Neurology: Past Paper Questions Flashcards
A 50-year-old woman presents to the emergency department with a 3-hour history of severe headache. She has taken paracetamol which has had no improvement to her symptoms. There are associated symptoms of photophobia, neck stiffness, and nausea.
Her medical history includes hypertension and polycystic kidney disease. She has a 25-year smoking pack history and drinks 2 standard drinks a night.
What would be the best initial investigation?
CRP
Contrast CT head
Lumbar puncture
MRI brain
Non-contrast CT head
Non- contrast CT head
SAH can present with signs of meningeal irritation
…… …… ……. is the gold standard for detecting intracranial haemorrhage.
Non-contrast CT
A 26-year-old male is struck on the side of the head above the ear by a fast moving golf ball. He lost consciousness for a few seconds, initially recovered, but then progressively lost consciousness again. He is taken immediately to the emergency department and a CT head revealed a right-sided extradural haematoma. He is noted to have a right-sided dilated and unreactive pupil.
What cranial nerve is being compressed in order to explain his pupillary abnormality?
2
3
4
5
6
3- oculomotor (efferent part of pupil reflex)
Uncal herniation causes a dilated pupil due to compression of the third cranial nerve
…….. causes a dilated pupil due to compression of the third cranial nerve
Uncal herniation
when to CT after head injury
CT head within 1 hour
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
after a subarachnoid ahemorrhage what may be found in the lumbar puncture
xanthochromia
yellow discoloration indicating the presence of bilirubin in CSF which appears as oxyhaemoglobin released from the breakdown of red blood cells following haemorrhage into the CSF is converted in vivo into bilirubin in a time-dependent manner.
A 57-year-old female attends the emergency department with a sudden onset of a severe occipital headache and two episodes of vomiting in the past hour. An urgent CT scan finds no abnormalities, however, a lumbar puncture taken 12 hours later is positive for xanthochromia, and subarachnoid haemorrhage (SAH) is diagnosed. Urgent neurosurgical review is requested and a CT cerebral angiography indicates a posterior communicating artery aneurysm as the cause of the SAH. The patient is otherwise fit and well.
Which option is most likely to be the optimal treatment for the aneurysm?
Insertion of an extraventricular drain
Extracranial-intracranial bypass
Coiling by an interventional neuroradiologist
Nimodipine only
Surgical clipping
Coiling by an interventional neuroradiologist
You are called to see a 33-year-old male on the ward who is recovering following a subarachnoid haemorrhage (SAH) he had three days ago. Today, he has become more drowsy and nauseous and is complaining of a new headache and muscle cramps. Physical examination is normal.
What is the most likely diagnosis?
Adrenal crisis
Cerebral herniation
Encephalitis
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Vasospasm
SIADH is a common consequence of subarachnoid haemorrhage
You are covering the neurosurgical unit over night. One of your patients is a man in his seventies, who presented with an intracerebral bleed. CT scan showed there was some extension of the bleed into the ventricles. The patient has remained stable during the day, but one of the nurses bleeps you to inform you that the patient’s Glasgow Coma Scale score has dropped. It was previously 15, but now he only localising to pain. What is the most likely cause of his symptoms?
Expansion of the haematoma
Hyponatraemia
Hydrocephalus
Vasospasm
Hypoglycaemia
Hydrocephalus is a common complication from intraventricular haemorrhages
A 37-year-old woman in her second pregnancy has delivered a live male infant. She has no past medical history of note. Ten minutes after delivery, she complains of a sudden onset severe occipital headache that is associated with vomiting. On examination there is evidence of photophobia. Shortly after this she losses consciousness and has a Glasgow coma score of 8. A CT scan shows blood in the sulci, fissures, basal cisterns. What is the most likely diagnosis?
Extra-dural haematoma
Sheehan’s syndrome
Sub-dural haematoma
Subarachnoid haemorrhage
Intracerebral haemorrhage
x
A subarachnoid haemorrhage (SAH) is a type of stroke which is usually the result of bleeding from a berry aneurysm in the Circle of Willis. Key clinical features include a sudden onset headache which reaches maximum severity in seconds to minutes (‘thunderclap headache’) and meningitic symptoms (for example photophobia and neck stiffness).
A 17-year-old male presents to the emergency department (ED) following a head injury during a rugby match.
His parents who witnessed the injury tell you he lost consciousness immediately after the collision for a number of minutes. He was then alert and himself for a couple of hours. They have now bought him to ED as he became drowsy and was complaining of a headache.
On examination his Glasgow coma scale (GCS) is 12, the pupils are unequal and there is a clear swelling on the right side of the head.
