Neurology Flashcards
A 50-year-old man presented to his GP with a 5-month history of increasing weakness of his right side (arm and legs). Over the past 3 months, he has been complaining of headaches, which are gradually getting more severe. Over the last 5 years, he has had a number of blackouts with incontinence.
O/E: weakness of right upper and lower limbs and papilloedema.
Which of the following would best explain his clinical picture?
A ) Cerebral abscess
B ) Left frontal meningioma
C ) Left sided cerebral haemorrhage
D ) Right frontal glioblastoma multiforme
E ) Sagittal sinus thrombosis
B ) Left frontal meningioma
A 43-year old woman presents to the ED after her husband noticed that her right lower eyelid seemed to lag last night and has a painful right ear. By the time they see you the following day, the corners of her mouth appear to droop a little on the right and she is experiencing mild dysarthria. She has come into the hospital fearing a stroke.
You also note small vesicles in the right external meatus. What does this patient likely have?
A ) Bell’s Palsy
B ) Lyme disease
C ) Parotid gland neoplasm
D ) Ramsey-Hunt syndrome
E ) Transient ischaemic attack
D ) Ramsey-Hunt syndrome
Answer: False, True, True, True, False
Bilateral recurrent nerve paralysis occurs in less than 0.1% of patients following thyroidectomy. This causes adduction of the vocal cords during inspiration, leading to obstruction of the airway and aphonia. It is a rare complication of total thyroidectomy that requires emergency airway management.
Occlusion of which dominant-hemisphere vessel can result in alexia without agraphia?
A ) ACA
B ) ICA
C ) MCA
D ) PCA
E ) PICA
D ) PCA
Occlusion of which vessel can lead to sensory loss of the ipsilateral face and contralateral arm?
A ) ACA
B ) ICA
C ) MCA
D ) PCA
E ) PICA
** E ) PICA**
This is known as lateral medullary syndrome (Wallenberg’s syndrome).
A 31-year-old man complains of daily headaches for the last two weeks. He has approximately eight episodes per day, each lasting 20 min. The headaches are described as ‘throbbing’, and localised to the left periorbital area. They are accompanied by tearing of the left eye, left ptosis, rhinorrhea, and facial redness. The patient remembers having a similar problem two years ago that lasted for three weeks. He did not seek medical help at that time. The patient feels that the headaches are often precipitated by drinking a glass of wine.
Which of the following is the most likely diagnosis?
A ) Trigeminal neuralgia
B ) Cluster headache
C ) Migraine headache
D ) Sinusitis
E ) Tension headache
B ) Cluster headache
Answer: Myasthenia gravis
Answer: Right lateral medullary stroke
A neurological examination of a 75-year-old male reveals that when the abdominal wall is stroked, the muscles of the abdominal wall of the side of the body stimulated failed to contract. Other neurological tests appeared normal. The likely region affected includes
A ) C1–C5 spinal segments
B ) C6–T1 spinal segments
C ) L1–L5 spinal segments
D ) T2–T7 spinal segments
E ) T8–T12 spinal segments
E) T8–T12 spinal segments
Explanation: In this case, there is a loss of superficial abdominal reflexes, which require that spinal segments T8–T12 are intact. The test for these reflexes is to stroke a quadrant of the abdominal wall with an object such as a wooden stick. The normal response is for the muscle of the quadrant stimulated to contract and for movement of the umbilicus in the direction of the stimulus.
A 20-year-old motorcyclist was rushed into ED. He has been involved in a traffic accident and was found alone on the road.
O/E: He appears drowsy and is making some grunting sounds, pupils are equal and reactive to light, eyes open to pain and he withdraws his hand while the nurses try to insert a cannula.
What is his Glasgow Coma Scale (GCS) score?
