Common diseases_ from the notes

Question 1

Investigations for MS and what can be seen

Answer 1

• MRI of the brain and spinal cord -> multiple lesions on white matter (the most common locations: periventricular region, corpus callosum, brainsteam, cervical cord)
• LP -> oligoclonal IgG bands and possibly increased proteins

Question 2

Treatment for relapsing-remitting MS

Answer 2

• Relapse management: high dose steroids (methylprednisolone) for a short time -> this will speed up the recovery
• Disease-modifying therapies:
• Interferon - beta -> to reduce relapse frequency
• Natalizumab -> given for those with aggressive relapses
• neurosensory rehab, MDT etc

Question 3

What are the elements of Charcot’s neurological triad in MS

Answer 3

Charcot’s triad (MS):

• dysarthria
• nystagmus
• intention tremor

Question 4

What’s Lhermitte’s sign?

Answer 4

Lhermitte’s sign is in a patient with MS

When a pt bend their neck forward -> an ‘electric shock’ runs from their back and radiates to the limbs

Question 5

What pattern of clinical presentation would Brown - Sequard syndrome cause?

Answer 5

Brown Sequard syndrome

• lateral hemisection of spinal cord

Injury pattern/mechanism:

• ipsilateral weakness (motor) below the lesion
• ipsilateral loss of proprioception and vibration sensation
• contralateral loss of pain and temperature sensation

*this is because the pathway for pain/temperature sensation decussates at the level of the nerve root.

Question 6

Pattern and features of Bell’s palsy

Answer 6

Bell’s palsy

Pattern: acute, unilateral, idiopathic facial nerve paralysis

Features:

• LMN facial n. palsy -> forehead is affected
• post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis (discomfort, hypersensitivity to loud noises)

Question 7

Management and prognosis in Bell’s Palsy

Answer 7

Management

• prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell’s palsy.

* Adding in aciclovir gives no additional benefit

• eye care is important - prescription of artificial tears and eye lubricants should be considered

Prognosis

• if untreated around 15% of patients have permanent moderate to severe weakness

Question 8

The pattern of weakness affecting forehead in:

• UMN
• LMN

Answer 8

• UMN: forehead is spared (not affected)
• LMN: forehead is affected

Question 9

What happens in cerebellar tonsil herniation?

Answer 9

Cerebellar tonsillar herniation

• affects the medulla oblongata
• often a terminal event in an unconscious patient
• results in asystolic cardio-respiratory arrest

Question 10

What’s the diagnosis?

A combination of ipsilateral ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy with contralateral hemisensory loss

Answer 10

Lateral Medullary Syndrome

(ischaemia of the lateral part of the medulla)

*from the blockage of vertebral a. or posterior cerebellar a.

Question 11

Isolated hemisensory loss

What’s possible pathology?

Answer 11

Lacunar infract

Question 12

(3) features of common lacunar stroke presentation

Answer 12

Lacunar strokes can present with

• unilateral motor disturbance affecting the face, arm or leg or all 3
• complete one sided sensory loss
• ataxia hemiparesis

Question 13

Gower’s sign - what is this

Answer 13

• suggestive of muscular dystrophy
• cannot get up off the floor without the use of the arms

Question 14

What’s the diagnosis?

Ptosis + dilated pupil

Answer 14

3rd nerve motor palsy

Question 15

What’s the diagnosis?

Ptosis + constricted pupil

Answer 15

Horne’s syndrome

Question 16

Classes of meds used in migraine

A. Prophylaxis

B. Acute attacks

Answer 16

A. Prophylaxis - 5HT receptor antagonist

B. Acute attacks - 5HT receptor agonist

Question 17

1st line Rx in acute migraine attack

Answer 17

irst-line: combination therapy: oral triptan and an NSAID, or an oral triptan and paracetamol

*Triptan = 5 HT agonist

Question 18

1st line prophylaxis Rx for migraine

• criteria
• meds used

Answer 18

Criteria: at least 2 migraine attacks per month

Meds: topiramate or propranolol’

* Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives

Topiramate = anti-convulsant

Question 19

Features of a headache associated with migraine

Answer 19

Headache has at least two of the following characteristics:

• 1. unilateral location*
• 2. pulsating quality (i.e., varying with the heartbeat)
• 3. moderate or severe pain intensity
• 4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

During headache at least one of the following:

1. nausea and/or vomiting
2. photophobia and phonophobia

Question 20

What diagnosis should we suspect in:

unilateral hearing loss who presents with reduced facial sensation and balance problems

Answer 20

Acustic neuroma/ vestibular schwannoma

*1st line investigation: audiogram & gadolinium enhanced MRI scan

Question 21

What’s the likely diagnosis?

Parkinsonism + autonomic disturbance

(e.g. urinary incontinence, hypotension)

Answer 21

Multiple System Atrophy

(Shy-Drager syndrome - type of Multiple System Atrophy)

Features:

• parkinsonism
• autonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
• cerebellar signs

Question 22

Neurofibromatosis type 1 vs neurofibromatosis type 2

Answer 22

NF1 NF2

• Café-au-lait spots (>= 6, 15 mm in diameter)
• Axillary/groin freckles
• Peripheral neurofibromas
• Iris hamatomas (Lisch nodules)in > 90%
• Scoliosis
• Pheochromocytomas
• Bilateral vestibular schwannomas
• Multiple intracranial schwannomas, mengiomas and ependymomas

Question 23

What’s CHA2DS2VASC used for?

Answer 23

CHA2DS2VASC

• it is used for a risk assessment of stroke in a patient with atrial fibrillation

Question 24

What’s ROSIER assessment for?

Answer 24

ROSIER is an acronym for ‘Recognition Of Stroke In the Emergency Room’.

• to assess stroke symptoms in an acute setting.

Question 25

What’s ABCD2 used for?

Answer 25

• ABCD2 is used to assess a patient’s stroke risk after a TIA

Question 26

Features of motor neurone disease

Answer 26

There are a number of clues which point towards a diagnosis of motor neuron disease:

• fasciculations
• the absence of sensory signs/symptoms*
• the mixture of lower motor neuron and upper motor neuron signs
• wasting of the small hand muscles/tibialis anterior is common

Other features

• doesn’t affect external ocular muscles
• no cerebellar signs
• abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature

Question 27

Wernicke’s aphasia is due to the lesion to what part of the brain?

Answer 27

Left superior-temporal gyrus

Question 28

Broca’s aphasia is a result of a lesion to what part of the brain?

Answer 28

Left inferior frontal gyrus

Question 29

1st line management for trigeminal neuralgia

Answer 29

Carbamazepine

*if that does not work or atypical features (e.g. trigeminal neuralgia in a patient <50y old) -> refer to neurology

Question 30

Management of a patient who presents with suspected TIA (within 24 hours of symptoms onset)

Answer 30

• Aspirin 300mg immediately
• urgent specialist referral (within 24 hours)