Neurology MCQ Flashcards
Which of the following is NOT a feature of myotonic dystrophy?
A. Weakness and wasting of the facial muscles
B. X-linked inheritance
C. Frontal baldness
D. Diabetes mellitus
E. Cardiac conduction defects
A. Weakness and wasting of the facial muscles
MyD is AD inheritance (19q13.3). Features incl:
* Myotonic facies = frontal baldness, bilateral ptosis, facial muscle weakness and wasting, jaw hanging due to masticatory muscle wasting
* Myotonia
* Cataract
* Cardiac – cardiomyopathy, conduction disorder
* Endocrine – DM, testicular atrophy
* Cognitive dysfunction
* Smooth muscle disorder, e.g. gut dysmotility, urine retention
Which of the following is true in Myasthenia gravis?
A. Thymectomy is only indicated in the presence of thymoma
B. Thymus abnormalities occur in about 75% of patients
C. It is due to a presynaptic defect with impaired release of acetylcholine
D. The tendon reflexes are diminished or absent
E. It is more common in males than females
B. Thymus abnormalities occur in about 75% of patients
A – also indicated in generalized MG with risk < benefit
C – post-synaptic (pre-synaptic describes congenital myasthenic syndrome)
D – reflex preserved
E – F>M = 4:3
Brown-Sequard syndrome manifests as:
A. Ipsilateral lower motor neuron weakness, loss of vibration and proprioception, and contralateral loss of sense of pain and temperature, below the level of the lesion
B. Ipsilateral lower motor neuron weakness, loss of sense of pain and temperature, and contralateral loss of sense of vibration and proprioception, below the level of the lesion
C. Ipsilateral upper motor neuron weakness, loss of sense of pain and temperature, and contralateral loss of sense of vibration and proprioception, below the level of the lesion
D. Ipsilateral upper motor neuron weakness, and loss of sense of vibration and proprioception, and contralateral loss of sense of pain and temperature, below the level of the lesion
E. Ipsilateral upper motor neuron weakness, and loss of sensation of all modalities below the level of the lesion
D. Ipsilateral upper motor neuron weakness, and loss of sense of vibration and proprioception, and contralateral loss of sense of pain and temperature, below the level of the lesion
Spinothalamic tract (motor) crosses at spinal cord), while DCML crosses in brainstem)
Which of the following is atypical for multiple sclerosis?
A. Urinary sphincter disturbance
B. Cerebellar ataxia
C. Areflexia
D. Internuclear ophthalmoplegia
E. Decreased visual acuity
C. Areflexia
MS is almost exclusively CNS
Common epileptic auras include all of the following except:
A. Gastric sensation
B. Feeling of fear
C. Unusual taste or smell
D. Desire to commit violence
E. Indescribable feeling
D. Desire to commit violence
Visceral sensation – e.g. epigastric sensation, gustatory/olfactory hallucination
Psychiatric – specific emotions, deja vu, jamais vu, depersonalization, blank staring
Other sensory – VH/AH, visual distortion
In subarachnoid haemorrhage,
A. Cerebral infarction is a major cause of morbidity
B. A CT scan of the brain showing no subarachnoid blood signal excludes this diagnosis
C. Surgical intervention is not indicated unless the patient deteriorates clinically
D. The actual incidence of subarachnoid haemorrhage decreases with age
E. Hypertension is not a risk factor
A. Cerebral infarction is a major cause of morbidity
Vasospasm is common and preventable, usu occurs d4-21.
B – CT often negative
C – rebleeding is common, essential to secure aneurysm early
E – HT increases risk of bleeding
Which of the following types of stroke has the highest mortality rate?
A. Cortical infarct
B. Lacunar stroke
C. Supratentorial intracerebral hemorrhage
D. Subarachnoid hemorrhage
E. Subcortical infarct
D. Subarachnoid hemorrhage (50% mortality rate in 1 month)
Which of the followings can help recovery from Guillain-Barré syndrome?
A. Intravenous pulse methylprednisolone
B. Intravenous cyclophosphamide
C. Intravenous human immunoglobulin (IVIgG)
D. Fresh frozen plasma
E. Cryoprecipitate
C. Intravenous human immunoglobulin (IVIgG)
Give IVIG 0.4g/kg/day for 5 days
Or plasmapharesis 50ml/kg/session of plasma for 5 exchanges over 2 weeks. Combination of IVIG and PE is not better than PE or IVIG alone.
