Cases

Question 1

Commonest cause of encephalitis

Answer 1

Viral: HSV,Varicella, enterovirus

• gastroenteritis association

Question 2

Differentiating between complications of acute sinusitis

Answer 2

CNS ABSCESS: sinusitis, focal, pyrexia, limbs!

vs

Cavernous sinus thrombosis: unilateral facial, oedema, proptosis, palsies (III, IV, V, VI)

Question 3

Commonest cause of neonatal meningitis

Answer 3

Group B Strep. (vaginal commensal)

Question 4

Commonest causes of meningitis in young adults

Answer 4

N. MENINGITIS = gram neg. diplococci

S. PNEUMON. = gram +ve diplococc.

Question 5

Meningioceph. is a common complication of

Answer 5

MUMPS

Question 6

Management of suspected meningiococcal meningitis

Answer 6

IV Cefotaxime

Question 7

Diagnosis of MG

Answer 7

ACh R Ab
Anti muscle specific tyrosine kinase Ab
Electromyography
CT Thorax to RULE OUT ASSOCIATED THYOMA
CK = normal

Question 8

Treatment for MG

Answer 8

> PREDNISOLONE
PYRIDOSTIGMINE (anti ACh inhib.)

+plasma exchange, Ig infusion, imm suppr.
+ Thymectomy

Question 9

Hallmarks of MG

Answer 9

• Descending asymm. weakness
• FATIGUE/time
• PTOSIS DIPLOPIA (occular MG)
• RESP FAILURE => !asp. pneumonia

Question 10

A 31-year-old intravenous drug user is brought to the emergency department with back pain, bilateral leg weakness and fever. What is the most likely diagnosis?

a. Epidural Abscess
b. Meningitis
c. Cervical Spondylosis
d. Prolapsed disc
e. Groin abscess

Answer 10

EPIDURAL ABSCESS

Question 11

An 82 year old man presents with back pain. This pain is typically worse lying down. He has noticed he has been more unsteady on his feet recently. He has a past medical history of prostate cancer which he is currency taking hormonal therapies for. Given the likely diagnosis what is the first line management?

a. Discharge with advice regular NSAIDs
b. Physiotherapy
c. IV mannitol
d. Radiotherapy
e. Oral Dexamethasone

Answer 11

Oral Dexamethasone

Question 12

A 45-year-old woman is admitted to the emergency department following a stabbing incident. She has multiple wounds on her flank and lower back that the medics suspect were caused by a knife.

You perform a full neurological examination which reveals the following:

weakness in extension and flexion of the right knee
loss of proprioception and vibration below mid thigh in the right leg
loss of pain sensation below the mid thigh in left leg

a. Brown Sequard Syndrome: Right lateral hemisection of the cord damaged
b. Brown Sequard Syndrome: Left lateral Hemisection of the cord damaged
c. Central cord syndrome
d. Laceration to the sciatic nerve
e. Anterior cord syndrome: hemisection of anterior cord damaged

Answer 12

a. Brown Sequard Syndrome: Right lateral hemisection of the cord damaged

Question 13

A 82-year old woman presents with a 2 day history of neck pain, paraesthesia in her fingers and progressive leg weakness. Which of the following investigations is the gold standard for diagnosing degenerative cervical myelopathy?

a. Xray Cervical Spine
b. Nerve conduction studies
c. CT Cervical spine
d. USS cervical spine
e. MRI Cervical spine

Answer 13

e. MRI Cervical spine

Question 14

A 59 year old man has presented to the GP with a 6 month history of neck and back pain. The pain is described as being like ‘electric shocks’ and is worse when he turns his head. There is no history of trauma and no other obvious trigger. He has no chronic conditions and is not taking any medications. On examination he has decreased sensation on the dorsal aspect of the thumb and index finger.

Answer 14

C6 radiculopathy

Question 15

A 65 year old man with a history of prostate cancer presents to his GP with back pain. It has been bothering him for a couple of months now. He is concerned that his prostate cancer has come back and read on the internet that it can spread to your spine. Which of the following features of back pain would you consider as alarming?

Select one or more:

a. Pain on lying down supine
b. Thoracic pain
c. Weight loss
d. Pain following exercise

Answer 15

Pain on lying down supine,
Thoracic pain,
Weight loss

Question 16

Hallmarks of Epidural Abscess

Answer 16

Spinal cord infection, RF: IVDU, imm suppr., malignancy, DM, recent spinal sx

back pain. This is often worse on movement and worse at night. Associated features can include pyrexia and radicular signs, progressing to weakness or paralysis in severe cases

Question 17

Epidural Abscess Diagnosis

Answer 17

gold standard investigation to visualise spinal infections is MRI imaging with contrast.

