Soal NC Compile 1-643 Flashcards
A pericallosal aneurysm would be found at which location on the lateral projection angiogram shown?
a. C
b. E
c. A
d. D
e. B
B
A patient is found to have a new hemiparesis after resection of a GBM. How does this finding impact his overall survival?
a. Unchanged survival if the deficit is permanent
b. Worsens survival if the deficit is temporary
c. Improves survival if the deficit is temporary
d. Worsens survival if the deficit is permanent
e. Improves survival if the deficit is permanent
d. Worsens survival if the deficit is permanent
A 65-year-old male presents with resting tremor,
rigidity, postural instability, and bradykinesia. Which of
the following symptoms is most likely to also be present?
a. Dry mouth
b. Hypertension
c. Diarrhea
d. Hyposmia
e. Diabetes
d. Hyposmia
Which of the following is most likely to DECREASE
during the physiologic compensation for acute anemia?
a. Cardiac index
b. Oxygen consumption
c. Stroke volume
d. Oxygen extraction
e. Systemic vascular resistance
e. Systemic vascular resistance
A 38 year-old woman underwent subtotal resection of a
WHO Grade 2 astrocytoma. What is the most appropriate
management of this patient?
a. Radiation
b. Observation
c. Chemotherapy
d. Radiation and chemotherapy
e. Radiation and immunotherapy
d. Radiation and chemotherapy
A 55 year-old man presents with worsening short-term memory
and confusion. On examination he appears depressed, has
difficulty with fine motor skills such as finger tapping, and shows
saccadic eye movements. His father died at age 60 after a
prolonged illness with worsening rigidity and dementia. His MRI
shows loss of striatal volume, with somewhat boxy lateral
ventricles. He most likely has early symptoms of which disorder?
a. Batten Disease (Neuronal Ceroid Lipofuscinosis)
b. Spinocerebellar Ataxia
c. Mitochondrial encephalomyopathy
d. Parkinson Disease
e. Huntington Disease
e. Huntington Disease
A 68 year-old male with a history of prostatic cancer presents with low-grade
fever and severe low back pain progressing to include lower extremity
numbness. Thoracic CT shows extensive destruction of the T11 and T12 vertebral
bodies with relative sparing of the T11-12 disc space, as well as a large
paraspinous abscess with calcification. Thoracic MRI shows a kyphotic deformity
with enhancing soft tissue and bone extending into the anterior spinal canal and
resulting in moderate stenosis and spinal cord compression. The MOST likely
pathologic process is:
a. Osteoporotic compression fracture
b. Discitis - Staph epidermidis
c. Spinal tuberculosis
d. Pathologic fracture
e. Discitis- Staph aureus
c. Spinal tuberculosis
A 50-year-old female patient presents with pelvic and leg pain.
What are the paired structures indicated by the white arrows in the
axial (Figure 1) and coronal (Figure 2) pelvic MRI?
a. Obturator nerves
b. Piriformis muscles
c. Sciatic nerves
d. Sacrospinous ligaments
e. Pudendal nerves
c. Sciatic nerves
A newborn presents with seizures. MRI of the brain shows Probst
bundles running superomedial to the lateral ventricles.
This is indicative of what pathological process?
a. Focal cortical dysplasia
b. Metabolic disorder
c. Agenesis of the corpus callosum
d. Holoprosencephaly
e. Kallman’s syndrome
c. Agenesis of the corpus callosum
An 84-year-old male has an MRI that reveals an enhancing
lesion involving the left internal acoustic canal (see figure). On
exam, he has diminished hearing in his left ear. What is the most
appropriate next step in the management of this patient?
a. Stereotactic radiosurgery in 3-5 fractions
b. Surgical removal via a translabyrinthine approach
c. Surgical removal via a restrosigmoid approach
d. Stereotactic radiosurgery in a single session
e. Reassurance and follow-up MRI in 6 months
e. Reassurance and follow-up MRI in 6 months
An ABG with PCO2 25 mmHg, pH 7.55, HCO3- 24 mEq/L is most
consistent with which diagnosis?
a. Respiratory alkalosis with metabolic compensation
b. Metabolic alkalosis with respiratory compensation
c. Metabolic alkalosis
d. Respiratory alkalosis
d. Respiratory alkalosis
Neurophysiological monitoring during translabrynthine
resection of a vestibular schwannoma with minimal extension into
the cerebellopontine angle includes which of the following?
a. SSEP and IX, X, XI nerves
b. BAER and VII nerve
c. BAER and IX, X, XI nerves
d. BAER and SSEP
e. SSEP and VII nerve
e. SSEP and VII nerve
A 35 year-old man was found down for an unknown period of time after a generalized seizure. In the emergency department, he complains of pain in his thighs, shoulders, and calves. On exam, he is GCS 14 with confusion, and his imaging shows a small left frontal subarachnoid hemorrhage. Rhabdomyolysis is suspected. What finding is most consistent with this diagnosis?
a. Myoglobinuria
b. Normal serum creatinine
c. Hematuria
d. Normal CPK level
e. Hypokalemia
a. Myoglobinuria
A 21 year-old-man sustained blunt force trauma to his head, had brief
loss-of-consciousness and was GCS 15 at initial evaluation, complaining
of headaches, nausea and visual disturbance. CT is shown in figures.
What is the best management of this patient?
a. Evacuation of hematoma with placement of
burr holes
b. Place ICP monitor and observe in the ICU
c. Manage conservatively in the ICU with a f/u CT
in 6 hrs.
d. Take to the OR emergently for a combined
Supra- and infratentorial approach
e. Cerebral angiogram and embolization of sinus
d. Take to the OR emergently for a combined
Supra- and infratentorial approach
When resecting a brain lesion near the corticospinal tract, what
modality is best suited to minimize the risk of motor impairment?
a. Direct cortical stimulation motor evoked potential monitoring
b. Somatosensory evoked potential monitoring
c. Quantitative subcortical motor mapping
d. Phase-reversal mapping
e. Nerve conduction study
c. Quantitative subcortical motor mapping
A 54 year-old male had a good result from left-sided thalamotomy for
essential tremor 10 years ago. He now wishes to have his other side
treated. What is the MOST appropriate surgical procedure for his
contralateral side?
a. Pallidal DBS
b. Subthalamic DBS
c. Thalamotomy
d. Pallidotomy
e. Thalamic DBS
e. Thalamic DBS
A patient undergoes a stereotactic biopsy of a grade IV astrocytoma.
When considering the discussion of the findings and prognosis, patients
indicate that the most important factors for effective communication
include:
a. Giving only best possible scenario to give the patient hope.
b. Careful scientific explanation of the histology, while withholding a grave
prognosis.
c. Demonstration of physician’s compassion, honesty, attention to
questions and use of clear language.
d. Using empathetic communication such as “It could be worse”, “I understand
how you feel” or “Nothing more can be done”
e. Physician’s familiarity with the patient and the use of touch (e.g. holding the
patient’s hand)
c. Demonstration of physician’s compassion, honesty, attention to
questions and use of clear language.
In addition to the negative effects on cerebral blood flow,
hyperventilation should be avoided in the management of severe closed
head injury for which of the following reasons?
a. Right shift of hemoglobin-oxygen dissociation curve and potential CO2
removal impairment
b. Left shift of the hemoglobin-oxygen dissociation curve and potential CO2
removal impairment
c. Right shift of hemoglobin-oxygen dissociation curve and potential oxygen
delivery impairment
d. Increased pH and potential for increased oxygen delivery
e. Left shift of the hemoglobin-oxygen dissociation curve and potential
oxygen delivery impairment
e. Left shift of the hemoglobin-oxygen dissociation curve and potential
oxygen delivery impairment
You are examining your patient with suspected carpal tunnel
syndrome and you ask that they aggressively flex their affected wrist.
This maneuver reproduces their carpal tunnel symptoms. What is this
response called?
a. Phalen sign
b. Lhermitte sign
c. Wartenberg sign
d. Froment sign
e. Tinel sign
a. Phalen sign
Which cannabinoid is thought to be most effective at treating pain?
a. Tetrahydrocannabinol (THC)
b. Cannabicyclol (CBL)
c. Cannabidiol (CBD)
d. Anandamide (AEA)
e. Cannabinol (CBN)
c. Cannabidiol (CBD
A 25 year-old man presents with a flail, anesthetic arm after an
industrial accident with closed injury to the brachial plexus. After 6
months, he has recovered shoulder, elbow, and wrist movement, but the
hand remains flail. Examination shows the presence of ptosis and miosis
ipsilateral to the injured arm. Electrodiagnostic studies show normal
sensory nerve action potentials of the ulnar nerve. Where is the most
likely injury?
a. Postganglionic injury of C7
b. Preganglionic injury of T1
c. Postganglionic injury of C8
d. Preganglionic injury of C7
e. Postganglionic injury of T1
b. Preganglionic injury of T1
The Food and Drug Administration (FDA) has issued limits on the per
dose and daily dose recommended for acetaminophen to prevent what
complication?
a. Kidney toxicity
b. Aplastic anemia
c. Steven-Johnson syndrome
d. Liver toxicity
e. Myositis
d. Liver toxicity
A diabetic patient with known peripheral vascular disease undergoes
an anterior cervical discectomy at C4-5. The operative course is
unremarkable; however, in the recovery room the patient is noted to have
decreased sensation in the 4th and 5th digits of the left hand and
decreased grip. What is the MOST likely diagnosis?
a. Residual muscle relaxation
b. Brachial plexus stretch injury
c. Positioning nerve injury
d. Surgical trauma
e. Embolic stroke
c. Positioning nerve injury
You performed an uneventful supraclavicular brachial plexus
exploration to remove an upper trunk schwannoma. Postoperatively, the
patient has a new complaint of dyspnea on exertion. On examination, her
vitals are normal at rest. On exertion she has shortness of breath without
tachycardia. She has full strength and sensation within an upper trunk
distribution.
What would be the most appropriate initial diagnostic test to evaluate the
etiology of her symptoms?
a. Lower extremity DVT ultrasound
b. Chest X-ray
c. Brachial plexus MRI
d. Thoracic outlet MRV
e. EMG / NCS
b. Chest X-ray
A 30 year-old undergoes an anterior temporal lobectomy for
intractable epilepsy secondary to mesial temporal sclerosis.
Postoperatively, the patient has new diplopia that improves over the next
4 months. Tilting his head to the right and tucking his chin improves his
symptoms. Damage to what structure accounts for this complication?
a. Trochlear nerve
b. Quadrigeminal plate
c. Meyer’s loop
d. Oculomotor nerve
e. Posterior communicating artery
a. Trochlear nerve
Of the following, which symptom, associated with advanced
Parkinson disease and/or its long-term medical treatment, is most reliably
controlled by the therapeutic lesion depicted in the magnetic resonance
image shown in Figure 1?
a. Rigidity
b. Ataxia
c. Tremor
d. Akinesia
e. Levodopa-induced dyskines
e. Levodopa-induced dyskines
A 54-year-old man presents with acute onset of right neck pain
radiating to his jaw. He denies any other symptoms. His clinical findings
are demonstrated on the photograph below. Which of the following would
be the most appropriate imaging study to order?
a. CT angiogram of the head
b. MRI of the brain and orbits
c. CT scan of the chest
d. CT angiogram of the neck
e. MRI of the cervical spine
d. CT angiogram of the neck
A patient with a baclofen pump presents with a temperature of 104
degrees F and hyperreflexia. What is the next appropriate treatment?
a. Intravenous dantrolene
b. Intrathecal baclofen administration
c. Cooling blanket
d. Broad spectrum antibiotics
e. Intravenous acetaminophen
b. Intrathecal baclofen administration
A 76 year-old undergoes a craniotomy for evacuation of a subdural
hematoma. Three days later, the patient is noted to have increased
confusion and a heart rate of 102 bpm. His blood pressure is 83/52, and
his respiratory rate is 31 breaths per minute. The nurse measures a
temperature of 38.5 degrees C. He has coarse breath sounds and his
urine output was 15cc/hr over the prior 6 hours. His symptoms do not
respond to a saline bolus. What is the most appropriate next step?
a. Obtain EKG and send cardiac enzymes
b. Send the patient for a STAT repeat head CT
c. Send blood cultures and start broad spectrum antibiotics
d. Obtain a CT chest to rule out pulmonary embolus
e. Administer a diuretic
c. Send blood cultures and start broad spectrum antibiotics
A 6-year-old with Down syndrome has a skull defect that has been
present since birth (Figures 1 & 2). What is the correct diagnosis?
a. Dermoid cyst
b. Healed skull fracture
c. Acute skull fracture
d. Bilateral parietal foramina
e. Aplasia cutis congenita
d. Bilateral parietal foramina
What is the appropriate sequence of steps during AVM
microsurgery ?
a. Ligation of the draining vein(s) – nidus resection – coagluaiton of feeding
arteries
b. Nidus resection - ligation of the draining vein(s) – coagluaiton of feeding
arteries
c. Coagulation of feeding arteries – nidus resection – ligation of the draining
vein(s)
d. Coagulation of feeding arteries – ligation of the draining vein(s) – nidus
resection
e. Ligation of the draining vein(s) - coagulation of feeding artery - nidus
resection
d. Coagulation of feeding arteries – ligation of the draining vein(s) – nidus
resection
After a motorcycle accident, a patient’s examination reveals eyes that
open to stimulation, incomprehensible vocalization, and withdrawal to
painful stimulus. Head CT scan demonstrates several punctate
contusions and a 2mm right-sided subdural hematoma. After intubation,
what is the next most appropriate step?
a. Repeat head CT within 1 hour
b. Administration of mannitol
c. Hyperventilation
d. Placement of ICP monitor
e. Craniotomy for evacuation of subdural
d. Placement of ICP monitor
What factor has had the single largest effect on the incidence of
myelomeningocele in the United States over the past 30 years?
a. Antenatal diagnosis followed by termination
b. Decreased numbers of children being born
c. Changes in population demographics
d. Folate supplementation
e. Decreased use of seizure medication during pregnancy
d. Folate supplementation
A 38 year old male experiences severe acute right arm pain and then
develops severe deltoid weakness and mild biceps and triceps
weakness. After 6 weeks, he seeks consultation. Axial MRI imaging at C4-
5 and C5-6 are shown. What is the next most appropriate step in
management?
a. EMG/NCS
b. Cervical traction
c. Epidural steroid injection
d. ACDF C4-5 and C5-6
e. CT myelogram
a. EMG/NCS
You are treating a patient with chronic, medically-refractory low back
pain. You decide to proceed with a trial of spinal cord stimulation. What
would be the most appropriate spinal level for electrode placement to
achieve the best stimulation coverage of the patient’s painful area?
a. T11
b. T9
c. L5
d. C1
e. L2
b. T9
What radiotherapy modality for intracranial meningioma is
associated with the lowest risk of symptomatic radiation
injury?
a. Fractionated radiation therapy
b. Proton Beam Radiotherapy
c. Gamma knife radiosurgery
d. Hypofractionated stereotactic radiotherapy
e. Linear accelerator radiosurgery
a. Fractionated radiation therapy
You are considering performing a multilevel lumbar spinal fusion in a
patient taking buprenorphine for opiate addiction. Which clinical effect
of buprenorphine will most likely complicate the management of this
patient?
a. Buprenorphine can cause severe respiratory depression.
b. Buprenorphine can block the analgesic effects of opioids.
c. Buprenorphine can impair rates of bone fusion.
d. Buprenorphine can block the effects of inhalational anesthetics.
e. Buprenorphine can cause seizures.
b. Buprenorphine can block the analgesic effects of opioids.
After a fall, a 20 year old skateboarder is asymptomatic but is found
to have a non-displaced fracture involving the petrous portion of the left
temporal bone. What is the most appropriate management of this
fracture?
a. Prophylactic antibiotics.
b. Steroid therapy.
c. Conservative management.
d. Surgical repair.
e. Lumbar drainage.
c. Conservative management.
You are performing surgery on a patient with a suspected nerve
entrapment, and discover that the nerve is severely narrowed (>50%)
along the point of entrapment. What is the most appropriate treatment for
this condition?
a. Internal neurolysis
b. Nerve transposition
c. Neuroplasty
d. Neurorrhaphy
e. Nerve transfer
a. Internal neurolysis
The current model of basal ganglia physiology suggests that the
‘negative symptoms’ of Parkinson disease (i.e., rigidity and bradykinesia)
are attributable to which of the following physiological events:
a. Excessive glutamatergic input from the
disinhibited subthalamic nucleus results in
GPi hyperactivity.
b. Inhibitory input to the globus pallidus pars
internus (GPi) via the direct pathway from
the striatum is decreased.
c. The hyperactive GPi hyperinhibits the
ventrolateral (VL) nucleus of the thalamus.
d. all of the above
e. Glutamatergic input from the VL thalamus
to the supplementary motor area is
decreased.
d. all of the above
What is the most common major complication of
stereoelectroencephalography (SEEG)?
a. Electrode migration
b. Infection
c. Status epilepticus
d. Intracranial hematoma
d. Intracranial hematoma
On this lateral projection angiogram, the indicated artery supplies
the:
a. Pre-central gyrus
b. Scalp
c. Dura
d. Cingulate gyrus
e. Superior parietal lobule
c. Dura
What visual field deficit is most common after right anterior temporal
lobectomy for epilepsy?
a. Left inferior quadrantanopsia
b. Scotoma
c. Left homonymous hemianopsia
d. Left superior quadrantanopsia
e. Bitemporal hemianopsia
d. Left superior quadrantanopsia
A 24-year-old woman presents with right arm weakness and the
accompanying T1-weighted, contrast-enhanced MRI. Stereotactic needle
biopsy demonstrates Rosenthal fibers on histopathological analysis.
