Neurology Practice Questions

Q: Bell's palsy involves

Ipsilateral upper and lower halves of the face.. ***Ipsilateral upper and lower halves of the face.*** - **Bell's palsy** is the most common cause of **idiopathic peripheral (Lower Motor Neuron - LMN)** facial nerve paralysis [1]. - A peripheral (LMN) lesion affects the **entire distribution** of the facial nerve on the affected side, resulting in paralysis of all muscles, including those controlling the forehead and eye closure. - Facial nerve palsies affect the **ipsilateral** side of the face relative to the site of peripheral nerve injury or brainstem nuclear lesion. *Contralateral upper and lower halves of the face.* - This presentation would imply a **bilateral upper and lower facial paralysis**, which is highly unusual for a single lesion like Bell's palsy. - Facial nerve palsies affect the **ipsilateral** side of the face, not contralateral. *Ipsilateral lower half of the face.* - Paralysis limited to the **ipsilateral lower half of the face** while sparing the upper face (forehead) is characteristic of a **Central (Upper Motor Neuron - UMN)** lesion (like a stroke) located in the contralateral cortex [1]. - This does not define Bell's palsy, which is a **peripheral (LMN)** lesion affecting the entire face. *Contralateral lower half of the face.* - This pattern, involving **paralysis of the lower face contralateral** to the lesion while sparing the forehead, is the classic presentation of a **Central (Upper Motor Neuron - UMN)** lesion [1]. - UMN lesions spare the upper face because the **facial nerve nucleus** receives bilateral cortical input for the muscles of the forehead.

Q: A woman presents with a history of headaches for the past 9 months that worsen in a recumbent position and improves as the day progresses. She also gives a history of taking oral contraceptives. Fundal examination shows papilledema. There are no focal neurological deficits. What is the probable cause of her headaches?

Pseudotumor cerebri. ***Pseudotumor cerebri*** - The presentation of headache that worsens in the **recumbent position** (due to increased intracranial pressure, ICP) and improves when upright is highly characteristic of **Idiopathic Intracranial Hypertension (IIH)** [1]. - Confirmation of **papilledema** (swollen optic disc) in a young, likely obese female taking **oral contraceptives** (a risk factor) without other focal signs confirms the diagnosis of **pseudotumor cerebri** [1]. *Myasthenia gravis* - This disease is a neuromuscular disorder characterized by fluctuating **muscle weakness** (diplopia, ptosis, difficulty chewing) that worsens with activity and improves with rest. - It is not associated with primary headache or signs of increased intracranial pressure like **papilledema**. *Temporal arteritis* - This diagnosis is reserved for older patients (usually >50 years) presenting with severe localized headache, **jaw claudication**, tenderness over the temporal artery, and elevated inflammatory markers (ESR/CRP) [2]. - The positional nature of the headache and the patient's young age (implied by OCP use, a risk factor for IIH) make this diagnosis unlikely. *Chronic migraine* - Migraine is a diagnosis of exclusion that typically involves severe, often **pulsatile** headaches, sometimes with aura, photophobia, or nausea [3]. - While chronic migraine involves frequent headaches, it does not cause **papilledema** or have headaches classically exacerbated by the **recumbent position**, which points instead toward a structural or ICP-related etiology [2].

Q: A 26-year-old male with a history of respiratory tract infection 4 weeks ago is unable to stand or walk for the past 2 weeks and the weakness is progressive, ascending, and symmetrical in nature. The lower limbs were involved before and gradually the upper limbs were also affected. On examination you note areflexia. Pain and proprioception are preserved. What is the probable diagnosis?

Guillain Barre syndrome. ***Guillain Barre syndrome*** - **Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)** - most common GBS variant [1] - Classic presentation: **progressive, ascending, symmetrical weakness** starting in lower limbs [1] - **Areflexia** is a hallmark feature due to peripheral nerve involvement [1] - **Preceding infection** (respiratory or gastrointestinal) occurs in 60-70% of cases, typically 1-4 weeks prior [1] - **Preserved sensory examination** for pain and proprioception (though may have paresthesias) [1] - **Motor weakness predominates** over sensory symptoms [1] - Diagnosis confirmed by: CSF showing albuminocytologic dissociation, nerve conduction studies showing demyelination - Treatment: **IV immunoglobulin (IVIG)** or **plasmapheresis** *Myasthenia gravis* - Presents with **fatigable weakness**, worsens with activity - **Ocular and bulbar muscles** typically affected first (ptosis, diplopia, dysphagia) - **Reflexes are preserved** (not areflexia) - No ascending pattern of weakness - Positive acetylcholine receptor antibodies, abnormal repetitive nerve stimulation *Polymyositis* - **Proximal muscle weakness** (shoulder and hip girdle), not ascending pattern - **Subacute onset** over weeks to months (not acute 2 weeks) - **Elevated creatine kinase (CK)** levels - Reflexes typically preserved initially - Muscle biopsy shows inflammatory infiltrates *Multiple sclerosis* - **Relapsing-remitting pattern** with episodes separated in time and space - **Sensory symptoms prominent** (numbness, tingling, vision changes) - **Hyperreflexia** with upper motor neuron signs (not areflexia) - Does not present with acute ascending paralysis - MRI shows demyelinating plaques in CNS

Q: A young male patient presents with ptosis and muscle weakness, which reportedly worsens in the evening and improves in the morning. This is relieved by neostigmine. What is the likely diagnosis?

