Neurology Flashcards
1
Q
Which of the following is a part of the core neurological exam? A. Gait B. Appearance C. Long tract signs D. Vital signs E. All of the above
A
E.
Also includes fundoscopy and vibration sensation
2
Q
A patient presents with a stiff, foot-dragging walk. What is this called and what might it indicate?
A
Spastic gait, indicating an upper motor neuron lesion (part of the long tract signs).
3
Q
You perform a neurological examination on a patient. Which of the following indicates a possible upper motor neuron lesion? A. Negative Hoffman’s Sign B. Ankle clonus C. Negative Babinski Reflex D. Hypotonia E. All of the above
A
B. Ankle clonus
If A and C positive then indicates UMN lesion.
D is a LMN lesion sign
4
Q
You perform a neurological examination on a patient. As you flick the middle finger of their right hand, the ipsilateral thumb flexes. What is this sign and what does it indicate?
A
Positive Hoffman’s Sign, indicates a UMN lesion.
5
Q
You perform a neurological examination on a patient. As you scrape your thumb up the sole of their foot you notice that the ipsilateral toe extends. What is this sign and what might it indicate?
A
Positive Babinski reflex, indicates a UMN lesion.
6
Q
A patient with confusion is found to have a lobar pneumonia in their right lung. What type of brain problem is this and what would you expect as their pneumonia is treated?
A
Secondary brain problem, neurological symptoms due to external factors.
As pneumonia is treated, confusion should improve (unless there is an as yet undiagnosed primary brain problem).
7
Q
A patient who has been involved in a car accident presents with a fixed dilated pupil in their left eye. Which structure is being compressed? A. The right optic nerve B. The left optic nerve C. The right occulomotor nerve D. The left occulomotor nerve E. The left opthalmic artery
A
D.
8
Q
Activation of which autonomic nervous system leads to pupil dilation?
A
Sympathetic.
9
Q
Activation of which autonomic nervous system leads to pupil constriction?
A
Parasympathetic
10
Q
Why does compression of the occulomotor nerve in brain injury cause fixed dilated pupils?
A
Compresses the parasympathetic fibres which run on the outside of the nerve. This leads to unopposed sympathetic dilation of the pupil, causing fixed dilation.
11
Q
An otherwise healthy patient has a single fixed dilated pupil. What is the most common cause for this?
A
Pharmacological blockade for opthalmic examination.
12
Q
A patient is found to have an aneurysm of their right posterior communicating artery. How might their pupils appear?
A
Right: fixed dilated due to local pressure on the right oculomotor nerve
Left: normal and reactive to light.
N.b. Rare
13
Q
In a patient with a fixed dilated pupil, how long have you got to perform lifesaving surgery and how might you maintain this window?
A
3-4 hours, give IV mannitol.
14
Q
Where is the best place to elicit a response to pain in a GCS examination?
A
Pressure between the mastoid and the mandible.
15
Q
What constitutes a mini-neurological exam?
A
General appearance, vital signs, pupils, GCS, lateralising signs
16
Q
A patient is opening their eyes to speech, confused and localising to pain. What is their GCS?
A
3+4+5 = GCS of 12
17
Q
You are assessing a patients GCS. They do not move their left arm and flex their right arm to pain. They do not open their eyes and are making incomprehensible sounds. What is their GCS and what else can you tell from this assessment?
A
4 (best motor)+1+2 = GCS of 7
They also present with a lateralising sign in their arms, suggestive of a right hemispheric problem as the response in the left arm to pain was absent but was present in the right arm.
18
Q
A patient is opening their eyes and flexing to pain. They are not producing appropriate words in response to questions. What is their GCS? A. 8 B. 9 C. 10 D. 11 E. None of the above
A
2+4+3 = GCS of 9 (Answer B.)
19
Q
Which of the following would count as a lateralising sign in a mini-neurological exam? A. Slurred speech B. Eyes open to pain C. Gaze paresis D. Left sided headache E. Flexion of arms to pain
A
C. Gaze paresis (can’t look one way)
N.b. If flexion unequal or motor response is asymmetric then that is lateralising.
20
Q
A patient is admitted with left sided visual inattetion. What else would you need to assess for to complete a mini-neurological examination on this patient?
A
General appearance, vital signs, pupils and GCS.
Has been assessed for lateralising signs.
21
Q
A patient presents with constricted pupils. Which nerve mediates this response? A. The occulomotor nerve B. The optic nerve C. The Abducens nerve D. The Trochlear nerve E. The sympathetic chain
A
A. The occulomotor nerve
Parasympathetic fibres that run with the nerve cause pupil constriction when activated.
22
Q
A patient has lost the ipsilateral direct and contralateral consensual reflex when a light is shone in their left eye. When a light is shone in their right eye both pupils constrict. Which nerve is affected? A. Right optic only B. Left optic only C. Right occulomotor only D. Left occulomotor only E. None of the above
A
B. Left optic nerve only
Shows that the afferent limb of the reflex in their left eye is affected which is mediated by the left optic nerve.
23
Q
A patient has no pupil constriction in their right eye when a light is shone in it however the contralateral consensual reflex in their left eye is intact. When a light is shone in their left eye only the left pupil constricts. Which nerve is affected? A. Right optic only B. Left optic only C. Right occulomotor only D. Left occulomotor only E. None of the above
A
C. Right occulomotor only
The efferent limb of the right eye is affected as they have contralateral response to light, showing that the afferent limb is intact. Lack of response to light in the left eye shows that there is no consensual efferent response in the right eye.
24
Q
A patient is showing a lack of pupillary constriction in both eyes when a light is shone into them. Which nerve is affected? A. Right optic only B. Left optic only C. Right occulomotor only D. Left occulomotor only E. None of the above
A
E.
No constriction in either eye suggests fixed dilated pupils therefore both the right and left occulomotor nerves are affected.
25
```
A patient has a left pupil that is not reactive to light when a light is shone into it however the contralateral pupil constricts to both direct and indirect light. Which nerve is affected?
A. Right optic only
B. Left optic only
C. Right occulomotor only
D. Left occulomotor only
E. None of the above
```
D. Left occulomotor only.
The efferent limb of the left eye is affected as they have contralateral response to light, showing that the afferent limb is intact. Lack of response to light in the right eye shows that there is no consensual efferent response in the left eye.
26
```
A patient has lost the ipsilateral direct and contralateral consensual reflex when a light is shone in their right eye. When a light is shone in their left eye both pupils constrict. Which nerve is affected?
A. Right optic only
B. Left optic only
C. Right occulomotor only
D. Left occulomotor only
E. None of the above
```
A. Right optic only
Shows that the afferent limb of the reflex in their right eye is affected which is mediated by the right optic nerve.
27
```
Which nerve transmits the afferent signals in response to light shone into in the left eye?
