Neurology Flashcards
(239 cards)
1
Q
UMN vs LMN lesions
A
UMN: muscle bulk preserved, hypertonia, slightly reduced/normal power, hyperreflexia.
LMN: reduced muscle bulk with fasciculations, hypotonia, reduced power and hyporeflexia.
2
Q
Describe the different types of gait
A
- Hemiplegic/diplegic gait: indicates an upper motor neurone lesion.
- Broad based gait/ataxic gait: indicates a cerebellar lesion.
- High stepping gait: indicates foot drop or a lower motor neurone lesion.
- Waddling gait: indicates pelvic muscle weakness due to myopathy.
- Antalgic gait (limp): indicates localised pain.
3
Q
List the causes of intracranial haemorrhage
A
- Spontaneous
- Secondary to ischaemic stroke, tumours, or aneurysm rupture.
4
Q
Give examples of types of intracerebral haemorrhage
A
- Lobar intracerebral haemorrhage
- Deep intracerebral haemorrhage
- Intraventricular haemorrhage
- Basal ganglia haemorrhage
- Cerebellar haemorrhage
5
Q
Describe the components of the GCS
A
MOTOR RESPONSE:
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
VERBAL RESPONSE:
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
EYE OPENING:
4. Spontaneous
3. To speech
2. To pain
1. None
6
Q
Management of myasthenic crisis?
A
IV immunoglobulins and plasmapheresis
7
Q
What is the first line drug for ocular myasthenia gravis?
A
Pyridostigmine
8
Q
Raised ICP can cause which type of CN palsy?
A
3rd nerve palsy due to herniation
9
Q
Describe the symptoms of raised ICP
A
Headaches, nausea, tinnitus and eye issues.
10
Q
Idiopathic intracranial hypertension can lead to…
A
Raised ICP
11
Q
Describe the features of third nerve palsy
A
- Eye is deviated ‘down and out’.
- Ptosis.
- Pupil may be dilated (sometimes called a ‘surgical’ third nerve palsy).
12
Q
Outline the causes of a third nerve palsy
A
- Diabetes.
- Vasculitis e.g. temporal arteritis, SLE.
- False localizing sign due to uncal herniation through tentorium if raised ICP.
- Posterior communicating artery aneurysm: pupil dilated and often associated pain.
- Cavernous sinus thrombosis.
- Weber’s syndrome: ipsilateral third nerve palsy with contralateral hemiplegia - caused by midbrain strokes.
- Other: amyloid, multiple sclerosis.
13
Q
Management of TIA presenting to GP within 7 days?
A
- 300mg aspirin daily.
- Refer for specialist review within 24 hours.
- Diffusion-weighted MRI scan.
- Urgent carotid doppler.
14
Q
Define TIA
A
Transient ischaemic attack - transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
15
Q
Outline the features and causes of cerebellar pathology
A
DANISH - dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia/hyporeflexia.
PASTRIES - paraneoplastic syndrome, abscess/atrophy, stroke/sclerosis, trauma/tumour, raised ICP, infection/inherited, ethanol, spinocerebellar ataxia.
16
Q
Cerebellar hemisphere vs cerebellar vermis lesions
A
- Cerebellar hemisphere lesions cause peripheral (‘finger-nose ataxia’).
- Cerebellar vermis lesions cause gait ataxia.
17
Q
A 59-year-old gentleman presents to the Emergency Department with a left sided hemiparesis which affects his lower limb more than his upper limb, with his face unaffected. He also has complete loss of both pain and light touch sensation in his left lower limb. He is able to clearly speak to you and understands what you say and does not have an ataxia, but he appears unable to see you when you stand on his left. Clinical examination of his visual fields reveals a left sided homonymous hemianopia.
Which clinical stroke syndrome does he have?
A
Partial anterior circulation infarct (PACI)
18
Q
Progressive peripheral polyneuropathy with hyporeflexia suggests which condition?
A
Guillain-Barre syndrome
19
Q
What is the most common cause of Guillain-Barre syndrome?
A
Campylobacter jejuni
20
Q
Define syringomyelia
A
Collection of cerebrospinal fluid within the spinal cord.
21
Q
Describe the features of syringomyelia
A
- ‘Cape-like’ (neck, shoulders and arms) loss of pain and temperature sensation but the preservation of light touch, proprioception and vibration - due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected.
- Spastic weakness (predominantly of the lower limbs).
- Neuropathic pain.
- Upgoing plantars.
22
Q
Describe two causes of bitemporal hemianopia
A
- Upper quadrant defect = pituitary tumour
- Lower quadrant defect = craniopharyngioma
23
Q
What are the red flags for trigeminal neuralgia?
A
- Sensory changes
- Deafness or other ear problems
- History of skin or oral lesions that could spread perineurally
- Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
- Optic neuritis
- A family history of multiple sclerosis
- Age of onset before 40 years
24
Q
Define normal pressure hydrocephalus
A
An abnormal build-up of CSF in the ventricles, causing them to enlarge, due to reduced CSF absorption at the arachnoid villi.
Risk factors:
- Old age.
- Head trauma.
- Brain infection.
- Brain tumour.
- Subarachnoid haemorrhage.
