Neurology — MCQs

Neurology Indian Medical PG Practice Questions and MCQs

Question 251: Factors that increase the risk of recurrence of febrile seizures include all except:

A. Initial seizure at less than 12 months of age
B. Positive family history
C. Temperature more than 40°C (Correct Answer)
D. Complex seizures

Explanation: ***Temperature more than 40°C*** - A **high fever** (over 40°C) during a febrile seizure **does not increase the risk of recurrence**. - In fact, **lower fever at onset** (<39°C) is actually associated with **higher recurrence risk**, as it suggests a lower seizure threshold. - The height of fever is **not a recognized predictor** of febrile seizure recurrence in major pediatric guidelines. *Initial seizure at less than 12 months of age* - **Younger age at the first febrile seizure** (especially under 12-18 months) is a significant predictor of future episodes. - The **immature nervous system** of younger infants makes them more susceptible to subsequent seizures with fever. - This is one of the strongest risk factors for recurrence. *Positive family history* - A **family history of febrile seizures** significantly increases a child's risk of recurrence. - This suggests a **genetic predisposition** to febrile seizures. - Children with affected first-degree relatives have approximately 2-3 times higher recurrence risk. *Complex seizures* - **Complex febrile seizures** (defined by prolonged duration >15 minutes, focal features, or multiple seizures within 24 hours) are associated with a higher risk of recurrence. - This indicates greater **neuronal excitability** or underlying susceptibility.

Question 252: A 10 year old child presented with headache, vomiting, gait instability and diplopia. On examination he had papilledema and gait ataxia. The most probable diagnosis is –

A. Suprasellar tumour
B. Hydrocephalus
C. Brain stem tumour
D. Midline posterior fossa tumour (Correct Answer)

Explanation: ***Midline posterior fossa tumour*** - The combination of **headache, vomiting, papilledema (signs of increased intracranial pressure)**, **gait instability, and ataxia** strongly suggests a **midline posterior fossa tumor** in a child. These tumors often obstruct CSF flow, leading to hydrocephalus and cerebellar symptoms. - Common tumors in this location in children include **medulloblastoma** and **pilocytic astrocytoma**, which frequently present with these symptoms due to their proximity to the **fourth ventricle** and **cerebellum**. *Suprasellar tumour* - **Suprasellar tumors** typically present with **visual field deficits** (e.g., bitemporal hemianopia) due to compression of the optic chiasm, and/or **endocrine dysfunction** (e.g., growth delay, diabetes insipidus). - While they can cause hydrocephalus and increased intracranial pressure if large, the prominent **gait instability and ataxia** point away from a primary suprasellar lesion as the most likely cause. *Hydrocephalus* - **Hydrocephalus** itself explains the **increased intracranial pressure (headache, vomiting, papilledema)** and sometimes **gait instability (ataxia)**. - However, hydrocephalus is usually a *consequence* of an underlying obstruction, and in a child presenting acutely with cerebellar dysfunction, a **tumor blocking CSF flow in the posterior fossa** is the most probable underlying cause, not hydrocephalus as the primary diagnosis. *Brain stem tumour* - **Brain stem tumors** typically cause **cranial nerve deficits** (e.g., facial weakness, dysphagia), **long tract signs (hemiparesis)**, and often **multiple types of ataxia**, alongside signs of increased intracranial pressure if they obstruct CSF flow. - While gait instability and diplopia can occur, the overall picture of prominent **gait ataxia** and papilledema without other focal cranial nerve signs makes a primary midline posterior fossa tumor compressing the cerebellum and fourth ventricle more likely.

Question 253: A 3 year old child is brought to you with history of frequent, violent and rapid swinging movement of the left arm for one week duration. What is the condition described in this scenario called?

