Neurosurgery Practice QnA 2nd Part Flashcards

Question

Irritability, seizures, ataxia, coma Match the following metals with the corresponding syndrome:

Answer 1

A. Mercury B. Manganese C. Arsenic D. Aluminum **E. Lead**

Answer 2

**A. Mercury** B. Manganese C. Arsenic D. Aluminum E. Lead

Answer 3

A. Mercury B. Manganese C. Arsenic **D. Aluminum** E. Lead

Answer 4

**A. Left atrium** B. Left ventricle C. Pulmonary veins D. Aorta E. Ventricular aneurysms ## Footnote Left atrium accounts for 65–75% of embolisms, mainly the left appendage. The left ventricle and ventricular aneurysms account for 5% each.

Answer 5

A. Diabetic ketoacidosis B. Cushing’s syndrome C. High intestinal obstruction D. Chronic diarrhea **E. Uremia** ## Footnote Uremia is most likely to cause potassium stores depletion.

Answer 6

A. Seizures **B. Tetany** C. Hypotension D. Loss of deep tendon reﬂ exes E. Stupor ## Footnote Tetany is the fi rst sign of magnesium depletion. Delirium occurs usually before convulsions. An increase in deep tendon refl exes is usually observed.

Answer 7

A. Na+ 130 mEq/L B. Cl· 109 mEq/L C. Lactate 28 mEq/L **D. Ca2+ 16 mEq/L** E. K+ 4 mEq/L ## Footnote Ca2+ concentration is 3 mEq/L.

Answer 8

A. The male to female ratio is 1.5:1. **B. Thoracic location is the most common.** C. It is usually low grade. D. It is the most common intramedullary tumor in children. E. Examination may reveal a combination of upper and lower motor neuron signs. ## Footnote The MRI scan demonstrates an intramedullary astrocytoma, which occurs most commonly in the cervical spine. Lower motor signs may be at the level of the lesion and may aid in localization. These types of tumors are the most common intramedullary tumors in children and are usually of fi brillary type. Intramedullary tumors may be treated empirically with cyberknife radiosurgery with good results forgoing the need for biopsy which can be risky. A lumbar puncture may be used for an indirect biopsy which is reasonably safe. It is however low yield but worth a try.

Answer 9

A. Amyotrophic lateral sclerosis B. Systemic lupus erythematosus **C. Metachromatic leukodystrophy** D. Lesch–Nyhan syndrome E. Niemann–Pick disease

Answer 10

**A. Amyotrophic lateral sclerosis** B. Systemic lupus erythematosus C. Metachromatic leukodystrophy D. Lesch–Nyhan syndrome E. Niemann–Pick disease

Answer 11

A. Amyotrophic lateral sclerosis B. Systemic lupus erythematosus C. Metachromatic leukodystrophy **D. Lesch–Nyhan syndrome** E. Niemann–Pick disease

Answer 12

A. Increased calcium, normal phosphate, and increased alkaline phosphatase B. Decreased calcium, increased phosphate, and normal alkaline phosphatase **C. Decreased calcium, decreased phosphate, and increased alkaline phosphatase** D. Normal calcium, normal phosphate, and increased alkaline phosphatase ## Footnote Rickets disease presents with increased alkaline phosphatase and decreased serum calcium and phosphate levels.

Answer 13

A. Increased calcium, normal phosphate, and increased alkaline phosphatase B. Decreased calcium, increased phosphate, and normal alkaline phosphatase C. Decreased calcium, decreased phosphate, and increased alkaline phosphatase **D. Normal calcium, normal phosphate, and increased alkaline phosphatase** ## Footnote Paget’s disease usually presents with increased alkaline phosphatase and normal serum calcium and phosphate levels; serum calcium levels may be increased depending on the stage of the disease

Answer 14

**A. Increased calcium, normal phosphate, and increased alkaline phosphatase** B. Decreased calcium, increased phosphate, and normal alkaline phosphatase C. Decreased calcium, decreased phosphate, and increased alkaline phosphatase D. Normal calcium, normal phosphate, and increased alkaline phosphatase ## Footnote Hyperparathyroidism usually presents with increased alkaline phosphatase, increased serum calcium, and decreased or normal phosphate levels.

Answer 15

A. Increased calcium, normal phosphate, and increased alkaline phosphatase B. Decreased calcium, increased phosphate, and normal alkaline phosphatase C. Decreased calcium, decreased phosphate, and increased alkaline phosphatase **D. Normal calcium, normal phosphate, and increased alkaline phosphatase** ## Footnote Primary osteoporosis usually presents with increased alkaline phosphatase and normal serum calcium and phosphate levels.

Answer 16

A. Increased calcium, normal phosphate, and increased alkaline phosphatase **B. Decreased calcium, increased phosphate, and normal alkaline phosphatase** C. Decreased calcium, decreased phosphate, and increased alkaline phosphatase D. Normal calcium, normal phosphate, and increased alkaline phosphatase ## Footnote Hypoparathyroidism usually presents with normal alkaline phosphatase, decreased serum calcium, and increased phosphate levels.

Answer 17

A. Chronic respiratory acidosis B. Non-anion gap metabolic acidosis and respiratory alkalosis C. Metabolic alkalosis and respiratory acidosis D. Wide anion gap metabolic acidosis **E. Chronic respiratory alkalosis**

Answer 18

A. Chronic respiratory acidosis **B. Non-anion gap metabolic acidosis and respiratory alkalosis** C. Metabolic alkalosis and respiratory acidosis D. Wide anion gap metabolic acidosis E. Chronic respiratory alkalosis

Answer 19

A. Chronic respiratory acidosis B. Non-anion gap metabolic acidosis and respiratory alkalosis **C. Metabolic alkalosis and respiratory acidosis** D. Wide anion gap metabolic acidosis E. Chronic respiratory alkalosis

Answer 20

**A. Chronic respiratory acidosis** B. Non-anion gap metabolic acidosis and respiratory alkalosis C. Metabolic alkalosis and respiratory acidosis D. Wide anion gap metabolic acidosis E. Chronic respiratory alkalosis

Answer 21

A. Chronic respiratory acidosis B. Non-anion gap metabolic acidosis and respiratory alkalosis C. Metabolic alkalosis and respiratory acidosis **D. Wide anion gap metabolic acidosis** E. Chronic respiratory alkalosis ## Footnote Here are some pointers in interpreting the arterial blood gas: The most useful information comes from the clinical description of the patient by the history and physical examination; however in this case this information is not given. Therefore, the next step is to look at the pH. If pH < 7.35, then there is an acidemia; if pH > 7.45, then there is an alkalemia. The pH may be normal in the presence of a mixed acid base disorder, particularly if other parameters of the ABG are abnormal. The third step is to look at PCO2 and HCO3- in order to determine the acid base process (alkalosis vs. acidosis) leading to the abnormal pH. In simple acid base disorders, both values are abnormal and direction of the abnormal change is the same for both parameters. One abnormal value will be the initial change and the other will be the compensatory response. Once the initial change is identifi ed, then the other abnormal parameter is the compensatory response if the direction of the change is the same. If not, suspect a mixed disorder. Once the initial chemical change and the compensatory response is distinguished, then identify the specifi c disorder. If PCO2 is the initial chemical change, then the process is respiratory; if HCO3- is the initial change, then the process is metabolic. Below is a brief description of the initial chemical change followed by the compensatory response in basic acid/base disorders: Respiratory Acidosis elevated PCO2 elevatedHCO3- Respiratory Alkalosis decrease PCO2 decrease HCO3- Metabolic Acidosis decrease HCO3- decrease PCO2 Metabolic Alkalosis elevated HCO3- elevated PCO2

Answer 22

A. Scan 1 B. Scan 2 **C. Scans 1 and 2** D. None of the above

Answer 23

A. Scan 1 **B. Scan 2** C. Scans 1 and 2 D. None of the above

Answer 24

**A. Scan 1** B. Scan 2 C. Scans 1 and 2 D. None of the above ## Footnote Scan 1 shows a wedge infarct and scan 2 shows a watershed infarct, which can also be due to small embolic infarcts. Both endocarditis and occlusive disease of a single artery may result in scan defi cits 1. Watershed infarcts may typically present with man-in-the-barrel syndrome due to hypoperfusion. Man-in-the-barrel syndrome is manifested by bilateral arm weakness, intact cranial nerves, and preservation of leg function, appearing as if the upper limbs were confi ned in a barrel. It is most frequently caused by cerebral vascular disorders and cardiac surgeries involving arterial hypotension, and the spinal cord may be involved as well. Other cases of man-in-the-barrel syndrome may be due to cerebral metastases, hemorrhagic contusion in trauma, ALS, and lower motor neuron disease.

