sans 2013

Question 1

A lateral view of the cortical surface bordering the right sylvian fissure that is commonly exposed in a frontotemporal craniotomy is shown in Figure 1. The lower ends of the precentral (1) and postcentral (2) gyri are in the exposure. The supramarginal gyrus is indicated by number:
A.9
B.5
C.6
D.8
E. 7

Answer 1

E. 7

Question 2

Bill’s bar separates the facial nerve from what other structure?
A. Greater Superficial Petrosal Nerve
B. Geniculate Ganglion
C. Superior Vestibular Nerve
D. Inferior Vestibular Nerve

Answer 2

C. Superior Vestibular Nerve

Question 3

The figure is a cadaveric dissection of the anterior portion of the left cavernous sinus. What deficit would be seen with damage to this structure?
A. Facial numbness
B. Diplopia that corrects with head tilt
C. Periocular numbness
D. Ptosis, meiosis and anhydrosis
E. Monocular blindness

Answer 3

D. Ptosis, meiosis and anhydrosis

Question 4

The following figure depicts an endoscopic view of the upper clival/retrosellar region in a cadaveric dissection. Which cranial nerve is indicated by numeral 1.
A. Trochlear
B. Oculomotor
C. Optic
D. Trigeminal
E. Abducens I

Answer 4

B. Oculomotor

Question 5

Three days after clipping of a ruptured anterior communicating artery aneurysm, a patient develops contralateral paresis of the arm and face, as well as dysarthria. A cerebral angiogram reveals focal vasospasm that eventually results in infarction of the corresponding vascular territory, confirmed by CT. What vessel was most likely affected
by vasospasm in this case?
A. Recurrent artery of Haubner
B. Anterior choroidal artery
C. Distal anterior cerebral artery
D. M1 branch of the middle cerebral artery
E. Posterior communicating artery

Answer 5

A. Recurrent artery of Haubner

Question 6

What artery (identified by the arrow in Figure 1) is encountered during a retrosigmoid approach for a vestibular schwannoma?
A. Superior cerebellar artery.
B. Anterior inferior cerebellar artery.
C. Posterior inferior cerebellar artery.
D. Vertebral artery.
E. Basilar artery.

Answer 6

B. Anterior inferior cerebellar artery.

Question 7

What structure passes through the foramen demonstrated with the white arrow?
A. V2
B. V1
C. Vidian nerve.
D. V3.
E. Optic nerve.

Answer 7

A. V2

Question 8

Which of the following structures of the superior orbital fissure pass around the annulus of Zinn:

A. Nasociliary nerve.
B. Inferior branch of oculomotor nerve.
C. Superior branch of oculomotor nerve.
D. Abducens nerve.
E. Trochlear nerve.

Answer 8

E. Trochlear nerve.

Question 9

A patient presenting for resection of a small parietal meningioma has a preoperative INR
of 1.5. What is the likelihood that the transfusion of 2 units of FFP would normalize her
INR?
A. 50o/o
B. 25%
C. <5%
D. 75%
E. 95%

Answer 9

C. <5%

Question 10

An otherwise healthy woman presents with an aneurysmal subarachnoid hemorrhage.
Admission troponin is 1.4ng/ml and transthoracic echocardiography demonstrates a left
ventricular ejection fraction of 15% with severe apical hypo-kinesis. The most likely
pathophysiological mechanism of the cardiac dysfunction is:

A. Catecholamine-induced myocardial stunning
B. Multi-vessel coronary artery spasm
C. Thrombotic coronary artery occlusion
D. Microvascular myocardial ischemia
E. Tachycardia induced cardiomyopathy

Answer 10

A. Catecholamine-induced myocardial stunning

Question 11

Cerebral-salt wasting syndrome (CSW) can be best described as the following:
A. lso-osmolar, euvolemic hyponatremia
B. Hypo-osmolar, hypervolemic hyponatremia
C. Hypo-osmolar, hypovolemic hyponatremia
D. Hypo-osmolar, euvolemic hyponatremia
E. Hyperosmolar, hypovolemic hypernatremia

Answer 11

C. Hypo-osmolar, hypovolemic hyponatremia

Question 12

During the creation of a burr hole for a deep brain stimulator, an awake, sedated patient develops the sudden onset of coughing, hypotension, and hypoxia. The clinical presentation suggest which of the following complications:
A. lntracranial hemorrhage
B. Aspiration pneumonia
C. Air embolism
D. Tension pneumocephalus
E. Seizure activity

Answer 12

C. Air embolism

Question 13

What is the most concerning side effect of dexmedetomidine infusion in ICU patients?
A. Inhibition of the locus ceruleus
B. Bradycardia
C. Systolic hypertension
D. Respiratory depression
E. lntracranial hypertension

Answer 13

B. Bradycardia

Question 14

Which of the following agents causes the largest decrease in the cerebral metabolic rate of oxygen (CMR02):
A. Sufentanil
B. Sodium thiopental
C. Ketamine
D. Diazepam
E. Propofol

Answer 14

B. Sodium thiopental

Question 15

Which of the following opioids has the slowest peak onset?
A. Sufentanil
B. Fentanyl
C. Alfentanil
D. Remifentanil
E. Morphine

Answer 15

E. Morphine

Question 16

Within the normal range of autoregulation, the alteration in cerebral blood flow with a 1- mmHg change in arterial carbon dioxide (PaC02) is best described by:
A. 10-11 ml/1 OOg/min
B. 4-5 ml/1 OOg/min
C. 7-8 ml/1 OOg/min
D. 1-2ml/1 OOg/min
E. 13-14ml/1 OOg/min

Answer 16

D. 1-2ml/1 OOg/min

Question 17

A PGY-2 resident has worked 75 hours in the current week. The resident began his call
shift yesterday at 06:00. The resident had 2 days completely off work in the previous two
weeks. During the call day, the resident admits a pediatric patient with a rare brain
tumor.

The next day, the resident hands off call responsibilities to another resident. However,
he then stays to assist with a rare pediatric brain tumor resection until noon. Which ACGME duty hour rule applies?
A. Adequate rest between duty periods
B. Minimum days off
C. Maximum duty period length
D. In house call limitation
E. 80 hour workweek

Answer 17

C. Maximum duty period length

Question 18

A Type 2 error (false negative) in interpreting clinical trials occurs when:
A. Inadequate informed consent was obtained in over half the cases.
B. A treatment is found to be ineffective but the sample size is too small.
C. A positive result relies on an incorrect statistical test.
D. The test is not randomized or controlled.
E. Gender makeup of the experimental and control populations are not equal.

Answer 18

B. A treatment is found to be ineffective but the sample size is too small.

Question 19

A medical device company is sponsoring a presentation regarding a new implant they
have developed for treatment of spinal instability. The presentation is followed by a
modest meal at a local restaurant. At the conclusion of the meal, the company
representative passes out gifts to the attending physicians, as a “thank you” for taking
time out of their personal lives to attend a work meeting. Which of the following gifts
would be acceptable under the AMA code of ethics and Advamed guidelines?
A. Tickets to professional basketball game the following week
23`
C. $100 gift certificate to restaurant
D. Golf shirt with company logo displayed on sleeve

Answer 19

B. Textbook of spinal anatomy with company logo imprinted on cover

Question 20

A physician chooses to utilize a questionnaire-based outcome measure in his/her
practice. The questionnaire is administered to a core group of patients and then
read ministered to the same patients within a few days. The purpose of this exercise is to
confirm that the replies to the same questions by the same patients do not change after a
few days. A statistical analysis is completed to assess the degree of similarity between
the first and second replies in this setting. This type of analysis for an outcome measure
is a reflection of its:
A. Responsiveness
B. Integrity
C. Reliability
D. Sensitivity
E. Validity

Answer 20

C. Reliability

Question 21

According to the Accreditation Council of Continuing Medical Education {ACCME), what
type of financial relationship is both necessary and sufficient to define a conflict of
interest (COi) between a commercial interest and an individual who can affect patient
care, research activities, or data interpretation?
A. Extraordinary
B. Relevant
C. Significant
D. Monetary

Answer 21

B. Relevant

Question 22

An appropriate way for a neurosurgeon working in a complex team environment to
mitigate stress and fatigue would be to:
A. Not acknowledge stress and fatigue, therefore reducing its effect on performance.
B. Recognize stress and fatigue, thereby increasing the use of threat and error management strategies.
C. Rely on previous experience of chronic stress and fatigue during residency training to overcome these factors.
D. Deny the existence of stress and fatigue in order to avoid distraction from the task at hand.

Answer 22

B. Recognize stress and fatigue, thereby increasing the use of threat and error management strategies.

Question 23

Certain medical conditions are subject to mandatory physician reporting. You evaluate a recent immigrant from Mexico complaining of occasional back pain. He has not been previously evaluated by a physician in the United States. Which of the following diagnoses are required by law to report, if the patient reveals it to you as part of their medical history?
A. Inactive TB
B. Assault
C. Polio
D. Cysticercosis
E. AIDS

Answer 23

E. AIDS

Question 24

Child abuse should be reported:
A. Only by a specially trained Child Protection expert when present in a
hospital.
B. By any physician when requested by law enforcement officials.
C. By any caregiver who suspects non-accidental traumatic injury to a child.
D. In every child under age 2 with a head injury.

Answer 24

C. By any caregiver who suspects non-accidental traumatic injury to a child.

Question 24

Company X offers surgeons $100 for each time they implant their patented device. Which
federal statute has been violated?
A. EMTALA
B. Anti-kickback
C. Stark
D. HIPAA
E. This is not a violation

Answer 24

B. Anti-kickback

Question 25

Dr. Jones designed a new instrument, patented it, and contracted with Company X to
manufacture and market the instrument. Dr. Jones uses the instrument on her patients
(including Medicare patients) and receives royalties for each instrument sold. Does this
relationship violate Federal Stark Law and/or Anti-kickback Statutes
A. Stark only
B. Both
C. Neither
D. Anti-kickback only

Answer 25

B. Both

Question 26

Dr. Jones is presenting a paper she co-authored at a CNS/AANS CME sanctioned meeting. She has disclosed a conflict of interest (COi) with Company Z prior to the meeting. Her presentation will include inforimation about products made by Company Z. In order for the paper to be presented, Dr. Jones must:
A. Limit her comments to research data and results.
B. Disclose COi without limiting comments.
C. Eliminate her COi with Company Z within one month prior to the meeting.
D. Have the paper presented by a co-author without COi.

Answer 26

A. Limit her comments to research data and results.

Question 27

Dr. Smith is part of a committee that is organizing a meeting of local neurosurgeons that will offer CNS/AANS sponsored CME. Dr.Smith also has a conflict of interest (COi} with a Company X whose products will be discussed at presentations during the meeting. Under what circumstances can Dr. Smith participate in organizing the meeting?
A. He can participate without restriction.
B. He can participate as long as he gains no financial benefit directly from this
meeting.
C. He cannot participate in the organization of the meeting.
D. He must disclose the COi and exclude himself during Company X discussion.
E. He must terminate this relationship with Company X.

Answer 27

D. He must disclose the COi and exclude himself during Company X discussion.

Question 28

uring pe ormance o a um ar 1sce omy, here is a delay in radiology availability. The spinal surgeon elects to proceed with laminotomy and disc space exploration but finds no
herniated disc material. A subsequent intra-operative radiograph demonstrates that the
neurosurgeon is operating at the wrong level. The spinal surgeon adjusts the level of approach and successfully completes the procedure. In this circumstance, of the following, the neurosurgeon should:
A. Consult risk management committee and ask them to disclose the error
B. Disclose the error to a quality assurance committee, but not to the patient
C. Request that the patient advocate disclose the error to the patient
D. Not disclose the error because the patient was not harmed
E. Disclose the error to the ~atient in a timelY-_fa_s_h_io_n

Answer 28

E. Disclose the error to the ~atient in a timelY-_fa_s_h_io_n

Question 29

Federal health care insurance agencies including Medicaid and Medicare have established
specific standards for medical coding, billing and reimbursement. Under these systems, primary responsibility for accurate coding and billing rests with:
A. The surgical practice manager.
B. The surgical coding specialist.
C. The hospital billing department.
D. The operative surgeon.
E. The hospital compliance officer.

Answer 29

D. The operative surgeon.

Question 30

In order to provide useful, high quality medical evidence, a clinical study should employ an outcome measure that has the following characteristics:
A. Published, Peer reviewed, and Objective
B. Subjective, Straightforward, and Simple to employ
C. Reproducible, Precise, and Accurate
D. Parametric, Nonbiased, and Comprehensive
E. Reliable, Valid, and Responsive

Answer 30

E. Reliable, Valid, and Responsive

Question 31

Steep gradients in authority can negatively impact patient safety when:
A. Fear of litigation results in physician migration out of a community.
B. Surgical instruments are incorrectly counted at the beginning of a case.
C. An incomplete medical record results in a missed drug allergy.
D. Overcrowded operating rooms create delays in scheduling.
E. A nurse who is unable to reach a resident and does not call an attending.

