Neurology Passmed Flashcards
Contralateral hemiparesis and sensory loss, lower extremity > upper
Where is the lesion?
Anterior cerebral artery
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
Where is the lesion?
Middle cerebral artery
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Where is the lesion ?
Posterior cerebral artery
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Where is the lesion?
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
What is the site of the lesion in a stroke that causes ipsilateral facial paralysis and deafness?
Anterior inferior cerebellar artery (lateral pontine syndrome)
Locked in syndrome is caused by a lesion of which artery?
Basilar artery
A 56-year-old man presents to the emergency department with sudden onset double vision and right-sided upper and lower limb weakness.
On examination, there is ptosis of the left eyelid and the left eye is shifted downward and laterally. There is reduced power and sensation in the upper and lower right limbs.
What is the most likely diagnosis?
Weber’s syndrome
a form of midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis
A 66-year-old woman reports that during the past 6 months she has had several episodes of a sharp, shooting ‘electric shock’ like pain on the left side of her face, which occur when she is combing her hair.
Given the likely diagnosis which one of the following treatments should be initiated?
Trigeminal neuralgia = carbamazepine
Carbamazepine should be started at 100 mg twice daily and titrated up until pain is relieved
A 72-year-old man develops visual problems. He is noted to have a left homonymous hemianopia with some macula sparing.
Where is the lesion?
Occipital cortex - suggested by macular sparing
A 54-year-old man complains of sweating, headaches and reduced visual fields, saying it’s like having ‘blinders’ on. He is noted to have a bitemporal hemianopia on examination.
Where is the lesion?
Optic chiasm
This patient has a pituitary tumour causing compression of the optic chiasm and bitemporal hemianopia. The sweating and headaches are consistent with acromegaly.
A 30-year-old man with a family history of early blindness is concerned that he is developing ‘tunnel vision’.
Where is the lesion?
Retina
This is a common presentation of retinitis pigmentosa. Extensive pigmentation would normally be noted on fundoscopy.
Which is the strongest risk factor for developing Bell’s palsy?
pregnancy (3x higher risk)
Widespread convulsions without conscious impairment =
Psychogenic non-epileptic seizure
Which nerve roots are tested by ankle reflexes?
S1-S2
Which nerve roots are tested by knee reflexes?
L3-L4
Which nerve roots are tested by biceps and triceps lesions?
Biceps C5-C6
Triceps C7-C8
At what GCS should you consider intubating a patient (e.g. with a cuffed endotracheal tube)?
less than 8 = INTUBATE
A woman suddenly has the sensation of smelling roses whilst at work. She is conscious throughout - what is the diagnosis?
focal aware seizure
Head trauma + fluctuating consciousness =
subdural haemorrhage
Normal pressure hydrocephalus presents in elderly patients with urinary incontinence,
reversible dementia and gait abnormality.
How does this appear on neuroimaging?
Ventriculomegaly with relative preservation of cortical sulci
A 30-year-old woman is admitted to hospital with an unprovoked first seizure. She attends neurology clinic and asks for advice regarding driving as she uses her car to drop her children to school. The neurologist has not made a formal diagnosis of epilepsy.
What should you advise her?
She should inform the DVLA and will have to be seizure free for 6 months before she can apply to have her license reinstated
If the patient has a formal diagnosis of epilepsy they must be seizure-free for at least 12 months before they may reapply to the DVLA for their license to be reissued
A 23-year-old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly weakened.
Where is the likely site of the nerve injury?
Median
median nerve damage = loss of function of the muscles of the thenar eminence
A 45-year-old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is impaired.
Where is the likely site of the nerve injury?
Intercostobrachial
The intercostobrachial nerves are frequently injured during axillary dissection.
An 8-year-old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand.
Where is the likely site of the nerve injury?
Median
Median nerve is responsible for pronation of the forearm
Brachial artery (responsible for radial pulse) runs alongside the median nerve
A 40-year-old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand.
Where is the likely site of the nerve injury?
Ulnar nerve
The interossei are supplied by the ulnar nerve.
A 23-year-old man is involved in a fight outside a nightclub and sustains a laceration to his right arm. On examination he has lost extension of the fingers in his right hand.
