Neuro Flashcards

Question

Q: What is Bell's palsy?

Answer 1

A: Bell's palsy is an acute, unilateral, idiopathic facial nerve paralysis.

Answer 2

A: The exact etiology is unknown, but the herpes simplex virus has been investigated as a possible cause.

Answer 3

A: The peak incidence is between 20-40 years.

Answer 4

A: Bell's palsy is more common in pregnant women.

Answer 5

A: Features include lower motor neuron facial nerve palsy affecting the forehead, post-auricular pain, altered taste, dry eyes, and hyperacusis.

Answer 6

A: Lower motor neuron facial palsy affects the forehead, whereas upper motor neuron lesions spare the upper face.

Answer 7

A: All patients should receive oral prednisolone within 72 hours of onset.

Answer 8

A: The addition of antivirals is debated, but UpToDate recommends their use for severe facial palsy. Antiviral treatments alone are not recommended.

Answer 9

A: Eye care is important to prevent exposure keratopathy. Measures include prescribing artificial tears, eye lubricants, and taping the eye closed with microporous tape at bedtime if necessary.

Answer 10

A: Patients should be referred urgently to ENT if there is no sign of improvement after 3 weeks.

Answer 11

A: A referral to plastic surgery may be appropriate for patients with more long-standing weakness, such as several months.

Answer 12

A: Most people make a full recovery within 3-4 months.

Answer 13

A: Around 15% of untreated patients have permanent moderate to severe weakness.

Answer 14

A: Erb-Duchenne paralysis is caused by damage to the C5 and C6 roots of the brachial plexus. It may result from a breech presentation during birth and is characterized by weakness or paralysis in the shoulder and upper arm muscles.

Answer 15

A: A common sign is a "winged scapula," where the scapula protrudes abnormally due to weakness in the muscles controlling it.

Answer 16

A: Klumpke's paralysis is caused by damage to the T1 root of the brachial plexus, often due to traction. It results in the loss of intrinsic hand muscles and may cause claw hand deformity.

Answer 17

A: The loss of intrinsic hand muscles, leading to difficulty with fine motor control and possibly claw hand deformity.

Answer 18

A: Brain abscesses can result from middle ear or sinus sepsis, trauma or surgery to the scalp, penetrating head injuries, and embolic events from endocarditis.

Answer 19

A: Symptoms may include headache (often dull and persistent), fever (which may be absent), focal neurology (e.g., oculomotor nerve palsy), raised intracranial pressure (leading to nausea, papilloedema, seizures), and other neurological deficits.

Answer 20

A: CT scanning is used to assess brain abscesses, revealing the abscess cavity and any mass effect.

Answer 21

A: Management includes surgery (craniotomy for abscess drainage), IV antibiotics (e.g., 3rd-generation cephalosporins + metronidazole), and intracranial pressure management (e.g., dexamethasone).

Answer 22

A: The abscess may reform because the head is closed following drainage, which may limit further drainage of residual infection.

Answer 23

A: Features of parietal lobe lesions include sensory inattention, apraxias, astereognosis (tactile agnosia), inferior homonymous quadrantanopia, and Gerstmann's syndrome (alexia, acalculia, finger agnosia, right-left disorientation).

Answer 24

A: Occipital lobe lesions can lead to homonymous hemianopia (with macula sparing), cortical blindness, and visual agnosia.

Answer 25

A: Temporal lobe lesions can cause Wernicke's aphasia (fluent but nonsensical speech with word substitutions and neologisms), superior homonymous quadrantanopia, auditory agnosia, and prosopagnosia (difficulty recognizing faces).

Answer 26

A: Frontal lobe lesions can cause expressive (Broca’s) aphasia (non-fluent, laboured speech), disinhibition, perseveration, anosmia, and inability to generate a list.

Answer 27

A: Midline cerebellar lesions cause gait and truncal ataxia, while hemisphere lesions lead to intention tremor, past pointing, dysdiadokinesis, and nystagmus.

Answer 28

A: Lesions in these areas are associated with Wernicke and Korsakoff syndrome.

Answer 29

A: Lesions in the subthalamic nucleus are associated with hemiballism.

Answer 30

A: Lesions in the striatum are associated with Huntington’s chorea.

Answer 31

A: Lesions in the substantia nigra lead to Parkinson’s disease.

Answer 32

A: Kluver-Bucy syndrome, associated with lesions in the amygdala, causes hypersexuality, hyperorality, hyperphagia, and visual agnosia.

Answer 33

A: The most common primary brain tumour in adults is glioblastoma multiforme. It is associated with a poor prognosis (~1 year) and presents as a solid tumour with central necrosis and contrast enhancement.

Answer 34

A: Meningiomas are benign, extrinsic tumours arising from the arachnoid cap cells of the meninges. They typically present with symptoms caused by compression of nearby structures. Treatment involves observation, radiotherapy, or surgical resection.

Answer 35

A: A vestibular schwannoma (acoustic neuroma) is a benign tumour of the eighth cranial nerve, commonly presenting with hearing loss, tinnitus, and facial nerve palsy. It is associated with neurofibromatosis type 2, which causes bilateral vestibular schwannomas.

Answer 36

A: The most common primary brain tumour in children is pilocytic astrocytoma. It is often diagnosed in childhood and presents with symptoms related to the location of the tumour.

Answer 37

A: A medulloblastoma is an aggressive paediatric brain tumour arising from the infratentorial compartment. It spreads through the CSF system, and treatment usually involves surgical resection and chemotherapy.

Answer 38

A: Ependymomas are commonly found in the 4th ventricle and may cause hydrocephalus. Treatment is typically surgical, and the tumour can be diagnosed by its histology showing perivascular pseudorosettes.

Answer 39

A: An oligodendroma is a benign, slow-growing tumour commonly found in the frontal lobes. It presents with calcifications that give a 'fried-egg' appearance on histology.

Answer 40

A: Haemangioblastomas are vascular tumours of the cerebellum, often associated with von Hippel-Lindau syndrome. They are characterized by foam cells and high vascularity on histology.

Answer 41

A: Pituitary adenomas can be secretory (e.g., Cushing's syndrome or acromegaly) or non-secretory. They can also be microadenomas (less than 1 cm) or macroadenomas (greater than 1 cm). They may cause visual disturbances like bitemporal hemianopia due to optic chiasm compression.

Answer 42

A: A craniopharyngioma is a solid/cystic tumour arising from the remnants of Rathke's pouch. It is common in children and may present with hormonal disturbances, hydrocephalus, or bitemporal hemianopia. Treatment is typically surgical with or without postoperative radiotherapy.

Answer 43

A: Brown-Sequard syndrome is caused by a lateral hemisection (or damage) of the spinal cord.

Answer 44

Ipsilateral (same side as the lesion): Weakness below the lesion Loss of proprioception and vibration sensation Contralateral (opposite side to the lesion): Loss of pain and temperature sensation

Answer 45

Epilepsy (particularly partial seizures, first-line treatment) Trigeminal neuralgia Bipolar disorder

Answer 46

A: Carbamazepine binds to sodium channels and increases their refractory period, reducing neuronal excitability.

Answer 47

Dizziness and ataxia Drowsiness Headache Visual disturbances (especially diplopia) Stevens-Johnson syndrome Leucopenia and agranulocytosis Hyponatraemia due to syndrome of inappropriate ADH secretion

Answer 48

A: Carbamazepine exhibits autoinduction, meaning that over time, the drug induces its own metabolism, potentially leading to a return of seizures after 3-4 weeks of treatment.

Answer 49

A: Carbamazepine is a P450 enzyme inducer, which can affect the metabolism of other drugs.

Answer 50

A: Cataplexy is the sudden and transient loss of muscular tone triggered by strong emotions, such as laughter or fear.

Answer 51

A: Around two-thirds of patients with narcolepsy experience cataplexy.

Answer 52

A: Features range from buckling knees to complete collapse.

Answer 53

A: Unilateral cerebellar lesions cause ipsilateral signs.

Answer 54

The mnemonic is DANISH: D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk' A - Ataxia (limb, truncal) N - Nystagmus (horizontal = ipsilateral hemisphere) I - Intention tremor S - Slurred staccato speech, Scanning dysarthria H - Hypotonia

Answer 55

Friedreich's ataxia, ataxic telangiectasia Neoplastic (e.g., cerebellar hemangioma) Stroke Alcohol Multiple sclerosis Hypothyroidism Drugs (e.g., phenytoin, lead poisoning) Paraneoplastic (e.g., secondary to lung cancer)

Answer 56

A: CPP is the net pressure gradient causing blood flow to the brain, and is tightly autoregulated to maximize cerebral perfusion.

Answer 57

CPP = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)

Answer 58

A sharp rise in CPP may result in a rising intracranial pressure (ICP). A fall in CPP may result in cerebral ischemia.

Answer 59

A: After trauma, CPP must be carefully controlled, which may require invasive monitoring of intracranial pressure (ICP) and mean arterial pressure (MAP).

Answer 60

A: Charcot-Marie-Tooth disease is the most common hereditary peripheral neuropathy, primarily resulting in motor loss.

Answer 61

A: There is no cure for Charcot-Marie-Tooth disease. Management focuses on physical and occupational therapy.

Answer 62

History of frequently sprained ankles Foot drop High-arched feet (pes cavus) Hammer toes Distal muscle weakness Distal muscle atrophy Hyporeflexia Stork leg deformity

Answer 63

A: A cluster headache is an extremely painful headache that occurs in clusters, often once a year, and is more common in men and smokers.

Answer 64

A: Intense sharp, stabbing pain around one eye, occurring once or twice a day, with each episode lasting 15 minutes to 2 hours.

Answer 65

Redness and lacrimation Lid swelling Nasal stuffiness Miosis and ptosis in a minority of cases Restlessness and agitation during an attack

Answer 66

A: MRI with gadolinium contrast is the investigation of choice, although underlying brain lesions are sometimes found even if the symptoms are typical.

Answer 67

100% oxygen (80% response rate within 15 minutes) Subcutaneous triptan (75% response rate within 15 minutes)

Answer 68

A: Verapamil is the drug of choice, with some evidence supporting a tapering dose of prednisolone.

Answer 69

A: Specialist advice should be sought if a patient develops cluster headaches, as specific treatments may be required, such as indomethacin for paroxysmal hemicrania.

Answer 70

A: The common peroneal nerve is a branch of the sciatic nerve and divides at the neck of the fibula.

Answer 71

A: Foot drop.

Answer 72

Weakness of foot dorsiflexion Weakness of foot eversion Weakness of the extensor hallucis longus muscle

Answer 73

A: Sensory loss over the dorsum of the foot and the lower lateral part of the leg.

Answer 74

A: Wasting of the anterior tibial and peroneal muscles.

Answer 75

A: Eye movement (medial rectus, inferior oblique, superior rectus, inferior rectus), pupil constriction, accommodation, eyelid opening.

Answer 76

A: Ptosis, 'down and out' eye, dilated, fixed pupil.

Answer 77

A: Eye movement (superior oblique).

Answer 78

A: Defective downward gaze, vertical diplopia.