Answer 31

E. A nurse who is unable to reach a resident and does not call an attending.

Question 32

The Agency for Healthcare Research and Quality (AHRQ) is charged in part with promoting evidence-based medical practice. AHRQ reports recommend Standards, Guidelines and Options for practice that are based on a scale of evidence class (or quality) from the peer-reviewed, clinical literature. In the case of a retrospective, case-controlled study of craniotomy plus whole brain radiation therapy versus stereotactic radiosurgery plus whole brain radiation therapy for solitary lung cancer brain metastasis, the evidence class is:
A. Not classifiable
B. Class Ill
C. Class I
D. Class II

Answer 32

D. Class II

Question 33

The Joint Commission on the Accreditation of Health Care Organizations (JCAHO} has
issued a set of National Patient Safety Goals to be implemented by all hospitals and hospital-based practitioners by January 1st. 2005. One of JCAHO’s 2005 national patient safety goals is:
A. Include the use of the patient room number as a patient identifier whenever
administering medications or performing procedures.
B. Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
C. Assure that the full range of manufactured drug concentrations and intravenous solutions are readily available within the hospital.
D. Implement a process to mark the surgical site involving nurses/O.R.
technicians.
E. For verbal telephone orders, verify the order by having the person receiving the order read-back the key portions.

Answer 33

B. Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.

Question 34

The class of evidence associated with a controlled study of severe closed head injury demonstrating reduced brain parenchymal loss and enhanced residual motor function in
rodents treated with hypertonic saline versus mannitol after injury is:
A. Class I
B. Class II
C. Class Ill
D. Not classifiable

Answer 34

D. Not classifiable

Question 35

Under Federal EMTALA law, what two conditions obligate a hospital to accept a transfer?
A. Appropriate transportation and Joint Commission Certification
B. Non-profit status and charity affiliation.
C. Capacity and capability.
D. Level I Trauma Certification and 24/7 ER coverage

Answer 35

C. Capacity and capability.

Question 36

What is the ACGME definition of systems-based practice?
A. Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.
B. Demonstrate an investigatory and analytic thinking approach to clinical
situations.
C. Know and apply the basic and clinically supportive sciences which are appropriate to their discipline.
D. Partner with health care managers and providers to assess, coordinate, and improve health care.
E. Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

Answer 36

D. Partner with health care managers and providers to assess, coordinate, and improve health care.

Question 37

What is the setting of the initial neurosurgeon-patient encounter of most medical malpractice claims?
A. Outpatient clinic
B. Hospital room (consultation)
C. Emergency room
D. Trauma scene

Answer 37

A. Outpatient clinic

Question 38

What percentage of the total settlement may a whistleblower receive from alerting the U.S.
Federal Government of a violation of Federal Stark Law?
A. 30-50%
B. 15-30%
C.10%
D.60%

Answer 38

B. 15-30%

Question 39

Which of the following activities must be submitted to institutional review board (IRB) for
supervision?
A. You investigate the relationship between socioeconomics and post-concussion syndrome by reviewing hospital records to correlate return visits with residential Zip code.
B. In response to an elevated CSF shunt infection rate, the hospital infection control service prospectively observes 20 shunt operations and discovers that holes in gloves correlate with infection. Double gloving is adopted.
C. A school-age child suffers a gun shot wound to the brachia! plexus and subsequently develops a neuropathic pain syndrome. You prescribe an off label use of gabapentin.
D. An 11-year-old harbors an incidentally discovered internal carotid bifurcation aneurysm. You treat this lesion with endovascular placement of coils approved
by the FDA for use in patients 18-years-old and older.
E. All neurosurgeons at your institution shave the scalp for cranial surgery. In response to an article about shaveless neurosurgery, you adopt this practice.

Answer 39

A. You investigate the relationship between socioeconomics and post-concussion syndrome by reviewing hospital records to correlate return visits with residential Zip code.

Question 40

A 16 year old with drug resistant complex partial seizures with independent bilateral
onsets is referred for vagus nerve stimulation {VNS). What is the most common side
effect of VNS?
A. Dyspepsia
B. Dyspnea
C. Cardiac arrhythmia
D. Voice hoarseness
E. Wound infection

Answer 40

D. Voice hoarseness

Question 41

A 23 year old woman with complex partial seizures was initially treated with phenytoin. then switched to carbamazepine. and is currently on levetiracetam after failing the first two therapies. After a seizure-free period of six months upon starting levetiracetam, she now has recurrence of 2-3 seizures/month. What is the most appropriate next step in her management?
A. Evaluation for vagus nerve stimulation.
B. Add-on therapy with oxcarbazepine.
C. Switch to therapy with oxcarbazepine.
D. Evaluation for resective epilepsy surgery.

Answer 41

D. Evaluation for resective epilepsy surgery.

Question 42

A 24 year old man has refractory complex partial seizures localized to the left
temporal lobe with EEG. MRI is consistent with left mesial temporal sclerosis. What is
the most appropriate next step in his management?
A. Temporal lobectomy
B. lntracranial EEG
C. lntracarotid amytal test
D. Vagal nerve stimulation
E. Corpus callosotomy

Answer 42

C. lntracarotid amytal test

Question 43

A 32 yr old male with intractable seizures and a normal MRI scan undergoes a noninvasive evaluation. Based on scalp EEG and seizure semiology, he had subdural
electrodes placed and seizures were localized to the left language-dominant supplementary motor area. Following surgical resection the patient will MOST likely
exhibit:
A. Temporary paresis on the left.
B. Left inferior quadrantopsia.
C. Temporary mutism.
D. Anemia and finger agnosia.

Answer 43

C. Temporary mutism.

Question 44

According to a randomized, double-blind study comparing medical vs. surgical therapy for epilepsy, the outcome of patients undergoing standard anterior temporal
lobectomy can BEST be described as:
A. 50- 60 % of surgical patients had adverse neurological effects.
B. 10- 20 % of medical patients were seizure-free.
C. 50- 60% of surgical patients were seizure-free.
D. 10- 20 % of medical patients had adverse neurological effects.

Answer 44

C. 50- 60% of surgical patients were seizure-free.

Question 45

An 8 year old with tuberous sclerosis experiences frequent debilitating seizures (complex partial with secondary generalization) that are refractory to medical therapy. EEG suggests the seizures originate in the right hemisphere. The MRI is depicted below. What is the most appropriate next step in her management?
A. Lesionectomy
B. Electrocorticography
C. Head CT
D. Callosotomy
E. Hemispherectomy

Answer 45

B. Electrocorticography

Question 46

In childhood epilepsy syndromes, patients with Lennox-Gastaut syndrome MOST often have the following EEG findings:
A. Multifocal slow spike and wave.
B. Normal or discontinuous.
C. Bilateral hypsarrhthmia.
D. Triphasic spike and wave.

Answer 46

A. Multifocal slow spike and wave.

Question 47

The MOST common clinical feature of medial temporal lobe seizures is:
A. Visual aura.
B. lctal oral automatisms.
C. lctal bicycling movements.
D. lpsilateral dystonic posturing.

Answer 47

B. lctal oral automatisms.

Question 48

West’s Syndrome is BEST characterized by which of the following seizure type:
A. Primary and secondarily generalized.
B. Generalized tonic clonic.
C. Complex partial.
D. Infantile spasms.
E.Atonic.

Answer 48

D. Infantile spasms.

Question 49

When treating status epilepticus in adults, which intravenous medication should be co-administered with benzodiazepines?
A. phenytoin
B. Propofol.
C. Phenobarbital.
D. Succinylcholine.
E. Nitroprusside.

Answer 49

A. phenytoin

Question 50

A 30 year old presents with unilateral hemifacial spasm. An MRI of the brain is ordered to discern an underlying etiology. What is the likelihood that a cause other
than vascular compression of the facial nerve at the root exit zone will be identified?
A. 6-8%
B. 3-5%
C. <3%
D. 9-10%
E. >10o/o

Answer 50

C. <3%

Question 51

A 42 year old male presents with a 5 year history of Parkinson’s disease (PD) with severe motor fluctuations. When discussing deep brain stimulation (DBS) surgery, which of the following is correct regarding the benefits of surgery?
A. DBS results in decreased OFF time freezing of gait.
B. He will have up to 4 hours more ON time without dyskinesias daily
C. DBS will eliminate the need for medications
D. Early surgical intervention changes the natural history of the disease
E. He has not had the disease long enough to benefit from surgery

Answer 51

B. He will have up to 4 hours more ON time without dyskinesias daily

Question 52

A 45-year-old male has a five-year history of progressive right arm intention tremor. A similar condition is present in his father and paternal uncle. The tremor improves with
alcohol ingestion, but has become increasingly refractory to propanolol, mysoline, as well as topamax. There is no rigidity, bradykinesia, or gait abnormality present. The MOST appropriate neurosurgical intervention is:
A. Thalamic deep brain stimulator
B. Globus pallidus deep brain stimulator
C. C6,7 selective rhizotomy
D. Stereotactic pallidotomy
E. Subthalamic nucleus deep brain stimulator

Answer 52

A. Thalamic deep brain stimulator

Question 53

A 63 year old patient with levodopa-responsive Parkinson’s Disease is referred for DBS. With respect to motor symptoms, DBS is likely to:
A. Increase “on” time with troublesome dyskinesias.
B. Decrease “off’ time.
C. Have minimal effect on UPDRS Ill scores.
D. Improve gait.
E. Reduce freezing events.

Answer 53

B. Decrease “off’ time.

Question 54

A patient is undergoing DBS lead placement in the subthalamic nucleus for Parkinson’s disease. During intraoperative testing the patient has good relief of
symptoms but also notes facial pulling and transient paresthesias. Different monopolar and bipolar options produce the same result. Which of the following is the
best option?
A. Subdural hemorrhage
B. Leave the DBS in its current location
C. Move the lead laterally
D. Move the lead medially
E. Abort implantation on this side and move on to DBS implantation on the left side.

Answer 54

D. Move the lead medially

Question 55

A patient who was previously implanted with bilateral DBS needs an MRI for a hip procedure. Which of the following is true regarding MRI compatibility and safety.
A. The generator must be removed but the brain leads can be left in place.
B. The MRI can be obtained safely if the DBS system is turned to 0 volts,
OFF and bipolar.
C. Obtaining an MRI with the use of a body coil safely requires the
complete removal of the DBS system.
D. The MRI has a small risk of breaking the DBS system but does not pose any risk of harm to the patient’s body or brain.
E. Lead to more patients with a vegetative state outcome at the end of the treatment period

Answer 55

C. Obtaining an MRI with the use of a body coil safely requires the
complete removal of the DBS system.

Question 56

Inferior extension of a therapeutic lesion placed in the posteroventral globus pallidus pars internus may induce which of the following adverse events:
A. Hemiballism.
B.Ataxia.
C. Sensory loss.
D. Hemiplegia.
E. Visual field deficit.

Answer 56

E. Visual field deficit.

Question 57

When performing spinal cord stimulation for a patient with failed back surgery syndrome and chronic pain of the right lower extremity, where should the electrode contacts be placed?
A. Right paramedian position in the thoracic epidural sublaminar space
B. Left paramedian position in the lumbar epidural sublaminar space
C. Right paramedian in the lumbar epidural sublaminar space
D. Left paramedian position in the thoracic epidural sublaminar space

Answer 57

A. Right paramedian position in the thoracic epidural sublaminar space

Question 58

A 16 year old severe traumatic brain injury patient is on continuous IV propofol for ICP/CPP management. He develops a low urine output, mild fever, and blood drawn for laboratory analysis is cloudy. A diagnosis of Propofol Infusion Syndrome is proposed. Which of the following laboratory values will BEST confirm the diagnosis:
A. Serum potassium of 3.4
B. Serum creatine kinase 75,000
C. ABG pH 7.35
D. Serum creatinine 1.2
E. Serum triglyceride 100

Answer 58

B. Serum creatine kinase 75,000

Question 59

A 28 year-old healthy woman who delivered her second child 10 days ago presents
with new onset headache, lethargy, and confusion. She has no focal deficits. A noncontrast head CT is obtained and shown below. What is the most appropriate
definitive treatment for this patient?
A. Endovascular embolization
B. Recombinant activated Factor VII
C. Intravenous heparin infusion
D. Craniotomy for hematoma evacuation
E. Observation only

Answer 59

C. Intravenous heparin infusion

Question 60

A 48 year-old man with a right middle cerebral artery distribution infarction. Despite
aggressive medical and endovascular therapy, the artery remains occluded. Two
days later he has a decline in mental status. His head CT is shown. What is the most
likely explanation for the patient’s new neurological deterioration?
A. Occlusive hyperemia
B. Reperfusion syndrome
C. Hemorrhagic conversion
D. Cerebral edema
E. Normal perfusion pressure breakthrough

Answer 60

D. Cerebral edema

Question 61

Hypoglossal nerve function monitoring during surgery is performed by placing
electrodes into which of the following muscles.
A. Palatoglossus
B. Genioglossus
C. Geniohyoid
D. Stylopharyngeus

Answer 61

B. Genioglossus

Question 62

lntracranial atherosclerotic disease and resulting stenosis is an important cause of
ischemic stroke. What ethnicity has the highest incidence of intracranial
atherosclerotic disease?
A. Caucasian
B.Asian
C. African American
D. Hispanic

Answer 62

C. African American

Question 63

The appropriate maintenance rate for IV fluid in a 2 week old child is:
A. 4 ml/kg/hr
B. 10 ml/kg/hr
C. 2 ml/kg/hr
D. 20 ml/kg/hr
E. 1 ml/kg/hr

Answer 63

A. 4 ml/kg/hr

Question 64

What sensory modality is most commonly affected by resection of a lesion in the postcentral gyrus?
A. Temperature
B. Pain
C. Proprioception
D. Light touch
E. Pressure

Answer 64

C. Proprioception

Question 65

A 23 year old male with a remote history of facial fractures presents with progressive
headaches over 4 days, low grade fever and confusion. His neurologic examination is
otherwise non-focal. A head CT with contrast is shown below. The MOST likely
diagnosis is:
A. Subarachnoid/subdural hemorrhage.
B. Chronic subdural hematoma.
C. Arachnoid cyst.
D. Subdural empyema.

