Comprehensive Examination (4) Flashcards
1. The cuneus is separated from the lingual gyrus by the (A) Rhinal sulcus (B) Calcarine sulcus (C) Parietooccipital sulcus (D) Collateral sulcus (E) Intraparietal sulcus
1–B. The calcarine sulcus separates the cuneus from the lingual gyrus. The banks of the calcarine
sulcus contain the visual cortex.
2. Which sinus receives drainage from the greatest number of arachnoid granulations? (A) Straight sinus (B) Transverse sinus (C) Sigmoid sinus (D) Superior sagittal sinus (E) Cavernous sinus
2–D. The superior sagittal sinus receives drainage from the greatest number of arachnoid granulations.
3. Which of the following statements concerning the Rathke pouch is true? (A) It is a mesodermal diverticulum (B) It is derived from the neural tube (C) It gives rise to the adenohypophysis (D) It gives rise to the epiphysis (E) It gives rise to the neurohypophysis
3–C. The Rathke pouch is an ectodermal outpocketing of the stomodeum anterior to the buccopharyngeal
membrane. It gives rise to the adenohypophysis (pars distalis, pars tuberalis, and
pars intermedia).
- Which of the following statements concerning the lateral horn of the spinal cord is true?
(A) It contains preganglionic parasympathetic neurons
(B) It gives rise to a spinocerebellar tract
(C) It is present at all spinal cord levels
(D) It gives rise to preganglionic sympathetic fibers
(E) It is most prominent at sacral levels
4–D. The lateral horn (T1–L3) gives rise to preganglionic sympathetic fibers.
- Which of the following statements concerning the nucleus dorsalis of Clarke is true?
(A) It is found in the ventral horn
(B) It projects to the cerebellum
(C) It is present at all spinal levels
(D) It is most prominent at upper cervical levels
(E) It is homologous to the cuneate nucleus of the medulla
5–B. The nucleus dorsalis of Clarke (C8–L3) gives rise to the dorsal spinocerebellar tract, which
ascends and enters the cerebellum through the inferior cerebellar peduncle.
6. Which of the following groups of cranial nerves is closely related to the corticospinal tract? (A) CN III, CN IV, and CN V (B) CN III, CN V, and CN VII (C) CN III, CN VI, and CN VIII (D) CN III, CN VI, and CN XII (E) CN III, CN IX, and CN X
6–D. In the midbrain, the pyramidal tract lies in the basis pedunculi; oculomotor fibers of CN III
pass through the medial part of the basis pedunculi. In the pons, the pyramidal tract lies in the
base of the pons; abducent fibers of CN VI pass through the lateral part of the pyramidal fasciculi.
In the medulla, the pyramidal tracts form the medullary pyramids; hypoglossal fibers of CN XII
lie just lateral to the pyramids.
7. The primary auditory cortex is located in the (A) Frontal operculum (B) Postcentral gyrus (C) Superior parietal lobule (D) Inferior parietal lobule (E) Transverse temporal gyri
7–E. The primary auditory cortex (areas 41 and 42) is located in the transverse temporal gyri of
Heschl, a part of the superior temporal gyrus.
8. The neocerebellum projects to the motor cortex via the (A) Anterior thalamic nucleus (B) Ventral anterior nucleus (C) Ventral lateral nucleus (D) Lateral dorsal nucleus (E) Lateral posterior nucleus
8–C. The neocerebellum (the posterior lobe minus the vermis and the paravermis) sends input to
the motor cortex through the ventral lateral nucleus of the thalamus. The pathway is the neocerebellar
cortex, dentate nucleus, contralateral ventral lateral nucleus of the thalamus, and
motor cortex (area 4)
9. The dentatothalamic tract decussates in the (A) Diencephalon (B) Rostral midbrain (C) Caudal midbrain (D) Rostral pons (E) Caudal pons
9–C. The dentatothalamic tract decussates in the caudal midbrain tegmentum at the level of the
inferior colliculus. This massive decussation of the superior cerebellar peduncles is characteristic
of this level.
10. A pituitary tumor is most frequently associated with (A) Homonymous hemianopia (B) Homonymous quadrantanopia (C) Bitemporal hemianopia (D) Binasal hemianopia (E) Altitudinal hemianopia
10–C. Pituitary tumors frequently compress the decussating fibers of the optic chiasm and produce
a bitemporal hemianopia. Nasal fibers decussate, and temporal fibers remain ipsilateral.
- Resection of the anterior portion of the left temporal lobe is most frequently associated
with
(A) Left homonymous hemianopia
(B) Right upper homonymous quadrantanopia
(C) Right lower homonymous quadrantanopia
(D) Left upper homonymous quadrantanopia
(E) Left lower homonymous quadrantanopia
11–B. Resection of the anterior portion of the temporal lobe transects the fibers of the loop of
Meyer and results in a contralateral upper homonymous quadrantanopia. Inferior retinal quadrants
are represented in the inferior banks of the calcarine sulcus.
