nMRCGP - AKT practice questions: neurology

In this new monthly series, questions from www.examdoctor.co.uk, produced according to RCGP curriculum topics, are provided to help registrars prepare for the applied knowledge test.

Demyelinated lesions in the brain of a patients with MS
Demyelinated lesions in the brain of a patients with MS

1. Which THREE statements regarding Raeder's syndrome are correct? Select THREE statements only.

  • a. Pain reaches peak in 40 minutes and lasts for more than eight hours
  • b. Can be associated with Horner's syndrome
  • c. Bilateral
  • d. Lithium may be used for prophylaxis
  • e. Exacerbated by alcohol
  • f. Amitriptyline is used for abortive therapy in acute attacks

2. Which THREE signs and symptoms may be seen in parkinsonism? Select THREE answers only.

  • a. Cog wheel rigidity
  • b. Clasp knife rigidity
  • c. Lead pipe rigidity
  • d. Macrographia
  • e. Resting tremors

3. Which TWO statements regarding multiple sclerosis (MS) are correct? Select TWO statements only.

  • a. Annual incidence in UK is 1 in 1,000,000
  • b. Common in temperate climates
  • c. Efferent papillary defect noted
  • d. Bilateral internuclear ophthalmoplegia is a typical feature of MS
  • e. Steroids reduce frequency of attacks
  • f. Oligoclonal bands are pathognomic of MS

4. Which FOUR statements regarding transient ischaemic attacks (TIAs) are correct? Select FOUR statements only.

  • a. May present with amaurosis fugax in ipsilateral eye
  • b. May present with vertigo
  • c. Symptoms may last for more than 24 hours
  • d. Migraine can mimic TIA
  • e. Cerebral infarcts never occur in TIAs
  • f. Myocardial infarction is the commonest mode of death in patients post TIA

5. Which THREE statements regarding acute ischaemic stroke are correct? Select THREE statements only.

  • a. Thrombolytic therapy is contraindicated within 30 days of surgery
  • b. Increased risk of cardiac arrhythmias
  • c. Severe hyperglycaemia can mimic stroke
  • d. Hyperglycaemia worsens ischaemia
  • e. Aspirin is contraindicated in the first 24 hours

This topic falls under section 15.7 of the RCGP curriculum 'Neurological problems', www.healthcarerepublic.com/curriculum

  • Questions reproduced with permission from www.examdoctor.co.uk, Royal Society of Medicine Press

ANSWERS: 1= B, D and E; 2= A, C and E; 3= B and D; 4= A, B, D and F; 5= B, C and D.

Answers explained

1. Cluster headaches are known by a variety of names: Raeder's syndrome, spheno-palatine neuralgia and histamine cephalgia. It is a treatable vascular headache. It is typically unilateral and paroxysmal, peaking at 5 minutes, and lasting for about 40 minutes to 2 hours. It often occurs at night. Autonomic disturbance is commonly associated with acute attacks. The most common type is episodic with multiple short-lived attacks in a day for a couple of weeks followed by complete remission (1 year). The chronic form is characterised by an absence of sustained periods of remission.

Raeder's syndrome is common in men. It is exacerbated by alcohol, nitroglycerine and histamine. Verapamil, lithium and sodium valproate are used for prophylaxis. Prednisolone can also be used as prophylaxis. Steroids in a short course (30 to 60mg) can be effective at the onset of a cluster.

Propanolol and amitriptyline have no role. High flow oxygen is used for abortive therapy.

2. Parkinsonism is due to depletion of pigmented dopaminergic neurons in the substantia nigra, Levy bodies in nigral cells and loss of neurons in the locus ceruleus. The prevalence of Parkinson’s disease is 15 per 10,000. It is less common in smokers. There is no sex predilection. There is no definite test for Parkinson’s disease (idiopathic). One should exclude other causes of parkinsonism (Wilson’s disease, drugs, etc.).

Clinical features: mask-like face, indistinct speech,  flexed posture, festination gait, decreased arm swinging and high inertia to initial walk, resting tremors, rigidity (cog wheel and lead pipe rigidity), bradykinesia (slow repeating movements and decreased facial expression) and micrographia.

Treatment is with L-dopa combined with carbidopa or benserazide is the most common form. Other drugs used include amantadine, selegiline and tolcapone.

3. MS is an autoimmune disease in which autoantibodies to oligodendrocytes/myelin cause demyelination.

It is one of the most common neurological diseases (1 in 100,000) with a female preponderance. It is more common in temperate climates.

Optic neuritis presents with decreased visual acuity and decreased colour perception; it is generally monocular but can be bilateral and an afferent papillary defect is noted. Internuclear ophthalmoplegia (impaired adduction of involved eye with nystagmus in abducting eye) is a common feature; when bilateral it is particularly specific for MS. Sensory disturbances: paraesthesias, hyperesthesia and Lhermit's syndrome.

Ataxia, cognitive dysfunction and vertigo may also be experienced. Oligoclonal bands raised, but not specific to MS.
Steroids are used for acute exacerbations and first attack but do not reduce the frequency of attacks. Interferon and glatiramer acetate are disease-modifying drugs.

4. TIAs are episodes of stroke symptoms that last only briefly (by definition should be less than 24 hours, but the average duration is approximately 12 minutes).

TIAs can occur because of emboli to the brain or from in situ thrombosis of an intracranial vessel.

Cerebral infarcts occur in 15–40 per cent of TIAs even though neurological signs and symptoms are absent. The majority involve the carotid territory.

TIAs may present with amaurosis fugax, or transient monocular blindness and vertigo when brain stem is involved.

Investigations are directed towards identifying the cause (carotid stenosis, cardiac source of emboli). Ultrasound and MRI are used to detect stenosis. The management is aspirin and treatment of risk factors.

5. Cerebral infarction is due to acute occlusion of an intracranial vessel either from an emboli or in situ thrombogenesis. Fever and hyperglycaemia dramatically worsen ischaemia. Hyperglycaemia itself can mimic a stroke. It is more common in males. The risk factors for stroke include age, diabetes, hypertension, smoking, alcohol, oral contraceptives and polycythaemia.
Patients often present with focal neurological deficits. Aphasia may also be seen at presentation.

MRI is the investigation of choice. CT is done to exclude haemorrhage in the early stages.

Management: cardiac monitoring is essential because of increased risk for cardiac arrhythmias. Good hydration is important. Airway maintenance is important. Aspirin within 12–24 hours benefits by preventing further embolism. Anticoagulation (heparin) does not have any additional benefit over aspirin, but can be given for DVT prophylaxis. Thrombolytic therapy is useful if started within three hours, however it is contraindicated if the patient underwent surgery in the last 14 days.

 

 

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