THE BLACK PANTHER ATTACK - NEURO

General NB topics for follow up questions

1. Parkinson’s
2. Myelopathies
3. Strokes

Common examination cases

 Examine the cerebellar function
 Examine the 5th, 7th , (3rd, 4th and 6th) cranial nerves
 Examine the sensation of the lower limb
 Motor exam of the upper or lower limb (tone, power, reflexes)
 Minimental
 Cerebellar system

Clinical exam cases and questions

1.
2. If you are asked to do an MMSE –most likely a dementia case
3. Eye movements
4. CN 7 and differentiate between upper and lower motor neuron
o Upper motor neuron:
 Unilateral lesion
 Contralateral upper half of face is spared – frontalis sparing.
 Little effect on speech
 Bilateral lesion
 Paralysis of the upper and lower facial muscles bilaterally
 Preservation of emotional expression
 Major difficulty producing labial and labiodental sounds
o Lower motor neuron:
 Ipsilateral atrophy
 Ipsilateral fasciculations of the peri-oral area and chin
 Paralysis of muscles on ipsilateral half of face (frontalis, oris, oculi,
buccinators)
 Loss of taste in anterior 2/3s of tongue
 Hyperacusis
 Decreased or absent lacrimation
 + synkinesis test
5. Causes of CN 7 LMN lesions
o V: CVI
o Idiopathic: Bell’s palsy (Pregnancy and DM)
 Bell’s sign: inability to close the eyelids and the appearance of the white
sclera due to reflex upward movement of eye during eye closure.
o N: Posterior fossa tumours
o Infective: herpes zoster (Ramsay hunt syndrome), EBV, CMV, HIV
o Inflammatory: Sarcoidosis
o A: RA
6. Causes of CN 7 UMN lesions:
o CVI
 o Intracranial tumors
o MS
o HIV
7. Treatment of CN 7 lesions:
o Treat the causes
o Bell’s palsy: steroids, artificial tears, taping of the eye
8. CN 7 palsy presentation: entire side of the face ipsilateral to the lesion droops;
o Forehead has no wrinkles
o Difficult to close eye
o Corner of mouth droops and drools
o Flattened nasolabial fold
9. Causes of rigidity:
o Parkinson’s
o Catatonia
o EPSEs of antipsychotics
o Neuroleptic malignant syndrome
o Tetanus
o tardive dyskinesia
10. Causes of spasticity:
o Cortical lesion: stroke (ischaemic or haemorrhagic)
o Spinal injury: myelopathies, trauma
o Multiple sclerosis
o Cerebral palsy
o Neurodegenerative disease affecting the upper motor neuron, pyramidal and
extrapyramidal pathways
11. Brisk reflexes diff dx:
o Cortical lesion: stroke (ischaemic or haemorrhagic), tumours
o Spinal injury: myelopathies (compressive and non-compressive), trauma
o Multiple sclerosis
o ALS
12. Diminished reflexes diff dx:
o Plexopathy (brachial or lumbar0
o Radiculopathy
 L5 and S1
o Peripheral neuropathy
 GBS
o Myopathy
 Polymyositis
 dermatomyositis
13. Differential for bilateral UMN signs in the lower limbs:
o Myelopathy
o cortex
 ACA artery stroke
 In the parafalx region: butterfly glioma, meningioma
o Subcortical: lacunar syndromes
o Brain stem:
 Midbrain:Weber: + 3rd nerve palsy
 Pons: Locked-in :
14. Cerebellar exam:
o Causes of unilateral cerebellar dysfunction
 Cerebellar astrocytoma
 Cerebellar hemangioblastoma
 Cerebellar infarct or haemorrhage
 Cerebellar abscess
 Demyelination
o Causes of bilateral cerebellar dysfunction
 Drugs (phenytoin overdose)
 Alcohol
 MS
 Cerebellar tumours: astrocytoma, hemangioblastoma, medulloblastoma,
metastases
 Disorders of craniocervical junction: Arnold-chiari malformation with
herniation of the cerebellar tonsils.
 Cerebellar degenerations
 Brainstem infarcts
 Arteritis
 Cerebellar abscesses
The DAM CDC is BAC