Answer 79

A: Facial sensation, mastication.

Answer 80

A: Trigeminal neuralgia, loss of corneal reflex (afferent), loss of facial sensation, paralysis of mastication muscles, deviation of jaw to the weak side.

Answer 81

A: Eye movement (lateral rectus).

Answer 82

A: Defective abduction, horizontal diplopia.

Answer 83

A: Facial movement, taste (anterior 2/3 of the tongue), lacrimation, salivation.

Answer 84

A: Flaccid paralysis of upper and lower face, loss of corneal reflex (efferent), loss of taste, hyperacusis.

Answer 85

A: Hearing, balance.

Answer 86

A: Hearing loss, vertigo, nystagmus, acoustic neuromas.

Answer 87

A: Taste (posterior 1/3 of the tongue), salivation, swallowing, mediates input from the carotid body and sinus.

Answer 88

A: Hypersensitive carotid sinus reflex, loss of gag reflex (afferent).

Answer 89

A: Phonation, swallowing, innervates viscera.

Answer 90

A: Uvula deviates away from the site of the lesion, loss of gag reflex (efferent).

Answer 91

A: Head and shoulder movement.

Answer 92

A: Weakness turning the head to the contralateral side.

Answer 93

A: Tongue movement.

Answer 94

A: Tongue deviates towards the side of the lesion.

Answer 95

A: CJD is caused by prion proteins that induce the formation of amyloid folds, resulting in tightly packed beta-pleated sheets resistant to proteases.

Answer 96

Rapid onset dementia Myoclonus

Answer 97

CSF: usually normal EEG: biphasic, high amplitude sharp waves (only in sporadic CJD) MRI: hyperintense signals in the basal ganglia and thalamus

Answer 98

A: 85% of cases are sporadic.

Answer 99

A: The mean age of onset is 65 years.

Answer 100

Affects younger patients (average age of onset = 25 years) Psychological symptoms such as anxiety, withdrawal, and dysphonia Prion protein encoded on chromosome 20 Methionine homozygosity at codon 129 of the prion protein is a risk factor

Answer 101

A: The median survival is 13 months.

Answer 102

Kuru Fatal familial insomnia Gerstmann Straussler-Scheinker disease

Answer 103

Smoking (due to its effects on intervertebral discs) Genetics Occupations with high axial loading

Answer 104

Pain (neck, upper or lower limbs) Loss of motor function (e.g., difficulty with digital dexterity, arm or leg weakness) Loss of sensory function (e.g., numbness) Loss of autonomic function (e.g., urinary or fecal incontinence, impotence) Hoffman's sign (positive reflex test for cervical myelopathy)

Answer 105

Hoffman’s sign is a reflex test where a flick of the finger on a patient’s hand causes twitching of the other fingers, indicating cervical myelopathy.

Answer 106

An MRI of the cervical spine is the gold standard test, which can reveal disc degeneration, ligament hypertrophy, and cord signal changes.

Answer 107

Early treatment (within 6 months) offers the best chance for full recovery, as any existing spinal cord damage may be permanent. Delayed diagnosis can result in irreversible damage.

Answer 108

Decompressive surgery is the only effective treatment, which can prevent disease progression. Close observation is an option for stable, mild disease.

Answer 109

Physiotherapy should be initiated by specialist services to prevent further spinal cord damage, as manipulation can worsen the condition.

Answer 110

Patients often experience an average of over 5 appointments and more than 2 years before being diagnosed with DCM.

Answer 111

Amiodarone

Answer 112

Vincristine

Answer 113

Nitrofurantoin

Answer 114

Metronidazole

Answer 115

6 months off

Answer 116

3 months off driving, and the DVLA must be informed

Answer 117

X-linked recessive

Answer 118

Dystrophin connects the muscle membrane to actin, a part of the muscle cytoskeleton

Answer 119

Progressive proximal muscle weakness begins around 5 years of age

Answer 120

Calf pseudohypertrophy

Answer 121

A child uses their arms to stand up from a squatted position, seen in Duchenne muscular dystrophy

Answer 122

After the age of 10 years

Answer 123

No, it is much less common compared to Duchenne muscular dystrophy

Answer 124

Increased action potential duration Increased action potential amplitude

Answer 125

Decreased action potential duration Decreased action potential amplitude

Answer 126

Diminished response to repetitive stimulation

Answer 127

Incremental response to repetitive stimulation

Answer 128

Extended series of repetitive discharges lasting up to 30 seconds

Answer 129

Fever Headache Psychiatric symptoms Seizures Vomiting Focal features (e.g., aphasia)

Answer 130

HSV-1 (Herpes Simplex Virus-1) is responsible for 95% of cases in adults, typically affecting the temporal and inferior frontal lobes.

Answer 131

Lymphocytosis Elevated protein PCR for HSV, VZV, and enteroviruses

Answer 132

Medial temporal and inferior frontal changes (e.g., petechial hemorrhages) MRI is better than CT Normal in one-third of patients

Answer 133

Intravenous aciclovir should be started in all suspected cases.

Answer 134

Brief spasms beginning in the first few months of life Flexion of head, trunk, limbs → extension of arms (Salaam attack) Lasts 1-2 seconds, repeat up to 50 times Progressive mental handicap EEG: Hypsarrhythmia Often secondary to neurological abnormalities (e.g., tuberous sclerosis, encephalitis, birth asphyxia), or may be idiopathic Treatment: Vigabatrin and steroids Prognosis: Poor

Answer 135

Onset: 4-8 years Duration: Few seconds to 30 seconds No warning, quick recovery, often multiple episodes per day EEG: 3Hz generalized, symmetrical Treatment: Sodium valproate, ethosuximide Prognosis: Good (90-95% become seizure-free in adolescence)

Answer 136

Onset: 1-5 years May develop from infantile spasms Features: Atypical absences, falls, jerks 90% have moderate to severe mental handicap EEG: Slow spike waves Treatment: Ketogenic diet may help

Answer 137

Most common in childhood, more common in males Features: Unilateral facial paraesthesia, usually upon waking up

Answer 138

Onset: Teenage years, more common in girls Features: Infrequent generalized seizures, often in the morning or after sleep deprivation Daytime absences Sudden, shock-like myoclonic seizures (may develop before generalized seizures) Treatment: Usually responds well to sodium valproate

Answer 139

Cerebral palsy (30% have epilepsy) Tuberous sclerosis Mitochondrial diseases

Answer 140

Febrile convulsions: Typically in children 6 months to 5 years, triggered by a rapid rise in temperature during a viral infection. Seizures are brief and generalized. Alcohol withdrawal seizures: Occur in patients with a history of alcohol excess who suddenly stop drinking, typically peaking at 36 hours after cessation. Psychogenic non-epileptic seizures: Seizures without electrical discharges, often in patients with mental health issues or personality disorders.

Answer 141

Where seizures begin in the brain Level of awareness during a seizure Other features of seizures

Answer 142

Focal aware seizures: Seizures that start in one area of the brain with preserved awareness. Focal impaired awareness seizures: Seizures that start in one area of the brain with impaired awareness. Focal seizures with other features: Can include motor (e.g., Jacksonian march), non-motor (e.g., déjà vu), or other features like aura.

Answer 143

Generalized seizures engage networks on both sides of the brain, with consciousness lost immediately. Subtypes include: Tonic-clonic (grand mal) Tonic Clonic Typical absence (petit mal) Myoclonic Atonic

Answer 144

A seizure that starts in one area of the brain and spreads to both lobes, previously termed secondary generalized seizures.

Answer 145

Infantile spasms (West's syndrome): Brief spasms, often with hypsarrhythmia on EEG. Lennox-Gastaut syndrome: A severe form of epilepsy with slow spike waves on EEG, often associated with mental handicap. Benign rolandic epilepsy: Unilateral facial paraesthesia, seizures occur at night. Juvenile myoclonic epilepsy (Janz syndrome): Myoclonic seizures often triggered by sleep deprivation, responds well to sodium valproate.

Answer 146

Tongue biting Incontinence of urine Postictal drowsiness and fatigue for about 15 minutes

Answer 147

EEG (electroencephalogram) Neuroimaging (usually MRI)

Answer 148

Antiepileptics are generally started after a second seizure.

Answer 149

Sodium valproate: Increases GABA activity, used for generalized seizures; adverse effects include weight gain, alopecia, ataxia, and teratogenicity. Carbamazepine: Sodium channel blocker, used for focal seizures; adverse effects include dizziness, leucopenia, and diplopia. Lamotrigine: Sodium channel blocker, used for generalized and focal seizures; adverse effects include Stevens-Johnson syndrome. Phenytoin: Sodium channel blocker, used for focal seizures; adverse effects include gingival hyperplasia, hirsutism, and peripheral neuropathy.

Answer 150

Seizures often stop spontaneously, but if they last longer than 5-10 minutes, medications like benzodiazepines (e.g., diazepam) may be used. In cases of status epilepticus, further treatment with benzodiazepines, antiepileptic infusions, or general anaesthesia may be needed.

Answer 151

Focal seizures start in a specific area of the brain on one side. They can be classified based on the level of awareness and other features: Focal aware seizures (previously 'simple partial') Focal impaired awareness seizures (previously 'complex partial') Awareness unknown Further classification includes: Motor features (e.g., Jacksonian march) Non-motor features (e.g., déjà vu, jamais vu) Other features (e.g., aura)

Answer 152

Generalized seizures engage both sides of the brain at onset, causing immediate loss of consciousness. They can be further subdivided into: Motor generalized seizures (e.g., tonic-clonic) Non-motor generalized seizures (e.g., absence) Specific types include: Tonic-clonic (grand mal) Tonic Clonic Typical absence (petit mal) Atonic

Answer 153

Seizures may occur with or without impairment of consciousness or awareness Aura: Most patients experience a rising epigastric sensation, often accompanied by psychic phenomena (e.g., déjà vu, jamais vu) Less commonly, hallucinations (auditory, gustatory, olfactory) Seizures typically last around one minute Automatisms: Lip smacking, grabbing, plucking

Answer 154

Head/leg movements Posturing Post-ictal weakness Jacksonian march (sequential motor involvement from one body part to another)

Answer 155

Paraesthesia (tingling or numbness)

Answer 156

Floaters or flashes (visual disturbances)

Answer 157

A: AEDs should be started after the first seizure if: The patient has a neurological deficit Brain imaging shows a structural abnormality The EEG shows unequivocal epileptic activity The patient or family considers the risk of a further seizure unacceptable

Answer 158

A: Sodium valproate

Answer 159

A: Lamotrigine or Levetiracetam Girls under 10 years old or women unable to have children may be offered sodium valproate first-line.

Answer 160

A: Lamotrigine or Levetiracetam

Answer 161

A: Ethosuximide Second-line: Males: Sodium valproate Females: Lamotrigine or Levetiracetam Carbamazepine may exacerbate absence seizures.

Answer 162

A: Sodium valproate

Answer 163

A: Levetiracetam

Answer 164

A: Sodium valproate

Answer 165

A: Lamotrigine

Answer 166

A: Autosomal dominant

Answer 167

A: Postural tremor, which is worse when the arms are outstretched.