25
Describe the clinical features of normal pressure hydrocephalus
- Progressively worsening memory lapses
- Personality and mood disturbances
- Difficulties with walking (gait abnormality)
- Dementia
- Urinary incontinence
26
Management of normal pressure hydrocephalus?
Ventriculoperitoneal (VP) shunt
27
Which drugs are associated with Steven Johnson syndrome?
Carbamazepine, lamotrigine, allopurinol, sulfonamide, phenobarbital.
28
Describe the features of Steven Johnson syndrome
- Flu-like symptoms, such as a high temperature, sore throat, cough and joint pain.
- Rash on hands, arms, face and legs.
- Blisters on mucous membranes.
29
MOA of carbamazepine
- Binds to sodium channels increases their refractory period.
- Sodium channel antagonist.
30
Describe the adverse effects of carbamazepine
- P450 enzyme inducer
- Dizziness and ataxia
- Drowsiness
- Headache
- Visual disturbances (especially diplopia)
- Steven-Johnson syndrome
- Leucopenia and agranulocytosis
- Hyponatraemia secondary to SIADH.
31
Describe the features of juvenile myoclonic epilepsy
- Infrequent generalized seizures, often in morning or following sleep deprivation.
- Daytime absences.
- Sudden, shock-like myoclonic seizure (these may develop before seizures).
32
Which spinal tracts are affected in subacute combined degeneration of the spinal cord?
- Dorsal column: distal tingling/burning/sensory loss is symmetrical (tends to affect the legs more than the arms) and impaired proprioception and vibration sense.
- Lateral corticospinal tracts: muscle weakness, hyperreflexia, and spasticity. Brisk knee reflexes, absent ankle jerks and extensor plantars.
- Spinocerebellar tracts: sensory ataxia → gait abnormalities, positive Romberg's sign.
33
Humeral shaft fracture is at risk of which nerve injury?
Radial nerve
34
Ulnar nerve injury typically causes what deformity?
Claw hand
35
What is the medical term for fast, involuntary muscle jerking?
Myoclonus
36
Define Lance-Adams syndrome
Incredibly rare complication of successful CPR, leading to post-hypoxic myoclonus caused by cerebral hypo-perfusion and global CNS damage.
37
Spinal cord damage can lead to…
Sphincter (bowel/bladder) disturbance and incontinence.
38
How would you test for a polyneuropathy?
Nerve conduction tests
39
Investigation of choice for suspected spinal injury?
MRI spine
40
Outline the causes of polyneuropathy
- Idiopathic.
- Diabetes mellitus.
- Systemic illness: critical illness polyneuropathy, hypothyroidism, chronic kidney disease, chronic liver disease, amyloidosis.
- Autoimmune: Guillain-Barré syndrome.
- Inflammatory: chronic inflammatory demyelinating polyneuropathy (CIDP).
- Toxic: Alcohol, chemotherapy, heavy metals.
- Neoplastic: myeloma, paraneoplastic syndrome, lymphoma.
- Hereditary: Charcot-Marie-Tooth.
- Nutritional: Vitamin B12, folate, pyridoxine, vitamin E deficiencies.
- Vasculitis.
- Medications: nitrofurantoin, isoniazid.
41
What is Guillain-Barré syndrome (GBS)?
An acute, autoimmune polyneuropathy.
42
What is the treatment for GBS?
- IV immunoglobulins (first-line)
- Plasmapheresis
43
Outline the complications of GBS
- Type 2 respiratory failure —> intubation and ventilation
- PE (a leading cause of death)
- Pneumonia
44
What would a LP show in GBS?
Raised protein and normal cell count
45
Dysphasia vs dysarthria
- Dysphasia: impairment in the production of language. Dysphasia is a disorder of language.
- Dysarthria: motor speech disorder where speech muscles are damaged, paralysed or weakened. Dysarthria is a disorder of speech.
46
In status epileptics, which causes need to be ruled out first?
Hypoxia and hypoglycaemia
47
Which nerve is adductor pollicis innervated by?
Ulnar nerve - damage results in loss of thumb adduction.
48
Cause of lateral medullary syndrome?
Occlusion of the posterior inferior cerebellar artery.
49
Describe the features of lateral medullary syndrome
Cerebellar features:
- Ataxia
- Nystagmus
Brainstem features:
- Ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
- Contralateral: limb sensory loss
50
Outline the UMN lesion signs
SPASTICITY:
- Flexion of UL.
- Extension of LL.
- Increased tone (clasp knife).
- Pyramidal weakness (weak UL extensors, weak LL flexors - imbalance).
- Brisk reflexes.
51
Describe the gait patterns for UMN lesion
- Scissor gait (hip adduction).
- Hemiplegic gait (circumduction of spastic leg).
52
What is Brown-Sequard syndrome?
- Lateral hemisection of the spinal cord.
- Causes ipsilateral motor weakness and loss of proprioception/vibration. Contralateral loss of pain/temperature.
53
Describe the MRC power grading scale
- Grade 0: No muscle movement
- Grade 1: Trace of contraction
- Grade 2: Movement at the joint with gravity eliminated
- Grade 3: Movement against gravity, but not against added resistance
- Grade 4: Movement against an external resistance with reduced strength
- Grade 5: Normal strength
54
Management for medication overuse headache
- Simple analgesics and triptans should be withdrawn abruptly.
