Neurology — MCQs
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A 69-year-old woman with Alzheimer's dementia (MMSE 14/30) is admitted with aspiration pneumonia. She has been treated with donepezil 10 mg daily for 18 months. Her daughter asks whether the medication should be continued during this acute illness. What is the most appropriate advice?
A 31-year-old woman with known epilepsy presents to the Emergency Department following three seizures over 30 minutes. She remains unconscious between seizures. IV access is obtained. What is the most appropriate first-line treatment?
A 62-year-old man with atrial fibrillation on warfarin (INR 2.8) presents 90 minutes after sudden onset left hemiparesis and dysphasia. CT head shows no haemorrhage. NIHSS score is 16. His renal function is normal. Which immediate management is most appropriate?
A 66-year-old man presents with a 12-month history of progressive cognitive decline. His wife reports personality changes with disinhibited behaviour and apathy. He has developed a sweet tooth and repetitive behaviours. MMSE is 23/30 with relatively preserved memory but poor verbal fluency. MRI shows frontal and anterior temporal lobe atrophy. What is the most likely diagnosis?
A 44-year-old woman presents with recurrent episodes of severe headache over 3 months. Each episode lasts 2-3 hours, occurs 2-3 times per week, and involves severe left temporal throbbing pain with nausea, photophobia, and phonophobia. She takes paracetamol, ibuprofen, and sumatriptan 12-15 days per month with limited relief. What is the most likely diagnosis?
A 78-year-old woman is admitted with confusion. Her daughter reports a 4-day history of increasing disorientation and visual hallucinations of children in her room. She was started on oxybutynin for urinary incontinence 2 weeks ago. On examination, she is agitated, disoriented in time and place, has a temperature of 38.1°C, and her abbreviated mental test score is 3/10. What is the most appropriate initial investigation?
A 58-year-old man with type 2 diabetes presents with a 3-week history of severe right-sided facial pain. He describes electric shock-like pains lasting seconds, triggered by chewing and touching his face. Examination shows no sensory deficit. MRI brain shows a vascular loop in contact with the right trigeminal nerve. What is the first-line medical treatment?
A 25-year-old woman has her first generalised tonic-clonic seizure. She describes a 2-year history of brief episodes occurring shortly after waking where her right arm jerks involuntarily for a few seconds without loss of consciousness. EEG shows generalised polyspike and wave discharges. What is the most likely diagnosis?
A 70-year-old woman presents with sudden onset left-sided weakness and dysphasia. CT head performed within 2 hours shows no haemorrhage. She has a history of atrial fibrillation but stopped warfarin 6 months ago. Her NIHSS score is 14. Blood pressure is 185/105 mmHg. Blood glucose is 8.2 mmol/L. What is the most appropriate immediate management?
A 52-year-old woman describes episodes where she experiences an unpleasant rising epigastric sensation, followed by impaired awareness lasting 1-2 minutes during which she makes chewing movements and picks at her clothes. Afterwards she is confused for several minutes. EEG shows spikes in the left temporal region. What is the most appropriate first-line antiepileptic drug?
Neurology UK Medical PG Practice Questions and MCQs
Question 71: A 69-year-old woman with Alzheimer's dementia (MMSE 14/30) is admitted with aspiration pneumonia. She has been treated with donepezil 10 mg daily for 18 months. Her daughter asks whether the medication should be continued during this acute illness. What is the most appropriate advice?