Answer 168

A: Alcohol and rest can improve the tremor.

Answer 169

A: Essential tremor is the most common cause of titubation.

Answer 170

A: Propranolol is the first-line treatment.

Answer 171

A: Primidone is sometimes used if propranolol is ineffective.

Answer 172

A: A collection of blood between the skull and the dura.

Answer 173

A: Trauma, most typically from low-impact injuries (e.g., a blow to the head or a fall).

Answer 174

A: In the temporal region, especially at the pterion overlying the middle meningeal artery.

Answer 175

A: Loss of consciousness, followed by a brief recovery (lucid interval), then another loss of consciousness due to expanding haematoma and brain herniation.

Answer 176

A: Compression of the parasympathetic fibers of the third cranial nerve due to temporal lobe uncus herniation around the tentorium cerebelli.

Answer 177

A: A biconvex (lentiform) hyperdense collection around the surface of the brain, limited by the suture lines of the skull.

Answer 178

A: Craniotomy and evacuation of the haematoma is the definitive treatment. For patients with no neurological deficit, clinical and radiological observation may be appropriate.

Answer 179

A: It supplies muscles of facial expression, the digastric muscle, and many glandular structures. It also carries taste sensation from the anterior two-thirds of the tongue and parasympathetic fibers to the lacrimal and salivary glands.

Answer 180

A: "Face, ear, taste, tear" Face: Muscles of facial expression Ear: Nerve to stapedius Taste: Anterior two-thirds of the tongue Tear: Parasympathetic fibers to lacrimal and salivary glands

Answer 181

A: Sarcoidosis, Guillain-Barre syndrome, Lyme disease, bilateral acoustic neuromas (neurofibromatosis type 2), and Bell’s palsy (25% of bilateral cases, but only 1% of Bell’s palsy cases).

Answer 182

A: Bell’s palsy, Ramsay-Hunt syndrome (herpes zoster), acoustic neuroma, parotid tumors, HIV, multiple sclerosis, diabetes mellitus (lower motor neuron), and stroke (upper motor neuron).

Answer 183

A: Upper motor neuron lesion spares the upper face (forehead), while a lower motor neuron lesion affects all facial muscles.

Answer 184

A: It originates in the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. It then travels through the facial canal, where it gives off three branches: greater petrosal nerve, nerve to stapedius, and chorda tympani. It exits the skull through the stylomastoid foramen and gives branches to the posterior auricular nerve, posterior belly of digastric muscle, and stylohyoid muscle.

Answer 185

A: Foot drop is weakness of the foot dorsiflexors, causing difficulty lifting the foot during walking.

Answer 186

A: Common peroneal nerve lesion, typically due to compression at the neck of the fibula.

Answer 187

A: Compression from leg crossing, squatting, kneeling, prolonged confinement, recent weight loss, Baker's cysts, or plaster casts.

Answer 188

A: L5 radiculopathy, sciatic nerve lesion, superficial or deep peroneal nerve lesion, and central nerve lesions (e.g., stroke).

Answer 189

A: Weakness of foot dorsiflexion and eversion, with normal reflexes.

Answer 190

A: L5 radiculopathy.

Answer 191

A: If there are bilateral symptoms, fasciculations, or other abnormal neurological findings (e.g., hyperreflexia).

Answer 192

A: Conservative management, including avoiding leg crossing, squatting, and kneeling. Symptoms typically improve over 2-3 months.

Answer 193

A: The fourth cranial nerve supplies the superior oblique muscle.

Answer 194

A: The superior oblique muscle is responsible for rotating the eye downward and outward, especially when the eye is adducted.

Answer 195

A: Vertical diplopia (double vision), subjective tilting of objects (torsional diplopia), and a head tilt.

Answer 196

A: The affected eye appears to deviate upwards and is rotated outwards.

Answer 197

A: Friedreich's ataxia is an autosomal recessive disorder.

Answer 198

A: It does not demonstrate the phenomenon of anticipation.

Answer 199

A: The typical age of onset is between 10 and 15 years old.

Answer 200

A: Gait ataxia and kyphoscoliosis.

Answer 201

A: Absent ankle jerks, extensor plantars, cerebellar ataxia, optic atrophy, and spinocerebellar tract degeneration.

Answer 202

A: Hypertrophic obstructive cardiomyopathy (90% of cases).

Answer 203

A: Diabetes mellitus (10-20%) and high-arched palate.

Answer 204

A: Ataxic telangiectasia tends to present much earlier, often at 1-2 years of age, whereas Friedreich's ataxia typically presents between 10 and 15 years.

Answer 205

6: Obeys commands 5: Localises to pain 4: Withdraws from pain 3: Abnormal flexion to pain (decorticate posture) 2: Extending to pain 1: None

Answer 206

5: Orientated 4: Confused 3: Words 2: Sounds 1: None

Answer 207

4: Spontaneous 3: To speech 2: To pain 1: None

Answer 208

A: Guillain-Barré syndrome is caused by immune-mediated demyelination of the peripheral nervous system. It is often triggered by an infection, such as Campylobacter jejuni. The pathogenesis involves the cross-reaction of antibodies with gangliosides in the peripheral nervous system.

Answer 209

A: Anti-ganglioside antibodies, such as anti-GM1, are found in 25% of Guillain-Barré syndrome patients. These antibodies correlate with clinical features, contributing to the disease process.

Answer 210

A: Miller Fisher syndrome is a variant of Guillain-Barré syndrome, characterized by ophthalmoplegia, areflexia, and ataxia. It usually presents as a descending paralysis (starting from the eyes) rather than the typical ascending paralysis seen in other forms of Guillain-Barré syndrome.

Answer 211

A: Anti-GQ1b antibodies are present in 90% of cases of Miller Fisher syndrome.

Answer 212

A: Back/leg pain is experienced by around 65% of patients in the initial stages of Guillain-Barré syndrome.

Answer 213

A: The characteristic feature is progressive, symmetrical weakness of all limbs, typically starting in the legs (ascending weakness). Reflexes are reduced or absent.

Answer 214

A: Sensory symptoms in Guillain-Barré syndrome tend to be mild, such as distal paraesthesia, with very few sensory signs.

Answer 215

History of gastroenteritis (often due to Campylobacter jejuni) Respiratory muscle weakness Cranial nerve involvement (e.g., diplopia, bilateral facial nerve palsy) Oropharyngeal weakness Autonomic involvement (e.g., urinary retention, diarrhoea)

Answer 216

A: Papilloedema (due to reduced CSF resorption) is a less common finding in Guillain-Barré syndrome.

Answer 217

A: Lumbar puncture typically shows albuminocytologic dissociation, where there is a rise in protein with a normal white blood cell count in 66% of patients.

Answer 218

Decreased motor nerve conduction velocity (due to demyelination) Prolonged distal motor latency Increased F wave latency

Answer 219

A: Migraine is a recurrent, severe headache that is usually unilateral and throbbing. It may be associated with aura, nausea, and photosensitivity. The headache is aggravated by, or causes avoidance of, routine activities, and patients often feel the need to "go to bed." In women, it may be associated with menstruation.

Answer 220

A: Tension headache is recurrent, non-disabling, and bilateral, often described as a "tight-band" sensation. It is not aggravated by routine activities of daily living.

Answer 221

A: Cluster headache typically involves intense pain around one eye, with recurrent attacks lasting 15 minutes to 2 hours. Attacks occur once or twice a day and last for 4-12 weeks. Patients are restless during attacks, and the headache is accompanied by redness, lacrimation, and lid swelling. It is more common in men and smokers.

Answer 222

A: Temporal arteritis typically affects patients over 60 years old and presents with rapid onset unilateral headache (usually < 1 month). It is associated with jaw claudication (65%), a tender, palpable temporal artery, and a raised ESR.

Answer 223

A: Medication overuse headache occurs when headaches are present for 15 days or more per month and worsen while taking regular symptomatic medication. Patients using opioids and triptans are at the highest risk, and psychiatric comorbidity may also be present.

Answer 224

Meningitis Encephalitis Subarachnoid hemorrhage Head injury Sinusitis Glaucoma (acute closed-angle) Tropical illness (e.g., Malaria)

Answer 225

Chronically raised intracranial pressure (ICP) Paget's disease Psychological causes

Answer 226

A: It is recommended to refer patients with trigeminal autonomic cephalgia (such as cluster headache, paroxysmal hemicrania, and SUNCT) for specialist assessment. Specific treatments, such as indomethacin for paroxysmal hemicrania, may be required.

Answer 227

A: Red flags for compromised immunity include a history of HIV or immunosuppressive drug use, which could increase the risk of infections like meningitis or brain abscesses.

Answer 228

A: A headache in patients under 20 years old with a history of malignancy, particularly one known to metastasize to the brain, is a red flag that warrants further investigation.

Answer 229

A: A thunderclap headache is characterized by sudden-onset headache that reaches maximum intensity within 5 minutes, and it can be indicative of serious conditions like subarachnoid hemorrhage.

Answer 230

A: Vomiting without an obvious cause may indicate increased intracranial pressure or conditions such as a brain tumor or hemorrhage.

Answer 231

A: Worsening headache with fever can be a red flag for conditions like meningitis or encephalitis and should be evaluated urgently.

Answer 232

A: New-onset neurological deficits or cognitive dysfunction with headache could indicate serious conditions like a brain tumor, stroke, or brain abscess.

Answer 233

A: A change in personality associated with headache could indicate a space-occupying lesion, such as a brain tumor or abscess.

Answer 234

A: A recent head trauma, particularly within the past 3 months, along with headache, warrants investigation for post-concussion syndrome, hematoma, or other traumatic brain injury-related conditions.

Answer 235

A: Headache triggered by coughing, Valsalva maneuver (bearing down), sneezing, or exercise can suggest a structural brain issue, such as a tumor or aneurysm, and needs further evaluation.

Answer 236

A: Orthostatic headache (worsening or improving with posture) may indicate conditions like a CSF leak or increased intracranial pressure and should be assessed promptly.

Answer 237

A: Symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma include scalp tenderness, jaw claudication, visual disturbances, and eye pain, which require urgent medical attention.

Answer 238

A: A substantial change in the pattern, intensity, or frequency of a patient’s headache could indicate a secondary cause such as a brain tumor, intracranial hemorrhage, or other serious pathology.

Answer 239

A: HSV-1 is responsible for 95% of cases of Herpes Simplex Encephalitis in adults.

Answer 240

A: Typical features include fever, headache, psychiatric symptoms, seizures, vomiting, and focal neurological signs such as aphasia.

Answer 241

A: The temporal lobes are most commonly affected in Herpes Simplex Encephalitis.

Answer 242

A: Peripheral lesions, such as cold sores, are not related to the presence of Herpes Simplex Encephalitis.

Answer 243

A: CSF findings include lymphocytosis, elevated protein, and a positive PCR for HSV.

