Neurology - Inflammatory disorders of the nervous system, multiple sclerosis Flashcards

1
Q

NEU - 3.1
Acute stage of viral meningitis is not associated with:
A) common negative clinical findings of cranial CT
B) negative findings on EEG exam
C) cloudy liquor, elevated cell and protein count
D) elevated lymphocyte count in the CSF

A

ANSWER
C) cloudy liquor, elevated cell and protein count

EXPLANATION
In acute viral meningitis, the inflammatory process affects only the soft meninges, the brain tissue is left intact. Therefore, cranial CT or EEG examinations detect no signs of damage to the brain tissue. Clouding of the liquor is not common, but is characteristic of purulent meningitis, also associated with highly elevated cell and protein count. In cases of viral meningitis, the liquor may be clear or colorless, with moderate elevation in cell and protein count.

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2
Q

NEU - 3.2
Acute stage of purulent meningitis is not associated with:
A) epileptic seizures
B) confusion
C) violent headaches
D) elevated lymphocyte and monocyte count in the CSF

A

ANSWER
D) elevated lymphocyte and monocyte count in the CSF

EXPLANATION
In purulent meningitis, the inflammatory process in the soft meninges is diffused and may, to varying degrees, spread to the cortical brain tissues. This may cause focal neurological symptoms or epileptic seizures to occur, and may even lead to cranial oedema which is accompanied by confusion. Violent, diffused headaches commonly accompany the massive, purulent inflammation.

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3
Q

NEU - 3.5
Characteristics of Guillain–Barre syndrome include:
A) segmental demyelinisation may be accompanied by axonal damage
B) axonal lesion does not occur
C) only sensory axonal lesion occurs
D) damage to myelin sheeth is always associated with axonal damage

A

ANSWER
A) segmental demyelinisation may be accompanied by axonal damage

EXPLANATION
In acute Guillain-Barre syndrome, the damage primarily affects the myelin sheath. Still, depending on the aggressiveness of the inflammation, or the prolonged period of convalescence, even the axon may be damaged. Disease damage affects both motor and sensory nerve fibers.

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4
Q

NEU - 3.6
Useful in prion disease treatment:
A) penicillin
B) AZT (azidothymidin)
C) macrolides
D) none of the above

A

ANSWER
D) none of the above

EXPLANATION
The infective agent known as prion (’protein only’) does not contain any nucleic acids, only proteins, which is the modified form of a common cellular protein (cellular prion precursor protein). Once the modified protein enters a normal cell, it induces further modification of the normal cell protein. Prion is resistant to formaline, heat, disinfectants, UV radiation, and ionizing radiation. There is no known cure against it.

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5
Q

NEU - 3.8
Initial stage of optic neuritis is characterized by central scotoma and:
A) papillary hyperaemia
B) papillary oedema
C) slight blur in vitreous humor
D) all of the above
E) none of the above

A

ANSWER
E) none of the above

EXPLANATION
Neuritis retrobulbaris is an inflammation in the optic nerve accompanied by segmental demyelinisation, which does not cause observable lesion in the papilla at an early stage of the disease. Temporal decoloration in the papilla may develop, which degeneration indicates subsequently detected optic nerve damage.

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6
Q

NEU - 3.10
Observed meningitis symptoms may include:
A) vomiting
B) avoiding light
C) signs of meningeal irritation
D) all of the above
E) none of the above

A

ANSWER
D) all of the above

EXPLANATION
Common symptoms of meningitis are fever, fatigability, irritability, and photo phobia. The neurological signs and symptoms, such as headache, vomiting, and other signs of meningeal excitement are partly due to the excited meninges. Purulent meningitis may be accompanied by forms of confusion, epileptic seizures, or focal neurological signs and symptoms due to diffused cortical involvement and oedema in the brain.

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7
Q

NEU - 3.11
Characteristic symptoms of encephalitis, except:
A) headache
B) decreased protein content in CSF
C) cranial nerve symptoms
D) changes in sleep rhythm
E) confusion, fever, headache, epileptic seizures

A

ANSWER
B) decreased protein content in CSF

EXPLANATION
Encephalitis is inflammation of the brain matter which may involve the grey or white matter, or both. Protein content of the brain fluid may increase due to damaged blood-liquor barrier, tissue damage, or immunoglobulin production. Total protein content may be within normal limits, but intrathecal immunoglobulin production indicates inflammation.

