Neuro

Question 1

Stroke: ACA

Answer 1

Contralateral hemiparesis and sensory loss, lower extremity > upper

Question 2

Stroke: MCA

Answer 2

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia - difficulty with language or speech

Question 3

Stroke: PCA

Answer 3

Contralateral homonymous hemianopia with macular sparing (preserves vision in the centre of the visual field)
Visual agnosia ( cannot recognise objects)

Question 4

Stroke: Basilar artery

Answer 4

Locked in syndrome

Question 5

Stroke: retinal/ ophthalmic artery

Answer 5

Amaurosis fugax

Question 6

What is a lacunar stroke?

Answer 6

present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
strong association with hypertension
common sites include the basal ganglia, thalamus and internal capsule

Question 7

Acute management of a stroke (what are the guidelines)

Answer 7

aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded

regards to atrial fibrillation, the RCP state: ‘anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke’

if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

BM’s, Sats, hydration and temperature should be normal

Question 8

What are the guidelines regarding thrombolysis for acute ischaemic strokes?

Answer 8

Thrombolysis with alteplase should only be given if:
it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Question 9

What are the guidelines regarding thrombectomy for acute acute ischaemic strokes?

Answer 9

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:
acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA).

Offer thrombectomy as soon as possible to people who were last known to be well between 6 hours and 24 hours previously (including wake-up strokes):
confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 10

What are the secondary prevention guidelines for stroke?

Answer 10

Recommendations from NICE include:
clopidogrel is now recommended by NICE ahead of combination use of aspirin plus modified-release (MR) dipyridamole in people who have had an ischaemic stroke
Aspirin plus MR dipyridamole is now recommended after an ischaemic stroke only if clopidogrel is contraindicated or not tolerated, but treatment is no longer limited to 2 years’ duration
MR dipyridamole alone is recommended after an ischaemic stroke only if aspirin or clopidogrel are contraindicated or not tolerated, again with no limit on duration of treatment

Question 11

What are NICE guidelines regarding the mx of Parkinson’s disease?

Question 12

What are the nice guidelines for Parkinson’s mx?

Answer 12

For first-line treatment:
if the motor symptoms are affecting the patient’s quality of life: levodopa
if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor

Question 13

Which parkinsons drug is best for motor symptoms and ADOLS mx?

Answer 13

Levadopa anyday over Dpamine agonists or MAO-B inhibitors

Question 14

What parkinsons drug can cause the the most motor complications and which one is the one that causes the most adverse events (sleepiness hallucinations etc):

Answer 14

Motor: Levodopa is the worst for side effects
Adverse events: Dopamine agonists

Question 15

Side effects of levadopa

Answer 15

Dry mouth
Anorexia
Palpitations
Psychosis
Postural HTN
Dyskinesias ( dystonia, chorea and athetosis)

Question 16

What is a TIA?

Answer 16

The original definition of a TIA was time-based: a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow. However, this has now changed as it is recognised that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ‘tissue-based’ definition is now used: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Question 17

What are the features of a TIA

Answer 17

Resolve within1-24hrs however are:

unilateral weakness or sensory loss.
aphasia or dysarthria
ataxia, vertigo, or loss of balance

visual problems:
sudden transient loss of vision in one eye (amaurosis fugax)
diplopia
homonymous hemianopia

Question 18

What would you do if you came across someone with a sus TIA?

Answer 18

give aspirin 300 mg immediately, unless
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team

Question 19

Investigations for a TIA!!!!!!

Answer 19

NICE recommend that CT brains should not be done ‘unless there is clinical suspicion of an alternative diagnosis that CT could detect’
MRI (including diffusion-weighted and blood-sensitive sequences) is preferred to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies
Carotid doppler!

Question 20

How would you treat a confirmed TIA?

Answer 20

Clopidogrel is recommended first line
Aspirin + dipyramidole for those patients who cannot.

Question 21

Features of a third nerve palsy ?

Answer 21

eye is deviated ‘down and out’
ptosis
pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy)

Question 22

Causes of a third nerve palsy?

