Neurology — MCQs

A 4-year-old child is observed to hold his eyelids open with his fingers and to close one eye periodically, especially in the evening. He has some trouble swallowing his food. He usually appears sad, although he laughs often enough. He can throw a ball, and he runs well. Which of the following is likely to result in the diagnosis?

Q67Medium

Which type of cerebral palsy is seen as a sequelae to bilirubin encephalopathy in the neonatal period?

Q68Medium

A baby on examination shows unilateral Moro's reflex with a positive palmar grasp reflex. What is the most likely site of the lesion?

Q69Medium

Which of the following statements is false about Sacral Meningomyelocele?

Q70Medium

A 3-year-old child presents with a history of one episode of generalized tonic-clonic seizure lasting for 3-4 minutes, 6 hours ago, accompanied by a fever of 102°F and mild coryza. On examination, the child is conscious and alert, hemodynamically stable, and has no meningeal signs. Which of the following is true about the child's condition?

Neurology Indian Medical PG Practice Questions and MCQs

Question 61: A child with Tubercular meningitis (TBM) presents with hydrocephalus after VP shunt, exhibiting polyuria and hyponatremia. What is the most probable diagnosis?

A. Central Diabetes insipidus
B. Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH)
C. Cerebral salt wasting (Correct Answer)
D. Shunt block

Explanation: ### Explanation The clinical presentation of **polyuria** (excessive urine output) and **hyponatremia** (low serum sodium) in a patient with a CNS insult (Tubercular Meningitis/VP Shunt) is the classic hallmark of **Cerebral Salt Wasting (CSW)**. #### Why Cerebral Salt Wasting is Correct: CSW occurs due to the release of brain natriuretic peptides or sympathetic dysfunction following CNS injury. This leads to: 1. **Renal salt wasting:** Excessive loss of sodium in urine. 2. **Polyuria:** Water follows sodium, leading to dehydration/hypovolemia. 3. **Hyponatremia:** Despite the salt loss, the primary laboratory finding is low serum sodium due to the massive natriuresis. #### Why Other Options are Incorrect: * **SIADH:** While SIADH also causes hyponatremia, it is characterized by **euvolemia or slight hypervolemia** with **oliguria** (concentrated urine). The presence of polyuria in this question definitively rules out SIADH. * **Central Diabetes Insipidus (DI):** DI presents with polyuria, but it causes **hypernatremia** (due to loss of free water) rather than hyponatremia. * **Shunt Block:** This would present with signs of increased intracranial pressure (vomiting, headache, altered sensorium) but does not typically cause specific electrolyte disturbances like hyponatremia with polyuria. #### NEET-PG High-Yield Pearls: * **Differentiating CSW vs. SIADH:** The key differentiator is **Volume Status**. CSW = Hypovolemia (Dehydration/Polyuria); SIADH = Euvolemia (Normal skin turgor/Oliguria). * **Treatment:** CSW is treated with **volume and sodium replacement** (Normal saline or 3% NaCl), whereas SIADH is treated with **fluid restriction**. * **TBM Association:** TBM is a common trigger for both SIADH and CSW; always check urine output and volume status to distinguish them.

Question 62: Microcephaly is related to which of the following conditions?

A. Alexander disease
B. Tuberous sclerosis
C. Cowden disease
D. Schizophrenia (Correct Answer)

Explanation: **Explanation:** **Correct Option: D. Schizophrenia** While Schizophrenia is primarily a psychiatric disorder, it is increasingly recognized as a neurodevelopmental condition. Neuroimaging and post-mortem studies have consistently demonstrated structural brain abnormalities in schizophrenic patients, including **reduced intracranial volume** and **decreased gray matter volume**. This reduction in brain size often manifests as a lower-than-average head circumference (microcephaly) compared to healthy controls, likely due to impaired neurogenesis or excessive synaptic pruning during development. **Analysis of Incorrect Options:** * **A. Alexander Disease:** This is a leukodystrophy caused by mutations in the *GFAP* gene. It typically presents with **macrocephaly** (megalencephaly) due to the accumulation of Rosenthal fibers and white matter destruction. * **B. Tuberous Sclerosis:** While it causes cortical tubers and subependymal nodules, it is not classically associated with microcephaly. In some cases, it can lead to obstructive hydrocephalus (due to SEGA), which would cause **macrocephaly**. * **C. Cowden Disease:** Part of the PTEN hamartoma tumor syndrome, this condition is a classic cause of **macrocephaly** (specifically megalencephaly) along with multiple hamartomas. **High-Yield Clinical Pearls for NEET-PG:** * **Macrocephaly (Megalencephaly) Differentials:** Alexander disease, Canavan disease, Cowden syndrome, Sotos syndrome, and Neurofibromatosis type 1. * **Microcephaly Differentials:** TORCH infections (especially Zika and CMV), Fetal Alcohol Syndrome, Down Syndrome, and Rett Syndrome. * **Schizophrenia Fact:** The most common structural finding on MRI in Schizophrenia is **enlargement of the lateral ventricles** (ventriculomegaly) secondary to decreased cortical volume.

