Dari UNPAD Flashcards by Neurosurgery Udayana

Which one of the following targets is most commonly used for the treatment of dystonia?

a. GPi
b. Vim thalamus
c. Vo thalamus
d. STN
e. Nucleus accumbens

A (Gpi)

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Damage to the subthalamic nucleus is associ- ated with which one of the following

a. Myoclonus
b. Dystonic tremor
c. Hemiballism
d. Levodopa-induced dyski

C (Hemibalism)

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A 4¬ month-¬old boy with psychomotor retardation develops repetitive, generalized limb extension and neck flexion spasms that occur more than 10 times daily. These episodes are associated with altered consciousness. Electroencephalographic evaluation demonstrates high-voltage polyspike and slow wave discharges between spasms and suppression of these bursts during the spasms. What is the patient’s most likely diagnosis?
a Absence seizures
b. West syndrome
c. Epilepsia partialis continua
d. Complex partial seizures
e. Juvenile myoclonic seizures

B. (West syndrome)

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During an infratentorial supracerebellar approach to a pineal tumor, what vein in the galenic draining group may be sacrificed safely without negative sequelae?
a. Basal vein of Rosenthal
b. Posterior mesencephalic vein
c. Straight sinus
d. Precentral cerebellar vein
e. Internal cerebral vein

D. (Precentral cerebellar vein)

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Site of entry for thoracic pedicle screw is best described as which one of the following?
a. Where the facet joint and transverse process intersect
b. Where the pars interarticularis and lam- ina intersect
c. Where the superior facet and lamina intersect
d. Where the inferior facet and lamina intersect
e. Where the transverse process and lamina intersect

A. (facet joint and transverse process)

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A 4-month-old girl presenting with apnea and loss of consciousness. CT head scan is shown. Which one of the following is most likely?

a. Fall from 3 ft height
b. Moya disease
c. Traumatic vertebral artery dissection
d. Shaken baby syndrome
e. Benign enlargement of the subdural space

D. (Shaken baby syndrome)

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Which one of thef ollowing is most likely in a child with the below MRI appearance pre- senting with increasing head circumference and shortness of breath?

a. Cavernous malformation
b. Developmental venous anomaly
c. Dural AV fistula
d. Tentorial AVM
e. Vein of galen malformation

e. Vein of galen malformation

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A 37-year-old man was diagnosed at age 25 when he had his first generalized tonic-clonic seizure while bowling. He was then noted to have complex partial seizures during which he would repeatedly respond by saying “what” to all questions, lip smack, and throw up his right arm. He was unaware of any auras and was amnestic for his seizures. Most of his seizures were from sleep with a frequency of about 2 per week. He had been involved in sev- eral car accidents secondary to seizures. Which one of the following is most likely?
a. Absence seizure
b. Complex partial seizure
c. Focal motor seizure
d. Generalized tonic-clonic seizure
e. Simple partial seizure

B (complex partial seizure)

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What deep brain structure is the most appropriate deep brain stimulation target for chronic nociceptive pain
a. VPL nucleus of thalamus
b. Globus Pallidus internus
c. Subthalamic nucleus
d. Periaqueductal gray matter
e. Anterior limb of internal capsule

Jawaban: D (periaqueductal)

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Which one of the following pathologies is most likely demonstrated by the angiogram?

a. Anterior choroidal artery aneurysm
b. Basilar tip aneurysm
c. MCA bifurcation
d. PCA aneurysm
e. Supraopthalmic aneurysm

e. Supraopthalmic aneurysm

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Which one of the following clinical findings would you look for in this patient?

a. Abducens palsy
b. Absent corneal reflex
c. Bitemporal hemianopia
d. Oculomotor palsy
e. Pituitary dysfunction

d. Oculomotor palsy

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A 75-year-old man with a history of recent memory impairment is admitted with headache, confusion, and a left hom- onymous hemianopsia. There is no history of hypertension or malignancy. Non- contrast CT scan and GRE MRI are shown. Which one of the following is the most likely cause of this patient‘s symptoms and signs?
a. Multi-infarct dementia
b. Mycotic aneurysm
c. Amyloid angiopathy
d. Undiagnosed hypertension
e. Gliomatosis cerebri

c. Amyloid angiopathy

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A 45-year-old woman is undergoing microsurgical clipping of the anterior communicating artery aneurysm. The surgeon wants to prevent complications that can occur from an inadvertent clipping of the perforators. Which of the following modalities can best help in achieving this?
A. Intraoperative adenosine injection
B. Transcranial Doppler study
C. Indocyanine green angiography
D. Endoscopy
E. MRA

C. Indocyanine green angiography

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A 40-year-old male without a significant past medical history presents with a severe headache that started about 14 hours ago. The patient was asleep when his headache started. The patient denies any head trauma and a family history of stroke or sudden death. CT brain without contrast is negative. On physical examination, blood pressure is 200/115 mm Hg, respiratory rate is 25/minute, pulse rate 100/minute, and oxygen saturation is 99% on ambient air. The patient is awake, alert, oriented, and can move all extremities. Which of the following is the best next step in management?
A. CT angiography head and neck
B. Magnetic resonance angiography head and neck (MRA)
C. Lumbar puncture
D. Digital subtraction angiography
E. CT Head contrast

C. Lumbar puncture

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A 60-year-old male complains of a severe, acute- onset headache that started three hours ago. He also complains of nausea that started one hour ago. He denies vomiting, syncope, or muscle weakness. The patient’s past medical history is significant for hypertension, diabetes mellitus type 2, and moderate-severity tension headache. He says this headache is different in location and severity from his usual headaches. His medications include hydrochlorothiazide and metformin. On examination, the temperature is 36.5 C, blood pressure is 161/92 mmHg, and pulse is 84 beats/min. The patient is in significant distress due to pain. He has right-sided ptosis, and his right pupil is larger than his left pupil. There is neck rigidity and loss of sensation in both of his feet. There is no ataxia or motor weakness. Deep tendon reflexes are normal, and Babinski reflex is flexor. Which of the following is most likely causing this patient’s symptoms?

