit
Secondary progressive - deteriorated, symptoms between attacks (gait, bladder)
Primary progressive - 10%, progressive from onset.

Symptoms are disseminated in time and space
= fatigue, optic neuritis, optic atrophy, Uhthoff’s (^body temp, v vision), internuclear ophthalmoplegia, oscillopsia
= Lhermitte’s (neck flexion, limb paresthesia), pins and needles, trigeminal neuralgia
= spastic weakness (^legs), ataxia, tremor, incontinence, sex issues, intellect

Question 11

MS: Management

Answer 11

Inv - MRI (high signal T2 lesions, periventricular plaques, Dawson fingers), CSF (oligoclonal bands, ^IgG synthesis), visual evoked potentials (delayed, well preserved)

Aim to reduce the frequency and duration of relapses

Acute relapse -> high dose PO/ IV methylpred 5d to shorten

Reducing relapse -> DMARDs if 2 relapses in 2yrs + walk (natalizumab, ocrelizumab, fingolimod, beta-interferon)

Symptoms -> amantadine (fatigue), baclofen and gabapentin (spasticity), US + catheters/ anti-Ach (bladder dysfunction), gabapentin (oscillating visual field)

Question 12

Migraine

Answer 12

RF - 3F:M, stress, tired, alcohol, COCP, cheese, periods

= severe, unilateral, throbbing, nausea, photo/ phonophobia, last 4-72hrs, 5-60min aura precedes (scintillating scotoma)

-> PO triptan + NSAID/ paracetamol, nasal if 12-17yrs, prophylaxis with propranolol or topiramate, acupuncture

Hemiplegic migraine: aura is motor weakness, FHx

Question 13

Visual Field Defects

Answer 13

Homonymous hemianopia: optic tract if incongruous, optic radiation/ cortex if congruous

Homonymous quadrantanopia: PiTs (parietal inferior, temporal superior)

Bitemporal hemianopia: lesion of optic chiasm, upper quadrant lost if inferior chiasm compressed (pit tumour), lower quadrant if craniopharyngioma

Question 14

Raised ICP

Answer 14

Normally 7-15mmHg (supine), CPP = mean arterial pressure - ICP

Causes - idiopathic IC HTN, trauma, meningitis, hydrocephalus, tumour

= headache, vom, v consciousness, papilledema, Cushing’s triad (widening pulse pressure, bradycardia, irregular breathing)

Inv - CT/ MRI, invasive ICP (catheter in lateral ventricles)

-> head elevation to 30°, IV mannitol, controlled hyperventilation (v pCO2 to constrict cerebral arteries), drain/ repeated LP/ VP shunt

Question 15

Oxford Stroke Classification - Anterior

Answer 15

Criteria
1. Unilateral hemiparesis +/- hemisensory loss
2. HH
3. Higher cognition loss

Total Anterior Circulation Infarcts (TACI): middle and ant cerebral arteries
= all 3

Partial ACI: small arteries of anterior circulation
= 2 out of 3

Question 16

Oxford Stroke Classification - Lacunar and Posterior

Answer 16

Lacunar Infarcts: perforating arteries of internal capsule/ thalamus/ BG
= 1 of; unilateral weakness/ sensory loss (arm +/- face or leg), pure sensory stroke, ataxic hemiparesis

Posterior Circulation Infarct (POCI): vertebrobasilar
= 1 of; cerebellar/ brainstem syndrome, LOC, isolated HH

Question 17

Stroke Management

Answer 17

-> PO aspirin 300mg (once bleed excl) for 2wks then swap to clopidogrel (or A+DP), statin at 48hrs

Thrombolysis (alteplase) if <4.5hrs and bleed excl

+/- Thrombectomy if;
<6hrs and proximal anterior occlusion on CTA (or 6-24hrs with potential to save)
<24hrs and proximal posterior occlusion on CTA

Carotid artery endarterectomy - stroke in carotid territory and >50/70% stenosis

Question 18

Stroke Anticoagulation in AF

Answer 18

2wk asp

Stroke -> start anticoag at 2wks (warfarin or Xa inh)

