Neurology Practice Questions

Q: Which of the following is typically seen in a patient with Guillain-Barré syndrome?

Ascending muscle weakness. ***Ascending muscle weakness*** - **Guillain-Barré syndrome (GBS)** is characterized by **acute onset of progressive muscle weakness** that typically starts in the lower extremities and ascends symmetrically [1]. - This **ascending paralysis** is a hallmark feature resulting from demyelination of peripheral nerves [1]. *Sensory loss* - While some patients with GBS may experience **mild sensory disturbances** like paresthesias, pronounced or severe sensory loss is **not the primary or most typical presentation** [1]. - The predominant symptom is **motor weakness**, indicating that nerve demyelination primarily affects motor fibers [1]. *Brisk reflexes* - GBS is a peripheral neuropathy that causes **damage to motor nerve fibers, leading to a loss of muscle tone and reflexes** [1]. - Therefore, **brisk reflexes** would indicate an upper motor neuron lesion, which is inconsistent with GBS. *Areflexia* - **Areflexia**, or the complete absence of reflexes, is a common and often profound finding in later stages of GBS due to the extensive damage to the peripheral nervous system [1]. - However, initially, patients may present with **hyporeflexia** before progressing to areflexia, making **ascending muscle weakness** a more universally typical initial presentation.

Q: All of the following are features of normal pressure hydrocephalus EXCEPT which of the following?

Increased intracranial pressure. ***Increased intracranial pressure*** - Normal pressure hydrocephalus (NPH) is characterized by **ventriculomegaly** with **normal cerebrospinal fluid (CSF) pressure** on lumbar puncture. [1] - While it involves impaired CSF absorption, the pressure inside the skull typically remains within normal limits, distinguishing it from other forms of hydrocephalus. [1] *Cognitive impairment* - **Dementia** is a key feature of NPH, often manifesting as **memory loss**, slowed thinking, and executive dysfunction. [2] - This cognitive decline is part of the classic clinical triad along with gait disturbance and urinary incontinence. *Gait disturbance* - A prominent and often early symptom of NPH is a **wide-based, shuffling gait**, described as "magnetic gait" due to difficulty lifting the feet. - This symptom can significantly impact mobility and increase the risk of falls. *Urinary incontinence* - **Urinary urgency**, frequency, and incontinence are common symptoms in NPH, occurring due to the compression of sacral motor fibers by the dilated ventricles. [2] - This feature completes the classic triad of symptoms that define normal pressure hydrocephalus.

Q: A 50-year-old man presents with persistent headaches, nausea, and vomiting. CT scan reveals a mass compressing the third ventricle. What is the most likely cause of his symptoms?

Hydrocephalus. ***Hydrocephalus*** - A mass compressing the **third ventricle** obstructs the flow of **cerebrospinal fluid (CSF)**, leading to its accumulation [1] and causing **hydrocephalus**. [1] - The classic symptoms of increased **intracranial pressure** due to hydrocephalus include persistent headaches, nausea, and vomiting. [1] *Migraine* - While migraines cause severe headaches, they are typically not associated with a **mass effect** or persistent nausea and vomiting directly caused by **ventricular compression**. - **Neurological imaging** in migraine is usually normal, differentiating it from a structural lesion. [1] *Stroke* - Stroke symptoms are generally characterized by focal neurological deficits such as sudden weakness, sensory loss, or speech difficulties, often without a preceding history of **persistent headache** and **nausea** from a growing mass. [1] - While strokes can cause headaches, a mass compressing the third ventricle with associated symptoms points away from an **ischemic** or **hemorrhagic** event as the primary cause. *Meningitis* - Meningitis involves inflammation of the **meninges**, presenting with fever, neck stiffness, and altered mental status, and is typically diagnosed via **CSF analysis**. - A **mass compressing the third ventricle** is not a feature of meningitis, which is an infectious or inflammatory process rather than a space-occupying lesion.

Q: A 50-year-old man presents with sudden onset of severe headache, vomiting, and neck stiffness. His blood pressure is 180/110 mmHg. CT scan shows blood in the subarachnoid space. What is the next best step in management?

