Neuro Block 4 Questions

A 32-year old male comes to you with malignant hypertension. His BP is 280 / 140 mm of Hg. CT scan of abdomen revealed a tumor arising from his right suprarenal medulla. His serum catecholamine levels and urinary vanillyl mandelic acid (VMA) levels were raised. After 5mg IV rapid injection of a test drug, his BP dropped more than 35mm Hg systolic and more than 25mm Hg diastolic within 2 minutes. What is the most likely mechanism of action of the test drug?

A. Alpha 1 agonistB. Alpha 1 blockerC. Alpha 2 agonistD. Beta 2 agonistE. Beta blocker

A 25-year old baseball player received a hit on the side of the head, following which he was unconscious for a few minutes. Thereafter he recovered sufficiently to complete the game. Later in the evening he began to lose consciousness again. There was a boggy swelling on his temporal region. Urgent non-contrast CT scan of head is shown below. Which is the most likely source of bleeding?

A. Superior cerebral veinsB. Posterior division of MMAC. Bridging cerebral veinsD. Anterior division of MMAE. Superior sagittal sinus

A 23-year old woman presents with severe headache that developed gradually over 5 days. This morning she found she was unable to walk because of weakness in both legs. What is the most likely vessel to be involved?

A. Sigmoid sinus B. Transverse sinus C. Middle cerebral vein D. Superior sagittal sinus E. Vein of Rosenthal

An 18-year old male presented to you with headache, photophobia, nuchal rigidity and fever. He had an attack of pneumonia one week back. Lumbar puncture and CSF studies showed predominantly PMN (neutrophil) cells, high albumin and very low glucose. CSF smear showed gram positive cocci. Which of the following is the most common route of spread of the infective agents that produced this clinical condition?

A. Via cribriform plate of ethmoidB. Via emissary veinsC. Via mastoid air cellsD. Via capillaries in choroid plexusE. Via valveless veins of Bateson

You are examining a non-contrast CT scan of brain of a 61-year old male. You notice a pair of calcified spots in the CT scan, as shown below. Where are these calcifications located?

A. Junction of fourth ventricle and cisterna magnaB. Junction of body, posterior and inferior horn of lateral ventricleC. Junction of third and fourth ventriclesD. Junction of anterior horn and body of lateral ventricleE. Junction of lateral and third ventricles

A 30-year old pregnant lady was exposed to TORCH infection after the 20th week of her pregnancy, which resulted in severe necrotizing encephalitis in the developing brain of the fetus. Which of the following congenital CNS malformation is most likely in the developing fetus?

A. AnencephalyB. HoloprosencephalyC. LissencephalyD. HydrancephalyE. Schizencephaly

You see a patient who is suspected of having a rare lesion involving his anterior hypothalamus. Which of the following is an unlikely manifestation of his lesion?

A. Osmotic instability B. Disruption of circadian rhythm C. Dysautonomia D. Poor temperature regulation E. Trouble sleeping

You see a patient who is suspected of having a rare lesion. This one involves the posterior hypothalamus. Which of the following is an unlikely manifestation of his lesion?

A. Disruption of appetite control B. Impaired arousal C. Poor memory performance D. Impaired vasoconstriction E. Poor temperature control

A 32-year old female patient has galactorrhea and amenorrhea, which persisted for 2 years after her last pregnancy. Lab investigations reveal high Luteotrophic Hormone (LTH) and low serum (and urinary) FSH and LH. Contrast CT and MRI of head reveal normal hypophyseal fossa. What is the most likely diagnosis in this patient?

A. Central diabetes insipidusB. Syndrome of inappropriate ADHC. Chiari-Frommel syndromeD. Ahumada del Castillo syndromeE. Forbes Albright syndrome

Your patient has a sense of fullness after a meal. What part of the hypothalamus is responding normally?

(A) Preoptic area of hypothalamus (B) Lateral zone of hypothalamus (C) Periventricular nuclei of hypothalamus (D) Ventromedial nuclei of hypothalamus (E) Mammillary body

A 52-year old woman presents with a left internal carotid artery dissection and associated right hemiparesis. Which of the following might be an associated finding?

A. Mydriasis on the left B. Mydriasis on the right C. Increased sweating left side face D. Miosis on the right E. Miosis on the left

You evaluate a 34-year old man who is recovering from a spinal cord injury sustained in a motorcycle accident. He confides in you that he has not been able to achieve an erection since his accident. Which of the following neurons is most likely to have been affected?

A. Preganglionic sympathetic neurons B. Neurons in splanchnic ganglia C. Cranial preganglionic parasympathetic neurons D. Postganglionic sympathetic neurons E. Sacral preganglionic parasympathetic neurons

Which of the following pathologies could result in a non-communicating hydrocephalus?

