Neurosurgery Practice QnA 2nd Part Flashcards
Relative contraindications for surgery for spinal metastasis include all of the following EXCEPT:
A. Multiple myeloma
B. Recurrence after maximal radiation
C. Multiple lesions at multiple levels
D. Total paralysis for > 48 hours
E. Expected survival < 3 monthsB. Recurrence after maximal radiation
Recurrence after maximal radiation is an indication to operate.
Which of the following is the usual radiation dose for spinal epidural metastasis?
A. 20 Gy in 2 Gy fractions over 10 days
B. 30 Gy in 3 Gy fractions over 10 days
C. 60 Gy in 6 Gy fractions over 10 days
D. 100 Gy in 10 Gy fractions over 10 days
E. 200 Gy in 50 Gy fractions over 30 days
There is a predilection to sensory and motor nerves of the limbs and ciliary muscle/nerve.
Match the following toxins with the appropriate fi ndings:
A. Tetanus
B. Botulism
C. Diphtheria
D. Reye’s syndrome
Diphtheria toxin has a predilection to sensory and motor nerves of the limbs
and ciliary muscles or nerves.
It typically presents with risus sardonicus.
Match the following toxins with the appropriate findings:
A. Tetanus
B. Botulism
C. Diphtheria
D. Reye’s syndrome
Tetanus may typically present with trismus, risus sardonicus, tonic spasms,
and generalized convulsions.
The initial symptom is usually diffi culty in convergence of the eyes.
Match the following toxins with the appropriate fi ndings:
A. Tetanus
B. Botulism
C. Diphtheria
D. Reye’s syndrome
Symptoms appear 12–48 hours after ingestion and may be preceded by nausea, vomiting, and diarrhea. The convergence diffi culty is usually followed by
ptosis and extraocular muscle paralysis
Encephalopathy typically develops 4 to 7 days after the onset of the illness
Match the following toxins with the appropriate fi ndings:
A. Tetanus
B. Botulism
C. Diphtheria
D. Reye’s syndrome
This is a typical feature of Reye’s syndrome
Which statement is true regarding the presentation of multiple myeloma in the spine?
A. Hypocalcemia occurs in 25% of patients.
B. Bone pain is characteristically at rest and with movement.
C. There is occurrence of amyloidosis.
D. Invasion of the spinal canal occurs in over 50% of patients.
E. Defi nitive diagnosis can be made by plain X-ray.
Patients with spinal multiple myeloma typically present with hypercalcemia,
bone pain characteristically absent at rest, and spinal canal invasion in about
10% of cases. Multiple myeloma (MM) and amyloid light-chain (AL) amyloidosis are caused by the expansion of monoclonal plasma cells and secretion
of dysproteinemia (Bence Jones protein and free light chain).
Criteria for the diagnosis of multiple myeloma include all of the following EXCEPT:
A. Biopsy-proven plasmacytoma
B. Myeloma cells in a single peripheral blood smear
C. Plasma cells > 10 of 1000 cells on marrow morphology
D. Radiographic survey demonstrating lytic lesions
E. Monoclonal immunoglobulins in the urine or blood
Myeloma cells in two or more peripheral blood smears are required.
The Batson plexus route of spinal metastases spread represents which type of spread?
A. Perinervous
B. Arterial
C. Venous
D. Direct extension
E. All of the above
It represents spread via spinal epidural veins. The Batson venous plexus is a
network of valveless veins in the human body that connect the deep pelvic
veins and thoracic veins to the internal vertebral venous plexuses.
Facioscapulohumeral dystrophy (Landouzy–Dejerine’s syndrome)
Match the following chromosomal abnormality with the appropriate disease or
syndrome:
A. 5q
B. 5p
C. 4
D. 9
E. None of the above
Facioscapulohumoral dystrophy, or Landouzy-Dejerine’s syndrome is associated with a defect on chromosome 4.
Match the following chromosomal abnormality with the appropriate disease or
syndrome:
A. 5q
B. 5p
C. 4
D. 9
E. None of the above
Werdnig-Hoff mann’s disease has autosomal recessive inheritance on chromosome 5q.
Myotonic muscular dystrophy
Match the following chromosomal abnormality with the appropriate disease or
syndrome:
A. 5q
B. 5p
C. 4
D. 9
E. None of the above
Myotonic muscular dystrophy has autosomal dominant inheritance on chromosome 19.
Cri du chat syndrome
Match the following chromosomal abnormality with the appropriate disease or
syndrome:
A. 5q
B. 5p
C. 4
D. 9
E. None of the above
Cri du chat syndrome is due to a 5p deletion and results in microcephaly,
hypertelorism, and congenital heart disease.
Friedreich’s ataxia
Match the following chromosomal abnormality with the appropriate disease or
syndrome:
A. 5q
B. 5p
C. 4
D. 9
E. None of the above
Friedreich’s ataxia has autosomal recessive inheritance on chromosome 9. It
is named after German pathologist and neurologist Nikolaus Friedreich who
identifi ed this disease in 1863.
Preferred agent for patients with systolic heart failure
Match the antiarrhythmic with the appropriate statement:
A. Verapamil
B. Diltiazem
C. Digoxin
D. Procainamide
E. Esmolol
Diltiazem is the preferred agent for patients with systolic heart failure because it produces less myocardial depression than verapamil.
Side effects of hypotension and negative inotropic effect
Match the antiarrhythmic with the appropriate statement:
A. Verapamil
B. Diltiazem
C. Digoxin
D. Procainamide
E. Esmolol
Verapamil’s side eff ects include hypotension and worsening of systolic heart
failure due to negative inotropic eff ect.
Indicated for chronic rate control of atrial fi brillation
Match the antiarrhythmic with the appropriate statement:
A. Verapamil
B. Diltiazem
C. Digoxin
D. Procainamide
E. Esmolol
Digoxin is indicated for chronic rate control of atrial fi brillation. Because of
its delayed action it is not indicated in acute atrial fi brillation.
Contraindicated in patients with prolonged QT interval
Match the antiarrhythmic with the appropriate statement:
A. Verapamil
B. Diltiazem
C. Digoxin
D. Procainamide
E. Esmolol
Procainamide is contraindicated in patients with prolonged QT interval because it prolongs QT interval and may be pro-arrhythmic. It is used to convert atrial fi brillation to normal sinus rhythm.
Indicated for rate control of atrial fi brillation in the setting of a hyperadrenergic state
Match the antiarrhythmic with the appropriate statement:
A. Verapamil
B. Diltiazem
C. Digoxin
D. Procainamide
E. Esmolol
Beta-blockers are indicated for rate control of atrial fi brillation in the setting
of a hyperadrenergic state such as acute myocardial infarction after bypass
surgery
A 56-year-old woman just had a large frontal tumor resected that stained positive for reticulin on immunostaining. The tumor histology contained mitotic fi gures as well as necrosis and pseudopalisading. The most likely diagnosis is
A. ganglioglioma.
B. gliosarcoma.
C. glioblastoma multiforme.
D. gliomatosis cerebri.
E. germinoma.
A. ganglioglioma.
B. gliosarcoma.
C. glioblastoma multiforme.
D. gliomatosis cerebri.
E. germinoma.
Gliosarcoma has the same histological features as glioblastoma multiforme.
