Questions Flashcards
1
Q
Start [] in all cases of suspected encephalitis as over 95% of encephalitis cases are caused by []
A
Start aciclovir in all cases of suspected encephalitis as over 95% of encephalitis cases are caused by herpes simplex virus (HSV), IV aciclovir (works against HSV) should be started in all patients urgently.
2
Q
Unilateral headache, periorbital inflammation, ophthalmoplegia → ? [1]
A
Unilateral headache, periorbital inflammation, ophthalmoplegia → ? cavernous sinus thrombosis
3
Q
Which cranial nerve is first effected in CVT [1]
Why? [1]
A
with the sixth nerve (abducens) often being the first affected due to its central location within the sinus.
4
Q
Painful third nerve palsy = [1] aneurysm
A
Painful third nerve palsy = posterior communicating artery aneurysm
5
Q
Restless leg syndrome - management includes [1]
A
Restless leg syndrome - management includes dopamine agonists such as ropinirole
6
Q
Lateral medullary syndrome aka [] lesion
- What is the presentation? [3]
A
Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
7
Q
Drugs that increase the risk of IIH. [6]
A
Drugs that increase the risk of IIH. COMAAR - ciclosporin, oral contraceptives, mineralocorticoids, amiodarone, antibiotics (tetracyclines, sulphonamides), retinoic acid.
8
Q
What is Ramsay-Hunt syndrome? [1]
How does it present? [1]
A
A facial palsy caused by an upper motor neuron lesion ‘spares’ the upper face i.e. forehead
- This is caused by reactivation of the varicella zoster virus in the facial nerve and so produces a lower motor neurone (LMN) lesion
9
Q
A 65-year-old man presents with a 3 month history of numbness and paraesthesia in his feet. On examination there is widespread numbness of both feet which does not fit a dermatomal distribution. A recent gamma-glutamyl transpeptidase (gamma GT) is 4 times the upper limit of normal.
What is the most likely diagnosis?
Alcoholic peripheral neuropathy
Diabetic peripheral neuropathy
Hepatic failure
Charcot-Marie-Tooth syndrome
Chronic inflammatory demyelinative polyneuropathy
A
Alcoholic peripheral neuropathy
- The neurological findings are suggestive of polyneuropathy. An increased gamma GT is suggestive of excessive alcohol consumption. Therefore the most likely answer is alcoholic peripheral neuropathy.
10
Q
Cranial MRI demonstrates a mass at the cerebellopontine junction.
Given the most likely diagnosis, which one of the following cranial nerves are most likely to be affected?
II, VII and VIII
II, VIII and IX
III, VIII and IX
V, VII and VIII
VII, VIII and X
A
V, VII and VIII
11
Q
[1] is the preferred way to support nutrition in patents with motor neuron disease
A
Percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition in patents with motor neuron disease
12
Q
[] have the strongest evidence base for reducing relapse in multiple sclerosis
A
Monoclonal antibodies such as natalizumab have the strongest evidence base for reducing relapse in multiple sclerosis
13
Q
He has clear fluid dripping down his nose. What is a quick and easy bedside test to perform to confirm that the fluid is CSF?
Test for lymphocytes
Test for breakdown products of bilirubin (Xanthochromia)
Test for erythrocytes
Check for glucose
Beta-3-transferrin
A
Check for glucose
- Glucose test would show positive as it is not present in mucus and is present in CSF.
14
Q
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?
Axillary nerve neuropathy
C8/T1 radiculopathy
Carpal tunnel syndrome
Cubital tunnel syndrome
Radial nerve neuropathy
A
Cubital tunnel syndrome
15
Q
How would you differentiate between cubital tunnel syndrome and C8/T1 radiculopathy? [1]
A
Cubital tunnel affects the hand, C8/T1 would affect more because of where the nerve is being compressed
16
Q
The sensation of fine touch, proprioception and vibration are all conveyed in the [area of spinal cord]
A
The sensation of fine touch, proprioception and vibration are all conveyed in the dorsal column.
17
Q
Pituitary lesions that cause following presentations.
