Neurology Flashcards
1
Q
What does this CT show?
A
Extradural haematoma
2
Q
Between which meningeal layers does a subarachnoid haemorrhage occur?
A
Between the arachnoid mater & pia mater
3
Q
Status epilepticus is pronounced after a generalised seizure has been ongoing for how long?
What is the 1st line management of status epilepticus?
~ when should it be given?
What is the 2nd line management of status epilepticus?
What is the 3rd line management of status epilepticus?
A
5 minutes
1st line: Buccal midazolam or IV lorazepam
~ given at 5 minutes
~ repeat again at 10 minutes if still ongoing
2nd line: Sodium valproate
3rd line: Anaesthesia and intubation (propofol)
4
Q
What are the 3 divisions of the trigeminal nerve & what numbers are they given? (eg V1, V2, V3)
A
V1 = ophthalmic nerve
V2 = maxillary nerve
V3 = mandibular nerve
5
Q
What area of the brain is responsible for memory storage & is usually atrophied in Alzheimers?
~ What lobe(s) are affected in Alzheimers?
What lobe(s) are affected in Frontotemporal dementia?
A
Hippocampus
~ Parietal lobe & temporal lobe
Frontal lobe & temporal lobe
6
Q
List 5 signs of an UMN lesion:
A
Muscle weakness
Hyper-reflexia
Hypertonia
Positive clonus
Positive babinski sign (big toe moves up)
7
Q
What condition does the following statement indicate a diagnosis of?
” 50y with gradual change in behaviour over past 2 years. Clear personality change & quite withdrawn “
A
Frontotemporal dementia
8
Q
What are some common triggers of trigeminal neuralgia? (5)
A
Cold
Wind
Chewing
Talking
Touching face
9
Q
If there is a lesion on the R accessory nerve, which way would the tongue deviate towards?
A
Right deviation
(The tongue deviates TOWARDS the side of the lesion)
10
Q
What drug class is used as the 1st line treatment to manage an acute migraine attack?
Give an example of a commonly used drug from this class.
A
Triptan
Sumatriptan
11
Q
Amyotrophic lateral sclerosis is a type of what disease?
List some features of this condition: (4)
What gene mutation is associated with this condition?
What is the treatment of this condition?
What type of penetrance does the disease have? - What does this mean for family members with the gene?
A
Motor neurone disease
ONLY motor symptoms!!!!!!
• Progressive muscle weakness (LMN)
• Muscle wasting (LMN)
• Hyper-reflexia (UMN)
• Spasticity (UMN)
SOD gene
NO TREATMENT
Incomplete penetrance:
~ People with the gene don’t always develop the disease so offspring may/ may not be affected
~ Environmental factors ‘switch’ the gene on - nobody knows how/ why
12
Q
What are the key clinical features in lewy body dementia? (3)
A
Fluctuating confusion throughout the day
Visual hallucinations
Parkinsonism symptoms (poor mobility, tremor)
13
Q
What is the function of the oculomotor nerve?
A
Eye movements
14
Q
Describe a cluster headache.
How long do they usually last for?
A
Sudden onset, unilateral pain behind one eye
Typically last between 15 mins - 3 hours
15
Q
Describe what you might see in the following seizures:
a) Tonic-clonic seizure
b) Myoclonic seizure
c) Absence seizure
d) Atonic seizure
A
Tonic-clonic seizure: Muscles stiffen (go rigid = tonic) before generalised jerking of limbs (clonic)
Myoclonic seizure: Sudden jerking of one limb - patient may be conscious!
Absence seizure: Patient ‘pauses’ for a few seconds before restarting activity - patient often has no recollection
Atonic seizure: Muscles suddenly loose all tone - patient falls over
16
Q
What is the function of the trigeminal nerve?
A
Motor function to muscles of mastication
Sensation of face
17
Q
There are 2 extremes of delirum. What are they called? List some symptoms seen in each: (3, 3)
A
Hyperactive delirium:
→ Aggression/ aggitation
→ Hallucinations
→ Restlessness
Hypoactive delirium:
→ Sleepiness/ fatigue
→ Withdrawn
→ Memory problems (temporary dementia)
18
Q
If someone presents with a thunderclap headache, what is the most likely diagnosis?
A
Subarachnoid haemorrhage
19
Q
What are the first 2 clinical features to show in Alzheimers disease?
