Neurological Investigations

Question 1

Where is CSF produced?

Answer 1

Choroid plexus in the lateral ventricles (3rd & 4th ventricle)

Question 2

Where does CSF circulate?
How much volume?

Answer 2

In the subarachnoid space and around the brain and spinal cord
125-150ml

Question 3

Youve been asked to take a lumbar puncture.
At what level does the spinal cord end?
At what level should you take the LP?
What landmarks are you using to take it?

Answer 3

Spinal cord ends at L1/L2 in adults
LP is taken at L3/L4 or L4/L5.

Landmarks are
Tuffier’s line or intercrestal line between the two iliac crests. This line crosses the spine at L4/L5 (moreso L4)
ASIS at L4

Question 4

What are the indications for an LP that are both diagnostic and therapeutic? (2)

Answer 4

Normal pressure hydrocephalus
Idiopathic Intracranial HTN

Question 5

Give 6 diagnostic and 4 therapeutic indications for an LP

Answer 5

Diagnostic:
CNS infection
SAH - Xanthochromia
CNS vasculitis
MS - Multiple sclerosis
GBS (Guillian Barre)
Paraneoplastic syndrome

Therapeutic:
Intrathecal chemo
spinal anaesthesia

Both: Normal pressure hydrocephalus
Idiopathic Intracranial HTN

Question 6

Give 4 contraindications for taking an LP

Answer 6

1) Raised ICP
2) Coagulopathy/bleeding diathesis (thrombocytopenia, coag deficiency, anti-coag use)
3) Suspected spinal epidural abscess
4) infection at puncture site (cellulitis)

Question 7

A patient has suspected raised ICP and your consultant has asked you to take an LP if possible. How will you check?

Answer 7

Fundoscopy - Papilloedema
CT - midline shift, space occupying lesion, intracranial haemorrhage

Question 8

Xanthochromia can appear in 2 scenarios. What are they?

Answer 8

SAH
Guillian Barre

Question 9

What are the components of CSF analysis?

Answer 9

Appearance
RCC
WCC
Protein
Glucose
Presence of organisms (gram stain and culture)

Question 10

CSF is typically clear, colourless, and almost acellular. What is the expected appearance of the CSF in the following scenarios:
Bacterial meningitis:
TB meningitis:
SAH:
Traumatic tap:
Viral meningitis:
Multiple Sclerosis:
Guillian-Barre:

Answer 10

Bacterial meningitis: Can be clear, cloudy, turbid or purulant => many possible
TB meningitis: often very cloudy, but can be clear
SAH: Yellow/pink discolouration (xanthochromia)
Traumatic tap: blood-stained
Viral meningitis: clear
Multiple Sclerosis: clear
Guillian-Barre: usually clear, but xanthochromia if very elevated protein

Question 11

CSF is typically clear, colourless, and almost acellular. Do you expect to see raised WCC in the following scenarios? If so, indicate the predominant cell type
Bacterial meningitis:
TB meningitis:
Viral meningitis:
Fungal CNS infection:
Multiple Sclerosis:
Guillian-Barre:
SAH:

Answer 11

Bacterial meningitis: Yes - PMN
TB meningitis: Yes - PMN early, Lymphocytes late
Viral meningitis: Yes - Lymphocytes
Fungal CNS infection: Yes - Lymphocytes
Multiple Sclerosis: Maybe - Lymphocytes
Guillian-Barre: No
SAH: Yes - >1:1000RBC + occasional eosinophilia

Question 12

How would you expect the glucose and protein levels to be in the following scenarios:
Bacterial meningitis:
TB meningitis:
Viral meningitis:
Fungal CNS infection:
Multiple Sclerosis:
Guillian-Barre:
SAH:
Abscess:
Malignancy:

Answer 12

Bacterial meningitis: low glucose very high protein
TB meningitis: low glucose, high protein
Viral meningitis: Normal glucose, normal protein
Fungal CNS infection: low glucose, high protein
Multiple Sclerosis: normal glucose, high protein
Guillian-Barre: normal glucose, high protein
SAH: low glucose, high protein
Abscess: normal glucose, high protein
Malignancy: normal glucose, high protein

Question 13

CSF results come back showing oligoclonal bands. What are your ddx?

Answer 13

SAH
Guillian barre syndrome
MS
CNS lymphoma
Lyme disease
Neurosarcoid

Question 14

You suspect meningitis. What will you send the CSF for?