How would you determine where this has occured? [2]
A
homonymous quadrantanopias
- PITS (Parietal-Inferior, Temporal-Superior)
Tumours in the parietal region can impinge upon the optic radiation, resulting in visual field defects such as homonymous inferior quadrantanopia
18
Q
First-line anti-epileptic in a 17-year-old girl with tonic-clonic seizures. She is not sexually active and does not use any form of contraception currently. She has previously had a reaction to levetiracetam.
What drug would you give instead? [1]
A
females: lamotrigine or levetiracetam
19
Q
[] is the preferred modality in patients with suspected TIA who require brain imaging
A
MRI brain with diffusion-weighted imaging is the preferred modality in patients with suspected TIA who require brain imaging
20
Q
A patient has ?subacute degeneration of spinal cord.
Which presenting features would support this dx? [3]
A
Distal sensory loss, tingling + absent ankle
Hypereflexia - jerks/extensor plantars + gait abnormalities/Romberg’s positive → subacute combined degeneration of the spinal cord
21
Q
[2] are first-line for spasticity in multiple sclerosis
A
Baclofen and gabapentin are first-line for spasticity in multiple sclerosis
22
Q
Neuropathic pain characteristically responds poorly to opioids. However, if standard treatment options have failed which opioid is it most appropriate to consider starting?
Tramadol
Morphine
Codeine
Oxycodone
Buprenorphine
A
Neuropathic pain characteristically responds poorly to opioids. However, if standard treatment options have failed which opioid is it most appropriate to consider starting?
Tramadol
Morphine
Codeine
Oxycodone
Buprenorphine
23
Q
What is a positive Hofman’s test? [1]
What is does a positive Hofman’s test indicate? [1]
A
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 or adjacent finger
A positive Hoffmans sign is a sign of upper motor neuron dysfunction and points to a disease of the central nervous system
24
Q
Loss of corneal reflex - CN []
A
Loss of corneal reflex - CN V
25
What is way of remembering valproate's side effects? [+]
**V - VALPROATE:**
**A** - Appetite increase --> weight gain
**L** - Liver failure
**P** - Pancreatitis
**R **- Reversible hair loss (alopecia)
**O** - Oedema
**A** - Ataxia
**T** - Teratogenic, tremor, thrombocytopaenia
**E** - Enzyme inhibitor (p450), encephalopathy (due to high ammonia)
26
A person has ?HSV encephalitis.
Where specifically would lesions appear on brain MRI? [1]
**Herpes simplex (HSV) encephalitis**
- virus characteristically **affects the temporal lobes**
- **bilateral temporal lobe changes are pathognomonic of HSE**
27
A 29-year-old woman with a history of intermittent episodes of limb weakness presents with symptoms of double vision, fatigue, and generalised aches and pains. On neurological examination, she has very brisk reflexes. Imaging of the brain and spine is ordered.
Which imaging modality is best for the above situation? [1]
**MRI with contrast** should be used to view demyelinating lesions
28
A 56-year-old woman with myasthenia gravis is due for an elective abdominal hysterectomy. Which commonly used anaesthetic agent would she most likely be resistant to?
Suxamethonium
Sevoflurane
Ketorolac
Neostigmine
Rocuronium
**Suxamethonium** is a depolarising NMBD - it acts by binding to and activating the receptor, at first causing muscle contraction, then paralysis. Again, due to a decreased number of available receptors, MG patients are typically resistant to depolarising NMBDs and may require significantly higher doses.
## Footnote
**So in MG**: Rocuronium “rocks!” (Hyperefficacious) and Suxaemethonium “sucks!” (Hypoefficacious)
29
A 21-year-old with a known Chiari 1 malformation undergoes a spinal MRI scan. The imaging reveals a cervical and thoracic syringomyelia. On closer examination, the patient is noted to have a cape-like loss of sensation to pain and temperature, but normal fine touch and proprioception.
Which of the following spinal cord structure are affected in order to cause this pattern of signs?
Dorsal columns
Spinocerebellar tract
Anterior white commisure
Dorsal root ganglion
Corticospinal tract
A 21-year-old with a known Chiari 1 malformation undergoes a spinal MRI scan. The imaging reveals a cervical and thoracic syringomyelia. On closer examination, the patient is noted to have a cape-like loss of sensation to pain and temperature, but normal fine touch and proprioception.
