Neurology Practice Questions

Q: An 85-year-old man presents with a sudden onset of severe occipital headache, vomiting on two occasions, and double vision. He has a history of hypertension. His examination findings are a Glasgow Coma Scale of 15/15, mild neck stiffness, and normal power in both upper and lower limbs. Where is the likely site of pathology?

Posterior communicating artery. ***Posterior communicating artery*** - Aneurysms in the **posterior communicating artery** are notorious for causing **oculomotor nerve (CN III) palsy**, leading to **double vision** due to impairment of eye movements. [2] - The sudden onset of severe **occipital headache** and **vomiting** suggests a subarachnoid hemorrhage, which is a common presentation of a ruptured cerebral aneurysm. [1] *Anterior communicating artery* - Aneurysms here typically present with **bifrontal headaches** and can cause **visual field defects** or **cranial nerve deficits** affecting the optic chiasm. - It usually does not specifically cause **double vision** due to oculomotor nerve involvement as a primary symptom. *Lenticulostriate artery* - These are small perforating arteries that supply the **basal ganglia** and **internal capsule**. - Rupture most commonly causes **intracerebral hemorrhage**, leading to motor or sensory deficits depending on the affected area, but less typically presents with isolated double vision or occipital headache. *P1 Segment of Posterior cerebral artery* - Aneurysms in the **P1 segment** are rare and typically involve structures around the **midbrain**, potentially causing specific neurological deficits like **contralateral hemiparesis** or **visual defects**. - While rupture can cause subarachnoid hemorrhage, presentation with isolated double vision from oculomotor nerve palsy is less characteristic than with a posterior communicating artery aneurysm.

Q: Not seen in case of hemorrhage in MCA territory is:

Urinary incontinence. ***Urinary incontinence*** - Urinary incontinence is typically associated with **anterior cerebral artery (ACA)** territory lesions, which affect the **paracentral lobule** responsible for bladder control. - MCA territory hemorrhage primarily impacts motor, sensory, speech, and attentional functions, not direct bladder control. *Contralateral hemiplegia* - Hemorrhage in the MCA territory commonly affects the **motor cortex** and its descending tracts, leading to **weakness or paralysis** on the opposite side of the body [1]. - This is a very common and expected symptom in MCA strokes. *Aphasia* - If the dominant hemisphere (usually left) is affected,MCA territory hemorrhage often involves **Broca's and Wernicke's areas**, leading to various forms of **aphasia** (expressive or receptive speech difficulties) [1]. - This is a hallmark symptom of dominant MCA strokes. *Dysarthria* - Dysarthria, or difficulty with articulation of speech, can result from MCA territory hemorrhage affecting the motor pathways that control the **muscles of speech** [1]. - It often co-occurs with hemiplegia and other motor deficits.

Q: Which of the following is not a treatment option for patients with relapsing-remitting multiple sclerosis?

Cyclophosphamide. ***Cyclophosphamide*** - This is an **immunosuppressant** primarily used in severe autoimmune conditions or certain cancers, not a standard maintenance treatment for **relapsing-remitting multiple sclerosis (RRMS)**. - While it has been explored for severe, rapidly worsening MS, it is not considered a first-line or common treatment option for RRMS due to its significant toxicity and side effect profile. *IFN-β1b* - **Interferon beta-1b** is a well-established **disease-modifying therapy** for RRMS, shown to reduce the frequency and severity of relapses. - It works by modulating the immune system to decrease inflammation and demyelination in the central nervous system. *IFN-β1a* - **Interferon beta-1a** (both intramuscular and subcutaneous formulations) is also a widely used **disease-modifying therapy** for RRMS. - Similar to interferon beta-1b, it helps to reduce relapse rates and slow the progression of disability in patients with RRMS. *Glatiramer acetate* - This is another common **disease-modifying therapy** for RRMS, which acts as a "decoy" myelin basic protein. - It works by inducing **T-cell anergy** and shifting the immune response from pro-inflammatory to anti-inflammatory, reducing attacks on myelin.

Q: What is Broca's aphasia?

