Neurology

Question 1

Which of the following is most likely to be the cause of multiple ring enhancing lesions observed by means of computed tomography (CT scan)?
A. Meningitis
B. Neurosyphilis
C. Cerebral embolism
D. Brain abscess
E. Dementia

Answer 1

D. Brain abscess

Ring-enhancing lesions seen on CT scan are indicative of brain abscess. Abscesses follow intravenous drug use, dental procedures, sinusitis, bacterial endocarditis, and immunodeficiency. Bacterial infections are the most common cause, but in AIDS, toxoplasmosis is the most common cause.

Question 2

An electroencephalogram (EEG) is most helpful to diagnose tumors in which of the following areas?
A. Posterior fossa
B. Deep in the cerebrum
C. The base of the brain
D. Near the surface of the cerebral hemispheres
E. None of the above

Answer 2

D. Near the surface of the cerebral hemispheres

Electroencephalography (EEG), which traces brain waves, is the most helpful investigative method for determining pathology near the surface of the cerebral hemispheres. (Note that the abbreviation EEG also is used to refer to the tracing itself, the electroencephalogram.) Magnetic resonance imaging (MRI) is the best method for visualizing the posterior fossa, pituitary gland, and optic nerves. It is also the best for visualizing the white-matter changes of multiple sclerosis. Computed tomography (CT scan) can rapidly detect acute hemorrhage from acute intracranial hematomas, subdural hematomas, and subarachnoid hemorrhages.

Question 3

Which of the following is associated with impaired consciousness?
A. Alcoholic hallucinosis
B. Wernicke's encephalopathy
C. Korsakoff syndrome
D. Dementia
E. Schizophrenia

Answer 3

C. Korsakoff syndrome

Wernicke’s encephalopathy is characterized by impairment of consciousness, ataxia, and ophthalmoplegia, typically palsy of the sixth cranial nerve. These symptoms reverse rapidly with administration of vitamin B1 (thiamine). Alcohol hallucinosis, schizophrenia, and dementia by definition occur without impairment of consciousness. Korsakoff syndrome is characterized by anterograde and retrograde amnesia and impairment in learning.

Question 4

Which of the following diagnoses is strongly suggested by lower limb areflexia with Babinski sign?
A. Infectious polymyalgia
B. Motor neuron disease
C. Tabes dorsalis
D. Friedreich ataxia
E. Cervical spine lesion

Answer 4

D. Friedreich ataxia

Friedreich ataxia is an autosomal recessive spinocerebellar degeneration. Eighty percent of persons diagnosed with Friedreich ataxia developed the disease before the age of 20 years. The most frequent presenting symptom is gait ataxia, followed by lower limb weakness and clumsiness. Lower limb reflexes are usually absent. Muscle tone is usually reduced. The coexistence of lower limb areflexia and Babinski sign strongly suggests Friedreich ataxia.

Question 5

Which of the following terms describes the primary mechanism of neurotransmission in the autonomic ganglia?
A. Serotoninergic
B. Noradrenergic
C. Cholinergic
D. GABAergic

Answer 5

C. Cholinergic

The transmitter that is mainly released from the preganglionic endings of sympathetic and parasympathetic fibers is acetylcholine.

Question 6

All of the following can occur in seizures with a temporal lobe focus except
A. Tinnitus
B. Smell of burning rubber
C. Rising epigastric sensation
D. Aggression
E. Micropsia

Answer 6

D. Aggression

Planned, goal-directed aggression is virtually never seen in seizure disorder. Ictal violence associated with seizures may injure people and damage property, but it is not directed or purposefully destructive and not based on aggression. Tinnitus, smell of burning rubber, rising epigastric sensation, and micropsia (seeing things as smaller than they actually are) are all part of aura in seizures with a temporal lobe focus.

Question 7

Which of the following is NOT true about magnetic resonance imaging (MRI)?
A. It is the investigation of choice for multiple sclerosis.
B. The presence of a pacemaker is an absolute contraindication.
C. It demonstrates calcification better than does CT.
D. Claustrophobia is a relative contraindication.
E. MRI is not as good as CT to detect intracranial bleeding.

Answer 7

C. It demonstrates calcification better than does CT.

CT scan is better than MRI to demonstrate calcification and bleeding in the brain. MRI is more useful to differentiate between white and gray matter. The presence of devices made of ferromagnetic (iron) metals such as older model pacemakers, intracranial aneurysm clip, or cochlear implants is a contraindication to performing an MRI.

Question 8

A 36-year-old man complains of double vision and difficulty walking down stairs. The physician examining him suspects a lesion in the brain. What is the most likely site of lesion?
A. Venteromedial pons
B. Medulla
C. Midbrain
D. Spinal cord
E. None of the above

Answer 8

C. Midbrain

Double vision is associated with damage to the fourth cranial nerve (trochlear), which originates in the midbrain. Walking down stairs requires that the eyes be able to move down, an ability that is governed by trochlear nerve. Because the trochlear nucleus is in the midbrain and the trochlear fibers cross the midbrain, the lesion is most likely to be in the midbrain.

Question 9

Which of the following psychological tests can detect organic brain damage?
A. Thematic Apperception Test (TAT)
B. Rorschach test
C. Stanford-Binet test
D. Wisconsin Card Sorting Test
E. Minnesota Multiphasic Personality Inventory (MMPI)

Answer 9

D. Wisconsin Card Sorting Test

The Wisconsin Card Sorting Test detects frontal lobe damage. The Thematic Apperception Test, Rorschach test, and MMPI are used for personality evaluation. Stanford-Binet is an intelligence test.

Question 10

What is the most common form of migraine?
A. Classic migraine
B. Migraine without aura
C. Hemiplegic migraine
D. Childhood migraine
E. Basilar migraine

Answer 10

B. Migraine without aura

Common migraine, which is migraine without aura, affects about 75% of patients who have migraine headaches. The headaches last for 4 to 24 hours and are throbbing or pulsating, hemicranial, and temporal, retro-orbital, or periorbital; they may be accompanied by nausea and vomiting. Classic migraine, which is migraine with aura, affects only about 15% of patients and is preceded by an aura, although the subsequent headache is similar to migraine without aura. Hemiplegic migraine is characterized by a combination of hemiparesis or aphasia preceding or accompanying typical migraine symptoms. In childhood migraine, the headache is more likely to be bilateral, briefer, and more severe; other symptoms, like nausea, may be prominent. In basilar migraine, headache is accompanied by symptoms suggestive of basilar artery dysfunction such as ataxia, vertigo, dysarthria, and diplopia.

Question 11

Which of the following is NOT a feature of migraine?
A. Occurrence in the evening
B. Aggravation by oral contraceptives
C. Onset at menarche
D. Higher incidence in women
E. Relief during pregnancy

Answer 11

A. Occurrence in the evening

In contrast to tension headaches, which tend to occur in the evening, migraine headaches begin in the early morning. They are more common in women and start at menarche, occur premenstrually, and are aggravated by oral contraceptives. The majority of women experience relief from the symptoms during pregnancy.

Question 12

During which stage of sleep does nocturnal migraine tend to arise?
A. Stage 1 sleep
B. Stage 2 sleep
C. Stage 3 sleep
D. Stage 4 sleep
E. REM sleep

Answer 12

E. REM sleep

Nocturnal migraine headaches tend to occur during REM sleep. Some people have migraine headaches only during sleep.

Question 13

A 38-year-old man presents with unilateral periorbital pain with ipsilateral tearing and nasal discharge. He also has ptosis and miosis. The pain is sharp and lasts for about 1 hour. What is the most likely diagnosis?
A. Brain tumor
B. Migraines
C. Tension headache
D. Cluster headache
E. Retinal detachment

Answer 13

D. Cluster headache

Cluster headache is a condition in which severe headaches occur daily for a period of 4 to 8 weeks, usually in the spring. The headaches are sharp, nonthrobbing, and bore into one eye and around the eye. The pain is excruciating and is associated with tearing, conjunctival injection, nasal congestion, and Horner-like syndrome. Cluster headache condition is more common in men aged 20-40 years than in others. Brain tumors and tension headaches are unlikely to present in such a dramatic manner. Retinal detachment does not typically cause pain.

Question 14

Which of the following is a common feature of cluster headache?
A. Increased prevalence in women
B. Familial predisposition
C. Association with smoking
D. Relieved by alcohol
E. A preceding aura

Answer 14

C. Association with smoking

Among persons diagnosed with cluster headache, more than 80% smoke and 50% drink alcohol excessively (although, unlike tension headache, the condition is not relieved by alcohol). The condition has no familial tendency. In the vast majority of cases, the symptoms are not preceded by an aura. The headaches may be treated with sumatriptan and oxygen inhalation.

Question 15

A 60-year-old male presents with a continual headache on both sides of his head. He also complains of his jaws aching when he chews. What is the most important intervention for this patient?
A. Reassurance
B. CT scan
C. Temporal artery biopsy
D. NSAIDs
E. High-dose steroids

Answer 15

E. High-dose steroids

The symptoms with which this patient presents are typical of temporal arteritis, a condition in which the temporal and other cranial arteries become inflamed. Patients present with dull, continual headache in one or both temples. There is also pain on chewing. Systemic signs such as malaise, fever, and weight loss may be present. Serious complications may occur, such as ophthalmic artery occlusion, causing blindness, or cerebral artery occlusion, causing cerebral infarcts. A blood test showing estimated sedimentation rate (ESR) greater than 40 mm per hour supports the diagnosis, and temporal artery biopsy is a definitive test. The most important intervention is the administration of high-dose steroids, which will relieve the headaches and prevent complications. CT and MRI are not indicated.

Question 16

A 55-year-old male being treated for hypertension has a headache of sudden onset that he describes as the worst ever in his life. What is the most likely cause of the headache?
A. Subarachnoid hemorrhage
B. Migraine
C. Cluster headache
D. Brain tumor
E. Meningitis

Answer 16

A. Subarachnoid hemorrhage

Subarachnoid hemorrhage is most commonly caused by rupture of a berry aneurysm. It can cause severe headaches and nuchal rigidity and can occur during exertion, including exercise or sexual intercourse. Blood can be seen on CT or MRI and on lumbar puncture. Headaches of such sudden onset are not characteristic of the other conditions listed in the question.

Question 17

All of the following awaken patients from sleep except
A. Cluster headaches
B. Brain tumors
C. Tension headaches
D. Subarachnoid hemorrhage
E. Migraine

Answer 17

C. Tension headaches

Tension headaches and trigeminal neuralgia do not awaken people from sleep. Subarachnoid hemorrhage and brain tumors can wake people up from sleep. Migraine can occur during sleep, as can cluster headaches.

Question 18

Which of the following does NOT cause chronic headaches?
A. Depression
B. Analgesic abuse
C. Tension headaches
D. Trigeminal neuralgia
E. Regular use of benzodiazepines

Answer 18

D. Trigeminal neuralgia

In trigeminal neuralgia, patients suffer from dozens of brief jabs of sharp excruciating facial pain lasting 20 to 30 seconds, which can be provoked by touching the affected area and which recur for days, weeks, or months. On touching the trigger area, usually around the mouth, patients may experience a shocklike sensation. Depression, chronic analgesic abuse, tension headaches, use of drugs like benzodiazepines, ergotamines, and narcotics can cause chronic daily headaches. NSAIDs are least likely to cause chronic daily headaches; however, other antimigraine medications, aspirin, and caffeine compounds can cause them.

Question 19

or what percentage of persons with seizure disorder does an interictal EEG appear normal?
A. 1%
B. 5%
C. 10%
D. 20%
E. 50%

Answer 19

D. 20%

There are two major seizure categories: partial seizures and primary generalized seizures. In primary generalized seizures, the thalamus or subcortical structures generate discharges, which spread upward to excite the entire cerebral cortex; these seizures are bilateral, symmetric, and without focal clinical or EEG findings.

Question 20

Which of the following is the phenomenon in which a focal seizure undergoes secondary generalization and spreads along the entire cortex?
A. Todd's palsy
B. Generalized status epilepticus
C. Jacksonian march
D. Uncinate seizures
E. Rolandic seizures

Answer 20

C. Jacksonian march

A partial seizure with elementary motor symptoms may begin in a limited body region and undergo secondary generalization. This progression is called Jacksonian march. A postictal monoparesis or hemiparesis is called Todd’s palsy and may persist for up to 24 hours. Partial seizures with olfactory symptoms are called uncinate seizures because olfactory hallucinations result from discharges in the amygdala or uncus. Rolandic epilepsy is the most common cause of childhood epilepsy; it begins between the ages of 5 and 9 and occurs in boys.

Question 21

Post-traumatic seizures are associated with all of the following except
A. Increased incidence as time passes after injury
B. Increased incidence with alcohol abuse
C. Depressed skull fracture
D. Linear fracture
E. Intracranial hematoma
F. Penetrating wound

Answer 21

D. Linear fracture

Post-traumatic seizure disorder is one of the most common complications of major traumatic brain injury, occurring in up to 50% of patients following major injury. Incidence increases in association with penetrating injuries, the presence of intracranial bleeding, and depressed fractures of the skull. The disorder is not particularly associated with linear fractures of the skull. The incidence is higher in patients using alcohol. The incidence increases, rather than decreases, as time passes after injury.

