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ICSM Year 6 > Medicine - Neurology > Flashcards

Medicine - Neurology Flashcards

1
Q

Recall some important initial investigations following a suspected TIA

A

BP
ECG
Carotid USS
Bloods to include cholesterol, lipids, glucose + clotting

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2
Q

What is the CHA2DS2VASc score used to estimate?

A

Risk of stroke in patients with atrial fibrillation

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3
Q

What scoring system predicts stroke risk following a TIA?

A

ABCD2

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4
Q

Recall the mainstay of immediate management for TIA, including some contraindications to this mainstay

A 
Aspirin 300mg 
Contraindicated if: 
- >7 days since signs and symptoms 
- Bleeding disorder/ on anti-coagulation 
- Already on regular low-dose aspirin
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5
Q

Recall some cases in which you would admit someone following a TIA to investigate them further

A 
>1 TIA ('crescendo' TIA) 
Severe carotid stenosis 
Suspected cardioembolic source 
Patient is on warfarin/DOAC
Patient has bleeding disorder
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6
Q

What should be the ongoing management for patients who have had a TIA? (1st and 2nd line)

A

1st line: 75mg clopidogrel OD + statin

2nd line: Aspirin + dypiridamole + statin

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7
Q

What is the indication for a carotid artery endarterectomy?

A

Stenosis >50% with <2w of signs/ symptoms

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8
Q

Define stroke

A

Rapid onset neurological deficit of a vascular origin that does not completely resolve within 24 hours

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9
Q

What % of strokes are ischaemic vs haemorrhagic?

A 
Ischaemic = 80% (thrombotic/ embolic) 
Haemorrhagic = 20% (intracerebral haeomorrhage, SAH)
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10
Q

What classification system is used for strokes, and how does it classify them?

A

Bamford classification

Based on initial presenting signs and symptoms

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11
Q

What are the 4 broad classifications of stroke under the Bamford classification?

A

Total anterior circulation stroke
Partial anterior circulation stroke
Posterior circulation stroke
Lacunar anterior circulation stroke

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12
Q

How does weakness compare in the legs vs arms in anterior vs middle cerebral artery infarcts?

A

Anterior cerebral artery: weakness in legs > arms

Middle cerebral artery: weakness in arms > legs

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13
Q

What are the 3 best forms of initial investigation in stroke?

A

Non-contrast CT
ECG
Carotid dopplers

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14
Q

Recall 2 scoring systems that can be used acutely in admission for stroke

A

NIHSS (max score 42)

ROSIER (professional version of FAST)

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15
Q

What is CT ASPECT?

A

Grading system used to assess early CT ischaemic changes following a stroke

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16
Q

What is the ‘penumbra’?

A

Area of hypoxic parenchyma following a stroke that is still salvageable

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17
Q

Describe the approach to imaging investigations in suspected subarachnoid haemorrhage

A

1st CT head

If this is negative –> LP to assess for xanthochromia (bilirubin in CSF)

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18
Q

Recall the general principles of management of subarachnoid haemorrhage

A

21 day course of nimodipine (CCB)
1st line: Coiling (IR procedure)
2nd line: Surgical clipping (requires craniotomy)

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19
Q

Recall the steps of managing an ischaemic stroke

A
  1. Exclude haemorrhagic stroke using CT
    Then:
    - If <4.5 hours –> thrombolysis (alteplase)
    ALSO do a thrombectomy IF proximal anterior circulation
  • If >4.5 hours –>

After 2 WEEKS:
1. 300mg aspirin PO OD + statin
If NO AF: add clopidogrel (aspirin 2nd line)
If AF: add Xa inhibitor (eg apixaban) (warfarin 2nd line)

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20
Q

Recall some aspects of management of stroke outside of immediate thrombolysis/ anti-coagulation

A

Control:

  • Fluid management (hypo/hypervolaemia can both worsen symptoms)
  • Glycaemic control (hyperglycaemia –> tissue acidosis, free radicals and increased BBB permeability)
  • BP control - ONLY use if BP is dangerously high as hypotension so dangerous - eg hypertensive emergency + hypertensive encephalopathy/ cardiac failure/ nephropathy/ eclampsia or aortic dissection
  • Cholesterol control (eg with statin)
  • Feeding assesment and management
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21
Q

What is the Barthel index and how is it used?

A

Index of disability post-stroke

10 tasks scored on a scale of independence from 0 to 10 to give a total score out of 100

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22
Q

What is the typical frequency of tremor in Parkinson’s?