Non-fluent aphasia. ***Non-fluent aphasia*** - Broca's aphasia is characterized by **non-fluent speech**, meaning speech is effortful, slow, and consists of short phrases with many pauses. [1] - Patients typically have **relatively preserved comprehension** but significant difficulty with speech production and repetition. [1] *Fluent aphasia* - This describes conditions like **Wernicke's aphasia**, where speech is fluent but often lacks meaning. [1] - Patients with fluent aphasia typically have **poor comprehension**, which is not the primary feature of Broca's aphasia. *Sensory aphasia* - This is another term for **Wernicke's aphasia**, primarily characterized by **impaired comprehension** of spoken and written language. - While it involves language deficits, the core issue is receptive, not expressive as in Broca's aphasia. *Conduction aphasia* - Conduction aphasia is characterized by **impaired repetition** despite relatively fluent speech and good comprehension. [1] - It results from damage to the **arcuate fasciculus**, connecting Broca's and Wernicke's areas. [1]

Q: All are reversible causes of dementia except one.

Alzheimer's disease. ### Alzheimer's disease - Alzheimer's disease is the most common cause of **irreversible, progressive neurodegenerative dementia**, characterized by the accumulation of **amyloid plaques** and **neurofibrillary tangles**. - There is currently no cure for Alzheimer's disease, and treatments focus on symptom management rather than reversal. *Hypothyroidism* - **Severe or untreated hypothyroidism** can cause cognitive impairment and dementia-like symptoms, which are often reversible with **thyroid hormone replacement therapy**. - Symptoms like **memory loss**, **slowed thinking**, and confusion can improve significantly once **euthyroid state** is achieved. *Hydrocephalus* - **Normal pressure hydrocephalus (NPH)** can cause a triad of symptoms including **gait disturbance**, **urinary incontinence**, and **dementia**, which can be reversible with a **shunt placement** [1]. - The cognitive decline in NPH is due to increased intracranial pressure affecting brain function, and surgical intervention can alleviate this pressure [1]. *Meningoencephalitis* - **Inflammation of the brain and its surrounding membranes** due to infection can lead to cognitive dysfunction and dementia, which may be reversible with **appropriate antimicrobial or antiviral treatment** [1]. - Early and aggressive treatment of the underlying infection is crucial for potential recovery of cognitive function and prevention of permanent damage.

Q: Tobey Ayer test is positive in

Spinal subarachnoid block. ***Spinal subarachnoid block*** - The **Queckenstedt-Tobey test** (or Tobey Ayer test) evaluates **CSF flow** by observing changes in CSF pressure upon **jugular vein compression**. - In a spinal subarachnoid block, compression of the jugular veins will show a **blunted or absent rise** in CSF pressure, indicating obstruction. *Spinal cord compression* - While spinal cord compression can lead to a subarachnoid block, the Tobey Ayer test primarily detects the **blockage of CSF flow**, not the compression itself. - The test helps in localizing the obstruction but is not specific to the **etiology of compression**. *Spinal stenosis* - **Spinal stenosis** refers to the narrowing of the spinal canal, which can *potentially* cause a CSF flow impediment. - However, the Tobey Ayer test directly assesses the **CSF dynamics** and flow blockage, it doesn't diagnose the underlying anatomical narrowing. *Normal CSF dynamics* - In individuals with normal CSF dynamics, jugular compression would result in a **rapid and significant rise** in CSF pressure, followed by a quick return to baseline upon release. - The absence of such a response is indicative of a **pathological CSF flow disturbance**.

Q: What is the preferred first-line treatment for a young patient (under 65 years) newly diagnosed with Parkinson's disease?