A
Loss of memory
Loss of executive function
20
Q
What is the function of the vagus nerve?
A
Motor & sensory innervation to pharynx (back of throat), heart, resp tract, GIT
21
Q
What is the textbook cause of an extradural haematoma?
A
Trauma to the head, eg car crash/baseball bat to the head
22
Q
What neuropathological features would be seen on imaging of someone with Alzheimer’s disease? (2)
A
Amyloid plaques
Tau protein tangles
23
Q
What is the 1st line medication used in mild/moderate Alzheimers?
A
Donepezil
24
Q
Which cranial nerves are responsible for the afferent & efferent pathways of the corneal reflex?
A
Afferent = V1 nerve (ophthalmic)
Efferent = VII nerve (facial)
25
What is the mode of inheritance of Huntington's Disease?
~ What is the repeated gene?
Explain what **anticipation** is:
List some symptoms/ signs of huntingtons: (4)
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Autosomal **dominant**
~ CAG gene repeats
**Anticipation:** Successive generations inherit more CAG repeats in the gene → earlier onset & increased severity of the disease
* Chorea (involuntary, abnormal movements)
* Dementia (poor memory/ cognitive function)
* Personality change
* Depression/ psychosis etc
**Full penetrant** - all family members with the gene will develop the disease at some point
26
A lesion at the optic chiasm produces what visual defect?
Bitemporal hemianopia
27
If there is a lesion on the Right accessory nerve, which side would the uvula deviate towards?
Left deviation
(The uvula deviates away from the side of the lesion)
28
What is an extradural haemorrhage?
A collection of blood between the skull and the dura mater
29
Which cranial nerves are responsible for the afferent & efferent pathways of the gag reflex?
Afferent = IX nerve (glossopharyngeal)
Efferent = X nerve (vagus)
30
Name the 4 lobes of the brain.
Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
31
If a patient presents with "the worst headache they've ever had", what diagnosis is this suggestive of?
Subarachnoid haemorrhage
Commonly presents with a thunderclap headache
32
What is the management of tension headaches?
Simple analgesia: NSAIDs / paracetemol
33
What is the 1st line medication for Parkinson's disease?
What is this medication usually given with & why?
Levodopa
Co-administered with **Carbidopa** - prevents L-dopa being converted into it's active form in the systemic circulation thus more reaches the brain
34
What is the first presenting symptom of:
a) Alzheimers dementia
b) Vascular dementia
c) Lewy-body dementia
d) Fronto-temporal dementia
a) Alzheimers: Loss of recent memory
b) Vascular: Step wise decrease in ADL (language affected first)
c) Lewy-body: Fluctuating confusion & visual hallucinations (+ parkinsonism symptoms)
d) Fronto-temporal: Personality change
35
List 5 signs of an LMN lesion:
Muscle weakness
Muscle wasting
Hypo-reflexia
Hypotonia
Fasiculations
36
What is the classic triad of presenting symptoms seen in normal pressure hydrocephalus?
Dementia, urinary incontinence, gait disturbance
37
What is the 1st line medication used to treat trigeminal neurlagia?
This medication is also used in the treatment of what?
**Carbamazepine**
Epilepsy!
38
What is a subdural haematoma?
Damage to which blood vessels cause a subdural haematoma?
A collection of blood between the dura mater and arachnoid mater
Tear in the bridging veins between the cortex and dura mater
39
What is the function of the abducens nerve?
What muscle does it innervate?
Eye movements
Lateral rectus muscle
40
What type of hallucinations are common in lewy body dementia?
Visual hallucinations:
→ animals in the house
→ faces in the wallpaper
41
Name the main neurones involved in the reward pathway & state which NT they release
How is activation of the reward pathway involved in addiction?
VTA neurones → nucleus accumbens → pre-frontal cortex
~ release dopamine
Release of dopamine creates feeling of pleasure → psychological cravings of this feeling then occur which result in dependence
\*\* VTA = Ventral tegmental area
42
Define what dementia is:
Dementia is a syndrome (a collection of different symptoms) associated with an progressive decline in brain functioning
43
What drug class is used as the 1st line treatment to manage an acute migraine attack?
Give an example of a commonly used drug from this class.
Triptans
Sumatriptan
44
What is often the first clinical feature seen in vascular dementia?