Answer 65

D. Subdural empyema.

Question 65

A 70 year-old man with an atrial valve replacement presents with fatigue, fever,
and headaches. He is neurologically intact. Laboratory studies reveal an elevated
erythrocyte sedimentation rate and C-reactive protein. He undergoes a
gadolinium-enhanced MRI (A) and a cerebral angiogram (B), demonstrating the
indicated lesions. What is the most appropriate initial treatment for this patient?
A. Intravenous corticosteroids and close observation
B. Endovascular repair of the lesion
C. Surgical repair of the lesion
D. Intravenous antibiotics and close observation
E. Observation only

Answer 65

D. Intravenous antibiotics and close observation

Question 66

Prophylactic intravenous antibiotics for a surgical procedure are BEST
administered:
A. Within twenty-four hours of surgery.
B. Within one hour of making incision.
C. Six hours prior to incision.
D. One hour prior to incision.

Answer 66

D. One hour prior to incision.

Question 67

What is the most likely causative organism for a brain abscess in a healthy
immunocompetent adult without a surgical history?
A. S. pneumoniae
B. H. influenzae
C. S. aureus
D. S. milleri
E. N. meningitidis

Answer 67

D. S. milleri

Question 68

The following CSF lab values are MOST consistent with which diagnosis: Opening
pressure: 40 cmH20 Appearance: Turbid White Cells (per mm3): 1500 Differential:
95°k PMNs 5% Lymphs Protein: 110 mg/dL Glucose: 15 mg/dL
A. Bacterial meningitis
B. Normal CSF
C. Fungal meningitis
D. TB meningitis
E. Viral meningitis

Answer 68

A. Bacterial meningitis

Question 69

A 17 year-old female has chronic severe progressive tremor and dysphagia. She
was recently hospitalized for an episode of psychosis. On examination she is
dysarthric, drools, and has marked tremor with extension of her arms. Eye
examination reveals yellow-brown granular deposits at the limbus of the cornea.
The most-likely diagnosis is:
A. Thyrotoxicosis
B. Sydenham Chorea
C. Tardive dyskinesia
D. Lesch-Nyhan Syndrome
E. Hepatolenticular degeneration

Answer 69

E. Hepatolenticular degeneration

Question 70

A 21 year-old male has a history of pregressive difficulty walking. On exam, he has absent position and vibration sense in his lower extremities. Deep tendon reflexes are absent. Toes are up-going bilaterally. Gait is broad-based and grossly impaired. His uncle had similar symptoms, developed diabetes and deafness, and died at age 55. The most likely diagnosis is:
A. Posterior fossa neoplasm
B. Multiple sclerosis
C. Wilson’s disease
D. Friedreich’s ataxia
E. Huntington’s chorea

Answer 70

E. Huntington’s chorea

Question 71

A 29-year-old man comes to the emergency department after awakening that morning with deep, boring pain in the right ear and sagging of the right side of his
face. Examination shows normal sensation in the affected area and there are no lesions on the pinna. Hearing is normal but he complains of increased sensitivity to sound in the right ear. A MR scan shows enhancement of the right facial nerve in the petrous bone. A photograph of him attempting to smile is shown. The MOST appropriate initial therapy should be:
A. Oral Prednisone
B. Oral Levaquin
C. Observation only
D. Oral acyclovir
E. Surgical decompression of the right facial nerve

Answer 71

A. Oral Prednisone

Question 72

A 27 year old male construction worker had the onset of new headaches, which began suddenly while doing heavy lifting at work. He was seen at a local emergency
room shortly after his symptoms began. Neurological examination, head CT and spinal fluid were said to be normal. Now he returns to the ER with persistent headaches and a left abducens palsy. The remainder of the neurological examination is normal. An MRI with gadolinium is shown. Spinal fluid has 95
lymphocytes. CSF protein is slightly elevated but the glucose is normal. The MOST likely diagnosis is:
A. Carcinomatous meningitis
B. Spontaneous intracranial hypotension
C. Hypertrophic interstitial pachymeningitis
D. Sarcoidosis
E. Lymphoma

Answer 72

B. Spontaneous intracranial hypotension

Question 73

A 34 year old male who is 8 years post liver transplantation is seen in the emergency department complaining of blurred vision. He has visual hallucinations. He has no paresis but there is bilateral asterixes. His pupils and optic discs are normal. He is hypertensive. He has a grand mal seizure. His MR
scan is shown. Which of the following is the MOST likely diagnosis:
A. Lymphoma
B. Diffuse glioma
C. Reversible posterior leukoencephalopathy
D. Progressive multifocal leukoencephalopathy
E. Ammonia intoxication with secondary cerebral edema

Question 74

A 36 year old postal worker is found next to her parked postal truck in convulsive status epilepticus. Her medical ID bracelet indictates a history of epilepsy, treated with phenytoin. After supplementation with IV phenytoin, re-establishing her typical serum level of 18, convulsions cease. 2 hours later she remains unresponsive, now with beating nystagmus to the left and occasional clonic jerking of the left arm. A STAT head CT is normal. The MOST appropriate diagnostic test is:
A. Electroencephalogram
B. Lumbar puncture
C. MR diffusion imaging
D. Serum sodium
E. MR angiogram

Answer 74

A. Electroencephalogram

Question 75

A 46 year old woman presents with 5 days of burning pain in the right mid-thoracic area. The pain radiates around her side to the abdomen in a band-like pattern. About the same time she developed malaise, nausea, and vomiting. On the day of
your exam she has developed clusters of vesicles on a red base in the area of burning pain (image shown). What is the BEST treatment?
A. Antiviral therapy
B. Vincristine
C. NSAID
D. Steroids
E. Penicillin

Answer 75

A. Antiviral therapy

Question 76

A 55 year-old man presents with worsening short term memory, confusion, and restlessness. On examination he appears depressed, has difficulty with fine motor skills such as finger tapping, and shows saccadic eye movements. His father died at age 60 after a prolonged illness with worsening rigidity and dementia. He has a 9 year-old daughter who recently developed severe dystonia and seizures. His MRI shows loss of striatal volume, with somewhat boxy lateral ventricles. He most likely has early symptoms of which disorder?
A. Mitochondrial encephalomyopathy
B. Huntington’s Disease
C. Parkinson’s Disease
D. Spinocerebellar Ataxia (SCA)
E. Batten Disease (Neuronal Ceroid Lipofuscinosis)

Answer 76

B. Huntington’s Disease

Question 77

A 61-year-old man presents with confusion. Axial gradient echo (susceptibilityweighted} images demonstrate multiple abnormalities. Together, these findings are most consistent with a diagnosis of:
A. Hypertensive hemorrhages
B. CADASIL (cerebral autosomal dominant arteriopathywith subcortical infarcts and leukoencephalopathy}
C. Cerebral amyloid angiopathy
D. Leptomeningeal carcinomatosis
E. Creutzfeldt-Jakob disease

Answer 77

C. Cerebral amyloid angiopathy

Question 78

A 65-year-old man is brought to the emergency department because of agitation and confusion, beginning one week previously and rapidly worsening. He experienced his
first generalized tonic-clonic seizure that morning and since then has been noted to be hallucinating. His temperature is 38.2 deg C. His examination reveals him to be poorly cooperative, confused and shows a left pronator drift with left hyper-reflexia. During the evaluation he has two episodes of chewing, head turning to the left and stiffening. He is loaded with dilantin. An MRI of the brain is shown. Which of the following is the most appropriate next intervention for his ongoing seizures?
A. Induction of coma with pentobarbital
B. Induction of coma with propofol
C. Intravenous lorazepam
D. Intramuscular diazepam
E. Intravenous thiamine

Answer 78

C. Intravenous lorazepam

Question 79

A 7 year-old child of migrant farm workers presents with to the emergency room with a
seizure. Parents describe 60 seconds of unresponsiveness with twitching movements of the right leg. Last month they noted several similar episodes when the child was sick
with an ear infection. On examination in the ED, he is sleepy but arousable, with a moderate right hemiparesis, most prominent in the leg. An MRI of the brain is shown in
the figure. Which of the following is the MOST appropriate diagnostic step?
A. TB skin test
B. Needle biopsy
C. Open resection
D. Serum/CSF immunologic testing
E. Positron emmision tomography

Answer 79

D. Serum/CSF immunologic testing

Question 80

A 7 4 year old man presents with progressive cognitive decline over one year, occasional
visual hallucinations, poor attention, short-term memory loss, and bilateral upper
extremity rigidity. What is the most likely diagnosis?
A. Alzheimer’s disease
B. Dementia with Lew bodies
C. Multi-infarct dementia
D. Wilson’s disease
E. Pick’s disease

Answer 80

B. Dementia with Lew bodies

Question 81

According to the World Federation of Neurology, amytrophic lateral sclerosis is diagnosed by which pattern of neurological dysfunction?
A. Upper or lower motor neuron dysfunction without progression
B. Isolated lower motor neuron dysfunction with progression
C. Isolated upper motor neuron dysfunction with progression
D. Both upper and lower motor neuron dysfunction with progression
E. Both upper and lower motor neuron dysfunction without progression

Answer 81

D. Both upper and lower motor neuron dysfunction with progression

Question 82

Diagnostic criteria for patients with tuberous sclerosis include:
A. Axial and inguinal freckling
B. Hypopigmented skin lesions
C. Trigeminal port wine stain
D. Posterior fossa hemangioblastomas
Q E. Bilateral acoustic neu romas

Answer 82

B. Hypopigmented skin lesions

Question 83

In 2009, the United States FDA (Food and Drug Administration) mandated updated
labeling for all anticonvulsant medications to indicate an increased risk of which of the
following?
A. Renal failure
B. Hepatic failure
C. Stevens Johnson syndrome
D. Suicidal ideation and behavior
E. Attention Deficit Disorder (ADD

Answer 83

D. Suicidal ideation and behavior

Question 84

Seven days ago a 3 year old boy developed a low-grade fever which resolved and was followed by a vesicular rash (see Figures). Two days ago, he had sudden onset of truncal ataxia and horizontal nystagmus. He has moderate dysmetria of both arms
when reaching for toys, cannot stand or walk, and his speech is slurred. His mental status is fully intact. Fundi show sharp disc margins. His strength is full and deep tendon reflexes are present. Which of the following is the MOST likely diagnosis?
A. Guillain-Barre Syndrome
B. Posterior fossa mass
C. Acute disseminated encephaloymyelitis
D. Opsoclonus myoclonus syndrome
E. Post-infectious cerebellar ataxia

Answer 84

E. Post-infectious cerebellar ataxia

Question 85

The most common risk factor for acute ischemic stroke in childhood (newborn to age 18y) is:
A. Inherited prothrombotic conditions
B. Indwelling catheters
C. Cardiac disorders (including congenital heart disease)
D. Arteriopathy
E. Head/neck trauma

Answer 85

D. Arteriopathy

Question 86

The cerebral hemispheric MRI findings MOST characteristic of multiple sclerosis (MS)
are:
A. White matter plaques commonly associated with pronounced atrophy.
B. Typically of the same radiographic age, as indicated by similar
enhancement patterns.
C. Plaques in the corpus callosum with horizontal plaques in the central white matter.
D. Periventricular lesions that are characteristically round and multiple, and at least one should be greater than 6 mm.

