Neurology

Question 1

spinal cord anatomy

where does it start and end?

Answer 1

foramen magnum to L1

terminates as conus medullaris

Question 2

what is the cauda equina?

Answer 2

bundle of spinal nerves continuing inferiorly to spinal cord

L2 to L5 nerves, Sacral 1 to 5 and the coccygeal nerves

Question 3

what suspends the spinal cord in the subarachnoid space?

Answer 3

denticulate ligaments

longitudinal support via filum terminale

Question 4

Blood supply to spinal cord?

Answer 4

• 3 longitudinal vessels
• 2 posterior spinal arteries: dorsal 1/3
• 1 anterior spinal artery: ventral 2/3
• reinforced by segmental feeder arteries
  e. g. artery of Adamkiewicz

Longitudinal veins drain into extradural verterbral plexus

Question 5

what part of the spinal cord is responsible for fine touch, vibration and proprioception?

Answer 5

Dorsal Columns

fasciulus gracilis

fasciculus cuneatus

Question 6

where does decussation of the dorsal columns occur?

Answer 6

in medulla forming the medial lemniscus

-> thus, damage below the medial lemniscus means

Question 7

what part of the spinal cord is responsible for pain and temperature sensation?

Answer 7

lateral spinothalamic tract

Question 8

where do the lateral spinothalamic tracts decussate?

Answer 8

in cord, at entry level.

This fact aids in determining whether a lesion is in the brain or the spinal cord. With lesions in the brain stem or higher, deficits of pain perception, touch sensation, and proprioception are all contralateral to the lesion. With spinal cord lesions, however, the deficit in pain perception is contralateral to the lesion, whereas the other deficits are ipsilateral.

Question 9

what part of the spinal cord is responsible for crude touch and firm pressure?

Answer 9

anterior spinothalamic tract

Question 10

what part of the spinal cord is responsible for motor function?

Answer 10

lateral corticospinal tract

Question 11

where does decussation of the lateral corticospinal tract occur?

Answer 11

pyramidal decussation in ventral medulla

Question 12

brain stem lesion -> what is affected??

in terms of pain/ temp, fine touch, motor

Answer 12

in a brain stem or higher lesion,

everything is affected contralateral to the lesion

Question 13

spinal cord lesion -> what is affected?

in terms of pain/temp, fine touch, motor

Answer 13

fine touch and motor are affected ipsilaterally

while pain/temp is affected contralaterally

Question 14

what part of the brain is involved with regulation of posture, balance, coordination, movement and speech?

Answer 14

Cerebellum

Question 15

what area of white matter carries axonal fibres from motor cortex to the pyramids of medulla?

Answer 15

internal capsule

infarcation of the internal capsule -> contralateral hemiparesis

Question 16

occipital lobe in charge of ?

Answer 16

visual cortex

Question 17

temporal lobes of brain involved in ?

Answer 17

memory

receptive language (Wernicke’s) in the dominant hemisphere

Question 18

what function is the parietal lobe involved with?

Answer 18

sensory cortex

body orientation

Question 19

what functions are the frontal lobe assoc w?

Answer 19

executive function

motor cortex

cognition and memory

dominant hemisphere: expressive speech (Broca’s area)

Question 20

what is the main neurotransmitter acting across the neuromuscular junction?

Answer 20

acetylcholine

which binds to nicotinic receptors on post-synaptic terminal

Question 21

What blocks presynaptic choline uptake?

Answer 21

hemicholine

(hemicholinium-3) decreases synthesis of acetylcholine

Question 22

what blocks acetylcholine vesicle fusion?

Answer 22

botulinum

Lambert-Eaton myasthenic syndrome (antibodies against VGCC decrease ACh release)

Question 23

what blocks nicotinic ACh receptors at the NMJ?

Answer 23

non-depolarising: atracurium, vecuronium

depolarising: suxamethonium

Question 24

Sympathetic NS vs Parasympathetic NS

Answer 24

sympathetic: T1-L2
para: CN 3, 7, 9, 10

Sympathetic: preganglionic fibres are myelinated and release ACh whereas postganglionic fibres are unmyelinateed and release NA (except for sweat glands)

Para: both pre and post release ACh

Para has long preganglionic and short postganglionic fibres.

Sympathetic has short preganglionic fibres and long postganglionic fibres

Question 25

absence of eye movements in caloric tests?

Answer 25

brainstem damage on the side being tested

Question 26

direction of nystagmus when cold water is used? and warm?

Answer 26

cold: opposite direction warm: same side

Question 27

what happens when warm water is placed in the ear during caloric testing?

Answer 27

warm water increases firing of vestibular nuclei -\> eyes turn to contralateral side with nystagmus to ipsilateral side

Question 28

UMN vs LMN signs

Answer 28

UMN: increased tone/ spasticity +/- clonus hyperreflexia up going plantars LMN: wasting fasciculation decreased tone hyporeflexia down-going plantars

Question 29

What is Brown sequard syndrome?

Answer 29

ipsilateral loss of proprioception/ vibration and weakness w contralateral loss of pain

Question 30

Cerebellar Syndrome what signs?

Answer 30

**DANISH** Dysdiadochokinesia + Dysmetria (past-pointing) Ataxia: limb/ trunkal Nystagmus: horizontal = ipsilateral hemisphere Intention tremor Speech: slurred, staccato, scanning dysarthria Hypotonia

Question 31

Common causes of cerebellar syndrome

Answer 31

**PASTRIES** Paraneoplastic: e.g. from Ca Alcohol: thiamine and B12 deficiency Sclerosis (Multiple) Trauma Raised ICP Infection/ iatrogenic: phenytoin Endo: Hypothyroidism Stroke: vertebrobasilar

Question 32

causes of locked in syndrome

Answer 32

central pontine myelinolysis: rapid correction of hypoNa ventral pons infarction: basilar artery

Question 33

features of subclavian steal syndrome?

Answer 33

syncope / presyncope or focal neurology on using the arm BP difference of \> 20mmHg between arms due to subclavian artery stenosis proximal to origin of verterbral artery -\> blood stolen by vertebral artery by retrograde flow

Question 34

features of Beck's syndrome/ anterior spinal artery infarct

Answer 34

para/ quadriparesis impaired pain and temp sensation preserved touch and proprioception infarction of spinal cord in distribution of anterior spinal artery: ventral 2/3 of cord e.g. due to aortic aneurysm dissection

Question 35

causes of mixed UMN and LMN signs?

Answer 35

MAST motor neurone disease ataxia: friedrich's Subacute combined degeneration of cord Taboparesis (tertiary syphilis)

Question 36

infectious causes of vertigo

Answer 36

ramsay hunt syndrome labyrinthitis

Question 37

trauma causing imbalance?

Answer 37

trauma to petrous temporal bone

Question 38

sudden vertigo provoked by head rotation?

Answer 38

benign positional vertigo

Question 39

recurrent vertigo, fluctuating tinnitus, increasing deafness feeling of fullness in ear

Answer 39

Meniere's disease

Question 40

lesions of nerve causing vertigo?

Answer 40

acoustic neuroma, vestibular schwannoma

Question 41

Causes of conductive hearing loss

Answer 41

**WIDENING** wax/ foreign body infection: otitis media drum perforation extra: ossicle discontinuity- otosclerosis, trauma neoplasia INjury: e.g. barotrauma Granulomatous: wegeners, sarcoid

Question 42

features of resting tremor

Answer 42

4-6 Hz, pill-rolling abolished on voluntary movement increases with distraction e.g. counting backwards

Question 43

tx of resting tremor

Answer 43

dopamine agonists antimuscarinic e.g. procyclidine

Question 44

features of intention tremor

Answer 44

\>6Hz, irregular, large amplitude worse at end of movement e.g. past pointing

Question 45

causes of intention tremor

Answer 45

cerebellar damage

Question 46

Features of action/ postural tremor

Answer 46

6-12 Hz absent at rest worse w outstretched hands or movement equally bad at all stages of movement

Question 47

causes of postural / action tremor

Answer 47

BEATS benign essential tremor endocrine: thyrotoxicosis, low glucose, phaeo alcohol withdrawal Toxins: B agonists, theophylline Sympathetic: anxiety

Question 48

autosomal dominant tremor that occurs w action and worse w anxiety, emotion, caffeine affects arm, neck, voice better w alcohol

Answer 48

benign essential tremor

Question 49

Causes of subarachnoid haemorrhage?

Answer 49

Rupture of berry aneurysm (80%) Arteriovenous malformations (15%)

Question 50

RFs of subarachnoid haemorrhage

Answer 50

Smoking, HTN, Alcohol Bleeding diathesis Subacute bacterial endocarditis (infected aneurysms) FH

Question 51

Where do berry aneurysms most commonly affect?

Answer 51

classically occurs at the point at which a cerebral artery departs from the circle of Willis e.g. bifurcation of MCA

Question 52

Berry Aneurysms are assoc w ?

Answer 52

PCKD Coarctation of aorta Ehlers Danlos

Question 53

Features of subarachnoid haemorrhage?

Answer 53

Sudden, severe occipital headache Collapse Meningism Seizures Drowsiness -\> coma

Question 54

Signs of subarachnoid haemorrhage?

Answer 54

Kernigs Retinal or subhyaloid haemorrhage Focal neuro - suggests aneurysm location

Question 55

Ix of Subarachnoid haemorrhage?

Answer 55

1. CT head ## Footnote LP after 12h if CT -ve and no contraindications-\> may show xanthochromia

Question 56

Mx of subarachnoid haemorrhage?

Answer 56

Frequent neuro obs: GCS, pupils, BP Maintain Cerebral perfusion pressure: Keep SBP \>160 Nimodipine for 3 wks -\> decrease cerebral vasospasm Endovascular coiling

Question 57

Complications of subarachnoid haemorrhage?

Answer 57

Rebleeding (most common cause of mortality) Cerebral ischaemia from cerebral vasospasm (most common cause of morbidity) Hydrocephalus hypoNa

Question 58

Causes of stroke?

Answer 58

Ischaemia (80%) Haemorrhage (20%)

Question 59

Causes of ischaemic stroke?

Answer 59

Atheroma Emboli e.g. from AF, endocarditis, MI

Question 60

Causes of haemorrhagic stroke?

Answer 60

High BP Trauma Aneurysm rupture Anticoagulation Thrombolysis

Question 61

When to do endarterectomy in carotid artery stenosis?

Answer 61

If \>70% symptomatic stenosis according to ECST criteria or \>50% according to NASCET criteria recommend if patient has suffered stroke or TIA in the carotid territory and are not severely disabled

Question 62

Posterior circulation stroke - what part of the circulation is affected?

Answer 62

Vertebrobasilar territory

Question 63

What would an infarct in the vertebrobasilar territory cause?

Answer 63

Cerebellar syndrome Brainstem syndrome Contralateral homonymous hemianopia (macular sparing)

Question 64

What is a total anterior circulation stroke?

Answer 64

All 3 of 1. Contralateral hemiparesis +/- sensory deficit (2 or more in face, arm, leg) 2. Contralateral homonymous hemianopia 3. Higher cortical dysfunction - dominant (L usually) lobe: dysphasia - non dominant: hemispatial neglect

Question 65

What is a partial anterior circulation stroke?

Answer 65

2/3 Usually 1. Contralateral hemiparesis +/- sensory deficit (2 or more in face, arm, leg) 2. Higher cortical dysfunction - dominant (L usually) lobe: dysphasia - non dominant: hemispatial neglect, constructional apraxia

Question 66

what would an infarct in the subthalamic nucleus usually present with?

