Neurology Practice Questions

Q: A 40-year-old woman presents with numbness and tingling in her hands and feet, progressive weakness, and areflexia. She has a recent history of an upper respiratory infection. Which condition is most likely?

Guillain-Barre syndrome. A 40-year-old woman presents with numbness and tingling in her hands and feet, progressive weakness, and areflexia. She has a recent history of an upper respiratory infection. Which condition is most likely? ***Guillain-Barre syndrome*** - The triad of **numbness and tingling** (sensory symptoms), **progressive weakness** (motor symptoms), and **areflexia** occurring after an upper respiratory infection is classic for **Guillain-Barre syndrome (GBS)** [1]. - GBS is an **acute demyelinating polyneuropathy** characterized by ascending paralysis, often preceded by an infection [1]. *Multiple sclerosis* - **Multiple sclerosis** typically presents with *disseminated lesions in space and time* affecting the central nervous system, leading to symptoms like *visual disturbances, ataxia, and spasticity*. - It does not usually present with **areflexia** or rapidly progressive ascending weakness following an infection. *Myasthenia gravis* - **Myasthenia gravis** causes *fluctuating muscle weakness* that worsens with activity and improves with rest, often affecting ocular, bulbar, and limb muscles. - It is characterized by *normal reflexes* and is not typically associated with sensory symptoms or a preceding infection as described. *Peripheral neuropathy* - While **peripheral neuropathy** can cause numbness, tingling, and weakness, the *rapid progression, ascending pattern,* and universal **areflexia** after a recent infection are more specific to Guillain-Barre syndrome [1]. - **Peripheral neuropathy** is a broad term, and while GBS is a type of acute peripheral neuropathy, the specific clinical context strongly points to GBS rather than a generic peripheral neuropathy.

Q: A patient with a lower motor neuron lesion affecting the facial muscles will likely exhibit weakness in which area of the face?

Entire unilateral. ***Entire unilateral*** - A **lower motor neuron (LMN) lesion** to the facial nerve (cranial nerve VII) results in weakness affecting **all muscles of facial expression** on the ipsilateral side [1]. - This is because the LMN directly innervates all facial muscles from the **nucleus of the facial nerve** in the pons, before it branches [2]. *Lower face* - Weakness isolated to the **lower face** is characteristic of an **upper motor neuron (UMN) lesion** (e.g., stroke) affecting the contralateral cortex [1]. - The forehead muscles receive bilateral cortical innervation, which spares the upper face in a UMN lesion [1]. *Upper face* - Isolated **upper face weakness** is rare and not typical for either UMN or LMN lesions affecting the facial nerve. - If present, it would suggest a highly specific and uncommon focal injury that spares the lower facial branches. *Entire bilateral weakness* - **Bilateral facial weakness** would indicate a lesion affecting **both facial nerves** or their nuclei. - This could be seen in conditions like **Guillain-Barré syndrome** or bilateral brainstem lesions, not a unilateral LMN lesion.

Q: In a patient with suspected bacterial meningitis, which cerebrospinal fluid finding is most indicative of the diagnosis?

High protein, low glucose, neutrophilic pleocytosis. ***High protein, low glucose, neutrophilic pleocytosis*** - **Elevated protein** and **low glucose** in the CSF are classic indicators of bacterial meningitis due to increased capillary permeability and bacterial metabolism of glucose [1]. - **Neutrophilic pleocytosis** (high white blood cell count with a predominance of neutrophils) is the hallmark of bacterial infection in the CNS, as neutrophils are the primary responders to bacteria [1]. *Low protein, normal glucose, lymphocytic pleocytosis* - This profile is more characteristic of **viral meningitis**, where protein levels may be normal or slightly elevated, glucose is typically normal, and lymphocytes predominate [1]. - The absence of significant protein elevation and glucose reduction, along with lymphocyte predominance, would argue against a bacterial etiology. *High protein, high glucose, eosinophilic pleocytosis* - While high protein can be seen in various conditions, **high glucose** in CSF rarely accompanies infection; rather, it often reflects a high blood glucose level without active consumption by pathogens. - **Eosinophilic pleocytosis** is rare and points towards parasitic infections, fungal infections, or drug reactions, not typical bacterial meningitis. *Normal protein, normal glucose, mononuclear pleocytosis* - **Normal protein and glucose** would generally rule out significant acute bacterial infection, as these parameters are usually altered in bacterial meningitis [2]. - **Mononuclear pleocytosis** (lymphocytes or monocytes) can be seen in viral, fungal, or chronic inflammatory conditions, but not typically in acute bacterial meningitis which is dominated by neutrophils [2].

