Tumor

Question 1

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

Answer 1

IDH mutation without 1p19q co-deletion

Question 2

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

Answer 2

75-100%

Question 3

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

Answer 3

Procarbazine/lomustine/vincristine (PCV)

Question 4

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

Answer 4

Cavernous sinus invasion

Question 5

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. Improves survival if the deficit is temporary
d. Worsens survival if the deficit is permanent
e. Unchanged survival if the deficit is permanent

Answer 5

Worsens survival if the deficit is permanent

Question 6

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

Answer 6

22

Question 7

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

Answer 7

Conformal radiotherapy

Question 8

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 levetiracetam
b. Intravenous phenobarbital
c. Intravenous fosphenytoin
d. Oral oxcarbazepine
e. Immediate surgical resection without anti-epileptic drug administration

Answer 8

Intravenous fosphenytoin

Question 9

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

Answer 9

Proton beam radiotherapy

Question 10

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

Answer 10

40 Gy in 15 fractions over 3 weeks

Question 11

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. Pilocytic astrocytoma
c. Ependymoma
d. Ganglioglioma
e. Glioblastoma

Answer 11

Ganglioglioma

Question 12

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. De novo glioblastoma
b. Bilateral vestibular schwannomas
c. Metastases outside the CNS
d. Unilateral optic nerve glioma
e. Pheochromocytoma

Answer 12

Metastases outside the CNS

Question 13

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. Complete microsurgical resection alone
b. Radiotherapy combined with high-dose corticosteroids
c. Radiotherapy alone
d. Complete microsurgical resection followed by adjuvant radiotherapy
e. Radiotherapy combined with IV methotrexate

Answer 13

Complete microsurgical resection alone

Question 14

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. Surgical resection of all three lesions
c. Needle biopsy of the largest lesion and subsequent chemotherapy
d. Stereotactic radiosurgery to all three lesions
e. Surgical resection of the largest lesion followed by radiation therapy

Answer 14

Surgical resection of the largest lesion followed by radiation therapy

Question 15

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 most likely be the cause of the findings described?
a. Pineal region tumor
b. Medulloblastoma
c. Acqueductal stenosis
d. Multiple sclerosis
e. Pontine glioma

Answer 15

Pineal region tumor

Question 16

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. Glioblastoma multiforme
c. Primary CNS lymphoma
d. Low grade glioma
e. Metastatic adenocarcinoma

Answer 16

Primary CNS lymphoma

Question 17

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. Facial nerve hemangioma
b. Bell palsy
c. Zoster oticusr
d. Vestibular schwannoma
e. Facial nerve schwannoma

Answer 17

Zoster oticus

Question 18

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. 12 Gy
b. 24 Gy
c. 18 Gy
d. 20 Gy
e. 15 Gy

Answer 18

24 Gy

Question 19

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. Papilledema.
b. Contralateral hemianopia.
c. Ipsilateral optic neuropathy.
d. Ipsilateral Horner’s syndrome
e. Contralateral hemiparesis.

Answer 19

Ipsilateral Horner’s syndrome

Question 20

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

Answer 20

Hydrocephalus

Question 21

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. Choroid plexus papilloma
d. Schwannoma
e. Endolymphatic sac tumor

Answer 21

Schwannoma

Question 22

A 70-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. multiple metastases.
b. central nervous system sarcoidosis.
c. multifocal glioma.
d. multiple sclerosis.
e. primary central nervous system lymphoma.

Answer 22

primary central nervous system lymphoma

Question 23

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

Answer 23

60 Gy

Question 24

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

Answer 24

Suprasellar region

Question 25

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. Craniopharyngioma c. Germinoma d. Pituitary macroadenoma e. Arachnoid cyst

Answer 25

Craniopharyngioma

Question 26

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. T12 vertebrectomy with pedicle screw instrumentation followed by radiotherapy. c. Posterior T12 laminectomy with pedicle screw instrumentation followed by radiotherapy. d. Fractionated external beam radiotherapy. e. Percutaneous biopsy and vertebroplasty followed by conventional fractionated radiotherapy.

Answer 26

Fractionated external beam radiotherapy

Question 27

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. glioblastoma multiforme. c. pilocytic astrocytoma. d. meningioma. e. medulloblastoma.

Answer 27

subependymoma

Question 28

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. Using empathetic communication such as “It could be worse”, “I understand how you feel” or “Nothing more can be done” b. Demonstration of physician's compassion, honesty, attention to questions and use of clear language. c. Careful scientific explanation of the histology, while withholding a grave prognosis. d. Giving only best possible scenario to give the patient hope. e. Physician's familiarity with the patient and the use of touch (e.g. holding the patient's hand).