Which of the following treatment paradigms is associated with long-term
disease control?
a. Complete microsurgical resection followed
by adjuvant radiotherapy
b. Complete microsurgical resection
alone
c. Radiotherapy combined with high-dose
corticosteroids
d. Radiotherapy combined with IV
methotrexate
e. Radiotherapy alone
b. Complete microsurgical resection
alone
A 65 year-old woman presents with progressively worsening gait
instability over 4 weeks. She has 4/5 strength in bilateral iliopsoas, 3+
patellar tendon reflexes, and difficulty with tandem gait. MRI of the
thoracic spine is depicted (Figure 1). Selective spinal angiography of the
right T11 intercostal artery is shown in the early (Figure 2A) and delayed
(Figure 2B) phases. What is the goal of surgery?
a. Gross total resection of the nidus
b. Decompression of the spinal cord via expansile duraplasty
c. Divide the arteriovenous connection at the nerve root sleeve
d. Coagulate the abnormal dilated pial veins
e. Sacrifice the feeding vessel to the anterior spinal artery
c. Divide the arteriovenous connection at the nerve root sleeve
A patient presents with bilateral nondisplaced fractures through the
C2 pars interarticularis (Hangman’s fracture). Flexion-extension dynamic
cervical radiographs show 2 mm motion and no significant deformity.
What is the most appropriate treatment modality?
a. External immobilization
b. Posterior C1-C3 fixation
c. Anterior odontoid screw fixation
d. C1-2 transarticular screw fixation
e. Anterior C2-3 discectomy and fusion
a. External immobilization
A 19-year-old woman presents with intermittent episodes involving a
motionless stare, lip smacking, dystonic posturing of the left arm, and
unresponsiveness. What type of seizure is this patient experiencing?
a. Aura
b. Secondarily generalized
c. Complex partial
d. Simple partial
e. Atonic
c. Complex partial
During an examination you ask your patient to squeeze their thumbs
and fingers together tightly. During this maneuver you note an
abnormality in the left hand seen in the figure. Weakness in which
muscle is responsible for this finding?
a. Flexor digitorum profundus
b. Flexor pollicis longus
c. Adductor pollicis
d. Dorsal interosseous
e. Abductor pollicis brevis
c. Adductor pollicis
What is the most likely diagnosis demonstrated by the findings in the
MRI images shown (see figures)?
a. Chordoma
b. Pilocytic astrocytoma
c. Multiple sclerosis
d. Basilar invagination
e. Chiari 1 malformation with syrinx
e. Chiari 1 malformation with syrinx
According to AHA guidelines for early ischemic stroke management,
IV tPA should be administered within what time frame after the onset of
symptoms?
a. 2.5 hours
b. 3.5 hours
c. 4.5 hours
d. 1.5 hours
e. 5.5 hours
c. 4.5 hours
A 19-year-old man has suffered from complex-partial seizures since
the age of 13. He has failed a trial of two anti-epileptic medications. His
brain MRI reveals no focal abnormalities. What is the most appropriate
next step in management?
a. Addition of a third anti-epileptic medication
b. Initiation of ketogenic diet
c. Evaluation by surgical epilepsy team for possible resective options
d. Implantation of a vagus nerve stimulator
e. Addition of cannabidiol (CBD oil), a cannabis derivative
c. Evaluation by surgical epilepsy team for possible resective options
47-year-old man with history of tympanomastoidectomy for cholesteatoma
presents to an otolaryngologist for headaches and fullness in the ear. A
temporal bone CT scan was performed which demonstrates a large tegmen
defect and soft tissue signal in the mastoid cavity. The otolaryngologist is
concerned about a cholesteatoma recurrence and cannot rule out presence of
an encephalocele. What would be the most appropriate imaging modality to
distinguish the two entities?
a. FDG-PET scan
b. CT cisternogram
c. Diffusion-weighted MRI
d. MR spectroscopy
e. Thin cut temporal bone CT
c. Diffusion-weighted MRI
A 7-year-old girl presents with slowly worsening urinary incontinence (after
previously being continent) and severe back pain radiating to the bottom of her
feet. An MRI is shown. What is the most likely diagnosis?
a. Lipomyelomeningocele
b. Diastamatomyelia
c. Fatty filum terminale
d. Meningocele
e. Myelomeningocele
a. Lipomyelomeningocele
A 6-month-old infant presents with enlarging head circumference, full
anterior fontanelle, splitting of the cranial sutures and developmental delay. The
results of a neurological examination are otherwise normal. Computed
tomographic scans are obtained (Figures 1 and 2). What is the most likely
diagnosis?
a. Dandy-Walker malformation
b. Aqueductal stenosis
c. Retrocerebellar arachnoid cyst
d. Chiari III malformation
a. Dandy-Walker malformation
Which factor has been strongly associated with increased
hemorrhage rate after radiosurgery of an arteriovenous malformation
(AVM)?
a. Margin dose
b. Number of prior hemorrhages
c. Target volume
d. Number of feeding arteries to the AVM
e. Superficial AVM location
b. Number of prior hemorrhages
A 42 year old woman suffers a gunshot injury to the abdomen. A CT
scan shows intraperitoneal free air as well as a bullet lodged within the
L3 vertebral body with minimal retropulsion of the posterior wall. She is
neurologically intact. What is the most appropriate next step in
management?
a. L3 laminectomy, removal of all loose bone fragments, and
antibiotic washout.
b. Administration of tetanus prophylaxis.
c. Gunshot wound cultures.
d. Administration of prophylactic antifungal coverage.
e. Exploratory laparotomy to repair intraperitoneal injury with L3
corpectomy and fusion.
b. Administration of tetanus prophylaxis.
What is the first priority in the overall assessment of a trauma patient
with an acute cervical spine fracture?
a. Spinal stability
b. Ongoing hemorrhage
c. Airway integrity
d. Neurological deficit
e. Blood pressure
c. Airway integrity
A 41 year-old woman undergoes gross total resection for the lesion
shown (Figure). Pathology confirms a grade 2 oligodendroglioma. What
is the recommended course of treatment?
a. Serial MRI
b. Clinical observation
c. Chemotherapy and radiation
d. Chemotherapy
e. Radiation
c. Chemotherapy and radiation
What is the approximate mortality rate of stereotactic brainstem
biopsy for suspected brainstem malignancy?
a. 20%
b. 1%
c. 10%
d. 5%
e. 15%
b. 1%
In the Hassler terminology, the ventrolateral thalamus is subdivided
into three regions, including which of the following:
a. Ventral oralis posterior (VOP), ventral intermediate (VIM), and
ventral caudalis (VC)
b. Ventral oralis anterior (VOA), ventral oralis posterior (VOP), and
ventral intermediate (VIM)
c. Ventraloralis anterior (VOA), ventral intermiate (VIM), and ventral
caudalis (VC)
d. Ventral lateral (VL), ventral intermediate (VIM), and ventral posterior
lateral (VPL)
e. Ventral oralis anterior (VOA), ventral oralis posterior (VOP), and
ventral caudalis (VC)
a. Ventral oralis posterior (VOP), ventral intermediate (VIM), and
ventral caudalis (VC)
The trigeminal cistern is an important structure in percutaneous
trigeminal procedures. Where is the trigeminal cistern located in relation
to the gasserian ganglion?
a. Inferolateral
b. Inferomedial
c. Superolateral
d. Posterior
e. Anterior
d. Posterior
You have been treating a patient with low back pain with opiates for
many years. His doses have been gradually increasing. Spinal imaging
has shown no significant changes. More recently he reports that his pain
has become progressively more severe, and increasing doses of opiates
are associated with increased pain. What is this phenomenon called?
a. Opioid addiction
b. Malingering
c. Opioid-induced hyperalgesia
d. Opioid dependence
e. Conversion disorder
c. Opioid-induced hyperalgesia
A 15 year-old boy complains of neck pain and intermittent pain about
his lumbar myelomeningocele scar. A recent shunt series shows no
disconnection and a head CT shows small dysmorphic ventricles. On
exam, the patients is neurologically stable with chronic weakness of
ankle dorsiflexion. What is the most likely source of the patient’s
symptoms?
a. Ventriculoperitoneal shunt infection.
b. Tethered spinal cord.
c. Ventricloperitoneal shunt malfunction.
d. Chiari II malformation.
e. Aseptic Meningitis
c. Ventricloperitoneal shunt malfunction.
In childhood epilepsy syndromes, patients with Lennox-Gastaut
syndrome MOST often have the following EEG findings:
a. Multifocal slow spike and wave activity
b. Bilateral hypsarrhthmia
c. Diffuse EEG slowing
d. Triphasic spike and wave activity
e. Normal or discontinuous EEG activity
a. Multifocal slow spike and wave activity
A 46-year-old IV drug abuser presents with a 2 week history of fever
and progressive low back pain. He is neurologically intact. MRI reveals
increased T2 signal in the L3-4 disc space with endplate destruction
without an appreciable fluid collection. There is no evidence of instability
or segmental kyphosis. Blood cultures are negative. What is the most
appropriate next step in management?
a. Posterior instrumentation and fusion without laminectomy
b. Anterior discectomy and interbody fusion
c. Needle biopsy of disc space
d. Laminectomy for surgical debridement
e. Empiric antibiotics
c. Needle biopsy of disc space
What is the main arterial supply of the motor tracts of the spinal cord
from T8 to the conus medullaris?
a. Median sacral artery
b. Medial spinal artery
c. Posterior spinal artery
d. Artery of Adamkiewicz
e. Lateral spinal artery
d. Artery of Adamkiewicz
A 30 year old woman presents with right arm weakness that has
progressed over a period of two months. MRI shows an enlarging mass
associated within the median nerve (see figure). Biopsy demonstrates
diffuse spindle-shaped cells with palisading hyperchromatic nuclei,
frequent mitotic figures, necrosis, and loss of S-100 immunoreactivity.
What is the best next step in management of this lesion?
a. Fractionated radiation therapy
b. En bloc excision with negative margins
c. Observation with surveillance imaging
d. Nerve-sparing excision
e. Limb amputation
b. En bloc excision with negative margins
You are performing a supraclavicular brachial
plexus exploration. Which of the following
incisions would be most appropriate?
a. Figure 1
b. Figure 2
c. Figure 4
d. Figure 5
e. Figure 3
e. Figure 3
A 15-year-old girl with a history of epilepsy and learning disability
presents with vomiting and somnolence. MRI shows obstructive
hydrocephalus with a 3 cm calcified, contrast-enhancing intraventricular
mass near the foramen of Monro, as well as several small subependymal
nodules. Which cutaneous findings are most likely to be observed on
physical examination?
a. Port-wine stain (nevus flammeus)
b. Café-au-lait spots
c. Melanoblastosis cutis linearis (pigmented dermatitis)
d. Adenoma sebaceum
e. Axillary freckles
d. Adenoma sebaceum
You are seeing a new patient with a spinal infusion pump in the
Emergency Room. They report having had a pump refill at an outside
institution earlier that day. No medical records are available for this patient.
They are complaining of severe pain, diarrhea, nausea, and a sensation of
skin crawling. On examination they show agitation, tachycardia, and
vomiting. What clinical syndrome do you suspect?
a. Bupivicaine overdose
b. Opioid withdrawal
c. Ziconotide withdrawal
d. Clonidine withdrawal
e. Baclofen overdose
b. Opioid withdrawal
Which MRI sequence is used to non-invasively assess the structural
connectivity of the brain?
a. FIESTA
b. T2
c. DWI
d. FLAIR
e. DTI
e. DTI
A 45 year old man presents with horizontal diplopia consistent with
a left abducens nerve palsy. Which of the following findings would
BEST localize the lesion to the cavernous sinus?
a. Contralateral hemianopia.
b. Ipsilateral Horner’s syndrome.
c. Contralateral hemiparesis.
d. Ipsilateral optic neuropathy.
e. Papilledema.
b. Ipsilateral Horner’s syndrome.
Which inclusion-based feature is classic for Parkinson’s disease?
a. Tau-positive inclusions
b. Neurofibrillary tangles
c. Lewy bodies
d. Ballooned neurons
e. Ubiquitin-positive inclusions
c. Lewy bodies
A 40 year old patient presents with headache and aneurysmal
subarachnoid hemorrhage. On physical exam she was awake, alert and
nonfocal with the exception of a right third nerve palsy and evidence of
nuchal rigidity. What is the Hunt and Hess grade for this patient?
a. 2
b. 4
c. 5
d. 3
e. 1
a. 2
A 42 year old male is undergoing L5-S1 anterior lumbar interbody
fusion for spondylolisthesis. What anatomic structure overlying the
disc space is potentially at risk during exposure for discectomy?
a. vena cava
b. genitofemoral nerve
c. iliolumbar vein
d. distal aorta
e. hypogastic plexus
e. hypogastic plexus
What is the maximal total dose of IV rtPA that can be administered
for acute ischemic stroke?
a. 0.8 mg/kg
b. 0.9 mg/kg
c. 0.7 mg/kg
d. 1 mg/kg
e. 1.1 mg/kg
b. 0.9 mg/kg
A 35-year-old female underwent microscopic transsephenoidal
resection of a non-functioning pituitary macroadenoma. Postoperative
MRI demonstrates residual tumor in the right cavernous sinus lateral to
the internal carotid artery. She has no neurological deficits. What is the
most appropriate next step?
a. Craniotomy for resection of residual tumor
b. Endoscopic transsphenoidal resection
c. Expectant management
d. Medical treatment with cabergoline
e. Stereotactic radiosurgery of residual nodule
c. Expectant management
Which finding on clinical exam can distinguish a third cranial
neuropathy that is caused by an aneurysm from that caused by diabetic
neuropathy?
a. miosis
b. double vision
c. ptosis
d. pupillary dilation
e. pai
d. pupillary dilation
A 60 year old man presents with 10 weeks of back pain. ESR and
CRP are elevated and WBC is normal. Blood cultures show no growth.
The patient has normal strength and sensation and no bowel or bladder
incontinence. The MRI reveals osteomyelitis and discitis of L3/4 without
epidural abscess or canal compromise. What is the best next step in
the management of this patient?
a. Surgical Debridement
b. Disc space biopsy
c. Lumbar Brace
d. Lumbar Puncture
e. Empiric antibiotics
b. Disc space biopsy
Which of the following muscles is innervated by the median nerve?
a. Flexor digitorum profundus IV
b. Supinator
c. Lumbrical IV
d. Adductor pollicis
e. Flexor carpi radialis
e. Flexor carpi radialis
Telomerase reverse transcriptase (TERT) promoter mutations
leading to elevated TERT expression are most closely associated with
what genetic alterations in gliomas?
a. 1p19q co-deletion
b. MGMT promoter methylation
c. P53 overexpression
d. Loss of ATRX expression
e. EGFRvIII expression
a. 1p19q co-deletion
When performing deep brain stimulation surgery, what is the most
likely clinical consequence of transgressing the ventricle?
a. Hemiparesis
b. Profound delirium
c. Coma
d. No effect
e. Intraventricular hemorrhage
d. No effect
What is the vascular malformation demonstrated in this figure?
a. Cavernous malformation
b. Capillary telangiectasis
c. Venous angioma
d. Arteriovenous malformation
e. Arteriovenous fistula
c. Venous angioma
What is one of the best ways to ascertain that ulnar nerve
compression is distal (at the wrist) and not proximal (at the elbow)?
a. Test ulnar sensation on the dorsal surface of the hand.
b. Test the strength of the abductor digiti minimi muscle.
c. Test the strength of the adductor pollicis muscle.
d. Test ulnar sensation on the 4th and 5th digits.
e. Test the strength of the first dorsal interosseous muscle
a. Test ulnar sensation on the dorsal surface of the hand.
A 30-year-old male cyclist presents wtih complete C5 quadriplegia after a motor
vehicle collision. Work up reveals right wrist fracture and C5 fracture involving the left
transverse foramen associated with a large spinal cord contusion. CT angiography of
the neck is negative for vascular injury. Two hours after presentation, the patient
becomes confused, bradycardic, and hypotensive. Which of the following is the most
likely explanation for these findings?
a. Occult dissection of the vertebral artery with associated brain stem infarction.
b. Disruption of spinal sympathetic outflow due to spinal cord injury.
c. Fat embolism from the patient’s bony injuries.
d. Pulmonary contusion resulting respiratory failure.
e. Delayed hemothorax due to thoracic trauma.
b. Disruption of spinal sympathetic outflow due to spinal cord injury.
A 58 year-old man with history of lung adenocarcinoma presents with headaches.
MRI of the brain shows 3 supratentorial lesions, the largest of which is shown
(Figure). The patient undergoes stereotactic radiosurgery to each of the three lesions.
Based on randomized controlled trials, how is the addition of whole brain radiation
therapy likely to affect overall survival?
a. It is likely not to affect overall
survival
b. It is likely to shorten overall survival.
c. It is likely to lengthen overall survival.
d. There is insufficient evidence regarding
overall survival.
e. There is conflicting evidence regarding
overall survival.
a. It is likely not to affect overall
survival
A 36 year old woman with a known history of epilepsy treated with
phenytoin presents in convulsive status epilepticus. After administration of
lorazepam and supplementation with IV phenytoin, convulsions cease. Two
hours later she remains unresponsive despite a normal head CT and normal
serum electrolyte levels and blood counts. What is the most appropriate next
diagnostic test?
a. Electroencephalogram
b. Angiogram
c. MRI of the brain, including diffusion imaging
d. Lumbar puncture
e. Repeat serum sodium
a. Electroencephalogram
A 40 year old obese patient with a history of diabetes mellitus presents
unresponsive to the ER and is subsequently intubated and admitted to the
ICU. The patient’s basic metabolic panel reveals a glucose level of 500. The
ABG reveals a PCO2 40 mmHg, pH 7.25, and HCO3- 18 mEq/L. With which
condition is this ABG most consistent?
a. Metabolic acidosis with respiratory compensation
b. Respiratory acidosis with metabolic compensation
c. Respiratory acidosis
d. Metabolic acidosis
d. Metabolic acidosis
The McGill Pain Questionnaire Short Form (MPQ-SF) is a standardized
pain assessment tool used for both clinical assessment and research. Which
pain scoring system is a component of this assessment tool?
a. Wong-Baker FACES Pain Scale
b. Numerical Rating Scale (NRS)
c. Visual Analog Scale (VAS)
d. Verbal Descriptor Scale (VDS)
e. Color Scale for Pain
c. Visual Analog Scale (VAS)
Patients with subcortical band heterotopia are characterized by:
a. X-linked migrational disorder.
b. Subependymal giant cell astrocytomas.
c. Infantile spasms.
d. Male predominance.
a. X-linked migrational disorder.
