NEUROLOGY QUICK REVISION for examination

Examination

1. NEUROLOGY QUICK REVISION

2. MYASTHENIA GRAVIS 2

3. All of the following are NM disorders except ? Eaton lambert syndrome Botulism Congenital Mysthenia Tetanus

4. Myasthenia gravis is caused by dysfunction of - a) Pineal gland b) Thymus gland c) Pituitary gland d) Parathyroid gland 4

5. Thymic abnomalities Thymic hyperplasia – 65% Thymoma – 10% 5

6. Q) Myasthenia gravis is associated with - a) Decreased acetylcholine at nerve endings b) Decreased myosin c) Absent troponin C d) Decreased myoneural junction transmission 6

7. HLA B 8 / HLA DR W3 Antibodies associated with thyroiditis/Grave's disease/ rheumatoid arthritis/ SLE .

8. All are clinical features of myasthenia gravis, except - a) Spontaneous remission b) Absent deep tendon reflexes c) Proximal muscle involvement d) Worsen by exertion 8

9. The muscles which are mainly affected are those innervated by motor nuclei of brainstem. - Occular - Masticatory , - Facial, - Deglutition and - Lingual muscles. 9

10. 10

11. 11

12. 12

13. A 50-year-old male presented with complaints of ptosis , difficulty in chewing and occasional difficulty in swallowing. There is no h/o diplopia or visual loss. On examination, there is asymmetric ptosis and mild restriction of exraocular muscle movement with finger abduction test 60 . Nerve conduction study shows decremental response in orbicularis only. ERG revealed a myopathic pattern. Anti AChR radioimmunoassay was negative. The most probable diagnosis would be - a) Ocular myasthenia gravis b) Generalized myasthenia gravis c) As the Anti- AChR radioimmunoassay is negative, you will consider an alternative diagnosis d) Chronic external Ophthalmoplegia 13

14. Occular myasthenia gravis is characterized by a triad of:- Ptosis Diplopia Orbicularis occuli weakness

15. In ocular MG Ab’s are anti MUSK ab’s Rx of choice is Prednisolone. 15

16. The most sensitive test for the diagnosis of myasthenia gravis is - a) Elevated serum ACH-receptor binding antibodies b) Repetitive nerve stimulation test c) Positive edrophonium test d) Measurement of jitter by single fibre electromyography 16

17. 17

18. 18

19. Ice pack test is due for - a) Myesthenia gravis b) Multiple system atrophy c) Hyperparathyroidism d) Hypokalemic periodic paralysis 19

20. Drug of choice for myasthenia gravis – a) Gallamine b) Succinylocholine c) D. tubocurare d) Pyridostigmine. 20

21. The treatment of this disease involves the careful use of two groups of drugs:- A) Anticholinesterases :- Physostigmine is the DOC for mild to moderate MG 21

22. B) Immunosuppressants :- Corticosteroids :- DOC for severe MG - Prednisolone 22

23. Myasthenic crisis is best managed with IVIG/ Plasmapheresis. Treatment of choice for ocular M. gravis is steroids 23

24. Role of thymectomy in patients with myasthenia gravis:- “Thymectomy is an appropriate procedure in practically all patients with uncomplicated myasthenia gravis between puberty and 55 years of age”. 24

25. Which one of the following is correct regarding Eaton-Lambert syndrome- a) It commonly affects the ocular muscle b) Neostigmine is the drug of choice for this syndrome c) Repeated electrical stimulation enhances muscle power in it d) It is commonly associated with adenocarcinoma of lung 25

26. Lambert Eaton Myaesthenic syndrome It is a paraneoplastic syndrome associated with cancer particularly small cell Ca of lung. It is a disorder of neuromuscular junction transmission ( Presynaptic ). 26

27. 27 Associated with Thymoma Oat cell Cancer of lung

28. Treatment:- The drug most effective in these patient is  3- 4 diaminopyrimidine . It blocks potassium channels in distal motor terminal thus prolonging depolarization and enhancing the release of Acetylcholine containing vesicles. 3, 4-DAP can be given alone or in combination with pyridostigmine . 28

29. BRAINSTEM SYNDROMES

30. Q) All of the following are true about Weber’s syndrome. A. Ipsilateral occulomotor nerve palsy B. Diplopia c. Contralateral hemiplagia D. Ipsilateral facial nerve palsy

31. Q) Benedikt's syndrome, all are true except : A. Contralateral tremor B. 3rd nerve palsy C. Involvement of the penetrating branch of the basilar artery D. Lesion at the level of the pons

32. Q) Millard Gubler syndrome includes the following except A. 5th nerve palsy B. 6th nerve palsy C. 7th nerve palsy D. Contralateral hemiparesis

