Neurology Practice Questions

Q: A 20-year-old girl complains of headache while studying. Her vision is found to be normal. In the initial medical evaluation of her headache, which of the following would be the LEAST essential to assess?

Her interest in studies. ***Her interest in studies*** - While **stress** and **academic pressure** can contribute to headaches, this represents a **psychosocial assessment** rather than a standard medical evaluation. - Among the listed options, this would be the **least essential** in the initial medical workup compared to the other clinical assessments. *Family history of headache* - Essential evaluation as many headache disorders, particularly **migraine** and **tension-type headache**, have strong **genetic predisposition**. - Family history helps establish diagnosis and guides appropriate management strategies for the patient's headaches. *Menstrual history* - Crucial in young women as **hormonal fluctuations** during the menstrual cycle are major triggers for headaches, especially **menstrual migraine**. - Understanding menstrual patterns can identify cyclical headache triggers and inform treatment approaches. *Fundoscopy examination* - Important to rule out **papilledema** (optic disc swelling) and signs of **increased intracranial pressure**, even with normal visual acuity. - Normal vision does not exclude underlying pathology that could be detected through **ophthalmoscopic examination** of the retina and optic nerve.

Q: Which of the following tests is not required for the diagnosis of multiple sclerosis?

Electronystagmogram. ***Electronystagmogram*** - An **electronystagmogram (ENG)** measures eye movements and nystagmus, which can be affected by MS but is not a **diagnostic criterion** for the disease. - While vestibulo-ocular dysfunction can occur in MS, an ENG is not required to establish the diagnosis. *Gadolinium-enhanced MRI* - **Gadolinium-enhanced MRI** of the brain and spinal cord is crucial for diagnosing MS as it identifies active lesions (enhancing lesions) and disseminated lesions in space and time [1]. - The presence of both **active and inactive lesions** on MRI helps fulfill the McDonald criteria for MS diagnosis [1]. *Visual evoked potential* - **Visual evoked potentials (VEPs)** measure electrical activity in the brain in response to visual stimuli, detecting subtle damage to the **optic nerve** even in the absence of clinical symptoms [1]. - Abnormal VEPs indicate demyelination and can contribute to fulfilling the **dissemination in space** criterion when lesions are not clearly visible on MRI in specific locations [1]. *Lumbar puncture* - A **lumbar puncture** to analyze **cerebrospinal fluid (CSF)** is often performed to look for **oligoclonal bands** and an **elevated IgG index**, which are characteristic findings in MS. - Although not always mandatory, CSF analysis can support the diagnosis, especially in cases where MRI findings are equivocal or incomplete.

Q: In Wernicke's aphasia all are seen except:

Spontaneous speech is reduced. ***Spontaneous speech is reduced*** - In **Wernicke's aphasia**, spontaneous speech is typically **fluent, copious, and often excessively verbose** (logorrhea), rather than reduced [1]. - The patient can produce many words, but the content is often meaningless due to **paraphasias** and **neologisms** [1]. *Neologism is present* - **Neologisms**, or made-up words, are characteristic of Wernicke's aphasia, contributing to the **incoherence** of speech [1]. - This reflects the severe impairment in **language comprehension** and word retrieval. *Paraphasia present* - **Paraphasias** (substitution of words or syllables) are a hallmark of Wernicke's aphasia, leading to **jumbled and nonsensical phrases** [1]. - Both semantic (e.g., "chair" for "table") and phonemic (e.g., "pipe" for "pike") paraphasias are common. *Speech is effortless* - The speech production in Wernicke's aphasia is typically **effortless and fluent**, often at a normal or even accelerated rate [1]. - This contrasts with non-fluent aphasias where speech is slow, labored, and requires significant effort.

Q: In a status epilepticus patient, first-line drug is

Benzodiazepine. ***Benzodiazepine*** - **Benzodiazepines** are the first-line treatment for status epilepticus due to their rapid onset of action in enhancing **GABAergic inhibition** [1]. - They effectively terminate seizures by binding to **GABA-A receptors**, leading to increased chloride influx and neuronal hyperpolarization. *Phenytoin* - **Phenytoin** is a second-line antiepileptic drug that can be used if benzodiazepines are unsuccessful, but it is not the initial treatment [1]. - Its mechanism involves blocking **voltage-gated sodium channels** to stabilize neuronal membranes and prevent seizure propagation [2]. *Magnesium* - **Magnesium sulfate** is primarily used in status epilepticus caused by **eclampsia** or severe **hypomagnesemia**, not as a general first-line agent. - It acts by stabilizing neuronal excitability and reducing acetylcholine release at the neuromuscular junction. *Barbiturates* - **Barbiturates** (e.g., phenobarbital) are typically considered third-line agents for refractory status epilepticus due to their significant side effects, including **respiratory depression** and hypotension. - They potentiate **GABA-A receptor** activity, similar to benzodiazepines, but with a higher risk profile.

