I.1. In which location along the carotid artery would a ruptured
aneurysm result in subarachnoid hemorrhage?
a. Carotid artery bifurcation
b. Extracranial internal carotid segment
c. Petrous carotid segment
d. Carotid cavernous segment
e. Ophthalmic carotid segment
I.1.
Answer e.
Carotid artery segments at or below the cavernous carotid
segment are extradural and would not result in subarach-
noid hemorrhage if ruptured.
I.2. Which of the following might result from a stroke due to inter-
ruption of the blood supply to the recurrent artery of Heubner?
a. Contralateral hemisensory loss
b. Abulia and executive dysfunction
c. Contralateral hemiataxia
d. Ipsilateral hemiataxia
e. Visuospatial disorientation
I.2. Answer b.
The recurrent artery of Heubner supplies the head of the
caudate. Injury to the caudate nucleus may result in frontal
lobe–type syndromes, including abulia, executive dysfunc-
tion, and confusion.
I.3. Which of the following arteries is not a component of the circle of Willis?
a. Anterior cerebral artery, A1 segment
b. Anterior communicating artery
c. Posterior communicating artery
d. Posterior cerebral artery, P1 segment
e. Posterior cerebral artery, P2 segment
I.3. Answer e.
The P2 segment of the posterior cerebral artery does not con-
tribute to the circle of Willis. The other arteries are all com-
ponents of the circle of Willis.
I.4. A 24-year-old woman presents with pain in the left side of the
neck, numbness on the left side of the face, and numbness of
the right arm and leg, all of which began soon after falling from
a horse. On examination she has dysphonia, left hemiataxia, left
miosis and ptosis, and reduced pinprick sensation on the left
side of the face and the right arm and leg. To which of the fol-
lowing structures does the lesion best localize?
a. Central pons
b. Left lateral medulla
c. Right lateral medulla
d. Left midbrain
e. The findings cannot be localized to a single structure
I.4. Answer b.
All the identified deficits correspond to a lesion in the left
lateral medulla. This woman’s presentation is suggestive of a
lateral medullary ischemic infarction caused by vertebral
artery dissection.
I.5. Which of the following accurately lists the order of branches
from the internal carotid artery?
a. Anterior choroidal, ophthalmic, posterior communicating
b. Superior cerebellar, ophthalmic, anterior choroidal
c. Ophthalmic, posterior communicating, anterior choroidal
d. Anterior choroidal, posterior communicating, ophthalmic
e. Posterior communicating, ophthalmic, anterior choroidal
I.5. Answer c.
The order of branches from the internal carotid artery is oph-
thalmic, posterior communicating, and anterior choroidal.
The superior cerebellar artery is a branch of the vertebral
artery.
I.6. Which of the following structures is supplied by the posterior
spinal arteries?
a. Spinothalamic tract
b. Rubrospinal tract
c. Spinoreticular tract
d. Dorsal column–medial lemniscal pathway
e. Tectospinal tract
I.6. Answer d.
The dorsal column–medial lemniscal pathway is supplied
by the posterior spinal arteries. The other structures are sup-
plied by the anterior spinal artery.
I.7. A 72-year-old man with a history of atrial fibrillation has an
abrupt onset of speech arrest and right hemiparesis. He is found
to have a large ischemic cerebral infarction in the distribution of
the left middle cerebral artery. Which of the following would be
the characteristic pathologic finding 3 weeks after onset?
a. Gliosis
b. Cytotoxic edema
c. Mononuclear cell infiltrate
d. Eosinophilic pyknotic (“red dead”) neurons
e. Infiltration of reactive astrocytes
I.7. Answer e.
The characteristic pathologic feature of subacute ischemic
stroke is infiltration of reactive astrocytes. Edema and eosin-
ophilic neurons are seen in the acute phase, followed by
mononuclear cell infiltrates. Gliosis is a feature of an old or
chronic infarction.
I.8. Which of the following best characterizes the function of cere-
brospinal fluid?
a. It is the primary mechanism of neuronal nutrient delivery
b. It serves as an intracellular transport pathway
c. It is not involved in homeostasis of the central nervous system
d. It provides buoyancy for the brain
e. It is a primary neuroendocrine secretory pathway
I.8. Answer d.
Cerebrospinal fluid provides buoyancy for the brain. It does
not have a primary role in intracellular transport, secretory
systems, or nutrient delivery.
I.9. An 83-year-old man with a history of mild dementia fell, hit his
head, and damaged several left-sided bridging veins. On imag-
ing studies, hemorrhage into which of the following spaces or
structures would be most likely?
a. Epidural space
b. Subdural space
c. Subarachnoid space
d. Cerebral parenchyma
e. Intraventricular space
I.9. Answer b.
