Neurology Practice Questions

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: 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: Which of the following is incorrect about the condition shown below?

Most common CT finding is intraventricular calcification. ***Most common CT finding is intraventricular calcification*** - This statement is **incorrect**. In neurocysticercosis, the most common CT finding is **parenchymal calcifications**, which represent the remnants of dead cysts, rather than intraventricular calcifications. - **Intraventricular calcifications** are possible but less frequent than parenchymal lesions and often arise from degenerating intraventricular cysts leading to obstructive hydrocephalus. *Most common presentation is partial seizures* - This statement is **correct**. **Partial seizures** (also known as focal seizures) are indeed the most common clinical presentation of neurocysticercosis, especially when **parenchymal cysts** are involved. - This is due to the cysts acting as a **focal irritant** within the cerebral cortex, leading to abnormal electrical activity. *Albendazole is given for 8 days* - This statement is **correct**. For neurocysticercosis, **Albendazole** is typically administered for a duration ranging from **8 days to 30 days**, depending on the number, location, and stage of the cysts. - The precise duration can vary based on clinical response and cyst resolution observed on follow-up imaging. *Steroids help in alleviating vasogenic oedema of ring enhancing lesion* - This statement is **correct**. **Corticosteroids**, such as dexamethasone, are frequently co-administered with anti-parasitic drugs like albendazole to manage the **inflammatory response** (vasogenic edema) caused by the dying parasites. - This edema often surrounds the **ring-enhancing lesions** seen on imaging and can exacerbate symptoms like seizures and headaches.

Q: A 15-year-old boy presented with day dreaming and decline in school performance. EEG shows.

Typical absence seizure. ***Typical absence seizure*** - The clinical presentation of **daydreaming** and decline in school performance in a 15-year-old is classic for absence seizures. - The EEG shows a characteristic **generalized 3 Hz spike-and-wave discharge**, which is pathognomonic for typical absence seizures. *Atonic seizure* - Characterized by a **sudden loss of muscle tone**, leading to falls, often referred to as "drop attacks." - EEG in atonic seizures often shows **polyspike-and-wave discharges** or generalized slow waves, but not the 3 Hz spike-and-wave pattern. *Myoclonic seizure* - Involves **brief, shock-like jerks** of a muscle or group of muscles, without loss of consciousness. - EEG typically shows **generalized polyspike-and-wave discharges** or fast spike-and-wave activity, which differs from the 3 Hz pattern. *Atypical absence seizure* - Clinical features include a **less abrupt onset and termination** of altered consciousness, often accompanied by changes in muscle tone. - EEG shows **slower spike-and-wave complexes (typically 1.5-2.5 Hz)** and more heterogeneous patterns than typical absence seizures.

Q: Which of the following is true regarding type of seizures shown in EEG?

Hyperventilation often precipitates an attack. ***Hyperventilation often precipitates an attack*** - The EEG shows a classic **3-Hz spike-and-wave pattern**, which is characteristic of **absence seizures**. - **Hyperventilation** is a common and effective activation procedure used during EEG recordings to **induce or exacerbate absence seizures**, making them more apparent. *Attack lasts for 60 to 90 seconds* - **Absence seizures** are typically brief, usually lasting only **5 to 30 seconds**, much shorter than the 60-90 seconds stated. - Longer seizures, especially those with postictal confusion, are more characteristic of **complex partial seizures** or **tonic-clonic seizures**. *Onset of disease in the first year of life* - **Childhood absence epilepsy** typically has an onset between **4 and 8 years of age**, with a peak around 5-6 years. - Seizures appearing in the first year of life would suggest other epilepsy syndromes, such as ** infantile spasms** or severe myoclonic epilepsy in infancy (Dravet syndrome). *Attack followed by postictal confusion* - Absence seizures are classic for **lacking a postictal period**; the individual typically resumes activity immediately after the seizure ends without confusion or disorientation. - **Postictal confusion** is a hallmark feature of **tonic-clonic seizures** and often complex partial seizures, indicating a more widespread and prolonged disruption of brain activity.

Q: A patient presents with facial deviation to the right, inability to close the left eye with Bell's sign, and unclear ability to produce wrinkles on the forehead based on the image. What is the most likely diagnosis?

Left lower motor neuron (LMN/peripheral) lesion. ***Left lower motor neuron (LMN/peripheral) lesion*** - Facial deviation to the **right** indicates weakness of the **left facial muscles**, as the unaffected right side pulls the face toward it. - Complete involvement of **forehead muscles** (inability to wrinkle forehead) along with **Bell's sign** indicates a **peripheral/LMN lesion** affecting the entire facial nerve. *Left upper motor neuron (UMN/central) lesion* - **Central lesions** typically **spare forehead muscles** due to bilateral cortical innervation of the upper facial muscles. - Would not cause complete facial paralysis including forehead involvement as seen in this case. *Right lower motor neuron lesion* - A **right-sided lesion** would cause facial deviation to the **left**, not to the right as described. - The clinical presentation clearly indicates **left-sided facial weakness**, not right-sided. *Right upper motor neuron lesion* - Would cause facial deviation to the **left side**, opposite to what is observed in this patient. - **Central lesions** spare the forehead due to **bilateral cortical representation**, which contradicts the forehead involvement seen here.

Q: The following diagram and its branches should be remembered. The blood vessel involved in medial medullary syndrome is anterior spinal artery.

