Neurology

Question 1

3 main causes of ischaemic strokes

Answer 1

thrombosis
embolism
dissection

Question 2

what are the causes of haemorrhagic strokes

Answer 2

hypertension 
vascular malformation 
tumours 
vasculitis 
bleeding disorders
trauma

Question 3

risk factors for strokes

Answer 3

smoking
diabetes
hypertension
hypercholesterolemia
obesity
AF
carotid artery disease
age
thrombophilic disorders (e.g. antiphospholipid syndrome)
sickle cell disease

Question 4

what is the bamford/oxford classification?

Answer 4

method to sub-classify strokes
- total anterior circulation stroke
- partial anterior circulation stroke 
- lacunar stroke 
posterior circulation stroke

Question 5

what blood vessels are affected in

TACS
PACS
LACS
POCS

Answer 5

TACS/PACS: ACA/MCA
LACS: deep perforating arteries
POCS: vertebrobasilar arteries

Question 6

TACS criteria

Answer 6

1. unilateral weakness +/- sensory deficit.
2. homonymous hemianopia.
3. higher cerebral dysfunction

Question 7

presentation of lacunar stroke

Answer 7

pure motor/sensory deficits?

ataxic hemiparesis
dysarthria
clumsy hand syndrome

Question 8

posterior stroke syndrome

Answer 8

nystagmus, vertigo, ipsilateral Horner’s syndrome, ipsilateral facial sensory loss, dysarthria + dysphagia, diplopia, contralateral pain + temperature loss, visual field defects, ataxia, dizziness

Question 9

presentation of haemorrhagic stroke

Answer 9

headache, altered mental status, nausea + vomiting, hypertension, seizures, focal neurological deficits

Question 10

what is the NIHSS score

Answer 10

predicts clinical outcome
<4 = good outcome
>26 CI for thrombolysis

Question 11

differential diagnosis for patient presenting with stroke symptoms

Answer 11

Toxic/metabolic: hypoglycemia, drug + alcohol consumption
neurological (seizure, migraine, Bell’s palsy)
space occupying lesion
infection (meningitis, encephalitis)
syncope
FND

Question 12

investigations for stroke

Answer 12

Bedside: observations, blood glucose, ECG (AF)
Bloods: FBC, U+E, bone profile, LFT, ESR, coagulation, lipid profile HBA1C
Imaging CT head +/- CT angiography
Special: echocardiography, carotid dopplers, 24 hour tape, young stroke screen

Question 13

management of haemorrhagic stroke

Answer 13

neurosurgical intervention if large bleed + deteriorating –> hemicraniotomy/suboccipital craniotomy

Question 14

acute management of ischaemic stroke

Answer 14

• thrombolysis with alteplase
• aspirin 300mg after 24-48h for 2w then 75mg clopidogrel (or anticoagulant if in AF)
• thrombectomy if appropriate

Question 15

long term management of ischaemic stroke

Answer 15

control BP, BM and lipids 
antiplatelets/anticoagulants 
carotid artery assessment 
swallow + nutrition assessment 
rehabilitation

Question 16

complications of stroke

Answer 16

Early: hemorrhagic transformation of ischaemic stroke, cerebral oedema, seizures, infection (e.g. aspiration pneumonia), cardiac arrythmias, VTE, malignant MCA infarction (rapid neurological deterioration due to cerebral oedema following MCA stroke) death

Late: mobility and sensory issues, bladder + bowel dysfunction, pain, fatigue, cognitive problems, visual problems, emotional and psychological issues, issues with swallowing, hydration and nutrition

Question 17

DVLA and stroke advice

Answer 17

need to stop driving for 1 month and inform DVLA if symptoms ongoing > 1 month or if drive large vehicles

Question 18

what is amaurosis fugax

Answer 18

short lived monocular blindness (DD: transient visual loss - migraine)

Question 19

imaging of choice for suspected TIA

Answer 19

MRI head with diffusion weighted imaging

Question 20

when is urgent admission indicated for patients with suspected TIA

Answer 20

Crescendo TIA: >1 TIA in past 7 days
Suspected cardioembolic source or severe carotid stenosis
Vulnerable patients e.g. lack of reliable observer at home
Bleeding disorder or taking an anticoagulant

Question 21

motor complications of PD

Answer 21

on-off fluctuations (switch from dyskinesia to immobility in a few minutes),
dyskinesia (medication induced hyperkinetic movement),
freezing of gait,
wearing off phenomenon towards end of dose,
falls

Question 22

non motor complication of PD

Answer 22

aspiration pneumonia, nutritional deficiency, dysphagia, weight loss, bladder, bowel + sexual dysfunction, pressure sores, sleep disorders, dementia, depression, postural hypotension, impulse control disorders and psychosis

Question 23

initial management of PD

Answer 23

levodopa - long term side effects
dopamine agonists (ropinirole, pramipexole) - impulse control problems 
MAOB inhibitors rasagiline

Question 24

differentials for PD

Answer 24

Parkinson plus syndromes

• Multi-system atrophy (rapidly progressing, severe autonomic dysfunction);
• Progressive supranuclear palsy (vertical gaze dysfunction, dysarthria + cognitive decline, no tremor);
• Dementia with Lewy-body (dementia precedes motor symptoms + hallucinations + fluctuating consciousness)
• Corticobasal degeneration (progressive dementia, parkinsonism + limb apraxia + alien limb)

Drug induced: anti psychotics, anti-emetics, lithium, methyldopa

Other pathology: post-encephalitis, tumor, vascular

Question 25

what is parkinsonism

Answer 25

bradykinesia + at least one of: Resting tremor, rigidity, postural instability

Question 26

non motor symptoms of parkinson

Answer 26

depression, dementia, sleep disturbance and autonomic dysfunction

Question 27

features of PD

Answer 27

Clinical features: bradykinesia, resting ‘pill-rolling’ tremor and cogwheel rigidity Other features: expressionless face, micrographia, soft voice, drooling, shuffling gait, glabellar tap, depression, bowel + bladder symptoms, sleep disorder, sexual dysfunction