1
Q
What are the clinical features of Multiple System Atrophy?
A
MSA characteristically presents with:
- Parkinsonism
- atuonomic disturbance (atonic bladder, postural hypotension, erectile dysfunction)
- Cerebellar Signs (ataxia, tremor, dysarthria)
2
Q
What are the Parkinson’s Plus Syndromes and their main features?
A
Parkinson-plus syndromes (aka. atypical parkinsonism) are a group of neurodegenerative diseasese that present with parkinsonism and a vareity of additional features.
Multiple System Atrophy:
- Atuonomic dysfunction with urogenital problems
- Lewy bodies
Progressive Supranucelar Palsy:
- Vertical gaze palsy
- Frontal lobe disturbances
Corticobasal degeneration:
- Alien limb phenomenon
- Asymmetric motor symptoms
Dementia with Lewy Bodies:
- Visual hallucinations
- Lewy bodies
3
Q
What are the diagnostic criteria for migraine without aura?
A
A: At least 5 attack fulfulling B-D
B: Headaches lasting 4-72 hours
C: Headache has at least 2 of the following characteristics:
- Unilateral
- Pulsating quality
- Moderate or severe pain intensity
- Aggrevation by, or causing avoidance of routine physical activity
D: During headache at least 1 of the following:
- Nausea ± vomiting
- Phtophobia and phonophobia
E: Not attributed to another disorder.
4
Q
What % of migraines present with auras
A
Around 25% of migraines have an aura. These tend to be easier to diagnose than those without aura.
NICE details on auras:
- Fully reversible
- Develop over at least 5 minutes
- last 5-60 minutes
5
Q
What type of drug is ondansetron?
What is a common side effect of this drug?
A
Ondansetron is an antiemetic that acts as a 5-HT3 antagonist.
Common side effects include constipation.
6
Q
What type of drug is metoclopramide?
What are common side effects?
A
Metoclopramide is an antiemetic that is a dopamine antagonist.
Side effects include:
- Parkinsonism/movement disorders
- Diarrhoea
- Hypotension
- Asthenia (abnormal physical weakness)
7
Q
What type of drug is domperidone?
What are common side effects?
A
Domperidone is an antiemetic that is a dopamine antagonist.
Side effects include:
- Asthenia (physical weakness)
- lactation disorders
- Loss of libido
- Diarrhoea
8
Q
What are common sequalae of bacterial meningitis?
A
- Deafness (most common)
- Other neurological: epilepsy, paralysis
- Infectious: Sepsis, intracerebral abscess
- Pressure: brain herniation, hydrocephalus
9
Q
How must patients abstain from driving following a first TIA?
How long if multiple TIAs?
A
Current guidelines state that patients must not drive for 1 month following a TIA. (no need to inform DVLA)
If there are multiple TIAs in a short period of time: 3 months.
The driver is legally responsible for infroming the DVLA about this; if they drive nonetheless, the doctor should contact the DVLA and inform the patient about such action.
10
Q
How must patients abstain from driving following a first unprovoked seizure?
How long after a diagnosis of epilepsy?
A
6 months if there are no relevant structural abnormalities on brain imaging, and no definite epileptiform activity on EEG. If these conditions are not met, then it increases to 12 months.
If diagnosed with epilepsy, the person needs to be seizure free for 12 months.
Once withdrawing from epilepsy medication the patient should stop driving, and continue this 6 months after last dose.
11
Q
How must patients abstain from driving following an episode of syncope?
A
Simple faint: no restriction
Singe episode, explained and treated: 4 weeks off
Single episode, unexplained: 6 months off.
≥ episodes: 12 months off.
12
Q
How does migraine in children differ to adults?
A
In children, attacks may be shorter lasting, headache is more commonly bilateral, and GI disturbances such as nausea and vomiting are more prominent.
13
Q
What is the commonest cause of bitemporal hemianopia that:
a) predominantly affects the lower quadrants
b) predominantly affects the upper quadrants
A
Upper quadrant defect predominant: inferior chiasmal compression. Commonly a pituitary tumour.
Lower quadrant defect predominant: superior chiasmal compressions. Commonly a craniopharyngioma.
14
Q
What are common side effects of sodium valproate?
A
- P450 inhibitor
- GI: nausea
- Increased appetitite and weight gain
- Alopecia (regorwth may be curley)
- Hepatotoxicity
- Teratogenicity
- Tremor
- Thrombocytopenia
- Hyponatraemia
- Hyperammonemic encepalopathy
15
Q
Describe the MRC scale of muscle power used in neurological examinations.
A
16
Q
How can you divide peripheral neuropathies?
Give examples for each category.
A
Peripheral neuropathies can be subdivided into those with predominant motor loss, and those with predominantly sensory loss.
Motor loss:
- Guillain-Barré
- Charcot-Marie-Tooth (Hereditary sensorimotor neuropathies)
- Chronic inflammatory demyelinating polyneuropahty (bit like long-lasting GBS)
- Porphyria, lead poisoning, diphtheria
Sensory loss:
- Diabetes
- Alcoholism (both directly due to toxic effects and due to viatmin deficiency)
- B12 deficiency (subacute combined degeneration of spinal cord. Dorsal column usually affected first (proprioception/vibration) prior to distal paraesthesia.
- Leprosy
- Uraemia, Amyloidosis
17
Q
Define neuropathic pain.
