review

Question 1

In order to withdraw cerebrospinal fluid (CSF) from the lumbar cistern (to perform a lumbar puncture), a needle tip must pass successively through the…

Answer 1

… epidural space, dura mater, subdural space, and arachnoid membrane

Question 2

The blood-brain barrier is created by which of the following cellular barriers?
Astrocyte tight junctions
Choroid epithelium tight junctions
Pia Mater
Capillary endothelial tight junctions

Answer 2

Capillary endothelial tight junctions

Question 3

A 54-year-old man presents complaining of weakness. He has a difficult time pinpointing an onset. He believes he first noticed weakness in his right foot and leg about 6 months ago. He reports that he frequently trips over his toes and drags his foot. He also gets frequent cramps when he stretches in bed in the mornings. The weakness is progressing to involve both legs now. On examination, you note tongue fasciculations. Deep tendon reflexes are 3+ at the knees and ankles. Strength is 4– at the extensors and flexors of the right foot and 4+ at the left foot. Hand grip strength is also 4+. Which of the following is the suspected pathologic cause of this patient’s symptoms?
A. Degeneration of the corticospinal tracts
B. Demyelinating plaques
C. Loss of anterior horn cells in the spinal cord
D. Loss of large pyramidal cells in the precentral gyrus
E. Lymphocytic infiltrate of spinal roots and nerves
F. A and C

Answer 3

A. Degeneration of the corticospinal tracts
C. Loss of anterior horn cells in the spinal cord

Amyotrophic lateral sclerosis (ALS): classic findings of both upper and lower motor neuron disease in ALS. The most common presenting symptom in ALS is asymmetric weakness of insidious onset, which is most prominent in the lower extremities. Muscle wasting and atrophy may be prominent. cramping with volitional movements, such as stretching, that is most common in the early morning hours. Fasciculations may be identified. Bulbar symptoms include difficulty with chewing, swallowing, and movements of the face and tongue. Upper motor neuron symptoms may lead to spasticity with increased deep tendon reflexes.

Question 4

A 45-year-old, previously healthy man has developed headaches over the past month. There are no remarkable findings on physical examination. A cerebral MR angiogram shows a 7-mm saccular aneurysm at the trifurcation of the right middle cerebral artery. Which of the following is the most likely complication from this lesion?
Cerebellar tonsillar herniation
Hydrocephalus
Epidural hematoma
Subarachnoid hemorrhage
Subdural hematoma

Answer 4

Subarachnoid hemorrhage

Rupture occurs into the subarachnoid space at the base of the brain, where the cerebral arterial distribution originates around the circle of Willis, and where saccular aneurysms are most likely to arise.

[Epidural hematomas arise from a tear of the middle meningeal artery, typically as a result of head trauma. Trauma also can cause a tear of bridging veins that produces a subdural hematoma.]

Question 5

Information about blood gas levels is transmitted to the CNS via…

Answer 5

the glossopharyngeal nerve.

Question 6

A patient has right-sided hypotonia and dysdiodochokinesia affecting the right arm and leg. A lesion in which of the following areas is most likely to produce these symptoms?
The left flocullonodular lobe
The right flocullonodular lobe
The vermis
The left cerebellar hemisphere
The right cerebellar hemisphere

Answer 6

The right cerebellar hemisphere

Question 7

A patient presents with a wide, ataxic, and unsteady gait. A tumor was detected from an MRI scan. The tumor affected most profoundly which of the following structures?
Dentate nucleus of the cerebellum
Interposed nucleus of the cerebellum
Red nucleus
Fastigial nucleus of the cerebellum
Middle cerebellar peduncle

Answer 7

Fastigial nucleus of the cerebellum: receives direct fibers from the vermal region of cerebellum and in turn, projects to the vestibular nuclei and reticular formation

Question 8

Age-related macular degeneration, or AMD, can be detected by means of…

Answer 8

Amsler grid: simple square containing a grid pattern and a dot in the middle. can show problem spots in your field of vision. For someone with AMD, an Amsler grid may appear to have wavy lines or blank spots.

Question 9

which type of age-related macular degeneration does this describe?
a. can result in loss of the retinal pigment epithelium function
b. can be treated by anti-VEGF therapy

Answer 9

can result in loss of the retinal pigment epithelium function = dry AMD

can be treated by anti-VEGF therapy = wet AMD

Question 10

A 65-year-old person complains of “seeing wavy lines” or “window blinds” when looking at the doorway with the right eye. The person has no pain or other ocular symptoms. Past medical history incudes hypertension and a 40-pack-year smoking history. On examination, visual acuity is 20/400 in the right eye. There is no RAPD and slit-lamp examination reveals that his anterior segment is normal. Examination of his right fundus reveals a subretinal hemorrhage involving his fovea.

What is the most likely diagnosis?

Answer 10

typical presentation of age-related macular degeneration (AMD)

Dry AMD is the non-neovascular form of AMD. It is characterized by drusen (yellow-white lesions in the outer retinal layers of the macula) or atrophy within the macula. Dry AMD may lead to wet (neovascular) AMD, which is associated with a choroidal neovascular membrane (CNVM). The CNVM is an abnormal growth of subretinal blood vessels, which grows in the macula or fovea and affects vision due to fluid leakage.

Question 11

A 55-year-old male complains of a gradual decrease in vision in both eyes. He notes glare with oncoming headlights while night driving. Despite this, he feels that he is able to read better without his bifocals.
Based on the history given, which of the following is the most likely cause of this patient’s complaints?

A. Retinal detachment
B. Cataracts
C. Glaucoma
D. Diabetic retinopathy
E. Presbyopia

Answer 11

B. Cataracts

Progressive visual loss and glare from oncoming headlights while driving at night are common complaints caused by cataracts.

Question 12

what are the classic symptoms of retinal detachment? (3)

Answer 12

1. flashing lights
2. visual field disruption
3. floaters

majority of vision will remain intact

Question 13

A 41-year-old man is brought to the Emergency Department after an accident at a construction site. The examination reveals a weakness (hemiplegia) and a loss of vibratory sensation and discriminative touch all on the left lower extremity, and a loss of pain and thermal sensations on the right lower extremity. CT shows a fracture of the vertebral column adjacent to the T8 level of the spinal cord.

Damage to which fiber bundle or tract would most likely explain the (A) loss of vibratory sensation AND (B) loss of pain and thermal sensation in this man (INCLUDE SIDE)?

