Neurology — MCQs
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A 54-year-old woman presents with progressive memory loss and language difficulties. MRI shows asymmetric temporal lobe atrophy. CSF shows tau elevation but normal amyloid. What is the most likely diagnosis?
A 63-year-old man presents with progressive memory loss and falls. His wife reports her is out violent dreams. He has visual hallucinations of animals. What is the most likely diagnosis?
A 27-year-old woman presents with sudden onset severe headache during intercourse. Of head shows subarachnoid hemorrhage. What is the most likely cause?
A 42-year-old man presents with progressive weakness in his hands and forearms over 12 months. He has muscle fasciculations but preserved reflexes. EMG shows chronic denervation. What is the most likely diagnosis?
A 58-year-old diabetic presents with sudden painless loss of vision in his left eye. Fundoscopy shows a swollen pale optic disc. What is the most likely diagnosis?
A 65-year-old man presents with progressive hearing loss and tinnitus in his right ear. Weber test lateralizes to the left. Rinne test is positive bilaterally. What type of hearing loss is this?
A 27-year-old man presents with acute psychosis and abnormal movements. He has a family history of similar symptoms. Slit-lamp examination shows brown deposits in the cornea. What is the most likely diagnosis?
A 65-year-old man presents with progressive weakness in his arms and legs over 6 months. He has difficulty swallowing and his speech is slurred. On examination, there is muscle wasting, fasciculations, and hyperreflexia. What is the most likely diagnosis?
A 40-year-old woman presents with recurrent episodes of severe headache lasting 4-12 hours, associated with nausea, vomiting, and photophobia. The headaches are preceded by visual aura consisting of zigzag lines. What is the most likely diagnosis?
A 70-year-old man presents with sudden onset weakness of his right face, arm, and leg. He is unable to speak but appears to understand commands. CT head shows no hemorrhage. What type of stroke is this most likely to be?
Neurology UK Medical PG Practice Questions and MCQs
Question 11: A 54-year-old woman presents with progressive memory loss and language difficulties. MRI shows asymmetric temporal lobe atrophy. CSF shows tau elevation but normal amyloid. What is the most likely diagnosis?
- A. Alzheimer's disease
- B. Frontotemporal dementia (Correct Answer)
- C. Lewy body dementia
- D. Vascular dementia
- E. Creutzfeldt-Jakob disease
Explanation: ***Frontotemporal dementia***- This presentation, dominated by early **language difficulties** (Primary Progressive Aphasia, PPA) along with progressive memory loss, and **asymmetric temporal lobe atrophy** is pathognomonic for the semantic variant of FTD (svPPA).- The critical CSF finding is **normal amyloid (Aβ42)**, which strongly argues against typical Alzheimer's disease pathology, thus favoring FTD, which is linked to tau or **TDP-43 proteinopathies**.*Alzheimer's disease*- While AD causes memory loss, early predominant **language deficits** are less typical; standard AD imaging shows bilateral **hippocampal/posterior cortical atrophy**, not asymmetric temporal atrophy.- Classical AD pathology is associated with abnormal amyloid processing, resulting in **decreased CSF Aβ42** (or elevated Aβ42/Aβ40 ratio), which contradicts the normal amyloid results shown here.*Lewy body dementia*- LBD's core features include **fluctuating cognition**, recurrent **detailed visual hallucinations**, and spontaneous **parkinsonism**; these are absent in the patient's presentation.- Imaging typically shows milder or preserved medial temporal lobes, and CSF findings often differ, sometimes showing only moderate non-specific elevation of tau.*Vascular dementia*- This condition is often characterized by a **stepwise cognitive decline** following cerebrovascular events, commonly affecting executive function before memory.- MRI results characteristic of vascular dementia would show extensive **white matter hyperintensities** or evidence of multiple territorial infarcts, rather than focal, progressive atrophy.*Creutzfeldt-Jakob disease*- CJD is characterized by **rapidly progressive dementia** (dementia progressing over weeks to months) and typically presents with **myoclonus** (startle movements) and ataxia.- MRI findings are usually diffuse, showing characteristic **DWI/FLAIR hyperintensities** in the cortical ribbon and/or basal ganglia, which is distinct from focal asymmetric atrophy.
Question 12: A 63-year-old man presents with progressive memory loss and falls. His wife reports her is out violent dreams. He has visual hallucinations of animals. What is the most likely diagnosis?
