Neurology Practice Questions

Q: A 25-year-old male presents with sudden onset of right-sided weakness. An MRI of the brain shows a lesion in the left internal capsule. What is the most likely diagnosis?

Ischemic stroke. ### Ischemic stroke - The sudden onset of neurological deficit, such as **right-sided weakness**, in a young male, coupled with a lesion in the **left internal capsule** on MRI, is highly suggestive of an ischemic stroke [1]. - The internal capsule contains various **motor and sensory tracts**, and a lesion here would cause contralateral motor weakness. *Hemorrhagic stroke* - While a hemorrhagic stroke can also cause sudden neurological deficits, an **MRI typically shows blood** (hyperintensity on certain sequences) rather than simply a "lesion" without further characterization, which is more ambiguous for hemorrhage [1]. - Hemorrhagic strokes often present with additional symptoms like **severe headache**, nausea, and vomiting due to increased intracranial pressure, which are not mentioned here. *Brain tumor* - Brain tumors typically present with a more **gradual onset of symptoms** over weeks to months, rather than the sudden onset described [1]. - While a tumor *can* be in the internal capsule, its presentation is generally chronic progressing, and imaging would often show mass effect, edema, or enhancement, not just a "lesion" with sudden onset [1]. *Multiple sclerosis* - Multiple sclerosis lesions are typically **demyelinating plaques** that are disseminated in space and time, often found in the white matter but less commonly causing focal, acute weakness in a single, well-defined lesion location like the internal capsule with sudden onset. - While it can cause weakness, the presentation is usually characterized by **relapsing-remitting episodes** or progressive neurological decline with multiple lesions in different areas of the central nervous system.

Q: A 25-year-old female presents with a history of episodes of sudden loss of consciousness accompanied by stiffening and jerking movements of the limbs. An EEG shows generalized spike-and-wave discharges. What is the most likely diagnosis?

Generalized tonic-clonic seizures. ***Generalized tonic-clonic seizures*** - The description of "sudden loss of consciousness accompanied by **stiffening** and **jerking movements** of the limbs" is classic for the tonic and clonic phases of a generalized tonic-clonic seizure [1]. - The EEG finding of **generalized spike-and-wave discharges** is consistent with generalized epilepsy, which includes tonic-clonic seizures [2]. *Absence seizures* - Characterized by **brief, sudden lapses of consciousness** without loss of postural tone, often presenting as staring spells [2]. - They lack the prominent **tonic (stiffening)** and **clonic (jerking)** movements described in the patient [1]. *Myoclonic epilepsy* - Involves **brief, shock-like jerks** of a muscle or group of muscles, typically without a preceding tonic phase or prolonged loss of consciousness [2], [3]. - While it can manifest with EEG generalized spike-and-wave, the description of sustained stiffening and jerking points away from isolated myoclonic jerks [1]. *Complex partial seizures* - Involve **focal onset** with impaired consciousness, often accompanied by **automatisms** (e.g., lip-smacking, fiddling with clothes) or other focal motor or sensory phenomena [4]. - They do not typically present with the generalized, symmetrical stiffening and jerking seen in **tonic-clonic seizures**.

Q: What is the first-line drug for the prophylaxis of cluster headaches?

Verapamil. ***Verapamil*** - **Verapamil**, a **non-dihydropyridine calcium channel blocker**, is the **first-line prophylactic agent** for chronic cluster headaches due to its efficacy in reducing headache frequency and severity. - It works by **stabilizing neuronal excitability** and has a **better safety profile** for long-term use compared to acute treatments. *Sumatriptan* - **Sumatriptan** is an **abortive therapy** used for the acute treatment of cluster headache attacks, not for long-term prophylaxis. - It acts as a **serotonin 5-HT1B/1D receptor agonist** to constrict cranial blood vessels and inhibit pain pathways. *Prednisone* - **Prednisone**, a corticosteroid, can be used as a **short-term bridge therapy** to provide rapid relief during the initiation of a long-term prophylactic agent but is not suitable for routine chronic prophylaxis due to significant side effects. - Its mechanism involves **reducing inflammation**, which can temporarily alleviate headache symptoms. *Lithium* - **Lithium** is an **alternative prophylactic agent** for cluster headaches, particularly effective in **chronic cluster headache** that is refractory to verapamil. - It is considered **second-line** due to its narrow therapeutic index and the need for regular blood level monitoring.

Q: A 60-year-old man presents with a sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension. What is the most likely diagnosis?

