MLA Neurology Flashcards
1
Q
Which dermatome is associated with a regimental badge distribution?
A
C5
Anterior shoulder dislocation can stretch and damage the axillary nerve which has the nerve root of C5. This supplies the sensation of the skin covering the inferior region of the deltoid muscle (regimental badge area), which is innervated by the superior lateral cutaneous nerve branch of the axillary nerve.
2
Q
Which anomaly is commonly found in patients with neurogenic thoracic outlet syndrome?
A
Cervical rib
3
Q
How long does a migraine without aura typically last for?
A
4-72 hours
4
Q
What are the common visual auras in a migraine?
A
scotoma or fortification spectra
5
Q
What is an episodic migraine x days/month?
A
<15 days/month
6
Q
What is the minimum number of migraine attacks required under the ICHD-3 criteria to diagnose migraine?
A
At least 5 attacks
7
Q
What are the headache characteristics associated with migraine?
A
- Unilateral location (hemicranial pain)
- Pulsating quality
- Moderate or severe intensity
- Aggravation by or causing avoidance of routine physical activity
8
Q
What is the first line investigation indicated for a patient with a migraine?
A
A headache diary
9
Q
What is the first line of management for migraines (symptomatic)?
A
Simple analgesia e.g., ibuprofen, aspirin or paracetamol
10
Q
What is the first line acute symptomatic medical (post analgesia) for migraines?
A
Oral triptans
11
Q
When should oral triptans be initiated during migraines?
A
At the start of the headache
12
Q
Which anti-emetic is recommended for migraines?
A
metoclopramide 10 mg or prochlorperazine 10 mg
13
Q
What are the serious adverse effects associated with metoclopramide?
A
Extrapyramidal symptoms
14
Q
What are the three prophylactic medications for migraine?
A
- Propranolol (80 – 160 mg daily, in divided doses).
- Topiramate (50 – 100 mg daily, in divided doses); contraindicated in pregnancy.
- Amitriptyline (25 – 75 mg at night).
15
Q
What is the first line migraine prophylaxis in patients with no contraindications?
A
propranolol or topiramate
16
Q
Which migraine prophylaxis is recommended as first in women?
A
propranolol
17
Q
Which migraine prophylaxis is contraindicated in women due to teratogenicity?
A
Topiramate
18
Q
What is the first line triptan indicated for patients with menstrual-related migraine?
A
frovatriptan (2.5 mg BDS) or zolmitriptan (2.5 mg BDS/TDS).
19
Q
Which cerebral structure is postulated to be involved in cluster headache pathogenesis?
A
Hypothalamus
20
Q
Which gender is most affected by cluster headache?
A
Male (5:1)
21
Q
What is the typical duration of cluster headaches?
A
15 minutes to 3 hours
22
Q
What is the characteristic location of cluster headaches?
A
unilateral orbital, supraorbital and/or temporal pain
23
Q
What adjunctive symptoms associated with cluster headaches?
A
- Autonomic symptoms:
- Conjunctival injection or lacrimation
- Nasal congestion or rhinorrhoea
- Eyelid oedema or forehead/facial swelling
- Facial flushing
- Sensation of fullness in the ear
- Miosis/ptosis (associated w/Horner Syndrome)
24
Q
Horner syndrome is associated with which type of headache?
A
Cluster headache
25
Patients pacing or rocking i n place is associated with which type of headache?
Cluster headache
26
In patients with suspected cluster headache, what is the next line of management?
Refer to a neurologist specialist for specialist assessment and confirmation of diagnosis
27
What is the first line management for acute attacks of cluster headache?
Sumatriptan subcutaneous injection – 6 mg for one dose, followed by 6 mg >1 hour if a recurrent headache – maximum 12 mg/day.
- Intranasal spray (aged 18-65 years) – 10-20 mg initial dose; followed by 10-20 mg >2 hours – maximum 40 mg/day.
AND
Short-burst oxygen therapy (high flow oxygen 100%)
28
What is the prophylaxis for cluster headaches?
Verapamil
29
What investigation is indicated in patients on Verapamil?
ECG every 6 months
30
What is the duration of tension-type headache?
30 minutes to 7 days
31
What are the characteristic features and criteria for a diagnosis of tension type headache?
* Bilateral localisation
* Pressing or tightening, non-pulsatile quality is often described as a sensation akin to a tight band. Pain may originate from or radiate into the neck, and there is frequent pericranial tenderness on manual palpation.
* Mild to moderate intensity
* Not exacerbated by, nor does it lead to avoidance of, routine physical activity, such as walking or climbing stairs.
32
What is the mainstay of management for tension type headaches?
Patient reassurance with self-guided resources
Advise on the risk of medication overuse headache
33
What is the recommended investigation in patients with tension type headaches?
Headache diary for a minimum of 8 weeks
34
What is the management of choice for chronic tension-type headaches?
Acupuncture
35
What are the characteristic 3 features (Oxford Classification System) for a total anterior circulation stroke?
1. Unilateral weakness or sensory loss of the face, arm and leg.
Sensory: Paraesthesia or numbness
2. Homonymous hemianopia
Gaze paresis – horizontal and unidirectional.
