UNDF - Neurology Flashcards
A 45 year old male presents with a unilateral drooping of an eyelid.
How can Horner’s syndrome be distinguished from a third nerve palsy on examination?
In a Horner’s syndrome there is a pupillary constriction (0.5 marks) and anhydrosis (0.5 marks) and enopthalmos. In a third nerve palsy the eye turns downward and outward (0.5 marks), and there is pupillary dilatation (0.5 marks).
(CCP Total 2 marks)
The patient shows clinical features of Horner’s syndrome.
List 3 regions where the lesion may be found.
- Hypothalamus
- Brain stem
- Cervical cord to T1
- Paravertebral sympathetic chain
- Internal carotid artery walls
The sympathetic nervous supply to the eye is s three neurone pathway originating in the hypothalamus and descending by way of the brainstem and cervical cord to T1 nerve root, paravertebral sympathetic chain and, on via the internal carotid artery, to the eye and face. Damage to any part of the pathway results in Horner’s syndrome. This is significant not only because it affects vision but also because it may indicate a serious underlying pathology.
A 75 year old female with multiple cardiovascular risk factors presents with sudden onset of left-sided weakness and numbness. On examination there is weakness of the muscles of the left lower face (with sparing of the forehead muscles) and left upper and lowe limb, with her arm being more affected than her leg.
Where is the most likely site of the lesion? (1 mark)
Right sided stroke (0.5 marks) in the territory of the middle cerebral artery (0.5 marks). (CCP 1 Total mark)
Middle cerebral artery stroke affects the upper and lower limb on the contralateral side to the stroke (arms are more affected than lower limbs).
A 45 year old female presents with blurred vision. On examination her right eye is unable to move towards the right.
Which nerve and muscle are affected?
The right abducens nerve (CN VI) (0.5 marks). The affected muscle is the lateral rectus (0.5 marks). (BCS Total 1 mark)
A 68 year old male presents with tremor, rigidity, and bradykinesia of several months duration.
List 3 differential diagnoses for his movement disorder, other than idiopathic Parkinson’s disease. (1.5 marks).
- Drug-induced Parkinsonism
- Progressive supranuclear palsy
- Lew body dementia
- Multiple systems atrophy
- Chronic traumatic encephalopathy (repeated head injury such as boxing)
- Wilson’s disease
- Corticobasal degeneration
(0.5 marks each to max 1.5 marks) (CCP Total 1.5 marks)
Early degeneration of which specific brainstem nucleus, as seen in the section of abnormal brain tissue on the left (with normal brain tissue on the right), accounts for his presentation of parkinsonism.
Substantia nigra (BCS 0.5 marks)
Name the brain pathway and neurotransmitter system directly affected by neuronal degeneration of this nucleus
= Substantia nigra
Brain pathway: nigrostriatal pathway (0.5 marks)
Neurotransmitter system: dopamine (0,5 marks)
(BCS Total 1 mark)
Describe the neuropathology of Parkinson’s disease from a cellular perspective, with reference to the micrograph shown (1.5 marks)
- Parkinson’s disease is an alpha synucleinopathy (0.5 marks).
- Insoluble polymers of alpha synuclein are deposited in the neuronal body, forming round lamellated eosinophilic cytoplasmic inclusions called Lewy bodies (LBs) (0.5 marks)
- Alpha synuclein is also deposited in neuronal processes (Lewy neurites), and in astrocytes and oligodendoglial cells: dopamine.
- Lewy bodies cause neuronal degeneration and death (0.5 marks)
(BCS Total 1.5 marks)
Describe the venous drainage of the brain from the inferior sagittal sinus to the superior vena cava. (2.5 marks)
- Inferior sagittal sinus →
- Straight sinus →
- Confluence of sinuses →
- Transerve sinus →
- Sigmoid sinus →
- Internal jugular vein →
- Brachiocephalic vein →
- Superior vena cava.
(Must. be in correct order to max 2.5 marks BCS)
Which blood vessel crosses the pterion?
Middle meningeal artery
List 4 behaviours of high standards of professional conduct as outlined by the AMCs Good Medical Practice Guidelines for doctors. (4 marks)
- Being courteous, respectful, compassionate and honest.
- Treating each patient as an individual.
- Protecting patient’s privacy and right to confidentiality, unless the release of information is required by law or public interest considerations.
- Encouraging and supporting patients and, when relevant, their carer or family, in caring for themselves and managing their health.
- Encouraging and supporting patients to be well informed about their health and to use this information wisely when they are making decisions.
- Recognizing that there is a power imbalance in the doctor-patient relationship, and not exploiting patients physically, emotionally, sexually, or financially.
(1 mark each to max 4 marks) (PPD Total 4 marks)
In which lobe or lobes are the post-central gyri located?