A
Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system.
18
Q
Summarise the treatment algorithm for the management of neuropathic pain.
A
For specific conditions management may vary.
1st line one of:
- Amitryptiline
- Duloxetine
- Gabapentin or pregabalin
If 1st line doesnt work, try one of the other three.
Tramodol may be used as rescue therapy for exacerbations of neruopathic pain.
Topical capsaicin may be used for localised neuropathic pain (e.g. postherpetic neuroalgia).
Referral to pain managment clinic may be indicated if probelms are difficult to treat and persist.
19
Q
What is Brown-Séquard Syndrome?
Describe the clinical features.
A
Brown-Séquard Syndrome is a rare spinal disorder that resluts from an injury to one side of the spinal cord, resulting in hemisection.
This results in:
- ipsilateral upper motor neurone signs
- ipsilateral dorsal column signs (loss of light touch and vibration and proprioception)
- contralateral spinothalamic signs (loss of pain and temperature sensation)
20
Q
Describe the main patters on motor and sensroy damage observed with a radial nerve palsy.
A
Motor: Wrist drop (as yupplies all the muscles in the forearm). Aka. saturday night palsy.
Sensory: Sensory loss to small area between the dorsal aspect of 1st and 2nd metacarpals.
21
Q
What criteria are used to diagnose multiple sclerosis?
A
The McDonald criteria.
Basically a sophisticated way of showing “two lesions seperated by time and space”.
22
Q
Describe the acute managment of migraines.
A
First-line: Offer compination therapy with an oral triptan plues either NSAID or paracetamol.
For young people (12-17) consider nasal spray triptan instead of oral.
If these measures are not effective, offer non-oral metoclopramide (a D2 antagonist) and non-oral NSIAD or Triptan.
23
Q
Summarise the prophylactic managment of migraines.
A
Prophylaxis should be given if experiencing ≥2 attacks/month.
1st line: topiramate or propanolol. (propanoloy preferred in women of childbearing age).
If this fails, offer 10 sessions of accupunture, or gabapentin.
Adivse that 400mg OD of riboflavin may help with migraines.
24
Q
What are the symptoms of cerebellar disease?
A
D - Dysdiedokinesia
A - Ataxia (limb and truncal)
N - Nystagmus (horizontal; ipsilateral hemisphere)
I - Intention tremor
S - Slurred staccato speech; Scanning dysarthria
H - Hypotonia
(P - Past pointing)
25
What are causes of cerebellar disease?
* Fridreich's Ataxia
* Neoplastic (e.g. cerebellar haemiangioma)
* Stroke
* Alcohol
* Multiple sclerosis
* Hypothyroidism
* Drugs: Phenytoin, lead poisoning
26
Roughly describe which area the PCA, MCA and ACA supply.
27
What is the name of the tool used to assess patients with suspected strokes?
ROSIER (Recognition of stroke in the emergency room) - recommended by NICE to assess stroke symptoms in the acute setting
NOTE: FAST is a tool only used by the general public to allow them to seek quick help.
28
What is autonomic dysreflexia?
Autonomic dysrelfexia is a **sudden and very exaggerated sympathetic nervous system** activation, presenting with **etreme hypertension, flushing** and **sweating above the level of the cord lesion**.
It is triggered by afferent signals, usually faecal impaction or urinary retention which cause a sympathetic spinal reflex via the thoracocolumbar outflow.
It occurs in patients with a **lesion above T6** in the spinal cord.
29
What are the characterisitc feautures of a common perineal leasion?
The most characteristic is **foot drop**. Others include:
* Weekness of foot dorsiflexion
* Weakness of foot eversion
* Weakness of extensor hallucis longus
* Sensory loss over dorsum of foot and lower part of leg
* Wasting of anterior tibial and peroneal muscles
30
What are the features that point towards a diagnosis of motor neurone disease?
Characteristic features:
* Fasciculations
* Absence of sensory signs/symptoms
* Mixture of upper and motor neurone signs
* Wasting of small muscles in hand/tibialis anterior is common
Other features:
* Doesn's affect occular muscles
* No cerebellar signs
* Abdominal reflexes and sphincter dysfunction if present is a late feature.
31
What is Hoffman's Sign?
In which conditions can this be observed?
Hoffman's sign is elicited by flicking the distal phalynx of the middle finger, causing momentary flexion. A positive result is exaggerated flexion of the terminal phalynx of the thumb.
This is an upper motor neurone sign, as seen in e.g.:
* Multiple sclerosis
* Degenerative cervical myelopathy
32
What is Kernig's Sign and when can this be observed?
Kernig's sign is pain on knee extension from a position of hip flexion and knee flexion.
It suggests meningeal irritation, e.g. **meningitis** or **subarachnoid haemorrhage**.
33
What is Tinel's test, and when can this be observed?
What is another test that is positive in this condition?
Tinel's test is a way to test for an irritated nerve. It is elicited by lightly tapping the nerve repeatedly. If positive, it will cause a tingling sensation.
It is most commonly used to diagnose **Carpal tunnes syndrome**; tap a the anterior wrist, and a **tingling should be felt in thumb, index and middle finger.**
Another test is **Phalen's Sign** (aka. reverse prayer sign). When this is held for 30-60 seconds, a positive sign would again elicit tingling/stinging/pain.
34
What is a complication of sinusitis that you need to suspect if someone develops focal neurological signs and fever?