Answer 13

a. loss of L vibratory sensation = damage to LEFT gracile fasciculus (ipsilateral tract)

b. loss of R pain/temp = damage to LEFT anterolateral system

Question 14

A 27-year-old man was involved in a street brawl, and during the fight, he was stabbed in the back. He lost consciousness and was rushed to the emergency department of a local hospital. After regaining consciousness, the patient received a neurologic examination. The patient indicated to the neurologist that he could not feel any pricks of a safety pin when tested along a band approximately 4 cm wide, which included both sides of his back. The patient was able to recognize tactile stimulation when tested on his arms and legs of both sides of the body as well as on the back or chest. Motor functions appeared to be intact. The neurologist concluded that the patient had damage of the:
Substantia Gelatinosa
Dorsal Root Ganglion bilaterally
The region surrounding the central canal
The lateral funiculus of the lumbar and thoracic cord
The dorsal columns of the thoracic cord, bilaterally

Answer 14

The region surrounding the central canal

Bilateral segmental loss of pain is the result of damage to the region surrounding the central canal of the spinal cord. This is due to damage to the crossing fibers of the lateral spinothalamic tracts (on each side) at a specific level of the cord.

[Dorsal column lesions would not affect the pathways mediating pain but instead would affect conscious proprioception]

Question 15

what is the function and location of the Substantia Gelatinosa

Answer 15

substantia gelatinosa is a collection of cells in the gray area (dorsal horns) of the spinal cord. Found at all levels of the cord, it receives direct input from the dorsal (sensory) nerve roots, especially those fibers from pain and thermoreceptors.

Question 16

Superior cerebellar peduncles carries information from the dentate nucleus to the

Answer 16

Thalamic VL nucleus and red nucleus on the contralateral side

Question 17

Nine year old child is seen in hospital by a neurologist. The child was hospitalized with fever and lethargic. Neurological exam showed left Sided hemiparesis, difficulty with speech and extensor plan to reflexes. Parents report patient had flu the previous week. MRI reveals areas of abnormal signal suggested of multifocal inflammation throughout the white and gray merit matter. Blood test for Lyme and anti-aquaporin4 antibodies are negative. She is diagnosed with a disease that mimics MS. What is the most likely diagnosis?

Answer 17

Acute disseminated encephalomyelitis (ADEM)

[anti-aquaporin 4 antibodies = neuromyelitis optica]

Question 18

26-year-old patient visits neurologist after being referred by internist. Patient developed muscle weakness in both legs over last week and reports tripping over their legs and feeling clumsy while walking. No reported previous significant illnesses other than upper respiratory infection three weeks prior. Neurological exam shows depressed Achilles and patellar deep tendon reflexes, but normal reflexes in upper arms. Reduced motor conduction velocity along the nerves supplying the lower limb muscles. Sensory tests were normal. Which of the following is more likely?
A. Post polio syndrome.
B. Guillain-Barré.

Answer 18

B. Guillain-Barré - classic signs are distal symmetric motor loss which ascends, following infection

Post polio would include history of polio

Question 19

Sensation of vibration in feet is carried by [medial/lateral] dorsal column

Answer 19

Medial dorsal column carries lower extremity vibration/proprioception in the fasciculus gracilis to nucleus gracilis

Question 20

Which of the following receptors detect vibration?
A. Meissner’s corpuscles
B. Pacinian corpuscles
C. Golgi tendon organs
D. Merkel’s discs
E. Ruffini corpuscles

Answer 20

B. Pacinian corpuscles - in deep dermis

Question 21

How are inner hair cells organized along the basilar membrane to detect various frequencies?

Answer 21

High frequency/pitch inner hair cells are at the base

Low frequency/pitch inner hair cells are at the apex

Question 22

Brainstem slice shows inferior olivery nuclei and 4th ventricle - what level is it showing?

Answer 22

Rostral (upper) medulla

Question 23

The ____ nucelus receives taste input from CN VII, IX, and X

Answer 23

nucleus solitarius

Question 24

According to gate theory of pain, shaking your hand reduces pain sensation following injury because:
A. A-beta fibers inhibit dorsal projection neurons via interneurons
B. Descending projections from raphe nuclei inhibit C fibers
C. A-delta fibers inhibit C fibers

Answer 24

A. A-beta fibers inhibit dorsal projection neurons via interneurons

Large, myelinated mechanosensitive afferents (A-beta) send collateral branches in dorsal horn to synapse onto interneurons before A-beta fibers ascend in dorsal column

These interneurons send inhibitory signals to 2nd order projection neurons in spinothalamic tract

Question 25

Angle closure glaucoma is more common in patients with [near/far]sightedness

Answer 25

Farsightedness - people with smaller eyes and more crowded angles

Question 26

How does the Organ of Corti allow focusing hearing on relevant sounds?

Answer 26

Outer hair cell activation by efferents - outer hair cells can amplify specific frequencies along Basilar membrane

Question 27

by what age should the primitive reflexes (moro, palmar grasp, rooting, etc) disappear?

Answer 27

3-6 months

Question 28

when should the following motor milestones occur?
a. head control
b. rolling
c. sitting without assistance
d. standing and walking
e. pull to stand
f. fine motor control (pincer grasp)
g. handedness (right or left preference)

Answer 28

a. head control: 1 month
b. rolling: 6 months
c. sitting without assistance: 6 months
d. standing and walking: 12-18 months
e. pull to stand: 9 months
f. fine motor control (pincer grasp): 12 months
g. handedness (right or left preference): 18 months

Question 29

what are the 3 types (presentations) of cerebral palsy?

Answer 29

1. spastic (most common): stiff muscles; can be diplegia, hemiplegia, or quadriplegia
2. dyskinetic: uncontrollable movements
3. ataxic: poor coordination and balance

Question 30

Patient with gunshot wound presents to ED. The bullet damaged the thoracic spinal cord at T2. Both sensory and motor pathways were affected. The entire spinal cord was severed. Which of the following would be expected from the motor examination?
A. Grade 0+ refluxes at the triceps tendon bilaterally.
B. Grade 3 strength in the ankle extensor muscles.
C. Great zero strength of the right, and left quadriceps muscles.

