Neurology Flashcards

Question

WHAT IS TEMPORAL ARTERITIS?

Answer 1

Giant cell arteritis is an inflammation of the lining of your arteries. Most often, it affects the arteries in your head, especially those in your temples. For this reason, giant cell arteritis is sometimes called temporal arteritis.

Answer 2

1. With giant cell arteritis, the lining of arteries becomes inflamed, causing them to swell. 2. This swelling narrows your blood vessels, reducing the amount of blood — and, therefore, oxygen and vital nutrients — that reaches your body's tissues 1. Polymyalgia rheumatica

Answer 3

1. Persistent, severe head pain, usually in your temple area + jaw pain when you chew or open your mouth wide 2. Scalp tenderness 3. Fever 4. Fatigue 5. Unintended weight loss 6. Vision loss or double vision, particularly in people who also have jaw pain 7. Sudden, permanent loss of vision in one eye

Answer 4

1. Blindness 2. Aortic aneurysm 3. Stoke

Answer 5

1. **Blood tests** * ESR * CRP 2. **Imaging** * Doppler ultrasound 3. **Biopsy** * Skip Lesions + Giant cells 4. **CK and EMG -** Normal

Answer 6

1. **High dose corticosteroid** * Prednisolone 2. May prescribe vitamin D supplements to help prevent bone loss

Answer 7

A stroke occurs when the blood supply to part of your brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. Brain cells begin to die in minutes.

Answer 8

Ischaemic stroke Haemorrhagic stroke

Answer 9

1. Motor weakness 2. Speech problems (dysphasia) 3. Swallowing problems 4. Visual field defects (homonymous hemianopia) 5. Balance problems

Answer 10

**Confirm diagnosis** 1. Non-contast CT is first line 2. Hyperdense sign in an artery **Estalish the site of pathology** 1. Carotid ultrasound 2. Echocardiogram 3. Cerebral angiogram **Identify factors which may influence management** 1. Chest X-ray - cardiac enlargement 2. Blood glucose - hyperglycaemia 3. Full Blood Count - polycythaemia, thrombocytopenia

Answer 11

Duplex ultrasound

Answer 12

**Ischaemic stroke** 1. Alteplase/tissue plasminogen factor within 4.5 hours 2. Once haemorrhagic stroke has been excluded give aspirin 300mg 3. Endovascular procedures - Thombectomy within 6 hours, an extended time of 6-24 hours may be considefed if CT shows salvagable tissue 4. **Thrombolysis and thrombectomy if under 4.5 hours** **Haemorrhagic stroke** 1. Blood thinners 2. Surgical clipping 3. Coiling

Answer 13

1. Clopidogrel 75mg - FIRST LINE 2. Aspirin + dipyridamole for patinet who cannot tolerate clopidogrel

Answer 14

Pontine haemorrhage is a life-threatening condition. It often occurs as a complication secondary to chronic hypertension

Answer 15

1. Reduced Glasgow coma score 2. Quadriplegia 3. Miosis 4. Absent horizontal eye movements

Answer 16

Posterior inferior cerebellar artery

Answer 17

A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.

Answer 18

A transient ischemic attack has the same origins as that of an ischemic stroke, the most common type of stroke. In an ischemic stroke, a clot blocks the blood supply to part of your brain. In a transient ischemic attack, unlike a stroke, the blockage is brief, and there is no permanent damage.

Answer 19

1. Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body 2. Slurred or garbled speech or difficulty understanding others 3. Blindness in one or both eyes or double vision 4. Vertigo or loss of balance or coordination

Answer 20

1. **Brain Imaging** * **CT brain** should not be done 'unless there is clinical suspicion of an alternative diagnosis that CT could detect' * **MRI** is preferred to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies 2. **Carotid imaging** * Atherosclerosis in the carotid artery may be a source of emboli in some patients * **All patients** should therefore have an **urgent carotid doppler** unless they are not a candidate for carotid endarterectomy

Answer 21

**Immediate antithrombotic therapy:** * Give aspirin 300 mg - this is for 2 weeks **Continued antithrombotic therapy after the event:** * Clopidogrel is recommended first-line * Aspirin + dipyridamole given to patients who cannot tolerate clopidogrel

Answer 22

Give aspirin 300 mg immediately, unless 1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage) 2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist 3. Aspirin is contraindicated: discuss management urgently with the specialist team

Answer 23

1. **If the patient has had more than 1 TIA ('crescendo TIA') or has a suspected cardioembolic source or severe carotid stenosis:** * Discuss the need for admission or observation urgently with a stroke specialist 2. **If the patient has had a suspected TIA in the last 7 days:** * Arrange urgent assessment (within 24 hours) by a specialist stroke physician 3. **If the patient has had a suspected TIA which occurred more than a week previously:** * Refer for specialist assessment as soon as possible within 7 days 1. Advise the person not to drive until they have been seen by a specialist.

Answer 24

Needs urgent CT head

Answer 25

Hypoglycaemia in diabetes

Answer 26

1. Stroke or TIA: **1 month** off driving, may not need to inform DVLA if no residual neurological deficit 2. Multiple TIAs over short period of times: 3 months off driving and inform DVLA

Answer 27

**Midline lesions** Can produce severe gait and truncal ataxia. As they extend they can also give fourth cranial nerve lesions and severe ipsilateral arm tremor, marked nystagmus **Cerebellar hemisphere** Lesions can produce classic ipsilateral limb ataxia (intention tremor, past pointing and mild hypotonia).

Answer 28

1. **Vascular** * ****Stroke 2. **Space-occupying lesion** 3. **Nutritional** * ****Thiamine * Vitamin E deficiency 4. **Infection** 5. **Truama**

Answer 29

**DANISH** Dysdiadochokinesia Ataxia (gait and posture) Nystagmus. Intention tremor Scanning dysarthria Heel-shin test positivity

Answer 30

Blood tests - FBC, LFTs, cholesterol, protein electrophoresis, copper and caeruloplasmin, immunoglobulins and glycoproteins. Electroencephalogram (EEG). Electromyogram (EMG). Imaging - MRI is the modality of choice.

Answer 31

Treat underlying condition

Answer 32

Epilepsy is a central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness.

Answer 33

**Focal seizures** **Generalised seizures**

Answer 34

From one part of the brain **Focal seizures without loss of consciousness** Alter emotions or change the way things look, smell, feel, taste or sound. They may also result in involuntary jerking of a body part, such as an arm or leg, **Focal seizures with impaired awareness** Stare into space, repetative movements

Answer 35

**Motor** * *Non-motor** (e. g. déjà vu, jamais vu; ) **Features such as aura** | (e.g. Jacksonian march)

Answer 36

It characteristically starts by affecting a peripheral body part such as a toe, finger or section of the lip and then spreads quickly 'marches' over the respective foot, hand or face. In some with Jacksonian march seizures (as in this case), the electrical disorder spreads over larger areas of the brain, causing the seizure to develop into a tonic-clonic seizure.

