neuro

Question 1

ACA vs MCA vs PCA stroke?

Answer 1

ACA:
contralateral sensory and motor loss
Lower> upper

MCA: (most common)
Contralateral sensory and motor loss
Upper> lower
aphasia
contralateral homonymous hemianopia

PCA:
Contralateral homonymous hemianopia with macular sparing
Visual agnosia (can’t recognise objects seen)

Question 2

Webers syndrome vs basilar artery stroke vs lacunar stroke?

Answer 2

Webers:
Affects branches of PCA which supply midbrain
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

Basilar artery: Locked in syndrome

Lacunar stroke: either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
common sites include the basal ganglia, thalamus and internal capsule

Question 3

Management of ischaemic stroke?

Answer 3

A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded

Question 4

Management of suspected temporal arteritis with visual loss and without visual loss?

Answer 4

1. Steroids: give urgent high dose steroids as soon as suspected, before biopsy IF no visual loss.
   If visual loss IV methylprednisolone is given prior to PO steroids as above.
   there should be a dramatic response, if not the diagnosis should be reconsidered
2. urgent ophthalmology review
3. bone protection with bisphosphonates due to high dose steroids

Question 5

cubital tunnel syndrome presentation?

Answer 5

Compression of ulnar nerve

Motor to:
medial two lumbricals
aDductor pollicis
interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris
‘claw hand’ - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits

Sensory to:
medial 1 1/2 fingers (palmar and dorsal aspects) - little finger

Question 6

What type of brain bleeding can present several weeks after head injury?

Answer 6

chronic subdural haematoma

Question 7

Wernickes vs brocas area?

Answer 7

Spoken word is heard at the ear. This passes to Wernicke’s area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area. The Broca’s area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).

Question 8

What are the indications for an urgent vs less urgent CT head according to NICE guidelines? What timeframe should they be done in?

Answer 8

CT head within 1 hour
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting

CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury

Question 9

If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, what should you do?

Answer 9

they should be admitted immediately for imaging to exclude a haemorrhage

Question 10

Wernicke’s encephalopathy triad

Answer 10

Confusion, gait ataxia, nystagmus + ophthalmoplegia are features

Question 11

Korsakoffs?

Answer 11

non-reversible
Confabulation
Anterograde and
Retrograde amnesia
Temperament altered

Question 12

SDH vs SAH vs extradural haemtoma on CT? What vascular involvement?

Answer 12

SDH: crescent (banana shape), crosses sutures , involved bridging veins

Epidural haemorrhage is associated with the middle meningeal artery

Subarachnoid haemorrhages are associated with vessels of the circle of Willis, such as basilar and anterior circulating arteries.

Question 13

Frontal vs temporal vs occipital vs partial lobe epilpesy?

Answer 13

Jacksonian movements are a feature of frontal lobe epilepsy. clonic movements travelling proximally

Temporal lobe seizures are associated with aura, lip smacking and clothes plucking.

Occipital seizures are associated with visual abnormalities.

Parietal seizures are associated with sensory abnormalities.

Question 14

What is the long term mx of an ishcaemic stroke?

Answer 14

What is the long term mx of stroke?
Aspirin + clopi for two weeks
Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole) for life

Question 15

What is internuclear opthalmoplegia?

Answer 15

Internuclear ophthalmoplegia (INO) occurs due to a lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement. This results in impairment of adduction of the ipsilateral eye. The contralateral eye abducts, however with nystagmus.

Question 16

How does spinal stenosis present?

Answer 16

Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnostic

Question 17

In B12 and folate deficiency what should be replaced first?

Answer 17

vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord

Question 18

What features are seen in tuberous sclerosis

Answer 18

Cutaneous features:
depigmented ‘ash-leaf’ spotswhich fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum(angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
cafe-au-lait spots may be seen, more common in neurofibroma

Neurological features: developmental delay, LD, epilepsy

Question 19

Mx of generalised seizures vs focal seizures?

Answer 19

Generalised tonic-clonic/ myoclonic/ tonic seizures
males: sodium valproate
females: lamotrigine or levetiracetam

Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine,

Question 20

Mx of absence seizures?

Answer 20

Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures

Question 21

Mx of meningitis in non-immunocomp adults?

Answer 21

IV ceftriaxone
If raised ICP then LP CI
Dexamethasone (CI in sepsis)

Question 22

How long after your first seizure can you not drive for? (if ix are normal vs abnormal)

Answer 22

first unprovoked/isolated seizure: 6 months off if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG.

If these conditions are not met then this is increased to 12 months

Question 23

What drug is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages

Answer 23

Nimodipine

Question 24

Partial vs total anterior circulation stroke?

Answer 24

1.Unilateral weakness (and/or sensory deficit) of the face, arm and leg
2.Homonymous hemianopia
3.Higher cerebral dysfunction (dysphasia, visuospatial disorder)

2/3 = partial
3/3 = total

Question 25

Posterior circulation stroke features?

Answer 25

1 of:
Cranial nerve palsy and a contralateral motor/sensory deficit
Bilateral motor/sensory deficit
Conjugate eye movement disorder (e.g. horizontal gaze palsy)
Cerebellar dysfunction (e.g. vertigo, nystagmus, ataxia)
Isolated homonymous hemianopia

Question 26

Posterior vs anterior inferior cerebellar stroke?

Answer 26

Posterior inferior cerebellar AKA wallenberg syndrome : Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus

Anterior inferior cerebllar AKA lateral pontine syndrome: Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness

Question 27

When is hoffmans sign post?

Answer 27

UMN lesion

Question 28

Anti-emetic of choice for migraines?

Answer 28

metoclopramide

Question 29

Mx of spasticity in MS?

Answer 29

baclofen
gabapentin

Question 30

Which arteries are involved in a posterior circulation infarct?

Answer 30

vertebrobasilar arteries

Question 31

What is an example of a dopamine receptor agonist? SE?

Answer 31

e.g. bromocriptine, ropinirole, cabergoline, apomorphine

SE: pulmonary + cardiac fibrosis
hallucinations

Question 32

If levodopa is stopped suddenly what can happen to patients?

Answer 32

acute dystonia
(need dopamine patch)

Question 33

Example of MAO-B (Monoamine Oxidase-B) inhibitors

Answer 33

e.g. selegiline

Question 34

Example of COMT (Catechol-O-Methyl Transferase) inhibitors

Answer 34

e.g. entacapone, tolcapone

Question 35

Mx of drug induced parkinsonisms?

Answer 35

Antimuscarinics
e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)

Question 36

Where is the lesion if someone is having a Homonymous hemianopia?

Answer 36

Occipital tract/ cortex

Question 37

Where is the lesions in Homonymous quadrantanopias (superior vs inferior)?

Answer 37

superior: lesion of the inferior optic radiations in the temporal lobe(Meyer’s loop)

inferior: lesion of the superior optic radiations in the parietal lobe

PITS (Parietal-Inferior, Temporal-Superior)

Question 38

where is the lesion in a bitemporal heminopia?

Answer 38

optic chiasm

upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour

lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma