Neuropathology Practice Questions

Q: In Myasthenia gravis, which of the following is the primary target of autoantibodies at the neuromuscular junction?

Post-synaptic ACh Receptor. ***Post-synaptic ACh Receptor*** - Myasthenia gravis is an autoimmune disorder where **IgG autoantibodies** are produced against the nicotinic **acetylcholine receptors (AChR)** on the post-synaptic muscle membrane [1], [2]. - These antibodies block acetylcholine from binding and also cause **complement-mediated destruction** and accelerated degradation of the receptors, leading to fatigable muscle weakness [1]. *Presynaptic ACh receptor* - Presynaptic acetylcholine receptors are involved in modulating the release of acetylcholine, but they are not the primary target of autoantibodies in Myasthenia Gravis. - Conditions targeting presynaptic components, like **Lambert-Eaton Myasthenic Syndrome**, involve a different pathophysiology. *Voltage-gated calcium channels at NMJ* - Autoantibodies against presynaptic **P/Q-type voltage-gated calcium channels (VGCCs)** are the hallmark of **Lambert-Eaton Myasthenic Syndrome (LEMS)**, not Myasthenia Gravis. - The blockade of these channels impairs the presynaptic release of acetylcholine, leading to a distinct clinical picture of weakness that often improves with activity. *Acetylcholinesterase* - **Acetylcholinesterase** is the enzyme that breaks down acetylcholine in the synaptic cleft; it is not the target of autoantibodies in this disease [3]. - **Acetylcholinesterase inhibitors**, such as pyridostigmine, are a primary treatment for Myasthenia Gravis because they increase the availability of acetylcholine at the neuromuscular junction [3]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of the Immune System, pp. 213-214. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, pp. 1237-1238. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Peripheral Nerves and Skeletal Muscles, pp. 1238-1239.

Q: A 40-year-old female presents with frequent headaches. Investigation reveals raised intracranial pressure and the presence of a dural-based tumor. Which of the following histological findings correlate with the diagnosis?

Psammoma bodies with whorling of tumor cells. ***Psammoma bodies with whorling of tumor cells***- The clinical picture of a **dural-based tumor** [2] causing symptoms of **raised intracranial pressure** (headache) is highly suggestive of a **Meningioma**.- **Psammoma bodies** (laminated calcified concretions) formed by the degeneration of the whorled cell clusters [1] are the classic histological hallmark of the transitional and **meningothelial meningioma** subtypes.*Fried egg appearance*- This histological appearance, characterized by clear perinuclear halos, is the classic finding for **Oligodendroglioma**, a type of parenchymal brain tumor.- Oligodendrogliomas typically arise within the cerebral **white matter** and are usually not primarily dural-based.*Flexner - Wintersteiner rosettes*- These are specialized structures representing an attempt at **retinal differentiation** and are the characteristic feature of **Retinoblastoma**.- They are also sometimes seen in highly aggressive midline CNS tumors, such as **Pineoblastoma**.*Homer - Wright rosettes*- These are seen in tumors exhibiting divergent **neuroectodermal differentiation** but lack a true central lumen or fenestration.- They are the characteristic histological finding in **Medulloblastoma** (a cerebellar tumor) and **Neuroblastoma** (a tumor of the adrenal medulla or sympathetic chain). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 727-728. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1316-1317.

Q: A 25-year old patient who had a Road traffic accident was initially conscious but later became unconscious and subsequently died. On postmortem examination, multiple petechial hemorrhages are seen in the corpus callosum, what is the probable diagnosis?

Diffuse axonal injury. ***Diffuse axonal injury*** - The characteristic finding of **multiple petechial hemorrhages** (microhemorrhages) specifically in deep structures like the **corpus callosum** and brainstem is the pathological hallmark of **Diffuse Axonal Injury** (DAI) [1]. - DAI results from severe acceleration/deceleration (shearing) forces during trauma, leading to widespread axonal disruption, which explains the progression from initial consciousness to coma [1]. *EDH* - Epidural Hematoma (EDH) involves an arterial bleed, typically from the **middle meningeal artery**, causing a hematoma external to the dura mater [1]. - Although EDH often presents with a clinical **lucid interval**, the post-mortem findings are limited to the hematoma collection external to the brain substance, not deep parenchymal petechiae [1]. *SDH* - Subdural hematoma (SDH) is caused by the tearing of **bridging veins** and collects between the dura and arachnoid mater. - While SDH can cause delayed deterioration due to haematoma expansion, the specific microscopic deep white matter hemorrhages described are the defining feature of **DAI**, not SDH. *Contusion* - Cerebral contusions present as focal areas of hemorrhagic necrosis, typically at the site of impact (coup) or opposite side (contrecoup), commonly affecting the frontal and temporal poles [1]. - Unlike DAI, contusions are macroscopic hemorrhagic lesions visible on gross examination, not the characteristic microscopic petechial hemorrhages in deep white matter structures like the corpus callosum [1]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1262-1264.