- Opioid analgesics should be gradually withdrawn.
55
Wrist drop is caused by damage to which nerve?
Radial nerve
56
What is the gold standard investigation for viewing demyelinating lesions?
MRI with contrast
57
Lesion in the hypoglossal nerve results in what?
Tongue deviates towards side of lesion.
58
What will a lesion in the facial nerve result in?
Spastic paralysis of the muscles in the contralateral lower quadrant of the face.
59
Classify subdural haematomas
- Acute: Symptoms usually develop within 48 hours of injury, characterised by rapid neurological deterioration.
- Subacute: Symptoms manifest within days to weeks post-injury, with a more gradual progression.
- Chronic: Common in the elderly, developing over weeks to months. Patients may not recall a specific head injury.
60
Describe the typical presentation of an acute subdural haematoma
- History of head trauma.
- Lucid interval followed by a gradual decline in consciousness.
- Headache, confusion, and lethargy.
61
What is Cushing's triad for raised ICP?
Bradycardia, hypertension and respiratory irregularities.
62
Which patients are at risk of chronic subdural haematomas?
Elderly and alcoholics - due to brain atrophy and therefore fragile or taut bridging veins.
63
Describe the typical presentation of a chronic subdural haematoma
Memory loss, confusion, reduced consciousness or neurological deficit.
64
Acute vs. Chronic subdural haematoma on CT scan
- Acute: hyperdense
- Chronic: hypodense
65
What is the management for chronic symptomatic subdural haematomas?
Surgical decompression with burr holes.
66
What is the management for acute symptomatic subdural haematomas?
Decompressive craniectomy/craniotomy.
67
Define the Arnold-Chiari malformation
The downward displacement, or herniation, of the cerebellar tonsils through the foramen magnum.
Features:
- Non-communicating hydrocephalus may develop as a result of obstruction CSF outflow.
- Headache.
- Syringomyelia.
68
Outline the features for intracranial venous sinus thrombosis
- Headache (may be sudden onset)
- Nausea & vomiting
- Reduced consciousness
- Raised d-dimer/RF for thrombosis
69
What is the gold standard investigation for intracranial venous sinus thrombosis?
MRI venography
70
Describe the features of meningitis
Symptoms:
- Headache
- Fever
- Nausea/vomiting
- Photophobia
- Drowsiness
- Seizures
Signs:
- Neck stiffness
- Purpuric rash (particularly with invasive meningococcal disease)
71
Describe the presentation of a psychogenic non-epileptic seizure
- Widespread convulsions without LOC.
- No post-ictal state.
- Can remember.
- Gradual onset.
- Past psychiatric history.
72
What can be used to differentiate between a true seizure and a pseudoseizure?
Prolactin - raised in a true epileptic seizure.
73
Outline the complications of meningitis
- Sensorineural hearing loss (most common).
- Seizures.
- Focal neurological deficit.
- Infective: sepsis, intracerebral abscess.
- Pressure: brain herniation, hydrocephalus.
- Memory loss.
- Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage).
74
A weakness of foot dorsiflexion (foot drop) and foot eversion is a result of which nerve palsy?
Common peroneal nerve
75
Which nerve is responsible for plantar flexion?
Tibial nerve
76
Define Lhermitte's sign
Paraesthesiae in limbs on neck flexion
77
Outline the features of MND
- Muscle wasting
- Fasciculations
- Dysphagia
- Slurred speech (dysarthria)
78
Describe the non-motor symptoms of PD
- Depression
- Dementia
- REM sleep disorder (vivid dreams)
- Anosmia
- Postural hypotension
- Constipation
- Stooped posture
- Monophonic speech
- Hypersalivation
- Dysphagia
79
How would you diagnose PD?
- Clinical.
- But can use DaTscan (SPECT) if clinical features are not obvious.
80
Outline the steps in a PD examination
- Inspection: tremor, face (limited facial expression).
- Tone: cogwheel rigidity.
- Bradykinesia.
- Power (normal).
- Reflexes (normal).
- Sensation.
- Extras: gait, writing, eye movements, cerebellar signs, postural BP.
81
What does Romberg’s sign test for?
Sensory ataxia
82
How would you assess a patient for neurodeficits?
- UMN/LMN/both?
- Pattern of signs: unilateral - brain; bilateral - spinal cord.
- Sphincter involvement: retention - UMN (e.g. spinal cord); incontinence - LMN (e.g. cauda equina).
- UL/LL/both affected?
- Autonomic dysreflexia: bradycardia, hypertension, retention, flushing/sweating above lesion (T6 and above).
83
Occlusion of which artery causes contralateral homonymous hemianopia with macular sparing and visual agnosia?
Posterior cerebral artery
84
Management of patients on warfarin/DOAC/bleeding disorders who are suspected of having a TIA?
CT head to exclude haemorrhage
85
Is there forehead sparing in UMN or LMN facial nerve palsy?
UMN
86
Broca’s vs. Wernicke’s aphasia
- Broca’s: expressive
- Wernicke’s: receptive
87
Fluctuating consciousness indicates what type of brain bleed?
