Neurology Flashcards
Which nerve is compressed in carpal tunnel syndrome?
Median
Which type of neurons have their cell body in the CNS?
Multipolar
How many pairs of spinal nerves are there?
31
How many pairs of sacral nerves are there?
5
How many pairs of cervical nerves are there?
8
How many pairs of coccygela nerves are there?
1
What is the surface landmark for the T4 dermatome?
Nipple
What is the surface landmark for the T10 dermatome?
Umbilicus
Which spinal levels supply the skin of the posterior scalp, neck, and shoulder?
C2-4
Which spinal levels supply the upper limb?
C5-T1
Which spinal levels supply the lower limb, gluteal region, and perineum?
L2-Co1
Which spinal levels contribute to the sacral plexus?
L5-S4
Where are the cell bodies of sympathetic nerves found?
Lateral horns of T1 to L2
Where do presynaptic sympathetic axons to the heart synapse?
T1 or cervical paravertebral ganglia
Which nerves carry postsynaptic sympathetic axons to the heart?
Cardiopulmonary splanchnic
Where do presynaptic sympathetic axons to the lung synapse?
Thoracic paravertebral ganglia
Which nerves carry postsynaptic sympathetic axons to the lung?
Cardiopulmonary splanchnic nerves
Where do presynaptic axons to the foregut synapse?
Coeliac prevertebral ganglia
Where do presynaptic sympathetic axons to the kidneys synapse?
Aorticorenal prevertebral ganglia
Where do presynaptic sympathetic axons to the midgut synapse?
Superior mesenteric prevertebral ganglia
Where do presynaptic sympathetic axons to the hindgut and pelvic organs synapse?
Inferior mesenteric prevertebral ganglia
Which organ refers pain to the neck?
Liver
Which cranial nerves carry parasympathetic fibres?
III, VII, IX, X
Which ganglion do parasympathetic fibres to the eye travel in?
Ciliary ganglion
From rostral to caudal, what are the three primary vesicles of the neural tube?
Prosencephalon, mesencephalon, rhomencephalon
Which secondary vesicle(s) are formed from the prosencephalon?
Telencephalon and diencephalon
Which secondary vesicle(s) are formed from rhombencephalon?
Metencephalon and myelencephalon
Which structure is derived from telencephalon?
Cerebral hemisphere
Which structures does diencephalon form in the mature brain?
Thalamus and hypothalamus
Which structure does mesencephalon form in the mature brain?
Midbrain
Which secondary vesicle do the pons and cerebellum form from?
Metencephalon
Which secondary vesicle forms the medulla?
Myelencephalon
At which stage of development do the prosencephalon and rhombencephalon divide into their secondary vesicles?
6-8 weeks
Brainstem structures rostral to caudal
Midbrain, pons, medulla
Which glial cells contribute to maintenance of the blood-brain barrier?
Astrocytes
Which glial cells have a rounded nucleus with numerous branches?
Oligodendrocytes
Which cells produce myelin in the CNS?
Oligodendrocytes
Which cells produce myelin in the PNS?
Schwann cells
Which glial cells have a haematopoeitic origin?
Microglia
What is the function of microglia?
Immune monitoring and antigen presentation
What are ependymal cells?
Ciliated cuboidal/columnar cells which line the ventricles
Which type of glial cells does this image show?
Astrocyte
Which type of glial cell does this image show?
Oligodendrocyte
Which type of glial cell does this image show?
Ependymal cell
What is structure A?
Substantia nigra
What is structure B?
Red nucleus
What is structure C?
External capsule
What is structure D?
(Posterior limb of) internal capsule
What is structure E?
Body of fornix
What is structure F?
Corpus callosum
What is structure G?
Caudate nucleus
What is structure H?
Putamen
What is structure I?
Thalamus
What is structure L?
Pons
What is structure N?
Hippocampus
What is structure O?
Inferior horn of lateral ventricle
What is structure A?
Putamen
What is structure B?
(Anterior limb of) internal capsule
What is structure C?
Caudate nucleus
What is structure D?
Corpus callosum
What is structure E?
External capsule
What is structure H?
Optic chiasm
What is structure I?
Optic nerve
What is structure A?
Insula
What is structure B?
Putamen
What is structure C?
Globus pallidus
What is structure D?
(Anterior limb of) internal capsule
What is structure E?
Caudate nucleus
What is structure F?
Corpus callosum
What is structure H?
Anterior commissure
What is structure I?
Optic tract
What is structure J?
Third ventricle
What is structure K?
Uncus
What is structure L?
Amygdala
What is structure M?
Hypothalamus
What is structure A?
Corpus callosum
What is structure B?
(Posterior horn of) lateral ventricle
What is structure C?
Pineal gland
What is structure D?
Hippocampus
What is structure E?
Fourth ventricle
What is structure F?
Middle cerebellar peduncle
What is structure G?
Superior cerebellar peduncle
What is structure H?
Inferior colliculus
What is structure I?
Superior colliculus
What is structure J?
Thalamus
What is structure K?
Fornix
Which ligament of the back contains elastin?
Ligamentum flavum
What is tract A?
Lateral corticospinal
What is tract B?
Anterior corticospinal
What is tract C?
Rubrospinal
What is tract D?
Reticulospinal
What is tract E?
Olivospinal
What is tract F?
Vestibulospinal
What is tract G?
Gracile fasciculus
What is tract H?
Cuneate fasciculus
What is tract I?
Posterior spinocerebellar
What is tract J?
Anterior spinocerebellar
What is tract K?
Lateral spinothalamic
What is tract L?
Anterior spinothalamic
What does the orange arrow indicate?
Cauda equina
What does the red line indicate?
Supraspinatous ligament
What does the green line indicate?
Ligamentum flavum
What does the yellow line indicate?
Posterior longitudinal ligament
What does the blue line indicate?
Anterior longitudinal ligament
Which line indicates ligamentum flavum?
Green
Which line indicates the supraspinous ligament?
Red
Which line indicates the anterior longitudinal ligament?
Blue
Where is the myenteric plexus located?
Outer layers of gut smooth muscle
What is A?
Internal carotid artery
What is B?
Anterio cerebral artery
What is C?
Anterior communivating artery
What is D?
Middle cerebral artery
What is E?
Basilar artery
What is F?
Posterior cerebral artery
What is H?
Vertebral artery
What is I?
Posterior inferior cerebellar artery
Which vein do the venous sinuses drain to?
Internal jugular
At what vertebral level does the dural sac end?
S2
What is the denticulate ligament composed of?
Pia and arachnoid tissue
Which ventricle is the central canal of the spinal cord continuous with?
4th
What is the artery of Adamkiewicz?
A particularly large segemntal artery around the T2 level
Where do the anterior and posterior venous plexuses of the spine lie?
Epidural space
At what section does the spinal cord have a rugby ball shape?
Cervical
At which section of the spinal cord are lateral horns present?
Thoracic
Which spinal levels does fasciculus gracilis carry informatiom from?
T6 and below
Which spinal levels does fasciculus cuneatus carry information from?
Above T6
Where do the 1st order neurons of the DCML system synapse?
The gracile and cuneate nuclei in the medulla
Where do 2nd order neurons of the DCML project?
Ventral posterolateral lobe of thalamus
Where does the DCML decussate?
In the medulla
Where do 2nd order neurons of the spinothalamic tract synapse?
Thalamus
What is the function of the corticospinal tract?
Fine movement, particulary of the distal limb muscles
What proportion of corticospinal tract fibres decussate?
85%
Where do corticospinal tract fibres decussate?
The decussation of the pyramids
Where do fibres of the ventral/anterior corticospinal tract cross over?
Segmentally at the level they supply
What are the consequences of CVA of the internal capsule?
Loss of descending control of the corticospinal tract resulting in spastic paralysis with upper limb hyperflexion (decorticate posturing).
What is the function of the tectospinal tract?
Mediation of head and neck movement in response to visual stimuli
Where do fibres of the tectospinal tract originate?
Superior colliculus of midbrain
Where do tectospinal fibres cross over?