Answer 37

**Absence seizures** Previously known as petit mal seizures. Staring into space or subtle body movements such as eye blinking or lip smacking **Tonic seizures** Tonic seizures cause stiffening of your muscles **Atonic seizures** Loss of muscle control, which may cause you to suddenly collapse or fall down. **Clonic seizures** Jerking muscle movements **Myoclonic seizures** Brief jerks or twitches of your arms and legs. **Tonic-clonic seizures** Grand mal seizures

Answer 38

1. **Genetic influence** 2. **Head trauma** 3. **Brain conditions** * Stroke 4. **Infectious diseases** * Meningitis, AIDS and viral encepthalitis 5. **Prenatal injury** 6. **Developmental disorders** * Autism

Answer 39

1. ECG 1st line 2. MRI 3. FBC, U+Es and glucose 4. Brain imaging and EEG but **CLINICAL DIAGNOSIS**

Answer 40

1. **Generalised tonic-clonic seizures** * Sodium valproate * Second line: lamotrigine, carbamazepine 2. **Focal seizures** * Carbamazepine or lamotrigine * Second line: levetiracetam, oxcarbazepine or sodium valproate 3. **Absence seizures\* (Petit mal)** * Sodium valproate or ethosuximide 4. **Myoclonic seizures** * Sodium valproate * Second line: clonazepam, lamotrigine

Answer 41

1. Hallucinations (auditory/gustatory/olfactory) 2. Epigastric rising/Emotional 3. **Automatisms (lip smacking/grabbing of clothes/plucking)** 4. Deja vu/Dysphasia post-ictal)

Answer 42

1. Head/leg movements 2. Posturing 3. Post-ictal weakness 4. Jacksonian march

Answer 43

Paraesthesia

Answer 44

Floaters/flashes

Answer 45

1. Absences last a few seconds and are associated with a quick recovery 2. Seizures may be provoked by **hyperventilation or stress** 3. The child is usually unaware of the seizure 4. They may occur many times a day 5. EEG: bilateral, symmetrical 3Hz spike and wave pattern

Answer 46

Sodium valproate Ethosuximide

Answer 47

Prolactin levels

Answer 48

Weakness of limbs after seizure

Answer 49

Vasovagal shorter post-ictal

Answer 50

1. Pelvic thrusting 2. Family member with epilepsy 3. Much more common in females 4. Crying after seizure 5. Don't occur when alone 6. Gradual onset

Answer 51

1. A heart condition that causes fainting 2. Diabetes or other metabolic disorders 3. Emotional pain 4. Mental pain 5. Being bullied 6. Physical or sexual abuse 7. A major accident

Answer 52

1. **EEG** A patient with NES will not show unusual electrical activity in the brain on the EEG. 2. **MRI + CT** Epilepsy 3. **Blood tests** Diabetes

Answer 53

**First unprovoked/isolated seizure** 1. **6 months off** if there are **no relevant structural abnormalities** on brain imaging and no definite epileptiform activity on EEG. 2. If these conditions are not met then this is increased to **12 months** **For patients with established epilepsy or those with multiple unprovoked seizures:** 1. → may qualify for a driving licence if they have been free from any seizure for **12 months** 2. → if there have been no seizures for **5 years (with medication if necessary) a ’til 70 licence is usually restored** 3. withdrawawl of epilepsy medication: should not drive whilst anti-epilepsy medication is being withdrawn and for **6 months** after the last dose

Answer 54

Suddenly causes a person to fall asleep at inappropriate times

Answer 55

Sudden loss of muscle tone typically triggered by emotion such as laughing or crying

Answer 56

Narcolepsy that occurs with cataplexy is called type 1 narcolepsy. Narcolepsy that occurs without cataplexy is known as type 2 narcolepsy.

Answer 57

1. Associated with **HLA-DR2** 2. Associated with low levels of **orexin (hypocretin)**, a protein which is responsible for controlling appetite and sleep patterns

Answer 58

1. Typical onset in teenage years 2. Hypersomnolence 3. Cataplexy (sudden loss of muscle tone often triggered by emotion) 4. **Sleep paralysis** 5. **Vivid hallucinations on going to sleep or waking up**

Answer 59

Multiple sleep latency EEG

Answer 60

**Stimulants** 1. Modafinil 2. Armodafinil **Improves nighttime sleep** 1. Sodium oxybate

Answer 61

It is not a single disease but a group of syndromes of cognitive impairment Caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease.

Answer 62

**Stroke (infarction) blocking a brain artery** With both silent and apparent strokes, the risk of vascular dementia increases with the number of strokes that occur over time. One type of vascular dementia involving many strokes is called multi-infarct dementia. **Narrowed or chronically damaged brain blood vessels**. These conditions include the wear and tear associated with aging, high blood pressure, abnormal aging of blood vessels (atherosclerosis), diabetes, and brain hemorrhage.

Answer 63

1. Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms 2. The difficulty with attention and concentration 3. Seizures 4. Memory disturbance 5. Gait disturbance 6. Speech disturbance 7. Emotional disturbance

Answer 64

1. A comprehensive history and physical examination 2. Formal screen for cognitive impairment 3. Medical review to exclude medication cause of cognitive decline 4. MRI scan – may show infarcts and extensive white matter changes

Answer 65

1. Often involves managing the risk factors 2. Lower blood pressure 3. Reduce your cholesterol levels 4. Prevent your blood from clotting 5. Help control your blood sugar

Answer 66

Horner's syndrome is a triad of features resulting from interruption of the sympathetic pathway from the hypothalamus to the orbit

Answer 67

1. Miosis (small pupil) 2. Ptosis 3. Enophthalmos\* (sunken eye) 4. Anhidrosis (loss of sweating one side)

Answer 68

1. A normal pupil is dilated by **cocaine and hydroxyamphetamine** 2. When the lesion is pre-ganglionic only **hydroxyamphetamine** causes dilatation 3. When the lesion is post-ganglionic only **adrenaline** causes dilatation

Answer 69

Treat underlying condition

Answer 70

Bell's palsy may be defined as an acute, unilateral, idiopathic, ## Footnote **Facial nerve paralysis** **7th Nerve**

Answer 71

1. **Weakness** to total paralysis on one side of your face — occurring within hours to days 2. **Lower motor neuron** facial nerve palsy - **forehead affected**\* 3. Post-auricular **pain** (may precede paralysis) 4. Altered taste 5. Dry eyes 6. Hyperacusis

Answer 72

Latent herpes viruses (herpes simplex virus type 1 and herpes zoster virus), which are reactivated from cranial nerve ganglia

Answer 73

Abnormal regrowth of nerve fibers. This may result in involuntary contraction of certain muscles when you're trying to move others (synkinesis) For example, when you smile, the eye on the affected side may close.

Answer 74

Diagnosis of exclusion

Answer 75

**Corticosteroids** Prednisolone **Antiviral drugs** Acyclovir **Articifical tears**

Answer 76

Bulbar palsy refers to a range of different signs and symptoms linked to impairment of function of the cranial nerves IX - 9 Glossopharyngeal X - 10 Vagus XI - 11 Accessory XII - 12 Hypoglossal

Answer 77

Lower motor neuron lesion in the medulla oblongata or from lesions of the lower cranial nerves outside the brainstem * **Vascular causes**: medullary infarction * **Degenerative diseases**: amyotrophic lateral sclerosis * **Inflammatory/infective**: Guillain–Barré syndrome, poliomyelitis * **Malignancy**: brain-stem glioma, malignant meningitis * **Toxic**: botulism * **Autoimmune**: myasthenia gravis

Answer 78

1. Dysphagia (difficulty in swallowing) 2. Difficulty in chewing 3. Nasal regurgitation 4. Slurring of speech 5. Difficulty in handling secretions

Answer 79

EMA - electromagnetic articulography EPG - electropalatography

Answer 80

Treat the underlying cause Baclofen for spasticity Anticholinergics for drooling

Answer 81

Shingles is an infection that causes a painful rash

Answer 82

Shingles is caused by the varicella-zoster virus — the same virus that causes chickenpox

Answer 83

* Pain, burning, numbness or tingling * Sensitivity to touch * A red rash that begins a few days after the pain * Stripe of blisters that wraps around either the left or right side of your torso. * Sometimes occurs around one eye or on one side of the neck or face * Fluid-filled blisters that break open and crust over * Itching

Answer 84

History of pain on one side of your body Along with the telltale rash and blisters

Answer 85

Acyclovir (Zovirax) Famciclovir Valacyclovir (Valtrex)

Answer 86

Lack of vitamin B-1 (thiamine)

Answer 87

1. Inability to afford medical care and proper food 2. Kidney dialysis, which reduces vitamin B-1 absorption 3. AIDS, which makes you more likely to develop conditions that lead to vitamin B-1 deficiency

Answer 88

* **ALCOHOL** * **Gastric bypass surgery**, which makes it difficult to meet nutritional needs due to limited food portions * **Gastric cancer**, which may limit the absorption of essential nutrients * **Colon cancer**, which can result in pain that causes you to put off eating * **Eating disorders**

Answer 89

1. Ophthalmoplegia/nystagmus 2. Ataxia 3. Confusion

Answer 90

1. Nystagmus (the most common ocular sign) 2. Ophthalmoplegia 3. Ataxia 4. Confusion, altered GCS 5. Pripheral sensory neuropathy

Answer 91

1. Decreased red cell transketolase 2. MRI

Answer 92

1. Thiamine (IV vitamin B-1) 2. Treatment for alcoholism

Answer 93

**Develop Korsafkoff syndrome** 1. Addition of antero- and retrograde amnnesia 2. Confabulation

Answer 94

Huntington's chorea is a hereditary disease that is marked by chronic, progressive chorea and marked mental deterioration in middle life, usually in the fourth decade.

