Week 12 - Neurology Flashcards

Question

Describe the clinical presentation of a neuropathy

Answer 1

* Depends on the type and distribution of affected fibres * Motor * Weakness/muscle atrophy * Sensory * Large (myelinated) fibres - sensory ataxia, loss of vibration sense +/- numbness and tingling * Small (thinly myelinated/unmyelinated) fibres - impaired pin prick, temperature, painful burning, numbness and tingling * Autonomic * Postural hypotension, erectile dysfunction, GI disturbance, abnormal sweating * Tendon reflexes may be reduced or absent

Answer 2

Surgery * Risks of damaging vestibulocochlear nerve and causing loss of hearing * Also risk damaging surrounding structures e.g. facial nerve * Use retrosigmoid approach (from behind sigmoid sinuses) to try to preserve hearing Radiation Observation - if small and slow growing

Answer 3

Raised shoulders and turn cheek against resistance

Answer 4

1. Caudate nucleus 2. Lentiform nucleus - globus pallidus + putamen 3. Substantia nigra 4. Subthalamic nucleus

Answer 5

* Blood pressure, urine dipstick, pregnancy test, temperature, weight * GCS, mental status examination * Palpation - skull, neck, greater occipital nerves, TMJ, temporal arteries, nuchal rigidity * Eyes * Acuity, visual fields (blind spot), fundi, assessment for papilloedema and spontaneous venous pulsation, movements * Presence or absence of Horner's 3rd, 6th nerve palsies * Autonomic features if during an attack * Cranial nerves, routine neurological examination * Skin exam (rashes), cervical lymphadenopathy, tympanic examination

Answer 6

* Ipsilateral ataxia

Answer 7

Jugular foramen

Answer 8

* Normal optic disc - orange/pink colour, regular clear edges * Papilloedema * Edges of optic disc blurred, hyperaemia * Swelling of optic nerve related to increased ICP * Optic atrophy * Pale, bright optic disc * E.g. in optic neuritis (possible MS)

Answer 9

* Trauma * Elevated ICP * Fever * Hypothermia * Seizure * Hypotension/severe hypertension * Hypoxia * Hypercapnia * Sepsis * Metabolic * Medications (e.g. sedatives) * Etc.

Answer 10

* Sensory input to CNS * Motor output to muscles * Innervation of viscera Incoming sensory information enters spinal cord via posterior root Motor infection exits spinal cord via anterior root Collections of nerve cell bodies in PNS known as ganglia

Answer 11

Jugular foramen

Answer 12

Internal occipital protuberance

Answer 13

* Trigger * Syncope - common * Seizure - rare (lights, hv) * Prodrome * Syncope - almost always * Seizure - common * Onset * Syncope - gradual (mins) * Seizure - usually sudden * Duration * Syncope - 1-30 secs * Seizure - 1-3 mins * Convulsive jerks * Syncope - common (brief) * Seizure - common (prolonged) * Incontinence * Syncope - uncommon * Seizure - common * Lateral TB * Syncope - very rare * Seizure - common * Colour * Syncope - very rare * Seizure - pale (CPS) red, blue * Post-ictal confusion * Syncope - rare * Seizure - common (in amb) * Recovery * Syncope - rapid * Seizure - slow (confused)

Answer 14

* Large fibres (myelinated) * Motor nerves * Proprioception, vibration and light touch * Thinly myelinated fibres * Light touch, pain and temperature * Small fibres (unmyelinated) * Light touch, pain and temperature

Answer 15

* Vomiting (more common in ICH than SAH or ischaemic CVA) * Haemorrhages associated w/ worse headache - feel nauseated * Ataxia * Eye deviation toward the opposite side of the bleed * Small sluggish pupils * Altered mental status

Answer 16

* Broca's - thoughts to motor speech * Non fluent, can comprehend * Left posterior inferior frontal gyrus (weak limbs) - next to limb strip so almost always have limb involvement

Answer 17

Alemtuzumab is licenced as a first line therapy and some specialist centres use it as an ‘induction’ therapy for aggressive MS instead of starting with weaker treatments and ‘escalating’

Answer 18

1. Ascend the posterior aspect of the neck through the transverse foramen of the cervical vertebrae 2. Enter the cranial cavity through the foramen magnum 3. Give off branches 4. Converge to form the basilar artery which gives of branches to supply the pons and cerebellum 5. Basilar artery terminates by bifurcating into posterior cerebral arteries

Answer 19

Veins empty into dural venous sinuses which eventually empty into the internal jugular veins

Answer 20

* E.g. Selegiline, Rasagiline * Prevents dopamine breakdown by binding irreversibly to monoamine oxidase * Can be prescribed as monotherapy in early disease or as adjunct in later disease * Well tolerated

Answer 21

* Normal DATSCAN SPECT - uptake highest in middle slices of striatum (light up) * In PD - dopamine neurones are lost, less uptake (dark patches)

Answer 22

Outer layer of the meninges, lies directly under the bones of the skull and the vertebral column

Answer 23

* Trauma - most common cause * Spontaneous SAH most commonly due to aneurysm * Localised dilatation of artery

Answer 24

* Photophobia * Meningism * Subhylaoid haemorrhages * Between vitreous and retina, boat shaped * Monocular blindness - bleed in vitreous * Raised ICP - double visioin (CN VI/III affected - enlarging basilar tip) * Vitreous haemorrhages (Terson's syndrome) * Speech and limb disturbance * Pulmonary oedema

Answer 25

* Immunoglobulin bands seen in blood and spinal fluid after protein electrophoresis * Presence of bands in CSF but not blood suggests immunoglobulin production in CNS * Supports diagnosis of MS but can be seen in other conditions

Answer 26

* Primary * Migraine * Trigeminal autonomic cephalgias * Secondary * Thunderclap headaches * High pressure headaches * Low pressure headaches * The neuralgias

Answer 27

* Bloods * If tremor present - thyroid function tests, copper/caeruloplasmin * Structural imaging * CT/MRI brain normal in PD * Abnormal in vascular parkinsonism, Parkinson plus disorders * Functional imaging * Imaging of presynaptic dopaminergic function using DAT SPECT is abnormal in degenerative parkinsonism

Answer 28

* Sensory * Nucleus location - medulla * Function - taste, proprioception for swallowing, blood pressure receptors * Structures innervated - posterior 1/3 of tongue, pharyngeal wall and carotid sinuses * Motor * Nucleus location - medulla * Function - swallow and gag reflex, lacrimation * Structures innervated - pharyngeal muscles, lacrimal glands * Parasympathetic * Function - saliva production * Structure innervated - parotid glands

Answer 29

Root of spread of infection from the upper teeth to the cranial cavity

Answer 30

* Dorsal stream * Where? * Position of object in space (dyspraxia) * Picking an object from a scene * Ventral stream * What? * Object recognition (visual agnosia) * Facial recognition (prosopagnosia)

Answer 31

Internal capsule, corpus callosum

Answer 32

* 3 weeks gestation - functioning brain, electrical activity

Answer 33

Processing and cognition

Answer 34

* Endovascular coiling * Introduce platinum coil into aneurysm using microcatheter, helps blood clot * Seal off the aneurysm, reduce pressure on outer wall - prevent rupture * Better for reducing long term morbidity * Neurosurgical clipping * Requires craniectomy * Close the base of the aneurysm with a clip * Decision as to which technique is employed is made on the bases of aneurysm morphology, patient characteristics and local experience * Longer-term morbidity and mortality better in endovascular coiling * Open surgical clipping may be favoured in cases that also require clot evacuation or decompressive surgery

Answer 35

* Frontal lobe - executive function/language * Temporal lobe - memory, language * Parietal lobe - visuospatial, praxia

Answer 36

* 3 subscales * Eye * Verbal * Motor

Answer 37

1. Is the environmental safe for me to enter? 2. How much time do I have to think? * A-B-C-DEFG and what is the story behind it? 3. If all is safe - where is the problem? * Assess GCS (response to environment, eyes, speech, movement) * Moving? * Neurological deficit? * Bloods - U&Es, ABGs, glucose, LFTs (? + tox screen)

Answer 38

Foramen ovale

Answer 39

Internal and external segments

Answer 40

* Leg \> arm weakness, grasp * Cognitive: muteness, perseveration, abulia

Answer 41

* Inflammation of the spinal cord * Weakness * Sensory loss * Incontinence can be only symptom * Many other causes than MS

Answer 42

* Largest - big bodies for weight bearing * Short spinous body - point less inferiorly

Answer 43

* With the glossopharyngeal nerve * Speech - hoarseness/difficulty pronouncing sounds (dysphonia) * Swallowing (dysphagia) * Position of palate and uvula (deviation = lesion on opposite side to deviation) * Gag reflex - not usually done

Answer 44

Connect the grey matter areas

Answer 45

1. Arises in pons - large motor and small sensory root 2. Roots travel through internal acoustic meatus in temporal bone 3. Enter facial canal (Z-shaped), roots fuse to give facial nerve, forms geniculate ganglion and gives off the greater petrosal nerve, nerve to stapedius and chorda tympani 4. Exits cranium via stylomastoid foramen 5. Gives off branches - posterior auricular nerve, nerve to posterior belly of digastric muscle and stylohyoid muscle 6. Motor root continues to parotid gland, splits to form 5 terminal branches

Answer 46

* L and R ventricles separated medially by the septum pellucidum * Roof formed by the body of the corpus callosum * Floor formed by the rostrum of the corpus callosum * Lateral wall formed by the caudate nucleus * Anterior wall formed by the genu of the corpus callosum

Answer 47

Signal - stretch of muscles, spinal cord sends signal to muscles to contract to correct

Answer 48

At the level of the iliac crest, marks the location of L4

Answer 49

* Anterior thigh – femoral nerve (quadricep) * Some hip flexion, mostly knee extension * Runs alongside femoral a/v * Sciatic nerve – hamstrings (posterior m in thigh) * Bottom of leg splits into 2 – tibial nerve posteriorly (calf), peroneal nerve round back of fibula (exposed to injury – muscles in front of shin, inability to bring foot up towards you = foot drop, common neuropathy, sensory problems over lateral shin and top of foot)

Answer 50

1. Anterior meningeal artery - branch of ethmoidal a 2. Middle meningeal artery - branch of maxillary a 3. Posterior meningeal artery - branch of ascending pharyngeal a 4. Accessory meningeal artery - branch of maxillary a

Answer 51

Sensory innervation of the scalp, forehead and nose

Answer 52

With the trochlear and abducens nerves

Answer 53

* Minimise side effects * Minimise seizure severity

Answer 54

* Recurrence risk after 1 seizure * Low risk * Medium risk * High risk * Recurrence risk after 2 seizures * 50-60%, start treatment

Answer 55

* Each spinal cord segment gives rise to 2 spinal nerves - L and R * C1-7 pass through their intervertebral foramen above the level of the corresponding vertebral body * C8 onwards exit below the level of the vertebral body

Answer 56

Neurodegenerative disorder - loss of sense of smell e.g. Alzheimer's Traumatic brain injury - shear olfactory nerve from cribiform plate

Answer 57

Managed with pyridostigmine (anti-acetylcholine esterase) and immunosuppressive therapies (e.g. steroids and IV immunoglobulin

Answer 58

- Provide supportive framework for cerebral and cranial vasculature - Act with CSF to protect the CNS from mechanical damage

Answer 59

Lines the inner surface of the cranial bones, only present around the brain (not in the vertebral column)

Answer 60

Symptoms are worse with exercise (heat) which is Uthoff's phenomenon - seen in demyelination

Answer 61

* Acute cerebrovascular event * Devastating effects on CNS * Profound impact on several other organs * Course of disease may be prolonged

Answer 62

* Single episode of neurological disability due to focal CNS inflammation * Can include optic neuritis and transverse myelitis * May be a first attack of MS * Can happen after infection and not be related to MS