Answer 30

C. Great zero strength of the right, and left quadriceps muscles.

Due to spinal shock – entire spinal cord is unresponsive below the level of the lesion. The upper extremity would not be affected because it is above T2.

Question 31

Patient presents with flaccid paralysis on the right side of the body. After several days, the flaccid process becomes a spastic paralysis. He has a Babinski sign, hypertonia, and hyperreflexia of the right arm and leg. MRI shows a large ischemic area in the left internal capsule. Which of the following would be expected of this man’s facial muscles?
A. the left lower facial muscles would be paralyzed, but the left upper facial muscles would be intact.
B. The right lower facial muscles would be paralyzed, but the right upper facial muscles would be intact.
C. All the upper and lower facial muscles on the right would be paralyzed.
D. All of the upper and lower facial muscles on the left would be paralyzed.

Answer 31

B. The right lower facial muscles would be paralyzed, but the right upper facial muscles would be intact.

Lesion of the corticobulbar tract in the internal capsule would cause contralateral paralysis

Question 32

Patient diagnosed with a tumor in the meninges that is pressing on the spinal cord at C-5. MRI shows displacement of the tissue in that area of the lateral corticospinal tract on the right side. The most lateral fibers in the tract are affected. Where do these fibers project?
A. Left upper limb.
B. Left lower limb.
C. Right upper limb.
D. Right lower limb.

Answer 32

D. Right lower limb.

The somatotropic arrangement of the corticospinal tract in the spinal cord, is with the upper limb/cervical fibers, located medial to those going to the motor neurons of the lower limb. This pathway is ipsilateral in the spinal cord.

Question 33

Patient with facial weakness is diagnosed with a lesion of the right motor cortex in the facial region. She has paresis of the left lower face. Which of the following is also expected?
A. The jaw deviates to the right
B. There is no jaw deviation
C. The jaw deviates to the left

Answer 33

B. There is no jaw deviation

The motor nucleus of CNV is supplied bilaterally – there should be no jaw deviation, these occur with lower motor neuron lesions

Question 34

Which of the following would most likely occur with a small infarction in the right cortex?
A. Focal neurological signs.
B. Headache.
C. Loss of consciousness.
D. Papilledema.

Answer 34

A. Focal neurological signs.

Small infarction is indicative of an ischemic stroke. Ischemic strokes do not usually produce headache or increased intracranial pressure. Focal neurological signs would be expected because of the small circumscribed lesion.

Question 35

What is the effect polio has on lower motor neurons?

Answer 35

Polio causes lower motor neurons to die

Does not cause demyelination

Question 36

Which of the following would be expected as a result of polio?
A. Decreased nerve conduction velocity.
B. Increased muscle fiber type grouping.
C. Demyelination of alpha motor neurons.

Answer 36

B. Increased muscle fiber type grouping.

Polio causes death of motor neurons, but does not cause demyelination.

Question 37

Which structure forms the major barrier to drugs entering the brain at the blood brain barrier?

Answer 37

Capillary endothelium tight junctions

Question 38

NMDA channels are important for learning and memory. These channels open only under certain conditions. Which of the following is required in addition to glutamate for postsynaptic NMDA channels to open?
A. Presynaptic calcium channel opening.
B. Presynaptic, sodium channel opening.
C. Postsynaptic depolarization

Answer 38

C. Postsynaptic depolarization

Question 39

Which of the following cell types are affected by multiple sclerosis?
A. Oligodendrocytes.
B. Schwann cells.

Answer 39

A. Oligodendrocytes – multiple sclerosis causes loss of central nervous system myelin

Question 40

Which of the following agents would be the most appropriate migraine prophylaxis in a patient with epilepsy?
A. Rizatriptan
B. Topiramate.
C. Naproxen.
D. Propranolol.

Answer 40

B. Topiramate = anticonvulsant, particularly useful for migraine, prophylaxis in patients with comorbid seizure disorders

Rizatriptan and naproxen are primarily for acute rather than preventative migraine therapy. Propranolol is better for patients with comorbid hypertension or angina.

Question 41

Muscle fasciculations indicate an upper or a lower motor neuron lesion?

Answer 41

Muscle fasciculations = lower motor neuron lesion

Question 42

Patient has loss of pain and temperature from the right body from T5 and below. MRI would most likely show a lesion in the
A. Right side of the thoracic cord.
B. Left side of the thoracic cord.

Answer 42

B. Left side of the thoracic cord.

Most likely a lesion in the anterolateral pathway, which would carry all pain and temperature sensation from below T5. The lesions would be contralateral to the symptoms, because of the second order neurons crossing at the level of the spinal cord.

Question 43

Neurologist asks a patient to close their eyes and move the left, great toe upwards, and downwards. The patient is asked to verbalize the direction of the toe as up or down. This test sensory afferents, and a spinal cord pathway that lies in the
A. Right dorsal column.
B. Left dorsal column.

Answer 43

B. Left dorsal column

Fibers carrying information from the left great toe are large diameter, afferents from joint and muscle receptors. They enter the left dorsal root, and go directly into the left dorsal column/fasciculus gracilis, to end in the nucleus gracilis.

Recall the dorsal columns do you cross over in the medulla, but these are AFFERENT fibers so in the spinal column, they are ipsilateral

Question 44

Patient with history of hypertension, reports photophobia and decreased vision in one eye. Examination reveals features of intra-retinal hemorrhage in all quadrants and swelling of the central macula. What is the most likely diagnosis?
A. Macular degeneration
B. Retinal detachment.
C. Central retinal vein occlusion (CRVO)
D. Central retinal artery occlusion.

Answer 44

C. Central retinal vein occlusion (CRVO)

Central retinal swelling and diffuse intro retinal hemorrhages (in all quadrants of the retina) are classic signs of CRVO. This is accompanied by early transient visual phenomena in some cases and vision loss as the central retina swells. Risk factors include autoimmune disease and hypertension.

Question 45

The ability to focus hearing on relevant sounds, is due in part, to which of the following processes in the organ of Corti?
A. Inner hair cell activation by efferents.
B. Inner hair cell activation by afferents
C. Outer hair cell activation by efferents
D. Outer hair cell activation by afferents.

Answer 45

C. Outer hair cell activation by efferents

Outer hair cells can amplify specific frequencies along the basilar membrane. They are also inhibited by efferents that influence the sound amplification.

Question 46

Aneurysm of which artery would produce a third nerve palsy?

