Neuro Year 3 MedEd Rehaan Khokar 2

Year 3 EOCP Block 4: Neurology
SBAs
Rehaan Khokar, MedEd President
[email protected]
FOLLOW US: @mededncl
Core conditions
• ‘Localise the lesion’ • Confusion
• TIA • Headache
• Stroke
• Involuntary movements
• Parkinson’s Disease
• Muscle weakness
• Migraine
• Seizure
• Meningitis
• Tremor
• Intracranial Bleed
• Ataxia
SBAs in Year 3
• SBAs are all focused on core conditions and their relevant core clinical
presentations
• For these, you may be asked to… (in relative order of frequency in the exam)
• Select the best diagnosis
• Select the best first-line management – conservative, medical or surgical
• Select the best first-line investigation(s) and/or imaging
• Select the ‘risk factor’ / ‘most likely cause’ from the stem
• Select the indication for referral / indication for investigation and/or imaging
• Select the most likely adverse effect of a drug, procedure or condition
• Select the next best step of management / intervention
• “Given the most likely diagnosis….” (where they don’t tell you the diagnosis !!!!)
• Other slightly more weird and wonderful Qs on interpretation of investigations

Y3 EOCP4
Outcomes

Sign-post
• Post-session resources will contain more slides that have
been “hidden” in this presentation
• Sadly there isn’t enough time to go through absolutely

everything but hopefully these slides will be useful for your
learning 

“Localise the lesion”
[email protected]
Select the best statement describing motor
neurone lesions
A. Lower motor neurone lesions present with a loss of tone

B. Upper motor neurone lesions present with flaccid
paralysis
C. Lower motor neurone lesions present with minimal
atrophy
D. Upper motor neurone lesions commonly present with
fasciculations

Select the best statement describing motor
neurone lesions
A. Lower motor neurone lesions present with a loss of
tone
B. Upper motor neurone lesions present with flaccid
paralysis
C. Lower motor neurone lesions present with minimal
atrophy
D. Upper motor neurone lesions commonly present with
fasciculations
UMNs vs LMNs
UMN LMN
Atrophy Minimal/No (there is Yes
weakness)
Fasciculations No Yes
Tone Spastic or Rigid Hypotonia
(increased). (decreased)
Velocity Dependent Velocity Independent
Paralysis Spastic Flaccid
Reflexes Brisk (hyper) Diminished or Absent
[Babinski Positive] (Hypo/areflexia)

Spinal cord
Sensory tract Motor tract
DCML
Afferent sensory neurones Efferent motor neurones

Ascending Pathways
Summary
Spinal Cord:
• DCML [Fine touch, vibration, proprioception]
• Gracile fasciculus (lower limbs)
• Cunate fasciculus (upper limbs)
• Anterolateral system [Pain, temperature, crude touch]
• Anterior spinothalamic tract
• Lateral spinothalamic tract
Cerebellum:
• Vestibulocerebellum [balance]
• Spinocerebellum [coordination, ongoing movement]
• Cerebrocerebellum [initiation and planning of movements, motor learning]

Ascending pathway lesions
Type Pathway Spinal Cord Cortex Lesion
Lesion
Ascending DCML
• Fine touch, pressure,
vibration, proprioception Ipsilateral Contralateral
• Decussates in medulla

ALS – Spinothalamic
Tract
• Non-discriminative
touch, pain, temperature Contralateral Contralateral
• Decussates in spinal
cord


Descending Pathways
Summary
Pyramidal:
• Corticospinal tract
• Anterior corticospinal tract [proximal muscles]
• Lateral corticospinal tract [distal muscles]
• Corticobulbar tract [cranial nerves excluding lower facial nuclei]
• Direct corticobulbar tract [CN V, VII, IX and XII]
• Indirect corticobulbar tract
Extrapyramidal:
• Rubrospinal tract [excites flexors, inhibits extensors]
• Reticulospinal tract [initiates patterned activity, induces temporary sleep paralysis]
• Vestibulospinal tract
• Lateral vestibulospinal tract: [excites extensors inhibits flexors]
• Medial vestibulospinal tract: [balance, posture]
• Tectospinal tract [orientation to visual stimuli]

Descending (pyramidal) pathway lesions
Type Pathway Spinal Cord Cortex Lesion
Lesion
Descending (pyramidal) Lateral corticospinal tract
(90%)

• Distal muscles
Ipsilateral Contralateral
Q: What is the • Decussates in medulla
name of the
OTHER Anterior corticospinal tract
(10%)
pyramidal
pathway? • Proximal muscles Contralateral Contralateral
• Decussates in spinal
cord

Corticobulbar tract
• The corticobulbar tract innervates cranial motor nuclei
bilaterally with the exception of the lower facial nuclei
(which innervates facial muscles below the eyes) and the
genioglossus muscle, which are innervated ONLY
unilaterally by the contralateral cortex.
• Nuclei that are bilaterally innervated are contralateral:
nuclei for cranial nerves V, VII, IX, and XII.
• Direct corticobulbar tract [CN V, VII, IX and XII]
• Indirect corticobulbar tract [others….]
Raja Gemini (they/them) comes into ED with a burn on their hand. Raja
explains this is from accidentally touching a hot plate from the oven for a
prolonged period without realising that it was hot. On examination, they are
unable to feel vibratory sensation in their left hand.
Which of the following is most likely to be true for Raja?