TIA -> start anticoag asap after bleed excluded

Question 19

TIA

Answer 19

Transient episode of neuro dysfunction caused by focal brain, spinal cord, or retinal ischaemia without infarction

Inv - MRI best, all get urgent carotid doppler

-> aspirin 300mg asap (unless bleeding disorder/ AC - image, on aspirin already), clopidogrel long term
-> specialist review (<24hrs if in last week, <7d if more than), no driving until assessed (1m), consider admitting if >1 (crescendo)

Question 20

Syringomyelia

Answer 20

Collection of CSF in the spinal cord

Cause - Arnold-Chiari (herniation of cerebellar tonsils through foramen magnum), trauma, tumour

= loss of temp sensation in cape distribution, spastic weakness (^lower limb), nerve pain, upgoing plantar

Inv - full MRI of spine and brain

Comp - scoliosis over years

Question 21

Ataxia Telangiectasia

Answer 21

AR disorder, one of the inherited combined immunodeficiency disorders

Cause - defect in ATM gene encoding DNA repair enzymes

= 1-5yrs, abnormal movements (cerebellar ataxia), telangiectasia, IgA deficiency, lymphoma/ leukaemia

Question 22

Autonomic Dysreflexia

Answer 22

Occurs in patients with spinal cord injury at or above T6

Cause - fecal impaction/ urinary retention causes sympathetic spinal reflex (no normal parasymp)

= extreme HTN, flushing, sweating above lesion level

-> remove/ control the stimulus, treat HTN and brady

Comp - haemorrhagic stoke

Question 23

Brachial Plexus Injuries

Answer 23

Erb-Duchenne - C5/6 damage, breech, winged scapula

Klumpke’s - T1 damage, traction injury, lose intrinsic hand muscles

Question 24

Brain Abscess

Answer 24

Causes - middle ear, sinus, trauma, surgery, endocarditis

= dull persistent headache, fever, focal neuro (nerve palsy 2nd to ^ICP), nausea, seizures, papilledema

Inv - CT (ring enhancing lesions)

-> craniotomy, debridement, IV 3rd gen cephalosporin + metronidazole, dex

Question 25

Brain Lesions

Answer 25

Parietal Lobe = sensory inattention, apraxia, astereognosis/ tactile agnosia, inferior homonymous quadrantanopia, Gestmann's syndrome (maths, fingers, R-L) Occipital Lobe = HH, cortical blindness, visual agnosia Temporal Lobe = Wernicke's, superior HQ, auditory agnosia, facial recognition Frontal Lobe = Broca's, disinhibition, preservation, anosmia, can't list Subthalamic nucleus of BG = hemiballism (suddenly fling arm)

Question 26

Types of Brain Tumour

Answer 26

Mostly supratentorial in adults, infratentorial in kids Mets - from lung, breast, bowel, melanoma, kidney Glioblastoma Multiforme - ^common adult primary, 1yr survival, central necrosis and enhanced rim Meningioma - benign, from arachnoid cap cells of meninges, next to dura = compression symptoms, spindle cells and psammoma bodies on histology Oligodendroma - benign, frontal lobe, fried egg calcification Kids Pilocytic Astrocytoma - ^common in kids, Rosenthal fibres Medulloblastoma - aggressive, small blue cells in rosette Ependymoma - 4th ventricle tumour, cause hydrocephalus Craniopharyngioma - most common paeds supratentorial, remnants of rathke's pouch, causes hormone issues, hydrocephalus, bitemp hemianopia

Question 27

Brown-Sequard Syndrome

Answer 27

Lateral hemisection of the spinal cord = below the lesion only, ipsilateral weakness, ipsilateral loss of proprioception/ vibration, contra loss of pain and temp

Question 28

Cerebellar signs

Answer 28

V - Vertigo A - Ataxia N - Nystagmus (downbeat) I - Intention tremor S - Slurred staccato speech, Scanning dysarthria H - Hypotonia E - Exaggerated broad based gait D - Dysdiadochokinesia, dysmetria

Question 29

Charcot Marie Tooth Disease

Answer 29

Most common hereditary peripheral neuropathy, mostly motor loss = footdrop, pes cavus, hammer toes, distal muscle weakness and atrophy (stork legs), hyporeflexia