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8
Q

NEU - 3.13
Which examination is least informative in polyneuropathy?
A) neurography
B) examination of reflexes
C) muscle biopsy
D) nerve biopsy

A

ANSWER
C) muscle biopsy

EXPLANATION
Polyneuropathy is a disorder of the peripheral nerves. Motor, sensory and vegetative fibers of neurons may be simultaneously affected, but to varying degrees. Several etiological factors are evident. Course of disease, physical examination, and electroneurography (ENG) are primer criteria to confirm the diagnosis. Neural biopsy is primarily useful in differentiating genetically determined diseases. Thorough gastrointestinal and genetic examinations are often necessary. A muscle biopsy may be performed, since tissue sample findings may indicate neurogenic lesion, but carries hardly any further informative value. Therefore, a muscle biopsy is usually not necessary.

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9
Q

NEU - 3.14
Of the following diagnostic procedures, which is most commonly pathological in Multiple Sclerosis?
A) eye movement examination
B) cranial CT
C) EEG
D) myelography

A

ANSWER
A) eye movement examination

EXPLANATION
Eye movement disorder is a common characteristic symptom in Multiple Sclerosis. Internuclear ophthamoplegia occurs in case of a pons-mesencephalon lesion, which is rarely caused by other diseases. Convergence of the bulbs may be preserved, but in case of looking sideways, adduction is impaired, and the abducting eye may develop monocular nystagmus. Damage to the vestibulocerebellar pathways or cerebellar lesions may cause nystagmus. Cranial CT using contrast material is able to detect demyelinisational foci, but its sensitivity is lower in contrast with MRI tests. Irregular, circumscribed organic damage or epileptic dysfunction may be present, but is rarely detectable with EEG test. Myelography is used to assess space-occupying lesions in the spinal canal, therefore it cannot detect the demyelinisational foci in Multiple Sclerosis.

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10
Q

NEU - 3.15
Diagnostic criteria for NMO (neuromyelitis optica) are:
1) Clinical signs of optic neuritis and/or spinal lesion
2) Presence of aquaporin-4 antibodies in serum
3) Presence of LTM (extensive myelitis overlying several segments) on spinal MR findings
4) Presence of OGP (sign of intrathecal IgG synthesis) in CSF

A) answer 1, 2 and 3 correct
B) answer 1 and 3 correct
C) answer 2 and 4 correct
D) only answer 4 correct
E) all 4 answers correct

A

ANSWER
A) answer 1, 2 and 3 correct

EXPLANATION
Diagnostic criteria for neuromyelitis optica (NMO) are: 1. longitudinally extensive myelitis with lesion extending over 3 vertebral segments on MRI examination, 2. optic neuritis (neuritis retrobulbaris unilaterally or bilaterally, often recurrent) 3. the presence of antigens against the aquaporin 4 antigen in serum (and/or in liquor). OGP is seldom detectable in the liquor, therefore it does not belong to diagnostic criteria

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11
Q

NEU - 3.16
Leading clinical signs of acute Guillain–Barre syndrome are:
1) possible cranial nerve lesion
2) ascending paresis
3) flaccid or absent deep reflexes
4) muscular atrophy

A) answers 1, 2 and 3 are correct
B) answers 1 and 3 are correct
C) answers 2 and 4 are correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
A) answers 1, 2 and 3 are correct

EXPLANATION
Acute Guillain-Barre syndrome involves peripheral motor and sensory symptoms. Deep reflexes may be flaccid or absent. Its typical form is characterized by ascending paresis and sensory loss starting from the lower extremity. The process may extend to the level of the cranial nerves. The disease rarely may begin by lesion of the cranial nerves, and this is its cranial form. In acute Guillan-Barre syndrome, muscle atrophy is not a common symptom.

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12
Q

NEU - 3.19
Characteristic alterations in the CSF in multiple sclerosis:
1) increased glucose content
2) elevated levels of relative immunglobulin- IgG values
3) increased polymorphonuclear leucocyte count in 1/3 of cases
4) increased protein content in app. 1/3 of cases

A) answer 1, 2 and 3 correct
B) answer 1 and 3 correct
C) answer 2 and 4 correct
D) only answer 4 correct
E) all 4 answers correct

A

ANSWER
C) answer 2 and 4 correct

EXPLANATION
The sugar content in the liquor does not change in Multiple Sclerosis, it is the protein content which changes. Total protein count tends to be within normal limits, but in app. 1/3 of the cases a moderate increase can be observed. Liquor IgG levels are increased, intrathecally synthesized IgG appears in oligoclonal bands (oligoclonal gammopathy, OGP) through electrophoresis. OGP is found in 80-90% of the cases, therefore, it is a significant sign for diagnosis. The appearance of polymorphonuclear leucocytes in the liquor are contraindications for Multiple Sclerosis diagnosis.

