Neurology Practice Questions

Q: In a patient with a pontine hemorrhage, what clinical presentation would be expected?

Quadriplegia. ***Quadriplegia*** - Pontine hemorrhages often cause **quadriplegia** because the **corticospinal tracts** that control motor function for all four limbs pass through the pons [2]. - The sudden onset and severity of a pontine bleed can lead to immediate and widespread motor neuron dysfunction, resulting in complete paralysis. *Asymmetrical mydriasis* - **Asymmetrical mydriasis** (unequal pupil dilation) typically indicates uncal herniation or direct oculomotor nerve (cranial nerve III) compression, usually due to supratentorial mass lesions [1]. - Pontine lesions more commonly cause **pinpoint pupils** (miosis) due to disruption of the descending sympathetic pathways. *Ataxic hemiparesis* - **Ataxic hemiparesis** is characterized by weakness on one side of the body accompanied by ipsilateral ataxia, often associated with lacunar infarcts in the pons or cerebellum. - While a pontine lesion could cause this, a large pontine hemorrhage is more likely to result in diffuse motor deficits like quadriplegia rather than an isolated ataxic hemiparesis. *Hypothermia* - **Hypothermia** due to central nervous system damage is primarily associated with lesions affecting the hypothalamus, which is a key thermoregulatory center. - Pontine hemorrhages, while severe, are not typically the primary cause of isolated hypothermia; instead, they often cause **hyperthermia** (central fever) due to sympathetic storm or dysregulation.

Q: Fine tremors are primarily associated with which of the following conditions?

Essential tremor. Essential tremor - Essential tremor is characterized by **fine, rhythmic tremors** that often affect the hands and can worsen with activity or stress. - It's typically an **action tremor**, meaning it occurs during voluntary movement, contrasting with resting tremors seen in other conditions. *Parkinson's disease* - Parkinson's disease primarily presents with a **resting tremor**, which is most noticeable when the affected limb is at rest [1]. - The tremor in Parkinson's is often described as a **"pill-rolling"** tremor, distinct from the fine action tremor of essential tremor [1]. *Multiple sclerosis* - Tremors in multiple sclerosis are typically **intention tremors**, meaning they appear or worsen during goal-directed movements, such as reaching for an object [2]. - These tremors are often **coarser and more irregular** than the fine tremors associated with essential tremor [2]. *None of the options* - This option is incorrect because essential tremor is a specific condition well-known for its characteristic fine tremor.

Q: A woman with bilateral headaches that worsen with emotional stress, who has two children both doing poorly in school, is diagnosed with:

Tension headache. ***Tension headache*** - **Tension headaches** are often described as a bilateral dull, constant ache, frequently associated with **stress** and muscle tension, as suggested by the patient's emotional stress with her children's schooling. - The lack of typical migraine features like **pulsating pain**, **photophobia**, **phonophobia**, or aura, and the bilateral nature, favor tension headache over migraine. *Migraine* - **Migraines** typically present as unilateral, pulsating pain, often accompanied by **nausea**, vomiting, photophobia, or phonophobia. - While stress can be a trigger, the **bilateral presentation** and absence of other hallmark migraine features make it less likely. *Cluster headache* - **Cluster headaches** are characterized by severe, unilateral pain, frequently around the eye (periorbital), and are associated with **autonomic symptoms** like lacrimation, rhinorrhea, or ptosis. - They occur in "clusters" over days or weeks and are not typically bilateral or primarily triggered by emotional stress in this manner. *Trigeminal neuralgia* - **Trigeminal neuralgia** causes sudden, severe, shock-like pain in the distribution of the trigeminal nerve, often triggered by light touch, chewing, or speaking. - It is not typically described as a continuous bilateral headache worsened by emotional stress.

Q: Which of the following is a known trigger for Bell's palsy?

Local and systemic infections. ***Local and systemic infections*** - Viral infections, particularly **herpes simplex virus (HSV-1)**, are strongly implicated in the etiology of Bell's palsy due to inflammation and demyelination of the **facial nerve** [1]. - Other infections such as **varicella-zoster virus**, **Epstein-Barr virus**, and **cytomegalovirus** have also been identified as triggers [3]. *Exposure to cold* - While historically believed to be a cause, **cold exposure** has not been scientifically proven to directly trigger Bell's palsy. - The sensation of cold may exacerbate symptoms due to nerve sensitivity, but it is not a direct etiologic factor. *Tooth extraction* - Tooth extraction is not a widely recognized trigger for Bell's palsy; however, **dental procedures** involving local anesthesia or trauma *can sometimes* lead to temporary facial nerve dysfunction, but this is distinct from Bell's palsy. - Such cases are usually due to direct nerve damage or hematoma, rather than the inflammation seen in Bell's palsy. *None of the options* - Since **local and systemic infections** are well-established triggers for Bell's palsy, this option is incorrect [2]. - The underlying mechanism involves **inflammation and swelling** of the facial nerve, often linked to viral reactivation.

