Section 5

Question 1

The differential diagnosis of a solitary intraparenchymal lesion in an adult p-fossa is what until proven otherwise?
● A. Abscess
● B. Metastasis
● C. Hemangioma
● D. Hemorrhage
● E. Medulloblastoma

Answer 1

B. Metastasis

Question 2

PHACES syndrome: acronym for a group of findings including which of the following?
● A. Posterior fossa malformations
● B. Truncal hemangioma
● C. Arterial anomalies of the head and neck
● D. Coarctation of the aorta and cardiac defects
● E. Eye anomalies and sternal cleft

Answer 2

B. Truncal hemangioma

Question 3

Differentiating feature of medulloblastoma and ependymoma are all of the following except?
● A. Ependymoma which tends to grow into the 4th ventricle from the floor
● B. Ependymoma may grow through the foramen of Luschka and/or Magendie
● C. Ependymomas tend to be inhomogeneous on T1WI MRI
● D. The exophytic component of ependymomas tends to be high signal on T2WI MRI
● E. Calcifications are more common in medulloblastoma

Answer 3

E. Calcifications are more common in medulloblastoma

Question 4

Tumor passing from the posterior fossa to the middle fossa though the incisura is highly suggestive of which of the following?
● A. Vestibular schwannoma
● B. Epidermoid cyst
● C. Cysticercosis
● D. Arachnoid cyst
● E. Lipoma

Answer 4

B. Epidermoid cyst

Question 5

All of the following are long tract signs found in foramen magnum lesion except?
● A. Brisk muscle stretch reflexes
● B. Loss of abdominal cutaneous reflexes
● C. Neurogenic bladder
● D. Contralateral Horner syndrome
● E. Nystagmus: classically downbeat

Answer 5

D. Contralateral Horner syndrome

Question 6

Which of following is not included in D/Dx of corpus callosum lesion?
● A. Lymphoma
● B. MS plaque
● C. Lipoma
● D. Diffuse axonal injury from trauma
● E. None of the above

Answer 6

E. None of the above

Question 7

Following conditions can lead to pituitary pseudotumor formation except?
● A. Primary hyperthyroidism
● B. Primary hypogonadism
● C. Pregnancy
● D. Ectopic GHRH secretion
● E. Intracranial hypotension

Answer 7

A. Primary hyperthyroidism

Question 8

Differentiating features of juxta sellar meningioma from macroadenoma are all except?
● A. Homogenous contrast enhancement
● B. Dural tail
● C. Suprasellar epicenter
● D. Pushing the carotids laterally
● E. None of the above

Answer 8

D. Pushing the carotids laterally

Question 9

All of the following are included in metastatic workup of intracranial lesions except?
● A. CT of chest
● B. CT of abdomen
● C. Bone scan
● D. PSA
● E. Mammogram

Answer 9

C. Bone scan

Question 10

What is the most common malignancy of the skull?
● A. Osteogenic sarcoma
● B. Chondrogenic sarcoma
● C. Hemangiosarcoma
● D. Fibrosarcoma
● E. None of the above

Answer 10

A. Osteogenic sarcoma

Question 11

Classic X-ray finding of “starburst” appearance is seen in which of the following?
● A. Hemangioblastoma
● B. Metastasis
● C. Multiple myeloma
● D. Lymphoma
● E. Brown tumor of hyperparathyroidism

Answer 11

A. Hemangioblastoma

Question 12

Meningiomas of CPA present with which of the following?
● A. Early facial nerve involvement
● B. Early hearing loss
● C. Less trigeminal neuralgia like pain than VS
● D. Tinnitus
● E. Rarely calcified

Answer 12

A. Early facial nerve involvement

Question 13

Which of the following features favor nasal glioma in contrast to encephalocele?
● A. Pulsatile
● B. Positive Furstenberg sign
● C. Absence of stalk
● D. Probe can be passed laterally
● E. Presence of hypertelorism

Answer 13

C. Absence of stalk

Question 14

Which of the following are the non-neoplastic thalamic lesions in pediatric and adult patients?
● A. Cavernous angioma
● B. Granuloma
● C. Heterotopias
● D. AVM
● E. Hamartoma

Answer 14

E. Hamartoma

Question 15

A patient presents with 2 months history of short-term memory deficit, seizures, and psychiatric symptoms of anxiety, depression, and behavioral changes. His MRI shows bilateral abnormalities highly restricted to medial temporal lobes on T2
FLAIR and CSF shows pleocytosis: WBCs > 5/mm3. On EEG, epileptic or slow-wave activity involving the temporal lobes is seen. What is the most likely diagnosis?
● A. Mesial temporal sclerosis
● B. Herpes encephalitis
● C. Autoimmune limbic encephalitis
● D. Temporal hamartoma
● E. PCA ischemic infarct

Answer 15

C. Autoimmune limbic encephalitis

Question 16

By the rule of thumb “the differential diagnosis of a
solitary intraparenchymal lesion in an adult posterior fossa is metastasis, metastasis, metastasis until proven otherwise.” Other differential diagnoses in P-fossa of adults include hemangioblastoma, cerebellar astrocytoma, brainstem glioma, choroid plexus tumor, cerebellar liponeurocytoma, abscess, cavernous hemangioma, or hemorrhage. Differential in pediatric posterior fossa includes medulloblastoma (27%), cerebellar astrocytoma (27%), brain stem gliomas (28%), ependymoma, choroid plexus papilloma, and metastasis. How can medulloblastoma be differentiated from ependymoma?
● A. Medulloblastoma arise from the roof of the 4th ventricle and most are solid while ependymoma arise from the floor of the 4th ventricle
● B. The 4th ventricle drapes around the medulloblastoma forming “banana sign” while ependymoma tends to grow through the foramen of Luschka or/and Magendie
● C. Ependymoma tends to homogenous on T1WI while medulloblastoma tends to be heterogenous
● D. The exophytic component of ependymomas tends to be high signal on T2WI MRI while medulloblastoma is only mildly hyperintense
● E. Calcifications are more common in ependymomas while in MB these are less than 10%
● F. All of the above

Answer 16

F. All of the above

Question 17

What is the most common cerebellopontine (CP) angle lesion among the following CP angle lesions listed below?
● A. Vestibular schwannoma
● B. Meningioma
● C. Epidermoid
● D. Arachnoid cyst
● E. Trigeminal neuroma or facial nerve neuroma

Answer 17

A. Vestibular schwannoma

Question 18

How can vestibular schwannoma be differentiated from meningioma in CP angle region?
● A. VS presents with progressive unilateral hearing loss usually with tinnitus, and facial nerve signs and symptoms occur late. In case of CP angle meningioma, early facial nerve involvement is more common, and hearing loss is usually late
● B. Trigeminal neuralgia like pain is more common with CP angle meningioma as compared to VS
● C. On imaging VS shows heterogenous signal and nonuniform enhancement while VP angle meningioma shows homogenous signal and enhancement
● D. Medium size tumor in case of VS look like ice cream in the cone (trumpet sign) with the tumor forming an acute angle between the tumor and petrous bone and enlargement of IAC is often present while in case of meningioma, IAC is usually not enlarged with the tumor flat against the petrous bone forming an obtuse angle with the bone
● E. Calcifications and bony hypertrophy may occur in case of meningioma while in case of VS these are often absent
● F. All of the above

Answer 18

F. All of the above

Question 19

A patient presents in neurosurgical OPD with complaints of craniocervical junction pain in the neck and occiput with increase in pain with increased head movement. This patient also has numbness and tingling in fingers with dissociated sensory loss (loss of pain and temperature contralateral to the lesion with preservation of tactile sensation). There is spastic weakness of the extremities which usually starts in the ipsilateral
upper limb, then the ipsilateral lower limb, then the contralateral lower limb, and finally contralateral upper limb (rotatory paralysis). Following are the differential diagnosis of foramen magnum lesion except?
● A. Meningioma
● B. Chordoma
● C. Ependymoma
● D. Neurilemmoma
● E. Epidermoid
● F. Chondroma
● G. Chondrosarcoma

Answer 19

C. Ependymoma

Question 20

Enhancing ring of tumor may be incomplete and irregular while in case of abscess, the ring is usually complete, often thinner and smoother than the tumor. Abscess is usually brighter than the tumor on DWI MRI. MR spectroscopy is ideal for differentiating the tumor from the abscess with the abscess
showing reduced NAA, Cr, and choline while the tumor shows increased choline peak. What are the differential diagnoses in case of ring-enhancing lesions?
● A. Metastasis (including lymphoma)
● B. Abscess
● C. Glioma (astrocytoma usually glioblastoma)
● D. Infarct
● E. Contusion
● F. Demyelination
● G. Radiation
● H. All of the above

Answer 20

H. All of the above

Question 21

Differential diagnosis of tumors in sellar, suprasellar, or parasellar region includes pituitary tumors (adenohypophyseal tumors and neurohypophyseal tumors), pituitary pseudotumors (thyrotroph hyperplasia, gonadotroph hyperplasia, somatotroph hyperplasia), juxtasellar or suprasellar tumors, or masses (craniopharyngioma, Rathke cleft cyst, meningioma, germ cell tumors, hypothalamic tumors, optic nerve or chiasma tumors). Which of the following are the differentiating points between
hypophysitis and adenoma?
● A. Enlargement of hypophyistis is symmetric while in case of adenoma it is asymmetric
● B. Pituitary stalk is thickened and nontapering in case of hypophysitis while it is not thickened, tapering, and deviated in case of adenoma
● C. Sellar floor is spared in hypophysitis while it may be eroded in case of tumor
● D. Enhancement is intense and may be heterogenous in case of adenoma, while it is less intense and usually homogenous in case of hypophysitis
● E. Mean size at the time of presentation of hypophysitis is 3-cm cube in case of hypophysitis, while it is 10-cm cube in case of adenoma

Answer 21

D. Enhancement is intense and may be heterogenous in case of adenoma, while it is less intense and usually homogenous in case of hypophysitis

Question 22

Differential of orbital tumors in adults include neoplastic lesions (cavernous hemangioma, capillary hemangioma, lymphangioma, melanoma, retinoblastoma, lymphoma), congenital lesion (retinopathy of prematurity, persistent hyperplastic
primary vitreous), infectious, inflammatory, and vascular lesions. What is the most common orbital lesion in pediatric patients among the following?
● A. Dermoid cyst
● B. Hemangioma
● C. Rhabdomyosarcoma
● D. Optic nerve glioma
● E. Lymphangioma

Answer 22

A. Dermoid cyst

Question 23

Following statements are correct regarding the type of intraventricular lesion by location except?
● A. Meningioma is the most common tumor in the atrium of lateral ventricle (trigone) in adults more than 30 years of age while in case of children less than 5 years of age, choroid plexus papilloma is the most common lesion at this location
● B. Astrocytoma is the most common lesion in the frontal horn of ventricle and then meningioma
● C. At the foramen of Monro region, SEGAs are most common in people 6 to 30 years of age with pilocytic astrocytoma in the second and CPP in the third number at this location, while in case of adults more than 30 years, metastasis is the most common tumor at this location
● D. The most common lesion at the 3rd ventricle is colloid cyst, then craniopharyngioma, and then astrocytoma
● E. Epidermoid is the most common lesion in the 4th ventricle and then comes medulloblastoma and ependymoma

Answer 23

E. Epidermoid is the most common lesion in the 4th ventricle and then comes medulloblastoma and ependymoma

Question 24

What is the most common periventricular solid enhancing lesion?
● A. Ependymoma
● B. Lymphoma
● C. Metastatic carcinoma
● D. Ventriculitis
● E. Medulloblastoma

Answer 24

B. Lymphoma

Question 25

How can an encephalocele be differentiated from nasal glioma?
● A. Encephalocele is frequently pulsatile while nasal glioma is nonpulsatile
● B. Encephalocele swells with Valsalva maneuver while nasal glioma does not
● C. Presence of hypertelorism suggests encephalocele while it does not correlate with nasal glioma
● D. Probe can be passed lateral to encephalocele while it cannot be passed lateral to a nasal glioma
● E. Encephalocele is attached to the CNS with a stalk while nasal glioma does not
● F. All of the above

Answer 25

F. All of the above

Question 26

Atlantoaxial subluxation in rheumatoid arthritis is due to which of the following?
● A. Erosion of insertion points of the TAL
● B. Congenital laxity of the TAL
● C. Disruption (tear) of the TAL
● D. Avulsion of the insertion points of the TAL
● E. Incompetence of the odontoid process

Answer 26

A. Erosion of insertion points of the TAL

Question 27

Fractures due to metastatic involvement show which of the following?
● A. Hyperintense on T1WI and hyperintense on T2WI
● B. Hypointense on T1WI and hyperintense on T2WI
● C. Isointense on T1WI and hypointense on T2WI
● D. Hypointense on T1WI and hypointense on T2WI
● E. Hyperintense on T1WI and hypointense on T2WI

Answer 27

B. Hypointense on T1WI and hyperintense on T2WI

Question 28

Criteria for vertebra plana include all of the following except?
● A. Increased density of vertebra
● B. Spares neural arches
● C. Normal disk and intervertebral disk space
● D. Intervertebral vacuum cleft sign
● E. Kyphosis

Answer 28

E. Kyphosis

Question 29

Destruction of the disk space which often involves at least two adjacent vertebral levels is highly suggestive of which of the following?
● A. Tumor
● B. Potts disease
● C. Pyogenic infection
● D. Metastasis
● E. None of the above

Answer 29

C. Pyogenic infection

Question 30

What is the most common sacral neoplasm?
● A. Chordoma
● B. Osteoma
● C. Metastasis
● D. Giant cell tumor
● E. Teratoma

Answer 30

C. Metastasis

Question 31

In which type of sacral agenesis, there is partial bilaterally symmetric defects in the sacrum, iliac bones articulate with S1, and distal segments of the sacrum and coccyx fail to develop?
● A. Type 1
● B. Type 2
● C. Type 3
● D. Type 4
● E. Type 5

Answer 31

B. Type 2

Question 32

Nodular enhancing lesions in spine occur in all of the following except?
● A. Neurofibromatosis
● B. Drop metastasis
● C. Meningioma
● D. Schwannoma
● E. Neurofibroma

Answer 32

C. Meningioma

Question 33

Which of the following is the cause of atlantoaxial subluxation?
● A. Incompetence of transverse atlantal ligament (TAL) which can be due to rheumatoid arthritis (causes erosion of insertion point of TAL), traumatic, congenital laxity of TAL (in Down syndrome), retropharyngeal infection, or chronic steroid use
● B. Incompetence of odontoid process which can be due to odontoid fractures, os odontoideum, erosion of odontoid due to rheumatoid arthritis, neoplastic erosion of odontoid (metastasis), local infection, or congenital absence
● C. Congenital absence of tectorial membrane
● D. Basilar invagination
● E. Both A and B

Answer 33

E. Both A and B

Question 34

Which of the following are the etiologies of pathologic fracture of spine?
● A. Osteoporosis
● B. Neoplasm (metastasis, lymphoma, hemangioma)
● C. Infection
● D. Avascular necrosis of vertebral bodies (with excessive use of steroids)
● E. All of the above

Answer 34

E. All of the above

Question 35

All of the following are destructive lesions of spine except?
● A. Neoplastic (metastatic or primary bone tumors like chordoma, osteoid osteoma, hemangioma)
● B. Paget’s disease
● C. Infection like vertebral osteomyelitis
● D. Ankylosing spondylitis
● E. Chronic renal failure causing spondyloarthropathy resembling infection