Answer 63

* Clinical diagnosis * Investigation * Same imaging as epilepsy * EEG only useful for prognosis of first seizure * Calculate recurrence risk * Abnormal scan/EEG, presence of risk factors - risk of recurrence 60% * Normal scan/EEG, no risk factors - risk of recurrence 20%

Answer 64

* Migraine is 3rd most common disease in the world * Migraine most disabling disorder worldwide in 15-49 y/o, 2nd overall * Affects 1 in 7 people (females \> males) * £150 million per year by NHS * £3.4 billion lost per year in productivity

Answer 65

* Vestibular fibres - balance * Cochlear fibres - hearing

Answer 66

* Degenerative * Dementia with Lewy bodies * Progressive supranuclear palsy * Multiple system atrophy * Corticobasal degeneration * Secondary * Drug-induced - chronic use of dopamine antagonists * Cerebrovascular disease * Toxins e.g. carbon monoxide, organophosphates, MPTP * Post-infectious

Answer 67

* 5 or more headache days per month - 37% * Need for bed rest - 53.7% * Attack related impairment - 92.8% * At least one day of activity restriction over 3 months - 35.1%

Answer 68

* Imbalance in CSF within the ventricular system * Obstruction due to clots, underdrainage due to inflammatory change * Increase in size of ventricles * Can complicate management of SAH * LP, EVD * Shunt

Answer 69

* Primary visual cortex * Visual association area - vision * Visual interpretation

Answer 70

* Precentral gyrus - primary motor cortex * Postcentral gyrus - primary somatosensory cortex * Superior temporal gyrus - inferior to lateral sulcus, primary auditory cortex

Answer 71

90 minutes

Answer 72

1. Meningeal branch - supplies falx cerebri 2. Anterior and posterior spinal arteries - supplies spinal cord 3. Posterior inferior cerebellar a - supplies cerebellum and pons

Answer 73

* Multiple Sclerosis is diagnosed when there is evidence of 2 or more episodes of demyelination disseminated in space and time * There is no definitive diagnostic test for MS * Clinical diagnosis is based on weight of evidence from history, examination and investigation

Answer 74

* C2-C6/7 spinous processes bifurcate * Transverse foramina transmit vertebral arteries to brain * C1/2 are unique (atlas/axis) - odontoid peg

Answer 75

* Visual processing - where? What? * Accurately localise objects * From history * Inability to recognise faces or common objects or to find objects in direct view despite good acuity, inability to operate simple implements, or orient clothing to the body

Answer 76

* Area of abnormality in otherwise normal brain * Symptoms related to the area of the brain of focal starting point * Positive motor phenomenon e.g. twitch, spasm * Negative motor phenomenon e.g. weakness * Positive sensory phenomenon e.g. burning, itching * Negative sensory phenomenon e.g. numbness * Positive visual phenomenon e.g. colours, shapes, memories * Negative visual phenomenon e.g. blind spots * Can spread across brain and lead to bilateral convulsive seizure * Partial/localised/focal epilepsy can cause secondarily generalised seizures

Answer 77

* Communicating pathways to and from the cortex, cerebellum and other parts of brainstem * Nerve nucleus * Nerve * Neuromuscular junction disorders * Muscle

Answer 78

* Begins as continuation of medulla oblongata, ends at conus medullaris * Becomes cauda equina * Cord terminates at L3/4 in newborns, L1/2 in adults - vertebral column lengthens more than spinal cord during development

Answer 79

1. Olfactory nerve 2. Optic nerve 3. Oculomotor nerve 4. Trochlear nerve 5. Trigeminal nerve 6. Abducens nerve 7. Facial nerve 8. Vestibulocochlear nerve 9. Glossopharyngeal nerve 10. Vagus nerve 11. Accessory nerve 12. Hypoglossal nerve

Answer 80

* Perampanel blocks AMPA receptors * Felbamate has weak affinity for NMDA receptors * Topiramate binds both AMPA and kainate receptors * Benzodiazepines, barbiturates, felbamate and topiramate increased the GABA A receptor activity (reduced neuronal excitability)

Answer 81

* Ischaemic stroke * Clot occluding artery - 85% * Intracerebral haemorrhage * Bleeding into brain - 10% * Subarachnoid haemorrhage * Bleeding around brain - 5%

Answer 82

At the bifurcation of the L and R common carotid arteries, at the level of C4

Answer 83

* Motor * Function - eyeball movement * Nucleus - pons * Structure innervated - lateral rectus muscles * Abducts eye in horizonal plane

Answer 84

* Glucose management * Infarction size and oedema increase with acute and chronic hyperglycaemia * Hyperglycaemia is an independent risk factor for haemorrhage when stroke is treated with tPA * Blood pressure management * In ICH, consider treatment if SBP over 150 * Higher threshold in ischaemic stroke (about 180-200) * Labetalol or GTN used, but not much evidence * Senior advice

Answer 85

Dopamine agonists * Longer half-life than L-dopa * Associated with fewer motor complications than L-dopa

Answer 86

* Fingolimod * Daily tablet * Less effective than natalizumab or alemtuzumab * Risk of infections * May slow heart rate * Dimethyl Fumarate * Twice daily tablet * Less effective than fingolimod * Low white cell counts * Risk of infections * Cladribine * Old chemotherapy drug * Two short courses of tablets (8 days) over two years * Targets B-cells * May stop MS activity for many years

Answer 87

* Migraine * Seizure * Hypoglycaemic, or other metabolic/toxic states * Tumour or other space occupying lesion (onset typically more insidious) * Cerebral metastases (can present acutely, especially if there is a bleed into a metastasis) * Cerebral venous sinus thrombosis * Inflammatory lesions such a demyelination (onset is not usually abrupt as in this case) * Peripheral neuropathy and entrapment neuropathy (there is clear cortical deficit in this man, so neuropathy is not the diagnosis) * Cardiovascular/syncope * Functional weakness

Answer 88

* Autologous haemopoeitic stem cell transplant * Approved in UK for very aggressive RRMS that has been treated with stronger drugs but activity ongoing * Limited trial data * Will not repair disability

Answer 89

* Trauma * Non-traumatic * 36% - hypertension * 36% - aneurysm * 11% - AV malformation * 17% - other * Bleeding into tumour, hypocoagulable state, haemorrhagic infarction, iatrogenic

Answer 90

* At least five attacks fulfilling criteria B-D * Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated) * Either or both of the following * At least one of the following symptoms or signs, ipsilateral to the headache * Conjunctival injection and/or lacrimation * Nasal congestion and/or rhinorrhoea * Eyelid oedema * Forehead and facial sweating * Forehead and facial flushing * Sensation of fullness in the ear * Miosis and/or ptosis * A sense of restlessness or agitation * Occurring with a frequency between once every other day and 8 per day * Not better accounted for by another ICHD-3 diagnosis

Answer 91

Separates the caudate nucleus and thalamus from the putamen and globus pallidus (Lentiform nucleus)

Answer 92

* Diffuse involvement of peripheral nerves * Age \>50 years * Length dependent - starts in toes/feet * Symmetrical * Slowly progressive * No significant sensory ataxia * Any weakness is distal and mild * Most common peripheral neuropathy

Answer 93

* Two short courses over a year then further treatment if needed * Stops relapses in 40% of patients * High risk of secondary autoimmune problems (thyroid, ITP, good pastures) * May improve disability

Answer 94

* Beta blockers e.g. Propranolol - start at 20mg bd, target 80mg bd NNT * Anti-emetics e.g. Topiramate - start at 15 or 25mg daily, target 50mg bd * Tricyclics e.g. Amitriptyline - start at 10mg, target 50mg * Helps w/ comorbidities e.g. depression, sleep problems * Candesartan - start at 4mg, target 16mg * Flunarazine - 10mg * Pizotifen - start at 1.5mg, target 3mg-4.5mg

Answer 95

Dopaminergic side effects +, somnolence, impulse control disorders (e.g. pathological gambling, hypersexuality) and nightmares

Answer 96

Superior orbital fissure

Answer 97

* Peripheral - nausea, vomiting, postural hypotension * Central - confusion, hallucinations * Longer term - approx. 50% of patients develop motor complications after 5 years L-dopa * Fluctuation in motor response * Dyskinesia - most commonly choreiform movements at peak dose

Answer 98

* Overall score = 100 * \<88/100 excludes dementia * Sensitivity 83%, specificity 71% * \>83/100 supports dementia * Sensitivity 82%, specificity 96% * Always consider not only score and pattern but any potential confounders

Answer 99

Regular opioid analgesia or combination analgesia (e.g. co-codamol) should be avoided in migraine due to potential for developing medication overuse headache (MOH) - common cause of chronic daily headache, stopping medication results in improvement in severity and frequency of headache

Answer 100

Site for epidural injections and lumbar punctures

Answer 101

* Lightly touch cornea with cotton wool * Afferent - V * Efferent VIII * Test of pontine function * Bilateral blinking = intact corneal response * Patients who use contact lenses can denervate cornea

Answer 102

* Blood pressure * ECG * Urinalysis * Bloods e.g. CRP, ESR, FBC, U&Es, thyroid function * Ct brain/MRI brain * Lumbar puncture (opening pressure, blood products, other constituents) * CT angiogram/MR angiogram * CT venogram/MRI venogram

Answer 103

* Contains ascending and descending axons, going to and from the cerebral cortex * Large part is cortiospinal tract - carries motor information from the primary motor cortex to lower motor neurons in the spinal cord

Answer 104

* Interaction between primary afferent nociceptive neurones/trigeminovascular system/brainstem/thalamus/hypothalamus/cortex i.e. brain disorder * Calcitonin gene related peptide (CGRP) * NOT a primary vascular problem * Attacks probably due to dysfunction within sensory brainstem nuclei * Pain results from interactions between components of the trigeminovascular system * Pain-sensitive cranial blood vessels * Trigeminal nerve fibres that innervate them * The cranial parasympathetic outflow * Functional MRI studies have shown that the aura phase of migraine is associated with reduction blood flow in hemispheric regions contralateral to affected symptoms

Answer 105

Partially divides the cerebellar hemispheres

Answer 106

* Prescribed as monotherapy in early disease or in combination with L-dopa * Longer-acting oral, transdermal and subcutaneous preparations available

Answer 107

Upper motor neuron e.g. stroke shows forehead sparing due to bilateral innervation of the forehead

Answer 108

* Sensory - external ear, larynx, pharynx and thoracic/abdominal viscera * Taste from epiglottis region of tongue * Smooth muscle of pharynx, larynx and most of GI tract

Answer 109

* First and worst headache * Severe headache * Sudden onset * Typically maximum at onset within 1 minute (but can be several minutes - SIGN and NICE define as 5 minutes) * Typical duration \>1h (dogged adherence to this rule unreliable)

Answer 110

* General sensory of anterior 2/3 of tongue, skin over mandible, lower teeth * Motor - muscles of mastication

Answer 111

Verbal scale not appropriate in non-verbal children GCS (modified for young children) Best verbal response (1-5) 1 - none 2 - restless, agitated 3 - persistently irritable 4 - consolable crying 5 - appropriate words, smiles, fixes/follows

Answer 112

* Anterior and posterior longitudinal ligament (run full length of vertebral column) * Ligamentum flavum * Interspinous/supraspinous ligaments * Intertrasverse ligaments

Answer 113

Torsional (rotational) diploplia, compensatory tilted head

Answer 114

Sensory language area - lexical processing

Answer 115

* Frontal * Parietal * Temporal * Occipital

Answer 116

* Motor * Nucleus location - pons * Function - muscles of expression * Sensory * Nucleus location - medulla * Function - taste * Structure innervated - anterior 2/3 of tongue * Parasympathetic * Nucleus location - medulla * Function - salivation and lacrimation * Structure innervated - salivary and lacrimal glands

Answer 117

The falx cerebri between the L and R cerebral hemispheres (in the longitudinal fissure) contains the superior and inferior sagittal and straight sinuses

Answer 118

* Incidence highest immediately following initial bleed * 5-10% over 1st 72 hours * Higher in poor grade patients * Larger aneurysms * Immediate repair reduces rebleeding risk