Bridging veins traverse the subdural space and drain into
venous sinuses. Damage to those veins can cause subdural
hemorrhage.
I.10. Which of the following describes the correct sequence of flow for cerebrospinal fluid after it is produced in the choroid plexus of the lateral ventricles?
a. Foramen of Magendie, cerebral aqueduct, fourth ventricle, arach-
noid granulations, superior sagittal sinus
b. Cerebral aqueduct, third ventricle, foramen of Monro, subarach-
noid space, arachnoid granulations
c. Third ventricle, fourth ventricle, cerebral aqueduct, foramen of
Magendie, lateral ventricle
d. Foramen of Monro, third ventricle, cerebral aqueduct, fourth
ventricle, foramina of Luschka
e. Arachnoid granulations, subarachnoid space, fourth ventricle,
third ventricle, lateral ventricle
I.10. Answer d.
The correct order is lateral ventricles, foramen of Monro,
third ventricle, cerebral aqueduct, fourth ventricle, either
foramina of Luschka or foramen of Magendie, subarachnoid
space, and arachnoid granulations into the venous sinuses.
I.11. An 11-year-old girl with tuberous sclerosis has headaches.
Imaging shows a large tumor near the foramen of Monro, which
is subsequently identified as a subependymal giant cell astrocy-
toma. Which of the following cerebrospinal fluid spaces would
most likely be enlarged on brain imaging?
a. Lateral ventricles
b. Third ventricle and lateral ventricles
c. Cerebral aqueduct, third ventricle, and lateral ventricles
d. Fourth ventricle, cerebral aqueduct, third ventricle, and lateral ventricles
e. Subarachnoid space, fourth ventricle, cerebral aqueduct, third
ventricle, and lateral ventricles
I.11. Answer a.
Patients with tuberous sclerosis are at increased risk for
intracranial lesions, including subependymal giant cell
astrocytomas. These tumors are characteristically found at
the foramen of Monro and can lead to obstructive hydro-
cephalus with enlargement of 1 or both lateral ventricles.
I.12. Which of the following best approximates the volume of cerebrospinal fluid in an adult at any point in time?
a. 50 mL
b. 35 mL
c. 150 mL
d. 500 mL
e. 725 mL
I.12. Answer c.
At any point in time, an adult typically has about 150 mL of
cerebrospinal fluid.
I.13. Which of the following best reflects a typical, normal cerebrospi-
nal fluid opening pressure in a healthy adult?
a. –20 mm H2O
b. 10 mm H2O
c. 150 mm H2O
d. 450 mm H2O
e. 700 mm H2O
I.13. Answer c.
The typical range of normal cerebrospinal fluid opening
pressure in adults is 65 to 200 mm H2O.
I.14. Which of the following is a characteristic feature of sensory
systems?
a. They rarely display topographic representation of receptive fields
b. They rely on stimulus coding for transduction
c. None use cortical control as a component of sensory relay
d. They rely primarily on disconnected pathways for processing
e. They are generally not limited to the properties of their respective receptive fields
I.14. Answer b.
Sensory organs convert “analog” sensory stimuli to “digital”
frequency information through a process of sensory coding.
Sensory processing generally relies on serial and parallel
processing, typically uses cortical control of relays, reflects
topographic organization, and is limited to properties of the
corresponding receptive fields.
I.15. Which of the following associations between sensory organ and modality is most correct?
a. Ruffini end-organ and perception of texture and form
b. Free nerve endings and joint-position sense
c. Merkel disk and proprioception
d. Pacini corpuscle and braille-like stimuli
e. Meissner corpuscle and edge contour
I.15. Answer e.
Meissner corpuscles mediate edge contour and braille-like
tactile stimulus perception. Ruffini end-organs mediate pro-
prioception, Merkel disks mediate perception of texture and
form, and Pacini corpuscles mediate vibration.
I.16. Which of the following sensory modalities bypasses thalamic
relay nuclei?
a. Olfactory
b. Visual
c. Auditory
d. Gustatory
e. Somatosensory
I.16. Answer a.
The olfactory system projects directly to the olfactory cortex.
All the other listed sensory modalities are relayed through
the thalamus.
I.17. Which of the following statements about sensory systems is most correct?
a. Heteromodal processing structures typically project to unimodal sensory pathways
b. Most pathways maintain topographic representations of receptive fields
c. There are no parallel pathways of sensory integration through the ventral and dorsal streams
d. All sensory systems contain at least 3 precortical synapses
e. All sensory systems are mediated through parenchymal sensory ganglia
I.17. Answer b.