Answer 22

DM , Vasculitis, PCA aneurysm (ASSOCIATED WITH PAIN!!!!!)
MS?

Question 23

How do we classify seizures?

Answer 23

1. Where seizures begin in the brain
2. Level of awareness during a seizure (important as can affect safety during seizure)
3. Other features of seizures

Question 24

What is a focal seizure?

Answer 24

these start in a specific area, on one side of the brain
the level of awareness can vary in focal seizures. The terms focal aware (previously termed ‘simple partial’), focal impaired awareness (previously termed ‘complex partial’) and awareness unknown are used to further describe focal seizures
further to this, focal seizures can be classified as being motor (e.g. Jacksonian march), non-motor (e.g. déjà vu, jamais vu; ) or having other features such as aura

Question 25

Gen seizures what are they ?

Answer 25

these engage or involve networks on both sides of the brain at the onset consciousness lost immediately. The level of awareness in the above classification is therefore not needed, as all patients lose consciousness generalised seizures can be further subdivided into motor (e.g. tonic-clonic) and non-motor (e.g. absence) tonic-clonic (grand mal) tonic clonic typical absence (petit mal) atonic

Question 26

What is Bells palsy? What is it caused by and who does it affect?

Answer 26

Bell's palsy may be defined as an acute, unilateral, idiopathic, facial nerve paralysis. The aetiology is unknown although the role of the herpes simplex virus has been investigated previously. The peak incidence is 20-40 years and the condition is more common in pregnant women.

Question 27

What are the features of Bell's palsy?

Answer 27

lower motor neuron facial nerve palsy - forehead affected in contrast, an upper motor neuron lesion 'spares' the upper face patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis

Question 28

Mx of bells palsy?

Answer 28

there is consensus that all patients should receive oral prednisolone within 72 hours of onset of Bell's palsy Eye care - artificial tears and tape etc If no improvement in 3 weeks urgent ENT referral

Question 29

What is a cluster headache and what is its pattern?

Answer 29

The name relates to the pattern of the headaches - they typically occur in clusters lasting several weeks, with the clusters themselves typically once a year. Men 3:1 and smokers more common

Question 30

Features of cluster headaches?

Answer 30

Features pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours clusters typically last 4-12 weeks intense sharp, stabbing pain around one eye (recurrent attacks 'always' affect same side) patient is restless and agitated during an attack accompanied by redness, lacrimation, lid swelling miosis and ptosis in a minority

Question 31

Acute and prophylaxis treatment of cluster headaches?

Answer 31

acute: 100% oxygen (80% response rate within 15 minutes), subcutaneous triptan (75% response rate within 15 minutes) prophylaxis: verapamil is the drug of choice. There is also some evidence to support a tapering dose of prednisolone NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging

Question 32

What is Myasthenia gravis?

Answer 32

Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 85-90% of cases*. Myasthenia is more common in women (2:1)

Question 33

What are the features of MG?

Answer 33

Fatigability which improves with rest: Extraocular muscle weakness + diplopia Proxismal muscle weakness (head and neck) Ptosis Dysphagia

Question 34

What is MG associated with?

Answer 34

Thymomas! and other autoimmune disorders

Question 35

What Ix would you do for MG?

Answer 35

single fibre electromyography: high sensitivity (92-100%) Autoantibodies - to acetylcholine receptors

Question 36

Mx of MG?

Answer 36

Pyridostigmine - first line. Can lead to horrible diarrhoea Most patients on some sort of long term immunosuppression

Question 37

What is a status epilepticus?

Answer 37

Status epilepticus is defined as: a single seizure lasting >5 minutes, or >= 2 seizures within a 5-minute period without the person returning to normal between them

Question 38

How would you manage status epilepticus?

Answer 38

ABC + blood glucose! First-line drugs are IV benzodiazepines such as diazepam or lorazepam in the prehospital setting PR diazepam or buccal midazolam may be given in hospital IV lorazepam is generally used. This may be repeated once after 10-20 minutes If ongoing (or 'established') status it is appropriate to start a second-line agent such as phenytoin or phenobarbital infusion

Question 39

How would you manage GBS?