Answer 119

* Anterior vertebral body * Weight bearing * Lined by hyaline cartilage * Separated by IVD * Posterior vertebral arch * Forms vertebral foramen, line up to give vertebral canal which spinal cord travels through * Spinous processes - posterior * Transverse processes - in thoracic articulate with ribs * Articular processes - join one vertebra to its corresponding vertebrae superiorly/inferiorly

Answer 120

* 8 cervical * 12 thoracic * 5 lumbar * 5 sacral * 1 coccygeal

Answer 121

* Classically starts in temporal lobe - episodic memory (mild stage) * Spreads to parietal and frontal lobes * Moderate stage - visuo-spatial * Severe stage - language

Answer 122

* Not all relapses need treatment * Important to discuss side effects of high dose steroids with patient * Steroids may speed up recovery from relapse with no effect on progression of disease * Steroids should not be given if any evidence of infection * If appropriate patient should get physiotherapy +/- occupational therapy * Sometimes in RRMS there may be a plan to organise MRI with contrast to look for active disease and change treatment * If patient is on treatment for RRMS the MS nurses should be informed - patient may be eligible for new treatment

Answer 123

* Language = * Speech (aphasia), reading (alexia), writing (agraphia) * Example of disorders * Progressive non-fluent aphasia (variant FTD), dominant MCA territory infarction * Testing using ACE-r * Naming * Repetition * 3 stage command (comprehension) * Reading

Answer 124

* Radial nerve - spirals round humerus, supplies extensors of arm * Not much sensation (back of hand – snuffbox) * Deltoid contraction – axillary n * Median nerve – forearm flexors, some muscles in hand * Muscles in hand (LOAF) * Sensation – lateral part of hand * Ulnar nerve – fine motor movements of hand, forearm/wrist flexion minorly * All muscles except LOAF – adduction and abduction etc. * Sensation – rest of hand not supplied by median

Answer 125

Orbicularis oculi muscle supplied by temporal/zygomatic branches of the facial nerve, facial nerve palsy results in inability to close the eye properly, leads to drying of the cornea and damage

Answer 126

Superior sagittal sinus, inferior sagittal sinus, straight sinus, transverse sinus, sigmoid sinus

Answer 127

* Bradykinesia * Slowness in initiation of voluntary movement with progressive reduction in speed and amplitude of repetitive actions * And at least one of the following * Muscular rigidity * 406 Hz resting tremor * Postural instability

Answer 128

* Airway, breathing, circulation, blood glucose * History - should not delay clinical assessment and investigations * Probably won't get history from patient - important to get focused history from witnesses * Time of onset or last time seen well - need time window for reperfusion therapies * Description of what happened, including evidence of seizure activity * Review of PMH - susceptibility to haemorrhage, contraindications for reperfusion therapy or ischaemia * Current medication including oral anti-coagulants * Social history * Examination * Airway, breathing and circulation stable? * Focus on key deficits commonly found in stroke * Should be nil by mouth until a formal speech and language therapy review is man * When IV access is obtained, blood tests should be performed

Answer 129

* Injected daily, several times week or weekly * Beta interferon, copaxone * Less effective than fingolimod or monoclonal antibodies * Patients often do not like injections * Work well for some people * May prolong life in some patients (long term data up to 16 years available) * Less people disabled over 20 years

Answer 130

* Subarachnoid haemorrhage * Approx. 15% of thunderclap headaches presenting to ED * Other causes * Intracerebral haemorrhage * Arterial dissection (vertebral or carotid) * Cerebral venous sinus thrombosis * Ischaemic stroke * Bacterial meningitis * Spontaneous intracranial hypotension * Pituitary apoplexy

Answer 131

* Input - cortex * Output - cortex and brainstem

Answer 132

* Motor * Function - head rotation and shoulder shrugging * Nucleus location - medulla * Structures innervated - sternocleidomastoid and trapezius muscles

Answer 133

* E.g. entacapone, tolcapone * Inhibiting catechol-o-methyltransferase results in longer L-dopa half-life/duration of action * Co-prescribed with L-dopa (available as combined table - Stalevo) in later disease * Side effects - dopaminergic and diarrhoea

Answer 134

* Post-lumbar puncture * Affects up to 1/3 cases * 90% develop within 3 days * Most resolve spontaneously * Spontaneous intracranial hypotension * Results from spontaneous dural tear * Can occur following Valsalva

Answer 135

* Of 780 patients * 276 patients no remission * 504 patients (64.6%) \>12 months remission * 399 patients (52%) no relapse * 105 patients (13%) some relapse * 63 patients (8%) regained remission * 42 patients (5%) no regained remission

Answer 136

* Motor - movement * Oculomotor - eye movement control * Lateral orbito-frontal - social behaviour * Dorsolateral prefrontal loop - executive functions/working memory Basal ganglia have role in maintaining posture and initiating voluntary movement.

Answer 137

Smell tested in each nostril separately, stimuli should be non-irritating and easily identifiable e.g. cinnamon, toothpaste

Answer 138

Thick, tough, inelastic

Answer 139

* Idiopathic inflammatory demyelinating disease of the CNS * Acute episodes of inflammation are associated with focal neurological deficits

Answer 140

* Bed rest * Volume depleted * Fluids - 2.5-3.0L normal saline * Anti-embolic stockings (considered pro-thrombotic) * Nimodipine - 60mg q 4Hr oral/NG or 2.5-10ml/Hr IV via central line * Calcium channel antagonist - reduce risk of developing late ischaemia (microcirculation going into spasm) * Analgesia * Doppler studies

Answer 141

Visual acuity and visual fields

Answer 142

* In general ambulance crews now issue a pre-alert for all cases of hyperacute stroke (within the first few hours) - teams assessing patients w/ stroke can prepare for the arrival of the patient * Methods of alert vary between sites and health services * Once alerted, stroke team mobilise to the ED * Prioritisation of acute stroke over TIA assessment * All professionals who will be involved in the hyperacute management should be alerted * Radiographers * Radiologists * Anaesthetists (id there is a thrombectomy service) * Sometimes if sufficient clinical details, request for imaging can be submitted before the patient arrives in hospital - reduce waiting time for scan * Designated area for assessing the patient should be cleared before they arrive * Bay in resuscitation room or an area in the acute stroke unit

Answer 143

* Motor * Nucleus location - midbrain (oculomotor) * Function - movement of eyeball and lens accommodation * Structure innervated - inferior oblique, superior, medial and inferior recti muscles, levator palpebrae superioris (all extraocular muscles except superior oblique and lateral rectus) * Parasympathetic * Nucleus location - midbrain (Edinger Westphal) * Function - pupil constriction * Structure innervated - ciliary muscle and pupillary constrictor muscles

Answer 144

* Hypertension * Hyperlipidaemia * Diabetes mellitus * Tobacco use * Sleep apnoea

Answer 145

* Basal ganglia * Cerebellum * Pons

Answer 146

* Pure motor stroke/hemiparesis * Ataxic hemiparesis * Dysarthria/clumsy hand * Pure sensory stroke * Mixed sensorimotor stroke

Answer 147

* Papilloedema on fundoscopy * Constriction of visual fields * Enlargement of the blind spots * Unilateral or bilateral VI nerve palsy may be a false localising sign of in raised ICP

Answer 148

* Glasgow Coma Scale * Patient fully resuscitated * Best motor, verbal and eye response * If flex and extend give highest score * Pain - * Supraorbital press * Trapezius pinch * Sternal rub - risk damage to skin with repeated * Distinguish between flexion and extension * Can monitor changes in GCS over time to identify deterioration/improvement

Answer 149

* Central * Fatigue * Cognitive impairment * Depression * Unstable mood * Visual * Nystagmus * Optic neuritis * Diplopia * Speech * Dysarthria * Throat * Dysphagia * Musculoskeletal * Weakness * Spasms * Ataxia * Sensation * Pain * Hypoesthesias * Parasethesias * Bowel * Incontinence * Diarrhoea or constipation * Urinary * Incontinence * Frequency or retention

Answer 150

* Inner grey matter * Dorsal horn (sensory) * Intermediate horn * Ventral horn (motor) * Outer white matter * Dorsal funiculus * Lateral funiculus * Ventral funiculus

Answer 151

* Demyelination results in loss of neurological function * Weak leg * Visual loss * Urinary incontinence * These deficits usually develop gradually, last for more than 24 hours and may gradually improve over days to weeks * Later in untreated disease patients may become progressively more disabled

Answer 152

* UK prevalence - 180 per 100,000 * Approx. 12,000 patients in Scotland * Prevalence 1.5x higher in men * Prevalence rises exponentially \>60 years * 300-500 per 100,000 in \>80 years * Mean duration from diagnosis to death - 15 years * Primarily a sporadic disorder * Monogenic causes of PD account for about 6% of UK cases * Significant economic burden

Answer 153

* 1-7% patients may suffer seizures after initial aneurysm rupture * Often a manifestation of re-rupture * Short course (3-7d) may be useful in patients with heavy blood load, parenchymal clots, infarcts or \>65 undergoing surgery

Answer 154

* Measure conduction of nerve signals in optic nerve to look for subclinical optic neuritis * Conduction will be slower if a patient has had optic neuritis in the past

Answer 155

- Primarily drains the cerebral cortex - Cortical veins - superior, middle and inferior groups - Drain into the superior sagittal sinus

Answer 156

* Results from ipsilateral disruption of cervical/thoracic sympathetic chain * Congenital * Brainstem stroke * Cluster headache * Apical lung tumour - Pancoast tumour * Multiple sclerosis * Carotid artery dissection * Cervical rib * Syringomyelia

Answer 157

* Sensory tracts * Dorsal columns * Light touch, vibration, proprioception * Crosses in lower brainstem * Spinothalamic tract * Pain and temperature * Crosses as soon as spinal cord * Motor tracts * Corticospinal tracts * Cross in brainstem, descends in spinal cord on side of limb being supplied * Anything above nerve root exit - upper motor neurone changes on that side (synapses with LMN before exits spinal cord) * Corticobulbar tracts

Answer 158

* 1-2 = medulla/pons and olfactory nucleus * Presymptomatic or pre-motor e.g. loss of smell * 3-4 = midbrain - substantia nigra pars compacta * Parkinsonism only becomes evident after extensive nigral damage * 5-6 = neocortex involvement * Development of PD dementia

Answer 159

* SAH induces a prothrombotic state * DVT in SAH 2-18% * Highest incidence in poor grade SAH * Timing of DVT prophylaxis in relation with aneurysm occlusion is controversial * Probably safer to use sequential compression devices initially then LMWH after aneurysm secured

Answer 160

Antiplatelets * Guidelines from SIGN/NICE/European Stroke Organisation are broadly consistent * Local guidance may vary * Acutely - evidence that aspirin effective * If the patient received thrombolytic therapy, then the patient should not receive this treatment for at least 24 hours, and not until a 24 hour CT scan has excluded significant haemorrhage * Should be given at 300mg daily until day 14, or discharge - whichever is sooner * Antiplatelets should be given for secondary prevention after * Clopidogrel 75mg once daily regimen * Aspirin 75mg and dipyridamole (modified release at 200mg bd) can be considered if the patient is intolerant to clopidogrel * If evidence of arterial dissection or atrial fibrillation consider full anti-coagulation * Combination of antiplatelet and anticoagulant not recommended for secondary prevention of stroke Statins * Prevent further stroke * SIGN guidelines allow consideration of all statins including atorvastatin 80mg and simvastatin 40mg * Benefit seen regardless of baseline cholesterol Antihypertensives * Lower BP to \<140/85mmHg * Started when patient is stable, generally not in the acute period * Consider starting ACE inhibitor e.g. perindopril and a thiazide diuretic e.g. indapamide together

Answer 161

Optic canal

Answer 162

* Dietary supplement * High dose vitamin * May lead to some symptom relief and mild improvement power * Ongoing large clinical trials * Gives energy to damaged nerve cells