Subarachnoid hemorrhage. ***Subarachnoid hemorrhage*** - A **sudden onset of severe headache**, often described as the "worst headache of my life," along with **nausea** and **vomiting**, is a classic presentation of a **subarachnoid hemorrhage** [1]. - A history of **hypertension** is a significant risk factor for **aneurysmal rupture**, which is the most common cause of spontaneous subarachnoid hemorrhage [1]. *Migraine* - While migraines can cause severe headaches with nausea and vomiting, their onset is usually **gradual** and they typically have **associated focal neurological symptoms** such as aura or photophobia, which are not mentioned here [2]. - The patient's age (60) and the **sudden, explosive nature** of the headache make migraine less likely. *Cluster headache* - Cluster headaches are characterized by **excruciating, unilateral pain** around the eye, associated with **autonomic symptoms** like lacrimation, rhinorrhea, and ptosis, usually occurring in clusters [3]. - The described headache is **generalized** and lacks these specific autonomic features. *Tension headache* - Tension headaches are usually **mild to moderate**, **bilateral**, and described as a tight band around the head, without associated nausea or vomiting [2]. - The **sudden onset and severe intensity** of the headache in this case are inconsistent with a tension headache.

Q: The investigation of choice for diagnosing myasthenia gravis is:

Acetylcholine receptor (AChR) antibodies. ***Acetylcholine receptor (AChR) antibodies*** - Detecting **AChR antibodies** in the serum is the most specific and sensitive test for diagnosing generalized Myasthenia Gravis [1]. - These antibodies are found in about 85% of patients with generalized MG and target the **postsynaptic acetylcholine receptors** at the neuromuscular junction, leading to muscle weakness [1]. *Nerve conduction study* - A standard nerve conduction study (NCS) typically shows **normal results** in myasthenia gravis as there is no primary nerve pathology. - NCS primarily assesses nerve fiber integrity and conduction velocities, which are usually unaffected in neuromuscular junction disorders [2]. *Muscle biopsy* - Muscle biopsy is **not a primary diagnostic test** for myasthenia gravis; it would typically show non-specific findings or no abnormalities. - It is more useful for diagnosing myopathies (muscle diseases) or inflammatory myositis, where structural muscle changes are evident [2]. *Repetitive nerve stimulation* - While **repetitive nerve stimulation** can be abnormal (showing a decremental response) in myasthenia gravis, it is more commonly used as a confirmatory or supportive test rather than the initial diagnostic investigation of choice [1]. - Its sensitivity is lower than AChR antibody testing, especially in ocular myasthenia gravis.

Q: Which of the following clinical tests when positive suggests presence of sensory ataxia?

Romberg test. A positive Romberg test indicates **sensory ataxia**, where the patient sways or falls when standing with feet together and eyes closed [1]. This occurs due to impaired **proprioception**, forcing reliance on visual input for balance, which is lost when eyes are closed [2]. *Adson test* - The Adson test is used to assess for **thoracic outlet syndrome**. - It involves palpating the radial pulse while the patient rotates the head towards the affected side, extends the neck, and takes a deep breath. A diminished or absent pulse suggests **vascular compression**. *Stinchfield test* - The Stinchfield test is used to assess for hip joint pathology or dysfunction, often related to **femoroacetabular impingement** or **labral tears**. - It involves resisted hip flexion while the patient is supine, causing pain if positive. *Crossed SLR test* - The crossed straight leg raise (SLR) test, or Well-leg SLR test, is a highly specific test for **lumbar radiculopathy**, indicating **disc herniation**. - It is positive if raising the *unaffected* leg causes pain to radiate down the *affected* leg.

Q: Which of the following is not a feature of Wernicke's Korsakoff Syndrome?

Normal pupillary response. ***Normal pupillary response*** - Patients with **Wernicke-Korsakoff Syndrome** often present with **abnormal pupillary responses**, such as sluggish or unequal pupils, as part of their ophthalmoplegia. - A **normal pupillary response** would generally argue against the severe brainstem dysfunction seen in Wernicke's encephalopathy. *Ataxia* - **Ataxia**, particularly **gait ataxia**, is a classic neurological sign of **Wernicke's encephalopathy**, resulting from cerebellar dysfunction due to thiamine deficiency [3], [4]. - It contributes to the characteristic triad of symptoms along with ophthalmoplegia and confusion [3]. *Psychosis* - While not a direct component of the classical triad, **psychotic features** such as **hallucinations and delusions** can be observed in patients with **Korsakoff's psychosis**, which is the chronic sequela of untreated Wernicke's encephalopathy. - This is primarily due to damage to the limbic system, affecting memory and emotional processing. *Ophthalmoplegia* - **Ophthalmoplegia**, often presenting as **nystagmus**, **lateral rectus palsy**, or **conjugate gaze palsies**, is a cardinal feature of **Wernicke's encephalopathy** [3]. - It results from damage to brainstem nuclei involved in eye movement control, secondary to **thiamine deficiency** [1], [2].