A.. Subarachnoid hemorrhage due to posterior communicating artery aneurysm
B. Subarachnoid hemorrhage due to anterior communicating artery aneurysm
C. Diabetes mellitus
D. Subarachnoid hemorrhage due to posterior inferior cerebellar artery aneurysm
E. Brain neoplasm

A.. Subarachnoid hemorrhage due to posterior communicating artery aneurysm

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A 27-year-old pregnant female presents to the ER with acute confusion, headaches and blurry vision. While ni the ER she is found to have acute fetal distress and a blood pressure of 210mmHg/110mmHg. After expedited delivery of the baby, a CT si performed, revealing patchy areas of hypodensity ni the posterior parietal and occipital lobes. An MRI is shown (figure). Which of the following is the most likely diagnosis?

A. Infiltrating neoplasm
B. Progressive multifocal leukoencephalopathy
C. Demyelination, likely multiple sclerosis
D. Acute infarction of the posterior cerebral arteries
E. Posterior Reversible Encephalopathy Syndrome (PRES)

E. Posterior Reversible Encephalopathy Syndrome (PRES)

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What is the most common presentation of an adult patient with moyamoya disease?
A. Dystonia
B. Gait disturbances
C. Intracranial hemorrhage
D. Ischemic infarcts/transient ischemic attacks
E. Seizure

C. Intracranial hemorrhage

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What is the most effective treatment ni secondary stroke prevention ni adults with Moyamoya disease?
A. Dual antiplatelet therapy
B. Aspirin alone
C. Direct revascularization
D. Anticoagulation
E. Indirect revascularization

C. Direct revascularization

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41 Which one of the following statements regarding average prognosis of patients pre- senting with Karnofsky of score less than 70 is most accurate?
A. A Karnofsky performance score less than 70 is associated with a median survival of 2 months
a. A Karnofsky performance score less than 70 is associated with a median survival of 4 months
b. A Karnofsky performance score less than 70 is associated with a median survival of 6 months
c. A Karnofsky performance score less than 70 is associated with a median survival of 8 months
d. A Karnofsky performance score less than 70 is associated with a median survival of 12 months

a. A Karnofsky performance score less than 70 is associated with a median survival of 4 months

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A 34-year-old male presents with seizures. He has no significant past medical history. MRI is shown (FLAIR) and T1 postcontrast imaging does not show any enhancement. Which one of the following management strategies is most appropriate?

A. Imaging surveillance until starts to show focal enhancement
B. Gamma knife surgery
C. Methotrexate chemotherapy
D. Dexamethasone
E. Maximal safe resection

E. Maximal safe resection

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A 27-year-old presents with a generalized tonic-clonic seizure. On examination there is no residual neurological deficit or speech dis- turbance. Some spots of calcification are seen on CT therefore MRI is performed. Which one of the following statements regarding this type of tumor is LEAST accurate?

A. Functional mapping is a perquisite for resection
B. MRS findings may include increased 2-hydroxyglutarate
C. Prognosis is related to extent of resection
D. The majority of patients with dominant hemisphere lesions of this type present with seizures
E. Tumor margins are usually seen best on T1+gad MRI sequences

E. Tumor margins are usually seen best on T1+gad MRI sequences

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Which one of the following chemotherapy options is most likely to be utilized in the context of anaplastic oligodendroglioma?
a. Anti-VEGF
b. Cyclophosphamide
c. Etoposide
d. PCV
e. Temozolomide

d. PCV

PCV, which is a combination of the drugs procarbazine, lomustine (CCNU),

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A 67-year-old patient presents with left hemisensory change. Postcontrast MRI is shown below, and diffusion weighted imag- ing shows the lesion to be dark on DWI and bright on ADC map. Which one of the following options is most appropriate next?

A. Urgent image-guided drainage of lesion
B. CT of chest, abdomen and pelvis with contrast
C. Imaging surveillance
D. Intravenous antibiotics
E. Lumbar puncture

B. CT of chest, abdomen and pelvis with contrast

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Which one of the following best describes the mechanism of dexamethasone action in reducing cerebral edema?
A. Reduces cytotoxic edema through nitric oxide inhibition
B. Reduces cytotoxic edema through VEGF inhibition
C. Reduces vasogenic edema throughVEGF inhibition
D. Reduces vasogenic edema through upre- gulation of aquaporins
E. Reduces vasogenic edema through nitric oxide signaling

C. Reduces vasogenic edema through VEGF inhibition

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Which one of the following types of cerebra edema is seen in malignant hypertension? a. Cytotoxic b. Hydrostatic c. Interstitial d. Osmotic e. Vasogenic

b. Hydrostatic

A 17- year old female present with an 8 month history of secondary amenorrhea. More recently she has noticed that she is more thirsty and is passing large volumes of urine. Her examination is otherwise unremarkable. Routine blood tests are normal and endocrine profile shows: FSH 5.5 U/L (follicular 0.5-5, mid-cycle 8-33, luteal 2-8), LH 2.8 U/L (fol- licular 3-12, mid-cycle 20-80, luteal 3-16), estradiol 32 pmol/L (follicular 17-260, luteal 180-1100), prolactin 990 mU/L (60-620), 9 am cortisol 400 nmol/L, fasting blood glu- cose 5.5 mmol/L, serum calcium 2.35 mmol/ L (2.2-2.6). Water deprivation test: serum osmolality 300 mOsmol/kg, urine 200 mOs- mol/kg at 6 h, post-DDAVP urine osmolality 800 mOsmol/kg. MRI head is shown. Which one of the following would you perform next? A. Serum and CSF HCG and AFP B. Ultrasound pelvis/ovaries C. Insulin tolerance test D. Short synacthen test E. Visual field tests

A. Serum and CSF HCG and AFP

A 36-year-old patient with Cushing’s syndrome but normal ACTH levels is referred. There is no visual compromise. Pituitary MRI shows a 3 mm hypodense area in the lat- eral aspect of the pituitary gland. Which one of the following is the next appropriate management? a. Laparoscopic adrenalectomy b. Transsphenoidal surgery c. Inferior petrosal sinus sampling d. High-dose dexamethasone test e. Start octreotide

c. Inferior petrosal sinus sampling

53. Which one of the following statements regarding Cushing’s disease is most accurate? A. It is often due to ACTH-secreting pituitary adenoma B. Primary management is surgical resection of the tumor C. High-dose dexamethasone suppression test is able to lateralize the side of ACTH-secreting microadenoma within the pituitary gland D. It may be caused by ectopic ACTH pro- ducing tumors E. Can cause amenorrhea in females and infertility in males

