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A 76-year-old man is admitted with a right hemiparesis. CT scan shows an ischaemic stroke and aspirin 300mg is

commenced. In terms of further management in the acute phase, which one of the following values should not be

corrected?ia

A.ABP 210/110ia

B.A Blood glucose 9.4 mmol/lia

C.A Oxygen saturation 94%ia

D.A Temp 38.3Cia

E.A Blood glucose 2.5 mmol/lia

Next question

Hypertension should not be treated in the initial period following a stroke

Elevated blood pressure should not be treated in the acute phase following a stroke unless complications develop.

Other physiological parameters should be kept within normal limits - an aggressive approach with respect to this has

been shown to improve outcome

Stroke: managementsqweqwesf erwrewfsdfs adasd dhe

The Royal College of Physicians published guidelines on the diagnosis and management of patients following a

stroke in 2004

he earaer aeraer asdsadas eerw dssdfsselleds

Selected points relating to the management of transient ischaemic attacks (TIA) include:

if a diagnosis of TIA is likely patients should be prescribed aspirin 300mg daily or an alternativeantiplatelet immediatelyhe

if there has been more than one TIA in a week then patients should be investigated in hospitalimmediatelyhe


Selected points relating to the management of acute stroke include:

blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limitshe blood pressure should not be lowered in the acute phase unless there are complications e.g. hypertensive

encephalopathyhe

aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has beenexcludedhe

anticoagulation should not be started until an haemorrhagic stroke has been excluded and usually not until14 days have passed since the strokehe

if the cholesterol is > 3.5 mmol/l patients should be commence on a statinheA 29-year-old man presents to his GP complaining of visual disturbance. Examination reveals a right superior

homonymous quadrantanopia. Where is the lesion most likely to be?ia
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A.A Optic chiasmia

B.ALeft temporal lobeia

C.A Right temporal lobeia

D.A Left optic nerveia

E.A Left parietal lobeia

Next question

Visual field defects:

left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tract homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior) incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortex

Visual field defectssqweqwesf erwrewfsdfs adasd dhe

Greater detail is required in the MRCP when assessing visual field defects - quadrantanopias are described as are

incongruous and congruous defects


The main points for the exam are:

left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tracthe homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)he incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortexhe


Homonymous hemianopia

incongruous defects: lesion of optic tracthe congruous defects: lesion of optic radiation or occipital cortexhe macula sparing: lesion of occipital cortexhe


Homonymous quadrantanopias

superior: lesion of temporal lobehe inferior: lesion of parietal lobehe mnemonic = PITS (Parietal-Inferior, Temporal-Superior)he


Bitemporal hemianopia

lesion of optic chiasmhe upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary

tumourhe

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lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly acraniopharyngiomahe

For patients with Parkinson's disease, which one of the following drugs is most useful in the management of

tremor?ia

A.A Apomorphineia

B.A Cabergolineia

C.A Selegilineia

D.A Amantadineia

E.A Benzhexolia

Next question

Parkinson's disease: managementsqweqwesf erwrewfsdfs adasd dhe

Currently accepted practice in the management of patients is to delay treatment until the onset of disabling

symptoms and then to introduce a dopamine receptor agonist. If patient is elderly, levodopa is sometimes used as an

initial treatment


Dopamine receptor agonists

bromocriptine, apomorphinehe newer agents: ropinirole, cabergoline, pergolidehe


Levodopa

usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheralmetabolism of levodopa to dopaminehe

reduced effectiveness with time (usually by 2 years)he unwanted effects: dyskinesia, 'on-off' effect he no use in neuroleptic induced parkinsonismhe


Selegiline

MAO-B inhibitorhe

reduces dopamine metabolismhe


Antimuscarinics

useful for tremorhe reduces inhibition of excitatory cholingeric neuronshe e.g. procyclidine, benzotropine, benzhexolhe

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Amantadine

prevents reuptake of dopamineheA 27-year-old man presents to A&E with 2 day history of severe headache and pyrexia (38.9C). A CT scan shows

petechial haemorrhages in the temporal and inferior frontal lobes. What is the most likely diagnosis?ia

A.A Brain abscessia

B.A Meningococcal meningitisia

C.A Cerebral malariaia

D.AHerpes simplex encephalitisia

E.A New variant CJDia

Next question

CT head showing temporal lobe changes - think herpes simplex encephalitis

Herpes simplex encephalitissqweqwesf erwrewfsdfs adasd dhe

Herpes simplex (HSV) encephalitis is a common topic in the MRCP. The virus characteristically affects the

temporal lobes - questions may give the result of imaging or describe temporal lobe signs e.g. aphasia


Features

fever, headache, psychiatric symptoms, seizures, vomitinghe focal features e.g. aphasiahe peripheral lesions (e.g. cold sores) have no relation to presence of HSV encephalitishe


Pathophysiology

HSV-1 responsible for 95% of cases in adultshe typically affects temporal and inferior frontal lobeshe


Investigation

CSF: lymphocytosis, elevated proteinhe PCR for HSVhe CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of

patientshe

MRI is betterhe EEG pattern: lateralised periodic discharges at 2 Hzhe

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Treatment

aciclovirhehe earaer aeraer asdsadas eerw dssdfsselleds

Prognosis

treated 25%he untreated 80%he A 27-year-old woman presents to A&E with a one-day history of headache and feeling generally unwell.