A. Lesion in the dorsal column at the level of C1
B. Lesion in the precentral gyrus of the left cerebral hemisphere
C. Lesion on the right side of the spinal cord at the level of C1
D. Lesion on the left side of the spinal cord at the level of C1
E. Lesion on the left side of the spinal cord at the level of T6

Raja Gemini (they/them) comes into ED with a burn on their hand. Raja
explains this is from accidentally touching a hot plate from the oven for a
prolonged period without realising that it was hot. On examination, they are
unable to feel vibratory sensation in their left hand.
Which of the following is most likely to be true for Raja?

A. Lesion in the dorsal column at the level of C1
B. Lesion in the precentral gyrus of the left cerebral hemisphere
C. Lesion on the right side of the spinal cord at the level of C1
D. Lesion on the left side of the spinal cord at the level of C1
E. Lesion on the left side of the spinal cord at the level of T6

Localise the lesion

Localise the lesion

CNS lesions
Lesion Location Clinical Picture Neuropathology
Cortex Impaired behaviour, cognition, memory, Stroke, tumours, epilepsy,
language, seizures, gait abnormalities (various) dementia/diffuse structural
changes
Basal ganglia Increased OR decreased movement depending Depletion: Parkinson’s
on dopamine depletion (PD) or excess (HD), Excess: Huntington’s
gait abnormalities (chorea, shuffling)
Brainstem and DANISH: dysdiadochokinesis, ataxia, Stroke, MS

cerebellum nystagmus, slurred speech, hypotonia
Spinal cord Motor/sensory impairment, bowel and bladder Spinal cord injuries, MS,
dysfunction tumours, spondylotic disc
disease
Cauda equina Motor/sensory impairment (lower limb), bladder Tumours, spondylotic disc
and bowel dysfunction, saddle anaesthesia* disease, cauda equina
syndrome

PNS lesions
Lesion Location Clinical Picture Neuropathology
Anterior horn cell of spinal Motor signs, fasciculations Motor neurone disease;
cord LMNs – impaired
neurotransmitter discharge
at motor units reducing
muscle function
Nerve root Motor/sensory signs, pain Spondylotic disc disease
Peripheral nerves Motor/sensory signs, Diabetic neuropathy,
hyporeflexia G-B syndrome
Neuromuscular junction Fatigue, wasting Myasthenia gravis (ptosis)
Muscle Proximal muscle weakness, Various myopathies,
wasting, normal sensation inflammation, damage

Select the best description of the clinical
presentation of Brown-Sequard syndrome
A. Contralateral loss of proprioception and vibration and ipsilateral loss of pain
and temperature sensation with contralaterally progressive hemiparaplegia
B. Contralateral loss of proprioception and vibration and contralateral loss of
pain and temperature sensation with ipsilaterally progressive hemiparaplegia
C. Ipsilateral loss of proprioception and vibration and contralateral loss of pain
and temperature sensation with ipsilaterally progressive hemiparaplegia
D. Ipsilateral loss of proprioception and vibration and ipsilateral loss of pain and
temperature sensation with contralaterally progressive hemiparaplegia
E. Ipsilateral loss of proprioception and vibration and contralateral loss of pain

Select the best description of the clinical
presentation of Brown-Sequard syndrome
A. Contralateral loss of proprioception and vibration and ipsilateral loss of pain
B. Contralateral loss of proprioception and vibration and contralateral loss of pain
and temperature sensation with ipsilaterally progressive hemiparaplegia
C. Ipsilateral loss of proprioception and vibration and contralateral loss of
pain and temperature sensation with ipsilaterally progressive
hemiparaplegia
D. Ipsilateral loss of proprioception and vibration and ipsilateral loss of pain and
temperature sensation with contralaterally progressive hemiparaplegia
E. Ipsilateral loss of proprioception and vibration and contralateral loss of pain

Brown-Sequard syndrome

Spinal cord lesions - summary
Motor:
Corticospinal tract (A/L)
Vibration/proprioception:
DCML
Pain/temperature:
Spinothalamic tract
[A]: Brown-Sequard [B]: Anterior Cord [C]: Central cord [D]: Subacute
syndrome combined
Ipsilateral Contralateral
degeneration
Motor Affected Spared Affected bilaterally Spared bilaterally (until Affected bilaterally
advanced disease)
Vibration/Prop Affected Spared Spared bilaterally Spared bilaterally Affected bilaterally

