41 - 81

Question 1

41. A 30-year-old male falls from his bicycle striking his head. He is not knocked unconscious and does not seek medical  care. When he attempts to resume his normal activities he is bothered by a lack of energy, headaches,and an inability to concentrate. His family physician, who is unable to provide him with an explanation refers him to a neurologist. His examination by the neurologist is normal. Which of the following disorders is the MOST likely problem?
A. meningitis
B. cerebrospinal fluid rhinorrhea
C. psychiatric disorder
D. epilepsy
E. postconcussive syndrome

Answer 1

E. postconcussive syndrome

Question 2

42. A newborn male is noted to have an enlarged head. Which of the following physical signs is consistent with a diagnosis of hydrocephalus?
A. bilateral abducents palsy
B. “setting sun” sign
C. distended scalp veins
D. head circumference greater than 35cm
E. all of the above

Answer 2

E. all of the above

Question 3

43. A 16 year old male dives in to shallow water and strikes the vertex of his head. He immediately notes the onset of quadriplegia, with complete loss of movement of sensation below the C5 neurological level. Subsequent cervical spine X-ray show no apparent fracture, but anterior subluxation of C5 on C6 noted. When placed in skeletal traction, he reduces, but the height of C5-6 disc space increases substantially. Which of the following treatment methods will MOST likely be need to stabilize his spinal injury?
A. skeletal traction with bedrest
B. vertebrectomy and strut graft fusion
C. hallo vest immobilization
D. minerva jacket
E. posterior spinal fusion

Answer 3

E. posterior spinal fusion

Question 4

44. A 38-year-old male is admitted to hospital with a T12-L1 fracture dislocation, He has complete paraplegia. Which of the following statements is FALSE?
    A. immediately start deep thrombosis prophylaxis with external intermittent calf and subcutaneous low heparin
    B. The patient become mildly dyspnea on day 5. A ventilation/erfusion scan is low probability for pulmonary embolism. Impedance plethysmography is completed and normal. No treatment for PE is required.
    C. On day 10,The patient develops a swollen left calf. The physical examination for DVT is reliable 85% to 90% the time and warrants treatment with intravenous heparin. No further investigation are required.
    D. Treatment of DVT commences with a loading dose of intravenous heparin followed with a continuous intravenous infusion. Warfarin is started immediately and to a therapeutic dose.
    E. Treatment of DVT with Warfarin in continues for 3 months. No further DVT prophylaxis is required at that time.

Answer 4

C. On day 10,The patient develops a swollen left calf. The physical examination for DVT is reliable 85% to 90% the time and warrants treatment with intravenous heparin. No further investigation are required.

Question 5

45. Which of the following statements regarding peripheral nerve sheath tumors is INCORRECT ?
    A. The Schwann cell is the primary cell of origin of all peripheral nerve sheath tumors.
    B. Cellular schwannomas are uncommon variants of the schwannomas.These tumors rarely transform into malignant peripheral nerve sheath tumors.
    C. Complete resection of a neurofibroma typically results in significant loss of neurologic function. Primary repair or interposition cable grafts should be attempted when feasible
    D. The average risk for presentation with a malignant peripheral nerve sheath tumor, during the lifetime of a patient with neurofibromatosis is 45% to 50%.
    E. The mean 5-year survival for patients with malignant peripheral nerve sheath tumors is greater for those patients without neurofibromatosis type 1 (NF 1) than with neurofibromatosis type 1 (NF 1)

Answer 5

D. The average risk for presentation with a malignant peripheral nerve sheath tumor, during the lifetime of a patient with neurofibromatosis is 45% to 50%.

Question 6

46. A lesion just distal to the geniculate ganglion along the facial nerve leads to:
    A. Hyperacusis
    B. interruption of secretomotor fibers from the inferior salivatory nucleus
    C. loss of taste to the posterior one third of the ipsilateral tongue
    D. impaired lacrimation in the ipsilateral eye
    E. paralysis of the lower two thirds of the face

