SANS 4 Flashcards
(204 cards)
1
Q
For which aspect of pain is the dorsal anterior cingulate cortex (dACC) responsible?
A
- Psychosomatic
- Affective
- Somatosensory
- Neurogenic
- Nociceptive
2
Q
A 14-year-old female presents with progressive difficulty writing. An MRI (figure) shows multiple nodular areas running along the cervical nerve roots and brachial plexus. Examination of her eyes also shows iris harmartomas. What is the most likely diagnosis?
A
- Ataxia-telangiectasia
- Neurofibromatosis-2
- Tuberous sclerosis
- Neurofibromatosis-1
- Von Hippel-Lindau
3
Q
A 15 year-old male presents with severe low back pain. The pain responds poorly to acetaminophen but responds well to aspirin. CT demonstrates a 1.5 cm dense lytic lesion with a calcified nidus and circumferential sclerosis (figure). What is the diagnosis?
A
- Oteoblastoma
- Osteoid osteoma
- Hemangioma
- Osteochondroma
- Fibrous dysplasia
4
Q
Compared to posterior surgery, what risk is associated with Anterior cervical surgery for OPLL?
A
- CSF leak
- OPLL growth
- Kyphosis
- C5 root palsy
- Shoulder girdle pain
5
Q
A 48-year-old man who has been managed on a stable dose of intrathecal morphine presents with sudden onset altered mental status, sweating, severe pain, and diarrhea. His airway and breathing are stable. What is the best initial diagnostic workup at this point?
A
- Blood and urine cultures
- Assessment by the Gastroenterology service
- Assessment by the Addiction Medicine service
- Plain X-rays of the pump system
- Head CT
6
Q
A 15-year-old presents with an incidental finding (figure). What is the most appropriate management strategy?
A
- Surgical resection of the mural nodule and entire cyst wall.
- Surgical resection of the mural nodule
- Drainage of the cyst to relieve mass effect.
- Surgical resection of the mural nodule with a 1 cm margin.
- Surgical resection of the mural nodule with biopsy proven, tumor positive, cyst wall
7
Q
A 68 year-old man presents to the office with neck pain and right upper extremity paresthesias. He reports mild difficulty with buttoning his shirt and initiating micturition. He has decreased sensation in the right first and second digit and loss of the right biceps reflex. He also has mild loss of balance with tandem gait. His cervical spine MRI is depicted (Fig 1). What is the most appropriate management?
A
- Right C5-C6 transforaminal epidural injection
- Surgical decompression of the cervical spinal cord
- Electrodiagnostic studies (EMG/NCV) to assess for carpal tunnel syndrome
- Structured physical therapy with gait training
- Medrol dose pack and soft cervical collar for 6 months
8
Q
What is the most likely vessel to make pathological contact with the glossopharyngeal nerve causing glossopharyngeal neuralgia?
A
- Posterior choroidal artery
- Posterior cerebral artery
- Basilar artery
- Posterior inferior cerebellar artery
- Superior cerebellar artery
9
Q
A 39-year-old female presents with subarachnoid hemorrhage. Her angiogram is shown. What is the most likely diagnosis?
A
- Blister aneurysm
- Fusiform aneurysm
- Infundibulum
- Supraclinoid ICA dissection
- Saccular Aneurysm
10
Q
According to the International Study of Unruptured Intracranial Aneurysms (ISUIA), what is the risk of rupture of a cavernous carotid artery aneurysm (< 7 mm) in a patient with a history of previous aneurysmal subarachnoid hemorrhage?
A
- 4%
- 3%
- 2%
- 1%
- 0%
11
Q
Which vein is indicated by the arrow in the figure?
A
- Thalmostriate vein
- Basal vein of Rosenthal
- Vein of Trolard
- Internal Cerebral vein
- Vein of Galen
12
Q
Which characteristic best distinguishes malignant from benign nerve sheath tumors?
A
- Cystic changes within the tumor
- Central T2 hypointensity (“target sign”) within the tumor
- Intensity of contrast enhancement in the tumor
- Extralesional T2 hyperintensity around the tumor
- Location of the tumor
13
Q
A 40 year-old male presents with a 3-year history of uncontrollable writhing movement of all four extremities and recent memory decline. He has a family history of early-onset dementia and suicide in male relatives. MRI reveals atrophy of the caudate nucleus bilaterally. What developmental abnormality would you expect to find?
A
- Parkin gene mutation
- Chromosome 14-21 translocation
- Expanded GAA repeats
- FMR1 gene mutation
- Expanded CAG repeats
14
Q
Approximately what percentage of cervical rotation occurs at the C1-2 level?
A
- 10%
- 25%
- 50%
- 75%
- 90%
15
Q
Exploration of a peripheral nerve lesion reveals a traumatic neuroma-in-continuity. Which of the following intraoperative diagnostic modalities would be most useful in deciding whether to proceed with excision of the neuroma and perform a graft repair?
A
- High-resolution ultrasound
- Nerve action potential recordings
- Frozen section
- Electromyography
- Intraoperative MRI
16
Q
Which of the following cerebrovascular pathologies exhibits early venous drainage on an angiogram?
A
- Capillary telangiectasia
- Amyloid angiopathy
- Cavernous angioma
- Arteriovenous Malformation
- Venous angioma
17
Q
A 28-year-old male presents with acute onset facial asymmetry, diplopia, and hemifacial numbness. The patient’s MRI is shown. What is the molecular mechanism for disease pathogenesis?
A
- Mutation of BRAF V600 E
- Activation of ERK/MAPK signaling
- Activation of SMO signaling
- Activation of MEKK3 signaling
- Activation of AKT1 signaling
18
Q
You are seeing a patient with neuropathic lower extremity pain. On examination, repetitive pinprick provokes increasingly severe burning pain on the dorsum of the foot. This phenomenon is called:
A
- Tinel sign
- Hyperpathia
- Mechanical hyperalgesia
- Paresthesia
- Allodynia
19
Q
Stimulation in what peri-Sylvian region would most likely cause speech arrest during awake speech mapping?
A
- Gyrus supramarginalis
- Gyrus angularis
- Pars opercularis
- Pars orbitalis
- Pars triangularis
20
Q
You are performing a radial to axillary nerve transfer for a patient who sustained a C5 nerve root avulsion injury 3 months previously. You have decided to utilize a posterior approach for this nerve transfer. What two muscles are separated to access the donor nerve?
A
- Biceps and pectoralis major
- Biceps and lateral head of triceps
- Deltoid and biceps
- Long and lateral heads of the triceps
- Biceps and brachioradialis
21
Q
What molecular subgroup has the best prognosis in a child diagnosed with medulloblastoma?
A
- Wnt
- Large cell
- Group 4
- Group 3
- Sonic hedgehog (SHH)
22
Q
Which of the following structures is BEST described as lateral to the hippocampal complex (hippocampus, subiculum and parahippocampal gyrus)?
A
- Posterior cerebral artery.
- Ambient cistern.
- Fusiform gyrus
- Brain stem.
- Oculomotor nerve.
23
Q
What imaging finding of a sphenoid wing meningioma significantly diminishes the possibility of safe gross-total resection?
A
- Infratemporal fossa extension
- Tumor size
- Cerebral edema
- Cavernous sinus invasion
- Optic canal extension
24
Q
What change in the intracranial pressure waveform is an early sign of elevated intracranial pressure?
A
- When P1 is higher than P2
- When P1 is higher than P3
- When P3 is higher than P1
- When P2 is higher than P3
- When P2 is higher than P1
25
An 18-year-old patient has sustained a gunshot wound through the mid thigh. At arrival to the emergency department, he is found to have intact pedal pulses but is unable to move his foot. The dorsum and sole of his foot have markedly decreased sensation. He can weakly flex his knee, although this is limited by pain. What is the most appropriate management of this suspected nerve injury?
* Emergent nerve exploration and possible repair.
* **Nerve exploration and possible repair at 3 months if no recovery**
* Nerve exploration and possible repair at 1 month if no recovery.
* Nerve exploration and possible repair at 1 year if no recovery.
* Emergent electrodiagnostic studies.
26
A 50-year-old woman diagnosed with Parkinson disease 10 years ago presents with increasingly frequent periods of involuntary writhing movements of her hands and arms. What is the most likely cause of her abnormal movements?
* Co-morbid Huntington disease
* Non-compliance with Parkinson medications
* **Levodopa-induced dyskinesias**
* Parkinson-plus syndrome
* Tardive dyskinesia from taking antipsychotic medications
27
Parkinsonian tremor can be diminished by high frequency stimulation of:
* Globus pallidus externa
* Dorsomedial thalamus
* **ViM thalamus**
* Cingulate bundle
* Subcaudate white matter
28
Which one of the following is an absolute contraindication for administration of intravenous tissue plasminogen activator (tPA) for acute cerebral infarction?
* History of aneurysm clipping six months prior to stroke onset.
