Neurology

Question 1

Subdural haematoma 1. Type of bleed 2. At-risk cohorts (2) 3. Symptoms 4. Signs 5. Imaging - type + finding 6. Management - medical 7. Management - surgical (+ indication) Extradural/epidural haematoma 8. Type of bleed 9. Symptoms 10. Signs 11. CT - findings 12. Management

Answer 1

1. Venous (bridging veins) 2. Elderly / alcoholics 3. Fluctuating consciousness, physical/intellectual slowing, sleepiness, headache, personality change, unsteadiness 4. Raised ICP, seizures, localising neurological symptoms (late) 5. CT; *crescent*-shaped clot over 1 hemisphere, crosses suture lines, hyperdense (bright), midline shift if large 6. Reverse clotting abnormalities 7. Clot evacuation if clot >10mm or shift >5mm 8. Arterial (commonest is middle meningeal) 9. Post-head injury lucid interval, then reduced GCS, increasingly severe headache, vomiting, 10. Raised ICP, spastic hemiparesis 11. Biconvex (lentiform) bleed, limited by suture lines, ventricular swelling, soft tissues swelling outside skull 12. Urgent clot excavation + vessel ligation

Question 2

Kernig’s sign 1. What it is 2. Signifies

Answer 2

1. Thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful 2. Meningitis, SAH

Question 3

Liehthem’s disease 1. What is it 2. Causes (2)

Answer 3

1. Degeneration of the posterior and lateral columns of the spinal cord 2. Deficiency (B12/copper)

Question 4

Anatomy - cord columns 1. Posterior (dorsal) column - function, decussate where 2. Anterior (spinothalamic) column - function, decussate where 3. Lateral column - fibres for what

Answer 4

1. Vibration, light touch, proprioception (brainstem) 2. Pain, temperature (at level of spinal cord) 3. Motor

Question 5

Brown-Sequard lesion 1. What is it 2. Presentation

Answer 5

1. Unilateral lesion of the whole spinal cord 2. Ipsilateral UMN signs in the leg and loss of joint position/vibration, contralateral loss of pain and temp

Question 6

Headache - descriptions 1. Tension 2. Trigeminal Neuralgia 3. Meningitis 4. Subarachnoid haemorrhage 5. Sinusitis 6. Migraine 7. Cluster 8. Raised ICP 9. Acute glaucoma 10. Temporal arteritis 11. Red flags

Answer 6

1. Tight ‘band’, brought on by stress 2. Brief, stabbing pain when brushing teeth/chewing 3. Photophobia, neck stiffness, fever 4. Sudden onset, ‘thunderclap’, excruciating pain 5. Facial tenderness, rhinorrhea 6. Unilateral, pounding, multiple triggers, hours, photophobia, phonophobia, preceding ‘aura’ 7. 20 minutes, unilateral, debilitating, retro-orbital, red/watering eye (give O2 + sublingual/nasal triptan) 8. Triggered changes in position/exertion, vision changes when leaning forward, progressive 9. Pain around eye, blurred vision, halos around lights 10. Tender scalp (thickened pulseless temporal arteries), >50, unilateral, jaw claudication 11. Sudden and intense, fever, rash, new neuro/cognitive decline, seizure, personality change, reduced GCS, head trauma within 3 months, triggered by cough / sneeze / exercise / posture, associated halos around lights/worse in dark, jaw claudication/tender scalp

Question 7

Subarachnoid haemorrhage (SAH) 1. Symptoms 2. Signs 3. Investigation - 1st line 4. LP - indication 5. LP - when 6. LP - findings 7. Management - optimum BP 8. Management - medical 9. Management - surgical 10. Potential complications (4) 11. Particular associations (2) 12. Spontaneous SAH - cause + examples 13. Imaging for this once SAH confirmed

Answer 7

1. Sudden onset, ‘thunderclap’, excruciating pain 2. Neck stiffness, Kernig’s sign, retinal/vitreous bleed 3. CT without contrast 4. If CT negative but symptoms suggestive 5. > 12 hours post-headache onset 6. Raised RBC, xanthochromia (increased bilirubin and oxyhaemoglobin - so yellow) 7. Systolic BP <160mmHg 8. Nimodipine (Ca2+ agonist) 3 weeks (less vasospasm and cerebral ischaemia) 9. Surgery: endovascular coiling/surgical clipping 10. Rebleeding, ischaemia, hydrocephalus (arachnoid granulations blocked), hyponatremia (but don’t restrict fluid) 11. Cocaine, sickle cell disease 12. Berry aneurysm (adult PKD, ED syndrome, coarctation of aorta) 13. CT / cerebral angiogram

Question 8

Collapse - suggestive symptoms 1. Hypertrophic Cardiomyopathy/Cardiogenic Syncope 2. Postural/Orthostatic Hypotension 3. Arrhythmia/Cardiogenic Syncope 4. Aortic Stenosis 5. Vasovagal Syncope 6. Carotid Sinus Hypersensitivity 7. Hypoglycaemia 8. Stokes-Adams attacks

Answer 8

1. Vigorous exercise in young person 2. Triggered by suddenly standing up 3. Palpitations, chest pain before, FH of SUD 4. Chest pain, breathlessness, collapse on exertion 5. Fear, pain, micturition, standing, pale/nauseous/sweaty before, no confusion afterwards 6. When shaving/turning head 7. Diabetic, tremor, hunger, perspiration 8. Transient arrhythmias, palpitations as warning, pale and weak pulses, then flushes + wakes up (seconds)

Question 9

Seizure - suggestive symptoms 1. Absence 2. Vasovagal 3. Generalised tonic clonic 4. Early morning myoclonus 5. Simple partial seizure 6. Complex partial seizure

Answer 9

1. Daydreaming, can be brought on by hyperventilation 2. Pale/sweaty before, non-rhythmic limb jerk, eye roll, short duration, no confusion 3. Stiffness, then rhythmic jerking that decreases in amplitude/frequency, confusion 30 minutes after 4. Twitching/jerking in the morning 5. Focal onset, awareness unimpaired, no post-ictal 6. Focal onset, awareness impaired, post-ictal symptoms

Question 10

Collapse/Seizure 1. History - patient (BEFORE) 2. History - witness (DURING) 3. History - patient/witness (AFTER) 4. Examinations 5. Investigations - if recurrent