Answer 6

A. Hyperacusis

Question 7

47. A 35–year-old Mexican male is involved in a motor vehicle accident and sustains brief loss consciousness (less than 2 minutes). He is brought to an emergency room where he is found to be neurologically intact. The patient has no complaints and no significant past medical history. He has a brother who suffers from seizures. A computed tomographic scan was obtained because of the history of loss of consciousness(Figure 47). Which of the following courses of therapy is now appropriate?
    A. intubation and hyperventilation
    B. administration of 500 of mannitol intravenously
    C. administration of dexamethasone intravenously
    D. observation and additional studies
    E. craniotomy for evacuation of mass lesions

Answer 7

D. observation and additional studies

Question 8

47. A 35–year-old Mexican male is involved in a motor vehicle accident and sustains brief loss consciousness (less than 2 minutes). He is brought to an emergency room where he is found to be neurologically intact. The patient has no complaints and no significant past medical history. He has a brother who suffers from seizures. A computed tomographic scan was obtained because of the history of loss of consciousness(Figure 47).
48. The patient in question 47 later undergoes a magnetic resonance imaging(see Figure48). The most likely diagnosis is:
    A. multiple cerebral contusions
    B. diffuse axonal injury
    C. multiple cavernous malformations
    D. arteriovenous malformations
    E. cerebral cysticercosis

Answer 8

C. multiple cavernous malformations

Question 9

49. A 70-year-old male presents with tinnitus and hearing loss in his right ear. A gadolinium-enhanced magnetic resonance image (Figure 49A) reveals an acoustic schwannoma. Because of his age, his neurosurgeon elects to treat the lesion with radiosurgery. He receives a dose of 1750 cGy to the 80% Gne of a 26 mm collimator. His I-year post treatment is shown in Figure 49B. Which of the following statements regarding radiosurgery for acoustic schwannoma is FALSE?
    A.Approximately 90% of these lesions are smaller or the same size on follow up radiographic examination.
    B.Up to 40% of such treatment will lead to temporary cranial neuropathy.
    C. Hearing is preserved in the vast majority of patients treated with radiosurgery
    D. The long-term ( greater than 20 years) success rate for radiosurgery is unknown.
    E. The trigeminal nerve can be permanently or temporarily damaged by radiosurgery

Answer 9

C. Hearing is preserved in the vast majority of patients treated with radiosurgery

Question 10

50. A 43-year-old woman with a 7-year history of multiple sclerosis presents complaining of paroxysmal right lower lip pain . Initially her pain responds to Carbamazepins 200 mg, administered twice daily. She return after 6 months with recurrence of her pain. Appropriate treatment at this point might include each of the following EXCEPT:
    A. additional pharmaceutical therapy using higher doses of or other drugs
    B. percutaneous radiofrequency thermal Rhizotomy
    C. percutaneous glycerol rhizotomy
    D.Craniotomy for microvascular decompression
    E. percutaneous balloon compression of the Gasserian ganglion

Answer 10

D.Craniotomy for microvascular decompression

Question 11

51. A patient presents after sustaining second right frontal hemorrhage. The patient has a mild hemiparesis resulting from the recent bleed. ,Magnetic resonance imaging reveals a venous malformation and a cavernous malformation adjacent to the hemorrhage. Cerebral angiography confirms the presence of venous malformation. You recommend which of the following:
    A. Operate to remove the venous malformation and blood clot.
    B. Operate to remove the cavernous malformation and the blood clot,
    C. Operate to remove the venous and cavernous malformations, as well as the blood clot.
    D. Operate to remove only the blood clot.
    E. Nonsurgical management is appropriate.

Answer 11

B. Operate to remove the cavernous malformation and the blood clot

Question 12

52. A 44-year-old female has a 2-year history of dull neck pain, bilateral arm numbness and progressive quadriparesis. Although she is able to walk without assistance, she has marked fatigue and is dragging her left foot. She frequently drops objects from her left hand and has difficulty raising her hands above her head. Physical exam reveals significant weakness in proximal muscle groups, left worse than right. There is diffuse hyper-reflexia with ankle clonus bilaterally and a positive left Babinski sign.
    Magnetic resonance imaging (MRI) with Gadolinum reveals an enhancing intramedullary spinal cord tumor from C3-6. Appropriate clinical management at this time would include which of the following?
    A. clinical observation with serial MRI
    B. needle biopsy followed by radiation therapy
    C. open biopsy with further therapy pending pathologic evaluation
    D. Empiric radiation and chemotherapy
    E. multilevel cervical laminectomy with attempted gross tumor removal