Answer 244

A: MRI is better than CT for detecting Herpes Simplex Encephalitis. CT may show medial temporal and inferior frontal changes, while MRI reveals hyperintensity in the affected white matter and cortex.

Answer 245

A: The EEG pattern typically shows lateralised periodic discharges at 2 Hz in Herpes Simplex Encephalitis.

Answer 246

A: The first-line treatment is intravenous aciclovir.

Answer 247

A: The newer term for Charcot-Marie-Tooth disease is Hereditary Sensorimotor Neuropathy (HSMN).

Answer 248

HSMN type I (demyelinating pathology) HSMN type II (axonal pathology)

Answer 249

A: HSMN type I follows an autosomal dominant inheritance pattern.

Answer 250

A: Features of HSMN type I often start at puberty.

Answer 251

A: The predominant symptom in HSMN type I is motor symptoms, including distal muscle wasting and weakness.

Answer 252

Distal muscle wasting Pes cavus Clawed toes Foot drop Leg weakness

Answer 253

A: The main clinical features at the onset of HSMN type I include foot drop and leg weakness.

Answer 254

A: Huntington's disease follows an autosomal dominant inheritance pattern.

Answer 255

A: Huntington's disease is caused by a trinucleotide repeat expansion of CAG in the huntingtin gene on chromosome 4.

Answer 256

A: Anticipation refers to the phenomenon where Huntington's disease presents at an earlier age in successive generations due to the trinucleotide repeat disorder.

Answer 257

A: Huntington's disease results in the degeneration of cholinergic and GABAergic neurons in the striatum of the basal ganglia.

Answer 258

A: Symptoms of Huntington's disease typically develop after 35 years of age.

Answer 259

A: The typical motor symptoms of Huntington's disease include chorea and dystonia.

Answer 260

Personality changes (e.g., irritability, apathy, depression) Intellectual impairment Saccadic eye movements

Answer 261

A: Idiopathic intracranial hypertension (IIH) is also known as pseudotumour cerebri and was formerly called benign intracranial hypertension.

Answer 262

A: Idiopathic intracranial hypertension is classically seen in young, overweight females.

Answer 263

Obesity Female sex Pregnancy Certain medications (e.g., combined oral contraceptive pill, steroids, tetracyclines, retinoids, lithium).

Answer 264

Headache Blurred vision Papilloedema (usually present) Enlarged blind spot Sixth nerve palsy may be present.

Answer 265

Weight loss (via diet and exercise) Carbonic anhydrase inhibitors (e.g., acetazolamide) Topiramate (inhibits carbonic anhydrase and promotes weight loss).

Answer 266

Optic nerve sheath decompression and fenestration (to prevent optic nerve damage) Lumboperitoneal or ventriculoperitoneal shunts (to reduce intracranial pressure).

Answer 267

A: Internuclear ophthalmoplegia (INO) is a cause of horizontal disconjugate eye movement due to a lesion in the medial longitudinal fasciculus (MLF).

Answer 268

A: The MLF controls horizontal eye movements by interconnecting the IIIrd, IVth, and VIth cranial nuclei, which are located in the paramedian area of the midbrain and pons.

Answer 269

Impaired adduction of the eye on the same side as the lesion Horizontal nystagmus of the abducting eye on the contralateral side.

Answer 270

Multiple sclerosis Vascular disease.

Answer 271

A: Intracranial venous thrombosis can cause cerebral infarction, but it is much less common than arterial causes.

Answer 272

A: Around 50% of patients have isolated sagittal sinus thrombosis. The remainder have coexistent lateral sinus and cavernous sinus thromboses.

Answer 273

Headache (which may be sudden onset) Nausea & vomiting Reduced consciousness.

Answer 274

A: MRI venography is the gold standard. CT venography is an alternative, but a non-contrast CT head is normal in about 70% of patients. D-dimer levels may also be elevated.

Answer 275

A: The typical management is anticoagulation: Low molecular weight heparin is used acutely Warfarin is typically used for long-term anticoagulation.

Answer 276

Seizures and hemiplegia Parasagittal biparietal or bifrontal haemorrhagic infarctions may be seen 'Empty delta sign' on venography.

Answer 277

Periorbital erythema and oedema Ophthalmoplegia (6th nerve damage occurs before 3rd & 4th) Trigeminal nerve involvement, causing hyperaesthesia of the upper face and eye pain Central retinal vein thrombosis.

Answer 278

A: Features include 6th and 7th cranial nerve palsies.

Answer 279

A: Lambert-Eaton syndrome is often seen in association with small cell lung cancer and, to a lesser extent, breast and ovarian cancer. It can also occur independently as an autoimmune disorder.

Answer 280

A: Lambert-Eaton myasthenic syndrome is caused by an antibody directed against presynaptic voltage-gated calcium channels in the peripheral nervous system.

Answer 281

repeated muscle contractions lead to increased muscle strength (in contrast to myasthenia gravis) Limb-girdle weakness, often starting in the lower limbs Hyporeflexia Autonomic symptoms: dry mouth, impotence, and difficulty micturating Unlike in myasthenia gravis, ophthalmoplegia and ptosis are not commonly seen.

Answer 282

A: EMG shows an incremental response to repetitive electrical stimulation.

Answer 283

Treatment of the underlying cancer Immunosuppression, for example with prednisolone and/or azathioprine 3,4-diaminopyridine is being trialled, which increases acetylcholine release by blocking potassium channel efflux at the nerve terminal Intravenous immunoglobulin therapy and plasma exchange may be beneficial.

Answer 284

A: Lamotrigine is used as a second-line antiepileptic for a variety of generalized and partial seizures.

Answer 285

A: Lamotrigine acts as a sodium channel blocker, inhibiting the spread of seizure activity.

Answer 286

A: A serious adverse effect of Lamotrigine is Stevens-Johnson syndrome, a life-threatening skin condition.

Answer 287

A: Lateral Medullary Syndrome is caused by occlusion of the posterior inferior cerebellar artery.

Answer 288

A: Lateral Medullary Syndrome presents with ataxia and nystagmus as cerebellar features.

Answer 289

A: Ipsilateral features include dysphagia, facial numbness, and cranial nerve palsy (e.g., Horner's syndrome). Contralateral features include limb sensory loss.

Answer 290

A: Levodopa is combined with a decarboxylase inhibitor to prevent the peripheral metabolism of L-dopa to dopamine, ensuring more L-dopa reaches the brain.

Answer 291

A: The effectiveness of levodopa typically reduces over time, usually by around 2 years.

Answer 292

A: Levodopa is not useful in neuroleptic-induced parkinsonism.

Answer 293

Dyskinesia 'On-off' effect Postural hypotension Cardiac arrhythmias Nausea & vomiting Psychosis Reddish discoloration of urine upon standing

Answer 294

A: The median nerve is formed by the union of a lateral root (C5, C6, C7) and a medial root (C8, T1) from the brachial plexus.

Answer 295

A: The median nerve provides sensory innervation to the palmar aspect of the thumb and lateral 2 ½ fingers and the distal regions on the dorsal aspect of the same fingers.

Answer 296

Paralysis and wasting of the thenar eminence muscles Opponens pollicis paralysis (leading to ape hand deformity) Sensory loss to the palmar aspect of the lateral 2 ½ fingers.

Answer 297

Inability to pronate the forearm Weak wrist flexion Ulnar deviation of the wrist.

Answer 298

Loss of pronation of the forearm Weakness of the long flexors of the thumb and index finger.

Answer 299

A: Medication overuse headache is one of the most common causes of chronic daily headache, affecting up to 1 in 50 people. It occurs when headaches are present for 15 days or more per month and develop or worsen with the use of regular symptomatic medication.

Answer 300

A: Opioids and triptans are the most common medications associated with medication overuse headache.

Answer 301

Simple analgesics and triptans should be withdrawn abruptly (which may initially worsen headaches). Opioid analgesics should be gradually withdrawn.

Answer 302

Vomiting Hypotension Tachycardia Restlessness Sleep disturbances Anxiety

Answer 303

Headache Fever Nausea/vomiting Photophobia Drowsiness Seizures

Answer 304

Neck stiffness Purpuric rash (particularly with invasive meningococcal disease)

Answer 305

Appearance: Cloudy Glucose: Low (< 1/2 plasma) Protein: High (> 1 g/l) White cells: 10 - 5,000 polymorphs/mm³

Answer 306

Appearance: Clear/cloudy Glucose: 60-80% of plasma glucose Protein: Normal/raised White cells: 15 - 1,000 lymphocytes/mm³

Answer 307

Appearance: Slight cloudy, fibrin web Glucose: Low (< 1/2 plasma) Protein: High (> 1 g/l) White cells: 10 - 1,000 lymphocytes/mm³

Answer 308

A: PCR (Polymerase Chain Reaction) is used, with a sensitivity of 75%, since Ziehl-Neelsen stain has only 20% sensitivity.

Answer 309

A: A low glucose level may be seen in a proportion of cases of mumps and herpes encephalitis.

Answer 310

Sensorineural hearing loss (most common) Seizures Focal neurological deficit

Answer 311

Sepsis Intracerebral abscess

Answer 312

Brain herniation Hydrocephalus

Answer 313

A: Waterhouse-Friderichsen syndrome is adrenal insufficiency due to adrenal hemorrhage, and it is a risk in patients with meningococcal meningitis.

Answer 314

Severe, unilateral, throbbing headache Associated with nausea, photophobia, and phonophobia Lasts up to 72 hours Patients often go to a dark, quiet room during an attack 'Classic' migraines may be preceded by an aura

Answer 315

Visual disturbance Progressive Lasts 5-60 minutes Often characterized by transient hemianopic disturbance or a scintillating scotoma

Answer 316

Tiredness, stress Alcohol Combined oral contraceptive pill Lack of food or dehydration Certain foods (cheese, chocolate, red wine, citrus fruits) Menstruation Bright lights

Answer 317

A. At least 5 attacks B. Headaches lasting 4-72 hours C. At least two of the following characteristics: Unilateral location Pulsating quality Moderate/severe pain intensity Aggravated by or causing avoidance of physical activity D. At least one of the following during headache: Nausea/vomiting Photophobia/phonophobia E. Not attributed to another disorder

Answer 318

A variant of migraine with motor weakness as part of the aura Affects around 0.01% of migraine patients More common in adolescent females Half of patients have a strong family history

Answer 319

Attacks may be shorter-lasting Headache is more commonly bilateral Gastrointestinal disturbance is more prominent

Answer 320

Migraine with aura occurs in around 25% of migraine patients Aura is progressive in nature and may occur hours prior to the headache Typical aura includes transient hemianopic disturbance or a spreading scintillating scotoma ('jagged crescent') Sensory symptoms may also occur

Answer 321

NICE criteria: Auras may occur with or without headache Auras are fully reversible Auras develop over at least 5 minutes and last 5-60 minutes NICE also mentions: Auras can be unilateral or bilateral Atypical symptoms that may prompt further investigation: motor weakness, double vision, visual symptoms affecting only one eye, poor balance, decreased level of consciousness

Answer 322

Motor weakness Double vision Visual symptoms affecting only one eye Poor balance Decreased level of consciousness

Answer 323

Combination therapy: An oral triptan and an NSAID, or An oral triptan and paracetamol

Answer 324

Consider a nasal triptan in preference to an oral triptan

Answer 325

Offer a non-oral preparation of metoclopramide or prochlorperazine Consider adding a non-oral NSAID or tripan

Answer 326

Caution is needed as acute dystonic reactions may develop in young patients

Answer 327

If migraine attacks significantly impact quality of life and daily function, for example, if they occur frequently (more than once a week on average) or are severe despite optimal acute treatment

Answer 328

Propranolol Topiramate (avoided in women of childbearing age due to teratogenicity and reduced effectiveness of hormonal contraceptives) Amitriptyline

Answer 329

A course of up to 10 sessions of acupuncture over 5-8 weeks

Answer 330

Riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people

Answer 331

Frovatriptan (2.5 mg twice a day) or Zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'

Answer 332

Paracetamol (1g) is the first-line treatment

Answer 333

NSAIDs (non-steroidal anti-inflammatory drugs) can be used as a second-line treatment

Answer 334

Aspirin Opioids such as codeine

Answer 335

The COC pill is absolutely contraindicated in patients with migraine with aura due to an increased risk of stroke (relative risk 8.72)

Answer 336

Mefanamic acid A combination of aspirin, paracetamol, and caffeine Triptans are recommended for acute situations

Answer 337

It is safe to prescribe HRT for patients with a history of migraine, but it may make migraines worse.