Answer 86

C. Plaques in the corpus callosum with horizontal plaques in the central white matter.

Question 87

What is the pathophysiological etiology of isolated unilateral weakness of dorsiflexion
and ankle inversion?
A. Peroneal mononeuropathy
B. L5 radiculopathy
C. 81 radiculopathy
D. L4 radiculopathy
E. Tibial mononeuropathy

Answer 87

B. L5 radiculopathy

Question 87

This 7 year old boy has had difficulty with ambulation and gross motor skills since early childhood. He did not walk until age 17 months. His symptoms are getting progressively worse. Mental status is unimpaired, and cognitive development is
normal. Based on this video clip, his MOST likely diagnosis is:
A. Muscular dystrophy
B. Myelodysplasia
C. Tethered cord syndrome
D. McArdle’s disease
E. Spinal cord tumor

Answer 87

A. Muscular dystrophy

Question 88

A 58-year-old woman with well-controlled diabetes and hypertension, without history
of trauma, presents with oculomotor synkinesis between the extraocular muscles causing adduction or globe retraction with attempted vertical gaze. What is the most
likely cause of her clinical findings?
A. Midbrain infarct
B. Parasellar mass lesion
C. Diabetic third nerve palsy
D. Thyroid associated orbitopathy
E. Pineal region tumor

Answer 88

B. Parasellar mass lesion

Question 88

A 25-year-old man presents with a new onset of right facial droop associated with binocular horizontal diplopia. MRI of the brain shows a brainstem hyperintensity on T2
and FLAIR images (see figure). What anatomical structure is affected by this lesion causing the diplopia?
A. Medial longitudinal fasciculus
B. Abducens fibers
C. Abducens nucleus
D. Trochlear nucleus
3E. Trapezoid body

Answer 88

C. Abducens nucleus

Question 89

A 27 yo pregnant woman presents with painless progressive vision loss in the right eye. Examination reveals no light perception or direct pupillary response in the right
eye, a pale right optic nerve, and a superior temporal visual field defect in the left eye. The etiology of her signs and symptoms is most likely:
A. Pituitary apoplexy
B. Optic neuritis
C. PRES (posterior reversible encephalopathy syndrome)
D. Suprasellar meningioma
E. Functional vision loss

Answer 89

D. Suprasellar meningioma

Question 90

A 48 year old women presents wite one week history of progressive facial paresis. severe right ear pain. vertigo, imbalance and hearing loss. Her past medical history is unremarkable. She has right beating nystagmus. Based on the
MRI scan (figures) what is your diagnosis:
A. Zoster oticus Faeial Nerve–Hemangioma
C. Facial Nerve Schwannoma
D. Bell Palsy
E. Vestibular schwannoma

Answer 90

A. Zoster oticus Faeial Nerve–Hemangioma

Question 91

A 77-year-old man with history of poorly controlled hypertension awakes with bilateral vision loss. Examination reveals no light perception in both eyes, normal pupillary responses without relative afferent defect. no gaze palsy and normal optic discs. He is slightly confused and language is fluent. However, during your examination, he becomes globally aphasic with gaze deviation to the left and tonic stiffening of his left arm for 45 seconds.
A. Posterior reversible encephalopathy syndrome
B. Top of the basilar syndrome
C. Hypertensive retinopathy
D. Balint syndrome
E. Amaurosis fugax

Answer 91

A. Posterior reversible encephalopathy syndrome

Question 92

A 65-year-old man presents with progressive horizontal diplopia worse in right gaze. His examination demonstrates partial abduction deficit in his right eye, mild right upper lid ptosis and presence of anisocoria with the right pupil smaller than the left. The remainder of his examination is unremarkable. Where is the most likely location
of the lesion?
A. Dorelle’s canal
B. Cavernous sinus
C. Orbital apex
D. Posterior communicating artery

Answer 92

B. Cavernous sinus

Question 93

The presence of macular sparing in a hemianopic visual field deficit localizes to which
part of the optic pathway:
A. Chiasm
B. Cortex
C. Radiations
D.Nerve
E. Tract

Answer 93

B. Cortex

Question 94

A 48 year o woman presen a one week history of progressive facial paresis, severe right ear pain, vertigo, imbalance and hearing loss. Her past medical history is unremarkable. She has right beating nystagmus. Based on the MRI scan (figures) what is your diagnosis:
A. Zoster oticus
B. Facial Nerve Hemangioma
C. Facial Nerve Schwannoma
D. Bell Palsy
E. Vestibular schwannoma

Answer 94

B. Facial Nerve Hemangioma

Question 94

A 50-year-old male banker presents with a several month history of a “hissing steam”
sound in the left ear associated with occasional muffled hearing. He has had five
episodes of profound vertigo that were sudden in onset and have twice forced him to
the ground for 5 to 15 minutes. He experienced nausea and vomiting with most
episodes and had to rest for several hours after each “attack.” Magnetic resonance
imaging of the brain is normal. An audiogram identifies low frequency hearing loss
with preserved speech discrimination. What is the MOST likely diagnosis:
A. vestibular neuronitis
B. acoustic neuroma
C. Meniere’s disease
D. benign positional vertigo
E. vertebra-basilar insufficiency

Answer 94

C. Meniere’s disease

Question 95

A 55-year-old accountant presents with gradually worsening hearing in his right ear over the last 12 months. He has been unable to use the telephone with that ear for 5
months. Speech audiometry reveals discrimination scores of 85% in the left ear at 60
dB and 30% in the right ear at 100 dB. MR imaging is shown in Figure 1. The MOST
likely result of brainstem auditory evoked responses (on the right) in this patient is:
A. prolongation of the 1-V interpeak latency
B. loss of wave VI-VII
C. loss of wave I
D. high frequency loss of the interaural difference in wave V latency

Answer 95

A. prolongation of the 1-V interpeak latency

Question 96

In the case of an intracanalicular vestibular schwannoma, what is the advantage of the middle cranial fossa approach over the retrosigmoid approach?
A. Decreased risk of injuring the greater superficial petrosal nerve.
B. Early identification of the facial nerve.
C. Improved preservation of vestibular nerve function.
D. Decreased risk of CSF leak.

Answer 96

B. Early identification of the facial nerve.

Question 97

A 24 year old woman complains of severe burning and aching pain in her distal right leg and foot. Physical exam reveals a red and swollen right foot with persistent
blanching after palpation. With which diagnosis is this most consistent?
A. Complex regional pain syndrome
B. Chronic lumbar radiculopathy
C. Raynaud’s phenomenon
D. Tarsal tunnel syndrome
E. Scleroderma

Answer 97

A. Complex regional pain syndrome

Question 97

A 48-year-old man who has undergone five operations on his lumbar spine after a work-related injury comes to your clinic complaining of severe low back pain. He is taking 300 mg/day of oral morphine and is on a Duragesic patch. He states that pain
relief is inadequate with these medications and that over the last five years his need
for these medications has risen dramatically. Which of the following BEST describes
this patient’s behavior?
A. Narcotic addiction
B. Narcotic tolerance
C. Narcotic withdrawl
D. Malingering

Answer 97

C. Narcotic withdrawl

Question 98

A 45-year-old woman is referred with complaints of debilitating paroxysmal,
lancinating pain involving the base of the tongue and tonsillar region on the left side.
The pain can be relieved by topical application of cocaine to the tonsillar pillar. Her
neurological examination is normal. A CT scan of the brain and skull base along with
an MRI of the brain are both normal. This patient’s pain is MOST likely due to which
one of the following:
A. Glossopharyngeal neuralgia
B. Eagle’s syndrome
C. Trigeminal neuralgia
D. Meningioma in the CPA angle
E. Geniculate neuralgia

Answer 98

A. Glossopharyngeal neuralgia

Question 98

A 45-year-old woman is referred with complaints of debilitating paroxysmal,
lancinating pain involving the deep aspect of the left ear canal. Her neurological
examination is normal. A CT scan of the brain and skull base along with an MRI of
the brain are both normal. She has failed medical management of her condition.
Which of the following represents the BEST surgical treatment option?
A. Nucleus caudalis DREZ ablation
B. Removal of the styloid process
C. Intradural rhizotomy of the 9th and upper 1 /3 of the 10th cranial nerves
D. Microvascular decompression of the trigeminal nerve
E. lntradural section of the nervus intermedius

Answer 98

E. lntradural section of the nervus intermedius

Question 99

A 48-year-old man who has undergone five operations on his lumbar spine after a
work-related injury comes to your clinic complaining of severe low back pain. He is
taking 300 mg/day of oral morphine and is on a Duragesic patch. He states that pain relief is inadequate with these medications and that over the last five years his need for these medications has risen dramatically. Which of the following BEST describes this patient’s behavior?
A. Narcotic addiction
B. Narcotic tolerance
C. Narcotic withdrawl
D. Malingering

Answer 99

B. Narcotic tolerance

Question 99

A fifty-year old female presents with medically refractory episodes of severe, deep-seated ear and throat pain, triggered by eating solid food. The best surgical treatment option include decompression or sectioning of:
A. Glossopharyngeal nerve
B. Nervus intermedius
C. Trigeminal nerve
D. Inferior portion of the vagus nerve
E. Hypoglossal nerve

Answer 99

A. Glossopharyngeal nerve

Question 100

A patient with lower extremity pain was treated successfully for 6 months with an
intrathecal pump delivering 25 mg/day of morphine. He now presents with increased
lower extremity pain and numbness. Physical examination reveals new lower extremity hyper-reflexia. What is the most likely explanation for his new symptoms?
A. Pump overinfusion
B. Fractured intrathecal catheter
C. Morphine withdrawal
D. Morphine-induced myelotoxicity
E. Catheter-tip granuloma

Answer 100

E. Catheter-tip granuloma

Question 100

In the diagram, which letter corresponds to the target of a cordotomy procedure?
A. 3
B. 2
C. 1
D. 4
E. 5

Answer 100

D. 4

Question 101

Placement of a spinal cord stimulator lead percutaneously has been attempted but
failed due to epidural scar formation. In order to treat the patient’s lower extremity
neuropathic pain, you decide to perform a surgical lead placement. The MOST
appropriate level for laminectomy is
A. C1-2
B. T10-11
C. T7-8
D. L2-3

Answer 101

B. T10-11

Question 102

The vessel MOST LIKELY to make pathologic contact with the glossopharyngeal
nerve in glossopharyngeal neuralgia is:
A. posterior cerebral artery
B. Posterior inferior cerebellar artery
C. Superior cerebellar artery
D. recurrent artery of Haubner

Answer 102

B. Posterior inferior cerebellar artery

Question 103

What is the typical arrangement of nerve fibers within the trigeminal ganglion?
A. V1 inferomedial, V3 superolateral
B. V1 superolateral, V3 inferomedial
C. V1 superomedial, V3 inferolateral
D. V1 inferolateral, V3 superomedial

Answer 103

C. V1 superomedial, V3 inferolateral

Question 104

Which of the following procedures is best suited for medically refractory pelvic
cancer pain?
A. Spinal cord stimulation
B. Anterolateral cordotomy
C. Punctate midline myelotomy
D. Dorsal root entry zone lesion

Answer 104

C. Punctate midline myelotomy

Question 105

You see a patient in your clinic with complete quadriplegia secondary to spinal cord injury at CS. He is complaining of severe rectal pain. On physical examination, he has complete anesthesia below C7. Which one of the following is the BEST treatment option?
A. Spinal cord stimulation
B. Thoracic cordotomy
C. Deep brain stimulation
D. Amitriptyline and/or carbemazapine
E. lntrathecal morphine pump

Answer 105

D. Amitriptyline and/or carbemazapine

Question 105

2.5 year old child presents with macrocephaly and poor height and weight gain. He has just begun to walk, but has age appropriate language development. A head CT scan and MRI show a large pineal region lesion. Serum Beta HCG and AFP are negative. The MOST appropriate procedure is:
A. Endoscopic Biopsy and CSF Shunt placement
B. Cerebral Angiogram
C. Stereotactic Biopsy
D. Open biopsy and possible resection

Answer 105

B. Cerebral Angiogram

Question 106

A 10 year old boy presents with 2 weeks of right-sided dysequilibrium and gait
disturbance. On examination he has an impaired gag reflex. Which of the following
is most often associated with the likely pathology.
A. Perivascular pseudorosettes
B. Fibrally astrocytes with atypia
C. INl-1 locus mutation
D. Loss of heterozygosity of chromosome 1 p/19q
E. Ki-67 index >4%

Answer 106

B. Fibrally astrocytes with atypia

Question 106

A 10-year-old boy with cerebral palsy and spastic diplegia is referred for treatment of
spasticity. The patient can ambulate with assistance. What is the most definitive
procedure for improving this patient, lower extremity spasticity?
A. Midline myelotomy
B. Selective dorsal rhizotomy
C. Botox injections
D. Selective peripheral neurectomy
E. DREZ thermocoagulation

Answer 106

B. Selective dorsal rhizotomy

Question 107

A 14 year old previously healthy girl presents to the emergency department with a several month history of upper thoracic back pain. She states the pain is significantly improved when lying down and significantly worse when upright. She denies any radiation of pain, numbness, tingling, orbowel/bladder involvement. She does not have history of prior trauma. Findings are shown in the figures. What is the most appropriate treatment of her lesion?
A. Ct guided biopsy
B. Empiric methotrexate therapy
C. Empiric antibiotic therapy
D. Resection and instrumented stabilization
E. Radiation therapy

Answer 107

D. Resection and instrumented stabilization

Question 108

A 15 year old male presents with severe low back pain. The pain responds poorly to Tylenol but responds well to aspirin. CT demonstrates a 1.5 cm dense lytic lesion of with a calcified nidus and circumferential sclerosis. What is the diagnosis?
A. Osteochondroma
B. Osteoid osteoma
C. Hemangioma
D. Oteoblastoma

Answer 108

B. Osteoid osteoma

Question 108

A 15 year old patient with a history of prematurity and post-hemorrhagic hydrocephalus presents to the emergency department with an intermittent fever of no higher than 100.2 deg. F, anorexia, and mild headache. His peripheral WBC is normal, at 9.3. The patient and his mother both deny the possibility of VP shunt malfunction. He states that “this is totally different than the symptoms I had 8 months ago when my shunt was blocked”. The MOST likely diagnosis is:
A. gastroenteritis
B. pseudotumor cerebri
C. proximal shunt obstruction
D. bowel perforation
E. abdominal pseudocyst

Answer 108

E. abdominal pseudocyst

Question 109

A 4 year old child with symptomatic unilateral moyamoya syndrome was treated with surgical revascularization. At 1-year postoperatively, an angiogram revealed stable arteriopathy and excellent surgical collateral development. Cerebral blood flow studies show normalization of flow and clinically the child is symptom-free. At this point, the appropriate follow-up plan is:
A. Clinical visits or imaging only if symptoms recur, otherwise just routine Follow-up with the pediatrician
B. Clinical visits annually with detailed neurologic examinations and MRl/MRA annually for 5 years
C. Clinical visits annually with detailed neurologic examination, but no imaging is needed.
D. Clinical visits with annual CT imaging
E. No follow-up is needed.