A. Right optic only
B. Left optic only
C. Right occulomotor only
D. Left occulomotor only
E. None of the above
```
B. Left optic only
28
A patient is admitted complaining of a curtain descending on their vision in their left eye. What is the name of this phenomenon and what is the underlying pathology?
Amaurosis fugax caused by occlusion of the retinal artery.
29
On fundoscopy you notice a patient has a pale optic disc and cherry red spot on their macula. What has happened and what symptom might they complain of?
Retinal artery occlusion leading to amaurosis fugax.
30
```
Inflammation of the optic nerve head is called?
A. Papilloedema
B. Papilloma
C. Optic neuritis
D. Papillitis
E. Optitis
```
D. Papillitis
31
What is the key difference between papillitis and papilloedema?
Papillitis is unilateral and causes vision loss. Papilloedema is bilateral and vision is usually unaffected.
32
In a patient with optic neuritis, what is your management plan?
Treat with steroids, will reduce pain and speed up recovery.
33
A young woman presents with pain in her left eye on movement and changes in her colour vision. On examination you notice a cold sore in the corner of her mouth?
What is the diagnosis and underlying aetiology?
Optic neuritis due to infection and inflammation of the left optic nerve by herpes simplex virus.
34
A 35 year old woman comes to see you complaining of pain in her right eye which is worse on movement. She is found to have a reduced visual acuity in that eye compared to the left. You take a history and she reveals she had similar symptoms in her left eye which subsequently recovered 2 months ago.
What is the underlying pathophysiology of the likely diagnosis and how might you confirm it?
Patient has MS, due to T-cell damage to myelin sheath of nerves, in this case the optic nerve. Heals poorly leading to relapsing-remitting course of the condition.
An MRI scan of her head would show white matter lesions, most likely around the course of the optic nerve.
35
```
A patient with MS presents with ataxia during an acute attack, where would you expect to see new lesions on an MRI scan?
A. Motor cortex
B. Thalamus
C. Cerebellum
D. Hypothalamus
E. Basal ganglia
```
C. Cerebellum
36
```
Which of the following indicates a poor prognosis in a new diagnosis of MS?
A. Female
B. Male
C. Memory loss
D. Larger lesions on MRI scan
E. Reduced visual acuity
```
B. Males have a worse prognosis.
Also older, motor signs at onset, many early relapses, axonal loss and higher numbers of lesions on an MRI scan.
37
```
Which of the following drugs would you consider in the treatment of MS?
A. Sulfasalazine
B. Natalizumab
C. Aspirin
D. Rivastigamine
E. Trastuzumab
(Bonus point: and how does it work?)
```
B. Natalizumab
Stops T-cells crossing the BBB and so reduces relapses by 68% and new lesions by 92%.
38
```
Which of the following drugs would you consider in the treatment of an acute relapse in a patient with MS?
A. Aspirin
B. Ibuprofen
C. Azathioprine
D. Methylprednisolone
E. Nalatizumab
```
D. Methylprednisolone is the most appropriate choice for an acute relapse.
C and E options for longer term treatment.
39
A patient has had an attack of optic neuritis thought to be due to MS. An MRI scan shows 2 lesions. What further evidence is needed to confirm the diagnosis?
Dissemination in time, either another MRI showing a lesion or a 2nd attack.
40
A patient has presented with tingling in their face, thought to be due to MS. An MRI scan shows 1 lesion. What further evidence is needed to confirm the diagnosis?
Dissemination in space and time. New lesion in a new location at a different time or an MRI that shows 2> lesions.
41
```
Which of the following is a cause of unilateral vision loss?
A. Venous sinus thrombosis
B. Subarachnoid Haemorrhage
C. Herpes simplex virus
D. Retinal vein occlusion
E. Meningitis
```
D. Retinal vein occlusion
Herpes simplex virus may cause optic neuritis which is a cause of unilateral vision loss.
42
A patient presents with optic neuritis. On examination you measure the acuity in the affected eye to be 4/60. What does this mean?
They could read the top line when the chart was 4m away.
43
A patient presents with optic neuritis. On examination you measure the acuity in the affected eye however they can’t even detect fingers held up 0.5m from their face. What is your next course of action?
Test if they can detect a flash of light from a pen torch.
44
A patient in the early stages of Parkinson’s disease complains of anosmia, which structure is affected?
The olfactory nerve (CN 1)
45
```
A patient only responds to you when you approach them from their right side. Where is there likely to be a lesion?
A. Left Parietal Lobe
B. Right Parietal Lobe
C. Left temporal lobe
D. Right temporal lobe
E. None of the above.
```
B. Right parietal lobe
Visual inattention often results from a lesion in the parietal lobe on the ipsilateral side.
46
```
You find a patient has an inferior quadrantopia. Which lobe is the lesion in?
A. Frontal
B. Temporal
C. Parietal
D. Occipital
E. Cerebellum
```
C. Parietal lobe
Radiation supplying inferior vision passes through the parietal lobe.
47
```
You find a patient has a superior quadrantopia, which lobe is the lesion in?
A. Frontal
B. Temporal
C. Parietal
D. Occipital
E. Cerebellum
```
B. Temporal lobe
Radiation supplying superior vision passes through the temporal lobe.
48
A patient has a bitemporal hemianopia. Which of the following is the most likely cause?
A. Right posterior cerebral artery infarction
B. Left anterior cerebral artery infarction
C. Glioblastoma within the temporal lobe
D. Craniopharyngioma
E. Posterior communicating artery aneurysm
D. Craniopharyngioma
49
What piece of equipment is used to test colour vision?
Isihara colour plates
50
```
Which of the following muscles is NOT supplied by the occulomotor nerve?
A. Medial rectus
B. Levator palpebrae superioris
C. Inferior oblique
D. Superior rectus
E. Lateral rectus
(Bonus: and what nerve does supply it?)
```
E. Lateral rectus
Supplied by the abducens nerve (CN6)
51
An elderly patient with a subdural haematoma presents with drowsiness. On examination you find they have a down and out gaze and a dilated pupil in their left eye. What other sign would you see and what might you see on fundoscopy?
Would be likely to see ptosis as patient has a CN3 palsy, most likely due to raised ICP due to their worsening subdural haematoma. Therefore on fundoscopy you might expect to find papilloedema.
52
A patient with a known brain tumour presents complaining of double vision which is worst when they are reading. Which cranial nerve has been affected?
A. Optic
B. Occulomotor
C. Trochlear
D. Abducens
E. All of the above.
(Bonus: and which muscle has subsequently been paralysed?)
C. Trochlear nerve
Paralysis of the superior oblique, affecting down and in gaze.
53
```
Which of the following make up Horner’s Syndrome?
A. Miosis
B. Ptosis
C. Anhidrosis
D. Apparent enopthalmos
E. All of the above
```
E. All of the above
54
A 77 year old man has suffered a stroke and now has a small pupil and partial ptosis of his right eye. What structure has been affected and what other sign might you expect to find?