A 58 year-old right handed male presents with bifrontal headaches
and a partial left ophthalmoplegia. MRI results are shown. Biopsy
revealed this tumor to be a chordoma. An extensive subtotal skullbased resection was performed. Which is the best choice for adjuvant
therapy regimen?
a. Conventional fractionated radiotherapy
b. Stereotactic radiosurgery
c. Brachytherapy
d. Proton beam radiotherapy
e. Procarbazine, CCNU and vincristine
(PCV) chemotherapy
d. Proton beam radiotherapy
A 50-year-old woman presents with a one-year history of
progressive low back pain and constipation. Magnetic resonance
imaging demonstrates a large sacral mass (figure). She is
neurologically intact. What is the most important next step to determine
further management?
a. CT-guided biopsy of the mass
b. Proctoscopic examination to assess the
consistency of lesion
c. MRI with contrast of the pelvis
d. MRI of the skull-base
e. Formal urodynamics studies
a. CT-guided biopsy of the mass
A 25-year old female presents with new onset weakness and vision
difficulties which worsen as the day progresses. Nerve conduction and
EMG testing shows improvement after the administration of
edrophonium. What is the diagnosis?
a. Dermatomyositis
b. Guillain-Barre syndrome
c. Lambert-Eaton syndrome
d. Myasthenia gravis
e. Polymyositis
d. Myasthenia gravis
An 8 year old boy was evaluated due to short stature and
headaches. Sagittal MRI with contrast below is most consistent with
which diagnosis?
a. Medulloblastoma
b. Germinoma
c. Craniopharyngioma
d. Pituitary macroadenoma
e. Arachnoid cyst
c. Craniopharyngioma
A 61-year-old man undergoes resection of a 3.5 cm glioblastoma
with 99% extent of resection. He is neurologically intact and has a postoperative Karnofsky Performance Status of 80. What is the most
appropriate selection for post-operative adjuvant radiation therapy in
this patient?
a. Stereotactic radiosurgery to the tumor bed at 12Gy
b. External-beam radiation to the tumor bed at 60Gy
c. Whole-brain radiation at 30Gy
d. No adjuvant radiation is indicated
e. Stereotactic radiosurgery to the tumor bed at 30Gy
b. External-beam radiation to the tumor bed at 60Gy
During deep brain stimulator implantation targeting the subthalamic
nucleus, macrostimulation testing reveals good tremor control with low
voltage stimulation but also parasthesias that resolve rapidly and
contralateral facial pulling and wrist flexion at low voltages. Similar
findings are noted with stimulation at all contacts. What is the most
appropriate next step?
a. Secure the electrode in the current position due to an adequate
therapeutic window.
b. Implantation should be aborted due to narrow therapeutic window.
c. The lead should be moved anteriorly due to the observation of transient
parasthesias.
d. The lead should be moved medially away from the internal capsule.
e. The lead should be moved laterally away from the red nucleus.
d. The lead should be moved medially away from the internal capsule.
A 12 year-old with Down syndrome has abnormal flexion-extension
cervical spine x-rays. The child has no significant neurologic
complaints or neck pain. On exam, the child has full range of motion
and no tenderness to palpation. The flexion-extension x-rays show a 7-
8 mm atlantodental interval in flexion which reduces to 4 mm in
extension. What is the most appropriate next step?
a. C1-2 wiring with halo placement and autologous fusion
b. Occipital cervical fusion with sublaminar wires
c. Observation with repeat flexion-extension in the future
d. C1-2 transarticular screw placement and autologous fusion
e. Observation with no repeat imaging necessary
c. Observation with repeat flexion-extension in the future
What combination of findings is most consistent with the diagnosis
of central diabetes insipidus?
a. Urine output of 40 cc/hr, urine specific gravity of 1.002 and serum sodium
of 135.
b. Urine output of 100 cc/hr, urine specific gravity of 1.030 and serum
sodium of 135.
c. Urine output of 40 cc/hr, urine specific gravity of 1.010, and serum
sodium of 145.
d. Urine output of 300 cc/hr, urine specific gravity of 1.030 and serum
sodium of 145.
e. Urine output of 300 cc/hr, urine specific gravity of 1.002, and serum
sodium of 145.
e. Urine output of 300 cc/hr, urine specific gravity of 1.002, and serum
sodium of 145.
An ultrasound of a 29-year-old pregnant woman reveals a lumbar
myelomeningocele in the fetus. What is the primary difference in
outcome for fetal myelomeningocele repair as opposed to post-natal
repair?
a. The chance of maternal pregnancy complications is not affected
b. The risk of symptomatic hindbrain herniation increases
c. The likelihood of premature birth is not affected
d. The rate of shunt placement for hydrocephalus decreases
e. The odds of walking without devices or braces decreases
d. The rate of shunt placement for hydrocephalus decreases
During atlantoaxial rotatory subluxation with left axial hyperrotation, several ligaments of the upper cervical spine can be torn. In
rotatory subluxation, which ligament is most likely to retain its
integrity?
a. Contralateral C1-C2 facet capsular ligament
b. Transverse ligament
c. Alar ligament
d. Ipsilateral C1-C2 facet capsular ligament
e. Accessory ligament
b. Transverse ligament
A 60 year old man presents with 3 months of worsening diffuse
severe unremitting left upper extremity pain, parasthesias, and hand
weakness. Exam shows 4/5 weakness of hand muscles including
abductor pollicus brevis and all intrinsics, scattered sensory loss on
the ulnar side of the forearm, normal deep tendon reflexes and no
evidence of myelopathy. MRI of the cervical spine shows mild
degenerative changes throughout the neck. What imaging study would
assist in the diagnosis?
a. Thermogram
b. Scoliosis survey
c. Chest CT
d. Cervical spine flexion-extension x-rays
e. Bone scan
c. Chest CT
What is the most important factor in determining whether a patient
with a history of seizures is allowed to drive?
a. History of seizure surgery
b. Seizure-free off medications
c. Number of anti-epileptics
d. Discretion of the treating physician
e. Seizure-free interval
e. Seizure-free interval
A 63 year old woman with Parkinson disease undergoes unilateral
deep brain stimulator (DBS) electrode implantation. 3 months later, she
returns to the office with redness, pain, swelling and purulence from
the cranial incision. Culture grows methicillin-sensitive S. aureus. What
is the most appropriate management?
a. Removal of the implantable pulse generator (IPG) only
b. Removal of the implantable pulse generator (IPG) and extension with
antibiotics
c. Removal of the entire hardware system with antibiotics
d. Removal of the intracranial lead only
e. Antibiotics only
c. Removal of the entire hardware system with antibiotics
Which anatomic feature best predicts risk of intracranial
hemorrhage related to dural arteriovenous fistulae (DAVF):
a. number of arterial feeders
b. size of the fistula
c. presence of cortical venous drainage
d. number of draining veins
e. presence of sinus drainage
c. presence of cortical venous drainage
Failure to account for which radiographic measurement is
associated with delayed treatment failure after surgical treatment of
positive sagittal imbalance?
a. Lumbar coronal Cobb angle
b. Central Sacral Vertical Line
c. Pelvic Incidence
d. Thoracic Kyphosis
e. Sacral Slope
c. Pelvic Incidence
During clipping of an anterior communicating artery aneurysm, an
artery arising at the junction of the A1 and A2 segments was
inadvertently occluded. This resulted in expressive aphasia and mild
hemiparesis. The artery was most likely the:
a. Anterior choroidal artery
b. Frontopolar artery
c. Right A2
d. Recurrent artery of Heubner
e. Orbitofrontal artery
d. Recurrent artery of Heubner
During lateral osteophyte removal in an anterior decompressive
discectomy, you encounter brisk bleeding in the region of the nerve
root. What is the best next step?
a. Order blood for transfusion
b. Explore the vertebral artery
c. Abort the procedure
d. Apply gelfoam and pressure
e. Call interventional radiology
d. Apply gelfoam and pressure
Hemangioblastomas are tumors characterized by prominent
capillary vasculature. What syndrome predisposes an individual to this
tumor?
a. Neurofibromatosis type II
b. Von Hippel-Lindau
c. Neurofibromatosis type I
d. Tuberous sclerosis
e. Sturge-Weber
b. Von Hippel-Lindau
What is the FDA Human Device Exemption (HDE) approved target
for deep brain stimulation for medically refractory obsessive
compulsive disorder?
a. Anterior cingulate gyrus
b. Medial forebrain bundle
c. Subgenual cingulate gyrus
d. Ventral capsule/ventral striatum
e. Subthalamic nucleus
d. Ventral capsule/ventral striatum
In patients who receive medical therapy alone for asymptomatic
carotid stenosis of 60-99%, what is the 5-year risk of stroke or death?
a. 5%
b. 23%
c. 17%
d. 11%
e. 29%
d. 11%
Based on the Guidelines for the Acute Management of Severe
Traumatic Brain Injury, in patients with severe head injury, what should
the cerebral perfusion pressure (CPP, mmHg) should be maintained
between?
a. 10-30
b. 50-70
c. 70-90
d. 90-110
e. 30-50
b. 50-70
A 47 year-old woman underwent a C5-6 ACDF via a left sided
approach. Postoperatively, she has a weak, drooping eyelid and a
constricted pupil. What technique reduces risk of this complication?
a. Deflate and re-inflate the endotracheal balloon after retractor placement
b. Perform surgical approach from the patient’s right side
c. Minimize distraction of the vertebral bodies
d. Place retractors under the medial edge of the longus colli muscles
during periosteal dissection
e. Minimize excessive traction on the shoulders when positioning
d. Place retractors under the medial edge of the longus colli muscles
during periosteal dissection
A patient presents with a classic type II odontoid fracture. A
magnetic resonance image and flexion-extension dynamic radiographs
of the cervical spine are consistent with disruption of the transverse
ligament. The MOST appropriate treatment is:
a. Hard cervical collar
b. Posterior C1-C2 fixation
c. Occipital-cervical fusion
d. Halo immobilization
e. Anterior odontoid screw fixation
b. Posterior C1-C2 fixation
A 10 year-old girl presents with signs of accelerated pubertal
stage, convergence-retraction nystagmus, and impaired upward gaze.
Which of the following lesions would most likely be the cause of the
findings described?
a. Pineal region tumor
b. Multiple sclerosis
c. Acqueductal stenosis
d. Pontine glioma
e. Medulloblastoma
a. Pineal region tumor
What is the most appropriate maintenance rate for IV fluid in a 2
week old child weighing less than 10 kg?
a. 2 ml/kg/hr
b. 10 ml/kg/hr
c. 4 ml/kg/hr
d. 1 ml/kg/hr
e. 20 ml/kg/hr
c. 4 ml/kg/hr
The ventral cervical plate pictured below spans three vertebral
levels, and reveals a pseudoarthrosis. It consists of two screws at each
end that are rigidly affixed to the plate. Which of following
biomechanical properties best describe the type of fixation pictured in
the radiograph that lead to the pseudoarthrosis?
a. Constrained dynamic.
b. Semi-constrained cantilever beam.
c. Constrained cantilever beam.
d. Semi-constrained four-point bending.
e. Constrained three-point bending.
c. Constrained cantilever beam.
A Central American patient presents with new onset seizures. CT
shows hydrocephalus, and multiple calcified lesions. MRI
demonstrates rim-enhancing cysts throughout the brain. What is the
most likely etiology?
a. Toxoplasma gondii
b. Schistosoma mansoni
c. Plasmodium falciparum
d. Entamoeba histolytica
e. Taenia solium
e. Taenia solium
In the case of an intracanalicular vestibular schwannoma, what is
the advantage of the middle cranial fossa approach over the
retrosigmoid approach?
a. Early identification of the distal facial nerve.
b. Decreased risk of postoperative seizure
c. Improved preservation of vestibular nerve function.
d. Decreased risk of injuring the greater superficial petrosal nerve.
e. Decreased risk of CSF leak
a. Early identification of the distal facial nerve.
A 44 year old man with a history of blunt head trauma 4 days
earlier presents with a progressively swollen and red right eye,
headache, and double vision. What is the most likely cause?
a. Direct, high flow lesion between ICA and cavernous sinus
b. Indirect, low flow lesion between meningeal ICA branches and cavernous
sinus
c. Vertebral artery dissection
d. Cervical internal carotid dissection
e. Indirect, low flow lesion between both ICA and ECA meningeal branches
and the cavernous sinus
a. Direct, high flow lesion between ICA and cavernous sinus
A 56-year-old man with a 5-cm right temporal glioma presents with
a generalized tonic-clonic seizure, which was not broken after two
doses of intravenous benzodiazepine administration. What is the most
appropriate acute management of this patient’s seizures?
a. Oral levetiracetam
b. Oral oxcarbazepine
c. Intravenous fosphenytoin
d. Immediate surgical resection without anti-epileptic drug administration
e. Intravenous phenobarbita
c. Intravenous fosphenytoin
A 47 year-old diabetic woman presents with pain across her
buttocks and bilateral lower extremities with ambulation, improved by
leaning forward. She reports transient response to epidural injections
and no response to NSAIDs and neuropathic pain medication. She has
no neurologic deficit. Imaging is shown (figures). What intervention is
most likely to best reduce her disability over 4 years?
a. Bilateral L4-5 hemilaminotomies with
preservation of midline structures
b. L4-5 dynamic interspinous spacer
placement
c. L4-5 decompression and fusion
d. L4-5 laminectomy
e. Long term corticosteroids
c. L4-5 decompression and fusion
You are seeing an adult patient who underwent left groin cannulation
three weeks ago for cerebral angiography. They developed weakness and
numbness of the left leg immediately afterwards. On your examination, they
have weakness of left hip flexion and knee extension, and anteromedial leg
numbness going down to the ankle. Electrodiagnostic studies reveal absent
motor and sensory potentials in the femoral nerve, and EMG sampling of the
lumbar paraspinal muscles is normal. Where is the most likely site of injury?
a. L4 nerve root
b. Femoral nerve, abdominal level
c. Femoral nerve, inguinal ligament level
d. Femoral nerve, thigh level
e. Saphenous nerve
b. Femoral nerve, abdominal level
A hypertensive 50 year-old man is found to have a blood pressure of
230/110 mmHg with a heart rate of 50 bpm. Physical exam reveals a fixed and
dilated right pupil, and CT scan shows a large right subdural hematoma with
midline shift. What is the most likely cause of the hypertension?
a. Peripheral vasoconstriction and catecholamine release
b. Exacerbation of baseline hypertension due to pain
c. Failure to comply with antihypertensive regimen
d. Decreased blood flow to the medulla
e. Shunting of blood flow from the myocardium to the brain
a. Peripheral vasoconstriction and catecholamine release
A 55 year old man presents with a headache and tenderness to palpation
of his right temporal artery. Which is the most likely vasculitic cause of his
headache?
a. Giant cell arteritis
b. Churg-Strauss syndrome
c. Behçet disease
d. Wegener’s granulomatosis
e. Polyarteritis nodosa
a. Giant cell arteritis
A 17-year old man presents with severe traumatic brain injury with a
Glasgow Coma Scale score of 7 and reactive pupils. A head CT indicates a thin
subdural hematoma on the right side with 6 mm shift of the midline structures
with visible but tight ambient cisterns. Despite sedation, intubation,
hypertonic saline and external ventricular drainage, his ICPs remain elevated.
What is the next best step in the management of this patient?
a. Hypothermia
b. Mannitol infusion
c. Insert brain tissue oxygen monitoring device
d. Pentobarbital coma
e. Decompressive hemicraniectomy
e. Decompressive hemicraniectomy
What is the most common first line of therapy for vein of Galen
malformation causing heart failure in children?
a. Medical management
b. Endovascular treatment
c. Microsurgical treatment
d. Radiosurgery
e. Observation
b. Endovascular treatment
Which form of systemic cancer therapy is associated with an
increased risk of radiation necrosis after stereotactic radiosurgery for
cerebral metastases?
a. Tumor Targeted Chemotherapy (e.g. EGFR or ALK antagonists)
b. Cytotoxic Chemotherapy (e.g. DNA synthesis / Mitosis Inhibitors)
c. Angiogenesis Inhibitors (e.g. Anti-VEGF antibody)
d. Glucocorticoid Therapy
e. Systemic Immunotherapy (e.g. PD-1 inhibitors)
e. Systemic Immunotherapy (e.g. PD-1 inhibitors)
What is the most common complication of anterior cervical
discectomy and fusion (ACDF)?
a. Thoracic duct injury
b. Dysphagia
c. Hoarseness
d. New radiculopathy
e. Horner’s syndrome
b. Dysphagia
A 35 year old female presents with headaches and progessive left
sided hearing loss. What is the BEST treatment for the lesion depicted
in the MR images?
a. Stereotactic aspiration.
b. Cystoperitoneal shunt.
c. Craniotomy for lesion removal.
d. Radiation therapy
e. Endoscopic fenestration.
c. Craniotomy for lesion removal
A 76-year-old female with a history of diabetes mellitus and
hypertension has asymptomatic atrial fibrillation. What medical
management paradigm would best reduce her future risk of stroke?
a. Clopidogrel
b. Aspirin
c. Warfarin and clopidogrel
d. Aspirin and clopidogrel
e. Warfarin
e. Warfarin
A 12-year-old boy presents with several years of dystonia in the
lower extremities and recent development of dystonia in the upper
extremities. His symptoms are mild in the morning but worsen as the
day progresses. His dystonia does not improve with inactivity, but
does improve after a full night’s sleep. What is the most appropriate
next step in his management?
a. DBS of the ventral intermediate nucleus (VIM).
b. Oral baclofen therapy.
c. Intrathecal baclofen therapy.
d. DBS of the globus pallidus interna (GPi).
e. Low-dose oral levodopa therapy.
e. Low-dose oral levodopa therapy.