Answer 35

B. Paget’s disease

Question 36

Following are the causes of vertebral hyperostosis except?
● A. Paget’s disease
● B. Osteoblastic metastasis (prostate in men and breast in women)
● C. Marfan’s syndrome or Ehlers Danlos syndrome
● D. Osteoid osteoma or osteoblastoma
● E. Bone island (also known as enostosis)

Answer 36

C. Marfan’s syndrome or Ehlers Danlos syndrome

Question 37

Which of the following is the most common sacral neoplasm?
● A. Metastasis
● B. Giant cell tumor
● C. Chordoma
● D. Teratoma
● E. None of the above

Answer 37

A. Metastasis

Question 38

Sacral agenesis is associated with increased incidence of spinal abnormalities like syrinx, tethered cord, lipoma, and lipomyelomeningocele. Which of the following are the types of sacral agenesis?
● A. Type 1: partial unilateral agenesis
● B. Type 2: partial bilaterally symmetric defects in the sacrum
● C. Type 3: total sacral agenesis plus iliac bone fuses with the lowest segment of the lumbar spine present
● D. Type 4: total sacral agenesis plus iliac bones fuse posteriorly in the midline
● E. All of the above

Answer 38

E. All of the above

Question 39

Following are the causes of enhancing nerve roots except?
● A. Tumor (meningeal carcinomatosis and lymphoma)
● B. Infection (CMV)
● C. Inflammatory (Guillain–Barre, arachnoiditis)
● D. Neurofibromatosis

Answer 39

D. Neurofibromatosis

Question 40

Which of the following are the differential of nodular enhancing lesions in the spinal canal?
● A. Neurofibromatosis
● B. Drop metastasis
● C. Neurofibroma
● D. Schwannoma
● E. All of the above

Answer 40

E. All of the above

Question 41

Which of the following are the differentials of intraspinal cysts?
● A. Spinal meningeal cysts
● B. Cystic neurofibroma
● C. Ependymoma
● D. Syringomyelia
● E. Dilated central canal
● F. All of the above

Answer 41

F. All of the above

Question 42

Which of the following are the differentials of diffuse enhancement of nerve roots/cauda equina?
● A. Guillain Barre
● B. Meningitis
● C. CMV
● D. Lymphoma
● E. Sarcoid
● F. All of the above

Answer 42

F. All of the above

Question 43

What is the most common cause of syncope?
● A. Reflex-mediated such as vasovagal or Valsalva/stress-induced
● B. Cardiac valvular etiology or arrhythmia
● C. Orthostatic due to autonomic dysregulation, dehydration, or polypharmacy
● D. Cerebrovascular due to stroke
● E. Seizure

Answer 43

A. Reflex-mediated such as vasovagal or Valsalva/stress-induced

Question 44

Most of transient ischemic attack (TIA) resolve within how long?
● A. < 5 minutes
● B. < 10 minutes
● C. < 20 minutes
● D. < 30 minutes
● E. < 40 minutes

Answer 44

C. < 20 minutes

Question 45

Wide base gait is defined as gait with feet spread of how much?
● A. > 1 to 2 inch apart
● B. > 2 to 4 inch apart
● C. > 4 to 6 inch apart
● D. > 6 to 8 inch apart
● E. > 8 to 10 inch apart

Answer 45

B. > 2 to 4 inch apart

Question 46

A patient presented with abdominal cramps, dry mouth, and diarrhea followed by symmetrical cranial nerve palsies, diplopia, ptosis, loss of accommodation, and pupillary light reflex and descending weakness. Sensory disturbances are absent. Sensorium is clear. What is the most likely diagnosis?
● A. Graves’ disease
● B. Myasthenia gravis
● C. Giant cell arteritis
● D. Botulism
● E. Pseudotumor cerebri

Answer 46

D. Botulism

Question 47

All of the following are causes of facial diplegia except?
● A. Mobius syndrome
● B. Guillain Barre syndrome
● C. Lyme disease
● D. Lhermitte Duclos syndrome
● E. Sarcoidosis

Answer 47

D. Lhermitte Duclos syndrome

Question 48

A 30-year-old patient presented with binocular vision loss after head trauma. All of the following are causes of binocular vision loss except?
● A. Amaurosis fugax
● B. Bilateral PCA flow impairment
● C. Bilateral occipital lobe injury
● D. Raised ICP
● E. Epileptic blindness

Answer 48

A. Amaurosis fugax

Question 49

Exophthalmos is defined as anterior displacement of globe by how much?
● A. > 14 mm
● B. > 16 mm
● C. > 18 mm
● D. > 20 mm
● E. > 22 mm

Answer 49

C. > 18 mm

Question 50

What is the most common cause of unilateral proptosis?
● A. Orbital tumor
● B. Infection (cellulitis)
● C. Hemorrhage
● D. Thyroid disease
● E. Cavernous sinus occlusion

Answer 50

D. Thyroid disease

Question 51

Which of the following investigations is not helpful for diagnosis (nonsensitive, nonspecific) of pulsatile tinnitus?
● A. MRI
● B. MRV
● C. Carotid USG
● D. Angiogram
● E. None of the above

Answer 51

C. Carotid USG

Question 52

How frequently is treatment required for arachnoid cyst?
● A. 10%
● B. 20%
● C. 30%
● D. 40%
● E. 50%

Answer 52

C. 30%

Question 53

Syncope is defined as one or more episodes of brief loss of consciousness with prompt recovery. Which of the following are the etiologies of syncope?
● A. Cerebrovascular (subarachnoid hemorrhage, intracerebral hemorrhage, brainstem infarction, pituitary apoplexy, vertebrobasilar insufficiency, rarely with migraine)
● B. Cardiovascular (carotid sinus syncope, vasopressor syncope, cardiac standstill, orthostatic hypotension)
● C. Infections (meningitis, encephalitis)
● D. Metabolic hypoglycemia
● E. All of the above

Answer 53

E. All of the above

Question 54

Following are the causes of transient neurologic deficit except?
● A. Transient ischemic attack
● B. Migraine
● C. Spinocerebellar degeneration
● D. Seizures
● E. TIA like syndrome (tumor TIA)

Answer 54

C. Spinocerebellar degeneration

Question 55

Wide based gait is a gait with feet spread more than 2 to 4 inches apart. Which of the following are included in the differentials of this symptom?
● A. Idiopathic normal pressure hydrocephalus
● B. Cerebellar ataxia
● C. Sensorimotor peripheral neuropathy
● D. Vestibular ataxia
● E. Myelopathy
● F. All of the above

Answer 55

F. All of the above

Question 56

Following are the causes of diplopia except?
● A. Cranial nerve palsy of any one or a combination of cranial nerves 3, 4, and 6
● B. Intraorbital mass compressing extraocular muscles
● C. Grave’s disease
● D. Myasthenia gravis
● E. Friderichsen syndrome
● F. Giant cell arteritis

Answer 56

E. Friderichsen syndrome

Question 57

Following are included in the most probable cause of gradual onset of anosmia except?
● A. Allergic rhinitis and sinus disease
● B. Intracranial neoplasms
● C. Head trauma
● D. Nasal polyps
● E. Intracranial neoplasms like olfactory groove meningioma

Answer 57

C. Head trauma

Question 58

Marble bone disease is a group of genetic disorders of defective osteoclastic resorption of bone resulting in increased bone density, which may be transmitted either as autosomal dominant or recessive. What is the other name of this disease?
● A. Paget’s disease
● B. Marfan syndrome
● C. Osteopetrosis
● D. Osteoporosis
● E. None of the above

Answer 58

C. Osteopetrosis

Question 59

All of the following are included in the differentials of binocular blindness except?
● A. Bilateral posterior cerebral artery flow impairment
● B. Amaurosis fugax due to giant cell arteritis or TIAs
● C. Bilateral vitreous hemorrhage
● D. Trauma with bilateral occipital lobe injury
● E. Posterior ischemic optic neuropathy usually in the setting of shock

Answer 59

B. Amaurosis fugax due to giant cell arteritis or TIAs

Question 60

Exophthalmos is abnormal protrusion of eyeball. It can be pulsatile or nonpulsatile. All of the following are included in nonpulsatile exophthalmos except?
● A. Intraorbital tumors like optic glioma, optic sheath neuroma, lymphoma or Graves disease or enlargement of periorbital fat
● B. Carotid cavernous fistula or transmitted intracranial pulsations due to defect in orbital roof or vascular tumors
● C. Inflammatory or hemorrhage or third nerve palsy
● D. Cavernous sinus occlusion
● E. Pseudo exophthalmos

Answer 60

B. Carotid cavernous fistula or transmitted intracranial pulsations due to defect in orbital roof or vascular tumors

Question 61

Ptosis is drooping of upper eyelid. Ptosis can be pupil sparing or not pupil sparing. Etiologies of pupil sparing ptosis includes the following except?
● A. Congenital
● B. Traumatic injury to eyelid or traumatic roof fracture
● C. Neurogenic involving third nerve palsy due to compression from tumors or pituitary apoplexy
● D. Myogenic ptosis due to botulism toxin or myasthenia gravis
● E. None of the above

Answer 61

C. Neurogenic involving third nerve palsy due to compression from tumors or pituitary apoplexy

Question 62

Following are the causes of macrocephaly with ventricular enlargement except?
● A. Hydranencephaly
● B. Constitutional ventriculomegaly
● C. External hydrocephalus
● D. Hydrocephalus ex vacuo
● E. Obstructive hydrocephalus

Answer 62

C. External hydrocephalus

Question 63

Which one of the following does not present as a spinal epidural mass?
● A. Bone fracture
● B. Extramedullary hematopoiesis
● C. Vertebral Paget disease
● D. Bony compression secondary to incompetence of odontoid process or transverse atlantal ligament
● E. Cervical or thoracic spinal stenosis

Answer 63

E. Cervical or thoracic spinal stenosis

Question 64

A 17-year-old male patient presents with insidious asymmetrical painless wasting of the distal UE muscles. What is the most likely diagnosis?
● A. Epidural lipomatosis
● B. Vertebral Paget disease
● C. OPLL
● D. Hirayama disease
● E. Idiopathic spinal cord herniation

Answer 64

D. Hirayama disease

Question 65

All are signs of ALS except?
● A. It is an upper and lower motor neuron disease
● B. Slight spasticity of LEs
● C. Atrophic weakness of the hands and forearms
● D. Fasciculations in the UE
● E. Loss of sphincter control

Answer 65

E. Loss of sphincter control

Question 66

What is the most common cause of sciatica?
● A. Diskitis
● B. Spinal stenosis
● C. Lumbar disk herniation
● D. Tumor
● E. None of the above

Answer 66

C. Lumbar disk herniation

Question 67

A patient presents with pain in the sciatic distribution and weakness of external rotation and abduction of the hip. On clinical examination, Freiberg test and Pace test are positive.
What is the most likely diagnosis?
● A. Piriformis syndrome
● B. Femoral neuropathy
● C. Diabetic neuropathy
● D. Sacral tumor
● E. Herniated lumbar intervertebral disk

Answer 67

A. Piriformis syndrome

Question 68

What is the most common etiology of pure motor hemiplegia?
● A. Ischemic lacunar infarct
● B. Tumor of motor strip
● C. Brainstem ischemic infarct
● D. Foramen magnum lesions
● E. Acute subdural hematoma

Answer 68

A. Ischemic lacunar infarct

Question 69

Which of the following conditions presents with descending paralysis with ophthalmoplegia?
● A. Guillain-Barre syndrome
● B. Tick borne paralysis
● C. Myasthenia gravis
● D. Spinal infections
● E. Ascending hematomyelia

Answer 69

D. Spinal infections

Question 70

In sacral plexus lesions, which of the following muscles will be spared on EMG?
● A. Gluteus maximus
● B. Gluteus medius
● C. Gluteus minimus
● D. Piriformis
● E. Both A and B

Answer 70

E. Both A and B

Question 71

Which of the following feature suggests L4 radiculopathy?
● A. Iliopsoas weakness
● B. Quadriceps weakness
● C. Preservation of power in thigh adductors
● D. Sensory loss in anterior thigh
● E. Intact sensations from knee to medial malleolus

Answer 71

B. Quadriceps weakness

Question 72

In patients with foot drop, which of the following muscles must be spared to differentiate common peroneal nerve palsy from L4–L5 radiculopathy?
● A. Anterior tibialis
● B. Posterior tibialis
● C. Extensor digitorum longus
● D. Extensor hallucis longus
● E. None of the above

Answer 72

B. Posterior tibialis

Question 73

Which of the following is not an etiology of Lhermitte’s sign?
● A. Multiple sclerosis
● B. Cervical spondylosis
● C. Subacute combined degeneration
● D. Central cord syndrome
● E. Anterior cord syndrome

Answer 73

E. Anterior cord syndrome

Question 74

All of the following are the congenital causes of myelopathy except?
● A. Arnold Chiari malformation
● B. Tethered cord or syringomyelia
● C. Cervical or thoracic spine stenosis
● D. Neurenteric cyst or hereditary spastic paraplegia
● E. Cord compression that occurs with some mucopolysaccharidoses

Answer 74

C. Cervical or thoracic spine stenosis

Question 75

Which of the following are the possible causes of myelopathy?
● A. Congenital
● B. Acquired
● C. Neoplastic (primary spine tumors, carcinomatous meningitis, or epidural metastasis)
● D. Vascular (spinal cord infarction, vascular malformation)
● E. All of the above

Answer 75

E. All of the above

Question 76

Causes of sciatica include congenital (meningeal cyst, conjoined nerve root), acquired (spinal stenosis, juxtafacet cyst, nerve root sheath cyst), infections, neoplastic, inflammatory, and vascular. What is the most common cause of sciatica?
● A. Radiculopathy due to herniated lumbar disk
● B. Bone or soft tissue tumors along the course of sciatic nerve
● C. Diskitis
● D. Spinal stenosis, spondylosis/spondylolysis/spondylolisthesis
● E. Nerve root sheath cyst

Answer 76

A. Radiculopathy due to herniated lumbar disk

Question 77

Which of the following are the points to differentiate femoral neuropathy from L4 radiculopathy?
● A. Distribution of sensory loss in femoral neuropathy is anterior thigh, while in case of L4 radiculopathy, it is dermatome from knee to medial malleolus sparing anterior thigh
● B. Iliopsoas is weak in case of femoral neuropathy while it is normal in case of L4 radiculopathy
● C. Thigh adductors are normal in case of femoral neuropathy while it may be weak in case of L4 radiculopathy
● D. Quadriceps are weak in case of both femoral neuropathy and in L4 radiculopathy
● E. All of the above

Answer 77

E. All of the above

Question 78

Following are the possible causes of acute paraplegia or quadriplegia except?
● A. In infancy spinal muscular atrophy, spinal cord injury, congenital myopathies, infantile botulism
● B. Traumatic spinal cord injury
● C. Congenital (achondroplasia, syringomyelia)
● D. Spinocerebellar degeneration
● E. Metabolic (thallium poisoning, central pontine myelinolysis)
● F. Infections
● G. Peripheral neuromuscular disorders (GBS, myopathies)

Answer 78

D. Spinocerebellar degeneration

Question 79

Following are the causes of hemiplegia or hemiparesis due to insult within the brain except?
● A. Lesions of the contralateral internal capsule
● B. Lesions of the brain stem
● C. Lesions of the cervicomedullary junction
● D. Unilateral spinal cord lesion
● E. Brain tumor or traumatic epidural or subdural hematoma

Answer 79

D. Unilateral spinal cord lesion

Question 80

Which of the following are the differentials of ascending paralysis?
● A. GBS
● B. Tick-borne paralysis
● C. Spinal infection
● D. Patients with a prior spinal cord injury which can be due to ascending hematomyelia or post-traumatic syringomyelia
● E. All of the above

