soal_san_v_20120731060332

Question 2

80. A 54-year-old man was in excellent health until 1 month prior hospital admission when he developed acute severe neck pain after bending over to pick up a newspaper. He went to the emergency room where plain x-rays showed only mild arthritic changes. Over the next 4 weeks he saw multiple physicians from different fields and had various therapies including rest, analgesics, and physical therapy, without relief. One week prior to admission he noticed the gradual onset weakness of both upper extremities as well as slowly progressive involuntary neck flexion. At this point, a bone scan revealed increased uptake of the fourth, fifth, and sixth cervical vertebrae. Magnetic resonance imaging demonstrated severe cord compression at the midcervical level. Physical examination at the time of admission indicated a middle-aged man who was ambulatory with a spastic gait. His neck was held in complete flexion and he was unable to extend it. He was afebrile with stable vital signs. There was marked tenderness of the midcervical spine. Neurologic examination demonstrated pronounced weakness with 0/5 strength inthe biceps and 1/5 strength in the deltoids bilaterally. Lower extremity examination showed minimal weakness and increased tone. Upper extremity reflexes were diminished bilaterally; the lower extremities had significant hyper-reflexia with sustained clonus. Toes were upgoing. Sensation was intact and rectal tone was normal. Lab data showed a moderately elevated white blood cell count with a normal differential. Chest xray was normal and lateral cervical spine x-rays demonstrated complete collapse of the fourth and fifth cervical vertebrae, with angulation at that level. The MOST likely diagnosis is:
    A. pyogenic vertebral osteomyelitis
    B. metastatic prostate cancer
    C. epidural hematoma
    D. nasopharyngeal carcinoma with contiguous spread
    E. osteoblastama

Answer 2

A. pyogenic vertebral osteomyelitis

Question 3

80. A 54-year-old man was in excellent health until 1 month prior hospital admission when he developed acute severe neck pain after bending over to pick up a newspaper. He went to the emergency room where plain x-rays showed only mild arthritic changes. Over the next 4 weeks he saw multiple physicians from different fields and had various therapies including rest, analgesics, and physical therapy, without relief. One week prior to admission he noticed the gradual onset weakness of both upper extremities as well as slowly progressive involuntary neck flexion. At this point, a bone scan revealed increased uptake of the fourth, fifth, and sixth cervical vertebrae. Magnetic resonance imaging demonstrated severe cord compression at the midcervical level. Physical examination at the time of admission indicated a middle-aged man who was ambulatory with a spastic gait. His neck was held in complete flexion and he was unable to extend it. He was afebrile with stable vital signs. There was marked tenderness of the midcervical spine. Neurologic examination demonstrated pronounced weakness with 0/5 strength inthe biceps and 1/5 strength in the deltoids bilaterally. Lower extremity examination showed minimal weakness and increased tone. Upper extremity reflexes were diminished bilaterally; the lower extremities had significant hyper-reflexia with sustained clonus. Toes were upgoing. Sensation was intact and rectal tone was normal. Lab data showed a moderately elevated white blood cell count with a normal differential. Chest xray was normal and lateral cervical spine x-rays demonstrated complete collapse of the fourth and fifth cervical vertebrae, with angulation at that level. The MOST likely diagnosis is:81. The BEST initial therapy for the patient described in question 80 would be:
    A. Gardner-Wells tongs followed by a computed tomography-guided biopsy
    B. Gardner-Wells tongs followed by elective surgery
    C. immediate operative decompression with methylmethacrylate reconstruction
    D. immediate operative decompression with autologous bone reconstruction
    E. high-dose methylprednisolone and radiation therapy

Answer 3

D. immediate operative decompression with autologous bone reconstruction

Question 4

82. In degenerative lumbar spondylosis, stenosis of the lateral recess is most to be caused by:
    A. the inferior medial aspect of the inferior facet of the vertebral body above the disc
    B. hypertrophied ligamentum flavum
    C. a deficient pars interarticularis
    D. the superior medial aspect of the superior facet of the vertebral body below the disc
    E. a laterally bulging intervertebral disc

Answer 4

D. the superior medial aspect of the superior facet of the vertebral body below the disc

Question 5

84. A 12-year-old boy presented with a history of generalized headache and a 3-month history of episodic unresponsiveness. The episodes were often preceded by a sense of anxiety and lasted several minutes each. His neurologic examination was normal. The magnetic resonance image shown in Figure 84A was obtained. Which of the following statements is TRUE?
    A.Cyst peritoneal shunting is not an acceptable treatment.
    B. The primary abnormality is failure of the temporal lobe to develop.
    C. The most likely diagnosis is arachnoid cyst.
    D. Craniotomy for complete removal of the mass and epileptic focus is indicated.
    E. The most likely diagnosis is epidermoid tumor.