Diplopia
Photophobia
3. Higher cerebral dysfunction (e.g., dysphasia, visuospatial loss)
Ataxia
Dysphasia
Dysarthria
36
DANISH symptoms?
Dysdiadochokinesis, ataxia, nystagmus, intention tremor, slurred speech, hypotonia/heel-shin test positive.
37
What type of stroke is associated with pure motor deficit?
Lacunar stroke
38
Lacunar strokes are associated with which structure?
Basal ganglia
Internal capsule
39
Duration of TIA?
<24 hours
40
What visual defect is typically associated with TIA?
Amaurosis fugax
41
Recurrent TIA suggests what underlying pathology?
Carotid artery stenosis - perform duplex carotid US
42
Which artery is most commonly affected by stroke?
Middle cerebral artery
43
What are the characteristic features of an anterior cerebral artery stroke?
Contralateral leg paresis, sensory loss, cognitive deficits (e.g., apathy, confusion, and poor judgement).
44
What are the characteristic features of MCA stroke?
Contralateral weakness and sensory loss of face and arm.
* Cortical sensory loss
* Contralateral homonymous hemianopia or quadrantanopia
* Left hemisphere (Dominant) – Aphasia.
* Right-hemisphere (Non-dominant) – Neglect + inattention.
* Eye deviation – Towards the side of the lesion and away from the weak side.
45
Which cranial nerves are involved in a posterior cerebral artery stroke (MIDBRAIN)?
CN III and IV palsy
46
An urgent carotid endarterectomy is indicated in symptomatic carotid stenosis >%?
50%
47
What is the first line investigation required for all patients with suspected stroke?
Non-contrast CT
48
What is the first line management for patients with ischaemic stroke?
300 mg aspirin
49
What is the first line management for ischaemic stroke <4.5 hours since symptom onset?
Thrombolysis (alteplase) and thrombectomy
50
What is the first line management for ischaemic stroke between 4.5 and 6 hours?
Thrombectomy
51
Blood pressure should be controlled to below what, for thrombolysis?
<185/110 mmHg
52
What investigation is used to assess salvageable brain tissue post-stroke?
Diffusion-weighted MRI/CT perfusion scan
53
What criteria is used to predict stroke?
NIHSS
54
What are the absolute contraindications for thrombolysis?
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
55
What scale is used to assess for pre-stroke functional status?
Rankin scale
56
A thrombectomy is indicated in which National Institutes of Health Stroke Scale (NIHSS) score?
>5
57
What is the first line anti-platelet therapy of choice post-stroke?
Clopidogrel 75 mg
58
Is clopidogrel is contraindicated, what is the preferred stroke prophylaxis?
Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily
59
If total cholesterol is >3.5 in stroke patents, what should be prescribed?
* 20-80 mg atorvastatin (reduce non-HDL cholesterol by >40%)
60
What is the stroke prophylaxis indicated in patients post-stroke with AF?
Interim 300 mg aspirin for 14 days, followed by adjusted-dose warfarin or direct factor XA inhibitor
61
What is the DVLA advice for post-stroke?
Do not drive for 1 month - no need to notify the DVLA
62
What is the DVLA advice for recurrent TIAs?
Notify the DVLA, cease driving for 3 months
63
Which artery is implicated in lateral medullary syndrome?
Posterior inferior cerebellar artery
64
Ipsilateral ataxia, nystagmus, and dysphagia with contralateral hemisensory loss is suggestive of what diagnosis?
Lateral medullary syndrome
65
Which type of visual field defect is associated with posterior cerebral artery stroke?
Macular sparing homonymous hemianopia.
66
Which index is used to measure disability in patients post-stroke?
Barthel index
67
What are the causes of a CN3 palsy?
* Vascular ischaemia
- Diabetes mellitus, and hypertension.
* Trauma
* Intracranial neoplasm
* Haemorrhage
* Congenital
68
Which aneurysm is associated with a surgical third nerve palsy?
Posterior communicating artery aneurysm
69
What is the presentation of a surgical third cranial nerve palsy?
Dilated down and out pupil
70
Why does a posterior community artery aneurysm cause a surgical third cranial nerve palsy?
Compression of the outer parasympathetic fibres
71
What is the main cause of a pupil-sparing third nerve palsy?
diabetes mellitus or hypertension microangiography – affect the vaso vasorum
72
A down and out pupil is associated with what cranial nerve palsy?
Third cranial nerve (oculomotor)
73
Which two extra-ocular muscles are spared by CN3 palsy?
Lateral rectus (LR6)
Superior Oblique (SO4)
74
What investigation is indicated in patients with a surgical CN3 palsy?
CT angiography for suspected aneurysm
75
Which cranial nerve innervates the superior oblique?
Trochlear nerve (4)
76
Which cranial nerve palsy is associated with abnormal head position, vertical diplopia (noticed when reading a book)?
Fourth cranial nerve palsy
77
An up and rotated out pupil is associated with what CN palsy?
CN 4
78
The abducens nerve innervated which extra-ocular muscle?
Lateral rectus (responsible for ipsilateral eye abduction)
79
Impaired adduction of the eye and horizontal nystagmus in the contralateral eye suggests what?
