Section 2 Flashcards
Hydrocephalus (HCP) is abnormal accumulation of CSF within ventricles of brain. What is the most common cause of communicating hydrocephalus in pediatric population?
● A. Chiari type 2 malformation with MMC
● B. Chiari type 1 malformation without MMC
● C. Periaqueductal stenosis
● D. Infection
● E. Post hemorrhagic
D. Infection
A 2-month-old child presents with irritability, N/V, and poor head control. On examination, he/she has bulging fontanelle, engorged scalp veins, setting sun sign, and positive Macewan’s sign. MRI of brain showed periaqueductal gliosis in this patient. Following are the causes of congenital hydrocephalus in pediatric population except?
● A. Chiari type 2 with MMC
● B. Chiari type 1 without MMC
● C. Secondary aqueductal gliosis
● D. Dandy Walker malformation
● E. Colloid cyst blocking CSF flow at aqueduct
E. Colloid cyst blocking CSF flow at aqueduct
Occipital frontal circumference is used to monitor head growth and to assess possible pathological process causing change in head measurement from normal. Active hydrocephalus, subdural hematoma, or subdural effusion is signified by which of the following?
● A. Progressive upward deviation from the normal curve
● B. Continued head growth of more than 1.25 cm/wk
● C. OFC measuring 2 standard deviations above normal
● D. Head circumference out of proportion to body length or weight
● E. All of the above
E. All of the above
Pregeniculate blindness is because of lesion anterior to the lateral geniculate body while postgeniculate blindness is because of lesion posterior to the lateral geniculate body. Following are the causes of blindness from hydrocephalus except?
● A. Occlusion of posterior cerebral arteries (caused by downward transtentorial herniation)
● B. Diffuse hypoxic injury to occipital lobes caused by hypotension
● C. Chronic papilledema causing injury to optic nerve at optic disk
● D. Dilatation of third ventricle with compression of optic chiasma
● E. Compression of PCA caused by upward herniation of cerebellum
B. Diffuse hypoxic injury to occipital lobes caused by hypotension
Following are the specific radiologic criteria for the diagnosis of hydrocephalus except?
● A. Evans ratio (FH/BPD) more than 0.3 shows hydrocephalus
● B. Size of both temporal horns > 2 mm shows HCP
● C. Slit third ventricle
● D. Periventricular low density on plain CT of brain and hyperintensity on MRI of brain
● E. Ballooning of lateral and frontal ventricles
C. Slit third ventricle
Following are features indicative of chronic hydrocephalus except?
● A. Beaten copper cranium
● B. Third ventricle herniating into sella
● C. Erosion of sella turcica
● D. The temporal horns are markedly prominent
● E. Atrophy and upward bowing of corpus callosum
D. The temporal horns are markedly prominent
Pseudohydrocephalus refers to conditions that may mimic hydrocephalus but are not due to inadequate CSF absorption. Which of the following can be called as pseudohydrocephalus?
● A. Hydrocephalus ex vacuo due to cerebral atrophy
● B. Developmental anomalies like agenesis of corpus callosum, septo-optic dysplasia, or hydranencephaly
● C. Otic hydrocephalus
● D. External hydrocephalus
● E. All of the above
E. All of the above
A 4-month-old child presents with macrocrania and frontal bossing. Plain CT of brain showed enlarged subarachnoid spaces over the cortical sulci of frontal poles. Basal cisterns and anterior hemispheric fissure are also seen to be enlarged. A diagnosis of external hydrocephalus or benign external hydrocephalus is made. What is the most appropriate treatment for this condition?
● A. Usually resolves spontaneously before 2 years of age
● B. Parents may need to periodically reposition the head while the child is sleeping
● C. Shunt may be needed for cosmetic reasons in severe macrocrania
● D. Parents are reinsured that this is not cortical atrophy
● E. All of the above are correct
E. All of the above are correct
A disconnected ventriculoperitoneal shunt may continue to function through an endothelialized subcutaneous tract. Which of the following statements is true regarding repair or removing of a VP shunt?
● A. Indications for shunt repair are marginally functioning shunt with signs and symptoms of increased ICP
● B. Most of the patients with spina bifida or aqueductal stenosis are not shunt dependent
● C. If a shunt is nonfunctioning and the patient is not shunt dependent then the shunt should be removed regardless of shunt infection or not
● D. A patient with nonfunctioning shunt with no symptoms does not need to be followed up
● E. All of the above are correct
A. Indications for shunt repair are marginally functioning shunt with signs and symptoms of increased ICP
A patient above 60 years of age presents with gait disturbance (wide based, short shuffling steps like glued to the ground), dementia with slowing of thoughts (bradyphrenia), and urinary incontinence with urgency. On examination, there is no papilledema, hyperreflexia, or lateralizing signs. LP was done which showed normal pressure. MRI showed ventricular enlargement without any blockage. Following are features that correlate with favorable response to shunt in this condition except?
● A. Periventricular low density on plain CT of brain and high intensity on T2WI MRI
● B. Compression of convexity sulci
● C. Rounding of the frontal horns
● D. Dilated subarachnoid spaces in high convexity
● E. Upward bowing and thinning of corpus collosum
D. Dilated subarachnoid spaces in high convexity
Which of the following is a component of iNPH Radscale?
● A. Evans ratio increased
● B. Tight high convexity
● C. Sylvian fissure enlargement
● D. Decrease of callosal angle
● E. All of the above are true
E. All of the above are true
Which of the following is true regarding treatment of normal pressure hydrocephalus?
● A. Positive response on tap test increase the likelihood of responding to shunting
● B. VP shunt is the procedure of choice with use of medium pressure valve
● C. ETV has been advocated by some authors
● D. Most likely symptom to improve with shunting is incontinence then gait disturbance and then dementia
● E. All of the above
E. All of the above
Diuretic therapy may be tried in premature infants with bloody CSF as long as there is no evidence of active hydrocephalus, and satisfactory control is reported in about half of the infants. What is the initial dose of acetazolamide in mg/kg/d in divided doses?
● A. 1
● B. 5
● C. 10
● D. 25
● E. 50
D. 25
A 4-year-old child was admitted with hydrocephalus and tectal glioma. He had no previous surgery. What is the ETV success score?
● A. 10
● B. 20
● C. 30
● D. 60
● E. 80
E. 80
What is the most common cause of shunt malfunction?
● A. Proximal end blockade
● B. Distal end blockade
● C. Shunt fracture
● D. Silicone allergy
● E. Streptococcus viridians infection
A. Proximal end blockade
Upward gaze palsy or setting sun sign is associated with which of the following?
● A. Parinaud’s syndrome
● B. Pulfrich syndrome
● C. Anton’s syndrome
● D. Ridoch’s phenomenon
● E. Weber syndrome
A. Parinaud’s syndrome
Contrast medium commonly used for X-ray shuntogram is what?
● A. Gadolinium
● B. Iohexol
● C. 99m-technetium pertechnetate
● D. Gadopentate dimeglumine
● E. Ferric ammonium citrate
B. Iohexol
What is the shunt malfunction rate in percentage during the first year of placement in the pediatric population?
● A. 1
● B. 3
● C. 7
● D. 17
● E. 49
D. 17
What is the treatment of choice for short-term symptoms of intracranial hypotension due to over-shunting of a VP shunt?
● A. Antibiotics
● B. Steroids
● C. Antisiphon device
● D. Shunt removal
● E. Y connector shunt
C. Antisiphon device
What do the three dots visible on the shunt valve on X-ray represent?
● A. Very low pressure
● B. Low pressure
● C. Medium pressure
● D. High pressure
● E. Very high pressure
D. High pressure
Diuretic therapy is used in premature infants for bloody CSF with no evidence of active hydrocephalus as an adjunct to definitive treatment or as a temporizing measure. Satisfactory control of hydrocephalus can also be achieved in children less than 1 year of age with stable vital signs, normal renal function, and no symptoms of elevated ICP (apnea, lethargy, vomiting) using diuretic therapy. Following are true regarding diuretic therapy except?
● A. Acetazolamide is started at 25 mg/kg/d with simultaneous start of furosemide at 1 mg/kg/d
● B. To counteract acidosis, tricitrate is used at a dose of 4 mL/kg/d
● C. There is no need to measure electrolytes along with diuretic therapy
● D. Weekly ultrasound or CT of brain is performed and ventricular shunt is inserted if ventriculomegaly occurs
● E. This therapy is used for 6 months and then dosage is tapered over 2 to 4 weeks
C. There is no need to measure electrolytes along with diuretic therapy
Surgical methods to control hydrocephalus include third ventriculostomy, various shunting methods, eliminating the obstruction like tumor, and choroid plexectomy. What is the goal of surgery in such patients?
● A. Normal sized ventricles
● B. Opened basal cisterns
● C. Optimum neurologic function and good cosmetic result
● D. Opened subarachnoid spaces
● E. Both A and B
C. Optimum neurologic function and good cosmetic result
Endoscopic third ventriculostomy is an endoscopic method of dealing with hydrocephalus. Which of the following is an indication of endoscopic third ventriculostomy?
