NEUROLOGY Flashcards

Question

how is neurocysticercosis managed?

Answer 1

- IV dexamethasone - albendazole - anti-convulsants

Answer 2

- Pain location: Unilateral peri-orbital pain associated. - Pain quality: Most often reported as sharp but this is variable. - Pain intensity: Severe or very severe. - Effects on activities: Restlessness or agitation. - Conjunctival injection - Lacrimation - Eyelid oedema - Forehead and facial sweating - Constricted pupil and eyelid drooping - Nasal congestion. - Duration: 15 minutes to 180 minutes.

Answer 3

- Offer 100% oxygen at a flow rate of least 12 litres per minute with a non-rebreathing mask and reservoir mask. Arrange provision of home and ambulatory oxygen. - Offer subcutaneous triptan (sumatriptan).

Answer 4

- Consider verapamil for prophylactic treatment during a bout of cluster headache. - Consider topiramate or lithium as a second line prophylactic treatment during a bout of cluster headaches. - Consider gammaCore to reduce the frequency and intensity of cluster headaches.

Answer 5

- Headache occurs on 15 or more days per month - regular overuse of symptomatic headache medication for more than 3 months - For triptans, opioids, ergotamine and combination analgesia, intake must be 10 days or more per months to be considered overuse. - For simple analgesics such as NSAIDs, aspirin, and paracetamol, intake must be 15 days or more per month to be considered overuse.

Answer 6

- Advise people to stop taking all overused acute headache medications for at least 1 month and to stop abruptly rather than gradually. - Review and reassess the underlying primary headache disorder 4–8 weeks after withdrawing the overused medication. - If appropriate, the overused medications may be reintroduced after 2 months, with clear restrictions on frequency of use.

Answer 7

- Family history of migraine. - Disturbed sleep. - Irregular or missed meals. - Excessive caffeine intake. - Lack of exercise. - Menstruation. - Obesity. - Stressful life events.

Answer 8

- Headache lasting 4-72 hours in adults or 2-72 hours in adolescents. - Unilateral location, more common bilateral in children. - Pulsating quality described as throbbing or banging. - Moderate or severe pain intensity. - Aggravation by, or causing avoidance of routine activities. - Headache with associated symptoms include at least one of: - --Nausea and vomiting. - --Photophobia and photophobia.

Answer 9

- Visual symptoms such as zigzag lines (positive symptom) and scotoma (negative symptom). - Sensory symptoms such as unilateral pins and needles or numbness. - Speech and language symptoms such as dysphagia. - At least three of the following: - --At least one aura symptoms spreads gradually over at least 5 minutes. - --Two or more aura symptoms occur in succession. - --Each individual aura symptom lasts 5-60 minutes and is fully reversible. - --At least one aura symptom is unilateral. - --At least one aura symptom is positive. - --The aura is accompanied, or followed within 60 minutes, by headache.

Answer 10

- Encourage the patient to keep a headache diary to identify triggers to be avoided and to review the effectiveness of treatment. - Recommend lifestyle changes - Offer simple analgesia - Trpitan - antiemetic

Answer 11

- topiramate (not in pregnancy) - propranolol - amitriptyline - propranolol or pizotifen in children

Answer 12

- Abdominal distention - Abdominal mass - Pain: abdominal with a mass, but there may be bone or back pain indicative of metastases - Decreased appetite - Weight loss - Fatigue - Periorbital ecchymosis and subcutaneous skin nodules associated with metastases - Signs of Horner’s syndrome if primary is in the upper portion of the thoracic outlet of cervical sympathetic chain - Signs of superior vena cava syndrome if the primary is in the upper portion of the thoracic outlet

Answer 13

- Measure urinary catecholamines: Positive - Perform ultrasound abdomen: heterogenous mass with internal vascularity; may show calcifications or areas of necrosis - Perform CT or MRI abdomen: heterogenous mass; may show calcifications or areas of necrosis - Consider performing 123-iodine-metaiodobenzylguanidine (MIBG) scintigraphy or PET with 18-F-deoxyglucose to identify sites of metastases

Answer 14

localised tumour with complete gross excision, with or without microscopic residual disease

Answer 15

localised tumour with incomplete gross excision

Answer 16

- localised tumour with or without complete gross excision | - with ipsilateral non-adherent lymph nodes positive for tumour

Answer 17

- unresectable unilateral tumour infiltrating across the midline - with or without regional lymph node involvement - localised unilateral tumour with contralateral regional lymph node involvement - midline tumour with bilateral extension via infiltration or lymph node involvement

Answer 18

any primary tumour with dissemination to distant lymph nodes, bone, bone marrow, liver, skin, and/or other organs

Answer 19

localised primary tumour, with dissemination limited to skin, liver, and/or bone marrow (limited to infants <1 year of age, marrow involvement <10% of total nucleated cells, 123-iodine-metaiodobenzylguanidine [MIBG] scan findings negative in the marrow).

Answer 20

-perform surgical tumour resection

Answer 21

0neo-adjuvant chemotherapy with carboplatin, etoposide, cyclophosphamide and doxorubicin - surgery - radiotherapy if resection is unsuccessful

Answer 22

- give induction chemotherapy with carboplatin, etoposide, cyclophosphamide and doxorubicin - surgical resection - consolidation chemotherapy with carboplatin, etoposide, cyclophosphamide, melphalan, busulfan or thiotepa followed by autologous bone marrow transplant - Local control of the tumour is achieved with radiotherapy - dinutuximab beta.

Answer 23

- personality change - cognitive changes - emotional lability - productive dysphasia - motor weakness

Answer 24

- contralateral homonymous upper quandrantinopia | - receptive aphasia

Answer 25

- sensory deficit | - contralateral homonymous lower quadrantinopia

Answer 26

-contralateral homonymous hemianopia

Answer 27

-truncal ataxia

Answer 28

- Grade 1: Well circumscribed. - Grade 2: Well defined margins; Hyper-intense T1; Hypo-intense T2. - Grade 3: Poorly defined markings; Hypo-intense T1; Hyper-intense T2. - Grade 4 (glioblastoma) Poorly defined; Significant oedema; necrosis.

Answer 29

- dexamethasone and mannitol for raised ICP - levetiracetam for seizures - maximal resection - maximal safe resection plus radiotherapy (60 Gy) for accessibly grade 2 and 3 tumours. For inaccessible tumours offer radiotherapy. - maximal safe resection plus radiotherapy plus chemotherapy (temozolomide) for accessible grade 4 tumours. For inaccessible tumours offer radiotherapy and chemotherapy.

Answer 30

- Headache. - Focal neurological deficits based on location and size of tumour. - Seizures

Answer 31

- surgical excision and adjunct stereotactic radiosurgery for symptomatic tumours in under 65s - stereotactic radiosurgery for symptomatic tumours in over 65s and poor surgical candidates. - salvage therapy for recurrent tumour following surgical resection or stereotactic radiosurgery.

Answer 32

- Asymmetrical hearing loss, usually gradual - Facial numbness - Progressive episodes of dizziness - Tinnitus - Difficulty localising sounds - Symptoms associated with other cranial nerve palsies as the tumour enlarges

Answer 33

- audiogram: sensorineural hearing loss - gadolinium enhanced MRI head: uniformly enhanced, dense mass extending into the internal acoustic meatus; Absence of dural tail

Answer 34

- observe - surgical resection - stereotactic radiotherapy

Answer 35

- Female sex. - Weight gain. - Obesity. - Drugs including the oral contraceptive pill, vitamin A, steroids, and indomethacin.

Answer 36

- Headache. - Visual field loss. - Pulse-synchronous headache. - Photophobia. - Decreased visual acuity. - Diplopia. - Sixth nerve palsy.

Answer 37

- Perform perimetry: Enlarged blind spot. - Perform optic disc photographs: Papilloedema. - Perform a lumbar puncture: Elevated opening pressure.

Answer 38

- Recommend weight reduction - carbonic anhydrase inhibitor (acetazolamide) to decrease intracranial pressure. - topiramate as a secondary option to decrease intracranial pressure. - CSF shunting for intractable headaches. - optic nerve sheath fenestration for patients with visual loss. - low dose amitriptyline for pain management.

Answer 39

- Thunderclap headache, a sudden severe headache that peaks within 1 to 5 minutes and lasts more than an hour. - Vomiting. - Photophobia. - Neck stiffness. - Depressed consciousness. - Confusion. - Kernig’s sign. - Features of third nerve compression e.g. eyelid drooping, diplopia and mydriasis, orbital pain.