33. A 65 year old diabetic woman develops weakness in the left side of face, right arm and right leg. She also has diplopia on left lateral gaze. What is the site of lesion? a. Right pons b. Left pons c. Right midbrain d. Left midbrain

34. Lateral medullary syndrome is caused by thrombosis of- a) Anterior inferior cerebral artery b) Posterior inferior cerebellar artery c) Vertebral artery d) Basilar artery 38

35. Q) Lateral medullary syndrome (Wallenberg syndrome) is characterized by all, Except – a) Giddiness b) Dysphagia c) Crossed hemianaesthesia d) Horner’s syndrome is rare 39

36. All are features of Wallenberg’s syndrome, except- a) Ipsilateral loss of pain and temperature b) Ipsilateral loss of taste sensation c) Ipsilateral loss of posterior column sensations d) Ipsilateral involvement of lower cranial nerves. 40

37. A middle aged patient presents with the worst headache of his life. What is the investigation of choice? a. NCCT b. CECT c. MRI d. Lumbar puncture

38. Subarachnoid haemorrhage M ost common cause of SAH :- Head trauma S econd most common cause of SAH :- Rupture of Berry Aneurysm CSF findings:- Xanthochromia CT cerebral Angiogram :- Localization of Berry Aneurysm

39. A middle aged patient presents with history of left sided weakness for 2 days. Currently the patient is extremely drowsy and underwent a NCCT brain. Which of the following is the best treatment for this patient? a. Aspirin/Clopidogrel b. Mechanical Thrombectomy c. Mannitol d. Decompressive surgery

40. • Endovascular Mechanical Thrombectomy is done for: Contraindications to lschemic Stroke 2. Failure to achieve vascular recanalization with iv thrombolysis

41. What is the window period of thrombolysis in a stroke patient? a. 1.5 hours b. 2.5 hours c. 3.5 hours d. 4.5 hours

42. Which of the following complications of stroke need not be treated? a. Fever b. Spasticity c. Neglect d. Dysphagia

43. • Hemi-neglect or spatial agnosia implies blockage of inferior division of MCA and is seen more common in nondominant parietal lobe lesion. Most patients will not be able to copy left side of the image. See the pie

44. Aphasia

45. Which of the following is not a feature of right middle cerebral artery territory infarct - a) Aphasia b) Hemiparesis c) Facial weakeness d) Dysarthria 54

46. Broca’s aphasia is - a) Fluent aphasia b) Non fluent aphasia c) Sensory aphasia d) Conduction aphasia 55

47. Brocas area :- Wernickes area:-

48. Wernicke’s aphasia  Empty meaningless and full of nonsensical paraphasic errors. Normal fluency Broca’s aphasia  Decreased Fluency and spared comprehension, Naming difficulties. Impaired repetition 57

49. Conduction Aphasia:- Arcuate fibers are bundle of nerve fibres that connect Brocas area to the Wernicke’s area. Damage to the arcuate fasciculus causes a disorder called conduction aphasia. Conduction Aphasia is a ‘Fluent’ Aphasia with preserved comprehension and impaired repetition. 58

50. Aphasia which affects the arcuate fibres is called- a) Global aphasia b) Anomic aphasia c) Conduction aphasia d) Broca’s aphasia 59

51. Fluent Aphasia with preserved comprehension and impaired repetition is – a) Broca’s b) Wernicke’s c) Anomic d) Conduction 60

52. Fluent Aphasia with preserved comprehension and impaired repetition is – a) Broca’s b) Wernicke’s c) Anomic d) Conduction 61

53. Brown Sequard syndrome

54. The following are components of Brown sequard syndrome except - a) Ipsilateral extensor plantar response b) Ipsilateral pyramidal tract involvement c) Contralateral spinothalamic tract involvement d) Contralateral posterior column involvement 63

55. Brown sequard syndrome Hemisection of the spinal cord. At the level of lesion the motor manifestations will LMN paralysis and Below the level of lesion it is UMN paralysis

56. Type of sensation lost on same side, in Brown sequard syndrome is - a) Pain b) Touch c) Proprioception d) Temperature 65

57. 66

58. 67

59. 68

60. A ventrolateral cordotomy is performed to produce relief of pain from the right leg. It is effective because it interrupts the - a) Left Dorsal Column b) Left Lateral Spinothalamic Tract c) Right Lateral Spinothalamic Tract d) Right corticospinal Tract 69