When placing bicortical sacral pedicle screws, which structure is
at most risk with a laterally placed screw that perforates the anterior
cortex?
a. Lumbosacral plexus
b. S1 nerve root
c. Internal Iliac artery
d. Aorta
e. L5 nerve root
e. L5 nerve root
A 24 year-old man has refractory complex partial seizures
localized to the left temporal lobe with EEG. MRI is consistent with left
mesial temporal sclerosis. What is the most appropriate next step in
his management?
a. Intracarotid amytal test
b. Vagal nerve stimulation
c. Corpus callosotomy
d. Invasive EEG monitoring
e. Temporal lobectomy
a. Intracarotid amytal test
A 27-year-old woman with a normal brain MRI experiences
seizures characterized by jerking of the left hand which occasionally
also spreads to the proximal arm. These episodes are nearly constant
throughout the day and are not associated with any impairment of
consciousness. Where are this patient’s seizures likely originating?
a. Temporal lobe
b. Prefrontal cortex
c. Occipital lobe
d. Supplementary motor area
e. Primary motor cortex
e. Primary motor cortex
According to the Guidelines for the Performance of Fusion
Procedures for Degenerative Disease of the Lumbar Spine, the
literature supports the use of fusion in lumbar decompression surgery
for degenerative stenosis when associated with what imaging finding?
a. congenital stenosis.
b. conjoined nerve root.
c. spina bifida.
d. focal disc herniation.
e. spondylolisthesis
e. spondylolisthesis
Which anti-epileptic agents would be BEST to use in a patient
receiving multiple other medications extensively metabolized by the
liver?
a. Phenytoin (Dilantin)
b. Oxcarbazepine (Trileptal)
c. Levetiracetam (Keppra)
d. Carbamazepine (Tegretol)
e. Phenobarbital (Luminal)
c. Levetiracetam (Keppra)
You are placing a deep brain stimulator in the GPi for Parkinson’s
disease. Your microelectrode has passed through the bottom of the
GPi. What is the next structure to check for?
a. Subthalamic nucleus
b. Substantia nigra reticulata
c. Globus pallidus externa
d. VPL thalamus
e. Optic tract
e. Optic tract
A patient presents after a MVA with the head CT shown in the
figure. His GCS is 14. His blood alcohol level is 0.31%. What is the
most appropriate initial management?
a. Admit to ICU for
observation
b. Intubate, sedate, and monitor
ICP
c. Placement of ventriculostomy
d. Bifrontal craniotomy and
evacuation of SDH
e. Bifrontal decompressive
craniectomy
a. Admit to ICU for
observation
A 9 month old boy presents with scaphocephaly. X-rays confirm a
sagittal synostosis. He a history of reflux disease that the family is
treating with antacids. He is exclusively breast fed and his height and
weight are in the 10th percentile, although occipitofrontal
circumference is 80th percentile. In this case, which associated
diagnosis is most likely?
a. Rickets
b. Congenital Adrenal Hyperplasia
c. Prader-Willi Syndrome
d. Celiac Sprue
e. Congenital Heart Disease
a. Rickets
The patient whose magnetic resonance image is shown in Figure 1
most likely underwent surgery to control which of the following
symptoms associated with which disease:
a. Torticollis associated with cervical
dystonia.
b. Akinesia associated with Parkinson
disease.
c. Rigidity associated with Parkinson
disease.
d. Levodopa-induced dyskinesia
associated with Parkinson disease
e. Tremor associated with Essential
Tremor
e. Tremor associated with Essential
Tremor
Which of the following diagrams most
accurately depicts the typical course of the
accessory nerve along the posterior triangle:
a. Figure 1
b. Figure 2
c. Figure 5
d. Figure 4
e. Figure 3
e. Figure 3
A 70-year old male presents with personality changes, gait
instability, bradykinesia, slurring of speech, and difficulty moving the
eyes. Which of the following imaging features is most consistent the
diagnosis?
a. PET scan showing asymmetrical reduced FDG-uptake in the
cerebral hemispheres
b. PET scan showing reduced FDG-uptake in the frontal
cortices, basal ganglia, and brainstem
c. MRI scan showing marked frontal and temporal cortical
atrophy
d. CT scan showing enlarged ventricles
e. PET scan showing decreased FDG-uptake in the cerebellum
and cortex
b. PET scan showing reduced FDG-uptake in the frontal
cortices, basal ganglia, and brainstem
A view from above into the anterior third ventricle is shown. The
ideal location for performing a third ventriculostomy is indicated by
which number?
a. 7
b. 8
c. 9
d. 6
e. 5
b. 8
A patient awakens from left-sided costotransversectomy at T10 for
resection of a ventral metastatic tumor with complete paraplegia and
loss of pain and temperature sensation. His sensation to light touch in
the lower extremities is spared. Post operative MRI reveals no evidence
of spinal cord compression or hematoma. What is the most likely
diagnosis?
a. Brown-Sequard syndrome.
b. Weber’s Syndrome
c. Posterior cord syndrome.
d. Central cord syndrome.
e. Anterior cord syndrome
e. Anterior cord syndrome
Which of the following pedicle screw characteristics increases
pullout strength?
a. increased minor - major diameter ratio
b. tapered screw shape
c. smaller inter-thread distance
d. unicortical purchase
e. bilateral screw triangulation with crosslink
e. bilateral screw triangulation with crosslink
An 8-year-old male complains of a painful swelling of his left
forehead. Its onset was insidious, starting several weeks earlier.
Radiographs are shown in Figures 1 and 2. What is the most likely
diagnosis?
a. Osteoblastoma
b. Fibrous dysplasia
c. Eosinophic granuloma
d. Dermoid cyst
e. Osteoid osteoma
c. Eosinophic granuloma
A 45-year-old male presents with several months of progressive
headaches and an intracranial lesion (figure). Following surgical
resection, histopathological analysis demonstrates a wellcircumscribed, uniformly cellular tumor with no atypia and numerous
ectatic, thin-walled branching vessels in staghorn configurations.
Which of the following is a possible associated clinical development?
a. Unilateral optic nerve glioma
b. Pheochromocytoma
c. De novo glioblastoma
d. Bilateral vestibular schwannomas
e. Metastases outside the CNS
e. Metastases outside the CNS
A 40 year old male develops left facial droop and left hemiparesis
48 hours after a motor vehicle accident despite initially being
neurologically intact after the accident. A non-contrast head CT at the
time of deterioration is negative. The most appropriate next diagnostic
evaluation is:
a. Cerebral perfusion study.
b. CT angiogram of the cervical spine.
c. Flexion Extension C-spine XRay
d. ICP monitoring.
e. CT of the cervical spine
b. CT angiogram of the cervical spine
A 24 year old pregnant woman in her third trimester presents with
severe headache and a non-focal neurological examination. A head CT
angiogram is shown. What is the most likely diagnosis?
a. Meningioma
b. Aneurysmal subarachnoid hemmorrhage
c. Posterior reveresible encephalopathy
syndrome
d. Dural venous sinus thrombosis
e. Eclampsia
d. Dural venous sinus thrombosis
A 65 year old female presents with a spontaneous basal ganglia
hemorrhage. Her blood pressure is 190/110 mmHg. The patient is not
exhibiting signs of intracranial hypertension. How should the blood
pressure of the patient be managed?
a. Maintain current blood pressure
b. Target a mean arterial pressure of 120 mmHg
c. Reduce her blood pressure to less than 185/102 mmHg
d. Reduce her blood pressure to less than 120/80 mmHg
e. Reduce her blood pressure to less than 160/90
mmHg
e. Reduce her blood pressure to less than 160/90
mmHg
A patient is undergoing DBS lead placement in the subthalamic
nucleus for Parkinson disease. During intraoperative testing the
patient has good relief of symptoms but also notes facial pulling and
transient paresthesias. Different monopolar and bipolar options
produce the same result. Which of the following is the best option?
a. Move the lead laterally
b. Leave the DBS in its current location
c. Advance the lead deeper
d. Abort implantation on this side and move on to DBS
implantation on the left side.
e. Move the lead medially
e. Move the lead medially
An 8 year-old presents after an accident in gymnastics. He felt the
immediate onset of sharp pain behind his right ear after a fall. In the
emergency department an hour later he was neurologically intact.
However, his head was immobile, being rotated to the right and tilted to
the left with the left ear touching the left shoulder. A CT scan of the
cervical spine was abnormal (Figure 1). What is the most appropriate
initial treatment?
a. Open reduction and Harms fusion
b. 15 pounds of cervical traction
c. Thermoplastic Minerva jacket
d. Brooks fusion in situ with halo-vest
immobilization
e. Rigid cervical orthosis
e. Rigid cervical orthosis
10-year-old boy underwent resection of a craniopharyngioma.
Postoperatively, he develops panhypopituitarism and delayed
hydrocephalus. What medication will need to be increased in
preparation for his shunt placement?
a. Levothyroxine
b. Growth hormone
c. Desmopressin
d. Hydrocortisone
e. Testosterone
d. Hydrocortisone
What is the most significant risk factor for normal perfusion
pressure breakthrough after AVM resection?
a. Deep venous drainage
b. Single feeding artery
c. Single draining vein
d. Large size
e. Infratentorial location
d. Large size
A 55 year-old woman has intractable seizures treated with
levetiracetam, oxcarbazepine, and vagus nerve stimulation (VNS). She
presents with increased seizure activity after 2 days of painful
coughing and odynophagia, preventing her from taking her
anticonvulsant medications. Examination reveals a hoarse voice. What
is the most appropriate initial intervention?
a. Inactivate VNS
b. Increase VNS frequency
c. Start phenytoin
d. Obtain electroencephalogram
e. Throat cultuate and administer antibiotics
a. Inactivate VNS
A 5-month-old infant was a passenger in a car seat in a high-speed
crash resulting in ejection. On exam, she only demonstrates right
parietal scalp swelling. A head CT scan shows separation of the
lambdoid suture and faint hypodensity in the subjacent brain (Figure
1). CT scanning of the cervical spine and other routine trauma
investigations were negative. She was discharged in stable condition
after 1 day. Which of the following is the most active concern for
outpatient follow-up?
a. Traumatic meningoencephalocele
b. Chronic subdural hematoma
c. Hydrocephalus
d. Atlanto-occipital instability
e. Hypopituitarism
a. Traumatic meningoencephalocele
Which of the following structures represents a potential site of
ulnar nerve entrapment?
a. Struther’s ligament
b. Bicipital aponeurosis
c. Pronator teres muscle
d. Supinator muscle
e. Osborne’s ligament
e. Osborne’s ligament
A 74 year old man presents with progressive cognitive decline
over one year, occasional visual hallucinations, poor attention, shortterm memory loss, and bilateral upper extremity rigidity. What is the
most likely diagnosis?
a. Multi-infarct dementia
b. Pick’s disease
c. Wilson’s disease
d. Dementia with Lewy bodies
e. Alzheimer’s disease
d. Dementia with Lewy bodies
A 42-year-old man with shock-like right facial pain radiating from
pre-auricular area of right ear into the right lower jaw, teeth and
tongue. Symptoms are triggered by facial movement, shaving, and
chewing. Empiric medical management with carbamazepine gave
incomplete pain relief but made him feel woozy. What is the next step
in the patient’s management?
a. Addition of a muscle-relaxing agent
b. Magnetic resonance imaging
c. Microvascular decompression
d. Stereotactic radiosurgery
e. Botox injection
b. Magnetic resonance imaging
What is the most common indication for surgical treatment of
Scheuermann’s thoracic kyphosis?
a. Severe compression fractures
b. Painful kyphosis
c. Radiculopathy from disc herniation
d. Progressive scoliosis
e. Pulmonary compromise
b. Painful kyphosis
This lumbosacral spine MRI (figure) is from a 23-year-old woman
who presented with severe low back pain radiating to her right leg.
Which nerve root is most likely compressed by the herniated disc?
a. Traversing S1 nerve root
b. Traversing L5 nerve root
c. Exiting S1 nerve root
d. Traversing L4 nerve root
e. Exiting L5 nerve root
a. Traversing S1 nerve root
A 35-year-old woman presents with an L1 burst fracture after a
motor vehicle accident. Which of the following characteristic(s)
predicts likelihood of instrumentation failure with short segment
posterior instrumented fusion?
a. Spinal canal compromise > 50%
b. Comminuted fracture with fragment displacement
and kyphosis
c. Involvement of both vertebral endplates
d. Incomplete neurologic deficit
e. Disrupted posterior ligamentous complex
b. Comminuted fracture with fragment displacement
and kyphosis
A 50 year old male is admitted to the ICU after a fall from a
scaffolding with severe diffuse TBI. ICP and BtpO2 monitors are
placed. Despite sedation, pain control and hyperosmolar therapy, ICP
remains at 25 mmHg and BtpO2 is 22 mmHg. His PaCO2 is 38 mmHg.
The trauma service would like to hyperventilate the patient with a goal
PaCO2 30 mmHg. When is hyperventilation indicated?
a. As temporizing measure
b. When brain oxygen is low
c. Within the first 24 hours
d. Never
e. Only in conjunction with barbiturate coma
a. As temporizing measure
A 38 year-old presents with a one month history of difficulty
swallowing, mild hoarseness and right facial numbness and tingling.
The imaging studies are shown below. What is the most likely
diagnosis?
a. Cavernous angioma
b. Capillary hemangioma
c. Arteriovenous malformation
d. Medulloblastoma
e. PICA aneurysm
a. Cavernous angioma
A 56 year-old woman presents with diffuse traumatic
subarachnoid hemorrhage on CT after a motor vehicle accident. On
exam, she is flexor posturing, and initial ICP is 15mmHg. Her CPP is
50mmHg. What management strategy is recommended by the Brain
Trauma Foundation Guidelines?
a. Maintain a minimum CPP of 60 mmHg
b. Maintain systolic blood pressure above 90mmHg
c. Maintain PCO2 less than 30 mm Hg
d. Maintain ICP less than 20 mm Hg
e. Monitor brain tissue oxygenation
a. Maintain a minimum CPP of 60 mmHg
A 4-week-old was transferred to the Trauma Service from an
outlying emergency department after an evaluation for a seizure that
included a CT scan of the head (Figure 1). What additional diagnostic
investigation is most appropriate?
a. Cerebral angiography
b. Echocardiography
c. Skeletal survey
d. Lumbar puncture
e. Urine amino acids
b. Echocardiography
Curvilinear restricted diffusion may be seen along the margin of a
resection cavity on immediate postoperative MRI after gross total
resection of a glioma. What pathological process does this restricted
diffusion pattern usually develop into?
a. Gliosis
b. Territorial infarct
c. Abscess
d. Hematoma
e. Recurrent tumor
a. Gliosis
Histopathology of a cerebellopontine angle tumor is shown in the
figures below. The findings are most consistent with what type of
pathology?
a. Cholesteatoma
b. Choroid plexus papilloma
c. Schwannoma
d. Psammomatous meningioma
e. Endolymphatic sac tumor
c. Schwannoma
A 22 year-old woman presents after a motor vehicle collision with
neck pain. She is neurologically intact. She has a non-displaced C4
lamina fracture. CTA of the neck shows a Biffl Grade 2 injury to the
right internal carotid artery. What is the most appropriate next step in
management?
a. MRI of the brain
b. Transcranial Doppler with emboli detection
c. Initiation of aspirin
d. Diagnostic cerebral angiogram
e. Carotid Doppler
c. Initiation of aspirin
A 25-year-old man presents with a new onset of right facial droop
associated with horizontal diplopia. MRI of the brain shows a
brainstem hyperintensity on T2 and FLAIR images (see figure). What
anatomical structure is affected by this lesion causing the diplopia?
a. Abducens nucleus
b. Abducens fibers
c. Medial longitudinal fasciculus
d. Trochlear nucleus
e. Trapezoid body
a. Abducens nucleus
You are performing a percutaneous radiofrequency lesioning
procedure in a patient with V3 distribution trigeminal neuralgia. After
placing the electrode into the Gasserian ganglion and performing the
test stimulation, the patient reports tingling in the V2 distribution. You
wish to reposition the electrode to achieve V3 stimulation instead. In
which direction will you move the electrode?
a. Superior and posterior
b. Superior and lateral
c. Inferior and lateral
d. Inferior and anterior
e. Inferior and medial
c. Inferior and lateral
A 47-year-old woman presented with a first seizure and underwent
magnetic resonance imaging of the brain with multi-voxel
spectroscopy. The spectroscopy shown in Figure 1 is most consistent
with what diagnosis?
a. meningioma
b. demyelinating plaque
c. toxoplasmosis
d. bacterial abscess
e. glial neoplasm
e. glial neoplasm
When considering targets for deep brain stimulation for a patient
with advanced Parkinson’s disease, what is true about the expected
benefits of stimulation of the subthalamic nucleus (STN) over the
globus pallidus internus (GPi)?
a. Greater longevity of therapy.
b. Superior motor outcomes in patients under age 50.
c. Greater medication reduction.
d. Fewer neurocognitive side effects.
e. Greater reduction in overall disability score.
c. Greater medication reduction.