Answer 66

Hemiballismus

Question 67

what is a lacunar stroke?

Answer 67

most common type of ischaemic stroke small infarcts around the basal ganglia/ internal capsule/ thalamus / pons

Question 68

what are the five classical lacunar syndromes?

Answer 68

1. pure motor: commonest. causes a hemiparesis. post limb of internal capsule affected 2. Pure sensory: affects contralateral side. post thalamus (VPL) 3. mixed sensorimotor: internal capsule 4. dysarthria/ clumsy hand 5. ataxic hemiparesis: cerebellar and motor symptoms on ipsilateral side.

Question 69

brainstem infarcts in the corticospinal tracts? presentation

Answer 69

hemi/ quadriparesis

Question 70

brainstem infarcts in the oculomotor system? presentation

Answer 70

conjugate gaze palsy

Question 71

brainstem infarct in the CN7 nucleus? presentation

Answer 71

facial weakness (LMN) forehead involved

Question 72

lesion in the CN8 nucleus? presentation

Answer 72

vertigo, nystagmus

Question 73

brainstem infarct in the CN9/10 nuclei? presentation

Answer 73

dysphagia dysarthria

Question 74

brainstem infarct in the cerebellar connections? presentation

Answer 74

ataxia dysarthria

Question 75

brainstem infarct in the sympathetic fibres? presentation

Answer 75

Horner's syndrome

Question 76

brainstem infarct in the reticular activating system? presentation

Answer 76

reduced GCS

Question 77

occlusion of what artery could cause wallenberg's syndrome/ lateral medullary syndrome?

Answer 77

Verterbral artery/ posterior inferior cerebellar artery

Question 78

features of wallenberg's syndrome/ lateral medullary syndrome?

Answer 78

DANVAH Dysphagia Ataxia (ipsilateral) Nystagmus (ipsilateral) Vertigo Anaesthesia - ipsilateral facial numbness + absent corneal reflex - contralateral pain loss Horner's syndrome (ipsilateral)

Question 79

what is Millard-Gubler syndrome?

Answer 79

aka ventral pontine syndrome lesion of the pons

Question 80

Millard-Gubler syndrome what parts of the pons are affected?

Answer 80

6th and 7th CN nuclei corticospinal tracts

Question 81

Millard-Gubler syndrome what features?

Answer 81

dipoplia (paralysis of the abducens CN VI) LMN facial palsy + loss of corneal reflex contralateral hemiplegia

Question 82

what is locked in syndrome?

Answer 82

pt aware and cognitively intact but completely paralysed except for the eye muscles

Question 83

causes of locked in syndrome?

Answer 83

ventral pons infarction: basilar artery central pontine myelinolysis: rapid correction of hypoNa

Question 84

acute mx of stroke?

Answer 84

Resus: ABCDE, stabilize patient airway, NBM until swallowing assessed by SALT Monitor: Glucose levels, BP, Neuro obs Imaging: urgent CT/ MRI

Question 85

what imaging modality is most sensitive for acute infarct?

Answer 85

diffusion-weighted MRI \*CT excludes primary haemorrhage

Question 86

why is CT head used in ix of stroke?

Answer 86

to visualize/ exclude haemorrhage

Question 87

what medical tx is used in acute stroke?

Answer 87

consider thrombolysis if 18-80 yrs and \< 4.5 h since onset of symptoms e.g. alteplase then CT head post-thrombolysis 24h to look for haemorrhage Aspirin 300mg +/- PPI ? modified release dipyridamole / clopidogrel

Question 88

when is neurosurgery indicated in stroke?

Answer 88

intracranial haemorrhage decompressive hemicraniectomy for some forms of infarction coiling of bleeding aneurysms

Question 89

Primary prevention of stroke?

Answer 89

Control RFs: HTN, high lipids, DM, smoking, cardiac disease Consider life-long anticoagulation in AF Carotid endarterectomy if symptomatic- 70% stenosis Exercise

Question 90

secondary prevention of stroke?

Answer 90

Risk factor control: statin Aspirin / Clopi 300mg for 2 wks after stroke then either: - Clopidogrel 75mg OD - Aspirin 75 mg OD + dypyridamole MR 200mg BD \*warfarin instead of aspirin/clopi if cardioembolic stroke/ AF. start from 2 wks post-stroke. Carotid endarterectomy if good recovery + ipsilateral stenosis \>70%

Question 91

Rehab in stroke?

Answer 91

MENDS MDT: physio, SALT, dietician, OT, specialist nurses, neurologist, family Eating: Swallowing screen - may need NG/ PEG, supplements if malnourished Neurorehab: physio and speech therapy DVT prophylaxis Sores: avoid bed sores

Question 92

what drug may be useful to help spasticity seen post-stroke?

Answer 92

botulinum

Question 93

What does OT post-stroke aim to do?

Answer 93

aims to minimise disability (e.g. can't write) and abolish handicap (e.g. cant work as accountant) impairment: e.g. paralysed arm

Question 94

what is a transient ischaemic attack?

Answer 94

sudden onset focal neurology lasting \<24h due to temporary occlusion of part of the cerebral circulation (~15% of 1st strokes are preceded by TIAs)

Question 95

signs of TIA?

Answer 95

brief symptoms global events e.g. syncope/ dizziness are not typical

Question 96

signs of causes of TIA?

Answer 96

Carotid bruits AF high BP heart murmur

Question 97

causes of TIA

Answer 97

atherothromboembolism from carotids cardioembolism: post-MI, AF, valve disease Hyperviscosity: polycythaemia, myeloma, Sickle cell

Question 98

IX of TIA

Answer 98

aim to find cause and define vascular risk FBC, U+E, ESR, Glucose, Lipids CXR ECG Echo Carotid doppler +/- angiography Consider brain imaging: diffusion weighted MRI

Question 99

Mx of TIA

Answer 99

avoid driving for 1 month 1. Antiplatelet therapy/ Anticoagulation: aspirin/ clopidogrel 300mg for 2 wks then 75mg/d (add dipyridamole to aspirin) warfarin if cardiac emboli: AF, MI, MS 2. Control cardiac RFs: smoking, BP, lipids, diet, exercise, DM 3. Assess risk of subsequent stroke: ABCD2 score 4. Specialist referral to TIA clinic

Question 100

what is the ABCD2 score?

Answer 100

**Age ≥** 60 **BP ≥** 140/90 **Clinical features** a. unilateral weakness (2 pts) b. speech distrubance w/o weakness **Duration** a. ≥ 1h (2 points) b. 10-59 min **DM** 7 points max predicts stroke risk following TIA

Question 101

What is the ABCD2 score used for?

Answer 101

predicts stroke risk following TIA score ≥ 6 = 8% risk within 2 days. 35% risk within 1 wk score ≥4 = pt assessment by specialist within 24h all pts w suspected TIA should be seen by specialist within 7d

Question 102

What is a subdural haemorrhage?

Answer 102

haematoma between dura and arachnoid bleeding from bridging veins between cortex and sinuses often due to minor trauma that occured a long time previously

Question 103

Risk factors of subdural haemorrhage?

Answer 103

elderly: brain atrophy falls: epileptics, alcoholics anticoagulation: increased bleeding risk

Question 104

symptoms of subdural haemorrhage?

Answer 104

headache fluctuating GCS, sleepiness gradual physical/ mental slowing unsteadiness

Question 105

signs of subdural haemorrhage?

Answer 105

raised ICP papilloedema localising signs occur late

Question 106

ix of subdural haemorrhage?

Answer 106

CT/ MRI head crescentic haematoma over one hemisphere clot goes from white -\> grey over time midline shift

Question 107

mx of subdural haemorrhage?

Answer 107

1st line: irrigation/ evacuation via burr-hole craniostomy 2nd: craniotomy then suction/ irrigation to remove the clot

Question 108

extradural haemorrhage usually due to?

Answer 108

fracture over pterion -\> laceration of middle meningeal artery and vein

Question 109

presentation of extradural haemorrhage?

Answer 109

after head injury, there may be a lucid interval. deterioration of GCS after head injury that caused no LOC/ following initial improvment in GCS increased ICP: headache, vomiting, confusion, fits, ipsilateral blown pupil (3rd n palsy) +/- hemiparesis w upgoing plantars and increased reflexes Brainstem compression

Question 110

signs of brainstem compression?

Answer 110

deep irregular breathing cushing response (late): high BP, low HR death by cardiorespiratory arrest

Question 111

Ix of extradural haemorrhage?

Answer 111

CT head - lens shaped haematoma - skull fracture

Question 112

subdural vs extradural haemorrhage? difference between where the blood is

Answer 112

extradural: blood between skull and dura subdural: blood between dura and arachnoid

Question 113

mx of extradural haemorrhage?

Answer 113

neuroprotective ventilation (Oxygen) if raised ICP -\> IV mannitol or hypertonic saline Craniectomy for clot evacuation and vessel ligation. if small haematoma -\> may be treated conservatively but must be observed in case of sudden deterioration

Question 114

if high ICP, IV mannitol or hypertonic saline?

Answer 114

Hypertonic saline is increasingly considered a safer and more effective alternative. In the trauma situation it has the advantage of repleting/preserving intravascular volume rather than increasing fluid loss by diuresis.

Question 115

what is neuroprotective ventilation?

Answer 115

O2\>100, CO2 35-40 excessive hypocapnia should be avoided, as it causes cerebral vasoconstriction.

Question 116

in extradural haemorrhage, what is the cut off for surgical management?

Answer 116

all patients with an EDH volume greater than 30 cm³ should have a surgical evacuation regardless of GCS.

Question 117

cerebral vein thrombosis risk factors?

Answer 117

triggered by infections of the ear, face, or neck oestrogen use (e.g ocp) and pregnancy inherited and acquired clotting disorders drugs e.g. tranexamic acid

Question 118

Sinus thrombosis symptoms?

Answer 118

severe headache (can be of sudden onset/ develops over few days) nausea, vomiting blurred vision serizures, confusion other neuro symtpoms symptoms depend on location and extension of clot

Question 119

sagittal sinus thrombosis symptoms?

Answer 119

Headache, vomiting, seizures, ↓ vision, papilloedema

Question 120

transverse sinus thrombosis symptoms?

Answer 120

Headache ± mastoid pain, focal neuro, seizures, papilloedema

Question 121

symptoms of sigmoid sinus thrombosis

Answer 121

cerebellar signs lower CN palsies

Question 122

symptoms of inferior petrosal sinus thrombosis?

Answer 122

5th and 6th CN palsies | (gradenigo's syndrome)

Question 123

symptoms of cavernous sinus thrombosis?

Answer 123

headache +/- tearing painful opthalmoplegia eyelid oedema proptosis fever

Question 124

Ix of cortical vein thrombosis?

Answer 124

exclude SAH and meningitis CT/ MRI venography LP: high pressure, may show RBCs, xanthochromia

Question 125

Mx of cortical vein thrombosis

Answer 125

LMWH -\> warfarin (INR 2-3) Fibrinolytics e.g. streptokinase Thrombophilia screen

Question 126

Features of meningitis

Answer 126

Headache neck stiffness - kernig's +ve - Brudzinski's +ve Photophobia N+V reduced GCS seizures, focal neurology

Question 127

what is Brudzinski's sign?

Answer 127

+ve in meningitis lifting head would cause flexion of legs and thighs due to neck rigidity

Question 128

What is Kernig's sign?

Answer 128

+ve in meningitis Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.

Question 129

signs in meningococcal septicaemia

Answer 129

fever high HR, low BP high CRT purpuric non blanching rash DIC

Question 130

antibiotic mx of meningitis in the community?