Q: A 25-year-old man presents with recurrent episodes of severe, electric shock-like pain along the distribution of the V2 and V3 branches of the trigeminal nerve. Which condition is most likely?

Trigeminal neuralgia. Trigeminal neuralgia - This condition presents with **recurrent episodes of severe, electric shock-like pain** in one or more branches of the **trigeminal nerve (V, V2, V3)**, precisely matching the patient's symptoms. - The pain is typically brief, but intense, and can be triggered by light touch, chewing, or speaking. *Cluster headache* - Characterized by **excruciating unilateral pain**, usually around the eye or temple, along with autonomic symptoms like **lacrimation, rhinorrhea, and ptosis** [1]. - The pain is usually sustained for minutes to hours, not described as electric shock-like, and does not follow a trigeminal nerve distribution [1]. *Migraine* - Typically involves a **throbbing, unilateral headache** often accompanied by **nausea, vomiting, photophobia**, and phonophobia [3]. - While severe, migraine pain is not usually described as electric shock-like nor restricted to specific trigeminal nerve branches. *Temporomandibular joint disorder* - Causes pain in the **jaw, ear, or face**, especially with jaw movement, chewing, or yawning [2]. - The pain is generally a dull ache or discomfort, not an electric shock-like sensation, and does not follow a nerve distribution [2].

Q: A patient is diagnosed with a large posterior fossa tumor compressing the cerebellum. Which symptom is most likely to be present?

Ataxia. ***Ataxia*** - Compression of the **cerebellum** directly impairs its function, leading to **ataxia**, which is characterized by problems with **coordination**, **balance**, and **gait** [1]. - Tumors in the posterior fossa frequently manifest with cerebellar signs due to their proximity [1]. *Aphasia* - **Aphasia** is a language disorder resulting from damage to brain regions involved in language processing, typically in the **frontal** or **temporal lobes** (e.g., Broca's or Wernicke's areas), which are not located in the posterior fossa. - While large tumors can cause global effects, aphasia is not a primary or direct symptom of cerebellar compression. *Hemiparesis* - **Hemiparesis** (weakness on one side of the body) is typically caused by lesions affecting the **corticospinal tracts** in the motor cortex, brainstem, or spinal cord, usually above the level of the cerebellum. - Although general brainstem compression from a large posterior fossa tumor can eventually cause motor deficits, it is not the most direct or primary symptom of cerebellar involvement. *Seizures* - **Seizures** are often associated with lesions or irritations in the **cerebral cortex**, which are located in the supratentorial compartment of the brain, not primarily the posterior fossa or cerebellum [2][3]. - While any significant intracranial mass can potentially cause seizures, tumors specifically compressing the cerebellum are less likely to present with seizures as a primary symptom compared to cortical lesions [2].

Q: A 45-year-old male presents with progressive ataxia, dysarthria, and intention tremor. MRI shows demyelinating plaques in the cerebellum. What is the most likely diagnosis?

Multiple sclerosis. ### Multiple sclerosis - The combination of **progressive ataxia**, **dysarthria**, and **intention tremor** (Charcot's triad) is highly suggestive of **multiple sclerosis** (MS), especially when coupled with cerebellar involvement [1]. - **Demyelinating plaques** seen on MRI, particularly in the cerebellum, are a hallmark pathological finding in MS, indicating an inflammatory demyelinating process in the central nervous system [1]. *Amyotrophic lateral sclerosis* - **Amyotrophic lateral sclerosis** (ALS) primarily affects **motor neurons**, leading to progressive muscle weakness, atrophy, and fasciculations, with **sensory and cerebellar functions typically spared** [2]. - While patients may experience dysarthria due to bulbar involvement, the presence of prominent ataxia and intention tremor, along with documented demyelination, makes ALS an unlikely diagnosis. *Friedreich's ataxia* - **Friedreich's ataxia** is a **hereditary neurodegenerative disorder** that typically presents in childhood or adolescence with **progressive gait and limb ataxia**, dysarthria, and loss of reflexes. - Although it causes cerebellar dysfunction, it is a genetic condition typically presenting much earlier than 45 years of age, and the MRI findings would show **cerebellar atrophy**, not demyelinating plaques, which are characteristic of inflammatory conditions. *Cerebellar tumor* - A **cerebellar tumor** could account for symptoms like **ataxia** and **dysarthria** due to mass effect or direct tissue damage [2]. - However, an MRI would typically reveal a **space-occupying lesion** rather than diffuse demyelinating plaques, and intention tremor is less specific to a tumor compared to its prevalence in MS.

Q: What is the preferred initial treatment for a patient diagnosed with Parkinson's disease who is under 65 years old and has minimal symptoms?

