Neurology Practice Questions

Q: Raised intracranial pressure should be suspected when there is?

Sixth cranial nerve palsy. **Explanation:** **Sixth cranial nerve (Abducens nerve) palsy** is a classic sign of raised intracranial pressure (ICP) and is often referred to as a **"false localizing sign."** This occurs because the abducens nerve has the longest intracranial course of all cranial nerves. When ICP increases, the brainstem can be displaced downward, stretching the nerve against the sharp border of the petrous temporal bone or compressing it within Dorello’s canal [1]. This results in weakness of the lateral rectus muscle, leading to horizontal diplopia and an inability to abduct the eye. **Analysis of Incorrect Options:** * **A. Neck stiffness:** This is a hallmark of **meningeal irritation**, typically seen in meningitis or subarachnoid hemorrhage. While it can coexist with raised ICP, it is not a specific indicator of the pressure itself. * **C. Episodic unilateral headache:** This is the classic presentation of **Migraine**. Headaches associated with raised ICP are typically generalized, worse in the morning, and aggravated by coughing or straining (Valsalva maneuver). * **D. Unilateral ptosis:** This suggests a **Third cranial nerve (Oculomotor) palsy** or Horner’s syndrome. While a 3rd nerve palsy can occur in late-stage raised ICP (due to uncal herniation), it is usually accompanied by a fixed, dilated pupil rather than isolated ptosis [1], [2]. **High-Yield Clinical Pearls for NEET-PG:** * **Cushing’s Triad:** A late sign of raised ICP consisting of Hypertension (with widened pulse pressure), Bradycardia, and Irregular respirations [1]. * **Papilledema:** The most reliable physical sign of chronic raised ICP, though it may be absent in acute settings. * **False Localizing Signs:** Besides the 6th nerve, the 3rd nerve can also occasionally act as a false localizing sign [1].

Q: Inability to perform rapid alternating repeated movements is characteristic of which neurological sign?

Dysdiadochokinesia. **Explanation:** The inability to perform rapid alternating movements (such as pronation and supination of the hands or tapping the feet) is known as **Dysdiadochokinesia** [1]. This is a classic sign of **cerebellar dysfunction**, specifically involving the cerebellar hemispheres [1]. It occurs because the cerebellum fails to coordinate the precise timing of agonist-antagonist muscle switching required for rhythmic, repetitive tasks. **Analysis of Options:** * **Dysdiadochokinesia (Correct):** Derived from Greek (*dys* - difficult, *diadocho* - successive, *kinesia* - movement). It is tested clinically by asking the patient to "pat" the palm of one hand with the front and back of the other hand in rapid succession [1]. * **Past pointing:** Also known as hypermetria, this occurs when a patient overshoots a target during a finger-to-nose test [4]. It is a component of ataxia but specifically refers to spatial inaccuracy rather than rhythm. * **Dysmetria:** A broader term for the lack of coordination of movement typified by the underestimation (hypometria) or overestimation (hypermetria) of distance [4]. While related to cerebellar lesions, it refers to the *trajectory* and *range* of movement. * **Dyskinesia:** A general term for involuntary, abnormal movements (like chorea or tremors) typically associated with **Basal Ganglia** disorders (e.g., Parkinson’s or Levodopa-induced dyskinesia), not cerebellar rhythm [2], [3]. **NEET-PG High-Yield Pearls:** * **VANISSH** Mnemonic for Cerebellar signs: **V**ertigo, **A**taxia, **N**ystagmus (coarse), **I**ntention tremor, **S**lurred speech (Scanning speech), **S**ign of rebound, **H**ypotonia/Dysmetria/**H**eart rate (rarely used). * **Midline/Vermis lesions** result in truncal ataxia and gait instability. * **Lateral/Hemisphere lesions** result in ipsilateral limb ataxia and dysdiadochokinesia [4].

Q: Identify the type of convulsion shown below?

