Neurology Passmed

Question 1

Contralateral hemiparesis and sensory loss, lower extremity > upper

Where is the lesion?

Answer 1

Anterior cerebral artery

Question 2

Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia

Where is the lesion?

Answer 2

Middle cerebral artery

Question 3

Contralateral homonymous hemianopia with macular sparing
Visual agnosia

Where is the lesion ?

Answer 3

Posterior cerebral artery

Question 4

Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

Where is the lesion?

Answer 4

Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)

Question 5

What is the site of the lesion in a stroke that causes ipsilateral facial paralysis and deafness?

Answer 5

Anterior inferior cerebellar artery (lateral pontine syndrome)

Question 6

Locked in syndrome is caused by a lesion of which artery?

Answer 6

Basilar artery

Question 7

A 56-year-old man presents to the emergency department with sudden onset double vision and right-sided upper and lower limb weakness.

On examination, there is ptosis of the left eyelid and the left eye is shifted downward and laterally. There is reduced power and sensation in the upper and lower right limbs.

What is the most likely diagnosis?

Answer 7

Weber’s syndrome

a form of midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis

Question 8

A 66-year-old woman reports that during the past 6 months she has had several episodes of a sharp, shooting ‘electric shock’ like pain on the left side of her face, which occur when she is combing her hair.

Given the likely diagnosis which one of the following treatments should be initiated?

Answer 8

Trigeminal neuralgia = carbamazepine

Carbamazepine should be started at 100 mg twice daily and titrated up until pain is relieved

Question 9

A 72-year-old man develops visual problems. He is noted to have a left homonymous hemianopia with some macula sparing.

Where is the lesion?

Answer 9

Occipital cortex - suggested by macular sparing

Question 10

A 54-year-old man complains of sweating, headaches and reduced visual fields, saying it’s like having ‘blinders’ on. He is noted to have a bitemporal hemianopia on examination.

Where is the lesion?

Answer 10

Optic chiasm

This patient has a pituitary tumour causing compression of the optic chiasm and bitemporal hemianopia. The sweating and headaches are consistent with acromegaly.

Question 11

A 30-year-old man with a family history of early blindness is concerned that he is developing ‘tunnel vision’.

Where is the lesion?

Answer 11

Retina

This is a common presentation of retinitis pigmentosa. Extensive pigmentation would normally be noted on fundoscopy.

Question 12

Which is the strongest risk factor for developing Bell’s palsy?

Answer 12

pregnancy (3x higher risk)

Question 13

Widespread convulsions without conscious impairment =

Answer 13

Psychogenic non-epileptic seizure

Question 14

Which nerve roots are tested by ankle reflexes?

Answer 14

S1-S2

Question 15

Which nerve roots are tested by knee reflexes?

Answer 15

L3-L4

Question 16

Which nerve roots are tested by biceps and triceps lesions?

Answer 16

Biceps C5-C6
Triceps C7-C8

Question 17

At what GCS should you consider intubating a patient (e.g. with a cuffed endotracheal tube)?

Answer 17

less than 8 = INTUBATE

Question 18

A woman suddenly has the sensation of smelling roses whilst at work. She is conscious throughout - what is the diagnosis?

Answer 18

focal aware seizure

Question 19

Head trauma + fluctuating consciousness =

Answer 19

subdural haemorrhage

Question 20

Normal pressure hydrocephalus presents in elderly patients with urinary incontinence,
reversible dementia and gait abnormality.

How does this appear on neuroimaging?

Answer 20

Ventriculomegaly with relative preservation of cortical sulci

Question 21

A 30-year-old woman is admitted to hospital with an unprovoked first seizure. She attends neurology clinic and asks for advice regarding driving as she uses her car to drop her children to school. The neurologist has not made a formal diagnosis of epilepsy.

What should you advise her?

