Tumor

Question 1

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?
a. surgical approach
b. Anatomical preservation of the facial nerve
c. Surgery for recurrent tumor
d. Tumor size
e. Cystic tumor features

Answer 1

b. Anatomical preservation of the facial nerve

Question 2

What imaging finding of a sphenoid wing meningioma significantly diminishes the possibility of safe gross-total resection?
a. cerebral edema
b. cavemous sinus invasion
c. Tumor size
d. Infratemporal fossa extension
e. Optic canal extension

Answer 2

b. cavemous sinus invasion

Question 3

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?
a. Pleomorphic xanthoastrocytoma
b. Ependymoma
c. Pilocytic astrocytoma
d. Ganglioglioma
e. Glioblastoma

Answer 3

d. Ganglioglioma

Question 4

A 4-week-old was transferred to the Trauma Service from an outlying emergency department after an evaluation for a seizure that
included a CT scan of the head (Figure 1). What additional diagnostic investigation is most appropriate?
a. Urine amino acids
b. Lumbar puncture
c. Cerebral angiography
d. Skeletal survey
e. Echocardiography

Answer 4

e. Echocardiography

Question 5

Parkinson’s triangle on the lateral wall of the cavernous sinus is bounded by which two cranial nerves or cranial nerve divisions:
a. Ophthalmic and maxillary divisions of trigeminal nerve.
b. Maxillary and mandibular divisions of trigeminal nerve.
c. Oculomotor nerve and maxillary division of trigeminal nerve.
d. Trochlear nerve and ophthalmic division of trigeminal nerve.
e. Abducens nerve and Oculomotor nerve.

Answer 5

d. Trochlear nerve and ophthalmic division of trigeminal nerve.

Question 6

What extent of surgical resection of low grade gliomas contributes to a survival benefit?
a. 25-50%
b. 0-25%
c. 50-75%
d. 75-100%

Answer 6

d. 75-100%

Question 6

A 48-year-old woman with metastatic colorectal cancer develops worsened left arm and leg weakness. The MRI demonstrates a 2.9 cm enhancing mass in the right
pre-motor cortex with extensive associated vasogenic edema and 3 mm of transfalcine herniation as well as two other subcentimeter lesions. Given the patient
otherwise has no systemic disease burden, what is the best treatment of this patient’s intracranial disease?
a. Whole brain radiation therapy alone
b. Needle biopsy of the largest lesion and subsequent chemotherapy
c. Surgical resection of the largest lesion followed by radiation therapy
d. Stereotactic radiosurgery to all three lesions
e. Surgical resection of all three lesions

Answer 6

c. Surgical resection of the largest lesion followed by radiation therapy

Question 6

What neurological deficit is most at risk with surgery for the lesion shown (figures 1 and 2)?
a. Gerstmann syndrome
b. Upgaze palsy
c. Expressive aphasia
d. Diplopia
e. Anterograde amnesia

Answer 6

e. Anterograde amnesia

Question 7

On which chromosome is the gene mutation associated with the syndrome depicted by the MRI shown (figure)?
a. 9
b. 11
c. 17
d. 22
e. 3

Answer 7

d. 22

Question 8

47-year-old man with history of tympanomastoidectomy for cholesteatoma presents to an otolaryngologist for headaches and fullness in the ear. A temporal bone CT
scan was performed which demonstrates a large tegmen defect and soft tissue signal in the mastoid cavity. The otolaryngologist is concerned about a cholesteatoma
recurrence and cannot rule out presence of an encephalocele. What would be the most appropriate imaging modality to distinguish the two entities?
a. MR spectroscopy
b. FDG-PET scan
c. Diffusion-weighted MRI
d. Thin cut temporal bone CT
e. CT cisternogram

Answer 8

c. Diffusion-weighted MRI

Question 9

Which form of systemic cancer therapy is associated with an increased risk of radiation necrosis after stereotactic radiosurgery for cerebral metastases?
a. Cytotoxic Chemotherapy (e.g. DNA synthesis / Mitosis Inhibitors)
b. Systemic Immunotherapy (e.g. PD-1 inhibitors)
c. Tumor Targeted Chemotherapy (e.g. EGFR or ALK antagonists)
d. Glucocorticoid Therapy
e. Angiogenesis Inhibitors (€.g. Anti-VEGF antibody)

Answer 9

b. Systemic Immunotherapy (e.g. PD-1 inhibitors)

Question 10

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?
a. E.Coli
b Staph. aureus
c. Enterococcus sp
d. Streptococcus
e. Propionibacterium acnes

Answer 10

b Staph. aureus

Question 11

A7-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?
a. Conformal radiotherapy
b. Whole-brain radiation
c. Surgical debulking
d. Gamma-knife
e. Chemotherapy.