Aphasia (problems with communication)
\* Memory is often spared until advanced disease
45
What is the 1st line medication used to treat trigeminal neurlagia?
Carbamazepine
46
Which anticonvulsant should be avoided in women of child bearing age & why?
Valproic acid - it causes neural tube defects
47
To be diagnosed with dementia, what type of imaging is required?
None. Dementia is a ***clinical diagnosis*** - imaging is done occasionally to confirm the diagnosis
48
Which vessels remove deoxygenated blood from the brain?
Where do these veins drain into?
Bridging veins
Drain into venous sinuses → internal jugular vein
49
Which cranial nerves are responsible for the afferent & efferent pathways of the pupillary reflex?
Afferent = II nerve (optic)
Efferent = III nerve (oculomotor)
50
What is a common trigger of tension headaches?
Stress
51
What is found within the subarachnoid space?
CSF (cerebralspinal fluid)
52
Name the 3 meninges from the skull inwards.
Dura mater (underneath skull)
Arachnoid mater
Pia mater
53
What type of headache is associated with autonomic symptoms? (Ptosis, miosis, lacrimation, nasal congestion)
Cluster headache
54
What is a subdural haematoma?
Damage to which blood vessels cause a subdural haematoma?
A collection of blood between the dura mater and arachnoid mater
Tear in the bridging veins between the cortex and dura mater
55
What are the 2 commonest causes of a subarachnoid haemorrhage?
Ruptured aneurysm, commonly in the cirle of willis
Severe head injury
56
What type of dementia is characterised by a step wise decline?
Vascular dementia
57
What is the maximum score of a GCS?
Explain each point in the GCS: (6 5 4, MOVE)
~ Eyes
~ Verbal response
~ Motor response
15/15
**Motor response:**
6 = Obeys commands
5 = Localised to pain
4 = Normal flexion
3 = Abnormal flexion
2 = Extends
1 = Nothing
**Verbal response:**
5 = Orientated
4 = Confused conversation
3 = Inappropriate words
2 = Incomprehensible sounds
1 = Nothing
**Eyes:**
4 = Spontaneously opens
3 = Opens to speech
2 = Opens to pain
1 = Nothing
58
What is the treatment of mild-moderate Alzheimers disease? (Drug & drug class)
~ Name a common S/E of this.
What is the treatment of severe Alzheimers disease/ if previous treatment has failed?
What is the treatment of Vascular dementia?
What is the treatment of Lewy-Body dementia? (Drug & drug class)
~ Name a common S/E of this.
What is the treatment of Fronto-temporal dementia?
Anticholinesterase inhibitors: **donepezil**
S/E = GI upset (nausea, vomiting, diarrhoea)
***Memantine***
Management of underlying vascular risk factors
Anticholinesterase inhibitors: **donepezil**
S/E = GI upset (nausea, vomiting, diarrhoea)
No current treatment..
59
What is expressive dysphasia?
Damage to which area of the brain causes expressive dysphasia?
When someone has comprehension of language (they know what they want to say) but they are unable to physically say the words
Broca's area
60
What is the 1st line treatment of **generalised** **seizures**?
What is the 1st line treatment of **focal (partial) seizures?**
What is the treatment of **absence seizures**?
**Generalised seizures:** Sodium valproate (lamotrigine for females)
**Focal seizures:** Lamotrigine
**Absence seizures:** Ethosuximide
61
What muscles does the oculomotor nerve innervate? (7)
Superior rectus muscle
Inferior rectus muscle
Medial rectus muscle
Inferior oblique muscle
Leveator palpebrae superioris muscle (eyelid)
Ciliary muscle (accomodation of pupils)
Constrictor pupillae (pupil size)
62
What type of dementia is most common in the under 65's age group?
Alcohol related brain damage (ARBD)
63
What are the 3 pathological features seen in the brains of patients with Alzheimers disease?
Amyloid plaques
Tau protein tangles
Reduced Ach
64
A 65 year old man with diabetes has developed painful peripheral diabetic neuropathy.
Name a medication & it's drug class, used as 1st line in treating this.
Amitriptylline - tricyclic antidepressant
65
What is the function of the vestibulocochlear nerve?
Vestibular = hearing
Cochlear = balance
66
What is the function of the olfactory nerve?