Answer 25

A. the tuberoinfundibular nucleus. **B. the preoptic nucleus.** C. the paraventricular nucleus. D. the mammillary bodies. E. None of the above ## Footnote The preoptic nucleus is considered part of the anterior hypothalamus.

Answer 26

A. Adie’s pupil B. Posterior communicating artery aneurysm **C. Kennedy syndrome** D. Horner’s syndrome E. Third nerve lesion ## Footnote All the other choices result in an eff erent defect

Answer 27

A. Macular degeneration B. Optic neuritis C. Papilledema **D. Metabolic optic neuropathy** E. Retinal lesion ## Footnote Metabolic neuropathy is typically symmetric and bilateral and will rarely present with an aff erent pupillary defect clinically.

Answer 28

A. Decreasing the positive end expiratory pressure to 0 cm H2O B. Hyperventilation **C. Improving mixed venous oxygen contents** D. Oxygen supplementation E. None of the above ## Footnote An improvement in mixed venous oxygen contents will often improve the hypoxemia in the setting of a shunt.

Answer 29

A. 96 hours. **B. 72 hours.** C. 48 hours. D. 24 hours. E. 12 hours

Answer 30

**A. Conversion of prothrombin to thrombin** B. Activation of contact factors C. Generation of thromboplastin D. Release of phospholipids from plate E. Conversion of fi brinogen to fi brin ## Footnote Conversion of prothrombin from thrombin is the most time consuming and is usually measured as the prothrombin time (PT); it is in the range of 11 to 13 seconds.

Answer 31

A. Image 1 **B. Image 2** C. Images 1 and 2 D. None of the above ## Footnote The second fi gure shows a venous angioma which can be caused by arrested development.

Answer 32

A. Image 1 B. Image 2 C. Images 1 and 2 **D. None of the above** ## Footnote Dural arteriovenous malformations are usually acquired after dural thrombosis. Neither cavernous malformation (fi rst image) nor venous angioma (second image) is an acquired lesion

Answer 33

A. Image 1 **B. Image 2** C. Images 1 and 2 D. None of the above ## Footnote Blue rubber nevus syndrome is associated with venous angiomas.

Answer 34

A. Ocular bobbing B. Jerk nystagmus C. See-saw nystagmus **D. Downbeat nystagmus** E. None of the above

Answer 35

A. Ocular bobbing B. Jerk nystagmus **C. See-saw nystagmus** D. Downbeat nystagmus E. None of the above

Answer 36

A. Ocular bobbing B. Jerk nystagmus C. See-saw nystagmus D. Downbeat nystagmus **E. None of the above**

Answer 37

A. Ocular bobbing **B. Jerk nystagmus** C. See-saw nystagmus D. Downbeat nystagmus E. None of the above

Answer 38

**A. Ocular bobbing** B. Jerk nystagmus C. See-saw nystagmus D. Downbeat nystagmus E. None of the above

Answer 39

A. Granule cell **B. Golgi cel**l C. Purkinje cell D. Basket cell E. Stellate cell ## Footnote The glomerulus is formed by the Golgi cell, the granule cell, and the mossy fi ber.

Answer 40

**A. Granule cell** B. Golgi cell C. Purkinje cell D. Basket cell E. Stellate cell ## Footnote The granule cell is the only excitatory cell within the cerebellum

Answer 41

A. Granule cell B. Golgi cell C. Purkinje cell **D. Basket cel**l E. Stellate cell ## Footnote Basket cells end in a rete of terminals around the Purkinje cell.

Answer 42

A. Granule cell B. Golgi cell **C. Purkinje cell** D. Basket cell E. Stellate cell ## Footnote Purkinje cells synapse with the deep cerebellar nuclei.

Answer 43

A. Blurred vision B. Diaphoresis C. Apnea **D. Hallucinations** E. Sneezing ## Footnote Early signs of cyanide poisoning include general weakness, malaise, early giddiness, inebriation, confusion, headache, vertigo, dizziness, confusion, and hallucinations. Tachypnea and hyperpnea generally precede apnea.

Answer 44

A. Manganese B. Zinc C. Iron D. Copper **E. All of the above** ## Footnote All are important in wound healing. Zinc is a mineral that is important for the action of collagenase. Manganese is necessary for the glycosylation of hydroxyproline residues in the formation of collagen. Copper is a cofactor of ceruloplasmin and is involved in the synthesis of oxidative metalloenzymes and elastics. Iron is a vital cofactor for proteins and enzymes involved in energy metabolism, respiration, DNA synthesis, cell cycle arrest, and apoptosis.

Answer 45

A. inhibition of DNA synthesis. B. cell membrane destruction. C. cell wall damage. **D. inhibition of protein synthesis.** E. None of the above ## Footnote Aminoglycosides act by inhibiting protein synthesis through irreversible ribosomal attachment. Examples of aminoglycoside antibiotics are amikacin, tobramycin, gentamicin, streptomycin, and neomycin.

Answer 46

A. Streptomycin B. Kanamycin C. Neomycin **D. Polymyxin** E. Gentamicin ## Footnote Polymyxin does not cause neuromuscular blockade.

Answer 47

A. The Allcock test is useful. **B. External ventricular drainage following subarachnoid hemorrhage from this type of aneurysm is an accepted temporizing treatment.** C. Proximal ligation is the preferred treatment. D. Vasospasm in this area is unlikely to cause respiratory compromise. E. A lumbar drain is contraindicated in this case. ## Footnote The image represents a vertebral artery aneurysm. The preferred treatment is direct aneurysm clipping of this aneurysm. The Allcock test will test patency of the circle of Willis via carotid occlusion. Vasospasm in this area can cause midbrain and medullary syndrome, including respiratory arrest and neurogenic pulmonary edema. A lumbar arachnoid catheter may also be used to allow CSF drainage.

Answer 48

A. The dura needs to be opened at either end well above the lesion. **B. Dilated veins are more likely to be encountered at the rostral end of the mass.** C. Myelotomy is to be done as close to the midline as possible. D. Intracapsular decompression of the tumor is necessary to avoid any traction. E. C-arm guidance for localization may be helpful. ## Footnote When removing an intramedullary spinal cord tumor one is more likely to encounter dilated veins at the caudal end of the mass. The other points are general principles of spinal cord tumor resection. Note that it is useful to seek out the blood supply of the tumor before debulking to keep the fi eld relatively free of blood.

Answer 49

**A. sulfatides.** B. galactocerebroside. C. ganglioside. D. long-chain fatty acids. E. None of the above ## Footnote Galactocerebroside accumulates in Krabbe’s disease. Ganglioside accumulates in Tay–Sachs’s and Sandhoff ’s diseases. Long chain fatty acids accumulate in adrenoleukodystrophy.

Answer 50

A. fl exor response as seen in decerebrate rigidity. B. crossed extensor refl ex. **C. monosynaptic stretch refl ex.** D. supramaximal stimulation of a mixed motor-sensory nerve. E. All of the above ## Footnote The T-refl ex represents the monosynaptic stretch refl ex elicited by tapping a tendon.

Answer 51

A. lower pons. B. upper pons. **C. lower midbrain**. D. upper midbrain. E. medulla. ## Footnote The trochlear nerve arises at the level of the lower midbrain (inferior colliculus level).

Answer 52

A. opsoclonus. B. increased glutamic acid decarboxylase. C. anti–Purkinje cell antibodies. **D. presynaptic acetylcholine receptor disorder.** E. multiple sclerosis. ## Footnote The patient likely has Lambert–Eaton myasthenic syndrome (LEMS) with small cell (oat cell) carcinoma. About 60% of those with LEMS have an underlying malignancy, most commonly small cell lung cancer.

Answer 53

A. 50 mEq **B. 150 mEq** C. 350 mEq D. 500 mEq E. 1000 mEq ## Footnote Total body potassium excess of 100 to 200 mEq is required to produce a rise of 1 mEq/L in serum potassium.

Answer 54

A. Lateral cord **B. Ulnar nerve** C. Musculocutaneous nerve D. Median nerve E. Lower subscapular nerve ## Footnote The ulnar nerve has no supply from the C6 root.

Answer 55

A. Brachial plexus **B. Cervical plexus** C. Lumbar plexus D. Cervical and brachial plexuses E. None of the above ## Footnote Cervical roots C2 and C3 innervate this muscle.

Answer 56

A. Brachial plexus B. Cervical plexus C. Lumbar plexus **D. Cervical and brachial plexuses** E. None of the above ## Footnote Involved in the phrenic nerve and the brachial plexus

Answer 57

A. Brachial plexus B. Cervical plexus **C. Lumbar plexus** D. Cervical and brachial plexuses E. None of the above ## Footnote Innervated by the obturator nerve (L2, L3).