Answer 21

She should inform the DVLA and will have to be seizure free for 6 months before she can apply to have her license reinstated

If the patient has a formal diagnosis of epilepsy they must be seizure-free for at least 12 months before they may reapply to the DVLA for their license to be reissued

Question 22

A 23-year-old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly weakened.

Where is the likely site of the nerve injury?

Answer 22

Median

median nerve damage = loss of function of the muscles of the thenar eminence

Question 23

A 45-year-old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is impaired.

Where is the likely site of the nerve injury?

Answer 23

Intercostobrachial

The intercostobrachial nerves are frequently injured during axillary dissection.

Question 24

An 8-year-old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand.

Where is the likely site of the nerve injury?

Answer 24

Median

Median nerve is responsible for pronation of the forearm

Brachial artery (responsible for radial pulse) runs alongside the median nerve

Question 25

A 40-year-old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand. Where is the likely site of the nerve injury?

Answer 25

Ulnar nerve The interossei are supplied by the ulnar nerve.

Question 26

A 23-year-old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination he has lost extension of the fingers in his right hand. Where is the likely site of the lesion?

Answer 26

radial nerve supplies the extensor muscles of the hand

Question 27

A 34-year-old contractor has fallen off some scaffolding at work onto his right arm and you suspect a mid-shaft humeral fracture. Which of the following would test the nerve most at risk in this situation?

Answer 27

Extend the wrist Mid-shaft humeral fractures are associated with radial nerve injury and wrist drop.

Question 28

What should you rule out in all patients with status epilepticus?

Answer 28

rule out hypoxia and hypoglycaemia

Question 29

Tx of choice for essential tremor?

Answer 29

propanolol

Question 30

First line tx for focal seizures?

Answer 30

lamotrigine or levetiracetam

Question 31

First line radiological investigation for suspected stroke?

Answer 31

non-contrast CT head

Question 32

An 85-year-old man is admitted with dense right-sided weakness. His blood pressure on admission is 175/95 mmHg . He has a past medical history of gastric ulcer disease and had a nephrectomy 2 months ago due to renal cell carcinoma. CT head shows a hyperdense collection in the left basal ganglia with evidence of chronic small vessel disease. What would be an absolute contraindication to thrombolysis in this case?

Answer 32

CT findings a hyperdense collection is suggestive of a haemorrhage and hence a contraindication to thrombolysis/thrombectomy

Question 33

Weakened dorsiflexion, inversion and eversion of the ankle =

Answer 33

L5 nerve lesion NOT a common peroneal nerve lesion Common peroneal nerve palsy does NOT affect INVERSION of the ankle Another specific sign to look for is loss of sensation over the first web space between the 1st and 2nd toes - that suggests an L5 nerve lesion

Question 34

Bitemporal hemianopia with lower quadrants primarily affected =

Answer 34

superior chiasmal compression, commonly a craniopharyngioma

Question 35

Bitemporal hemianopia with upper quadrants primarily affected =

Answer 35

inferior chiasmal compression, commonly a pituitary tumour

Question 36

fever, seizure and CT head showing temporal lobe changes =

Answer 36

think herpes simplex encephalitis Herpes simplex encephalitis (HSE) is the commonest cause of sporadic encephalitis Start IV aciclovir!!!

Question 37

What blood marker can be used to differentiate between a true seizure and a pseudoseizure?

Answer 37

Prolactin

Question 38

What is the most common complication following meningitis?

Answer 38

Sensorineural hearing loss

Question 39

A lesion of which area causes Wernicke's aphasia?

Answer 39

superior temporal gyrus

Question 40

A lesion of which area causes Broca's aphasia?

Answer 40

inferior frontal gyrus

Question 41

A 36-year-old man is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity. What is the diagnosis? How should you treat?

Answer 41

neuroleptic malignant syndrome stop antipsychotic, IV fluids to prevent renal failure, consider bromocriptine (dopamine agonist)

Question 42

When and how can anti epileptic drugs be stopped?