Subdural haematoma
88
What is the first line imaging investigation for a suspected stroke?
Non-contrast CT head
89
Describe the features of a posterior circulation stroke
- Homonymous hemianopia.
- 5 D’s: dizziness, drowsiness, dysarthria, diplopia, dysphagia.
90
Compare the signs seen on CT for an acute ischaemic stroke vs haemorrhagic stroke
- Ischaemic: ‘hyperdense artery’ sign.
- Haemorrhagic: hyperdense material (blood) surrounded by low density (oedema).
91
Do cerebellar lesions cause contralateral or ipsilateral limb signs?
Ipsilateral
92
What are the functions of the extra-ocular muscles?
- Medial Rectus: adduction
- Lateral Rectus: abduction
- Superior Rectus: elevation and intorsion
- Inferior Rectus: depression and extorsion
- Superior Oblique: intorsion and depression
- Inferior Oblique: extortion and elevation
93
Which cranial nerves innervate the ocular muscles?
LR6 SO4
CN III - all the rest
94
Outline the forms of MND
- Primary lateral sclerosis (UMN signs).
- Spinal muscle atrophy (LMN signs).
- Progressive bulbar palsy.
- Amyotrophic lateralsclerosis (UMN and LMN signs).
95
What is the mean age of onset for MS?
30
96
What is the most common presentation of MS?
Optic neuritis
97
What causes a positive Lhermitte’s sign?
MS - caused by stretching the demyelinated dorsal column.
98
Which analgesia can lead to a medication overuse headache?
Opioids
99
Provide 4 examples of neuropathic pain
- Diabetic neuropathy
- Post-herpetic neuralgia
- Trigeminal neuralgia
- Prolapsed intervertebral disc
100
What features may suggest a sinister headache?
- Vomiting more than once with no other cause.
- New neurological deficit (motor or sensory).
- Reduction in conscious level (as measured by the Glasgow coma score).
- Valsalva (associated with coughing or sneezing) or positional headaches.
- Progressive headache with a fever.
If two or more of the 'red-flag' criteria are present then an urgent CT scan should be performed.
101
What are the risk factors for idiopathic intracranial hypertension?
- Obesity
- Female sex
- Pregnancy
- Drugs: COCP, steroids, tetracyclines, retinoids/vitamin A, lithium, ciclosporin, mineralocorticoids, amiodarone.
102
Describe the features of idiopathic intracranial hypertension
- Headache
- Blurred vision
- Papilloedema (usually present)
- Enlarged blind spot
- Sixth nerve palsy (may be present)
103
Outline the treatment of idiopathic intracranial hypertension
- Weight loss
- Carbonic anhydrase inhibitors e.g. acetazolamide
104
A woman suddenly falls to the ground then lays motionless
Atonic seizures
105
First line treatment for a woman of childbearing age who presents with generalised tonic-clonic seizures?
Lamotrigine or levetiracetam
106
Management of an acute MS relapse
High dose steroids
107
Define Parkinsonism
The presence of bradykinesia and at least one of:
- Resting tremor
- Rigidity
- Postural instability
108
Parkinson’s tremor vs benign essential tremor
Parkinson’s tremor:
- Asymmetrical
- 4-6 Hz
- Worse at rest
- Improves with movement
- Other PD features
- No change with alcohol
Benign essential tremor:
- Symmetrical
- 6-12 Hz
- Improves with rest
- Worse with intentional movement
- No other PD features
- Improves with alcohol
109
Which primary tumours are the most common cause of brain metastases?
Lung
110
What is the most common cause of polyneuropathy in the western world?
Diabetes
111
ABCDE mnemonic of peripheral neuropathy causes
- A – Alcohol.
- B – B12 deficiency.
- C – Cancer (e.g. myeloma) and Chronic kidney disease.
- D – Diabetes and Drugs (e.g., isoniazid, amiodarone, leflunomide and cisplatin).
- E – Every vasculitis.
112
Define palsy
The motor component of a neuropathy (i.e. the weakness).
113
A 75-year-old man presents to the emergency department via ambulance after experiencing a 15-minute episode of slurred, confused speech, dizziness, sweating and generalised weakness. His medical history includes hypercholesterolaemia and type 2 diabetes, which are managed with atorvastatin, metformin, and gliclazide. Apart from dysphasia, his neurological examination is unremarkable.
What investigation should be done first to investigate this presentation?
Capillary blood glucose - hypoglycaemia can lead to focal neurological symptoms and needs to be ruled out as a mimic of TIA.
114
Describe features of a pontine haemorrhage
- Reduced GCS.
- Paralysis.
- Bilateral pin point pupils.
115
Outline the DVLA guidance for seizures and epilepsy
- First unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months.
- For patients with established epilepsy or those with multiple unprovoked seizures: may qualify for a driving licence if they have been free from any seizure for 12 months, or if there have been no seizures for 5 years (with medication if necessary) a 'til 70 licence is usually restored.
- Withdrawal of epilepsy medication: should not drive whilst anti-epilepsy medication is being withdrawn and for 6 months after the last dose.
116
Management of migraines
- Acute: triptan + NSAID, or triptan + paracetamol.
- Prophylaxis: propranolol, topiramate (teratogenic - avoid in women of childbearing age), or amitriptyline.