A

4-6 Hz

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23
Q

Recall 3 signs of Parkinson’s disease that might be seen in the eyes

A

Nystagmus (in MSA)
Vertigal gaze palsy (in PSP)
Saccades slow

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24
Q

Recall some autonomic nervous system symptoms of Parkinson’s

A 
Postural hypotension (in MSA) 
Urgency/ frequency (in MSA) 
Constipation 
Hypersalivation 
Hyperhidrosis 
ED
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25
Q

What is the glabellar tap?

A

Confirmatory test of Parkinson’s disease

If you tap the patient’s forehead, the eyes blink

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26
Q

Recall some symptoms of sleep disturbance that may be seen in Parkinson’s

A 
Inability to turn 
Restless legs 
Early morning dystonia (drug wearing off) 
Nocturia 
OSA 
Insomnia is BIG
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27
Q

Recall the names of 4 Parkinson PLUS syndromes

A

MSA - multiple systems atrophy
PSP - progressive supranuclear palsy
CBD (corticobasilar degeneration)
DLB (dementia with lewy bodies)

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28
Q

Recall some symptoms of multiple systems atrophy

A

Autonomic dysfunction
Cerebellar dysfunction
Rigidity > tremor

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29
Q

Recall some symptoms of progressive supranuclear palsy

A

Vertigal gaze palsy
Postural insability that leads to falls
Speech disturbance

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30
Q

Recall some symptoms of corticobasilar degeneration

A

Unilateral parkinsonianism
Aphasia
Astereognosis (–> alien limb phenomenon)

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31
Q

Recall some symptoms of dementia with lewy bodies

A

Visual hallucinations

Fluctuating cognition

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32
Q

Recall some differences between Parkinsonism and Parkinson’s

A

Parkinsonism: symmetrical, rapid progression, poor response to levodopa

Parkinson’s: asymmetrical, progressive nature, good response to levodopa

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33
Q

Recall some causes of Parkinsonism

A

VITAMIN CD

Vascular (strokes) 
Idiopathic - nil
Trauma (eg dementia pugilistica) 
Autoimmune (encephalitis) 
Metabolic (eg neuroglycopaenic) 
Infective (eg Syphilis, HIV, CJD) 
Neoplasm - nil?

Congenital (eg Wilson’s)
Drugs (eg antipsychotics)

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34
Q

What is a DaTscan and what is it used for?

A

Dopamine Transporter Scan
Tracer binds to DA neurons to allow visualisation of substantia nigra
Used in Parkinson’s to exclude other causes of tremor eg BET

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35
Q

What are the 1st line medications used in Parkinson’s treatment?

A 
Levodopa 
MAO-B inhibitors (eg selegiline) 
DA agonists (eg ropinarole)
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36
Q

Recall some side effects of levodopa

A 
DOPAMINE 
Dyskinesia
On/off phenomena
Psychosis 
Arterial BP decrease
Mouth dryness
Insomnia
Nausea and vomiting
EDS
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37
Q

What is the drug of choice to treat nausea in Parkinson’s, and what nausea drug should be avoided in these patients?

A

Domperidone is best option

Metoclopramide should be avoided

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38
Q

What is the drug of choice to treat psychosis in Parkinson’s, and which antipsychotic should be avoided in these patients?

A

Best choice: quetiapine

Don’t use: haloperidol

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39
Q

What might COMT inhibitors be useful for in treating Parkinson’s?

A

Can be given as an adjunct to levodopa to increase compliance, but may increase side effects

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40
Q

In a tonic clonic seizure, how does the side the head turns to relate to the side of the seizure?

A

It’s the opposite side

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41
Q

For how long does a seizure have to last to be classed as status epilepticus?

A

> 5 mins

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42
Q

Recall the 4 steps of status epilepticus management

A
  1. Buccal midazolam/ IV lorazepam
  2. IV lorazepam
  3. IV phenytoin (or phenobarbital if already on phenytoin)
  4. Rapid sequence induction of anaesthesia using thiopental sodium
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43
Q

Recall 2 side effects of carbamazepine

A

Hyponatraemia

Rash

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44
Q

Recall 9 side effects of valproate

A

VALPROATE

Vomiting
Anorexia 
Liver toxicity 
Pancreatitis
Retention of weight 
Oedema
Alopecia
Tetarogenicity 
Enzyme inhibition
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45
Q

Which anti-epileptic drug can cause steven johnson syndrome?

A

Lamotrigene

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46
Q

What is the typical presentation of Alzheimer’s?

A 
The four 'A's
Amnesia 
Aphasia (Broca's) 
Agnosia (typically faces) 
Apraxia (typically dressing)
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47
Q

Recall 3 examples of anti-cholineesterases

A

Donepezil
Galantamine
Rivastigmine

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48
Q

What is the mechanism of action of memantine?