Answer 42

Can be considered if seizure free for > 2 years, with AEDs being stopped over 2-3 months

Question 43

A patient describes a 'curtain closing' from the left side of his vision which left him with a crescent of blackness on his left. What is the most likely underlying cause?

Answer 43

Atherosclerosis of the left internal carotid- amaurosis fugax of the left retinal/ophthalmic artery

Question 44

If a patient presents with a conductive aphasia, and the question asks if it originated from their left or right MCA, how can you tell which one?

Answer 44

MCA lesions in the DOMINANT hemisphere cause aphasia so if the patient is right handed, the left is their dominant hemisphere, and it will be a lesion of their LEFT MCA that causes aphasia

Question 45

Which muscles are typically spared in MND?

Answer 45

Ocular muscles

Question 46

Which anti-Parkinsons medications are associated with the highest chance of inhibition disorders?

Answer 46

Dopamine receptor agonists e.g. bromocriptine, ropinirole, cabergoline, apomorphine

Question 47

Syncopal episodes can present with muscle jerks. How can they be differentiated from generalised seizures if they present in this way?

Answer 47

rapid recovery and short post-ictal period lack of incontinence or tongue biting

Question 48

What can be given for secondary prevention following stroke if clopidogrel is not tolerated?

Answer 48

aspirin and modified release dipyramidole

Question 49

Patient with suspected Parkinson's disease and diplopia =

Answer 49

consider an alternative diagnosis Diplopia is not common in Parkinson's disease and may suggest an alternative cause of parkinsonism such as progressive supranuclear palsy

Question 50

LP findings in Guillain Barre syndrome?

Answer 50

Increased protein levels with normal white cell count

Question 51

A 37-year-old hypertensive woman presents to ED with a 1-hour history of sudden onset headache and N+V. Since arrival in the department, she has complained of new onset facial pain over her right maxilla. Her D dimer is 1500 (normal =500). What is the likely diagnosis? How can you investigate?

Answer 51

Venous sinus thrombosis MR Venogram is the gold standard test for diagnosing venous sinus thrombosis

Question 52

When is carotid endarterectomy considered for TIA patients ?

Answer 52

carotid artery stenosis exceeding 50% on the side contralateral to the symptoms

Question 53

Bell's palsy management ?

Answer 53

commence on a course of prednisolone (if present within 72 hours of onset) and give eye care advice

Question 54

Confusion, ataxia, nystagmus/ophthalmoplegia→

Answer 54

give Pabrinex (IV B/C vitamins) likely Wernicke's encephalopathy

Question 55

A 47-year-old female is reviewed in the neurology clinic. She was diagnosed with epilepsy whilst a teenager and her seizures are well controlled. She is however concerned about increasing numbness of her fingers and soles of her feet. Which epilepsy medication is most likely to be responsible?

Answer 55

Phenytoin Can't PHEEL-y-TOE-n

Question 56

first-line medications for spasticity in multiple sclerosis?

Answer 56

Baclofen and gabapentin

Question 57

Urinary incontinence + gait abnormality + dementia =

Answer 57

normal pressure hydrocephalus

Question 58

A 58 year old man presents with left sided paraesthesias affecting his thumb and first finger. He complains of grip weakness and dropping objects unintentionally. On examination, there is wasting over the thenar eminence. Which of the following signs would suggest a diagnosis other than carpal tunnel syndrome?

Answer 58

Hoffmans sign : a sign of upper motor neuron dysfunction e.g. DCM To elicit it, the examiner should flick the patients distal phalanx (usually of the middle finger) to cause momentary flexion. A positive sign is exaggerated flexion of the thumb.

Question 59

What adverse effects may be associated with triptan use?

Answer 59

'triptan sensations' - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure

Question 60

How may aura associated with migraine be described?

Answer 60

spreading scintillating scotoma ('jagged crescent')

Question 61

NICE recommends to offer thrombectomy and thrombolysis within 6 hours of sx onset for ischaemic stroke. When may an extended target time of 6-24 hours be considered?