Answer 5

C. The most likely diagnosis is arachnoid cyst.

Question 6

85. A 25-year-old man presents with interscapular pain, hypalgesia below T6 and a spastic paraparesis that has progressed in severity for 1.5 years. The magnetic resonance image shown in Figure 85 was obtained. Which of the following treatments is indicated?
    A. biopsy and chemotherapy if high-grade astrocytoma is found
    B. syrinx to pleural shunt
    C. gross removal ependymoma or low-grade glioma is found
    D. gross removal and radiation if ependymoma is found
    E. empiric radiation

Answer 6

C. gross removal ependymoma or low-grade glioma is found

Question 7

86. A 54-year-old man with chronic hypertension requiring medication presents with a 6-year history of involuntary twitching on the left side of his face and a 2-month history of left facial pain. The facial movements had evolved from twitching of the palpebral part orbicularis oculi into spasmodic contractions of most of the muscles about the left eye and cheek. His facial pain is lancinating in nature, precipitated by touching a trigger zone in the orbital temporal region, and radiating superolaterally from above his left eye in the distribution of the supraorbital nerve. Except for mild weakness of the facialmuscles, his neurologic exam is normal. A magnetic resonance image is obtained (seeFigure 86). Which of the following statements is TRUE?A. Tic convulsive may antecede more extensive facial dystonias
    B. Endovascular treatment may improve the patient’s symptoms.
    C. An attempt at microvascular decompression is contraindicated
    D. A trial of carbamazepine is warranted.
    E. The mass is best approached by a transoral transclival route.

Answer 7

D. A trial of carbamazepine is warranted.

Question 8

87. A 54-year-old man with severe rheumatoid arthritis presents with a 1-week history of progressively increasing midthoracic back pain. He also complains of occasional paresthesia in both anterior thighs with ambulation. His only medication is prednisone, 10 mg/day, which has been taking for 15 years. Examination reveals pain to percussion over the spinous processes of T5-9, associated with paraspinal spasm in the same distribution. Neurologic exam is completely normal, including rectal tone and perianal sensation. Plain radiographs show osteoporosis with compression fractures at T6 and T8 and approximately 30%loss of vertebral body height at both levels. A computed tomographic is obtained and shows an extradural mass extending from T4-10. There is anterior displacement of the spinal cord. Attenuation numbers of the mass suggest fat. The most appropriate and treatment would be:
    A. blood, urine, and sputum cultures followed by emergent thoracic laminectomy and initiation of broad spectrum antibiotics
    B. magnetic resonance imaging with gadolinium enhancement, pancultures, urgent thoracic larninectomy,and broad spectrum anti biotics
    C. Thoracolumbar sacral orthosis bracing, short-term increase in prednisone dosage for cord compression
    D. MRI with gadolinium,tapering dose of steroids, and rheumatology consult
    E. urgent thoracic vertebrectomy T6-8 with sturt grafting followed by thoracic laminectomy with spinal instrumentation

Answer 8

D. MRI with gadolinium,tapering dose of steroids, and rheumatology consult

Question 9

83. A 62-year-old man with a 3-month history of progressive spastic cervical myelopathy had a metrizamide computed tomographic scan (Figure 83). All scan slices from C3-5, have the same appearance. Which the following statements is TRUE ?
    A. The tumor is most likely an osteochondroma
    B. A chest CT scan is indicated to rule out metastatic spread
    C. Postoperative radiation, but not chemotherapy, is indicated D. Multilevel medial corpectomy and interbody fusion are indicated
    E. Calcification of an extrude disc fragment is seen.

Answer 9

D. Multilevel medial corpectomy and interbody fusion are indicated

Question 10

There are myriad etiologies of lesions in the pediatric and young adult population. Match each disease or lesion in questions 88-92, with the most appropriate clinical, pathologic, or radiographic feature listed in A-E. Some answers may be used more than once:
A. colonic polyposis, epidermal inclusion cysts
B. “pearlyt” cysts
C. Birbeck granule
D. radiating spicules of bone
E. midline predisposition88. Hand-Schuller-Christian disease

Answer 10

C. Birbeck granule

Question 11

There are myriad etiologies of lesions in the pediatric and young adult population. Match each disease or lesion in questions 88-92, with the most appropriate clinical, pathologic, or radiographic feature listed in A-E. Some answers may be used more than once:
A. colonic polyposis, epidermal inclusion cysts
B. “pearlyt” cysts
C. Birbeck granule
D. radiating spicules of bone
E. midline predisposition89. osteomas

Answer 11

A. colonic polyposis, epidermal inclusion cysts

Question 12

There are myriad etiologies of lesions in the pediatric and young adult population. Match each disease or lesion in questions 88-92, with the most appropriate clinical, pathologic, or radiographic feature listed in A-E. Some answers may be used more than once:
A. colonic polyposis, epidermal inclusion cysts
B. “pearlyt” cysts
C. Birbeck granule
D. radiating spicules of bone
E. midline predisposition90. Metastatic neuroblastoma

Answer 12

D. radiating spicules of bone

Question 13

There are myriad etiologies of lesions in the pediatric and young adult population. Match each disease or lesion in questions 88-92, with the most appropriate clinical, pathologic, or radiographic feature listed in A-E. Some answers may be used more than once:

Answer 13

D. radiating spicules of bone

Question 14

There are myriad etiologies of lesions in the pediatric and young adult population. Match each disease or lesion in questions 88-92, with the most appropriate clinical, pathologic, or radiographic feature listed in A-E. Some answers may be used more than once:A. colonic polyposis, epidermal inclusion cystsB. “pearlyt” cystsC. Birbeck granuleD. radiating spicules of boneE. midline predisposition92. Epidermoid

Answer 14

B. “pearlyt” cysts

Question 15

93. A 60-year-old woman with non-Hodgkin lymphoma is diagnosed as having lymphomatous meningitis following a lumbar puncture. Which of the following are associated with this complication of her disease? a. L5 radiculopathyb. focal seizures, ataxiac. facial nerve palsyd. decreased CSF levels of B-2 microglobulin\