She is pyrexial at 38.7C and there is no rash.


Serum glucose 5.1 mmol/l

he earaer aeraer asdsadas eerw dssdfsselledsLumbar puncture reveals:


Appearance Cloudy

Glucose 1.9 mmol/l

Protein 1.7 g/l

White cells 250 / mm (85% polymorphs)

he earaer aeraer asdsadas eerw dssdfsselledsWhat is the most likely diagnosis?ia

A.A Guillain-Barre syndromeia

B.A Viral meningitisia

C.ABacterial meningitisia

D.A Cerebral malariaia

E.A Tuberculous meningitisia

Next question

Meningitis: CSF analysissqweqwesf erwrewfsdfs adasd dhe

The table below summarises the characteristic CSF findings in meningitis:


Bacterial Viral Tuberculous

Appearance Cloudy Clear/cloudy Fibrin web

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Glucose Low (< 1/2 plasma) Normal Low (< 1/2 plasma)

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

White cells 10 - 5,000

polymorphs/mm

15 - 1,000

lymphocytes/mm

10 - 1,000

lymphocytes/mm

he earaer aeraer asdsadas eerw dssdfsselledsThe Ziehl-Neelsen stain is only 20% sensitive in the detection of tuberculous meningitis and therefore PCR

is sometimes used (sensitivity = 75%)


*mumps is unusual in being associated with a low glucose level in a proportion of cases

A 33-year-old man presents to his GP complaining of visual disturbance. Examination reveals a bitemporal

hemianopia with predominately the upper quadrants being affected. What is the most likely lesion?ia

A.A Craniopharyngiomaia

B.A Brainstem lesionia

C.APituitary macroadenomaia

D.A Frontal lobe lesionia

E.A Right occipital lesionia

Next question


lesion of optic chiasm upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary

tumour

lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly acraniopharyngioma

An upper quadrant defect implies inferior chiasmal compression making a pituitary macroadenoma the most likely

diagnosis

Visual field defectssqweqwesf erwrewfsdfs adasd dhe

Greater detail is required in the MRCP when assessing visual field defects - quadrantanopias are described as are

incongruous and congruous defects


The main points for the exam are:

left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tracthe

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homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)he incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortexhe


Homonymous hemianopia

incongruous defects: lesion of optic tracthe congruous defects: lesion of optic radiation or occipital cortexhe macula sparing: lesion of occipital cortexhe


Homonymous quadrantanopias

superior: lesion of temporal lobehe inferior: lesion of parietal lobehe mnemonic = PITS (Parietal-Inferior, Temporal-Superior)he



lesion of optic chiasmhe upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary

tumourhe

lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly acraniopharyngiomahe

What is the most common type of multiple sclerosis?ia

A.ARelapsing-remitting diseaseia

B.A Amyotrophic lateral sclerosisia

C.A Secondary progressive diseaseia

D.A Progressive-relapsing diseaseia

E.A Primary progressive diseaseia

Next question

Multiple sclerosis

sqweqwesf erwrewfsdfs adasd dhe

Multiple sclerosis is chronic disorder characterised by demyelination in the central nervous system.he earaer aeraer asdsadas eerw dssdfsselleds

Genetics

monozygotic twin concordance = 30%he dizygotic twin concordance = 2%he


A variety of subtypes have been identified:

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Relapsing-remitting disease

most common form, 70-80% of patients initiallyhe acute attacks (e.g. last 1-2 months) followed by periods of remissionhe

he earaer aeraer asdsadas eerw dssdfsselledsSecondary progressive disease

describes relapsing-remitting patients who have deteriorated and have developed neurological signs andsymptoms between relapseshe


Primary progressive disease

accounts for 10% of patientshe progressive deterioration from onsethe more common in older peoplehe


Progressive-relapsing disease

primary progressive patients with superimposed relapseheA 21-year-old female is seen in the first seizure clinic in the outpatient department. A decision is made not to start

her on anti-epileptic medication. What restrictions on driving should she be informed about?ia

A.ANo restrictions but inform DVLAia

B.A No restrictions, no need to inform DVLA if not on medicationia

C.A Cannot drive for 1 month from date of seizureia

D.A Cannot drive for 6 months from date of seizureia

E.A Cannot drive for 1 year from date of seizureia

Next question

Patients cannot drive for 1 year following a seizure

DVLA: neurological disorderssqweqwesf erwrewfsdfs adasd dhe

The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating

to drivers of heavy goods vehicles tend to be much stricter


Specific rules

first seizure - 1 year off drivinghe

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stroke - 1 month off drivinghe multiple TIAs over short period of times - 3 months off drivinghe craniotomy - 1 year off driving* he narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'he


*if the tumour is a benign meningioma and there is no seizure history, licence can be reconsidered 6 months aftersurgery if remains seizure free