Answer 80

E. All of the above

Question 81

Chronic low-back pain is pain in back after 3 months. What are the causes of chronic low-back pain?
● A. Degenerative conditions like spinal stenosis, degenerative spondylolisthesis
● B. Spondyloarthropathies like ankylosing spondylitis
● C. Osteitis condensans ilii which is increased density in the ilium which is usually found in pregnant women
● D. Psychological overlay
● E. All of the above

Answer 81

E. All of the above

Question 82

Foot drop is because of weakness of anterior tibialis muscle which is innervated by deep peroneal nerve. What is the most common cause of foot drop?
● A. L4/L5 radiculopathy
● B. Common peroneal nerve palsy
● C. Parasagittal lesion in the brain
● D. Lumbosacral plexus neuropathy
● E. Muscular dystrophy

Answer 82

A. L4/L5 radiculopathy

Question 83

Lhermitte’s sign is electric shock like sensation radiating down the spine usually provoked by neck flexion. Which of the following are the etiologies in which this sign can be positive?
● A. Multiple sclerosis
● B. Cervical spondylosis
● C. Cervical cord tumor
● D. Cervical disk herniation
● E. Chiari type 1 malformation
● F. All of the above

Answer 83

F. All of the above

Question 84

Owing to risk of developing paraparesis, quadriplegia, multiple cranial nerves, dementia, and hydrocephalus, which of the following dyes must not be used as stain in neurosurgical procedures?
● A. Indigo carmine
● B. Methylene blue
● C. Flourescien
● D. Indocyanine green
● E. Gentian violet

Answer 84

B. Methylene blue

Question 85

For children below 3 years of age, the knob of Mayfield head holder clamp housing the tension spring and gauge is tightened up to how much?
● A. 20 to 30 lbs
● B. 30 to 40 lbs
● C. 40 to 50 lbs
● D. 50 to 60 lbs
● E. Not applicable

Answer 85

E. Not applicable

Question 86

Microfibrillar collagen promotes adhesion and aggregation of platelets and leads to chemical hemostasis. It is rendered ineffective if platelets count is how much?
● A. < 50,000/mL
● B. < 40,000/mL
● C. < 30,000/mL
● D. < 20,000/mL
● E. < 10,000/mL

Answer 86

E. < 10,000/mL

Question 87

Which of the following is an important imaging view of MRI to identify L5–S1 disk space for preoperative localization of level by identifying sacral ala?
● A. Sagittal view
● B. Coronal view
● C. Axial view
● D. Both A and B
● E. Both A and C

Answer 87

C. Axial view

Question 88

If best osteoconductive and osteogenic properties are required, which bone graft is preferable?
● A. Cancellous bone graft
● B. Cortical bone graft
● C. Vascularized autograft
● D. Bone marrow aspirate
● E. Devascularized bone graft

Answer 88

A. Cancellous bone graft

Question 89

Bone growth stimulators are indicated to be used in all of following conditions except?
● A. Diabetes
● B. Inflammatory arthritis
● C. Systemic vascular disease
● D. Malignancy
● E. Cigarette smokers

Answer 89

D. Malignancy

Question 90

Which of the following dural substitutes is absorbable, retains suture, and can be used with dural sealant?
● A. Tutopatch®
● B. Neuro-Patch®
● C. DuraGen®
● D. Durepair®
● E. DuraMatrix®

Answer 90

A. Tutopatch®

Question 91

What is the lateral limit of safe region for posterior iliac crest bone graft in order to protect superior cluneal nerves crossing iliac crest?
● A. 3 cm
● B. 5 cm
● C. 6 cm
● D. 8 cm
● E. 9 cm

Answer 91

D. 8 cm

Question 92

Indigo carmine is a blue dye that can be used intrathecally to locate CSF leaks. Fluorescein is another dye which can be used intrathecally or IV. Fluorescein is used in diluted form because it can cause which of the following side effects?
● A. Brain stem herniations
● B. Increased ICP
● C. Seizures
● D. Blindness
● E. Memory impairment

Answer 92

C. Seizures

Question 93

A patient is given IT dye after which he/she develops quadriplegia, multiple cranial nerve palsy, dementia, and hydrocephalus. Which dye is given to this patient?
● A. Indigo carmine
● B. Methylene blue
● C. Fluorescein
● D. Indigo cyanine
● E. Ultravist

Answer 93

B. Methylene blue

Question 94

For spine cases, the ideal location of observer’s eye piece is directly opposite the surgeon. For intracranial work, the observer’s eye piece is placed to the right of the operators except in which of the following cases where it is placed to the left?
● A. Transsphenoidal surgery
● B. Right posterior fossa craniotomy in lateral oblique position
● C. For supine position surgery with head tilt toward one side
● D. For craniotomy of posterior fossa in prone position
● E. Both A and B

Answer 94

E. Both A and B

Question 95

Pin-based head fixation include the Mayfield head holder or head frame. Following are the indications for pin stabilization except?
● A. Craniotomy for most intracranial vascular operations
● B. Craniotomy for most tumor operations especially if there is need of retractor system that attaches to the Mayfield head holder
● C. When intraoperative image guidance system is used
● D. For craniotomy in patients less than 3 years of age
● E. In cervical spine often used for posterior cervical operations

Answer 95

D. For craniotomy in patients less than 3 years of age

Question 96

Which of the following are the complications of pin head fixation?
● A. Malposition of pins through unintended anatomic structure like pinna, orbit, superficial artery, or poor fixation by not properly placing pins close to the equator
● B. Skin penetration by pins which can cause injury to intracranial structures
● C. Skin necrosis or skull fracture
● D. Slippage of any of the joints or connections to the OR table or clamp breakage or bleeding from pin site
● E. All of the above

Answer 96

E. All of the above

Question 97

All of the following are included in the mechanical means of hemostasis except?
● A. Bone wax use
● B. Ligature
● C. Use of monopolar or bipolar cautery
● D. Use of silver clips (hemoclips)
● E. None of the above

Answer 97

C. Use of monopolar or bipolar cautery

Question 98

All of the following are means of chemical hemostasis except?
● A. Gelatin sponge
● B. Oxidized cellulose
● C. Bone wax
● D. Microfibrillar collagen
● E. Thrombin

Answer 98

C. Bone wax

Question 99

All of the following are included in the allograft for use as dural substitutes except?
● A. Reconstituted material like processed gelatin
● B. Processed intact natural materials like ovine or bovine
● C. Fascia lata or galea or pericranium
● D. Synthetic materials like polyesterurethane
● E. Biosynthetic materials like cellulose

Answer 99

C. Fascia lata or galea or pericranium

Question 100

Which of the following are the components of bone graft that are important for fusion?
● A. Osteoinduction which is recruitment of mesenchymal cells and the stimulation of these cells to develop into osteoblast or osteoclasts
● B. Osteogenesis which is formation of new bone by host or graft mesenchymal stem cells
● C. Osteoconduction which is the structure of the graft that acts as a scaffold upon which new bone and blood vessels form
● D. Mechanical stability which is the structural anatomical biomechanical support
● E. All of the above

Answer 100

E. All of the above

Question 101

Which of the following bone graft material has the best osteogenic property?
● A. Cancellous graft
● B. Cortical autograft
● C. Bone marrow aspirate
● D. Vascularized autograft
● E. Demineralized bone matrix

Answer 101

A. Cancellous graft

Question 102

Intraoperative brain swelling etiologies include all of the following except?
● A. Extraparenchymal bleeding: from a vessel or intraoperative aneurysm rupture
● B. Intracerebral hemorrhage
● C. Venous outflow obstruction
● D. Vasodilatation induced by hypocarbia
● E. Severe diffuse cerebral edema

Answer 102

D. Vasodilatation induced by hypocarbia

Question 103

What is the last life-saving measure for uncontrollable intraoperative brain swelling?
● A. Reverse Trendelenburg position
● B. Removal of swollen brain
● C. Decompressive craniectomy
● D. Apply pressure on the brain
● E. Place the head in neutral position

Answer 103

B. Removal of swollen brain

Question 104

Cranioplasty following posterior fossa surgery for vestibular schwannoma reduced the incidence of postoperative headache to how much?
● A. 4%
● B. 17%
● C. 50%
● D. 70%
● E. 100%

Answer 104

A. 4%

Question 105

What is the incidence of postoperative headache after posterior fossa surgery?
● A. 100%
● B. 80%
● C. 95%
● D. 97%
● E. 90%

Answer 105

B. 80%

Question 106

A patient who underwent tumor resection and awake craniotomy develops lethargy, confusion, severe headache, nausea, vomiting, and seizures. For awake craniotomy, skull block is being done for which local anesthetic agents injection must be applied at many regions?
● A. 1 region
● B. 2 regions
● C. 3 regions
● D. 4 regions
● E. 5 regions

Answer 106

D. 4 regions

Question 107

Definitive treatment of syndrome of trephination is indicated if headache does not settle within how long?
● A. 2 months
● B. 3 months
● C. 4 months
● D. 5 months
● E. 6 months

Answer 107

B. 3 months

Question 108

During awake craniotomies, what is the maximum current that can be used to stimulate any area of cortex?
● A. 2 mA
● B. 4 mA
● C. 6 mA
● D. 8 mA
● E. 10 mA

Answer 108

E. 10 mA

Question 109

Which of the following nerves must not be anesthetized during awake craniotomies?
● A. Supraorbital nerve
● B. Facial nerve
● C. Postauricular nerve
● D. Lesser occipital nerve
● E. Third occipital nerve

Answer 109

B. Facial nerve

Question 110

During awake craniotomy, total speech arrest occurs by stimulating which area of nondominant hemisphere?
● A. Pars opercularis
● B. Frontal operculum
● C. Posterior middle temporal gyrus
● D. Anterior supramarginal gyrus
● E. None of the above

Answer 110

A. Pars opercularis

Question 111

Which of the following is a contraindication of awake craniotomy?
● A. Thalamic tumor
● B. Epileptic foci in eloquent brain area
● C. Removal of brainstem tumors
● D. Tumor near motor strip
● E. Significant speech/motor deficits

Answer 111

E. Significant speech/motor deficits

Question 112

The FDA released a number of recommendations for use of drill to reduce injury during craniotomy which are the following?
● A. Selection of appropriate perforator based on the skull thickness (pediatric vs. adults)
● B. Keeping the perforator perpendicular to the skull throughout the drilling process
● C. Do on rock, rotate, or change the angel of the device during drilling
● D. Avoid using excessive pressure on the drill
● E. Use caution when drilling through areas of irregular bone contour, curvature, or variations in thickness or drilling where bone might be diseased or incompetent
● F. All of the above

Answer 112

F. All of the above

Question 113

All of the following are etiologies of intraoperative brain swelling except?
● A. Extraparenchymal bleeding from a vessel or intraoperative aneurysm rupture
● B. Intracerebral hemorrhage
● C. Venous outflow obstruction
● D. Vasoconstriction induced by hypercapnia
● E. Severe diffuse cerebral edema following stroke or traumatic brain injury

Answer 113

D. Vasoconstriction induced by hypercapnia

Question 114

Management of intraoperative brain swelling include finding out the cause and treating that cause. Other measures that should be taken for decreasing brain swelling include which of the following?
● A. Elevation of head of bed
● B. Making sure the jugular veins are not kinked
● C. Ruling out hypercarbia, making sure that endotracheal tube is not kinked, and checking the patient’s end tidal pCO2
● D. Measures to lower ICP are adopted, which includes giving mannitol, draining CSF, tapping and draining ventricle, having the anesthesiologist hyperventilate the patient’s pCO2 to 30 to 35 mmHg
● E. Emergency intubation for patients are undergoing awake craniotomy and intraoperative ultrasound or CT of brain
● F. All of the above

Answer 114

F. All of the above

Question 115

The overall risk of postoperative hemorrhage is 0.8 to 1.1%. Which hematomas constitute 43 to 60% of these?
● A. Intraparenchymal
● B. Epidural
● C. Subdural
● D. Intrasellar
● E. Mixed

Answer 115

A. Intraparenchymal

Question 116

What are the postoperative medications that are given to a patient after craniotomy for brain tumor?
● A. Dexamethasone and H2 antagonist
● B. Antiepileptic drugs
● C. Cardene drip to keep systolic BP less than 160 mmHg and diastolic BP less than 100 mmHg
● D. Prophylactic antibiotics are continued
● E. Acetaminophen and codeine are also given for pain relief
● F. All of the above

Answer 116

F. All of the above

Question 117

All of the following are causes of postoperative deterioration of patients after craniotomy except?
● A. Hematoma or cerebral infarction (from compromise of normal arteries or veins)
● B. Postoperative seizures or acute hydrocephalus
● C. Syringomyelia formation
● D. Pneumocephalus or brain edema
● E. Persistent anesthetic effect or vasospasm

Answer 117

C. Syringomyelia formation

Question 118

What are the causes of postoperative headache in a patient after craniotomy?
● A. Traction of the dura when the bone is not replaced
● B. Traction on dura due to tight dural closure
● C. Temporalis or nuchal muscle dissection
● D. Nerve entrapment in the closing suture or healing scar
● E. Intradural blood and/or CSF leak
● F. All of the above

Answer 118

F. All of the above

Question 119

Phase reversal technique can be used to see primary sensory or motor cortex. What is the use of intraoperative cortical mapping in a patient undergoing craniotomy?
● A. Motor strip localization
● B. Sensory cortex localization
● C. Speech centers determination
● D. All of the above

Answer 119

D. All of the above

Question 120

Indications of awake craniotomy include surgery in eloquent brain area, removal of brain stem tumors, or for some seizure surgery to look for seizure focus. All of the following are contraindications of awake craniotomy except?
● A. Patients who are unable to cooperate
● B. Very young or very elderly patients
● C. Confused patients
● D. Those with significant speech deficit already present
● E. Those with no language barrier

Answer 120

E. Those with no language barrier

Question 121

What is the typical sequence of anesthesia in case of awake craniotomy?
● A. In the preoperative holding area, precedex is started
● B. Induction of anesthesia is given using propofol and skull block is applied
● C. Inhalational anesthesia is started and continued until dura starts to open, at which point inhalational anesthesia is stopped
● D. Remifentanil is given for pain control with neurophysiologic resting performed at this time
● E. Once the intracranial part of the operation is complete, general anesthesia is given again and the operation is completed
● F. All of the following

Answer 121

F. All of the following

Question 122

Advantages of sitting position for posterior fossa craniotomies include improved drainage of blood and CSF out of the surgical site, enhanced venous drainage which helps reduce venous bleeding, easy ventilation, and patients’ head can be kept at exactly midline. Which of the following are included in the
disadvantages of sitting position?
● A. Possible air embolism
● B. Fatigue of operator’s hand and risk of postoperative hematoma at the surgical site
● C. Possible brachial plexus injury and mid cervical quadriplegia
● D. Extent of postoperative pneumocephalus is more pronounced and venous pooling of blood in the lower extremities
● E. All of the above

Answer 122

E. All of the above

Question 123

Air embolism is suspected in any operative case in which the surgical site is higher than the heart. Transesophageal echocardiography and precordial Doppler ultrasound are the tests to see air embolism in heart. Following are included in the treatment of air embolism except?
● A. The site of air entry is found and occluded and the patient’s head is lowered if at all possible
● B. Jugular venous compression or aspiration of air from right atrium
● C. Nitrous oxide is given if it is not being used
● D. Patient is ventilated with 100% oxygen
● E. Pressors volume expanders are used to maintain blood pressure