Where is the likely site of the lesion?
radial nerve
supplies the extensor muscles of the hand
A 34-year-old contractor has fallen off some scaffolding at work onto his right arm and you suspect a mid-shaft humeral fracture. Which of the following would test the nerve most at risk in this situation?
Extend the wrist
Mid-shaft humeral fractures are associated with radial nerve injury and wrist drop.
What should you rule out in all patients with status epilepticus?
rule out hypoxia and hypoglycaemia
Tx of choice for essential tremor?
propanolol
First line tx for focal seizures?
lamotrigine or levetiracetam
First line radiological investigation for suspected stroke?
non-contrast CT head
An 85-year-old man is admitted with dense right-sided weakness. His blood pressure on admission is 175/95 mmHg .
He has a past medical history of gastric ulcer disease and had a nephrectomy 2 months ago due to renal cell carcinoma.
CT head shows a hyperdense collection in the left basal ganglia with evidence of chronic small vessel disease.
What would be an absolute contraindication to thrombolysis in this case?
CT findings
a hyperdense collection is suggestive of a haemorrhage and hence a contraindication to thrombolysis/thrombectomy
Weakened dorsiflexion, inversion and eversion of the ankle =
L5 nerve lesion NOT a common peroneal nerve lesion
Common peroneal nerve palsy does NOT affect INVERSION of the ankle
Another specific sign to look for is loss of sensation over the first web space between the 1st and 2nd toes - that suggests an L5 nerve lesion
Bitemporal hemianopia with lower quadrants primarily affected =
superior chiasmal compression, commonly a craniopharyngioma
Bitemporal hemianopia with upper quadrants primarily affected =
inferior chiasmal compression, commonly a pituitary tumour
fever, seizure and CT head showing temporal lobe changes =
think herpes simplex encephalitis
Herpes simplex encephalitis (HSE) is the commonest cause of sporadic encephalitis
Start IV aciclovir!!!
What blood marker can be used to differentiate between a true seizure and a pseudoseizure?
Prolactin
What is the most common complication following meningitis?
Sensorineural hearing loss
A lesion of which area causes Wernicke’s aphasia?
superior temporal gyrus
A lesion of which area causes Broca’s aphasia?
inferior frontal gyrus
A 36-year-old man is admitted with an acute episode of mania. He is initially treated with haloperidol which seems to improve his mental state. Later that day he develops a high fever, tachycardia, tachypnoea and muscle rigidity.
What is the diagnosis?
How should you treat?
neuroleptic malignant syndrome
stop antipsychotic, IV fluids to prevent renal failure, consider bromocriptine (dopamine agonist)
When and how can anti epileptic drugs be stopped?
Can be considered if seizure free for > 2 years, with AEDs being stopped over 2-3 months
A patient describes a ‘curtain closing’ from the left side of his vision which left him with a crescent of blackness on his left.
What is the most likely underlying cause?
Atherosclerosis of the left internal carotid- amaurosis fugax of the left retinal/ophthalmic artery
If a patient presents with a conductive aphasia, and the question asks if it originated from their left or right MCA, how can you tell which one?
MCA lesions in the DOMINANT hemisphere cause aphasia
so if the patient is right handed, the left is their dominant hemisphere, and it will be a lesion of their LEFT MCA that causes aphasia
Which muscles are typically spared in MND?
Ocular muscles
Which anti-Parkinsons medications are associated with the highest chance of inhibition disorders?
Dopamine receptor agonists
e.g. bromocriptine, ropinirole, cabergoline, apomorphine
Syncopal episodes can present with muscle jerks.
How can they be differentiated from generalised seizures if they present in this way?
rapid recovery and short post-ictal period
lack of incontinence or tongue biting
What can be given for secondary prevention following stroke if clopidogrel is not tolerated?
aspirin and modified release dipyramidole
Patient with suspected Parkinson’s disease and diplopia =
consider an alternative diagnosis
Diplopia is not common in Parkinson’s disease and may suggest an alternative cause of parkinsonism such as progressive supranuclear palsy
LP findings in Guillain Barre syndrome?
Increased protein levels with normal white cell count
A 37-year-old hypertensive woman presents to ED with a 1-hour history of sudden onset headache and N+V. Since arrival in the department, she has complained of new onset facial pain over her right maxilla. Her D dimer is 1500 (normal =500).
What is the likely diagnosis?
How can you investigate?