Answer 338

Asymmetric limb weakness is the most common presentation of ALS.

Answer 339

Mixture of upper and lower motor neuron signs Wasting of small hand muscles or tibialis anterior Fasciculations Absence of sensory signs/symptoms (vague sensory symptoms like limb pain may occur early but never full sensory signs)

Answer 340

External ocular muscles are not affected.

Answer 341

No cerebellar signs Abdominal reflexes are usually preserved Sphincter dysfunction is a late feature

Answer 342

The diagnosis is clinical. Nerve conduction studies show normal motor conduction, helping exclude a neuropathy. Electromyography shows a reduced number of action potentials with increased amplitude. MRI is used to exclude other diagnoses such as cervical cord compression and myelopathy.

Answer 343

A: A chronic cell-mediated autoimmune disorder characterized by demyelination in the central nervous system.

Answer 344

A: 3 times more common in women.

Answer 345

A: Between 20-40 years.

Answer 346

A: Relapsing-remitting disease.

Answer 347

A: Acute attacks lasting 1-2 months followed by periods of remission.

Answer 348

A: Around 85%.

Answer 349

A: Describes relapsing-remitting patients who have deteriorated and developed neurological signs and symptoms between relapses.

Answer 350

A: Gait and bladder disorders.

Answer 351

A: Progressive deterioration from onset.

Answer 352

A: More common in older people.

Answer 353

Diagnosis requires demonstration of lesions disseminated in time and space.

Answer 354

High signal T2 lesions Periventricular plaques Dawson fingers: hyperintense lesions often seen on FLAIR images, perpendicular to the corpus callosum.

Answer 355

Oligoclonal bands (present in CSF, not in serum). Increased intrathecal synthesis of IgG.

Answer 356

Delayed, but well-preserved waveform.

Answer 357

Treatment is focused on reducing the frequency and duration of relapses. There is no cure for multiple sclerosis.

Answer 358

High-dose steroids (e.g., oral or IV methylprednisolone) for 5 days to shorten the length of the relapse. Steroids shorten the duration of relapse but do not affect recovery (whether the patient returns to baseline function).

Answer 359

Relapsing-remitting disease with 2 relapses in past 2 years and able to walk 100m unaided. Secondary progressive disease with 2 relapses in past 2 years and able to walk 10m (aided or unaided).

Answer 360

Natalizumab: monoclonal antibody, inhibits leucocyte migration across the blood-brain barrier, given intravenously. Ocrelizumab: anti-CD20 monoclonal antibody, high-efficacy, given intravenously. Fingolimod: sphingosine 1-phosphate receptor modulator, prevents lymphocytes from leaving lymph nodes, available orally. Beta-interferon: less effective, given subcutaneously/intramuscularly. Glatiramer acetate: immunomodulating drug, acts as an immune decoy, given subcutaneously.

Answer 361

Trial of amantadine after excluding other causes (e.g., anaemia, thyroid problems, depression). Mindfulness training and CBT may also be helpful.

Answer 362

First-line treatments: baclofen and gabapentin. Other options: diazepam, dantrolene, tizanidine. Physiotherapy is important. Cannabis and botox are undergoing evaluation.

Answer 363

Ultrasound to assess bladder emptying first. Intermittent self-catheterisation if significant residual volume. Anticholinergics may help if no significant residual volume and can improve urinary frequency.

Answer 364

Gabapentin is first-line for managing oscillopsia.

Answer 365

MSA-P: Predominant Parkinsonian features. MSA-C: Predominant Cerebellar features

Answer 366

Shy-Drager syndrome is a type of Multiple System Atrophy (MSA).

Answer 367

Parkinsonism (similar to Parkinson's disease) Autonomic disturbance Erectile dysfunction (often an early feature) Postural hypotension Atonic bladder Cerebellar signs (e.g., ataxia)

Answer 368

Muscle fatigability: Muscles become progressively weaker during periods of activity and improve after rest.

Answer 369

Extraocular muscle weakness: Diplopia (double vision) Proximal muscle weakness: Face, neck, and limb girdle muscles Ptosis Dysphagia (difficulty swallowing)

Answer 370

Thymomas: Found in 15% of cases Autoimmune disorders: Pernicious anemia, autoimmune thyroid disorders, rheumatoid arthritis, SLE Thymic hyperplasia: Found in 50-70% of cases

Answer 371

Single fiber electromyography: High sensitivity (92-100%) CT thorax: To exclude thymoma Antibodies to acetylcholine receptors: Positive in 85-90% of cases Tensilon test: IV edrophonium temporarily improves muscle weakness (not commonly used due to cardiac arrhythmia risk)

Answer 372

Pyridostigmine (long-acting acetylcholinesterase inhibitor)

Answer 373

Prednisolone (initially) Azathioprine, Cyclosporine, Mycophenolate mofetil (may be used later)

Answer 374

Plasmapheresis Intravenous immunoglobulins (IVIg)

Answer 375

Exertion: Physical activity leads to increased fatigability, which is the hallmark feature of Myasthenia Gravis. Symptoms become more marked during the day.

Answer 376

Penicillamine Quinidine and Procainamide Beta-blockers Lithium Phenytoin Antibiotics: Gentamicin Macrolides Quinolones Tetracyclines

Answer 377

DM1 (Dystrophia Myotonica Type 1) DM2 (Dystrophia Myotonica Type 2)

Answer 378

Autosomal dominant inheritance Trinucleotide repeat disorders

Answer 379

Myotonic facies (long, 'haggard' appearance) Frontal balding Bilateral ptosis Cataracts Dysarthria

Answer 380

Myotonia (tonic spasm of muscles) Distal muscle weakness (initially in arms and legs) Mild mental impairment Diabetes mellitus Testicular atrophy Cardiac involvement (heart block, cardiomyopathy) Dysphagia

Answer 381

Narcolepsy is associated with HLA-DR2

Answer 382

Narcolepsy is associated with low levels of orexin (hypocretin), a protein responsible for controlling appetite and sleep patterns.

Answer 383

Early onset of REM sleep

Answer 384

Typical onset is in teenage years

Answer 385

Hypersomnolence (excessive daytime sleepiness) Cataplexy (sudden loss of muscle tone, often triggered by emotion) Sleep paralysis Vivid hallucinations (on going to sleep or waking up)

Answer 386

Multiple sleep latency EEG

Answer 387

Daytime stimulants (e.g., modafinil) Nighttime sodium oxybate

Answer 388

NF1 (von Recklinghausen's syndrome) NF2

Answer 389

Both NF1 and NF2 are inherited in an autosomal dominant fashion.

Answer 390

Cafe-au-lait spots (≥ 6, 15 mm in diameter) Axillary/groin freckles Peripheral neurofibromas Iris hamartomas (Lisch nodules) in > 90% Scoliosis Pheochromocytomas

Answer 391

Bilateral vestibular schwannomas Multiple intracranial schwannomas, meningiomas, and ependymomas

Answer 392

NMS is a rare but potentially fatal condition that can occur in patients taking antipsychotic medications or dopaminergic drugs (e.g., levodopa for Parkinson’s). It can happen when these medications are suddenly stopped or doses are reduced.

Answer 393

The exact pathophysiology is unknown, but one theory is that dopamine blockade by antipsychotics triggers massive glutamate release, leading to neurotoxicity and muscle damage.

Answer 394

NMS typically develops within hours to days of starting an antipsychotic medication.

Answer 395

Pyrexia (fever) Muscle rigidity Autonomic lability (e.g., hypertension, tachycardia, tachypnoea) Agitated delirium with confusion

Answer 396

Raised creatine kinase (CK) (often markedly elevated) Leukocytosis (elevated white blood cell count) Acute kidney injury (secondary to rhabdomyolysis) in severe cases

Answer 397

Stop antipsychotic medications Transfer to a medical ward or intensive care unit IV fluids to prevent renal failure Dantrolene (helps decrease excitation-contraction coupling in skeletal muscle) Bromocriptine (dopamine agonist) can also be used

Answer 398

Both conditions can cause elevated creatine kinase (CK), but this is more strongly associated with NMS. NMS also tends to present with more muscle rigidity and autonomic instability.

Answer 399

Neuropathic pain is pain that arises following damage or disruption to the nervous system. It often responds poorly to standard analgesia.

Answer 400

Diabetic neuropathy Post-herpetic neuralgia Trigeminal neuralgia Prolapsed intervertebral disc

Answer 401

First-line treatments include: Amitriptyline Duloxetine Gabapentin Pregabalin If the first-line treatment does not work, another of the listed drugs should be tried.

Answer 402

Drugs for neuropathic pain are typically used as monotherapy. If a drug does not work, it should be switched to another rather than added on top of the existing treatment.

Answer 403

Tramadol may be used as rescue therapy.

Answer 404

Topical capsaicin may be used for localized neuropathic pain.

Answer 405

Pain management clinics may be useful for patients with resistant neuropathic pain problems.

Answer 406

Carbamazepine is used first-line for trigeminal neuralgia.

Answer 407

Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients, often due to reduced CSF absorption at the arachnoid villi, which can be secondary to head injury, subarachnoid hemorrhage, or meningitis.

Answer 408

Urinary incontinence Dementia and bradyphrenia Gait abnormality (may be similar to Parkinson's disease)

Answer 409

Imaging shows hydrocephalus with ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement.

Answer 410

Ventriculoperitoneal shunting is the primary management.

Answer 411

Around 10% of patients who have shunts experience significant complications such as seizures, infection, and intracerebral hemorrhages.

Answer 412

Parkinson's disease is a progressive neurodegenerative condition caused by the degeneration of dopaminergic neurons in the substantia nigra, resulting in a classical triad of features: bradykinesia, tremor, and rigidity.