Question 22

Which of the following is NOT a manifestation of partial complex seizures?
A. They always have impaired consciousness.
B. Patients may have amnesia for the event.
C. They are usually accompanied by violent acts.
D. Tonic-clonic activity is not usually present.
E. They may consist only of simple purposeless repetitive movements.

Answer 22

C. They are usually accompanied by violent acts.

Violent acts may accompany the seizure but are not common. Partial complex seizures begin in late childhood through the early 30s. This is the most common seizure variety, affecting about 65% of patients. Most patients only display a blank stare during which they are inattentive or uncommunicative. They always have impaired consciousness and may have memory loss. Physical manifestations usually only consist of automatisms like lip smacking, fumbling, scratching, and rubbing. About 40% of patients have elevated prolactin level after the seizure.

Question 23

Which of the following is a feature of frontal lobe seizures?
A. Gradual onset
B. Absence of aura
C. Duration longer than 1 hour
D. Detectable by EEG
E. Postictal confusion lasting more than 1 hour

Answer 23

B. Absence of aura

Frontal lobe seizures often arise abruptly without an aura and are of relatively short duration (

Question 24

Which of the following is not associated with seizures?
A. Random kicking
B. Verbal abuse
C. Screaming
D. Murder
E. Damage to property

Answer 24

D. Murder

Planned aggressive acts do not happen during a seizure episode. Random violent acts like kicking, verbal abuse, screaming, and damage to property can occur.

Question 25

Which of the following is true of psychosis related to epilepsy? A. Symptoms are usually depressive. B. Affect is normal. C. Deterioration of personality is seen. D. Increased family incidence of schizophrenia. E. Symptoms arise in late teens.

Answer 25

B. Affect is normal. Schizophrenia-like symptoms are seen in up to 10% of patients with partial complex seizures. Symptoms such as hallucinations and paranoia are seen. However, their affect is relatively normal, they do not deteriorate, and the incidence of schizophrenia in the family is not increased. There is no deterioration of personality and symptoms arise on an average when patients are about 30 years old.

Question 26

``` Which of the following may be the cause of confusion in a person with epilepsy? A. Postictal confusion B. Antiepileptic drug intoxication C. Status epilepticus D. Stopping drugs E. All of the above ```

Answer 26

E. All of the above Confusion can be caused by postictal confusion, antiepileptic drug intoxication, status epilepticus, or stopping antiepileptic drugs.

Question 27

``` What is the most common site of lesion in partial complex seizures? A. Parietal lobe B. Temporal lobe C. Occipital lobe D. Frontal lobe E. Cerebellum ```

Answer 27

A. Parietal lobe Partial complex seizures have a temporal lobe focus in about 90% of patients.

Question 28

``` 7-year-old boy suddenly starts staring while in the middle of a conversation. He is mute, rolls up his eyes, and blinks. After about 3 seconds, he resumes talking. What is the most likely diagnosis? A. Partial complex seizure B. Tonic-clonic seizures C. Rolandic seizures D. Absence seizure E. Focal seizure ```

Answer 28

D. Absence seizure

Question 29

``` Which of the following is characteristic of absence seizures? A. Presence of aura B. Simple repetitive movements C. Treatment with carbamazepine D. Duration of 1 to 10 seconds E. Autosomal recessive inheritance ```

Answer 29

D. Duration of 1 to 10 seconds Absence seizures do not have auras or postictal confusion. Valproate and ethosuximide are the preferred treatments.

Question 30

Which of the following is more likely to occur in a pseudoseizure than in a true seizure? A. A tonic phase B. Incontinence C. Elevated prolactin level after the seizure D. Absence of postictal depression on the EEG E. Self-injury

Answer 30

D. Absence of postictal depression on the EEG Pseudoseizures or psychogenic nonepileptic seizures are psychogenic seizure-like episodes. They can be present in patients with true seizures. They develop slowly and are accompanied by prominent flailing, struggling, agitation, and alternating limb movements. The duration of 2 to 5 minutes is longer than the average epileptic seizure. They usually have no tonic phase or incontinence. Consciousness is preserved and patients have no postictal symptoms like confusion, headache, or retrograde amnesia. The EEG obtained during a pseudoseizure is normal, and a postictal EEG does not show postictal depression. The serum prolactin concentration is not elevated. EEG video monitoring can help differentiate pseudoseizures from an epileptic seizure. Self-injury is rare, although patients may bite the lip or tip of the tongue rather than the side of the tongue as in epilepsy.

Question 31

``` Ipsilateral paralysis of the soft palate and pharynx, producing hoarseness and dysphagia is caused by paralysis of which of the following? A. Fifth cranial nerve B. Seventh cranial nerve C. Tenth cranial nerve D. Eleventh cranial nerve E. Twelfth cranial nerve ```

Answer 31

C. Tenth cranial nerve Axons of the tenth cranial nerve innervate the soft palate and pharynx. Damage to these axons causes dysphagia, hoarseness, and paralysis of the soft palate. These symptoms can be caused by damage to the ninth cranial nerve as well.

Question 32

``` Which of the following is required for a definitive diagnosis of carotid artery stenosis? A. CT scan B. Arteriography C. Doppler ultrasound D. EEG E. SPECT ```

Answer 32

B. Arteriography A definitive diagnosis of carotid artery stenosis is made by arteriography. However, because arteriography acquires catheterization, magnetic resonance angiography is preferred. Doppler ultrasonography (ultrasound) is also reliable for revealing carotid artery stenosis.

Question 33

``` A 45-year-old man presents vertigo and tinnitus, the onset of which was sudden. He also reports vomiting. Upon examination, he is observed to have numbness around the mouth and nystagmus and to be ataxic. Which artery is most likely involved? A. Anterior cerebral B. Middle cerebral C. Vertebrobasilar D. Carotid E. Anterior common ```

Answer 33

C. Vertebrobasilar The symptoms are most suggestive of involvement of the vertebrobasilar system, which supplies the brainstem, cerebellum, and posterior inferior cerebrum. The symptoms result from brainstem ischemia and include circumoral paresthesias, dysarthria, nystagmus, ataxia, and vertigo. Patients may have drop attacks when generalized brainstem ischemia impairs consciousness and body tone and causes them to collapse.

Question 34

Which of the following is seen in transient global amnesia? A. Impaired general knowledge B. Amnesia for personal information C. Inability to perform tasks learned before the event D. Confabulation E. Anterograde amnesia

Answer 34

E. Anterograde amnesia Basilar artery transient ischemic attacks (TIAs) are the most likely cause of transient global amnesia. TIAs impair circulation in the artery's terminal branches, the posterior cerebral arteries, which supply the temporal lobe, thus causing temporary amnesia. Patients cannot learn new information; that is, they have anterograde amnesia. They also have retrograde amnesia. General knowledge and personal information is retained. There is no confabulation, and the motor system is completely spared. The TIAs happen in middle-aged and older individuals. They have a sudden onset and the recurrence rate is about 10%.

Question 35

``` Transient global amnesia is most commonly caused by a TIA in which of the following arteries? A. Anterior cerebral B. Posterior cerebral C. Anterior communicating D. Anterior common E. Carotid ```

Answer 35

B. Posterior cerebral

Question 36

``` Which of the following is not a risk factor for stroke? A. Atrial fibrillation B. Diabetes mellitus C. Migraine D. Cigarette smoking E. Type A personality ```

Answer 36

E. Type A personality The greatest risk factor for strokes is age. Hypertension, valvular disease, acute MI, and atrial fibrillation are other cardiovascular risk factors. Diabetes mellitus, cigarette smoking, migraines, and drug abuse are also risk factors. Type A personality and stress have not been shown to be risk factors.

Question 37

``` Which of the following is caused by a lesion in the pons? A. Oculomotor nerve paresis B. Limb ataxia C. Horner syndrome D. Palatal paresis E. Abducens nerve palsy ```

Answer 37

E. Abducens nerve palsy Lesions of the pons cause abducent nerve and contralateral palsy. Oculomotor nerve palsy is caused by lesions of the midbrain. Lateral medullary infarctions cause ipsilateral ataxia, Horner syndrome, contralateral hypalgesia, and palatal paresis.

Question 38

``` All of the following can occur in cerebellar hemorrhage except A. Contralateral lower limb hemiparesis B. Occipital headache C. Gait ataxia D. Dysarthria E. Lethargy ```

Answer 38

A. Contralateral lower limb hemiparesis Cerebral hemorrhages are characterized by occipital headaches, gait ataxia, dysarthria, and lethargy. They should be evacuated immediately as a life-saving step. Contralateral lower limb paresis is caused by occlusion of the anterior cerebral artery.

Question 39

``` Poststroke depression is classically associated with lesion in which of the following? A. Right frontal lobe B. Right parietal lobe C. Left frontal lobe D. Left temporal lobe E. Occipital lobe ```

Answer 39

C. Left frontal lobe Poststroke depression may affect 30-50% of patients following a stroke. The classic association of depression following stroke is with lesion in the left frontal region of the brain. However, this has not been supported by recent studies. (It is still reasonable to answer “left frontal” to exam questions about lesion associated with depression nonetheless.) It has been suggested that depression immediately following stroke could be due to lesion in the left frontal region, whereas in the long term it is more likely to be associated with right occipital lesions.

Question 40

Poststroke depression is associated with all of the following EXCEPT: A. Older age of patient B. Greater functional disability C. Increased risk of subsequent stroke D. Increased risk of subsequent myocardial infarction E. Good response to MAOIs

Answer 40

E. Good response to MAOIs A number of factors are associated with poststroke depression; among them are the age of the patient and the degree of functional disability. Being depressed also places patients at greater risk of a further stroke, myocardial infarction, and death. Only nortriptyline, citalopram, and fluoxetine have been studied in the treatment of poststroke depression.

Question 41

``` Which of the following is not seen in locked-in syndrome? A. Quadriplegia B. Muteness C. Cognitive deficits D. Normal EEG ```

Answer 41

C. Cognitive deficits The locked-in syndrome results from an infarction of the base or ventral surface of the pons due to occlusion of the basilar artery. Patients are mute because of bulbar palsy and quadriplegic because of interruption of the corticospinal tract. The upper brainstem and connections with the cerebral cortex are intact, and hence patients are alert and retain normal cognition.

Question 42

``` Which of the following is seen in persistent vegetative state? A. Absence of all reflexes B. Suspended animation C. Incontinence D. Lack of eye movements ```

Answer 42

C. Incontinence Massive cerebral injury can result in a persistent vegetative state. Patients are unaware of themselves or their surroundings, devoid of cognitive capacity, and unable to interact or communicate in any manner. They are bedridden with quadriparesis and incontinence. Patients are neither in suspended animation nor prolonged sleep. Eye movements are present.

Question 43

``` Which of the following is a feature of carotid artery occlusion? A. Vertigo B. Nystagmus C. Diplopia D. Monocular amaurosis fugax E. Cortical blindness ```

Answer 43

D. Monocular amaurosis fugax Carotid artery occlusion causes monocular amaurosis fugax. The other symptoms are caused by basilar artery occlusion.

Question 44

``` A 58-year-old man presents with paralysis of the right side of the lower face, deviation of the tongue with no atrophy or loss of taste, and right spastic paralysis of the limbs. Where is the lesion most likely to be? A. Left internal capsule B. Right internal capsule C. Right base of medulla D. Left base of medulla ```

Answer 44

A. Left internal capsule All of these deficits are caused by lesion in the left internal capsule. Since the motor fibers from the cortex that supply all three of these regions are crossed, a lesion in the internal capsule will produce these deficits.

Question 45

``` Which of the following most accurately describes the pathologic process in multiple sclerosis? A. Inflammatory B. Infectious C. Degenerative D. Demyelinating E. Metabolic ```

Answer 45

D. Demyelinating Multiple sclerosis is a demyelinating disease. Demyelinated plaques are scattered throughout the optic nerve, brain, and spinal cord. Demyelinated patches cause neurologic deficits because axons deprived of their myelin sheath cannot properly transmit nerve impulses. The deficits resolve as the inflammation spontaneously subsides. The most common course is relapsing-remitting, and it is also the most amenable to treatment.

Question 46

Which of the following is NOT true of multiple sclerosis? A. It is a multiphasic disease. B. It is asymmetric. C. It affects deep white matter. D. It is associated with perivascular infiltration of plasma cells. E. Spontaneous recovery never occurs.

Answer 46

E. Spontaneous recovery never occurs.

Question 47

Which of the following is true of multiple sclerosis? A. Seizures are common. B. Mean age of onset is 15 years. C. Incidence is equal worldwide. D. Onset is usually monosymptomatic. E. Progressive relapse is the most common variety.

Answer 47

D. Onset is usually monosymptomatic. The most frequent symptoms of multiple sclerosis are caused by plaques on the white-matter tracts of the spinal cord, brainstem, and optic nerves. Symptoms may begin between 15 and 50 years of age; the mean age of onset is 33 years. The incidence is greatest in patients who have lived in cool northern latitudes of the United States and Europe. There are three variants of disease progression: the disease most commonly begins with a relapsing-remitting (RR) course; primary-progressive (PP) MS is a gradual decline; secondary-progressive (SS) is RR followed by PP. Progressive-relapsing (PR) MS is rare.

Question 48

``` Which of the following is not a feature of multiple sclerosis? A. Optic neuritis B. Involuntary movement disorders C. Incontinence D. Impaired gait E. Impotence ```

Answer 48

B. Involuntary movement disorders Multiple sclerosis does not cause involuntary movement disorders. Symptoms include ataxia, tremors, trigeminal neuralgia, optic neuritis, nystagmus, internuclear ophthalmoplegia, diplopia, paresis with hyperactive deep tendon reflexes and Babinski sign, sexual impairment, generalized fatigue, and depression.