In addition, it does stain for reticulin in the sarcomatous part of the tumor.
Approximately 2% of glioblastomas are gliosarcomas
Which of the following is true regarding management of the blunt injury shown here?
A. Those with mild neurological defi cits and accessible lesions are better managed by repair than ligation.
B. Proximal occlusion may be accomplished by an anterior approach with mobilization of the sternocleidomastoid.
C. Endovascular embolization with detachable balloons may be used for management.
D. All of the above are true.
E. None of the above are true.
Blunt trauma injuries to the cervical vertebral artery are more often managed by ligation than repair. Ligation may be risky since only ~ 20% of the
general population has a complete collateral circulation. Proximal occlusion
may be accomplished by an anterior approach with mobilization of the sternocleidomastoid. Endovascular treatment with detachable balloons is a valid
option for management.
Peripheral neuropathy, malaise, nausea, and vomiting
Match the following metals with the corresponding syndrome:
A. Mercury
B. Manganese
C. Arsenic
D. Aluminum
E. Lead
Arsenic causes peripheral neuropathy, nausea, and vomiting.
Encephalitis in children
Match the following metals with the corresponding syndrome:
A. Mercury
B. Manganese
C. Arsenic
D. Aluminum
E. Lead
Lead causes encephalitis in children as well as pica, irritability, seizures, abdominal cramping, ataxia, coma, and high intracranial pressure.
Rigidity, bradykinesia
Match the following metals with the corresponding syndrome:
A. Mercury
B. Manganese
C. Arsenic
D. Aluminum
E. Lead
Manganese causes a Parkinson-like syndrome.
Irritability, seizures, ataxia, coma
Match the following metals with the corresponding syndrome:
A. Mercury
B. Manganese
C. Arsenic
D. Aluminum
E. Lead
Peripheral neuropathy, ataxia, renal tubular necrosis
Match the following metals with the corresponding syndrome:
A. Mercury
B. Manganese
C. Arsenic
D. Aluminum
E. Lead
Mimics the defi cit of cortical cholinergic neurotransmission seen in Alzheimer’s
Match the following metals with the corresponding syndrome:
A. Mercury
B. Manganese
C. Arsenic
D. Aluminum
E. Lead
Out of the following choices, which represents the most common source of arterial embolus?
A. Left atrium
B. Left ventricle
C. Pulmonary veins
D. Aorta
E. Ventricular aneurysms
Left atrium accounts for 65–75% of embolisms, mainly the left appendage.
The left ventricle and ventricular aneurysms account for 5% each.
Potassium depletion would MOST likely result from which of the following diseases?
A. Diabetic ketoacidosis
B. Cushing’s syndrome
C. High intestinal obstruction
D. Chronic diarrhea
E. Uremia
Uremia is most likely to cause potassium stores depletion.
Which of the following is the fi rst sign of hypomagnesemia?
A. Seizures
B. Tetany
C. Hypotension
D. Loss of deep tendon refl exes
E. Stupor
Tetany is the fi rst sign of magnesium depletion. Delirium occurs usually before convulsions. An increase in deep tendon refl exes is usually observed.
All of the following are appropriate concentrations of ions in Ringer’s lactate
solution EXCEPT:
A. Na+ 130 mEq/L
B. Cl· 109 mEq/L
C. Lactate 28 mEq/L
D. Ca2+ 16 mEq/L
E. K+ 4 mEq/L
Ca2+ concentration is 3 mEq/L.
All of the following statements are associated with the type of tumor exemplifi ed by this MRI scan EXCEPT:
A. The male to female ratio is 1.5:1.
B. Thoracic location is the most common.
C. It is usually low grade.
D. It is the most common intramedullary tumor in children.
E. Examination may reveal a combination of upper and lower motor neuron signs.
The MRI scan demonstrates an intramedullary astrocytoma, which occurs
most commonly in the cervical spine. Lower motor signs may be at the level
of the lesion and may aid in localization. These types of tumors are the most
common intramedullary tumors in children and are usually of fi brillary type.
Intramedullary tumors may be treated empirically with cyberknife radiosurgery with good results forgoing the need for biopsy which can be risky. A
lumbar puncture may be used for an indirect biopsy which is reasonably safe.
It is however low yield but worth a try.
Arylsulfatase A defi ciency
Match the disorder with the appropriate disease:
A. Amyotrophic lateral sclerosis
B. Systemic lupus erythematosus
C. Metachromatic leukodystrophy
D. Lesch–Nyhan syndrome
E. Niemann–Pick disease
Superoxide dismutase mutation
Match the disorder with the appropriate disease:
A. Amyotrophic lateral sclerosis
B. Systemic lupus erythematosus
C. Metachromatic leukodystrophy
D. Lesch–Nyhan syndrome
E. Niemann–Pick disease
HGPRT defi ciency
Match the disorder with the appropriate disease:
A. Amyotrophic lateral sclerosis
B. Systemic lupus erythematosus
C. Metachromatic leukodystrophy
D. Lesch–Nyhan syndrome
E. Niemann–Pick disease
Rickets
Match the appropriate serum levels with the corresponding disease:
A. Increased calcium, normal phosphate, and increased alkaline phosphatase
B. Decreased calcium, increased phosphate, and normal alkaline phosphatase
C. Decreased calcium, decreased phosphate, and increased alkaline phosphatase
D. Normal calcium, normal phosphate, and increased alkaline phosphatase
Rickets disease presents with increased alkaline phosphatase and decreased
serum calcium and phosphate levels.
Paget’s disease
Match the appropriate serum levels with the corresponding disease:
A. Increased calcium, normal phosphate, and increased alkaline phosphatase
B. Decreased calcium, increased phosphate, and normal alkaline phosphatase
C. Decreased calcium, decreased phosphate, and increased alkaline
phosphatase
D. Normal calcium, normal phosphate, and increased alkaline phosphatase
Paget’s disease usually presents with increased alkaline phosphatase and
normal serum calcium and phosphate levels; serum calcium levels may be
increased depending on the stage of the disease
Hyperparathyroidism
Match the appropriate serum levels with the corresponding disease:
A. Increased calcium, normal phosphate, and increased alkaline phosphatase
B. Decreased calcium, increased phosphate, and normal alkaline phosphatase
C. Decreased calcium, decreased phosphate, and increased alkaline
phosphatase
D. Normal calcium, normal phosphate, and increased alkaline phosphatase
Hyperparathyroidism usually presents with increased alkaline phosphatase,
increased serum calcium, and decreased or normal phosphate levels.
Primary osteoporosis
Match the appropriate serum levels with the corresponding disease:
A. Increased calcium, normal phosphate, and increased alkaline phosphatase
B. Decreased calcium, increased phosphate, and normal alkaline phosphatase
C. Decreased calcium, decreased phosphate, and increased alkaline
phosphatase
D. Normal calcium, normal phosphate, and increased alkaline phosphatase
Primary osteoporosis usually presents with increased alkaline phosphatase
and normal serum calcium and phosphate levels.