Most sensory modalities have some degree of central topo-
graphic representation. In general, unimodal sensory path-
ways project to heteromodal centers for processing. The
ventral and dorsal streams provide parallel processing of
multimodal sensory information. Cell bodies for first-order
neurons in somatosensory pathways generally reside in
peripheral ganglia.
I.18. Which of the following modalities is primarily carried by the
dorsal column–medial lemniscal system?
a. Pain and temperature from the face
b. Bulbar joint position sense
c. Light touch from the face
d. Pain and temperature from the body
e. Vibration and joint position sense from the body
I.18. Answer e.
The dorsal column–medial lemniscal system carries vibra-
tion and joint position sensation from the body. Pain and
temperature are mediated through the spinothalamic path-
ways, and bulbar somatosensation is mediated through the
trigeminal system.
I.19. The thalamic relay for the sensation of pain includes which of
the following?
a. Mediodorsal, ventral posteromedial, and ventral posterolateral nuclei
b. Pulvinar, ventral posterolateral, and ventral posteromedial nuclei
c. Anterior nucleus
d. Ventral posterolateral and ventral posteromedial nuclei
e. Medial and lateral geniculate bodies
I.19. Answer a.
The localization and body sensation of pain relays through
the ventral posteromedial and ventral posterolateral nuclei,
whereas the affective-emotional component of pain relays
through the mediodorsal nucleus.
I.20. Unmyelinated C axons terminate in which Rexed laminae of the dorsal horn?
a. I and II
b. II and III
c. III and IV
d. IV and V
e. I through V
I.20. Answer a.
Unmyelinated C axons terminate in Rexed laminae I and II.
Although other laminae are active in relaying nociceptive
signaling, these specific axons terminate in only laminae I
and II.
I.21. A 24-year-old woman has intermittent pain and redness in the
feet, often precipitated by aerobic exercise. Her father had a
similar syndrome. Mutations in which of the following channels
may be responsible for this disorder?
a. Nav1.7 channel
b. P/Q-type calcium channel
c. TRPV1 channel
d. Nav1.9 channel
e. Kvα11 channel
I.21. Answer a.
The patient most likely has familial erythromelalgia, which
has been associated with mutations in the Nav1.7 channel.
I.22. Nociception is mediated primarily by which of the following
nerve fiber types?
a. Type 2A
b. Type 2B
c. Aβ
d. Aδ and C
e. Aα
I.22. Answer d.
Nociception is mediated primarily by Aδ and C fibers.
I.23. For which process is the superior olive important?
a. Transmission of sound frequency
b. Transmission of light touch and vibration
c. Sound localization
d. Vestibuloocular coordination
e. Comparison of intended action to actual action
I.23. Answer c.
The superior olive is an important structure for sound local-
ization. The inferior olive is important for correction of limb
movement.
I.24. Activation of the right horizontal semicircular canal stimulates
which muscles as a result of the vestibuloocular reflex?
a. Left superior oblique and right inferior rectus
b. Right superior oblique and left inferior rectus
c. Right lateral rectus and left medial rectus
d. Left lateral rectus and right medial rectus
e. Right and left medial rectus’
I.24. Answer d.
Activation of the right horizontal semicircular canal by
rightward head rotation stimulates the left abducens nucleus
and the medial rectus subnucleus of the right oculomotor
nucleus, so that the left lateral rectus and right medial rectus
muscles produce conjugate leftward eye movements.
I.25. Which of the following cell types has a glial function in the retina?
a. Ganglion
b. Photoreceptor
c. Amacrine
d. Bipolar
e. Müller
I.25. Answer e.
Müller cells provide a glial support function in the retina.
Ganglion, amacrine, photoreceptor, and bipolar cells all
serve neuronal functions.
I.26. A patient has numbness of the lateral aspect of the left thigh
without weakness or pain. On neurologic examination, lower
extremity strength and reflexes at the knees and ankles are nor-
mal. On sensory examination, the lateral aspect of the thigh has
decreased sensation to a pin. What is the most likely diagnosis?
a. Left lateral femoral cutaneous neuropathy
b. Left L3 radiculopathy
c. Left femoral neuropathy
d. Left obturator neuropathy
e. Left superficial peroneal neuropathy
I.26. Answer a.
Sensory loss in the distribution described without changes
in motor strength or reflexes would be consistent with a left
lateral femoral cutaneous syndrome (also called meralgia
paresthetica) (see Figure 6.1A).