Presentation of Horner’s Syndrome due to a stroke in the brainstem affecting the sympathetic supply of the right-hand side of the face. Would also expect to find anhidrosis.
55
A 36 year old woman with MS presents with an acute flare up. On examination you notice that she has limited lateral gaze in her left eye. What structure has been affected?
The left abducens nerve (CN6)
56
```
Which cranila nerve passes through the parotid gland?
A. The trigeminal nerve
B. The hypoglossal nerve
C. The facial nerve
D. The vagus nerve
E. The glossopharyngeal nerve
```
C. The facial nerve
57
You perform a Rinne’s test on a patient complaining of deafness. The test detects better conduction of sound over the mastoid process of their right ear. What test might you do as well and what would it find?
Webber’s Test
Would find sound was louder in the right ear due to conductive hearing loss on this side.
58
```
A patient’s uvula is deviated to the left. Which nerve is affected?
A. Right vagus
B. Left vagus
C. Hypoglossal nerve
D. Right glossopharyngeal
E. Left glossopharyngeal
```
A. Right vagus
Deviation is away from the side of the lesion.
59
On examining a patients tongue you ask them to stick it our and wave it from side to side. You note there is a slowness of movement but no wasting. Is the patient suffering an upper or lower motor neuron lesion and which nerve is affected?
Upper motor neuron lesion of the hypoglossal nerve.
Tongue is exhibiting spasticity but no wasting, suggestive that this is where the lesion is.
60
```
What is a normal ICP?
A. <20mmHg
B. <5mmHg
C. <10mmHg
D. <15mmHg
E. <25mmHg
```
D. <15mmHg
Anything above that is considered raised and requires investigation and treatment.
61
```
A patient presents to the A+E department with a trochlear nerve palsy and a headache that is worse when they cough. Which of the following is an appropriate course of action?
A. Depress the head to 60 degrees
B. Elevate the head to 30-40 degrees
C. Give IV saline bolus
D. Lumbar puncture
E. All of the above
```
B. Head elevation to 30-40 degrees.
C = fluid restriction to under 1.5L/day
D = caution needed as should not be used in an extradural haematoma therefore do not perform until this is excluded.
62
A patient with raised ICP is found to have a tumour. Given this information what additional treatment might you give to stop it rising further?
Dexamethasone.
| Give IV steroids to reduce ICP in patients with cerebral oedema only, won’t work in other causes.
63
```
A patient with raised ICP is found to have a large extradural haematoma. What treatment course is the most appropriate?
A. IV saline bolus
B. Try to raise PaCO2
C. IV dexamethasone
D. Burrhole
E. All of the above
```
D. Burrhole
A. Fluid restriction, not bolus
B. Reduce PaCO2 to cause cerebral vasoconstriction
C. Only effective iIn cases of cerebral oedema
64
Give 4 causes of raised ICP.
4 from...
Tumours, head injury, extradural haematoma, subdural haematoma, subarachnoid bleed, intracerebral bleed, intraventricular bleed, infection (meningitis, encephalitis, abcesses), hydrocephalus, cerebral oedema, status epilepticus.
65
Why might you perform a CXR in a patient with raised ICP?
To check for a source of infection which may lead to meningitis or an abscess.
66
A patient presents with ataxia, vomiting and a GCS of 12. You notice they have a 6th nerve palsy. Which muscle has been paralysed and what might be the sinister underlying aetiology?
The lateral rectus has been paralysed, most likely due to raised ICP leading to a Cerebellar tonsil herniation.
The 6th nerve can be compressed or stretched when the brain expands from the posterior fossa and into the foramen magnum.
67
Give 3 signs or symptoms of a raised ICP.
Headache, vomiting, reduced GCS, drowsiness, listlessness, irratibility, coma, falling pulse and rising BP (Cushing’s Respone), Cheyne-stokes respiration, dilated pupils, reduced visual acuity, papilloedema.
68
A patient who has suffered a traumatic brain injury presents with bilateral fixed dilated pupils. On examination you notice Cheyne-Stokes respiration. Why might these concern you?
They are strong suggestions that the patient has coned and so the respiratory centres are being compressed.
The patient is unlikely to survive at this point.
69
A male patient presents with a history of headache for the last few weeks. On examination you notice he has thinning facial and body hair. What might you find when you examine his eyes and what is the possible underlying cause of his presentation?
Find a bitemporal hemianopia.
Caused by a tumour or lesion compressing the pituitary gland and optic chiasm, leading to his symptoms.
70
What is mannitol used for?
For short-term reduction of raised ICP, hyperosmotic fluid.
71
```
A patient presents with pain over their thumb and reduced muscle mass of their bicep. Which nerve root has been compressed?
A. C4
B. C5
C. C6
D. C7
E. C8
```
C. C6
72
```
A patient presents with pain over their middle finger and reduced muscle mass of their tricep. Which nerve root has been compressed?
A. C4
B. C5
C. C6
D. C7
E. C8
```
D. C7
73
```
A patient presents with pain across the top of their foot. On examination you find a reduction in dorsiflexion power. Which nerve root has been affected?
A. L2
B. L3
C. L4
D. L5
E. S1
```
D. L5
74
```
A patient present with pain across the outside and sole of their foot. They also complain that driving has become more difficult. Which nerve root has been affected?
A. L2
B. L3
C. L4
D. L5
E. S1
```
E. S1
Problems with S1 lead to reduced plantarflexion, which is what you need for pressing a car pedal.
75
Give 3 key differences between radiculopathy and myelopathy?
- There will be no pain in myelopathy.
- myelopathy is UMN, radiculopathy is LMN signs
- Radiculopathy affects the nerve roots. myelopathy affects the spinal cord.
- myelopathy will have a more insidious onset.
76
```
A 76 year old patient presents complaining of progressive difficulty writing which has come on over the last month or so. On examination you notice they have brisk reflexes in both their upper limbs. What is the most likely diagnosis?
A. Radiculopathy
B. Myelopathy
C. Stroke
D. Cerebellar syndrome
E. Motor neuron disease
```
B. Myelopathy.
A. No pain.
C. Insidious onset, bilateral signs
D. Same as above
E. Brisk reflexes are a long tract sign
77
```
A 68 year old woman presents complaining that for the last month or so she has felt like she can no longer tell her feet what to do. On examination you find she has a positive cross-adductor test. What is the most likely diagnosis?
A. Radiculopathy
B. Myelopathy
C. Stroke
D. Spinal claudication
E. Motor neuron disease
```
B. Myelopathy
A. No pain.
C. Insidious onset.
D. No pain on walking
E. UMN sign
78
A patient presents with headache, neck stiffness and photophobia. What are you able to infer from these symptoms?