Answer 15

a. L5 radiculopathyb. focal seizures, ataxiac. facial nerve palsy

Question 16

94. Which of the following statements regarding brain stem auditory evoked potentials(BAEPs) are TRUE (Figure 94 A) ? a. Waves I and II generated in the vestibulocochlear (VIII) nerve.b. Signal averaging computers must be used to detect this signal.c. BAEPs are useful in preventing deafness as a complication of posterior fossa surgery.d. BAEPs are very resistant to general anesthesia

Answer 16

a. Waves I and II generated in the vestibulocochlear (VIII) nerve.b. Signal averaging computers must be used to detect this signal.c. BAEPs are useful in preventing deafness as a complication of posterior fossa surgery.d. BAEPs are very resistant to general anesthesia

Question 17

95. Which of the following statements regarding Creutzfeldt-Jakob disease are m e ? a. It is rapidly progressive and death usually occurs within year of onset.b. The recognition of spongiform degeneration is central to the pathologic process.c. Distinct changes in the EEG sharacterize the diseased. The agent responsible for transmission can be inactivated by autoclaving or formalin fixation.

Answer 17

a. It is rapidly progressive and death usually occurs within year of onset.b. The recognition of spongiform degeneration is central to the pathologic process.c. Distinct changes in the EEG

Question 18

96. A 34-year-old man presents to the emergency room with a complaint of acute visual loss in his right eye. It is thought that he has retrobulbar optic neuritis. Which of the following would cast doubt on that diagnosis?a.periocular painb. a Marcus Gunn pupilc . normal optic nerve headd. constriction of the visual field in the affected eye

Answer 18

Bukan semua

Question 19

97. A 19-year-old man presents with complaints of unquenchable thirst. Physical examination remarkable bitemporal hemianopia, and evidence of panhypopituitarism. A complete craniospinal MRI is obtained which demonstrates a densely enhancing mass in the suprasellar region. A stereotactic biopsy is performed. Frozen sections are remarkable for large, round, neoplastic cells intermixed with smaller lymphocytes. The following statements regarding this tumor are TRUE: a. Complete craniospinal radiation is usually required.b. Serum levels of placental alkaline may be elevated.c. This is the most common site of origin for this tumor.d. The biopsy specimen may have contained noncaseating granulomas

Answer 19

a. Complete craniospinal radiation is usually required.b. Serum levels of placental alkaline may be elevated.c. This is the most common site of origin for this tumor.d. The biopsy specimen may have contained noncaseating granulomas

Question 20

98. Which of the following statements BEST characterize neurosarcoidosis? a. Evidence of systemic involvement is found in the vast majority of patients.b. Cerebrospinal fluid findings are specific and all patients with suspected neurosarcoidosis should have a lumbar puncture performed.c. A facial nerve palsy is the most frequent manifestation.d. Seizures are a common occurrence.

Answer 20

a. Evidence of systemic involvement is found in the vast majority of patients.c. A facial nerve palsy is the most frequent manifestation.

Question 21

99. A 30-year-old cosmetician presents with a complaint of unequal pupils. She noted the asymmetry at work today, but cannot be certain how long it has been present. There are no complaints of headache or facial pain. Examination of the globe and fundus are normal. The right pupil measures 7 mm,has no direct or consensual reaction to light. The left pupil measures 7 mm and has no direct or consensual reaction to light. Visual acuity is 20/20 OU. Visual fields and color vision are normal. The right eye shows an incomplete and slow constriction while fixating on a near object. It dilates to 7mm upon changing fixation to a distant object, but this too is slow. response of the left eye to near-far fixation is normal. When is instilled into the right eye, the pupil responds after 15-30 minutes. The remainder of the neurologic exam is normal. The MOST likely diagnosis in this case is:A. deaffereanted pupilB. toxic pupilC. paralytic pupilD. Adie’s pupilE. Argyll Robertson pupil

Answer 21

D. Adie’s pupil

Question 22

100. Which of the following statements regarding the diencephalic syndrome is FALSE?A. The responsible lesion is usually a tumor of the anterior hypothalamus and/or the optic chiasmB. Soft tissue x-rays show a complete absence of subcutaneous fat.C. Other signs of hypothalamic or visual system disease are often absent.D. Serum levels of growth hormone are depressed.E. Nystagmus may be the first sign of the neurologic nature of the syndrome.

Answer 22

D. Serum levels of growth hormone are depressed.

Question 23

101. A 3-year-old child presents visual loss in the right eye. She has acuity of less than 20/100 ODand 20/20 OS. Visual fields on the left are normal. She has no hydrocephalus,no diabetes insipidus, and no endocrine abnormalities. Magnetic resonance imaging shows a 2,5cm irregular lesion in the suprasellar region extending into the anterior third. Portions enhance with gadolinium. There is no calcification on computed scan, At surgery, under microscope left optic nerve and chiasm are normal and the right optic nerve is barely discernible over the surface of the tumor. A frozen section is interpreted as a low-grade fibrillary astrocytoma. At this juncture the most satisfactory decision would be to:A. be sure that there is sufficient tissue for permanent sections, close, and plan to give radiation therapyB. carry out an intracapsular excision of the tumor and plan to give radiation therapyC. carry out an intracapsular subtotal excision of the tumor and withhold adjuvant therapy for documented progressionD. open the optic foramen on the right, sacrifice the right optic nerve from globe to chiasm, and carry out a radical tumor removalE. perform a radical resection by taking the right half of the chiasm and the right optic nerve to a point 1 cm anterior to identifiable tumor

