Neurology

Question 1

Define Multiple Sclerosis

Answer 1

MS is an autoimmune disorder which results in the loss of myelin from neurons of the central nervous system

Question 2

List the 6 main symptoms of multiple sclerosis.

How do these symptoms tend to present themselves?

Answer 2

Blurred vision (Usually in one eye, described as looking through petroleum jelly, may have pain moving eye and color discrimination)

Fatigue

Difficulty walking

Parathesia in different parts of the body (tingling or numbness)

Muscle stiffness and spasms

Symptoms usually last for over 48 hours, and are often asymetric, involving one side of the body or one limb (bilateral can occur however)

Parathesia can be band-like or hemi-band like which is indicative of a spinal cord lesion

Question 3

What are the 4 main risk factors for multiple sclerosis?

Answer 3

Female

Age (20-40)

Family history of MS

Northern latitude (North hemisphere regions)

Question 4

Detection of fibrilations can be detected using which medical investigation?

Answer 4

Electromyography (EMG)

Question 5

What findings can be found in patients with multiple sclerosis on an EMG?

Answer 5

EMG shows no abnormalities as it is a condition affecting the CNS

Question 6

What imaging test should be performed in patients suspected of multiple sclerosis?

Answer 6

MRI

Question 7

List 6 investigations that should be performed in patiens suspected of multiple sclerosis.

Answer 7

MRI- Brain

MRI - Spinal cord

FBC (to rule out differentials and concurrent illness)

Comprehensive metabolic panel (Calcium, billirubin, glucose, pottasium ect)

TSH blood test

Vitamin B12 blood test

Question 8

What are 2 other investigations to consider in patients suspected of MS and when would you justify using them?

Answer 8

Evoked potentials (When MRI is contraindicted)

CSF evaluation (When all non-invasive investigations have been pursued due to its invasiveness)

Question 9

What CSF evaluation finding supports the diagnosis of MS?

Answer 9

Elevation in IgG and IgG synthesis rates

Oligoclonal bands

Question 10

What MRI findings are indicative of MS?

Answer 10

MRI Brain: Lesions involving the corpus callosum (e.g. finger-like projections perpendicular to corpus callosum)

MRI spinal cord: Lesions (appearing white) usually affecting the cervical spinal cord

Question 11

What treatment should be given to a patient with MS suffering from an acute relapse episode?

Answer 11

Glucocorticoid (Methylprednisolone) IV administered

Question 12

For patients with relapsing-remitting multiple sclerosis, what is the first line ongoing treatment option?

Answer 12

Immunomodulators (e.g. Interferon beta 1a or 1b)

Question 13

Define Aparaxia

Answer 13

Disorder of skilled movement. Patients are not paretic but have lost information about how to perform skilled movements (e.g. tie up shoelace or button up shirt)

Question 14

What brain lesion areas tend to result in the presentation of aparaxia?

Answer 14

Inferior parietal lobe

Frontal lobe (Supplementary and premotor areas)

Question 15

What are the two most common causes of aparaxia?

Answer 15

Stroke

Dementia

Question 16

Define Motor Neurone Disease (MND).

What is an alternative name for MND?

Answer 16

Spectrum of proggresive neurodegenrative disorders affecting the motor system.

AKA Ayomyotrphic Lateral Sclerosis (ALS)

Question 17

List 6 upper motor neurone signs and 5 lower motor neurone signs of multiple sclerosis

Answer 17

Upper:

Spasticity (increased tone) of limbs and tongue

Brisk limbs and jaw reflexes

Babinski’s sign

Loss of dexterity

Dysarthria (difficulty speaking)

Dysphagia (difficulty swallowing)

Lower:

Weakness

Nasal speech

Toungue fasciculations and wasting

Muscle wasting

Question 18

Define Parkinson’s Disease.

Answer 18

A neurological disease characterised by uncontrollabale movement caused by degenrative changes in dopaminergic neurones of the substania nigra.

Question 19

List 5 main symptoms and signs of Parkinson’s Disease.

Answer 19

Bradykinesia (Slowed movement)

Akinesia (Difficulty initiation movement)

Hypomimic face

Rigidity

Tremor at rest (Pin rolling tremor) [Usually starting in one hand and then spreads to other parts of the body overtime]

Question 20

How is Parkinson’s Disease diagnosed?

