Neurology Practice Questions

Q: A 60-year-old man presents with sudden onset weakness on the right side of his body and difficulty speaking. MRI confirms an ischemic stroke. Which part of the brain is most likely affected?

Left frontal lobe. ***Left frontal lobe*** - **Weakness on the right side of the body** (hemiparesis) indicates an issue in the **contralateral motor cortex**, which is located in the frontal lobe [2]. - **Difficulty speaking** (aphasia), particularly expressive aphasia, is often associated with damage to **Broca's area**, which is typically located in the **left frontal lobe** in most individuals [1]. *Right frontal lobe* - Damage to the **right frontal lobe** would typically cause **weakness on the left side of the body**, not the right [2]. - While it plays a role in prosody and non-verbal communication, significant **expressive aphasia** is not primarily associated with right frontal lobe lesions [1]. *Left parietal lobe* - The **left parietal lobe** is primarily involved in **sensory processing**, spatial awareness, and language comprehension (Wernicke's area) [1]. - Damage here might lead to sensory deficits or receptive aphasia, but it is not the primary site for motor weakness or expressive aphasia. *Right parietal lobe* - The **right parietal lobe** is important for **spatial awareness**, attention, and recognizing faces and objects. - Lesions in this area can cause **left-sided neglect** or visuospatial deficits, but not typically right-sided weakness or speech production difficulties.

Q: A 50-year-old male presents with chronic headaches and dizziness. MRI shows periventricular and subcortical T2/FLAIR hyperintensities, some of which enhance with gadolinium. What is the likely diagnosis?

Multiple sclerosis. ***Multiple sclerosis*** - The presence of both **periventricular and subcortical T2/FLAIR hyperintensities** that **enhance with gadolinium** is highly characteristic of demyelinating plaques seen in MS, indicating active inflammation [1]. - The combination of **chronic headaches** and **dizziness**, along with imaging findings of active and older lesions (due to both enhancing and non-enhancing lesions), points strongly towards multiple sclerosis, especially given the pattern of lesions and enhancement [1]. Specific regions typical for multiple sclerosis include the periventricular, juxtacortical, and infratentorial areas [1]. *Chronic small vessel ischemic disease* - This condition typically presents with **non-enhancing white matter lesions** (leukoaraiosis) and lacunar infarcts, usually in older patients with vascular risk factors. - Enhancement with gadolinium is **not typical** for chronic small vessel ischemic disease. *Primary CNS vasculitis* - This condition can cause diffuse white matter changes and enhancement, but it often presents with strokes, encephalopathy, and focal neurological deficits, and the enhancement pattern might be **more diffuse or nodular** rather than distinctly plaquiform as in MS. - While it can cause headaches, the specific pattern of periventricular and subcortical lesions with both active and inactive plaques is **less typical** than for MS. *Migraine with white matter lesions* - Migraine can be associated with **non-specific white matter hyperintensities**, especially in individuals with a history of severe migraines. - However, these lesions typically **do not enhance with gadolinium** and are usually smaller and less numerous than those seen in MS, and they do not explain the dizziness in this pattern.

Q: A 35-year-old male presents with episodes of sudden, severe, unilateral headache, accompanied by nasal congestion and lacrimation. What is the most likely diagnosis?

Cluster headache. Detailed Analysis: ***Cluster headache*** - This condition presents with **sudden, severe, unilateral head pain**, often accompanied by ipsilateral **autonomic symptoms** such as nasal congestion, lacrimation, and ptosis [1]. - The episodic nature and association with these specific autonomic signs are highly characteristic of a cluster headache [1]. *Migraine* - While migraines cause **unilateral, throbbing headaches**, they are typically associated with **photophobia, phonophobia**, and nausea/vomiting, which are not mentioned here [3]. - Migraines are usually longer-lasting (4-72 hours) compared to cluster headaches, which are shorter but more frequent [1]. *Tension-type headache* - These headaches are typically **bilateral, mild-to-moderate in intensity**, and described as a **tight band around the head**, without associated autonomic symptoms [2]. - They lack the severe, unilateral pain and prominent autonomic features seen in the patient. *Trigeminal neuralgia* - This condition involves brief, **stabbing, excruciating pain** lasting seconds to minutes, primarily affecting the distribution of the **trigeminal nerve**. - It is typically triggered by touch, chewing, or talking, and does not present with the autonomic symptoms like nasal congestion or lacrimation described.

