Neurology Conditions A

Question 1

Ischaemic Stroke - Description

Answer 1

rapid onset focal neurological deficit lasting more than 24 hours due to arterial stenosis or occlusion

Question 2

Ischaemic Stroke - Causes (7)

Answer 2

1) small vessel occlusion
2) large vessel atherothromboembolism
3) cardioembolism (AF, MI, IE)
4) vasculitis
5) sickle cell disease
6) polycythaemia
7) hypoperfusion (inc. caused by sepsis)

Question 3

Ischaemic Stroke - Risk Factors (13)

Answer 3

1) older age
2) male
3) family history
4) Afro-Caribbean
5) transient ischaemic attack
6) atrial fibrillation
7) diabetes mellitus
8) hypertension
9) dyslipidaemia
10) hypercoagubility
11) oral contraceptive pill
12) smoking
13) alcohol

Question 4

Ischaemic Stroke - Symptoms (General) (4)

Answer 4

FAST

1) facial drooping
2) arm weakness
3) slurred speech
4) time (sudden onset)

Question 5

Ischaemic Stroke - Symptoms (Anterior Cerebral Artery) (6)

Answer 5

1) contralateral numbness (esp. leg)
2) contralateral weakness (esp. leg)
3) truncal ataxia
4) gait ataxia
5) incontinence
6) drowsiness

Question 6

Ischaemic Stroke - Symptoms (Middle Cerebral Artery) (4)

Answer 6

1) contralateral numbness (arm+leg)
2) contralateral weakness (arm+leg)
3) dysphasia —> aphasia
4) visuospatial disturbances

Question 7

Ischaemic Stroke - Symptoms (Posterior Cerebral Artery) (5)

Answer 7

1) contralateral homonymous hemianopia
2) cortical blindness
3) visual agnosia
4) prosopagnosia
5) unilateral headache (esp. haemorrhagic)

Question 8

Ischaemic Stroke - Symptoms (Vertebrobasilar Artery) (5)

Answer 8

1) quadriplegia
2) dysarthria
3) dysphasia
4) visual disturbances
5) locked in syndrome

Question 9

Ischaemic Stroke - Complications (5)

Answer 9

1) haemorrhage
2) deep vein thrombosis
3) seizure
4) aspiration pneumonia
5) depression

Question 10

Ischaemic Stroke - Investigations (5/1)

Answer 10

initial
1) urgent head CT (brain parenchyma hypoattenuation, dark)
2) brain diffusion weighted imaging MRI (infarct hyperattenuation, bright)
3) serum glucose (exclude hypoglycaemia/hyperglycaemia)
4) ECG + BP
5) FBC
consider
1) CT/MRI angiogram (identify stenosis/occlusion)

Question 11

Ischaemic Stroke - Management (5/4/1)

Answer 11

conservative
1) nil by mouth until swallowing assessment (aspiration pneumonia)
2) maintain oxygen (>95%)
3) maintain hydration
4) head CT post thrombolysis (24 hours later)
5) CVS risk factor control
medical
1) thrombolysis (IV alteplase) (<4.5 hours of onset)
2) aspirin (24 hours after IV alteplase) (2 weeks)
3) clopidogrel (unknown onset or >4.5 hours of onset) (lifelong)
4) prophylactic anticoagulant (DVT)
surgery
1) thrombectomy (large artery occlusion)

Question 12

Haemorrhagic Stroke - Description

Answer 12

rapid onset focal neurological deficit lasting more than 24 hours due to an intracerebral haemorrhage

Question 13

Haemorrhagic Stroke - Causes (7)

Answer 13

1) cerebral amyloid angiopathy
2) hypertension (Charcot Bouchard aneurysm)
3) aneurysm rupture
4) ateriovenous malformation
5) anticoagulants
6) trauma —> carotid artery dissection
7) subarachnoid haemorrhage

Question 14

Haemorrhagic Stroke - Risk Factors (7)

