Neurology

Question 1

What are the 5 different syndromes that could be caused by a lacunar stroke?

Answer 1

1. Pure motor stroke/hemiparesis (most common lacunar syndrome: 33–50%)
2. Pure sensory
3. Mixed sensorimotor
4. Ataxic hemiparesis
5. Dysarthria/clumsy hand

Question 2

When are 6 months vs 12 months driving bans enforced in relation to seizures?

Answer 2

Patients cannot drive for 6 months following a first unprovoked or isolated seizure if brain imaging and EEG normal

12 months driving ban applies to individuals who have had an epilepsy diagnosis or due to an abnormality in imaging or EEG. Epileptics who have had no seizures whilst awake for 12 months can return to driving if the DVLA are satisfied with the absence of seizures.

Question 3

What is order of antiplatelet treatments for secondary prevention of ischaemic stroke or TIA:

Answer 3

(1) Clopidogrel
(2) Aspirin + MR Dipyridaomole (if Clopi not tolerated)
(3) MR Dipyridamole (if Aspirin not tolerated)

Question 4

What is the criteria for thrombolysis in an acute stroke?

Answer 4

1. Haemorrhage has been definitively excluded (i.e. Imaging has been performed)
2. It is administered within 4.5 hours of onset of stroke symptoms
   It recommends that patients with an acute ischaemic stroke, regardless of age or stroke severity, who were last known to be well more than 4.5 hours earlier, should be considered for thrombolysis with alteplase if:
3. Treatment can be started between 4.5 and 9 hours of known onset, or within 9 hours of the midpoint of sleep when they have woken with symptoms, AND
   they have evidence from CT/MR perfusion (core-perfusion mismatch) or MRI (DWI-FLAIR mismatch) of the potential to salvage brain tissue

Question 5

Offer thrombectomy as soon as possible and within … of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have:

Answer 5

Within 6 hours of symptom onset

acute ischaemic stroke and
confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA)

Question 6

Offer thrombectomy as soon as possible to people who were last known to be well between … previously (including wake-up strokes):

Answer 6

Between 6 hours and 24 hours previously
confirmed occlusion of the proximal circulation demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 7

Consider thrombectomy together with intravenous thrombolysis (if within 4.5 hours) as soon as possible for people last known to be well up to … previously (including wake-up strokes):

Answer 7

24 hours

who have acute ischaemic stroke and confirmed occlusion of the proximal posterior or anterior circulation (that is, basilar or posterior cerebral artery) demonstrated by CTA or MRA and
if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Question 8

Most common complication following meningitis?

Answer 8

Sensorineural hearing loss

Question 9

What neurological function is typically spared in MND?

Answer 9

sensory, autonomic, and oculomotor systems (Most the time cognition*)

While some patients with ALS develop frontotemporal dementia (FTD) or mild cognitive/behavioral changes, many retain normal cognitive abilities.

Question 10

Which of the cranial nerves are the only ones which cross over to the other side?

Answer 10

II (optic nerve [the nasal field]) and IV (trochlear nerve). So right vertical diplopia = left trochlear/CN IV lesion.

Question 11

Status epilepticus is defined as: a single seizure lasting >5 minutes, or…

Answer 11

> = 2 seizures within a 5-minute period without the person returning to normal between them

Question 12

What is titubation?

Answer 12

Bobbing or rhythmic swaying of the head and trunk. Often associated with cerebellar disorders but can be seen in essential tremor.

Question 13

Apart from facial weakness, what other symptoms may someone with Bell’s palsy have?

Answer 13

Post-auricular pain (may precede paralysis)
Altered taste
Dry eyes
Hyperacusis

Question 14

What is used for long-term prophylaxis of cluster headaches?

Answer 14

Verapamil

Question 15

What is used first-line for spasticity in multiple sclerosis?

Answer 15

Baclofen and gabapentin

Question 16

What difference does MRI make in assessing MS with contrast or not?

Answer 16

Gadolinium contrast highlights areas where the blood-brain barrier is disrupted, indicating active lesions, which helps:

1. Confirm disease activity.
2. Differentiate active from chronic lesions.
3. Assess treatment response.

Plain MRI shows lesion location and extent but cannot distinguish active from inactive lesions.
*Suspected MS should always start with a contrast MRI

Question 17

Contraindication of triptans in migraines?

Answer 17

Patients with a history of, or significant risk factors for, ischaemic heart disease or cerebrovascular disease

Question 18

First line treatment for trigeminal neuralgia?

Answer 18

Trigeminal neuralgia - carbamazepine is first-line

Question 19

Why is B6 given to patients taking isoniazid?
But ironically excess B6 can cause what?

Answer 19

To reduce the risk of peripheral neuropathy.
Excess B6 can cause peripheral neuropathy (more than 200mg a day for months)

Question 20

What are DVLA rules following a TIA?

Answer 20

Can start driving is symptom free after 1 month - do not need to inform the DVLA

Question 21

First-line pain relief for post-herpetic neuralgia?

Answer 21

amitriptyline, duloxetine, gabapentin or pregabalin

Question 22

What condition is often misdiagnosed as carpel tunnel syndrome and often affects both hands?

Answer 22

Degenerative cervical myelopathy

Question 23

What would be examination findings of a HINTS exam if the cause is central (stroke/cerebellar lesion)
What would a reassuring examination show?

Answer 23

Abnormal (any of the following)
Head impulse = normal*
Nystagmus = bidirectional, doesn’t improve with fixation
Test of skew = abnormal

Reassuring (all three must be present):
Abnormal head impulse
Unidirectional nystagmus or nystagmus that improves with fixation
No vertical skew deviation

Note that normal head impulse does not rule out a peripheral cause of vertigo, but an abnormal head impulse rules out a central cause

Question 24

How long is prednisolone given to treat Bell’s palsy and when must treatment be started?
When is a full recovery expected?
When would you refer to ENT?

Answer 24

Oral prednisolone should be continued for 10 days in the management of Bell’s palsy, according to the UK guidelines. This is typically started within 72 hours of symptom onset. The dosage is usually 25-60mg daily.
Full recovery expected in 3-4 months
If no improvement in 3 weeks then refer to ENT

Question 25

What abnormal neurological finding can be found in patients with cluster headache?

Answer 25

Horner’s syndrome (ptosis, miosis)

Question 26

What three antiemetics must you avoid in Parkinson’s?

Answer 26

Haloperidol, Metoclopramide, prochlorperazine - all three of these block dopamine receptors
Note domperidone is a dopamine antagonist which does not cross the BBB so it’s okay in Parkinson’s disease

Question 27

What nerve damage and clinical sign may be present after a mid shaft humerus fracture?

Answer 27

Radial nerve, wrist drop

Question 28

Why might Ropinirole cause hallucinations when treating Parkinson’s?

Answer 28

Its a dopamine agonist. Dopamine agonists have higher risk of hallucinations as a side effect.

Question 29

What must be considered when starting phenytoin for status epilepticus

Answer 29

When starting a phenytoin infusion cardiac monitoring is required due to the pro-arrhythmogenic effects it elicits.