- A. Continue donepezil at current dose (Correct Answer)
- B. Discontinue donepezil permanently as MMSE indicates severe disease
- C. Reduce donepezil dose to 5 mg during acute illness
- D. Stop donepezil temporarily and restart after recovery
- E. Switch to rivastigmine patch during acute illness
Explanation: ***Continue donepezil at current dose***- Sudden **discontinuation** of acetylcholinesterase inhibitors like **donepezil** can lead to rapid **cognitive decline** and worsening of behavioral symptoms that may not be reversible upon restarting.- Current guidelines recommend continuing cognitive enhancers during **acute illness** unless there are specific contraindications such as **severe bradycardia**, gastrointestinal obstruction, or severe active vomiting.*Discontinue donepezil permanently as MMSE indicates severe disease*- An MMSE score of 14/30 represents **moderate dementia**, not severe; donepezil is clinically indicated for use in **mild to moderate** stages and often continued into severe stages.- Permanent cessation should only be considered if there is evidence of lack of clinical benefit or **intolerable side effects**, rather than the presence of an intercurrent infection.*Reduce donepezil dose to 5 mg during acute illness*- There is no clinical indication for **dose reduction** during an acute infection like **aspiration pneumonia** if the patient has been stable on 10 mg for 18 months.- Reducing the dose risks losing the achieved **neuroprotective benefits** and stabilizing effects of the medication at a time when the patient is already physiologically stressed.*Stop donepezil temporarily and restart after recovery*- Temporary cessation is unnecessary and potentially harmful due to the risk of **rebound cognitive impairment** and increased **delirium risk** during hospitalization.- If the patient can still take oral medications or if the drug can be administered via a **nasogastric tube**, it should be maintained throughout the admission.*Switch to rivastigmine patch during acute illness*- Switching to a **rivastigmine patch** is not indicated unless the patient is unable to swallow or is experiencing severe **GI side effects** from oral donepezil.- Routine switching of stable medications during acute illness increases the risk of **drug errors** and side effects without providing additional therapeutic benefit for the pneumonia.
Question 72: A 31-year-old woman with known epilepsy presents to the Emergency Department following three seizures over 30 minutes. She remains unconscious between seizures. IV access is obtained. What is the most appropriate first-line treatment?
- A. IV lorazepam 4 mg (Correct Answer)
- B. IV phenytoin 15-18 mg/kg
- C. Rectal diazepam 10 mg
- D. IM midazolam 10 mg
- E. IV levetiracetam 40 mg/kg
Explanation: ***IV lorazepam 4 mg*** - The patient is in **status epilepticus**, defined as two or more seizures without recovery of consciousness between them; **IV lorazepam** is the gold-standard first-line treatment when **IV access** is available. - It is preferred over other benzodiazepines due to its **rapid onset** and longer duration of action within the central nervous system. *IV phenytoin 15-18 mg/kg* - This is a **second-line** treatment used if seizures persist after two doses of a benzodiazepine. - Phenytoin requires **cardiac monitoring** and is administered more slowly, making it inappropriate for immediate initial stabilization. *Rectal diazepam 10 mg* - Rectal administration is only indicated when **IV access cannot be obtained**, which is not the case here. - It has a shorter duration of action compared to lorazepam and is generally less effective in an **emergency department** setting. *IM midazolam 10 mg* - **Intramuscular midazolam** is a first-line option specifically when **intravenous access** has not yet been established. - Since this patient already has functional **IV access**, IV lorazepam is the preferred route due to more predictable pharmacokinetics. *IV levetiracetam 40 mg/kg* - Like phenytoin, levetiracetam is considered a **second-line anti-epileptic drug (AED)** for status epilepticus. - It is used only after **benzodiazepines** have failed to terminate the seizure activity.
Question 73: A 62-year-old man with atrial fibrillation on warfarin (INR 2.8) presents 90 minutes after sudden onset left hemiparesis and dysphasia. CT head shows no haemorrhage. NIHSS score is 16. His renal function is normal. Which immediate management is most appropriate?
