Neurology

Question 1

Which organism causes GBS?

Answer 1

Guillain-Barre syndrome is classically triggered by Campylobacter jejuni infection

Question 2

What is Gower’s sign?

Answer 2

Gower’s sign: Seen in Duchenne muscular dystrophy, when a child used their arms to aid standing from a squat

Question 3

What does the biceps reflex test?

Answer 3

C5-C6 nerve root

Question 4

What do C7 and C8 do?

Answer 4

Although these cervical nerve roots do contribute to upper limb function - specifically wrist flexion (C7) and finger flexion (C8) - they are not primarily involved in eliciting the biceps reflex which tests mainly C5-C6 nerve root integrity.

Question 5

Give three common sites of lacunar strokes

Answer 5

Common sites of lacunar strokes are the basal ganglia, thalamus and internal capsule

Question 6

Which artery is affected in locked in syndrome?

Answer 6

Basilar

Question 7

What is affected in Wallenburg syndrome?

Answer 7

Posterior inferior cerebellar artery

Question 8

How do lacunar strokes present?

Answer 8

Either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia

Question 9

What is Saturday Night Palsy?

Answer 9

Saturday night palsy’ caused by compression of the radial nerve against the humeral shaft, possibly due to sleeping on a hard chair with his hand draped over the back. Means you are unable to extend your wrist.

Question 10

What is adhesive capsulitis?

Answer 10

Frozen shoulder - stiffness and pain in her left shoulder, which started around a month ago. She had a similar episode that resolved by itself. Examination reveals limited external rotation.

Question 11

How does degenerative cervical myelopathy present?

Answer 11

Degenerative cervical myelopathy leads to loss of fine motor function in both upper limbs. There is a delay in diagnosis of degenerative cervical myelopathy, which is estimated to be >2 years in some studies [1]. It is most commonly misdiagnosed as carpal tunnel syndrome and in one study, 43% of patients who underwent surgery for degenerative cervical myelopathy, had been initially diagnosed with carpal tunnel syndrome [1]

Question 12

What is the tremor seen in cerebellar disease?

Answer 12

Intention tremor

Question 13

What is Hoffmans sign? Where is it seen?

Answer 13

degenerative cervical myelopathy [DCM], which is associated with upper motor neuron signs. Hoffmans sign is elicited by flicking the distal phalaynx of the middle finger to cause momentary flexion. A positive result is exaggerated flexion of the terminal phalanyx of the thumb.

Question 14

Why is topiramate avoided in women of child-bearing age?

Answer 14

Whilst topiramate is an agent used for migraine prophylaxis, it is not the first choice in a woman of childbearing age when there is another equally suitable agent such as propranolol. This is because topiramate is teratogenic and can also impair hormonal contraception.

Question 15

How does neuroleptic malignant syndrome present?

Answer 15

It occurs within hours to days of starting an antipsychotic (antipsychotics are also known as neuroleptics, hence the name) and the typical features are:
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion

A raised creatine kinase is present in most cases. Acute kidney injury (secondary to rhabdomyolysis) may develop in severe cases. A leukocytosis may also be seen

Question 16

How does DCM present?

Answer 16

DCM symptoms can include any combination of [1]:
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
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.

Question 17

How do we manage DCM?

Answer 17

Urgent referral.
Currently, decompressive surgery is the only effective treatment. It has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or more severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.

Question 18

What causes Parkinson’s disease?

Answer 18

Parkinson’s Disease is a neurodegenerative disorder involving death of neurones in the substantia nigra

Question 19

What are first-line for spasticity in MS?

Answer 19

Baclofen and gabapentin are first-line for spasticity in multiple sclerosis

Question 20

Which facial palsy is associated with parotid gland surgery?

Answer 20

Parotid pathology can cause a lower motor neurone facial palsy

Question 21

Where do you see loss of corneal reflex?

Answer 21

Acoustic neuroma

Question 22

What is an acoustic neuroma, and how does it present?

Answer 22

An acoustic neuroma (or vestibular schwannoma) is a benign tumour of the vestibulocochlear nerve. Symptoms include vertigo, tinnitus and unilateral sensorineural hearing loss.

Question 23

How does Ramsay-Hunt syndrome present?

Answer 23

It typically presents with a triad of symptoms: ipsilateral facial paralysis, ear pain and vesicles in the auditory canal or on the tympanic membrane.

Question 24

What is the pathognomonic feature of MND?

