Neurology Flashcards
1
Q
postural tremor: worse if arms outstretched
A
Essential tremor
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
2
Q
5-HT3 antagonists such as*** can predispose to prolonged QT interval and increased risk of polymorphic VT
A
ondansetron
3
Q
Ethosuximide is primarily used in
A
absence seizures
4
Q
carbamazepine may exacerbate
A
absence seizures
5
Q
Focal seizures
first line: lamotrigine or levetiracetam
second line:
A
carbamazepine, oxcarbazepine or zonisamide
6
Q
A
7
Q
Contralateral hemiparesis and sensory loss, lower extremity > upper
A
Anterior cerebral artery
8
Q
Middle cerebral artery
A
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
9
Q
Posterior cerebral artery
A
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
10
Q
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
A
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
11
Q
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
A
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
12
Q
Ipsilateral: facial paralysis and deafness
A
Anterior inferior cerebellar artery (lateral pontine syndrome) Symptoms are similar to Wallenberg’s (see above), but:
13
Q
is characterised by word finding difficulties (hence only 4 animals named) and difficulty in repeating phrases. However, people with conduction difficulties still have intact language comprehension and relatively fluent speech and the sentence structure is intact, but may lack meaning.
A
Conductive dysphasia
14
Q
this describes a dysphasia with characteristic word finding difficulties with the use of generic fillers (e.g. ‘thing’) or circumlocution. People with this dysphasia are fluent, their comprehension is intact and repetition of words/phrases good.
A
Anomic dysphasia
15
Q
speech is non-fluent and repetition of words is also poor. Comprehension is normal
A
Brocas dysphasia
16
Q
. This dysphasia presents similarly to Broca’s dysphasia, but there are strong repetition skills; speech is non-fluent and comprehension intact.
A
Transcortical motor dysphasia
17
Q
Wernicke’s dysphasia is incorrect as this results from damage to Wernicke’s area in the temporal lobe and impairs
A
language comprehension, repetition of words and phrases. In Wernicke’s dysphasia speech is fluent with intact sentence structure but lacks meaning.
18
Q
selegiline or rasagiline work by blocking the enzyme monoamine oxidase B that breaks down dopamine in the brain. This increases the levels of dopamine and can help control symptoms of Parkinson’s disease
A
Monoamine oxidase B (MAO-B) inhibitors
19
Q
A 44-year-old man presents to his GP complaining of weakness in his hands and legs and numbness in his feet. He first noticed some problems with walking in his late teens and reports that he’s always been ‘clumsy’ and will often trip over. He is otherwise well and takes no regular medications. On examination, he has a high-stepping gait with wasting of the lower legs and high arches. Power is reduced in all limbs and reflexes are difficult to elicit. There is a reduction in sensation which is more pronounced distally. Coordination is intact.
A
Charcot-Marie-Tooth disease can affect both motor and sensory peripheral nerves
20
Q
is an inherited myopathy. It is caused by progressive degeneration and weakness of specific muscle groups. Most patients lose the ability to walk by 12 years of age and require ventilatory support by the age of 25. Sensation is intact in these patients.
A
Duchenne muscular dystrophy
21
Q
**** describes the sudden and transient loss of muscular tone caused by strong emotion (e.g. laughter, being frightened). Around two-thirds of patients with narcolepsy have cataplexy.
Features range from buckling knees to collapse.
A
Cataplexy
22
Q
Recreational nitrous oxide inhalation may also result in vitamin B12 deficiency →
A
subacute combined degeneration of the spinal cord.
23
Q
can lead to an upper motor neuron pattern of weakness in the lower limbs, its likelihood is considerably reduced in a 24-year-old woman since it predominantly occurs in an older demographic.
A
cervical spine osteoarthritis
25
Q
** is characterized by the acute onset of anterograde amnesia (the inability to form new memories). The aetiology is unknown, thought to be due to transient ischaemia to the thalamus (in particular the amygdala and hippocampus).