Question 18

Which CN leave the pontomedullary junction

Answer 18

ABDUCENS
FACIAL
VESTIBULOCOCHLEAR

Question 19

What cranial nerve has a special visceral component that is responsible for taste to the posterior ⅓ of the tongue?

Answer 19

CN IX

Question 20

A 22 year old patient presents to an emergency appointment with a 4-day history of pain behind her right ear. She has woken up today with a facial paralysis. You notice her mouth is drooping downwards on the right and she cannot completely close her right eye. Given the most likely diagnosis is Bell’s Palsy, what finding would you expect if you asked the patient to raise her right eyebrow and why?

Answer 20

Inability to raise the left eyebrow as Bell’s palsy is due to a lower motor neuron lesion

Question 21

A 70-year old woman presents to the Emergency Department by ambulance. She had a severe headache and nausea then had a subsequent epileptic fit. Fundoscopy shows papilloedema. She complains of diplopia when asked to look laterally.

What is the most likely cranial nerve responsible for the symptoms?

a. Trochlear Nerve
b. Optic Nerve
c. Trigeminal Nerve
d. Abducens Nerve
e. Oculomotor nerve

Answer 21

ABDUCENS

Question 22

A 34 year old lady is admitted with visual disturbance. On examination she is noted to have mydriasis and diminished direct response to light shone into the affected left eye. The consensual response in the affected eye is preserved. She also experiences pain in her left eye that comes on with movement. Her right eye is completely normal. She remembers that last year she developed some paresthesia in her left foot that resolved after a few weeks. She did not seek medical advice at the time.

What is the most likely cranial nerve responsible for the eye symptoms?

Answer 22

OPTIC N.
= OPTIC NEURITIS d/t RAPD

*suspicion of MS

Question 23

A 35 year old male was involved in a head on collision with a tractor whilst riding his motorbike through the country roads in Aberdeenshire. He was airlifted to ARI where he was initially seen by the consultant in A+E resus. He is now in ICU and as the registrar in Neurosurgery you have been asked to go and assess him. He does not open his eyes and is unresponsive when you speak to him. He extends his right elbow, internally rotates his shoulder and flexes his elbow in response to pain.

What is his GCS?

Answer 23

EYE = 1

SPEECH = 1

MOTOR = 2 (ext.)

Question 24

Commonest brain tumours in adults and children

Answer 24

ADULTS = GB MULTIFORME

CHILDREN = MEDULLOBLASTOMA

Question 25

Which type of herniation syndrome is most worrying as it can cause cardiovascular and respiratory compromise?

Answer 25

Tonsillar herniation occurs when the cerebellar tonsils are forced downwards through the foramen magnum, causing compression on the brain-stem (causing respiratory and cardiovascular compromise which can be fatal). This is called CONING.

Question 26

In uncal herniation (transtentorial herniation) which concerning clinical sign may be elicited on examination?

Answer 26

Uncal herniation results in 3rd nerve (Oculomotor nerve) palsy. In a 3rd nerve palsy the eye will have a down and out appearance with a dilated pupil that fails to constrict. . Down and out position of the ipsilateral

Question 27

All of the following are classical clinical features found in Parkinson’s Disease except? a. Bradykinesia b. Micrographia c. Cogwheel Rigidity d. Intention Tremor e. Anosmia

Answer 27

INTENTION TREMOR (cerebellar, slow, extremities)

Question 28

What is the most likely vessel damaged in an Extradural Haemorrhage? a. Emissary Veins b. Middle cerebral artery c. Middle meningeal artery d. Ophthalmic artery e. Bridging veins

Answer 28

MMA d/t pterion fracture

Question 29

A 68-year-old woman comes in with a headache, blurred vision and sleepiness. She is recovering alcoholic and has a past medical history of falls. Examination reveals papilloedema and other than a GCS of 12. On CT a crescent shaped haemorrhage is identified that is not limited by the cranial sutures. Given the most likely diagnosis what damaged vessel(s) describes these signs and symptoms?

Answer 29

SDH = bridging veins

Question 30

A 57-year-old female attends the emergency department with a sudden onset of a severe occipital headache and has vomited 3 times in the past hour. An urgent CT scan finds no abnormalities, however, a lumbar puncture taken 12 hours later is positive for xanthochromia What is the most likely diagnosis? a. Intracerebral haemorrhage b. Extradural Haemorrhage c. Subarachnoid haemorrhage d. Subdural haemorrhage e. Diffuse axonal injury

Answer 30

SAH Xanthochromia, the yellow discoloration of cerebrospinal fluid (CSF) caused by hemoglobin catabolism, is classically thought to arise within several hours after subarachnoid hemorrhage (SAH).

