Neuro Presentations

Question 1

EDH

Answer 1

young - assault/sports
brief LOC then lucid interval
progressive hemiparesis and stupor

lentiform/egg-shaped, white, crosses midline
middle meningeal artery and pterion

burr hole/craniotomy: release pressure

Question 2

SDH

Answer 2

chronic: elderly/alcohol (shrink + fall)
acute: severe accel/decel + brain damage
Sx fluctuant, may have latent period; GCS, focal, headache

crescent shape, sulcal loss, doesn’t cross midline
venous bleed; chronic/old = darker + liquifaction

may self-resolve; may need craniotomy/burr holes

Question 3

SAH

Answer 3

occipital thunderclap, sudden and severe, exertion trigger
meningism, photophobia, focal neuro, N&V

aneurysm: ACoA commonest site, PCoA commonest rupture
AVM: can cause epilepsy, more re-bleeds

CT +/- LP (>12h)
anti-HTN, analgesia, hydrate, dex (oedema), NIMODIPINE (vasospasm)
clips, coils, embolise, drain, direct surgery/RDT for AVM

Question 4

SAH complications

Answer 4

death (30% immediate)
ischaemia and infarction (commonest morbidity)
Intracerebral haemorrhage and ^ICP
acute hydrocephalus: vascular spasm + oedema
chronic hydrocephalus: fibrosis blocks granulations
re-bleed: 30% <1y (most <1/12); commonest CoD

Question 5

ICH (intracerebral haemorrhage)

Answer 5

10% of strokes (40% of young strokes)

deep: Charcot-Bouchard aneurysms rupture: subcortical
lobar: older patients; cortical

headache, rapid LOC, BS/Cb signs, hydroceph, coma

CT: bright ‘blotches’ + dark edge (oedema), sulcal loss, ventricular

Mx: HTN control + neurosurgery consult

Question 6

Tension Headache

Answer 6

tight band
throbbing/bursting
retro-orbital pressure
triggers (stress, noise, visual effort, fumes)
neck/scalp tenderness and tension

Question 7

Migraine

Answer 7

recurrent headache + visual/GI disturbance
NO FEVER but similar to meningitis
unilateral pulsing, photo/phono

Classic: prodrome (visual +/- focal neuro), attack, post-migraine (sleepy)
Common: vague prodrome (no aura); N&V + malaise
Basilar: BS/Cb aura (oral tingle, vertigo, ataxia)
rare: Hemiparetic, opthalmo (CN III/IV), facioplegic (unilat facial weakness)

*RULE OUT TIA and SAH
prevent (BB, topiramate) and rescue (triptan)

Question 8

Cluster Headache

Answer 8

intense pain, crescendo
unilateral, one eye, cheek/nose congestion
wakes from sleep, vomiting, +/- transient Horner’s
Attacks in clusters
Tx: O2, triptan, prevent with pred/verapamil

Question 9

ICP

Answer 9

‘pressure’ - dull, persistent ache, AM/waking
positional, and straining/coughing triggers
N&V
CN III/papilloedema (painful CN III = PCA aneurysm)
focal neuro, CVA, Cushing’s Triad, Cheyne-stokes

*IIH: obese females; blurred vision; give topoimerate and diuretics (acetazolamide)

Question 10

Temporal Arteritis/PMR

Answer 10

TA/GCA: headache, jaw claudication, visual issues (CRAO, ION), scalp
normo anaemia, ESR, Bx
HD-CST for 12-18months (+Ca/vitD/BPP)

PMR: severe limb-girdle pain, stiff, weak; AM

Question 11

Brain tumours

Answer 11

^ICP, epilepsy, or progressive neuro deficit
CT (Gadolinium) + dex (oedema), AED, surgery

paraneoplastic: MG, hormones, LES (better with exertion; SCC), CB degeneration

Glioma/blioblastoma; astrocytoma; oligodendroglioma; ependymomas; meningioma; medulloblastoma; PNET; neuronal

Question 12

Meningitis

Answer 12

Meningism: headache, neck stiffness, FEVER
photophobia, irritability, N&V

rash = immediate ABx
CT + LP (CSF); cultures, swabs, glucose, bloods

Benpen/Ceftriaxone/Cefotaxime 10 days
Contacts: rifampicin/ciprofloxacin

Question 13

Bacterial Meningitis Complications

Answer 13

hydrocephalus, chronic headache
oedema, abscess
venous sinus thrombosis
seizures, ataxia
focal neuro, hearing loss, hemi/quadraparesis
septicaemia, gangrene
death (20-30% pn., septic shock >50%)

Question 14

Epilepsy types

Answer 14

Abscene: ‘trance’ +/- automatism; LOC; 3Hz spike-and-wave
Myoclonic: mornings; bilateral ‘shocks;
tonic-clonic: groan + rigid, then rapid-to-slow jerks
tonic and akinteic: LOC, generalised

simple partial: unilateral, +/- aura, focal neuro
complex partial: altered LOC, automatism, focal (EEG/effect)

Question 15

Epilepsy Management (Ix + Tx)

Answer 15

video, syncope tests (ECG/tile), bloods, EEG, echo, CT/MRI, ABG

generalised: valproate; 2nd lamotrigine; ethoxux for absence
partial: lamotrigine/carbamazepine; 2nd valproate/leve/topiramate
pregnant: levetiracetam

DVLA 1y
stop meds 2-3 year seizure free

Question 16

Syncope vs. epilespy vs. NEA

Answer 16

epilepsy: tongue biting, at rest, infrequent, post-ictal, injury

syncope: prodome (SANS), short and rapid recovery, triggers
* orthrostatic, neuro (vagal), cardo (!!)

