Neurology

Question 1

Patient presents with suddent onset headache - key differentials?

Answer 1

1. Subarachnoid haemorrhage
2. Pituitary apoplexy
3. haemorrhage into mass lesion
4. arterial dissection
5. reversible cerebral vasoconstriction syndrome

Question 2

Patient presents wiht first ever headache with focal neurological signs, confusion or drowsiness

Answer 2

stroke, venous sinus thrombosis, reversible cerebral vasoconstriction syndrome, meningitis/encephalitis

Question 3

Patient older than 50 years presents with headache DDx

Answer 3

giant cell arteritis, mass lesion or stroke

Question 4

Headache after trauma ddx

Answer 4

Subdural haemorrhage, epidural haemorrhage

Question 5

Headache frequency/severity increases over weeks to months

Answer 5

mass lesion, subdural haemorrhage, analgesic rebound

Question 6

New onset headache in a patient with HIV or cancer or immunosupressed

Answer 6

meningitis, abcess, metastasis

Question 7

Headache with signs of systemic illness (eg fever, rash neck flexion stiffness)

Answer 7

systemic infection, meningitis, encephalitis, vaculitis

Question 8

Headache with papilloedema Ddx

Answer 8

mass lesion, idiopathic intracranial hypertension, venous sinus thrombosis

Question 9

Positional headache (eg worse lying down) and cough headache (Especially if prolonged)

Answer 9

Space occupying or posterior fossa lesion, chiari malformation

Question 10

How does a migraine present clinically?

Answer 10

Typically one sided but NOT side locked - can be bilateral

Recurrent attacks

Last 4 to 72 hrs

pulsating

moderate-severe intensity

aggravated by routine phys activity

associated with: nausea and/or photophobia, phonophobia, osmophobia (intolerance to smells)

WITH OR WITHOUT AURA

CAN present as neck pain or mid facial pain rather than headache - use the other symptoms to make the diagnosis

Question 11

What is a migranous aura? What is an aura mimic that must be exluded

Answer 11

Reversible neuro symptoms that develop over 5-20 minutes and last less than 60 minutes.

Affect senses, vision, speech, language, motor function, brainstem and retina

EXCLUDE TIA

Question 12

What is an aura without headache? What is the most common form?

Answer 12

Typical aura of migraine which is not followed by a headache.

Most common is scintillating scotoma.

Question 13

Features of a tension headache?

Answer 13

Lasts 30 minutes to 7 days

Usually bilateral

Feels like pressure or tightness in the head

Mild to moderate intensity (Rarely severe enough to prevent walking or climbing stairs)

NOT associated with nausea

may have photophobia or phonophobia

Question 14

What are the trigeminal autonomic cephalagias? How do they present clinically?

Answer 14

Cluster, paroxysmal hemicrania,SUNCT and hemicrania continua

UNILATERAL AND SIDE LOCKED headache

usually follow first division of trigeminal nerve

with UNILATERAL autonomic features (eg tearing, conjunctival irritation/redness, ptosis, nasal stuffiness or rhinorea, fullness of the ear, tinnitus, facial flusing or sweating)

Possible unilateral photphobia or phonophobia

Patient Often agitated and restless

Question 15

How does a reversible cerebral vasoconstriction syndrome present?

Answer 15

Thunderclap

Recurring over 1-2 weeks.

Triggers -exertion, valsalva, sex, emotion

Angiography shows: String and bead appearance (can be normal in week one). MRI changes - mainly posterior - include oedema,infarction, SAH or intracranial haemorrhage

Question 16

Features of a primary headache associated with sexual activity

Answer 16

Occurs before or at orgasm. Usually benign.

Thunderclap at orgasm - think about Reversible vasoconstriction syndrome. Exclude space occupying lesion or aneurysm

Question 17

Features of primary stabbing headache?

Answer 17

Transient and localised stabs of pain in the head

NO associated autonomic features

Can occur with a migraine and will often ease when migraine is treated.