Internuclear Ophthalmoplegia
80
Where is the lesion in Internuclear Ophthalmoplegia?
medial longitudinal fasciculus
81
ALS affects which type of cells and tracts?
Anterior horn cells and corticospinal tracts
82
Which mutations are associated with ALS?
SOD2
83
What is the most common type of MND?
* Amyotrophic lateral sclerosis
84
* Amyotrophic lateral sclerosis presents with what?
- Constellation of LMN (in arms – flaccid paralysis) and UMN signs (in legs – spastic paralysis).
85
Which type of MDN is associated with the worst prognosis (due to loss of brainstem nuclei?
* Progressive bulbar palsy:
- Palsy of the tongue, muscles of mastication, dysphagia, dysphasia; due to loss of function of brainstem motor nuclei.
- Worst prognosis.
86
Which type of MND is associated with UMN signs only?
* Primary lateral sclerosis
87
Which type of MND is associated with lower motor neurone signs only?
* Progressive muscular atrophy:
- LMN signs only; affects distal muscles before proximal (best prognosis).
88
List LMN signs:
* Weakness
* Hypotonia
* Muscle atrophy
* Fasciculations
* Hyporeflexia
* Loss of deep tendon reflexes
89
List UMN signs:
* Spasticity
* Hyperreflexia
* Clonus
* Babinski sign
90
What is the first line disease modifying drug indicated for management of MND?
Riluzole
91
Which drug is indicated for the management of muscle cramps in MND?
Quinine
92
What is the first line medical management for MND spasticity?
Baclofen
93
What is the mechanism of action of baclofen?
GABA-B receptor agonist
94
In patients with respiratory impairment what is the first line management (MND)?
Non-invasive respiratory ventilation e.g., CPAP
95
What is the preferred first line management for patients with MND presenting with dysphagia?
percutaneous gastrostomy tube in at-risk patients
96
Which type of focal seizures are associated with deja vu, rising epigastric sensation and automatisms e.g., plucking, fidgeting?
Temporal lobe
97
What are the findings associated with temporal lobe focal seizures?
* Aura:
- Rising epigastric sensation
- Psychic or experiential phenomena e.g., déjà vu, jamais vu
- Hallucinations (auditory/gustatory/olfactory) – less common.
* Automatisms (~60%): Repetitive, stereotyped movements e.g., picking, fidgeting, fumbling, chewing and lip-smacking.
* Post-ictal confusion
- EEG findings: Epileptiform sharp waves over the temporal region.
98
Which type of focal seizure is associated with a Jacksonian march?
Frontal lobe focal seizure
99
What are the findings associated with frontal lobe focal seizures?
Frontal Lobe (motor)
* Head/leg movements, posturing (fencing), post-ictal weakness, Jacksonian march.
* Bicycling automatisms e.g., pelvic thrusting and sexual automatisms
* Vocalisations
* The figure of four (localising contralateral to the extended arm)
100
What is the definition of epilepsy?
at least two unprovoked seizures occurring >24 hours apart
101
What is the most common type of generalised seizures?
Tonic-clonic
102
What neurocutaneous syndromes are associated with epilepsy?
Neurofibromatosis, tuberous sclerosis, and Sturge–Weber syndrome
103
Which type of seizure is associated with abrupt muscle contractions?
* Myoclonic seizures
104
Which type of seizure is associated with a blank facial expression?
Absence seizure
105
Which type of seizure is associated with a sudden loss of muscle control?
Atonic seizure
106
When should an EEG be performed post-seizure?
Within 72 hours
107
Following a first episode seizure, what is the next most appropriate management step?
Urgent referral (within 2 weeks) for an assessment after a first suspected seizure (first fit clinic).
108
What is the first line drug for tonic-clonic seizures in males?
- Sodium valproate
109
What is the first line of monotherapy for tonic-clonic seizures in women and girls with childbearing potential?
- Lamotrigine or levetiracetam
110
What is the first line monotherapy for focal seizures?
Lamotrigine, levetiracetam
111
What is the preferred drug of choice in absence seizures?
Ethosuximide
112
Which anti-epileptic drug is not recommended in patients with absence seizures?
carbamazepine
113
Following a first unprovoked seizure, what is the minimum driving suspension period?
6 months
114
What is the DVLA advice for patients with epilepsy?
Suspension of driving license unless seizure-free for one year.
115
Sodium valproate is contraindicated in what disorder?
Acute porphyria
116
Status epileptics is defined as what?
Prolonged seizure >5 minutes or >2 within a 5 minute period without the patient returning to normal
117
What is the first-line drug indicated for patients with Status Epilepticus (without IV access)?
Buccal midazolam or rectal diazepam (10 mg)
118
What is the 1st line drug indicated for Status Epilepticus (with IV access)?
IV lorazepam (4 mg)
119
What is the 2nd line drug management for patients with Status Epilepticus ?
IV lorazepam within 5-10 minutes
120
What is the third medical management step for Status Epilepticus unresponsive to two doses of benzodiazepines?
IV levetiracetam, phenytoin or sodium valproate.
121
What is the mechanism of action of phenytoin?
Voltage-gated sodium channel blocker
122
What effect does phenytoin have on cytochrome p450?
* Cytochrome P450 inducer
123
What are the acute adverse effects associated with phenytoin?