Hypoparathyroidism
Match the appropriate serum levels with the corresponding disease:
A. Increased calcium, normal phosphate, and increased alkaline phosphatase
B. Decreased calcium, increased phosphate, and normal alkaline phosphatase
C. Decreased calcium, decreased phosphate, and increased alkaline
phosphatase
D. Normal calcium, normal phosphate, and increased alkaline phosphatase
Hypoparathyroidism usually presents with normal alkaline phosphatase, decreased serum calcium, and increased phosphate levels.
pH 7.44, pCO2 32 mm Hg, pO2 90 mm Hg; serum sodium 140 mEq/L; potassium
4.2 mEq/L; chloride 109 mEq/L; bicarbonate 21 mEq/L
Match the blood gas and electrolyte data to the relevant acid–base disorder:
A. Chronic respiratory acidosis
B. Non-anion gap metabolic acidosis and respiratory alkalosis
C. Metabolic alkalosis and respiratory acidosis
D. Wide anion gap metabolic acidosis
E. Chronic respiratory alkalosis
pH 7.40, pCO2
19 mm Hg, pO2 89 mm Hg; serum sodium, 140 mEq/L; potassium
4.3 mEq/L; chloride 117 mEq/L; bicarbonate 11 mEq/L
Match the blood gas and electrolyte data to the relevant acid–base disorder:
A. Chronic respiratory acidosis
B. Non-anion gap metabolic acidosis and respiratory alkalosis
C. Metabolic alkalosis and respiratory acidosis
D. Wide anion gap metabolic acidosis
E. Chronic respiratory alkalosis
pH 7.40, pCO2
51 mm Hg, pO2 87 mm Hg; serum sodium, 140 mEq/L; potassium
4.5 mEq/L; chloride 97 mEq/L; bicarbonate 31 mEq/L
Match the blood gas and electrolyte data to the relevant acid–base disorder:
A. Chronic respiratory acidosis
B. Non-anion gap metabolic acidosis and respiratory alkalosis
C. Metabolic alkalosis and respiratory acidosis
D. Wide anion gap metabolic acidosis
E. Chronic respiratory alkalosis
pH 7.32, pCO2 50 mm Hg, pO2 63 mm Hg; serum sodium 140 mEq/L; potassium
4 mEq/L; chloride 100 mEq/L; bicarbonate, 28 mm Hg
A. Chronic respiratory acidosis
B. Non-anion gap metabolic acidosis and respiratory alkalosis
C. Metabolic alkalosis and respiratory acidosis
D. Wide anion gap metabolic acidosis
E. Chronic respiratory alkalosis
pH 7.29, pCO2
20 mm Hg, pO2 87 mm Hg; serum sodium, 137 mEq/L; potassium
4.5 mEq/L; chloride 100 mEq/L; bicarbonate, 9 mEq/L
Match the blood gas and electrolyte data to the relevant acid–base disorder:
A. Chronic respiratory acidosis
B. Non-anion gap metabolic acidosis and respiratory alkalosis
C. Metabolic alkalosis and respiratory acidosis
D. Wide anion gap metabolic acidosis
E. Chronic respiratory alkalosis
Here are some pointers in interpreting the arterial blood gas: The most useful information comes from the clinical description of the patient by the history and physical examination; however in this case this information is not
given. Therefore, the next step is to look at the pH. If pH < 7.35, then there is
an acidemia; if pH > 7.45, then there is an alkalemia. The pH may be normal
in the presence of a mixed acid base disorder, particularly if other parameters of the ABG are abnormal. The third step is to look at PCO2 and HCO3- in
order to determine the acid base process (alkalosis vs. acidosis) leading to the
abnormal pH. In simple acid base disorders, both values are abnormal and
direction of the abnormal change is the same for both parameters. One abnormal value will be the initial change and the other will be the compensatory response. Once the initial change is identifi ed, then the other abnormal
parameter is the compensatory response if the direction of the change is the
same. If not, suspect a mixed disorder. Once the initial chemical change and
the compensatory response is distinguished, then identify the specifi c disorder. If PCO2 is the initial chemical change, then the process is respiratory; if
HCO3- is the initial change, then the process is metabolic.
Below is a brief description of the initial chemical change followed by the
compensatory response in basic acid/base disorders:
Respiratory Acidosis
elevated PCO2
elevatedHCO3-
Respiratory Alkalosis
decrease PCO2
decrease HCO3-
Metabolic Acidosis
decrease HCO3-
decrease PCO2
Metabolic Alkalosis
elevated HCO3-
elevated PCO2
Valve prosthesis
Match the appropriate scan with the syndrome:
A. Scan 1
B. Scan 2
C. Scans 1 and 2
D. None of the above
Man-in-the-barrel syndrome
Match the appropriate scan with the syndrome:
A. Scan 1
B. Scan 2
C. Scans 1 and 2
D. None of the above
Perforating branch occlusion
Match the appropriate scan with the syndrome:
A. Scan 1
B. Scan 2
C. Scans 1 and 2
D. None of the above
Scan 1 shows a wedge infarct and scan 2 shows a watershed infarct, which
can also be due to small embolic infarcts. Both endocarditis and occlusive
disease of a single artery may result in scan defi cits 1. Watershed infarcts
may typically present with man-in-the-barrel syndrome due to hypoperfusion. Man-in-the-barrel syndrome is manifested by bilateral arm weakness,
intact cranial nerves, and preservation of leg function, appearing as if the
upper limbs were confi ned in a barrel. It is most frequently caused by cerebral vascular disorders and cardiac surgeries involving arterial hypotension,
and the spinal cord may be involved as well. Other cases of man-in-the-barrel syndrome may be due to cerebral metastases, hemorrhagic contusion in
trauma, ALS, and lower motor neuron disease.
The nucleus secreting hormones that stimulate release of luteinizing hormone
(LH) and follicle-stimulating hormone (FSH) and which projects to the medial
eminence is
A. the tuberoinfundibular nucleus.
B. the preoptic nucleus.
C. the paraventricular nucleus.
D. the mammillary bodies.
E. None of the above
The preoptic nucleus is considered part of the anterior hypothalamus.
Eff erent pupillary defects are seen in the following disorders EXCEPT:
A. Adie’s pupil
B. Posterior communicating artery aneurysm
C. Kennedy syndrome
D. Horner’s syndrome
E. Third nerve lesion
All the other choices result in an eff erent defect
Relative aff erent pupillary defects are seen in the following disorders EXCEPT:
A. Macular degeneration
B. Optic neuritis
C. Papilledema
D. Metabolic optic neuropathy
E. Retinal lesion
Metabolic neuropathy is typically symmetric and bilateral and will rarely
present with an aff erent pupillary defect clinically.
Hypoxemia due to a 50% shunt is most likely to be improved by which of the
following measures?
A. Decreasing the positive end expiratory pressure to 0 cm H2O
B. Hyperventilation
C. Improving mixed venous oxygen contents
D. Oxygen supplementation
E. None of the above
An improvement in mixed venous oxygen contents will often improve the
hypoxemia in the setting of a shunt.
The half-life of platelets used for transfusion is
A. 96 hours.
B. 72 hours.
C. 48 hours.
D. 24 hours.
E. 12 hours
Which phase of blood coagulation is the most time consuming?
A. Conversion of prothrombin to thrombin
B. Activation of contact factors
C. Generation of thromboplastin
D. Release of phospholipids from plate
E. Conversion of fi brinogen to fi brin
Conversion of prothrombin from thrombin is the most time consuming and
is usually measured as the prothrombin time (PT); it is in the range of 11 to
13 seconds.