Answer 109

B. Clinical visits annually with detailed neurologic examinations and MRl/MRA annually for 5 years

Question 110

A 9-year-old male presented to his pediatrician with headaches and growth delay. Pathological specimens of his tumor obtained at operation are shown in the photomicrographs. What is the MOST likely diagnosis:
A. Colloid cyst.
B. Craniopharyngioma.
C. Pilocytic astrocytoma.
D. Hypothalamic hamartoma.
E. Pituitary adenoma.

Answer 110

B. Craniopharyngioma.

Question 111

What is the appropriate first-line management of a Type 1 spinal dural arteriovenous fistula (see figure)?
A. Radiosurgery directed at the proximal portion of the fistula
B. Superselective catheterization and attempted embolization
C. Observation
D. Fractionated stereotactic radiotherapy
E. Surgical obliteration of the fistula

Answer 111

B. Superselective catheterization and attempted embolization

Question 111

A 5 year old presents with headache and vomiting. CT and MR imaging reveals the presence of a 4th ventricular tumor. A suboccipital craniotomy is performed for total resection of a medulloblastoma. Resection is followed by protocol based chemotherapy and total neuroaxis radiotherapy, with a boost to the posterior fossa. Which endocrinological complication is MOST likely after radiotherapy for a posterior fossa tumor in childhood?
A. Diabetes lnsipidus
B. Cushing’s Syndrome
C. Growth Hormone Deficiency
D. Growth Hormone Excess
E. Addison’s Syndrome

Answer 111

C. Growth Hormone Deficiency

Question 112

A 9-year-old male presented to his pediatrician with headaches and growth delay. Pathological specimens of his tumor obtained at operation are shown in the
photomicrographs. What is the MOST likely diagnosis:
A. Colloid cyst.
B. Craniopharyngioma.
C. Pilocytic astrocytoma.
D. Hypothalamic hamartoma.
E. Pituitary adenoma.

Answer 112

B. Craniopharyngioma

Question 112

A five-year-old right-handed boy has medically intractable epilepsy for 4 years and has
frequent persistent focal motor seizures on top of other semilogies. Evaluation
demonstrates developmental delay, worsening of verbal IQ and right-sided hemiparesis. EEG and SPECT demonstrate several epileptogenic foci over the left parietal lobe. MRI imaging is shown. Aside from invasive monitoring, which of the following is the most appropriate surgical treatment?
A. Vagus Nerve Stimulation
B. Functional hemispherectomy
C. Corpus Callosotomy
D. Parietal lobectomy
E. Selective temporal amygdalohippocampectomy

Answer 112

B. Functional hemispherectomy

Question 113

Children of mothers with diabetes mellitus have an increased incidence of which spinal disorder?
A. Meningocele manque
B. Sacral agenesis
C. Spinal dysraphism
D. Thoracic hemivertebrae
E. lntraspinal lipomas

Answer 113

B. Sacral agenesis

Question 114

Cranial dermoid cysts may appear in various locations. Which of the following dermoid
cyst locations carries the GREATEST risk of intradural extension?
A. Inion
B. Brow
C. Pterion
D. Anterior fontanelle

Answer 114

A. Inion

Question 115

Current pediatric head injury guidelines suggest maintenance of the minimum
cerebral perfusion pressure above 40 to 65 mm Hg, depending on:
A. Skull thickness
B. Patient age
C. Status of fontanelle
D. Core temperature
E. Time since injury

Answer 115

B. Patient age

Question 116

Premature closure of the metopic suture results in what head shape?
A. Brachycephaly
B. Scaphocephaly
C. Trigonocephaly
D. Pachycephaly
E. Plagiocephaly

Answer 116

C. Trigonocephaly

Question 117

The axial noncontrast head CT shown from an affected neonate results from which of
the following deformities.
A. Unicoronal synostosis
B. Lambdoid synostosis
C. Sagittal synostosis
D. Metopic synostosis
E. Bicoronal synostosis

Answer 117

D. Metopic synostosis

Question 118

The incidence of myelomeningocele has decreased during the past decade. Before the 1980s, the incidence was 1 to 2 per 1000 live births. The current incidence is 3 per 10,000 live births. One reason for this decline may be the recommendation by
physicians and obstetricians for women to supplement their folic acid intake. The
American College of Obstetrics and Gynecology recommends the following supplementation guideline to all women from menarche to menopause:
A. 400 micrograms every day.
B. 800 micrograms during first trimester.
C. 4 grams every day.
D. 4 grams every week.
E. 400 micrograms after positive pregnancy

Answer 118

A. 400 micrograms every day

Question 119

The most common presentation of symptomatic moyamoya syndrome is:
A. Seizure
B. Hemorrhagic Stroke
C. Ischemic Stroke
D. Chorea
E. Tremor

Answer 119

C. Ischemic Stroke

Question 119

What is the likely future ambulatory status of a newborn with a L4 myelomeningocele?
A. Wheelchair-bound
B. Ambulation with orthoses and walking aid
C. Independent ambulation
D. Stand but not ambulate

Answer 119

B. Ambulation with orthoses and walking aid

Question 120

What proportion of pediatric patients who undergo temporal lobectomy for intractable epilepsy have a favorable outcome (seizure freedom or substantial decrease in seizure frequency)?
A. 50-65%
B. 80-95%
C. 65-80%
D. 35-50%

Answer 120

C. 65-80%

Question 121

Which medication has been shown to both reduce the risk of IVH and improve outcome
in preterm infants:
A. lndomethacin
B. Phenobarbital
C. Corticosteroid
D. Ibuprofen
E. Vitamin E

Answer 121

C. Corticosteroid

Question 122

Which of the following neurocutaneous syndromes are transmitted in an autosomal recessive fashion?
A. Tuberous sclerosis
B. Neurofibromatosis type 2
C. Neurofibromatosis type 1
D. Von Hippel Lindau
E. Ataxia-telangectasia

Answer 122

E. Ataxia-telangectasia

Question 123

A 15-year-old high school wrestler sustains a left shoulder dislocation during a match. After the shoulder is relocated, he has difficulty abducting his arm, although he has a strong grip and normal sensation to pin in his hand and fingers. Your examination
demonstrates normal function of the biceps, triceps and external rotators of the
shoulder. The MOST likely explanation of these findings is injury of:
A. Axillary nerve
B. C5 nerve root
C. Suprascapular nerve
D. Diffuse brachia! plexus stretch

Answer 123

A. Axillary nerve

Question 124

A 16 year old female presents with a sharp laceration to the posterior thigh. Examination showed complete lack of foot dorsiflexion and eversion consistent with peroneal nerve injury. Imaging studies show no vascular compromise. What is the best next step.
A. Obtain electrodiagnostic studies
B. Close the wound acutely then explore and repair if needed at 3 weeks
C. Wash and close the wound
D. Repair the nerve acutely

Answer 124

D. Repair the nerve acutely

Question 125

A 22-year-old man presents with a dropped right foot that occured after twisting his knee
and straining his back during a football game. He also reports numbness from the lateral
calf to the dorsum of the foot but denies worsening pain with Valsalva maneuver. Examination of the right leg reveals an inability to dorsiflex or evert the right ankle, and
an inability to dorsiflex the right toes. Ankle inversion is intact. and DTR’s of the knee and ankle are symmetric. Lasegue’s sign is absent. What is the MOST likely diagnosis:
A. Common peroneal nerve injury
B. Isolated deep peroneal nerve injury
C. Isolated superficial peroneal nerve injury
D. L5 radiculopathy
E. Tibial nerve injury

Answer 125

A. Common peroneal nerve injury

Question 125

A 25 year-old man presents with a flail, anesthetic arm after an industrial accident with
closed injury to the brachia! plexus. After 6 months, he has recovered shoulder, elbow,
and wrist movement, but the hand remains flail. Examination shows the presence of ptosis and meiosis ipsilateral to the injured arm. Electrodiagnostic studies show
normal sensory nerve action potentials of the ulnar nerve. Where is the most likely
injury?
A. Post-ganglionic injury of T1
B. Pre-ganglionic injury of C7
C. Post-ganglionic injury of C7
D. Pre-ganglionic injury of T1
E. Post-ganglionic injury of CB

Answer 125

D. Pre-ganglionic injury of T1

Question 126

A 38 year old male experiences severe acute right arm pain and then develops severe deltoid weakness and mild biceps and triceps weakness. After 6 weeks, he seeks consultation. Axial MRI imaging at C4-5 and C5-6 are shown. The next appropriate step is:
A. EMC/NCS
B. Epidural steroid injection
C. Physical therapy
D. CT myelogram
E. ACDF C4-5 and C5-6

Answer 126

A. EMC/NCS

Question 126

A 40-year old patient undergoes resection of a facial schwannoma that is infiltrating the facial nerve from the cisternal segment to the mastoid segment. The nerve is resected with the tumor for a gross total resection. When considering a facial to hypoglossal anastomosis, what is the ideal timing of surgical intervention to maximize return of facial nerve function?
A. Within 12 months of facial nerve paralysis
B. Within 6 months of facial nerve paralysis
C. Within 2 months of facial nerve paralysis
D. Within 24 months of facial nerve paralysis
E. There is no relationship between the duration of facial nerve paralysis and functional recovery

Answer 126

E. There is no relationship between the duration of facial nerve paralysis and functional recovery

Question 127

A 45 year old truckdriver presents with left medial hand pain and paresthesias (dorsal
and palmar), and weakness and atrophy of the adductor pollicis and first dorsal
interosseous. The weakness is progressive and refractory to conservative management. Electrodiagnostic studies confirm peripheral nerve entrapment without
radiculopathy or intrinsic neuromuscular disease. What is the best surgical treatment
for the entrapped nerve?
A. Release of the pronator tunnel
B. Decompression of the cubital tunnel
C. Release of the supinator tunnel
D. Decompression of the transverse carpal ligament
E. Release of the Guyon’s canal

Answer 127

B. Decompression of the cubital tunnel

Question 127

A 48 year old man presents with pain and paresthesias on the medial aspect of the
right hand, years after injuring his arm while lowering a heavy object. Exam demonstrates weakness of the first dorsal interosseous, abductor digiti minimi and hand instrinsics, but not the abductor pollicis brevis or opponens pollicis. Sensation is decreased in the small finger, medial half of the ring finger, and the ventral aspect of the medial palm, but not the dorsal aspect of the hand. Compression at what
anatomical region is most consistent with these signs and symptoms?
A. C7-T1 foramen
B. Thoracic outlet
C. Cubital tunnel
D. Guyon’s canal
E. Deltopectoral groove

Answer 127

D. Guyon’s canal

Question 128

A 65 year old man presents with a peroneal nerve lesion at the fibular neck with an
incomplete palsy. lntraoperative frozen section of the resected lesion is consistent with a malignant peripheral nerve sheath tumor. What is the most appropriate surgical strategy?
A. Lesion resection with nerve preservation
B. Amputation distal to the lesion
C. Wide local excision with clean margins
D. Resection of the peroneal nerve
E. Closure of the wound

Answer 128

A. Lesion resection with nerve preservation

Question 129

A patient with which of the following conditions is most likely to have completely
normal sensory nerve conduction studies of the upper extremity?
A. carpal tunnel syndrome
B. cervical radiculopathy
C. ulnar neuropathy
D. demyelination
E. axonal radial neuropathy

Answer 129

B. cervical radiculopathy

Question 129

A slim 27 year old woman underwent a right ventriculoperitoneal shunt placement. The track of the catheter passes through the right posterior triangle of the neck. After surgery, she is unable to shrug the right shoulder. Injury to what nerve caused this weakness?
A. Suprascapular nerve
B. Dorsal scapular nerve
C. CS nerve root
D. Spinal accessory nerve
E. Long thoracic nerve

Answer 129

D. Spinal accessory nerve

Question 130

Exploration of a median nerve lesion reveals a traumatic neuroma. Which
intraoperative diagnostic modality would guide the decision to perform an excision and graft repair as opposed to an internal neurolysis?
A. Nerve action potentials
B. Frozen section
C. Ultrasound
D. Electromyography
E. MRI

Answer 130

A. Nerve action potentials

Question 131

In doing a nerve transfer procedure to recover elbow flexion, which of the following two nerves are coapted?
A. Ulnar and radial
B. Radial and musculocutaneous
C. Spinal accessory and suprascapular
D. Ulnar and musculocutaneous
E. Radial and median

Answer 131

D. Ulnar and musculocutaneous

Question 132

Lack of function in which muscle indicates a very proximal C5 nerve root injury?
A. Rhomboid
B. Flexor carpi ulnaris
C. Opponens pollicis
D. Supinator
E. Biceps

Answer 132

A. Rhomboid

Question 132

A 37 year-old man has a tonic-clonic seizure and is found to have an unruptured 2 cm
AVM located in the sensorimotor cortex. Angiography shows that there are no associated aneurysms, and it has both superficial and deep venous drainage. The
patient elects to undergo radiosurgery for his Spetzler-Martin Grade Ill AVM. The 3.6 cc AVM volume was treated with 20 Gy to the 50% isodose line. Which of the following is
the MOST likely clinical outcome:
A. Radiation induced deficit
B. Hemorrhage induced deficit
C. Complete AVM obliteration
D. Subtotal AVM obliteration