● A. It is used in patients with obstructive hydrocephalus
● B. In managing shunt infection as a means to remove all hardware without subjecting the patient to increased ICP
● C. It is also proposed as an option for patients who developed subdural hematomas after shunting in which the shunt is removed before ETV is performed
● D. It is also indicated for slit ventricle syndrome
● E. All of the above are indications of ETV
E. All of the above are indications of ETV
During ETV complications can occur such as injury to basilar artery, PCom, or PCA, injury to pituitary stalk and hypothalamus, or transient 3rd and 6th nerve palsies. ETV has low success rate in infants because of which of the following?
● A. There are higher chances of complications to occur
● B. It is difficult to do ventriculostomy in infants
● C. Mortality in infants in high after ETV
● D. They may not have a normally developed subarachnoid space
● E. All of the above
D. They may not have a normally developed subarachnoid space
ETV success score is used to predict the likelihood of success of ETV. Scores less than 40% correlate with very low chance of success while scores more than 80% show better chance of success compared to shunting. A child 3 years of age with tectal tumor and no history of previous shunt has ETV success score of what?
● A. 60%
● B. 70%
● C. 80%
● D. 90%
● E. 50%
C. 80%
There are various types of shunts including ventriculoperitoneal shunt (VP), ventriculoatrial shunt (VA), Torkildsen shunt (shunts ventricles to CSF space), ventriculopleural shunt, and
lumboperitoneal shunt. VP shunt is the most commonly used shunt in modern era. What are indications of VA shunt instead
of VP shunt in a patient?
● A. Extensive abdominal surgery
● B. Peritonitis
● C. Morbid obesity
● D. In patients who have had NEC
● E. All of the above
E. All of the above
What is the most common complication of a shunt?
● A. Obstruction
● B. Disconnection at a junction or breakage at any point
● C. Infection
● D. Seizures
● E. Extraneural metastasis of certain tumors
A. Obstruction
A child underwent VP shunting with reprogrammable shunt, the pressure setting on which can be seen using an X-ray perpendicular to the shunt valve. This boy after some time presents with N/V, headache, lethargy, and ataxia. On physical examination, this child has bulging fontanelles and upward gaze palsy. What is the appropriate method for evaluation of shunt malfunction?
● A. Shunt series (plain X-rays to visualize the entire shunt)
● B. Using ultrasound in patient with open fontanelles
● C. Plain CT of brain
● D. MRI of brain
● E. All of the above
A. Shunt series (plain X-rays to visualize the entire shunt)
What are possible complications of over-shunting of VP shunt?
● A. Dilated ventricles
● B. Intracranial hypertension
● C. Subdural hematomas
● D. Wide opened sylvian aqueduct
● E. All of the above
C. Subdural hematomas
A patient after VP shunting presents after 1 year with intermittent headaches, nausea, vomiting, irritability, and impaired mentation. Plain CT of brain showed totally collapsed ventricles. What is the procedure of choice in this patient?
● A. Expectant management
● B. Upgradation to a higher-pressure valve
● C. Upgradation to low-pressure valve
● D. Removal of shunt and reinserting again
● E. Antisiphon devices have no role in these patients
B. Upgradation to a higher-pressure valve
A patient was brought to the OPD with history of seizures. His mother showed you a video recording of seizure episode where you noticed fairly symmetric, bilateral, synchronous, semirhythmic jerking of the upper and lower extremities, with
elbow flexion and knee extension. What are these?
● A. Partial seizures
● B. Tonic seizures
● C. Clonic seizures
● D. Atonic seizures
● E. Astatic seizures
C. Clonic seizures
A patient presented to you with history of seizures. On further inquiry you find that there is no history of aura, motor involvement, and postictal confusion. His EEG revealed spike and wave at exactly 3/sec. These features are most consistent which of the following?
● A. Uncal seizures
● B. Mesial temporal seizures
● C. Absence seizures
● D. Partial seizures
● E. Grand mal seizures
● C. Absence seizures
What is the most common cause of intractable temporal lobe epilepsy?
● A. Absence seizures
● B. Uncal epilepsy
● C. Mesial temporal sclerosis
● D. Superior temporal gyrus syndrome
● E. Temporal lobe hemorrhagic contusion
C. Mesial temporal sclerosis
A patient with recently diagnosed epilepsy presented to the OPD for follow-up. During the review of the radiology, the clinician notices hippocampal atrophy on MRI. What is the most likely diagnosis?
● A. West syndrome
● B. Lennox Gustate syndrome
● C. Mesial temporal lobe epilepsy
● D. Juvenile myoclonic epilepsy
● E. Uncinate seizures
C. Mesial temporal lobe epilepsy
A patient with known case of temporal lobe epilepsy presents with kakosmia. This subtype of seizures is classified as?
● A. Uncinate seizures
● B. Complex seizures
● C. Focal seizures
● D. Sensory seizures
A. Uncinate seizures
Factors that lower the seizure threshold (make it easier to provoke a seizure) include sleep deprivation, hyperventilation, photic stimulation, infection, metabolic disturbances, and head trauma. Todd’s paralysis is a phenomenon that occurs after seizure activity. Which of the following is true regarding Todd’s paralysis?
● A. Partial or total paralysis usually occurs in areas involved in a partial seizure
● B. It occurs more commonly in nonstructural lesion
● C. The paralysis usually resolves over days to weeks
● D. Postictal aphasia or hemianopia are not included in this
● E. All of the above are true
A. Partial or total paralysis usually occurs in areas involved in a partial seizure
A patient presents in neurosurgical emergency with complaint of first occurrence of focal seizure with retained consciousness (simple partial seizure). As a rule of thumb, what is the cause of such seizure?
● A. Metabolic cause
● B. Insult to brain within previous 2 weeks
● C. Structural lesion within brain
● D. Febrile seizure
● E. None of the above
C. Structural lesion within brain
Tonic–clonic seizure is a type of motor seizure which is a generalized seizure that evolves from tonic to clonic motor activity. A patient presenting with other type of motor seizure in which there is shock-like body jerks (one or more in succession) with generalized EEG discharges is said to have which
type of seizure?
● A. Clonic
● B. Tonic
● C. Myoclonic tonic clonic
● D. Myoclonic
● E. Myoclonic-tonic
D. Myoclonic
A patient with known family history of seizure is presented with complex partial seizure that begins with arrest and stare, and oroalimentary and complex automatism signs with posturing of arm. This seizure activity lasts for 1 to 2 minutes and
there is preictal olfactory aura for few seconds as well. He is suspected to have mesial temporal lobe epilepsy or mesial temporal sclerosis. Which of the following will help in the diagnosis in this case?
● A. MRI of brain showing hippocampal atrophy and signal alteration with ipsilateral dilatation of temporal horn of lateral ventricle
● B. Unilateral or bilateral independent anterior temporal EEG spikes with maximal amplitude in basal electrodes
● C. PET scan showing hypometabolism in temporal lobe
● D. Neuropsychological testing showing memory dysfunction specific to involved temporal lobe
● E. All of the above
E. All of the above
A patient with strong family history of epilepsy presents with history of myoclonic jerks on waking up in morning. EEG shows poly spike discharges and MRI shows no structural lesion. The patient is suspected to have a generalized epilepsy syndrome with generalized tonic clonic and absence types in
addition to the type mentioned above. What is this syndrome called?
● A. West syndrome
● B. Lennox–Gastaut syndrome
● C. Juvenile myoclonic epilepsy
● D. Temporal lobe syndrome
● E. Juvenile tonic clonic epilepsy
C. Juvenile myoclonic epilepsy
Which of the following is true regarding West syndrome?
● A. It is a seizure disorder that typically begins in first year of life
● B. It consists of recurrent gross fixation and occasionally extension of trunks and limbs
● C. It is usually associated with mental retardation with EEG showing interictal hypsarrhythmia or modified hypsarrhythmia
● D. Seizures usually respond dramatically to ACTH or corticosteroids
● E. All of the above
E. All of the above
Hippocampus is composed of Ammon’s horn and dentate gyrus. The dorsal hippocampus subserves aspects of spatial memory, verbal memory, and learning conceptual information. Hippocampal sclerosis can cause which of the following?
● A. Total memory impairment
● B. Loss of all functions of basal ganglia
● C. Olfactory loss
● D. Intractable temporal lobe epilepsy
● E. All of the above
D. Intractable temporal lobe epilepsy
Following are motor seizures except?
● A. Tonic
● B. Gelastic seizures
● C. Clonic
● D. Atonic
● E. Epileptic spasms
B. Gelastic seizures
Symptomatic seizure also known as secondary seizure results from structural abnormality within the brain. Which of the following is included in this type of seizure?
● A. Cavernous malformation
● B. Stroke
● C. Brian tumor
● D. Mesial temporal sclerosis
● E. All of the above
E. All of the above
Mortality in patients with epilepsy is 2 to 4 times that of general population. Which of the following deaths are directly related to seizure?
● A. Status epilepticus
● B. Accidents during seizure activity
● C. Suicides
● D. Sudden unexplained death in epilepsy
● E. All of the above
A. Status epilepticus
A patient is on antiepileptic drugs (AED) for 2 years. On follow-up, his liver function tests were deranged. AED should be discontinued based on derangement of which parameter?
● A. Fatty liver on USG
● B. Acute decrease in ALT
● C. Decrease in ALT/AST ratio
● D. GGT levels twice the normal
● E. Hyperalbuminemia
D. GGT levels twice the normal
What is the dose adjustment of phenytoin in renal failure?