Answer 10

1. Well previously? (infection, dehydration, no sleep, drugs) 2. Any precipitant? (e.g. postural trigger) 3. Any prior warning? (presyncopal/focal signs) 1. How did they fall? (floppy vs stiff) 2. Any shaking? (rhythmic vs random) 3. Complexion change e.g. pale, cyanosis 4. LOC duration? (under or over one minute) 1. First memory? (soon or late?) 2. Any pain/side of tongue biting/incontinence? 3. Previous similar events? 4. Other neurological symptoms? 5. Length of time acting weird after Cardiovascular (+ lying/standing BP), neurological ECG + 24 hour ECG, bloods (U+E, FBC, BM, Mg2+, Ca2+)

Question 11

Focal onset seizure 1. Common starting place 2. Suggestive signs

Answer 11

1. Temporal lobe 2. Auditory/olfactory hallucinations, deja-vu, rising epigastric sensation, fear, focal twitching

Question 12

Seizure - non-epileptic causes 1. Metabolic 2. Withdrawal from (2) 3. Infectious/Neurological (3) 4. Temperature 5. Drugs (2)

Answer 12

1. High/low Na+, low Ca2+, Mg2+, phosphate, glucose, uraemia (kidney disease), liver disease 2. Benzodiazepines, alcohol 3. Meningitis, encephalitis, raised ICP 4. Febrile 5. Tricyclics, cocaine

Question 13

Epilepsy - general 1. Causes - structural 2. Cause if multiple febrile seizures as child 3. Causes - other 4. 1st seizure - referral time 5. Diagnosis 6. Imaging - first line 7. EEG when 8. Other investigations 9. Driving - can only drive if 10. Stop driving for how long after breakthrough seizure 11. Stop driving for how long after AED change 12. Pregnancy - drug to avoid 13. Drug to take 14. Which AEDs not present in breast milk 15. Which AED present in breast milk but safe for infants 16. Contraception - what makes progesterone-only unreliable 17. Contraception - oestrogen containing does what

Answer 13

1. Cortical scarring, developmental, SOL, stroke 2. Mesial temporal sclerosis - hippocampal scarring 3. Tuberous sclerosis, sarcoid, SLE, PAN 4. <2 weeks for specialist assessment/investigation 5. Clinical, by specialist 6. MRI brain 7. To support diagnosis, not to exclude 8. ECG, bloods (maybe) 9. Seizure-free for a year 10. Legally required to inform DVLA; licence held for 6 months 11. 6 months 12. Sodium valproate 13. 5mg folic acid daily in first trimester 14. Valproate, carbamazepine 15. Lamotrigine 16. Enzyme-inducing AEDs 17. Lowers lamotrigine levels (may need higher dose)

Question 14

Seizures - management Acute 1. Management - 1st line 2. 2nd line 3. Refractory 4. CNS sedation 5. When is SE considered refractory Long-term 6. Generalised - 1st line 7. Partial - 1st line 8. Partial - 2nd line 9. Absence 10. Myoclonic 11. Myoclonic/absence - what to avoid

Answer 14

1. IV lorazepam / buccal midazolam 2. IV valproate / phenytoin / levetiracetam 3. IV midazolam (ICU for resp support) 4. IV propofol and theopentone 5. When seizures not under control after trying 2+ AEDs 6. Valproate (avoid in pre-menopausal women if possible) / lamotrigine 7. Carbamezipine / lamotrigrine 8. Valproate 9. Valproate / ethosuximide 10. Valproate / levetiracetem 11. Carbemazepine

Question 15

Epilepsy medications - pros/cons 1. Valproate 2. Do not use in Status epilepticus 3. Propofol 4. Thiopentone 5. Phenytoin 6. Levetiracetem (Kepra) 7. Which requires regular serum monitoring

Answer 15

1. Effective, peripheral cannula, no ECG/BP monitoring, However risk of NTDs (spina bifida, anencephaly), foetal valproate syndrome (dysmorphia, DD, cognitive impairment), and not ideal for localised seizures which become generalised (raised ammonia levels) 2. Females pre-menopause 3. Needs invasive ventilation 4. Very good at reducing seizures but increased sedation and longer ventilation 5. Easily available, but many SEs (arrythmia, hypotension, skin reaction, tetarogenic) 6. Effective, peripheral cannula sufficient, no ECG/BP monitoring 7. Phenytoin

Question 16

Lower motor neurone 1. Parts involved 2. Clinical signs 3. Anterior Horn Cell disease - pathophysiology 4. Causes (3)

Answer 16

1. Motor nerve, neuromuscular junction, anterior horn cell, nerve root 2. Decreased reflexes, normal/decreased tone, downgoing plantars, fasciculations, wasting 3. LMNs affecting skeletal muscle 4. ALS, polio(myelitis), spinal muscular atrophy

Question 17

Movement Disorders 1. Increased symptoms 2. Decreases symptoms

Answer 17

1. Chorea, hemiballismus, dystonia 2. Parkinson’s disease (bradykinesia, rigidity, tremor)

Question 18

Cord Syndrome - associated symptoms 1. Inflammation/disc prolapse 2. Systemic involvement (e.g. rash) 3. Previous episodes (e.g. blurred/double vision) 4. Previous drug use (e.g. NO) 5. Diet/bowel symptoms Cervical cord syndrome - type/cause 6. Inflammatory 7. Compressive 8. Infective 9. Metabolic

Answer 18

1. Infection/trauma 2. Lupus, behcet’s, sarcoidosis 3. Multiple sclerosis 4. Posterior cord syndrome (loss of vibration / proprioception) 5. B12 deficiency 6. MS, PI, Devic’s, NMO, CTD (lupus, sjogren’s, sarcoid) 7. Disc, tumour 8. Viral (VSV, HSV) 9. B12/copper deficiency

Question 19

Raised intracranial pressure (ICP) 1. Normal CSF opening pressure, necessary conditions 2. Causes (4) 3. Signs/symptoms 4. Signs of optic nerve impingement 5. Management - nausea

Answer 19

1. 20-21 (24 if obese), needs to be lying flat 2. SOL, cerebral oedema, infection, hydrocephalus 3. Headache (worse in morning, lying down, bending forward or coughing), vomiting and papilloedema 4. Visual changes on coughing / sneezing, VF defect 5. Cyclizine