Q: A child presents with visual disturbances and delayed growth. Imaging reveals a suprasellar mass, and histopathology shows the presence of "wet keratin" (compact, eosinophilic anucleate keratin). What is the most likely diagnosis?

Craniopharyngioma. ***Craniopharyngioma*** - This tumor is classically located in the **suprasellar region** and presents in children with visual field deficits and **endocrine dysfunction** (e.g., delayed growth, short stature) due to hypothalamic or pituitary stalk compression. - The histopathology description of **"wet keratin"** (or keratin nests with peripheral palisading of epithelial cells) is pathognomonic for the adamantinomatous subtype of craniopharyngioma. *Medulloblastoma* - This is primarily a **posterior fossa tumor** originating in the cerebellum, typically causing signs of increased intracranial pressure and **ataxia**, not primarily suprasellar syndromes. - Histologically, it is a small, round blue cell tumor of **primitive neuroectoderm (PNET)** origin; it does not exhibit keratin formation. *Glioma* - While gliomas (e.g., optic pathway gliomas) can involve the suprasellar area, the cellular morphology would consist of **astrocytic** or oligodendroglial cells. - Gliomas lack the epithelial components and definitive **keratin formation** that are characteristic of craniopharyngioma. *Pituitary adenoma* - Pituitary adenomas are typically **intrasellar** and are much more common in adults, causing symptoms associated with hormone excess or deficiency (hypopituitarism) [1]. - Histology shows sheets and cords of uniform **polygonal cells** derived from pituitary endocrinocytes [2]; they do not contain squamous elements or keratin. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Endocrine System, p. 1081. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 417-418.

Q: A 50-year-old woman presents with daily early morning frontal headache and projectile vomiting. The image shows:

Meningioma. **Meningioma** - The MRI shows a **well-circumscribed, extra-axial mass** that is significantly enhancing, particularly in the frontal lobe near the convexity. Histopathology of a meningioma characteristically features **whorls of meningothelial cells** and **psammoma bodies** (calcified concentric lamellae), which are visible in the image. - The clinical symptoms of **early morning headaches** and **projectile vomiting** are indicative of **increased intracranial pressure**, which can be caused by any space-occupying lesion, including a meningioma, especially if it grows to a significant size. *Medulloblastoma* - This is a highly malignant brain tumor typically occurring in the **cerebellum of children**, not usually seen in a 50-year-old woman in the frontal lobe. - Histologically, medulloblastomas are composed of small, round, **blue cells** with little cytoplasm (small blue cell tumor), which is distinct from the provided image. *Glioma* - **Gliomas** originate within the brain parenchyma and are often **poorly circumscribed** with an infiltrative growth pattern, which contrasts with the well-defined lesion seen on MRI. - While gliomas can cause increased intracranial pressure, their diverse histological appearances depend on their specific subtype (e.g., astrocytoma, oligodendroglioma), none of which perfectly match the characteristic **whorls and psammoma bodies** seen here. *Glioblastoma multiforme* - **Glioblastoma multiforme** (GBM) is a highly aggressive grade IV astrocytoma, characterized by **ring-enhancing lesions** with central necrosis and significant edema on MRI. - Histologically, GBM exhibits features like **pseudopalisading necrosis**, microvascular proliferation, and pleomorphic tumor cells, which are not depicted in the provided histopathology image.

Q: Which of the following are the aetiological factors associated with a communicating hydrocephalus ? I. Post haemorrhagic II. Lesions within the ventricle III. CSF infection IV. Raised CSF protein Select the correct answer using the code given below :

I, III and IV. ***I, III and IV*** - **Communicating hydrocephalus** occurs when there is impaired CSF absorption in the **subarachnoid space** despite a patent ventricular system. - **Post-hemorrhagic**, **CSF infection** (meningitis), and **raised CSF protein** (e.g., from tumors or inflammation) can all obstruct the arachnoid villi, preventing proper CSF reabsorption [1]. *I, II and III* - While **post-hemorrhagic** and **CSF infection** are causes of communicating hydrocephalus, **lesions within the ventricle** typically cause **non-communicating (obstructive) hydrocephalus** by blocking CSF flow *within* the ventricular system itself [1]. - This option incorrectly includes an obstructive cause and omits **raised CSF protein**, which is a known cause of impaired CSF absorption. *II, III and IV* - This option incorrectly includes **lesions within the ventricle** as a cause of communicating hydrocephalus, which usually leads to **non-communicating hydrocephalus** [1]. - It correctly identifies **CSF infection** and **raised CSF protein** but omits **post-hemorrhagic** causes, which are a common etiology [1]. *I, II and IV* - This option incorrectly includes **lesions within the ventricle**, which typically cause **non-communicating hydrocephalus** [1]. - While **post-hemorrhagic** and **raised CSF protein** are valid causes, the inclusion of an obstructive cause makes this option incorrect for *communicating* hydrocephalus. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 703-704.