A ) 10
B ) 4
C ) 5
D ) 8
E ) 9
Answer: 8
Eye – open to pain = 2
Verbal – inappropriate sounds – 2
Motor – withdraws from pain – 4
A 22-year-old woman presents with diplopia for several weeks. She admits to occasional vertigo and ataxia. Six months ago, she had urinary incontinence for 1 month. Examination of the eyes reveals a gaze-evoked nystagmus, and fundoscopic exam reveals swelling of the optic nerve (papillitis). The patient has increased muscle tone of the lower extremities and is hyperreflexic. She has bilateral extensor plantar reflexes and loss of position sense up to the ankle.
Which of the following is the most likely diagnosis?
A ) Acute transverse myelitis
B ) Brown-Séquard syndrome
C ) Friedreich’s ataxia
D ) Multiple sclerosis
E ) Syringomyelia
D ) Multiple sclerosis
_____ is an autosomal recessive disease in which young patients present with pes cavus foot deformity, spasticity, areflexia, ataxia, and cardiomyopathy.
A ) Acute transverse myelitis
B ) Brown-Séquard syndrome
C ) Friedreich’s ataxia
D ) Multiple sclerosis
E ) Syringomyelia
Friedreich’s ataxia
____ is characterised by contralateral loss of pain and temperature and ipsilateral spasticity, weakness, hyperreflexia, extensor plantar reflex, and loss of proprioception (vibration and position sense).
A ) Acute transverse myelitis
B ) Brown-Séquard syndrome
C ) Friedreich’s ataxia
D ) Multiple sclerosis
E ) Syringomyelia
Answer: Brown-Séquard syndrome
Answer: Amyotrophic lateral sclerosis
Answer: Internuclear ophthalmoplegia
Answer: Cervical myelopathy
Answer: Right lenticulostriate branches of the middle cerebral artery
Answer: ESR
Answer: Sparing of sensation; ocular muscles; and bowel, bladder, and sphincter function
Answer: Small cell carcinoma
Answer: Thymoma
If immediate improvement is essential for survival, which of the following options is the fastest way to manage myasthenia gravis?
A ) Antivirals
B ) Glucocorticoids
C ) High dose cyclophosphamide
D ) IVIg
E ) Thymectomy
D ) IVIg
Answer: The deep tendon reflexes are normal
Explanation: The options below are helpful in distinguishing between Lambert Eaton syndrome, botulism, and myasthenia gravis. The reflexes of a person with Lambert-Eaton syndrome and botulism are diminished or absent, however, in a person with myasthenia gravis, the DTR’s are normal.
Which of the following pathologies causes a combination of ipsilateral spastic paresis below the lesion, ipsilateral loss of proprioception and vibration sensation, and contralateral loss of pain and temperature sensation?
A ) Anterior spinal artery occlusion
B ) Brown-Sequard Syndrome
C ) Friedrich’s ataxia
D ) Neurosyphilis
E ) Subacute combined degeneration of the spinal cord
Answer: Brown-Sequard Syndrome
Which thalamic nucleus carries visual information from the optic tracts to the optic radiations and occipital lobe?
A ) Lateral geniculate nucleus
B ) Lateral portion of the ventral posterior nucleus
C ) Medial geniculate nucleus
D ) Medial portion of the ventral posterior nucleus
E ) Ventral anterior/lateral nuclei
A ) Lateral geniculate nucleus
Answer: Anterior interosseous
The anterior interosseous nerve arises from the median nerve about 5cm above the medial epicondyle supplying the flexor digitorum profundus and the flexor pollicis longus muscles. It can be compromised by direct trauma or by compression by surrounding muscles (pronator teres), ligaments, or scar tissue. The result is the inability to pinch the thumb and forefinger together (in the way shown in the question) and thus difficulty with fine motor pincer movements.
OK sign without anterior interosseous weakness is shown below.
Answer: Hypersensitivity to sounds Explanation: All the other options can occur in any case of facial nerve palsy. Only A is seen in Bell’s (idiopathic) palsy due to hyperacusis from stapedius palsy.