Answer 58

A. Brachial plexus B. Cervical plexus C. Lumbar plexus **D. Cervical and brachial plexuses** E. None of the above ## Footnote Innervated by C3, C4 (cervical nerves) and C5 (dorsal scapular nerve which arises from the brachial plexus).

Answer 59

A. Brachial plexus B. Cervical plexus C. Lumbar plexus D. Cervical and brachial plexuses **E. None of the above** ## Footnote Innervated by the pudendal nerve (S2–S4).

Answer 60

A. Brachial plexus **B. Cervical plexus** C. Lumbar plexus D. Cervical and brachial plexuses E. None of the above ## Footnote Innervated by the accessory nerve and C2 roots.

Answer 61

**A. Hallucinations while sleeping** B. Convulsions while sleeping C. Daytime hyperalertness D. NREM onset of sleep E. Gelastic seizures ## Footnote Hypnagogic hallucinations are seen with narcolepsy. Hypnagogic or hypnopompic hallucinations are visual, tactile, auditory, or other sensory events, usually brief but occasionally prolonged, that occur at the transition from wakefulness to sleep (hypnagogic) or from sleep to wakefulness (hypnopompic). People with narcolepsy have a reduced number of neurons that produce the protein orexin-A.

Answer 62

A. Thiamine B. B6 C. Cobalamine D. Niacin **E. Vitamin A** ## Footnote Vitamin A intoxication is associated with pseudotumor cerebri.

Answer 63

**A. Thiamine** B. B6 C. Cobalamine D. Niacin E. Vitamin A ## Footnote Beriberi is associated with thiamin defi ciency (B1). Beriberi is divided into three separate entities depending on which body system is involved: peripheral nervous system (dry beriberi), cardiovascular system (wet beriberi), or gastrointestinal system.

Answer 64

A. Thiamine B. B6 **C. Cobalamine** D. Niacin E. Vitamin A ## Footnote Increased serum homocysteine and methylmalonic acid is associated with vitamin B12 defi ciency.

Answer 65

A. Thiamine **B. B6** C. Cobalamine D. Niacin E. Vitamin A ## Footnote Pyridoxine defi ciency is associated with lower extremity paresthesias.

Answer 66

**A. Type A GABA agonist** B. Type B GABA agonist C. GABA antagonist D. No eff ect on GABA receptors ## Footnote Barbiturates are used as antiepileptics and in the treatment of intractable increased intracranial pressure.

Answer 67

A. Type A GABA agonist B. Type B GABA agonist **C. GABA antagonist** D. No eff ect on GABA receptors ## Footnote Both picrotoxin and bicuculline are GABA receptor blockers.

Answer 68

A. Type A GABA agonist **B. Type B GABA agonist** C. GABA antagonist D. No eff ect on GABA receptors ## Footnote Baclofen in used as a centrally acting muscle relaxant. Baclofen can be administered transdermally, orally, or intrathecally.

Answer 69

A. Type A GABA agonist B. Type B GABA agonist **C. GABA antagonist** D. No eff ect on GABA receptors ## Footnote Bicuculline is a selective GABA-A antagonist directly at the site where GABA binds.

Answer 70

A. anterior communicating and superior hypophyseal. B. basilar and anterior communicating. C. PICA and superior hypophyseal. D. PICA and basilar. **E. basilar and posterior communicating.** ## Footnote The two aneurysms are a calcifi ed thrombotic basilar artery aneurysm and a posterior communicating artery aneurysm.

Answer 71

A. A common presenting sign is papilledema. B. It arises from the diencephalic recess of the postvellar arch. C. Risk of sudden death is attributable to CSF dynamics or disturbances in hypothalamic-related cardiovascular control. **D. Lumbar puncture is part of the initial workup.** E. The patient may require a shunt postoperatively ## Footnote The lesion presented is a colloid cyst of the third ventricle. A lumbar puncture is contraindicated prior to the placement of a shunt or a ventricular catheter due to the risk of herniation.

Answer 72

A. Phasic changes of amplitude and polarity of ventricular complexes B. Hypokalemia C. Hypomagnesemia **D. Narrowed QT intervals** E. May be predisposed by erythromycin ## Footnote Torsades de pointes presents with prolonged QT intervals.

Answer 73

A. In early ARDS, the hypoxemia is more pronounced and the chest X-ray abnormalities are more evident. B. In early ARDS, the hypoxemia is less pronounced and the chest X-ray abnormalities are more evident. **C. In early ARDS, the hypoxemia is more pronounced and the chest X-ray abnormalities are less evident.** D. In early ARDS, the hypoxemia is less pronounced and the chest X-ray abnormalities are less evident. E. None of the above ## Footnote In early ARDS, the chest X-ray may be unrevealing, whereas the patient may present with a hypoxemia refractory to supplemental oxygen.

Answer 74

A. Insulin **B. Alkali therapy** C. Potassium D. Crystalloids E. Phosphate ## Footnote Bicarbonate therapy does not improve outcome in diabetic ketoacidosis, regardless of the severity of the acidosis.

Answer 75

A. metastasis. **B. hemangioblastoma.** C. glioma. D. central nervous system (CNS) lymphoma. E. pilocytic astrocytoma. ## Footnote The MRI shows an enhancing mural nodule with an associated cyst. Pathology shows highly vascular tissue and stromal cells characteristic of hemangioblastoma.

Answer 76

A. glioblastoma multiforme resection. B. radiation therapy. C. trauma. **D. encephalitis.** E. cerebral atrophy ## Footnote This T2-weighted MRI shows enhancement of the medial temporal lobe, a fi nding representative of herpes encephalitis.

Answer 77

A. deep peroneal nerve. **B. superfi cial peroneal nerve.** C. common peroneal nerve. D. sciatic nerve. E. tibial nerve. ## Footnote The superfi cial peroneal nerve innervates the peroneus longus and brevis, which evert the foot. A lesion of the deep peroneal nerve will aff ect ankle dorsifl exion. A lesion of the common peroneal or sciatic nerves will aff ect both ankle dorsifl exion and foot eversion. A sciatic nerve lesion will also affect foot fl exion and inversion.

Answer 78

A. the trunk. B. the branch. **C. the cord.** D. the root. E. None of the above ## Footnote The order of the brachial plexus structures is: root, trunk, division, cord, and branch.

Answer 79

A. Defi nitive clipping, temporary clipping, fi ssure splitting, dissection of M2 branch from dome B. Dissection of M2 branch from dome, fi ssure splitting, temporary clipping, defi nitive clipping **C. Fissure splitting, temporary clipping, dissection of M2 branch from dome, defi nitive clipping** D. Temporary clipping, fi ssure splitting, dissection of M2 branch from dome, defi nitive clipping E. Fissure splitting, dissection of M2 branch from dome, temporary clipping, defi nitive clipping ## Footnote Fissure splitting, temporary clipping, dissection of M2 branch from dome, and defi nitive clipping is the proper order of steps for clipping this diffi cult aneurysm.

Answer 80

A. Overexpression of CDK4 B. Deletion of p53 C. Mutation of retinoblastoma **D. Amplifi cation of K-ras** E. Overexpression of CDK6 ## Footnote Aberrations of genes coding for cell cycle regulatory proteins involved in the control of G1/S phase transition have been found in gliomas and include mutation or deletion of genes like p53, retinoblastoma, cyclic AMP-dependent kinase number 2 (CDKN2) A/B, and amplifi cation or overexpression of CDK4 and CDK6

Answer 81

A. 1p **B. 7** C. 9p D. 19q E. 22 ## Footnote Oligodendrogliomas may exhibit loss of chromosomal regions on 1p and 19q13. Other chromosomal regions that may be lost from oligodendrogliomas are 1p36, 9p, and 22. There may be evidence of increased numbers of chromosome 7.

Answer 82

A. Stellate ganglionectomy is used in the treatment of long QT syndrome. B. Anhydrosis occurs with ganglionectomy. C. Each intercostal nerve is connected to the sympathetic trunk by at least one white ramus and two gray rami. **D. The inferior hypogastric plexus lies in front of the promontory of the sacrum between the two common iliac arteries and is sometimes called the presacral nerve.** E. Sympathetically conveyed stimulus to the sweat glands is transmitted by acetylcholine. ## Footnote The superior hypogastric plexus lies in front of the promontory of the sacrum between the two common iliac arteries and is sometimes called the presacral nerve. It then divides into the right and left inferior hypogastric plexuses

Answer 83

A. Cingulate gyrus B. Hippocampus **C. Amygdala** D. Mammillary bodies E. Anterior nucleus of the thalamus

Answer 84

A. Cingulate gyrus B. Hippocampus **C. Amygdala** D. Mammillary bodies E. Anterior nucleus of the thalamus

Answer 85

A. Cingulate gyrus **B. Hippocampus** C. Amygdala D. Mammillary bodies E. Anterior nucleus of the thalamus ## Footnote The circuit of Papez includes the cingulate gyrus, hippocampus, mammillary bodies, and anterior nucleus of the thalamus. The lateral parabrachial nucleus of the amygdala receives inputs from the lateral olfactory tract, pyriform cortex, hypothalamus, paraventricular thalamus, and solitary tract nucleus. The medial septal nucleus projects to the fi mbria to the hippocampus.