A. Athetosis
B. Dystonia
C. Chorea
D. Hemiballismus (Correct Answer)

Explanation: ***Hemiballismus*** - **Hemiballismus** is characterized by sudden, involuntary, wild, rapid, and **flailing movements** of one side of the body, primarily affecting the proximal musculature such as the arm and leg. - The description of "frequent, violent and rapid swinging movement of the left arm" perfectly aligns with the clinical presentation of hemiballismus, often resulting from a lesion in the **subthalamic nucleus**. *Athetosis* - **Athetosis** involves slow, writhing, involuntary movements, especially in the distal parts of the limbs (fingers and toes). - This condition is typically slower and more sustained than the "violent and rapid swinging" described in the scenario. *Dystonia* - **Dystonia** is characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements or postures. - While it can involve forceful movements, it usually results in sustained postures or twisting movements rather than the rapid, flailing motion described. *Chorea* - **Chorea** refers to irregular, unpredictable, brief, and jerky movements that flow from one body part to another in a dance-like manner. - Unlike the violent, large-amplitude movements of hemiballismus, chorea typically involves more distal and less organized movements.

Question 254: All of the following are true of febrile seizures except-

A. Prognosis is good
B. Does not last more than 15 minutes
C. Most commonly seen between 9 months and 5 years
D. Almost invariably develop into epilepsy (Correct Answer)

Explanation: ***Almost invariably develop into epilepsy*** - This statement is **false**; only a small percentage (2-7%) of children with febrile seizures later develop **epilepsy**. - Febrile seizures are generally considered **benign** and do not typically lead to a diagnosis of epilepsy. *Prognosis is good* - The **prognosis for simple febrile seizures is excellent**, with no long-term neurological sequelae or cognitive impairment. - The risk of recurrence is present but usually decreases with age, and **most children outgrow them**. *Does not last more than 15 minutes* - **Simple febrile seizures** are defined as generalized tonic-clonic seizures lasting **less than 15 minutes**. - Seizures lasting longer than 15 minutes are considered **complex febrile seizures**, which have a slightly higher risk of recurrence but do not necessarily change the overall good prognosis. *Most commonly seen between 9 months and 5 years* - Febrile seizures typically occur in children between **6 months and 5 years of age**, with a peak incidence around **18 months**. - This age range reflects the developing brain's susceptibility to febrile illness and its ability to generate a generalized seizure response.

Question 255: Duchenne's muscular dystrophy affects which group of muscles commonly:

A. Calf muscles
B. Shoulder muscles
C. Respiratory muscles
D. Proximal muscles (Correct Answer)

Explanation: ***Proximal muscles*** - Duchenne's muscular dystrophy (DMD) is characterized by **progressive proximal muscle weakness**, which is the hallmark feature of this X-linked recessive disorder. - The weakness typically begins in the **pelvic girdle muscles** (hip flexors, quadriceps) and later progresses to involve the **shoulder girdle muscles**. - This proximal pattern of weakness leads to classic clinical features: difficulty **climbing stairs**, **rising from the floor** (Gower's sign), **waddling gait**, and difficulty **raising arms overhead**. - The term "proximal muscles" accurately encompasses the characteristic distribution of muscle involvement in DMD, making it the most correct answer. *Shoulder muscles* - While shoulder girdle muscles are indeed affected in DMD, they are typically involved **after the pelvic girdle muscles**. - This option is too specific and does not capture the **generalized proximal muscle weakness** that defines DMD. - Shoulder muscle weakness becomes prominent as the disease progresses, but it is not the initial or most characteristic presentation. *Calf muscles* - Calf muscles may show **pseudohypertrophy** (apparent enlargement due to replacement of muscle with fat and connective tissue), which is a characteristic finding in DMD. - However, pseudohypertrophy does not represent true muscle strength, and the calves are **distal muscles**, not the primary site of weakness. - DMD is a **proximal myopathy**, not a distal myopathy. *Respiratory muscles* - **Respiratory muscle weakness** (diaphragm and intercostal muscles) is a serious and life-threatening complication of DMD. - However, respiratory involvement occurs **later in the disease course**, typically in the second decade of life. - Progressive respiratory failure is a major cause of morbidity and mortality in DMD but is not the early or most characteristic muscle group affected.