Angiography. ***Angiography*** - A CT scan has already confirmed **subarachnoid hemorrhage (SAH)**. The next critical step is to identify the source of bleeding, which is usually a **ruptured aneurysm**. [1] - **Cerebral angiography** (CTA, MRA, or conventional angiography) is crucial for visualizing intracranial vessels and precisely locating the aneurysm for subsequent treatment planning. [1], [2] *Lumbar puncture* - A **lumbar puncture** is used to diagnose SAH when initial imaging (CT scan) is negative but clinical suspicion remains high. [1], [3] - In this case, the **CT scan has already shown blood** in the subarachnoid space, making a lumbar puncture redundant for diagnosis. *Corticosteroids* - **Corticosteroids** are typically used to reduce cerebral edema in conditions like **brain tumors** or significant **ischemic stroke**. - They are generally **contraindicated** in acute SAH as they may worsen outcomes or mask other complications without addressing the underlying bleeding source. *MRI of the brain* - While an **MRI** can provide detailed anatomical information, it is generally **less sensitive than CT** for acute blood detection in SAH and is not the first-line imaging for acute SAH. - Its role is usually delayed, potentially for **follow-up** or to investigate other causes if angiography is negative, rather than as an immediate step after confirmed SAH.

Q: A 60-year-old man with atrial fibrillation presents with sudden right arm and leg weakness, speech loss, and right facial droop that started 2 hours ago. CT scan shows no bleeding. What is the next step in management?

Intravenous thrombolysis. No change to the explanation was requested other than the addition of citations. ***Intravenous thrombolysis*** - The patient presents with **acute ischemic stroke symptoms** [1] within the 4.5-hour window from symptom onset , and the CT scan shows no hemorrhage , making him a candidate for **tPA**. - **Atrial fibrillation** puts the patient at high risk for cardioembolic stroke , which can be effectively treated with tPA if given early . *Surgical thrombectomy* - This is an intervention for **large vessel occlusion** but is typically considered for patients who are outside the IV tPA window (usually 4.5 hours) or have contraindications, and it often has a longer therapeutic window (up to 24 hours in select cases). - While it may be considered for this patient, **IV thrombolysis** is the immediate next step given he is within the 4.5-hour window and has no contraindications. *Heparin* - **Anticoagulation with unfractionated heparin** is not recommended for acute ischemic stroke without clear indications due to the increased risk of hemorrhagic transformation. - While the patient has atrial fibrillation, starting anticoagulation acutely is usually deferred for at least 24 hours after tPA administration or in cases of larger infarcts due to the risk of bleeding. *Aspirin* - **Aspirin** is an antiplatelet agent used for **secondary stroke prevention** and in some cases for acute ischemic stroke, but it is less effective than tPA for acute reperfusion . - While it may be given later, it is not the primary immediate treatment for acute ischemic stroke eligible for thrombolysis.

Q: A 35-year-old woman presents with frequent episodes of intense, stabbing pain in her right cheek, triggered by chewing and touching the face. What is the most likely diagnosis?

Trigeminal neuralgia. ***Trigeminal neuralgia*** - This condition presents with **lancinating**, severe pain in the distribution of the trigeminal nerve, often triggered by light touch, chewing, or facial movements. - The patient's description of sudden, **stabbing pain in the right cheek** that is triggered by chewing and touching the face is classic. *Cluster headache* - Characterized by **severe, unilateral pain**, typically around the eye or temple, accompanied by autonomic symptoms like lacrimation, rhinorrhea, and ptosis [1]. - While intense, the pain pattern and triggers are distinctly different from the described facial pain [1]. *Migraine* - Migraines cause a **throbbing or pounding headache**, often unilateral, associated with nausea, vomiting, photophobia, and phonophobia [3]. - The pain is usually duller and more prolonged than the sharp, brief pains seen in trigeminal neuralgia, and triggers are typically not mechanical [3]. *Temporomandibular joint dysfunction* - Leads to pain in the **jaw joint and surrounding muscles**, often exacerbated by jaw movement, chewing, or yawning [2]. - While chewing can trigger pain, the pain is typically described as an ache or dull pain, localized to the joint, and not the sharp, electrical-shock-like pain of trigeminal neuralgia [2].

Q: A 40-year-old woman presents with numbness and tingling in her hands and feet, progressive weakness, and areflexia. She has a recent history of an upper respiratory infection. Which condition is most likely?

