Neurology Flashcards
Stroke: contralateral hemiparesis and sensory loss, lower extremity > upper
Where is the lesion?
Anterior cerebral artery
Stroke: contralateral hemiparesis and sensory loss (upper extremity > lower), contralateral homonymous hemianopia, aphasia
Where is the lesion?
Middle cerebral artery
Stroke: contralateral homonymous hemianopia with macular sparing, visual agnosia
Where is the lesion?
Posterior cerebral artery
Stroke: ipsilateral CN III palsy, contralateral weakness of upper and lower extremity
Where is the lesion?
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
Stroke: ipsilateral: facial pain and temperature loss, contralateral: limb/torso pain and temperature loss, ataxia, nystagmus
Where is the lesion?
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
Stroke: ipsilateral CN III palsy, contralateral weakness of upper and lower extremity, facial paralysis and deafness
Where is the lesion?
Anterior inferior cerebellar artery (lateral pontine syndrome)
Stroke: amaurosis fugax
Where is the lesion?
Retinal/ophthalmic artery
Stroke: ‘locked-in’ syndrome
Where is the lesion?
Basilar artery
Describe the presentation of lacunar strokes
- Present with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
- Strong association with hypertension
What is Miller Fisher syndrome?
- Subtype of Guillain-Barre syndrome characterised by areflexia, ophthalmoplegia, and ataxia
- Descending weakness is also a classic feature of this condition, as opposed to the ascending weakness seen in more common forms of GBS
What are the features of Wernicke’s encephalopathy?
Confusion, gait ataxia, nystagmus + ophthalmoplegia
Fever, headaches, and behavioural changes such as irritability, followed by seizures.
CT head showing temporal lobe changes.
What is the diagnosis?
Herpes simplex encephalitis
What is the first line treatment for tonic/atonic seizures in females?
Lamotrigine
Describe the management of autonomic dysreflexia
Involves removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia
A 65-year-old man presents with a 3 month history of numbness and paraesthesia in his feet. On examination there is widespread numbness of both feet which does not fit a dermatomal distribution. A recent gamma-glutamyl transpeptidase (gamma GT) is 4 times the upper limit of normal.
What is the most likely diagnosis?
Alcohol peripheral neuropathy
A 73-year-old man presents to the emergency department with a left-sided facial droop. On cranial nerve testing, when testing the facial muscles, he is unable to smile on the left side but can close his eyes, raises his eyebrows and wrinkle his forehead.
Where is the lesion located which has caused this particular facial nerve palsy?
Right upper motor neuron
Driving restrictions: first unprovoked or isolated seizure if brain imaging and EEG normal
Cannot drive for 6 months
What findings on nerve conduction studies are associatd with GBS?
Decreased motor nerve conduction velocity on nerve condution studies secondary to demyelination
What type of dysphagia: speech fluent, but repetition poor, comprehension is relatively intact
Conductive dysphagia
How does Creutzfeldt-Jakob disease present?
Rapid onset dementia and myoclonus
Patient presents with stroke. What CT findings would be a contraindication to thrombolysis/thrombectomy?
A hyperdense collection is suggestive of a haemorrhage and hence a contraindication
Headache worse on lying down or coughing. What is contraindicated?
Lumbar puncture (raised ICP until proven otherwise so do CT first)
What complicaton of acute sinusitis presents with headache, fever, and focal neurology?
Brain abscess
Defective eye abduction and horizontal diplopia indicates a palsy in which nerve?
CN VI
Ptosis, down and out eye, dilated fixed pupil indicates a lesion in which nerve?
CN III
Horizontal diplopia indicates a lesion in which nerve?
CN VI
CN X nerve palsy. Uvula deviates to which side?
Away from site of lesion
CN XII nerve palsy. Tongue deviates to which side?
Towards site of lesion
Where is the lesion:
Incongrous homonymous hemianopia
Optic tract
Where is the lesion:
Congrous homonymous hemianopia
Optic radiation or occipital cortex
Where is the lesion:
Homonymous hemianopia with macula sparing
Occipital cortex
Where is the lesion:
Superior homonymous quadrantanopia
Inferior optic radiations in the temporal lobe (Meyer’s loop)
Where is the lesion:
Inferior homonymous quadrantanopia
Superior optic radiations in the parietal lobe
Where is the lesion:
Bitemporal hemianopia, upper quadrant > lower quadrant
Inferior chiasmal compression, commonly a pituitary tumour
Where is the lesion:
Bitemporal hemianopia,lower quadrant > upper quadrant
Superior chiasmal compression, commonly a craniopharyngioma
The neurosurgery team review a 55-year-old patient who was admitted for a newly diagnosed brain tumour. He is noted to have a third nerve palsy.
