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Neurology 22nd May 2025 - Dr Katherine Wostenholme & Dr Yi SimLearningObjectives ● Stroke: Types (ischemic, hemorrhagic), risk factors, management ● Seizures: Classification, causes, and treatment ● Multiple sclerosis: Presentation, diagnosis, and disease-modifying treatments ● Parkinson’s disease: Diagnosis, management, medications ● Headaches: Tension, migraine, cluster, red flags ● Neurological examination: Key signs and findingsQuestion 1 A 74-year-old man with a history of hypertension and atrial fibrillation presents to the emergency department with sudden-onset right-sided weakness and expressive aphasia. He arrived 45 minutes after symptom onset. Non-contrast CT head shows no acute hemorrhage. His ECG shows atrial fibrillation with a ventricular rate of 88 bpm, and blood pressure is 178/96 mmHg. What is the most likely underlying mechanism of his stroke? A. Small vessel (lacunar) infarct due to chronic hypertension B. Embolic infarct from cardiac source C. Large artery atherosclerosis D. Intracerebral haemorrhage E. Watershed infarct from global hypoperfusionQuestion 1 A 74-year-old man with a history of hypertension and atrial fibrillation presents to the emergency department with sudden-onset right-sided weakness and expressive aphasia. He arrived 45 minutes after symptom onset. Non-contrast CT head shows no acute hemorrhage. His ECG shows atrial fibrillation with a ventricular rate of 88 bpm, and blood pressure is 178/96 mmHg. What is the most likely underlying mechanism of his stroke? A. Small vessel (lacunar) infarct due to chronic hypertension B. Embolic infarct from cardiac source C. Large artery atherosclerosis D. Intracerebral haemorrhage E. Watershed infarct from global hypoperfusionQuestion 1-Explanation The patient’s atrial fibrillation and sudden focal neurological deficit are highly suggestive of a cardioembolic stroke, typically resulting in cortical signs such as aphasia or visual field defects. The CT being normal early on does not exclude ischaemic stroke. Small vessel (lacunar) strokes usually cause pure motor or sensory deficits without cortical signs. Watershed infarcts are associated with hypotension or hypoperfusion, which is not the case here.Question 2 Which of the following is the strongest modifiable risk factor for ischaemic stroke? A. Smoking B. Diabetes mellitus C. Hypertension D. Atrial fibrillation E. HyperlipidaemiaQuestion 2 Which of the following is the strongest modifiable risk factor for ischaemic stroke? A. Smoking B. Diabetes mellitus C. Hypertension D. Atrial fibrillation E. HyperlipidaemiaQuestion 2-Explanation Hypertension is the most significant modifiable risk factor for both ischaemic and haemorrhagic strokes. Chronic high blood pressure damages blood vessel walls, accelerates atherosclerosis, and increases the risk of small vessel disease and vessel rupture. While atrial fibrillation, smoking, diabetes, and hyperlipidaemia all contribute to stroke risk, hypertension is the most prevalent and impactful, especially at the population level. Effective blood pressure control significantly reduces stroke incidence.Question 3 A 64-year-old man presents 1.5 hours after onset of left-sided weakness. CT head confirms no bleed. What is the next best step? A. Aspirin 300 mg orally B. Alteplase (thrombolysis) C. Clopidogrel 75 mg D. MRI brain E. Neurosurgical referralQuestion 3 A 64-year-old man presents 1.5 hours after onset of left-sided weakness. CT head confirms no bleed. What is the next best step? A. Aspirin 300 mg orally B. Alteplase (thrombolysis) C. Clopidogrel 75 mg D. MRI brain E. Neurosurgical referralQuestion 3-Explanation This patient presents within the 4.5-hour window for intravenous thrombolysis with alteplase, and his CT excludes hemorrhage, making him eligible for thrombolysis. Alteplase is a tissue plasminogen activator (tPA) that dissolves clots and is the first-line treatment for eligible patients with acute ischaemic stroke. Prompt administration improves outcomes, particularly when given earlier within the window. ● Aspirin is used after 24 hours post-thrombolysis or as first-line if thrombolysis is contraindicated or outside the time window. ● Clopidogrel is generally introduced later as part of long-term secondary prevention. ● MRI is more sensitive for detecting early ischaemia but is not required before thrombolysis if CT rules out bleed. ● Neurosurgical referral is needed for haemorrhagic strokes or those requiring decompressive hemicraniectomy—not relevant in this case. Thus, alteplase is the correct and time-critical intervention.Question 4 A 24-year-old woman experiences an episode of