* Seizure at the onset of stroke symptoms.
* Warfarin use with INR 1.3.
* **Platelet count of 80,000**
* Abdominal surgery six weeks prior to stroke onset.
29
This brain micrograph of a 68 yo male nursing home resident who had a vague history of dementia and relatively rapid decline shows which of the following?
* Acute traumatic brain injury
* **Chronic Traumatic
Encephalopathy**
* Subacute brain degeneration
* Pick’s Disease
* Jakob-Creutzfeldt Disease
30
A patient with a history of left trigeminal neuralgia has undergone a percutaneous radiofrequency rhizotomy, which gave her 2 years of pain relief. This was followed by stereotactic radiosurgery of the trigeminal nerve root, resulting in absence of her lancinating pain. She now has new left facial pain that is constant and aching. On examination, her left face is anesthetic to light touch and pinprick. What is her diagnosis?
* Type 2 trigeminal neuralgia
* Symptomatic trigeminal neuralgia
* Trigeminal deafferentation pain
* **Anesthesia dolorosa**
* Trigeminal neuropathic pain
31
According to randomized control trials of hemicraniectomy for malignant MCA infarction, what is the time frame for the performance of hemicraniectomy associated with reduced mortality?
* 12 hours
* 24 hours
* **48 hours**
* 3 hours
* 6 hours
32
The MOST common clinical feature of mesial temporal lobe seizures is:
* **Ictal oral automatisms**
* Ictal bicycling movements.
* Ipsilateral dystonic posturing.
* Visual auras.
33
A 2-month-old full-term previously healthy male presents with obstructive hydrocephalus due to an extensive hemorrhagic posterior fossa mass involving both cerebellar hemispheres and the vermis. Genetic analysis of a biopsy reveals a SMARCB1 / INI deletion in the long arm of chromosome 22 (22q11.2). What is the most likely diagnosis?
* WHO grade III ependymoma
* Immature teratoma
* Medulloblastoma
* **Atypical teratoid/rhabdoid tumor (AT/RT)**
* Choroid plexus papilloma (CPP)
34
A 6 year-old girl presents with progressive scoliosis. Physical examination reveals a club foot and a midline hairy nevus in the lumbar region. MRI is shown (Figure 1). What is the most likely diagnosis?
* Myelomeningocele
* Dermal sinus tract
* Neurenteric cyst
* **Diastematomyelia**
* Lipomyelomeningocele
35
Which of the following analgesics works by binding to spinal cord vanilloid (TRVP1) receptors, thus causing prolonged depolarization and defunctionalization of the pain pathways?
* Bupivacaine
* Ibuprofen
* Fentanyl
* Ziconotide
* **Capsaicin**
36
After a type II odontoid fracture, the function of which ligament/membrane most strongly influences treatment options:
* interspinous
* **transverse**
* apical
* anterior longitudinal
* alar
37
According to the International Study of Unruptured Intracranial Aneurysms, what is the 5 year cumulative rupture rate of a 10 mm posterior communicating aneurysm?:
* 4.5%
* 9.5%
* 0%
* 19.5%
* **14.5%**
38
After invasive grid monitoring and mapping of eloquent cortex, surgical resection is recommended for a 19-year-old man with drug-resistant epilepsy. The patient’s seizures involve speech arrest with tonic posturing of the upper extremities in a “fencing posture”. Where is the likely seizure focus?
* Primary motor cortex
* Lateral temporal lobe
* Primary sensory cortex
* Mesial temporal lobe
* **Supplementary motor area**
39
A 19 year-old man presents after a helmeted ATV accident. On examination the patient is neurologically intact. He denies any midline tenderness. Trauma survey and labs are normal. What imaging test should be ordered before clearing his collar.
* Cervical MRI
* Cervical CT Scan
* Cervical X-ray
* Cervical CTA
* No imaging.
40
A 7-year-old child with a two week history of difficulty walking, dysarthric speech and facial weakness has the MRI shown in the figure. What is the most appropriate initial treatment?
* Surgical debulking.
* Gamma-knife.
* Chemotherapy.
* Whole-brain radiation.
* **Conformal radiotherapy**
41
An 8 year-old child with a history of myelomeningocele presents with progressive back pain, scoliosis, right calf numbness, right leg weakness, incontinence, and bladder spasticity. Which of her symptoms is most likely to improve following a third untethering procedure?
* Leg numbness
* Leg weakness
* Scoliosis
* Bladder spasticity
* **Back pain**
42
For which spinal disorder are children of mothers with diabetes mellitus at risk?
* Intraspinal lipomas
* Meningocele manque
* Spinal dysraphism
* Thoracic hemivertebrae
* **Sacral agenesis**
43
A 45-year-old woman is referred with complaints of debilitating paroxysmal, lancinating pain involving the deep aspect of the left ear canal. Her neurological examination is normal. A CT scan of the brain and skull base along with an MRI of the brain are both normal. She has failed medical management of her condition. Which of the following represents the BEST surgical treatment option?
* Removal of the styloid process
* Microvascular decompression of the trigeminal nerve
* Intradural rhizotomy of the 9th and upper 1/3 of the 10th cranial nerves
* **Intradural section of the nervus intermedius**
* Nucleus caudalis DREZ ablation
44
Which genetic or chromosomal alteration is associated with primary adult glioblastoma?
* Wnt signaling pathway mutations
* TP53 and ATRX mutations
* SMARCB1/INI1 mutation or deletion
* 1p19q chromosomal deletion
* **EGFR and CDNK2A/CDNK2B mutations**
45
A 55 year old woman developed a severe headache, acute vision loss, and bilateral ptosis. Examination also reveals complete ophthalmoplegia of both eyes. What is the most likely diagnosis?
* Myasthenic crisis.
* **Pituitary apoplexy**
* Complicated migraine.
* Kearns-Sayre syndrome.
* PCOM aneurysm.
46
A 50-year-old male patient with a history of atrial fibrillation presents with acute onset left hemiparesis and drowsiness for 24 hours. MRI of the brain is shown. The National Institute of Health Stroke Scale (NIHSS) score is 16. What treatment option has been shown to decrease mortality rates for such a patient?
* Intra-arterial tPA
* External ventricular drainage
* Medical management only
* Mechanical thrombectomy
* **Decompressive hemicraniectomy**
47
You are called to the NICU to see a 1 day old child who appears as demonstrated in figures 1 and 3. His CT scan is shown in figure 2. He has been stable, although with occasional apnea when agitated. On exam, he has a bulging fontanelle. His parents wish to pursue aggressive care. When should he undergo a cranial vault procedure?
* At 12 months of age.
* At 6 months of age.
* At 18 months of age.
* At 24 months of age.
* **In the next several days**
48
You are operating on a patient with neurofibromatosis-1 that you suspect has a benign neurofibroma of the sciatic nerve, and have performed the initial exposure of the lesion, shown in the figure. What is the most appropriate maneuver at this point?
* Biopsy the lesion for frozen and permanent sections and close
* **Perform direct nerve stimulation to identify a safe zone to incise**
* Perform an internal debulking of lesion
* Perform en bloc excision of the tumor, nerve, and surrounding muscle
* Excise the lesion and perform a graft repair of the nerve
49
Mutation of which of the following genes has been linked to cerebral amyloid angiopathy?
* Endoglin
* KRIT-1
* Apoliporprotein E
* Tau
* **Presenilin (PS)**
50
What is the most common location of cranial dural arteriovenous fistulas?
* Superior sagital sinus
* Inferior sagital sinus
* **Transverse sinus**
* Straight sinus
* Posterior cavernous sinus
51
A pineal mass was completely resected and the pathologist diagnoses a mature teratoma. What is the best treatment for this patient?
* Fractionated local radiation therapy
* Craniospinal irradiation
* Chemotherapy
* Radiosurgery to the resection cavity
* **Observation**
52
A patient treated with deep brain stimulation (DBS) for generalized dystonia presents to your clinic 1 month after DBS with complaints that it is not effective. What would be the most appropriate next step?
* Offer revision surgery
* **Counsel patient**
* Recommend genetic testing
* Recommendation implantation of additional leads
* Explant due to surgical failure
53
Orally administered baclofen may be useful in the treatment of the spasticity of cerebral palsy BECAUSE IT:
* Has little sedative effect compared with other medications.
* Weakens muscles by inhibiting the release of calcium from sarcoplasmic reticulum.
* Has a specific beneficial effect on dystonia.
* Increases nor-adrenergic inhibition in the spinal cord.
* **Is a GABA agonist that inhibits presynaptic neurotransmitter release**
54
A 58-year-old male dies from respiratory failure after battling a disease for 3 years. Microscopic examination of the spinal cord is shown below. Which disease lead to the death of patient?
* Vitamin B12 deficiency
* Spinal muscular bulbar atrophy (SMBA)
* **Amyotrophic lateral sclerosis**
* Guillain-Barre syndrome
* Spinal muscular atrophy (SMA)
55
Approximately what percentage of patients experience favorable outcomes (Engel Class I) 3-5 years after temporal lobectomy for temporal lobe epilepsy?