Immediately, at superior colliculus
Where do fibres of the reticulospinal tract originate?
The reticular formation in the pons and medulla
What is the function of reticulospinal tract fibres from the pons?
Faciliate extensor movements, inhibit flexor movements
What is the function of the reticulospinal tract fibres from the medulla?
Facilitate flexor movements, inhibit extensor movements(medulla has an L)
What is the function of the vestibulospinal tract?
Excitatory input to antigravity extensor muscles
Where do fibres of the vestibulospinal tract originate?
Vestibular nuclei of the pons and medulla
Lesions of which area can cause loss of control of the vestibulospinal tract?
Midbrain
What symptoms are seen in Brown-Sequard syndrome?
Ipsilateral spastic paralysisIpsilateral hyperreflexia and extensor plantar reflexIpsilateral loss of vibration sense and proprioceptionContralateral loss of pain and temperature
Loss of control of which tract causes extensor plantar reflex and hyperreflexia in Brown-Sequard syndrome?
Lateral corticospinal tract
Which structures does the tentorium cerebelli separate?
Separates cerebellum and brainstem from occipital lobes
Which structures does the falx cerebri separate?
The hemispheres of the brain
What structures does the falx cerebelli separate?
Cerebellar hemispheres
Which structures attach the cerebellum to the brainstem?
The superior, middle, and inferior peduncles
What are the three layers of the cerebellar cortex?
Molecular outermost
Purkinje cell layer
Granule cell layer
What is the result of unilateral cerebellar hemisphere lesion?
Ipsilateral limb coordination disturbance, intention tremor, unsteady gait
What is the result of midline cerebellar lesion?
Disturbance of postural control but spares limb coordination
Describe the direct pathway
Cerebral cortex excites neostriatum with glutamate
Neostriatum inhibits medial lobe of globus pallidus with GABA
Medial lobe is unable to inhibit thalamus with GABA
Thalamic activity increases, increasing cerebral stimulation and therefore movement
Describe the indirect pathway
Cerebral cortex excites neostriatum with glutamateNeostriatum inhibits lateral lobe of globus pallidus with GABALateral lobe cannot inhibit subthalamic nucleus with GABASubthalamic nucleus excites medial lobe of globus pallidusIncrease inhibition of thalamus, decreased movement(Lateral lobe means less movement, medial means more)
What are the two groups of intrinsic back muscles?
Erector spinae (superficial)Transversospinalis (deep)
What are the attachments of erector spinae?
Superiorly: Fibres attach via tendon to a rib, transverse process, or spinous processInferiorly: Common tendon attaches to sacrum and iliac crest
Where does transversospinalis run?
Between the transverse and spinous processes
Which muscles facilitate flexion of the spine?
Psoas major and rectus abdominis
Which muscles extend the spine?
Erector spinae, transversospinalis
What is the normal lordosis in the adult spine?
2 degrees cervical2 degrees lumbar
What is the normal kyphosis in the adult spine?
1 degree thoracic1 degree sacral
What is the outer ring of the intervertebral disc called?
Annulus fibrosus
What is the name of the inner soft pulp of the intervertebral disc?
Nucleus pulposus
Which areas have no intervertebral disc?
Between C1 and C2, sacrum, and coccyx
Which structures does ligamentum flavum connect?
Laminae of adjacent vertebrae
Which structures does the interspinous ligament connect?
The superior and inferior surfaces of adjacent spinous processes
Which ligament prevents overflexion of the spine?
Posterior longitudinal
Which ligament prevents overextension of the spine?
Anterior longitudinal
Which ligament is indicated in red?
Anterior longitudinal ligament
Which ligament is indicated in purple?
Posterior longitudinal ligament
Which ligament is indicated in blue?
Ligamentum flavum
Which ligament is indicated in green?
Interspinous ligament
Which ligament is indicated in yellow?
Supraspinous ligament
Which colour indicates the interspinous ligament?
Green
Which colour indicates the posterior longitudinal ligament?
Purple
What are the characteristic features of cervical vertebrae?
Transverse foramen, bifid spinous processes, triangular vertebral foramen
What are the atypial features of C1?
Anterior and posterior arch in place of body and spinous process
What type of joint are the atlanto-occipital joints?
Synovial
What % of translation occurs in stage 2 vertebral dislocation?
25%
What % of translation occurs in stage 3 vertebral dislocation?
50%
How many atlanto-axial joints are there, and where do they lie?
Two between the inerior articular facets of atlas and the super articular facets of axisOne between the anterior arch of atlas and odontoid process of axis
At what vertebral level does the spinal cord end?
L1/2
Which layers are passed through in laminectomy?
Skin, superficial fascia, aponeurosis of trapezius/thoracolumbar fascia, ligaments (supraspinous, interspinous, flavum), lamina, spinous process, epidural fat, dura mater, arachnoid mater
Whqt area of skin is supplied by C2?
Back of scalp, Adam’s apple
What area of skin is supplied by C3?
Back of neck, jugular notch
What area of skin is supplied by C4?
Clavicle and shoulder tip
What area of skin is supplied by C5?
Badge patch, lateral arm
What area of skin is supplied by C6?
Lateral forearm, lateral hand, thumb
What area of skin is supplied by C7?
Middle aspect of hand
What area of skin is supplied by C8?
Medial hand
What area of skin is supplied by T1?
Medial forearm
What area of skin is supplied by T2?
Medial arm and sternal angle
What area of skin is supplied by L1?
Groin - “hands in pockets”
What area of skin is supplied by L2?
Anterior thigh
What area of skin is supplied by L3?
Anterior knee
What area of skin is supplied by L4?
Medial leg and ankle
What area of skin is supplied by L5?
Lateral leg, dorsum of foot
What area of skin is supplied by S1?
Lateral foot, heel
What area of skin is supplied by S2?
Posterior knee and thigh
What area of skin is supplied by S3?
Buttock (outermost part of ‘bullseye’)
What area of skin is supplied by S4?
Perineum
What area of skin is supplied by S5?
Perianal skin (middle of bullseye)
Which cranial nerve exits the brainstem posteriorly?
Trochlear
Which cranial nerve exits the brainstem laterally?
Vestibulocochlear
Which cranial nerve is purely sensory?
Olfactory
Which cranial nerves are purely motor?
III, IV, VI, XII
Which nucleus gives sympathetic fibres to the oculomotor nerve?
E
What is nucleus A?
Mesencephalic nucleus of trigeminal
What is nucleus B?
Sensory nucleus of trigeminal
What is nucleus C?
Spinal nucleus of trigeminal
What is nucleus D?
Solitary nucleus
What is nucleus E?
Edinger-Westphal nucleus
What is nucleus F?
Oculomotor nucleus
What is nucleus G?
Trochlear nucleus
What is nucleus H?
Motor nucleus of trigeminal
What is nucleus I?
Abducens nucleus
What is nucleus J?
Superior salivatory nucleus
What is nucleus K?
Facial nucleus
What is nucleus L?
Inferior salivatory nucleus
What is nucleus M?
Hypoglossal nucleus
What is nucleus N?
Dorsal motor nucleus of vagus
What is nucleus O?
Nucleus ambiguus
What is nucleus P?
Spinal accessory nucleus
Which muscle of the tongue is not supplied by the hypoglossal nerve?
Palatoglossus
Which cranial nerve passes through the interpeduncular fossa in the midbrain?
Oculomotor
Which cranial nerves does nucleus O give fibres to?
IX, X and accessory XI
What are the functions of the trigeminal nerve?
Somatosensation of faceProprioception e.g. in chewingMotor control of muscles of mastication, tensor tympani, mylohyoid, digastric, tensor veli palatini
Which nucleus receives proprioceptive information from the muscles of mastication?
Mesencephalic trigeminal (A)
Which nucleus receives discriminative touch and vibration information from the face?
Main sensory/pontine/principal trigeminal nucleus (B)
Which nucleus receives pain and temperature information from the face?
C (spinal trigeminal)
What are the functions of the facial nerve?
