NEUROLOGY PEER TUTORING - Doesnt include Question 5 (parkinsons), 6 (multiple sclerosis), 7 (meningitis), 8 (stroke)

Question 1

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 1. A mother notices that her 4 year old son has episodes where he “just stops and stares”. On an EEG you see a 3 Hz spike and wave pattern

Answer 1

C - This is an absence seizure Type of primary generalised seizure Associated with the childs eyes rolling upwards also and usually only lasts 10 or so seconds

Question 2

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 2. A 4 year old girl having episodes of sudden collapse and flaccidity

Answer 2

F - This is an atonic seizure Another type of primary generalised seizure Child becomes flaccid ans usually falls because of this

Question 3

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 3. A 23 year old male who is observed having a period of increased tone followed by jerking movements of his arms and legs. After his seizure he is confused and has blood in his mouth

Answer 3

A - Generalised tonic clonic seizure There is the period of increased tone in then his limbs start jerking - this is what majority of public think when they here epilespy Also known as a grand mal seizure

Question 4

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 4. An 18-year-old male patient describes periods of twitching of the left side of his face that spreads to affect his left arm and shoulder. Afterwards he describes weakness of his left arm

Answer 4

B -Jacksonian seizure Followed by a Todd’s palsy can happen after frontal lobe seizures

Question 5

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 5. A 12 year old boy describes a feeling of unreality followed by seeing things that he knows aren’t there

Answer 5

E - Temporal lobe seizure Type of partial seizure * Can get automatism - non-purposeful, repetitive movement control * Memory phenomena, hippocampal (emotional change), uncal (hullucinations of visual/taste/dreamlike reality) * Delusion Dysphasia * Abdominal rising sensation or pain

Question 6

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 6. 30 year old woman with a long history of seizures. They are typically 10 minutes long, & involve violent thrashing about & shouting with no post ictal confusion. She has been managed with a variety of non epileptic drugs with little effect.

Answer 6

G - Functional seizure Also known as non-epileptic attack disorder Usually occurs in females around 10-30 years of age Doesnt respond to epileptic drugs Psychological cause Features suggestive are - seizure over two minutes, gradul onset, violent thrashing, eyes closed Treatment - CBT

Question 7

Question 1: Fits and seizures - What is the likely diagnosis. a Generalised tonic clonic seizure e Temporal lobe seizure b Jacksonian seizure f Atonic seizure c Absence seizure g Functional Seizure d Febrile convulsion h Vasovagal 7. 6 month old baby presented to the GP with a “fit” lasting 60 seconds. It was noted the child had a fever just before this.

Answer 7

D - Febrile convulsion Typically present in children aged 0.5-5years Fever notcied and child then comes in with a tonic clonic seizure If lasting greater than 5 minutes, can treat with a benzo - not given any anti-epileptics however

Question 8

How are partial and generalised seizures treated?

Answer 8

Partial (simple, complex +/- secondary generalisation) * 1st line - carbamezapine * 2nd line - lamotrigine then sodium valproate Primary generalised seizures * Generalised tonic clonic - 1st line - sodium valproate or lamortrigine, 2nd line- carbamezapine/topiramte * Tonic, myoclonic, atonic - 1st line - same as tonic-clonic, avoid carbameapine and oxycarbazepine * Absence - Sodium valproate, lamotrigine or ethosuximide

Question 9

Question 2: Headaches - Answer and how this develops? a Subarachnoid Haemorrhage e Extradural haematoma b Cluster headache f Giant cell arteritis c Tension headache g Migraine d Subdural haematoma h Benign intracranial hypertension 1. 70 year old alcoholic presented with gradual onset headache. He cannot remember falling or any traumatic injury. On examination he appears drowsy and unsteady on his feet

Answer 9

D - This is a subdural haematoma Due to bleeding between the cortex and venous sinuses in the bridging veins- causes accumulation of haematoma between dura and arachnoid matter. The bridging veins are weaker in the elderly and therefore more likely to bleed, associated with alcohol and patients on anti-coagulants also Usually patient has a fall but is a while ago and therefore the trauma can be forgotten Very gradual onset as well