- A 65-year-old farmer has had dull frontal headaches for the last 3 weeks. Neurologic examination reveals spastic hemiparesis on the
right side and a pronator drift on the right side. What is the most likely diagnosis?
(A) Brain tumor
(B) Myasthenia gravis
(C) Progressive supranuclear palsy
(D) Pseudotumor cerebri
(E) Subacute combined degeneration
12–A. Headache and papilledema are signs of brain tumor, and pronator drift is a frontal lobe
sign due to weakness of the supinator muscle. Tumor pressure on the corticospinal tract results in
contralateral spastic hemiparesis. In progressive supranuclear palsy the patient cannot look down.
In myasthenia gravis there is weakness of skeletal muscle. In pseudotumor cerebri there are no
mass lesions but headache and papilledema. In subacute combined degeneration the posterior
columns and the corticospinal tracts are affected.
- An 18-year-old high school student has fractured a cervical vertebra in an automobile accident. Neurologic examination reveals
hemiparesis on the right side, Babinski and Hoffmann signs on the right side, loss of pain and temperature sensation on the left side, and
normal pallesthesia in all extremities. The spinal cord lesion that would most likely explain the deficits involves the
(A) Dorsal column, left side
(B) Dorsal column, right side
(C) Lateral column, left side
(D) Lateral column, right side
(E) Anterior column, bilateral
13–D. The lateral corticospinal tract and the lateral spinothalamic tract are both found in the lateral
column. Transection of the corticospinal tract results in ipsilateral paresis, and transection of
the spinothalamic tract results in contralateral loss of pain and temperature sensation.
Pallesthesia (vibration sense) is normal.
14. Light shone into the left eye elicits a direct pupillary reflex but no consensual reflex. A lesion in which of the following structures accounts for this deficit? (A) Optic nerve, left eye (B) Optic nerve, right eye (C) Optic tract, right side (D) Oculomotor nerve, right side (E) Oculomotor nerve, left side
14–D. The contralateral oculomotor nerve is responsible for the consensual reaction.
- A 53-year-old housewife has a normal corneal blink reflex on her left side but no consensual blink on her right side. Which of the
following neurologic deficits or signs would you expect to find on the right side?
(A) Hyperacusis
(B) Hemianhidrosis
(C) Hemianesthesia
(D) Internal ophthalmoplegia
(E) Severe ptosis
15–A. Hyperacusis is increased acuity of hearing and undue sensitivity to low tones. It results
from paralysis of the stapedius muscle (CN VII). The stapedius reduces the amplitude of sound
vibrations of the stapes in the oval window.
- A 49-year-old man has a loss of tactile sensation involving the anterior two-thirds of his tongue on the left side. Neurologic examination
reveals paralysis of the masseter muscle on the left side and loss of pain and temperature sensation from the teeth of the mandible on
the left side. He has a lesion involving which one of the following nerves?
(A) Chorda tympani nerve
(B) Facial nerve
(C) Hypoglossal nerve
(D) Trigeminal nerve, mandibular division
(E) Trigeminal nerve, ophthalmic division
16–D. The mandibular division of the trigeminal nerve (CN V-3) innervates the muscles of mastication
(e.g., masseter muscle) and mediates the tactile sensation of the anterior two-thirds of the
tongue. The glossopharyngeal nerve (CN IX) provides the tactile, nociceptive, and taste innervation
of the posterior third of the tongue. The facial nerve (CN VII) provides taste innervation to
the anterior two-thirds of the tongue.
- A 62-year-old lawyer has a stroke and falls while cutting his lawn. He does not lose consciousness. Neurologic examination reveals loss of pain sensation on the right side of the face and on the left side of the body, falling and past pointing to the right side, difficulty swallowing, horizontal nystagmus to the right side, deviation of the uvula to the left when asked to say ah, and Horner syndrome on the
right side. The most likely site of this man’s lesion is the
(A) Internal capsule, left side
(B) Midbrain, right side
(C) Pontine tegmentum
(D) Lateral medulla, right side
(E) Medial medulla, right side
17–D. This is the classic lateral medullary syndrome, which is also known as Wallenberg syndrome
(see Figure 14-1B).
- A 64-year-old pharmacology professor complains of weakness in his right leg and double vision, especially when moving his eyes to
the left. Neurologic examination reveals a dilated pupil and ptosis on the left side and a Babinski sign (extensor plantar reflex) on the right side. The most likely site of this patient’s lesion is the
(A) Midbrain crus cerebri, right side
(B) Midbrain crus cerebri, left side
(C) Pontine base, left side
(D) Pontine tegmentum, right side
(E) Internal capsule, right side
18–B. This is a classic medial midbrain lesion characteristic of Weber syndrome. It includes the
crus cerebri and the exiting intra-axial fibers of the oculomotor nerve (see Figure 14-3C).