Pain/temp Spared Affected Affected bilaterally Affected bilaterally Spared bilaterally
UL>>LL
Ischaemia, infarction, infection and
haemorrhage:
TIA, Stroke, Intracranial Bleed, Ataxia, Meningitis
[email protected]
Robbie (he/him), a 78-year old man is brought to the emergency department due
to new-onset left-sided weakness. Robbie is orientated and able to clearly
describe waking up this morning and noticing weakness on their left side. On
examination, he has reduced left arm and leg power, a left facial droop and left
homonymous hemianopia.
Which one of the following best describes Robbie’s
presentation?
A. Lacunar infarct
B. Lateral medullary syndrome
C. Partial anterior circulation infarct
D. Posterior circulation infarct
E. Total anterior circulation infarct

Robbie (he/him), a 78-year old man is brought to the emergency department due
to new-onset left-sided weakness. Robbie is orientated and able to clearly
describe waking up this morning and noticing weakness on their left side. On
examination, he has reduced left arm and leg power, a left facial droop and left
homonymous hemianopia.
Which one of the following best describes Robie’s
presentation? Q: What artery is likely
A. Lacunar infarct to be infarcted in
Robbie’s case?
B. Lateral medullary syndrome
C. Partial anterior circulation infarct Q: What parts of the
D. Posterior circulation infarct
brain does this artery
supply?
E. Total anterior circulation infarct

Partial anterior circulation infarct
• PACS needs any TWO of the following (i.e. any 2/3 of the
symptoms of TACS)
• Contralateral, unilateral hemiparesis and/or hemisensory loss of
the 2/3 of face, arm and/or leg
• (bilateral) homonymous hemianopia
• higher cognitive dysfunction e.g. dysphasia
• ALL THREE of the above would be TACS.

Infarction of the circle of Willis – symptomology
(An SBA favourite – easy to learn!)
• Contralateral hemiparesis +/-
sensory motor loss
• Lower limbs >> upper limbs
• Cortical defect e.g. dysphagia
• Contralateral hemiparesis +/-

sensory motor loss
• Upper limbs >> lower limbs
• Contralateral homonymous
hemianopia

• Contralateral homonymous hemianopia with
macular sparing
• Visual agnosia
Branches of PCA supplying midbrain:
• Ipsilateral CNIII palsy – down and out, ptosis
(droopy eyelid), mydriasis (dilated pupil)
• Contralateral hemiparesis
• Ipsilateral facial paralysis and deafness
• Contralateral loss of pain and temperature
• Cerebellar ataxia, nystagmus
• Ipsilateral Horner’s syndrome (ptosis,
anhidrosis, miosis)
• Ipsilateral facial pain and temperature

sensation
• Contralateral loss of pain and temperature of
the body
• Cerebellar ataxia, nystagmus
• Ipsilateral Horner’s syndrome
AICA vs PICA?
AICA: facial paralysis + deafness
PICA: pain + temperature loss

Danny Beard (they/them) presents to the emergency department with their
partner. They were having dinner when they started coughing and having trouble
eating. Danny tried to get up, but they could not walk properly and felt dizzy. On
examination, Danny has clear ataxia. Nystagmus is observable in both eyes.
They have right-sided facial pain and temperature sensory loss. Their right eyelid
is drooping and the pupil looks constricted. There is left-sided upper and lower
limb pain and temperature sensory loss, with normal power in all muscle groups.
Given the most likely diagnosis, where is the lesion?
• Left midbrain branches of posterior cerebellar artery
• Right anterior inferior cerebellar artery
• Left posterior inferior cerebellar artery
• Right posterior inferior cerebellar artery
• Left anterior inferior cerebellar artery

Danny Beard (they/them) presents to the emergency department with their
partner. They were having dinner when they started coughing and having trouble
eating. Danny tried to get up, but they could not walk properly and felt dizzy. On
examination, Danny has clear ataxia. Nystagmus is observable in both eyes.
They have right-sided facial pain and temperature sensory loss. Their right eyelid
is drooping and the pupil looks constricted. There is left-sided upper and lower
limb pain and temperature sensory loss, with normal power in all muscle groups.
Given the most likely diagnosis, where is the lesion?
• Left midbrain branches of posterior cerebellar artery
• Right anterior inferior cerebellar artery
• Left posterior inferior cerebellar artery
• Right posterior inferior cerebellar artery
• Left anterior inferior cerebellar artery

PICA
• Ipsilateral facial pain and temperature loss: due to damage to
the trigeminal nucleus, which run ipsilaterally
• Contralateral limb/torso pain and temperature loss: due to
damage to the lateral spinothalamic tract, which do decussate
• Ataxia: due to damage to the inferior cerebellar peduncle
• Nystagmus: due to damage to the vestibular nucleus
• Horner’s syndrome: due to damage to the sympathetic
connections descending from the hypothalamus into the cervical
cord.