Answer 86

A. Amyotrophic lateral sclerosis (ALS) B. Huntington’s disease C. Acute respiratory distress syndrome **D. AIDS** E. Multiple sclerosis ## Footnote AIDS is frequently associated with platelet disorders.

Answer 87

A. Congestive heart failure B. Pulmonary hypertension C. Renal failure **D. Microcephaly** E. Subarachnoid hemorrhage ## Footnote This MRI scan shows a vein of Galen malformation, which is usually associated with macrocephaly and hydrocephalus.

Answer 88

**A. The most common location is cervicothoracic.** B. The presence of a malignancy is a predisposing condition. C. There is increased incidence with epidural anesthesia. D. The incidence is 1:10,000 in the United States. E. There is increased incidence with drug abuse. ## Footnote The following MRI scan demonstrates an epidural abscess, which more frequently occur in the thoracolumbar region.

Answer 89

A. antibiotic therapy. **B. diuretics.** C. secretory diarrhea. D. diabetes mellitus. E. dilantin therapy ## Footnote Urinary magnesium loss is most prominent with loop diuretics.

Answer 90

A. Jugular B. Nodose **C. Pterygopalatine** D. Ciliary E. Superior cervical ## Footnote The superior salivatory nucleus sends axons via the nervus intermedius (VII) to the greater superfi cial petrosal nerve and then to the pterygopalatine ganglion.

Answer 91

A. Jugular B. Nodose C. Pterygopalatine **D. Ciliary** E. Superior cervical ## Footnote The oculomotor nerve (III) carries parasympathetics from Edinger–Westphal’s nucleus to the ciliary ganglion.

Answer 92

**A. Jugular** B. Nodose C. Pterygopalatine D. Ciliary E. Superior cervical ## Footnote Arnold’s nerve is a branch of the vagus nerve (X) supplying sensation to the dura of the posterior fossa.

Answer 93

A. Jugular B. Nodose C. Pterygopalatine D. Ciliary **E. Superior cervical** ## Footnote The deep petrosal nerve carries sympathetic fi bers from the internal carotid artery from the superior cervical ganglion.

Answer 94

A**. Loss of sensation to the outer ear** B. Loss of taste on the tongue surface C. Loss of salivatory secretion from a gland D. Weakness of the pharynx E. Strength of facial muscles ## Footnote Both nerves contain sensory inputs from the outer ear. The glossopharyngeal nerve controls elevation of the pharynx, whereas the facial nerve has no actions on pharyngeal muscles.

Answer 95

A. dopamine. **B. dobutamine.** C. neosinephrine. D. epinephrine. E. isoproterenol. ## Footnote Dobutamine is an adrenergic agent that does not cause peripheral vasoconstriction.

Answer 96

A. cyanide. **B. thiocyanate.** C. nitric oxide. D. thiosulfate. E. vitamin B12. ## Footnote Thiocyanate is cleared by the kidneys and its accumulation with the use of nitroprusside may cause a toxic syndrome.

Answer 97

A. Lesion 1 **B. Lesion 2** C. Lesions 1 and 2 D. None of the above ## Footnote Single punched out lesion without sclerotic edges is typical.

Answer 98

A. Lesion 1 **B. Lesion 2** C. Lesions 1 and 2 D. None of the above ## Footnote Eosinophilic granuloma may be a monostotic form of Langerhans cell histiocytosis.

Answer 99

A. Lesion 1 B. Lesion 2 **C. Lesions 1 and 2** D. None of the above ## Footnote In Paget’s disease, one may observe bony destruction (early) and sclerosis (late).

Answer 100

**A. Lesion 1** B. Lesion 2 C. Lesions 1 and 2 D. None of the above ## Footnote Albright’s syndrome is characterized by unilateral fi brous dysplasia, pigmented skin lesions, and precocious puberty

Answer 101

A. Lesion 1 B. Lesion 2 C. Lesions 1 and 2 **D. None of the above** ## Footnote Epidermoid has characteristic scalloped edges.

Answer 102

**A. Pneumocystis carinii pneumonia.** B. cytomegalovirus infections. C. toxoplasmosis. D. AIDS encephalitis. E. hydrocephalus. ## Footnote Pneumocystis carinii pneumonia is the most common cause of ICU admission in HIV-positive patients. It is usually treated with trimethoprim-sulfamethoxazole. Toxoplasma is the most common intracranial infection in HIV-positive patients

Answer 103

A. 9%. B. 0.9%. **C. 0.09%.** D. 0.009%. E. 0.0009% ## Footnote There are 9 cases of transmission for every 10,000 exposures. It is advisable to wear two pairs of gloves at surgery and to replace the top pair every 90 minutes of arduous surgery.

Answer 104

A. Chordoma B. Epidermoid C. Basilar tip aneurysm **D. Arachnoid cyst** E. Low-grade glioma ## Footnote The lesion most likely represents a lobulated arachnoid cyst. An aneurysm would not display such septations.

Answer 105

A. Golgi organelle B. Endoplasmic reticulum C. Both A and B **D. None of the above**

Answer 106

**A. Golgi organelle** B. Endoplasmic reticulum C. Both A and B D. None of the above ## Footnote The Golgi organelle possesses enzymes that are important in sugar and lipid chemistry of the eukaryotic cell.

Answer 107

A. Golgi organelle **B. Endoplasmic reticulum** C. Both A and B D. None of the above ## Footnote The endoplasmic reticulum is important in drug detoxifi cation; for example, adding hydroxyl groups to a lipid soluble–type compound makes it more water soluble and thus easier to remove from the body.

Answer 108

A. Golgi organelle **B. Endoplasmic reticulum** C. Both A and B D. None of the above ## Footnote Glycogen formation and breakdown occur in the endoplasmic reticulum; this is particularly important in the liver. Glycogen, a polymer of glucose-1-phosphate, represents a quick source of energy.

Answer 109

A. Golgi organelle B. Endoplasmic reticulum **C. Both A and B** D. None of the above ## Footnote Both the Golgi membranes closest to the nucleus (forming face) and the endoplasmic reticulum have a lamellar or tube-like membranous system. The Golgi membranes away from the nucleus (maturing face) are much more like plasma or organelle membranes.

Answer 110

A. Accumulates in neurons of the substantia nigra B. Found in the locus ceruleus **C. Made by tyrosinase** D. Is a cathecholamine waste product E. Chelates metal ions such as aluminum and iron ## Footnote True melanin is made by tyrosinase. Tyrosinase is an oxidase that is the rate-limiting enzyme for controlling the production of melanin. Neuromelanin is biosynthesized from L-dopa by tyrosine hydroxylase and aromatic acid decarboxylase.

Answer 111

**A. Nucleus accumbens** B. Pyriform cortex C. Solitary tract nucleus D. Locus ceruleus E. Prefrontal cortex ## Footnote The amygdala sends eff erents to the nucleus accumbens via the amygdalostriate fi bers. All others are aff erent sources to the amygdala.

Answer 112

A. Hypercapnia B. Acalculous cholecystitis C. Impaired oxygenation **D. Calculous cholecystitis E. Increased incidence of infectio**n ## Footnote Total parenteral nutrition has been known to cause hypercapnia due to excessive carbohydrates promoting carbon dioxide retention, impaired oxygenation due to fatty acid damage to pulmonary capillaries, and acalculous cholecystitis due to bile stasis secondary to absence of lipids in the proximal small bowel.

Answer 113

**A. May have elevated carcinoembryonic antigen (CEA) levels** B. Associated with Schiller–Duval bodies C. Derived from extraembryonic tissue D. Ingestion of food with fecal contamination E. Multiple sclerosis ## Footnote This scan shows a teratoma, which is associated with elevation of CEA levels.

Answer 114

A. Anti-Yo antibodies **B. Anti-Hu antibodies** C. Anti-Ri antibodies D. Antibodies to presynaptic voltage-gated receptors E. None of the above ## Footnote Paraneoplastic sensory neuropathy with anti-Hu antibodies is associated with limbic encephalitis (as seen on this MRI scan), seizures, epilepsia partialis continua, cerebellar ataxia, autonomic instability, myelitis with patchy weakness, and brainstem encephalitis.