Motor supply to muscles of facial expressionParasympathetic innervation to pterygopalatine and submandibular gangliaTaste to anterior 2/3 of tongue
Which muscle receives motor supply from the glossopharyngeal nerve?
Stylopharyngeus
Which cranial nerves give fibres to the solitary nucleus?
VII, IX, X
Which cranial nerves receive fibres from the superior and inferior salivatory nuclei?
VII and IX
Which cranial nerves does nucleus J give fibres to?
VII, IX (sup. salivatory)
Which nerves exit the brainstem in the pontomedullary junction?
VI, VII, VIII
Where does CN IV exit the brainstem?
Posterior midbrain
How is auditory information transmitted from the cochlea to the cortex?
Spiral ganglion -> dorsal ventral cochlear nuclei in medulla ->superior olivary nucleus in pons -> inferior colliculus in midbrain ->medial geniculate body in thalamus -> primary auditory cortex in superior temporal gyrus
Which aspect of the auditory cortex maps to low frequency sound?
Anterolateral
Where does Broca’s area lie?
Inferior frontal gyrus (usually left hemisphere)
What is Broca’s aphasia?
Expressive aphasia - difficulty producing language, but no issues comprehending it
Where does Wernicke’s area lie?
Superior temporal gyrus (usually left)
What is Wernicke’s aphasia?
Receptive aphasia - difficulty comprehending language
What is structure A?
Ciliary body
What is structure B?
Sclera
What is structure C?
Choroid
What is structure D?
Retina
What is structure E?
Optic nerve
What is structure F?
Macula
What is structure G?
Fovea
What is structure H?
Lens
What is structure I?
Anterior chamber
What is structure J?
Pupil
What is structure K?
Cornea
What is structure L?
Iris
What are the layers of the retina, from deep to superficial?
Inner limiting membrane
Layer of optic nerve fibers
Ganglion cell layer
Inner plexiform layer
Inner nuclear layer
Outer plexiform layer
Outer nuclear layer
Outer limiting membrane
Rods and cones
Retinal pigment epithelium
Where do the lower visual fields project to?
Gyrus superior to calcarine sulcus
Where does the macula project to?
Posterior pole of visual cortex
Which brainstem nucleus is involved in the consensual light reflex?
Edinger-Westphal
What are the features of the accomodation reflex?
Convergence of gaze, contraction of ciliary muscles, pupil constriction
5 layers of the scalp
Skin Connective tissue Aponeurosis Loose connective tissue Pericranium
Branches of which artery supply the scalp?
External carotid
Which layer of the scalp contains a rich anastomotic network?
Connective tissue
Which bones meet at the pterion?
Frontal, parietal, temporal, sphenoid
What is foramen A?
Cribriform plate of ethmoid
What is foramen B?
Optic canal
What is foramen C?
Superior orbital fissure
What is foramen D?
Foramen rotundum
What is foramen E?
Foramen ovale
What is foramen F?
Foramen lacerum
What is foramen G?
Foramen spinosum
What is foramen H?
Carotid canal
What is foramen I?
Internal acoustic meatus
What is foramen J?
Jugular foramen
What is foramen K?
Hypoglossal canal
What is foramen L?
Foramen magnum
Which cranial nerves pass through the internal acoustic meatus?
VII and VIII
Which cranial nerves pass through the superior orbital fissure?
III, IV, V1, VI
Which cranial nerve passes through foramen rotundum?
V2
Which cranial nerve passes through foramen ovale?
V3
Which cranial nerves pass through the jugular foramen?
IX, X, XI
Which cranial nerve gives sensory supply to the dura?
V
Which bone does the tentorium cerebelli attach to?
Petrous temporal bone
What are the attachments of the falx cerebri?
Crista galli of ethmoid anteriorly, internal occipital protuberance posteriorly
Where does the confluence of the sinuses lie?
At the internal occipital protuberance
What foramen allows passage of CSF from the lateral ventricles to third ventricle?
Foramen of Munro
How does CSF pass from the 3rd to 4th ventricle?
Through the cerebral aqueduct
Which type of haemorrhage is caused by rupture of the middle meningeal artery?
Extradural
Which type of haemorrhage is seen in the elderly and those with alcohol problems?
Subdural
Which type of haemorrhage can occur due to rupture of aneurysm in the circle of Willis?
Subarachnoid
Which type of haematoma is lemon shaped?
Extradural
Which type of haematoma is crescent-shaped?
Subdural
Which type of haemorrhage presents with a ‘worst ever’ thunderclap headache?
Subarachnoid
Which cranial nerves travel in the wall of the cavernous sinus?
III and IV
Which cranial nerve travels within the cavernous sinus?
VI
Which cranial nerve runs with the carotid sheath?
XII
Where will the tongue deviate in CN XII pathology?
Towards the affected side
Which foramina do the divisions of CN V pass through?
V1 - SOFV2 - rotundumV3 - ovale
Which nerve gives sensory supply to the angle of the mandible?
Great auricular nerve (C2, 3)
Which muscle of mastication closes the jaw?
Lateral pterygoid
What nerve forms the afferent limb of the corneal reflex?
Long ciliary nerve (from nasociliary branch of V1)
Where does the facial nerve exit the skull?
Stylomastoid foramen
What are the five divisions of the facial nerve?
TemporalZygomaticBuccalMarginal mandibularCervical
Which ganglion receives parasympathetic fibres from CN VII?
Pterygopalatine
What is the position of the vagus nerve within the carotid sheath?
Posterior to and between the common carotid and internal jugular
At what level does the oesophagus pass through the diaphragm?
T10
In pathology of the vagus nerve, what abnormality of the uvula is seen?
Deviation away from the affected side
Which cell organelle is seen as Nissl substance?
Rough endoplasmic reticulum
What is the most common excitatory transmitter of the CNS?
Glutamate
What are the most common inhibitory neurotransmitters of the CNS?
GABA, glycine
Name 3 amino acid neurotransmitters
Glycine, GABA, glutamate
Name 3 amine neurotransmitters
Dopamine, histamine, serotonin, noradrenaline
Name 3 peptide neurotransmitters
CCK, somatostatin, substance P, TRH, VIP
Which fibres and receptors are found in Merkel cells?
AB fibres, SA1 receptors
How would a mechanoreceptor with fast adaptation and a small receptive field be classified?
FA1
Where are Merkel cell complexes found?
Basal epithelium of fingers, palms, dorsum of hand, sole of foot
What do Merkel cell complexes detect?
Sustained pressure and texture
Which type of fibres and receptors do Meissner corpuscles have?
AB, FA1
Where are Meissner corpuscles found?
Basal epithelium in skin areas of high acuity
What do Meissner corpuscle detect?
Stroking, flutter, low frequency vibration
What type of fibres and receptors do Ruffini endings have?
AB, SA2
Which type of mechanoreceptor has a collagen core?
Ruffini ending
Where are Ruffini endings found?
The dermis of glabrous and hairy skin, and joint capsules
What are Ruffini endings sensitive to?
Drag
What type of fibres and receptors do Pacinian corpuscles have?
AB, FA2
Which mechanoreceptors resemble onions?
Pacinian corpuscles
Where are Pacinian corpuscles found?
Close to the periosteum
What are Pacinian corpuscles sensitive to?
Vibration 200-300 Hz
Which type of fibres do free nerve endings have?
Adelta or C
Which laminae of the spinal cord contain nociceptors?
I and II
Which laminae of the spinal cord contain proprioceptors?
VII to IX
Which type of receptor has direct gating?
Ionotropic
What is stereognosis?
The ability to recognise an object by touch
What is detected by the DCML?
Vibration, stereognosis, fine touch, proprioception
How does somatic information from the face reach the cortex?
Trigeminal nerve -> chief sensory/spinal nucleus, then decussation and projection via trigeminal lemniscus to VPN of thalamus. 3rd order from thalamus to cortex.
Which Broadmann areas around found in the central sulcus?
1, 2, 3a, 3b
Layers of somatosensory cortex
MolecularExternal granularExternal pyramidalInternal granularInternal pyramidalMultiform
Which layer of somatosensory cortex do thalamic inputs terminate in?