- Syncope, diplopia, nystagmus, slurred speech, ataxia; confusion and seizures
124
What common chronic adverse effects are associated with phenytoin?
Gingival hyperplasia (secondary to increased expression of PDGF); hirsutism, coarsening of facial features, drowsiness
125
What haematological abnormality is associated with phenytoin?
- Megaloblastic anaemia
126
What are the main risk factors associated with idiopathic intracranial hypertension?
Overweight women of childbearing age
Obesity
Pregnancy
Drugs e.g., steroids, COCP, retinoids, lithium
127
What is the characteristic headache presentation for IIH?
Throbbing/pulsatile
128
What precipitates the headache in IIH?
- Precipitated by changes in position (e.g., standing, worse in the morning), Valsalva, bright light or eye movement.
129
What characteristic aural feature is associated with IIH?
Pulsatile tinnitus
130
What first line investigation is indicated for IIH?
* Ophthalmoscopy – Optic disc oedema
- Perimetry testing + visual acuity testing.
131
What is diagnostic of IIH?
Diagnostic lumbar puncture
132
What is the conservative management for IIH?
Weight loss
133
What is the first line drug indicated for IIH?
Acetazaolamide
134
What class of drug is acetazolamide and moa?
* Carbonic anhydrase (acetazolamide) – decreases CSF production
135
What are the adverse effects associated with acetazolamide?
Hypokalaemia, paraesthesia of extremities
136
What are the two drugs recommended in the management of IIH?
acetazolamide
topiramate
137
What additional effect does topiramate confer in patients with IIH?
Weight loss
138
What is the surgical intervention recommended for patients with refractory IIH?
* Optic nerve sheath defenestration
139
What type of hypersensitivity reaction is associated with MS?
Type IV hypersensitivity
140
Which modifiable factor adversely effects disease outcomes in MS?
Smoking and obesity
141
T-cell mediated hypersensitivity reactions against what in MS?
Oligodendrocyte proteins e.g., basic myelin protein
142
What is the most common type of multiple sclerosis?
* Relapsing-remitting MS
143
At what age does MS typically arise?
20-50 years
144
Which visual symptom is commonly reported by patients with MS?
Optic neuritis
145
Which term describes a transient recurrence of pre-existing neurological deficit due to small elevations in body temperature?
* Uhthoff’s phenomenon
146
Which pupillary defect is typically observed in patients with multiple sclerosis?
Relative afferent pupillary defect
147
What corticospinal tract manifestation is associated with multiple sclerosis?
Transverse myelitits
148
Which term/sign describes a shock-like sensation radiating down the spine?
Lhermitte's phenomena
149
What finding is observed in patients with MS on LP?
CSF-specific oligoclonal bands
150
What is the diagnostic investigation for MS?
* MRI (T2) with and without gadolinium contrast
151
What is the first line acute management of multiple sclerosis?
High-dose corticosteroids (initiated within 14 days of symptom onset)
152
What disease-modifying drug is indicated in the management of MS?
- Natalizumab
153
How is MS spasticity managed?
baclofen
154
Which bacteria is commonly implicated in the pathogenesis of GBS?
campylobacter jejuni
155
Which auto-antibodies are formed in patients with Guillain–Barre syndrome?
ganglioside antibodies
156
What is the characteristic clinical presentation of GBS?
Ascending symmetrical muscle weakness
157
What severe complication is associated with GBS?
Respiratory failure
158
Which type of GBS is associated with ophthalmoplegia, areflexia, and ataxia (as descending paralysis)?
Miller Fischer Syndrome
159
What finding on LP is associated with GBS?
albuminocytologic dissociation
160
Which investigations are indicated for the diagnosis of GBS?
Lumbar puncture
Nerve conduction studies/Electromyography
161
What abnormalities are detected on EMG for GBS?
Absent H-reflexes and prolonged distal latency
162
What is the first line management of GBS?
IV immunoglobulins or plasma exchange
163
What respiratory function should be measured in patients with GBS?
Forced vital capacity
164
Which nerve roots form the median nerve?
C5-T1
165
Which group of muscles are innervated by the median nerve (motor function)?
Thenar muscles and the lateral two lumbricals
166
Which muscles are included in the thenar muscles? (3)
Flexor pollicis brevis, abductor pollicis brevis, opponens pollicis.
167
What is the motor function of the median nerve?
Innervates the flexor and pronator muscles in the anterior compartment in the hand
168
What is the sensory function of the median nerve?
Lateral 3 ½ fingers on the anterior surface of the hand.
169
What nerve runs in the carpal tunnel?
Median nerve
170
What are the two layers of the carpal tunnel?
Deep carpal arch and superficial flexor retinaculum
171
What are the risk factors for carpal tunnel syndrome?
* Repetitive wrist flexion or hand elevation
* Obesity
* Pregnancy
* Osteoarthritis of the MCP joint of the thumb – compression of the median nerve by osteophytes
* Inflammatory joint disease e.g., rheumatoid arthritis (due to synovitis in the carpal tunnel).
* Ganglion cysts, tumour, scar tissue.
* Hypothyroidism
* Diabetes mellitus.
172
What are the characteristic findings observed in carpal tunnel syndrome?