Joe (he/him), is a 65-year-old right-handed man presents to the emergency
department with speech difficulties and right-sided weakness. He states he first
noticed this at 9 am this morning. He has a history of hyperlipidaemia, for which
he takes atorvastatin. He smokes 20 cigarettes a day and drinks 15 units of
alcohol per week. A non-contrast CT head is performed and is normal. A loading
dose of Aspirin is given. It is now 12:45pm and his symptoms are still present.
Select the next best management step
A. Continue aspirin and offer TIA clinic review
B. Thrombectomy only
C. Offer clopidogrel and offer TIA clinic review
D. Thrombolysis and thrombectomy
E. Thrombolysis only

Joe (he/him), is a 65-year-old right-handed man presents to the emergency
department with speech difficulties and right-sided weakness. He states he first
noticed this at 9 am this morning. He has a history of hyperlipidaemia, for which
he takes atorvastatin. He smokes 20 cigarettes a day and drinks 15 units of
alcohol per week. A non-contrast CT head is performed and is normal. A loading
dose of Aspirin is given. It is now 12:45pm and his symptoms are still present.
Select the next best management step
A. Continue aspirin and offer TIA clinic review
B. Thrombectomy only
C. Offer clopidogrel and offer TIA clinic review
D. Thrombolysis and thrombectomy
E. Thrombolysis only

Ischaemic stroke: initial management
• TIA
• Do NOT offer CT brain if TIA (!); instead the “best” imaging is diffusion-weighted MRI
• Aspirin 300mg daily and refer immediately to TIA specialist clinic within 24hrs (where a
diffusion-weighted MRI will likely be performed)
• IF carotid cause then urgent carotid doppler for carotid endarterectomy.
• Ischaemic stroke
• Non-contrast CT brain
• IV thrombolysis with alteplase if presenting within 4.5hrs of symptom onset AND intracranial
haemorrhage has been excluded (!)
• Offer thrombectomy within 6hrs* of symptom onset if confirmed ischaemic stroke + confirmed
occlusion of anterior circulation..
• Aspirin 300mg + PPI ASAP rocky once haemorrhage excluded, for 14 days after onset of
stroke symptoms
Haemorrhagic stroke: initial management
• Haemorrhagic strokes should only be monitored by specialist neurologists and
if suspected should be referred immediately for CT brain.
• Return clotting levels to normal as soon as possible in people with a primary
intracerebral haemorrhage who were receiving warfarin before their stroke
(and have elevated international normalised ratio). Do this by reversing the
effects of the warfarin using a combination of prothrombin complex
concentrate and intravenous vitamin K
• BP control: aim to reach systolic BP of <140mmHg; ensure magnitude of drop
of BP does not exceed 60mmHg within 1hr of starting treatment.
• Decompressive hemicraniectomy should be performed within 48hrs onset

Secondary prevention
• Clopidrogrel
• OR offer Aspirin + MR-dipyridamole if clopidrogrel contraindicated
• OR MR-dipyridamole alone if aspirin/clopidrogrel contraindicated

What about statins?
• Offer statins if patient’s cholesterol is >3.5mmol/L.
• Immediate initiation of statin treatment is NOT recommended in patients with
stroke
• However, if a patient was already taking a statin then, obviously, continue this!

Antiplatelets and anticoagulants
Example(s) MOA
Anticoagulants Warfarin Vitamin K reductase inhibitor
(VKORC1)
Antiplatelets Aspirin (NSAID) COX-1 and COX-2 inhibitor
Clopidogrel P2Y12 inhibitor
Ticagrelor
Prasugrel
Ticlopidine
Dipyridamole Platelet cAMP phosphodiesterase
inhibition and adenosine inhibition
Direct Oral Dabigatran Direct thrombin inhibitor
Anticoagulants (DOACs)
Rivaroxaban Selective Xa inhibitor
Apixaban
Edoxaban
Low molecular weight Dalteparin Anti-thrombin III inhibitor
heparins (LMWHs) / Enoxaparin
Heparin Tinzaparin
Fondaparinux

Gladys Duffy (they/them) telephones her GP practice. They are well in
themselves but recently received a phone call from the hospital regarding their
brother who was admitted with a fever, headache, confusion and a non-
blanching, red-purple blotchy rash. The hospital informed Gladys to ask their GP
for prophylactic antibiotics.
What antibiotic would be the single best choice for Gladys in

this scenario?
A. Amoxicillin
B. Benzylpenicillin
C. Ceftoxamine
D. Vancomycin
E. Ciprofloxacin

Gladys Duffy (they/them) telephones her GP practice. They are well in
themselves but recently received a phone call from the hospital regarding their
brother who was admitted with a fever, headache, confusion and a non-
blanching, red-purple blotchy rash. The hospital informed Gladys to ask their GP
for prophylactic antibiotics.
What antibiotic would be the single best choice for Gladys in

this scenario?
A. Amoxicillin Q: What is the
B. Benzylpenicillin MOA of
C. Ceftoxamine ciprofloxacin?
D. Vancomycin
E. Ciprofloxacin
Meningitis treatment
Meningococcal IV benzylpenicillin
Pneumococcal IV cefotaxime OR IV ceftriaxone
H.Influenza
Listeria monocytogenes IV amoxicillin and gentamycin
• Close-contact prophylaxis for people exposed to

confirmed case of (bacterial) meningitis:
- Oral ciprofloxacin OR Rifampicin
- Offer meningococcal vaccine to close contacts