* **70%**
* 10%
* 90%
* 30%
* 50%
56
During a far lateral approach, exposure of what anatomic structure first indicates that more than the posterior one-third of the occipital condyle has been removed?
* The vertebral artery
* **The anterior condylar vein**
* Transverse ligament of atlas
* Jugular bulb
* The dentate ligament
57
Injury to the suprascapular nerve results in which of the following neurological deficits?
* Weakness of scapular rotation, weakness of scapular elevation
* Weakness of external shoulder rotation, numbness of lateral shoulder
* **Weakness of shoulder abduction, weakness of external shoulder rotation**
* Weakness of shoulder circumduction, numbness of posterior shoulder
* Weakness of internal shoulder rotation, numbness of anterior shoulder
58
A 29 year old female presents after a motor vehicle accident with left hemiplegia, weak localization on right, and a dilated unreactive right pupil. Her head CT is shown. What is the most appropriate surgical management?
* **Craniotomy and hematoma evacuation**
* Placement of ventriculostomy.
* Placement of brain tissue oxygenation and ICP probe.
* Temporal burr hole and hematoma drainage.
* Decompressive right hemicraniectomy.
59
What clinical finding best characterizes cauda equina syndrome?
* Decreased patellar tendon reflex
* Foot drop
* Sciatica
* Ankle plantar flexion weakness
* **Saddle anesthesia**
60
Which calcium channel blocker has been demonstrated to improve outcome in patients with aneurysmal subarachnoid hemorrhage?
* Oral Felodipine
* IV Felodipine
* **Oral nimodipine**
* Oral verapamil
* IV diltiazem
61
A 37-year-old female with long-standing epilepsy despite anti-epileptic medications and prior epilepsy surgery, reports to her physician that she has been seizure-free for 12 months. What is the most likely psychosocial pressure motivating the patient to report that she has been seizure-free for a 12-month period?
* **Holding an active driver's license**
* Commuting via public transportation
* Living independently
* Full-time employment
* Financial independence
62
What is the best method to screen for cervical spine injury in the unconscious, intubated multitrauma patient?
* C-Spine MRI
* Dynamic traction fluoroscopy
* Fluoroscopic Flexion/Extension Imaging
* A/P, Lateral, Oblique, and Open Mouth Odontoid radiographs
* **C-spine CT**
63
A 64-year old woman with multiple comorbidities undergoes emergent craniotomy after a fall. On post-operative day 4, she develops worsening tachypnea, tachycardia, hypotension, and fever of 101.5°F. Chest X-ray shows a new opacity in the right lower lobe. Bronchoscopy reveals thick, purulent secretions. What is the most appropriate next step in management?
* Rifampin
* Await culture results prior to antibiotics
* Daptomycin
* **Broad-spectrum antimicrobial therapy**
* Vancomycin
64
What is the most likely mechanism underlying an intracranial hemorrhage associated with an intracranial dural fistula?
* Brain edema
* Increased intracranial pressure
* Arterial aneurysm rupture
* Hyperemia
* **Venous hypertension**
65
What is the mortality rate of a MCA infarction with malignant cerebral edema managed with intensive non-operative care?
* 20%
* 40%
* 0%
* **80%**
* 60%
66
A 76 year-old man presents with worsening back pain unresponsive to conservative measures. 36-inch radiographs were performed at his office visit (Figure 1). What Schwab grade osteotomy (Figure 2) will provide the best correction of his sagittal plane deformity over one segment?
* Grade 4
* Grade 5
* Grade 1
* Grade 3
* **Grade 2**
67
A 75-year-old woman presents 3 months after resection of a frontal meningioma with complaints of headache, low grade fevers, and a tender fluctuance under her previous created craniotomy flap. A contrast-enhanced computed tomograpic scan of her head is shown in the figure. What is the most common organism for a post-surgical infection after elective craniotomy?
* Enterococcus sp
* E. Coli
* Streptococcus
* Propionibacterium acnes
* **Staph. aureus**
68
A 27-year-old pregnant female presents to the ER with acute confusion, headaches and blurry vision. While in the ER she is found to have acute fetal distress and a blood pressure of 210mmHg/110mmHg. After expedited delivery of the baby, a CT is performed, revealing patchy areas of hypodensity in the posterior parietal and occipital lobes. An MRI is shown (figure). Which of the following is the most likely diagnosis?
* Acute infarction of the posterior cerebral arteries
* **Posterior Reversible Encephalopathy Syndrome (PRES)**
* Infiltrating neoplasm
* Demyelination, likely multiple sclerosis
* Progressive multifocal leukoencephalopathy
69
A 22-year-old sustained a spinal cord injury after a fall with an L2 burst fracture and canal compromise. More than half of the muscles below the level of injury have astrength grade less than 3. There is impaired pain and temperature sensation below the middle of the thighs bilaterally, but preserved light touch and proprioception. There is bilateral Babinski sign and loss of anal tone and wink reflex. According to the 2000/2002 ASIA Standards, what (modified) ASIA Impairment Scale classification is this patient?
* D
* A
* **C**
* B
* E
70
A 54 year-old man presents with biopsy-proven esthesioneuroblastoma has a normal neurological exam. MRI shows involvement of the right nasal cavity with minimal intracranial extension through the cribriform plate (Figure 1). There is no cervical adenopathy or evidence of metastatic disease. Which of the following is the best management strategy for this patient?
* Chemotherapy alone
* **Surgical resection followed by conformal radiation therapy to the tumor bed**
* Surgical resection followed by conformal radiation therapy to the tumor bed and systemic chemotherapy
* Neo-adjuvant radiation therapy followed by chemotherapy
* Surgical resection
71
Aside from bilateral ICA occlusions, what is a typical angiographic finding in moyamoya disease?
* Fetal posterior cerebral artery
* **Diffuse hypertrophy of the lenticulostriate arteries**
* Persistent fetal trigeminal artery
* Duplication of the M1 segment of the middle cerebral artery
* Bilateral giant internal carotid artery aneurysms
72
A patient with a severe closed head injury exhibits a decreasing serum sodium over a 48 hour period to 125 mEq/l. Serum osmolality is diminished, urine sodium is elevated. What parameter is critical to understand in the ensuing management of this patient?
* **Circulating blood volume**
* Urine Osmolality
* Hematocrit
* Blood pressure
* Serum potassium
73
Following resection of a frontal supplementary motor area (SMA) cortex tumor, the patient develops impaired speech fluency. What pathway connects the inferior frontal lobe with the SMA?
* **Frontal aslant tract**
* Arcuate fasciculus
* Superior longitudinal fasciculus II
* Superior longitudinal fasciculus III
* Uncinate fasciculus
74
What lateral plain film measurements of the cervical spine is used to make the diagnosis of atlanto-occipital dislocation (AOD)?
* Mcgregor's line
* Chamberlain's line
* Combined C1 Lateral mass displacement
* Atlanto-dens interval
* **Basion-posterior axial line and basion-dens interval**
75
Which of the following is the first line treatment for craniocervical dystonia (excluding oromandibular)?
* Selective dorsal rhizotomy
* Intrathecal baclofen
* Deep brain stimulation
* **Botulinum toxin**
* Selective peripheral denervation
76
Which of the following is a characteristic of primary generalized dystonia?
* The presence of bradykinesia
* The involvement of a single body part
* The presence of a distinct underlying neuropathology
* **The presence of familial predisposition**
* The presence of developmental delay
77
You are referred a patient who developed severe leg pain, redness, and swelling after undergoing an open reduction and internal fixation of a tibial fracture. What diagnostic test would be most useful in distinguishing complex regional pain syndrome type 1 from type 2?
* Lumbar sympathetic block
* Three phase bone scan of the whole body
* Plain radiographs at the site of the fracture
* Neuropsychological testing
* **Electrodiagnostic studies of the lower extremities**
78
A 21 year-old man was admitted following a motorcycle crash with diffuse axonal injury. An ICP monitor and brain tissue oxygenation monitor are placed. After 24 hours, his brain partial pressure of oxygen decreases from 20mmHg to 10mmHg. What threshold for treatment of brain hypoxia is recommended by the most recent Brain Trauma Foundation Guidelines (4th edition)?
* **There is no recommended threshold for treatment**
* 10 mmHg
* 20mmHg
* 25 mmHg
* 15 mmHg
79
A 60-year-old generally healthy man with Parkinson disease (PD) is considering undergoing deep brain stimulation electrode implantation. He was diagnosed with PD 8 years ago and responded extremely well to levodopa therapy initially. Last year, he began to develop levodopa-related dyskinesias. Which of the following factors is most predictive of his response to deep brain stimulation?
