Neurology question bank

Neurology
by Medical Educator Neurology

Neurology is the branch of medicine that deals with the diagnosis and treatment of disorders of the nervous system, including the spinal cord, peripheral nerves and muscles. Neurological conditions include multiple sclerosis (MS), Parkinson’s disease, epilepsy and stroke.

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Table of Contents

ADAPKD case

A 34 year old patient with ADAPKD (Autosomal Dominant Adult Polycystic Kidney Disease) is admitted a sudden reduction in his Glasgow Coma Score.

He was seen to collapse whilst eating a hamburger n a fast food restaurant. A witness is present in the A&E department and said he simply collapsed with no warning and was noted to be snoring loudly.


On arrival
Moaning incomprehensible sounds.
Flexing his arms to pain
Eyes shut and not opening to verbal commands
BP 130/70
Pulse 120
Fingerprick Blood Glucose 3.8 mmol/l
O2 Sats 92% on Air

He is under follow up at a Hospital in another region and he has no other past medical history available.

What is the most likely cause of his sudden deterioration?

  • Haemorrhagic Stroke
  • Thrombotic Stroke
  • Embolic Stroke
  • Meningitis
  • Encephalitis

Haemorrhagic Stroke

If you have no knowledge of ADAPKD note the following:

A fit and well man has collapsed suddenly.

Its therefore not encephalitis or meningitis unless he’s suffered from a seizure and there is no mention of this in the history. Therefore its likely that he’s had one of the other 3 options i.e. some form of stroke.

ADAPKD is associated with berry aneurysm of the cerebral arterial system. It seems most likely in this case that a ruptured aneurysm is the most likely culprit here.

ADAPKD case – 2

Continued from previous question:

It is suggested he has an urgent computed tomography (CT) scan to look for a haemorrhagic stroke.
The nursing staff are concerned about the fact he is snoring. What is the most appropriate airway management prior to the CT scan?

  • Nasopharyngeal Airway
  • Oro-pharyngeal Airway
  • Intubation and Ventilation
  • No airway needed at this time: however to be observed closely by an anaesthetist
  • None of the listed answers are correct

Intubation and Ventilation

His GCS is 5 and he is making snoring sounds.

For the purposes of an exam this means he’s not protecting his airway.

If he were to vomit / obstruct his airway the only definite airway protection would be intubation with a cuffed endotracheal tube.

For the purposes of an exam / viva a suggested answer is along the lines of “There is clear evidence the patient is not protecting his airway. I would instigate initial airway manoeuvres to protect his airway however he needs an urgent anaesthetic / senior assessment for intubation”.

Anyone with a GCS of 8 or less should be assessed for definitive airway management.

Remember: In the case of taking a patient to CT scan he will be left on a bed for the test with the practitioners outside the “scanning room”.

ADAPKD case – 3

Continued from previous question:

It is suggested he has an urgent computed tomography (CT) scan to look for a haemorrhagic stroke.]

What would you expect to see on a CT scan in an acute haemorrhagic stroke?

  • Hyperdense
  • Hypodense
  • Isodense

Hyperdense

Fresh blood on CT looks “white”.

Infarcts (approx 85% of all strokes) look initially isodense in the acute phase on C.T. (same colour as normal brain). Following this they appear hypodense as infarcted brain tissue.

A history of weakness and fatigue

A 64 year old man presents with a history of weakness and fatigue. He has lost 3 stone in weight. On systemic enquiry, he has no other clinical symptoms, other than a mild dry cough which he has had for 3 days and some occasional dysuria, present intermittently for 6 months. His examination findings are as follows:

  • No Jaundice , anaemia, cyanosis, jaundice or lymphadenopathy
  • noted rash under both eyelids.
  • BP 134/66
  • Pulse 78 regular
  • Sats 98% air
  • BM 4.5 mmol/l  RR 16
  • Normal Cardiovascular Respiratory Gastrointestinal examination.

Neurology as follows:

  • Grade 4 power upper and lower limbs symmetrically.
  • Normal sensory examination.
  • Normal reflexes.
  • No clonus
  • No fatigability

Where is the likely pathology?