- A. Alzheimer's disease
- B. Parkinson's disease dementia
- C. Lewy body dementia (Correct Answer)
- D. Vascular dementia
- E. Frontotemporal dementia
Explanation: ***Lewy body dementia***- The clinical presentation involves the classic triad of **dementia**, recurrent **visual hallucinations** (often well-formed, non-threatening images like animals), and **parkinsonism** (leading to falls).- The presence of **violent dreams** indicates **REM sleep behavior disorder (RBD)**, which is a highly suggestive supportive feature often preceding or occurring early in the course of LBD.*Alzheimer's disease*- While it causes memory loss, AD is less likely to present early with prominent **visual hallucinations**, significant **parkinsonism** (falls), and **REM sleep behavior disorder**.- AD typically features cortical symptoms like early episodic memory loss, with motor symptoms developing much later in the disease course.*Parkinson's disease dementia*- This diagnosis requires that the **motor symptoms (parkinsonism)** must precede the onset of **dementia** by at least one year (the '**1-year rule**').- Given that the presentation emphasizes memory loss concurrently with falls and other symptoms, LBD is the preferred diagnosis over PDD, though the underlying pathology is similar.*Vascular dementia*- VasD usually presents with a **stepwise decline** in cognition and prominent deficits in **executive function**, often linked to focal ischemic lesions on brain imaging.- **Visual hallucinations**, severe **parkinsonism**, and **RBD** are not characteristic features of pure vascular dementia.*Frontotemporal dementia*- FTD primarily presents with significant changes in **personality** and **social behavior** (behavioral variant) or **language dysfunction** (aphasia).- Memory loss and **falls** may occur, but early visual hallucinations and **RBD** are not typical core diagnostic criteria for FTD.
Question 13: A 27-year-old woman presents with sudden onset severe headache during intercourse. Of head shows subarachnoid hemorrhage. What is the most likely cause?
- A. Arteriovenous malformation
- B. Berry aneurysm (Correct Answer)
- C. Carotid dissection
- D. Venous thrombosis
- E. Hypertensive hemorrhage
Explanation: ***Berry aneurysm*** - Rupture of a **berry aneurysm** is the single most common cause of non-traumatic **subarachnoid hemorrhage (SAH)**, accounting for about 80% of cases. - The sudden onset of a severe headache (thunderclap headache) immediately following activities that transiently increase blood pressure, such as **intercourse** or straining, is the classic presentation of an aneurysmal rupture. *Arteriovenous malformation* - While AVMs are the second most common cause of SAH, they generally present with associated **intraparenchymal hemorrhage**, seizures, or progressive neurological deficits. - AVM rupture accounts for only a minority of acute, isolated non-traumatic SAH cases compared to **berry aneurysms**. *Carotid dissection* - Carotid dissection typically presents with ipsilateral neck pain, head pain, and features of **cerebral ischemia** (stroke) or **Horner syndrome**. - Isolated SAH is an extremely uncommon presentation of cervical carotid dissection, which primarily involves the vessel wall. *Venous thrombosis* - Cerebral venous thrombosis usually manifests with signs of raised intracranial pressure (severe headache, nausea) and focal deficits secondary to underlying **venous infarction**. - While hemorrhage may occur in the infarcted area, pure SAH is rare unless the event is massive or extends directly into the subarachnoid space. *Hypertensive hemorrhage* - **Hypertensive hemorrhage** is the most common cause of spontaneous **intraparenchymal hemorrhage**, typically affecting areas like the basal ganglia, not predominantly the subarachnoid space. - Such hemorrhages are strongly associated with long-standing, poorly controlled hypertension, which is less likely to be the primary cause of SAH in a young, otherwise healthy patient.
Question 14: A 42-year-old man presents with progressive weakness in his hands and forearms over 12 months. He has muscle fasciculations but preserved reflexes. EMG shows chronic denervation. What is the most likely diagnosis?