● A. Continue same dosage
● B. Two-thirds of the previous dosage
● C. Half the previous dose
● D. Double the previous dose
● E. Only give on SOS basis
A. Continue same dosage
What is the parenteral loading dose of phenytoin for adults?
● A. 16 mg/kg
● B. 18 mg/kg
● C. 20 mg/kg
● D. 22 mg/kg
● E. 25 mg/kg
B. 18 mg/kg
What is the most common electrolyte imbalance associated with carbamazepine?
● A. Hypernatremia
● B. Hyponatremia
● C. Hypochloremia
● D. Hyperchloremia
● E. Hypermagnesia
B. Hyponatremia
Carbamazepine should be discontinued when CBC shows a WBC count of what?
● A. < 10,000
● B. < 7000
● C. < 6000
● D. < 5000
● E. < 4000
< 4000
Oxcarbazepine was prescribed to a patient for epilepsy. Which blood tests should be employed to monitor the side effects?
● A. CBC
● B. RFTs
● C. Electrolytes
● D. Urinalysis
● E. No blood tests required
E. No blood tests required
What is the maximum recommended adult dose of valproic acid?
● A. 20 mg/kg/d
● B. 30 mg/kg/d
● C. 40 mg/kg/d
● D. 50 mg/kg/d
● E. 60 mg/kg/d
E. 60 mg/kg/d
What is the therapeutic level of valproic acid?
● A. 5 to 10 μg/mL
● B. 10 to 20 μg/mL
● C. 20 to 30 μg/mL
● D. 30 to 40 μg/mL
● E. 50 to 100 μg/mL
E. 50 to 100 μg/mL
What is the loading dose of phenobarbital in adults?
● A. 10 mg/kg
● B. 12 mg/kg
● C. 15 mg/kg
● D. 18 mg/kg
● E. 20 mg/kg
E. 20 mg/kg
What is the recommended daily dose of ethosuximide in adults?
● A. 500 to 1,500 mg/d
● B. 500 to 1,000 mg/d
● C. 250 to 500 mg/d
● C. 100 to 200 mg/d
● D. 100 to 300 mg/d
A. 500 to 1,500 mg/d
What is the initial dose of levetiracetam in adults?
● A. 500 mg oral twice daily
● B. 400 mg oral twice daily
● C. 300 mg oral twice daily
● D. 250 mg oral twice daily
● E. 100 mg thrice daily
A. 500 mg oral twice daily
What is the maximum daily dose of levetiracetam for adults?
● A. 1,000 mg
● B. 1,500 mg
● C. 2,000 mg
● D. 3,000 mg
● E. 1 g
D. 3,000 mg
When given for epilepsy, what is the usual target dosage of gabapentin?
● A.100 mg/d
● B. 1,000 mg/d
● C. 500 to 1,000 mg/d
● D. 800 to 1,800 mg/d
● E. 5 g/d
D. 800 to 1,800 mg/d
The maximum effect of topiramate for seizures control is observed at what dose?
● A. 100 mg/d
● B. 200 mg/d
● C. 400 mg/d
● D. > 600 mg/d
● E. 1 g/d
D. > 600 mg/d
The anticonvulsant effect of lamotrigine is due to presynaptic inhibition of release of what?
● A. Calcium
● B. Potassium
● C. Albumin
● D. Glutamate
● E. Serotonin
D. Glutamate
Fetal hydantoin syndrome is associated with which of the following?
● A. Valproic acid
● B. Levetiracetam
● C. Lamotrigine
● D. Phenytoin
● E. Benzodiazepines
D. Phenytoin
Ethosuximide is drug of choice for what?
● A. Absence seizures
● B. GTC seizures
● C. Myoclonic seizures
● D. Tonic seizures
● E. Atonic seizures
A. Absence seizures
Aside from some specific agents for some particular seizure types, there is generally no significant difference in efficacy of antiseizure medication. Hence, choices are made on the basis of tolerability, adverse effects, effects on comorbidities, drug–drug interactions, or availability of dosing form. What is the goal of antiseizure medication?
● A. Seizure control which is seizure-free time for at least 3 years for an epileptic patient and no or minimum chances of seizure in future
● B. Seizure control which is reduction of seizure frequency and severity to very low
● C. Seizure control which is reduction of seizure frequency and severity so that the patient can live normal life without epilepsy-related limitations
● D. Seizure control which is reduction of seizure frequency and severity so that the patient can live normal life without epilepsy-related limitations with minimal or no drug toxicity
● E. None of above
D. Seizure control which is reduction of seizure frequency and severity so that the patient can live normal life without epilepsy-related limitations with minimal or no drug toxicity
In person with focal onset seizure with or without retained awareness and with or without secondary generalization, the indicated antiseizure medications (ASM) are carbamazepine, phenytoin, phenobarbital, and primidone. Which of the follow-ing is the drug indicated in absence seizure?
● A. Ethosuximide
● B. Valproic acid
● C. Clonazepam
● D. Methsuximide
● E. All of the above
E. All of the above
Valproic acid, lamotrigine, levetiracetam, and zonisamide are considered as broad spectrum ASM. A patient presenting with low platelet counts in neurosurgical OPD with primary generalized tonic clonic seizures is to be started with ASM. Which
ASM is indicated in this patient as first-line medication?
● A. Valproic acid
● B. Phenytoin
● C. Levetiracetam
● D. Phenobarbital
● E. Lamotrigine
A. Valproic acid
Following statements regarding antiseizure medication are true except?
● A. A given medication dose is increased until seizures are controlled or side effects become intolerable
● B. Monotherapy is tried with different drugs before resorting to two drugs together as 80% of epileptics can be controlled with monotherapy
● C. When more than two ASMs are needed, it is considered that the patient is having nonepileptic seizure
● D. An ASM is discontinued if GGT levels exceed normal levels
● E. When first evaluating a patient on multiple drugs, the most sedating ones are withdrawn first
D. An ASM is discontinued if GGT levels exceed normal levels
Oral loading dose of phenytoin is 300 mg every 4 hours until 17 mg/kg is given while IV loading dose is 18 mg/kg slow IV. Maintenance dose in adults is 200 to 500 mg/d and 4 to 7 mg/kg/d in children. It is diluted only in normal saline and given at slow rate of 20 mg/min or maximum up to 40 mg/min because of risk of which following side effect?
● A. Hypotension
● B. Arrythmias
● C. Laryngeal spasm
● D. Acute kidney failure
● E. Both A and B
E. Both A and B
Carbamazepine is indicated for focal onset seizures, generalized tonic clonic seizures with or without secondary generalization, and trigeminal neuralgia. Dosage range in adults is 600 to 2,000 mg/d, while in children it is 20 to 30 kg/mg/d but it is started at low dosage and increased slowly like 200 mg per oral
every day for 1st week, then 200 mg twice a day for next week, then 200 mg thrice a day for next week, and so on. Which test is necessary before starting carbamazepine therapy?
● A. CBC
● B. Platelet count
● C. Serum iron
● D. Liver enzymes
● E. A, B, and C
E. A, B, and C
Levetiracetam is used as an adjunctive therapy for partial onset seizures with secondary generalization in patients 4 years of age and older. It is also used in myoclonic seizure (juvenile myoclonic epilepsy) and generalized tonic clonic seizures. It can cause somnolence, fatigue, dizziness, asthenia, or infection
as side effect. What is the maximum safe recommended dose of this medication per day?
● A. 2,000 mg
● B. 2,500 mg
● C. 3,000 mg
● D. 3,500 mg
● E. 4,000 mg
C. 3,000 mg
What is the most effective ASM for generalized genetic epilepsies with generalized tonic clonic seizures, which is also effective for all focal onset seizures, and generalized onset seizures including absence seizure and myoclonic seizures? (Adult dosage range of this drug is 600 to 3,000 mg/d, while in children it is 15 to 60 mg/kg/d, while it is contraindicated in pregnancy or in patients below 2 years of age.)
● A. Levetiracetam
● B. Valproate
● C. Phenytoin
● D. Phenobarbital
● E. Lamotrigine
B. Valproate
After cessation of ASM, which of the following factors are found to affect the likelihood of relapse after seizure-free interval of 2 years?
● A. Seizure type: more relapse in patients with generalized seizures as compared to partial seizures
● B. More the number of seizures before control is attained, the more the chance of relapse
● C. Use of multiple ASM is related with more chance of relapse
● D. EEG class 4 has worst prognosis for relapse
● E. All of the above
E. All of the above
For most women of child-bearing potential, monotherapy with the lowest dose of carbamazepine is indicated. What is the second indicated drug in such patients if therapy with carbamazepine is ineffective?
● A. Levetiracetam
● B. Valproic acid
● C. Phenytoin
● D. Lamotrigine
● E. Phenobarbital
B. Valproic acid
What is the most common cause of first type seizures in pediatric age group?
● A. Febrile
● B. Hydrocephalus
● C. Electrolyte imbalance
● D. Vascular event
● E. Idiopathic
A. Febrile
Prophylactic antiepileptic drugs reduce the incidence of late post-traumatic epilepsy by how much?
● A. One-fourth
● B. One-third
● C. Half
● D. No effect
● E. Increase the incidence by drug resistance
D. No effect
What is the most common cause of nonepileptic seizures?
