Neurology Flashcards
Where does damage occur between in an UMN lesion?
Damage to motor fibres between pre-central gyrus and anterior horn cells of spinal cord (More detailed explanation: UMN lesions occur in the pyramidal/corticospinal tract. Inputs from premotor cortex, primary motor cortex and supplementary motor area [all 3 are located in the pre central gurus] are all passing through to the anterior horn cells of the spinal cord [the anterior/ventral horn is responsible for sending motor signals to muscles/glands].
What is the difference in pattern of sensory loss between UMN and LMN lesions?
UMN: central sensory loss
LMN: glove-stocking/nerve distribution sensory loss
(UMN are responsible for getting signals from cortex to spinal cord, LMNs then take it to muscle so sensory loss in LMN lesions is more focal to the area that neurone is supplying. Remember motor neurones can receive some sensory afferents hence us talking about sensory loss.)
What is the difference in pattern of tendon reflexes and tone between UMN and LMN lesions?
UMN: hyper-reflexia, hyper-tonia
LMN: hypo-reflexia, hypo-tonia
Where does damage occur between in a LMN lesion?
Damage to motor fibres between anterior horn cells of spinal cord, peripheral nerve, neuromuscular junction or the muscle
The anterior cerebral artery supplies which parts of the brain? What would be the clinical signs as a result of damage to this artery?
Supplies frontal and medial part of the cerebrum (ACA supplies all the highlighted areas in the image)
Weakness and numbness in the contralateral leg + arm symptoms
The middle cerebral artery supplies which parts of the brain? What would be the clinical signs as a result of damage to this artery?
Supplies lateral hemispheres and many deep brain structures
Contralateral hemiparesis + hemisensory loss in face and arm
(head, upper limbs or trunk can be affected. If precentral gyrus is affected this will cause contralateral loss of motor innervation to these areas. If post central gyrus is affected this will cause contralateral sensation loss to these areas).
Contralateral homonymous hemianopia
Cognitive change - dysphasia, visuo-spatial disturbance
List red flags for headache
New onset in over 55 yo Early morning onset Known/previous cancer Immunosuppressed Exacerbated by Valsalva Autonomic upset
List red flags for headache
New onset in over 55 yo (could be brain tumour, GCA or stroke) Early morning onset (indicates raised ICP) Known/previous cancer Immunosuppressed Exacerbated by Valsalva (could indicate raised ICP) Autonomic upset
an elderly alcoholic man presents with a persistent headache after falling over the previous day. On examination he has a fluctuating level of consciousness
what is this a sterotypical history for?
subdural haemorrhage
a middle-aged man presents with a head injury after falling down some stairs. After losing consciousness he quickly recovers but complains of a headache. Over the next few hours he becomes more confused and has one seizure
what is this a sterotypical history for?
extradural haematoma
The posterior cerebral artery supplies which parts of the brain? What would be the clinical signs as a result of damage to this artery?
Supplies occipital lobe
isolated/homonymous hemianopia with macular sparing
The middle cerebral artery supplies which parts of the brain? What would be the clinical signs as a result of damage to this artery?
Supplies lateral hemispheres
Contralateral hemiparesis + hemisensory loss in face and arm
Contralateral homonymous hemianopia
Cognitive change - dysphasia, visuo-spatial disturbance
List general causes of headache
Raised ICP Infections (meningitis) Giant cell arteritis Haemorrhage, trauma Venous sinus thrombosis Sinusitis Acute glaucoma
What are some prodromal signs of migraine?
Yawning
Food craving
Change in sleep/appetite/mood
What is the criteria for diagnosing migraine without aura?
5 or more eps of headache lasting 4-72h
1 of nausea, vomiting, photophobia, phonophobia
2 of unilaterality, pulsating, limiting, worse on activity
What is the treatment for acute migraine?
-NSAID (aspirin, ibuprofen)
-Anti-emetic
-Triptan (rizatriptan)
triptans are 5HT agonists
What drugs can be used for migraine prophylaxis?
1. Amitryptilline (s/e - anticholinergic i.e. dry mouth, postural hypotension, sedation) 2. Propranolol (s/e bronchospasm, peripheral vascular disease) 3. Topiramate (s/e parasthesia and weight loss) other options; Valproate Gabapentin
What are some contraindications to triptan use?
- Ischaemic Heart Disease, coronary spasm
(triptans are a 5HT agonist that work by causing vasocontriction- this counteracts the vasodilation that produces throbbing headaches- this mechasnism can also cause reduced blood flow to the heart so triptans are contrandicated in IHD)
- Uncontrolled BP
- Recent lithium/SSRI use (due to risk of serotonin syndrome- v. high levels of serotonin in the body)
How is cauda equina syndrome treated?
Immediate surgical decompression. This is a surgical emergency (consistent compression can cause irreversible nerve damage, permanent incontinence and sexual dysfunction).
If suspected do a rectal exam to look for perineal numbness and reduced surgical sphincter tone.
What causes subacute degeneration of the spinal cord?
Prolonged vitamin B12 deficiency
How do you treat an acute episode of MS?
High dose steriods (500mg oral or 1000 mg IV of methylprednisolone for 3-5 days)
N.B. This shortens the period of disability but is not treating the condition
What is Hoffman’s sign? And what does a positive Hoffman’s sign indicate?
Flexion and abduction of the thumb and flexion of the index finger when you forcefully flick the thumb of the patient’s middle finger.