lip-smacking, staring, and unresponsiveness for about a minute, followed by confusion. What type of seizure is this? A. Generalised tonic-clonic seizure B. Myoclonic seizure C. Absence seizure D. Focal impaired awareness seizure E. Atonic seizureQuestion 4 A 24-year-old woman experiences an episode of lip-smacking, staring, and unresponsiveness for about a minute, followed by confusion. What type of seizure is this? A. Generalised tonic-clonic seizure B. Myoclonic seizure C. Absence seizure D. Focal impaired awareness seizure E. Atonic seizureQuestion 4-Explanation This is a classic description of a focal impaired awareness seizure, previously called a complex partial seizure. These seizures originate in one hemisphere—commonly the temporal lobe—and often involve: ● Automatisms (e.g. lip-smacking, hand movements), ● Impaired consciousness, and ● Post-ictal confusion (lasting minutes). Key distinguishing features: ● Absence seizures typically occur in children, are very brief (seconds), and do not cause post-ictal confusion or automatisms. ● Generalised tonic-clonic seizures involve loss of consciousness and bilateral convulsions, not just unresponsiveness and automatisms. ● Myoclonic seizures involve sudden, brief jerks without loss of awareness. ● Atonic seizures involve sudden loss of muscle tone, leading to falls, again without the described automatisms. This case strongly supports a focal onset with impaired awareness, particularly due to the automatisms and post-ictal period.Question 5 A 38-year-old man with known epilepsy is brought to the emergency department by ambulance. He has had a generalised tonic-clonic seizure lasting over 10 minutes and has not regained consciousness between episodes. He has received high-flow oxygen and IV access has been established. What is the most appropriate next step in his management? A. Administer IV levetiracetam B. Give IV lorazepam C. Start phenytoin infusion D. Administer rectal diazepam E. Perform urgent CT headQuestion 5 A 38-year-old man with known epilepsy is brought to the emergency department by ambulance. He has had a generalised tonic-clonic seizure lasting over 10 minutes and has not regained consciousness between episodes. He has received high-flow oxygen and IV access has been established. What is the most appropriate next step in his management? A. Administer IV levetiracetam B. Give IV lorazepam C. Start phenytoin infusion D. Administer rectal diazepam E. Perform urgent CT headQuestion 5-Explanation This patient meets the criteria for status epilepticus (SE)—defined as a seizure lasting more than 5 minutes, or recurrent seizures without recovery of consciousness between them. Management of Status Epilepticus (UK guidelines): 1st-line: ● IV lorazepam 4 mg is the drug of choice. ● If no IV access: buccal midazolam or rectal diazepam can be used. 2nd-line (if seizures continue after 10 minutes): ● Start longer-acting AED: IV levetiracetam, phenytoin, or valproate. 3rd-line (refractory SE): ● Anaesthetic agents in ICU (e.g. propofol, thiopental), with airway support.Question 6 Which of the below clinical examination findings is specific to Idiopathic Parkinson’s Disease? A) Cogwheel Rigidity B) Lead pipe Rigidity C) REM Sleep disorder D) Unilateral Pill rolling tremor E) Shuffling gaitQuestion 6 Which of the below clinical examination findings is specific to Idiopathic Parkinson’s Disease? A) Cogwheel Rigidity B) Lead pipe Rigidity C) REM Sleep disorder D) Unilateral Pill rolling tremor E) Shuffling gaitSleep: REM SLEEP DISORDER (re-enactments of dreams during REM phase of sleep, commonly violent) Mood: Depression +/- Psychosis Presence of drooling? Autonomic features (Parasympathetic problems); Constipation, Orthostatic Hypotension, Erectile Dysfunction, excessive diaphoresis/sweating Hypomimia/Amamia; "Mask like faces" (expressionless)? Micrographia: e.g difficulty writing names, signatures, drawing over time Olfactory Losses: loss of smell?AVOID DOPAMINE ANTAGONISTS such as Haloperidol or Metoclopramide if needing to prescribe in a Parkinsonism patient! Question 7 A 20-year-old male was rushed into the emergency deparment due to his parents' concerns of him not being able to move both legs. 3 weeks prior to this he had multiple episodes of diarrhoea following eating his takeaway gone bad back in his university accommodation. Since then he noticed numbness and weakness that has travelled up both his legs, now reaching his thighs. He has now started to notice this in his fingertips. He has no prior PMHx, drinks 7 units of alcohol/week, no smoking or illicit substance Hx, or any FHx. Examination revealed Hypotonia, MCS Power 2/5 for his lower limbs, and 3/5 