Answer 23

C. carry out an intracapsular subtotal excision of the tumor and withhold adjuvant therapy for documented progression

Question 24

102. A 38-year-old female patient presented with a history of headaches for 3 years and spastic paraparesis for a month. Computed tomography with contrast enhancement revealed a large parasagital homogeneous mass with hyperostosis of the parietal bones. Bilateral selective external and internal carotid angiography was done, prior the preoperative embolization. What in the angiogram (Figure 102) makes embolization much more hazardous than usual?A. persistent trigeminal arteryB. persistent hypoglossal arteryC. aberrant ophthalmic arteryD. aberrant middle meningeal arteryE. aberrant anterior meningeal artery

Answer 24

C. aberrant ophthalmic artery

Question 25

103. A 53-year-old right-handed businessman was taken by his wife to a physician. Although the patient admitted to no specific probIem, he did state that he “hadn’t felt well for months.” The wife noted that the patient had been progressively more disorganized, had been distracted, failed to report towork and had significant memory failure over a period of months. On examination, the patient had a stiff neck and photophobia. He was disoriented as to his location, although he knew who he was and knew the approximatedate. Spinal tap revealed lymphocytic pleocytosis (4351mm3). GIucose was 50 mg%and protein was 100 mg%. Oligoclonal bands were not noted. The gamma globulin fraction was markedly elevated. His gadoIinium-enhanced magnetic resonance image is shown in Figure103A. Human immunodeficiency (HIV) tiers were negative. Serum Lyme titer was negative. Spinal fluid Lyme titer was positive for IgM and for IgG was negative. FTA was positive in the serum but not in the cerebrospinal fluid.antigen was negative. The MOST likely diagnosis is a chronic meningitis secondary to:A. Lyme diseaseB. HIVC. tuberculosisD. herpesE. syphilis

Answer 25

A. Lyme disease

Question 26

104. A 24-year-old female was seen in consultation for an abnormal head computed tomographic scan, obtained following a mild concussion with no sequelae, which revealed the incidental finding of an enhancing mass. The patient had no complaints and had a normal neurologic exam, including normal visual fields. Her past medical history was unremarkable , other than mild hypothyroidism, diagnosed many years earlier, for which she had originally taken thyroid replacement but had stopped about 2 years ago because it made her heart “race.”The CT scan is reviewed and shows an enhancing mass with 20 mm a vertical extension. The bony sella is not expanded. Her laboratory studies are as follows :Thyroxine 2.1 (normal 4.5-13)T3 52 (normal 90-225)T3 uptake 24.7%(normal 34-48)Prolactin 82 (normal 0-30)FSH NormalLH NormalGH NormalTSH >60 ( normal

Answer 26

D. start thyroid replacement, obtain a magnetic resonance image, and repeat endocrine studies in 2-3 months

Question 27

105. Intracranial pressure (ICP) monitoring is a well-accepted and frequently used component in the care of the severely head-injured patient. ICP monitoring, however, does have associated risks. Which of the following patients be MOST safely without managed ICP monitoring?A. a 65-year-old normotensive male with a Glasgow Coma Scale score of 8, normal pupillary examination, and a normal head computed tomographic scanB. a 21-year-old female with a GCS score of 7, a normal pupillary examination, a normal CT of the head, and 2 episodes of systolic blood pressure less than 90 HgC. a 39-year-old normotensive male with a score of 4, a normal pupillary examination, and a normal CT scan of the headD. an 18 year old normotensive female with GCS score of 8, normal pupil, and CT scan of the head showing compressed cisterns without mass lesionE. a 31-year-old normotensive male with a score 6 (no abnormal motor response, a normal pupillary examination, a normal CT scan of the head and a blood alcohol level of 310 mg%.)

Answer 27

E. a 31-year-old normotensive male with a score 6 (no abnormal motor response, a normal pupillary examination, a normal CT scan of the head and a blood alcohol level of 310 mg%.)

Question 28

106. Halo immobilization is frequently utilized in the treatment of odontoid fractures. Certain factors, however, can reliably predict nonunion with this methodology. Which of the following patients should MOST strongly be considered for primary surgical management?A. a 35-year-old male with a Type II odontoid fracture showing anterior displacement of the fracture fragment of 2 mmB. a 51 year old female with a Type III odontoid fracture showing anterior displacement of the fracture fragment of 5 mmC. a 66-year-old with a Type II odontoid fracture showing a posterior displacement of the fracture fragment of 3mmD. a 39-year-old with a Type I odontoid fracture showing an anterior displacement of the fracture fragment of 5 mmE. a 20-year-old with a Type II odontoid fracture showing a posterior displacement of the fracture fragment of 3mm

Answer 28

C. a 66-year-old with a Type II odontoid fracture showing a posterior displacement of the fracture fragment of 3mm

Question 29

107. A previously healthy 12 year old black female sustained a large, spontaneous right intracerebral hemorrhage (Figure 107A). Following stabilization, an angiogram was obtained (Figure 107B) The MOST LIKELY cause of hemorrhage is:A. rupture of flow-related aneurysmB. moyamoya diseaseC. essential hypertensionD. vasculitisE. normal perfussion pressure breakthrough in an arterivenous malformation (AVM)

Answer 29

A. rupture of flow-related aneurysm

Question 30

108. Based on the natural history of this disease, its location and the of patient, the BEST treatment for the lesion identified in question 107 consists of:A. surgical clipping of the aneurysmB. conservative management with follow upC. steroid therapyD. surgical excision of the AVME. therapeutic followed by radiosurgery