Question 20

Space-Occupying Lesions 1. Types (4) 2. Symptoms 3. Cerebral oedema - management 4. Optic nerve lesions - causes (2) 5. Papilloedema - findings on fundoscopy

Answer 20

1. Tumour, aneurysm, abscess, chronic subdural haematoma) 2. Raised ICP, seizures, evolving focal neurology, personality changes 3. Dexamethasone, mannitol if raised ICP 4. Papilloedema from raised ICP, optic neuritis 5. Blurred disc margins, increased of cup to disc ratio, usually bilateral

Question 21

Idiopathic Intracranial Hypertension 1. Classic patient 2. Symptoms 3. Associated conditions 4. Associated medications 5. Management - lifestyle 6. Management - medication 7. Prognosis

Answer 21

1. Obese, female, around 30yo 2. Narrowed visual fields, blurred vision AND diplopia, 6th nerve palsy (false localising sign), and increased blind spot if papilloedema, headache Preserved consciousness/cognition 3. Endocrine abnormalities, SLE, CKD 4. Drugs (tetracycline, steroids, nitrofurantoin, COCP) 5. Weight loss 6. Acetazolamide (mild chronic) prednisolone (acute symptomatic) 7. Often self-limiting; 10% have permanent VF reduction

Question 22

Guillain-Barré Syndrome (GBS) 1. Type of disease 2. How antibodies attack nerves 3. Commonest causative organism (+ why) 4. So commonly occurs after what 5. Other triggers (6) 6. Specific symptom in CMV GBS 7. Associated malignancy (+ why) 8. Associated syndrome, sign + cause of sign 9. Symptoms/signs - motor 10. Symptoms/signs - sensory 11. Symptoms/signs - autonomic 12. Symptoms/signs - what is spared 13. Name of syndrome involving eyes 14. MFS triad of symptoms 15. MFR antibody involved

Answer 22

1. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) 2. Macrophage-mediated schwann cell plasmalemma 3. Campylobacter Jejuni; similar gangliocide to neuronal membrane 4. Respiratory/GI (diarrhoea) infection 5. CMV, HUV, Hodgkin’s, myoplasma, zoster, EBV 6. Facial nerve weakness 7. Multiple myeloma (B-cell proliferation) 8. SIADH (hyponatremia due to blood dilution) 9. Symmetrical, often ascending (90% start in legs) muscle weakness (proximal muscles worse e.g. CN7) 10. Paraesthesia, pain (often back), loss of proprioception 11. Sweat, HR up, BP change, arrhythmia, constipation 12. No sphincter involvement or encephalopathy 13. Miller-Fisher syndrome 14. Ophthalmoplegia, ataxia, arreflexia 15. GQ1b gangiocide antibody

Question 23

Guillain-Barré Syndrome (GBS) - investigations + management 1. Diagnostic tests (2) 2. CSF findings 3. NCS findings 4. Antibody to check for 5. Groups (2), + how they are differentiated 6. Management - medical 7. Management - drug not used 8. Ventilation - check FVC how often 9. Ventilation - indications (FVC, PaO2, PaCO2) 10. Other differentials (+ signs) 11. Other IDPs (2), + which medication works in these

Answer 23

1. CSF, nerve conduction studies 2. Raised protein >5.5 (due to root involvement), normal WCC, cytoalbuminologic dissociation 3. Slow 4. Antiganglioside antibodies 5. Demyelinating (attacks roots) - slow/blocked nerve conduction, increased or reduced F waves on NCS Axonal (attacks nodes of Ranvier) - small motor amplitudes on NCS but normal velocity 6. IV Immunoglobulin 0.4g/kg/day for 5 days, plasma exchange, thromboprophylaxis 7. Steroids 8. Check FVC every 4 hours 9. FVC <1.5L, PaO2 <10kPa, PaCO2 >6kPa 10. Acute myelopathies, botulism (descending + ophthalmoplegia), porphyria (increased autonomic + abdominal pain) 11. Subacute + chronic; steroids work

Question 24

Acute limb weakness Causes of raised CSF protein 1. If >5 2. If >50

Answer 24

1. Consider spinal block (Froin’s syndrome - raised protein, marked CSF coagulation and xanthochromia, caused by meningeal irritation and CSF flow blockage) 2. HIV

Question 25

Lumbar Puncture results - OP, white cells, protein, glucose, other 1. Bacterial 2. Viral 3. Tuberculosis 4. Malignancy

Answer 25

1. Raised OP, neutrophilia, raised Protein, decreased glucose, check PCR 2. Normal OP, lymphocytosis, modest raised protein, normal glucose, check PCR 3. Extremely raised OP, lymphocytosis, extremely raised protein, extremely reduced glucose, do oramine microbiological stain 4. Normal OP, raised WCC, raised protein, extremely decreased glucose, abnormal cytology

Question 26

Lumbar puncture Specific findings 1. Bacterial - which white cells 2. Viral - which white cells 3. Half-treated - which white cells 4. Oligoclonal bands - seen when 5. Subarachnoid haemorrhage

Answer 26

1. Neutrophils 2. Lymphocytes 3. Mixed 4. In CNS inflammation e.g. transverse myelitis, MS Synthesis of IgG in CSF, not blood in MS 5. Raised RBC, xanthochromia (increased bilirubin and oxyhaemoglobin)

Question 27

Lumbar puncture - normal range 1. OP 2. WCC 3. RCC 4. Protein 5. Glucose 6. Indication for performing (4 broad)

Answer 27

1. <20cm 2. <5 wbc 3. None 4. <0.45 g/L 5. 2/3 of plasma 6. Headache, infection, inflammation (e.g. GBS), cancer (10ml needed)

Question 28

Acute bilateral leg weakness 1. Three things to consider to locate lesion 2. Main differentials (3)

Answer 28

1. Flaccid (LMN) or Spastic (UMN); Sensory loss? (‘level’ = SC disease); Bladder/bowel disturbance? (CM/CE) 2. Cord compression, cauda equina, conus medullaris