A. They will go on to develop a rash
B. Their headache was sudden onset
C. A lumbar puncture will return pink CSF
D. They will be pyrexic
E. None of the above.
E. None of the above
Symptoms are from a classic presentation of meningeal irritation. This is all you can infer at this point as there is no clue as to whether the irritation is due to blood (B and C) or pus (A and D) touching the meninges.
79
A patient presents with weakness of shoulder abduction. What nerve has been damaged and what injury might they have suffered to cause this?
Axillary nerve damaged leading to deltoid and teres minor weakness. Due to dislocation of shoulder damaging/impinging the nerve.
80
A patient presents with wrist drop. What nerve has been damaged and what injury may they have suffered to cause this?
Radial nerve has been affected, possibly due to a fractured humerus.
81
A patient is found to have a slipped L5/S1 disc. Which root has been affected and what symptoms might they complain of?
S1, second number of a disc is the root number and so the root affected by any disc pathology.
Symptoms may include...
Numbness/tingling/pain over the outside and sole of the foot and the back of the heel on the affected side. Would also see reduced plantarflexion.
82
In a patient with benign paroxysmal positional vertigo, what manoeuvre is diagnostic and what manoeuvre is curative in 90-95% of patients?
Holpikes manoeuvre is diagnostic, the Epley manoeuvre is curative.
83
```
A patient presents with right sided, fast-phase nystagmus and a broad base gait, where is the lesion likely to be?
A. Left motor cortex
B. Left temporal lobe
C. Right Cerebellar hemisphere
D. Left Cerebellar hemisphere
E. Left occipital lobe
```
C. Wide base gait is typical of a cerebellar lesion and direction of the fast phase nystagmus indicates side of the lesion.
84
```
Which of the following can suggest a Cerebellar lesion?
A. Ptosis
B. Down and out eye position
C. Vertigo
D. Hypophonia
E. Hyperphonia
```
E. Hyperphonia, patients may speak more loudly to overcome slurring or staccato speech.
A and B. Signs of a CN3 palsy
C. Sign of a vestibular issue
85
```
Which of the following is a possible cause of cerebellar ataxia?
A. Vitamin E deficiency
B. Amiodarone
C. Creuzfeldt-Jacob Disease
D. Phenytoin
E. All of the above
```
E. All of the above
86
Give the 6 major causes of ataxia and an example condition/problem from each.
Metabolic: B12 deficiency, thiamine deficiency, Vitamin E deficiency, hypothyroidism
Toxic: excessive alcohol, anti-epileptic medications (phenytoin can cause permanent damage), amiodarone
Infections: post-infectious cerebellitis (esp. chicken pox in paeds), HIV infection, prion disease (e.g. CJD)
Autoimmune: gluten ataxia, paraneoplastic (in ca. Breast or ovary).
Degenerative: multi-system atrophy
Genetic: Friedereichs Ataxia (recessive inheritance), spino-cerebellar ataxia (SCA-6 most common variant in UK, dominant inheritance)
87
A patient presents with nystagmus and intention tremor. You take some blood and find a raised transglutaminase, low B12 and low Hb. What is the underlying cause and how would you treat it?
Gluten ataxia due to coeliac disease. This is autoimmune mediated damage to the cerebellum and occurs in those with a gluten intolerance. Treat with a tight gluten free diet.
N.b. Low B12 can also cause ataxia and so contributes to the overall picture.
88
```
A patient with history of alcohol abuse presents with slurred speech. On examination you notice they have a wide base gait and an intention tremor. What is the most likely underlying cause?
A. Hypothyroidism
B. Thiamine deficiency
C. Gluten allergy
D. Amiodarone
E. None of the above
```
B. Thiamine deficiency
Cause of cerebellar ataxia especially in patients with excessive alcohol intake.
There is no evidence to support the other options but it is also entirely possible he is just very drunk.
89
```
A patient presents complaining of diffculty with fine movements such as doing up buttons and stumbling when she walks. On examination you find she has nystagmus. You take her past medical history, which of the following may go some way to explaining the cause of her symptoms.
A. Motor neuron disease
B. Labyrinthitis
C. Lung cancer
D. Pernicious anaemia
E. None of the above
```
D. Pernicious anaemia. This is suggests a B12 deficiency which may also cause Cerebellar ataxia.
90
```
Which of the following is a recessively inherited cerbellar ataxia?
A. Friedereich’s ataxia
B. SCA-6
C. SCA-10
D. SCA-3
E. All of the above
```
A. Only Friedereich’s ataxia is recessivelt inherited, the rest have a dominant inheritance pattern.
91
```
A patient presents with ataxia and on examination you find dysdiadokinesia in their left hand. Where is the lesion?
A. Left motor cortex
B. Left temporal lobe
C. Right Cerebellar hemisphere
D. Left Cerebellar hemisphere
E. Left occipital lobe
```
D. Left cerebellar hemisphere. Signs are ipsilateral to side of the lesion.
92
```
A male patient in his 50s presents with a 3 month history of slurred speech and slow, unsteady gait. He is started on L-DOPA however, there is no improvement in his symptoms. What is the likely diagnosis?
A. Multi-system atrophy
B. Parkinson’s disease
C. Stroke
D. Friedereich’s ataxia
E. Paraneoplastic cerebellar ataxia
```
A. Multisystem atrophy. Typical age of onset and presentation similar to Parkinson’s which does not respond to L-DOPA. May also appear as a cerebellar ataxia when it presents.
B. No response to L-DOPA
C. Gradual onset
D. Onset is in childhood
E. Gradual onset, most common causative cancers are breast and ovarian.
93
```
A patient presents with worsening fine motor control and staccato speech. Which medication might be to blame for this?
A. Carbamazepine
B. Phenytoin
C. Amiodarone
D. Lamotrigine
E. All of the above
```
E. All of the above
All drugs listed can cause cerebellar ataxia. Phenytoin can cause long-term, irreversible damage so avoid in the young where possible.
94
A patient has a positive head thrust test, which structure has been affected?
A. The cochlear
B. The timpanic membrane
C. The vestibulocochlear nerve
D. Semi-circular canal
E. The cerebellum
(Bonus: what is the most common cause of this finding?)
D. The semi-circular canal
| Test is for detecting unilateral pathology of the semi-circular canals, commonly due to labyrinthitis.
95
A patient who has just recovered from the the flu presents complaining of abrupt onset nausea and vertigo. There is no hearing loss in either ear. What is the most likely diagnosis, how would you prove it and how would you treat them?
Labyrinthitis. Post-viral infection damage to the inner ear. Prove diagnosis with a head thrust test. Recommend rest as the ears adapt slowly and recover.
96
What is vertigo and what causes it?
An illusion of rotary movement due to damage to the vestibular system.
97
```
A patient presents complaining of feeling as though the room is rotating, made worse by movement. What is the name of this symptom?
A. Vertigo
B. Faintness
C. Light headedness.
D. Ataxia
E. None of the above
```
A. Vertigo
98
A patient has a positive head thrust test when their head is moved sharply to the right. What would you see and which inner ear is affected?