Caused by arrested development
A. Image 1
B. Image 2
C. Images 1 and 2
D. None of the above
The second fi gure shows a venous angioma which can be caused by arrested
development.
Acquired after dural thrombosis
A. Image 1
B. Image 2
C. Images 1 and 2
D. None of the above
Dural arteriovenous malformations are usually acquired after dural thrombosis. Neither cavernous malformation (fi rst image) nor venous angioma
(second image) is an acquired lesion
Associated with blue rubber nevus syndrome
A. Image 1
B. Image 2
C. Images 1 and 2
D. None of the above
Blue rubber nevus syndrome is associated with venous angiomas.
Foramen magnum compression
Match the associated ocular fi nding with the correct pathological state:
A. Ocular bobbing
B. Jerk nystagmus
C. See-saw nystagmus
D. Downbeat nystagmus
E. None of the above
Craniopharyngioma
A. Ocular bobbing
B. Jerk nystagmus
C. See-saw nystagmus
D. Downbeat nystagmus
E. None of the above
Germinoma
A. Ocular bobbing
B. Jerk nystagmus
C. See-saw nystagmus
D. Downbeat nystagmus
E. None of the above
Pentobarbital infusion
A. Ocular bobbing
B. Jerk nystagmus
C. See-saw nystagmus
D. Downbeat nystagmus
E. None of the above
Pontine glioma
A. Ocular bobbing
B. Jerk nystagmus
C. See-saw nystagmus
D. Downbeat nystagmus
E. None of the above
Forms the glomerulus together with the granule cell
Match the cerebellar cell type with the appropriate description:
A. Granule cell
B. Golgi cell
C. Purkinje cell
D. Basket cell
E. Stellate cell
The glomerulus is formed by the Golgi cell, the granule cell, and the mossy
fi ber.
Excitatory neurotransmitter
Match the cerebellar cell type with the appropriate description:
A. Granule cell
B. Golgi cell
C. Purkinje cell
D. Basket cell
E. Stellate cell
The granule cell is the only excitatory cell within the cerebellum
End in a rete of terminals around the cell bodies of the Purkinje cell
Match the cerebellar cell type with the appropriate description:
A. Granule cell
B. Golgi cell
C. Purkinje cell
D. Basket cell
E. Stellate cell
Basket cells end in a rete of terminals around the Purkinje cell.
Synapse with the interposed nuclei
Match the cerebellar cell type with the appropriate description:
A. Granule cell
B. Golgi cell
C. Purkinje cell
D. Basket cell
E. Stellate cell
Purkinje cells synapse with the deep cerebellar nuclei.
Which of the following is the earliest sign of cyanide poisoning?
A. Blurred vision
B. Diaphoresis
C. Apnea
D. Hallucinations
E. Sneezing
Early signs of cyanide poisoning include general weakness, malaise, early
giddiness, inebriation, confusion, headache, vertigo, dizziness, confusion,
and hallucinations. Tachypnea and hyperpnea generally precede apnea.
Which of the following minerals is important in wound healing?
A. Manganese
B. Zinc
C. Iron
D. Copper
E. All of the above
All are important in wound healing. Zinc is a mineral that is important for
the action of collagenase. Manganese is necessary for the glycosylation of
hydroxyproline residues in the formation of collagen. Copper is a cofactor of
ceruloplasmin and is involved in the synthesis of oxidative metalloenzymes
and elastics. Iron is a vital cofactor for proteins and enzymes involved in energy metabolism, respiration, DNA synthesis, cell cycle arrest, and apoptosis.
The mechanism of action of aminoglycosides is best described by
A. inhibition of DNA synthesis.
B. cell membrane destruction.
C. cell wall damage.
D. inhibition of protein synthesis.
E. None of the above
Aminoglycosides act by inhibiting protein synthesis through irreversible ribosomal attachment. Examples of aminoglycoside antibiotics are amikacin,
tobramycin, gentamicin, streptomycin, and neomycin.
Antimicrobial agents causing neuromuscular blockade include all of the following EXCEPT:
A. Streptomycin
B. Kanamycin
C. Neomycin
D. Polymyxin
E. Gentamicin
Polymyxin does not cause neuromuscular blockade.
Given the aneurysm exposed by a far lateral approach (cerebellum retracted)
(see intraoperative picture), which statement is true?
A. The Allcock test is useful.
B. External ventricular drainage following subarachnoid hemorrhage from
this type of aneurysm is an accepted temporizing treatment.
C. Proximal ligation is the preferred treatment.
D. Vasospasm in this area is unlikely to cause respiratory compromise.
E. A lumbar drain is contraindicated in this case.
The image represents a vertebral artery aneurysm. The preferred treatment
is direct aneurysm clipping of this aneurysm. The Allcock test will test patency of the circle of Willis via carotid occlusion. Vasospasm in this area can
cause midbrain and medullary syndrome, including respiratory arrest and
neurogenic pulmonary edema. A lumbar arachnoid catheter may also be
used to allow CSF drainage.
In this tumor resection case (see intraoperative picture), which of these
statements is FALSE?
A. The dura needs to be opened at either end well above the lesion.
B. Dilated veins are more likely to be encountered at the rostral end of the
mass.
C. Myelotomy is to be done as close to the midline as possible.
D. Intracapsular decompression of the tumor is necessary to avoid any
traction.
E. C-arm guidance for localization may be helpful.
When removing an intramedullary spinal cord tumor one is more likely to
encounter dilated veins at the caudal end of the mass. The other points are
general principles of spinal cord tumor resection. Note that it is useful to seek
out the blood supply of the tumor before debulking to keep the fi eld relatively free of blood.
Accumulations seen in metachromatic leukodystrophy are
A. sulfatides.
B. galactocerebroside.
C. ganglioside.
D. long-chain fatty acids.
E. None of the above
Galactocerebroside accumulates in Krabbe’s disease. Ganglioside accumulates in Tay–Sachs’s and Sandhoff ’s diseases. Long chain fatty acids accumulate in adrenoleukodystrophy.
The T-refl ex represents
A. fl exor response as seen in decerebrate rigidity.
B. crossed extensor refl ex.
C. monosynaptic stretch refl ex.
D. supramaximal stimulation of a mixed motor-sensory nerve.
E. All of the above
The T-refl ex represents the monosynaptic stretch refl ex elicited by tapping a
tendon.
The trochlear nerve arises from the brainstem at the level of the
A. lower pons.
B. upper pons.
C. lower midbrain.
D. upper midbrain.
E. medulla.
The trochlear nerve arises at the level of the lower midbrain (inferior colliculus level).
A 57-year-old man with a known history of lung cancer presents with
generalized muscle weakness. The most likely associated fi nding is
A. opsoclonus.
B. increased glutamic acid decarboxylase.
C. anti–Purkinje cell antibodies.
D. presynaptic acetylcholine receptor disorder.
E. multiple sclerosis.
The patient likely has Lambert–Eaton myasthenic syndrome (LEMS) with
small cell (oat cell) carcinoma. About 60% of those with LEMS have an underlying malignancy, most commonly small cell lung cancer.