Question 63: All of the following are associated with Apraxia, EXCEPT?

A. No motor disability is seen (Correct Answer)
B. Gross and fine motor skills are affected
C. Speech and language are affected
D. Poor attention span and poor concentration

Explanation: ### Explanation **Apraxia** (specifically Developmental Coordination Disorder or Childhood Apraxia of Speech) is a neurological disorder characterized by the **inability to perform learned, purposeful movements** despite having the physical desire and the capacity to move. #### Why Option A is the Correct Answer The statement "No motor disability is seen" is **incorrect** regarding Apraxia, making it the right choice for an "EXCEPT" question. By definition, Apraxia is a **motor planning disorder**. While the patient has normal muscle strength, tone, and coordination (no paralysis or ataxia), they exhibit a significant **functional motor disability** because the brain cannot coordinate the complex muscle movements required to execute a task. #### Analysis of Other Options * **Option B (Gross and fine motor skills):** Patients often struggle with "clumsiness." They have difficulty with gross motor tasks (jumping, riding a bike) and fine motor tasks (buttoning a shirt, handwriting) because these require sequential motor planning. * **Option C (Speech and language):** **Childhood Apraxia of Speech (CAS)** is a specific subtype where the child knows what they want to say, but the brain fails to plan the precise sequence of jaw, lip, and tongue movements, leading to unintelligible speech. * **Option D (Attention and concentration):** Apraxia frequently co-exists with ADHD or learning disabilities. The intense mental effort required to plan basic movements often leads to a short attention span and easy distractibility. #### NEET-PG High-Yield Pearls * **Key Distinction:** In Apraxia, the "hardware" (muscles/nerves) is intact, but the "software" (motor programming in the posterior parietal cortex or premotor cortex) is faulty. * **Constructional Apraxia:** Inability to draw or build simple configurations (often seen in right parietal lobe lesions). * **Ideomotor Apraxia:** The most common type; the patient cannot perform a task on command (e.g., "pretend to brush your teeth") but may do it spontaneously. * **Management:** Long-term repetitive physical, occupational, and speech therapy.

Question 64: A 2-year-old female child, normal at birth with normal early development, now presents with microcephaly, regression of acquired language and motor milestones, along with abnormal stereotypic hand-wringing movements. What is the most likely diagnosis?

A. Angelman syndrome
B. Rett syndrome (Correct Answer)
C. Asperger syndrome
D. Metachromatic leukodystrophy

Explanation: **Explanation:** The clinical presentation described is classic for **Rett syndrome**, a neurodevelopmental disorder predominantly affecting females. It is caused by a mutation in the **MECP2 gene** on the X chromosome. **Why Rett Syndrome is correct:** The hallmark of Rett syndrome is a period of **normal early development** (usually 6–18 months) followed by a rapid **regression** in language and motor skills. Key diagnostic features present in this case include: * **Acquired Microcephaly:** Deceleration of head growth is a characteristic early sign. * **Stereotypic Hand Movements:** Purposeful hand use is replaced by repetitive, involuntary movements like **hand-wringing**, clapping, or washing. * **Loss of Milestones:** Regression of speech and gait. **Why the other options are incorrect:** * **Angelman Syndrome:** Characterized by "happy puppet" demeanor (frequent laughter), ataxia, and seizures. While it involves intellectual disability, it lacks the specific regression and hand-wringing pattern of Rett. * **Asperger Syndrome:** Now part of the Autism Spectrum Disorder (ASD) continuum; it involves social challenges and restricted interests but **does not** feature regression of motor milestones or microcephaly. * **Metachromatic Leukodystrophy:** A lysosomal storage disease causing progressive demyelination. While it involves motor regression, it typically presents with upper motor neuron signs (spasticity) and peripheral neuropathy, not stereotypic hand movements. **High-Yield Clinical Pearls for NEET-PG:** * **Genetics:** X-linked dominant; usually lethal in males (hence seen almost exclusively in females). * **Respiratory pattern:** Patients often exhibit episodes of hyperventilation followed by apnea during wakefulness. * **Seizures:** Common in up to 80% of affected children. * **Scoliosis:** A frequent long-term orthopedic complication.