Cerebral abscess.
Other than from sinusitis, this can also be a complication of middle ear infections.
35
What is cavernous sinus thrombosis?
How does it present?
A blood clot within the cavernous sinus can be septic or aseptic.
Septic is more common, as a result of infection spreading from **nose/sinuses/ears.** Other causes include: neoplasia, trauma.
Clinical features include:
* Opthalmoplegia (6th nerve typically before 3rd and 4th)
* Trigeminal nerve involvment may occur. -\> Hyperaesthesia of upper face and eye pain
* Central retinal vein thrombosis
36
With regards to hearing, what is acommon complaint of facial nerve palsy?
The facial nerve also supplies the corda timpani, which supplies the stapedius muscle. This muscle reduces loudness, and therefore paralysis is associated with **hyperacusis**. Other features of a facial nerve palsy include:
* Facial muscles: paralysis. Can't close eyelids, but it's droopy
* Tasta: loss of anterior 2/3rds of tongue
* Parasympathetic: lacrimal and salivary glands.
37
What are the clinical features of tuberous sclerosis?
**Clinical features**
Cutaneous:
* Depigmented "**ash**-**leaf**" spots with fluoresce under UV light
* Roughened patches of skin over lumbar spine (**Shagreen** **patches**)
* Adenoma sebaceum (aka. **Angiofibromas**): butterfly distribution over nose
* Fibromata beneath nails (**subungal** **fibromata**)
* **Café-au-lait spots** may be seen (though more associated with neurofibromatosis)
Neurological feautres:
* **Developmental** **delay**
* **Epilepsy**
* Intellectual impairment
Others:
* Increased lifetime risk of **cancer**
* **Retinal** **hamartomas** (dense white areas on retina)
* Rhabdomyomas of the heart
* Gliomatous changes that occur in brain lesions
* Polycystic kidneys,
* Lung cysts (lymphangioleiomyomatosis)
38
Distinguish between Erb's and Klumpke's Paralysis.
Erb's:
* Damage to C5 and C6 nerve roots
* Leads to winged scapula
* Arm in "waiter's tip position"
Klumpke's:
* Damage to C8 and T1 nerve roots
* leads to claw hand by affecting intrinsic muscles of the hand
39
Compare and contrast the skin lesions seen in tuberous sclerosis and neurofibromatosis.
Tuberous sclerosis:
* Ash-leaf (depigmented) spots (depigmented)
* Angiofibroma (facial rash)
* Shagreen pathches
* Subungal fibromata
Neurofibromatosis:
* Café-au-lait spots
* Neurofibromas
* Frackling in skin folds
40
What is the first-line medication used after a TIA or stroke (after 14 days)?
First line: **clopidogrel 75mg** + statin
Second Line: **aspirin 75mg + dipyridamole** + statin
Third line: **dipyridamole** + statin
41
Summarise the antiplatelet regimens for a patient with an ischaemic stroke.
Aspirin 300mg OD for 2 weeks, then clopidogrel 75mg long-term.
Plus a statin.
42
Describe the muscles of the eye and their inntervation.
Third nerve:
* Medial rectus
* Inferior Oblique
* Inferior rectus
* Superior recus
4th nerve:
* Superior oblique
6th nerve:
* Lateral rectus
43
What are the contraindications to prescribing triptans?
Triptans should not be prescribed in patients with a history of, or significant risk for:
* Ischaemic Heart Disease
* Cerebrovascular Disease
44
How should triptans be taken?
* Should be taken as soon as possible after the onset of headache (rather than onset of aura)
* There are several modes of administration:
* Oral, nasal spray, SC injections
45
What are the adverse effects of triptans?
Tingling, head, heaviness, pressure, tighness in throat and chest.
46
Describe when AED can be considered to be stopped.
Can be considered to be stopped if seizure free for \> 2 years, with AEDs being stopped over **2-3 months.**
47
What is degenerative cervical myelopathy?
DCM involves cord dysfunction from compression in the neck.
Due to its mobility, the vertebral column of the neck is particularly prone to degenerative changes such as disc herniation, ligament hypertrophy or ossification, and osteophyte formation.
DCM is more common with age.
48
What are the common symptoms of degenerative cervical myelopathy?
A common presentation is **paraesthesia**, which make it easily confused with **carpal tunnel syndrome .** Other symptoms include:
* Neck pain/stiffness
* Unilateral limb weakness, numbness, loss of dexterity
* Unilateral body pain
* Autonomic dysfunction (bowel/bladder incontinence, ED)
* Imbalance/falls
49
What are the common signs of degenerative cervical myelopathy?
* Motor signs:
* Pyramidal weakness
* Limb hyperreflexia
* Spasticity
* Hoffman's sign
* Babinski's sign
* Lhermitte's sign (electric shock sensation down the spine on eck felxion)
50
Summarise the management of Parkinson's disease.
Fist-line treatment:
* If _motor_ _symptoms_ **are** affecting the patients QoL: **levodopa** (often in conjunction with a decarboxylase inhibitor such as **carbidopa**)
* If motor symptoms are **not** affecting the patient's QoL:
* **Dopamine agonist** (e.g. ropinirole, apomorphine)
* Levodopa
* Monoamine oxidase B (MAO-B) inhibitors (e.g.slelgiline)
If a patient continues to have smptoms despite optimal levodopa treatment, add dopamine agonist, MAO-B inhibitor or catechol-O-methyltransferase inhibitor (e.g. entecapone, opicapone) as an adjunct.