Eyes will overshoot when head is moved sharply to the right then correct to re-focus on the examiners nose. Indicates pathology of the right sided vestibular system.
99
What is the underlying pathology of benign paroxysmal positional vertigo?
A. Tumour of CN8
B. Cerebellar lesion
C. Damage to the semi-circular canals
D. Crystal deposition within the canals
E. Inner ear infection
(Bonus: what is the diagnostic and what is the curative manoeuvre)
D. Crystal deposition within the semi-circular canals causes damage to the hairs and loss of inertia movement.
Test with Holpike’s Manoeuvre
Treat with Epley’s Manoeuvre
100
A patient has to move their head quickly to re-focus quickly on different objects. What structure has been damaged and which reflex is now uninhibited?
Damage to the cerebellum leading to a lack of inhibiton of the vestibular-ocular reflex which allows the eyes to focus on an object while the head moves.
101
```
A right handed patient presents with Wernicke's aphasia. Which lobe has been affected?
A. Frontal lobe
B. Temporal lobe
C. Parietal lobe
D. Occipital lobe
E. Cerebellum
(Bonus: which hemisphere?)
```
B. Temporal lobe, left hemisphere
102
```
A left handed patient presents with unilateral weakness of their right arm. Which lobe has been affected?
A. Frontal lobe
B. Temporal lobe
C. Parietal lobe
D. Occipital lobe
E. Cerebellum
(Bonus: which hemisphere?)
```
A. Frontal lobe, left hemisphere.
103
```
A right handed patient has been knocking into objects on their left hand side. Which lobe has been affected?
A. Frontal lobe
B. Temporal lobe
C. Parietal lobe
D. Occipital lobe
E. Cerebellum
(Bonus: which hemisphere?)
```
D. occipital lobe, right hemisphere
104
```
A left handed patient presents with reduced sensation in their left arm. Which lobe has been affected?
A. Frontal lobe
B. Temporal lobe
C. Parietal lobe
D. Occipital lobe
E. Cerebellum
(Bonus: which hemisphere?)
```
C. Parietal lobe, right hemisphere
105
```
A right handed patient presents with new onset dyscalculia and dyslexia. Which lobe has been affected?
A. Frontal lobe
B. Temporal lobe
C. Parietal lobe
D. Occipital lobe
E. Cerebellum
(Bonus: which hemisphere?)
```
C. Parietal lobe, left hemisphere.
If patient presents with the 'dys's' then it is in the parietal lobe on their dominant side.
106
```
A patient presents complaining of feeling drunk and problems with fine tying their shoe laces and doing their buttons. Which lobe has been affected?
A. Frontal lobe
B. Temporal lobe
C. Parietal lobe
D. Occipital lobe
E. Cerebellum
```
E. Cerebellum
n.b. symptoms are ipsilateral to side of lesion.
107
Define epilepsy.
The tendency to have seizures, 2 seizures within 2 years needed for diagnosis.
108
Give 5 aetiological factors for seizures
Basically 5 things which can increase your risk of having a seizure, pick from...
Trauma, surgery, hypoxia, pyrexia, mass lesions, anti-psychotic medications, alcohol excess, alcohol withdrawal, hydrocephalus, CNS infections, stroke, aneurysms, hypogylcaemia, hypocalcaemia, hyponatraemia, uraemia, mitochondrial disease, degenerative diseases, increased age.
109
Which of the following neurotransmitters is implicated in the aetiology of epilepsy?
A. Adrenaline
B. Acetylcholine
C. Nor-adrenaline
D. GABA
E. All of the above
(Bonus: and name the other one not on this list)
D. GABA
Loss of the inhibitory effects of GABA can lead to hyper-excitability of neurons and lead to seizures.
Bonus: Glutamate, excess of this neurotransmitter leads to neuron hyper-excitability
110
Why is an EEG not always diagnostic of epilepsy?
Because there is no guarantee you will catch the abnormal brain activity of a seizure while a patient is under EEG monitoring.
111
What might you do to induce a seizure while a patient is having an EEG?
Stress the patient to induce a seizure e.g. times tables quickly or use flashing lights if patient is photosensitive
112
```
What is the only change on an EEG associated which confirms a diagnosis of epilepsy?
A. Spike pattern
B. Slow wave pattern
C. Spike and slow wave pattern
D. Spike and fast wave pattern
E. No changes visible
```
C. Spike and slow wave pattern.
113
```
Which of the following is a possible trigger for seizures?
A. Genetic mutations
B. Low alcohol intake
C. Mental exertion
D. Steady, bright lights
E. Physical exhaustion
```
E. Physical exhaustion
A. Risk factor, not trigger
B. High alcohol intake/withdrawal a trigger
C. Mental exhaustion is a trigger
D. Flickering lights can trigger seizures
114
Patients with the same triggers for their seizures have the same seizure threshold, true or false?
False, threshold is different from patient to patient even if triggers are the same.
115
What are the 2 main types of seizure?
Focal or generalised
116
Give 4 different types of epileptic seizure.
```
Focal aware seizures (partial seizures)
Focal impaired awareness seizures (complex partial)
Tonic-clonic seizures
Absence seizures
Myoclonic seizures
Tonic seizures
Atonic seizures
```
117
There are 4 major types of primary generalized epilepsy, name them.
Childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy, GTCS on awakening.
118
```
Which of the following drugs is the first line option in the treatment of childhood absence epilepsy?
A. Carbamazepine
B. Lamotrigine
C. Sodium valproate
D. Phenytoin
E. None of the above
```
C. Sodium valproate
119
A patient presents to A+E. This morning she collapsed during breakfast and her husband witnessed her arms and legs freeze before shaking for about 90 seconds. She came around in the ambulance and did not know how she had got there. The patient reveals she has a 1 month history of a twitch in her right arm which she first noticed when she spilled tea on herself at breakfast.
a) What type of epilepsy is this?
b) What types of seizures has she suffered?
c) What is the first line treatment option?
a) primary generalized epilepsy, specifically GTCS on awakening.
b) A GTCS, preceded by myoclonic seizures
c) Sodium Valproate
120
A 7 year old child is brought in by their mother who tells you that at school they have occasionally been accused of day dreaming. She reveals that his father died a few years ago when he suffered a seizure while swimming on holiday.
a) What type of epilepsy is this likely to be?
b) Give two options for treatment
c) What is the significance of the family history?
d) What safety advice might you give the mother?
a) Childhood absence epilepsy (primary generalised)
b) Sodium valproate or ethosuximide
c) There is a large genetic component in primary generalised epilepsy
d) Do not let him bath or swim unattended until the seizures are controlled.
121
What is a 'Jacksonian march'?