● A. Psychogenic
● B. Basilar migraine
● C. Cardiac arrhythmias
● D. Cyclic vomiting syndrome
● E. Dyskinesias
A. Psychogenic
According to the definition of status epilepticus, seizure lasting more than how many minutes warrants management according to status epilepticus protocol?
● A. 1
● B. 3
● C. 5
● D. 30
● E. 60
C. 5
What is the most common cause of status epilepticus?
● A. Low levels of antiepileptic drugs
● B. Metabolic
● C. Hypoxia
● D. Tumor
● E. Cerebrovascular event
A. Low levels of antiepileptic drugs
What is the first-line treatment for status epilepticus?
● A. Benzodiazepine
● B. Fosphenytoin
● C. Phenytoin
● D. Valproic acid
● E. Phenobarbital
A. Benzodiazepine
What is the drug of choice for myoclonic status epilepticus?
● A. Benzodiazepine
● B. Fosphenytoin
● C. Phenytoin
● D. Valproic acid
● E. Phenobarbital
D. Valproic acid
Antiseizure medication can be tapered off in which of the following cases after 7 days?
● A. Penetrating brain injury
● B. Development of late PTS
● C. Prior seizures history
● D. Patient undergoing craniotomy
● E. Linear skull fracture
E. Linear skull fracture
The etiologies of first-time seizure include neurologic insult (stroke, head trauma, CNS infection, birth asphyxia), underlying CNS abnormality (congenital, degenerative, CNS tumor, hydrocephalus, AVM), acute systemic metabolic disturbance (electrolyte disorders, alcohol withdrawal, cocaine toxicity, opioids, phenothiazine antiemetics), and idiopathic. Which of the following neurologic insult is the most common cause of
first-onset seizure in pediatric population?
● A. CNS infection
● B. Birth asphyxia
● C. Febrile seizures
● D. Idiopathic
● E. Head trauma
C. Febrile seizures
An adult person comes in neurosurgical OPD with history of new-onset seizure in the absence of obvious cause like alcohol withdrawal. His/her MRI with and without contrast and systemic workup come out to be negative. How this adult should
be followed up?
● A. No need for further follow-up in absence of seizure
● B. Follow-up after 6 months with repeat MRI which if found negative then no need for further follow-up
● C. Further follow-up if seizure occurs again
● D. Further follow-up after 6 months with repeat MRI, then at 1 year with repeat MRI, and possibly at 2 years to rule out tumor in brain
● E. Start antiepileptic medication and follow-up after 6 months
D. Further follow-up after 6 months with repeat MRI, then at 1 year with repeat MRI, and possibly at 2 years to rule out tumor in brain
Post-traumatic seizures (PTS) can occur in patients after head injury. These can adversely affect the patient as it may elevate ICP, may adversely affect blood pressure or oxygen delivery, and may worsen other injuries. Hence, antiseizure medication (levetiracetam, phenytoin, carbamazepine) should be started within 24 hours in patients meeting high-risk criteria for PTS. These high-risk criteria include the following except?
● A. ASD hematoma, EDH, ICH, or open depressed skull fracture with parenchymal injury
● B. No history of significant alcohol abuse
● C. Seizures within the first 24 hours after injury
● D. Penetrating head injury
● E. GCS less than 10 or cortical contusion
B. No history of significant alcohol abuse
Antiseizure medications (ASMs) are given for 1 week and then tapered as it prevents from early-onset post-traumatic seizure (within 7 days of injury). However, ASMs are continued for 6 to 12 months in patients after head injury in which of the following conditions?
● A. Penetrating head injury
● B. Development of late PTS (a seizure lasting more than 7 days following head injury)
● C. Prior seizure history
● D. Patients undergoing craniotomy
● E. All of the above
E. All of the above
Alcohol withdrawal seizure can occur within 7 to 30 hours of cessation or reduction of alcohol intake in habituated drinkers. These seizures are treated with diazepam or lorazepam if they continue for 3 to 4 minutes or phenytoin. What is the loading dose (mg/kg) of phenytoin for such patients?
● A. 16
● B. 18
● C. 20
● D. 22
● E. 24
B. 18
Differentials of nonepileptic seizures include psychologic disorders (anxiety, dissociative, psychonic, impulse control, attention deficit), cardiovascular disorders (syncope, cardiac ar-
rythmias, TIAs), migraine syndrome, movement disorders (tremors, dyskinesias, tic), parasomnias with sleep-related disorders, and others like malingering or cognitive disorders. Following are features associated with nonepileptic seizure disorder except?
● A. Manifestations altered by distraction
● B. Intermittent arrhythmic and out-of-phase convulsive activity
● C. Nonfluctuating intensity and severity during seizure
● D. Bilateral motor activity with preserved consciousness
● E. Absence of stereotypy
C. Nonfluctuating intensity and severity during seizure
A febrile seizure is said to be a seizure in infants or children associated with fever with no defined cause and unaccompanied by acute neurologic illness. Which statement is most appropriate regarding management of these seizures?
● A. There are recommendations for prescribing antiseizure medication in these cases
● B. Phenobarbital can be used with no effect on kid’s IQ
● C. Valproate has no serious risks in the kids younger than 2 years
● D. Recurrence of febrile seizures in children can be reduced using diazepam 0.33 mg/kg per oral every 8 hours during a febrile episode and continuing until 24 hours after the fever subsides
● E. None of the above
D. Recurrence of febrile seizures in children can be reduced using diazepam 0.33 mg/kg per oral every 8 hours during a febrile episode and continuing until 24 hours after the fever subsides
Status epilepticus is a continuous seizure activity or more than equal to two sequential seizures without full recovery of consciousness between seizures for more than 30 minutes. The goal of treatment in such patients is rapid termination of clinical and electrical seizure activity as continuation of seizure activity for more than 30 minutes can cause permanent neurologic deficit. What is the most common cause of status epilepticus?
● A. Low level of prescribed ASM in a patient with a seizure disorder
● B. Remote symptomatic cause
● C. Stroke
● D. Metabolic disturbance
● E. Hypoxia
A. Low level of prescribed ASM in a patient with a seizure disorder
Treatment of status epilepticus is divided into four phases with phase 1 comprising from 0 to 5 minutes, phase 2 from 5 to 20 minutes, phase 3 from 20 to 40 minutes, and phase 4 from 40 to 60 minutes. First 0 to 5 minutes phase is called as
stabilization phase. Following are the components of this phase except?
● A. ABC, that is, assessment and correction of airway, breathing, circulation with adequate oxygenation and arterial blood gases (ABG) monitoring
● B. 50 mL of dextrose 50 is given by IV push before giving 100 mg thiamine IV
● C. Baseline investigation is sent for with start of IV fluid and neurologic examination
● D. Initial additional measures include EEG monitoring if possible, head CT without contrast, correction of any suspected electrolyte imbalance, and CNS sampling for suspected CNS infection with start of antibiotics
● E. General medication for unknown suspected poisoning cases includes naloxone 0.4 mg IV for narcotics, bicarbonate to counter acidosis, and for neonates less than 2 years, pyridoxine 100 mg IV push is given
B. 50 mL of dextrose 50 is given by IV push before giving 100 mg thiamine IV
During the second phase of status epilepticus treatment, which last from 5 to 20 minutes, benzodiazepine is the drug of choice with IM midazolam or IV lorazepam or IV diazepam in
dosage of 10 mg (for adult) or 0.1 mg/kg/dose or 0.15 to 0.2 mg/kg/dose given, respectively, once. If all the above meds are unavailable or contraindicated, then IV phenobarbital (15 mg/
kg/dose) or rectal diazepam (0.2 to 0.5 mg/kg) or intranasal midazolam or buccal midazolam can be given. What is the component of the second therapy phase which lasts from 20 to 40 minutes?
● A. IV phosphenytoin
● B. IV valproic acid 40 mg/kg/dose up to max 3,000 mg/dose
● C. IV levetiracetam 60 mg/kg/dose up to max 4,500 mg/dose
● D. IV phenobarbital 15 mg/kg/dose
● E. All of the above
E. All of the above
A 35-year-old young woman presents with left-sided facial pain without any numbness. She had several episodes in the last few months, and her pain triggers after eating, talking, and touching her cheek. MRI shows a vessel compressing cranial nerve V. Which vessel is most commonly involved?
● A. Superior cerebral artery
● B. AICA
● C. PICA
● D. PCA
A. Superior cerebral artery
A 25-year-old young male presented with painful vesicular eruption. It was in dermatomal distribution on one side of thorax. What is the effective treatment for the pain of acute attack?
● A. Epidural
● B. Intercostal block
● C. Antiviral
● D. Both A and B
D. Both A and B
A 60-year-old female with history of breast cancer, with metastasis to bone and pain in right arm, reports 3 weeks of worsening of pain (burning in right hand—brachial plexus neuropathy). She was prescribed tricyclic antidepressant, use of which is limited by which of the following?
● A. Anticholinergic effect
● B. Central effects
● C. Limited pain relief
● D. All of the above
D. All of the above
Ramsay Hunt syndrome is characterized by which of the following triads?
● A. Contralateral facial paralysis, ear pain, and vesicle on face,
ear, or in the ear
● B. Recurrent oral ulcers, genital ulcers, and iridocyclitis
● C. Sixth cranial n. palsy, persistent ear discharge, deep-seated retro-orbital pain
● D. Ipsilateral facial paralysis, ear pain, and vesicle on face, ear, or in the ear
D. Ipsilateral facial paralysis, ear pain, and vesicle on face, ear, or in the ear
Which of the following is correct regarding primary otalgia?