Answer 40

-Order an emergency non-contrast CT: Hyper-dense areas of blood in the subarachnoid space and basal cisterns. -CT/MR angiography to identify the causal pathology -Perform a lumbar puncture: Bloody and xanthochromic appearance

Answer 41

- ABC approach - nimodipine - analgesia and supportive care - reverse anticoagulation - endovascular coiling or surgical clipping - bed rest

Answer 42

- Headache. - Nausea and vomiting. - Drowsiness. - Confusion. - Otorrhoea and rhinorrhoea indicate occult basilar skull fracture. - Hemiparesis. - Localised weakness. - Loss of bowel and bladder continence.

Answer 43

-Perform non-contrast CT scan: Crescentic subdural fluid collection that can cross suture lines; Hyper-dense in acute SDH; Hypo-dense in chronic SDH.

Answer 44

- Perform a trauma craniotomy for acute subdural haematomas that are larger than 10 mm in size or midline shift greatest than 5 mm. - Offer prophylactic antiepileptics (phenytoin or levetiracetam) - Stop anti platelet or anticoagulant therapy. - Offer an intracranial pressure lowering regimen

Answer 45

- Offer antiepileptics (phenytoin or levetiracetam) - Perform burr-hole craniotomy with irrigation or a test drill craniotomy with drain placement for symptomatic chronic haematoma.

Answer 46

- Head injury with a brief duration of unconsciousness, followed by improvement (the lucid interval). - Stupor - Ipsilateral dilated pupil - Contralateral hemiparesis, with rapid transtentorial coning. - Bilateral fixed dilated pupils, tetraplegia and respiratory arrest follow.

Answer 47

-Perform a CT head: bi-convex hyperlucency limited by sutures; Features of mass effect such a midline shift, subfalcine and uncal herniation; swirl sign with ongoing bleeding

Answer 48

- headache, often followed by stupor/coma and signs of cerebellar/brainstem origin (e.g. nystagmus, ocular palsies). - Gaze deviates towards the haemorrhage. - Skew deviation - acute hydrocephalus

Answer 49

- Location: Bilateral pain. - Pressing or tightening, non-pulsating. - Pain intensity: Mild to moderate. - Not aggravated by routine activities of daily living. - No nausea or vomiting - no more than one of photophobia or photophobia. - 30 minutes to continuous.

Answer 50

- simple analgesia (aspirin, paracetamol, ibuprofen) for an acute episode. - acupuncture (10 sessions over 5-8 weeks) for the prophylactic treatment of chronic tension-type headaches. - pharmacological prophylaxis (amitriptyline) taking into account comorbidities and risk of adverse effects, this is an ‘off-label’ indication.

Answer 51

- Increasing age - Female sex - Head trauma - Prolonged recumbent position - Migraines - Inner ear surgery - Labrynthitis - Meniere’s disease

Answer 52

- Vertigo provoked by specific head movements (looking up, bending down, getting up, turning the head and rolling over on one side). - Vertigo of <30 seconds - Nausea, imbalance and lightheaded feeling - No associated neurological or otological symptoms

Answer 53

-dix hallpike

Answer 54

- epley or semont | - brandt-daroff exercises

Answer 55

- Vertigo lasting minutes to hours - Hearing loss - Tinnitus, usually described as roaring - Aural fullness - Drop attacks

Answer 56

- short course of prochlorperazine, or an antihistamine (for example cinnarizine, cyclizine, or promethazine teoclate). - trial betahistine to reduce the frequency and severity of attacks of hearing loss, tinnitus, and vertigo.

Answer 57

- Spontaneous, rotational vertigo that can develop on walking and worsens over the day - Exacerbated by changing head position, but initially is constant - Nausea and vomiting - Malaise, pallor and sweating - Falls due to affect on balance - Follows viral illness - Fine, horizontal nystagmus

Answer 58

- To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or an intramuscular injection of prochlorperazine or cyclizine. - To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine teoclate).

Answer 59

- Symptoms are atypical - Symptoms persist with no improvement for more than one week during treatment - Symptoms last longer than 6 weeks

Answer 60

- Viral infections - Chronic suppurative otitis media - Acute otitis media - Cholesteatoma - Meningitis - Inner ear malformations

Answer 61

- Acute rotational vertigo lasting 72 hours - Nausea and vomiting - Hearing loss - Otorrhoea - Nystagmus - Tinnitus - Vertigo-related quick head or body movements

Answer 62

- To rapidly relieve severe nausea or vomiting associated with vertigo, consider giving buccal prochlorperazine, or an intramuscular injection of prochlorperazine or cyclizine. - To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine teoclate). - If viral associated labyrinthitis with no HIV, give prednisolone for 10 to 14 days - In any other cause, give vestibular suppressants and anti-emetics and treat the underlying condition

Answer 63

- Progressive memory loss: loss of recent memory first - Disorientation - Nominal dysphasia: Difficulties naming people and objects - Misplacing items and getting lost - Apathy: become more passive, sleep more than usual or not want to perform usual activities - Decline in activities of daily living and instrumental activities of daily living - Personality change - Poor abstract thinking - Construction dyspraxia - Prosopagnosia: failure to recognise faces - Autoprosopagnosia: failure to recognise oneself in the mirror

Answer 64

- bedside cognitive testing - rule out reversible causes - perform MRI head, FDG-PET or perfusion SPECT

Answer 65

- acetylcholinesterase inhibitors | - memantine

Answer 66

- Male - Age >60 years - Obesity - Hypertension - Cigarette smoking - Diabetes mellitus - Hypercholesterolaemia - Alcohol abuse

Answer 67

- History of stroke/TIA - Difficulty solving problems - Apathy - Disinhibition - Slowed processing of information - Poor attention - Retrieval memory deficit - Frontal release reflexes: including grasp, glabella tap and jaw-jerk. - Focal neurology and impaired gait and balance - Stepwise course of cognitive decline

Answer 68

- bedside cognitive testing - rule out reversible causes - CT/MRI head: vascular lesions - carotid duplex: carotid artery stenosis

Answer 69

- manage vascular risk factors - Offer group cognitive stimulation therapy, group reminiscence therapy or occupational therapy to patients living with mild to moderate dementia

Answer 70

- Cognitive fluctuations - Visual hallucinations: often take the form of people or animals or the sense of a presence (extracampine) - At least one Parkinsonism symptom - REM sleep behavioural disturbance - Autonomic dysfunction - Attention and visuospatial abnormalities - Delusions

Answer 71

- bedside cognitive testing - rule out reversible causes - MRI head: cortical atrophy with preservation of medial temporal lobe - SPECT/PET: low basal ganglia dopamine transporter uptake

Answer 72

- donepezil or rivastigmine | - galatamine if not tolerated

Answer 73

- coarsening of personality: disregard for social conventions, slovenly appearance, impatience and irritability, argumentativeness, lewd and tactless remarks, child-like and impulsive actions, loss of empathy and concern for others, compulsions, and rigid adherence to routines. - Progressive loss of language fluency or comprehension - Development of memory impairment, disorientation or apraxia - Progressive self-neglect and abandonment of work, activities and social contacts - Inattentiveness, puerile pre-occupations, economy of effect and impulsive responding.

Answer 74

- bedside cognitive testing - rule out reversible causes - perform FDG-PET or perfusion SPECT: Focal hypo metabolism in the frontal and anterior temporal lobes

Answer 75

-anti-psychotic as needed

Answer 76

- Cognitive impairment - Limb or gait ataxia - Myoclonus - Parkinsonism - Psychiatric symptoms - Visual changes - Insomnia and dysautonomia

Answer 77

- brain MRI: demonstrates hyperintensity in the cerebral cortex, basal ganglia, and thalamus on diffusion-weighted imaging and FLAIR sequences; hypointensity (restricted diffusion) on attenuated diffusion coefficient map (ADC) sequences - EEG: generalised slowing, focal or diffuse and periodic poly spike wave complexes - quaking-induced conversion: positive

Answer 78

- Provide supportive care - Consider a benzodiazepine or antidepressant for mild to moderate anxiety and agitation - Consider a second generation anti-psychotic for moderate to severe agitation or psychosis - Consider a benzodiazepine or anti-convulsant for distressing myoclonus - Consider an SSRI for depression - Consider a hypnotic for insomnia - Give analgesia for skeletal muscle pain

Answer 79

- Bradykinesia - Resting, pill rolling tremor of 4-6Hz with asymmetrical onset - Cogwheel, lead pipe rigidity - Postural instability - Mask-like facies - Hypophonia - Micrographia - Stooped posture with shuffling gait - Conjugate gaze disorders - Features of autonomic neuropathy - Prodromal symptoms that occur approximately 7 years before diagnosis: anosmia, depression, anxiety, aches and pains, REM sleep disorder, autonomic features, constipation and restless leg syndrome

Answer 80

- Parkinson’s disease is a clinical diagnosis: improvement in symptoms with a dopaminergic agent supports the diagnosis - Consider 123I FP CIT single photon emission computed tomography (SPECT) for people with tremor if essential tremor cannot be clinically differentiated from parkinsonism.