Answer 163

Ptosis, down and out deviation, fixed and dilated pupil

Answer 164

* Large vessel strokes usually due to vessel occlusion by thrombus * Sources of thrombus e.g. embolism from plaques on atheromatous large vessels such as the carotid artery or aorta, or from a cardiac source * Size of arterial occlusion depends on size of thrombus * Occlusion impedes passage of blood, reducing cerebral blood flow to the brain territories distal to the clot * When blood flow drops below a critical threshold, a cascade of events is set motion which may ultimately result in cell death, which occurs may 5 major mechanisms * Exotoxicity * Peri-infarct depolarisation * Oxidative stress * Inflammation * Apoptosis * Tissue does not die immediately but instead there is a time window when the tissue is compromised to reduced blood flow but is still potentially salvageable if there is reperfusion in a timely fashion * In this case, can infer that thrombolytic therapy has led to recanalisation of the artery and reperfusion of the ischaemic penumbra

Answer 165

* Proximal limb weakness * Difficulty raising harms above head, arising from seated position * Facial weakness * Characteristic myopathic facies * Drooling * Eyes * Ptosis * Ophthalmoplegia * Bulbar * Dysarthria * Dysphagia * Neck and spine * Head drop * Scoliosis * Respiratory * Breathlessness (especially on lying flat) * Myocardial * Exercise intolerance, palpitations

Answer 166

* Impact * Consistent strong associated between motor score and 6-month GOS across all studies * Eye and verbal components were also strongly associated with GOS * Crash * GCS and 14 day mortality is linear * GCS and 6 month poor outcome is linear

Answer 167

* Articulates w/ apex of sacrum * Lack of vertebral arch - no spinal cord

Answer 168

* Tissue plasminogen activator * 'Clot buster'

Answer 169

* CSF oligoclonal bands (need matched blood sample) * CSF cell counts - exclude mimics * CSF glucose (matched blood sample) * CSF protein

Answer 170

With the vagus nerve

Answer 171

* Strategies to improve pharmacokinetics of L-dopa (e.g. oral liquids, controlled-release preparations) have limited benefit * Available in 2 common preparations * L-dopa + carbidopa = Sinemet * L-dopa + benserazide = Madopar * Dosing 200-1000mg per day

Answer 172

A tendency to have recurrent unprovoked seizures - usually more than one event. Majority are paroxysmal - intermittent seizures with periods of no issues in between

Answer 173

1. Move superiorly through the neck in the carotid sheath 2. Enter brain via foramen lacerum (carotid canal), 3. Pass anteriorly through cavernous sinus 4. Give off branches 5. Continue as middle cerebral arteries

Answer 174

* Inferior frontal gyrus (pars opercularis and pars triangularis) * Most commonly in L hemisphere (dominant in 90%)

Answer 175

1. Vertebral arteries 2. Internal carotid arteries

Answer 176

Ascending flaccid tetraparesis - medical emergency

Answer 177

PDS on EEG manifests as a spike or sharp wave

Answer 178

* Knee = L3, 4 * Ankle = L5 * Biceps = C5, 6 * Triceps = C7 * Brachioradialis = C5, 6

Answer 179

1. Ophthalmic artery - supplies structures of the orbit 2. Posterior communicating artery - connects the circle of Willis posteriorly 3. Anterior choroidal artery - supplies structures in the brain responsible for motor control and vision 4. Anterior cerebral artery - supplies anterior parts of the cerebrum

Answer 180

* Red desaturation * Relative afferent papillary defect * Optic disc pallor implying optic atrophy

Answer 181

* 50% mortality before hospital * 30-40% mortality at 30 days * Significant morbidity – around 50% of patients unable to return to work post-SAH * Predictors of poor outcome: * Focal neurological deficit or reduced GCS at presentation * Rebleeding * Vasospasm * Hydrocephalus

Answer 182

Initiate and maintain appropriate motor output

Answer 183

* Postcentral gyrus - primary somatosensory area * Sensory association areas * Body orientation * Motor feedback * Primary gustatory cortex - taste

Answer 184

* Localised onset - Lamotrigine, carbamazepine, levetiracetam * Generalised onset - valproate, levetiracetam, lamotrigine * Valproate has effect on foetal IQ and increases risk of congenital malformations - avoid in women of reproductive age

Answer 185

* Autoimmune disorder - antibodies to acetylcholine receptor at post synaptic NMJ * Association with other autoimmune disorders * May be associated with thymic hyperplasia or thymoma * Affects young women in 20s in older men in 70s * Fatiguable weakness of ocular, bulbar, neck, respiratory and/or limb muscles

Answer 186

500ml produced per day, about 140ml circulates

Answer 187

* Diagnosis explained and discussed with patient * Avoid triggers identified * Reduce caffeine * Reduce alcohol * Good sleep management * Regular meals

Answer 188

90% of aneurysms in anterior cerebral circulation, most commonly at the bifurcation of the anterior communicating artery and the anterior cerebral artery, the internal carotid artery and the posterior communicating artery and at the middle cerebral artery bifurcation

Answer 189

Motor - raise eyebrows, tightly close eyes, puff out cheeks, purse lups, show teeth Corneal reflex (motor innervation) Sensory - change in taste/hearing

Answer 190

- Middle layer - Layers of connective tissue, avascular, no innervation - Subarachnoid space underneath, contains CSF - Projections of arachnoid mater into dura (arachnoid granulations) allow CSF to re-enter the circulation via dural venous sinuses

Answer 191

One per cerebral hemisphere (L + R)

Answer 192

* Brain already insulted by SAH * Hyponatraemia problem - fluid shits from ECM --\> ICM, cerebral oedema (can cause seizures etc.) * Sodium maintains transmembrane potential - cells easily fire action potential (siezures) * CWS vs SIADH * Establish volume status * Hypertonic saline * Fludrocortisone * Other causes of hyponatraemia * Drugs, anaemia, hypothyroidism, chronic kidney disease - exclude

Answer 193

Dural venous sinuses -\> IJV

Answer 194

* 3 longitudinal arteries * Anterior spinal arteries - from branches of vertebral arteries, run in anterior median fissure * 2 posterior spinal arteries - from vertebral or posteroinferior cerebellar arteries, anastomose in pia * + anterior and posterior segmental medullary arteries - small vessels, enter with nerve roots * Largest anterior segmental medullary artey = artery of Adamkiewicz (from inferior intercostal or upper lumber arteries, supplies inferior 2/3 of spinal cord)

Answer 195

Between the outer (endosteal/periosteal) and inner (meningeal) layers of the dura mater

Answer 196

Irritants would stimulate the trigeminal nerve as well as the olfactory nerve, giving a false result

Answer 197

* History of presenting complaint * History of eye witness * History of past medical problems etc. * E.g. alcohol withdrawal/drug use, abnormality of cerebral cortex predisposes to epilepsy

Answer 198

* Pentagons * Cubes * 3D letters * Dots counting * Other tests * Assess higher motor control, deficit result in impairment of purposeful motor skills (praxia) * Pantomime gestures to command * Appropriate use of everyday objects e.g. toothbrush * Copying meaningless gestures

Answer 199

* Most return to normal sponanteously * Eye care - drops, tarsorrhaphy * Oral steroids

Answer 200

* SIGN 107 * Treat as medical emergency - same day specialist assessment * NCCT ASAP, preferable within 12 hours of onset * If CT normal, lumbar puncture (for blood products - oxybilirubin) * No other investigations suggested * CT/LP normal consider other investigations * MRI * MR/CT venogram * MR/CT angiogram

Answer 201

* Affects 7000pts/yr UK * Approx. 3500 pts dead or severe disability/yr * Combined mortality and morbidity 50% * 1/3 survivor dependent

Answer 202

1. Temporal 2. Zygomatic 3. Buccal 4. Marginal mandibular 5. Cervical

Answer 203

Episodic and semantic memory

Answer 204

Inhibiting muscular activity and reducing muscle tone

Answer 205

* No licensed DMT at present * Focus on treating symptoms * Hope that treating RRMS will reduce progression to SPMS * Potential treatment for PPMS - ocrelizumab * Potential treatment for SPMS - siponimod

Answer 206

* Day 3-10 * Progressive deterioration in LOC associated with new deficit * Neurologic deficit, progressively drowsy * Angiographic spasm, microcirculation shuts down * Fluid management (CVP, colloid infusions) * Nimodipine * Inotropes * Angioplasty (balloon angioplasty, intra-arterial Nimodipine) * Balloon segments in spasm

Answer 207

* MRI scan performed in patients who do not have symptoms or signs of MS * Incidental finding that looks like MS * May develop MS (but may not) * Can cause unnecessary distress for patient

Answer 208

* Neurological examination normal - in keeping with migraine * Focal neurological deficit would suggest a secondary cause for headache

Answer 209

* 12 pairs of nerves that emerge from brainstem and supply head and neck * Sensory, motor and parasympathetic activity * Numbered I-XII in descending anatomical order

Answer 210

Fibrous tissue which extends from conus medullaris to sacrum - stops movement of the cauda equina

Answer 211

* Neurological symptoms that develop over a few days * A history of transient neurological symptoms that have lasted for more than 24 hours and spontaneously resolved * Hidden relapses * Optic neuritis/visual disruption * 'Bell's palsy' (what do you mean by Bell's palsy?) * Labyrinthitis * Sensory symptoms * Bladder symptoms in young man/woman without children

Answer 212

* Pharmacological aim - restore dopamine levels * Clinical aim - improve motor symptoms/improve QOL * No evidence of neuro-protective effect

Answer 213

* Middle cerebral artery * Anterior cerebral artery * Posterior cerebral artery * Cerebellum

Answer 214

Through the interventricular foramen of Monro

Answer 215

* Occasional memory loss * 18% of 35 y/o controls report memory problems * 13% need to take notes to help remember * Names of colleagues/friends * Retaining telephone numbers, new pin * Infrequently used factual information * Occasionally misplacing things * College students (17-26 y/o) * 27% word finding lapses * 14.5% mental decline * 10% memory gaps

Answer 216

* Sensory CN II * Parasympathetic response (pupil constriction) CN III

Answer 217

Generalised - brain with a genetically driven change in neurotransmission, receptor pharmacology etc. * 20% of adult epilepsy (majority are localisation related) * Brain fires all at once, without warning, emerges simultaneously in brain

Answer 218

Contralateral homonymous hemianopia (loss of L or R visual field in both eyes)

Answer 219

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Answer 220

Filtrate of blood produced by the choroid plexus in the ventricular system of the brain

Answer 221

* Fatigue * Common symptom and may be due to the disease itself, medication side effects, sleep problems, increased muscular effort due to weakness or to depression * If due to depression should be treated * If disease related, modafinil/amantadine may benefit * Urinary symptoms * In MS may be due to spinal disease * Storage dysfunction due to detrusor hyperreflexia will manifest as urgency, frequency, nocturia and incontinence * Should respond to anti-cholinergic agents such as oxybutynin * A urologist may consider injecting the bladder wall with Botox * Emptying dysfunction due to diminished detrusor contractility and sphincter hypertonia will manifest as dribbling, hesitancy, urgency, incontinence and frequency - may be treated with self-catheterisation and drugs such as tamsulosin for sphincter hypertonia * Combined storage and emptying dysfunction may be treated with a combination of self-catheterisation and anti-cholinergics. * Spasticity * Common in MS * Patients should see physiotherapy and OT * Therapies include baclofen, tizanidine, dantrolene, benzodiazepines, gabapentin (for generalised spasticity) and Botox (for focal spasticity)

Answer 222

* Length dependent neuropathy - glove and stocking distribution * Process affecting sensory nerve function - affects longest first, legs then arms * Numbness affecting waist and trunk downwards - distal to lesion in spinal cord * Sensory roots * Single dorsal column lesion * Transverse thoracic spinal cord lesion * Central cord lesion * Mid-brain stem lesion * Hemisphere (thalamic) lesion * Unilateral cord lesion (Brown-Sequard) * Loss of dorsal column function on one side and spinothalamic function on other side * Paralysis and loss of proprioception on ipsilateral side * Loss of pain and temperature on contralateral side * Caused by lesion affecting one half of spinal cord i.e. a hemisection of the spinal cord