Which of the following spinal cord structure are affected in order to cause this pattern of signs?
Dorsal columns
Spinocerebellar tract
**Anterior white commisure**
Dorsal root ganglion
Corticospinal tract
30
Which symptom related to hearing is seen in 1/3 of Bell's palsy patients? [1]
**Hyperacusis** is seen in around a third of patients.
31
A vesicular rash around the ear would suggest a diagnosis of **[] syndrome**
A **vesicular rash** around the ear would suggest a diagnosis of **Ramsey Hunt syndrome**
32
The most common pattern for progression of multiple sclerosis is **[1]**
- Describe this pattern [2]
The most common pattern for progression of multiple sclerosis is **relapsing-remitting**
- Patients experience **relapses of new or worsening symptoms**. These **vary in duration and often come without warning**.
- **Patients then tend to have periods of remission** between attacks **where there are no worsening symptoms**. These periods of remission can last up to **years**.
33
[**Treatment**] is recommend for patients with an acute ischaemic stroke who present **within 4.5 hours**
**A combination of thrombolysis AND thrombectomy** is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
34
Describe and explain eye sign might see in ICP [2]
**Raised** **ICP** can cause a **third nerve palsy** due to herniation
- **Eye deviation 'down and out'**
35
The Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in [3]
The Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in **hypertension, bradycardia and bradypnoea**
36
**Defective downward gaze and vertical diplopia** - which cranial nerve? [1]
*A 54-year-old man attends the GP complaining of double vision. He says it is worse when he walks down the stairs.*
*On inspection, he is sitting with his head tilted towards the right. The left eye deviates supero-laterally.*
Defective downward gaze and vertical diplopia - **CN IV**
**4th nerve palsy - BOOT WOOG**
**B**etter **o**n **o**pposite **t**ilt (e.g. here they are tilting their head to the right)
**W**orse **o**n **o**pposite **g**aze (it would get worse when they try to look right)
37
A 50-year-old man has a history of recurrent mechanical falls with no loss of consciousness. He is seen in the neurology clinic by the registrar following an MRI scan. On examination he has an intention tremor and an ataxic gait, but only very minimal past-pointing. The MRI brain has revealed a lesion.
**Where is the most likely location of the lesion?**
**Gait ataxia** is caused by **cerebellar vermis** lesions
38
What is the difference in presentation between damage to cerebellar vermis or hemisphere? [1]
You can remember it that the **vermis** (or **centre**) of the cerebellum **causes central ataxia**, whereas **peripheral cerebellar lesions cause peripheral ataxia.**
*the vermis is in the middle so it deals with your trunk.*
*the hemispheres are on the outside so deal with your arms and stuff.*
39
**[]** is used for long-term prophylaxis of cluster headaches
**Verapamil** is used for long-term prophylaxis of cluster headaches
40
What would a headache that worsens with valsalva manoeuvres indicate? [1]
Why is this clinically significant? [1]
Headache linked to Valsalva manoeuvres = **raised ICP** until proven otherwise so LP is contraindicated
41
*A 26-year-old male patient has been referred for EMG testing following ongoing muscle weakness. The results showed a diminished response with repetitive stimulation.*
What disease is this? [1]
**MG**
42
Stroke:
Current guidelines recommend maintaining blood pressure **< [] mmHg** before and during reperfusion therapies.