  • Central Brain Lesion
  • Brainstem Lesion
  • Cord Lesion
  • Peripheral Nerve
  • Neuromuscular Junction
  • Acetylcholimesterase enzyme problem
  • Muscle lesion
  • None of the above

So here we go with the likely pathology …

Symmetrical findings make a central lesion less likely (they would localise).
The reflexes and sensation are intact, making a cord or peripheral nerve lesion unlikely.
The absence of fatigability makes a neuromuscular junction lesion less likely (myasthenia etc).
This sounds like a myopathy: the rash therefore suggests polymyositis (the rash is a heliotropic rash named after the purple heliotrope flower). The CK is likely to be very high (in the thousands, NR <150 iu/l).
The dysuria and cough are intended as distracters.

Bells Vs UMN

A pregnant 26 year old female presents wakes up with a left sided facial weakness.

Her forehead is spared however she cannot close her eye properly.

What is the most likely diagnosis?

  • Right UMN CNVII Lesion
  • Left Upper motor CNVII lesion
  • Right Lower Motor CNVII lesion
  • Left LMN Lesion VII lesion
  • None of the answers listed here

Left LMN Lesion VII lesion

The 7th cranial nerve innervates the muscles of facial expression. The top 1/3 of the face has bilateral innervation from the ipsilateral and contralateral cerebral hemisphere.

The lower 2/3 of the face is innervated by the ipsilateral LMN lesion.

Bells Vs UMN – 2

Continued from previous question:
In this patient which further test or investigation would you perform to diagnose Ramsay Hunt Syndrome assuming that a general physical examination had been otherwise normal?

  • Otoscopy
  • Opthalmoscopy
  • MRI Brain
  • CT Brain
  • Magnetic Resonance Angiography

Otoscopy

Ramsay Hunt gave his name to the CN VII palsy associated with vesicles in the ear / hard pallate and tounge associated with the herpes zoster virus. The key examination is otoscopy to look for vesicles in the external auditory meatus.

Clinical Examination

A 55 year old obese musician presents with a painful left eye. She has not visited her GP in the last 13 years. She has longstanding pains in her feet also. Her neurological examination is as follows.

A neurological exam reveals the following

Upper LimbsLower Limbs
RightLeftRightLeft
ToneNNNN
Power5/5Proximal distribution5/5Proximal Distribution4/54/5
CoordinationNNNN
SensationFine touchProprioception?NNN? glove and stockingN? glove and stockingN
ReflexesBicepstricepssupinator++++-+KneeAnklePlantar+–?++?

Which of the following is the most likely diagnosis?

  • Myositis
  • Motor Neurone disease
  • Polio
  • Myasthenia gravis
  • Multiple sclerosis
  • Guillain Barre
  • Stroke
  • Syphillis
  • Creutzfeldt Jacob disease
  • Diabetes Mellitus

Diabetes Mellitus

Essentially there’s a mixed motor / sensory neuropathy. No other worrying signs or features are seen. (No signs of UMN lesion / weakness / localising signs).

So from the list causing a peripheral motor and sensory neuropathy, diabetes is the most likely cause.

Other causes include drugs (e.g. chemotherapeutic agents) but remember B12 deficiency, Hereditary Motor sensory neuropathy (HSMN: Formerly known as Charcot Marie Tooth; made famous by characteristic leg appearances of “champagne bottle legs” – muscle wasting peripherally and pes cavus).

Clinical Examination – 2

A 55 year old obese musician presents with difficulty swallowing. She also has non specific malaise. She feels weak. She has had a persisting cough.

A neurological exam reveals the following

Upper LimbsLower Limbs
RightLeftRightLeft
ToneNN?N
Power4/53/53/52/5
CoordinationNNNN
SensationFine touchProprioceptionNNNNNNNN
ReflexesBicepstricepssupinator+++++-+KneeAnklePlantar++–?+++?

Which of the following is the most likely diagnosis?

  • Myositis
  • Motor Neurone disease
  • Polio
  • Myasthenia gravis
  • Multiple sclerosis
  • Guillain Barre
  • Stroke
  • Syphillis
  • Creutzfeldt Jacob disease
  • Diabetes Mellitus

Motor Neurone disease

MND will give you a mixture of UMN and LMN signs. Remember the fasciculation which can occur.

The absence of sensory signs supports the diagnosis.

The cough may represent chronic aspiration from bulbar symptoms.

MND can be classified into different groups. Forms of motor neurone disease include:
Amyotrophic lateral Sclerosis (UMN and LMN)
Bulbar (pseudobulbar is UMN Bulbar is LMN)
Primary Lateral Sclerosis (UMN only)

2 year survival is approximately 50%. New therapies are emerging and the use of assisted ventilation (e.g. Continuous Positive Airways Pressure-CPAP) are changing the course of disease.