Persistent can respond to indomethacin.

Question 18

Primary cough headache

Answer 18

Provoked by cough or valsalva manoeuver

Can last seconds to 2 hours

Exclude space occupying lesion or aneurysm, posterior fossa pathology, chiari malformation and cerebrospinal fluid obstruction

Question 19

What types of secondary headache exist?

Answer 19

1. 1. Low CSF - worse in evening, improved by lying flat. Can have associated coat hanger pain across shoulders or pulastile tinnitus. Can Be spontaneous. or follow dural puncture.
2. Increased CSF pressure headache - Associated with raised ICP. Worse in the morning and when lying flat, improved by upright posture. Aggravated by cough, strain, valsalva. Associated visual symptoms, pulsatile tinnitus and papilloedema. Causes - Idiopathic Intracranial Hypertension (esp if recent weight gain), Space occupying lesion, VSThrombosis or obstruction, drugs - tetracyclines, or Vitamin A analogues (isotretinoin).
3. Cervicogenic headache - neck pain, unilateral, side locked, radiation ant/post. Provoked by neck manoever and digital pressure.
4. Drug induced headache
5. Headache induced by other medical/metabolic ondition - GCA, OSA, HTN, Hypoglycaemia, Phaeo
   6.

Question 20

Minimum delerium work up in elderly?

Answer 20

oxygen saturation with or without blood gas measurement

electrocardiogram (ECG)

blood glucose concentration

serum urea, creatinine, electrolyte and calcium concentrations

liver biochemistry

full blood count

urine dipstick analysis (and urine microscopy and culture if appropriate).

Extended testing is performed in particular clinical situations based on features identified from history and physical examination. Examples include:

computerised tomography (CT) head scan—there is a low threshold for this in the elderly and those on anticoagulants

chest X-ray

cardiac enzymes

blood cultures.

Question 21

DDx for hyposmia or anosmia?

Answer 21

Upper respiratory tract infection

Head Trauma

Neurodegenerative disorders eg Parkinsons

Medications eg ACEi

Intoxicants - eg alcohol

Post surgical

Question 22

Causes of sudden onset anosmia?

Answer 22

Viral infections
Head Trauma

Question 23

Causes of gradual onset anosmia?

Answer 23

allergic rhinitis

nasal polyps

neoplasm

Question 24

causes of intermittent smell loss

Answer 24

allergic rhinitis

Topical drugs

Question 25

Treatment for anosmia?

Answer 25

Treat cause Allergic rhinitis - oral antihistamin, intranasal glucocorticoid Head trauma and viral infections causing anosmia - no effective treatment olfactory neurons do have partial regenerative capacity and some smell may be recovered without treatment

Question 27

Types of MS

Answer 27

1. Relapsing, remitting 2. Primary progressive

Question 28

What is L'hermitte phenomeon - what does it suggest?

Answer 28

Electric shock radiating from back of neck upon neck flexion. It suggests that there is a lesion in the posterior spinal cord (MS) - Requires urgent MRI and referral

Question 29

What are some specific signs of MS

Answer 29

Acute painful loss of vision in one eye (optic neuritis) Limb weakness and numbness that occur with or without bladder/bowel dysfunction - transverse myelitis ataxia, facial numbness, or diplopia - brain stem syndrome new onset of L'hermitte phenomenon first episode of trigeminal neuralgia

Question 30

What is the differential for MS?

Answer 30

**Neuroinflammatory diseases** Acute disseminated encephalomyelitis neuromyelitis optica spectrum disorders Sarcoidosis SLE **Mimics of MS** Vitamin b12 deficiency Spinal cord masses or fistulae genetic syndromes (eg hereditary spastic paresis)

Question 31

How is MS treated

Answer 31

Immunotherapy Corticosteroids By Neurologist

Question 32

What is the mechanism of RAPD

Answer 32

Question 33

What neurological symptoms can an MS patient present with?