Question 30

Cluster Headache

Answer 30

RF: 3M:F, smokers, alcohol may trigger an attack = 15m-2hrs of intense, sharp, stabbing pain around one eye, clusters last 4-12wks, restless, lacrimation, red, lid swelling, nasal stuffiness, miosis, ptosis Inv - MRI with gadolinium contrast -> 100% oxygen and SC triptan, verapamil to prevent

Question 31

Common Peroneal Nerve

Answer 31

Branch of the sciatic nerve, risk at neck of fibula = foot drop (+ weakness of hip abduction is L5 radiculopathy), weak dorsiflexion and eversion, weak EHL, sensory loss over dorsum of foot and lateral leg

Question 32

Creutzfeldt-Jakob Disease

Answer 32

Prion proteins cause rapidly progressing dementia and myoclonus Causes - 85% sporadic (65yrs), new variant (25yrs) Inv - LP (normal CSF), EEG (biphasic, high amplitude), MRI (hyperintense in BG and thalamus)

Question 33

Degenerative Cervical Myelopathy

Answer 33

= variable, neck/ limb pain, loss of motor function (v dexterity, gait, imbalance), numbness, incontinence, impotence, Hoffman's sign (flick finger, others on same hand twitch) Inv - MRI cervical spine (disc degeneration, ligament hypertrophy) -> urgent referral to neurosurgery/ ortho, decompressive surgery <6m

Question 34

Causes of PN

Answer 34

D - Diabetes A - Alcohol V - Vitamin B12 issues I - Infective / inherited D - Drugs (amiodarone, isoniazid, vincristine, nitrofurantoin, metronidazole)

Question 35

Muscular Dystrophies

Answer 35

X-linked recessive, dystrophin gene on chr21 Duchenne = progressive prox msucle weakness from 5yrs, calf pseudohypertrophy, gower's sign, 30% v intellect Becker = milder form, after age 10

Question 36

Childhood Epilepsy Syndromes

Answer 36

Infantile Spasms (West syndrome) Usually 2nd to neuro abnormality e.g., TS = flexion of head/ trunk/ limbs (salaam attack), progressive v intellect -> poor prognosis, vigabatrin and steroids Lennox-Gastaut May be extension of West = 1-5yrs at onset, atypical absence, falls, jerks, 90% mod mental handicap Benign Rolandic = boys, unilateral facial paresthesia on waking Juvenile Myoclonic (Janz syndrome) = teenage girls, generalised seizures after sleep deprivation, daytime absence, sudden myoclonus

Question 37

Absence Seizures

Answer 37

Causes - hyperventilation, stress = 4-8yr at onset, last a few seconds, no awareness Inv - EEG (3Hz spike and wave) -> ethosuximide, 90% seizure-free by teen

Question 38

Classification of Seizures

Answer 38

Focal: start in specific area on one side of the brain = aware or impaired awareness, split by location; Temporal - (HEAD) hallucinations, epigastric rising, automatisms/ aura, deja vu/ dysphasia Frontal - post-ictal weakness (Todd's), Jacksonian march, posturing, head/ leg movements Parietal - paraesthesia Occipital - flashes, floaters Generalised: involve networks on both sides of the brain = all lose consciousness, split into tonic-clonic, tonic, clonic, absence or atonic

Question 39

Epilepsy: Management

Answer 39

Tonic-Clonic M - sodium valproate F - lamotrigine or levetiracetam Focal 1) Lamotrigine or levetiracetam 2) carbamazepine Myoclonic M - sodium valproate F - levetiracetam Tonic/ Atonic M - sodium valproate F - Lamotrigine Absence 1) ethosuximide 2) sodium valproate for M, L/L for F

Question 40

Status Epilepticus

Answer 40

Single seizure >5mins or 2+ without returning to baseline in between -> A-E, PR diazepam/ buccal midazolam in community or IV lorazepam in hopsital, repeat once after 5-10mins, if ongoing use levetiracetam/ phenytoin/ SV, refractory (45mins) use GA or phenobarbital