Q: The most common type of brain tumour associated with neurofibromatosis type 1 is

astrocytoma. ***Astrocytoma*** - **Pilocytic astrocytoma** is the most common brain tumor associated with **Neurofibromatosis type 1 (NF1)**, particularly in children and young adults [1]. - These tumors often occur in the **optic pathways**, **brainstem**, or **cerebellum** in patients with NF1. *Acoustic neuroma* - **Vestibular schwannomas** (acoustic neuromas) are characteristic of **Neurofibromatosis type 2 (NF2)**, not NF1 [2]. - NF2 typically involves **bilateral vestibular schwannomas** and other cranial nerve tumors [2]. *Meningioma* - Meningiomas are also more commonly associated with **NF2**, though they can occur sporadically [2]. - They are generally less common in NF1 patients and are not considered the hallmark brain tumor. *Medulloblastoma* - Medulloblastoma is a **highly malignant primary brain tumor** that occurs predominantly in children but is not specifically linked to NF1 [1]. - Its presence is not a defining feature of the NF1 syndrome. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Central Nervous System, pp. 1319-1320. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Manifestations Of Central And Peripheral Nervous System Disease, pp. 724-728.

Question 1

In Myasthenia gravis, which of the following is the primary target of autoantibodies at the neuromuscular junction?

Accepted Answer

Post-synaptic ACh Receptor

Answer

Acetylcholinesterase

Answer

Voltage-gated calcium channels at NMJ

Answer

Presynaptic ACh receptor

Question 2

The CSF findings in bacterial meningitis would include which of the following?

Accepted Answer

Elevated protein and decreased glucose

Answer

Elevated WBC count with normal glucose

Answer

Decreased protein and elevated glucose

Answer

Normal white blood cell count

Question 3

A male presents with a history of vestibular schwannoma and psammoma bodies in the brain. Which of the following is the most likely diagnosis?

Accepted Answer

Meningioma

Answer

Oligodendroglioma

Answer

Pilocytic astrocytoma

Answer

GBM (Glioblastoma Multiforme)

Question 4

A 40-year-old female presents with frequent headaches. Investigation reveals raised intracranial pressure and the presence of a dural-based tumor. Which of the following histological findings correlate with the diagnosis?

Accepted Answer

Psammoma bodies with whorling of tumor cells

Answer

Flexner - Wintersteiner rosettes

Answer

Homer - Wright rosettes

Answer

Fried egg appearance

Question 5

A 25-year old patient who had a Road traffic accident was initially conscious but later became unconscious and subsequently died. On postmortem examination, multiple petechial hemorrhages are seen in the corpus callosum, what is the probable diagnosis?

Accepted Answer

Diffuse axonal injury

Answer

Epidural hematoma

Answer

Subdural hematoma

Answer

Contusion

Question 6

A 45-year-old female presents with a 2-year history of progressive unilateral hearing loss, tinnitus, and unsteadiness. An MRI scan reveals a well-defined tumor located in the cerebellopontine angle (CPA). A surgical resection is performed, and subsequent histopathological examination of the tumor tissue is given below. Based on these histopathological findings, what is the most likely diagnosis?

Accepted Answer

Schwannoma

Answer

Meningioma

Answer

Neurofibroma

Answer

Ependymoma

Question 7

A child presents with visual disturbances and delayed growth. Imaging reveals a suprasellar mass, and histopathology shows the presence of "wet keratin" (compact, eosinophilic anucleate keratin). What is the most likely diagnosis?

Accepted Answer

Craniopharyngioma

Answer

Medulloblastoma

Answer

Glioma

Answer

Pituitary adenoma

Question 8

A 50-year-old woman presents with daily early morning frontal headache and projectile vomiting. The image shows:

Accepted Answer

Meningioma

Answer

Medulloblastoma

Answer

Glioma

Answer

Glioblastoma multiforme

Question 9

Which of the following are the aetiological factors associated with a communicating hydrocephalus ?
I. Post haemorrhagic
II. Lesions within the ventricle
III. CSF infection
IV. Raised CSF protein

Select the correct answer using the code given below :

Accepted Answer

I, III and IV

Answer

I, II and III

Answer

II, III and IV

Answer

I, II and IV

Question 10

The most common type of brain tumour associated with neurofibromatosis type 1 is

Accepted Answer

astrocytoma

Answer

acoustic neuroma

Answer

meningioma

Answer

medulloblastoma

Neuropathology — MCQs

Neuropathology — MCQs

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