Question 49

``` Which MRI finding is most closely correlated with cognitive impairment? A. Enlarged lateral ventricles B. Atrophy of the corpus callosum C. Total lesion load D. Periventricular lesions E. Cerebellar atrophy ```

Answer 49

C. Total lesion load Cognitive impairment and dementia induced by multiple sclerosis correlate with physical disability, duration of illness, enlarged cerebral ventricles, atrophy of the corpus callosum, periventricular white-matter demyelination, total lesion load as shown by MRI, and cerebral hypometabolism as shown by PET. Of these, the closest correlation is with “lesion load” (number of lesions) detected by MRI.

Question 50

``` What is the concordance rates of multiple sclerosis in monozygotic twins? A. 5% B. 10% C. 30% D. 50% E. 100% ```

Answer 50

C. 30% The concordance rate among monozygotic twins is 30%; among dizygotic twins it is 5%

Question 51

``` All of the following are features of Guillain-Barre syndrome except A. Symmetric paresis B. Psychosis C. Flaccidity D. Areflexia E. Monophasic paresis ```

Answer 51

B. Psychosis Guillain-Barre syndrome is a demyelinating disease of the peripheral nervous system. It affects young and middle-aged adults and causes paraparesis or quadriparesis. It is characterized by a single monophasic attack, lasting weeks to months, of symmetric, flaccid, areflexic paresis. It does not cause cognitive impairment or psychosis.

Question 52

``` Which of the following may be the cause of central pontine myelinolysis? A. Hypokalemia B. Hyponatremia C. Rapid correction of hyponatremia D. Hypernatremia E. Hyperthyroidism ```

Answer 52

C. Rapid correction of hyponatremia Central pontine myelinolysis is caused by rapid correction of hyponatremia. It is associated with severe debilitating illnesses. Delayed appearance of an acute spastic quadriparesis with pseudobulbar palsy is the classic manifestation. Behavioral changes and decreased consciousness are also seen.

Question 53

``` Postinfectious encephalomyelitis is commonly seen after which of the following? A. Chickenpox B. Rubella C. Measles D. Mumps E. Herpes simplex ```

Answer 53

C. Measles Measles does not usually acutely affect the central nervous system, but in 1 in 1,000 patients with measles, on average at 5 days after the onset of the rash, it produces a postinfectious, immune-mediated encephalomyelitis. This results in death in 10% of patients and severe sequelae with seizures, mental regression, and focal deficits in others.

Question 54

``` Loss of which of the following occurs in Huntington disease? A. Serotonin B. Dopamine C. Substance P D. Acetylcholine and GABA ```

Answer 54

D. Acetylcholine and GABA In Huntington disease, there is a reduction in acetylcholine and GABA in the basal ganglia.

Question 55

``` Which of the following is NOT a feature of Parkinson disease? A. Tremor B. Rigidity C. Bradykinesia D. Increased blinking E. Micrographia ```

Answer 55

D. Increased blinking Parkinson disease is characterized by tremor, rigidity, bradykinesia, masked facies, paucity of movement, micrographia, and decreased blinking and facial expression.

Question 56

``` Which of the following is seen in Parkinson disease? A. Bilateral onset B. Essential tremors C. Loss of postural reflexes D. Loud speech E. Lead-pipe rigidity ```

Answer 56

C. Loss of postural reflexes Symptoms in Parkinson disease develop in an asymmetric or unilateral pattern. The tremor is most evident at rest. As the disease progresses, patients lose their postural reflexes. This, in combination with akinesia and rigidity results in a festinating gait, is characterized by a tendency to lean forward and accelerate the gait. The voice becomes low in volume and monotonous. Rigidity is classically of the cogwheel variety.

Question 57

``` All of the following are common presentations of psychosis in patients with Parkinson disease EXCEPT: A. Auditory hallucinations B. Visual hallucinations C. Delusions D. Paranoid ideas E. Nighttime worsening of symptoms ```

Answer 57

A. Auditory hallucinations Psychosis is seen in about 10% of patients with Parkinson disease. It is associated with dementia, older age, long-standing illness, and excessive levels of antiparkinsonian medication. The most common manifestations are visual hallucinations, delusions, paranoia, and chronic confusion with a nighttime worsening of symptoms. Auditory hallucinations are rarely seen. Typical antipsychotics should be avoided. Clozapine and quetiapine are considered the best medications to use because they do not exacerbate parkinsonism.

Question 58

``` Which of the following describes dementia associated with Parkinson disease? A. Aphasia B. Apraxia C. Agnosia D. Sudden onset E. Difficulty shifting mental sets ```

Answer 58

E. Difficulty shifting mental sets Dementia affects about 20% of patients with Parkinson disease and is more common with increased duration of the illness. It increases in proportion to physical impairments, especially bradykinesia. The dementia associated with Parkinson disease is a subcortical dementia characterized by inattention, poor motivation, difficulty shifting mental sets, slowed thinking, and gait impairment. Aphasia, apraxia, and agnosia are symptoms of cortical dementia. A sudden onset usually excludes a diagnosis of dementia and warrants a search for other causes.

Question 59

``` Which of the following symptoms does not respond to antiparkinsonian agents? A. Tremor B. Rigidity C. Hallucinations D. Bradykinesia E. Disturbances of gait ```

Answer 59

C. Hallucinations Hallucinations do not respond to antiparkinsonian drugs and may in fact be worsened by them because of increased dopamine.

Question 60

``` Antipsychotic-induced parkinsonism is related to blockade of which of the following receptors? A. D1 B. D2 C. D3 D. D4 E. D5 ```

Answer 60

B. D2 The tendency of typical antipsychotics to produce parkinsonism is related to their ability to block D2 receptors. Risperidone in doses more than 6 mg also can cause parkinsonism. Other medications, like metoclopramide, cisapride, trimethobenzamide, and prochlorperazine, also block D2 receptors and cause parkinsonism.

Question 61

``` Which of the following antipsychotic medications has no effect on dopamine 2 (D2) receptors? A. Risperidone B. Quetiapine C. Haloperidol D. Olanzapine E. Chlorpromazine ```

Answer 61

B. Quetiapine Quetiapine and clozapine have very little affinity for D2 receptors and hence do not cause parkinsonism.

Question 62

``` Which of the following is the most disabling feature of Parkinson disease? A. Tremor B. Rigidity C. Masklike facies D. Bradykinesia E. Micrographia ```

Answer 62

D. Bradykinesia Bradykinesia is reported by patients to be the most disabling symptom of parkinsonism. Tremor and rigidity are also distressing. Masklike facies and micrographia do not cause disability.

Question 63

``` Which of the following causes the abrupt onset and remission of parkinsonian symptoms after years of well-controlled antiparkinsonian treatment? A. Absence attacks B. Drug toxicity C. On-off phenomenon D. Treatment resistance E. Acute dystonia ```

Answer 63

C. On-off phenomenon Patients with Parkinson disease who have been well controlled on medication for years may suddenly develop symptoms of parkinsonism, which may remit abruptly. The mechanism for this is not well understood and is called on-off phenomenon.

Question 64

``` Which of the following denotes slow, regular, twisting movements that are bilateral and affect distal parts of limbs? A. Tremors B. Athetosis C. Dystonia D. Chorea E. Tardive dyskinesia ```

Answer 64

B. Athetosis Athetosis is the slow, regular, continual twisting movements that are typically bilateral and symmetric and affect distal parts of the limbs. Chorea consists of random, discrete, brisk movements that jerk the pelvis, trunk, and limbs. The walking gait has an irregular, jerky pattern. Dystonia consists of involuntary movements caused by muscle contraction.

Question 65

``` What is the mode of transmission of Huntington disease? A. X-linked recessive B. Autosomal recessive C. Autosomal dominant D. Polygenic inheritance E. Sex-linked dominant ```

Answer 65

C. Autosomal dominant Huntington disease is autosomal dominant and is characterized by chorea and dementia. Occasionally sporadic cases may be seen.

Question 66

``` Which of the following is seen in Huntington disease? A. Depression B. Psychosis C. Euphoria D. Suicide E. All of the above ```

Answer 66

E. All of the above A variety of psychiatric sequelae are seen with Huntington disease. Depressive symptoms are the most common. A high rate of affective disorders, including bipolar disorder, has been reported. Paranoid symptoms and schizophrenia are more common than in the general population, although the incidence of schizophrenia among relatives is not increased. Dementia is usual in the later stages and insight is preserved until late. Patients are also prone to commit suicide.

Question 67

``` What is most common initial site of development of chorea in patients with Huntington disease? A. Face B. Upper limbs C. Trunk D. Lower limbs E. Muscles of deglutition ```

Answer 67

A. Face The most common initial site of development of chorea is the face. The chorea may consist of only excessive facial gestures (grimaces) or hand gestures and twitchiness. It interferes with normal eye movements, and patients have difficulty making sudden and smooth shifts of gaze. It also affects movements of the upper limbs, trunk, lower limbs, and the swallowing muscles.

Question 68

``` Which of the following pathologic changes is seen in Huntington disease? A. Cortical atrophy B. Atrophy of corpus striatum C. Dilatation of lateral ventricles D. Atrophy of thalamus E. All of the above ```

Answer 68

E. All of the above The characteristic gross pathologic finding in Huntington disease is atrophy of the caudate nuclei. The corpus striatum consists of the caudate, putamen, and globus pallidus. The loss of caudate nuclei permits the lateral ventricles to balloon outward and become voluminous. The cerebral cortex also undergoes atrophy as the illness progresses. There is atrophy of the thalamus as well. PET studies demonstrate caudate hypometabolism early in the illness.

Question 69

``` Where is the gene responsible for Huntington disease located? A. Chromosome 4 B. Chromosome 5 C. Chromosome 11 D. Chromosome 13 E. Chromosome 17 ```

Answer 69

A. Chromosome 4 The Huntington gene responsible for Huntington disease lies on the short arm of chromosome 4. The Huntington gene is unstable and tends to expand further in successive generations. The progressive expansion and amplification explains why carriers in successive generations show signs at younger ages.

Question 70

``` Which of the following is a feature of hemiballismus? A. Cognitive impairment B. Contralateral hemiparesis C. Unilateral flinging motion D. Spasticity E. Hyperreflexia ```

Answer 70

C. Unilateral flinging motion Hemiballismus consists of intermittent gross movements on one side of the body. The movements are usually unilateral and consist of a flinging motion. The lesion is usually in the caudate nucleus or other basal ganglia structures. No cognitive impairment, paresis, or corticospinal tract signs accompany hemiballismus.

Question 71

``` Which of the following is caused by lesion in the subthalamic nucleus? A. Tremors B. Tardive dyskinesia C. Hemiballismus D. Akathisia ```

Answer 71

C. Hemiballismus Lesions in the subthalamic nucleus result in hemiballismus.

Question 72

``` Akinetic mutism is caused by lesions in which of the following areas? A. Right temporal lobe B. Left parietal lobe C. Right frontal lobe D. Pons and midbrain E. Right parietal lobe ```

Answer 72

D. Pons and midbrain Strokes in the pons and midbrain, which often result from occlusion of the basilar artery, can produce coma or a variant called akinetic mutism. The EEG shows a pattern associated with slow wave sleep, but eye movements are preserved.

Question 73

``` Which of the following is produced by lesions of the lateral hypothalamus? A. Increased thirst B. Aphagia C. Hyperthermia D. Hyperphagia ```

Answer 73

B. Aphagia Aphagia is produced by a lesion of the lateral hypothalamus. The lateral hypothalamus is the “hunger center” and the ventromedial hypothalamus is the “satiety center.” The preoptic region regulates temperature and thirst.

Question 74

``` All of the following are features of Lesch-Nyhan syndrome EXCEPT: A. Dystonia B. Self-mutilation C. Seizures D. Normal intelligence E. Hyperuricemia ```

Answer 74

D. Normal intelligence Lesch-Nyhan syndrome is a sex-linked recessive condition. Affected children, aged between 2 and 6 develop dystonia, self-mutilation, mental retardation, corticospinal tract signs, seizures, and hyperuricemia. The basic abnormality is a deficiency of hypoxanthine guanine phosphoribosyl transferase (HGPRT), which is an enzyme required for urea metabolism.