117
Why are LPs contraindicated with raised ICP?
If there is a SOL in the brain, removing CSF from the spinal column may cause brain tissue to herniate through the foramen magnum, causing brain stem compression.
118
A sudden onset ‘thunderclap’ headache reaching maximum intensity within 5 mins, is suggestive of what?
Subarachnoid haemorrhage
119
What influences balance?
- Vision
- Motor praxis
- Sensory awareness
- Cerebellum
- Vestibular function
120
Which CN does the pupillary light reflex use?
- Optic nerve - afferent fibres sense light.
- Oculomotor nerve - efferent fibres contract pupillary sphincter.
121
Which gland does the facial nerve travel through?
Parotid gland
122
Why can hyperacusis occur in Bell’s palsy?
Due to weakness of the stapedius muscle, which is innervated by a branch of the facial nerve.
123
Pseudobulbar palsy
- Due to an UMN lesion caused by bilateral disturbance of the corticobulbar tracts.
- Characterised by dysarthria, dysphagia, facial and tongue weakness, and emotional lability.
124
LMN facial nerve palsy and a vesicular rash around ear
Ramsay Hunt syndrome
125
List differentials for LMN facial nerve palsy
- Bell’s palsy.
- Ramsay Hunt syndrome.
- Infections: otitis media, otitis externa, HIV, Lyme disease.
- Systemic diseases: diabetes, sarcoidosis, leukaemia, MS, GBS.
- Tumours: acoustic neuroma, parotid tumour, cholesteatoma.
- Trauma: direct nerve injury, surgery, base of skull fractures.
126
Describe the function of the 12 cranial nerves
- Olfactory (I): smell.
- Optic (II): sight.
- Oculomotor (III): eye movements (MR, IO, SR, IR), pupil constriction, accommodation, eyelid opening.
- Trochlear (IV): eye movements (SO - move eye down and in, intorsion).
- Trigeminal (V): facial sensation, muscles of mastication.
- Abducens (VI): eye movements (LR - abduction).
- Facial (VII): muscles of facial expression, taste anterior 2/3 tongue, lacrimation, salivation.
- Vestibulocochlear (VIII): hearing, balance.
- Glossopharyngeal (IX): taste posterior 1/3 tongue, salivation, swallowing, input from carotid body & sinus.
- Vagus (X): phonation, swallowing, innervated viscera.
- Accessory (XI): head and shoulder movement.
- Hypoglossal (XII): tongue movement.
127
Which cranial nerves are sensory, motor or both?
- I: sensory
- II: sensory
- III: motor
- IV: motor
- V: both
- VI: motor
- VII: both
- VIII: sensory
- IX: both
- X: both
- XI: motor
- XII: motor
Some Say Marry Money But My Brother Says Big Brains Matter Most
128
Describe the features of a trochlear nerve palsy
Defective downward gaze → vertical diplopia.
129
In a vagus nerve palsy, which way would the uvula deviate?
Away from site of lesion
130
Accessory nerve palsy
Weakness turning head to contralateral side.
131
What are the afferent and efferent nerves of the corneal reflex?
- Afferent: ophthalmic division of trigeminal nerve.
- Efferent: facial nerve.
132
What are the afferent and efferent nerves of the gag reflex?
- Afferent: glossopharyngeal nerve.
- Efferent: vagus nerve.
133
Describe the features of benign rolandic epilepsy
- Paraesthesia (e.g. unilateral face), usually on waking up or at night.
- Partial seizures, but secondary generalisation may occur —> tonic-clonic movements.
134
Myasthenia gravis is associated with what other condition?
Thymomas
135
Which muscle types are not usually affected by myasthenia gravis?
Cardiac and smooth muscle.
136
What does fatiguability mean with regards to myasthenia gravis?
Increased muscle weakness on repeated use.
137
What will nerve conduction studies in MND show?
They will be normal.
138
Which nerve roots are affected in Klumpke’s palsy?
C8/T1
139
Finger abduction weakness suggests which nerve root lesion?
T1
140
What is the MOA of phenytoin?
- Binds to sodium channels increasing their refractory period.
- Sodium channel antagonist.
141
Describe the adverse effects of phenytoin
- P450 enzyme inducer
- Dizziness and ataxia
- Megaloblastic anaemia (secondary to altered folate metabolism)
- Peripheral neuropathy
- Toxic epidermal necrolysis
- Hepatitis
- Aplastic anaemia
- Teratogenic: cleft palate and congenital heart disease
- Gum hypertrophy and cerebellar atrophy.
142
Why can PD cause postural hypotension?
Due to autonomic dysfunction
143
Describe the features of neuroleptic malignant syndrome
It occurs within hours to days of starting an antipsychotic and the typical features are:
- Pyrexia.
- Muscle rigidity.
- Autonomic lability: hypertension, tachycardia and tachypnoea.
- Bradykinesia, hyporeflexia and lead-pipe rigidity.
- Agitated delirium with confusion.
- Raised CK —> AKI.
144
Lip smacking and post-ictal dysphasia are localising features of which type of seizure?
Temporal lobe seizure
145
Describe the features of lateral pontine syndrome
Similar to lateral medullary syndrome, but ipsilateral facial paralysis and deafness.