Answer: Obtain an EEG and a neuroimaging study
Answer: Obtain a repeat EEG and MRI to help guide decisions on continued use of sodium valproate prior to pregnancy
Answer: CT scan of the head without contrast
Answer: Pilocytic Astrocytoma
Answer: Glioblastoma
Answer: Meningioma
Answer: Cuneate nucleus
The cuneate nucleus, one of the dorsal column nuclei, is a wedge-shaped nucleus in the closed part of the medulla oblongata. It contains cells that give rise to the cuneate tubercle, visible on the posterior aspect of the medulla. It lies laterally to the gracile nucleus and medial to the spinal trigeminal nucleus in the medulla.
Answer: Nucleus ambiguus
The nucleus ambiguus is a group of large motor neurons, situated deep in the medullary reticular formation. The nucleus ambiguus contains the cell bodies of nerves that innervate the muscles of the soft palate, pharynx, and larynx which are strongly associated with speech and swallowing. As well as motor neurons, the nucleus ambiguus in its “external formation” contains cholinergic preganglionic parasympathetic neurons for the heart.
Answer: Vestibular nucleus
The vestibular nuclei are the cranial nuclei for the vestibular nerve.
Answer: Nasopharyngeal carcinoma
The sympathetic nervous supply to the eye is a three neurone pathway originating in the hypothalamus and descending by way of the brainstem and cervical cord to T1 nerve root, paravertebral sympathetic chain and, on via the carotid artery, to the eye. Damage to any part of the pathway results in Horner’s syndrome. This is significant not only because it affects vision but also because it may indicate a serious underlying pathology.
Answer: Right frontal lobe, ACA
Answer: Acetylcholine receptor antibody
Which of these is unlikely to cause a watershed stroke?
A ) Cardiogenic shock
B ) Carotid artery stenosis
C ) Iron deficiency anaemia
D ) Ruptured berry aneurysm
E ) Thrombus in the internal carotid artery
** C) Iron deficiency anaemia**
A watershed stroke is a form of ischaemic stroke. They tend to be caused by insufficient blood flow to the brain (e.g. carotid artery stenosis, arrhythmia or heart failure) or a vascular blockage/restriction far upstream of the infarct. This results in an infarct of the border zones between the tissues supplied by the ACA, MCA, and PCA.
Answer: L5/S1 disc prolapse
Answer: L3/L4 disc prolapse
Answer: L4/L5 disc prolapse
When you examine a patient’s capacity to abduct their shoulders, which muscle, nerve root, and nerve are being tested?
A ) Biceps, C6, axillary nerve
B ) Biceps, C6, musculocutaneous nerve
C ) Deltoid, C5, axillary nerve
D ) Deltoid, C6, musculocutaneous nerve
E ) Triceps, C7, radial nerve
Answer: Deltoid, C5, axillary nerve
On examination of a patient’s routine walking, you notice a high-stepping gait. This would suggest what kind of lesion?
A ) Cerebellar lesion
B ) Dorsal column lesion/sensory neuropathy
C ) Frontal lobe lesion
D ) Lower motor neuron L5 root lesion
E ) Parkinsonism
Answer: Lower motor neuron L5 root lesion
Answer: Motor neurone disease
Answer: Absent sensation to temperature in the left hand
Answer: Anterior cerebral artery
Name the vascular territory likely affected in the following stroke syndrome:
- Contralateral hemiplegia
- Contralateral hemisensory loss
- Hemianopia
- Gaze deviation towards side of infarct
- Aphasia if dominant hemisphere involved
- Neglect: non-dominant hemisphere
A ) Anterior cerebral artery
B ) Middle cerebral artery
C ) Posterior cerebral artery
D ) Posterior inferior cerebellar artery
E ) Posterior limb of internal capsule
B ) Middle cerebral artery
Name the vascular territory likely affected in the stroke syndrome below:
- Vertigo
- Nausea
- Truncal ataxia
A ) Anterior cerebral artery
B ) Middle cerebral artery
C ) Posterior cerebral artery
D ) Posterior inferior cerebellar artery
E ) Posterior limb of internal capsule
D ) Posterior inferior cerebellar artery
