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General Remarks
Part One: Each item below contains a question or incomplete
statement followed by suggested responses. Select the one best
response to each question.
1. Tremor in the hands that is most obvious when the patient is awake and
trying to perform an action is most likely due to disease in which of the
following structures?
a. Thalamus
b. Cerebellum
c. Substantia nigra
d. Spinal cord
e. Internal capsule
2. In the person with Parkinson’s disease, the tremor that is evident when
a limb is at rest changes in what way when the patient falls asleep?
a. It becomes more rapid
b. Its amplitude increases
c. It generalizes to limbs that were uninvolved when the patient was
awake
d. It disappears
e. It transforms into choreiform movements
3. A 25-year-old woman with a history of epilepsy presents to the
emergency room with impaired attention and unsteadiness of gait. Her
phenytoin level is 37. She has white blood cells in her urine and has a
mildly elevated TSH. Examination of the eyes would be most likely to
show which of the following?
a. Weakness of abduction of the left eye
b. Lateral beating movements of the eyes
c. Impaired convergence
d. Papilledema
e. Impaired upward gaze
4. A 75-year-old generally healthy man has noticed worsening problems
maneuvering over the past 4 months. He has particular trouble getting out
of low seats and off toilets. He most likely has which of the following?
a. Poor fine finger movements
b. Poor rapid alternating movements
c. Distal muscle weakness
d. Proximal muscle weakness
e. Gait apraxia
5. A 50-year-old right-handed man has presented to a neurologist because
of gradually progressive hearing loss. A vibrating tuning fork is applied to
the center of his forehead. This helps to establish which of the following?
a. Which ear has the wider range of frequency perception
b. Which ear has the larger external auditory meatus
c. Which ear has infection of the external ear canal
d. Which ear has the longer eustachian tube
e. Which ear has conductive or sensorineural hearing loss
6. A 48-year-old left-handed man develops increased sensitivity to sound
in his left ear. A brain MRI reveals a posterior fossa mass. This symptom
may develop in one ear with damage to which of the following ipsilateral
cranial nerves?
a. V
b. VII
c. VIII
d. IX
e. X
7. A 42-year-old woman is being evaluated for gait difficulties. On
examination, it is found that her ability to walk along a straight line
touching the heel of one foot to the toe of the other is impaired. This
finding is most common with which of the following?
a. Cerebellar dysfunction
b. Parietal lobe damage
c. Temporal lobe damage
d. Ocular motor disturbances
e. Dysesthesias in the feet
8. A 55-year-old woman is being examined. The clinician notices the
presence of fine twitching movements beneath the surface of the tongue
and wasting of one side of the tongue. This finding suggests damage to
which of the following cranial nerves?
a. V
b. VII
c. IX
d. X
e. XII
9. A 46-year-old longshoreman has lower back pain radiating down the
posterior aspect of his left leg, and paresthesias in the lateral aspect of his
left foot. This has been present for 6 months. Strength and bowel and
bladder function have been normal. Examination would be most likely to
show which of the following?
a. Left Babinski sign
b. Loss of pinprick sensation over the web space between the first and
second digits of the left foot
c. Hyperreflexia at the left knee jerk
d. Hyporeflexia in the left Achilles tendon reflex
e. Decreased rectal tone
10. A 28-year-old graduate student presents with confusion and mild right
hemiparesis developing over the course of an evening. His girlfriend
relates that he has been having severe headaches each morning for the
past 2 weeks. While being evaluated in the emergency room, he has a
generalized tonic-clonic seizure. When examined 2 h later, he is lethargic
and unable to recall recent events, has difficulty naming, and has a right
pronator drift. There is mild weakness of abduction of the eyes bilaterally.
Funduscopic examination might be expected to show which of the
following?
a. Pigmentary degeneration of the retina
b. Hollenhorst plaques
c. Retinal venous pulsations
d. Blurring of the margins of the optic disc
e. Pallor of the optic disc
11. Taking a normal, awake person who is lying supine with head slightly
elevated (30°) and irrigating one external auditory meatus with warm
water will induce which of the following?
a. Tonic deviation of the eyes toward the ear that is stimulated
b. Nystagmus in both eyes toward the ear that is stimulated
c. Tonic deviation of the ipsilateral eye toward the ear that is
stimulated
d. Nystagmus in both eyes away from the ear that is stimulated
e. Tonic deviation of both eyes away from the ear that is stimulated
12. A 33-year-old woman has the acute onset of right orbital pain after a
tennis match. The following morning, her 10-year-old son comments that
her right eye looks funny. On examination, she has a mild right ptosis and
anisocoria. The right pupil is 2 mm smaller than the left, but both react
normally to direct light stimulation. Visual acuity, visual fields, and eye
movements are normal. The site of injury is due to interruption of fibers
from which of the following structures?
a. Optic tract
b. Optic chiasm
c. Cranial nerve III
d. T1 nerve root
e. Superior cervical ganglion
13. An 81-year-old woman with a history of type 2 diabetes mellitus and
atrial fibrillation presents with right body weakness and slurred speech.