Answer 223

* Component of consciousness which allows filtering of information to allow one to focus on a particular stimuli * Essential for all aspects of cognition * Pathological process - delirium (depression) * Testing ACEr * Orientation * Serial 7s * Working memory facet of attention/concentration e.g. Digit span * Meaningful cognitive testing is difficult with impaired attention/concentration

Answer 224

* Memory * Impaired ability to acquire and remember new information - symptoms include; repetitive questions or conversations, misplacing personal belongings, forgetting events or appointments, getting lost on a familiar route * Executive function - impairment often seen in associated with behavioural changes * Impaired reasoning and handling of complex tasks, poor judgement - symptoms include: poor understanding of safety risks, inability to manage finances, poor decision-making ability, inability to plan complex or sequential activities * Visuospatial * Impaired visuospatial abilities - symptoms include: inability to recognise faces or common objects or to find objects in direct view despite good acuity, inability to operate simple implements, or orient clothing to the body * Language * Impaired language functions (speaking, reading, writing) - symptoms include: difficulty thinking of common words while speaking, hesitations, speech, spelling and writing errors

Answer 225

* Precentral gyrus = primary motor area (movement) * Motor association area - movement * Primary olfcatory area - smell * Broca's area - motor speech production * Cognitive thought and memory * Control of voluntary movements

Answer 226

* MRI brain and cervical spine with gadolinium contrast * It is possible to make the diagnosis of MS with one scan * Evidence of demyelination in 2 regions (e.g. periventricular and spinal cord) can indicate dissemination in space * If enhancing and non-enhancing areas of demyelination are seen this can indicate dissemination in time

Answer 227

Motor aspect of speech

Answer 228

Foramen rotundum

Answer 229

* Sensory * Function = smell * Tract - olfactory cells of nasal mucosa --\> olfactory bulbs --\> pyriform cortex

Answer 230

* IV tPa window 4.5 hours * Alteplase is the currently licensed thrombolytic drug * Administered intravenously * Effective up to 4.5 hours post stroke, clinical outcome better the earlier the treatment is given - patient assessment should be prompt in all cases * Perfusion MRI scan - shows areas still alive but with reduced blood flow * Can see potentially viable brain which can be saved w/ treatment * Disability risk reduced by 30% despite 5% symptomatic ICH risk

Answer 231

Verbal response 1. None 2. Incomprehensible sounds 3. Inappropriate 4. Confused 5. Oriented - time, place, person

Answer 232

* Haemodynamic stress - branch point in BVs (maximal stress) * Extensive inflammatory and immunological reactions are common in unruptured intracranial aneurysms and may be related to aneurysm formation and rupture * Repair processes hold aneurysm - if overwhelmed rupture * Aneurysms close to pia can break through to the subarachnoid space, close to arachnoid can cause subdural haemorrhage

Answer 233

* Carbamazepine, lamitrigine, oxcarbazepine etc. inhibit voltage-gated Na+ channel (increases excitability and drives action potentials) * Retigabine increases activity of voltage gated K+ channel (reduces neuronal excitability) * Levetiracetam inhibits SV2A (required for release of neurotransmitter from vescicles) * Pregabalin and gapapentin inhibit voltage gated Ca2+ channel (drives neurotransmitter release)

Answer 234

* Central sulcus * Lateral sulcus * Luneate sulcus * Calcarine sulcus

Answer 235

* Sympathetic stimulation and catecholamine release can lead to myocardial injury ('stunned myocardium') * Non-specific T wave changes * Elevations of troponin I can occur in 35% * Arrythmias (35%) * Wall motion abn (25%) * Can be associated with sudden death (12%) * Myocardial function usually returns to normal in 1-3 days

Answer 236

* Positive when hip and knee flexed at 90 degrees and subsequent extension at the knee is painful * Headache, photophobia, neck stiffness and a positive Kernig's sign suggest meningism (irritation of the meninges)

Answer 237

* Risk of bleeding 1 in 20 * Gut from ulcer * Into brain

Answer 238

* Gag reflex not done in conscious patients * Swallow assessment - drink and observe swallow * Uvula should be central - deviates away from side of lesion

Answer 239

Has an anterior head which is wider, then tapers to a body and posterior tail, with a 'knee' (genu) between

Answer 240

Post-infectious autoimmune aetiology (e.g. campylobacter, CMV, EBV)

Answer 241

* Implicit memory * Declarative (explicit) memory * Episodic - personally experienced events, specific to time/place * Semantic - long-term memory that processes ideas and concepts not drawn from personal experience e.g. general knowledge (not specific to time and place) * Working - temporarily holds information available for processing

Answer 242

* Surgical 3rd nerve palsy * Pupil fixed and dilated * Parasympathetic fibres (pupil constriction) on the outside of the nerve, first to be affected by compression resulting in a fixed and dilated pupil * 'Surgical' causes e.g. tumour, aneurysm, trauma cause compression and affect the parasympathetic fibres * Medical 3rd nerve palsy * Pupil sparing * Caused by ischaemia e.g. diabetic neuropathy, hypertension, hyperlipiaemia * Outer parasympathetic fibres not affected

Answer 243

* Look at tongue as it rests in mouth then stick out tongue * Deviates towards side of lesion * Wasting and fasciculations of tongue * LMN * Motor neurone disease

Answer 244

1. None 2. Extension 3. Abnormal flexion 4. Normal flexion 5. Localises pain 6. Obeys command N.B. cannot be assessed if patient has received muscle relaxants, also spinal injury

Answer 245

* Sensory * Nucleus location - pons and medulla * Structure innervated - face (ophthalmic, mandibular and maxillary divisions) and anterior 2/3 of tongue * Motor * Function - mastication (close jaw) * Nucleus location - pons * Structure innervated - masseter, temporalis, medial and lateral pterygoids

Answer 246

Examples - Ropinirole, Pramipexole, Rotigotine, Apomorphine

Answer 247

- C-shaped structure - Inferior horn (in temporal lobe) -\> body (in parietal/frontal lobe) -\> interventricular foramen - Posterior horn projects backwards into the occipital lobe - Anterior horn projects further into frontal lobe - Triangular area between occipital and temporal lobes = trigone

Answer 248

Part of cerebral cortex folded deep within the lateral sulcus, lateral to lentiform nucleus

Answer 249

Semantic dementia (variant frontotemporal dementia)

Answer 250

* Surgical clipping * Endovascular (coils, stents and glue) * Conservative - only a very small number of patients don't benefit from treatment, managed conservatively

Answer 251

* No cure, manage symptoms * Dietary changes, salt restriction, diuretics * Gentamicin injection - risk of hearing loss * Pressure pulse treatment * Surgery - cut nerve (rare)

Answer 252

Contralateral inferior quadrantopia

Answer 253

* Anastomose closely with venous drainage of abdominal/pelvic organs * Major route of spread of cancer from deep pelvic regions * Valveless

Answer 254

Eye opening 1. None 2. To pain 3. To verbal command 4. Spontaneous N.B. - cannot be assessed if eyes are swollen

Answer 255

4 parts - splenium (posterior), body, genu and rostrum (anterior)

Answer 256

* White matter sheet that continues ventrally as the internal capsule * Sheet of ascending and descending axons to and from the cerebral cortex * Fibres radiate out from cortex and come together in the brainstem * Associated w/ corticopontine, corticobulbar and corticospinal tracts

Answer 257

* Benign, usually slow growing tumour that develops through overproduction of schwann cells around the vestibular/cochlear nerves * Causes damage to nerves through compression - hearing loss, tinnitus, vertigo * Can also affect * Trigeminal nerve - loss of face sensation * Facial nerve - weakness/paralysis of muscles of facial expression * Glossopharyngeal/vagus nerves - swallowing difficulties, loss of gag reflex

Answer 258

Superior orbital fissure

Answer 259

* Progressive cognitive decline * Interfere with the ability to function at work or usual activities, and * Represent a decline from previous levels of functioning and performing, and * Is not explained by delirium or major psychiatric disorder * The cognitive or behavioural impairment involves a minimum of two of the following domains * Memory * Executive function * Language * Apraxia/visuospatial * Severe, acquired and must involve more than one brain region

Answer 260

In the occipital lobe, calcarine sulcus marks the position of the primary visual cortex

Answer 261

* Optic disc swelling - papilloedema * Impaired visual acuity/colour vision * Restricted visual fields/enlarged blind spot * 3rd nerve palsy * 6th nerve palsy (false localising sign) * Focal neurological signs

Answer 262

* Seizure control is common but not invariable * 47% patients seizure-free monotherapy, 1st AED * 13% patients seizure-free monotherapy, 2nd AED * 1% patients seizure-free monotherapy, 3rd AED * 3% patients seizure-free polytherapy * 36% patients not seizure-free, all regimens attempted * Some will have very mild seizures, some frequent/severe seizures (major cortical change)

Answer 263

* Difficulty looking down, diplopia when looking down * Double vision always when looking in direction of action of muscle affected

Answer 264

* Non-modifiable * Age * Gender - female * Previous SAH * Polycystic kidney disease * Connective tissue disorders - Ehlers Danlos, Marfan's * AVM * Family history - 2+ primary relatives * Modifiable * Hypertension * Smoking * Alcohol * Sedentary lifestyle

Answer 265

Receptive aphasia, extremely poor comprehension of speech

Answer 266

* Proverbs * Verbal fluency - ACEr - verbal letter \> category fluency * Estimates * Planning

Answer 267

Involved in the emotional response to pain

Answer 268

Forms the lateral wall of the lateral ventricles, separated from putamen by white matter fibres (internal capsule)

Answer 269

* Middle ear pathology - tumour/infection * Parotid gland pathology - tumour, parotitis, surgery * Idiopathic (Bell's palsy) - viral, diabetes mellitus, pregnancy * Ramsey-Hunt syndrome

Answer 270

Have large ventral and dorsal horns - innervate limbs so need high sensory and motor output

Answer 271

Spontaneous rupture of a small artery deep in the brain due to excessive pressure

Answer 272

Superior orbital fissure

Answer 273

* Direct fistula between arteries and veins * Lots of haemodynamic stress on vessels supplying AVM * Associated with aneurysms

Answer 274

* Many patients live fairly normal lives and work * A significant proportion become progressively more disabled with time * Difficult to prognosticate with the emergence of modern treatments for MS over past decade * May present to general medicine with neurological deterioration or with other medical problems * Seldom admitted to acute neurology units

Answer 275

* Sensory * Nucleus location - medulla * Function - chemoreceptors, pain receptors (dura), sensation * Structures innervated - blood oxygen concentration, carotid bodies, respiratory and digestive tracts, external ear, larynx and pharynx * Motor * Nucleus location - medulla * Function - heart rate and stroke volume, peristalsis, air flow, speech and swallowing * Structures innervated - pacemaker and ventricular muscles, smooth muscles of the digestive tract, smooth muscles in bronchial tubes, muscles of larynx and pharynx * Parasympathetic * Structures innervated - smooth muscles and glands and the same areas innervated by motor component, as well as thoracic and abdominal areas

Answer 276

* At least 10 episodes of headache occurring on \<1 day/month on average (\<12 days/year) and fulfilling criteria B-D * Lasting from 30 minutes to 7 days * At least two of the following four characteristics: * Bilateral location * Pressing or tightening (non-pulsating) quality * Not aggravated by routine physical activity such as walking or climbing stairs * Both of the following * No nausea or vomiting * No more than one of photophobia or phonophobia * Not better accounted for by another ICHD-3 diagnosis

Answer 277

1. Central spinal canal - bathes the spinal cord 2. Subarachnoid cisterns - bathes brain, between arachnoid and pia mater (where CSF is reabsorbed back into the circulation)