Features
patients may appear anxious and repeatedly ask the same question
episodes are self-limited and resolve within 24 hours
A
Transient global amnesia
26
Anti-Musk is associated with
myasthenia gravis patients
27
anti-Jo1 and anti-Mi2 with
inflammatory myositis
28
anti-mitochondrial antibody with
primary biliary cirrhosis.
29
According to the national clinical guidelines for stroke issued in 2023, thrombolysis is indicated for acute ischaemic stroke within a. ****** hour window from symptom onset, provided imaging shows salvageable brain tissue
4.5 to 9
30
Use ****** MRI in diagnosis of multiple sclerosis
MRI FLAIR sequence
MRI FLAIR sequences are particularly adept at identifying hyperintense lesions on T2-weighted images, which are characteristic of MS; they effectively reveal lesions within periventricular areas and can detect the pathognomonic Dawson fingers that extend perpendicular to the corpus callosum. This imaging modality is proficient at detecting disseminated lesions across both time and space, which are crucial criteria for diagnosing MS.
31
MRI STIR in
Thyroid eye disease ( soft tissue image)
32
MRI******* is primarily utilised for detecting acute ischaemic strokes by highlighting areas of restricted diffusion.
diffusion-weighted sequence
33
The MRI******* is invaluable for identifying microhaemorrhages or iron deposits within cerebral tissues in conditions such as haemochromatosis. It also has applications in cases involving cerebral microhaemorrhages and vascular anomalies
susceptibility-weighted sequence
34
The MRI******* provides high-resolution images that delineate anatomical structures clearly and can be essential when assessing brain anatomy and atrophy
T1-weighted sequence
35
Ramsey hunt syndrome Rx
Full recovery is more likely if antiviral treatment is started within 72 hours of the onset of symptoms. First-line treatment includes aciclovir 800 mg orally five times daily for 7 days and prednisone 60 mg orally daily for 5 days.
36
Brain abscess:Rx
IV 3rd-generation cephalosporin + metronidazole
37
IV ceftriaxone and ampicillin is mainly used for the management of suspected meningitis in young children, those over 50 years or patients who are immunocompromised. The addition of ampicillin, to the standard 3rd generation cephalosporin, is recommended to cover for potential Listeria monocytogenes infection more common in these patient groups.
38
IV ceftriaxone and co-trimoxazole can cover a range of bacterial, fungal and protozoan infections however it is mainly used as a prophylactic drug to prevent infections such as pneumocystis pneumonia and toxoplasmosis in patients with HIV/AID or other immunosuppressive conditions.
39
IV ceftriaxone and gentamicin can be used in combination to treat certain infections such as
infective endocarditis or neutropenic sepsis
40
ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
Weber's syndrome
41
A 72-year-old man becomes confused at the end of a charity walk for Alzheimer's. He is brought to the hospital by paramedics because he repeatedly asked other attendees on the walk why he was there and how he had got there. There is no past medical history of note and he takes no regular medication. He is orientated in time and person and knows he has been brought to the hospital. His blood pressure is 123/82 mmHg, his pulse is 70 beats per minute and regular. The neurological exam is unremarkable, routine blood tests and CT head are normal. He gradually recovers over the course of 3hrs.
TGA Transient global amnesia
42
Baclofen. MOA?
stimulates GABA receptors in the central nervous system, thereby inhibiting the release of excitatory neurotransmitters. This results in the blocking of mono- and polysynaptic reflex transmission. Clinically, this leads to reduced muscle spasticity, which can improve pain and mobility in patients with MS.
43
Ropinirole , Dopamine agonist is used in
RLS Restless Leg syndrome
44
Dystrophia myotonica - DM1
distal weakness initially
autosomal dominant
diabetes
dysarthria
45
form of muscular dystrophy mainly resulting in weakness of the facial muscles, the upper arms and the hip girdle. Symptoms normal develop from the age of 15 to 30 years and weakness can be asymmetrical. Other associated symptoms of ***** include high frequency-hearing loss and abnormality of the retinal arteries (although vision is rarely affected).