It describes the progress of a seizure over the motor cortex. Typically presents as twitching in the arms or face which then moves to other areas of the motor cortex
122
A patient presents with a seizure which has been witnessed by his partner. She reports that before the seizure he turned his head quickly to the left, his arms then moved to his chest before his limbs began to shake rhythmically for about 2 minutes.
a) What type of epilepsy might this suggest?
b) What two types of seizure has he had?
c) Which hemisphere did the seizure originate from?
a) secondary generalised, partial seizure becomes tonic-clonic.
b) Adverse seizure, progressing to a GTCS
c) Right hemisphere, in an adverse seizure the head moves away from the side of seizure.
123
What is 'Todd's Paralysis'?
Limb weakness following a seizure, often after GTCS, may last a few hours.
124
What two types of seizure might someone with focal epilepsy suffer from?
Either simple partial or complex partial.
125
A patient presents with a 2 month history of episodes that cause her right eyelid to blink uncontrollably. The episodes last for about 30 seconds and she is aware of them happening.
a) What type of seizures is she having?
b) One day the seizure continues and the twitching moves down the patients arm, what has happened?
c) What is the first line treatment for this patient?
a) Simple partial seizures.
b) Jacksonian march as it spreads over the motor cortex
c) Carbamazepine
126
```
A patient presents with seizures during which he chews and smacks his lips. Post-ictally he suffers from some dysphasia which eventually resolves. He does not remember exactly what happens during his seizures and so the history is taken from a witness. What type of seizures are these?
A. Simple partial seizure
B. Temporal complex partial seizure
C. Frontal complex partial seizure
D. Myoclonic seizure
E. None of the above
```
B. Temporal complex partial seizure
The history is strongly suggestive of a seizure originating in the temporal lobe.
127
```
A patient presents with dysphasia and left sided weakness following a collapse 1 hour ago. A friend says the patient started blinking rapidly before falling to the floor as her left leg went stiff and then began to twitch. What type of seizure has she suffered?
A. Simple partial seizure
B. Temporal complex partial seizure
C. Frontal complex partial seizure
D. Myoclonic seizure
E. None of the above
```
C. Frontal complex partial seizure
Story is strongly suggestive of a seizure originating in a frontal lobe, the weakness following the seizure is a Todd's Palsy, showing the motor area was affected. There is also evidence of a Jacksonian march.
128
```
A patient presents complaining of a 2 months history of flashes and lights in her vision about 3 times a week which last 30 seconds each time. She has no headache or nausea with them and is conscious throughout. There is no weakness or change in sensation in her limbs, what is the most likely diagnosis?
A. Focal seizures
B. TIA
C. Migraine
D. Complex partial seizures
E. Brain tumour
```
A. Focal Seizures
Patient is conscious throughout, most likely due to an occipital lobe pathology.
B. no weakness, very short duration
C. no headache
D. no loss of consciousness
E. no evidence to definitively prove this or evidence of a raised ICP
129
A patient with learning difficulties comes to see you in clinic with his mother. She reports that he has been suffering repeated episodes of collapse where his legs and arms go floppy and he falls to the floor, often hitting his head. The attacks are often preceded by stress. He recovers straight away and is able to stand up, although he often feels tired.
a) What type of seizures is he suffering from?
b) What type of epilepsy might this be?
c) What advice might you give his mother?
a) atonic seizures
b) generalised epilepsy, impossible to determine if primary or secondary from the history
c) Ensure he does not swim or go in the bath unaccompanied, if attacks continue then consider a head guard
130
```
A patient collapses in the waiting room. When you see them they are on the floor with arms flexed and legs extended, with their eyes rolled into the back of their head. They recover after about 60 seconds and cannot remember falling. What type of seizure have they suffered?
A. Atonic seizure
B. Tonic-clonic seizure
C. Myoclonic seizure
D. Tonic Seizure
E. Focal seizure
```
D. Tonic seizure
A. Increased tone, not loss of tone
B. No clonic phase
C. No jerking movements
E. Patient is unconscious
131
```
A patient presents complaining of occasional jerks in his left arm and leg which resolve themselves after a few seconds. He has had a about 3 episodes a week and there are no pre/post-ictal signs. He finds that the seizures tend to be worse in the morning. What type of seizure has he suffered?
A. Atonic seizure
B. Tonic-clonic seizure
C. Myoclonic seizure
D. Tonic Seizure
E. Temporal lobe seizure
```
C. Myoclonic seizure
A. No loss of muscle tone or collapse to the floor
B. No generalisation
D. No stiffness of muscles
E. No typical pre or post-ictal signs associated with a temporal lobe seizure.
132
```
A patient is seen collapsing in the street. They go stiff and their eyes roll back and then they begin a rhythmic jerking which lasts for about 1 minute. What type of seizure have they suffered?
A. Atonic seizure
B. Tonic-clonic seizure
C. Myoclonic seizure
D. Tonic Seizure
E. Temporal lobe seizure
```
B. Tonic-clonic seizure
133
```
Which of the following is an automatism associated with temporal lobe seizures?
A. Jacksonian March
B. Todd's Palsy
C. Dysphagia
D. Arm weakness
E. Lip smacking
```
E. Lip smacking
134
Give three automatisms seen in a temporal lobe seizure.
Lip smacking, chewing, fumbling, grabbing, singing, kissing, violence.
135
```
Which of the following is the first line treatment for complex partial seizures?
A. Sodium valproate
B. Lamotrigine
C. Carbamazepine
D. ethosuximide
E. phenytoin
```
C. Carbamazepine
If it doesn't help then consider sodium valproate or lamotrigine.
136
```
Which of the following is associated with a tonic-clonic seizure?
A. Constricted pupils
B. Increased respiration rate
C. Eyes closed
D. Flexion of the legs
E. Cyanosis
```
E. Cyanosis
A. Pupils dilate
B. Low respiration rate
C. Eyes open
D. Extension of the legs, flexion of the arms
137
```
Which of the following is associated with a tonic-clonic seizure?
A. Erythema
B. Post-ictal confusion
C. Post-ictal alertness
D. Extension of the arms
E. Bell's Palsy
```
B. Post-ictal confusion
A. Cyanosis
C. Post-ictal drowsiness
D. Flexion of the arms
E. Todd's Palsy
138
```
Which of the following is associated with a tonic-clonic seizure?
A. Lip smacking
B. Loss of muscle tone
C. Fixed rigidity of all limbs
D. Lasts over 5 minutes
E. Lasts less than 2 minutes
```
E. Lasts less than 2 minutes (typically 90 seconds)
A. Temporal lobe automatism
B. Increased muscle tone (tonic)
C. Only in tonic phase, then limbs shake
D. Either status epilepticus or psychogenic seizures
139
A patient has been seizing for 15 minutes. They have had periods of rigidity followed by periods of shaking without regaining consciousness in between episodes.
a) what is the likely diagnosis?
b) what is the main risk in this situation and why?
c) what are the 1st, 2nd and 3rd line treatments and what are the most important cautions for each?
d) What other differential should you consider.
a) Status epilepticus
b) brain swelling leading to death
c) 1st line: diazepam. Caution = resp. depression
2nd line: phenobarbital. Caution = resp. depression
3rd line: Phenytoin IV. Caution = severe arrythmias
d) consider non-epileptic attack disorder
140
A patient is in status epilepticus. They cannot tolerate any oral medication and there is no IV access. What is the first line treatment and route?