NEA: psychosical; frequent, fluctuant, fast strong jerks
*can mimic syncope or epilepsy e.g. automatism

Question 17

MS presentation

Answer 17

Dx: time and space (MRI/clinical; McDonald)

asymmetrical/ unilateral;
visual: optic neuritis, visual loss
brainstem: diplopia, vertigo, dysarthria, nystagmus
SC/sensorimotor: UMN, Lhermitte’s, Uhthoff, urinary

Question 18

MS Management (Ix + Tx)

Answer 18

bloods (incl, TFT + anti-NMO), MRI, EMG (velocity)
CSF: IgG, oligoclonal bands

non-pharma: MDT, support, triggers, lifestyle etc.
prevent: immunomodulators (INF-b), mabs, aza/cyclo
symptoms: neuropathic pain, urinary, spasticity (baclofen)
acute relapse: infection, CST (IV methylpred)

Question 19

Parkinson’s Disease Presentation

Answer 19

‘TRAP’: tremor, rigidity (cogwheel), akinesia, postural instability
asymmetrical at onset
Motor: mask facies, fatigabiltiy, stoop, gait, speech, hyperreflexia
non-M: sleepy, halls, REM, anx/depp, GI, ANS, urine

Tx: non until disabling Sx
DA agonists (bromo, ropinirole), MAOI (selegine)
L-DOPA + carbidopa +/- Entacapone
SE: dyskinesia, on-off, fibrosis (DA), N&V, chorea, cognition/halls

Question 20

Parkinson Plus Syndromes

Answer 20

PSP: limited down gaze, dementia, falls
MSA: horizontal nystagmus, postural hypoTN, bladder
CBD:
LBD: vivid hallucinations, dementia

Question 21

PD DDx

VODKA = ?secondary

Answer 21

idiopathic vs. genetic (Parkin gene)
vascular: bilateral; gait prominent
drugs: haloperidol, TCA, chlorpromazine, APD/anti-Da, anti-H
Wilson’s disease, hypothyroidism
Dementia, severe depression, hypdrocephalus

*Dx: DAT scan (decreased SN uptake)

Question 22

MND

Answer 22

PMA: best prognosis; spinal LMN; distal first
PLS: cortical UMN only; rare; progressive tetraparesis
ALS: commonest; LMN in arms, UMN in legs
*spastic tetraparesis or paraparesis
Progressive bulbar/pseudobulbar: lower CN UMN/LMN; worst prognosis;

• motor only; fasciculations common; middle-age
• riluzole: prolongs life in ALS ~3/12

Question 23

MG

Answer 23

AI IgG against post-synaptic ACh-R NMJ

fatigability; ocular, ptosis, dysphagia, speech, proximal weakness
*progression: eyes > bulbar > face > trunk
MG crisis: respiratory weakness

Tx: anticholinesterases, IVIG, immunosupp, thymectomy

• 25% have thymom, 65% have hyperplasia
• AI assoc: SLE, pernicious, RhA

Question 24

GBS

DDx: polio, CIDP, cord compression, MD

Answer 24

post-infection (1-3/52); progressive; resolves ~6/52

ascending numbness and weakness; affects proximal>distal
CN involved (esp. CN VII), LMN signs, pain common
may have SANS and sensory

Tx: IVIG (reduce duration/severity), SC heparin, ventilatory if rapid (resp in 20%)

Question 25

Peripheral Neuropathy DDx

Answer 25

mono: compression/entrapment, systemic, DM
mono mulit: vasculitis, DM, infection, systemic
poly axonal (amplitude): toxins, drugs, FH/genetic
poly demye (speed): GBS, myeloma, DM, infection
radiculopathy (root): disc prolapse, stenosis, spondylosis

mono multi: asymmetrical

poly: symmetrical; sensorimotor, sensory, motor, ANS
radiculopathy: pain +/- paraesthesia, LMN

• motor: GBS, CMT, CIDP
• sensory: DM, alcohol, uraemia, B12, amyloid

Question 26

Specific neuropathy

Answer 26

B12: DC before paraesthesia
alcohol: widespread, non-dermatomal, GGT

CMT: pes cavus, hammer/claw toe, champagne legs, ataxic, foot drop, heavy step

Carpal tunnel: worse in morning/night wake, sensorimotor; wrist splint Tx

Question 27

Myopathy

Answer 27

DMD: XLR; childhood weakness, ^CK, ^calves, Gower’s sign, cardiomyopathy
Myotonic Dystrophy: AD; weak, contracted; distal/facial weakness

Polymyositis: CTD-assoc; proximal/facial weak, ptosis + dysphagia; myalgia
dermatomyositis: heliotrope rash
Inclusion body: polymyositis but DISTAL > proximal

*EMG: short, spiky, polyphasic +/- fibrillation

Question 28

Alzheimer’s

Answer 28

memory loss, aphasia, apraxia, agnosia, exec function
later: behaviour gait, sensorimotor
bilateral temporal/hippocampal lesions

anticholinesterases: donepezil, rivastigmine, galantamine
NMDA-agonists: mimantine

Question 29

Vascular Dementia

Answer 29

stepwise
vascular history e.g. TIA and CVA
focal neuro (infarct site-dependent))

Question 30

LBD Dementia

Answer 30

fluctuating cognition/attention/alertness
early memory loss
visuospatial hallucination, depp, sleep disorder
parkinsonism

*sensitive to neuroleptics (e.g. haloperidol)

Question 31

Picks (FTD)

Answer 31

behavioural/social > memory
progressive dis-inhibition and personality change
memory/IQ/language later

Question 32

Delerium

Answer 32

acute/subacute onset, rapid freq fluctuations
attention, arousal, alertness
delusions, hallucinations, disorientated
abnormal movements (tremor, myoclonus) and ANS
hypo/hyper/mixed