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Neurology
DrTaba KhanNeurology forclinical exams
• Stroke
• Epilepsy andseizures
• Parkinson's disease
• Cranial nerve palsy
• Multiple Sclerosis
• Guillain-Barre syndrome
• Peripheral neuropathyA65-year-oldmalepatientpresentstotheemergencydepartmentwithsudden
onsetleftsidedweakness.HehasapastmedicalhistoryofType2diabetesmellitus
andhypertension.Physicalexaminationrevealsreducedpowerinleftarmandleg,a
leftsidedhomonymoushemianopia,andleftsidedneglect.Thereisno facial
weakness.Whichofthefollowingcorrectlydefinesthemostlikelydiagnosis.
• A) Total anteriorcerebralinfarct(rightanteriorandmiddle cerebralartery)
• B) Total anteriorcerebralinfarct(left anteriorandmiddle cerebralartery)
• C) Partial anteriorcerebralinfarct(rightmiddle cerebralartery)
• D) Partial anteriorcerebralinfarct(left middle cerebralartery)
• E) Lacunarstroke(perforatingarteriesoftheleft internalcapsule)A65-year-oldmalepatientpresentstotheemergencydepartmentwithsudden
onsetleftsidedweakness.HehasapastmedicalhistoryofType2diabetesmellitus
andhypertension.Physicalexaminationrevealsreducedpowerinleftarmandleg,a
leftsidedhomonymoushemianopia,andleftsidedneglect.Thereisno facial
weakness.Whichofthefollowingcorrectlydefinesthemostlikelydiagnosis.
• A) Total anteriorcerebralinfarct(right anteriorandmiddle cerebralartery)
• B) Total anteriorcerebralinfarct(left anteriorandmiddle cerebralartery)
• C) Partial anteriorcerebralinfarct(rightmiddle cerebralartery)
• D) Partial anteriorcerebralinfarct(left middle cerebralartery)
• E) Lacunarstroke(perforatingarteriesoftheleft internalcapsule)Types ofstroke
85%ofstrokesareischaemic 15%ofstrokesarehaemorrhagic • family historyofischaemicstroke,
hypertension,smoking,diabetes,
highcholesteroland atrial
fibrillation.
• Haemorrhagicstroke:age,male
sex,hypertension,anticoagulation
therapy,illicit sympathomimetic
Riskfactors drugs(suchascocaineand
amphetamines)andvascular
malformations(AVMs)Bamford/OxfordClassificationofstrokeA 72-year-oldmalepatientpresentstotheemergencydepartmentwithsudden
onsetdifficultyspeakingandaninabilityto raisehisrightarm.Hehasapastmedical
historyofhypertension.Hewaslastknown tobefullyfunctional3hoursagowhen
hisdaughterspketohimonthephone.Physicalexaminationrevealsareceptive
aphasiaandrightarmparalysis.Thebloodpressureis145/95mmHg,butvitalsigns
areotherwisewithinnormalrange.CT headrevealsahyper-intenselesionintheleft
middlecerebralarteryvascularterritory.Which ofthefollowingisthemost
appropriateacutemanagementforthemostlikelydiagnosis?
• A) Intravenousalteplase
• B) Supportivemanagementandneurosurgicalreferral
• C) Aspirin300mg orally
• D) Endovascularintervention(clot-retrieval)
• E) IntravenouslabetalolA 72-year-oldmalepatientpresentstotheemergencydepartmentwithsudden
onsetdifficultyspeakingandaninabilityto raisehisrightarm.Hehasapastmedical
historyofhypertension.Hewaslastknown tobefullyfunctional3hoursagowhen
hisdaughterspoketohimon thephone.Physicalexaminationrevealsareceptive
aphasiaandrightarmparalysis.Thebloodpressureis145/95mmHg,butvitalsigns
areotherwisewithinnormalrange.CT headrevealsahyper-intenselesionintheleft
middlecerebralarteryvascularterritory.Which ofthefollowingisthemost
appropriateacutemanagementforthemostlikelydiagnosis?
• A) Intravenousalteplase
• B) Supportivemanagementandneurosurgicalreferral
• C) Aspirin300mg orally
• D) Endovascularintervention(clot-retrieval)
• E) Intravenouslabetalol CT scanofa spontaneous subarachnoid Subduralhemorrhage: Acute onChronic
haemorrhage.
Bleeds CT scanofa heamorrhagicstroke CT scanofanepiduralhemorrhage
BleedsSuB-dural ePI-dural
SuB=Banana Pi=pie=lemonmirenguepieAcute Management of stroke
• ABCDE!