Answer 14

Microscopy
Culture/PCR
Gram stain

Question 15

You are performing an LP and notice it is kind of red. What are your top 3 ddx

Answer 15

Traumatic tap
SAH
Guillian barre

Question 16

What is the normal amount of RBC and WCC per microlitre of CSF?

Answer 16

both 0-5 cells/microlitre

Question 17

What is the normal serum glucose level?
What is the normal amount of glucose in CSF?

Answer 17

Normal serum is 4-6mmol/L
Normal glucose is 60-70% of the serum glucose taken at that time so about 2-4

Question 18

A 19 year old student presents to the emergency department with a 1 day history of headache, photophobia and fevers. Neurological exam
reveals no signs of focal neurology and there are no signs of raised intracranial pressure. A lumbar puncture is carried out which reveals the
following. Serum glucose is 6mmol/L.

What is the most likely diagnosis?
What additional investigations should be performed on CSF?

Answer 18

Bacterial Meningitis

CSF culture

Question 19

What are the most common organisms to cause meningitis?

Answer 19

Meningococcal meningitis (fungus)

Pneumococcal meningitis
Neisseria meningitidis
Hib
Listeria
E coli

Viral: Enteroviruses, HSV, VZV, mumps, HIV!!

Question 20

A 29 year old man presents to the emergency department at 9pm with a 1 hour history of a sudden onset severe occipital headache. He has
some mild neck stiffness on examination. CT Brain reveals no acute abnormalities. The following morning he undergoes a lumbar puncture. Serum glucose is 6 mmol/L.

What was the most likely diagnosis?
Why were 3 samples taken?

Answer 20

SAH
To ensure it wasnt a traumatic LP

Question 21

A 29 year old man presents to the emergency department at 9pm with a 1 day history of a headache. He complains of generalised myalgia
and chills. CT Brain reveals no acute abnormalities. A lumbar puncture is performed. Routine bloods show mildly elevated white cell count with lymphopaenia, with mildly elevated CRP. Serum glucose is 6 mmol/L.

What is the most likely diagnosis?

Answer 21

Traumatic LP
You can see that as more samples were taken, the results varied significantly

Question 22

If you were asked for the causes of a traumatic LP, what would you say?

Answer 22

Incorrect location
Poorly skilled physician
Incorrect positioning of patient
Movement of the patient
Anatomical variation

Question 23

A 32 year old woman presents to the emergency department. She has a 1 day history of gradual onset left upper limb weakness. She also reports an episode of painful blurred vision three months ago which resolved fully. Examination reveals reduced power and brisk reflexes in her left upper limb. Serum glucose is 6 mmol.

What is the most likely diagnosis?
What additional testing on the CSF will confirm the diagnosis?
What other tests should be performed to confirm the diagnosis?

Answer 23

Multiple sclerosis (active)

CSF analysis for oligoclonal bands

MRI brain looking for while demyelinated plaques

Question 24

A 46 year old man is brought to the emergency department. He has been complaining of headaches and fevers for several days, and became more unwell today with vomiting and confusion. He has
been living in a homeless shelter for several months, has a known diagnosis of HIV and has been non-compliant with his anti-retroviral medication. Temperature is 38.2 degrees Celsius, GCS is 13/15 and there is photophobia on examination. Serum glucose is 6 mmol/L.

What is the most likely diagnosis?

What additional testing should be performed on the CSF to confirm the diagnosis?

Answer 24

Cryptococcal meningitis (HIV made him susceptible to it)

Cryptococcal antigen test or CSF PCR. Also must rule out TB which is also a possibility in an immunocompromised patient => Acid-fast bacilli stain and culture

Question 25

What is an EEG? Give 4 indications What are you looking to interpret when looking at an EEG graph

Answer 25

Electroencephalogram measures the electrical activity of the brain over several minutes via standardized placement of electrodes. Indications: Diagnosis of patients with non-convulsive status epilepticus dx of patients with diffuse brain disease e.g. encephalopathy dx of possible epilepsy !!Distinguishing pseudoseizures from true seizures Looking for !!Periodic and epileptiform discharges (interictal, lateralised, and generalised) Slowing amplitude changes Assymmetry

Question 26

What is an EMG? Give 6 indications Give 2 clinical examples which classically use EMG in their diagnosis

Answer 26

Electromyography is the study of electricle activity in muscle fibers via controlled electrical stimulation which provokes action potentials within nerves. These action potentials are detected via surface or needle electrodes and presented as a graph Indications: 1) Radiculopathies 2) Myopathies 3) Motor neuropathies 4)!Distinguishes if abnormality is neurogenic or myopathic 5) Neuromuscular diseases (Myasthenia gravis) 6) Motor neuron disease 7) Plexopathies Clinical examples include motor neuron disease and myasthenia gravis

Question 27

What are you expecting to find on an EMG of motor neuron disease? Is this neurogenic or myopathic?

