MRCP Part 2 Category: Neurology

MRCP2-3472

An 85-year-old male presents as a blue light ambulance call with a sudden onset inability to move his right side that has been ongoing for twelve hours. Upon examination, there is an expressive and receptive dysphasia accompanied by a dense right sensorimotor syndrome. The cardiovascular examination is unremarkable except for an irregular heartbeat at 80 per minute. A hyperacute CT head reveals a large area of ischaemia in the left middle cerebral artery vascular territory. The patient is not eligible for thrombolysis and is started on 300mg aspirin. A subsequent echocardiogram shows a 60% ejection fraction with no mural thrombus, while a carotid Doppler reveals 40% left and 35% right stenosis. A 24-hour tape demonstrates new atrial fibrillation. What measures can be taken to reduce the risk of future strokes?

MRCP2-3473

A 75-year-old patient presents with complaints of severe headaches and lethargy for the past 3 weeks. The patient has a medical history of atrial fibrillation and is currently taking warfarin. A CT head (with contrast) is conducted:

What is the probable diagnosis?

MRCP2-3474

A 49-year-old woman presents to the emergency department with a severe headache that started earlier that day while she was walking around her office. The pain was felt across her entire head and was much improved when she lay down flat. There were no associated symptoms and the patient had been feeling well in the preceding days. She has no past medical history and is nulliparous. She is a non-smoker who consumes 15 units of alcohol per week.

On clinical examination, there is no evidence of focal neurological deficit or meningism. Simple analgesia given in the emergency department had limited impact on the patient’s headache. CT brain with venogram showed no evidence of intra-axial or extra-axial bleeding, space-occupying lesion, hydrocephalus, or venous sinus thrombosis. Lumbar puncture revealed an opening pressure of 5 mmHg, red cells 8 mm³, white cells 1 / mm³, and no xanthochromia.

What is the most appropriate next investigation to confirm the likely diagnosis?

MRCP2-3475

A 28 year old female has been referred for a neurological consultation. She reports experiencing two instances of unilateral blurred vision loss in the past six months. Her symptoms developed gradually over a few days and included vision blurring and pain, especially when moving her eyes. On both occasions, her symptoms peaked within three days and then gradually resolved over a two week period. Lumbar puncture results show an elevated protein level and CSF pleocytosis. Additionally, her serum Aquaporin-4 test is positive. What is the most probable diagnosis?

MRCP2-3476

An 86-year-old man was urgently referred by his General Practitioner to the stroke team for an outpatient assessment following a concerning episode reported by his care staff. The patient had a history of mild dementia but was mostly independent with daily activities and only required minimal assistance from his caregivers. However, he was found to be unusually drowsy and unresponsive in his armchair one week prior, with difficulty following commands and weakness in his left arm and leg. Although the symptoms resolved within 30 minutes, the patient remained confused and had reduced mobility. Upon further questioning, it was revealed that he had also fallen a few days prior to the episode.

The patient’s medical history included myocardial infarction, atrial fibrillation, and mild dementia. He was taking aspirin, ramipril, bisoprolol, simvastatin, and warfarin, which had been well-controlled with no recent fluctuations in his INR levels. He did not drink and was a former smoker. Despite his cognitive impairment, there was no evidence of dysphasia during examination, and his pupils were equal and reactive to light. However, he did have an irregular pulse and a left plantar response.

Based on the results of investigations performed during his clinic assessment, including an electrocardiogram, chest x-ray, carotid doppler, and transthoracic echocardiogram, what is the most likely finding on his subsequent CT brain scan?

MRCP2-3445

A 32-year-old woman is brought to the Emergency Department after being found wandering aimlessly on the street. She has a history of drug abuse and has been living in a shelter. The shelter staff report that she has been coughing and losing weight for several months. On admission, she is disoriented and lethargic. Further tests reveal the following results:

Cerebral spinal fluid (CSF) cells Lymphocytic picture with 800 cells/cm per mm cubed < 5/mm3
CSF glucose 2.0 mmol/l 2.5–3.9 mmol/l
CSF protein 2.0 g/l < 0.45 g/l
Blood glucose 6.0 mmol/l 3.5–5.5 mmol/l
CT scan Obstructive hydrocephalus

What is the most likely diagnosis for this patient?

MRCP2-3461

A 32-year-old woman has presented to the Emergency Department (ED) with suspected disc prolapse. She visited her GP with stiffness and weakness in both lower limbs, which developed over the last 24 hours. She has started to develop difficulty passing urine over the last 6 hours. She has no other medical history. When seen in ED, she is is able to walk, although she has a stiff-legged gait. Tone is increased in both legs. Power is 4±5 with pathologically brisk reflexes and sustained beats of clonus at both ankles. The plantars are up-going bilaterally. There is decreased soft touch sensation until a level around the umbilicus. There are no neurological abnormalities in the arms. The cranial nerve examination is also normal.
The orthopaedic registrar reviewed the patient earlier in the day and requested urgent magnetic resonance imaging (MRI) of the lumbar spine. This was reviewed by the radiologist and was reported as showing no structural lesions. The scan shows from the T9 vertebrae down to the sacral area.
The orthopaedic registrar feels that this is not a surgical problem and wonders whether it might be multiple sclerosis. They ask you, the medical registrar, what you would like to do with the patient. You examine the patient and agree with the physical signs.
What is your plan of action?

MRCP2-3446

A 28-year-old female patient comes to you with a sudden onset of vertigo and slurred speech that has been going on for 2 days. She has no medical history and does not smoke. During the examination, you observe partial ptosis and miosis on the left side. Her left arm’s finger-nose coordination is impaired, and she has decreased sensation to your cold tuning fork on her left face, right arm, and right leg. What is the probable diagnosis?

MRCP2-3462

A 33 year-old teacher presents to the neurology clinic.

For the past year, she has been experiencing severe headaches. These headaches usually occur in the morning and sometimes wake her up from sleep. The pain is sudden and stabbing, located behind her right eye. During the attacks, she feels the need to pace around the room and pound her head to ease the pain. Her right eye becomes watery and her nose congested. She has also noticed that her left pupil appears enlarged during the attacks. The pain is so severe that she has considered jumping out of the top floor of the school building where she works. Each attack lasts for one to two hours, and she feels fine between the attacks.

She has been keeping a detailed headache diary, which shows that she had a period of nine days in January with several attacks daily, followed by a headache-free period in February and March. In April, she developed severe headaches that occurred almost every day until June. She then had another period of relief until August, and so on.

The patient has no other past medical history and no allergies.

Upon examination, there are no remarkable findings.

What is the best prophylactic treatment for this patient’s headaches?

MRCP2-3447

A 35-year-old woman presents with weakness in her hands and legs. In particular, she reports difficulties carrying her toddler. On examination, bilateral ptosis with a smooth forehead and thinning hair is noted. Fundoscopy proves difficult because of bilateral cataracts. Facial expression is reduced, with wasting of the temporalis muscles, masseters and sternocleidomastoids. Slow release of hand grip is present bilaterally, with weakness and wasting in the distal muscles of the upper limb. Deep tendon jerks are depressed.

After consulting with her local neurologist, she has been informed that her symptoms are likely related to an inherited condition. The patient is concerned about the risk of passing this condition on to her children.

What would be the most appropriate test to confirm the likely diagnosis?