- A. Administer IV alteplase immediately
- B. Administer prothrombin complex concentrate and IV alteplase (Correct Answer)
- C. Give aspirin 300 mg and start IV heparin
- D. Withhold all treatment until INR <1.7
- E. Arrange urgent mechanical thrombectomy without thrombolysis
Explanation: ***Administer prothrombin complex concentrate and IV alteplase*** - In acute ischaemic stroke, thrombolysis with **IV alteplase** is generally contraindicated if the **INR is >1.7** due to the high risk of haemorrhage. - Rapid reversal of **warfarin** using **Prothrombin Complex Concentrate (PCC)** can lower the INR to safe levels (≤1.7) within minutes, allowing for safe administration of thrombolysis within the 4.5-hour window. *Administer IV alteplase immediately* - Direct administration of thrombolytics while the patient has an **INR of 2.8** is unsafe and significantly increases the risk of **symptomatic intracranial haemorrhage**. - Current guidelines strictly mandate checking the coagulation profile in patients on warfarin before proceeding with **fibrinolytic therapy**. *Give aspirin 300 mg and start IV heparin* - **Aspirin** should be delayed for at least 24 hours after thrombolysis and is not the primary treatment for hyperacute stroke within the thrombolysis window. - **IV heparin** is not indicated for the acute management of ischaemic stroke and may increase the risk of **haemorrhagic transformation** without improving outcomes. *Withhold all treatment until INR <1.7* - Waiting for the **INR** to drop naturally would result in the closure of the therapeutic window for thrombolysis, leading to worse neurological outcomes ("time is brain"). - Unlike **Vitamin K**, which takes hours to work, PCC provides the immediate reversal necessary to proceed with **reperfusion therapy**. *Arrange urgent mechanical thrombectomy without thrombolysis* - While this patient is a candidate for **mechanical thrombectomy** (NIHSS 16, large vessel occlusion likely), thrombolysis should not be withheld if it can be safely delivered via reversal. - Standard of care is "bridging therapy" where **alteplase** is administered alongside the arrangement of **thrombectomy** to maximize the chances of recanalization.
Question 74: A 66-year-old man presents with a 12-month history of progressive cognitive decline. His wife reports personality changes with disinhibited behaviour and apathy. He has developed a sweet tooth and repetitive behaviours. MMSE is 23/30 with relatively preserved memory but poor verbal fluency. MRI shows frontal and anterior temporal lobe atrophy. What is the most likely diagnosis?
- A. Alzheimer's disease
- B. Vascular dementia
- C. Frontotemporal dementia (Correct Answer)
- D. Dementia with Lewy bodies
- E. Normal pressure hydrocephalus
Explanation: ***Frontotemporal dementia*** - This presentation is classic for **behavioral variant FTD**, characterized by early **personality changes**, **disinhibition**, apathy, a newfound **preference for sweets**, and **repetitive behaviours**. - Neuroimaging typically demonstrates focal **frontal and anterior temporal lobe atrophy**, which correlates with the poor **verbal fluency** and behavioral symptoms despite relatively preserved memory. *Alzheimer's disease* - Primarily presents with **early episodic memory loss** (e.g., difficulty recalling recent events) rather than prominent behavioral changes as the initial symptom. - Neuroimaging usually shows **hippocampal atrophy** and posterior parietal/temporal involvement, not focal frontal-lobe predominant atrophy. *Vascular dementia* - Characterized by a **stepwise decline** in cognitive function related to **cerebrovascular events** or chronic white matter ischemia. - Diagnosis requires evidence of **focal neurological signs** or relevant vascular burden on imaging, which is absent in this description. *Dementia with Lewy bodies* - Features a clinical triad of **fluctuating cognition**, recurrent **visual hallucinations**, and spontaneous **parkinsonism**. - While it can involve neuropsychiatric symptoms, it does not typically show the focal **frontal lobe atrophy** seen on this patient's MRI. *Normal pressure hydrocephalus* - Presents with the classic clinical triad of **gait disturbance** ("magnetic gait"), **urinary incontinence**, and cognitive impairment. - Imaging characteristically shows **ventriculomegaly** out of proportion to sulcal atrophy, not focal frontal/temporal atrophy.
Question 75: A 44-year-old woman presents with recurrent episodes of severe headache over 3 months. Each episode lasts 2-3 hours, occurs 2-3 times per week, and involves severe left temporal throbbing pain with nausea, photophobia, and phonophobia. She takes paracetamol, ibuprofen, and sumatriptan 12-15 days per month with limited relief. What is the most likely diagnosis?