Answer 123

C. Nitrous oxide is given if it is not being used

Question 124

Lateral oblique position is also known as Park Bench position. Axillary roll is used for the down-side arm and upper arm is supported on pillows or towels. Adhesive tape is used to pull down the upper shoulder. Thorax is usually elevated to what degrees in such cases?
● A. 10 to 15 degrees
● B. 20 to 25 degrees
● C. 30 to 35 degrees
● D. 40 to 45 degrees
● E. It is kept flat

Answer 124

A. 10 to 15 degrees

Question 125

Indications for paramedian suboccipital craniectomy include all of the following except?
● A. Access to CPA lesions like vestibular schwannoma or for microvascular decompression
● B. For lesions in the cerebellar hemisphere
● C. For access to the posterior communicating artery aneurysms
● D. For access to the vertebral artery for aneurysms or for vertebral endarterectomy
● E. For access to the anterolateral brain stem

Answer 125

C. For access to the posterior communicating artery aneurysms

Question 126

Which of the following statements are correct regarding access to CP angle lesions through paramedian incision?
● A. A slightly curved retromastoid incision is made 5 mm medial to the mastoid notch
● B. 5–4-6 incision (5 mm medial to mastoid notch, 6 cm above notch, and 4 cm below notch) is made for approach to the fifth nerve like in microvascular decompression
● C. 5–5-5 incision (5 mm medial to mastoid notch, 5 cm above notch, and 5 cm below notch) is used for microvascular decompression for hemifacial spasm or for small vestibular schwannoma
● D. 5–4-6 incision (5 mm medial to notch, 4 cm above notch, and 6 cm below notch) is used for glossopharyngeal neuralgia
● E. All of the above

Answer 126

E. All of the above

Question 127

For microvascular decompression, a craniectomy of 2 cm is used in the angle between transverse sinus and sigmoid sinus while for small tumors (< 2.5 cm), a 4-cm craniectomy is used in the same space. What are the boundaries of craniectomy for large tumors?
● A. Transverse sinus superiorly
● B. Foramen magnum inferiorly
● C. Sigmoid sinus laterally
● D. Midline medially
● E. All of the above

Answer 127

E. All of the above

Question 128

Burr hole for placement of emergency ventriculostomy is done at Frazier point which is 3 to 4 cm from midline and how much distance from the inion?
● A. 6 to 7 cm above the inion
● B. 3 to 4 cm above the inion
● C. 6 to 7 cm above the inion in adults, while 3 to 4 cm above inion in children
● D. 8 cm above inion in adults, while 5 cm above inion in children
● E. None of the above

Answer 128

C. 6 to 7 cm above the inion in adults, while 3 to 4 cm above inion in children

Question 129

For midline suboccipital craniectomies, Y-shaped durotomy is often used and craniectomy is done with no intention of replacing the bone. What is the advantage of not replacing the bone at this location?
● A. It is cumbersome to place bone here
● B. It can dip into cerebellum when the patient lies on head
● C. If there is postoperative swelling, the inelastic bone will cause more pressure to be transmitted to the brainstem
● D. There is more chance of postoperative infection if bone is placed
● E. None of the above

Answer 129

C. If there is postoperative swelling, the inelastic bone will cause more pressure to be transmitted to the brainstem

Question 130

The two main approaches for the 4th ventricle are transvermian approach and telovelar approach. Following statements are correct regarding these approaches except?
● A. Transvermian approach gives wider and slightly more rostral exposure than telovelar approach
● B. The risks of caudal vermis syndrome, cerebellar mutism, and injury to caudate nucleus are more in case of transvermian approach
● C. No nerve tissue is harmed in case of telovelar approach
● D. Telovelar approach causes decreased access to the lateral recess of the 4th ventricle
● E. Telovelar approach provides narrower corridor as compared to transvermian approach

Answer 130

D. Telovelar approach causes decreased access to the lateral recess of the 4th ventricle

Question 131

The causes of CSF fistula are abnormal CSF hydrodynamics, poor wound closure, or subarachnoid scarring. The treatment of CSF fistula includes elevation of the head of bed, lumbar
subarachnoid drainage, reinforcement of skin incisions, or surgical correction. What are the treatment options for suboccipital pseudomeningocele?
● A. Noninvasive measures like expectant management, fluid restriction, head wrapping, keeping head of bed elevated, and acetazolamide use
● B. Percutaneous aspiration
● C. Direct surgical exploration with multilayer closure
● D. Lumbar drainage or ventricular drainage
● E. All of the above

Answer 131

E. All of the above

Question 132

Which of the following is not an ideal indication of pterional craniotomy?
● A. All aneurysms of anterior circulation
● B. Basilar tip aneurysms
● C. Direct surgical approach to cavernous sinus
● D. Primarily sellar PitNET
● E. Craniopharyngioma

Answer 132

D. Primarily sellar PitNET

Question 133

What is the head rotation required in pterional craniotomy for exposure of Acom artery aneurysm?
● A. 30 degrees from vertical
● B. 45 degrees from vertical
● C. 60 degrees from vertical
● D. 75 degrees from vertical
● E. 90 degrees from vertical

Answer 133

C. 60 degrees from vertical

Question 134

What must be linear incision for small craniectomy in temporal region for laterally located vestibular schwannoma?
● A. 0.5 cm anterior to the EAC, extending 7 to 8 cm above the zygomatic arch
● B. 1 cm anterior to the EAC, extending 7 to 8 cm above the zygomatic arch
● C. 0.5 cm anterior to the EAC, extending 3 to 4 cm above the zygomatic arch
● D. 2 cm anterior to the EAC, extending 7 to 8 cm above the zygomatic arch
● E. 1.5 cm anterior to the EAC, extending 7 to 8 cm above the zygomatic arch

Answer 134

A. 0.5 cm anterior to the EAC, extending 7 to 8 cm above the zygomatic arch

Question 135

Without the use of mapping techniques to localize speech, one can usually safely resect up to how much from the temporal tip in dominant hemisphere?
● A. 3 to 4 cm
● B. 4 to 5 cm
● C. 6 to 7 cm
● D. 7 to 8 cm
● E. 1 to 2 cm

Answer 135

B. 4 to 5 cm

Question 136

Which of the following points is not considered a danger point during frontal craniotomy?
● A. Motor speech area
● B. Anterior cerebral artery
● C. Sensory speech area
● D. Superior sagittal sinus
● E. Corpus callosum

Answer 136

C. Sensory speech area

Question 137

Sylvian fissure is considered a danger point in temporal craniotomy owing to the presence of which structure?
● A. ACA
● B. MCA
● C. Wernicke’s area
● D. Sylvian vein
● E. None of the above

Answer 137

B. MCA

Question 138

All of the following are indications of pterional craniotomies except?
● A. For aneurysms which include anterior circular aneurysms and basilar tip aneurysms
● B. Direct surgical approach to cavernous sinus
● C. Suprasellar tumors like pituitary adenoma or craniopharyngioma
● D. Third ventricular tumors like colloid cyst
● E. Sphenoid wing meningioma tumors

Answer 138

D. Third ventricular tumors like colloid cyst

Question 139

For pterional approach, skin incision is started 1 cm anterior to the tragus from the zygomatic arch with curving slightly anteriorly and staying behind the hairline to widow’s peak. Which of the following statements are correct regarding position of head?
● A. It is kept 30 degrees from vertical for posterior exposure, for example, for ICA, P comm, carotid terminus, or basilar bifurcation aneurysms
● B. 45 degrees from vertical for middle exposure, for example, for ICA–MCA aneurysms
● C. 60 degrees from vertical for anterior circle of Willis exposure, for example, for a-comm aneurysms, suprasellar tumors
● D. All of the above

Answer 139

D. All of the above

Question 140

The sylvian fissure can be exposed by starting at a point where the carotid artery penetrates the fissure and working laterally (which is easier when prolific veins overlie the junction of the frontal and temporal lobes) or by working from lateral aspect of fissure medially. Which artery crosses the sylvian
fissure which needs to be spared during opening of fissure?
● A. Middle cerebral artery
● B. Anterior cerebral artery
● C. Internal carotid artery
● D. Artery of sylvian fissure
● E. No artery crosses the sylvian fissure

Answer 140

E. No artery crosses the sylvian fissure

Question 141

Which of the following are the indications of temporal craniotomy?
● A. Temporal lobe biopsy or temporal lobectomy
● B. Temporal lobe hematoma evacuation or tumors of temporal lobe
● C. Small laterally placed vestibular schwannomas or for access to the floor of the middle cranial fossa
● D. Access to the medial temporal lobe
● E. All of the above

Answer 141

E. All of the above

Question 142

To access the temporal tip, incision is placed midway between the lateral canthus and which of the following?
● A. Mastoid notch
● B. Tragus
● C. External auditory canal
● D. Inion
● E. Mastoid tip

Answer 142

C. External auditory canal

Question 143

For dominant temporal lobe lobectomy, safe resection up to 4 to 5 cm from the temporal tip can be used, while on nondominant hemisphere, it is 6 to 7 cm. It is best to amputate the temporal lobe backward from the tip and medially up to incisura to prevent damage to brainstem. What structure of brain is at risk of injury at this region?
● A. Broca’s area
● B. Wernicke’s area
● C. Motor cortex
● D. Auditory brain cortex
● E. None of the above

Answer 143

B. Wernicke’s area

Question 144

Which of the following are the indications of frontal craniotomy?
● A. Access to the frontal lobe of brain for infiltrating brain tumors
● B. Approach to the 3rd ventricle
● C. Approach to sellar tumors in some situations
● D. Repair of ethmoidal CSF fistula
● E. All of the above

Answer 144

E. All of the above

Question 145

Danger points in case of frontal craniotomy are the following except?
● A. Anterior cerebral arteries in midline
● B. Injury to Wernicke’s area
● C. Injury to superior sagittal sinus with excessive bleeding
● D. Injury to corpus callosum
● E. Injury to Broca’s area

Answer 145

B. Injury to Wernicke’s area

Question 146

What is the most commonly injured artery during deep dissection of the sylvian fissure?
● A. Middle cerebral artery
● B. Anterior cerebral artery
● C. Internal carotid artery
● D. Anterior choroidal artery
● E. None of the above

Answer 146

A. Middle cerebral artery

Question 147

Large bifrontal skin incision from ear to ear is also known what?
● A. Pterional skin incision
● B. Modified Frazier’s incision
● C. Souttar skin incision
● D. Frontal temporal zygomatic skin incision
● E. None of the above

Answer 147

C. Souttar skin incision

Question 148

Which of following approaches to trigone of lateral ventricles is not used if neurology of the patient is intact?
● A. Lateral temporal parietal
● B. Superior parietal occipital
● C. Tanscallosal
● D. Transtemporal horn
● E. Occipital lobe incision or occipital lobectomy

Answer 148

E. Occipital lobe incision or occipital lobectomy

Question 149

Which approach is preferred for tumors in the 3rd ventricle extending into lateral ventricle with gross hydrocephalus?
● A. Transcallosal approach
● B. Transsphenoidal approach
● C. Transcortical approach
● D. Subfrontal approach
● E. Subtemporal approach

Answer 149

C. Transcortical approach

Question 150

What are the parameters for craniotomy while using transcallosal approach to the 3rd ventricle so as to preserve important structures?
● A. 3 cm anterior and 3 cm posterior to coronal suture
● B. 4 cm anterior and 3 cm posterior to coronal suture
● C. 2 cm anterior and 4 cm posterior to coronal suture
● D. 4 cm anterior and 2 cm posterior to coronal suture
● E. 4 cm anterior and 4 cm posterior to coronal suture

Answer 150

D. 4 cm anterior and 2 cm posterior to coronal suture

Question 151

To prevent complication of disconnection syndrome, callosotomy performed must not exceed how much?
● A. 0.5 cm
● B. 2.5 cm
● C. 3.5 cm
● D. 4.5 cm
● E. 1.5 cm

Answer 151

B. 2.5 cm

Question 152

Bilateral forniceal lesions can result in loss of short-term memory and ability for new learning, which can be avoided while approaching the 3rd ventricle via all methods except?
● A. Stay as close to midline as possible
● B. If needed open foramen of Monro laterally
● C. Making incision posteriorly sacrificing thalamostriate vein
● D. Incising the anterosuperior margin of the foramen through the column of both fornices
● E. Interforniceal approach

Answer 152

D. Incising the anterosuperior margin of the foramen through the column of both fornices

Question 153

After decompressive craniectomy, bone flap can be stored externally for future reimplantation by saturating with sterile preservative solution (e.g., RPMI medium). It must be stored at what temperature?
● A.−80C
● B.−70C
● C.−60C
● D.−50C
● E.−40C

Answer 153

A.−80C

Question 154

In noncontaminated situations, cranioplasty can be done after how long?
● A. 1 to 2 weeks
● B. 3 to 4 weeks
● C. 5 to 10 weeks
● D. 6 to 12 weeks
● E. 6 months

Answer 154

D. 6 to 12 weeks

Question 155

For transcallosal approach to the lateral or third ventricle, thorax should be elevated up to what degrees?
● A. 10 degrees
● B. 20 degrees
● C. 30 degrees
● D. 40 degrees
● E. 50 degrees

Answer 155

B. 20 degrees

Question 156

Which of the following statements are correct regarding approaches to the lateral ventricle?
● A. Approaches to the atrium (trigone) include middle temporal gyrus, lateral temporal parietal approach, superior parietal occipital approach, transcallosal, transtemporal horn, and
through occipital lobe incision or occipital lobectomy
● B. Approach to frontal horn is through middle frontal gyrus
● C. Midventricular body approach includes through transcallosal and middle frontal gyrus approach
● D. Temporal horn is approached by dissection through middle temporal gyrus and transtemporal horn
● E. All of the above

Answer 156

E. All of the above

Question 157

Approaches to the third ventricle include which of the following?
● A. Transcortical approach
● B. Transcallosal approach
● C. Subfrontal approach
● D. Transsphenoidal approach
● E. Subtemporal approach
● F. All of the above

Answer 157

F. All of the above

Question 158

Transcallosal approach to the lateral or third ventricle is performed through an interhemispheric approach to the corpus callosum via a parietal craniotomy, usually right sided in a left hemisphere dominant patient. Following statements are correct regarding indications of this approach except?
● A. Colloid cysts is excised through this approach
● B. Craniopharyngiomas in the third ventricle can also be approached through this approach
● C. Cysticercosis cyst cannot be removed through this approach
● D. Thalamic gliomas can also be removed using this approach
● E. AVM can also be excised using this approach

Answer 158

C. Cysticercosis cyst cannot be removed through this approach

Question 159

During approach to corpus callosum through interhemispheric approach, the two cingulate gyri can be easily mistaken for the corpus callosum. This error may be compounded by mistaking the callosomarginal arteries for the pericallosal arteries. What are the differentiating points between corpus callosum and cingulate gyrus?
● A. Corpus callosum is a pure white structure
● B. Corpus callosum is usually deeper than one anticipates
● C. Corpus callosum is appreciated beneath the paired pericallosal arteries
● D. Image-guided surgery or measuring the depth of the corpus callosum on the preoperative MRI may help
● E. All of the above are correct

Answer 159

E. All of the above are correct

Question 160

The callosotomy is usually performed between the two pericallosal arteries. Disconnection syndrome can occur with it which is more common with posterior callosotomy where more information crosses. The risk is reduced by creating the callosotomy of what distance?
● A. < 5.5 cm
● B. < 4.5 cm
● C. < 3.5 cm
● D. < 2.5 cm
● E. < 1.5 cm

