Questions

Question 1

Start [] in all cases of suspected encephalitis as over 95% of encephalitis cases are caused by []

Answer 1

Start aciclovir in all cases of suspected encephalitis as over 95% of encephalitis cases are caused by herpes simplex virus (HSV), IV aciclovir (works against HSV) should be started in all patients urgently.

Question 2

Which symptom related to hearing is seen in 1/3 of Bell’s palsy patients? [1]

Answer 2

Hyperacusis is seen in around a third of patients.

Question 3

A vesicular rash around the ear would suggest a diagnosis of [] syndrome

Answer 3

A vesicular rash around the ear would suggest a diagnosis of Ramsey Hunt syndrome

Question 4

The most common pattern for progression of multiple sclerosis is [1]
- Describe this pattern [2]

Answer 4

The most common pattern for progression of multiple sclerosis is relapsing-remitting
- Patients experience relapses of new or worsening symptoms. These vary in duration and often come without warning.
- Patients then tend to have periods of remission between attacks where there are no worsening symptoms. These periods of remission can last up to years.

Question 5

[Treatment] is recommend for patients with an acute ischaemic stroke who present within 4.5 hours

Answer 5

A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours

Question 6

Describe and explain eye sign might see in ICP [2]

Answer 6

Raised ICP can cause a third nerve palsy due to herniation
- Eye deviation ‘down and out’

Question 7

The Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in [3]

Answer 7

The Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in hypertension, bradycardia and bradypnoea

Question 8

Defective downward gaze and vertical diplopia - which cranial nerve? [1]

A 54-year-old man attends the GP complaining of double vision. He says it is worse when he walks down the stairs.

On inspection, he is sitting with his head tilted towards the right. The left eye deviates supero-laterally.

Answer 8

Defective downward gaze and vertical diplopia - CN IV

4th nerve palsy - BOOT WOOG
Better on opposite tilt (e.g. here they are tilting their head to the right)
Worse on opposite gaze (it would get worse when they try to look right)

Question 9

A 50-year-old man has a history of recurrent mechanical falls with no loss of consciousness. He is seen in the neurology clinic by the registrar following an MRI scan. On examination he has an intention tremor and an ataxic gait, but only very minimal past-pointing. The MRI brain has revealed a lesion.

Where is the most likely location of the lesion?

Answer 9

Gait ataxia is caused by cerebellar vermis lesions

Question 10

What is the difference in presentation between damage to cerebellar vermis or hemisphere? [1]

Answer 10

You can remember it that the vermis (or centre) of the cerebellum causes central ataxia, whereas peripheral cerebellar lesions cause peripheral ataxia.

the vermis is in the middle so it deals with your trunk.
the hemispheres are on the outside so deal with your arms and stuff.

Question 11

[] is used for long-term prophylaxis of cluster headaches

Answer 11

Verapamil is used for long-term prophylaxis of cluster headaches

Question 12

What would a headache that worsens with valsalva manoeuvres indicate? [1]

Why is this clinically significant? [1]

Answer 12

Headache linked to Valsalva manoeuvres = raised ICP until proven otherwise so LP is contraindicated

Question 13

A 26-year-old male patient has been referred for EMG testing following ongoing muscle weakness. The results showed a diminished response with repetitive stimulation.

What disease is this? [1]

Answer 13

MG

Question 14

Stroke:
Current guidelines recommend maintaining blood pressure < [] mmHg before and during reperfusion therapies.

Answer 14

Current guidelines recommend maintaining blood pressure < 185/110 mmHg before and during reperfusion therapies

Question 15

What timelines are given for stroke mx with regards to thrombolysis and thrombectomy [2]

Answer 15

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours

Question 16

[2] are first-line for spasticity in multiple sclerosis

Answer 16

Baclofen and gabapentin are first-line for spasticity in multiple sclerosis

Question 17

All TIA patients should have an [Ix] unless they are not a candidate for [Mx]

Answer 17

All TIA patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy

Question 18

Describe how a left PICA stroke would present [+]

Answer 18

Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner’s

Question 19

What is the acute treatment and prophylactic treatment of migraines? [2]

Answer 19

Propranolol is preferable to topiramate in women of childbearing age (i.e. the majority of women with migraine) is used for prophylaxis

Triptans are used for treatment

Question 20

Trigeminal neuralgia - [] is first-line

Answer 20

Trigeminal neuralgia - carbamazepine is first-line

Question 21

The most characteristic feature of a common peroneal nerve lesion is [1]

Other features include: [6]

Answer 21

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

Question 22

What causes conduction aphasia? [1]

How does it present? [3]