* Intermittent paraesthesia, numbness or altered sensation, and burning or pain in the distribution of the median nerve (the thumb, index, middle finger and the radial half of the ring finger).
173
What alleviates carpal tunnel syndrome pain?
Changing hand posture or shaking the wrist (‘the flick sign’).
174
What hand weakness features are associated with carpal tunnel syndrome?
- Loss of grip strength
- Hand weakness
Atrophy of the thenar muscles
Trophic ulceration at the tips of the digits
Weakness of thumb abduction and opposition
- Reduced manual dexterity (doing up buttons, holding objects and opening jars).
175
What sign denotes tapping the nerve in the carpal tunnel to elicit pain in the median nerve distribution?
Tinel's sign
176
What is Phalen's manoeuvre?
Holding the wrist in flexion for 60 seconds to elicit numbness/pain in the median nerve distribution.
177
What specialist assessment is used for the diagnosis of carpal tunnel syndrome?
* Nerve conduction studies
178
What is the fist line management for mild-moderate carpal tunnel syndrome?
Wrist splint for 6 weeks or single corticosteroid injection
179
What is the definitive management for carpal tunnel syndrome?
Carpal tunnel surgery (decompression) – flexor retinaculum division.
180
What is the gold-standard investigation to confirm degenerative cervical myelopathy?
MRI of the cervical spine
181
What is the characteristic finding of degenerative cervical myelopathy?
Wide-based spastic gate, with clumsy upper extremity function due to compression of the lateral corticospinal tracts and spinocerebellar tracts
182
What is the definitive management for degenerative cervical myelopathy?
Decompressive surgery
183
Upper quadrant bitemporal hemianopia is caused by what?
Inferior chiasmal compression (pituitary tumour)
184
What causes a lower quadrant bitemporal hemianopia?
* Lower quadrant defect = Superior
185
Superior homonymous quadrantopia is caused by what?
Lesion of the inferior optic radiations in the temporal lobe
186
Inferior homonymous qudrantopia is caused by what?
* Inferior: Lesion of the superior optic radiations in the parietal lobe
187
Temporal arteritis is frequently associated with what?
polymyalgia rheumatica.
188
Which visual defect is associated with GCA?
* Anterior ischaemic optic neuropathy – Transient vision loss, amaurosis fugax and optic atrophy.
and optic neuritis
189
What is the first line blood investigation for suspected GCA?
Seru ESR >50 mm/hour
190
What is the diagnostic investigation to confirm GCA?
Temporal arterial biopsy
191
What findings are observed in a temporal artery biopsy?
multinucleated giant cells or panarteritis (skip lesions).
192
On duplex ultrasound, what is seen in temporal arteritis?
Halo sign
193
What demographic is most affected by GCA?
>50 years of age
194
What is the first line management for temporal arteritis?
High dose corticosteroids e.g., prednisolone 40-60 mg/day
195
What is the first line management for temporal arteritis with new visual loss or double vision?
urgent same-day ophthalmic assessment
and
500 mg - 1g of IV methylprednisolone
196
Myasthenia Gravis affects what?
The neuromuscular junction
197
Which autoantibodies are implicated in myasthenia Gravis?
Autoantibodies against postsynaptic membrane proteins (e.g., n-AChR, MuSK and LPR4)
198
What typically precipitates myasthenia Gravis?
Infections, immunisations, surgeries, pregnancy and drugs e.g., aminoglycosides
199
What is the paraneoplastic subtype of myasthenia Gravis?
Lambert–Eaton Myasthenic syndrome
200
Which lung cancer is associated with Lambert–Eaton Myasthenic syndrome?
Small cell carcinoma
201
What is the characteristic ocular finding observed in Myasthenia Gravis?
* Extraocular muscle weakness (~85%)—diplopia and ptosis
202
Which test can demonstrate amelioration of muscle weakness in myasthenia gravis?
ice-pack test
203
What tests are indicated as first-line for patients with suspected myasthenia gravis?
Serology testing for anti-AChR and MuSK
204
What is the most sensitive test for diagnosing myasthenia gravis?
* Single-fibre electromyography (most sensitive): Mean jitter value is higher than normal.
205
What is the first line management for myasthenia gravis?
Cholinesterase enzyme inhibitors e.g., long-acting pyridostigmine
206
What neck procedure may be indicated in myasthenia gravis?
thymectomy
207
What is the first line management for a myasthenic crisis?
IVIG or plasma exchange
208
What parameter is used to monitor respiratory function during a myasthenic crisis?
Forced vital capacity (FVC)
209
Which nerve is implicated in Bell's palsy?
Facial nerve
210
What is the characteristic presentation of Bell's Palsy?
Unilateral non-forehead sparing facial weakness
211
Why is Bell's palsy non-forehead sparing?
Affects the lower motor neurones (whereas in stroke, there is innervation from the unilateral motor cortex)
212
What are the common risk factors for Bell's palsy?
Intranasal influenza vaccination
Pregnancy
Infection
213
When do Bell's palsy symptoms fully evolve?
Within 72 hours
214
What scale is used to measure disease progression in patients with Bell's palsy?
House–Brackmann scale
215
What serology testing is indicated in certain patients with Bell's palsy?