Dopamine agonists. ***Dopamine agonists*** - For **younger patients** (under 65) with mild Parkinson's symptoms, dopamine agonists are often preferred as initial therapy. - They tend to cause fewer motor complications compared to levodopa, delaying the onset of **dyskinesias** for several years. *Levodopa* - While highly effective, **levodopa** is typically reserved for older patients or those with more advanced symptoms due to the increased risk of **motor fluctuations** and **dyskinesias** with long-term use, especially in younger individuals. - It is the most potent symptomatic treatment for Parkinson's disease, but its long-term side effects are a concern for younger patients. *MAO-B inhibitors* - **MAO-B inhibitors** are often used as monotherapy for very mild symptoms or as an adjunct therapy to reduce the "off" time in patients already on levodopa. - They provide only modest symptomatic benefit and do not typically offer the same level of symptom control as dopamine agonists or levodopa in initial treatment. *Anticholinergics* - **Anticholinergics** are primarily used to manage **tremor** in younger patients with Parkinson's disease. - They are associated with significant side effects such as cognitive impairment, dry mouth, and constipation, making them less suitable as an initial broad-spectrum treatment, especially in older patients.

Q: A 25-year-old man presents with a history of recurrent muscle cramps, myoglobinuria, and elevated serum creatine kinase levels. Which condition is most likely?

McArdle disease. ***McArdle disease*** - **McArdle disease** (glycogen storage disease type V) is characterized by a deficiency in **myophosphorylase**, leading to an inability to break down muscle glycogen for energy during exercise. - This results in **exercise-induced cramps**, **myoglobinuria**, and significant **elevations in creatine kinase** due to muscle breakdown [1]. *Duchenne muscular dystrophy* - This is an X-linked recessive disorder caused by a mutation in the **dystrophin gene**, leading to progressive muscle degeneration [1]. - While it causes elevated CK and muscle weakness, **recurrent muscle cramps and myoglobinuria upon exertion** are not its primary defining features; rather, it presents with progressive weakness, Gowers' sign, and eventually cardiomyopathy. *Becker muscular dystrophy* - **Becker muscular dystrophy** is a milder form of Duchenne, also due to mutations in the **dystrophin gene**, but with partially functional dystrophin. - Patients experience progressive muscle weakness and elevated CK, but **recurrent exercise-induced myoglobinuria and acute cramps** are less common and less severe than in McArdle disease. *Polymyositis* - **Polymyositis** is an inflammatory myopathy characterized by immune-mediated muscle damage, leading to **proximal muscle weakness**, dysphagia, and elevated CK. - While it features elevated CK, **myoglobinuria and acute exercise-induced cramps are not typical** presenting symptoms; it's generally associated with chronic progressive weakness.

Q: A patient presents with bilateral loss of vision following a stroke. Which artery is most likely affected?

Basilar artery. ***Basilar artery*** - Occlusion of the **basilar artery** can lead to bilateral cerebral infarctions, including the **occipital lobes**, which are responsible for visual processing. - This results in sudden onset **bilateral vision loss**, often accompanied by other brainstem signs like dizziness, dysphagia, or diplopia [1]. *Anterior cerebral artery* - A stroke in the **anterior cerebral artery** typically affects the frontal and parietal lobes, leading to symptoms like **contralateral leg weakness** and sensory loss, as well as behavioral changes [1]. - It does not directly supply the primary visual cortex, so isolated bilateral vision loss is not a common presentation. *Middle cerebral artery* - The **middle cerebral artery** supplies large parts of the frontal, parietal, and temporal lobes, and is the most common site of ischemic stroke [1]. - Symptoms usually include **contralateral hemiparesis**, sensory loss, aphasia (if the dominant hemisphere is affected), and hemineglect, but not primary bilateral vision loss [1]. *Posterior cerebral artery* - A stroke in a single **posterior cerebral artery** would typically cause a **contralateral homonymous hemianopsia** (loss of vision in the same half of the visual field in both eyes). - While it supplies the occipital lobe, bilateral vision loss would require occlusion of both posterior cerebral arteries, which is less common than basilar artery occlusion for this presentation.

Q: A 60-year-old man presents with a history of recurrent transient ischemic attacks (TIAs) and now has a sudden onset of right-sided weakness and aphasia. MRI shows an infarct in the territory of the left middle cerebral artery. Which intervention is most appropriate?