Answer 22

Classically due to a stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area

Speech is fluent but repetition is poor. Aware of the errors they are making

Comprehension is normal

Question 23

Autonomic dysreflexia can only occur if the spinal cord injury occurs above the [] level

Answer 23

Autonomic dysreflexia can only occur if the spinal cord injury occurs above the T6 level

Question 24

Myasthenia gravis - [] antibodies

Answer 24

Anti-nicotinic receptor antibody

Question 25

Creutzfeldt-Jakob disease is characterised by **[2]**

Answer 25

Creutzfeldt-Jakob disease is characterised by **rapid onset dementia and myoclonus**

Question 26

How do you manage a patient with TIA but who is on anticoagulants? [1]

Answer 26

If a patient is on **warfarin/a DOAC/** or has a **bleeding disorder** and they are suspected of having a TIA, they should be **admitted immediately for imaging to exclude a haemorrhage**

Question 27

**[]** movements are typically spared in motor neurone disease

Answer 27

**Eye movements** are typically spared in motor neurone disease

Question 28

Describe how timing of a headache would indicate SAH [1]

Answer 28

A **sudden**-onset headache, **reaching maximum intensity within 5 minutes**, is a red flag requiring further evaluation to exclude a subarachnoid haemorrhage

Question 29

**[]** are common precipitants of myasthenic crises.

Answer 29

**Beta-blockers** such as bisoprolol are common precipitants of myasthenic crises.

Question 30

A 46-year-old man is an inpatient on a stroke ward following the onset of left sided arm weakness earlier that day. On examination, the doctor auscultates a carotid bruit. A head computerised tomography (CT) scan is performed which shows an area of cortical hypodensity suggestive of ischaemia. How should the carotid bruit be investigated? Angiography Chest X-ray Duplex ultrasound Computerised tomography (CT) angiography Magnetic resonance imaging (MRI) scan

Answer 30

**Duplex ultrasound** - Carotid artery stenosis is diagnosed (and degree of stenosis assessed) via duplex ultrasound

Question 31

Describe how a painful third nerve palsy would present [6]

Answer 31

left eye is **depressed and laterally deviated**, and there is **left-sided ptosis.** (eyelid droop) The left pupil is **dilated** and he has **diplopia** at rest with **pain on all movements of the left eye**

Question 32

**Painful third nerve palsy** = **[] artery aneurysm**

Answer 32

Painful third nerve palsy = **posterior communicating artery aneurysm **

Question 33

How would you distinguish between an MCA and PCA stroke?

Answer 33

**MCA**: - UMN motor lesions > lower limbs - BUT - heman - NO visual agnosia (have difficulty recognizing visually presented objects despite normal vision and other cognitive abilities) - Aphasia likely **PCA**: * **Weber's syndrome** is a form of **midbrain stroke** characterised by the an **ipsilateral CN III palsy and contralateral hemiparesis** * **Contralateral HH with macular sparing**

Question 34

What are the three core presenting features of Wernicke's encephalopathy ? [3] What would be mainstay of treatment ? [1

Answer 34

**Confusion, ataxia, nystagmus/ophthalmoplegia**→ give **Pabrinex (IV B/C vitamins)**

Question 35

Management of myasthenic crisis - [2]?

Answer 35

Management of myasthenic crisis - **intravenous immunoglobulin, plasmapheresis**

Question 36

A 72-year-old woman is brought into the emergency department following a fall. Her left arm appears swollen and, upon further imaging, a displaced mid-shaft humeral fracture is diagnosed. What nerve is most likely to be damaged as a result of this fracture, and how would this present clinically? * Axillary nerve, loss of sensation over the 'sergeant patch' region of the shoulder * Radial nerve, inability to flex the 1st, 2nd and 3rd digits of the hand * Radial nerve, wrist drop * Ulnar nerve, inability to extend the 4th and 5th digits of the hand * Ulnar nerve, loss of sensation on the dorsum of the hand over the thumb and index finger

Answer 36

* **Radial nerve, wrist drop**

Question 37

Describe what is meant by an ataxic gait [1]

Answer 37

A **wide-based gait** with **loss of heel to toe walking** is called an ataxic gait

Question 38

An 80-year-old male presents with sudden onset weakness of his left arm and leg. On examination you note left sided arm and leg weakness. There is no evidence of higher function deficits or visual field defects. You suspect a stroke and send him for an urgent CT. What is the best description of this stroke? Left sided partial anterior circulation syndrome Posterior circulation stroke syndrome Left sided total anterior circulation syndrome Right sided total anterior circulation syndrome Lacunar stroke

Answer 38

**Lacunar stroke**

Question 39

How do lacunar infarcts present? [4]

Answer 39

Question 40

(NICE) recommends that **mechanical** **thrombectomy** be performed as soon as possible, ideally within **[] hours from symptom onset**.