Answer 115

**A. 40-year-old man with chronic encephalitis and Argyll Robertson pupils** B. 15-year-old hyperglycemic with severe lower extremity weakness C. 55-year-old man with spastic gait, weakness, and fasciculation in all extremities D. 4-year-old boy with bilateral symmetric proximal limb weakness E. 60-year-old female with spondylolisthesis at L5–S1 ## Footnote Tabes dorsalis presents 15 to 20 years after initial syphilitic infection and is characterized by dorsal root and posterior column involvement as seen on this myelin-stained cord section.

Answer 116

A. Respiratory acidosis B. Respiratory alkalosis **C. Both** D. Neithe

Answer 117

A. Respiratory acidosis **B. Respiratory alkalosis** C. Both D. Neithe

Answer 118

A. Respiratory acidosis **B. Respiratory alkalosis** C. Both D. Neithe

Answer 119

A. Respiratory acidosis B. Respiratory alkalosis C. Both D. Neithe ## Footnote Massive pulmonary embolism can result in signifi cant increased dead space and respiratory acidosis; on the other hand, smaller pulmonary embolisms can present with hyperventilation and hence respiratory alkalosis. Liver cirrhosis may also cause hyperventilation. Aminoglycosides can be presynaptic at the neuromuscular junction, causing respiratory acidosis.

Answer 120

A. Water diff usion is hindered anteriorly by the presence of a large tumor. **B. Connections between frontal and occipital lobe are impaired on the right side.** C. There are intersecting white matter tracts between the splenium and the fronto-occipital tracts. D. Tractography gives information about the direction of fl ow. E. Bundles of axons provide a barrier to perpendicular diff usion and a path for parallel diff usion along the orientation of the fi bers. ## Footnote Tractography is a procedure to demonstrate the neural tracts. It uses special techniques of magnetic resonance imaging (MRI), and computer postprocessing. Information about direction of fl ow is provided by tractography but not about connections between diff erent structures in the brain.

Answer 121

**A. It is associated with dermal sinus tract.** B. It secretes histamine. C. On histopathology, one may see densely packed elongated spindle cells in interlocking fascicles with a tendency toward palisading. D. All of the above are true. E. None of the above are true. ## Footnote The scan shows an atypical dermoid cyst. Dermoid cysts can contain fat which gives them high signal intensity on T1-weighted sequences. A congenital dermal sinus tract can be associated with a dermoid cyst. Choice B is associated with paraganglioma. Choice C is representative of Antoni A pattern in acoustic neuromas.

Answer 122

A. Abnormality in protein merlin B. Posterior capsular lens opacities **C. Intertriginous freckling** D. Pigmented area of skin with excess hair E. May be associated with an autosomal disorder located on chromosome 22 ## Footnote The MRI scan shows bilateral acoustic neuromas, pathognomonic of neurofi - bromatosis type 2. Intertriginous freckling is a feature of neurofi bromatosis type 1.

Answer 123

A. Amphotericin B B. Lithium C. Toluene **D. Carbonic anhydrase inhibitors** E. Cyclamat ## Footnote Carbonic anhydrase inhibitors (e.g., acetazolamide) can cause proximal renal tubular acidosis.

Answer 124

A. Hydrocortisone sodium succinate (Solucortef) for glucocorticoid emergencies B. Fludrocortisone (Florinef) for mineralocorticoid emergencies **C. Methylprednisolone (Solumedrol) for glucocorticoid emergencies** D. Cortisone acetate for glucocorticoid emergencies E. Intravenous fl uids ## Footnote Methylprednisolone is not recommended in the treatment of emergent Addisonian crisis. Long-term use of methylprednisolone can cause Addisonian crisis if stopped abruptly and not tapered.

Answer 125

A. furosemide. B. phenytoin. C. lithium. **D. All of the above** E. None of the above ## Footnote All three medications have been shown to help in the treatment of syndrome of inappropriate antidiuretic hormone (SIADH), with variable side-eff ect patterns.

Answer 126

**A. B and O plasma types** B. B and AB plasma types C. B plasma type only D. All of the above E. None of the above ## Footnote Plasma types B and O can be safely transfused in a patient with blood type B because both of these plasma types do not contain antibodies against B type blood.

Answer 127

A. Increased arteriolar tone B. Increased in peripheral vascular resistance C. Cool molten skin D. Hypertension **E. Bradycardia** ## Footnote Neurogenic shock is characterized by dilatation of arterioles and venules and decreased peripheral vascular resistance. It also presents with warm, dry skin, bradycardia, and hypotension.

Answer 128

**A. urinary tract infection.** B. pneumonia. C. wound infection. D. gastrointestinal infection. E. pressure ulcers. ## Footnote The urinary system is the most commonly involved in patients with gram-negative septicemia, followed by the respiratory system.

Answer 129

A. Latex agglutination test B. Tissue culture assay for cytotoxin **C. Stool culture** D. Stool microscopy E. Polymerase chain reaction (PCR) analysis ## Footnote Stool culture has a sensitivity of > 90% in diagnosing C. diffi cile enterocolitis. Both latex agglutination and tissue culture assay for cytotoxin have a sensitivity of ~ 70%. Stool microscopy is not used to diagnose this condition.

Answer 130

A. Isofl urane B. Enfl urane C. Thiopental **D. Halothane** ## Footnote Halothane increases cerebral blood fl ow the most followed by enfl urane and isofurane.

Answer 131

A. Isofl urane B. Enfl urane **C. Thiopental** D. Halothane ## Footnote Thiopental decreases intracranial pressure. The other listed agents will increase intracranial pressure.

Answer 132

**A. Isofl urane B. Enfl urane** C. Thiopental D. Halothane ## Footnote Isofurane has been shown to cause tachycardia transiently in children.

Answer 133

A. Isofl urane **B. Enfl urane** C. Thiopental D. Halothane ## Footnote Enfurane increases systemic vascular resistance. Isofurane will decrease it.

Answer 134

A. Neurofi bromatosis type 1 (NF1) B. Neurofi bromatosis type 2 (NF2) **C. Both A and B** D. None of the above ## Footnote Both NF1 and NF2 have autosomal dominant patterns of inheritance.

Answer 135

A. Neurofi bromatosis type 1 (NF1) B. Neurofi bromatosis type 2 (NF2) C. Both A and B **D. None of the above** ## Footnote Retinal hemangiomas are associated with von Hippel–Lindau disease.

Answer 136

**A. Neurofi bromatosis type 1 (NF1)** B. Neurofi bromatosis type 2 (NF2) C. Both A and B D. None of the above ## Footnote Iris hamartomas or Lisch nodules are seen in NF1.

Answer 137

A. Neurofi bromatosis type 1 (NF1) B. Neurofi bromatosis type 2 (NF2) C. Both A and B **D. None of the above** ## Footnote Neurofi bromatosis type 5 is the segmental type.

Answer 138

A. The neck of the aneurysm is unobstructed. B. The neck of the aneurysm is obstructed by the dome. C. The neck of the aneurysm is obstructed by the optic nerve. D. The neck of the aneurysm is obstructed by the carotid artery. **E. The neck of the aneurysm is obstructed by the anterior clinoid process.** ## Footnote The anterior clinoid process is most likely going to have to be drilled to gain access to the neck of this aneurysm.

Answer 139

A. Superior cerebellar artery, abducens nerve B. Anterior inferior cerebellar artery, trochlear nerve **C. Superior cerebellar artery, trochlear nerve** D. Anterior inferior cerebellar artery, abducens nerve E. Superior cerebellar artery, oculomotor nerve ## Footnote The superior cerebellar artery is seen in neurovascular confl ict with the trigeminal nerve. More proximally though, the artery is seen near the tentorium which is in very close relation to the trochlear nerve.

Answer 140

**A. Supracerebellar infratentorial approach for cyst resection** B. Midline frontal approach for cyst resection C. Third ventriculostomy D. Midline frontal approach for cyst decompression E. Endoscopic cyst resection ## Footnote The posterior approach is unfavorable in this case since the angle of the tentorium is very steep and would necessitate severe retraction on the cerebellum. In addition, the posterior approach presents a very narrow corridor limited by the internal cerebral veins.