(Clearer explanation and video: https://www.physio-pedia.com/Hoffmann%27s_Sign )
+ve sign indicates corticospinal tract dysfunction of the cervical segment of segments of the spinal cord (SAME AS +VE BABINKSKI’S SIGN)
What is clonus?
muscular spasm involving repeated, often rhythmic, contractions
What condition does the presence of urinary bence jones proteins indicate? Do all patients with the condition test positive?
Multiple myeloma
No; most people with MM will have positive urinary bender jones proteins but not all of them (between 50-80% of MM patients).
What is the winking owl sign? And what does the winking owl sign indicate?
In AP thoracolumbar radiographs, this sign occurs when the pedicle is absent.
It indicates osteolytic spinal metastases- typically indicates MM (but can be other cancers)
In patients who have a subarachnoid haemorrhage but a negative CT, how might you try and figure out if they have had a subarachnoid haemorrhage?
Can do a lumbar puncture- this will show xanthochromic CSF (discoloured yellow due to breakdown products of blood), within 6-48 hours after the initial bleed this is safe in patients with no focal neurology, papilloedema, or a normal CT head
What condition is the screenshot describing?
Subarachnoid haemorrhage
How is hydrocephalus managed?
Lumbar puncture, external ventricular drain or VP shunt
You are covering A&E for your remote & rural location. You meet your next patient, a 25-year-old man called Mr. Morphy. Earlier in the evening, he was taking part in a boxing match where he was punched in the side of the head. His friend, who has attended with him, tells you that after the punch he was initially unconscious. He says, however, that this was only brief and he soon recovered and seemed well. A few hours later though, he then began to complain of a severe headache, and vomited three times. His friend therefore decided to call an ambulance for him. While waiting for the ambulance, he became unconscious. What condition is this patient most likely to have?
Extradural haematoma
What artery and bone are most likely to be implicated in an extradural haematoma?
Usually, an extradural haematoma is due to the rupture of the middle meningeal artery (in the temporoparietal region).
It can be associated with a temporal bone fracture.
What condition is the following a typical history for?
A young patient with a traumatic head injury and an ongoing headache. They have a period of improved neurological symptoms and consciousness, followed by a rapid decline over hours as the haematoma gets large enough to compress the intracranial contents.
Extradural haematoma
How are subdural and extradural haematoma managed?
Smaller bleeds can be managed conservatively with repeated imaging.
Surgical options are a craniotomy or burr holes.
What blood vessels rupture in a subdural haematoma?
Sub-cortical bridging veins
How are cluster headaches treated? (Acute presentation and prophylaxis)
Acute presentation- high flow oxygen and subcutaneous sumatriptans
Prophylaxis- verapamil and advise to reduce alcohol intake
Additionally, once verapamil has been titrated up to maximum dose, if patient is still experiencing symptoms, you can try topiramate or lithium (also consider psychological comorbidities and sleep issues may need addressing as these can worsen the headaches)
What is the window for administering thrombolysis post stroke?
Within 4.5 hours of the initial onset of symptoms, but within 90 minutes is most effective
What treatment is first line for trigeminal neuralgia?
Carbamazepine
What is synringomyelia?
Fluid filled cyst in the spinal cord
A 30 year old man presented with a stab wound in his back. He has right sided weakness starting at T5 and left sided loss of pinprick sensation and temperature starting at T7.
What did the man develop?
Brown Sequard Syndrome
This condition is characterised by paralysis/weakness/proprioceptive deficits on the ipsilateral side of injury and loss of pain and temperature sensation on the other side.
Where is the primary auditory cortex located?
Superior temporal gurus of the temporal lobe
Match the following function to the appropriate spinal tract:
Fine touch, pressure and vibration
G
Dorsal column medial leminiscus is responsible for two point discrimination, conscious proprioception and vibration sensations from all over the body (except the head).
Match the following function to the appropriate spinal tract:
Pain and temperature
D
The spinothalamic tract is a sensory tract that carries nociception, temperature, crude touch and pressure from the skin to the somatosensory area of the thalamus
Match the following function to the appropriate spinal tract:
Excites flexor muscles and inhibits extensor muscles of the upper body
E
Rubrospinal tract controls proximal and axial muscles and is responsible for gross movements (whole body movements involving large muscles) like locomotion, reaching and posture.
Roughly what dermatome is the nipple?
T4
think T4 is teat pore
Roughly what dermatome is the umbilicus at?
T10
think ‘T10 for belly butt ten’
A 28 year old man with neck pain has some sensory loss on the outer aspect of his left forearm and arm including the thumb. He also has weakness in flexing his left elbow. MRI imaging showed a herniated disc. Based on the man’s symptoms, the root at which level is most likely to be affected?
C6
What condition is shown in these MRIs? (Focus on the red circles)
Arnold Chiari malformations
This occurs during feral development in some babies. Part of the cerebellum herniates through the foramen magnum into the spinal canal (this can block CSF outflow).
What is the classic symptom triad for normal pressure hydrocephalus?
Urinary incontinence, gait disturbance and dementia
3Ws - wet, wacky, wobbly
A 66-year-old man presented with several falls over the course of the past few months. On examination, he had symmetrical weakness of his legs and mild weakness of his hand. He had an abnormal gait. His reflexes were extremely brisk in his legs with upgoing planters bilaterally. Based on this and the scan, what is the most likely diagnosis?