Answer 160

D. < 2.5 cm

Question 161

Venous infarction during interhemispheric approach can occur because of which of the following?
● A. Damage to the critical cortical draining veins
● B. Damage or thrombosis of superior sagittal sinus
● C. Damage to thalamostriate veins
● D. Damage to vein of Trolard
● E. Both A and B

Answer 161

E. Both A and B

Question 162

Transcortical approach to the lateral or third ventricle is used for tumors of atrium of lateral ventricle, tumor of the roof of the third ventricle, or third ventricular tumors with significant extension onto lateral ventricle. Which of the following are the
approaches included in transcortical approach?
● A. Posterior parietal approach
● B. Middle temporal gyrus
● C. Middle frontal gyrus
● D. All of the above

Answer 162

D. All of the above

Question 163

Indications for cranioplasty include cosmetic restoration of the external skull appearance, relief of symptoms (pain or tenderness, syndrome of trephined or focal deficit related to the defect), protection from trauma, reduction of irritation of
brain, and improving from cognitive deficits. Contraindications of cranioplasty include infection, brain protruding from the confines of skull, or untreated hydrocephalus. What materials
can be used for cranioplasty?
● A. The patient’s own bone
● B. Polymethylmethacrylate (PMMA)
● C. Titanium
● D. Prefabricated custom bone flaps like PMMA, polyether ether ketone, titanium, or acrylic
● E. Split-thickness calvaria
● F. All of the above

Answer 163

F. All of the above

Question 164

Which of the following is the complication of cranioplasty that constitutes 8% of total complications?
● A. Infection
● B. Hematoma (epidural or subdural)
● C. Seizures
● D. Brain injury
● E. Hydrocephalus

Answer 164

A. Infection

Question 165

For noncontaminated situations like stroke, re-implantation can be considered after about how long?
● A. 2 to 4 weeks
● B. 6 to 12 weeks
● C. 2 to 4 months
● D. 8 to 10 months
● E. None of the above

Answer 165

B. 6 to 12 weeks

Question 166

What is the percentage of patients undergoing transoral removal of the odontoid process who required posterior fusion afterwards due to ligamentous instability?
● A. 20%
● B. 45%
● C. 75%
● D. 80%
● E. 90

Answer 166

C. 75%

Question 167

Transoral approach for odontoidectomy is preferred if the patient is able to open mouth up to how much?
● A. 55 mm
● B. 45 mm
● C. 35 mm
● D. 25 mm
● E. 15 mm

Answer 167

D. 25 mm

Question 168

What is the range of motion reduced after occipitocervical fusion?
● A. Flexion/extension: reduced by 30%
● B. Lateral rotation: 15 degrees is lost
● C. Lateral bending: 8 degrees is lost
● D. Flexion/extension: reduced by 20%
● E. Both A and C

Answer 168

E. Both A and C

Question 169

What screws are used for atlanto-occipital transarticular fusion?
● A. 22 to 24 mm cannulated lag screws
● B. 24 to 28 mm cannulated lag screws
● C. 28 to 32 mm cannulated lag screws
● D. 32 to 34 mm cannulated lag screws
● E. 34 to 36 mm cannulated lag screws

Answer 169

C. 28 to 32 mm cannulated lag screws

Question 170

All of the following are considered to be contraindications of anterior odontoid fixation?
● A. All fractures of the C2 vertebral body
● B. Disruption of transverse atlantal ligament (TAL)
● C. Large odontoid fracture gap
● D. Irreducible fracture
● E. Pathological odontoid fracture

Answer 170

A. All fractures of the C2 vertebral body

Question 171

While drilling for placement of C2 pedicle screws, if brisk bleeding occurs after withdrawing the drill, what is the next best step?
● A. Abort procedure immediately
● B. Placement of screw at drilled site
● C. Screw placement on both sides
● D. Securing hemostasis by locating the bleed site
● E. None of the above

Answer 171

B. Placement of screw at drilled site

Question 172

For LMS placement by Magerl method where is the entry point?
● A. 2 mm medial to midpoint
● B. 3 mm medial to midpoint
● C. 1 mm medial to midpoint
● D. 2 mm superior to midpoint
● E. 2 mm inferior to midpoint

Answer 172

A. 2 mm medial to midpoint

Question 173

Which of the following are the anterior approaches to the cervical spine?
● A. Anterior odontoid screw
● B. For upper cervical spine (c1–c3) transoral approach including odontoidectomy
● C. For upper cervical spine (c1–c3) extrapharyngeal approach including medial extrapharyngeal approach and lateral extrapharyngeal approach
● D. For c3–c7 cervical spine, standard anterior cervical diskectomy approach is used
● E. All of the above

Answer 173

E. All of the above

Question 174

Indications for anterior transoral odontoidectomy includes anterior extradural compression of the cervicomedullary junction as with pannus from rheumatoid arthritis, irreducible basilar invagination, tumors of c2, or infection. Following are the preoperative requirements for transoral approach except?
● A. Patient’s mouth can be opened at least up to 25 mm. If not, then other approaches like translabiomandibular should be considered
● B. For conditions resulting in malalignment or basilar invagination, cervical traction for 1 or more days is sometimes required
● C. Radiographic evaluation cervical MRI with and without contrast to define the soft tissue pathology, and CT of the craniocervical junction with sagittal and coronal reconstruction
● D. Intradural pathology is best dealt with this approach because watertight dural closure is easier and there are very low chances of postoperative meningitis in case of intradural pathology
● E. CTA should be done to assess position and involvement of the vertebral arteries. Measuring the distance between vertebral arteries provides useful information

Answer 174

D. Intradural pathology is best dealt with this approach because watertight dural closure is easier and there are very low chances of postoperative meningitis in case of intradural pathology

Question 175

Which of the following statements are correct regarding transoral surgery?
● A. Video laryngoscope and second choice fiberoptic bronchoscopy are now the intubation methods of choice
● B. Three-point fixation with a Mayfield head holder is typically used
● C. A specialized retractor, for example, Crockard transoral retractor or a conventional Dingman retractor, is used
● D. The tubercle of the atlas can be palpated through the posterior pharynx to locate the midline and for craniocaudal orientation with infiltration of mucosa of posterior pharynx with 1% lidocaine with epinephrine
● E. A 3-cm long vertical incision is used with a working window of 20 to 25 mm between the two vertebral arteries
● F. Occipitocervical fusion or posterior c1–c2 arthrodesis is often used in case of basilar invagination or c1–c2 instability alone respectively
● G. All of the above

Answer 175

G. All of the above

Question 176

Indications of occipitocervical fusion includes traumatic occipitoatlantal dislocation, absence of a complete arch of c1, congenital anomalies of the occipitocervical joints, upward migration of odontoid into the foramen magnum, or marked irreducible shifts of c1 or c2. The occipital screws are cortical
screws (narrow pitched) with distal blunt tip (to avoid dural injury) and have dimensions of 4.5-mm diameter or 8- to 12-mm length. Following are the options of occipitocervical fusion except?
● A. Keel plate (placed centrally over the thickest portion of the occipital bone) which is connected via rods to the cervical screws (c2 pedicle screw and c3 lateral mass screws)
● B. Occipital condyle–C1 polyaxial screws
● C. Occipital–c1 (also known as atlantooccipital) transarticular screws
● D. c1–c2 transarticular screws
● E. Looped rod wired to the occiput via wire cables placed through holes drilled in the occiput which reduces the range of motion to only 31% of normal

Answer 176

D. c1–c2 transarticular screws

Question 177

The entry point of occipital condyle screws is 4 to 5 mm lateral to foramen magnum and 1 to 2 mm rostral to the atlantooccipital joint. Screws are 3.5-mm diameter polyaxial screws and bicortical purchase is obtained using screws of 20- to 24-
mm length. Following are the structures that are needed to be preserved while using these screws except?
● A. Hypoglossal nerve in hypoglossal canal
● B. Carotid arteries
● C. Vertebral arteries
● D. Accessory nerve
● E. Jugular bulb

Answer 177

D. Accessory nerve

Question 178

Horizontal skin incision is given at c5–c6 level for anterior odontoid screw fixation. Indication for this procedure is a reducible odontoid type 2 fracture or type 3 fracture where fracture line is in the cephalad portion of the body of c2 in an elderly patient. Which of the following are the contraindications of this procedure?
● A. Fracture of c2 vertebral body
● B. Disruption of transverse atlantal ligament
● C. Large odontoid fracture gap
● D. Irreducible fracture
● E. Patients with short thick neck and barrel chest or pathologic odontoid fracture
● F. All of the above

Answer 178

F. All of the above

Question 179

Indications of atlantoaxial fusion includes instability of c1–c2 joint due to incompetence of transverse atlantal ligament or because of incompetence of odontoid process, hangman’s fracture, or vertebrobasilar insufficiency. How much of head rotation is lost after c1–c2 fusion?
● A. 30%
● B. 40%
● C. 50%
● D. 60%
● E. 70%

Answer 179

C. 50%

Question 180

Which of the following are the surgical options for c1–c2 fusion?
● A. Rigid instrumentation with c1 lateral mass and c2 pedicle screws
● B. Posterior cervical wiring and fusion
● C. Halifax clamps and fusion
● D. Odontoid compression screws
● E. Combined anterolateral and posterior bone grafting
● F. All of the above

Answer 180

F. All of the above

Question 181

Options for c2 screws include which of the following?
● A. Pedicle screws
● B. Lateral mass screws
● C. c1–c2 transarticular screws
● D. Translaminar screws
● E. All of the above

Answer 181

E. All of the above

Question 182

Cervical laminoplasty is a procedure which is similar to laminectomy except that the decompressed posterior elements are not removed. Following are the advantages of this procedure except?
● A. Lower incidence of postoperative kyphosis
● B. It might protect against some posterior trauma
● C. There is no impact on postoperative range of motion in extension after this procedure
● D. Provides decompression of cervical cord
● E. None of the above

Answer 182

C. There is no impact on postoperative range of motion in extension after this procedure

Question 183

For anterior access to midthoracic spine, why left-sided approach may be preferred?
● A. Heart does not impede access
● B. Mediastinum does not block access
● C. Brachiocephalic vein does not interfere with exposure
● D. It is easier to mobilize aorta
● E. It is easier to mobilize vena cava

Answer 183

D. It is easier to mobilize aorta

Question 184

Screws for smaller pedicles (usually T1–T4, especially in females) usually require the smallest screw diameter—typically 4.5 mm. What is the typical length?
● A. 5 to 10 mm
● B. 10 to 15 mm
● C. 20 to 25 mm
● D. 30 to 35 mm
● E. 45 to 50 mm

Answer 184

C. 20 to 25 mm

Question 185

Which of the following is not an advantage of anatomic (“freehand”) thoracic pedicle screw placement technique?
● A. Accuracy as good as or better than other techniques
● B. Avoids the challenges of getting fluoro aligned for each level in a scoliotic spine, especially when a rotational component is present
● C. Releases joints which facilitates reduction of scoliosis
● D. Can be used if anatomy is distorted by previous fusions or congenital anomalies
● E. Not impeded in areas that are difficult to image on fluoroscopy

Answer 185

D. Can be used if anatomy is distorted by previous fusions or congenital anomalies

Question 186

In freehand thoracic pedicle screw placement technique, pedicle breach rates are highest between which levels?
● A. T1 and T3
● B. T2 and T4
● C. T4 and T6
● D. T6 and T8
● E. T10 and T12

Answer 186

C. T4 and T6

Question 187

For anterior lumbar interbody fusion (ALIF), what is the usual incision?
● A. Costotransversectomy
● B. Anterolateral
● C. Trans-sternal
● D. Grid iron
● E. Pfannenstiel’s

Answer 187

E. Pfannenstiel’s

Question 188

What is the medial angle for lumbar pedicle screw at L1?
● A. 5 degrees medially
● B. 10 degrees medially
● C. 15 degrees medially
● D. 20 degrees medially
● E. 25 degrees medially

Answer 188

A. 5 degrees medially

Question 189

According to Gertzbein classification of pedicle screw medial breach, a breach distance of > 4 mm is what grade?
● A. 0
● B. 1
● C. 2
● D. 3
● E. 4
● F. 5

Answer 189

D. 3

Question 190

What should be the diameter of lumbosacral pedicle screws in adult lumbar spine?
● A. ≥ 2 mm
● B. ≥ 3 mm
● C. ≥ 4 mm
● D. ≥ 5 mm
● E. ≥ 6 mm

Answer 190

D. ≥ 5 mm

Question 191

Approach for upper thoracic spine or for cervicothoracic junction is through sternal splitting procedure which can give access up to T3 or from T5 level. For mid or lower thoracic levels, transthoracic or retropleural approach is used. Which of the following is the most appropriate statement about advantages of right-sided thoracotomy over left-sided thoracotomy?
● A. The heart, mediastinum, or brachiocephalic vein do not impede access through right-sided approach
● B. It is easier to make position on the right side as compared to the left side
● C. Aorta is easier to mobilize and retract than vena cava on the right side
● D. There is no impedance of inflow of blood into the heart while using right-sided approach
● E. None of the above

Answer 191

A. The heart, mediastinum, or brachiocephalic vein do not impede access through right-sided approach

Question 192

Which of the following are the options for thoracic screws placement?
● A. By using intraoperative fluoroscopy
● B. Using anatomic (free hand) thoracic pedicle screw placement method based on anatomic landmarks
● C. Performing small laminotomies and assessing position of the pedicle either by visualization or by palpating medial and superior aspects of pedicles using a dissector
● D. By using image guidance that is fitted with instruments with specialized markers that are tracked in real time by cameras that project the drill or screw location on CT or on X-ray
● E. All of the above

Answer 192

E. All of the above

Question 193

What is the uniform entry point for free hand pedicle screw placement?
● A. 1 mm inferior to the junction of the lateral edge of the superior facet and the transverse process
● B. 3 mm inferior to the junction of the lateral edge of the superior facet and the transverse process
● C. 4 mm inferior to the junction of the lateral edge of the superior facet and the transverse process
● D. 5 mm inferior to the junction of the lateral edge of the superior facet and the transverse process
● E. 7 mm inferior to the junction of the lateral edge of the superior facet and the transverse process

Answer 193

B. 3 mm inferior to the junction of the lateral edge of the superior facet and the transverse process

Question 194

Which of the following statements is correct regarding entry points and direction of screw placement in pedicles?
● A. Entry point in the T1, T2, T3, and T12 is even with the middle of the transverse process
● B. Entry point in the T7, T8, and T9 is even with the top of the transverse process
● C. For levels T4, T5, and T6, the entry point gradually move slightly superiorly at each level from mid transverse process at T3 to the top of the transverse process at T7
● D. The mediolateral trajectory is slightly lateral (−5 degree) at T12; at T11 it is 0 degree; from here upward it increases medially at 2 degrees per level up to T1 where it is 27 degrees medially
● E. All of the above

Answer 194

E. All of the above

Question 195

What is the typical thoracic screw length?
● A. 30 to 35 mm
● B. 35 to 40 mm
● C. 40 to 45 mm
● D. 45 to 50 mm
● E. 50 to 55 mm

Answer 195

B. 35 to 40 mm

Question 196

Entry point in the lumbar spine for screws is at the base of transverse process at the intersection of the center of the transverse process and the lateral aspect of superior facet. Which of the following statements is correct regarding medial angle of the pedicle screws?
● A. At L1 it is 5 degrees medially
● B. At L2 it is 10 degrees medially
● C. At L3 it is 15 degrees medially
● D. At L4 it is 20 degrees medially
● E. At L5 and S1 it is 25 degrees medially
● F. At S2 it is 40 to 45 degrees laterally
● G. All of the above