E. Can cause amenorrhea in females and infertility in males

Which one of the following would be most appropriate treatment following failure of transsphenoidal surgery to treat Cushing’s disease? A. Surveillance imaging B. Repeat transsphenoidal surgery C. Cabergoline D. Octreotide E. Bilateral adrenalectomy

B. Repeat transsphenoidal surgery

61. A 55-year-old right handed male presents with headache and cognitive slowing. There is no significant past medical history. MRI is shown. Which one of the following management strategies is most appropriate? a. Surveillance imaging b. Awake craniotomy with goal of maximal safe resection c. Cerebral angiogram d. Gross total resection under general anesthetic e. Stereotactic biopsy for molecular classification

b. Awake craniotomy with goal of maximal safe resection

64. A 56-year-old presents with a 2-month history of headache and visual disturbance. Confrontation testing revealed a bitemporal hemianopia. Routine bloods were normal and endocrine profile is: FT4 pmol/L 8.5 (11.5-22), TSH 0.5 mU/L (0.35-5.5), FSH 1.0 U/L (1.4-18.1), LH 2.5 U/L (3-8), prolactin 900 mU/L (45-375), testosterone 3.5 nmol/L (8.4-28.7), 9 am cortisol 405 nmol/L. MRI is shown. Which one of the following is most likely? a. Non-functioning adenoma b. Thyrotropinoma c. GH-secreting pituitary adenoma d. Prolactinoma e. Cushing’s disease

a. Non-functioning adenoma

65. Gorlin or nevoid basal cell carcinoma syndrome is asscocited with increased of medulloblastoma. The syndrome is caused by a germ line mutation in which gene? a. PTCH1 b. Wnt c. TP53 d. APC e. SMO

a. PTCH1

68. A 58 year-old right handed male presents with bifrontal headaches and a partial left ophthalmoplegia. MRI results are shown. biopsy revealed this tumor to be a chordoma. an extensive subtotal skull-based resection was performed. which is the best choice for adjuvant therapy regimen? a. Brachytherapy b. Proton beam radiotherapy c. Stereotactic radiosurgery d. Procarbazine, CCNU and Vincristine (PCV) chemotherapy e. Conventional fractioned radiotherapy

b. Proton beam radiotherapy

Which one of the following is a biomarker for traumatic brain injury? a. GFAP b. TP53 c. ATRX d. VEGF e. IDH-1

a. GFAP

A27-year-old presentsto ED after an assault. His GCS is 15/15 but he has evidence of facial fractures involving the frontal sinus and evidence of some CSF rhinorrhea. He is admitted for observation and initial conser vative management of CSF leak. On D3 post injury, he developed three episodes of vomit- ing and became drowsy. On examination he was obtunded and lethargic, but arousable. His BP was 140/90 mmHg, heart rate 59/ min, and respiratory rate 20/min and main- tained a saturation of 92% on room air. Examination revealed a dilated right pupil whereas the rest of neurological and systemic examination was normal. CT head was repeated (shown). Which one of the follow- ing is most appropriate acute management? a. High flow oxygen b. Burr hole decompression c. Cranialization of the frontal sinus d. Decompressive craniectomy e. Minicraniotomy

b. Burr hole decompression

Which one of the following AP diameters of a decompressive hemicraniectomy flap is the minimum size thought to prevent local com plications relating to brain herniation? a. 10cm b. 12cm c. 14cm d. 16cm e. 18cm

b. 12cm

What cranial nereve injury is most likely to be associated with transvenous embolization of a cavernous- carotid fistula? a. Abducens b. Occulomotor c. Trigeminal d. Trochlear e. Optic

a. Abducens

A 23 year old male sustains a gunshot wound to the head. On examination, his GCS is 3T, his pupils are bilaterally fixed and dilated, he has a weak gag and cough reflex, and he intermittently draws a spontaneous respiration. His non- contrast head CT demonstrates a transventricular bullet tract and a 3 mmright subdural hematoma. What is the most appropriate management for this patient? a. Evacuation of subdural hematoma b. Ventriculostomy c. Debridement of bullet tract d. Decompresive hemicraniectomy e. Expectant care

e. Expectant care

1. The medial posterior choroidal artery originates from which segment of the posterior cerebral artery? A. P1 B. P2 C. P3 D. P4 E. P5

B. P2

What structures pass through the annulus tendineus (of Zinn)? 1. Ophthalmic vein 2. Lateral rectus muscle 3. Lacrimal branch of ophthalmic nerve 4. Inferior division of oculomotor nerve A. 1, 2, and 3 are correct B. 1 and 3 are correct C. 2 and 4 are correct D. Only 4 is correct E. All of the above

D. Only 4 is correct

3. What blood vessel is at risk of injury during a Chiari decompression? A. Lateral medullary segment of the posterior inferior cerebellar artery B. Telovelotonsillar segment of the posterior inferior cerebellar artery C. Tonsillomedullary segment of the posterior inferior cerebellar artery D. Posterior spinal artery E. V2 segment of the vertebral artery

C. Tonsillomedullary segment of the posterior inferior cerebellar artery

4. Through what structure do fibers from the inferior olives reach the cerebellum? A. Superior cerebellar peduncle B. Inferior cerebellar peduncle C. Middle cerebellar peduncle D. Vestibular nucleus E. Flocculonodular lobe

B. Inferior cerebellar peduncle

6. This triangle is bordered by the greater superficial petrosal nerve and drilling here will expose the petrous segment of the internal carotid artery: A. lateral triangle B. paramedial triangle C. Glasscock’s triangle D. Kawase’s triangle E. Parkinson’s triangle

D. Kawase’s triangle

7. Which of the following is true of the occipital eye field? A. It is localized to a relatively small area. B. It sub serves pursuit eye movements that are largely voluntary. C. Lesions in this area are associated with transient deviation of the eyes away from the side of the lesion. D. The threshold for excitation in this area is lower than in the frontal eye fields. E. With lesions in this area, the patient can direct the eyes to a particular location on command.