Answer 413

Bradykinesia Tremor Rigidity

Answer 414

Poverty of movement, also referred to as hypokinesia Short, shuffling steps with reduced arm swinging Difficulty in initiating movement

Answer 415

Most marked at rest, 3-5 Hz Worse when stressed or tired, improves with voluntary movement Typically 'pill-rolling', i.e., in the thumb and index finger

Answer 416

Lead pipe rigidity Cogwheel rigidity: due to superimposed tremor

Answer 417

Mask-like facies Flexed posture Micrographia Drooling of saliva Psychiatric features: depression (most common), dementia, psychosis, and sleep disturbances Impaired olfaction REM sleep behavior disorder Fatigue Autonomic dysfunction, including postural hypotension

Answer 418

Motor symptoms are generally rapid onset and bilateral Rigidity and rest tremor are uncommon

Answer 419

Diagnosis is usually clinical. However, if there is difficulty differentiating between essential tremor and Parkinson's disease, NICE recommends considering 123I-FP-CIT single photon emission computed tomography (SPECT).

Answer 420

A specialist with expertise in movement disorders should diagnose and initiate the management of Parkinson's disease.

Answer 421

Dopamine agonist (non-ergot derived) Levodopa Monoamine oxidase B (MAO-B) inhibitor

Answer 422

Dry mouth Anorexia Palpitations Postural hypotension Psychosis

Answer 423

Large variations in motor performance, with normal function during the 'on' period, and weakness and restricted mobility during the 'off' period.

Answer 424

NICE recommends the addition of a dopamine agonist, MAO-B inhibitor, or catechol-O-methyl transferase (COMT) inhibitor as an adjunct.

Answer 425

Examples include bromocriptine, ropinirole, cabergoline, and apomorphine. Side effects include impulse control disorders, excessive daytime somnolence, hallucinations in older patients, nasal congestion, and postural hypotension.

Answer 426

Antimuscarinics block cholinergic receptors and are now more commonly used to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease. They help with tremor and rigidity (e.g., procyclidine, benzotropine, trihexyphenidyl).

Answer 427

A medication review looking at potential causes should be done. If symptoms persist, midodrine can be considered.

Answer 428

Patients should not drive, medication should be adjusted to control symptoms, and modafinil can be considered if alternative strategies fail.

Answer 429

Acutely stopping levodopa can lead to acute akinesia or neuroleptic malignant syndrome. If a patient with Parkinson's disease cannot take levodopa orally, they can be given a dopamine agonist patch as rescue medication to prevent acute dystonia.

Answer 430

A syndrome characterized by tremor, bradykinesia, rigidity, and postural instability, typically associated with Parkinson's disease but can also have other causes.

Answer 431

Antipsychotics Metoclopramide

Answer 432

Domperidone

Answer 433

PSP is a neurodegenerative disease involving the gradual deterioration of cells in the brain, leading to symptoms of Parkinsonism.

Answer 434

Multiple system atrophy (MSA)

Answer 435

Wilson's disease is a genetic disorder in which copper builds up in the body, leading to neurological symptoms, including Parkinsonism.

Answer 436

Post-encephalitis Parkinsonism can occur after an inflammation of the brain, often due to viral infection, leading to damage in regions controlling movement.

Answer 437

A type of severe, unilateral headache that typically occurs in the orbital, supraorbital, or temporal region.

Answer 438

Less than 30 minutes.

Answer 439

Multiple times a day.

Answer 440

Trigeminal autonomic cephalgias.

Answer 441

Cluster headache.

Answer 442

It is completely responsive to indomethacin.

Answer 443

Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies (Charcot-Marie-Tooth), chronic inflammatory demyelinating polyneuropathy (CIDP), diphtheria.

Answer 444

Diabetes, uraemia, leprosy, alcoholism, vitamin B12 deficiency, amyloidosis.

Answer 445

Sensory symptoms.

Answer 446

A condition seen in vitamin B12 deficiency where both the dorsal columns and the lateral corticospinal tracts of the spinal cord are affected.

Answer 447

Dizziness Diplopia Nystagmus Slurred speech Ataxia Confusion Seizures (later)

Answer 448

Gingival hyperplasia Hirsutism Coarsening of facial features Drowsiness Megaloblastic anaemia Peripheral neuropathy Osteomalacia Lymphadenopathy Dyskinesia

Answer 449

Phenytoin is associated with cleft palate and congenital heart disease in the offspring.

Answer 450

Phenytoin levels should be checked if: Adjusting the phenytoin dose Suspecting toxicity Detecting non-adherence to the prescribed medication

Answer 451

Coarsening of facial features.

Answer 452

Gingival hyperplasia, secondary to increased expression of platelet-derived growth factor (PDGF).

Answer 453

Pituitary apoplexy is the sudden enlargement of a pituitary tumor, usually a non-functioning macroadenoma, secondary to hemorrhage or infarction.

Answer 454

Hypertension Pregnancy Trauma Anticoagulation

Answer 455

Sudden onset headache (similar to subarachnoid hemorrhage) Vomiting Neck stiffness Visual field defects (classically bitemporal superior quadrantic defect) Extraocular nerve palsies Features of pituitary insufficiency (e.g., hypotension, hyponatraemia secondary to hypoadrenalism)

Answer 456

MRI is diagnostic.

Answer 457

Urgent steroid replacement due to loss of ACTH Careful fluid balance Surgery

Answer 458

It usually develops within 24-48 hours after the lumbar puncture but may occur up to one week later.

Answer 459

Worsens with an upright position Improves with recumbent position May last several days

Answer 460

Supportive initially (analgesia, rest) If pain continues for more than 72 hours, specific treatments include: blood patch, epidural saline, and intravenous caffeine.

Answer 461

Postural instability and falls Stiff, broad-based gait Impairment of vertical gaze (worse downward gaze) Parkinsonism with prominent bradykinesia Cognitive impairment, primarily frontal lobe dysfunction

Answer 462

Impairment of vertical gaze, with difficulty looking down more than up (difficulty reading or descending stairs).

Answer 463

Pseudoseizures.

Answer 464

Pelvic thrusting Family member with epilepsy Much more common in females Crying after seizure Seizures don't occur when alone Gradual onset

Answer 465

Tongue biting Raised serum prolactin

Answer 466

It is hypothesized that the spread of electrical activity to the ventromedial hypothalamus triggers the release of a specific prolactin regulator into the hypophyseal portal system, although the exact mechanism is not fully understood.

Answer 467

It supplies the skin of the proximal phalanges on the dorsal aspect of the hand (excluding the little finger and part of the ring finger).

Answer 468

Shoulder (long head of triceps): Minor effect on shoulder stability in abduction Arm (triceps): Loss of elbow extension Forearm: Weakening of supination of the prone hand and elbow flexion in a mid-prone position

Answer 469

Wrist drop and sensory loss to a small area between the dorsal aspect of the 1st and 2nd metacarpals.

Answer 470

Paralysis of the triceps Loss of elbow extension

Answer 471

7-15 mmHg in adults in the supine position.

Answer 472

CPP = Mean arterial pressure (MAP) - ICP

Answer 473

Idiopathic intracranial hypertension Traumatic head injuries Infection (e.g. meningitis) Tumours Hydrocephalus

Answer 474

Headache Vomiting Reduced levels of consciousness Papilloedema Cushing's triad (widening pulse pressure, bradycardia, irregular breathing)

Answer 475

Widening pulse pressure Bradycardia Irregular breathing

Answer 476

Neuroimaging (CT/MRI) Invasive ICP monitoring (via catheter placed in the lateral ventricles

Answer 477

Investigate and treat the underlying cause Head elevation to 30º IV mannitol (osmotic diuretic) Controlled hyperventilation (to reduce pCO2 and vasoconstrict cerebral arteries) Removal of CSF (via intraventricular drainage, repeated lumbar puncture, or ventriculoperitoneal shunt for hydrocephalus)

Answer 478

Uncontrollable urge to move the legs (akathisia), often accompanied by paraesthesias like crawling or throbbing sensations.

Answer 479

Symptoms initially occur at night but may also occur during the day as the condition progresses.

Answer 480

Periodic limb movements of sleep (PLMS), which may be noted by a partner.

Answer 481

The diagnosis is clinical, although blood tests such as ferritin to exclude iron deficiency anaemia may be useful.

Answer 482

Dopamine agonists (e.g., pramipexole, ropinirole) Benzodiazepines Gabapentin

Answer 483

Walking Stretching Massaging the affected limbs

Answer 484

A severe, progressive encephalopathy affecting children, accompanied by fatty infiltration of the liver, kidneys, and pancreas.

Answer 485

There is a known association with aspirin use, and a viral cause has been postulated.

Answer 486

A history of preceding viral illness Encephalopathy: confusion, seizures, cerebral oedema, coma Fatty infiltration of the liver, kidneys, and pancreas Hypoglycaemia

Answer 487

Management is supportive.

Answer 488

Check the airway and apply oxygen if appropriate. Place the patient in the recovery position. If the seizure is prolonged, administer benzodiazepines.

Answer 489

Neonate: 1.25 - 2.5 mg Child 1 month - 1 year: 5 mg Child 2 - 11 years: 5 - 10 mg Child 12 - 17 years: 10 mg Adult: 10 - 20 mg (max. 30 mg) Elderly: 10 mg (max. 15 mg)

Answer 490

Neonate: 300 mcg/kg (unlicensed) Child 1 - 2 months: 300 mcg/kg (max. 2.5 mg, unlicensed) Child 3 - 11 months: 2.5 mg Child 1 - 4 years: 5 mg Child 5 - 9 years: 7.5 mg Child 10 - 17 years: 10 mg Adult: 10 mg (unlicensed)

Answer 491

Diazepam may be repeated once after 10-15 minutes if necessary.

Answer 492

Sodium valproate is primarily used in the management of epilepsy and is first-line therapy for generalized seizures. It works by increasing GABA activity.

Answer 493

Sodium valproate is teratogenic and is associated with neural tube defects. Maternal use increases the risk of neurodevelopmental delay in children. It should not be used during pregnancy or in women of childbearing age unless absolutely necessary and only under specialist advice.

Answer 494

Common gastrointestinal side effects include nausea and increased appetite, which may lead to weight gain.

Answer 495

Alopecia (regrowth may be curly) Ataxia Tremor Hepatotoxicity Pancreatitis Thrombocytopaenia Hyponatraemia Hyperammonemic encephalopathy (can be treated with L-carnitine)

Answer 496

Spastic paraparesis refers to upper motor neuron weakness in the lower limbs, characterized by spasticity and weakness.

Answer 497

Demyelination: e.g., multiple sclerosis Cord compression: trauma, tumour Parasagittal meningioma Tropical spastic paraparesis Transverse myelitis: e.g., HIV Syringomyelia Hereditary spastic paraplegia Osteoarthritis of the cervical spine

Answer 498

ALS affects both upper and lower motor neurons, leading to a combination of upper motor neuron signs (e.g., spasticity) and lower motor neuron signs (e.g., muscle weakness, atrophy).