A 65-year-old man is referred to the neurology outpatient clinic due to a resting tremor of his right hand. A

diagnosis of Parkinson's disease is made. He is otherwise well and is not currently disabled by his symptoms. What

is the most appropriate treatment?ia

A.A Selegilineia

B.ANo treatmentia

C.A New generation dopamine receptor agonist e.g. ropiniroleia

D.A Conventional dopamine receptor agonist e.g. bromocriptineia

E.A Antimuscarinicsia

Next question




initial treatmenthe earaer aeraer asdsadas eerw dssdfsselleds




Levodopa




Selegiline

MAO-B inhibitorhe reduces dopamine metabolismhe

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Antimuscarinics



Amantadine

prevents reuptake of dopamineheEach one of the following is associated with normal pressure hydrocephalus, except:ia

A.APapilloedemaia

B.A Dementiaia

C.AUrinary incontinenceia

D.A Gait abnormalityia

E.A Enlarged fourth ventricleia

Next question

Urinary incontinence + gait abnormality + dementia = normal pressure hydrocephalus

Normal pressure hydrocephalussqweqwesf erwrewfsdfs adasd dhe

Normal pressure hydrocephalus is a reversible cause of dementia seen in elderly patients. It is thought to be

secondary to reduced CSF absorption at the arachnoid villi. These changes may be secondary to head injury,

subarachnoid haemorrhage or meningitis


A classical triad of features is seen

urinary incontinencehe dementiahe gait abnormality (may be similar to Parkinson's disease)he


Imaging

hydrocephalus with an enlarged fourth ventriclehehe earaer aeraer asdsadas eerw dssdfsselleds

Management

ventriculoperitoneal shuntinghe

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A 47-year-old man with a known history of schizophrenia is admitted to A&E due to confusion. A bottle of

procyclidine tablets are found in his pocket. On examination the temperature is 38.1C with a blood pressure of

155/100 mmHg. Neurological examination reveals a GCS of 13/15 but assessment of his peripheral nervous system

is difficult due to generalised increased muscle tone. What is the most likely diagnosis?ia

A.ANeuroleptic malignant syndromeia

B.A Procyclidine overdoseia

C.A Catatonic schizophreniaia

D.A Clozapine induced agranulocytosisia

E.A Quetiapine induced rhabdomyolysisia

Next question

Neuroleptic malignant syndromesqweqwesf erwrewfsdfs adasd dhe

Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking antipsychotic medication.

It carries a mortality of up to 10% and can also occur with atypical antipsychotics


Features

more common in young male patientshe onset usually in first 10 days of treatment or after increasing dosehe pyrexiahe rigidityhe tachycardiahe

he earaer aeraer asdsadas eerw dssdfsselledsA raised creatine kinase is present in most cases. A leukocytosis may also be seen


Management

stop antipsychotiche IV fluids to prevent renal failurehe dantrolene may be useful in selected caseshe bromocriptine, dopamine agonist, may also be usedhe

In the treatment of migraine, sumatriptan is an example of a: ia

A.A Beta-blockeria

B.A Alpha-blocker and a partial 5-HT2 agonistia

C.ASpecific 5-HT1 agonistia

D.A 5-HT2 antagonistia

E.A Tricyclic antidepressantia

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Next question

Migraine

acute: 5-HT1 agonist prophylaxis: 5-HT2 antagonist

Migraine: drugssqweqwesf erwrewfsdfs adasd dhe

It should be noted that 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor

antagonists are used in prophylaxis


Acute treatmenthe earaer aeraer asdsadas eerw dssdfsselleds

Standard analgesia

may be poorly absorbedhe often combined with anti-emetic e.g. metoclopramide to relieve associated nauseahe


Sumatriptan

specific 5-HT1 agonist - opposes vasodilationhe very effectivehe


Ergotamine

alpha-blocker and a partial 5-HT1 agonisthe often induces nausea and vomitinghe



Prophylaxishe earaer aeraer asdsadas eerw dssdfsselleds

Prophylaxis should be given if patients are experiencing two or more attacks per month. Modern treatment is effect

about 60% of patients


5-HT2 antagonists

e.g. pizotifen, methysergidehehe earaer aeraer asdsadas eerw dssdfsselleds

Beta-blockers

e.g. propranololhehe earaer aeraer asdsadas eerw dssdfsselleds

Tricyclic antidepressants

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e.g. amitriptylineheIn patients with Guillain-Barre syndrome, respiratory function should be monitored with:ia

A.A Oxygen saturationsia

B.A PEFRia

C.AFlow volume loopia

D.A Arterial blood gasesia

E.A FVCia

Next question

FVC is used to monitor respiratory function in Guillain-Barre syndrome

Guillain-Barre syndrome: managementsqweqwesf erwrewfsdfs adasd dhe

Guillain-Barre syndrome describes an immune mediated demyelination of the peripheral nervous system often

triggered by an infection (classically Campylobacter jejuni)


Management

plasma exchangehe IV immunoglobulinshe steroids and immunosuppressants have not been shown to be beneficialhe

