Neurology Practice Questions

Q: A 35-year-old man presents with daily headache. He describes two attacks per day over the last 3 weeks. Each attack lasts about an hour and awakens him from sleep. The patient has noticed associated tearing and reddening of the right eye as well as nasal stuffiness. The pain's deep, excruciating, and limiting to the right side of the head. The neurological examination is normal. What is the most likely diagnosis?

Cluster headache. ***Cluster headache*** - This classic presentation includes **daily, brief, severe unilateral headache attacks** often accompanied by **autonomic symptoms** (tearing, redness of eye, nasal stuffiness) and occurring in "clusters" over weeks [1]. - The pain is typically **excruciating** and often **wakes the patient from sleep**, fitting the described symptoms [1]. *Migraine headache* - While migraines can be severe, they are typically **longer-lasting** (4-72 hours) and often associated with **nausea, vomiting, photophobia, and phonophobia**, which are not mentioned here [3]. - Though unilateral, migraine pain is usually **pulsating** rather than the "deep, excruciating" quality described in cluster headache. *Brain tumour* - A brain tumour would likely present with **progressive neurological deficits**, such as focal weakness, seizures, or changes in mental status, which are absent in this case as the neurological exam is normal [4]. - Headaches associated with brain tumours are generally **progressive and persistent**, not episodic with distinct attack patterns and autonomic features like in cluster headache [2]. *Tension headache* - Tension headaches are typically described as a **mild to moderate, dull, aching pain** that feels like a band around the head, and they are usually **bilateral** [2]. - They lack the **autonomic features** and the severe, stabbing, unilateral pain characteristic of cluster headaches.

Q: Inability to abduct left eye with LMN fascial palsy on same side. The lesion is in

Left pons. ***Left pons*** - A lesion in the **left pons** can affect both the **left abducens nucleus** (leading to inability to abduct the left eye) and the **left facial nucleus or nerve fibers** (causing left lower motor neuron facial palsy). [2] - This specific combination of ipsilateral (same-sided) symptoms is characteristic of a brainstem lesion, particularly within the pons where these cranial nerve nuclei are in close proximity. [1] *Cerebellar lesions* - **Cerebellar lesions** primarily cause symptoms like **ataxia**, dysmetria, and nystagmia, but typically do not cause isolated cranial nerve palsies of the abducens and facial nerves. [1] - While coordinating movements, the cerebellum does not house the nuclei for direct eye abduction or facial muscle control. *CP angle tumor* - A **cerebellopontine (CP) angle tumor** can affect cranial nerves VI and VII, but it typically presents with other symptoms like **vestibulocochlear nerve (VIII) dysfunction (hearing loss, vertigo)** early on due to its anatomical location. - While it can eventually compress the abducens and facial nerves, the combination of **isolated abducens and facial palsy** without VIII nerve involvement points more directly to an intraparenchymal pontine lesion. *Right pons* - A lesion in the **right pons** would cause **right-sided inability to abduct the eye** and **right-sided LMN facial palsy**, not left-sided as described in the case. - Brainstem lesions typically produce ipsilateral cranial nerve deficits due to the close proximity of the nuclei and fascicles before decussation of some pathways.

Q: A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans two or three times a month would provide complete relief. Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement. Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a "pain shot." The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?

Medication overuse headache. The patient's history of increasing headache frequency and severity, decreased response to triptans, and frequent use of combination analgesics (acetaminophen, caffeine, butalbital) strongly suggests **medication overuse headache (MOH)**. This condition is characterized by daily or near-daily headaches in a patient with a primary headache disorder, caused or exacerbated by **chronic excessive use of acute headache medications** [1]. **CNS vasculitis** is less likely given the long history of headaches starting in menses (suggesting a primary headache disorder) [2]. While it can cause headaches, CNS vasculitis typically presents with acute or subacute onset of various neurological deficits. **Space-occupying intracerebral lesion** is unlikely given the normal neurological examination and absence of papilledema [2]. Headaches due to brain tumors often worsen over time, but are typically associated with other neurological signs or symptoms, such as focal deficits, which are not present here.

