Neuro Formative Qs

Question 1

What are the three main types of primary headache?

Answer 1

Migraine, Cluster and tension

Question 2

Give key features of primary headache types to help distinguish between them

Answer 2

(1. ) Migraine
- unilateral, pulsating, mod/severe, aggravated by routine activity.
- May or may not have an aura.
- During headache will have at least one of nausea (and/or vomiting) or photophobia and phonophobia.

(2. ) Tension
- Tight band round the head, bilateral, mild/moderate, not aggravated by activity and no photophobia or nausea/vomiting

(3. ) Cluster
- Severe or very severe periorbital unilateral headache accompanied by ipsilateral autonomic features, 1 every other day to 8 daily, 1 month gaps (minimum) between clusters

Question 3

Give a first line treatment option for migraine – for both acute attacks and prophylaxis

Answer 3

(1. ) Acute: Triptan + NSAID or paracetamol

2. ) Prophylaxis: Topiramate (anti-convulsant) or Propranolol (bblocker

Question 4

You are working in the community and a patient presents with possible meningitis. They have no rash – what is the most appropriate course of action?

Answer 4

(1. ) NICE: 999 is the priority in patients without a rash.
(2. ) The rash is likely to indicate sepsis. If no rash get them to hospital ASAP.

(3,) If a rash (or obvious signs of sepsis) or a potential delay then give IM Benzylpenicillin (cefotaxime an alternative) whilst getting the 999 response.

Question 5

What is the commonest first symptom of multiple sclerosis? What are the other common first signs?

Answer 5

(1. ) The commonest first sign is weakness, mainly in peripheral muscles.
(2. ) Other signs include paraesthesia, visual loss, incoordination, vertigo and sphincter impairment.

Question 6

What features can help us distinguish syncope from epilepsy?

Answer 6

(1. ) Epilepsy – Tongue biting, head turning, muscle pain, loss of consciousness >5 mins, cyanosis, post-ictal confusion
(2. ) Syncope – Prolonged upright position, sweating prior to LOC, Nausea, pre-syncopal symptoms, Pallor

NOTE: patients having a syncopal episode can still shake so this alone is not a sufficient indicator of fit v syncope

Question 7

Which intracerebral haemorrhage is most likely in an elderly patient following relatively low energy head trauma?

Which type of haemorrhage most commonly leads to a “lucid interval”?

Answer 7

(1. ) Subdural haemorrhages are most likely in this group due to chronic slow bleeds due to tears in bridging veins.
(2. ) The Lucid Interval is most commonly seen in extradural haemorrhage where the bleed spreads with the patient conscious but followed by rapid unconsciousness as the brain trauma progresses with coning.

Question 8

What are the typical features associated with lower motor neurone lesions?

Answer 8

(1. ) Muscle tone normal or reduced (flaccid)
(2. ) Muscle wasting
(3. ) Fasciculation - visible spontaneous contraction of motor units
(4. ) Reflexes depressed or absent

Question 9

What are the three cardinal presenting symptoms in a patient with a brain tumour?

Answer 9

(1. ) Symptoms of raised intracranial pressure – Headache, vomiting, reduced conscious level
(2. ) Progressive neurological defect
(3. ) Epilepsy

Question 10

What are the typical features of a raised intracranial pressure headache?

Answer 10

• Worst on waking from sleep in the morning.
• Increased by coughing, straining and bending forwards
• Sometimes relieved by vomiting

Question 11

11. List the primary types of dementia – which is most common and what are its primary features?

Answer 11

(1. ) Alzheimers - commonest with the amnesic variant the most usually seen.
- Early degeneration of medial temporal lobe before degeneration spreads to temporal neocortex, frontal and parietal association areas.
- Selective amnesia. Semantic and language impairments
- Complex attention (divided, selective, attention switching)
- Visuospatial, sustained attention and executive functioning skills
- Global deficits.

(2.) Main other dementia types are vascular and lewy body (associated with parkinsonism)

Question 12

How do we define somatisation or functional disorders?

Answer 12

(1. ) When physical symptoms are caused by mental (psychological) or emotional factors.
(2. ) Somehow the mental or emotional problem is expressed as one or more physical symptoms. The symptoms are real and are not imagined.
(3. ) The term functional is used when no known physical cause can be found for a physical symptom.

Question 13

Which condition is characterised by the autoimmune blockage or destruction of nicotinic receptors for acetylcholine at the neuromuscular junction?

What are its typical features?

Answer 13

(1. ) Myasthenia Gravis
(2. ) In around 70% primary symptoms are around the eyes with ptosis and diplopia.
(3. ) Other symptoms include dysphagia, difficulty with mastication, dysarthria, dysphonia.
(4. ) There can be difficulty to hold the mouth closed as well as chest muscle weakness .

Question 14

Give five clinical signs of cerebellar disease

Answer 14

• Nystagmus (other abnormalities of eye movements)
• Dysarthria
• Action tremor
• Dysdiadochokinaesia
• Truncal ataxia
• Limb ataxia
• Gait ataxia

Question 15

What area of the brain suffers cell loss in parkinsons disease and what neurotransmitter is deficient?

Answer 15

Substantia nigra, dopamine

Question 16

What are the three cardinal features of Parkinson’s disease and how do they present?

Answer 16

(1. ) Brady/Akinesia - Problems with doing up buttons, keyboard etc, Writing smaller, Walking deteriorated: Small stepped, dragging one foot etc
(2. ) Tremor - At rest, May be unilateral
(3. ) Rigidity - Pain, Problems with turning in bed

Question 17

How does carpal tunnel syndrome classically present? What is its pathophysiology? How is it managed?

Answer 17

Pathophysiology:
- Due to compression of the median nerve in the carpal tunnel where it runs deep to the extensor retinaculum.

Presentation
(1.) Typical Sx: intermittent tingling, numbness or altered sensation and burning or pain in thumb, index finger, middle finger, and radial half of the ring finger.

(2. ) Sx are worse at night and can disrupt sleep.
(3. ) May affect one or both hands.
(4. ) Pain in the hand may radiate up the arm into the wrist or as far as the shoulder.
(5. ) The person may complain of loss of grip strength, clumsiness and reduced manual dexterity for example when doing up buttons

Tx
- Treat by optimising any underlying conditions, splinting (especially at night), corticosteroid injection or surgery

Question 18

What is the commonest cause of stroke?

What is the most appropriate imaging for stroke and why is it primarily performed when presenting to the Emergency Department?

Answer 18

(1. ) Ischaemic stroke is the commonest type (around 85%) due to occlusion of the blood supply to the brain.
(2. ) On arrival at the ED all eligible patients (within 4½ hrs of Sx onset) should have a CT scan.
(3. ) This is performed to establish if the stroke is ischaemic or haemorrhagic and thus the patients suitability for thrombolysis.