FVC regularly to monitor respiratory functionhe


Prognosis

20% suffer permanent disability, 5% dieheWhich one of the following is most characteristically associated with a very high protein level in the cerebrospinal

fluid?ia

A.A Myasthenia gravisia

B.A Multiple sclerosisia

C.A New variant CJDia

D.A Motor neuron diseaseia

E.A Guillain-Barre syndromeia

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Next question

Cerebrospinal fluid: raised proteinsqweqwesf erwrewfsdfs adasd dhe

Normal values of cerebrospinal fluid (CSF) are as follows:

pressure = 60-150 mm (patient recumbent)he protein = 0.2-0.4 g/lhe glucose = > 2/3 blood glucosehe cells: red cells = 0, white cells < 5/mmhe


The following conditions are associated with raised protein levels

Guillain-Barre syndromehe TB/fungal/bacterial meningitishe spinal block (Froin's syndrome)he viral encephalitishe

What is the first line medication in the treatment of adults with generalised seizures?ia

A.A Gabapentinia

B.A Lamotrigineia

C.ASodium valproateia

D.A Carbamazepineia

E.A Phenytoinia

Next question

Epilepsy medication: first-line

generalised seizure: sodium valproate partial seizure: carbamazepine

Epilepsy: treatment

sqweqwesf erwrewfsdfs adasd dheMost neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting

antiepileptics after the first seizure if any of the following are present:

the patient has a neurological deficithe brain imaging shows a structural abnormalityhe the EEG shows unequivocal epileptic activity he the patient or their family or carers consider the risk of having a further seizure unacceptable he
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Sodium valproate is considered the first line treatment for patients with generalised seizures with carbmazepine used

for partial seizures


Tonic-clonic seizures

sodium valproatehe second line: lamotrigine, carbamazepinehe


Absence seizures (Petit mal)

sodium valproate or ethosuximidehe sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised

epilepsyhe


Myoclonic seizures

sodium valproatehe second line: clonazepam, lamotriginehe


Partial seizures

carbamazepinehe second line: sodium valproate, lamotriginehe

Which one of the following features is most associated with frontal lobe lesions?ia

A.A Wernicke's aphasiaia

B.A Gerstmann's syndromeia

C.APerserverationia

D.A Cortical blindnessia

E.A Superior homonymous quadrantanopiaia

Next question

Brain anatomysqweqwesf erwrewfsdfs adasd dhe

The following neurological disorders/features may allow localisation of a brain lesion:


Parietal lobe lesions

sensory inattentionhe apraxiashe astereognosis (tactile agnosia) he

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inferior homonymous quadrantanopiahe Gerstmann's syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left

disorientationhe


Occipital lobe lesions

homonymous hemianopiahe cortical blindnesshe visual agnosiahe


Temporal lobe lesion

Wernicke's aphasiahe superior homonymous quadrantanopiahe auditory agnosiahe

he earaer aeraer asdsadas eerw dssdfsselledsFrontal lobes lesions

expressive (Broca's) aphasiahe disinhibitionhe perserverationhe anosmiahe

Which of the following features is least likely to be found in a patient with tuberose sclerosis?ia

A.A Adenoma sebaceumia

B.A Caf?au-lait spotsia

C.A Retinal hamartomasia

D.A'Ash-leaf' spotsia

E.A Lisch nodulesia

Next question

Lisch nodules are seen in neurofibromatosis

Tuberous sclerosissqweqwesf erwrewfsdfs adasd dhe

Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. As is neurofibromatosis, the

majority of features seen are neuro-cutaneous


Cutaneous features

depigmented 'ash-leaf' spots which fluoresce under UV lighthe roughened patches of skin over lumbar spine (Shagreen patches)he

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adenoma sebaceum: butterfly distribution over nosehe fibromata beneath nails (subungual fibromata)he caf?au-lait spots* may be seenhe


Neurological features

developmental delayhe epilepsy (infantile spasms or partial)he intellectual impairmenthe


Also

retinal hamartomas: dense white areas on retina (phakomata)he rhabdomyomas of the hearthe gliomatous changes can occur in the brain lesionshe polycystic kidneys, renal angiomyolipomatahe


*these of course are more commonly associated with neurofibromatosis. However a 1998 study of 106 children with

TS found caf?au-lait spots in 28% of patients

An obese 24-year-old female presents with headache and blurred vision to her GP. Examination reveals bilateral

blurring of the optic discs but is otherwise unremarkable with no other neurological signs. Blood pressure is 130/74

and she is apyrexial. What is the most likely underlying diagnosis?ia

A.A Multiple sclerosisia

B.A Meningococcal meningitisia

C.A Brain abscessia

D.ANormal pressure hydrocephalusia

E.A Idiopathic intracranial hypertensionia

Next question

Obese, young female with headaches / blurred vision think idiopathic intracranial hypertension

The combination of a young, obese female with papilloedema but otherwise normal neurology makes idiopathic

intracranial hypertension the most likely diagnosis

Idiopathic intracranial hypertensionsqweqwesf erwrewfsdfs adasd dhe

Idiopathic intracranial hypertension (also known as pseudotumour cerebri and formerly benign intracranial

hypertension) is a condition classically seen in young, overweight females.