Rectal diazepam
141
What neurosurgical emergency causes downbeat nystagmus?
Arnold-Chiari malformation (cerebellum and brainstem extend into the foramen magnum)
142
What are the 3 primary underlying causes of nystagmus?
Cerebellar, vestibular and congenital
143
How can you tell if a facial palsy is caused by an upper or lower motor neuron lesion?
Forehead sparing in an upper motor neuron lesion.
144
```
Which of the following is the cause of an upper motor neuron facial palsy?
A. Bell's Palsy
B. Sjorgren's
C. Stroke
D. Shingles
E. Demyelination
```
C. Stroke
All others are causes of LMN facial palsies
145
```
A patient presents with a 3 day history of right ear pain and a headache. On examination you find they have a right sided Bell's Palsy. They tell you that 4 months ago they had an itching, blistering strip of rash across their ribs. What is the cause of their facial droop.
A. Sarcoidosis
B. Herpes zoster
C. SLE
D. Shingles
E. Sjorgren's
```
D. Shingles
All the rest can cause a facial palsy, however only shingles gives this characteristic rash over the ribs.
n.b. sarcoidosis may have skin lesions, but these are in about 25% of patients and are commonly on the shins.
146
```
A patient presents with a facial palsy and a 3 month history of a dry cough and shortness of breath. They complain of painful, raised areas of rash, especially on their shins. Which of the following conditions might they have and what other condition can it mimic on an MRI scan?
A. Sarcoidosis
B. Herpes zoster
C. SLE
D. Shingles
E. Sjorgren's
```
A. Sarcoidosis
If granulomas in the brain then can mimic MS appearance.
147
Which type of MND has a worse prognosis?
Bulbar onset MND has a worse prognosis than limb onset MND.
148
```
Which of the following is needed for a diagnosis of Parkinson's to be made?
A. Postural instability
B. Tremor
C. Rigidity
D. Bradykinesia
E. All of the above
```
E. All of the above
149
```
In a patient with suspected MND, which of the following would you not expect to see?
A. Proximal muscle wasting
B. Fasiculations
C. Gait issues
D. Ocular muscle involvement
E. Dysphagia
```
D. Ocular muscle involvement
All the other options could be seen in limb onset (A, B or C) or bulbar onset (E).
150
A patient is found to have a lesion affecting the right sided medial longitudinal fasiculus of the brain. What eye signs might you find on examination?
This is a right sided INO (internuclear opthalmoplegia). On leftward gaze the right eye will continue to look forward as there is no adduction of the right eye. Both eyes will be able to look right.
151
Give 5 risk factors for stroke.
AF, age, AVM, family Hx, smoking, HTN, diabetes, high lipids, alcohol excess, obesity, arrythmias, ethnicity (S. Asian, African or Caribbean), female, pre-eclampsia, low clotting
152
```
A patient has suffered a stroke which has caused quadriplegia and gaze disturbances. Which artery is likely to have been occluded?
A. Middle cerebral
B. Anterior cerebral
C. Posterior cerebral
D. PICA
E. Basilar
```
E. Basilar
The symptoms are suggestive of a brainstem infarct.
153
```
A patient has suffered a stroke which has caused facial droop and aphasia. Which artery has been occluded?
A. Middle cerebral
B. Anterior cerebral
C. Posterior cerebral
D. PICA
E. Basilar
```
A. Middle cerebral
154
```
A patient has suffered a stroke which has caused brisk patellar reflexes, increased tone and ankle clonus Which artery has been occluded?
A. Middle cerebral
B. Anterior cerebral
C. Posterior cerebral
D. PICA
E. Basilar
```
B. Anterior cerebral
155
```
A patient has suffered a stroke and now has a total loss of vision on their right hand side. Which artery has been occluded?
A. Middle cerebral
B. Anterior cerebral
C. Posterior cerebral
D. PICA
E. Basilar
```
C. Posterior cerebral
156
A patient has suffered a stroke and is now ataxic. Which artery has been occluded?
D. PICA
157
A patient reports to hospital with new onset facial and arm weakness which began at 2:15pm. The time is now 5pm. Is thrombolysis indicated?
Yes. It is within the 4-5 hour window
158
A patient is worried about suffering from a stroke. Give three possible courses of action to reduce their risk.
Anti-hypertensives, improve DM control, statin, increase exercise, folate supplementation, quit smoking, start on anti-coagulation if valve pathology/AF
159
A patient with AF has been started on warfarin to reduce their risk of suffering a stroke. What is the target INR?
A. 1.0 - 2.0
B. 2.0 - 3.0
C. 0 - 1.0
D. 3.0 - 4.0
E. 2.0 - 4.0
(Bonus: They don’t like the idea of regular blood tests, what’s another option?)
B. 2.0 - 3.0
Bonus: start on apixaban/dabigatran
160
```
Which of the following is NOT part of the CHADVASC risk score?
A. Hypertension
B. Male
C. Age > 75
D. Diabetes
E. Vascular disease
```
B. Male
Female gender scores 1.
161
What makes up the ABCD2 score and what does it show?
| Bonus: and what’s the maximum score possible?
Age >60 = 1
BP >140/90 = 1
Clinical features: unilateral weakness = 2
Speech issues only = 1
Duration: >60mins = 2, 10-59mins = 1
Diabetes = 1
Total possible = 7
Gives risk of suffering a stroke after a TIA.
162
```
In ‘Cushing’s Response’, what changes in BP and pulse would you see?
A. Both raised
B. Both fall
C. HR raised, BP falls
D. BP raised, HR falls
E. No change
(Bonus: How do you treat it?)
```
D. BP raised and HR falls
It is a response to reduced perfusion pressure in the brain due to a bleed. BP raises and you get vasodilation to try and correct this but it makes things worse. If you see it it suggests coning is not far away.
Treat with sitting upright and IV mannitol.
163
An elderly patient is found to have suffered an ischaemic stroke 2 hours ago.
A) what medication might you consider (and what route?)
B) She has portal hypertension, why might this medication be contraindicated?
C) Give 4 other reasons why this medication might be contraindicated
D) What other treatment might be possible?
A) IV tissue plasminogen activator (TPA)
B) portal HTN leads to oesophageal varices so there is an increased risk of uncontrollable GI bleeding.