15. Cerebellar dysfunction signs: VARNISHDDTT

o Vertigo
o Ataxia
o Rebound
o Nystagmus
o Intention tremor
o Speech- staccato or searching
o Hypotonia
o Dysmetria
o Dysdiadokinesia
o Tremor
o Titubation
16. Cortical Stroke presentation
o Contralateral paresis (facial and limbs)
o Contralateral sensory loss
o Contralateral homonymous hemianopia
17. Brainstem stroke presentation
o Ipsilateral CN fallout
o Contralateral paresis and sensory loss
18. Causes of stroke in young people and work-up
o Embolic causes
 Rheumatic heart disease
 AFib
 Cardiomyopathy
 Previous MI
 Patent foramen ovale
Investigations: hx, cardiac exam, ECG, CXR and cardiac echo
 o Vessel wall disease
 HIV
 Syphillis
 Collagen vascular disorders
 Secondary to acute or chronic meningitis
 Sarcoidosis
 Wegener’s granulomatosis
 Extracranial arterial dissection
Investigations: syphilis and HIV serolog; urine dipstix for haematuria and
proteinuria; rheumatoid factor
o Hypercoaguable states
 Antiphospholipid antibody syndrome
 Thrombotic thrombocytopenic purpura
Investigations: FBC, PTT, anti-phospholipid antibodies
19. Causes of polyneuropathies/peripheral neuropathies, and investigations –
a. Vasculitis – SLE, RA [ANAs]
b. Infection: HIV CMV, HTL1, diphtheria [blood serology]
c. Toxins: Alcohol, Lead, mercury, arsenic, tobacco, cocaine[blood screen]
d. A
e. Metabolic: Diabetes, hypothyroidism, porphyria, Vitamin B12, B6 and E deficiencies[
FBG, HBA1c, TFTs, Folate levels, Aquaporin 4 antibodies screen, FBC (macrocytic
anaemia due to b12 deficiency)]
f. Idiopathic
g. Inherited: CMT
h. Neoplastic: paraneoplastic syndrome secondary to lung and ovarian carcinoma[CXR
and CA125 markers]
i. Drugs: INH, anti-retroviral drugs, phenytoin, chemotherapy, amiodarone, statins [Hx
and blood drug levels]
20. Tx of neuropathic pain: Trepilline, carbamazepine, gabanpentin
21. Definition of tone: the resting resistance of muscle
22. Difference between spasticity and rigidity
23. Tremors classification
o Resting tremors Parkinson’s
 Jaw tremor
 Leg tremor
o Action tremors
 Essential
 Postural – against gravity
 Kinetic e.g. when moving hand
 Intention
24. Tx of tremors:
o Alcohol (key to outpatient diagnosis)
o Beta-blockers
o Benzos
o AEDs: phenobarbitone
25. Causes of ptosis
o Horner’s syndrome
o CN 3 fallout
o Bell’s palsy
o Myasthenia gravis
o Diabetic neuropathy
o CN7 weakness secondary to stroke
26. CN 2 course
o Eyes
o Optic chiasm
 o Optic tract
o Lateral geniculate bodies
o Optic radiation
o Visual cortex
27. Causes of myopathies
o Metabolic
 Mitochondrial
 Thyroid
 Steroid
o Toxic
o Hereditary
o Dystrophies
 Duchenne’s
 Becker’s
 Fascioscapulohumeral MD
 Oculopharyngeal
 Myotonia dystrophica  only one with distal weakness
o Inflammatory:
 Polymyositis
 Dermatomyositis
 Inclusion body myositis
28. Migraine Rx
o Non-pharmacological
 Regular exercise
 Regular sleep patter
 CBT
 Avoid dietary triggers e.g. red wine
 Avoid smoking
o Pharmacological
 Acute mx
 Disprin 300-600mg
 Analgesia: NSAIDS
 PPI if NSAIDs or disprin given
 Tryptans
 Ergotamine
 Metoclopramide
 Prophylaxis:
 Amitryptilline 10mg
 Anti-hypertensives: Propanalol, verapamil (CCB)
 Atypical CCV: flunarizine
 Anti-epileptic: sodium valproate, topiramate
29. Cluster headache tx:
o Acute: O2 therapy or tryptans
o Prophylactic: Prednisone and verapamil
30. Tension-type headache tx:
o Acute:
 Mild: Disprin, NSAIDS
  Severe: Tryptans
o Prophylaxis:
 Amitryptyline
31. Pain management