• CT Head-normal?Treatas ischaemic
• Ifwithin 4.5 hrsandnocontraindications->thrombolysiswithalteplase*
• CT Head= Bleed? Discusswith neurosurgery,BP control
• CT Headnormal +notwithinwindow-Give300mg Aspirinfor2weeks
then75 mg clopidogrel
• All will needPT/OT +furtherinvestigations
• LargeVesselthrombusonCT = considerthrombectomy
*Thrombolysiscontraindications-Recenttrauma,GI/ICH,recent surgery,veryhighBP,low plateletcount,highINR,onanticoagulationChronic stroke Management: HALTSS
• Hypertension
• Antiplaetlets/Anticoagulation:After2 weeks,75mg clopidogrelOD or
anticoagulationwith warfarin/DOACifAF
• Lipidloweringtherapy
• Tobacco:Smokingcessation
• Sugar:screenandmanagediabetes
• Surgery: ipsilateralcarotidartery stenosisof70-90% shouldbereferred
forcarotidendarterectomy.A 23-year-oldwomandevelopsacuteonsetweaknessinherlefsshortlyafter
returningfromholidayinSpain.Overthenextfewdays,shedevelopsworsening
weaknessinthelegsandweaknessinbotharms.Whatisthemostimportantinitial
investigation?
• A) FBC
• B) Peakflow
• C) VitalCapacity
• D) SerumPotassium
• E) ABGA 23-year-oldwomandevelopsacuteonsetweaknessinherlegsshortlyafter
returningfromholidayinSpain.Overthenextfewdays,shedevelopsworsening
weaknessinthelegsandweaknessinbotharms.Whatisthemostimportantinitial
investigation?
• A) FBC
• B) Peakflow
• C)Vital Capacity
• D) SerumPotassium
• E) ABGGuillianBarre
Syndrome
• Ascendingpolyneuropathy
• Associatedwith LRTI/GIinfection,
especiallymycoplasma and
campylobacter (alsoCMV,EBV)
• Mainlymotor butcanhavesensory
signs
• Riskofrespiratoyfailure
• Bessentialrometry(FVC)is
• PlasmaexchangeandIVIG
• MayneedITUA54-year-oldRussianmancomplainsofalteredsensationinhisfeetfor several
months.Hispastmedicalhistoryisnotableforessentialhypertension,gout and
pulmonaryTBtreatedinRussia1yearago.Whatisthemostlikelycauseofhis
symptoms?
• A) Diabeticneuropathy
• B) Isoniazidetoxicity
• C) Vincristinetoxicity
• D) MotorNeuronDisease
• E) GuillainBarreSyndromeA54-year-oldRussianmancomplainsofalteredsensationinhisfeetfor several
months.Hispastmedicalhistoryisnotableforessentialhypertension,gout and
pulmonaryTBtreatedinRussia1yearago.Whatisthemostlikelycauseofhis
symptoms?
• A) Diabeticneuropathy
• B) Isoniazidtoxicity
• C) Vincristinetoxicity
• D) MotorNeuronDisease
• E) GuillainBarreSyndromePeripheral
Neuropathy
• Sub-divisions:snsory/sensorymotor, motor
• Drugs: askabout chemotherapy
• Investigations:bloodtests,nerveconductionstudies
• ABCDE
o Alcohol
o B12 andFolate
o CKD
o Diabetes Romberg's testis used to testfor
o Everythingelse(CMT, Vasculitis,leadtxicity) sensory loss
Positive: Unstable with eyes closed
onlyA45-year-oldmancomplainsofdoublevision.On examinationthedoctornotesthat
hisrighteyeisabducteddownwards,andhispupilislargerthanintheothereye.An
MRI scanof hisbrainandorbitsfindsatumourpressingonwhichof thefollowing
structure?
• A) Abducensnerve
• B) Optic nerve
• C) Occipital cortex
• D) Occulomotor nerve
• E) OpticchiasmA45-year-oldmancomplainsofdoublevision.On examinationthedoctornotesthat
hisrighteyeisabducteddownwards,andhispupilislargerthanintheothereye.An
MRI scanof hisbrainandorbitsfindsatumourpressingonwhichof thefollowing
structure?
'Surgical' causes like
Parasympatheticneurons tumoursand
aneurysms affect
• A) Abducensnerve Motor Neuronsof 3rdnerve parasympathetic
fibres causing a
• B) Optic nerve dilated pupil
• C) Occipital cortex
• D)Occulomotor nerve
'Medical' causes like
• E) Opticchiasm Parasympatheticneurons tumoursand
vascular disease
Motor Neuronsof 3rdnerve affect motorfibres
anddon't tendto
affect thepupil Ophthalmoplegia
• 3rd nerve palsy- surgical vs medical
• Internuclear ophthalmoplegia- MS,stroke, tumour
• 6th nerve palsy-raised ICP, MS
• 4th- Trauma, MS
• CN3supplies all extra-ocular muscles except Superior Oblique (CN4)
and Lateral Rectus (CN6) – SO4LR6
If theeye cannotmovelaterally: thereis a CN6lesion
If theeye cannotmoveinferiorly when facing medially: there isa CN4
lesion
If themajority of theeye’s movements areimpaired and theeye rests in
a‘down andout’position: thereis aCN3 lesion
If there aredramatically abnormal eye movements which do notfit with
a single nerve lesion: thereis‘complex ophthalmoplegia’ (Graves/
mitochondrial/myasthenia/brainstem lesion)55-year-oldmanpresentstohisGP withunilateralfacialdroopandweakness.On
furtherquestioningyoufindthatitwassuddenonset6hours agoandwasnot
associatedwithothersymptoms(includingpainorintercurrentillness).On
Examination,thereisevidenceof foreheadsparingon thesideofthefacial
weakness.Whatisthesinglemostlikelydiagnosis?