● A. More common in children
● B. Mostly unilateral
● C. Cold, air, and water most common triggers
● D. 75% associated with aural symptoms (hearing loss, tinnitus, and vertigo)
● E. All of the above
E. All of the above
A European solider presented to the emergency department after 24 hours of being shot, with classical triad of burning pain, autonomic dysfunction, and trophic change (complex re-
gional pain syndrome) on his upper extremity. Which of the following statements is true?
● A. Medical therapy is sufficient
● B. Sympathetic block may not help
● C. Guanethidine commonly used intravenous injection
● D. No role of tricyclic antidepressants
● E. All of the above
C. Guanethidine commonly used intravenous injection
There are three major types of pain, namely, nociceptive pain (somatic and visceral), deafferentation pain, and sympathetically maintained pain. Pain which is caused by lesion or
compression of peripheral or central nervous system manifesting as sensory signs and symptoms is called as neuropathic pain. Following are peripheral neuropathic pain syndromes except?
● A. Acute and chronic inflammatory demyelinating polyneuropathy
● B. Entrapment neuropathies
● C. Cervical spondylotic myelopathy
● D. Post herpetic neuralgia
● E. Painful diabetic neuropathy
C. Cervical spondylotic myelopathy
Which of the following statements regarding medical treatment of neuropathic pain is true?
● A. Traditional treatment includes narcotic analgesic and tricyclic antidepressants (amitriptyline 75 mg daily)
● B. Gabapentin is effective for post herpetic neuralgia, painful diabetic neuropathy, trigeminal neuralgia, postoperative state, spinal cord injury, cancer, MS, and migraine
● C. Lidocaine patch is applied for 12 hours/d over the most painful area
● D. Tramadol is a centrally acting analgesic which is effective for these patients
● E. All of the above
E. All of the above
Possible pathways for facial pain include trigeminal nerve, facial nerve, and cranial nerve eight. Which of the following is a cause of cephalic neuralgia?
● A. Tic convulsif: otalgia and deep prosopalgia
● B. Diabetic neuritis of oculomotor nerve
● C. Nerve injury to superior or inferior alveolar nerves
● D. Sinusitis of frontal, maxillary, sphenoidal, or ethmoidal sinus
● E. All of the above
A. Tic convulsif: otalgia and deep prosopalgia
Primary otalgia is unilateral in most cases, and it is mostly triggered by cold air or water. It is associated with aural symptoms like hearing loss, vertigo, and tinnitus. Following is true regarding the management of primary otalgia except?
● A. An initial trial with medications used in trigeminal neuralgias like carbamazepine, phenytoin, and baclofen is the first
line of defense
● B. Suboccipital exploration of the 7th cranial nerve or lower cranial nerve with MVD has no role in these cases
● C. Ultimate treatment is sectioning of nervus intermedius, the 9th and upper two fibers of 10th nerve, and a geniculate ganglionectomy
● D. Pain relief with nerve block of pharyngeal tonsils suggests glossopharyngeal neuralgia
● E. CT or MRI should be done in any case where no cause is found
B. Suboccipital exploration of the 7th cranial nerve or lower cranial nerve with MVD has no role in these cases
A woman 50 years of age presented with unilateral pain in forehead with tenderness on one side of forehead. The pain is temporarily relieved with nerve block in the region of orbital roof. This condition responds to gabapentin, pregabalin, or topical capsaicin. What is the most likely diagnosis in this case?
● A. Trigeminal neuralgia
● B. Migraine
● C. Supraorbital neuralgia
● D. Hemi crania continua
● E. Trochleitis
C. Supraorbital neuralgia
Herpes varicella zoster virus is responsible for painful vesicular cutaneous eruptions mostly in the area of thorax or in distribution of trigeminal neuralgia. If pain from this condition persists for more than 1 month, then this condition is called
post herpetic neuralgia. The recommended medical treatment for this condition includes which of the following?
● A. Acyclovir 800 mg every 4 hours for 7 days
● B. Tricyclic antidepressants
● C. Gabapentin
● D. Lidocaine patch
● E. All of the above
E. All of the above
For post herpetic neuralgia, gabapentin is started at a dose of 300 mg once a day for first day, 300 mg twice a day on second day, and 300 mg thrice a day on third day. Which side effect of gabapentin makes a surgeon to start it at night with slow increments of doses?
● A. Ataxia and fatigue
● B. Drowsiness
● C. Peripheral edema and confusion
● D. Depression
● E. All of the above
B. Drowsiness
Capsaicin patches or lidocaine patches are helpful in post herpetic neuralgia patients. Intrathecal steroid with methylprednisolone plus 3% lidocaine once every week for 4 weeks has shown good to excellent pain relief for up to 2 years. What is the surgical treatment that is uniformly successful in treating post herpetic neuralgias?
● A. Nerve block
● B. Neurectomies
● C. Cordotomy
● D. Rhizotomy
● E. None of the above
E. None of the above
Complex regional pain syndrome also known as causalgia is a disproportionate pain syndrome which can cause burning pain, autonomic dysfunction, or trophic changes. Which of the following is true regarding the cause of this syndrome?
● A. These are high velocity missile injuries (also known as CRPS type 2)
● B. Sympathetic dystrophy or causalgia minor is caused by nonpenetrating injury and is called as CRPS type 1
● C. It can occur in postoperative patients following carpal tunnel surgery or surgery on lumbar or cervical spine
● D. It can occur because of direct injury to nerve or because of injury to surrounding soft tissue
● E. All of the above
E. All of the above
CRPS mostly affects limbs with hand and foot involvement. Examination (in such patients is difficult because of tenderness) may show vasodilatation, vasoconstriction, or trophic
changes. Following are recommended treatment options in these patients except?
● A. Gabapentin
● B. Tricyclic antidepressants
● C. Sympathetic block
● D. Surgical sympathectomy
● E. Spinal cord stimulation
A. Gabapentin
A 16-year-old boy presented to the OPD for follow-up after 2 months of brachial plexus injury. Initially, his reflexes were absent. Which maneuver will help you to further support your finding?
● A. Jendrassick maneuver
● B. Hamlick maneuver
● C. tENS
● D. Stimulation
A. Jendrassick maneuver
A 35-year-old female is suffering from wrist drop after getting IM injection from a quack. Her tone is decreased and reflexes are absent. What kind of lesion is this?
● A. Upper motor neuron
● B. Mixed
● C. Myopathic
● D. Lower motor neuron
D. Lower motor neuron
There are three innervations of thumb. Pick up the correct sequence.
● A. Median nerve: opposition; ulnar nerve: adduction; and radial nerve: extension
● B. Median nerve: extension; ulnar nerve: abduction; and radial nerve: extension
● C. Median nerve: flexion; ulnar nerve: abduction; and radial
nerve: extension
● D. None of the above
A. Median nerve: opposition; ulnar nerve: adduction; and radial nerve: extension
A patient suffered from foot drop after peroneal nerve injury during car accident. Which of the following statements is true regarding nerve injury?
● A. After 24 months of denervation, most muscle cannot recover useful function even with reinnervation
● B. The longer the distance from the injury site to the function unit to be innervated, the earlier the surgical intervention should be considered
● C. There is some degree of continuity in > 60% of nerve injury
● D. All of the above
D. All of the above
A 30-year-old weight lifter presented to the OPD with severe back ache which started right after his workout. Since then his right foot is numb, and he cannot move his lower limb without pain. MRI spine shows disk prolapse at L5–S1. Which is best way to test L5 clinically?
● A. Extensor hallucis longus
● B. Plantar flexion of big toe
● C. Tibialis anterior and extensor digitorum
● D. None of the above
A. Extensor hallucis longus
A young patient came to electrophysiology department for NCS/EMG for carpel tunnel syndrome. Despite complete absence of a median nerve evoked compound muscle action potential from the thenar eminence, the patient had significant preservation of function and minimal muscle atrophy. Activation of the ulnar nerve at both the wrist and elbow generated easily obtainable compound muscle action potentials from the thenar eminence with initial negative onset. This observed
preservation of function and electrophysiologic responses are best explained by the presence of what?
● A. Martin Gruber anastomosis
● B. Medial and radial nerve anastomosis
● C. Radial and anterior interosseous nerve anastomosis
● D. Richie–Cannieu anastomosis
D. Richie–Cannieu anastomosis
A young male was referred to the OPD 6 weeks after a fall from the roof. Immediately after the fall he was not able to extend his wrist and unable to extend his fingers, along with weakness of brachioradialis muscle. The most likely radial nerve injury is where?
● A. Axillary area
● B. Spiral groove
● C. At wrist
● D. Forearm
B. Spiral groove
The peripheral nervous system consists of nerve fibers and axons that connect the central nervous system with motor and sensory, somatic, and visceral end organs. Following are included in peripheral nervous system except?
● A. Cranial nerves one and two
● B. Cranial nerves three to twelve
● C. Spinal nerves
● D. Nerves of extremities
● E. Cervical, brachial, and lumbosacral plexus
A. Cranial nerves one and two
Medical Research Council scale (MRC scale) is used for muscle strength grading. A patient presented to neurosurgical OPD with reduced power of right upper limb. The patient can move the limb actively with gravity eliminated. What is MRC grade of this patient?