Drugs Post Stroke

A 66 year old man has a right hemiparesis following an ischemic stroke. He is hypertensive at 150/100.
He is now 1 month post stroke and mobile with a stick.
He has been in sinus rhythm throughout.
A Carotid Doppler has shown 40% Left internal carotid artery stenosis (by European criteria)
His total cholesterol is 4.6

Which medication / intervention should he take post stroke with regards to reducing his vascular risk / increasing his life expectancy.

Please choose up to 4 answers

  • Aspirin 300mg
  • Aspirin 75mg
  • Dipyridamole MR 200mg BD
  • Beta Blocker
  • Statin
  • Ace inibitor
  • Warfarin
  • Carotid Endarterectomy
  • Thrombolysis
  • Calcium Channel blocker
  • Isosorbide Mononitrate
  • Digoxin

Aspirin 75mg
Dipyridamole MR 200mg BD
Statin
Ace inibitor

ACEi reduces mortality as does statins and low dose aspirin (Aspirin 300mg post stroke for 2 weeks)

Statin reduces vascular risk: One method: start if Total cholesterol is >3.

Theres no role for endarterectomy with stenosis <70% (European) or <50% (American) criteria.

There is no role for warfarinising patients in sinus rhythm.

Headache case

A 27 year old female presents with a headache. She has had it for 3 days. She has no other symptoms. She has a normal CT brain.

Her lumbar puncture whows the following.

CSF Opening Pressure (10-20cm H20)42
Macroscopic appearanceClear
Bottle 1Bottle 3RBC 150, WCC1RBC 0,WCC0
Gram stainNegative
MCSNo growth
Glucose4.5
Xanthochromianegative

What is the most likely diagnosis?

  • Stroke
  • Sub arachnoid haemorrhage
  • Tension headache with traumatic Lumbar Puncture
  • Sub arachnoid haemorrhage missed on CT
  • Benign Intracranial Hypertension
  • TB Meningitis

Benign Intracranial Hypertension

The pressure is very high! The CT was normal essentially excluding raised intracranial pressure secondary to an obstructive hydrocephalus (e.g. meningioma obstructing the 4th ventricle draining CSF). The red cells are high in the first sample of csf but as further CSF is tapped off, this clears. This supports a slightly “traumatic” tap. Xanthochromia testing in the sample is negative, providing no evidence of a prior bleed into the CSF which has then been broken down into xanthochromia.

To diagnose a S.A.H. you have to have either blood or altered blood in the CSF. As a rule of thumb yOu should have “no” red cells in the CSF if its not a traumatic tap and there is no other pathological processes.

Headache case 2

A 22 year old presents with a 12 hour history of a gradual onset headache.
She has no other motor/sensory/visual/olfactory/ or neurological symptoms

She is markedly obese.
She takes the oral contraceptive pill but no other medication.

Her neurological examination is normal.
She has a normal CT scan.

Her Lumbar Puncture (LP) result is shown below.

CSF Protein0.36g/l (normal)
CSF WCC0 cells mm3
XanthochromiaNegative
CSF Opening Pressure14 cm water
Gram StainNegative

What is the most likely diagnosis?

  • Benign Intracranial Hypertension
  • Tension Headache
  • Viral Meningitis
  • Viral Encephalitis
  • Bacterial Meningitis

Tension Headache

A catch: Obese / headache / normal CT scan? Sounds like BIH.

But… Her CSF pressure is normal, essentially ruling out the diagnosis for exam purposes.

All her tests are “normal” and therefore there is no other evidence to support another disorder from the list given.

(Viral meningitis: lymphocytic CSF, raised protein etc)

Left arm weakness

A 68 year old man has an episode of left arm weakness which comes on suddently whislt watching cricket on television.
His wife notices a drooping of his face.
His symptoms settle within 24 hours and when he presents the next day he feels his normal self.

He has a persisting mild left sided facial weakness.

What is the most likely diagnosis?

  • Transient Ischaemic attack
  • Bells Palsy
  • Stroke
  • Brain Tumour/ Space occupying lesion
  • The Facial and arm weakness are likely to be 2 different pathologies

Stroke

A stroke in the right cerebral hemisphere will produce left sided face and leg symptoms.

As the symptoms have not settled within 24 hours the diagnosis by definition cannot be a TIA. Therefore it’s most likely a stroke.

Although a space occupying lesion is possible, its much less likely than an acute stroke. Vascular events characteristically have a sudden onset.