Answer 11

a. Conformal radiotherapy

Question 12

In a 50 year old female presenting with a 1 cm pineal region mass, what would be the most likely diagnosis (based upon incidences cited in the literature)?
a. Germ cell tumor.
b. Pineocytoma.
c. Pineoblastoma.
d. Metastasis.
e. Meningioma.

Answer 12

b. Pineocytoma.

Question 13

Following transsphenoidal resection of a large craniopharyngioma, the manifestations of a classic triphasic response are which of the following?
a. Hypemnatremia - Normonatremia or Hyponatremia - Hypernatremia.
b. Hyponatremia - Normonatremia or Hypernatremia - Hyponatremia.
c. Hyponatremia - Hypernatremia - Hyponatremia.
d. Normonatremia - Hyponatremia - Normonatremia.
e. Normonatremia - Hypernatremia - Normonatremia.

a. Hypemnatremia - Normonatremia or Hyponatremia - Hypernatremia.

Question 14

A 24-year-old woman presents with a history of menstrual iregularity and headache. Magnetic resonance (MR) imaging reveals a nonenhancing 1.6-cm tumor of the
sellar/suprasellar region with displacement of the optic chiasm. If the patient was noted to have a prolactin level of 265, which of the following is the most appropriate
management strategy?
a. craniotomy for decompression of the optic apparatus.
b. stereotactic radiosurgery
c. transsphenoidal resection.
d. observation
e. dopamine agonist with serial visual fields

Answer 14

e. dopamine agonist with serial visual fields

Question 15

A 61-year-old man undergoes resection of a 3.5 cm glioblastoma with 99% extent of resection. He is neurologically intact and has a post-operative Karnofsky
Performance Status of 80. What is the most appropriate selection for post-operative adjuvant radiation therapy in this patient?
a. External-beam radiation to the tumor bed at 60Gy
b. Stereotactic radiosurgery to the tumor bed at 12Gy
c. Stereotactic radiosurgery to the tumor bed at 30Gy
d. No adjuvant radiation is indicated
e. Whole-brain radiation at 30Gy

Answer 15

a. External-beam radiation to the tumor bed at 60Gy

Question 16

A 25-year-old man presents with a new onset of right facial droop associated with horizontal diplopia. MRI of the brain shows a brainstem hyperintensity on T2 and FLAIR images (see figure). What anatomical structure is affected by this lesion causing the
diplopia?
a. Abducens fibers
b. Trapezoid body
c. Trochlear nucleus
d. Medial longitudinal fasciculus
e. Abducens nucleus

Answer 16

e. Abducens nucleus

Question 17

The addition of which chemotherapeutic agent to radiation therapy has been shown to increase overall survival in patients with newly diagnosed anaplastic
oligodendroglioma?
a. Carbotaxol
b. Procarbazine/lomustine/vincristine (PCV)
c. Bevacizumab
d. Lomustine (CCNU)
e. Methotrexate

Answer 17

b. Procarbazine/lomustine/vincristine (PCV)

Question 18

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?
a. Seizure
b. Direct injury to neural structures
c. Abscess
d. Edema
e. Ischemia

Answer 18

e. Ischemia

Question 19

A view from above into the anterior third ventricle is shown. The ideal location for performing a third ventriculostomy is indicated by
which number?
a. 6
b. 8
c. 9
d. 7
e. 5

Answer 19

b. 8

Question 20

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?
a. The anterior condylar vein
b. The dentate ligament
c. Transverse ligament of atlas
d. Jugular bulb
e. The vertebral artery

Answer 20

a. The anterior condylar vein

Question 21

Neurophysiological monitoring during translabrynthine resection of a vestibular schwannoma with minimal extension into the cerebellopontine angle includes which of
the following?
a. BAERand IX, X, XI nerves
b. BAER and SSEP
c. BAER and VIl nerve
d. SSEP and VIl nerve
e. SSEP and IX, X, XI nerves

Answer 21

d. SSEP and VIl nerve

Question 22

Which genetic or chromosomal alteration is associated with primary adult glioblastoma?
a. 1p19q chromosomal deletion
b. Wnt signaling pathway mutations
c. TP53 and ATRX mutations
d. SMARCB1/INI1 mutation or deletion
e. EGFR and CDNK2A/CDNK2B mutations

Answer 22

e. EGFR and CDNK2A/CDNK2B mutations

Question 23

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? a. Phonemic b. Semantic c. Remote d. Perseverative e. Neologistic

