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Short Cases > CNS > Flashcards

CNS Flashcards

1
Q

DDx of Diplopia / complex ophthalmoplegia? (5)

A

Brain stem: Stroke, SOL, MS

The base of skull problems: granulomatous disease, meningitis

Peripheral nerve: mononeuritis, cavernous sinus lesions

NMJ: Myasthenia

Soft tissue: Grave’s

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2
Q

What would you look for in fundoscopy in diabetics? (5)

A

Cotton wool spot

Hard exudates

Intra-retinal haemorrhages

Microaneurysms

Proliferative: neovascularisation

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3
Q

Ophthalmoscopy finding of hypertensive retinopathy? (5)

A

AV nipping

Silver wiring (narrowing of retinal arterioles)

Dot/flame haemorrhages

Cotton wool spots

Hard exudates

Microaneurysms

Papilloedema

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4
Q

CN III lesion features? (3) What is the key feature distinguishing between compressive vs. mononeuritis?

A

Eyes in inferolateral at the neutral position (ipsilateral eye)

Ptosis

Dilated, non-reactive pupil (if present, indicates compressive neuropathy). If mononeuritis (e.g. from diabetics, this is spared)

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5
Q

Causes of CNIII palsy? (4)

A

Posterior Communicating Artery Aneurysm - until proven otherwise.

Cavernous sinus lesions

Midbrain lesions: MS, SOL, Stroke

Mononeuritis multiplex (pupil spared)

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6
Q

How would you distinguish between CN II vs. CN III lesion? (2)

A

Optic nerve lesion: no pupil constriction with direct and indirect

Oculomotor: no pupil constriction with direct but with indirect, constriction present.

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7
Q

Jaw jerk and Corneal reflex are to test which nerve?

A

CN V

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8
Q

Causes of CN VI palsy? (4)

A

Raised ICP - is a false localising sign

Pontine lesions: MS, Stroke, SOL

Trauma or Tumour compressing on anywhere along it’s path

Mononeuritis multiplex.

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9
Q

CN VII signs (5)

A

The weakness of facial muscles

Loss of corneal reflex (CN VII - efferent, CN V - afferent)

Loss of taste sensation anterior 2/3rds

Hyperacusis (stapedius muscle)

Decreased tearing (lacrimal gland)

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10
Q

Facial nerve causes of LMN pattern weakness? (i.e. involves forehead/upper face) - 4

A

Most common = Bell’s palsy (idiopathic or viral)

Peripheral nerve lesion - Herpes Zoster, GBS, Sarcoid

Otitis media

Pons (ipsilateral, affecting nucleus): MS, stroke, SOL (e.g. acoustic neuroma)

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11
Q

Facial nerve causes of UMN?

A

Lesion affecting contralateral UMN fibres (above nucleus to cerebral motor cortex)

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12
Q

Clinical signs of CN 9-10 palsy? (6)

A
  • Fibres travel together, so their clinical testing is not easily separable.

Loss of taste in posterior 1/3rd (IX)

Uvula deviates (away UMN, towards LMN)

Hoarseness (recurrent LN to vocal cords)

Dysphagia (swallowing muscles - X)

Dysphonia (speech muscles - X)

Decreased Gag reflex

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13
Q

Causes of CN IX - X palsy? (4)

A

UMN: 10th nerve tract

MND

Medulla lesions: stroke, SOL, MS

Trauma or Tumour along the CN

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14
Q

Signs of CN XI weakness (2) and causes? (3)

A

Weak SCM and Trapezius (Accessory nerve)

Causes:

Medulla lesions: stroke, SOL, MS

Tumour or trauma along it’s path

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15
Q

Clinical sign of hypoglossal nerve palsy? (CN XII). Where is the lesion?

A

Protrusion of tongue away (for UMN) or towards (LMN) from side of lesion

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16
Q

Causes of hypoglossal nerve palsy? (4)

A

UMN: 12th nerve tract (as part of pseudobulbar palsy)

MND

Medulla: MS, stroke, SOL

Tumour or trauma along it’s path

17
Q

Where in brainstem CN are located?