Question 75

``` What is the most common involuntary movement disorder? A. Parkinson disease B. Acute dystonia C. Essential tremor D. Focal dystonia E. Tardive dystonia ```

Answer 75

C. Essential tremor The most common involuntary movement disorder is essential tremor. Parkinson disease is the second most common, but it causes the most disability.

Question 76

``` Which of the following is NOT true of essential tremor? A. It has a frequency of 6-9 Hz. B. It develops in young adults. C. Anxiety may increase the tremor. D. Alcohol worsens the tremor. E. Beta-blockers suppress the tremor. ```

Answer 76

D. Alcohol worsens the tremor. Patients with essential tremor have fine tremors (measured as oscillation between 6 and 9 Hz) of the wrist, hands, or fingers. Essential tremor usually develops in young and middle-aged adults. It follows a pattern of autosomal dominant inheritance with variable penetrance. Family history is present in about 30%. Anxiety can intensify tremor. Almost 50% of patients have a resolution of the tremors with alcohol. Beta-blockers can suppress tremors.

Question 77

``` Klüver-Bucy syndrome is caused by lesions in which of the following regions? A. Cingulate gyrus B. Medial hypothalamus C. Lateral hypothalamus D. Amygdala ```

Answer 77

D. Amygdala Klüver-Bucy syndrome is manifested by hyperorality and hypersexuality. It results from lesions in the temporal lobe in which parts of the amygdala are involved.

Question 78

Which of the following is true regarding chronic inflammatory demyelinating polyneuropathy? A. It is most common in the third and fourth decades of life. B. It typically shows predominantly motor involvement. C. Proximal and distal groups of muscles are equally involved. D. Muscle wasting is commonly seen. E. Pain is common.

Answer 78

C. Proximal and distal groups of muscles are equally involved. CIDP is most commonly seen in the fifth and sixth decades of life. It typically shows symmetric motor and sensory involvement. Wasting is rarely seen, and pain is uncommon. Proximal and distal muscles are equally involved, and lower limbs are more severely involved.

Question 79

``` What is the most common central nervous system infection in patients with AIDS? A. Tuberculosis B. Cytomegalovirus C. Toxoplasmosis D. Cryptococcus E. Herpes simplex ```

Answer 79

C. Toxoplasmosis The most common infection of the central nervous system in patients with AIDS is toxoplasmosis. Tuberculosis, cytomegalovirus, cryptococcus, and herpes simplex also have an increased prevalence in patients with AIDS.

Question 80

Which of the following characterizes astrocytomas in adults? A. The cure rate is 90%. B. Extensive infiltration to surrounding structures occurs. C. The cerebellum is the most common site. D. They do not evolve into more malignant forms. E. Total surgical removal is possible without sacrificing surrounding structures.

Answer 80

B. Extensive infiltration to surrounding structures occurs. Astrocytomas arise from the astrocytes, which are glial cells. They affect children and adults. In children, they tend to be cystic and are located in the cerebellum and brainstem. They may be totally removed and have a cure rate of about 90%. In adulthood, they occur predominantly in the cerebrum, infiltrate extensively, and may evolve into more malignant forms like glioblastomas. Total surgical removal requires sacrificing surrounding structures. Cure rates are low.

Question 81

Which of the following is true about meningiomas? A. They arise from glial cells. B. They are associated with neurofibromatosis type 1. C. They are common in children. D. Radiotherapy is the treatment of choice. E. They are metastatic tumors.

Answer 81

B. They are associated with neurofibromatosis type 1. Meningiomas arise from cells of the meninges. They are often associated with neurofibromatosis type 1. They grow slowly and develop almost exclusively in adults. They cause symptoms by compressing the underlying brain and spinal cord. Most meningiomas can be totally removed by surgery.

Question 82

``` Which of the following is the most common origin of metastatic tumor in the brain? A. Breast B. Bone C. Prostate D. Kidney E. Lung ```

Answer 82

E. Lung Metastatic tumors spread through the blood into the brain and spinal cord. They tend to be multiple, surrounded by edema, and grow rapidly. The most common site of origin is the lung. Other sites include breast, kidney, skin, bone, and prostate. Gastrointestinal and pelvic cancers rarely spread to the brain.

Question 83

Which of the following is NOT a typical feature of an intracranial neoplasm? A. Partial complex seizure B. Headache accompanied by vomiting C. Petit mal seizures D. Headache worse in the morning E. Headache is the presenting clinical feature in almost 35% of the patients.

Answer 83

C. Petit mal seizures Petit mal or absence seizures are not seen with intracranial neoplasms. Seizures are usually either partial elementary or partial complex. Tumors can cause headaches, accompanied by nausea and vomiting, which are worse early in the morning, predominantly unilateral, and may wake patients up from sleep. Increased intracranial pressure can develop and can cause generalized, nonspecific cognitive changes and papilledema. Tumors can also cause hemiparesis and cranial nerve palsies. Headache is the presenting clinical feature in almost 35% of patients.

Question 84

Which of the following visual field effects is classically produced by pituitary adenomas? A. Left central scotoma B. Bilateral scotoma C. Bitemporal hemianopia D. Left homonymous hemianopia E. Bitemporal inferior quadrant hemianopia

Answer 84

C. Bitemporal hemianopia Pituitary adenomas, by pressure on the optic chiasma, can cause bitemporal hemianopia. They also cause headaches, hormonal irregularities including infertility, amenorrhea, decreased libido, anergia, apathy, and listlessness. The investigation of choice is an MRI.

Question 85

``` Which of the following is NOT a feature of acoustic neuroma? A. Tinnitus B. Vertigo C. Loss of smell D. Hearing impairment E. Imbalance ```

Answer 85

C. Loss of smell Acoustic neuroma is caused by the proliferation of the Schwann cells of the eighth cranial nerve. It develops in the internal auditory canal and cerebellopontine angle and may compress adjacent structures. Symptoms include hearing impairment, tinnitus, imbalance, and vertigo. If it compresses the fifth cranial nerve, patients develop facial sensory loss. With compression of the seventh cranial nerve, facial muscle weakness develops.

Question 86

``` Spinal-cord compression can cause all of the following EXCEPT: A. Depression B. Cognitive impairment C. Paraplegia D. Loss of sensation E. Incontinence of urine ```

Answer 86

B. Cognitive impairment Spinal cord compression causes pain, quadriplegia, paraplegia, loss of sensation, and incontinence of urine and feces. Cognitive capacity is preserved though depression may ensue.

Question 87

``` Alpha activity on an EEG is most prominent with which of the following? A. Eyes open B. Concentration C. Anxiety D. Eyes closed ```

Answer 87

D. Eyes closed Alpha activity is EEG activity with a frequency of 8-13 Hz. It is most prominent on the occipital leads with eyes closed.

Question 88

``` A thin 68-year-old man presents with headaches that began 1 month earlier. Likely causes include all of the following except A. Brain tumor B. Subdural hematoma C. Pseudotumor cerebri D. Temporal arteritis E. Nitroglycerin medication ```

Answer 88

C. Pseudotumor cerebri Pseudotumor cerebri is characterized by excessive fluid accumulation in the brain parenchyma. It may cause headache, papilledema, and visual field defects. It affects obese young women.

Question 89

``` A 50-year-old woman presents with a complaint of “the worst headache in my life.” This was followed by a loss of consciousness, after which the patient recovers. What is the most likely cause? A. Middle meningeal artery occlusion B. Trauma of bridging meningeal veins C. Vertebrobasilar artery occlusion D. Rupture of a berry aneurysm E. Rupture of posterior cerebral artery ```

Answer 89

D. Rupture of a berry aneurysm This is a typical presentation of subarachnoid hemorrhage, the most common cause of which is rupture of a berry aneurysm. Symptoms include sudden onset of headaches and nuchal rigidity. This is usually preceded by physical exertion. CT or MRI reveals blood in the subarachnoid space at the base of the brain, and lumbar puncture reveals bloody cerebrospinal fluid (CSF).

Question 90

``` What is the most common cause of major head trauma in persons 15 to 24 years old? A. Physical assaults B. Sporting injuries C. Motor vehicle accidents D. Suicide attempts E. Domestic falls ```

Answer 90

C. Motor vehicle accidents Motor vehicle accidents are the most common cause of head trauma in adolescence and early adulthood.

Question 91

``` In traumatic brain injury, lesion in which of the following regions is most closely correlated with the impairment it produces? A. Right parietal B. Left frontal C. Left temporal D. Occipital E. Right temporal ```

Answer 91

C. Left temporal Lesion to the left temporal region has the closest correlation with the impairment produced. Frontal lobe trauma is the most common.

Question 92

``` All of the following are features of postconcussional syndrome except A. Anxiety B. Depression C. Fatigue D. Poor concentration E. Schizophrenia ```

Answer 92

E. Schizophrenia Schizophrenia, by definition, exists in the absence of any brain injury or substance use. Psychotic symptoms are not part of a postconcussional syndrome. Postconcussional syndrome is the most important long-term consequence of minor head trauma. The core symptoms are headaches, memory impairment, and insomnia lasting 2 to 3 months after a concussion. Other symptoms include anxiety, depression, fatigue, and poor concentration.

Question 93

``` Personality change following head injury is most commonly seen after injury to which of the following? A. Caudate nuclei B. Frontal lobe C. Parietal lobe D. Occipital lobe E. Cerebellum ```

Answer 93

B. Frontal lobe Personality change following head injury is most common after injury to the frontal or temporal lobe. Damage to the frontal lobe impairs the brain's inhibitory centers, which can lead to aggressiveness and emotional lability.

Question 94

``` What is the most commonly seen psychiatric manifestation of neurosyphilis? A. Mania B. Schizophrenia C. Depression D. Anxiety E. Obsessive-compulsive disorder ```

Answer 94

C. Depression The most common psychiatric manifestation of neurosyphilis is depression. Dementia is common as well. Although euphoria and mania are also seen, they are not as common as depressi

Question 95

``` In which of the following conditions is the cerebrospinal fluid clear on lumbar puncture? A. Bacterial meningitis B. Neurosyphilis C. Tuberculus meningitis D. Subarachnoid hemorrhage E. Fungal meningitis ```

Answer 95

B. Neurosyphilis When tested by means of lumbar puncture, cerebrospinal fluid is clear in neurosyphilis and also in Guillain-Barre (GB) syndrome. It is turbid with bacterial, tuberculous, and fungal meningitis. It may be either clear or turbid with viral meningitis. Bloody CSF is found in subarachnoid hemorrhage.

Question 96

``` Decreased glucose levels in the cerebrospinal fluid on lumbar puncture is seen in all of the following except A. Bacterial meningitis B. Viral meningitis C. Tuberculous meningitis D. Fungal meningitis ```

Answer 96

B. Viral meningitis Normal CSF glucose of 50 to 80 mg per dl is seen in viral meningitis and Guillain-Barre syndrome. It is decreased in all the other conditions mentioned.

Question 97

Which of the following is true regarding Creutzfeldt-Jakob disease? A. The age group most commonly affected is young adults. B. The disease is self-limiting. C. Presents with dementia and myoclonus. D. It is a viral infection. E. Patients have a lifespan of about a decade from diagnosis.

Answer 97

Presents with dementia and myoclonus. CJD is an infection with a prion, which is a subviral replicative protein. It causes a rapidly progressive cortical pattern dementia. The age of onset is in the sixth or seventh decade. Clinical symptoms initially may be nonspecific, but later, symptoms like dementia, myoclonus, and pyramidal and extrapyramidal signs develop. EEG shows diffuse symmetric slow waves. Definitive diagnosis is made on postmortem exam. Death usually ensues within 6 months to 2 years following onset of the illness.

Question 98

Which of the following is NOT true regarding HIV-associated dementia? A. It develops late in the course of disease. B. It is a cortical dementia. C. It causes decreased concentration and increased forgetfulness. D. Aphasia and apraxia are uncommon. E. Behavior problems may be present.

Answer 98

B. It is a cortical dementia. AIDS dementia affects about 20% of all AIDS patients and about 30% to 60% of those in the late stages of their illness. It is a subcortical type of dementia with decreased concentration, forgetfulness, slowed mentation, apathy, and social withdrawal. Aphasia and apraxia, which are cortical signs, are uncommon, at least in the early stages. Motor symptoms like slow limb movements, clumsy and slow gait, frontal signs, ataxia, increased tone, and hyperactive reflexes may present. Behavior problems are common as well.

Question 99

``` What is the most common neuropathy seen in HIV-positive patients? A. Distal symmetric polyneuropathy B. Autonomic neuropathy C. Toxic neuropathy D. Mononeuritis multiplex E. Myeloradiculopathy ```

Answer 99

A. Distal symmetric polyneuropathy Distal symmetric polyneuropathy is the most frequent neuropathy seen in HIV disease. It is usually a painful sensorimotor polyneuropathy. The major symptoms are paresthesias and dysesthesias in the lower extremities, with the upper extremities affected later. Diminution or abolition of tendon reflexes is an invariable sign. Sensation is affected more than motor function in the distal segments, more in the legs than arms. Vibratory sense is involved more than position and tactile senses. Weakness is generally limited to the foot muscles. Toxic neuropathy is associated with anti-retroviral treatment, and autonomic neuropathy is infrequently seen.

