Neurology Practice Questions

Q: Which one of the following statements truly represents Bell's paralysis?

Idiopathic ipsilateral paralysis of the facial nerve. ***Idiopathic ipsilateral paralysis of the facial nerve*** - **Bell's palsy** is defined as an **idiopathic acute peripheral facial nerve palsy**, meaning it has no identifiable cause and affects the facial nerve directly [1]. - The paralysis is **ipsilateral**, meaning it affects the same side of the face as the affected facial nerve. *Facial nerve paralysis and contralateral Hemiparesis* - This description suggests a central nervous system lesion, possibly a stroke, which would typically cause **contralateral hemiparesis** along with **facial weakness** (often sparing the forehead) [1]. - Bell's palsy is a peripheral nerve disorder and does not present with **hemiparesis** [1]. *Combined paralysis of the facial, trigeminal and abducens nerves* - Involvement of multiple cranial nerves, such as the **facial (VII)**, **trigeminal (V)**, and **abducens (VI)**, points towards a more extensive cranial neuropathy or a lesion in the brainstem. - **Bell's palsy** specifically affects only the **facial nerve (VII)**, not other cranial nerves. *Facial nerve paralysis with uveitis and parotid enlargement* - This combination of symptoms (facial nerve paralysis, uveitis, and parotid enlargement) is characteristic of **Heerfordt's syndrome**, a rare manifestation of **sarcoidosis**. - **Bell's palsy** is not associated with uveitis or parotid gland enlargement.

Q: True about lower motor neuron palsy of VIIth nerve:

All of the options. ***All of the options*** - All statements regarding **lower motor neuron (LMN) palsy of the VIIth cranial nerve** (facial nerve) are accurate. - This type of injury affects the entire ipsilateral side of the face, including the forehead and eye, which require specific protective measures [1]. *Melkersson's syndrome causes recurrent paralysis* - **Melkersson-Rosenthal syndrome** is characterized by the triad of **facial nerve palsy** (often recurrent), **orofacial swelling**, and **fissured tongue**. - The facial palsy in this syndrome is typically a **lower motor neuron lesion**. *Forehead muscles are affected unlike upper motor neuron lesions* - In a **lower motor neuron lesion**, all muscles of the ipsilateral face, including the **frontalis muscle** (which controls the forehead), are affected due to damage to the facial nerve nucleus or its peripheral branches. - In contrast, **upper motor neuron lesions** spare the forehead muscles because the upper face receives bilateral innervation from the cerebral cortex [1]. *Eye protection is done* - Due to paralysis of the **orbicularis oculi muscle**, patients cannot fully close their eye (lagophthalmos), leading to exposure keratitis and dryness. - **Eye protection** with artificial tears, lubricating ointments, and eyelid taping is crucial to prevent corneal damage [1].

Q: L'Hermitte's sign is a characteristic feature of

Multiple sclerosis. ***Multiple sclerosis*** [1] - **L'Hermitte's sign** is a classic symptom of **demyelination** in the cervical spinal cord, commonly seen in multiple sclerosis. - It presents as an **electric shock sensation** radiating down the spine and into the limbs upon neck flexion. *Parkinsonism* - Characterized by **bradykinesia**, **rigidity**, **tremor**, and **postural instability**, without the presence of L'Hermitte's sign. - It is primarily a **movement disorder** due to dopamine depletion in the basal ganglia. *Tabes dorsalis* - This is a late-stage manifestation of **syphilis** affecting the dorsal columns of the spinal cord and dorsal roots. - Symptoms include **ataxia**, **lightning pains**, **Argyll Robertson pupils**, and loss of proprioception, not L'Hermitte's sign. *Syringomyelia* [2] - A condition involving a **fluid-filled cyst (syrinx)** within the spinal cord, leading to loss of pain and temperature sensation. - It typically causes a **cape-like distribution sensory loss** over the shoulders and arms, distinct from L'Hermitte's sign. [2]

Q: A 60-year-old man has resting tremor, pill-rolling movements, rigidity, and bradykinesia. Which of the following is most likely to be decreased in this man?

