The following MCQs are related to certain basics in neurology. Please read them carefully and review your answers.
Answers:
Q1: Answer: F, F, T, T, F
It is (together with olfactory nerve) located supratentorially. Its lesion can cause varieties of scotomas and unilateral blindness. Leber's optic neuropathy is a form of mitochondrial cytopathy.
Q2: Answer: F, T, F, T, F
It originates from the upper midbrain. A compressive lesion produces pupillary dilatation as the first sign (so-called surgical 3rd nerve palsy); the medical 3rd nerve palsy is pupillary sparing (like the classical diabetic 3rd acute nerve palsy. It supplies the constrictor pupillae and ciliary body with parasympathetic fibers.
Q3: Answer: T, T, F, T, F.
It supplies the superior oblique, horizontal diplopia is seen in 6th nerve palsy.
Q4: Answer: T, T, F, T, F
It is the afferent loop of the corneal reflex. It does not carry parasympathetic fibers to any structure.
Q5: Answer: T, F, F, F, T
It exits from the ponto-medullary junction. It lesion causes horizontal diplopia. It enters the orbit through the superior orbital fissure.
Q6: Answer: T, T, F, F, F
It is attached the lateral portion of the pontomedullary junction (the 5th cranial nerve is attached to the ventral mid portion of the pons), it is a mixed nerve (motor, sensory, and autonomic), and Ramsay Hunt syndrome produces complete palsy of a lower motor neuron type (the upper face is spared in upper motor neuron lesions).
Q7: Answer: T, T, T, F, F
The resulted nystagmus is away from the side of the lesion. It leaves the posterior fossa through the internal auditory meatus and canal.
Q8: Answer: T, T, F, T, F
It carries taste and general somatic sensations from the posterior 1/3rd of the tongue.
Q9: Answer: T, T, T, F, F
The platysma is supplied by the facial nerve, and never involved in motor neuron disease.
Q10: Answer: F, F, F, F, T
The spinal root enters the skull through the foramen magnum afte arising from the 1st 5 cervical cord segements; its lesions cause weakness of ipsilateral trapezius and sternomastoid (has nothing to do with neck extension). It's, rarely if ever, ivloved in upper motor neuron lesion above the medulla.
Q11: Answer: T, F, F, T, T
It causes deviation of the tongue towards the paralyzed side (pushed by the normal side) when damaged, and it arises from the lower medulla.
Q12: Answer: T, T, F, T, T
It is usually examined properly when the clinical picture is suggestive. eg a frontal lobe meningioma beneath the frontal lobe.
Q13: Answer: T, T, T, F, F
It is supplied by the anterior circulation (ie carotid system), a frontal sinus abscess can extend to the frontal lobe. A mastoid abscess usually produces cerebellar or temporal lobe abscesses.
Q14: Answer: T, T, F, F, T
The middle cerebral artery supplies its lateral surface, and positive palmo-mental reflex (a frontal release sign) indicates a frontal lobe lesion.
Q15: Answer: T, T, T, F, F
The hippocampus and amgdala lie in the temporal lobe (both are parts of the limbic system).
Q16: Answer: T, T, T, T, T
Notice that vertigo can be a cortical sign (but very a rare one), and the uncus is responsible for compressing the midbrain and 3rd cranial nerve when it herniates through the tentorial hiatus.
Q17: Answer: F, F, F, F, F
It lies in the middle crania fossa, and its medial surface is supplied by the posterior cerebral artery, and the optic radiation loops back around the tip of the temporal lobe, and can be resected as a mode of treatment of medically refractory complex partial seizures of hippocampal sclerosis. Petit mal epilepsy is a primary generalized epilepsy (not a focal one).
Q18: Answer: F, F, T, T, F
The primary sensory cortex lies in the parietal lobe; formed visual hallucinations indicate a temporal lobe lesion; Dressing and constructional apraxias indicate a non-dominant parietal lobe lesion.
Q19: Answer: T, T, T, F, T
Notice that the limbic lobe is synthetic lobe, not a true lobe, composed of gray matter structures at the medial and basal parts of the hemispheres that form a limbus (border) around the midbrain.
Q20: Answer: T, T, T, T, T
Notice that the limbic system is "the limbic lobe and all cortical and subcortical structures related to it". Besides the mentioned structures, the thalamus (particularly the anterior thalamus) and the brainstem reticular formation are parts of the limbic system.
