Neurology EMQs (solved just to have the answer)

Theme:Clinical features of upper limb nerve damageAInferior brachial plexus injuryBMedian nerveCMusculocutaneous nerveDRadial nerveESuperior brachial plexus injuryFUlnar nerve

For each item below select the most appropriate nerve injured:

Following injury, a 20-year-old male presents with weakness of elbow flexion and supination. There is loss of sensation over lateral surface of forearm.

Incorrect - The correct answer is Musculocutaneous nerve

The musculocutaneous nerve supplies the coracobrachialis, biceps and brachialis muscle. It also supplies sensation to the lateral surface of forearm by the lateral antebrachial cutaneous nerve.

A 52-year-old diabetic male presents with weakness of elbow extension and he has an inability to extend wrist resulting in wrist-drop.

Incorrect - The correct answer is Radial nerve

The radial nerve supplies the triceps, brachioradialis, supinator and extensor muscles of wrist and digits.

A 42-year-old male with polyarteritis nodosa presents with weakness of the thenar muscles and adjacent two lumbricals. He has an inability to oppose the thumb with little finger. You also note a loss of sensation over thumb and index, middle and lateral half of ring finger.

Incorrect - The correct answer is Median nerve

The median nerve supplies the lateral two lumbricals, opponens pollicis, abductor pollicis and flexor pollicis brevis.

Inferior brachial plexus injury

Superior brachial plexus injury

Musculocutaneous nerve

A 42-year-old male presents following injury with a loss of sensation over the medial one and half fingers. You also note weakness of adduction of the thumb as well as small muscles of hand and the hand assumes a claw appearance.

Incorrect - The correct answer is Ulnar nerve

The ulnar muscle supplies all small muscles of the hand except for LOAF which are supplies by the median nerve.

You see a 16-year-old male who following a birth injury has a right arm weakness with the assumption of a waiter's tip position.

Correct

The superior brachial plexus may become injured during motorcycle accidents or due to excess stretching on a newborn's arm.

Theme:Effect of destructive cortical lesions in a right handed individual.AFrontal lobe, bilateralBFrontal lobe left sideCFrontal lobe right sideDTemporo-parietal region left sideETemporo-parietal region right sideFTemporal lobe left sideGTemporal lobe right sideHParietal lobe, left sideIParietal lobe, right sideJOccipital lobe, bilaterallyKOccupital lobe, left sideLOccipital lobe, right side

For the following clinical features select the most likely region of the brain which has been injured in a right-handed individual.

Following a head injury, a 49-year-old male presents with personality change; intellectual impairment and urinary incontinence.

Incorrect - The correct answer is Frontal lobe, bilateral

Radial nerve

Superior brachial plexus injury

Frontal lobe right side

Following a stroke, a 72-year-old male has pure expressive aphasia.

Incorrect - The correct answer is Frontal lobe left side

A 73-year-old female presents with suddent onset receptive aphasis, acalculia, agraphia and has a right homonymous field defect.

Correct

A 82-year-old male presents with increasing confusion, an inability to recognise familiar faces and has a left homonymous field defect

Incorrect - The correct answer is Temporal lobe right side

A 77-year-old female presents with sudden onset visual loss and is noted to have cortical blindness

Correct

A lesion to the left side of the frontal lobe causes reduced fluency of speech with comprehension preserved, this due to Broca's area being damaged. Patients who recover report that they know what they wanted to say but could not get the words out. A lesion to the left temporo-parietal (Wernicke's area) causes fluency of speech to be preserved but the words come out incorrectly. Patients who recover report that they did not understand their or anyone else's speech. Non-dominant temporal lobe lesions result in abnormalities of perception. A bilateral lesion to the occipital lobe causes cortical blindness. Patients have a papillary reflex and normal fundoscopic appearance. Cortical blindness is associated with Anton's syndrome where the patient denies being blind despite ample evidence to the contrary.