Answer 130

benpen 1.2g IM

Question 131

antibiotic mx of meningitis in under 50s?

Answer 131

IV Ceftriaxone 2g or IM BD

Question 132

antibiotic mx of meningitis in \>50s?

Answer 132

Ceftriaxone + Ampicillin IV

Question 133

viral meningitis mx?

Answer 133

aciclovir

Question 134

organisms that cause meningitis

Answer 134

enteroviruses/ HSV2 Meningococcus Pneumococcus Listeria TB cryptococcus

Question 135

why is dexamethasone used in acute bacterial meningitis?

Answer 135

Bacterial meningitis is fatal in 5% to 40% of children and 20% to 50% of adults despite treatment with adequate antibiotics. corticosteroids can reduce the inflammation assoc w infection

Question 136

CSF findings: turbid appearance, mainly neutrophils, high WCC, low glucose (\<1/2 plasma), high protein

Answer 136

Bacterial meningitis

Question 137

CSF findings: clear, lymphocytic, normal glucose, normal protein

Answer 137

viral meningitis

Question 138

CSF findings: fibrin web, lymphocytic, low glucose, high protein

Answer 138

TB meningitis

Question 139

Contraindications to LP?

Answer 139

signs of raised ICP: reduced GCS, bradycardia/hypotension, focal neuro, abnormal posturing, papilloedema, tense bulging fontanelle shock DIC convulsions until stabilised coagulation abnormalities superficial infection at LP site resp insufficiency

Question 140

why is LP contraindicated in resp insufficiency?

Answer 140

lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency

Question 141

CT head of encephalitis caused by HSV - most likely finding?

Answer 141

focal bilateral temporal involvement

Question 142

Ix of encephalitis?

Answer 142

Bloods: cultures, PCR, malaria film CT head LP

Question 143

mx of encephalitis

Answer 143

aciclovir STAT supportive measures phenytoin for seizures

Question 144

risk factors for cerebral abscess

Answer 144

infection of ear, sinus, dental skull # congenital heart disease endocarditis bronchiectasis immunosuppression

Question 145

signs of cerebral abscess

Answer 145

seizures fever signs of raised ICP localizing signs signs of infection elsewhere

Question 146

Ix of Cerebral abscess

Answer 146

CT/MRI head: ring enhancing lesion raised WCC, ESR

Question 147

Mx of cerebral abscess

Answer 147

neurosurgical referral treat raised ICP (mannitol/ hypertonic saline) Antibiotics e.g. ceftriaxone

Question 148

what is epilepsy?

Answer 148

recurrent tendency to spontaneous, intermittent, abnormal electrical activity in part of the brain, manifest as seizures

Question 149

causes of non-epileptic / provoked seizures

Answer 149

alcohol/ benzo/ opiate withdrawal metabolic: Glucose, Na, Ca, urea, NH2 raised ICP: meningitis, encephalitis, HIV, cysticerosis eclampsia pseudoseizures

Question 150

causes of acquired seizures

Answer 150

post-stroke cortical scarring: trauma, infection SOL MS SLE sarcoidosis

Question 151

what is the prodrome of a seizure?

Answer 151

change in mood/ behaviour lasting hrs- days

Question 152

simple seizure?

Answer 152

awareness intact

Question 153

complex seizure?

Answer 153

impaired awareness

Question 154

secondary generalised seizure?

Answer 154

focal -\> generalized e.g. aura -\> tonic clonic

Question 155

what is an aura?

Answer 155

simple partial seizure (usually temporal) experienced as a strange feeling: - deja vu/ jamais vu - automatisms - smells, lights, sounds

Question 156

diagnostic features of seizure

Answer 156

aura specific trigger e.g. flashing lights lateral tongue biting typical movements e.g. tonic-clonic cyanosis post-ictal phase

Question 157

features of west syndrome/ infantile spasms?

Answer 157

clusters of head nodding and arm jerks EEG shows hypsarrhythmia

Question 158

atonic seizure?

Answer 158

sudden loss of muscle tone -\> fall no LOC

Question 159

myoclonic seizure?

Answer 159

sudden jerk of limb, face/ trunk

Question 160

absence seizure features?

Answer 160

Abrupt onset and offset Short: \<10s Eyes: Glazed, blank stare Clonus or automatisms may occur EEG: 3hz spike and wave stimulated by hyperventilation

Question 161

localising features of seizures suggesting involvement of occipital lobe?

Answer 161

visual phenomena: spots, lines, flashes

Question 162

localising features of seizures suggesting involvement of parietal lobe?

Answer 162

sensory disturbance: tingling, numbness

Question 163

localising features of seizures suggesting frontal lobe involvement?

Answer 163

motor features: jacksonian march, Tood's palsy, arrest

Question 164

what is a jacksonian march?

Answer 164

The characteristic features of Jacksonian march are (1) it only occurs on one side of the body; (2) it progresses in a predictable pattern from twitching or a tingling sensation or weakness in a finger, a big toe or the corner of the mouth, then marches over a few seconds to the entire hand, foot or facial muscles.

Question 165

what is Todd's paresis?

Answer 165

transient weakness of a hand, arm, or leg after focal seizure activity within that limb. The weakness may range in severity from mild to complete paralysis.

Question 166

localising features of seizures suggesting temporal lobe involvement?

Answer 166

automaticisms: lip smacking, chewing, fumbling deja/ jamais vu abdominal rising/ N+V emotional disturbance: terror, panic, anger, elation tastes, smells delusional behaviour

Question 167

Pt had a one off seizure while awake and lost consciousness what advice regarding DVLA and driving?

Answer 167

cannot drive for 6 months (providing no more attacks) + DVLA's medical advisers decide there isnt a high risk pt will have another seizure (ie. normal MRI/ EEG)

Question 168

If first seizure but abnormal EEG/ MRI advice regarding DVLA and driving?

Answer 168

cannot drive for 12 months

Question 169

Seizures only when asleep? what advice regarding DVLA and driving

Answer 169

cannot drive until past 12 months since first attack

Question 170

Pt has had epileptic attacks while awake and lost consciousness. advice re driving and DVLA?

Answer 170

Cannot drive til no attack for at least a year

Question 171

if a epilepsy pt had a seizure because doctor had changed/ reduced anti-epilepsy medicine what advice re DVLA and driving?

Answer 171

have to stop driving until seizure \> 6m ago or back on previous medication for 6 months

Question 172

seizures that dont affect consciousness or driving? advice re driving and DVLA

Answer 172

need to contact DVLA. You may still qualify for a licence if these are the only type of attack you’ve ever had and the first one was 12 months ago.

Question 173

Bus, coach or lorry license. advice if pt has had more than one seizure?

Answer 173

cannot drive unless - no seizure for 10 years - haven't taken any anti-epileptic mx for 10 yrs - \<2% risk of another seizure

Question 174

bus, coach or lorry license. if pt had a one-off seizure?

Answer 174

no epileptic attack for 5 years no anti-epileptic mx for 5 years must have been assessed in the past 12 months by a neurologist

Question 175

general advice about epilepsy and seizures

Answer 175

diagnosis made by specialist dont diagnose epilepsy from one seizure after any seizure, advise against driving, swimming, bath until Dx established after dx, cannot drive until seizure-free for \>1 yr

Question 176

indications for MRI after a seizure?

Answer 176

developed epilepsy as an adult any evidence of focal onset seizures continue despite 1st line tx

Question 177

1st line tx of absence seizures?

Answer 177

ethosuximide sodium valproate

Question 178

1st line mx of focal seizures?

Answer 178

carbamazepine or lamotrigine

Question 179

1st line mx of generalized tonic-clonic seizures

Answer 179

sodium valproate

Question 180

1st line mx of myoclonic seizures

Answer 180

sodium valproate

Question 181

1st line mx of atonic/ tonic seizures

Answer 181

sodium valproate

Question 182

tx of epilepsy in pregnancy

Answer 182

avoid valproate take lamotrigine/ carbamazepine 5 mg folic acid daily

Question 183

side effects of lamotrigine?

Answer 183

skin rash-\> SJS rash may be assoc w hypersensitivity -\> fever, raised LFTs, DIC diplopia, blurred vision levels affected by enzyme inhibitors/ inducers

Question 184

status epilepticus mx?

Answer 184

ABC approach IV lorazepam 2-4 mg IV bolus over 30s (or buccal midazolam/ rectal diazepam) can repeat if no response within 2 min

Question 185

Mx of status epilepticus after first line tx?

Answer 185

IV Infusion of Phenytoin monitor ECG and BP CI: bradycardia or heart block or IV Diazepam Call anaesthetic for airway support

Question 186

mx of cerebral oedema with malignancy?

Answer 186

dexamethasone

Question 187

primary survey of pt w head injury

Answer 187

A to E approach A: immobilize C-spine (Hard collar), stabilize airway-\> jaw thrust, ?intubation B: 100% O2, RR C: IV access, HR, BP D: GCS, pupils E: expose pt, look for obvious injuries

Question 188

Head injury secondary survey what would you look for specifically?

Answer 188

lacerations obvious facial/ skull deformity CSF leak from nose or ears Battle's sign, Racoon eyes Blood behind Tympanic Membrane C spine tenderness /deformity

Question 189

Hx after head injury

Answer 189

GCS after injury ?LOC headache fits vomiting amnesia alcohol?

Question 190

mx of head injury?

Answer 190

neurosurgical opinion if signs of raised ICP, CT evidence of intracranial bleed, significant skull # Admit if: - abnormalities on imaging - CNS signs: vomiting, severe headache - GCS not returned to 15 - difficult to assess: alcohol, post ictal Neuro obs half hourly until GCS 15: GCS, pupils, HR/ BP/ RR/ SpO2/ Temp

Question 191

Guidelines to intubate after head injury

Answer 191

GCS ≤ 8 PaO2 \< 9kPa on air / \<13 kPa on O2 or PCO2 \> 6 kPa Spontaneous hyperventilation: PCO2 \< 4 KPa Respiratory irregularity

Question 192

GCS Eyes what is 1-4?

Answer 192

4 - spontaneous eye opening 3 - open to voice 2 - open to pain 1 - no opening

Question 193

GCS Verbal what is 1- 5?

Answer 193

5 - Orientated conversation 4 - confused conversation 3 - inappropriate speech 2 - incomprehensible sounds 1 - no speech

Question 194

GCS Motor what is 1-6?

Answer 194

6: obeys commands 5 - localises pain 4 - withdraws to pain 3 - decorticate posturing to pain (flexor) 2 - decerebrate posturing to pain (extensor) 1 - no movement

Question 195

After Head injury, CT head guidelines?

Answer 195

BANGS LOC Break: open, depressed or base of skull # Amnesia \> 30 min retrograde Neuro deficit or seizure GCS: \<13 at any time or \<15 2h after injury Sickness: Vomited \>1x LOC or amnesia and any of: - Age ≥65 - dangerous mechanism: RTA, fall from great height - coagulopathy (inc warfarin)

Question 196

risk of intracranial haematoma in adults if confused + skull #?

Answer 196

1:4

Question 197

risk of intracranial haematoma in adults if fully conscious + skull #?

Answer 197

1:30

Question 198

risk of intracranial haematoma in adults if confused + no skull #?

Answer 198

1:100

Question 199

risk of intracranial haematoma in adults if fully conscious + no skull #?