Question 41

Psychogenic Seizures

Answer 41

= ^females, pelvic thrusting, crying after, never occur alone, gradual onset More likely to be true seizure if ^prolactin and tongue biting

Question 42

Essential Tremor

Answer 42

AD, affects both upper limbs = postural (worse when arms outstretched and on voluntary movement, better with alcohol and rest, titubation (head tremor) -> propranolol

Question 43

Subdural Haemorrhage

Answer 43

= fluctuating consciousness, confusion, unilateral headache Acute (<48hrs) Cause - high-impact trauma Inv - CT (hyperdense crescent, not limited by sutures) -> observe small, craniotomy for large, Chronic (weeks-months) Cause - rupture of small bridging veins in elderly/ alcoholic Inv - CT (hypodense) -> leave if no symptoms, surgical decompression with burr holes Comp - ^ICP and herniation (low GCS, abnormal posturing, CN3 palsy, seizures)

Question 44

Extradural Haematoma

Answer 44

Collection of blood between the skull and dura, ^middle meningeal artery due to thin skull in temporal region Causes - low impact trauma = lose consciousness, lucid interval (brief regain), lose again, CN palsy (fixed dilated pupil) Inv - CT (convex, limited by suture lines)

Question 45

Subarachnoid Haemorrhage

Answer 45

Bleed in the subarachnoid space Causes - head injury, spontaneous (berry aneurysm, AV malformation, pit apoplexy) = sudden onset severe occipital headache, n+v, meningism, seizures, coma Inv - ECG (ST elevation), non-contrast CT head, if done >6hrs and neg then do an LP at 12hrs (xanthochromia), CT angiogram for cause -> refer to neurosurgery, coil, PO nimodipine to prevent vasospasm Comp - rebleed, hydrocephalus, vasospasm (7-14d), SIADH and v Na

Question 46

Facial Nerve Palsy

Answer 46

Exits brainstem at cerebellopontine angle, role in face (expression), ear (stapedius), taste (ant 2/3), tear Causes Bilateral; sarcoid, GBS, lyme, NF2, Bell's palsy Unilateral; Bell's, ramsay-hunt, acoustic neuroma, HIV, MS, DM, stroke

Question 47

4th Nerve Palsy

Answer 47

Supplies superior oblique (moves eye down and in) = eye is up and out, vertical diplopia (reading, downstairs), subjective tilting of objects/ head tilt

Question 48

Freidreich's Ataxia

Answer 48

AR, trinucleotide repeat disorder, no genetic anticipation = 10-15yrs, gait ataxia, kyphoscoliosis, absent ankle jerk, optic atrophy, high-arched palate Comp - 90% HOCM (^mort), DM

Question 49

GCS

Answer 49

M (6-1) - obeys, localises to pain, withdraws, abnormal flexion, extension, none Verbal (5-1) - orientated, confused, words, sounds, none Eyes (4-1) - spontaneous, to speech, pain, none

Question 50

Guillain-Barre Syndrome

Answer 50

Immune-mediated demyelination of PNS, molecular mimicry, 80% recover, 5% mort Causes - triggered by infection (^campylobacter) = 4wks after infection, symmetrical ascending paralysis, v reflexes, v sensation Inv - normal WCC, LP (^protein), v motor nerve conduction, anti-GM1 Ab (25%) -> support, VTE prophylaxis, IV Ig, plasma exchange Miller Fisher: sub-type, eyes and descending paralysis, anti-GQ1B Ab

Question 51

Huntington's

Answer 51

AD, TNR disorder causing degeneration of cholinergic and GABA neurons in BG, death <20yrs of onset Causes - Huntingtin (chr 4, anticipation) = <35yrs, chorea (involuntary abnormal movements), personality change, v intellect, dystonia, saccadic eye movement

Question 52

Idiopathic Intracranial HTN

Answer 52

RF - young fat F, tetracyclines, COCP, steroids, lithium = headache, blurred vision, papilledema, enlarged blind spot, CN6 palsy -> weight loss, acetazolamide (CA inh), LP, surgery