To produce 1 mEq/L rise in serum potassium, the total body potassium stores
need to increase by what quantity?
A. 50 mEq
B. 150 mEq
C. 350 mEq
D. 500 mEq
E. 1000 mEq
Total body potassium excess of 100 to 200 mEq is required to produce a rise
of 1 mEq/L in serum potassium.
If the C6 nerve root is severed, all of the following may be aff ected EXCEPT:
A. Lateral cord
B. Ulnar nerve
C. Musculocutaneous nerve
D. Median nerve
E. Lower subscapular nerve
The ulnar nerve has no supply from the C6 root.
Inferior belly of the omohyoid
Match each plexus with its innervation:
A. Brachial plexus
B. Cervical plexus
C. Lumbar plexus
D. Cervical and brachial plexuses
E. None of the above
Cervical roots C2 and C3 innervate this muscle.
C5 nerve root
Match each plexus with its innervation:
A. Brachial plexus
B. Cervical plexus
C. Lumbar plexus
D. Cervical and brachial plexuses
E. None of the above
Involved in the phrenic nerve and the brachial plexus
Obturator nerve
Match each plexus with its innervation:
A. Brachial plexus
B. Cervical plexus
C. Lumbar plexus
D. Cervical and brachial plexuses
E. None of the above
Innervated by the obturator nerve (L2, L3).
Levator scapulae
Match each plexus with its innervation:
A. Brachial plexus
B. Cervical plexus
C. Lumbar plexus
D. Cervical and brachial plexuses
E. None of the above
Innervated by C3, C4 (cervical nerves) and C5 (dorsal scapular nerve which
arises from the brachial plexus).
External urethral sphincter
Match each plexus with its innervation:
A. Brachial plexus
B. Cervical plexus
C. Lumbar plexus
D. Cervical and brachial plexuses
E. None of the above
Innervated by the pudendal nerve (S2–S4).
Sternocleidomastoid
Match each plexus with its innervation:
A. Brachial plexus
B. Cervical plexus
C. Lumbar plexus
D. Cervical and brachial plexuses
E. None of the above
Innervated by the accessory nerve and C2 roots.
Which of the following is a characteristic of narcolepsy?
A. Hallucinations while sleeping
B. Convulsions while sleeping
C. Daytime hyperalertness
D. NREM onset of sleep
E. Gelastic seizures
Hypnagogic hallucinations are seen with narcolepsy. Hypnagogic or hypnopompic hallucinations are visual, tactile, auditory, or other sensory events,
usually brief but occasionally prolonged, that occur at the transition from
wakefulness to sleep (hypnagogic) or from sleep to wakefulness (hypnopompic). People with narcolepsy have a reduced number of neurons that produce the protein orexin-A.
Pseudotumor cerebri
For the following items, match the vitamin excess or defi ciency and the clinical
disorder:
A. Thiamine
B. B6
C. Cobalamine
D. Niacin
E. Vitamin A
Vitamin A intoxication is associated with pseudotumor cerebri.
Beriberi
For the following items, match the vitamin excess or defi ciency and the clinical
disorder:
A. Thiamine
B. B6
C. Cobalamine
D. Niacin
E. Vitamin A
Beriberi is associated with thiamin defi ciency (B1). Beriberi is divided into
three separate entities depending on which body system is involved: peripheral nervous system (dry beriberi), cardiovascular system (wet beriberi), or
gastrointestinal system.
Increased serum homocysteine
For the following items, match the vitamin excess or defi ciency and the clinical
disorder:
A. Thiamine
B. B6
C. Cobalamine
D. Niacin
E. Vitamin A
Increased serum homocysteine and methylmalonic acid is associated with
vitamin B12 defi ciency.
Lower extremities paresthesias
For the following items, match the vitamin excess or defi ciency and the clinical
disorder:
A. Thiamine
B. B6
C. Cobalamine
D. Niacin
E. Vitamin A
Pyridoxine defi ciency is associated with lower extremity paresthesias.
Barbiturates
Match the eff ect with the pharmacological agent:
A. Type A GABA agonist
B. Type B GABA agonist
C. GABA antagonist
D. No eff ect on GABA receptors
Barbiturates are used as antiepileptics and in the treatment of intractable
increased intracranial pressure.
Picrotoxin
Match the eff ect with the pharmacological agent:
A. Type A GABA agonist
B. Type B GABA agonist
C. GABA antagonist
D. No eff ect on GABA receptors
Both picrotoxin and bicuculline are GABA receptor blockers.
Baclofen
Match the eff ect with the pharmacological agent:
A. Type A GABA agonist
B. Type B GABA agonist
C. GABA antagonist
D. No eff ect on GABA receptors
Baclofen in used as a centrally acting muscle relaxant. Baclofen can be administered transdermally, orally, or intrathecally.
Bicuculline
Match the eff ect with the pharmacological agent:
A. Type A GABA agonist
B. Type B GABA agonist
C. GABA antagonist
D. No eff ect on GABA receptors
Bicuculline is a selective GABA-A antagonist directly at the site where GABA
binds.
The two aneurysms seen in this intraoperative picture are
A. anterior communicating and superior hypophyseal.
B. basilar and anterior communicating.
C. PICA and superior hypophyseal.
D. PICA and basilar.
E. basilar and posterior communicating.
The two aneurysms are a calcifi ed thrombotic basilar artery aneurysm and a
posterior communicating artery aneurysm.
Transcallosal approach for tumor resection shows this lesion (see intraoperative picture; the pertinent MRI is also shown). Which of the following statements is FALSE?
A. A common presenting sign is papilledema.
B. It arises from the diencephalic recess of the postvellar arch.
C. Risk of sudden death is attributable to CSF dynamics or disturbances in
hypothalamic-related cardiovascular control.
D. Lumbar puncture is part of the initial workup.
E. The patient may require a shunt postoperatively
The lesion presented is a colloid cyst of the third ventricle. A lumbar puncture is contraindicated prior to the placement of a shunt or a ventricular
catheter due to the risk of herniation.
All of the following are associated with torsades de pointes EXCEPT:
A. Phasic changes of amplitude and polarity of ventricular complexes
B. Hypokalemia
C. Hypomagnesemia
D. Narrowed QT intervals
E. May be predisposed by erythromycin
Torsades de pointes presents with prolonged QT intervals.
Which of the following enables one to distinguish early acute respiratory
distress syndrome (ARDS) from early cardiogenic pulmonary edema?
A. In early ARDS, the hypoxemia is more pronounced and the chest X-ray
abnormalities are more evident.
B. In early ARDS, the hypoxemia is less pronounced and the chest X-ray abnormalities are more evident.
C. In early ARDS, the hypoxemia is more pronounced and the chest X-ray
abnormalities are less evident.
D. In early ARDS, the hypoxemia is less pronounced and the chest X-ray abnormalities are less evident.
E. None of the above
In early ARDS, the chest X-ray may be unrevealing, whereas the patient may
present with a hypoxemia refractory to supplemental oxygen.
All of the following are recommended therapeutic measures for diabetic ketoacidosis EXCEPT:
A. Insulin
B. Alkali therapy
C. Potassium
D. Crystalloids
E. Phosphate
Bicarbonate therapy does not improve outcome in diabetic ketoacidosis, regardless of the severity of the acidosis.