Question 31

A SAH is diagnosed. Urgent neurosurgical review is requested and a CT cerebral angiography indicates a posterior communicating artery aneurysm as the cause of the SAH. The patient is otherwise fit and well. Which option is most likely to be the optimal treatment for the aneurysm? a. Surgical clipping b. Insertion of an extraventricular drain c. Coiling by an interventional neuroradiologist d. Extracranial-intracranial bypass e. Nimodipine only

Answer 31

Coiling by an interventional neuroradiologist is the correct answer, as this is the most common treatment for intracranial aneurysms following a SAH. This works on the concept of excluding the aneurysm from intracranial circulation and involves the insertion of soft metallic coils within the lumen. +NIMODIPINE (reduce spasm) - less invasive as sx clipping - extraventricular drains if hydroceph arises as a complication

Question 32

You review an 80-year-old woman four days after she was admitted with a suspected stroke. She has a right sided sensory loss affecting her arms more than the legs and a right sided homonymous hemianopia. What area is the stroke most likely to have affected?

Answer 32

MCA

Question 33

A 63 year old man presents with a left sided hemiparesis which affects his lower limb more than his upper limb, with his face unaffected. He also has complete loss of both pain and light touch sensation in his left lower limb. He is able to clearly speak to you but understands what you say. He does not have an ataxia, but he appears unable to see you when you stand on his left. Clinical examination of his visual fields reveals a left sided homonymous hemianopia. Which clinical stroke syndrome does he have?

Answer 33

PACS (2/3 nil higher cognition defects)

Question 34

A 65 year old man noticed thinning of muscles in hands, with weakness He also noticed some twitching in the muscles in his thigh, and cramps in the legs The patient did not experience any numbness or tingling He has lost 1/2 stone in weight and you notice he has slurred speech Patient was dysarthric and had a brisk jaw jerk Fasciculations/wasting in the tongue, deltoids, biceps, and quadriceps observed Weakness in all four limbs, brisk reflexes in arms, absent reflexes in legs were also noted Most likely dx?