Answer 61

if there is the potential to salvage brain tissue CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 62

What is the preferred modality in patients with suspected TIA who require brain imaging?

Answer 62

MRI brain with diffusion-weighted imaging

Question 63

Management of myasthenic crisis?

Answer 63

IV immunoglobulin, plasmapheresis

Question 64

rapid onset dementia and myoclonus =

Answer 64

Sporadic Creutzfeldt-Jakob disease (CJD)

Question 65

What can be used for migraine prophylaxis in women of childbearing age?

Answer 65

Propranolol preferable to topiramate in women of childbearing age

Question 66

Gait ataxia is caused by lesions in which part of the brain?

Answer 66

Cerebellar vermis

Question 67

A 66-year-old woman comes to see you following her first TIA. She would like to know more about when she can start driving her car again. What would you advise?

Answer 67

Can start driving if symptom free after 1 month - no need to inform the DVLA

Question 68

A 40-year-old woman presents with weakness and numbness of her hand which gets worse when she raises her hands above her head. She is also complaining of a painful neck and generalised headache. On examination there is wasting in her thenar eminence. Which is the most likely cause of her symptoms?

Answer 68

Neurogenic Thoracic outlet syndrome

Question 69

investigation of choice for narcolepsy ?

Answer 69

multiple sleep latency EEG

Question 70

Middle-aged, personality changes, involuntary movements →

Answer 70

?Huntington's disease

Question 71

Which type of motor neuron disease carries the worst prognosis?

Answer 71

Progressive bulbar palsy

Question 72

Which cranial nerves may be affected by acoustic neuromas?

Answer 72

V, VII and VIII

Question 73

'Young' stroke blood tests are performed in those under 55 with no obvious cause of a stroke. What do they include?

Answer 73

Autoimmune and thrombophilia screening Syphilis serology

Question 74

Headache linked to Valsalva manoeuvres =

Answer 74

raised ICP until proven otherwise so LP is contraindicated request urgent CT head

Question 75

Which diet is most likely to be effective in epilepsy for improving symptom control?

Answer 75

Ketogenic diet

Question 76

How should you investigate an MS patient with bladder dysfunction?

Answer 76

Ultrasound kidneys, ureters and urinary bladder (KUB) to assess bladder emptying

Question 77

A 52-year-old male with a known pituitary macroadenoma presents with a severe headache and reduced visual acuity. He also complains of neck stiffness and has vomited twice. The patient has a blood pressure of 96/48 mmHg and a heart rate of 125 bpm. A CT head shows areas of hyperdensity within the sellar region. What is the likely diagnosis? What is the most appropriate immediate next step?

Answer 77

pituitary apoplexy: bleeding/infarction within the pituitary adenoma, rare and life threatening complication tx with urgent steroid replacement due to loss of ACTH

Question 78

What is the risk of giving folate to a patient deficient in B12 ?

Answer 78

can precipitate subacute combined degeneration of the cord

Question 79

Intracerebral haemorrhage is an uncommon but serious complication of thrombolysis in an acute ischemic stroke. How should you manage this?

Answer 79

Stop Aspirin 300mg & control BP

Question 80

A 75-year old gentleman presents with a short history of neck pain, paraesthesia in his finger tips and progressive leg weakness. Following a MRI scan of his spine, he is diagnosed with degenerative cervical myelopathy due to a C4/5 disc prolapse. What is the most appropriate management?

Answer 80

Cervical decompressive surgery

Question 81

What is used for long-term prophylaxis of cluster headaches?

Answer 81

Verapamil

Question 82

What is the tetrad of neuroleptic malignant syndrome?

Answer 82

hyperthermia, muscle rigidity, autonomic instability, altered mental status

Question 83

Patient on antipsychotics presents with hyperthermia, muscle rigidity, autonomic instability, and altered mental status. What is the diagnosis?