Answer 199

very low. \<1:1000

Question 200

symptoms of raised ICP

Answer 200

headache: worse on waking, lying down, bending forward, on straining, coughing Vomiting reduced consciousness visual disturbance: transient visual obscurations and visual loss pulse synchronous tinnitus (pulsatile tinnitus) | (red flag: waking pt up from sleep)

Question 201

signs of raised ICP

Answer 201

papilloedema diplopia due to sixth cranial nerve palsy (or other) reduced GCS

Question 202

Most common brain tumour is?

Answer 202

secondary metastases: e.g. from breast, lung, melanoma

Question 203

most common primary brain tumour in adults?

Answer 203

glioblastoma multiforme

Question 204

presentation of idiopathic intracranial hypertension?

Answer 204

typically obese females signs and symptoms of raised ICP e.g. headache, visual disturbances e.g. blurred vision, 6th CN palsy, enlarged blind spot

Question 205

causes of idiopathic intracranial HTN?

Answer 205

usually idiopathic may be secondary to venous sinus thrombosis or drugs

Question 206

mx of idiopathic intracranial HTN

Answer 206

weight loss if overweight Acetazolamide: reduces CSF production loop diuretics prednisolone - to relieve headaches and reduce the risk of vision loss regular LPs to drain excess CSF lumbar-peritoneal shunt may be necessary if drugs fail and visual loss deteriorates

Question 207

ix of idiopathic intracranial HTN

Answer 207

full neurological examination assessment of eyes and vision CT/ MRI head LP to detect opening pressure

Question 208

prognosis of idiopathic intracranial HTN?

Answer 208

usually self limiting permanent visual loss in 10%

Question 209

types of cerebral oedema

Answer 209

Vasogenic (increased capillary permeability): trauma, tumour, ischaemia, infection Cytotoxic: e.g. from hypoxia Interstitial: e.g. obstructive hydrocephalus, low Na+

Question 210

what are some causes of raised ICP?

Answer 210

haemorrhage SOL- tumours, abscess infection hydrocephalus cerebral oedema cerebral venous thrombosis

Question 211

what is Cushing's Reflex?

Answer 211

a physiological nervous system response to increased ICP results in Cushing's triad of: raised BP, bradycardia, irregular breathing usually seen in terminal stages of acute head injury and may indicate imminent brain herniation

Question 212

what is Cheyne-Stokes respiration?

Answer 212

an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease then stop. pattern repeats with each cycle usually taking 30s - 2 min

Question 213

acute mx of raised ICP

Answer 213

ABC Treat seizures and correct hypotension Elevate bed to 40 degrees Neuroprotective ventilation: PaO2\>13, PCO2: 4.5, Good sedation +/- NM blockade Mannitol or hypertonic Saline: may reduce ICP in short-term but may cause rebound raised ICP later

Question 214

what is tonsillar herniation?

Answer 214

increased pressure in posterior fossa leading to displacement of cerebellar tonsils through foramen magnum. -\> compression of brainstem and cardiorespiratory centres in medulla

Question 215

symptoms of tonsillar herniation?

Answer 215

CN6 palsy upgoing plantars - \> irregular breathing - \> apnoea Death

Question 216

what is an uncal hernation?

Answer 216

compression of ipsilateral inferomedial temporal lobe (uncus) against free margin of tentorium cerebelli

Question 217

uncal herniation symptoms?

Answer 217

ipsilateral CN3 palsy: dilation of pupil then down and out ipsilateral corticospinal tract: contralateral hemiparesis may cause compression of contralateral corticospinal tracts -\> ipsilateral hemiparesis (Kernohan's notch)

Question 218

what is the kernohan's notch?

Answer 218

a secondary condition caused by a primary injury on the opposite hemisphere of the brain due to transtentorial (uncal) herniation -\> causes ipsilateral motor weakness/ paralysis

Question 219

what is a subfalacine herniation?

Answer 219

displacement of cingulate gyrus (medial frontal lobe) under falx cerebri

Question 220

Symptoms of subfalcine herniation?

Answer 220

compression of ACA -\> stroke symptoms e.g. contralateral motor/sensory loss in legs\>arms abulia (pathological laziness)

Question 221

Postural instability -\> falls + speech distrubance (+ dementia) + vertical gaze palsy Dx?

Answer 221

Progressive supranuclear palsy

Question 222

Autonomic dysfunction: postural hypotension, bladder dysfunction + cerebellar + pyramidal signs + rigidity \> tremor?

Answer 222

Multiple systems atrophy | (shy drager)

Question 223

parkinsonism + visual hallucinations + fluctuating cognition?

Answer 223

Lewy body dementia

Question 224

parkinsonism + aphasia, dysarthria, apraxia + akinetic rigidity in one limb + astereognosis (cortical sensory loss) + alien limb phenomenon

Answer 224

Corticobasilar degeneration

Question 225

what is astereognosis?

Answer 225

Astereognosis (or tactile agnosia if only one hand is affected) is the inability to identify an object by active touch of the hands without other sensory input, such as visual or sensory information.

Question 226

what is alien hand syndrome?

Answer 226

prevalent in 60% of ppl with corticobasal degeneration failure of an individual to control the movements of his or her hand, which results from the sensation that the limb is "foreign" + The movements of the alien limb are a reaction to external stimuli and do not occur sporadically or without stimulation

Question 227

other causes of parkinsonism e.g. infection, vascular, drugs, trauma, genetic

Answer 227

infection: syphilis, HIV, CJD vascular: multiple infarcts in substantia nigra drugs: antipsychotics, metoclopramide trauma: dementia pugilistica Genetic: wilson's disease

Question 228

features of parkinsonism?

Answer 228

tremor: worse at rest, exacerbated by distraction, pill rolling rigidity: increased tone (lead pipe), rigidity + tremor -\> cog wheel rigidity bradykinesia gait: decreased arm swing, festinance, freezing

Question 229

what produces the cog wheel rigidity in parkinsons?

Answer 229

rigidity (increased tone in all muscle groups) + tremor

Question 230

features of bradykinesia of parkinsons?

Answer 230

slow initiation of movement with reduction of amplitude on repetition expressionless face monotonous voice micrografia

Question 231

how is Parkinson's disease diagnosed?

Answer 231

Clinical diagnosis DaTSCAN: Ioflupane has a high binding affinity for presynaptic dopamine transporters (DAT)

Question 232

on-off effect of motor fluctuations in parkinsons?

Answer 232

refers to a switch between mobility and immobility in levodopa-treated patients, which occurs as an end-of-dose or “wearing off” worsening of motor function or, much less commonly, as sudden and unpredictable motor fluctuations. Over time: much less ON and more OFF

Question 233

invasive mx of parkinsons?

Answer 233

deep brain stimulation Consider deep brain stimulation for people with advanced Parkinson's disease whose symptoms are not adequately controlled by best medical therapy

Question 234

Mx of Parkinson's disease symptoms by MDT?

Answer 234

PD specialist nurses: point of contact for support, including home visits when appropriate + clinical monitoring and medicines adjustment Physiotherapy Occupational Therapy: help w ADLs SALT: to improve speech and communication + improve the safety and efficiency of swallowing to minimise the risk of aspiration Dietician:

Question 235

mx of drooling of saliva in PD pts when SALT has been ineffective?

Answer 235

glycopyrronium bromide contraindicated (for example, in people with cognitive impairment, hallucinations or delusions, or a history of adverse effects following anticholinergic treatment)

Question 236

mx of Parkinson's disease dementia?

Answer 236

anticholinesterase inhibitor e.g. rivastigmine

Question 237

mx of psychotic symptoms (hallucinations and delusions) in PD pts?

Answer 237

Do not treat hallucinations and delusions if they are well tolerated or Reduce the dosage of any Parkinson's disease medicines that might have triggered hallucinations or delusions, taking into account the severity of symptoms and possible withdrawal effects. or Quetiapine

Question 238

mx of daytime sleepiness in PD pts

Answer 238

advise not to drive adjust PD medications consider modafinil

Question 239

mx of rapid eye movement sleep behaviour disorder in PD pts?

Answer 239

Consider clonazepam or melatonin if a medicines review has addressed possible pharmacological causes

Question 240

1st line mx of PD patients whose motor symptoms impact on their quality of life

Answer 240

levodopa e.g. pts who are biologically frail with comorbidities w lower baseline fitness

Question 241

1st line mx of PD patients in early stages where motor symptoms do not impact on their quality of life

Answer 241

e.g. pts who are biologically fit Dopamine agonists e.g. ropinirole, pramipexole Levodopa MAO-B inhibitors: rasagiline, selegiline

Question 242

what is multiple sclerosis?

Answer 242

A chronic inflammatory condition of the CNS characterised by multiple plaques of demyelination disseminated in time and space.

Question 243

classification of multiple sclerosis?

Answer 243

Relapsing-remitting: 80% Secondary progressive Primary progressive: 10% Progressive relapsing

Question 244

pathophysiology of multiple sclerosis?

Answer 244

Plaques of demyelination are hallmark CD4 cell-mediated destruction of oligodendrocytes →demyelination and eventual neuronal death.

Question 245

what is Lhermitte's sign?

Answer 245

seen in MS neck flexion -\> electric shocks traveling down neck -\> trunk -\> limbs

Question 246

presentation of MS?

Answer 246

TEAM tingling (sensory disturbance) eye: optic neuritis (decreased central vision + pain w eye movement) ataxia + other cerebellar signs Motor: usually spastic paraparesis

Question 247

clinical features of sensory disturbance in MS patients?

Answer 247

paraesthesia decreased vibration sense trigeminal neuralgia

Question 248

clinical features of motor disturbance of MS patients?

Answer 248

spastic weakness transverse myelitis (inflammation extends across the entire width of the spinal cord)

Question 249

GI disturbances in MS?

Answer 249

swallowing problems constipation

Question 250

Genitourinary problems in MS?

Answer 250

Erectile dysfunction + anorgasmia urinary retention incontinence

Question 251

cerebellar disturbances in MS?

Answer 251

falls scanning dysarthria trunk and limb ataxia

Question 252

eye disturbances in MS?

Answer 252

diplopia visual phenomena bilateral conjugate gaze palsy optic neuritis -\> atrophy

Question 253

what is Uhthoff's phenomenon?

Answer 253

worsening of neurologic symptoms in multiple sclerosis (or other neurological, demyelinating conditions) when the body gets overheated e.g. from hot weather, fever, exercise, saunas or hot tubs

Question 254

presenting complaint of optic neuritis in multiple sclerosis patients?

Answer 254

pain on eye movement rapidly worsening central vision uhthoff's phenomenon: vision worsens with heat (hot meal, bath, exercise)

Question 255

Findings of optic neuritis on examination?

Answer 255

Decreased visual acuity decreased colour vision (usually red affected first) central scotoma RAPD

Question 256

what is internuclear ophthalmoplegia?

Answer 256

a disorder of conjugate lateral gaze in which the affected eye shows impairment of adduction 1. affected (ipsilateral) eye adducts minimally, if at all 2. contralateral eye abducts, with nystagmus 3. divergence of the eyes leads to horizontal diplopia convergence generally preserved

Question 257

what is the pathology causing internuclear ophthalmoplegia?

Answer 257

multiple sclerosis is often the cause- may cause bilateral INO caused by injury/ disruption of medial longitudinal fasciculus that allows conjugate eye movement by connecting contralateral (PPRF-abducens) CN6 to ipsilateral (oculomotor) CN3

Question 258

Ix of Multiple Sclerosis?

Answer 258

MRI Brain + Spine: typically hyper intense plaques LP: IgG oligoclonal bands Antibiodies: anti-Myelin basic protein Evoked potentials: delayed auditory, visual and sensory

Question 259

Diagnosis of MS?