4 (internal granular)
Which area is damaged in hemispatial neglect syndrome?
Right parietal cortex - esp. posterior
Which vitamin deficiency causes Wernicke’s encephalopathy?
B1 (thiamine)
What are the three deficits seen in Wernicke’s encephalopathy
Gait ataxia, oculomotor dysfunction, encephalopathy
How are LMNs arranged in the ventral horn?
Axial muscles medial to distalFlexors dorsal to extensors
Which type of muscle fibres derive ATP from glycolysis?
Type IIb (fast fatiguing)
Which channel do tip links gate?
TMC1
Types of visual migraine aura
Central scotomata, central fortification, hemainopic loss
Abortive treatment of migraines
NSAIDs - aspirin 900, naproxen 250, ibuprofen 400 +/- anti-emetic
What is the action of triptans?
5-HT agonist
Triptans used in migraine
Rizatriptan, eletriptan
Drugs used for migraine prophylaxis
Propranolol
Topiramate
Amitriptyline
Gabapentin
Pizotifen
Sodium valproate
Drugs used in tension headache
Amitriptyline Dothiepin
Treatment of cluster headaches
High flow o2 for 20 mins6mg sc sumatriptan 2 week course steroidsprophylaxis - verapimil
Cluster headache presentation
Occur in 30-40s, predominantly menCircadian and seasonal variationSevere unilateral pain lasting 45-90 minutes, occurring multiple times per day during bouts
What are SUNCT headaches?
Short-lived (15-120s)UnilateralNeuralgiformConjunctival injectionsTearing
Treatment of SUNCT headache
Lamotrigine Gabapentin
Management of idiopathic intracranial hypertension
Weight lossAcetazolamideVentricular atrial/lumbar peritoneal shift
Trigeminal neuralgia presentation
Occurs in elderly, mostly womenStabbing pain in v2/3 lasting 1-90s 10-100 times per day during bout
Treatment of trigeminal neuralgia
Carbamazepine, gabapentin, phenytoin, baclofen, surgery
What is Kernig sign?
Neck stiffness in meningitis
Which types of meningitis have low CSF glucose?
Bacterial and fungal/TB
Which type of meningitis will have PMNs/granulocytes in CSF?
Bacterial
Which type of white cells are found in CSF in viral meningitis?
Lymphocytes
What is the motor function of the obturator nerve?
Adduction of the thigh
What is the motor function of the sciatic nerve?
Leg flexion at knee
What is the motor function of the tibial nerve?
Foot plantarflexion, inversion
What is the motor function of the superficial peroneal nerve?
Foot eversion
What is the motor function of the deep peroneal nerve?
Foot dorsiflexion, toe extension
Which area does the deep peroneal nerve give sensory supply to?
Space between 1st and 2nd toes
What area does the tibial nerve give sensory supply to?
Sole
What are the motor functions of the radial nerve?
Extension at arm, wrist, and proximal finger jointsForearm supinationThumb abduction
What are the motor functions of the median nerve?
Thumb flexion and oppositionFlexion of digits 2 and 3Wrist flexion and abductionForearm pronation
What are the motor functions of the ulnar nerve?
Finger adduction and abduction
Thumb adduction
Flexion of digits 4 and 5
Wrist flexion and adduction
What are the motor functions of the axillary nerve?
Abduction of arm beyond first 15 degrees
What are the motor functions of the musculocutaneous nerve?
Flexion of arm at elbowSupination of forearm
Which area does the median nerve give sensory supply to?
Palm, thumb, digits 2 and 3
Which area does the ulnar nerve give sensory supply to?
Medial palm, digits 4 and 5
Which area does the axillary nerve give sensory supply to?
Badge patch
Which area does the musculocutaneous nerve give sensory supply to?
Lateral forearm
Which nerve palsy gives a claw-like appearance of the hand?
Ulnar
Which nerve palsy causes preacher’s hand?
Median
Which nerve palsy causes simian hand?
Median and ulnar
Common drugs which precipitate epileptic seizure
Aminophylline
Tramadol
Antibiotics
Anti-emetics
Opioids
When is acute CT indicated after a fall/LOC?
Clinical or radiological skull fracture
Deteriorating GCS
Focal signs
Head injury with seizure
GCS <15 after 4 hours
How long should patients stop driving after a first seizure?
6 months
What is the difference between simple and complex partial seizures?
Complex have impaired consciousness
Treatment of choice for primary generalised epilepsy
Sodium valproate
First line treatment for focal onset epilepsy
Carbamazepine or lamotrigine
How does carbamazepine work?
Inhibits voltage-gated Na channels
How does lamotrigine work?
Inhibits voltage-gated Na channels
How does sodium valproate work?
Enhances GABA synthesis
First line for partial seizures
Carbamazepine or lamotrigine
First line for absence seizures
Sodium valproate, ethosuxamide
First line for myoclonic seizures
Sodium valproate, levetiracetam, clonazepam
First line for tonic and tonic clonic seizures
Sodium valproate, levetiracetam, topiramate, lamotrigine
Sodium valproate side effects
Weight gain, teratogenicity, hair loss, fatigue
Carbamazepine contraindications
Worsens primary generalised epilepsies
Topiramate side effects
Sedation, dysphasia, weight loss
Complications of status epilepticus
Respiratory insuffiency, hypotension, hyperthermia, rhabdomyolysis
What is Lambert Eaton Myasthenic Syndrome?
Autoimmune condition with antibodies against presynaptic calcium channels
How low is ACh receptor function when symptoms of myasthenia gravis occur?
~30%
Incidence peaks for myasthenia gravis
20s for women50s and 60s for men
Treatment of myasthenia gravis
AChesterase inhibitor - pyridostigmine
IVIG
Thymectomy
Steroids
Drugs to avoid in myasthenia gravis
Antibiotics esp. gentamicin
Antimalarials
Beta blockers
Many psych/neuro drugs
Which channels are often affected in myotonic disorders?
Chloride
Blood test for polymyositis
Creatine kinase
Main symptom distinguishing dermatomyositis from polymyositis
Heliotrope rash on face
Which immune-mediated muscle disorder is often associated with underlying malignancy?
Dermatomyositis
Which form of myositis characteristically spares the thumbs?
Inclusion body myositis
What is the genetic defect in myotonic dystrophy?
Trinucleotide repeat disorder inherited in autosomal dominant manner
Triad of signs/symptoms in rhabdomyolysis
MyalgiaMuscle weaknessMyoglobinuria
What muscle power rating would movement against gravity but not resistance be?
3
How is a muscle power rating of 1 described?
A flicker of movement
Summarise muscle power rating
0 - no movement at all
1 - flicker of movement when attempting to contract muscle
2 - some muscle movement if gravity removed but none against gravity
3 - movement against gravity but not against resistance
4 - movement against resistance but not full strength
5 - normal strength
Where are the cell bodies of the rubrospinal tract?
Red nucleus
What is the function of the rubrospinal tract?
Control of limb flexors
Where are the cell bodies of the tectospinal tract?
Superior colliculus
Which type of nociceptive fibre is unmyelinated?
C fibre
Which type of nociceptive fibre mediates ‘first’, or fast, pain?
Aδ
Which family of receptors is triggered by thermal stimuli?
TRP
What is the action of horizontal cells in the retina?
Receive input from photoreceptors and project to other photoreceptors and bipolar cells
What is the function of amacrine cells in the retina?
Receive input from bipolar cells and project to ganglion cells, bipolar cells, and other amacrine cells
How does light result in the closure of Na channels in the retina?
Light stimulates rhodopsin, activating G protein transducin, which in turn activates cGMP phosphodiesterase, reducing cGMP and leading to closure of Na channels
Properties of rod cells
Found in peripheryLow densityHigh convergence-> low acuity but increased sensitivity
Properties of cone cells
Found in highest concentration in foveaHigh densityLow convergence (only a couple per ganglion cell)
How do off bipolar cells respond to light?
By releasing less glutamate
What do M type retinal ganglion cells detect?