Answer 132

C. Complete AVM obliteration

Question 133

A 46 year-old woman with recurrent Cushing’s disease after trans-sphenoidal
resection has MR proven extension of tumor into the cavernous sinus. She elects to
undergo radiosurgery. What is the MOST likely complication after pituitary adenoma
radiosurgery:
A. Diabetes insipidus
B. Diplopia
C. Anterior pituitary insufficiency
D. Visual loss
E. Carotid artery occlusion

Answer 133

C. Anterior pituitary insufficiency

Question 134

A 48 year-old woman with medically refractory trigeminal neuralgia chooses radiosurgical therapy. Which of the following is the MOST appropriate maximum radiation dose for trigeminal neuralgia radiosurgery:
A. 20 Gy
B. 40 Gy
C. 60 Gy
D. 80 Gy
E. 100 Gy

Answer 134

D. 80 Gy

Question 134

A 56 year-old man with history of renal cell carcinoma presents with localized back
pain but without myelopathy. Radiographs showed normal alignment and no evidence
of instability. MRI showed a dorsal. enhancing paraspinal mass with extension into the
spinal canal. Which of the following is the MOST likely outcome of stereotactic
radiosurgery for this spine metastasis:
A. Tumor stabilization but persistent back pain
B. Tumor stabilization with an improvement in back pain
C. Tumor stabilization with new onset myelopathy
D. Tumor progression causing spinal cord compression
E. Tumor progression causing vertebral collapse

Answer 134

B. Tumor stabilization with an improvement in back pain

Question 135

A 59 year-old man presents with high frequency sensorineural hearing loss, near normal speech discrimination (>90% at 40 dB), and an MRI showing a uniformly enhancing 10-mm mass extending into the internal auditory canal. The MOST likely complication of stereotactic radiosurgery for this lesion is:
A. Diplopia
B. Facial numbness
C. Hearing loss
D. Facial weakness
E. Swallowing difficulty

Answer 135

C. Hearing loss

Question 136

A 63 yo man with a history of non small cell lung cancer presents with headaches. An
MRI of the brain demonstrates two enhancing lesions each measuring 2 cm, with mild
vasogenic edema and no mass effect. Which of the following is supported by Class 1 evidence regarding stereotactic radiosurgery (SRS} and whole brain radiation therapy
(WBRT)?
A. For patients with one to three metastases, SRS alone results in better early cognitive outcomes than SRS plus WBRT.
B. For patients with one to four metastases, SRS alone is associated with poorer survival than SRS plus WBRT.
C. For patients with one to three metastases, WBRT plus SRS boost prolongs survival as compared to WBRT alone.
D. For patients with one brain metastasis, SRS provides improved survival compared to WBRT.

Answer 136

A. For patients with one to three metastases, SRS alone results in better early cognitive outcomes than SRS plus WBRT.

Question 137

A 65-year old female with a growing left intracanalicular 6 mm tumor and progressively worsening yet still serviceable hearing presents with the MRI
shown. What is the most appropriate management strategy?
A. Surgical removal via translabyrinthine approach
B. Stereotactic radiosurgery
C. Surgical removal via a retrosigmoid approach
D. Reassurance, observation, and follow-up MRI in one year

Answer 137

B. Stereotactic radiosurgery

Question 138

What is a safe maximum point dose that the spinal cord can tolerate in single session
spinal radiosurgery?
A.16 Gy
B.14 Gy
C. 10 Gy
D. 20 Gy

Answer 138

C. 10 Gy

Question 139

Which of the following cranial nerves is most susceptible to radiation injury after
radiosurgery of a cavernous sinus lesion?
A. Trochlear.
B. Abducens.
C. Oculomotor.
D. Trigeminal.
E. Optic.

Answer 139

E. Optic.

Question 139

A 15 year old boy presents with neck pain. He is neurologically intact. A CT of the cervical spine reveals an osteolytic lesion with multiple fluid-filled cavities involving the body of C4. What is the most likely diagnosis?
A. Ewing’s sarcoma.
B. Aneurysmal bone cyst.
C. Osteosarcoma.
D. Eosinophilic granuloma.
E. Fibrous dysplasia.

Answer 139

B. Aneurysmal bone cyst

Question 140

A 22-year-old sustained a spinal cord injury after a fall with an L2 burst fracture and
canal compromise. More than half of the muscles below the level of injury have a strength grade less than 3. There is impaired pain and temperature sensation below the middle of the thighs bilaterally, but preserved light touch and proprioception. There is bilateral Babinski sign and loss of anal tone and wink reflex. According to the 2000/2002 ASIA Standards, what {modified) ASIA Impairment Scale classification is this patient:
A. C
B. B
C. A
D. D
E. E

Answer 140

A. C

Question 140

A 35 year old woman present s with progressive upper and lower extremity myelopathy. MR imaging reveals a well defined, contrast enhancing lesion 2 cm in diameter in her cervical spinal cord. What is the most appropriate treatmen for this patient?
A. Open biopsy of the lesion followed by appropriate chemotherapy and
radiotherapy.
B. CT guided biopsy followed by appropriate chemotherapy and radiotherapy.
C. Serial MR imaging every three months.
D. Complete surgical excision of the lesion. if possible.

Answer 140

D. Complete surgical excision of the lesion. if possible.

Question 141

A 35-year-old man presents with a several week history of left calf weakness and urinary retention. The MRI scan of the lumbar spine is most consistent with a myxopapillary ependymoma of the conus medullaris. What is the most appropriate initial management of this patient?
A. Laminectomy and tumor resection.
B. Laminectomy and biopsy.
C. CT-guided biopsy.
D. Spinal radiosurgery.
E. Clinical observation with early repeat imaging.

Answer 141

A. Laminectomy and tumor resection.

Question 142

A 45 year old man presents with a history of severe right upper extremity pain for 2
weeks. The pain faded but his arm became extremely weak and has remained so for
the past month. Weakness is more proximal than distal. The left arm is unaffected. MRI
of the cervical spine is unremarkable. An EMG is ordered for both the right and left upper extremity. Why is the left upper extremity being tested with EMG?
A. Bilateral abnormal EMG could suggest compressive myelopathy
B. Findings could support diagnosis of Brachial Plexitis
C. The left arm provides a good control for comparison
D. The patient likely has ALS
E. The patient likely has diabetic polyneuropathy

Answer 142

B. Findings could support diagnosis of Brachial Plexitis

Question 143

A 45-year-old male with renal cell cancer, currently on chemotherapy, presents to your clinic with a C2 body metastasis and intractable neck pain. The patient is neurologically intact, and there is no evidence of cord compression or instability on imaging. What is the most appropriate treatment option for this patient?
A. Conventional radiation therapy
B. Surgical resection
C. No additional therapy
D. Stereotactic radiosurgery

Answer 143

D. Stereotactic radiosurgery

Question 143

A 47-year-old woman presents with bilateral arm paresthesias and neck and shoulder pain since childhood. A cervical spine MRI sequences are shown (T1– left, STI R– right). What is the likely diagnosis?
A. Meningioma
B. Neurofibroma
C. Spinal glioma
D. Chondrosarcoma
E. Lipoma

Answer 143

E. Lipoma

Question 144

A 50-year-old woman presents with a one-year history of progressive low back pain
and constipation. Magnetic resonance imaging demonstrates a large sacral mass (figure). She is neurologically intact. What is the most important next step to determine further management?
A. Formal urodynamics studies
B. MRI with contrast of the pelvis
C. CT-guided biopsy of the mass
D. MRI of the skull-base
E. Proctoscopic examination to assess the integrity

Answer 144

C. CT-guided biopsy of the mass

Question 145

A 54 year old male with non-small cell lung cancer (NSCLC) presents with progressive myelopathy over the past 2 months along with incontinence and an inability to ambulate over the past 48 hours. Imaging is as shown. What is the most accurate statement regarding surgical decision making in this patient?
A. Regardless of surgery, performance status, serum calcium and albumin
levels are the most important prognostic factors.
B. The presence of a spinal metastasis carries an extremely poor prognosis,
therefore no surgery should be pursued.
C. Aggressive surgical decompression and reconstruction should be
performed, as life expectancy in this patient is> 2 years.
D. Surgical decompression should be pursued in the face of neurologic deterioration during radiotherapy given its clear benefit relative to risk.

Answer 145

A. Regardless of surgery, performance status, serum calcium and albumin
levels are the most important prognostic factors.

Question 145

A 60 year old man presents with 3 months of worsening diffuse severe unremitting left
upper extremity pain, parasthesias, and hand weakness. Exam shows 4/5 weakness of hand muscles including abductor pollicus brevis and all intrinsics, scattered sensory loss on the ulnar side of the forearm, normal deep tendon reflexes and no evidence of myelopathy. MRI of the cervical spine shows mild degenerative changes throughout the neck. What imaging study would be very contributory to the diagnosis of this patient disorder?
A. Scoliosis survey
B. Cervical spine flexion-extension x-rays
C. Chest CT
D. Bone scan
E. Thermogram

Answer 145

C. Chest CT

Question 146

A 60 year old man presents with 3 months of worsening diffuse severe unremitting
right upper extremity pain, parasthesias, and hand weakness. Exam shows 4/5
weakness of hand muscles including abductor pollicus brevis and all intrinsics,
scattered sensory loss on the ulnar side of the forearm, normal deep tendon reflexes
and no evidence of myelopathy. MRI of the cervical spine shows mild degenerative
changes throughout the neck. What other neurologic finding might contribute
significantly to diagnosing this patient disorder?
A. Symmetric Hoffman’s sign
B. Homer’s syndrome
C. Palmomental reflex
D. Tinel’s sign over the elbow
E. Diffuse fasciculations

Answer 146

B. Homer’s syndrome

Question 147

A 60 year old man presents with progressive pain at the level of his sacrum over the
course of 6 months. MR imaging reveals an 8 cm lesion within his sacrum most
consistent with a chordoma. What is the most appropriate and best treatment option
for this patient that is associated with the best long-term outcome?
A. lntralesional tumor decompression to alleviate the pain and allow for a
tissue diagnosis followed by referral for proton beam radiotherapy.
B. CT guided biopsy of the lesion to confirm the diagnosis followed by en bloc resection of the lesion including resection of the biopsy tract.
C. CT guided biopsy of the lesion to confirm the diagnosis followed by referral for proton beam radiotherapy.
D. Proton beam radiotherapy alone without biopsy to avoid seeding tumor in the biopsy tract given that the MR appearance of chordomas is highly specific.

Answer 147

B. CT guided biopsy of the lesion to confirm the diagnosis followed by en bloc resection of the lesion including resection of the biopsy tract.

Question 148

A 62 year old with known metastatic renal cell cancer presents with unbearable back pain and lower extremity myelopathy after a fall. Her imaging is displayed in the
accompanying figures. The best management strategy of this lesion would be:
A. Kyphoplasty/Vertebroplasty followed by radiotherapy
B. Stereotactic Radiosurgery
C. Conventional external beam radiotherapy
D. Laminectomy and resection of epidural disease followed by radiotherapy
E. Vertebrectomy with posterior stabilization followed by radiotherapy

Answer 148

E. Vertebrectomy with posterior stabilization followed by radiotherapy

Question 149

A 66-year old male with a history of ACDF performed 3 months ago presented with a 6
week history of fever, dysphagia, and neck pain. The patient was neurologically intact. MR imaging is consistent with cervical vertebral osteomyelitis. What test is most helpful to diagnose the source of the infection?
A. Echocardiogram
B. Bone scan
C. Peripheral blood cultures
D. Tagged white blood-cell scan
E. Esophagoscopy

Answer 149

E. Esophagoscopy.

Question 150

A 70 year old male with a Type 11 dens fracture has non-union of the dens despite 6 months of halo fixation. His new cervical CT scan demonstrates nonunion of the dens with 6 mm of posterior displacement. Cervical x-rays reveal that anatomic reduction of the fracture is not possible. No other associated fractures are identified. He is otherwise neurologically intact and is in good medical condition. What is the most appropriate treatment option at this time?
A. Continued halo management for an additional 3 months.
B. Management in a hard cervical collar for 3 months.
C. Removal of halo fixation and observation.
D. Anterior odontoid screw fixation.
E. Posterior C1-2 instrumented arthrodesis.

Answer 150

E. Posterior C1-2 instrumented arthrodesis

Question 150

A patient awakens from left-sided costotransversectomy at T10 for resection of a ventral metastatic tumor with complete paraplegia and loss of pain and temperature
sensation. His sensation to light touch in the lower extremities is spared. Post operative MRI reveals no evidence of spinal cord compression or hematoma. What is the most
likely diagnosis?
A. Posterior cord syndrome.
B. Anterior cord syndrome.
C. Central cord syndrome.
D. Brown-Sequard syndrome.