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13
Q

NEU - 3.20
Characteristic symptoms of Guillain–Barre syndrome are:
1) flaccid paresis, absent deep reflexes
2) sensory deficit does not occur
3) cell-protein dissociation is commonly observed in the CSF
4) survival extends usually for a few months, maximum two years

A) answers 1, 2 and 3 correct
B) answers 1 and 3 correct
C) answers 2 and 4 correct
D) only answer 4 correct
E) all of the answers correct

A

ANSWER
B) answers 1 and 3 correct

EXPLANATION
Guillain-Barre syndrome is an inflammatory polyneuropathy, affecting the motor, sensory and vegetative fibers of the peripheral nerves. Due to the damage to motor fibers, hypotonia, paresis, flaccidity or absence of deep reflexes are observed. Sensory dysfunction is characterized by polyneuropathy. If sensory dysfunction is absent, supervision of the diagnosis is indicated. Acute Guillain-Barre syndrome involves elevation in liquor protein content, but is not followed by elevation in cell count. This phenomenon is termed cell-protein dissociation, and also appears in spinal space-occupying lesions (liquor under compression). Recovery may last for months. Death may result in 3-5% of cases during the progressive stage of disease, due to paralysis of respiratory muscles, or cardiac arrhythmias from autonomic dysfunctions. In later stages of the disease, lung embolism, or pneumonia may lead to death (permanent immobilization).

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14
Q

NEU - 3.21
Characteristics of multiple sclerosis are:
1) it is more common is white people
2) it is most common in a relapse-remission pathological form
3) multifocal neurological symptoms
4) first symptoms usually present over age 50

A) answer 1, 2 and 3 are correct
B) answer 1 and 3 are correct
C) answer 2 and 4 are correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
A) answer 1, 2 and 3 are correct

EXPLANATION
Epidemiological studies show that prevalence of Multiple Sclerosis is higher among white people. Detection of several neurological foci is fundamental in establishing the correct diagnosis. Relapse and remission commonly alternate. In app. 50% of cases, the disease begins between 20-40 years, its first presentation is very rare over 50 years of age.

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15
Q

NEU - 3.22
Common clinical signs of multiple sclerosis are:
1) paraesthesia
2) optic neuritis
3) paresis
4) ataxia

A) answers 1, 2 and 3 are correct
B) answers 1 and 3 are correct
C) answers 2 and 4 are correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
E) all 4 answers are correct

EXPLANATION
In Multiple Sclerosis demyelinisation foci may appear in any part of the neurological system. Therefore, clinical signs may be varied. The disease often begins with inflammation of the optic nerve (neuritis retrobulbaris), or with unusually located paraesthesia. Paresis and ataxia also appear in most cases.

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16
Q

NEU - 3.23
Common chronic symptoms of multiple sclerosis are:
1) pathological tiredness (fatigue)
2) disordered optic pathways and eye movement
3) vigorous reflexes
4) epilepsy

A) answers 1, 2 and 3 correct
B) answers 1 and 3 correct
C) answers 2 and 4 correct
D) only answer 4 correct
E) all of the answers correct

A

ANSWER
A) answers 1, 2 and 3 correct

EXPLANATION
Patients are usually fatigable due to involvement of the motor system, and coordination disturbances. Due to damage to pyramidal pathways, vigorous or increased deep reflexes are observed. Eye movement abnormalities are common physical symptoms (internuclear ophthalmoplegia). Epileptic seizures are rare, but may occur in Multiple Sclerosis.

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17
Q

NEU - 3.24
Common chronic symptoms of multiple sclerosis may be:
1) dizziness
2) confabulation
3) weakness in the extremities, spasticity
4) brain oedema

A) answers 1, 2 and 3 are correct
B) answers 1 and 3 are correct
C) answers 2 and 4 are correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
B) answers 1 and 3 are correct

EXPLANATION
Multiple Sclerosis may involve an elated mood, loss of critical sense and cognitive decline due to damage to the frontal lobe. Memory is usually not impaired and confabulation is not a characteristic symptom. The disease does not cause brain oedema or confusion. Damage to central motor neurons, the brain stem and to cerebellum cause characteristic symptoms.