Facioscapulohumeral muscular dystrophy (FSHMD) is a
46
a form of motor neurone disease, is a neurodegenerative condition causing progressive loss of voluntary muscle control. As the disease progresses patients commonly develop global weakness with difficulty speaking and swallowing. Approximately 50% of patients suffer at least mild cognitive issues. Most cases of **** are sporadic with no clear cause or family history.
Amyotrophic lateral sclerosis (ALS),
47
Becker muscular dystrophy is another form of dystrophy associated with slowly progressive muscle weakness of the legs and pelvis. LL>>>>>UL
X linked recessive
48
The patient has slowly progressive conductive hearing loss, tinnitus and positive family history, making this a likely diagnosis. In this disorder, there is the formation of new bone around the base of the stapes, which is a bone in the middle ear. This results in progressive conductive hearing loss.
Otosclerosis
49
Alport syndrome
Progressive hearing loss + family history + renal function decline
50
Syncope
simple faint: no restriction
single episode, explained and treated: 4 weeks off
single episode, unexplained: 6 months off
two or more episodes: 12 months off
DVLA OFF DRIVING
51
******* , as this condition actually causes mydriasis (pupillary dilation) rather than miosis. also known as tonic pupil, is characterised by a large, poorly reactive pupil due to damage to the ciliary ganglion or post-ganglionic parasympathetic fibres.
Holmes-Adie pupil
52
Normal values of cerebrospinal fluid (CSF) are as follows:
pressure =
protein =
glucose =
cells:
pressure = 60-150 mm (patient recumbent)
protein = 0.2-0.4 g/l
glucose = > 2/3 blood glucose
cells: red cells = 0, white cells < 5/mm³
53
The following conditions are associated with raised protein levels
Guillain-Barre syndrome
tuberculous, fungal and bacterial meningitis
Froin's syndrome*
viral encephalitis
*describes an increase in CSF protein below a spinal canal blockage (e.g. tumour, disc, infection)
54
This describes hemisection of the spinal cord and will impact both sensory tracts and the lateral corticospinal tracts. Patients will often describe a traumatic event and present with ipsilateral motor weakness due to loss of the corticospinal tracts, ipsilateral loss of dorsal column modalities and contralateral loss of spinothalamic modalities.
Brown-Sequard syndrome
55
Freidrichs ataxia
Has more cerbellar signs , compared to SACD
56
Syringomyelia
Loss of UL spinothalamic modalities
57
The following drugs may exacerbate myasthenia:
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
58
59
60
Hemiballism results in involuntary, sudden, jerking movements which occur contralateral to the side of the lesion
Basal ganglia
61
5HT3 , Dopamine antagonist anti-emetics such as haloperidol, domperidone and metoclopramide can also cause
QT prolongation.
62
Nabilone is a cannabinoid anti-emetic which is also sometimes considered for refractory chemotherapy-induced nausea
63
Bilateral and symmetric onset of motor symptoms, strongly favours drug-induced parkinsonism (DIP) over idiopathic Parkinson’s disease (PD)
rigidity and rest tremor are uncommon
64
Alcohol is a common trigger for****** headaches
cluster
65
For thrombectomy in acute ischaemic stroke, an extended target time of 6-24 hours may be considered 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
66
The correct answer is that warfarin should be started after****** days in a patient with ischaemic stroke and atrial fibrillation.
14
67
complication of meningococcal meningitis and is caused by adrenal haemorrhage. This is known as Waterhouse-Friderichsen syndrome
Adrenal insufficiency
68
It is worth noting complications are more likely with pneumococcal meningitis than in meningococcal meningitis but 57% of those with meningococcal septicaemia will have some form of complication.
69
Central pontine myelinolysis is a disease of the brainstem and therefore typically causes quadraparesis (in this case the arms are mostly spared). The weakness would be expected to come on more rapidly.
70
Charcot-Marie-Tooth is a hereditary neuropathy
71
Miller Fisher syndrome is a variant of GBS that typically affects the
cranial nerves.