Answer 150

B. Anterior cord syndrome

Question 151

After a ground level fall, a 62 year-old man with a history of ankylosing spondylitis reports persistent mid-back pain. CT reveals a fracture through the entire T7 vertebral body and an otherwise densely ankylosed and hyper-kyphotic thoracic spine. STIR signal MRI reveals marrow edema within the T7 vertebral body and the T6-7 disc space and posterior ligamentous injury without evidence of canal compromise. What is the most appropriate management?
A. Transthoracic T6-7 discectomy and anterior instrumentation
B. Cervico-thoracic orthosis
C. Thoraco-lumbo-sacral orthosis
D. Posterior T 4-9 instrumented fusion
E. T7 Vertebroplasty

Answer 151

D. Posterior T 4-9 instrumented fusion

Question 152

During lateral osteophyte removal in an anterior cervical decompressive discectomy,
you encounter brisk bleeding in the region of the nerve root. Your next action should be:
A. Apply gelfoam and pressure
B. Order blood for transfusion
C. Call interventional radiology
D. Abort the procedure
E. Explore the vertebral artery

Answer 152

A. Apply gelfoam and pressure

Question 153

In positioning an interbody spacer via a right TLIF approach at L3-4, what nerve root is immediately superior to your manipulations?
A. Right L3
B. Right L2
C. Right L4
D. Right L5

Answer 153

A. Right L3

Question 154

Posterior cervical foraminotomy and discectomy is an effective treatment for acute nerve root compression due to disc herniation. What would preclude a posterior
approach to a cervical radiculopathy due to disc herniation?
A. Degenerative changes at other levels
B. Lateral disc herniation
C. Paracentral disc herniation
D. Occupation that requires no fusion
E. Adjacent level disease

Answer 154

C. Paracentral disc herniation

Question 155

This lumbosacral spine MRI is from a 23-year-old woman who presented with severe low back pain radiating to her right leg. The left image is a sagittal T2 and the right image is an axial T2. Which nerve roots are most likely compressed by the herniated disc?
A. Traversing L5 nerve roots
B. Exiting L5 nerve roots
C. Traversing L4 nerve roots
D. Exiting 51 nerve roots
E. Traversing 51 nerve roots

Answer 155

E. Traversing 51 nerve roots

Question 156

What is the most likely diagnosis seen on the MRI (figures)?
A. Basilar invagination
B. Chiari 1 malformation
C. Pilocytic astrocytoma
D. Multiple sclerosis
E. Chordoma

Question 157

What is the radiographic tumor control rate for renal cell carcinoma oligometastases to
the spine treated with radiosurgery?
A. 40-60°/o
B. 20-40%
C. Less than 20%
D. 60-80%
E. Greater than 80%

Answer 157

E. Greater than 80%

Question 157

What radiographic finding is a contraindication to cervical laminoplasty?
A. Spinal cord signal change. B. Ossified posterior longitudinal ligament (OPLL).
C. Multilevel cervical spondylosis.
D. Cervical kyphosis.
E. Congenital cervical stenosis.

Answer 157

D. Cervical kyphosis.

Question 158

What type of pain related to spinal metastases is most responsive to radiation?
A. Nocturnal pain
B. Mechanical pain
C. Radicular pain
D. Neuropathic pain

Answer 158

A. Nocturnal pain

Question 159

A 40 year old male develops left facial droop and left hemiparesis 48 hours after a
motor vehicle accident despite initially being neurologically intact after the accident. A
non-contrast head CT at the time of deterioration is negative. The most appropriate
next diagnostic evaluation is:
A. Cerebral perfusion study.
B. CT of the cervical spine.
C. MRI of the cervical spine.
D. CT angiogram of the cervical spine.
E. ICP monitoring.

Answer 159

D. CT angiogram of the cervical spine.

Question 160

Comminution of the occipital condyle is most often associated with which cranial nerve palsy?
A. X.
B. IX.
C. VII.
D. XI.
E. XII.

Answer 160

E. XII.

Question 161

Loss of consciousness occurs in what percentage of sports-related concussions?
A. 20-30%
B. 10-20%
C. Less than 10%
D. 30-40%
E.40-50%

Answer 161

C. Less than 10%

Question 162

The particular type of acceleration that results in a diffuse axonal injury is:
A. Rotational
B. Impact
C. Linear
D. Translational

Answer 162

A. Rotational

Question 163

What is a typical clinical feature of second impact syndrome?
A. It is more common in children than adults
B. Reversible, transient altered mental status following repetitive head injuries
C. Transient neurological injury following a head injury in the recovery period of a prior concussion
D. Is only associated with severe concussions
E. Has a high incidence amongst athletes

Answer 163

A. It is more common in children than adults

Question 163

What is the best method to screen for cervical spine injury in the unconscious,
intubated multitrauma patient?
A. Dynamic traction fluoroscopy
B. Fluoroscopic Flexion/Extension Imaging
C. A/P, Lateral, Oblique, and Open Mouth Odontoid radiographs
D. C-spine CT
E. C-Spine MRI

Answer 163

D. C-spine CT

Question 164

What is the definition of a concussion?
A. A loss of consciousness resulting from head trauma with significant
parenchymal disruption or abnormalities.
B. A loss of consciousness resulting from head trauma without significant
parenchymal disruption or abnormalities.
C. A transient alteration of consciousness resulting from head trauma without
significant parenchymal disruption or abnormalities.
D. A transient alteration of consciousness resulting from head trauma with
significant parenchymal disruption or abnormalities.

Answer 164

C. A transient alteration of consciousness resulting from head trauma without
significant parenchymal

Question 164

Which of the following is a major defining feature of the diagnosis of concussion?
A. lntracranial hemorrhage
B. Rapid, short-lived alteration of mental status
C. Seizures
D. Severe cerebral edema
E. Delayed onset of neurological deficit

Answer 164

B. Rapid, short-lived alteration of mental status

Question 165

Which of the following is characteristic of second impact syndrome?
A. Diffuse axonal injury
B. Petechial hemorrhage on imaging
C. Malignant cerebral edema
D. lschemic Stroke
E. Seizures

Answer 165

C. Malignant cerebral edema

Question 166

Which of the following statements concerning glucose metabolism after severe
traumatic brain injury is true?
A. Tight glucose control {80-110 mg/dL) may precipitate metabolic crisis
B. Cellular distress results in a decreased lactate/pyruvate ratio
C. Increases in metabolic demand are coupled to increased glucose supply
D. Subclinical seizures do not alter glucose concentration

Answer 166

A. Tight glucose control {80-110 mg/dL) may precipitate metabolic crisis

Question 167

A 65 year old patient with a KPS of 70 undergoes subtotal resection of a 7 cm left frontal low grade glioma with intraoperative functional mapping. According to the
EORTC trials, what is the most appropriate management following surgical resection?
A. Radiation therapy at 59 Gy
B. Radiation therapy at 45 Gy
C. Chemotherapy alone
D. Serial post-operative imaging

Answer 167

B. Radiation therapy at 45 Gy

Question 168

What characteristic histological feature of a meningioma is depicted in the encircled
areas of the slide?
A. Mitotic figures
B. Verocay bodies
C. Endothelial proliferation
D. Vacuolation
E. S-100 reactivity

Answer 168

D. Vacuolation

Question 169

A 34 year old female presents with a prolactin level of 48 ng/ml (normal, less than 25
ng/ml). She has amenorrhea but not galactorrhea. The MOST likely explanation for
this combination of findings is:
A. False-negative (hook effect) lab value.
B. False-positive lab value.
C. Macroadenoma with stalk effect.
D. Empty sella.
E. Prolactinoma.

Answer 169

C. Macroadenoma with stalk effect.

Question 170

A 50-year old patient presents with a single enhancing mass in the right frontal
periventricular region. Biopsy demonstrates primary CNS lymphoma. What is the most
appropriate management?
A. Stereotactic radiosurgery.
B. Surgical resection and chemotherapy.
C. Surgical resection alone.
D. Chemotherapy alone.
E. Radiotherapy alone.

Answer 170

D. Chemotherapy alone.

Question 170

A 58 year-old right handed male presents with bifrontal headaches and diplopia. On
exam he has partial left opthalmoplegia. MRI results are shown in the Figure. Biopsy
revealed this tumor to be a chordoma. An extensive subtotal skull-based resection
was performed. In this case which is the BEST subsequent treatment option:
A. Conventional fractionated radiotherapy
B. Procarbazine, CCNU and vincristine (PCV) chemotherapy
C. Proton beam radiotherapy
D. Gamma Knife or LINAC-based radiosurgery

Answer 170

C. Proton beam radiotherapy

Question 170

A 59-year-old female with a remote history of non-small cell lung cancer presents with
a solitary brain metastasis and no evidence of active extracranial disease. She has
headaches but is otherwise functionally independent. What is her recursive partitioning
analysis (RPA) class?
A. 3
B. 2
C. 1
D. 4
E. 5

Answer 170

C. 1

Question 170

A 62 year-old male presents with a 12 month history of headache, ataxia and
nystagmus. MR imaging is obtained. Which of the following diagnoses is MOST
likely:
A. Subependymoma.
B. Diffuse intrinsic pontine glioma.
C. Chordoid glioma.
D. Central neurocytoma.
E. Choroid plexus papilloma.

Answer 170

A. Subependymoma.

Question 171

A 62-year-old male was admitted with subacute onset double vision, imbalance and
headaches. His neurologic exam was significant for cerebellar dysfunction and
diplopia on horizontal gaze to the right. On MRI imaging, he had a 4.3-cm diameter
mass noted in the right cerebellum with minimal enhancement or edema (shown below). What is the MOST likely diagnosis:
A. Hemangioblastoma.
B. Metastatic carcinoma.
C. Lhermitte-Duclos.
D. Medulloblastoma.
E. Pilocytic astrocytoma.

Answer 171

C. Lhermitte-Duclos.

Question 172

A suprasellar neoplasm displaying squamous epithelial characteristics and solid
growth in an older adult is most likely:
A. Metastatic adenocarcinoma.
B. Germinoma.
C. Pituitary adenoma.
D. Papillary craniopharyngioma.

Answer 172

D. Papillary craniopharyngioma.

Question 172

According to the American Academy of Neurology guidelines, how should patients with brain metastases without a history of seizure be treated with regard to seizure
prophylaxis?
A. No indication for seizure prophylaxis.
B. Treat with levetiracetam (Keppra).
C. Treat with phenytoin (Dilantin).
D. Treat with gabapentin (Neurontin}.

Answer 172

A. No indication for seizure prophylaxis.

Question 173

An astrocytoma with cytological atypia lacking mitosis, necrosis or vascular
proliferative changes would be classified as World Health Organization grade:
A. IV.
B. II.
C. Ill.
D. I.

Answer 173

B. II.

Question 174

During the resection of a large vestibular schwannoma via a sub-occipital, retrosigmoid approach, you suddenly encounter severe cerebellar swelling and herniation, the next best step would be:
A. As the anesthesiologist to give mannitol and begin hyperventilation
B. Resect accessible areas of the lateral cerebellum
C. Remove the retractor and wait to see if the swelling subsides.
D. Create a parietoccipital burr hole and place a posterior ventriculostomy catheter for CSF drainage

Answer 174

D. Create a parietoccipital burr hole and place a posterior ventriculostomy catheter for CSF drainage

Question 175

During tumor dissection and debulking at the medial aspect in the ponto-medullary region. the facial nerve is most commonly encountered near the:
A. Ventral-Central aspect of the tumor
B. Ventral-Inferior aspect of the tumor
C. Ventral-Superior aspect
D. Superficial (dorsal) aspect of the tumor

Answer 175

C. Ventral-Superior aspect

Question 176

For low grade gliomas, what is the range of maximal diameters (in cm) that have been identified as a threshold for negative prognosis?
A. 6-8
B. 4-6
C. 2-4
D. 8-10
E. Size is not prognostic

Answer 176

B. 4-6

Question 177

Germinoma ought to be suspected when a pineal region tumor presents with a tumor in what other location?
A. Frontal lobe.
B. Suprasellar region.
C. Fourth ventricle.
D. The orbit.

Answer 177

B. Suprasellar region.

Question 178

In a 50 year old female presenting with a one cm pineal region mass, the most likely diagnosis (based upon incidences cited in the literature) would be:
A. Pineoblastoma.
B. Pineocytoma.
C. Germ cell tumor.
D. Meningioma.

Answer 178

B. Pineocytoma.

Question 178

In addition to hearing loss, vestibular schwannomas with minimal extension into the
cerebellopontine angle most commonly present with which of the following symptoms?
A. facial numbness
B. tinnitus
C. facial weakness
D. gait ataxia
E. nystagmus

Answer 178

B. tinnitus

Question 179

Neurophysiological monitoring during translabrynthine resection of a vestibular
schwannoma with minimal extension into the cerebellopontine angle includes which of
the following?
A. BAER and IX, X, XI nerve
B. SSEP and VI I nerve
C. BAER and VII nerve
D. BAER and SSEP

Answer 179

B. SSEP and VI I nerve

Question 180

Primary intracranial squamous cell carcinomas may arise from which of the following
leions?
A. Meningiomas
B. Ependymomas
C. Epidermoid tumors
D. Chordomas
E. Arachnoid cysts

Answer 180

C. Epidermoid tumors

Question 181

There is class 1 evidence to suggest that single dose stereotactic radiosurgery (SRS)
when used along with whole brain radiation (WBXRT) improves survival relative to
WBXRT alone in which patient population?
A. Patients with a single brain metastasis and a KPS < 70.
B. Patients with a single brain metastasis and a KPS > 70.
C. All patients with greater than 4 brain metastases and a KPS > 70.
D. Patients with 2-3 brain metastases and a KPS < 70.

