Neuro

Question 1

LMN Signs

Answer 1

 Wasting
 Fasciculation
 Hypotonia
 Hyporeflexia

Question 2

UMN Signs

Answer 2

↑tone

Pyramidal distribution of weakness
 Leg: extensors stronger than flexors
 Arm: flexors stronger than extensors

Hyper-reflexia
Extensor plantars

Question 3

Causes of bilateral LL: spastic paraparesis

Answer 3

Common
 MS
 Cord compression
 Cord Trauma
 CP

Other
 Familial spastic paraparesis
 Vascular: e.g. aortic dissection → Beck’s syndrome
 Infection: HTLV-1
 Tumour: ependymoma
 Syringomyelia

Question 4

Causes of bilateral LL spastic paraparesis with mixed UMN/ LMN signs

Answer 4

MAST

 MND
 Ataxia, Friedrich’s
 SCDC: B12
 Taboparesis

Question 5

Unilateral LL UMN signs

Answer 5

Hemisphere → Spastic Hemiparesis
 Stroke 
 MS
 SOL
 CP

Hemicord → Spastic Hemiparesis or Monoparesis
 MS
 Cord Compression

Question 6

Causes of cerebellar syndrome

Answer 6

DAISIES

 Demyelination
 Alcohol
 Infarct: brainstem stroke
 SOL: e.g. schwannoma + other CPA tumours
 Inherited: Wilson’s, Friedrich’s, Ataxia, Telangiectasia, VHL
 Epilepsy medications: phenytoin
 System atrophy, multiple

Question 7

Causes of Parkinsonism

Answer 7

Idiopathic PD

Parkinson Plus Syndromes
 Progressive supranuclear palsy 
 MSA
 Lewy Body Dementia
 Corticobasilar degeneration

Multiple infarcts in the substantia nigra

Wilson’s disease

Drugs: neuroleptics and metoclopramide

Question 8

Main symptoms of PD

Answer 8

Bradykinesia
Pill rolling tremor
Rigidity
Postural instability

Question 9

Mx of PD

Answer 9

General
 MDT: neurologist, PD nurse, physio, OT, social worker,
GP and carers
 Assess disability
 e.g. UPDRS: Unified Parkinson’s Disease Rating Scale
 Physiotherapy: postural exercises
 Depression screening

Specific
 L-DOPA + Carbidopa or benserazide 
 Da agonists: ropinerole, pramipexole 
 Apomorphine: SC rescue drug
 MOA-B inhibitors: rasagiline
 COMT inhibitors: tolcapone
 Amantidine
 Anti-muscarinics: procyclidine

Adjuncts
 Domperidone: nausea
 Quetiapine: psychosis
 Citalopram: depression

Other
 Deep brain stimulation
 Basal ganglia disruption

Question 10

Signs of MSA

Answer 10

 Autonomic dysfunction: postural hypotension
 Parkinsonism
 Cerebellar ataxia

If autonomic features predominate, may be referred to as Shy Drager Syndrome

Question 11

Features of Progressive supranuclear palsy

Answer 11

 Postural instability → falls
 Vertical gaze palsy
 Pseudobulbar palsy: speech and swallowing problems
 Parkinsonism

Question 12

Signs of cerebellar dysfunction

Answer 12

 Dysdiadochokinesia: hands and feet
 Ataxia 
 Nystagmus + Rapid Saccades
 Intention tremor and dysmetria
 Slurred speech
 Hypotonia

Question 13

What is lateral medullary syndrome?

Answer 13

Occlusion of vertebral artery or PICA

Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s

contralateral: limb sensory loss

Question 14

Features of cord compression

Answer 14

Pain
 Local, deep
 Radicular

Weakness
 LMN @ level
 UMN below level

Sensory level
Sphincter disturbance

Question 15

Signs of a TACS (MCA and ACA territory)

Answer 15

 Hemiparesis and/or hemisensory deficit
 Homonymous hemianopia
 Higher cortical dysfunction (e.g. dominant: aphasia)

Question 16

Features of a lacunar stroke

Answer 16

Infarct around basal ganglia, internal capsule, thalamus and pons

 Pure motor: post. limb of internal capsule
 Pure sensory: post. thalamus (VPL)
 Mixed sensorimotor: internal capsule
 Dysarthria / clumsy hand
 Ataxic hemiparesis: ant. limb of internal capsule

Question 17

Features of Posterior circulation stroke?

Answer 17

 Cerebellar syndrome
 Brainstem syndrome
 Homonymous hemianopia

Question 18

Classifications of MS

Answer 18

 Relapsing-remitting: 80%
 Secondary progressive
 Primary progressive: 10%
 Progressive relapsing

Question 19

Definition of LMN lesion

Answer 19

Pathology anywhere from anterior horn to muscle itself

Question 20

Causes of proximal myopathy

Answer 20

Inherited: muscular dystrophy

Inflammation
 Polymyositis
 Dermatomyositis

Endocrine
 Cushing’s Syndrome 
 Acromegaly
 Thyrotoxicosis
 Osteomalacia
 Diabetic Amyotrophy

Drugs: alcohol, statins, steroids

Malignancy: paraneoplastic

Question 21

Causes of peripheral polyneuropathy

Answer 21

Mainly Sensory
 DM
 Alcohol
 B12 deficiency
 Chronic Renal Failure and Ca (paraneoplastic)
 Vasculitis
 Drugs: e.g. isoniazid, vincristine

Mainly Motor
 Hereditary Motor & Sensory Neuropathy / Charcot Marie Tooth
 Paraneoplastic: Ca lung, RCC
 Lead poisoning
 Acute: GBS and botulism

Question 22

In a patient with PD, how can you assess cogwheel rigidity?