Sense of smell
67
**Erb's palsy** results in damage to what nerves of the brachial plexus?
What obstetric emergency can result in **Erb's palsy?**
**C5 & C6**
Shoulder dystocia
68
What is the typical presentation of a subdural haematoma? (5)
Older person had a fall days-weeks ago
Progressive headache
Nausea / vomiting
Confusion
Reduced GCS
69
What is the management of an acute cluster headache attack?
100% oxygen through a mask
70
What is the classic traid of clinical features seen in Wernicke's encephalopathy?
Ataxia (lack of coordination of movements)
Ophthalmoplegia (paralysis of the eye muscles)
Encephalopathy (brain damage)
71
What is the typical presentation of trigeminal neuralgia?
Recurrent, short episodes of severe stabbing pain, affecting one side of the face, in the trigeminal nerve distribution (usually V2 / V3)
72
Name all of the 12 pairs of cranial nerves and state their numbers.
I = olfactory nerve
II = optic nerve
III = oculomotor nerve
IV = trochlear nerve
V = trigeminal nerve
→ V1 = ophthalmic nerve
→ V2 = maxillary nevre
→ V3 = mandibular nerve
VI = abducens nerve
VII = facial nerve
VIII = vestibulocochlear nerve
IX = glossopharyngeal nerve
X = vagus nerve
XI = accessory nerve
XII = hypoglossal nerve
73
An extradural haemorrhage is commonly caused by a tear in which artery?
A # in which part of the skull usually causes this tear?
Middle meningeal artery
A # of the pterion - the pterion is weakest part of the skull & lies above the middle meningeal artery
74
How long does a migraine attack usually last for?
4 - 72h
75
What is the definition of epilepsy?
State the difference between generalised and partial (focal) seizures:
State whether the following types of epilepsy are generalised or partial:
a) tonic-clonic
b) simple partial
c) complex partial
d) absence seizures
e) myoclonic seizures
f) secondary generalised
g) tonic seizures
h) atonic seizures
i) clonic seizures
Epilepsy - More than 1 unprovoked seizure
Generalised seizures: electrical activity spreads across both hemispheres of brain
Partial (focal) seizures: electrical activity only involves one hemisphere/ lobe
* *a) tonic-clonic:** generalised seizure
* *b) simple partial:** partial seizure
* *c) complex partial:** partial seizure
* *d) absence seizures:** generalised seizure
* *e) myoclonic seizure:** generalised seizure
* *f) secondary generalised:** partial seizure
* *g) tonic seizure:** generalised seizure
* *h) atonic seizure:** generalised seizure
* *i) clonic seizure:** generalised seizure
76
What are the common symptoms of a migraine? (5)
Unilateral, throbbing headache that's aggravated by movement
Photophobia (light makes it worse)
Phonophobia (loud noises make it worse)
Nausea / vomiting
+/- Aura
77
In which age group is a subdural haematoma most common?
What is the most common cause of a subdural haematoma?
Older population
Common cause is a minor head injury
78
List the 5 most prevelant types of dementia:
Alzheimers disease
Vascular dementia
Lewy body dementia
Mixed dementia (when someone has a mixture of 2 dementia's)
Frontotemporal dementia
79
List the triad of symptoms that Parkinsons Disease presents with.
Bradykinesia
Tremor (pin-rolling)
Rigidity (cog-wheel)
80
What is the classic triad of symptoms seen in normal pressure hydrocephalus?
Urinary incontinence
Dementia
Gait abnormality
81
Which lobes of the brain are usually affected first in Alzheimers disease?
Parietal & temporal lobes
82
What is the function of the optic nerve?
Vision
83
What does this CT show?
Subdural haematoma
84
What is the function of the facial nerve? (3)
Supplies muscles of facial expression
Taste to anterior 2/3 of tongue
Innervates submandibular & sublingual glands
85
What are 2 common triggers of cluster headaches?
Smoking
Alcohol
86
What is the function of the accessory nerve?
Innervates trapezius & sternocleidomastoid muscles
87
What are common signs of raised ICP? (4)
Headache that is worse in the morning & when bending over/coughing
Headache that is relieved by lying down
Papillodema
Vomiting
88
What are some common triggers for a migraine? (5)
Stress
Combined contraceptive pill
Chocolate
Sleep deprivation
Changes in the weather
89
What is a common presentation of a cluster headache? (6)
Male with sudden onset, severe pain, behind one eye
Associated with:
~ watery, bloodshot eye
~ lacrimation
~ ptosis
~ miosis
~ runny nose (rhinorrhea)
90
What investigation is **essential** in order to diagnose meningitis in children?