Given the likely diagnosis of an intracranial haemorrhage, which vessel has most likely been damaged?
Bridging veins
Carotid artery
Circle of Willis
Dural artery
Middle meningeal artery
Middle meningeal artery
Extradural or subdural haemorrhage?
Extradural = lucid period, usually following major head injury. Subdural = fluctuating consciousness, often following trivial injury in the elderly or alcoholics
A 55-year-old man presents to his GP with visual disturbance.
On examination, the patient is noted to have visual field abnormalities; he is unable to perceive stimuli in the superior temporal field of his left eye and the superior nasal field of his right eye.
The GP requests an MRI urgently.
Where is a lesion most likely to be found?
Left parietal lobe
Left temporal lobe
Optic chiasm
Right parietal lobe
Right temporal lobe
Right temporal lobe
Superior homonymous quadrantanopias are caused by lesions of the inferior optic radiations in the temporal lobe
A 27-year-old man attends his GP with increasing ascending weakness in his legs. He is otherwise well, although he had an episode of diarrhoea and vomiting from a barbecue outing with his friends 3 weeks ago. He does not have any other medical conditions.
On examination, there are reduced ankle reflexes and mild distal paraesthesia of his legs.
What symptom is commonly seen in patients with the likely diagnosis?
Back pain
Diarrhoea
Diplopia
Fasciculations
Papilloedema
Back/leg pain is seen in the majority of patients with Guillain-Barre syndrome
Important for meLess important
Back pain is the correct answer. The patient’s recent history of gastroenteritis followed by peripheral nerve symptoms suggests Guillain-Barre syndrome, an immune-mediated peripheral neuropathy that often occurs 1-3 weeks post-infection. Pain, particularly in the back and legs, is a common early feature due to nerve root inflammation and may precede motor symptoms such as weakness. This pain, described as deep, aching or cramping, serves as an important early clinical clue in diagnosing Guillain-Barre syndrome, especially when coupled with a history of recent infection and symptoms of ascending weakness.
first symptom of GBS usually
back pain
A 17-year-old girl is referred to a neurologist for recurrent episodes of ‘jerks’. These often occur in the morning and involve a sudden brief jerk in one of her limbs. So far she has had 6 episodes. On questioning, she has not had any episodes when she has lost consciousness.
She lives with her parents, is a non-smoker, rarely drinks alcohol, and is sexually active. She has no other past medical history.
What is the most appropriate step in her management?
Carbamazepine
Ethosuximide
Levetiracetam
Phenytoin
Sodium valproate
Myoclonic seizures: levetiracetam is first-line for females
treatment of myoclonic seizures in males
sodium valproate
Drug treatment according to the type of epilepsy
Generalised tonic-clonic seizures
males: sodium valproate
females: lamotrigine or levetiracetam
girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
Myoclonic seizures
males: sodium valproate
females: levetiracetam
Tonic or atonic seizures
males: sodium valproate
females: lamotrigine
which seizure type isnt treated with sodium valproate
Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
A 45-year-old man presents to the emergency department with pain in his lower back, buttocks, and legs over the last 5 days that persists at rest. Today he has noticed weakness and pins and needles. He has a history of ischaemic heart disease, type 2 diabetes, and an episode of gastroenteritis 2 weeks ago. He has a family history of ankylosing spondylitis. The patient works as a builder.
He is afebrile, his pulse is 85 bpm, and his blood pressure is 135/75 mmHg. Despite having paraesthesia, lower limb sensation is intact. There is bilateral lower limb weakness and hyporeflexia.
What is the most likely diagnosis?
Ankylosing spondylitis
Guillain-Barré syndrome
Lumbar spinal stenosis
Neoplastic spinal cord compression
Peripheral arterial disease
Guillain-Barré syndrome (GBS) is correct.
- Gastroenteritis followed by 1-3 weeks of** lower back and leg** pain along with paraesthesia and weakness suggests GBS.
- Despite having paraesthesia, many patients still have intact sensation.
- GBS is a peripheral neuropathy, meaning it affects nerves outside the central nervous system (CNS, the brain and spinal cord)- lower motor neurone (LMN) signs, such as flaccidity and hyporeflexia.
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. On examination, there is no obvious limb weakness, but you note bitemporal hemianopia. A CT head shows areas of hyperdensity within the sellar region.
What is the most appropriate immediate next step?
CT head with contrast
Formal visual field testing
IV hydrocortisone
MRI pituitary
Refer to neurosurgery for pituitary adenoma resection
Pituitary apoplexy - urgent steroids priority
Pituitary apoplexy
Sudden enlargement of a pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction.