- While working in his shop, a 21-year-old machinist is struck by a penetrating metal fragment in the side of the head. Neurologic examination reveals the following language deficits: fluent speech, no ability to read aloud, no ability to repeat what you say, no ability to compensate by writing. The patient understands the problem but cannot resolve it. Where would you expect to find the fragment?
(A) Between the supramarginal gyrus and the inferior frontal gyrus
(B) In the angular gyrus
(C) In the transverse gyri
(D) In the posterior third of the superior temporal gyrus
(E) In the paracentral gyrus
19–A. The metal fragment is found between the inferior frontal gyrus and the supramarginal
gyrus. The two gyri are connected by the arcuate fasciculus; transection results in conduction
aphasia. The arcuate fasciculus interconnects Broca area and Wernicke area. The key deficit is the
inability to repeat (see Figure 24-1).
- The catecholamine norepinephrine is the primary neurotransmitter found in the
(A) Adrenal cortex
(B) Adrenal medulla
(C) Postganglionic parasympathetic neurons to the circular smooth muscle layer of the jejunum
(D) Postganglionic sympathetic neurons to the smooth muscle of the renal arterioles
(E) Postganglionic sympathetic neurons to the sweat glands
20–D. Norepinephrine is the neurotransmitter of postganglionic sympathetic neurons, with the
exception of sweat glands and some blood vessels that receive cholinergic sympathetic innervation.
Epinephrine is produced by the chromaffin cells of the adrenal medulla.
- A 30-year-old man sustains brain damage as the result of an automobile accident. Neurologic examination reveals incomplete retrograde
amnesia, severe anterograde amnesia, and inappropriate social behavior, including hyperphagia, hypersexuality, and general disinhibition.
The brain injury would most likely involve the
(A) Frontal lobes, lateral convexity
(B) Frontal lobes, medial surface
(C) Temporal lobes, lateral convexity
(D) Temporal lobes, medial surface
(E) Thalami
21–D. Bilateral damage of the medial temporal gyri, including the amygdalae, may cause severe
memory loss (hippocampal formations). Such damage to the amygdalae may lead to inappropriate
social behavior (e.g., hyperphagia, hypersexuality, general disinhibition). Bilateral destruction
of the amygdalae results in Klüver-Bucy syndrome.
22. A 55-year-old woman has difficulty reading small print. She most likely has (A) Astigmatism (B) Cataracts (C) Optic atrophy (D) Macular degeneration (E) Presbyopia
22–E. Presbyopia is progressive loss of the ability to accommodate, the decreased ability to focus
on near objects. Astigmatism is the difference in refracting power of the cornea and lens in different
meridians. Cataracts are opacities of the lens that appear with aging. Optic atrophy is
degeneration of the optic nerve and papillomacular bundle and loss of central vision.
- The principal postnatal change in the pyramids is due to
(A) An increase of corticospinal neurons from the paracentral lobule
(B) An increase in the total number of corticospinal axons
(C) A large increase of Schwann cells in the motor cortex
(D) An increase in endoneural tubes to guide sprouting axons
(E) Myelination of preexisting corticospinal axons
23–E. The corticospinal fibers are not completely myelinated at birth; this does not occur until
18 months to 2 years of age. During this time, the Babinski reflex can be elicited; later it is suppressed.
24. Special visceral afferent neurons that innervate receptor cells in taste buds synapse in the (A) Geniculate ganglion (B) Inferior salivatory nucleus (C) Nucleus of the solitary tract (D) Spinal trigeminal nucleus (E) Ventral posteromedial nucleus
24–C. The nucleus of the solitary tract receives taste fibers from cranial nerves VII, IX, and X.
Neurons of this tract project to the ventral posteromedial nucleus of the thalamus.
- A woman receives an injection of a radioisotope to determine regional blood flow in the brain. She has a positron emission tomography
scan to visualize variations in cortical blood flow. The examiner asks her to think about flexing her index finger without actually doing it.
In which of the following cortical areas would you expect to see increased blood flow?
(A) Broca area
(B) Angular gyrus
(C) Motor strip
(D) Supplementary motor cortex
(E) S-I somatosensory cortex
25–D. The supplementary motor cortex plans for motor activity. Broca area is a language center.
The angular gyrus is concerned with mnemonic constellations. The motor strip gives rise to
the corticospinal and corticobulbar tracts. The S-1 somatosensory cortex subserves somatic sensibility.
26. Destruction of the right cuneate nucleus results in which of the following sensory deficits? (A) Apallesthesia, left hand (B) Apallesthesia, right hand (C) Apallesthesia, left foot (D) Analgesia, left hand (E) Analgesia, right foot
26–B. Destruction of the right cuneate nucleus results in apallesthesia (loss of vibration sensation)
in the right hand. The cuneate nucleus, a way station in the posterior column-medial lemniscus
pathway, mediates tactile discrimination and vibration sensation.