Which clinical findings would be most consistent with this?
Ptosis, downward and outward deviation of the eye, mydriasis
Raised ICP can cause a third nerve palsy due to herniation
Third nervy palsy presenting with a large pupil.
What investigation should you perform?
Urgent CT brain - indicates a surgical cause
What is the most likely operation to be done for symptomatic chronic subdural bleeds?
Burr hole evacuation
A 45-year-old female with multiple sclerosis complains of tingling in her hands which comes on when she flexes her neck. What is this an example of?
Lhermitte’s sign
What is syringomyelia?
Collection of cerebrospinal fluid within the spinal cord
Describe the clinical presentation of a syringomyelia
Cape-like loss of pain and temperature sensation
How does a syringomyelia cause a cape-like loss of pain and temperature sensation?D
Due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine
Describe the presentation of a vestibular schwannoma
Vertigo, hearing loss, tinnitus and an absent corneal reflex
Fixed and dilated pupil with an eye deviated inferiorly and laterally (‘down and out’) + decreasing conscious level and an intracranial mass
What is the diagnosis?
Trans-tentorial, or uncal, herniation
What is Uhthoff ‘s phenomenon?
Neurological symptoms are exacerbated by increases in body temperature, typically associated with multiple sclerosis
Describe the presentation of multiple system atrophy
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension)
How does a common perineal nerve lesion present?
Weakness of foot dorsiflexion and foot eversion
What is the Cushing reflex?
The Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in hypertension (with a wide pulse pressure) and bradycardia
Describe the presentation of venous sinus thrombosis
Sudden onset headache, features of increased intracranial pressure such as nausea and vomiting, and a raised d-dimer
What is the gold standard test for diagnosing venous sinus thrombosis?
MR Venogram
How do you differentiate between vasovagal syncope and a seizure?
- Syncopal episodes are associated with a rapid recovery and short post-ictal period
- Seizures are associated with a far greater post-ictal period
A 75-year-old lady presents to the emergency room after falling onto her left elbow. She has marked bruising and tenderness of the left upper arm. On examination, you note a left wrist drop.
What is the most likely injury?
Fracture of the shaft of the humerus causing radial nerve damage
Describe the presentation of a cluster headache
Episodic, intense, unilateral eye pain, lacrimation, restless
Describe the acute management of a cluster headache
High flow oxygen and SC sumatriptan
Describe the presentation of Charcot-Marie-Tooth disease
- Sensor and motor peripheral neuropathy
- Patients can present with lower motor neurone signs in all limbs and reduced sensation (more pronounced distally
What is the first line investigation for suspected stroke?
Non-contract head CT
What are the features of Wernicke’s encephalopathy
Confusion, gait ataxia, nystagmus + ophthalmoplegia (lateral rectus palsy, conjugate gaze palsy)
What nerves are resposible for the ankle reflex?
S1-S2
What nerves are responsible for the knee reflex?
L3-L4
What nerves are responsible for the biceps reflex?
C5-C6
What nerves are responsible for the triceps reflex?
C7-C8
What important causes should be ruled out in the initial management of status epilepticus?
Hypoxia and hypoglycaemia
What is Hoffmans sign?
Sign associated with upper motor neuron conditions such as cervical myelopathy and MS
Flicking the distal phalaynx of the middle finger to cause momentary flexion
What are the common triggers for migraines?
Migraine triggers include the mnemonic CHOCOLATE: chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel, exercise
Describe the presentation of a cranial thid nerve palsy
- Ptosis, pupil dilation and absent light reflex with intact consensual contriction
- ‘Down and out’ position
What is Broca’s dysphagia?
Speech non-fluent, comprehension normal, repetition impaired
Where is Broca’s area located?
Left inferior frontal gyrus (in frontal lobe)
If left hemisphere dominant
Strokes to which artery can cause Broca’s dysphagia?