* Duration of disease
* Lack of medical comorbidities
* **Levodopa responsiveness**
* Age
* Development of levodopa-induced dyskinesias
80
A 30 year old male with history of IV drug use presents to the ER with fever and low back pain. His MRI demonstrates a small sacral epidural abscess. He has blood cultures positive for methicillin resistant staph aureus. His erythrocyte sedimentation rate (ESR) on presentation is elevated at 110 mm/ hr. He is neurologically intact. He is to undergo 8 weeks of vancomycin IV. What is the most appropriate test for determining that his sacral epidural abscess has resolved at the conclusion of antibiotic therapy?
* Repeat MRI with and without contrast
* CT guided biopsy
* Repeat blood culture
* **Repeat ESR**
* Bone scan
81
What is the next appropriate step in management following resection of an epidermoid tumor?
* Prophylactic antibiotics
* Intracystic chemotherapy
* Brachytherapy
* Fractionated radiotherapy
* **Radiographic surveillance**
82
What characteristic histological feature of a meningioma is depicted in the encircled areas of the slide?
* Mitotic figures
* Endothelial proliferation
* Verocay bodies
* Psammoma bodies
* **Vacuolation**
83
Which symptomatic hormone deficiency is most common after pediatric moderate-to-severe traumatic brain injury?
* Prolactin
* **Growth Hormone**
* Gonadotropic Hormones
* Thyroid Hormone
* Cortisol
84
A 26 year old male presents to the emergency room after a motor vehicle accident. He is orally intubated, does not open his eyes to verbal or painful stimuli but does localize briskly with his right upper extremity. What is this patient's GCS?
* 3T
* 5T
* 10T
* 6T
* **7T**
85
In a patient with traumatic quadriparesis and difficulty breathing, vertical displacement of the occipital condyles from the lateral masses of C1 is most consistent with rupture of what soft tissue structures?
* **Rupture of the tectorial membrane and alar ligaments**
* Rupture of ligamentum flavum.
* Rupture of the anterior longitudinal ligament.
* Rupture of the posterior longitudinal ligament.
* Rupture of the transverse ligament.
86
The right obturator nerve is inadvertently sectioned sharply during a gynecologic procedure. What is the best management of this injury?
* **Immediate tension-free end-to-end anastomosis**
* No repair, physical therapy.
* Delayed tension-free end-to-end anastomosis.
* Delayed repair with graft
* Immediate repair with graft.
87
The nurse calls you to see an intubated postoperative patient noting worsening oxygenation with oxygen saturation of 85%. ABG shows PaO2 of 50 and PaCO2 of 43. While the patient was previously following commands, he has stopped responding to the nurse. Upon your arrival, the patient’s blood pressure drops suddenly from 110/62 to 76/40, with a CVP of 1, and his oxygen saturation drops further to 79%. What is the next most appropriate step in management of this unstable patient?
* Initiate norepinephrine for pressor support
* Initiate heparin for presumed pulmonary embolism
* Take the patient for a STAT CT of the Chest, PC protocol
* **Increase the patient's FiO2 and ventilator rate**
* Take the patient for a STAT head CT
88
How does the amount of radiation differ when standing 4 feet away from a radiation source as opposed to 1 foot?
* 1/4
* 1/64
* 1/8
* **1/16**
* 1/12
89
When treating status epilepticus in adults, which intravenous medication should be co-administered with benzodiazepines?
* Phenobarbital.
* Nitroprusside.
* Propofol.
* Succinylcholine.
* **Phenytoin**
90
You have diagnosed your patient with a nerve entrapment and have decided to decompress the entrapped nerve. Which of the following procedures would be most appropriate for the majority of nerve entrapments?
* Nerve transposition
* **Neuroplasty**
* Nerve transfer
* Internal neurolysis
* Neurorrhaphy
91
Which syndrome is most likely to benefit from hemispherectomy?
* Lennox-Gastaut Syndrome
* **Rasmussen’s Encephalitis**
* Nonlesional Extratemporal Epilepsy
* Mesial temporal Sclerosis
* Drop attacks
92
Vertebral artery injury during C1-2 transarticular screw placement is most likely to result when the screw is misplaced in which direction?
* anteriorly
* laterally
* **caudally**
* cranially
* medially
93
According to Suzuki and Takaku classification of the angiographic appearance of moyamoya disease, what imaging findings are asssociated with stage 2 disease?
* **Moyamoya vessels begin to develop at the base of the brain**
* Near complete disappearance of the major cerebral arteries with the cerebral hemispheres receiving blood from the abnormal extracranial-intracranial anastomoses.
* Diminishing moyamoya vessels with progression of extracranial circulation
* Stenosis of the carotid artery at the suprasellar portion with no moyamoya vessels
94
Following aneurysmal subarachnoid hemorrhage, which cardiac complication is the most significant independent predictor of mortality?
* **Cardiac failure**
* Myocardial stunning
* Tachyarrhythmias
* Myocardial infarction
* Heart block
95
A 14 year-old is involved in a MVC and does not lose consciousness. He has a GCS of 15 and no focal deficits on neurological exam. He has no other injuries. His toxicology screen is negative. You remove his collar, and he has no palpable spinal tenderness or pain with range of motion. The correct next step would be which of the following?
* Obtain flexion/extension cervical spine x-rays
* Send patient for a CT scan of the cervical spine
* Obtain adequate cervical spine x-rays
* Send patient for a MRI of the cervical spine
* **Remove the cervical collar and backboard**
96
A 32 year-old male has intractable seizures localized to the left language-dominant supplementary motor area. What neurological deficit will most likely result following surgical resection?
* Left inferior quadrantopsia.
* Anomia and finger agnosia.
* Alexia without agraphia
* **Temporary mutism**
* Temporary paresis on the left.
97
A 52 y/o restrained driver presented after a motor vehicle accident with an L2 sensory level, 4/5 strength in his proximal and 4-/5 strength in his distal lower extremities and a severe L2 fracture. What is this patient's ASIA Impairment Scale score (modified Frankel score)?
* B
* **D**
* A
* E
* C
98
A 5-year-old undergoes surgical resection of a posterior fossa medulloblastoma followed by chemotherapy and total neuroaxis radiotherapy, with a boost to the posterior fossa. Which endocrinological complication is most likely after radiotherapy for a posterior fossa tumor in childhood?
* Addison's Syndrome
* Cushing's Syndrome
* Diabetes Insipidus
* Growth Hormone Excess
* **Growth Hormone Deficiency**
99
A 71 year-old man with cervical myelopathy underwent C4-6 laminoplasty. On postoperative day 2, he develops deltoid and biceps 3/5 weakness and sensory loss in a C5 dermatomal pattern. Postoperative CT and MRI are unremarkable. What is the most likely outcome?
* Chronic C5 neuropathic pain
* Recovery of sensory function but permanent motor deficit
* Permanent motor and sensory deficit
* Recovery of motor function but permanent sensory deficit
* **Complete resolution of motor and sensory deficit**
100
A 32 year-old man has surgery for a low grade glioma. What genetic profile is associated with the best prognosis?
* IDH wild type with TERT promoter mutation
* IDH wild type without TERT promoter mutation
* IDH mutation without 1p19q co-deletion
* **IDH mutation with 1p19q co-deletion**
* IDH wild type without 1p19q co-deletion
101
A 2-year-old child presents with new-onset headaches, nausea and vomiting. Imaging reveals a solid, enhancing mass arising from the fourth ventricle floor and resultant mild obstructive hydrocephalus. Histopathologic evaluation of a representative portion reveals both perivascular pseudorosettes and true rosettes. Which of the following is true concerning the prognosis of this patient?
* The prognosis in this patient is better than that of a 2-year old child with the same tumor pathology located in the spine*
* **The prognosis is worse in this patient than in a 20-year-old with the same tumor**
* Surgical resection has little effect on survival.
* Post-operative radiation therapy does not confer improved survival benefit.
102
What is a known possible side effect of corpus callosotomy for epilepsy?
* Superficial cerebral hemosiderosis
* **Disconnection syndrome**
* Hemibalismus
* Hemiplegia
* Gerstmann syndrome
103
A 20-year-old man was thrown from his motorcycle, sustaining severe injury to his right shoulder, including fractures of the clavicle and scapula. He had no right radial pulse, and an infraclavicular and supraclavicular mass was noted. He was not moving his right arm. Angiography revealed a tear of the second segment of the axillary artery and the patient underwent emergent surgical exploration and vascular repair. What neurosurgical procedure should be performed in a concurrent fashion?
* **Evaluation of the plexus through the operative site, with identification and tagging of any disrupted elements**
* Wide and total exploration of the plexus when vascular repair is completed.
* No intervention or evaluation is indicated intraoperatively
* Intraoperative nerve action potential recordings (NAPs) across the injured segments.
* Evaluation of the plexus at the operative site after vascular repair is complete, with repair of any disrupted elements.
104
A 45 year old man presents with sudden onset of vomiting, dysarthria and ataxia and a CT scan demonstrating a cerebellar infarction. Thirteen hours after onset of symptoms, he develops abducens nerve palsy and depressed mental status. What is the most appropriate definitive management of this patient?