A

NMDA (glutamate) receptor partial agonist

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49
Q

What is the first line medical management of Alzheimer’s disease?

A

If mild-moderate: anticholinesterases

If moderate-severe: memantine

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50
Q

Who are you legally required to inform if you make a diagnosis of any type of dementia?

A

DVLA

Insurers

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51
Q

What is the most important thing to check before prescribing anticholineesterases?

A

ECG

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52
Q

Recall 4 drugs that are absolute contraindications for prescribing anticholineesterases

A

NSAID
Anticholinergics (prevent ACh from binding)
Beta blockers
Muscle relaxants

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53
Q

Recall 3 features of an ECG that are relative contraindications to prescribing anticholineesterases

A

AV block
Sick sinus syndrome
Bradycardia

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54
Q

Recall 2 drugs that can be used in the prophylaxis of migraines

A

Propranolol

Topiramate

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55
Q

What are the key signs and symptoms of cluster headache?

A

Intense pain around eye that may cause watering, lasting 15 mins to 2 hours

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56
Q

What is the acute management of cluster headache?

A

100% oxygen

SC triptan

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57
Q

What drug can be used as prophylaxis for cluster headaches?

A

Verapamil

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58
Q

Recall some signs and symptoms of temporal arteritis

A

Headache
Jaw claudication
Tender scalp

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59
Q

Define multiple sclerosis

A

An autoimmune demyelinating disorder of the CNS characterised by multiple plaques of separate in time and space

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60
Q

What are the 4 subtypes of MS?

A

Relapsing remitting
Primary progressive
Secondary progressive
Progressive relapsing

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61
Q

Recall some key signs and symptoms of MS

A

Tingling
Optic neuritis
Ataxia
Spastic paraparesis eg shoulder paralysis

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62
Q

Recall some symptoms of optic neuritis in MS

A 
CRAP 
Central scomata 
RAPD (relative afferent pupillary defect) 
Acuity decreased 
Pain on movement
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63
Q

In what ways is acuity affected by optic neuritis?

A

Decreased central and colour vision

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64
Q

What is RAPD?

A

Relative afferenr pupil defect

Pupils respond differently to light stimuli shone in one eye at a time

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65
Q

What are Lhermitte’s sign and Uhthoff’s sign?

A

Lhermitte’s sign: Neck flexion –> electric shocks in trunk and limbs

Uhthoff’s sign: temporary worsening of MS symptoms following an increase in temperature eg hot bath or exercise

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66
Q

What criteria are used for MS diagnosis?

A

Revised McDonald’s criteria

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67
Q

What sort of MRI is most useful in MS diagnosis?

A

Gadalonium-enhanced, T2 weighted

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68
Q

What would be seen on LP in MS?

A

IgG oliclonal bands

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69
Q

Recall 2 blood antibodies that might be seen in MS?

A

Anti-MBP (myelin basic protein)

NMO-IgG (neuromyelitis optica - only in Devic’s syndrome)

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70
Q

What is the main drug and dosage used to treat acute attacks of MS?

A

Methylprednisolone 1g IV/PO OD for 3 days

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71
Q

Recall some drugs that can be used in the management of chronic MS

A

DMARDs such as IFN-beta

Biologicals eg natalizumab and alemtuzumab (these are first line for RRMS)

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72
Q

Recall one drug that can be useful for fatigue in MS

A

Modafinil

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73
Q

Recall 2 drugs that can be used to manage in pain in MS

A

Amitriptyline

Gabapentin

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74
Q

What are the 1st and 2nd line options for medically managing spasticity in MS

A

1st line: baclofen + gabapentin

2nd line: dantrolene

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75
Q

What is the most useful drug to treat tremor in MS?

A

Clonazepam

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76
Q

Are sensory or motor signs at the onset of MS associated with a better prognosis?

A

Sensory signs at onset = better prognosis than motor signs at onset

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77
Q

What is the typical age of onset of myasthaenia gravis in women vs men?

A

Women: 20-30y
Men: 60-70y

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78
Q

Which autoimmune disorder is strongly associated with thymic hyperplasia?

A

Myasthaenia gravis

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79
Q

Recall 2 abnormalities on eye examination that could be seen in myasthaenia gravis

A

Diplopia

Ptosis

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80
Q

Recall some signs and symptoms of myasthaenia gravis

A 
Muscle fatiguability is the main one
Also: 
Extra-ocular muscle weakness
Proximal myopathy 
Dysphagia
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81
Q

Recall some drugs that can exacerbate myasthaenia gravis

A 
Beta-blockers
Lithium 
Phenytoin
Numerous antibiotics 
Penicillinamine
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82
Q

How is a myasthaenic crisis defined?