Dopamine agonist. ***Dopamine agonist*** - For younger patients (typically under 65-70 years) with Parkinson's disease, **dopamine agonists** (e.g., pramipexole, ropinirole) are traditionally preferred as initial therapy to delay the introduction of levodopa. - This approach aims to reduce the risk of **motor complications** (e.g., dyskinesias, motor fluctuations) associated with long-term levodopa use. - This represents the **classical treatment strategy** commonly taught for medical examinations, though current clinical practice increasingly emphasizes individualized treatment decisions. *Levodopa* - While the **most effective symptomatic treatment** for Parkinson's disease, levodopa is traditionally reserved for older patients or those with more severe symptoms requiring greater symptomatic control. - Long-term use of levodopa, especially when started young, has been associated with **motor complications** like dyskinesia and wearing-off phenomena. - However, levodopa provides superior quality of life benefits and remains the gold standard for motor symptom control. *MAO-B inhibitor* - **MAO-B inhibitors** (e.g., selegiline, rasagiline) offer **mild symptomatic benefit** and may have neuroprotective properties. - Their efficacy for significant motor symptoms is less than dopamine agonists or levodopa. - They are often used as **adjunct therapy** or in very early disease with mild symptoms, not typically as first-line monotherapy for managing primary motor symptoms in younger patients. *Amantadine* - **Amantadine** is primarily used to relieve **levodopa-induced dyskinesia** in later stages of Parkinson's disease. - It also has mild symptomatic benefit for tremor and rigidity but is **not a first-line agent** due to weaker efficacy compared to dopamine agonists. - Side effects include livedo reticularis and confusion, particularly in elderly patients.

Q: Which of the following statements is true regarding lower motor neuron lesions?

There may be wasting of muscles in long standing cases. **There may be wasting of muscles in long standing cases** * **Lower motor neuron (LMN)** lesions directly affect the nerve supply to muscles, leading to **denervation** and subsequent **atrophy** or **wasting** of the affected muscle over time [1]. * The absence of neural input causes the muscle fibers to shrink and be replaced by fibrous tissue, which is evident as muscle wasting, especially in **chronic LMN disorders** [1]. *Spastic paralysis is observed.* * **Spastic paralysis** is characteristic of **upper motor neuron (UMN)** lesions, causing increased muscle tone and exaggerated reflexes [1][2]. * In contrast, **LMN lesions** typically result in **flaccid paralysis**, characterized by reduced muscle tone and weakness [1]. *Fasciculations are absent.* * **Fasciculations** are often present in LMN lesions, representing spontaneous, uncoordinated contractions of a small number of muscle fibers that can be seen or felt under the skin [1]. * They result from **irritation or denervation of motor units**, indicating a problem with the LMNs themselves [1]. *Exaggerated tendon reflexes are present.* * **Exaggerated tendon reflexes (hyperreflexia)** are typically observed in **UMN lesions** due to the disruption of inhibitory pathways from the brain [1]. * In **LMN lesions**, the reflex arc is interrupted, leading to **diminished or absent tendon reflexes (hyporeflexia or areflexia)**.

Q: A 27-year-old patient with a chief complaint of mild vertigo of 3-month duration is seen by a neurologist. Examination reveals a positional (horizontal and vertical) nystagmus that is bidirectional, and the patient reports the absence of tinnitus. Which of the following is the most likely etiology of the vertigo?

Lesion of the flocculonodular lobe of the cerebellum. ### Lesion of the flocculonodular lobe of the cerebellum - **Bidirectional nystagmus**, especially when it's positional (horizontal and vertical) but not consistent with peripheral etiologies, strongly suggests a central lesion, such as one in the **flocculonodular lobe** [1]. - The absence of **tinnitus** and the chronicity of the mild vertigo further support a central rather than peripheral vestibular cause [1]. ### Labyrinthitis - **Labyrinthitis** is typically characterized by **unidirectional nystagmus** and a sudden onset of severe, often debilitating vertigo, which is not described here [1]. - It frequently involves associated symptoms like **hearing loss** and **tinnitus**, which are absent in this patient. ### Ménière’s syndrome - **Ménière’s syndrome** presents with episodic, intense vertigo accompanied by **tinnitus, hearing loss**, and a feeling of aural fullness, none of which are reported in this patient. - The nystagmus in Ménière's is typically **unidirectional** during acute attacks. ### Lesion of the spinocerebellum (affecting limb coordination) - A lesion of the **spinocerebellum** primarily affects **gait and limb coordination**, leading to **ataxia** and dysmetria, rather than isolated vertigo or nystagmus as the chief complaint [1]. - While cerebellar lesions can cause nystagmus, a lesion in the spinocerebellum would prominently feature motor incoordination symptoms not mentioned.