Answer 39

IVig + plasma exchange

Question 40

What is GBS? What is it caused by?

Answer 40

Guillain-Barre syndrome describes an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).

Question 41

What are the characteristic features of GBS?

Answer 41

The characteristic features of Guillain-Barre syndrome is progressive, symmetrical weakness of all the limbs. the weakness is classically ascending i.e. the legs are affected first reflexes are reduced or absent sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs

Question 42

Ix for GBS?

Answer 42

Lumbar puncture - rise in protein but normal WBC count Decreased motor nerve conduction - due to demyelination

Question 43

How do you manage migraines acutely?

Answer 43

first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol

Question 44

What is the prophylactic tx of migraines?

Answer 44

NICE advise either topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age

Question 45

Temporal love focal seizure mnemonic?

Answer 45

HEAD Hallucinations (auditory/gustatory/olfactory), Epigastric rising/Emotional, Automatisms (lip smacking/grabbing/plucking), Deja vu/Dysphasia post-ictal)

Question 46

Frontal lobe seizure features?

Answer 46

MOTOR Head/leg movements, posturing, post-ictal weakness, Jacksonian march.

Question 47

Parietal lobe seizure features? Occipital lobe?

Answer 47

Paraesthesia - parietal Floater and flashes- occipital

Question 48

What is the epi of MND?

Answer 48

Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before 40 years and various patterns of disease are recognised including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.

Question 49

What features point towards a diagnosis of MND?

Answer 49

fasciculations the absence of sensory signs/symptoms* the mixture of lower motor neuron and upper motor neuron signs wasting of the small hand muscles/tibialis anterior is common Often no cerebellar or ocural signs

Question 50

What is wenickes aphasia?

Answer 50

This area 'forms' the speech before 'sending it' to Broca's area. Lesions result in sentences that make no sense, word substitution and neologisms but speech remains fluent - 'word salad' Comprehension is impaired

Question 51

Brocas aphasia?

Answer 51

Due to a lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA Speech is non-fluent, laboured, and halting. Repetition is impaired

Question 52

Acute mx of MS?

Answer 52

High dose steroids (e.g. oral or IV methylprednisolone) may be given for 5 days to shorten the length of an acute relapse. Shortens relapse does not cure

Question 53

MS long term meds?

Answer 53

1. Natalizumab - monoclonal antibody Others???? Beta interferon no longer thought of as effective?

Question 54

What is the symptom pattern of parkinsons?!!!

Answer 54

Asymmetrical Classic triad of: bradykinesia, termor and rigidity You cannot have parkinsons without bradykinesia!!!!!

Question 55

Features of parkinsons?

Answer 55

Bradykinesia: hypokinesia, short shuffling steps with reduced arm swing, difficulty starting mvmnt Pill rolling tremor that is worse when stressed or tired - improves with voluntary movement (3-5hz) Lead pipe/cogwheel rigidity Essential ones above You can also have: mask like facies (lack of facial expressions), micrographia, REM and Parkinsons +++???

Question 56

Investigations for a stroke when not TIA?

Answer 56

non-contrast CT head to determine what therapy to start

Question 57

MS ix?

Answer 57

CSF: Oligoclonal bands MRI: High signal T2 lesions, plaques

Question 58

MS features?

Answer 58

75% present with sig lethargy Visual: Optic neuritis, Uhtoffs (worsening vision after heat) Sensory: Lhermittes (paraesthesia in limbs on neck flexion), trigeminal neuralgia, numbness Cerebellar: ataxia + tremor Other: spastic weakness (mostly legs), sexual dysfunction and urinary incontinence

Question 59

What is optic neuritis?

Answer 59

Optic neuritis occurs when swelling (inflammation) damages the optic nerve — a bundle of nerve fibers that transmits visual information from your eye to your brain. Common symptoms of optic neuritis include pain with eye movement and temporary vision loss in one eye.

Question 60

How can you differentiate acute and chronic subdural haematomas on CT?

Answer 60

Acute: hyperdense bright crescent shape whilst chronic is darker hypodense crescent shape.

Question 61

How do we manage MND?