146
Lateral pontine syndrome affects which artery?
Anterior inferior cerebellar artery
147
‘Locked-in’ syndrome affects which artery?
Basilar artery
148
What is the investigation of a choice for an acoustic neuroma?
MRI of the cerebellopontine angle
149
Describe general tonic-clonic (grand mal) seizures
- Involves tonic (muscle tensing) and clonic (muscle jerking) associated with complete LOC.
- Aura (abnormal sensation) may occur before seizure.
- There may be tongue biting, incontinence, groaning and irregular breathing.
- Prolonged post-ictal period after - confused, tired, irritable or low.
150
Describe focal (partial) seziures
- Occurs in an isolated area of the brain e.g. temporal lobes.
- Remain awake.
- Focal aware (simple partial) or focal impaired awareness (complex partial).
- Non-motor: Déjà vu, strange smells, tastes, sight or sound sensations, unusual emotions.
- Motor: abnormal behaviours, Jacksonian march (clonic movements travelling proximally) - frontal lobe.
151
Describe myoclonic seziures
- Sudden, brief muscle contractions, like an abrupt jump or jolt.
- Remain awake.
152
Describe tonic seizures
- Sudden onset of increased muscle tone, where the entire body stiffens.
- Lasts seconds or minutes.
153
Describe atonic seizures
- ‘Drop attacks’.
- Sudden loss of muscle tone, often resulting in a fall.
- Only last briefly and usually aware.
- Begin in childhood.
- May be indicative of Lennox-Gastaut syndrome.
154
Describe absence seizures
- Usually seen in children.
- Patient becomes blank, stares into space, and then abruptly returns to normal.
- Unaware of surroundings.
- Last 10-20 secs.
155
Outline the differential diagnosis for seizures
- Vasovagal syncope (fainting).
- Pseudoseizures (non-epileptic attacks).
- Cardiac syncope (e.g. arrhythmias or structural heart disease).
- Hypoglycaemia.
- Hemiplegic migraine.
- TIA.
156
Outline the management of epilepsy
- Generalised tonic-clonic: Sodium valproate (men), Lamotrigine or Levetiracetam (women of childbearing age).
- Focal: Lamotrigine or Levetiracetam (first-line), or Carbamazepine (second-line).
- Myoclonic: Sodium valproate (men), Levetiracetam (women of childbearing age).
- Tonic and atonic: Sodium valproate (men), Lamotrigine (women of childbearing age).
- Absence: Ethosuximide.
157
What is the MOA of sodium valproate?
Increases GABA activity
158
List the side effects of sodium valproate
- Teratogenic (NTD and developmental delay)
- Liver damage and hepatitis
- Hair loss
- Tremor
- Reduce fertility
- Inhibits P450 enzyme
- Thrombocytopenia
159
Where should patients be referred after an initial presentation and management of a suspected epileptic seizure?
First fit clinic
160
What is the MOA of lamotrigine?
Sodium channel antagonist
161
What are the complications from seizures?
- Trauma, drowning, road traffic accidents and falls.
- Status epilepticus.
- Sudden unexpected death in epilepsy (SUDEP).
162
Investigations for first seizure?
- EEG
- MRI brain
163
Outline the monitoring of anti-convulsants
- Carbamazepine: plasma concentration for optimal response measured after 1-2 weeks.
- Sodium valproate: monitor LFTs before therapy and during first 6 months, measure FBC before starting and before surgery (bleeding risk).
164
In GBS, what do nerve conduction studies show?
Decreased motor nerve conduction velocity - due to demyelination.
165
List the causes of headaches
- Tension headaches
- Migraines
- Cluster headaches
- Secondary headaches
- Sinusitis
- Giant cell arteritis
- Glaucoma
- Intracranial haemorrhage
- Venous sinus thrombosis
- Subarachnoid haemorrhage
- Medication overuse
- Hormonal headache
- Cervical spondylosis
- Carbon monoxide poisoning
- Trigeminal neuralgia
- Raised ICP
- Brain tumours
- Meningitis
- Encephalitis
- Brain abscess
- Pre-eclampsia
166
Define trigeminal autonomic cephalalgias (TACs)
A collection of primary headache disorders characterised by unilateral headache (in the trigeminal distribution) and ipsilateral parasympathetic autonomic features.
167
Name the four types of TACs
- Cluster headache (most common).
- Paroxysmal hemicrania.
- Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).
- Hemicrania continua.
168
A 72-year-old man develops visual problems. He is noted to have a left homonymous hemianopia with some macula sparing.
Occipital cortex
169
A 54-year-old man complains of sweating, headaches and reduced visual fields, saying it's like having 'blinders' on. He is noted to have a bitemporal hemianopia on examination.
Optic chiasm
170
A 30-year-old man with a family history of early blindness is concerned that he is developing 'tunnel vision'.
Retina
171
When can anti-epileptic drugs be stopped?
- Seizure free for > 2 years.
- Stopped over 2-3 months.
172
What part of the brain does herpes simplex encephalitis affect?
Temporal lobes
173
Describe the features of HSV encephalitis
- Fever, headache, psychiatric symptoms, seizures, vomiting.
- Focal features e.g. aphasia.