Question 29

Spinal infection 1. Signs 2. Cause

Answer 29

1. Acute bilateral leg weakness, fever, tender on palpation, raised WCC/ESR/CRP 2. Extradural abscess

Question 30

Cord compression 1. Commonest cause (+ 5 original locations) 2. Other causes (5) 3. Symptoms - early 4. Symptoms - late 5. Sensory level signs 6. Differentials 7. Investigations - bloods 8. Investigations - imaging 9. Management

Answer 30

1. Secondary Malignancy (breast, lung, prostate, thyroid, kidney) 2. Infection, disc prolapse, haematoma, myeloma, intrinsic cord tumour 3. Bilateral weakness, sensory level, back pain 4. Sphincter/bladder involvement 5. Normal above, LMN at compression level, UMN below 6. Transverse myelitis, MS, cord vasculitis, trauma, GBS, spinal artery thrombosis/aneurysm 7. FBC, ESR, B12, syphilis, U+E, LFT 8. MRI spine, CXR 9. Urgent dexamethasone (malignancy), then radio/chemo and decompressive laminectomy

Question 31

1. Cauda equina syndrome (CES) - symptoms/signs 2. Classification (3) 3. Conus medullaris disease - symptoms/signs 4. Causes of both

Answer 31

1. Flaccid, areflexic legs, back pain, radicular pain down legs, decreased sphincter tone Sensory loss in root (dermatomal) distribution 2. With retention (loss of urinary control), incomplete (with altered urinary sensation), suspected (only suggestion of sphincter disturbance) 3. Mixed UMN/LMN signs (e.g. absent knee jerk and upgoing plantars), leg weakness, erectile dysfunction, early urinary retention/constipation, back pain 4. Secondary malignancy, infection (epidural abscess), disc prolapse, congenital lumbar disc disease, lumbosacral nerve lesions

Question 32

Other patterns of leg weakness - differentials 1. Paraparesis - definition 2. Chronic spastic (5) 3. Chronic flaccid (2) 4. Bilateral, but no sensory loss (2) 5. Unilateral foot drop 6. Absent knee jerk + extensor plantars (mixed)

Answer 32

1. Bilateral UMN signs in legs 2. MS, malignancy, syringomyelia, MND, schistosomiasis 3. Peripheral neuropathy, myopathy 4. MND, polio 5. DM, common peroneal nerve palsy, stroke, disc prolapse, MS 6. Conus medullaris, MND, B12 deficiency, Friedrich’s

Question 33

Tremor - cause + description 1. Resting 2. Intention 3. Postural 4. Re-emergence 5. Benign essential tremor - inheritance 6. Improved / worsened by 7. Locations 8. Management 9. Test to differentiate parkinsonian from benign essential

Answer 33

1. Parkinsonism; abolished on voluntary movement, fine, ‘pill rolling’ 2. Cerebellar damage (MS, stroke); irregular, coarse, worse at end of purposeful acts 3. Benign essential, alcohol withdrawal, low BM, anxiety, thyrotoxicosis, beta agonists; absent at rest, present on maintained posture (e.g. arms outstretched), worse on movement 4. Parkinson’s disease; postural tremor developing after 10 seconds delay 5. Autosomal dominant 6. Improved by alcohol/rest, worse by stress/caffeine 7. Arms, jaw, legs on VOLUNTARY movement 8. Propranolol 80mg bd 9. DAT scan - (Dopamine active transporters) scan - shows how dopamine active transporters are working

Question 34

Parkinson’s disease - general 1. Average age of onset 2. Cause (+ where, which type) 3. Risk factor (job) + why 4. Symptoms - extrapyramidal triad 5. Tremor - exacerbated by 6. Symptoms - other neurological 7. Symptoms - neuropsychiatric 8. Gait - characteristics 9. Examination - rigidity - how best to test 10. How to distinguish from spasticity 11. What remains intact on neurological exam 12. Diagnosis - based on what 13. What needs to be excluded prior to diagnosing PD 14. Specialist referral - at what stage

Answer 34

1. 60 2. Dopaminergic neuron degeneration in substantia nigra 3. Farmer (pesticides) 4. Tremor (resting, asymmetrical, fine, ‘pill rolling’; Rigidity (with tremor - ‘cogwheeling’ during rapid pronation / supination); Bradykinesia (slow initiation, decreased amplitude on repetition e.g. blinking/micrographia) 5. Distraction, emotion 6. Anosmia, decreased autonomic (postural hypotension, constipation, increased urinary frequency) 7. REM sleep disturbance, depression, dementia, psychosis 8. ‘Festinant’; pitched forward, shuffling, reduced arm swing, bad balance, ‘freezing’, slow turn 9. Passive movement of the arms 10. EQUAL in both extensors and flexors 11. Power 12. Clinical - bradykinesia with at least one of tremor and rigidity 13. Cerebellar disease/frontotemporal dementia 14. Whilst untreated

Question 35

Ataxic gait 1. Three main groups 2. Sensory - which area involved (2) 3. How to tell between them 4. Cerebellar - symptoms (DANISH) 5. Other system causing nystagmus 6. Vestibular - symptoms (3)

Answer 35

1. Sensory, cerebellar, vestibular 2. Dorsal columns (proprioception), peripheral nerves/roots 3. Dorsal (L’Hermitte’s phenomenon, tight band sensation around torso, bladder disturbance); peripheral (worse when can’t see) 4. Disdidadokinesia, ataxic gait, nystagmus, intention tremor, staccato/slurred speech (dysarthria), hypotonia Often unilateral arm incoordination 5. Central posterior 6. Vertigo, desequilibrium, nausea

Question 36

Multiple sclerosis (MS) - general 1. What it is 2. Typical patient 3. Plaques - main types (2) 4. AA - features 5. AA - how they damage body 6. C - subtypes + how are they different (2) 7. Commonest type (regarding symptoms timing) 8. Other main types (2) 9. SP - features 10. PP - potential effect of pregnancy 11. Inflammatory mimicking conditions (3) 12. What to ask to differentiate 13. Neurosarcoidosis - suggestive features (2)