Superior devision of middle cerebral artery
What is Wernicke’s aphasia?
- Fluent speech (i.e. speech flows well, speech is not broken) but makes no sense
- Word substitutions and neologisms (making up new words) are features of Wernicke’s dysphasia
- However, comprehension is impaired so patients are unaware of the impairment.
Where is Wernicke’s area?
Left superior temporal gyrus (in temporal lobe)
If left hemisphere dominant
Strokes to which artery can cause Wernicke’s dysphagia?
Inferior middle cerebral artery
What is pituitary apoplexy?
Rare and life-threatening complication of a pituitary adenoma and is defined as bleeding/infarction within the pituitary macroadenoma
Describe the management of pituitary apoplexy
IV hydrocortisone
When can anti-epileptic drugs be stoppped?
Can be considered if seizure free for > 2 months, with AEDs being stopped over 2-3 months
When is carotid endartectomy indicated?
Patient who has had a TIA with carotid artery stenosis exceeding 50% (NASCET criteria) on the side contralateral to the symptoms
A 75-year-old female presents with weakness of her left hand. On examination, wasting of the hypothenar eminence is seen and there is weakness of finger abduction. Thumb adduction is also weak. Where is the lesion most likely to be?
Ulnar nerve
Sudden-onset headache, reaching maximum intensity within 5 minutes. What is the next appropriate step?
Urgent non-contrast head CT
A 60-year-old gentleman with a background of lumbar spondylosis and chronic back pain presents with gradually worsening bilateral upper limb paraesthesias and leg stiffness.
What is the best investigation?
MRI cervical spine
What is restless legs syndrome?
Syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia
Describe the clinical presentation of restless legs syndrome
- Uncontrollable urge to move legs (akathisia)
- Symptoms initially occur at night but as condition progresses may occur during the day
- Symptoms are worse at rest
- Paraesthesias e.g. ‘crawling’ or ‘throbbing’ sensations
What is the first line treatment for moderate-severe restless leg syndrome?
Dopamine agonists e.g. ropinirole
How does controlled hyperventilation help patients with raised ICP?
Hyperventilation reduces CO2 leading to vasoconstriction of the cerebral arteries, which reduces ICP
What is the definition of a TIA?
Transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
No longer time based (symptoms lasting < 24 hours)
What is dgenerative cervical myelopathy?
Spinal cord compression due to degenerative changes of the surrounding spinal structures; e.g. from disc herniation, ligament hypertrophy or calcification, or osteophytes
What is the first line investigation for degenerative cervical myelopathy?
MRI
What are the cliincal signs associated with cerebellar lesions?
- D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’
- A - Ataxia (limb, truncal)
- N - Nystamus (horizontal = ipsilateral hemisphere)
- I - Intention tremour
- S - Slurred staccato speech, Scanning dysarthria
- H - Hypotonia
What is the Barthel index?
Scale that measures disability or dependence in activities of daily living in stroke patients
A 65-year old gentleman with a background of osteoarthritis and previous cervical laminectomy for degenerative cervical myelopathy presents with a 2-month history of worsening gait instability and urinary urgency.
Which of the following is the most likely explanation for his symptoms?
Recurrent degenerative cervical myelopathy
Postoperatively, patients with cervical myelopathy require ongoing follow-up as pathology can ‘recur’ at adjacent spinal levels, which were not treated by the initial decompressive surgery
What is the main adverse effect of lamotrigine?
Stevens-Johnson syndrome
What is the key diagnostic test for GBS?
Lumbar puncture
What lumbar puncture findings are associated with GBS?
Rise in protein with a normal white blood cell count (albuminocytologic dissociation)
What type of anti-emetic can predispose to prolonged QT interval and increased risk of polymorphic VT?
5-HT3 antagonists such as ondansetron
Patient presents with confusion 4 weeks after a traumatic head injury. What is the most likely diagnosis?
Subdural haematoma
Loss of corneal reflex is associated with a lesion of which nerve?
CN V1
Describe the clinical findings associated with subacute combined degeneration of the spinal cord
Loss of proprioception and vibration sensation, muscle weakness, and hyperreflexia
Dorsal columns and lateral corticospinal tracts are affected
A 70-year-old man presents to the emergency department with a two-day history of confusion and fevers. A CT scan of the head reveals subtle low-density enhancement in the anterior and medial aspects of the temporal lobes bilaterally.