Answer 28

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

Question 29

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. Superior longitudinal fasciculus II b. Uncinate fasciculus c. Frontal aslant tract d. Arcuate fasciculus e. Superior longitudinal fasciculus III

Answer 29

Frontal aslant tract

Question 30

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

Answer 30

Anatomical preservation of the facial nerve

Question 31

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. Chemotherapy and radiation b. Clinical observation c. Radiation d. Serial MRI e. Chemotherapy

Answer 31

Chemotherapy and radiation

Question 32

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. Abscess b. Gliosis c. Hematoma d. Recurrent tumor e. Territorial infarct

Answer 32

Gliosis

Question 33

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

Answer 33

Radiation and chemotherapy

Question 34

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. FDG-PET scan b. CT cisternogram c. Diffusion-weighted MRI d. Thin cut temporal bone CT e. MR spectroscopy

Answer 34

Diffusion-weighted MRI

Question 35

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. Ptosis, meiosis and anhydrosis b. Monocular blindness c. Facial numbness d. Diplopia that corrects with head tilt e. Periocular numbness

Answer 35

Ptosis, meiosis and anhydrosis

Question 36

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. Observation b. Transcortical transventricular resection c. Everolimus therapy d. Stereotactic radiosurgery e. Interhemispheric transcallosal resection

Answer 36

Everolimus therapy

Question 37

An 84-year-old male has an MRI 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. Stereotactic radiosurgery in 3-5 fractions b. Reassurance and follow-up MRI in 6 months c. Surgical removal via a restrosigmoid approach d. Stereotactic radiosurgery in a single session e. Surgical removal via a translabyrinthine approach

Answer 37

Reassurance and follow-up MRI in 6 months

Question 38

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. Vertebral artery. b. Middle Cerebral Artery c. Petrous Internal Carotid Artery d. Condylar vein. e. Sigmoid sinus

Answer 38

Petrous Internal Carotid Artery

Question 39

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

Answer 39

Vacuolation

Question 40

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? a. Anterior pituitary insufficiency b. Diabetes insipidus c. Visual loss d. Carotid artery occlusion e. Diplopia

Answer 40

Anterior pituitary insufficiency

Question 41

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

Answer 41

Pituitary apoplexy.

Question 42

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? a. Microsurgery b. Fractionated radiotherapy c. Bevacizumab d. Stereotactic radiosurgery (SRS) e. Observation until tumor progression

Answer 42

Observation until tumor progression

Question 43

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

Answer 43

Uncinate fasciculus and inferior fronto-occipital fasciculus

Question 44

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

Answer 44

The anterior condylar vein

Question 45

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. Cerebral angiography b. Skeletal survey c. Urine amino acids d. Lumbar puncture

Answer 45

Echocardiography

Question 46

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

Answer 46

Early identification of the distal facial nerve.

Question 47

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

Answer 47

Glioma

Question 48

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

Answer 48

5

Question 49

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. Hydrocortisone b. Fludricortisone c. Haloperidol d. Fosphenytoin e. Heparin

Answer 49

Hydrocortisone

Question 50

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. Germinoma b. Craniopharyngioma c. Pituitary macroadenoma d. Medulloblastoma e. Arachnoid cyst

Answer 50

Craniopharyngioma

Question 51

Telomerase reverse transcriptase (TERT) promoter mutations leading to elevated TERT expression are most closely associated with what genetic alterations in gliomas? a. EGFRvIII expression b. 1p19q co-deletion c. MGMT promoter methylation d. P53 overexpression e. Loss of ATRX expression

Answer 51

1p19q co-deletion

Question 52

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

Answer 52

Neurofibromatosis-1

Question 53

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 presence of hydrocephalus at presentation b. The extent of resection of the cyst walls c. The extent of resection of the enhancing mass d. The presence of endothelial proliferation on histology e. The presence of mitoses on histology | The extent of resection of the enhancing mass

Answer 53

The extent of resection of the enhancing mass

Question 54

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

Answer 54

EGFR and CDNK2A/CDNK2B mutations

Question 55

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. TP53 b. SMO c. APC d. Wnt e. PTCH1

Answer 55

PTCH1

Question 56

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 100µg/L/day, compared to preoperative levels b. Age- and sex- matched normalization of serum IGF-1 levels and GH level of 0.4µg/L following oral glucose load c. Age- and sex- matched normalization of serum GH levels, and fasting morning IGF-1 levels of 0.4µg/L d. Delayed normalization of GH levels which were elevated immediately after surgery e. Random serum GH level of 0.4µg/L, and age- and sex- matched normalization of random IGF-1 serum levels

Answer 56

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

Question 57

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. Choriocarcinoma b. Embryonal carcinoma c. Germinoma d. Endodermal sinus tumor e. Meningioma

Answer 57

Germinoma

Question 58

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 seizures b. Post-operative visual deficit c. Post-operative Gerstmann Syndrome d. Post-operative motor deficit e. Post-operative speech deficit

Answer 58

Post-operative speech deficit

Question 58

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

Answer 58

Chromaffin cells of neuro-ectodermal origin

Question 59

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

Answer 59

85-99%

Question 60

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. Whole-brain radiation at 30Gy b. Stereotactic radiosurgery to the tumor bed at 30Gy c. No adjuvant radiation is indicated d. External-beam radiation to the tumor bed at 60Gy e. Stereotactic radiosurgery to the tumor bed at 12Gy