Endovascular thrombectomy. ***Endovascular thrombectomy*** - This intervention is appropriate for **acute ischemic stroke** with **large vessel occlusion**, especially when performed within 6-24 hours of symptom onset in select patients, as suggested by the sudden onset of severe neurological deficits and MCA territory infarct. - Given the patient's **sudden onset of significant neurological deficits** (right-sided weakness and aphasia) and an infarct in the **left middle cerebral artery territory**, it implies a large vessel occlusion, which benefits most from **endovascular thrombectomy**. *Antiplatelet therapy* - While essential for **secondary stroke prevention**, antiplatelet therapy alone is generally insufficient for the immediate treatment of an acute, severe ischemic stroke caused by a large vessel occlusion [1]. - It would be initiated after acute management, typically within 24-48 hours, to prevent further thrombotic events, but not as the primary acute reperfusion strategy. *Intravenous thrombolysis* - **Intravenous thrombolysis** (e.g., rtPA) is effective for acute ischemic stroke if administered within a **4.5-hour window from symptom onset** and if there are no contraindications [1]. - However, for large vessel occlusions, as implied by the severe symptoms and MCA infarct, its efficacy may be limited, and it is frequently used as a bridge to **endovascular thrombectomy** rather than a standalone treatment. *Anticoagulation therapy* - Anticoagulation therapy is typically used for stroke prevention in cases of **cardioembolic stroke** (e.g., atrial fibrillation) rather than for acute ischemic stroke due to large vessel occlusion [1]. - Initiating anticoagulation immediately after an acute ischemic stroke can increase the risk of **hemorrhagic transformation** of the infarct, making it generally contraindicated in the acute phase unless specific cardiac indications prompt it after careful assessment [1].

Question 1

A 40-year-old woman presents with numbness and tingling in her hands and feet, progressive weakness, and areflexia. She has a recent history of an upper respiratory infection. Which condition is most likely?

Accepted Answer

Guillain-Barre syndrome

Answer

Multiple sclerosis

Answer

Myasthenia gravis

Answer

Peripheral neuropathy

Question 2

A patient with a lower motor neuron lesion affecting the facial muscles will likely exhibit weakness in which area of the face?

Accepted Answer

Entire unilateral

Answer

Lower face

Answer

Upper face

Answer

Entire bilateral weakness

Question 3

In a patient with suspected bacterial meningitis, which cerebrospinal fluid finding is most indicative of the diagnosis?

Accepted Answer

High protein, low glucose, neutrophilic pleocytosis

Answer

Low protein, normal glucose, lymphocytic pleocytosis

Answer

High protein, high glucose, eosinophilic pleocytosis

Answer

Normal protein, normal glucose, mononuclear pleocytosis

Question 4

A 25-year-old man presents with recurrent episodes of severe, electric shock-like pain along the distribution of the V2 and V3 branches of the trigeminal nerve. Which condition is most likely?

Accepted Answer

Trigeminal neuralgia

Answer

Cluster headache

Answer

Migraine

Answer

Temporomandibular joint disorder

Question 5

A patient is diagnosed with a large posterior fossa tumor compressing the cerebellum. Which symptom is most likely to be present?

Accepted Answer

Ataxia

Answer

Aphasia

Answer

Hemiparesis

Answer

Seizures

Question 6

A 45-year-old male presents with progressive ataxia, dysarthria, and intention tremor. MRI shows demyelinating plaques in the cerebellum. What is the most likely diagnosis?

Accepted Answer

Multiple sclerosis

Answer

Amyotrophic lateral sclerosis

Answer

Friedreich's ataxia

Answer

Cerebellar tumor

Question 7

What is the preferred initial treatment for a patient diagnosed with Parkinson's disease who is under 65 years old and has minimal symptoms?

Accepted Answer

Dopamine agonists

Answer

Levodopa

Answer

MAO-B inhibitors

Answer

Anticholinergics

Question 8

A 25-year-old man presents with a history of recurrent muscle cramps, myoglobinuria, and elevated serum creatine kinase levels. Which condition is most likely?

Accepted Answer

McArdle disease

Answer

Duchenne muscular dystrophy

Answer

Becker muscular dystrophy

Answer

Polymyositis

Question 9

A patient presents with bilateral loss of vision following a stroke. Which artery is most likely affected?

Accepted Answer

Basilar artery

Answer

Anterior cerebral artery

Answer

Middle cerebral artery

Answer

Posterior cerebral artery

Question 10

A 60-year-old man presents with a history of recurrent transient ischemic attacks (TIAs) and now has a sudden onset of right-sided weakness and aphasia. MRI shows an infarct in the territory of the left middle cerebral artery. Which intervention is most appropriate?

Accepted Answer

Endovascular thrombectomy

Answer

Antiplatelet therapy

Answer

Intravenous thrombolysis

Answer

Anticoagulation therapy

Neurology — MCQs

Neurology — MCQs

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