A

Midbrain: CN 3-4

Pons: CN 5-8

Medulla: 9-12 and nuclei 5 (descending)

18
Q

Cerebellopontine angle CNs are?

A

CN 5,6,7,8

19
Q

Cavernous sinus anatomy? and Mnemonic to describe location of CNs within it?

A

OTOM-CAT.

20
Q

INO cause?

A

Lesion in MLF (medial longitudinal fasciculus) - PONTINE lesion.

21
Q

Causes of complex ophthalmoplegia (diplopia)?

A
22
Q

Causes of ptosis? (4)

A

Muscular: Myotonic dystrophy

NMJ: Myasthenia gravis

PN: CN III palsy, neurosyphilis

Horner’s

23
Q
A
24
Q

What are the causes of Horner’s syndrome? (anhydrosis, ptosis, miosis)

A

Aka - occulosympathetic paresis

  • 1st order (central): brainstem MS, SOL, stroke, Lateral Medullary Syndrome
  • 2nd order (pre-ganglionic): Pancoast tumour, cervical rib
  • 3rd order (post-ganglionic): carotid artery dissection/tumour
25
Q

Expressive aphasia

  • Describe
  • Where is the lesion?
A

Expressive aphasia:

Able to comprehend + read

Non-fluent and impaired repetition

The lesion in Broca’s area = left (dominant) inferior frontal

26
Q

Receptive aphasia

  • Describe
  • Where is the lesion?
A

Wernicke’s aphasia

  • Fluent but impaired comprehension.
  • Voluminous, meaningless speech
  • Lesion in Wernicke’s area:

= left, superior temporal + inferior parietal

Ex: “dorflur” for “shoe” (paraphrase)

Ex: “jet” for “airplane” or “knife” for “fork” (paraphrase)

Ex: “bap” for “map” (neologism)

Ex: “uhhh it’s white…it’s flat…you write on it…” (when referencing paper; talking around the target - called circumlocution)

27
Q

Which cerebral artery is occluded/compromised in Expressive vs. Receptive aphasia?

A

Broca’s (expressive) = anterior MCA

Wernicke’s (receptive) = posterior MCA

28
Q

Left Homonymous Hemianopia with macular sparing.

Where is the lesion?

A

Right Occipital Lobe, likely due to PCA occlusion. The macula is spared due to dual blood supply of macula by MCA.

29
Q

Left Homonymous Hemianopia - where is the lesion? (3)

A

Lesion would be contralateral

  1. R optic tract
  2. R optic radiation involving both parietal + temporal lobe (i.e. concomitant superior + inferior quadrantanopia) - rare, means massive infarct.
  3. R occipital lobe (usually macula is spared)
30
Q

Lateral medullary syndrome features?

A

4S’s

Ipsilateral face pain & temperature sensation (the sensory nucleus of 5th CN)

Contralateral pain & temperature affecting arm/legs (spinothalamic)

Ipsilateral Horner’s (ptosis, miosis, anhydrosis) - sympathetic

Ipsilateral Ataxia arms/legs (spinocerebellar)

31
Q

List 3 sensory pathways in the spinal cord

  • Their function (which sensation do they carry)
  • Deccusation point
A

Dorsal columns (medial lemniscus): crude (well-localised) touch, proprioception + vibration

Lateral Spinothalamic Tract: pain & temperature

Anterior spinothalamic tract: light-touch (poorly localised)

Dorsal column decussate at medulla

Spinothalamic: decussate at the level of spinal cord

32
Q

List 2 motor pathways in the spinal cord: where do they deccusate?

A
  • Corticospinal (motor / UMN)
    1. Lateral corticospinal (90% - arms/legs / fine movements): decussates just before the spinal cord (medulla oblongata – cervicomedullary junction)
    2. Anterior corticospinal (axial – trunk / neck muscles): decussate at the level of spinal cord

Short Cases (5 decks)

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