I.27. A 75-year-old man with prostate cancer has had a gradual onset
of his foot slapping the ground when he walks. On examination,
he has weakness of the right peroneal, right anterior tibial, and
right posterior tibial muscles. His reflexes are normal at the
knees and ankles. What is the most likely localization?
a. Right superficial peroneal neuropathy
b. Right deep peroneal neuropathy
c. Right L4 radiculopathy
d. Right L5 radiculopathy
e. Right sciatic neuropathy
I.27. Answer d.
A patient with weakness of the right peroneal (peroneal
nerve; L5-S1), anterior tibial (deep peroneal nerve; L4-5),
and posterior tibial (tibial nerve; L5-S1) muscles without
weakness of the biceps femoris muscle (sciatic nerve; L5-S1)
would most likely have a lesion that localized to the right
lumbar L5 nerve root.
I.28. A 72-year-old man with diabetes mellitus presents with subacute
pain and weakness in the left thigh. On examination, he has
moderate weakness of the left quadriceps muscles and hip
adductors. The stretch reflexes of the quadriceps muscles are
reduced, but the ankle jerks are preserved. To which structure
does the lesion best localize?
a. S1 spinal root
b. Lumbar plexus
c. Femoral nerve
d. Obturator nerve
e. Sciatic nerve
I.28. Answer b.
A lesion in the lumbar plexus would include the quadriceps
(femoral nerve; L2-3-4) and abductor longus (obturator nerve; L2-3-4) muscles. Patients with diabetes may have diabetic
lumbosacral plexitis characterized by pain and weakness.
I.29. A 15-year-old boy presents for evaluation of right shoulder pain.
On examination, you find that his right scapula moves posteri-
orly when he leans forward against the wall with both hands. To
which structure does the lesion best localize?
a. Left precentral gyrus
b. Long thoracic nerve
c. Spinal accessory nerve
d. Dorsal scapular nerve
e. Suprascapular nerve
I.29. Answer b.
The long thoracic nerve (from roots C5-7) innervates the serra-
tus anterior muscle, which pulls the scapula forward and is an
antagonist of the rhomboid muscle. Weakness of the serratus
anterior muscle results in scapular winging, which can be tested
by having the patient lean forward and press against a wall.
I.30. What lesion is compatible with loss of pain and temperature sen-
sation on the right side below the level of the umbilicus, left leg
weakness, and loss of proprioception in the left leg?
a. Commissural syndrome at the T10 level
b. Occlusion of the anterior spinal artery with ventral cord syn-
drome at the T10 level
c. Central cervical cord syrinx
d. Cauda equina syndrome
e. Left T10 hemicord syndrome (Brown-Séquard syndrome)
I.30. Answer e.
Brown-Séquard syndrome generally results in dysfunction
of the corticospinal tract and dorsal columns ipsilateral to
the lesion and dysfunction in the spinothalamic tract contra-
lateral to the lesion.
I.31. A 64-year-old man with prostate cancer presents with progressive
back pain and gait deterioration over 3 months. On neurologic
examination, he has weakness of the hamstring and anterior tibi-
alis muscles bilaterally, increased knee and ankle reflexes, bilat-
eral Babinski signs, and reduced sensation to vibration and
proprioception but not to pin prick. What other symptom or sign
might you expect in this patient?
a. Fasciculations
b. Urinary retention
c. Tongue weakness
d. Lhermitte sign
e. Decreased temperature sensation
I.31. Answer b.
The patient has dorsal column–medial lemniscal and corti-
cospinal tract dysfunction in both legs, suggestive of a mid-
line dorsal lesion at the spinal level. Bowel and bladder
dysfunction, including urinary retention, may also result
from midline spinal lesions.
I.32. A 50-year-old man presents with a 1-year history of progressive
weakness and fasciculations of his right lower extremity with
subsequent spasticity, weakness, and fasciculations of his right
upper extremity. Over the past month, he has also had difficulties
with slurred speech and dysphagia. He does not have associated
pain or sensory symptoms. What combination of abnormalities
would be the likely cause of this presentation?
a. Damage to the corticospinal tract and the spinothalamic tract
b. Damage to the anterior horn cells and the cortical motor neurons
c. Damage to the fasciculus gracilis and the fasciculus cuneatus
d. Damage to the anterior horn cells and the fasciculus gracilis
e. Damage to the cortical motor neurons and the spinothalamic
tract
I.32. Answer b.