Theme:Visual field defectsABitemporal hemianopiaBCentral scotomaCCortical blindnessDEnlarged blind spotEHomonymous hemianopia

Frontal lobe, bilateral

Temporo-parietal region left side

Temporo-parietal region left side

Occipital lobe, bilaterally

FInferior homonymous quadrantanopiaGSuperior homonymous quadrantanopiaHTunnel visionIUniocular blindness

Select the most appropriate visual field defect that would be expected in association with the following conditions.

Parietal lobe tumour

Incorrect - The correct answer is Inferior homonymous quadrantanopia

Bilateral occipital lobe infarction

Correct

Central retinal artery occlusion

Incorrect - The correct answer is Uniocular blindness

A parietal lobe tumour is associated with disturbed sensation including localisation of touch and disturbed two-point discrimination. The typical associated visual field defect is a lower homonymous quadrantanopia and it affects the upper fibres of the optic radiation. Light sensation is finally received in the occipital cortex.

Bilateral occipital infarction results in cortical blindness where the brain is unable to process the light signals it receives from the retina and optic nerves.

A central retinal artery occlusion would typically result in sudden uniocular blindness. Causes of central retinal artery occlusion include emboli (carotid stenosis, AF) and giant cell arteritis.

Uniocular blindness

Cortical blindness

Inferior homonymous quadrantanopia

Theme:Compression of spinal cord rootsARight L5/ S1 nerve root compressionBRight L4/ L5 nerve root compressionCRight L3/ L4 nerve root compressionDRight L2/ L3 nerve root compressionERight C5/ C6 nerve root compressionFRight C4/ C5 nerve root compressionGRight C6/C7 nerve root compressionHRight C3/ C4 nerve root compression

For each of the situations below, select the most likely diagnosis from the list of options.

A 60-year-old retired bus driver presents to outpatient clinic complaining of a ‘shooting pain’ down the side of his right thigh. When he is examined, you note weakness when he is asked to extend his toes or dorsiflex his foot. You also note a numbness of his lateral leg.

Incorrect - The correct answer is Right L4/ L5 nerve root compression

A 57-year-old shop keeper consults her general practitioner. She complains of numbness on the back of her right leg which she has noticed when putting on shoes. On examination, the GP finds weakness of plantar flexion of the ankle and is unable to elicit an ankle jerk.

Right C3/ C4 nerve root compression

Incorrect - The correct answer is Right L5/ S1 nerve root compression

A 48-year-old management consultant sees a neurologist as he is concerned as he has lost sensation in his right index and middle finger. He has suffered with pain in his neck for some time which he had thought was due to bad posture at work. On examination he is noticed to have slight weakness of finger and elbow extension

CorrectA slipped disc is caused by herniation of the nucleus pulposus through the annulus. This can lead to compression of the nerve roots, which then gives rise to the neurological symptoms. Compression of the L5 nerve root will be caused by herniation of the disc posteriorly into the L4/L5 foramen, as the L4 nerve root has already exited. Herniation of the disc on the right side will cause ipsilateral symptoms. Neurological findings may be sensory – altered or absent sensation over the L5 dermatome (lateral leg); or motor- weakness of extension of his toes (extensor hallucis longus) or dorsiflexion of the ankle. Where the pathology is long standing, wasting of the involved muscle groups may also be visible.

2. The symptoms that this patient describes correspond to compression of the S1 nerve root. The L5 / S1 level is the most common area for a prolapsed disc. As prevoiously described, this is caused by a posterolateral prolapse. If there is direct posterior collapse, this can lead to cauda equina syndrome.

3. Prolapse of a disc in the cervical area will cause a similar picture to disc prolpase in the lumbar spine. Prolapse into C6/ C7 will lead to compression of the C7 nerve root and symptoms in the motor and sensory distribution of this nerve.