Q: A 25-year-old female presents with a history of episodes of sudden loss of consciousness accompanied by stiffening and jerking movements of the limbs. An EEG shows generalized spike-and-wave discharges. What is the most likely diagnosis?

Generalized tonic-clonic seizures. ***Generalized tonic-clonic seizures*** - The description of "sudden loss of consciousness accompanied by **stiffening** and **jerking movements** of the limbs" is classic for the tonic and clonic phases of a generalized tonic-clonic seizure [1]. - The EEG finding of **generalized spike-and-wave discharges** is consistent with generalized epilepsy, which includes tonic-clonic seizures [2]. *Absence seizures* - Characterized by **brief, sudden lapses of consciousness** without loss of postural tone, often presenting as staring spells [2]. - They lack the prominent **tonic (stiffening)** and **clonic (jerking)** movements described in the patient [1]. *Myoclonic epilepsy* - Involves **brief, shock-like jerks** of a muscle or group of muscles, typically without a preceding tonic phase or prolonged loss of consciousness [2], [3]. - While it can manifest with EEG generalized spike-and-wave, the description of sustained stiffening and jerking points away from isolated myoclonic jerks [1]. *Complex partial seizures* - Involve **focal onset** with impaired consciousness, often accompanied by **automatisms** (e.g., lip-smacking, fiddling with clothes) or other focal motor or sensory phenomena [4]. - They do not typically present with the generalized, symmetrical stiffening and jerking seen in **tonic-clonic seizures**.

Q: A 25-year-old male presents with sudden onset of right-sided weakness. An MRI of the brain shows a lesion in the left internal capsule. What is the most likely diagnosis?

Ischemic stroke. ### Ischemic stroke - The sudden onset of neurological deficit, such as **right-sided weakness**, in a young male, coupled with a lesion in the **left internal capsule** on MRI, is highly suggestive of an ischemic stroke [1]. - The internal capsule contains various **motor and sensory tracts**, and a lesion here would cause contralateral motor weakness. *Hemorrhagic stroke* - While a hemorrhagic stroke can also cause sudden neurological deficits, an **MRI typically shows blood** (hyperintensity on certain sequences) rather than simply a "lesion" without further characterization, which is more ambiguous for hemorrhage [1]. - Hemorrhagic strokes often present with additional symptoms like **severe headache**, nausea, and vomiting due to increased intracranial pressure, which are not mentioned here. *Brain tumor* - Brain tumors typically present with a more **gradual onset of symptoms** over weeks to months, rather than the sudden onset described [1]. - While a tumor *can* be in the internal capsule, its presentation is generally chronic progressing, and imaging would often show mass effect, edema, or enhancement, not just a "lesion" with sudden onset [1]. *Multiple sclerosis* - Multiple sclerosis lesions are typically **demyelinating plaques** that are disseminated in space and time, often found in the white matter but less commonly causing focal, acute weakness in a single, well-defined lesion location like the internal capsule with sudden onset. - While it can cause weakness, the presentation is usually characterized by **relapsing-remitting episodes** or progressive neurological decline with multiple lesions in different areas of the central nervous system.

Q: A 50-year-old male with chronic alcoholism presents with ataxia and nystagmus. MRI reveals degeneration in which part of the brain?