Answer 30

E. therapeutic followed by radiosurgery

Question 31

109. An 18-year-old female presents with thoracic spine pain of 8 months duration. The patient is neurologically intact. Plain x-rays (Figure 109) and a CT myeiogram are obtained. These studies demonstrate:A. aneurysmal bone cystB. giant cell tumorC. chordomaD. hemangioma of boneE. vertebral tuberculosis

Answer 31

D. hemangioma of bone

Question 32

110. The vertebral lesion progresses and the patient in question 109 develops a myelopathy.The best treatment for this patient would be:A. radiation therapyB. decornpressive larminectomyC. embolizationD. curettage and external bracingE. vertebrectomy with reconstruction

Answer 32

E. vertebrectomy with reconstruction

Question 33

111. A 30-year-old 70 kg male is 2 weeks status post-clipping of an anterior communicating artery aneurysm. He has become progressively lethargic. Laboratory values are Na 122, K 4.8, Cl 98,glucose 140, creatinine 0.9, serum ossmolarity 250, urine osmolarity 500, urine sodium 170, urine volume 90 ml/hr, central venous pressure 4 mmHg. The MOST likely diagnosis is:A. syndrome of inappropriate antidiuretic hormoneB. hypovolemic shockC. cerebral salt wastingD. mannitol therapyE. Addison’s disease

Answer 33

C. cerebral salt wasting

Question 34

112. The most useful value in distinguishing SIADH from cerebral salt wasting due to atrial natriuretic secretion is:A. serum sodiumB. serum osmolarityC. serum chlorideD. central venous pressureE. creatinine

Answer 34

D. central venous pressure

Question 35

A 30-year-old 70 kg male is 2 weeks status post-clipping of an anterior communicating artery aneurysm. He has become progressively lethargic. Laboratory values are Na 122, K 4.8, Cl 98,glucose 140, creatinine 0.9, serum ossmolarity 250, urine osmolarity 500, urine sodium 170, urine volume 90 ml/hr, central venous pressure 4 mmHg113. The preferred treatment for the condition identified in question 111 is:A. salt restrictionB. water restrictionC. saline hydrationD. Hypertonic salineE. steroids

Answer 35

C. saline hydration

Question 36

114. An 1 8-year-old driver wearing a seat belt is involved in a motor vehicle accident. On presentation he complains of back pain. The patient is neurologically intact. The injury is demonstrated by plain x-rays (Figure 114A) and reformatted computed tomography (Figures 114B,C). The mechanism of injury is most likely:A, axial compressionB. axial rotationC. flexion-distractionD. extensionE. Translation

Answer 36

C. flexion-distraction

Question 37

115. A 52-year-old female with deforming erosive generalized rheumatoid arthritis is seen for evaluation of neck pain, facial pain and an ataxic gait disorder. She has horizontal nystagmus bilaterally on her ocular exam, a mild quadriparesis and bouth truncal and extremity ataxia. Her magnetic resonance image is shown in Figure 115. The NEXT step should be:A. posterior cervical dccompression, consisting laminectomy C1,C2, and a suboccipital craniectomyB. transoral excision of the odontoidC. halo traction and subsequent placement in a halo vest for cervical immobilizationD. cervical traction E. cervical traction and subsequent posterior occipital cervical fusion

Answer 37

D. cervical traction

Question 38

116. Optimum initial management of victims of severe closed head injury without intracranial mass lesions includes: a. maintaining normal intravascular volumeb. maintaining normal-arterial pC02c. keeping the head midlined. administering intravenous fluids with high dextrose content

Answer 38

a. maintaining normal intravascular volumeb. maintaining normal-arterial pC02c. keeping the head midline

Question 39

117. A victim of a high-speed motor vehible accident who is rendered comatose is; a. more likely to have an intracranial mass lesion than a victim of low velocity blunt injury.b. most likely to have a large intracranial hemorrhage if hypotension is present.c. more likely to have a higher GCS score immediately after the injury than 1 hour laterd. more likely have diffuse axonal injury than a victim of low velocity blunt trauma.

Answer 39

d. more likely have diffuse axonal injury than a victim of low velocity blunt trauma.

Question 40

118. Elevation of an open depressed skull fracture is indicated for : a. cosmetic deformitiesb. improving neurologic functionc. reducing the risk of central nervous system infectiond. reducing risk for seizures

Answer 40

a. cosmetic deformitiesc. reducing the risk of central nervous system infection

Question 41

119. Which of the following compounds have been shown to play an important role in secondary brain injury following head trauma? a. H2O2.OHb. glutamatec. lactic acidd. alanine

Answer 41

a. H2O2.OHb. glutamatec. lactic acid

Question 44

120. Following severe closed head injury, cerebral blood (CBF) is: a. typically abnormally low during the first few hours after injury, and increases over the next 2-3 daysb. uniformly reduced by 3% to 4% per torr decrease in arterial pCO2 with little regional variationc. usually the major contributor to brain swelling by the third day after injuryd. not affected by barbiturates

Answer 44

a. typically abnormally low during the first few hours after injury, and increases over the next 2-3 daysc. usually the major contributor to brain swelling by the third day after injury

Question 45

121. While cooking dinner a healthy 42-year-old woman felt a sudden “snap” in her neck and had the onset of severe posterior cervical and left shoulder pain. With the onset pain, she reported “seeing stars.” When examined 5 days later she still complained of left neck and shouider pain made worse when turning in any direction. Neurologic examination was normal. The cervical magnetic resonance image is shown in Figure 121. The origin of this patient’s pain involves which of the following structures:A. boneB. discC. blood vesselD. spinal cordE. facet joint