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18
Q

NEU - 3.25
Useful diagnostic procedures of multiple sclerosis:
1) patient’s medical history and detailed neurological examination
2) cranial MRI examination
3) evoked potential tests
4) CSF test

A) answer 1, 2 and 3 correct
B) answer 1 and 3 correct
C) answer 2 and 4 correct
D) only answer 4 correct
E) all 4 answers correct

A

ANSWER
E) all 4 answers correct

EXPLANATION
The McDonald criteria is used to establish the diagnosis for Multiple Sclerosis. It involves the documentation of the disseminated appearance of symptoms in terms of both time and space relationships. An accurate medical history is inevitable to confirm the course of disease (primary progressive form, relapse-remission form etc.). Physical examination, MRI, and triggered response reaction tests are used to detect the neurological lesions in Multiple Sclerosis. In app. 90% of cases, oligoclonal gammopathy (OGP) appears in the liquor. Which means, all the above mentioned modalities of assessment are significant elements in establishing the correct diangosis.

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19
Q

NEU - 3.26
The following patients are at an increased risk for multiple sclerosis:
1) young adults
2) women
3) North-European whites
4) a person who has a close relative suffering from multiple sclerosis

A) answers 1, 2 and 3 correct
B) answers 1 and 3 correct
C) answers 2 and 4 correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
E) all 4 answers are correct

EXPLANATION
The disease appears between the ages of 20-40 in half of the cases, and women are app. 1,4 to 2 times more likely to contract it than men. Disease prevalence is highest in white people living under moderate climate (average of 30-80 patients in every 100,000 inhabitants). Blood relatives are at a 15 times higher risk for developing the disease.

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20
Q

NEU - 3.27
Diagnostic specificities of multiple sclerosis (MS):
1) high IgG index in the CSF is specific for MS
2) extended latency values on VEP (visually evoked potentials) are specific for MS
3) gadolinium accumulating white matter lesions detected on MRI are specific for MS
4) dissemination of clinical signs in space and time is prime criterion for the diagnosis

A) answers 1, 2 and 3 are correct
B) answers 1 and 3 are correct
C) answers 2 and 4 are correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
D) only answer 4 is correct

EXPLANATION
There is no single paraclinical test that is specific for MS, therefore, test results must always be evaluated together with the clinical picture. Diagnosis is primarily based on the dissemination of clinical signs in space and time. Intracerebral immunoglobulin synthesis is determined by calculating the IgG index values. Intracerebral IgG synthesis is an important sign of the disease, but not specific for MS. Triggered response reaction tests are used to detect subclinical lesions, but are not disease specific, either. Native MRI tests are similar from that respect, and are used to test for the demyelinisating character of the foci, and may also indicate the multiplied nature of the process, while possible gadolinium enhancement may indicate disease activity. These deviations on MR findings do not occur only with MS.

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21
Q

NEU - 3.28
During the treatment of multiple sclerosis relapse:
1) high dose intravenous methylprednisolon for 3–5 days are administered
2) steroid use is not prescribed in the treatment of psychosis
3) in severe diabetes or acute infection, steroids are not administered
4) beta-interferon is administered instantenously

A) answer 1, 2 and 3 correct
B) answer 1 and 3 correct
C) answer 2 and 4 correct
D) only answer 4 correct
E) all 4 answers correct

A

ANSWER
A) answer 1, 2 and 3 correct

EXPLANATION
Short term treatment with the administration of high-dose steroids (so called shock therapy), or schub treatment, is advised for Multiple Sclerosis. Due to the common steroid side effects, this treatment is contraindicated in patients with psychosis, diabetes mellitus, or infectious diseases. β-interferon treatment is an immunomodulatory periodic treatment.

22
Q

NEU - 3.31
The following drugs are used to reduce multiple sclerosis relapse rate:
1) azathioprin
2) ABCR self-administered injections (beta-interferons, glatiramer acetate)
3) INH (isonicid)
4) monoclonal antibodies (natalizumab, alemtuzumab)

A) answers 1, 2 and 3 are correct
B) answers 1 and 3 are correct
C) answers 2 and 4 are correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
C) answers 2 and 4 are correct

EXPLANATION
β-interferons and glatiramer acetate are effective compounds to reduce shub frequency during the periodic treatment of Multiple Sclerosis. Second line therapy medications also include monoclonal antibody medications (eg. natalizumab, alemtuzumab). Azathioprin treatment has been tried as a treatment option and certain statistical data suggested, it reduced the frequency of relapse, but there is no convincing data to confirm its effectiveness. INH treatment is found ineffective in Multiple Sclerosis.