*(NB that bromocriptine and cabergoline have been associated with pulmonary/cardiac fibrosis and are therefore not recommended first line)*
51
What medication can be used to control drug induced parkinsonism?
Antimuscarinics, such as procyclidine, can be used to control drug induced parkinsonism (block cholinergic receptors).
52
What are the symptoms of normal pressure hydrocephalus?
They can be remembered as **wet, wobbly and whacky**.
* Urinary incontinence
* Gait abnormality (may be similar to Parkinson's disease)
* Dementia and bradyphrenia
~60% of patients will have all 3 at diagnosis; symptoms develop over a few months.
53
What are the investigations of normal pressure hydrocephalus?
* **CT head** (non-contrast)/**MRI**
* Would show snlarged ventricles with cortical atrophy
* **Levodopa challenge**
* Parkinson's is an important differential, so patient is given therapeutic trial of levodopa. If symptomsa re responsive, NPH can be ruled out.
54
Summarise the management of normal pressure hydrocephalus.
If patient is suitable for surgery:
* Ventriculoperitoneal shunt
* Control of cardiovascular risk factors (HTN, diabetes, statins etc)
If not suitable for surgery:
* Control of cardiovascular risk factors
* Large-volume CSF taps
55
What is the mode of inheritance of Charcot-marie-Tooth disease?
CMT disease is autosomal dominant.
56
What is Charcot-Marie-Tooth disease?
CMT, a hereditary sensorimotor neuropathy (HSMN), is an autosomal dominant disease of the peripheral nerves. It is due to a defect in the **PMP-22 gene** which codes for **myelin**. As the name suggests, it affects both motor and sensory preipheral nerves.
This leads to progressive peripheral nerve damage:
* Distal muscle wasting (pes cavus, hammer toe)
* Foot drop
* Leag weakness
Symptoms often start in puberty.
57
What is Multiple System Atrophy?
MSA is a rare neurodegenerative disorder characterised by:
* Parkinsonian features
* Autonomic dysfunction
* Impotence
* Urinary incontinence
* Urinary retention
* Postural instability
* Orthostatic hypotension
It is a **Parkinsons Plus** disease, and responds poorly to dopaminergic medication.
There are 2 types, MSA-P and MSA-C; the former presents with predominantly Parkinsonian features, the latter with Cerebellar features.
58
Summarise the Oxford Stroke Classification.
The Oxford Stroke Classification (Bamford Classification) classifies strokes based on the initial symptoms. Summary as follows:
1. Unilateral hemiparesis and/or hemisensory loss of the face, arm and leg.
2. Homonymous Hemianopia
3. Higher cognitive dysfunction (e.g. dysphasia)
**Total anterior circulation infarcts:**
* Involves MCA and ACA
* All 3 of above criteria present
**Partial circulation infarcts:**
* Involves smaller arteries of the anterior circulation, e.g. upper or lower division of MCA
* 2 of the above symptoms present
**Lacunar infarcts:**
* Involves perforating arteries of the internal capsule
* Presents with one of the following:
* Unilateral weakness (± sensory deficit) of face and arm, arm and leg or all three
* Pure sensory stroke
* Ataxic hemiparesis
**Posterior Circulation infarcts**:
* Involves **vertebrobasilar arteries**
* Presents with one of the following
* Cerebellar of brainstem syndromes
* LoC
* Isolated homonymous hemianopia
59
What is the most effective treatment for degenerative cervical myelopathy?
Decompressive surgery is the most effective treatment currently - has been shown to prevent disease progression.
60
What is an internuclear ophthalmoplegia?
INO occurs due to a lesion of the **medial longitudinal fasciculus**, a tract that allows conjugate eye movement. This results in impariment of adduction of the ipsilateral eye. The contralateral eye aboducts - with nystagmus. (*see image*)
A common cause of this condition in younger patients is **MS**.
61
What is cavernous sinus syndrome?
Cavernous sinus syndrome is a syndrome characterised by neuropahties of the cranial nerves passing through the cavernous sinus. These include:
* Occulomotor
* Trochlear
* Ophthalmic
* Maxillary (V2)
* Abducens
Clinical features:
* Palsies of the nerves above
62
What are potential causes of cavernous sinus syndrome?
* Infection
* Vascular:
* Aneurysm
* Thrombosis
* Inflammation (SLE, amyloidosis)
* Neoplasia
63
Summarise the aetiology and risk factors for Bell's Palsy.
The aetiology is not fully known. Potentially **viral-associated** (HSV) or **Lyme** **disease**.
Risk factors include **pregnancy**: 3x more common.
64
How is Bell's Palsy managed?
* Prednisolone 1 mg/kg for 10 days within 72 hours of onset (aciclovir has no benefit)
* Eye care: artificial tears/eye lubricants
65
Which condition is associated with motor neurone disease?
**Frontotemporal** **dementia** is associated with motor neurone disease.
66
What is idiopathic intracranial hypertension, in whom and how does present?
This condition is characterised by incrased intracranial pressure without a detectable cause.