72
Multiple system atrophy
There are 2 predominant types of multiple system atrophy
1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features
Shy-Drager syndrome is a type of multiple system atrophy.
Features
parkinsonism
autonomic disturbance
erectile dysfunction: often an early feature
postural hypotension
atonic bladder
cerebellar signs
73
Migraine during pregnancy
Rx
paracetamol 1g is first-line
NSAIDs can be used second-line in the first and second trimester
avoid aspirin and opioids such as codeine during pregnancy
74
The commonest cancer associated with the VHL syndrome is
renal cell carcinoma
75
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = 1
lower quadrant defect > upper quadrant defect = 2
1- inferior chiasmal compression, commonly a pituitary tumour
2- superior chiasmal compression, commonly a craniopharyngioma
76
SJS - drugs
Lamotrigine and phenytoin
77
****** , an antimalarial drug also used for nocturnal leg cramps, is known to cause tinnitus as a side effect.
Quinine
This ototoxicity is often reversible upon discontinuation of the drug. The patient's age and the bilateral nature of her symptoms are consistent with medication-induced tinnitus.
78
Ciprofloxacin - Otitis externa/media
79
Tinnitus - drugs
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
80
Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner's
81
. This is caused by a lesion affecting the pons. It results in ipsilateral 6th and 7th nerve palsies and contralateral hemiparesis.
Millard-Gubler syndrome
82
Bilateral spastic paresis and loss of pain and temperature sensation - lateral corticosteroid spinal and spinothalamic tract , at the site of lesion and below
anterior spinal artery occlusion
83
Causes of Idiopathic ICHT
Risk factors
obesity
female sex
pregnancy
drugs
combined oral contraceptive pill
steroids
tetracyclines
retinoids (isotretinoin, tretinoin) / vitamin A
lithium
84
Charcot-Marie-Tooth disease (hereditary sensorimotor neuropathy type I) is an autosomal dominant condition and therefore 50% of children will be affected
85
Signs of uncal herniation may include
loss of consciousness, hypertension, bradycardia and Cheyne-Stokes respiration.
86
Causes of 3rd nerve palsy
Causes
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm
pupil dilated
often associated pain
cavernous sinus thrombosis
Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis
87
Angular gyrus
Gerstman syndrome
88
Arcuate fasciculus . Lesions in this area result in
Conduction aphasia is characterised by fluent speech, relatively intact comprehension, and poor repetition. Lesions in this region would not account for the halting and effortful
89
Brodmann area 22 in the superior temporal gyrus
. Wernicke's area is traditionally thought to reside in Brodmann area 22, which is located in the superior temporal gyrus. This area 'forms' the speech before 'sending it' to Broca's area. Lesions result in sentences that make no sense, word substitution, and neologisms but speech remains fluent - 'word salad'.
90
Mononeuritis multiplex is a
painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 separate nerve areas. Multiple nerves in random areas of the body can be affected. Causes include diabetes mellitus, vasculitides, sarcoidosis and rheumatoid arthritis.
91
A blood patch
involves injecting autologous blood into the epidural space near the puncture site, which forms a clot that seals the dural defect and prevents further CSF leakage.
92
Migraine prophylaxis
Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment'
93
Carbamazepine in epilepsy , can cause auto- induction
Auto-induction. Carbamazepine induces its own metabolism via the hepatic microsomal enzyme system CYP3A4 system. This process is known as auto-induction. The half-life of carbamazepine decreases considerably as auto-induction takes place. In practical terms, this means that carbamazepine levels fall significantly (by about 50%) after several weeks of treatment, which may result in seizure recurrence within this period of auto-induction. For this reason, the dose should be increased every 2 weeks.
94
Michaelis-Menten kinetics describes enzymatic reactions where a maximum rate of reaction is reached when drug concentration achieves 100% enzyme saturation
95
a rapidly diminishing response to successive doses of a drug, rendering it less effective. The effect is common with drugs acting on the nervous system.