• A) Acutestroke
• B) Bell's Palsy
• C) Cholesteatoma
• D) Spaceoccupyinglesion
• E) Conversiondisorder55-year-oldmanpresentstohisGP withunilateralfacialdroopandweakness.On
furtherquestioningyoufindthatitwassuddenonset6hours agoandwasnot
associatedwithothersymptoms(includingpainorintercurrentillness).On
Examination,thereisevidenceof foreheadsparingon thesideofthefacial
weakness.Whatisthesinglemostlikelydiagnosis?
• A) Acutestroke
• B) Bell's Palsy
• C) Cholesteatoma
• D) Spaceoccupyinglesion
• E) Conversiondisorder
Differentials:https://oscestop.education/clinical-examination/neurological-differential-diagnosis/7thNerve
Palsy
• UMN vsLMN = UMN foreheadsparing
• UMN: Stroke,MS
• LMN
• Bell's palsy
• Ramsey Hunt
• Immune (sarcoid, GBS)
• Local malignancy (eg: Parotid)
• 5,7,8= Cerebellopontineangletumour74-year-oldright-handedwomanpresentsinthegeneralneurology clinicwitha
restingtremorinherrighthandandahistoryoffrequentfallsoverthepastyear
whichsheattributestopoor balance.Bradykinesiaisnoted (moreon therightside).
Restingtremorispresentinherrighthand.Noposturaltremorisnoted.Whatwould
bethemostappropriatemedicationwhichcouldhelpwithhersymptoms?
• A) Propranolol
• B) Levodopa
• C) Deepbrainstimulation
• D) Apomorphineinjections
• E) Ropinirole74-year-oldright-handedwomanpresentsinthegeneralneurology clinicwitha
restingtremorinherrighthandandahistoryoffrequentfallsoverthepastyear
whichsheattributestopoor balance.Bradykinesiaisnoted(moreon therightside).
Restingtremorispresentinherrighthand.Noposturaltremorisnoted.Whatwould
bethemostappropriatemedicationwhichcouldhelpwithhersymptoms?
• A) Propranolol
• B) Levodopa
• C) Deepbrainstimulation
• D) Apomorphineinjections
• E) RopiniroleParkinsonismisa
syndrome
• bradykinesia, postural instability
• Differentials: Parkinsons disease,
vascular, drugs, Parkinson's plus
• PD is asymmetrical
• Differentiate between ET and
Parkinsonism: get them to write!
• Complications of PD: dementia,
depressionParkinson’sTremor Benign Essential Tremor
Asymmetrical Symmetrical
4-6 hertz 6-12 hertz
Worse atrest Improves atrest
Improves withintentionalmovement Worse withintentionalmovement
OtherParkinson’s features Noother Parkinson’s features
Nochangewithalcohol Improves withalcoholManagementof
Parkinson'sDisease
• decarboxylaseinhibitors)
o Co-beneldopaorMadopa
o Co-careldopaorSinemet
• COMTinhibitors
• Dopamineagonists
• Monoamineoxidase-B inhibitors
• SCapomorphine
• Deepbrain stimulation Amantadineisa glutamateantagonistthatmaybeused to
managedyskinesia associatedwithlevodopa.You areassessinga30-year-oldpatientinA&Ewho hasbeenseizingformorethan5
minutes.He hasalong historyoftonic-clonicseizuresforwhichheistakingsodium
valproate.Hehasahistoryof alcoholexcess,andhe hasbeenwellinthefewdays
priortohisadmission.Which ofthefollowingisthemostlikelycauseof hisseizure?
• A) Acutestroke
• B) Epilepsy
• C) Subduralhaemorrhage
• D) MS
• E) MeningitisYou areassessinga30-year-oldpatientinA&Ewho hasbeenseizingformorethan5
minutes.He hasalong historyoftonic-clonicseizuresforwhichheistakingsodium
valproate.Hehasahistoryof alcoholexcess,andhe hasbeenwellinthefewdays
priortohisadmission.Which ofthefollowingisthemostlikelycauseof hisseizure?