Answer 34

MND -bilateral tongue fasiculations most likely MND

Question 35

``` Another patient presents with unilateral complete right ptosis On examination: (1) the right eye is down and out, (2) complete ptosis and (3) right pupil is dilated ``` Dx?

Answer 35

IIIn palsy

Question 36

A 55 year old male presents to the general practitioner complaining of double vision and drooping of the right eyelid. He does not report pain in the eye. On physical examination there is right sided ptosis. On elevation of the eyelid the GP notes the eye to be deviated inferiorly and laterally at rest. The direct and consensual reflexes are present bilaterally. Neurological examination is otherwise normal. Which of the following is the most likely underlying cause of this presentation? - Horners - Cavernous Sinus Thrombosis - DM - PCA aneurysm - Midbrain infarct

Answer 36

DM Medical IIIn palsy d/t DM (commonest) Vs Sx IIIn palsy = fixed dilated pupil + pain

Question 37

A 34 year old woman presents to the emergency department complaining of peripheral tingling affecting her left foot. She first noticed the symptoms in her toes early that morning, and by evening they had progressed to involve her ankle and calf – they were particularly noticeable after taking a bath. She reports similar, more mild, symptoms in her left foot some three months previously. Which of the follow features would you expect to find on MRI imaging? - subsegmental MCA infarct - normal MRI head - widespread white matter disease - ventriculomegaly - plaques of gadolinium-enhancing T2 hyperintensity

Answer 37

plaques of gadolinium-enhancing T2 hyperintensity d/t suggestive of MS thus plaques of demyelination and axonal loss = hallmark of MS

Question 38

A 69-year-old female presents to the general practitioner complaining of an episode of weakness earlier in the morning, which lasted one hour. She has a past medical history of peripheral arterial disease, deep vein thrombosis (DVT) 3 years ago, atrial fibrillation, type 2 diabetes mellitus, and a pulmonary embolism seven years ago. A diagnosis of transient ischaemic attack (TIA) is made. She is deemed a suitable candidate for anticoagulation with a direct oral anticoagulant such as Apixaban. Which aspect of her history makes Apixaban a suitable treatment option for her?

Answer 38

AF = source of emboli, common, ensure anticoagulation in patients who have had TIAs

Question 39

A 74 year old gentleman presents to his GP with a headache, right arm weakness and numbness and tingling in his right hand for the past 3 months. His past medical history includes COPD and heart failure. On examination, there is numbness over the right middle finger and there is weakness on extension of the right elbow, MRC grading 3/5. His observations are stable. What is the most likely diagnosis?

Answer 39

C7 cervical spondylosis * dermatome affected * elbow extension = triceps = C7-C8

Question 40

A 25 year old man is admitted to the intensive care unit with fulminant hepatic failure, following paracetamol overdose. On examination he is comatose with a Glasgow coma score of 4 (E1, V1, M2). His pupils are dilated and minimally reactive to light, and he has papilloedema on fundoscopy. His observations show a blood pressure of 90/40mmHg and a heart rate of 102bpm. He is afebrile and his saturations are 98% on ventilation with 100% oxygen. Which of the following first-line interventions are appropriate in the management of this patient? - hypoventilation - IV dexamethasone - IV mannitol - IV glyceryl trinitrate infusion

Answer 40

* raised ICP signs (papillodema, ⇧systolic BP) therefore > Mannitol to reduce brain water content alternatively: hypertonic saline Vs Dexamethasone: inidicated only in raised ICP d/t malignancy

Question 41

An 84 year old man presents to his GP reporting pain in his buttocks when walking, most notable when walking down the stairs in his house. The pain is cramping in quality, radiates down into the leg, and is associated with a tingling and burning sensation. It is relieved by rest, especially when seated. On examination in the leg is warm and well perfused with no evidence of abnormal skin changes. Pulses are palpable in both feet bilaterally. His past medical history is unremarkable, and he takes only regular paracetamol for osteoarthritis. What is the most likely cause of his presentation? - osteoarthritis of the hip - atherametous disease - lumbar spinal stenosis - giant cell arteritis

Answer 41

lumbar spinal stenosis: neeurogenic claudication | * pain on exercise; worse. with extension iimproved by flexion

Question 42

A 65-year-old woman presents to her General Practitioner with a history of acute right facial weakness. She is otherwise asymptomatic. Limb strength and sensation is unremarkable, as is examination of the ears. Her doctor suspects Bell's palsy. What is the most appropriate treatment of Bell's palsy?

Answer 42

>prednisolone

Question 43

A 29-year-old man presents to his GP, complaining of “crazy movements”. Upon further questioning, he explains that now and then, his right arm jerks violently. He mentions that at times, he has thrown cups and plates against the wall, unintentionally. He is completely aware of these episodes and otherwise reports no additional symptoms. Neurological examination shows no physical abnormalities. His GP suspects epilepsy. What is the best description for this patient's symptoms? - atonic seizure - myoclonic seizure - reflex anoxic seizure - tonic-clonic seizure

Answer 43

MYOCLONIC SEIZURE = quick jerking, often after waking up. rhythmic movements. sensation of an electric shock. unusual clumsiness.

Question 44

A 14 year old boy is referred to the neurology clinic with frequent falls and lower limb weakness. He reports his grandfather suffered from similar problems. On physical examination there is wasting of the lower limb muscles, spastic hypertonia, reduced power, absent knee and ankle reflexes, and upgoing plantars. The neurologist also notes a pes cavus and kyphoscoliosis. Which of the following is true of this condition? - condition is autosomal dominant - dx via MRI head - condition is aa trinucleotide repeat disorder - associated with T2DM

Answer 44

-condition is trinucleotide repeat disorder: frataxin protein - triple repeat of the FXN gene Friedreich's ataxia (FRDA or FA) is an autosomal-recessive genetic disease that causes difficulty walking, a loss of sensation in the arms and legs, and impaired speech that worsens over time. Symptoms generally start between 5 and 20 years of age. Great impact on mobility. * hypertrophic cardiomyopathy * T1DM associations

Question 45

An 80 year old male patient presents to the emergency department with a 1 hour history of sudden onset double vision and pain behind his right eye. He has a past medical history of hypertension. On physical examination there is right-sided ptosis, the right eye is deviated inferiorly and laterally, and the right pupil is fixed in dilation. Neurological examination is otherwise unremarkable. Which of the following is the anatomical location of the causative lesion? - Midbrain - CoW - Abducens N - Orbit - Cavernous Sinus

Answer 45

- CoW | d/t IIIn palsy; Sx IIIn palsy d/t PAIN, FIXED DILATATION arising from posterior comm. aartery aneurysm (CoW)

Question 46

Foot Drop

Answer 46

Foot drop is caused by weakness of the muscles of ankle dorsiflexion (tibialis anterior) supplied by the common peroneal nerve (L4, L5 and S1 nerve root). Foot drop may therefore be caused by: Isolated common peroneal nerve palsy (e.g. secondary to trauma or compression) L5 radiculopathy (e.g. disc prolapse) Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, Charcot-Marie Tooth disease)

Question 47

Discerning between Foot drop like causes

Answer 47

Peroneal N V L5 root Inversion of the foot is retained in L5 but not in peroneal n palsy and pathology