Q21: Answer: T, T, F, F, F
It plays an important role in: Memory, emotional behavior, sexual behavior, motivation, and integration of homeostatic responses like those related to preservation of species, securing food, fight and flights responses…etc.
Q22: Answer: F, T, F, T, T
It is formed by the choroid plexus, and in cases of choroid plexus papilloma the CSF is formed at a higher rate causing hydrocephalus. The concentration of sodium, chloride, and magnesium ions in the CSF is higher that that of plasma, where its concentration of potassium and calcium ions is lower than that of plasma.
Q23: Answer: T, F, F, T, F
It is also absorbed through perineural spaces.
Q24: Answer: F, T, F, T, T
Cisterna magna (cisterna cerebellomedullaris) is the largest of all cisterns and lies between the medulla oblongata, cerebellum, and occipital bone. Cisterna interpeduncularis lies between the cerebral peduncles of the midbrain. Knowing the exact manes and locations of these cisterns is important in MRI.
Q25: Answer: T, T, F, F, F
The followings occur in the REM sleep (desynchronization sleep, dreaming sleep, and paradoxical sleep):
1- Marked hypotonia.
2- An increase in blood pressure and heart rate with irregular respirations ( all are decreased in non-REM sleep with regular respirations).
3- Erection in males.
4- Teeth grinding.
5- Dreaming (hence the name dreaming sleep).
6- Rapid eye movements (50-60 movements per minutes, hence the name rapid eye movement sleep or REM sleep).
7- Rapid low voltage irregular EEG activity resembling the waking pattern (so-called desynchronization pattern).
8- Increased threshold of arousal, hence the deep sleep.
Q26: Answer: T, T, F, F, F
In non-REM (also synchronized, light, or slow wave) sleep, we see the followings:
1- Hypotonia.
2. A decrease in heart rate, blood pressure, and respiratory rate which regular.
3- A slow EEG activity of high voltage, hence the name slow-wave sleep.
Q27: Answer: T, F, T, F, F
The hippocampus is supplied by the posterior cerebral artery. The spinal cord is also supplied by many local "radicular arteries" at different segments. The micturition center in the mesial frontal lobe is supplied anterior cerebral artery.
Q28: Answer: F, F, F, F, T
The pyramidal system has contribution from the prefrontal motor cortex including area 6 and 8, and also some contribution from the post central gyrus (area 3, 1, 2). It decussates in the lower medulla and occupies the lateral compartment of the cord. Chorea is caused by basal ganglia lesions.
Q29: Answer: F, F, F, T, T
Notice that complete paralysis is not consistent with pyramidal lesions; instead they cause paresis of the muscles not paralysis. Although cord lesions can cause painful flexor or extensor spasms, dysthesic pain indicates sensory system dysfunction. Ill sustained clonus could be a normal finding, especially in anxious people; a pathological clonus (more that 3 sustained beats) is consistent with pyramidal lesions. Clasp knife, not lead pipe rigidity, is an upper motor neuron sign.
Q30: Answer: F, T, T, T, T
Notice that cerebellar lesions cause incoordination of motor movements, not a severe weakness, with pendular knee jerk. Eye signs in cerebellar diseases are almost always overlooked in clinical practice; these are apart from nystagmus: defective saccadic eye movements, impaired pursuit eye movements, transient gaze paresis, inability to maintain an eccentric gaze, failure to suppress the optokinetic nystagmus upon fixation, moderate increase in vestibule-ocular reflexes.
Q31: Answer: T, F, F, F, F
The anterior and lateral spinothalmics occupy the anterior and lateral columns, and convey crude touch, pressure, pain and thermal sensations. They are characteristically spared in vitamin B12 deficiency, and unilateral cord lesions produce contralateral signs, 2-3 segments below the level of the lesion.
Q32: Answer: F, T, T, T, F
It extends from the foramen magnum to the level of lower border of L2 vertebra in adults. It has 2 normal enlargements; the lower cervical and lumbosacral enlargements corresponding to the brachial and lumbosacral plexuses. The upper cervical segments give rise to spinal accessory nerve, which is the only cranial nerve that has a cord contribution.
Q33: Answer: F, T, T, F, T
Lambert Eaton syndrome (like botulism) attacks the nerve terminal (presynaptic) side; while myasthenia gravis attacks the muscle (postsynaptic) side. Acetylcholine is the neurotransmitter which acts on acetylcholine receptors on the postsynaptic side.