* **Suboccipital craniectomy**
* High dose Dexamethasone
* Intravenous tPA
* Barbiturate coma
* Hypertonic saline
105
A 42 year-old man undergoes resection of this tumor (Figure 1). The immunohistochemistry for BRAF V600E mutation is shown (Figure 2). What is the most likely diagnosis?
* Pilocytic astrocytoma
* Glioblastoma
* Pleomorphic xanthoastrocytoma
* **Ganglioglioma**
* Ependymoma
106
You are seeing a patient with neuropathic lower extremity pain. On examination, light touch provokes severe burning pain on the dorsum of the foot. What is this phenomenon called?
* Tinel sign
* **Allodynia**
* Paresthesia
* Hyperpathia
* Mechanical hyperalgesia
107
A 42 year old male presents with a 5 year history of Parkinson disease (PD) with severe motor fluctuations. What would be his expected benefit from deep brain stimulation (DBS) surgery?
* **DBS will provide improvement in motor symptoms comparable to the effects of Levadopa medication, with less motor fluctuations and without the medication-induced dyskinesia**
* DBS will provide no benefit, because he has not had the disease long enough.
* DBS will provide improvement in freezing of gait, a motor symptom frequently associated with Parkinson disease.
* DBS will result in reduction in progression of the natural history of Parkinson disease.
* DBS will eliminate the need for Parkinson medications.
108
When a patient with neurofibromatosis type II (NF-2) presents with a small vestibular schwannoma with serviceable hearing, what is the most effective treatment strategy to maximize auditory longevity?
* **Observation until tumor progression**
* Microsurgery
* Fractionated radiotherapy
* Bevacizumab
* Stereotactic radiosurgery (SRS)
109
A 50-year-old patient has a history of right-sided hemiparesis and recurrent seizures. On examination, he has a port-wine stain in the left V1 and V2 distribution. What is the most likely diagnosis?
* **Encephalotrigeminal angiomatosis**
* Neurocutaneous melanosis
* Hemorrhagic hereditary telangiectasia (Rendu-Osler-Weber syndrome)
* Tuberculosis with leptomeningeal involvement
* Meningioangiomatosis
110
Which of the major nerves arising from the brachial plexus has the worst prognosis for return of motor function following injury?
* Median
* Musculocutaneous
* **Ulnar**
* Radial
* Axillary
111
A 63 year old patient with levodopa-responsive Parkinson's disease is referred for deep brain stimulation surgery (DBS). With respect to motor symptoms, what benefit is DBS most likely to provide?
* **Decrease medication "off"-time**
* Increase medication "on"-time with troublesome dyskinesias.
* Improve gait.
* Raise UPDRS III scores.
* Reduce freezing events.
112
Which medication has been shown to both reduce the risk of IVH and improve outcome in preterm infants?
* Ibuprofen
* Indomethacin
* Vitamin E
* Phenobarbital
* **Corticosteroids**
113
A craniotomy using frameless stereotactic guidance is planned. After the surgeon registers the patient and image, the fiducial reference frame moves in relation to the patient. Which of the following is the best option before proceeding with the operation?
* Touch a skull reference point
* Ignore the shift if minor
* **Re-register**
* Return the reference frame to its previous position
* Use a software correction algorithm
114
Four days after aneurysmal subarachnoid hemorrhage, a 49 year old female develops hyponatremia (serum Na = 129mmol/L). She is not on diuretics. Her lab work shows the following: serum Osm = 265mOsm/kg, urine Osm = 210mOsm/kg, and urine Na = 50mmol/L. Her fluid balance has been negative for the past 3 days; her creatinine and hemoglobin have increased since yesterday. What is most likely the cause of her hyponatremia?
* Adrenal insufficiency
* Extrarenal fluid loss
* Renal failure
* **Cerebral salt wasting**
* Syndrome of inappropriate anti-diuretic hormone (SIADH
115
Which cranial nerve injury is most likely to be associated with transvenous embolization of a cavernous-carotid fistula?
* Oculomotor
* Trochlear
* Optic
* **Abducens**
* Trigeminal
116
A 34-year-old female presents with spontaneous proptosis and chemosis of the left eye. Cerebral angiography (left common carotid injection) is shown . What is the best management option?
* Craniotomy
* Optic nerve sheath fenestration
* **Transvenous embolization**
* Transarterial carotid sacrifice
* Ventriculoperitoneal shunt
117
When performing invasive monitoring for epilepsy, when is stereo-EEG monitoring preferred over subdural grids and strips?
* **Putative involvement of a functional network**
* Greater than average skull thickness
* Desire to reduce the need for continuous antibiotics
* Need to perform language mapping
* Desire to perform resection during the same admission
118
You are seeing an adult patient with a history of tarsal tunnel syndrome, who presents with plantar foot discomfort sparing the heel. You decide to decompress the nerve at its typical area of entrapment. Which of the following incisions would be most appropriate to do this?
* Figure 3
* Figure 2
* Figure 4
* **Figure 5**
* Figure 1
119
A 51 year old man presents with a severe thunderclap headache, meningismus, photophobia and nausea. His CT scan is shown below and his cerebral angiogram is negative. What is the appropriate treatment option at presentation?
* Hyperdynamic therapy
* **Observation**
* Endovascular treatment
* Surgical exploration
* Anticonvulsants
120
A 78 year-old man with a 10-year history of intermittent chronic neck pain has cervical spine X-rays (Figure 1) and MRI (Figure 2). The patient denies any current neck pain, radiculopathy or subjective symptoms of myelopathy. His exam is normal. What is the recommended management for this patient?
* Serial MRI
* **Clinical observation**
* High-dose steroids and cervical traction
* Surgery
* Immobilization with cervical collar
121
58 year old male is in coma from a stroke. The intensivist wants to begin feeding. What is the best plan for early feeding of this patient (first 7 days after stroke)?
* Peripheral parenteral nutrition
* **Nasogastric tube**
* Intravenous isotonic solution with electrolyte replacement
* Gastrostomy tube
* Total parenteral nutrition
122
You are seeing a patient complaining of problems in her hand. You suspect that the patient has anterior interosseous neuropathy. In what pair of muscles would you expect to find weakness?
* Pronator teres and pronator quadratus
* First lumbrical and second lumbrical
* Flexor digitorum superficialis and flexor digitorum profundus
* **Flexor pollicis longus and flexor digitorum profundus 1**
* Opponens pollicis and abductor pollicis brevis
123
A 30 year-old woman presents with progressive difficulty using her hands and gait dysfunction. She has pain in the back of her neck that radiates into her head. She notes pain and pareasthesias in both arms that are refractory to neuropathic pain medication. Her imaging is shown in the figures. What is the most appropriate initial surgical management?
* Cervical laminectomy and duraplasty
* **VP shunt**
* Cyst fenestration
* Suboccipital decompression
* Cyst shunt
124
A patient with severe closed head injury is suspected of having diabetes insipidus. What electrolyte and volume profile best fits this diagnosis?
* Diminished blood volume, hyponatremia.
* Increased blood volume, hyponatremia.
* Increased blood volume, hypernatremia.
* **Diminished blood volume, hypernatremia**
125
A 67 year old man presents to the emergency room with worsening parasthesias of the ipsilateral face and contralateral extremity. The symptoms are provoked with head turning. Where is the most likely site of vascular compression in this patient?
* Subclavian artery
* Carotid Bifurcation
* Basilar artery
* Posterior inferior cerebellar artery
* **Dominant vertebral artery**
126
An 80-year-old female presents with an occipital lobe hemorrhage on CT imaging. She has a prior history of parietal and temporal hemorrhages. What is the most likely diagnosis?
* Venous angioma
* Vasculitis
* Arteriovenous malformation
* Coagulopathy
* **Amyloid angiopathy**
127
What factor is most predictive of postoperative intracerebral hemorhage after carotid endarterectomy?
* Calcified plaque
* Length of stenosis
* **Cerebral hypoperfusion**
* Young age
* Female Sex
128
A 30-year-old male with no prior medical history presents with four days of rapidly progressive bilateral lower extremity weakness, reduced sensation below the level of the umbilicus, and urinary retention. See figure for MRI of the thoracic spine T2 and T1 with contrast. Spinal fluid evaluation including NMO IgG are unremarkable. Which of the following is the most effective first line management of this patient’s condition?
* T10-T12 laminectomy for spinal cord decompression
* Supportive care including maintenance of MAP > 80 mmHg
* Interferon
* Excisional biopsy with subsequent radiation and chemotherapy
* **High dose intravenous glucocorticoid therapy**
129
You are revising an intrathecal catheter in a chronic pain patient who developed myelopathy after several years of benefit from a spinal infusion pump. You note the mass shown in the figure at the end of the catheter tip. Which of the following factors predisposes to the formation of these lesions?