Myoclonic. ***Myoclonic*** - Characterized by **brief, shock-like muscle jerks** that are sudden and involuntary, typically lasting less than 100 milliseconds. - **EEG shows spike-and-wave complexes** with preserved consciousness during the brief jerking movements. *Tonic* - Involves **sustained muscle contraction** causing rigid posturing and stiffening of limbs for several seconds. - **Loss of consciousness** occurs with continuous muscle tension, not brief jerky movements. *Generalized Tonic-Clonic Seizure (GTCS)* - Begins with **tonic phase** (stiffening) followed by **clonic phase** (rhythmic jerking), lasting 1-3 minutes. - Associated with **complete loss of consciousness**, **tongue biting**, and **post-ictal confusion**, which are more severe than myoclonic jerks. *Atonic* - Characterized by **sudden loss of muscle tone** causing the patient to drop or fall ("drop attacks"). - Results in **collapse or head drop** due to muscle weakness, opposite to the jerky movements seen in myoclonic seizures.

Q: A simple partial seizure is diagnosed by which of the following investigations?

Electroencephalogram (EEG). **Explanation:** **1. Why EEG is the Correct Answer:** A seizure is defined as a transient occurrence of signs and symptoms due to abnormal excessive or synchronous neuronal activity in the brain. The diagnosis of any seizure type—including **simple partial seizures** [2] (now referred to as focal aware seizures)—is primarily clinical, but the definitive investigation to confirm and categorize the electrical nature of the event is the **Electroencephalogram (EEG)** [1]. EEG records the electrical activity of the cerebral cortex and can identify focal spikes or sharp waves in the specific brain region corresponding to the clinical symptoms [1]. **2. Why Other Options are Incorrect:** * **BAER (Brainstem Auditory Evoked Response):** This test evaluates the integrity of the auditory pathway from the ear to the brainstem. It is used for diagnosing hearing loss or brainstem lesions (like acoustic neuroma), not cortical electrical discharges. * **CT Scan & MRI:** These are **neuroimaging** modalities. While they are crucial for identifying the *structural cause* of a seizure (e.g., a tumor, stroke, or cortical dysplasia), they cannot diagnose the seizure activity itself, as a patient with epilepsy can have a perfectly normal-looking brain on imaging. **3. Clinical Pearls for NEET-PG:** * **Gold Standard:** While a routine EEG is often used, **Video-EEG monitoring** is the gold standard for diagnosing and localizing seizure foci. * **Sensitivity:** A single interictal (between seizures) EEG may be normal in up to 50% of patients with epilepsy. * **Terminology Update:** Per the latest ILAE classification, "Simple Partial Seizure" [2] is now termed a **Focal Aware Seizure**. * **MRI vs. CT:** MRI is the preferred imaging modality for epilepsy due to its superior sensitivity in detecting subtle lesions like Mesial Temporal Sclerosis (MTS).

Q: An obese 43-year-old female complains of transient visual obscuration, headache, and diplopia. All the following are associated findings EXCEPT?

Cerebral venous thrombosis. The clinical presentation of an **obese female** with **headache**, **transient visual obscurations (TVO)**, and **diplopia** (likely due to 6th nerve palsy) is a classic description of **Idiopathic Intracranial Hypertension (IIH)**, also known as Pseudotumor Cerebri. ### Why "Cerebral Venous Thrombosis" is the Correct Answer The diagnosis of IIH is based on the **Modified Dandy Criteria**, which requires the absence of any structural or systemic cause for increased intracranial pressure. **Cerebral Venous Thrombosis (CVT)** is a secondary cause of raised ICP. If CVT is present, the condition is no longer "idiopathic." Therefore, while CVT can mimic the symptoms of IIH, it is not a finding *associated* with the diagnosis of IIH itself; rather, it is a differential diagnosis that must be ruled out via MRV (Magnetic Resonance Venography). ### Explanation of Incorrect Options * **A. Papilledema:** This is the hallmark ophthalmic finding of IIH due to transmission of high CSF pressure to the optic nerve sheath. * **B. Increased intracranial pressure:** By definition, IIH involves elevated opening pressure on lumbar puncture (typically >25 cm H₂O) with normal CSF composition. * **C. 6th nerve palsy:** This occurs as a "false localizing sign." The increased ICP causes the abducens nerve to be stretched against the petrous temporal bone, leading to diplopia. ### High-Yield Clinical Pearls for NEET-PG * **Demographics:** Most common in "Fat, Fertile, Females of Forty" (though "Fertile" refers to childbearing age). * **Drugs associated with IIH:** Oral contraceptives, Tetracyclines, Vitamin A toxicity, and Steroid withdrawal. * **Visual Field Defect:** The most common field defect is an **enlarged blind spot**. * **Management:** Weight loss is primary; **Acetazolamide** is the first-line medical treatment. Surgical options include Optic Nerve Sheath Fenestration (for vision loss) or CSF shunting (for headache).