Theme:Nerves of the upper limbADamage to median nerve at the wristBDamage to the median nerve at the elbowCDamage to the radial nerveDMusculocutaneous nerve injuryEUlnar nerve palsyFDamage to posterior interosseus nerveGAxillary nerve injuryHC7 nerve root injury

For each of the situations below, select the most likely diagnosis from the list of options.

Right C5/ C6 nerve root compression

Right C6/C7 nerve root compression

A 46-year-old barrister is admitted from fracture clinic for plating of a fracture of a humeral shaft fracture. Pre op there is no neurological deficit. The orthopaedic SpR who has carried out the operation sees the patient on the morning after the operation. The patient complains of an inability to extend his wrist, and some difficulty in extending his fingers. When the SpR examines the patient sensation seems to be intact apart from one small area on the back of the hand.

Incorrect - The correct answer is Damage to the radial nerve

A 26-year-old window cleaner attends A+E after falling off a ladder. He has fallen onto his left elbow, which is extremely tender to touch. He is very reluctant to move his elbow and cradles it with his other arm. The fingers on the same hand are clenched inwards as if forming a fist, particularly on the ulnar side. He also complains of being unable to feel his little finger on the same side.

Incorrect - The correct answer is Ulnar nerve palsy

An 32-year-old man has sustained a deep laceration to his upper limb. He complains of decreased sensation over his index and middle fingers and to a lesser degree his thumb. Movements of the thumb are difficult.

Incorrect - The correct answer is Damage to median nerve at the wrist1. The radial nerve can be injured at several different sites- at the axilla, the

humeral shaft (as in this case), the proximal radius or the posterior interosseus nerve. The sensory deficit is small, confined to a small area over the first web space dorsally. This is due to overlap with the median and ulnar nerves. Injury to the radial nerve in the axilla will lead to loss of elbow extension, although this does not occur in the case of mid shaft fractures of the humerus. There will be loss of forearm extensor leading to ‘wrist drop’. There will be weakness of metacarpophalangeal joint.

2. The ulnar nerve is a branch of the medial cord of the brachial plexus. Ulnar nerve palsy classically presents with ‘claw hand’. The nerve can be injured at the elbow (where it tranverses the posterior surface of the medial epicondyle) or at the wrist. The metarcarpophalangeal joints are hyperextended and the interphalangeal joints are flexed. The degree of deformity depends on the site of the lesion- clawing is more severe in distal lesions (the ‘ulnar paradox’. This

Axillary nerve injury

Musculocutaneous nerve injury

Damage to posterior interosseus nerve

is because clawing involves flexor digitorum profundus, and when the muscle action is affected by a high lesion the clawing is less severe.

3. The motor component of the median nerve supplies the 1st and 2nd lumbricals, the opponens pollicis muscle, the abductor pollicis brevis muscle and the flexor pollicis brevis muscle (‘LOAF’). In the hand, as well as flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, pronator quadratus and the radial half of flexor digitorum profundus in the forearm. It also has a sensory component, supplying the thumb, index, middle and radial half of the ring finger’s palmar skin. An injury to the median nerve at the elbow will lead to loss of function of the long flexors, an injury to the median nerve at the wrist will mean that these muscles are intact.

Theme:Compression of spinal cord rootsARight L5/ S1 nerve root compressionBRight L4/ L5 nerve root compressionCRight L3/ L4 nerve root compressionDRight L2/ L3 nerve root compressionERight C5/ C6 nerve root compressionFRight C4/ C5 nerve root compressionGRight C6/C7 nerve root compressionHRight C3/ C4 nerve root compression

For each of the situations below, select the most likely diagnosis from the list of options.

A 60-year-old retired bus driver presents to outpatient clinic complaining of a ‘shooting pain’ down the side of his right thigh. When he is examined, you note weakness when he is asked to extend his toes or dorsiflex his foot. You also note a numbness of his lateral leg.

Incorrect - The correct answer is Right L4/ L5 nerve root compression

A 57-year-old shop keeper consults her general practitioner. She complains of numbness on the back of her right leg which she has noticed when putting on shoes. On examination, the GP finds weakness of plantar flexion of the ankle and is unable to elicit an ankle jerk.