- A. Cervical myelopathy
- B. Progressive muscular atrophy (Correct Answer)
- C. Amyotrophic lateral sclerosis
- D. Spinal muscular atrophy
- E. Inclusion body myositis
Explanation: ***Progressive muscular atrophy***\n - This disorder is a pure **Lower Motor Neuron (LMN)** variant of Motor Neuron Disease (MND), characterized by progressive muscle weakness, **atrophy**, and **fasciculations**.\n - The key differentiating feature from ALS is the sparing of the Upper Motor Neurons (UMNs), which explains why the reflexes are **preserved** (or absent, but not hyperreflexic).\n*Cervical myelopathy*\n - Significant cervical myelopathy typically presents with mixed LMN signs at the level of compression and **UMN signs** (e.g., hyperreflexia) below the level of compression/lesion in the cord.\n - The isolated LMN signs (fasciculations, chronic denervation) without corresponding sensory findings or UMN signs make this diagnosis less likely.\n*Amyotrophic lateral sclerosis*\n - ALS is characterized by degeneration of **both Upper Motor Neurons (UMNs)** and Lower Motor Neurons (LMNs).\n - The diagnosis requires evidence of UMN pathology (e.g., hyperreflexia, spasticity, Babinski sign), which is absent in this patient who has preserved reflexes.\n*Spinal muscular atrophy*\n - While SMA is a pure LMN disease, it is a genetically determined condition primarily characterized by onset in **infancy or childhood** due to loss of the **SMN1 gene**.\n - Adult-onset forms (Type 4) are rare and generally slowly progressive, but the sporadic, isolated LMN presentation in a 42-year-old is classically described as **Progressive Muscular Atrophy (PMA)**.\n*Inclusion body myositis*\n - This is an **inflammatory myopathy** (muscle disease), not a primary motor neuron disease; therefore, it usually lacks prominent features associated with denervation, such as widespread **fasciculations**.\n - IBM classically involves the **quadriceps** and forearm finger flexor muscles, and diagnosis requires confirmation via muscle biopsy showing distinctive rimmed vacuoles.
Question 15: A 58-year-old diabetic presents with sudden painless loss of vision in his left eye. Fundoscopy shows a swollen pale optic disc. What is the most likely diagnosis?
- A. Central retinal artery occlusion
- B. Central retinal vein occlusion
- C. Anterior ischemic optic neuropathy (Correct Answer)
- D. Diabetic retinopathy
- E. Vitreous hemorrhage
Explanation: ***Anterior ischemic optic neuropathy***- The presentation of **sudden, painless loss of vision** in a **diabetic** patient, coupled with a **swollen pale optic disc** on fundoscopy, is highly characteristic of **anterior ischemic optic neuropathy (AION)**.- AION occurs due to **ischemia of the optic nerve head**, often associated with systemic **vascular risk factors** like diabetes and hypertension.*Central retinal artery occlusion*- Fundoscopy typically reveals a **pale retina** with a **cherry-red spot** in the fovea, indicating an occluded central retinal artery, which differs from the described swollen optic disc.- While causing **sudden painless vision loss**, CRAO affects retinal perfusion rather than primarily the optic nerve head.*Central retinal vein occlusion*- Fundoscopy presents with a characteristic "**blood and thunder**" appearance, including **diffuse retinal hemorrhages**, dilated tortuous veins, and **optic disc edema**, which is more extensive than a simple pale, swollen disc.- Vision loss can be sudden or gradual, but the extensive retinal hemorrhage is a key differentiating feature.*Diabetic retinopathy*- While prevalent in diabetics, this condition typically causes **gradual vision loss** and shows signs like **microaneurysms**, **hemorrhages**, **exudates**, and sometimes **neovascularization** on fundoscopy, not an acutely swollen pale optic disc.- Sudden, severe vision loss in diabetic retinopathy is more often due to complications like **vitreous hemorrhage** or **retinal detachment**, which have distinct fundoscopic features.*Vitreous hemorrhage*- This condition causes **sudden vision loss** and on fundoscopy, there would be **obscuration of retinal details** and loss of the red reflex due to blood within the vitreous cavity, rather than a clearly visible swollen optic disc.- It is a common complication of **proliferative diabetic retinopathy**, but the fundoscopic findings are different from those described.
Question 16: A 65-year-old man presents with progressive hearing loss and tinnitus in his right ear. Weber test lateralizes to the left. Rinne test is positive bilaterally. What type of hearing loss is this?
- A. Conductive hearing loss
- B. Sensorineural hearing loss (Correct Answer)
- C. Mixed hearing loss
- D. Functional hearing loss
- E. Normal hearing
Explanation: ***Sensorineural hearing loss*** - The **Weber test lateralizing to the left ear** indicates a sensorineural deficit in the contralateral (right) ear, as sound is perceived louder in the ear with better **bone conduction** relative to air conduction if the other ear has sensorineural loss. - A **positive Rinne test bilaterally (AC > BC)** confirms that there is no significant conductive component in either ear, supporting sensorineural involvement in the symptomatic right ear.*Conductive hearing loss* - With **conductive hearing loss**, the Weber test would lateralize to the *affected* ear (the right ear in this scenario), due to the **occlusion effect** making bone conduction seem louder. - The Rinne test would be **negative (BC > AC)** in the affected right ear, indicating a problem with sound transmission through the outer or middle ear.*Mixed hearing loss* - **Mixed hearing loss** would involve elements of both conductive and sensorineural loss, meaning the Rinne test would likely be negative in the affected ear. - This condition would present with a combination of conductive and sensorineural findings on audiometry, which is not fully supported by the given test results. *Functional hearing loss* - **Functional hearing loss** (or non-organic hearing loss) is a psychological condition with no organic cause. - This diagnosis is typically made after excluding organic causes and often presents with inconsistent or contradictory audiometric test results, unlike the clear pattern seen here. *Normal hearing* - A patient with **normal hearing** would not present with progressive hearing loss and tinnitus in one ear. - While a positive Rinne bilaterally and non-lateralizing Weber are consistent with normal hearing, the presence of symptoms rules out this option.