Pip (he/him), a 6-year old boy presents to the ED with his mother. His mother
describes a 6-hour history of fever, headache and neck-stiffness. Examination
identified marked photophobia as well as a positive Kernig’s sign. A lumbar
puncture is performed, with some of the results shown below.
What organism is the most likely underlying cause of

Pip’s presentation?
Glucose 2.1mmol/L
A. Streptococcous pneumoniae
Protein 1.2g/L
B. Staphylococcous aureus Cells 4050 polymorphs/mm3
C. Mycobacterium tuberculosis
D. Listeria monocytogenes
E. E.Coli

Pip (he/him), a 6-year old boy presents to the ED with his mother. His mother
describes a 6-hour history of fever, headache and neck-stiffness. Examination
identified marked photophobia as well as a positive Kernig’s sign. A lumbar
puncture is performed, with some of the results shown below.
What organism is the most likely underlying cause of

Pip’s presentation?
Glucose 2.1mmol/L
A. Streptococcous pneumoniae
Protein 1.2g/L
B. Staphylococcous aureus Cells 4050 polymorphs/mm3
C. Mycobacterium tuberculosis
D. Listeria monocytogenes
E. E.Coli

Q: What are the
Lumbar puncture analysis contraindications
to the use of LP?
Bacterial Viral TB Fungal
Slight cloudy,
Appearance Cloudy Clear/cloudy
fibrin web
Cloudy
60-80% of Low (< 1/2

Glucose Low (< 1/2 plasma)
plasma glucose* plasma)
Low
Protein High (> 1 g/l) Normal/raised High (> 1 g/l) High

20 - 200
10 - 5,000 15 - 1,000 30 - 300
White cells polymorphs/mm³ lymphocytes/mm³ lymphocytes/mm³
lymphocytes/m
m³

Lumbar puncture: contraindications
Spinal epidural Thrombocytopeni
Raised ICP
abscess a
• Increased risk of • Risk of puncturing • Increased risk of

coning of the brain abscess bleeding
 Cushing’s • Might encourage • Likewise, LP
triad colonisation of contraindicated if
• Bradycardia, bacteria patient is on
hypertension/wide (S.aureus) into anticoagulant
pulse pressure, subarachnoid therapy
decreased RR space

Clinical signs
• KErnig
• KNEE
EXTENSION
• is painful
• BrudiNsKi
• NECK flexion
• KNEE flexion
Confusion and disorientation:
Migraines, headaches, seizures
[email protected]
Alysha (she/her), 45-year-old alcoholic patient, starts to fit in the waiting room.
You place her in the recovery position and apply oxygen. After 5 minutes she is
still fitting.
What is the most apt medication to administer?

A. Rectal midazolam
B. IV phenytoin
C. Buccal lorazepam
D. Rectal diazepam
E. Buccal chlordiazepoxide

Alysha (she/her), 45-year-old alcoholic patient, starts to fit in the waiting room.
You place her in the recovery position and apply oxygen. After 5 minutes she is
still fitting.
What is the most apt medication to administer?

A. Rectal midazolam
B. IV phenytoin
C. Buccal lorazepam
D. Rectal diazepam
E. Buccal chlordiazepoxide

Management of status epilepticus
• First-line drugs are IV benzodiazepines e.g. lorazepam
• in the prehospital setting PR diazepam or buccal midazolam may be
given
• in hospital IV lorazepam is generally used. This may be repeated
once after 10-20 minutes
• If ongoing (or 'established') status it is appropriate to start a
second-line agent such as phenytoin or phenobarbital infusion
• If no response ('refractory status') within 45 minutes from onset,
then the best way to achieve rapid control of seizure activity is
induction of general anaesthesia.

James (he/him) is found unresponsive outside the emergency department. He is
confirmed to be in status epilepticus. No medical history is available and the care
team begin to treat him.
What is the most important cause of status epilepticus to

rule out first?
A. Meningitis
B. Alcohol withdrawal
C. Uncontrolled epilepsy
D. Subdural haematoma
E. Hypoxia

James (he/him) is found unresponsive outside the emergency department. He is
confirmed to be in status epilepticus. No medical history is available and the care
team begin to treat him.
What is the most important cause of status epilepticus to

rule out first?
A. Meningitis
B. Alcohol withdrawal Q: What other cause
C. Uncontrolled epilepsy
must also be ruled out?
D. Subdural haematoma
E. Hypoxia

Joanne (they/them), is an obese 22-year-old presenting to the GP with a 2-
week history of daily headaches. Their headaches are bilateral in nature,
across the forehead and are reportedly constant throughout the day and made
worse on bending over. On fundoscopy, blurring of the optic disc is observed.
Select the most likely diagnosis
A. Migraine headache
B. Cluster headache
C. Tension headache
D. Idiopathic intracranial hypertension
E. Venous sinus thrombosis

A. Migraine headache
B. Cluster headache
C. Tension headache
E. Venous sinus thrombosis

A. Migraine headache – unilateral, +/- aura,
photophobia/phonophobia
B. Cluster headache – intense, sharp eye pain, ipsilateral
autonomic symptoms e.g. lacrimation, swelling, nasal stuffiness
C. Tension headache – ‘tight-band’, triggers*
E. Venous sinus thrombosis – N+V, reduced GCS, 6th nerve palsy
Zayd (he/him), a 41-year-old man presents with a two week history of extremely
painful headaches around the left side of his face associated with watery eyes. He
describes having about two episodes a day each lasting around 30 minutes.