Cervical myelopathy
This is a condition in which the spinal cord is compressed usually due to gradual degeneration of the spine (typically seen in those over 50yrs old)
What condition is shown in this MRI?
Syringomyelia
This is a fluid filled cyst in the spinal cord- the majority of cases of this continue are associated with chiari malformation (a.k.a Arnold chiari malformation)
A 67 year man complains of a burning sensation down the back of both legs. The pain is not as bad when he is walking uphill. Which of the following conditions is this likely to be?
Lumbar stenosis-
Narrowing of the area of the lumbar region of the spine can lead to irritation or compression of the nerves travelling down the legs.
What is spondylosis?
Degeneration of intervertebral discs
What condition is the following describing?
A 35 year old builder complains of lower back pain after lifting a heavy bag of cement. He has been in A and E for the past four hours and a DRE shows reduced perineal sensation and anal sphincter tone.
Cauda equina syndrome
A 45 year old call centre worker is complaining of lumbar pain for the past two months. He gets stiffness in the morning and the pain gets worse on prolonged sitting and turning over in bed. Which of the following conditions is the most likely diagnosis?
F
Worse on sitting is present in herniated discs and mechanical back pain. However, twisting and turning motions causing pain indicate that muscles and/or ligaments around the spine are strained/sore.
An 80-year-old ex-smoker with uncontrolled hypertension presented with the acute onset of numbness of his left arm and leg. On examination, there was decreased sensation to all his left side of the body and face. What type of stroke does this patient have?
D
A 66-year-old female with atrial fibrillation presents with dysphasia and left hemiparesis.
What type of stroke is this?
B
70-year-old male with left homonymous hemianopia. He has no other symptoms.
What type of stroke is this?
E
Choose which investigation would provide a definitive diagnosis for…
A 70 year old patient presents with progressive headaches and nausea with gradual loss of sensation in her right arm. Imaging reveals a mass in the temporal lobe.
F
Choose which investigation would provide a definitive diagnosis for…
A 25 year old boxer lost consciousness in his final fight due to a punch in the head but was in a good state straight after. However, 4 hours later his GCS was 6/15.
B-
Patient is likely to have an extradural haematoma. Need CT to locate bleed and any potential temporal bone fracture associated with this.
What investigation would provide the most definitive diagnosis for the following…
A 25-year-old man developed a sudden onset ‘worst ever’ headache and collapsed.
Remember, if you can locate the haemorrhage using a CTA, you can figure out whether it is a subarachnoid haemorrhage causing the bleeding and where to use endovascular coiling to control the bleeding.
CTA is the gold standard diagnostic test for a subarachnoid haemorrhage
In the image, a lesion in which area of the brain would cause expressive aphasia/dysphasia?
2- this is broca’s area
Broca’s area is in the dominant hemisphere, just above the lateral fissure that sits between the frontal and temporal lobes
Looking at the image, in which area would a lesion cause receptive dysphasia/aphasia?
4- Wernicke’s area
This is located in the posterior segment of the superior temporal gyrus in the dominant hemisphere
Looking at the image, a lesion in which area would result in nystagmus, intention tremor and dysarthria?
6- the cerebellum
The cerebellum coordinates voluntary movements, balance, posture and equilibrium. It also helps refine fine motor movements to make them more smooth and precise. Also involved in some cognitive functions like attention and language processing.
It is primarily monitoring and regulating motor behaviour so there’s no need for conscious awareness
Choose the anatomical area that contains the primary auditory cortex
C
Choose the anatomical area of the brain that controls the temperature of the body
H
The hypothalamus helps manage body temperature, thirst, hunger, mood, blood pressure, sex drive and sleep.
Choose the anatomical area that contains the oculomotor nucleus
E
Oculomotor and trochlea nuclei exit the caudal colliculus and pass along the midbrain
A 7 year old boy presents with progressive headache, wide based ataxia and difficulty speaking. Imaging and biopsy confirms the presence of a pilocytic astrocytoma. Where is this brain tumour most likely to be located?
G
This is a brain tumour most commonly seen in children and young adults, originating from astrocytes. They usually arise in the cerebellum, near the brainstem, in the hypothalamic region or the optic chiasm.
A 56-year-old man presented to the hospital with a seizure. He had been complaining of headaches for the past several months and has been “bumping into things”. On examination, it was revealed that he has a left superior quadrantopia. Imaging and biopsy confirmed a Glioblastoma multiforme.
Where is the tumour most likely to be located?
D
Superior quadrantopia indicates contralateral temporal lobe lesions (as there is damage to inferior optic radiations (a.k.a Meyer’s loop)
Additional information:
Glioblastoma multiforme is most commonly seen in the frontal lobe (often seen in supratentoral regions such as the frontal, temporal, parietal and occipital regions).
Glioblastoma multiforme is a grade 4 astrocytoma poor prognosis
This is the most common type of primary malignant brain tumour seen in adults
A 40 year old right-handed accountant presents with difficulty in writing and that he “wasn’t as good with numbers as before”. On examination, he had a left-right disorientation. Imaging and biopsy confirmed the presence of a meningioma. Where is this patient’s brain tumour most likely located?
A
The most active parietal lobe is the opposite one to your dominant hand so in this case the left side.