What is the most likely causative organism for this man’s presentation?
Herpes simplex
You are examining a patient who complains of double vision. Whilst looking forward the patient’s right eye turns downwards and outwards. On attempting to look to the patient’s left the patient is unable to adduct the right eye and double vision worsens. On looking right the angle of the squint is less.
What is the most likely underlying problem?
Right 3rd nerve palsy
A 65 year-old female presents with neck pain and loss of dexterity in both hands. She has been struggling to type at work and use her mobile phone. Her symptoms have been deteriorating gradually over the preceding months.
What is the most likely diagnosis and best management?
Degenerative cervical myelopathy
Refer for spine surgery
What are the features of neurofibromatosis 1?
- Cafe-au-lait spots (>= 6, 15 mm in diameter)
- Axillary/groin freckles
- Peripheral neurofibromas
- Iris hamatomas (Lisch nodules) in > 90%
- Scoliosis
- Pheochromocytomas
What are the features of neurofibromatosis 2?
- Bilateral vestibular schwannomas (sensorineural hearing loss)
- Multiple intracranial schwannomas, mengiomas and ependymomas
Should drugs for neuropathic pain be used in combination?
No - typically used as monotherapy i.e. if not working then drugs should be switched, not added
Which nerve supplies the sensation to the skin on the palmar aspect of the thumb?
Median nerve
Which nerve supplies the sensation to the skin on the nailbed of the index finger?
Median nerve
Which nerve supplies the sensation to the skin on the skin overlying the medial aspect of the palm?
Ulnar nerve
Describe the presentation of damage to the ulnar nerve
- Wasting of hypothenar muscles
- Loss of thumb adduction
- Wasting of 1st web space and ulnar claw hand (hyperextension at metacarpophalangeal joint, flexion at interphalangeal joint)
What nerves are affected in vestibular schwannomas?
V, VII and VIII
A 65-year-old male with known nasopharyngeal carcinoma presents with double vision over a few weeks. On examination he is found to have left eye proptosis and it is down and out. He reports pain on attempting to move the eye. There is an absent corneal reflex. What is the most likely diagnosis?
Cavernous sinus syndrome
What is the most suitable anti-emetic for patients with Parkinson’s?
Domperidone - does not cross blood-brain barrier
Describe the presentation of Brown-Sequard syndrome
Same sided weakness and proprioception/vibration loss and loss of pain/temperature on the opposite side to the hemisection
A 36-year-old man is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity.
Which drug may be beneficial in the treatment of this patient?
Bromocriptine
What drugs can increase the risk of idiopathic intracranial hypertension?
- Combined oral contraceptive pill
- Steroids
- Tetracyclines e.g. doxycycline
- Retinoids (isotretinoin, tretinoin) / vitamin A
- Lithium
Which nerve palsy can be the first sign of brain metastasis?
CN6 - medially pointing right eye and horizontal diplopia
What is the management of status epilepticus?
- ABCDE
- Benzodiazepines (pre-hospital: PR diazepam or buccal midazolam, hospital IV lorazepam)
- Give up to 2 doses of benzos
- If established status: second-line agent such as levetiracetam, phenytoin or sodium valproate
For a patient with Bells palsy, when should you refer urgently to ENT?
If the paralysis shows no sign of improvement after 3 weeks
What findings on neuroimaging are associated with normal pressure hydrocephalus?
Ventriculomegaly out of proportion to sulcal enlargement
A 23-year-old man presents to his GP. He describes episodes of leg weakness following bouts of laughing whilst out with friends. The following weekend his friends described a brief collapse following a similar episode. What is the most likely diagnosis?
Cataplexy
Describe the presentation of neurogenic thoracic outlet syndrome
Typically presents with muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms
Why is the COCP contraindicated in patients who have migraines with aura?
Significantly increased risk of ischaemic stroke
What blood tests are associated with neuroleptic malignant syndrome?
Raised CK and leukocytosis
A 66-year-old woman presents with a six-month history of urinary frequency and incontinence. She has a background in relapsing-remitting multiple sclerosis (MS).
A urine dip is normal.
What is the most appropriate next step in her management?