Current guidelines recommend maintaining blood pressure **< 185/110 mmHg** before and during reperfusion therapies
43
What timelines are given for stroke mx with regards to thrombolysis and thrombectomy [2]
Offer **thrombectomy** as soon as possible and **within 6 hours of symptom** onset, together with **intravenous** **thrombolysis** (if **within 4.5 hours**
44
[2] are first-line for spasticity in multiple sclerosis
**Baclofen and gabapentin** are first-line for spasticity in multiple sclerosis
45
All **TIA** patients should have an **[Ix]** unless they are not a candidate for **[Mx]**
All TIA patients should have an **urgent carotid doppler** unless they are **not a candidate for carotid endarterectomy**
46
Describe how a left PICA stroke would present [+]
Lateral medullary syndrome - PICA lesion - **cerebellar signs, contralateral sensory loss & ipsilateral Horner's**
47
What is the acute treatment and prophylactic treatment of migraines? [2]
**Propranolol** *is preferable to topiramate in women of childbearing age (i.e. the majority of women with migraine)* is used for **prophylaxis**
**Triptans** are used for **treatment**
48
Trigeminal neuralgia - **[]** is first-line
Trigeminal neuralgia - **carbamazepine** is first-line
49
The most characteristic feature of a **common peroneal nerve lesion** is **[1]**
Other features include: **[6]**
The most characteristic feature of a common peroneal nerve lesion is **foot drop.**
**Other features include:**
* **weakness** of **foot** **dorsiflexion**
* **weakness** of **foot eversion**
* **weakness** of **extensor hallucis longus**
* **sensory loss over the dorsum of the foot** and the **lower lateral part of the leg**
* **wasting of the anterior tibial and peroneal muscles**
50
What causes conduction aphasia? [1]
How does it present? [3]
Classically due to a **stroke** affecting the **arcuate fasiculus** - the **connection between Wernicke's and Broca's area**
**Speech is fluent** but **repetition is poor**. **Aware of the errors they are making**
**Comprehension is normal**
51
Autonomic dysreflexia can only occur if the spinal cord injury occurs **above** the **[]** level
Autonomic dysreflexia can only occur if the spinal cord injury occurs **above the T6 level**
52
Myasthenia gravis - **[] antibodies**
**Anti-nicotinic receptor antibody**
53
Creutzfeldt-Jakob disease is characterised by **[2]**
Creutzfeldt-Jakob disease is characterised by **rapid onset dementia and myoclonus**
54
How do you manage a patient with TIA but who is on anticoagulants? [1]
If a patient is on **warfarin/a DOAC/** or has a **bleeding disorder** and they are suspected of having a TIA, they should be **admitted immediately for imaging to exclude a haemorrhage**
55
**[]** movements are typically spared in motor neurone disease
**Eye movements** are typically spared in motor neurone disease
56
Describe how timing of a headache would indicate SAH [1]
A **sudden**-onset headache, **reaching maximum intensity within 5 minutes**, is a red flag requiring further evaluation to exclude a subarachnoid haemorrhage
57
**[]** are common precipitants of myasthenic crises.
**Beta-blockers** such as bisoprolol are common precipitants of myasthenic crises.
58
A 46-year-old man is an inpatient on a stroke ward following the onset of left sided arm weakness earlier that day.
On examination, the doctor auscultates a carotid bruit. A head computerised tomography (CT) scan is performed which shows an area of cortical hypodensity suggestive of ischaemia.
How should the carotid bruit be investigated?
Angiography
Chest X-ray
Duplex ultrasound
Computerised tomography (CT) angiography
Magnetic resonance imaging (MRI) scan
**Duplex ultrasound**
- Carotid artery stenosis is diagnosed (and degree of stenosis assessed) via duplex ultrasound
59
Describe how a painful third nerve palsy would present [6]
left eye is **depressed and laterally deviated**, and there is **left-sided ptosis.** (eyelid droop)
The left pupil is **dilated** and he has **diplopia** at rest with **pain on all movements of the left eye**
60
**Painful third nerve palsy** = **[] artery aneurysm**
Painful third nerve palsy = **posterior communicating artery aneurysm
**
61
How would you distinguish between an MCA and PCA stroke?
**MCA**:
- UMN motor lesions > lower limbs
- BUT - heman
- NO visual agnosia (have difficulty recognizing visually presented objects despite normal vision and other cognitive abilities)
- Aphasia likely
**PCA**:
* **Weber's syndrome** is a form of **midbrain stroke** characterised by the an **ipsilateral CN III palsy and contralateral hemiparesis**
* **Contralateral HH with macular sparing**
62
What are the three core presenting features of Wernicke's encephalopathy ? [3]
What would be mainstay of treatment ? [1
**Confusion, ataxia, nystagmus/ophthalmoplegia**→ give **Pabrinex (IV B/C vitamins)**
63
Management of myasthenic crisis - [2]?
Management of myasthenic crisis - **intravenous immunoglobulin, plasmapheresis**
64
A 72-year-old woman is brought into the emergency department following a fall. Her left arm appears swollen and, upon further imaging, a displaced mid-shaft humeral fracture is diagnosed.