Answer 46

Posterior communicating artery

Question 47

A medial medullary syndrome affecting the left medulla would cause which of the following?
A. Loss of pain and temperature on the right side.
B. Ataxia of the left limbs.
C. And ability to move the right lower half of the face.
D. Loss of sense of touch and vibration on the right body.

Answer 47

D. Loss of sense of touch and vibration on the right body.

Medial medullary syndrome would affect the medial lemniscus and the corticospinal tract. Since the medial lemniscus carries information that arises from the opposite side of the body, then there would be a loss of discriminative, touch, vibration, and proprioception from the right body.

Question 48

A left medial pontine syndrome would cause which of the following?
A. Right sided lateral gaze palsy
B. Left-sided lateral gaze palsy.

Answer 48

B. Left-sided lateral gaze palsy.

Due to lesion of the left abducens nucleus. There could also be the lower motor neuron associated sign of esotropia.

Question 49

Patient has sudden onset of right sided hemiparesis. There is also loss of proprioception sense on the right limbs. Where is the stroke most likely?
A. Right medial medulla.
B. Right lateral medulla.
C. Left medial medulla.
D. Left lateral medulla.

Answer 49

C. Left medial medulla.

In the brainstem, the pyramidal tract has not yet crossed - crosses at the border of the spinal cord and medulla. The pyramidal tract is always ventromedial.

Question 50

12-year-old girl has complaints of worsening double vision over the last month. During right gaze, neither the right nor the left eye moves past midline. Leftward gaze also shows that the left eye abducts and demonstrates nystagmus, while the right eye does not move medially. The right eye has esotropia. Vertical gaze and convergence are normal. There is most likely a lesion in the:
A. Right nucleus of CNVI, and the right MLF.
B. Left nucleus of CNVI and the left MLF
C. Right vestibular nuclei.
D. Left vestibular nuclei.
E. Left CNVI and right CNIII
F. Right CNVI and left CNIII

Answer 50

A. Right nucleus of CNVI, and the right MLF.

Symptoms suggest one and a half syndrome that may be caused by a tumor or MS. This syndrome affects the right MLS/INO with the right CNVI nucleus.

If CN III was affected, there would be exotropia in the affected eye, along with problems with convergence and vertical gaze. The vestibular abnormalities might produce nystagmus, but it would be in both eyes.

Question 51

74-year-old. Patient seen by neurologist has pupillary abnormalities. The patient’s pupils do not constrict to light bilaterally. However, they respond to accommodation. The most likely lesion site is.
A. Visual cortex.
B. Superior cervical ganglion.
C. Edinger Westphal nucleus.
D. Pre-tectal area of the dorsal midbrain.
E. Optic chiasm.

Answer 51

D. Pre-tectal area of the dorsal midbrain.

Light-near dissociation is often associated with neurosyphilis (Argyll Robertson pupil), but can also be associated with other diseases like Lyme disease and MS.

Question 52

You are assessing a patient with dizziness and observe that rapidly rotating her head to the right side results in a brief catch up saccade in both eyes to the left. What is the most likely mechanism of this phenomenon?
A. Right vestibular nerve dysfunction, which causes right vestibular hypofunction, preventing the eye movements from completely compensating for the head turn.
B. Lesion in the right medial longitudinal fasciculus
C. Lesion in the left cerebellum which causes left Central vestibular hypofunction.

Answer 52

A. Right vestibular nerve dysfunction, which causes right vestibular hypofunction, preventing the eye movements from completely compensating for the head turn.

The exam maneuver described is the head impulse and is used to assess for peripheral vestibular dysfunction of the eighth cranial nerve

Question 53

Episodic vertigo triggered by positional change + leaning without falling + Unidirectional upbeating nystagmus =
A. Occlusion of the right posterior inferior cerebellar artery.
B. Endolymphatic hydrops on the right.
C. Canalithiasis in the right posterior semicircular canal.
D. Viral inflammation of the eighth cranial.

Answer 53

C. Canalithiasis in the right posterior semicircular canal - deposition of calcium crystals

This describes benign, proximal positional vertigo. On examination, movement triggers delayed unilateral, upbeat, nystagmus with rotatory component toward the affected ear. Nystagmus usually resolves quickly due to central compensation.

Endolymphatic hydrops = Ménière disease (attacks begin with hearing loss, followed by vertigo)

Question 54

Coma versus persistent vegetative state versus brain death

Answer 54

Coma = absence of meaningful responses

Persistent vegetative state = coma that last several weeks with EEG testing showing the return of sleep wake cycles

Brain death = complete absence of brainstem reflexes

Question 55

Coma is caused by damage to the reticular activating system in the _____, _____, ______, or _______.

Answer 55

Dorsal pons, midbrain, bilateral thalami, or bilateral hemispheres

Question 56

A 55-year old patient was diagnosed with parkinsonism with the major symptom being bradykinesia, and almost no tremor. A physician decided to postpone levodopa therapy since the symptoms were still mild. A patient was prescribed a single drug that relieved the symptoms. Which of the following drugs was most likely prescribed?
Anticholinergic drug
Dopamine antagonist
Apomorphine
Entacapone
Rasagiline

Answer 56

Rasagiline could be used as a monotherapy in patients with mild disease. Anticholinergic drugs have little effects on bradykinesia.

Question 57

A 74-year-old woman has a recent diagnosis of small-cell lung cancer. She is now complaining of headaches, and her family has noticed confusion as well. Metastatic disease to the brain is suspected. A mass lesion on magnetic resonance imaging (MRI) is demonstrated in the right parietal lobe. Which MRI technique would best identify the extent of the edema surrounding the lesion?
A. Magnetic resonance angiography
B. Fluid-attenuated inversion recovery (FLAIR)
C. T1-weighted
D. T2-weighted
E. B and D

Answer 57

E. B and D

Fluid-attenuated inversion recovery (FLAIR) is a type of T2-weighted image that suppresses the high-intensity signal of CSF. As a result, images created by the FLAIR technique are more sensitive to detecting water-containing lesions or edema than the standard spin images.

Question 58

Patient with history of HTN collapses. Exam reveals paralysis of the right arm and leg and lower part of the right face. Patient has mild dysarthria, but mental status reveals normal language. Memory and attention are unimpaired. Which artery is most likely involved in this stroke?
A. Right lenticulostriate
B. Left lenticulostriate
C. Right anterior cerebral artery.
D. Left anterior cerebral artery.
E. Right superior middle cerebral artery
F. Left superior middle cerebral artery.