A 54-year-old man who is a heavy smoker presents with balance problems and
the MRI scan and pathology slide from surgery shown here. The most likely
diagnosis is
A. metastasis.
B. hemangioblastoma.
C. glioma.
D. central nervous system (CNS) lymphoma.
E. pilocytic astrocytoma.
The MRI shows an enhancing mural nodule with an associated cyst. Pathology shows highly vascular tissue and stromal cells characteristic of hemangioblastoma.
A 64-year-old man was admitted with mental status changes and a temperature of 103.4°F. Spinal fl uid was obtained and showed 118 WBC, 49 RBC, 102
protein, and 79 glucose. The patient had an MRI scan, shown here. The most
likely diagnosis is
A. glioblastoma multiforme resection.
B. radiation therapy.
C. trauma.
D. encephalitis.
E. cerebral atrophy
This T2-weighted MRI shows enhancement of the medial temporal lobe, a
fi nding representative of herpes encephalitis.
After a motorcycle accident, a patient is able to dorsifl ex and invert his foot but
is unable to evert his foot. The most likely nerve lesioned is the
A. deep peroneal nerve.
B. superfi cial peroneal nerve.
C. common peroneal nerve.
D. sciatic nerve.
E. tibial nerve.
The superfi cial peroneal nerve innervates the peroneus longus and brevis,
which evert the foot. A lesion of the deep peroneal nerve will aff ect ankle
dorsifl exion. A lesion of the common peroneal or sciatic nerves will aff ect
both ankle dorsifl exion and foot eversion. A sciatic nerve lesion will also affect foot fl exion and inversion.
The brachial plexus structure just distal to the division is
A. the trunk.
B. the branch.
C. the cord.
D. the root.
E. None of the above
The order of the brachial plexus structures is: root, trunk, division, cord, and
branch.
This intraoperative picture shows a middle cerebral artery bifurcation
aneurysm. What is the proper order of steps to ensure safe clipping of this
aneurysm?
A. Defi nitive clipping, temporary clipping, fi ssure splitting, dissection of M2
branch from dome
B. Dissection of M2 branch from dome, fi ssure splitting, temporary clipping,
defi nitive clipping
C. Fissure splitting, temporary clipping, dissection of M2 branch from dome,
defi nitive clipping
D. Temporary clipping, fi ssure splitting, dissection of M2 branch from dome,
defi nitive clipping
E. Fissure splitting, dissection of M2 branch from dome, temporary clipping,
defi nitive clipping
Fissure splitting, temporary clipping, dissection of M2 branch from dome,
and defi nitive clipping is the proper order of steps for clipping this diffi cult
aneurysm.
Which of the following is NOT associated with the fi nding on this scan?
A. Congestive heart failure
B. Pulmonary hypertension
C. Renal failure
D. Microcephaly
E. Subarachnoid hemorrhage
This MRI scan shows a vein of Galen malformation, which is usually associated with macrocephaly and hydrocephalus.
All the following are associated with the fi nding on this MRI scan EXCEPT:
A. The most common location is cervicothoracic.
B. The presence of a malignancy is a predisposing condition.
C. There is increased incidence with epidural anesthesia.
D. The incidence is 1:10,000 in the United States.
E. There is increased incidence with drug abuse.
The following MRI scan demonstrates an epidural abscess, which more frequently occur in the thoracolumbar region.
Eosinophilic granuloma
Match the lesions shown here with the correct disease:
A. Lesion 1
B. Lesion 2
C. Lesions 1 and 2
D. None of the above
Single punched out lesion without sclerotic edges is typical.
Langerhans cell histiocytosis
Match the lesions shown here with the correct disease:
A. Lesion 1
B. Lesion 2
C. Lesions 1 and 2
D. None of the above
Eosinophilic granuloma may be a monostotic form of Langerhans cell
histiocytosis.
Paget’s disease
Match the lesions shown here with the correct disease:
A. Lesion 1
B. Lesion 2
C. Lesions 1 and 2
D. None of the above
In Paget’s disease, one may observe bony destruction (early) and sclerosis
(late).
Albright’s syndrome
Match the lesions shown here with the correct disease:
A. Lesion 1
B. Lesion 2
C. Lesions 1 and 2
D. None of the above
Albright’s syndrome is characterized by unilateral fi brous dysplasia,
pigmented skin lesions, and precocious puberty
Diff erential diagnosis of the lesion shown here includes the listed choices
EXCEPT:
A. Chordoma
B. Epidermoid
C. Basilar tip aneurysm
D. Arachnoid cyst
E. Low-grade glioma
The lesion most likely represents a lobulated arachnoid cyst. An aneurysm
would not display such septations.
Which of the following fi ndings is most closely associated with the lesion on
this scan?
A. May have elevated carcinoembryonic antigen (CEA) levels
B. Associated with Schiller–Duval bodies
C. Derived from extraembryonic tissue
D. Ingestion of food with fecal contamination
E. Multiple sclerosis
This scan shows a teratoma, which is associated with elevation of CEA levels.
Which of the following is this scan fi nding associated with?
A. Anti-Yo antibodies
B. Anti-Hu antibodies
C. Anti-Ri antibodies
D. Antibodies to presynaptic voltage-gated receptors
E. None of the above
Paraneoplastic sensory neuropathy with anti-Hu antibodies is associated
with limbic encephalitis (as seen on this MRI scan), seizures, epilepsia partialis continua, cerebellar ataxia, autonomic instability, myelitis with patchy
weakness, and brainstem encephalitis.
Match the fi nding on this myelin-stained section with the most likely associated
presentation:
A. 40-year-old man with chronic encephalitis and Argyll Robertson pupils
B. 15-year-old hyperglycemic with severe lower extremity weakness
C. 55-year-old man with spastic gait, weakness, and fasciculation in all
extremities
D. 4-year-old boy with bilateral symmetric proximal limb weakness
E. 60-year-old female with spondylolisthesis at L5–S1
Tabes dorsalis presents 15 to 20 years after initial syphilitic infection and is
characterized by dorsal root and posterior column involvement as seen on
this myelin-stained cord section.
All of the following statements are correct regarding this diff usion tractography
scan EXCEPT:
A. Water diff usion is hindered anteriorly by the presence of a large tumor.
B. Connections between frontal and occipital lobe are impaired on the right side.
C. There are intersecting white matter tracts between the splenium and the
fronto-occipital tracts.
D. Tractography gives information about the direction of fl ow.
E. Bundles of axons provide a barrier to perpendicular diff usion and a path
for parallel diff usion along the orientation of the fi bers.
Tractography is a procedure to demonstrate the neural tracts. It uses special techniques of magnetic resonance imaging (MRI), and computer postprocessing. Information about direction of fl ow is provided by tractography
but not about connections between diff erent structures in the brain.
Which of the following is true regarding the fi nding on this MRI scan?
A. It is associated with dermal sinus tract.
B. It secretes histamine.
C. On histopathology, one may see densely packed elongated spindle cells in
interlocking fascicles with a tendency toward palisading.
D. All of the above are true.
E. None of the above are true.
The scan shows an atypical dermoid cyst. Dermoid cysts can contain fat
which gives them high signal intensity on T1-weighted sequences. A congenital dermal sinus tract can be associated with a dermoid cyst. Choice B is associated with paraganglioma. Choice C is representative of Antoni A pattern
in acoustic neuromas.