Question 65: Which of the following statements is false regarding simple benign febrile seizures?

A. It is the commonest seizure disorder of childhood.
B. Has no genetic predisposition. (Correct Answer)
C. Commonly occurs between 6 months to 1 year of age.
D. It is usually a generalized tonic-clonic seizure.

Explanation: ### Explanation **1. Why Option B is the Correct (False) Statement:** Febrile seizures have a **strong genetic predisposition**. A positive family history is found in approximately 25–40% of cases. The inheritance pattern is often polygenic, though some cases follow an autosomal dominant pattern (e.g., GEFS+ syndrome). Therefore, stating there is "no genetic predisposition" is medically incorrect. **2. Analysis of Other Options:** * **Option A (True):** Febrile seizures are indeed the **most common** seizure disorder in the pediatric population, affecting 2–5% of children. * **Option C (True):** The typical age range is **6 months to 5 years**, with the peak incidence occurring between 12–18 months. Since 6 months to 1 year falls within this range, it is a true clinical observation. * **Option D (True):** By definition, a **Simple Febrile Seizure** must be **generalized** (usually tonic-clonic), last less than 15 minutes, and not recur within 24 hours. **3. High-Yield Clinical Pearls for NEET-PG:** * **Simple vs. Complex:** Complex febrile seizures are focal, last >15 minutes, or occur >1 time in 24 hours. * **Risk of Epilepsy:** The risk of developing epilepsy after a simple febrile seizure is only ~1–2% (near the baseline population risk), whereas complex seizures carry a higher risk (5–10%). * **Management:** The drug of choice for an active seizure is **Intravenous/Rectal Diazepam** or **Intranasal Midazolam**. Prophylaxis (Intermittent Diazepam) is only considered if seizures are frequent or cause significant parental anxiety. * **Lumbar Puncture (LP):** Always consider LP in infants <12 months to rule out meningitis, as fever and seizures are its hallmark.

Question 66: A 4-year-old child is observed to hold his eyelids open with his fingers and to close one eye periodically, especially in the evening. He has some trouble swallowing his food. He usually appears sad, although he laughs often enough. He can throw a ball, and he runs well. Which of the following is likely to result in the diagnosis?

A. Muscle biopsy
B. Creatine phosphokinase (CPK)
C. Effect of a test dose of endrophonium (Correct Answer)
D. Chest x-ray

Explanation: ### Explanation The clinical presentation is classic for **Juvenile Myasthenia Gravis (JMG)**. The child exhibits hallmark signs of fluctuating muscle weakness and fatigability: * **Ptosis:** Holding eyelids open with fingers and closing one eye (to compensate for diplopia). * **Diurnal Variation:** Symptoms worsen in the evening as neurotransmitters are depleted. * **Bulbar Symptoms:** Difficulty swallowing. * **"Myasthenic Snarl":** Appearing "sad" despite laughing refers to facial muscle weakness that prevents a normal smile. * **Normal Gross Motor:** Preserved ability to run and throw a ball distinguishes this from muscular dystrophies. **Why the correct answer is right:** The **Edrophonium (Tensilon) test** is a diagnostic tool for Myasthenia Gravis. Edrophonium is a short-acting acetylcholinesterase inhibitor that increases the availability of acetylcholine at the neuromuscular junction, leading to a rapid, transient improvement in muscle strength (especially ptosis). **Why other options are incorrect:** * **Muscle Biopsy (A):** Used for muscular dystrophies or inflammatory myopathies (e.g., Dermatomyositis). In MG, muscle morphology is typically normal. * **Creatine Phosphokinase (B):** CPK levels are elevated in primary muscle diseases (like Duchenne Muscular Dystrophy). In MG, CPK is characteristically normal because the pathology is at the synapse, not the muscle fiber. * **Chest X-ray (D):** While performed to look for a **Thymoma**, it is a staging/screening tool rather than a primary diagnostic test for the disease itself. Thymomas are also much rarer in children than in adults with MG. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Single-fiber electromyography (SFEMG) is the most sensitive; Anti-AChR antibody testing is the most specific. * **Ice Pack Test:** A bedside alternative to Edrophonium; cold improves neuromuscular transmission in MG. * **Association:** Always screen for thyroid dysfunction and other autoimmune disorders in JMG patients.