Answer 12

E. multilevel cervical laminectomy with attempted gross tumor removal

Question 13

For questions 53, 54,55,56,and 57, select the answer from the following possibilities:
A. dural spinaI arteriovenous malformation (AVM) (type (typeI)
B. glomus spinal AVM (type 2)
C. both
D. neither

53. typically becomes symptomatic in younger patients
54. low flow, high pressure
55. low flow, low pressure
56. most commonly fed by the spinal arteries
57. the most common type of spinal AVM

Answer 13

53. B. Gloms spinal avm (tipe 2)
54. A. dural spinaI arteriovenous malformation (AVM) (type (typeI)
55. D. neither
56. B. glomus spinal AVM (type 2)
57. A. dural spinaI arteriovenous malformation (AVM) (type (typeI)

Question 14

58. The disease characterized by the x-ray findings seen in Figure 58 is:
    A. rheumatoid arthritis
    B. associated with HLA-827 antigen
    C. resistant to fracture formation
    D. osteogenesis imperfecta
    E. not commonly associated with spinal cord injury

Answer 14

B. associated with HLA-827 antigen

Question 15

59. You are asked to consult on a young, restrained passenger involved in a motor vehicle accident. The 3-year-old child was brought to the emergency room by the paramedics in a cervical collar and on a backboard. Both systemic and neurologic examination are normal. Screening x-rays are performed in an effort to clear the child’s cervical spine (Figure 59). The following statements are true concerning the pediatric cervical spine EXCEPT:
    A. Developmentally, the body and transverse process appear in the cartilage about sixth fetal month and are fused with main ossification centre by the sixth year.
    B. The neural arches eventually become the lamina and facets and then fuse to the vertebral body at about 25 years.
    C. The vertebral rings may begin to ossify by age 7 years in girls, and then fuse the vertebral body about 25 years.
    D. Motion segments in the cervical spine are very common, especially at th C2-3 and C3-4 levels. The distance of C6 is usually the accepted upper level of normal for subluxation during movement.
    E. Unusual elongation of the anterior tubercle of transverse process of C6 may frequently be present and mistaken for a fracture.

Answer 15

D. Motion segments in the cervical spine are very common, especially at th C2-3 and C3-4 levels. The distance of C6 is usually the accepted upper level of normal for subluxation during movement.

Question 16

60. A 6-year-old gils falls from a swimming pool ladder and complains of mild neck discomfort. She is neurologically normal on examination. Cervical spine x-rays and computed scan are obtained (Figure 60). The patient's diagnosis is :
A. ossiculum terminale persistens
B. os odontoideum
C. type I odontoid fracture
D. hangman's fracture
E. normal

Answer 16

E. normal

Question 17

61. The Pterion is formed by which of the following bones?
    A. lesser wing of sphenoid, frontal bone, and parietal bone
    B. frontal bone, parietal bone and squamous portion of temporal bone
    C. sphenoid bone, frontal bone, parietal bone and squamous portion of temporal bone
    D. Zygomatic arch and squamous portion of temporal bone
    E. Zygomatic arch, frontal bone, parietal bone, and nasion

Answer 17

C. sphenoid bone, frontal bone, parietal bone and squamous portion of temporal bone

Question 18

For questions 62,63, 64,and 65 select the answer from the following possibilities:
A. neuropraxia
B. axonotmesis 
C. both
D. neither

62. requires regeneration for of function
63. involves WalIerian degeneration
64. The perineurium is intact
65. stab wound with complete anatomic transection of nerve

Answer 18

62. B. axonotmesis
63. B. axonotmesis
64. C. both
65. D. neither

Question 19

66. Which of the following structures travel through the foramen lacerum :
    A. middle meningeal
    B. maxillary branch of the trigeminal nerve
    C. mandibular branch of the trigeminal nerve
    D. sympathetic nerves
    E. internal jugular vein

Answer 19

D. sympathetic nerves

Question 20

67. A 45-year-old female complains of progressive headaches and a change in personality. A computed tomographic scan demonstrates a falcine meningioma. Angiography reveals that the majority of the blood supply to the tumor is from the anterior falx artery. The anterior falx artery is most often a branch of which artery'?
A. ophthalmic artery
B. middle meningeal artery
C. internal maxillary artery
D. superficial temporal artery
E. anterior cerebral artery