Answer 95

Autosomal dominant disorder CAG repeats

Answer 96

1. **Movement disorders** * Involuntary jerking or writhing movements (chorea) * Muscle problems, such as rigidity or muscle contracture (dystonia) 2. **Cognitive disorder** * Difficulty organizing, prioritizing or focusing on tasks * Lack of impulse control that can result in outbursts, acting without thinking and sexual promiscuity 3. **Psychiatric disorders** * Feelings of irritability, sadness or apathy * Social withdrawal

Answer 97

**Neurological examination** Motor symptoms, such as reflexes, muscle strength and balance Sensory symptoms, including sense of touch, vision and hearing Psychiatric symptoms, such as mood and mental status ## Footnote **Brain imaging** **Genetic testing**

Answer 98

**Control movement** 1. Tetrabenazine 2. Deutetrabenazine **Antipsychotic drugs** 1. Haloperidol 2. Fluphenazine **Antidepressants** 1. Citalopram **Psychotherapy**

Answer 99

Parkinson's disease is a condition in which parts of the brain become progressively damaged over many years

Answer 100

Lack of dopamine Exact cause is unknown Due to genetic factors and environmental triggers

Answer 101

1. **Tremor** * unilateral tremor that improves with voluntary movement 2. Bradykinesia 3. Rigid muscles 4. Impaired posture and balance 5. Loss of automatic movements 6. Speech changes 7. Writing changes

Answer 102

1. Mainly clinical 2. Can do a SPECT scan

Answer 103

1. Progressive supranuclear palsy 2. Multiple system atrophy 3. Drug-induced e.g. **antipsychotics, metoclopramide**\* 4. Wilson's disease

Answer 104

1. If symptoms are affecting quality of life then levodopa first 2. If not affecting quality of life then dopamine agonist or MOA **Medications** 1. **Dopamine agonists** * Ropinirole, cabergoline, pramipexole - Associated with inhibition 2. **MAO B inhibitors** * ****Selegiline, rasagiline Prevent the breakdown of dopamine 3. **Catechol O-methyltransferase (COMT) inhibitors** * ****Entacapone Blocks an enzyme that breaks down dopamine 4. **Carbidopa-levodopa** **Deep brain stimulation**

Answer 105

1. Dopamine agonist therapy 2. A history of previous impulsive behaviours 3. A history of alcohol consumption and/or smoking

Answer 106

Haloperidol

Answer 107

Ropinirole

Answer 108

Most common cause of dementia Causes the brain cells to degenerate and die

Answer 109

Exact cause is unknown Brain proterins fail to function properly, disrupt brain neurons and unleash a series of toxic events

Answer 110

**Plaques** Beta-amyloid is a leftover fragment of a larger protein. When these fragments cluster together, they appear to have a toxic effect on neurons and to disrupt cell-to-cell communication. These clusters form larger deposits called amyloid plaques, which also include other cellular debris. **Tangles** Tau proteins play a part in a neuron's internal support and transport system to carry nutrients and other essential materials. In Alzheimer's disease, tau proteins change shape and organize themselves into structures called neurofibrillary tangles. The tangles disrupt the transport system and are toxic to cells

Answer 111

1. **Memory** * ****Early sign of the disease, difficulty remembering recent events 2. **Thinking and reasoning** 3. **Making judgements and decisions** 4. **Planning and performing familiar tasks** 5. **Changes in personality and behaviour** 6. **Preserved skills** * ****Reading or listening to books

Answer 112

**Age** **Family history and genetics** Apolipoprotein E gene (APOE) **Down syndrome** Three copies of chromosome 21, appear 10 to 20 years earlier **Woman** Live longer than men

Answer 113

1. **Brain imaging -** MRI/CT * **Widespread cerebral atrophy, particulary the coretex and hippocampus** * Cortical plaques due to depositiuon of type A-beta-amyloid protein and intraneuronal neurofibriallry tau tangles 2. ******Lab tests** * ****Thyroid disorders or vitamin deficiencies * Deficit of acetylcholine from damage to ascending forebrain projection 3. **PET**

Answer 114

**Treat cognitive symptoms** * Cholinesterase inhibitors - preserve acetylcholine * *Donepezil, galantamine, rivastigmine** * N-methyl-d-aspartate (NMDA) inhibitor - glutamate * *Memantine** **Safe environment** **Alternative medicine** * Omega-3 fatty acids * Curcumin

Answer 115

Frontotemporal lobar degeneration (FTLD) is the third most common type of cortical dementia after Alzheimer's and Lewy body dementia

Answer 116

1. Frontotemporal dementia (Pick's disease) 2. Progressive non fluent aphasia (chronic progressive aphasia, CPA) 3. Semantic dementia

Answer 117

1. Onset before 65 2. Insidious onset 3. Relatively preserved memory and visuospatial skills 4. Personality change and social conduct problems

Answer 118

1. Personality change and impaired social conduct. Other common features include 1. Hyperorality 2. Disinhibition 3. Uncreased appetite 4. Perseveration behaviours

Answer 119

1. **Focal gyral atrophy with a knife-blade appearance is characteristic of Pick's disease.** 2. **Macroscopic changes seen in Pick's disease include:-** * Atrophy of the frontal and temporal lobes 3. **Microscopic changes include:-** * Pick bodies - spherical aggregations of tau protein (silver-staining) * Gliosis * Neurofibrillary tangles * Senile plaques

Answer 120

1. NICE do not recommend that AChE inhibitors or memantine are used in people with frontotemporal dementia

Answer 121

Excess cerebrospinal fluid accumulates in the ventricles Called "normal pressure" because despite the excess fluid, CSF pressure as measured during a spinal tap is often normal.

Answer 122

Tumor, head injury, hemorrhage, infection or inflammation In most cases, the cause of the fluid buildup remains unknown

Answer 123

1. Difficulty walking 2. Mild dementia 3. Decline in thinking skills 4. Loss of bladder control

Answer 124

**Brain imaging** Enlargement of the ventricles **Lumbar puncture** CSF normal or intermittently raised

Answer 125

Ventriculoperitoneal shunting

Answer 126

Hydrocephalus is the buildup of fluid in the cavities (ventricles) deep within the brain

Answer 127

Hydrocephalus is caused by an imbalance between how much cerebrospinal fluid is produced and how much is absorbed into the bloodstream ## Footnote **Obstruction** **Poor absorption** **Overproduction**

Answer 128

**Patients with hydrocephalus present with symptoms due to raised intracranial pressure, which include:** 1. Headache (typically worse in the morning, when lying down and during valsalva) 2. Nausea and vomiting 3. Papilloedema 4. Coma (in severe cases)

Answer 129

1. **CT head** - first line 2. **MRI** * May be used to investigate hydrocephalus in more detail 3. **Lumbar puncture**\* * Is both diagnostic and therapeutic since it allows you to sample CSF, measure the opening pressure, but also to drain CSF to reduce the pressure

Answer 130

1. An **external ventricular drain (EVD)** is used in acute, severe hydrocephalus and is typically inserted into the right lateral ventricle and drains into a bag at the bedside 2. A v**entriculoperitoneal shunt (VPS)** is a long-term CSF diversion technique that drains CSF from the ventricles to the peritoneum 3. In **obstructive hydrocephalus**, the treatment may involve surgically treating the obstructing pathology

Answer 131

* Lung (most common) * Breast * Bowel * Skin (namely melanoma) * Kidney

Answer 132

Glioblastoma multiforme

Answer 133

Dexamethosone

Answer 134

Pilocytic astrocytoma

Answer 135

Inflammatory, demyelinating disease. Specific to the central nervous system. Has relapsing and remitting symtptoms.