Answer 60

External-beam radiation to the tumor bed at 60Gy

Question 61

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. Pan-hypopituitarism c. Mutism d. Blindness e. Seizure disorder

Answer 61

Pan-hypopituitarism

Question 62

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

Answer 62

Re-register

Question 63

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

Answer 63

SSEP and VII nerve

Question 64

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

Answer 64

Fractionated radiation therapy

Question 65

A 24-year-old woman presents with a history of menstrual irregularity 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. transsphenoidal resection. b. observation c. dopamine agonist with serial visual fields. d. stereotactic radiosurgery e. craniotomy for decompression of the optic apparatus

Answer 65

dopamine agonist with serial visual fields

Question 66

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. Trochlear nucleus b. Abducens fibers c. Trapezoid body d. Abducens nucleus e. Medial longitudinal fasciculus

Answer 66

Abducens nucleus

Question 67

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. Craniotomy for lesion removal. b. Cystoperitoneal shunt. c. Stereotactic aspiration. d. Endoscopic fenestration. e. Radiation therapy

Answer 67

Craniotomy for lesion removal.

Question 68

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

Answer 68

Staph. aureus

Question 69

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. Endoscopic transsphenoidal resection b. Expectant management c. Medical treatment with cabergoline d. Craniotomy for resection of residual tumor e. Stereotactic radiosurgery of residual nodule

Answer 69

Expectant management

Question 70

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. Hearing loss b. Diplopia c. Facial numbness d. Swallowing difficulty e. Facial weakness

Answer 70

Hearing loss

Question 71

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. Meningioma. c. Metastasis. d. Pineoblastoma. e. Pineocytoma.

Answer 71

Pineocytoma

Question 72

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 neurological 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. Progressive multifocal leukoencephalopathy b. Demyelinating plaque c. Glioblastoma multiforme d. Subacute sclerosing panencephalitis e. Lymphoma

Answer 72

Demyelinating plaque

Question 73

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. Magnetic resonance imaging b. Stereotactic radiosurgery c. Addition of a muscle-relaxing agent d. Microvascular decompression e. Botox injection

Answer 73

Magnetic resonance imaging

Question 74

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

Answer 74

GSPN, arcuate eminence, superior petrosal sinus, V3

Question 75

On histopathology, central neurocytoma has strong positivity with which stain? a. GFAP b. EMA c. Synaptophysin d. Vimentin e. S100

Answer 75

Synaptophysin

Question 76

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

Answer 76

Radiographic surveillance

Question 77

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

Answer 77

IDH mutant, 1p-19q intact

Question 78

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

Answer 78

Anterograde amnesia

Question 79

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

Answer 79

Higher stimulation amplitudes for cortical stimulation

Question 80

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. Chemotherapy c. Radiosurgery to the resection cavity d. Observation e. Fractionated local radiation therapy

Answer 80

Observation

Question 81

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

Answer 81

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

Question 82

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

Answer 82

Phonemic

Question 83

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

Answer 83

Quantitative subcortical motor mapping

Question 84

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. 8 b. 6 c. 9 d. 7 e. 5

Answer 84

8

Question 85

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 bevacizumab treatment b. No additional treatment necessary c. Surveillance brain MRI every three months d. Prophylactic cranial radiation e. Prophylactic erlotinib treatment

Answer 85

Prophylactic cranial radiation

Question 86

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

Answer 86

Surgical resection

Question 87

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

Answer 87

Ischemia

Question 88

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

Answer 88

Trochlear nerve and ophthalmic division of trigeminal nerve.

Question 89

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

Answer 89

Gangliogliomas

Question 90

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

Answer 90

Primary Visual Cortex

Question 91

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

Answer 91

IV methotrexate

Question 92

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

Answer 92

Sphenopalatine artery

Question 93

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

Answer 93

Meningohypophyseal trunk.

Question 94

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. It is likely to lengthen overall survival. b. There is insufficient evidence regarding overall survival. c. It is likely not to affect overall survival d. There is conflicting evidence regarding overall survival. e. It is likely to shorten overall survival.

Answer 94

It is likely not to affect overall survival

Question 95

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 horn of the lateral ventricle. a. 1 b. 5 c. 3 d. 2 e. 4

Answer 95

2

Question 96

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. glial neoplasm b. bacterial abscess c. meningioma d. toxoplasmosis e. demyelinating plaque

Answer 96

glial neoplasm

Question 97

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

Answer 97

Hypernatremia - Normonatremia or Hyponatremia - Hypernatremia.

Question 98

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

Answer 98

DTI

Question 99

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. glioblastoma multiforme. b. subependymoma. c. medulloblastoma. d. meningioma. e. pilocytic astrocytoma.

Answer 99

subependymoma