A

FVC <1L
Negative inspiratory force<20cmH2O
Need for ventilation

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83
Q

How should a myasthaenic crisis be managed?

A

Plasmapheresis, IV Ig, intubation

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84
Q

What is the most important investigation to do to investigate myasthaenia gravis?

A

Single fibre EMG

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85
Q

Recall 2 tests that can be used to assess fatiguability in myasthaenia gravis

A

Repetitive nerve stimulation

Serial pulmonary function testing

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86
Q

Recall 2 antibodies you might test for when investigating myasthaenia gravis

A

Anti-ACh-R

Anti-muscle-specific-receptor tyrosine kinase

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87
Q

Describe the tensilon test for myasthaenia

A

IV edrophonium bromide relives muscle weakness temporarily

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88
Q

What is the first line management for symptomatic myasthaenia?

A
  1. Long acting acetylcholine esterase inhibitors eg pyridostigmine, neostigmine
  2. Immunosuppression: azothioprine, cyclosporine, mycophenolate mofetil
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89
Q

What is the surgical option for treating myasthaenia gravis?

A

Thymectomy

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90
Q

What is Lambert Eaton Myasthaenic Syndrome and what causes it?

A

Myasthaenia associated with small cell lung cancer

Caused by antibody directed against pre-synaptic voltage gated calcium channels in the peripheral nervous system

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91
Q

How are the symptoms of Lambert Eaton Myasthaenic Syndrome different from Myasthaenia gravis?

A

Muscles get progressively stronger with use in LEMS, rather than fatiguing like in MG
Eye signs are much less common in LEMS than MG

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92
Q

Which cancers are associated with Lambert Eaton Myasthaenic Syndrome?

A

Small cell lung cancer (key one)
Breast cancer
Lung cancer

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93
Q

Where in the nervous system are the lesions that cause symptoms of amyotrophic lateral sclerosis?

A

Corticospinal tracts

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94
Q

Where in the nervous system are the lesions that cause symptoms of primary lateral sclerosis?

A

Motor cortex (loss of Betz cells)

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95
Q

Where in the nervous system are the lesions that cause symptoms of progressive muscular atrophy?

A

Anterior horn cells

96
Q

Where in the nervous system are the lesions that cause symptoms of progressive bulbar palsy?

A

Cranial nerves 9-12

97
Q

For each type of motor neuron disease, are the symptoms predominantly UMN or LMN?

A

ALS: mixed UMN/LN
PLS: UMN
PMA: LMN
PBP: bulbar

98
Q

Which type of motor neuron disease has the worse prognosis?

A

Progressive bulbar palsy

99
Q

Recall some differentials for a neurological presentation with mixed UMN/LMN signs?

A

MAST:
Motor neuron disease
Ataxia (Friederich’s)
SCDC (subacute combined degeneration of the cord)
Taboparesis (combined tabes dorsalis with general paresis)

100
Q

What are the diagnostic criteria for motor neuron disease called?

A

Revised El Escorial criteria

101
Q

Recall 3 useful investigations in the investigation of motor neuron disease

A

MRI brain +/- spinal cord - to exclude structural causes
EMG - to demonstrate faciculations
LP - to exclude inflammatory causes

102
Q

What drug can be used to delay need for ventilation in patients with motor neuron disease?

A

Riluzole

103
Q

What drug can be used to manage drooling in motor neuron disease?

A

Amitriptyline

104
Q

How will muscles appear on inspection in an UMN pathology?

A

Atrophied with no fasciculations

105
Q

How can you use gait to differentiate between unilateral and bilateral UMN lesions?

A

UL lesion –> circumducting gait

BL lesion –> scissoring gait

106
Q

What is a positive Babinski’s sign and what does it indicate?

A 
Extensor plantars (upward movement of great toe) 
UMN pathology
107
Q

What is the Hoffman sign and what does it test for?

A

Hoffman sign = involuntary flexion movement of the thumb and or index finger when the examiner flicks the fingernail of the middle finger down
Indicative of UMN pathology

108
Q

Recall the direction of tongue and uvula deviation in UMN pathology

A

Tongue goes towards side of lesion

Uvula goes to opposite side

109
Q

What is the difference between the causes of spasticity vs rigidity?

A 
Spasticity = pyramidal 
Rigidity = extra-pyramidal
110
Q

What are the pyramidal tracts?

A

Corticospinal tract and corticobulbar tracts

111
Q

What is subacute combined degeneration of the spinal cord?