Answer 141

A. Meperidine B. Thyroid hormones C. Fluconazole **D. Papaverine**

Answer 142

A. Meperidine B. Thyroid hormones **C. Fluconazole** D. Papaverine

Answer 143

A. Meperidine **B. Thyroid hormones** C. Fluconazole D. Papaverine

Answer 144

A. Meperidine B. Thyroid hormones **C. Fluconazole** D. Papaverine

Answer 145

**A. Meperidine** B. Thyroid hormones C. Fluconazole D. Papaverine ## Footnote Papaverine inhibits antiparkinsonian eff ect of levodopa. Fluconazole increases serum phenytoin and decreases warfarin metabolism. Thyroid hormones enhance clotting factor catabolism. Meperidine may cause hypertension, rigidity, and excitation when used with monoamine oxidase inhibitors.

Answer 146

A. Epinephrine B. Isofl urane C. Halothane **D. Thiopental** E. All of the above ## Footnote The other medications will tend to further exacerbate the symptoms of malignant hyperthermia.

Answer 147

A. Lung carcinoma B. Breast carcinoma **C. Colon carcinoma** D. Renal cell carcinoma E. Prostate carcinoma ## Footnote Colon carcinoma has a predilection to metastasize to the liver and other visceral organs.

Answer 148

A. Brachiocephalic artery **B. Axillary artery** C. Subcalvian artery D. Brachial artery E. Internal carotid artery ## Footnote The lateral, medial, and posterior cords carry their names in relation to the second and third segments of the axillary artery

Answer 149

A. Traumatic B. Degenerative **C. Isthmic** D. Pathological E. Dysplastic ## Footnote This type of spondylolisthesis is caused by a defect in the pars interarticularis, occurs in 90% of cases at L5–S1, and is usually bilateral and more common in males.

Answer 150

A. Homonymous hemianopia B. Upper homonymous quadrantanopia C. Bilateral central scotomas **D. Monocular loss of vision with contralateral upper outer quadrantanopia** E. Lower homonymous quadrantanopia ## Footnote The superior outer quadrantanopia is due to involvement of Willebrand’s knee.

Answer 151

**A. Homonymous hemianopia** B. Upper homonymous quadrantanopia C. Bilateral central scotomas D. Monocular loss of vision with contralateral upper outer quadrantanopia E. Lower homonymous quadrantanopia

Answer 152

**A. Homonymous hemianopia** B. Upper homonymous quadrantanopia C. Bilateral central scotomas D. Monocular loss of vision with contralateral upper outer quadrantanopia E. Lower homonymous quadrantanopia

Answer 153

A. Homonymous hemianopia B. Upper homonymous quadrantanopia **C. Bilateral central scotomas** D. Monocular loss of vision with contralateral upper outer quadrantanopia E. Lower homonymous quadrantanopia

Answer 154

A. Homonymous hemianopia **B. Upper homonymous quadrantanopia C. Bilateral central sco**tomas D. Monocular loss of vision with contralateral upper outer quadrantanopia E. Lower homonymous quadrantanopia ## Footnote Meyer’s loops are interrupted causing a homonymous superior quadrantanopia.

Answer 155

A. Homonymous hemianopia B. Upper homonymous quadrantanopia C. Bilateral central scotomas D. Monocular loss of vision with contralateral upper outer quadrantanopia **E. Lower homonymous quadrantanopia**

Answer 156

A. Struthers ligament **B. Arcade of Struthers** C. Arcade of Frohse D. Guyon’s canal ## Footnote Ulnar nerve entrapment can occur at the arcade of Struthers.

Answer 157

A. Struthers ligament B. Arcade of Struthers **C. Arcade of Frohse** D. Guyon’s canal ## Footnote Extensor carpi ulnaris palsy may be due to a constriction at the arcade of Frohse.

Answer 158

**A. Struthers ligament** B. Arcade of Struthers C. Arcade of Frohse D. Guyon’s canal ## Footnote The brachial artery along with the median nerve pass under the Struthers ligament.

Answer 159

**A. Reservoir sign** B. Early morning headache C. Meningitis D. Visual defi cits E. Sinus congestion ## Footnote Reservoir sign, or intermittent large volume CSF rhinorrhea, is a relatively uncommon occurrence in patients with sphenoid sinus encephaloceles. The leakage of fl uid is usually insidious.

Answer 160

A. Radicular pain **B. Scoliosis** C. Weakness D. Atrophy E. None of the above ## Footnote Scoliosis occurs in 66%, whereas radicular pain occurs in 50% of patients.

Answer 161

A. Radicular pain B. Scoliosis **C. Weakness** D. Atrophy E. Cardiac ischemia ## Footnote Weakness occurs in 51%, whereas radicular pain occurs in 44% and scoliosis in 36% of patients.

Answer 162

A. 1, 2, and 3 B. 1 and 3 C. 2 and 4 **D. 1, 2, 3, and 4** E. 2 and 3 ## Footnote All are valid mechanisms.

Answer 163

A. It is caused by frequent repetitive motion at the wrist. B. Pain and tenderness occurs in the wrist near the thumb. C. The Finkelstein test is positive. **D. Nerve conduction velocities are decreased.** E. There is diffi culty with gripping. ## Footnote De Quervain’s syndrome is characterized by tenosynovitis of the abductor pollicis longus and extensor pollicis brevis muscles. The nerve conduction velocities are typically normal.

Answer 164

**A. Fourth ventricle roof** B. Fourth ventricle fl oor C. Both of the above D. None of the above

Answer 165

A. Fourth ventricle roof **B. Fourth ventricle fl oor** C. Both of the above D. None of the above

Answer 166

A. Fourth ventricle roof **B. Fourth ventricle fl oor** C. Both of the above D. None of the above

Answer 167

A. Fourth ventricle roof **B. Fourth ventricle fl oor** C. Both of the above D. None of the above ## Footnote The roof of the fourth ventricle contains both the superior and inferior medullary veli. The fl oor of the fourth ventricle is formed by the rhomboid fossa, which contains the facial colliculus and hypoglossal trigone.

Answer 168

A. Surgical evacuation B. Systemic antibiotics **C. Head wrapping** D. Radiation therapy E. VP shunt ## Footnote The scan shows a cephalohematoma which is treated with head wrapping and possibly needle aspiration.

Answer 169

A. Basal plate **B. Notochord** C. Neural crest cells D. Somites E. Endoderm ## Footnote The notochord induces the formation of the neural plate and neural tube. The neural tube regions give rise to the alar and the basal plates. The alar plate contains sensory/integrative nerve cell bodies of the brain and spinal cord and gives rise to the dorsal horns. The basal plate contains motor neurons of the brain and spinal cord and gives rise to the ventral horn.

Answer 170

A. Cheyne–Stokes respiration B. Apneustic respiration **C. Ataxic respiration** D. Central neurogenic hyperventilation

Answer 171

A. Cheyne–Stokes respiration B. Apneustic respiration C. Ataxic respiration **D. Central neurogenic hyperventilation**

Answer 172

A. Cheyne–Stokes respiration **B. Apneustic respiration** C. Ataxic respiration D. Central neurogenic hyperventilation

Answer 173

**A. Cheyne–Stokes respiration** B. Apneustic respiration C. Ataxic respiration D. Central neurogenic hyperventilation ## Footnote Cheyne–Stokes respiration occurs with diencephalon lesions. Central neurogenic hyperventilation occurs with midbrain lesions. Apneustic respiration occurs with pontine lesions. Ataxic respiration occurs with medulla lesions.

Answer 174

A. Middle cerebellar peduncle **B. Inferior cerebellar peduncle** C. Nodulus D. Flocculus E. None of the above

Answer 175

**A. Middle cerebellar peduncle** B. Inferior cerebellar peduncle C. Nodulus D. Flocculus E. None of the above ## Footnote The middle cerebellar peduncle contains only aff erent fi bers.

Answer 176

A. It connects the basilar artery between the superior cerebellar and the anterior inferior cerebellar arteries by passing through the petrous bone. **B. It connects the basilar artery by passing through the internal auditory meatus.** C. It is present in 0.1% of the population. D. There is increased frequency of arteriovenous malformations. E. It is the second most common persistent fetal circulation. ## Footnote The angiogram demonstrates a primitive trigeminal artery. The persistent acoustic artery passes through the internal auditory meatus.

Answer 177

A. 75% B. 50% C. 25% D. 2% **E. 0.3%** ## Footnote The overall rate of HIV transmission from a single percutaneous exposure to HIV-infected blood with high viral load is of the order of 0.3%. Postexposure prophylaxis (PEP) has been shown in one study to reduce this rate by 80%. It is important to check viral loads of patients prior to elective surgery to keep operating room staff and surgeons safe.

Answer 178

A. 75% B. 50% C. 25% **D. 2%** E. 0.3% ## Footnote Epidemiological studies of health care workers exposed to hepatitis C virus through a needlestick or other percutaneous injury have found that the incidence of infection averages 1.8% per injury.