Movement
What do P type retinal ganglion cells detect?
Form and colour
What do non-M-non-P type retinal ganglion cells detect?
Colour
Which cancer should NF patients be screened for?
Thyroid
What are the different categories of GCS scored out of?
Eyes out of 4, verbal out of 5, motor out of 6
GCS E2 V4 M5
GCS E4 V1 M2
GCS E3 V3 M4
GCS E1 V5 M2
GCS E4 V5 M5
GCS E2 V4 M1
GCS E2 V3 M5
GCS E2 V1 M4
Which nerve supplies the skin posterior to the external ear?
Lesser occipital (C2)
Which nerve supplies the skin over the angle of the mandible?
Great auricular nerve (C2,3)
Which nerve supplies the skin over the anterior neck?
Transverse cervical (C2,3)
Which nerve roots are found in the musculocutaneous nerve?
C5/6/7
Which nerve roots around found in the axillary nerve?
C5/6
Which nerve roots around found in the radial nerve?
C5-T1
Which nerve roots around found in the median nerve?
C5-T1
Which nerve roots around found in the ulnar nerve?
C8, T1
Which nerve roots are found in the ilioinguinal nerve?
L1
Which nerve roots around found in the obturator nerve?
L2,3,4
Which nerve roots around found in the femoral nerve?
L2,3,4
Which nerve roots are found in the superficial fibular nerve?
L4,L5,S1
Which nerve roots are found in the deep fibular nerve?
L5
Which nerve roots are found in the sural nerve?
S1,2
Which area of skin is supplied by the femoral nerve?
Anterior thigh
Which area of skin is supplied by the saphenous nerve?
Anteromedial leg
Which area of skin is supplied by the deep fibular nerve?
First web space
Which muscle compartment is supplied by the musculocutaneous nerve?
Anterior arm
Which muscle compartment is supplied by the median nerve?
Anterior forearm
Which muscle compartment is supplied by the radial nerve?
Posterior arm and forearm
Which muscle compartment is supplied by the sciatic nerve?
Posterior leg
Which muscle compartment is supplied by the deep fibular branch of sciatic nerve?
Anterior leg
Which muscle compartment is supplied by the superficial fibular branch of sciatic nerve?
Lateral compartment
Most common extra-axial intracranial neoplasm
Meningioma
Which cells do meningioma arise from?
Residual mesenchymal cells of the meninges
Most common presentations of brain tumour
Progressive neurological deficitMotor weaknessHeadacheSeizure
Perseveration is a sign seen in tumours of which lobe?
Frontal
Tumours of which lobe can present with dyspraxia and neglect?
Parietal
What is glioblastoma multiforme?
An astrocytic tumour with necrosis
Grades of astrocytomas
I - Pilocytic. Truly benign, slow growing.II - Low grade fibrillary, gemistocytic, or protoplasmic. Often present with seizures, can become high grade. Treated surgicallyIII - Anaplastic astrocytoma. No contrast enhancement. Median survival 2 years.IV - GBM. Survival under a year. Treatment focused on symptom management, includes surgery, chemo.
Features distinguish oligodendroglial tumours from astrocytomas
Calcification, cysts, peritumoural haemorrhage.Subarachnoid accumulations can look like toothpaste
Risk factors for meningioma
NF2, breast cancer
Aggressive forms of meningioma
Clear cell, chorioid, rhabdoid, papillary
Which cranial nerves are affected by acoustic neuroma?
V VII VIII
Symptoms of acoustic neuroma
Hearing loss, tinnitus, disequilibrium
Epidemiology of germ cell tumours
More men than women, almost exclusively under 20s
Most common CNS germ cell tumour
Germinoma
Markers for germ cell tumours
Alpha fetoprotein (yolk sac, teratoma)HCG (choriocarcinoma, germinoma)Placental alkaline phosphate (PLAP) (germinoma, choriocarcinoma, yolk sac)
Symptoms of pituitary tumours
Bitemporal hemianopiaHeadacheEndocrine abnormalities
Treatment of prolactinoma
Cabergoline
Treatment of GH and IGF-1 tumours
Surgery, somatostatin analogues
Main complication of cortisol-secreting tumours
Cushings
Signs of panhypopituitarism
Pale/yellow skin, skin wrinkling, absent axillary hair, puffy and expressionless face, diabetes insipidus
Treatment of bacterial meningitis (pre-culture result)
Ceftriaxone IV 2g BD (chloramphenicol if pen allergic)+ dexamethasone IV 10mg qdsIf listeria cover required add amoxicillin IV 2g 4 hourly (co-trimox if pen allergic)
When should listeria be considered in bacterial meningitis?
Age >60
Immunocompromise (inc. alcohol dependency and DM)
Causitive organisms of bacterial meningitis in neonates
Listeria, group B strep, E coli
Causitive organisms of bacterial meningitis in young children
H influenzae
Causitive organisms of bacterial meningitis in 10-21 year olds
Neisseria meningitidis
Causitive organisms of bacterial meningitis in adults over 21
Strep pneumoiae, followed by Neisseria
Causitive organisms of bacterial meningitis in over 65s
Streptococcus pneumoniae, listeria
Which type of meningitis does cribriform plate fracture predispose to?
Strep pneumoniae meningitis
Which cranial nerves are mostly vulnerable to exudate collection in bacterial meningitis?
III, VI
What type of organism is Neisseria meningitidis?
Gram-negative coccus
Which type of H influenzae is the most common cause of meningitis in under 4s?
B
What type of bacteria is H influenzae?
Gram-negative coccobaccilus
Which groups are most susceptible to Strep pneumo meningitis?
Hospitalised patientsPatients with skull fracturesDiabeticsAlcoholics Young children
What type of bacteria is listeria monocytogenes?
Gram-positive bacilli
Management of tuberculous meningitis
Isoniazid, rifampicin, pyrazinamide, ethambutol
Treatment of cryptococcal meningits
IV amphotericin C
Symptoms of encephalitis
Meningismus, stupor, coma, seizures, paralysis, confusion, psychosis, speech and memory problems.
Which form of meningitis may have normal CSF protein?
Viral
When should CT be performed before LP in suspected bacterial meningitis
Immunocompromise, history of CNS disease, new onset seizure, papilloedema, altered consciousness, focal neurologic deficit
Contact prophylaxis for bacterial meningitis
600mg rifampicin 12-hourly for 4 dosesLR500mg ciprofloxacin single dose
Stroke mimics
Seizure, sepsis, toxic/metabolic causes, SOL, syncope, delirium, vestibular dysfunction, functional disorders, dementia
Total anterior circulation stroke presentation
Hemplegia of at least 2 of face, arm, leg.Homonymous hemianopiaCortical signs such as dysphasia and neglect
Total anterior circulation stroke survival
40% alive at 1 year, only 5% independent
Partial anterior circulation syndrome presentation
Two of the three features of TACS or isolated cortical dysfunction or pure/motor sensory signs less severe than lacunar syndrome
Partial anterior circulation stroke survival
84% alive at 1 year, 55% independent
Lacunar stroke presentation
Pure motor or sensory deficits affecting two of face, arm, leg, or dysarthria, or acute onset movement disorders
Posterior stroke presentation
Cranial nerve palsies, bilateral motor and/or sensory deficits, eye movement disorders, isolated homonymous hemianopia, cortical blindness, cerebellar deficits.
Stroke in which hemisphere is more likely to affect language?
Dominant (usually left)
Stroke in which hemisphere is more likely to affect spatial awareness?
Non-dominant (usually right)
Drugs used in prevention of stroke recurrent
Perindopril plus indapamide
Most successful method of preventing stroke recurrence
Carotid endartectomy
How much CSF does a normal adult have?
~140ml
Mean CSF pressure
10mmHg/14cm
Where is CSF produced?
Chorioid plexus
Which drug can reduce CSF production?
Acetazolamide
How are streptococci arranged?