Answer 45

C. blood vessel

Question 46

122. A 47-year-old woman with neuralgia is treated with carbamazepine. After 3 months of treatment with good relief of pain, her white blood count is 2300 and Her platelet count is 10.000. Liver enzymes are mildly elevated, The neurosurgeon MOST APPROPRIATE response would be to;A. stop carbamazepine therapy and switch DilantinB. stop Carbamazepine and advise operationC. continue carbamazepine with repeat lab studies every 2-4 weeksD. continue carbamazepine in decreased dosesE. continue carbamazepine after discussing the situation in detail with the patient, with lab studies every 3-6 months, or sooner if alarming symptoms develop

Answer 46

E. continue carbamazepine after discussing the situation in detail with the patient, with lab studies every 3-6 months, or sooner if alarming symptoms develop

Question 47

123. A 24-year-old man undergoes a cervical lymph node biopsy by a general surgeon. Postoperatively he is have an injury to the spinal accessory nerve. Which one of the following statement is trueA. The resulting impairment will be mild.B. The prognosis for spontaneous recovery is good.C. The nerve is most vulnerable to injury along the upper one third of the anterior border of the sternomastoid muscle.D. Exploration and possible grafting should be considered if there is no sign of recovery of function in 3 months.E. Athletic trauma is the most common cause of spinal accessory nerve injury.

Answer 47

D. Exploration and possible grafting should be considered if there is no sign of recovery of function in 3 months.

Question 48

124. A 50-year-old undergoes Iiver transplantation for cirrhosis. On the fourth postoperative day he becomes lethargic, tremulous, and experiences visual hallucinations. Several days later all of his extremities are weak and he appears to be in a state of akinetic mutism. His pupils are equal and reactive. A T2-weighted magnetic resonance image shows diffuse areas of increased intensity in the white matter of the cerebral hemisfer and brain stem. The most appropriate therapy for this patient would be to:A. stop phenothiazine antiemetics and give intravenous anticholinergicsB. stop cyclosporineC. start anticoagulants for cardiac emboli if verified on transesophageal echocardiographyD. lower serum ammoniaE. treat hyponatremia slowly

Answer 48

B. stop cyclosporine

Question 49

125. A 32-year-old woman has bad headaches 2 to 4 times per months, lasting several hours to several days. Her pain is bilateral and has a pressing, nonthrobbing quality. She has no nausea or vomiting with the headache, but sometimes experiences mild photophobia. Routine movement, such as walking stairs, does not aggravate her pain. She will usually cancel her appointments when the headaches occur. According to the International Headache Society Classification(1998)the most appropriate diagnosis ofher headache would be:A. cluster headacheB. episodic tension type headacheC. Classic migraineD. common migraineE. tumor type headache

Answer 49

B. episodic tension type headache

Question 50

126. For which of the following primary brain tumors of childhood is the extent of resection believed to be an important prognostic factor? a. ependymoma of the fourth ventricleb. fibrillary astrocytoma of the hemispherec. medulloblaastomad. chiasmatic glioma

Answer 50

a. ependymoma of the fourth ventriclec. medulloblaastoma

Question 51

127. Which of the following signs are associated with a poor prognosis in newborns withbirth injuries of the brachial plexus? a. Horner’s syndromeb. obliteration of cortical somatosensory evoked potentials with preservation of sensory nerve conductionc. pseudomeningocele formationd. failure of recovery of palpable muscle contractions in the biceps and deltoid within three months

Answer 51

a. Horner’s syndromeb. obliteration of cortical somatosensory evoked potentials with preservation of sensory nerve conductionc. pseudomeningocele formationd. failure of recovery of palpable muscle contractions in the biceps and deltoid within three months

Question 52

128. Which of the following statements concerning birth injuries of the brachial plexus are TRUE? a. Nerve root avulsion at C5 and C6 levels are common lesions in severe cases.b. Despite paralysis of limb musculature, osseous development proceeds normally.c. Injuries of the upper plexus are associated with selective weakness of the suscapularis leading eventually to limited active and passive internal rotation of glenohumeral jointd. rupture of the upper trunk is a common lesion in severe cases

Answer 52

d. rupture of the upper trunk is a common lesion in severe cases

Question 53

129. A full term infant with a vertex presentation underwent a precipitous delivery by means of a vacuum extractor. The patient had been stable for 18 hours when she began to exhibit intermittent bradycardia and apneic spells. The fontanelle was tense and a T1W MRI was obtained ( figure 129). Which of the following statements is true? a. the patients has a cephalohematoma.b. .the patients has acute hydrocephalusc. the patients has a posterior fossa subdural hematomad. . the patients has a caput succedaneum

Answer 53

a. the patients has a cephalohematoma.b. the patients has acute hcpc. the patients has a posterior fossa subdural hematoma

Question 54

130. Which of the following are NOT relevant in the pathogenesis of meningioma ?A. deletion of chromosome 22B. expression of the cis oncogeneC. smoking excessivelyD. neurofibromatosisE. previous low-level radiation to the head

Answer 54

C. smoking excessively

Question 55

131. The following statements about Cushing’s disease are true EXCEPT:A. Cushing’s disease is caused by an adrenocorticotrophic hormone (ACTH) secreting pituitary adenomaB. It may be difficult to differentiate from alcoholism or depression.C. It may present with vertebral body fracture.D. It can be excluded with a normal gadolinium-enhanced magnetic resonance image.E. Surgical treatment can result in approximately an 80% cure rate.