A

Progressive degenration of the spinal cord due to B12 deficiency (can be caused by NO inhalation)

112
Q

Which antibody is associated with guillain barre syndrome?

A

Anti-ganglioside (GQ1b)

113
Q

Recall 2 autoimmune causes of proximal myopathy

A

Myasthaenia gravis

Polymyositis

114
Q

Recall 3 drugs that can cause proximal myopathy

A

Ethanol
Statins
Steroids

115
Q

Recall a congenital cause of proximal myopathy

A

Muscular dystrophy

116
Q

Recall some endocrine causes of proximal myopathy

A 
Acromegaly 
Cushing's 
Diabetic amyotrophy
Hyperthyroid 
Osteodystrophy
117
Q

What is the eponym by which hereditary motor sensory neuropathy is more commonly known?

A

Charcot Marie Tooth disease

118
Q

What is the inheritance pattern of charcot marie tooth?

A

Autosomal dominant

119
Q

What might be seen on inspection in Charcot Marie Tooth?

A

Pes cavus (high arch of foot that doesn’t flatten when weight-bearing)

Distal muscle wasting

Thickened nerves (especially common peroneal)

120
Q

Describe the abnormalities of gait that may be seen in more severe charcot marie tooth disease?

A

Foot drop

High stepping gait

121
Q

How can nerve conduction studies differentiate between charcot marie tooth types 1 and 2, and why is there this difference?

A

Type 1 - decreased conduction velocity
Type 2 - decreased conduction amplitude
Type 1 is caused by demyelination
Type 2 is caused by axonal degeneration

122
Q

Which gene mutations can cause charcot marie tooth disease?

A

HSMN1

PMP22 (peripheral myelin protein 22)

123
Q

What are the components of DANISH?

A 
Dysatrhria/ dysdiadochokinesia/ dysmetria 
Ataxia 
Nystagmus 
Intention tremor 
Speech (scanning/ staccato) 
Hypotonia
124
Q

Systematically recall some causes of cerebellar syndrome

A 
Vascular: vertebrobasilar stroke 
Infection: encephalitis/ abscess
Trauma: raised ICP
Autoimmune: multiple sclerosis/ paraneoplastic cerebellar degeneration
Metabolic: ethanol/ poisons (phenytoin) 
Iatrogenic: nil
Neoplastic: Posterior fossa tumour
Congenital: Spinocerebellar ataxia 
Degenerative: nil
Endocrine: nil
Functional: nil
125
Q

How does nystagmus differ depending on whether it is caused by a cerebellar or vestibular lesion?

A

Fast phase:

  • Cerebellar = towards lesion
  • Vestibular = away from lesion

Maximal looking:

  • Cerebellar = towards lesion
  • Vestibular = away from lesion
126
Q

What are the 3 regions of the cerebellum, and what are their functions?

A

Spinocerebellum - movement and posture
Neocerebellum - motor planning
Vestibulocerebellum - balance and vision

127
Q

Recall the signs and symptoms specific to lesions in each portion of the cerebellum

A

Spinocerebellum: truncal ataxia
Neocerebellum: dysmetria, intention tremor, dysdiadochokinesia
Vestibulocerebellum: diplopia, nystagmus, vertigo

128
Q

What is Wallenberg’s syndrome also known as?

A

Lateral medullary syndrome

129
Q

What is the most common cause of Wallenberg’s syndrome?

A

Occlusion of the posterior inferior cerebellar artery

130
Q

What are the signs and symptoms of Wallenberg’s syndrome?

A

My PANDAS:

Miosis (Horner’s)
nYstagmus

Ptosis (Horner's) 
Anhidrosis (Horner's) 
Nystagmus 
Dysphagia (ipsilateral) 
Ataxia 
Sensory loss of limb (contralateral)
131
Q

Where is the lesion in a bitemporal hemianopia?

A

Optic chiasm

132
Q

What is a Marcus Gunn pupil?

A

Relative afferent pupil defect (swingint torch test)

133
Q

Recall 3 causes of Marcus Gunn pupil?

A

MS
Glaucoma
Retinal disease

134
Q

What is Weber’s syndrome?

A

Ipsilateral 3rd nerve palsy (‘down and out’ pupil) with contralateral hemiplegia - caused by midbrain strokes

135
Q

For how long is driving not permitted following a first episode of unprovoked seizure?

A

6 months if normal EEG/ imaging

Otherwise 12 months

136
Q

For how long is driving not permitted following a seizure, in those with established epilepsy?

A

1 year

If 5 years seizure-free, license usually kept until 70 y/o

137
Q

For how long is driving not permitted following a nocturnal seizure?