Precipitating factors
hypertension
pregnancy
trauma
anticoagulation
Features
* sudden onset headache similar to that seen in subarachnoid haemorrhage
* vomiting
* neck stiffness
* visual field defects: classically bitemporal superior quadrantic defect
* extraocular nerve palsies
* features of pituitary insufficiency
* e.g. hypotension/hyponatraemia secondary to hypoadrenalism
Investigation
MRI is diagnostic
Management
* urgent steroid replacement due to loss of ACTH
* careful fluid balance
* surgery
A 50-year-old man presents with a facial droop. On examination, he has a crooked smile that droops on the left. He cannot close his left eye or wrinkle the left side of his forehead. He has no upper or lower limb weakness or sensory changes.
What is the most likely cause of this presentation?
Lateral medullary syndrome
Left cranial nerve VII lower motor neuron lesion
Left cranial nerve VII upper motor neuron lesion
Right cranial nerve VII lower motor neuron lesion
Right cranial nerve VII upper motor neuron lesion
Bell’s palsy is a lower motor neuron condition. Unlike UMN conditions of the face, in LMN conditions the entire side of the patients face is affected
A 65-year-old woman presents with a 4-week history of progressive deafness and ringing in the right ear. On examination, there is a normal tympanic membrane and ear canal. Rinne’s test was normal on both sides with air conduction better than bone however on Weber’s testing the sound is heard best in the left ear.
What is the most likely diagnosis?
Otosclerosis
Otitis media
Presbyacusis
Meniere’s disease
Acoustic neuroma
Acoustic neuroma is an important differential diagnosis in patients with unilateral deafness or tinnitus
- sensineural hearing loss
A 77-year-old gentleman reports an ongoing feeling of ringing in his right ear for the past 3 months. For the past 3-weeks, he has also noticed that he struggles to hear from his right ear.
On examination, Rinne’s test shows that air conduction is louder than bone conduction in the right ear and Weber’s test lateralises to the left ear.
Unilateral tinnitus associated with deafness is likely to be a feature of which one of these conditions?
Multiple sclerosis
Chronic otitis media
Acoustic neuroma
Stroke
Labyrinthitis
Acoustic neuroma
- unilateral hearing loss
- tinnitus
A 23-year-old man with difficult to control epilepsy is reviewed in clinic, four months after a change in his antiepileptic medication. He has remained seizure free but has gained 5 kg in weight since last reviewed. Which one of the following antiepileptic drugs is most associated with weight gain?
Ethosuximide
Sodium valproate
Levetiracetam
Carbamazepine
Lamotrigine
Sodium valproate may cause weight gain
A 35-year-old man presents with progressive weakness of his hands. On examination you notice wasting of the small muscles of the hand. A diagnosis of syringomyelia is suspected. Which one of the following features would most support this diagnosis?
Hyper-reflexia in the upper limbs
Loss of vibration sensation in the hands
Loss of temperature sensation in the hands
Loss of light touch sensation in the hands
Fasciculation of the small muscles of the hand
Loss of temperature sensation in the hands
Syringomyelia - spinothalamic sensory loss (pain and temperature)
An 18-year-old girl with a known Chiari 1 malformation presents to her General Practitioner with loss of sensation in both of her arms and forearms, and on the back of her neck. On testing, she specifically can’t feel pain and temperature but can detect fine touch, proprioception and vibration.
Which of the following abnormalities has this patient most likely have?
Syringomyelia
Hydrocephalus
Brain stem compression
Cerebellar compression
Peripheral neuropathy
Chiari malformations are often associated with syringomyelia due to disturbed cerebrospinal fluid flow at the foramen magnum
A 64-year-old woman with a background of rheumatoid arthritis now presents with a high-stepping gait and an inability to dorsiflex her left foot. The foot is not painful.
On examination she is systemically well. There is reduced tone in the left foot but no pain on passive movement of the joint. There is no pain on straight leg raise and hip abduction is normal. Plantars are downgoing. There is some sensory loss over the dorsum of the left foot and the lateral left lower leg.
What is the most likely pathology?
Anterior cerebral artery infarct
L5 radiculopathy
Common peroneal nerve palsy
Septic arthritis
Charcot-Marie-Tooth syndrome
‘Foot drop’ - ?common peroneal nerve lesion
Important for meLess important
Injury often occurs at the neck of the fibula
The most characteristic feature of a common peroneal nerve lesion is foot drop.
Other features include:
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
miller fisher syndrome
- variant of Guillain-Barre syndrome
- associated with ophthalmoplegia, areflexia and ataxia
- The eye muscles are typically affected first
usually presents as a descending paralysis rather than ascending as seen in other forms of Guillain-Barre syndrome - anti-GQ1b antibodies are present in 90% of cases