- A. Chronic migraine
- B. Medication overuse headache (Correct Answer)
- C. Cluster headache
- D. Tension-type headache
- E. Hemicrania continua
Explanation: ***Medication overuse headache*** - The patient's frequent use of acute headache medications (paracetamol, ibuprofen, sumatriptan) for **12-15 days per month** for over 3 months, combined with recurrent severe headaches, strongly points to **medication overuse headache (MOH)**. - MOH is characterized by headache occurring **≥15 days per month** in a patient with a pre-existing primary headache disorder, caused by regular overuse of acute symptomatic medication. *Chronic migraine* - **Chronic migraine** is defined by headache occurring on **≥15 days per month** for at least 3 months, with at least 8 days per month having migraine features. - While the patient experiences frequent headaches with migraine features, the extensive use of abortive medications is the more immediate and crucial diagnosis of **medication overuse headache**, which often underlies and exacerbates chronic migraine. *Cluster headache* - **Cluster headaches** typically involve excruciating, strictly **unilateral periorbital, supraorbital, or temporal pain** lasting 15-180 minutes, accompanied by prominent **ipsilateral autonomic symptoms** (e.g., lacrimation, rhinorrhea, ptosis). - The patient's symptoms (nausea, photophobia, phonophobia) are classic migraine features, and the lack of characteristic autonomic symptoms differentiate it from cluster headache. *Tension-type headache* - **Tension-type headache** is usually described as a bilateral, pressing or tightening pain of mild to moderate intensity, typically **not throbbing** and **not associated with nausea, photophobia, or phonophobia**. - The patient's description of severe **left temporal throbbing pain** with associated nausea, photophobia, and phonophobia is inconsistent with a typical tension-type headache. *Hemicrania continua* - **Hemicrania continua** is characterized by a **continuous, strictly unilateral headache** of moderate intensity with superimposed exacerbations of severe pain, and it shows an **absolute response to indomethacin**. - The patient's headaches are episodic, lasting 2-3 hours and occurring 2-3 times per week, rather than continuous, and there's no mention of indomethacin responsiveness.
Question 76: A 78-year-old woman is admitted with confusion. Her daughter reports a 4-day history of increasing disorientation and visual hallucinations of children in her room. She was started on oxybutynin for urinary incontinence 2 weeks ago. On examination, she is agitated, disoriented in time and place, has a temperature of 38.1°C, and her abbreviated mental test score is 3/10. What is the most appropriate initial investigation?
- A. CT head
- B. Urinalysis and culture (Correct Answer)
- C. Serum thyroid function tests
- D. Lumbar puncture
- E. EEG
Explanation: ***Urinalysis and culture*** - This patient presents with **acute delirium** (disorientation, agitation, and visual hallucinations); in elderly patients, a **Urinary Tract Infection (UTI)** is the most common reversible cause of such presentations. - The presence of a **fever (38.1°C)** strongly points toward an underlying infection, making a screen for **urosepsis** the most appropriate and immediate diagnostic step. *CT head* - Indicated primarily when there is a history of **head trauma**, new **focal neurological deficits**, or signs of raised intracranial pressure. - While important in some cases of confusion, it is less urgent than ruling out common **sepsis** or metabolic triggers in a febrile elderly patient. *Serum thyroid function tests* - Hypo- or hyperthyroidism can cause cognitive changes, but they typically lead to a more **subacute or chronic** metabolic encephalopathy rather than an acute febrile delirium. - These tests are part of a **dementia screen** or workup for persistent confusion but are not the priority in the acute stage of suspected infection. *Lumbar puncture* - Reserved for cases where **meningitis** or **encephalitis** is suspected, usually accompanied by neck stiffness, photophobia, or extreme lethargy. - It is an invasive procedure and should only be performed after more common sources of infection, like **UTIs or pneumonia**, have been excluded. *EEG* - Primarily used in the evaluation of **non-convulsive status epilepticus** or specific encephalopathies like Creutzfeldt-Jakob disease. - Although delirium shows **generalized slowing** on an EEG, it lacks the specificity needed to identify the underlying trigger and does not guide initial management.
Question 77: A 58-year-old man with type 2 diabetes presents with a 3-week history of severe right-sided facial pain. He describes electric shock-like pains lasting seconds, triggered by chewing and touching his face. Examination shows no sensory deficit. MRI brain shows a vascular loop in contact with the right trigeminal nerve. What is the first-line medical treatment?