The parietal lobe deals with sensory information (touch, pain, pressure, heat, cold, tension), a person’s ability to judge size, shape and distance and symbol interpretation (inc. written and spoken language, mathematical problems, codes snd puzzles).
Left lobe deals with letters, numbers and symbols. Right lobe deals with image interpretation and spatial relationships.
Which one of the following is NHS standard of care for a symptomatic, easily accessible glioblastoma in a young, fit patient?
6
A 20-year-old male presented to A&E after being in a car accident. Neurologic evaluation was as follows: he opened his eyes only to the sound of his name, he was able to localize to a painful stimulus but failed to move his arms and legs to command only. When asked where he was his reply was “my house to go”.
What is his GCS score?
11
A 70-year-old woman presents with a headache and confusion, 4 weeks after she suffered from a fall. She opens her eyes spontaneously and moves her arms and legs when told to.
What is the GCS score?
14
A 25-year-old man developed a severe headache and collapsed. Upon calling his name, he does not respond nor opens his eyes. However, when a painful stimulus is applied he internally rotates his shoulders and flexes his forearm and wrists while extending his legs.
What is his GCS score?
5
A patient presents with unilateral pupil mydriasis that does not constrict to light following a car accident. On CT, an intracranial haemorrhage was identified. What is the most likely cause from the options below?
In patients with an intracranial haemorrhage or tumour, the development of unilateral mydriasis is a neurological emergency because it may indicate the beginning of uncal herniation
Uncal herniation: Descending transtentorial herniation (brain tissue goes from one intracranial compartment to another) involving the uncus. This caused by raised intracranial pressure.
A 75 year old patient presents with a progressive shuffling gait and urinary incontinence. He denies any back pain. His wife is claiming that he has been forgetting his keys and taking his medication. What is the most likely diagnosis?
Normopressure hydrocephalus
The classic triad of symptoms for this condition are: dementia, urinary incontinence and gait disturbance
A 56-year-old man presents with a headache, severity 8/10 with associated nausea. On examination he has ptosis, and miosis.
Which of the following is the most likely diagnosis?
A
56-year-old man presents with a headache, severity 10/10 with associated vomiting. On examination he has neck stiffness and photophobia.
Which of the following is the most likely diagnosis?
G
A patient develops retro-orbital pain in his right eye described as a boring, worst pain he has ever felt, lasting 20 minutes. Associated tearing of that eye and a stuffy nose. He has 10 episodes of this pain for the past week.
Which of the following is the most likely diagnosis?
F
A 25 year old man is brought to A&E responsive following a fall from a horse. His friend claims he hit his head. One hour later he spontaneously regains consciousness and appears lucid. There is no visible bleeding or skull fracture. A CT scan is requested. What radiological finding is most likely to be seen on this CT scan?
B
This is an extradural haematoma
A 25 year old man is brought to A&E responsive following a fall from a horse. His friend claims he hit his head. One hour later he spontaneously regains consciousness and appears lucid. There is no visible bleeding or skull fracture. A CT scan is requested. What radiological finding is most likely to be seen on this CT scan?
B
This is an extradural haematoma
What is the most common motor neurone disease? And how does it present?
Amyotrophic lateral sclerosis
Mixture of upper motor neurone signs (such as hyperreflexia, spasticity and weakness) and lower motor neurone signs (such as fasciculations, decreased reflexes, decreased tone and muscle atrophy).
Typical early presentation includes weakness and fasciculations in arm or leg, spasticity and difficulty with speech, eating or drinking.
A 51-year-old man presents with progressive weakness over the past couple of months. The weakness is mainly affecting his legs which results in him struggling to climb his stairs at home. The weakness is also now affecting his right hand and has led to him dropping objects. On examination, you note thenar muscle atrophy and fasciculations. There is also increased tone in the lower limbs and hyperreflexia of the knee and ankle jerks. No sensory deficit is identified. What is the most likely diagnosis?
Amyotrophic lateral sclerosis- lower and upper motor neurone signs are present
A 57 year old man has two week history of muscle twitching and weakness. He has frontotemporal dementia. Thenar atrophy can be seen bilaterally. Neurological assessment reveals increased tone and brisk reflexes in upper and lower limbs. Motor neurone disease is suspected. What type of motor neurone disease best fits this description?
Amyotrophic lateral sclerosis
ALS is associated with frontotemporal dementia and a mixture of upper (i.e. increased tone and brisk reflexes) and lower (i.e. fasciculations and weakness) motor neurone symptoms.
Thenar atrophy is commonly seen in ALS and can be assessed clinically by assessing pincer grip (holding piece of paper between thumb and index finger).
Vascular Parkinsonism - typically affects gait and comes on slowly
Drug induced Parkinsonism typically presents within a month of taking the drug. Metoclopromide is contraindicated in Parkinson’s due to its ability to exacerbate Parkinson’s. However, symptoms would appear within a few months.
note: haloperidol and prochlorperazine are also contraindicated
Lewy body dementia present as with symptoms of dementia, Parkinsonism, visual disturbances/hallucinations, REM sleep disorders. In this condition, cognitive impairment and visual disturbances/hallucinations often occur before Parkinsonism.
Multiple system atrophy presents with Parkinsonism alongside autonomic dysfunction (e.g. postural hypotension, abnormal sweating, constipation, sexual dysfunction) and cerebellar dysfunction (causing ataxia). Autonomic dysfunction isn’t seen here.