Answer 259

clinical demonstration of lesions disseminated in time and space may use Macdonald Criteria

Question 260

what is Devic's syndrome?

Answer 260

loss of vision and spinal cord function. optic neuritis + spinal cord dysfunction -\> muscle weakness, reduced sensation/ loss of bladder or bowel control similar to Multiple Sclerosis

Question 261

differentiate between MS and Devic's syndrome?

Answer 261

**Neuromyelitis optica (NMO)- IgG**: highly specific for Devic's syndrome Devic's = neuromyelitis optica MS variant w transverse myelitis and optic atrophy

Question 262

mx of multiple sclerosis long-term

Answer 262

MDT team: specialist nurse, neurologist, physio, OT regular follow up in MS clinic Regular MRI scans (yearly)

Question 263

mx of Multiple Sclerosis during an acute attack?

Answer 263

methylprednisolone - decreases duration and severity of attacks - doesnt influence long-term outcome e. g. oral methylprednisolone 0.5 g daily for 5 days

Question 264

what are some disease-modifying agents recommended for use for preventing relapse in MS patients?

Answer 264

Natalizumab: anti-alpha 4 integrin Ab (decreases relapses by 2/3 in RRMS) Alemtuzumab: anti-CD52 (2nd line in RRMS) IFNB Cladiribine, Dimethyl fumarate, fingolimod, ocrelizumab, teriflunomide

Question 265

symptomatic medication for MS patients suffering from fatigue?

Answer 265

amantadine Explain that MS-related fatigue may be precipitated by heat, overexertion and stress or may be related to the time of day.

Question 266

symptomatic medication for MS patients suffering from depression?

Answer 266

SSRI e.g. citalopram

Question 267

symptomatic medication for MS patients suffering from pain?

Answer 267

if trigeminal neuralgia: carbamazepine other neuropathic pain: gabapentin, pregabalin, amitriptyline, duloxetine

Question 268

symptomatic medication for MS patients suffering from spasticity?

Answer 268

assess and offer treatment for factors that may aggravate spasticity such as constipation, urinary tract or other infections, inappropriately fitted mobility aids, pressure ulcers, posture and pain. gabapentin/ baclofen

Question 269

symptomatic management of MS patients suffering from oscillopsia?

Answer 269

gabapentin

Question 270

symptomatic management of MS patients suffering from urgency/ frequency?

Answer 270

oxybutynin/ tolterodine

Question 271

symptomatic management of MS patients suffering from emotional lability?

Answer 271

amitriptyline

Question 272

better vs worse prognostic signs of MS?

Answer 272

better: female, \<25, sensory signs @ onset, long interval between relapses, few MRI lesions poor: older, male, motor signs @ onset, many relapses early on, many MRI lesions, axonal loss

Question 273

The following cranial nerves also carry parasympathetic fibres: a. oculomotor b. trigeminal c. trochlear d. hypoglossal e. optic

Answer 273

A Cranial nerves 3, 7, 10 and S3-5 carry parasympathetic fibres.

Question 274

what is horner's syndrome?

Answer 274

lesion of sympathetic supply to the eye meiosis, ptosis, anhidrosis

Question 275

what is the visual change assoc with swollen optic discs (papilloedema)?

Answer 275

enlarged blind spot visual obscurations starting from periphery

Question 276

features of optic neuritis?

Answer 276

painful on eye movement reduced visual acuity loss of red green colour vision central scotoma

Question 277

herniation of uncus of the temporal lobe can cause what type of nerve palsy?

Answer 277

third nerve palsy

Question 278

causes of mononeuropathies?

Answer 278

vasculitides e.g. polyarteritis nodosa diabetes - causes microvascular infarcts in individual nerves entrapment and pressure palsies e.g. Carpal tunnel

Question 279

homonymous hemianopia where could the lesion be?

Answer 279

optic tract optic radiation occipital lobe

Question 280

grasp reflex absent which lobe has pathology?

Answer 280

frontal lobe

Question 281

what is pseudobulbar palsy?

Answer 281

characterized by the inability to control facial movements (such as chewing and speaking) condition is usually caused by the bilateral damage to corticobulbar pathways (UMN lesion)

Question 282

which cranial nerves lie in close proximity to the cerebellopontine angle?

Answer 282

V, VII, VIII cranial nerves

Question 283

what type of deafness does otosclerosis produce?

Answer 283

conductive deafness due to reduced compliance in the bony ossicles

Question 284

how does excess prolonged noise lead to deafness?

Answer 284

damages the cochlear hair cells -\> sensorineural deafness

Question 285

what is an acoustic neuroma?

Answer 285

develops on the vestibular portion of the VIII th nerve -\> progressive unilateral sensorineural deafness

Question 286

tx of physiological/ essential tremors?

Answer 286

usually respont to beta blockers

Question 287

commonest cause of small, poorly reactive pupil?

Answer 287

old age

Question 288

lesion in midbrain may cause what change to eyes?

Answer 288

enlarged pupil

Question 289

what is a sixth nerve palsy?

Answer 289

decreased abduction of affected eye lateral rectus palsy

Question 290

how does third nerve palsy present?

Answer 290

pupillary dilatation (third n carries parasympathetic fibres to the constrictor pupillae) ptosis (levater palpebrae superioris) diplopia in all positions of gaze

Question 291

internuclear ophthalmoplegia - where is the lesion?

Answer 291

medial longitudinal fasciculus

Question 292

feature of ramsay-hunt syndrome?

Answer 292

painful vesicles hyperacusis (nerve to stapedius affected) loss of taste to anterior 2/3rd of tongue

Question 293

features of anterior spinal artery occlusion?

Answer 293

loss of pain and sensation dorsal columns (proprioception and vibration) spared

Question 294

what causes painful neuropathies?

Answer 294

due to damage of slow unmyelinated fibres in peripheral nerves that carry pain and temp sensation common causes: alcohol overuse, diabetes

Question 295

what is cervical spondylosis?

Answer 295

age-related wear and tear affecting the spinal disks in your neck

Question 296

features of cervical spondylosis?

Answer 296

can cause UMN signs due to compression of cervical spinal cord +/- LMN signs due to compression of cervical roots pain often worse at night secondary headaches are common

Question 297

what is temporal arteritis assoc with?

Answer 297

polymyalgia rheumatica

Question 298

features of temporal arteritis?

Answer 298

headache jaw claudication and scalp tenderness (due to ischaemia of scalp/ muscles of mastication)

Question 299

what is the dominant lobe involved with?

Answer 299

the dominant cerebral cortex is on the LEFT in majority of R-handed people and is specifically involved in reading, maths (dyscalculia), writing and langugage. More subtle functions of the dominant parietal lobe include naming fingers (finger agnosia) and left-right discrimination.

Question 300

monocular visual loss associated with pain on eye movement suggests?

Answer 300

Optic neuritis

Question 301

MS typically presents with?

Answer 301

optic neuritis

Question 302

what is capgras syndrome seen in? (patient accusing spouse of being an imposter)

Answer 302

Lewy body dementia

Question 303

why is thymoma removed in multiple sclerosis?

Answer 303

remove potential risk of malignant transformation and not to improve the underlying disease

Question 304

features of gerstmann syndrome?

Answer 304

Dysgraphia/agraphia: deficiency in the ability to write Dyscalculia/acalculia: difficulty in learning or comprehending mathematics Finger agnosia: inability to distinguish the fingers on the hand Left-right disorientation

Question 305

A left homonymous hemianopia may be due to?

Answer 305

lesion on right optic tract/ radiation or lesion of right occipital lobe

Question 306

where is the lesion? superior quadrantanopia

Answer 306

mnemonic = PITS (Parietal-Inferior, Temporal-Superior) lesion in temporal lobe or due to upper optic radiation

Question 307

where is the lesion? inferior quadrantanopia

Answer 307

mnemonic = PITS (Parietal-Inferior, Temporal-Superior) lesion in parietal lobe or lower optic radiation

Question 308

what happens when u give folate to a pt with B12 deficiency?

Answer 308

giving folate to a patient deficient in B12 can precipitate subacute combined degeneration of the cord Always ensure vitamin B12 levels are checked (and replenished) before giving folate for a macrocytic anaemia.

Question 309

features of subacute combined degeneration of the cord?

Answer 309

Damage to the dorsal columns - loss of proprioception, light touch and vibration sense (sensory ataxia and a positive Romberg's test). Damage to lateral columns - spastic weakness and upgoing plantars (UMN signs). Damage to peripheral nerves - absent ankle and knee jerks (LMN signs).

Question 310

what is mononeuritis multiplex?

Answer 310

simultaneous or sequential involvement of individual non-contiguous nerve trunks. acute or subacute loss of sensory and motor function of individual nerves as the disease progresses, deficit(s) becomes more confluent and symmetrical, making it difficult to differentiate from polyneuropathy.

Question 311

what psychiatric conditions are common comorbidities of parkinsons?

Answer 311

depression is the most common feature (affects about 40%) dementia psychosis sleep disturbances

Question 312

acute mx of migraine?

Answer 312

triptan + NSAID or triptan + paracetamol

Question 313

prophylactic mx of migraine?

Answer 313

topiramate or propranolol 'according to the person's preference, comorbidities and risk of adverse events'. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives

Question 314

what is Hoffman's sign?

Answer 314

Hoffmann sign was elicited by flicking the nail of the middle finger. Any flexion of the ipsilateral thumb and/or index finger was considered positive. 'finger flexor reflex' problem in corticospinal tract (CNS)

Question 315

what is degenerative cervical myelopathy?

Answer 315

often mistaken for carpal tunnel syndrome 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

Question 316

ix of degenerative cervical myelopathy?

Answer 316

MRI of cervical spine = gold standard test It may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change.

Question 317

mx of degenerative cervical myelopathy?

Answer 317

urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery). decompressive surgery timing of surgery is important, as any existing spinal cord damage can be permanent Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery

Question 318

mx of malignancy causing cord compression?

Answer 318

Dexamethasone IV consider chemo, radiotherapy and decompressive laminectomy

Question 319

mx of abscess causing cord compression?

Answer 319

abx and surgical decompression

Question 320

what is the cauda equina?

Answer 320

spinal cord itself ends at L1 horse's tail a bundle of spinal nerves and spinal nerve rootlets, L2-5, S1-5 and coccygeal n

Question 321

cauda equina syndrome?

Answer 321

saddle anaesthesia back pain radicular pain down legs bilateral flaccid arreflexic lower limb weakness urinary/ faecal incontinence poor anal tone neurosurgical emergency

Question 322

Mx of cauda equina syndrome?

Answer 322

Neurosurgical emergency! urgent imaging (MRI spine) surgical decompression

Question 323

what is the conus medullaris?

Answer 323

the tapered, lower end of the spinal cord. occurs near lumbar vertebral L1, L2, occasionally lower.

Question 324

conus medullaris syndrome?

Answer 324

mixed UMN/ LMN weakness early constipation and retention back pain sacral sensory disturbanced ED

Question 325

Mx of conus medullaris syndrome?

Answer 325

neurosurgical emergency urgent Imaging surgical decompression

Question 326

What is spondylosis?

Answer 326

degeneration of the spinal column from any cause usually due to trauma or age related wear and tear commonly affects verterbral bodies and facet joints may cause -\> spinal cord or nerve root compression

Question 327

presentation of cervical spondylosis?