Answer 61

Riluzole which prolongs life by 3 months then resp care. PEG for nutrition However 50% will still die in 3 years

Question 62

How can you differentiate a pseudoseizure from a true epi seizure?

Answer 62

Pseudo is morelikely: When not alone, crying after seizure, gradual onset. Epileptic seizures: Tongue biting + raised serum PROLACTIN

Question 63

Patterns of damage for radial nerve?

Answer 63

Patterns of damage wrist drop sensory loss to small area between the dorsal aspect of the 1st and 2nd metacarpals

Question 64

What is trigeminal neuralgia?

Answer 64

Trigeminal neuralgia is a pain syndrome characterised by severe unilateral pain. The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems may occur.

Question 65

What are the features of a trigeminal neuralgia?

Answer 65

a unilateral disorder characterised by brief electric shock-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve the pain is commonly evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously small areas in the nasolabial fold or chin may be particularly susceptible to the precipitation of pain (trigger areas) the pains usually remit for variable periods

Question 66

Mx of trigeminal neuralgia?

Answer 66

carbamazepine is first-line failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology

Question 67

What is wernickes encephalopathy ?

Answer 67

A classic triad of ophthalmoplegia/nystagmus, ataxia and confusion caused by thiamine deficiency which is most commonly seen in alcoholics.

Question 68

What Ix would you do for Wernickes encephalopathy? What tx?

Answer 68

Investigations decreased red cell transketolase MRI Tx: Thiamine

Question 69

Relationship between Wernickes encephalopathy and Korsakoffs syndrome?

Answer 69

If not treated Korsakoff's syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation in addition to the above symptoms. Opthalmoplegia, ataxia and confusion

Question 70

What is Menieres disease?

Answer 70

Meniere's disease is a disorder of the inner ear of unknown cause. It is characterised by excessive pressure and progressive dilation of the endolymphatic system.

Question 71

Features of Menieres disease?

Answer 71

* recurrent episodes of vertigo, hearing loss and tinnitus * sensation of aural fullness or pressure is a common feeling *Symptoms are unilateral but bilateral symptoms may develop after a few years

Question 72

Mx of Menieres disease?

Answer 72

ENT assessment to confirm diagnosis DVLA- dont drive till symptoms controlled Acute: Buccal or IM prochlorperazine

Question 73

What is narcolepsy? What are some features?

Answer 73

Disease where patients fall asleep at inappropriate times Features: teenage years sleep paralysis, Cataplexy (sudden loss of muscle tone triggered by emotion).

Question 74

Mx of narcolepsy

Answer 74

Daytime stimulants such as modafinil

Question 75

What is an essential tremor?

Answer 75

Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs. Features: * Postural tremor (worse if arms outstretched) * improved by alcohol and rest

Question 76

Management of essential tremor?

Answer 76

Management propranolol is first-line

Question 77

What do you know about Huntingtons?

Answer 77

Genetics - death in 20 years autosomal dominant trinucleotide repeat disorder: repeat expansion of CAG as Huntington's disease is a trinucleotide repeat disorder, the phenomenon of anticipation may be seen, where the disease is presents at an earlier age in successive generations results in degeneration of cholinergic and GABAergic neurons in the striatum of the basal ganglia due to defect in huntingtin gene on chromosome 4

Question 78

Features of Huntingtons?

Answer 78

chorea personality changes (e.g. irritability, apathy, depression) and intellectual impairment dystonia saccadic eye movements

Question 79

What is lyme disease caused by?

Answer 79

Lyme disease is caused by the spirochaete Borrelia Burgdorferi, which is transmitted via Ixodes ticks in wooded areas.

Question 80

What is encephalitis?

Answer 80

Encephalitis is a histological diagnosis characterised by inflammation of the "encephalon" (or brain parenchyma).

Question 81

What is the main culprit in encephalitis?

Answer 81

Encephalitis is usually of viral aetiology, with herpes simplex virus type 1 as the most common culprit.

Question 82

Clinical features of encephalitis?

Answer 82

the cardinal feature of which is altered mental status (not as prominent in meningitis). Other suggestive features include fever, a flu-like prodromal illness, and early seizures.