Answer 40

(NICE) recommends that mechanical thrombectomy be performed as soon as possible, ideally within **6 hours from symptom onset.** ## Footnote **NB** - thrombolysis is only within 4.5h of onset of symptoms

Question 41

A patient has ?TIA. How do you invetigate them acutely? [1]

Answer 41

All TIA patients should have an **urgent carotid doppler** unless they are not a candidate for carotid endarterectomy - Many TIAs are caused by **atherosclerotic stenosis of the carotid artery**, so all of these patients should have an urgent carotid Doppler study to look for this unless a carotid endarterectomy

Question 42

**[]** increase the risk of idiopathic intracranial hypertension

Answer 42

**Tetracyclines** increase the risk of idiopathic intracranial hypertension

Question 43

Wernicke's aphasia is due to a lesion of the **[]**

Answer 43

Wernicke's aphasia is due to a lesion of the **superior temporal gyrus**

Question 44

A lesion to the **[]** would result in Broca's aphasia - How would this present? [2]

Answer 44

A lesion to the **left inferior frontal gyrus** would result in **Broca's aphasia** - **Speech is non-fluent, laboured, and halting. Repetition is impaired**

Question 45

A lesion to the **[]** region would result in **transcortical sensory aphasia** - How would this present? [2]

Answer 45

A lesion to the **temporo-occipital region** would result in transcortical sensory aphasia

Question 46

A lesion to the **[]** would result in **conduction aphasia** - How would this present? [2]

Answer 46

A lesion to the **arcuate fasciculus** would result in conduction aphasia - **Speech is fluent but repetition is poor. Aware of the errors they are making**

Question 47

A lesion to the angular gyrus would result in **[]** Syndrome

Answer 47

A lesion to the angular gyrus would result in **Gerstmann Syndrome**

Question 48

Patients cannot drive for [] months following a **first unprovoked or isolated seizure if brain imaging and EEG normal**

Answer 48

Patients cannot drive for **6 months** following a first unprovoked or isolated seizure if brain imaging and EEG normal

Question 49

What are methods of remembering Webers and Wallenburg sx? [+]

Answer 49

**Weaky weber** (weakness in the muscles) and **Wobbly wallenburg** (ataxia, and altered sensation) and **for both of them it is ipsilateral in the head, contralateral in the body**

Question 50

A 27-year-old female presents to her General Practitioner with severe morning headaches associated with nausea. She is referred for an MRI head scan that reveals a large tumour arising from the falx cerebri and pushing on the brain. There is a well-defined border between the tumour and the brain parenchyma. What is the most likely diagnosis? Glioblastoma Metastasis Low-grade glioma Meningioma Craniopharyngiom

Answer 50

A 27-year-old female presents to her General Practitioner with severe morning headaches associated with nausea. She is referred for an MRI head scan that reveals a large tumour arising from the falx cerebri and pushing on the brain. There is a well-defined border between the tumour and the brain parenchyma. What is the most likely diagnosis? **Meningioma** - Meningiomas are typically benign tumours that arise from the arachnoid cells next to the dura mater of the meninges. They are extra-axial lesions, meaning they do not arise from the brain parenchyma. They do not invade the brain substance, but rather cause symptoms by compression.

Question 51

The **[] index** is a scale that measures disability or dependence in activities of daily living in stroke patients

Answer 51

The **Barthel index** is a scale that measures disability or dependence in activities of daily living in stroke patients

Question 52

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

Answer 52

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? **Loss of temperature sensation in the hands** - Syringomyelia - spinothalamic sensory loss (pain and temperature) ## Footnote Syringomyelia = Superman - Something about a cape and can't feel no pain

Question 53

What is Paroxysmal hemicrania (PH) ? [1]

Answer 53

**Paroxysmal hemicrania (PH)** is defined by attacks of **severe, unilateral headache, usually in the orbital, supraorbital or temporal region.** - These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day.

Question 54

**Paroxysmal hemicrania** is completely responsive to treatment with **[]**

Answer 54

Paroxysmal hemicrania is completely responsive to treatment with **indomethacin**

Question 55

**[]** is the preferred way to support nutrition in patents with motor neuron disease

Answer 55

**Percutaneous gastrostomy tube (PEG)** is the preferred way to support nutrition in patents with motor neuron disease

Question 56

Which one of the following is a contraindication to the use of a triptan in the management of migraine? Concurrent pizotifen use Patients older than 55 years A history of epilepsy Previous intracranial tumour A history of ischaemic heart disease

Answer 56

**A history of ischaemic heart disease** - They cause **vasoconstriction** of cranial blood vessels and inhibit the release of vasoactive peptides. However, they can also **cause coronary artery vasospasm** and are therefore contraindicated in patients with a history of ischaemic heart disease due to the increased risk of myocardial infarction.