Answer 24

Specialist said pathognonomic feature is tongue fasciculations + jaw jerk - UMN and LMN together.

Question 25

Which organism is associated with GBS?

Answer 25

Campylobacter jejuni

Question 26

Give two treatments for cluster headaches

Answer 26

Oxygen and triptans

Question 27

How does encephalitis present differently to meningitis?

Answer 27

This patient is presenting with symptoms (fever, headache, vomiting and seizures) and investigation findings (the most sensitive being prominent swelling and increased signal of the brain on MRI) suggestive of encephalitis.

Question 28

How do we treat essential tremor?

Answer 28

Propranolol

Question 29

First line tx for trigeminal neurlagia?

Answer 29

Carbamazepine

Question 30

How do common peroneal nerve lesions present?

Answer 30

Common peroneal nerve lesion can cause weakness of foot dorsiflexion and foot eversion

Question 31

What does an increased gamma GT show?

Answer 31

An increased gamma GT is suggestive of excessive alcohol consumption

Question 32

What makes up the GCS?

Answer 32

GCS: Motor (6 points) Verbal (5 points) Eye opening (4 points). Can remember as ‘654…MoVE’

Question 33

Where do you see anti-acetylcholine receptor antibodies?

Answer 33

Anti-acetylcholine receptor antibodies are present in myasthenia gravis.

Question 34

What do we use for the long-term prophylaxis of cluster headaches

Answer 34

Verapamil

Question 35

Name an anti-epileptic that can cause weight gain

Answer 35

Sodium valproate

Question 36

What nerve is most likely to be damaged as a result of a mid-shaft humeral fracture?

Answer 36

Radial nerve - wrist drop

Question 37

What is amaurosis fugax?

Answer 37

Amaurosis fugax is a form of stroke that affects the retinal/ophthalmic artery

Question 38

How do we diagnose MS?

Answer 38

MRI with contrast

Question 39

How does sciatic nerve damage present?

Answer 39

weakness to all muscles groups below the knee, intact knee jerk but weak ankle jerk

Question 40

What supplies the sciatic nerve?

Answer 40

It is supplied by L4-5, S1-3

Question 41

How do we manage acute ischaemic stroke in pts who present within 4.5 hours

Answer 41

A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours

Question 42

Name three SEs of phenytoin

Answer 42

peripheral neuropathy, characterized by numbness and reduced sensation in a glove-and-stocking distribution. Additionally, phenytoin can cause gingival hyperplasia, which may lead to bleeding gums. Lymphadenopathy is another potential side effect of phenytoin.

Phenytoin - can’t PHEELY my TOEn

Question 43

When does NMS usually occur?

Answer 43

Neuroleptic malignant syndrome is typically seen in patients who have just commenced treatment

Question 44

A patient is noted to have an absent ankle reflex. Which nerve root does this correspond to?

Answer 44

S1-S2

Question 45

Name the reflex mneumonic

Answer 45

S1 S2 buckle my shoe (ankle)
L3 L4 kick the door (knee)
C5 C6 pick up sticks (biceps)
C7 C8 shut the gate (triceps)

Question 46

How do lacunar strokes present?

Answer 46

Lacunar strokes can present with
unilateral motor disturbance affecting the face, arm or leg or all 3.
complete one sided sensory loss.
ataxia hemiparesis.

Question 47

How does a total anterior circulation infarct present?

Answer 47

1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia

Question 48

Describe essential tremor

Answer 48

Features
postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)

Management
propranolol is first-line
primidone is sometimes used

Question 49

What is Hoffman’s sign?

Answer 49

To elicit it, the examiner should flick the patients distal phalanx (usually of the middle finger) to cause momentary flexion. A positive sign is exaggerated flexion of the thumb.

Question 50

Where would you see Hoffman’s sign?

Answer 50

A positive Hoffmans sign is a sign of upper motor neuron dysfunction and points to a disease of the central nervous system - in this case from the history degenerative cervical myelopathy [DCM] affecting the cervical spinal cord is most likely.

Question 51

PEG vs NG?

Answer 51

Therefore, a definitive long-term management option for this patient would be a PEG tube.

NG is removed after 4-6/52

Question 52

How do you distinguish MND vs myasthenia gravis?

Answer 52

Myasthenia gravis is the second most likely differential, as facial weakness, hypophonic speech, and difficulty swallowing can be present. Ocular signs are usually present however and therefore MND is more likely.