What nerve is most likely to be damaged as a result of this fracture, and how would this present clinically?
* Axillary nerve, loss of sensation over the 'sergeant patch' region of the shoulder
* Radial nerve, inability to flex the 1st, 2nd and 3rd digits of the hand
* Radial nerve, wrist drop
* Ulnar nerve, inability to extend the 4th and 5th digits of the hand
* Ulnar nerve, loss of sensation on the dorsum of the hand over the thumb and index finger
* **Radial nerve, wrist drop**
65
Describe what is meant by an ataxic gait [1]
A **wide-based gait** with **loss of heel to toe walking** is called an ataxic gait
66
An 80-year-old male presents with sudden onset weakness of his left arm and leg. On examination you note left sided arm and leg weakness. There is no evidence of higher function deficits or visual field defects. You suspect a stroke and send him for an urgent CT.
What is the best description of this stroke?
Left sided partial anterior circulation syndrome
Posterior circulation stroke syndrome
Left sided total anterior circulation syndrome
Right sided total anterior circulation syndrome
Lacunar stroke
**Lacunar stroke**
67
How do lacunar infarcts present? [4]
68
(NICE) recommends that **mechanical** **thrombectomy** be performed as soon as possible, ideally within **[] hours from symptom onset**.
(NICE) recommends that mechanical thrombectomy be performed as soon as possible, ideally within **6 hours from symptom onset.**
## Footnote
**NB** - thrombolysis is only within 4.5h of onset of symptoms
69
A patient has ?TIA.
How do you invetigate them acutely? [1]
All TIA patients should have an **urgent carotid doppler** unless they are not a candidate for carotid endarterectomy
- Many TIAs are caused by **atherosclerotic stenosis of the carotid artery**, so all of these patients should have an urgent carotid Doppler study to look for this unless a carotid endarterectomy
70
**[]** increase the risk of idiopathic intracranial hypertension
**Tetracyclines** increase the risk of idiopathic intracranial hypertension
71
Wernicke's aphasia is due to a lesion of the **[]**
Wernicke's aphasia is due to a lesion of the **superior temporal gyrus**
72
A lesion to the **[]** would result in Broca's aphasia
- How would this present? [2]
A lesion to the **left inferior frontal gyrus** would result in **Broca's aphasia**
- **Speech is non-fluent, laboured, and halting. Repetition is impaired**
73
A lesion to the **[]** region would result in **transcortical sensory aphasia**
- How would this present? [2]
A lesion to the **temporo-occipital region** would result in transcortical sensory aphasia
74
A lesion to the **[]** would result in **conduction aphasia**
- How would this present? [2]
A lesion to the **arcuate fasciculus** would result in conduction aphasia
- **Speech is fluent but repetition is poor. Aware of the errors they are making**
75
A lesion to the angular gyrus would result in **[]** Syndrome
A lesion to the angular gyrus would result in **Gerstmann Syndrome**
76
Patients cannot drive for [] months following a **first unprovoked or isolated seizure if brain imaging and EEG normal**
Patients cannot drive for **6 months** following a first unprovoked or isolated seizure if brain imaging and EEG normal
77
What are methods of remembering Webers and Wallenburg sx? [+]
**Weaky weber** (weakness in the muscles)
and
**Wobbly wallenburg** (ataxia, and altered sensation)
and
**for both of them it is ipsilateral in the head, contralateral in the body**
78
A 27-year-old female presents to her General Practitioner with severe morning headaches associated with nausea. She is referred for an MRI head scan that reveals a large tumour arising from the falx cerebri and pushing on the brain. There is a well-defined border between the tumour and the brain parenchyma.
What is the most likely diagnosis?
Glioblastoma
Metastasis
Low-grade glioma
Meningioma
Craniopharyngiom
A 27-year-old female presents to her General Practitioner with severe morning headaches associated with nausea. She is referred for an MRI head scan that reveals a large tumour arising from the falx cerebri and pushing on the brain. There is a well-defined border between the tumour and the brain parenchyma.
What is the most likely diagnosis?
**Meningioma**
- Meningiomas are typically benign tumours that arise from the arachnoid cells next to the dura mater of the meninges. They are extra-axial lesions, meaning they do not arise from the brain parenchyma. They do not invade the brain substance, but rather cause symptoms by compression.
