Neuro Long

Question 1

DDx for MS

Answer 1

Paraneoplastic syndromes
CNS neoplasm
Vit B12 deficiency
CNS vasculitis
SLE 
Sarcoidosis
HIV and syphilis
Migraine
Somatoform disorders

Question 2

MS Symptoms to ask about

Answer 2

1. Spastic paraparesis, hemiparesis, tetraparesis
2. Limb parasthesia
3. Visual disturbance - loss of acuity, pain or eye movement, loss of central visual field (optic neuritis), diplopia
4. Ataxia, dysarthria, and tremor - Charcot’s triad (cerebellar or posterior column involvement)
5. Band sensations around trunk or limbs
6. Urinary urgency, incontinence of faeces

Question 3

Ask about Factors that worsen MS symptoms

Answer 3

heat
infection
fever
pregnancy - post partum mainly
exercise

Question 4

DDX for multiple CNS lesions

Answer 4

MS
SLE
Sjogrens
Behcet's 
Small vessel ischemia
Acue disseminated encephalomyelitis
meningovascular syphilis
paraneoplastic effects of sarcoid
Lyme disease
Multiple emboli from any source

Question 5

Ix for MS

Answer 5

MRI
Visual evoked responses
CSF: oligoclonal bands and altered IgG: albumin ratio

Question 6

Tx approach to MS

Answer 6

1. Supportive and symptomatic
   - Bladder dysfunction, severe spasticity (Baclofen)
   - URgency (Amitriptylline)
   - Tic douloureux, facial spasm (Carbamazepine and physio)
2. Immunomodulation/immunosuppression

Question 7

Interferon Beta SE

Answer 7

Hepatotoxicity 
Cytopenia
Injection site reaction
Flu like Sx
Depression

Monitor:
LFT and FBE 1, 3 months then annually

Question 8

Glatiramer Acetate SE

Answer 8

Hepatotoxicity
cytopenia
Injection site reaction
Lipoatrophy

Monitoring
LFT and FBE at start and annually

Question 9

Teriflunamide SE

Answer 9

Hepatotoxicity 
cytopenia
Infections
Nausea and diarrhea
Loss of hair

Monitoring
LFT and FBE

Question 10

Fingolimod SE

Answer 10

Hepatotoxicity
macular oedema
lymphoedema
Bradycardia
Herpes zoster and simplex
Back pain
Headache

Monitoring:
6 hour cardiac monitoring post first dose

Question 11

Dimethyl fumerate side effects

Answer 11

Lymphopenia
Proteinuria
PML
Flushing
GIT Sx

Monitoring
Urine protein, FBE

Question 12

Natalizumab SE

Answer 12

PML
Hepatotoxicity
Headache
Infusion reaction

Monitoring
MRIB 6 monthly, LFTs and FBE

Question 13

Alemtuzimab SE

Answer 13

Autoimmune thyroid disease
Goodpastures
ITP
Infusion reation

Monitoring
Serial MRI, bloods including TFTs

Question 14

Symptoms for Hx of MG

Answer 14

1. Ocular - diplopia, drooping eyelids
2. Bulbar - choking (weakness of pharyngeal muscles), dysarthria, difficulty with chewing and swallowing
3. Neck - dropped head
4. Limb girdle -prox muscle weakness

Ask about:

• Difficult anasethesia - prolonged muscle relaxation
• Pneumonia due to aspriation
• OTher organ specific autoimmune disease

Question 15

IX for MG

Answer 15

Bloods:

• Anti AChR
• MuSK antibodies (muscle specific kinase antibodies)

Other

• Electromyogram
• Thymoma Ix: CXR, CT chest, MRI chest
• Lung function tests

Associated conditions:
-TFTs, RF, ANA

Question 16

Key Features of Lambert Eaton Syndrome to differentiate MG

Answer 16

• Prox muscle weakness and pain that may improve with repeated stimulation; reflexes absent or reduced
• Ocular and bulbar muscles spared usually
• EMG: High Freq: increment; Low Freq: decrement in AP amplitudes

Question 17

Mx of MG

Answer 17

1. Symptomatic
   - Anticholinergics - Pyridostigmine
   - Potassium supplements/ K+ sparing diuretics
   - Avoid precipitants: Gentamycin, procainamide etc.
   - Myasthenic crisis - often triggered by infection, Resp support, PLEX
2. Disease Suppression
   - Steroids (can make Sx worse in first week)
   - AZA, Cyclosporin, MMF are added if needed
   - Thymectomy - 70% show improvement and 25% have remission; Failed response usually due to incomplete removal, ectopic, and fulminant disease