23
Q

NEU - 3.32
In multiple sclerosis, introduction of immunomodulatory treatment should be indicated:
1) in relapsing-remitting clinical form, during the active phase
2) in the primary, progressive form
3) in the early stage, until the patient retains mobility
4) in a secondary, progressive form, over age 50

A) answer 1, 2 and 3 correct
B) answer 1 and 3 correct
C) answer 2 and 4 correct
D) only answer 4 correct
E) all 4 answers correct

A

ANSWER
B) answer 1 and 3 correct

EXPLANATION
Immunomodulating treatment in the relapse-remission form of MS significantly reduce relapse frequency, and moderates the degree of tissue damage. Its effectiveness in other forms of the disease have not been satisfactorily elucidated. Its use is usually not indicated in patients with severe deterioration of movement (who lost individual walking capacity).

24
Q

NEU - 3.34
Side effects of interferon treatment:
1) fever and influenza-like symptoms at the beginning of treatment
2) may increase symptoms of depression
3) local reaction on the site of injection
4) it increases blood pressure

A) answers 1, 2 and 3 correct
B) answers 1 and 3 correct
C) answers 2 and 4 correct
D) only answer 4 is correct
E) all 4 answers are correct

A

ANSWER
A) answers 1, 2 and 3 correct

EXPLANATION
β-interferon is a cytokin with several biological effects. 2-6 hours following the administration of injection, cold-like and influenza-like symptoms commonly appear associated with muscle and joint pains. Even temporary aggravation of symptoms may occur, but these symptoms usually resolve within 24 hours. Experience of tiredness and depression may appear during treatment, which causes a group of patients to discontinue their treatment. Medications should be combined with antidepressive treatment. Interferon has no significant effect on blood pressure.

25
Q

NEU-3.35-3.38
Link the abnormal laboratory results with the matching pathological clinical picture.
A) acute Guillain–Barré syndrome
B) multifocal motor neuropathy
C) multiple sclerosis
D) adrenoleukodystrophy

NEU - 3.35 - GM1 antibodies appear in the serum or CSF

NEU - 3.36 - Oligoclonal gammopathy is present in the CSF

NEU - 3.37 - Cell-protein dissociation in the CSF is typical

NEU - 3.38 - Long chain saturated fatty acids accumulate in the serum

A

ANSWER
NEU - 3.35 - GM1 antibodies appear in the serum or CSF - B)

NEU - 3.36 - Oligoclonal gammopathy is present in the CSF - C)

NEU - 3.37 - Cell-protein dissociation in the CSF is typical - A)

NEU - 3.38 - Long chain saturated fatty acids
accumulate in the serum - D)

26
Q

NEU-3.39-3.42
Match the following:
A) progressive multifocal leukoencephalopathy (PML)
B) tuberculosis
C) aspergillosis
D) toxoplasmosis

NEU - 3.39 - A JC virus infection, acquired in childhood, usually plays a part in the disease

NEU - 3.40 - Fungal disease

NEU - 3.41 - Domestic cats play a part in its spreading

NEU - 3.42 - It can cause septic embolism in the brain

A

ANSWER
NEU - 3.39 - A JC virus infection, acquired in childhood, usually plays a part in the disease - A)

NEU - 3.40 - Fungal disease - C)

NEU - 3.41 - Domestic cats play a part in its spreading - D)

NEU - 3.42 - It can cause septic embolism in the brain - C)

27
Q

NEU-3.43-3.46
Match the following:
A) Ramsay Hunt syndrome
B) Bell’s palsy
C) Guillain-Barré syndrome
D) Melkersson-Rosenthal syndrome

NEU - 3.43 - Sudden onset of idiopathic facial paralysis

NEU - 3.44 - Facial paralysis caused by the herpes of the ear canal

NEU - 3.45 - Facial paralysis with swollen lips

NEU - 3.46 - Bilateral facial paralysis may occur

A

ANSWER
NEU - 3.43 - Sudden onset of idiopathic facial paralysis - B)

NEU - 3.44 - Facial paralysis caused by the herpes of the ear canal - A)

NEU - 3.45 - Facial paralysis with swollen lips - D)

NEU - 3.46 - Bilateral facial paralysis may occur - C)

28
Q

NEU - 3.52
Based on the signs and symptoms, the case can be:

A 48 years old male patient, who regularly consumes alcohol, became restless in the morning on the day of the hospital admission, and suffered a Grand Mal Seizure. He was scheduled for a surgery due to colon cancer half a year ago. Three days prior to the admission, he experienced a fever and his temperature rose to 38 ° C. Upon examination, a mild stiffness in the neck, a horizontal nystagmus (while looking in both directions), and a moderate limb and trunk ataxia were discovered. He was slightly somnolent.