Features

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headachehe blurred visionhe papilloedema (usually present)he enlarged blind spothe sixth nerve palsy may be presenthe

he earaer aeraer asdsadas eerw dssdfsselledsRisk factors

obesityhe female sexhe pregnancyhe drugs: oral contraceptive pill, steroids, tetracycline, vitamin A he


Management

weight losshe diuretics e.g. acetazolamidehe repeated lumbar puncturehe

A 45-year-old man is noted to have a peripheral motor neuropathy on examination. He has a long history of

recurrent abdominal pain. What is the most likely diagnosis?ia

A.AAcute intermittent porphyriaia

B.A Myelomaia

C.A Huntingdon's diseaseia

D.A Lawrence-Moon-Biedl syndromeia

E.A Friedreich's ataxiaia

Next question

In the MRCP, neurological signs combined with abdominal pain is acute intermittent porphyria or lead poisoning

until proven otherwise

Acute intermittent porphyriasqweqwesf erwrewfsdfs adasd dhe

Acute intermittent porphyria (AIP) is a rare autosomal dominant condition caused by a defect in porphobilinogen

deaminase, an enzyme involved in the biosynthesis of haem. The results in the toxic accumulation of delta

aminolaevulinic acid and porphobilinogen. It characteristically presents with abdominal and neuropsychiatric

symptoms in 20-40 year olds. AIP is more common in females (5:1)


Features

abdominal: abdominal pain, vomitinghe neurological: motor neuropathyhe

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psychiatric: e.g. depressionhe hypertension and tachycardia commonhe


Diagnosis

classically urine turns deep red on standinghe raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks)he assay of red cells for porphobilinogen deaminasehe raised serum levels of delta aminolaevulinic acid and porphobilinogenhe

Which one of the following infections is most strongly associated with the development of Guillain-Barre

syndromeia

A.A Shigellaia

B.A Salmonellaia

C.A E. coli H7:0157ia

D.A Herpes simplexia

E.A Campylobacter jejuniia

Next question

Campylobacter jejuni is strongly associated with the development of Guillain-Barre syndrome

Guillain-Barre syndromesqweqwesf erwrewfsdfs adasd dhe

Guillain-Barre syndrome describes an immune mediated demyelination of the peripheral nervous system often

triggered by an infection (classically Campylobacter jejuni)


Pathogenesis

cross reaction of antibodies with gangliosides in the peripheral nervous systemhe correlation between anti-ganglioside antibody (e.g. anti-GM1) and clinical features has been

demonstratedhe

anti-GM1 antibodies in 25% of patientshehe earaer aeraer asdsadas eerw dssdfsselleds

Miller-Fisher syndrome

variant of Guillain-Barre syndromehe associated with areflexia, ataxia, ophthalmoplegiahe anti-GQ1b antibodies are present in 90% of caseshe

A patient is referred by her GP due to a third nerve palsy associated with a headache. On examination meningism is

present. Which one of the following diagnoses needs to be urgently excluded?ia

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A.A Weber's syndromeia

B.A Internal carotid artery aneurysmia

C.A Multiple sclerosisia

D.APosterior communicating artery aneurysmia

E.A Anterior communicating artery aneurysmia

Next question

Painful third nerve palsy = posterior communicating artery aneurysm

Given the combination of a headache and third nerve palsy it is important to exclude a posterior communicating

artery aneurysm

Third nerve palsysqweqwesf erwrewfsdfs adasd dhe

Features

eye is deviated 'down and out'he ptosishe pupil may be dilated (sometimes called a 'surgical' third nerve palsy)he


Causes

diabetes mellitushe vasculitis e.g. temporal arteritis, SLEhe false localizing sign due to uncal herniation through tentorium if raised ICPhe posterior communicating artery aneurysm (pupil dilated)he cavernous sinus thrombosishe Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain

strokeshe

other possible causes: amyloid, multiple sclerosisheA 34-year-old female presents with collapse and vomiting preceded by an occipital headache of acute onset. On

examination she was conscious and alert with photophobia but no neck stiffness. CT brain is reported as normal.

Which one of the following investigations would yield the diagnosis?ia

A.A CT brain with contrastia

B.A Repeat CT brain in 24hia

C.ACSF examinationia

D.A Cerebral angiographyia

E.A MRI brainia

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Next question

Subarachnoid haemorrhagesqweqwesf erwrewfsdfs adasd dhe

Causes

85% are due to rupture of berry aneurysms (conditions associated with berry aneurysms include adultpolycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta)he AV malformationshe traumahe tumourshe


Investigations

CT: negative in 5%he LP: done after 12 hrs (allowing time for xanthochromia to develop)he

he earaer aeraer asdsadas eerw dssdfsselledsComplications

rebleeding (in 30%)he obstructive hydrocephalus (due to blood in ventricles)he vasospasm leading to cerebral ischaemiahe