A

Can drive with nocturnal seizures as long as no daytime symptoms in last 3 years

138
Q

For how long is driving not permitted after withdrawal from epilepsy medication?

A

Do not drive during withdrawal or within 6 months of last dose

139
Q

For how long is driving not permitted following a stroke or TIA?

A

1 month if no long-lasting neurological deficit

140
Q

What is the biggest risk factor for clostridium botulinum infection?

A

IVDU

141
Q

What are the symptoms of clostridium botulinum infection?

A

Descending paralysis, diplopia, bulbar palsy

142
Q

What is the cause of autonomic dysreflexia?

A

Usually spinal injuries above T6 - due to lack of splanchnic outflow from T6-12

143
Q

What is autonomic dysreflexia

A

Sudden onset of severe hypertension

144
Q

What are the key symptoms of normal pressure hydrocephalus?

A

Wet, wacky, wobbly
Incontinence
Dementia
Falls

145
Q

What are some possible causes of syringomyelia?

A

Chiari malformations
Trauma
Tumours
Idiopathic

146
Q

What are the symptoms of syringomyelia?

A

Main symptoms are:
Loss of sensation to pain and temperature, especially in hands
Progressive limb weakness and stiffness

147
Q

What is the best investigation to diagnose syringomyelia?

A

Contrast MRI of full spine and brain

148
Q

What is the management of syringomyelia?

A

Shunting

149
Q

What is the main differential in suspected cluster headache?

A

Paroxysmal hemicrania

150
Q

What medication can completely resolve the symptoms of paroxysmal hemicrania?

A

Indomethacin

151
Q

What are the components of Horner’s sydrome?

A

Ptosis
Miosis
Anhidrosis
Enopthalmos

152
Q

What sign might point towards congenital Horner’s syndrome, rather than another cause?

A

Heterochromia

153
Q

What does the presence of anhidrosis in a case of Horner’s syndrome indicate?

A

Central lesions = anhidrosis of the face and trunk
Pre-ganglionic lesions = anhidrosis of the face
Post-ganglionic lesions = no anhidrosis

154
Q

Recall some central causes of Horner’s syndrome

A

Stroke
Syringomyelia
Sclerosis (multiple)
Wallenburg’s lateral medullary syndrome

155
Q

Recall some pre-ganglionic causes of Horner’s syndrome

A

Tumour (pancoast)
Thyroidectomy
Cervical rib

156
Q

Recall some post-ganglionic causes of Horner’s syndrome

A

Carotid artery dissection (most likely to be cause if painful)
Cavernous sinus thrombosis
Cluster headache

157
Q

What sort of tuning fork should you use for Rinne’s and Weber’s?

A

512Hz

158
Q

Describe broadly how Rinne’s and Weber’s tests are performed?

A

Rinne’s: hold tuning fork to mastoid process until pt can’t hear anymore then bring in front of ear to see if they cn hear it again. Tests air vs bone conduction.

Weber’s: Place tuning fork in midline of forehead and see which ear they hear it louder in

159
Q

If a patient hears the tuning fork better on the mastoid process than in front of the ear during Rinne’s, and Weber’s lateralises to the same ear, what does it mean?

A

Conductive hearing loss

160
Q

What is the pathology if Rinne’s demonstrates bone conduction > air conduction, and Weber’s also lateralises left?

A

Conductive loss in left ear

161
Q

What is the most common cause of degenerative cervical myelopathy?

A

Cervical spondylosis

162
Q

Recall some signs and symptoms of degenerative cervical myelopathy

A

Pain in the neck and limbs
Loss of ANS fx (incontinence, impotence)
Hoffman’s positive
Loss of digital dexterity (fumbling with hands)
Loss of sensory fx and numbness

163
Q

What is the most useful investigation in suspected degenerative cervical myelopathy?

A

Cervical spine MRI

164
Q

What is the definitive management for degenerative cervical myelopathy?

A

Neuro/orthopaedic surgery will do urgent decompression surgery (<6 months)

165
Q

What structure is damaged in conduction aphasia?

A

Arcuate fasciculus - the connection between Wernicke’s and Broca’s area

166
Q

Describe Wernicke’s and Broca’s aphasia

A

Broca’s = expressive aphasia - can say words but makes lots of mistakes they are unaware of. Comprehension and repetition is impaired

Wernicke’s = receptive aphasia - speech is non-fluent, halting and laboured - comprehension is normal.

167
Q

What sort of cerebellar lesion would cause someone to have a broad-based, lumbering, ataxic gait?

A

Midline cerebellar lesion

168
Q

What sort of cerebellar lesion would cause someone to have a veering, ataxic gait?

