Neuro2 Flashcards
Cranial nerves and ophthalmology (100 cards)
1
Q
What are the common pathologies which can affect a cranial nerve?
A
Diabetes mellitus MS Tumours Sarcoid Vasculitis SLE Syphilis
2
Q
What should you look for on general inspection when performing a cranial nerve exam?
A
Dysarthria Asymmetry Ptosis Horner's/Bell's Glasses Hearing aids Eye patch Walking stick
3
Q
What is the medical term for a loss of sense of smell?
A
Anosmia
4
Q
What can cause anosmia?
A
Ageing Traumatic brain injury Parkinson's Alzheimer's Tumour
5
Q
What should you assess for in the optic nerve?
A
Acuity Fields Reflexes Ophthalmoscope Colour
6
Q
How should you assess the Pt’s acuity?
A
Using a Snellen Chart from 6m away
7
Q
What are the causes of a loss of acuity?
A
Refractive error Ocular media -cataracts -diabetes Retina -age related macular degeneration -diabetic retiniopathy Optic neuropathy -MS -ischaemia
8
Q
What is conjunctivitis?
A
Inflammation of the conjunctiva
9
Q
What are the symptoms of conjunctivitis?
A
Conjunctival hyperaemia Chemosis (conjunctival swelling) Crust/discharge Foreign body sensation Photophobia
10
Q
What are the causes of conjunctivitis?
A
Bacterial
Viral
Allergic
11
Q
How can you typically differentiate a bacterial conjunctivitis from viral conjunctivitis?
A
B- unilateral, thick discharge, reduced vision, ?urethritis/vaginal discharge
V- bilateral, watery discharge, normal vision, signs of viral infx
12
Q
What is allergic conjunctivitis?
A
Type 1 hypersensitivity reaction
13
Q
What are the common triggers of allergic conjunctivitis?
A
Pollen, dust, chemical scents
14
Q
What are the clinical features of allergic conjunctivitis?
A
Conjunctivitis
Itching
Sneezing
Red, watery, oedematous eye
15
Q
What are cataracts?
A
Clouding of the lens of the eye
16
Q
What are the clinical features of cataracts?
A
Visual impairment
Glare/halos around light
Painless
Reduced red reflex
17
Q
What are the risk factors for cataracts?
A
Old age
Congenital
Diabetes
Steroids
18
Q
What is glaucoma?
A
Vision loss from optic nerve damage due to raised intraocular pressure
2nd leading cause of blindness
In an acute red painful eye, you need to rule out closed-angle glaucoma
19
Q
What is affected in open-angle glaucoma?
A
Dysfunction of trabecular meshwork
20
Q
What is affected in closed-angle glaucoma?
A
Compression of trabecular meshwork
21
Q
What are the differences between open-angle and closed-angle glaucoma?
A
OA- 90%, bilateral, progressive vision loss, initially asymptomatic, non specific symptoms
CA- 10%, unilateral, sudden onset, severe pain, N+V, cloudy cornea, headache, dilated pupil
22
Q
What are the investigations for glaucoma?
A
Fundoscopy
Gonioscope
Slit lamp
Tonometry
23
Q
What is the uvea made up of?
A
Choroid
Ciliary body
Iris
24
Q
What is uveitis?
A
Inflammation of the uvea
Can be anterior, posterior, complete, and intermediate
25
What are the causes of uveitis?
Systemic inflammation
| Infection
26
What is affected in anterior uveitis?
Iris
Ciliary body
Most common
27
What is affected in posterior uveitis?
Vitreous body
Choroid
Retina
28
What are the investigations for uveitis?
Fundoscopy
| slit lamp examination
29
What visual defect will present in a chiasmal lesion?
Bitemporal hemianopia
30
What visual defect will present in a pre-chiasmal lesion?
Ipsilateral monocular loss
31
What are the causes of a pre-chiasmal lesion?
Ischaemia- TIA (amaurosis fugax)
| Inflammation- MS
32
What are the causes of a chiasmal lesion?
Pituitary adenoma
| Chraniopharyngioma
33
A lesion in which part of the optic pathway can cause a contralateral homonymous hemianopia?
Optic tract lesion
34
A lesion in which part of the optic pathway can cause a contralateral homonymous superior quadrantanopia?
Lateral optic radiation lesion
35
A lesion in which part of the optic pathway can cause a contralateral homonymous inferior quadrantanopia?
Medial optic radiation lesion
36
A lesion in which part of the optic pathway can cause a macular sparing contralateral homonymous hemianopia?
Occipital visual cortex lesion
37
What is the cause of visual neglect?
Damage to the contralateral parietal lobe
38
What are some causes of Marcus Gunn pupil (RAPD)?
Optic neuritis
| Retrobulbar optic neuritis
39
What is anisocoria?
Unequal size of the pupils
40
What does Horner's syndrome consist of?
Ptosis
Miosis
Anhydrosis
41
What are some causes of Horner's syndrome?
```
Loss of sympathetic innervation due to either:
Carotid artery dissection
Pancoast tumour
SOL/stroke
MS
Cavernous sinus thrombosis
```
42
What is the sympathetic pathway that supplies the eye?