Answer 81

- levodopa/co-careldopa - dopamine agonists or MAO-B inhibitors if motor symptoms do not affect QoL - ergot derived drugs if dyskinesia or motor fluctuations not controlled by other drugs

Answer 82

- intermittent apomorphine injection - continuous subcutaneous apomorphine infusion. - deep brain stimulation

Answer 83

- rivastigmine | - memantine

Answer 84

-syncope caused by bradycardia, tachycardia, or hypotension due to low cardiac index, blood flow obstruction, vasodilatation, or acute vascular dissection.

Answer 85

is syncope due to a reflex that causes vasodilation, bradycardia, or both

Answer 86

- A known precipitant e.g. fear, venesection, pain or prolonged standing - Dizziness and lightheadedness - Nausea - Sweating - Feeling hot - Visual grey out - Associated with standing too rapidly in orthostatic hypotension - Rapid recovery

Answer 87

- Little or no warning - May be associated with palpitations or chest pain - Can occur at rest or during exercise

Answer 88

- 12 lead ECG - blood glucose - FBC

Answer 89

-stiffening of muscles resulting in a fall

Answer 90

-muscles suddenly relax, and they become floppy.

Answer 91

- EEG: atonic show rhythmic spike and wave complexes; tonic seizures show diffuse or generalised accelerating low amplitude activity - MRI

Answer 92

- sodium valproate | - lamotrigine

Answer 93

- Weakness - Wasting - Hypotonia - Reflex loss - Fasciculation - Fibrillation potentials on EMG - Muscle contractures - Trophic changes in skin and nails

Answer 94

- Upper limb extensor muscles weaker than flexors - Lower limb flexors weaker than extensor - Finer more skilful movements most severely impaired - spasticity - muscle wasting - hyperreflexia - positive babinski sign

Answer 95

- Upper extremity weakness with difficulties of ADL - Stiffness with poor co-ordination and balance - Spastic, unsteady gait - Painful muscle spasms - Difficulties in rising from seated and climbing stairs - Foot drop - Head drop - Progressive difficulties in maintaining erect posture with stooping - Muscle atrophy - Increased lumbar lordosis and abdominal protuberance - Hyper-reflexia - Dyspnoea - Choking and coughing - Strained, slow speech - Slurred, nasal and dysphonic speech - Emotional incontinence associated with pseudobulbar palsy

Answer 96

- clinical diagnosis | - EMG: diffuse, ongoing, chronic denervation

Answer 97

- riluzole - quinine, baclofen, tizanidine, dantrolene or gabapentin for muscle cramps - anti-muscarinic or glycopyrrolate for sialorrhoea

Answer 98

- Staring episode lasing 5 to 10 seconds with no aura and no post-ictal state - Childhood onset - Hyperventilation induced seizure - Simple automatisms - Recent decline in school performance

Answer 99

generalised 3Hz spike and wave

Answer 100

- ethosuximide | - sodium valproate

Answer 101

-combine ethosuximide and lamotrigine or ethoxusimide and sodium valproate

Answer 102

- Focal neurological deficits may be present if there is an underlying cause for the epilepsy e.g. space occupying lesion - Loss of consciousness or awareness - Initial tonic stiffening followed by clonic phase with synchronous jerking of the limbs - Eyes remain open throughout - A post-ictal period of flaccid unresponsiveness

Answer 103

generalised epileptiform activity

Answer 104

- sodium valproate - lamotrigine - consider carbamazepine or oxcarbazepine

Answer 105

- Movement of one side of the body or one specific body part - Premonitory sensation or experience (epigastric sensation, deja/jamais vu) in temporal lobe epilepsy - Temporary post-ictal hemiparesis (Todd’s Paresis) - Temporary aphasia and automatisms such as lip-smacking, picking at clothes or posturing - Staring and being unaware of surroundings

Answer 106

-focal spikes or sharp waves with associated slowing of the electrical activity in area of the spikes

Answer 107

- carbamazepine or lamotrigine | - second line: levetiracetam or oxcarbazepine or sodium valproate

Answer 108

-jerking in the morning

Answer 109

Generalised 4-6Hz polyspike and wave

Answer 110

- sodium valproate | - lamotrigine, levetiracetam, topiramate

Answer 111

- Symmetrical, bilateral, brief spasms of the axial muscle groups occurring in clusters - Head nodding - Neurodevelopmental delay or regression - Abnormal eye movements

Answer 112

hypsarrhythmia or modified hypsarrhythmia

Answer 113

- prednisolone | - vigabatrin

Answer 114

-All three of unilateral weakness and/or sensory deficit of the face, arm and leg, homonymous hemianopia and higher cerebral dysfunction (dysphasia, visuospatial disorder)

Answer 115

-Two of unilateral weakness and/or sensory deficit of the face, arm and leg, homonymous hemianopia and higher cerebral dysfunction

Answer 116

-one of cranial nerve palsy and a contralateral motor/sensory deficit, conjugate eye movement disorder, cerebellar dysfunction or isolated homonymous hemianopia or cortical blindness

Answer 117

- one of pure sensory stroke, pure motor stroke, sensorimotor stroke or ataxic hemiparesis

Answer 118

- Sudden onset and brief duration of symptoms - Unilateral weakness or paralysis, which can occur in both anterior and posterior circulation TIAs - Bilateral limb weakness is a feature of vertebrobasilar ischaemia - Dysphasia in anterior circulation ischaemia - Ataxia, vertigo or loss of balance which is common in posterior circulation - Sudden transient loss of vision in one eye (Amaurosis Fugax) - Homonymous hemianopia in posterior circulation TIA - Diplopia in posterior circulation TIA

Answer 119

- Offer 300mg of oral aspirin - refer for specialist investigation within 24 hours - offer secondary prevention

Answer 120

- carotid stenosis of 50 to 99% according to the NASCET criteria - 70% using ECST criteria

Answer 121

- Prolonged or repeated tonic-clonic seizures with an altered level of consciousness - Altered level of consciousness, confusion or change in personality with limited or absent motor findings - Presence of risk factors: - --Poor anti-convulsant adherence - --Alcohol use or withdrawal - --Disturbances in water, glucose or electrolyte metabolism - --Cortical structural damage - --Recreational drug use

Answer 122

- blood glucose - ABG - U and E - anti-convulsant drug levels and toxicology - chest x-ray (aspiration post-ictus) - CT head

Answer 123

- buccal midazolam or rectal diazepam/ IV lorazepam if IV access - secure airway - transfer to hospital

Answer 124

- secure airway - give thiamine and glucose if indicated - IV lorazepam 2 doses - IV phenobarbital or phenytoin - Transfer to ITU - give midazolam, propofol or thiopental sodium to adults - give midazolam or thiopental sodium to children and young adults

Answer 125

- Febrile illness with a temperature of >38.3oC - Generalised tonic-clonic seizure lasting less than 15 minutes - No post-ictal abnormalities

Answer 126

- Diagnosis is clinical, but other investigations may be conducted with regards to the febrile illness: - Lumbar puncture to rule out meningitis - Viral studies - Blood cultures

Answer 127

- monitor and protect from injury - check airway and place in recovery position on cessation of seizure - if longer than 5 minutes, give benzodiazepine rescue medicine if recommend for the child - if 10 minutes, transfer to hospital

Answer 128

- Features of generalised tonic clonic seizure - Features suggesting NES include: duration over two minutes, gradual onset, fluctuating course, violent thrashing movements, side-to-side head movement, asynchronous movements, eyes closed and recall for period of unresponsiveness.