Q: All of the following signs are associated with thalamic hemorrhage, except which of the following?

Ocular bobbing. ***Ocular bobbing*** - **Ocular bobbing** is a sign of severe pontine or cerebellar dysfunction, not typically associated with thalamic hemorrhage. [1] - It involves a rapid downward movement of the eyes followed by a slow drift upward, which is distinct from the eye signs seen in thalamic lesions. *Miosis* - **Miosis** (pinpoint pupils) can occur in thalamic hemorrhage due to disruption of descending sympathetic pathways that originate in the diencephalon and brainstem. - Involvement of the **pretectal area** or descending sympathetic fibers can lead to pupillary constriction. *Gaze palsy* - A **gaze palsy** can result from thalamic hemorrhage, particularly if the hemorrhage extends into structures involved in ocular motor control. - Depending on the specific location and extent, it can manifest as an **upgaze palsy** (Parinaud syndrome) or **horizontal gaze abnormalities**. *Hemianopia* - **Hemianopia** (loss of vision in half of the visual field) is a common finding in thalamic hemorrhage, especially when the posterior thalamus is affected. - Damage to the **optic radiations** that pass through or near the thalamus, or direct involvement of the lateral geniculate body, can lead to contralateral hemianopia.

Question 1

An 85-year-old man presents with a sudden onset of severe occipital headache, vomiting on two occasions, and double vision. He has a history of hypertension. His examination findings are a Glasgow Coma Scale of 15/15, mild neck stiffness, and normal power in both upper and lower limbs. Where is the likely site of pathology?

Accepted Answer

Posterior communicating artery

Answer

Lenticulostriate artery

Answer

P1 Segment of Posterior cerebral artery

Answer

Anterior communicating artery

Question 2

Not seen in case of hemorrhage in MCA territory is:

Accepted Answer

Urinary incontinence

Answer

Contralateral hemiplegia

Answer

Aphasia

Answer

Dysarthria

Question 3

Which of the following is not a treatment option for patients with relapsing-remitting multiple sclerosis?

Accepted Answer

Cyclophosphamide

Answer

IFN-β1b

Answer

IFN-β1a

Answer

Glatiramer acetate

Question 4

What is Broca's aphasia?

Accepted Answer

Non-fluent aphasia

Answer

Fluent aphasia

Answer

Sensory aphasia

Answer

Conduction aphasia

Question 5

All are reversible causes of dementia except one.

Accepted Answer

Alzheimer's disease

Answer

Hydrocephalus

Answer

Meningoencephalitis

Answer

Hypothyroidism

Question 6

Tobey Ayer test is positive in

Accepted Answer

Spinal subarachnoid block

Answer

Spinal cord compression

Answer

Normal CSF dynamics

Answer

Spinal stenosis

Question 7

What is the preferred first-line treatment for a young patient (under 65 years) newly diagnosed with Parkinson's disease?

Accepted Answer

Dopamine agonist

Answer

MAO-B inhibitor

Answer

Amantadine

Answer

Levodopa

Question 8

Which of the following statements is true regarding lower motor neuron lesions?

Accepted Answer

There may be wasting of muscles in long standing cases

Answer

Spastic paralysis is observed.

Answer

Fasciculations are absent.

Answer

Exaggerated tendon reflexes are present.

Question 9

A 27-year-old patient with a chief complaint of mild vertigo of 3-month duration is seen by a neurologist. Examination reveals a positional (horizontal and vertical) nystagmus that is bidirectional, and the patient reports the absence of tinnitus. Which of the following is the most likely etiology of the vertigo?

Accepted Answer

Lesion of the flocculonodular lobe of the cerebellum

Answer

Ménière’s syndrome

Answer

Labyrinthitis

Answer

Lesion of the spinocerebellum (affecting limb coordination)

Question 10

All of the following signs are associated with thalamic hemorrhage, except which of the following?

Accepted Answer

Ocular bobbing

Answer

Hemianopia

Answer

Miosis

Answer

Gaze palsy

Neurology — MCQs

Neurology — MCQs

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