A) purulent meningitis
B) brain abscess
C) brain tumor of metastatic origin
D) all of the above
E) none of the above

A

ANSWER
D) all of the above

EXPLANATION
People, who regularly consume alcohol, are more susceptible to infections, and they are more likely to develop central nervous system complications. A high fever, stiffness in the neck, epileptic attacks and an impaired consciousness point towards purulent meningitis. Although physical examinations describing organic damage are not documented, largely due to the disorientation, the possibility of brain abscess of space occupying nature, accompanying febrile illnesses, should be maintained. Intracranial space-occupying processes, apart from disorientation, too, can cause mild stiffness in the neck, or epileptic attacks. One of the common sources of metastatic brain tumors is colon carcinoma. This, too, needs to be taken into account. Given that there are signs of intracranial hypertension, acute imaging (CT or MRI) tests should be arranged. In the case of purulent meningitis, the cerebrospinal fluid cell count significantly increased (10000/3 or up to a multiple of this). We also find a significant increase in CSF total protein, which can be double of the normal amount, or even greater. The examination of the cerebrospinal fluid may have diagnostic value in the case of both meningitis, brain abscess and metastatic cancer. Lumbar puncture should be avoided in the case of papilledema. A cranial CT and MRI play an important role in determining both brain abscess and metastatic brain tumors.

29
Q

NEU - 3.53
Which of the following examinations is to be carried out first?

A 48 years old male patient, who regularly consumes alcohol, became restless in the morning on the day of the hospital admission, and suffered a Grand Mal Seizure. He was scheduled for a surgery due to colon cancer half a year ago. Three days prior to the admission, he experienced a fever and his temperature rose to 38 ° C. Upon examination, a mild stiffness in the neck, a horizontal nystagmus (while looking in both directions), and a moderate limb and trunk ataxia were discovered. He was slightly somnolent.

A) chest X-ray
B) ECG
C) EEG
D) CT
E) lumbar puncture

A

ANSWER
D) CT

EXPLANATION
People, who regularly consume alcohol, are more susceptible to infections, and they are more likely to develop central nervous system complications. A high fever, stiffness in the neck, epileptic attacks and an impaired consciousness point towards purulent meningitis. Although physical examinations describing organic damage are not documented, largely due to the disorientation, the possibility of brain abscess of space occupying nature, accompanying febrile illnesses, should be maintained. Intracranial space-occupying processes, apart from disorientation, too, can cause mild stiffness in the neck, or epileptic attacks. One of the common sources of metastatic brain tumors is colon carcinoma. This, too, needs to be taken into account. Given that there are signs of intracranial hypertension, acute imaging (CT or MRI) tests should be arranged. In the case of purulent meningitis, the cerebrospinal fluid cell count significantly increased (10000/3 or up to a multiple of this). We also find a significant increase in CSF total protein, which can be double of the normal amount, or even greater. The examination of the cerebrospinal fluid may have diagnostic value in the case of both meningitis, brain abscess and metastatic cancer. Lumbar puncture should be avoided in the case of papilledema. A cranial CT and MRI play an important role in determining both brain abscess and metastatic brain tumors.

30
Q

NEU - 3.54
If the CSF examination will take place, the case of purulent meningitis stands, if:

A 48 years old male patient, who regularly consumes alcohol, became restless in the morning on the day of the hospital admission, and suffered a Grand Mal Seizure. He was scheduled for a surgery due to colon cancer half a year ago. Three days prior to the admission, he experienced a fever and his temperature rose to 38 ° C. Upon examination, a mild stiffness in the neck, a horizontal nystagmus (while looking in both directions), and a moderate limb and trunk ataxia were discovered. He was slightly somnolent.

2) 1) clear CSF
2) increased amount of white blood cells
3) oligoclonal gammopathy
4) 1 g/l quantities of total protein

A) answer 1, 2 and 3 correct
B) answer 1 and 3 correct
C) answer 2 and 4 correct
D) only answer 4 correct
E) all 4 answers correct

A

ANSWER
C) answer 2 and 4 correct

EXPLANATION
People, who regularly consume alcohol, are more susceptible to infections, and they are more likely to develop central nervous system complications. A high fever, stiffness in the neck, epileptic attacks and an impaired consciousness point towards purulent meningitis. Although physical examinations describing organic damage are not documented, largely due to the disorientation, the possibility of brain abscess of space occupying nature, accompanying febrile illnesses, should be maintained. Intracranial space-occupying processes, apart from disorientation, too, can cause mild stiffness in the neck, or epileptic attacks. One of the common sources of metastatic brain tumors is colon carcinoma. This, too, needs to be taken into account. Given that there are signs of intracranial hypertension, acute imaging (CT or MRI) tests should be arranged. In the case of purulent meningitis, the cerebrospinal fluid cell count significantly increased (10000/3 or up to a multiple of this). We also find a significant increase in CSF total protein, which can be double of the normal amount, or even greater. The examination of the cerebrospinal fluid may have diagnostic value in the case of both meningitis, brain abscess and metastatic cancer. Lumbar puncture should be avoided in the case of papilledema. A cranial CT and MRI play an important role in determining both brain abscess and metastatic brain tumors.