Question 100

``` Which of the following has been proven conclusively to be a risk factor for Alzheimer disease? A. NSAIDs B. Aluminum C. Maternal age D. Age E. Male sex ```

Answer 100

D. Age Age is the only proven risk factor for dementia, the incidence of which increases with increasing age. Women have a slightly greater risk of developing dementia. NSAIDs may confer a protective effect. Maternal age per se is not a risk factor for the development of Alzheimer disease. Exposure to aluminum has been postulated to be a risk factor but has not been proven.

Question 101

``` Gene mutation on all of the following chromosomes is associated with Alzheimer disease except A. Chromosome 1 B. Chromosome 15 C. Chromosome 14 D. Chromosome 19 E. Chromosome 21 ```

Answer 101

B. Chromosome 15 Chromosome 15 is not associated with Alzheimer disease. Mutation in three genes (the APP gene on chromosome 21, presenilin-1 (PS1) on chromosome 14, and presenilin-2 (PS2) on chromosome 1) produce the autosomal dominant form of Alzheimer disease, which can manifest as early as the third decade of life. The mutations are rare, highly penetrant, and all carriers develop Alzheimer disease. A polymorphism of the APOE gene on chromosome 19 is also a susceptibility marker for Alzheimer disease. Not all patients with APOE4 develop Alzheimer disease.

Question 102

``` The progression of Alzheimer disease may be delayed by the use of all of the following except A. Radical scavengers B. Antioxidants C. Cholinesterase inhibitors D. Anti-inflammatory drugs E. Antipsychotics ```

Answer 102

E. Antipsychotics Antipsychotic drugs may worsen the cognitive deficits. Agents shown to be helpful in delaying the progression of Alzheimer disease include radical scavengers, antioxidants like vitamin D and selegiline, cholinesterase inhibitors like donepezil, galantamine, and rivastigmine, and anti-inflammatory drugs.

Question 103

In Alzheimer disease, neuroimaging shows all of the following changes except A. Enlargement of ventricles B. Periventricular hyperintensities shown by MRI C. Extensive deep white-matter hyperintensities D. Medial temporal lobe atrophy E. Temporoparietal hypoperfusion shown by SPECT

Answer 103

C. Extensive deep white-matter hyperintensities Deep white-matter hyperintensities are seen in vascular dementia not Alzheimer's. Imaging studies in Alzheimer disease show generalized atrophy and ventricular enlargement with reduced medial temporal lobe width and periventricular white-matter lesions. Single photon emission computed tomography (SPECT) reveals temporoparietal hypoperfusion.

Question 104

``` What is the most frequently seen disturbance of behavior in patients with Alzheimer disease? A. Agitation B. Anxiety C. Irritability D. Apathy E. Dysphoria ```

Answer 104

D. Apathy Answer: D. All of the symptoms mentioned are seen in patients with dementia. However, apathy has been reported most frequently in more than two-thirds of patients. This is followed by agitation, anxiety, irritability, and dysphoria. Disinhibition, delusions, and hallucinations are also common. The frequency and severity of apathy, agitation, dysphoria, and aberrant motor behavior correlate with the degree of cognitive impairment.

Question 105

All of the following are features of linguistic deficits in patients with early Alzheimer disease except A. Impaired word retrieval B. Meaningless speech and nonsense sounds C. Circumlocutionary language D. Impaired comprehension of verbal material E. Simplification of syntax

Answer 105

B. Meaningless speech and nonsense sounds Answer: B. A number of abnormalities of speech are seen in Alzheimer disease. These include impaired word retrieval, circumloculatory language, impaired comprehension of verbal material, and simplification of syntax. In more advanced stages of the disease, speech deteriorates to meaningless speech and nonsense words.

Question 106

``` All of the following are seen in Alzheimer disease except A. Neuronal loss B. Cortical gliosis C. Extraneuronal neurofibrillary tangles D. Neuritic plaques E. Granulovacuolar degeneration ```

Answer 106

C. Extraneuronal neurofibrillary tangles Answer: C. The major pathologic changes in Alzheimer disease include neuronal loss, cortical gliosis, neuritic plaques, granulovacuolar degeneration, and amyloid angiopathy of cerebral vessels. Neurofibrillary tangles are composed of altered microtubule protein “tau.” They are intraneuronal not extraneuronal.

Question 107

All of the following are suggestive of vascular dementia except A. Dementia within 3 months of a stroke B. Presence of delirium C. Abrupt deterioration in cognitive ability D. Stepwise progression of impairment E. Early gait disturbance

Answer 107

B. Presence of delirium Answer: B. The absence of delirium and psychosis are necessary criteria to diagnose vascular dementia. Vascular dementia is a dementing condition produced by ischemia or hemorrhage with brain injury. Classically it is characterized by an abrupt onset, stepwise deterioration, patchy pattern of intellectual deficits, focal neurologic symptoms and signs, history of hypertension, and associated cardiovascular disease. Vascular dementia is most common after the age of 50. Early gait disturbance with falls, urinary symptoms, pseudobulbar palsy, and personality changes also support a diagnosis of vascular dementia.

Question 108

``` Which of the following is not a risk factor for vascular dementia? A. Hypertension B. Diabetes mellitus C. Elevated lipids D. Age E. Female sex ```

Answer 108

E. Female sex Answer: E. Vascular dementia is more common in men than in women. The other risk factors of stroke are also risk factors for vascular dementia.

Question 109

``` In vascular dementia, which of the following does imaging reveal? A. Reduced medial temporal lobe width B. Caudate atrophy C. Cortical atrophy D. Shrinkage of ventricles E. Hypoperfusion of frontal lobes ```

Answer 109

C. Cortical atrophy Answer: C. Vascular dementia is associated with cortical and central atrophy. It is also associated with increased prevalence of infarcts and extensive white-matter change. In particular, bilateral left-sided lesions, diffuse white-matter change, and small infarcts in strategic regions are all important in causing cognitive impairment. SPECT shows patchy multifocal perfusion deficits.

Question 110

Which of the following dementias does not have a vascular etiology? A. Multi-infarct dementia B. Strategic single-vessel-infarct dementia C. Binswanger disease D. Progressive supranuclear palsy E. Lacunar dementia

Answer 110

D. Progressive supranuclear palsy Answer: D. Binswanger disease, one of the causes of multi-infarct dementia, is characterized by extensive ischemic injury of the white matter. Multi-infarct dementia results from the cumulative effect of multiple small-vessel and large-vessel occlusions. Strategic single-vessel infarct dementia is caused by strategically located solitary infarcts. Progressive supranuclear palsy is a chronic progressive disorder associated with eye movement abnormalities, parkinsonism, and dementia; mutations on chromosome 17 account for the majority of cases. Lacunar dementia is caused by multiple small lacunar infarctions of the basal ganglia and thalamus.

Question 111

``` Which of the following features is most likely to distinguish dementia with Lewy bodies from Alzheimer disease? A. Dementia B. Fluctuations in cognitive functions C. Auditory hallucinations D. Depression E. Falls ```

Answer 111

B. Fluctuations in cognitive functions Answer: B. Dementia with Lewy bodies (DLB) should be suspected in the presence of a dementia syndrome with the triad of fluctuating cognitive impairment, extrapyramidal symptoms, and visual hallucinations. Falls are also more likely in DLB although not they are not a feature that distinguishes DLB from Alzheimer disease. Auditory hallucinations, depression, and dementia are seen in both.

Question 112

Which of the following is not seen by neuroimaging in dementia with Lewy bodies? A. Atrophy of medial temporal lobes B. Periventricular white-matter lesions shown by MRI C. Blood flow patterns similar to Alzheimer disease D. Decreased blood flow in basal ganglia

Answer 112

A. Atrophy of medial temporal lobes Answer: A. In dementia with Lewy bodies, there is generalized ventricular enlargement with relative preservation of medial temporal lobe structures. White-matter changes are similar to Alzheimer disease but less extensive than vascular disease. SPECT shows posterior deficits and reduced D2 receptor density and dopamine transporters.

Question 113

``` Which of the following does not suggest a diagnosis of dementia with Lewy bodies? A. Recurrent visual hallucinations B. Parkinsonian features C. History of strokes D. Neuroleptic sensitivity E. Syncope ```

Answer 113

C. History of strokes Answer: C. A history of strokes is more suggestive of vascular dementia. Visual hallucinations and parkinsonian symptoms are features of DLB. More than one-third of patients are sensitive to antipsychotic drugs. They are also prone to falls and syncopal attacks.

Question 114

``` All of the following are features of frontotemporal dementia except A. Disinhibition B. Delusions C. Preservation of affect D. Overeating E. Stereotyped behaviors ```

Answer 114

C. Preservation of affect Answer: C. Frontotemporal dementia (FTD) is a group of disorders with atrophy of frontal and temporal lobes. The main features are personality alteration with disinhibition, emotional coarsening, loss of the ability to empathize, apathy, inability to interpret social cues, and poor judgment, planning, and insight. It begins between the ages of 40 and 65 years. Memory and visuospatial skills are relatively preserved, although language may be affected. FTD is sometimes associated with lability of affect.

Question 115

``` Which of the following is seen in frontotemporal dementia? A. Myoclonus B. Cerebellar ataxia C. Choreoathetosis D. Apraxia E. Hyperorality ```

Answer 115

E. Hyperorality Answer: E. Hyperorality with oral exploration of objects is a prominent behavioral disturbance in frontotemporal dementia, or FTD. Abrupt onset with seizures, head trauma, early amnesia, apraxia, spatial disorientation, myoclonus, cerebellar ataxia, and choreoathetosis are not prominent features, and their presence goes against a diagnosis of FTD.

Question 116

In frontotemporal dementia, which of the following is revealed by neuroimaging? A. Generalized atrophy, more prominent in the parietal regions B. Frontal hypermetabolism, found by PET C. Parietal hypoperfusion, found by SPECT D. Parietal hypometabolism E. Frontal hypometabolism, found by PET

Answer 116

B. Frontal hypermetabolism, found by PET Answer: B. Positron emission tomography (PET) reveals frontal hypermetabolism in frontotemporal dementia.

Question 117

``` Which of the following is not a feature of dementia of normal pressure hydrocephalus? A. Impaired attention B. Poor learning C. Impaired judgment D. Apraxia E. Gait disturbance ```

Answer 117

D. Apraxia Answer: D. Normal pressure hydrocephalus (NPH) is characterized by dementia, gait disturbance, and urinary incontinence. The dementia consists of impaired attention, poor learning, visuospatial disturbance, impaired attention and impaired judgment. Aphasia, apraxia, and agnosia are usually absent. Personality alterations, anxiety, mood changes, and rarely psychosis may also be present.

Question 118

``` All of the following are clinical features of Alzheimer dementia except A. Disorder of language and praxis B. Depression C. Loss of primitive reflexes D. Persecutory delusions E. Long-term memory loss ```

Answer 118

C. Loss of primitive reflexes Answer: C. Disorder of language, apraxia, and impaired naming; impaired auditory comprehension; poor calculation, abstraction, and judgment; depression; delusions; and both short-term and long-term memory loss are seen in Alzheimer disease. As the disease progresses, there is emergence of primitive reflexes.

Question 119

Which of the following is true about vascular dementia? A. Slow, gradual deterioration occurs. B. MRI shows areas of multiple infarction. C. Depression is rare. D. PET shows symmetric changes in the cortex. E. SPECT shows global hyperperfusion.

Answer 119

B. MRI shows areas of multiple infarction. Answer: B. In vascular dementia, MRI shows areas of multiple infarcts. About one-quarter to one-third of patients with vascular dementia also develop depression. Vascular dementia is characterized by a stepwise deterioration in cognitive abilities. SPECT shows global hypoperfusion.

Question 120

``` Which of the following is seen in Pick disease? A. Senile plaques B. Neurofibrillary tangles C. Atrophy of frontal and parietal lobes D. Knife-blade atrophy ```

Answer 120

D. Knife-blade atrophy Answer: D. Pick disease is a degenerative dementia seen in about 5% of demented patients. It is diagnosed by the autopsy finding of focal degeneration of the frontal or temporal lobes. “Knife-blade” atrophy of the frontal and temporal lobes is found. Personality changes and behavioral disturbance, along with apathy or impulsivity, sexual disinhibition, roaming, and hyperorality may be seen. Patients also demonstrate signs of frontal lobe impairment with loss of executive functions. The dementia syndrome is characterized by early disruption of expressive speech, with reduced verbal output and echolalia, and impairment of judgment.