Tachyphylaxis
96
Hemiballismus
Hemiballismus is a movement disorder characterised by very violent movements of the arm or limbs. People can seriously injure themselves. Caused by a stroke or other lesion of the subthalamic nucleus.
Contralateral to the side of lesion
97
98
Central cord syndrome usually presents with
bilateral motor weakness.
99
Anterior cord syndrome
usually affects motor function, pain and temperature sensation. Proprioception is usually spared.
100
Posterior cord syndrome usually affects proprioception.
101
Migraine and COCP , significantly increase the risk of ischeamic stroke
oestrogen content, which can cause hypercoagulability. Therefore, prescribing COCP to this patient would not be recommended according to UK guidelines.
102
Upbeat nystagmus
cerebellar vermis lesions
Downbeat nystagmus - foramen magnum lesions
Arnold-Chiari malformation
103
The virus characteristically affects the temporal lobes - questions may give the result of imaging or describe temporal lobe signs e.g. aphasia.
Herpes simplex (HSV) encephalitis
104
Benign rolandic epilepsy presents
in children aged 5-12 on average, causing focal aware seizures or generalised tonic-clonic seizures occurring during the night. Seizures are infrequent, and the majority of children do not require treatment and become seizure-free in adulthood.
105
Hypnogogic myoclonus is a physiological phenomenon that causes sudden and involuntary jerking just as a person is falling asleep. They are often associated with a feeling of shock.
106
Lennox-Gastaut syndrome is an epileptic encephalopathy causing both tonic and atonic seizures. The condition presents in pre-school years and carries a poor prognosis.
Rett syndrome is a genetic disorder causing developmental regression after 12-18 months of normal development. Seizures can occur, but not in every case; the first presentation is often around 1 year of age.
107
108
38-year-old woman presented with blurring of her vision on lateral gaze. She has previously suffered an episode pain on moving her eyes with difficulty in seeing red colours 6 months ago which resolved spontaneously after a week.
She was seen in a neurology clinic and examined by a neurologist. On rightward gaze the left eye failed to adduct and the right eye exhibited nystagmus. Leftward, upward and downward gazes were unremarkable. The pupils are equal and both reactive to light.
The peripheral examination was unremarkable.
An MRI brain scan is subsequently performed and the report is awaited.
Where is the lesion most likely located from this presentation?
The most likely diagnosis for this patient is multiple sclerosis. Here she is presenting with internuclear ophthalmoplegia. Internuclear ophthalmoplegia occurs due to a lesion in the medial longitudinal fasciculus. The medial longitudinal fasciculus is a highly myelinated tract which communicates information from the vestibular nucleus to the oculomotor, trochlear and abducens nuclei to coordinate eye movements. She previously suffered an episode of what is very likely to be optic neuritis. This points further to a diagnosis of multiple sclerosis. Internuclear ophthalmoplegia is a disorder of conjugate lateral gaze in which the eye on the side of the lesion in the medial longitudinal fasciculus fails to adduct and the contralateral eye exhibits nystagmus. Multiple sclerosis is a disorder which affects the axonal myelin sheath and hence highly myelinated areas are commonly affected.
109
FVC less than 20 ml/kg or a rapid decrease in FVC indicates impending respiratory failure and is an indication for intubation.
GBS
110
Uraemic polyneuropathy is correct.
uraemic polyneuropathy causes predominantly sensory neuropathy. This affects the cell body, axon or myelin of peripheral sensory neurons and occurs in 60-100% of patients who are undergoing dialysis for chronic kidney disease.
111
Focal seizures not responding to first-line drug - try lamotrigine or levetiracetam (i.e. the first-line drug not already tried) and if neither help then carbamazepine
112
Medication overuse headache RX
Management (from 2008 SIGN guidelines)
simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches)
opioid analgesics should be gradually withdrawn
113
****** is a non-dihydropyridine CCB and is used in the management of angina and hypertension - as a non-dihydropyridine CCB, it also slows the heart rate.