Q: Two or more oligoclonal bands in cerebrospinal fluid are most often positive in-

Multiple sclerosis. Multiple sclerosis - The presence of two or more oligoclonal bands (OCBs) in the cerebrospinal fluid (CSF) is a hallmark finding in multiple sclerosis (MS), indicating intrathecal immunoglobulin synthesis [1]. - OCBs are found in over 90% of MS patients, reflecting a chronic inflammatory process within the central nervous system [1]. Acute bacterial meningitis - CSF analysis in acute bacterial meningitis typically shows elevated white blood cell count (neutrophils), decreased glucose, and elevated protein, but not characteristic OCBs [2]. - While there may be a generalized immune response, it does not typically produce the specific, persistent OCB pattern seen in MS. Subarachnoid hemorrhage - CSF findings in subarachnoid hemorrhage are characterized by xanthochromia (yellow discoloration due to bilirubin), red blood cells, and elevated protein, but OCBs are not a diagnostic feature [2]. - OCBs are related to intrathecal immunoglobulin production, not the breakdown products of blood. Polyneuropathy - Polyneuropathies, such as Guillain-Barré syndrome, are characterized by albuminocytological dissociation (elevated protein with normal cell count) in CSF, or other findings depending on the specific cause. - While some inflammatory neuropathies can have CSF abnormalities, they do not typically present with the same diagnostic pattern of OCBs as observed in MS.

Q: True about juvenile myoclonic epilepsy - a) Focal seizure b) Generalised seizure c) Myoclonus d) Responses to Sodium Valproate e) Spike and waves in EEG

bcde. ***bcde*** - **Juvenile Myoclonic Epilepsy (JME)** is a form of **generalized epilepsy**, meaning it affects both sides of the brain from the onset [1]. - The hallmark feature of JME is **myoclonic seizures**, characterized by brief, shock-like jerks, often most prominent in the mornings [2]. It also responds well to **Sodium Valproate** and shows characteristic **spike and wave discharges** on EEG [2]. *abcd* - This option is partially correct as it includes generalized seizure, myoclonus, and response to Sodium Valproate, but incorrectly includes focal seizure and omits the characteristic EEG findings. - **Focal seizures** are inconsistent as JME is a generalized epilepsy syndrome [1]. *abde* - This option incorrectly states JME involves **focal seizures** and omits **myoclonus**, which is the defining seizure type in this syndrome [2]. - While JME does respond to Sodium Valproate and shows spike and waves, the inclusion of focal seizures and exclusion of myoclonus make this choice incorrect. *acde* - This option incorrectly includes **focal seizure** as a feature of JME, which is a generalized epilepsy. - While myoclonus, response to Sodium Valproate, and spike and waves are characteristic, the inclusion of focal seizure renders this option incorrect. *abce* - This option incorrectly includes **focal seizure** as a characteristic of JME, which is a **generalized** epilepsy. - It also omits the mention of responses to Sodium Valproate, a key pharmacological aspect of JME management [2].

Q: A 26-year-old woman complains of early fatigue and weakness in doing strenuous activity. Her symptoms are worse near the end of the day. She appears well, muscle bulk, tone, and reflexes are normal. Handgrip strength decreases with repetitive testing.For the above patient with muscle weakness, select the most likely anatomic site for the disorder

neuromuscular junction. ***neuromuscular junction*** - The **fatigability** and **end-of-day worsening** of weakness, along with the **decreased handgrip strength with repetitive testing**, are classic signs of **myasthenia gravis**, a disorder of the neuromuscular junction [1], [2]. - In myasthenia gravis, **acetylcholine receptor antibodies** block or destroy receptors at the neuromuscular junction, impairing nerve-to-muscle signal transmission [3]. *muscle* - Primary muscle disorders (myopathies) typically present with **proximal muscle weakness** but do not usually show the characteristic **fatigability with repetitive use** or end-of-day worsening. - Muscle bulk, tone, and reflexes would often be affected in significant primary muscle disease. *peripheral nerve* - Peripheral nerve disorders (neuropathies) usually cause **sensory changes** (tingling, numbness) along with motor weakness, and often present with **diminished reflexes**. - The distinguishing feature of **fatigability with repetitive testing** is not typical of peripheral neuropathies. *anterior horn cell* - Anterior horn cell disorders, such as **amyotrophic lateral sclerosis (ALS)**, cause progressive weakness, muscle atrophy, and fasciculations. - While they cause weakness, they typically do not exhibit the significant **day-to-day fluctuation** or **fatigability with repetitive use** described.