Venous sinus thrombosis
MR Venogram is the gold standard test for diagnosing venous sinus thrombosis
When is carotid endarterectomy considered for TIA patients ?
carotid artery stenosis exceeding 50% on the side contralateral to the symptoms
Bell’s palsy management ?
commence on a course of prednisolone (if present within 72 hours of onset) and give eye care advice
Confusion, ataxia, nystagmus/ophthalmoplegia→
give Pabrinex (IV B/C vitamins)
likely Wernicke’s encephalopathy
A 47-year-old female is reviewed in the neurology clinic. She was diagnosed with epilepsy whilst a teenager and her seizures are well controlled. She is however concerned about increasing numbness of her fingers and soles of her feet.
Which epilepsy medication is most likely to be responsible?
Phenytoin
Can’t PHEEL-y-TOE-n
first-line medications for spasticity in multiple sclerosis?
Baclofen and gabapentin
Urinary incontinence + gait abnormality + dementia =
normal pressure hydrocephalus
A 58 year old man presents with left sided paraesthesias affecting his thumb and first finger. He complains of grip weakness and dropping objects unintentionally. On examination, there is wasting over the thenar eminence.
Which of the following signs would suggest a diagnosis other than carpal tunnel syndrome?
Hoffmans sign : a sign of upper motor neuron dysfunction e.g. DCM
To elicit it, the examiner should flick the patients distal phalanx (usually of the middle finger) to cause momentary flexion. A positive sign is exaggerated flexion of the thumb.
What adverse effects may be associated with triptan use?
‘triptan sensations’ - tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
How may aura associated with migraine be described?
spreading scintillating scotoma (‘jagged crescent’)
NICE recommends to offer thrombectomy and thrombolysis within 6 hours of sx onset for ischaemic stroke.
When may an extended target time of 6-24 hours be considered?
if there is the potential to salvage brain tissue
CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume
What is the preferred modality in patients with suspected TIA who require brain imaging?
MRI brain with diffusion-weighted imaging
Management of myasthenic crisis?
IV immunoglobulin, plasmapheresis
rapid onset dementia and myoclonus =
Sporadic Creutzfeldt-Jakob disease (CJD)
What can be used for migraine prophylaxis in women of childbearing age?
Propranolol
preferable to topiramate in women of childbearing age
Gait ataxia is caused by lesions in which part of the brain?
Cerebellar vermis
A 66-year-old woman comes to see you following her first TIA. She would like to know more about when she can start driving her car again.
What would you advise?
Can start driving if symptom free after 1 month - no need to inform the DVLA
A 40-year-old woman presents with weakness and numbness of her hand which gets worse when she raises her hands above her head. She is also complaining of a painful neck and generalised headache. On examination there is wasting in her thenar eminence.
Which is the most likely cause of her symptoms?
Neurogenic Thoracic outlet syndrome
investigation of choice for narcolepsy ?
multiple sleep latency EEG
Middle-aged, personality changes, involuntary movements →
?Huntington’s disease
Which type of motor neuron disease carries the worst prognosis?
Progressive bulbar palsy
Which cranial nerves may be affected by acoustic neuromas?
V, VII and VIII
‘Young’ stroke blood tests are performed in those under 55 with no obvious cause of a stroke. What do they include?
Autoimmune and thrombophilia screening
Syphilis serology
Headache linked to Valsalva manoeuvres =
raised ICP until proven otherwise so LP is contraindicated
request urgent CT head
Which diet is most likely to be effective in epilepsy for improving symptom control?
Ketogenic diet
How should you investigate an MS patient with bladder dysfunction?
Ultrasound kidneys, ureters and urinary bladder (KUB) to assess bladder emptying
A 52-year-old male with a known pituitary macroadenoma presents with a severe headache and reduced visual acuity. He also complains of neck stiffness and has vomited twice. The patient has a blood pressure of 96/48 mmHg and a heart rate of 125 bpm. A CT head shows areas of hyperdensity within the sellar region.
What is the likely diagnosis?
What is the most appropriate immediate next step?
pituitary apoplexy: bleeding/infarction within the pituitary adenoma, rare and life threatening complication
tx with urgent steroid replacement due to loss of ACTH
What is the risk of giving folate to a patient deficient in B12 ?
can precipitate subacute combined degeneration of the cord
Intracerebral haemorrhage is an uncommon but serious complication of thrombolysis in an acute ischemic stroke.