Question 53

Internuclear Opthalmoplegia

Answer 53

Horizontal disconjugate eye movement RF - MS, vascular disease Cause - unilateral lesions in medial longitudinal fasciculus (CN6 to CN3) = impaired ipsi adduction, contralateral horizontal abducting nystgamus/ saccade

Question 54

Intracranial Venous Thrombosis

Answer 54

Less common cause of cerebral infarct Subtypes Sagittal sinus - seizures, hemiplegia Cavernous sinus - periorbital oedema, CN6 palsy before 3/4, trigeminal issues, central retinal vein thrombosis Lateral sinus - CN 6/7 palsy = headache, n+v, v consciousness Inv - MRI venography (empty delta sign in SST), non-contrast CT head (70% normal) -> LMWH, warfarin long-term

Question 55

Lambert-Eaton Syndrome

Answer 55

Antibody directed against VG-Ca2+ channels in PNS, inhibits release of acetylcholine Causes - small cell lung ca, breast/ ovarian, independent AI disorder = ^strength with repeated contraction, limb girdle weakness (legs first), v reflexes, dry mouth, impotence, LUTS, post-tetanic potentiation (reflexes temp normal after strong muscle contraction) Inv - EMG (incremental response to repeated stim) -> treat cause, IS, 34-diaminopyridine

Question 56

Motor Neuron Disease

Answer 56

Progressive degeneration of U/LMN, spares sensory neurons, 50% die in 3 years RF - >40yrs, genetics, heavy metals, smoking = UMN + LMN signs, asymmetric limb weakness, small hand/ tibialis anterior wasting, fasciculation, no sensory/ extra-ocular/ cerebrellar Inv - clinical, nerve conduction (normal motor), EMG (v number of APs, ^amplitude) -> riluzole (v glutamate, ^LE by 3m), BIPAP (^LE by 7m), PEG tube

Question 57

MND: Types

Answer 57

Amyotrophic lateral sclerosis: ^common, LMN in arms, UMN in legs Primary lateral sclerosis: UMN signs only Progressive muscular atrophy: LMN signs only, distal muscles first, best prog Progressive bulbar palsy: palsy of tongue, chewing and swallowing, worst prog

Question 58

Multiple System Atrophy

Answer 58

Degeneration of neurons in multiple systems of brain Types - Shy-Drager syndrome = parkinsonism, cerebellar, autonomic (impotence, postural hypotension, atonic bladder)

Question 59

Progressive supranuclear palsy

Answer 59

A Parkinson-plus syndrome = postural instability, falls, impaired vertical gaze (down is worse, reading/ downstairs), prominent bradykinesia, cog impairment -> poor response to L dopa

Question 60

Myasthenia Gravis

Answer 60

AI disorder, Ab to acetylcholine receptors in 90% RF - 2F:M, worse with b-blockers, lithium, phenytoin, Abx Link - thymoma, AI (pernicious, thyroid, RA, SLE) = F<40 (M>60), fatigability (worse with activity), diplopia, prox muscles weakness, ptosis, distended neck veins with thymoma Inv - single fibre EMG, CT thorax (excl. thymoma), ACh receptor Ab, Tensilon test (Edrophonium blocks AchE, not used anymore) -> pyridostigmine (long acting AChE inhibitor), thymectomy, in crisis use plasmapheresis and IV Ig, monitor FVC for resp function

Question 61

Pathophysiology of Myasthenia

Answer 61

Acetylcholine released at NMJ, antibodies block these receptors Receptors are used more during activity so more get blocked leading to worsening weakness In 15% there are other Ab - Muscle specific kinase and Lipoprotein receptor related protein (create and organise the receptor) Special tests incl. repeated arm abduction, ptosis with repeated blinking, held upward gaze worsens diplopia

Question 62

Myotonic Dystrophy

Answer 62

AD, TNR inherited myopathy, DM1 (^distal weakness), DM2 (^proximal) = onset in 20s, long haggard face, frontal balding, bilateral ptosis, dysarthria, cataracts Comp - DM, testicular atrophy, heart block, CM