Question 10

Question 2: Headaches - How is this treated? a Subarachnoid Haemorrhage e Extradural haematoma b Cluster headache f Giant cell arteritis c Tension headache g Migraine d Subdural haematoma h Benign intracranial hypertension 2. 64 year old hypertensive male admitted with sudden onset headache “like being hit over the head by a bat”. On examination he had a stiff neck and photophobia. His CSF appeared xanthochromic

Answer 10

A - Subarachnoid haemorrhage Hypertension is a major risk factor The pain is severe and acute Usually due to berry aneurysm rupture in the circle of willis Signs of meningism because blood irritates the meninges Ct to confirm, CT angiogram to exclude multiple aneurysms Endovascular coiling (or clipping) - prevents re-bleeding Nimoipine - prevent delayed ischaemia - also aim for SBP >/=160mmHg, haemodilute and treat hyponatraemia

Question 11

Question 2: Headaches a Subarachnoid Haemorrhage e Extradural haematoma b Cluster headache f Giant cell arteritis c Tension headache g Migraine d Subdural haematoma h Benign intracranial hypertension 3. 73 year old man presented to his GP with very tender scalp and pain in his jaw during eating. You notice a prominent, non-pulsatile vessel around the tender site.

Answer 11

F - Giant cell arteritis Large cell vasculitis occuring mainly in patients over 40/50 Associated with polymyalgia rheumatica - pain stiffness and inflammation in shoulders and hips Treat with high dose steroids - 60mg Take bloods - Look for raised CRP Should have no antibodies present

Question 12

Question 2: Headaches - State the features and treatment? a Subarachnoid Haemorrhage e Extradural haematoma b Cluster headache f Giant cell arteritis c Tension headache g Migraine d Subdural haematoma h Benign intracranial hypertension 4. 24 year old woman presents to A&E with gradual onset of headache lasting 4 hours. The pain is localised to the left side above and around the eye. She prefers to lie in a darkened room.

Answer 12

G - Migraine • Typical – throbbing unilateral headache, lasts 4-72 hrs • Assoc nausea, vomiting, photophobia, photophonia, can have aura * NSAIDs 1st line * Triptans 2nd line * If 3or more migraines, give propranolol as prophylaxis or amitriptyline or topiramate

Question 13

Question 2: Headaches a Subarachnoid Haemorrhage e Extradural haematoma b Cluster headache f Giant cell arteritis c Tension headache g Migraine d Subdural haematoma h Benign intracranial hypertension 5. A 19 year old obese woman presents to her GP with an 8 week history of morning headache, made worse by coughing, and of several episodes of transient blurring of vision. Fundoscopy demonstrates bilateral papilloedema.

Answer 13

H -Benign intracranial hypertension Worse in morning due to increase in ICP (same as for coughing) Bilateral pappiloedema shows raised intracranial pressure * • Classic story – morning headache, worse on straining, vision affected, papilloedema * • Typically young obese females * • Prednisolone acutely, acetazolamide chronically to reduce ICP * • May need lumbar puncture to relieve symptoms

Question 14

How dos this typically present and the treatment and prophylaxis?

Answer 14

B - Cluster headaches * Severe stabbing and unilateral - typical of trigeminal autonomic cephalgias * Seeks relief by keeping active * Headache lasts between 15minutes - 3hours Treatment * High flow O2 20minutes, 6mg sumitriptan subcut, give steroids 40mg reducing over next 2 weeks * Prophylaxis - verapimil

Question 15

Question 3: CNS Lesions a Conus lesion e L5/S1 Disc prolapse b Wernicke’s area f L3/L4 Disc prolapse c Right T10 Cord Hemisection g Broca’s area d Left T10 Cord Hemisection h Central Cord lesion 1. Patient presents with left sided leg weakness, loss of fine touch and loss of proprioception with right sided loss of pain sensation below the level of umbilicus