Question 18

Precipitants of GBS to ask about

Answer 18

• Resp infection
• Campylobacter diarrheal illness
• Mycoplasma
• EBV
• Influenza

Precipitating event
-Surgical operations, vaccinations, Malignant disease, SLE, HIV

Question 19

IX for GBS

Answer 19

Immune stimulus
-Monospot, cold agglutinins, CMV, HIV, Campylobacter

CSF Fluid
-Raised protein

Lung function tests
-FEVx, FVC

EMG
-Takes 10 days to 3 weeks for evidence to appear

Antibodies if indicated

Question 20

DDX for acute ascending motor paralysis

Answer 20

GBS
Diptheria
Polio
PAN
Acute intermittant porphyria
Botulism

Question 21

DDX for autonomic neuropathy

Answer 21

GBS
Diabetes
Alcoholism
Acute intermittant porphyria
Amyloidosis

Question 22

Tx of GBS

Answer 22

1. PT to prevent contractures
   - Resp support in ICU if FVC <1 L
2. Steriods, immunosuppression, IVIG, and PLEX
   - IVIG and PLEX shorten recovery time from resp pparalysis and hasten return to mobility, PLEX has less relapse rates than IVIG

Question 23

Causes of Presyncope

Answer 23

1. Cardiac
   - AS, HOCM
   - Arrhythmia
2. Autonomic
   - Vasovagal
   - Autonomic neuropathy
   - MSA, e.g. associated with Parkinsons
3. Drugs
   - Antihypertensives, antipsychotics
4. Hypovolemia
   - Hemorrhage, dehydration, addisonian crisis
5. Cerebrovascular
   - Vertebrobasilar insufficiency

Question 24

Ix for syncope

Answer 24

-FBE, ESR, glucose, cholesterol, urinalysis -?renovascular disease
ECG/Holter/Implanted cardiac loop
CTB
MRI - Cerebral tumor/vascular malformation/stroke
EEG

Question 25

Carbamazepine SE

Answer 25

``` Dizziness Sedation Hyponatremia Aplastic anaemia Steven Johnsons Syndrome Rash ```

Question 26

Gabapentin SE

Answer 26

Sedation Oedema Weight gain

Question 27

Lamotrigine SE

Answer 27

``` Acne Insomnia Headache Dizziness Diplopia Steven Johnsons Rash Hepatic Failure ```

Question 28

Phenytoin SE

Answer 28

``` Sedation OEdema WEight gain Steven Johnsons Rash Hepatic Syndrome Lupus like syndrome Cardiac conduction abnormalities Gingivial hyperplasia ```

Question 29

Sodium Valproate SE

Answer 29

``` Hirsuitism WEight gain Tremor Hepatic failure Pancreatitis Thrombocytopenia ```

Question 30

CAuses of ischemic stroke

Answer 30

1. Embolus from heart 2. Large artery disease 3. Subcortical (Lacunar) 4. Cryptogenic 5. Vasculitis, genetic, Venous sinus thrombosis

Question 31

Stroke DDx

Answer 31

- Large vessel ischemia: atherosclerosis risk factors - Small vessel ischemia: HTN (lacunar infarcts) - Cardio-embolic: AF, IE, LV thrombus - Young: consider vasculopathies, thrombophilia, PFO, venous infarct Haemorrhagic: HTN, aneurysm, amyloid, trauma, anticoagulation

Question 32

Stroke Ix

Answer 32

- CTB + CTA + CT Perfusion acutely - Ischemic vs Hemorrhagic - MRI DWI - Ischemic stroke - Identify cause: ○ Assess BP on arrival to ED and as inpatient ○ ECG/Holter monitor - for AF ○ TTE - IE, LV Thrombus, PFO ○ Carotid US - ICA stenosis ○ CTD/Vasculitis Screen and ESR Thrombophilia screen

Question 33

PFO Closure indication

Answer 33

Age <60 with no other cause found for stroke apart from PFO who have associated atrial septal aneurysm or moderate to large right to left shunt Note transient increased risk of AF post closure for 4-6 weeks

Question 34

DDx for Cognitive impairment and their presentations

Answer 34

- Symptoms suggestive of a particular aetiology: ○ Alzheimer's: early STML, language problems, insidious onset ○ Lewy Body: Visual hallucinations, frequent falls, Parkinsonism features ○ Vascular: history of strokes ○ Alcohol history Consider mimics for cognitive impairment: Mood disturbance, stroke, infection (delerium)