Dopamine neurons in the substantia nigra. ***Dopamine neurons in the substantia nigra*** - The symptoms described—**resting tremor**, **pill-rolling movements**, **rigidity**, and **bradykinesia**—are classic signs of **Parkinson's disease** [5]. - Parkinson's disease is pathologically characterized by the degeneration of **dopamine-producing (dopaminergic) neurons** in the **substantia nigra pars compacta**, leading to decreased dopamine levels in the **striatum** [1]. *GABA neurons in the caudate nucleus and putamen* - **GABAergic neurons** in the **caudate nucleus and putamen** are primarily affected in conditions like **Huntington's disease**, where their degeneration leads to increased involuntary movements (chorea) [4]. - While there can be secondary changes in these neurons in Parkinson's, the primary deficit is not in GABA but in dopamine. *Serotonin neurons in the raphe nuclei* - **Serotonin neurons** in the **raphe nuclei** are involved in mood regulation, sleep, and appetite, and their dysfunction is primarily linked to conditions like **depression**, anxiety, and certain sleep disorders [3]. - While some serotonergic involvement can occur in Parkinson's, it is not the primary neurological deficit explaining the motor symptoms. *Acetylcholine neurons in the forebrain* - **Acetylcholine neurons** in the **nucleus basalis of Meynert** (part of the forebrain) are primarily implicated in **Alzheimer's disease**, where their degeneration contributes to cognitive decline [2]. - While some cholinergic deficits may be present in advanced Parkinson's, they are not the hallmark pathology or the initial cause of the characteristic motor symptoms.

Q: A 79-year-old woman is brought to the clinic for assessment of frequent falls. There is no loss of consciousness associated with the falls, and she reports no postural change or symptoms prior to the falls. She also describes difficulty in "getting going" when she starts walking and notices that her balance is "not right." Her gait is slow and shuffling on inspection. Which of the following is the most likely finding in a patient with Parkinson disease?

akinesia. ***Akinesia*** - The patient's symptoms of difficulty "getting going" and slow, shuffling gait are classic descriptions of **akinesia** or **bradykinesia**, a core motor symptom of Parkinson disease [1]. - **Akinesia** refers to the absence or loss of the power of voluntary movement, often manifesting as freezing of gait or difficulty initiating movements [1]. *Muscle atrophy* - This is not a typical feature of Parkinson disease; instead, patients may experience **rigidity** and **spasticity**, but not significant muscle wasting [1]. - Muscle atrophy is more characteristic of conditions like motor neuron disease or disuse. *Fine hand tremor with movement* - Parkinson disease typically presents with a **resting tremor** which improves with voluntary movement, rather than a tremor that occurs with movement (**action tremor**) [1]. - An action tremor is more typical of **essential tremor** [1]. *Pupillary constriction* - This is not a characteristic feature of Parkinson disease. - Pupillary changes are generally not a primary diagnostic criterion for Parkinson disease.

Q: A 24-year-old female with long standing history of sinusitis present with fevers, headache (recent origin) and personality changes; Fundus examination revealed papilledema. Most likely diagnosis is:

Frontal lobe abscess. ***Frontal lobe abscess*** - The combination of **chronic sinusitis** (a potential source of infection), **fevers, headache, personality changes**, and **papilledema** (indicating increased intracranial pressure) is highly suggestive of a frontal lobe abscess [1]. - An abscess in the frontal lobe can lead to **focal neurological deficits** and changes in higher cognitive functions and personality. *Frontal bone osteomyelitis* - While chronic sinusitis can lead to **frontal bone osteomyelitis** [2], this condition primarily involves bone infection and may not directly explain the rapid onset of **personality changes** and **papilledema** without direct intracranial extension. - Although it can cause headache and fever, it's less likely to cause such profound neurological and intracranial pressure signs as the primary diagnosis. *Meningitis* - **Meningitis** typically presents with fever, headache, and **neck stiffness**, but **papilledema** is an uncommon finding, especially at presentation, unless complicated by hydrocephalus or significant brain swelling. - While personality changes can occur in severe cases, the constellation of symptoms points more towards a **space-occupying lesion**. *Encephalitis* - **Encephalitis** involves inflammation of the brain parenchyma, leading to fever, headache, and **altered mental status**, which may include personality changes. - However, **papilledema** is less common in typical encephalitis and is more indicative of a localized mass effect or significant intracranial pressure, which an abscess would cause.