C) bleed on CT, AVM, aneurysm, recent trauma/surgery, artery/venepunctre at a non-compressible site, previous CNS bleed, liver disease, presents with seizures, INR >1.7, platelets <100 x10^9, BP >220/30
D) could consider a PC thrombectomy if the patient has presented to a specialist centre.
164
A 74 year old, right handed patient has suffered an ischaemic stroke which has caused left sided facial droop and left arm weakness.
A) His speech is not affected, why?
B) Which artery has been occluded?
C) What might you see on CT
i) 1 hour after it happened?
ii) 6 hours after it happened?
D) You notice he chokes when trying to take a drink of water. What might he need?
E) What medication may you start him on to prevent another stroke?
A) right handed therefore dominant hemisphere is the left. However in this case the stroke is right hemisphere.
B) Middle cerebral artery
Ci) No pathological changes visible
Cii) darkened patch over territory of the right MCA, most likely over the right motor cortex.
D) SALT assessment
E) clopidogrel, best option for secondary prevention in a patient who does not have AF.
165
A 76 year old woman presents with a history of sudden onset right leg weakness which lasted about 3 hours then resolved. You diagnose a TIA. She has a BP of 132/78.
A) What is her ABCD2 score and the interpretation of this?
B) What is the definition of a TIA?
C) Which artery is likely to have been occluded?
You request a 72hr ECG tape which finds runs of irregular heart beats with no visible P-waves.
D) What is the likely diagnosis?
E) Why might this have caused a TIA?
F) What medication should you prescribe in this patient?
A) 5 (moderate risk of stroke)
B) A temporary disruption of the blood supply to part of the brain that lasts less than 24 hours.
C) the left anterior cerebral artery
D) paroxysmal AF
E) AF leads to pooling of the blood, causing clot formation and these can be transported to the brain, leading to a TIA or stroke.
F) warfarin/apixaban
166
You suspect a patient has developed myasthenia gravis. Describe the test you would use to confirm this and what you find if it was positive.
Tension test: give edrophonium + atropine. In MG the symptoms will improve within seconds and then gradually the effect wears off.
167
A 34 year old female presents with weakness of her face that worsens over the course of the day. As she speaks to you her voice appears to become quieter.
A) What is the most likely diagnosis?
B) What is the pathophysiology behind the diagnosis?
C) What test might you do to confirm this?
D) What might you find when you examine her eyes?
E) What class of medication would you prescribe and give an example.
A) Myashtenia gravis
B) IgG mediated damage to the post-synaptic Ach-R at the NMJ
C) Tensilon test
D) Ptosis and diplopia
E) Ach-erase inhibitors, e.g. pyridostigmine
168
A patient with known myasthenia gravis presents with difficulty breathing.
A) What complication has arisen?
B) What is the appropriate management course?
A) they are having a crisis affecting their respiratory muscles.
B) Plasmapharesis and IV Ig. May need ventilatory support.
169
A patient presents with weakness and fatigue in their hips and thighs with hyporeflexia. They have mild ptosis and diplopia. You request a chest x-ray which shows a hilar mass with mediastinal widening.
A) What is the mass likely to be and therefore what is the diagnosis?
B) What would you expect to find in a Tensilon Test?
C) What will happen when the patient exercises?
A) They have Lambert-Eaton Myasthenic Sydrome, a paraneoplastic complication of their SCLC which has shown up on the CXR.
B) No change in symptoms on Tensilon test.
C) The symptoms will improve.
170
```
Which of the following is never affected in MND?
A) The autonomic nervous system
B) Motor neurons
C) Anterior horn cells
D) The motor cortex
E) All of the above
```
A) The autonomic NS
Sensory neurons and the ocular muscle nerves are also not affected. All the others are affected.
171
```
Where is the lesion in the progressive muscular atrophy pattern of MND?
A) The motor cortex
B) The anterior horn cells
C) The motor neurons
D) The bulbar neurons
E) The spinal nerve
```
B) the anterior horn cells
172
Where is the lesion in the primary lateral Sclerosis pattern of MND?
A) The motor cortex
B) The anterior horn cells
C) The motor neurons
D) The bulbar neurons
E) The spinal nerve
(Bonus: what is the specific name of the cells)
C) The motor cortex, specifically the the Betz Cells.
173
Which pattern of MND will not have any upper motor signs and why?
Progressive muscular atrophy as it only affects the anterior horn cells
174
Which cranial nerves are affected in the progressive bulbar palsy pattern of MND and give 2 signs/symptoms a patient might present with.
CN9-CN12
Problems with speech and swallowing, tongue fasiculations, absent jaw jerk, hypophonia
175
Which pattern of MND is the most common and which nerves does it affect?
ALS, 50% of cases. Affects the motor cortex and anterior horn cells.
176
What is the split hand sign in the context of MND?
Wasting of interossei shows excessive wasting with more muscle loss than in the hypothenar eminence. Characteristics of ALS.
177
A 45 year old male presents with a 3 month history of problems walking. On examination you find he has a spastic gait with muscle wasting evident in both his thighs. The Babinski reflex is positive in the right foot. When you examine his shoulders you find a weakness on abduction of the left shoulder.
a) What is the probable diagnosis in this patient?
b) What might you find when you examine his hands?
C) He presents 1 year later with swallowing difficulties, where has the damage progressed to?
D) Giving his swallowing difficulties, what are some possible treatment options?
A) MND, specifically ALS given the mix of upper and lower motor neuron signs
B) split hand sign and weak grip
C) bulbar neurons
D) blend food or NG tube
178
A patient presents complaining of slow speech which has developed over the past 48 hours. On examination you find brisk jaw reflexes. As the consultation your patient seems to become more tearful.
A) What is the likely diagnosis?
B) What can cause this condition?
C) What would you expect to see when you ask the patient to move their tongue?
A) pseudobulbar palsy
B) stroke or MS
C) slowness of tongue movements
The weeping without provocation is aka ‘the pseudobulbar effect’.
179
A 38 year old woman presents with difficulties walking and standing up from a chair. She is concerned she my be developing MND as her brother suffers from it.
On examination you find muscle wasting of her arms and legs, with accompanying hypereflexia. As you examine her eyes she complains of a gritty pain and objects to the pen torch used to test her pupils.
A) What is the likely diagnosis in this case?
B) What might you expect to find on testing her blood?
C) Give two other physical signs you may notice on examination.
A) patient has hyperthyroidism (Grave’s Disease).
B) Low TSH, raised T4 and T3
C) exopthalmos, thin skin and hair, dry skin, redness around the eyes, increased sweating, pretibial myxoedema, raised HR.
180
A patient presents with symptoms you fear are due to MND. Give 3 investigations you might carry out and the rationale for doing so.
EMG: shows dennervation and fibrillation
MRI: exclude cord compression, spinal tumours
TFTs: exclude hyperthyroidism
Calcium studies: to exclude high Ca or parathyroid problems
CK level: looks for raised CK from increased muscle breakdown.