E. With lesions in this area, the patient can direct the eyes to a particular location on command.

8. Descending fiber of the medial longitudinal fasciculus (MLF) arise from all of the following structures except the A. Inferior colliculus B. Cajal’s interstitial nucleus C. Medial vestibular nucleus D. Pontine reticular formation E. Superior colliculus

A. Inferior colliculus

All of the following can be seen in ulnar nerve entrapment at the wrist except A. Motor deficits in the adductor pollicis B. Motor deficits in the deep head of the exor pollicis brevis C. Motor deficits in the third and fourth lumbricals D. Sensory deficits in the dorsum of the hand E. Sensory deficits in the palmar surface of the hypothenar eminence

D. Sensory deficits in the dorsum of the hand

10. The anterior choroidal artery supplies portions of each of the following structures except the A. Amygdala B. Globus pallidus C. Hippocampus D. Hypothalamus E. Internal capsule

D. Hypothalamus

11. The pulvinar has well-defined projections to the I. Occipital cortex II. Parietal cortex III. Temporal cortex IV. Frontal cortex i. I, II, III ii. I, III iii. II, IV iv. IV v. All of the above

i. I, II, III

12. Each of the following is true of the fornix except A. It is the main efferent fiber system of the hippocampus. B. Postcommissural fibers of the fornix project to the mammillary bodies. C. The columns of the fornix lie anterior to the anterior commissure. D. The body of the fornix runs to the rostral margin of the thalamus. E. The fornical commissure (psalterium) is rostral to the anterior commissure

C. The columns of the fornix lie anterior to the anterior commissure.

13. You are seeing a patient with a right sided ophthalmic segment aneurysm that is growing and causing compression of the optic nerve. This initially led to an ipsilateral superior nasal quadrantanopsia. Now he reports that he is developing an inferior nasal quadrantanopsia. What structure is causing further compression of the optic nerve? A. Falciform ligament B. Tuburculum sellae C. Anterior clinoid process D. Middle clinoid process E. Optic strut

A. Falciform ligament

The secondary somatic sensory area (SII) is located on the A. Medial surface of the superior frontal gyrus B. Medial surface of the superior parietal lobule C. Superior bank of the lateral sulcus D. Ventral posterolateral nucleus of the thalamus E. Same area as the primary somatic sensory area

C. Superior bank of the lateral sulcus

15. Which of the following about the utricle and saccule is correct? A. With the head in an upright position, the utricle is oriented vertically on the medial wall of the vestibule B. They respond to angular acceleration C. In the utricular macula, the hair cells are arranged with the kinocilium oriented away from the striola D. The surface of the macula extends into the membranous labyrinth and is bathed in perilymph E. The tips of the hair cells are covered by the overlying otolithic membrane, which is embedded with calcium carbonate crystals (otoconia)

E. The tips of the hair cells are covered by the overlying otolithic membrane, which is embedded with calcium carbonate crystals (otoconia)

16. What is the resting membrane potential for nerve cells? A. -100 mV B. - 90 mV C. - 80 mV D. - 65 mV E. -40 mV

D. - 65 mV

17. Which of the following is true regarding cerebrospinal fluid (CSF)? A. 90% is secreted by the choroid plexus B. Volatile anesthetic agents and CO2 increase CSF format ion C. The exit of CSF via the arachnoid villi is volume dependent D. About 750 cc of CSF is produced each day E. Norepinephrine increases the rate of CSF formation

B. Volatile anesthetic agents and CO2 increase CSF format ion

18. Cortical projections to the striatum use what neurotransmitter? A. Glutamate B. GABA C. Dopamine D. Acetylcholine E. Glycine

A. Glutamate

19. The vertebral arteries travel in the transverse foramina of A. C6 to C2 B. C4 to C2 C. C7 to Cl D. C7 to C2 E. C8 to Cl

A. C6 to C2

20. The intracranial dura is innervated by I. Cranial nerve V II. Upper cervical spinal nerves III. Cranial nerve X IV. Cranial nerve VII A. I, II, III B. I, III C. II, IV D. IV E. All of the above

A. I, II, III

21. What is considered to be normal blood flow to the brain? A. 30 cc/100 g/min B. 50 cc/100 g/min C. 70 cc/100 g/min D. 90 cc/100 g/min E. 100cc/100 g/min

B. 50 cc/100 g/min

22. Which of the following statements about neurons is correct? A. Golgi type I neurons form the short fiber tracts of the brain and spinal cord B. Golgi type II neurons have long axons that terminate in the neighborhood of the cell body C. Golgi type I neurons are inhibitory D. The volume of cytoplasm within the cell body always exceeds that found in the neurites E. Golgi type II neurons greatly outnumber type I neurons

E. Golgi type II neurons greatly outnumber type I neurons

23. Each of the following is true of the Na/K pump except that it A. Contributes to the resting potential of the cell B. Hyperpolarizes the membrane C. Is electrogenic D. Transports three Na1 ions out for two K1 ions in E. Utilizes two molecules of adenosine triphosphate (ATP) for every three Na ions transported

E. Utilizes two molecules of adenosine triphosphate (ATP) for every three Na ions transported

24. Which of the following is true of myelination? A. It has no effect on transmembrane resistance but increases membrane capacitance. B. It decreases both transmembrane resistance and membrane capacitance. C. It decreases transmembrane resistance and increases membrane capacitance. D. It increases transmembrane resistance and decreases membrane capacitance. E. It increases both transmembrane resistance and membrane capacitance.

D. It increases transmembrane resistance and decreases membrane capacitance.

25. Contraction of the detrusor muscle of the bladder is achieved through activation of A. Parasympathetic fibers from T9 to L1 B. Parasympathetic fibers from S2 to S4 C. Sympathetic fibers from T9 to L1 D. Sympathetic fibers from S2 to S4 E. Pudendal nerves

B. Parasympathetic fibers from S2 to S4

26. The thalamus is fed by (the) I. Medial posterior choroidal artery 2. II. Anterior choroidal artery 3. III. Basilar artery branches 4. IV. Middle cerebral artery branches A. I, II, III B. I, III C. II, IV D. IV E. All of the above

A. I, II, III

27. Which is true of events occurring after a typical axon is severed? A. Chromatolysis is always associated with decreased protein synthesis. B. Retraction bulbs form only at the proximal end of the cut nerve. C. Terminal degeneration leads to the loss of presynaptic terminals D. Wallerian degeneration occurs before terminal degeneration. E. Wallerian degeneration leads to loss of the proximal axon segment