* Borrelia burgdorferi
216
Bell's palsy with a vesicular rash in the auditory canal suggests whats?
Herpes zoster infection - Ramsay Hunt Syndrome
217
What is the first line management for Bell's palsy?
Prednisolone 50mg OD for 10 days
218
What is the management for Ramsay Hunt Syndrome?
Oral prednisolone and acyclovir
219
What conservative management is indicated in patients with Bell's palsy?
Corneal protection with protective glasses or artificial tears
220
What is a common acute complication associated with Bell's palsy?
Keratoconjunctivitis sicca
221
SAH typically concerns ruptures of saccular aneurysms where?
Circle of Willis
222
What is the main contributing risk factor for a subarachnoid haemorrahge?
Hypertension
223
Which conditions are associated with a subarachnoid haemorrhage?
Adult polycystic kidney disease, Marfan’s syndrome, pseudoxanthoma elasticum, Ehlers-Danlos Syndrome,
224
What is the characteristic headache presentation for SAH?
Sudden-onset thunderclap headache in the occipital region associated with photophobia
225
What is the emergency first line investigation for patients with suspected SAH?
Non-contrast CT within 6 hours
226
What is revealed on a non-contrast CT in patient with a SAH?
Hyperdense areas in the basal regions of the skull
227
When is a lumbar puncture indicated in a SAH?
>12 hours of symptom onset
228
What is revealed on lumbar puncture in patients with a SAH?
Xanthochromia
229
Which investigation confirms the causative pathology for SAH?
* CT intracranial angiogram
230
Which ECG changes are typically observed in patients with a SAH?
ST-elevation
231
What drug is indicated to reduce vasopasm in patients with SAH?
* Nimodipine
232
What is the definitive management of SAH?
Endovascular coiling
233
How is hydrocephalus managed acutely?
External ventricular drain
234
What is the common precipitating trigger for a subdural haemorrhage?
Shearing of bridging veins due to trauma e.g., shaken baby syndrome
235
What is Cushing's triad?
Bradycardia, hypertension and respiratory irregularities.
236
On CT imaging, what finding is observed in a patient with a subdural haematoma?
Crescenteric in shape
Acute = hyperdense
Chronic = hypodense
237
What i the surgical intervention for patients with subdural haematoma?
Burr-hole evacuation or craniotomy.
238
Which vessel is commonly involved in an extradural haemorrhage?
Middle meningeal artery
239
What is the initial presentation of an extradural haemorrhage?
Lucid interval: Initial episode of unconsciousness, followed by transient consciousness, reverting to complete unconsciousness
240
A lentiform hyperdense collection on CT indicates what?
Extradural Haemorrhage
241
What is the definitive management for an extradural haemorrhage?
craniotomy and evacuation of the haematoma.
242
Which genetic disorder is associated with bilateral acoustic neuroma?
* Neurofibromatosis type 2
243
Which cranial nerve is implicated in acoustic neuroma?
vestibulocochlear nerve
244
Where do acoustic neuromas typically reside?
cerebellopontine angle
245
What type of hearing loss is associated with acoustic neuroma?
unilateral, high-frequency retro-cochlear sensorineural hearing loss
246
What are the characteristic features associated with acoustic neuroma?
Unilateral sensorineural hearing loss
Vertigo
Headache
Tinnitus
247
What is the first line audiological investigation for acoustic neuroma?
Pure tone audiometry
248
What is the diagnostic investigation for acoustic neuroma?
Contrast-enhanced MRI
249
What is the first line management for acoustic neuroma size 1.5 to 3 cm?
stereotactic radiotherapy
250
What is the first line management for large acoustic neuroma (>3 cm)?
Surgical resection
251
What monitoring is required during surgical resection of acoustic neuroma?
Intraoperative facial nerve monitory
252
What disorder is associated with fluctuating sensorineural hearing loss, vertigo and tinnitus?
Meniere’s Disease
253
What is the typical duration of Meniere’s Disease ?
20 minutes
254
What is indicated for the symptomatic relief of Meniere’s Disease ?
prochlorperazine or an antihistamine
255
What is the prophylactic management for Meniere’s Disease?
betahistine
256
What is the typical duration of BPPV episode?
<60s
257
Which semicircular canal is predominantly affected by BPPV?
Posterior semicircular canal
258
Which manoeuvre is used to diagnose BPPV?
Dix–Hallpike manoeuvre
259
What is the long term management for BPPV?
Epley and Sermont manoeuvres
260
What are the risk factors associated with brain abscess?
* Direct local spread:
- Inferior temporal lobe: Otitis media, and mastoiditis
- Frontal lobe: Dental infections, ethmoid sinuses
N.B: Paranasal sinus infections account for ~30-50% of brain abscesses.
261
What is the imaging study of choice for brain abscess?
CT scan
262
What is observed on CT scan for brain abscess?
Ring-enhancing lesion
263
What is the first line management for brain abscess?
IV 3rd generation cephalosporin (ceftriaxone) and metronidazole.
264
What is the definitive management for brain abscess?
Craniotomy + abscess debridement
265
Lisch nodules cafe au lait macules and optic pathway gliomas are associated with what genetic disorder?