Answer 14

1) older age
2) male
3) Afro-Caribbean
4) family history
5) hypertension
6) haemophilia
7) anticoagulants

Question 15

Haemorrhagic Stroke - Symptoms (General) (7)

Answer 15

FAST
1) facial drooping
2) arm weakness
3) slurred speech
4) time (sudden onset)
other
5) neck stiffness
6) severe headache
7) impaired consciousness

Question 16

Haemorrhagic Stroke - Symptoms (Anterior Cerebral Artery) (6)

Answer 16

1) contralateral numbness (esp. leg)
2) contralateral weakness (esp. leg)
3) truncal ataxia
4) gait ataxia
5) incontinence
6) drowsiness

Question 17

Haemorrhagic Stroke - Symptoms (Middle Cerebral Artery) (4)

Answer 17

1) contralateral numbness (arm+leg)
2) contralateral weakness (arm+leg)
3) dysphasia —> aphasia
4) visuospatial disturbances

Question 18

Haemorrhagic Stroke - Symptoms (Posterior Cerebral Artery) (5)

Answer 18

1) contralateral homonymous hemianopia
2) cortical blindness
3) visual agnosia
4) prosopagnosia
5) unilateral headache (esp. haemorrhagic)

Question 19

Haemorrhagic Stroke - Symptoms (Vertebrobasilar Artery) (5)

Answer 19

1) quadriplegia
2) dysarthria
3) dysphasia
4) visual disturbances
5) locked in syndrome

Question 20

Haemorrhagic Stroke - Complications (5)

Answer 20

1) hydrocephalus
2) deep vein thrombosis
3) seizure
4) aspiration pneumonia
5) depression

Question 21

Haemorrhagic Stroke - Investigations (4/1)

Answer 21

initial
1) urgent head CT (brain parenchyma hyperattenuation, bright)
2) serum glucose (exclude hypoglycaemia/hyperglycaemia)
3) ECG + BP
4) FBC
consider
1) CT/MRI angiogram (identify aneurysm, arteriovenous malformation)

Question 22

Haemorrhagic Stroke - Management (5/3/2)

Answer 22

conservative
1) monitor GCS
2) nil by mouth until swallowing assessment (aspiration pneumonia)
3) maintain oxygen (>95%)
4) maintain hydration
5) CVS risk factor control
medical
1) IV prothrombin complex concentrate + vitamin K (anticoagulant reversal)
2) diuretic (mannitol) (lower ICP)
3) prophylactic anticoagulant (DVT) (once haemorrhage controlled)
surgery
1) craniotomy + drainage (severe)
2) cerebral shunt (hydrocephalus)

Question 23

Transient Ischaemic Attack - Description

Answer 23

rapid onset reversible focal neurological deficit lasting less than 24 hours due to arterial stenosis or occlusion

Question 24

Transient Ischaemic Attack - Causes (7)

Answer 24

1) small vessel occlusion
2) large vessel atherothromboembolism* (esp. carotid)
3) cardioembolism (AF, MI, IE)
4) vasculitis
5) sickle cell disease
6) polycythaemia
7) hypoperfusion (inc. caused by sepsis)

Question 25

Transient Ischaemic Attack - Risk Factors (13)

Answer 25

1) older age 2) male 3) family history 4) Afro-Caribbean 5) transient ischaemic attack 6) hypertension 7) atrial fibrillation 8) diabetes mellitus 9) dyslipidaemia 10) hypercoagubility 11) oral contraceptive pill 12) smoking 13) alcohol

Question 26

Transient Ischaemic Attack - Symptoms (Anterior Circulation) (5)

Answer 26

90% 1) dysphasia —> aphasia 2) contralateral numbness 3) contralateral weakness 4) contralateral hemianopia 5) amaurosis fugax (sudden loss of vision in one eye)

Question 27

Transient Ischaemic Attack - Symptoms (Posterior Circulation) (6)