Answer 20

A. ophthalmic artery

Question 21

68. An 18-year-old male with a severe  closed head injury has the following clinical findings: decorticate posturing, eye opening to painful stimuli, and anisocoria (R>L). The patient mumbles incomprehensibly. His Glasgow Coma Score is:
A. 8
B. 4
C. 5
D. 6
E. 7

Answer 21

E. 7

Question 22

69. A 24-year-old female, who recently emigrated from the West Indies is admitted the hospital with seizures. Her mother states that the patient has had seizures since infancy and is mentally retarded. Physical examination reveals an exanthem in a butterfly distribution over the nose and midface. A computed tomographic s can demonstrates a large ventricular mass originating at the right foramen of Monro with unilateral hydrocephalus. Which of the following is NOT characteristic of this disease?
A. retinal angiomatosis
B. tumors of the heart and kidney
C. neuroglial nodules in the brain
D. autosomal dominant transmission
E. depigmented skin lesions

Answer 22

A. retinal angiomatosis

Question 23

70. A 7-year-old right-handed female presents with a 4-day history of vomiting, dehydration, headache, and difficulty walking. On physical exam, she has bilateral dysmetria, ataxia, and nystagmus on lateral gaze bilaterally. Figure 70 shows her gadolinium-enhanced magnetic resonance image Therapy should include all of the following EXCEPT:
    A. DecadronTM
    B. biopsy of the lesion, followed by a shunt and radiation therapy
    C. a total or near total surgical resection
    D. possibly postoperative radiation therapy and chemotherapy
    E. postoperative metastatic workup including a contrast-enhanced MRI A total axis myelogram

Answer 23

B. biopsy of the lesion, followed by a shunt and radiation therapy

Question 24

71. Eighteen months later, a contrast-enhanced MRI(Figure 71) shows:
A. a large, tumor recurrence
B. no evidence of disease
C. postoperative changes
D. subarachnoid metastatic disease
E. subarachnoid hemorrhage

Answer 24

D. subarachnoid metastatic disease

Question 25

72. A 3-year-old presents with lethargy, headache, vomiting 2 months following insertion of a left VP-shunt for aquaductal stenosis. The head circumference is greater than the 98th percentile, unchanged from that prior to surgery. The original cerebrospinal fluid shunt consisted of a medium pressure burr hole reservoir and a low pressure distal slit valve. Neurologic exam, including examination of the ocular fundi is unremarkable. A computed tomographic scan is shown in Figure 72.
    Which of the following treatment options would be MOST to succeed?
    A. burr drainage of the subdural and addition of an antisiphon device below the valve reservoir
    B. replacement of the entire shunt system and installation of a high-pressure valve
    C. insertion of a subdural catheter “Y” above the shunt valve.
    D. notification of the appropriate authorities regarding child abuse
    E. none of the above

Answer 25

A. burr drainage of the subdural and addition of an antisiphon device below the valve reservoir

Question 26

73. A previously well 7-year-old male presents with a 4 week history of headaches, nausea, and vomiting. Two days prior to admission, he became ataxic and tended to fall to the right. On examination, he has bilateral papil edema gaze-evoked nystagmus, and a right lower motor neuron facial palsy. Magnetic resonance imaging is performed and shows a large cystic posterior fossa mass lesion extending out through the right foramen of Luscka(Figure 73A,T1”weighted, nonenhanced). The lesion also involves the perimesencephalic and prepontine cisterns (Figure 73B, T2 weighted, non enhanced). He is taken to surgery whereupon the bulk of the tumor is removed from the posterior fossa. The neuropathologic describes the lesion as being highly cellular, composed of round to oval cells with scant cytoplasm. Mitoses and Homer-Wright rosettes are abundant throughout. Immediately after surgery, the patient is well, without new neurologic deficit. A small of residual tumor is seen in the posterior fossa on a postoperative computed tomographic scan at 24 hours. The tumor in the perimesencephalic and prepontine cisterns was not operated upon, and was unchanged in appearance on the postoperative CT. The best management of this child from this point on would be to:
    A. obtain a postoperative scan of the spine. a CT myelogram to fully stage the extent of the disease along the neuraxis
    B. insert a VP-shunt containing a tumor filter
    C. perform subtempoal approach to the disease in the basal cisterns
    D. perform a subfrontal approach to the disease in the basal cisterns
    E. treat the remaining disease with radiosurgery