Risk factors include:
* Obestiy
* female sex
* Pregnancy
* Drugs: OCP, Steroids, Tetracycline, vitamin A, lithium
Clinical features are:
* Headache
* Blurred vision
* Papilloedema
* enlarged blindspot
* 6th nerve palsy
67
How do you manage idiopathic intracranial hypertension?
* Weight Loss
* Diuretics
* Topiramate
* Repeated LPs
* Surgery (ventriculoperitoneal shunt, optic nerve sheath ecompression)
68
What lifestyle factor is an identifired trigger of cluster headaches?
Alcohol
69
What is mononeuritis multiplex?
Simultaneous or sequential involvement of individual non-contiguous nerve trunks; typically presents with acute or subacute loss of sensory and motor function of individual nerves
70
What is the most common type of MS?
Relapsing remitting
71
Summarise the initial treatment for a TIA
* Give Aspirin 300mg immediately, unless
* The patient has a bleeding disorder or is taking an anticoagulant (in this case admission for imaging)
* Patient is already taking low-dose aspirin
* Aspirin is contraindicated
* If \>1 TIA (crescendo TIA) or suspected cardioembolic/CAS
* Discuss need for admission/observation with a stroke specialist
* If suspected TIA within 7 days:
* Arrange **urgent assessment with stroke specialist** (within 24 hrs)
* If suspected TIA \>7 days ago: assessment within 7 days
The person should **not drive** until assessed.
72
Describe the longer term management for TIAs
Antithrombotic therapy:
* Clopidogrel
* If cannot tolerate: aspirin + dipyrimadole
Carotid endarterectomy if:
* Stroke in carotid territory and **not** severely disabled
* Stenosis \>70% (ECST criteria) or \>50% (NASCET criteria)
73
What is the target time for thrombectomy in acute ischaemia stroke?
6 hours.
74
Summarise the medical treatment of Bell's Palsy
Prednisolone and lubricating eye drops.
Evidence has shown that use of corticosteroids increases the likelihood of complete recovery compared with placebo or aciclovir. As this patient cannot close her eye, eye drops and tape would be important to protect the cornea. NICE does not recommend the use of aciclovir in the management of Bell's palsy.
75
Which antiepileptic is most associated with weight gain?
Sodium Valproate
76
What is the difference between drug induced and idiopathic Parkinson's disease in terms of tremor?
In drug induced Parkinson's can be bilateral, whereas in idiopathic it is usually unilateral.
77
Summarise the acute treatment for cluster headaches.
Subcutaneous sumatriptan + 100% O2
78
Summarise the prophylactic treatment for cluster headaches.
Verapamil (consider tapering dose of steroid)
79
What is the commonest neurological manifestation of sarcoid?
**Facial nerve palsy** (often bilaterally) is a common manifestation of sarcoid.
80
What is a cholesteatoma?
A cholesteatome is an abnormal collection of skin cells deep inside your ear.
It is characterised by:
* Abnormal and **purulent ear discharge**, resistant to ABx treatment
* **Hearing** **loss**/tinnitus
* Less commonly, otalgia, vertigo, or **facial nerve (VII)** involvement (altered taste or facial weakness) may be present, often indicating more advanced disease.
81
Which condition are subungal fibromatas associated with?
Tuberous sclerosis
82
What is synringiomyelia?
Syringiomyelia is a collection of cerevrospinal fluid within the spinal cord.
Causes include:
* A chiari malformation (brain tissue extends into spinal canal)
* Trauma
* Tumour
* Idiopathic
Presentation:
* "cape-like" (neck and arms) **loss of sensation** to **temperature** but **preservation of light touch, proprioception and vibration**.
* Spastic weakness (predominantly of upper limbs)
* Paraesthesia
* Neuropathic pain
* Upgoing plantars
* Bowel and bladder abnormalities
83
What scoring system can be used to differentiate between an actue stroke and stroke mimcs?
The ROSIER (recognition of stroke in the ER) scale.
84
Which territory is most likely affected in a stroke that presents with global aphasia?
The left hemisphere, and as the MCA supplies both Wernicke's and Broca's area, this is the most likely artery to be affected.
85
Summarise the management of epilepsy.
Usually, anitepileptics are now started after the **second** seizure. They may be started after the first if:
* Patient has neurological deficit
* Structural brain abnormality
* EEG shows unequivocal epileptic activity
* Unacceptable risk to having a further seizure
**Sodium valproate** is first-line for **generalised seizures**; lamotrigine and carbamezapine are second-line.
For **Focal seizures**, **carbamezapine** as first, leviteracetam or oxcarbazepine second-line.
Absence seizures: Sodium valproate or ethosuximide
Myoclonic: sodium valproate. 2nd line: clonazepam, lamotrigine
86
Summarise the acute managment of a migraine.
* First line: **oral triptan + paracetamol/NSAID**
* Young people, consider nasal triptan over oral
* If this is ineffective, add non-oral metoclopramide or prochlorperazine. Consider adding non-oral NSAID/triptan
87
Summarise the prophylactic managment of a migraine.
Prophylaxis should be given if patients are experiencing **≥2** migraine attacks per month.
* **Topiramate** or **propanolol** (depending on patient's preference)
* If this fails, **10 sessions of accupuncture** over 5-8 weeks
* Advise that riboflavin (400mg OD) may be effective
* **Menstrual** **migraine**: frovatriptan or zolmitriptan
88
What are the important risk factors for MS?