32. Approach to epilepsy

33. Nerve roots of reflexes
34. Nerve roots of muscles in power exam
35. Differences between UMN and LMN lesions

36. Differences between surgical and medical cranial nerve 3 fallout

o Medical (pupil is not dilated, thus no parasympathetic damage) causes
 Mononeuritis multiplex – classically diabetes
 MS
 Midbrain infarction
 Migraine
o Surgical (pupil is dilated, thus there is parasympathetic damage) causes
 Cavernous sinus pathology e.g. thrombosis
 PCA aneurysm – classically painful
37. Variants of CIDP and rx

38. Causes of ataxia

o Infective: viral cerebellitis (herpes zoster); creutzfeld Jacob disease (mad cow
disease)
o Neoplastic: metastases; primary brain tumours, parneoplastic cerebellar
degeneration
o Drugs: phenytoin
o Inflammation: demyelination, sarcoidosis
o Toxins: Alcohol
o Structural: Arnold-chiari malformations
o Endo:
 hypothyroidism
  Vitamin E and B1 (thiamine) deficiency

39. Types of cerebellar ataxia
o Rostral vermis syndrome: wide-based stance and gait
o Caudal vermis syndrome: axial (trunk) dysequillibrium
o Hemispheric: discoordination of the ipsilateral limb movements
40. Internuclear opthalmoplegia

Internuclear ophthalmoplegia is characterized by:

 paresis of eye adduction in horizontal gaze but not in convergence (CN 3 palsy impairs
adduction in convergence).
 It can be unilateral or bilateral.
 Nystagmus in the abducting eye
 Diplopia
INO is caused by: a lesion the medial longitudinal fasciculus

 Young people: MS – bilateral

 Elderly: stroke – unilateral
 Rare: neurosyphillis, tumor, head trauma, nutritional: wernicke’s encephalopathy

During horizontal gaze, the medial longitudinal fasciculus (MLF) on each side of the brain stem
enables abduction of one eye to be coordinated with adduction of the other. The MLF connects the
following structures:

 6th cranial nerve nucleus (which controls the lateral rectus, responsible for abduction)
 Adjacent horizontal gaze center (paramedian pontine reticular formation)
 Contralateral 3rd cranial nerve nucleus (which controls the medial rectus, responsible for
adduction)

If a lesion in the MLF blocks signals from the horizontal gaze center to the 3rd cranial nerve, the eye
on the affected side cannot adduct (or adducts weakly) past the midline. The affected eye adducts
normally in convergence because convergence does not require signals from the horizontal gaze
center.This finding distinguishes internuclear ophthalmoplegia from 3rd cranial nerve palsy, which
impairs adduction in convergence (this palsy also differs because it causes limited vertical eye
movement, ptosis, and pupillary abnormalities).

During horizontal gaze to the side opposite the affected eye, images are horizontally displaced,
causing diplopia; nystagmus often occurs in the abducting eye.

41. Supranuclear ophthalmoplegia (progressive): Rare degenerative CNS disorder

o Impairs voluntary eye movements: NB vertical movements
o Bradykinesia
o Rigidity
o Pseudobulbar palsy
o dementia
42. Marcus gunn pupil
o A Marcus Gunn pupil is said to occur when there is a unilateral lesion in the aff erent
visual pathway anterior to the chiasm.
 o The integrity of the afferent pathway may be ascertained by rapidly stimulating each
eye in succession with a torch and observing the direct and consensual light response
in each. The normal light response is pupillary constriction. In a Marcus Gunn pupil,
there is reduced afferent input and the pupils fail to constrict fully. Stimulation of
the normal eye produces full constriction in both pupils. Immediate subsequent
stimulus of the affected eye produces an apparent dilation in both pupils since the
stimulus carried through that optic nerve is weaker.
43. Bulbar vs Pseudobulbar