* Catheter allergy
* **High drug concentration**
* Immunosuppressed status
* Catheter fracture
* Contaminated pump refills
130
A 24 year-old man is brought to the emergency department following a single midline gunshot wound to the forehead. On arrival, he is GCS 7T with bilateral sluggishly reactive pupils and localizing in the left upper extremity to noxious stimulus. His non-contrast head CT is depicted (Figure 1). This patient is most at risk for what acute complication of penetrating brain injury?
* Traumatic arterial dissection
* Arteriovenous malformation
* Venous sinus thrombosis
* Cavernous-carotid fistula
* **Traumatic intracranial aneurysm**
131
A 44 year old man presents with seizure, headache, and left visual field cut. MRI is shown. What is the most likely benefit of embolization for this lesion?
* Decreased risk of seizures
* **Reducing AVM volume for subsequent treatment**
* Complete obliteration of the AVM
* Decreased risk of rupture before further therapy
* Improvement of vision
132
A 46 year-old woman with recurrent Cushing's disease after transsphenoidal resection has MR proven extension of tumor into the cavernous sinus without suprasellar extension. She elects to undergo radiosurgery. What is the MOST likely complication after pituitary adenoma radiosurgery?
* **Anterior pituitary insufficiency**
* Diplopia
* Carotid artery occlusion
* Visual loss
* Diabetes insipidus
133
A 17-year-old cerebral palsy patient with spasticity undergoes intrathecal baclofen pump placement with significant objective improvement. 15 months later, he presents to the emergency department with recurrent spasticity. He is otherwise medically well, afebrile and without signs or symptoms of infection. What is the next most appropriate step in management?
* Surgery for pump replacement
* Temporary intrathecal catheter placement for baclofen injection
* AP and lateral radiographs of intrathecal catheter
* **Interrogation of the pump and review the programming**
* Radiopaque dye injection through the catheter access port
134
When a peripheral nerve is severed, the axon segments distal to the site of injury disappear over time, leading to the gradual loss of nerve conduction distal to the injury. What is this process called?
* Denervational change
* **Wallerian degeneration**
* Axon sprouting
* Exocytosis
* Demyelination
135
What is the most common presentation of an adult patient with moyamoya disease?
* Dystonia
* Gait disturbances
* Seizure
* Ischemic infarcts/transient ischemic attacks
* **Intracranial hemorrhage**
136
In semilobar holoprosencephaly, brain imaging is most likely to show what findings?
* **A single ventricle anteriorly, with some separation of the occipital horns; dysgenesis of the anterior corpus callosum; may or may not have fused thalami**
* A normal ventricular system, corpus callosum, and thalami
* A single ventricle; complete lack of corpus callosum and interhemispheric fissure; fused thalami
* A normal ventricular system and corpus callosum; failed separation of the posterior frontal and parietal lobes; near-normal thalami
* A near-normal ventricular system; lack of the genu of the corpus callosum, with the rest of the corpus callosum identifiable; near-normal thalami
137
Following transsphenoidal resection of a large craniopharyngioma, the manifestations of a classic triphasic response are which of the following?
* **Hypernatremia - Normonatremia or Hyponatremia - Hypernatremia**
* Hyponatremia - Hypernatremia - Hyponatremia.
* Normonatremia - Hyponatremia - Normonatremia.
* Normonatremia - Hypernatremia - Normonatremia.
* Hyponatremia - Normonatremia or Hypernatremia - Hyponatremia.
138
Inferior extension of a therapeutic lesion placed in the posteroventral globus pallidus pars internus may induce which of the following adverse events:
* Hemiballism.
* **Visual field deficit**
* Hemiplegia.
* Sensory loss.
* Ataxia.
139
You are consulted to perform a sural nerve biopsy to evaluate a peripheral neuropathy. What would be the most appropriate incision for this patient?
* Figure 1
* Figure 3
* Figure 4
* Figure 5
* **Figure 2**
140
Paragangliomas of the jugular foramen derive from what cell type?
* Cerebellar stem cells
* **Chromaffin cells of neuro-ectodermal origin**
* Epithelial cells of ectodermal origin from the stomodeum
* Meningoepithelial cells
* Germ cells that migrated aberrantly
141
A 56- year old man presents with a 4-year history of progressive lower extremity numbness, paresthesias, weakness and spastic gait. MRI and CT Myelogram of the thoracic spine is shown (Figure 1 & 2). What is the most appropriate treatment option?
* Fenestration of dorsal arachnoid cyst
* Observation and physical therapy
* Thoracotomy for thoracic discectomy
* Thoracic laminectomy and posterior fusion
* **Intradural exploration and detethering of ventral spinal cord**
142
A 3 month old boy, otherwise healthy with normal prenatal and perinatal history, is brought by his parents for concerns they have regarding his head shape. They noticed some asymmetry soon after birth that has become more noticeable over the past few weeks (Fig 1). What is the diagnosis?
* Lambdoid synostosis
* **Positional plagiocephaly**
* Coronal synostosis
* Metopic synostosis
* Sagittal synostosis
143
During awake speech mapping, stimulation of a temporal lobe site results in patient saying “gorange” instead of “orange”. This is an example of what type of paraphasia?
* Remote
* Perseverative
* **Phonemic**
* Neologistic
* Semantic
144
A 4-week-old, 26 week premature infant presents with a Grade IV intraventricular hemorrhage and posthemorrhagic hydrocephalus (Figure 1). Examination reveals stable vital signs, normal head circumference growth curve, and soft anterior fontanelle. Weight is 1.2 kg. What is the best initial management of the hydrocephalus?
* Placement of a ventricular reservoir
* Placement of external ventricular drain
* Creation of a permanent ventriculoperitoneal shunt
* **Serial cranial ultrasounds with daily head circumference measurements**
* Serial lumbar punctures
145
Which of the following neuropathic pain medications works by binding to voltage-gated calcium channels in neurons?
* Amitriptyline
* Ketamine
* **Gabapentin**
* Clonidine
* Baclofen
146
A 10 year old boy presents with loss of consciousness followed by a lucid interval following a closed head injury. A head CT is shown (figure). Damage to which of the following vessels is most likely responsible for the imaging findings?
* Vein of Labbe
* Superficial temporal artery
* Middle cerebral artery
* **Middle meningeal artery**
* Cerebral bridging vein
147
A 50 year-old man has a 15 year history of worsening bilateral (right worse than left) hand tremor that is worse with movement, such as writing and dressing. The tremor is partially alleviated with alcohol. He does not have a resting tremor or rigidity. Propranolol reduces the tremor, but side effects limit its utility. What is the most likely diagnosis?
* Dystonic Tremor
* **Essential Tremor**
* Parkinson’s Disease
* Orthostatic Tremor
* Dyskinesia
148
A 25 year-old man presents to the emergency room with a GCS of 3 after a high-speed motor vehicle accident. He undergoes a hemicraniectomy and evacuation of a large left hemispheric subdural hematoma. On postoperative day 4, he develops a fever with increasing oxygen requirements on the ventilator. Chest X-ray shows bilateral lung opacities. What finding best supports the diagnosis of acute respiratory distress syndrome?
* Brain natriuretic peptide level >600 pg/mL
* **Ejection fraction of 55-60% consistent with normal cardiac function**
* Lung biopsy showing interstitial fibrosis
* PaO2/FiO2 ratio >500 mm Hg
* Bronchoalveolar lavage (BAL) specimen showing 45% eosinophils
149
When comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS), what is the main difference between the two procedures in terms of stroke and cardiovascular complications?
* The rate of overall complications were higher in CAS than CEA
* **Stroke had a greater adverse effect than did myocardial infarction**
* CEA was associated with more strokes
* CAS was associated with more myocardial infarction
* CAS was associated with higher incidence of vessel rupture
150
Intraoperative test stimulation is being performed during a subthalamic nucleus deep brain stimulator placement. Stimulation at low voltages evokes dysconjugate gaze. The lead position is likely too far in which direction?
* Posterior
* Lateral
* Anterior
* **Medial**
* Superficial
151
A 9 month old male with no significant medical history presents with one week of progressive irritability and emesis. There is no reported history of trauma. Examination shows a well-developed, irritable infant with a full fontanelle but without focal neurologic deficits. He has no external signs of trauma. Head circumference has increased from the 65th percentile to the 92nd percentile since his 6-month visit. Non-contrast head computed tomography (CT) is shown. What is the most likely diagnosis?
* Subdural empyema
* **Non-accidental trauma**
* Ruptured arachnoid cyst
* Intracranial hypotension
* Benign enlargement of the subarachnoid spaces
152
A 40 year-old woman presents with acute headache, mild right arm weakness and a CT scan showing a small hemorrhage in the left frontoparietal region. Cerebral angiogram shows a 4 cm compact, superficial AVM with superficial venous drainage and deep perforating arteries. What factor increases this patient’s surgical risk?