Answer 129

- Vision loss or vision field defect - Weakness: Pure hemiparesis suggests a lacunar stroke, where other deficits suggest MCA occlusion - Aphasia (dominant hemisphere ischaemia) - Ataxia: In the absence of weakness suggests cerebellar infarction - Sensory loss - Diplopia in posterior circulation ischaemia - Dysarthria, particularly in cerebellar or brainstem dysfunction - Gaze paresis in anterior circulation strokes - Vertigo with posterior circulation infarction - Nausea and vomiting that may reflect posterior circulation ischaemia or raised ICP - Neck or facial pain with arterial dissection, particularly in patients with Marfan’s, or following a hairdresser appointment or osteopathic manipulation - Horner’s syndrome with posterior circulation - In an anterior circulation stroke with Horner’s syndrome, consider carotid artery dissection - Altered level of consciousness

Answer 130

- Perform an urgent non-contrast CT head: - hypoattenuation of the parenchyma - loss of grey-white differentiation and sulcal effacement - hyperattenuation in an artery indicates clot in the lumen - primary function is to exclude haemorrhage

Answer 131

- ABCDE - endotracheal intubation with GCS <8 - 300mg aspirin If unsuitable for thrombosis

Answer 132

- Stroke or head trauma in previous 3 months - Any prior history of intracranial haemorrhage - Major surgery with 2 weeks or bleeding within 21 days - MI in the prior 3 months - Arterial or lumbar puncture within 7 days - Persistent systolic BP >185, diastolic >110 or requiring aggressive therapy - Pregnancy - Active bleeding or trauma - Thombocytopenia - INR >1.7 - Elevated APTT

Answer 133

- 6 hours of symptoms onset, together with confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA - within 6 to 24 hours of symptoms onset with confirmed occlusion of the proximal anterior circulation demonstrated by CTA or MRA, and there is potential to salvage brain tissue as shown by CT perfusion imaging - less than 3 on pre-functional modified Rankin scale - 5 or more on NIHSS

Answer 134

- The standard treatment is clopidogrel 75mg daily - Modified-release dipyridamole 200 mg twice daily may be used if both clopidogrel and aspirin are contraindicated or cannot be tolerated. - Aspirin 75mg daily may be used if both clopidogrel and modified-release dipyridamole are contraindicated or cannot be tolerated. - Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily may be used if clopidogrel cannot be tolerated. - Dual therapy with aspirin and clopidogrel may be initiated in secondary care for the first three months following ischaemic stroke or TIA due to severe symptomatic intracranial stenosis or for another condition such as acute coronary syndrome.

Answer 135

- Progressive symmetrical muscle weakness, usually affecting the lower extremities and distal muscles first - Flaccid paralysis with areflexia - Respiratory distress - Paraesthesia in the hands and feet that progresses proximally - Back or leg pain - Bulbar dysfunction - Extra-ocular muscle weakness

Answer 136

- Perform nerve conduction studies: slowing of nerve conduction velocities - Perform a lumbar puncture: elevated CSF protein; normal or slightly raised lymphocytes - Perform spirometry at 6-hourly intervals: reduced vital capacity, maximal inspiratory pressure and maximal expiratory pressure

Answer 137

- Start plasma exchange or IV immunoglobulin for 5 days (if there is no IgA deficiency) - Monitor respiratory function and intubate if needed - Ensure DVT prophylaxis is instituted

Answer 138

- Graying or blurring of vision in one eye; there may be pain on moving that eye and loss of colour discrimination, particularly reds (optic neuritis) - Peculiar sensory phenomena - Lhermitte’s sign - Weakness on walking that settles on rest - Leg cramps or jerking in the calves - Fatigue - Urinary frequency, detrusor instability and urinary retention - Bowel dysfunction such as constipation - Spasticity and increased muscle tone - Hyperreflexia and ankle clonus - Imbalance and incoordination - Abnormal eye movements: internuclear ophthalmoplegia (nystagmus of the abducting eye with absent adduction of the other eye) - Symptoms worsen with heat (Uhthoff’s phenomenon)

Answer 139

- clinical demyelination disseminated in time and space - MRI brain: hyperintensities in the periventricular white matter - MRI spine: Demyelinating lesions in the spinal cord, particularly the cervical spinal cord; detection of alternative diagnosis, such as cervical spondylosis

Answer 140

- Offer oral methylprednisolone 0.5g daily for 5 days - Consider IV methylprednisolone 1g daily for 3-5 days for people in whom oral steroids have failed or are not tolerated, or who need admitting to hospital for a severe relapse or other disease monitoring.

Answer 141

- Interferon 1a | - glatiramer acetate

Answer 142

- Interferon 1b - teriflunomide - alemtuzumab - ocrelizumab

Answer 143

-2 clinically significant relapses in the previous 2 years

Answer 144

- fingolimod | - cladribine

Answer 145

- natalizumab | - cladribine

Answer 146

-An unchanged/increased relapse rate, or ongoing relapses compared with the previous year despite treatment

Answer 147

-2 or more disabling relapses in 1 year, and one or more gadolinium-enhancing lesions on brain MRI or a significant increase in T2 lesion load compared with a previous MRI

Answer 148

- Positive family history - Impaired work or school performance - Personality change, particularly irritability or temper outbursts - Impulsivities - Chorea - Twitching or restlessness - Loss of coordination - Deficit in fine motor coordination - Slow saccadic eye movements - Motor impersistence - Impaired tandem walking - Concentration impairment - Cognitive decline - Changes in personal habits - Disinhibition or anxious behaviour

Answer 149

- Diagnosis is clinical - Perform CAG repeat testing: Positive with >40 CAG repeats on 1 of the 2 alleles - Perform an MRI or CT scan: Caudate or striatal atrophy

Answer 150

- Prescribe tetrabenazine, sulpiride, a second generation anti-psychotic, benzodiazepines or amantadine to manage chorea without behavioural problems - Prescribe SSRIs for depression - To manage temper outbursts or irritability with carbamazepine or valproate - Give SSRIs or CBT with obsessive compulsive behaviours - To manage chorea, bradykinesia, weight loss or an acute presentation, give haloperidol, quetiapine, olanzapine or sulpiride - For bradykinesia without behavioural problems, give levodopa or amantadine - ECT can be used for refractory depression in Huntington’s

Answer 151

- Numbness of the hand in the median nerve distribution (palmar aspect of the first 4 fingers) with sparing of the thenar eminence, that is worse at night - Weakness of the hand, particularly for rotational movements - Clumsiness - Weakness of thenar muscles (thumb abduction)

Answer 152

- Perform electromyography: focal slowing of conduction velocity in the median sensory nerves across the carpal tunnel; prolongation of the median distal motor latency; possible decreased amplitude of median sensory and/or motor nerves - Perform USS or MRI wrist: space-occupying lesion may be seen - Perform blood tests as appropriate if underlying cause suspected

Answer 153

- Refer to an appropriate specialist if: the diagnosis is unclear, severe symptoms, reduced functional ability, recurrence following surgery, failed conservative managed or serious condition suspected - Optimise treatment of underlying condition and give lifestyle advice - Offer wrist splitting in a neutral position at night - Offer corticosteroid injections and follow up monthly - If this fails, refer for surgical decompression

Answer 154

- clawing of the hand - wasting of interossei and hypothenar muscles - weakness of interossei and medial two lumbricals – with sensory loss in the little finger and splitting the ring finger.