Answer 15

D - Left T10 cord hemisection - known as Brown-Sequard syndrome The T10 dermatome is at the level of the umbilicus and therefore hemisection at this level will affect below the umbilcus Corticospinal tract is ipsilateral - decussates at medulla (85%) DCML - ipsilateral - decussates at medulla Spinothalamic is contralateral - decussates at spinal cord level (couple levels above to be precise)

Question 16

Question 3: CNS Lesions a Conus lesion e L5/S1 Disc prolapse b Wernicke’s area f L3/L4 Disc prolapse c Right T10 Cord Hemisection g Broca’s area d Left T10 Cord Hemisection h Central Cord lesion 2. Loss of pain and temperature sensation of both arms and the upper chest. Proprioception and fine touch are relatively unaffected

Answer 16

h - central cord lesion Spares the lower limbs as the fibers for the lower limbs lie more laterally in the spinal cord Dorsal column sensation is also spared Spinothalamic sensation and motor below level of lesion is affected - usually lesion in cervical cord

Question 17

Question 3: CNS Lesions a Conus lesion e L5/S1 Disc prolapse b Wernicke’s area f L3/L4 Disc prolapse c Right T10 Cord Hemisection g Broca’s area d Left T10 Cord Hemisection h Central Cord lesion 3. Patient with long history of bilateral radiculopathy, presents with urinary retention and perianal anaesthesia. Knee reflexes are lost bilaterally

Answer 17

A - Conus lesion Lesion in the conus medullaris - about the L1/2 region will therefore affect the whole cauda equina leading to cauda equina syndrome Clinical features: urinary & fecal incontinence, sensory numbness of the buttocks & the backs of the thighs (saddle anaesthesia), lower motor neurone weakness, the precise features of which depend upon the level at which cauda equina is compressed

Question 18

Question 3: CNS Lesions a Conus lesion e L5/S1 Disc prolapse b Wernicke’s area f L3/L4 Disc prolapse c Right T10 Cord Hemisection g Broca’s area d Left T10 Cord Hemisection h Central Cord lesion 4. Known arteriopath presents with non-fluent, laboured speech which you recognise as an expressive aphasia.

Answer 18

G - Broca’s area - found in the frontal lobe Broca’s area is for speech production - therefore difficulty producing speech here but no difficulty understanding it Problems here means Broca’s aphasia aka expressive aphasia Wernicke’s area for speech comprehension - cannot understand speech properly - temporal lobe Speaks with no problem but the words make no sense

Question 19

https://s3.amazonaws.com/classconnection/403/flashcards/11907403/png/picture2jpgpngjpgpngjpg-1628369CDC87D182824.png

Answer 19

1. Lateral corticospinal tract 2. Dorsal horn 3. Dorsal column 4. Spinothalamic tract 5. Anterior corticospinal tract

Question 20

Describe a-h briefly a Anterior Corticospinal Tract e Spinothalamic Tract b Dorsal Horn f Ventral Horn c Posterior Column g Lateral Corticospinal Tract d Spinocellebellar Tract h Reticulospinal Tract Only describe a,b,c,d on this flashcard

Answer 20

* Anterior corticospinal tract - fibres decussate at spinal cord (15%) - supply axial/girdles * Lateral corticospinal tract - fibres decussate in the medulla (85%) - supply the limbs * Dorsal horn - posterior area of grey matter containing cell bodies of neurones * Posterior column - carries ascending neurones- fine touch, vibration, proprioception * Spinocerebrellar tract- ascending tract, carries fibres for proprioception from lower limb (lower limb only is not dorsal column)

Question 21

Describe a-h briefly a Anterior Corticospinal Tract e Spinothalamic Tract b Dorsal Horn f Ventral Horn c Posterior Column g Lateral Corticospinal Tract d Spinocellebellar Tract h Reticulospinal Tract Only describe e,f,g,h on this flashcard

Answer 21

* Spinothalamic tract - ascending tract, carries fibres for crude touch and pressure (anterior), pain and temperature (lateral). Fibres decussate at spinal cord level & therefore symptoms on opposite sides * Ventral horn - anterior area of grey matter containing cell bodies of motor neurones * Reticulospinal tract – descending motor tract involved in posture and crude, imprecise movements, originate in the reticular formation (brainstem)