On histopathology, central neurocytoma has strong positivity with
which stain?
a. EMA
b. Vimentin
c. S100
d. GFAP
e. Synaptophysin
e. Synaptophysin
Pain circuits within the substantia gelatinosa receive descending,
inhibitory, serotonergic and adrenergic inputs from which brain
structure?
a. Red nucleus
b. Superior olivary nucleus
c. Locus ceruleus
d. Interlaminar thalamic nucleus
e. Cuneate nucleus
c. Locus ceruleus
A 30 year old laborer presents with worsening burning arm pain
radiating to fourth and fifth digits with objective hand weakness,
thenar and hypothenar wasting. These symptoms are exacerbated by
extending his arm and turning the head towards the affected side.
What is the most likely diagnosis?
a. Carpal tunnel syndrome
b. C7/T1 herniated disk
c. Central cervical stenosis
d. Pancoast tumor
e. Neurogenic thoracic outlet syndrome
e. Neurogenic thoracic outlet syndrome
Seven days ago a 3 year old boy developed a low-grade fever
which resolved and was followed by a vesicular rash (see Figures).
Two days ago, he had sudden onset of truncal ataxia and horizontal
nystagmus. He has moderate dysmetria of both arms when reaching
for toys, cannot stand or walk, and his speech is slurred. His mental
status is fully intact. Fundi show sharp disc margins. His strength is
full and deep tendon reflexes are present. What is the MOST likely
diagnosis?
a. Post-infectious cerebellar ataxia
b. Acute disseminated encephaloymyelitis
c. Opsoclonus myoclonus syndrome
d. Posterior fossa mass
e. Guillain-Barre Syndrome
a. Post-infectious cerebellar ataxia
A 7-year-old female presents with worsening gait disturbance and
upper back pain. A spinal MRI is shown. After surgical exposure, frozen
specimen analysis suggests juvenile pilocytic astrocytoma. What is the
next best step in intraoperative management?
a. Gross total resection along the tumor capsule
b. Divide dentate ligaments to permit spinal cord
rotation
c. Duraplasty and laminoplasty with no further
tumor resection
d. Multiple sample biopsies for diagnostic
confirmation
e. Internal debulking and resection until the
normal-abnormal boundary is indistinct
e. Internal debulking and resection until the
normal-abnormal boundary is indistinct
A 34-year-old man with left temporal lobe epilepsy experiences a
two-minute episode involving loss of consciousness and tonic
stiffening of all four limbs, followed by relatively symmetric rhythmic
convulsive jerking of the limbs. What type of seizure is this patient
experiencing?
a. Simple partial
b. Absence
c. Complex partial
d. Secondarily generalized
e. Primary generalized
d. Secondarily generalized
A patient with a history of whole brain radiation for metastatic
disease presents with a new 1.5 cm brain metastasis. What is the
RTOG criteria for the maximum radiation dose that should be given in a
single fraction to the new lesion?
a. 15 Gy
b. 24 Gy
c. 20 Gy
d. 18 Gy
e. 12 Gy
b. 24 Gy
What is the etiology of malignant cerebral edema in children
after traumatic brain injury?
a. Acute hydrocephalus
b. Nonconvulsive status epilepticus
c. Cerebral hypoperfusion
d. Loss of autoregulation
e. Venous sinus thrombosis
d. Loss of autoregulation
What structure does the arrow point to in the figure?
a. Superior ophthalmic vein
b. Internal jugular vein
c. Superior petrosal sinus
d. Cavernous sinus
e. Inferior petrosal sinus
a. Superior ophthalmic vein
An immunocompromised patient presents with fever,
encephalopathy and a hemorrhagic abscess. The microscopic
appearance of a biopsy specimen is shown below. What is the
most likely organism?
a. Candida albicans
b. Aspergillus fumigatus
c. Cryptococcus neoformans
d. Coccidomycosis
e. Mucor and Rhizopus species
b. Aspergillus fumigatus
A 47 year old man presents with confusion, agitation,
fatigue, fever (104F), hyponatremia, hypoglycemia, and
hypotension after resection of a right frontal metastasis lesion 3
weeks ago. Phenytoin and steroids were discontinued at 2.5
weeks post-operatively. Head CT reveals no acute abnormality.
What is the most appropriate management of this patient?
a. Heparin
b. Fosphenytoin
c. Fludricortisone
d. Haloperidol
e. Hydrocortisone
e. Hydrocortisone
You are seeing a semi-professional baseball pitcher who has
weakness of right shoulder external rotation and abduction.
There is muscle atrophy as indicated by the arrows in the figure.
You recommend a nerve decompression. Which of the following
incisions would be the most appropriate for this patient?
a. Figure 4
b. Figure 5
c. Figure 1
d. Figure 2
e. Figure 3
b. Figure 5
A 9-year-old male presented to his pediatrician with
headaches and growth delay. He was found to have tumor in the
region of the sella. Histology is shown. What is the most likely
diagnosis:
a. Pilocytic astrocytoma.
b. Hypothalamic hamartoma.
c. Craniopharyngioma.
d. Pituitary adenoma.
e. Colloid cyst.
c. Craniopharyngioma.
A 68 year-old woman presents with progressive myelopathy
with MRI shown. Why is an isolated posterior approach
contraindicated in this patient?
a. Ventral compressive pathology
b. Fixed kyphotic deformity
c. Posterior ligamentous hypertrophy
d. Compressive pathology across multiple levels
e. Subluxation at C3/4 and C4/5
b. Fixed kyphotic deformity
If pelvic alignment is not addressed during spinal deformity
surgery, what clinical outcome is most likely to occur?
a. Spinal misalignment
b. Hip dislocation
c. Acetabular fracture
d. Hardware failure
e. Piriformis syndrome
a. Spinal misalignment
What are the standard radiographic criteria for
ventriculomegaly in order to diagnose hydrocephalus?
a. Frontal horns are >50% of brain width
b. Frontal horns are >20% of the brain width
c. Temporal horn’s width >1 mm
d. Temporal horn’s width >0.5 mm
e. Frontal horns are >30% of the brain width
a. Frontal horns are >50% of brain width
In a patient with Guillain-Barre syndrome, what does the
presence of significant cerebrospinal fluid pleocytosis suggest?
a. preceding herpes virus infection
b. preceding Campylobacter jejuni infection
c. preceding influenza vaccination
d. coexistent Epstein-Barr virus infection
e. coexistent human immunodeficiency virus type 1
infection
e. coexistent human immunodeficiency virus type 1
infection
What radiographic finding is most commonly associated
with Chiari I malformations?
a. Synringomyelia.
b. Scoliosis.
c. “Pigeon Breast” deformity of the brainstem.
d. Spina Bifida
e. Hydrocephalus
a. Synringomyelia
You are seeing a patient who developed new lower extremity
symptoms after a surgical procedure. It is now 1 month postprocedure. You are considering a sciatic nerve injury vs. an
idiopathic lumbosacral plexopathy as the most likely diagnoses.
EMG abnormalities in which muscle would suggest the latter
diagnosis?
a. Short head of the biceps
b. Semimembranosus
c. Gluteus medius
d. Anterior tibialis
e. Gastrocnemius
c. Gluteus medius
A 6-year-old female presents with progressive
hemiparesthesia, hemiparesis, and sixth nerve
palsy, all on the right side. Her CT and MRI are
shown (figures). What is the most likely
diagnosis?
a. Ependymoma
b. Choroid plexus carcinoma
c. Choroid plexus papilloma
d. Central neurocytoma
e. Meningioma
a. Ependymoma
A 54-year old Hispanic male was incidentally found to have two
cavernous malformations located in the left frontal and right temporal
lobes on CT scan. What is the best study to rule out additional cavernous
malformations?
a. Diffusion weighted magnetic resonance imaging
b. Contrast enhanced computed tomography
c. Computed tomography angiography
d. Gradient echo magnetic resonance imaging
e. Digital subtraction angiography
d. Gradient echo magnetic resonance imaging
A pedicle subtraction osteotomy (PSO) hinges on which
anatomic region?
a. Anterior to the spinal column
b. The posterior column of the spine
c. The anterior column of the spine
d. The middle column of the spine
e. Posterior to the spinal column
c. The anterior column of the spine
A 4 year-old boy with a history of congenital hydrocephalus and
VP shunt placement near birth presented one week following proximal
shunt revision with lethargy, fevers to 38.4 C and erythema along the
shunt tract. He underwent complete removal of the VP shunt system
and placement of an external ventricular drain. CSF cultures grow
MSSA and the patient is started on intravenous oxacillin, when should
the shunt be replaced?
a. After 5 days negative CSF cultures
b. After 21 days of negative CSF cultures
c. After 10 days of negative CSF cultures
d. After 1 day of negative CSF culture
e. After 3 days negative CSF cultures
c. After 10 days of negative CSF cultures
Which of the following neuropathic pain medications works
as a GABA-b receptor agonist?
a. Amitriptyline
b. Clonidine
c. Baclofen
d. Ketamine
e. Gabapentin
c. Baclofen
What is the most common adverse event following
laminoplasty for cervical spondylotic myelopathy?
a. Inadequate cord decompression
b. Progressive cervical kyphosis
c. Loss of cervical range of motion
d. C5 root palsy
e. Accelerated adjacent level deterioration
c. Loss of cervical range of motion
After being struck in the head, a 12 year old boy presents
with a scalp laceration over a palpable skull deformity. A CT scan
is obtained (Figure 1). His GCS is 14 (E3, M6, V5). What is the
most appropriate management for this injury?
a. Bedside wound closure and IV
antibiotics
b. Venticulostomy for ICP management
c. Bedside irrigation, debridement, and
wound closure
d. Allow wound to heal by secondary
intention
e. Surgical exploration, fracture
elevation, and debridement
e. Surgical exploration, fracture
elevation, and debridement
A 28 year-old healthy woman who delivered her second
child 10 days ago presents with new onset headache, lethargy,
and confusion. She has no focal deficits. A non-contrast head CT
is obtained and shown below. What is the most appropriate
definitive treatment for this patient?
a. Recombinant activated Factor VII
b. Observation only
c. Endovascular embolization
d. Craniotomy for hematoma evacuation
e. Intravenous heparin infusion
e. Intravenous heparin infusion
A 24 year old patient with a gunshot wound to C2 is
resuscitated after a PEA code and found to have fixed and
dilated pupils, absent corneal reflexes, and absent cough and
gag reflex. A head CT reveals diffuse cerebral edema with loss of
grey-white differentiation. He is normothermic and normotensive
and his urine toxicology screen and electrolyte panels are within
normal limits. Which component of the brain death examination
cannot be used in this patient to evaluate for brain death?
a. Nuclear cerebral blood flow study
b. Cold caloric testing
c. Apnea testing
d. EEG
e. Transcranial Doppler ultrasonography
c. Apnea testing
You are examining a patient who recently sustained multiple
missile injuries to the upper extremity following an IED
explosion. You suspect a brachial plexus injury. Motor testing of
which of the following muscles would be most helpful in
distinguishing a medial cord from a lower trunk injury?
a. First dorsal interosseous
b. Adductor pollicis
c. Extensor digitorum communis
d. Flexor carpi ulnaris
e. Abductor pollicis brevis
c. Extensor digitorum communis
What finding on MRI carries the highest risk for
development of seizures in the setting of a newly diagnosed
posterior fossa lesion?
a. Size greater than 3cm
b. Extensive T2 hyper-intensity in the surrounding tissue
c. Presence of blood-product on gradient echo imaging
d. Homogenous enhancement after administration of
gadolinium
e. Hydrocephalus
e. Hydrocephalus
What is the most appropriate initial management of newlydiagnosed primary CNS lymphoma in an immunocompetent
patient?
a. IV methotrexate
b. Oral temozolomide
c. Intrathecal cytarabine
d. Gross total resection
e. Stereotactic radiosurgery
a. IV methotrexate
A 68-year-old man presents with progressive neurologic
deficit due to a spinal dural arteriovenous fistula fed by the left
L4 radicular artery. Treatment for the spinal dural AV fistula
requires occlusion of which vascular structure?
a. The L4 radicular artery
b. The arterial feeder immediately proximal to the fistula
c. The draining vein immediately distal to the fistula.
d. The draining vein in the spinal cord.
e. The anterior spinal artery
c. The draining vein immediately distal to the fistula.
A 43-year old patient experienced a visual field defect and
hemisensory loss after clipping of a PCA aneurysm. What is the
most likely site of injury?
a. Lateral posterior choroidal artery
b. Superior hypophyseal artery
c. Superior cerebellar artery
d. Anterior choroidal artery
e. Posterior communicating artery
a. Lateral posterior choroidal artery
You are seeing a patient with neuropathic upper extremity
pain. She reports a spontaneous, pins-and-needles and crawling
sensation in the skin of the affected area. This symptom is
called:
a. Mechanical hyperalgesia
b. Allodynia
c. Tinel sign
d. Hyperpathia
e. Paresthesia
e. Paresthesia
What mechanism underlies the injury depicted in Figures 1
and 2?
a. Distractive flexion
b. Compressive flexion
c. Compressive extension
d. Torsional rotation
e. Distractive extension
b. Compressive flexion
A 14-year-old male presented with months of slowly
worsening tingling in his hands. His exam was intact. Diagnostic
work-up included an MRI of the cervical and thoracic spine
(figure). What is the most likely diagnosis?
a. Hemangiopericytoma
b. Astrocytoma
c. Neuroblastoma
d. Neurofibroma
e. Ependymoma
e. Ependymoma
A 45-year-old male patient presents with right foot pain.
What is the structure indicated in the MRI at the level of the
popliteal fossa (Figure)?
a. Sciatic nerve
b. Common peroneal nerve
c. Tibial nerve
d. Popliteal artery
e. Popliteal vein
c. Tibial nerve
During a retroperitoneal approach to the lumbar spine, what
structure runs along the medial aspect of the psoas muscle and
lateral aspect of the spine?
a. Ureter
b. sympathetic trunk
c. Aorta
d. Ilioinguinal nerve
e. Genitofemoral nerve
b. sympathetic trunk
Based on the ISUIA study, what is the 5-year cumulative
rupture risk of an unruptured 5mm middle cerebral artery
aneurysm?
a. 10%
b. 7.5%
c. 2.5%
d. 5%
e. 0%
e. 0%
A 19 year old male presents with tussive headaches located at
the posterior base of the skull. Neurologic examination reveals
weakness of the hands bilaterally with hypesthesia. MR of the brain
and cervical spine are shown in the figures. What is the best initial
management strategy for this presentation?
a. Ventriculoperitoneal shunt
b. Syringo-subarachnoid shunt
c. Posterior cervical decompression
d. Anterior transoral odontoid resection
e. Posterior fossa decompression
e. Posterior fossa decompression
In preparation for a frame-based needle biopsy, a stereotactic frame
is applied to a patient’s head and an MRI is obtained. After imaging, the
frame is noted to have shifted due to poor fixation. What is the most
appropriate next step in the management of this patient?
a. Proceed with surgery without using stereotactic guidance; anatomical
landmarks should be enough of a guide.
b. Re-fix the frame and use a software correction algorithm before
proceeding with surgery and stereotactic guidance; the software
adjustment will correct for the change in frame position.
c. Proceed with surgery with the loosened frame using the stereotactic
guidance; the guidance will adjust accordingly.
d. Firmly re-affix the frame to the patient’s skull in the same place, and
proceed with surgery using stereotactic guidance; since the frame is in
roughly the same position, it should still be accurate.
e. Re-fix the frame, re-image the patient, and then proceed with
surgery using the updated stereotactic guidance.
e. Re-fix the frame, re-image the patient, and then proceed with
surgery using the updated stereotactic guidance.