Diltiazem
114
, a rare and inflammatory condition affecting either the cavernous sinus or superior orbital fissure, does not align with our patient’s presentation—it typically presents with severe orbital or retro-orbital pain along with painful ophthalmoplegia affecting multiple cranial nerves (e.g., IV and VI).
Tolosa-Hunt syndrome
115
AICA (Anterior inferior cerebellar artery)
Lateral pontine syndrome usually presents with contralateral paresthesia, ipsilateral facial weakness, ipsilateral facial paraesthesia, ipsilateral limb and gait ataxia, ipsilateral Horner's syndrome and deafness.
116
The Barthel index is a scale that measures disability or dependence in activities of daily living in stroke patients
117
The ROSIER scale, or 'Recognition of Stroke in the Emergency Room', is used in an emergency setting to differentiate acute stroke from stroke mimics
The Waterlow score is used to estimate the risk of development of a pressure sore in a patient, factoring in variables such as mobility
118
is a fatal, degenerative brain disorder caused by infectious prion proteins. These misfolded proteins can result in normally folded proteins also becoming misfolded. The key features of CJD included rapidly progressive dementia and myoclonus that, although maybe absent at the initial onset of the disease, occurs in approximately 90% of CJD cases.
Creutzfeldt-Jakob disease (CJD)
119
Cerebral salt-wasting syndrome is known to occur following subarachnoid haemorrhage but the sodium loss is accompanied by water loss as the kidneys are still functioning normally so urine output is high and there is a relative fluid depletion.
120
Acute vertigo following a recent viral URTI + horizontal nystagmus
Vestibular neuronitis
121
Acute vertigo+ hearing loss+ tinnitus , following viral infection
Viral Labrynthitis
122
Drug causes of gingival hyperplasia
phenytoin
ciclosporin
calcium channel blockers (especially nifedipine)
Other causes of gingival hyperplasia include
acute myeloid leukaemia (myelomonocytic and monocytic types)
123
This patient has developed myoclonic seizures likely secondary to an intracerebral lesion. Myoclonus is characterised by sudden, brief, shock-like jerks. They are often stimulus sensitive. Focal cortical myoclonus is the most common form of myoclonus and is usually caused by an underlying lesion of the sensori-motor cortex, which produces hyperexcitability (e.g. vascular, inflammatory or neoplastic).
Myoclonic - sodium valproate - 1st line
2 nd - leviteracetam
124
Cerebrospinal fluid (CSF) oligoclonal bands not present in serum is the correct answer because the detection of oligoclonal bands (OCBs) exclusively in cerebrospinal fluid, with their absence in serum, is a characteristic feature of multiple sclerosis (MS). This finding suggests local production of IgG within the central nervous system. OCBs are found in approximately 95% of individuals diagnosed with MS and serve as an important diagnostic marker when considered alongside clinical presentation and imaging results.
125
is a condition characterised by herniation of the cerebellar tonsils through the foramen magnum. It causes symptoms by compressing the brainstem, cerebellum and by disturbing the flow of cerebrospinal fluid (CSF). Disturbed CSF flow either causes hydrocephalus (uncommon) or syringomyelia (common; ~50%).
Chiari 1 malformation
126
Acoustic neuroma -
imbalance rather than vertigo + snhl + tinnitus
127
The HINTS exam
is used to differentiate between central and peripheral causes of vertigo. It is an acronym that stands for the different aspects of the test: head impulse, nystagmus and test of skew. This should only be used in patients who are actively vertiginous with nystagmus.
128
A 23-year-old woman gives birth to a baby boy. She has a complex past medical history of bipolar disorder, epilepsy and anti-phospholipid syndrome. She is also taking codeine and naproxen frequently for chronic back pain following a car accident. When preparing her discharge letter, she informs you that she intends to breastfeed her baby.
Out of her regular medications below, which is the only drug that can be continued whilst breastfeeding?
Lamotrigine is the correct answer. Nearly all anti-epileptic drugs are considered safe for use in breastfeeding - however, breastfed infants should be monitored for apnoea, lethargy and poor weight gain.