Answer 23

a. Phonemic

Question 24

Which of the following indicates a biochemical cure of acromegaly after surgical resection of a GH-secreting pituitary adenoma? a. IGF-1 increase immediately postoperatively of 100pg/L/day, compared to preoperative levels b. Random serum GH level of 0.4pg/L, and age- and sex- matched normalization of random IGF-1 serum levels c. Age- and sex- matched normalization of serum IGF-1 levels and GH level of 0.4pg/L following oral glucose load d. Delayed normalization of GH levels which were elevated immediately after surgery e. Age- and sex- matched normalization of serum GH levels, and fasting morning IGF-1 levels of 0.4pg/L

Answer 24

c. Age- and sex- matched normalization of serum IGF-1 levels and GH level of 0.4pg/L following oral glucose load

Question 25

An 8-year-old boy was evaluated due to short stature and headaches. Sagittal MRI with contrast (figure) is most consistent with what diagnosis? a. Craniopharyngioma b. Germinoma c. Arachnoid cyst d. Medulloblastoma e. Pituitary macroadenoma

Answer 25

a. Craniopharyngioma

Question 26

During a pterional exposure of the sylvian fissure, you encounter significant brain swelling. In order to achieve rapid brain relaxation, identify the most appropriate point on the associated figure through which to place a ventriculosotomy and access the frontal hom of the lateral ventricle a. 5 b. 3 c. 2 d. 4 e. 1

Answer 26

c. 2

Question 27

A neurologically intact 63-year-old man is diagnosed with small-cell lung cancer (SCLC) after biopsy. Brain MRI reveals no evidence of metastatic lesions. He has mediastinal lymph node involvement and is started on chemotherapy with good systemic response. What additional treatment strategy is helpful to improve odds of survival? a. Prophylactic erlotinib treatment b. No additional treatment necessary c. Prophylactic bevacizumab treatment d. Prophylactic cranial radiation e. Surveillance brain MRI every three months

Answer 27

d. Prophylactic cranial radiation

Question 28

A 32 year-old man has surgery for a low grade glioma. What genetic profile is associated with the best prognosis? a. IDH wild type without TERT promoter mutation b. IDH mutation with 1p19q co-deletion c. IDH mutation without 1p19q co-deletion d. IDH wild type without 1p19q co-deletion e. IDH wild type with TERT promoter mutatio

Answer 28

b. IDH mutation with 1p19q co-deletion

Question 29

A 58 year-old man with history of lung adenocarcinoma presents with headaches. MRI of the brain shows 3 supratentorial lesions, the largest of which is shown (Figure). The patient undergoes stereotactic radiosurgery to each of the three lesions. Based on randomized controlled trials, how is the addition of whole brain radiation therapy likely to affect overall survival? a. tis likely not to affect overall survival b. There is conflicting evidence regarding c. overall survival c.. Itis likely to shorten overall survival d. There is insufficient evidence regarding overall survival e. tis likely to lengthen overall survival

Answer 29

A 58 year-old man with history of lung adenocarcinoma presents with headaches. MRI of the brain shows 3 supratentorial lesions, the

Question 30

To which part of the optic pathway would the presence of macular sparing in a hemianopic visual field deficit localize? a Optic Tract b. Optic Nerve c. Primary Visual Cortex d. Optic Chiasm e. Optic Radiation

Answer 30

c. Primary Visual Cortex

Question 31

Curvilinear restricted diffusion may be seen along the margin of a resection cavity on immediate postoperative MRI after gross total resection of a glioma. What pathological process does this restricted diffusion pattern usually develop into? a.Territorial infarct b. Recurrent tumor c. Hematoma d. Abscess e. Gliosis

Answer 31

e. Gliosis

Question 32

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? a. Pituitary apoplexy. b. Complicated migraine. c. Myasthenic crisis. d.Keams-Sayre syndrome. e. PCOM aneurysm

Answer 32

a. Pituitary apoplexy.

Question 33

In a patient with the MRI shown in the figure, a tumor in what other location would increase the probability of germinoma? a. Suprasellar region b. Fourth ventricle c. Frontal lobe d. Orbit e. Brainstem

Answer 33

a. Suprasellar region

Question 34

A 56-year-old man with a 5-cm right temporal glioma presents with a generalized tonic-clonic seizure, which was not broken after two doses of intravenous benzodiazepine administration. What is the most appropriate acute management of this patient's seizures? a. Oral oxcarbazepine b. Intravenous phenobarbitalO c. Immediate surgical resection without anti-epileptic drug administration d. Oral levetiracetam e. Intravenous fosphenytoin

Answer 34

e. Intravenous fosphenytoin

Question 35

A pineal mass was completely resected and the pathologist diagnoses a mature teratoma. What is the best treatment for this patient? a. Craniospinal irradiation b. Radiosurgery to the resection cavity c. Observation d. Fractionated local radiation therapy e. Chemotherapy