Answer 136

1. **Vit D deficiency** 2. **Genetics** * Female * HLA DR2 3. **Environment** * Infections

Answer 137

1. Optic neuritis (impaired vision and eye pain) 2. Nystagmus, double vision and vertigo 3. Bladder and sexual dysfunction 4. Spasticity and other pyramidal signs 5. Sensory symptoms and signs * Reduced visual acuity after exercise = **Uhthoff's phenomenon** * **Lhermitte's sign** (electric shock-like sensation that occurs on flexion of the neck.)

Answer 138

1. **CONTRAST MRI** * High signal T2 lesions * Periventricular plaques * Dawson fingers 2. **CSF** * Oligoclonal bands (and not in serum) * Increased intrathecal synthesis of IgG 3. **Visual evoked potentials** * Delayed, but well preserved waveform

Answer 139

Two or more CNS lesions disseminated in time and space Exclusion of conditions giving a similar clinical picture

Answer 140

1. **Treatment to modify progression** * Primary-progressive - ocrelizumab 2. **For MS attacks** * Oral or IV Methylpredisolone for 5 days * Plasmapheresis

Answer 141

Guillain-Barre syndrome describes an immune-mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni).

Answer 142

1. The exact cause of Guillain-Barre syndrome isn't known. 2. The disorder usually appears days or weeks after a **respiratory** or **digestive tract infection** 3. **Classically Campylobacter jejuni**

Answer 143

Progressive, symmetrical weakness of all the limbs 1. The weakness is classically **ascending** i.e. the legs are affected first 2. Reflexes are reduced or absent 3. Sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs

Answer 144

1. **Lumbar puncture** * Rise in protein with a normal white blood cell count (albuminocytologic dissociation) - found in 66% 2. **Nerve condution studies may be performed** * Decreased motor nerve conduction velocity (due to demyelination) * Prolonged distal motor latency * Increased F wave latency

Answer 145

1. Plasma exchange 2. Immunoglobulin therapy

Answer 146

Motor neurone disease (MND) is a neurodegenerative condition that affects the brain and spinal cord. MND is characterised by the degeneration of primarily motor neurones, leading to muscle weakness.

Answer 147

Clues which point towards motor neuron disease: 1. Fasciculations 2. The absence of sensory signs/symptoms\* 3. The mixture of lower motor neuron and upper motor neuron signs 4. Wasting of the small hand muscles/tibialis anterior is common Other features 1. **Doesn't affect external ocular muscles** 2. No cerebellar signs 3. Abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature

Answer 148

**Nerve conduction studies** Normal motor conduction and can help exclude a neuropathy. **Electromyography** Reduced number of action potentials with increased amplitude. **MRI** Exclude the differential diagnosis of cervical cord compression and myelopathy

Answer 149

**Riluzole** Prevents stimulation of glutamate receptors Used mainly in amyotrophic lateral sclerosis Prolongs life by about 3 months **Respiratory care** Non-invasive ventilation (usually BIPAP) is used at night Studies have shown a survival benefit of around 7 months

Answer 150

1. Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction e.g. dysphasia

Answer 151

**Involves middle and anterior cerebral arteries** 1. Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction e.g. dysphasia

Answer 152

Involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery 1. Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction e.g. dysphasia 2 of the above criteria are present

Answer 153

Involves perforating arteries around the internal capsule, thalamus and basal ganglia

Answer 154

**Presents with 1 of the following:** 1. Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three 2. Pure sensory stroke 3. Ataxic hemiparesis

Answer 155

Involves vertebrobasilar arteries

Answer 156

**Presents with 1 of the following:** 1. **SIGHT** - Isolated homonymous hemianopia 2. **MOVEMENT** - Cerebellar or brainstem syndromes 3. Loss of **consciousness**

Answer 157

1. **Ipsilateral:** * Ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's 2. **Contralateral:** * Limb sensory loss

Answer 158

1. Ipsilateral III palsy (closed eyelid and eye outward and down) 2. Contralateral weakness

Answer 159

Genetic condition that causes mainly non-cancerous (benign) tumours to develop in different parts of the body.

Answer 160

Autosomal dominant

Answer 161

**Wood's light** Ultraviolet used to reveal hypopigmented patches on skin **CT or MRI** Detect tubers and calcification **Echocardiography** If any cardiac rhabdomyomas are suspected

Answer 162

**Cutaneous features** 1. Depigmented '**ash-leaf' spots** which fluoresce under UV light 2. Roughened skin over lumbar spine (Shagreen patches) 3. Adenoma sebaceum (angiofibromas): butterfly distribution over nose 4. Fibromata beneath nails (subungual fibromata) 5. Café-au-lait spots\* may be seen **Neurological features** 1. Developmental delay 2. Epilepsy (infantile spasms or partial) 3. Intellectual impairment Retinal hamartomas: dense white areas on retina (phakomata)

Answer 163

**Medications** Anti-seizure **Surgery** Remove organs

Answer 164

Sleep paralysis is when you cannot move or speak as you are waking up or falling asleep. It can be scary but it's harmless and most people will only get it once or twice in their life

Answer 165

**Paralysis** This occurs after waking up or shortly before falling asleep **Hallucinations** Images or speaking that appear during the paralysis

Answer 166

1. Insomnia 2. Disrupted sleeping patterns – for example, because of shift work or jet lag 3. Narcolepsy – a long-term condition that causes a person to suddenly fall asleep 4. General anxiety disorder 5. Panic disorder

Answer 167

Clonazepam

Answer 168

1. The third cranial nerve controls the movement of **four** of the **six** eye muscles. 2. These muscles **move** the eye **inward, up and down**, and they control **torsion** (rotating the eye downward and toward the ear on the same side) 3. The third cranial nerve also controls **constriction** of the **pupil,** the position of the upper eyelid, and the ability of the eye to focus

Answer 169

1. Diabetes mellitus 2. Vasculitis e.g. temporal arteritis, SLE 3. Posterior communicating artery aneurysm 4. Cavernous sinus thrombosis 5. **Weber's syndrome**: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes

Answer 170

Eye is deviated 'down and out' Ptosis Pupil may be dilated (sometimes called a 'surgical' third nerve palsy)

Answer 171

Palsy results in defective downward gaze → vertical diplopia

Answer 172

Palsy results in defective abduction → horizontal diplopia

Answer 173

Relief of pressure on the third nerve from a tumor or blood vessel (aneurysm) with surgery may improve the third nerve palsy.

Answer 174

Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 85-90% of cases

Answer 175

1. Antibodies that attack acetylcholine receptors 2. Thymus gland maintains the production of these

Answer 176

1. Progressive weakness with movement 2. **Extraocular muscle weakness** * ****Diplopia 3. **Proximal muscle weakness** * Face, neck, limb girdle 4. **Ptosis** 5. **Dysphagia**

Answer 177

1. Thymomas in 15% 2. Thymic hyperplasia in 50-70% 3. Autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE

Answer 178

1. **Single fibre electromyography** * High sensitivity (92-100%) 2. **CT thorax to exclude thymoma** 3. **CK normal** 4. **Autoantibodies - DIAGNOSIS** * 85-90% of patients antibodies to acetylcholine receptors. In the remaining patients, 40% positive for anti-muscle-specific tyrosine kinase antibodies 5. **Tensilon test** * IV edrophonium reduces muscle weakness temporarily - not commonly used anymore due to the risk of cardiac arrhythmia

Answer 179

1. Penicillamine 2. Quinidine, procainamide 3. Beta-blockers 4. Lithium 5. Phenytoin 6. Antibiotics: gentamicin, macrolides, quinolones, tetracyclines

Answer 180

1. **Long-acting acetylcholinesterase inhibitors** * Pyridostigmine is first-line 2. **Immunosuppression** * Prednisolone initially * Azathioprine, cyclosporine, mycophenolate mofetil may also be used 3. **Thymectomy**

Answer 181

Myasthenic crisis is a life-threatening complication of myasthenia gravis. It’s when the muscles that you use to breathe get so weak that you can’t get air in and out of your lungs.