Guillain-Barre syndrome. A 40-year-old woman presents with numbness and tingling in her hands and feet, progressive weakness, and areflexia. She has a recent history of an upper respiratory infection. Which condition is most likely? ***Guillain-Barre syndrome*** - The triad of **numbness and tingling** (sensory symptoms), **progressive weakness** (motor symptoms), and **areflexia** occurring after an upper respiratory infection is classic for **Guillain-Barre syndrome (GBS)** [1]. - GBS is an **acute demyelinating polyneuropathy** characterized by ascending paralysis, often preceded by an infection [1]. *Multiple sclerosis* - **Multiple sclerosis** typically presents with *disseminated lesions in space and time* affecting the central nervous system, leading to symptoms like *visual disturbances, ataxia, and spasticity*. - It does not usually present with **areflexia** or rapidly progressive ascending weakness following an infection. *Myasthenia gravis* - **Myasthenia gravis** causes *fluctuating muscle weakness* that worsens with activity and improves with rest, often affecting ocular, bulbar, and limb muscles. - It is characterized by *normal reflexes* and is not typically associated with sensory symptoms or a preceding infection as described. *Peripheral neuropathy* - While **peripheral neuropathy** can cause numbness, tingling, and weakness, the *rapid progression, ascending pattern,* and universal **areflexia** after a recent infection are more specific to Guillain-Barre syndrome [1]. - **Peripheral neuropathy** is a broad term, and while GBS is a type of acute peripheral neuropathy, the specific clinical context strongly points to GBS rather than a generic peripheral neuropathy.

Q: A patient with a lower motor neuron lesion affecting the facial muscles will likely exhibit weakness in which area of the face?

Entire unilateral. ***Entire unilateral*** - A **lower motor neuron (LMN) lesion** to the facial nerve (cranial nerve VII) results in weakness affecting **all muscles of facial expression** on the ipsilateral side [1]. - This is because the LMN directly innervates all facial muscles from the **nucleus of the facial nerve** in the pons, before it branches [2]. *Lower face* - Weakness isolated to the **lower face** is characteristic of an **upper motor neuron (UMN) lesion** (e.g., stroke) affecting the contralateral cortex [1]. - The forehead muscles receive bilateral cortical innervation, which spares the upper face in a UMN lesion [1]. *Upper face* - Isolated **upper face weakness** is rare and not typical for either UMN or LMN lesions affecting the facial nerve. - If present, it would suggest a highly specific and uncommon focal injury that spares the lower facial branches. *Entire bilateral weakness* - **Bilateral facial weakness** would indicate a lesion affecting **both facial nerves** or their nuclei. - This could be seen in conditions like **Guillain-Barré syndrome** or bilateral brainstem lesions, not a unilateral LMN lesion.

Q: A 25-year-old man presents with recurrent episodes of severe, electric shock-like pain along the distribution of the V2 and V3 branches of the trigeminal nerve. Which condition is most likely?

Trigeminal neuralgia. Trigeminal neuralgia - This condition presents with **recurrent episodes of severe, electric shock-like pain** in one or more branches of the **trigeminal nerve (V, V2, V3)**, precisely matching the patient's symptoms. - The pain is typically brief, but intense, and can be triggered by light touch, chewing, or speaking. *Cluster headache* - Characterized by **excruciating unilateral pain**, usually around the eye or temple, along with autonomic symptoms like **lacrimation, rhinorrhea, and ptosis** [1]. - The pain is usually sustained for minutes to hours, not described as electric shock-like, and does not follow a trigeminal nerve distribution [1]. *Migraine* - Typically involves a **throbbing, unilateral headache** often accompanied by **nausea, vomiting, photophobia**, and phonophobia [3]. - While severe, migraine pain is not usually described as electric shock-like nor restricted to specific trigeminal nerve branches. *Temporomandibular joint disorder* - Causes pain in the **jaw, ear, or face**, especially with jaw movement, chewing, or yawning [2]. - The pain is generally a dull ache or discomfort, not an electric shock-like sensation, and does not follow a nerve distribution [2].

Q: In a patient with suspected bacterial meningitis, which cerebrospinal fluid finding is most indicative of the diagnosis?