```
Hypothalamus
T1
Superior cervical ganglion
Carotid artery
Cavernous sinus
Target sites (dilator pupillae, lacrimal gland)
```
43
What are the investigations for Horner's syndrome?
CXR (Pancoast)
CT Head (stroke)
MRI/MRA (tumour/dissection)
Refer
44
What signs may you see on fundoscopy?
Diabetic retinopathy
Hypertensive retinopathy
Papilloedemea
45
How will a Pt with a CN3 palsy present?
Ipsilateral pupil looking down and out
Ipsilateral ptosis
Mydriasis (as pSymp fibres run with CN3)
46
Why doesn't every patient with a CN3 palsy present with both mydriasis and ophthalmoplegia?
The parasympathetic fibres run outside the nerve, whereas the oculomotor fibres run on the inside. Usually only one is affected, causing mydriasis (surgical palsy) or ophthalmoplegia (medical palsy)
47
What are the causes of a medical CN3 palsy?
DM
| Vasculitis
48
What are the causes of a surgical CN3 palsy?
Raised ICP
| Aneurysm rupture
49
How may a Pt with a CN4 palsy present?
Ipsilateral pupil looking up and in
| Tilted head to contralateral side
50
What are the commonest causes of a CN4 palsy?
Idiopathic
Head trauma
Diabetes
51
How may a Pt with a CN6 palsy present?
Failure to abduct ipsilateral eye
52
What are the causes of a CN6 palsy?
```
Stroke
Trauma
Viral illness
SOL
Inflammation
```
53
How does a Pt with internuclear ophthalmolegia present?
Ipsilateral eye has an inability to adduct, and contralateral eye elicits horizontal nystagmus upon abduction
54
What are the causes of internuclear ophthalmoplegia?
If young and bilateral, MS
| If old and unilateral, stroke
55
What are the pathways for the corneal reflex?
V1 -> VII
56
What are the pathways for the jaw jerk reflex?
V3 -> V
57
Which part of the trigeminal nerves would be affected if there was a higher central lesion?
Contralateral nerves
58
What are the causes of a higher central trigeminal lesion?
Stroke
59
Which part of the trigeminal nerves would be affected if there was a brainstem lesion?
Ipsilateral nerves
60
What are the causes of a brainstem trigeminal lesion?
Stroke
| Raised ICP
61
Which part of the trigeminal nerves would be affected if there was a peripheral lesion?
Branch distribution
62
What are the causes of a peripheral trigeminal lesion?
Raised ICP
| Trauma
63
What are the branches of the facial nerve?
```
Two
Zebras
Bit
My (Massive)
Cock
```
```
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
```
64
What is Bell's palsy?
Facial paralysis of the ipsilateral side
65
What are the causes of Bell's palsy?
Idiopathic
Compression of the facial nerve
Inflammation (eg. viral)
-herpes simplex type 1, varicella zoster
66
What are the risk factors for Bell's palsy?
Diabetes
67
What are the investigations for Bell's palsy?
Serology
| -Lyme, herpes, zoster
68
What is the management for Bell's palsy?
Prevent corneal abrasions- wear an eye patch
| Steroids- prednisolone
69
What is Ramsay Hunt syndrome?
LMN facial palsy due to varicella zoster
70
What are the features of Ramsay Hunt syndrome?
Pain
Vesicles in ipsilateral ear, hard palate, anterior tongue
Deafness/vertigo/other CN features
71
If the forehead is spared in a CN7 pathology, where is the lesion?
UMN lesion
72
What is Weber's test assessing for?
Sensorineural and conductive hearing loss
73
What is Rinne's test assessing for?
Conductive hearing loss
74
What is a Rinne's positive sign?
Air is louder than bony conduction
75
What is the diagnosis:
Weber's: lateralises to the left
Rinne's L: negative
Rinne's R: positive
Left conductive hearing loss
76
What is the diagnosis:
Weber's: lateralises to the right
Rinne's L: negative
Rinne's R: positive
Mixed hearing loss
77
What is the diagnosis:
Weber's: lateralises to the left
Rinne's L: positive
Rinne's R: positive
Right sensorineural hearing loss
78
What is the diagnosis:
Weber's: no lateralisation
Rinne's L: positive
Rinne's R: positive
No abnormality
79
What are the causes of conductive hearing loss?
```
EAM:
-wax
-foreign body
-otitis externa
Drum:
-perforation
Middle ear:
-acute/serous otitis media
Oval window:
-otosclerosis
```
80
What are the causes of sensorineural hearing loss?
```
Inflammation:
-meningitis
-MMR
Tumour:
-acoustic neuroma (neurofibromatosis T2)
Ototoxic drugs:
-aminoglycoside ABx
-aspirin overdose
-loop diuretics
Trauma
Meniere's disease
```
81
What are the inheritance patterns for neurofibromatosis type 1 and 2?
Autosomal dominant
82
What is the gene and chromosome affected in NF1?