Chains
Chemical functions of CSF
Ionic homeostasis
Transport of micronutrients such as vitamin C and thyroxine
Clearing neuron waste products such as 5HIAA
Causes of spinal arachnoid webs
Idiopathic
Infection
Intracranial haemorrhage
Signs of congenital hydrocephalus
Large head, thin shiny scalp with visible veins, bulging or tense fontanelles, downward-looking eyes, poor feeding, irritability, vomiting, sleepiness
Congenital causes of paediatric hydrocephalus
Chiari malformation, spina bifida, X-linked aqueductal stenosis, Dandy-Walker complex, congenital arachnoid cysts, atresia of the foramen of Munro
Complications of shunts
Overdrainage (acute subdural, slit ventricles)Underdrainage (blockage, displacement)InfectionIntracerebral haemorrhageSeizuresCraniosynostosisUmbilical fistula
Signs of blocked shunt
Headache and vomitingSunsetting (children)Lack of upgaze (adults)
Alternative to shunt in hydrocephalus
Endoscopic 3rd ventriculostomy (high failure rate though)
What type of haemorrhage can cause xanthochromic CSF?
Subarachnoid
IQ range of moderate learning disability
35-49
Which neurotransmitter is involved in appetite and approach systems?
Dopamine
What type of visual field defect is associated with a lateral optic nerve lesion anterior to the chiasm?
Junctional scotoma
What type of visual field defect occurs in a lesion of the optic chiasm?
Bitemporal hemianopia
What type of visual field defect occurs in damage to the right optic tract?
Left homonymous hemianopia
Nominal aphasia is due to disorder of which area of the brain?
Angular gyrus
Inheritance pattern of Becker’s muscular dystrophy
X-linked recessive
Inheritance pattern of myoclonic epilepsy with ragged red fibers
Mitochondrial
Which area of the brain is affected first in Alzheimer’s?
Nucleus basalis of Meynert
Which neurotransmitter is reduced in withdrawal from sedative drugs?
GABA
Nerve root(s) for knee jerk reflex
L3/4
Nerve root(s) for ankle jerk reflex
S1 (and S2?)
Triad of symptoms in normal pressure hydrocephalus
Ataxia, memory decline, incontinence
Causes of normal pressure hydrocephalus
SAH, meningitis, trauma, craniotomy (but often idiopathic)
Gait in normal pressure hydrocephalus
Broad-based and shuffling
Treatment of normal pressure hydrocephalus
Lumboperitoneal shunts, ventriculoperitoneal shunts, or endoscopic ventriculostomy
Risk factors for IIH
Female sex, obesity, sleep apnoea, hypothyroidism, Addison’s disease, uraemia, SLE, lithium, antibiotics
Management of IIH
Weight loss, diuretics, LP, shunts
Symptoms of spontaneous intracranial hypotension
Orthostatic headache, neck/interscapular/arm pain, diplopia, dizziness, muffled hearing, impaired sphincter control, subdural haematoma
Causes of kinetic tremor
Cerebellar diseaseWilson’s disease
Treatment of essential tremor
Propranolol, anticonvulsants (primidone)
Core diagnostic criteria for essential tremor
Bilateral action tremor of hands and forearmsAbsence of other neurological signs
Which type of tremor is improved by alcohol?
Essential tremor
Which area is stimulated in DBS for essential tremor?
Ventralis intermedius nucleus
What is palilalia?
Repetition of the same phrase, word, or syllable
Diagnostic criteria for Tourette’s syndrome
Present of multiple motor tics AND one or more vocal ticsTics many times a day, nearly every day, or intermittently for over a yearOnset under 18Exclusion of secondary causes
Treatment of Tourette’s
Clonidine, tetrabenazine, CBT
Drugs that can cause secondary tic disorders
Cocaine, amphetamines, anticonvulsants
Drugs that can cause chorea
Dopamine receptor blockers, levodopa, stimulants, OCP, anticonvulsants
Gene defect in Huntington’s
Autosomal dominant CAG triplet repeat in huntingtin gene on chromosome 4 (>40 repeats pathological)
When does benign infantile myoclonus tend to occur?
During feeding or sleep
Common triggers in juvenile myoclonic epilepsy
Alcohol, sleep deprivation
Treatment of juvenile myoclonic epilepsy
Sodium valproate, levetiracetam
EEG pattern in juvenile myoclonic epilepsy
3-5Hz polyspike and wave pattern
What is classified as early dystonia?
Onset under 26 years
Mutation frequently found in young onset primary dystonia
GAG deletion in DYT1 gene on chromosome 9q
Which drug should be trialled in young onset dystonia?
Levadopa
Clinical features of cervical dystonia
Abnormal head posture, head tremor, head pain
Clinical features of oromandibular dystonia
Jaw clenching, jaw in opening position, lateral jaw shift
Clinical features of axial dystonia
Movements of shoulders, back, or abdomen
Clinical features of blepharospasm
Increased blink rate, forced eye closure, difficulty opening eyes
What is photopsia
A visual disturbance with bright flashes, streaks, or balls of light
Which type of sleep occurs early in the night?
NREM
Which type of sleep occurs later in the night?
REM
What proportion of sleep is NREM in young adults?
75%
Physiological changes in NREM sleep
Reduced HR, BP, tidal volumeNon-narrative images
EEG activity in NREM sleep
Synchronised, rhymic
EEG activity in REM sleep
Fast
Which type of sleep is important in early brain development?
REM
Which psychiatric drugs suppress REM sleep?
Tricyclics
Proportion of REM sleep in neonates
50%
Peaks of sleepiness
Midnight - 6am large peakAfternoon smaller peak
Normal circadian rhythm length
24h20m - 25h
REM parasomnias
Dreaming, simple behaviours
Non-REM parasomnias
Confusional arousals, sleep walking, sleep terrors, paralysis, bruxis, restless legs,periodic limb movements of sleep
Onset peaks in narcolepsy
Age 15 and 36
Features of narcolepsy
Daytime sleepiness, cataplexy, hypnagogic hallucinations, sleep paralysis
Investigations in narcolepsy
Overnight polysomnography (sleep study)Multiple sleep latency test
Which substance is found in CSF in abnormally low levels in narcolepsy?
Hypocretin
Histological appearance of acute neuronal injury
Red neuron after ~12-24 hours:Shrinking and angulation of nuclei, loss of nucleolus, red cytoplasm
Which embryonic tissue are glial cells derived from?
Neuroectoderm
Main cell of repair and scar formation in the CNS
Astrocyte
Appearance of gliosis
Hyperplasia and hypertroph of astrocytesEnlargement of nucleusExpansion of cytoplasmRamifying processes extend
M1 vs M2 microglia
M1 - pro-inflammatory, found in chronic injuryM2 - anti-inflammatory, phagocytic, found in acute injury
Mechanism of excitotoxicity
Energy failure (from hypoxia etc.) results in glutamate release and oxygen free radical formation, leading to calcium influx, mitochondrial dysfunction, oxidative stress, and apoptosis and necrosis
Mechanism of cytotoxic oedema
Dying cells accumulate water as Na and Cl move into the cells
Mechanism of vasogenic oedema
Disruption of tight junctions in the BBB allows plasma proteins to cross into the extracellular space and bring water with them
Areas supplied by ACA
Midline portions of frontal lobes and superior medial parietal lobes
Areas supplied by MCA
Lateral cerebral cortex, anterior temporal lobes, insula
Areas supplied by PCA
Posterior brain (occipital lobe)
Most common artery for atheroma to form
Basilar
Appearance of stroke at 12-24 hours
Macro: pale, soft, swollen. Ill-defined margin between injured and normal brainMicro: red neuron, oedema
Appearance of stroke at 2-14 days
Macro: Brain gelatinous. Reduction in surrounding tissue oedema demarcates lesionMicro: microglia become predominant cell type. Reactive gliosis occurs
Appearance of stroke after several months
Macro: increased liquification, eventual formation of cavity lined by dark grey tissueMicro: Ongoing phagocytosis, gliotic scar formation
When does neutrophil infiltration decrease after stroke?
~48 hours
How does carotid artery stroke present?