A

Unilateral cerebellar lesion, ipsilateral to veering

169
Q

If Romberg’s test is positive, what does this indicate?

A

There is either a loss of vestibular function (eg Meniere’s) or proprioceptive function (eg peripheral neuropathy)

170
Q

Where is the lesion if a patient has saccadic dysmetria?

A

Ipsilateral cerebellar

171
Q

How can you assess for saccadic dysmetria?

A

Hand at peripheral vision and ask patient to look at finger then your nose - assess for overshoots (hypermetric saccades) and undershoots (hypometric saccades)

172
Q

How do you assess for ataxic dysarthria?

A

Ask the patient to say ‘British constitution’

173
Q

Where is the cerebellar lesion if a patient has ataxic dysarthria?

A

Left cerebellar hemisphere

174
Q

Where is the lesion if a patient has pronator drift?

A

Ipsilateral either cerebellar or dorsal column

175
Q

When assessing cerebellar function, what would you assess in the upper limbs?

A

Tone
Pronator drift
Rebound phenomenon
Coordination (dysdiadochokinesia, dysmetria)

176
Q

In which part of the brain are changes most likely to be found in early Alzheimer’s
disease?

A

Temporal lobe

177
Q

Which genetic disorder is associated with subarachnoid haemorrhage?

A

PCKD

178
Q

What is the main way to differentiate between Bell’s palsy and Ramsay Hunt syndrome clinically?

A

Ramsay Hunt associated with rash in ear as caused by zoster, whereas Bell’s not associated with rash

179
Q

What is the most common cause of Bell’s palsy

A

HSV infection causing facial nerve palsy

180
Q

Recall 3 things that are done to manage Bell’s palsy

A
  1. Encourage eye closure by hand or using tape at night
  2. Oral antiviral
  3. Short course oral prednisolone
181
Q

What sort of seizure does the following describe?

“Features of aura (smell and fear) and posturing with automatisms without complete loss of consciousness (partial loss of awareness- as unable to respond)”

A

Complex partial seizures

182
Q

Which lobe is most likely to be involved in complex partial seizures?

A

Temporal

183
Q

How does raised ICP affect vision?

A

Enlarged blind spots and constricted fields

184
Q

What are the 2 medications used as first line for treating essential tremor?

A

Primidone

Propranolol

185
Q

What is the most likely cause of a painful 3rd nerve palsy?

A

Posterior communicating artery aneurysm

186
Q

Recall a cause of ptosis for large/normal/small pupil?

A

Large: 3rd nerve palsy
Normal: Myasthaenia gravis
Small: horner’s

187
Q

If a pt has lost their vision on the right hand side in both eyes, where is ths stroke?

A

Left occipital lobe

188
Q

If a patient has left-sided dysdiadochokinesia and left-sided nystagmus, where is the lesion?

A

Left cerebellum - cerebellar fibres do not dessucate

189
Q

If there is a sensory level at the umbilicus, where is the lesion?

A

T10

190
Q

If someone has a seizure in which they have clonic movements that move proximally, which lobe is likely to be affected?

A

Frontal lobe

191
Q

In what patients are triptans contra-indicated and why?

A

Patients with coronary artery disease

Triptans have the potential to cause coronary vasospasm

192
Q

If a patient presents to a GP with a suspected TIA in the past few days, what action should the GP take?

A

If symptoms within past 7 days, give 300mg aspirin stat and refer for specialist review within 24 hours

193
Q

In which patient group may it be appropriate to stop TCAs eg amitriptyline?

A

Elderly patients with dementia - TCAs can impair cognitive function

194
Q

What imaging modality is most appropriate for confiming a suspected TIA?

A

MRI with diffusion weighting

195
Q

What causes a ‘down and out’ pupil?

A

Third nerve palsy

196
Q

How do you know where the lesion is in a homonymous quadrantopia?

A
  • Lesion is contralateral to side where vision loss is
  • Remember rule is ‘PITS’ - parietal inferior, temporal superior
    eg left inferior homonymous quandrantopia is right parietal lobe
197
Q

What is the best management for extradural haematoma?

A

Parietotemporal craniotomy

198
Q

What is the first line treatment for trigeminal neuralgia?

A

Carbamazapine 100mg bd

199
Q

What are the 2 most common triggers for autonomic dysreflexia?

A

Urinary retention

Faecal impaction

200
Q

In trauma, how can you check if a fluid running from the nose is csf or mucous?

A

Check glucose - present in csf but not mucous

Can also do beta-2-transferrin (more niche, less bedside)

201
Q

What type of seizure is carbamazapine ineffective in?