- a. Frontal
- b. Frontal and temporal
- c. Occipital
- d. Parietal
- e. Temporal
In which lobe or lobes are the post-central gyri located?
- a. Frontal
- b. Frontal and temporal
- c. Occipital
- d. Parietal
- e. Temporal
Which drug is used as a prophylactic treatment for migraine?
- a. Corticosteroids
- b. NSAIDs
- c. Paracetamol
- d. Propanolol
- e. Sumatriptan
Which drug is used as a prophylactic treatment for migraine?
- a. Corticosteroids
- b. NSAIDs
- c. Paracetamol
- d. Propanolol
- e. Sumatriptan
Which herbal medication has some evidence of efficacy in migraine prevention?
- a. Feverfew
- b. Garlic
- c. Ginger
- d. Ginko
- e. St John’s Wort
Which herbal medication has some evidence of efficacy in migraine prevention?
- a. Feverfew
- b. Garlic
- c. Ginger
- d. Ginko
- e. St John’s Wort
A 54 year old female presents with a unilateral stabbing pain of her scalp and around her eye. Pain is precipitated by washing or touching those areas. What the most likely cause of her presentation?
- a. Benign intracranial hypertension
- b. Caffeine withdrawal
- c. Migraine without aura
- d. Sinusitis
- e. Trigeminal neuralgia
A 54 year old female presents with a unilateral stabbing pain of her scalp and around her eye. Pain is precipitated by washing or touching those areas. What the most likely cause of her presentation?
- a. Benign intracranial hypertension
- b. Caffeine withdrawal
- c. Migraine without aura
- d. Sinusitis
- e. Trigeminal neuralgia
A 75 year old woman presents with headache, drowsiness and unsteadiness over the last couple of days. There is a history of a fall two weeks ago. She is confused, her GCS is 14/15. What is the most likely cause of her presentation?
- a. Aortic stenosis
- b. Extradural haemotoma
- c. Stroke
- d. Subarachnoid haemorrhage
- e. Subdural hematoma
A 75 year old woman presents with headache, drowsiness and unsteadiness over the last couple of days. There is a history of a fall two weeks ago. She is confused, her GCS is 14/15. What is the most likely cause of her presentation?
- a. Aortic stenosis
- b. Extradural haemotoma
- c. Stroke
- d. Subarachnoid haemorrhage
- e. Subdural hematoma
A 46 year old male presents with a severe headache of sudden onset three hours ago, as if kicked in the back of the head. He has vomitted twice and is now feeling sick. On examination the patient is afebrile, has neckstiffness and photophobia. Kernig’s sign is negative. What is the most likely cause of his presentation?
- a. Extradural haemotoma
- b. Intracerebral hemorrhage
- c. Stroke
- d. Subarachnoid hemorrhage
- e. Subdural hemotoma
A 46 year old male presents with a severe headache of sudden onset three hours ago, as if kicked in the back of the head. He has vomitted twice and is now feeling sick. On examination the patient is afebrile, has neckstiffness and photophobia. Kernig’s sign is negative. What is the most likely cause of his presentation?
- a. Extradural haemotoma
- b. Intracerebral hemorrhage
- c. Stroke
- d. Subarachnoid hemorrhage
- e. Subdural hemotoma
A 38-year-old businesswoman presents with repeated attacks of headache that seem to worsen by the end of the day. When specifically asked the patient states that it feels like a tight band around her head. There is no history of fever or visual symptoms. What is the most likely cause of her presentation?
- a. Benign intracranial hypertension
- b. Cluster headache
- c. Giant cell arteritis
- d. Migraine without aura
- e. Tension headache
= e. Tension headache
Rationale: Headache lasting from 30 minutes to 7 days. Headache has at least 2 of the following characteristics:
- Bilateral location
- Pressing/tightening (non-pulsating) quality
- Mild or moderate intensity
- Not aggravated by routine pbyscal activity such as walking or climbing stairs
- Both of the following: no nausea or vomiting
- No more than one of photophobia or phonophobia
- Worse by the end of the day
A 26 year old female presents with a unilateral throbbing headache lasting 6 hours associated with vomiting and photophobia. She has had several episodes in the past. She knew this was coming as she felt tired yesterday. What is the most likely cause of her presentation?
- a. Cluster headache
- b. Subarachnoid headache
- c. Migraine without aura
- d. Tension headache
- e. Trigeminal neuralgia
= c. Migraine without aura
Rationale: The classic description of migraine includes a preceding aura before the onset of the headache, but this feature does not occur in most patients. Feeling tired is part of the prodrome rather than the aura.
Which ascending pathway carries sensory information pertaining to pain and temperature?
- a. Anterolateral tract (spinothalamic)
- b. Arcuate fasciculus
- c. Dorsal columns
- d. Medial lemniscus
- e. Tuberoinfudibular pathway
= a. Anterolateral tract (spinothalamic)
A 50 year old male presents with violent and involuntary ballistic movements that are jerky and irregular on one side of the body. Where is the lesion most likely to be located?