Contralateral weakness or sensory lossIf dominant hemisphere, aphasia or apraxia may be present
Presentation of middle cerebral artery lesion
Weakness predominantly contralateral face and arm
Presentation of anterior cerebral artery lesion
Weakness and sensory loss in contralateral leg
Presentation of vertebrobasilar artery disease
Vertigo, ataxia, dysarthria, dysphasia
Presentation of subarachnoid haemorrhage
Abrupt onset of severe headache, vomiting, and LOC. Meningeal signs may be present
Peak age of MS onset
20-30 years
Appearance of demyelination on MRI
Hyperintense regions on T2-weighted scans
Appearance of MS plaques
Well circumscribed, well demarcated, irregularly shaped areas with glassy appearance.
Which virus may be implicated in development of MS?
EBV
MS genetic association
HLA DRB1
Secondary causes of dementia
Vascular dementia, infection, (HIV, syphilis), trauma, metabolic causes, alcohol, B12 deficiency, paraneoplastic syndromes, SOL, and chronic hydrocephalus
Why is there increased Alzheimer’s in trisomy 21?
Amyloid precursor protein is a product of genes on chromosome 21
Which areas of the brain do not undergo atrophy in Alzheimer’s?
Occipital lobe, brainstem, cerebellum
What are neurofibrillary tangles composed of?
Insoluble microtubules,Tau
What are neuritic plaques composed of?
Dilated, tortous neuritic processes surrounding a central amyloid core
Most common familial cause of Alzheimer’
Mutation of apolipoprotein E e4 allele
What is amyloid angiopathy?
Accumulation of amyloid AB pleated sheets in the walls of arterioles
What are Lewy bodies?
Eosinophilic cytoplasmic inclusions consisting of a dense core surrounded by fibrils of alpha-synuclein and ubiquitin
Macroscopic changes in Huntington’s
Atrophy of basal ganglia, and later cortex. Expansion of lateral and third ventricles
Presentation of Pick’s disease
Progressive changes in character and social deterioration leading to impairment of intellect, memory, and language.
Factors distinguishing vascular dementia from Alzheimer’s
Abrupt onset, stepwise progression, history of HTN/stroke, stroke on imaging
What is subfalcine herniation?
Expansion of a cerebral hemisphere displaces the cingulate gyrus under the falx cerebri
What is tentorial herniation?
Medial aspect of temporal lobe herniates over tentorium cerebelli. Results in 3rd nerve palsy
What is tonsillar herniation?
Displacement of the cerebellar tonsils through the foramen magnum. Causes brainstem compression
What is transcalvarial herniation?
Swollen brain herniates through defects in dura and skull.
Most common malignant brain tumour
Astrocytoma
Most common benign brain tumour
Meningioma
How do subdural haematomas occur?
Disruption of bridging veins that extend from the surface of the brain into the subdural space
Presentation of optic neuritis
Painful visual loss over 1-2 weeks, with colour vision being lost first
Management of fatigue in MS
Amantadine, modafinil, hyperbaric oxygen
Management of acure exacerbation of MS
Mild - symptomatic
Moderate - oral steroids
Severe - admitted for IV steroids
Management of sensory symptoms in MS
Gabapentin, amitriptyline, TENS, acupuncture, lignocaine
First line disease modifying therapy for MS
Interferon beta, glitiramer acetate, tecfedira
Second line disease modifying therapy in MS
Monoclonal antibodies, fingolimod
Third line disease modifying therapy in MS
Mitoxantrone
How does fingolimod work?
Spingosine-1-phosphate (S1P) modulator
Which MS patients are monoclonal antibodies used for?
Rapidly evolving severe relapsing remittingPatients with high disease activity despite interferon treatment
Action of NSAIDs
Inhibition of cyclooxygenase and decreased prostaglandin synthesis
Action of gabapentin
Binding to presynaptic voltage-dependent Ca channels
What is pseudoathetosis?
Abnormal writhing movements, usually of the fingers, caused by a failure of proprioception
What is Charcot-Marie-Tooth also known as?
Hereditary sensory motor neuropathy
Presentation of Guillain-Barre syndrome
Progressive paraplegia occurs over days-4 weeks, with sensory symptoms preceding weakness. Peak symptoms 10-14 days after onset
Treatment of GBS
Immunoglobulin infusion, plasma exchange
Inheritance of hereditary motor sensory neuropathy type 1
Autosomal dominant
Presentation of hereditary motor sensory neuropathy
Nerve abnormalities in legs and feet - tingling, weakness, spinothalamic deficits, as well as open sores and muscle wasting. With progression, can spread to upper limb
Drugs causing axonal neuropathy
Alcohol
Amiodarone
Phenytoin
Chemo (cisplatin, vincristine)
Treatment of vasculitis-related neuropathy
IV methylprednisolone and cyclophosphamide
Presentation of cervical disc prolapse
Arm pain in dermatomal and myotomal pattern, LMN deficits
Relieving factors for spinal claudication
Rest, spine flexion
Presentation of cervical myelopathy
‘Numb clumsy hands’
What is Hoffman’s reflex test?
Loosely hold middle finger and flick it downwards, allowing finger to flick upward reflexively.Pos response - ipsilateral thumb flexion and adduction, suggests hypertonia
What is Lhermitte’s sign?
An ‘electrical’ sensation through back and into limbs, elicited by bending head forward or whacking them in the neck. Caused by posterior column deficit
Causes of SAH
Berry aneurysm, AVM, idiopathic
Gold standard investigation for SAH
Cerebral angiography
When does delayed ischaemic neurological deficit occur after SAH?
3-12 days
Treatment of delayed ischaemic neurological deficit
NimodipineTriple H therapy - induction of hypertension, hypervolaemia, and haemodilution
Presentation of central cord syndrome
Predominantly distal upper limb weakness
Cape-like spinothalamic sensory loss
Which gene defect is associated with ALS and FTD?
C9ORF hexanucleotide repeat expansions
Wasting of which muscles of the hand is common in ALS?
Thenar - known as split hand
Action of riluzole
Blocks TTX-sensitive Na channels, which are associated with damaged neurons
What drug is used in MND?
Riluzole
Which inclusions are found in most MND?
TD943
Pathways affected in MND
Ubiquitin proteasome pathwayAggregration of prion-like proteins leading to neuroinflammation
Which areas of the brain are involved in modifying nociceptive input?
PAGNucleus raphe magnusLocus coeruleus
Action of opioids:
G protein-coupled receptors signal to produce inhibition of voltage-activated Ca channels (presyn), opening of K channels (postsyn), and inhibition of adenylate cycl\se
Which opioid receptors are responsible for most of the analgesic effect?
Mu/MOP
Which opioid receptors are proconvulsant?
Delta
Which opioid receptors are associated with sedation, dysphoria, and hallucinations?
Kappa
Which opioid receptors are involved in respiratory side effects?
Mu and delta
Which opioid receptors are involved in GI side effects?
Mu and kappa
First line treatment of trigeminal neuralgia
Carbamazepine
Presentation of facial nerve UMN lesion
Paralysis of lower half of face, forehead spared
Presentation of facial nerve LMN lesions
Paralysis of half of face including forehead (Bell’s palsy)
Which structures does the anterior longitudinal ligament connect?
Anterolateral aspects of vertebral bodies and IV discs
Layers LP needle passes through
SkinFasciaSupraspinous ligamentInterspinous ligamentLigamentum flavumEpidural spaceDura
Most common locations for lumbar disc herniation
L4/5, L5/S1
Presentation of L5/S1 prolapsed disc
Pain along posterior thigh radiating to heelSometimes weakness of plantarflexionSensory loss lateral footReduced/absent ankle jerk
Presentation of L4/5 prolapsed disc
Pain posterior/posterolateral thigh radiating to dorsum and great toeWeakness of dorsiflexionParaesthesia dorsum and great toe
Presentation of L3/4 prolapsed disc
Pain anterior thighWasting quadricepsWeakness quadricecps, dorsiflexionDiminished sensation anterior thigh, knee, medial legReduced knee jerk
Which area of the brain contains the angular gyrus?