Q: Todd's paralysis is experienced following which type of seizure?

Focal seizures. ***Focal seizures*** - **Todd's paralysis** is a transient post-ictal focal weakness or paralysis that occurs after a **focal seizure**, specifically a **focal motor seizure** [1]. - It typically affects the body part that was involved in the seizure activity and can last from minutes to hours. *Absence seizures* - These seizures are characterized by brief, sudden lapses of consciousness without loss of postural tone and are often described as "staring spells" [4]. - They do not typically involve significant motor activity or post-ictal phenomena like paralysis [4]. *Myoclonic seizures* - Myoclonic seizures involve sudden, brief, shock-like jerks of a muscle or group of muscles [2]. - While they are a type of motor seizure, they do not typically lead to post-ictal focal weakness or paralysis. *Generalized seizures* - This category includes various seizure types affecting both hemispheres of the brain from the onset, such as tonic-clonic seizures [4]. - While **tonic-clonic seizures** can result in post-ictal confusion and drowsiness, they do not typically cause isolated, focal paralysis known as Todd's paralysis [3].

Question 1

A 25-year-old male presents with sudden onset of right-sided weakness. An MRI of the brain shows a lesion in the left internal capsule. What is the most likely diagnosis?

Accepted Answer

Ischemic stroke

Answer

Hemorrhagic stroke

Answer

Brain tumor

Answer

Multiple sclerosis

Question 2

A 25-year-old female presents with a history of episodes of sudden loss of consciousness accompanied by stiffening and jerking movements of the limbs. An EEG shows generalized spike-and-wave discharges. What is the most likely diagnosis?

Accepted Answer

Generalized tonic-clonic seizures

Answer

Absence seizures

Answer

Myoclonic epilepsy

Answer

Complex partial seizures

Question 3

What is the first-line drug for the prophylaxis of cluster headaches?

Accepted Answer

Verapamil

Answer

Sumatriptan

Answer

Prednisone

Answer

Lithium

Question 4

A patient with Parkinson's disease experiences severe motor fluctuations. Discuss the implications for basal ganglia pathways and identify the most appropriate advanced treatment option.

Accepted Answer

Decreased direct pathway activity; deep brain stimulation is the most effective advanced treatment.

Answer

Increased direct pathway activity; dopamine agonists may help.

Answer

Decreased indirect pathway activity; physical therapy is beneficial.

Answer

Increased indirect pathway activity; anticholinergic drugs are sometimes used.

Question 5

A 60-year-old man presents with a sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension. What is the most likely diagnosis?

Accepted Answer

Subarachnoid hemorrhage

Answer

Migraine

Answer

Cluster headache

Answer

Tension headache

Question 6

The investigation of choice for diagnosing myasthenia gravis is:

Accepted Answer

Acetylcholine receptor (AChR) antibodies

Answer

Nerve conduction study

Answer

Muscle biopsy

Answer

Repetitive nerve stimulation

Question 7

What is the condition characterized by difficulty in recognizing faces?

Accepted Answer

Inability to recognize familiar faces despite normal vision.

Answer

Inability to recognize objects due to visual impairment.

Answer

Difficulty in recognizing voices or sounds.

Answer

Difficulty in distinguishing between similar-looking objects.

Question 8

Which of the following clinical tests when positive suggests presence of sensory ataxia?

Accepted Answer

Romberg test

Answer

Adson test

Answer

Stinchfield test

Answer

Crossed SLR test

Question 9

Which of the following is not a feature of Wernicke's Korsakoff Syndrome?

Accepted Answer

Normal pupillary response

Answer

Ataxia

Answer

Psychosis

Answer

Ophthalmoplegia

Question 10

Todd's paralysis is experienced following which type of seizure?

Accepted Answer

Focal seizures

Answer

Myoclonic seizures

Answer

Absence seizures

Answer

Generalized seizures

Neurology — MCQs

Neurology — MCQs

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