Myasthenia gravis. ***Myasthenia gravis***- The presentation of muscle weakness, specifically **ptosis**, that worsens with fatigue (evening) or activity and improves with rest (morning), is the classic hallmark of the autoimmune condition **Myasthenia Gravis (MG)**.- The dramatic improvement upon administration of **neostigmine** (an acetylcholinesterase inhibitor) is diagnostic, confirming impaired transmission at the **neuromuscular junction** due to autoantibodies against **acetylcholine receptors (AChR)** [1].*Huntington chorea*- This is a progressive, inherited neurodegenerative disorder primarily characterized by involuntary, jerky movements (**chorea**) and cognitive decline. - It is related to excessive CAG trinucleotide repeats on chromosome 4, leading to neuronal loss in the **caudate nucleus**, and does not respond to neostigmine.*Amyotrophic lateral sclerosis*- ALS is a motor neuron disease characterized by progressive and unrelenting weakness due to the loss of both **upper and lower motor neurons**.- The weakness in ALS is permanent, not fluctuating diurnally, and does not improve with acetylcholinesterase inhibitors like neostigmine.*External ophthalmoplegia*- This is a descriptive term referring to weakness or paralysis of the external eye muscles; while it is often seen in MG (where it is often called ocular MG), it is a symptom, not the overall diagnosis.- This term does not explain the generalized muscle weakness, the pattern of **fatigability**, or the characteristic response to **neostigmine**.

Q: Which of the following about lumbar puncture is incorrect?

Post-tap headache is more common in females and old age. ***Post-tap headache is more common in females and old age*** - **Post-dural puncture headache (PDPH)** is more common in **younger patients** (adolescents and young adults) and **females**. - The incidence decreases significantly with increasing age, making the statement that it is more common in **old age** incorrect. ***Urgent indication if suspected SAH with inconclusive CT*** - If a patient presents with a **thunderclap headache** suggestive of **Subarachnoid Hemorrhage (SAH)**, and the initial **CT scan is negative**, an urgent lumbar puncture is mandatory to rule out SAH (looking for **xanthochromia**) [1], [2]. - This confirms the diagnosis in up to 3% of patients with negative CT scans or those presenting late after symptom onset. ***Can be done in thrombocytopenia (platelet count >10,000 )*** - While the ideal platelet count for an LP is >50,000, LPs can often be safely performed with extreme caution in patients with platelets as low as **20,000 to 50,000**. - A platelet count of **>10,000** would typically be considered a relative contraindication unless the risk of **intracranial pathology** outweighs the risk of spinal hematoma, but the statement implies feasibility and is technically not the most incorrect option regarding general practice guidelines. ***Meningitis is an unusual complication*** - Post-procedural **bacterial meningitis** due to contamination is an extremely rare complication of lumbar puncture when standard sterile techniques are meticulously followed. - The risk is very low (often cited as less than 1 in 10,000 procedures), hence it is considered an **unusual complication**.

Q: Which is not true regarding the procedure done with the needle shown below?

Breath holding is not necessary. ***Breath holding is not necessary*** - This statement is **FALSE** - breath holding **IS necessary** during lumbar puncture to maximize **opening pressure** measurement and reduce **CSF pressure variations**. - Patients are typically instructed to hold their breath in **expiration** to minimize movement artifacts and obtain accurate pressure readings. *Coagulopathy is not an absolute contraindication* - This statement is **TRUE** - coagulopathy is considered a **relative contraindication**, not an absolute one for lumbar puncture. - The procedure can often be performed safely after **correcting clotting abnormalities** or with careful risk-benefit assessment and meticulous technique. *Bevel should be facing upwards while inserting the needle* - This statement is **TRUE** - the needle should be inserted with the **bevel facing upwards** (or laterally in lateral position) to minimize **dural trauma**. - This orientation allows dural fibers to **spread rather than cut**, reducing the risk of **post-dural puncture headache (PDPH)**. *To be done in lateral recumbent position* - This statement is **TRUE** - **lateral recumbent position** is one of the standard positions for lumbar puncture, especially for measuring **opening pressure** accurately. - Alternative **sitting position** may be used for obese patients or those with difficult anatomical landmarks, but lateral recumbent remains a correct approach.