High protein, low glucose, neutrophilic pleocytosis. ***High protein, low glucose, neutrophilic pleocytosis*** - **Elevated protein** and **low glucose** in the CSF are classic indicators of bacterial meningitis due to increased capillary permeability and bacterial metabolism of glucose [1]. - **Neutrophilic pleocytosis** (high white blood cell count with a predominance of neutrophils) is the hallmark of bacterial infection in the CNS, as neutrophils are the primary responders to bacteria [1]. *Low protein, normal glucose, lymphocytic pleocytosis* - This profile is more characteristic of **viral meningitis**, where protein levels may be normal or slightly elevated, glucose is typically normal, and lymphocytes predominate [1]. - The absence of significant protein elevation and glucose reduction, along with lymphocyte predominance, would argue against a bacterial etiology. *High protein, high glucose, eosinophilic pleocytosis* - While high protein can be seen in various conditions, **high glucose** in CSF rarely accompanies infection; rather, it often reflects a high blood glucose level without active consumption by pathogens. - **Eosinophilic pleocytosis** is rare and points towards parasitic infections, fungal infections, or drug reactions, not typical bacterial meningitis. *Normal protein, normal glucose, mononuclear pleocytosis* - **Normal protein and glucose** would generally rule out significant acute bacterial infection, as these parameters are usually altered in bacterial meningitis [2]. - **Mononuclear pleocytosis** (lymphocytes or monocytes) can be seen in viral, fungal, or chronic inflammatory conditions, but not typically in acute bacterial meningitis which is dominated by neutrophils [2].

Question 1

Which of the following is typically seen in a patient with Guillain-Barré syndrome?

Accepted Answer

Ascending muscle weakness

Answer

Sensory loss

Answer

Brisk reflexes

Answer

Areflexia

Question 2

All of the following are features of normal pressure hydrocephalus EXCEPT which of the following?

Accepted Answer

Increased intracranial pressure

Answer

Cognitive impairment

Answer

Gait disturbance

Answer

Urinary incontinence

Question 3

A 50-year-old man presents with persistent headaches, nausea, and vomiting. CT scan reveals a mass compressing the third ventricle. What is the most likely cause of his symptoms?

Accepted Answer

Hydrocephalus

Answer

Migraine

Answer

Stroke

Answer

Meningitis

Question 4

A 50-year-old man presents with sudden onset of severe headache, vomiting, and neck stiffness. His blood pressure is 180/110 mmHg. CT scan shows blood in the subarachnoid space. What is the next best step in management?

Accepted Answer

Angiography

Answer

Lumbar puncture

Answer

Corticosteroids

Answer

MRI of the brain

Question 5

A 60-year-old man with atrial fibrillation presents with sudden right arm and leg weakness, speech loss, and right facial droop that started 2 hours ago. CT scan shows no bleeding. What is the next step in management?

Accepted Answer

Intravenous thrombolysis

Answer

Surgical thrombectomy

Answer

Heparin

Answer

Aspirin

Question 6

A 35-year-old woman presents with frequent episodes of intense, stabbing pain in her right cheek, triggered by chewing and touching the face. What is the most likely diagnosis?

Accepted Answer

Trigeminal neuralgia

Answer

Cluster headache

Answer

Migraine

Answer

Temporomandibular joint dysfunction

Question 7

A 40-year-old woman presents with numbness and tingling in her hands and feet, progressive weakness, and areflexia. She has a recent history of an upper respiratory infection. Which condition is most likely?

Accepted Answer

Guillain-Barre syndrome

Answer

Multiple sclerosis

Answer

Myasthenia gravis

Answer

Peripheral neuropathy

Question 8

A patient with a lower motor neuron lesion affecting the facial muscles will likely exhibit weakness in which area of the face?

Accepted Answer

Entire unilateral

Answer

Lower face

Answer

Upper face

Answer

Entire bilateral weakness

Question 9

A 25-year-old man presents with recurrent episodes of severe, electric shock-like pain along the distribution of the V2 and V3 branches of the trigeminal nerve. Which condition is most likely?

Accepted Answer

Trigeminal neuralgia

Answer

Cluster headache

Answer

Migraine

Answer

Temporomandibular joint disorder

Question 10

In a patient with suspected bacterial meningitis, which cerebrospinal fluid finding is most indicative of the diagnosis?

Accepted Answer

High protein, low glucose, neutrophilic pleocytosis

Answer

Low protein, normal glucose, lymphocytic pleocytosis

Answer

High protein, high glucose, eosinophilic pleocytosis

Answer

Normal protein, normal glucose, mononuclear pleocytosis

Neurology — MCQs

Neurology — MCQs

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