Progressive supranuclear palsy presents with vertical supranuclear gaze palsy (unable to look properly up or down), postural instability with unexplained falls, akinesia and cognitive dysfunction.
A 69-year-old man presents to his GP with mobility issues having suffered multiple falls in the past 6 months. He denies any preceding symptoms such as loss of consciousness or palpitations and says the falls seem to happen suddenly. His walking has also slowed down recently. Whilst he is talking, the GP notes that his voice is soft and his speech is slurred. When performing a cranial nerve examination, the patient has an impaired downward movement of the eye bilaterally. What is the most likely diagnosis?
Progressive supranuclear palsy
A 66 year old male is referred to neurology clinic by his GP. His wife has noticed that he finds it difficult following instructions such as “pick up the phone”, but can do them voluntarily. Additionally, she has noticed that he tends to kick her in her sleep and he has developed a rest tremor. His movements have also become much slower as of late and he has experienced more falls than usual. On further questioning, he says that he becomes incontinent of urine. What is this patient’s diagnosis?
Corticobasal degeneration
A 65 year old woman is referred to a neurologist via her GP, due to a tremor of her left hand. Examination reveals cogwheel rigidity of the tremulous hand, and a slow, shuffling gait. Her arm is also noted to be flailing around during the consultation. The patient says she has no control over these movements. The neurologist suspects a Parkinsonian syndrome. What is the most likely diagnosis?
Corticobasal degeneration
A 57 year old male patient presents to the emergency department with sudden onset slurred speech and right arm weakness. He has a past medical history of Type 2 diabetes mellitus and hypertension.
After presentation he becomes tetraplegic with lower cranial nerve dysfunction. He has preserved consciousness and preserved vertical gaze.
Which of the following lesion sites is consistent with the most likely diagnosis?
-paramedian branches of upper basilar and proximal posterior cerebral arteries
-anterior inferior cerebellar artery
-posterior inferior cerebellar artery
-basilar artery
-posterior cerebral artery
Basilar artery
A 65 year old male patient is brought to the emergency department after his wife noticed he had sudden difficulty speaking and an inability to raise his right arm. He has a past medical history of hypertension. He is a non-smoker but admits to drinking 5 units of alcohol per day.
CT head is performed on arrival to the emergency department and reveals hyper-attenuation in the left middle cerebral artery vascular territory.
Which of the following pathophysiological processes is responsible for the most likely diagnosis?
-cerebral amyloid angiopathy
-vertebral artery dissection
-cerebral small vessel atherosclerosis
-large vessel atherosclerosis
-left atrial thrombosis-embolism
Cerebral amyloid angiopathy
Hyper attenuation indicates haemorrhagic stroke. Will see hypoattentuation in ischaemic stroke due to reduced blood supply.
Broca’s area is responsible for speech production (mouth movements wise) and Wernicke’s area is responsible for speech comprehension
Stroke describes a sudden onset of focal neurologic deficit resulting from brain infarction or ischaemia in a vascular territory. The middle cerebral artery, or MCA, is most commonly affected during a stroke.
What territories in the brain are supplied exclusively by the middle cerebral artery?
-Lateral surface of hemispheres, excluding inferior parts of the temporal lobe
-Medial surface of hemispheres, including inferior parts of the temporal lobe
-Lateral surface of hemispheres, including medial aspect of the frontal lobe
-Medial surface of hemispheres, excluding inferior parts of the temporal lobe
-Lateral surface of hemispheres, including inferior parts of the temporal lobe
A 70 year-old man is brought to the emergency department, having been found on the street by a passerby. His speech is slurred and difficult to understand, but you establish that he felt ‘very giddy’ prior to falling, and continues to feel like the ‘world is spinning round and round’. He says this started two hours ago. He was unable to get up afterwards by himself. He denies loss of consciousness, head injury, tinnitus or new hearing loss.
He has a past medical history of presbycusis, myocardial infarction with two coronary stents, and type II diabetes. He enjoys a single glass of whisky once a week with meals, and walks without assistance.
On examination, he has difficulty following instructions for neurological examination, but you note he has poor coordination and evidence of an isolated homonymous hemianopia.
What type of stroke is this man likely to have had?
-total anterior circulation stroke
-partial anterior circulation stroke
-basilar artery stroke
-posterior circulation stroke
-lacunar stroke
Posterior circulation stroke
A 10 year old girl is pushed whilst playing football. She does not fall. Instead,
her legs extend, and she stumbles until she regains balance.
Which tract of the motor pathway is responsible for this action?
E
Vestibulospinal tract- the main job is to activity antigravity extensor muscles
A 10 year old girl is pushed whilst playing football. She does not fall. Instead,
her legs extend, and she stumbles until she regains balance.
Which tract of the motor pathway is responsible for this action?
E
Vestibulospinal tract- the main job is to activity antigravity extensor muscles
A 16 year old boy presents to A&E after he had a fit at school.
He felt fine in the morning when having breakfast. He suddenly collapsed in a lesson, went stiff and then his limbs jerked for about one minute. He was confused afterwards. He is normally well, takes no medicines and has no allergies. No one in the family has epilepsy.
On arrival in A&E, he tolerates an oropharyngeal airway, his respiratory rate is 18 and saturations are 99% in air. His capillary refill is less than 2 seconds, heart rate is 74 and blood pressure is 118/78. His GCS is 8, pupils are equal and reactive and glucose is 5.8. He is afebrile and does not have a rash. Visual field testing is normal. There are no focal signs on neurological testing.