- A. Carbamazepine (Correct Answer)
- B. Gabapentin
- C. Amitriptyline
- D. Sumatriptan
- E. Prednisolone
Explanation: ***Carbamazepine*** - The clinical presentation of **paroxysmal**, electric shock-like pain triggered by tactile stimuli, along with MRI evidence of **neurovascular compression** of the trigeminal nerve, is classic for **trigeminal neuralgia**. - **Carbamazepine** is the established **first-line medical treatment** for trigeminal neuralgia, working by stabilizing inactivated sodium channels and reducing neuronal excitability. *Gabapentin* - While effective for various forms of **neuropathic pain** and sometimes used in trigeminal neuralgia, **gabapentin** is generally considered a second-line agent or an add-on therapy. - It is typically reserved for patients who cannot tolerate or do not respond adequately to **carbamazepine** or oxcarbazepine. *Amitriptyline* - **Amitriptyline**, a **tricyclic antidepressant**, is commonly used for chronic neuropathic pain syndromes such as **post-herpetic neuralgia** or **fibromyalgia**. - It is not considered a first-line agent for the acute, paroxysmal, and distinct electric shock-like pain characteristic of **trigeminal neuralgia**. *Sumatriptan* - **Sumatriptan** is a **5-HT1B/1D receptor agonist** primarily used for the acute treatment of **migraine** and **cluster headaches**. - It has no role in the management of **trigeminal neuralgia**, which is a condition involving the trigeminal nerve itself, often due to compression. *Prednisolone* - **Prednisolone**, a corticosteroid, is used for inflammatory conditions like **temporal arteritis** or certain autoimmune neuropathies. - **Trigeminal neuralgia** is typically caused by neurovascular compression, not inflammation, so **corticosteroids** are not an effective treatment.
Question 78: A 25-year-old woman has her first generalised tonic-clonic seizure. She describes a 2-year history of brief episodes occurring shortly after waking where her right arm jerks involuntarily for a few seconds without loss of consciousness. EEG shows generalised polyspike and wave discharges. What is the most likely diagnosis?
- A. Temporal lobe epilepsy
- B. Juvenile myoclonic epilepsy (Correct Answer)
- C. Panayiotopoulos syndrome
- D. Focal motor epilepsy with secondary generalisation
- E. Progressive myoclonic epilepsy
Explanation: ***Juvenile myoclonic epilepsy*** - Characterized by **myoclonic jerks** that occur shortly after waking, often of the upper limbs, and a **generalized tonic-clonic seizure**, typically presenting in adolescence or early adulthood. - The EEG showing **generalized polyspike and wave discharges** is a diagnostic hallmark, especially in a young adult with these clinical features. *Temporal lobe epilepsy* - Presents with **focal seizures** involving altered awareness, often preceded by a distinct **aura** (e.g., epigastric rising, olfactory hallucinations). - EEG typically shows **focal epileptiform discharges** or slowing localized to the **temporal regions**, not generalized polyspike discharges. *Panayiotopoulos syndrome* - This is a benign childhood epilepsy, typically affecting children aged **3 to 6 years**, not a 25-year-old adult. - Seizures are characterized by prominent **autonomic symptoms** (e.g., vomiting, pallor) and are often **nocturnal**, which differs from the patient's presentation. *Focal motor epilepsy with secondary generalisation* - While the arm jerks are focal, the crucial differentiating factor is the EEG showing **generalized polyspike and wave discharges**, not focal epileptiform activity preceding generalization. - The characteristic onset shortly after waking and the generalized EEG pattern point away from a purely focal onset with secondary generalization. *Progressive myoclonic epilepsy* - A rare group of severe disorders characterized by myoclonus, tonic-clonic seizures, and **progressive neurological decline** (e.g., ataxia, dementia). - The patient's 2-year history lacks any mention of **neurological deterioration**, which is a defining feature of this condition.
Question 79: A 70-year-old woman presents with sudden onset left-sided weakness and dysphasia. CT head performed within 2 hours shows no haemorrhage. She has a history of atrial fibrillation but stopped warfarin 6 months ago. Her NIHSS score is 14. Blood pressure is 185/105 mmHg. Blood glucose is 8.2 mmol/L. What is the most appropriate immediate management?