Answer 196

G. All of the above

Question 197

What is the recommended titanium rod diameter for lumbar pedicle screw fixation?
● A. 4.5 mm
● B. 5.5 mm
● C. 6.5 mm
● D. 7.5 mm
● E. 3.5 mm

Answer 197

B. 5.5 mm

Question 198

What is the use of postoperative X-rays after fixation and fusion?
● A. To see alignment
● B. Position of graft is used
● C. Integrity of hardware
● D. Lucencies around screws which may indicate motion and implies nonunion
● E. All of the above

Answer 198

E. All of the above

Question 199

What is the postoperative care for PLIF or TLIF or ALIF?
● A. For single-level lumbar LLIF, the patient is mobilized in the immediate postoperative period without a brace
● B. Hip flexion pain on the approach side is anticipated during the immediate postoperative period
● C. Transient hip flexion weakness related to psoas muscle manipulation is usually self-limited and improves by 8 weeks postoperatively
● D. In case of significant leg weakness, a lumbar CT or MRI is indicated to rule out compression by a psoas hematoma
● E. All of the above

Answer 199

E. All of the above

Question 200

Which of the following is incorrect regarding Gertzbein classification of pedicle screw medial breach?
● A. Grade 0 is no breach
● B. Grade 1 is breach of less than 2 mm
● C. Grade 2 is breach of 2 to 4 mm
● D. Grade 3 is breach of more than 4 mm
● E. Grade 4 is breach of more than 6 mm

Answer 200

E. Grade 4 is breach of more than 6 mm

Question 201

What should be the size of spinal needle for percutaneous ventricular tap in adults?
● A. 14 to 16 Ga
● B. 16 to 18 Ga
● C. 18 to 20 Ga
● D. 20 to 22 Ga
● E. 22 to 24 Ga

Answer 201

B. 16 to 18 Ga

Question 202

To drain subdural collections and to obtain fluid for diagnostic tests such as culture, repeat taps may be used, but surgery should be considered after how many taps?
● A. 2 to 3 taps
● B. 3 to 4 taps
● C. 4 to 5 taps
● D. 5 to 6 taps
● E. 6 to 7 taps

Answer 202

D. 5 to 6 taps

Question 203

Which of following is not considered a contraindication of lumbar puncture?
● A. Risk of tonsillar herniation
● B. Platelet count > 50,000/mm3
● C. Suspected aneurysmal SAH
● D. Infection at puncture site
● E. Complete spinal block

Answer 203

B. Platelet count > 50,000/mm3

Question 204

For estimating true total CSF protein content with a traumatic tap, what is the correction applied?
● A. Subtract 1 mg/100 mL of protein for every 1,000 RBC/mm3
● B. Subtract 10 mg/100 mL of protein for every 1,000 RBC/mm3
● C. Subtract 1 mg/100 mL of protein for every 500 RBC/mm3
● D. Subtract 1 mg/100 mL of protein for every 700 RBC/mm3
● E. Subtract 10 mg/100 mL of protein for every 100 RBC/mm3

Answer 204

A. Subtract 1 mg/100 mL of protein for every 1,000 RBC/mm3

Question 205

What is the mortality risk for delaying treatment of acute bacterial meningitis?
● A. Increase by 10% per hour
● B. Increase by 11% per hour
● C. Increase by 12% per hour
● D. Increase by 13% per hour
● E. Increase by 15% per hour

Answer 205

D. Increase by 13% per hour

Question 206

Which of the following factors are found not to affect the incidence of post LP H/A?
● A. Age of the patient
● B. Pregnancy
● C. Volume of fluid removed during LP
● D. Prior history of headache
● E. Needle size

Answer 206

C. Volume of fluid removed during LP

Question 207

What should be the trajectory for insertion of ventricular catheter from Kocher’s point?
● A. Toward nasion
● B. Toward ipsilateral medial canthus in coronal plane
● C. Toward contralateral medial canthus in coronal plane
● D. Toward ipsilateral medial canthus in AP plane
● E. Toward EAM in coronal plane

Answer 207

B. Toward ipsilateral medial canthus in coronal plane

Question 208

What should be the length of ventricular catheter inserted from Frazier burr hole with stylet initially?
● A. 3 cm
● B. 4 cm
● C. 5 cm
● D. 6 cm
● E. 7 cm

Answer 208

D. 6 cm

Question 209

Tip of VA catheter in children should be advanced up to which level?
● A. T4
● B. T5
● C. T6
● D. T8
● E. T10

Answer 209

E. T10

Question 210

All of following are considered locations for making an opening in the floor of the third ventricle during ETV except?
● A. In the midline
● B. In the region of the tuber cinereum
● C. Anterior to the infundibular recess
● D. Anterior to the mammillary bodies
● E. Anterior to the tip of the basilar artery

Answer 210

C. Anterior to the infundibular recess

Question 211

During sural nerve biopsy, sural nerve is differentiated by which point from lesser saphenous vein?
● A. Nerve has many branches at right angle
● B. Vein has branches at right angle
● C. Nerve lies superficial and posterior to vein
● D. Vein has branches at acute angle
● E. None of the above

Answer 211

B. Vein has branches at right angle

Question 212

What is the actual cable tension for titanium alloy cables for spine fusion?
● A. 20 lbs
● B. 30 lbs
● C. 40 lbs
● D. 60 lbs
● E. Depends on quality of bone

Answer 212

E. Depends on quality of bone

Question 213

Following are the contraindications of lumbar puncture except?
● A. Risk of tonsillar herniation (known or suspected intracranial mass or noncommunicating hydrocephalus)
● B. Infection in the region desired of lumbar puncture
● C. Coagulopathy
● D. Can be used without any hazard in suspected SAH
● E. Caution in patients with complete spinal block

Answer 213

D. Can be used without any hazard in suspected SAH

Question 214

The intercristal line passes through (in most adults) which of the following?
● A. At L4 spinous process
● B. Between L4 and L5 spinous processes
● C. Between L3 and L4 spinous processes
● D. At L5 spinous process
● E. Both A and B

Answer 214

E. Both A and B

Question 215

What is the desirable spinal needle size for diagnostic purpose?
● A. 16 G
● B. 18 G
● C. 20 G
● D. 22 G
● E. 24 G

Answer 215

C. 20 G

Question 216

What is the normal opening pressure in the left lateral decubitus position during performing an LP?
● A. 12.2 ± 3.4 cm H2O
● B. 14.2 ± 3.4 cm H2O
● C. 11 cm H2O
● D. 9 cm H2O
● E. 17 cm H2O

Answer 216

A. 12.2 ± 3.4 cm H2O

Question 217

In case of traumatic tap, how can we get WBC count that is other than peripheral blood in a nonanemic patient?
● A. By subtracting 1 WBC for every 500 RBC
● B. By subtracting 1 WBC for every 700 RBC
● C. By subtracting 1 WBC for every 100 RBC
● D. By subtracting 1 WBC for every 1000 RBC
● E. By subtracting 1 WBC for every 1200 RBC

Answer 217

B. By subtracting 1 WBC for every 700 RBC

Question 218

Which of the following are the differentiating points between traumatic tap and subarachnoid hemorrhage on LP?
● A. RBC count is less than 2,000/mm cube in traumatic tap while in case of SAH it is usually more than 1,00,000 RBC/mm cube
● B. Clearing of RBCs from the first tube to the last tube declines as CSF drains in case of traumatic tap, while in case of SAH, it changes little as CSF drains
● C. Ratio of WBC to RBC is similar to ratio in peripheral blood in case of traumatic tap, while it usually promotes leukocytosis in case of SAH
● D. Supernatant in case of traumatic tap is clear, while it is xanthochromic in case of SAH
● E. All of the above

Answer 218

E. All of the above

Question 219

Which of the following are the treatment options for headache after LP?
● A. Flat in bed for at least 24 hours
● B. Hydration per oral or IV
● C. Analgesics for headache
● D. Tight abdominal binder
● E. Deoxycortisone acetate 5 mg IM every 88 hours
● F. Caffeine sodium benzoate 500 mg in 2 mL IV every 8 hours up to 3 days max
● G. High-dose steroids
● H. Blood patch if refractory
● I. All of the above

Answer 219

I. All of the above

Question 220

Which of the following are the indications of lumbar catheter CSF drainage?
● A. To reduce CSF pressure at the site of CSF leak (e.g., dural breach during spine surgery or for spontaneous CSF fistula)
● B. To reduce intracranial pressure in case of communicating hydrocephalus
● C. To reduce CSF pressure to attempt to increase perfusion of the spinal cord, for example, during surgery for aortic abdominal aneurysms
● D. All of the above

Answer 220

D. All of the above

Question 221

Which of the following are the indications of ventricular catheterization?
● A. Intracranial pressure measurement
● B. Temporary CSF diversion in case of hydrocephalus when definite shunting is not immediately indicated or practical
● C. For management of infected shunt occasionally in case of meningitis when repeated LPs or a lumbar drain is not suitable
● D. For intrathecal drug administration
● E. All of the above

Answer 221

E. All of the above

Question 222

What are the VP shunt postoperative orders?
● A. Flat in bed to avoid overshunting and possible postoperative hematoma, with gradual mobilization
● B. If peritoneal end is new or revised, do not feed until bowel sound resumes
● C. Shunt series X-rays for future comparison
● D. All of the above

Answer 222

D. All of the above

Question 223

What is the desirable level of platelets for stereotactic brain biopsy?
● A. ≥ 10,000/mL
● B. ≥ 30,000/mL
● C. ≥ 50,000/mL
● D. ≥ 1,00,000/mL
● E. ≥ 1,50,000/mL

Answer 223

D. ≥ 100,000/mL

Question 224

Which of following is not included in indications of deep brain stimulation?
● A. Movement disorders
● B. Obesity
● C. Hypotension
● D. Epilepsy
● E. Drug addiction

Answer 224

C. Hypotension

Question 225

If tremor is predominant symptom of Parkinson’s disease, then what should be the target of stimulation?
● A. Ventralis intermedius nucleus of the thalamus
● B. Pedunculopontine nucleus
● C. Subthalamic nucleus
● D. Anterior limb of internal capsule
● E. Globus pallidus

Answer 225

A. Ventralis intermedius nucleus of the thalamus

Question 226

Immediately after DBS, anti-Parkinson drugs are continued without any change in dosage for how long?
● A. 1 month
● B. 2 months
● C. 3 months
● D. 4 months
● E. 5 months

Answer 226

B. 2 months

Question 227

In the treatment of dystonia, pallidal stimulation has best results for which of the following types of dystonia?
● A. Postanoxic dystonia
● B. Postencephalitic dystonia
● C. Primary dystonia
● D. Perinatal dystonia
● E. Poststroke dystonias

Answer 227

C. Primary dystonia

Question 228

Local injection of botulinum toxin works for which of the following types of torticollis?
● A. Retrocollis
● B. Anterocollis
● C. Lateral collis
● D. Extrapyramidal torticollis
● E. Horizontal type

Answer 228

A. Retrocollis

Question 229

A patient had H/O spinal trauma 3 months ago. Now the patient has increased tone in limbs but could move limbs passively with ease. According to Ashworth score of spasticity grading, what would be the grade?
● A. 1
● B. 2
● C. 3
● D. 4
● E. 5

Answer 229

C. 3

Question 230

What are the selection criteria for baclofen pump?
● A. Age < 18 years
● B. Not able to give informed consent
● C. Moderate new-onset spasticity
● D. Spasticity responsive to oral baclofen
● E. No CSF block

Answer 230

E. No CSF block

Question 231

What is the maximum dose of dantrolene recommended for spasticity?
● A. 25 mg/d
● B. 25 mg BID
● C. 50 mg BID
● D. 100 mg TID
● E. 100 mg QID

Answer 231

E. 100 mg QID

Question 232

Which of the following is not an ideal candidate for dorsal rhizotomy?
● A. Most often used in children > 2 years of age
● B. Some surgeons reserve SDR for patients who have failed IT baclofen
● C. Mild-to-moderate LE weakness with the ability to walk or maintain antigravity posture
● D. Spasticity hampers gait and/or development of motor skills
● E. Arms worse than legs

Answer 232

E. Arms worse than legs

Question 233

What is the only movement disorder which persists in sleep?
● A. Tourette’s syndrome
● B. Parkinson’s tremors
● C. Palatal myoclonus
● D. Essential tremors
● E. None of the above

Answer 233

C. Palatal myoclonus

Question 234

In trigeminal neuralgia, if immediate relief of pain is required, which procedure should not be used due to its latency?
● A. Radiofrequency rhizotomy
● B. Stereotactic radiosurgery
● C. Balloon compression
● D. Glycerol injection
● E. MVD

Answer 234

B. Stereotactic radiosurgery

Question 235

Once stimulation is achieved during RFR, how should lesioning be done?
● A. 30 to 40C × 90 sec
● B. 60 to 70C × 90 sec
● C. 70 to 80C × 90 sec
● D. 80 to 90C × 90 sec
● E. 20 to 30C × 90 sec

Answer 235

B. 60 to 70C × 90 sec

Question 236

Functional neurosurgery (FN) involves the use of electrical stimulation, ablative therapy, or therapeutic infusions to mask or relieve symptoms of aberrant neurophysiology. FN may be used in the treatment of which of the following?
● A. Movement disorders
● B. Microvascular compression syndromes
● C. Autonomic dysfunction or psychiatric disease
● D. Pain or epilepsy
● E. All of the above

Answer 236

E. All of the above

Question 237

Following are the indications of stereotactic surgery except?
● A. Biopsy for deeply located cerebral lesions or brain stem lesions or for multiple lesions
● B. Catheter placement for drainage of deep lesions or for indwelling catheter placement for intratumoral chemotherapy
● C. Electrode placement for epilepsy or for deep brain stimulation
● D. Lesion generation for movement disorder or for treatment of chronic pain
● E. It cannot be used for evacuation of intracerebral hemorrhage
● F. Stereotactic radiosurgery or for localization of lesion for open craniotomy

Answer 237

E. It cannot be used for evacuation of intracerebral hemorrhage

Question 238

What is the most frequent complication of stereotactic radiosurgery?
● A. Seizure
● B. Hemorrhage
● C. Headache
● D. Memory impairment
● E. Hearing impairment

Answer 238

B. Hemorrhage

Question 239

Deep brain stimulation (DBS) is the use of electrical stimulation through surgically implanted electrodes to produce neuromodulation of electrical signals for the purpose of symptom improvement. The conditions that may be treated using DBS include which of the following?
● A. Movement disorders like parkinsonism or dystonia
● B. Epilepsy
● C. Pain
● D. Potential uses include psychiatric disorders, obesity, or drug addiction
● E. All of the above

Answer 239

E. All of the above

Question 240

An early treatment for Parkinson’s disease was ligation of anterior choroidal artery. Pallidotomy of which area of thalamus is most effective in diminishing tremors?
● A. Anterolateral thalamus
● B. Ventrolateral thalamus
● C. Anterodorsal thalamus
● D. Anteromedial thalamus
● E. Mediolateral thalamus

Answer 240

B. Ventrolateral thalamus

Question 241

Anterodorsal pallidotomy became an accepted procedure in the long-term improvement of rigidity while tremors and bradykinesia did not improve with it. What are the other areas that can be targeted in the treatment of Parkinson’s disease?
● A. Globus pallidus pars interna
● B. Ventral intermediate nucleus of thalamus
● C. Ventrolateral thalamus
● D. Ventralis intermediate nucleus of thalamus
● E. All of the above

