Stroke and TIA — MCQs

10 questions

A 49-year-old man presents with progressive weakness in his arms and legs over 24 months. He has bulbar symptoms including dysphagia and dysarthria. EMG shows widespread denervation. What is the most important prognostic factor?

A 28-year-old woman presents with sudden onset severe headache during exercise. She vomits and has neck stiffness. CT head shows subarachnoid hemorrhage. What is the most likely cause?

A 41-year-old man presents with progressive weakness in his hands and arms over 12 months. He has muscle fasciculations and hyperreflexia. EMG shows both acute and chronic denervation changes. What is the prognosis?

A 48-year-old man presents with progressive weakness in his hands and forearms. He has muscle fasciculations and wasting but normal sensation. EMG shows chronic denervation in C8-T1 distribution. What is the most likely diagnosis?

A 62-year-old man presents with progressive weakness in his arms and legs over 18 months. He has difficulty speaking and swallowing. EMG shows widespread denervation. What is the most important prognostic factor?

A 57-year-old woman presents with progressive memory loss and behavioral changes. MRI shows frontotemporal atrophy. What is the most likely initial symptom domain affected?

A 67-year-old man presents with confusion, falls, and urinary incontinence over 4 months. MRI shows ventricular dilatation with periventricular changes. What is the most appropriate diagnostic test?

A 48-year-old man presents with progressive memory loss and abnormal movements. He has a family history of similar symptoms. Genetic testing confirms Huntington's disease. What is the mode of inheritance?

A 54-year-old man presents with progressive weakness in his hands and arms. He has muscle fasciculations and hyperreflexia. EMG shows both acute and chronic denervation. What is the most likely diagnosis?

Q10

A 57-year-old man presents with progressive muscle weakness and difficulty swallowing. EMG shows myopathic changes. Muscle biopsy shows rimmed vacuoles. What is the most likely diagnosis?

Stroke and TIA UK Medical PG Practice Questions and MCQs

Question 1: A 49-year-old man presents with progressive weakness in his arms and legs over 24 months. He has bulbar symptoms including dysphagia and dysarthria. EMG shows widespread denervation. What is the most important prognostic factor?

A. Age at onset
B. Rate of progression
C. Bulbar involvement (Correct Answer)
D. Site of onset
E. Family history

Explanation: ***Bulbar involvement*** - The presence of **bulbar symptoms** (dysphagia and dysarthria) at presentation or early in the disease course is the single most important predictor of shorter survival in **Amyotrophic Lateral Sclerosis (ALS)**. - This is primarily because bulbar dysfunction leads quickly to difficulty swallowing, increasing the risk of **aspiration pneumonia** and malnutrition, and often precedes necessary respiratory intervention. *Age at onset* - While a factor, **older age (>65 years)** at onset is associated with a worse prognosis but is generally considered less influential than the pattern of motor neuron involvement. - Patients with **younger onset** (e.g., in their 40s) tend to have a slightly better prognosis than those with onset in their 70s. *Rate of progression* - The **rate of progression** directly determines the prognosis (survival time) itself, reflecting the speed of motor neuron loss. - However, **bulbar involvement** is often the underlying *predictor* or characteristic that drives a rapid rate of progression, making the bulbar site the more fundamental prognostic factor. *Site of onset* - The specific **site of onset** is critical, distinguishing between **limb-onset** and **bulbar-onset** ALS. - Because bulbar onset conveys the worst prognosis, selecting the specific involvement (**bulbar**) is more precise than selecting the general concept of

Question 2: A 28-year-old woman presents with sudden onset severe headache during exercise. She vomits and has neck stiffness. CT head shows subarachnoid hemorrhage. What is the most likely cause?