Answer 36

1. Inflammatory plaques of demyelination disseminated in time (<30 days) and space 2. 30yo, caucasian, F:M 3:1 3. Acute active; Chronic 4. Mostly in RRMS and cause relapses; Infiltrated by macrophages (degrade myelin, spare axons) 5. BBB breakage - CD8 infiltration, complement activation, immunoglobulin deposition; Oligodendrocyte apoptosis 6. Active (inactive centre, rim of active microglia, axonal damage, little myelin degradation product); Inactive: (completely demyelinated, sharply circumscribed, hypocellular) 7. Relapsing-Remitting (85-90%) 8. Secondary Progressive; Primary Progressive (10%) 9. Occurs after relapsing-remitting MS; axonal degeneration so loss of nerve cells; less inflammation 10. Symptoms may improve during pregnancy and increase 3-6 months post-partum 11. Sjogren’s; Anticardiolipin syndrome; Neurosarcoidosos 12. Systemic symptoms 13. Hilar enlargement, meningeal enhancement

Question 37

Multiple sclerosis (MS) - symptoms + diagnosis 1. Sensory 2. Other conditions causing L’Hermitte’s sign (3) 3. Motor 4. Cerebellar 5. GI 6. Ophthalmic 7. Sexual/GU 8. Diagnostic criteria 9. What does the criteria consider 10. Diagnostic imaging 11. Findings on imaging 12. CSF findings (2)

Answer 37

1. Dysaesthesia, paraesthesia, decreased vibration sense, trigeminal neuralgia, L’hermitte’s sign (meck flexion leads to ‘electric shock’ in trunk/limbs) 2. Cervical spondylosis, cord tumours, B12 deficiency 3. Spastic weakness, myelitis 4. Trunk and limb ataxia, falls, intention tremor, monotonous speech 5. Swallowing disorders, constipation 6. Diplopia, hemianopia, ON, visual changes on exercise, bilateral internuclear ophthalmoplegia, pupil defects 7. ED, anorgasma, urinary retention / incontinence 8. McDonald Criteria 9. 2+ relapses and 2+ lesions - no additional data needed Lesions must be separated ‘in time and space’ 10. T2 weighted MRI brain/spine with gadolinium contrast 11. Lesions in paraventricular region 12. Oligoclonal (IgG) bands on electrophoresis that aren’t in serum, pleocytosis

Question 38

Multiple sclerosis (MS) - management 1. Lifestyle 2. Relapse - 1st line drug 3. What it does 4. What to check before given + wju 5. Maximum times given + why 6. Steroids - SEs 7. Disease modifying drugs (DMDs) - used when 8. Commonest DMDs (+ MOA) 9. Spasticity - 1st line 10. 2nd line 11. 3rd line 12. Tremor 13. Fatigue 14. Neuropathic pain - 1st line 15. Other options 16. Neuropathic bladder - 1st line (+ side effect) 17. What if residual urine >100ml 18. What if residular urine <100ml

Answer 38

1. Exercise, stop smoking, avoid stress 2. Methylprednisolone 0.5-1mg/day iv/po for 3-5 days 3. Decreases relapse length 4. Always check FBC/glucose/urine/U+E - can’t have infection 5. Maximum 2 times/year due to steroid SEs 6. GI disturbance (give PPI), psychiatric (agitation, insomnia, low mood, steroid psychosis) bone (osteoporosis, avascular necrosis of hip), hyperglycaemia, HTN 7. At least 2 significant relapses in 2 years 8. Dimethyl fumarate; Alemtuzumab (against T-cells); Natalizumab (stop VLA-4 receptors, so immune cells don’t cross BBB) 9. Baclofen (also sedates)/gabapentin 10. Tizanidine/dantrolene 11. Benzodiazepines 12. Botulinium toxin type A injection 13. Amantadine 14. Gabapentin/pregabalin 15. TCAs (sedation, dry mouth); carbemazapine (trigeminal neuralgia); duloxetine (GI disturbance) 16. Oxybutinin (anticholinergic) - SE of incomplete emptying so US bladder 17. Self-catheterisation 18. Tolterodine

Question 39

Multiple sclerosis (MS) - Optic Neuritis 1. What it is 2. Causes (2 broad areas) 3. Symptoms 4. Mimic - deficiency 5. Mimic - syndrome 6. NMO - triad 7. Uhthoff’s phenomenon

Answer 39

1. Autoimmune inflammation and demyelination of optic nerve (CN 2) 2. Autoimmune (SLE, e/GPA, APA syndrome, sarcoid), infection (HIV, syphilis, hepatitis B/C) 3. Unilateral rapidly decreasing central vision (central scotoma), pain on movement, red colour saturation; pale papilloedema, RAPD 4. Vitamin B12 5. Devic’s (neuromyelitis optica) 6. Longitudinal (3 vertebra) transverse myelitis; Optic atrophy; Anti-aquaporin (AQP4/NMO) antibodies 7. Worsening of MS symptoms in heat

Question 40

Trigeminal neuralgia 1. Nerve - branches (3) 2. Presentation 3. Investigation 4. Management

Answer 40

1. Ophthalmic, maxillary, mandibular 2. Unilateral sharp stabbing pain, usually in mandibular region, worse on washing / shaving / eating 3. MRI to exclude secondary compressive causes 4. Carbamazepine

Question 41

Bell’s palsy 1. Definition 2. Infective causative syndrome 3. Risk factors (2) 4. Symptoms - weakness 5. Other 6. Examination - cannot do what (shows LMN involvement) 7. Management 8. Recovery

Answer 41

1. Acute LMN facial nerve (CN 7) palsy 2. Ramsay-Hunt (VSV antibodies); HSV 3. Pregnancy (x3), DM (x5) 4. Whole half face (eyebrow/forehead included) 5. Ipsilateral numbness/pain around ear, sound hypersensitivity (stapedius palsy) 6. Wrinkle forehead or whistle 7. High dose prednisolone within first 72 hours, eye care, add aciclovir if Ramsay hunt (vesicular rash around ear) 8. 80% in 2 months

Question 42

Other palsies 1. UMN CN 7 palsy - presentation, why 2. CN 7 causes (not BP) - often bilateral 3. CN 8 lesion - causes 4. Bulbar - definition 5. Causes 6. Presentation - speech 7. Presentation - jaw jerk 8. Presentation - gag reflex 9. Presentation - tongue 10. Pseudobulbar - definition 11. Causes 12. Presentation - speech 13. Presentation - jaw jerk 14. Presentation - gag reflex 15. Presentation - tongue 16. Presentation - other