174
Describe the patterns of homonymous quadrantanopias
PITS (Parietal-Inferior, Temporal-Superior)
- Superior: lesion of the inferior optic radiations in the temporal lobe (Meyer's loop)
- Inferior: lesion of the superior optic radiations in the parietal lobe
175
Which condition is associated with bilateral vestibular schwannomas?
Neurofibromatosis type 2
176
Which nerve is at risk for a surgical neck of humerus fracture?
Axillary nerve
177
A 32-year-old window cleaner is admitted after falling off the roof. He reports that he had slipped off the top of the roof and was able to cling onto the gutter for a few seconds. The patient has
Horner's syndrome. Which nerve roots are at risk?
Brachial Trunks C8-T1 (Klumpke’s paralysis)
178
A 32-year-old rugby player is hit hard on the shoulder during a rough tackle. Clinically his arm is hanging loose on the side. It is pronated and medially rotated. Which nerve roots are affected?
Brachial Trunks C5-6 (Erb’s palsy)
179
Which nerve is at risk with humeral supracondylar fracture?
Median nerve
180
Which nerve is at risk with a fractured humeral medial epicondyle?
Ulnar nerve
181
Outline causes of bacterial meningitis
- Neisseria meningitidis (gram negative diplococci).
- Streptococcus pneumoniae (pneumococcus - gram positive diplococci).
- Haemophilus influenzae.
- Group B streptococcus (GBS) (neonates).
- Listeria monocytogenes (neonates).
182
Outline the causes of viral meningitis
- Enteroviruses (e.g. coxsackievirus).
- Herpes simplex virus.
- Varicella zoster virus.
183
What CSF result would you expect with bacterial meningitis?
- High neutrophils
- Low glucose
- High protein
184
Investigations for bacterial meningitis?
- Meningococcal PCR
- Blood cultures
- LP
185
Describe the management of meningitis
- < 3 months: cefotaxime + amoxicillin.
- > 3 months: ceftriaxone.
- Aciclovir (viral).
- Vancomycin (if risk of penicillin-resistant pneumococcal infection).
- Dexamethasone in bacterial meningitis to reduce risk of hearing loss.
- Notifiable diseases to the UK Health Security Agency.
186
What should be done is someone has been in close contact with a meningococcal infection within 7 days of illness onset?
Post-exposure prophylaxis - single dose of ciprofloxacin.
187
Name one key complication from meningitis
Hearing loss
188
Where is the CSF located?
Subarachnoid space
189
What are the triad of symptoms indicating meningism?
Headache, neck stiffness and photophobia.
190
In the community, if a patient has suspected meningitis plus a non-blanching rash, what should be done?
IV/IM benzylpenicillin
191
If a patient has a severe penicillin allergy, what is the antibiotic of choice for meningitis?
Chloramphenicol, but discuss with microbiology first.
192
Which vaccines protect against meningitis?
- Hib
- MenB and MenACWY
- Pneumococcal
193
Epigastric aura and automatisms are features of which focal seizure?
Temporal lobe seizure
194
What is the ROSIER tool?
Recognition Of Stroke In the Emergency Room - gives a score based on the clinical features and duration. Stroke is possible in patients scoring one or more.
195
Which conditions mimic strokes?
- Toxic/metabolic: hypoglycaemia, drug and alcohol consumption.
- Neurological: seizure, migraine, Bell’s palsy.
- Space occupying lesion: tumour, haematoma.
- Infection: meningitis/encephalitis, systemic infection with ‘decompensation’ of old stroke.
- Syncope: extremely uncommon presentation of TIA, many other causes.
- Non-organic: functional neurological disorders (FND).
196
What is the NIHSS score?
- A scoring system out of 42, which has been designed as a predictive score of clinical outcome in stroke.
- < 4 associated with a good clinical outcome.
- > 22 indicates a significant proportion of the brain is affected by ischaemia, and as such, there is higher risk of cerebral haemorrhage with thrombolysis.
- ≥ 26 is often considered a contraindication to thrombolysis.
197
Name 2 complications from strokes
- Long-term disability.
- Mortality (4th leading cause of mortality in the UK).
198
Define amaurosis fugax and its causes
- Short-lived monocular blindness - described as a black curtain coming across the vision.
- Transient visual loss of ischaemic origin.
- Causes: transient obstruction of the ophthalmic artery, giant cell arteritis and CRAO.
199
Define Todd’s paresis
Weakness or paralysis in part or all of the body after a seizure.
200
Describe the features of degenerative cervical myelopathy
- Pain (affecting the neck, upper or lower limbs).
- Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance).
- Loss of sensory function causing numbness.
- Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition.
- Hoffman's sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient's hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
201
What is the gold standard test for degenerative cervical myelopathy?
MRI of the cervical spine
202
Describe the features of herpes simplex encephalitis
Fever, headache, psychiatric symptoms, seizures, focal features e.g. aphasia.
203
What score can be used to measure disability or dependence in activities of daily living in stroke patients?
The Barthel index
204
What is the standard target time for thrombectomy in an acute ischaemic stroke?
Within 6 hours
205
Which disease-modifying drug is used first-line in preventing MS relapses?
