neurology

Question 1

clinical features of MND/ALS

Answer 1

cognitive decline
muscle weakness/wasting
spasticity
dysphagia/dysarthria

due to death of upper and lower nerves

Question 2

Risk factors for ALS/MND

Answer 2

mostly sporadic
mild increase if FHx

400 people living in NZ w ALS

Question 3

tx of ALS/MND

Answer 3

no curative tx

MDT support
NIV
some supportive medications

Question 4

what is MS

Answer 4

Autoimmune demyelinating disease of CNS nerves. Peripheral nervous system unaffected.

• inappropriate immune cell activation and destruction with myelin (which surrounds/protects nerves). leaves plaques behind
  Early: remyelination
  Later: nerve unable to repair itself

Question 5

Risk factors for MS

Answer 5

HLA-DR2
Female
age 20-40yrs
further from equator / vit D deficiency
infections
FHx
Smoking/EBV

Question 6

Types of MS

Answer 6

relapsing/remitting: bouts of immune attack (most common 85% )

secondary progressive
primary progressive
progressive relapsing

Question 7

how does MS present

Answer 7

sudden episode of neurological sx
- optic neuritis, diplopia
- weakness, gait disturbances and ataxia
- tremor
- bladder dysfunction, bowel or erectile problems
- sensory changes
- muscle spasm/pain
- neuralgia
- fatigue (85%)

worsen over days-weeks then gradually resolve

often (50%) later develop depression and cognitive decline

Question 8

Lhermitte’s symptom

Answer 8

An electric shock sensation down the spine when the neck is flexed

characteristic, but not specific, for MS

Question 9

how does optic neuritis (MS) present

Answer 9

optic neuritis are
- reduced visual acuity
-reduced colour vision (red desaturation)
- eye pain, especially on eye movement.

O/E: papilloedema and RAPD (due to optic nerve damage)

main cause MS
ddx: ischaemic optic neuropathy, inflammatory optic neuropathies

Question 10

what is the Mcdonalds criteria with MS

Answer 10

a diagnosis of MS requires 2 or more episodes of inflammatory demyelination to occur on separate occasions, at least 30 days apart, in different locations within the CNS.

sometimes MRI scans can be used instead when there’s a prev hx

Question 11

MS and pregnancy

Answer 11

MS does not affect fertility

Relapses are less likely during pregnancy, but more common 3-6 months post partum

Disease-modifying medicines should be avoided 3 mths prior and during pregnancy

Question 12

timing for stroke thrombolysis

Answer 12

has to be <4.5hrs from symptom onset
ideally <3 hrs

usually with alteplasia - 30% more likley to have no disability @ 3mths

Question 13

when do you give aspirin in the setting of a stroke

Answer 13

once a haemorrhagic streoke has been excldue from imaging

given 150-300mg asap, if thrombolysing delay by a few days
cont 100mg long term

Question 14

What is idiopathic intracranial hypertension (IIH)?

Answer 14

Raised ICP in the absence of a mass lesion or of hydrocephalus.

appears to be due to impaired CSF absorption

can lead to significant visual impairment, so prompt recognition and treatment are needed to prevent potentially permanent visual changes including partial or total loss of vision.

Question 15

Risk factors for Idiopathic intracranial hypertension

Answer 15

obese women at childbearing age
menstrual irregularity

assoc w endocrine pathology and some meds

Question 16

symptoms of IIH

Answer 16

Headache worst first thing in the morning and last thing at night.
- relieved on standing
- worse with straining, coughing or a change in position

Gradual visual field defects;
- moderate or gross bilateral papilloedema without significant focal intracranial signs.

Daily transient visual obscurations (TVOs) (‘greying out’) on bending or stooping, halo or a short episode of visual wheel flashes, persistent blurring, scotoma or horizontal diplopia often occur.

Nausea, vomiting, drowsiness.