Answer 58

B. Left lenticulostriate - internal capsule is affected (pure motor signs)

Question 59

Which of the following best describes the effect of the dopamine on basal ganglia circuits?
A. Via D1 receptors, excites the direct pathway
B. Via D2 receptors, excites the indirect pathway.
C. Via D1 receptors, inhibits the indirect pathway.
D. Via D2 receptors, inhibits the direct pathway.

Answer 59

A. Via D1 receptors, excites the direct pathway

Question 60

61 year old man being treated with Sinemet for Parkinson’s disease, develops dyskinesias. He was prescribed drug to alleviate dyskinesias. Which of the following is most likely used?
A. Pramipexole.
B. Selegiline
C. Apomorphine.
D. Anticholinergic drug.
E. Amantadine.

Answer 60

E. Amantadine - can favorably influence bradykinesia, rigidity, and tremor, and in addition also has anti dyskinetic properties

Question 61

70 year old woman collapses. In ED, woman continues to talk a lot, but makes little to no sense. She could not follow basic directions. Communication problems were determined to be a language deficit rather than cognitive. Which of the following deficits would you also expect to see in the stroke?
A. Right visual field defect.
B. Left-sided neglect.
C. Right sided ataxia.
D. Left sided hemiplegia affecting the arm and face.
E. Deviation of the eyes to the right.

Answer 61

A. Right visual field defect.

Patient had a stroke, producing Wernicke’s aphasia. Stroke affects superior temporal gyrus, supplied by inferior branch of the left MCA. This also supplies the white matter visual projections, bringing visual field information from the opposite visual field into the occipital lobe.

Question 62

A patient with Parkinson’s disease is taking Sinemet. He was recently prescribed a drug to reduce wearing off symptoms. What is the most likely mechanism of this drug?
A. Inhibits COMT.
B. Inhibits MAO-B
C. Dopamine agonist
D. DOPA-decarboxylase inhibitor.

Answer 62

A. Inhibits COMT - entacapone and tolcapone are used in advanced PD to help relieve end of dose symptoms. Both inhibit COMT, which increases the peripheral bioavailability of levodopa.

Question 63

70-year-old man admitted to hospital for increasing confusion. No fevers and strength exam is normal. He is only oriented to person. Good reflexes but decreased vibratory sense on exam. Lumbar puncture reveals 30 lymphocytes, normal glucose, and elevated protein. Which of the following tests would you also expect to be positive?
A. Serological test for syphilis.
B. PCR assay for herpes Simplex.
C. Blood cultures for staphylococcus aureus.

Answer 63

A. Serological test for syphilis - CSF findings are classic for neurosyphilis, and the decreased vibratory sense is highly suggestive

Other choices would be associated with fever.

Question 64

18 year old man who has been traveling in rural India presents to ED with generalized tonic clonic seizures. He has been having pain in the right groin for one week since returning from a trip. Patient is confused and has swelling over the right eye and tenderness in the right testes. MRI of head shows numerous well-defined cystic lesions throughout the cerebral cortex. The cysts were most likely formed by which?
A. Virus
B. Fungus.
C. Parasite.
D. Prion.

Answer 64

C. Parasite - most likely neurocysticercosis, which often presents with seizures. Diagnosis can be made by the history of exposure that occurs more in Latin America, Africa, Asia, and Europe. Typical radiologic appearance of multiple cysts.

Question 65

70-year-old man with history of carotid stenosis is seen in ED because of language difficulties. No sensory or motor deficits. He can follow commands but cannot repeat even single words that are spoken to him. His self generated language is otherwise fluent. This type of aphasia is caused by a lesion where? What is the type of aphasia called?

Answer 65

Conduction aphasia caused by lesion in the pathway connecting wernicke and Broca’s areas

Question 66

60 year old man referred to neurologist because of suspected Parkinson’s disease. Demonstrates difficulty with vision and has had balance problems and motor slowing, which have progressively worsened over the last year. He has had many falls in the last five months. Extraocular exam demonstrates slowed and limited vertical gaze. He has trunk rigidity that is bilateral and masked facies, but there is no tremor. What are the symptoms most consistent with?

Answer 66

supranuclear palsy: affects rostral midbrain

Distinguished from PD by primary loss of vertical eye movements, lack of tremor, and symmetrical bradykinesia affecting trunk more than limbs.

Question 67

How would an older subdural hematoma (chronic hematoma) appear on CT scan?

Answer 67

Hypodense – darker than brain tissue

Question 68

where are the “what” vs “where” pathways in the brain for interpreting visual information?

Answer 68

visual information is received in occipital cortex and relayed along pathways to association cortex for higher-order processing:

”what” = ventral/ P pathway, projecting to occipitotemporal association cortex for identification of letters, colors, shapes, faces

”where” = dorsal/ M pathway, projecting to parietooccipital association cortex for processing motion and spatial relationships

Question 69

Which of the following symptoms are indicative of a temporal lobe dysfunction?
A. Verbal comprehension deficit.
B. Prosopagnosia.
C. Visuospatial impairment.
D. Retrograde amnesia.
E. Apathy.

Answer 69

A. Verbal comprehension deficit - localized to temporal lobe
B. Prosopagnosia - “what” stream in temporal association cortex
D. Retrograde amnesia - can be caused by hippocampal formation lesions in the temporal lobe, but can also be related to cortical atrophy

Question 70

Postoperative vomiting is uncommon with this intravenous agent, and patients are often able to ambulate sooner than those who receive other anesthetics.
Enflurane
Etomidate
Midazolam
Propofol
Thiopental

Answer 70

Propofol - extensively in anesthesia protocols, favorable properties of the drug include an antiemetic effect and recovery more rapid than that after use of other intravenous drugs

has very short half life (2-8mins)

Question 71

_______ has the lowest MAC value of the inhaled anesthetics

Answer 71

Methoxyflurane has the lowest MAC value of the inhaled anesthetics

MAC = minimal anesthetic concentration

Question 72

Simultaneous use of opioid analgesics [increases/decreases] the MAC for inhaled anesthetics

Answer 72

Simultaneous use of opioid analgesics (or other CNS depressants) DECREASES the MAC for inhaled anesthetics

Question 73

Which changes would you expect to see in the respiratory pattern of a patient breathing spontaneously under a volatile anesthetic?