Answer 278

* Paroxysmal depolarising shift * Tonic phase - brain floods with inhibitory neurotransmitters to stop discharge (increases muscle tone) * During a seizure, there is failure of adequate inhibitory mechanisms and no hyperpolarisation following the PDS occurs * This prolonged depolarisation with action potentials corresponds to the tonic phase of the seizure * Clonic phase - intermittent activity, jerking * When inhibition is reinitiated, there are brief periods of depolarisation followed by hyperpolarisation - corresponds to the clonic phase of the seizure

Answer 279

Bitemporal hemianopia (loss of temporal visual field in each eye - nasal retinal fibres cross at optic chiasm)

Answer 280

* Modern treatments are effective and hopefully getting better * Potential treatment to slow progression in PPMS and SPMS over next few years - ocrelizumab and siponimod * Currently treatments will reduce relapses but nothing that will repair a lot of damage yet

Answer 281

* General sensation to posterior 1/3 tongue, external ear, middle ear, carotid body and sinuses * Taste from posterior 1/3 tongue * Parotid gland - parasympathetic innervation * Motor - stylophyaryngeus muscle

Answer 282

1. Ophthalmic 2. Maxillary 3. Mandibular

Answer 283

* Most likely related to decreased level of consciousness (LOC), dysarthria, dysphagia * GCS \< 8 - INTUBATE * Avoid hyperventilation or hypoventilation * NBM until swallow assessment complete - high aspiration risk (risk of aspiration pneumonitis) * Begin mobilisation as soon as clinically safe

Answer 284

Between the L + R thalamus

Answer 285

* Inner ear disorder * Causes tinnitus, vertigo, partial deafness * No definitive cause known - excess fluid in inner ear

Answer 286

* We don’t know * Genetic factors * Sunlight/vitamin D exposure * Viral trigger - possibly EBV * Multifactorial - smoking

Answer 287

Innervates the lateral rectus muscle

Answer 288

* Cervical lordosis * Thoracic kyphosis * Lumbar lordosis * Sacral kyphosis

Answer 289

Innervates the intrinsic and extrinsic muscles of the tongue (except the palatoglossus)

Answer 290

* Largest part of the brain * 2 cerebral hemispheres - L + R, separated by the falx cerebri of the dura mater * Separated from cerebellum by tentorium cerebelli

Answer 291

* Primary headaches * Not associated with an underlying pathology * Include migraine, tension-type and cluster headache * Secondary headaches * Result from an underlying pathological disorder that may be vascular, neoplastic, infectious or related to disturbances in CSF pressure

Answer 292

* Treated with IV immunoglobulin or apheresis * CIDP - chronic form (steroid and IVIG responsive)

Answer 293

Usually in posterior area of superior temporal gyrus, most commonly in L hemisphere

Answer 294

* Sensory * Function = vision * Tract - retinal ganglion cells --\> optic chiasm --\> thalamus --\> primary visual cortex in occipital lobe * Has its own meningeal covering and blood supply

Answer 295

Innervates 4 extrinsic eye muscles, levator palpebrae superioris muscle and the pupillary sphincter

Answer 296

* Antibodies to AChR present in 85% of cases * Single fibre EMG and repetitive nerve stimulation also abnormal

Answer 297

* Fibrocartilaginous cylinder, between vertebrae * Allows flexibility of spine, acts as shock absorber * Wedge shaped in lumbar and thoracic * Two parts - nucleus pulposus (gelatinous) and annulus fibrosis (tough, collagenous, surrounds nucleus pulposus)

Answer 298

I - Olfactory II - Optic III - Oculomotor IV - Trochlear V - Trigeminal VI - Abducens VII - Facial VIII - Vestibulocochlear IX - Glossopharyngeal X - Vagus XI - Spinal accessory XII - Hypoglossal

Answer 299

* Facet of frontal lobe function * Behaviour, social awareness (orbitofrontal) * Working memory, cognitive estimates, planning (dorsolateral prefrontal cortex) * Motivation (anterior cingulate)

Answer 300

* Folded to give sulci (grooves) and gyri (ridges) * Divided into 2 hemispheres by the longitudinal fissure - runs in median sagittal plane

Answer 301

* Risk of further stroke highest early on * After TIA/minor stroke the risk is as high as 10% at 1 week and 18% at three months * Average annual risk after the first year is 4-5% * Can use figures to emphasise need for compliance with secondary prevention strategies

Answer 302

* Optic discs with ophthalmoscope * Pupillary response - 2nd/3rd CN * Direct and indirect pupil constriction * Swinging flashlight test for RAPD * Accommodation reflex * Visual acuity (using Snellen chart) * Visual fields and blind spot (tested by confrontation)

Answer 303

* Smoking * Female sex * F:M 1.5:1 * Hypertension * Positive family history * ADPCK, Ehlers Danlos, Marfan's syndrome, coarctation of the aorta

Answer 304

* A relapse usually involves a new neurological deficit that lasts for more than 24 hours in the absence of pyrexia or infection * A pseudo-relapse is the reemergence of previous neurological symptoms or signs related to an old area of demyelination in the context of heat or infection * If evidence of infection this should be treated

Answer 305

* Semantic variant * Poor confrontation naming * Impaired single word comprehension * Poor object/person recognition, surface dyslexia, spared repetition * Semantic dementia * Logopenic variant * Impaired single word retrieval * Impaired repetition, speech sound errors (phenomic) * Spared object/person recognition, single word recognition * Alzheimer's dementia * Non-fluent variant * Effortful, halting speech * Phenomic errors * Spared object/person recognition, single word recognition * Progressive non-fluent aphasia

Answer 306

* Muscular dystrophies * Dystrophinopathies (Duchenne/Becker), fascioscapulohumeral (FSH) dystrophy, limb girdle, oculopharyngeal * Metabolic muscle disorders * Glycogen storage diseases, defects of fatty acid metabolism * Mitochondrial disorders * Myotonic dystrophies * Inflammatory muscle disorders * Polymyositis, dermatomyositis, inclusion body myositis * Neuromuscular junction disorders * Myasthenia gravis, Lambert Eaton syndrome

Answer 307

* Onabotulinum toxin A * Chronic migraine, \>15 headache days per month, 8 of which are migraine days, MOH previously addressed, failed on at least 3 prophylactics * Approved for restricted use by SMC based on economic benefit * CGRP inhibitors (monoclonal antibodies) * Erenumab approved for restricted use in Scotland

Answer 308

Provides mechanical and immunological protection to the brain and spinal cord

Answer 309

* Unilateral facial palsy caused by Herpes Zoster virus, reactivation of Varicella zoster virus from geniculate nucleus * Severe ear pain, facial palsy, vertigo, hyperaccusis, tinnitus * Vessels of concha, anterior 2/3 tongue, soft palate become visible

Answer 310

Ipsilateral monocular vision loss

Answer 311

* Upper motor neurone lesion - weakness of inferior facial muscles * Lower motor neurone lesion - weakness of superior and inferior facial muscles

Answer 312

* Reflects * Level of arousal (RAS) * Presence of cognitive behaviour (cerebral hemispheres)

Answer 313

* Pin-point but reactive pupils * Abrupt onset of coma * Decerebrate posturing or flaccidity * Ataxic breathing pattern

Answer 314

Innervates the superior oblique muscle

Answer 315

* No disease modifying treatment for secondary progressive MS * Most treatment is aimed at rehabilitation * Control of symptoms * Bladder * Fatigue * Mood * Spasticity * Mobility

Answer 316

Oral aciclovir

Answer 317

* Rinne test * Bone vs air conduction * Bone \> air - conductive hearing loss * Air \> bone - normal or sensorineural hearing loss * Weber test * Louder in normal ear in sensorineural hearing loss * Louder in defective ear in conductive hearing loss

Answer 318

Reinforcement and coordination of learned motor skills

Answer 319

With the oculomotor and abducens nerves

Answer 320

Dark appearance due to neuromelanin

Answer 321

Act directly on post-synaptic striatal dopamine receptors (D2 subtype)

Answer 322

* Taken up by dopaminergic neurones and decarboxylated to dopamine within presynaptic terminals * Prescribed with dopa-decarboxylase inhibitor

Answer 323

* V shaped * 3 parts - * Bend in V = genu * Anterior limb * Posterior limb

Answer 324

* Neuropsychiatric * Dementia * Depression * Anxiety * Autonomic * Constipation * Urinary urgency/nocturia * Erectile dysfunction * Excessive salivation/sweating * Postural hypotension * Sleep * REM sleep behaviour disorder * Restless legs syndrome * Other * Reduced olfactory function * Fatigue * Pain and sensory symptoms

Answer 325

* Grey matter - surface of cerebral hemispheres (cortex) * White matter - deeper parts of brain

Answer 326

1. Memory 2. Attention/concentration 3. Language 4. Visuospatial 5. Executive function

Answer 327

Expressive aphasia, non-fluent, slow speech

Answer 328

* Diagnosis of PD is largely clinical * Diagnostic certainty improves with follow-up * Disorders commonly mistaken for PD * Benign tremor disorders e.g. essential tremor * Dementia with Lewy bodies * Vascular parkinsonism * Parkinson plus disorders (e.g. progressive supranuclear palsy, multiple system atrophy) * Drug-induced parkinsonism/tremor

Answer 329

* Presenting complaint * Background history * Vascular disease including stroke, trauma, cancer, major mental health issues * 'Drug' history * Prescribed drugs (care anti-cholinergic elderly), illicit drugs, alcohol * Family history Take history from patient and always from next of kin

Answer 330

* High BP * Appropriate treatment reduces stroke risk by 50% * Atrial fibrillation * 5x risk of stroke * 1 in 10 people at 70 y/o * Atrium fibrillating - blood stagnant in L atrial appendage, clot formation, travels to brain * Diabetes * Increased risk of all CV disease, esp. if poorly managed * Smoking * Poor diet, hypercholesterolaemia * Cholesterol - bigger effect on heart disease, more likely to die of MI but also increases risk of stroke * Excess alcohol consumption * Binge drinking esp. in young people increases risk of stroke

Answer 331

1. Falx cerebri 2. Tentorium cerebelli 3. Cerebellar falx 4. Sellar diaphragm

Answer 332

* Generalised - sleep deprivation, excess alcohol * 20% triggered by flashing lights - usually generalised * Patients can often identify their own individual triggers * Important to keep medication intake stable

Answer 333

Innervation of the trapezius and sternocleidomastoid muscles

Answer 334

* Bilateral convulsive seizure (generalised tonic-clonic seizure) - previously referred to as 'grand mal' * Partial seizures - stay in one part of brain (discharge restricted by brain) * With loss of awareness * With motor phenomena * With sensory phenomena * With psychological phenomena * With cognitive phenomena

Answer 335

Frontal lobes * Orbitofrontal lobe - behaviour, social awareness * Dorsolateral prefrontal cortex - working memory, cognitive estimates, planning, understanding proverbs

Answer 336

* Hoffman's sign is an upper motor neurone (UMN) sign and parallels the extensor plantar sign in the lower limb * Positive when there is flexion of the ipsilateral thumb after tapping the nail bed of the third finger

Answer 337

* Haemorrhage * SBP \>185 or DBP \>110 * Recent surgery, trauma or stroke * Coagulopathy * Seizure at onset of symptoms * NIHSS \>21 * Age? * Glucose \<2.2

Answer 338

Jugular foramen

Answer 339

* Painful visual loss that comes on over a few days * May resolve after a few weeks * 30% develop MS by 5 years * 50% develop MS by 15 years * Risk of MS depends on MRI scan and oligoclonal bands

Answer 340

* Miosis * Ptosis * Apparent enophthalmos * Anhidrosis

Answer 341

* Disorder of conjugate gaze * Failure of adduction of affected eye with nystagmus on lateral gaze in contralateral eye * Can be unilateral or bilateral * Results from lesion of medial longitudinal fasciculus (connects 3rd and 6th nerve nuclei) * Commonly seen in multiple sclerosis

Answer 342

Superior orbital fissure

Answer 343

* Hemianopia - contralateral half of vision lost * Cognitive: memory loss/confusion, alexia

Answer 344

Through the cerebral aqueduct

Answer 345

* Inability to * Obey commands * Speak * Open eyes to pain

Answer 346

* A good bedside assessment - quick, easy and reproducible * During the test consider - what domains are involved? * Simple bedside cognitive assessment may allow evaluation of cognitive function * Large number of assessments available 1. Folstein MMSE (30) 2. Addenbrookes cognitive assessment (100) Testing evaluates both the extent of the problem and also the pattern of impairment.