Answer 42

1. Incomplete, just lower half of the face (duel supply from cortex of nerves innervating upper face) - eyebrow spared 2. Lyme (Borrelia antibodies) Stroke, DM, sarcoid (parotid gland enlargement), tumour (acoustic neuroma) 3. Tumours, MS, trauma, meningitis, gentamicin 4. LMN lesion of 9, 10, 11 and 12 5. GBS, MND, tumour 6. Quiet and hoarse speech 7. Absent jaw jerk 8. Absent or reduced gag reflex, dysphagia, nasal food regurgitation 9. Wasted tongue, flaccid with fasciculations 10. UMN lesion of 9, 10, 11 and 12 11. Stroke, MND, MS 12. Slow monotonous speech 13. Brisk jaw jerk 14. Brisk gag reflex, dysphagia 15. Small spastic tongue 16. May be UMN signs in arms

Question 43

Pyramidal (UMN) disease 1. Tract - definition 2. Parts insolved 3. ‘Pyramidal (UMN) weakness’ - signs 4. Lesion above - weakness where 5. Lesion below - weakness where 6. Clinical Signs

Answer 43

1. UMNs that originate in cerebral cortex and terminate in spinal cord (corticospinal) or brainstem (corticobulbar) 2. Spinal cord, white matter tracts, motor cortex 3. Loss of power in the arm extensors + leg flexors 4. Contralateral side 5. Ipsilateral side 6. Increased reflexes, increased tone, upgoing plantars, pyramidal weakness, no wasting/fasciculations

Question 44

Myasthaenia gravis 1. What it is 2. Pathophysiology 3. Gland usually abnormal (+ how to check) 4. Location/type of weakness 5. Symptoms 6. Investigation 7. Result of investigation + why 8. Management - symptom control 9. Management - relapses 10. Management - surgical 11. Management - crisis 12. Crisis - other differential 13. Lambert-Eaton - causes (2 broad) 14. Antibodies - to what, where 15. Management

Answer 44

1. Chronic autoimmune disorder of NMJ 2. Antibodies directed against acetylcholine receptors on post-synaptic muscle membrane (Anti-AChR) 3. Thymus (do chest imaging to rule out thymoma) 4. Proximal, fatiguable, eye signs first 5. Ptosis, diplopia, problems swallowing/chewing 6. Tensellin test 7. Symptoms improve - tensellin (edrephonium) is an anticholesterase agent 8. PO anti-cholinesterase (pyridostigmine) 9. Immunosuppressants e.g. prednisolone 10. Thymectomy 11. IV immunoglobulins 12. Cholinergic crisis from very high dose pyridostigmine 13. Paraneoplastic (SCLC), autoimmune 14. Pre-synaptic voltage-gated Ca2+ channels 15. Treat SCLC, steroids

Question 45

Migraine 1. Symptoms 2. Triggers 3. Diagnosis 4. Management - acute (3) 5. Management - prophylactic (2) 6. Triptan - when to take 7. Side effects 8. Contraindications (2)

Answer 45

1. Unilateral, pounding, multiple triggers, hours, photophobia, phonophobia, preceding ‘aura’ 2. Tiredness, stress, alcohol, COCP, hungry/thirsty, menstruation, bright lights, cheese / chocolate /wine / 3. Clinical, based on history (if no aura, must be 5+ times) 4. Triptan, NSAIDS, metoclopromide (antiemetic) 5. Propranolol / topiramate 6. As soon after the start of the migraine 7. Tingling, heat, tightness in throat/chest, heaviness, pressure 8. PMH of IHD / TIA

Question 46

Charcot-Marie tooth (CMT) disease 1. What it is 2. Motor characteristics 3. Sensation characteristics 4. Foot deformities (2)

Answer 46

1. Hereditary demyelinating neuropathy (1 in 2500 people) 2. Distal foot/leg wasting/atrophy and weakness (‘inverted champagne bottle’, ankle dorsiflexion lost), then spreads to arms, reduced reflexes, reduced tone 3. Glove and stocking sensation loss 4. Pes cavus (high arch), toe clawing (hammer toe)

Question 47

Brain tumour 1. Commonest type 2. Presentation (3 types) 3. Secondary - metastasise from

Answer 47

1. Glioma 2. Seizure, raised ICP symptoms, neurological deficit 3. Lung, breast, kidney, malignant melanoma

Question 48

Friedrich’s ataxia 1. Inheritance 2. Age of onset 3. Clinical features 4. Investigations

Answer 48

1. Autosomal recessive 2. < 20 3. Ataxia Sensory +/- cerebellar, foot deformities, weakness, distal wasting, loss of leg reflexes, gradual sensory loss, nystagmus 4. MR, genetics

Question 49

Parkinsonism - other causes 1. Commonest drug 2. Disease to suspect if patient <40

Answer 49

1. Neuroleptics 2. Wilsons disease

Question 50

Muscular dystrophy 1. Blood test 2. Organ to monitor 3. Prognosis

Answer 50

1. Creatinine kinase 2. Heart 3. 20 years

Question 51

Peripheral polyneuropathies 1. Sensory - causes (4) 2. Motor - causes (2) 3. Cranial nerves - symptom examples 4. Important history points

Answer 51

1. DM, alcohol, low B12, chronic renal failure 2. GBS, CMT 3. Speech/swallowing difficulties, diplopia 4. PMH (DM, CKD), alcohol abuse, anaemia symptoms

Question 52

Mononeuropathies 1. Carpal tunnel syndrome - caused by 2. Associated diseases (4) 3. Symptoms (+ location) 4. Management - conservative 5. Management - medical 6. Management - surgical 7. Ulnar nerve (C7-T1) - weakness where 8. Radial nerve (C5-T1) weakness where 9. Foot drop - causes 10. Sensation differences

Answer 52

1. Median nerve (C6-T1 ) compression 2. RA, hypothyroidism, acromegaly, pregnancy 3. Numbness, tingling, burning, pain, clumsiness (thumb and index, middle, and ring fingers) 4. Splinting 5. Steroid injections 6. Decompression by division of flexor retinaculum 7. Medial wrist flexors, interossei (cannot cross fingers), medial two lumbricals ‘claw hand’ 8. Wrist/finger drop, snuffbox paraesthesia 9. Sciatic (L4-S3) / common peroneal (L4-S1) 10. Sciatic (loss below knee), CP (loss over dorsal foot)