C. Terminal degeneration leads to the loss of presynaptic terminals

28. The effect of succinylcholine at the neuromuscular junction is A. Amplified by increased muscle temperature B. Hyperpolarization C. Not reversed by anticholinesterase agents D. Not similar to that of decamethonium E. Similar to that of D-tubocurarine

C. Not reversed by anticholinesterase agents

29. Which of the following structures is assessed by the doll's eye maneuver? A. Lateral vestibulospinal tract B. Medial vestibulospinal tract C. Vestibular nerve D. Cerebellum E. Cerebral cortex

C. Vestibular nerve

30. The pineal gland synthesizes melatonin from A. Acetylcholine B. Dopamine C. Histidine D. Norepinephrine E. Serotonin

E. Serotonin

31. Cheyne-Stokes respirations are thought to arise from destruction of what brain region? A. Medullary destruction B. Pontine destruction C. Bifrontal destruction D. Bithalamic destruction E. Pontomedullary destruction

D. Bithalamic destruction

32. A 52-year-old male with a history of diabetes mellitus and hypertension presents to a local emergency department with left hemiparesis ai1d an evolving infarct involving portions of the right middle cerebral artery (lvrCA) distribution. A four-vessel angiogram of the brain reveals occlusion of the right MCA proximal to the bifurcation. Data obtained from the National Institute of Neurologic Disorders and Stroke (NINDS) trial showed that administering t-PA within how many hours of stroke resulted in improved functional outcome at 3 months and 1 year? A. 3 hours B. 6 hours C. 8 hours D. 12 hours E. 24 hours

A. 3 hours

33. This MRI demonstrates lesions discovered in a 29-year-old man with known AIDS. What is the diagnosis? A. HIV encephalopathy B. Staph aureus abscess C. Listeria abscess D. Toxoplasmosis E. PML

D. Toxoplasmosis

34. Small, pinpoint pupils may be seen in all of the following, EXCEPT? A. Pontine tegmental lesions B. Bilateral diencephalic dysfunction C. Narcotic intoxication D. Oculomotor nerve compression E. Cholinergic drugs

D. Oculomotor nerve compression

35. At the ischemic penumbra, the cerebral blood flow is A. <8 mL/100 g/min B. 8-23 mL/100 g/min C. 24-49 mL/100 g/min D. 50 mL/100 g/min E. 51-100 mL/100 g/min

B. 8-23 mL/100 g/min

36. Taste sensation of the anterior 2/3 of tongue is carried by A. Trigeminal n B. Chorda tympani n C. Glossopharyngeal n D. Vagus n E. None of the above

B. Chorda tympani n

37. Each of the following is true of G proteins except A. Each G protein is regulated by only one type of receptor. B. Each G protein m ay regulate multiple effectors. C. The a subunit binds guanosine triphosphate (GTP). D. The b and g subunits help anchor the a subunit to the plasm a membrane. E. The b and g subunits modulate guanosine diphosphate (GDP)/GTP exchange

A. Each G protein is regulated by only one type of receptor.

38. The sensation of sharp, pricking pain is mediated by A. Aa fibers B. Ab fibers C. Ag fibers D. Ad fibers E. C fibers

D. Ad fibers

39. A 52-year-old construction worker noted some weakness in his hands while at work, followed by thickening of his speech and swallowing problems a few months later. Although he complained of generalized fatigue and aching in his upper and lower extremities, no numbness or other sensory abnormalities were noted on physical examination. There were marked fasciculations and atrophy of his arms, legs, and tongue, as well hyperactive reflexes and Babinski Signs. The most likely diagnosis in this middle-aged man would be? A. Cervical myelopathy B. Multiple sclerosis C. Myasthenia gravis D. Guillain-Barre syndrome E. Amyotrophic lateral sclerosis

E. Amyotrophic lateral sclerosis

40. An abnormal optokinetic response is more likely to be obtained by rotating the optokinetic nystagmus drum A. Away from an occipital lobe lesion B. Away from a parietal lobe lesion C. Toward an occipital lobe lesion D. Toward a parietal lobe lesion E. Toward a temporal lobe lesion

D. Toward a parietal lobe lesion

41. Which of the following is true of papilledema? A. Absence of venous pulsations is a reliable indicator of papilledema. B. Pupillary light reflexes remain normal. C. The congested capillaries derive from the central retinal vein. D. Unilateral edema of the optic disk is never seen. E. Visual acuity usually decreases.

B. Pupillary light reflexes remain normal.

42. Which of the following is true of tuberculous meningitis? A. Headache is usually absent. B. If untreated, the clinical course is self-limited. C. The inflammatory exudate is conned to the subarachnoid space. D. The inflammatory exudate is found mainly at the convexities. E. The protein content of the cerebrospinal fluid (CSF) is almost always elevated

E. The protein content of the cerebrospinal fluid (CSF) is almost always elevated

43. Each of the following is characteristic of a diabetic third nerve palsy except A. It develops over a few hours B. It spares the pupil C. It is usually painless D. The lesion involves the center of the nerve E. The prognosis for recovery is good

C. It is usually painless

44. Fasciculation potentials indicate A. Motor nerve fiber irritability B. Motor nerve fiber destruction C. Motor unit denervation D. Muscle atrophy E. Reinnervation of muscle units

A. Motor nerve fiber irritability

45. Each of the following is true of central pontine myelinolysis except A. A marked inflammatory response with destruction of nerve cells in the pons is seen. B. It is associated with rapid correction of hyponatremia. C. It is associated with chronic alcoholism D. Quadriplegia, pseudobulbar palsy, and a locked-in syndrome can occur. E. Some patients have no signs or symptoms referable to the pontine lesion.