44. Cauda equine vs conus medullaris syndromes

MCQs
3 rd year MCQs

1. The definition of status epilepticus:

 When the seizure lasts for longer than 20-30 minutes

2. Anti-epileptic drug for status epilepticus:

 Phenytoine
 Sodium valproate
 Other options = benzodiazapenes (only used to stop seizure and not an anti-epileptic drug)
lorazepam + 11entobarbital

3. The definition of epilepsy:

 Paroxysmal electrical disturbance of cerebral neurons that cause seizures
 Incorrect options = motor signs + sensory signs (could only choose two)

4. Definition of generalized epilepsy:

 Originates in the diencephalon and then travels to both hemispheres
5. Possible complications of the Rx of status epilepticus:
 Arrythmias
 Respiratory arrest
 Incorrect = Wernicke’s encephalopathy (if not give thiamine)

6. The organism causing epidemics of meningitis:

 Neisseria meningitides

7. An unlikely presentation of cryptococcal meningitis is:

 Hydrocephalus
 Focal neurological Sx
 Clinical picture = neck stiffness + headache + fever and focal + photophobia or nausea or
vomiting

8. Ampicillin is used for which bacteria causing meningitis:

 Neisseria meningitides?

9. Rx of Cryptococcus Neoformans meningitis:

 Amphotericin B IVI x 2 weeks and add fluconazole orally high dose x 8 weeks + them
maintenance low dose lifelong

10. Viral meningitis CSF results protein is:

 Slightly elevated or normal

11. The organism seen via Indian Ink stain?

 Cryptococcus neoformans

12. The cells elevated in TB meningitis:

 Neutrophils
 Or it was Tuberculostearic acid

13. The colour of CSF on CT scan:

 Black
14. How CT scans are prodced:
 Computed tomography
 Other options = ionizing radiation

15. The contrast medium used for MRI:

 Gadolinium

16. Sleep apnoea causes:

 Day sleepiness
 Increased risk of CVD
 Reduced cognitive performance + psychosocial problems

17. The polysomnogram records what for diagnosis of sleep apnoea:

 EEG + eye movements + muscle tone
 Respiration = airflow + respiratory movements + snoring sounds
 Arterial oxygen saturation
 ECG
 Limb movements

18. The method of diagnosis for Myasthenia Gravis and Lambert-Eaton syndrome:
 Repetitive nerve stimulation

19. Factors to consider when deciding whether an EEG is normal or abnormal:

 Age
 State of arousal

20. The clinical EEG is the most useful in:

 Coma
 Epilepsy

21. The EEG frequency bands of beta:

 More than 13 Hz

22. Causes of bilateral Bell’s palsy:

 Lyme’s disease
 Sarcoidosis

23. Torticollis:
 A sign of a fourth nerve palsy

24. A child has a Gower sign- where is the pathology located:

 The proximal muscles of the lower limb
 Peripheral nerve
 Spinal cord
 Cerebral hemispheres

25. A neurocutaneous marker:

 Portwine stain

26. Child has fourth nerve palsy what is the presentation:

 Compensatory torticollis
 A squint might not be obvious, but if the child is asked to look down the eye will be adducted

27. An inappropriate gag reflex lesion:

 CN IX + X

28. Aphasia:
 Due to a L. hemisphere lesion usually
 A loss of ability to produce and/or understand written or spoken language is called aphasia

29. Apraxia:
 Unable to perform learned motor movements in the absence of primary deficits in motor and
spatial abilities
 Dominant parietal lobe lesion

30. Agnosia:
 Disorders in which patients fail to recognise familiar objects despite adequate perception +
memory + language
31. Grestmann syndrome:
 Right-left orientation is not correct with finger agnosia + dysgraphia + acalculia + localizes to
lesions in the posterior left hemisphere

32. McEwan’s cracked pot sign is indicative of:

 Craniotabes
 Raised intracranial pressure

33. When considering primary headaches, which of the following is true:

 Migraines can be treated using tryptans
 Cluster headaches are more common in males

34. Trigeminal neuralgia:

 Brief electric shock-like pains
 Limited to distribution of one or more divisions of trigeminal nerve
 Most common is the ophthalmic division affected
 Precipitated from trigger factors