Q34: Answer: F, F, T, T, T
Our muscles have 2 types of fibers:
1- Type I: slowly contracting, red, fatigue resistant, rich in oxidative enzymes (and myoglobin, mitochondria, lipids, and local capillary density) but has low phosphorylase and glycogen contents. It has an oxidative metabolism. The erector spinae is an example.
2- Type IIa: Very rare human.
3- Type IIb: Fast twitching and fatigable, white, rich in phosphorylase and glycogen and it has a glycolytic metabolism.
Q35: Answer: F, T, T, T, F
It is preferred to be taken from a muscle that is clinically affected but not severely as we may see only atrophy or fibrosis; however, we can choose other subclinically muscles because the affected muscles might be severely weakened by that disease under investigation. It is generally useless in motor end plate diseases to be examined by light microscope (EM is useful here).
Q36: Answer: T, T, T, T, T
Notice that these "pictures" are commonly seen in the MRCP examination and you should know them.
Q37: Answer: T, T, F, F, F
Notice that the biopsy findings in most neuromuscular diseases are not that pathognomonic or diagnostic. Lymphorrhages are localized collection of lymphocyte (similar to that of Hashimoto's thyroiditis). Fiber type grouping is seen in neurogenic atrophy with re-innervation. Muscle fiber regeneration is against myasthenia gravis, and indicates an ongoing process of fiber necrosis and regeneration due to for example polymyositis. Extensive eosinophilic infiltration is seen in eosinophilic myositis.
Q38: Answer: T, T, F, F, F
Normal brain waves and rhtytms:
1-Alpha rhythm: between 8-13 cps, mainly seen at the posterior hemispheres.
2- Beat rhythm: between 14-30 cps, seen over wide areas of the hemispheres, and accentuated in those taking sedatives.
3- Theta rhythm: between 4-7 cps, normally seen at the temporal lobes mainly in old people.
4- Delta rhythm: between 0.5-3 cps, normally seen in the non-REM sleep. The presence of a focal slowing in a fully alert person always indicates a local lesion like a tumor, and diffuse slowing is usually seen in encephalopathies.
Q39: Answer: T, T, F, F, F
Locus cerulus is found in the lower midbrain; nucleus fastigius is one of the deep cerebellar nuclei; the amygdala is located in the medial temporal lobe.
Q40: Answer: T, F, T, F, F
Hemiballismus is seen in lesions of the nucleus subthalamicus; anomia is a cortical sign.
Q41: Answer: T, T, T, T, T
Notice that the microglial cells proliferate in CNS diseases; the choroidal epithelial cells secrete the CSF; astrocytes provide a supporting framework.
Q42: Answer: T, T, F, T, F
Tanycytes line the floor of the 3rd ventricle; choroidal epithelial cells cover the surface of the choroid plexuses. Notice that the fibrous astrocytes are found in the white matter.
Q43: Answer: T, T, F, F, T
Merkel's disc is related to touch sensation; skin temperature sensation is mediated by free nerve endings; Meissner's corpuscles is related to touch sensation; muscle tension
is mediated neuron-tendinous spindles.
Q44: Answer: T, T, F, T, F
Both 4-aminopyridine and Guanidine hydrochloride increases the release of acetylcholine at the motor end plate, hence their use in Lambert Eaton syndrome.
Q45: Answer: T, T, T, T, T
Also; the substantia nigra, superior colliculi, and the 4th cranial nerve.
Q46: Answer: T, T, F, F, T
The uncus is in the medial temporal lobe; the mammillary bodies are part of the hypothalamus.
Q47: Answer: T, T, F, T, F
Mesencephalic nucleus of trigeminal nerve is found in the midbrain.
Q48: Answer: F, F, F, F, F
The optic nerve passes through the optic foramen and canal. The hypoglossal nerve passes through the hypoglossal foramen. The Abducens passes through the superior orbital fissure. The oculomotor nerve passes through the superior orbital fissure. The trigeminal nerve main trunk does not pass through any foramen.
Q49: Answer: T, F, T, F, F
Wernicke's aphasia is due to lesion in the upper lateral temporal lobe. Conductive aphasia is due to lesion in the in the arcuate fasciculus in the insula. Anomic aphasia is a cortical sign.
Q50: Answer: T, T, T, T, T
Thalamic aphasia has an excellent prognosis; cortical dysarthria is rare and has a better prognosis also. Lacunar strokes are not associated with seizures, impaired consciousness, hemianopia, or aphasia.
End..
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