A. Cluster headache
B. Acute closed angle glaucoma
C. Migraine
D. Trigeminal neuralgia
E. Tension headache

Zayd (he/him), a 41-year-old man presents with a two week history of extremely
painful headaches around the left side of his face associated with watery eyes. He
describes having about two episodes a day each lasting around 30 minutes.

A. Cluster headache
B. Acute closed angle glaucoma
C. Migraine
D. Trigeminal neuralgia
E. Tension headache

Charlotte (she/her), a 21-year old girl presents to the ED declaring she’s had a
stroke. When probed on her symptoms, she explains she was sitting in a MedEd
lecture on neurology and suddenly smelt roses. She asked her friend, George
(he/him), next to her where the smell was coming from but George could not
smell anything. She explains how the smell lasted for a few minutes and then
disappeared. She denies any headaches.
A. Migraine with aura
B. Transient ischaemic attack
C. Focal aware seizure
D. Sinusitis
E. Acute psychotic episode
Charlotte (she/her), a 21-year old girl presents to the ED declaring she’s had a
stroke. When probed on her symptoms, she explains she was sitting in a MedEd
lecture on neurology and suddenly smelt roses. She asked her friend, George
(he/him), next to her where the smell was coming from but George could not
smell anything. She explains how the smell lasted for a few minutes and then
disappeared. She denies any headaches.
A. Migraine with aura
B. Transient ischaemic attack
C. Focal aware seizure - a sudden but short-lived change in senses
D. Sinusitis
E. Acute psychotic episode
Disorders of movement:
Parkinson’s disease, tremors, muscle weakness
and involuntary movements
[email protected]
Marie Curie (she/her) presents to the neurology clinic with a persistent tremor
which, on examination, is worse when her arms are outstretched.
Given the likely diagnosis, what is the most suitable first-line

treatment for Marie?
A. Propranolol
B. Levodopa
C. Diazepam
D. Amitriptyline
E. Penicillamine

Marie Curie (she/her) presents to the neurology clinic with a persistent tremor
which, on examination, is worse when her arms are outstretched.
Given the likely diagnosis, what is the most suitable first-line

treatment for Marie?
A. Propranolol
B. Levodopa
C. Diazepam
D. Amitriptyline
E. Penicillamine

Dakota Schiffer (she/her), a 60-year old woman, presents with progressive
slurred speech for the past few months. She explains how embarrassing this is
for her at work and her manager warned her to “stop coming to work drunk”.
What is the most likely cause of

Dakota’s presentation? Cranial nerve examination reveals the following:
A. Multiple sclerosis - Difficulty in swallowing a sip of water
- Fasciculations of the tongue when protruded
B. Parkinson’s disease - Inability to say “British constitution”
Motor and sensory exam reveal the following:
C. Motor neuron disease - Generalised mild weakness and hypotonia
- Hyperreflexia of knee and ankle only
D. Cerebellar tremor
E. Partial anterior circulation infarct

Dakota Schiffer, (she/her) a 60-year old woman, presents with progressive
slurred speech for the past few months. She explains how embarrassing this is
for her at work and her manager warned her to “stop coming to work drunk”.
What is the most likely cause of

Dakota’s presentation? Cranial nerve examination reveals the following:
A. Multiple sclerosis - Difficulty in swallowing a sip of water
- Fasciculations of the tongue when protruded
B. Parkinson’s disease - Inability to say “British constitution”
Motor and sensory exam reveal the following:
C. Motor neuron disease - Generalised mild weakness and hypotonia
- Hyperreflexia of knee and ankle only
D. Cerebellar tremor
E. Partial anterior circulation infarct

Motor neurone disease
Amyotrophic lateral sclerosis,
progressive muscular atrophy,
progressive bulbar palsy
• Pattern of UMN and LMN signs e.g.
fasciculations, progressive
weakness, dysarthria, dysphagia
• Motor disease so there are NOT
sensory signs
• Absence of cerebellar signs
Babinski positive
(DANISH)
• Does NOT affect external ocular
muscles

Levi (he/him), a 75-year old man, is brought into your GP clinic by his husband, Panther
(they/them). Panther has expressed great concern about Levi’s movement, describing
them as much slower and reports a few recent falls. On examination you note Levi’s
tremor and elicit cog-wheel rigidity on examination of upper limb tone on examination.
Given the most likely diagnosis, which of the following

statements best describes the tremor you are most likely to see?
A. Unilateral tremor which improves with voluntary movements
B. Bilateral tremor of the upper limbs which worsens with action
C. Tremor which worsens as Levi reaches out to the examiners finger
D. Unilateral tremor which worsens when arms are held outstretched
E. Bilateral tremor which improves with rest.