A CT head shows a heterogeneous single mass in both the right and left frontal lobes. Which of the following is the most likely diagnosis?
-pilocytic Astrocytoma
-ependymoma
-craniopharnygioma
-glioblastoma multiforme
-meningioma
Glioblastoma multiforme
Possible answers:
-neurofibromatosis type 2
-lynch syndrome
-neurofibromatosis type 1
-familial adenomatous polyposis
-sturge Weber syndrome
A 40 year old woman presents to her GP with chronic headache.
On further questioning she explains the headache is bilateral, non-pulsatile and typically worse in the morning (on occasion she has vomited on waking because of the pain). She does not report any visual symptoms.
On examination she is obese with a BMI of 38, but the examination is otherwise unremarkable with normal observations, and no features of meningism or focal neurological deficit.
Which of the following would be most consistent with the likely underlying diagnosis?
-bilateral papilloedema
-positive anti aquaporin 4 antibodies
-upgoing plantars
-scintillating scotoma
-response to IV ceftriaxone 2g BD
Bilateral papilloedema
A 67-year-old woman on the Oncology ward being treated for meningioma reports worsening headache. On examination, she appears drowsy and is irritable. Her pupils are non-reactive. Raised intracranial pressure (ICP) is suspected.
Which of the following clinical features are associated with raised ICP?
-decreased blood pressure, tachycardia and irregular breathing
-urinary incontinence, gait disturbance and progressive cognitive impairment
-increased blood pressure, bradycardia and irregular breathing
-Pupils that constrict to accommodation but non-reactive to light
-Confusion, ophthalmoplegia and ataxia
A 48-year-old woman attends the emergency department with excruciating pain in the back of her head. She states it came on suddenly whilst at the gym. She is eight hours post-symptoms when she presents to the emergency department. On examination, the patient is also displaying signs of meningism. An urgent CT head is ordered which comes back with no abnormal findings. What is the next best investigation?
-X-ray skull
-MRI venogram
-immediate lumbar puncture
-CT angiogram
-lumbar puncture 12 hours after symptom onset
A 31 year old man presents to the emergency department from a local prison. He does not speak much english, but the prison officers say that he has been behaving oddly over the last 4-5 days. During assessment in the emergency department he suffers a convulsive seizure which is terminated with IV lorazepam, followed by a phenytoin infusion.
On examination he is alert, but confused (GCS 14), with a fever of 39, tachycardia of 122 and tachypnoea of 26. His blood pressure is normal, and he is saturating on room air. There are no focal neurological signs or features of meningism. His heart, chest and urine dipstick are all normal and his abdomen is soft. Examination of the skin is unremarkable.
First line blood tests reveal evidence of a non-specific acute inflammatory reaction with neutrophilic leukocytosis and a raised CRP. His liver function and U&Es are normal. A CT head is unremarkable, but a lumbar puncture reveals lymphocytes and raised CSF protein.
What is the most likely underlying diagnosis?
-acute encephalitis
-acute meningitis
-high grade glioma
-drug fever
-cerebral abscess
An 8 year old boy attends A&E following a seizure. He has had three seizures
in last two weeks and reports severe headaches that wake him up in the
morning, and blurred vision over the past three days. A computed tomography
scan reveals a mass in the frontal lobe. A ‘fried egg’ appearance is seen on
biopsy. What is the most likely cause of this presentation?
Oligodendrocytoma
Astrocytomas are the most common, malignant brain tumour. Headaches (especially ones that are worse in the morning or wake you up in the night), double vision, blurred vision etc. are typical presentation due raised ICP.
The most common presentation of oligodendrocytomas is seizures.
Fried egg appearance is a clear marker of oligodendrocytoma (regular cells with spherical nuclei containing finely granular chromatin surrounded by a halo of cytoplasm). They are also typically located in the frontal lobes. Astrocytomas most commonly develop in the cerebellum. Pituitary carcinoma would present with bilateral hemianopia and panhypopituitarism (pale, no axillary hair) A
schwannoma tends to present with bilateral conductive hearing loss and is associated with the condition neurofibromatosis. Myelomas tend to occur in children and comes from arachnoid cells. Clear cells can be seen on histology.
Options:
-methylprednisolone
-antibiotics
-cyclophosphamide
-rutixamab
-plasma exchange
Options:
-mixed absence tonic clonic seizures
-temporal lobe epilepsy
-pseudo-epilepsy
-atonic seizure
A 25 year old female presents to the General Practice with two episodes of blackouts in the past week. As she works a cleaner in a hotel, she has noticed that both episodes occurred unwitnessed while she was cleaning rooms. She reports an “uneasy feeling” followed by finding herself on the floor and feeling “groggy and confused” after the episode, so she takes the rest of the day off. She has not noticed any abnormal lightheadedness or sweating. Her electrocardiogram is normal.
Which of the following is the most likely diagnosis?
-vasovagal syncope
-stokes Adams attack
-non-epileptiform attack disorder seizure
-epileptic seizure
-situational syncope
A 33-year-old woman presents to her GP, complaining of “falls”. Upon further questioning, she explains that around every two weeks, she falls to the floor. She says these episodes feel as though she loses control of her muscles and they “just drop.” These episodes are not associated with loss of consciousness or additional symptoms. Neurological examination shows no physical abnormalities. Her GP suspects epilepsy. What is the best description for this patient’s epileptic syndrome?