She realized that there was a problem on awakening in the morning, and
her husband called EMS, who brought her to the emergency room. There
are no word-finding difficulties, dysesthesia, or headaches. She is taking
warfarin. Physical exam findings include blood pressure of 210/95 and
irregularly irregular heartbeat. There is left-side neglect with slurred
speech. There is a corticospinal pattern of weakness of the right body,
with the face and upper extremity worse than the lower extremity.
Routine chemistries and cell counts are normal. Her INR is 1.7. A head
CT reveals a large rightsided subdural hematoma. The intracranial
material appearing most dense on computed tomography (CT) of the head
is which of the following?
a. Blood clot
b. White matter
c. Gray matter
d. Cerebrospi
e. Pia mater
14. A 15-year-old boy developed a left Bell’s palsy over the course of 1
week. He was treated with acyclovir and prednisone. Over the next 3
months he seemed to recover almost fully. However, he has noticed
involuntary twitching at the left corner of the mouth each time he tries to
blink the left eye. This is most likely caused by which of the following?
a. A habit spasm
b. Cerebellar damage producing impaired coordination
c. Aberrant regeneration of the facial nerve
d. Trigeminal neuralgia
e. Focal seizures
15. You are working in the emergency room when a 30-year-old man
presents with a headache that started yesterday. As he was shoveling snow,
he felt a sudden pain in the front of his head. The pain does not throb and
has been relatively constant since. He says that now his neck also has
become a little stiff. He carries a diagnosis of migraine headaches, but
says that this is different than his usual headaches. He is afebrile and has
a normal exam except for slight photophobia and mild discomfort with
neck flexion. Which of the following is the most appropriate next step
in management?
a. Obtain a brain MRI
b. Obtain a brain CT
c. Obtain a cerebral angiogram
d. Obtain an EEG
e. Obtain a psychiatry consult
16. A 56-year-old right-handed woman presents to the emergency room
with a sudden-onset, severe, left-sided headache. The pain began when
she stood up from her couch while watching TV. A head CT is normal.
Which of the following is the most appropriate next step in management
of this patient?
a. Begin intravenous heparin
b. Perform a lumbar puncture
c. Obtain a brain MRI
d. Obtain a cerebral angiogram
e. Give the patient a prescription for zolmitriptan and send her home
17. In this MRI scan, the site most likely to produce a noncommunicating
hydrocephalus when it is obstructed is identified by which of the
following?
a. Curved white arrow
b. Straight white arrow
c. Curved black arrow
d. Black arrow head
e. Straight black arrow
18. The location of the cerebellar tonsil in the MRI scan suggests which
of the following?
a. Arnold-Chiari type 1 malformation
b. Arnold-Chiari type 2 malformation
c. Giant cisterna magna
d. Dandy-Walker syndrome
e. Normal posterior fossa
19. Which of the following is the most appropriate course of action for
the management of most meningiomas?
a. Anticoagulation
b. Triple therapy with isoniazid, rifampin, and ethambutol
c. Surgical resection
d. Proton beam irradiation
e. Craniospinal axis irradiation
20. A patient with bilateral posterior fossa masses has café au lait spots
and reports a family history of bilateral hearing loss at a relatively young
age. A gene abnormality should be suspected on which chromosome?
a. 5
b. 13
c. 17
d. 21
e. 22
Part Two: Fill in the blanks
1. General sensation include
,
,
.
2. The patient with Slurred speech, dysphagia, restricted out tongue and
tongue muscle atrophy mainly due to the damage of
and
nerve.
3. Scissors gait will be found in patient with
disease.
,
,
4. Babinski syndrome is due to the damage of
5. Awareness campaign including
.
and
.
6. Chorea and Athetosis are due to the damage of
.
7. CSF finding in Guillain-Barre’ syndrome will be
8. Clinical signs of SAH include
,
,
9. Kayser-Fleischer rings can be found in patients with
.
,
.
disease.
10. Time window for use of rt-PA in acute cerebral infarction is _______.
Part Three: Definitions
1. Syncope
2. Brown-sequard syndrome
3. Lhermitte’s symptom
4. Locked-in syndrome
5. Horner’s syndrome
Part Four: General questions
1. what are the characteristics of cerebellar lesions?
2. What’s the difference between upper and lower motor neuron damage?
3. what’s the performance of oculomotor nerve palsy?
4. List principles of treatment for ICH.
5. Describe clinical manifestations of Herpes Simplex Encephalitis.
Part Five: Case analysis
A 24-year-old white woman has a 12-year history of headaches.
These headaches started in grade school, and the patient remembers
missing school because of her headaches. Typically, she gets one of these
headaches one to two times per month. The headache starts over the right
eye, and the headache is usually preceded by flashing lights and zigzag
lines. Once the headache begins, there is extreme nausea and vomiting,
and the patient goes into a dark room to minimize her head pain.