31
Q

NEU - 3.57
The brain contusion almost always involves a loss of consciousness, and no abnormalities are visible on the CT scan and the CSF is often bloody.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
In the case of contusio cerebri (cerebral contusion), the patient loses consciousness. However, in rare cases with localized force, loss of consciousness does not necessarily occur. The brain is damaged, which can be detected by cranial CT or MRI at the early stage. During cerebral contusion, the CSF, also at an early stage, can be bloody or xantochrom.

32
Q

NEU - 3.58
The postoperative survival of patients suffering from glioblastoma multiforme usually ranges from a few months up to a year or two.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
The glioblastoma multiforme is very fast-growing, and the most aggressive tumour originating in astrocytes (WHO Grade IV astrocytoma). With histological certainty the expected survival on average ranges between 8-18 months.

33
Q

NEU - 3.59
The number of cells increases and protein content decreases in the CSF during encephalitis.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
There could be a mild degree of cell growth (50-100/3) in encephalitis, as a larger number of cells is considered not typical. Similarly, the protein level of the CSF can be normal or slightly increased.

34
Q

NEU - 3.60
Brain abscess is often caused by an extracerebral premise.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
Brain abscess develops as a result of pyogenic bacteria, fungi and protozoa reaching the brain. The primary, extracerebral source of the pathogen can be found in more than 80% of the cases.

35
Q

NEU - 3.61
Cauda equina syndrome is not pyramidal.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
The cauda equina is a bundle of motor and sensory roots associated with the lumbar and sacral segments. Accordingly, any damage to the cauda does not create any pyramid symptoms signaling the abuse of the central motor neuron.

36
Q

NEU - 3.62
The visual evoked potential (VEP) is still intact in most patients suffering from multiple sclerosis.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
Multiple sclerosis often affects the optic nerve, and in many cases, the first sign of the disease is optic neuritis. The visual evoked potential (VEP) may indicate (subclinical) optic nerve damage in patients, who did not voice strong complaints.

37
Q

NEU - 3.63
Generally, a vertical nystagmus can be observed in the case of vertigo of peripheral origin.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
Vertical nystagmus in the mesencephalon is a sign of brainstem damage. It does not occur in the case of peripheral vestibular disease.

38
Q

NEU - 3.64
The level of the anti-measles antigens rises in the CSF during neuromyelitis optica.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
The aquaporin antibody level may be increased in seropositive neuromyelitis optica. Viral antibodies are typically not present.

39
Q

NEU - 3.65
Multiple sclerosis is a disease of unknown etiology, in which environmental, genetic and immunological factors may play a role in its development.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
Epidemiological studies indicate that environmental factors have a greater importance in the risk of multiple sclerosis. The role of genetics is smaller, around 20-40%. Migration research justifies the importance of environmental factors. If someone relocates prior to the age of 15 to an area in which the incidence of MS is higher than the original place of residence, the risk of acquiring the disease for the immigrant becomes the same with the others living in the host country. The significant change in the geographical distribution, the resistance in certain ethnic groups against MS, and twin studies point towards genetic determinism. Hereditary conditions are likely to be linked to multiple genes, and these genetic defects are certainly affecting the body’s immunity.

40
Q

NEU - 3.66
Multiple sclerosis is an autoimmune disease, in which T-cell mediated immune response has an important role.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
The exact pathomechanism of multiple sclerosis is unknown. According to one of the most widely accepted hypothesis, it’s a CD4 + T cell-mediated autoimmune disease in the central nervous system. The CD4 + T (Th1)-lymphocytes induce proinflammatory cytokines, leading to demyelization.

41
Q

NEU - 3.67
With multiple sclerosis, the myelin sheath suffers a segmental damage, the axon, however, remains in good condition.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
It was proven, in addition to/past myelin damage, axonal damage is also present during multiple sclerosis, and the latter is responsible for the permanent and worsening conditions in the primary and secondary progressive forms.