only on wrist flexion and extension. He is also hyporeflexic at his lower limbs, with sensory disturbance too. What is the most likely diagnosis? A. Motor Neuron Disease B. Myasthenia Gravis C. Subacute Degeneration of the Spinal Cord D. Guillain Barre Syndrome E. Miller Fisher Syndrome Question 7 A 20-year-old male was rushed into the emergency deparment due to his parents' concerns of him not being able to move both legs. 3 weeks prior to this he had multiple episodes of diarrhoea following eating his takeaway gone bad back in his university accommodation. Since then he noticed numbness and weakness that has travelled up both his legs, now reaching his thighs. He has now started to notice this in his fingertips. He has no prior PMHx, drinks 7 units of alcohol/week, no smoking or illicit substance Hx, or any FHx. Examination revealed Hypotonia, MCS Power 2/5 for his lower limbs, and 3/5 only on wrist flexion and extension. He is also hyporeflexic at his lower limbs, with sensory disturbance too. What is the most likely diagnosis? A. Motor Neuron Disease B. Myasthenia Gravis C. Subacute Degeneration of the Spinal Cord D. Guillain Barre Syndrome E. Miller Fisher SyndromeQuestion 8 Which one of the following is NOT a feature of Multiple Sclerosis? A. Patchy paraesthesia B. Transverse Myelitis C. Uhthoff's Phenomenon D. Optic Neuritis E. Risus SardonicusQuestion 8 Which one of the following is NOT a feature of Multiple Sclerosis? A. Patchy paraesthesia B. Transverse Myelitis C. Uhthoff's Phenomenon D. Optic Neuritis E. Risus SardonicusQuestion 9 A 60-year-old woman has started to complain of persisting pain and numbness initially starting on the back of her neck. She currently describes loss of sensation around her little finger, and has noted she struggles to grip objects or attempt to make a fist. You suspect a Cervical Disc Herniation. Based on these symptoms where would the most likely location be prior to checking it on imaging? A) C8/T1 B) C7/T1 C) C7/C8 D) C6/C7 E) C6/C5Question 9 A 60-year-old woman has started to complain of persisting pain and numbness initially starting on the back of her neck. She currently describes loss of sensation around her little finger, and has noted she struggles to grip objects or attempt to make a fist. You suspect a Cervical Disc Herniation. Based on these symptoms where would the most likely location be prior to checking it on imaging? A) C8/T1 B) C7/T1 C) C7/C8 D) C6/C7 E) C6/C5Question 10 A 55-year-old man presents to A&E after his GP advised him to do so. He states he has ongoing recurrent episodes of severe headaches over the past month. He describes the pain as excruciating around his right eye. The attacks last about 45 minutes and occur once or twice daily, often waking him from sleep. He also reports right-sided nasal congestion, lacrimation, and a bright red, watery eye during these episodes. He denies nausea, photophobia, or phonophobia. Over-the-counter analgesics provide no relief. PMHx includes Asthma, Contact Dermatitis and COVID 19. He is a current smoker of 15 cigarettes/day. On examination between attacks, neurological assessment is normal. Which of the following is the most appropriate acute treatment for his condition? A. Nasal sumatriptan and IV Paracetamol B. High-flow oxygen via non-rebreather mask and Subcutaneous Sumatriptan C. IV Acetazolamide and admission for Iridotomy D. PO Verapamil E. PO PropranololQuestion 10 A 55-year-old man presents to A&E after his GP advised him to do so. He states he has ongoing recurrent episodes of severe headaches over the past month. He describes the pain as excruciating around his right eye. The attacks last about 45 minutes and occur once or twice daily, often waking him from sleep. He also reports right-sided nasal congestion, lacrimation, and a bright red, watery eye during these episodes. He denies nausea, photophobia, or phonophobia. Over-the-counter analgesics provide no relief. PMHx includes Asthma, Contact Dermatitis and COVID 19. He is a current smoker of 15 cigarettes/day. On examination between attacks, neurological assessment is normal. Which of the following is the most appropriate acute treatment for his condition? A. Nasal sumatriptan and IV Paracetamol B. High-flow oxygen via non-rebreather mask and Subcutaneous Sumatriptan C. IV Acetazolamide and admission for Iridotomy D. PO Verapamil E. PO PropranololOther headaches to read on about: 1) Migraines (including Vestibular and Atypical) 2) Tension 3) Medication overuse 4) GCA 5) Haemorrhages 6) SOLs 7) Hydrocephalus 8) Meningitis 9) Encephalitis SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! 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