Question 63

Neuroleptic Malignant Syndrome

Answer 63

Dopamine blockage with antipsychotics triggers a massive glutamate release Causes - antipsych, Parkinson's drugs stopped/ reduced = onset hrs-days, fever, lead-pipe rigidity, ^BP, ^HR, v reflexes, agitated delirium, confusion, AKI (2nd to rhabdomyolysis) Inv - ^CK, leukocytosis -> stop the antipsych, IV fluids, dantrolene, dopamine agonists (bromocriptine)

Question 64

Normal Pressure Hydrocephalus

Answer 64

Reversible cause of dementia in elderly RF - head injury, SAH, meningitis Cause - 2nd to v CSF absorption in arachnoid villi = wet (incontinent), wobbly (gait abnormality), wacky (dementia) Inv - CT (hydrocephalus with ventriculomegaly ≠ sulcal enlargement) -> VP shunt

Question 65

Parkinsons Disease

Answer 65

Degeneration of dopaminergic neurons in SN Bradykinesia = poverty of movement, short shuffling steps, v arm swinging, hard to initiate Tremor = worse at rest/ stress/ distracted, better with voluntary movement, 3-5hz, pill-rolling, asymmetrical Rigidity = cogwheel, lead pipe = mask face, flexed posture, micrographia, depression, dementia, REM issues, fatigue, postural hypotension Inv - clinical, SPECT if doubt

Question 66

Parkinson's Disease: Management

Answer 66

Diagnosed and started by specialist -> levodopa if motor affecting QoL, if not use dopamine agonists/ levodopa/ MAOB inhibitor, if continues then add 2nd or COMT inhibitor Impulse control disorders: ^risk with dopamine agonists, Hx of impulsive behaviour, Hx of alcohol/ smoking

Question 67

Drug-Induced Parkinsonism

Answer 67

= rapid onset motor symptoms, bilateral Rigidity and resting tremor uncommon

Question 68

Paroxysmal Hemicrania

Answer 68

A type of trigeminal autonomic cephalgia (also contains cluster) = attack of severe unilateral headache, usually orbital/ temporal, autonomic features, last <30mins, multiple times a day -> completely responsive to indomethacin

Question 69

Pituitary Apoplexy

Answer 69

Sudden enlargement of a pituitary tumour 2nd to bleed or infarct RF - HTN, pregnancy, trauma, anticoagulation = headache, vomiting, neck stiffness, visual field (^bitemporal superior quadrantic defect), pituitary insufficiency Inv - MRI ->urgent steroid replacement (v ACTH), fluid balance

Question 70

Post-LP headache

Answer 70

RF - ^needle size, direction of bevel, not replacing stylet, ^number of attempts, young skinny F = 1-2days after, worse when upright -> supportive, treat if >72hrs with blood patch, epidural saline or IV caffeine

Question 71

Restless Legs Syndrome

Answer 71

Spontaneous continuous lower limb movements, may be paraesthesia RF - FHx, iron def anaemia, uraemia, DM, pregnancy = uncontrollable urge to move legs (akathisia), initially at night but worsens, crawling/ throbbing sensations Inv - clinical, ferritin -> treat anaemia, dopamine agonists (ropinirole, pramipexole)

Question 72

Reye's Syndrome

Answer 72

Severe progressive encephalopathy, associated fatty infiltration of the liver kidneys and pancreas RF - aspirin use in children = 2yrs, Hx preceding virus, confusion, seizures, cerebral oedema, v glucose -> supportive, 20% mort

Question 73

Spontaneous Intracranial Hypotension

Answer 73

Rare cause of headaches caused by CSF leak from the thoracic nerve root sleeves RF - CTD e.g., Marfan's = headache worse when upright Inv - MRI with gadolinium -> conservative, epidural blood patch

Question 74

Subacute Combined Degeneration of the Cord

Answer 74

Due to vit B12 deficiency, affects DC/ lateral CS/ SC tracts = distal sensory loss (^legs), loss of proprioception and vibration, spastic muscle weakness, ^ knee jerk, absent ankle jerk, Rhomberg +ve, abnormal gait