Question 121

All of the following are features of dementia of Lewy bodies except A. Extrapyramidal symptoms B. Clouding of consciousness C. Longer clinical course than Alzheimer disease D. Sensitivity to antipsychotic drugs

Answer 121

C. Longer clinical course than Alzheimer disease Answer: C. Dementia with Lewy bodies (DLB) tends to be more rapidly progressive than Alzheimer disease. It is characterized by Lewy bodies found in the neurons in the neocortical (frontal, temporal, parietal lobe), allocortical (hippocampal complex, entorhinal cortex), and subcortical (substantia nigra and locus caeruleus) regions of the brain. The clinical characteristics include progressive dementia with relatively little memory impairment at first but with poor attention and executive function, fluctuating cognitions, visual hallucinations, extrapyramidal features, tremor, and sensitivity to neuroleptics in one-third of patients.

Question 122

Which of the following is true regarding HIV encephalopathy associated with AIDS? A. Insight is preserved until late in the course of the disease. B. EEG is abnormal in the early stages. C. Frank dysphoria is common. D. Memory is usually preserved. E. Treatment has no influence on course of the disease.

Answer 122

A. Insight is preserved until late in the course of the disease. Answer: A. Insight is usually preserved until late in HIV encephalopathy (AIDS dementia complex). The EEG is normal early, with diffuse slowing as the illness progresses. Adjustment reactions are common; however, frank dysphoria is not. Impairment of memory is an early symptom. Treatment with antiviral drugs does influence the course of the disease.

Question 123

Which of the following is true regarding Lewy bodies? A. They do not occur in normal brains. B. Their presence confirms Parkinson disease. C. They are extracellular bodies. D. They occur in Alzheimer disease.

Answer 123

D. They occur in Alzheimer disease. Answer: D. Lewy bodies are intracellular inclusion bodies that are present in the normal brain and a wide variety of dementias, including Alzheimer disease. Their presence does not indicate Parkinson disease.

Question 124

``` Which of the following is commonly seen following frontal lobe injury? A. Contralateral optic atrophy B. Dyspraxia C. Ipsilateral spastic paresis D. Disinhibition E. Anosognosia ```

Answer 124

D. Disinhibition Answer: D. Frontal lobe injury causes a number of sequelae. Among them are disinhibition, Broaca's aphasia, anterograde and retrograde amnesia with confabulation, and, with left-sided lesions, impaired working memory for verbal material. Right-sided lesions cause expressive aprosody, akinetic mutism, amnesia, and impaired working memory for nonverbal spatial material and impaired nonverbal intellect.

Question 125

``` Which of the following is seen in nondominant parietal lobe lesions? A. Prosopagnosia B. Dyspraxia C. Alexia D. Body image disorders E. Hyperorality ```

Answer 125

A. Prosopagnosia Answer: A. In prosopagnosia, patients are unable to recognize familiar faces. This is caused by lesions in the nondominant parietal and temporal lobes. The other symptoms are neglect, anosognosia, tactile object agnosia, and defective music recognition.

Question 126

``` Which of the following is seen in lesions of the dominant temporal lobe? A. Impaired visual memory B. Dysprosody C. Deep prosopagnosia D. Retained verbal memory E. Visual object agnosia ```

Answer 126

C. Deep prosopagnosia Answer: C. Left temporal lobe lesion causes deep prosopagnosia (partial recognition defect). It also causes impaired verbal memory. Visual object agnosia is caused by a bilateral temporal lobe lesions.

Question 127

``` Which of the following is not caused by bilateral temporal lobe lesion? A. Hyperorality B. Hypersexuality C. Cortical blindness D. Amnestic syndrome E. Visual agnosia ```

Answer 127

C. Cortical blindness Answer: C. Hyperorality, hypersexuality, amnestic syndrome, and visual agnosia are caused by bilateral temporal lobe lesions.

Question 128

``` Occipital lobe lesions can cause all of the following except A. Visual field defects B. Anton syndrome C. Visual hallucinations D. Sensory neglect E. Prosopagnosia ```

Answer 128

D. Sensory neglect Answer: D. Sensory neglect is caused by parietal lobe lesions not by lesions of the occipital lobe. Parietal lobe lesions can cause visual field effects, visual hallucinations, and prosopagnosia, especially in lesions of occipitotemporal junction. Anton syndrome is denial of blindness, seen in patients with acquired cortical blindness, arising from bilateral occipital cortex damage.

Question 129

``` Parietal lobe lesions can cause all of the following except A. Dressing apraxia B. Gerstmann syndrome C. Pure agraphia without aphasia D. Personality changes E. Visual field defects ```

Answer 129

D. Personality changes Answer: D. Personality changes are associated with lesions of the frontal and temporal lobes. Parietal lobe lesions cause dressing apraxia, pure agraphia without aphasia, and visual field defects. Gerstmann syndrome consists of agraphia, acalculia, right-left disorientation, and finger agnosia.

Question 130

``` Which of the following can be caused by frontal lobe lesion? A. Hypersexuality B. Indifference to feelings of others C. Dyscalculia D. Pure alexia E. Ocular apraxia ```

Answer 130

B. Indifference to feelings of others Answer: B. Frontal lobe lesions cause indifference to the feelings of others, defective social conduct, and acquired sociopathy. Hypersexuality is caused by a temporal lobe lesion. Dyscalculia is caused by parietal lobe dysfunction. Pure alexia resulting in a complete or partial impairment in reading is caused by occipital lobe lesions. Ocular apraxia is an inability to voluntarily direct the gaze toward a stimulus located in the peripheral vision to bring it to a central focus. It is also due to occipital lobe dysfunction.

Question 131

``` Which of the following is the most commonly affected muscle in myasthenia gravis? A. Upper limb B. Lower limb C. Oropharyngeal D. Respiratory E. Ocular ```

Answer 131

E. Ocular Answer: E. Ocular muscles are involved first in 40% of cases of myasthenia gravis and ultimately in 80%. Patients with oropharyngeal or respiratory muscle involvement may develop myasthenic crisis.

Question 132

All of the following are true about Gilles de la Tourette syndrome except A. Echolalia B. Improves with haloperidol C. High incidence of complex partial seizures D. Autosomal dominant with low penetrance E. Associated with obsessive-compulsive disorder

Answer 132

C. High incidence of complex partial seizures Answer: C. Tourette syndrome is a familial disorder with incomplete autosomal dominant transmission characterized by the association of tics and obsessive-compulsive features. It is not associated with a high incidence of seizures. Children with Tourette syndrome may have ADHD. The syndrome is believed to be due to an abnormality in the dopaminergic transmission. It is treated symptomatically with neuroleptics like haloperidol. Clonidine may also help.

Question 133

Which of the following is true about severe closed head injury? A. Headaches are inevitable. B. Recovery is completed within a year. C. Dementia is never seen. D. About 20% suffer from post-traumatic seizures. E. Post-traumatic amnesia is the best prognostic indicator.

Answer 133

E. Post-traumatic amnesia is the best prognostic indicator. Answer: E. The presence and duration of post-traumatic amnesia is the best prognostic indicator for the outcome of head injury. Headaches may or may not be present. Recovery may take longer than a year. Dementia is a known sequela. Only about 1-2% of persons affected with post-traumatic amnesia develop seizures.

Question 134

Which of the following suggests that seizures may be pseudoseizures? A. Presence of interictal EEG abnormalities B. Incontinence C. Seizures occurring at night D. Seizures lasting longer than 30 minutes E. Seizures always occurring when patient is alone

Answer 134

D. Seizures lasting longer than 30 minutes Answer: D. Seizures lasting as long as 30 minutes are very strongly suggestive of pseudoseizure as absence of tonic phase and incontinence, lack of increased prolactin following a seizure, and absence of postictal confusion. If the seizures always occur in the presence of others, they are likely to be manifestations of pseudoseizure.

Question 135

``` Which of the following is not seen in Gerstmann syndrome? A. Finger agnosia B. Alexia C. Acalculia D. Agraphia E. Right-left disorientation ```

Answer 135

B. Alexia

Question 136

``` A 70-year-old presents for evaluation of forgetfulness. Early dementia is suspected. Alzheimer dementia is most likely with which of the following symptoms? A. Sudden onset of forgetfulness B. Seizures C. Gait disturbance D. Progressive agnosia E. Incontinence ```

Answer 136

D. Progressive agnosia Answer: D. Progressive agnosia, apraxia, and aphasia are suggestive of Alzheimer disease. A sudden onset is highly unlikely in any dementing process. Seizures and incontinence are classically seen in more advanced stages.

Question 137

Which of the following is caused by lesion at the level of C5? A. Sensory loss over little finger B. Motor loss of triceps function C. Loss of triceps tendon jerk D. Sensory loss over biceps E. Loss of flexion in interphalangeal joints

Answer 137

D. Sensory loss over biceps Answer: D. Lesions of the C5 can cause sensory loss over the lateral aspects of the biceps. Sensory loss over the little finger is seen in C8 injury, and loss of triceps tendon jerk is seen in lesions of C6, C7, and C8.

Question 138

``` Which of the following is seen in Tourette syndrome? A. Coprophagia B. Paralysis of limbs C. Choreiform movements D. Subjective sudden release of tension E. Violent automatisms ```

Answer 138

D. Subjective sudden release of tension

Question 139

``` Which of the following is a feature of transient global amnesia? A. Loss of identity B. Confabulation C. Decreased attention span D. Dissociative phenomena E. Global memory deficits ```

Answer 139

E. Global memory deficits Answer: E. Global memory deficits are seen in transient global amnesia. There is no loss of identity or confabulation. The attention span is normal. It is not a dissociative phenomenon.

Question 140

``` Which of the following is not seen in damage to the frontal lobes? A. Emotional changes B. Visual distortion C. Difficulty planning tasks D. Grasp reflex E. Incontinence ```

Answer 140

B. Visual distortion Answer: B. Visual distortions are not seen in frontal lobe damage. Incontinence, difficulty planning tasks, emotional changes, and reemergence of grasp reflex are all seen in frontal lobe dementia.

Question 141

``` Which of the following is not seen with parietal lesions? A. Left-right disorientation B. Alexia with agraphia C. Topopagnosia D. Perseveration ```

Answer 141

C. Topopagnosia Answer: C. Neglect of the left side of the body is seen with lesions of the right parietal lobe. It also causes impaired object recognition. The three other symptoms listed as answer choices are caused by lesions of the left parietal lobe.

Question 142

``` What is the most sensitive test for detection of multiple sclerosis? A. CT B. MRI C. Evoked potentials D. SPECT E. EEG ```

Answer 142

B. MRI Answer: B. MRI is the most sensitive test to differentiate between white and gray matter and hence is the most useful investigation in multiple sclerosis.

Question 143

``` In which stage of sleep is vivid dreaming most common? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. REM sleep ```

Answer 143

E. REM sleep Answer: E. REM sleep is strongly associated with dreaming; in sleep lab studies, 80% of awakenings during REM sleep produce a dream report. Dreams occurring in REM sleep are more vivid and intense than in non-REM sleep.

Question 144

``` In which region of the spine are spinal epidural abscesses most commonly found? A. Cervical B. Thoracic C. Lumbar D. Sacral E. Coccygeal ```

Answer 144

B. Thoracic Answer: B. Epidural abscess is most frequently seen in the thoracic spine. The clinical features are pain in a root distribution and transverse spinal cord syndrome with paraparesis, sensory impairment, and sphincter dysfunction.

Question 145

``` What is the treatment of choice for subacute combined degeneration? A. Oral folic acid B. Parenteral folic acid C. Oral vitamin B12 D. Parenteral vitamin B12 E. Parenteral iron ```

Answer 145

D. Parenteral vitamin B12 Answer: D. Subacute combined degeneration of the cord is characterized by myelopathy with predominant pyramidal and posterior column deficits in association with polyneuropathy, mental changes, and optical neuropathy. It is caused by vitamin B12 deficiency and is treated with parenteral B12.

Question 146

``` Which of the following can result from brainstem ischemia? A. Jacksonian seizures B. Complex partial seizures C. Drop attacks D. Todd's palsy E. Grand mal epilepsy ```

Answer 146

C. Drop attacks

Question 147

``` Which of the following is not a feature of pseudobulbar palsy? A. Brisk jaw jerk B. Emotional lability C. Fasciculating tongue D. Presence of gag reflex E. Dysphagia ```

Answer 147

C. Fasciculating tongue Answer: C. Pseudobulbar palsy arises from an upper motor neuron lesion of the bulbar muscles. The tongue is small and bunched and moves slowly. The jaw jerk is brisk and patients have emotional lability. Dysphagia may also be present.

Question 148

Which of the following is true of acute porphyria? A. Presence of abdominal pain B. Cloudy urine C. Widespread necrosis in the central nervous system D. Convulsions E. Weakness

Answer 148

A. Presence of abdominal pain Answer: A. Porphyria is an inherited disorder of enzymes in the hemibiosynthetic pathway. It is characterized by many features including abdominal pains and seizures. However, seizures are not common, and it is not a common cause of weakness.