- A. Administer IV alteplase and defer antihypertensive treatment
- B. Reduce blood pressure to below 185/110 mmHg then administer IV alteplase (Correct Answer)
- C. Start aspirin 300 mg immediately
- D. Arrange CT angiography before any treatment
- E. Administer IV alteplase and commence IV labetalol simultaneously
Explanation: ***Reduce blood pressure to below 185/110 mmHg then administer IV alteplase*** - This patient presents with acute ischemic stroke symptoms within the **4.5-hour window**, has no hemorrhage on CT, and a high **NIHSS score (14)**, making her a candidate for **IV alteplase**. - However, the patient's current blood pressure of 185/105 mmHg is above the threshold; it must be lowered to **below 185/110 mmHg** *before* alteplase administration to minimize the risk of **symptomatic intracranial hemorrhage**. *Administer IV alteplase and defer antihypertensive treatment* - Administering **alteplase** with a blood pressure at or above **185/110 mmHg** is a major contraindication due to the significantly increased risk of **hemorrhagic transformation**. - Blood pressure *must* be reduced promptly using intravenous agents like **labetalol** or **nicardipine** prior to initiating thrombolysis. *Start aspirin 300 mg immediately* - For patients eligible for **IV thrombolysis**, aspirin is strictly contraindicated for **24 hours** after the alteplase infusion to prevent an increased risk of bleeding. - Aspirin is the immediate management only if thrombolysis is contraindicated or the patient presents outside the eligible time window. *Arrange CT angiography before any treatment* - While **CT angiography** is crucial for identifying **large vessel occlusions** for potential **endovascular thrombectomy**, it should not delay the administration of **IV alteplase** in an eligible patient. - The principle of "**time is brain**" dictates that thrombolysis should be initiated as soon as non-contrast CT excludes **hemorrhage** and blood pressure is controlled. *Administer IV alteplase and commence IV labetalol simultaneously* - Current guidelines stipulate that the target blood pressure of **<185/110 mmHg** must be achieved *prior* to starting the **alteplase** bolus. - Simultaneous administration does not guarantee that the blood pressure is adequately controlled *before* the thrombolytic agent exerts its effects, thus increasing the risk of **intracranial hemorrhage**.
Question 80: A 52-year-old woman describes episodes where she experiences an unpleasant rising epigastric sensation, followed by impaired awareness lasting 1-2 minutes during which she makes chewing movements and picks at her clothes. Afterwards she is confused for several minutes. EEG shows spikes in the left temporal region. What is the most appropriate first-line antiepileptic drug?
- A. Lamotrigine or levetiracetam (Correct Answer)
- B. Sodium valproate
- C. Carbamazepine
- D. Phenytoin
- E. Ethosuximide
Explanation: ***Lamotrigine or levetiracetam*** - The patient's presentation with a **rising epigastric sensation**, **impaired awareness**, **automatisms** (chewing movements, picking at clothes), and **post-ictal confusion** are classic features of **focal seizures with impaired awareness**, specifically originating from the **temporal lobe** as indicated by the EEG spikes. - Both **Lamotrigine** and **Levetiracetam** are recommended as first-line monotherapy for focal seizures due to their broad efficacy, good tolerability profile, and fewer drug interactions compared to older antiepileptics. *Sodium valproate* - While effective for various seizure types, **sodium valproate** is typically considered a primary option for **generalized epilepsies** and is less preferred as first-line for focal seizures compared to newer agents. - It carries significant **teratogenic risks**, including neural tube defects and developmental delays, making it a less suitable choice for women of childbearing potential unless no other options are available and a pregnancy prevention program is in place. *Carbamazepine* - **Carbamazepine** was historically a first-line agent for focal seizures but is now often bypassed due to its **enzyme-inducing properties**, which lead to numerous drug-drug interactions, and its potential for more adverse effects. - It can cause side effects such as **hyponatremia** and has a higher risk of teratogenicity compared to newer drugs like lamotrigine or levetiracetam. *Phenytoin* - **Phenytoin** is generally considered a second- or third-line antiepileptic drug for chronic management of focal seizures due to its **narrow therapeutic index** and dose-dependent, non-linear pharmacokinetics, making dosing challenging. - Long-term use is associated with notable side effects including **gingival hyperplasia**, **hirsutism**, **acne**, and potentially **cerebellar atrophy**. *Ethosuximide* - **Ethosuximide** is specifically and exclusively indicated for the treatment of **absence seizures** (petit mal seizures) and is not effective for focal seizures or generalized tonic-clonic seizures. - Its mechanism of action involves blocking **T-type calcium channels** in the thalamus, which is specific to the pathophysiology of absence seizures and does not address the type of focal seizure seen in this patient.
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