Ultrasound kidneys, ureters and urinary bladder (KUB)
What is the first line treatment for focal seizures?
Lamotrigine or levetiracetam
A 63-year-old man is admitted with a severe headache, nausea and a recent epileptic fit. Fundoscopy shows papilloedema. He is also noted to have diplopia when asked to look laterally.
What cranial nerve is affected?
Abducens nerve
A 32-year-old lady is admitted with weakness, visual disturbance and periorbital pain. On examination she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response in the affected eye is preserved.
What cranial nerve is affected?
Optic nerve
Describes RAPD
An 18-year-old man who has been stabbed in the neck is found to have an inability to contract the sternocleidomastoid and upper fibers of trapezius muscles on that side.
What cranial nerve is affected?
Accessory nerve
Neuropathic pain characteristically responds poorly to opioids. However, if standard treatment options have failed which opioid is it most appropriate to consider starting?
Tramadol
What is Hoover’s sign?
- Specific manoeuvre used to distinguish between an organic and non-organic paresis of a particular leg
- If a patient is genuinely making an effort, the examiner would feel the ‘normal’ limb pushing downwards against their hand as the patient tries to lift the ‘weak’ leg
- Noticing this is indicative of an underlying organic cause of the paresis
- If the examiner fails to feel the ‘normal’ limb pushing downwards as the patient tries to raise their ‘weak’ leg, then this is suggestive of an underlying functional weakness, also known as ‘conversion disorder’
What is the most common pattern for progression of multiple sclerosis?
Relapsing-remitting
What is the most common neurological manifestation of sarcoid?
Facial nerve palsy
A 22-year-old man presents with symptoms of lethargy and bilateral facial nerve palsy. On examination he has bilateral parotid gland enlargement.
What is the most likely diagnosis
Sarcoidosis
Describe the CT findings associated with a chronic subdural haematoma
Hypodense (dark), crescentic collection around the convexity of the brain
Describe the CT findings associated with a subdural haemorrhage
Crescent-shaped white-grey discrete lesion
Which type of haemorrhage is caused by damage to bridging veins between cortex and venous sinuses?
Subdural haemorrhage
Which type of haemorrhage is caused by damage to the middle meningeal artery?
Extra-dural haematoma
What features must be present to diagnose a total anterior ciculation infarct?
All 3 of the following:
- Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- Homonymous hemianopia
- Higher cognitive dysfunction e.g. dysphasia
Describe the presentation of a pontine haemorrhage
Commonly presents with reduced GCS, paralysis and bilateral pin point pupils
Name a feature that would suggest idiopathic Parkinson’s rather than a drug-induced disease
Asymmetrical symptoms
Which drugs that can cause a medication overuse headache can be stopped abruptly?
Simple analgesia and triptans
Which drugs that can cause a medication overuse headache should be withdrawn gradually?
Opioids
What drugs can exacerbate symptoms of myasthenia gravis?
- Penicillamine
- Quinidine, procainamide
- Beta-blockers
- Lithium
- Phenytoin
- Antibiotics: gentamicin, macrolides, quinolones, tetracyclines
Name a common side effect of triptans
Tightness of the throat and chest
Male patient with rhythmic jerking of limbs. What is the first line anti-epileptic?
Sodium valproate
Sodium valproate is the first-line treatment for generalised tonic-clonic seizures in males
A 16-year-old boy was out roller skating when he sustained a fall on an outstretched hand. He felt severe pain immediately following the fall and has noticed significant degrees of swelling and bruising in his wrist. On examination, you notice that he has lost the ability to abduct his thumb.
Which nerve is most likely to have been injured?
Median
What is the most likely diagnosis?
Tuberous sclerosis - depigmented ‘ash-leaf’ spots
A 72-year-old woman presents to the emergency department. She describes to the doctors that a few minutes ago she felt a tingling sensation in her left little toe followed by jerking movements on the rest of her left side of the body.
Given the likely diagnosis, what part of her brain is affected?
Frontal lobe epilepsy
Jacksonian movement (clonic movements travelling proximally)
Which nerve is most likely to be injured in a Colle’s fracture?
Median
Which anti-Parkinson medication are associated with the highest chance of inhibition disorders?
Dopamine receptor agonists e.g. ropinirole, bromocriptine
Motor neurone disease typically spares which muscles?