- The elaboration of acetylcholine results in which of the following postganglionic sympathetic responses?
(A) Constriction of cutaneous blood vessels
(B) Contraction of arrector pili muscles
(C) Decreased gastrointestinal motility
(D) Increased ventricular contractility
(E) Stimulation of eccrine sweat glands
27–E. Eccrine sweat glands are innervated by postganglionic sympathetic cholinergic fibers.
Apocrine sweat glands are innervated by postganglionic sympathetic norepinephrinergic fibers.
28. Nausea is mediated by which of the following neural structures? (A) Celiac ganglion (B) Greater splanchnic nerve (C) Superior mesenteric ganglion (D) Inferior mesenteric ganglion (E) Vagal nerves
28–E. The vagal nerves mediate the feeling of nausea via general visceral afferent fibers.
29. Cerebrospinal fluid enters the bloodstream via the (A) Arachnoid villi (B) Choroid plexus (C) Interventricular foramen of Monro (D) Lateral foramina of Luschka (E) Median foramen of Magendie
29–A. Cerebrospinal fluid enters the bloodstream via the arachnoid villi. Hypertrophied arachnoid
villi are called arachnoid granulations or pacchionian bodies.
- Computed tomography of the head of a newborn infant reveals enlargement of the lateral ventricles and the third ventricle. The cause of
this hydrocephalus is most likely which of the following?
(A) Aqueductal stenosis
(B) Adhesive arachnoiditis
(C) Choroid plexus papilloma
(D) Calcification of the arachnoid granulations
(E) Stenosis of the median foramen
30–A. Aqueductal stenosis results in enlargement of the third and lateral ventricles. The condition
is strongly associated with prenatal infections (e.g., cytomegalovirus infection). Congenital
hydrocephalus occurs in 1 in 1000 live births. Mental retardation, spasticity, and tremor are common.
Shunting is the treatment of choice; cerebrospinal fluid is shunted from the distended ventricle
to the peritoneal cavity.
31. The cellular neuropathology of Alzheimer disease resembles most closely that seen in (A) Huntington disease (B) Multi-infarct dementia (C) Pick disease (D) Neurosyphilis (E) Trisomy 21
31–E. Alzheimer disease is commonly seen in trisomy 21, or Down syndrome, after 40 years of
age. It is the most common single cause of mental retardation. The neuropathology of Down syndrome
is similar to that of Alzheimer disease: reduced choline acetyltransferase activity, cell loss
in the nucleus basalis of Meynert, an increase of amyloid -protein, and Alzheimer neurofibrillary
changes and neuritic plaques are always found.
- A 40-year-old carpenter visits his general practitioner. He complains of shortness of breath and difficulty in performing his construction
work. During the history taking, he tells his physician that he had an attack of gastroenteritis 3 weeks ago. The neurologic examination reveals ascending weakness and tingling in the legs and absence of muscle stretch reflexes in the legs. Cerebrospinal fluid analysis shows elevated protein without significant pleocytosis. The most likely diagnosis is
(A) Amyotrophic lateral sclerosis
(B) Guillain-Barré syndrome
(C) Multiple sclerosis
(D) Myasthenia gravis
(E) Werdnig-Hoffmann syndrome
32–B. This describes classic Guillain-Barré syndrome, with prior infection, ascending paralysis,
distal paresthesias, and albuminocytologic dissociation.
- A 25-year-old female high school teacher has had difficulty walking. Five years ago she experienced a loss of vision in her left eye that
improved in 3 weeks. Neurologic examination reveals a right afferent pupillary defect, hyperreflexia in both legs, reduced proprioception in
both feet, and extensor plantar reflexes. Cerebrospinal fluid analysis shows oligoclonal bands. The most likely diagnosis is
(A) Amyotrophic lateral sclerosis
(B) Guillain-Barré syndrome
(C) Multiple sclerosis
(D) Syringobulbia
(E) Subacute combined degeneration
33–C. This is a classic description of multiple sclerosis. Characteristics of the condition are exacerbations
and remissions, involvement (demyelination) of long tracts, blurred vision, and an
afferent pupillary defect. Cerebrospinal fluid contains electrophoretically detectable oligoclonal
immunoglobulin (oligoclonal bands). In addition, rates of synthesis and concentration of
intrathecally generated immunoglobulin G and immunoglobulin M in the cerebrospinal fluid are
elevated. Oligoclonal bands are also found in syphilis, meningoencephalitis, subacute sclerosing
panencephalitis, and Guillain-Barré syndrome.
- A 48-year-old woman complains of a progressive loss of hearing and a buzzing noise in her right ear. Neurologic examination reveals
an absent corneal reflex on the right side and sagging of the right corner of the mouth. Magnetic resonance imaging shows a mass in the right cerebellopontine angle. The neoplasm would most likely arise from proliferation of which of the following cell types?