Answer 182

1. Non-compliance with medication 2. Excessive activity 3. Infection 4. Drugs Penicillamine Beta-blockers Lithium Phenytoin **Antibiotics:** gentamicin, macrolides, quinolones, tetracyclines

Answer 183

Laboured shallow breathing

Answer 184

1. Plasmapheresis 2. IVIg

Answer 185

Lambert-Eaton myasthenic syndrome is seen in association with small cell lung cancerand to a lesser extent breast and ovarian cancer. It may also occur independently as an autoimmune disorder. Lambert-Eaton myasthenic syndrome is caused by an antibody directed against presynaptic voltage-gated calcium channel in the peripheral nervous system.

Answer 186

1. repeated muscle contractions lead to increased muscle strength (in contrast to myasthenia gravis) 2. in reality, this is seen in only 50% of patients and following prolonged muscle use muscle strength will eventually decrease 3. limb-girdle weakness (affects lower limbs first) 4. hyporeflexia 5. autonomic symptoms: dry mouth, impotence, difficulty micturating 6. ophthalmoplegia and ptosis not commonly a feature (unlike in myasthenia gravis)

Answer 187

incremental response to repetitive electrical stimulation

Answer 188

1. Treatment of underlying cancer 2. Immunosuppression, for example with prednisolone and/or azathioprine 3. 3,4-diaminopyridine is currently being trialled * Works by blocking potassium channel efflux in the nerve terminal so that the action potential duration is increased. Calcium channels can then be open for a longer time and allow greater acetylcholine release to the stimulate muscle at the end plate 4. Intravenous immunoglobulin therapy and plasma exchange may be beneficial

Answer 189

Optic chiasm

Answer 190

A congruous defect is complete or symmetrical visual field loss Incongruous defect is incomplete or asymmetric

Answer 191

Upper quadrant defect \> lower quadrant defect = Inferior chiasmal compression, commonly a **pituitary tumour** Lower quadrant defect \> upper quadrant defect = Superior chiasmal compression, commonly a **craniopharyngioma**

Answer 192

1. Incongruous defects: lesion of optic tract 2. congruous defects: lesion of optic radiation or occipital cortex 3. macula sparing: lesion of occipital cortex

Answer 193

Superior: lesion of temporal lobe Inferior: lesion of parietal lobe mnemonic = PITS (Parietal-Inferior, Temporal-Superior)

Answer 194

A myotome is a group of muscles innervated by the ventral root a single spinal nerve

Answer 195

1. Simple faint: no restriction 2. Single episode, explained and treated: 4 weeks off 3. Single episode, unexplained: 6 months off 4. Two or more episodes: 12 months off

Answer 196

1. A single seizure lasting \>5 minutes, or 2. \>= 2 seizures within a 5-minute period without the person returning to normal between them

Answer 197

1. RULE OUT HYPOXIA AND GLUCOSE FIRST 2. Stroke 3. Imbalance of substances in the blood, such as low blood sugar 4. Drinking too much alcohol or having alcohol withdrawal after previous heavy alcohol use

Answer 198

1. Muscle spasms 2. Falling 3. Confusion 4. Unusual noises 5. Loss of bowel or bladder control 6. Clenched teeth 7. Irregular breathing 8. Unusual behavior 9. Difficulty speaking 10. A "daydreaming" look

Answer 199

EEG Spinal Tap

Answer 200

1. **ABC** * ****Oxygen * Check Blood Glucose 2. **PR Benzodiazepams Prehospital - IV if in hospital** * PR Diazepam or * IV lorazepam (can be repeated once after 10-20 minutes) 3. **If prolonged** * ****Phenytoin * General anaesthetic

Answer 201

Pain syndrome characterised by severe unilateral pain

Answer 202

1. Sensory changes 2. Deafness or other ear problems 3. History of skin or oral lesions that could spread perineurally 4. Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally 5. Optic neuritis 6. A family history of multiple sclerosis 7. Age of onset before 40 years

Answer 203

The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems may occur.

Answer 204

1. Type 2. Pain 3. **Triggers** * Eating, talking or even encountering a cool breeze.

Answer 205

1. **Carbamazepine** is first-line 2. failure to respond to treatment or atypical features (e.g. \< 50 years old) should prompt referral to neurology

Answer 206

Neurofibromatosis is a genetic disorder that causes tumors to form on nerve tissue

Answer 207

**NF1 and NF2** Autosomal dominant **NF1** is also known as von Recklinghausen's syndrome. Chromosome 17 **NF2** Chromosome 22

Answer 208

**NF1** 1. Café-au-lait spots 2. Axillary/groin freckles 3. Peripheral neurofibromas 4. Iris hamatomas (Lisch nodules)in \> 90% 5. Scoliosis 6. Pheochromocytomas **NF2** 1. Bilateral vestibular schwannomas 2. Multiple intracranial schwannomas, mengiomas and ependymomas

Answer 209

1. \>6 cafe au lait spots 2. Eye exam 3. Hearing and balance exam 4. Imaging 5. Genetic testing

Answer 210

1. Monitor 2. Surgery to remove tumours 3. Stereotactic surgery 4. Cochlear implants

Answer 211

1. Vertigo 2. Hearing loss 3. Tinnitus 4. Absent corneal reflex

Answer 212

1. **Gadolinium-enhanced MRI of the cerebellopontine angle** is the investigation of choice. 2. Audiometry is also important as only 5% of patients will have a normal audiogram.

Answer 213

D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear 'Drunk' A - Ataxia (limb, truncal) N - Nystamus (horizontal = ipsilateral hemisphere) I - Intention tremour S - Slurred staccato speech, Scanning dysarthria H - Hypotonia

Answer 214

1. Friedreich's ataxia, ataxic telangiectasia 2. Neoplastic: cerebellar haemangioma 3. Stroke 4. Alcohol 5. Multiple sclerosis 6. Hypothyroidism 7. Drugs: phenytoin, lead poisoning 8. Paraneoplastic e.g. secondary to lung cancer

Answer 215

A result of damage to the nerves outside of the brain and spinal cord (peripheral nerves)

Answer 216

* Guillain-Barre syndrome * Diphtheria * Lead poisoning * Hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth * Porphyria * Chronic inflammatory demyelinating polyneuropathy (CIDP)

Answer 217

1. Diabetes 2. Vitamin B12 deficiency 3. Alcoholism 4. Amyloidosis 5. Leprosy

Answer 218

Inflammation of the meningies lining the brain

Answer 219

1. Sudden high fever 2. Stiff neck 3. Severe headache that seems different from normal 4. Headache with nausea or vomiting 5. Confusion or difficulty concentrating 6. Seizures 7. Sleepiness or difficulty waking 8. Sensitivity to light 9. No appetite or thirst 10. Skin rash (sometimes, such as in meningococcal meningitis)

Answer 220

**0 - 3 months** * Group B Streptococcus (most common cause in neonates) * E. coli * Listeria monocytogenes **3 months - 6 years** * Neisseria meningitidis * Streptococcus pneumoniae * Haemophilus influenzae **6 years - 60 years** * Neisseria meningitidis * Streptococcus pneumoniae

Answer 221

1. Herpes simplex virus 2. HIV 3. Mumps virus

Answer 222

Cryptococcal meningitis India ink

Answer 223

1. **Sensorineural hearing loss (most common)** 2. Seizures 3. Focal neurological deficit 4. Infective * Sepsis * Intracerebral abscess 5. pressure * Brain herniation * Hydrocephalus

Answer 224

1. Full blood count 2. CRP 3. Coagulation screen 4. Blood culture 5. Whole-blood PCR 6. Blood glucose 7. Blood gas 8. Lumbar puncture if no signs of raised intracranial pressure

Answer 225

1. **IM Benzylpenicillin** at GP 2. **Antibiotics** \< 3 months: IV amoxicillin + IV cefotaxime \> 3 months: IV cefotaxime 3. **Steroids** Dexamethasone 4. **Give contacts some prophylaxis** Ciprofloxacin Rifampicin

Answer 226

Describe the level of consciousness in a person following a traumatic brain injury

Answer 227

Rifampicin OR Ciprofloxacin within 7 days of contact

Answer 228

**M**otor response - 6 **V**erbal reponse - 5 **E**ye opening response - 4

Answer 229

6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Flexion 2. Extension 1. None

Answer 230

5 - Orientated 4 - Confused 3 - Words 2. - Sounds 1 - None

Answer 231

* 4 - Spontaneous * 3 - To speech * 2 - To pain * 1 - None

Answer 232

Test used in an exam of neurological function for balance, and also as a test for driving under the influence of an intoxican

Answer 233

Patient clenches the teeth, flexes both sets of fingers into a hook-like form, and interlocks those sets of fingers together. The tendon below the patient's knee is then hit with a reflex hammer to elicit the patellar reflex.