Question 67: Which type of cerebral palsy is seen as a sequelae to bilirubin encephalopathy in the neonatal period?

A. Spastic Quadriplegia
B. Spastic Hemiplegia
C. Dyskinetic cerebral palsy (Correct Answer)
D. Hypotonic cerebral palsy

Explanation: **Explanation:** **Why Dyskinetic Cerebral Palsy is Correct:** Bilirubin encephalopathy (Kernicterus) occurs when unconjugated bilirubin crosses the blood-brain barrier. It has a specific predilection for the **Basal Ganglia** (particularly the globus pallidus and subthalamic nuclei). Since the basal ganglia are responsible for the coordination and regulation of voluntary motor movements, damage to this area results in **Dyskinetic (Athetoid) Cerebral Palsy**. This is characterized by involuntary, purposeless movements (choreoathetosis) and fluctuating muscle tone. **Why the Other Options are Incorrect:** * **Spastic Quadriplegia/Hemiplegia:** Spastic types of CP are typically caused by damage to the **Pyramidal tract** or motor cortex. Spastic quadriplegia is most commonly associated with severe hypoxic-ischemic encephalopathy (HIE) or periventricular leukomalacia (PVL) in preterm infants. * **Hypotonic Cerebral Palsy:** This is a rare form often associated with genetic syndromes or diffuse cerebellar/cortical damage. While some CP cases start with an initial hypotonic phase, it is not the classic sequelae of bilirubin toxicity. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of Kernicterus:** 1. Choreoathetoid cerebral palsy, 2. Sensorineural hearing loss (high-frequency), and 3. Gaze abnormalities (upward gaze palsy). * **MRI Finding:** The characteristic imaging finding in chronic bilirubin encephalopathy is increased T2 signal intensity in the **Globus Pallidus**. * **Dental Finding:** Bilirubin staining can lead to **enamel hypoplasia** and green-stained deciduous teeth. * **Most common cause of CP overall:** Spastic Diplegia (often linked to prematurity).

Question 68: A baby on examination shows unilateral Moro's reflex with a positive palmar grasp reflex. What is the most likely site of the lesion?

A. C3–C4
B. C5–C6 (Correct Answer)
C. C8–T1
D. C1–C2

Explanation: ### Explanation The clinical presentation described is characteristic of **Erb’s Palsy**, which results from an injury to the upper trunk of the brachial plexus, specifically the **C5–C6** nerve roots. **1. Why C5–C6 is correct:** The **Moro reflex** requires the abduction and extension of the upper limb (mediated by C5–C6). In Erb’s Palsy, the paralysis of the deltoid, supraspinatus, and biceps leads to an asymmetrical or unilateral Moro reflex on the affected side. However, the **Palmar Grasp reflex** is mediated by the **C8–T1** nerve roots. Since the lower trunk is intact in Erb’s Palsy, the grasp reflex remains positive (present). This "asymmetric Moro + present grasp" is the classic diagnostic hallmark of an upper brachial plexus injury. **2. Why other options are incorrect:** * **C8–T1 (Klumpke’s Palsy):** This involves the lower trunk. In this condition, the Moro reflex is usually present (as C5–C6 are intact), but the **Palmar Grasp reflex is absent**. It typically presents with a "claw hand." * **C3–C4:** Injury here would primarily affect the phrenic nerve, leading to diaphragmatic palsy and respiratory distress, rather than isolated limb weakness. * **C1–C2:** High cervical cord injuries are usually fatal or result in complete quadriplegia and respiratory failure, not a unilateral peripheral nerve deficit. **Clinical Pearls for NEET-PG:** * **Erb’s Palsy Position:** "Waiters tip" or "Porter’s tip" deformity (Arm adducted, internally rotated, forearm extended and pronated). * **Associated Sign:** Look for **Phrenic nerve palsy** (C3-C5) if there is associated respiratory distress (Hofmann’s sign). * **Total Plexus Palsy (C5–T1):** Both Moro and Palmar Grasp reflexes will be absent. * **Prognosis:** Most cases of Erb’s palsy resolve spontaneously with physical therapy, but C8–T1 injuries (Klumpke’s) generally have a poorer prognosis.