A. A marked inflammatory response with destruction of nerve cells in the pons is seen.

46. You are called to the emergency department to evaluate a child with headaches and a known shunt for long-standing obstructive hydrocephalus. He was wrestling with his older brother 2 days ago and has now developed headaches over the last 24 hours. X-ray is demonstrated. What is the best course of action? A. Shunt tap/culture B. Observation C. Decrease the shunt valve setting D. Distal shunt revision E. Proximal shunt revision

D. Distal shunt revision

1. During an infratentorial supracerebellar approach to a pineal tumor, what vein in the galenic draining group may be sacrificed safely without negative sequelae? A. Basal vein of Rosenthal B. Posterior mesencephalic vein C. Straight sinus D. Precentral cerebellar vein E. Internal cerebral vein

D. Precentral cerebellar vein

9-year-old boy presents with headache, upgaze paresis, and a pineal region tumor. A cerebrospinal fluid analysis is performed showing elevated levels of β-HCG. What tumor type is suspected? A. Choriocarcinoma B. Embryonal carcinoma C. Germinoma D. Teratoma E. Yolk sac tumor

A. Choriocarcinoma

49. You are evaluating a 9-year-old boy who presented with headaches and has the following MRI findings. What would you recommend as initial treatment in this patient? A. Supracerebellar, infratentorial resection B. Endoscopic third ventriculostomy C. Endoscopic third ventriculostomy and biopsy D. Shunt implantation E. Chemotherapy

C. Endoscopic third ventriculostomy and biopsy

50. You are called by the pediatric team to come and see a child with the abnormality pictured below (preoperative and intraoperative pictures). They are asking about preoperative care. You suggest that they keep the child laying on his abdomen, cover the lesion with a sterile dressing, and start what prophylactic antibiotic regimen? A. Vancomycin/cefepime B. Ampicillin/gentamicin C. Erythromycin monotherapy D. Fluconazole E. Dicloxacillin

B. Ampicillin/gentamicin

51. The abnormality depicted below is associated with what syndrome? A. Arnold–Chiari type I malformation B. Arnold–Chiari type II malformation C. Arnold–Chiari type III malformation D. Arnold–Chiari type IV malformation E. Arnold–Chiari type 0 malformation

52. You are evaluating a 5-year-old boy with known neurofibromatosis type I who has developed visual loss in the right eye. Imaging demonstrates a suspected right optic pathway glioma. What characteristic will determine if you are able to surgically cure this patient? A. Baseline visual field tests B. Optic chiasm involvement C. Enhancement pattern on MRI D. Location (right vs. left) E. Patency of retinal artery on angiogram

B. Optic chiasm involvement

53. “Trilateral retinoblastoma” describes bilateral ocular retinoblastomas and a(n) A. Astrocytoma B. Medulloblastoma C. Neurofibroma D. Optic nerve sheath tumor E. Pineoblastoma

E. Pineoblastoma

54. The most common presenting symptom of neonates with vein of Galen aneurysms is A. Congestive heart failure B. Hydrocephalus C. Intracerebral hemorrhage D. Seizures E. Subarachnoid hemorrhage

A. Congestive heart failure

55. The cleft in the spinal cord associated with diastematomyelia is most commonly located in the A. Cervical region B. Lumbar region C. Sacral region D. Thoracic region E. Craniovertebral junction

B. Lumbar region

56. Approximately what percentage of infants with myelomeningocele have magnetic resonance imaging (MRI) evidence of a Chiari II malformation? A. 20% B. 40% C. 60% D. 80% E. 100%

E. 100%

57. The aneurysm depicted below would be classified as what type of aneurysm? A. Posterior communicating B. Superior hypophyseal C. Carotid–ophthalmic D. Anterior communicating E. ICA terminus

C. Carotid–ophthalmic

58. The most common location for a saccular brain aneurysm? A. Anterior communicating a (ACOM) B. Posterior communicating a (PCOM) C. Middle cerebral a (MCA) D. Basilar a tip E. Posterior inferior cerebellar a (PICA)

A. Anterior communicating a (ACOM)

59. A 65-year-old male had transient aphasia and was found to have 75% ICA stenosis. The ideal treatment is A. Observation and treatment of risk factors B. Daily Aspirin 81 mg C. Daily Aspirin 325 mg D. IV heparin followed by oral Coumadin E. Carotid endarterectomy

E. Carotid endarterectomy

You are evaluating an angiogram in a patient with an AVM. The characteristics are: size = 3.6 cm; drainage = internal cerebral vein; location = right frontal. Based on Spetzler-Martin grade, what is the rate of good surgical outcome (no deficit postop)? A. 95% B. 84% C. 73% D. 69% E. 53%

B. 84%

61. A 54-year-old female was taken to an emergency room after collapsing at work. She was alert and communicative, with a severe headache, photophobia, nuchal rigidity, and blurry vision. Computed tomography (CT) of the brain revealed diffuse subarachnoid blood in the basal cisterns, mild hydrocephalus, and no intraparenchymal hematoma. Her angiogram is depicted below. What is the clinical Hunt and Hess grade of this patient? A. Grade I B. Grade II C. Grade III D. Grade IV E. Grade V

C. Grade II

62. Some posterior communicating artery (PComA) aneurysms do not produce any third nerve deficit. Why should special attention be given to the angiogram in these cases? A. If the aneurysm is projecting posterolaterally rather than in a more common medial position, there is an increased risk of injuring the perforating vessels from the PComA during microdissection B. An aneurysm projecting laterally onto the medial edge of the temporal lobe argues against premature retraction of the temporal lobe C. The angiogram may reveal a ventral carotid wall aneurysm instead of a PComA lesion, which is often better managed with coiling D. To look for any other associated aneurysms and/or vasospasm E. It may help with surgical planning, as medially projecting lesions are better approached through the carotidoculomotor triangle

B. An aneurysm projecting laterally onto the medial edge of the temporal lobe argues against premature retraction of the temporal lobe

63. What is the order of clamp placement on the arteries during carotid endarterectomy? A. External, internal, common B. Internal, common, external C. External, common, internal D. Common, external, internal E. Common, internal, external

B. Internal, common, external

64. A 56-year-old female underwent clipping of the aneurysm depicted on the angiogram below. Upon awakening from surgery, she was noted to have greater weakness in her left arm than in her left leg. What is the most likely reason for this new deficit? A. Injury of a blood vessel originating from the A2 segment of the anterior cerebral artery B. Venous infarct from excessive frontal lobe retraction C. Injury to the small perforating blood vessels originating from the anterior communicating artery D. Posterior internal capsule infarction from microemboli originating from the internal carotid artery E. Mesial temporal lobe retraction

A. Injury of a blood vessel originating from the A2 segment of the anterior cerebral artery

65. You are asked to consult on an 82-year-old woman with a large cerebellar hematoma from a presumed spontaneous cerebellar hemorrhage. Her admission GCS was 6 and there is evidence of intraventricular hemorrhage. The hematoma volume is measured to be 31 mL and there is brainstem compression. What is her 30-day mortality according to the ICH score? A. 13% B. 26% C. 72% D. 97% E. 100%

E. 100%

66. Occlusion of the anterior choroidal artery results in I. Contralateral hemiplegia II. Hemihypesthesia III. Homonymous hemianopsia IV. Impaired cognition A. I, II, III B. I, III C. II, IV D. IV E. All of the above

A. I, II, III

67. Each of the following statements is true of AVMs except A. Higher pressures have been measured in the feeding arteries of smaller as compared with larger AVMs. B. Smaller AVMs are more likely to bleed than larger AVMs. C. The annual risk of death from a ruptured AVM is 1%. D. The risk of bleeding from an unruptured AVM is 3 to 4% a year. E. The risk of rebleed in the first year after hemorrhage is highest in the first 2 weeks.