All of the following fi ndings may be associated with this MRI scan EXCEPT:
A. Abnormality in protein merlin
B. Posterior capsular lens opacities
C. Intertriginous freckling
D. Pigmented area of skin with excess hair
E. May be associated with an autosomal disorder located on chromosome 22
The MRI scan shows bilateral acoustic neuromas, pathognomonic of neurofi -
bromatosis type 2. Intertriginous freckling is a feature of neurofi bromatosis
type 1.
This is an intraoperative picture showing clipping of an ophthalmic artery
aneurysm. With regard to the neck of the aneurysm, which statement is true?
A. The neck of the aneurysm is unobstructed.
B. The neck of the aneurysm is obstructed by the dome.
C. The neck of the aneurysm is obstructed by the optic nerve.
D. The neck of the aneurysm is obstructed by the carotid artery.
E. The neck of the aneurysm is obstructed by the anterior clinoid process.
The anterior clinoid process is most likely going to have to be drilled to gain
access to the neck of this aneurysm.
During microvascular decompression for trigeminal neuralgia, this intraoperative picture is taken and the off ending artery is seen. What is the artery and
what structure does it come close to more proximally in this picture?
A. Superior cerebellar artery, abducens nerve
B. Anterior inferior cerebellar artery, trochlear nerve
C. Superior cerebellar artery, trochlear nerve
D. Anterior inferior cerebellar artery, abducens nerve
E. Superior cerebellar artery, oculomotor nerve
The superior cerebellar artery is seen in neurovascular confl ict with the
trigeminal nerve. More proximally though, the artery is seen near the tentorium which is in very close relation to the trochlear nerve.
Which of the following is the LEAST favorable therapeutic approach for the lesion depicted on the MRI scans?
A. Supracerebellar infratentorial approach for cyst resection
B. Midline frontal approach for cyst resection
C. Third ventriculostomy
D. Midline frontal approach for cyst decompression
E. Endoscopic cyst resection
The posterior approach is unfavorable in this case since the angle of the tentorium is very steep and would necessitate severe retraction on the cerebellum. In addition, the posterior approach presents a very narrow corridor
limited by the internal cerebral veins.
Which of the following is the LEAST likely presenting sign in a patient with
rhinorrhea and this metrizamide CT scan fi nding
A. Reservoir sign
B. Early morning headache
C. Meningitis
D. Visual defi cits
E. Sinus congestion
Reservoir sign, or intermittent large volume CSF rhinorrhea, is a relatively
uncommon occurrence in patients with sphenoid sinus encephaloceles. The
leakage of fl uid is usually insidious.
What is the best therapeutic option in this 1-year-old with the lesion appearing
on this MRI?
A. Surgical evacuation
B. Systemic antibiotics
C. Head wrapping
D. Radiation therapy
E. VP shunt
The scan shows a cephalohematoma which is treated with head wrapping
and possibly needle aspiration.
All the following are associated with this angiogram fi nding EXCEPT:
A. It connects the basilar artery between the superior cerebellar and the anterior inferior cerebellar arteries by passing through the petrous bone.
B. It connects the basilar artery by passing through the internal auditory
meatus.
C. It is present in 0.1% of the population.
D. There is increased frequency of arteriovenous malformations.
E. It is the second most common persistent fetal circulation.
The angiogram demonstrates a primitive trigeminal artery. The persistent
acoustic artery passes through the internal auditory meatus.
This scan of a 35-year-old woman on hormonal contraceptives is most consistent with the diagnosis of
A. tentorial subdural hemorrhage.
B. subarachnoid hemorrhage.
C. normal CT scan.
D. dural sinus thrombosis.
E. arteriovenous fi stula.
The scan shows straight sinus thrombosis.
Which of the following is the lesion on this MRI scan associated with?
A. Cerebral aneurysm
B. Arteriovenous malformation
C. Endocrinopathy
D. Venous angioma
E. Progressive supranuclear palsy
The scan shows a cavernous angioma occurring at the thalamocaudate recess. These lesions may be associated with venous angiomas.
Which of the following changes are represented at the end plates of L4–L5 levels
on this T2-weighted MRI scan?
A. Type 1 Modic changes
B. Type 2 Modic changes
C. Yellow marrow replacement
D. Hypovascularization of the end plates
E. None of the above
Type 1 Modic changes show decreased intensity on T1-weighted images and
increased intensity on T2-weighted images. Type 2 Modic changes show increased intensity on T1-weighted images and isointense signal intensity on
T2-weighted images. Histopathology on type 1 changes demonstrates disruption and fi ssuring of the end plates and vascularized fi brous tissue. On
type 2 changes, yellow marrow replacement is seen. Type 1 changes may
convert to type 2 after a few years. There appears to be a spectrum of vertebral body marrow changes associated with degenerative disk disease.
All of the following neurological defi cits may be present with the lesion seen on
this MRI scan EXCEPT:
A. Ataxia
B. Ipsilateral hearing defi cits
C. Contralateral temperature sensation loss
D. Lateral rectus palsy
E. Balance problems
The lesion represents a syrinx at the level of the inferior cerebellar peduncle.
The abducens nerve arises at a higher level and is less likely to be aff ected.
The anterolateral system courses ventral to the lesion and may be aff ected.
The vestibulocochlear nucleus is also located at this level.
Which of the following statements is not associated with the images shown
here?
A. Froin’s syndrome
B. Positive Queckenstedt’s sign
C. Male predominance with peak age in mid-40s
D. Cellular type
E. Neoplastic disease
The scans show a typical intramedullary ependymoma with blockage of CSF
fl ow, which is associated with Froin’s syndrome (clotting and xanthochromia
in the CSF) and Queckenstedt’s sign, which is failure of jugular vein compression to increase CSF. The cervical type of intramedullary ependymoma is
usually of the cellular type, more frequent in females in the mid-40s.
Which of the following is associated with this set of MRI scans in a patient with
a functional ventriculoperitoneal shunt placed in the right ventricle?
A. Syringobulbia
B. Elevated serum angiotensin-converting enzyme
C. Aqueductal stenosis
D. Hallervorden–Spatz disease
E. Subdural hematoma
The MRI set demonstrates basilar meningitis with a trapped fourth ventricle and foramina of Luschka which occurs in sarcoidosis. Elevated angiotensin-converting enzyme levels is also a feature of this disease.
Which of the following prognostic factors is true in the case of a 16-year-old
boy with failure to thrive and the following fi ndings on MRI scan?
A. The most signifi cant factor associated with recurrence is extent of
resection.
B. A factor associated with recurrence is histology.
C. MIB-1 LI >7% is associated with a low likelihood of recurrence.
D. Malignant transformation to carcinoma frequently occurs.
E. Recurrence is dependent on the presence of intracytoplasmic inclusions.
The images show craniopharyngioma. The most signifi cant factor associated
with recurrence is extent of resection. Histology type is not correlated with
frequency of recurrence. MIB-1 LI > 7% is associated with a higher likelihood
of recurrence. Malignant transformation to carcinoma exceptionally occurs.
This tumor shows on histopathology uniform round cells with perinuclear halos. Its immunohistochemistry is positive for synaptophysin. What is the most
likely diagnosis?