Neurofibromatosis Type 1
266
What is the inheritance pattern for Neurofibromatosis Type 1?
Autosomal dominant
267
Which characteristic skin manifestation is observed in tuberous sclerosis?
Ash-leaf shaped white macules
Angiofibromas
Shagreen patach
268
What is Vogt diagnostic triad for tuberous sclerosis?
seizures, intellectual disability and facial angiofibromas.
269
What is the most common viral cause of encephalitis?
HSV-1
270
HSV-1 typically affects which part of the brain?
Temporal and inferior frontal lobes
271
What are the characteristic features observed in encephalitis?
* Fever
* Seizures
* Vomiting
* Headache
* Behavioural changes/Mental state alteration – Confusion; deteriorating GCS.
* Focal neurological symptoms: Dysphagia, hemiplegia, aphasia (Hallmark feature)
272
What is the first line investigation for encephalitis?
CT
and Lumbar puncture
273
What CT findings are consistent with a diagnosis of encephalitis?
medial temporal and inferior frontal lobe changes e.g., petechial haemorrhages
274
What is the first line management for encephalitis?
IV acyclovir (10 mg/kg TDS); IV ceftriaxone
275
Which artery is associated with trigeminal neuralgia?
superior cerebellar artery
276
What is the investigation of choice for confirming trigeminal neuralgia?
* MRI (if persistent): Evidence of compression of the trigeminal nerve by the superior cerebellar artery.
277
What is the first line drug for trigeminal neuralgia?
Carbamazepine
278
Unresponsive refractory trigeminal neuralgia can be managed with what?
microvascular decompression surgery of the trigeminal nerve (if evidenced arterial compression).
279
What is the main characteristic feature for multisystem atrophy?
* Dysautonomia
- Urinary incontinence, anhidrosis and orthostatic hypotension.
- Erectile dysfunction (early feature)
- Atonic bladder
280
What is the most common cause of meningitis in neonates?
Group B streptococcus
281
What is the most common cause of bacterial meningitis in 10-19 year olds?
N. meningitis
282
What is the most common cause of bacterial meningitis in adults?
Streptococcus pnuemoniae
283
What is the most common cause of viral meningitis?
enterovirus (e.g., Coxsackie, echovirus)
284
Which sign denotes resistance on full extension of the knee when the hip is flexed?
Kernig sign
285
Which sign denotes the following:
Flexion of the patient’s neck causes the hips and knees to flex?
* Brudzinski sign
286
What are the first line investigations for suspected meningococcal disease?
Blood culture, white cell count, CRP, lactate levels, and whole-blood diagnostic PCR.
287
What is the first line antibiotic therapy for bacterial meningitis?
Empirical antibiotic therapy (high-dose ceftriaxone) should promptly be initiated within 1 hour of presentation accompanied by immediate fluid resuscitation in septic patients.
288
Primary care management for bacterial meningitis?
IM benzylpenicillin
289
In confirmed non-meningococcal disease what is the management for meningitis?
V ceftriaxone and corticosteroids
290
What are the two signs for a basal skull fracture?
Racoon eyes
Battle sign
291
What is battle sign?
Basilar skull fracture – bruise over the mastoid process – takes 1 day to appear.
292
What is the first line management for raised ICP?
Head elevation and IV mannitol
293
Which genes are associated with early-onset Alzheimer's disease?
presenilin 1 protein (PSEN1), PSEN2
294
What genes are associated with late-onset Alzheimer's disease?
APOE e4 allele increases risk
295
What are the extracellular deposits in Alzheimer's disease?
Beta-amyloid
296
What are the intracellular deposits in Alzheimer's disease?
neurofibrillatory tangles.
297
What is the diagnostic cut off for diagnosis fo Alzheimer's disease on a MoCa?
<26
298
An AMTS
<7
299
Rapidly progressing dementia is suggestive of what?
Creutzfeldt-Jakob disease
300
What is the investigation of choice for Creutzfeldt-Jakob disease?
CSF examination
301
What MRI findings are consistent with Alzheimer's disease?
302
What is the first line drug for Alzheimer's disease?
Acetylcholinesterase (AChE) inhibitor monotherapy
e.g., Donepezil, galantamine, rivastigmine
303
What is the first line management for severe Alzheimer's disease?
Memantine
304
What is the mechanism of action of memantine?
NMDA partial receptor agonist
305
What is the pathological hallmark of Lewy-body dementia?
Eosinophilic intracytoplasmic inclusions (Lewy Bodies) – contain aggregated alpha-synuclein.
306
What are the characteristic features of Lewy-body dementia?
* Recurrent visual hallucinations
- Well-formed and detailed – people, children or small animals.
- Lilliputian hallucinations.
* Fluctuating confusion with marked variations in alertness levels
o Associated with lucid intervals.
* Rapid eye movement (REM) sleep behaviour disorder
- Parasomnia is characterised by dream enactment.
* Motor features of Parkisonism:
- Bradykinesia
- Rest tremor
- Anosmia – early sign of PD
- Antipsychotic sensitivity
o Antipsychotic drugs Acute reactions – irreversible parkinsonism, and impaired consciousness.