Answer 33

UMN signs (motor will always be upper) Vertigo Eyes - diplopia, eye pain, visual loss, colour discrimination loss, eye pain retrobullbar neuritis (doesnt affect vision but affects nerve) or optic neuritis, Sensory - numbness, paraesthesiae, walking on cotton wool, clumsiness (ataxia)

Question 34

What is the association between vitamin D and MS

Answer 34

low vit D can trigger flare. Make sure vitamin D Replete

Question 35

What are the characteristics of Parkinsons disease

Answer 35

BART with Postural instability (late) Bradykinesia/Akinesia Rigidity Tremor Its defined as Bradykinesia/Akinesia plus one of the others

Question 36

Other characteristics of Parkinsons?

Answer 36

Shuffling gait Mask facies Micrographia Pill rolling tremor autonomic dysfunction (bladder, bowel, postural hypotension) Sleep disturbance neuropsych - depression, psychosis dementia in late (40%)

Question 37

Is tremor in PD unilateral or bilateral?

Answer 37

Begins unilateraly Most cases - unilateral

Question 38

Red flags in parkinsons?

Answer 38

Poor response to levodopa Rapid onset dementia (lewy body) Anterocollis Retrocollis Dystonia Myoclonus

Question 39

Parkinsons disease management?

Answer 39

Refer to neurology for commencement of PD treatment eg levodopa or dopamine agonist like bromocriptine Multidiscipilinary management team refferals - physio, OT, dietician, Physical therapy Patient and family education regarding disease and prognosis Regular follow up

Question 40

What are the sideeffects of levo dopa

Answer 40

Note that levodopa does not halt disease progression but helps with motor dysfunction in PD - it can increase life expectancy by improving motor function. SIDE effects **MOTOR** **Drug induced chorea or dystonia** **Different pattern of motor fluctuations** **other** Headache, dizziness, diarrhoea, constipation,

Question 41

How would you treat orthostatic hypotension in parkinsons disease?

Answer 41

Non pharm: Avoid standing up too quickly, avoid extreme heat or cold sleep with head of the bed raised Regular exercise in horizontal position (Eg swimming) Pharm: **Fludrocortisone 0.1 mg daily PRN**

Question 42

Parkinsons dementia presentation and management?

Answer 42

Language is preserved Executive dysfunction and visuospatial impairment Acetylcholinesterase inhibitors can be useful Trial of 2-3 months **Donepezil 5mg orally daily (if tolerated increase to 10mg at night) review in 3 months)** **Side effects - nausea, vomiting, diarrhoea** If stopping - taper dose to stop rebound symptoms

Question 43

Features of an upper motor neuron lesion?

Answer 43

No wasting, hypertonia, hyperreflexia, positive babinski and clasp knife

Question 44

Features of a lower motor neuron lesion

Answer 44

Wasting, hypotonia, hyporeflexia, fasciculations, Absent babinski and clasp knife

Question 45

Triad of features of essential tremor and managment

Answer 45

**Simple Kinetic or Postural tremor (on movement)** **Positive family history (autosomal dominant)** **Normal Gait** (Can also get a head tremor) _(Exacerbated by anxiety, relieved by alcohol)_ Relaxation techniques, explanation and reassurance **Propranolol 10mg bd orally monitor and r/v prn**

Question 47

Types of tremor

Answer 47

Question 48

Whats the cerebellar tetrad?

Answer 48

ataxia, intention tremor, dysarthria, nystagmus

Question 49

Which drugs can induce Parkinsonism?

Answer 49

Phenothiazine Butyraphones Reserpine

Question 51

Causes of syncope

Answer 51

Neurogenic - neurovascular, seizure, vagal syncope, (neuro assessment, AVPU, GCS) Cardiogenic - arrhythmia, MI, (ECG) Postural hypotension - (Blood pressure and vitals) Metabolic - Hypoglycaemia (check bsl)