A

Absence seizures

202
Q

What is the key deficit in conduction aphasia?

A

Difficulty repeating phrases

203
Q

Which nerve roots are involved in klumke’s vs erb’s palsy?

A 
Klumpke's = C8-T1
Erb's = C56
204
Q

Which nerve is most likely to be affected by a suprachondylar humeral fracture?

A

Median

205
Q

Which part of the spinal cord is affected byb syringiomyelia?

A

Spinothalamic tracts

206
Q

Which class of abx increases the risk of idiopathic intracranial hypertension?

A

Tetracyclines

207
Q

Where is the lesion in Wernicke’s aphasia?

A

Left superior temporal gyrus

208
Q

Which antiepileptic can cause weight gain?

A

Sodium valporate

209
Q

How long can people not drive for following a first presentation of seizure?

A

6 months providing no diagnosis of epilepsy is made and EEG and MRI are normal

210
Q

How does an isolated L5 lesion present?

A

Weakened dorsiflexion, inversion and eversion of the foot

211
Q

What is the most common neurological manifestation of sarcoidosis?

A

Facial nerve palsy

212
Q

Which nerve is most susceptible to damage following fracture of the shaft of the humerus?

A

Radial

213
Q

Which nerve is most susceptible to damage following fracture of the surgical neck of the humerus?

A

Axillary nerve

214
Q

What is thoracic outlet syndrome?

A

A disorder involving compression of brachial plexus, subclavian artery or vein at the site of the thoracic outlet - usually following trauma

215
Q

What are the key features of a temporal lobe seizure?

A

Lip smacking and post-ictal dysphasia

216
Q

How can you differentiate a cluster headache from a migraine?

A
  • Typically shorter in duration than a migraine
  • Will be more intense, “worst pain they’ve ever had” and usually at the same time each day
  • May be more irritable and agitated, whereas migraines often cause people to need to be still in the dark etc.
217
Q

What is a cause of a painful third nerve palsy?

A

PCom (posterior circulation) aneurysm

218
Q

What is another cause of a thunderclap’ headache aside from a SAH?

A

RCVS (reversible cerebral vasoconstriction syndrome)

219
Q

What can cause RCVS?

A
  • Medications (e.g. SSRIs)
  • Post-exertion (exercise, sex)
220
Q

How would a CVST present?

A

Can present like a stroke due to to a blockage of draining veins, a resultant backpressure in the brain and consequent secondary haemorrhage

221
Q

How is a CVST diagnosed?

A

CT or MR venogram

222
Q

How is. CVST treated?

A
  • SC or IV heparin
  • Used even if there is a haemorrhage present as it is a low-pressure venous bleed
  • Thrombectomy can be used in severe cases
223
Q

What is PRES?

A

Posterior reversible encephalopathy syndrome

224
Q

How is PRES treated?

A

IV magnesium

225
Q

How does PRES present?

A

Can cause drowsiness, seizures and coma

226
Q

What is meant by stupor?

A

Acute confusional state where an individual is only rousable to pain

227
Q

Who are CVSTs typically seen in?

A
  • Younger individuals
  • Females
  • On OCP
  • After long-haul flights
228
Q

What are some causes of anosmia?

A
  • Parkinson’s disease - can be the first sign
  • Meningioma - CN1 runs close to the meninges
  • Post-covid anosmia
229
Q

How can you tell between a lens error or a vision error?

A

Using the pinhole test - if vision improves, more likely to be a lens error

230
Q

Where is the lesion in a bitemporal hemianopia and what are some examples?

A

Optic chiasm

  • Craniopharyngioma
  • Pituitary tumour
  • Meningioma
231
Q

Where is the lesion typically in patients with a central scotoma?

A

After the optic chiasm

232
Q

Where is the lesion in a homonymous hemianopia?

A

Behind optic chiasm on contralateral side

233
Q

What are the symptoms of a third nerve palsy?

A
  • Down and out eye
  • Ptosis
  • Pupil constriction
234
Q

Why is the pupil constricted in a 3rd nerve palsy?

A

Due to compression of the parasympathetic nerve fibres in the iris which are affected more than the sympathetic nerve fibres here

235
Q

What is Horner’s syndrome?

A

Disruption of the sympathetic chain causing miosis (pupil constriction), anhydrosis and ptosis

236
Q

What are some causes of ptosis?

A
  • Myasthenia gravis
  • Horner’s syndrome
  • 3rd nerve palsy
237
Q

How can you tell whether facial weakness is due to a UM or LM neuron lesion?

A

UM facial weakness will be forehead-sparing due to dual innervation (left and right hemisphere) of the forehead

ICSM Year 6 (21 decks)

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