* Compact architecture
* **Deep perforating arteries**
* Superficial venous drainage
* Superficial location
* Ruptured Presentation
153
A 55-year-old man presents to the emergency department with an acute onset of right hemiplegia that occurred 30 minutes prior. CT scan is negative for hemorrhage. What factor would contraindicate the administration of IV tPA?
* INR of 1.5
* **Refractory hypertension (SBP>180mmHg)**
* Severe Symptoms (NIHSS>8)
* Past medical history of bleeding stomach ulcer 2 years ago
* Major surgery 12 months ago
154
With respect to microsurgical resection of vestibular schwannomas, when the facial nerve loses intraoperative proximal electrical responsiveness, what factor is most predictive of facial nerve recovery postoperatively?
* **Anatomical preservation of the facial nerve**
* Cystic tumor features
* Surgical approach
* Surgery for recurrent tumor
* Tumor size
155
A 23 year old male sustains a gunshot wound to the head. On examination, his GCS is 3T, his pupils are bilaterally fixed and dilated, he has a weak gag and cough reflex, and he intermittently draws a spontaneous respiration. His non-contrast head CT demonstrates a transventricular bullet tract and a 3 mm right subdural hematoma. What is the most appropriate management for this patient?
* **Expectant care**
* Debridement of bullet tract
* Ventriculostomy
* Evacuation of subdural hematoma
* Decompressive hemicraniectomy
156
In addition to higher pre-operative seizure frequency and the presence of generalized seizures, what factor best predicts less favorable seizure outcome in the surgical management of patients with focal neocortical epilepsy?
* Gender
* Laterality of seizure origin
* **Normal MRI**
* Socioeconomic status
* Patient age
157
A 3 year old child with moyamoya is scheduled for an encephaloduroarteriosynangiosis (EDAS) indirect bypass. What is the most common cause of new perioperative neurological deficit?
* Intracranial hemorrhage
* **Cerebral ischemia**
* Cerebral edema
* Hyponatremia
* Seizure
158
What are the borders of Kawase’s triangle?
* GSPN, arcuate eminence, inferior petrosal sinus, V2
* **GSPN, arcuate eminence, superior petrosal sinus, V3**
* Foramen spinosum, arcuate eminence, superior petrosal sinus, V3
* V2, V3, and a line from the foramen rotundum and foramen ovale
* Arcuate eminence, inferior petrosal sinus, V2, V3
159
A 51 year-old woman presents to the ED with a subcutaneous fluid collection in the lumbar area two days after undergoing a redo L4-5 laminectomy/discectomy at another institution. She is afebrile and has no neurological deficits but complains of headache when she sits up or stands. What is the most likely etiology of her fluid collection?
* wound seroma
* wound hematoma
* wound infection
* subcutaneous foreign body
* cerebrospinal fluid leak
160
You are operating on a patient with a sciatic nerve sheath tumor who presents with pain and no significant neurologic defecit, and have performed the initial exposure of the lesion. You have incised the epineurium, but are unable to identify a distinct plane between tumor and nerve. What is the most appropriate maneuver at this point?
* Perform en bloc excision of the tumor, nerve, and surrounding muscle
* Excise the lesion and perform a graft repair of the nerve
* **Biopsy the lesion for frozen and permanent sections and close**
* Perform a radical subtotal excision of the lesion
* Perform nerve action potential recordings
161
You are seeing an adult male patient who sustained a left-sided brachial plexus injury 3 months ago. On examination he has weakness in the upper trunk muscles, and absent sensation in the C5 and C6 dermatomes. Electrodiagnostic studies reveal absent motor conduction in the musculocutaneous and axillary nerves. Sensory nerve action potentials in the axillary and musculocutaneous nerves are normal. What would be the most appropriate subsequent management step?
* Posterior cord graft repair
* **Nerve transfer**
* Axillary nerve neurolysis
* Observation for an additional 3 months
* Upper trunk graft repair
162
Occlusion of which artery causes the stroke shown in the figure?
* Artery of Percheron
* Medial lenticulostriate perforator
* Recurrent artery of Heubner
* **Subcallosal artery**
* Orbitofrontal Artery
163
Which of the following answers most appropriately pairs a sign or symptom of hydrocephalus (or shunt malfunction in the setting of a patient with a shunt) and an appropriate age or patient population?
* Infant - visual loss
* Adult - progressive macrocephaly
* Child - tense fontanel
* Adult - suture splaying
* Child - decline in IQ or school performance
164
During surgical resection of a brainstem cavernous malformation, a developmental venous anomaly (DVA) was detected. Which of the following is an appropriate step to take during surgery?
* Apply a clip to the DVA prior to removal of cavernous malformation
* Perform indocyanine green (ICG) video angiography
* Coagulate the associating DVA after removing the cavernous malformation
* **Preserve the associated DVA**
* Perform an intraoperative angiogram
165
In the acute workup of clinically suspected subarachnoid hemorrhage what would be the most appropriate next step in evaluation following a negative head CT?
* CT with contrast
* **Lumbar Puncture for CSF analysis**
* CT angiogram
* MRI brain with GRE sequence
* MRA circle of Willis
166
A 24 year old man presents to the ER with an acute subdural hematoma (ASDH) after falling down the stairs. CT scan shows a hematoma of 13 mm thickness. What is the appropriate management?
* **Surgical evacuation regardless of the GCS**
* Surgical Evacuation only if GCS<10
* Surgical Evacuation only if GCS>11
* Medical Management is GCS <10
* Medical management if Glascow Coma Scale (GCS) >11
167
A 6-month-old girl with a lipomyelomeningocele is undergoing surgical detethering of their lumbar lipoma, filum sectioning, arachnoid adhesion lysis, and aggressive debulking of the intradural lipoma to the margins of the neural placode. What is the next surgical step?
* Primary dural closure with an absorbable, braided suture
* Patch-graft duraplasty
* Primary dural closure with a nonabsorbable monofilament suture
* Further lipoma resection until a gross total resection is achieved
* **Pial closure and tubularization of the placode/distal cord**
168
A 58 year old male presents with longstanding progressive neck and back pain and dysphagia. The following CT is obtained. What is the most likely diagnosis?
* hypercalcemia
* rheumatoid arthritis
* age-appropriate spine
* **diffuse idiopathic skeletal hyperostosis**
* ankylosing spondylitis
169
What deep brain structure is the most appropriate deep brain stimulation target for chronic nociceptive pain?
* Subthalamic nucleus
* Ventral posterolateral nucleus of the thalamus
* **Periaqueductal grey **
* Anterior limb of the internal capsule
* Globus pallidus internus
170
A 17-year-old male presented with a heterogeneously contrast-enhancing mass within the spinal cord causing significant spinal cord expansion and compression. After laminectomy, an expansile intramedullary mass that appeared highly vascularized and infiltrative was found. A frozen section showed glioblastoma. What is the most appropriate next step in management?
* Gross total resection
* **Duraplasty without resection**
* Primary dural closure without resection
* Partial resection
* En bloc resection
171
What is the Fisher score in a patient with a 2 mm thick subarachnoid hemorrhage with no intraventricular or parenchymal extension?
* IV
* II
* I
* V
* **III**
172
A 54 year old male presented with a ruptured anterior communicating artery aneurysm. The patient underwent surgical repair. On postoperative day 5, the patient complained of mild weakness in his left leg. Transcranial Doppler showed moderate vasospasm of the right anterior cerebral artery. What is the most appropriate initial management?
* **Hyperdynamic therapy**
* Statins
* nimodipine
* intraarterial verapamil injection
* Angioplasty
173
An 11-month-old female with a history of myelomeningocele repair and ventriculoperitoneal shunt placement presents with new stridor and vocal cord paralysis. What is the most appropriate next step in management?
* Observation
* **Shunt evaluation**
* Chiari decompression
* EEG
* Tethered spinal cord release
174
A 4-year-old boy presents with progressive gait dysfunction, headache, and vomiting. A CT shows hyperdense areas suggestive of calcification. The MRI is shown (figures). What is the most likely diagnosis?
* Atypical teratoid / rhabdoid tumor (AT/RT)
* Medulloblastoma
* **Ependymoma**
* Pilocytic astrocytoma
* Choroid plexus papilloma
175
A 10-year-old girl was playing outside when she fell and landed on her head. She experienced complete loss of motor and sensory function from the neck down that resolved over the next 15 minutes. A CT is shown (figure). What is the most appropriate treatment?
* **Posterior C1-2 fusion**
* External Rigid Collar
* External Halo vest immobilization for 6-12 weeks
* Observation
* Transoral odontoidectomy
176
A 68 year-old man undergoes resection of a GBM. Post-operative imaging is shown. He awakes from surgery with left arm numbness and mild weakness. What is the most likely cause of his new deficit?
* Seizure
* Abscess
* **Ischemia**
* Edema
* Direct injury to neural structures
177
A 25 year old patient is involved in a motor vehicle accident and is intubated and sedated in the field before a complete neurological examination can be obtained. His non-contrast head CT is shown. (figure 1) What is the appropriate next step in management?