- a. Amygdala
- b. Caudate nucleus
- c. Putamen
- d. Substantia nigra
- e. Subthalamic nucleus
= e. Subthalamic nucleus
Rationale: Ballism refers to the sudden uncontrolled flinging movements of the extremities. Usually occurs following a stroke affecting the STN (often one side). In this hyperkinetic disorder, symptoms occurs on the contralateral side (hemiballism).
The leptomeninges are often primarily affected in meningitis. What structures do the leptomeninges refer to?
- a. Arachnoid and pia mater
- b. Dura and arachnoid mater
- c. Periosteal and meningeal layers of dura mater
- d. Pia mater and choroid plexus
- e. Pia mater and ependymal cells
Leptomeninges = a. Arachnoid and pia mater
What structure forms the roof of the 4th ventricle?
- a. Cerebellum
- b. Pons
- c. Medulla
- d. Superior and inferior colliculi
- e. Tegmentum of midbrain
What structure forms the roof of the 4th ventricle?
- a. Cerebellum
- b. Pons
- c. Medulla
- d. Superior and inferior colliculi
- e. Tegmentum of midbrain
A 65 year old presents with ptosis of the left eye. On examination, the left eye is abducted and depressed and the light reflex is absent. Angiograph reveals an aneurysm (indicated by the arrow) of an artery compressing the nerve responsible for the symptoms. What describes the location of the aneurysm?
- a. Basilar artery between the left superior cerebellar and posterior cerebral arteries
- b. Division of the ICA into middle and anterior cerebral arteries
- c. ICA in the cavernous sinus
- d. Junction of the left and right vertebral arteries forming the basilar
- e. Left vertebral artery at the junction with the basilar artery
a. Basilar artery between the left superior cerebellar and posterior cerebral arteries
Rationale: The aneurysm is lying on the basilar artery between the left superior cerebellar and posterior cerebral artery. This corresponds to the junction of the pons and midbrain and the position of the origin of the oculomotor nerve. The oculomotor nerve innervates all the extraocular muscles except for lateral rectus (abducens) and superior oblique (trochlear). Compression of the nerve by the aneurysm will result in the eye being abducted (unopposed lateral rectus) and depressed (superior oblique). Ptosis is due to the loss of input to the levator palpebrae muscle.
An 88-year old male is diagnosed with Alzheimer’s disease. His physician starts him on donepezil. What enzyme is inhibited by this medication?
- a. Acetlycholinesterase
- b. Amino acid decarboxylase
- c. Choline acetyltransferase
- d. Glutaminase
- e. Tyrosine hydroxylase
= a. Acetlycholinesterase
Rationale: Acetlycholinesterase is the major enzyme the catalyzes acetylcholine in the synaptic cleft. Therapeutic agents in Alzheimer’s disease are limited to the acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine and memantine, which is an NMDA receptor antagonist). The cholinergic hypothesis of Alzheimer’s disease is based on the pathological evidence of deterioration in the cholinergic nucleus basalis of Meynert. Centrally acting acetlycholinesterase increase the levels of acetylcholine in this region, preserving memore function for a limited period of time.
A 78 year old male is diagnosed with early stage Parkinson’s disease and started on therapy with levodopa, which helps his symptoms. He is also started on carbidopa to block the conversion of levodopa to dopamine outside the central nervous system (CNS). Which enzyme is inhibited by carbidopa?
- a. Acetlycholinesterase
- b. Amino acid decarboxylase
- c. Choline acetyltransferase
- d. Glutaminase
- e. Tyrosine hydroxylase
= b. Amino acid decarboxylase
Which is a sign of unilateral damage to the cerebellum?
- a. A positive Babinski reflex contralaterally
- b. Increased tendon reflexes contralaterally
- c. Intention tremor ipsilaterally
- d. Muscular weakness contralaterally
- e. Myoclonus ipsilaterally
Which is a sign of unilateral damage to the cerebellum?
- a. A positive Babinski reflex contralaterally
- b. Increased tendon reflexes contralaterally
- c. Intention tremor ipsilaterally
- d. Muscular weakness contralaterally
- e. Myoclonus ipsilaterally
Which regions of the cerebellum (labelled A to F) receive input from the spinocerebellar tracts, and are involved in the regulation of muscle tone?
- a. A and B
- b. A and D
- c. B and C
- d. C and D
- e. D and F
= a. A and B
Mastoiditis can erode the thin layer of bone between the mastoid air cells and the posterior cranial fossa and spread most commonly into which venous sinus?
- a. Cavernous
- b. Inferior sagittal
- c. Sigmoid
- d. Straight
- e. Superior sagittal
= c. Sigmoid