Question 53

Transverse myelitis 1. What it is 2. Symptoms 3. Investigations 4. Findings 5. Acute - management (1st line) 6. Management - 2nd line

Answer 53

1. Heterogeneous focal inflammatory disorder of the spinal cord 2. Acute/subacute motor weakness, sensory impairment, and autonomic dysfunction 3. LP, MRI spine 4. MRI (focal hyperintense lesion); CSF (pleocytosis) 5. Corticosteroids 6. Plasmapherisis

Question 54

Normal pressure hydrocephalus 1. Triad

Answer 54

1. Apraxia, urinary incontinence and dementia

Question 55

Major neurotransmitters + associated drugs 1. Dopamine - agonists 2. Dopamine - antagonists 3. Serotonin - agonists 4. Serotonin - antagonists 5. Amino acids - GABA agonists 6. Amino acids - glutamate antagonist

Answer 55

1. Levodopa, ropinirole, pramipexole 2. Metoclopramide, chlorpromazine 3. Lithium, sumatriptan, fluoxetine, sertraline 4. Ondansetron, mirtazapine, olanzapine, clozapine 5. Gabapentin, valproate, benzodiazepines, baclofen 6. Memantine

Question 56

Gait disorders 1. Spastic - description 2. Cause 3. Extrapyramidal - description 4. Cause 5. Apraxic - description 6. Cause 7. Ataxic - description 8. Cause 9. Myopathic - description 10. Cause

Answer 56

1. Stiff circumduction of leg, scuffling of shoe toe 2. UMN lesion 3. Flexed posture, shuffling feet, slow to start, postural instability 4. Parkinson’s disease 5. ‘Gluing to floor’ on attempting to walk, wide-based, unsteady, tendency to fall 6. Normal pressure hydrocephalus, multi-infarct states 7. Wide-based, falls, cannot walk heel to toe, worse when cannot see 8. Cerebellar lesion (MS, alcohol), proprioceptive sensory loss (sensory neuropathy, B12) 9. Waddling, cannot climb stairs/stand from sitting 10. Hip girdle weakness

Question 57

Dyskinesias 1. Chorea - description 2. Cause 3. Worsened by what 4. Hemiballismus - descripton 5. Cause 6. Athetosis - commonest cause 7. Pseudoathetosis 8. Tics - medical management if severe 9. Benign essential myoclonus (childhood) - management 10. Asterixis (‘metabolic flap’) - causes 11. Tardive syndromes - cause 12. Drugs less likely to cause this 13. Generalised dytonia - exclude which disease 14. Acute dystonia - drug cause 15. Acute dystonia - management

Answer 57

1. Non-rhythmic, jerky, purposeless movements moving from one place to another 2. Huntington’s, sydenham’s (group A streptoccus) 3. Levodopa 4. Large amplitude, flinging hemichorea 5. Contralateral to vascular lesion of subthalamic nucleus 6. Cerebral palsy - slow 7. Severe proprioceptive loss 8. Clonazepam / clonidine 9. Valproate 10. Liver/renal failure, low Na+ high CO2, gabapentin 11. Chronic exposure to dopamine antagonists (antipsychotics, antiemetics) 12. Olanzapine, quetiapine, clozapine 13. Wilson’s 14. Starting neuroleptics, metoclopramide, cyclizine 15. Anticholinergic drug

Question 58

Parkinson’s plus syndromes - general 1. Definition 2. Types (4) 3. Progressive Supranuclear Palsy - indicated by what 4. Characteristics (3) 5. Multiple System Atrophy - characteristics 6. Corticobasal degeneration - characteristics Secondary parkinsonism 7. Vascular - classic patient 8. Signs (3) 9. Drug-induced (4)

Answer 58

1. Other forms of parkinsonism that have clinical features not typical of PD 2. MSA, Dementia with Lewy Bodies, PSP, Corticobasal Degeneration 3. Little response to L-dopa 4. Vertical gaze palsy, falls early on (backwards), symmetrical parkinsonism, trunk more rigid than limbs, cognitive decline, speech/swallowing problems 5. Early autonomic (impotence, incontinence, posteral hypotension. Rigidity > tremor, symmetrical, cerebellar signs 6. One limb akinetic rigidity, cortical sensory loss, apraxia 7. DM/HTN + postural instability/falls 8. Lower body signs predominate, tremor less common, lack of facial expression 9. Neuroleptics, metoclopromide, prochloroperazine, lithium

Question 59

Parkinson’s disease - management 1. Management - early PD (no motor effect on QOL) 2. Dopamine agonist - examples (2) + side effect 3. MAO-B inhibitor - example + function 4. Management - progressing PD (+ components) 5. Levodopa - specifically improves (2) 6. Hold off before what age 7. Give alongside 8. Which drug type helps tremors, + example 9. Side effects (5) 10. Anti-emetic given, and why

Answer 59

1. Dopamine agonist or MAO-B inhibitor 2. Ropinirole, bromocriptine; N+V 3. Selegiline, can delay need for L-dopa 4. Levodopa (dopamine precursor)) 5. Bradykinesia and rigidity 6. < 55 7. Carbidopa (peripheral dopa decarboxylase inhibitor, so stops it becoming dopamine peripherally, so crosses BBB) 8. Anticholinergics, e.g. benzhexol 9. Dry mouth, constipation, urinary retention, blurred vision, hallucinations 10. Domperidone - does not cross BBB

Question 60

Motor neuron disease (MND) 1. Clinical patterns (4) 2. ALS - neurons lost where 3. Signs 4. PBP - affects what 5. PMA - neurons lost where, so which signs 6. PLS - neurones lost where, so which signs 7. Associated dementia type 8. ALS - drug to slow disease progression

Answer 60

1. Amytrophic lateral sclerosis, progressive bulbar palsy, progressive muscular atrophy, primary lateral sclerosis 2. Motor cortex + anterior horn cells 3. Mixed UMN + LMN signs 4. Cranial nerves 9-12 5. Only anterior horn cells, so LMN signs only 6. Betz cells in motor cortex, so UMN (+ pseudobulbar) 7. Frontotemporal 8. Riluzole

