Neurology Quiz | Neuroq quiz | Practice MCQ #mcq.ImBooz

• (A) Order placement of an indwelling urinary catheter.
• (B) Order methacholine to regulate bladder emptying.
• (C) Request a surgical consultation in anticipation of an exploratory laparotomy.
• (D) Order placement of a condom catheter.

Check AnswerSolution[D]:-Urinary incontinence is an expected consequence of status epilepticus and consequently should not arouse concern for abdominal or urologic disturbances. Keeping the patient dry is important because of the risk of skin breakdown with any comatose patient, but mechanical intervention is sufficient. An indwelling catheter is unnecessary and introduces the risk of urinary tract infection. A condom catheter will keep the patient dry, allow urine to be collected, and enable the staff to more rigorously monitor fluid output. The urine is likely to be darkened by myoglobin, a pigment that collects in the urine when muscle breaks down after protracted seizure activity.

• (A) Intravenous clonidine to lower the blood pressure
• (B) Neurosurgical consult
• (C) Intravenous tissue plasminogen activator (TPA)
• (D) Placement of a cardiac pacemaker to manage the bradyarrhythmia

Check AnswerSolution[B]:-An expanding intracranial mass will produce an elevated blood pressure and a slow heart rate. This is called the Cushing response. This man may have a neoplasm in the brain or amyloid bleed. The site of the hemorrhage is unlikely with chronic hypertension or aneurysm. A biopsy of the mass would help identify the underlying lesion, although it is not urgent. Metastatic neoplastic disease is a possibility but is less likely than a glioblastoma multiforme at this age. The administration of TPA is contraindicated because this drug will increase the risk of rebleeding. Placement of a drain is not suggested by the clinical picture because there was no evidence of obstruction to the flow of CSF.

• (A) Cranial radiotherapy
• (B) Intravenous methotrexate
• (C) Intravenous fludarabine
• (D) Intravenous cyclophosphamide

Check AnswerSolution[A]:-There are several different grading schemes for astrocytoma, but Kernohan’s classification of grades from I (least malignant) to IV (most malignant) is the one most widely used. Glioblastoma multiforme is an older term for the grade IV astrocytoma and is still in general use. This is a highly malignant tumor that develops most often in the cerebral hemispheres. The most malignant tumors usually exhibit areas of necrosis and have a poor prognosis. Survival with glioblastoma multiforme is usually measured in months rather than years. Treatment generally consists of gross total resection and radiation therapy. Survival may be increased to 40 weeks after this combination of therapies, whereas it is on average only 14 weeks after surgery alone. The intravenous medications listed are antineoplastic agents, but they are not effective against this type of tumor. Some chemotherapy has been generally regarded as useful for this type of primary brain tumor including 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU), which increases survival only marginally.

• (A) Head CT
• (B) Cerebral angiogram
• (C) C-spine MRI
• (D) Positron emission tomography scan

Check AnswerSolution[A]:-The head CT scan is the mainstay of emergency department diagnosis of acute stroke. It is crucial to exclude intracranial hemorrhage prior to the potential administration of intravenous thrombolytic agents. A cerebral angiogram may play a role in the management of the acute stroke patient, particularly if there is evidence of cerebral or subarachnoid hemorrhage, or if there exists a possibility of performing intra-arterial thrombolysis, but CT scan is required first. In some centers, an MRI of the brain may be obtained nearly as quickly as a head CT and may be an alternative option. In the absence of evidence of trauma at the time of the patient’s fall, C-spine MRI and skull x-rays play no role in management.

• (A) Intravenous rTPA
• (B) Intravenous streptokinase
• (C) Oral aspirin
• (D) Intravenous heparin

Check AnswerSolution[A]:-In a large, multicenter randomized trial sponsored by the National Institutes of Health, thrombolytic therapy with intravenous rTPA has been shown to be of benefit to patients with acute ischemic stroke who can be treated early enough. The study demonstrated a statistically significant benefit for the use of rTPA in the treatment of ischemic stroke patients, who can be treated within 3 hours of symptom onset. A total of 624 patients arriving at the hospital within 3 hours of symptom onset underwent CT scan to exclude hemorrhagic stroke. Patients were randomized to receive either 0.9 mg/kg of rTPA or placebo. At 3 months, treated patients were at least 30% more likely to have minimal or no disability on several disability scales. Even with a symptomatic hemorrhage rate of 6.4% within 36 hours among the active treatment patients, the mortality and disability among treated patients was less than that among placebo patients at 3 months. The overall acute neurological deterioration even after accounting for early hemorrhages was the same in treated and placebo patients, indicating that the increased risk of hemorrhage with rTPA therapy is offset by an increased risk of neurological deterioration from progressing stroke, cerebral edema, and other causes in nontreated patients. The benefit of rTPA was not limited to patients with cardioembolic or large-vessel strokes, but also benefited patients with small-vessel strokes, who had a better prognosis.