• A) Acutestroke
• B) Epilepsy
• C) Subduralhaemorrhage
• D) MS
• E) MeningitisYou areassessinga30-year-oldpatientinA&Ewho hasbeenseizingformorethan5
minutes.He hasalong historyoftonic-clonicseizuresforwhichheistakingsodium
valproate.Hehasahistoryof alcoholexcess,andhe hasbeenwellinthefewdays
priortohisadmission.Which ofthefollowingisthemostlikelycauseof hisseizure?
CRAP GPS
• A) Acutestroke induce me
• B) Epilepsy to rage
• C) Subduralhaemorrhage Carbamazepine
Rifampicin
• D) MS Alcohol(chronic)
• E) Meningitis Phenytoin
Griseofulvin
Phenobarbital
Sulfonylureas Types ofseizure
Triggers:
• Focal • Poorsleep
▪ Complex (lose consciousness)
▪ Simple (don't lose • Alcoholanddrugs
consciousness) (withdrawal)
▪ generalised)neralised (Focal -> • Stroke
• Intracranial
haemorrhage
• Generalised
▪ Absence • Space-occupying
lesions
▪ Tonic-Clonic • Metabolic
▪ Myoclonic
▪ Atonic disturbances(eg.
Hyponatraemia) • EEG
• MRIbrain
• ECG
Management
• Serumelectrolytes
• Bloodglucose
• Bloodcultures,urine culturesandlumbarpuncture
Rule ofthumb: Men Women able to have
Seizure Type Women who cannot children
• Lamotragine, levetiracetamandvalproateare have children
goodfor allseizuretypes. Generalised tonic- Lamotrigine or
clonic Sodium valproate Levetiracetam
• Carbamazepine,gabapentinand phenytoinare
Lamotrigine or
Partial (or focal) Levetiracetam <-
betterfor focal(including secondary generalised)
Myoclonic Sodium valproate Levetiracetam
seizures.
• Ethosuximide isthe drug ofchoicefor absence Tonicand atonic Sodium valproate Lamotrigine
seizures. <-
Absence Ethosuximide
• Carbamazepinemay worsenmyoclonic seizuresStatusepilepticus
Lasts>5minutes Lorry, Lorry, funny, call ITU
Multipleseizures without regainingconsciousness
Ato Eapproach:
Secure airway
Oxygen
BMs
IVaccess
Medical Treatment:
1. Benzodiazepine- repeat 5-10 mins if seizure
continues
2. After 2 doses of benzodiazepine- IV levetiracetam,
phenytoin or sodium valproate
3. Phenobarbital or generalised anaesthesiaA600-year-oldmanattendsyour clinicwitha3-monthhistoryoflegweakness.On
examination,thetoneisnormalandthereisreducedpowerbilaterallyindistallower
limbs.The anklereflexisabsentbilaterally,butkneereflexesarepresent.Plantars
areupgoing.Whichof thefollowingclinicalsignsismostinkeepingwiththe
diagnosis?
• A) Pale opticdisc
• B) PositiveRomberg'ssign
• C) PosturalHypotension
• D) Wastingofsmall handmuscles
• E) Internuclearophthalmoplegia UMN +LMN signs?
Think MND
A600-year-oldmanattendsyour clinicwitha 3-monthhistoryoflegweakness.On
examination,thetoneisnormalandthereisreducedpowerbilaterallyindistallower
limbs.The anklereflexisabsentbilaterally,butkneereflexesarepresent.Plantars
areupgoing.Whichof thefollowingclinicalsignsismostinkeepingwiththe
diagnosis?
• A) Pale opticdisc - opticneuritis, more likely in MS
• B) PositiveRomberg'ssign – sensory, wouldn't be affected in MND
• C) PosturalHypotension – Autonomicrather than motor
• D)Wastingof small handmuscles – LMN sign,in keeping with mixed picture.Also common inMND
• E) Internuclearophthalmoplegia – Oculomotor notaffected in MND, morelikely in MS • Spastic paraparesis:MS,cordcompression,stroke
• Spastic hemiparesis:Stroke,tumour,MS
• Parkinsonism:idiopathicParkinsons,VascularPArkinsons,
drugs
• Cerebellar:Alcohol,stroke,MS
• Medical3rdnervepalsy:Diabetes,hypertension,stroke
Summaryof
• haemorrhagenervepalsy:Aneurysm,tumour, intracranial
'T op3'
• 4thCranialnerve:Trauma
Differentials • Bulbar palsy:Stroke,MND,MyastheniaGravis– NOTMS!
brainstem)causebulbar byaffecting LMNastheyleave
• SACDdUMN+LMNsigns:MND,cervicalspondylopathy,
Differentials:https://oscestop.education/clinical-examination/neurological-differential-diagnosis/Fin.
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