Question 61

Cervical spondylosis 1. What degenerates 2. What forms + where 3. Consequence 4. Symptoms 5. Signs 6. Radiculopathy (root) compression - distribution of change/symptoms 7. Causes (2 groups) 8. Cervical cord compression - symptoms/signs 9. Investigations 10. If no red flags 11. If no improvement in 4-6 weeks

Answer 61

1. Annulus fibrosus 2. Osteophytes on adjacent vertebrae 3. Narrowing of spinal canal so spinal cord hits spurs 4. Neck stiffness, crepitus when moving, stabbing/dull arm pain, forearm/wrist pain 5. Limited, painful neck movement, L’Hermitte’s sign 6. Dermatomal; pain/electrical sensations, LMN signs below 7. Compressive (disc), non-compressive (inflammatory/cancer) 8. Progressive, UMN leg signs (below), LMN arm signs 9. Urgent MRI/specialist referral if red flags 10. Analgesia, gentle exercise 11. MRI, consider neurosurgical referral

Question 62

Myopathy 1. Suggestive symptoms 2. If rapid onset, suggests 3. If fatiguable, suggests 4. Bloods - results 5. Muscular dystrophies - signs/examination 6. Duchenne’s - inheritance, gene 7. Symptoms, blood result 8. Becker’s - inheritance, gene 9. Myotonic dystrophy - what it causes 10. Inheritance, symptoms

Answer 62

1. Gradual, proximal muscles affected, selected muscle weakness, preserved reflexes, no paraesthesia/bladder problems, no LMN signs 2. Toxic/drug/metabolic cause, or neuropathy 3. Myasthaenia gravis 4. Raised ESR, CK, AST, LDH 5. Unusually firm muscles, select weakness, muscle fibre size variation on histology 6. X-linked recessive, non-functional dystrophin 7. 4yo M, clumsy walking, then standing, very high CK 8. X-linked recessive, hypofunctional dystrophin 9. Tonic muscle spasm (myotonia) 10. Autosomal dominant, distal weakness/wasting

Question 63

Neurofibromatosis 1. General - inheritance 2. Neurofibroma - types, description Type 1 3. Signs 4. Complications - neuro, GI, bone, BP 5. Associated malignancies (2) Type 2 6. First symptom 7. Other symptoms 8. Signs 9. Associated juvenile ophthalmic issue 10. Associated malignancies (3) 11. Complications of schwannoma surgery (2)

Answer 63

1. Autosomal dominant 2. Dermal (gelatinous, itchy, appear at puberty), Nodular (firm, clearly demarcated, pins + needles if pressed) 3. Many café-au-lait spots by 1yo (6+ by adult), skin fold freckling, neurofibromas, iris lisch nodules, short, macrocephaly 4. Mild learning disability, nerve root compression, GI bleed/obstruction, bone cystic lesions/scoliosis, HTN (RAS / phaeochromocytoma) 5. Optic glioma, sarcoma in neurofibromas 6. Sensorineural hearing loss in 20s 7. Tinnitus, vertigo 8. Bilateral acoustic neuromas, fewer CAL spots, neurofibromas 9. Juvenile cataracts 10. Meningioma, glioma, schwannoma 11. Hearing deterioration, facial palsy

Question 64

Syringomyelia 1. Syrinx - definition 2. Cause - general 3. Commonest malformation 4. Other causes 5. Syrinx presses on which pathway 6. Linked sensory symptoms 7. Other symptoms 8. Exacerbated by 9. Syringobulbia - meaning 10. Signs 11. Imaging - 1st line

Answer 64

1. Tubular cavity in/close to cervical cord central canal 2. Blocked CSF circulation 3. Arnold-Chiari 4. Myelitis, cord trauma, AV malformation rupture 5. Decussating anterolateral pathway 6. Absent pain/temperature sensation in root distribution 7. Hand wasting/weakness/claw, bilateral Horner’s syndrome, wrist/shoulder Charcot joints 8. Coughing, sneezing as increased pressure causes extension 9. Syrinx extending into brainstem 10. Nystagmus, tongue atrophy, dysphagia, pharyngeal/palatal weakness, CN10 sensory loss 11. MRI

Question 65

Retroviruses + neurology 1. Associated with acute infection (3) 2. Main CNS pathogen in AIDS 3. Symptoms 4. CT/MRI - findings 5. Management 6. Pathogen causing chronic meningitis with fever + headache 7. Subsequent signs 8. Management 9. CMV - can cause what 10. JC virus - can cause what 11. White matter signs 12. CNS malignancy linked to EBV 13. Other CNS malignancy 14. HIV-associated neuro disorder - symptoms 15. Commonest neuropathy in HIV

Answer 65

1. Transient aseptic meningoencephalitis, myelopathy, neuropathy 2. Toxoplasma gondii 3. Cerebral abscesses (focal seizures, hemiparesis) 4. Ring-shaped contrast-enhancing lesions 5. Pyrimethamine 6. Cryptococcus neoformans 7. Slow cognition change, seizures, coma 8. Amphotericin + fluconazole 9. Encephalopathy 10. Progressive multifocal leukoencephalopathy 11. Progressive white matter inflammation 12. Primary cerebral lymphoma 13. B-cell lymphoma 14. Progressive behaviour change, memory loss, poor attention, bradykinesia 15. Painful, predominantly sensory peripheral neuropathy

Question 66

Levodopa - counselling 1. Action 2. Timeline 3. How to take 4. Length of time 5. Effects - time before 6. Tests 7. Important side effects 8. Complications 9. Contraindications

Answer 66

1. Replaces some of the dopamine that brain can’t make, improves rigidity + slow movements 2. 3-4 daily with food (reduced nausea) 3. Tablet, give alongside carbidopa 4. As long as works effectively 5. Fast-acting 6. - 7. Psychosis, N+V, dyskinesias (on), postural hypotension BUT other drugs help with these 8. End-dose deterioration + on-off effect after 5 years 9. Glaucoma

Question 67

Huntington’s chorea 1. Inheritance + issue 2. Degeneration - what, where 3. Presents when 4. Features

Answer 67

1. AD; trinucleotide disorder (repeat expansion of CAG) 2. Cholinergic/GABAergic neurons in basal ganglia striatum 3. >35 years old 4. Chorea, personality changes (e.g. irritability, apathy, depression), intellectual impairment, dystonia, saccadic eye movements