A. Arteriovenous malformation
B. Berry aneurysm (Correct Answer)
C. Carotid dissection
D. Hypertensive hemorrhage
E. Trauma

Explanation: ***Berry aneurysm*** - The sudden onset of a severe, explosive **thunderclap headache** coupled with signs of meningeal irritation (vomiting, neck stiffness) and the finding of **subarachnoid hemorrhage (SAH)** on CT head is the classic presentation of a ruptured saccular (**berry**) aneurysm. - Exertion (exercise) acts as a common trigger for aneurysm rupture due to the sudden increase in **intracranial pressure** and transmural wall stress. *Arteriovenous malformation* - AVMs more commonly present with **intraparenchymal hemorrhage** (ICH) or seizures, rather than isolated SAH, especially when triggered by exertion. - While AVMs can cause SAH, they are a less frequent cause of widespread spontaneous SAH compared to ruptured **berry aneurysms**. *Carotid dissection* - Carotid artery dissection typically manifests as severe neck/facial pain, headache, and signs of **cerebral ischemia** (stroke symptoms) due to vessel stenosis or occlusion. - Dissections rarely cause primary, widespread SAH; they are more often associated with **subintimal hemorrhage** leading to stroke or pseudoaneurysm formation. *Hypertensive hemorrhage* - Hemorrhage due to chronic or severe hypertension (hypertensive hemorrhage) almost exclusively causes deep **intraparenchymal hemorrhage** (ICH), usually in the basal ganglia, thalamus, or brainstem. - The primary finding of SAH, rather than ICH and the patient's young age, makes uncontrolled hypertension highly unlikely as the underlying cause. *Trauma* - Although trauma is the single most frequent overall cause of SAH, the clinical history describes a **spontaneous event** triggered by exertion (exercise) without any external injury. - Traumatic SAH is clinically differentiated by the history of a specific injury and usually involves bleeding adjacent to the site of impact.

Question 3: A 41-year-old man presents with progressive weakness in his hands and arms over 12 months. He has muscle fasciculations and hyperreflexia. EMG shows both acute and chronic denervation changes. What is the prognosis?

A. Excellent with treatment
B. Good with supportive care
C. Variable depending on subtype
D. Poor with 3-5 year survival (Correct Answer)
E. Stable with medication

Explanation: ***Poor with 3-5 year survival*** - The presentation with **progressive weakness**, **muscle fasciculations** (lower motor neuron sign), and **hyperreflexia** (upper motor neuron sign), along with mixed **acute and chronic denervation** on EMG, is highly characteristic of **Amyotrophic Lateral Sclerosis (ALS)**. - **ALS** is a rapidly progressive neurodegenerative disease, and the typical survival time from diagnosis is **3 to 5 years**, often due to respiratory failure. *Excellent with treatment* - **ALS** is an incurable disease, and current treatments such as **Riluzole** or **Edaravone** only offer a modest slowing of disease progression or symptom management, not an excellent prognosis. - There is no known treatment that can halt or reverse the neurodegeneration characteristic of **ALS**. *Good with supportive care* - While **supportive care** (e.g., respiratory support, physical therapy, nutritional guidance) is essential for managing symptoms and improving quality of life in **ALS**, it does not alter the underlying progressive and fatal nature of the disease. - The relentless degeneration of motor neurons continues despite comprehensive supportive measures, leading to eventual paralysis and death. *Variable depending on subtype* - While there are different clinical presentations (e.g., bulbar vs. limb onset) and genetic forms of **ALS**, the overall prognosis for classic **ALS** is uniformly poor. - Although a small percentage of patients may have a longer survival, the vast majority follow a progressive course with a limited life expectancy, making a

Question 4: A 48-year-old man presents with progressive weakness in his hands and forearms. He has muscle fasciculations and wasting but normal sensation. EMG shows chronic denervation in C8-T1 distribution. What is the most likely diagnosis?

A. Cervical radiculopathy
B. Motor neuron disease (Correct Answer)
C. Carpal tunnel syndrome
D. Ulnar neuropathy
E. Brachial plexopathy