Q: A 35-year-old man presents with daily headache. He describes two attacks per day over the last 3 weeks. Each attack lasts about an hour and awakens him from sleep. The patient has noticed associated tearing and reddening of the right eye as well as nasal stuffiness. The pain's deep, excruciating, and limiting to the right side of the head. The neurological examination is normal. What is the most likely diagnosis?

Cluster headache. ***Cluster headache*** - This classic presentation includes **daily, brief, severe unilateral headache attacks** often accompanied by **autonomic symptoms** (tearing, redness of eye, nasal stuffiness) and occurring in "clusters" over weeks [1]. - The pain is typically **excruciating** and often **wakes the patient from sleep**, fitting the described symptoms [1]. *Migraine headache* - While migraines can be severe, they are typically **longer-lasting** (4-72 hours) and often associated with **nausea, vomiting, photophobia, and phonophobia**, which are not mentioned here [3]. - Though unilateral, migraine pain is usually **pulsating** rather than the "deep, excruciating" quality described in cluster headache. *Brain tumour* - A brain tumour would likely present with **progressive neurological deficits**, such as focal weakness, seizures, or changes in mental status, which are absent in this case as the neurological exam is normal [4]. - Headaches associated with brain tumours are generally **progressive and persistent**, not episodic with distinct attack patterns and autonomic features like in cluster headache [2]. *Tension headache* - Tension headaches are typically described as a **mild to moderate, dull, aching pain** that feels like a band around the head, and they are usually **bilateral** [2]. - They lack the **autonomic features** and the severe, stabbing, unilateral pain characteristic of cluster headaches.

Q: Inability to abduct left eye with LMN fascial palsy on same side. The lesion is in

Left pons. ***Left pons*** - A lesion in the **left pons** can affect both the **left abducens nucleus** (leading to inability to abduct the left eye) and the **left facial nucleus or nerve fibers** (causing left lower motor neuron facial palsy). [2] - This specific combination of ipsilateral (same-sided) symptoms is characteristic of a brainstem lesion, particularly within the pons where these cranial nerve nuclei are in close proximity. [1] *Cerebellar lesions* - **Cerebellar lesions** primarily cause symptoms like **ataxia**, dysmetria, and nystagmia, but typically do not cause isolated cranial nerve palsies of the abducens and facial nerves. [1] - While coordinating movements, the cerebellum does not house the nuclei for direct eye abduction or facial muscle control. *CP angle tumor* - A **cerebellopontine (CP) angle tumor** can affect cranial nerves VI and VII, but it typically presents with other symptoms like **vestibulocochlear nerve (VIII) dysfunction (hearing loss, vertigo)** early on due to its anatomical location. - While it can eventually compress the abducens and facial nerves, the combination of **isolated abducens and facial palsy** without VIII nerve involvement points more directly to an intraparenchymal pontine lesion. *Right pons* - A lesion in the **right pons** would cause **right-sided inability to abduct the eye** and **right-sided LMN facial palsy**, not left-sided as described in the case. - Brainstem lesions typically produce ipsilateral cranial nerve deficits due to the close proximity of the nuclei and fascicles before decussation of some pathways.

Q: A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans two or three times a month would provide complete relief. Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement. Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a "pain shot." The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?

Medication overuse headache. The patient's history of increasing headache frequency and severity, decreased response to triptans, and frequent use of combination analgesics (acetaminophen, caffeine, butalbital) strongly suggests **medication overuse headache (MOH)**. This condition is characterized by daily or near-daily headaches in a patient with a primary headache disorder, caused or exacerbated by **chronic excessive use of acute headache medications** [1]. **CNS vasculitis** is less likely given the long history of headaches starting in menses (suggesting a primary headache disorder) [2]. While it can cause headaches, CNS vasculitis typically presents with acute or subacute onset of various neurological deficits. **Space-occupying intracerebral lesion** is unlikely given the normal neurological examination and absence of papilledema [2]. Headaches due to brain tumors often worsen over time, but are typically associated with other neurological signs or symptoms, such as focal deficits, which are not present here.