Answer 73

Decreased tidal volume + increased respiratory rate = decreased minute volume

Question 74

Patient returning from a trip to Latin America, Africa, Asia, or Europe + presenting with seizures + multiple cysts seen on radiologic imaging =

Answer 74

Neurocysticercosis (parasite)

Question 75

Which hypnotic drugs come with an FTA mandated black box warning for rare but serious complex sleep behaviors?

Answer 75

GABAergic non-benzodiazepine hypnotics (“Z drugs”) - eszopliclone

Question 76

What type of tumors do patients with the following genetic conditions develop?
A. Li-Fraumeni syndrome.
B. Neurofibromatosis type 1
C. Neurofibromatosis type 2
D. Tuberous sclerosis complex.
E. Von Hippel Lindau syndrome.

Answer 76

A. Li-Fraumeni syndrome - early onset breast and ovarian carcinomas and sarcomas

B. Neurofibromatosis type 1 - optic gliomas + PNS tumors like cutaneous neurofibromas

C. Neurofibromatosis type 2 - meningiomas, bilateral schwannomas

D. Tuberous sclerosis complex - subependymal giant cell astrocytomas and cortical tubers

E. Von Hippel Lindau syndrome - hemangioblastoma and renal cell carcinoma

Question 77

Dementia versus mild cognitive impairment

Answer 77

Dementia require significant functional deficits

Mild cognitive impairment is a decline in cognitive function that is worse than expected for normal aging, but does not produce significant functional impairments

Question 78

Rapidly progressing dementia + truncal ataxia + startle myoclonus =

Answer 78

Creutzfeldt-Jakob disease - Prion infection

Question 79

What is the order of loss of neurologic function in a neuraxial blockade – spinal, epidural, or caudal?
- somatosensory
- motor
- autonomic

How does this compare to a peripheral blockade?

Answer 79

Spinal/epidural/caudal: autonomic blockade —> somatosensory loss —> motor loss

Peripheral: motor loss —> proximal sensory loss —> distal sensory loss

Question 80

Ataxia + mild proximal rigidity + memory loss + hallucinations =

Answer 80

Lewy body dementia: Parkinsonism + hallucinations

Question 81

Which cranial nerves converge on the nucleus of the solitary tracks?

Answer 81

CN VII, IX, X

If there is loss of taste to an entire side of the tongue, lesion is localized to the solitary tract

Question 82

Narcolepsy type one is associated with loss of _____ neurons in the hypothalamus

Answer 82

Orexin neurons

Question 83

How might head trauma cause anosmia?

Answer 83

Neurons in the olfactory nerve are susceptible to shearing forces that occur during trauma – damage to the olfactory nerves

This is because they travel through the cribriform plate

Question 84

Which childhood seizure disorder is characterized by spike and wave activity in the centro-temporal regions of the brain?

Answer 84

Benign rolandic seizure: nighttime pattern of occurrence and initial facial symptoms, such as gurgling and salivating

Question 85

Which of the following insomnia agents has the least potential for abuse or development of dependence?
A. Triazolam.
B. Zolpidem.
C. Temazepam.
D. Suvorexant
E. Ramelteon

Answer 85

E. Ramelteon: melatonin receptor agonist

All others are schedule IV
A. Triazolam = hypnotic benzodiazepine
B. Zolpidem = non-benzodiazepine hypnotic
C. Temazepam = hypnotic benzodiazepine.
D. Suvorexant = dual Orexin receptor antagonist (DORA)

Question 86

Which of the following determines the rate of the onset of inhaled anesthesia?
A. Lipid solubility.
B. Minimal alveolar concentration.
C. Solubility in the blood.

Answer 86

C. Solubility in the blood - aka blood:gas partition coefficient

Major factor in determining the transfer of an anesthetic from the lungs to the arterial blood

Question 87

Adult with brain tumor with densely packed anaplastic cells with a high mitotic rate + endothelial cell proliferation and necrosis =

Answer 87

Glioblastoma

Question 88

Which of the following antiseizure drug is least likely to interfere with the efficacy of oral contraceptives?
A. Carbamazepine.
B. Leviteracetum
C. Phenobarbital.
D. Phenytoin.

Answer 88

B. Leviteracetum

Others are inducers of hepatic CYP
enzymes

Question 89

Where does convergence of olfactory, taste, and oral somatosensory input occur?

Answer 89

Orbitofrontal cortex and amygdala

Question 90

54-year-old woman brought to neuropsychologist. According to partner woman has had difficulty walking, as well as worsening memory. Patient has history of alcohol use disorder, malnourishment, and depression. Memory testing reveals no impairments in immediate recall, but deficits with recent and remote memory. Also evidence of confabulation. These deficits are most likely associated with bilateral lesions of the:
A. Orbitofrontal cortex.
B. Mammillary bodies and dorsal medial nucleus.
C. Caudate and putamen
D. Hippocampal formation.

Answer 90

B. Mammillary bodies and dorsal medial nucleus.

Degeneration of the mammillary bodies is associated with Korsakoff syndrome

Question 91

60 year old man referred to neurologist because of suspected Parkinson’s. Demonstrates difficulty with vision and has balance problems and motor slowing. These have progressively worsened over the last year. He has had many falls in the last five months. Extraocular exam demonstrates slowed and limited vertical gaze. He has trunk rigidity that is bilateral and masked facies. There is no tremor. What is the most likely diagnosis?

Answer 91

Supranuclear palsy: bilateral degeneration of the rostral mid brain

Distinguished from PD by primary loss of vertical eye movements, lack of tremor, and symmetrical bradykinesia affecting trunk more than limbs

Question 92

What information does the cuneus gyrus vs the lingual gyrus of the striate cortex of the occipital lobe receive?

Answer 92

Striate cortex of each hemisphere receives information about the contralateral visual field from the ipsilateral geniculate nucleus via the optic radiation

Cuneus gyrus receives information from the upper retina (lower visual field)

Lingual gyrus receives information from the lower retina (upper visual field)

Question 93

Which structure is damaged and conduction aphasia?

Answer 93

Caused by interruption of the pathway connecting Wenicke and Brocas area’s

Question 94

How does chronic hematoma versus acute bleeds show up on CT scan?