Meningism case

A 36 year old man is admitted with a fever and meningism.

He has no rash. His neurological examination is normal apart from slight drowsiness and a stiff neck. His temperature is 39 degrees Celsius. He has photophobia making fundoscopy impossible, however his pupils are equal and reactive to light.

His blood tests are sent but unavailable. Blood cultures are sent but unreported.

He has been in the A&E department for 1hour. Its Midday and the CT scanner is “shut for lunch”.

As the A&E doctor what is the correct management?

  • Arrange urgent CT (some time in the next 1-2 hours), then Lumbar puncture and wait for the results
  • Arrange an urgent CT (some time in the next 1-2 hours), then perform lumbar puncture. Following LP institute local policy for treatment of bacterial meningitis.
  • As a CT cannot be performed in the next 30 minutes perform the LP now and then commence local policy for treatment of bacterial meningitis.
  • As a CT cannot be performed in the next 30 minutes perform commence empirical antibiotics now, and arrange for the CT to be done as an urgent case provisionally with the LP following this
  • As a CT cannot be performed in the next 30 minutes give the antibiotics first (local policy for treatment of bacterial meningitis) , then perform the LP.

As a CT cannot be performed in the next 30 minutes perform commence empirical antibiotics now, and arrange for the CT to be done as an urgent case provisionally with the LP following this.

This is really quite important. For the purposes of an exam:

You should never delay giving antibiotics in meningitis for long periods.

You should not delay treatment for >30 minutes whilst waiting for a CT in meningitis. This means if you’re going to be waiting for >30 mins, treat empirically.

You should not perform an LP in someone with the rash of meningococcal septicaemia (risk of coagulopathies etc).

You should seek senior advice immediately.

If you cant see the fundi you should essentially never perform a lumbar puncture without excluding raised intracranial pressure (risk of coning).

Neurological exam

A 44 year old builder presents with weakness over the past 48 hours

A neurological exam reveals the following (N=normal):

 Upper Limbs  Lower Limbs 
 RightLeft RightLeft
ToneNreduced NN
Power (MRC)4/54/5 3/54/5
CoordinationNN NN
Sensation Fine touch ProprioceptionN NN N N NN N
Reflexes Biceps triceps supinator  – (absent) – (absent) +  – (absent) – (absent) + with reinforcement  Knee Ankle Plantar  – (absent) – (absent) down  – (absent) – (absent) down

Which of the following is the most likely diagnosis?

a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome

Guillain Barre Syndrome.

Now check your hypothesis against the clinical signs:

Tone Any sign of UMN lesion or hypotonia (cerebellar?) NO

But there is some reduced tone in the left arm:
Power He is weak and its come on
over the past few days: this is classical of GBS: an ascending peripheral
motor and sensory poylneuropathy.
Coordination Normal: as expected
Sensation Normal: So can it still be
GBS???

YES! The sensory signs are often vary vague: there may be only back
pain as the presenting feature.
Reflexes Clinical tip: no reflexes
Auggests a lower motor neurone problem. Could it me MND? Very unlikely:
there’s only LMN signs and the onset of the illness is too acute.
Other things GBS: measure the Forced Vital Capacity:

If this is low: the patient may need ventilation.

Also remember: cardiac conduction deficits (monitor the patient on
a cardiac monitor)

Remember FVC monitoring in GBS.

Neurological exam 1

Continued from Previous question.

A medical student suggests that he may need a lumbar puncture. What would you expect the results of a lumbar puncture and subsequent cerebro spinal fluid (CSF) to show in this case?

  • Lumbar puncture is contraindicated in cases of GBS
  • Elevated White cell count: predominantly lymphocytes
  • Elevated White cell count: predominantly neutrophills
  • Normal Lumbar Puncture result
  • Elevated CSF protein

Elevated CSF protein

GBS in itself is not a contraindication to lumbar puncture.

The classic finding in the CSF is a markedly elevated CSF protein i.e. >2g/l (normal CSF protein <0.4g/l)

10% of patients will have normal CSF protien levels: a normal LP does not rule out the diagnosis.

You would not expect elevated levels of lymphocytes or neutrophills.

Neurological exam 2

A 63 year old man presents with weakness and lethargy

A neurological exam reveals the following

Upper LimbsLower Limbs
RightLeftRightLeft
ToneNNNN
Power4/5Proximal distribution4/5Proximal Distribution5/55/5
CoordinationNNNN
SensationFine touchProprioceptionNNNNNNNN
ReflexesBicepstricepssupinator++++++KneeAnklePlantar++?++?