Q: Which of the following grading methods is used to evaluate the prognosis/outcome after subarachnoid hemorrhage

Hess and Hunt scale. ***Hess and Hunt scale*** - The **Hess and Hunt scale** is specifically designed to grade the severity of **subarachnoid hemorrhage (SAH)** based on clinical presentation [1]. - It correlates with the patient's **prognosis** and the risk of complications like re-bleeding and cerebral vasospasm [1][2]. *Intracerebral hemorrhage score* - This score, often referred to as the **ICH score**, is used to predict **mortality** after **intracerebral hemorrhage (ICH)**, not SAH. - It considers factors like Glasgow Coma Scale (GCS) score, age, ICH volume, and location. *Glasgow-Blatchford bleeding score* - This score is used for **upper gastrointestinal bleeding** to assess the need for intervention and predict **mortality**. - It evaluates parameters such as hemoglobin, blood pressure, urea, and comorbidities. *Glasgow coma scale* - The **Glasgow Coma Scale (GCS)** is a universal neurological assessment tool used to measure a person's level of **consciousness** [2]. - While it's a component of the Hess and Hunt scale, it is not a specific grading system for the prognosis of subarachnoid hemorrhage itself.

Q: Myasthenia gravis may be associated with:

Thymoma. ***Thymoma*** - Approximately 10-15% of patients with **myasthenia gravis** (MG) have an associated **thymoma**, a tumor of the thymus gland [1]. - The thymus gland plays a crucial role in the development of T-cells and can be involved in the production of **autoantibodies** that target acetylcholine receptors in MG. *B lymphocyte dysfunction* - While MG is an **autoimmune disease** characterized by autoantibodies produced by **B cells**, "B lymphocyte dysfunction" is a general statement and not the most specific or common association as an underlying cause or specific comorbidity. - The dysfunction is the result of the autoimmune process, not typically the initiating association. *Viral infection* - While certain **viral infections** can trigger or exacerbate autoimmune conditions, there isn't a direct or consistently strong association between a specific viral infection and the development of myasthenia gravis as a primary cause. - MG typically involves a more systemic autoimmune response targeting the **neuromuscular junction**. *Drug intake* - Some medications can *exacerbate* myasthenia gravis, or induce a myasthenia-like syndrome (e.g., **aminoglycosides**, **beta-blockers**, **magnesium**). - However, drug intake is generally not considered a primary *cause* or a common associated comorbidity that develops *with* myasthenia gravis in the same way a thymoma is.

Q: Most common symptom of Wernicke's encephalopathy

Confusion. ***Confusion*** - **Confusion** is the most common symptom of **Wernicke's encephalopathy**, occurring in over 80% of cases. - It presents as a state of altered mental status, ranging from mild disorientation to profound encephalopathy [1]. *Ocular changes* - **Ocular changes**, such as **nystagmus** and **ophthalmoplegia**, are common but present in less than 30% of patients. - While being a classic triad component, they are not the most frequently observed symptom [1]. *Ataxia* - **Ataxia**, characterized by difficulty with coordination and gait, is also part of the classic triad but occurs in less than 25% of cases [1]. - It often manifests as a wide-based, unsteady gait. *Hypothermia* - **Hypothermia** can occur in severe cases of Wernicke's encephalopathy due to **hypothalamic dysfunction**, but it is not a common presenting symptom. - It is often seen in more advanced or neglected instances of the disease.