Answer 155

- Wrist drop | - weakness of brachioradialis and finger extension

Answer 156

- foot drop - preserved ankle jerk - patch of numbness on the anterolateral border of the dorsum of the foot/lateral calf

Answer 157

- Ischaemic: vasculitis and diabetes mellitus - Inflammatory or immune mediated - Infectious - Drug induced: sulphonamides, PTU, hydralazine, allopurinol, cefaclor, minocycline, D-penicillamine, phenytoin, isotretinoin, methotrexate, interferons, TNF-alpha inhibitors, quinolones, leukotriene inhibitor - Genetics - Mechanical - Secondary to malignancy

Answer 158

- Perform electromyography in the clinically relevant areas - Perform investigations to find the underlying cause - Peform a muscle or nerve biopsy: tissue evidence of neuropathy

Answer 159

- Family history of neuropathy, pes cavus or abnormal gait - Walking difficulties due to weakness and atrophy of the lower leg and foot - Pes cavus - Steppage gait - Diffuse tendon hyporeflexia or areflexia - Reduced muscle strength - Reduced sensation and sensory ataxia - Ankle weakness - Toe walking - Delayed motor milestones

Answer 160

- Perform nerve conduction studies: conduction velocities of 15-38 m/second, reduced or absent sensory responses, and prolonged distal latencies in demyelination; reduced amplitudes and normal conduction velocities (>38m/second) in axonal loss - Perform genetic testing: gene mutation associated with specific CMT subtype

Answer 161

- Offer physiotherapy, exercise and occupational therapy to all patients - Patients should be evaluated for bracing of the feet to ensure proper alignment - Some patients may require orthopaedic surgery for foot deformities associated with CMT, or for secondary complications such as osteoarthritis

Answer 162

- swelling - severe deformaties - instability

Answer 163

- Disease progression - Weakness that is typically symmetrical and involves all four limbs - Altered sensation - Decreased deep tendon reflexes - Incoordination

Answer 164

- slow conduction velocities - prolonged distal latencies - prolonged F-wave latencies - conduction block

Answer 165

- Observe patients with mild disease - Consider initial monotherapy with corticosteroids, IVIG or plasma exchange - Give treatment for neuropathic pain with amitriptyline, gabapentin, pregabalin or carbamazepine - If initial treatment fails, combine steroids with either IVIG or plasma exchange , or change which steroid is in use (methylprednisolone, dexamethasone or prednisolone) - alternative immunosuppressant such as ciclosporin, azathioprine, mycophenolate mofetil or rituximab

Answer 166

- Decreased sensation of the legs - Reduced tendon reflexes - Progressive muscle weakness and wasting

Answer 167

- Measure erythrocyte thiamine pyrophosphate: reduced | - Perform an ABG: raised anion gap metabolic acidosis and elevated lactate

Answer 168

- numbness and tingling of fingers and toes - distal sensory loss, particularly posterior column (discriminative touch, vibration and proprioception), absent ankle jerks - with cord involvement, exaggerated knee jerks and extensor plantars. - Optic atrophy and retinal haemorrhage may occur. - In later stages sphincter disturbance, severe generalized weakness and dementia develop.

Answer 169

- inhalational anaesthetics | - suxamethonium

Answer 170

- Increased minute ventilation in a spontaneously breathing patient; if mechanically ventilated, there will be a substantial increase in minute ventilation required to maintain a normal end tidal CO2 - Elevated core temperature - Muscular rigidity - Tachycardia - Decreased urine output

Answer 171

- Discontinuation of inhalational anaesthetic: partial resolution of hypercapnia, tachycardia and muscular rigidity - Perform a VBG: hypercapnia - Measure serum electrolytes: Hyperkalaemia - Measure creatinine kinase: >20,000 IU following suxamethonium, >10,000 without exposure - Perform urinalysis: positive for blood and raised urine myoglobin

Answer 172

- Discontinue the triggering agent - Administer IV dantrolene - Give cold IV normal saline without potassium, uncover the patient and place cold packs in the groin, axillae, neck and around the head - Admit patients to ICU - If there is myoglobinuria or low renal output, consider bicarbonate therapy to alkalinise the urine and prevent myoglobinuria induced AKI - Give mannitol to increase urine output

Answer 173

- Muscle fatiguability - Ptosis - Diplopia - Dysphagia - Dysarthria - Facial paresis - Proximal limb weakness - Shortness of breath

Answer 174

- elevated AChR or MuSK - repetitive nerve stimulation: 10% decline in compound muscle action potential (CMAP) amplitude between the first and fourth potential in a train of 10 stimulations of the motor nerve at 2 to 3 Hz is considered a positive response - edrophonium test

Answer 175

- pyridostigmine - further immunosuppression with prednisolone, or a steroid-sparing agent such as azathioprine, mycophenolate mofetil, tacrolimus or ciclosporin, and thymectomy if enlarged - If this is inadequate, consider rituximab

Answer 176

- Intubate and give mechanical ventilation if: forced vital capacity (FVC) 15 mL/kg or less (normal ≥60 mL/kg) and negative inspiratory force (NIF) 20 cm H2O or less (normal ≥70 cm H2O). Some patients may require a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube - Perform plasma exchange or IV immunoglobulin with high dose prednisolone

Answer 177

- Limb weakness that begins in the proximal leg muscles and tends to improve after a few minutes of muscular contraction - Xerostomia - Waddling gait - Dysarthria - Areflexia - Ptosis - Diplopia - Impotence - Dysphagia - Orthostatic hypotension

Answer 178

- Perform nerve conduction studies and low frequency repetitive nerve stimulation: doubling of compound muscle action potential amplitude post-exercise - Perform anti P/Q voltage-gated calcium channel serology: positive - Perform chest CT: malignancy

Answer 179

- Treat the underlying cause - Give amifampridine and pyridostigmine for symptomatic improvement - If symptoms do not improve, give immunomodulators such as prednisolone, azathioprine, mycophenolate mofetil or ciclosporin - intubate if needed

Answer 180

- progressive distal muscle weakness - ptosis - weakness - thinning of the face and sternomastoids. - Myotonia - Cataracts - Frontal baldness - Cognitive impairment (mild) - Oesophageal dysfunction (and aspiration) - Cardiomyopathy and conduction defects (sudden death can occur in type 1) - Small pituitary fossa and hypogonadism - Glucose intolerance - Low serum IgG.

Answer 181

- Gait ataxia - Cognitive impairment - Urinary frequency, urgency or incontinence - Faecal incontinence

Answer 182

- Perform CT or MRI head: - mild to moderate ventricular enlargement - periventricular leukomalacia (i.e., damage to the white matter around the cerebral ventricles) - cerebral infarction - relative preservation of cortical gyri and sulci - aqueduct flow void - reduced diameter of the corpus callosum and decreased callosal angle

Answer 183

-ventriculoperitoneal shunting or endoscopic third ventriculostomy

Answer 184

- In infants with hydrocephalus, as their skull sutures have not fused, the head circumference may be disproportionately large or show an excessive rate of growth. - The skull sutures separate, the anterior fontanelle bulges and the scalp veins become distended. - An advanced sign is fixed downward gaze or sun setting of the eyes - Older children will develop signs and symptoms of raised intracranial pressure.

Answer 185

- vascular occlusion - cortical migration disorders or structural maldevelopment of the brain during gestation. - Other antenatal causes are genetic syndromes and congenital infection. - Hypoxic-ischaemic injury during delivery - Periventricular leucomalacia (PVL) secondary to ischaemia and/or severe intraventricular haemorrhage in preterm infants - Postnatal causes are meningitis/encephalitis/ encephalopathy, head trauma from accidental or non- accidental injury, symptomatic hypoglycaemia, hydrocephalus and hyperbilirubinaemia.

Answer 186

- unilateral involvement of the arm and leg - fisting of the affected hand - flexed arm - pronated forearm - asymmetric reaching or hand function

Answer 187

- all four limbs affected - opisthotonus - poor head control - low central tone

Answer 188

-all four limbs, but the legs are affected to a much greater degree than the arms,

Answer 189

- chorea - athetosis - dystonia

Answer 190

- Systemic disease – thyrotoxicosis, SLE, antiphospholipid syndrome, primary polycythaemia - Genetic disorders – Huntington’s disease and genetic phenocopies, neuroacanthocytosis, benign hereditary chorea - Structural and vascular disorders affecting the basal ganglia - Drugs (e.g. levodopa and OC pill) - Post-infectious (Sydenham’s chorea), following months after streptococcal infection or as part of acute rheumatic fever - Pregnancy.