A. HD B. Posterior fossa tumor C. Meningeal adhesions D. A and C E. All of the above

Which of the following pathologies could result in a communicating hydrocephalus?

A. HD B. Posterior fossa tumor C. Meningeal adhesions D. A and C E. All of the above

A 14-year old boy has a bulky posterior fossa tumor at the level of midbrain, immediately inferior to tentorium cerebelli in the midline. If it were to cause CSF obstruction, the patient would most likely have which of the following?

A. Dilatation of lateral ventricles B. Dilatation of third ventricle C. Dilatation of third and fourth ventricles D. Dilatation of lateral and third ventricles E. All of the above

Which of the following is the primary structure creating the blood-CSF barrier?

A. Choroid plexus B. Modified cilia C. Tight junctions D. Arachnoid granulation E. Arachnoid villi

A 2 month-old baby is noted to have macrocephaly (large head) and developmental delay. On ultrasound, the baby has significant hydrocephalus. The pediatrician is suspicious of congenital stenosis of the aqueduct of Sylvius. Which of the following are the most likely findings in this infant?

A 58-year old woman presents to your office complaining of severe headache that has been troubling her for the past one week. Over the past 24 hours she has developed ringing in the right ear and severe positional vertigo. Which structure is most likely involved.

A. Superior sagittal sinus B. Inferior sagittal sinus C. Transverse sinus D. Cavernous sinus E. Vein of Galen

A 45-year old assault victim is struck with a brick on the left side of the head and is now unresponsive. Which of the following vessels is most likely to have been injured?

A. Middle cerebral vein B. Middle meningeal artery C. MCA D. Transverse sinus E. Superior sagittal sinus

A 64-year-old man is diagnosed with an acute stroke. His main deficit is a partial loss of his visual field. The neurologist diagnoses a lesion of the occipital lobe. Which of the following arteries is likely to be involved?

A. Internal carotid B. External carotid C. Middle cerebral D. Posterior cerebral

A 68-year old man presents to your office complaining of severe headache and eye pain on the right. He is proptotic on the right. Which structure is most likely to be involved?

A. Superior sagittal sinus B. Inferior sagittal sinus C. Transverse sinus D. Cavernous sinus E. Vein of Galen

An MRI reveals the presence of a tumor in the third ventricle compressing the arcuate nuclei of the hypothalamus. Which of the following is the patient most likely to present with?

(A) Altered circadian rhythms (B) Aphagia (C) Galactorrhea and amenorrhea (D) Diabetes insipidus (E) Amnesia with confabulations

A 47-year-old man presents to his neurologist with an unsteady, broad-based gait and slow, slurred speech. Neurologic examination reveals dysdiadochokinesia, intention tremor, hypotonia, and nystagmus. The patient's lesion is in a brain structure that derives from which of the following embryonic structures?

(A)Diencephalon (B)Mesencephalon (C)Metencephalon (D)Myelencephalon (E)Telencephalon

A 37-year old man collapses while jogging during the summer. He is stuporous and has bilateral upgoing toes. Which of the following vessels is most likely involved?

A. Middle cerebral vein B. Middle meningeal artery C. MCA D. Bridging vein E. Superior sagittal sinus

A 16-year old girl is attending a hockey game when she is struck on the head by a stray puck. Although she is initially arousable and complains of pain over her left temple where she was struck, she becomes progressively more somnolent and is rushed to the hospital. Upon arrival 1 hour later, she is comatosed. What would the head CT be expected to show?

A. Left temporal skull fracture with cerebral contusion B. Left temporal skull fracture with a crescentic mass adjacent to brain with

mass effect C. Left temporal skull fracture with football-shaped mass adjacent to brain

with mass effect D. Left temporal skull fracture with calcified mass adjacent to brain with

mass effect E. Intact skull with cerebral edema and mass effect

A 12-year-old girl is brought to the emergency department by her parents because of a 3-day history of fever and a 12-hour history of lethargy. Her parents say that she has been sleeping most of the day and has been unresponsive when awake. Her temperature is 39.2°C (102.6°F). Physical examination shows numerous petechial hemorrhages and nuchal rigidity. A lumbar puncture yields cloudy cerebrospinal fluid (CSF) that clots in the collection tube. Microscopic examination of the CSF shows numerous segmented neutrophils, and a Gram stain shows gram-negative diplococci. Which of the following is the most likely causal organism?

(A) Haemophilus influenzae (B) Mycoplasma pneumoniae (C) Neisseria meningitidis (D) Salmonella typhi (E) Streptococcus pneumoniae

You evaluate a newborn for excessive vomiting. He was born 48 hours ago and has still not passed any meconium. His abdomen is distended. You are able to appreciate colonic peristalsis and note a palpable fecal mass. You are able to determine that several family members have had similar problems. What neurons are affected?