Q: Guillain-Barré syndrome can be seen following which type of immunization?

Killed Influenza vaccine. ### Explanation **Correct Option: D. Killed Influenza vaccine** Guillain-Barré Syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy. The association between GBS and the influenza vaccine was first significantly noted during the 1976 Swine Flu (H1N1) vaccination campaign. While the absolute risk is extremely low (approximately 1–2 additional cases per million doses), it remains a classic association in medical literature and exams. The underlying mechanism is believed to be **molecular mimicry**, where the immune response against vaccine antigens cross-reacts with gangliosides in the peripheral nerves. **Analysis of Incorrect Options:** * **A. Pertussis:** The Whole-cell Pertussis (wP) vaccine is more commonly associated with febrile seizures and, historically, a controversial link to encephalopathy, but not GBS. * **B. Measles:** Measles vaccination is associated with a rare risk of Subacute Sclerosing Panencephalitis (SSPE)-like symptoms in immunocompromised individuals or idiopathic thrombocytopenic purpura (ITP), but GBS is not a standard complication. * **C. Diphtheria:** Diphtheria toxoid is generally considered safe; while the diphtheria *infection* can cause neuropathy (via exotoxin), the vaccine is not a recognized trigger for GBS. **High-Yield Clinical Pearls for NEET-PG:** * **Most common antecedent infection for GBS:** *Campylobacter jejuni* (presents with bloody diarrhea). * **Other associated vaccines:** Oral Polio Vaccine (OPV) and Rabies vaccine (Neural tissue derived - Semple vaccine) have historical associations with neurological complications. * **Key CSF Finding in GBS:** **Albuminocytologic dissociation** (High protein with normal cell count). * **Treatment of choice:** Intravenous Immunoglobulin (IVIG) or Plasmapheresis. Steroids are generally not effective.

Q: Which condition commonly involves the V1 distribution of the trigeminal nerve?

Post herpetic neuralgia. **Explanation:** **1. Why Post-herpetic Neuralgia (PHN) is correct:** Post-herpetic neuralgia is a complication of Herpes Zoster (shingles), caused by the reactivation of the Varicella-Zoster Virus (VZV) latent in sensory ganglia [1]. When VZV involves the Trigeminal (V) nerve, it most frequently affects the **Ophthalmic division (V1)**, a condition known as *Herpes Zoster Ophthalmicus*. This predilection for V1 is a classic clinical hallmark, often presenting with a vesicular rash in the supraorbital region and potential corneal involvement (Hutchinson’s sign). **2. Why the other options are incorrect:** * **Trigeminal Neuralgia (Tic Douloureux):** Characterized by paroxysmal, lancinating pain, it most commonly involves the **V2 (Maxillary)** and **V3 (Mandibular)** divisions. V1 involvement is rare (only ~5% of cases). * **Trotter’s Syndrome:** This is a triad associated with nasopharyngeal carcinoma. It involves the **V3 (Mandibular)** nerve (causing numbness in the lower jaw/tongue), ipsilateral palatal paralysis (CN X), and conductive deafness (Eustachian tube blockage). * **Hunt’s Syndrome (Ramsay Hunt Syndrome):** This involves VZV reactivation in the **Geniculate ganglion of the Facial nerve (CN VII)**. It presents with facial palsy and vesicles in the external auditory canal, not primary V1 distribution. **Clinical Pearls for NEET-PG:** * **Hutchinson’s Sign:** Vesicles on the tip of the nose indicate involvement of the nasociliary branch of V1, predicting a high risk of ocular complications. * **Drug of Choice (DOC):** For PHN, first-line treatments include **Gabapentin, Pregabalin**, or Amitriptyline. * **Trigeminal Neuralgia DOC:** **Carbamazepine** remains the gold standard medical treatment.