During a pterional exposure of the sylvian fissure, you encounter
significant brain swelling. In order to achieve rapid brain relaxation,
identify the most appropriate point on the associated figure through
which to place a ventriculosotomy and access the frontal horn of the
lateral ventricle.
a. 2
b. 5
c. 1
d. 3
e. 4
a. 2
An open, comminuted, and depressed skull fracture over
what region of the dural venous sinus system has the lowest
risk of venous infarct?
a. Posterior 1/3 of the superior sagittal sinus
b. Middle 1/3 of the superior sagittal sinus
c. Left transverse sinus
d. Right sigmoid sinus
e. Anterior 1/3 of the superior sagittal sinus
e. Anterior 1/3 of the superior sagittal sinus
The North American Symptomatic Carotid Endarterectomy
Trial (NASCET) reported the surgical results in patients who
underwent carotid endarterectomy (CEA). According to the trial,
what is the rate of perioperative permanent disabling stroke and
death related to CEA?
a. 5-10%
b. 20-25%
c. 10-15%
d. <5%
e. 15-20%
d. <5%
You are considering a surgical procedure to treat your
patient with medically refractory pelvic cancer pain. A lesion at
which of the following locations would be most likely to
effectively treat this pain syndrome?
a. 4
b. 5
c. 3
d. 2
e. 1
e. 1
What is the most common location of a cavernous
malformation of the central nervous system?
a. Brainstem
b. Spinal cord
c. Optic Pathway
d. Cerebellum
e. Cerebral hemisphere
e. Cerebral hemisphere
What is the definitive treatment of atlanto-occipital
dislocation (AOD)?
a. Cranio-cervical internal fixation and fusion
b. Rigid cranio-cervico-thoracic orthosis
c. Observation with serial radiographs
d. Cervical traction
e. Halo vest immobilization
a. Cranio-cervical internal fixation and fusion
A 75 year-old healthy woman suffered a fall 3 months ago
and immediately noticed neck pain. She has been treating her
pain with over-the-counter medications, but the pain continues
to worsen over time. On exam, she has no focal deficits. X-ray
(Figure 1) and CT (Figure 2) are depicted. What is the optimal
management for this patient?
a. C1-2 posterior fusion
b. Odontoid screw placement
c. Cervical collar
d. Halo-vest placement
e. Occipital-cervical fusion
a. C1-2 posterior fusion
What type of pain related to spinal metastases is most
responsive to radiation?
a. Nocturnal pain
b. Neuropathic pain
c. Radicular pain
d. Mechanical pain
a. Nocturnal pain
A 55 year-old female presents with back pain, progressive
right leg pain, atrophy and weakness. Exam reveals bilateral
non-dermatomal lower extremity hypalgesia and a hemangioma
with hypertrichosis over the lumbar spine. Imaging reveals a 10
degree thoracic scoliosis, right sided disc bulge at L1/2, conus
terminating at L4, and a fatty filum terminale (3mm). What is the
treatment of choice for this patient?
a. Release of filum terminale
b. Spinal deformity correction
c. L1/L2 microdiscectomy
d. Monitoring with serial imaging
e. Conservative therapy (PT, NSAIDS, etc)
a. Release of filum terminale
What is the best estimate of blood volume in a 13 month-old
child weighing 10 kilograms?
a. 700 mL
b. 600 mL
c. 1000 mL
d. 800 mL
e. 900 mL
a. 700 mL
A 8-month-old infant was sent for imaging (figures) by his
pediatrician because of irritability, poor feeding, and
macrocephaly with a bulging fontanel. The preceding pregnancy
and delivery had been unremarkable. The infant had been well
up until this presentation, and review of systems was
noncontributory. What additional diagnostic investigation is
indicated?
a. Dilated funduscopic examination
b. Pyloric ultrasound
c. Measurement of parents’ head
circumferences
d. Urine amino acids
e. Blood lead level
a. Dilated funduscopic examination
What structure is indicated by the arrow on this lateral
projection angiogram?
a. Basal vein of Rosenthal
b. Vein of Labbe
c. Internal cerebral vein
d. Thalamostriate vein
e. Inferior saggital sinus
b. Vein of Labbe
According to the NASCET trial, what is the best treatment
for a symtpmatic carotid artery narrowing of 25%?
a. Carotid artery stenting
b. Carotid endarterectomy
c. EC/IC bypass
d. Antiplatelet therapy
e. Observation
d. Antiplatelet therapy
Which of the following is most likely to help reduce
infections associated with primary ventriculoperitoneal shunt
insertion?
a. Injection of bacitracin in the shunt tract
b. Double gloving of OR personnel
c. Administration of post-operative antibiotics for more than 24
hours
d. Decreasing number of OR personnel
e. Antibiotic irrigation
b. Double gloving of OR personnel
The figure is a cadaveric dissection of the anterior portion
of the left cavernous sinus. What deficit would be seen with
damage to this structure?
a. Monocular blindness
b. Facial numbness
c. Periocular numbness
d. Diplopia that corrects with head tilt
e. Ptosis, meiosis and anhydrosis
e. Ptosis, meiosis and anhydrosis
A 62 year old with known metastatic renal cell cancer presents
with unbearable back pain and lower extremity myelopathy after a
fall. Her imaging is displayed in the accompanying figures. The best
management strategy of this lesion would be:
a. Kyphoplasty/Vertebroplasty followed by
radiotherapy
b. Conventional external beam radiotherapy
c. Vertebrectomy with posterior
stabilization followed by radiotherapy
d. Stereotactic Radiosurgery
e. Laminectomy and resection of epidural
disease followed by radiotherapy
c. Vertebrectomy with posterior
stabilization followed by radiotherapy
Which of the following is the most effective sedative for pediatric trauma with severe traumatic brain injury and increased intracranial pressure?
a. Propofol
b. Fentanyl
c. Dexmedetomidine
d. Sevoflurane
e. Thiopental
b. Fentanyl
During the creation of a burr hole for a deep brain stimulator, an
awake, sedated patient develops the sudden onset of coughing,
hypotension, and hypoxia. This clinical presentation is most
suggestive of which complication?
a. Tension pneumocephalus
b. Seizure activity
c. Intracranial hemorrhage
d. Air embolism
e. Aspiration pneumonia
d. Air embolism
A 62 year-old right handed woman with a malignant glioma
undergoes awake craniotomy and gross total resection of the
contrast enhanced tumor. What clinical deficit can have the most
negative impact on overall survival?
a. Post-operative speech deficit
b. Post-operative motor deficit
c. Post-operative seizures
d. Post-operative visual deficit
e. Post-operative Gerstmann Syndrome
a. Post-operative speech deficit
A 50 year old patient presenting to the ICU with 2 days of severe
vomiting. The ABG reveals a PCO2 40 mmHg, pH 7.55, and HCO3- 30
mEq/L. With which condition is this ABG most consistent?
a. Metabolic alkalosis
b. Respiratory alkalosis
c. Metabolic alkalosis with respiratory compensation
d. Respiratory alkalosis with metabolic compensation
a. Metabolic alkalosis
You are seeing a patient with new onset foot drop and dorsal
foot numbness and pain. You obtain the following MRI. What is the
most likely diagnosis?
a. Tibial nerve hematoma
b. Intraneural ganglion cyst
c. Baker cyst
d. Tibulofibular joint dislocation
e. Peroneal nerve schwannoma
b. Intraneural ganglion cyst
What condition is present when reducing a drug effect results in
a withdrawal syndrome?
a. Use disorder
b. Habituation
c. Tolerance
d. Dependence
e. Addiction
d. Dependence
A patient who was shunted for hydrocephalus after intracerebral
hemorrhage presents with severe headaches. Head CT is shown.
What is the most likely diagnosis?
a. Shunt malfunction
b. Overdrainage
c. New intracranial hemorrhage
d. Shunt infection
e. Post-hemorrhagic headache syndrome
b. Overdrainage
A 25 year-old man presents after assault with bilateral
contusions and subarachnoid hemorrhage. His admission GCS is 4T,
and an ICP monitor is placed. ICP steadily increases despite
sedation, CSF diversion, hyperosmolar therapy, and hypothermia.
What additional non-surgical intervention is most appropriate?
a. Maintain CPP > 60mmHg
b. Increase PEEP > 10 mmHg
c. 10mg IV dexamethasone
d. Hyperventilate with goal PCO2 <30mmHg
e. Acetazolamide
a. Maintain CPP > 60mmHg
A head trauma patient on your service for the past 12 days has
been in a coma. You notice that that his sleep-wake cycles have
returned. However, he does not exhibit evidence of cognitive
function. What term best describes this patient’s level of
consciousness?
a. Lethargy
b. Obtundation
c. Minimally conscious state
d. Stupor
e. Vegetative state
e. Vegetative state
Anterior interosseous neuropathy causes weakness in the flexor
pollicis longus, flexor digitorum profundus 1 and which muscle?
a. Pronator quadratus
b. Pronator teres
c. First dorsal interosseous
d. Opponens pollicis
e. Abductor pollicis brevis
a. Pronator quadratus
You are seeing a patient with multiple stab wounds to the upper
extremity. The patient has isolated deficits in finger extension and ulnar
wrist extension. What is the most likely level of injury?
a. Radial nerve at the elbow
b. Radial nerve at the distal forearm
c. Ulnar nerve at the mid forearm
d. Median nerve at the elbow
e. Posterior interosseous nerve
e. Posterior interosseous nerve
A 24-year-old gravida 1 para 0 abortus 0 woman presents in her
third trimester with hypertension, proteinuria, hemolysis, elevated liver
enzymes, low platelets and seizure. What is the most definitive
treatment for this patient?
a. Bedrest
b. Magnesium sulfate
c. Deliver the baby
d. Corticosteroids
e. Intravenous blood pressure medication
c. Deliver the baby
In a 50 year old female presenting with a 1 cm pineal region mass,
what would be the most likely diagnosis (based upon incidences cited in
the literature)?
a. Pineoblastoma.
b. Germ cell tumor.
c. Pineocytoma.
d. Meningioma.
e. Metastasis.
c. Pineocytoma.
What is the recommended radiotherapy regimen for GBM patients
older than 70 years of age with poor performance status?
a. 60 Gy in 30 fractions over 6 weeks
b. 20 Gy in 10 fractions over 3 weeks
c. 50 Gy in 30 fractions over 6 weeks
d. 30 Gy in 20 fractions over 3 weeks
e. 40 Gy in 15 fractions over 3 weeks
e. 40 Gy in 15 fractions over 3 weeks
What is the nerve that is compressed in tarsal tunnel syndrome?
a. Deep peroneal nerve
b. Superficial peroneal nerve
c. Sural nerve
d. Saphenous nerve
e. Tibial nerve
e. Tibial nerve
A 76-year-old female has a history of lancinating pain just below
her right eye. You performed stereotactic radiosurgery on her 1 year
ago, giving her excellent pain relief for 9 months. She now returns to
you complaining of constant burning pain and diminished sensation
where her lancinating pain used to be. What is this patient’s most likely
diagnosis at follow-up?
a. Symptomatic trigeminal neuralgia
b. Trigeminal deafferentation pain
c. Trigeminal neuropathic pain
d. Type 1 trigeminal neuralgia
e. Anesthesia dolorosa
b. Trigeminal deafferentation pain
For which type of lumbar fusion is the use of recombinant
human bone morphogenetic protein 2 (rhBMP-2) FDA approved?
a. Posterior lumbar interbody fusion procedures
b. Instrumented posterolateral lumbar fusion procedures
c. Transforaminal lumbar interbody fusion procedures
d. Anterior lumbar interbody fusion procedures
e. Non-instrumented posterolateral lumbar fusion procedures
d. Anterior lumbar interbody fusion procedures
You are consulted about a patient who suffered a cardiac arrest
secondary to an asthma attack. Hypothermia to 33° C has been initiated.
CT reveals diffuse edema with slit ventricles, sulcal effacement, and
obliteration of the basal cisterns. You suggest assessing median nerve
somatosensory evoked potentials for aid in prognostication. Which SSEP
component is most commonly measured to identify patients with a
probable poor neurological outcome?
a. Wave V
b. N20
c. Wave II
d. EP (Erb’s point)
e. N13 (C5s)
b. N20
Injury to the axillary nerve will result in a deficit in which of the
following movements?
a. External rotation of the shoulder
b. Abduction of the shoulder from 60 - 120”
c. Depression of the scapula
d. Internal rotation of the shoulder
e. Elevation of the scapula
b. Abduction of the shoulder from 60 - 120”
What primary intracranial tumor type has the highest frequency
of BRAF-V600E mutations?
a. Pituitary adenomas
b. Gangliogliomas
c. Schwannomas
d. Meningiomas
e. Glioblastomas
b. Gangliogliomas
Anatomic hemispherectomy historically is associated with what
complication?
a. Syndrome of the trephined
b. Hemibalismus
c. Superficial cerebral hemosiderosis
d. Gerstmann syndrome
e. Callosal syndrome
c. Superficial cerebral hemosiderosis
What is the recommended treatment of an isolated unilateral
occipital condylar fracture (OCF) without associated atlantooccipital ligamentous injury or evidence of instability?
a. Cervical immobilization
b. Cranio-cervical instrumentation and arthrodesis
c. Observation with serial radiographs
d. Physical therapy
e. Foramen magnum decompression
a. Cervical immobilization
What radiographic finding is a contraindication to cervical
laminoplasty?
a. Cervical kyphosis.
b. Multilevel cervical spondylosis.
c. Congenital cervical stenosis.
d. Spinal cord signal change.
e. Ossified posterior longitudinal ligament (OPLL).
a. Cervical kyphosis.
What characteristic of the pain associated with Type 2
trigeminal neuralgia differentiates it from Type 1 trigeminal
neuralgia?
a. Pain that radiates to the occipital region
b. Pain that is associated with lacrimation and rhinorrhea
c. Pain that is constant
d. Pain that is of psychogenic origin
e. Pain that is bilateral
c. Pain that is constant
What characteristic imaging finding on MRI would best
differentiate neuromyelitis optica from multiple sclerosis?
a. An intramedullary spinal cord lesion spanning 3 or more
segments.
b. Presence of high burden of periventricular, juxtacortical and
infratentorial demyelinating lesions.
c. Multiple enhancing intramedullary spinal lesions spanning 1-2
segments.
d. Optic nerve enhancement.
e. Multiple non-enhancing intramedullary spinal lesions spanning 1-
2 segments.
a. An intramedullary spinal cord lesion spanning 3 or more
segments.
An 8 year-old presents with a small dimple located at the nasion
which intermittently drains. MR imaging shows that this lesion does
extend intracranially. His past-medical history is significant for two
bouts of meningitis. What is the most common organism which
causes meningitis in these cases?
a. Pseudomonas aeruginosa
b. Staphylococcus epidermidis
c. Propionibacterium acnes
d. Staphylococcus aureus
e. Haemophilis influenzae
d. Staphylococcus aureus
30 year old female, 2 weeks post-partum, presents to the ED
after 4 hours with acute onset right hemiplegia, lethargy and left
gaze deviation. Her NIHSS score is 24. Her angiogram is shown.
What is the best management option?
a. Thrombectomy with stent-retrieval
b. EC/IC bypass
c. Aspirin
d. IV tPA
e. IV abciximab
a. Thrombectomy with stent-retrieval
A patient presents 3 months after a motor vehicle accident with
the following isolated injury to the right C5 nerve root. What would
be the most appropriate treatment?
a. C5 nerve rootlet reimplantation
b. C5 to upper trunk graft repair
c. Observation
d. Accessory to suprascapular nerve
transfer
e. Ulnar to musculocutaneous (Oberlin)
nerve transfer
d. Accessory to suprascapular nerve
transfer
A 16-year-old boy presents with headaches, nausea, and
blurred vision. His neurological examination is remarkable for
impaired upgaze and convergence nystagmus. Contrast-enhanced
MRI of the brain is shown (figure). Serum beta-HCG and alphafetoprotein levels are normal. What is the most likely diagnosis?
a. Embryonal carcinoma
b. Endodermal sinus tumor
c. Choriocarcinoma
d. Meningioma
e. Germinoma
e. Germinoma
A 60 year old male with type 2 diabetes presents with fever,
back pain and < 24 hours of acute onset 2/5 motor weakness in the
lower extremities. Thoracic MRI (Figure 1) and CT (Figure 2) imaging
is performed. What is the most appropriate management for this
patient’s acute neurologic deficits?
a. Corpectomy and instrumented fusion
b. Percutaneous aspiration
c. Antibiotic therapy and external orthosis
d. Kyphoplasty
e. Thoracic laminectomy
a. Corpectomy and instrumented fusion
A patient complains of hip and thigh pain 2 months following
thoracolumbar fusion surgery (figure). Based on the provided
radiograph, what is the best treatment option to correct the primary
problem producing pain and disability?
a. Extension of instrumented fusion to the pelvis
b. Re-arthrodesis to address pseudarthrosis
c. T12 to L5 decompressive Laminectomy
d. Extension of instrumented fusion to T10
e. Pedicle subtraction osteotomy
e. Pedicle subtraction osteotomy
A 27 year old patient presents following a trauma that involved
an axial load to the spine. He has undergone CT imaging. He notes
neck pain but otherwise has a normal neurological examination.
What does the following coronal CT scan of the cervical spine
depict (figure)?
a. C1-2 Rotatory Subluxation
b. Occipital condyle fracture
c. Type 1 odontoid fracture
d. C2 Hangman’s Fracture
e. Unstable C1 (Jefferson) fracture
e. Unstable C1 (Jefferson) fracture
A 12-year-old boy presents complaining of left eye visual loss
and occasional headache. Endocrine evaluation reveals the
presence of mild diabetes inspidus and hypothyroidism. His MRI is
shown in Figure 1&2. You recommend an attempt at complete tumor
resection . Which of the following is the most likely surgical
complication?
a. Mutism
b. Hydrocephalus
c. Blindness
d. Pan-hypopituitarism
e. Seizure disorder
d. Pan-hypopituitarism
A 21-year-old male presents to the emergency department after
being involved in a gunfight. His GCS is 15 with a non-focal
examination but several bullet holes are noted in his scalp with
protruding cerebral tissue. His CT scan of the head is shown in the
figure. What is the BEST definitive management strategy for this
injury?
a. Surgical removal of all bullet fragments
b. Surgical durotomy repair
c. Bedside laceration repair
d. 14-day course of antibiotics
e. Cranioplasty and removal of accessible
fragments
e. Cranioplasty and removal of accessible
fragments
What finding is more frequently associated with nasal and
occipital dermoid cysts compared to other locations?
a. Malignant transformation
b. Cyst rupture
c. Intracranial extension
d. Superinfection
e. Hydrocephalus
b. Cyst rupture
c. Intracranial extension
A 26 year old male presents after motor vehicle crash with absent
right and partially preserved left lower extremity motor function (more
than half of left leg muscles have less than antigravity strength).
Sensation to pain and temperature is markedly diminished in the left leg.
Proprioception is markedly diminished in the right leg . Neuro-imaging
studies are obtained and depicted in Figures 1 and 2. Which spinal cord
syndrome BEST describes the injury?
a. Anterior spinal
b. Central cord
c. Cauda equina
d. Posterior cord
e. Brown-Sequard
e. Brown-Sequard
The radiographic and magnetic resonance imaging findings at
L2-L3 (shown in Figures 1-3) are most consistent with a diagnosis
of:
a. discitis/osteomyelitis.
b. degenerative disc disease.
c. fracture.
d. metastatic carcinoma.
e. chordoma.
a. discitis/osteomyelitis.