~ What would be an absolute contraindictation to this?
**Lumbar puncture**
~ signs of raised ICP
91
Describe a cluster headache.
How long do they usually last for?
Sudden onset, unilateral pain behind one eye
Typically last between 15 mins - 3 hours
92
What drug class is used for the treatment of Alzheimers disease & Lewy Body dementia?
Give an example of a medication from this class.
Acetylcholinesterase inhibitors
Donepezil
93
What is the function of the glossopharyngeal nerve? (3)
Taste to posterior 1/3 of tongue
Sensation from pharynx & tonsils
Movement of throat muscles (stylopharyngeus muscles)
94
What is the function of the trochlear nerve?
Which muscle does it innervate?
Eye movement
Superior oblique muscle
95
What is the typical presentation of someone with an extradural haemorrhage? (symptoms)
Head trauma +/- unconsciousness followed by lucid period (as the blood is pooling)
Progressive headache
Nausea / vomiting
Decreasing GCS
96
How might someone describe a tension headache?
Bilateral, non-pulsatile headache
"Feels like a tight band around my forehead"
97
Describe what nociceptive pain is:
Describe what neuropathic pain is:
Note whether they have a protective function or not.
Nociceptive pain = pain when there is tissue injury or illness (eg when you cut yourself)
~ has a protective function (the pain causes you to stop whatever is causing the pain)
Neuropathic pain = pain caused by nervous system damage / abnormality
~ no protective function, often occurs long after there has been trauma!
98
What is receptive dysphasia?
Damage to which area of the brain results in receptive dysphasia?
When someone is unable to comprehend language but is able to physically say words (as a result they often say things that don't make sense)
Wernicke's area
99
What is the function of the hypoglossal nerve?
Movement of the tongue
100
What *classical* position will the eyes fall into if there is a CN III palsy?
What other things may you notice in the affected eye? (2)
‘Down and out’ position
1. Ptosis
2. Dilated pupil
101
Which nerve is responsible for the **afferent** pathway of the pupillary reflex?
Which nerve is responsible for the **efferent** pathway of the pupillary reflex?
**Afferent:** Optic nerve (CN II)
**Efferent:** Occulomotor nerve (CN III)
102
What 3 branches does the **trigeminal nerve (CN V)** split into?
**V1:** ophthalmic nerve
**V2:** maxillary nerve
**V3:** mandibular nerve
103
List some of the symptoms associated with **Bells Palsy: (5)**
* Unilateral droopy face
* Auricular pain
* Decreased taste
* Hypersensitivity to sounds
* _Dry eye_
104
Should you be worried if someone with a suspected bells palsy can raise their eyebrows? - why?
YES
If the eyebrows can be raised then this suggests an UML (eg, stroke)
105
If someone with a suspected bells palsy can raise their eyebrows, what condition MUST you rule out?!
STROKE
106
The triad of: **vertigo**, **unilateral hearing loss and tinnitus** suggest which condition?
Vestibular schwannoma (tumour of the vestibular nerve)
107
What type of NT is GABA?
What type of NT is Glutamate?
* *GABA:** inhibitory NT
* *Glutamate:** excitatory NT
108
What is the 1st line pharmacological management of tonic-clonic seizures? (aka, *grand mal seizures)*
Which population group may this medicine be avoided in? - *why?*
*~* which medication would be 1st line in this group of people?
Sodium valproate
Women of child bearing age - it can cause neural tube defects
~ lamotrigine
109
What is the 1st line pharmacological management of simple partial seizures? (aka, *focal seizures)*
Lamotrigine
110
What is the 1st line pharmacological management of frontal lobe seizures? (*a type of focal seizure)*
Lamotrigine
111
In general terms, what pharmacological management is 1st line in males/females for:
~ Generalised seizures
~ Focal (partial) seizures
**Generalised:** *males -* sodium valproate, *females -* lamotrigine
**Focal:** *males & females -* lamotrigine
112
If all investigations are normal, how long after 1 seizure can you not drive for?