* Smoking
* Previous infectious mononucleosis
* Hypovitaminosis D
* Genetics (HLA DR1\*15)
89
What medication has shown to have a survival benefit in motor neurone disease?
Riluzole. It prevents the stimulation of glutamate receptors, and is used mainly in ALS, prolonging life by around 3 months.
This is in addition to repiratory care and other supportive measures.
90
What would headaches, visual disturbances and papilloedema and high opening pressure on LP point towards?
Idiopathic intracranial hypertension
91
How can you check fluid leaking from the nose or ear is CSF?
Glucose - mucus would be low whereas CSF has glucose\
Also beta-2-transferrin (good standard)
92
Which drug commonly used in anaesthesia would a patient with myasthenia gravis be resistant to?
**Suxamethonium**. This is a neuromuscular blocking drug; it acts by binding to and activating the receptor (at first causing muscle contraction, then paralysis). Due to decreased number of available receptors, MG patients are typically resistant to depolarising NMBDs and may require significantly higher doses.
**Rocuronium** also is a NMBD, but it acts by binding and antagonising the poast-synaptic receptor; in MG there are already fewer receptors available for ACh, so lower doses are required.
93
Which drugs are associated with exacerbation of myasthenia gravis?
* Beta Blockers
* Penicillamine
* Lithium
* Antibiotics: gentamicing, macrolides, quinolones, tetracyclines
94
Which muscle is supplied by the 6th cranial nerve?
Lateral rectus, responsible for lateral movement of the eye.
95
Summarise the role of:
* Corticospinal tract
* Dorsal Column
* Spinothalamic
* Anterior White Commisure
* Spinocerebellar
* Dorsal root ganglion
* Corticospinal tract: carries motor information from brain
* Dorsal Column: Fine touch
* Spinothalamic which crosses in the anterior white comisure: Pain/temperature
* Spinocerebellar: proprioception
* Dorsal root ganglion: Synapse of peripheral sensory neves
96
What can you prescribe a Parkinson's patietn who cannot swallow safely?
Dopamine agonist patch, to prevent acute dystonia.
97
Which vitamin in Pabrinex can help to reduce Wernicke's?
Thiamine, vitamin B1.
98
What is the tratment for a myasthenic crisis?
Ensuring adequate respiration (e.g. with ventilation) is key.
Plasma electrophoresis followed by IVIG are specific MG treatment.
99
Differentiate between the hand signs/symptoms of an ulnar and a median nerve lesion.
Median:
* Thenar wasting
* Weak thumb ABDuction
* Weak thumb opposition
Ulnar:
* Hypothenar wasting
* Weak thumb ADDuction
100
What finding do you expect in the CSF of someone with MS?
Oligoclonal bands. They are positive in ~80% of MS patients.
Elevated IgG levels are another common finding.
101
What is the most common psychiatric problem in Parkinson's Disease?
**Depression**, in ~40% of patients.
Dementioa is also common.
102
Name and describe the sign that can help differentiate between an organic and non-organic lower leg weakness.
**Hoover's Sign** of leg paresis.
Ask the patient to raise the affected leg. If the examiner can feel the "normal" limb pushing downwards as the patient tries to lift the affected, then he is genuinely trying to make an effort. If not, then this is suggestive of underlying functional weakness (conversion disorder).
103
Describe ataxic gait.
Ataxic gait is often described as **wide-based, loss of Heel-to-toe pattern** and **instability**.
104
What are common causes of ataxic gait?
P - Posterior fossa tumour
A - Alcohol
S - Multiple sclerosis
T - Trauma
R - Rare causes
I - Inherited (e.g. Friedreich's ataxia)
E - Epilepsy treatments
S - Stroke
105
What is a medical treatment for idiopathic intracranial hypertension?
**Acetazolamide**; this is a carbonic anhydrase inhibitor - thus reducing the production of CSF and subsequently reducing intracranial pressure.
**Topiramate** is another medication.
106
Summarise the treatment for neuropathic pain.
NICE:
* 1st line: amitryptiline, duloxetine, gabapentin, pregabalin
* 2nd line: a drug from above that hasn't been tried
* Rescue therapy: tramodol (for exacerbations)
* For topical (e.g. pos-herpetic neuralgia): topical capsaicin
Always recommend going to pain clinics if the pain is generalised, severe or doesn't get better.
107
Is the MRI for the diagnosis of MS with or without contrast?
MRI **with** contrast is best investigation for diagnosing MS. This would show **enhancing _new_ lesions**. Non-contrast MRI would show lesions, but could not show dissemination in time, and is therefore used for disease-monitoring and not diagnosis.
108
What would you see on MRI in a patient with MS?
* High signal T2 lesions
* Periventricular plaques
* Dawson fingers: hyperintense lesions perpendicular to the corpus callosum (see image)
109
What are the clinical features of restless legs syndrome?
* Uncontrollable urge to move legs (akathesia). This often initially occurs at night, but as the condition progresses, may occur during the day. Worse at rest.
* Paraesthesias (crawling or throbbing sensation)
* Movements dueing sleep (noted by partner) "periodic limb movements of sleeps" (PLMS)
110
What are some causes and associations of restless legs syndrome?
* Positive FHx (in 50%)
* IDA
* Uraemia
* DM
* Pregnancy
111
Summarise the managment of restless legs syndrome.