Answer 27

10% 1) dysarthria —> choking 2) contralateral numbness 3) contralateral hemianopia 4) diplopia 5) vertigo 6) transient global amnesia (episode of amnesia/confusion that resolves within 24 hours)

Question 28

Transient Ischaemic Attack - Complications (2)

Answer 28

1) stroke (30% in 5 years) | 2) myocardial infarction (15% in 5 years)

Question 29

Transient Ischaemic Attack - Investigations (5/2)

Answer 29

initial 1) brain diffusion weighted imaging MRI (exclude haemorrhage) 2) serum glucose (exclude hypoglycaemia/hyperglycaemia) 3) ECG + BP 4) FBC 5) carotid artery Doppler ultrasound (stenosis) consider 1) carotid CT/MRI angiogram (if stenosis) 2) echocardiogram (cardioembolism)

Question 30

Transient Ischaemic Attack - Stroke Risk (ABCD2) (5)

Answer 30

>6 - immediate specialist referral; >4 - <24 hour specialist referral A) age >60 years old (1) B) BP >140/90 (1) C) clinical features: unilateral weakness (2); speech disturbances without weakness (1) D) duration: <1 hour (1); >1 hour (2) D) diabetes mellitus (1)

Question 31

Transient Ischaemic Attack - Management (3/3/1)

Answer 31

``` conservative 1) specialist referral (<1 week minimum) 2) no driving (4 weeks) 3) CVS risk factor control medical 1) aspirin (first 2 weeks) 2) clopidogrel (after 2 weeks) 3) anticoagulant (if cardioembolism) surgery 1) carotid endarterectomy or stent (>50% stenosis) ```

Question 32

Subarachnoid Haemorrhage - Description

Answer 32

spontaneous bleeding into subarachnoid space (in between arachnoid and pia)

Question 33

Subarachnoid Haemorrhage - Causes (4)

Answer 33

1) berry aneurysm rupture (80%) 2) arteriovenous malformation (15%) 3) vasculitis 4) idiopathic

Question 34

Subarachnoid Haemorrhage - Risk Factors (10)

Answer 34

1) >50 years old (esp. 50-55) 2) female 3) family history 4) Afro-Caribbean 5) hypertension 6) smoking 7) polycystic kidney disease 8) Ehlers-Danlos syndrome 9) Marfan syndrome 10) aorta coarctation

Question 35

Subarachnoid Haemorrhage - Symptoms (7)

Answer 35

1) sudden severe occipital headache (thunderclap) 2) neck stiffness 3) vomiting 4) collapse 5) seizure 6) coma 7) photophobia

Question 36

Subarachnoid Haemorrhage - Signs (3)

Answer 36

1) Kernig’s sign (inability to extend knee when hip is flexed) (6 hour later) 2) Brudzinski’s sign (when neck is flexed, hip and knee also flex) 3) papilloedema

Question 37

Subarachnoid Haemorrhage - Complications (7)

Answer 37

1) rebleeding (20%) 2) vasospasm —> cerebral ischaemia 3) hydrocephalus 4) cerebral oedema 5) hyponatraemia 6) coma 7) death

Question 38

Subarachnoid Haemorrhage - Investigations (1/2)

Answer 38

initial 1) head CT* (star shaped lesion) consider 1) lumbar puncture (if CT negative) (xanthochromic - yellow) 2) CT angiogram (number/extent of aneurysms)

Question 39

Subarachnoid Haemorrhage - Management (0/3/2)

Answer 39

medical 1) IV fluids (maintain cerebral perfusion) 2) nimpdipine (CCB) (reduce vasospasm —> cerebral ischaemia risk) 3) dexamethasone (corticosteroid) (reduce cerebral oedema) surgery 1) endovascular coiling* 2) surgical clipping

Question 40

Subdural Haematoma - Description

Answer 40

accumulation of clotted blood in subdural space (in between dura and arachnoid)

Question 41

Subdural Haematoma - Risk Factors (5)

Answer 41

1) traumatic head injury (esp. decelerating injuries) 2) aging —> cerebral atrophy 3) alcohol —> cerebral atrophy 4) anticoagulation 5) coagulopathy

Question 42

Subdural Haematoma - Pathophysiology (2)

Answer 42

1) rupture of bridging vein between cortex and venous sinus | 2) accumulation of clotted blood in subdural space

Question 43

Subdural Haematoma - Symptoms (Acute) (7)

Answer 43

1) headache 2) fluctuating consciousness 3) nausea 4) vomiting 5) seizure 6) coma 7) focal neurological deficit (e.g. hemiparesis)

Question 44

Subdural Haematoma - Symptoms (Chronic) (4)

Answer 44

1) headache 2) fluctuating consciousness 3) cognitive decline 4) personality change

Question 45

Subdural Haematoma - Complications (5)

Answer 45

1) epilepsy 2) stroke 3) cerebral oedema 4) coma 5) death

Question 46

Subdural Haematoma - Investigations (1/0)

Answer 46

initial | 1) head CT (diffuse hyperdense crescent shaped mass, shifting of midline structures)

Question 47

Subdural Haematoma - Management (1/2/1)

Answer 47