Question 75

Thoracic Outlet Syndrome

Answer 75

Compression of brachial plexus, subclavian artery/ vein RF - 40yrs, thin F, long neck, drooping shoulders, cervical rib Neurogenic (90%) = painless wasting of hand, hand weakness, numbness Vascular = diffuse arm swelling vs painful claudication Inv - CXR, cervical spine XR, CT/ MRI, venography/ angio -> conservative for neuro, surgery if fails or vascular

Question 76

Trigeminal Neuralgia

Answer 76

Cause - idiopathic, compression of trigeminal root = unilateral electric shock like pains, abrupt onset and termination, brought on by light touch/ spont -> carbamazepine, refer to neuro if no response Red flags incl; Sensory changes Deafness Pain only in ophthalmic division Optic neuritis FHx of MS Age <40yrs

Question 77

Neurofibromatosis

Answer 77

AD, neurocutaneous disorders NF1: Chr17 = cafe au lait spots, axillary/ groin freckles, peripheral neurofibromas, iris hamartoma (Lisch nodules), scoliosis, phaeochromocytoma NF2: Chr22 = bilateral AN, other neuro tumours

Question 78

Tuberous Sclerosis

Answer 78

AD, neurocutaneous disorder = depigmented ash-leaf spots (fluoresce under UV), Shagreen patches (rough lumbar), angiofibroma (butterfly over nose), subungual fibromata, cafe au lait spots, developmental delay, v intellect, epilepsy Organ involvement - retinal hamartomas (white), heart rhabdomyoma, glioma, PCKD, lung cysts

Question 79

Von Hippel-Lindau

Answer 79

AD, predisposition to neoplasia, Chr3 = Cerebellar and retinal hemangiomas, renal/ pancreatic/ liver cysts, phaeochromocytoma, clear cell RCC

Question 80

Wernicke's Encephalopathy

Answer 80

Neuropsychiatric disorder caused by thiamine deficiency RF - alcoholism, persistent vomiting, stomach ca, diet = nystagmus, ophthalmoplegia, gait ataxia, encephalopathy Inv - v red cell transketolase -> urgent replacement of thiamine Comp - if not treated can lead to Korsakoffs syndrome (ant/retrograde amnesia and confabulation)

Question 81

NICE CT head guidelines

Answer 81

Within 1 hour: GCS <13 initially or <15 at 2hrs Suspect open/ depressed/ basal skull fracture Seizure Focal neuro issue >1 vomit Within 8 hours: warfarin, or LOC/ amnesia + 65+ Bleeding / clotting issues / on AC >30min retrograde amnesia Dangerous mechanism - height of 1m or 5 stairs

Question 82

Upper Limb Dermatomes

Answer 82

C4 - AMC joint C5 - regiments patch C6 - thumb C7 - middle finger C8 - palmar little finger T1 - medial ACF

Question 83

Upper Limb Myotomes

Answer 83

C4 - shoulder shrugs C5 - shoulder abduction and external rotation C6 - wrist extension C7 - wrist flexion and elbow extension C8 - thumb extension and finger flexion T1 - finger abduction

Question 84

Pneumonic for Leva dopa side effects

Answer 84

D - dyskinesia O - on and off effect P - psychosis A - arterial Bp low M - mouth dry I - insomnia N - n+v E - excessive daytime somnolence

Question 85

Pontine Haemorrhage

Answer 85

Complication of chronic HTN = reduced GCS, quadriplegia, bilateral miosis

Question 86

UMN signs vs LMN signs

Answer 86

UMN - ^tone, ^reflexes, upgoing planar, pyramidal weakness (extensors weaker than flexors in arms, opposite in legs) LMN - v tone, v reflexes, downgoing plantar, wasting, fasciculations

Question 87

Common side effect of spinal anaesthesia

Answer 87

Low pressure headache

Question 88

Mononeuritis Multiplex vs Polyneuropathy

Answer 88

Mononeuritis - non-contiguous nerves (different nerves all over body) Polyneuroapthy - all from similar sites of body

Question 89

Anterior Spinal Artery Occlusion

Answer 89

Affects lateral corticospinal/ ST tracts = bilateral spastic paresis, bilateral loss of pain and temperature sensation

Question 90

Neurosyphilis (Tabes Dorsalis)

Answer 90

Affects dorsal column = loss of proprioception and vibration, normal motor