Answer 20

Condition is diagnosed clinically and investigations are usually not required

Question 21

What are the 5 first line treatment options for patients with Parkinson’s Disease?

Answer 21

Carvidopa/Levodopa

Dopamine agonists

MAO-B Inhbitors

Amantidine (increases dopamine release and reduced re-uptake)

Trihexyphenidyl (antispasmodic drug)

Question 22

What 2 non-pharmacological treatment options are also offered to patients with Parkinson’s Disease?

Answer 22

Exercise

Physiotherapy

Question 23

Define Huntington’s Disease.

Answer 23

Genetic neurodegenerative disorder characterised by degeneration of GABAergic neurones in the striatum, cuadate and putamen

Question 24

What are the main signs and symptoms of Huntington’s Disease?

Answer 24

Cognitive, Mood and Physical manifestations

Motor: Choreic movements, Dysphagia, Unsteady gait, Saccadic eye movements, Motor impersistence (e.g. cant stick toungue out and hold it for more than 10 seconds).

Mood: Deppresion, Anxiety

Cognitive: Loss of coordination (e.g. dropping things, car accidents), Impaired concentration, changes in personal habits and hygeine

Question 25

What is the 1st line treatment option and other treatment options for patients with Huntington's Disease? (3)

Answer 25

First line: Counselling Antideppresants Anxiolytics

Question 26

Define Ballism and the most common cause.

Answer 26

Sudden uncontrollable fling of the extremeties. Cause is due to damage to the subthalamic nuclei (e.g. stroke)

Question 27

How does ballism tend to present itself?

Answer 27

Symptoms occur contralaterally (usually hemiballismus)

Question 28

List 5 main signs of a cerebellar dysfunction

Answer 28

**Ataxia** (Disorder affecting balance, coordination and speech): E.g. Wide-based 'drunken' gait. **Dysmetria** (Inappropriate force and distance for target-directed movements): E.g. Intending to grab a cup but instead knock it over. **Intention tremor**: Increasingly oscillatory trajectory of a limb in a target-directed movement (nose-finger tracking). **Dysdiadochokinesia**: Inability to perform rapidly alternating movements (rapidly pronating and supinating hands and forearms) **Scanning speech** (Impaired coordination of speech muscles)

Question 29

What are the 4 main types of haemorrage?

Answer 29

Extradural Subdural Subarahnoid Intracerebral

Question 30

How does the timing of clinical manifestations of extradural and subdural haemorrhages differ from eachother?

Answer 30

Extradural: Rapid due to arterial high pressure Subdural: Delayed due to low venous pressure

Question 31

List the 5 main risk factors for stroke.

Answer 31

Age Smoking Hypertension Cardiac disease Diabetes mellitus

Question 32

Stroke symptoms differ depending on which cerebral perfusion fields are affected. What symptoms indicate that the **anterior cerebral artery** is affected?

Answer 32

Paralysis of contralateral structures (Legs more than the arms) Abulia (Disturbance of intellect, executive function and judgement) Loss of appropriate social behaviour

Question 33

Stroke symptoms differ depending on which cerebral perfusion fields are affected. What 4 main symptoms indicate that the middle cerebral artery is affected?

Answer 33

Contralateral hemiplegia (Arms \> legs) Contralateral hemisensory deficits Hemianopia Aphasia (Indicative of left-sided lesion)

Question 34

Stroke symptoms differ depending on which cerebral perfusion fields are affected. What symptoms indicate that the posterior cerebral artery is affected?

Answer 34

Homonymous hemianopia Visual agnosia

Question 35

What visual symptom is indicative of a intracerebral haemorrhage having brainstem involvement?

Answer 35

Dipoplia

Question 36

Difference between aphasia and dysphasia?

Answer 36

Aphasia is the medical term for full loss of language, while dysphasia stands for partial loss of language

Question 37

Photophobia oftens presents with which type of intracerebral haemorrhage?

Answer 37

Spontaneous intracerebral haemorrhage (non-traumatic haemorrhages e.g. burst aneurysms)

Question 38

Describe the two main types of headache that often presents in patients with intra-cerebral haemorrhage?