Answer 191

- Persistent low back pain that worsens with axial loading and improves with recumbence - Radicular leg pain - Restriction in lumbar motion - Positive straight leg raise test - Neurological deficit if there is nerve root dysfunction or cauda equina syndrome

Answer 192

- lumbar spine x-ray: degenerative changes (osteophytes, disc space narrowing, foraminal stenosis, endplate sclerosis, ligament calcification) may be seen - Perform MRI spine: signs of degeneration (decreased signal on T2-weighted images [black disc]), evaluation of disc height, presence or absence of annular tears, endplate changes - Perform flexion/extension spine x-rays: lumbar motion segment instability

Answer 193

- Give paracetamol or an NSAID and topical analgesia - Advise a short period of bed rest for 2-3 days - Opioid analgesia can be given if pain is not controlled - Give a muscle relaxant such as diazepam for short term relief - Offer physiotherapy

Answer 194

- Continue routine pain management and refer to pain clinic - Offer amitriptyline for neuropathic pain - Offer physiotherapy - Refer to specialist for consideration of nerve block or decompression

Answer 195

- Bilateral, radiating leg pain - Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion or foot dorsiflexion - Difficulty initiating micturition or impaired sensation of urinary flow or urinary retention - Loss of sensation of rectal fullness or faecal incontinence - Perianal, perineal or genital sensory loss - Laxity of the anal sphincter

Answer 196

- Insidious onset of activity related back pain - Leg pain when walking: neurogenic claudication that improves with rest or leaning forward - Stooped posture when walking: walking leant forward to flex the spine and increase the size of the spinal canal - Leg numbness or paraesthesia

Answer 197

- Perform plain spinal x-rays: degenerative changes or spondylolisthesis - Perform spinal MRI: compression of the neural elements and soft tissues - Perform EMG: increased F latency values

Answer 198

- If there is significant acute neurological deficit, perform surgical decompression - Otherwise, give standard analgesia and advise a short period of bed rest until the acute episode settle - If anti-inflammatory drugs and paracetamol fail, give a short course of steroids - For chronic symptoms, advise standard analgesia and chronic pain agents such as amitriptyline or gabapentin - decompressive laminectomy after 3 months

Answer 199

- Maternal risk factors, increased triple or quadruple test markers or USS abnormality - Closed spina bifida lesion: asymmetrical gluteal fold or dimple, haemangioma, hairy patch or other cutaneous markings - Abnormal urinary voiding - Leakage of meconium or stool - Absence of rectal tone - Asymmetry of spontaneous arm and leg movement - Difficulty with changing nappies or dressing due to spasticity - Abnormal muscle tone and bulk in arms and legs - Decreased sensation - Clubfoot - Vertical talus - Hip and knee flexion contractures

Answer 200

- antenatal | - spinal ultrasound; tethering, diastomyelia, hydromyelia or syringomyelia

Answer 201

- Bilateral upper limb action tremor, with the absence of other neurology - Difficulties with fine motor tasks - Abatement of tremor after consumption of alcohol, benzodiazepines, barbiturates or gabapentin - Head or voice tremor

Answer 202

- Offer propranolol, primidone or gabapentin to improve functioning - Treatments for refractory essential tremor is deep brain stimulation, focused US thalamotomy and gamma knife thalamotomy

Answer 203

- Patients with trauma, disc disease or malignancy - Back pain - Numbness or paraesthesia - Weakness or paralysis: loss of fine finger movements, difficulty walking - Bladder or bowel dysfunction are seen in long standing compression and cauda equina - Hyper-reflexia - Loss of tone below the level of an injury - Hypotension and bradycardia if associated with neurogenic shock

Answer 204

-Perform MRI spine: disc displacement; epidural enhancement; mass effect; T2 cord signal

Answer 205

- If there is acute spinal cord injury, use an ABCDE approach and immobilise the spine and perform decompressive or stabilisation surgery - Give intravenous corticosteroids to reduce oedema of the spinal cord - If a non-traumatic cause, perform decompressive laminectomy - In malignant spinal cord compression, give steroids to reduce oedema and perform surgery or radiation as needed - If there is an epidural abscess, give vancomycin, metronidazole and cefotaxime with surgical drainage

Answer 206

- Unilateral leg pain radiating to below the knee to the foot or toes - Low back pain - Numbness, paraesthesia and muscle weakness in the distribution of the L5 dermatome - Positive straight leg raise

Answer 207

-Offer self-management advice and analgesia such as NSAIDs (with gastroprotection), or if contraindicated offer co-codamol - For patients at a higher risk of a poor outcome: - --Offer referral for a group exercise programme - --Consider referral to physiotherapy - consider offering treatment for neuropathic pain - If there is progressive, persistent or severe neurological deficit, refer urgently to neurosurgery

Answer 208

- Slurring of speech - Swallowing difficulties - Oscillopsia - Clumsiness - Action tremor - Loss of precision of fine motor skills - Unsteadiness when walking that is worse in the dark - Stumbles/falls

Answer 209

- nystagmus - Dysarthria - Action tremor - Dysdiadochokinaesia - Truncal ataxia - Limb ataxia - Gait ataxia

Answer 210

- vascular - infection - TBI, brain tumour, syncope - electrolyte disorders - endocrine disorders - inborn errors of metabolism - toxic

Answer 211

- Insomnia - Poor concentration and attention span - Observed periodic breathing or cessation of breathing or snoring during sleep - Transient dyspnoea that awakens from sleep - Headaches on arising

Answer 212

-Polysomnography >5 central apnoeas or hypopnoeas per hour of sleep and the total number of central apnoeas and/or central hypopnoeas is >50% of the total number of apnoeas and hypopnoeas

Answer 213

- CPAP | - supplemental oxygen

Answer 214

- Features of intracerebral haemorrhage - Seizures - Headaches

Answer 215

- Perform CT brain: reveals intracerebral haemorrhage; identifies AVM by calcification and isointense or slightly hyperintense vessels - Perform MRI brain detects AVMs ± haemorrhage, and thrombosed vessels - Perform brain angiogram: early venous filling (indicating arteriovenous shunting) during arterial phase

Answer 216

- In a non-ruptured AVM, surgical resection or staged embolisation can be performed (for larger AVM) - Stereotactic radiosurgery is possible in inaccessible AVMs

Answer 217

- Epilepsy - Cardiac rhabdomyoma - Renal angiomyolipomas - Lymphangioleiomyomatosis of the lung - Cerebral subependymal calcified nodules - Giant cell astrocytoma - Facial angiofibromas - Cephalic plaque - Non-traumatic ungual or periungual fibromas - Hypomelanocytic macules - Shagreen patches - Numerous dental enamel pits - Gingival fibromas - Retinal nodular hamartomas - Cognitive impairment - Depigmented ‘ash leaf’-shaped patches which fluoresce under ultraviolet light

Answer 218

- Progressive weakness of the extremities - Paraesthesias or sensory loss, beginning in the distal limbs and settling at or a few levels below the spinal lesion - Urinary disturbance and bowel symptoms - Paroxysmal tonic spasms - Upper motor neurone signs - Sensory level: reduced pain or temperature sensation below the level of the lesion - Back pain

Answer 219

- If there is acute neurological deficit, give corticosteroids, plasma exchange and supportive care - If the patient is found to have idiopathic TM, observe

Answer 220

- Headache (worse on coughing, leaning forwards), vomiting - Altered GCS: drowsiness, listlessness, irritability, coma - History of trauma - Low heart rate and high blood pressure; Cheyne-Stokes Response - Pupil changes: constriction at first, later dilation – do not mask by using tropicamide to dilate to aid fundoscopy - Low visual acuity; peripheral visual field loss - Papilloedema is an unreliable sign, but venous pulsation at the disc may be absent

Answer 221

- Correct hypotension, maintain mean arterial pressure >90mmHg and treat seizures as necessary - Elevate the head of the bed to 30-40o - If the patient is intubated, hyperventilate to a PaCO2 of 3.5-4kPa). - Give 20% mannitol 0.25-5g/kg IV over 10-20 minutes and follow serum osmolality, aiming for 300mosmol/kg, and not exceeding 310 - Give dexamethasone to reduce oedema surrounding tumours - Restrict fluid to <1.5L/day - Monitor the patient and consider ICP monitoring - Treat hyperglycaemia and hyponatraemia as necessary - Treat the underlying cause

Answer 222

- Unilateral complete ptosis (levator weakness) - Eye deviated down and out (unopposed lateral rectus and superior oblique) - A fixed and dilated pupil.

Answer 223

- torsional diplopia (two objects at an angle) when attempting to look down (e.g. descending stairs) - the head is tilted away from that side.