Answer 35

c. Observation

Question 36

A 62 year-old right handed woman with a malignant glioma undergoes awake craniotomy and gross total resection of the contrast enhanced tumor. What clinical deficit can have the most negative impact on overall survival? a. Post-operative speech deficit b. Post-operative motor deficit c. Post-operative Gerstmann Syndrome d. Post-operative seizures e. Post-operative visual deficit

Answer 36

a. Post-operative speech deficit

Question 37

A 47 year old man presents with confusion, agitation, fatigue, fever (104F), hyponatremia, hypoglycemia, and hypotension after resection of a right frontal metastasis lesion 3 weeks ago. Phenytoin and steroids were discontinued at 2.5 weeks post-operatively. Head CT reveals no acute abnormality. What is the most appropriate management of this patient? a. Haloperidol b. Hydrocortisone c. Fludricortisone d. Heparin e. Fosphenytoin

Answer 37

b. Hydrocortisone

Question 38

A 48 year old woman presents with a one week history of progressive facial paresis, severe right ear pain, vertigo imbalance and hearing loss. Her past medical history is unremarkable. She has right beating nystagmus. Based on the MRI scan (figures) what is your diagnosis a. Vestibular schwannoma b. Zoster oticus c. Facial nerve schwannoma d. Facial nerve hemangioma e. Bell palsy

Answer 38

b. Zoster oticus

Question 39

A 33 year old woman with no neurological history complains of subtle left upper extremity weakness without headache or other symptoms. She is noted to have a mild left hemiparesis and otherwise normal neuroiogical examination. EEG is normal. The MR scan is shown (figure). A stereotactic biopsy yields no evidence of glioma. What is the most likely diagnosis? a. subacute sclerosing panencephalitis b. Progressive multifocal leukoencephalopathy c. Demyelinating plaque d. Glioblastoma multiforme e. Lymphoma

Answer 39

c. Demyelinating plaque

Question 40

An 8 year old boy was evaluated due to short stature and headaches. Sagittal MRI with contrast below is most consistent with which diagnosis? a. Medulloblastoma b. Germinoma c. Arachnoid cyst d. Craniopharyngioma e. Pituitary macroadenoma

Answer 40

d. Craniopharyngioma

Question 41

revealed this tumor to be a chordoma. An extensive subtotal skull-based resection was performed. Which is the best choice for adjuvant therapy regimen? a. Stereotactic radiosurgery b. Proton beam radiotherapy c. Procarbazine, CCNU and vincristine (PCV) chemotherapy d. Brachytherapy e. Conventional fractionated radiotherapy

Answer 41

b. Proton beam radiotherapy

Question 42

AT70-year-old man presents with new onset progressive confusion, expressive dysphasia, and right hemiparesis. MRI shows multiple enhancing intracerebral masses with surrounding edema that resolve after a short course of steroids. What is the most likely diagnosis of these lesions? a. central nervous system sarcoidosis. b. multifocal glioma. c. multiple sclerosis. d. multiple metastases. e. primary central nervous system lymphoma.

Answer 42

e. primary central nervous system lymphoma.

Question 43

A 42-year-old man with shock-like right facial pain radiating from pre-auricular area of right ear into the right lower jaw, teeth and tongue. Symptoms are triggered by facial movement, shaving, and chewing. Empiric medical management with carbamazepine gave incomplete pain relief but made him feel woozy. What is the next step in the patient's management? a Microvascular decompression b. Stereotactic radiosurgery c. Addition of a muscle-relaxing agent d. Magnetic resonance imaging e. Botox injection

Answer 43

d. Magnetic resonance imaging

Question 44

What is the most appropriate initial management of newly-diagnosed primary CNS lymphoma in an immunocompetent patient? a. Stereotactic radiosurgery b. Gross total resection c. Oral temozolomide d. Intrathecal cytarabine e. IV methotrexate

Answer 44

e. IV methotrexate

Question 45

Histopathology of a cerebellopontine angle tumor is shown in the figures below. The findings are most consistent with what type of pathology? a. Psammomatous meningioma b. cholesteatoma c. Endolymphatic sac tumor d. Choroid plexus papilloma e. Schwannoma

Answer 45

e. Schwannoma

Question 46

What primary intracranial tumor type has the highest frequency of BRAF-V600E mutations? a. Pituitary adenomas b. Meningiomas c. Gangliogliomas d. Schwannomas e. Glioblastomas

Answer 46

c. Gangliogliomas

Question 47

A 59 year-old man presents with high frequency sensorineural hearing loss, near normal speech discrimination (90% at 40 dB), and an MRI showing a uniformly enhancing 10-mm mass extending into the internal auditory canal. What is the most likely complication of stereotactic radiosurgery for this lesion? a. Diplopia b. Swallowing difficulty c. Facial numbness d. Facial weakness e. Hearing loss