Answer 27

Features of acute and chronic denervation and reinnervation This is neurogenic because fibrillation and fasciculations with spontaneous activity is seen in motor neuron disease Extra: Acute would show fibrillation, fasciculations, and positive sharp waves Chronic would show increased amplitude and duration of action potentials with reduced interference

Question 28

What type of disease is myasthenia gravis? What are the 3 classical early signs of myasthenia gravis? What are you expecting to find on an EMG of myasthenia gravis?

Answer 28

Neuromuscular disease characterized by these 3 early features: 1) Ptosis and weakness of smile 2) Progressively worse diplopia and slurred speech (evidence of fatiguing) as day goes on 3) Reduced power in neck extenders when neck fully flexed (on chest) EMG showing progressive decline in action potential amplitude with repeated stimulation => demonstrates fatiguability

Question 29

One of the main indications of an EMG is to determine if an abnormality is neurogenic or myopathic. Explain with 3 differences

Answer 29

1) Electrical activity at rest: Myopathy has little to no spontaneous electrical activity whereas neurogenic abnormalities have spontaneous discharge with fibrillations and fasciculations. This is increased with needle insertion 2) Motor unit potential: Myopathy typically has low amplitude and shortened motor unit potentials whereas neuropathic have large amplitude and prolonged action potential 3) Interference pattern on EMG: Myopathies have full interference pattern with high frequency but low amplitude. Neuropathic ones have reduced interference => low frequency but large amplitude

Question 30

Nerve conduction studies govern both sensory and motor nerves. T or F

Answer 30

Yes

Question 31

Carpal tunnel affects what nerve?

Answer 31

Median nerve

Question 32

What are nerve conduction studies? Give 5 indications Give 2 classical clinical examples that nerve conduction studies are used for

Answer 32

Nerve conduction studies measure conduction velocities of electrical impulses through individual nerves. Indications: 1) Polyneuropathy e.g. Diabetic neuropathy, Charcot Marie tooth 2) Entrapment neuropathies e.g. Carpal tunnel 3) Guillian Barre syndrome 4) Radiculopathy 5) Motor neuron disease

Question 33

Give the 3 main pathological features to look for on nerve conduction studies including how it shows on the graph Which pathological feature is seen in polyneuropathies such as diabetic polyneuropathy Which pathological feature is commonly seen in carpal tunnel? Which pathological feature is commonly seen in Guillian barre

Answer 33

Axonal degeneration -> reduced amplitude of action potential (diabetic polyneuropathy) Demyelination -> reduced conduction velocity (GBS + CMT type 1 + Carpal tunnel) Conduction block -> Drop in amplitude between proximal and distal sites (severe carpal tunnel)

Question 34

Briefly explain what Guillian Barre syndrome is Include definition, most common sx, coarse of disease, main trigger, and most common mx for sx reduction for 5/5

Answer 34

GBS is an acute autoimmune disorder of demyelination of the peripheral nerves leading to rapidly progressing weakness, numbness, and paralysis. This typically begins with paraesthesia of the legs before ascending more proximally to the upper body and respiratory muscles. It is typically triggered by an infection and managed with IVIG.

Question 35

Nerve conduction studies are typically performed alongside which other neurological investigation?

Answer 35

EMG - electromyography

Question 36

Nerve conduction studies are often conducted along with EMG studies. What 2 indications would warrant that?

Answer 36

Radiculopathy Motor neuron disease

Question 37

What is VEP? Give 3 clinical applications of this investigation.

Answer 37

Evoked potentials measures the electrical activity of the brain in response to stimulation of specific sensory nerve pathways. Used in: Optic neuritis, acoustic neuroma, diagnosis of brainstem death!, anesthetic monitoring

Question 38

Can you use nerve conduction studies for MS? Why or why not?

Answer 38

MS causes demyelination of the CNS and not peripheral nerves => no. The peripheral version of MS is guillian barre which is done here