Q: The following test is performed for evaluating the integrity of: (Recent NEET Pattern 2016-17)

Cerebellum. ***Cerebellum*** - The image depicts a person performing a **tandem gait** (walking heel-to-toe along a straight line), which is a common test for **cerebellar function**. - The cerebellum is critical for **coordination**, balance, and **fine motor control**, including the ability to maintain a straight path during walking. *Basal ganglia* - The basal ganglia are primarily involved in the **initiation and modulation of movement**, and their dysfunction leads to characteristic movement disorders such as **Parkinsonism (bradykinesia, rigidity, tremor)** or **Huntington's disease (chorea)**. - While gait can be affected in basal ganglia disorders (e.g., shuffling gait in Parkinson's), tandem gait specifically emphasizes balance and coordination more directly attributed to cerebellar function. *Corticospinal pathway* - The **corticospinal pathway** (pyramidal tract) is responsible for **voluntary, skilled movements**, particularly of the distal limbs. - Damage to this pathway typically results in **weakness (paresis)**, spasticity, and hyperreflexia, which would manifest as difficulty with initiating or executing movements rather than purely balance and coordination issues highlighted by tandem gait. *Spinothalamic pathway* - The spinothalamic pathway transmits **pain** and **temperature** sensations from the body to the brain. - Evaluating this pathway involves sensory testing (e.g., pinprick, hot/cold sensation), which is unrelated to the motor task of tandem walking.

Q: What is the drug of choice for this medical condition showing periventricular lesions?

β-interferon. ***β-interferon*** - The MRI image shows **periventricular white matter lesions** which are characteristic of **Multiple Sclerosis (MS)**. - **Beta-interferons (β-interferon)** are a cornerstone in the treatment of **relapsing-remitting multiple sclerosis (RRMS)**, acting as disease-modifying therapies to reduce the frequency and severity of relapses and slow disease progression. *α-interferon* - **Alpha-interferon (α-interferon)** is primarily used in the treatment of certain **cancers** and **viral infections** (e.g., hepatitis B and C), not for demyelinating diseases like MS. - It has a different spectrum of biological activities and clinical applications compared to beta-interferons. *□-interferon* - The option "□-interferon" is not a recognized or standard classification for interferon subtypes in medical or pharmaceutical contexts. - This option is likely a distractor and does not represent a known therapeutic agent for any condition, including MS. *Natalizumab* - **Natalizumab** is a highly effective disease-modifying therapy for MS, but it is typically reserved for patients with **highly active MS** or those who have responded inadequately to other treatments, such as beta-interferons. - While effective, it carries a risk of inducing **progressive multifocal leukoencephalopathy (PML)**, making it a second-line or escalated therapy rather than the initial drug of choice for MS.

Q: The MRI findings shown in the image are consistent with multiple sclerosis. All of the following drugs are useful for management of this patient EXCEPT:

Intravenous immunoglobulin. ***Intravenous immunoglobulin*** - The image shows multiple **periventricular and juxtacortical white matter lesions**, characteristic of **multiple sclerosis (MS)**. IVIG is generally not a first-line treatment or disease-modifying therapy for MS. - While IVIG is used for some autoimmune neurological conditions (e.g., Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy) and acute MS exacerbations in specific cases, it is not a standard long-term management drug for MS. *Methylprednisolone* - **High-dose intravenous methylprednisolone** is the standard treatment for acute exacerbations or relapses in multiple sclerosis to reduce inflammation and shorten the duration of an attack. - It helps to restore the **blood-brain barrier** integrity and reduce edema associated with active demyelinating lesions. *Fingolimod* - Fingolimod is an **oral disease-modifying therapy (DMT)** approved for relapsing forms of MS. - It works by trapping lymphocytes in lymph nodes, preventing them from entering the central nervous system and causing demyelination. *Mitoxantrone* - Mitoxantrone is an **antineoplastic agent** that also has immunosuppressant properties, approved for worsening relapsing-remitting, secondary progressive, and progressive-relapsing MS. - It is used in more **aggressive forms of MS** due to its potential for serious side effects, including cardiotoxicity.

Q: A 12-year-old boy presents with difficulty in noting from blackboard in school. Initially refraction error was considered but visual acuity was normal. He has started complaining of diplopia on watching TV or after studying for long. He takes very long time to finish his meals and his speech becomes very difficult to understand after speaking continuously for few minutes. All tests are indicated for diagnosis except?