61. Conus medullaris & Cauda equina

62. 71

63. 73

64. DISORDERS OF CRANIAL NERVES 74

65. A patient presents with recurrent episodes of sharp pain over his right cheek that is precipitated on chewing. Between attacks patients is otherwise normal. The most probable diagnosis is- a) Preherpetic neuralgia b) Trigeminal neuralgia c) Mumps d) Thalamic syndrome 75

66. Clinical features:- Paroxysmal, intense, sharp, superficial, or stabbing pain in the distribution . Facial muscle spasms 76

67. Tic douloureux”. Lasts for one to several seconds . 77

68. TN is typically unilateral. Occasionally - B ilateral, though rarely on both sides simultaneously. Distribution of pain - V2 > V3 subdivisions of the trigeminal nerve. 78

69. Autonomic symptoms - V 1 trigeminal distribution, including lacrimation, conjunctival injection, and rhinorrhea . 79

70. Triggers of Trigeminal neuralgia:- Lightly touching these zones Other triggers - chewing, talking, brushing teeth, cold air, smiling, and/or grimacing . 80

71. Drug of choice for Trigeminal Neuralgia is - a) Chlorpromazine b) Carbamezapine c) Gabapentin d) Fluoxetine 81

72. FACIAL NERVE

73. Causes of facial palsy are - a) Bell’s palsy b) Herpes infection c) Ramsay Hunt syndrome d) Acoustic neuroma 83

74. B R A S H

75. Causes of Facial narve palsy:- Bell’s palsy (idiopathic) Herpes infection Ramsay Hunt Syndrome (Herpes zoster of geniculate ganglia) Rosenthal Melkerson syndrome . Sarcoidosis Acoustic neuroma causes VIIth Nerve palsy and involve facial Nerve by local compression. 85

76. TRUE regarding upper motor neuron Vllth nerve paralysis is - a) Ipsilateral upper face paresis b) Ipisilateral lower face paresis c) Contralateral upper face paresis d) Contralateral lower face paresis 86

77. 87

78. 88

79. Q ) LMN type Facial palsies - a) Cornea should be protected b) Bilateral paralysis is seen in Melkerson syndrome c) Unilateral paralysis is seen in Mobius syndrome d) Prognosis affected before repeated electric stimulation 89

80. Moebius syndrome  is a rare neurological condition that primarily affects the muscles that control facial expression and eye movement. The signs and symptoms of this condition are present from birth Weakness or paralysis of the facial muscles is one of the most common features of  Moebius syndrome . Moebius syndrome  is  caused  by the absence or underdevelopment of the 6th and 7th cranial nerves , which control eye movement and facial expression.

81. A

82. 92

83. Differential diagnosis of Headache

84. Most common cause of headache a) Tension headache b) Migraine c) Cluster headache d) Trigeminal neuralgia 94

85. 95

86. Most common type of headache is  Most common type of 2° headache  MCC of head ache in Females  MCC of head ache in Males  MCC of frontal HA  96

87. Most common type of headache is tension headache. Most common type of 2° headache is due to infection. MCC of head ache in Females  Tension HA >Migraine MCC of head ache in Males  Tension HA >Migraine> Cluster HA MCC of frontal HA  Tension HA 97

88. For diagnosis of migraine POUND Mnemonic is used: P – 0- U - N - D - 98

89. For diagnosis of migraine POUND Mnemonic is used: P - Pulsating headache 0- One day duration (4-72 hours) U - Unilateral N - Nausea D - Disabling in character, throbbing type If 4 out of 5 criteria are present & 5 attacks per year diagnosed to have migraine. 99

90. Status migraniosus

91. Status migraniosus If duration is >72hrs  Status migraniosus

92. Migraine is predominantly of two types 102

93. Migraine is predominantly of two types Migraine with aura (classical migraine) Migraine without aura (common migraine) Migraine without aura is more common The ratio of classic to common migraine is 1: 5 103

94. 104

95. 105

96. For Status Migraniosus :- 106

97. For Status Migraniosus :- DOC is prochlorperazine 107

98. 108

99. A 45-year old man presents with a daily headache. He describes two attacks per day over the past 3 weeks. Each attack lasts about an hour and awakens the patient from sleep. The patient has noted associated tearing and reddening of his right eye as well as nasal stuffiness. The pain is deep, excruciating, and limited to the right side of the head. The neurologic examination is nonfocal . The most likely diagnosis of this patient’s headache is- a) Migraine headache b) Cluster headache c) Tension headache d) Brain tumour 109

100. Characteristics of pain :- Attack duration: One more characteristic feature of cluster headache is: - 110

101. Characterized by characteristics unilateral periorbital localization i.e., the pain is felt in and around the eyes. As a rule the pain is very intense and nonthrobbing & explosive in quality. Attack duration: < 3 hours One more characteristic feature of cluster headache is: - Nightly recurrence between and 2hr after the onset of sleep, or several times during the night. 111