Answer 179

A. 75% B. 50% C. 25% **D. 2%** E. 0.3% ## Footnote The risk of acquiring hepatitis B from a needlestick when the source was hepatitis B antigen-positive ranges from approximately 2 to 40%, depending on the source’s level of viremia

Answer 180

A. tentorial subdural hemorrhage. B. subarachnoid hemorrhage. C. normal CT scan. **D. dural sinus thrombosis**. E. arteriovenous fi stula. ## Footnote The scan shows straight sinus thrombosis.

Answer 181

**A. There is an autosomal recessive inheritance pattern.** B. In 20% of cases there is no hyperthermia accompanying the muscle rigidity. C. It may be associated with autonomic instability. D. It may be caused by muscle relaxants. E. A mutation in the ryanodine receptor is related to malignant hyperthermia (MH). ## Footnote Malignant hyperthermia has an autosomal dominant inheritance pattern. It may be caused by halothane or succinylcholine. Body temperature increase is about 1°C every 5 minutes. It is treated with dantrolene and discontinuation of the anesthetic.

Answer 182

A. Cerebral aneurysm B. Arteriovenous malformation C. Endocrinopathy **D. Venous angioma** E. Progressive supranuclear palsy ## Footnote The scan shows a cavernous angioma occurring at the thalamocaudate recess. These lesions may be associated with venous angiomas.

Answer 183

**A. Type 1 Modic changes** B. Type 2 Modic changes C. Yellow marrow replacement D. Hypovascularization of the end plates E. None of the above ## Footnote Type 1 Modic changes show decreased intensity on T1-weighted images and increased intensity on T2-weighted images. Type 2 Modic changes show increased intensity on T1-weighted images and isointense signal intensity on T2-weighted images. Histopathology on type 1 changes demonstrates disruption and fi ssuring of the end plates and vascularized fi brous tissue. On type 2 changes, yellow marrow replacement is seen. Type 1 changes may convert to type 2 after a few years. There appears to be a spectrum of vertebral body marrow changes associated with degenerative disk disease.

Answer 184

A. Ataxia B. Ipsilateral hearing defi cits C. Contralateral temperature sensation loss **D. Lateral rectus palsy** E. Balance problems ## Footnote The lesion represents a syrinx at the level of the inferior cerebellar peduncle. The abducens nerve arises at a higher level and is less likely to be aff ected. The anterolateral system courses ventral to the lesion and may be aff ected. The vestibulocochlear nucleus is also located at this level.

Answer 185

**A. Ketamine** B. Thiopental C. Halothane D. Enfl urane E. Isofl urane ## Footnote Ketamine raises systemic arterial blood pressure but not necessarily the perfusion in hypovolemic states. In hypotensive states of short duration from endotoxin treatment, it improved the hemodynamics by augmenting the perfusion and the systemic pressur

Answer 186

A. Froin’s syndrome B. Positive Queckenstedt’s sign **C. Male predominance with peak age in mid-40s** D. Cellular type E. Neoplastic disease ## Footnote The scans show a typical intramedullary ependymoma with blockage of CSF fl ow, which is associated with Froin’s syndrome (clotting and xanthochromia in the CSF) and Queckenstedt’s sign, which is failure of jugular vein compression to increase CSF. The cervical type of intramedullary ependymoma is usually of the cellular type, more frequent in females in the mid-40s.

Answer 187

A. Syringobulbia **B. Elevated serum angiotensin-converting enzyme** C. Aqueductal stenosis D. Hallervorden–Spatz disease E. Subdural hematoma ## Footnote The MRI set demonstrates basilar meningitis with a trapped fourth ventricle and foramina of Luschka which occurs in sarcoidosis. Elevated angiotensin-converting enzyme levels is also a feature of this disease.

Answer 188

A. Proximal renal tubular function **B. Distal renal tubular function** C. Kidney glomerular function D. None of the above

Answer 189

A.** Proximal renal tubular function** B. Distal renal tubular function C. Kidney glomerular function D. None of the above

Answer 190

A. Proximal renal tubular function **B. Distal renal tubular function** C. Kidney glomerular function D. None of the above

Answer 191

A. Proximal renal tubular function B. Distal renal tubular function **C. Kidney glomerular function** D. None of the above ## Footnote The proximal tubule plays a role in secreting organic acids and reabsorbing Na+ , water, glucose, bicarbonate, amino acids, and phosphate. The distal tubule’s role involves secretion of H+ and K+ and reabsorption of Na+ and Cl. The glomerular fi ltration rate is at its peak in young adulthood, at about 120 mL/min.

Answer 192

**A. The most signifi cant factor associated with recurrence is extent of resection.** B. A factor associated with recurrence is histology. C. MIB-1 LI >7% is associated with a low likelihood of recurrence. D. Malignant transformation to carcinoma frequently occurs. E. Recurrence is dependent on the presence of intracytoplasmic inclusions. ## Footnote The images show craniopharyngioma. The most signifi cant factor associated with recurrence is extent of resection. Histology type is not correlated with frequency of recurrence. MIB-1 LI > 7% is associated with a higher likelihood of recurrence. Malignant transformation to carcinoma exceptionally occurs.

Answer 193

**A. Central neurocytoma** B. Oligodendroglioma C. Ependymoma D. Endodermal sinus tumor E. Yolk sac tumor ## Footnote Central neurocytoma appears like oligodendroglioma histologically but is positive for synaptophysin on immunohistochemistry

Answer 194

**A. Operculum** B. Sylvian fi ssure C. Precentral sulcus D. Rolandic fi ssure E. None of the above ## Footnote The parietal operculum is caudal to the inferior frontal gyrus. Directly inferior to the inferior frontal gyrus is the sylvian fi ssure.

Answer 195

A. 1% per year B. 2% per year C. 4% per year **D. 13% per year** E. 26% per year

Answer 196

A. Nitroglycerine binds the surface of endothelial cells. B. Nitroglycerine undergoes two chemical reductions to form nitric oxide. **C. Nitric oxide promotes the formation of cyclic guanosine triphosphate.** D. Nitric oxide moves out of the endothelial cell into adjacent smooth muscle cell. E. Nitric oxide increases cAMP in smooth muscle cells. ## Footnote Nitric oxide promotes the formation of cyclic guanosine monophosphate (cGMP).

Answer 197

A. 1% per year **B. 2% per year** C. 4% per year D. 13% per year E. 26% per year

Answer 198

A. 1% per year B. 2% per year **C. 4% per year** D. 13% per year E. 26% per year ## Footnote Symptomatic 70–90% stenosis of the carotid on angiogram carries a risk of stroke of 26% over 2 years, or 13% per year. Asymptomatic 70–90% stenosis of the carotid on angiogram carries a risk of stroke of 11% over 5 years, or 2% per year. Postcarotid endarterectomy in preoperative symptomatic 70–90% stenosis of the carotid on angiogram carries a risk of stroke of 9% over 2 years, or 4.5% per year.

Answer 199

**A. Amphotericin** B. Angiotensin-converting enzyme inhibitors C. Aspirin D. Cyclosporin E. Heparin ## Footnote All the other medications cause hyperkalemia.

Answer 200

A. 2 hours B. 2 days **C. 12 days** D. 22 days E. 32 days ## Footnote Intracellular methemoglobin appears as hyperintense on T1 and hypointense on T2, and is usually present from 3 days to 2 weeks after a hemorrhage. Extracellular methemoglobin appears after 2 weeks and is hyperintense on T1 and T2. The images show hyperintensity on T1 and iso- to hypointensity on T2, consistent with intracellular methemoglobin toward the end of 2 weeks following the hemorrhage.

Answer 201

A. Ethanol B. Acetone **C. Methanol** D. Ethylene glycol (antifreeze) E. Acethaldehyde

Answer 202

A. Ethanol B. Acetone C. Methanol **D. Ethylene glycol (antifreeze)** E. Acethaldehyde ## Footnote Ethanol has a molecular weight of 46 and is lethal at levels > 350 mg/dL (least lethal). Methanol has the lowest molecular weight (32) and is the least lethal out of the three remaining substances (80 mg/dL needed for lethality). Ethylene glycol has the highest molecular weight (61) and is the most lethal (only 21 mg/dL needed to cause death).

Answer 203

A. whole blood. B. fi brinogen. C. platelets. D. packed red blood cells. **E. cryoprecipitate.** ## Footnote Cryoprecipitate is used to treat acute blood loss in von Willebrand’s disease.

Answer 204

A. Ipsilateral Horner’s syndrome B. Downbeat nystagmus C. Loss of abdominal cutaneous refl ex **D. Neurogenic bladder** E. Extremity weakness ## Footnote The scan shows a foramen magnum tumor. All the stated clinical fi ndings are associated with this tumor location; however, neurogenic bladder tends to occur very late.