Aspirin is incorrect. Aspirin is found in breast milk, conveying risk of metabolic acidosis and Reye's syndrome to infants.
Codeine is incorrect. Codeine is excreted in breast milk and hence should be avoided when breastfeeding.
Lithium is incorrect. Evidence shows lithium is transferred to neonates in breast milk and can potentially cause renal and thyroid dysfunction. The guidance is generally to avoid where possible when breastfeeding.
Naproxen is demonstrated to be present in breast milk, more readily than other NSAIDs. Although there is generally inconclusive evidence, there are several case reports of increased risk of bleeding and thrombocytopaenia linked to naproxen in breast milk. Alternative NSAIDs such as ibuprofen are therefore recommended in breastfeeding patients.
129
Diagnosis can be made on the basis of two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse.
Multiple sclerosis
130
Uhthoff's phenomenon: worsening of vision following rise in body temperature
Multiple sclerosis
131
Lhermitte's syndrome: paraesthesiae in limbs on neck flexion
Multiple sclerosis
132
Freidrichs ataxia , hereditary disorder that usually emerges during adolescence and progressively deteriorates over time
spastic paraparesis and ataxia are typical in Friedrich's ataxia, one would also expect to find impaired vibration sense and proprioception
133
Tabes dorsalis,
manifestation of tertiary syphilis, entails infiltration of the spinal cord by the infection. It typically results in diminished proprioception and vibration sense
134
Transverse myelitis refers to inflammation across an entire cross-section of the spinal cord. It can have various aetiologies including HIV infection and multiple sclerosis itself.
Transverse myelitis typically presents with both spastic paraparesis and complete sensory loss below the affected level within the spinal cord;
135
This syndrome reflects a frontal lobe tumour - usually a meningioma in this age group - leading to ipsilateral optic atrophy and papilloedema of the contralateral optic nerve. The reason for the optic atrophy is as a result of direct damage from the space occupying lesion. Other causes are AVMs and juvenile nasopharyngeal angiofibroma.
Foster-Kennedy syndrome.
136
Global aphasia
Both wernicke and broca
137
Painful third nerve palsy = posterior communicating artery aneurysm
138
Hypoglossal nerve palsy
If damaged, the tongue will deviate towards the side of lesion when protruded due to unopposed action of muscles on opposite side
139
Dementia with Lewy bodies and Parkinson's disease with dementia both present with cognitive impairment and parkinsonism. In the former, the cognitive impairment precedes the motor manifestations or occurs within 1 year of the onset of motor manifestations
Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus
140
An 18-year-old woman presents for a routine neurology review. She has a longstanding history of seizures, occurring several times per day. During these episodes, she completely stops what she is doing and becomes unresponsive to voice or tactile stimulation. Her eyelids rapidly flutter for approximately 20 seconds, before the episode finishes. She is able to quickly resume activity after this.
Absence seizure, avoid carbamazepine
141
Trypanosoma cruzi is the causative infective agent of *********, also known as American trypanosomiasis, spread by insects known as Triatominae that are present throughout Central and South America. The condition normal comprises an acute stage, which develops a few weeks after the insect bite and includes mild symptoms of fever and malaise followed by a chronic stage which develops over many years and consists of chronic fatigue, enlargement of the liver, spleen, and lymph nodes. If untreated patients can eventually progress to developing cardiac issues such as arrhythmias and cardiomyopathies.
Chagas’ disease
142
A 39-year-old-male present with morning headaches associated with nausea for the last 2 months and an inability to look upwards. On examination, while upgaze is diminished bilaterally, downgaze is preserve and it is not corrected by the doll's-head-manoeuvre. On examination of his pupils, his pupils constrict on accommodation but did not constrict on exposure to light. One also notices some mild eyelid retraction bilaterally. Where is the lesion localised to?