Cerebellum. ***Cerebellum*** - **Chronic alcoholism** is a significant risk factor for **cerebellar degeneration**, leading to symptoms like **ataxia** (impaired coordination) and **nystagmus** (involuntary eye movements) [1]. - The cerebellum is crucial for **motor control**, balance, and coordination, and its damage manifests clearly in these clinical signs [2]. *Basal ganglia* - Dysfunction of the **basal ganglia** is typically associated with movement disorders such as **Parkinson's disease** (tremor, bradykinesia) or **Huntington's disease** (chorea). - While basal ganglia can be affected by alcohol due to **hepatolenticular degeneration** (Wilson's disease), the primary symptoms of ataxia and nystagmus point more directly to cerebellar involvement. *Hippocampus* - The **hippocampus** is primarily involved in **memory formation** and spatial navigation. - Damage to the hippocampus, often seen in **Wernicke-Korsakoff syndrome** (also associated with alcoholism), would lead to severe memory deficits (amnesia) rather than prominent ataxia and nystagmus as the presenting neurological signs [3]. *Thalamus* - The **thalamus** acts as a **relay station** for sensory and motor signals to the cerebral cortex and plays a role in consciousness. - While damage to the thalamus can cause various neurological deficits, **ataxia** and **nystagmus** are not its primary clinical manifestations; these symptoms are much more characteristic of cerebellar pathology [1], [3].

Q: What is the first-line drug for the prophylaxis of cluster headaches?

Verapamil. ***Verapamil*** - **Verapamil**, a **non-dihydropyridine calcium channel blocker**, is the **first-line prophylactic agent** for chronic cluster headaches due to its efficacy in reducing headache frequency and severity. - It works by **stabilizing neuronal excitability** and has a **better safety profile** for long-term use compared to acute treatments. *Sumatriptan* - **Sumatriptan** is an **abortive therapy** used for the acute treatment of cluster headache attacks, not for long-term prophylaxis. - It acts as a **serotonin 5-HT1B/1D receptor agonist** to constrict cranial blood vessels and inhibit pain pathways. *Prednisone* - **Prednisone**, a corticosteroid, can be used as a **short-term bridge therapy** to provide rapid relief during the initiation of a long-term prophylactic agent but is not suitable for routine chronic prophylaxis due to significant side effects. - Its mechanism involves **reducing inflammation**, which can temporarily alleviate headache symptoms. *Lithium* - **Lithium** is an **alternative prophylactic agent** for cluster headaches, particularly effective in **chronic cluster headache** that is refractory to verapamil. - It is considered **second-line** due to its narrow therapeutic index and the need for regular blood level monitoring.

Q: A 60-year-old man presents with a sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension. What is the most likely diagnosis?

Subarachnoid hemorrhage. ***Subarachnoid hemorrhage*** - A **sudden onset of severe headache**, often described as the "worst headache of my life," along with **nausea** and **vomiting**, is a classic presentation of a **subarachnoid hemorrhage** [1]. - A history of **hypertension** is a significant risk factor for **aneurysmal rupture**, which is the most common cause of spontaneous subarachnoid hemorrhage [1]. *Migraine* - While migraines can cause severe headaches with nausea and vomiting, their onset is usually **gradual** and they typically have **associated focal neurological symptoms** such as aura or photophobia, which are not mentioned here [2]. - The patient's age (60) and the **sudden, explosive nature** of the headache make migraine less likely. *Cluster headache* - Cluster headaches are characterized by **excruciating, unilateral pain** around the eye, associated with **autonomic symptoms** like lacrimation, rhinorrhea, and ptosis, usually occurring in clusters [3]. - The described headache is **generalized** and lacks these specific autonomic features. *Tension headache* - Tension headaches are usually **mild to moderate**, **bilateral**, and described as a tight band around the head, without associated nausea or vomiting [2]. - The **sudden onset and severe intensity** of the headache in this case are inconsistent with a tension headache.