● A. 1
● B. 2
● C. 3
● D. 4
● E. 5
B. 2
Muscle stretch reflex grading scale is used for deep tendon
reflex. It typically ranges from 0 to 4 + . Which of the following
statements is true regarding these reflexes?
● A. 2 + is normal while 3 + is less brisk than normal
● B. 0.5 + means reflex is elicitable only with reinforcement
● C. In the lower extremities, reinforcement consists of having patients clench their teeth
● D. In the upper extremities, reinforcement consists of hooking tip of fingers of right hand into left hand and pulling (Jendrassik maneuver)
● E. 5 + means hyperreflexic with clonus
B. 0.5 + means reflex is elicitable only with reinforcement
Possible etiologies of upper motor neuron (UMN) paralysis are stroke, spinal cord injury, and cervical spondylotic myelopathy while of lower motor neuron (LMN) paralysis are herniated intervertebral disk, nerve entrapment syndrome, polio, and progressive muscular atrophy. Which of the following statements is incorrect regarding difference between UMN paralysis and LMN paralysis?
● A. Muscle tone in UMN paralysis is initially flaccid then later spastic with clasping resistance while in LMN paralysis it is flaccid
● B. Tendon reflexes are hyperactive in UMN paralysis while these are absent in LMN paralysis
● C. Pathologic reflexes like Babinski and Hoffman are present in UMN paralysis while these are absent in LMN paralysis
● D. Atrophy does not occur in UMN paralysis while it does occur in LMN paralysis
● E. Spontaneous spasms may occur in UMN paralysis while in LMN paralysis fibrillations and fasciculations occur
D. Atrophy does not occur in UMN paralysis while it does occur in LMN paralysis
Fasciculations are coarse muscle contractions that are visible to the naked eye while fibrillations are not visible and require EMG to detect. Fasciculations most often occur in diseases involving anterior horn cells which includes which of the following?
● A. Amyotrophic lateral sclerosis
● B. Spinal muscular atrophy
● C. Polio
● D. Syringomyelia
● E. All of the above
E. All of the above
What is the common root value of deltoid muscle (abducts arm from 30 to 90), biceps brachii (flex forearm and supinate forearm), and brachialis (flex forearm)?
● A. C4, c5
● B. C6, c7
● C. C5, c6
● D. C5, c6, c7
● E. C4, c5, c6
C. C5, c6
C7, C8, and T1 roots collectively supply which muscle in upper extremities?
● A. Flexor pollicis longus (flex distal phalanx of thumb)
● B. Flexor digitorum profundus 1 and 2 (radial part) (flex distal phalanx of digits 2 and 3, also flexes wrist)
● C. Palmaris longus (wrist flexion)
● D. Flexor digitorum superficialis (flexion of middle phalanx of digits 2 to 5, flexes wrist)
● E. All of the above
E. All of the above
Flexion and extension of thumb occurs in the plane of palm while adduction and abduction occur in plane at right angle to the palm and opposition is bringing the thumb across the hand to the little finger. All of the following statements regarding innervation of thumb muscles is correct except?
● A. Median nerve innervates abductor pollicis brevis which causes abduction
● B. Ulnar nerve supplies adductor pollicis which causes adduction of thumb
● C. Radial nerve supplies extensor pollicis brevis and longus which cause extension of thumb
● D. Radial nerve also supplies opponens brevis which causes opposition
● E. Median nerve also supplies flexor pollicis brevis which causes flexion
D. Radial nerve also supplies opponens brevis which causes opposition
Which muscle is supplied by only L5 and S1 nerve roots?
● A. Extensor digitorum longus which causes extension of toes 2 to 5 and foot dorsiflexion
● B. Extensor hallucis longus which causes great toe extension and foot dorsiflexion
● C. Extensor digitorum brevis which causes extension of great toe and toes 2 to 5
● D. Peroneus longus and brevis which cause planter flexion of pronated foot and eversion
● E. All of the above
E. All of the above
A nerve action potential (NAP) is produced if a normal healthy nerve fiber is stimulated with an electrical stimulus that has an amplitude and duration which exceed nerve fiber threshold. Presence of NAP (regardless of amplitude and la-
tency) distal to lesion in continuity in the first few months after injury usually indicates that operative intervention will not be needed. What is the recommended timing to obtain NAP recording?
● A. 2–4 months for relatively focal contusions
● B. 4–5 months for stretch injuries such as brachial plexus
● C. Any time for partial injuries, entrapments, compressive lesions, and tumors
● D. Acutely to identify an area of nerve block
● E. All of the above are true
E. All of the above are true
Pick the false statement about entrapment neuropathy.
● A. It can be either an external force or a force by nearby structure
● B. One or repetitive insult
● C. Most common symptom is pain which frequently occurs at rest and is more severe at night
● D. Never consider the possibility of systemic disease
● E. None of the above
D. Never consider the possibility of systemic disease
A young female presented with pain in occiput with trigger point at the back of head. Any pressure on that reproduces the pain which radiates up along the vertex. She was diagnosed with occipital nerve entrapment. Treatment options for this patient are the following except?
● A. Idiopathic cases are self-limiting
● B. Temporary relief with occipital nerve block
● C. TENS provide no relief
● D. Collar for 2 weeks may help
● E. C and D
E. C and D
A coal mine worker presented with weak grip in his dominant hand. His hands get fatigued easily now with poorly localized paresthesia in index finger and thumb. What are the salient features to differentiate pronator teres syndrome from carpal tunnel syndrome (CTS)?
● A. Pain in palm rule out CTS
● B. Nocturnal exacerbation
● C. More common than CTS
● D. Involvement of ulnar nerve
A. Pain in palm rule out CTS
A young female with moderate obesity often visits OPD with tingling in the hand, on palmar side of thumb, index finger, middle finger, and radial half of ring finger. Now all of sudden it has become severe. Acute carpel tunnel syndrome is uncommon and is associated with which of the following?
● A. Exertion or trauma
● B. Median artery thrombosis
● C. Hematoma in transverse carpal ligament (TCL)
● D. All of the above
D. All of the above
A young female complains about tingling on palmer side of hand involving the thumb, index, middle, and half of ring finger, which wakes her up at night with painful numbness. Her grip gradually became weak. How much increase in carpel tunnel pressure produces sensory and motor dysfunction?
● A. 40 mmHg
● B. Less than 20
● C. 30
● D. 20–30
A. 40 mmHg
Regarding carpel tunnel syndrome, which statement is false?
● A. Most common entrapment neuropathy
● B. Females are 4 times more affected
● C. Pain at palmar area is characteristic of pronator teres syndrome
● D. Neutral position splint relieves only 20% of patients
● E. Steroid injection may improve symptoms in 75% of patients
D. Neutral position splint relieves only 20% of patients
In carpel tunnel syndrome, surgical intervention is recommended for which of the following?
● A. Constant numbness
● B. Symptoms lasting > 1 year
● C. Sensory loss
● D. Thenar atrophy
● E. All of the above
E. All of the above
A 32-year-old male presented to the OPD with discomfort in little finger and medial half of ring finger, with slight hand weakness of 4 + power and mild muscle atrophy. What is the grade of ulnar nerve injury classification of this patient?
● A. Grade 1
● B. Grade 2
● C. Grade 3
● D. Grade 4
B. Grade 2
Which one is a wrong statement about ulnar nerve?
● A. Elbow is most vulnerable for entrapment
● B. Tardy ulnar palsy is due to delayed onset following bony injury at the elbow
● C. NCS shows 4 m/sec faster than median nerve
● D. Early symptoms of ulnar nerve entrapment may be purely motor
D. Early symptoms of ulnar nerve entrapment may be purely motor
A manual labor worker with frequent use of pneumatic drill presented to the OPD with Froment’s sign and claw hand deformity with no sensory loss at dorsum of hand. Most probably
injury to which of the following has caused the lesion?
● A. Cubital tunnel
● B. Osborne ligament
● C. Guyon’s canal
● D. Struther’s arcade
C. Guyon’s canal
How can radial nerve injury be distinguished from posterior cord injury?
● A. Involvement of all forearm extensor
● B. Patchy sensory loss in the distribution of radial nerve
● C. Sparing of deltoid and latissimus dorsi muscles
● D. Purely motor involvement
Injury to radial nerve proximal to radial groove of humerus will involve which of the following?
● A. Wrist extensors only
● B. Finger extensors only
● C. Triceps only
● D. Triceps, wrist, and finger extensors
A young male was hit by a car while he was riding a bike. He is unable to dorsiflex his ankle and shows weakness of lateral hamstring. Which nerve will be involved in this case?
● A. Common peroneal nerve
● B. Posterior tibial nerve
● C. Deep peroneal nerve
● D. Superficial peroneal nerve
A. Common peroneal nerve
A male presented to the OPD with complains of spontaneous rubbing or massaging of upper lateral aspect of thigh, along with burning dysesthesia and hyperpathia. How can meralgia paresthetica be differentiated from femoral neuropathy?
● A. Sensory changes on upper lateral aspect
● B. Purely sensory involvement
● C. No motor weakness
● D. None of the above
A. Sensory changes on upper lateral aspect
A patient presented with complaint of pain that is more severe at night, frequently at rest, often with retrograde radiation, causing more proximal lesion to be suspected. The patient also has tenderness at the site of pain. He is suspected to have entrapment neuropathy. What are most common associations
with entrapment neuropathy?