Q: A 24-year-old woman presents with progressively worsening foot and leg weakness over the past week. Initially, she experienced tingling in her feet and difficulty lifting them, which has now progressed to difficulty standing and walking due to leg weakness. Three weeks prior, she had a resolved upper respiratory infection. On examination, muscle bulk is normal, motor strength is 2/5 in the quadriceps and 1/5 in the feet. Deep tendon reflexes at the ankles and knees are absent, and sensory testing is normal. Upper limb examination is normal. Cerebrospinal fluid shows very high protein, normal glucose, and a slightly elevated cell count. What is the most likely diagnosis?

Guillain-Barre syndrome. **Explanation:** The clinical presentation is classic for **Guillain-Barré Syndrome (GBS)**, specifically the Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP) subtype. The hallmark of GBS is an **acute, symmetric, ascending paralysis** following a triggering event (usually a respiratory or gastrointestinal infection, often *Campylobacter jejuni*) [1]. **Why GBS is correct:** 1. **Clinical Progression:** Rapidly progressive weakness starting in the lower extremities (ascending) over one week [1]. 2. **Physical Findings:** Lower Motor Neuron (LMN) signs, specifically **areflexia** (absent DTRs) and flaccid weakness [1]. 3. **CSF Analysis:** The finding of **Albuminocytologic Dissociation** (elevated protein with a normal/near-normal cell count) is pathognomonic for GBS. **Why the other options are incorrect:** * **Diabetic/Alcoholic Neuropathy:** These are typically chronic, slowly progressive, and predominantly sensory-motor "stocking-glove" neuropathies. They do not present with acute, rapidly ascending motor paralysis. * **Cyanide Poisoning:** Presents acutely with altered mental status, seizures, metabolic acidosis, and cardiovascular collapse, rather than an isolated ascending motor paralysis. **NEET-PG High-Yield Pearls:** * **Most common trigger:** *Campylobacter jejuni* (associated with the AMAN variant). * **Earliest sign:** Loss of deep tendon reflexes (Areflexia) [1]. * **Treatment:** IV Immunoglobulin (IVIG) or Plasmapheresis. **Steroids are not effective.** * **Monitoring:** Frequent monitoring of **Forced Vital Capacity (FVC)** is crucial to detect impending respiratory failure [1]. * **Miller-Fisher Syndrome:** A GBS variant characterized by the triad of Ataxia, Areflexia, and Ophthalmoplegia (associated with anti-GQ1b antibodies) [1].

Q: A 52-year-old female complains of sudden visual abnormalities. Her history reveals a 30 pack-year history of smoking, hypertension, and hypercholesterolemia. A head CT shows a lesion in the right occipital lobe, and an angiogram reveals an embolic stroke of the right posterior cerebral artery. What type of visual deficit is she most likely experiencing?

Left homonymous hemianopia. ### Explanation **1. Why the Correct Answer is Right:** The patient has suffered an embolic stroke of the **right Posterior Cerebral Artery (PCA)**, leading to an infarct in the **right occipital lobe** (primary visual cortex). * **Neuroanatomy:** The visual pathway posterior to the optic chiasm (optic tract, lateral geniculate nucleus, optic radiations, and visual cortex) carries fibers from the **contralateral** visual field. * A lesion in the right occipital lobe results in a loss of vision in the left half of the visual field in both eyes, a condition known as **Left Homonymous Hemianopia**. * *Note:* While PCA strokes often present with "macular sparing" due to collateral supply from the Middle Cerebral Artery (MCA) to the occipital pole, the primary deficit remains a homonymous hemianopia. **2. Why the Incorrect Options are Wrong:** * **A. Bitemporal hemianopia:** This occurs due to a lesion at the **optic chiasm** (e.g., pituitary adenoma), affecting the decussating nasal retinal fibers. * **B. Central scotoma:** This is typically seen in **macular degeneration** or **optic neuritis** (lesion of the macula or optic nerve). * **D. Left superior quadrantanopia:** Also known as "pie in the sky," this results from a lesion in the **Right Meyer’s Loop** (temporal lobe), not the entire occipital cortex. **3. Clinical Pearls for NEET-PG:** * **PCA Stroke Triad:** Homonymous hemianopia (with macular sparing), hemisensory loss (thalamic involvement), and alexia without agraphia (if the dominant hemisphere/splenium is involved). * **Macular Sparing:** Occurs because the occipital pole (representing the macula) has a **dual blood supply** from both the PCA and MCA. * **Rule of Thumb:** Any lesion **behind the chiasm** produces a contralateral homonymous deficit.