Supportive mangement
Monitor pulmonary dysfunction (vital capacity). Consider mechanical ventilation if hypercarbia and/or hypoxemia, FVC <15ml per kg of BW. Bulbar weakness, impaired swallowing, insufficient cough, tachypnoea
Watch for autonomic dysfunction (potentially fatal); cardiac monitoring (arrhythmia and severe bradycardia), BP monitoring (fluctuate betwen severe hypertension and hypotension)
GI: susceptible to the development of paralytic ileus –> monitor swallowing/+/- temporary non oral feeding
Other supportive measures: DVT prevention, urinary retention, clear secretion, early mobilization, medical treatment for pain and paraesthesia
Which is false about glioblastoma multiforme? A. Infiltrative margin B. Lung metastasis C. Spread to contralateral hemisphere D. CSF metastasis
B. Lung metastasis
Intracranial tumors rarely metastasize outside the CNS
Putamen homogenous oval shape hyperdense lesion on CT brain, extending into lateral ventricles. Which is not true?
A. This condition commonest occur in cerebellum
B. Mannitol can be given to reduce ICP
C. Routine dexamethasone is given in this condition
D. Must monitor patient carefully in acute phase
E. Surgery should not be performed because of ?low GCS unless ?acute hydrocephalus developed
C. Routine dexamethasone is given in this condition
An 80-year-old lady with long history of Parkinson’s disease with recent increase in dose and frequency of Sinemet from 40 mg TD to 40 mg QID and addition of bromocriptine. His daughter says his father has ‘depressed mood’. He no longer takes part in the activities that he likes in the past e.g. playing mahjong. He also has visual hallucination. Which is the likely explanation?
A. Meningitis
B. Encephalitis
C. Adverse effect of Sinemet
D. Natural aging
E. Schizophrenia
C. Adverse effect of Sinemet (l-dopa + carbidopa (DOPA decarboxylase inhibitor))
VH can be caused by increase in levodopa and addition of DA. Apathy/anhedonia is more likely due to progression of underlying PD.
Which of the following is most consistent with the imbalance of neurotransmitters in Parkinson’s disease?
A. Decrease in 5-HT
B. Decrease in GABA
C. Increase in dopamine
D. Decrease in dopamine decarboxylase level
E. Normal acetylcholine
A. Decrease in 5-HT
PD a/w:
* Dopamine depletion (neurotransmitter produced by substantia nigra)
* Acetylcholine excess
* Serotonin depletion (caudate as well as hypothalamus and frontal cortex) → accounts for PD-depression
C6/C7 transection is NOT associated with:
A. V/Q mismatch
B. Diaphragmatic breathing
C. Long term artificial ventilation dependent
D. Sputum retention
E. Impaired cough reflex
A. V/Q mismatch
Extrathoracic pathologies do not cause V/Q mismatch.
B – theoretically, phrenic nerve is still intact, so the pt should still be able to breath autonomously
Which of the following is NOT a common cause of stroke?
A. Atherothrombosis
B. Arterio-arterial embolism
C. Cardioembolism
D. Arterial dissection
E. Atrial fibrillation
D. Arterial dissection (can happen but not common)
Which of the following is most suggestive of bacterial meningitis?
A. Neck stiffness
B. Kernig’s sign
C. High fever
D. Lymphocytosis in blood
E. Low sugar in CSF
E. Low sugar in CSF
Neck stiffness, Kernigs sign are generalized to meningitis (not subtype)
Lymphocytosis can either be acute bacterial meningitis phase/TB or viral meningitis
Concerning Guillain-Barré syndrome, which is TRUE?
A. It can never occur in children younger than 10 years old
B. It is ascending muscle paralysis sparing facial and bulbar muscles
C. It can lead to respiratory failure
D. Hyperreflexia is a feature
E. Involvement of sensory more prominent than motor
C. It can lead to respiratory failure (hence requires monitoring of vital capacity –> may require mechanical ventilation)
A – can occur <10y, but increase with age
B – affects facial, oropharyngeal, EOM, respiratory muscles
E – affect motor > sensory
Regarding motor neuron disease, which statement is FALSE?