-pseudoseizures
-cataplexy
-atonic seizures
-absence seizures
-narcolepsy
A 23 year old girl attends general practice after several sudden lapses of consciousness over the past two weeks. Her friends have noticed she will stare blankly for up to ten seconds, before returning to normal. They also note she rubs her fingers together during these episodes.
Which is the most appropriate first line management option?
Ethosuximide
Acetazolamide
Weight loss and review meds to see if any meds are adding to this
Acetazolamide is the first line pharmacological management
Atypical antipsychotics
Typical antipsychotics (e.g Haloperidol and Chlorpromazine) are dopamine receptor antagonists so they exacerbate extrapyramidal side effects of Parkinson’s
As such, atypical antipsychotics can be used to manage delusions associated with Parkinson’s (e.g. Risperidone, Olanzapine, Aripiprazole)
An 81 year old man is seen in A&E following a fall. He is under the care of the dementia service. His wife is with him and tearfully describes trying to ‘calm down’ her agitated husband by giving him ‘one of her daughter’s tablets’. Upon further questioning you learn that the couple’s daughter has schizophrenia managed with haloperidol. You suspect that this contributed to the fall.
Which dementia subtype is the use of haloperidol contraindicated in?
A 72 year old man presents with episodes of urinary incontinence and difficulty in walking, with some rigidity of his movements. His daughter has reported that both are very unusual, as her father was previously completely independent and fit and well. She also reports concerns about his memory and on formal testing his mini-mental state examination (MMSE) is 13/30.
CT head demonstrates significant enlargement of the ventricles, with no sulcal atrophy.
What is the most effective management for this patient?
A 22-year-old woman presents with a 3-hour history of confusion. She is disorientated to time and place. She was admitted to the ward 2 days ago for treatment of anorexia nervosa. She is agitated and wants to leave the ward. She has an ataxic gait; however, her observations are normal. Her capillary blood glucose is 5.0 mmol/l.
Her most recent blood test results are as follows:
Sodium: 136 mmol/l (133–146)
Potassium: 3.8 mmol/l (3.5–5.3)
Adjusted calcium: 2.4 mmol/l (2.2–2.6)
Magnesium: 0.8 mmol/l (0.7–1.0)
Phosphate: 0.9 mmol/l (0.74–1.4)
Chloride: 102 mmol/l (98–106)
Urea: 8.1 mmol/l (2.5–7.8)
Creatinine 76 µmol/l (45–84)
Which is the most appropriate definitive management?
A 61-year-old woman is brought to her GP surgery by her son, who is concerned about personality changes. This has been occurring gradually over the past 6 months. She has become more outgoing than previously, and has fallen out with numerous friends after making controversial political claims or insulting them. She is systemically well with no evidence of infection or trauma. Notably, her grandmother had a similar problem.
During the consultation there is some evidence of word-finding difficulty, although the patient remains oriented to time and place.
Which of the following is the most likely underlying diagnosis?
A 52 year old man is brought into the GP surgery by his wife. She says that she is at “the end of her tether” with her husband. Over the past few months he has started to act extremely out of character, going gambling most evenings and eating huge amounts of sweet food. Her mother recently passed away and her husband was unsympathetic and uncaring about organizing the funeral.
When you speak to the husband, he denies any problems.
Which of the following is the next best step in the management of this patient?
A 25 year old female patient presents to the emergency department with confusion. She is 10 weeks pregnant.
On physical examination the patient has an unsteady, broad-based gait and gaze-evoked nystagmus.
Which of the following is true of this condition?
-The condition is caused by B12 deficiency
-If untreated, the condition can progress to cause non-declarative memory deficits
-The management of choice is oral thiamine
-The condition is caused by a lesion to Wernicke’s area
-Hyperemesis gravidarum is a risk factor
A 40 year old female patient is brought in by ambulance after losing consciousness at home. Her husband reports that she complained of a sudden onset very severe pain at the back of her head a few moments before collapsing. She is previously fit and well. Her mother and sister suffer from chronic kidney disease.
On arrival to the emergency department her Glasgow Coma Scale is E1V2M2 (5/15) and she has been intubated.
Which of the following signs is suggestive of the underlying diagnosis?
-Jaundice and ascites
-pinpoint pupils
-spontaneous upbeat nystagmus
-Petechial rash
-bilateral flank masses
A 15 year old boy with hard to control epilepsy is started on a new anti-epileptic. He has the following blood test results: AST 310, ALT 290.
Which anti-epileptic is most likely to have caused this?
Sodium valproate
A 34 year old man presents to the Emergency Department with a week-long history of worsening headaches and malaise, accompanied with fever. He feels his headache is worse when exposed to light, or when he looks at his phone. He also feels that his neck is stiff and painful when he moves it. In the last day, he feels that his vision has been getting a bit blurry.
The patient is HIV positive. He has been abroad in Tanzania for 2 years and only returned last week. He has not been having his Antiretroviral therapy as he ran out of his supply. He has no other medical or surgical history.
On examination, he is warm and well perfused. Capillary refill time is less than 2 seconds. Heart sounds are normal and the chest is clear. There are multiple umbilicated papules on his face.