Q: What is the MOST COMMON side effect of vagal nerve stimulation?

voice changes. ***voice changes*** - **Voice changes**, such as **hoarseness** or dysphonia, are the most frequently reported side effect due to the proximity of the stimulator to the **recurrent laryngeal nerve** [1]. - These changes often occur during stimulation and can be managed by adjusting the device settings. *coughing* - While **coughing** can occur, it is a less common side effect compared to voice changes. - It results from irritation of the **laryngeal or pharyngeal branches** of the vagus nerve. *nausea* - **Nausea** is a less common side effect and typically occurs due to activation of the **gastrointestinal afferent fibers** of the vagus nerve [2]. - It usually resolves with adjustment of stimulation parameters or over time. *throat discomfort* - **Throat discomfort** or pain can occur, but it is less frequent than voice changes and may be associated with the surgical implantation site or local irritation from the lead. - It is distinct from the functional changes in voice caused by direct nerve stimulation.

Q: Which of the following is NOT a feature of seizures or syncope?

Nausea and tunneling of vision are features of syncope.. ***Nausea and tunneling of vision are features of syncope.*** - **Nausea** and **tunneling of vision** are **prodromal symptoms** specific to syncope, occurring due to reduced cerebral blood flow before loss of consciousness [1], [4]. - These symptoms are **NOT features of seizures**, which typically have sudden onset without warning symptoms like nausea or visual changes [1]. *Becomes immediately unconscious* - Both **seizures** and **syncope** are characterized by sudden loss of consciousness, making this a common feature of both conditions [2], [4]. - This **immediate unconscious state** distinguishes both conditions from gradual neurological changes or other causes of altered mental status [3]. *No precipitating factors* - **Seizures** often occur without identifiable precipitating factors, making their onset sudden and unpredictable. - **Syncope** can also occur without obvious triggers, though it may be precipitated by **orthostatic stress**, dehydration, or emotional factors [1]. *Tonic or clonic seizures lasting more than 60 seconds* - While typical **generalized tonic-clonic seizures** usually last less than 60 seconds, seizures **CAN last longer** than 60 seconds [2]. - **Status epilepticus** refers to seizures lasting more than 5 minutes or recurrent seizures without recovery, making prolonged seizures still a feature of seizure disorders.

Q: Which one of the following is the characteristic feature of juvenile myoclonic epilepsy?

Myoclonic seizures frequently occur in morning. ***Myoclonic seizures frequently occur in morning*** - A key diagnostic feature of **juvenile myoclonic epilepsy (JME)** is the occurrence of **myoclonic jerks**, specifically upon **waking up or in the morning** after sleep [1]. - These jerks are often exacerbated by **sleep deprivation** and certain stimuli. *Complete remission is common* - While treatment with **antiepileptic drugs (AEDs)** can achieve good seizure control, **complete remission** (i.e., being seizure-free without medication) is relatively uncommon [1]. - Most patients with JME require **lifelong medication** to prevent seizure recurrence [1]. *Response to anticonvulsants is poor* - JME generally has a **good prognosis** with appropriate medication, particularly with **valproic acid**, which is highly effective [1]. - The disease is typically **well-controlled** with AEDs, and response to treatment is often favorable [1]. *Associated absence seizures can occur in some patients but not the majority.* - **Absence seizures** are a common associated seizure type in individuals with JME, affecting about **one-third of patients** [1]. - **Generalized tonic-clonic seizures (GTCS)** are also very common, affecting over **90%** of JME patients, often appearing after the myoclonic jerks [1].

Q: Which of the following is not part of the classic triad of Parkinson's disease?

Preserved postural reflexes. ***Preserved postural reflexes*** - **Loss of postural reflexes** is a key feature of Parkinson's disease, leading to balance problems and falls, not preserved reflexes [4]. - The classic triad focuses on motor symptoms, and the inability to maintain posture is a direct consequence of the disease's progression [4]. *Rigidity* - **Rigidity**, or increased muscle tone, is a fundamental motor symptom in Parkinson's, often described as **cogwheel** or **lead-pipe rigidity** [2]. - This symptom contributes to the characteristic stiffness and reduced range of motion seen in affected individuals. *Resting tremors* - **Resting tremors**, typically a pill-rolling tremor that disappears with voluntary movement, are a hallmark symptom of Parkinson's disease [2]. - This involuntary shaking at rest is often one of the earliest and most recognizable signs of the condition [3]. *Bradykinesia* - **Bradykinesia**, or slowness of movement, is a core diagnostic criterion for Parkinson's disease [1]. - It manifests as difficulty initiating movements, reduced amplitude of movements, and overall decreased spontaneous movement.

Q: An adolescent female has headaches that are intermittent in episodes, associated with tinnitus, vertigo, and hearing loss. There is a history of similar complaints in her mother. What is the most likely diagnosis?