Question 149

``` Memory deficits can occur with lesion in which of the following areas? A. Wernicke's area B. Wall of the third ventricle C. Broaca's area D. Parietal cortex E. Lateral nucleus ```

Answer 149

B. Wall of the third ventricle Answer: B. Memory deficits occur with lesion of the wall of the third ventricle.

Question 150

``` Which of the following is not a part of the limbic system? A. Corpus callosum B. Parahippocampal gyrus C. Anterior nucleus of thalamus D. Subcallosal gyrus E. Hypothalamus ```

Answer 150

A. Corpus callosum Answer: A. Parahippocampal gyrus, anterior nucleus of thalamus, subcallosal gyrus, and hypothalamus constitute the limbic system.

Question 151

``` In which of the following does diplopia occur? A. Huntington disease B. Diabetes insipidus C. Facial nerve neuropathy D. Oculomotor nerve neuropathy E. Parkinson disease ```

Answer 151

D. Oculomotor nerve neuropathy Answer: D. Oculomotor neuropathy can cause diplopia. Diabetes insipidus does not cause diplopia. Facial nerve neuropathy causes paralysis of the muscles of the face depending on the site of the lesion.

Question 152

``` Which of the following is not associated with benign intracranial hypertension? A. Polycythemia B. Oral contraceptives C. Myxedema D. Hypoparathyroidism E. Tetracyclines ```

Answer 152

C. Myxedema Answer: C. Benign intracranial hypertension is the term used to describe a persistent rise in CSF pressure in the absence of a space-occupying lesion and with ventricles of normal or reduced size. It usually occurs in women and has peak incidence in the third and fourth decades. The women are often obese, and there is an association with oral contraceptive use, pregnancy, and miscarriage. Headache is the most common complaint.

Question 153

``` A 55-year-old presents with a cerebrovascular accident. Which of the following suggests occlusion of a posterior inferior cerebellar artery? A. Ipsilateral Horner syndrome B. Dissociated analgesia C. Contralateral facial analgesia D. Ipsilateral limb analgesia E. Contralateral ataxia ```

Answer 153

A. Ipsilateral Horner syndrome Answer: A. Posterior inferior cerebellar artery occlusion, also known as Wallenberg syndrome, is characterized by loss of ipsilateral pain and temperature sensation in the face with loss of pain and temperature sensation in the contralateral limbs, ipsilateral Horner syndrome, and ipsilateral weakness of the palate, pharynx, and larynx.

Question 154

``` Nystagmus can occur in A. Brainstem legions B. Cerebellar lesions C. Healthy subjects D. Rotational stimulation E. All of the above ```

Answer 154

E. All of the above Answer: E. Nystagmus is an oscillation that is initiated by a slow eye movement. The direction of the nystagmus is determined by the direction of the quick phase.

Question 155

``` Which of the following features would arouse a suspicion of basilar artery occlusion? A. Monoplegia B. Contralateral cerebellar signs C. Hypopyrexia D. Contralateral cranial nerve palsies ```

Answer 155

A. Monoplegia Answer: A. Basilar artery occlusion can produce paralysis or weakness of extremities, diplopia, blindness, and visual field effects, bilateral cerebellar ataxia, and coma.

Question 156

``` A 40-year-old man presents with sudden onset of blindness. Possible causes include all of the following except A. Vitreous hemorrhage B. Acute glaucoma C. Methanol ingestion D. Prolapsed intervertebral disc E. Retinal detachment ```

Answer 156

D. Prolapsed intervertebral disc

Question 157

``` Which of the following is a function of the limbic system? A. Emotional behavior B. Motivation C. Sexual activity D. Conditioned reflexes E. All of the above ```

Answer 157

E. All of the above

Question 158

Which of the following is a feature of Brown-Séquard syndrome? A. Contralateral loss of kinesthesia B. Ipsilateral loss of crude touch C. Contralateral loss of temperature D. Contralateral loss of two-point discrimination

Answer 158

C. Contralateral loss of temperature Answer: C. Lesion on one side of the spinal cord causes Brown-Séquard syndrome, an ipsilateral paralysis with loss of vibratory and position sense on the same side and a contralateral loss of pain and temperature.

Question 159

Which of the following is a feature of complete spinal-cord transection? A. Retention of voluntary movements below the lesion B. Hyperactive reflexes C. Loss of all sensation below the lesion D. Loss of all reflexes after 3 weeks E. Development of automatic bladder within first 3 days

Answer 159

C. Loss of all sensation below the lesion Answer: C. Complete spinal cord transection causes loss of all sensations and voluntary movements below the level of lesion. Pain may occur at the level of the lesion. Damage to the lateral and anterior columns will result in upper motor neuron signs below the level of lesion, with a pyramidal pattern of weakness, spasticity, and deep tendon hyperreflexia, with absent abdominal reflexes and extensor plantar responses. Acute severe cord lesions produce a flaccid paraplegia with a temporary phase of hypotonia and areflexia before appearance of upper motor neuron signs.

Question 160

``` Dopaminergic cells are found in all of the following except A. Median raphe nucleus B. Ventral tegmental area C. Substantia nigra D. Arcuate nucleus of hypothalamus ```

Answer 160

A. Median raphe nucleus Answer: A. 5-HT neurons are found in the median raphe nucleus.

Question 161

``` Which of the following occurs on carotid sinus stimulation? A. Hypertension B. Tachycardia C. Peripheral vasodilatation D. Raised intracranial pressure E. Hyperventilation ```

Answer 161

C. Peripheral vasodilatation Answer: C. Stimulation of the carotid sinus in the young rarely causes any symptoms. In the elderly, it can cause bradykinesia and syncope. Most commonly, this is due to reflex vagal inhibition of the heart.

Question 162

``` Components of the pyramidal system include all of the following except A. Anterior horn cells B. Vestibular nuclei C. Pyramidal tract D. Corticospinal tract ```

Answer 162

B. Vestibular nuclei

Question 163

``` Which of the following is a component of the circle of Willis? A. Anterior inferior cerebellar artery B. Posterior spinal artery C. Superior cerebellar artery D. Posterior communicating artery ```

Answer 163

D. Posterior communicating artery Answer: D. The circle of Willis is formed by the proximal part of the two anterior cerebral arteries connected by the anterior communicating artery and the proximal part of the two posterior cerebral arteries, which are connected to the distal internal carotid arteries by the posterior communicating artery.

Question 164

``` Which of the following is not a feature of cerebellar disease? A. Dysdiadochokinesis B. Past pointing C. Scanning dysarthria D. Resting tremor ```

Answer 164

D. Resting tremor Answer: D. Cerebellar hemisphere damage causes ipsilateral dysmetria or ataxia and hypotonicity. Midline damage to the cerebellar vermis causes gait ataxia, truncal ataxia, and dysarthria. Lesions of the flocculonodular lobe produce eye-movement abnormalities.

Question 165

Which of the following is not a sign of posterior column damage? A. Impaired two-point discrimination B. Loss of perception of pain C. Inability to detect direction and speed of a moving stimulus on the skin D. Loss of proprioception E. Loss of vibration sense

Answer 165

B. Loss of perception of pain Answer: B. Posterior column syndrome causes loss of vibration and position sense below the lesion, but the perception of pain and temperature is affected very little. Loss of sensory functions that follow a posterior column lesion include impaired two-point discrimination, detection of size, shape, weight, and texture of objects and ability to detect the direction and speed of a moving stimulus on the skin.

Question 166

``` Which of the following is a feature of upper motor neuron disease? A. Clonus B. Flexor plantar response C. Wasting of muscles D. Decreased tendon reflexes E. Cogwheel rigidity ```

Answer 166

A. Clonus Answer: A. Clonus, extensor plantar response, hypertonicity, and increased tendon reflexes are seen with upper motor neuron disease.

Question 167

``` Which of the following is a feature of lower motor neuron lesion? A. Hypertonicity B. Clasp-knife rigidity C. Parkinsonism D. Absent reflexes E. Tardive dyskinesia ```

Answer 167

D. Absent reflexes Answer: D. Lower motor neuron lesion causes absent reflexes and hypotonia.

Question 168

``` Which of the following can be caused by posterior cerebral artery occlusion? A. Ipsilateral hemianesthesia B. Ipsilateral hemianalgesia C. Ipsilateral hemiplegia D. Ipsilateral hemianopia E. Spontaneous pain ```

Answer 168

E. Spontaneous pain Answer: E. Spontaneous pain can occur in association with paresthesias in peripheral nerve disorders. Spontaneous pain can also arise from thalamic and spinothalamic tract lesions.

Question 169

``` Which of the following can result in papilledema? A. Hypoparathyroidism B. Hypercapnia C. Cranial arteritis D. Cavernous sinus thrombosis E. All of the above ```

Answer 169

E. All of the above Answer: E. The presence of papilledema signifies the presence of raised intracranial pressure.

Question 170

``` All of the following are due to disorders of the extrapyramidal system except A. Tremor B. Spasmodic torticollis C. Clasp-knife rigidity D. Akathisia E. Festinant gait ```

Answer 170

C. Clasp-knife rigidity Answer: C. Clasp-knife rigidity results from an exaggeration of the stretch reflex.

Question 171

``` Which of the following is true about essential tremor? A. It has a frequency of 2-4 Hz. B. It is abolished on action. C. Alcohol may reduce essential tremor. D. It most commonly affects the head. ```

Answer 171

C. Alcohol may reduce essential tremor. Answer: C. Essential tremor is characterized by action-induced and posture-induced rhythmic shaking with a frequency range of 4 to 12 Hz. The hands are most commonly affected. In about half of patients with essential tremor, small amounts of alcohol reduce the symptoms.

Question 172

``` All of the following can occur with lesions of the parietal lobe except A. Astereognosis B. Gerstmann syndrome C. Dressing apraxia D. Tactile inattention E. Expressive dysphagia ```

Answer 172

E. Expressive dysphagia Answer: E. Expressive dysphasia is also called Broaca's aphasia. It is caused by a lesion in the Broaca's area, around the posterior part of the inferior frontal convolution.

Question 173

``` Which of the following is a feature of Horner syndrome? A. Paralysis of lower part of face B. Ptosis of the eyelid C. Pupillary dilatation D. Sweating on the affected side E. Ataxia ```

Answer 173

B. Ptosis of the eyelid Answer: B. Horner syndrome consists of miosis and ptosis. There may also be depigmentation of the affected iris. It may also be associated with vasomotor and sudomotor changes on the affected side of the face, such as loss of sweating and facial flushing.

Question 174

A 62-year-old man with diabetes and hypertension is admitted to the emergency department because he has a severe headache and acute onset of double vision. Examination reveals that the man has ptosis on the right side and an inability to elevate or adduct the right eye, although lateral eye movements are spared. The man's right pupil is dilated and unreactive. What is the most likely diagnosis? A. Myasthenia gravis B. Pontine hemorrhage C. Extradural hemorrhage D. Diabetic palsy of cranial nerve III E. Berry aneurysm of the right posterior communicating artery

Answer 174

E. Berry aneurysm of the right posterior communicating artery Answer: E. In this patient, both the motor and the parasympathetic components of the oculomotor nerve are affected, which can result from a berry aneurysm of the posterior communicating artery. In diabetic palsy of the third cranial nerve, only the motor component is affected. Myasthenia gravis causes weakness of muscles.

Question 175

For which of the following is a CT scan superior to an MRI scan? A. Detecting lesions in the spinal cord B. Detecting demyelination secondary to multiple sclerosis C. Differentiating hemorrhage from edema D. Showing early ischemic changes E. Detecting small tumor

Answer 175

C. Differentiating hemorrhage from edema Answer: C. CT scan is particularly useful in detecting hemorrhage. Ischemic changes are better seen in MRI. MRI is the investigation of choice in multiple sclerosis to detect demyelination. Small tumors and lesions in the spinal cord are, again, better seen by MRI.

Question 176

``` A 42-year-old man is referred for a psychiatric evaluation 4 years after sustaining a head injury in a car accident. Prior to the accident, he was a stable, happily married man. Since the accident, he has been described as very talkative and irresponsible. His marriage has ended in a divorce and he lost his job. Neuropsychiatic testing reveals that the man has average intelligence and no detectable memory deficits. The patient's clinical presentation is most consistent with damage to which of the following brain areas? A. Thalamus B. Temporal lobe C. Corpus striatum D. Amygdaloid body E. Frontal lobe ```

Answer 176

E. Frontal lobe Answer: E. This patient has signs and symptoms suggestive of frontal lobe injury. Disinhibition and irresponsible behavior (i.e., poor judgment) suggest frontal dysfunction. Injury to the amygdala is more likely to cause emotional problems than injury to the temporal lobe, which usually leads to seizures, memory problems, and other symptoms.

Question 177

``` When examined, a 65-year-old man is found to be apathetic, forgetful, and confused, with psychomotor retardation. When he is admitted to the hospital for a routine transurethral retrograde prostatectomy, a psychiatric consultation is requested. The only medication the man has been taking is over-the-counter (OTC) cold remedies. Which of the following is included in the differential diagnoses for this patient? A. Parkinson disease B. Dementia C. Depression D. Anticholinergic side effects E. All of the above ```

Answer 177

E. All of the above Answer: E. This elderly patient could be suffering from any of the conditions listed in the question. Parkinsonism, depression, and dementia can cause apathy and psychomotor retardation. Memory problems and confusion can be caused by depression, dementia, and anticholinergic side effects.