Q: Two or more oligoclonal bands in cerebrospinal fluid are most often positive in-

Multiple sclerosis. Multiple sclerosis - The presence of two or more oligoclonal bands (OCBs) in the cerebrospinal fluid (CSF) is a hallmark finding in multiple sclerosis (MS), indicating intrathecal immunoglobulin synthesis [1]. - OCBs are found in over 90% of MS patients, reflecting a chronic inflammatory process within the central nervous system [1]. Acute bacterial meningitis - CSF analysis in acute bacterial meningitis typically shows elevated white blood cell count (neutrophils), decreased glucose, and elevated protein, but not characteristic OCBs [2]. - While there may be a generalized immune response, it does not typically produce the specific, persistent OCB pattern seen in MS. Subarachnoid hemorrhage - CSF findings in subarachnoid hemorrhage are characterized by xanthochromia (yellow discoloration due to bilirubin), red blood cells, and elevated protein, but OCBs are not a diagnostic feature [2]. - OCBs are related to intrathecal immunoglobulin production, not the breakdown products of blood. Polyneuropathy - Polyneuropathies, such as Guillain-Barré syndrome, are characterized by albuminocytological dissociation (elevated protein with normal cell count) in CSF, or other findings depending on the specific cause. - While some inflammatory neuropathies can have CSF abnormalities, they do not typically present with the same diagnostic pattern of OCBs as observed in MS.

Question 1

Which one of the following statements truly represents Bell's paralysis?

Accepted Answer

Idiopathic ipsilateral paralysis of the facial nerve

Answer

Facial nerve paralysis and contralateral Hemiparesis

Answer

Combined paralysis of the facial, trigeminal and abducens nerves

Answer

Facial nerve paralysis with uveitis and parotid enlargement

Question 2

True about lower motor neuron palsy of VIIth nerve:

Accepted Answer

All of the options

Answer

Forehead muscles are affected unlike upper motor neuron lesions

Answer

Melkersson's syndrome causes recurrent paralysis

Answer

Eye protection is done

Question 3

L'Hermitte's sign is a characteristic feature of

Accepted Answer

Multiple sclerosis

Answer

Parkinsonism

Answer

Tabes dorsalis

Answer

Syringomyelia

Question 4

A 60-year-old man has resting tremor, pill-rolling movements, rigidity, and bradykinesia. Which of the following is most likely to be decreased in this man?

Accepted Answer

Dopamine neurons in the substantia nigra

Answer

GABA neurons in the caudate nucleus and putamen

Answer

Serotonin neurons in the raphe nuclei

Answer

Acetylcholine neurons in the forebrain

Question 5

A 79-year-old woman is brought to the clinic for assessment of frequent falls. There is no loss of consciousness associated with the falls, and she reports no postural change or symptoms prior to the falls. She also describes difficulty in "getting going" when she starts walking and notices that her balance is "not right." Her gait is slow and shuffling on inspection. Which of the following is the most likely finding in a patient with Parkinson disease?

Accepted Answer

akinesia

Answer

muscle atrophy

Answer

fine hand tremor with movement

Answer

pupillary constriction

Question 6

A 24-year-old female with long standing history of sinusitis present with fevers, headache (recent origin) and personality changes; Fundus examination revealed papilledema. Most likely diagnosis is:

Accepted Answer

Frontal lobe abscess

Answer

Frontal bone osteomyelitis

Answer

Meningitis

Answer

Encephalitis

Question 7

A 35-year-old man presents with daily headache. He describes two attacks per day over the last 3 weeks. Each attack lasts about an hour and awakens him from sleep. The patient has noticed associated tearing and reddening of the right eye as well as nasal stuffiness. The pain's deep, excruciating, and limiting to the right side of the head. The neurological examination is normal. What is the most likely diagnosis?

Accepted Answer

Cluster headache

Answer

Migraine headache

Answer

Brain tumour

Answer

Tension headache

Question 8

Inability to abduct left eye with LMN fascial palsy on same side. The lesion is in

Accepted Answer

Left pons

Answer

Cerebellar lesions

Answer

CP angle tumor

Answer

Right pons

Question 9

A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans two or three times a month would provide complete relief. Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement. Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a "pain shot." The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?

Accepted Answer

Medication overuse headache

Answer

CNS vasculitis

Answer

Status migrainosus

Answer

Space-occupying intracerebral lesion

Question 10

Two or more oligoclonal bands in cerebrospinal fluid are most often positive in-

Accepted Answer

Multiple sclerosis

Answer

Acute bacterial meningitis

Answer

Subarachnoid hemorrhage

Answer

Polyneuropathy

Neurology — MCQs

Neurology — MCQs

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