E. The risk of rebleed in the first year after hemorrhage is highest in the first 2 weeks

68. A 33-year-old man is attempting to perform BMX tricks on a bicycle and is not wearing a helmet. He goes over the handlebars and hits his head on a concrete surface. He loses consciousness at the scene but regains consciousness in the trauma bay and is GCS 15. CT is shown below. What is the next best step? A. Observation B. IV antibiotics C. Operative elevation/debridement D. Discharge home E. Burrhole

C. Operative elevation/debridement

69. The CT scan of the brain is depicted below. Why did this patient develop hemiparesis on the same side as the hematoma? A. Shift of the brainstem away from the mass, producing compression of the contralateral cerebral peduncle against the tentorium B. The patient likely suffered a Duret hemorrhage C. There was likely a contusion in the underlying motor cortex on the contralateral side that was not detected on the initial CT scan D. The patient likely had a left internal ca rotid artery dissection that subsequently showered emboli to the distal vasculature E. There was an associated fracture of the transverse foramen on the left, which produced a vertebral artery dissection and small infarct in the ventral pons

A. Shift of the brainstem away from the mass, producing compression of the contralateral cerebral peduncle against the tentorium

70. A 34-year-old female is involved in a motor vehicle collision, suffers a severe closed head injury, and develops a significant posttraumatic tremor in the right arm. Although posttraumatic tremors are generally difficult to manage, which surgical procedure may help control tremors, which are otherwise refractory to medical therapy? A. Thalamic stimulation B. Subthalamic nucleus stimulation C. Motor cortex stimulation D. Capsulotomy E. Multiple subpial transections

A. Thalamic stimulation

71. You are seeing a patient in the trauma bay with evidence of acute increased ICP who has subsequently been intubated. You are taking the patient to the OR for decompression. In order to temporize the situation, you sit up the patient’s head of bed and tell the anesthesiologist to hyperventilate in order to decrease intracranial pressure. What is the target PaCO2 you are aiming for? A. 16 to 20 mm Hg B. 21 to 25 mm Hg C. 26 to 30 mm Hg D. 31 to 35 mm Hg E. 36 to 40 mm Hg

D. 31 to 35 mm Hg

72. The Cantu system for concussion grading uses what three variables to determine severity? A. Loss of consciousness, transient confusion, and symptom duration B. Loss of consciousness, posttraumatic amnesia, and neurologic deficits C. Eye opening, motor response, and verbal response D. Loss of consciousness, posttraumatic amnesia, and symptom duration E. Loss of consciousness, verbal response, confusion

D. Loss of consciousness, posttraumatic amnesia, and symptom duration

73. Which of the following neoplasms is not associated with neurofibromatosis type 2? A. Ependymoma B. Schwannoma C. Meningioma D. Glioma E. Plexiform neurofibroma

E. Plexiform neurofibroma

74. A 58-year-old male presents with focal seizures and is found to have a large frontal lobe mass originating from the gray-white junction on MRI. The patient underwent a diagnostic biopsy of this lesion, and the specimen was CD45- negative, vimentin-positive, cytokeratin-AE1I3 positive, and EMA-negative. This is most consistent with which of the following neoplasms? A. Lymphoma B. Metastatic carcinoma C. Glioblastoma D. Hemangiopericytoma E. Meningioma

C. Glioblastoma

76. You just resected a known, solitary lung cancer metastasis from the right frontal lobe in a 62-yearold man. Pathology confirms lung cancer metastasis. What is the next step for treatment? A. Proton-beam radiation B. Stereotactic radiosurgery C. Whole brain radiation D. Observation E. Chemotherapy

C. Whole brain radiation

77. A 55-year-old female presented with the acute onset of a mild right hemiparesis. What neoplasm is depicted in the following enhanced Tl-weighted MRI? A. CNS lymphoma B. Teratoma C. Oligodendroglioma D. Glioblastoma multiforme E. Melanoma

D. Glioblastoma multiforme

78. Which of the following ratios is typically decreased with primary CNS neoplasms on MR spectroscopy? A. Myoinositol:total creatine B. CholineN-acetyl aspartate C. Choline:total creatine D. N-acetyl aspartate: total creatine E. Myoinositol:N-acetyl aspartate

D. N-acetyl aspartate: total creatine

79. Which tumor is associated with hydrocephalus and sudden death? A. Colloid cyst B. Glioblastoma multiforme C. Lymphoma D. Pilocytic astrocytoma E. Medulloblastoma

A. Colloid cyst

83. According to the 3-column model of Denis, the posterior vertebral body is located in what column of the spine? A. Anterior column B. Middle column C. Posterior column D. Ligamentous complex E. Medial column

B. Middle column

84. What is the approximate AP diameter of the normal cervical spinal canal? A. 10 mm B. 13 mm C. 17 mm D. 21 mm E. 25 mm

C. 17 mm

85. What Meyerding grade would this spondylolisthesis be? A. 1 B. 2 C. 3 D. 4 E. 5

B. 2

86. Which pelvic parameter is determined by an angle measured from a line drawn from the mid-sacral surface to the midpoint of the femoral head and then straight up? A. Sacral slope B. Pelvic tilt C. Pelvic incidence D. Sagittal vertical axis E. None above