Answer 47

e. Hearing loss

Question 48

During endoscopic endonasal transsphenoidal surgery, which of the following vascular structures is most likely to be injured? a. Sphenopalatine artery b. Basilar artery c. Internal maxillary artery d. Carotid artery e. Vidian artery

Answer 48

a. Sphenopalatine artery

Question 49

Which MRI sequence is used to non-invasively assess the structural connectivity of the brain? a. DWI b. FIESTA c. DTl d. FLAIR e. T2

Answer 49

c. DTl

Question 50

What radiotherapy modality for intracranial meningioma is associated with the lowest risk of symptomatic radiation injury? a. Fractionated radiation therapy b. Linear accelerator radiosurgery c. Gamma knife radiosurgery d. Hypofractionated stereotactic radiotherapy e. Proton Beam Radiotherapy

Answer 50

a. Fractionated radiation therapy

Question 51

A 10 year-old girl presents with signs of accelerated pubertal stage, convergence-retraction nystagmus, and impaired upward gaze. Which of the following lesions would amost likely be the cause of the findings described? a. Muttiple sclerosis b. Pineal region tumor c. Pontine glioma d. Medulloblastoma e. Acqueductal stenosis

Answer 51

b. Pineal region tumor

Question 52

Based on the cerebral angiogram, which vessel is the PRIMARY arterial blood supply for this tumor? a. Superior cerebellar artery. b. Meningohypophyseal trunk c. Middle meningeal artery. d. Persistent trigeminal artery. e. Ascending pharyngeal artery.

Answer 52

b. Meningohypophyseal trunk

Question 53

A 45-year-old male presents with several months of progressive headaches and an intracranial lesion (figure). Following surgical resection, histopathological analysis demonstrates a well-circumscribed, uniformly cellular tumor with no atypia and numerous ectatic thin-walled branching vessels in staghorn configurations. Which of the following is a possible associated clinical development? a. Bilateral vestibular schwannomas b. Unilateral optic nerve glioma c. De novo glioblastoma d. Pheochromocytoma e. Metastases outside the CNS

Answer 53

e. Metastases outside the CNS

Question 54

A 47-year-old woman presented with a first seizure and underwent magnetic resonance imaging of the brain with multi-voxel spectroscopy. The spectroscopy shown in Figure 1 is most consistent with what diagnosis? a. toxoplasmosis b. demyelinating plague c. meningioma d. glial neoplasm e. Dbacterial abscess

Answer 54

d. glial neoplasm

Question 55

A 24-year-old woman presents with right arm weakness and the accompanying T1-weighted, contrast-enhanced MRI. Stereotactic needle biopsy demonstrates Rosenthal fibers on histopathological analysis. Which of the following treatment paradigms is associated with long-term disease control? a. Radiotherapy combined with high-dose corticosteroids b. Radiotherapy alone c. Radiotherapy combined with IV methotrexate d. Complete microsurgical resection followed by adjuvant radiotherapy e. Complete microsurgical resection alone

Answer 55

e. Complete microsurgical resection alone

Question 56

During the extended middle fossa approach for a skull base tumor resection, removal of the bone posterior to the foramen ovale and beneath the greater superficial petrosal nerve has a risk of injury to which vascular structure? a. Middle Cerebral Artery b. Petrous Internal Carotid Artery c. Condylar vein. d. Sigmoid sinus. e. Vertebral artery.

Answer 56

b. Petrous Internal Carotid Artery

Question 57

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 Tuberous sclerosis b. Ataxia-telangiectasia c. Von Hippel-Lindau d. Neurofibromatosis-1 e. Neurofibromatosis-2

Answer 57

d. Neurofibromatosis-1

Question 58

A 35 year old female presents with headaches and progessive left sided hearing loss. What is the BEST treatment for the lesion depicted in the MR images? a. Endoscopic fenestration b. Craniotomy for lesion removal c. Radiation therapy d. Stereotactic aspiration e. Cystoperitoneal shunt

Answer 58

b. Craniotomy for lesion removal

Question 59

Gorlin or nevoid basal cell carcinoma syndrome is associated with increased incidence of medulloblastoma. The syndrome is caused by a germ line mutation in which gene? a. ApcC b. TP53 c. SMO d. Whnt e. PTCH1

Answer 59

e. PTCH1

Question 60

What factor may increase the risk of seizures during awake craniotomy procedures starting with general anesthesia as compared to conscious sedation? a. Allergic reaction to general anesthesia b. Higher stimulation amplitudes for cortical stimulation c. Negative seizure history d. The transition from asleep to awake states e. Lower seizure thresholds during general anesthesia

Answer 60

b. Higher stimulation amplitudes for cortical stimulation

Question 61

In the case of an intracanalicular vestibular schwannoma, what is the advantage of the middle cranial fossa approach over the retrosigmoid approach? a. Improved preservation of vestibular nerve function. b. Early identification of the distal facial nerve. c. Decreased risk of injuring the greater superficial petrosal nerve. d. Decreased risk of CSF leak. e. Decreased risk of postoperative seizure

Answer 61

b. Early identification of the distal facial nerve.