● A. Diabetes mellitus and hypothyroidism
● B. Acromegaly and amyloidosis
● C. Carcinomatosis and polymyalgia rheumatica
● D. Rheumatoid arthritis
● E. All of the above
E. All of the above
What is the mechanism of injury in case of entrapment neuropathy?
● A. Chronic compression can cause axonolysis and Wallerian degeneration
● B. Acute compression can compromise axoplasmic flow, which can reduce membrane excitability
● C. There can be ischemia due to vascular supply compromise
● D. Venous stasis can produce ischemia which can lead to edema outside the axonal sheath, which can further exacerbate ischemia
● E. All of the above
E. All of the above
A patient after trauma to back of the head presents with headache mostly in back and myofascial spasm. Diagnosis of occipital nerve entrapment was made which occurs due to entrapment of the great occipital nerve, which is a sensory branch of C2. All of the following are surgical options for treatment of occipital neuralgia except?
● A. Decompression of C2 nerve root if compressed between c1 and c2
● B. Occipital neurectomy
● C. Occipital nerve block with local anesthetic and steroids
● D. Occipital nerve stimulators
● E. Ganglionectomy
C. Occipital nerve block with local anesthetic and steroids
The median nerve is supplied by nerve roots C5 through T1 and it arises from medial and lateral cords of brachial plexus. In the cubital fossa, it passes just behind the lacertus fibrosus (bicipital aponeurosis) and enters the upper forearm between the two heads of pronator teres and supplies this muscle. Following statements regarding median nerve are correct except?
● A. Anterior interosseous nerve is purely motor branch of median nerve that supplies all but two muscles of finger and wrist flexion
● B. Near the wrist, it lies medial to the tendon of flexor carpi radialis and passes under transverse carpal ligament which also contains the tendons of FDP and FDS deep to the median nerve
● C. The second motor branch of the median nerve arises deep to the TCL and supplies LOAF muscles in the hand
● D. Palmaris cutaneous branch of the median nerve passes under the TCL and provides sensory innervation to the base of thenar eminence
● E. In the case of main trunk injury of the median nerve, a benediction hand is made when trying to make a fist (due to weakness of flexor digitorum 1 and 2)
A patient presents in neurosurgical emergency with complaint of difficulty in grasping small objects between the thumb and the index finger with no sensory loss. Pinch sign is positive. EMG assesses pronator quadratus and flexor pollicis longus. What is the diagnosis in this patient?
● A. Anterior interosseus neuropathy
● B. Pronator teres syndrome
● C. Carpal tunnel syndrome
● D. Injury to the main trunk of median nerve
● E. None of the above
A bulky female of 45 years of age presents in the OPD with complaints of pain in the palmer aspect of radial three and half fingers, dorsal side of these same fingers distal to PIP, and radial half of palm. The patient gets awakened at night by painful
numbness in the hands. There is also hand weakness especially grip. Phalen’s test (wrist flexion to 90 degrees angle reproduces the pain) is positive. What is the diagnosis in this patient?
● A. Cervical radiculopathy
● B. Pronator teres syndrome
● C. Carpal tunnel syndrome
● D. Reflex sympathetic atrophy
● E. De Quervain’s syndrome
E. De Quervain’s syndrome
In case of carpal tunnel syndrome patient, EMG shows sensory latencies of 3.7 to 4 and 4.1 to 5 in mild and moderate CTS, respectively, while motor latencies are 4.4 to 6.9 and 7 to 9.9 in mild and moderate CTS. Laboratory workup for these pa-
tients include all of the following except?
● A. Thyroid hormone levels
● B. CBC
● C. There is no role of serum electrolytes in CTS patients
● D. HbA1c and glucose
● E. Vitamin B12, folate, and MMA
Which statement is true regarding treatment of carpal tunnel syndrome?
● A. NSAIDs, pyridoxine, and diuretics have strong evidence of good efficacy with no obvious benefits of neutral position splint for 2 to 4 weeks or steroid injection of 10 to 25 mg hydrocortisone into carpal tunnel
● B. Surgery is recommended for symptoms less than 1 year duration with no sensory or motor symptoms
● C. Recurrent motor branch which innervates muscles of the thenar eminence is also called as million dollar nerve because its injury can lead to loss of thumb function and a possible malpractice lawsuit
● D. Kaplan’s cardinal line runs from the base of the thumb web space to the hook of hamate which has no link with anastomosis between superficial and deep palmer arches
● E. Incision extends from the proximal wrist flexion crease up to Kaplan’s cardinal line between digits 3 and 4
Ulnar nerve has components of c7, c8, and T1. It is second most common entrapment neuropathy after CTS. Potential sites of its compression are above the elbow by arcade of Struthers, at the elbow in retroepicondylar groove (ulnar groove), cubital tunnel, at the point of exit from flexor carpi ulnaris, and in the wrist at Guyon’s canal. What are the motor findings in ulnar entrapment neuropathy?
● A. Wasting of interossei may occur
● B. Wartenberg’s sign: patients may complaint that the little finger does not make it in when they reach into their pocket due to abducted little finger because of the weakness of the third palmer interosseous muscle
● C. Froment’s prehensile thumb sign: grasping a piece of paper between the thumb and the extended index finger results in extension of the proximal phalanx of the thumb and flexion of the distal phalanx
● D. Claw deformity of hand: benediction sign when trying to open the fist from closed position, which is fingers 4 and 5 are hyperextended at MCP joints and flexed at the interphalangeal joint
● E. All of the above
What is the most common cause for peripheral neuropathy?
● A. Diabetes
● B. Arteritis
● C. Monoclonal gammopathy
● D. Acute idiopathic polyneuritis
● E. Sjogren syndrome
A. Diabetes
In critical illness polyneuropathy (CIP), CPK levels are normal or mildly elevated while EMG shows what?
● A. Decrease in amplitudes of compound muscle action potentials
● B. Increase in amplitudes of compound muscle action potentials
● C. Amplitudes of compound muscle action potentials remain unchanged
● D. Two spikes per second
● E. Nonlocalizing changes
A. Decrease in amplitudes of compound muscle action potentials
Idiopathic brachial plexitis usually starts to show some improvement by when?
● A. 3rd day
● B. 2nd week
● C. 4th week
● D. 2nd month
● E. 3rd month
C. 4th week
EMG changes can be appreciated in neuralgic amyotrophy of the upper extremity after how long?
● A. 24 hours
● B. 48 hours
● C. 72 hours
● D. 2 weeks
● E. 3 weeks
E. 3 weeks
A diabetic patient presents with abrupt onset of asymmetric pain in back, hip, buttocks, thigh, and leg usually deep aching/burning with superimposed lancinating paroxysms, severe at night. Progressive weakness in proximal and distal muscles was preceded by weight loss. Patellar reflexes are absent. Sensory loss is minimal. EMG findings consistent with demyelination are invariably accompanied by axonal degeneration, with involvement of paraspinals and no evidence of myopathy. These findings are consistent with what?
● A. Guillain Barre syndrome
● B. Bruns-Garland syndrome
● C. Ramsay Hunt syndrome
● D. Tolosa Hunt syndrome
● E. Brachial plexitis
B. Bruns-Garland syndrome
Which of the following is not associated with drug-induced neuropathy?
● A. Metronidazole
● B. Ciprofloxacin
● C. Phenytoin
● D. Thallium
● E. Cisplatin
What is the most common cause of femoral neuropathy?
● A. Diabetes
● B. Nerve entrapment
● C. Intra-abdominal tumor
● D. Femoral artery catheterization
● E. Retroperitoneal hematoma
Peripheral nerves regeneration rate in mm/d is about how
much?
● A. 1
● B. 2
● C. 3
● D. 5
● E. 10
B. 2
According to the Sunderland system for classification of peripheral nerve injury what is neurotmesis?
● A. First degree
● B. Second degree
● C. Third degree
● D. Fourth degree
● E. Fifth degree
In which of the following complete interruption of axons and myelin sheaths takes place and Wallerian degeneration occurs whereas supporting structures including endoneurium remain intact?
● A. Neuropraxia
● B. Axonotmesis
● C. Neurotmesis
● D. Axonolysis
● E. First degree injury of Sunderland system
Lesions of peripheral nerves can produce somatic findings (combination of weakness, sensory disturbance, and reflex changes) and/or autonomic disturbances. Etiologies of nonentrapment peripheral neuropathies include which of the follow-
ing?
● A. Diabetes
● B. Alcoholism
● C. Guillain-Barre syndrome
● D. Vasculitis/arteritis
● E. All of the above
E. All of the above
A patient admitted in ICU developed critical illness neuropathy (CIP) also known as neuropathy of critical illness or ICU neuropathy. For evaluation of the patient, blood work with fasting electrolytes, Hgb-A1C, CBC, ESR, CRP, vitamin B12, methylmalonic acid, serum protein electrophoresis with serum
immunofixation, and electrodiagnostics (EMG/NCV) are done to rule out the cause of neuropathy. Following are the diagnostic criteria of CIP except?