Management

neurosurgical opinion: no clear evidence over early surgical intervention against delayed interventionhe nimodipine (e.g. 60mg / 4 hrly, if BP allows) has been shown to reduce the severity of neurological deficits

but doesn't reduce rebleeding*he


*the way nimodipine works in subarachnoid haemorrhage is not fully understood. It has been previously postulated

that it reduces cerebral vasopasm (hence maintaining cerebral perfusion) but this has not been demonstrated in

studies

A 45-year-old man presents to A&E following the sudden onset of pain in his right eye whilst hammering a nail into

the wall. The pain is described as severe with occasional exacerbations. On examination he has a mild right ptosis

and small right pupil. What is the most likely diagnosis?ia

A.A Trigeminal neuralgiaia

B.A Glaucomaia

C.ACarotid artery dissectionia

D.A Cluster headacheia

E.A Migraineia

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Next question

This patient has Horner's syndrome caused by a carotid artery dissection. This may be caused by relatively benign

trauma to the neck such as hyperextension whilst doing DIY

Horner's syndrome

sqweqwesf erwrewfsdfs adasd dheFeatures

miosis (small pupil)he ptosishe enophthalmos (sunken eye) he anhydrosis (loss of sweating one side)he


Distinguishing between causes

heterochromia (difference in iris colour) is seen in congenital Horner'she

anhydrosis: see belowhe


Anhydrosis

if affects head, arm and trunk suggests central lesionhe if affects just face suggests pre-ganglionic lesionhe if absent suggests post-ganglionic lesionhe


Central causes (from origin of sympathetic supply)

strokehe syringomyeliahe multiple sclerosishe tumourhe encephalitishe


Pre-ganglionic causes

Pancoast's tumourhe cervical ribhe thyroidectomyhe traumahe


Post-ganglionic causes

carotid artery dissectionhe internal carotid aneurysmhe cavernous sinus thrombosishe

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Each of the following are causes of peripheral neuropathy. Which one is associated with predominately motor

loss?ia

A.A Vitamin B12 deficiencyia

B.AGuillain-Barre syndromeia

C.A Uraemiaia

D.A Diabetesia

E.A Leprosyia

Next question

Peripheral neuropathysqweqwesf erwrewfsdfs adasd dhe

Peripheral neuropathy may be divided into conditions which predominately cause a motor or sensory loss


Predominately motor loss

Guillain-Barre syndromehe porphyriahe lead poisoninghe hereditary sensorimotor neuropathies (HSMN) - Charcot-Marie-Tooth he chronic inflammatory demyelinating polyneuropathy (CIDP)he diphtheriahe


Predominately sensory loss

diabeteshe uraemiahe leprosyhe alcoholismhe vitamin B12 deficiencyhe amyloidosishe


Alcoholic neuropathy

secondary to both direct toxic effects and reduced absorption of B vitaminshe sensory symptoms typically present prior to motor symptomshe


Vitamin B12 deficiency

subacute combined degeneration of spinal cordhe dorsal column usually affected first (joint position, vibration) prior to distal paraesthesiahe

Which part of the brain does herpes simplex encephalitis characteristically affect?ia

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A.ATemporal lobeia

B.A Parietal lobeia

C.A Occipital lobeia

D.A Cerebellumia

E.A Medullaia

Next question

CT head showing temporal lobe changes - think herpes simplex encephalitis

The inferior frontal lobe may also be affected

Herpes simplex encephalitissqweqwesf erwrewfsdfs adasd dhe

Herpes simplex (HSV) encephalitis is a common topic in the MRCP. The virus characteristically affects the

temporal lobes - questions may give the result of imaging or describe temporal lobe signs e.g. aphasia


Features

fever, headache, psychiatric symptoms, seizures, vomitinghe focal features e.g. aphasiahe peripheral lesions (e.g. cold sores) have no relation to presence of HSV encephalitishe


Pathophysiology

HSV-1 responsible for 95% of cases in adultshe typically affects temporal and inferior frontal lobeshe


Investigation

CSF: lymphocytosis, elevated proteinhe PCR for HSVhe CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of

patientshe

MRI is betterhe EEG pattern: lateralised periodic discharges at 2 Hzhe


Treatment

aciclovirhe

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Prognosis

treated 25%he untreated 80%he

Which one of the following drugs is used in the management of multiple sclerosis?ia

A.ABeta-interferonia

B.A Gamma-interferonia

C.A Infliximabia

D.A Rituximabia

E.A Alpha-interferonia

Next question

Multiple sclerosis: managementsqweqwesf erwrewfsdfs adasd dhe

Treatment in multiple sclerosis is focused at reducing the frequency and duration of relapses. There is no cure. High

dose steroids (e.g. IV methylprednisolone) may be given for 3-5 days to shorten the length of an acute relapse.