Conservative:
* Encourage walking, stretching, massaging the affected limbs
Medical:
* Treat and iron deficiency
* Dopamine agonists: **Pramipexole**, **ropinirole**
* Benzodiazepines
* Gabapentin
112
What nerve roots do the common reflexes correspond to?
113
Which AED are useful in the management of absecne seizures?
Sodium valproate and ethosiximide are first line.
Carbamezapine is not indicated in absence seizures.
114
How long must drivers of Group 2 vehicles, e.g. buses, be seizure free before driving again with a diagnosis of epilepsy?
10 years.
115
Summarise the managment of stroke.
* Perform non-contrast CT to rule out haemorrhagic stroke
* Give **300mg Aspirin** (orally, via NG tube if unsafe swallow or rectally)
* If within 4.5 hours of onset of symptoms:
* Thrombolysis with e.g. alteplase
* Thrombectomy (performed in addition to thrombolysis if within 4.5 hours) if:
* If **within 6 hours** of symptom onset and confirmed **proximal** **anterior** **circulation** stroke
* If within 24 hours and confirmed **proximal anterior circulation** occlusion and there is potential to salvag brain tissue
* Consider thrombectomy if:
* wihtin 24 hours and **proximal posterior circulation** occlusion and potential to salvage brain tissue.
116
When would you start anticoagulation in a patient presenting with an acute stroke and known AF?
Anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually **not until 14 days have passed** from the onset of an ischaemic stroke
117
Summarise the secondary prevention for stroke.
* Clopidogrel 75mg bd lifelong
* Aspirin + dipyrimadole if clopidogrel not indicated
* MR dipyrimadole alon if aspirin and clopi are not indicated
118
What is trigeminal neuralgia?
* Unilateral disorder characterised by:
* Brief electric shock-like pains, abrupt in onset and termination
* Limited to one or more divisions of the tirgeminal nerve
* Pain evoked by light touch (brushing, shaving, talking)
119
What is the managment of trigeminal neuralgia?
**Carbamezapine** is first-line.
Failure to respond to treatment, or atypical features should prompt neurology referral.
120
What is Neurofibromatosis II associated with?
Bilateral vestibular schwannomas.
This presents with sensorineural hearing loss in late-teens, tinnitus and vertigo.
Other tumours include intracranial schwannomas and meningiomas.
121
Which anti-emetic can be used in Parkinson's disease?
**Domperidone**.
Whilst this is a D2-receptor antagonis, like metocloparmide, it cannot cross the BBB and therfore doesn't worsen Parkinsonian symptoms.
Antihistamines such as cyclizine or prochlorperazine, may excerbate Parkinson's disease.
122
What can provoke absence seizures in a child?
Seizures are characteristically provoked by **hyperventilation**.
123
What are the blood results in a patient with neuroleptic malignant syndrome?
* Raised CK
* Raised K+
* Leukocytosis
* Low or normal Ca2+
124
How might phenytoin alter the FBC?
Phenytoin can cause a megaloblastic anaemia by altering folate metabolism.
125
What are the features of Wenicke's encepalopathy?
Features
* nystagmus (the most common ocular sign)
* ophthalmoplegia
* ataxia
* confusion, altered GCS
* peripheral sensory neuropathy
If this is left untreated it can progress to Korsakoff syndrome, which also has **amnesia** and **confabulation.**
126
What are vestibular schwannomas?
Vestibular schwannomas, aka acoustic neuromas, are **tumours at the cerebro-pontine angle**.
They account for 5% of intracranial tumours. Due to their position, they can compress certain cranial nerves:
* VIII: vertigo, unilateral sensorineural earing loss, tinnitus
* V: absent corenal reflex
* VII: facial palsy
If suspected, refer for ENT and **gadolinium enhanced MRI** + audiometry. They usually then get removed surgically ± radiotherapy.
127
What is Todd's paresis?
Todd's paresis is weakness in part or all of the body **after a seizure.**
This can occur e.g. after a **patial frontal lobe seizure**
128
Which medications are associated with idiopathic intracranial hypertension?
* Tetracycline ABx
* Isotretinoin
* Contraceptives
* Steroids
* Levothyroxine
* Lithium
* Cimetidine
129
What is the function of Broca's and Wernicke's area respectivley?
Where do each of these regions lie in the brain?
Broca's area is responsible for speech production, it lies in the **inferior frontal gyrus**. Lesion here cuases inability to speak.
Wernicke's area is responsible for speech reception, it lies in the **superior temporal gyrus**. Lesion here causes inability to understand and therefore leads to abnormal speech production.
130
What can occur when you suddenly stop anti-Parkinsonism medications?
Neuroleptic malignant syndrome.
Acute withdrawal of levodopa can precipitate neuroleptic malignant syndrome. This is a serious condition with a mortality of at least 10% and must be managed in ITU. As a result, levodopa is a critical medication, and must be given on time and not missed with acute admissions.
131
How can you distinguish acute vs chronic subdural Hämatoms on CT?
Acute: the blood is hyperdense
Chronich the blood is hypodense.
132
What would an LP show in a patient with GBS?
Clear, normal glucose and WCC.
**Raised** protein.
133
What is the managment of a low pressure headache?
First line:
* Caffeine and IV Fluids
Second line:
* Blood patch. Using the patient's own blood to form a patch. Used if still present after a few days.
134
What are vestibular schwannomas - also summarise their presentation.