Question 62

On histopathology, central neurocytoma has strong positivity with which stain? a. s100 b. Synaptophysin c. EMA d. Vimentin e. GFAP

Answer 62

b. Synaptophysin

Question 63

When resecting a brain lesion near the corticospinal tract, what modality is best suited to minimize the risk of motor impairment? a. Quantitative subcortical motor mapping b.Direct cortical stimulation motor evoked potential monitoring c. Somatosensory evoked potential monitoring d. Phase-reversal mapping e. Nerve conduction study

Answer 63

a. Quantitative subcortical motor mapping

Question 64

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? a. Uncinate fasciculus b. Arcuate fasciculus c. superior longitudinal fasciculus Il d. superior longitudinal fasciculus 11l e. Frontal aslant tract

Answer 64

e. Frontal aslant tract

Question 65

What are the borders of Kawase's triangle? a. Arcuate eminence, inferior petrosal sinus, V2, V3 b. V2, V3, and a line from the foramen rotundum and foramen ovale c. GSPN, arcuate eminence, inferior petrosal sinus, V2 d. Foramen spinosum, arcuate eminence, superior petrosal sinus, V3 e. GSPN, arcuate eminence, superior petrosal sinus, V3

Answer 65

e. GSPN, arcuate eminence, superior petrosal sinus, V3

Question 66

What characteristic histological feature of a meningioma is depicted in the encircled areas of the slide? a. Endothelial proliferation b.Vacuolation c. Verocay bodies d. Mitotic figures e. Psammoma bodies

Answer 66

b.Vacuolation

Question 67

A 45 year old man presents with horizontal diplopia consistent with a left abducens nerve palsy. Which of the following findings would BEST localize the lesion to the cavernous sinus? a. Ipsilateral optic neuropathy. b. Contralateral hemianopia. c. Contralateral hemiparesis. d. Ipsilateral Horner's syndrome. e. Papilledema.

Answer 67

d. Ipsilateral Horner's syndrome.

Question 68

Following surgical resection of glioblastoma, standard therapy includes radiotherapy with concomitant temozolomide. What is the standard radiation dose given over 30 fractions? a. 30 Gy b. 50 Gy c. 60 Gy d. 20 Gy e. 40 Gy

Answer 68

c. 60 Gy

Question 69

What is the diagnostic success rate of a stereotactic brainstem biopsy for a suspected tumor? a. 85-99% b. 70-84% c. 25-39% d. 40-54% e. 55-69%

Answer 69

a. 85-99%

Question 70

What combination of IDH and 1p-19q status in diffuse glioma is most predictive of detecting a P53 gene mutation? a. IDH mutant, 1p-19q co-deleted b. IDH mutant, 1p-19q intact c. IDH wild-type, 1p-19q intact d. IDH wild-type, 1p-19q co-deleted e. IDH mutant, 1p intact and 19q deleted

Answer 70

b. IDH mutant, 1p-19q intact

Question 71

A 10-year-old boy presents with headache and imbalance. Examination discloses mild papilledema, right-sided dysmetria, and ataxia. MRI with contrast is shown in the figure. What is the most important prognostic factor for this patient? a. The extent of resection of the cyst walls b. The extent of resection of the enhancing mass c. The presence of endothelial proliferation on histology d. The presence of mitoses on histology e. The presence of hydrocephalus at presentation

Answer 71

b. The extent of resection of the enhancing mass

Question 72

A 58 year old woman with a history of breast cancer presents with lower thoracic spine pain. The pain is worse at night and does not worsen with movement. She is neurologically intact. An MRI reveals a contrast-enhancing lytic lesion isolated to the T12 body without evidence of fracture. There are multiple smaller lesions noted throughout her entire spinal axis. She is currently undergoing systemic therapy for her bone only disease. What is the most appropriate treatment option for this patient? a. Percutaneous biopsy and vertebroplasty followed by radiosurgery. b. Fractionated extemal beam radiotherapy. c. T12 vertebrectomy with pedicle screw instrumentation followed by radiotherapy. d. Percutaneous biopsy and vertebroplasty followed by conventional fractionated radiotherapy. e. Posterior T12 laminectomy with pedicle screw instrumentation followed by radiotherapy.

Answer 72

b. Fractionated extemal beam radiotherapy.