A. Preganglionic sympathetic neurons B. Postganglionic parasympathetic neurons C. Preganglionic parasympathetic neurons D. Postganglionic sympathetic neurons E. Neurons in splanchnic ganglia

You are examining a 76-year old male with apraxic, magnetic and bradykinetic gait, features of subcortical dementia, increased urinary frequency, incontinence and uninhibited bladder. 24-hour CSF pressure monitoring reveals intermittent B waves, but at other times CSF pressure is normal. MRI scan of head is shown below. Removal of 50 ml of CSF by LP also partially relives his gait symptoms. What would be the best management approach for this patient?

A. Ventriculo-cisternostomyB. Carbonic anhydrase inhibitorC. DiureticsD. Ventriculo-peritoneal shuntE. Lumbar-peritoneal shunt

A 46-year old woman has been having a terrible headache that is constant and came on suddenly several weeks ago. It was initially associated with vertigo, but this has resolved. The headache does not have any classic migraine features. She has no previous history of such headaches. Which of the following vessels do you suspect to be involved?

A. Vein of Galen B. Transverse sinus C. MCA D. Bridging vein E. Cavernous sinus

The family of the patient you have just evaluated would like to know the cause of his transcortical sensory aphasia. You explain that he has had a stroke. Compromise of which of the following vascular territories would lead to his deficit?

A. Right MCA B. Left MCA C. Left MCA/ACA border zone D. Left MCA/PCA border zone E. Left PCA

An 85-year old man complains of complete inability to see for the last 15 minutes. He describes a ‘shade’ or ‘blind’ that abruptly covers his vision. Vision of right eye is relatively unaffected. Fundus shows a pale retina on the left side. What is the most likely explanation?

A. Ocular migraine B. Acute left ophthalmic artery occlusion C. Acute right occipital lobe infarct D. Acute left occipital lobe infarct E. Elevated ICP

A 28 year old male suspected felon is being subjected to a lie detector test on a polygraph machine. The transient pupillary dilatation that the machine detects each time he lies is due to stimulation of which of the receptors?

A. Beta 1 receptorsB. Alpha 2 receptorsC. Alpha 1 receptorsD. Muscarinic receptorsE. Beta 2 receptors

A 79-year old woman in a nursing home is noticed to have difficulty using her right leg over the past several days. She does not complain of any pain. The leg’s appearance has not changed. There is diffuse weakness affecting flexors and extensors in thigh, leg and foot. What is the most likely diagnosis?

A. Left ACA occlusion B. Pelvic mass impinging on right sciatic and femoral nerve C. Left MCA occlusion D. Acom occlusion E. Left deep femoral vein thrombosis

A 60-year old man has right vertebral occlusion. Which of the following symptoms is he most likely to manifest?

A. Right-sided weakness B. Loss of pain and temperature on the left C. Left-sided Horner’s syndrome D. Left-sided weakness E. Loss of pain and temperature on the right

You evaluate a 12-year old boy with intractable epilepsy. His seizures are characterized by episodes of uncontrollable laughter with retained consciousness. After the spells he reports that he does not find anything particularly funny. He is rather scared during his spells. Which of the following regions is likely to be affected?

A. Amygdala B. Hypothalamus C. Hippocampus D. Parahippocampal cortex E. Entorhinal cortex

A 73-year old woman has complete loss of sensation on the left (hemianesthesia) involving face, arm, trunk, and leg equally. She has full strength. Which artery is most likely involved?

A. Left vertebral artery B. Right PCA C. Right vertebral artery D. Left PCA E. Basilar artery

A 67-year old man has had sudden loss of vision in his right visual field. Which arterial distribution is most likely involved?

A. Left vertebral artery B. Right PCA C. Right vertebral artery D. Left PCA E. Basilar artery

A 45-year old man presents with right-sided weakness. His symptoms quickly resolve, leaving only a mild finger-to-nose dysmetria on the right. His MRI scan reveals a rather large new infarction. Which vascular territory is most likely affected?

A. Left vertebral artery B. Right PICA C. Right vertebral artery D. Left MCA E. Left PICA

A 63-year old man has been diagnosed with right-sided posterior communicating artery aneurysm. Which of the following might be an associated finding?

A. Mydriasis on the left B. Mydriasis on the right C. Increased sweating left side face D. Miosis on the right E. Miosis on the left

A patient has suffered a stroke caused by occlusion of the right anterior cerebral artery. This patient is most likely to present with

(A) a loss of pain and temperature sensations in the left leg

(B) weakness of the right leg (C) drooping of the corner of the mouth on the left (D) a non-fluent aphasia (E) a loss of discriminitive touch from the right side of

the face

Your female patient has suffered a stroke. She has difficulty copying simple diagrams, even though she hears and understands your requests to do so. You notice that she only has make-up on the right side of her face and does not seem to know where her left hand is in space. Which blood vessel might have been occluded to cause these symptoms?