102. Treatment Acute cluster headache:- 112

103. Treatment Acute cluster headache:- High flow oxygen at 12 L/min (First Line Treatment) Sumatriptan injection Gabapentin/pregabalin Prophylaxis Verapamil Greater occipital nerve block. 113

104. A woman has bilateral headache that worsens with emotional stress: she has two children, both doing badly in school diagnosis is a) Migraine b) Cluster headache c) Tension headache d) Trigeminal neuralgia 114

105. Tension headache 115

106. Primary parkinsonism

107. Primary parkinsonism Paralysis agitans or Parkinson's disease or idiopathic parkinsonism

108. Secondary (symptomatic) Post-encephalitic Toxins Drugs Ischaemic Tumours Punch-drunk syndrome lnfections

109. Secondary (symptomatic) Post-encephalitic (post-encephalitis lethargica) Toxins-e.g. MPTP (methyl-phenyl-tetrahydropyridine), manganese, carbon monoxide Drugs-e.g. reserpine, phenothiazines, butyrophenones (including haloperidol), a-methyldopa, metoclopramide Ischaemic (vascular parkinsonism) Tumours in basal ganglion Punch-drunk syndrome in boxers lnfections -e.g. HIV, influenza

110. Earliest feature of parkinsonism ? a) Resting tremors b) Brady or hypokinesia c) Rigidity d) Loss of postural reflexes 120

111. A RAT

112. 122 (Anosmia & constipation precedes development of motor symptoms by 4 years Resting tremors are earliest motor symptoms.

113. 123

114. 125

115. MENINGITIS

116. DEFINITION Bacterial meningitis is an acute purulent infection within the ? Subarachnoid space Subdural space Extradural space All the above 127

117. A

118. Q) The organisms most often responsible for community acquired bacterial meningitis are? Streptococcus pneumoniae Neisseria meningitidis Group B streptococci Listeria monocytogenes 129

119. A

120. Which organism causes post meningitis deafness? L isteria Monocytogenes Pneumococcus H emophilus Influenzae Staphylococci

121. C

122. c/f Triad: 133

123. c/f Triad: Fever, H.ache , Nuchal rigidity Decr . Consciousness, N.V, Photophobia Papilledema, Dilated pupil(Compression of 3 rd N.) Sixth N palsy(false localizing sign) – Due to long course Decorticate posturing as the severity progress 134

124. 136

125. What is the correct sequence to be followed in suspected bacterial meningitis? a. Draw blood culture sample, empirical antibiotics, neuroimaging followed by LP b. Empirical antibiotics, neuroimaging, blood culture sample followed by LP c. LP, Empirical antibiotics and CSF culture d. Empirical antibiotics, mannitol, LP followed by neuroimaging

126. Ans. (a) Draw blood culture sample, empirical antibiotics, neuroimaging followed by LP

127. What is the site for Lumbar puncture? L1 – L2 L2 – L3 L3 – L4 L4 – L5

128. C

129. Work up Needle - Quincke needle & Sprottes needle 141

130. Maximum CSF removed is ? Rate of production is ? Total amnt of CSF is ? 142

131. Ptns will have post L.P head ache  Advised ? Characteristic feature? Rx – ?

132. Maximum CSF removed is 20-30 ml Rate of production is 20ml/hr Total amnt of CSF is 150ml. Ptns will have post L.P head ache  Advised bed rest(6-8hrs) If Head ache is incr. on straining it is post L.P HA. Rx – IV caffeine(DOC), codein  If it persists then u have to inject low volume blood patch to seal the rent 144

133. CSF NORMAL ACUTE BM TBM VIRAL MENINGITIS GBS FUNGAL MENINGITIS PRESSURE COLOUR CELLS GLUCOSE PROTEINS

134. CSF collected in a Test tube. Diagnosis? 147

135. Hypoglycorachia – Low glc . In CSF Zero in Ac.Bacterial meningitis Cob web coagulum(proteins) seen in TBM 148

136. A Patient with TBM, Idetify the lesion ? 149

137. Rich focus - is a tuberculous granuloma occurring within the  cortex or meninges of the brain that ruptures into the subarachnoid space , causing tuberculous meningitis. 150

138. Rich focus

139. Rich focus The Rich focus is named for  Arnold Rice Rich, a pathologist at Johns Hopkins Hospital , who along with his colleague Howard McCordock  first described the post-mortem finding of caseous foci within the cerebral cortex or meninges which appeared to predate the development of meningitis.