``` conservative 1) anticoagulant/antiplatelet cessation medical 1) IV mannitol (high ICP) 2) IV prothrombin complex concentrate + vitamin K (anticoagulation reversal) surgery 1) craniotomy (haematoma evacuation) ```

Question 48

Extradural Haematoma - Description

Answer 48

accumulation of clotted blood in extradural space (in between skull and dura)

Question 49

Extradural Haematoma - Risk Factors (1)

Answer 49

1) traumatic head injury (temporal/parietal fracture)

Question 50

Extradural Haematoma - Pathophysiology (3)

Answer 50

1) fracture of temporal or parietal bone 2) laceration of middle meningeal artery 3) accumulation of clotted blood in extradural space

Question 51

Extradural Haematoma - Symptoms (6)

Answer 51

``` 1) post traumatic loss of consciousness —> lucid interval (hours/days) —> decrease in consciousness high ICP 2) headache 3) nausea 4) vomiting 5) coma ```

Question 52

Extradural Haematoma - Investigations (2/0)

Answer 52

initial 1) head CT* (hyperdense lemon shaped mass adjacent to skull) 2) skull x-ray

Question 53

Extradural Haematoma - Management (1/2/1)

Answer 53

``` conservative 1) anticoagulant/antiplatelet cessation medical 1) intubation + ventilation 2) IV mannitol (high ICP) surgery 1) craniotomy (haemotoma evacuation ± blood vessel ligation) ```

Question 54

Depression - Description

Answer 54

disorders characterised by persistent low mood and anhedonia

Question 55

Depression - Risk Factors (8)

Answer 55

1) >65 years 2) female (2x) 3) family history 4) chronic disease (1/3) 5) postpartum (20%) 6) oral contraceptive pill 7) corticosteroids 8) propranolol

Question 56

Depression - Symptoms (10)

Answer 56

1) low mood* 2) anhedonia* (decreased interest and/or pleasure in all activities) 3) functional impairment 4) sleep disturbances (insomina/hypersomnia) 5) fatigue 6) guilt (inc. worthlessness) 7) weight change 8) libido change 9) poor concentration 10) suicidal intention

Question 57

Depression - Diagnosis (DSM-5 Criteria) (2/8)

Answer 57

``` 2 week period, ≥5 symptoms nearly everyday, ≥1 major criteria major criteria 1) low mood 2) anhedonia (decreased interested and/or pleasure in all activities) minor criteria 1) functional impairment 2) sleep disturbances (insomnia/hyperosomnia) 3) fatigue 4) guilt (inc. worthlessness) 5) weight change 6) libido change 7) poor concentration 8) suicidal intention ```

Question 58

Depression - Management (5/3/0)

Answer 58