Answer 94

Chronic hematoma = hypodense (darker than brain tissue)

Acute bleeds = hyperdense

Question 95

Internal capsule strokes are typically caused by…

Answer 95

… lacunar strokes, via lipohyalinosis: collagenous thickening and inflammation of the vessel wall that occurs with chronic hypertension

Question 96

68-year-old woman with history of hypertension collapses and cannot move her right arm and leg. Neuro exam reveals paralysis of right arm and leg, as well as lower part of face on the right. Six months later, she has a spastic hemiplegia on the right side together with facial weakness of the lower right side of the face. She has mild dysarthria, but her mental status exam reveals normal language. Memory and attention are normal and she is alert. Which artery is most likely involved in the stroke?
A. Right lenticulostriate.
B. Left lenticulostriate
C. Right anterior cerebral artery.
D. Left anterior cerebral artery.
E. Right superior middle cerebral artery.
F. Left superior middle cerebral artery.

Answer 96

B. Left lenticulostriate

Other options can be ruled out because there are no cortical signs. Motor signs indicate corticospinal and cortical bulbar tracts – pure motor hemiparesis. Most likely location is internal capsule.

[Ventral ponds lesions via stroke to paramedian branches of the basilar artery could also produces motor syndrome with no cortical deficits.]

Question 97

70 year old woman collapses. In ED, woman continues to talk a lot, but makes little to no sense. She could not follow basic directions. Communication problems were determined to be a language deficit rather than cognitive. Which of the following deficits would you also expect to see?
A. Left sided neglect.
B. R visual field deficit.
C. Left sided hemiplegia affecting the face and arm
D. Right sided ataxia.
E. Deviation of the eyes to the right.

Answer 97

B. R visual field deficit.

Woman is presenting with Wernicke‘s aphasia - affects posterior superior temporal gyrus, supplied by MCA

MCA also supplies white matter visual projections, bringing visual field information from the opposite visual field into the occipital lobe

Question 98

Patient presents with severe left retro orbital pain for six weeks that is continuous and refractory to treatment. Left eye shows ptosis, mydriasis with tendency to drift to the left. Patient complains bitterly of left sided headache. The remainder of the neurological examination was normal. Which of the following is the most likely cause of these symptoms?
A. Loss of blood flow in basilar artery.
B. AVM in left posterior cerebral artery.
C. Aneurysm in left PICA.
D. Aneurysm in left posterior communicating artery.

Answer 98

D. Aneurysm in left posterior communicating artery.

Pain + 3rd nerve palsy = pressure on left oculomotor nerve, which can be caused by aneurysm in posterior communicating artery

Question 99

MRI determines that patient has medial medullary syndrome affecting the left medulla. The patient is unable to move his right limbs. Which of the following symptoms would you expect to see in addition to his right sided hemiparesis?
A. Lots of pain and temperature on the right side.
B. Ataxia of the left limbs.
C. Inability to move the right lower half of the face.
D. Loss of the sense of touch on vibration on the right body.

Answer 99

D. Loss of the sense of touch on vibration on the right body.

Medial medullary syndromes affect the medial let meniscus in addition to the corticospinal tract - medium lemniscus carries information from the opposite side of the body = loss of discriminative touch, vibration, proprioception from the right body

Question 100

Patient with poorly controlled HTN and type 2 diabetes presents with blurry vision, and a shadow that developed across the visual field of his left eye. Denies recent headaches, double vision, vertigo, light sensitivity, or nausea. Pupils are equal and reactive to light. Funduscopic exam reveals flame-shaped hemorrhage in the left temporal hemiretina. Transmission of visual information through which of the following will be disrupted?
A. Left inferior colliculus.
B. Left lateral geniculate body.
C. Right inferior colliculus.
D. Right lateral geniculate body.

Answer 100

B. Left lateral geniculate body.

Question 101

Patient presents with double vision. Right eye has esotropia. During right gaze, neither right nor left eye moves past midline. During left gaze, left eye abducts and demonstrates nystagmus while the right eye does not move medially. Vertical gaze and convergence are normal. There is most likely a lesion in the:
A. Left nucleus of CNVI end left MLF.
B. Right nucleus of CNVI and right MLF
C. Right vestibular nuclei
D. Left vestibular nuclei.
E. Left CNVI and right CNIII
F. Right CN VI and left CN III.

Answer 101

B. Right nucleus of CNVI and right MLF

1 1/2 syndrome - can be caused by tumor or MS

If CN 3 was affected, there would be exotropia in the affected eye together with problems with convergence and vertical gaze. Vestibular abnormalities my produces nystagmus, but it would be in both eyes.

Question 102

Looking to the right tests which of the following sets of CNS structures?
A. R MLF, L medial rectus, R PPRF
B. L MLF, R abducens nucleus, L frontal eye field
C. L PPRF, L abducens nerve, R oculomotor nerve
D. R PPRF, R lateral rectus, R MLF

Answer 102

B. L MLF, R abducens nucleus, L frontal eye field

Question 103

Pupils that do not constrict to light bilaterally, but respond to accommodation are due to a lesion in the:
A. Visual cortex.
B. Superior cervical ganglion.
C. Edinger Westphal nucleus.
D. Pretectal area of the dorsal midbrain.

Answer 103

D. Pretectal area of the dorsal midbrain.

Light - near dissociation, which is often associated with neurosyphilis (Argyll Robertson pupil), but can also be associated with other diseases, such as Lyme disease or MS.

Question 104

86-year-old woman presents with spinning and vertigo. Her nausea causes her to vomit. She has gait instability, but does not fall. Denies hearing changes, weakness, or hearing loss. Symptoms improve dramatically when she sits still and avoids head movement. There are no focal neurological deficits. she leans to the right without falling. When rapidly lowered to supine position with her head turns to the right, after a short delay, there is a prominent Unidirectional upbeating nystagmus with a torsional component towards the right ear. This results within 30 seconds. What is the most likely pathology?

Answer 104

Benign paroxysmal positional vertigo caused by canalithiasis, deposition of calcium crystals, in the right posterior semicircular canal

Causes intense vertigo triggered by movement, especially in the direction of the posterior semicircular canal - neck extended and head rotated to the right

Nystagmus usually resolves quickly due to central compensation.

Question 105

Locked in syndrome is due to a lesion where?