(A) Fibrous astrocytes
(B) Protoplasmic astrocytes
(C) Microglia
(D) Schwann cells
(E) Oligodendrocytes
34–D. Proliferating Schwann cells may give rise to schwannomas, which are also called acoustic
neuromas or neurilemmomas.
35. A 50-year-old plumber complains of weakness in his left leg and a loss of pain and temperature in his right leg. Neurologic examination reveals exaggerated muscle stretch reflexes in the left leg and an extensor plantar reflex on the left side. The lesion would most likely be located in the (A) Crus cerebri (B) Internal capsule (C) Lateral medulla (D) Medial medulla (E) Spinal cord
35–E. Hemisection of the spinal cord would result in ipsilateral spastic paresis below the lesion
and loss of pain and temperature on the contralateral side. The plantar response would be extensor
and ipsilateral (Babinski sign).
36. A 20-year-old comatose man has sustained massive head injuries in a automobile accident. Ice water injected into the external auditory meatus elicits no ocular response. Head rotation does not result in the doll’s-eye phenomenon. The lesion causing the injuries most likely affects the (A) Cochlear nuclei (B) Dentate nuclei (C) Ossicles (D) Utricles (E) Vestibular nuclei
36–E. A lesion of the vestibular nuclei (lower brainstem) eliminates oculovestibular reflexes.
37. Which of the following agents may be used as an alternative to L-dopa to alleviate the chemical imbalance found in the striatum of a patient with Parkinson disease? (A) Aspartate (B) An anticholinergic agent (C) Glutamate (D) A dopamine antagonist (E) A serotonin reuptake inhibitor
37–B. An anticholinergic agent (e.g., trihexyphenidyl) may be used as an alternative to L-dopa to
alleviate the chemical imbalance found in the striatum of a patient with Parkinson disease.
38. Which of the following antidepressants is the most selective inhibitor of serotonin reuptake? (A) Amitriptyline (B) Doxepin (C) Fluoxetine (D) Nortriptyline (E) Tranylcypromine
38–C. Fluoxetine (Prozac) is the most selective inhibitor of serotonin reuptake.
- A 20-year-old woman suddenly develops double vision. Neurologic examination reveals diplopia when she attempts to look to the left,
inability to adduct the right eye, nystagmus in the left eye on attempted lateral conjugate gaze to the left, and convergence of both eyes on a
near point. These deficits would result from occlusion of a branch of which of the following arteries?
(A) Anterior cerebral
(B) Basilar
(C) Middle cerebral
(D) Posterior cerebral
(E) Ophthalmic
39–B. The paramedian (transverse pontine) branches of the basilar artery supply the medial longitudinal
fasciculus of the pons. Destruction of this fasciculus results in medial longitudinal fasciculus
syndrome, or internuclear ophthalmoplegia. In addition, the superior cerebellar artery
may irrigate the medial longitudinal fasciculus.
- A 50-year old man had a stroke and developed ipsilateral paralysis and atrophy of the tongue, contralateral loss of vibrations sense,
contralateral hemiplegia, contralateral Babinski sign. The level of this vascular syndrome is in the
(A) Medial medulla
(B) Lateral medulla
(C) Pontine tegmentum
(D) Pontine base
(E) Midbrain
40–B. This is a classic national-board lesion, the lateral medullary syndrome, also called
Wallenberg syndrome; symptoms include contralateral loss of pain and temperature sensation
from the face, loss of gag reflex, hemiataxia and hemiasynergia of cerebellar type, Horner’s syndrome,
ipsilateral nystagmus. The affected structures are the medial and inferior vestibular nuclei,
inferior cerebellar peduncle, nucleus ambiguus of CN IX, CN X, and CN XI (somatic visceral efferent),
glossopharyngeal nerve roots, vagal nerve roots, spinothalamic tracts, the spinal trigeminal
nucleus and tract, and the descending sympathetic tract.
41. Tritiated proline is injected into the left upper quadrant of the left retina for anterograde transport. Radioactive label would be found in the (A) Cuneus, left side (B) Cuneus, right side (C) Lingual gyrus, left side (D) Lingual gyrus, right side (E) Optic nerve, left side
41–A. A lesion of the upper left retinal quadrant in the left eye would show radioactive label in
the left cuneus. Lesions of the cuneus result in lower field defects, and lesions of the lingual gyrus
result in upper field defects. Remember, upper retinal quadrants project to the upper banks of the
calcarine fissure, and lower retinal quadrants project to the lower banks of the calcarine fissure.