How should you manage this?
Stop Aspirin 300mg & control BP
A 75-year old gentleman presents with a short history of neck pain, paraesthesia in his finger tips and progressive leg weakness. Following a MRI scan of his spine, he is diagnosed with degenerative cervical myelopathy due to a C4/5 disc prolapse.
What is the most appropriate management?
Cervical decompressive surgery
What is used for long-term prophylaxis of cluster headaches?
Verapamil
What is the tetrad of neuroleptic malignant syndrome?
hyperthermia, muscle rigidity, autonomic instability, altered mental status
Patient on antipsychotics presents with hyperthermia, muscle rigidity, autonomic instability, and altered mental status.
What is the diagnosis?
neuroleptic malignant syndrome
A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present.
Which diagnosis needs to be urgently excluded?
posterior communicating artery aneurysm
A 50-year-old man who, on examination, you notice his jaw appears deviated towards the right and he has an absent right-sided corneal reflex.
Which cranial nerve palsy would explain this?
Trigeminal
A 64-year-old woman who reports vertical diplopia, in particular, whilst reading in bed at night time.
Which cranial nerve palsy would explain this?
Trochlear
A 72-year-old man who has noticed a change in his voice with some difficulty swallowing. On examination, you notice his uvula deviates towards the right.
Which cranial nerve palsy would explain this?
Vagus (left side)
A 65-year-old male with known nasopharyngeal carcinoma presents with double vision. On examination he is found to have left eye proptosis and it is down and out. He reports pain on attempting to move the eye. There is an absent corneal reflex.
What is the most likely diagnosis?
Cavernous sinus syndrome
the nasopharyngeal malignancy has locally invaded the left cavernous sinus
Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner’s syndrome
Which common medication may trigger migraine?
oral COCP
A 23-year-old man wakes up on a Sunday morning unable to extend his wrist . He had been drinking heavily the previous night.
What is the likely cause of his weakness?
Radial nerve palsy
‘Saturday night palsy’ caused by compression of the radial nerve against the humeral shaft, possibly due to sleeping on a hard chair with his hand draped over the back
A concerned mother brings her 4-year-old son to you the GP. She says her son has not been growing relative to his peers in school. On examination, he has 6 individual, 4cm oval pigmented lesions on his trunk and has freckles in both of his axillae.
What is the most likely diagnosis?
Neurofibromatosis type 1
A patient who has experienced significant head trauma presents with clear fluid dripping down his nose. What is a quick and easy bedside test to perform to confirm that the fluid is CSF?
Check glucose
Glucose test would show positive as it is not present in mucus and is present in CSF.
A 25-year-old man attends with a 3-month history of numbness in his right hand. On examination, you note the loss of sensation to the palmar and dorsal aspect of the 5th digit. Sensation of the forearm is preserved.
What is the most likely diagnosis?
Cubital tunnel syndrome - ulnar nerve neuropathy
Laughter → fall/collapse =
?cataplexy
Autonomic dysreflexia can only occur if the spinal cord injury occurs above which level?
T6
Which medications are associated with idiopathic intracranial hypertension?
tetracycline antibiotics
isotretinoin
contraceptives
steroids
levothyroxine
lithium
What should be given if a patient with status epilepticus is not responding to benzos (e.g. lorazepam)?
IV levetiracetam, phenytoin or sodium valproate
What would provide a definitive diagnosis of medication overuse headaches?
Symptoms resolve (or revert to their original pattern) within 2 months of stopping co-codamol
What should be offered for patients with newly diagnosed Parkinson’s who have motor symptoms affecting their quality of life?
Levodopa
Distal sensory loss, tingling + absent ankle jerks/extensor plantars + gait abnormalities/Romberg’s positive →
subacute combined degeneration of the spinal cord
A 34-year-old woman presents with a 3 month history of double vision. On examination the right eye fails to adduct and the left eye develops coarse nystagmus in abduction.
What is the most likely diagnosis?
Internuclear ophthalmoplegia (INO)
occurs due to a lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement
Jacksonian movement (clonic movements travelling proximally) suggests what?
frontal lobe epilepsy
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension) =
Multiple System Atrophy