Answer 205

A. Saddle bilateral sensory defi cit B. Symmetric motor loss C. Loss of ankle jerk **D. Autonomic symptoms that occur late** E. Urinary retention and atonic anal sphincter that cause overfl ow urinary incontinence and fecal incontinence ## Footnote Autonomic symptoms occur early.

Answer 206

**A. Sensory dissociation** B. Asymmetric motor loss C. Late autonomic symptoms D. Absence of ankle jerk and knee jerk E. Numbness that tends to be more localized to saddle area ## Footnote There is no sensory dissociation. Red fl ags for cauda equina syndrome are erection diffi culty, extreme back pain, and groin numbness. An MRI scan taken in a lying down position may not display the stenosis so a standing MRI scan, if available, is necessary. These patients should be sent to an emergency room at once for stat MRI. In the setting of groin numbness only with back pain, urodynamics and Foley catheter may not be absolutely necessary. One should not delay care of these patients to the point in time where urodynamics become necessary. If these patients present in the emergency room, they should not be sent home to follow up electively, they should be decompressed and stabilized on that hospital admission.

Answer 207

A. Brachiocephalic artery B. Right subclavian artery C. Left subclavian artery D. Right carotid artery **E. Left carotid artery** ## Footnote The aorta gives off , from proximal to distal, the brachiocephalic trunk, left common carotid, and left subclavian arteries.

Answer 208

A. Convergence defi cit **B. Adduction defi cit** C. Horizontal gaze palsy D. Vertical gaze palsy E. Parinaud’s syndrome ## Footnote With bilateral internuclear ophthalmoplegia there is an adduction defi cit in both eyes. This is observed in bilateral lesions of the medial longitudinal fasciculus.

Answer 209

**A. Acetylcholine** B. Noradrenaline C. Dopamine D. GABA E. Glutamate ## Footnote Preganglionic sympathetic fi bers secrete acetylcholine

Answer 210

A. Acetylcholine **B. Noradrenaline** C. Dopamine D. GABA E. Glutamate ## Footnote The locus ceruleus contains noradrenaline.

Answer 211

A. Acetylcholine **B. Noradrenaline** C. Dopamine D. GABA E. Glutamate ## Footnote The periaqueductal gray contains the locus ceruleus. It also contains the dorsal raphe nucleus and enkephalin-releasing neurons.

Answer 212

A. 1, 2, and 3 are true. B. 1 and 3 are true. **C. 2 and 4 are true.** D. Only 4 is true. E. All of the above are true. ## Footnote Both Wernicke’s and global aphasias display repetition and comprehension defi cits.

Answer 213

A. Regional hypotension B. CBF below critical level **C. Atrial fi brillation** D. Cardiac arrest E. Anaphylaxis ## Footnote Watershed infarcts occur in areas between the three major vascular territories and are due to a global decrease in cerebral perfusion.

Answer 214

A. Bernasconi’s artery B. Persistent stapedial artery C. Heubner’s artery **D. McConnell’s artery** E. Vidian artery ## Footnote McConnell’s capsular artery arises directly from the intracavernous carotid artery.

Answer 215

A. Thirty to fi fty percent of patients are febrile. B. Spontaneous fusion of vertebral bodies may occur. C. Haemophilus infl uenzae may be a causative organism in juvenile cases. **D. Radionuclide scans have a relatively low sensitivity.** E. There is increased incidence with intravenous drug abuse. ## Footnote Radionuclide scans have a relatively high sensitivity in detecting diskitis.

Answer 216

**A. Increased neuronal density** B. Increased metabolism C. Increased excitatory neurotransmission D. Necrosis E. None of the above ## Footnote N-acetylaspartate (NAA), found in neurons and axons, is used as a neuronal marker. A reduction in the NAA signal refl ects neuronal loss or injury, as seen in many brain pathologies including neurodegenerative diseases. NAA peaks typically represent increased neuronal density. Moderately increased choline peaks and reduced NAA signal intensities indicate low-grade gliomas; highgrade tumors are characterized by distinctly higher choline peaks and even lower NAA signals, and the presence of lipid signals indicates tissue necrosis.

Answer 217

A. Mucor **B. Aspergillus** C. Coccidioides D. E. histolytica E. Virus

Answer 218

A. Perivascular invasion B. Hemorrhagic infarcts C. Paranasal sinus mycetoma **D. Caseating granulomas** E. Increased prevalence with the use of chemotherapy and corticosteroids ## Footnote Aspergillus has a predilection for the basal ganglia in some cases. It tends to invade blood vessels, cause hemorrhagic infarcts, and may cause formation of paranasal sinus mycetoma. Coccidioides can cause meningitis and caseating granulomas. The diagnosis of early cerebral infarction in a patient considered at risk for invasive aspergillosis, even without overt pulmonary disease, is an indication to institute aggressive antifungal therapy

Answer 219

A. Intravenous antibiotics B. Surgical resection **C. Systemic chemotherapy and whole-brain radiation** D. Ommaya reservoir placement and intrathecal chemotherapy E. Ventriculoperitoneal shunt ## Footnote The MRI scan demonstrates leptomeningeal gliomatosis associated with a high-grade glioma in the left occipital area. The best therapeutic option, given the diff use nature of the disease is, initially, chemotherapy and radiation.

Answer 220

A. Stapedius B. Tensor veli palatini **C. Stylopharyngeus** D. Posterior belly of digastric E. None of the above ## Footnote The glossopharyngeal nerve innervates the stylopharyngeus.

Answer 221

C ## Footnote Functional residual capacity (D) does not change during exercise and is usually 2.4L. It is the sum or residual volume (C) and expiratory reserve volume (ERV), or the diff erence between vital capacity (B) and ERV. Vital capacity (VC) is usually around 4.4 to 5 L and is measured by having the patient inhale profoundly and exhale fully into a spirometer. Residual volume cannot be measured directly and needs to be calculated as a percentage of exhaled versus inhaled 10% helium-containing solution.

Answer 222

A. Elevated N-acetylaspartate (NAA) peak and normal choline (Chol) and creatine (Cr) peaks B. Elevated Cr peak and decreased Chol and NAA peaks **C. Increased Chol:Cr ratio and decreased NAA peak** D. Increased Cr:Chol ratio and decreased NAA peak E. All of the above

Answer 223

A. Increased astrocytic density at point 3 as compared with point 1 **B. Presence of tumor cells at point 3** C. Presence of necrosis at point 3 D. Increased metabolism at point 3 E. All of the above ## Footnote Point 3 on the MR spectroscopy represents an area of tumor (glioma), which shows an elevated Chol:Cr ratio and a decreased NAA peak. Other changes seen in tumors may be decreased Chol and elevated NAA.

Answer 224

A. Oxygen delivery **B. Oxygen uptake** C. Oxygen extraction ratio D. Oxygen content E. None of the above ## Footnote The formula represents oxygen uptake.

Answer 225

A. Cc O2 − Ca O2 / Cv O2 − Ca O2 B. (Cc O2 − Cv O2)/(Cc O2 − Ca O2) C. Cc O2 − Ca O2/Cc O2 − Cv O2 **D. (Cc O2 − Ca O2)/(Cc O2 − Cv O2)** E. (Cc O2 − Ca O2)/(Cv O2 − Ca O2) ## Footnote (Cc O2 − Ca O2 )/(Cc O2 − Cv O2 ) = Qs/Qt = shunt fraction.

Answer 226

**A. Q = Pπr4/8VL** B. Q = 8PL/Vπr4 C. Q = Vπr4/8PL D. Q = 8Vπr4/PL E. None of the above ## Footnote Q = Pπr4/8VL

Answer 227

A. immediately in the ER. B. before a CT scan. **C. in the operating room.** D. before antibiotics are given. E. after the patient has been stabilized. ## Footnote If the pencil is pulled from his eye, there should be adequate measures to stop bleeding and irrigate the wound. This can be properly performed only in the operating room. This patient should be managed with antiepileptic medication, broad-spectrum antibiotics, CT scan, immediate open surgical debridement, and follow-up MRI in about a week.

Answer 228

A. Single-level anterior cervical diskectomy and fusion (ACDF) B. Two-level ACDF C. Posterior decompression **D. Cervical corpectomy and fusion** E. Three-level ACDF ## Footnote The patient has ossifi cation of the posterior longitudinal ligament (OPLL), which is best managed with cervical corpectomy and fusion. It cannot be stressed enough that severe cervical compression seen on MRI should be followed with a CT scan to get an idea of the osteophytes and/or OPLL near the cord.

Neurosurgery Practice QnA 2nd Part Flashcards

(255 cards)