Q: Burst suppression on EEG is seen in

SSPE. ***SSPE*** - **Subacute sclerosing panencephalitis (SSPE)** is a rare, fatal, and chronic progressive encephalitis caused by persistent measles virus infection, often presenting with **burst suppression** on EEG. - **Burst suppression** EEG patterns are characterized by periods of high-amplitude electrical activity alternating with periods of profound suppression or inactivity, reflecting severe global brain dysfunction. *Epilepsy* - **Epilepsy** typically presents with various EEG patterns such as **spikes, sharp waves, or spike-and-wave complexes**, reflecting hyperexcitable neuronal networks [2]. - While prolonged seizures (status epilepticus) can lead to a suppressed EEG, classic burst suppression is not a hallmark of typical epileptic seizures [1]. *Prions disease* - **Prion diseases**, such as Creutzfeldt-Jakob disease (CJD), often show characteristic EEG abnormalities like **periodic sharp wave complexes** or generalized slowing. - **Burst suppression** is not a typical or specific finding in prion diseases, although non-specific slowing or background disruption can occur in advanced stages. *Herpes* - **Herpes simplex encephalitis (HSE)** typically causes **focal abnormalities** like periodic lateralizing epileptiform discharges (PLEDs) or slowing over the temporal lobes on EEG. - While HSE can lead to severe brain damage and generalized slowing, **burst suppression** is not a characteristic EEG finding.

Q: In Millard-Gubler syndrome, all are involved except:

Oculomotor nerve. ***Oculomotor nerve*** - Millard-Gubler syndrome is a **ventral pontine syndrome** usually caused by a brainstem lesion in the **pons**. - This syndrome affects the **abducens (VI) and facial (VII) cranial nerves** and the **corticospinal tract**, but not the oculomotor (III) nerve. *Abducens nerve* - Involvement of the **abducens nerve nucleus** or fibers leads to **ipsilateral lateral rectus palsy**, resulting in **exotropia** (eye turned outward) and impairment of ipsilateral eye abduction. - This is a hallmark feature of Millard-Gubler syndrome. *Facial nerve* - Damage to the **facial nerve nucleus** or fascicles causes **ipsilateral facial paralysis** of the lower motor neuron type [2], affecting all facial muscles. - This is another characteristic component of the syndrome. *Corticospinal tract* - Involvement of the **descending corticospinal tract** results in **contralateral hemiparesis or hemiplegia** [1], impacting motor control on the opposite side of the body. - This long tract deficit is crucial for localizing the lesion to the pontine base.

Q: A patient presents with headache for one hour on awakening, associated with nasal stuffiness and reddening of eye. Suggestive of

Cluster headache. ***Cluster headache*** - This presentation describes a **cluster headache**, which is characterized by **severe, unilateral pain** affecting the area around the eye, often accompanied by **autonomic symptoms** like nasal stuffiness and conjunctival injection (reddening of the eye). [1] [2] - Cluster headaches typically occur in **clusters**, with attacks lasting from 15 minutes to 3 hours, and frequently occur at the same time each day, often awakening the patient from sleep. [1] *Migraine* - **Migraines** usually involve **throbbing, pulsating pain** and are often accompanied by **photophobia, phonophobia**, and nausea/vomiting, which are not mentioned here. [3] - While migraines can cause eye symptoms, the combination with pronounced nasal stuffiness and the specific pattern of awakening and duration are more characteristic of cluster headaches. [1] *Tension headache* - **Tension headaches** are typically described as a **tight band or pressure** around the head, involving the entire head, and are generally **mild to moderate** in intensity. [2] - They lack the severe pain and distinct autonomic symptoms (nasal stuffiness, eye reddening) seen in this patient. *All of the options* - This option is incorrect because the specific combination of symptoms points clearly to a **cluster headache** and excludes migraines and tension headaches due to their distinct clinical features. - While all are types of headaches, their presentations vary significantly, making only one the most likely diagnosis in this scenario.

Q: Pure motor paralysis is seen in :

Polio. **Polio** - Polio primarily infects motor neurons in the **anterior horn of the spinal cord** [3], leading to **flaccid paralysis** without sensory involvement [4]. - The destruction of these motor neurons results in **muscle weakness and atrophy**, consistent with pure motor paralysis [3]. *Sub-Acute Combined Degeneration* - This condition is caused by **vitamin B12 deficiency** and affects both the **posterior and lateral columns** of the spinal cord. - It typically presents with a combination of **motor deficits** (weakness, spasticity) and **sensory deficits** (paresthesias, proprioception loss), making it not purely motor [2]. *Diabetes mellitus* - Diabetic neuropathy can cause various types of nerve damage, including **motor, sensory, and autonomic neuropathies** [2]. - While motor weakness can occur, it is rarely a **pure motor paralysis** and is often accompanied by significant sensory symptoms (e.g., numbness, tingling) [1]. *Guillain-Barré syndrome* - GBS is an acute demyelinating polyneuropathy that causes **progressive symmetrical weakness**, often starting in the lower limbs. - Although primarily motor, it can also involve **sensory disturbances** (paresthesias, pain) and autonomic dysfunction, so it is not strictly pure motor.

Q: A patient was treated for mantle cell Hodgkin lymphoma with radiation therapy. After 6 months he develops an electric shock-like pain along the spine on flexing his neck. What is the diagnosis?