Question 1

Raised intracranial pressure should be suspected when there is?

Accepted Answer

Sixth cranial nerve palsy

Answer

Neck stiffness

Answer

Episodic unilateral headache

Answer

Unilateral ptosis

Question 2

Inability to perform rapid alternating repeated movements is characteristic of which neurological sign?

Accepted Answer

Dysdiadochokinesia

Answer

Past pointing

Answer

Dysmetria

Answer

Dyskinesia

Question 3

Identify the type of convulsion shown below?

Accepted Answer

Myoclonic

Answer

Tonic

Answer

Generalized Tonic-Clonic Seizure (GTCS)

Answer

Atonic

Question 4

A simple partial seizure is diagnosed by which of the following investigations?

Accepted Answer

Electroencephalogram (EEG)

Answer

Brainstem Auditory Evoked Response (BAER)

Answer

CT scan

Answer

MRI

Question 5

An obese 43-year-old female complains of transient visual obscuration, headache, and diplopia. All the following are associated findings EXCEPT?

Accepted Answer

Cerebral venous thrombosis

Answer

Papilledema

Answer

Increased intracranial pressure

Answer

6th nerve palsy

Question 6

Guillain-Barré syndrome can be seen following which type of immunization?

Accepted Answer

Killed Influenza vaccine

Answer

Pertussis

Answer

Measles

Answer

Diphtheria

Question 7

Which condition commonly involves the V1 distribution of the trigeminal nerve?

Accepted Answer

Post herpetic neuralgia

Answer

Trigeminal Neuralgia

Answer

Trotter’s syndrome

Answer

Hunt’s syndrome

Question 8

A 24-year-old woman presents with progressively worsening foot and leg weakness over the past week. Initially, she experienced tingling in her feet and difficulty lifting them, which has now progressed to difficulty standing and walking due to leg weakness. Three weeks prior, she had a resolved upper respiratory infection. On examination, muscle bulk is normal, motor strength is 2/5 in the quadriceps and 1/5 in the feet. Deep tendon reflexes at the ankles and knees are absent, and sensory testing is normal. Upper limb examination is normal. Cerebrospinal fluid shows very high protein, normal glucose, and a slightly elevated cell count. What is the most likely diagnosis?

Accepted Answer

Guillain-Barre syndrome

Answer

Diabetic neuropathy

Answer

Alcoholic neuropathy

Answer

Cyanide poisoning

Question 9

A patient with traumatic paraplegia due to injury of the T3 thoracic cord level presents with a blood pressure of 210/120. What should be the initial management?

Accepted Answer

Nifedipine

Answer

Subcutaneous low molecular weight heparin

Answer

Steroids

Answer

Normal saline / Dextrose

Question 10

A 52-year-old female complains of sudden visual abnormalities. Her history reveals a 30 pack-year history of smoking, hypertension, and hypercholesterolemia. A head CT shows a lesion in the right occipital lobe, and an angiogram reveals an embolic stroke of the right posterior cerebral artery. What type of visual deficit is she most likely experiencing?

Accepted Answer

Left homonymous hemianopia

Answer

Bitemporal hemianopia

Answer

Central scotoma

Answer

Left superior quadrantanopia

Neurology — MCQs

Neurology — MCQs

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