• (A) Yes
• (B) No
• (C) Phenytoin
• (D) Baclofen

Check AnswerSolution[A]:-The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed a significant benefit of CE for patients with >/= 70% symptomatic stenosis. Two-year ipsilateral stroke risk was 26% in the patients treated with medication and 9% in the CE group ( P < .001). A combined analysis of trials of symptomatic patients showed a benefit of CE for 50% to 69% stenosis (adjusted relative risk [ARR], 4.6% over 5 years) and for >/= 70% (ARR, 16% over 5 years). The overall rate of stroke or death for all surgical patients within 30 days of trial surgery was 7.1%.

• (A) Patients with supratentorial ICH who are within 96 hours of ictus
• (B) Patients with lobar clots within 1 cm of the surface
• (C) Patients with cerebellar hemorrhage > 3 cm in diameter who are deteriorating neurologically
• (D) Patients with brainstem compression or ventricular obstruction resulting from hemorrhage

Check AnswerSolution[A]:-The decision about whether and when to operate on ICH remains controversial. The following recommendations are based on the latest American Heart Association and American Stroke Association guidelines. Patients with small hemorrhages or minimal neurologic deficits should be treated medically because they generally do well with medical treatment alone. Patients with a GCS score 3 cm in diameter who are deteriorating neurologically or who have brainstem compression and hydrocephalus should have surgery as soon as possible. Routine evacuation of supratentorial hemorrhage by standard craniotomy is not recommended within 96 hours of ictus. However, patients with lobar clots within 1 cm of the surface may be considered for surgical evacuation.

• (A) Yes
• (B) No
• (C) Phenytoin
• (D) Baclofen

Check AnswerSolution[A]:-Although information on the safety and efficacy of IV tPA in very old patients with acute ischemia is scarce, some data suggest that the risk for bleeding is not increased in elderly patients. A study showed that the rate of parenchymal hemorrhage was not significantly higher in elderly patients (>/= 80 years of age) compared with younger patients (6.3% vs 5.3%; P = 1.000). The rate of symptomatic intracerebral hemorrhage was similar between the groups (2.6% vs 2.6%; P = 1.000).

• (A) Watchful waiting
• (B) Craniotomy and clipping of the aneurysm
• (C) Endovascular coiling
• (D) Endovascular coiling.

Check AnswerSolution[C]:-The International Subarachnoid Trial (ISAT) was stopped early when use of endovascular coils for the treatment of subarachnoid hemorrhage demonstrated significant benefit compared with craniotomy and the use of vascular clips. In this study of 2143 patients, the rate of death or dependence (modified Rankin scale score of 3 to 6) was 30.6% in the neurosurgery group and 23.7% in the endovascular group ( P = .0019). Mortality was 10.1% for the neurosurgical group and 8.1% for the endovascular group. The study suggests that the most appropriate treatment for patients with subarachnoid hemorrhage related to a ruptured intracranial aneurysm usually is endovascular coiling

• (A) 0.0005
• (B) 0.01
• (C) 0.05
• (D) 0.2

Check AnswerSolution[C]:-A meta-analysis by Giles and Rothwell showed that the risk for major stroke after TIA is 5.2% at 7 days. The investigators reviewed 18 cohort studies with a total of 10,126 patients who had experienced a TIA. This was the first meta-analysis of stroke risk for the early period after TIA; results of previous, individual studies have been inconsistent

• (A) 0.01
• (B) Less than 10%
• (C) More than 25%
• (D) Up to 40%.

Check AnswerSolution[D]:-Depression is underdiagnosed in patients with PD. It can affect up to 40% of patients and is the most common neuropsychiatric manifestation of PD. Indeed, symptoms of depression can precede the onset of motor manifestations of PD. The diagnosis of depression in PD is challenging because many symptoms of depression (apathy, anhedonia, sleep and appetite disturbances, and changes in libido) overlap with the primary symptoms of PD. The most commonly used scales to screen for depression are the Beck Depression Scale, Hamilton Depression Scale, and the Geriatric Depression Scale.

• (A) L-dopa-resistant Parkinson’s disease
• (B) Progressive supranuclear palsy
• (C) Amyotrophic lateral sclerosis
• (D) Progressive supranuclear palsy

Check AnswerSolution[B]:-Progressive supranuclear palsy (PSP) is a neurodegenerative disease that affects eye movements, posture, and cognition. It was first described in 1964. The cardinal manifestations of PSP are supranuclear ophthalmoplegia, pseudobulbar palsy, prominent neck dystonia, parkinsonism, behavioral and cognitive disturbances, and gait imbalance. The mean age at onset is 63 years. The diagnosis is purely clinical; PSP is associated with no specific laboratory or imaging findings, although neuroimaging studies may be used to rule out other disorders. Medication is generally ineffective, and the response in patients who do respond is short-lived and incomplete. No medication is effective in halting the progression of PSP.