Answer 327

usually asympto neck stiffness +/- crepitus stabbing/ dull arm pain upper limb motor and sensory disturbances according to compression level can -\> myelopathy w quadraparesis and sphincter dysfunction

Question 328

Lhermitte's sign?

Answer 328

neck flexion -\> tingling down spine seen in MS/ compression of spinal cord

Question 329

signs of cervical spondylosis?

Answer 329

Lhermitte's sign: neck flexion -\> tingling down spine Hoffmann's reflex: flick to middle finger pulp → brief pincer flexion of thumb and index finger (suggests hypertonia)

Question 330

ix of cervical spondylosis?

Answer 330

MRI c spine

Question 331

mx of cervical spondylosis?

Answer 331

conservative: stiff collar, analgesia Medical: transforaminal steroid injection Surgical: decompression- laminectomy or laminoplasty

Question 332

presentation of lumbosacral spondylosis?

Answer 332

L5 and S1 roots most commonly compressed by prolapse of L4/5, L5/S1 discs may present as severe pain on sneezing/ coughing lower back pain sciatica - shooting radicular pain down buttock and thigh

Question 333

signs of lumbosacral spondylosis?

Answer 333

limited spinal flexion pain on straight leg raise

Question 334

L5 root compression features?

Answer 334

weak hallux extension +/- foot drop (in foot drop due to L5 radiculopathy, weak inversion (tib post) helps distinguish from peroneal n palsy) decreased sensation on inner dorsum of foot

Question 335

S1 root compression features?

Answer 335

Weak foot plantarflexion and eversion loss of ankle jerk calf pain decreased sensation over sole of foot and back of calf

Question 336

mx of lumbar spondylosis?

Answer 336

Conservative: rest, analgesia, mobilisation/physio Medical: transforaminal steroid injection Surgical: discectomy or laminectomy may be considered in cauda-equina syndrome, continuing pain or muscle weakness.

Question 337

what is spinal stenosis?

Answer 337

Developmental predisposition ± facet joint osteoarthritis→ generalized narrowing of lumbar spinal canal. most often lower back and neck

Question 338

presentation of spinal stenosis?

Answer 338

**spinal claudication** aching or heavy buttock and lower limb pain on walking rapid onset parasthesiae/ numbness pain eased by leaning forward pain on spine extension negative straight leg raise

Question 339

ix of spinal stenosis?

Answer 339

MRI

Question 340

mx of spinal stenosis?

Answer 340

corsets NSAIDs epidural steroid injection canal decompression surgery

Question 341

Pathophysiology of bell's palsy?

Answer 341

inflammatory oedema from entrapment of CNVII in narrow facial canal usually of viral origin (HSV 1) 75% of facial palsy

Question 342

features of Bell's Palsy?

Answer 342

sudden onset e.g. overnight complete, unilateral facial weakness in 24-72 h - failure of eye closure -\> dryness - bell's sign: eyeball rolls up on attempted closure - drooling, speech difficulty Numbness or pain around ear decreased taste Hyperacusis: stapedius palsy

Question 343

Ix of Bell's Palsy?

Answer 343

Serology: Borrelia or VZV abs MRI: SOL, stroke, MS LP

Question 344

Mx of Bell's Palsy?

Answer 344

**prednisolone** within 72 h 60mg/d PO for 5/7 followed by tapering **valaciclovir** if zoster suspected **protect eye:** dark glasses, artificial tears, tape eyes closed at night

Question 345

complications of Bell's palsy?

Answer 345

aberrant neural connections synkinesis: e.g. blinking causes up turning of mouth crocodile tears: eating stimulates unilateral lacrimation, not salivation

Question 346

pathophysiology of ramsay hunt syndrome?

Answer 346

reactivation of VZV in geniculate ganglion of CNVII (Facial N)

Question 347

features of ramsay hunt syndrome?

Answer 347

preceding ear pain or stiff neck vesicular rash in auditory canal +/- tympanic membrane, pinna, tongue, hard palate ipsilateral facial weakness, ageusia, hyperacusis may affect CN8 -\> vertigo, tinnitus, deafness

Question 348

mx of Ramsay Hunt syndrome?

Answer 348

if diagnosis suspected give valaciclovir and prednisolone within first 72h

Question 349

what is mononeuritis multiplex?

Answer 349

2 or more peripheral nerves affected usually systemic cause: DM most commonly

Question 350

median nerve palsy?

Answer 350

sensory: radial 3.5 fingers and palm tinels and phalens +ve Thenar wasting most hand muscles of the anterior forearm -\> weakness of wrist and finger flexion + thumb abduction/ flexion/ opposition

Question 351

ulnar nerve palsy?

Answer 351

sensory loss: ulnar 1.5 fingers motor: partial claw hand, hypothenar wasting weakness and wasting of 1st dorsal interosseous froment's sign +ve

Question 352

Radial n palsy?

Answer 352

sensory: dorsal thumb root (snuff box) motor: low lesion: finger drop high: wrist drop v high: triceps paralysis, wrist drop

Question 353

tibial n palsy?

Answer 353

sensory loss: sole of foot motor: cant plantar flex -\> cant stand on tiptoe weak foot inversion weak toe flexion

Question 354

common peroneal n palsy?

Answer 354

sensory loss: below knee laterally motor: foot drop (cant walk on heels) weak ankle dorsiflexion, eversion (inversion intact)

Question 355

sciatic n palsy?

Answer 355

sensory loss: below knee laterally and foot motor: hamstrings all muscles below knee

Question 356

phrenic n palsy?

Answer 356

C3-5 orthopnoea + raised hemidiaphragm

Question 357

lateral cutaneous n of thigh palsy?

Answer 357

meralgia paraesthetica - anterolateral burning thigh pain

Question 358

peripheral neuropathy main causes?

Answer 358

DM B12 deficiency Alcohol

Question 359

features of peripheral neuropathy?

Answer 359

glove and stocking distribution deep tendon reflexes may be decreased/ absent signs of trauma or joint deformity (charcot's joints) diabetic and alcoholic neuropathies are painful

Question 360

B12 deficiency -\> SCDC what fibres are lost first?

Answer 360

dorsal columns

Question 361

causes of autonomic neuropathy?

Answer 361

DM HIV SLE GBS, LEMS

Question 362

features of autonomic neuropathy?

Answer 362

postural hypotension ED, ejaculatory failure decreased sweating constipation/ nocturnal diarrhoea urinary retention horners

Question 363

Autonomic function tests?

Answer 363

BP: postural drop \> 20/10 mmHg ECG: variation \> 10 bpm w respiration

Question 364

what is Miller-Fisher syndrome?

Answer 364

variant of guillain-barre opthalmoplegia + ataxia + areflexia

Question 365

causes of guillain- barre?

Answer 365

antibodies cross react to gangliosides may be idiopathic bacteria: campylobacter jejuni, mycoplasma Viruses: CMV, EBV, HSV Vaccines: esp rabies

Question 366

features of guillain barre?

Answer 366

symmetrical, ascending flaccid weakness/ paralysis LMN signs: areflexia, fasciculations progressive phase lasts ≤ 4wks autonomic neuropathy \*\*breathing problems

Question 367

ix of guillain barre syndrome?

Answer 367

serology for anti-ganglioside abs evidence for infection e.g. stool sample demyelinating nerve conduction studies: slow conduction velocities Protein in CSF: protein often \> 5.5 g/L, normal WCC

Question 368

Mx of Guillain Barre Syndrome?

Answer 368

Supportive: airway/ ventilation: ITU if FVC \< 1.5L analgesia: NSAIDs, gabapentin autonomic: may need inotropes, catheter Antithrombotic: TEDS, LMWH Immunosuppression: IVIG, plasma exchange Physiotherapy: prevent flexion contractures

Question 369

what is charcot marie tooth syndrome?

Answer 369

a type of hereditary motor and sensory neuropathy HMSN1: commonest form demyelinating AD mutation HMSN2: second commonest axonal degeneration

Question 370

clinical features of charcot marie tooth

Answer 370

onset at puberty thickened, enlarged nerves esp common peroneal Motor: foot drop -\> high stepping gait weak ankle dorsiflexion and toe extension absent ankle jerks symmetrical muscle atrophy: "champagne bottle" legs due to peroneal muscle wasting, claw hands Pes cavus (high arched feet) Sensory: variable loss of sensation in a stocking distribution neuropathic pain in some

Question 371

Mx of Charcot Marie Tooth?

Answer 371

Supportive Physio Podiatry Orthoses e.g. ankle braces

Question 372

Ix of Charcot Marie Tooth?

Answer 372

Genetic Testing: PMP22 gene mutation Nerve conduction studies: decreased conduction speed in HMSN1

Question 373

Characteristics of Motor Neuron Disease?

Answer 373

Cluster of degenerative disease characterised by axonal degeneration of neurones in the motor cortex, CN nuclei and anterior horn cells. **UMN and LMN signs** **NO** sensory loss or sphincter disturbance dont affect eye movements

Question 374

Causes of motor neuron disease?

Answer 374

unknown 10% familial: e.g. SOD1 mutation

Question 375

Ix of motor neuron disease?

Answer 375

Brain/ Cord MRI: exclude structural cause LP: exclude inflammatory cause EMG: shows denervation

Question 376

Diagnosis of motor neuron disease?

Answer 376

Use Revised El Escorial Diagnostic criteria

Question 377

Mx of motor neuron disease?

Answer 377

MDT: neurologist, physio, OT, specialist nurse, GP, family Riluzole: antiglutamatergic that prolongs life by ~3 mo Supportive: drooling: propantheline or amitriptyline dysphagia: NG/ PEG feeding Resp failure: NIV Pain: analgesia spasticity: baclofen

Question 378

prognosis of motor neuron disease?

Answer 378

most die within 3 years -\> from bronchopneumonia and resp failure worse prognosis: elderly, female, bulbar involvement

Question 379

types of MND?

Answer 379

_Amyotrophic Lateral Sclerosis: 50%_ loss of motor neurones in cortex and ant horn -\> UMN signs and LMN wasting + fasciculation _Progressive Bulbar Palsy: 10%_ only affects CN 9-12 -\> bulbar palsy _Progressive muscular atrophy: 10%_ anterior horn cell lesion -\> LMN signs only Distal to proximal _Primary lateral sclerosis_ loss of Betz cells in motor cortex -\> mainly UMN signs Marked spastic leg weakness and pseudobulbar palsy no cognitive decline

Question 380

which type of Motor neuron disease has LMN signs only?

Answer 380

progressive muscular atrophy -\> only anterior horn cell lesions

Question 381

Features of Bulbar Palsy?

Answer 381

LMN lesions of tongue, talking and swallowing flaccid, fasciculating tongue speech: quiet or nasal normal/ absent jaw jerk loss of gag reflex

Question 382

Pseudobulbar Palsy features?

Answer 382

Bilateral lesions above mid pons e.g. corticobulbar tracts -\> **UMN** lesions of swallowing and talking Spastic tongue slow tongue movements w slow deliberate speech: hot potato speech Brisk jaw jerk Emotional incontinence

Question 383

Bulbar vs Pseudobulbar palsy?

Answer 383

Bulbar: LMN lesions of tongue, swallowing, speaking Pseudobulbar: UMN lesions of tongue, swallowing, talking,

Question 384

features of poliomyelitis?

Answer 384

asymmetric LMN paralysis No sensory involvement may be confined to upper or lower limbs or both resp muscle paralysis can -\> death + fever, sore throat, myalgia poliovirus affects anterior horn cells

Question 385

Pathophysiology of Duchenne's Muscular Dystrophy?