Which of the following is the most likely diagnosis?

  • Myositis
  • Motor Neurone disease
  • Polio
  • Myasthenia gravis
  • Multiple sclerosis
  • Guillain Barre
  • Stroke
  • Syphillis
  • Creutzfeldt Jacob disease

Myositis

Check your hypothesis against the clinical signs. For each condition consider if it would be in keeping with the findings. Even if you do not know much about any of the conditions you can still take a reasonably informed “guess”.

Tone:any sign of UMN lesion or hypotonia (cerebellar?) NO
Power:any weakness? YES- expected. Remember tone is normal so it doesn’t look like UMN lesion at this stage
Coordination:Normal: as expected Cerebellar involvement? does not seem likely at this stage
SensationNormal: as expected and this goes against there being either a peripheral sensory neuropathy and makes a cord lesion/CNS lesion less likely.
Reflexes:Normal as expected in Myositis until the later stages when thay may be reduced. i.e. he does not have an UMN or a LMN problem
Other things..The lack of motor neuron signs and sensory neuron signs suggests this may not be a “nerve problem”. There are no UMN signs to suggest a central cause.
Guillan Barre: Ascending mixed motor and sensory neuropathy-No evidence of this
Stroke: Unilateral findings or UMN findings? No evidence
Polio: Acute viral infection essentially eradicated from Western Europe. In exams its classically old signs: Unilateral spastic wasted leg with no sensory signs? Consider previous polio
It fits with a “myositis”

Remember key facts about myositis:
Autoimmune inflammatory muscle disease: weakness, high CK onset over days/weeks/months
Jo1 positive, weakness with normal reflexes: the nerves are not affected.
Treatment: Corticosteroids high dose +/- IV immunoglobulin/ Cyclophosphamide


Neurological exam 3

Continued from previous question.

He is noted to have a rash on the backs of his hands. The name of this rash is most likely:

  • Seborrheic Dermatitis
  • Erythema multiforme
  • Gotron’s papules
  • Impetigo
  • Dermatis herpetiformis

Gotron’s papules

If he’s has mositis and a rash then its likely to be dermatomyositis.

Dermatological features are:
Gotron’s papules (purple papules on the backs of knuckles)
Heliotropic rash (violaceous/purple rash around the eyes)

Dermatomyositis is under the umbrella group of myositis.

Causes include:
Ideopathic
Autoimmune
Toxic
Drug Related

Most forms of myositis are associated with an increased risk of diagnosis of malignancy either at the time of presentation or up to 5 years down the line. (RR approximately 2). As such often patients are screened for features of malignancy that may include:

Full clinical Examination
CT Scan Chest/ Abdomen/ Pelivs
Bone Marrow Biopsy
Fine needle aspiration/ resection of any pathological lymph nodes
FBC U&E LFT CRP Immunoglobulins and protein electrophoresis
Urinalysis/MSU/+/- OGD/Colonoscopy as directed by results of blood tests.

Power (MRC scale)

A patient tries to lift his leg off an examination couch and is unable to do so because of weakness. He can however move his leg from side to side on the examination couch. What is his Power (MRC scale)

  • Grade 0
  • Grade 1
  • Grade 2
  • Grade 3
  • Grade 4
  • Grade 5

Grade 2

The MRC scale is the Medical Research Council scale:

0 = no movement
1 = flicker
2 = with gravity
3 = against gravity
4 = reasonable but weak
5 = normal

Wandering case

A 78 year old man is found wandering about by his neighbour. He is known to have dementia. His GP treated him 3 days ago for a suspected Urinary tact infection.

Urine dipstic: + nitrites, – blood, – protein, -leucocytes
MSU no growth.

ON arrival in the A&E department his neighbour tells you he is his normal self.
A few hours later he is quite drowsy and incoherent but 30 minutes following this he is back to his normal self.

What is the diagnosis?

  • Dementia
  • Alzheimers
  • Picks Disease
  • Delirium
  • Urinary tract infection

Delirium

Delirium is an alteration in conscious level and can be caused by “anything” including:

Infection
Metabolic problems (e.g. Hyponatraemia)
Head injury
Stroke
Encephalitis
Drug Cause
Post Seizure

An alteration in conscious level should not be attributed to simple “dementia” although the 2 conditions commonly coexist i.e. alteration in conscious level = delirium.