```
NF1
Chr 17 (neurofibromatosis: 17 letters)
```
83
What is the gene and chromosome affected in NF2?
NF2
| Chr 22
84
What is the presentation of NF1?
```
Cafe-au-lait spots
Freckling in skin folds
Neurofibromas
Lisch nodules
spinal scoliosis
Short stature
Mild intellectual disability
```
85
What is the presentation of NF2?
Sensorineural hearing loss
Bilateral acoustic neuromas
Symptomatic at the age of 20
Possible tinnitus/vertigo
86
What can you do/look at to assess CN IX and X?
```
Soft palate and uvula
Gag reflex
Cough
Swallow
Assess speech quality and hoarseness
```
87
What two muscles are supplied by CN XI?
Sternocleidomastoid
| Trapezius
88
What are you looking for when assessing CN XII?
Wasting
Fasciculations
Deviation of the tongue
Power of the tongue
89
What is a bulbar palsy?
Lesion affecting the medulla oblongata and its associated cranial nerves IX-XII
90
What are the clinical features of a bulbar palsy?
```
Absent gag reflex
Wasting/fasciculation of the tongue
Absent palatal movement
Absent/normal jaw jerk
Nasal speech
Normal emotions
Signs of underlying cause eg. limb fasciculations
```
(UMN signs)
91
What is a pseudobulbar palsy?
Lesion affecting the UMN supplying the medulla oblongata
92
What are the clinical features of a pseudobulbar palsy?
```
Increased/normal gag reflex
Spastic tongue
Absent palatal movement
Increased jaw jerk
Monotonous, slurred, high-pitched Donald Duck dysarthria
Labile emotions
Bilateral UMN limb signs
```
(LMN signs)
93
What are some causes of a bulbar palsy?
MND
| Guillain-Barre
94
What are some causes of a pseudobulbar palsy?
Stroke
MND
MS
95
A 24 year old woman presents to her GP with a red painful eye with blurry vision. She has noticed a lot of clear discharge coming from her eye. She has otherwise been well, apart from some recent diarrhoea. What is the most likely diagnosis?
```
A. Viral conjunctivitis
B. Bacterial conjunctivitis
C. Anterior uveitis
D. Posterior uveitis
E. Closed angle glaucoma
```
C. Anterior uveitis
Firstly, because this is not an acute presentation (she’s presented to her GP), we can rule out closed angle glaucoma.
Posterior uveitis and viral conjunctivitis are usually painless making them unlikely.
Although bacterial conjunctivitis is painful, it normally gives thick muculopurent discharge.
The clear discharge is most likely to be increased lacrimation, which is in keeping with anterior uveitis.
96
A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:
```
A. Internuclear ophthalmoplegia
B. Anhidrosis, miosis and ptosis
C. Down and out pupil
D. Mydriasis
E. Down and out pupil with mydriasis
```
C. Down and out pupil
The palsy is why the patient has diplopia. The length dependent sensory neuropathy is indicative of diabetes, and if the peripheral sensory nerves are affected then a cranial nerve may be affected.
DM can cause a medical palsy, so the oculomotor nerve is affected first before the sympathetic, therefore will see down and out pupil. Wont see mydriasis yet until parasympathetic is affected, ruling out D and E.
A is not associated with DM, and B is describing Horner’s.
97
A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?
```
A. Stroke
B. Bell’s Palsy
C. MS
D. Ramsay Hunt syndrome
E. Horner’s
```
B. Bell’s Palsy
As the patient is young a stroke is very unlikely, given she cannot wrinkle her forehead. This also makes MS unlikely.
MS also unlikely as there is an infective cause, but not Ramsay Hunt since this would normally be varicella zoster, not HSV1.
98
A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?
```
A. Meningitis
B. Otitis media
C. Foreign body
D. Meniere's disease
E. Neurofibromatosis type 2
```
B. Otitis media
As Rinne's test is negative in the left ear we know it is a conductive problem in left ear, further supported by fact Weber’s lateralises to the left as well. This rules out meningitis and NF2 as they are a sensorineural problem, as is Meniere’s – Meniere’s is triad of sensorineural hearing loss, vertigo and tinnitus.
the fact they had a cold earlier points more towards B as this is an inner ear infection.
99
A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?
```
A. Stroke
B. Parkinson’s
C. Motor neuron disease
D. MS
E. Achalasia
```
C. Motor neuron disease
With this question the patient is old, making MS and achalasia unlikely – this is further supported by the LMN signs.
Stroke and Parkinson’s would give UMN signs, although both can cause dysphagia. The jaw jerk is normal suggesting that CNV is not affected, as is the case with a bulbar palsy.
100
A 66 year old woman presents with left sided upper and lower facial weakness as well as vertigo, which has worsened over the past few days. She is also suffering from a burning sensation over the left side of her face . This morning, she noticed a new rash in her left ear. On examination, clusters of vesicles on an erythematous base are noted in the patient’s left ear.
A. Bells Palsy
B. Ramsay Hunt syndrome
C. NF T2
D. Stroke
B. Ramsay Hunt syndrome