Correct

Right C6/C7 nerve root compression

Right L5/ S1 nerve root compression

A 48-year-old management consultant sees a neurologist as he is concerned as he has lost sensation in his right index and middle finger. He has suffered with pain in his neck for some time which he had thought was due to bad posture at work. On examination he is noticed to have slight weakness of finger and elbow extension

Correct1. A slipped disc is caused by herniation of the nucleus pulposus through the

annulus. This can lead to compression of the nerve roots, which then gives rise to the neurological symptoms. Compression of the L5 nerve root will be caused by herniation of the disc posteriorly into the L4/L5 foramen, as the L4 nerve root has already exited. Herniation of the disc on the right side will cause ipsilateral symptoms. Neurological findings may be sensory – altered or absent sensation over the L5 dermatome (lateral leg); or motor- weakness of extension of his toes (extensor hallucis longus) or dorsiflexion of the ankle. Where the pathology is long standing, wasting of the involved muscle groups may also be visible.

2. The symptoms that this patient describes correspond to compression of the S1 nerve root. The L5 / S1 level is the most common area for a prolapsed disc. As prevoiously described, this is caused by a posterolateral prolapse. If there is direct posterior collapse, this can lead to cauda equina syndrome.

3. Prolapse of a disc in the cervical area will cause a similar picture to disc prolpase in the lumbar spine. Prolapse into C6/ C7 will lead to compression of the C7 nerve root and symptoms in the motor and sensory distribution of this nerve.

2. Theme:Head injury - GCS3. AGCS 15 /15

BGCS 14 /15CGCS 13/ 15DGCS 10/ 15EGCS 9/ 15FGCS 5/ 15GGCS 4/ 15HGCS 3/ 15

4. For each of the situations below, select the most likely diagnosis from the list of options.

5. A 27-year-old female with a past medical history of spina bifida and hydocephalus is found collapsed at her day care centre. On initial assessment, she will open her eyes when you press on her

Right C6/C7 nerve root compression

sternum, and reaches up to try and pull your arm away. She makes sounds but these do not appear to contain recognisable words.

6.

7. Incorrect - The correct answer is GCS 9/ 15

8. A 45-year-old man suffers an intracranial bleed following a difficult craniotomy. The day after the haemorrhage, he will not open his eyes at all. He does not make any speech or sounds of any description. His upper limb extends outwards in response to a painful stimuli

9.

10. Incorrect - The correct answer is GCS 4/ 15

11. A 20-year-old student is brought into the accident and emergency department by paramedics on Saturday night. He has been found collapsed on the pavement in the town centre. He smells strongly of alcohol. You can see him rolling around the bed before you examine him and when you start speaking to him he keeps his eyes open. He is confused when you speak to him and is not sure where he is or what has happened.

12.

13. Incorrect - The correct answer is GCS 14 /15

14. 1. The Glasgow Coma Score assesses best response to three different variables: eye opening, verbal response and motor response. These are scored as shown:

EYE OPENING4- spontaneously3- to speech2- to pain1- not at all

MOTOR RESPONSE6- obeys command5- localizes pain4- withdraws from pain3- abnormal flexion to pain2- extension to pain

GCS 3/ 15

GCS 10/ 15

GCS 4/ 15

1- no response

VERBAL RESPONSE5- orientated4- confused conversation3- inappropriate words2- incomprehensible sounds1- no sounds

When recording GCS, it is essential that not just an overall score is recorded, but that the individual components are also recorded. This is so that it can be seen why any change in GCS measurement has occurred. The first patient has a GCS of 9 (E2, M5, V2). Patient 2 scores a GCS of 4 (E1, M2, V1), whilst that of patient 3 is 14 (E4, M6, V4).

A patient with a GCS of 8 or below will be unable to protect there airway and should be assessed by an anaesthetist for intubation.