Question 69: Which of the following statements is false about Sacral Meningomyelocele?

A. Spasticity of the lower limbs is seen (Correct Answer)
B. Hydrocephalus is seen
C. Bladder incontinence may be seen
D. Lax anal sphincter is present

Explanation: **Explanation:** The correct answer is **A (Spasticity of the lower limbs is seen)** because this statement is false. Meningomyelocele is a type of neural tube defect where the spinal cord and meninges protrude through a vertebral defect. This results in a **Lower Motor Neuron (LMN)** type of lesion at and below the level of the defect. Consequently, patients present with **flaccid paralysis**, hypotonia, and areflexia, rather than spasticity (which is a feature of Upper Motor Neuron lesions). **Analysis of other options:** * **Option B (Hydrocephalus):** This is a common association. Over 80-90% of children with meningomyelocele develop hydrocephalus, often due to the associated **Chiari II malformation**, which obstructs CSF flow. * **Option C & D (Bladder/Bowel involvement):** Since the sacral nerves (S2-S4) control the detrusor muscle and anal sphincter, a sacral lesion typically leads to a neurogenic bladder (incontinence/dribbling) and a lax anal sphincter (fecal incontinence). **Clinical Pearls for NEET-PG:** 1. **Level of Lesion:** The most common site is the lumbosacral region. 2. **Prevention:** Supplementation of **Folic Acid (400 mcg/day)** pre-conceptionally reduces the risk by 70%. For mothers with a previous affected child, the dose is increased to **4 mg/day**. 3. **Screening:** Elevated **Maternal Serum Alpha-Fetoprotein (MSAFP)** at 16-18 weeks gestation is a key screening marker. 4. **Associated Malformation:** Always look for **Arnold-Chiari Malformation Type II** (downward displacement of the cerebellum and medulla).

Question 70: A 3-year-old child presents with a history of one episode of generalized tonic-clonic seizure lasting for 3-4 minutes, 6 hours ago, accompanied by a fever of 102°F and mild coryza. On examination, the child is conscious and alert, hemodynamically stable, and has no meningeal signs. Which of the following is true about the child's condition?

A. Antiepileptics should be started and given for at least 2 years.
B. Intermittent prophylaxis with Clobazam is recommended. (Correct Answer)
C. Lumbar puncture and CSF study should be done.
D. Paracetamol will decrease the recurrence risk of seizures.

Explanation: This case describes a **Simple Febrile Seizure**. The child meets the criteria: age (6 months to 5 years), generalized seizure type, duration <15 minutes, and no recurrence within 24 hours. ### Why Option B is Correct In children with febrile seizures, **intermittent prophylaxis** is indicated if there is significant parental anxiety or a high risk of recurrence. **Clobazam** (0.5–1 mg/kg/day) or oral Diazepam is administered only during the febrile episode (starting at the onset of fever and continuing for 48–72 hours) to elevate the seizure threshold. ### Why Other Options are Incorrect * **Option A:** Long-term antiepileptic therapy (e.g., Valproate) is not indicated for simple febrile seizures. It is only considered for atypical/complex cases or if there is an underlying neurological deficit. * **Option C:** Lumbar puncture is not routinely required for a 3-year-old who is conscious, alert, and lacks meningeal signs. It is primarily considered in infants <12 months or if meningitis is clinically suspected. * **Option D:** While antipyretics like Paracetamol improve the child's comfort, clinical trials have shown they **do not reduce the risk of seizure recurrence** during that febrile illness. ### High-Yield Clinical Pearls for NEET-PG * **Most common age group:** 6 months to 5 years (Peak: 18 months). * **Simple vs. Complex:** Complex seizures are focal, last >15 minutes, or occur >1 time in 24 hours. * **Risk of Epilepsy:** Only ~1–2% (similar to the general population) for simple febrile seizures. * **Risk Factors for Recurrence:** Age <1 year, low degree of fever at onset, family history of febrile seizures, and short duration between fever onset and seizure.

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Seizure Disorders and Epilepsy

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Febrile Seizures

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Headache Disorders

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Cerebral Palsy

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Neural Tube Defects

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Neuromuscular Disorders

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Neurodegenerative Disorders

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CNS Infections

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Hydrocephalus

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Movement Disorders

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Traumatic Brain Injury

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Neuroimaging in Pediatrics

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Neurology — MCQs

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