Answer 241

E. All of the above

Question 242

Following are the indications for surgical treatment of Parkinson disease except?
● A. Patients refractory to medical treatment
● B. Patients with significant dementia
● C. Primary indication is patients with levodopa-induced dyskinesias
● D. Gait and postural instability
● E. Patients primarily with rigidity and bradykinesia (unilateral or bilateral), on-off fluctuations, or dystonia

Answer 242

B. Patients with significant dementia

Question 243

Which of the following are the contraindications of surgical treatment of Parkinson’s disease?
● A. Patients with significant dementia
● B. Patients at risk of intracerebral hemorrhage
● C. Patients with ipsilateral hemianopsia
● D. Age more than or equal to 85 years
● E. Patients with secondary parkinsonism
● F. Patients with normal dopamine transport scan which may rule out PD as the cause of tremors
● G. All of the above

Answer 243

G. All of the above

Question 244

Significant improvement of levodopa-induced dyskinesias occurred in 90% cases after surgical treatment for Parkinson’s disease, rigidity improved in 75% cases while tremors improved in 57% of cases. What is the percentage of improvement
of bradykinesia after surgical treatment?
● A. 70%
● B. 85%
● C. 95%
● D. 60%
● E. 40%

Answer 244

B. 85%

Question 245

Which of the following steps are included in the deep brain stimulation technique?
● A. Medications (antitremors or antiparkinsonism) are withheld the morning of the procedure to bring out symptoms
● B. A stereotactic frame is applied under local anesthetic parallel to orbitomeatal line
● C. Radiologic target localization is done using MRI or CT of brain
● D. Awake or asleep placement of DBS electrodes is done
● E. All of the above

Answer 245

E. All of the above

Question 246

Which of the following vessels is the main offender in disabling positional vertigo?
● A. SCA
● B. AICA
● C. PICA
● D. VA
● E. BA

Answer 246

B. AICA

Question 247

What is the treatment of status trigeminus?
● A. IV diazepam
● B. IV epival
● C. IV carbamazepine
● D. IV phenobarbital
● E. IV levetiracetam

Answer 247

C. IV carbamazepine

Question 248

In which of the following, trigeminal neuralgia (TGN) is more common?
● A. Right side
● B. Left side
● C. Bilaterally
● D. In v1 distribution
● E. In all three divisions

Answer 248

A. Right side

Question 249

Which of the following is best for v3 neuralgia?
● A. Radiofrequency
● B. Balloon compression
● C. Glycerol injection
● D. Motor cortex stimulation
● E. SRS

Answer 249

A. Radiofrequency

Question 250

What is the dose of SRS used for TGN at the center of lesion?
● A. 30 to 40 Gy
● B. 40 to 50 Gy
● C. 50 to 60 Gy
● D. 60 to 70 Gy
● E. 70 to 80 Gy

Answer 250

E. 70 to 80 Gy

Question 251

How is percutaneous trigeminal radiofrequency rhizotomy (RFR) lesioning done?
● A. 60 to 70 C × 30 sec
● B. 60 to 70 C × 30 sec
● C. 60 to 70 C × 90 sec
● D. 70 to 90 C × 90 sec
● E. 70 to 90 C × 60 sec

Answer 251

C. 60 to 70 C × 90 sec

Question 252

What is the success rate of microvascular decompression (MVD) for TGN?
● A. 30 to 50%
● B. 50 to 75%
● C. 75 to 80%
● D. 80 to 90%
● E. 90 to 95%

Answer 252

C. 75 to 80%

Question 253

Which of the following is an effective medical management for hemifacial spasm?
● A. Carbamazepine
● B. Phenytoin
● C. Botulinum toxin
● D. Baclofen
● E. Dantrolene

Answer 253

C. Botulinum toxin

Question 254

Tic convulsif is a combination of which of the following?
● A. GeN + hemifacial spasm
● B. GeN + focal UE fits
● C. Hemifacial spasm + focal UE fits
● D. GeN + status trigeminus
● E. Hemifacial spasm + glossopharyngeal neuralgia

Answer 254

A. GeN + hemifacial spasm

Question 255

Post vagal section for glossopharyngeal neuralgia, 24 hours monitoring is required for which of the following?
● A. BP
● B. Syncope
● C. Cardiovascular complications
● D. Respiratory failure
● E. Neck hematoma

Answer 255

C. Cardiovascular complications

Question 256

Which of the following are neurovascular compression syndromes?
● A. Trigeminal neuralgia due to 5th cranial nerve involvement
● B. Hemifacial spasm due to 7th cranial nerve involvement
● C. Geniculate neuralgia or disabling positional vertigo due to 7th cranial nerve (nevus intermedius) or 8th cranial nerve involvement respectively
● D. Glossopharyngeal neuralgia due to 9th cranial nerve involvement
● E. All of the above

Answer 256

E. All of the above

Question 257

TGN is caused by compression on 5th nerve by which artery?
● A. Anterior inferior cerebellar artery
● B. Posterior inferior cerebellar artery
● C. Superior cerebellar artery
● D. Vertebral artery
● E. Posterior inferior cerebellar artery

Answer 257

C. Superior cerebellar artery

Question 258

What percentage of trigeminal neuralgia patients will ultimately fail medical therapy and require surgery?
● A. 25%
● B. 50%
● C. 75%
● D. 85%
● E. 95%

Answer 258

C. 75%

Question 259

Which of the following is included in the medical therapy of TGN?
● A. Carbamazepine (Tegretol) 100 mg PO BID, increased by 200 mg/d up to maximum of 1,200 mg/d divided TID
● B. Oxcarbazepine (Trileptal) 300 mg PO BID, increased by 600 mg/d every week up to maximum of 2,400 mg/d
● C. Baclofen 5 mg PO TID, increase every day by 5 mg/dose up to maximum of 80 mg/d in QID
● D. Gabapentin started with 100 mg PO BID, titrate to 5 to 7 mg/kg/d (3,600 mg/d maximum)
● E. All of the above

Answer 259

E. All of the above

Question 260

Complications of percutaneous radiofrequency include all of the following except?
● A. Partial masseter weakness
● B. Oculomotor paresis (usually temporary)
● C. Bitemporal hemianopsia
● D. Reduced hearing (secondary to paresis of tensor tympani)
● E. Neuroparalytic keratitis (keratitis due to fifth nerve deficit which impairs sensation)

Answer 260

C. Bitemporal hemianopsia

Question 261

Radiofrequency rhizotomy, glycerol injection into Meckel’s cave, mechanotrauma by inflation of no. 4 Fogarty catheter balloon, or injection of sterile boiling water is used to selectively destroy A delta and C fibers while preserving A alpha and beta fibers. All of these procedures come under which
heading?
● A. Blocking the trigger
● B. Percutaneous trigeminal rhizotomy
● C. Intradural retrogasserian trigeminal nerve section
● D. Stereotactic radiosurgery
● E. Peripheral trigeminal nerve branch procedures to block or ablate the division involved with pain

Answer 261

B. Percutaneous trigeminal rhizotomy

Question 262

For stereotactic radiosurgery, 4 to 5 mm isocenter in the trigeminal nerve root entry zone is used which is identified on MRI. What is the dose of radiation that is used for this procedure?
● A. 50 to 60 Gy
● B. 60 to 70 Gy
● C. 70 to 80 Gy
● D. 80 to 90 Gy
● E. 40 to 50 Gy

Answer 262

C. 70 to 80 Gy

Question 263

What is the postoperative care after percutaneous trigeminal rhizotomy?
● A. Ice pack to face on the side of procedure for 4 hours
● B. Soft diet
● C. Routine activity when alert
● D. Avoid narcotics
● E. If corneal reflex is impaired, then natural tear drops 2 to 3 drops every 2 hours is used on the affected side
● F. All of the above

Answer 263

F. All of the above

Question 264

How is dura opened during microvascular decompression for trigeminal neuralgia?
● A. Curvilinear with each end at the sinus and convexity away from the junction
● B. Inverted T shaped
● C. In x shape
● D. In y-shaped pattern
● E. Both A and B

Answer 264

E. Both A and B

Question 265

Hemifacial spasm is typically caused by compression of facial nerve by which of the following?
● A. PICA
● B. SCA
● C. VA
● D. AICA
● E. MCA

Answer 265

D. AICA

Question 266

For unilateral pain in head, face, neck, and upper extremity, what is the pain procedure to be done?
● A. Cingulotomy
● B. Cordotomy
● C. Commisural myelotomy
● D. Stereotactic mesencephalotomy
● E. Dorsal rhizotomy

Answer 266

D. Stereotactic mesencephalotomy

Question 267

The success of cordotomy is known by which of the following?
● A. Loss of pinprick sensation on the affected site
● B. Weakness of the affected side
● C. Ipsilateral Horner syndrome
● D. Muscle tetany on the affected side
● E. None of the above

Answer 267

C. Ipsilateral Horner syndrome

Question 268

Which of following is considered to be a relative contraindication of spinal cord stimulation?
● A. Failed back syndrome
● B. Regional pain syndrome
● C. Cancer pain
● D. Diabetic neuropathy
● E. Postherpetic neuralgia

Answer 268

C. Cancer pain

Question 269

For commissural myelotomy, where is laminectomy done?
● A. Single level above highest dermatome involved in pain
● B. Two levels above highest dermatome involved in pain
● C. Three levels above highest dermatome involved in pain
● D. Two levels below highest dermatome involved in pain
● E. Three levels below highest dermatome involved in pain

Answer 269

C. Three levels above highest dermatome involved in pain

Question 270

Dorsal root entry lesions are indicated for all except?
● A. Phantom pain
● B. Cancer pain
● C. Spinal cord injuries
● D. Postherpetic neuralgia
● E. Deafferentation pain

Answer 270

B. Cancer pain

Question 271

What is the most common complication of cordotomy?
● A. Ataxia
● B. Ipsilateral paresis
● C. Bladder dysfunction
● D. Postcordotomy dysesthesia
● E. Sleep-induced apnea

Answer 271

A. Ataxia

Question 272

Which of the following are the types of pain procedures which are being used currently?
● A. Electrical stimulation (deep brain stimulation or spinal cord stimulation)
● B. Direct drug administration into the CNS (spinal, epidural, intrathecal, or intraventricular)
● C. Intracranial ablative procedures (cingulotomy, medial thalamotomy)
● D. Spinal ablative surgical procedures like cordotomy or cordectomy or commissural myelotomy
● E. Sympathectomy or peripheral nerve procedures like nerve block
● F. All of the above

Answer 272

F. All of the above

Question 273

Cordotomy is the procedure of choice for unilateral pain below C5 dermatomal level. Which of the following fibers are interrupted in this procedure?
● A. Lateral spinothalamic tract fibers
● B. Anterior spinothalamic tract fibers
● C. Posterior spinothalamic tract fibers
● D. Medial spinothalamic tract fibers
● E. All of the above

Answer 273

A. Lateral spinothalamic tract fibers

Question 274

Following are the postcordotomy complications except?
● A. Ataxia
● B. Ipsilateral paresis
● C. Sleep-induced apnea never occurs with it
● D. Bladder dysfunction
● E. Postcordotomy dysfunction

Answer 274

C. Sleep-induced apnea never occurs with it

Question 275

In experienced hands, 94% of patients will achieve at least significant pain relief at the time of hospital discharge. This level of analgesia falls with time. At 1 year, what percentage of patients will be pain free?
● A. 80%
● B. 70%
● C. 60%
● D. 50%
● E. 40%

Answer 275

C. 60%

Question 276

Commissural myelotomy is performed for interruption of pain fibers crossing in the anterior commissure on their way to the lateral spinothalamic tract. It is done for bilateral or midline pain primarily below the thoracic levels. What percentage of patients have complete pain relief after the operation?
● A. 50%
● B. 60%
● C. 70%
● D. 80%
● E. 90%

Answer 276

B. 60%

Question 277

Administration of narcotics can be done in epidural space or intrathecally for pain relief. Which of the following are the advantages of CSN administration of narcotics over systemic narcotics?
● A. It causes less sedation or confusion
● B. It causes less interference with GI motility
● C. It causes less nausea and vomiting
● D. All of the above

Answer 277

D. All of the above

Question 278

Which of the following are the indications of spinal cord stimulation?
● A. Failed back surgery syndrome and complex regional pain syndrome are FDA-approved indications
● B. Diabetic neuropathy or refractory angina pectoris
● C. Postthoracotomy pain
● D. Postherpetic neuralgia or painful limb ischemia
● E. All of the above

Answer 278

E. All of the above

Question 279

Dorsal root entry zone lesions appear to be most effective in treating all of the following except?
● A. Deafferentation pain resulting from nerve root evulsion
● B. Spinal cord injuries with pain around the lowest spared dermatome
● C. Postherpetic neuralgia
● D. Generally used for cancer pain
● E. Postamputation phantom limb pain

Answer 279

D. Generally used for cancer pain

Question 280

Which of the following are the potential complications of spinal cord stimulation?
● A. Lead migration or lead breakage
● B. Infection
● C. Hardware malfunction or unwanted stimulation
● D. CSF leak, radicular pain, intermittent interference with cardiac pacemaker
● E. All of the above

Answer 280

E. All of the above

Question 281

Nociceptive pain syndromes are more likely to be benefitted
from stimulation of which of the following?
● A. Periventricular gray matter
● B. Periaqueductal gray matter
● C. Basal ganglia region
● D. Thalamus stimulation
● E. Both A and B

Answer 281

E. Both A and B

Question 282

Region of cortex produces interictal spikes detected on scalp or invasive EEG, magnetoencephalography (MEG), or triggered fMRI. Isolated spikes that generally do not produce clinical symptoms are called?
● A. Epileptogenic zone
● B. Ictal onset zone
● C. Symptomatogenic zone
● D. Irritative zone
● E. Functional deficit zone

Answer 282

D. Irritative zone

Question 283

What surgical procedure is recommended for drop attacks?
● A. Hemispherectomy
● B. Amygdalohippocampectomy
● C. Callosotomy
● D. Temporal lobectomy
● E. None of the above

Answer 283

C. Callosotomy

Question 284

Resection of 6 to 7 cm of temporal lobe on nondominant side can lead to which of the following?
● A. Partial contralateral upper quadrant homonymous hemianopsia
● B. Complete contralateral upper quadrantanopsia
● C. Partial contralateral lower quadrant homonymous hemianopsia
● D. Speech deficit
● E. Memory disturbance

Answer 284

A. Partial contralateral upper quadrant homonymous hemianopsia

Question 285

After seizure surgery, antiepileptic drugs must be continued for how long?
● A. 2 months
● B. 6 months
● C. 1 to 2 years
● D. 2 to 4 years
● E. No need

Answer 285

C. 1 to 2 years

Question 286

Follow-up MRI after seizure surgery is obtained after how long?
● A. 1 month
● B. 3 months
● C. 6 months
● D. 1 year
● E. 2 years

Answer 286

B. 3 months

Question 287

After seizure surgery, if there is worthwhile reduction in seizures, then what would be the class according to the modified Engel classification?
● A. Class I
● B. Class II
● C. Class III
● D. Class IV
● E. None of the above

Answer 287

C. Class III

Question 288

Which of the following is the largest group of surgical candidates among the types of seizures that are amenable to seizure surgery?
● A. Focal onset seizures of temporal origin
● B. Focal onset seizures of extratemporal origin
● C. Symptomatic generalized seizures
● D. Unilateral, multifocal epilepsy associated with infantile hemiplegia syndrome
● E. All of the above