Neurology exam revealed a GCS of 15/15. The patient’s right eye was turned medially when he was looking straight, and he was unable to abduct it. Otherwise, all other cranial nerves were intact. The patient was photophobic and Kernig’s sign positive. Neurology of upper and lower limbs was otherwise intact.
Chest X-ray was normal
CT head showed no acute intracranial pathology.
A lumbar puncture (LP) was performed:
A 25 year old female patient is on the wards recovering from a thyroidectomy for thyroid carcinoma.
The post-operative period has been complicated by nausea, vomiting, and pain around the wound site so she has been prescribed post-operative medication accordingly. 24 hours after surgery she becomes increasingly restless and is noted to have forced extension of the neck, rigid opening of the jaw, and sustained upward deviation of the eyes.
Which of the following is the most likely cause of this presentation?
-phenytoin
-carbamazepine
-levetiracetam
-sodium valproate
-lamotrigine
A 32-year-old man is reviewed in the neurology clinic for the first time. He has a history of abnormal episodes occurring 1-2 times per day for the last 3 months. His partner describes the episodes: she reports he goes vacant for 15-30 seconds and then an abnormal chewing movement starts. The whole episode lasts about 1 minute. The patient says he can sense when they are about to happen as he gets an unpleasant taste in his mouth.
He has had a set of normal blood tests and a normal CT and MRI scan. He is referred for video telemetry.
What is the first-line treatment for his condition?
A 50-year-old male presents to the Emergency Department with an acute traumatic subarachnoid haemorrhage following a road traffic accident. He has a severe headache and vomited once upon arrival. He develops sudden-onset jerking of all four limbs with uprolling of his eyes and urinary incontinence. He is given two boluses of intravenous lorazepam 4mg without improvement. What is the next best step?
-IV phenytoin infusion
-rectal diazepam
-IV lorazepam
-decompressive crainectomy
-buccal midazolam
-gabapentin
-nasal triptan
-oral triptan
-paracetamol
-carbamazepine
Carbamazepine is first line treatment for trigeminal neuralgia
32 year old woman presents to ED with a severe, throbbing headache occurring all across her head. She also feels nauseated and has vomiting several times. On examination, you notice bilateral papilloedema and she appears confused. Non contrast CT shows hyper density in superior Sagittal sinus. What’s the most appropriate treatment?
Low molecular weight heparin
What is the most likely diagnosis?
Idiopathic intracranial hypertension
Which of the following is the most likely underlying cause?
-autoimmune encephalitis
-tetracycline
-metformin
-stroke
-bacterial encephalitis
Tetracycline- this has caused idiopathic intracranial hypertension in this patient
What is the most likely diagnosis?
A 2 year old girl is referred to the paediatrician with delayed motor milestones. She is otherwise well and there is no family history of note. She is crawling but has not yet been cruising or walking. She was born at 30 weeks by normal vaginal delivery and weighed 1.2kg.
On physical examination there is spastic hypertonia in the lower limbs, weakness of lower limbs flexor muscles, knee/ankle hyper-reflexia and upgoing plantars.
The most likely underlying lesion is located at which anatomical location?
Barthel index
A 37 year old pregnant woman arrives to the Emergency Department with a sudden onset 7/10 retro-orbital headache associated with vomiting. She is apyrexial at the time of assessment but has a low blood pressure 85/42 and HR 121. She is afebrile. A collateral history states she has been well in herself but has been having some ongoing visual problems over the past few months.
On routine bloods you note she has a low sodium and on clinical examination an ocular palsy is present with no rash or neck stiffness.
What is the diagnosis?
A 21-year-old man presents to the emergency department after sustaining a head injury whilst playing sports. He is worried that his skull may have been fractured. On examination, the doctor finds that there is a loss of sensation to the forehead, upper eyelids and part of the nose. The doctor also notes that when the cornea is lightly touched, the patient does not blink.
Which nerve is most likely affected?
A 45-year-old woman visits her doctor with complaints of strange sensations and weakness in her right leg. She mentions feeling ‘numb’ on the front of her right knee and on the inside of her right ankle. She also finds it difficult to straighten her right knee and move it closer to the other leg in bed. Upon examination, there is a reduced right knee reflex.
Which nerve root is likely affected?
L4
A 23-year-old presents to the emergency department following a blow to the face after he was involved in a brawl that started on a night out. On examination, he has tenderness around his nose and cheeks with bruises under his eyes that resemble ‘panda eyes’. The doctor is suspicious of multiple skull fractures, including a basal skull fracture. Cranial nerve examination reveals anosmia in addition to vertical diplopia.
Damage to which of cranial nerves is likely to be causing his symptoms?
During a neck dissection, a nerve is noted to pass posterior to the medial aspect of the first rib. Which of the nerves listed below is this most likely to be?
-Medial cord of the brachial plexus
-Long thoracic nerve
-Nerve to subclavius
-Medial pectoral nerve
-Phrenic nerve
the phrenic nerve runs posterior to the medial aspect of the first rib. Superiorly, it lies on the surface of scalenus anterior.
A young man is attacked in a bar fight and develops a neck injury. When he is seen in the emergency department he has a drooping left eyelid, a constricted and non-reactive left pupil and he has visible sweat over the right side of his face but none on the left.
Which of the following nervous structures are most likely to have been injured in the attack?
-Oculomotor nerve
-Brachial plexus
-Cervical sympathetic chain
-Facial nerve
-Vagus nerve