- Rigidity
- Frequent falls
o Supportive clinical features:
Postural instability
Autonomic dysfunction
Syncope
Delusions
Non-visual hallucinations
Apathy
Anxiety
Depression
307
What is the management of choice for Sleep disturbance in Lewy body dementia?
Clonazepam
308
What drug is indicated for the management of frontotemporal dementia?
Anti-depressants
309
Which pathway is affected in Parkinson's disease?
Nigrostriatal pathway
310
What is the difference in tremor between drug-induced and idiopathic Parkinson's?
Drug-induced = bilateral
311
What is the first line management for Parkinson's disease?
Levodopa
312
What is co-prescribed with levodopa in Parkinson's disease?
Levodopa, co-administered with a dopa decarboxylase inhibitor
313
What are the common adverse effects associated with Parkinson's disease manaegment?
postural hypotension, nausea, and vomiting.
314
Which drug is indicated for motor symptoms in Parkinson's disease?
Oral dopamine agonists e.g., ropinirole
315
What are the adverse effects associated with oral dopamine agonists?
sleepiness, hallucinations, and impulse control disorders
316
What is the management of dyskinesia in Parkinson's disease?
amantadine
317
What disorder is associated with a vertical supranuclear gaze palsy?
Progressive supranuclear palsy
318
What is the clinical triad for Wernicke's encephalopathy?
ophthalmoplegia, gait ataxia, and encephalopathy
319
Which vitamin is deficient in Wernicke's encephalopathy?
thiamine (Vitamin B1) deficiency
320
What oculomotor dysfunction is associated with Wernicke's encephalopathy?
* Nystagmus
* Lateral rectus palsy
* Conjugate gaze palsies
321
What is a complication of Wernicke's encephalopathy characterised by confabulation?
Korsakoff’s syndrome
322
What is Hakim's clinical triad in NPH?
gait disturbance, cognitive deterioration, and urinary incontinence
323
What is the preferred investigation for NPH?
MRI is the preferred confirmatory investigation for a definitive diagnosis of NPH
324
What is the management for NPH?
ventriculoperitoneal shunting or endoscopic third ventriculostomy
325
What is the presentation of essential tremor?
* Bilateral action tremor:
- Affecting the hands and arm
* Exaggerated with posture holding (arms are held in a fixed posture against gravity) and with goal-directed limb movements.
326
What is the first line management of essential tremor?
Propranolol
327
What is the inheritance pattern of Huntington's disease?
Autosomal dominant
328
What trinucleotide repeat is implicated in Huntington's disease?
36 CAG trinucleotide
329
What is this the management for chorea symptoms in Huntington's disease?
VMAT inhibitors (e.g., tetrabenazine)
330
Recreation use of which drug causes subacute degeneration of the spinal cord?
Nitric oxide
331
Subacute degeneration of the spinal cord is associated with which type of vitamin deficiency?
Vitamin B12
332
What should be measured in patients with nitrous oxide use presenting with subacute degeneration of the spinal cord?
measure homocysteine and methylmalonic acid
333
The radial nerve innervates which muscle groups?
The triceps brachii and the extensor muscles in the forearm
334
What are the nerve roots for the radial nerve?
C5 -T1
335
What is the clinical manifestation of a radial nerve palsy?
Wrist drop
336
What is the clinical manifestation of an ulnar nerve palsy?
Claw hand and sensory loss of the medial 1 1/2 fingers
337
What is the first line drug indicated in patients with neuropathic pain?
Amitriptyline, duloxetine, gabapentin or pregabalin.
338
What is the management for diabetic gastroparesis?
Small particle size diet and consideration of a prokinetic drug e.g., metoclopramide
339
What distribution pattern is observed in patients with peripheral diabetic neuropathy?
stocking-glove distribution
340
What are the autonomic dysfunction features associated with diabetic neuropathy?
- Postural hypotension (defined as a drop in systolic blood pressure >30 mmHg when transitioning from a supine to a standing position).
- Diabetic gastroparesis: Delayed gastric emptying, bloating, nausea and post-prandial vomiting.
Advise: Small-particle-size diet (mashed or pureed food) for symptom relief + referral to a gastroenterologist for consideration of a prokinetic drug (e.g., metoclopramide, domperidone, or erythromycin).
- Lower gastrointestinal involvement: Lower abdominal pain, unexplained diarrhoea, and faecal incontinence.
- Unexplained urinary symptoms e.g., hesitancy, reduced frequency, inadequate bladder emptying and urinary retention.
341
What is the rescue therapy for exacerbations of neuropathic pain?
Tramadol
342
What is the most common cause of sciatica?
Intervertebral disc herniation
343
Which nerve roots are involved in sciatica?
L4 - S1
344
A positive straight leg test is indicative of what disorder?
Sciatica (Lumbar Radiculopathy)
345
What is the first line management for sciatica?
Analgesia (e.g., paracetamol) to manage back pain – Low-dose NSAIDs.
* Group exercise programme
* Physiotherapist for manual therapy
* CBT
346
What autoantibodies are associated with Lambert-Eaton syndrome?
presynaptic voltage-gated calcium channel antibodies
347
What is the characteristic finding associated with Lamber-Eaton syndrome?
Weakness improves with activities
348
What is the first line medical management for Lambert–eaton syndrome?