Diplopia (due to VI cranial nerve palsy)

Question 17

Ix in IIH

Answer 17

Bloods
eye exam
lumbar puncture
CT or MRI

Question 18

predictors of poorer outcomes in patients with a concussion

Answer 18

Initial symptom burden
Previous concussions
Pre-existing mental health conditions
Being female.
The presence of migraine-like symptoms or a history of migraine
Younger and older age groups
People with alcohol and substance abuse issues
Predominance of vestibular symptoms,

Question 19

what are the recommended time frames for return-to-sport in patients post concussion

Answer 19

24 – 48 hours of physical and mental rest

2 – 13 days post-injury, progressively re-engage in normal daily activities, should be guided by symptoms.

> 14 days and symptom free: re-engage in full contact training

> 21 days and symptom free during training: return to competition

Question 20

bloods to do when differentiating dementia from delerium

Answer 20

Full blood count
electrolytes, creatinine, calcium, glucose, HbA1c, renal and liver function
TFTs
B12 and folate
CRP
HIV and syphilis testing
Mid-stream urinalysis – if a UTI is suspected

Question 21

what symptoms would you see with a common peroneal nerve injury

Answer 21

foot drop (weak dorsiflexion and foot eversion)
sensory loss over the dorsum of the foot and the lower lateral part of the leg

The sciatic nerve divides into the tibial and common peroneal nerves. Injury often occurs at the neck of the fibula

Question 22

what would you see in a tibial nerve injury

Answer 22

weak plantarflexion (pointing the foot downward)
weak inversion of the foot.

These are the opposite movements to those affected by common peroneal nerve injuries.

Question 23

stroke long term prevention

Answer 23

1. Clopidogrel monotherapy is generally considered the best first-line

Dose is 300 mg immediately, then 75 mg daily.
Dual antiplatelet therapy (DAPT) with clopidogrel (300 mg load then 75 mg daily) + aspirin (300 mg load then 100 mg daily) is recommended for 3 weeks in patients with a TIA or minor stroke. DAPT is not used after a moderate or severe stroke.
After 3 weeks, stop the aspirin and continue with clopidogrel monotherapy.

2. Dipyridamole + aspirin (100 mg daily)
3. Aspirin monotherapy (100 mg daily)

Question 24

what is Bells palsy

Answer 24

acute, unilateral, idiopathic, facial nerve paralysis
Lower motor neuron palsy, forehead affected

treatment: PO pred (if <72 hrs) and artificial tears and taping (prevent keratopathy)

Question 25

prognosis for Bells Palsy

Answer 25

most people make a full recovery within 3-4 months

if untreated around 15% of patients have permanent moderate to severe weakness

refer to ENT if no improvement on steroids after 3-4 weeks

Question 26

arm fracture resulting in radial nerve damage, what would you see on exam

Answer 26

wrist drop
reduced sensation on dorsal hand 1-2nd MCPs

Question 27

signs of a 3rd nerve palsy

Answer 27

eye is deviated ‘down and out’
ptosis
pupil may be dilated

Question 27

how do lacunar strokes present

Answer 27

1. purely motor
2. purely sensory
3. sensorimotor stroke
4. ataxic hemiparesis

due to occlusion of a single penetrating branch of a large cerebral artery and affect the internal capsule, thalamus and basal ganglia.

Question 28

when can you return to driving after a TIA

Car or motorcycle licence:
Single TIA
Multiple TIAs

Commercial licence:
Single TIA:
Multiple TIAs:

Answer 28

Car or motorcycle licence:
Single TIA – 1-month
Multiple TIAs – 3-month + on tx

Commercial licence:
Single TIA: Minimum 6-month + specialist clearance
Multiple TIAs: Minimum 12-month

Question 29

classic symptoms for an acoustic neuroma

Answer 29

vertigo, unilateral tinnitus, hearing loss, absent corneal reflex

Question 30

how to treat a medication overuse headache

Answer 30

abrupt withdrawawl of everything (except benzos and opiods)

if that doesnt work start a TCA or topirimate and retry

++ sleep and avoid caffeine