Question 57

Answer 57

**The correct answer is Tuberous sclerosis**. Tuberous sclerosis is a genetic disorder that causes non-cancerous (benign) tumours to grow in different parts of the body. It often affects the brain and can lead to conditions such as epilepsy. **The image shows characteristic adenoma sebaceum on the nose.**

Question 58

**[]** is used to treat idiopathic intracranial hypertension

Answer 58

**Acetazolamide is a carbonic anhydrase inhibitor** that is used to treat idiopathic intracranial hypertension

Question 59

Describe the mechanism in which could reduce ICP via breathing techniques [2]

Answer 59

**Hyperventilation -> reduce CO2 -> vasoconstriction of the cerebral arteries -> reduced ICP**

Question 60

Describe how the position of bitemporal hemianopia can determine what the cause of the lesion is? [2]

Answer 60

**Bitemporal hemianopia** - lesion of optic chiasm * **upper quadrant defect >** lower quadrant defect = **inferior chiasmal compression**, commonly a **pituitary tumour** * **lower quadrant defect >** upper quadrant defect = superior chiasmal compression, commonly a **craniopharyngioma**

Question 61

How do you manage a patient who has neuropathic pain, but their neuropathic analgesia hasn't worked? [1]

Answer 61

Drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be **switched**, **not added**

Question 62

She is prescribed pyridostigmine amongst other agents. What is the mechanism of the aforementioned drug? Short acting acetylcholinesterase inhibitor Long acting acetylcholinesterase inhibitor Muscarinic agonist Calcineurin inhibitor Dihydrofolic acid reductase inhibitor

Answer 62

She is prescribed pyridostigmine amongst other agents. What is the mechanism of the aforementioned drug? Short acting acetylcholinesterase inhibitor **Long acting acetylcholinesterase inhibitor** Muscarinic agonist Calcineurin inhibitor Dihydrofolic acid reductase inhibitor

Question 63

A 33-year-old man presents complaining of visual disturbance. Examination reveals a bitemporal hemianopia with predominately the upper quadrants being affected. What is the most likely lesion? Craniopharyngioma Brainstem lesion Pituitary macroadenoma Frontal lobe lesion Right occipital lesion

Answer 63

**Bitemporal hemianopia** * lesion of optic chiasm * upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour * lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Question 64

A 69-year-old lady is brought to hospital by an ambulance crew with a suspected stroke. On review in the emergency department she is unable to speak although she is able to follow instructions which have been written down. She has no past medical history. A blockage of which of the following cerebral arteries is most likely to be the cause of this woman's symptoms? Right anterior cerebral artery Left anterior cerebral artery Right middle cerebral artery Left middle cerebral artery Right posterior cerebral artery

Answer 64

**Left middle cerebral artery** - The middle cerebral artery on the **dominant side supplies** both Wernicke's and Broca's areas of the cortex which are responsible for understanding and production of speech. - most likely affected side is the left as the percentage of right and left handed individuals with a dominant left hemisphere is 90% and 60% respectively, making the left always the most likely affected side regardless of handedness.

Question 65

You are the FY1 on the Acute Medical Unit. A 32-year-old male who has come in for recurrent seizure-like episodes falls to the ground and his whole body begins to convulse. Once the patient is stabilised, you want to conduct a blood test to help determine if this could, in fact, be a pseudo seizure. Which blood test would you do? Prolactin ADH Magnesium FSH LH

Answer 65

You are the FY1 on the Acute Medical Unit. A 32-year-old male who has come in for recurrent seizure-like episodes falls to the ground and his whole body begins to convulse. Once the patient is stabilised, you want to conduct a blood test to help determine if this could, in fact, be a pseudo seizure. Which blood test would you do? **Prolactin** * Prolactin can be used to differentiate between a true seizure and a pseudoseizure

Question 66

A patient presents with IIH. They have lost 10kg already but this has made no difference to the headaches they have. What is the next stage in treatment? [1]

Answer 66

**Acetazolamide** is a carbonic anhydrase inhibitor that is used to treat idiopathic intracranial hypertension

Question 67

W status epilepticus - what do you need to rule out before treating? [2]

Answer 67

**Status epilepticus**: rule out **hypoxia** and **hypoglycaemia** before thinking of other causes