Answer 26

A. obtain a postoperative scan of the spine. a CT myelogram to fully stage the extent of the disease along the neuraxis

Question 27

74. A 6-year-old boy with Sturge-Weber disease has intractable epilepsy. His seizures are characterized predominantly by tonic clonic movements of the right upper extremity,with occasional generalized seizures and attacks of status epilepticus. Five medications in varying combinations have failed to control his seizures. The seizures started in the first week of life and have progressively increased in frequency and severity. Clinical exam reveals right-sided hemiathrophy and with a right homonymous hemianopia and an angioma over the left cheek and temple. The EEG shows multifocal epileptic discharges, predominately in the central area. His computed tomographic scan and magnetic resonance image are compatible with a diagnosis of Sturge-Weber disease. The best management option would be:
A. a new combination of anticonvulsants
B. a left fron lobe resection
C. a left functional hemispherectomy
D. a left temporal lobectomy
E. corpus callosotomy

Answer 27

C. a left functional hemispherectomy

Question 28

75. An adult has been treated with partial resection and external beam fractionated radiation for a supratentorial malignant astrocytoma. Twelve months later clinical and radiologic recurrence is documented. Which of the following would not be considerations in the decision to offer this patient further therapy and/or the specific choice of therapy?
    A. age
    B. Karnofsky score
    C. location of lesion
    D. histology (malignant astrocytoma versus glioblastoma)
    E. presence of other lesions in the brain

Answer 28

D. histology (malignant astrocytoma versus glioblastoma)

Question 29

76. A 24-year-old woman presents with a grand mal seizure and has a normal neurologic examination. Computed tomography and magnetic resonance imaging show a lesion in the dominant temporal lobe, typical of a low-grade astrocytoma. Treatment consists of seizure prophylaxis and observation. Six years later, she developed increased seizure frequency and mild expressive dysphasia. Gadolinum enhanced MRI (Figure76) demonstrates the lesion to be slightly larger and to have significantly more enhancement. Which of the following options would be BEST?
    A. interstitial brachytherapy
    B. systemic chemotherapy
    C. craniotomy, gross excision, and no further therapy
    D. Decadron tm, plus repeat MRI in 3 months
    E. stereotactic biopsy, followed by external beam radiation

Answer 29

E. stereotactic biopsy, followed by external beam radiation

Question 30

77. Current theories that may explain delayed-onset, arterial narrowing(vasospasm) seen after subarachnoid hemorrhage include all the following EXCEPT:
    A. in release of spasmogenic chemicals fram the subarachnoid clot
    B. alterations in release of the normal vasodilating and vasoconstricting compounds from endothelial cells
    C. damage to perivascular nerves surrounding the vessels of the circle of Willis, with loss of vasodilatory influences
    D. a direct mechanical compression from subarachnoid clot
    E. direct toxic effect of hemoglobin

Answer 30

D. a direct mechanical compression from subarachnoid clot

Question 31

78. A 14-year-old girl is referred by an orthopedic surgeon who has been following her because of scoliosis. Her spinal cord has deteriorated over the past 9 months and she is experiencing increasing back pain, stiffness,and recurrent urinary tract infections. Her is characterized by a cutaneous hairy patch located in the midline of her thoracolumbar junction, weakness of left ankle dorsifexors, a samller left calf, numbness of L5-S1 dermatomes and a cavus left foot. A relevant axial section of a computed
    tomographic is shown in 78. With regard to the lesion, which of the following is CORRECT?
    A. A thickened filum terminale may be an associated feature.
    B. The spinal cord lies within a single dural sac
    C. The offending lesion is most commonly found at T2-3
    D. The aims of surgery are to improve gait, bladder performance, and to cure the scoliosis.
    E. Decompressive laminectomy is an adequate operative treatment

Answer 31

A. A thickened filum terminale may be an associated feature.

Question 32

79. Patient M.S. is an 11-year-old boy who has sustained an accidental gunshot wound his right popliteal fossa. Clinically, he had a complete distal sciatic nerve paralysis which was unimproved 3 months after injury. (EMG) confirmed complete denervation of peroneal and posterior tibial musculature. Surgical exploration revealed neuromas-in-continuity, involving the deep peroneal, superficial peroneal and posterior tibial nerves. Which of the following options would be BEST?
    A. Resect the neuromas and anastomosis or graft the nerves
    B. perform nerve action potential to determine whether the lesion is neurotmetic or axonotmetic
    C . Palpate the neuromas and resect if they are fibrotic.
    D. Perform an intraoperative EMG study.
    E. Close and allow more time for spontaneous recovery to occur.