Question 73

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? a. Touch a skull reference point b. Ignore the shift if minor c. Re-register d. Use a software correction algorithm e. Return the reference frame to its previous position

Answer 73

c. Re-register

Question 74

A Central American patient presents with new onset seizures. CT shows hydrocephalus, and multiple calcified lesions. MRI demonstrates rim-enhancing cysts throughout the brain. What is the most likely etiology? a. Entamoeba histolytica b. Taenia solium c.Toxoplasma gondii d. Schistosoma mansoni e. Plasmodium falciparum

Answer 74

b. Taenia solium

Question 75

What is the next appropriate step in management following resection of an epidermoid tumor? a. Prophylactic antibiotics b.Radiographic surveillance c.Fractionated radiotherapy d. Brachytherapy e.Intracystic chemotherapy

Answer 75

b.Radiographic surveillance

Question 76

A patient with a history of whole brain radiation for metastatic disease presents with a new 1.5 cm brain metastasis. What is the RTOG criteria for the maximum radiation dose that should be given in a single fraction to the new lesion? a.18 Gy b.20 Gy c.15 Gy d.24 Gy e.12 Gy

Answer 76

d.24 Gy

Question 77

What tumor histology is associated with highest risk of cerebral hemorrhage in patients receiving therapeutic anticoagulation for deep vein thromboses and pulmonary emboli? a. Melanoma b.Glioma c. Non-Small Cell Lung Carcinoma d. Renal Carcinoma e. Choriocarcinoma

Answer 77

b.Glioma

Question 78

The figure is a cadaveric dissection of the anterior portion of the left cavernous sinus. What deficit would be seen with damage to this structure? a Facial numbness b Diplopia that corrects with head tilt c Monocular blindness d Periocular numbness e Ptosis, meiosis and anhydrosis

Answer 78

e Ptosis, meiosis and anhydrosis

Question 79

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? a chemotherapy alone b Surgical resection followed by conformal radiation therapy to the tumor bed and systemic chemotherapy c Surgical resection followed by conformal radiation therapy to the tumor bed d Surgical resection e Neo-adjuvant radiation therapy followed by chemotherapy

Answer 79

c Surgical resection followed by conformal radiation therapy to the tumor bed

Question 80

A 46 year-old woman with recurrent Cushing's disease after transsphenoidal resection has MR proven extension of tumor into the cavernous sinus without supraseliar extension. She elects to undergo radiosurgery. What is the MOST likely complication after pituitary adenoma radiosurgery? a.Carotid artery occlusion b.Visual loss c.Diplopia d.Anterior pituitary insufficiency e.Diabetes insipidus

Answer 80

d.Anterior pituitary insufficiency

Question 81

What finding on MRI carries the highest risk for development of seizures in the setting of a newly diagnosed posterior fossa lesion? a. Extensive T2 hyper-intensity in the surrounding tissue b.Presence of blood-product on gradient echo imaging c.Size greater than 3cm d.Homogenous enhancement after administration of gadolinium e.Hydrocephalus

Answer 81

e.Hydrocephalus

Question 82

Paragangliomas of the jugular foramen derive from what cell type? a. Meningoepithelial cells b. Epithelial cells of ectodermal origin from the stomodeum c. Cerebellar stem cells d. Chromaffin cells of neuro-ectodermal origin e. Germ cells that migrated aberrantly

Answer 82

d. Chromaffin cells of neuro-ectodermal origin

Question 83

A 75-year-old woman presents with a 2-month history of progressive difficulty walking, headache, and memory difficulties. Magnetic resonance imaging is shown (figure). Histopathology shows nests of small blue cells amid a pink fibrillary matrix. What is the most likely diagnosis? a. subependymoma b pilocytic astrocytoma c meningioma d glioblastoma multiforme. e medulloblastoma

Answer 83

a. subependymoma

Question 84

When a patient with neurofibromatosis type Il (NF-2) presents with a small vestibular schwannoma with serviceable hearing, what is the most effective treatment strategy to maximize auditory longevity? a. Microsurgery b. Observation until tumor progression c. Stereotactic radiosurgery (SRS) d. Fractionated radiotherapy e. Bevacizumab

Answer 84

b. Observation until tumor progression

Question 85

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? a. Ependymoma b.Low grade glioma c. Glioblastoma multiforme d. Primary CNS lymphoma e. Metastatic adenocarcinoma

Answer 85

d. Primary CNS lymphoma

Question 86

A 41 year-old woman undergoes gross total resection for the lesion shown (Figure). Pathology confirms a grade 2 oligodendroglioma What is the recommended course of treatment? a Serial MRI b Chemotherapy and radiation c Chemotherapy d Clinical observation e Radiation

Answer 86

b Chemotherapy and radiation

Question 87

A patient undergoes a stereotactic biopsy of a grade IV astrocytoma. When considering the discussion of the findings and prognosis, patients indicate that the most important factors for effective communication include: a. careful scientific explanation of the histology, while withholding a grave prognosis. b. Using empathetic communication such as “It could be worse”, “I understand how you feel” or “Nothing more can be done” c. Giving only best possible scenario to give the patient hope. d. Demonstration of physician's compassion, honesty, attention to questions and use of clear language. e. Physician's familiarity with the patient and the use of touch (e.g. holding the patient's hand).