Levi (he/him), a 75-year old man, is brought into your GP clinic by his husband, Panther
(they/them). Panther has expressed great concern about Levi’s movement, describing
them as much slower and reports a few recent falls. On examination you note Levi’s
tremor and elicit cog-wheel rigidity on examination of upper limb tone on examination.
Given the most likely diagnosis, which of the following statements

best describes the tremor you are most likely to see?
A. Unilateral tremor which improves with voluntary movements
B. Bilateral tremor of the upper limbs which worsens with action
C. Tremor which worsens as Levi reaches out to the examiners finger
D. Unilateral tremor which worsens when arms are held outstretched
E. Bilateral tremor which improves with rest.

Parkinson’s Disease
• Depigmentation of substantia nigra pars
compacta  loss of dopaminergic
neurones
• Asymmetrical, unilateral…
• Bradykinesia
• Difficulty in initiation of movement
• Marked ‘pill-rolling’ resting tremor that
improves with voluntary movement
• Lead-pipe rigidity and cogwheeling
• Depression
• Daytime somnolence
• Postural hypotension (due to autonomic
failure)

Parkinson’s Disease
• Depigmentation of substantia nigra pars
compacta  loss of dopaminergic
neurones
• Asymmetrical, unilateral…
• Bradykinesia
• Difficulty in initiation of movement
• Marked ‘pill-rolling’ resting tremor that
improves with voluntary movement
• Lead-pipe rigidity and cogwheeling
• Depression
• Daytime somnolence
• Postural hypotension (due to autonomic
failure)

Hatt Mancock (he/him) is seen in the neurology clinic. His posture is stooped and
he moves with a slow, shuffling gait. His face is expression and speaks in a very
quite voice with little inflection. An astute junior doctor notices a new bilateral-pill
rolling tremor in the hands that is exacerbated on distraction

A. Cerebellar lesion
B. Alcohol-induced tremor
C. Drug-induced parkinsonism
D. Parkinson’s disease
E. Essential tremor
Hatt Mancock (he/him) is seen in the neurology clinic. His posture is stooped and
he moves with a slow, shuffling gait. His face is expression and speaks in a very
quite voice with little inflection. An astute junior doctor notices a new
bilateral-pill rolling tremor in the hands that is exacerbated on distraction
A. Cerebellar lesion
B. Alcohol-induced tremor
C. Drug-induced parkinsonism
D. Parkinson’s disease
E. Essential tremor
ADDITIONAL SBA QUESTIONS
[email protected]
Momo undergoes a spinal MRI scan. The imaging reveals a cervical and
thoracic syringomyelia. On closer examination, Momo is noted to have a
cape-like loss of sensation to pain and temperature, but normal fine touch
and proprioception. Select the most likely spinal cord structure affected,
causing this pattern of presentation.
A. Dorsal columns
B. Spinocerebellar tract
C. Anterior white commissure
D. Dorsal root ganglion
E. Corticospinal tract

Momo undergoes a spinal MRI scan. The imaging reveals a cervical and
thoracic syringomyelia. On closer examination, Momo is noted to have a
cape-like loss of sensation to pain and temperature, but normal fine touch
and proprioception. Select the most likely spinal cord structure affected,
causing this pattern of presentation.
A. Dorsal columns
B. Spinocerebellar tract
C. Anterior white commissure
D. Dorsal root ganglion
E. Corticospinal tract

Toto presents to the emergency department with a left hemi
section of their T12 vertebrae. Which of the following patterns
of presentations best describes this pathology?
A. Moderate weakness and paraesthesia on their left side, increased pain and
temperature sensation on their right side
B. Moderate weakness and paraesthesia on their left side, decreased pain and
C. Paralysis and loss of fine touch and proprioception on their left side,
increased pain and temperature sensation on their right side
D. Paralysis and loss of fine touch and proprioception on their left side,
decreased pain and temperature sensation on their right side
E. Paralysis, loss of fine touch, proprioception, pain, and temperature sensation
on both sides
Toto presents to the emergency department with a left hemi
section of their T12 vertebrae. Which of the following patterns
of presentations best describes this pathology?
A. Moderate weakness and paraesthesia on their left side, increased pain and
B. Moderate weakness and paraesthesia on their left side, decreased pain and
C. Paralysis and loss of fine touch and proprioception on their left side,
increased pain and temperature sensation on their right side
D. Paralysis and loss of fine touch and proprioception on their left side,
decreased pain and temperature sensation on their right side
E. Paralysis, loss of fine touch, proprioception, pain, and temperature sensation
on both sides
Rehaan is stabbed in the back. On examination you note
a complete loss of sensation at the level of his nipple.
Which dermatome is responsible for this?
A. T1
B. T2
C. T3
D. T4
E. T5