A. Deep tendon reflex is usually retained until late stage of disease
B. Non-fluent dysphasia is a recognized feature
C. Abdominal reflexes are usually retained
D. Muscle fasciculation is a conspicuous feature
E. Positive family history is found in 5–10% of patients
B. Non-fluent dysphasia is a recognized feature
Although MND is a/w FTD, it is usu a/w behavioural variant FTD instead of primary progressive aphasia. A – weak and wasted muscles with retained reflexes is highly suggestive of MND
C – abdominal reflexes usu retained until late stage
A 68-year-old right-hand dominant man presented with transient episode of speech disturbance and right sided weakness. He has history of hypertension and type 2 DM. Physical exam shows BP 140/80, neurological exam normal, irregular pulse. On investigation CT brain is normal, Duplex Doppler shows 50% carotid stenosis. Atrial fibrillation confirmed by ECG. Which is the MOST appropriate stroke prevention approach?
A. Aspirin
B. Aspirin + clopidogrel
C. Carotid endarterectomy
D. Warfarin
E. ACEI
D. Warfarin
CHAD VASc: TIA already scores 2 + HT + DM + Age
Carotid endarterectomy only indicated if >70% stenosis
Which one is characteristic of trigeminal neuralgia? A. Chemosis
B. Bilateral involvement
C. Diclofenac can be a treatment of choice
D. Amendable to microvascular decompression
E. Continuous pain
D. Amendable to microvascular decompression
TN is characterized by attacks of brief shock-like severe pain in V2/3 distribution. 80-90% a/w vascular loop compression, therefore is amenable to microvascular decompression esp in young. Classic TN usu treated by carbamazepine (75% responsive) or other anti-epileptics
Which drug cannot be used in patients with myasthenia gravis?
A. Atropine
B. IVIG
C. Penicillamine
D. Penicillin
C. Penicillamine
Penicillamine (copper chelator) notorious for A/I manifestation, can precipitate MG crisis.
Which of the following is true in Parkinson’s disease?
A. Use of metoclopramide is indicated in nausea in L-dopa treatment
B. You will usually find affected family members
C. Painful dystonia can complicate L-dopa therapy
C. Painful dystonia can complicate L-dopa therapy
Dystonia can occur as part of motor fluctuation with prolonged levodopa therapy. A – domperidone is preferred as it does not cross BBB B – usu not familial
Which of the following is not a clinical feature of lateral medullary syndrome?
A. Dysphagia
B. Ipsilateral loss of trigeminal sensation
C. Ipsilateral Horner’s syndrome
D. Ipsilateral loss of spinothalamic sensation of limbs and trunk
E. Ipsilateral ataxia of limb
D. Ipsilateral loss of spinothalamic sensation of limbs and trunk
Lateral medullary syndrome a/w PICA and vertebral artery infarct.
Contralateral loss of fine touch, vibration, 2 point discrimination and proprioception (DCML decussates at the medulla oblongata)
Contralateral loss of pain and temp sensation (spinothalamic tracts already decussate at spinal cord)
Ipsilateral Cerebellar Ataxia and Ptosis (i.e. Horner)
Vertigo, Vocal cord dysfunction and other bulbar functions
A patient presented with right sided facial sensation defect and left sided body sensation defect, which is the most likely location of the lesion?
A. Right-sided brainstem
B. Left-sided brainstem
C. High cervical spine
D. Putamen
E. Right-sided parietal lobe
A. Right-sided brainstem
Right sided facial sensation defect that means located at the medulla oblongata if combined with the hemiparesthesia
Left sided body sensation defect –> therefore the DCML are already decussated at the medulla oblongata on the right side
A 40-year-old man presented of recurrent strange sensation of tongue, smells something strange, with sensation of deja vu. What is the most likely diagnosis? A. Acute psychosis B. Delirium tremens C. Hypoglycaemia D. Subarachnoid haemorrhage E. Temporal lobe epilepsy
E. Temporal lobe epilepsy
Which is not a common cause of meningitis? A. Neisseria meningitidis B. Streptococcus pneumoniae C. Haemophilus influenzae D. Cryptococcus neoformans E. Streptococcus suis
D. Cryptococcus neoformans (immunocompromised state)
Which of the following is characteristic of myasthenia gravis?