Q: Fasciculation is seen in -

LMN type of lesion. ***LMN type of lesion*** - **Fasciculations** are spontaneous, visible twitchings of muscle bundles, indicative of **lower motor neuron (LMN) pathology** [1]. - They result from the **denervation hypersensitivity** of muscle fibers that have lost their normal nerve supply, leading to spontaneous firing [1]. *Peripheral neuropathy* - While some severe peripheral neuropathies can involve LMN damage, **fasciculations** are not a primary and consistent feature across all types. - Peripheral neuropathies often present with sensory symptoms, weakness, and **diminished reflexes** without prominent fasciculations unless there is significant axonal loss. *UMN type of lesion* - **Upper motor neuron (UMN)** lesions are characterized by spasticity, **hyperreflexia**, positive Babinski sign, and **no fasciculations** [1], [2]. - UMN lesions affect motor pathways in the brain and spinal cord *above* the anterior horn cells, so the direct innervation of muscle fibers remains intact [2]. *Myoneural junction* - Disorders of the **myoneural junction** (neuromuscular junction), such as myasthenia gravis, cause muscle weakness that fatigues with sustained effort. - These conditions do not typically cause **fasciculations**; instead, they might feature **fatigability** and **ptosis**, but not spontaneous muscle twitches.

Question 1

A 35-year-old man presents with daily headache. He describes two attacks per day over the last 3 weeks. Each attack lasts about an hour and awakens him from sleep. The patient has noticed associated tearing and reddening of the right eye as well as nasal stuffiness. The pain's deep, excruciating, and limiting to the right side of the head. The neurological examination is normal. What is the most likely diagnosis?

Accepted Answer

Cluster headache

Answer

Migraine headache

Answer

Brain tumour

Answer

Tension headache

Question 2

Inability to abduct left eye with LMN fascial palsy on same side. The lesion is in

Accepted Answer

Left pons

Answer

Cerebellar lesions

Answer

CP angle tumor

Answer

Right pons

Question 3

A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans two or three times a month would provide complete relief. Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement. Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a "pain shot." The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?

Accepted Answer

Medication overuse headache

Answer

CNS vasculitis

Answer

Status migrainosus

Answer

Space-occupying intracerebral lesion

Question 4

Two or more oligoclonal bands in cerebrospinal fluid are most often positive in-

Accepted Answer

Multiple sclerosis

Answer

Acute bacterial meningitis

Answer

Subarachnoid hemorrhage

Answer

Polyneuropathy

Question 5

True about juvenile myoclonic epilepsy - a) Focal seizure b) Generalised seizure c) Myoclonus d) Responses to Sodium Valproate e) Spike and waves in EEG

Accepted Answer

bcde

Answer

abcd

Answer

abde

Answer

acde

Answer

abce

Question 6

A 26-year-old woman complains of early fatigue and weakness in doing strenuous activity. Her symptoms are worse near the end of the day. She appears well, muscle bulk, tone, and reflexes are normal. Handgrip strength decreases with repetitive testing.For the above patient with muscle weakness, select the most likely anatomic site for the disorder

Accepted Answer

neuromuscular junction

Answer

muscle

Answer

peripheral nerve

Answer

anterior horn cell

Question 7

Which of the following grading methods is used to evaluate the prognosis/outcome after subarachnoid hemorrhage

Accepted Answer

Hess and Hunt scale

Answer

Intracerebral hemorrhage score

Answer

Glasgow-Blatchford bleeding score

Answer

Glasgow coma scale

Question 8

Myasthenia gravis may be associated with:

Accepted Answer

Thymoma

Answer

B lymphocyte dysfunction

Answer

Viral infection

Answer

Drug intake

Question 9

Most common symptom of Wernicke's encephalopathy

Accepted Answer

Confusion

Answer

Ocular changes

Answer

Ataxia

Answer

Hypothermia

Question 10

Fasciculation is seen in -

Accepted Answer

LMN type of lesion

Answer

Peripheral neuropathy

Answer

UMN type of lesion

Answer

Myoneural junction

Neurology — MCQs

Neurology — MCQs

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