Answer 55

D. It can be excluded with a normal gadolinium-enhanced magnetic resonance image.

Question 56

132. Which of the following statements regarding moyamoya disease is FALSE?A. It is characterized by stenosis of the internal carotid artery.B. It usually presents with hemorrhage in children.C. It is associated with Factor VIII deficiency.D. Intimal thickening of the pancreatic arteries is occasionally seen.E. Women are more commonly affected than men.

Answer 56

B. It usually presents with hemorrhage in children.

Question 57

133. Which of the following is NOT a feature of Friedreich’s ataxia?A. familialB. ScoliosisC. Pes cavusD. onset in early mid 30’sE. mental status changes

Answer 57

D. onset in early mid 30’s

Question 58

134. Important factors in the secondary injury after spinal cord damage include all of the following EXCEPT:A. arachidonic acis cascadeB. calcium influxC. lipid peroxidationD. hypertensionE. bradykinin

Answer 58

D. hypertension

Question 59

135. Which of the following statements regarding ophthalmic segment aneurysms is FALSE?A. They comprise approximately 5% of all aneurysms.B. There is a female predominance.C. There is a greater incidence of multiplicity and bilaterally than with other aneurysms.D. They may present with hemorrhage or visual symptoms.E. They are usually small (

Answer 59

E. They are usually small (

Question 60

136. A 67-year-old normotensive right-handed woman presents with headache, then evolving over 10 hours. On examination, she is lethargic, purposefully moving her right side more than her left side. Brain stem reflexes are intact. Computed tomographic scan shows a multilobulated 4x4 cm hemorrhage in the right parietal lobe, with a small amount of overlying subdural blood. There is no enhancement with the addition of contrast material. In the emergency room she develops an anisocoria and increased left-sided weakness. The MOST likely cause of this hemorrhage is:A. hypertensionB. ruptured arteriovenous malformationC. ruptured aneurysmD. amyloid angiopathyE. trauma

Answer 60

D. amyloid angiopathy

Question 61

137. The BEST management of the patient in question 136 would be:A. intubation, hyperventilation, diuresis and pressure monitoringB. angiography followed by craniotomyC. urgent craniotomyD. no therapy, if the family agrees, because her prognosis is so poorE. acute medical management with later definitive radiosurgery

Answer 61

C. urgent craniotomy

Question 62

138. Which of the following statements regarding amyloid angiopathy is FALSE?A. The cardinal clinical manifestation of arnyloid angiopathy is dementia.B. Hematomas from arnyloid angiopathy tend to be “lobar,” especially near the cortical surfaces of the occipital and parietal areas.C. The amyloid is a proteinaceous compound deposited in the walls of cerebral and leptomeningeal vessels.D. Familial forms of the disease have not been described,E. A green yellow birefringence can be noted when affected vessel stained with Congo red is visualized under polarized light

Answer 62

D. Familial forms of the disease have not been described,

Question 63

139. Which statement regarding craniosynostosis is TRUE’!A. Increased radioisotope activity along a suture is diagnostic of craniosynostosisB. There is a female preponderance in sagittal synostosis.C. Increased bone growth parallel to the fused suture is the rule.D. Lambdoisd synostosis is the most common cause of posterior plagiocephalyE. Sagittal synostosis is frequently part of a recognizable syndrome.

Answer 63

C. Increased bone growth parallel to the fused suture is the rule.

Question 64

140. Middle cerebral artery (MCA)aneurysms accounts for 20% of all intracranial aneurysms. With regard to these aneurysms, which of the following is TRUE?A. Giant aneurysms are rare in this location,B. Ischemic symptoms such as transient ischemic attacks (TIA)are sometimes associated.C. Vasospasme is very common, compared to other aneurysms.D. These aneurysms areless likely than others to be associated with seizures.E. A superior temporal gyrus approach is particularly for proximally located MCA aneurysms.

Answer 64

B. Ischemic symptoms such as transient ischemic attacks (TIA)are sometimes associated.

Question 65

141. A 28-year-old right-handed white male is admitted to the neurosurgical service after a rollover motor vehicle accident. He is neurologically normal. Further examination reveals drainage of clear fluid the right ear. Which of the following statements is ‘TRUE?A. Fracture lines transverse to the long axis of the petrous pyramids commonly result in otorrheaB. Meningitis in this patient would be unexpected, as it only occurs in 1% to 2% of patients with traumatic CSF leaks.C.Leakage will most likely spontaneously stop within a weekD. Immediate surgery for repair of the CSF leak should be undertakenE. A glucose level in the fluid of 10mg% would be highly suggestive of CSF

Answer 65

C.Leakage will most likely spontaneously stop within a week

Question 66

142. With regard to cerebrospinal fluid leaks, which of the following is TRUE?A.Nontraumatic CSF leakage is rarely due to a tumorB.CSF flow is greater in traumatic leaks than in nontraumatic leaks.C. Risks of infection are greater in spontaneous leaks than in traumatic leaks.D. Spontaneous cessation of leakage may occur in as many as onethird of nontraumatic casesE. In spontaneous rhinorrhea, leakage through the cribriform plate itself is seen rarely

Answer 66

D. Spontaneous cessation of leakage may occur in as many as onethird of nontraumatic cases

Question 67

143. A 59-year-old patient presents with back pain radiating to the left flank and abdomen. A plain lumbar film reveals enlargement of the T12-L1 foramen on the left. Which of the following statements is TRUE?A. Pathology results will likely show Antoni A and Antoni B tissue.B. The patient probably is a female.C. The patient probably is a male.D. A search of primary tumor is indicatedE. This lesion is found more in the cervical region

Answer 67

A. Pathology results will likely show Antoni A and Antoni B tissue.

Question 68

144. Which of the following findings suggest shunting will improve a patient with idiopathic adult communicating hydrocephalus?A. evidence of cerebrovascular disease on radiographic studiesB. a history of gait disturbance preceding disturbance in mentationC. slowing on EEGD. absence of B waves or high pressure peaks during intracranial pressure monitoringE. none of the above

Answer 68

B. a history of gait disturbance preceding disturbance in mentation

Question 69

145. Which of the following statements regarding medulloblastoma are TRUE? a. There is a 2: 1 male predominance.b. The peak age of occurrence is 8 years.c. True rosettes are seen on pathologic examination.d. Hydrocephalus is a late finding.

