PACES neuro

Question 1

Top causes of spastic paraparesis

Answer 1

Demyelination (multiple sclerosis)
Cord compression
Trauma
Anterior horn cell disease (motor neuron disease)
Cerebral palsy

Question 2

Spastic paraparesis with sensory level

Answer 2

Cord compression (due to disc disease/tumour/trauma/infection such as epidural abscess, spinal TB/vascular problem such as haematoma or epidural haemorrhage)

Cord infarction

Transverse myelitis (due to infection, autoimmune, paraneoplastic, sarcoid, neuromyelitis optica)

Question 3

Spastic paraparesis and dorsal column loss (joint position sense and vibration):

Answer 3

MS
Friedrichs ataxia
Subacute degeneration fo the spinal cord
Syphillis

Question 4

Spastic paraparesis and spinothalamic loss (pain and temperature):

Answer 4

Syringomyelia
Anterior spinal artery infarction

Question 5

Spastic paraparesis and cerebellar signs:

Answer 5

Demyelination (Multiple sclerosis)
Friedreich’s ataxia
Spinocerebellar ataxia
Arnold Chiari Malformation
Syringomyelia

Question 6

Spastic paraparesis and small hand muscle wasting:

Answer 6

Cervical myelopathy (C5-T1)
Anterior horn cell disease (motor neuron disease)
Syringomyelia

Question 7

Spastic paraparesis and absent ankle jerk

Answer 7

Motor neuron disease
Friedreich’s ataxia
Subacute combined degeneration of the cord
Syphilis
Cervical myelopathy and peripheral neuropathy of any cause

Question 8

MS Ix

Answer 8

MRI with contrast spine and head - 2 lesions separated by time and space - central NS only
LP- oligoclonal bands

Question 9

Tx of MS

Answer 9

MDT
Methylprednisolone 5d- IV
Natalizumab
Pain- amitriptyline
Spasticity- physio and baclofen
SSRI- depression

Question 10

Spastic hemiparesis dxx

Answer 10

Anterior circulation vascular event affecting the right cortex (either ischaemic or haemorrhagic stroke) or lacunar infarct (if no visual field defect and no higher cortical dysfunction)

Space-occupying lesion eg. tumour, subdural haemorrhage, abscess

Hemiplegic cerebral palsy

Question 11

Ix of stroke

Answer 11

FBC, U and E, LFT
ECG, Urine dip
CT head - may be normal in acute phase

Dopplers- if anterior stroke

Question 12

Mx of stroke

Answer 12

A-E, exclude hypo

<4.5- Ct head clear- thrombolysis

Admit to hyperacute stroke unit (MDT approach)
Regular neuro obs (dropping GCS may mean haemorrhagic transformation)

Post thrombolysis CT head at 24 hours

Aspirin 300mg PO (or PR/ by enteral tube if dysphagic) +PPI for 2 weeks then clopidogrel 75mg PO for life NB: hold off aspirin until 24 hours after thrombolysis
Atorvastatin 80mg OD
AC

Sip test, NBM, SALT assessment, dietician +/- NG feeding

Physio, Occupational

Monitor for complications- haemorrhage, aspiration pneumonia, DVT/PE

Question 13

Cause of flaccid paraparesis

Answer 13

Anterior horn- MND
Cauda equina
Neuro- GBS, CIDP, CMT

Junction- MG
Myopathy- polymyosiits, endocrine, drugs- steroids

Question 14

CMT presenting

Answer 14

Lipodermateroslcerosis
Clawed hands
Mild sensory loss

Romberg
Areflexia

Pes cavus
Scoliosis

Question 15

Cause of sensory peripheral neuropathy

Answer 15

Alcohol
B12
Diabetes
Endocrine
Folate
Gran- sarcoid
Hereditary- CMT
Infection- syphyllis

Question 16

Cause of foot drop

Answer 16

Anterior horn- MND
L5 root- dermatone, ankle preserved
Sciatic nerve damage- weak knee flexion, lose ankle jerk
Common perineal nerve damage - ankle in tact sensory loss between 1st and 2nd
Muscle- myopathy

Question 17

Myopathy vs peripheral neuropathy

Answer 17

Distal- neuro, proximal myo
Sensory in neuro
Reflexes lost in neuro
Fasculations- neuro

Question 18

Mx of MND

Answer 18

Physio, OT, SALT, dietician
Medical- treat infections, baclofen and riluzole (releases glutamic acid)