``` conservative 1) watchful waiting (2 week GP follow-up) 2) regular exercise (inc. yoga) 3) self-help books 4) psychotherapy 5) cognitive behavioural therapy (inc. computer based) medical 1) SSRI (e.g. fluoxetine) 2) TCA (e.g. amitriptyline) 3) St. John’s wort ```

Question 59

Epilepsy - Description

Answer 59

recurrent spontaneous, intermittent, abnormal electrical brain activity manifesting as seizures

Question 60

Epilepsy - Causes (5)

Answer 60

1) idiopathic (2/3) 2) cortical scarring (head injury, cerebrovascular disease, CNS infection) 3) tumour 4) tuberous sclerosis 5) dementia

Question 61

Epilepsy - Risk Factors (9)

Answer 61

1) family history 2) premature birth 3) febrile seizure 4) dementia 5) drugs (e.g. cocaine) 6) head trauma 7) cerebrovascular disease (e.g. stroke) 8) CNS infection (e.g. meningitis) 9) tumour

Question 62

Epilepsy - Types (7)

Answer 62

``` focal (57%) 1) simple 2) complex 3) with secondary generalised (2/3 of focal) generalised (40%) 4) absence (petit-mal) 5) myoclonic 6) tonic-clonic (grand-mal) 7) atonic ```

Question 63

Epilepsy - Pathophysiology (Focal) (1)

Answer 63

1) electrical discharge limited to one part of the cortex (80% in temporal lobe)

Question 64

Epilepsy - Pathophysiology (Generalised) (1)

Answer 64

1) electrical discharge simultaneously throughout whole cortex

Question 65

Epilepsy - Phases (4)

Answer 65

1) prodromi 2) aura 3) ictus (i.e. seizure 4) post-ictus

Question 66

Epilepsy - Symptoms (Focal - Temporal) (5)

Answer 66

80% of focal 1) deja vu (feeling of unfamiliar feeling familiar) 2) jamais vu (feeling of familiar feeling unfamiliar) 3) auditory hallucinations 4) olfactory hallucinations 5) anxiety —> fear

Question 67

Epilepsy - Symptoms (Focal - Frontal) (1)

Answer 67

1) motor features

Question 68

Epilepsy - Symptoms (Focal - Parietal) (1)

Answer 68

1) sensory features

Question 69

Epilepsy - Symptoms (Focal - Occipital) (1)

Answer 69

1) visual features (e.g. visual hallucinations, visual loss)

Question 70

Epilepsy - Symptoms (Generalised - Absence) (2)

Answer 70

1) <10 second pause in activity (e.g. stops talking mid-sentence) 2) unaware of attack

Question 71

Epilepsy - Symptoms (Generalised - Myoclonic) (1)

Answer 71

1) sudden jerk of limb, face, trunk (e.g. thrown to ground or violently disobedient limb)

Question 72

Epilepsy - Symptoms (Generalised - Tonic-Clonic) (4)

Answer 72

1) loss of consciousness 2) still limbs —> jerking limbs (tonic —> clonic) 3) drowsiness (post-ictus) 4) confusion (post-ictus)

Question 73

Epilepsy - Symptoms (Generalised - Atonic) (1)

Answer 73

1) sudden loss of muscle tone —> fall

Question 74

Epilepsy - Complications (4)

Answer 74

1) head trauma 2) fractures 3) memory loss 4) sudden, unexpected death in epilepsy (SUDEP)

Question 75

Epilepsy - Investigations (3/2)

Answer 75

``` initial 1) head CT 2) electroencephalogram (not diagnostic) 3) serum glucose (exclude hypoglycaemia/hyperglycaemia) consider 1) head MRI (identify causative lesion) 2) genetic testing ```

Question 76

Epilepsy - Diagnosis (1)