6 months (normal car)
5 years (HGV)
113
Damage to which cranial nerve results in **bells palsy?**
CN VII (facial nerve)
114
**_Bilateral_** **vestibular schwannomas** are usually seen in which underlying **genetic condition**?
~ what is this condition?
**Neurofibromatosis type 2**
~ a genetic condition that causes tumours (usually benign) to grow along the nerves
115
A 66y/o woman states that during the past 6 months she has had several episodes of a **sharp, shooting 'electric shock' like pain** on the left side of her **face**, which occur when she is combing her hair.
What is the most likely diagnosis?
What is the management of this condition?
**Trigeminal neuralgia** (*electric shock like pain, think TN!!)*
Carbemazepine
116
A **mid-shaft humeral fracture** is associated with **which nerve** injury?
Radial nerve
117
In the **GCS** calculation, how many points are awarded for:
1. Motor
2. Verbal
3. Eye opening
1. Motor: **6**
2. Verbal: **5**
3. Eye opening: **4**
* 654 MoVE*
118
A stroke involving the **anterior cerebral artery** would cause what associated effects? (1)
**Contralateral** hemiparesis (**weakness**) + **sensory** **loss** affecting **LOWER** body (legs) \> upper body (arms)
119
Explain the visual field defects in **homonymous hemianopia (**eg, caused by a defect in the L side of the brain)**:**
Loss of vision in L eye in NASAL field
Loss of vision in R eye in TEMPORAL field
120
A stroke involving the **middle cerebral artery** would cause what associated effects? (3)
* **Contralateral** hemiparesis (**weakness**) + **sensory** **loss** affecting **UPPER** body (arms) \> lower body (legs)
* Contralateral **homonymous hemianopia**
* **Aphasia** (problems with speech)
121
A stroke involving the **basilar artery** would cause what associated effects? (1)
Locked-in syndrome
122
Locked-in syndrome can be caused by a stroke involving which artery?
The **basilar artery**
123
A stroke involving the **posterior cerebral artery** would cause what associated effects? (2)
* Contralateral **homonymous hemianopia** ***_with macular sparing_***
* **Visual agnosia** (inability to recognise visually presented objects)
124
A 61y/o female presents with sudden onset **weakness** in her **right lower leg**. She had a similar episode 2 days ago but these symptoms resolved within an hour. She can **speak well** and **fully understands** what you tell her, but there is **decreased touch sensation on the right leg**.
PMH: T2DM, hypertension, hypercholesterolaemia
A CT scan at 12 hours showed **hypo-attenuation** in a region of the brain.
**Which artery** is most likely to be **occluded** to cause this presentation? (*be specific, include the side of the brain*)
**Left anterior cerebral artery**
125
EVERYONE that presents with symptoms of a **stroke** should get which **investigation**?
Why is this?
**CT head**
To determine whether they had an **ischaemic** stroke OR a **haemorrhagic** stroke
126
A patient presents to ED with left sided weakness and slurred speech. A CT head reveals the patient has had an **ischaemic stroke**.
Within what **timeframe** would the patient be eligible for **thrombolysis**?
What **medication** is used in **thrombolysis**?
If the patient presented outside this timeframe, what initial management would they recieve?
Within **4.5 hours** of symptom onset
*(after this time, the tissue damage is irreversible)*
IV **alteplase**
**300mg aspirin**
127
A patient presents to ED with left sided weakness and slurred speech that started **8 hours ago**. A CT head reveals the patient has had an **ischaemic stroke**.
What would their initial management be?
**300mg aspirin**
128
A patient presents to ED with left sided weakness and slurred speech that started **3 hours ago**. A CT head reveals the patient has had an **ischaemic stroke**.
What would their initial management be?
**Thrombolysis with IV alteplase + 300mg aspirin**
129
A 46y/o woman presents to A&E at **8am** with an **acute onset headache** which started at **21:00** the previous night whilst watching TV on her sofa.
She describes this as the **worst headache that she has ever had**.
An initial **CT scan** of the head is **normal**.
What is the most likely **diagnosis**?
What would be the most appropriate **next step** in her management?
**Subarachnoid haemorrhage**
Lumbar puncture **12 hours after the onset** of symptoms
130
A **subdural haematoma** is caused by bleeding from **which** **vessel**?
**Bridging veins**
131
An **extradural haematoma** is caused by bleeding from **which vessel**?