B. Pelvic tilt

87. Which of the following statements concerning stabilization of the lumbar spine with segmental pedicle screw fixation is correct? A. The lateral stability is significantly enhanced if the pedicle screw angle is 30 degrees or greater B. The use of transfixation increases the rotational but not the lateral load stability of the construct C. Without a transfixator, the vertebral column is stable in lateral load D. None of the above E. All of the above

A. The lateral stability is significantly enhanced if the pedicle screw angle is 30 degrees or greater

88. What abnormality is depicted on the sagittal MRI below? A. Klippel-Feil syndrome B. Histiocytosis X C. Basilar invagination D. Os odontoideum E. None of the above

C. Basilar invagination

91. You are evaluating a 52-year-old man with medically refractory epilepsy that appears to be located in eloquent cortex (motor cortex) on the right side. There are no other options and you and the patient are considering a procedure to perform multiple pial transections in attempt to control the epilepsy. What should you council this patient about during the postoperative course? A. Permanent motor deficit B. Temporary motor deficit C. Initial seizure worsening D. High risk of infection E. High risk of postoperative hemorrhage

B. Temporary motor deficit

92. You are seeing a patient in clinic with drug resistant epilepsy who is being considered for surgical treatment. She describes her seizure onset including a rising epigastric sensation just prior to initiation of her seizure episode. Where is the most likely location of her epilepsy? A. Medial frontal lobe B. Occipital lobe C. Temporal lobe D. Lateral frontal lobe E. Parietal lo

C. Temporal lobe

93. Which of the following is NOT a functional indication for stereotactic radiosurgery? A. trigeminal neuralgia refractory to medication B. glossopharyngeal neuralgia in a patient with carbamazepine hypersensitivity. C. unilateral essential tremors refractory to medication D. Parkinson’s tremor in the left upper extremity with levodopa-induced dyskinesias E. Huntington’s chorea

E. Huntington’s chorea

94. During a selective amygdalohippocampectomy for intractable seizures, the surgeon must be aware that the most medial part of the amygdala is in close proximity A. to the basal ganglia. B. to the anterior commissure. C. to the caudate nucleus. D. all of the above E. none of the above

D. all of the above

95. Dopamine loss in Parkinson’s disease is believed to lead A. to disinhibition of the subthalamic nucleus. B. to high activity of Gpi/SNr. C. to inhibition of the motor thalamus. D. all of the above E. none of the above

D. all of the above

All of the following are true of toxoplasmosis EXCEPT: A. It is the most common cause of intracerebral mass associated with HIV infection when CD4 counts fall below 100/mm3. B. Chorea in a patient with AIDS may be pathognomonic of toxoplasmosis. C. Radiographic images show an asymmetric target sign. D. The presenting neurologic symptom is nonfocal and superimposed on a global encephalopathy. E. Therapy includes pyrimethamine and sulfadiazine.

D. The presenting neurologic symptom is nonfocal and superimposed on a global encephalopathy.

101. What is the most common neurologic complication in patients with AIDS? A. Toxoplasmosis B. Primary lymphoma C. Leukoencephalopathy D. Bacterial abscess E. Glioma

C. Leukoencephalopathy

102. Which of the following bladder abnormalities is most likely to result from acute cauda equina syndrome? A. Detrusor hyperreflexia B. Detrusor areflexia C. Decreased bladder compliance D. Increased urinary flow rate E. None of the above

B. Detrusor areflexia

You are evaluating a 35-year-old homeless man who reports intravenous (IV) drug use who has developed persistent headaches. An abnormality is seen on CT; findings are shown below. What is the most likely diagnosis? A. Metastasis B. Cerebral abscess C. Glioblastoma D. Meningioma E. Tuberculoma

B. Cerebral abscess

105. You are caring for a 26-year-old man who was thrown from his motorcycle at 30 mph without wearing a helmet while intoxicated. He was found to have a transverse fracture of the clivus. He is now postinjury day 7 and he is noted to have a persistent fever. His mental status has decreased, and you are concerned for the development of meningitis. What is the most common causative organism of meningitis in patients with skull base fractures? A. Neisseria meningitidis B. Group B streptococci C. Staphylococcus aureus D. Streptococcus pneumoniae E. Pseudomonas aeruginosa

D. Streptococcus pneumoniae

106. All of the following are true regarding hyperbaric oxygen therapy in postoperative neurosurgical infection, EXCEPT: A. It increases the oxygen tension in the infected tissues. B. It results in a direct bactericidal effect on anaerobic organisms. C. It results in improved phagocytosis of Staphylococcus. D. It should be used as an adjunct to surgery and antibiotics. E. It is a temporizing measure until definitive therapy can be instituted

E. It is a temporizing measure until definitive therapy can be instituted

108. Which of the following meningioma variants is a World Health Organization (WHO) grade II neoplasm? A. Psammomatous B. Microcystic C. Papillary D. Secretory E. Clear cell

E. Clear cell

114. You are asked to see a patient who is having severe, episodic pain in the right lower jaw. She describes lancinating pain that is worsened by brushing her teeth. You suspect trigeminal neuralgia. What is the best initial management of her condition? A. Balloon compression B. Radiofrequency rhizotomy C. Microvascular decompression D. Medical management E. Glycerol rhizotomy

D. Medical management

115. A patient states that he has a sharp electric-like pain that begins when he touches the lower side of his nose. The pain then shoots down into the cheek, then up above the eye. Which of the following divisions should be treated? A. V1 only B. V2 only C. V3 only D. V2 and V3 E. V1, V2, and V3

B. V2 only

118. With regard to shunt infections, which of the following is FALSE? A. Staphylococcus is the organism implicated in a majority of cases. B. Symptoms include shunt failure, headache, nausea, and vomiting. C. Elevated temperature is a more reliable sign of infection in VA as opposed to VP shunts. D. There is a greater risk of shunt infection with distal revision than proximal revision. E. Staphylococcus infections may cause obstruction without fever.

D. There is a greater risk of shunt infection with distal revision than proximal revision.

119. What is the most common isolate from brain abscesses? A. S. penumoniae B. H. infleunzae C. S. milleri D. E. coli E. P. aeruginosa

C. S. milleri

120. Which of the following spectroscopy peaks would you expect to be elevated in this 36-year-old patient with a past medical history significant for regular IV drug use and new onset headache? A. Myo-inositol B. NAA C. Choline D. Creatine E. Lactate

E. Lactate

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