Parinaud syndrome
Rostral interstitial nucleus of medial longitudinal fasciculus lies at the dorsal midbrain and control vertical gaze. They project to the vestibular nuclei. It results in the following symptoms:
Upward gaze palsy, often manifesting as diplopia
Pupillary light-near dissociation (Pseudo-Argyll Robertson pupils)
Convergence-retraction nystagmus
143
Internuclear ophthalmoplegia is a disorder of conjugate gaze with the failure of adduction seen on the affected eye.
This is caused by injury on the medial longitudinal fasciculus, located along the paramedian area of the midbrain and pons.
144
Facioscapulohumeral muscular dystrophy is an
austosomal dominent disorder
145
Substituting gabapentin for amitriptyline would be a possible treatment strategy for neuropathic pain. However, for this patient, starting an antimuscarinic agent risks precipitating an exacerbation of symptoms from glaucoma.
146
Lesions in optic
The key points to remember are:
Lesions before the chiasm affect one eye only
Chiasmal lesions cause bitemporal defects
Post-chiasmal lesions cause homonymous defects
The more posterior the lesion, the more congruous the defect
Optic tract lesions cause incongruous homonymous hemianopia contralateral to the side of the lesion
147
Chorea is caused by damage to the basal ganglia, especially the caudate nucleus.
Causes of chorea
Huntington's disease, Wilson's disease, ataxic telangiectasia
SLE, anti-phospholipid syndrome
rheumatic fever: Sydenham's chorea
drugs: oral contraceptive pill, L-dopa, antipsychotics
neuroacanthocytosis
pregnancy: chorea gravidarum
thyrotoxicosis
polycythaemia rubra vera
carbon monoxide poisoning
cerebrovascular disease
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hyperammonemic encephalopathy: L-carnitine may be used as treatment if this develops
Na valproate
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Progressive bulbar palsy primarily affects the lower cranial nerves (IX, X, XII), leading to dysarthria, dysphagia, and tongue fasciculations.
The involvement of bulbar muscles controlling swallowing and respiration significantly increases the risk of aspiration pneumonia and respiratory failure. Patients with progressive bulbar palsy typically have a median survival of approximately 2-3 years from symptom onset, which is shorter than other motor neuron disease variants. The rapid progression of bulbar symptoms often leads to earlier respiratory compromise and nutritional difficulties, contributing to the poor prognosis.
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, an anti-epileptic drug, is most likely to cause visual field defects. This medication inhibits the enzyme GABA transaminase, increasing levels of gamma-aminobutyric acid (GABA) in the brain and thereby reducing seizure activity. However, a significant side effect of vigabatrin is peripheral visual field constriction or even loss.
Vigabatrin
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Absence seizures - good prognosis: 90-95% become seizure free in adolescence
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JE ; MRI ?
B/L thalamic involvement
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Transverse myelitis can be caused by viral infection - such as varicella, herpes simplex, EBV and HIV
Causes of transverse myelitis
viral infections: varicella-zoster, herpes simplex, cytomegalovirus, Epstein-Barr, influenza, echovirus, human immunodeficiency virus
bacterial infections: syphilis, Lyme disease
post-infectious (immune mediated)
first symptom of multiple sclerosis (MS) or neuromyelitis optica (NMO)
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for women with predictable menstrual migraine treatment NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of 'mini-prophylaxis'
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Raised lymphocytes in CSF causes
The following conditions are associated with raised lymphocytes
viral meningitis/encephalitis
TB meningitis
partially treated bacterial meningitis
Lyme disease
Behcet's, SLE
lymphoma, leukaemia
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Phenytoin induces vitamin K metabolism, which can cause a relative vitamin K deficiency, creating the potential for heamorrhagic disease of the newborn
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There is a repeat expansion of CAG trinucleotide in Huntington's disease
Other important commonly tested trinucleotide repeats:
GAA: Friedrich Ataxia
CTG: Myotonic dystrophy
CGG: Fragile X syndrome
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The MRI finding of enhancement of the mamillary bodies due to petechial haemorrhages is specific for
Wernicke's encephalopathy, although sensitivity is only 50%.