Answer 38

1) Insidious headache increasing in intensity overtime (more common in ICH than ischaemic stroke) 2) Thunderclap headache (sudden, severe headache that reaches maximum intensity upon onset)

Question 39

Thunderclap headaches in ICH patients tends to often indicate which type of ICH?

Answer 39

Subarachnoid haemorrhage

Question 40

Patients suspected of having a stroke and presentation of ataxia is indicative that which brain structure is involved?

Answer 40

Cerebellum

Question 41

Coma is most likely to present in stroke patients with haemorrhage affecting which brain structure?

Answer 41

Brainstem

Question 42

List 5 factors which increase risk of spontaneous ICH

Answer 42

**Hypertension** Age Anticoagulants Family history of ICH Heavy alcohol, amphetamine,methamphetamine or cocaine use

Question 43

What are the key characteristics of a tension headache?

Answer 43

Generalised bilateral head pain (Not pulsatile in nature) Often in frontal and occipital regions Often described as a dull pain Pain described as a tight band around head

Question 44

What are 6 red flag characteristics of headaches that should be explored in a history?

Answer 44

**Onset:** Thunderclap, acute (hours or days) subacute (days or weeks) **Menningism**: Photophobia, phonophobia, neck stiffness, vomitting **Systemic symptoms:** Fever, Rash, Weight loss **Neurological symptoms or focal signs:** Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema **Orthostatic:** Better lying down **Strictly unilateral**

Question 45

What are the 4 main signs/symptoms of a 3rd nerve palsy?

Answer 45

Ptosis Dipoplia Strabismus (eye misalignment) [Down and out] Enlarged pupil that does not react to light

Question 46

What are the common causes of a third nerve palsy? (7)

Answer 46

Microvascular complications: e.g. diabetes, hypertension Infection (e.g. syphillis, HIV, Lyme disease) Vaccination (MMR, influenza) Trauma Compression from a neoplasm: e.g. brain tumor Post-neurosurgery Anuerysm

Question 47

What are the main signs/symptoms of Horner Sydnrome?

Answer 47

Miosis (Constricted pupil) Ptosis (droopy eyelid) Anhidrosis (Failure to sweat)

Question 48

What are some of the main causes of Horner's syndrome? (7)

Answer 48

Congenital causes: e.g. damage to brachial plexus during childbirth, aorta defects Neuroblastoma (For new onset Horner's Syndrome in children) Adults: Apical lung tumor (or other tumors) Trauma and surgery Demyelinating diseases (e.g. MS) Aneurysm (Especially if ispilateral headache or vision loss) Carotid dissection (Especially if ipsilaterla headache or vision loss)

Question 49

What are the 3 main signs of a subarachnoid haemorrhage? What are 3 other common signs of a subarachnoid haemorrhage?

Answer 49

Thunderclap headache (Tends to peak within 1-5 minutes and lasts for more than an hour) Deppresed level or loss of consciousness (2/3rds in which half fall into a coma) [Biggest predictor of prognosis] Neck stiffness and muscle ache (alongside onset of headache) Other common signs: Photophobia, vomitting, confusion

Question 50

What main investigations should be conducted in a patient suspected of a SAH?

Answer 50

Investigations: **1) CT scan asap (ALWAYS DO FOR THUNDERCLAP)** 2) FBC (Leukocytosis associated with SAH) 3) Serum electrolytes (50% have hyponatraemia) 4) Clotting profile 5) Troponin 1 (elevated in absence of coronary artery disease) 6) Serum glucose (Hyperglycaemia ofen present with acute brain injury) 7) **ECG (arrytmia and iscehamic changes, prolonged QT, ST/T-wave abnormalities)**

Question 51

What other investigation should be considered in a patient suspected of SAH and when should it be performed?

Answer 51

Lumbar puncture (12 hours from onset of symptoms for xanthochromia to appear) Perform if CT scan is negative but high clincal suspicion of SAH. Xanothochromia and RBC

Question 52

What is the management plan for a patient with a SAH?

Answer 52

**Neuro or ICU referal** **Nimodipine** (increases blood flow to injured brain tissue) **BP control and monitoring** (e.g. isotonic saline solution, stop antihypertensives unless extreme hypertension) **Monitor pupil size** (Bilateral, fixed and dilated pupils is a poor prognosis)