A. Generalized muscle weakness
B. Complete ptosis with ophthalmoplegia
C. Absence of muscle jerk
D. Absence of sensory loss
D. Absence of sensory loss
20/F previously healthy, NKDA, presented with increasingly worsen headache over 24 hours, fever 39 degree, neck stiffness and generalized petechial rash. She has otherwise no neurological signs. Your immediate management should be: A. Immediate IV meningitic dose of penicillin, blood culture, lumbar puncture B. CT head, blood culture, LP C. CT head, ESR, temporal artery biopsy and analgesics D. MRI head, EEG, phenytoin E. MRI head, EEG, (???)
A. Immediate IV meningitic dose of penicillin, blood culture, lumbar puncture
Neisseria meningitidis (petechial rash): gram -ve intracellular diplococci
Petechiae due to bacteremia and sepsis sydnrome: fever, petechiae and purpura
A 67-year-old man with Parkinson’s for 7 years on levodopa experiences nausea after taking the medication. Which of the following drug is most appropriate for treating his nausea?
A. Metoclopramide (Maxolon)
B. Cinnarizine (Stugeron)
C. Prochlorperazine (Stemetil)
D. Ondansetron (Zofran)
E. Domperidone (Motilium)
E. Domperidone (Motilium)
Domperidone is a peripheral D2 blocker. It does not cross BBB, and therefore does not interfere with levodopa.
Domperidone will act on the chemoreceptor trigger zone of vomiting center located on the dorsal surface of medulla oblongata: floor of the 4th ventricle of the brain (no BBB)
Patient on warfarin. Conscious. Right-sided ataxia and nystagmus. SBP 160 mmHg. Right cerebellar haemorrhage seen on CT brain. Which of the following is an appropriate action?
A. Monitor GCS qid
B. Insert Ryle’s tube for feeding and giving medication
C. Lower blood pressure by giving nifedipine via Ryle’s tube
D. Give IV phenytoin to control seizure
E. Look for coagulopathy, give FFP if necessary
E. Look for coagulopathy, give FFP if necessary
Reversal of anticoagulation is most important in this case, although PCC may be preferred.
D – infratentorial lesion will not cause seizures
C – BP lowering is indicated in ICH when (1) SBP >200 or MABP >150, or (2) SBP >180 or MABP >130 if no signs of ↑ICP
30/M, presented with continuous GTC. URTI 5 days before convulsion. Physical exam showed fever of 37.8°C otherwise normal. Intubated and ventilated. What is the best treatment for seizure control?
A. IV sodium valproate
B. Carbamazepine via Ryle’s tube
C. Lamotrigine via Ryle’s tube
D. IV phenobarbitone
E. IV diazepam + loading dose of phenytoin
E. IV diazepam + loading dose of phenytoin
Status epilepticus
68/M, GPH, sore throat, fever, rhinorrhoea for 1 week followed by slurred speech. Found unconscious in home. Has involuntary movement of left upper and lower limbs followed by generalized jerky movement and LOC. CBC, L/RFT, electrolytes normal. Urgent CT brain normal. What is your next step?
A. IV ceftriaxone and something
B. Empirical anti-TB and phenytoin
C. LP and IV acyclovir after CSF PCR + VE
D. LP and empirical acyclovir
E. LP and empirical acyclovir and phenytoin
E. LP and empirical acyclovir and phenytoin
Likely viral encephalitis. AED can be started to cover the acute period where acute symptomatic seizure can recur.
A 53-year-old patient presented with 3 days of fever, worsening headache, nausea and vomiting. He was later diagnosed to have acute hydrocephalus with dilated ventricles. What will be your immediate management?
A. Lumbar puncture
B. Treat with anti-tuberculous drugs and steroids
C. Refer to neurosurgery for urgent drainage
D. Empirical acyclovir
E. Close observation
B. Treat with anti-tuberculous drugs and steroids
Hydrocephalus is classical for TBM. It may be managed medically provided that neurological status is not deteriorating rapidly.
25/F, swimming coach, presents with 3 episodes of GTC seizures in the past year. Good past health, no family history, no personal history of febrile seizure, all physical and neurological examinations normal. EEG and MRI brain normal.