Answer 385

X-linked recessive, 30% spontaneous -\> non functional dystrophin Dystrophin is important to maintain the muscle fiber's cell membrane

Question 386

Presentation of duchenne's muscular dystrophy?

Answer 386

~4 yo muscle loss -\> weakness difficulty standing calf pseudohypertrophy Gower's sign +ve resp failure

Question 387

Ix of Duchenne's muscular dystrophy?

Answer 387

creatine kinase levels extremely high

Question 388

pathophysiology of Becker's muscular dystrophy?

Answer 388

X linked recessive partially functioning dystrophin presents later than duchenne's, is less severe and has better prognosis

Question 389

pathophysiology of fascioscapulohumeral muscular dystrophy (landouzy-dejerine)?

Answer 389

autosomal dominant affects the skeletal muscles of the face (facio), scapula (scapulo) and upper arms (humeral)

Question 390

presentation of fascioscapulohumeral muscular dystrophy?

Answer 390

onset @ 12-14 yo weakness of face, shoulders and upper arms (often asymmetric w deltoids spared) Winging of scapula foot drop bilat sensorineural hearing loss life expectancy threatened by resp insufficiency

Question 391

pathophysiology of myotonic dystrophy?

Answer 391

autosomal dominant gradually worsening muscle loss and weakness muscles often contract and are unable to relax (tonic muscle spasm)

Question 392

presentation of myotonic dystrophy?

Answer 392

**face:** myopathic facies: long, thin, expressionless wasting of fascial muscles and SCM bilateral ptosis dysarthria **hands**: myotonia: slow relaxation e. g. unable to release hand after shake wasting and weakness of distal muscles + areflexia -\> wrist drop percussion myotonia: percuss thenar eminance -\> involuntary thumb flexion others: frontal balding cataracts DM Cardiomyopathy dysphagia testicular atrophy

Question 393

mx of Myotonic dystrophy?

Answer 393

no mx for weakness phenytoin may improve myotonia caution w GA: high risk of anaesthetic complications

Question 394

features of inclusion body myositis?

Answer 394

type of inflammatory myopathy asymmetric weakness affecting distal and prox muscles - early involvement of quads, ankle dorsiflexors and wrist/ finger flexors - \> loss of grip strength and decreased dexterity dysphagia is v common myalgia is uncommon

Question 395

what drugs are assoc w idiopathic intracranial HTN?

Answer 395

oral contraceptive pill, steroids, tetracycline, vitamin A, lithium

Question 396

what antiplatelet regimens are recommended for secondary prevention following acute ischaemic stroke?

Answer 396

Aspirin 300 mg for 2 weeks after stroke then Clopi 75 mg for the long term

Question 397

Indications for thrombolysis?

Answer 397

administered within 4.5 hours of onset of stroke symptoms ## Footnote haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Question 398

what thrombolysis mx is currently recommended?

Answer 398

alteplase

Question 399

pathophysiology of NF1 vs NF2?

Answer 399

both autosomal dominant NF1: aka von Recklinghausen's syndrome. It is caused by a gene mutation on chromosome 17 which encodes neurofibromin NF2: gene mutation on chromosome 22

Question 400

Features of NF1?

Answer 400

Café-au-lait spots (\>= 6, 15 mm in diameter) Axillary/groin freckles Peripheral neurofibromas Iris hamartomas (Lisch nodules) in \> 90% Scoliosis Pheochromocytomas

Question 401

Features of NF2?

Answer 401

Bilateral vestibular schwannomas (SNHL first sign) Multiple intracranial schwannomas, mengiomas and ependymomas

Question 402

cafe au lait spots in NF1? at least how many? and size?

Answer 402

\> 6, \>15mm across

Question 403

complications of neurofibromas?

Answer 403

sarcomatous change compression: - nerve roots: weakness, pain, paraesthesia GI: bleeds, obstruction

Question 404

What are Lisch nodules?

Answer 404

iris hamartomas seen in NF1 use a slit lamp

Question 405

mx of NF1?

Answer 405

MDT Yearly BP and cutaneous review Excise some neurofibromas genetic counselling

Question 406

Juvenile posterior subcapsular lenticular opacity?

Answer 406

form of cataract bilateral assoc w NF2 occur before other manifestations and may be useful for screening those @ risk

Question 407

Mx of NF2?

Answer 407

Hearing tests from puberty in affected families (bilat vestibular schwannomas) MRI brain if abnormality detected (look for schwannomas, meningiomas, gliomas)

Question 408

pathophysiology of myasthenia gravis?

Answer 408

autoimmune disease mediated by antibodies against nicotinic Ach receptors interferes with neuromuscular transmission via depletion of working post synaptic receptor sites

Question 409

presentation of myasthenia gravis?

Answer 409

increasing muscular fatigue - extra-ocular: bilateral ptosis, diplopia - bulbar: voice deteriorates on counting to 50 - face: myastthenic snarl on attempting to smile - neck: head droop - limb: asymmetric proximal weakness normal tendon reflexes weakness worsened by pregnancy, infection, emotion, drugs (BB, gent, opiates, tetracyclines)

Question 410

Ix of myasthenia gravis?

Answer 410

Tensilon Test: IV edrophonium, +ve if power improves within 1 min Anti-AChR abs increased EMG: decreased response to a train of impulses Resp function: decreased FVC Thymus CT (thymoma may be present) TFTs

Question 411

Pathophysiology of Lambert-Eaton Myasthenic Syndrome?

Answer 411

antibodies to VGCC -\> decreased influx of calcium during presynaptic excitation -\> decreased presynaptic ACh-vesicle fusion

Question 412

causes of lambert eaton myasthenic syndrome?

Answer 412

autoimmune paraneoplastic e.g SCLC

Question 413

presentation of lambert eaton myasthenic syndrome?

Answer 413

Muscle fatigue - movement improves symptoms leg weakness early (before eyes) autonomic neuropathy and areflexia small response to edrophonium

Question 414

antibodies found in lambert eaton myasthenic syndrome?

Answer 414

Anti-VGCC abs

Question 415

mx of lambert eaton myasthenic syndrome?

Answer 415

IVIG Do regular CXRs as symptoms may precede Cancer by 4 years

Question 416

Myasthenia gravis assoc w ?

Answer 416

\<50 yrs: more common in women assoc with other autoimmune disease (DM, RA, Graves) thymic hyperplasia

Question 417

Treatment of myasthenia gravis?

Answer 417

symptom control - anticholinesterase e.g. pyridostigmine Immunosuppression: - tx relapses with prednisolone Thymectomy: - consider if young onset and disease not controlled by anticholinesterases - remission in 25%, benefit in further 50%

Question 418

Complications of Myasthenia gravis?

Answer 418

myasthenic crisis: - weakness of respiratory muscles - monitor FVC -\> ventilation support if \< 20ml/kg - plasmapheresis or IVIG - tx trigger for relapse (e.g. drugs, infection)

Question 419

pathophysiology of botulism?

Answer 419

Botulinum toxin prevents ACh vesicle release

Question 420

Presentation of botulism?

Answer 420

Descending flaccid paralysis with no sensory signs Anti-cholinergic effects: mydriasis, cycloplegia, n/v, dry mouth, constipation

Question 421

mx of botulism?

Answer 421

benpen + antiserum

Question 422

cerebellar vermis vs cerebellar hemisphere lesions?

Answer 422

Cerebellar hemisphere lesions cause peripheral ('finger-nose ataxia') Cerebellar vermis lesions cause gait ataxia (locomotion)

Question 423

Acute vs chronic subdural haematoma on CT?

Answer 423

On CT imaging, acute haematomas appear bright (hyperdense) whereas chronic haematomas appear dark (hypodense).

Question 424

who is at risk of chronic subdural haematomas?

Answer 424

Elderly and alcoholic patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taught bridging veins. Rupture of the small bridging veins within the subdural space rupture and cause slow bleeding. Presentation is typically a several week to month progressive history of either confusion, reduced consciousness or neurological deficit.

Question 425

presentation of intrinsic cord disease?

Answer 425

Painless Early sphincter / erectile dysfunction Bilateral motor and sensory disturbance below lesion

Question 426

what is brown-sequard syndrome?

Answer 426

Hemi-cord lesion Ipsilateral loss of proprioception and vibration sense Ipsilateral UMN weakness Contralateral loss of pain sensation (since pain fibres decussate at level of entry)

Question 427

bilateral acoustic neuromas assoc w?

Answer 427

NF2

Question 428

Ix of vestibular schwannoma / acoustic neuroma?

Answer 428

MRI cerebellopontine angle

Question 429

what is syringomyelia?

Answer 429

syrinx: fluid filled cavity formed within the spinal cord commonly in cervical cord Symptoms may be static for yrs but then worsen fast  e.g. on coughing, sneezing as ↑ pressure → extension Syrinx expands ventrally affecting: - Decussating spinothalamic neurones - Anterior horn cells - ant Corticospinal tracts

Question 430

causes of syringomyelia?

Answer 430

Blocked CSF circulation w decreased flow from posterior fossa - Arnold-Chiari malformation - masses Spina bifida 2^o to cord trauma, myelitis, cord tumours, and AVMs

Question 431

signs of syringomyelia?

Answer 431

Dissociated sensory loss: - absent pain and temp - preserved touch, proprioception and vibration - root distribution reflects syrinx location (usually cape distribution: upper limbs and chest) Wasting/ weakness of hands +/- claw hand Loss of reflexes in upper limb Charcot joints: shoulder and elbow Horner's syndrome syringobulbia: cerebellar and lower CN signs UMN weakness in lower limbs w upgoing plantars

Question 432

ix of syringomyelia?

Answer 432

MRI spine

Question 433

what is friedrich's ataxia?

Answer 433

auto recessive progressive degeneration of Dorsal root ganglions, spinocerebellar and corticospinal tracts and cerebellar cells mitochondrial disorder onset in teenage years assoc w HOCM and mild dementia

Question 434

Adult T cell leukaemia/ lymphoma + Tropical spastic paraplegia - slowly progessing spastic paraplegia - sensory loss and parasthesia - bladder dysfunction

Answer 434

HTLV- 1 -\> HTLV myelopathy

Question 435

gold standard of venous sinus thrombosis?

Answer 435

MR venogram

Question 436

mx of cluster headaches?

Answer 436

Acute: 100% Oxygen triptans e.g. sc sumatriptan 2/52 course of steroids may reduce attack frequency at onset of the cycle

Question 437

what anaesthetic drug is not as effective in myasthenia gravis pts?

Answer 437

suxamethonium

Question 438

What kind of diet is an established treatment for children with epilepsy that is hard to control and is generally unresponsive to antiepileptic medications?

Answer 438

Ketogenic diet high in fat, low in carb, controlled protein

Question 439

prophylaxis of migraine?

Answer 439

1st line: topiramate or propranolol

Question 440

presentation of lacunar infarct?

Answer 440

1 of the following: 1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three. 2. pure sensory stroke. 3. ataxic hemiparesis

Question 441

presentation of Weber's syndrome?

Answer 441

ipsilateral III palsy contralateral weakness

Question 442

Answer 442

CT head high density fluid (Blood) in the cerebral sulci, sylvian fissure and basal ganglia -\> subarachnoid haemorrhage usually due to rupture of berry aneurysm

Question 443

Most common cause of mengitis in adults?

Answer 443

neisseria meningitidis Pneumococcus

Question 444

Complications of Meningitis?

Answer 444

deafness (most common) other neurological: epilepsy, paralysis infective: sepsis, intracerebral abscess pressure: brain herniation, hydrocephalus

Question 445

what triggers pain in trigeminal neuralgia?