The axial noncontrast head CT (obtained for unrelated reasons)
shown from an affected neonate results from which of the following
deformities?
a. Bicoronal synostosis
b. Unicoronal synostosis
c. Lambdoid synostosis
d. Sagittal synostosis
e. Metopic synostosis
e. Metopic synostosis
An 8-year-old boy was evaluated due to short stature and
headaches. Sagittal MRI with contrast (figure) is most consistent
with what diagnosis?
a. Medulloblastoma
b. Craniopharyngioma
c. Germinoma
d. Pituitary macroadenoma
e. Arachnoid cyst
b. Craniopharyngioma
A lateral view of the cortical surface bordering the right sylvian
fissure that is commonly exposed in a frontotemporal craniotomy is
shown in Figure 1. The lower ends of the precentral (1) and
postcentral (2) gyri are in the exposure. The supramarginal gyrus is
indicated by what number?
a. 8
b. 7
c. 6
d. 9
e. 5
b. 7
A 28-year-old with NF-1 has progressive headaches. Axial and
coronal T1-weighted MR images with gadolinium are shown (Figures
1 and 2). The next morning she becomes suddenly unresponsive
with a dilated right pupil. What is the most likely diagnosis?
a. Metastatic tumor
b. Meningioma
c. Ganglioglioma
d. High-grade astrocytoma
e. Pilocytic astrocytoma
d. High-grade astrocytoma
A 9-year-old girl visits her optometrist because of a 1-month
progressive history of blurry vision and headaches. The optometrist
notes papilledema. Imaging is obtained. What course of action is
indicated?
a. LP shunt insertion
b. Lumbar puncture for cytology and markers
c. Endoscopic third ventriculostomy
d. Stereotactic biopsy
e. Conformal radiation therapy
c. Endoscopic third ventriculostomy
An 18 year old functionally independent girl with tuberous
sclerosis presents with progressive headaches. Imaging is shown
(figure). What is the best treatment option for this patient?
a. Observation
b. Everolimus therapy
c. Interhemispheric transcallosal resection
d. Transcortical transventricular resection
e. Stereotactic radiosurgery
b. Everolimus therapy
Which artery is indicated by the arrow in the figure?
a. Opthalmic artery
b. Anterior chorodial artery
c. Vidian Artery
d. Posterior communicating artery
e. Bernasconi and Cassinari
e. Bernasconi and Cassinari
A 4-year-old male presents with new onset headaches, nausea,
and vomiting and is found to have a posterior fossa tumor. The
tumor is resected and the histopathologic specimen is shown
(figure 1). Which of the following is the most likely diagnosis?
a. Pilocytic astrocytoma
b. Ependymoma
c. Pilomyxoid astrocytoma
d. Medulloblastoma
e. Glioblastoma multiforme
d. Medulloblastoma
An asymptmatic 2-year-old child with macrocephaly has the
finding seen on CT (Figure 1). He has no signs or symptoms of
increased intracranial pressure. Six months later, a routine followup MRI is obtained (Figure 2) and repeat testing reveals mild
developmental delay and early papilledema. There is no diffusion
restriction. What is the most likely diagnosis?
a. Astrocytoma
b. Encephalomalacia
c. Arachnoid cyst
d. Epidermoid
e. Abscess
c. Arachnoid cyst
A 48 year old woman presents with a one week history of
progressive facial paresis, severe right ear pain, vertigo, imbalance
and hearing loss. Her past medical history is unremarkable. She has
right beating nystagmus. Based on the MRI scan (figures) what is
your diagnosis:
a. Facial nerve hemangioma
b. Zoster oticus
c. Bell palsy
d. Facial nerve schwannoma
e. Vestibular schwannoma
b. Zoster oticus
A 61-year-old man presents with confusion. Susceptibilityweighted MR imaging demonstrates multiple abnormalities
(figure). What is the most likely diagnosis?
a. Leptomeningeal carcinomatosis
b. Cerebral amyloid angiopathy
c. Creutzfeldt-Jakob disease
d. CADASIL (cerebral autosomal
dominant arteriopathy with subcortical
infarcts and leukoencephalopathy)
e. Hypertensive hemorrhages
b. Cerebral amyloid angiopathy
A 60 year old female presents with sudden onset of vertigo,
headache, vomiting and imbalance. Her imaging (after 2 days) is
shown. What is the cause of the patient’s symptoms?
a. Lhermitte-Duclos disease
b. Multiple sclerosis
c. Cerebellar abscess
d. Cerebellar astrocytoma
e. Cerebellar infarction
e. Cerebellar infarction
The tumor represented in this photomicrograph most
frequently occurs in association with what condition?
a. Von Hippel-Lindau syndrome
b. Tuberous sclerosis
c. Turcot syndrome
d. Neurofibromatosis-2
e. Sturge-Weber syndrome
d. Neurofibromatosis-2
A patient initially presents after closed head injury with a
GCS of 14. Head CT demonstrates a small amount of
pneumocephalus. Two hours later, the patient becomes
unresponsive (GCS 4). A repeat head CT is obtained (Fig. 1).
What is the most appropriate next step in management?
a. Lumbar puncture to rule out
meningitis.
b. Administer 1g/kg of mannitol.
c. Repeat head CT with fine cuts to
identify a basal skull fracture.
d. Surgical evacuation of
pneumocephalus.
e. Treatment with high flow oxygen
d. Surgical evacuation of
pneumocephalus.
A 75-year-old woman presents with a 2-month history of
progressive difficulty walking, headache, and memory
difficulties. Magnetic resonance imaging is shown (figure).
Histopathology shows nests of small blue cells amid a pink
fibrillary matrix. What is the most likely diagnosis?
a. glioblastoma multiforme.
b. meningioma.
c. subependymoma.
d. medulloblastoma.
e. pilocytic astrocytoma
c. subependymoma.
A 10-year-old boy presents with headache and imbalance.
Examination discloses mild papilledema, right-sided dysmetria, and
ataxia. MRI with contrast is shown in the figure. What is the most
important prognostic factor for this patient?
a. The extent of resection of the cyst walls
b. The presence of endothelial proliferation
on histology
c. The extent of resection of the
enhancing mass
d. The presence of hydrocephalus at
presentation
e. The presence of mitoses on histology
c. The extent of resection of the
enhancing mass
To what structure does the arrow point?
a. McConnel’s Capsular artery
b. Caroticotympanic artery
c. Vidian artery
d. Persistent stapedial artery
e. Persistent otic artery
c. Vidian artery
A 33 year old woman with no neurological history complains of
subtle left upper extremity weakness without headache or other
symptoms. She is noted to have a mild left hemiparesis and otherwise
normal neurological examination. EEG is normal. The MR scan is shown
(figure). A stereotactic biopsy yields no evidence of glioma. What is the
most likely diagnosis?
a. Glioblastoma multiforme
b. Lymphoma
c. Subacute sclerosing panencephalitis
d. Progressive multifocal leukoencephalopathy
e. Demyelinating plaque
e. Demyelinating plaque
A 47 year-old woman with a history of multiple prior lumbar spine
surgeries with temporary relief of back and leg pain after each, now
presents with severe low back pain. Her pain worsens throughout the
day, requiring her to use a walker in the evening. She denies new
radicular symptoms and is neurologically intact on exam. X-rays are
obtained (Figure 1) . What is the likely etiology of her pain and
disability?
a. Adjacent level foraminal stenosis
b. Residual lumbar stenosis
c. Pseudarthrosis
d. Sacroiliac joint dysfunction
e. Positive sagittal imbalance
e. Positive sagittal imbalance
A patient sustains an accessory nerve injury during a lymph node
biopsy. The biopsy incision is indicated by the dotted line in the images.
Which of the following incisions permits the most effective exposure for
assessment and possible repair of this nerve?
a. Figure 1
b. Figure 3
c. Figure 4
d. Figure 2
e. Figure 5
a. Figure 1
You have performed a nerve biopsy on a patient with a suspected
peripheral neuropathy. Congo Red staining reveals abnormal deposits
in the tissue (Figure). What is the most likely diagnosis?
a. HIV neuropathy
b. Amyloidosis
c. Small fiber neuropathy
d. Sarcoidosis
e. Vasculitis
b. Amyloidosis
What is the most likely appearance of a chronic subdural
hematoma on MRI?
a. Hyperintense on both T1 and T2
b. Hypointense on both T1 and T2
c. Hyperintense on T1 and hypointense on T2
d. Hypointense on T1 and hyperintense on T2
e. Isointense on both T1 and T2
a. Hyperintense on both T1 and T2
Based on the cerebral angiogram, which vessel is the PRIMARY
arterial blood supply for this tumor?
a. Superior cerebellar artery.
b. Meningohypophyseal trunk.
c. Middle meningeal artery.
d. Persistent trigeminal artery.
e. Ascending pharyngeal artery.
b. Meningohypophyseal trunk.
A 72-year-old female presents with an incidentally discovered
lesion as shown in the figure. What is her estimated 5-year risk of
hemorrhage or new neurological deficit related to this lesion?
a. 21-30%
b. 0-10%
c. 41-50%
d. 11-20%
e. 31-40%
b. 0-10%
A sagittal, upright long-cassette radiograph is shown (figure) for a
54-year-old woman with a history of T12-L5 instrumented fusion 2
months ago who now presents with back and thigh pain. Which of the
following diagnoses is most likely based on her history and imaging?
a. Flatback syndrome
b. Instrumentation failure
c. Sagittal spinal imbalance
d. Adjacent segment disease
e. Pseudarthrosis
a. Flatback syndrome
A five-year-old right-handed boy has had medically intractable
epilepsia partials continua for 4 years. Evaluation demonstrates
developmental delay, worsening of verbal IQ and right-sided
hemiparesis. EEG demonstrate several epileptogenic foci over the left
parietal lobe. MRI imaging is shown. Aside from invasive monitoring,
which of the following is the most appropriate surgical treatment?
a. Functional hemispherectomy
b. Parietal lobectomy
c. Corpus callosotomy
d. Vagus nerve stimulation
e. Selective amygdalohippocampectomy
a. Functional hemispherectomy
Anterograde blood flowing in the indicated vascular structure on
this lateral projection cerebral angiogram drains into which structure?
a. Cavernous sinus
b. Inferior petrosal sinus
c. Inferior sagittal sinus
d. Vein of galen
e. Superior petrosal sinus
d. Vein of galen
A 6-year-old girl presents with a deviated gluteal skin fold and
lumbosacral dimple. A representative axial T1 non-contrast image from
the patient’s lumbar MRI is shown (figure). If she is symptomatic, which
is most likely?
a. Flat feet
b. Urinary incontinence
c. L5 paresthesias
d. Anterior thigh pain
e. Hypotonia
b. Urinary incontinence
A 12-year-old African-American male with a history of asthma
presents with fever, lethargy, seizure activity, and left hemiparesis.
Inflammatory markers are elevated. After stabilization, a CT head with
contrast is obtained (figure). What is the most appropriate next step
in management?
a. Sinus surgery
b. Burrholes
c. Craniotomy / craniectomy
d. Lumbar puncture
e. Bedside subdural drain
c. Craniotomy / craniectomy
A 65-year-old man presents with one week history of agitation
and confusion. He sustained a generalized tonic-clonic seizure and
is hallucinating. On exam, he is febrile, confused and has a left
pronator drift with hyper-reflexia. An MRI of the brain is shown
(figure). Which of the following is the most likely diagnosis?
a. Neurosyphilis
b. Hemorrhagic stroke
c. Herpes simplex virus
d. Low grade glioma
e. Sarcodosis
c. Herpes simplex virus
Twelve months after undergoing Gamma Knife radiosurgery to
treat an AVM, a patient experiences headaches and a seizure. What is
the underlying cause of the new onset of symptoms and edema
shown on the attached CT and MRI?
a. Acute thrombosis of the draining vein
b. Secondary tumor
c. Radiation necrosis
d. Peri-lesional cyst
e. Hemorrhage from the nidus
a. Acute thrombosis of the draining vein
A 54-year old female presented with recurrent headaches. The
patient was found to have an arteriovenous malformation with a 4 cm
diameter centered in the primary motor cortex. On angiography, the
arteriovenous malformation was found to have deep draining veins.
What is the Spetzler-Martin grade?
a. Grade 5
b. Grade 1
c. Grade 4
d. Grade 3
e. Grade 2
c. Grade 4
Which of the following most accurately defines, from a
biomechanical perspective, the location of rod fracture as depicted in
Figure 1? The point of:
a. maximum stress application.
b. greatest flexibility.
c. maximum strain application.
d. 3-point bending.
e. narrowest diameter
a. maximum stress application.
A 17 year old sustains a gunshot wound to the head. On examination, he has
decorticate posturing on the right and he localizes on the left. His left pupil is 2 mm
larger than the right but is still reactive. His non-contrast head CT (see figures)
demonstrates metal and bone fragments within the left frontal region with an
associated subdural hematoma with midline shift. What is the most appropriate
management of this patient?
a. Right frontal ventriculostomy placement
b. Craniotomy, hematoma evacuation, removal of all bone
and metal fragments
c. Craniotomy, hematoma evacuation, superficial
debridement
d. Expectant care
e. Superficial debridement of wound
c. Craniotomy, hematoma evacuation, superficial
debridement
On which chromosome is the gene mutation associated with the
syndrome depicted by the MRI shown (figure)?
a. 11
b. 9
c. 3
d. 22
e. 17
d. 22
You are seeing an adult patient with a history of a painless left
ankle mass, as indicated by the dotted outline and asterisk. Imaging
is suggestive of a peripheral nerve sheath tumor. Within which nerve
distribution do you suspect the nerve is located:
a. Saphenous nerve
b. Deep peroneal nerve
c. Tibial nerve
d. Sural nerve
e. Superficial peroneal nerve
c. Tibial nerve
What neurological deficit is most at risk with surgery for the
lesion shown (figures 1 and 2)?
a. Gerstmann syndrome
b. Diplopia
c. Expressive aphasia
d. Anterograde amnesia
e. Upgaze palsy
d. Anterograde amnesia
You are performing radiosurgery on a patient with left medicallyrefractory, lancinating ear and throat pain triggered by eating and
drinking. Which figure shows the most optimal location of the
radiation target?
a. Figure 3
b. Figure 2
c. Figure 4
d. Figure 5
e. Figure 1
b. Figure 2
A 14-year-old female presents with progressive difficulty writing.
An MRI (figure) shows multiple nodular areas running along the
cervical nerve roots and brachial plexus. Examination of her eyes
also shows iris harmartomas. What is the most likely diagnosis?
a. Ataxia-telangiectasia
b. Neurofibromatosis-2
c. Tuberous sclerosis
d. Neurofibromatosis-1
e. Von Hippel-Lindau
d. Neurofibromatosis-1
A 15 year-old male presents with severe low back pain. The pain
responds poorly to acetaminophen but responds well to aspirin. CT
demonstrates a 1.5 cm dense lytic lesion with a calcified nidus and
circumferential sclerosis (figure). What is the diagnosis?
a. Oteoblastoma
b. Osteoid osteoma
c. Hemangioma
d. Osteochondroma
e. Fibrous dysplasia
b. Osteoid osteoma
A 15-year-old presents with an incidental finding (figure). What is
the most appropriate management strategy?
a. Surgical resection of the mural nodule
and entire cyst wall.
b. Surgical resection of the mural
nodule.
c. Drainage of the cyst to relieve mass
effect.
d. Surgical resection of the mural nodule
with a 1 cm margin.
e. Surgical resection of the mural nodule
with biopsy proven, tumor positive, cyst
wall
b. Surgical resection of the mural
nodule.
A 68 year-old man presents to the office with neck pain and right
upper extremity paresthesias. He reports mild difficulty with
buttoning his shirt and initiating micturition. He has decreased
sensation in the right first and second digit and loss of the right
biceps reflex. He also has mild loss of balance with tandem gait. His
cervical spine MRI is depicted (Fig 1). What is the most appropriate
management?
a. Right C5-C6 transforaminal epidural injection
b. Surgical decompression of the cervical spinal
cord
c. Electrodiagnostic studies (EMG/NCV) to assess for
carpal tunnel syndrome
d. Structured physical therapy with gait training
e. Medrol dose pack and soft cervical collar for 6
months
b. Surgical decompression of the cervical spinal
cord
A 39-year-old female presents with subarachnoid hemorrhage.
Her angiogram is shown. What is the most likely diagnosis?
a. Blister aneurysm
b. Fusiform aneurysm
c. Infundibulum
d. Supraclinoid ICA dissection
e. Saccular Aneurysm
c. Infundibulum
According to the International Study of Unruptured Intracranial
Aneurysms (ISUIA), what is the risk of rupture of a cavernous carotid
artery aneurysm (< 7 mm) in a patient with a history of previous
aneurysmal subarachnoid hemorrhage?
a. 4%
b. 3%
c. 2%
d. 1%
e. 0%
e. 0%
Which vein is indicated by the arrow in the figure?
a. Thalmostriate vein
b. Basal vein of Rosenthal
c. Vein of Trolard
d. Internal Cerebral vein
e. Vein of Galen
b. Basal vein of Rosenthal
A 28-year-old male presents with acute onset facial asymmetry,
diplopia, and hemifacial numbness. The patient’s MRI is shown. What
is the molecular mechanism for disease pathogenesis?
a. Mutation of BRAF V600 E
b. Activation of ERK/MAPK signaling
c. Activation of SMO signaling
d. Activation of MEKK3 signaling
e. Activation of AKT1 signaling
d. Activation of MEKK3 signaling
This brain micrograph of a 68 yo male nursing home resident
who had a vague history of dementia and relatively rapid decline
shows which of the following?
a. Acute traumatic brain injury
b. Chronic Traumatic Encephalopathy
c. Subacute brain degeneration
d. Pick’s Disease
e. Jakob-Creutzfeldt Disease
b. Chronic Traumatic Encephalopathy
A 6 year-old girl presents with progressive scoliosis. Physical
examination reveals a club foot and a midline hairy nevus in the
lumbar region. MRI is shown (Figure 1). What is the most likely
diagnosis?
a. Myelomeningocele
b. Dermal sinus tract
c. Neurenteric cyst
d. Diastematomyelia
e. Lipomyelomeningocele
d. Diastematomyelia
According to the International Study of Unruptured Intracranial
Aneurysms, what is the 5 year cumulative rupture rate of a 10 mm
posterior communicating aneurysm?:
a. 4.5%
b. 9.5%
c. 0%
d. 19.5%
e. 14.5%
e. 14.5%
A 7-year-old child with a two week history of difficulty walking,
dysarthric speech and facial weakness has the MRI shown in the
figure. What is the most appropriate initial treatment?
a. Surgical debulking.
b. Gamma-knife.
c. Chemotherapy.
d. Whole-brain radiation.
e. Conformal radiotherapy.
e. Conformal radiotherapy.