Basilar migraine. ***Basilar migraine*** - This diagnosis is characterized by **headaches**, **tinnitus**, **vertigo**, and **hearing loss**, which are all symptoms of **basilar artery involvement**. - The familial history (**similar complaints in her mother**) suggests a genetic predisposition often seen with migraines [1]. *Cervical spondylosis* - This condition involves **degenerative changes** in the cervical spine, often presenting with neck pain, stiffness, and radicular symptoms. - It does not typically cause **hearing loss**, and while it can cause headaches and vertigo, the combination of symptoms and family history points away from spondylosis. *Temporal arteritis* - This is a **vasculitic condition** usually affecting older adults (>50 years) and presents with unilateral headache, scalp tenderness, and jaw claudication [2]. - It is unlikely in an **adolescent female** and does not typically involve the specific constellation of tinnitus and vertigo found here. *Vestibular neuronitis* - This condition causes **acute, severe vertigo**, often preceded by a viral infection, and can last for days or weeks. - While it causes vertigo, it is typically **not associated with headache** or hearing loss and is usually a self-limiting episode rather than intermittent.

Q: On electromyography, all of the following features suggest denervation, EXCEPT:

Less insertional activity is observed in denervated muscles. ***Less insertional activity is observed in denervated muscles*** - **Decreased insertional activity** is actually seen in **fibrotic** or **fatty infiltrated muscle**, not denervated. - In denervated muscle, **increased insertional activity** (brief discharge of motor unit potentials) is typically observed. *Giant polyphasic potentials arise from motor units* - **Giant polyphasic potentials** are characteristic of chronic denervation followed by reinnervation, indicating **motor unit remodeling** [1]. - They reflect a larger, more complex motor unit where remaining nerves sprout to reinnervate orphaned muscle fibers [1]. *Presence of positive sharp waves* - **Positive sharp waves** are a common sign of **acute denervation** and muscle fiber irritability. - They indicate spontaneous depolarization of muscle fibers that have lost their nerve supply. *Spontaneous firing of motor units* - **Spontaneous firing of motor units** (fibrillations and fasciculations) is a hallmark of denervation [1]. - **Fibrillations** are spontaneous discharges of individual muscle fibers, while **fasciculations** are visible twitches of muscle bundles caused by spontaneous firing of a motor unit [1].

Question 1

In a patient with a pontine hemorrhage, what clinical presentation would be expected?

Accepted Answer

Quadriplegia

Answer

Asymmetrical mydriasis

Answer

Ataxic hemiparesis

Answer

Hypothermia

Question 2

Fine tremors are primarily associated with which of the following conditions?

Accepted Answer

Essential tremor

Answer

Parkinson's disease

Answer

Multiple sclerosis

Answer

None of the options

Question 3

A woman with bilateral headaches that worsen with emotional stress, who has two children both doing poorly in school, is diagnosed with:

Accepted Answer

Tension headache

Answer

Migraine

Answer

Cluster headache

Answer

Trigeminal neuralgia

Question 4

Which of the following is a known trigger for Bell's palsy?

Accepted Answer

Local and systemic infections

Answer

Exposure to cold

Answer

Tooth extraction

Answer

None of the options

Question 5

What is the MOST COMMON side effect of vagal nerve stimulation?

Accepted Answer

voice changes

Answer

nausea

Answer

coughing

Answer

throat discomfort

Question 6

Which of the following is NOT a feature of seizures or syncope?

Accepted Answer

Nausea and tunneling of vision are features of syncope.

Answer

Becomes immediately unconscious

Answer

No precipitating factors

Answer

Tonic or clonic seizures lasting more than 60 seconds

Question 7

Which one of the following is the characteristic feature of juvenile myoclonic epilepsy?

Accepted Answer

Myoclonic seizures frequently occur in morning

Answer

Complete remission is common

Answer

Response to anticonvulsants is poor

Answer

Associated absence seizures can occur in some patients but not the majority.

Question 8

Which of the following is not part of the classic triad of Parkinson's disease?

Accepted Answer

Preserved postural reflexes

Answer

Rigidity

Answer

Resting tremors

Answer

Bradykinesia

Question 9

An adolescent female has headaches that are intermittent in episodes, associated with tinnitus, vertigo, and hearing loss. There is a history of similar complaints in her mother. What is the most likely diagnosis?

Accepted Answer

Basilar migraine

Answer

Cervical spondylosis

Answer

Temporal arteritis

Answer

Vestibular neuronitis

Question 10

On electromyography, all of the following features suggest denervation, EXCEPT:

Accepted Answer

Less insertional activity is observed in denervated muscles

Answer

Spontaneous firing of motor units

Answer

Giant polyphasic potentials arise from motor units

Answer

Presence of positive sharp waves

Neurology — MCQs

Neurology — MCQs

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