42. Tritiated leucine [(3H)-leucine] is injected into the left inferior olivary nucleus for anterograde transport. Radioactive label would be found in the (A) Lateral cuneate nucleus, left side (B) Nuclei of the lateral lemnisci (C) Dentate nucleus, right side (D) Nucleus dorsalis of Clarke (E) Superior olivary nucleus, left side
42–C. The dentate nucleus receives massive input from the contralateral inferior olivary nucleus;
it projects crossed fibers to the ventral lateral nucleus of the thalamus and red nucleus (parvocellular
part). The lateral cuneate nucleus gives rise to the cuneocerebellar tract, and the lateral lemniscus
and its nuclei are important way stations in the auditory pathway.
43. Tritiated proline [(3H)-proline] is injected into the right ventral posterolateral nucleus for retrograde transport. Radioactive label would be found in the (A) Nucleus ruber, right side (B) Nucleus gracilis, left side (C) Nucleus gracilis, right side (D) Lateral cuneate nucleus, left side (E) Ventral lateral nucleus
43–B. The right ventral posterolateral nucleus receives posterior column modalities via the medial
lemniscus from the left side of the body. The nucleus ruber is a midbrain motor nucleus: it plays
a role in the control of flexor tone. The lateral cuneate nucleus projects unconscious proprioception
to the cerebellum, (e.g., from muscles and tendons). The ventral lateral nucleus receives
input from the cerebellum (dentate nucleus).
44. Horseradish peroxidase is injected into the nucleus of the inferior colliculus for retrograde transport. Label would be found in which of the following nuclei? (A) Medial geniculate nucleus (B) Lateral geniculate nucleus (C) Superior olivary nucleus (D) Inferior olivary nucleus (E) Transverse gyrus of Heschl
44–D. The nucleus of the inferior colliculus projects retrogradely to the inferior olivary nucleus
of the caudal pons. The medial geniculate nucleus is an auditory way station, the inferior olivary
nucleus is a cerebellar relay station, and the transverse gyrus of Heschl is a primary auditory center.
Retrograde transport studies show that horseradish peroxidase is picked up by the axon terminals
and transported to the perikarya; anterograde studies show that labeled amino acids are
taken up by the perikarya and transported anterograde to distant nuclei.
- A 30-year old barber complains of difficulty chewing and weakness in the contralateral extremities and loss of pain and temperature
sensation from the ipsilateral face. This lesion would most likely be found in which one of the following choices?
(A) Medulla, medial
(B) Medulla, lateral
(C) Pons, tegmentum
(D) Pons, base
(E) Midbrain, base
45–D. The base of the pons contains intra-axial root fibers of CN V, corticobulbar fibers to nucleus
CN XII, and corticospinal fibers. Spinotrigeminal fibers mediate pain and temperature sensation
from the ipsilateral face.
- A 45-year-old carpenter had bilateral paralysis of the tongue. Fasciculations could be seen on the tongue and bilateral loss of deep sensibility (proprioception) in the trunk and limbs. The lesion would most likely be in the
(A) Open medulla, medial lemniscus bilateral, root fibers CN XII, bilateral
(B) Closed medulla pyramidal decussation
(C) Pons, base
(D) Pons, tegmentum
(E) Midbrain, tegmentum
46–A. The open medulla contains the medial lemniscus bilateral and root fibers of CN XII bilateral.
Deficits to the medial lemniscus would result in contralateral loss of proprioception, discriminative
tactile sensation, and vibration sensation from the trunk and lower extremity. The
medulla gives rise to CN IX, CN X, CN XI, and CN XII, and CN XII controls movement of the
tongue.
47. A 25-year-old woman has paralysis of the face and lateral rectus muscle, medial rectus palsy on attempted lateral conjugate gaze, nystagmus, normal convergence, miosis, ptosis, and multiple sclerosis. Where would this lesion most likely be found? (A) Medial medulla (B) Lateral medulla (C) Pons, tegmentum (D) Pons, base (E) Midbrain, tegmentum
47–C. The pontine tegmentum contains CN VI and CN VII; the medial longitudinal fasciculus
(MLF), medial lemniscus, spinotrigeminal nucleus and tract; spinal thalamic tract; and the spinohypothalamic
tract (Horner syndrome). Internuclear ophthalmoplegia, also known as MLF syndrome,
results from a lesion of the MLF. Lesions occur in the dorsomedial pontine tegmentum
and may affect one or both MLFs. This is a frequent sign of multiple sclerosis; it results in medial
rectus palsy on attempted lateral gaze and monocular nystagmus in the abducting eye with
normal convergence.
48. A 40-year-old man had a stroke and developed ipsilateral paralysis and atrophy of the tongue, contralateral loss of vibration sense, contralateral hemiplegia, and contralateral Babinski sign. Thrombosis of which artery would result in these neurologic deficits? (A) Anterior spinal artery (B) Posterior spinal artery (C) Posterior inferior cerebellar artery (D) Anterior inferior cerebellar artery (E) Labyrinthine artery
48–A. Thrombosis of the anterior spinal artery results in the medial medullary syndrome.