They are cerebropontine angle tumours.
They present with features depending on the underlying nerve affected:
* VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
* V: absent corneal reflexes
* VII: facial palsy
135
What is a Chiari malformation?
A Chiari malformation, previously called an Arnold-Chiari malformation, is where the **lower part of the brain pushes down into the spinal canal.**
136
What are atypical features of trigeminal neuralgia?
Some atypical (and therfore red flag) features include:
* Deafness or other ear problems
* History of skin or oral lesions that could spread perineurally
* Oain only in ophthalmic division, or bilaterally
* Optic neuritis
* Onset before 40 years
137
What artery is implicated in lateral medullary syndrome?
The posterior inferior cerebellar artery, **PICA**.
Symptoms include:
* Ipsilateral facial pain and temperature loss
* Contralateral limb pain and temperature loss
* Ataxia
* Nystagmus
* Hoarseness and dysphagia
138
What are the LOAF muscles of the hand?
Which nerve supplies these?
The LOAF muscles are:
* **L**ateral 2 lumbricals
* **O**pponens pollicis
* **A**bductor pollicis brevis
* **F**lexor pollicis brevis
These muscles are supplied by the **median** **nerve**.
All other flexor muscles of the hand are supplied by the ulnar, all extensor by the radial nerve.
139
What is cataplexy?
Cataplexy describes the sudden and transient **loss of muscular tone** caused by **strong** **emotion**.
140
What is the sensory deficit seen in common peroneal nerve palsy?
Sensory loss over the **dorsum of the foot** and the **lower part of the leg**.
141
How can you distinguish between L5 radiculopathy and a common peroneal nerve palsy?
Both present with foor drop.
Common peroneal nerve injury, **inversion is spared**, whilst with L5 radiculopathy both inversion and eversion will be affected.
142
What is complex regional pain syndrome?
CRS is the umbrella term for neurological and related smptoms following surgery or minor injury. There are 2 types:
I: No demonstrable lesion to a major nerve
II: lesion to major nerve
143
What are features of complex regional pain syndrome?
Clinical features:
* Progresive, disproportionate symptoms to the original injury/surgery
* Allodynia (painful perception of non-painful stimuli)
* Temperature and skin colour changes
* Oedema and sweating
* Motor dysfunction
144
What additional investigations might you consider in a young person with an ischaemic stroke?
You strokes (\< 55) should be investigated as per usual, and additionally for **autoimmune diseases** and **thrombophilia**.
This includes ANA, APL, anticardiolipin, lupus anticoagulant, coagulation screen, ESR.
145
146
Why is the OCP contraindicated in patients with miraines with aura?
In patients with migraines with aura, there is an absolute increased risk of stroke if the OCP is taken.
147
What is Arnold-Chiari malformation?
What are the features of this?
Arnold-Chiari malformation describes the downward displacement, or herniation, of the cerebellar tonsils through the foramen magnum. This may be **congenital** or **acquired** e.g. via trauma.
Features include:
* Non-communicating hydrocephalus (CSF outflow obstruction)
* Headache
* Syringomyelia
148
Which cranial nerve is commonly affected in a trans-tentorial herniation?
Occulomotor
149
What are the most common **secondary brain tumours?**
* Lung (most common)
* Breast
* Bowel
* Skin (melanoma)
* Kindey
150
Which nerves innervates the pronator muscles of the hand?
The median nerve.
The **anterior interosseus nerve** supplies the **pronator quadratus**.
151
How does pyridostigmine work?
Pyridostigmine is a long acting acetylcolinesterase inhibitor, therby increasing the amounts of acetylcholine found in the cleft.
152
Which medications are used in migraine prophylaxis?
**Propanolol** and **topiramate**.
Accupuncture is also recommended.
Topiramate should be avoided in pregnancy
153
Why do should you replace B12 before folate in a patient that is deficient in both?
Replacing folate in a patient that also is B12 deficient can lead to **subacute degeneration of the spinal cord.**
154
What is Weber's Syndrome?
Weber's Syndrome is a **midbrain stroke syndrome** that involves the fascicles of the occulomotor nerve resultin in an **ipsilateral** **CN III palsy** and a **contralateral** **hemiplegia** or **hemiparesis**.
155
What is the management of a hameorrhagic transformation after treatment of an ischaemic storke?
* Stop all anticoagulatn medications
* Maintain systolic BP to 140 mmHg
Further managment depends on the case and is handled by seniors.
156
What two easily treateble causes of status epilepticus need to be ruled out/reversed?
**Hypoxia**
**Hypoglycaemia**
157
158
What is Schwartz sign?
This is a sign on otoscopy, that shows a hypervascular bone "pinkish" discolouration behind the eardrum.
This is seen in **otosclerosis**.
159
Which nerves are affected in cerebellar pontine angle pathology, and what are the subsequent symptoms?
7 - Facial nerve palsy
8 - Deafness, tinnitus, vertigo
6 - Diplopia
160
What is Meniere's Disease?
Meniere's disease is a **disorder of the inner ear** of unknown cause, characterised by excessive pressure and progressive dilation of the endolymphatic system.
161
What are features of Meniere's Disease?
* Recurrent episodes of **vertigo** (most prominent), **tinnitus** and hearing loss (sensorinerual
*
162
What is normal LP opening presure?
6-20 mm H2O (some sources say up to 25 mm H2O is normal)
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