Q: The investigation of choice for diagnosing myasthenia gravis is:

Acetylcholine receptor (AChR) antibodies. ***Acetylcholine receptor (AChR) antibodies*** - Detecting **AChR antibodies** in the serum is the most specific and sensitive test for diagnosing generalized Myasthenia Gravis [1]. - These antibodies are found in about 85% of patients with generalized MG and target the **postsynaptic acetylcholine receptors** at the neuromuscular junction, leading to muscle weakness [1]. *Nerve conduction study* - A standard nerve conduction study (NCS) typically shows **normal results** in myasthenia gravis as there is no primary nerve pathology. - NCS primarily assesses nerve fiber integrity and conduction velocities, which are usually unaffected in neuromuscular junction disorders [2]. *Muscle biopsy* - Muscle biopsy is **not a primary diagnostic test** for myasthenia gravis; it would typically show non-specific findings or no abnormalities. - It is more useful for diagnosing myopathies (muscle diseases) or inflammatory myositis, where structural muscle changes are evident [2]. *Repetitive nerve stimulation* - While **repetitive nerve stimulation** can be abnormal (showing a decremental response) in myasthenia gravis, it is more commonly used as a confirmatory or supportive test rather than the initial diagnostic investigation of choice [1]. - Its sensitivity is lower than AChR antibody testing, especially in ocular myasthenia gravis.

Question 1

A 60-year-old man presents with sudden onset weakness on the right side of his body and difficulty speaking. MRI confirms an ischemic stroke. Which part of the brain is most likely affected?

Accepted Answer

Left frontal lobe

Answer

Right frontal lobe

Answer

Left parietal lobe

Answer

Right parietal lobe

Question 2

A 50-year-old male presents with chronic headaches and dizziness. MRI shows periventricular and subcortical T2/FLAIR hyperintensities, some of which enhance with gadolinium. What is the likely diagnosis?

Accepted Answer

Multiple sclerosis

Answer

Chronic small vessel ischemic disease

Answer

Primary CNS vasculitis

Answer

Migraine with white matter lesions

Question 3

A 35-year-old male presents with episodes of sudden, severe, unilateral headache, accompanied by nasal congestion and lacrimation. What is the most likely diagnosis?

Accepted Answer

Cluster headache

Answer

Migraine

Answer

Tension-type headache

Answer

Trigeminal neuralgia

Question 4

A 25-year-old female presents with a history of episodes of sudden loss of consciousness accompanied by stiffening and jerking movements of the limbs. An EEG shows generalized spike-and-wave discharges. What is the most likely diagnosis?

Accepted Answer

Generalized tonic-clonic seizures

Answer

Absence seizures

Answer

Myoclonic epilepsy

Answer

Complex partial seizures

Question 5

A 25-year-old male presents with sudden onset of right-sided weakness. An MRI of the brain shows a lesion in the left internal capsule. What is the most likely diagnosis?

Accepted Answer

Ischemic stroke

Answer

Hemorrhagic stroke

Answer

Brain tumor

Answer

Multiple sclerosis

Question 6

A 50-year-old male with chronic alcoholism presents with ataxia and nystagmus. MRI reveals degeneration in which part of the brain?

Accepted Answer

Cerebellum

Answer

Basal ganglia

Answer

Hippocampus

Answer

Thalamus

Question 7

What is the first-line drug for the prophylaxis of cluster headaches?

Accepted Answer

Verapamil

Answer

Sumatriptan

Answer

Prednisone

Answer

Lithium

Question 8

A patient with Parkinson's disease experiences severe motor fluctuations. Discuss the implications for basal ganglia pathways and identify the most appropriate advanced treatment option.

Accepted Answer

Decreased direct pathway activity; deep brain stimulation is the most effective advanced treatment.

Answer

Increased direct pathway activity; dopamine agonists may help.

Answer

Decreased indirect pathway activity; physical therapy is beneficial.

Answer

Increased indirect pathway activity; anticholinergic drugs are sometimes used.

Question 9

A 60-year-old man presents with a sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension. What is the most likely diagnosis?

Accepted Answer

Subarachnoid hemorrhage

Answer

Migraine

Answer

Cluster headache

Answer

Tension headache

Question 10

The investigation of choice for diagnosing myasthenia gravis is:

Accepted Answer

Acetylcholine receptor (AChR) antibodies

Answer

Nerve conduction study

Answer

Muscle biopsy

Answer

Repetitive nerve stimulation

Neurology — MCQs

Neurology — MCQs

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