Answer 32

B. perform nerve action potential to determine whether the lesion is neurotmetic or axonotmetic

Question 33

80. A 54-year-old man was in excellent health until 1 month prior hospital admission when he developed acute severe neck pain after bending over to pick up a newspaper. He went to the emergency room where plain x-rays showed only mild arthritic changes. Over the next 4 weeks he saw multiple physicians from different fields and had various therapies including rest, analgesics, and physical therapy, without relief. One week prior to admission he noticed the gradual onset weakness of both upper extremities as well as slowly progressive involuntary neck flexion. At this point, a bone scan revealed increased uptake of the fourth, fifth, and sixth cervical vertebrae. Magnetic resonance imaging demonstrated severe cord compression at the midcervical level. Physical examination at the time of admission indicated a middle-aged man who was ambulatory with a spastic gait. His neck was held in complete flexion and he was unable to extend it. He was afebrile with stable vital signs. There was marked tenderness of the midcervical spine. Neurologic examination demonstrated pronounced weakness with 0/5 strength in
    the biceps and 1/5 strength in the deltoids bilaterally. Lower extremity examination showed minimal weakness and increased tone. Upper extremity reflexes were diminished bilaterally; the lower extremities had significant hyper-reflexia with sustained clonus. Toes were upgoing. Sensation was intact and rectal tone was normal. Lab data showed a moderately elevated white blood cell count with a normal differential. Chest xray was normal and lateral cervical spine x-rays demonstrated complete collapse of the fourth and fifth cervical vertebrae, with angulation at that level. The MOST likely diagnosis is:
    A. pyogenic vertebral osteomyelitis
    B. metastatic prostate cancer
    C. epidural hematoma
    D. nasopharyngeal carcinoma with contiguous spread
    E. osteoblastama

Answer 33

A. pyogenic vertebral osteomyelitis

Question 34

80. A 54-year-old man was in excellent health until 1 month prior hospital admission when he developed acute severe neck pain after bending over to pick up a newspaper. He went to the emergency room where plain x-rays showed only mild arthritic changes. Over the next 4 weeks he saw multiple physicians from different fields and had various therapies including rest, analgesics, and physical therapy, without relief. One week prior to admission he noticed the gradual onset weakness of both upper extremities as well as slowly progressive involuntary neck flexion. At this point, a bone scan revealed increased uptake of the fourth, fifth, and sixth cervical vertebrae. Magnetic resonance imaging demonstrated severe cord compression at the midcervical level. Physical examination at the time of admission indicated a middle-aged man who was ambulatory with a spastic gait. His neck was held in complete flexion and he was unable to extend it. He was afebrile with stable vital signs. There was marked tenderness of the midcervical spine. Neurologic examination demonstrated pronounced weakness with 0/5 strength in
    the biceps and 1/5 strength in the deltoids bilaterally. Lower extremity examination showed minimal weakness and increased tone. Upper extremity reflexes were diminished bilaterally; the lower extremities had significant hyper-reflexia with sustained clonus. Toes were upgoing. Sensation was intact and rectal tone was normal. Lab data showed a moderately elevated white blood cell count with a normal differential. Chest xray was normal and lateral cervical spine x-rays demonstrated complete collapse of the fourth and fifth cervical vertebrae, with angulation at that level.
81. The BEST initial therapy for the patient described in question 80 would be:
    A. Gardner-Wells tongs followed by a computed tomography-guided biopsy
    B. Gardner-Wells tongs followed by elective surgery
    C. immediate operative decompression with methylmethacrylate reconstruction
    D. immediate operative decompression with autologous bone reconstruction
    E. high-dose methylprednisolone and radiation therapy

Answer 34

D. immediate operative decompression with autologous bone reconstruction