Symptoms of medial medullary syndrome include contralateral hemiparesis of the trunk and
extremities; contralateral loss of proprioception, discriminative tactile sensation, and vibration
sensation from the trunk and extremities; and ipsilateral flaccid paralysis of the tongue.
- A 55-year-old right-handed man had abnormal speech and language usage. The psychiatric interview revealed poor comprehension,
fluent speech, poor repetition, and the neighborhood signs contralateral quadrantanopia and contralateral hemisensory loss. Match the neurologic deficits to the anatomic substrata.
(A) Precentral gyrus
(B) Superior temporal gyrus
(C) Inferior frontal gyrus
(D) Middle frontal gyrus
(E) Inferior temporal gyrus
49–B. Wernicke speech area is in the posterior superior temporal gyrus (Brodmann’s area 22).
Wernicke aphasia is characterized by faster-than-normal speech, difficulty finding the right words to
express ideas, and poor comprehension of the speech of others. Patients appear unaware of the deficit.
50. Which disease is preferentially found in the frontal lobe? (A) Creutzfeldt-Jakob disease (B) Pick disease (C) Down syndrome (D) Tuberous sclerosis (E) Sturge-Weber syndrome
50–B. Pick disease, frontotemporal lobar degeneration, shows an extreme degree of atrophy in
the temporal and frontal lobes. Creutzfeldt-Jakob is a human prion disease affecting the central
nervous system. Down syndrome is a chromosomal anomaly characterized by trisomy 21.
Tuberous sclerosis and Sturge-Weber syndrome are neurocutaneous diseases that result in lesions
of the skin and neurologic problems (e.g. mental retardation, seizures).
- A 60-year-old right-handed man had abnormal speech and language usage. The psychiatric interview revealed the following speech and
language findings: good comprehension of spoken and written language; spontaneous speech fluent but paraphasic; poor repetition; inability
to repeat polysyllabic words. A neighborhood sign is contralateral quadrantanopia. Match the neurologic deficits with the anatomic substrata.
(A) Arcuate fasciculus
(B) Arcuate nucleus
(C) Dorsal longitudinal fasciculus
(D) Medial longitudinal fasciculus
(E) Indusium griseum
51–A. The arcuate fasciculus (superior longitudinal fasciculus) is a fiber trajectory that interconnects
Broca speech area (44, 45) with Wernicke speech area (22). Transection of this fiber bundle
results in conduction aphasia with poor repetition of spoken language, relatively good speech
comprehension and expression, paraphrasic errors (using incorrect words), and impaired object
naming. Patients are aware of the deficit.
52. Which of the following structures contains calcium concrements? (A) Cerebral peduncle (B) Cerebral aqueduct (C) Inferior colliculus (D) Pineal gland (E) Oculomotor nerve
52–D. The pineal body is a midline diencephalic structure that contains calcium concrements; it
is seen in computed tomographic images. The cerebral peduncles, the superior and inferior colliculi,
the oculomotor nerves, and the cerebral aqueduct are found in the midbrain. Stenosis of the
aqueduct results in noncommunicating hydrocephalus.
53. Is derived from the walls of the diencephalic vesicle (A) Abducent nerve (B) Accessory nerve (C) Facial nerve (D) Glossopharyngeal nerve (E) Hypoglossal nerve (F) Oculomotor nerve (G) Olfactory nerve (H) Optic nerve (I) Trigeminal nerve (J) Trochlear nerve (K) Vagal nerve (L) Vestibulocochlear nerve
53–H. The optic nerve is derived from the wall of the diencephalic vesicle.
54. Is often damaged in the process of transtentorial herniation (A) Abducent nerve (B) Accessory nerve (C) Facial nerve (D) Glossopharyngeal nerve (E) Hypoglossal nerve (F) Oculomotor nerve (G) Olfactory nerve (H) Optic nerve (I) Trigeminal nerve (J) Trochlear nerve (K) Vagal nerve (L) Vestibulocochlear nerve
54–F. The oculomotor nerve is often damaged in the process of transtentorial herniation.
55. Mediates the sensory and motor innervation of pharyngeal arches 4 and 6 (A) Abducent nerve (B) Accessory nerve (C) Facial nerve (D) Glossopharyngeal nerve (E) Hypoglossal nerve (F) Oculomotor nerve (G) Olfactory nerve (H) Optic nerve (I) Trigeminal nerve (J) Trochlear nerve (K) Vagal nerve (L) Vestibulocochlear nerve
55–K. The vagal nerve mediates the sensory and motor innervation of the pharyngeal arches 4 and 6.