Answer 234

1. Involuntary flexion movement of the thumb and or index finger when the examiner flicks the fingernail of the middle finger down 2. A positive Hoffmann's sign is suggestive of **corticospinal tract dysfunction** localized to the **cervical segments of the spinal cord** 3. In this regard, it is analogous to the Babinski sign.

Answer 235

The purpose of the test is to distinguish between leg paresis that is psychogenic from that which is genuine.

Answer 236

An extradural (or ‘epidural’) haematoma is a collection of blood that is between the skull and the dura

Answer 237

It is almost always caused by trauma and most typically by ‘low-impact’ trauma (e.g. a blow to the head or a fall).

Answer 238

Middle meningeal artery

Answer 239

1. ‘Lucid interval’ 2. This is lost eventually due to the expanding haematoma and brain herniation. 3. As the haematoma expands the uncus of the temporal lobe herniates around the tentorium cerebelli and the patient develops a fixed and dilated pupil due to the compression of the parasympathetic fibers of the third cranial nerve.

Answer 240

Biconvex (or lentiform), hyperdense collection around the surface of the brain. They are limited by the suture lines of the skull.

Answer 241

Craniotomy and evacuation of the haematoma

Answer 242

A subdural haematoma is a collection of blood deep to the dural layer of the meninges. The blood is not within the substance of the brain and is therefore called an ‘extra-axial’ or ‘extrinsic’ lesion. They can be unilateral or bilateral.

Answer 243

1. CT imaging is the first-line investigation and will show a crescentic collection, not limited by suture lines. 2. They will appear hyperdense (bright) in comparison to the brain. 3. Large acute subdural haematomas will push on the brain (‘mass effect’) and cause midline shift or herniation.

Answer 244

Small or incidental acute subdurals can be observed conservatively. Surgical options include monitoring of intracranial pressure and decompressive craniectomy.

Answer 245

Rupture of the **small bridging veins** within the subdural space rupture and cause slow bleeding. **Elderly and alcoholic** patients are particularly at risk of subdural haematomas since they have brain atrophy and therefore fragile or taut bridging veins. **Infant**s also have fragile bridging veins and can rupture in shaken baby syndrome.

Answer 246

On CT imaging they similarly are crescentic in shape, not restricted by suture lines and compress the brain (‘mass effect’). In contrast to acute subdurals, chronic subdurals are hypodense (dark) compared to the substance of the brain.

Answer 247

1. Conservative OR 1. If the patient is confused, has an associated neurological deficit or has severe imaging findings then **surgical decompression** with **burr holes** is required.

Answer 248

The ability to grasp the meaning of spoken words and sentences is impaired, while the ease of producing connected speech is not very affected. herefore Wernicke's aphasia is also referred to as 'fluent aphasia' or 'receptive aphasia'. Comprehension is impaired

Answer 249

Superior temporal gyrus It is typically supplied by the inferior division of the l**eft middle cerebral artery**

Answer 250

Partial loss of the ability to produce language (spoken, manual, or written) A person with expressive aphasia will exhibit effortful speech. Comprehension is normal

Answer 251

Due to a lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA

Answer 252

Speech fluent, repetition poor

Answer 253

P450 inhibitor 1. Gastrointestinal: nausea 2. Increased appetite and weight gain 3. Alopecia: regrowth may be curly 4. Ataxia 5. Tremor 6. Hepatotoxicity 7. Pancreatitis 8. Thrombocytopaenia 9. Teratogenic 10. Hyponatraemia

Answer 254

1. Amitriptyline 2. Duloxetine 3. Gabapentin 4. Pregabalin if the first-line drug treatment does not work try one of the other 3 drugs 1. Tramadol Rescue therapy

Answer 255

* **Dyskinesia** * **'on-off' effect** * **Postural hypotension** * Cardiac arrhythmias * Nausea & vomiting * Psychosis * Reddish discolouration of urine upon standing

Answer 256

Effective in the initial differentiation of acute stroke from stroke mimics.

Answer 257

1. Compromised immunity 2. Age under 20 years and a history of malignancy 3. A history of malignancy known to metastasis to the brain 4. Vomiting without other obvious cause 5. Worsening headache with fever 6. Sudden-onset headache reaching maximum intensity within 5 minutes - 'thunderclap' 7. New-onset cognitive dysfunction 8. Change in personality 9. Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise 10. Orthostatic headache (headache that changes with posture)

Answer 258

1. **Ischaemic heart disease** 2. **Cerebrovascular disease** * E.g Stroke, aneurysm

Answer 259

Pseuodtumour cerebri describes raised intracranial pressure in the absence of a mass lesion or of hydrocephalus

Answer 260

1. Fat 2. Famle 3. Forty 4. Pregnancy Drugs\*: oral contraceptive pill, steroids, tetracycline, vitamin A, lithium

Answer 261

1. Headache 2. Blurred vision 3. Papilloedema (usually present) 4. Enlarged blind spot 5. Sixth nerve palsy may be present

Answer 262

1. **Weight loss** 2. **Diuretics** * e.g. acetazolamide 3. **Topiramate** (anti-convulsant) is also used, and has the added benefit of causing weight loss in most patients 4. **Repeated lumbar puncture** 5. **Surgery** * ****Optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. * A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure

Answer 263

1. Fever, headache, psychiatric symptoms, seizures, vomiting 2. Focal features e.g. aphasia 3. Peripheral lesions (e.g. cold sores) have no relation to presence of HSV encephalitis

Answer 264

HSV-1 responsible for 95% of cases in adults Typically affects temporal and inferior frontal lobes

Answer 265

1. **CSF** * Lymphocytosis, elevated protein * PCR for HSV 2. **CT** * Medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients * LOW DENSITY 3. **Note - MRI is better** 4. **EEG pattern** * Lateralised periodic discharges at 2 Hz

Answer 266

IV aciclovir

Answer 267

Protamine sulphate

Answer 268

A squint is a condition in which the visual axes of each eye are not directed simultaneously at the same object.