Question 178

``` Episodes of staring, lip smacking, and amnesia preceded by fear and a smell of burning rubber are most commonly associated with an electrical abnormality in which of the following? A. Cerebellum B. Occipital lobe C. Temporal lobe D. Frontal lobe E. Parietal lobe ```

Answer 178

C. Temporal lobe Answer: C. This is typical petit mal, or absence seizure, the focus of which is in the temporal lobe. An aura followed by a staring spell, automatic movements, and amnesia for the episode is characteristic of temporal lobe seizures.

Question 179

``` A 50-year-old man is assessed for headaches and memory problems. CT and MRI scans reveal ventriculomegaly that is out of proportion to sulcal atrophy. Which diagnosis does this finding support? A. Pick disease B. Normal pressure hydrocephalus C. Alzheimer disease D. Huntington disease E. Parkinson disease ```

Answer 179

B. Normal pressure hydrocephalus Answer: B. Ventriculomegaly that is out of proportion to the sulcal atrophy in a middle-aged male is suggestive of normal pressure hydrocephalus. In Pick disease, there is frontotemporal atrophy. In Alzheimer disease, apart from ventriculomegaly, widening of sulci and narrowing of gyri are noticed. In Huntington disease, atrophy of the caudate nucleus is prominent. Progressive supranuclear palsy, results from lesions in the subcortical structures and ventricular volumes are relatively normal.

Question 180

Which of the following statements is true about early-onset Alzheimer disease? A. Occurs sporadically B. Autosomal dominant inheritance C. No response to cholinesterase inhibitors D. More common in Black population E. More agitation and aggression

Answer 180

B. Autosomal dominant inheritance Answer: B. Early-onset Alzheimer disease is thought to have autosomal dominant inheritance and typically affects individuals as young as 45 to 50 years old. Cholinesterase inhibitors are found to be useful in controlling the cognitive decline in the early stages. It is no more prevalent in Blacks than in people of other races.

Question 181

``` Prosopagnosia means the inability to do which of the following? A. Recognize faces B. Understand written text C. Follow directions D. Remember names E. Read fluently ```

Answer 181

A. Recognize faces Answer: A. Prosopognosia is the inability to recognize faces. It is caused by a lesion in the nondominant parieto-occipital lobe.

Question 182

``` A 56-year-old patient who is an alcoholic experiences unsteadiness of gait. He has a history of drinking alcohol every day for the past 30 years. Examination reveals minimal appendicular ataxia in the patient's lower extremities only and normal eye movements. The patient walks with a lurching, broad-based gait. What is the most appropriate diagnosis? A. Hysterical gait disorder B. Alcoholic cerebellar degeneration C. Chronic subdural hematoma D. Spinocerebellar degeneration E. Multiple sclerosis ```

Answer 182

B. Alcoholic cerebellar degeneration Answer: B. A patient with chronic alcohol problems with the presentation described in the question is most likely to have alcoholic cerebellar degeneration. Frontal lobe dysfunction is more likely to cause behavioral disturbances. The patient does not have the transient neurologic deficits that are associated with multiple sclerosis.

Question 183

``` A 65-year-old patient is diagnosed with severe Alzheimer disease. Where would you expect to see the maximum density of senile plaques and neurofibrillary tangles? A. Substantia nigra B. Subthalamic nucleus of Luys C. Hippocampus D. Dentate nucleus E. Parietal lobe ```

Answer 183

C. Hippocampus Answer: C. Hippocampus, responsible for memory function, has the highest concentration of neurofibrillary tangles and senile plaques.

Question 184

``` With which of the following is internuclear ophthalmoplegia most commonly seen? A. Optic neuritis B. Multiple sclerosis C. Amyotrophic lateral sclerosis D. Cerebellar dysfunction E. Pituitary tumor ```

Answer 184

B. Multiple sclerosis Answer: B. Internuclear ophthalmoplegia, a condition that affects the medial longitudinal fasciculus, is most commonly seen in patients with multiple sclerosis. It is a disturbance of the horizontal gaze leading to displacement of objects and nystagmus. In the elderly, stroke is a common cause of this condition.

Question 185

Which of the following does MRI of the brain show in Huntington disease? A. Bilateral caudate atrophy B. Enlargement of ventricles C. Narrowing of pars compacta of substantia nigra D. Basal ganglia atrophy E. Frontotemporal atrophy

Answer 185

A. Bilateral caudate atrophy Answer: A. In Huntington disease, bilateral caudate atrophy is noticed. On MRI, it gives a “box car” appearance. Frontotemporal atrophy is noticed in Pick disease. Enlargement of the ventricles associated with widening of the sulci and narrowing of the gyri is a feature of Alzheimer disease.

Question 186

A 45-year-old man experiences a sudden onset of back pain while playing tennis. Examination reveals some spasms in the paraspinal muscles in the right lumbar region. He is able to perform a straight leg raise to 90 degrees with some increase in pain. Knee jerks and ankle jerks are normal and symmetric with no weakness in the muscles of the hip, leg, or foot. Sensory examination is within normal limits. What is the most appropriate next step in management? A. MRI of the lumbar spine B. Refer to physical therapy C. X-ray of the lumbar spine D. Psychiatric consultation for somatization disorder E. Bed rest and administration of analgesics

Answer 186

E. Bed rest and administration of analgesics Answer: E. With the history of pain and absence of any signs or symptoms to suggest spinal cord compression, bed rest, and analgesics will be the most appropriate therapy.

Question 187

``` A 64-year-old woman is examined because she has been getting lost on her way home in her neighborhood during the past several weeks. A Mini-Mental Status examination is administered to screen for cognitive deficits. She answers all of the questions correctly, but she has difficulty copying intersecting pentagons. In which of the following regions of the brain has this woman most likely experienced a stroke? A. Left occipital lobe B. Left frontal lobe C. Left parietal lobe D. Right parietal lobe E. Right temporal lobe ```

Answer 187

D. Right parietal lobe Answer: D. This patient has problems with topographic disorientation and visuospatial dysfunction, which are associated with lesions of the right (nondominant) parietal lobe.

Question 188

``` A 58-year-old man suffers a stroke and is admitted to a rehabilitation unit for physical therapy. He is unable to wash the left side of his body and denies that his left arm belongs to him even though he clearly visualizes it. Examination reveals that the patient's somatosensory system is intact. These findings indicate that the patient may have a lesion. In which area of the brain is the lesion? A. Substantia nigra B. Caudate nucleus C. Right parietal cortex D. Left parietal cortex E. Right frontal cortex ```

Answer 188

C. Right parietal cortex Answer: C. This patient has hemisensory neglect, which is typically seen in patients who have a lesion of the right parietal cortex.

Question 189

A 36-year-old woman has experienced anxiety with intrusive mental images involving sex with animals. These experiences are accompanied by intense distress and unsuccessful attempts at resisting the thoughts. She relieves this anxiety by counting up to 100. In the last few weeks, she has been having severe problems with these episodes and they have caused significant distress. What is a PET scan in this patient likely to reveal? A. Increased metabolic rates in the temporoparietal cortex B. Increased metabolic rates in the temporofrontal cortex C. Increased metabolic rates in the caudate nucleus and the prefrontal cortex D. Decreased metabolic rates in the caudate nucleus and the prefrontal cortex E. Decreased metabolic rates in the temporal and frontal cortex

Answer 189

C. Increased metabolic rates in the caudate nucleus and the prefrontal cortex Answer: C. This patient has obsessive-compulsive disorder. PET scans have revealed increased glucose metabolism in the caudate nucleus and prefrontal cortex. Treatment with SSRIs or CBT results in normalization of the increased metabolism.

Question 190

``` A 34-year-male is assessed for speech problems following a “small stroke.” Examination reveals no obvious language problems except for severe difficulty with fluency. The man has no problems with comprehension. His articulation is good, and nothing abnormal is detected on examination of the articulation muscles. What is the most likely site of the lesion? A. Right parietal lobe B. Right temporal lobe C. Right caudate nucleus D. Left parietal lobe E. Left frontal lobe ```

Answer 190

E. Left frontal lobe Answer: E. This patient has expressive aphasia, which is caused by a lesion in the left frontal lobe secondary to a stroke. If the lesion were in the left temporal region, it would cause receptive aphasia and lead to problems with comprehension.

Question 191

A 20-year-old man is assessed for new onset psychosis. He is observed to have paranoid delusions and occasional auditory hallucinations. On physical examination, the psychiatrist also notices some abnormal movements of the arms and legs. Examination of the eyes reveals some abnormality with the cornea, but the physician is not sure what exactly the problem is. What is the most important next step in the management of this patient? A. Start treatment with antipsychotic medications B. Order a blood test to measure the level of ceruloplasmin C. Order an MRI of the brain D. Order a CT scan of the brain E. Refer the patient to a neurologist

Answer 191

B. Order a blood test to measure the level of ceruloplasmin Answer: B. Although all the options listed in the question are appropriate to a certain extent, a blood test to determine the ceruloplasmin level is the most important step in management of this patient. History of new onset psychosis, movement disorder, and abnormality in the eyes (maybe Kayser-Fleischer rings) are all suggestive of Wilson disease. This condition has a definitive treatment and should not be missed.

Question 192

``` Characteristics of Huntington disease include all of the following except A. Progressive dementia B. Autosomal dominant transmission C. Caudate nucleus atrophy D. Transient neurologic abnormalities E. Personality changes ```

Answer 192

D. Transient neurologic abnormalities Answer: D. Huntington disease is an abnormality of triplet gene repetition (CAG, CAG, …) and is inherited by autosomal dominant transmission. It is characterized by chorea, progressive dementia, personality changes, paranoia, and depression. Transient neurologic signs and symptoms are a feature of multiple sclerosis.

Question 193

On an EEG, which of the following characterizes the second stage of NREM sleep? A. Predominant (more than 50%) delta waves B. Predominant alpha waves C. Sleep spindles and K complexes D. Rapid eye movements E. Less than 50% of delta waves

Answer 193

C. Sleep spindles and K complexes Answer: C. Stage 2 of NREM (non-rapid eye movement) sleep is characterized by sleep spindles and K complexes. Alpha waves are seen predominantly in the arousal state. Delta waves are seen in deep sleep. Stage 3 has less than 50% of delta waves, and stage 4 has more than 50% of delta waves.

Question 194

A 54-year-old woman with a history of depression is currently in remission after 6 months of treatment. However, she had sleep problems preceding the depression, and she continues to complain of daytime fatigue and nonrefreshing sleep. A detailed history reveals that she has a history of snoring and currently is borderline overweight. She had rhinoplasty a few years ago. Which of the following conditions does this patient probably have? A. Sleep problems secondary to depression B. Obstructive sleep apnea C. Somatization disorder D. Narcolepsy E. Psychophysiologic insomnia

Answer 194

B. Obstructive sleep apnea Answer: B. From the history, this patient appears to be in remission from depression, and she does not have the sleep problem of early morning awakening typically associated with depression. She probably has obstructive sleep apnea. A polysomnogram or referral to a physician specializing in sleep disorders will be helpful for making the diagnosis.

Question 195

``` A 54-year-old woman presents for assessment because of headaches and vision problems. Examination reveals that the patient has bitemporal hemianopia. What is the most likely cause of the patient's problems? A. Meningioma B. Lesion of optic nerve C. Multiple sclerosis D. Pituitary tumor E. Migraine ```

Answer 195

D. Pituitary tumor Answer: D. Pituitary tumor can cause these symptoms. Because of the crossing over of nerve fibers in optic chiasma, compression in the medial region typically causes bitemporal hemianopia.

Question 196

All of the following are true about Pick disease except A. Age of onset is 40-60 years. B. Memory loss occurs early in the course of the disease. C. Autosomal dominant inheritance is present in 20% of cases. D. Psychiatric symptoms are often the first manifestations. E. Linkage to chromosome 17 is established in some cases.

Answer 196

B. Memory loss occurs early in the course of the disease Answer: B. In Pick disease, memory loss occurs relatively late. This lateness is one of the features that helps to distinguish Pick disease from Alzheimer disease. Psychiatric symptoms like personality changes, agitation, and lack of judgment are often seen before memory problems.

Question 197

All of the following are features of Gerstmann syndrome except A. Lesion in the nondominant parietal lobe B. Right-left disorientation C. Acalculia D. Finger agnosia E. Agraphia

Answer 197

A. Lesion in the nondominant parietal lobe Answer: A. Gerstmann syndrome results from a lesion in the dominant parietal lobe and is characterized by right-left disorientation, finger agnosia, acalculia, and agraphia.

Question 198

``` Which of the following do patients with Anton syndrome have? A. Language problems B. Articulation problems C. Denial of blindness D. Auditory problems E. Olfactory problems ```

Answer 198

C. Denial of blindness Answer: C. Patients with Anton syndrome have denial of blindness. They frequently bump into objects but, when confronted, they vehemently deny any visual problems. The condition is thought to be a form of anosognosia. The lesion is thought to be in both occipital cortex and higher order association cortex.