(A) Left vertebral artery (B) Right middle cerebral artery (C) Left anterior cerebral artery (D) Right posterior cerebral artery (E) Right anterior cerebral artery

A 35-year-old man complains of the worst headache of his life, grabs onto the back of his neck, and then slumps onto the floor. At the hospital, his CT findings are consistent with a subarachnoid hemorrhage. Which of the following is the most likely etiology?

A. Carotid artery occlusion B. Vertebrobasilar artery occlusion C. Middle meningeal artery laceration D. Rupture of a berry aneurysm

A 65-year-old man has loss of pain and temperature sensation on the right side of the face and from the neck down on the left. Examination shows partial paralysis of the soft palate, larynx, and pharynx, and ataxia, all on the right. The most likely cause of these findings is thrombosis to which of the following arteries?

(A) Basilar (B) Right posterior inferior cerebellar (C) Left posterior inferior cerebellar (D) Right superior cerebellar (E) Left superior cerebellar

A 4-month-old boy is brought to the physician by his mother for a well-child examination. He is at the 98th percentile for head circumference. Physical examination shows dilation of the scalp veins and spasticity of the lower extremities. The physician suspects excessive cerebrospinal fluid accumulation in the ventricular system of the brain. The source of this fluid is most likely which of the following?

(A) Choroid plexus (B) Dura mater (C) Pia mater (D) Roof of the third ventricle

A patient has trouble sleeping due to a decreased production of melatonin. What neural structure increases melatonin synthesis at night?

(A) Preoptic nuclei (B) Lateral geniculate body (C) Suprachiasmatic nucleus (D) Supraoptic nucleus (E) Neurohypophysis

A 31-year-old woman comes to the physician for a periodic health maintenance examination. She has no complaints at this time. She has a normal menstrual period every 28 days. She had an appendectomy at the age of 18 and has had no other surgeries. She takes no medications and is allergic to sulfa. She lives with her husband and works as a computer programmer. Physical examination, including breast and pelvic examinations, is normal. She is planning on becoming pregnant in the next few months. The physician should advise her to begin taking folate supplements to reduce the risk of which of the following fetal abnormalities?

(A)Arnold-Chiari malformations (B)Germinal matrix hemorrhage (C)Holoprosencephaly (D)Neural tube defects (E)Syringomyelia

A 52-year-old man is brought into the emergency department by his wife because he has been complaining of a severe headache. Physical examination reveals ptosis of the right eyelid with the right eye facing down and out. There is a fixed and dilated right pupil with an inability to accommodate. Subarachnoid blood appears on non contrast CT scan. Magnetic resonance angiog-raphy (MRA) would be expected to reveal an aneurysm of which of the following arteries?

(A)Anterior cerebral (B)Anterior choroidal (C)Anterior communicating (D)Middle cerebral (E)Posterior communicating

A 26-year old man had a sudden onset of worst headache of his life while straining on the toilet. Which of the following vessels is most likely involved?

A. Middle cerebral vein B. Middle meningeal artery C. MCA D. Bridging vein E. Superior sagittal sinus

A 76-year-old man presents to his physician complaining of an inability to empty his bladder for the past 3 days and a continual leakage of urine for the past 2 days. A cystometrogram reveals that his bladder has an abnormally large capacity, and an MRI reveals a lesion limited to the sacral spinal cord. Which of the following is the most likely diagnosis?

(A)Automatic neurogenic bladder (B)Autonomous neurogenic bladder (C)Motor neurogenic bladder (D)Sensory neurogenic bladder (E)Uninhibited neurogenic bladder

A 64-year-old man with atherosclerosis suffers an embolic stroke that leaves him with a left leg paresis. Physical examination reveals a Babinski sign on the left and diminished sensation over his left leg. Blockade of which of the following vessels is responsible for his symptoms?

(A)Left anterior cerebral artery (B)Left middle cerebral artery (C)Left posterior cerebral artery (D)Right anterior cerebral artery (E)Right middle cerebral artery

A 49-year-old woman comes to the emergency department because of right upper quadrant pain, nausea, vomiting, and fever. She also complains of pain in her right shoulder. A right upper quadrant ultrasound reveals multiple gallstones and pericholecystic fluid. Which of the following dermatomes is most likely involved in her shoulder pain?

(A)CI-C2 (B)C3-C5 (C)C6-C8 (D)Tl-T3 (E)T4-T6

Branches from which of the following vessels would be most likely affected in a 56-year old male hypertensive patient with pontine lacunar infarction?

A. Basilar artery B. PICA C. AICA D. Vertebral artery E. SCA