Answer 269

1. Facial appearance 2. Corneal reflections - symmetrical on pupil 3. Head tilt 4. Test ocular movements 5. Cover test

Answer 270

1. Referral to secondary care 2. Eye patches can be useful to prevent ambylopia

Answer 271

Disorder of movement and posture due to a non-progressive lesion of the motor pathways in the developing brain

Answer 272

1. Antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV) 2. Intrapartum (10%): birth asphyxia/trauma 3. Postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma

Answer 273

1. Spastic (70%): hemiplegia, diplegia or quadriplegia 2. Dyskinetic 3. Ataxic 4. Mixed

Answer 274

1. Abnormal tone early infancy 2. Delayed motor milestones 3. Abnormal gait 4. Feeding difficultie.

Answer 275

1. Learning difficulties (60%) 2. Epilepsy (30%) 3. Squints (30%) 4. Hearing impairment (20%)

Answer 276

1. MDT appraoch 2. Spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy 3. Anticonvulsants, analgesia as required

Answer 277

Compression of nerve roots Spinal damage distal to L1

Answer 278

1. Surgical decompression by full laminectomy

Answer 279

In cauda equina you get 1. Saddle anaesthesia 2. Bladder dysfunction 3. Sexual dysfunction 4. Decreased anal tone Sciatica is just 1. Back pain

Answer 280

Foot drop Numbness Saddle anesthesia Bladder and Bowel incontinence

Answer 281

1. URGENT MRI - Within 6 hours

Answer 282

1. Myelopathy= CORD gives UMN 1. Oseophytes 2. Disc prolapse (slower onset) 3. Tumour (slow onset) 1. Surgical decompression

Answer 283

**Radiculopathy** 1. NERVE ROOT gives LMN **Caused by:** 1. Disc prolapse 2. Osetoarthrits **Treatment:** 1. Conservative

Answer 284

Pain in the distribution of the sciatic nerve, ie felt in the thigh and, MOST IMPORTANTLY, below the knee A pain that is not felt below the knee is not sciatica

Answer 285

1. Conservative treatment for 6-8 weeks. Keep active Provide - paracetamol, NSAIDs, codiene, morphine 2. Steroid injections If pain doesn't improve after 6-8 weeks then you should refer to MSK 1. Surgery Laminectomy Discetomy

Answer 286

1. MRI 2. Check for red flags e. g. malignancy, fractures, cauda equina syndrome 3. **Pain on straight leg raise**

Answer 287

1. Disc herniation: Common sites of herniation are L4-L5 and L5-S1 2. Malignancy 3. Infection 4. Vascular compression

Answer 288

**Personal factors including:** Age (peak 45-64 years) Increasing risk with height Smoking Psychological stress **Occupational factors include:** Strenuous physical activity - for example, frequent lifting, especially while bending and twisting Driving Vibration of the whole body

Answer 289

Nucelus pulposus surrounded by annulus fibrosis Herniates out and compresses spine

Answer 290

Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.

Answer 291

1. Back pain, buttocks, thighs or legs 2. Cramping of burning feeling 3. Problems with balance 4. Sensory loss 5. Muscle weakness

Answer 292

1. Laminectomy

Answer 293

Disease of a single peripheral or cranial nerve is called a mononeuropathy. It may be associated with systemic illnesses such as diabetes mellitus, sarcoidosis, rheumatoid arthritis or polyarteritis nodosa. The most common cause worldwide is leprosy.

Answer 294

1. Humerus fracture 2. Carpal tunnel syndrome

Answer 295

1. Paralysis of thenar muscles, oppenens pollicis 2. Loss of sensation in the palmar aspect of lateral 3 1/2 fingers

Answer 296

Motor + sensory: prolongation of the action potential

Answer 297

1. Corticosteroid injection 2. Wrist splints at night 3. Surgical decompression (flexor retinaculum division)

Answer 298

1. Crutch palsy' - due to compression of the nerve above the spiral groove by crutches as the weight is borne in the axilla 2. Saturday night palsy' - due to compression of the nerve in the upper part of the arm as a result of resting the medial side of the arm against a sharp edge such as the back of a chair for a prolonged period. The person is usually intoxicated. It may also be seen after surgery when the anaesthetised patient is allowed to hang over the edge of the operating theatre table. 3. **Humeral fracture of the shaft** 4. Rarely, dislocation of the elbow

Answer 299

1. Weakness of forearm extension and flexion - triceps and brachioradialis 2. Wrist drop and finger drop - paralysis of the extensors of the wrist and digits 3. Weakness of the long thumb abductor and extensor muscles 4. Sensory loss on the dorsum of hand and forearm appropriate to the cutaneous distribution - see radial nerve anatomy

Answer 300

1. Splint in extensor position 2. Should heal within 4 to 8 months

Answer 301

1. Elbow behind the medial epicondyle

Answer 302

1. Wasting and weakness of the small muscles of the hand and partial clawing of the ring and little finger 2. Hypothenar eminence 3. Weakness of thumb adduction and abduction 4. Loss of sensation of the little and ring finger

Answer 303

1. Avoidance of full elbow flexion 2. Decompression of nerve

Answer 304

1. Dislocation of shoulder 2. Break of humerus

Answer 305

1. Loss of sensation over a small area of skin on the lateral aspect of upper arm 2. Loss of function of the deltoid muscle, inability to initate abduction of the arm from a position of zero abduction.

Answer 306

1. Splinting in a position of abduction at the shoulder

Answer 307

1. Acute trauma - direct blows and laceration 2. External pressure - Nerve compression, sitting cross-legged

Answer 308

1. Foot drop 2. Weakness of dorsiflexion of the foot

Answer 309

1. Should self resolve if a result of compression

Answer 310

1. Often occurs during sport after a blow to the ribs 2. Mastectomy

Answer 311

1. Winging of the scapula

Answer 312

1. Usually nothing, self resolving

Answer 313

Spinal cord compression is characterised by a combination of a progressive history of neurological deficit and a sensory level on examination.

Answer 314

1. Trauma 2. Congenital bone anomalies 3. Disc prolapse 4. Neoplasia 5. Abscess

Answer 315

Depends on: 1. Site of lesion - intramedullary lesions produce within spinal segmental damage only; others produce cord both root and segmental damage 2. Extent of lesion - partial, e.g. Brown Sequard, or complete 3. Level of lesion - roots only damaged below L1 4. Speed of onset - rapidly progressive lesions usually produce permanent deficits 5. 'Spinal shock' - upper motor neurone disease - but with a flaccid paralysis, loss of reflexes, absent plantar reflexes

Answer 316

1. FBC, U&E, kidney function, LFTs 2. Chest x-ray 3. Spinal x-ray 4. **MRI - investigation of choice**

Answer 317

1. Analgesia 2. Bispohphonates 3. Radiotherapy 4. Vertebroplasty 5. **Corticosteroids - particularly in neoplastic spinal cord compression**

Answer 318

Rupture of the arteries forming the circle of Willis Often because of ‘Berry aneurysms’

Answer 319

1. Trauma 2. Berry aneurysm 3. Arteriovenous (AV) malformations 4. Idiopathic

Answer 320

**Symptoms** 1. Sudden onset severe headache (‘Thunderclap headache’) 2. Meningism 3. Photophobia 4. Reduced consciousness 5. Vomiting 6. Collapse **Sign** 1. **Kernig's sign** 2. Terson syndrome (retinal, subhyaloid and vitreous bleeds) 3. 3rd oculomotor palsy (posterior communicating artery) 4. **Sentinel headache**

Answer 321

1. **CT** * Spider sign 2. **LP** * CSF bloody early * Becomes xanthochromic (yellow), breakdown of haem to bilibrubin * Normal or raised opening pressure 3. **Angio** * To determine location

Answer 322

1. Neurosurgery!!!! 2. **Nimodipine (recued vasospasm)** 3. **If anneurysm deteced either coil or clipping**

Answer 323

1. Hyponatraemia 2. Urea and electrolytes

Answer 324

1. Idiopathic intracranial hypertension 2. Traumatic head injuries 3. Infection * meningitis 4. Tumours 5. Hydrocephalus

Answer 325

1. Headache 2. Vomiting 3. Reduced levels of consciousness 4. Papilloedema 5. **Cushing's triad** * Widening pulse pressure * Bradycardia * Irregular breathing

Answer 326

1. **Neuroimaging (CT/MRI)** * Effacement of the cerebral ventricles and loss of grey-white matter differentiation 2. **Invasive ICP monitoring** * Catheter placed into the lateral ventricles of the brain to monitor the pressure * May also be used to take collect CSF samples and also to drain small amounts of CSF to reduce the pressure * A cut-off of \> 20 mmHg is often used to determine if further treatment is needed to reduce the ICP

Answer 327

1. Investigate and treat the underlying cause 2. **head elevation to 30º** 3. **IV mannitol** may be used as an osmotic diuretic 4. **Controlled hyperventilation** * aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP * leads to rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain 5. **Removal of CSF**, different techniques include: * drain from intraventricular monitor (see above) * repeated lumbar puncture (e.g. idiopathic intracranial hypertension) * **ventriculoperitoneal shunt** (for hydrocephalus)

Answer 328

1. Drug overdose 2. Metabolic causes 3. Acute central nervous system infection 4. Acute systemic infection 5. Cerebral vascular causes 6. Cerebral pressure causes 7. A variety of other causes, of which the principal is head injury

Answer 329

Brainstem death is the point at which the brain has ceased to be capable of maintaining life. It is a concept which has developed from the advent of improved intensive care facilities and better resuscitation techniques.