Question 256: All the following are Causes of spasticity in a 2 year old child except

A. Congenital muscular dystrophy (Correct Answer)
B. Cerebral Palsy
C. Kernicterus
D. Birth asphyxia

Explanation: ***Congenital muscular dystrophy*** - This condition is characterized by **muscle weakness and hypotonia**, not spasticity, due to primary muscle pathology. - Spasticity is a sign of **upper motor neuron involvement**, whereas muscular dystrophies are disorders of peripheral muscle fibers resulting in **flaccid weakness**. *Cerebral Palsy* - This is the **most common cause of spasticity in children**, resulting from **non-progressive brain injury during development**. - **Spastic cerebral palsy** accounts for 70-80% of CP cases, characterized by increased muscle tone, hyperreflexia, and extensor plantar responses. *Kernicterus* - **Bilirubin encephalopathy** from severe neonatal hyperbilirubinemia causes **basal ganglia damage**. - Results in **extrapyramidal cerebral palsy** with spasticity, choreoathetosis, and developmental delays. *Birth asphyxia* - **Hypoxic-ischemic encephalopathy** from perinatal asphyxia causes **upper motor neuron damage**. - Leads to spastic quadriplegia or diplegia with increased tone, hyperreflexia, and developmental impairment.

Question 257: A 4-year-old male child presents with muscle weakness. His mother reports that her child has difficulty in climbing stairs and getting up from the floor. On muscle biopsy, small degenerated muscle fibers and absence of dystrophin were found. What is the diagnosis?

A. Myotonic dystrophy
B. Becker's muscle dystrophy
C. Limb-girdle muscular dystrophy
D. Duchenne muscular dystrophy (Correct Answer)

Explanation: ***Duchenne muscular dystrophy*** - The classic presentation of a young boy with **progressive muscle weakness**, difficulty climbing stairs (**Gowers' sign**), and **absent dystrophin** on muscle biopsy is characteristic of Duchenne muscular dystrophy. - It is an **X-linked recessive disorder** that leads to severe muscle degeneration and weakness due to a complete lack of functional dystrophin protein. *Myotonic dystrophy* - This condition is characterized by **myotonia** (delayed relaxation of muscles after contraction) and typically affects adults, although congenital forms exist. - While it causes muscle weakness, the primary differentiating feature of **myotonia** and its later onset are not present in this case. *Becker's muscle dystrophy* - Becker's muscular dystrophy (BMD) is also an X-linked recessive disorder and a milder form of muscular dystrophy, caused by a **reduced but still functional dystrophin** protein. - Patients with BMD typically present later in childhood or adolescence with slower progression and **some dystrophin** presence, unlike the absent dystrophin and early onset here. *Limb-girdle muscular dystrophy* - This is a group of muscular dystrophies that primarily affect the **pelvic and shoulder girdle muscles**. - It can present with similar weakness, but the **complete absence of dystrophin** found on biopsy points specifically to Duchenne muscular dystrophy, not typical limb-girdle dystrophy, which involves other genetic defects.

Question 258: A 6-year-old with recurrent febrile seizures presents lethargic with a high fever. What is the most appropriate next step in management?

A. Perform lumbar puncture (Correct Answer)
B. Consider using antipyretics for comfort
C. Start anticonvulsants
D. Order urgent EEG

Explanation: ***Perform lumbar puncture*** - The combination of **lethargy**, high fever, and a history of recurrent febrile seizures in a 6-year-old child raises suspicion for **meningitis or encephalitis**, necessitating a prompt **lumbar puncture** to analyze **cerebrospinal fluid (CSF)**. - While febrile seizures alone are benign, **altered mental status (lethargy)** in conjunction with fever is a red flag for **central nervous system infection**. *Consider using antipyretics for comfort* - **Antipyretics** can help reduce fever and improve comfort but do not address the underlying cause of lethargy and potential CNS infection. - Delaying definitive diagnostic steps like a **lumbar puncture** while waiting for antipyretics to work could worsen the patient's prognosis if a serious infection is present. *Start anticonvulsants* - **Anticonvulsants** are primarily used for managing ongoing seizures or preventing recurrent non-febrile seizures but are **not indicated as a first-line diagnostic or emergency treatment** for a child presenting with **fever and lethargy without active seizures**. - There is no clinical indication of current seizure activity, and the immediate concern is detecting a potential **CNS infection**. *Order urgent EEG* - An **EEG (electroencephalogram)** is useful for evaluating seizure disorders or encephalopathy but is **not the most appropriate initial diagnostic step** when a **serious CNS infection like meningitis** is suspected. - A **lumbar puncture** is crucial for diagnosing or ruling out meningitis, which requires immediate treatment.