A. Central neurocytoma
B. Oligodendroglioma
C. Ependymoma
D. Endodermal sinus tumor
E. Yolk sac tumor
Central neurocytoma appears like oligodendroglioma histologically but is
positive for synaptophysin on immunohistochemistry
What is the most likely age of the hemorrhage shown here?
A. 2 hours
B. 2 days
C. 12 days
D. 22 days
E. 32 days
Intracellular methemoglobin appears as hyperintense on T1 and hypointense
on T2, and is usually present from 3 days to 2 weeks after a hemorrhage. Extracellular methemoglobin appears after 2 weeks and is hyperintense on T1
and T2. The images show hyperintensity on T1 and iso- to hypointensity on
T2, consistent with intracellular methemoglobin toward the end of 2 weeks
following the hemorrhage.
Which of the following is least likely to be associated with the fi nding on this
MRI scan?
A. Ipsilateral Horner’s syndrome
B. Downbeat nystagmus
C. Loss of abdominal cutaneous refl ex
D. Neurogenic bladder
E. Extremity weakness
The scan shows a foramen magnum tumor. All the stated clinical fi ndings are
associated with this tumor location; however, neurogenic bladder tends to
occur very late.
Typical presentation of patients with cauda equina lesions includes all of the
following EXCEPT:
A. Sensory dissociation
B. Asymmetric motor loss
C. Late autonomic symptoms
D. Absence of ankle jerk and knee jerk
E. Numbness that tends to be more localized to saddle area
There is no sensory dissociation. Red fl ags for cauda equina syndrome are
erection diffi culty, extreme back pain, and groin numbness. An MRI scan taken in a lying down position may not display the stenosis so a standing MRI
scan, if available, is necessary. These patients should be sent to an emergency
room at once for stat MRI. In the setting of groin numbness only with back
pain, urodynamics and Foley catheter may not be absolutely necessary. One
should not delay care of these patients to the point in time where urodynamics become necessary. If these patients present in the emergency room,
they should not be sent home to follow up electively, they should be decompressed and stabilized on that hospital admission.
All the following statements are true regarding the fi ndings of this scan EXCEPT:
A. Thirty to fi fty percent of patients are febrile.
B. Spontaneous fusion of vertebral bodies may occur.
C. Haemophilus infl uenzae may be a causative organism in juvenile cases.
D. Radionuclide scans have a relatively low sensitivity.
E. There is increased incidence with intravenous drug abuse.
Radionuclide scans have a relatively high sensitivity in detecting diskitis.
Choose the best answer based on the following MRI fi nding in a 20-year-old
woman with Hodgkin’s lymphoma and an opportunistic infection. Which of the
following is the most likely infection?
A. Mucor
B. Aspergillus
C. Coccidioides
D. E. histolytica
E. Virus
Characteristic features of the organism referred to in the preceding question
include all of the following EXCEPT:
A. Perivascular invasion
B. Hemorrhagic infarcts
C. Paranasal sinus mycetoma
D. Caseating granulomas
E. Increased prevalence with the use of chemotherapy and corticosteroids
Aspergillus has a predilection for the basal ganglia in some cases. It tends to
invade blood vessels, cause hemorrhagic infarcts, and may cause formation
of paranasal sinus mycetoma. Coccidioides can cause meningitis and caseating granulomas. The diagnosis of early cerebral infarction in a patient considered at risk for invasive aspergillosis, even without overt pulmonary disease,
is an indication to institute aggressive antifungal therapy
What is the best treatment option in a 63-year-old woman with mental status
changes and the following imaging study?
A. Intravenous antibiotics
B. Surgical resection
C. Systemic chemotherapy and whole-brain radiation
D. Ommaya reservoir placement and intrathecal chemotherapy
E. Ventriculoperitoneal shunt
The MRI scan demonstrates leptomeningeal gliomatosis associated with a
high-grade glioma in the left occipital area. The best therapeutic option, given the diff use nature of the disease is, initially, chemotherapy and radiation.
Equals 2.4 L at rest and 2.4 L during exercise
Match the following choices with the appropriate measurements on the lung volume spirogram:
D
Represents vital capacity minus expiratory reserve volume
Match the following choices with the appropriate measurements on the lung volume spirogram:
D
Measured at ~4.4 to 5 L in healthy adults
Match the following choices with the appropriate measurements on the lung volume spirogram:
B
Calculated after having the patient inspire a mixture containing 10% helium
from a spirometer at 21°C
Match the following choices with the appropriate measurements on the lung volume spirogram:
C
Functional residual capacity (D) does not change during exercise and is usually 2.4L. It is the sum or residual volume (C) and expiratory reserve volume
(ERV), or the diff erence between vital capacity (B) and ERV. Vital capacity
(VC) is usually around 4.4 to 5 L and is measured by having the patient inhale profoundly and exhale fully into a spirometer. Residual volume cannot
be measured directly and needs to be calculated as a percentage of exhaled
versus inhaled 10% helium-containing solution.
Point 1 being closest to normal and point 3 showing the most abnormality,
which of the following statements with regard to spectroscopy is correct
regarding point 3?
A. Elevated N-acetylaspartate (NAA) peak and normal choline (Chol) and creatine (Cr) peaks
B. Elevated Cr peak and decreased Chol and NAA peaks
C. Increased Chol:Cr ratio and decreased NAA peak
D. Increased Cr:Chol ratio and decreased NAA peak
E. All of the above
What do the preceding MR spectroscopy fi ndings most likely represent?
A. Increased astrocytic density at point 3 as compared with point 1
B. Presence of tumor cells at point 3
C. Presence of necrosis at point 3
D. Increased metabolism at point 3
E. All of the above
Point 3 on the MR spectroscopy represents an area of tumor (glioma), which
shows an elevated Chol:Cr ratio and a decreased NAA peak. Other changes
seen in tumors may be decreased Chol and elevated NAA.
A prisoner with suicidal tendencies is brought to the emergency room after
stabbing himself in the eye with a pencil. The patient is started on broad-spectrum antibiotics, antiseizure medication, and taken immediately for open
surgical debridement. The CT scan shown here is taken. The foreign object
should be removed
A. immediately in the ER.
B. before a CT scan.
C. in the operating room.
D. before antibiotics are given.
E. after the patient has been stabilized.
If the pencil is pulled from his eye, there should be adequate measures to
stop bleeding and irrigate the wound. This can be properly performed only
in the operating room. This patient should be managed with antiepileptic
medication, broad-spectrum antibiotics, CT scan, immediate open surgical
debridement, and follow-up MRI in about a week.
A 48-year-old woman presents with progressive myelopathy and diffi culty
walking for several months. Her MRI and CT scans are shown here. What would
be the best management of the off ending lesion?
A. Single-level anterior cervical diskectomy and fusion (ACDF)
B. Two-level ACDF
C. Posterior decompression
D. Cervical corpectomy and fusion
E. Three-level ACDF
The patient has ossifi cation of the posterior longitudinal ligament (OPLL),
which is best managed with cervical corpectomy and fusion. It cannot be
stressed enough that severe cervical compression seen on MRI should be
followed with a CT scan to get an idea of the osteophytes and/or OPLL near
the cord.