Ocular
Describe the presentation of juvenile myoclonic epilepsy?
Classically associated with seizures in the morning/following sleep deprivation
A 22-year-old man presents with a one day history of a generalised headache. He prefers being in the dark and says he is ‘sleepy’. He has no neck stiffness. His temperature is 38.2ºC
What is the most likely diagnosis?
Meningitis
Neck stiffness is absent in around 30% of patients with meningitis
What are the most common triggers of autonomic dysreflexia?
Faecal impaction / urinary retention
What is the management of Bell’s palsy?
Course of prednisolone and eye care advice
What is the management of a myasthenic crisis?
Intravenous immunoglobulin, plasmapheresis
A 65-year-old male presents with sudden onset hemiparesis affecting the right face, arm and leg. The symptoms started approximately 12 hours ago. On examination you note right sided hemiparesis, aphasia, and a right homonymous hemianopia. A CT scan confirms left sided ischaemic stroke. An ECG demonstrates an irregularly irregular rhythm with absence of P waves. He has has a CHA2DS2-VASc Score of 4.
What is the most important initial treatment to provide?
Aspirin
Thrombolysis is not indicated as it has been greater than 4.5 hours since the onset of symptoms
A woman suddenly has the sensation of smelling roses whilst at work. She is conscious throughout.
What type of seizure is this?
Focal aware seizure
A 50-year-old man who, on examination, you notice his jaw appears deviated towards the right and he has an absent right-sided corneal reflex.
Which cranial nerve palsy would explain this?
Trigeminal
A 64-year-old woman who reports vertical diplopia, in particular, whilst reading in bed at night time.
Which cranial nerve palsy would explain this?
Trochlear
A 72-year-old man who has noticed a change in his voice with some difficulty swallowing. On examination, you notice his uvula deviates towards the right.
Which cranial nerve palsy would explain this?
Vagus (left side)
A 23-year-old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly weakened.
What is the most likely nerve injury?
Median
A 45-year-old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is impaired.
What is the most likely nerve injury?
Intercostobrachial
An 8-year-old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand.
What is the most likely nerve injury?
Median
How long should antiplatelet agents be continued following an ischaemic stroke?
Lifelong
22-year-old woman is seen in the clinic with 4 unprovoked episodes of rapid bilateral upper and lower limb muscle contraction and relaxation lasting around 10 seconds before stopping. She denies any loss of consciousness and can continue doing her activities after each episode. A collateral history is taken, and it is established that no incontinence or tongue biting occurs.
There is no history of head trauma. She does not take any regular medication.
Given the likely diagnosis, what is this patient most likely to be started on?
Levetiracetam
Myoclonic seizures: levetiracetam is first-line for females
What is the management of degenerative cervical myelopathy?
Refer to spinal surgery or neurosurgery
What is the treatment of choice for essential tremor?
Propranolol
Describe the clinical presentation of a brain abscess
Headache, fever and focal neurology
What is the treatment of choice for a woman of childbearing age who presents with generalised tonic-clonic seizures?
Lamotrigine or levetiracetam
Describe the features of a temporal lobe seizure
Aura in most patients - typically rising epigastric sensation, also psychic or experiential phenomena e.g. de-ja-vu
Seizures typically last around 1 minute - automatisms e.g. lip smacking, grabbing/plucking of clothes are common
Describe the features of a frontal lobe seizure
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
Which type of seizure presents with sensory abnormalities?
Parietal
Which type of seizure presents with flashes/floaters?
Occipital lobe
What is the management of acute relapse of MS?
High dose steroids e.g. methylprednisolone
What is the preferred modality in patients with suspected TIA who require brain imaging?
MRI brain with diffusion-weighted imaging
A 70 year-old man complains of numbness in his feet bilaterally and is finding it difficult to walk. On examination he has normal pain and temperature sensation in his lower limbs, but decreased appreciation of light touch and proprioception.
Where is the most likely site of a neurological lesion?
Dorsal column
The sensation of fine touch, proprioception and vibration are all conveyed in the dorsal column
What are the differences between a third nerve palsy and Horner’s?
Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner’s
What is the most likely diagnosis for a painful third nerve palsy (eye down and out, ptosis, dilated pupil)?