Choice B: Anterior spinal artery. ***Choice B: Anterior spinal artery*** - The **anterior spinal artery** supplies the medial medulla, and its occlusion leads to **medial medullary syndrome**. - This syndrome is characterized by contralateral hemiparesis (due to involvement of the pyramidal tract), contralateral loss of proprioception and vibratory sensation (due to medial lemniscus involvement), and ipsilateral tongue deviation (due to hypoglossal nerve nucleus involvement).

Q: Which of the following is characteristic of Parinaud's syndrome?

Dorsal midbrain lesion. ***Dorsal midbrain lesion*** - Parinaud's syndrome, also known as the **dorsal midbrain syndrome**, is characterized by a constellation of symptoms resulting from damage to the **tectal plate** and **pretectal area** of the midbrain. - This damage often affects the **superior colliculi** and adjacent structures, impairing **vertical gaze** and **pupillary reflexes**. *Ventral midbrain lesion* - Lesions in the **ventral midbrain** typically affect the **substantia nigra** and **cerebral peduncles**, causing different symptoms. - This location would result in **parkinsonian features** or **hemiparesis**, not the characteristic eye movement abnormalities of Parinaud's syndrome. *Pontine lesion* - Pontine lesions commonly cause **horizontal gaze palsy** and **internuclear ophthalmoplegia**, not vertical gaze dysfunction. - The **paramedian pontine reticular formation (PPRF)** controls horizontal eye movements, distinct from the vertical gaze control in the midbrain. *Thalamic lesion* - Thalamic lesions typically cause **altered consciousness**, **memory deficits**, or **sensory disturbances**. - While some thalamic lesions can affect eye movements, they don't produce the specific **upward gaze paralysis** and **light-near dissociation** seen in Parinaud's syndrome.

Q: The EEG of a 16-year-old boy with early morning involuntary movements of hands in his sleep noticed by parents, was performed. Immunization is complete. What does EEG show? (Recent NEET Pattern 2016-17)

Juvenile myoclonic epilepsy. ***Juvenile myoclonic epilepsy*** - The EEG shows generalized **polyspike-and-slow-wave discharges**, which are characteristic of juvenile myoclonic epilepsy (JME), especially when associated with early morning myoclonus. - The clinical presentation of a **16-year-old boy** with **involuntary movements of hands in his sleep** (suggesting myoclonic jerks), particularly in the morning, is highly consistent with JME. *SSPE* - Subacute sclerosing panencephalitis (SSPE) typically presents with characteristic EEG patterns like **Radermacker complexes** or **periodic complexes**, which are not seen here. - Clinical features of SSPE include progressive cognitive decline, myoclonus, and other neurological deficits, usually following a measles infection, which are not described. *Benign rolandic epilepsy* - Benign rolandic epilepsy (BRE) is characterized by **centrotemporal spikes** on EEG, often exacerbated by sleep, and presents with focal seizures affecting the face and mouth. - The generalized polyspike-and-slow-wave pattern and the clinical description of hand myoclonus do not fit the profile of BRE. *Huntington chorea* - Huntington's chorea is a **neurodegenerative genetic disorder** characterized by involuntary movements (chorea), cognitive decline, and psychiatric problems. - EEG findings in Huntington's chorea are often non-specific or show generalized slowing, and it is not an epilepsy syndrome with specific high-amplitude epileptiform discharges like those seen.

Question 1

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 2

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 3

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 4

Which of the following is incorrect about the condition shown below?

Accepted Answer

Most common CT finding is intraventricular calcification

Answer

Most common presentation is partial seizures

Answer

Albendazole is given for 8 days

Answer

Steroids help in alleviating vasogenic oedema of ring enhancing lesion

Question 5

A 15-year-old boy presented with day dreaming and decline in school performance. EEG shows.

Accepted Answer

Typical absence seizure

Answer

Atonic seizure

Answer

Myoclonic seizure

Answer

Atypical absence seizure

Question 6

Which of the following is true regarding type of seizures shown in EEG?

Accepted Answer

Hyperventilation often precipitates an attack

Answer

Attack lasts for 60 to 90 seconds

Answer

Onset of disease in the first year of life

Answer

Attack followed by postictal confusion

Question 7

A patient presents with facial deviation to the right, inability to close the left eye with Bell's sign, and unclear ability to produce wrinkles on the forehead based on the image. What is the most likely diagnosis?

Accepted Answer

Left lower motor neuron (LMN/peripheral) lesion

Answer

Right upper motor neuron lesion

Answer

Left upper motor neuron (UMN/central) lesion

Answer

Right lower motor neuron lesion

Question 8

The following diagram and its branches should be remembered. The blood vessel involved in medial medullary syndrome is anterior spinal artery.

Accepted Answer

Choice B: Anterior spinal artery

Answer

Choice A

Answer

Choice C

Answer

Choice D

Question 9

Which of the following is characteristic of Parinaud's syndrome?

Accepted Answer

Dorsal midbrain lesion

Answer

Ventral midbrain lesion

Answer

Thalamic lesion

Answer

Pontine lesion

Question 10

The EEG of a 16-year-old boy with early morning involuntary movements of hands in his sleep noticed by parents, was performed. Immunization is complete. What does EEG show? (Recent NEET Pattern 2016-17)

Accepted Answer

Juvenile myoclonic epilepsy

Answer

SSPE

Answer

Benign rolandic epilepsy

Answer

Huntington chorea

Neurology — MCQs

Neurology — MCQs

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