Explanation: ***Motor neuron disease*** - The combination of **progressive weakness**, muscle **fasciculations**, and **wasting** with *preserved sensation* is the classic presentation of Amyotrophic Lateral Sclerosis (**ALS**), the most common form of MND. - The EMG findings of chronic denervation in the C8-T1 distribution confirm the **Lower Motor Neuron (LMN)** damage necessary for this diagnosis. *Cervical radiculopathy* - While it can cause weakness in a specific root distribution (C8-T1), it almost invariably presents with **radicular pain** and objective **sensory loss** or paresthesia, which are absent here. - Radiculopathy is usually limited to one or two nerve roots and does not cause the widespread and progressive motor involvement characteristic of MND. *Carpal tunnel syndrome* - This is a **median nerve mononeuropathy** and primarily causes sensory disturbances (tingling/numbness) in the index and middle fingers, often sparing C8-T1 muscles like the ulnar-innervated intrinsic hand muscles. - It is a focal disorder and would not account for the extensive muscle **wasting** and **fasciculations** seen in the forearm. *Ulnar neuropathy* - This is a focal entrapment neuropathy usually causing sensory loss over the medial 1.5 digits and specific intrinsic hand muscle atrophy, not generalized forearm weakness. - Similar to CTS, this highly localized condition is typically associated with **sensory deficits** and does not explain the ongoing progressive nature or pure motor syndrome seen in MND. *Brachial plexopathy* - Damage to the brachial plexus usually results from trauma, inflammation (e.g., neuralgic amyotrophy), or infiltration. - A plexopathy would affect multiple nerve distributions and cause significant **sensory loss** or **intractable pain** in the hand/forearm, features that differentiate it from pure motor disease.

Question 5: A 62-year-old man presents with progressive weakness in his arms and legs over 18 months. He has difficulty speaking and swallowing. EMG shows widespread denervation. What is the most important prognostic factor?

A. Age at onset
B. Site of onset
C. Rate of progression
D. Bulbar involvement (Correct Answer)
E. Genetic factors

Explanation: ***Bulbar involvement***- Bulbar involvement, manifesting as **dysphagia** (difficulty swallowing) and **dysarthria** (difficulty speaking), is the single most important adverse prognostic factor in **Amyotrophic Lateral Sclerosis (ALS)**.- Patients with bulbar onset generally have a significantly shorter median survival (often <3 years) than those with limb onset, primarily due to earlier development of **respiratory failure** and aspiration pneumonia.*Age at onset*- Although *older age* (e.g., >60 years) at diagnosis is generally associated with a poorer prognosis, it is less predictive of overall survival time than the specific neuroanatomical site of disease onset.- Younger age at onset is often correlated with a slightly slower disease trajectory, but the presence of bulbar symptoms overrides this factor.*Site of onset*- The site of onset is prognostic (bulbar vs. spinal/limb), but **Bulbar involvement** is specifically highlighted as the poor prognostic indicator because it directly impairs vital functions like swallowing and breathing control.- While *spinal onset* (limb/trunk) is associated with a better prognosis, the focus must remain on the most severe factor, which is the compromise of brainstem functions.*Rate of progression*- A fast **rate of progression** (measured by declining physiological function) is highly predictive of shorter survival, but bulbar involvement is often the *cause* or *primary determinant* of this rapid decline leading to early death.- While important, the rate itself is a consequence, whereas the location of the disease (bulbar) is the fundamental factor dictating the accelerated mortality risk.*Genetic factors*- Specific genetic mutations (e.g., **C9orf72**) can influence the clinical phenotype and prognosis, but they account for only a small percentage (5-10%) of ALS cases (familial).- In the context of sporadic ALS, clinical features such as bulbar involvement are stronger and more relevant predictors of survival for the majority of patients.

Question 6: A 57-year-old woman presents with progressive memory loss and behavioral changes. MRI shows frontotemporal atrophy. What is the most likely initial symptom domain affected?

A. Memory loss
B. Language difficulties
C. Behavioral changes (Correct Answer)
D. Motor symptoms
E. Visual problems

Explanation: ***Behavioral changes***- **Frontotemporal dementia (FTD)**, indicated by **frontotemporal atrophy** on MRI, typically presents with prominent **behavioral or language changes** in its initial stages. - In **behavioral variant FTD (bvFTD)**, early symptoms include progressive changes in personality, social conduct, and executive function, such as **disinhibition**, **apathy**, or **loss of empathy**.*Memory loss*- While memory loss can occur in FTD, it is typically **not the initial or most prominent symptom** in the behavioral variant, differentiating it from Alzheimer's disease.- In bvFTD, **episodic memory** is often relatively preserved in the early stages, with more significant deficits in executive function and social cognition.*Language difficulties*- **Primary progressive aphasia (PPA)** is another major subtype of FTD where language difficulties are the initial and prominent symptom.- However, the question highlights "behavioral changes" as a key presenting feature, which is characteristic of the behavioral variant of FTD, where language issues are usually not primary.*Motor symptoms*- Motor symptoms like parkinsonism, amyotrophy (ALS-like symptoms), or supranuclear gaze palsy can be associated with specific FTD subtypes (e.g., FTD with **motor neuron disease**).- These are generally **later manifestations** or indicate distinct clinical syndromes, not typically the initial domain affected in the most common presentations of bvFTD.*Visual problems*- Visual problems are **not a typical initial symptom domain** in frontotemporal dementia.- Such symptoms are more commonly associated with posterior cortical atrophy (a variant of Alzheimer's disease) or other neurodegenerative conditions affecting visual pathways.