35. Lady cannot stand on her toes and has no cerebral palsy- what is the lesion:
 Cerebellum?

36. Rx for TTH:

 Analgesics
 Tricyclic antidepressants (for prophylaxis)

37. Reasons to do a CT scan when a child has a migraine:

 Recent onset of severe headache
 Change in the type of headache
 Signs of increased IC pressure (nausea + vomiting + blurred vision)
 Change in the level of consciousness or seizures
 Worsened by coughing or sneezing
 Worse upon waking up and then gets better
 Increasing frequency and severity
 Relieved by effortless vomiting

38. Signs of raised IC pressure:

 Papilloedema
 Nausea + vomiting
 Blurred vision
39. All of the following supply the basal ganglia except for:
 Anterior cerebral artery
 Middle cerebral artery
 Anterior choroidal artery
 Ophthalmic artery

40. The artery that does not form part of the circle of Willis:
 Vertebral artery
 ICA
 Anterior cerebellar aa
 Anterior communicating aa
 Posterior cerebellar aa
 Posterior communicating aa

41. The spinothalamic tract decussates at the level of:

 Spinal cord
 Thalamus

42. The corticospinal tract has:

 Descending tracts

43. The great cerebral vein (of Galen) drains into which of the following:
 Inferior sagittal sinus
 Transverse sinus
 Straight sinus
 Pterygoid sinus
44. What is the function of the flocculonodular node of the cerebellum?
 Balance and movement
 Hunger
 Sensory perception
 Muscle tone

45. The cavernous sinus drains into the IJV via the:
 Sigmoid sinus

46. Cranial nerve VII can present as:

 Spared forehead movement
 Unilateral facial weakness
 Unilateral sensory loss
 Ptosis
SIC MCQs

1. Risk factors for stroke: age, DM, protein S and protein C deficiency
2. Suggestive of cerebellar disease: broad based gait, hypotonia, titubation
3. Symptomatic tx of a peripheral neuropathy: Carbamazepine, Vit B12
4. Drug resistant TB is defined as resistance to 2 anti TB drugs: isoniazid and rifampicin
5. HIV infection can result in: endocarditis, low platelet count and vasculitis.
6. Narcolepsy can be characterized by: excessive daytime sleepiness, cataplexy, hypnogogic and
hypnopompic hallucinations
7. Mestinon used in MG: is an acetylcholinesterase inhibitor
8. Non-organic weakness may be characterised by: fluctuating weakness, La-belle indifference
9. Vit B12 deficiency may cause: myelopathy, peripheral neuropathy
10. Side effects of sodium valproate: hair loss, tremor, weight gain
11. Wernicke aphasia is characterized by: neologisms
12. Cranial nerve nuclei:
a. Midbrain = 3+4
b. Pons = 5+6+7
c. Medulla = 9+10+12
13. The platysma is supplied by CN VII
14. Pt with a left sided cerebellar lesion may show: left sided intention tremor
15. Pt with a compressive lesion at level T6 may show: sensory level at T8; absent bladder and
bowel function
16. Pt with a compressive lesion at T12 may show: bilateral spasticity in the legs; bilateral
Babinski responses; absent bladder and bowel function.
17. Occlusion of the left MCA: Aphasia, weakness on the right
18. In a patient with an acute stroke: consider placing a nasogastric tube
19. True regarding cluster headache: a unilateral red eye may develop, oxygen inhalation aborts
an acute attack.
20. True regarding Parkinson’s disease: resting tremors are characteristic, festination is one of the
gait problems that patients develop.
21. Tx of Parkinson’s: Deep brain stimulation may be used in selected patients; anticholinergic
medications may be of value.
22. Biceps muscle supply: Musculocutaneous nerve
23. In CN IV palsy: lateral rectus is affect; it can be a false localizing sign in increased ICP
24. Regarding multiple sclerosis: demyelination occurs in the brain, optic neuritis may be a
presenting symptoms of MS
25. True regarding Wallenberg Syndrome: horner syndrome, ataxia, vertigo
26. True/False
a. Exercise is indicated in tx of acute headache
b. SSRIs are indicated in muscle spasm headache
c. Cluster headache will response to verapamil
d. Migraine and depression always coexist
e. Tryptans can predispose to MI
27. True regarding spinal cord lesions:
a. Demyelination is one of the causes
b. HIV can cause myelopathy
c. Can be due to CMV in association with HIV
 28. True regard inflammatory myopathies: patients with dermatomyositis can show a heliotrope
rash
29. True regarding fascioscapulohumeral muscle dystrophy
a. Facial weakness is prominent especially eye closure
b. The condition is inherited in an autosomal dominant way
c.