140. MOTOR NEURON DISEASE

141. Which is pathognomic for motor neuron disease - a) Fasciculation b) Bladder, bowel involvement c) Pseudohypertrophy d) Sensory loss in patchy manner 154

142. Introduction

143. Introduction Motor neuron disease in adults generally commences between 30 and 60 years of age. There is degeneration of the anterior horn cells in the spinal cord, the motor nuclei of the lower cranial nerves, and the corticospinal and corticobulbar pathways.

144. Risk factor:-

145. Risk factor:- Cigarette smoking may be one risk factor.

146. 159 Amyotrophic lateral sclerosis is most common type of motor neuron disease.

147. MCC of death in MND is respiratory failure. 160

148. Riluzole

149. Riluzole Riluzole , 50 mg orally twice daily, which reduces the presynaptic release of glutamate, increased short-term survival in ALS in randomized trials. The only drug that has a modest effect on survival is riluzole , a sodium-channel blocker that inhibits glutamate release.

150. Edaravone

151. Edaravone Edaravone , a free radical scavenger, slows disease progression in patients with mild disease. It is administered in monthly cycles as a 60 mg intravenous infusion on days 1-14 in the first month and days 1-10 in the subsequent months.

152. MULTIPLE SCLEROSIS

153. Drug that causes maximum reduction in appearance of new lesions and change in disease severity in relapsing remitting multiple sclerosis is: a. Natalizumab b. Glatiramer c. Interferon beta la d. Interferon beta lb

154. Ans. (a) Natalizumab

155. Introduction

156. Etiology :- 169 HLA ?

157. Etiology 1 . Genetic 2. Polygenetic: The HLA-DR2 gene has been demonstrated to be a genetically susceptible area. 30% concordance for monozygotic twins 3. Environmental MS is more common in region with less sun exposure and thus, lower stores of vitamin D 4. MS has also been linked to certain viruses, particularly with EBV. 170

158. Which is the MC Clinical Patterns of MS ? 1. Relapsing remitting (RRMS 2. Primary progressive (PPMS) 3. Progressive relapsing (PRMS) 4. Secondary progressive (SPMS) 171

159. 1

160. Clinical Patterns of MS 173

161. 174 RRMS. There maybe residual deficit from an attack, but the baseline between attacks remains stable until the next attack. (B) PPMS. There are no acute attacks, but a gradual worsening over time.

162. 175 (C) SPMS. After an initial course of RRMS the baseline deficit gradually worsens, with or without intervening acute attacks. (D) PRMS. Starts as primary progressive MS, but has subsequent acute attacks at some point after onset.

163. Unthoff ' s phenomenon seen in MS is due to? A. Increased conduction of nerves B. Decreased conduction of nerves C. Destruction of nerves D. Recovery of nerves

164. B

165. Lhermittes sign/ Barber chair syndrome Etiology :-

166. Lhermittes sign/Barber chair syndrome Etiology of Lhermitte sign: • Demyelination • Head and neck radiotherapy • Subacute combined degeneration of cord due to vitamin B12 deficiency • Traumatic or compressive cervical myelopathy • Epidural or subdural intraparencymal tumors • Radiation myelitis • Pyridoxine toxicity • Inflammation SLE, Behcet disease herpes zoster myelitis • Cavernous Angioma of cervical cord

167. Name of the criteria

168. MS Variants Devic's disease neuromyelitis optica (NMO): 184

169. MS Variants Devic's disease neuromyelitis optica (NMO): Severe optic neuritis and extensive transverse myelitis extending >3 vertebral segments Clinically isolated syndrome (CIS) : single MS-like episode 185

170. A 30-year old female presents with complaints of gradual onset weakness of legs for one month with reduction in visual acuity and urinary incontinence for past few days. Contrast MRI shows periventricular lesions. Which of the following drugs is not used in these patients? a. Fingolimod b. Beta interferon c. Glatiramer acetate d. Mitotane

171. Ans. (d) Mitotane

172. Treatment 188

173. Treatment Acute treatment: Methylprednisolone 500- 1000 mg IV daily X 3-7 days ± taper for optic neuritis 189

174. Disease modifying therapy (DMT) : 190

175. Disease modifying therapy (DMT) : 3. Glatiramer acetate 4. Natalizumab 5. Fingolimod 6. Mitoxantrone 7. Dimethyl fumarate 8. Teriflunomide and 9. Alemtuzumab. 191

176. 192

177. 193

178. Medically refractory Epilepsy 194

179. Medically refractory Epilepsy Ketotic diet Vagal nerve stimulation Deep brain stimulation Best results are seen with surgery 195

180. Adverse effects of valproic acid

181. 197