Answer 83

neuroleptic malignant syndrome

Question 84

A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present. Which diagnosis needs to be urgently excluded?

Answer 84

posterior communicating artery aneurysm

Question 85

A 50-year-old man who, on examination, you notice his jaw appears deviated towards the right and he has an absent right-sided corneal reflex. Which cranial nerve palsy would explain this?

Answer 85

Trigeminal

Question 86

A 64-year-old woman who reports vertical diplopia, in particular, whilst reading in bed at night time. Which cranial nerve palsy would explain this?

Answer 86

Trochlear

Question 87

A 72-year-old man who has noticed a change in his voice with some difficulty swallowing. On examination, you notice his uvula deviates towards the right. Which cranial nerve palsy would explain this?

Answer 87

Vagus (left side)

Question 88

A 65-year-old male with known nasopharyngeal carcinoma presents with double vision. On examination he is found to have left eye proptosis and it is down and out. He reports pain on attempting to move the eye. There is an absent corneal reflex. What is the most likely diagnosis?

Answer 88

Cavernous sinus syndrome the nasopharyngeal malignancy has locally invaded the left cavernous sinus Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner's syndrome

Question 89

Which common medication may trigger migraine?

Answer 89

oral COCP

Question 90

A 23-year-old man wakes up on a Sunday morning unable to extend his wrist . He had been drinking heavily the previous night. What is the likely cause of his weakness?

Answer 90

Radial nerve palsy 'Saturday night palsy' caused by compression of the radial nerve against the humeral shaft, possibly due to sleeping on a hard chair with his hand draped over the back

Question 91

A concerned mother brings her 4-year-old son to you the GP. She says her son has not been growing relative to his peers in school. On examination, he has 6 individual, 4cm oval pigmented lesions on his trunk and has freckles in both of his axillae. What is the most likely diagnosis?

Answer 91

Neurofibromatosis type 1

Question 92

A patient who has experienced significant head trauma presents with clear fluid dripping down his nose. What is a quick and easy bedside test to perform to confirm that the fluid is CSF?

Answer 92

Check glucose Glucose test would show positive as it is not present in mucus and is present in CSF.

Question 93

A 25-year-old man attends with a 3-month history of numbness in his right hand. On examination, you note the loss of sensation to the palmar and dorsal aspect of the 5th digit. Sensation of the forearm is preserved. What is the most likely diagnosis?

Answer 93

Cubital tunnel syndrome - ulnar nerve neuropathy

Question 94

Laughter → fall/collapse =

Answer 94

?cataplexy

Question 95

Autonomic dysreflexia can only occur if the spinal cord injury occurs above which level?

Answer 95

T6

Question 96

Which medications are associated with idiopathic intracranial hypertension?

Answer 96

tetracycline antibiotics isotretinoin contraceptives steroids levothyroxine lithium

Question 97

What should be given if a patient with status epilepticus is not responding to benzos (e.g. lorazepam)?

Answer 97

IV levetiracetam, phenytoin or sodium valproate

Question 98

What would provide a definitive diagnosis of medication overuse headaches?

Answer 98

Symptoms resolve (or revert to their original pattern) within 2 months of stopping co-codamol

Question 99

What should be offered for patients with newly diagnosed Parkinson's who have motor symptoms affecting their quality of life?

Answer 99

Levodopa

Question 100

Distal sensory loss, tingling + absent ankle jerks/extensor plantars + gait abnormalities/Romberg's positive →

Answer 100

subacute combined degeneration of the spinal cord

Question 101

A 34-year-old woman presents with a 3 month history of double vision. On examination the right eye fails to adduct and the left eye develops coarse nystagmus in abduction. What is the most likely diagnosis?

Answer 101

Internuclear ophthalmoplegia (INO) occurs due to a lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement

Question 102

Jacksonian movement (clonic movements travelling proximally) suggests what?

Answer 102

frontal lobe epilepsy

Question 103

Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension) =

Answer 103

Multiple System Atrophy