Answer 181

B. Patients with a single brain metastasis and a KPS > 70.

Question 182

What is the median survival for patients with hemispheric low grade gliomas?
A. 5-10 Years.
B. 3-5 Years.
C. 1-3 Years.
D. 10-15 Years.
E. 15-20 Years.

Answer 182

A. 5-10 Years.

Question 182

Which cranial nerve is the MOST likely to be compressed by a clival tumor:
A. Trochlear nerve.
B. Facial nerve.
C. Oculomotor nerve.
D. Trigeminal nerve.
E. Abducens nerve.

Answer 182

E. Abducens nerve.

Question 183

Which of the following genetic abnormalities is MOST commonly associated with the
tumor identified in this photomicrograph:
A. Loss of heterozygosity (LOH) 1 p and 19q.
B. NF1 gene mutation.
C. Loss of heterozygosity (LOH) of chromosome 17.
D. TP53 gene mutation.
E. EGFR amplification.

Answer 183

A. Loss of heterozygosity (LOH) 1 p and 19q.

Question 184

Which of the following genetic profiles of a glioma carries a favorable prognosis?
A. IDH1 Mutation
B. Loss of 1 Oq
C. Loss of 9q
D. PTEN Mutation
E. RB1 Mutation

Answer 184

A. IDH1 Mutation

Question 185

Which of the following is the most important parameter indicating compromise of the
auditory pathway in brainstem auditory evoked response (BAER) monitoring?
A. Wave Ill amplitude
B. Wave 1-11 latency
C. Wave I amplitude
D. Wave 1-V latency
E. Wave VI amplitude

Answer 185

D. Wave 1-V latency

Question 185

Which of the following statements regarding intramedullary spinal cord ependymoma is TRUE:
A. These tumors are almost uniformly malignant.
B. Radiotherapy following gross total resection has no proven long term benefit.
C. These tumors can only rarely be removed in a gross total manner due to infiltrating margins.
D. Spinal cord ependymomas typically display faint, heterogeneous contrast
uptake on MRI.
E. Males are affected twice as commonly as females.

Answer 185

B. Radiotherapy following gross total resection has no proven long term benefit.

Question 186

A 22 year old female presents with headache and a non-focal neurological examination
during the final trimester of her first pregnancy. A non-contrast head CT scan is shown. The MOST appropriate immediate intervention is:
A. Mannitol bolus
B. Corticosteroids
C. ICP monitor placement
D. Hematoma evacuation
E. Intravenous heparinization

Answer 186

E. Intravenous heparinization

Question 187

A 36-year-old man presents with a 4-month history of slowly progressive gait difficulty and headaches. MRI and MRA of the brain show a partially thrombosed giant
intracranial aneurysm of the left vertebral artery causing brainstem compression and
mild hydrocephalus. Cerebral angiography shows bilateral patent vertebral arteries
and a giant fusiform left V4 aneurysm. Which of the following is the most appropriate next step in management?
A. Craniotomy, bypass and trapping of aneurysm.
B. Balloon test occlusion.
C. Ventriculoperitoneal shunt.
D. Stenting with upfront coiling of aneurysm.
E. Stenting with staged coiling of aneurysm.

Answer 187

B. Balloon test occlusion.

Question 188

A 44 year old male presents with acute onset of headache and left visual field cut. A CT
scan demonstrates acute hemorrahge in the right occipital lobe. MR imaging and
angiography are provided. What is the most likely benefit of embolization for this
lesion?
A. Decreased risk of rupture before further therapy
B. Reducing AVM volume for subsequent treatment
C. Complete obliteration of the AVM
D. Decreased risk of seizures
E. Improvement of vision

Answer 188

B. Reducing AVM volume for subsequent treatment

Question 188

A 45-year-old woman underwent right-sided craniotomy for clipping of a ruptured right posterior communicating artery aneurysm. Post-operatively she developed left hemiplegia, left hemianesthesia, and a left homonymous visual field deficit. A non-contrast head CT revealed a new focal area of hypodensity indicated by the arrow. Occlusion of which artery produced this infarct and clinical syndrome?
A. Recurrent artery of Heubner
B. Posterior cerebral artery
C. Middle cerebral artery
D. Anterior choroidal artery
E. Posterior choroidal artery

Answer 188

D. Anterior choroidal artery

Question 189

A 54 year old man presents with several years of progressive pulsatile tinnitus in the right ear and new headaches. He undergoes cerebral angiography which
demonstrates the presence of venous shunting through the posterior fossa during
selective injection of the right ascending pharyngeal artery (figure: AP angiogram,
Townes projection). Based on the angiographic findings, if left untreated, a rupture of this malformation will most likely present with what?
A. Subdural hemorrhage
B. Intraparenchymal hemorrhage
C. No symptoms
D. Subarachnoid hemorrhage
E. Dural sinus thrombosis

Answer 189

D. Subarachnoid hemorrhage

Question 190

A 56 year-old male with a history of diabetes mellitus and hypertension presents with
several episodes of headache, light-headedness, and dysarthria within the past year.
Head CT is normal. An anteroposterior view of his left internal carotid artery
angiogram is shown. What is the most likely diagnosis?
A. Carotid dissection
B. Dural arteriovenous fistula
C. Ruptured cerebral aneurysm
D. lntracranial atherosclerosis
E. Carotid-cavernous fistula

Answer 190

D. lntracranial atherosclerosis

Question 190

Which cranial nerve is most often first affected by a cavernous sinus region arteriovenous fistula?
A. CN IV.
B. CN Ill.
C. CN VI.
D. CN V.
E. CN II.

Answer 190

C. CN VI.

Question 191

A 58 year old woman presents with headaches and an angiographic evidence of a
2.5mm infundibulum of the posterior communicating artery. Which of the following
regarding an infundibulum is true?
A. They have a higher risk of rupture than saccular aneurysms of the same
size.
B. The most common site for an infundibulum is at the ophthalmic artery
C. An infundibulum commonly progress to an aneurysm
D. They are found in up to 25% of otherwise normal angiograms
E. They are most commonly saccular in shape.

Answer 191

D. They are found in up to 25% of otherwise normal angiograms

Question 191

A 67 year old man presents to the emergency room with worsening parasthesias of
the ipsilateral face and contralateral extremity. The symptoms are provoked with head turning. Where is the most likely site of vascular compression in this patient?
A. Dominant vertebral artery
B. Posterior inferior cerebellar artery
C. Carotid Bifurcation
D. Basilar artery
E. Subclavian artery

Answer 191

A. Dominant vertebral artery

Question 192

A 75 year old male presents to you in consultation with an MRA of the neck (see
Figure 1). Based on this MRA, the degree of carotid stenosis is best estimated as:
A. >70%
B.>90%
C.>80%
D.>95%

Answer 192

A. >70%

Question 193

A 75 year old male presents with acute right sided weakness and mild expressive dysphasia. A representative MR image and ipsilateral carotid angiogram are provided. According to the CREST study, compared to carotid endarterectomy, angioplasty and stenting has a significantly higher incidence of which peri-procedural complication?
A. Dysphagia
B. lschemic Stroke
C. Mortality
D. Hypoglossal nerve injury
E. Myocardial infarction

Answer 193

B. lschemic Stroke

Question 194

A 75 year old male presents with progressive difficulty ambulating, let weakness/numbness and bladder incontinence over the past 12 months. A representative MRI and spinal angiogram (left TB intercostal injection) is shown.
What is the most likely diagnosis?
A. Spinal cord glioma
B. Hemangioblastoma
C. Ruptured intramedullary spinal cord AVM
D. Thoracic disc herniation
E. Dural arteriovenous fistula

Answer 194

E. Dural arteriovenous fistula

Question 195

A patient presents with a 2 hour history of left hemiparesis but is otherwise awake and
alert. Her exam is also notable for a blood pressure of 195/120 despite aggressive
medical treatment. Her head CT demonstrates a ribbon sign with loss of cortical gray-white differentiation but no mass effect or hemorrhage, and a proximal MCA cutoff. Along with aggressive anti-hypertensive treatment, what is the most appropriate next
step in treatment?
A. Administration of intravenous recombinant tPA at a dose of 0.6 mg/kg
B. Administration of intravenous recombinant tPA at a dose of 0.9 mg/kg
C. Brain magnetic resonance imaging (MRI)
D. Decompressive craniectomy
E. Endovascular mechanical thombectomy

Answer 195

E. Endovascular mechanical thombectomy

Question 196

A young patient is identified to have a posterior fossa dural arteriovenous fistula that is
fed solely by distal branches of the right ascending pharyngeal artery (see Figure 1: AP view, Townes projection) and drains exclusively via subarachnoid veins to the dural sinuses. Which of the following treatment options poses the greatest risk of permanent neurologic deficit to the patient?
A. Trans-venous coil embolization of draining vein just distal to point of
fistulization
B. Trans-arterial embolization via ascending pharyngeal artery with Onyx
C. Far lateral skull base craniotomy and clip ligation of draining vein
D. Stereotactic radiosurgery to the point of fistulization

Answer 196

B. Trans-arterial embolization via ascending pharyngeal artery with Onyx

Question 197

According to the North American Symptomatic Carotid Endarterectomy Trial (NASCET), in patients with symptomatic carotid stenosis of >70%, by how much does carotid endarterectomy (CEA) reduces the rate of cerebrovascular accident (CVA) and death from any cause at 2 years compared to best medical therapy?
A. 16.5%
B. 12.5%
C. 5.8%
D. 20.5%
E. 24.5%

Answer 197

A. 16.5%

Question 198

According to the meta-analysis of three randomized studies (HAMLET, DESTINY, and
DECIMAL), compared to best medical management, what effect does decompressive
hemicraniectomy within 48 hours of stroke onset in patients <60 years old with space occupying cerebral infarctions have on mortality and poor outcome (modified Rankin Score [mRS] >3) at 1 year?
A. Decrease both in mortality and poor outcome rates
B. No change in mortality but decreased rate of poor outcomes
C. Decrease in mortality with no change in poor outcome rates
D. Decrease in mortality with an increased rate of poor outcomes
E. No change in either mortality or rate of poor outcomes

Answer 198

A. Decrease both in mortality and poor outcome rates

Question 198

An 80 year-old man with a history of dementia and prior intracerebral hemorrhage is
found unresponsive with the head CT shown in the figure. What is the histopathological
hallmark of the most likely condition?
A. Areas of abnormally phosphorylated tau protein
B. Beta amyloid deposition within the tunica media of vessels
C. Thickened walls with subintimal lipid-rich hyaline deposits
D. Deposition of antigen-antibody complexes and inflammatory cell
infiltration
E. Cholesterol deposits and fibrous plaques

Answer 198

B. Beta amyloid deposition within the tunica media of vessels

Question 199

Based on the ISUIA study, surgical outcomes of this unruptured AComm aneurysm
depends on:
A. Age of patient
B. Daughter sacs
C. Aneurysm configuration
D. History of prior SAH
E. History of tobacco use

Answer 199

A. Age of patient

Question 200

The Carotid Revascularization Endarderectomy vs. Stenting Trial (CREST) recently
concluded that the risk of stroke within 4 years after undergoing carotid
endarderectomy is no different than the risk of undergoing carotid artery stenting.
What did the CREST study find with respect to heart attacks and stroke within 2 months of treatment and the impact of these events on quality of life?
A. Patients undergoing carotid artery stenting suffered less strokes within 2 months of the procedure compared to patients undergoing carotid
0 endarderectomy and the study showed that stroke impacts quality of life
less so than heart attack.
B. Patients undergoing carotid endarderectomy suffered more heart attacks within 2 months of the procedure compared to patients undergoing carotid artery stenting and the study showed that heart attack
impacts quality of life less so than stroke.
C. Patients undergoing carotid artery stenting suffered more heart attacks 0 within 2 months of the procedure compared to patients undergoing carotid endarderectomy and the study showed that heart attack impacts quality of life more so than stroke.
D. Patients undergoing carotid artery stenting suffered more strokes within 2 months of the procedure compared to patients undergoing Q carotid endarderectomy and the study showed that stroke impacts quality of more so than heart attack.
E. Patients undergoing carotid endarderectomy suffered more heart attacks and within 2 months of the procedure compared to patients
0 undergoing carotid artery stenting and the study showed that heart attack impacts quality of life more so than stroke.

Answer 200

B. Patients undergoing carotid endarderectomy suffered more heart attacks within 2 months of the procedure compared to patients undergoing carotid artery stenting and the study showed that heart attack
impacts quality of life less so than stroke.

Question 201

The surgical approach to the lesion shown (Figure 1) that carries the LOWEST risk of
neurological injury is:
A. Pterional
B. Far lateral suboccipital
C. Orbitozygomatic
D. Midline suboccipital
E. Presigmoid

Answer 201

B. Far lateral suboccipital

Question 202

There is typically a close association of an ophthalmic aneurysm with the optic nerve
(see Figure}. Visual deficit is a risk with surgery on these lesions. Surgical strategies to
prevent visual deficit include:
A. Sectioning of small blood vessels to the nerve to allow access to the aneurysm neck.
B. Early opening of the optic canal and falciform ligament to free the optic nerve.
C. Retraction of the optic nerve to optimize visualization of the aneurysm dome.
D. Early opening of the cavernous sinus to allow access to the most 0 common site of origin of the ophthalmic artery from the internal carotid
artery.
E. Resection of part of the gyrus rectus to allow better visualization.

Answer 202

B. Early opening of the optic canal and falciform ligament to free the optic nerve.