A. Do not give AED because reproductive age
B. Normal EEG and MRI rules out epilepsy
C. Use valproate as AED
D. Use lamotrigine as AED
E. She is suffering from temporal lobe epilepsy
D. Use lamotrigine as AED
Lamictal is a/w lowest teratogenicity.
A – not prescribing is not an option because maternal seizure causes fetal hypoxia and has devastating consequences
B – interictal EEG is only 50% abnormal
E – TLE is usu a/w temporal lobe aura and a/w hippocampal sclerosis on MRI
Young female preparing for pregnancy, admitted to AED. Her friends and family reported she had repeated episodes of staring into space and decreased alertness lasting for minutes. Some episodes had concurrent smacking of lips. On current occasion, initial presentation was similar to previous episodes, then loss of consciousness and generalized tonic-clonic seizure lasting for more than 10 minutes, spontaneously stop with residual drowsiness, thus admitted to AED. What most likely happened?
A. Absence seizure
B. Autonomic epilepsy with partial seizure, secondary complex generalized tonic-clonic seizure
C. Cortical epilepsy with partial seizure, secondary complex generalized tonic-clonic seizure
C. Cortical epilepsy with partial seizure, secondary complex generalized tonic-clonic seizure
TLE with SGTCS (temporal lobe epilepsy with secondarily generalized tonic clonic seizure)
Anti-aquaporin 4 antibodies are specific markers for which disease?
A. Devic’s disease
B. Wilson’s disease
C. Huntington’s disease
D. Steele-Richardson-Olszewski syndrome
A. Devic’s disease (NMO)
A female presented (1) past history of autoimmune thyroiditis; (2) PE shows decreased reflex in both UL, (3) eyes movement restricted, appeared that multiple CN and extraocular muscles affected, (4) history of fatigue for 1 month. Which of the above is not compatible with diagnosis of myasthenia gravis? A. 1
B. 2
C. 3
D. 4
B. 2
Concerning the management of a patient presenting with acute stroke. Choose the correct statement:
A. Acute lowering of BP is indicated
B. Body cooling should be indicated
C. Cerebral imaging can be delayed 72 hours
D. Intravenous thrombolysis is indicated if intracerebral bleeding is excluded and the patient presents early
E. Patients should be given intravenous heparin
D. Intravenous thrombolysis is indicated if intracerebral bleeding is excluded and the patient presents early (<4.5 hours, <3 hours is ideal for benefit)
An elderly female patient, good past health, presented with diffuse distending headache, which worsens on coughing and sneezing. There is no nausea or vomiting. Physical examination showed no focal neurological signs. Which is most likely?
A. Acute meningitis
B. Brain tumour
C. Headache due to cervical spondylosis
D. Late onset migraine
E. Giant cell arteritis
B. Brain tumour
Worsen on coughing/sneezing typical for ↑ICP.
D – migraine usu unilateral
E – GCA usu temporal (jaw claudication, temporal tenderness)
35/F, present with distal muscle wasting and numbness with glove and stocking pattern. Physical examination shows distal muscle wasting and absence of deep tendon reflexes. Babinski’s response is absent. What is the most likely site of the lesion?
A. Cauda equina
B. Cervical plexus
C. Cervical spinal cord
D. Neuromuscular junction
E. Peripheral nerves
E. Peripheral nerves
Glove and stocking loss of sensation (not dermatomal distribution –> not spinal root)
A 20-year-old patient with known epilepsy after HSV encephalitis 2 years ago is currently on Epilim chrono (sodium valproate) 500mg BD. He recently travelled from Singapore to Hong Kong on a busi- ness trip. His mother said he left his medication in at home 5 days ago. He was admitted for a generalized tonic-clonic seizure lasting for 5 minutes. At the medical ward, he experienced another generalized tonic-clonic seizure before consciousness has been fully regained. Which of the following is to be given immediately?
A. IV midazolam + IV levetiracetam
B. IV midazolam + IV maintenance midazolam
C. IV midazolam + IV loading dose of phenytoin
D. IV midazolam + IV sodium valproate
E. IV midazolam + sodium valproate via NG tube
D. IV midazolam + IV sodium valproate
Stage 1: Early status use short acting BDZ as 1st line: IV midazolam
Stage 2 (10-60 mins): best to use long acting AED that patient was previously using –> IV sodium valproate