Question 259: A 7-year-old child presents with ataxia and slurred speech. An MRI shows a mass in the cerebellum. What is the most likely diagnosis?

A. Astrocytoma (Correct Answer)
B. Brainstem glioma
C. Arachnoid cyst
D. Medulloblastoma

Explanation: ***Astrocytoma*** - **Cerebellar pilocytic astrocytoma** is one of the most common posterior fossa tumors in children, accounting for approximately 10-20% of pediatric brain tumors. - Typically presents with **ataxia, slurred speech**, and signs of increased intracranial pressure due to cerebellar involvement. - On MRI, these tumors are often **cystic with a mural nodule** and show contrast enhancement, appearing as well-circumscribed masses in the cerebellar hemispheres. - They are generally **low-grade (WHO Grade I)** with an excellent prognosis after surgical resection. *Medulloblastoma* - **Medulloblastoma** is the most common **malignant** posterior fossa tumor in children and would also be a strong differential diagnosis. - Typically arises from the **cerebellar vermis** (midline), while astrocytomas more commonly occur in the **cerebellar hemispheres** (lateral). - Appears as a **solid, densely enhancing mass** on MRI with potential for **leptomeningeal spread** and CSF dissemination. - Without specific imaging details about location (vermis vs hemisphere) or characteristics (solid vs cystic), both tumors remain in the differential, though the question stem suggests a more typical astrocytoma presentation. *Brainstem glioma* - **Brainstem gliomas** (particularly diffuse intrinsic pontine gliomas) present with cranial nerve palsies, long tract signs, and ataxia, but the mass would be localized to the **brainstem** on MRI, not the cerebellum. - The location of the tumor on MRI is the key differentiator, as brainstem lesions are distinct from cerebellar masses. *Arachnoid cyst* - An **arachnoid cyst** is a benign, congenital, fluid-filled lesion that is typically asymptomatic or causes symptoms due to mass effect. - Appears as a **non-enhancing, CSF-intensity lesion** on MRI (same signal as CSF on all sequences) and would not be described as a solid "mass." - Does not cause tumor-like symptoms unless very large and compressive.

Question 260: A 2-year-old boy presents with generalized tonic-clonic seizures, and his development has been normal. Which investigation should be performed first?

A. Electrolyte levels (Correct Answer)
B. CT scan of the head
C. EEG
D. MRI

Explanation: ***Electrolyte levels*** - This is the **first-line investigation** for new-onset seizures, especially in children, to rule out common and easily treatable metabolic causes. - **Hypoglycemia**, **hypocalcemia**, and **hyponatremia** can all trigger seizures and are readily identifiable with a basic metabolic panel. *CT scan of the head* - While useful for acute structural abnormalities like **hemorrhage** or large tumors, it exposes the child to **radiation** and is usually reserved for cases where other causes have been ruled out or if there are focal neurological signs. - It provides less detail than an MRI for soft tissue and subtle lesions. *EEG* - An **EEG** is performed to characterize the **epileptic discharges** and classify the type of seizure or epilepsy syndrome, and hence is useful for guiding long-term management. - It is not typically the first investigation for an **unexplained acute seizure**, as it doesn't identify the immediate underlying cause in most emergent situations. *MRI* - **MRI** provides much more detailed imaging of brain structure than CT and is preferred for investigating **structural causes of epilepsy**, especially for subtle lesions, congenital malformations, or hippocampal sclerosis. - However, it is a more time-consuming and expensive test, often requiring **sedation** in young children, and is usually performed after ruling out acute metabolic causes.

Practice by Chapter

Seizure Disorders and Epilepsy

Practice Questions

Febrile Seizures

Practice Questions

Headache Disorders

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Cerebral Palsy

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Neural Tube Defects

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Neuromuscular Disorders

Practice Questions

Neurodegenerative Disorders

Practice Questions

CNS Infections

Practice Questions

Hydrocephalus

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Movement Disorders

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Traumatic Brain Injury

Practice Questions

Neuroimaging in Pediatrics

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Neurology — MCQs

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