**Middle meningeal artery**
132
A 46y/o woman presents to A&E at **8pm** with an **acute onset headache** that started at **5pm** the earlier that evening whilst watching TV on her sofa.
She describes this as the **worst headache that she has ever had**.
An initial **CT scan** of the head is **normal**.
What would be the most appropriate **next step** in her management?
**Think of an alternative diagnosis** (as CT head was done within 6 hours of symptom onset, if there was a bleed then you would see it)
*\*\*\* NO lumbar puncture is required \*\*\**
133
A 24y/o male was brought to ED by ambulance after being involved in an RTA. On initial assessment he **withdraws from pain,** **groans** in response to your questioning and **wont open his eyes**.
What is his **GCS**?
**GCS = 7**
~ M = 4
~ V = 2
~ E = 1
134
Name the **most likely** causative **organism** that causes bacterial **meningitis** in **newborns (0-3 months)**:
Group B strep
135
Name the **most likely** causative **organism** that causes bacterial **meningitis** in **children aged 3m-6y**:
Strep pneumoniae
136
Name the **most likely** causative **organism** that causes bacterial **meningitis** in **teenagers/young adults** (\<60y):
Neisseria meningitidis
137
Name the **most likely** causative **organism** that causes bacterial **meningitis** in **older adults** (\>60y):
Strep pneumoniae
138
A 17y/o boy has repeated episodes characterised by a **funny rising sensation in his abdomen** followed by a **loss of awareness**. Friends have also noticed that during these episodes he **stares into space** and waves his left arm around in a writing manner.
Where is the most likely **cranial** **site of origin** of these episodes?
**Right temporal lobe** - commonest site of origin for **focal** seizures
~ it starts as a *focal* lesion and then spreads over the brain
~ the fact that he has the funny abdominal sensation = an aura → aura's before headaches are associated with the temporal lobe!
139
Where is the commonest site of origin of **focal seizures?**
Temporal lobe
140
Where is the commonest site of origin of **generalized tonic-clonic seizures?**
Frontal lobe
141
A 25y/o patient attends the neurology clinic **reporting** several episodes of **involuntary movement** in their right hand. These episodes usually **last around 2 minutes** and **return to normal immediately afterwards**.
What is the most likely diagnosis?
**Focal aware seizure**
~ *focal as it's only involving certain myotomes*
142
**Lhermitte's sign** is associated with which neurological condition?
How do you elicit this sign and if it's positive, what would you expect to happen?
Lhermitte's sign = **multiple sclerosis**
Flexing the neck will cause an **electric shock sensation** to travel down the spine and into the limbs
143
Name the **first symptom** that people with **MS** commonly present with:
OPTIC NEURITIS!
*unilateral reduced vision +/- pain on eye movements*
144
Name the **3 disease patterns in MS**:
Which one of the above is the **most common** pattern at **initial diagnosis** of MS?
* Relapsing-remitting - **commonest pattern at initial diagnosis**
* Secondary progressive
* Primary progressive
145
Name **2 investigations** that can be used to support a **diagnosis of MS** and state the evidence they'd prove to support an MS diagnosis:
**MRI scan**
~ show's typical lesions
**Lumbar puncture**
~ this will detect oligoclonal bands in the CSF (*indicates inflammation in the CNS*)
146
```
Name the class of medications that are used in **MS to treat relapses**:
~ give the commonly used drug from this class that is used for this purpose
```
Steroids: **methylprednisolone**
147
Motor neurone disease is an umbrella term that encompasses a variety of specific diagnoses in which the motor neurones stop functioning.
Name the **commonest type of motor neurone disease**:
~ name the gene associated with this disease
Name the type of MND that primarily affects the muscles involved in **talking and swallowing**:
Amylotropic lateral sclerosis (ALS)
~ SOD gene
Progressive bulbar palsy
148
Motor neurone disease is an umbrella term that encompasses a variety of specific diagnoses in which the motor neurones stop functioning.
Currently there are no treatments that will stop progression of the disease, however one medication is used to **slow the progression** of amylotropic lateral sclerosis (**ALS**)**. Name this medication.**
**Riluzole**
149
A 68y/o woman presents to her GP complaining of chronic and **progressive weakness** in her **legs**, and a recently worsened tendency to **trip over** when walking.
Her past medical history was unremarkable and there was no family history of neurological disease. On closer questioning, she did report a recent **tendency to cough when eating**.