Radiation-induced myelopathy. ***Radiation-induced myelopathy*** - This diagnosis is signaled by the **electric shock-like pain** along the spine upon neck flexion (Lhermitte's sign) developing 6 months after receiving **radiation therapy** for lymphoma. - This condition represents a delayed complication of radiation, affecting the **spinal cord's white matter**. *Multiple sclerosis* - While it can present with **Lhermitte's sign**, the patient's history of **radiation therapy** and its timing strongly favor myelopathy. [1] - MS is a demyelinating disease usually presenting with a **variety of neurological symptoms** over time, rather than isolated Lhermitte's sign post-radiation. *Cervical arthritis* - This condition would typically present with **neck pain and stiffness**, possibly radiating pain, and limited range of motion, but not specifically an electric shock sensation on neck flexion (Lhermitte's sign). [2] - While an osteophyte might cause compression, the specific **Lhermitte's sign** points away from simple degenerative changes. *Spinal cord compression* - While Lhermitte's sign can indicate spinal cord involvement, **spinal cord compression** usually implies an acute or subacute onset with more severe and progressive neurological deficits, such as motor weakness or sensory loss, and bladder/bowel dysfunction. [3] - Given the 6-month delay and the isolated Lhermitte's sign after radiation, **radiation-induced myelopathy** is a more specific and likely cause.

Q: A 76 year old male comes with a history of frequent falls and difficulty in looking downwards and laterally. The diagnosis is

Supranuclear palsy. Supranuclear palsy - Progressive supranuclear palsy (PSP) is characterized by early and prominent postural instability, leading to frequent falls, as well as vertical gaze palsy (difficulty looking downwards and upwards). - While the patient has difficulty looking downwards and laterally, vertical gaze palsy (specifically downward gaze) is a hallmark feature of PSP, often more pronounced than lateral gaze issues initially. Alzheimer's disease - Primarily defined by progressive memory loss and cognitive decline, not typically by early signs of falls or specific gaze palsies [1]. - While falls can occur in advanced stages, they are not the prominent presenting symptom related to gait instability and gaze deficits. Amyotropic lateral sclerosis - This is a neurologic disorder characterized by progressive muscle weakness and atrophy due to the degeneration of upper and lower motor neurons [2]. - It does not typically present with oculomotor dysfunction or early frequent falls due to balance issues. Oculomotor nerve palsy - An oculomotor nerve palsy would cause specific paresis of muscles innervated by the third cranial nerve, leading to symptoms like ptosis, dilated pupil, and ophthalmoplegia (difficulty moving the eye up, down, and medially) [3]. - It would not explain the generalized symptom of frequent falls due to central balance issues, and the gaze restriction is more localized rather than a supranuclear pattern [3].

Question 1

A 20-year-old girl complains of headache while studying. Her vision is found to be normal. In the initial medical evaluation of her headache, which of the following would be the LEAST essential to assess?

Accepted Answer

Her interest in studies

Answer

Family history of headache

Answer

Menstrual history

Answer

Fundoscopy examination

Question 2

Which of the following tests is not required for the diagnosis of multiple sclerosis?

Accepted Answer

Electronystagmogram

Answer

Gadolinium-enhanced MRI

Answer

Visual evoked potential

Answer

Lumbar puncture

Question 3

In Wernicke's aphasia all are seen except:

Accepted Answer

Spontaneous speech is reduced

Answer

Neologism is present

Answer

Paraphasia present

Answer

Speech is effortless

Question 4

In a status epilepticus patient, first-line drug is

Accepted Answer

Benzodiazepine

Answer

Phenytoin

Answer

Magnesium

Answer

Barbiturates

Question 5

Burst suppression on EEG is seen in

Accepted Answer

SSPE

Answer

Epilepsy

Answer

Prions disease

Answer

Herpes

Question 6

In Millard-Gubler syndrome, all are involved except:

Accepted Answer

Oculomotor nerve

Answer

Abducens nerve

Answer

Facial nerve

Answer

Corticospinal tract

Question 7

A patient presents with headache for one hour on awakening, associated with nasal stuffiness and reddening of eye. Suggestive of

Accepted Answer

Cluster headache

Answer

Migraine

Answer

Tension headache

Answer

All of the options

Question 8

Pure motor paralysis is seen in :

Accepted Answer

Polio

Answer

Sub-Acute Combined Degeneration

Answer

Diabetes mellitus

Answer

Guillain-Barré syndrome

Question 9

A patient was treated for mantle cell Hodgkin lymphoma with radiation therapy. After 6 months he develops an electric shock-like pain along the spine on flexing his neck. What is the diagnosis?

Accepted Answer

Radiation-induced myelopathy

Answer

Multiple sclerosis

Answer

Cervical arthritis

Answer

Spinal cord compression

Question 10

A 76 year old male comes with a history of frequent falls and difficulty in looking downwards and laterally. The diagnosis is

Accepted Answer

Supranuclear palsy

Answer

Alzheimer's disease

Answer

Amyotropic lateral sclerosis

Answer

Oculomotor nerve palsy

Neurology — MCQs

Neurology — MCQs

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