Answer 445

light touch, including washing, shaving, smoking, talking, and brushing the teeth

Question 446

Mx of trigeminal neuralgia?

Answer 446

1st line carbamazepine

Question 447

Gold standard Ix for Cervical myelopathy?

Answer 447

MRI cervical spine

Question 448

Mx of cervical myelopathy?

Answer 448

All should be urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery) early tx is essential, as any existing spinal cord damage can be permanent **decompressive surgery** only effective treatment. close observation is an option for mild stable disease. Beware of physio: only initiated by specialist services, as manipulation can cause more damage

Question 449

Diagnosis of Lewy Body Dementia?

Answer 449

usually clinical SPECT increasingly used - specificity of 100%

Question 450

Mx of Lewy Body dementia?

Answer 450

both acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) and memantine can be used as they are in Alzheimer's.

Question 451

Mx of Acute ischaemic stroke which develops into haemorrhagic transformation?

Answer 451

stop aspirin 300mg & control BP (\<140)

Question 452

features of fourth n palsy?

Answer 452

Cant depress eye, look medially ## Footnote vertical diplopia classically noticed when reading book or going down stairs

Question 453

subungual fibromata?

Answer 453

tuberous sclerosis: ash leaf spots shagreen patches adenoma sebaceum

Question 454

1st line ix for suspected vestibular schwannoma?

Answer 454

audiogram and gadolinium-enhanced MRI head scan (MRI of cerebellopontine angle)

Question 455

adverse effects of Levodopa?

Answer 455

dyskinesia 'on-off' effect postural hypotension cardiac arrhythmias nausea & vomiting psychosis reddish discolouration of urine upon standing

Question 456

levodopa features?

Answer 456

usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of L-dopa to dopamine reduced effectiveness with time (usually by 2 years) no use in neuroleptic induced parkinsonism

Question 457

features of essential tremor?

Answer 457

Postural tremor: worse if arms outstretched Improved by alcohol and rest Titubation (nodding movement of head or body) Often strong FH

Question 458

Features of migraine more common in children?

Answer 458

attacks may be shorter-lasting headache is more commonly bilateral GI disturbance is more prominent.

Question 459

What are some typical auras with migraines?

Answer 459

transient hemianopic disturbance or a spreading scintillating scotoma ('jagged crescent'). Sensory symptoms may also occur

Question 460

Features of Neuroleptic malignant syndrome?

Answer 460

more common in young male patients onset usually in first 10 days of treatment or after increasing dose pyrexia rigidity tachycardia raised CK and WCC

Question 461

Mx of neuroleptic malignant syndrome?

Answer 461

stop antipsychotic IV fluids to prevent renal failure dantrolene\* may be useful in selected cases bromocriptine, dopamine agonist, may also be used

Question 462

triggers for neuroleptic malignant syndrome?

Answer 462

antipsychotics dopaminergic drugs (such as levodopa) for Parkinson's disease, usually when the drug is suddenly stopped or the dose reduced

Question 463

bilateral sensorineural hearing loss + cafe au lait spots?

Answer 463

NF II Neurofibromatosis type 2 is associated with bilateral vestibular schwannomas

Question 464

what cranial nerves pass through the superior orbital fissure?

Answer 464

III, IV, V1, VI

Question 465

trigeminal nerve palsy causes?

Answer 465

trigeminal neuralgia loss of corneal reflex (afferent) loss of facial sensation paralysis of mastication muscles deviation of jaw to weak side

Question 466

Facial n palsy causes?

Answer 466

flaccid paralysis of upper + lower face loss of corneal reflex (efferent) loss of taste hyperacusis

Question 467

Hypoglossal n palsy?

Answer 467

Tongue deviates towards side of lesion

Question 468

Accessory n palsy?

Answer 468

Lesions may result in; ## Footnote weakness turning head to contralateral side

Question 469

Vagus n palsy causes?

Answer 469

uvula deviates away from site of lesion loss of gag reflex (efferent)

Question 470

glossopharyngeal n palsy causes?

Answer 470

hypersensitive carotid sinus reflex loss of gag reflex (afferent)

Question 471

Corneal reflex afferent and efferent?

Answer 471

afferent: V1 Efferent: Facial n

Question 472

Jaw jerk afferent and efferent?

Answer 472

afferent: mandibular nerve V3 efferent: Mandibular nerve

Question 473

gag reflex / carotid sinus afferent and efferent?

Answer 473

afferent: glossopharyngeal (IX) Efferent: Vagal (X)

Question 474

Lacrimation afferent and efferent?

Answer 474

afferent: ophthalmic V1 efferent: facial n

Question 475

bitemporal hemianopia upper quadrant defect \> lower quadrant defect?

Answer 475

inferior chiasmal compression, commonly a pituitary tumour

Question 476

bitemporal hemianopia lower quadrant defect \> upper quadrant defect?

Answer 476

superior chiasmal compression, commonly a craniopharyngioma

Question 477

ondansetron MOA?

Answer 477

5-HT3 antagonists used mainly in the management of chemotherapy related nausea act in the chemoreceptor trigger zone area of the medulla oblongata SE: constipation is common

Question 478

A 60 year-old male presents with clumsy hands. He has been dropping cups around the house. His wife complains he doesnt answer his mobile as he struggles to use it. His symptoms have been gradually deteriorating over the preceding months.

Answer 478

Degenerative cervical myelopathy loss of fine motor function in both upper limbs

Question 479

in what situation might you consider stopping a pt's anti epileptic drugs?

Answer 479

if seizure free \> 2 yrs AEDs stopped over 2-3 mo

Question 480

ix. of degenerative cervical myelopathy?

Answer 480

MRI cspine may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change.

Question 481

features of common peroneal n palsy?

Answer 481

weakness of foot dorsiflexion weakness of foot eversion weakness of extensor hallucis longus sensory loss over the dorsum of the foot and the lower lateral part of the leg wasting of the anterior tibial and peroneal muscles

Question 482

prophylaxis of migraine?

Answer 482

topiramate or propranolol riboflavinn may help menstrual migraine: frovatriptan

Question 483

MRC power grading?

Answer 483

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

Question 484

recommended screening tool to assess for likelihood of stroke?

Answer 484

ROSIER is an acronym for 'Recognition Of Stroke In the Emergency Room' Exclude hypoglycaemia first, then assess A stroke is likely if \> 0

Question 485

mx of acute cluster headaches?

Answer 485

100% oxygen (80% response rate within 15 minutes) subcutaneous triptan (75% response rate within 15 minutes)

Question 486

prophylaxis of cluster headache?

Answer 486

verapamil some evidence to support a tapering dose of prednisolone

Question 487

blockage of which artery causes aphasia?

Answer 487

Dominant hemisphere middle cerebral artery strokes cause aphasia usually L

Question 488

triad of normal pressure hydrocephalus?

Answer 488

urinary incontinence dementia and bradyphrenia gait abnormality (may be similar to Parkinson's disease)

Question 489

what is autonomic dysreflexia?

Answer 489

clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention cause a sympathetic spinal reflex via thoracolumbar outflow. The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion. -\> unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported.

Question 490

antiemetic recommended for Parkinsons?

Answer 490

Domperidone Domperidone does not cross the blood-brain barrier and therefore does not cause extra-pyramidal side-effects

Question 491

which type of MND carries the worst prognosis?

Answer 491

Progressive bulbar palsy - palsy of the tongue, muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei

Question 492

mx of fatigue in MS?

Answer 492

once other problems (e.g. anaemia, thyroid or depression) have been excluded NICE recommend a trial of amantadine CBT/ mindfulness

Question 493

mx of spasticity in MS?

Answer 493

baclofen and gabapentin are first-line physio

Question 494

mx of bladder dysfunction in MS?

Answer 494

guidelines stress the importance of getting an ultrasound first to assess bladder emptying - anticholinergics may worsen symptoms in some patients if significant residual volume → intermittent self-catheterisation if no significant residual volume → anticholinergics may improve urinary frequency

Question 495

Mx of oscillopsia (visual fields appear to oscillate) in MS?

Answer 495

gabapentin is first-line

Question 496

what anti-emetics are impt in chemotx related nausea?

Answer 496

5-HT3 antagonists e.g. ondansetron granisetron mainly act in the chemoreceptor trigger zone area of the medulla oblongata.

Question 497

what is a lacunar stroke?

Answer 497

most common type of ischaemic stroke, and results from the occlusion of small penetrating arteries that provide blood to the brain's deep structures 5 classic syndromes 1. hemiparesis / pure motor 2. Ataxic hemiparesis 3. dysarthria/ clumsy hand 4. Pure sensory 5. Mixed sensorimotor

Question 498

what to give Parkinsons patients if they are unable to take their levodopa orally?

Answer 498

dopamine agonist patch as rescue medication to prevent acute dystonia

Question 499

viral labyrinthitis vs vestibular neuritis?

Answer 499

vestibular neuritis = only vestibular nerve is involved -\> no hearing impairment Labyrinthitis = both vestibular nerve and labyrinth involved -\> vertigo and hearing impairment

Question 500

symptoms of viral labyrinthitis?

Answer 500

vertigo: not triggered by movement but exacerbated by movement nausea and vomiting hearing loss: may be unilateral or bilateral, with varying severity tinnitus preceding or concurrent symptoms of upper respiratory tract infection

Question 501

signs of labyrinthitis?

Answer 501

spontaneous unidirectional horizontal **nystagmus** towards the **unaffected** side sensorineural hearing loss abnormal head impulse test: signifies an impaired vestibulo-ocular reflex gait disturbance: the patient may fall towards the affected side normal skew test abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection

Question 502

What is intranuclear ophthalmoplegia?

Answer 502

problem in the communication between CN VI (abducens) of the R eye and CN III (occulomotor) of the L eye or vice versa - cant maintain conjugate gaze -\> diplopia - the side able to abduct will develop compensatory nystagmus

Question 503

mx of recalcitrant psoriasis (not responsive to conventional treatment)?

Answer 503

topical retinoids phototherapy oral drugs e.g. methotrexate, cyclosporin

Question 504

what hormone can be used to differentiate between true seizure and pseudoseizure?

Answer 504

serum prolactin

Question 505

what is Hoover's sign?

Answer 505

differentiates between organic and non-organic lower leg weakness due to synergistic contraction: examiner would feel the 'normal' limb pushing downwards against their hand as the patient tries to lift the 'weak' leg. if -ve: not a true weakness

Question 506

Features of Lambert-Eaton?

Answer 506

repeated muscle contractions lead to **increased** muscle strength\* limb girdle weakness (affects lower limbs first) hyporeflexia autonomic symptoms: dry mouth, impotence, difficultly micturating

Question 507

EMG in Lambert Eaton?

Answer 507

incremental response to repetitive electrical stimulation

Question 508

Mx of Lambert Eaton syndrome?

Answer 508

treatment of underlying cancer (ie. SCLC) immunosuppression (prednisolone and/or azathioprine) intravenous immunoglobulin therapy and plasma exchange may be beneficial

Question 509

causes of lambert eaton syndrome?

Answer 509

autoimmune malignancy: SCLC, breast, ovarian ca

Question 510

What blood tests are done to exclude reversible causes of dementia?

Answer 510

FBC, U&E, LFTs, calcium, glucose, TFTs, vitamin B12 and folate levels.

Question 511

In secondary care, what ix can be done to exclude reversible causes of dementia?

Answer 511

neuroimaging e.g. subdural, normal pressure hydrocephalus