Answer 224

-horizontal diplopia

Answer 225

- unilateral sensory loss on the face - scalp anterior to the vertex, anterior two-thirds of the tongue and buccal mucosa - the jaw deviates to that side as the mouth opens (motor fibres). - Diminution of the corneal reflex is an early and sometimes isolated sign of a Vth nerve

Answer 226

- Unilateral facial weakness - Keratoconjunctivitis sicca (dry eye) - Post-auricular pain and otalgia - Facial synkinesis - Hyperacusis

Answer 227

- Advise the patient to keep the affected eye lubricated with lubricating eye drops and tape the eye shut at night - For people presenting within 72 hours of the onset of symptoms, consider prednisolone

Answer 228

- Motor weakness - Loss of fine motor co-ordination - Spasticity - Paraesthesia, numbness and dysaesthesia - Hyper-reflexia

Answer 229

- Perform MRI: Vertebral body or spinal cord lesions | - Perform EMG: Decreased spinal cord conduction

Answer 230

- If there is evidence of a progressive neurological deficit, the patient should be urgently assessed and there should be surgical decompression - If there is autonomic dysreflexia, treat the cause of the excessive autonomic response e.g. treat constipation or urinary retention - If symptoms persist despite treatment, give nifedipine or GTN to lower the BP - If the neurological status is stable, offer physiotherapy and mobilisation, with supportive care including bladder and bowel management and pain management with anti-neuropathic agents

Answer 231

- Rapid onset of symptoms - Headache - Fever - Periorbital oedema - Chemosis and proptosis - Lateral gaze palsy - Ophthalmoplegia - Sepsis - Ptosis and mydriasis - Decreased corneal reflex - Hypo or hyperaesthesia in the distribution of V1 and V2

Answer 232

- expansion of the cavernous sinuses - convex bowing of lateral walls - increased dural enhancement - sphenoid sinus pathology may be present

Answer 233

-vancomycin, ceftriaxone and metronidazole

Answer 234

-Offer people diagnosed with cerebral venous sinus thrombosis full dose anticoagulation (heparin then warfarin with an INR of 2 to 3)

Answer 235

- Pain in the neck, shoulder and/or arm that approximates to that of a dermatome. - It is usually unilateral, but may be bilateral. - The pain may be severe enough to wake the person at night. - Sensory symptoms, such as absent or altered sensation (for example, shooting pains, numbness, and hyperaesthesia). - Sensory symptoms are more common than motor symptoms. - Motor symptoms, such as muscle weakness. - Gradual onset, although it may be abrupt. - Retro-orbital and temporal pain suggest referral from the upper cervical levels (C1 to C3)

Answer 236

- Postural asymmetry - If the asymmetry is long-standing, muscle wasting may be present. - Neck movements - Dural irritation - Neurological problems — for example, upper limb weakness, paraesthesia, dermatomal sensory or motor deficit, or diminished tendon reflexes at the appropriate level. - Atypical signs of cervical radiculopathy include: deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, and headaches.

Answer 237

- Provide conservative management - Encourage activity - Advice that a firm pillow may provide comfort at night - Offer NSAIDs, paracetamol or codeine - Consider offering amitriptyline, duloxetine, pregabalin or gabapentin and muscle relaxants - if more than 6 weeks, confirm diagnosis with MRI and consider epidural or surgery

Answer 238

- Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain - Consider capsaicin cream for people with localised neuropathic pain - refer to pain service

Answer 239

- carbamazepine | - microvascular decompression

Answer 240

- Imbalance of lower limb strength - Lower extremity musculotendinous contractures - Delayed motor milestones - Calf hypertrophy - Ambulation difficulty and falls. - Diminished muscle tone and deep tendon reflexes - Normal sensation - Gowers’ sign: patient climbs up his legs - Toe walking

Answer 241

- Measure serum creatinine kinase: 50 to 100 times normal - Perform genetic testing: Xp21 mutation - Perform EMG: myopathic reading with fast firing, short duration but polyphasic and decreased amplitude motor units with early recruitment in the affected muscles - Perform muscle biopsy: absence of dystrophin with Duchenne muscular dystrophy; diminished quantity or quality of dystrophin with Becker muscular dystrophy

Answer 242

- Give prednisolone therapy to improve muscle strength and function - Provide physiotherapy, exercise and psychological support - Perform surgery for contractures - Give carvedilol and lisinopril for cardioprotection from 10 years old - As vital capacity diminishes, give intermittent positive pressure ventilation and consider indwelling gastrostomy to maximise nutrition - Perform surgery for scoliosis

Answer 243

- Fever - Sore throat - Myalgia - Meningeal irritation - Decreased tone and motor function - Decreased tendon reflexes - Muscle atrophy - No sensory changes: distinguishes from GBS

Answer 244

- Provide supportive care with rehydration and neurological monitoring - Offer physiotherapy with mobilisation - If there is respiratory paralysis, intubate and ventilate

Answer 245

- Spontaneous onset of neck pain - Cervical muscle pain and spasm - Headaches or occipital pain - Weakness or numbness and radiating arm pain with associated radiculopathy

Answer 246

- Offer physiotherapy and NSAIDs for axial neck pain - Offer muscle relaxants if there is cervical muscle spasm - Consider corticosteroid injections into the joint

Answer 247

- Six or more café-au-lait spots>5mm in size before puberty, >15 mm after puberty - Axillary freckling - Neurofibromas - Compromised vision due to optic gliomas - Iris Lisch nodules - Sphenoid wing dysplasia

Answer 248

- Bilateral acoustic neuromata - deafness - cerebellopontine angle syndrome with a facial (VIIth) nerve paresis and cerebellar ataxia.

Answer 249

- Meningism - Headache - Cranial nerve palsy: 3rd and 6th nerve - Positive Kernig or Brudzinski sign - Fever - Neurological findings - In children: increased head circumference and bulging fontanelle

Answer 250

-Ring-enhancing lesion

Answer 251

- Suspicion of non-accidental injury - Post-traumatic seizure with no history of epilepsy - GCS <14, or if under 1 GCS <15 - GCS <15 after 2 hours - Suspected open or depressed skull fracture or tense fontanelle - Any sign of basal skull fracture (haemotypanum, panda eyes, CSF leakage from the ear or nose, Battle’s sign/bruising over the mastoid) - Focal neurology - Bruise, swelling or laceteration >5cm on the head if under 1 - More than 5 minutes loss of consciousness - Abnormal drowsiness - Three or more discrete episodes of vomiting - Dangerous mechanism of injury - Amnesia

Answer 252

- GCS <13 or <15 after 2 hours - Suspected skull fracture or any sign of basal skull fracture (haemotypanum, panda eyes, CSF leakage from the ear or nose, Battle’s sign/bruising over the mastoid) - Post-traumatic seizure - Focal neurological deficit - More than 1 episode of vomiting

Answer 253

- 65 years or older - History of bleeding or clotting disorders - Dangerous mechanism of injury - More than 30 minutes of retrograde amnesia of events immediately before the head injury - anticoagulant treatment

Answer 254

- Was involved in a simple rear-end motor vehicle collision - Is comfortable in a sitting position - Has been ambulatory - Has no midline c-spine tenderness - Presents with delayed onset of neck pain

Answer 255

- child cannot actively rotate their neck 45 degrees to the left and right on assessment of the neck - Dangerous mechanism of injury e.g. fall from height of more than 1 metre, axial load to the head, high speed crash, rolled motor vehicle, ejection from motor vehicle, accident involving motorised recreational vehicles or bicycle collision - Safe assessment of the range of movement of the neck is not possible

Answer 256

- It is not safe to assess range of neck movement | - Safe assessment of neck movement shows that the patient cannot actively rotate their neck 45 degrees

Answer 257

- GCS <13 - The patient is intubated - Focal peripheral neurology - Paraesthesia in the upper or lower limbs - A C-spine injury diagnosis is needed prior to surgery - The patient is having other body areas scanned - There is strong clinical suspicion despite normal x-rays or there are significant bony injuries on x-ray

Answer 258

- GCS less than 13 on initial assessment. - The patient has been intubated. - Plain X-rays are technically inadequate - Plain X-rays are suspicious or definitely abnormal. - A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery). - The patient is having other body areas scanned for head injury or multi-region trauma. - The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply: over 65, dangerous mechanism, focal neurology, paraesthesia in limbs

Answer 259

- Patients with new, clinically significant abnormalities on imaging. - Patients whose GCS has not returned to 15 after imaging, regardless of the imaging results. - When a patient has indications for CT scanning but this cannot be done within the appropriate period. - Continuing worrying signs (for example, persistent vomiting, severe headaches) - Other sources of concern to the clinician (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak).