Baclofen is helpful in controlling spasticity. Hallucinations are occasionally seen on the withdrawal of baclofen


Beta-interferon has been shown to reduce the relapse rate by up to 30%. Certain criteria have to be met before it is

used:

relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaidedhe secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)he reduces number of relapses and MRI changes, however doesn't reduce overall disabilityhe

A 52-year-old man is prescribed apomorphine for Parkinson's disease. What is the mechanism of action?ia

A.ADopamine receptor agonistia

B.A Dopamine receptor antagonistia

C.AMAO-B inhibitoria

D.A Decarboxylase inhibitoria

E.A Antimuscarinicia

Next question

Apomorphine is one of the older dopamine receptor agonists. Newer agents such as ropinirole and cabergoline have

since been developed

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initial treatment





Levodopa




Selegiline

MAO-B inhibitorhe reduces dopamine metabolismhe


Antimuscarinics



Amantadine

prevents reuptake of dopamineheA 25-year-old female with a history of bilateral vitreous haemorrhage is referred due to progressive ataxia. What is

the likely diagnosis?ia

A.ANeurofibromatosis type Iia

B.A Neurofibromatosis type IIia

C.A Tuberose sclerosisia

D.AVon Hippel-Lindau syndromeia

E.A Sarcoidosisia

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Next question

Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are

bilateral in 25% of patients and may lead to vitreous haemorrhage

Von Hippel-Lindau syndrome

sqweqwesf erwrewfsdfs adasd dheVon Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an

abnormality in the VHL gene located on short arm of chromosome 3


Features

cerebellar haemangiomas: he retinal haemangiomas: vitreous haemorrhagehe renal cysts (premalignant)he phaeochromocytomahe

Each one of the following is associated with the development of chorea, except:ia

A.AHaemochromatosisia

B.A Ataxic telangiectasiaia

C.ACarbon monoxide poisoningia

D.A SLEia

E.A Huntingdon's diseaseia

Next question

Choreasqweqwesf erwrewfsdfs adasd dhe

Chorea describes rapid, jerky movements which often move from one part of the body to another. Slower, sinuous

movement of the limbs is termed athetosis. Chorea is caused by damage to the basal ganglia, especially the caudate

nucleus


Causes of chorea

Huntingdon's disease, Wilson's disease, ataxic telangiectasiahe SLE, anti-phospholipid syndromehe rheumatic fever: Sydenham's choreahe drugs: oral contraceptive pill, L-dopa, antipsychoticshe neuroacanthocytosishe chorea gravidarumhe thyrotoxicosishe polycythaemia rubra verahe carbon monoxide poisoninghe

Which one of the following features is not associated with an oculomotor nerve palsy?ia

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A.AMiosisia

B.A Ptosisia

C.A Eye is deviated 'down and out'ia

D.APain if due to a posterior communicating artery aneurysmia

E.A Diplopiaia

Next question

Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner's

Oculomotor nerve palsy is typically associated with a dilated pupil

Third nerve palsysqweqwesf erwrewfsdfs adasd dhe

Features

eye is deviated 'down and out'he ptosishe pupil may be dilated (sometimes called a 'surgical' third nerve palsy)he


Causes

diabetes mellitushe vasculitis e.g. temporal arteritis, SLEhe false localizing sign due to uncal herniation through tentorium if raised ICPhe posterior communicating artery aneurysm (pupil dilated)he cavernous sinus thrombosishe Weber's syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain

strokeshe

other possible causes: amyloid, multiple sclerosisheNeurofibromatosis type 1 is associated with a gene defect on which chromosome?ia

A.A Chromosome 4ia

B.A Chromosome 11ia

C.AChromosome 16ia

D.AChromosome 17ia

E.A Chromosome 22ia

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Next question

One of our registered users sent the following mnemonic to us:

NF1: chromosome 17 - as neurofibromatosis has 17 charactershe NF2: chromosome 22 - all the 2'she

Neurofibromatosissqweqwesf erwrewfsdfs adasd dhe

Overview

two types, NF1 and NF2he both autosomal dominanthe


NF1

also known as von Recklinghausen's syndromehe caused by gene mutation on chromosome 17 which codes for neurofibrominhe affects 1 in 4,000he


NF2

caused by gene mutation on chromosome 22he affects 1 in 100,000he


NF1 features

caf-au-lait spots (>= 6)he

axillary/groin freckleshe peripheral neurofibromashe iris: Lisch nodules in > 90%he


NF2 features

bilateral acoustic neuromasheWhich one of the following is least likely to produce a lymphocytosis in the cerebrospinal fluid?ia

A.A Systemic lupus erythematousia

B.AGuillain-Barre syndromeia

C.A Viral encephalitisia

D.APartially treated bacterial meningitisia

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E.A Behcet's syndromeia

Next question

Cerebrospinal fluid: raised lymphocytes

sqweqwesf erwrewfsdfs adasd dheNormal values of cerebrospinal fluid (CSF) are as follows:

pressure = 60-150 mm (patient recumbent)he protein = 0.2-0.4 g/lhe glucose = > 2/3 blood glucosehe cells: red cells = 0, white cells < 5/mmhe


The following conditions are associated with raised lymphocytes

viral meningitis/encephalitishe

TB meningitishe partially treated bacterial meningitishe Lyme diseasehe Behcet's, SLEhe lymphoma, leukaemiahe

Which one of the following features is most associated with temporal lobe lesions?ia

A.A Astereognosisia

B.AAuditory agnosiaia

C.AVisual agnosiaia

D.A Disinhibitionia

E.A Expressive (Broca's) aphasiaia

Next question

Brain anatomysqweqwesf erwrewfsdfs adasd dhe

The following neurological disorders/features may allow localisation of a brain lesion:


Parietal lobe lesions

sensory inattentionhe apraxiashe astereognosis (tactile agnosia) he inferior homonymous quadrantanopiahe Gerstmann's syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left

disorientationhe

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Occipital lobe lesions

homonymous hemianopiahe cortical blindnesshe visual agnosiahe


Temporal lobe lesion

Wernicke's aphasiahe superior homonymous quadrantanopiahe auditory agnosiahe


Frontal lobes lesions

expressive (Broca's) aphasiahe disinhibitionhe perserverationhe anosmiahe

Each of the following features are seen in myotonic dystrophy, except:ia

A.A Mild mental impairmentia

B.ARound faceia

C.A Frontal baldingia

D.A Myotoniaia

E.A Cataractsia

Next question

Myotonic dystrophysqweqwesf erwrewfsdfs adasd dhe

Inherited myopathy with features developing at around 20-30 years old. Affects skeletal, cardiac and smooth muscle


Genetics

autosomal dominanthe a trinucleotide repeat disorderhe CTG repeat at the end of the DPMK gene on chromosome 19he


Facial features

myotonic facies (long, 'haggard' appearance)he frontal baldinghe

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bilateral ptosishe cataractshe dysarthriahe


Other features

myotonia (tonic spasm of muscle)he weakness of arms and legs (distal initially)he mild mental impairmenthe diabetes mellitushe testicular atrophyhe cardiomyopathyhe dysphagiahe

A 34-year-old man is reviewed in the neurology clinic. He has been established on sodium valproate for primary

generalised epilepsy. Despite now taking a therapeutic dose he continues to have seizures and is troubled by weight

gain since starting sodium valproate. He asks to stop the his current medication and try a different drug. Which one

of the following drugs would be the most appropriate second-line treatment?ia

A.ALamotrigineia

B.A Ethosuximideia

C.A Pregabalinia

D.A Gabapentinia

E.A Tiagabineia

Next question

Monotherapy with another drug should be attempted before combination therapy is started. Caution should be

exercised when combining sodium valproate and lamotrigine as serious skin rashes such as Steven-Johnson's

syndrome may be provoked

Epilepsy: treatmentsqweqwesf erwrewfsdfs adasd dhe

Most neurologists now start antiepileptics following a second epileptic seizure. NICE guidelines suggest starting

antiepileptics after the first seizure if any of the following are present:

the patient has a neurological deficithe

brain imaging shows a structural abnormalityhe the EEG shows unequivocal epileptic activity he the patient or their family or carers consider the risk of having a further seizure unacceptable he


Sodium valproate is considered the first line treatment for patients with generalised seizures with carbmazepine used

for partial seizures


Tonic-clonic seizures

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sodium valproatehe second line: lamotrigine, carbamazepinehe


Absence seizures (Petit mal)

sodium valproate or ethosuximidehe sodium valproate particularly effective if co-existent tonic-clonic seizures in primary generalised

epilepsyhe


Myoclonic seizures

sodium valproatehe second line: clonazepam, lamotriginehe


Partial seizures

carbamazepinehe second line: sodium valproate, lamotriginehe

As part of a routine cranial nerve examine the following results are obtained:


Rinne's test: Air conduction > bone conduction in both ears

Weber's test: Localises to the right side

he earaer aeraer asdsadas eerw dssdfsselledsWhat do these tests imply?ia

A.A Left conductive deafnessia

B.A Normal hearingia

C.A Right conductive deafnessia

D.A Right sensorineural deafnessia

E.A Left sensorineural deafnessia

Next question

Rinne's and Weber's testsqweqwesf erwrewfsdfs adasd dhe

Performing both Rinne's and Weber's test allows differentiation of conductive and sensorineural deafness


Rinne's test

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tuning fork is placed over mastoid process, followed by repositioning just over external acoustic meatushe air conduction (AC) is normally better than bone conduction (BC)he if BC > AC then conductive deafnesshe


Weber's test

tuning fork is placed over middle of forehead, patient is asked which side is loudesthe in unilateral sensorineural deafness, sound is localised to the 'good' sidehe in unilateral conductive deafness, sound is localised to the 'bad' sidehe

Which one of the following is least characteristic of Wernicke's encephalopathy?ia

A.A Ataxiaia

B.A Confusionia

C.A Ophthalmoplegiaia

D.AConfabulationia

E.A Nystagmusia

Next question

An inability to acquire new memories and confabulation suggests the development of Korsakoff's syndrome

Wernicke's encephalopathysqweqwesf erwrewfsdfs adasd dhe

Wernicke's encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly

seen in alcoholics. Rarer causes include: persistent vomiting, stomach cancer, dietary deficiency. A classic triad of

nystagmus, ophthalmoplegia and ataxia may occur. In Wernicke's encephalopathy petechial haemorrhages occur in a

variety of structures in the brain including the mamillary bodies and ventricle walls


Features

nystagmushe ophthalmoplegiahe ataxiahe confusion, altered GCShe peripheral sensory neuropathyhe

he earaer aeraer asdsadas eerw dssdfsselledsInvestigations

decreased red cell transketolasehe MRIhe


Treatment is with urgent replacement of thiamine

Documents

Emrcp CNS 1-37