Answer 105

Ventral pons

Question 106

The superior cerebellar peduncle carries information from the dentate nucleus on one side to the…

Answer 106

Thalamic VL nucleus and red nucleus on the contralateral side

Question 107

______ fibers from the contralateral inferior olivary nucleus are [excitatory/inhibitory] to the deep cerebellar nuclei and to the Purkinje cell neurons

Answer 107

Climbing fibers from the contralateral inferior olivary nucleus are excitatory to the deep cerebellar nuclei and to the Purkinje cell neurons

Remember that excitatory inputs go into cerebellum, but only inhibitory outputs go out

Question 108

Muscle fasciculations indicate a lower or upper motor neuron lesion?

Answer 108

LOWER

Question 109

9 year old child in hospital with fever and lethargy. Neuro exams shows left-sided hemiparesis, difficulty with speech, extensor plantar reflexes. Patient had a flu the previous week. MRI of brain shows abnormal signal suggestive of multifocal Inflammation throughout the white and gray matter. Blood test for Lyme and anti-aquaporin 4 antibodies are negative. She is diagnosed with a disease that mimics multiple sclerosis. Which disease is most likely?
A. Guillain-Barré.
B. Neuromyelitis optica spectrum disorders.
C. Amyotrophic lateral sclerosis.
D. Acute disseminated encephalomyelitis.

Answer 109

Acute disseminated encephalomyelitis (ADEM): follows infection or immunization, includes fever, shows areas of inflammation in the brain

Anti-aquaporin 4 antibodies = neuromyelitis optica – associated with lesions of the optic nerve and the spinal cord
ALS does not present with acute cognitive changes, lethargic, and is not typical for children.
Guillain-Barré syndrome is associated with lower motor neuron symptoms/decreased deep tendon reflexes.

Question 110

56-year-old patient in ED for a third time in six months for the same symptoms. Report feeling dizzy and also feeling moody and irritable. There is a positive Romberg test and reduced vibration sense. Syphilis test is negative. Which of the following would you expect to be found?
A. Decreased blood B12 levels.
B. Decreased blood glucose levels.
C. Elevated white blood cell counts.
D. Subdural hematoma

Answer 110

A. Decreased blood B12 levels.

B12 deficiency can produce lesions in the spinal cord that affect proprioception and balance, and can also affect the central nervous system leading to problems that are sometimes considered to be psychiatric in nature.

Diabetes does not affect CNS neurons. Subdural hematoma might increase intracranial pressure, but would not be likely to produce the vibration and proprioception losses.

Question 111

Describe the classic signs of Guillain-Barré syndrome

Answer 111

Distal symmetric motor loss that ascends and follows an infection

Question 112

Which of the following is a specific finding of a demyelinating process?
A. Decreased nerve conduction velocity.
B. Fibrillation potentials in the muscles.
C. Positive Romberg test
D. Impaired two point discrimination.

Answer 112

A. Decreased nerve conduction velocity.

Fibrillation potential provide information about denervation of a muscle, but will not distinguish between demyelination or other cause. Romberg test and two point discrimination are affected with dorsal column lesions, but do not distinguish between demyelination or interruption of fibers.

Question 113

[inner/outer] hair cells are responsible for pitch discrimination

Answer 113

Inner hair cells are responsible for pitch discrimination – high frequencies at the base of the cochlea, low frequencies at the apex of the cochlea

Question 114

If you can see the inferior olivary nuclei and the fourth ventricle where are you in the spinal cord?

Answer 114

Rostral medulla

Question 115

After hitting your thumb, shaking your hand reduces the pain sensation because…

Answer 115

According to gate theory of pain, Abeta fibers inhibit dorsal horn projection neurons via interneurons

Large myelinated mechanosensitive afferents (Abeta fibers) send collateral branches in the dorsal horn to synapse onto interneurons before ascending in the dorsal column medial lemniscus system. Those interneurons send inhibitory signals to the second order projection neurons in the spinothalamic tract. Thus activating Abeta fibers by shaking, or, rubbing, your hand reduces the activation of the spinothalamic tract, and diminishes the transmission of nociceptive information to higher centers.

Question 116

Central retinal swelling and diffuse intraretinal hemorrhage, in all quadrants of the retina, are classic signs of…

Answer 116

Central retinal vein occlusion (CRVO) - accompanied by early transient visual phenomena in some cases and vision loss as the central retina swells.

Hypertension and autoimmune disease are important risk factors

Question 117

Contrast the presentations of central retinal vein occlusion with central retinal artery occlusion

Answer 117

CRA occlusion: retina appears grossly swollen and pale, with a prominent fovea that would otherwise be obscured by a normal, pinkish-red background

CRV occlusion: disc is massively swollen with splotches of hemorrhage and cotton wool spots diffusely

While branch or central retinal vein occlusion can have a gradual onset, the symptoms of a blocked retinal artery occur suddenly

Question 118

MRI reveals displacement of tissue in the area of the lateral corticospinal tract on the right side due to a tumor in the meninges that is pressing on the spinal cord at C5. The most lateral fibers in the tracked are affected. These fibers project to the:
A. Left upper limb.
B. Left lower limb.
C. Right upper limb.
D. Right lower limb.

Answer 118

D. Right lower limb.

Somatotopic arrangement of the corticospinal tract in the spinal cord is with the upper limb/cervical fibers located medial to those going to the motor neurons in the lower limb. Pathways is ipsilateral in the spinal cord.

Question 119

Patient with right motor cortex lesion in the facial region has paresis of the left lower face. What would you expect to see you when examining the jaw and the tongue respectively?

Answer 119

No jaw deviation, but tongue deviation to the left (remember in the cortex motor innovation to the face is contralateral, and tongue “licks lesion” side)

CN V is supplied bilaterally by the corticobulbar tract so there should be no jaw deviation – this would occur with lower motor neuron lesions

Question 120

What is the mechanism by which ubrogepant relieves migraine symptoms?

Answer 120

“Gepants” are small molecule antagonist at CGRP receptors

Question 121

For which patients is onabotulinumtoxin A (BoNTA) indicated?

Answer 121

Preventative migraine therapy for patients experiencing migraines more than 15 days per month! So a lot of migraines!!

Question 122

A stroke affecting which lobe of the brain would cause a patient to be in an agitated state?

Answer 122

Temporal lobe – lesions here can produce agitation due to affecting the limbic areas, such as the amygdala