Answer 330

1. Ensure certain pre-conditions - relating to the patient and to the staff involved 2. Perform the diagnostic tests - two sets, usually within 24 hours depending upon the primary pathology and the course of the disease 3. Record results - by hand and in the notes to avoid possible tampering

Answer 331

In cortical brain death, the cortex is destroyed. Often the brainstem is still intact, e.g. persistent vegative state, i.e. the patient can survive indefinitely if sufficient nutrition

Answer 332

For this condition to be diagnosed there must be a demonstration of no perfusion of the cortex via cerebral angiography. It is not sufficient to just show no EEG activity.

Answer 333

Brain abscess is a focal collection of pus within the brain parenchyma. Abscesses can develop as a result of:

Answer 334

1. **Haematogenous spread** * Usually, from a primary site in the heart, lung or distal bones - for example: * Subacute bacterial endocarditis - usually causing multiple abscesses 2. **Direct implantation of organisms** * Usually, trauma, neurosurgery 3. **Local extension from adjacent foci** * Suppurative otitis media } mainly to temporal lobe 4. **Mastoiditis** } less to cerebellum 5. **Impaired immunity / diabetes**

Answer 335

1. Headache - dull 2. Fever 3. Focal neurology - oculomotor nerve palsy or abducens nerve palsy

Answer 336

1. **Surgery** * A craniotomy is performed and the abscess cavity debrided * The abscess may reform because the head is closed following abscess drainage. 2. IV antibiotics: IV 3rd-generation cephalosporin + metronidazole 3. Intracranial pressure management: e.g. dexamethasone

Answer 337

Myopathies are diseases of muscle. Like neuropathies, myopathies are characterised by: 1. Muscle weakness 2. Muscle atrophy 3. The pattern of muscle weakness seen in myopathies is usually proximal and symmetrical - this compares with a distal, or nerve or root distribution seen in neuropathies. 4. Tone normal or reduced 5. Reflexes normal or reduced Sensory loss is not seen in myopathies.

Answer 338

1. Proximal muscle weakness Also contibute by hypokalaemia 1. Minimise corticosteroid excess

Answer 339

Inherited myopathy with features developing at around 20-30 years old. It affects skeletal, cardiac and smooth muscle

Answer 340

Autosomal dominant

Answer 341

1. Myotonic facies (long, 'haggard' appearance) 2. Frontal balding 3. Bilateral ptosis 4. Cataracts 5. Dysarthria

Answer 342

1. Cardiac arrhythmias 2. Abnormalities of glucose/insulin metabolism 3. Reproductive dysfunction

Answer 343

1. Slightly raised CPK enzyme levels 2. Conduction abnormalities on ECG 3. **Characteristic myopathic EMG, with so-called dive bomber noise** 4. Cataracts may be seen by slit lamp examination 5. If urinary glucose is positive, it is followed by glucose tolerance test to confirm diabetes

Answer 344

1. **Membrane stabilisers** to reduce myotonia, including procainamide, **phenytoin**, quinine, quinidine, acetazolamide 2. Identification and treatment of cataracts and diabetes mellitus 3. Genetic counselling 4. Avoiding sedative drugs as sensitivity is increased

Answer 345

1. Myalgia 2. Myositis 3. Rhabdomyolysis 4. Asymptomatic raised creatine kinase

Answer 346

Duchenne muscular dystrophy is a common and possibly the best known muscular dystrophy. It follows an aggressive and progressive course.

Answer 347

1. Progressive proximal muscle weakness from 5 years 2. **Calf pseudohypertrophy** 3. **Gower's sign**: child uses arms to stand up from a squatted position 4. Associated with **dilated cardiomyopathy** 5. 30% of patients have i**ntellectual impairment**

Answer 348

1. CK 30 to 200 times higher than normal

Answer 349

**Largely supportive** 1. Mobility aids 2. Steroids 3. ACEI

Answer 350

1. Weakness - the extensors are weaker than the flexors in the arms, but the reverse is true in the legs 2. Muscle wasting is absent or slight - muscle wasting is prominent in a lower motor neurone lesion 3. Hyper-reflexia and clonus - reflexes are absent or reduced in a lower motor neurone lesion 4. Spasticity 5. **No fasciculations - fasciculations occur in a lower motor neurone lesion** 6. Extensor plantar responses

Answer 351

1. Weakness of the muscles innervated 2. Prominent muscle wasting - slight or absent in upper motor neurone disease 3. Absent or reduced reflexes - there are increased reflexes in upper motor neurone disease 4. Hypotonicity 5. Fasciculations - absent in upper motor neurone disease 6. Flexor or absent plantar responses

Answer 352

Sensation to the face **Three branches** 1. Opthalmic 2. Maxillary 3. Mandibular

Answer 353

Essential tremor (previously called benign essential tremor) is an autosomal dominant condition which usually affects both upper limbs

Answer 354

1. postural tremor: worse if arms outstretched 2. improved by alcohol and rest 3. most common cause of titubation (head tremor)

Answer 355

1. propranolol is first-line 2. primidone is sometimes used

Answer 356

1. Damage to C5,6 roots 2. Winged scapula 3. May be caused by a breech presentation

Answer 357

1. Damage to T1 2. Loss of intrinsic hand muscles 3. Due to traction

Answer 358

1. Beta-2 transferrin 2. If not available glucose

Answer 359

T6 Faecal impaction or urinary retention

Answer 360

1. Caffeine 2. Fluids

Answer 361

After a lumbar puncture

Answer 362

1. uncontrollable urge to move legs (akathisia). Symptoms initially occur at night but as condition progresses may occur during the day. Symptoms are worse at rest 2. paraesthesias e.g. 'crawling' or 'throbbing' sensations 3. movements during sleep may be noted by the partner - periodic limb movements of sleeps (PLMS)

Answer 363

1. there is a positive family history in 50% of patients with idiopathic RLS 2. iron deficiency anaemia 3. uraemia 4. diabetes mellitus 5. pregnancy

Answer 364

1. simple measures: walking, stretching, massaging affected limbs 2. treat any iron deficiency 3. dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole) 4. benzodiazepines 5. gabapentin

Answer 365

Creutzfeldt-Jakob disease (CJD) is rapidly progressive neurological condition caused by prion proteins. These proteins induce the formation of amyloid folds resulting in tightly packed beta-pleated sheets resistant to proteases.

Answer 366

1. Dementia (rapid onset) 2. Myoclonus

Answer 367

1. CSF is usually normal 2. EEG: biphasic, high amplitude sharp waves (only in sporadic CJD) 3. MRI: hyperintense signals in the basal ganglia and thalamus

Answer 368

Charcot-Marie-Tooth disease is a hereditary sensory and motor peripheral neuropathy. UMN signs are not present in these patients. Patients can present with lower motor neurone signs in all limbs and reduced sensation (more pronounced distally).

Answer 369

'Locked-in' syndrome

Answer 370

1. due to vitamin B12 deficiency 2. dorsal columns + lateral corticospinal tracts are affected 3. joint position and vibration sense lost first then distal paraesthesia 4. upper motor neuron signs typically develop in the legs, classically extensor plantars, brisk knee reflexes, absent ankle jerks 5. if untreated stiffness and weakness persist

Answer 371

1. GCS \< 13 on initial assessment 2. GCS \< 15 at 2 hours post-injury 3. suspected open or depressed skull fracture. 4. any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). 5. post-traumatic seizure. 6. focal neurological deficit. 7. more than 1 episode of vomiting

Answer 372

1. age 65 years or older 2. any history of bleeding or clotting disorders 3. dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) 4. more than 30 minutes' retrograde amnesia of events immediately before the head injury 5. If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.