79
The **[] index** is a scale that measures disability or dependence in activities of daily living in stroke patients
The **Barthel index** is a scale that measures disability or dependence in activities of daily living in stroke patients
80
A 35-year-old man presents with progressive weakness of his hands. On examination you notice wasting of the small muscles of the hand. A diagnosis of syringomyelia is suspected. Which one of the following features would most support this diagnosis?
Hyper-reflexia in the upper limbs
Loss of vibration sensation in the hands
Loss of temperature sensation in the hands
Loss of light touch sensation in the hands
Fasciculation of the small muscles of the hand
A 35-year-old man presents with progressive weakness of his hands. On examination you notice wasting of the small muscles of the hand. A diagnosis of syringomyelia is suspected. Which one of the following features would most support this diagnosis?
**Loss of temperature sensation in the hands**
- Syringomyelia - spinothalamic sensory loss (pain and temperature)
## Footnote
Syringomyelia = Superman - Something about a cape and can't feel no pain
81
What is Paroxysmal hemicrania (PH) ? [1]
**Paroxysmal hemicrania (PH)** is defined by attacks of **severe, unilateral headache, usually in the orbital, supraorbital or temporal region.**
- These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day.
82
**Paroxysmal hemicrania** is completely responsive to treatment with **[]**
Paroxysmal hemicrania is completely responsive to treatment with **indomethacin**
83
**[]** is the preferred way to support nutrition in patents with motor neuron disease
**Percutaneous gastrostomy tube (PEG)** is the preferred way to support nutrition in patents with motor neuron disease
84
Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Concurrent pizotifen use
Patients older than 55 years
A history of epilepsy
Previous intracranial tumour
A history of ischaemic heart disease
**A history of ischaemic heart disease**
- They cause **vasoconstriction** of cranial blood vessels and inhibit the release of vasoactive peptides. However, they can also **cause coronary artery vasospasm** and are therefore contraindicated in patients with a history of ischaemic heart disease due to the increased risk of myocardial infarction.
85
**The correct answer is Tuberous sclerosis**. Tuberous sclerosis is a genetic disorder that causes non-cancerous (benign) tumours to grow in different parts of the body. It often affects the brain and can lead to conditions such as epilepsy. **The image shows characteristic adenoma sebaceum on the nose.**
86
**[]** is used to treat idiopathic intracranial hypertension
**Acetazolamide is a carbonic anhydrase inhibitor** that is used to treat idiopathic intracranial hypertension
87
Describe the mechanism in which could reduce ICP via breathing techniques [2]
**Hyperventilation -> reduce CO2 -> vasoconstriction of the cerebral arteries -> reduced ICP**
88
Describe how the position of bitemporal hemianopia can determine what the cause of the lesion is? [2]
**Bitemporal hemianopia** - lesion of optic chiasm
* **upper quadrant defect >** lower quadrant defect = **inferior chiasmal compression**, commonly a **pituitary tumour**
* **lower quadrant defect >** upper quadrant defect = superior chiasmal compression, commonly a **craniopharyngioma**
89
How do you manage a patient who has neuropathic pain, but their neuropathic analgesia hasn't worked? [1]
Drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be **switched**, **not added**
90
She is prescribed pyridostigmine amongst other agents.
What is the mechanism of the aforementioned drug?
Short acting acetylcholinesterase inhibitor
Long acting acetylcholinesterase inhibitor
Muscarinic agonist
Calcineurin inhibitor
Dihydrofolic acid reductase inhibitor
She is prescribed pyridostigmine amongst other agents.
What is the mechanism of the aforementioned drug?
Short acting acetylcholinesterase inhibitor
**Long acting acetylcholinesterase inhibitor**
Muscarinic agonist
Calcineurin inhibitor
Dihydrofolic acid reductase inhibitor
91
A 33-year-old man presents complaining of visual disturbance. Examination reveals a bitemporal hemianopia with predominately the upper quadrants being affected. What is the most likely lesion?
