Neuro

Question 1

Migraine management acute and prophylactic

Answer 1

Acute: paracetamol/aspirin + triptan (sumatriptan) + NSAID

Prophylactic: propranolol/topiramate/amitriptyline

Question 2

Trigeminal neuralgia management

Answer 2

Carbamazepine, gabapentin 2nd line

Unresponsive to medical therapy:
Classical - micro vascular decompression
Idiopathic - ablative surgery
Secondary - treat secondary cause

Question 3

Focal seizure management

Answer 3

Lamotrigene/levetiracetam

Question 4

Generalised seizure management

Answer 4

Sodium valproate/valproic acid

Question 5

Status epilepticus management

Answer 5

Benzodiazepine - lorazepam/diazepam
Second line - IV phenytoin

Question 6

How does a focal seizure present (different areas of brain)

Answer 6

Frontal: Jacksonian March (muscle spasm), post-ictal flaccid weakness, disinhibition

Temporal: Automatisms, epigastric discomfort, hallucinations

Parietal: Sensory disturbances e.g. tingling, pain, numbness

Occipital: visual phenomena

Question 7

What investigation is done for a brain abscess and what do you expect to see

Answer 7

CT head/MRI for ring enhancing lesion

Question 8

Brain abscess management

Answer 8

Vancomycin + metronidazole/clindamycin + ceftriaxone (3rd gen ceph)

Anticonvulsants: phenytoin/carbamazepine/valproic acid/levetiracetam

Dexemethasone in acutely decompensating patient

Surgical decompression

Question 9

Management for essential tremor

Answer 9

Propranolol
Primidone (barbiturate) sometimes

Question 10

Management for Bell’s palsy

Answer 10

Oral prednisolone
Eye protection e.g. artificial tears

Severe palsy/complete paralysis:
Consider antiviral therapy (valaciclovir)

No improvement after 3 weeks —> refer to ENT urgently

Question 11

Management for encephalitis?

Answer 11

IV acyclovir initially if viral cause suspected (most common)

Question 12

Investigations for encephalitis and results

Answer 12

Diagnostic MRI shows hyper intense lesions

CT brain in all patients with altered mental status

CSF analysis if 2/4 symptoms present: fever, headache, altered mental status, meningismus

EEG

Question 13

Management for meningitis

Answer 13

GP: benzylpenicillin IM/IV + hospital admission

Hospital: IV ceftriaxone/cefotaxime + IV dexamethasone within 1 hour

If viral cause confirmed: supportive care e.g. paracetamol/ibuprofen

Question 14

Investigations for meningitis

Answer 14

Lumber puncture for CSF analysis
CT head before LP if any symptoms of raised ICP or reduced consciousness

2 blood cultures before ABs (don’t delay however)
Blood glucose
FBC

Question 15

Management for meniere’s

Answer 15

Nausea/vomiting: prochlorperazine
Vertigo: vestibular suppressant (meclizine)/anti-emetic/corticosteroid
Tinnitus: tinnitus maskers
Sudden hearing loss: corticosteroid

Prophylaxis: betahistine trial

If therapies fail do surgery

Question 16

What is diagnostic of BPPV

Answer 16

Did-hallpike manoeuvre

Question 17

Management for subarachnoid haemorrhage

Answer 17

Nimodipine (prevent vasospasm/delayed cerebral ischaemia)

Endovascular coiling/clipping

Question 18

Imaging for TIA

Answer 18

MRI - determine territory of ischaemia

CT if patient has bleeding disorder or is on anticoagulant to rule out haemorrhage

Question 19

TIA management

Answer 19

Aspirin

Clopidogrel - long term secondary prevention
High intensity statin

Question 20

Management for cluster headaches?

Answer 20

Acute:
- 100% O2
- subcut triptan

Prophylaxis:
- verapamil

Question 21

Investigation for cluster headache

Answer 21

MRI with gadolinium contrast

Question 22

How does tension type headache present

Answer 22

Headband pain distribution (bilateral, non-throbbing, constricting)

Pain/tenderness can also be:
- pericranial
- sternocleidomastoid
- trapezius
- temporalis
- lateral pterygoid
- masseter

Normal neurological exam

Question 23

Management for tension headache

Answer 23

Acute - aspirin, paracetamol, NSAIDs

Chronic - antidepressants e.g. amitriptyline

Question 24

How to tell if meningitis is bacterial or viral with glucose?

Answer 24

Bacterial: CSF glucose < 1/2 of serum glucose

Viral vice versa

Question 25

Prophylaxis for meningitis in close contacts

Answer 25

Ciprofloxacin/rifampicin

Question 26

What’s the difference in appearance of subdural/extradural haemorrhage on CT

Answer 26

Subdural: crescent shaped Extradural: oval shaped

Question 27

Myasthenia gravis management

Answer 27

Pyridostigmine Prednisolone Thymectomy Myasthenic crisis: - Intubation and mechanical vent - Plasmapharesis - IVIG

Question 28

Multiple sclerosis management

Answer 28

Acute relapse: oral methylprednisolone RRMS: immunomodulators e.g. natalizumab/alemtuzumab/dimethyl fumarate SPMS: Siponimod/methylprednisolone PPMS: Ocrelizumab Further drugs/management for specific symptoms

Question 29

Investigations for subarachnoid haemorrhage

Answer 29

Non contrast CT If -ve and after 6 hrs of onset: LP within 12 hrs If +ve do CT angiogram (MR if preg/contrast allergy)

Question 30

Management for Alzheimer’s

Answer 30

Mild: donepezil/rivastigmine/galantamine (cholinesterase inhibitors) Moderate/severe: switch to or add memantine

Question 31

Describe the tremor seen in Parkinson’s

Answer 31

Unilateral improving with voluntary movement

Question 32

Management of MND

Answer 32

Riluzole + supportive care Resp symptoms - NIPPV/IMV Mucus - carbocisteine (mucolytic) Dysphasia/weight loss - PEG/diet mod Drooling - hyoscyamine/amitriptyline/atropine Muscle weakness - PT/OT Spasticity - baclofen

Question 33

Management for subdural haematoma

Answer 33

Anti-epileptic prophylaxis for all patients e.g. phenytoin < 10mm and midline shift < 5mm and stable/GCS 9-15: - observation, monitoring, CT follow up > 10mm or midline shift > 5mm or unstable/GCS < 9: - Burr-hole/trauma craniotomy

Question 34

Extradural haematoma management

Answer 34

Burr-hole/craniotomy immediately

Question 35

What does a headache worse on lying down mean and vice Verda

Answer 35

Worse on lying down: increase ICP Worse on standing: low ICP