Answer 288

A. Focal onset seizures of temporal origin

Question 289

Noninvasive evaluation techniques for seizures include all of the following except?
● A. Video EEG monitoring
● B. CAT scan
● C. PET scan
● D. Wada test or intracarotid amytal test
● E. SPECT scan and MEG

Answer 289

D. Wada test or intracarotid amytal test

Question 290

Which of the following are the surgical techniques of seizure surgery?
● A. Resections (resection of epileptic focus or anterior temporal lobectomy or resection of neocortical areas)
● B. Disconnections (section of corpus callosum, functional hemispherectomy)
● C. Stimulations (vagus stimulation or deep brain stimulation)
● D. All of the above

Answer 290

D. All of the above

Question 291

Following are the indications of corpus callosotomy except?
● A. Frequent episodes of atonic seizures
● B. Possibly for generalized seizure disorder with unilateral hemisphere damage
● C. Patients with speech and dominant handedness in opposite hemisphere
● D. Some patients with generalized seizures without identifiable, resectable focus

Answer 291

C. Patients with speech and dominant handedness in opposite hemisphere

Question 292

Disconnection syndrome can occur with commissural resection which includes left tactile anomia, left-sided dyspraxia, pseudohemianopsia, right-sided anomia for smell, or decreased
spontaneity of speech. How much time a patient usually requires to adapt to most daily activities?
● A. 2 to 3 months
● B. 8 to 9 months
● C. 1 to 2 years
● D. 3 to 4 years
● E. 6 to 7 years

Answer 292

A. 2 to 3 months

Question 293

Which of the following are the approaches for selective amygdalohippocampectomy?
● A. Transcortical through inferior temporal gyrus
● B. Transsylvian
● C. Subtemporal through temporal fossa approach
● D. All of the above

Answer 293

D. All of the above

Question 294

Risks of seizure surgery include all of the following except?
● A. Removal of essential areas of cortex
● B. Memory impairment
● C. Injury to medullary core underlying cortical resection
● D. Injury to vessels in area of resection
● E. Injury to nearby cranial nerves

Answer 294

B. Memory impairment

Question 295

Postoperative management for seizure surgery includes all of the following except?
● A. Observation in ICU for 24 hours
● B. Load appropriately with IV phenytoin or Keppra
● C. 10 mg dexamethasone IV before surgery followed by every 8 hours as necessary
● D. Antiseizure medication is not needed beyond 2 to 4 weeks
● E. Neuropsychiatric evaluation should be done after 6 to 12 months

Answer 295

D. Antiseizure medication is not needed beyond 2 to 4 weeks

Question 296

Which of the following are included in the modified Engel and ILAE classification of seizure surgery outcome?
● A. Class 1 is seizure-free or residual auras
● B. Class 2 is rare disabling seizure (less than three complex
partial seizures per year)
● C. Class 3 is worthwhile improvement
● D. Class 4 is no worthwhile seizure improvement
● E. All of the above

Answer 296

E. All of the above

Question 297

Following are ablative techniques other than seizure surgery except?
● A. Radiofrequency ablation
● B. MRI-guided laser interstitial thermal therapy
● C. Stereotactic radiosurgery of mesial temporal lobe
● D. Application of local block to prevent occurrence of seizures

Answer 297

D. Application of local block to prevent occurrence of seizures

Question 298

CNS tumors that are very radiosensitive includes all of the following except?
● A. Gliosarcoma
● B. Germinoma
● C. Metastatic lung cancer
● D. Lymphoma
● E. Choriocarcinoma

Answer 298

A. Gliosarcoma

Question 299

For most metastatic spine tumors treated with conventional radiation therapy (i.e., not stereotactic radiosurgery), what is the usual fractionation?
● A. 20 Gy administered over 10 fractions
● B. 30 Gy administered over 10 fractions
● C. 60 Gy administered over 10 fractions
● D. 30 Gy administered over 5 fractions
● E. 30 Gy administered over 20 fractions

Answer 299

B. 30 Gy administered over 10 fractions

Question 300

For acute spinal cord paralysis from lymphoma, if emergency surgery is not a consideration, what is the emergency radiation that can be given in the 1st fraction?
● A. 2 Gy
● B. 3 Gy
● C. 4 Gy
● D. 6 Gy
● E. 8 Gy

Answer 300

E. 8 Gy

Question 301

In chronic, progressive myelopathy, what is the commonly reported radiation myelopathy type?
● A. I
● B. II
● C. III
● D. IV
● E. V

Answer 301

D. IV

Question 302

What is the source of particle generation PET scan?
● A. Cyclotron
● B. Tungsten
● C. Cobalt 60
● D. Cobalt 62
● E. Chromium

Answer 302

A. Cyclotron

Question 303

A patient presented with sudden-onset loss of consciousness. According to Virginia Radiosurgery AVM Scale, a 3 cm3 thalamic AVM presenting with hemorrhage will be awarded how many points?
● A. 1
● B. 2
● C. 3
● D. 4
● E. 5

Answer 303

C. 3

Question 304

An old female patient with breast cancer presents with first-time seizures. What is the recommended dose of SRS for a 25-mm metastatic brain lesion?
● A. 10 Gy
● B. 18 Gy
● C. 24 Gy
● D. 28 Gy
● E. 30 Gy

Answer 304

B. 18 Gy

Question 305

A patient presented with unilateral hearing loss, tinnitus, and disequilibrium. What is the recommended single dose SRS for hearing preservation and to minimize new onset or worsening of cranial nerve deficits?
● A. 12 Gy
● B. 16 Gy
● C. 18 Gy
● D. 20 Gy
● E. 25 Gy

Answer 305

A. 12 Gy

Question 306

A young female presented with galactorrhea amenorrhea and visual field defects. What is the usual SRS dose for secretory pituitary tumors?
● A. 10 Gy
● B. 12 Gy
● C. 20 Gy
● D. 25 Gy
● E. 30 Gy

Answer 306

D. 25 Gy

Question 307

What is the rate of clinical improvement after interstitial brachytherapy?
● A. 100%
● B. 90%
● C. 75%
● D. 50%
● E. Rare chances

Answer 307

E. Rare chances

Question 308

What are the four Rs of radiobiology that are referred by radiation oncologists?
● A. Repair of sublethal damage
● B. Reoxygenation of tumor cells that were hypoxic before radiotherapy
● C. Repopulation of tumor cells
● D. Redistribution of cell within the cell cycle
● E. All of the above

Answer 308

E. All of the above

Question 309

All of the following are the CNS tumors that are very radiosensitive except?
● A. Lymphoma
● B. Thyroid adenocarcinoma
● C. Germ cell tumors
● D. Metastatic small cell cancer

Answer 309

B. Thyroid adenocarcinoma

Question 310

Radiation therapy is the main treatment modality for radiosensitive spinal metastasis. Even tumors that are considered radioresistant can respond to radiotherapy. What is the usual fractionated therapy for spinal tumors?
● A. 20 Gy administrated over 10 fractions
● B. 30 Gy administrated over 10 fractions
● C. 40 Gy administrated over 10 fractions
● D. 50 Gy administrated over 10 fractions
● E. 60 Gy administrated over 10 fractions

Answer 310

B. 30 Gy administrated over 10 fractions

Question 311

Following are the side effects of spinal radiation except?
● A. Radiation myelopathy
● B. Due to overlap, radiation injury to GI tract
● C. Bone marrow hyperactivity
● D. Growth retardation in children
● E. Risk of development of cavernous malformation of spinal cord

Answer 311

C. Bone marrow hyperactivity

Question 312

Small artery injury because of radiation therapy causes which phase of radiation injury?
● A. Acute phase
● B. Early delayed which starts from few weeks to 2 to 3 months following completion of radiation therapy
● C. Late delayed phase which remains from 3 months to 12 years
● D. None of the above

Answer 312

C. Late delayed phase which remains from 3 months to 12 years

Question 313

Manifestation of radiation effects includes all of the following except?
● A. Decreased cognition
● B. Radiation necrosis
● C. Injury to optic pathways or injury to hypothalamic pituitary axis
● D. Primary hyperthyroidism
● E. May induce formation of new tumor or malignant transformation or leukoencephalopathy

Answer 313

D. Primary hyperthyroidism

Question 314

Which of the following tests can be done to differentiate radiation necrosis from recurrent tumor?
● A. MRI spectroscopy
● B. DWI
● C. Nuclear brain scan
● D. Computerized radionuclide studies including SPECT or PET
● E. All of the above

Answer 314

E. All of the above

Question 315

Which of the following are included in the treatment of radiation necrosis which may cause mass effect or otherwise toxicity?
● A. Steroids
● B. Bevacizumab
● C. Reoperation or excision
● D. Hyperbaric oxygen and anticoagulation
● E. All of the above

Answer 315

E. All of the above

Question 316

Types of radiation myelopathy include which of the following?
● A. Type 1 is mild form with mild sensory symptoms which commonly resolves within several months
● B. Type 2 is injury to anterior horn cells with lower motor neuron signs in arms or legs
● C. Type 3 is described only in experimental animals after doses larger than normal radiation. Complete cord lesion within hours occurs due to injury to blood vessels
● D. Type 4 is chronic progressive myelopathy which is commonly reported
● E. All of the above

Answer 316

E. All of the above

Question 317

Following are indications of stereotactic radiosurgery except?
● A. Vascular lesions including AVMs or cavernous malformaions
● B. Tumors which include lesions less than 3 cm which can be metastasis, vestibular schwannomas, meningiomas, pituitary adenomas, or gliomas
● C. Compressive tumors of the spinal cord, brain stem, or optic structures
● D. Functional disorders like trigeminal neuralgia or intractable chronic pain, movement disorders of psychiatric disease

Answer 317

C. Compressive tumors of the spinal cord, brain stem, or optic structures

Question 318

What is evaluation of flow through the posterior communicating arteries by vertebral injection with simultaneous common carotid artery compression in the neck called?
● A. Allcock test
● B. Wada test
● C. Froin’s
● D. Queckensdest’s
● E. Widal

Answer 318

A. Allcock test

Question 319

Reversal of aspirin can be achieved with which of the following?
● A. Protamine sulfate
● B. Vitamin K
● C. RBC transfusion
● D. FFPs
● E. Platelets

Answer 319

E. Platelets

Question 320

According to weight-based protocol, heparin is given as 70 units/kg followed by maintenance intravenous dose of how much (units/kg/h)?
● A. 18
● B. 22
● C. 25
● D. 28
● E. 30

Answer 320

A. 18

Question 321

Lidocaine overdose is reversed with which of the following given intravenously?
● A. Calcium
● B. Potassium
● C. Magnesium
● D. Albumin
● E. Lipid emulsion

Answer 321

E. Lipid emulsion

Question 322

Which aneurysm feature is a not a high risk for rupture?
● A. Irregular shape
● B. Size > 7 mm
● C. Aspect ratio > 2.7
● D. Posterior circulation
● E. 10-mm cavernous segment aneurysm

Answer 322

E. 10-mm cavernous segment aneurysm

Question 323

For chemical spasmolysis to treat vasospasm, what is the drug of first choice?
● A. Verapamil
● B. Nimodipine
● C. Beta blockers
● D. Steroids
● E. Alpha blockers

Answer 323

A. Verapamil

Question 324

Which of the following is the hallmark for aggressive dural arteriovenous fistula (DAVF)?
● A. Cortical venous reflux
● B. Intracerebral hemorrhage
● C. Focal neurological deficit
● D. Increased intraocular pressure
● E. Audible bruit

Answer 324

A. Cortical venous reflux

Question 325

The method of choice for carotid-cavernous fistula (CCF) is transarterial embolization with which of the following?
● A. Coil
● B. Clip
● C. Onyx
● D. NCBA
● E. PVA

Answer 325

A. Coil

Question 326

Which of the following is not included in the 5 Ds of vertebrobasilar insufficiency?
● A. Diplopia
● B. Dysarthria
● C. Defective vision
● D. Drop attacks
● E. Diastematomyelia

Answer 326

E. Diastematomyelia

Question 327

Which of the following statements regarding risk of cerebral angiography is incorrect?
● A. Arterial dissection can occur because of it
● B. Perforation of artery or aneurysm can occur during the procedure
● C. Air embolism is the most common complication of cerebral angiography
● D. Cerebral angiography can also cause embolic thrombus
● E. There can also be puncture site complications like hematoma formation or embolism distal to puncture site

Answer 327

C. Air embolism is the most common complication of cerebral angiography

Question 328

Indications and case selection of aspirin include diagnostic cerebral angiography, coil embolization of aneurysms, stent complications, balloon test occlusion, or therapeutic occlusion of large arteries. What is the maximum dose of aspirin that is used in 1 day?
● A. 275 mg
● B. 300 mg
● C. 325 mg
● D. 350 mg
● E. 375 mg

Answer 328

C. 325 mg

Question 329

Daily dose of clopidogrel is 75 mg. Following are the indications of clopidogrel use except?
● A. Coil embolization of wide neck cerebral aneurysms where stent will be used
● B. Stent implantation
● C. Therapeutic occlusion of large arteries
● D. Parent artery coil prolapse or herniation
● E. Thrombus or clot on coil phenomena
● F. All of the above

Answer 329

F. All of the above

Question 330

Heparin is used in embolization of brain AVM or dural AVF, cervical or intracranial angioplasty, intra- or extracranial stent implantation, or balloon test occlusion of carotid, vertebral, or other large cerebral arteries. Which of the following is used for
reversal of heparin?
● A. FFPs
● B. Warfarin
● C. Protamine sulfate
● D. Steroids
● E. Analgesics

Answer 330

C. Protamine sulfate

Question 331

All of the following are included in the exclusion criteria of tissue plasminogen activator except?
● A. History of previous intracranial hemorrhage
● B. Recent intracranial or intraspinal surgery
● C. Diagnosis of ischemic stroke with onset of symptoms in less than or equal to 3 hours
● D. Intracranial neoplasm, AVM, or aneurysm
● E. Active internal bleeding or elevated blood pressure

Answer 331

E. Active internal bleeding or elevated blood pressure

Question 332

What is the intravenous dose of tissue plasminogen activator?
● A. 0.7 mg/kg
● B. 0.9 mg/kg
● C. 1.1 mg/kg
● D. 1.3 mg/kg
● E. 1.5 mg/kg

Answer 332

B. 0.9 mg/kg

Question 333

Which of the following is used for reversal of tissue plasminogen?
● A. Cryoprecipitate
● B. Tranexamic acid
● C. Protamine sulfate
● D. FFPs
● E. All of the above

Answer 333

A. Cryoprecipitate

Question 334

Which of the following are the factors that affect the selection of aneurysm for treatment?
● A. Ruptured or unruptured aneurysms (ruptured aneurysms need to be treated urgently)
● B. Symptoms other than rupture like cranial nerve palsy or loss of vision or ischemia as aneurysms causing these kind of symptoms are at increased risk of rupture
● C. Large aneurysms (size more than 7–10 mm) are more likely to rupture than small aneurysms
● D. An irregular-shaped aneurysm is at increased risk of rupture than a spherical saccular aneurysm
● E. All of the above

Answer 334

E. All of the above

Question 335

Which of the following are the endovascular options for treatment of neurosurgical patients?
● A. Coiling
● B. Coiling with stenting
● C. Balloon-assisted coiling
● D. Dual catheter technique
● E. All of the above

Answer 335

C. Balloon-assisted coiling

Question 336

Following are the treatments of aneurysmal rupture during coiling except?
● A. Inflate balloon if balloon-assisted coiling
● B. Immediately lower blood pressure
● C. Immediately anticoagulation is given
● D. An extraventricular drainage
● E. All of the above

Answer 336

E. All of the above