Answer 347

Inferior to thalamus, above substantia nigra

Answer 348

* Surgery beneficial if * There is a single lesion * The lesion can be reached * The removal will not cause a neurological deficit by damaging surrounding areas * Less than 2% of patients with epilepsy candidates for surgery * Corpus callostomy * Split anterior 2/3 of corpus callosum (communication between L and R hemisphere) * Reduce seizure severity in some patients - reduced spread of electrical activity through brain * Often connections reform

Answer 349

* Ictal (epileptic) 52% * Syncope 30% * Psychiatric 7% * Unknown 3% * Non-epileptic attack disorder (NEAD) 3% * Reflex anoxic seizure (RAS) 2%

Answer 350

* Headache worse on sitting/standing up and relieved by lying down * Results from CSF leakage * Loss of CSF volume causes traction on meninges, cerebral/cerebellar veins and CN V, IX and X

Answer 351

ICDH-3 Criteria * At least five attacks fulfilling criteria B-D * Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated) * Headache has at least two of the following four characteristics * Unilateral location * Pulsating quality * Moderate or severe pain intensity * Aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs) * During headache at least one of the following * Nausea and/or vomiting * Photophobia and phonophobia * Not better accounted for by another ICHD-3 diagnosis

Answer 352

Lines the endosteal layer, only layer present in the vertebral column

Answer 353

* Injection into epidural space, doesn't penetrate the meninges * Done at L3/4 or L4/5 vertebral level * Used to administer analgesia - block sensory fibres to prevent pain

Answer 354

* Penetrates dura to access CSF * Diagnostic - withdraw and test CSF or test pressure of CSF * Therapeutic - antibiotic administration, route for chemotherapy * L3/4 or L4/5 vertebral level - cauda equina won't be damaged

Answer 355

* Large vessel * Look for cortical signs * Small vessel * No cortical signs on examination * Posterior circulation * Crossed signs * Cranial nerve findings

Answer 356

Excitation * EAA - excitatory amino acids e.g. glutamate, aspartate * Action on NMDA/AMPA/Kainate * Na+/Ca2+ influx Inhibition * GABA/glycine * Action on GABA-R * Cl- influx

Answer 357

To give a larger surface area to volume ratio

Answer 358

* Weakness/paralysis of muscles of facial expression * Depending on location of lesion * Chorda tympani - reduced salivation, loss of taste on ispilateral posterior 2/3 of tongue * Nerve to stapedius - ipsilateral hyperaccusis (hypersensitive to sound) * Greater petrosal nerve - ipsilateral reduced lacrimal fluid production

Answer 359

1. Affect pre-synaptic excitability and neurotransmitter release 2. Affect the GABAergic system 3. Reduce post-synaptic activity

Answer 360

Cavernous sinus is anterior, receives blood from the ophthalmic vein and empties into the superior and inferior petrosal sinuses which drain into the sigmoid sinuses (-\> IJV)

Answer 361

Lateral ventricles --\> 3rd ventricle --\> 4th ventricle

Answer 362

* 1g of IV methylprednisolone for 3 days * OR 500mg of oral methylprednisolone for 5 days and PPI for gastroprotection * Ideally prescribe at 9AM to avoid sleep disruption

Answer 363

Early Alzheimer's disease, limbic encephalitis

Answer 364

1. Endosteal/periosteal layer 2. Meningeal layer

Answer 365

* Cranial nerve palsy (ipsilateral) with contralateral motor/sensory defect * Bilateral motor or sensory defect * Eye movement disorder * Cerebellar signs * Isolated homonymous hemianopia

Answer 366

* Paroxysmal depolarising shift, a large and prolonged depolarisation with generation of action potential spikes * Horizontal bars represent the period during which the particular channel is open (sodium, calcium and potassium - conductance of ions across the membranes), the beginning of the bar indicated the opening of the channel and the end of the bar its closure * At the onset of the PDS, the AMPA channel opens, which allows Na+ to enter the cell and begin the process of depolarisation * The NMDA channel then opens allowing both Na+ and Ca2+ to enter * Following depolarisation, there is opening of the K+ and activation of GABA channels with Cl- entering the cell * Both the influx of Cl- and efflux of K+ lead to hyperpolarisation of the cell (corrective for depolarisation)

Answer 367

* High risk TIA (ABCD2 or 4 or more) or minor ischaemic stroke (NIH 3 or less) * DAPT for 10-21 days * Low risk TIA or other ischaemic stroke in SR * Aspirin 300mg od until discharge then clopidogrel * Ischaemic stroke or TIA in AF * NOAC (or warfarin) * Cerebral haemorrhage * No (murder)

Answer 368

Sensory innervation of the cheeks, lower eyelid, nasal mucosa, upper lip and teeth and palate

Answer 369

* Tiagabine inhibits the GABA transporter (removes GABA from the synapse - elevate GABA levels) * Vigabatrin and valproate inhibit GABA metabolism (degrades GABA - elevate GABA levels)

Answer 370

* Motor * Function - speech and swallowing * Nucleus location - medulla * Structure innervated - tongue

Answer 371

* Standard from 6m * Each eye separately * Tests visual acuity

Answer 372

WFNS Grades I-V * GCS 15 - grade I * GCS 13-14 without deficit - grade II * GCS 13-14 with deficit - grade III * GCS 7-12 - grade IV * GCS 3-6 - grade V Higher WFNS grade - worse outcome

Answer 373

Between L + R hemispheres of the cerebrum in the longitudinal fissure Attached anteriorly to the crista galli of the ethmoid bone and posteriorly to the tentorium cerebelli

Answer 374

* Imaging * CT - good visualisation of brain * MRI - better at picking up cortical abnormalities with seizures * Electroencephalography - sometimes abnormal in epilepsy but shouldn’t be used as screening * 'Brainwaves' * Normal * Epileptiform * Seen in 5-10% of young people, esp. with a family history of epilepsy

Answer 375

* Optic neuritis * Clinically isolated syndromes * Transverse myelitis * Radiologically isolated syndromes

Answer 376

Deviation of uvula away from side of lesion

Answer 377

Dorsal striatum = caudate nucleus + putamen Ventral striatum = olfactory tubercle + nucleus accumbens

Answer 378

* CT * Confirms diagnosis * Clues to aetiology * Identifies complications - infarction, haematoma, hydrocephalus * Prognostic - Fisher grade * Thickness of blood in basal cisterns, thicker = worse prognosis * High sensitivity/specificity esp. first few hours after SAH (90% first 24 hours) * LP - xanthochromia, bilirubin vs oxyhaemoglobin * Yellowing of CSF, due to blood breakdown products * Blood cells lyse - oxyhaemaglobin --\> bilirubin by haem oxygenase * Bilirubin only present after 10-12 hours, indicates bleed * Lots of red cell contamination, oxyhaemoglobin can mask bilirubin * CTA * MRA * DSA - stroke, diabetics * Gold standard for aneurysm imaging * Hyponatraemia * ECG changes * Elevated troponin levels - not as high as in MI * Echocardiography - tako tsubo cardiomyopathy

Answer 379

* Progressive (ascending) weakness over days * Flaccid, quadriparesis with areflexia * +/- respiratory/bulbar/autonomic involvement

Answer 380

Patients who have non-traumatic SAH in whom an aneurysm cannot be found are described as perimesencephalic SAH (10-15% of SAH). In general, these patients have a more benign presentation and an improved outcome. No intervention indicated.

Answer 381

Stick tongue out - check for deviation (deviates to weak side if lesion)

Answer 382

* Primary auditory area - hearing * Auditory association area - hearing * Wernicke's area - speech comprehension * Learning and memory (retrieval) * Emotions

Answer 383

* Worse on lying flat, improved on sitting/standing up * Worse in the morning * Persistent nausea/vomiting * Worse on Valsalva (e.g. coughing, laughing, straining) * Worse with physical exertion * Transient visual obscurations with change in posture

Answer 384

* AF is significant risk factor for stroke * Consider oral anticoagulation if no contraindications * When oral anticoagulation is started, antiplatelet agent should be stopped * For non-valvular atrial fibrillation, either Warfarin (target INR 2-3) or the direct oral anticoagulants (e.g. dabigatran, apixaban) should be considered * DOACs have benefit of more stable anticoagulation without the need for monitoring, associated with less intracranial haemorrhage * Higher rates of GI bleeding than warfarin (especially dabigatran and rivaroxaban) * Use more limited in renal impairment * Should not be used in patients with valvular AF e.g. prosthetic valves

Answer 385

* Supplies most of cortex * Arm \> leg weakness * LMCA cognitive: aphasia * RMCA cognitive: neglect, topographical difficulty, apraxia, constructional impairment, anosognosia

Answer 386

* Total anterior circulation stroke - large cortical stroke in middle/anterior cerebral artery areas * Diagnosis, all 3 of the following * Unilateral weakness (and/or sensory deficit) of face, arm and leg * Homonymous hemianopia * Higher cerebral dysfunction (dysphasia, visuospatial disorder) * Partial anterior circulation syndrome - cortical stroke in middle/anterior cerebral artery areas * Diagnosis, two of * Unilateral weakness (and/or sensory deficit) of face, arm and leg * Homonymous hemianopia * Higher cerebral dysfunction (dysphasia, visuospatial disorder) * Posterior circulation syndrome * Diagnosis, one of * Cerebellar or brainstem syndromes * Loss of consciousness * Isolateral homonymous hemianopia * Lacunar syndrome - subcortical stroke due to small vessel dis., no evidence higher cerebral dysfunction * Diagnosis, one of * Unilateral weakness (and/or sensory deficit) or face and arm, arm and leg or all three * Pure sensory stroke * Ataxis hemiparesis

Answer 387

* Heart looks like lobster pot * Rarely seen following subarachnoid haemorrhage * Self-limiting * 2-3 days * Can be associated with pulmonary oedema

Answer 388

* Is it a seizure - if yes * Immediate measures - secure airway, oxygen administration, assess pulse, BP, respiration * Seizure continues \>5 minutes * Assess * Blood glucose/BM stick * Oximetry * Bloods - FBC, U&Es, LFTs, Ca * Clotting screen * AED levels * Arterial blood gases * Cardiac monitor * Initial therapy * Treat seizure - secure IV access, administer benzodiazepine (lorazepam IV, diazepam IV/rectal, mizaloam buccal, as per local prtocols) * Treat potential cause - IV glucose if potential hypoglycaemia, IV thiamine if potential alcohol abuse or poor nutrition * Seizure continue for further 5 minutes * Repeat BDZ dosing * Administer usual AEDs where indicated (nasogastric tube or IV as necessary) * Seizures continue * IV dosing with phenytoin or valproate * Seizures continue * Admit to ITU * Monitor using EEG * Sedation with general anaesthetic * Refer for specialist advice

Answer 389

Reduced abduction, eye positioned laterally

Answer 390

* Avoid opiates and restrict acute medication to 2 days a week * Simple analgesics aspirin 900mg or ibuprofen 400-600mg * Triptans * Sumtriptan 50-100mg is first choice * All oral triptans are gastrically absorbed, so may not work if patient vomiting * Triptans only work once headache starts * General efficacy is to work for 2 out of 3 attacks * Early or persistent vomiting * Add anti-emetic - metoclopramide 10mg or prochloperazine 10mg * Consider nasal zolmitriptan or subcutaneous sumatriptan * No response * Try other triptans * Try triptan and NSAID combinations