Rehaan is stabbed in the back. On examination you note
a complete loss of sensation at the level of his nipple.
Which dermatome is responsible for this?
A. T1
B. T2
C. T3
D. T4
E. T5

Nigella Lawson presents to their GP with a sudden right-sided
loss of fine touch and vibration. On examination, the GP elicits
ipsilateral loss of proprioception. Select the most likely
anatomical structure damaged.
A. Left dorsal column

B. Left spinothalamic tract
C. Right dorsal column
D. Right spinocerebellar right
E. Right spinothalamic tract

Nigella Lawson presents to their GP with a sudden right-sided
loss of fine touch and vibration. On examination, the GP elicits
ipsilateral loss of proprioception. Select the most likely
anatomical structure damaged.
A. Left dorsal column

B. Left spinothalamic tract
C. Right dorsal column
D. Right spinocerebellar right
E. Right spinothalamic tract

A 69-year-old lady is brought to hospital by an ambulance crew with a
suspected stroke. On review in the emergency department she is unable to
speak although she is able to follow instructions which have been written down.
She has no past medical history.
A blockage of which of the following cerebral arteries is most likely to be the
cause of this woman's symptoms?
A. Right anterior cerebral

B. Left anterior cerebral
C. Right middle cerebral
D. Left middle cerebral
E. Right posterior cerebral
A 69-year-old lady is brought to hospital by an ambulance crew with a
suspected stroke. On review in the emergency department she is unable to
speak although she is able to follow instructions which have been written down.
She has no past medical history.
A blockage of which of the following cerebral arteries is most likely to be the
cause of this woman's symptoms?
A. Right anterior cerebral

B. Left anterior cerebral
C. Right middle cerebral
D. Left middle cerebral
E. Right posterior cerebral
A 62-year old gentleman reports to his GP with his granddaughter following a recent TIA. The
patient was discharged from hospital and booked a review appointment with his GP. The
patients granddaughter (who is currently in her second year of medical school) asks the GP if
they could explain some of the signs their father had during the TIA.
The GP read the patients hospital notes and finds the following:
* Sudden onset R sided weakness, loss of pain and temperature sensation.
* L sided facial drooping.
Select the best explanation the GP could give.

A. Damage to contralateral spinothalamic tract and ipsilateral CN VII UMN lesion
B. Damage to ipsilateral spinothalamic tract and contralateral CN VII LMN lesion
C. Damage to contralateral spinothalamic tract and contralateral CN VII UMN lesion
D. Damage to ipsilateral spinothalamic tract and ipsilateral CN VII LMN lesion

A 62-year old gentleman reports to his GP with his granddaughter following a recent TIA. The
patient was discharged from hospital and booked a review appointment with his GP. The
patients granddaughter (who is currently in her second year of medical school) asks the GP if
they could explain some of the signs their father had during the TIA.
The GP read the patients hospital notes and finds the following:
* Sudden onset R sided weakness, loss of pain and temperature sensation.
* L sided facial drooping.
Select the best explanation the GP could give.

A. Damage to contralateral spinothalamic tract and ipsilateral CN VII UMN lesion
B. Damage to ipsilateral spinothalamic tract and contralateral CN VII LMN lesion
C. Damage to contralateral spinothalamic tract and contralateral CN VII UMN lesion
D. Damage to ipsilateral spinothalamic tract and ipsilateral CN VII LMN lesion

Cranial nerve 7
• Bell’s palsy
• Lower motor neurone lesion
• Cuts lower motor supply AND upper motor
• Innervation lost to upper and lower face
• NO forehead sparing
• Stroke
• Upper motor neurone lesion
• Cuts upper motor supply BUT spares lower motor
• Innervation only lost to lower face
• THERE IS forehead sparing

THANK YOU AND GOOD LUCK!
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Neuro Year 3 MedEd Rehaan Khokar 2

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Neuro Year 3 MedEd Rehaan Khokar 2

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Year 3 EOCP Block 4: Neurology

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• Sadly there isn’t enough time to go through absolutely

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A. Lower motor neurone lesions present with a loss of tone

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Afferent sensory neurones Efferent motor neurones

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Which of the following is most likely to be true for Raja?

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Which of the following is most likely to be true for Raja?

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Brainstem and DANISH: dysdiadochokinesis, ataxia, Stroke, MS

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Vibration/Prop Affected Spared Spared bilaterally Spared bilaterally Affected bilaterally

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• ALL THREE of the above would be TACS.

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• Contralateral hemiparesis +/-

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• Ipsilateral facial pain and temperature

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What antibiotic would be the single best choice for Gladys in

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What antibiotic would be the single best choice for Gladys in

• Close-contact prophylaxis for people exposed to

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What organism is the most likely underlying cause of

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What organism is the most likely underlying cause of

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Bacterial Viral TB Fungal

60-80% of Low (< 1/2

Protein High (> 1 g/l) Normal/raised High (> 1 g/l) High

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• Increased risk of • Risk of puncturing • Increased risk of

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What is the most apt medication to administer?