* Awaken the patient for neurological examination
* **Take to the OR for an emergent craniotomy for evacuation of hematoma**
* Place an intracranial pressure monitor and admit to ICU
* Obtain an urgent MRI with Diffusion weighted imaging
178
A 35-year-old woman has been experiencing excruciating early morning headaches localized behind the right eye, associated with ptosis and ipsilateral nasal congestion, lasting approximately 20 minutes. These symptoms have been present intermittently for 10 days. She had experienced several similar episodes in the past, lasting 1 to 2 weeks, followed by a pain-free interval. What is the most effective treatment option to abort this patient's headache once it has begun?
* Subcutaneous sumatriptan
* Intravenous fosphenytoin
* Oral dexamethasone
* **Lying in bed in a dark, quiet room**
* Oral lithium
179
A 37 year-old man presents with worsening low back pain and right L5 radicular pain and a normal examination. Lumbar spine MRI (Figure 1) and CT (Figure 2) are shown. Work-up revealed this solitary lesion. What is the most appropriate next step in management?
* Observation with serial imaging
* External beam radiotherapy
* **CT-guided biopsy**
* Open surgical biopsy
* Surgical excision and stabilization
180
When counseling a patient regarding temporal lobectomy for temporal lobe epilepsy, what is the most consistent and important predictor of a very favorable outcome after surgery?
* Greater than 50 years old
* Confirmation of laterality based on invasive monitoring
* Duration of epilepsy 20 years
* **Absence of generalized seizures preoperatively**
* Male gender
181
Decompressive craniectomy has been shown to have what effect in adult patients with severe traumatic brain injury and elevated intracranial pressure (ICP) values that are refractory to first-tier therapies?
* **Reduce ICP**
* Increase number of days in the ICU stay
* Increase mortality
* Decrease rates of vegetative state
* Improved the rate of good outcome as assessed by the Extended Glasgow Outcome Scale at 6 months
182
In Yasargil’s classification, a type 4 vein of Galen malformation (VGA) is:
* **A parenchymal arteriovenous malformations (AVMs) which drains into the vein of Galen**
* A VGA associated with an aneurysm
* A direct fistulous communication with the vein of Galen
* A VGA associated with a cavernoma
* A VGA associated with hydrocephalus
183
A 36 year old restrained driver presented after a motor vehicle collision. What is the classification of the spinal injury illustrated in the figure?
* Burst fracture
* Fracture dislocation
* **Chance fracture**
* Teardrop fracture
* Compression fracture
184
What is the first clinically important branch given off by the upper trunk of the brachial plexus?
* **Suprascapular nerve**
* Axillary nerve
* Dorsal scapular nerve
* Musculocutaneous nerve
* Phrenic nerve
185
What is the most common side effect of vagus nerve stimulation?
* **Voice hoarseness**
* Dyspepsia
* Wound infection
* Cardiac arrhythmia
* Dyspnea
186
An 80-year-old male presents with headache, confusion, and the accompanying MR imaging (figure). If the perfusion MRI demonstrates low relative cerebral blood flow, what is the most likely diagnosis?
* Glioblastoma multiforme
* **Primary CNS lymphoma**
* Low grade glioma
* Ependymoma
* Metastatic adenocarcinoma
187
In a patient with the MRI shown in the figure, a tumor in what other location would increase the probability of germinoma?
* **Suprasellar region**
* Brainstem
* Fourth ventricle
* Orbit
* Frontal lobe
188
Pathology at the level of which structure is most likely to cause isolated, unilateral weakness of ankle dorsiflexion and inversion?
* S1 nerve root
* **L5 nerve root**
* L4 nerve root
* Peroneal nerve
* Tibial nerve
189
What monitoring modality has the greatest sensitivity for detection of a venous air embolus?
* Precordial Doppler
* **Transvenous intracardiac echocardiography**
* EKG
* Pulmonary artery pressure
* Pulse oximetry
190
A view of the fundus (lateral end) of the internal acoustic meatus is shown in the figure. Which number represent the location of the cochlear nerve segment?
* 1
* **5**
* 2
* 3
* 4
191
What is the mechanism of action of clopidogrel (Plavix)?
* Direct inhibition of thrombin
* Direct inhibition of factor Xa
* Inhibition of plasminogen
* Activation of antithrombin III
* **Inhibition of the adenosine diphosphate (ADP) chemoreceptor, P2Y**
192
Which of the following are the cardinal motor symptoms of Parkinson disease (PD) that are most amenable to treatment with deep brain stimulation (DBS)?
* Dyskinesia, bradykinesia and rigidity
* **Bradykinesia, rigidity and tremor**
* Dystonia, dyskinesia and tremor
* Dyskinesia, dystonia and freezing of gait
* Freezing of gait, rigidity and tremor
193
A 4 year old child with symptomatic unilateral moyamoya syndrome was treated with surgical revascularization. At 1-year postoperatively, an angiogram revealed stable arteriopathy and excellent postsurgical collateral development. Cerebral blood flow studies show normalization of flow and clinically the child is symptom-free. What is the appropriate follow-up plan?
* **Clinical visits annually with detailed neurologic examinations and MRI/MRA annually for 5 years**
* Clinical visits or imaging only if symptoms recur, otherwise just routine follow-up with the pediatrician
* Clinical visits with annual CT imaging
* Clinical visits annually with detailed neurologic examination, but no imaging is needed
* No follow-up is needed.
194
A 10 year old child is referred to your interdisciplinary spasticity clinic. It is determined that he has spasticity as well as significant disabling dystonia in all four extremities, the face, and the neck. His symptoms have been medically refractory. What is the most appropriate treatment?
* Stereotactic pallidotomy
* **Intrathecal baclofen therapy**
* Selective dorsal rhizotomy
* Deep brain stimulation
* Botox injections
195
A 65-year-old male with a history of hypertension and diabetes presents to the emergency room after experiencing severe headache. The Glasgow Coma Scale (GCS) is 14. On head CT scan, the patient was found to have a 2 cm acute cerebellar hematoma with no hydrocephalus. What is the most appropriate management?
* Posterior fossa craniectomy
* **Medical management in an ICU setting**
* External ventricular drainage
* Stereotactic aspiration and infusion of thrombolytic agents
* Surgical evacuation
196
A four-year-old presents with occipital headaches and a lesion on brain MRI. He also has cafe-au-lait spots and axillary freckling. Patients with his disease are most likely to have a tumor in what intracranial location?
* Auditory canal
* Brainstem
* Cerebral cortex
* Cerebellum
* **Optic pathway**
197
What is a known genetic predisposition to cavernous malformations?
* There is no genetic predisposition
* VHL gene
* BRAF gene
* **KRIT1 gene**
* IDH1 gene
198
A chronic alcoholic presents in acute withdrawal with hypoglycemia and altered mental status. Administraton of glucose must be preceded by which of the following?
* Ativan
* Insulin
* **Thiamine**
* Labetaolol
* Fosphenytoin
199
A 23 year-old man presents to the emergency department after an intoxicated fall and head injury. He has a moderate occipital headache and nausea without vomiting. On exam, the patient has normal vital signs and no focal neurological deficits. His non-contrast head CT is shown (Figure 1). The volume of the hematoma is measured to be 35 cm3. What is the most appropriate treatment for this patient?
* **Posterior fossa craniotomy for evacuation of hematoma**
* Embolization of the transverse sinus
* Burr hole evacuation of hematoma
* External ventricular drain for CSF diversion and intracranial pressure monitoring
* Close neurological monitoring with serial head CT imaging
200
An 8-year-old girl presents with obstructive triventricular hydrocephalus requiring endoscopic exploration of the ventricular system. What is the most appropriate site for surgical fenestration?
* **Third ventricle floor anterior to the mammillary bodies**
* Septum pellucidum superior to the fornices
* Pineal recess
* Lamina terminalis above the suprachiasmatic recess
* Third ventricle floor anterior to the infundibular recess
201
A 9 month old boy presents with single sutural synostosis (figure 1). On exam his fontanelle is closed and there is no papilledema. What associated finding may be diagnosed in this patient?
* Chiari type II malformation
* Syringomyelia
* Tethered cord syndrome
* **Increased intracranial pressure**
* Dandy-Walker malformation
202
What type of tumor harbors the histopathological structure seen in the figure?
* Glioblastoma
* Pilomyxoid astrocytoma
* Ependymoma
* Anaplastic oligodendroglioma
* **Pleomorphic xanthoastrocytoma**
203
A 55-year-old man is seen with early Parkinson disease manifested by tremor, rigidity, and bradykinesia. What is the preferred initial medication for treating this patient's Parkinson disease?
* catechol methyltransferase inhibitor
* levodopa
* **dopamine agonist**
* combination of levodopa and an anticholinergic
* anticholinergic
204