Answer 391

* Small vessel (Lacunes \<1.5cm) * Damage to tiny blood vessels of brain, supply white matter and some of brainstem * Pure motor, pure sensory or sensorimotor - no cortical involvement

Answer 392

Sub-control of voluntary movement

Answer 393

* No accepted uniform classification * Reflects the heterogenicity * GCS * Minor = 14-15 * Moderate = 9-13 * Severe = \<8

Answer 394

* Episodic memory deficit - Alzheimer's * Semantic memory deficit - Semantic dementia (variant FTD) * Attention/concentration deficit - Delirium * Naming/fluency deficit - progressive non-fluent aphasia (variant FTD) * Visuospatial - PD plus syndrome or variants AD

Answer 395

* Monthly infusions * Very effective treatment for relapses * Serious risk of fatal PML is infected with JC virus

Answer 396

Areas where infolding of the dura mater occurs, partitioning the cranial cavity

Answer 397

* 3 anterior and 3 posterior spinal veins - valveless, form anastomosing network on surface of spinal cord + radicular veins * Drain into internal and external venous plexus, which drain to the systemic segmental veins * Internal vertebral plexus drain to dural venous sinuses superiorly * Epidural space contains Baston's veins/plexus * Also subarachnoid veins * Veins exit at segmental levels

Answer 398

* Scotland has highest incidence and prevalence of MS in world * Approximately 1 in 600 people in Scotland have MS * Highest prevalence in Orkney Islands (1 in 243) * Lanarkshire - 1 in 421 * Lower prevalence near the equator * Still seen in places like Spain or India * Rare disease China

Answer 399

L and R from subclavian artery

Answer 400

Collection of nuclei strongly associated with the cerebellum, brainstem and cerebral cortex

Answer 401

* Motor * Function - moves eyeball down * Nucleus location - midbrain (inferior colliculus) * Structure innervated - superior oblique muscles * Depresses the adducted eye and intorts the abducted eye * Longest intracranial course * II and IV are the only nerves to decussate to contralateral side

Answer 402

* Lumbar puncture * Bloods - exclude other conditions * Visual evoked potentials * CXR - exclude sarcoidosis

Answer 403

* Mainly to exclude other causes of presentation * B12/folate * Serum ACE * Lyme serology * ESR/CRP - should be normal * ANA/ANCA/Rheumatoid factor * Aquaporin 4 antibodies (if transverse myelitis/optic neuritis)

Answer 404

Between the occipital lobe of the cerebrum and the cerebellum, divides the cranial cavity into supratentorial and infratentorial areas

Answer 405

* Don’t routinely examine olfactory * Ask patient about noticing change in sense of smell (or family members) * Slow loss harder to identify

Answer 406

* Motor * Motor complications * 'On/off' fluctuations * L-dopa induced dyskinesia * Poor balance/falls * Speech/swallowing disturbance * Cognitive * Dementia

Answer 407

In the subarachnoid space of the brain and spinal cord

Answer 408

Separates frontal/parietal lobes from the temporal lobe

Answer 409

* Rehaemorrhage * Delayed ischaemia * Hydrocephalus * Hyponatraemia * ECG changes, LVF (Tako-tsubo cardiomyopathy) * LRTI, PE, UTI

Answer 410

Depending on the deficit the patient has, consider: * Physiotherapy * Speech therapy * Occupational therapy * Smoking cessation * Dietician

Answer 411

Contralateral homonymous hemianopia

Answer 412

* Horizontal diplopia * Two images separated, look to side more separated * Can be sign of raised intracranial pressure

Answer 413

* Observe normal position of eye (deviation/strabism) and look for spontaneous movements (nystagmus) * Eye movements - draw H shape with finger, movement should be free and coordinated

Answer 414

- Drains the thalamus, hypothalamus, internal capsule, septum pellucidum, choroid plexus, corpus striatum and white matter - Deep cerebral veins = subependymal, medullary - Drain into the trasverse, straight and sigmoid sinuses

Answer 415

* History adapted to lesion * HPC * Personal history of migraine or tendency (previous migraines, perimenstrual HA, undeserved hangovers, motion sickness, FH of migraines) * How many HA type * For each HA type * Age of onset * Chronic HA, episodic (define pattern), constant, new type of HA * Premonitory symptoms * Onset - time to peak * Progression * Location * Character * Intensity - use visual analogue scale 0-10 * Precipitating factors * Exacerbating or relieving factors (features of high or low pressure) * Associated symptoms * What they do during an attack? * Impact * Concerns, expectations * PMH * Immunosuppression * Cancer * Foreign travel * Cardiac, cerebrovascular, renal, hepatic, psychiatric, gastric disease * DH * Medications that cause HA * Drug-drug interactions for potential therapy * FH * Migraine * Tumour * SH * Sleep * Meals * Exercise * Caffeine * Illicit drugs, alcohol (falls?) * Gas appliances

Answer 416

* GP * Neurologist/care of the elderly physician * Parkinson's disease nurse specialist * Physiotherapist * Speech and language therapist * Psychiatrist * Psychologist * Occupational therapist * Palliative care team * Neurosurgeon

Answer 417

Patient typically awake and often stressed, the abrupt onset of symptoms with acute decompensation and smooth progression

Answer 418

* Wernicke's - decodes spoken word into meaningful language, checks that what you say makes sense * Fluent, can't comprehend * Posterior part of the superior temporal gyrus * Located on the dominant side (left) of the brain * Next to Wernicke's - angular gyrus, responsible for interpreting written language * With Wernicke's angular gyrus also usually affected, usually can't read

Answer 419

* Relapsing remitting MS * Unpredictable attacks which may or may not leave permanent defects followed by periods of remission * Primary progressive MS * Steady increase in disability without attacks * Secondary progressive MS * Initial relapsing-remitting multiple sclerosis that suddenly begins to have decline without periods of remission * Benign MS * Progressive-relapsing MS * Steady decline since onset with super-imposed attacks

Answer 420

Cribiform foramina of the cribiform plate

Answer 421

* A sustained and synchronised electrical discharge in the brain causing symptoms or signs * Burst/discharge of electrical activity in brain - sustained/prolonged * Change in neurone - potassium/sodium/neurotransmitters

Answer 422

* Unknown - 57% * Vascular - 11% * Hippocampal sclerosis - 7% * Infection - 6% * Trauma - 6% * Other - 5% * MCD - 3% * Tumour - 2% * Degenerative - 2%

Answer 423

* Articulate with ribs * Spinous processes point inferiorly + posteriorly

Answer 424

* Vestibular branch from vestibular nuclei complex in pons/medulla, cochlear branch from ventral + dorsal cochlear nuclei in inferior cerebellar peduncles * Combine in pons, exits cranium via internal acoustic meatus * Splits in distal internal acoustic meatus, vestibular branch to vestibular organs of inner ear, cochlear to cochlea of inner ear, forming the spiral ganglion

Answer 425

* Very powerful drugs with lots of side effects * Alemtuzumab * Natalizumab * Less powerful drugs with fewer side effects - oral treatments * Fingolimod * Dimethyl Fumarate * Cladribine * Need careful monitoring, only prescribed by MS specialists

Answer 426

* Sudden onset headache - thunderclap headache * Sudden onset, rises to crescendo, 'worst headache I've ever had' * Nausea/vomiting * LOC, seizures, visual, speech and limb disturbance * Sentinel headache * Precedes SAH by days-weeks * Sudden, intense, persistent

Answer 427

* Wide, thick white matter nerve tract * Spans part of longitudinal fissure, connecting the cerebral hemispheres * Forms part of walls of lateral ventricles

Answer 428

Lies within the brainstem, at the junction of the pons and the medulla oblongata

Answer 429

* Down and out deviation * Ptosis * Pupil dilation

Answer 430

Forms a partial roof over the hypophysial fossa, covers the pituitary fland, aperture for passage of the infundibulum of the pituitary

Answer 431

PD is a common slowly progressive asymmetrical neurodegenerative disorder predominantly affecting the elderly. * Loss of dopaminergic neurones within substantia nigra * Surviving neurones contain Lewy bodies * PD manifests clinically after loss of approximately 50% of dopaminergic neurones

Answer 432

* Big clots - distal internal carotid, middle cerebral artery * Catheter into artery, stent in, open stent to trap clot, remove stent with clot * Often used with tPa * Effective - reduces symptoms post-stroke, more likely to have good outcome

Answer 433

Anterior spinal artery syndrome - loss of urinary and/or faecal continence, impaired motor function in legs/spasticity

Answer 434

Common - 0.5% prevalence active epilepsy Any age - 5-10% risk single seizure

Answer 435

* Circle of Willis is a collateral network of large arteries situated at the base of the brain within the subarachnoid space, surrounded by CSF * SAH occurs when blood extravasates into this space between the arachnoid membrane and the pia mater * Most common reason for SAH is trauma * 85% of spontaneous/non-traumatic SAH result from saccular or berry aneurysms * Outpouchings of the intimal layer through the muscular wall of artery * Congenital weakness within muscular layer, later vulnerable to effects of smoking/hypertension, responsible for development of Berry aneurysms * Rare cases - polycystic kidney disease and connective tissue disease (e.g. Ehlers Danlos syndrome, Marfan syndrome)

Answer 436

* Hearing * Whisper voice test - each ear individually, need 3/6 to pass * Audiometry * Rinne test - air vs bone conduction, normal = air \> bone, abnormal suggests conductive hearing loss * Weber test - test symmetrical inner ear function, press tuning fork against forehead * Balance * March on spot with eyes closed - turn to side of lesion * Test vestibulocochlear reflex - turn head quickly

Answer 437

* Sensory * Function - balance * Nucleus - pons and medulla * Structure innervated - nerve endings within semi-circular canals --\> cerebellum and spinal cord * Sensory * Function - hearing * Nucleus - pons and medulla * Structure innervated - cochlear --\> auditory cortex in the temporal lobes

Answer 438

* Cavernous sinus - CN III, IV, V (1st and 2nd divisions), VI Horner's syndrome * Superior orbital fissure - III, IV, V (1st division), VI * Cerebellopontine angle - V, VII, VIII * Jugular foramen - IX, X (and XI) * Bulbar/pseudobulbar palsy - IX, X, XI (and XIII)

Answer 439

* Sudden onset * Peripheral signs - areflexia, glove and stocking distribution, muscle wasting, fasciculations * Major cognitive involvement * Reduced level of consciousness * Prominent seizures * Pyrexia/evidence of infection * Normal MRI scan

Answer 440

* Relevant investigations * MRI (CT), SPECT, CSF etc. * Cognitive assessment * History including functional status * Physical examination - often less relevant

Answer 441

SSSNOOPPP * Systemic symptoms * Secondary risk factors * Seizures * Neurological symptoms * Onset * Older * Progression (including change in attack frequency, nature) * Papilloedema * Precipitated by cough, exertion, sleep, Valsalva CSF * Change in nature of headache (or new headache) * Systemic symptoms or signs * Focal neurological deficit Image those in whom a primary headache cannot be diagnosed.

Answer 442

* Visual field - cover one eye, move finger in all 4 quadrants * Peripheral fields - move fingers in upper and lower quadrants at periphery, say which finger moves * Visual acuity - cover one eye and read letters from Snellen chart (start at 6m away, wear glasses if needed) * Pupil reflexes - direct and consensual responses, swinging flashlight test

Answer 443

* L-dopa * Dopamine agonists * MAO-B inhibitors * COMT inhibitors

Answer 444

- V thin, tightly adhered to surface of brain/spinal cord - Follows contours of brain gyri/sucli - Highly vascularised, BVs perforate through to supply the underlying neural tissue - Anchored to brain by processes of astrocytes (glial cells) - Unicellular membrane

Answer 445

Hypoglossal canal

Answer 446

Area of potentially salvageable tissue, damaged by ischaemia

Answer 447

Contralateral superior quadrantopia