Craniopharyngioma
Brainstem lesion
Pituitary macroadenoma
Frontal lobe lesion
Right occipital lesion
**Bitemporal hemianopia**
* lesion of optic chiasm
* upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
* lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
92
A 69-year-old lady is brought to hospital by an ambulance crew with a suspected stroke. On review in the emergency department she is unable to speak although she is able to follow instructions which have been written down. She has no past medical history.
A blockage of which of the following cerebral arteries is most likely to be the cause of this woman's symptoms?
Right anterior cerebral artery
Left anterior cerebral artery
Right middle cerebral artery
Left middle cerebral artery
Right posterior cerebral artery
**Left middle cerebral artery**
- The middle cerebral artery on the **dominant side supplies** both Wernicke's and Broca's areas of the cortex which are responsible for understanding and production of speech.
- most likely affected side is the left as the percentage of right and left handed individuals with a dominant left hemisphere is 90% and 60% respectively, making the left always the most likely affected side regardless of handedness.
93
You are the FY1 on the Acute Medical Unit. A 32-year-old male who has come in for recurrent seizure-like episodes falls to the ground and his whole body begins to convulse. Once the patient is stabilised, you want to conduct a blood test to help determine if this could, in fact, be a pseudo seizure.
Which blood test would you do?
Prolactin
ADH
Magnesium
FSH
LH
You are the FY1 on the Acute Medical Unit. A 32-year-old male who has come in for recurrent seizure-like episodes falls to the ground and his whole body begins to convulse. Once the patient is stabilised, you want to conduct a blood test to help determine if this could, in fact, be a pseudo seizure.
Which blood test would you do?
**Prolactin**
* Prolactin can be used to differentiate between a true seizure and a pseudoseizure
94
A patient presents with IIH.
They have lost 10kg already but this has made no difference to the headaches they have.
What is the next stage in treatment? [1]
**Acetazolamide** is a carbonic anhydrase inhibitor that is used to treat idiopathic intracranial hypertension
95
W status epilepticus - what do you need to rule out before treating? [2]
**Status epilepticus**: rule out **hypoxia** and **hypoglycaemia** before thinking of other causes
96
What is meant by cataplexy ? [1]
How does it typically present? [2]
**Cataplexy**
- is a **sudden and transient episode of muscle weakness**, typically triggered by **strong** **emotions** such as **laughter, anger or surprise**.
- It is often associated with narcolepsy, a sleep disorder that causes excessive daytime sleepiness and fragmented night-time sleep. The patient's symptoms of leg weakness following bouts of laughter and brief collapse are characteristic of cataplexy.
- **Features range from buckling knees to collapse.**
97
**[2]** can help in the diagnosis of **Guillain-Barre syndrome**
- *Describe positive results*
**Investigations**:
**lumbar puncture:**
* **rise** in **protein** with a **normal white blood cell count** (albuminocytologic dissociation) - found in 66%
**nerve conduction studies may be performed**
* **decreased motor nerve conduction velocity** (due to demyelination)
* **prolonged distal motor latency**
* **increased F wave latency**
98
Raised ICP can cause a third nerve palsy due to herniation
- How would this present? [3]
**Ptosis, downward and outward deviation of the eye, mydriasis** (dilated pupil)
## Footnote
myDriasis = Dilated
99
What is pituitary apoplexy? [1]
**Pituitary apoplexy**
* Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
100
What are the precipitating factors [4] and features [+] of pituitary apoplexy
**Precipitating factors**
* hypertension
* pregnancy
* trauma
* anticoagulation
**Features**
* sudden onset headache similar to that seen in subarachnoid haemorrhage
* vomiting
* neck stiffness
* visual field defects: classically bitemporal superior quadrantic defect
* extraocular nerve palsies
* features of pituitary insufficiency
* e.g. hypotension/hyponatraemia secondary to hypoadrenalism
101
Draw and name the vision loss seen in pituitary apoplexy [1]
visual field defects: classically **bitemporal superior quadrantic defect**
102
Ix [1] and Mx [3] for pituitary apoplexy?