● A. Presence of sepsis, multiorgan failure, septic inflammatory response syndrome, or respiratory failure
● B. Difficulty weaning from ventilator or extremity weakness
● C. EMG showing increased amplitudes of compound muscle action potentials
● D. Widespread muscle denervation potentials
● E. Normal or only mild increase in serum CPK levels
A male patient 30 years of age develops acute onset of intense pain in right upper extremity some days after a viral illness. Weakness of the same limb developed acutely after 2 weeks of pain onset. Arm movements exacerbated the pain. EMG/NCV showed the portion of brachial plexus involved.
What is the most probable diagnosis in this patient?
● A. Parsonage Turner syndrome
● B. Immune-mediated brachial plexus neuropathy
● C. Neuralgic amyotrophy of the upper extremity
● D. Brachial plexitis
● E. All of the above
A patient presents to neurosurgical OPD with history of sudden onset of pain in lower extremity with weakness of quadriceps femoris muscle, SLR positive. EMG/NCV was done which showed patchy denervation involving at least two segmental
levels with sparing of the paraspinal muscles. What is the most likely diagnosis in this case?
● A. L4 and L5 acute rupture of intervertebral disk
● B. Lumbosacral plexus neuropathy
● C. Rupture of AVM at L4 and L5 level
● D. Sudden compression of lumbosacral plexus
● E. None of the above
About 50% of patients with diabetes mellitus develop neuropathic symptoms or show slowing of nerve conduction velocities on electrodiagnostic studies. What is the most appropriate treatment of diabetic amyotrophy?
● A. Mexiletine started at 150 mg every 8 hours
● B. Gabapentin 1800 to 3600 mg every day
● C. Pregabalin up to a maximum of 100 mg TID
● D. Amitriptyline and fluphenazine
● E. All of the above
E. All of the above
Drugs that are most notorious for peripheral neuropathy include all of the following except?
● A. Thalidomide
● B. Macrolides
● C. Phenytoin
● D. Amitriptyline
● E. Metronidazole
AIDS patients can develop vague numbness, tingling, and sometimes painful feet. There may be reduction of light touch and vibratory sense. What is this condition called?
● A. Distal symmetric polyneuropathy
● B. Mononeuropathy multiplex
● C. Meralgia paresthetica
● D. Lumbar polyradiculopathy
● E. All of the above
A. Distal symmetric polyneuropathy
Following are most common nerves that can be involved in perioperative neuropathy except?
● A. Ulnar nerve
● B. Brachial plexus
● C. Median nerve
● D. Radial nerve
● E. Common peroneal nerve
Which of the following statements is incorrect regarding the Sunderland system of peripheral nerve injury classification?
● A. First degree is physiologic transection with local conduction block with usually complete recovery in 2 to 3 weeks and is also called neuropraxia
● B. Second degree is complete interruption of axons and myelin sheath, with supporting structures including endoneurium intact with recovery at 1 mm/d and is also called axonotmesis
● C. Third degree is endoneurium disrupted with intact epineurium and perineurium and is also called axonotmesis
● D. Fourth degree is interruption of all neural and supporting elements with only epineurium intact and is also called neurotmesis
● E. Fifth degree is complete transection with loss of continuity
A lesion in diencephalon will present with which nystagmus type?
● A. See-saw
● B. Convergence
● C. Retractorius
● D. Downbeat
● E. Upbeat
A. See-saw
Brun’s nystagmus is associated with lesion in which of the following?
● A. Medial longitudinal fasciculus
● B. Lateral longitudinal fasciculus
● C. Pontomedullary junction
● D. Midbrain tegmentum
● E. Medulla
C. Pontomedullary junction
Low degree of papilledema with elevation of nasal margin, 360-degree disk swelling (circumferential halo) but no obscuration of major vessels on fundoscopy characterize which modified Frisen grade papilledema?
● A. Grade I
● B. Grade II
● C. Grade III
● D. Grade IV
● E. Grade V
B. Grade II
Homonymous superior quadrantanopsia in the contralateral visual field (“pie in the sky” deficit) is caused by lesion of which of the following?
● A. Optic tract
● B. Optic chiasma
● C. Meyer’s loop
● D. Optic radiation
● E. Occipital cortex
C. Meyer’s loop
Aneurysm of which of the following most commonly
presents with third nerve palsy?
● A. A comm
● B. P comm
● C. ACA
● D. MCA trifurcation
● E. DACA
B. P comm
Which of the following is not a part of complete Horner syndrome?
● A. Miosis
● B. Ptosis
● C. Enophthalmos
● D. Hyperemia of internal ear
● E. Anhidrosis of half of face
D. Hyperemia of internal ear
What is the most common cause of bilateral internuclear ophthalmoplegia in young adults?
● A. Ocular tuberculosis
● B. Herpes zoster
● C. Congenital
● D. Multiple sclerosis
● E. Horner syndrome
D. Multiple sclerosis
Which of the following is not a cause of pupil-sparing oculomotor palsy?
● A. Uncal herniation
● B. Diabetic neuropathy
● C. Atherosclerosis
● D. Giant cell arteritis
● E. Myasthenia gravis
A. Uncal herniation
Which of the following nerves is not involved in superior orbital fissure syndrome?
● A. III
● B. IV
● C. V1
● D. V2
● E. VI
D. V2
Mastoiditis with involvement of petrous apex presenting with classic triad of abducens palsy, retro-orbital pain, and draining ear is which of the following?
● A. Raeder’s neuralgia
● B. Tolosa Hunt syndrome
● C. Gradenigo’s syndrome
● D. Orbital apex syndrome
● E. Inferior orbital fissure syndrome
C. Gradenigo’s syndrome
Nystagmus is involuntary rhythmic oscillations of the eyes, usually conjugate, most common form of which is jerk nystagmus in which the direction of the nystagmus is defined by the direction of the fast component. A patient with structural lesion in the posterior fossa at the cervicomedullary junction including Chiari malformation type 1, basilar impression, basilar impression, or syringobulbia has which type of nystagmus?
● A. Upbeat nystagmus
● B. Vestibular nystagmus
● C. Downbeat nystagmus
● D. See-saw nystagmus
● E. Convergence nystagmus
C. Downbeat nystagmus
Papilledema also known as choked optic is optic disk swelling caused by increased intracranial pressure (ICP). Elevated ICP is transmitted through the subarachnoid space of the optic nerve sheath to the region of the optic disk which causes axoplasmic stasis and papilledema. How long it typically takes to
develop papilledema after development of a sustained rise in ICP?
● A. 6 to 24 hours
● B. > 6 hours
● C. 12 to 24 hours
● D. 24 to 48 hours
● E. 48 to 72 hours
D. 24 to 48 hours
Papilledema can cause posterior globe flattening or elevation of the optic nerve head and dilatation of the optic nerve sheath (optic nerve sheath hydrops) which can be demonstrated on MRI or CT brain. Following statements regarding modified Frisen scale for papilledema on fundoscopic examination are correct except?
● A. Grade 0 is normal optic disk with minimal swelling of nasal margin, nerve fiber layer is clear, vessels are not obscured, and cup is also not obscured
● B. Grade 1 is minimal papilledema with 230-degree C-shaped swelling of nasal superior and inferior borders with normal temporal margin, and cup, if present, is maintained
● C. Grade 2 is low degree of papilledema with elevation of nasal margin, 360-degree disk swelling, and obscuration of major vessel starting from margins of disk
● D. Grade 3 is moderate degree of papilledema with elevation of entire disk, 360-degree disk swelling, obscuration of greater than or equal to 1 segment of major blood vessel at disk margin, and cup may be obscured
● E. Grade 4 is marked degree of papilledema with nerve fiber layer opaque, 360-degree disk swelling. Vessels obscured at disk margin, not completely obscured at disk surface
C. Grade 2 is low degree of papilledema with elevation of nasal margin, 360-degree disk swelling, and obscuration of major vessel starting from margins of disk
Which of the following is not an etiology of unilateral papilledema?
● A. Compressive lesions like intraorbital meningiomas, optic nerve sheath schwannoma, or optic nerve glioma
● B. Local inflammatory disorders
● C. Foster Kennedy syndrome
● D. Demyelinating disease such as multiple sclerosis
● E. Elevated ICP due to frontal lobe glioma
E. Elevated ICP due to frontal lobe glioma
The normal eye can detect stimuli as far as 60 degrees superiorly, 70 degrees inferiorly, 60 degrees nasally, and 100 degrees temporally. Confrontational method is a bed side test to
detect any gross peripheral field defect while Humphrey visual field, octopus perimeters, and Goldmann perimetry are more accurate in detecting visual field defect. Which of the following
statements is incorrect?
● A. Optic nerve and knee of Wilbrand injury on one side will cause junctional scotoma of ipsilateral eye (monocular blindness) while superior temporal quadrantanopsia of the same side eye
● B. Injury to optic chiasma causes bitemporal hemianopia
● C. Injury to right optic nerve or optic radiation causes left homonymous hemianopia with macular splitting of the left visual field
● D. Injury to right Meyer’s loop causes homonymous left superior quadrantanopsia with macular sparing of left visual field
● E. Partial lesion of right optic radiation or visual cortex causes left homonymous hemianopsia with macular sparing of left visual field
A. Optic nerve and knee of Wilbrand injury on one side will cause junctional scotoma of ipsilateral eye (monocular blindness) while superior temporal quadrantanopsia of the same side eye