Answer 22

Froment’s maneuver

• Ask them to do something with the other hand while you assess the hand with PD

Question 23

What does it mean if a patient has a pronator drift?

Answer 23

The presence of pronator drift indicates a contralateral pyramidal tract lesion.

i.e. a problem between the cerebral cortex and the spinal cord

Question 24

What is the difference between spasticity and rigidity?

Answer 24

Spasticity is associated with pyramidal tract lesions (e.g. stroke) and rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson’s disease).

Spasticity is velocity-dependent whereas rigidity is velocity independent

Question 25

Myotomes assessed in the upper limb examination

Answer 25

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

Question 26

Myotomes assessed in the lower limb examination

Answer 26

``` L2: hip flexion L3: knee extension L4: ankle dorsiflexion L5: big toe extension S1: ankle plantarflexion S4: bladder and rectum motor supply ```

Question 27

What is a myotome?

Answer 27

A myotome is a group of muscles innervated by a single spinal nerve

Question 28

What is a bulbar palsy?

Answer 28

Impairment of the function of the cranial nerves 9, 10, 11 and 12, which occurs due to a LMN lesion in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem

Question 29

What is a pseudobulbar palsy?

Answer 29

Impairment of cranial nerves 5, 7, 10, 11 and 12 due to UMN lesion

Question 30

Signs of bulbar palsy?

Answer 30

Fasciculating tongue Tongue atrophy Absent jaw jerk

Question 31

Causes of bulbar palsy?

Answer 31

MND GBS MG Central pontine myelinolysis

Question 32

Signs of pseudobulbar palsy?

Answer 32

Inability to protrude tongue Dysarthria/slurred speech Increased jaw jerk

Question 33

Causes of pseudobulbar palsy?

Answer 33

Parkinson's disease | Parkinson's plus syndromes e.g. PSP

Question 34

Causes of an UMN facial nerve palsy?

Answer 34

SOL Stroke MS

Question 35

Causes of a LMN facial nerve palsy?

Answer 35

``` Compressive: Parotid tumours Sarcoid TB Cerebellar pontine angle lesions ``` ``` Neurological: Bell's palsy MG GBS Lyme disease Ramsay Hunt syndrome ```

Question 36

Causes of mioisis?

Answer 36

``` Medications - opioids, anticholinesterases, pilocarpine Horner's syndrome Brainstem stroke Argyll Robertson pupil Cluster headache ```

Question 37

Causes of mydriasis?

Answer 37

Medications - tropicamide, anticholinergics (atropine), phenylephrine Surgical 3rd N palsy - posterior communicating artery aneurysm

Question 38

Causes of Horner's syndrome?

Answer 38

Pre-ganglionic (superior cervical ganglion): Pancoast tumour Cervical rib ``` Central (also anhydrosis): Stroke Cluster headache SOL MS ``` Post-ganglionic (also anhydrosis): Carotid artery dissection/aneurysm

Question 39

Features of 3rd N palsy?

Answer 39

eye is deviated 'down and out' ptosis absent light reflex but preserved consensual constriction in other eye pupil may be dilated and painful ('surgical' third nerve palsy)

Question 40

Causes of 3rd N palsy?

Answer 40

DM Vasculitis: temporal arteritis, SLE Raised ICP: false localising sign* due to uncal herniation through tentorium Posterior communicating artery aneurysm (most common cause of surgical 3rd N) Cavernous sinus thrombosis Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia (caused by midbrain strokes) Systemic: Amyloid, MS

Question 41

Causes of bilateral facial nerve palsy?

Answer 41

``` sarcoidosis Guillain-Barre syndrome Lyme disease bilateral acoustic neuromas (NF2) Bell's palsy (since it is relatively common it accounts for up to 25% of cases f bilateral palsy, but this represents only 1% of total Bell's palsy cases) ```

Question 42

Causes of ataxic gait

Answer 42

``` P - Posterior fossa tumour A - Alcohol S - Multiple sclerosis T - Trauma R - Rare causes I - Inherited (e.g. Friedreich's ataxia) E - Epilepsy treatments S - Stroke ```

Question 43

Signs you might see O/E in MS?

Answer 43

Eyes: optic neuritis: common presenting feature optic atrophy Uhthoff's phenomenon: worsening of vision following rise in body temperature internuclear ophthalmoplegia ``` Sensory: pins/needles numbness trigeminal neuralgia Lhermitte's syndrome: paraesthesiae in limbs on neck flexion ``` Motor spastic weakness: most commonly seen in the legs Cerebellar ataxia: more often seen during an acute relapse than as a presenting symptom tremor

Question 44

Bamford stroke classification of TACS?

Answer 44

All 3 must be present 1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia

Question 45

Bamford stroke classification of PACS?

Answer 45

2 must be present 1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. homonymous hemianopia 3. higher cognitive dysfunction e.g. dysphasia

Question 46

Bamford stroke classification of lacunar stroke?

Answer 46

presents with 1 of the following: 1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three. 2. pure sensory stroke. 3. ataxic hemiparesis

Question 47

Bamford stroke classification of posterior stroke?

Answer 47

presents with 1 of the following: 1. cerebellar or brainstem syndromes 2. loss of consciousness 3. isolated homonymous hemianopia