56. Innervates the muscle that depresses, intorts, and abducts the globe (A) Abducent nerve (B) Accessory nerve (C) Facial nerve (D) Glossopharyngeal nerve (E) Hypoglossal nerve (F) Oculomotor nerve (G) Olfactory nerve (H) Optic nerve (I) Trigeminal nerve (J) Trochlear nerve (K) Vagal nerve (L) Vestibulocochlear nerve
56–J. The trochlear nerve innervates the muscle that depresses, intorts, and abducts the globe.
For each patient described, select the most likely involved neurologic substrate. 57. A 50-year-old policeman complains of a tremor in both hands. This tremor is most obvious at rest. While the man is reaching for an object, the tremor disappears. (A) Basal ganglia (B) Cerebellum (C) Frontal lobe (D) Occipital lobe (E) Parietal lobe (F) Temporal lobe (G) Subthalamic nucleus (H) Ventral horn
57–A. Parkinson disease is characterized by a symptom triad: pill-rolling tremor, rigidity, and
hypokinesia. The substantia nigra (a basal ganglion) bears the brunt of the cell loss. (Other basal
ganglia are the caudate nucleus, putamen, and globus pallidus.) Cerebellar disease is characterized
by intention tremor, ataxia, and hypotonia. Destruction of the subthalamic nucleus results in
contralateral hemiballismus.
For each patient described, select the most likely involved neurologic substrate.
58. A 35-year-old tennis player is concerned about weakness in his arms and hands, and he notices a loss of muscle mass in the upper
limbs. His muscle stretch reflexes are exaggerated in the lower extremities, and he has muscle twitches in the upper limbs.
(A) Basal ganglia
(B) Cerebellum
(C) Frontal lobe
(D) Occipital lobe
(E) Parietal lobe
(F) Temporal lobe
(G) Subthalamic nucleus
(H) Ventral horn
58–H. In amyotrophic lateral sclerosis there is loss of both ventral horn cells and cortical pyramidal
cells that give rise to the pyramidal tract. This motor system disease consists of an upper
motor neuron component and a lower motor neuron component. There are no sensory deficits
in amyotrophic lateral sclerosis.
Match each of the following structures with the appropriate part of the brain.
59. Cerebral aqueduct (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
59–C. The cerebral aqueduct is in the midbrain (mesencephalon). It interconnects the third and
fourth ventricles.
Match each of the following structures with the appropriate part of the brain.
60. Cranial nerves III and IV (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
60–C. The tegmentum of the midbrain contains the nuclei of the oculomotor nerve (CN III) and
the trochlear nerve (CN IV). The midbrain also contains the mesencephalic nucleus of the trigeminal
nerve (CN V).
Match each of the following structures with the appropriate part of the brain.
61. Caudate nucleus (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
61–E. The caudate nucleus, a basal ganglion, is located in the white matter of the telencephalon.
It forms the lateral wall of the frontal horn of the lateral ventricle.
Match each of the following structures with the appropriate part of the brain.
62. Optic chiasma (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
62–A. The optic chiasma is in the diencephalon between the anterior commissure and the
infundibulum of the pituitary gland (hypophysis).63–B. The olive and the pyramid are prominent structures on the surface of the medulla. The
olive contains the inferior olivary nucleus. The pyramid contains the corticospinal tract.
Match each of the following structures with the appropriate part of the brain.
63. Olive and the pyramid (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
63–B. The olive and the pyramid are prominent structures on the surface of the medulla. The
olive contains the inferior olivary nucleus. The pyramid contains the corticospinal tract.
Match each of the following structures with the appropriate part of the brain.
64. Pineal gland (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
64–A. The pineal gland (epiphysis cerebri) is part of the epithalamus, which is a subdivision of
the diencephalon.
Match each of the following structures with the appropriate part of the brain.
65. Cranial nerves IX, X, XI, and XII (A) Diencephalon (B) Medulla (C) Midbrain (D) Pons (E) Telencephalon
65–B. Cranial nerves IX, X, XI, and XII are located in the medulla.
Match each of the following descriptions with the most appropriate type of cell.
66. Are derived from the neural crest (A) Astrocytes (B) Ependymal cells (C) Microglial cells (D) Oligodendrocytes (E) Schwann cells
66–E. Schwann cells of the peripheral nervous system are neural crest derivatives.
Match each of the following descriptions with the most appropriate type of cell.
67. May myelinate numerous axons (A) Astrocytes (B) Ependymal cells (C) Microglial cells (D) Oligodendrocytes (E) Schwann cells
67–D. Oligodendrocytes of the central nervous system may myelinate numerous axons. Schwann
cells myelinate only one internode.
Match each of the following descriptions with the most appropriate type of cell.
68. Have filaments that contain glial fibrillary acidic (A) Astrocytes (B) Ependymal cells (C) Microglial cells (D) Oligodendrocytes (E) Schwann cells
68–A. The filaments of astrocytes contain fibrillary glial acidic protein, a marker for astrocytes
and astrocytic tumor cells. Another biochemical marker is glutamine synthetase found exclusively
in astrocytes.