Question 17: A 27-year-old man presents with acute psychosis and abnormal movements. He has a family history of similar symptoms. Slit-lamp examination shows brown deposits in the cornea. What is the most likely diagnosis?
- A. Schizophrenia
- B. Wilson's disease (Correct Answer)
- C. Huntington's disease
- D. Drug-induced psychosis
- E. Bipolar disorder
Explanation: ***Wilson's disease***- The constellation of acute psychosis, abnormal movements (neurological dysfunction), and the pathognomonic finding of **Kayser-Fleischer rings** (brown deposits in the cornea seen on slit-lamp exam) strongly confirms the diagnosis of **Wilson's disease**, an autosomal recessive disorder of copper metabolism.- This inherited condition typically presents in adolescence or early adulthood, causing abnormal **copper deposition** leading to liver damage and neuropsychiatric symptoms such as **dysarthria**, tremor, psychiatric changes, and dystonia.*Schizophrenia*- While psychosis is a key feature, **Schizophrenia** is a primary psychiatric illness that does not cause progressive abnormal movements or the characteristic **Kayser-Fleischer rings** seen in copper storage disorders.- Psychiatric symptoms in Wilson's disease can mimic schizophrenia, but the presence of objective neurological signs and KF rings rules out a diagnosis of primary schizophrenia.*Huntington's disease*- Huntington's disease is characterized by progressive **chorea**, psychological changes, and dementia, but it is an **autosomal dominant** disorder and usually presents later in life (30s–50s).- This condition does not involve **copper accumulation** and therefore does not cause **Kayser-Fleischer rings**. *Drug-induced psychosis*- Drug-induced psychosis is an acute toxicology finding and would not explain the patient's strong **family history** or the presence of the chronic, specific deposit of copper in the cornea (**Kayser-Fleischer rings**).- It generally presents only with psychiatric symptoms and lacks the objective neurological findings (abnormal movements) seen here. *Bipolar disorder*- Bipolar disorder is a primary mood disorder characterized by cyclical episodes of mania and depression, sometimes involving psychosis.- It does not cause progressive neurological deterioration, **abnormal movements**, or the systemic finding of copper deposition and **Kayser-Fleischer rings**.
Question 18: A 65-year-old man presents with progressive weakness in his arms and legs over 6 months. He has difficulty swallowing and his speech is slurred. On examination, there is muscle wasting, fasciculations, and hyperreflexia. What is the most likely diagnosis?
- A. Multiple sclerosis
- B. Myasthenia gravis
- C. Motor neuron disease (Correct Answer)
- D. Guillain-Barré syndrome
- E. Cervical myelopathy
Explanation: ***Motor neuron disease*** - The co-existence of **Upper Motor Neuron (UMN)** signs (hyperreflexia) and **Lower Motor Neuron (LMN)** signs (wasting, fasciculations) in the limbs, along with **bulbar symptoms** (dysphagia, slurred speech), is the classic presentation of **Amyotrophic Lateral Sclerosis (ALS)**, the most common form of MND.- The progression of symptoms over 6 months is consistent with the relentless, neurodegenerative nature of this disease.*Multiple sclerosis* - MS is characterized by episodic or progressive central nervous system demyelination that predominantly causes **UMN signs** (spasticity) and lacks LMN signs such as **muscle wasting** and **fasciculations**.- It typically involves sensory, visual, or cerebellar pathways and does not present with this constellation of diffuse UMN/LMN/bulbar deficits simultaneously.*Myasthenia gravis* - MG causes fluctuating, fatigable muscle weakness, mediated by **acetylcholine receptor antibodies**, but it is a disorder of the neuromuscular junction, not the motor neurons.- Key differentiating features are the absence of **wasting**, **fasciculations**, and **hyperreflexia**.*Guillain-Barré syndrome* - GBS is an **acute** demyelinating process characterized by rapidly ascending paralysis and purely **LMN signs** (e.g., severe weakness and **areflexia**).- The 6-month progressive course and the presence of hyperreflexia rule out this typically acute and monophasic illness.*Cervical myelopathy* - Cervical myelopathy can cause mixed UMN/LMN signs, but it rarely causes diffuse, symmetrical progression and is typically localized, lacking the characteristic **bulbar involvement** (dysphagia, dysarthria) seen here.