Answer 499

Poliomyelitis affects the anterior horns of the spinal cord, resulting in lower motor neuron signs such as muscle weakness and atrophy.

Answer 500

Lateral corticospinal tract: Ipsilateral spastic paresis below the lesion Dorsal columns: Ipsilateral loss of proprioception and vibration sensation Lateral spinothalamic tract: Contralateral loss of pain and temperature sensation

Answer 501

This condition is caused by vitamin B12 and E deficiencies, affecting: Lateral corticospinal tracts: Bilateral spastic paresis Dorsal columns: Bilateral loss of proprioception and vibration sensation Spinocerebellar tracts: Bilateral limb ataxia

Answer 502

Both conditions affect the same spinal tracts, but Friedrich's ataxia also causes cerebellar ataxia and other symptoms such as intention tremor.

Answer 503

Lateral corticospinal tracts: Bilateral spastic paresis Lateral spinothalamic tracts: Bilateral loss of pain and temperature sensation

Answer 504

Syringomyelia affects the ventral horns and lateral spinothalamic tract, leading to: Flaccid paresis (typically affecting the intrinsic hand muscles) Loss of pain and temperature sensation

Answer 505

Multiple sclerosis involves asymmetrical damage to varying spinal tracts, leading to a combination of motor, sensory, and ataxia symptoms.

Answer 506

Neurosyphilis affects the dorsal columns, leading to loss of proprioception and vibration sensation.

Answer 507

Spontaneous intracranial hypotension results from a cerebrospinal fluid (CSF) leak, often from the thoracic nerve root sleeves.

Answer 508

Risk factors include connective tissue disorders such as Marfan's syndrome.

Answer 509

The headache has a strong postural relationship, being much worse when upright. Patients may be bed-bound due to this headache.

Answer 510

MRI with gadolinium typically shows pachymeningeal enhancement.

Answer 511

Management is usually conservative, but if this fails, an epidural blood patch may be used.

Answer 512

A single seizure lasting >5 minutes, or ≥ 2 seizures within a 5-minute period without the person returning to normal between them.

Answer 513

First-line drugs are benzodiazepines. In the prehospital setting, PR diazepam or buccal midazolam may be given. In hospital, IV lorazepam is generally used, with the option to repeat it after 5-10 minutes.

Answer 514

If seizures continue, second-line agents such as levetiracetam, phenytoin, or sodium valproate are used.

Answer 515

If no response after 45 minutes, induction of general anaesthesia or phenobarbital should be used to achieve rapid control of seizure activity.

Answer 516

Contralateral hemiparesis and sensory loss, with lower extremity > upper.

Answer 517

Contralateral hemiparesis and sensory loss, with upper extremity > lower. Contralateral homonymous hemianopia. Aphasia

Answer 518

Contralateral homonymous hemianopia with macular sparing. Visual agnosia.

Answer 519

Ipsilateral CN III palsy. Contralateral weakness of the upper and lower extremity.

Answer 520

Ipsilateral: facial pain and temperature loss. Contralateral: limb/torso pain and temperature loss. Ataxia, nystagmus.

Answer 521

Symptoms similar to Wallenberg’s (lateral medullary syndrome) but with: Ipsilateral facial paralysis and deafness.

Answer 522

Amaurosis fugax is temporary vision loss, associated with a retinal/ophthalmic artery lesion.

Answer 523

'Locked-in syndrome' (complete paralysis except for eye movements).

Answer 524

Isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia. Strong association with hypertension. Common sites: basal ganglia, thalamus, and internal capsule.

Answer 525

Regularly assess hydration to maintain normovolaemia. Oral hydration is preferable for patients able to swallow safely. If necessary, use isotonic saline without dextrose for intravenous hydration. Be cautious of both hypovolaemia and over-hydration.

Answer 526

Aim to maintain blood glucose levels between 4-11 mmol/L. Intensive management is needed for diabetic patients, using intravenous insulin and glucose infusions. Avoid hypoglycaemia as it can cause neuronal injury and mimic stroke deficits.

Answer 527

The Barthel index measures functional status and disability after stroke. It assesses 10 tasks such as feeding, bathing, dressing, and mobility. Scores range from 0 (completely dependent) to 100 (completely independent), and it is used to monitor recovery and rehabilitation progress.

Answer 528

Ischaemic Stroke – caused by a blockage in the blood vessel. Subtypes: Thrombotic (from large vessels like the carotid) and Embolic (caused by blood clots or other materials). TIA (Transient Ischaemic Attack) is a subtype with temporary symptoms. Haemorrhagic Stroke – caused by a blood vessel bursting, leading to bleeding in the brain. Subtypes: Intracerebral haemorrhage and Subarachnoid haemorrhage.

Answer 529

Motor weakness Speech problems (dysphasia) Swallowing problems Visual field defects (e.g., homonymous hemianopia) Balance problems Brainstem infarctions may cause more severe symptoms like quadriplegia or lock-in syndrome.

Answer 530

Decreased level of consciousness (seen in up to 50% of patients) Headache Nausea and vomiting Seizures (in up to 25% of patients)

Answer 531

CT scan MRI These help differentiate between ischaemic and haemorrhagic strokes, aiding treatment decisions like thrombolysis.

Answer 532

Thrombolysis if criteria are met (e.g., within 4.5 hours of symptom onset). Aspirin 300mg as soon as possible after ruling out haemorrhagic stroke. Continue antiplatelet therapy.

Answer 533

Immediate aspirin 300mg unless contraindicated. If recurrent TIAs or suspected cardioembolism, consult a stroke specialist urgently. If suspected TIA occurred within the last 7 days, arrange urgent assessment within 24 hours.

Answer 534

Consult neurosurgical team for possible interventions. Stop anticoagulants and antithrombotics to minimize bleeding. Reverse anticoagulation if necessary and manage blood pressure acutely to improve outcomes.

Answer 535

The ROSIER score helps healthcare professionals assess the likelihood of stroke. A score > 0 suggests that a stroke is likely.

Answer 536

A non-contrast CT head scan is the first-line radiological investigation for suspected stroke. It helps differentiate between ischaemic and haemorrhagic strokes and detect other possible pathologies like a tumour.

Answer 537

Low density areas in the grey and white matter of the affected brain territory. The 'hyperdense artery' sign, which represents a clot in the responsible artery, often visible immediately.

Answer 538

Hyperdense material (blood) within the brain. Surrounding low-density areas due to oedema. This is a characteristic feature of haemorrhagic strokes.

Answer 539

Blood pressure should not be lowered unless there are complications (e.g., hypertensive encephalopathy) or if the patient is being considered for thrombolysis. Blood pressure control should be considered if systolic BP > 150 mmHg within 6 hours of symptom onset.

Answer 540

Aspirin 300 mg orally or rectally should be given as soon as possible.

Answer 541

Anticoagulants should not be started until brain imaging has excluded haemorrhage and typically not until 14 days after an ischaemic stroke.

Answer 542

The patient should be started on a statin, although many physicians delay treatment for at least 48 hours due to the risk of haemorrhagic transformation.

Answer 543

Administered within 4.5 hours of stroke symptom onset. Haemorrhage has been excluded via imaging.

Answer 544

Patients with an acute ischaemic stroke who were last known to be well more than 4.5 hours ago can be considered for thrombolysis if: Treatment can be started between 4.5 and 9 hours of onset or within 9 hours of waking up with symptoms, and Imaging shows potential to salvage brain tissue (core-perfusion mismatch or DWI-FLAIR mismatch).

Answer 545

Blood pressure should be lowered to 185/110 mmHg before thrombolysis.

Answer 546

Previous intracranial haemorrhage Seizure at onset of stroke Intracranial neoplasm Active bleeding Uncontrolled hypertension (>200/120 mmHg) Gastrointestinal haemorrhage in the past 3 weeks Recent stroke/brain injury in the past 3 months

Answer 547

Mechanical thrombectomy should be offered to patients with confirmed proximal anterior circulation occlusion (via CTA or MRA) within 6 hours of symptom onset, and within 24 hours for those with potential salvageable brain tissue, as shown by imaging. Thrombectomy can be combined with intravenous thrombolysis if within 4.5 hours.

Answer 548

Clopidogrel is preferred over combination aspirin and modified-release dipyridamole for secondary prevention. Aspirin should be used only if clopidogrel is contraindicated or not tolerated.

Answer 549

Recommended for patients with >50% stenosis in the carotid artery, especially in those who are not severely disabled. It should be performed as soon as possible within 7 days of the stroke or TIA.

Answer 550

Involves middle and anterior cerebral arteries. All three criteria (hemiparesis, homonymous hemianopia, and higher cognitive dysfunction) are present. Occurs in approximately 15% of strokes.

Answer 551

Involves smaller arteries of the anterior circulation (e.g., upper or lower division of the middle cerebral artery). Two of the three criteria are present. Occurs in approximately 25% of strokes.

Answer 552

Involves perforating arteries around the internal capsule, thalamus, and basal ganglia. Presents with one of the following: Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg, or all three. Pure sensory stroke. Ataxic hemiparesis. Occurs in approximately 25% of strokes.

Answer 553

Involves the vertebrobasilar arteries. Presents with one of the following: Cerebellar or brainstem syndromes. Loss of consciousness. Isolated homonymous hemianopia. Occurs in approximately 25% of strokes.Q: What is Lateral Medullary Syndrome (Wallenberg's Syndrome) and its clinical features?

Answer 554

Involves the posterior inferior cerebellar artery. Ipsilateral symptoms: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy (e.g., Horner's syndrome). Contralateral symptoms: limb sensory loss.

Answer 555

Ipsilateral oculomotor nerve (III) palsy. Contralateral weakness (hemiparesis).

Answer 556

Cause: Vitamin B12 deficiency (can also be caused by recreational nitrous oxide inhalation). Tracts involved: Dorsal columns Lateral corticospinal tracts Spinocerebellar tracts

Answer 557

Distal tingling/burning/sensory loss: Symmetrical, more prominent in legs than arms. Impaired proprioception and vibration sense.

Answer 558

Muscle weakness Hyperreflexia and spasticity Upper motor neuron signs: Typically develop in the legs first. Brisk knee reflexes, absent ankle jerks, extensor plantars.

Answer 559

Sensory ataxia: Gait abnormalities. Positive Romberg's sign.

Answer 560

Syringomyelia is a collection of cerebrospinal fluid (CSF) within the spinal cord. Syringobulbia is a similar condition with a fluid-filled cavity in the medulla of the brainstem.

Answer 561

Chiari malformation: Strong association Trauma Tumours Idiopathic

Answer 562

'Cape-like' distribution of sensory loss (neck, shoulders, and arms) Loss of temperature sensation, but preservation of light touch, proprioception, and vibration Spastic weakness (mainly in lower limbs) Neuropathic pain Upgoing plantars Autonomic features: Rare Horner's syndrome (due to sympathetic chain compression) Bowel and bladder dysfunction Scoliosis (if untreated)

Answer 563

Full spine MRI with contrast to exclude a tumor or tethered cord. Brain MRI to exclude a Chiari malformation

Answer 564

Treatment focuses on addressing the underlying cause of the syrinx. If the syrinx is persistent or symptomatic, a shunt may be placed to drain the fluid.