Natalizumab - mAb that antagonises alpha-4 beta-1-integrin found on the surface of leuckocytes, inhibiting migrating of leukocytes across the BBB.
206
MOA of triptans?
5-HT1 agonists
207
What are the contraindications to triptans?
CVD or cerebrovascular diease
208
Obese, young female with headaches/blurred vision
Idiopathic intracranial hypertension
209
Spasticity vs rigidity
- Spasticity is associated with pyramidal tract lesions (e.g. stroke).
- Rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson’s disease).
- Spasticity and rigidity both involve increased tone.
- Spasticity is ‘velocity-dependent’ - the faster you move the limb, the worse it is. There is typically increased tone in the initial part of the movement which then suddenly reduces past a certain point (‘clasp knife spasticity’). Spasticity is also typically accompanied by weakness.
- Rigidity is ‘velocity independent’ - it feels the same if you move the limb rapidly or slowly.
Two main sub-types of rigidity:
- Cogwheel rigidity involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb. This subtype of rigidity is associated with Parkinson’s disease.
- Lead pipe rigidity involves uniformly increased tone throughout the movement of the muscle. This subtype of rigidity is typically associated with neuroleptic malignant syndrome.
210
Describe the surgical sieve
VITAMIN CDEF
- Vascular
- Infective/inflammatory
- Traumatic
- Autoimmune
- Metabolic
- Iatrogenic/idiopathic
- Neoplastic
- Congenital
- Developmental/degenerative
- Endocrine/environmental
- Functional
211
What is autonomic dysreflexia?
- A clinical syndrome occurring in patients who have had a spinal cord injury at, or above T6 spinal level.
- Features include: hypertension, bradycardia, flushing and sweating.
212
What is the most common trigger for autonomic dysreflexia?
Faecal impaction or urinary retention
213
Rapid onset dementia and myoclonus
Creutzfeldt-Jakob disease
214
Presentation of hydrocephalus in infants
Increased head circumferences, a bulging fontanelle and sunsetting of the eyes (impaired upwards gaze).
215
Define meningiomas
Benign tumours that arise from the arachnoid cap cells of the meninges but are typically located next to the dura
216
Middle-aged, personality changes, involuntary movements
Huntington’s disease
217
What is the inheritance of Huntington’s disease?
- Autosomal dominant
- Trinucleotide repeat disorder
- Anticipation may be seen, where the disease presents at an earlier age in successive generations
- Results in degeneration of cholinergic and GABAergic neurons in the striatum of BG
218
Describe the features of Huntington’s disease
- Chorea (multiple involuntary, irregular or unpredictable muscle movements)
- Personality changes and intellectual impairment
- Dystonia
- Saccadic eye movements
219
List the complications of SAH
- Re-bleed
- Hydrocephalus
- Vasospasm
- Hyponatraemia due to SIADH
- Seizures
220
Management of viral meningitis
Supportive care - antivirals are of no benefit unless HSV
221
What is the most common cause of viral meningitis in adults?
Enterovirus
222
What is the most common cause of viral meningitis in adults?
Enterovirus
223
A 68-year-old man presents to the plastics team with severe burns to his hands. He is not distressed by the burns. He has bilateral charcot joints. On examination; there is loss of pain and temperature sensation of the upper limbs.
Syringomyelia
224
Reflex nerve roots
One, two buckle my shoe. Three, four kick the door. Five, six pick up sticks. Seven, eight shut the gate.
- S1, S2 ankle jerk.
- L3, L4 knee jerk.
- C5, C6 biceps.
- C7, C8 triceps.
225
A 76-year-old man presents to the emergency department accompanied by his wife complaining of changes in his vision. He was cooking when he suddenly realised that he could not see properly from his right eye.
On examination, the right eye looks normal. There is no redness, swelling or flushing. The pupil is normal in size. The patient describes a partial loss of vision in the left field of the right eye which came down 'like a curtain' blocking his vision. He is otherwise well and a neurological examination is normal.
Given the most likely diagnosis, where is the lesion?
Right retinal artery
226
Areflexia, ataxia, ophthalmoplegia
Miller Fisher syndrome (subtype of Guillain-Barre syndrome)
227
Syncopal episodes vs seziures
- Syncopal episodes are associated with a rapid recovery and short post-ictal period.
- Seizures are associated with a far greater post-ictal period
228
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
Multiple System Atrophy
229
Which drugs should be avoided in patients with myasthenia gravis?
Beta blockers
230
Define syncope
A transient loss of consciousness due to a lack of blood supply (hypoperfusion) to the brain.
231
What is the first line treatment for essential tremor?
Propranolol
232
Define conduction dysphasia
Speech fluent, but repetition poor. Comprehension is relatively intact.
233
What are the triggers for migraines?
CHOCOLATE: chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel, exercise.
234
What are the most common triggers of autonomic dysreflexia?
Faecal impaction or urinary retention
235
Fourth nerve palsy
When looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards
236
Weber's syndrome
- Midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis.
- Branches of the posterior cerebral artery that supply the midbrain.
237
What is the preferred antiplatelet for secondary prevention following stroke?
Clopidogrel
238
Absent corneal reflex + proptosis
Cavernous sinus thrombosis
239
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension)
Multiple System Atrophy