A 50-year-old male patient with a history of atrial fibrillation
presents with acute onset left hemiparesis and drowsiness for 24 hours.
MRI of the brain is shown. The National Institute of Health Stroke Scale
(NIHSS) score is 16. What treatment option has been shown to decrease
mortality rates for such a patient?
a. Intra-arterial tPA
b. External ventricular drainage
c. Medical management only
d. Mechanical thrombectomy
e. Decompressive hemicraniectomy
e. Decompressive hemicraniectomy
. You are called to the NICU to see a 1 day old child who appears as
demonstrated in figures 1 and 3. His CT scan is shown in figure 2. He
has been stable, although with occasional apnea when agitated. On
exam, he has a bulging fontanelle. His parents wish to pursue
aggressive care. When should he undergo a cranial vault procedure?
a. At 12 months of age.
b. At 6 months of age.
c. At 18 months of age.
d. At 24 months of age.
e. In the next several days.
e. In the next several days.
You are operating on a patient with neurofibromatosis-1 that you
suspect has a benign neurofibroma of the sciatic nerve, and have
performed the initial exposure of the lesion, shown in the figure. What is
the most appropriate maneuver at this point?
a. Biopsy the lesion for frozen and
permanent sections and close
b. Perform direct nerve stimulation to
identify a safe zone to incise
c. Perform an internal debulking of lesion
d. Perform en bloc excision of the tumor,
nerve, and surrounding muscle
e. Excise the lesion and perform a graft
repair of the nerve
b. Perform direct nerve stimulation to
identify a safe zone to incise
A 58-year-old male dies from respiratory failure after battling a
disease for 3 years. Microscopic examination of the spinal cord is
shown below. Which disease lead to the death of patient?
a. Vitamin B12 deficiency
b. Spinal muscular bulbar atrophy (SMBA)
c. Amyotrophic lateral sclerosis
d. Guillain-Barre syndrome
e. Spinal muscular atrophy (SMA)
c. Amyotrophic lateral sclerosis
A 29 year old female presents after a motor vehicle accident with
left hemiplegia, weak localization on right, and a dilated unreactive right
pupil. Her head CT is shown. What is the most appropriate surgical
management?
a. Craniotomy and hematoma evacuation.
b. Placement of ventriculostomy.
c. Placement of brain tissue oxygenation and
ICP probe.
d. Temporal burr hole and hematoma drainage.
e. Decompressive right hemicraniectomy
a. Craniotomy and hematoma evacuation.
A 76 year-old man presents with worsening back pain unresponsive
to conservative measures. 36-inch radiographs were performed at his
office visit (Figure 1). What Schwab grade osteotomy (Figure 2) will
provide the best correction of his sagittal plane deformity over one
segment?
a. Grade 4
b. Grade 5
c. Grade 1
d. Grade 3
e. Grade 2
e. Grade 2
A 27-year-old pregnant female presents to the ER with acute confusion,
headaches and blurry vision. While in the ER she is found to have acute fetal
distress and a blood pressure of 210mmHg/110mmHg. After expedited delivery
of the baby, a CT is performed, revealing patchy areas of hypodensity in the
posterior parietal and occipital lobes. An MRI is shown (figure). Which of the
following is the most likely diagnosis?
a. Acute infarction of the posterior cerebral
arteries
b. Posterior Reversible Encephalopathy
Syndrome (PRES)
c. Infiltrating neoplasm
d. Demyelination, likely multiple sclerosis
e. Progressive multifocal leukoencephalopathy
b. Posterior Reversible Encephalopathy
Syndrome (PRES)
A 54 year-old man presents with biopsy-proven esthesioneuroblastoma
has a normal neurological exam. MRI shows involvement of the right nasal
cavity with minimal intracranial extension through the cribriform plate (Figure
1). There is no cervical adenopathy or evidence of metastatic disease. Which
of the following is the best management strategy for this patient?
a. Chemotherapy alone
b. Surgical resection followed by conformal
radiation therapy to the tumor bed
c. Surgical resection followed by conformal
radiation therapy to the tumor bed and
systemic chemotherapy
d. Neo-adjuvant radiation therapy followed by
chemotherapy
e. Surgical resection
b. Surgical resection followed by conformal
radiation therapy to the tumor bed
What characteristic histological feature of a meningioma is depicted in
the encircled areas of the slide?
a. Mitotic figures
b. Endothelial proliferation
c. Verocay bodies
d. Psammoma bodies
e. Vacuolation
e. Vacuolation
A 42 year-old man undergoes resection of this tumor (Figure 1). The
immunohistochemistry for BRAF V600E mutation is shown (Figure 2). What is
the most likely diagnosis?
a. Pilocytic astrocytoma
b. Glioblastoma
c. Pleomorphic xanthoastrocytoma
d. Ganglioglioma
e. Ependymoma
d. Ganglioglioma
A 50-year-old patient has a history of right-sided hemiparesis and
recurrent seizures. On examination, he has a port-wine stain in the left V1 and
V2 distribution. What is the most likely diagnosis?
a. Encephalotrigeminal angiomatosis
b. Neurocutaneous melanosis
c. Hemorrhagic hereditary telangiectasia (Rendu-Osler-Weber
syndrome)
d. Tuberculosis with leptomeningeal involvement
e. Meningioangiomatosis
a. Encephalotrigeminal angiomatosis
A 34-year-old female presents with spontaneous proptosis and chemosis
of the left eye. Cerebral angiography (left common carotid injection) is shown .
What is the best management option?
a. Craniotomy
b. Optic nerve sheath fenestration
c. Transvenous embolization
d. Transarterial carotid sacrifice
e. Ventriculoperitoneal shunt
c. Transvenous embolization
You are seeing an adult patient with a
history of tarsal tunnel syndrome, who
presents with plantar foot discomfort sparing
the heel. You decide to decompress the nerve
at its typical area of entrapment. Which of the
following incisions would be most appropriate
to do this?
a. Figure 3
b. Figure 2
c. Figure 4
d. Figure 5
e. Figure 1
d. Figure 5
A 51 year old man presents with a severe thunderclap headache,
meningismus, photophobia and nausea. His CT scan is shown below and his
cerebral angiogram is negative. What is the appropriate treatment option at
presentation?
a. Hyperdynamic therapy
b. Observation
c. Endovascular treatment
d. Surgical exploration
e. Anticonvulsants
b. Observation
A 78 year-old man with a 10-year history of intermittent chronic neck pain
has cervical spine X-rays (Figure 1) and MRI (Figure 2). The patient denies any
current neck pain, radiculopathy or subjective symptoms of myelopathy. His
exam is normal. What is the recommended management for this patient?
a. Serial MRI
b. Clinical observation
c. High-dose steroids and cervical traction
d. Surgery
e. Immobilization with cervical collar
b. Clinical observation
A 30 year-old woman presents with progressive difficulty using her hands
and gait dysfunction. She has pain in the back of her neck that radiates into
her head. She notes pain and pareasthesias in both arms that are refractory to
neuropathic pain medication. Her imaging is shown in the figures. What is the
most appropriate initial surgical management?
a. Cervical laminectomy and duraplasty
b. VP shunt
c. Cyst fenestration
d. Suboccipital decompression
e. Cyst shunt
b. VP shunt
A 30-year-old male with no prior medical history presents with four days
of rapidly progressive bilateral lower extremity weakness, reduced sensation
below the level of the umbilicus, and urinary retention. See figure for MRI of
the thoracic spine T2 and T1 with contrast. Spinal fluid evaluation including
NMO IgG are unremarkable. Which of the following is the most effective first
line management of this patient’s condition?
a. T10-T12 laminectomy for spinal cord
decompression
b. Supportive care including maintenance
of MAP > 80 mmHg
c. Interferon
d. Excisional biopsy with subsequent
radiation and chemotherapy
e. High dose intravenous glucocorticoid
therapy
e. High dose intravenous glucocorticoid
therapy
You are revising an intrathecal catheter in a chronic pain patient who
developed myelopathy after several years of benefit from a spinal infusion
pump. You note the mass shown in the figure at the end of the catheter tip.
Which of the following factors predisposes to the formation of these lesions?
a. Catheter allergy
b. High drug concentration
c. Immunosuppressed status
d. Catheter fracture
e. Contaminated pump refills
b. High drug concentration
A 24 year-old man is brought to the emergency department following a
single midline gunshot wound to the forehead. On arrival, he is GCS 7T with
bilateral sluggishly reactive pupils and localizing in the left upper extremity to
noxious stimulus. His non-contrast head CT is depicted (Figure 1). This
patient is most at risk for what acute complication of penetrating brain injury?
a. Traumatic arterial dissection
b. Arteriovenous malformation
c. Venous sinus thrombosis
d. Cavernous-carotid fistula
e. Traumatic intracranial aneurysm
e. Traumatic intracranial aneurysm
A 44 year old man presents with seizure, headache, and left visual field
cut. MRI is shown. What is the most likely benefit of embolization for this
lesion?
a. Decreased risk of seizures
b. Reducing AVM volume for subsequent treatment
c. Complete obliteration of the AVM
d. Decreased risk of rupture before further therapy
e. Improvement of vision
b. Reducing AVM volume for subsequent treatment
You are consulted to perform a
sural nerve biopsy to evaluate a
peripheral neuropathy. What would be
the most appropriate incision for this
patient?
a. Figure 1
b. Figure 3
c. Figure 4
d. Figure 5
e. Figure 2
e. Figure 2
A 56- year old man presents with a 4-year
history of progressive lower extremity numbness,
paresthesias, weakness and spastic gait. MRI and
CT Myelogram of the thoracic spine is shown
(Figure 1 & 2). What is the most appropriate
treatment option?
a. Fenestration of dorsal arachnoid cyst
b. Observation and physical therapy
c. Thoracotomy for thoracic discectomy
d. Thoracic laminectomy and posterior fusion
e. Intradural exploration and detethering of
ventral spinal cord
e. Intradural exploration and detethering of
ventral spinal cord
A 3 month old boy, otherwise healthy with normal prenatal and
perinatal history, is brought by his parents for concerns they have
regarding his head shape. They noticed some asymmetry soon after
birth that has become more noticeable over the past few weeks (Fig 1).
What is the diagnosis?
a. Lambdoid synostosis
b. Positional plagiocephaly
c. Coronal synostosis
d. Metopic synostosis
e. Sagittal synostosis
b. Positional plagiocephaly
A 4-week-old, 26 week premature infant presents with a Grade IV
intraventricular hemorrhage and posthemorrhagic hydrocephalus
(Figure 1). Examination reveals stable vital signs, normal head
circumference growth curve, and soft anterior fontanelle. Weight is 1.2
kg. What is the best initial management of the hydrocephalus?
a. Placement of a ventricular reservoir
b. Placement of external ventricular
drain
c. Creation of a permanent
ventriculoperitoneal shunt
d. Serial cranial ultrasounds with
daily head circumference
measurements
e. Serial lumbar punctures
d. Serial cranial ultrasounds with
daily head circumference
measurements
A 10 year old boy presents with loss of consciousness followed by
a lucid interval following a closed head injury. A head CT is shown
(figure). Damage to which of the following vessels is most likely
responsible for the imaging findings?
a. Vein of Labbe
b. Superficial temporal artery
c. Middle cerebral artery
d. Middle meningeal artery
e. Cerebral bridging vein
d. Middle meningeal artery
A 23 year old male sustains a gunshot wound to the head. On
examination, his GCS is 3T, his pupils are bilaterally fixed and dilated, he has
a weak gag and cough reflex, and he intermittently draws a spontaneous
respiration. His non-contrast head CT demonstrates a transventricular bullet
tract and a 3 mm right subdural hematoma. What is the most appropriate
management for this patient?
a. Expectant care
b. Debridement of bullet tract
c. Ventriculostomy
d. Evacuation of subdural hematoma
e. Decompressive hemicraniectomy
a. Expectant care
Occlusion of which artery causes the stroke shown in the figure?
a. Artery of Percheron
b. Medial lenticulostriate perforator
c. Recurrent artery of Heubner
d. Subcallosal artery
e. Orbitofrontal Artery
d. Subcallosal artery
A 58 year old male presents with longstanding progressive neck and back
pain and dysphagia. The following CT is obtained. What is the most likely
diagnosis?
a. hypercalcemia
b. rheumatoid arthritis
c. age-appropriate spine
d. diffuse idiopathic skeletal hyperostosis
e. ankylosing spondylitis
d. diffuse idiopathic skeletal hyperostosis
A 17-year-old male presented with a
heterogeneously contrast-enhancing mass within
the spinal cord causing significant spinal cord
expansion and compression. After laminectomy,
an expansile intramedullary mass that appeared
highly vascularized and infiltrative was found. A
frozen section showed glioblastoma. What is the
most appropriate next step in management?
a. Gross total resection
b. Duraplasty without resection
c. Primary dural closure without resection
d. Partial resection
e. En bloc resection
b. Duraplasty without resection
A 4-year-old boy presents with progressive gait dysfunction,
headache, and vomiting. A CT shows hyperdense areas suggestive of
calcification. The MRI is shown (figures). What is the most likely
diagnosis?
a. Atypical teratoid / rhabdoid tumor (AT/RT)
b. Medulloblastoma
c. Ependymoma
d. Pilocytic astrocytoma
e. Choroid plexus papilloma
c. Ependymoma
A 10-year-old girl was playing outside when she fell and landed on
her head. She experienced complete loss of motor and sensory function
from the neck down that resolved over the next 15 minutes. A CT is
shown (figure). What is the most appropriate treatment?
a. Posterior C1-2 fusion
b. External Rigid Collar
c. External Halo vest immobilization for
6-12 weeks
d. Observation
e. Transoral odontoidectomy
a. Posterior C1-2 fusion
A 68 year-old man undergoes resection of a GBM. Post-operative
imaging is shown. He awakes from surgery with left arm numbness and
mild weakness. What is the most likely cause of his new deficit?
a. Seizure
b. Abscess
c. Ischemia
d. Edema
e. Direct injury to neural structures
c. Ischemia
A 25 year old patient is involved in a motor vehicle accident and is
intubated and sedated in the field before a complete neurological
examination can be obtained. His non-contrast head CT is shown.
(figure 1) What is the appropriate next step in management?
a. Awaken the patient for
neurological examination
b. Take to the OR for an emergent
craniotomy for evacuation of
hematoma
c. Place an intracranial pressure
monitor and admit to ICU
d. Obtain an urgent MRI with
Diffusion weighted imaging
b. Take to the OR for an emergent
craniotomy for evacuation of
hematoma
A 37 year-old man presents with worsening low back pain and right
L5 radicular pain and a normal examination. Lumbar spine MRI (Figure
1) and CT (Figure 2) are shown. Work-up revealed this solitary lesion.
What is the most appropriate next step in management?
a. Observation with serial imaging
b. External beam radiotherapy
c. CT-guided biopsy
d. Open surgical biopsy
e. Surgical excision and stabilization
c. CT-guided biopsy
A 36 year old restrained driver presented after a motor vehicle collision.
What is the classification of the spinal injury illustrated in the figure?
a. Burst fracture
b. Fracture dislocation
c. Chance fracture
d. Teardrop fracture
e. Compression fracture
c. Chance fracture
An 80-year-old male presents with headache, confusion, and the
accompanying MR imaging (figure). If the perfusion MRI demonstrates low
relative cerebral blood flow, what is the most likely diagnosis?
a. Glioblastoma multiforme
b. Primary CNS lymphoma
c. Low grade glioma
d. Ependymoma
e. Metastatic adenocarcinoma
b. Primary CNS lymphoma
In a patient with the MRI shown in the figure, a tumor in what
other location would increase the probability of germinoma?
a. Suprasellar region
b. Brainstem
c. Fourth ventricle
d. Orbit
e. Frontal lobe
a. Suprasellar region
A view of the fundus (lateral end) of the internal acoustic meatus
is shown in the figure. Which number represent the location of the
cochlear nerve segment?
a. 1
b. 5
c. 2
d. 3
e. 4
b. 5
A 23 year-old man presents to the emergency department after an
intoxicated fall and head injury. He has a moderate occipital headache and
nausea without vomiting. On exam, the patient has normal vital signs and
no focal neurological deficits. His non-contrast head CT is shown (Figure 1).
The volume of the hematoma is measured to be 35 cm3. What is the most
appropriate treatment for this patient?
a. Posterior fossa craniotomy for evacuation of
hematoma
b. Embolization of the transverse sinus
c. Burr hole evacuation of hematoma
d. External ventricular drain for CSF diversion and
intracranial pressure monitoring
e. Close neurological monitoring with serial head CT
imaging
a. Posterior fossa craniotomy for evacuation of
hematoma
An 8-year-old girl presents with obstructive triventricular
hydrocephalus requiring endoscopic exploration of the
ventricular system. What is the most appropriate site for
surgical fenestration?
a. Third ventricle floor anterior to
the mammillary bodies
b. Septum pellucidum superior to the
fornices
c. Pineal recess
d. Lamina terminalis above the
suprachiasmatic recess
e. Third ventricle floor anterior to the
infundibular recess
a. Third ventricle floor anterior to
the mammillary bodies
A 9 month old boy presents with single sutural synostosis
(figure 1). On exam his fontanelle is closed and there is no
papilledema. What associated finding may be diagnosed in this
patient?
a. Chiari type II malformation
b. Syringomyelia
c. Tethered cord syndrome
d. Increased intracranial pressure
e. Dandy-Walker malformation
d. Increased intracranial pressure
What type of tumor harbors the histopathological
structure seen in the figure?
a. Glioblastoma
b. Pilomyxoid astrocytoma
c. Ependymoma
d. Anaplastic oligodendroglioma
e. Pleomorphic xanthoastrocytoma
e. Pleomorphic xanthoastrocytoma