Posterior communicating artery aneurysm
Describe the clinical presentation of narcolepsy
- Sudden onset sleep during day
- Episodes of sleep paralysis at night
What is the investigation of choice for narcolepsy?
Multiple sleep latency EEG
A 24-year-old man with focal seizures. He previously developed a rash whilst taking lamotrigine.
What is the next line treatment?
Levetiracetam
First-line anti-epileptic in a 17-year-old girl with tonic-clonic seizures. She is not sexually active and does not use any form of contraception currently. She has previously had a reaction to levetiracetam.
What is the next line treatment?
Lamotrigine
First-line antiepileptic for a boy who presents with absence seizures
Ethosuximide
What is the first line treatment for trigeminal neuralgia?
Carbamazepine
What are the side effects of phenytoin?
- Peripheral neuropathy, characterized by numbness and reduced sensation in a glove-and-stocking distribution
- Lymphadenopathy
- Bleeding gums
What is the most common presentation of ALS?
Asymmetric limb weakness
Mixture of LMN and UMN signs
Patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA.
What is the management?
Immediate admission for imaging to exclude haemorrhage
What are the features of a cluster headache?
Episodic, intense, unilateral eye pain, lacrimation, restless
What is the first line management for prophylaxis of cluster headaches?
Verapamil
What is the definitive management for patients with an acute ischaemic stroke who present within 4.5 hours?
Combination of thrombolysis AND thrombectomy
Autonomic dysreflexia can only occur if the spinal cord injury occurs above which level?
T6
TIA. First line management?
Clopidogrel (initial dose 300 mg followed by 75 mg od) + aspirin (initial dose 300 mg followed by 75 mg od for 21 days) followed by monotherapy with clopidogrel 75 mg od
This patient is being treated for epilepsy. What is the most likely underlying diagnosis?
Tuberous sclerosis
A 23-year-old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination he has lost extension of the fingers in his right hand.
Where is the most likely nerve injury?
Radial nerve
A 40-year-old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand.
Where is the most likely nerve injury?
Ulnar nerve
A 28-year-old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit overlying the point of deltoid insertion into the humerus.
Where is the most likely nerve injurt?
Axillary nerve
What is the investigation of choice for syringomyelia?
MRI spine
What driving guidance should be given to patients who have had a TIA?
Can start driving if symptom-free for 1 month and there is no need for them to inform the DVLA
What are the target times for thrombolysis and thrombectomy in acute ischaemic stroke?
Thrombolysis: 4.5 hours
Thrombectomy: 6 hours
What visual field defect would be seen in a patient with primary open angle glaucoma in the right eye?
Unilateral peripheral visual field loss
What visual field defect would be seen in a patient with a pituitary gland tumour?
Bitemporal hemianopia, lower quadrant defect
What visual field defect would be seen in a patient who has had an extensive stroke with right-sided hemiplegia?
Right homonymous hemianopia
Name one contraindication for the use of triptans
Patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease
What GCS score warrents intubation?
< 8
What is the most suitable device to maintain a patients airway with a low GCS?
Cuffed endotracheal tube
What are the first-line drugs for spasticity in MS?
Baclofen and gabapentin
Describe the presentation of degenerative cervical myelopathy
- Pain (affecting the neck, upper or lower limbs)
- Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
- Loss of sensory function causing numbness
- Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
A 45-year-old alcoholic patient starts to fit in the waiting room. You place him in the recovery position and apply oxygen. After 5 minutes he is still fitting. What is the most appropriate medication to administer?
Rectal diazepam 10 mg
What is the normal duration for a cluster headache?
15 mins to 2 hours
What is the site of action of ondansetron?
CTZ of the medulla oblongata
Progressive peripheral polyneuropathy with hyporeflexia suggests what diagnosis?
Guillain-Barre syndrome
A 42-year-old teacher is admitted with a fall. An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?
Axillary nerve
A 32-year-old window cleaner is admitted after falling off the roof. He reports that he had slipped off the top of the roof and was able to cling onto the gutter for a few seconds. The patient has Horner’s syndrome.
Where is the most likelysight of the lesion?
Brachial Trunks C8-T1
Klumpke’s paralysis
A 32-year-old rugby player is hit hard on the shoulder during a rough tackle. Clinically his arm is hanging loose on the side. It is pronated and medially rotated.