• (A) Patients with PD only display problems with impulse control when they are on dopamine agonists
• (B) The incidence of ICD is higher in patients with PD who are not taking dopamine agonists
• (C) The incidence of ICD is higher in patients with PD when they are taking dopamine agonists.
• (D) The problem of ICD is not typically associated with PD

Check AnswerSolution[C]:-According to the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM), ICDs are characterized by “the failure to resist an impulse, drive, or temptation to perform an act that is harmful to the person or to others.” Although the incidence of ICD in patients with PD is as high as 13.7% when they are taking a dopamine agonist, several studies have shown that 6% to 7% of patients with PD meet the criteria for an ICD even when they are not receiving treatment with a dopamine agonist. The most common ICD behaviors reported in association with PD are gambling, sex, shopping, and eating. Both pathologic gambling and compulsive sexual behavior or hypersexuality occurred in approximately 2% to 4% of PD patients.

• (A) 75 mg
• (B) 150 mg
• (C) 300 mg
• (D) 1200 mg

Check AnswerSolution[D]:-CoQ10 is an antioxidant and a mitochondrial energy stabilizer. Mitochondrial dysfunction is present in PD and is theorized to be one of the factors that can initiate the apoptosis cascade. Patients with PD have been reported to have significantly lower serum CoQ10 levels than age-comparable patients. A preliminary study found that subjects with early PD receiving 1200 mg of CoQ10 daily experience significantly less decline than patients treated with placebo. A more recent study showed that patients with midstage PD receiving 300 mg daily did not note improvements in PD symptoms. A large study of CoQ10 in patients with early PD is planned.

• (A) Peripheral neuropathy with paresthesias
• (B) Restless legs syndrome with periodic limb movements of sleep.
• (C) Parasomnias
• (D) Parkinson’s disease with paresthesias

Check AnswerSolution[B]:-Restless legs syndrome (RLS) is characterized by paresthesias or dysesthesias, an urge to move the limbs, and motor restlessness. The onset or exacerbation of symptoms occurs in the evening and improves with limb movement or walking. Despite its common occurrence (2% to 15%), it is underrecognized and misdiagnosed. In order to make a diagnosis of RLS, patients should meet the criteria of the International RLS Study Group and the National Institutes of Health: (1) an urge to move the legs; (2) temporary relief with movement; (3) onset or worsening of symptoms with rest or inactivity; and (4) worsening or onset of symptoms in the evening or night. Many patients with RLS also have periodic limb movements of sleep. These are stereotyped, repetitive flexion movements of the legs more than the arms, which may arouse patients from sleep and can interfere with the bed partner’s ability to sleep

• (A) Yes
• (B) NO
• (C) Imipramine
• (D) Phenytoin

Check AnswerSolution[A]:-The findings from MRI were officially incorporated into the International Panel Criteria, the diagnostic criteria of MS, in 2001. The International Panel Criteria incorporated the McDonald Criteria as the criteria for the diagnosis of MS based on MRI. In order to make the diagnosis of MS based on MRI findings, there must be demonstration of dissemination in time or space on the MRI.

• (A) Multiple sclerosis
• (B) Acute disseminated encephalomyelitis
• (C) Susac syndrome
• (D) Conversion reaction

Check AnswerSolution[C]:-Susac syndrome is a microangiopathy involving the arterioles of the brain, the retina, and the cochlea and clinically presents with subacute encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss.

• (A) Yes
• (B) NO
• (C) Imipramine
• (D) Phenytoin

Check AnswerSolution[B]:-The Betaferon/Betaseron in Newly Emerging MS for Initial Treatment (BENEFIT) study, which evaluated interferon-beta-1b in patients with CIS, demonstrated that with early treatment, the risk for a second relapse diagnostic of clinically definite MS (CDMS) was reduced by 50% compared with delaying treatment for 2 years or until the next event. A second phase of the study showed that patients treated sooner had a lower risk for disability progression based on the Expanded Disability Status Scale score. Early treatment not only delayed the diagnosis of CDMS but reduced disability progression after 3 years.

• (A) Frequent relapses during the first 2 to 5 years
• (B) Optic neuritis occurs within the first 2 years.
• (C) Incomplete recovery from relapses
• (D) Large lesion volume

Check AnswerSolution[B]:-Both clinical and MRI measures of disease activity during the first 2 to 5 years after a clinically isolated syndrome are important predictors of long-term disability. Natural history studies have shown that frequency of relapses during the first 2 to 5 years, intervals between relapses during the first 2 years, and incomplete recovery from relapses during the first 5 years are robust predictors of long-term disability. In 1 study of 79 patients with clinically isolated syndrome, the most robust predictor of disease progression was large lesion volume. No study has shown that the occurrence of optic neuritis within the first 2 years predicts long-term disability.

• (A) Pick’s disease
• (B) Frontal lobe dementia
• (C) Mild cognitive impairment
• (D) Vascular dementia

Check AnswerSolution[C]:-Mild cognitive impairment (MCI) refers to the transitional state between the cognitive changes of normal aging and the fully developed clinical features of dementia. MCI has garnered much attention from researchers as a treatment target for neurodegenerative processes before extensive damage has occurred. The 2 subtypes of MCI are amnestic (including memory impairment) and nonamnestic (other nonmemory cognitive domains impaired). MCI is diagnosed when a patient has a cognitive symptom that is not normal for age and not attributable to dementia, with essentially normal functional activities.