Answer 565

Tension-type headache is an episodic primary headache characterized by a tight band or pressure sensation around the head. Symptoms are typically bilateral, unlike migraines, which are often unilateral. It is usually of lower intensity than a migraine and is not associated with aura, nausea, vomiting, or aggravated by routine physical activity.

Answer 566

Described as a tight band or pressure sensation around the head. Bilateral headache, unlike unilateral migraines. Lower intensity than migraines. No aura, no nausea/vomiting, and not aggravated by physical activity. May be associated with stress. Can co-exist with migraine.

Answer 567

Defined as tension-type headaches occurring on 15 or more days per month.

Answer 568

Aspirin, paracetamol, or NSAIDs are first-line treatments for acute episodes of tension-type headache.

Answer 569

Acupuncture: Up to 10 sessions over 5-8 weeks. Low-dose amitriptyline: Though widely used in the UK, NICE did not support pharmacological prophylaxis for tension-type headaches due to insufficient evidence. They suggest that the assessment may reveal coexisting migraine, leading to a possible diagnosis of chronic migraine.

Answer 570

Eye deviated "down and out". Ptosis (drooping eyelid). Pupil may be dilated (sometimes referred to as a "surgical" third nerve palsy).

Answer 571

TOS is a disorder involving compression of the brachial plexus, subclavian artery, or subclavian vein at the site of the thoracic outlet. Neurogenic TOS accounts for 90% of cases.

Answer 572

A TIA is a brief period of neurological deficit due to a vascular cause, typically lasting less than an hour. The new definition is tissue-based: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Answer 573

Sudden onset of focal neurological deficits that resolve typically within 1 hour. Unilateral weakness or sensory loss. Aphasia or dysarthria. Ataxia, vertigo, or loss of balance. Visual problems: Amaurosis fugax (sudden transient loss of vision in one eye). Diplopia or homonymous hemianopia.

Answer 574

Aspirin 300 mg should be given immediately unless contraindicated. The patient should be assessed urgently within 24 hours by a stroke specialist clinician.

Answer 575

Hypoglycaemia Intracranial haemorrhage (patients on anticoagulants or with similar risk factors should be admitted for urgent imaging to exclude haemorrhage).

Answer 576

MRI (including diffusion-weighted and blood-sensitive sequences) is preferred to determine the territory of ischaemia or detect haemorrhage/alternative pathologies. CT is not recommended unless there is clinical suspicion of an alternative diagnosis like haemorrhage.

Answer 577

Immediate antithrombotic therapy (if no contraindication to bleeding): Aspirin 300 mg for resolved TIA symptoms, clopidogrel + aspirin for 21 days for high-risk patients. After 21 days, clopidogrel 75 mg daily for long-term secondary prevention. For atrial fibrillation, anticoagulation should be started once intracranial haemorrhage is excluded. Lipid modification with a high-intensity statin (e.g., atorvastatin 20-80 mg daily) to reduce non-HDL cholesterol by more than 40%.

Answer 578

Carotid imaging (carotid duplex ultrasound, CT angiography, or MR angiography) should be done if carotid atherosclerosis is suspected, especially if a carotid intervention is considered. Carotid endarterectomy is recommended for patients with symptomatic carotid stenosis (>50% stenosis according to NASCET criteria). Carotid imaging should be performed within 24 hours of assessment.

Answer 579

DAPT (clopidogrel + aspirin) is recommended for patients with TIA or minor ischaemic stroke within 24 hours of onset, provided there is no high risk of bleeding. Clopidogrel (300 mg loading dose followed by 75 mg daily) + Aspirin (300 mg loading dose followed by 75 mg daily) for 21 days, then monotherapy with clopidogrel. Ticagrelor + clopidogrel can be an alternative.

Answer 580

Resolved TIA symptoms, awaiting specialist review: Aspirin. Reviewed by specialist, initial 21 days (high risk): Aspirin + Clopidogrel. Long-term secondary prevention (after 21 days): Clopidogrel.

Answer 581

A pain syndrome characterised by severe unilateral pain. The pain is described as brief electric shock-like pains, abrupt in onset and termination. Limited to one or more divisions of the trigeminal nerve. Often triggered by light touch (e.g., washing, shaving, smoking, talking, brushing teeth). Pain may occur spontaneously and remit for variable periods.

Answer 582

Light touch, such as from: Washing, Shaving, Smoking, Talking, Brushing teeth.

Answer 583

Sensory changes, Deafness or other ear problems, History of skin or oral lesions that could spread perineurally, Pain only in the ophthalmic division (eye socket, forehead, and nose), or bilateral pain, Optic neuritis, Family history of multiple sclerosis, Onset of symptoms before 40 years of age.

Answer 584

Carbamazepine is the first-line treatment.

Answer 585

Refer the patient to neurology if there is failure to respond to treatment or atypical features (e.g., onset < 50 years old).

Answer 586

Triptans are specific 5-HT1B and 5-HT1D agonists used in the acute treatment of migraine. Typically used first-line in combination therapy with an NSAID or paracetamol.

Answer 587

Triptans should be taken as soon as possible after the onset of headache, rather than at the onset of aura.

Answer 588

'Triptan sensations': Tingling, Heat, Tightness (e.g., throat and chest), Heaviness, Pressure.

Answer 589

Patients with a history of, or significant risk factors for ischaemic heart disease or cerebrovascular disease should avoid Triptans.

Answer 590

Tuberous sclerosis is an autosomal dominant genetic condition.

Answer 591

Depigmented 'ash-leaf' spots that fluoresce under UV light. Shagreen patches (roughened patches of skin over lumbar spine). Adenoma sebaceum (angiofibromas) in a butterfly distribution over the nose. Fibromata beneath the nails (subungual fibromata). Cafe-au-lait spots (less common but may be seen, found in 28% of patients with TS).

Answer 592

Developmental delay. Epilepsy, including infantile spasms or partial seizures. Intellectual impairment.

Answer 593

Retinal hamartomas: dense white areas on retina (phakomata). Rhabdomyomas of the heart. Gliomatous changes in brain lesions. Polycystic kidneys and renal angiomyolipomata. Lymphangioleiomyomatosis: multiple lung cysts.

Answer 594

The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1).

Answer 595

Medial 1 1/2 fingers (palmar and dorsal aspects).

Answer 596

Claw hand: Hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits. Wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals). Wasting and paralysis of hypothenar muscles. Sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects).

Answer 597

Same as damage at wrist (claw hand, wasting, and sensory loss), but with an ulnar paradox where the clawing is more severe in distal lesions. Radial deviation of the wrist

Answer 598

Vertigo, Hearing loss, Tinnitus, Absent corneal reflex.

Answer 599

Neurofibromatosis type 2.

Answer 600

MRI of the cerebellopontine angle is the investigation of choice. Audiometry is also important, as 5% of patients will have a normal audiogram.

Answer 601

Surgery, Radiotherapy, Observation (since they are often slow-growing and benign).

Answer 602

Left homonymous hemianopia refers to a visual field defect where the left side of the visual field is lost in both eyes, caused by a lesion of the right optic tract.

Answer 603

Homonymous quadrantanopias involve visual field loss in one quadrant of both eyes. Superior quadrantanopia: Lesion of the inferior optic radiations in the temporal lobe (Meyer's loop). Inferior quadrantanopia: Lesion of the superior optic radiations in the parietal lobe. Mnemonic: PITS (Parietal-Inferior, Temporal-Superior).

Answer 604

Incongruous defects are asymmetric or incomplete visual field losses, typically due to a lesion of the optic tract.

Answer 605

Congruous defects refer to symmetrical or complete visual field loss, typically due to a lesion of the optic radiation or occipital cortex.

Answer 606

Macula sparing suggests a lesion of the occipital cortex, where the central visual field (macula) remains intact.

Answer 607

Lesion of the optic chiasm causes bitemporal hemianopia, where both outer fields are lost in both eyes.

Answer 608

Inferior chiasmal compression, commonly caused by a pituitary tumour.

Answer 609

Superior chiasmal compression, commonly caused by a craniopharyngioma.

Answer 610

Von Hippel-Lindau syndrome is an autosomal dominant condition.

Answer 611

Cerebellar haemangiomas (may cause subarachnoid haemorrhages). Retinal haemangiomas (can lead to vitreous haemorrhage). Renal cysts (premalignant). Phaeochromocytoma. Extra-renal cysts (epididymal, pancreatic, hepatic). Endolymphatic sac tumours. Clear-cell renal cell carcinoma.

Answer 612

Cerebellar haemangiomas can cause subarachnoid haemorrhages.

Answer 613

Retinal haemangiomas, which can lead to vitreous haemorrhage.

Answer 614

Renal cysts (often premalignant) are commonly found in patients with VHL.

Answer 615

Clear-cell renal cell carcinoma is a notable risk in patients with VHL.

Answer 616

Wernicke's encephalopathy is caused by thiamine deficiency, most commonly seen in alcoholics. Other rare causes include persistent vomiting, anorexia nervosa, stomach cancer, and dietary deficiency.

Answer 617

Oculomotor dysfunction (nystagmus, ophthalmoplegia). Ataxia (gait disturbances). Encephalopathy (confusion, disorientation, inattentiveness).

Answer 618

Nystagmus (most common ocular sign). Ophthalmoplegia, such as lateral rectus palsy and conjugate gaze palsy.

Answer 619

Peripheral sensory neuropathy is common in Wernicke's encephalopathy.

Answer 620

Decreased red cell transketolase levels. MRI of the brain may show characteristic changes.

Answer 621

Urgent thiamine replacement is crucial for treatment.

Answer 622

Korsakoff syndrome may develop, leading to anterograde and retrograde amnesia and confabulation, in addition to the symptoms of Wernicke's encephalopathy.

Answer 623

Optic neuritis (common presenting feature). Optic atrophy. Uhthoff's phenomenon (worsening of vision with increased body temperature). Internuclear ophthalmoplegia.

Answer 624

Pins and needles. Numbness. Trigeminal neuralgia. Lhermitte's syndrome (paraesthesiae in limbs on neck flexion).

Answer 625

Spastic weakness (most commonly in the legs).

Answer 626

Ataxia (more common during acute relapse). Tremor.

Answer 627

Urinary incontinence. Sexual dysfunction. Intellectual deterioration.

Answer 628

subacute degeneration of spinal cord

Answer 629

Take the best score

Answer 630

pancoasts tumour

Answer 631

butterfly pattern in the caudate nucleus

Answer 632

7 - facial nerve

Answer 633

only delirium

Answer 634

penicillamine quinidine, procainamide beta-blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Answer 635

ABC in community - buccal midazolam/rectal diazepam in hospital IV lorazepam, repeated once after 5-10mins second line agent if still going levetiracetam or phenytoin or valproate

Answer 636

initially every other day then every 3 months

Answer 637

lumbar puncture