Answer 260

- Coma – not obeying commands, not speaking, not eye opening (that is, GCS 8 or less). - Loss of protective laryngeal reflexes. - Ventilatory insufficiency as judged by blood gases: hypoxaemia (PaO2 < 13 kPa on oxygen) or hypercarbia (PaCO2 > 6 kPa). - Spontaneous hyperventilation causing PaCO2 < 4 kPa. - Irregular respirations.

Answer 261

- Fever - Spinal pain or tenderness - Weakness of extremities - Paralysis - Sensory disturbance - Abnormal reflexes

Answer 262

-Gadolinium enhanced diffusion weighted MRI spine: infection in epidural space

Answer 263

- Nausea - Drowsiness - Confusion - Hallucinations - Hypotension - Wearing off effect where adverse effects worsen towards the end of the dosage interval.

Answer 264

- Caution in the elderly - Caution with existing cognitive or psychiatric disease due to confusion and hallucinations - Caution with cardiovascular disease due to hypotension.

Answer 265

-Antipsychotics and metoclopramide because their effects on dopamine receptors are contradictory.

Answer 266

- Respiratory depression due to reduced respiratory drive - Neurological depression - Nausea and vomiting by activating CTZ - Pupillary constrictor due to stimulation of Edinger-Westphal nucleus - Constipation due to activation of mu receptors in the gut - Histamine release from mast cells causes itching, hypotension and bronchoconstriction - Tolerance and dependence - Withdrawal reaction characterised by pain, breathlessness and pupillary dilation.

Answer 267

- Avoid in biliary colic due to spasm of sphincter of Oddi which may worsen pain; - Caution in hepatic failure - Caution in renal impairments - Caution in the elderly - Avoid in respiratory failure except under senior guidance.

Answer 268

Administration with sedating drugs require close monitoring.

Answer 269

-Opioid withdrawal reaction characterised by pain, anxiety, nausea and vomiting, dilated pupils, cold dry skin and piloerection.

Answer 270

- Nausea - Constipation (tramadol causes less) - Dizziness - Drowsiness - Neurological and respiratory depression in overdose - Anaphylactic reaction if given intravenously

Answer 271

- Avoid tramadol in patients with epilepsy as it lowers seizure threshold - Caution in significant respiratory disease - Caution in renal impairment - Caution in hepatic impairment - Caution in the elderly

Answer 272

- Increased sedative effect with other sedating drugs such as antipsychotics, benzodiazepines - Increased risk of seizures with other drugs that lower seizure threshold e.g. SSRIs, TCAs.

Answer 273

-liver failure in excess

Answer 274

- Avoid in chronic excessive alcohol use due to increased NAPQI production; - Avoid in malnutrition and severe hepatic impairment due to reduced glutathione stores.

Answer 275

-CP450 inducers such as phenytoin and carbamazepine increase rate of NAPQI production and increase risk of liver toxicity.

Answer 276

- GI upset including nausea and vomiting - Neurological effects including dizziness and ataxia - Hypersensitivity manifests as a maculopapular skin rash - Antiepileptic hypersensitivity syndrome manifests as severe skin reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis), fever and lymphadenopathy, and systemic toxicity - Oedema - Hyponatraemia.

Answer 277

- Caution in pregnancy due to neural tube defects, cardiac and urinary abnormalities, and cleft palate - Avoid with prior antiepileptic hypersensitivity syndrome; - Caution with hepatic, renal or cardiac disease due to increased risk of toxicity.

Answer 278

- CYP450 inducer so it reduced concentration of warfarin, decreases its anticoagulant effect and increases INR. Also reduces efficacy of oestrogens and progestogens. - Reduced plasma concentration with CYP450 inhibitors such as macrolides. - Complex interactions with other antiepileptic drugs - Efficacy reduced by drugs that lower seizure threshold (e.g. SSRIs, TCAs, antipsychotics, tramadol).

Answer 279

- Drowsiness - Dizziness - Ataxia.

Answer 280

-renal impairment

Answer 281

-Increased sedative effect with other sedating drugs e.g. benzodiazepines.

Answer 282

- Blurred vision - Aggression - Agitation - Stevens-Johnson syndrome - Toxic epidermal necrolysis - Disseminated intravascular coagulation - Bone marrow failure.

Answer 283

- Avoid in pregnancy - Avoid in patients with known hypersensitivity to lamotrigine - Discontinue if rash or serious skin reaction occurs - Caution in hepatic or renal impairment; - Caution in patients myoclonic seizures.

Answer 284

- Induces CYP450 enzymes so reduces plasma concentration and efficacy of drugs that are metabolised by P450 enzymes, including warfarin, oestrogens and progestogens - CYP450 inhibitors (e.g. macrolide) increase its concentration and adverse effects - Complex interactions with other antiepileptic drugs; Efficacy reduced by drugs that lower seizure threshold (e.g. SSRIs, TCAs, antipsychotics, tramadol).

Answer 285

- Nasopharyngitis - Aggression - Agitation - Dizziness and drowsiness - Stevens- Johnson syndrome.

Answer 286

- Avoid in pregnancy and breastfeeding | - Caution in hepatic and renal impairment.

Answer 287

-Efficacy reduced by drugs that lower seizure threshold (e.g. SSRIs, TCAs, antipsychotics, tramadol).

Answer 288

- GI upset including nausea and diarrhoea - Neurological and psychiatric effects including tremor, ataxia and behaviour disturbances - Thrombocytopenia - Transient increase in liver enzymes - Hair loss - Severe liver injury - Pancreatitis - Bone marrow failure - Antiepileptic hypersensitivity syndrome.

Answer 289

- Avoid in women of child bearing age - Avoid in first trimester of pregnancy - Avoid in hepatic impairment - Caution in severe renal impairment.

Answer 290

- CYP450 inhibitor so it increases concentration of warfarin, increasing its anticoagulant effect and decreases INR. Also increases concentration of oestrogens and progestogens. - Reduced concentration by CYP450 inducers such as phenytoin and carbamazepine. - Increased adverse effects with CYP450 inhibitors such as macrolides. - Efficacy reduced by drugs that lower seizure threshold (e.g. SSRIs, TCAs, antipsychotics, tramadol).

Answer 291

- Drowsiness - Sedation - Coma - Airway obstruction and death in overdose - Dependence - Withdrawal reaction.

Answer 292

- Avoid with respiratory impairment - Avoid with neuromuscular disease such as myasthenia gravis - Avoid in liver failure as they may precipitate hepatic encephalopathy, however if essential lorazepam is best choice as it depends less on liver for its elimination.

Answer 293

- Increased sedation with other sedating drugs including alcohol and opioids - Increased effects with CYP450 inhibitors including amiodarone, diltiazem, macrolides and fluconazole.

Answer 294

- P: P450 Interactions - H: Hirsutism - E: Enlarged gums - N: Nystagmus - Y: Yellow-browning of skin - T: Teratogenic / Toxicity in overdose (cardiovascular collapse and respiratory depression) - O: Osteomalacia by inducing vitamin D metabolism. - I: Interferes with folate metabolism leading to anaemia. - N: Neuropathy including vertigo and ataxia

Answer 295

- Avoid in patients of Han Chinese or Thai origin due to increased risk of Stevens- Johnson syndrome - Caution in patients undergoing enteral feeding - Caution in hepatic impairment.

Answer 296

- Adverse effects are worsened by amiodarone, diltiazem and fluconazole - Complex interactions with other antiepileptic drugs - Efficacy reduced by drugs that lower seizure threshold (e.g. SSRIs, TCAs, antipsychotics, tramadol).

Answer 297

- Dizziness - Drowsiness - Confusion - Thrombosis.

Answer 298

- Avoid in severe hepatic impairment - Caution in cardiac disease - Caution with a history of convulsions

Answer 299

Increased risk of CNS toxicity with amantadine and ketamine.

Answer 300

- Daytime sleepiness - Rebound insomnia when stopped - Nightmares - Amnesia - Zopiclone causes taste disturbance - Zolpidem causes GI upset - Dependence and withdrawal symptoms beyond four weeks characterise by headache, muscle pains and anxiety - Drowsiness, coma and respiratory depression in overdose.

Answer 301

- Avoid in obstructive sleep apnoea - Avoid in respiratory muscle weakness - Avoid in respiratory depression - Caution in the elderly.

Answer 302

- Enhances sedative effects of antihistamines and benzodiazepines - P450 inhibitors (macrolides) enhance sedation - P450 inducers impair sedation.

NEUROLOGY Flashcards

(326 cards)