Question 19: A 40-year-old woman presents with recurrent episodes of severe headache lasting 4-12 hours, associated with nausea, vomiting, and photophobia. The headaches are preceded by visual aura consisting of zigzag lines. What is the most likely diagnosis?
- A. Tension headache
- B. Cluster headache
- C. Migraine with aura (Correct Answer)
- D. Temporal arteritis
- E. Subarachnoid hemorrhage
Explanation: ***Migraine with aura*** - The presentation of recurrent, severe headaches lasting 4-12 hours, accompanied by **nausea**, **vomiting**, and **photophobia**, meets the primary criteria for a migraine. - The presence of a preceding **visual aura** (e.g., scintillating scotomas or zigzag lines) confirms the specific diagnosis of **migraine with aura**.*Tension headache* - Tension headaches are typically **mild to moderate**, bilateral, and described as a non-pulsatile **tightening or pressure**. - They are generally not associated with severe autonomic features like **nausea** and **vomiting**, nor do they present with an aura.*Cluster headache* - Cluster headaches are characterized by extremely severe, **unilateral pain** in the orbital, supraorbital, or temporal regions, lasting 15 to 180 minutes. - They are associated with **ipsilateral cranial autonomic symptoms** (e.g., lacrimation, miosis, rhinorrhea) but generally **do not involve aura**.*Temporal arteritis* - This condition typically affects patients over the age of **50** and is associated with systemic inflammation, **jaw claudication**, and **tender temporal arteries**. - It does not present with recurrent episodes preceded by the **classic visual aura** seen in this patient.*Subarachnoid hemorrhage* - SAH presents as a sudden, maximal intensity **“thunderclap” headache** and is not typically recurrent or preceded by an aura. - It is a medical emergency frequently associated with signs of **meningismus** (nuchal rigidity) or altered mental status.
Question 20: A 70-year-old man presents with sudden onset weakness of his right face, arm, and leg. He is unable to speak but appears to understand commands. CT head shows no hemorrhage. What type of stroke is this most likely to be?
- A. Lacunar stroke
- B. Posterior circulation stroke
- C. Total anterior circulation stroke (Correct Answer)
- D. Partial anterior circulation stroke
- E. Transient ischemic attack
Explanation: ***Total anterior circulation stroke***- The patient's presentation with sudden onset **dense right-sided weakness** (face, arm, leg) and **expressive aphasia** (unable to speak but understands commands) indicates a significant lesion affecting a large part of the cerebral hemisphere.- This clinical picture includes both dense motor/sensory deficit and higher cortical dysfunction (aphasia), fulfilling the diagnostic criteria for a **Total Anterior Circulation Stroke (TACS)**, typically involving the proximal **Middle Cerebral Artery** or internal carotid artery. *Lacunar stroke*- **Lacunar strokes** typically result in pure motor, pure sensory, or ataxic hemiparesis, but *do not* involve **cortical signs** such as aphasia, neglect, or homonymous hemianopia.- These strokes are caused by **small vessel disease** affecting deep brain structures like the internal capsule or basal ganglia, not the extensive cortical areas implied by the patient's symptoms. *Posterior circulation stroke*- Symptoms of a **posterior circulation stroke** often include **ataxia**, vertigo, nystagmus, diplopia, cranial nerve palsies, or **crossed deficits** (e.g., facial weakness on one side, body weakness on the other).- The specific combination of dense hemiparesis and aphasia is highly indicative of **anterior circulation** involvement, not typically seen in isolated posterior circulation events. *Partial anterior circulation stroke*- A **Partial Anterior Circulation Stroke (PACS)** involves **two of the three** major TACS criteria (e.g., motor/sensory deficit plus higher cortical dysfunction, or motor/sensory deficit plus homonymous hemianopia) or isolated higher cortical dysfunction.- This patient's presentation with both dense motor/sensory deficits and aphasia suggests a more extensive lesion covering all three components, making TACS a more fitting diagnosis. *Transient ischemic attack*- A **Transient Ischemic Attack (TIA)** is characterized by **transient neurological symptoms** that resolve completely, by definition within 24 hours, without evidence of acute infarction on imaging.- The description of sudden onset and sustained weakness implies an ongoing or established stroke, not a transient event, as there is no mention of symptom resolution.
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