**Investigation**
* MRI is diagnostic
**Management**
* urgent steroid replacement due to loss of ACTH
* careful fluid balance
* surgery
103
Useful for managing tremor in drug-induced parkinsonism
A. Levodopa
B. Amantadine
C. Entacapone
D. Procyclidine
E. Ropinirole
F. Cabergoline
**Procyclidine**
104
Which of the following are used in conjunction with levodopa in patients with established PD
A. Levodopa
B. Amantadine
C. Entacapone
D. Procyclidine
E. Ropinirole
F. Cabergoline
Which of the following are used in conjunction with levodopa in patients with established PD
A. Levodopa
B. Amantadine
C. **Entacapone**
D. Procyclidine
E. Ropinirole
F. Cabergoline
105
Which one of the following is least characteristic of Wernicke's encephalopathy?
Ataxia
Confusion
Ophthalmoplegia
Confabulation
Nystagmus
**Confabulation**
- An inability to acquire new memories and confabulation suggests the development of Korsakoff's syndrome
106
What's a mneumonic that helps distinguish between Wernicke's and Korsakoff's [4]
**COAT RACK**
**Wernicke's**:
* **C**onfusion
* **O**pthamoplegia
* **A**taxia
* **T**hiamine Deficiency
**Korsakoff's:**
* **R**etrograde amnesia
* **A**nterograde amnesia
* **C**onfabulation
* **K**orsakoff's psychosis
107
Describe how you differentiate between partial and total anterior circulation infarcts? [
**The following criteria should be assessed:**
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
**Total anterior circulation infarcts (TACI, c. 15%)**
* involves middle and anterior cerebral arteries
* all 3 of the above criteria are present
**Partial anterior circulation infarcts (PACI, c. 25%)**
* involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
* 2 of the above criteria are present
108
Management of myasthenic crisis - [2]
Management of myasthenic crisis - **intravenous immunoglobulin, plasmapheresis**
109
What is Amaurosis fugax? [1]
A stroke impacting which area would indicate this? [1]
**amaurosis fugax (literally translated to 'fleeting darkness')**
- a form of stroke that affects the **retinal artery.**
110
A patient describes a 'curtain closing' from the left side of his vision which left him with a crescent of blackness on his left.
Explain where the lesion is [1]
**left internal carotid** is one of the 4 arteries that supplies circle of willis (left internal carotid, right internal carotid, left vertebral, right vertebral).
before the left internal carotid splits in to MCA, ACOM, PCOM it has an **ophthalmic artery branch (left)** which is where the **left central retinal artery arises, hence affecting left eye**
## Footnote
Left side of vision = left eye. Supplied by left retinal artery. The ischaemia is at the retina and not in the brain.
111
What are the three key presenting features of venous sinus thrombosis? [3]
**Presentation of VST is usually in 1 of 3 ways:**
1. **Raised ICP** (headache, vomiting, papilloedema, vision problems)
2. **Focal syndrome** (focal neurological deficits, seizures, or both; or as specific affected sinus syndromes such as cavernous sinus syndrome)
3. **Encephalopathy** (multifocal signs, stupor, coma)
112
A patient has ?Parkinson's
Given the likely diagnosis, which finding points towards idiopathic disease rather than a drug-induced disease?
Age of onset
Asymmetrical symptoms
Bradykinesia
Cogwheel rigidity
Micrographia
**Asymmetrical** symptoms suggests **idiopathic Parkinson's**
113
What are the key symptoms that would help differentiate idiopathic PD and drug induced? [2]
**Drug induced:**
- **motor** **symptoms** are **generally rapid onset and bilateral**
- **rigidity and rest tremor** are **uncommon**
114
If **clopidogrel** is contraindicated or not tolerated, give **[]** for **secondary prevention following stroke**
If **clopidogrel** is **contraindicated** or not tolerated, give **aspirin** for secondary prevention following stroke
115
NICE recommend that CT brains should not be done 'unless there is clinical suspicion of an alternative diagnosis that CT could detect'
- What would be an example exception and how would you manage this? [1]
an example exception would be when there is a **concern about haemorrhage as the patient is taking anticoagulants**
- A case of **suspected TIA should be admitted and CT** head performed to exclude haemorrhage in patients taking an anticoagulant like warfarin/direct oral anti-coagulant or with a bleeding disorder.
116
The **[] index** is a scale that measures disability or dependence in activities of daily living in stroke patients
The **Barthel index** is a scale that measures disability or dependence in activities of daily living in stroke patients
