Neurology Flashcards
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
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.
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
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.
Which of the following is associated with impaired consciousness? A. Alcoholic hallucinosis B. Wernicke's encephalopathy C. Korsakoff syndrome D. Dementia E. Schizophrenia
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.
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
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.
Which of the following terms describes the primary mechanism of neurotransmission in the autonomic ganglia? A. Serotoninergic B. Noradrenergic C. Cholinergic D. GABAergic
C. Cholinergic
The transmitter that is mainly released from the preganglionic endings of sympathetic and parasympathetic fibers is acetylcholine.
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
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.
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.
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.
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
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.
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)
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.
What is the most common form of migraine? A. Classic migraine B. Migraine without aura C. Hemiplegic migraine D. Childhood migraine E. Basilar migraine
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.
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
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.
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
E. REM sleep
Nocturnal migraine headaches tend to occur during REM sleep. Some people have migraine headaches only during sleep.
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
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.
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
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.
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
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.
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
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.
All of the following awaken patients from sleep except A. Cluster headaches B. Brain tumors C. Tension headaches D. Subarachnoid hemorrhage E. Migraine
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.
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
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.
or what percentage of persons with seizure disorder does an interictal EEG appear normal? A. 1% B. 5% C. 10% D. 20% E. 50%
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.
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
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.
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
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.
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.
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.
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
B. Absence of aura
Frontal lobe seizures often arise abruptly without an aura and are of relatively short duration (
Which of the following is not associated with seizures? A. Random kicking B. Verbal abuse C. Screaming D. Murder E. Damage to property
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.
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.
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.
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
E. All of the above
Confusion can be caused by postictal confusion, antiepileptic drug intoxication, status epilepticus, or stopping antiepileptic drugs.
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
A. Parietal lobe
Partial complex seizures have a temporal lobe focus in about 90% of patients.
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
D. Absence seizure
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
D. Duration of 1 to 10 seconds
Absence seizures do not have auras or postictal confusion. Valproate and ethosuximide are the preferred treatments.
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
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.
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
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.
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
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.
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
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.
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
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%.
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
B. Posterior cerebral
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
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.
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
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.
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
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.
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
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.
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
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.
Which of the following is not seen in locked-in syndrome? A. Quadriplegia B. Muteness C. Cognitive deficits D. Normal EEG
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.
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
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.
Which of the following is a feature of carotid artery occlusion? A. Vertigo B. Nystagmus C. Diplopia D. Monocular amaurosis fugax E. Cortical blindness
D. Monocular amaurosis fugax
Carotid artery occlusion causes monocular amaurosis fugax. The other symptoms are caused by basilar artery occlusion.
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
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.
Which of the following most accurately describes the pathologic process in multiple sclerosis? A. Inflammatory B. Infectious C. Degenerative D. Demyelinating E. Metabolic
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.
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.
E. Spontaneous recovery never occurs.
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.
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.
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
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.
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
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.
What is the concordance rates of multiple sclerosis in monozygotic twins? A. 5% B. 10% C. 30% D. 50% E. 100%
C. 30%
The concordance rate among monozygotic twins is 30%; among dizygotic twins it is 5%
All of the following are features of Guillain-Barre syndrome except A. Symmetric paresis B. Psychosis C. Flaccidity D. Areflexia E. Monophasic paresis
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.
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
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.
Postinfectious encephalomyelitis is commonly seen after which of the following? A. Chickenpox B. Rubella C. Measles D. Mumps E. Herpes simplex
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.
Loss of which of the following occurs in Huntington disease? A. Serotonin B. Dopamine C. Substance P D. Acetylcholine and GABA
D. Acetylcholine and GABA
In Huntington disease, there is a reduction in acetylcholine and GABA in the basal ganglia.
Which of the following is NOT a feature of Parkinson disease? A. Tremor B. Rigidity C. Bradykinesia D. Increased blinking E. Micrographia
D. Increased blinking
Parkinson disease is characterized by tremor, rigidity, bradykinesia, masked facies, paucity of movement, micrographia, and decreased blinking and facial expression.
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
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.
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
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.
Which of the following describes dementia associated with Parkinson disease? A. Aphasia B. Apraxia C. Agnosia D. Sudden onset E. Difficulty shifting mental sets
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.
Which of the following symptoms does not respond to antiparkinsonian agents? A. Tremor B. Rigidity C. Hallucinations D. Bradykinesia E. Disturbances of gait
C. Hallucinations
Hallucinations do not respond to antiparkinsonian drugs and may in fact be worsened by them because of increased dopamine.
Antipsychotic-induced parkinsonism is related to blockade of which of the following receptors? A. D1 B. D2 C. D3 D. D4 E. D5
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.
Which of the following antipsychotic medications has no effect on dopamine 2 (D2) receptors? A. Risperidone B. Quetiapine C. Haloperidol D. Olanzapine E. Chlorpromazine
B. Quetiapine
Quetiapine and clozapine have very little affinity for D2 receptors and hence do not cause parkinsonism.
Which of the following is the most disabling feature of Parkinson disease? A. Tremor B. Rigidity C. Masklike facies D. Bradykinesia E. Micrographia
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.
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
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.
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
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.
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
C. Autosomal dominant
Huntington disease is autosomal dominant and is characterized by chorea and dementia. Occasionally sporadic cases may be seen.
Which of the following is seen in Huntington disease? A. Depression B. Psychosis C. Euphoria D. Suicide E. All of the above
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.
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
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.
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
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.
Where is the gene responsible for Huntington disease located? A. Chromosome 4 B. Chromosome 5 C. Chromosome 11 D. Chromosome 13 E. Chromosome 17
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.
Which of the following is a feature of hemiballismus? A. Cognitive impairment B. Contralateral hemiparesis C. Unilateral flinging motion D. Spasticity E. Hyperreflexia
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.
Which of the following is caused by lesion in the subthalamic nucleus? A. Tremors B. Tardive dyskinesia C. Hemiballismus D. Akathisia
C. Hemiballismus
Lesions in the subthalamic nucleus result in hemiballismus.
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
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.
Which of the following is produced by lesions of the lateral hypothalamus? A. Increased thirst B. Aphagia C. Hyperthermia D. Hyperphagia
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.
All of the following are features of Lesch-Nyhan syndrome EXCEPT: A. Dystonia B. Self-mutilation C. Seizures D. Normal intelligence E. Hyperuricemia
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.
What is the most common involuntary movement disorder? A. Parkinson disease B. Acute dystonia C. Essential tremor D. Focal dystonia E. Tardive dystonia
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.
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.
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.
Klüver-Bucy syndrome is caused by lesions in which of the following regions? A. Cingulate gyrus B. Medial hypothalamus C. Lateral hypothalamus D. Amygdala
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.
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.
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.
What is the most common central nervous system infection in patients with AIDS? A. Tuberculosis B. Cytomegalovirus C. Toxoplasmosis D. Cryptococcus E. Herpes simplex
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.