O/E: she had **reduced power** bilaterally (more pronounced distally) with evidence of **fasciculations** in the large thigh muscles. In addition, she was **briskly hyper-reflexive with upgoing plantars**. **Sensory examination** and cranial nerve assessment were **normal**.
She is referred to a specialist who excludes reversible causes of her presentation and performs an MRI of the spine which is structurally normal.
What is the most likely **diagnosis**?
What is the most appropriate **management** for this patient?
**Amylotropic lateral sclerosis** (ALS) *- a type of motor neurone disease*
Management: **riluzole** (*slows progression of disease*)
150
A 60y/o man presents to clinic complaining of **pain** and **weakness** **in his legs** over the last few months. He has also noticed a change in his gait. On examination, his **reflexes are brisk** bilaterally in the legs. His **gait** is also noticed to be ‘**scissoring**’ and a cranial nerve examination reveals a **brisk jaw jerk**. His voice sounds ‘strained’. His **sensory** examination is **normal** and Mini-Mental State Examination is completely normal.
What is the **diagnosis**? - what **group of conditions** does this disease fall under?
~ Why is this the diagnosis and not another type of this condition?
**Primary lateral sclerosis** - MND
~ the man is is **only** presenting with **UMN** **symptoms**
151
A 61y/o man accompanied by his wife, present to clinic complaining of **slurred speech** and **dysphagia** over the past couple of months. On further questioning he mentions that he has felt very **tired** recently and **generally weaker**.
O/E you note **tongue fasiculations**, however **sensory** and **cranial nerve** examinations were **normal** aside from this.
What is the **diagnosis**? - what **group of conditions** does this disease fall under?
~ Why is this the diagnosis and not another type of this condition?
**Progressive bulbar palsy** - MND
~ the man is presenting with **bulbar** symptoms: slurred speech, dysphagia, tongue fasiculations!
152
A lumbar pubcture shows an **isolated** **raised protein** in the CSF.
What condition does this most likely indicate?
**Guillan-Barre**
153
A 67y/o female with rheumatoid arthritis attends a clinic for her annual review. She reports that she has noticed a **loss of sensation in both her hands over the last 4 months and that it has been getting worse.** In addition to arthritis, she also has hypertension and diabetes. She is currently taking infliximab, metformin, glipizide, and amlodipine. Her last HbA1c was 53 mmol/mol.
O/E: there is **bilateral** **loss of temperature and pain sensation** on the medial aspect of both hands and elbows. **Proprioception and vibration sensation are preserved**.
What is the most likely diagnosis?
Nerve fibres in which spinal tract are affected in this condition? (eg the tract that carries temperature & pain sensation!)
**Syringomyelia**
~ a cavity filled with CSF that commonly forms in the middle of the spinal cord at the cervical level
~ it classically presents with *cape-like loss of pain and temperature* sensation due to compression of the **spinothalamic tract fibres** when they cross over the middle of the spinal cord (therefore the cavity compresses them!)
154
**Pyridostigmine** is a long-acting acetylcholinesterase inhibitor.
What condition would pyridostigmine form part of the management?
Myasthenia gravis
155
A 76y/o man presents to ED. His wife is struggling to cope with him. The wife tells you that he has been getting confused and more forgetful since last month. She is worried as he's been more unsteady on his feet and has fallen in the last week, she was unable to help him up as he is too heavy. When you examine him you notice that he has been incontinent of urine.
What is the most likely diagnosis?
Which triad of symptoms indicate this diagnosis?
**Normal pressure hydrocephalus**
1. Urinary incontinence
2. Dementia (confusion/forgetfullness)
3. Gait abnormalities (eg falls)
156
In regards to** muscle fatigue/weakness**, state the difference between **Lambert-Eaton Myasthenic Syndrome **and **Myasthenia Gravis**:
Name the enzyme/electrolyte/molecule that the antibodies are targetted against in each of the above conditions:
Which **cancer** is Lambert-Eaton Myasthenic Syndrome associated with?
**Lambert-Eaton Myasthenic Syndrome:** muscle fatigue/weakness **improves** with exercise
~ antibodies against **voltage gated calcium channels**
~ small cell lung cancer
**Myasthenia Gravis:** muscle fatigue/weakness **worsens** with exercise
~ antibodies against **nicotinic acetylcholine receptors**