Where is the most likely sight of the lesion?
Brachial Trunks C5-6
Erb’s palsy
What neuroimaging findings are associated with a meningioma?
- Tumour arising from the falx cerebri and pushing on the brain
- Typically located next to the dura
- Well-defined border between the tumour and the brain parenchyma
What is a meningioma?
Typically benign tumours that arise from the arachnoid cap cells of the meninges
Name a drug useful for managing tremor in drug-induced parkinsonism
Procyclidine
What drug used in the management of parkinson’s has been associated with pulmonary fibrosis?
Cabergoline
What drug used in the management of parkinson’s often has a reduced effectiveness with time?
Levodopa
Name two important differentials for a TIA
- Hypoglycaemia
- Intracranial haemorrhage
Describe the tremor seen in Parkinson’s
Unilateral tremor that improves with voluntary movement
What causes subacute combined degeneration of the spinal cord?
Vitamin B12 deficiency
Describe the clinical presentation of subacute combined degeneration of the spinal cord
- Dorsal column involvement: distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms, impaired proprioception and vibration sense
- Lateral corticospinal tract involvement: muscle weakness, hyperreflexia, and spasticity
- Spinocerebellar tract involvement: sensory ataxia will lead to gait abnormalities, positive Romberg’s sign
Describe the presentation of infantile spasms
- Brief spasms beginning in the first few months of life
- Flexion of head, trunk, limbs → extension of arms (Salaam attack)
- Last 1-2 secs, repeat up to 50 times
- Progressive mental handicap
What is the typical EEG finding associated with infantile spasms?
Hypsarrhythmia
What is the first line management for migraine prophylaxis?
Topiramate - avoid in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives
Propranolol
What is the management of a brain abscess?
IV 3rd-generation cephalosporin e.g. ceftriaxone + metronidazole
What is ?the most common complication following meningitis??
Sensorineural hearing loss
Chronic history of lower limb weakness characterised by a pyramidal distribution, where flexors are more affected than extensors in the lower limbs.
What is the most likely diagnosis?
MS
A 35-year-old woman is seen in clinic with a 7-month history of progressive unilateral hearing loss. During this time, she has had intermittent episodes of room spinning and tinnitus in the affected ear.
Where is the site of the lesion?
Right cerebellopontine angle
Vestibular schwannoma: benign tumour of Schwann cells around the vestibulocochlear nerve that tends to occupy the cerebellopontine angle
A 24-year-old lady presents to her GP where she proceeds to have a convulsive episode involving her whole body in the waiting room. During the episode, she is not able to speak but can make eye contact when her name is called. After the episode she quickly returns to normal and is able to remember everything that happened during the episode. Her past medical history includes post-traumatic stress disorder and alcohol overuse.
What is the most likely diagnosis?
Psychogenic non-epileptic seizure
Widespread convulsions without conscious impairment is likely to represent a pseudoseizure
What is the investigation of choice for MS?
MRI with contrast
The presence of neurological motor symptoms and fasciculations with mixed upper motor neurone (UMN), lower motor neurone (LMN) signs, and very few or absent sensory signs should raise suspicion of what condition?
Motor neuron disease
An 86-year-old woman with Parkinson’s disease presents to her neurologist. She is taking levodopa three times daily and complains of worsening symptoms in the lead-up to taking each dose. Her neurologist decreases her dose of levodopa and increases its frequency to five times daily.
What clinical sequelae of treatment is the neurologist attempting to mitigate?
End-of-dose wearing-off phenomenon
What are the red flags for patients presenting with a headache?
- Compromised immunity, caused, for example, by HIV or immunosuppressive drugs
- Age under 20 years and a history of malignancy
- A history of malignancy known to metastasis to the brain
- Vomiting without other obvious cause
- Worsening headache with fever
sudden-onset headache reaching maximum intensity within 5 minutes - ‘thunderclap’ - New-onset neurological deficit
- New-onset cognitive dysfunction
- Change in personality
- Impaired level of consciousness
- Recent (typically within the past 3 months) head trauma
- Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
- Orthostatic headache (headache that changes with posture)
- Symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
- A substantial change in the characteristics of their headache
What is the management of a low pressure headache following a lumbar puncture?
Caffeine and fluids
