Y3 Questions/buzzwords

Question 1

What is Cushing’s triad?

Answer 1

widened pulse pressure (due to increased cortisol production), bradycardia and irregular breathing

Question 2

Which diuretic is used in managing raised ICP?

Answer 2

Mannitol, it is an osmotic diuretic

Question 3

Managing which type of brain-related emergency involves use of lactulose?

Answer 3

Hepatic encephalopathy
Clear gut to reduce colonic transit time, so that there is less chance for bacteria to produce nitrogenous waste

Question 4

Which parts of the spinal cord can be affected in subacute combined degeneration of the spinal cord? How would these present clinically?

Answer 4

Dorsal Columns - distal symmetrical impaired sensation (more commonly in legs), impaired proprioception & vibration

Lateral cortical spinal tracts - muscle weakness, hyperreflexia, and spasticity (UMN signs), brisk knee jerks, absent ankle jerks, extensor plantar

Spinocerebellar tract involvement - sensory ataxia leading to gait abnormality, +ve Romberg’s sign

Question 5

What causes subacute combined degeneration of the spinal cord?

Answer 5

Vitamin B12 deficiency (can be caused by recreational nitrous oxide inhalation)

Question 6

What are the four drugs listed as first-line for managing neuropathic pain?

Answer 6

Amitriptyline, duloxetine, gabapentin or pregabalin

If one isn’t working very well, SWITCH to another instead of ADDING them

Question 7

How does chronic subdural haematoma classically present?

Answer 7

It comes on insidiously, developing over weeks to months, with a lucid interval followed by gradual decline in consciousness

Dull headache, confusion, and lethargy

Question 8

How would extradural haematoma usually present?

Answer 8

EDH typically results from significant head trauma associated with a skull fracture and presents acutely with a lucid interval followed by rapid neurological decline.

Question 9

What is the one key feature of multiple sclerosis compared to other similar neurological conditions?

Answer 9

The dissemination of symptoms in time and space

Patients typically experience different neurological symptoms affecting different parts of the central nervous system at different times

Question 10

What is the key feature of myasthenia gravis and what are some presentations?

Answer 10

Muscle fatigability

Diplopia (extraocular muscle weakness), Proximal muscle weakness, ptosis, dysphagia

Question 11

What is the preferred medication for secondary prevention following a stroke?

Answer 11

Clopidogrel

Question 12

In what condition are DOACs used for prevention?

Answer 12

preventing strokes in non-valvular atrial fibrillation or venous thromboembolism

Question 13

Which is preferred for secondary stroke prevention - anti-coagulants or anti-platelets?

Answer 13

Anti-platelets

Question 14

When is tissue plasminogen activator (like Alteplase) indicated following an acute stroke?

Answer 14

It is indicated in patients presenting within 4.5 hours of symptom onset and with no contraindications to thrombolysis

Question 15

What are things that can lead to contraindications of thrombolysis?

Answer 15

INR >1.7
Past history of intracranial haemorrhage
Major surgery in the last 14 days
GI or urinary tract bleeding in the last 21 days
Suspicion of subarachnoid haemorrhage, even if CT normal
Uncontrolled blood pressure >185 systolic and/or >110 diastolic

Question 16

How to manage crescendo TIA?

Answer 16

Aspirin 300mg and review within 24h

Question 17

First line treatment in optic neuritis?

Answer 17

Intravenous methylprednisolone

Question 18

What is the main purpose in performing a non-contrast CT Head in acute ischaemic stroke?

Answer 18

To exclude the presence of an intracranial haemorrhage

Question 19

What imaging should be undertaken following an ischaemic stroke?

Answer 19

This is done to figure out potential cause of the emboli

Carotid ultrasound (to identify critical carotid artery stenosis)
CT/MR angiography (to identify intracranial and extracranial stenosis)
Echocardiogram (if a cardio-embolic source is suspected)

Question 20

Main risk factor for haemorrhagic stroke?

Answer 20

Hypertension, cerebral amyloid angiopathy, anticoagulation

Question 21

Three cardinal signs of middle cerebral artery stroke

Answer 21

Contralateral hemiplegia, contralateral homonymous hemianopia, (if in dominant hemisphere) dysphasia

NB: not to confuse dysphasia with dysphagia

Question 22

What is the Oxford-Bamford criteria for a total anterior circulation stroke?

Answer 22

All three of:

1. Unilateral weakness and/or sensory deficit in the face, arm and leg
2. Homonymous hemianopia
3. Higher cerebral dysfunction (dysphasia, visuospatial disorder)

Question 23

What are the causes of ischaemic stroke (including % of cases for each cause)?

Answer 23

25% of ischaemic strokes are caused by intracranial small vessel atherosclerosis

50% of ischaemic strokes are caused by large vessel atherosclerosis e.g. carotid artery stenosis

20% of ischaemic strokes are cardio-embolic e.g. in atrial fibrillation there is stasis of blood flow in the left atrium, predisposing to thrombus formation in the left atrium, and subsequent embolisation to the brain.

Rare causes of ischaemic stroke include primary vascular causes (such as vasculitis and arterial dissection) and haematological causes (prothrombotic states).

Question 24

Should aspirin 300mg be given to patients who are candidates for thrombolysis?

Answer 24

No, aspirin should be withheld until 24hrs after thrombolysis when a repeat CT head is done to avoid bleeding risk

Question 25

What is the clinical presentation of Bell’s palsy?

Answer 25

Unilateral facial droop with eyebrow involvement

Only involves cranial nerves

Question 26

What is the clinical presentation of a lacunar stroke?

Answer 26

Hemiparesis/contralateral changes in sensation/ataxia

There should be NO eye signs or involvement

Question 27

What is the clinical presentation of lateral pontine syndrome?

Answer 27

Unilateral facial paralysis and deafness due to respective CN nuclei involvement
Hemiparesis

Question 28

How would rhabdomyolysis typically feature in an exam question?

Answer 28

As a patient who has had a fall or prolonged epileptic seizure and is found to have an acute kidney injury on admission

Creatinine kinase would be above 5 times raised than normal

Question 29

What conditions can give a positive Hoffmann’s sign?

Answer 29

Any upper motor neurone lesion (eg. MS) or cervical myelopathy that affects the motor reflex in the hand

Question 30

What are the urinary findings in a clinical picture of acute tubular necrosis and what are causes for this condition?

Answer 30

High sodium (impaired sodium reabsorption) and low or normal urinary osmolality (impaired water reabsorption)

Prolonged ischaemia to the kidney tubular cells (eg an endurance event like ultra-marathon) or nephrotoxins (eg NSAIDs)

Question 31

What is the acute medical management of migraine?

Answer 31

NSAIDs - take as early as possible
Triptans - asap when headache starts, but NOT during aura

Question 32

What are adverse effects of triptans?

Answer 32

tingling, heat, tightness (e.g. throat and chest), heaviness, pressure