Answer 87

d. Demonstration of physician's compassion, honesty, attention to questions and use of clear language.

Question 88

An 18 year old functionally independent girl with tuberous sclerosis presents with progressive headaches. Imaging is shown (figure). What is the best treatment option for this patient? a Everolimus therapy b Interhemispheric transcallosal resection c stereotactic radiosurgery d Observation e Transcortical transventricular resection

Answer 88

a Everolimus therapy

Question 89

What is the recommended radiotherapy regimen for GBM patients older than 70 years of age with poor performance status? a 40 Gy in 15 fractions over 3 weeks b 30 Gy in 20 fractions over 3 weeks c 50 Gy in 30 fractions over 6 weeks d 60 Gy in 30 fractions over 6 weeks e 20 Gy in 10 fractions over 3 weeks

Answer 89

a 40 Gy in 15 fractions over 3 weeks

Question 90

Telomerase reverse transcriptase (TERT) promoter mutations leading to elevated TERT expression are most closely associated with what genetic alterations in gliomas? a MGMT promoter methylation b EGFRUuIII expression c Loss of ATRX expression d P53 overexpression e 1p19g co-deletion

Answer 90

e 1p19g co-deletion

Question 91

A 16-year-old boy presents with headaches, nausea, and blurred vision. His neurological examination is remarkable for impaired upgaze and convergence nystagmus. Contrast-enhanced MRI of the brain is shown (figure). Serum beta-HCG and alpha-fetoprotein levels are normal. What is the most likely diagnosis? a Embryonal carcinoma b Germinoma c Choriocarcinoma d Endodermal sinus tumor e Meningioma

Answer 91

b Germinoma

Question 92

During resection of a WHO grade Il insular glioma, what white matter language tracts run through the tumor and under the insula? a. Superior longitudinal fasciculus Il and arcuate fasciculus b. Inferior fronto-occipital fasciculus and superior longitudinal fasciculus-temporal parietal portion c. Uncinate fasciculus and inferior fronto-occipital fasciculus d. Uncinate fasciculus and arcuate fasciculus e. Arcuate fasciculus and medial longitudinal fasciculus

Answer 92

c. Uncinate fasciculus and inferior fronto-occipital fasciculus

Question 93

A 38 year-old woman underwent subtotal resection of a WHO Grade 2 astrocytoma. What is the most appropriate management of this patient? a Observation b Radiation c Radiation and chemotherapy d Radiation and immunotherapy e Chemotherapy

Answer 93

c Radiation and chemotherapy

Question 94

An 84-year-old male has an MR that reveals an enhancing lesion involving the left internal acoustic canal (see figure). On exam, he has diminished hearing in his left ear. What is the most appropriate next step in the management of this patient? a Surgical removal via a restrosigmoid approach b stereotactic radiosurgery in a single session c Reassurance and follow-up MRI in 6 months d stereotactic radiosurgery in 3-5 fractions e Surgical removal via a translabyrinthine approach

Answer 94

c Reassurance and follow-up MRI in 6 months

Question 95

A patient is found to have a new hemiparesis after resection of a GBM. How does this finding impact his overall survival? a Worsens survival if the deficit is temporary b Improves survival if the deficit is permanent c Worsens survival if the deficit is permanent d Unchanged survival if the deficit is permanent e Improves survival if the deficit is temporary

Answer 95

c Worsens survival if the deficit is permanent

Question 96

A 12-year-old boy presents complaining of left eye visual loss and occasional headache. Endocrine evaluation reveals the presence of mild diabetes inspidus and hypothyroidism. His MRI is shown in Figure 1&2. You recommend an attempt at complete tumor resection Which of the following is the most likely surgical complication? a. Hydrocephalus b. Blindness c. seizure disorder d. Mutism e. Pan-hypopituitarism

Answer 96

e. Pan-hypopituitarism

Question 97

A 35-year-old female underwent microscopic transsephenoidal resection of a non-functioning pituitary macroadenoma. Postoperative MRI demonstrates residual tumor in the right cavernous sinus lateral to the internal carotid artery. She has no neurological deficits. What is the most appropriate next step? a. Medical treatment with cabergoline b. Endoscopic transsphenoidal resection c. Expectant management d. Stereotactic radiosurgery of residual nodule e. Craniotomy for resection of residual tumor

Answer 97

c. Expectant management

Question 98

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? a. 1 b. 4 c. 5 d. 2 e. 3

Answer 98

c. 5