42
Q

NEU - 3.68
The most common form of multiple sclerosis is the manifestation with relapses and remitting.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
The most common form of multiple sclerosis is the process involving relapses and remitting (RRMS). During the later stage of the disease, it will develop into a secondary progressive form (SPSM), once the level of axonal damage reaches a certain threshold. In fewer than 10% of the patients, the symptoms of the disease demonstrated a slow progressive worsening from the very beginning, without obvious relapses and it is referred to as its primary progressive form (PPSM). It never develops into another form.

43
Q

NEU - 3.69
In about 10% of the multiples sclerosis diseases, it occurs in a primary progressive form from the beginning.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
The most common form of multiple sclerosis is the process involving relapses and remitting (RRMS). During the later stage of the disease, it will develop into a secondary progressive form (SPSM), once the level of axonal damage reaches a certain threshold. In fewer than 10% of the patients, the symptoms of the disease demonstrated a slow progressive worsening from the very beginning, without obvious relapses and it is referred to as its primary progressive form (PPSM). It never develops into another form.

44
Q

NEU - 3.70
The relapsing-remitting multiple sclerosis with the later stage of the clinical course develops into a secondary progressive form.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
The most common form of multiple sclerosis is the process involving relapses and remitting (RRMS). During the later stage of the disease, it will develop into a secondary progressive form (SPSM), once the level of axonal damage reaches a certain threshold. In fewer than 10% of the patients, the symptoms of the disease demonstrated a slow progressive worsening from the very beginning, without obvious relapses and it is referred to as its primary progressive form (PPSM). It never develops into another form.

45
Q

NEU - 3.71
The primary progressive form of multiple sclerosis can develop into a secondary progressive form.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
The most common form of multiple sclerosis is the process involving relapses and remitting (RRMS). During the later stage of the disease, it will develop into a secondary progressive form (SPSM), once the level of axonal damage reaches a certain threshold. In fewer than 10% of the patients, the symptoms of the disease demonstrated a slow progressive worsening from the very beginning, without obvious relapses and it is referred to as its primary progressive form (PPSM). It never develops into another form.

46
Q

NEU - 3.72
Generally, the prognosis of the primary progressive form of the disease is worse than the relapse-remitting form or the secondary progressive form of multiple sclerosis.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
Primary progressive multiple sclerosis is characterized by the delayed start, the pronounced spinal cord symptoms, continuous progression, which, however, is in very different degrees. Several statistical data indicate that, it has a faster progression than other forms, and approximately 20% of the progress of the diseases is benign

47
Q

NEU - 3.73
With appropriate treatment and care, the life expectancy of patients with multiple sclerosis is only a few years less than that of the general population of the same age.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
By providing regular monitoring by specialists, appropriate medical treatment, counseling and social care, the disease shortens the life of the patient by only a few years

48
Q

NEU - 3.75
The diagnosis of multiple sclerosis is not of clinical symptoms, but is based on the CSF and the MRI test results.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
The diagnosis of multiple sclerosis is essentially based on the clinical picture. MRI, the evoked response, and cerebrospinal fluid tests only strengthen or weaken the strength of the diagnosis, or may indicate the activity.

49
Q

NEU - 3.76
The cranial MRI is important, but not specific, in the effective diagnosis of multiple sclerosis.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
In the MRI images the signal intensity changes that appear in the white matter may be typical of multiple sclerosis, but not specific. In the brain/spinal cord, the appearance of 4-9 pieces of 3 mm or larger in diameter white matter foci is considered a strong signal in support of the diagnosis.

50
Q

NEU - 3.78
Without specific treatment, neuromyelitis optica leads to serious permanent damage or even death.

A) true
B) false

A

ANSWER
A) true

EXPLANATION
Without the use of immunomodulatory therapy, there is a 50% chance that patients will develop blindness within five years or become wheelchair-bound, or 30% of them die due to respiratory paralysis due to myelencephalon involvement. If the treatment of the disease is initiated without delay and is consistently maintained, severe neurological damage, the symptoms, and the chances of relapse can be significantly reduced.

51
Q

NEU - 3.79
Neuromyelitis optica is a T cell-mediated autoimmune disease, like multiple sclerosis and the treatment is identical.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
The immunomodulatory treatments used in MS are not effective in the NMO, since immunopathology (B-cell mediated) is different. Following the administration of a steroid, long-term azathioprine therapy is necessary and is supplemented by a course of sustaining a steroid, in parallel, for at least half a year, and often longer.

52
Q

NEU - 3.80
In the background of epileptic illnesses, the inflammatory disease of the nervous system can never be found.

A) true
B) false

A

ANSWER
B) false

EXPLANATION
Epileptic episodes may occur in purulent meningitis, brain abscesses, and in case of encephalitis.