Generally, the headache lasts 4 to 6 hours, but the patient feels tired and
listless for the next 24 hours. The patient feels that the headache worsens
with her menstrual cycle, and certain foods especially red wine can
exacerbate her headache. Her general and neurologic examinations are
normal.
1. What is the most likely diagnosis?
2. What kind of differential diagnosis should be considered?
3. What is the next diagnostic step?
4. What is the next step in therapy?
Answers
Part One: Choice questions
1 to 5:
bdbde
11 to 15:
beacb
6 to 10: b a e d d
16 to 20:
baece
Part Two: Fill in the blanks
1. Shallow feeling, Deep feeling, Composite feeling
2. Glossopharyngeal, Vagus, Hypoglossal
3. Spinal cord or cerebral paralysis
4. The pyramidal tract
5. Arousal state, Content of awareness
6. Extrapyramidal
7. elevated protein level without accompanying pleocytosis
8. headache, loss of consiousness, neck stiffness, vomitting, oculomotor
nerve palsy, seizure
9. Wilson’s
10. 3～4.5h
Part Three: Definitions
1. Syncope: Abrupt and transient loss of consciousness; Absence of
postural tone; Spontaneous rapid and full recovery
2. Brown-sequard syndrome: Injury of hemisection of the spinal cord
will cause ipsilateral weakness, loss of joint position and vibratory
sense; Contralateral loss of pain and temperature sense.
3. Lhermitte’s symptom: an electric shock–like sensation (typically
induced by flexion or other movements of the neck) that radiates down
the back into the legs. It can occur with disorders of the cervical spinal
cord, especially multiple sclerosis.
4. Locked-in syndrome: It is a condition in which an individual is fully
conscious, but all the voluntary muscles of the body are completely
paralyzed, with the exception of the muscles controlling eye. The most
common cause involves any condition that affects an area of the brain
called the ventral pons.
5. Horner syndrome: It is sympathetic paralysis syndrome, which
including enophthalmos, miosis, ptosis, vasodilation and sweat-free on
face and neck in ipsilateral.
Part Four: General questions
1. Characteristics of cerebellar lesions are:
⑴ Incoordination of muscle activity:
• in the head: nystagmus, dysarthria;
• in the arms: finger–nose ataxia, kinetic tremor, difficulty with rapid
alternating movements (dysdiadochokinesia);
• in the legs: heel-knee-shin ataxia, gait ataxia, falls.
⑵ There is no weakness. (Alcohol in large doses impairs cerebellar
function. Intoxicated people show all the features of muscular
incoordination mentioned above, but may be very strong.)
⑶ In a unilateral cerebellar lesion, the neurological deficit is ipsilateral
to the side of the lesion. A patient complaining of malfunction of the left
leg due to a left cerebellar lesion would have heel-knee-shin ataxia most
marked in the left leg, and gait ataxia with deviation to the left. There
might also be left arm cerebellar signs, and nystagmus most marked
looking to the left.
2. The differences are:
Characteristic of upper motor neurone lesions:
• no wasting;
• increased tone of clasp-knife type;
• weakness most evident in anti-gravity muscles;
• increased reflexes and clonus;
• extensor plantar responses.
Characteristics of lower motor neurone lesions:
• wasting;
• fasciculation;
• decreased tone (i.e. flaccidity);
• weakness;
• decreased or absent reflexes;
• flexor or absent plantar responses.
3. The performance of oculomotor nerve palsy: ptosis, exotropia, diplopia
mydriasis. At the same time the light reflecting and regulating reflex
disappear. The eyeball can’t achieve to move inward and upward, and the
downward movement is extremely restricted. The common causes
including hippocampal sulcus hernia, posterior communicating artery
aneurysm and the midbrain lesions.
4. 1) medical treatment:
Keep quiet, rest in bed, avoid meeting
Keep water & electrolyte balance and nutrition
Control brain edema, decrease ICP: antiedema agents, e.g. mannitol
Control blood pressure: antihypertensive agents or diuretic such as
furosemide
Prevent complications: rebleeding, herniation, infection
2) surgical treatment
3) rehabilitation
5. Evolve over several days
Fever, headache, seizures, confusion, stupor and coma
Olfactory or gustatory hallucinations, anosmia, temporal lobe seizures,
personality change, bizzare behavior, delirium, aphasia, hemiparesis
Temporal lobe herniation
Part Five: Case analysis
1. migraine
2. ⑴ Secondary headaches, such as headache secondary to meningitis,
intracranial hemorrhage, brain tumor, temporal arteritis
⑵ Other primary headaches
3. CT or MRI scan of the head
4. ⑴ nonpharmacologic management: avoidance of specific headache
triggers; regulated lifestyle
⑵ treatment of acute attacks: anti-pain; antimigraine (ergots and
tripans)
⑶ preventive treatment: Beta-adrenergic blocking agents; Calcium
channel blockers; Antiepileptic drugs; Tricyclic antidepreessants; 5-HT
antagonists