Answer 69

a. There is a 2: 1 male predominance.b. The peak age of occurrence is 8 years.c. True rosettes are seen on pathologic examination.

Question 70

146. Angiographis vasospasm is present in up to what percent of patients subarachnoid hemorrhage?A. 10%B. 25%C. 50%D. 75%E. 100 %

Answer 70

D. 75%

Question 71

147. Signs of vasospasm include all of the following EXCEPT:A. feverB. meningitisC. lethargyD. seizuresE. Hypernatremia

Answer 71

E. Hypernatremia

Question 72

148. Which transcranial Doppler velocity in the middle cerebral artery correlates best with the presence of severe angiographic vasospasm?A. 20 cm/secB. 50 cm/secC. 100 cm/secD. 150 cm/secE. 200 cm/sec

Answer 72

E. 200 cm/sec

Question 73

149. In clinical trials nimodipine has been demonstrated to:A. decrease the incidence of angiographic vasospasm when compared to placebo controlsB. decrease the incidence of delayed ischemic neurologic deficits when compared with placebo controlsC. increase cerebral blood flow in patients having vasospasmD. have high incidence of induced hypotension with usageE. eliminate the need of hypervolemic hypertensive therapy

Answer 73

B. decrease the incidence of delayed ischemic neurologic deficits when compared with placebo controls

Question 74

150. Current management of clinically active cerebral vasospasm should include:A. nimodipine, 60 mg PO q4h ,B. hypervolemic hemodilution to improve the rheologic characteristics of the cerebral circulationC. reduction of intracranial pressure to promote cerebral blood flowD. Angioplasty in medically refractory casesE. All of the above

Answer 74

E. All of the above

Question 75

151. The major disadvantage of radiosurgery in the treatment of artericrvennus malformations( AVMs) is :A. lack of study with long term follow upB. the rarity of total obliteration of the AVMC. the high rate of neurologis complicationsD. the lack of efficacy in smalI lesionE. the long latency between traetment and subsequent obliteration of the AVM

Answer 75

E. the long latency between traetment and subsequent obliteration of the AVM

Question 76

152. The MOST common cause of neurologic symptoms in AIDS is:A. viral encephalitisB. toxoplasmosisC. central nervous system lymphomaD. herpes encephalitisE. progressive multifocal leukoencepahalopaty

Answer 76

A. viral encephalitis

Question 77

153. Factors affecting biopsy decisions in HIV-positive patients with cerebral lesions include:A.lesions enhancementB. state of systemic diseaseC . responsive to an antibiotics therapy for toxoplasmosisD. Karnofsky scoreE. all of the above

Answer 77

E. all of the above

Question 78

154. HIV positive patients with cerebral lesions LATE in their illness should:A. he treated with an empiric toxoplasmosis antimicrobial therapy if the lesion enhanceB. undergo stereotactic biopsy if the lesion enhancesC. undergo biopsy if the lesion does not enhanceD. receive supportive careE. be treated for progressive multifocal leukoencepalopathy

Answer 78

B. undergo stereotactic biopsy if the lesion enhances

Question 79

155. A 21-year-old female patient with a 6 months history of galactorrhea and amenorrhea is referred for evaluation. Other than a 30 lb weight gain she has no other symptoms. A serum prolactin is 359. Possible explanations for this elevation include:A. pituitary stalk compressionB. stressC. pituitary adenomaD. hypothyroidismE. all of the above

Answer 79

C. pituitary adenoma

Question 80

156. The patient in question 155 undergoes magnetic resonance (Figure 156). Treatment options:A. differ from those for microadenomaB. are affected by the possibility of pregnancyC. may not be likely to result in cureD. include transphenoidal surgeryE. include all of the above

Answer 80

E. include all of the above

Question 81

A. H-reflexB. F WaveC. nerve conduction velocity (NCV)D. electromyogramE. Somatosensory evoked potentials(SSEPs)157. will reveal fibrillations or fasciculatians if denervation is present

Answer 81

D. electromyogram

Question 82

A. H-reflexB. F WaveC. nerve conduction velocity (NCV)D. electromyogramE. Somatosensory evoked potentials(SSEPs)158. abnormalities reflected by increased “latencies”

Answer 82

C. nerve conduction velocity (NCV)

Question 83

A. H-reflexB. F WaveC. nerve conduction velocity (NCV)D. electromyogramE. Somatosensory evoked potentials(SSEPs)159. generated by antidromic stimulation of the motoneuron pool

Answer 83

B. F Wave

Question 84

A. H-reflexB. F WaveC. nerve conduction velocity (NCV)D. electromyogramE. Somatosensory evoked potentials(SSEPs)160. can be recorded from peripheral nerve, spinal cord, or brain

Answer 84

E. Somatosensory evoked potentials(SSEPs)