Anti-TPO antibody. ***Anti-TPO antibody*** - This test measures antibodies against **thyroid peroxidase**, which are associated with autoimmune thyroid conditions like Hashimoto's thyroiditis. - The patient's symptoms (diplopia, dysphagia, dysarthria, fatigue worsening with activity) are highly suggestive of **myasthenia gravis**, not a primary thyroid disorder, making Anti-TPO antibodies **not indicated** for diagnosis. *Edrophonium test* - The **edrophonium (Tensilon) test** is a classic diagnostic tool for myasthenia gravis, where rapid, temporary improvement in muscle weakness is observed after intravenous administration of edrophonium. - This test is highly indicated due to the patient's fluctuating and fatigable muscle weakness affecting ocular, bulbar, and possibly limb muscles. *Single fiber EMG* - **Single fiber electromyography (SFEMG)** is considered the most sensitive diagnostic test for myasthenia gravis. - It detects increased **neuromuscular jitter and blocking**, which are characteristic findings in myasthenia gravis due to impaired neuromuscular transmission. *Nerve conduction velocity* - Standard **nerve conduction velocity (NCV)** studies are typically normal in myasthenia gravis as it is a disorder of the neuromuscular junction, not nerve conduction itself. - However, **repetitive nerve stimulation (RNS)**, a specialized electrodiagnostic study, shows a characteristic **decremental response** (>10% reduction in amplitude) and **is indicated** for diagnosis of myasthenia gravis. - In the context of this question, NCV likely refers to standard nerve conduction studies (which are less helpful), but electrodiagnostic testing including RNS is part of the diagnostic workup.

Question 1

Bell's palsy involves

Accepted Answer

Ipsilateral upper and lower halves of the face.

Answer

Contralateral upper and lower halves of the face.

Answer

Ipsilateral lower half of the face.

Answer

Contralateral lower half of the face.

Question 2

A woman presents with a history of headaches for the past 9 months that worsen in a recumbent position and improves as the day progresses. She also gives a history of taking oral contraceptives. Fundal examination shows papilledema. There are no focal neurological deficits. What is the probable cause of her headaches?

Accepted Answer

Pseudotumor cerebri

Answer

Myasthenia gravis

Answer

Temporal arteritis

Answer

Chronic migraine

Question 3

A 26-year-old male with a history of respiratory tract infection 4 weeks ago is unable to stand or walk for the past 2 weeks and the weakness is progressive, ascending, and symmetrical in nature. The lower limbs were involved before and gradually the upper limbs were also affected. On examination you note areflexia. Pain and proprioception are preserved. What is the probable diagnosis?

Accepted Answer

Guillain Barre syndrome

Answer

Myasthenia gravis

Answer

Polymyositis

Answer

Multiple sclerosis

Question 4

A young male patient presents with ptosis and muscle weakness, which reportedly worsens in the evening and improves in the morning. This is relieved by neostigmine. What is the likely diagnosis?

Accepted Answer

Myasthenia gravis

Answer

Huntington chorea

Answer

Amyotrophic lateral sclerosis

Answer

External ophthalmoplegia

Question 5

Which of the following about lumbar puncture is incorrect?

Accepted Answer

Post-tap headache is more common in females and old age

Answer

Urgent indication if suspected SAH with inconclusive CT

Answer

Can be done in thrombocytopenia (platelet count >10,000 )

Answer

Meningitis is an unusual complication

Question 6

Which is not true regarding the procedure done with the needle shown below?

Accepted Answer

Breath holding is not necessary

Answer

Bevel should be facing upwards while inserting the needle

Answer

To be done in lateral recumbent position

Answer

Coagulopathy is not an absolute contraindication

Question 7

The following test is performed for evaluating the integrity of: (Recent NEET Pattern 2016-17)

Accepted Answer

Cerebellum

Answer

Basal ganglia

Answer

Corticospinal pathway

Answer

Spinothalamic pathway

Question 8

What is the drug of choice for this medical condition showing periventricular lesions?

Accepted Answer

β-interferon

Answer

α-interferon

Answer

□-interferon

Answer

Natalizumab

Question 9

The MRI findings shown in the image are consistent with multiple sclerosis. All of the following drugs are useful for management of this patient EXCEPT:

Accepted Answer

Intravenous immunoglobulin

Answer

Methylprednisolone

Answer

Fingolimod

Answer

Mitoxantrone

Question 10

A 12-year-old boy presents with difficulty in noting from blackboard in school. Initially refraction error was considered but visual acuity was normal. He has started complaining of diplopia on watching TV or after studying for long. He takes very long time to finish his meals and his speech becomes very difficult to understand after speaking continuously for few minutes. All tests are indicated for diagnosis except?

Accepted Answer

Anti-TPO antibody

Answer

Edrophonium test

Answer

Single fiber EMG

Answer

Nerve conduction velocity

Neurology — MCQs

Neurology — MCQs

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