Answer 76

1) history of >2 unprovoked seizures >24 hours apart

Question 77

Epilepsy - Management (4/4/2)

Answer 77

conservative 1) ABCDE (esp. maintain airways) 2) protect from injury 3) check glucose 4) inform DVLA medical 1) IV diazepam or IV lorazepam x2 (1st line, during seizure) 2) IV phenytoin (2nd line, during seizure) 3) carbamazepine (focal) 4) sodium valproate (generalised) surgery 1) surgical resection (hippocampal sclerosis or tumour) (70% resolution) 2) neurostimulation system (e.g. vagal nerve stimulation or deep brain stimulation)

Question 78

Parkinson’s Disease - Description

Answer 78

progressive neurodegenerative movement disorder due to decreased DA in substantia nigra

Question 79

Parkinson’s Disease - Causes (1)

Answer 79

1) unknown

Question 80

Parkinson’s Disease - Risk Factors (6)

Answer 80

1) age* (peak onset 55-65 years old) 2) male 3) family history 4) GBA gene mutation (Gaucher’s disease) (5x) 5) MPTP exposure (e.g. cocaine) 6) insecticide/herbicide exposure

Question 81

Parkinson’s Disease - Pathophysiology (6)

Answer 81

1) mitochondrial dysfunction and oxidative stress on substantia nigra 2) progressive degeneration of dopaminergic neurones of substantia nigra 3) decreased DA synthesis in the striatum 4) decreased DA release 5) decreased thalamus activity 6) decreased movement

Question 82

Parkinson’s Disease - Symptoms (Non-Motor Prodrome) (3)

Answer 82

up to 7 years prior to motor symptoms 1) anosmia 2) urgency 3) constipation

Question 83

Parkinson’s Disease - Symptoms (Parkinson’s Triad) (3)

Answer 83

1) tremor (esp. at rest, in hand) 2) rigidity 3) bradykinesia

Question 84

Parkinson’s Disease - Symptoms (Rigidity) (2)

Answer 84

1) leadpipe rigidity (sustained resistance to passive movements) 2) cogwheel rigidity (jerky resistance to passive movements)

Question 85

Parkinson’s Disease - Symptoms (Bradykinesia) (5)

Answer 85

1) slow movement initiation 2) slow repetition (e.g. blinking) 3) decreased amplitude in action repetition (e.g. micrographia (small handwriting)) 4) hypophonia (decreased voice volume) 5) hypomimesis (expressionless face)

Question 86

Parkinson’s Disease - Symptoms (Other) (2)

Answer 86

1) fine motor skill difficulty (e.g. buttons) | 2) gait (stooped posture, small shuffling steps, narrow base, reduce arm swing, difficulty turning)

Question 87

Parkinson’s Disease - Complications (7)

Answer 87

1) aspiration pneumonia 2) depression 3) anxiety 4) REM sleep disorders 5) postural hypotension 6) Lewy body depression 7) dyskinesia

Question 88

Parkinson’s Disease - Investigations (0/2)

Answer 88

consider 1) levodopa trial (symptoms improve) (if unclear clinical diagnosis, confirmation) 2) MRI brain

Question 89

Parkinson’s Disease - Management (3/2/1)

Answer 89

``` conservative 1) SALT (speech and language therapy) 2) physiotherapy (balance, gait) 3) physical activity medical 1) levodopa* (>70 years old or severe) 2) decarboxylase inhibitor (e.g. co-careldopa) (decreases levodopa SEs, increases levodopa efficacy) surgery 1) deep brain stimulation (refractory, party DA responsive) ```

Question 90

Parkinson’s Disease - Management (Delay Levodopa) (3)

Answer 90

1) dopamine agonist (e.g. ropinirole) 2) monomanie oxidase b inhibitors (e.g. selegiline) 3) catechol-o-methyl transferase inhibitors (e.g. tolcapone)