Question 7: A 67-year-old man presents with confusion, falls, and urinary incontinence over 4 months. MRI shows ventricular dilatation with periventricular changes. What is the most appropriate diagnostic test?

A. Lumbar puncture with pressure measurement
B. Large-volume lumbar puncture (Correct Answer)
C. CSF flow studies
D. Intracranial pressure monitoring
E. Cognitive testing

Explanation: ***Large-volume lumbar puncture*** - This procedure, often called the **CSF tap test**, is the primary diagnostic intervention for **Normal Pressure Hydrocephalus (NPH)**, which is characterized by the triad of gait disturbance, urinary incontinence, and dementia. - The removal of 30-50 mL of CSF is performed to assess for **immediate symptomatic improvement**, particularly in **gait dysfunction**, which strongly predicts a positive response to eventual ventriculoperitoneal shunting. *Lumbar puncture with pressure measurement* - While an initial step, **CSF pressure measurement** in NPH typically yields a result within the **normal range** (10-15 mmHg), confirming the "normal pressure" component but not definitively predicting surgical outcome. - Measuring only pressure does not provide the crucial information regarding symptomatic relief achieved by **CSF drainage**, which is necessary for treatment planning. *CSF flow studies* - Studies like **radionuclide cisternography** are used to confirm **abnormal CSF circulation** (e.g., failure of tracer to flow over the cerebral convexities) in NPH, supporting the diagnosis. - Although helpful, these studies are supportive imaging tests and do not directly assess the patient's functional response or **symptom improvement following CSF removal**, which is the primary goal of the tap test. *Intracranial pressure monitoring* - Continuous invasive monitoring is primarily used for evaluating hydrocephalus associated with **elevated intracranial pressure** or to characterize specific pressure waves (e.g., B-waves). - NPH is defined by **normal opening pressure**, meaning monitoring is generally considered secondary or reserved for equivocal or unclear cases after a failed **tap test**. *Cognitive testing* - Cognitive testing (e.g., MMSE or MoCA) is part of the **baseline assessment** to quantify the severity of the **dementia** component of the NPH triad. - This is a measurement tool, not a **diagnostic intervention** to establish the responsiveness of the symptoms to CSF volume reduction, unlike the tap test.

Question 8: A 48-year-old man presents with progressive memory loss and abnormal movements. He has a family history of similar symptoms. Genetic testing confirms Huntington's disease. What is the mode of inheritance?

A. Autosomal recessive
B. Autosomal dominant (Correct Answer)
C. X-linked recessive
D. X-linked dominant
E. Mitochondrial

Explanation: ***Autosomal dominant***- Huntington's disease (HD) is caused by a mutation in the **HTT gene** located on **chromosome 4**, and only one mutated copy is sufficient to cause the disease.- This inheritance pattern is characterized by **vertical transmission** (appearing in every generation) and equal prevalence in males and females, which fits the given family history.*Autosomal recessive*- This mode requires **two copies** of the mutated gene for disease expression, meaning individuals typically have unaffected carrier parents.- Autosomal recessive disorders often **skip generations**, which is inconsistent with the clear family history of similar symptoms provided.*X-linked recessive*- The gene is located on the X chromosome, typically affecting **males more severely** and being passed from carrier mothers to sons.- This is ruled out because the gene responsible for Huntington's disease (HTT) is found on an **autosomal chromosome (chromosome 4)**, not an X chromosome.*X-linked dominant*- Affected fathers pass the trait to **all daughters** but no sons, and females are usually more commonly affected than males.- This pattern is not applicable as the Huntington's disease gene is located on an **autosomal chromosome**, not the X chromosome.*Mitochondrial*- These disorders are exclusively **maternally inherited**, meaning only mothers can pass the condition to all their offspring.- The inheritance of Huntington's disease is not solely dependent on maternal lineage and follows a **Mendelian autosomal pattern**.