Inferior parietal lobe
Presentation of frontal lobe tumour
Contralateral weakness
Personality changes
Urinary incontinence (micturition inhibition centre)
Gaze abnormalities
Seizures
Expressive dysphasia if left Broca’s area involved
WHO classification of brain tumours
I - no morphological featuresII - atypia aloneIII - atypia and mitosisIV - atypia and mitosis with vascular proliferation or necrosis
Appearance of glioblastoma
Heterogeneously enhancing SOL, with areas of necrosis, and sometimes ‘butterfly’ appearance
Which inherited condition predisposes to optic pathway gliomas?
NF1
Which inherited condition predisposes to meningioma?
NF2
What is Foster-Kennedy syndrome?
Optic atrophy in ipsilateral eye and papilloedema in contralateral eye, can occur in meningioma in olfactory groove
Presentation of prolactinoma
Amenorrhoea, infertility, galactorrhoea, loss of libido, ED
Presentation of growth hormone secreting tumour
Gigantism (if before puberty), acromegaly (if after puberty).Diabetes, osteoarthritis, arthralgia, sleep apnoea, headaches…
Test for GH secreting tumour
Measure GH levels after oral glucose loading
Presentation of ACTH-secreting tumour
(Cushing’s disease)Central obesity, hirsutism, abdominal striae, acne, hypertension, glucose intolerance, muscle wasting, osteoporosis, puffy face
Test for ACTH-secreting tumour
Low-dose dexamethasone suppression test
Presentation of thyrotropinoma
Palpitations, weight loss, insomnia, anxiety, goiter
Most common cause of chiasmal compression in adults
Pituitary macroadenoma
Medical management of GH-secreting tumours
Pegivisomant
Somatostatin analogues such as octreotide
Which condition should be suspected in bilateral acoustic neuroma in a young person?
NF2
Which tumour are Verocay bodies found in?
Acoustic neuroma
Which condition are haemangioblastomas most commonly associated with?
Hippel-Landau syndrome
Level of carotid bifurcation
C4
Which artery runs in the Sylvian fissure?
MCA
Appearance of cavernous malformation on MRI
Focal lesion with popcorn-like appearance, surrounded by ring of hypo-intensity
Diseases associated with cerebral aneurysm
Polycystic kidney diseaseFibromuscular dysplaseEDS 4
Most common aneurysm locations in circle of Willis
Junction of ACA and ACommAJunction of PCommA with ICA
Which cranial nerve can be compressed by a posterior communicating artery aneurysm?
III
Which cranial nerve can be compressed by a anterior communicating artery aneurysm?
Optic (chiasm)
Components of ABCD2 score for stroke risk in TIA
Age (>60 1 point)BP (>140/90 1 point)Clinical features (speech - 1 limb weakness - 2)Duration (min) (10-59 - 1pt >59 - 2pts)Diabetes (Yes - 1 pt)
Which cranial nerves originate in the pons?
5, 6, 7, 8
Which nerves are involved in the pupillary light reflex?
Afferent - opticEfferent - oculomotor
What is neuromyelitis optica (Devic’s disease)?
Demyelinating disorder characterised by bilateral severe optic neuritis and transverse myelitis in three or more vertebral columns. IgG antibodies against AQP4
What is anterior ischaemic optic neuropathy?
Optic neuritis occuring due to damage to the optic nerve as the result of ischaemia, common in elderly.
Which drug can be used to confirm Horner’s syndrome?
Topical apraclonidine (alpha-1 receptor agonist) - Horner’s pupil will dilate, normal won’t.
Presentation of lateral medullary syndrome (Wallenberg’s syndrome)
Vertigo, vomiting, nystagus, Horner’s, spinothalamic loss, dysphagia, hoarseness
What is Adie’s pupil?
Anisocoria (large affected pupil) and blurring on near vision due to slow accomodation, absent light reflex.Due to loss of postganglionic sympathetic innervation to iris sphincter and ciliary muscle e.g. damage to ciliary ganglion
What is Holmes-Adie syndrome?
Adie’s pupil + diminished/absent lower limb reflexes
Which drug can be used to confirm Adie’s pupil
Low dose topical pilocarpine - Adie’s pupil constricts, normal doesn’t.
What is Argyll Robertson pupil
Bilateral, irregular, small pupils, unreactive to light but with normal accomodation.Caused by neurosyphilis, diabetes
Visual lesion caused by pituitary adenoma
Bilateral superior quadrantanopia progressing to bitemporal hemianopia
Visual lesion resulting from craniopharyngioma
Bilateral inferior quadrantanopia progessing to bitemporal hemianopia
Visual defect caused by tuberculum sellae meningioma
Junctional scotoma
What is Weber’s syndrome
Stroke affecting ventral midbrain, characterised by ipsilateral third nerve palsy with contralateral hemiparesis
What is Benedikt’s syndrome?
Stroke affecting dorsal midbrain, characterised by ipsilateral third nerve palsy with contralateral tremor, ataxia, or chorea
Presentation of IV nerve palsy
Vertical diplopia (worse looking down)
Hypertropia
Limited depression of eye
Compensatory head tilt
Presentation of VI nerve palsy
Horizontal diplopia
Esotropia
Limited abduction
In which condition does ptosis improve after application of ice?
Myasthenia gravis
Features of NF1
Neurofibromas, cafe au lait spots, axillary freckling, optic nerve glioma, plexiform neurofibromas of eyelid
Management of benign essential blepharospasm
Artificial tearsBotox
Features of cavernous sinus syndrome
Ptosis and opthalmoplegia, loss of corneal reflex, maxillary sensory loss, Horner’s, periorbital swelling
Decorticate posturing
Abnormal flexion of arms, hands clenched into fists, legs extended and feet turned inward
Decerebrate posturing
Head arches back, both arms and legs extended
Most common cause of congenital hydrocephalus
Aqueductal stenosis
Chiari I vs Chiari II
Caudal displacement of cerebellar tonsils below the foramen magnum in both, but II, which is more severe, has herniation of the 4th ventricle
What drug is used to reverse benzos?
Flumazenil
Which neurotransmitter is increased in schizophrenia?
Dopamine
What is the action of ADH?
Increases blood volume by increasing water permeability in the collecting ducts
Which anti-epileptics alter efficacy of COCP?
Carbamazepine, oxcarbazepine, phenobarbitol, phenytoin, primidone, topiramate(by inducing hepatic enzymes)
Which structure separates the scala vestibuli from the scala media?
Reissner’s membrane
Which structure separates the scala tympani from the scala media?
Basilar membrane
Which two cavities of the cochlea are continuous?
Scala tympani and scala vestibuli
Which cavity of the cochlea connects to the oval window?
Scala tympani
Which cavity of the cochlea connects to the round window?
Scala vestibuli
Which type of hair cell mainly provides afferent signals to the auditory nerve?
Inner
Which hair cells have a motor protein composed of prestin which changes the length of the cell?
Outer
What is the effect of furosemide in the inner ear?
Inactivates the membrane motor in outer hair cells so the cell cannot change length
Which part of the brain generates an interaural time difference for determining the location of sound?
Medial superior olive
Which part of the brain receives excitatory input from the ipsilateral anteroventral cochlear nucleus and inhibitory input from the contralateral?
Lateral superior olive
Which structures of the vestibular system detect angular acceleration (e.g. rotation) of the head?
Semicircular canals
Which structures of the vestibular system detect linear acceleration of the head?
Saccule and utricle
Which structures of the vestibular system detect acceleration and gravity
Saccule and utricle
Which otolith organ detects movement in the vertical plane?
Saccule
Which otolith organ detects movement in the horizontal plane?
Utricle
Why does vertigo occur when drunk?
The cupula becomes less dense than the surrounding endolymph and bends further from the ground, causing hair cells to bend as if you were rotating
What are the triggers of ADH release?
Increased osmotic pressure detected by hypothalamusHypovolaemia detected by atrial baroreceptorsAngiotensin II
Which type of neurons have their cell body in the PNS?
Unipolar