OSCE – 5 slides of clinical pictures/investigations

1. CT-scan give diagnosis
2. CT-scan label

Right sided MCA infarction

Thrombus in the Right MCA

Cerebellar vermis

Lateral and 3rd ventricles

4th ventricle

Tentorial incisure
Corpus callosum

Colliculi
With midline shift.
Without blood

Without blood
Sulci and gyri not differentiated in the left CT. A right MCA infarction.

And…
A chronic haemorrhage.
Typical of rapid deceleration injuries
3. LP give diagnosis and treat
Emperic tx:

Bacterial: Ceftriaxone 2g IV bd

TB: RIPE 2 months, RI 7 months

Cryptococcus: Amphotericin B 1mg/kg IV 4 hourly

Viral: analgesia, if HSV aciclovir

4. Deviated eyes – give diagnosis

5. If a drug is asked give the: drug, dose, frequency and route.
6. Parkinson’s clinical picture (the signs)
a. Positive motor: pill rolling tremor, lead pipe and cogwheel rigidity
b. Negative motor: bradykinesia
c. Masked facies
d. Hypophonia
e. Monotonous speech
f. Dysarthria
g. Micrographia
h. Shuffling gait
i. Fenstination secondary to postural instability
 j. Freezing
k. Cognition: bradyphrenia and dementia
l. Behaviour: depression, anxiety, sleep disturbances
m. Autonomic: urinary retention, depression, sleep disturbances, anxiety
7. Essential tremor:
a. Exclude and manage alternate causes, such as drugs, thyrotoxicosis,
hyperadrenergic states and psychiatric disorders.
b. Tx: Propranolol, oral,
i. Start at 20 mg daily and titrate as needed up to 80 mg 8 hourly.
ii. Monitor BP.
8. Blood results interpretation:
a. FBC test and left shift

The term “left shift” means that a particular population of cells is “shifted” towards more immature
precursors

Most of the time, when you see a left shift, it means that the patient has an infection – often a
bacterial one. Sometimes a left shift can occur when there is inflammation or necrosis.

Beware, though, if you see nucleated red cells in addition to left-shifted neutrophils. This is called a
leukoerythroblastotic reaction, and it may indicate a more serious problem. Sometimes, a
leukoerythroblastotic reaction is physiologic. If the hemoglobin is very low (for whatever reason –
severe iron deficiency, massive blood loss), the bone marrow tries very hard to make new red cells
and send them out into the blood as fast as possible. Sometimes, it is a little overzealous, and it lets a
few red cell precursors (nucleated red cells) slip out of the marrow too. And sometimes, it is so
freaked out that it starts letting neutrophil precursors (metamyelocytes, myelocytes, promyelocytes)
out too!

9. Sensation on the dermatome of the middle finger

a. C7
b. 2 muscles mainly innervated by it: Extensor digitorum, extensor policis longus?
10. TB myelopathy
a. How would it present
i. clinical sign of pulmonary TB or gibbus on the spine. Patients with this
disease often show skinny appearance and complaining of cold sweat and
chronic cough. Therefore, patients with tuberculous spine disease usually
come with radiculopathy and/or myelopathy
b. How would you differentiate it from an anterior horn cell disease
i.
c. On special investigation what would one expect to find
i. Diagnosis of skeletal tuberculosis is established by obtaining a sample by
spine or paravertebral biopsy with assistance of radiological examination or
ultrasonography.
ii. MRI will show destruction of vertebral body and myelum involvement
iii. LP
11. Patient with atrophy of the trapezius and shoulder.
a. Causes:?
i. Thoracic outlet syndrome
ii. FSHMD
iii. Brachial neuritis
iv. Kennedy’s disease