Question 9: A 54-year-old man presents with progressive weakness in his hands and arms. He has muscle fasciculations and hyperreflexia. EMG shows both acute and chronic denervation. What is the most likely diagnosis?

A. Cervical myelopathy
B. Amyotrophic lateral sclerosis (Correct Answer)
C. Peripheral neuropathy
D. Myasthenia gravis
E. Polymyositis

Explanation: ***Amyotrophic lateral sclerosis*** - This diagnosis is strongly supported by the simultaneous presence of **Upper Motor Neuron (UMN)** signs (**hyperreflexia**) and **Lower Motor Neuron (LMN)** signs (**fasciculations** and weakness). - The **EMG** findings of widespread **acute and chronic denervation** confirm ongoing motor neuron degeneration affecting both UMN and LMN pathways. *Cervical myelopathy* - While this can cause UMN signs (**hyperreflexia**) in the arms and legs, it typically results from focal spinal cord compression and does not cause widespread **fasciculations** or globally progressive LMN signs. - The EMG findings would typically show more focal changes, usually related to specific nerve root levels if compression is involved, rather than the extensive generalized denervation seen here. *Peripheral neuropathy* - Peripheral neuropathies primarily cause **LMN signs** (weakness, reduced/absent reflexes, fasciculations) but would not cause the associated **hyperreflexia** (UMN sign) found in this patient. - Motor and sensory involvement is common, and the pathology is confined to peripheral nerves, lacking evidence of central motor neuron damage. *Myasthenia gravis* - This condition presents with **fluctuating, fatigable weakness** that worsens throughout the day and with repetitive use, unlike the progressive, steady weakness described. - It affects the neuromuscular junction, therefore it does not cause **hyperreflexia** or **fasciculations**, which are signs of motor neuron disease. *Polymyositis* - This is an inflammatory myopathy causing **proximal muscle weakness** (difficulty rising from a chair or lifting objects) and elevated muscle enzymes (CK), but sparing the motor neurons. - Being a muscle disorder (myopathy), it does not cause **hyperreflexia** (UMN sign) or significant **fasciculations** (LMN sign).

Question 10: A 57-year-old man presents with progressive muscle weakness and difficulty swallowing. EMG shows myopathic changes. Muscle biopsy shows rimmed vacuoles. What is the most likely diagnosis?

A. Polymyositis
B. Dermatomyositis
C. Inclusion body myositis (Correct Answer)
D. Muscular dystrophy
E. Myasthenia gravis

Explanation: ***Inclusion body myositis*** - The patient's age (57-year-old), **progressive muscle weakness**, difficulty swallowing (dysphagia), and crucial finding of **rimmed vacuoles** on muscle biopsy are pathognomonic for **inclusion body myositis**. - EMG showing **myopathic changes** further supports a primary muscle disorder, and IBM typically involves distal muscles (forearm flexors) and quadriceps, making dysphagia common. *Polymyositis* - While polymyositis causes **proximal muscle weakness** and **myopathic changes** on EMG, it does not typically show **rimmed vacuoles** on muscle biopsy. - It is often associated with immune-mediated inflammation, but the specific biopsy finding guides towards IBM in this case. *Dermatomyositis* - **Dermatomyositis** is characterized by distinct **cutaneous manifestations** (e.g., Gottron's papules, heliotrope rash) in addition to proximal muscle weakness, which are absent in this patient's presentation. - Muscle biopsy in dermatomyositis typically shows perivascular and perimysial inflammation, not **rimmed vacuoles**. *Muscular dystrophy* - Most **muscular dystrophies** are inherited disorders with onset typically in childhood or adolescence, making a new diagnosis at 57 less common for classic forms. - Although they cause **myopathic changes**, the specific presence of **rimmed vacuoles** on biopsy is not a typical feature of most common muscular dystrophies. *Myasthenia gravis* - **Myasthenia gravis** is a **neuromuscular junction disorder**, not a primary muscle disease, and presents with fluctuating weakness that worsens with activity and improves with rest. - EMG in myasthenia gravis would show a **decremental response** on repetitive nerve stimulation, and muscle biopsy would be normal, without **myopathic changes** or **rimmed vacuoles**.

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