The clinical presentation is classic for amyotrophic lateral
sclerosis, which is a degenerative process of upper and lower
motor neurons (cortical motor neurons and anterior horn cells
of the spinal cord). Sensory symptoms, when present, gener-
ally result from musculoskeletal causes, such as joint pain or
muscle pain as a result of weakness, or from muscle cramps.
I.33. Which of the following describes cranial nerve IX?
a. Innervates the stylopharyngeus muscle
b. Innervates the sublingual and submandibular glands
c. Innervates the glossopharyngeal muscle
d. Participates in the efferent limb of the baroreceptor reflex
e. Receives touch sensation to the forehead
I.33. Answer a.
The glossopharyngeal nerve, cranial nerve IX, innervates the
stylopharyngeus muscle and the parotid gland. Cranial nerve
IX participates in the afferent limb of the baroreceptor reflex,
taste sensation, and touch sensation of the posterior pharynx.
I.34. Which of the following tracts or pathways does not cross in the
brainstem?
a. Dorsal column–medial lemniscal pathway
b. Trigeminothalamic tract
c. Gustatory tract
d. Corticospinal tract
e. Dentato-rubro-olivary pathway
I.34. Answer c.
Taste fibers from the nucleus solitarius travel ipsilaterally to
the ventral posteromedial nucleus of the thalamus and then
to the opercular cortex.
I.35. Which of the following features may result from a lateral medul-
lary infarction?
a. Contralateral decrease in pain and temperature sensations of the
face, arm, and leg
b. Contralateral hemiataxia
c. Horner syndrome
d. Tongue deviation ipsilateral to the lesion
e. Spastic dysarthria
I.35. Answer c.
The lateral medullary syndrome includes ipsilateral decrease
in temperature and pain sensations of the face, contralateral
decrease in pain and temperature sensations of the extremi-
ties, ipsilateral hemiataxia, Horner syndrome, dysarthria due
to palatal weakness, and dysphagia. Cranial nerve XII fibers
to the muscles of the tongue exit from the preolivary sulcus
and are not involved in the lateral medullary syndrome.
I.36. Which sensory pathway does not relay in the thalamus?
a. Light touch
b. Olfactory
c. Visual
e. Pain and temperature
I.36. Answer b.
The olfactory pathway does not relay in the thalamus.
I.37. Villaret syndrome is a composite of ipsilateral paralysis of the
soft palate, pharynx, and larynx resulting in hoarseness and dys-
phagia, ipsilateral weakness of the sternocleidomastoid and tra-
pezius muscles, and ipsilateral weakness of the tongue with
atrophy. In addition, there is ipsilateral ptosis, miosis, and facial
anhidrosis. Where would these findings localize?
a. Nucleus ambiguus
b. Jugular foramen
c. Pterygopalatine ganglia
d. Retropharyngeal space
e. Hypoglossal foramen
I.37. Answer d.
Findings that involve cranial nerves X, XI, and XII and sym-
pathetic fibers might localize to the retropharyngeal space.
I.38. A patient presents with pulsatile tinnitus, mild proptosis of the
right eye, right sixth nerve palsy, and mild numbness of the right
side of the forehead. Where would this process most likely localize?
a. Jugular foramen
b. Cavernous sinus
c. Rostral pons
d. Meckel cave
e. Cribiform plate
I.38. Answer b.
Cranial nerves III, IV, and VI; the V1 and V2 sensory divi-
sions of cranial nerve V; and the carotid artery run through
the cavernous sinus. The patient described has a carotid cav-
ernous fistula.
I.39. Which of the following describes the spinal tract and nucleus of
cranial nerve V?
a. Crosses at the pons
b. Carry light touch and unconscious proprioception
c. Ascend to the ventral posterolateral nucleus of the thalamus
d. Part of the afferent limb of the blink reflex
e. Nucleus is within the midbrain
I.39. Answer d.
The spinal tract and nucleus of cranial nerve V carry pain and
temperature sensation from the face. The axons enter at the
pons but descend to the medulla and upper cervical cord
before crossing as the ventral trigeminothalamic tract. The tract
ascends to the ventral posteromedial nucleus of the thalamus.
I.40. A petroclival meningioma may result in dysfunction of which cranial nerve?
a. II
b. III
c. IV
d. V
e. VI
I.40. Answer e.
Cranial nerve VI travels up the clivus, through the Dorello
canal, and along the petroclival ridge before entering the
cavernous sinus and the superior orbital fissure.
I.41. What may result from a unilateral lesion in the rostral midbrain
affecting the inferior colliculus?
a. Difficulty with sound localization
b. Unilateral deafness
c. Pure word deafness
d. Anomia
e. No deficit
I.41. Answer a.
A unilateral lesion in the brainstem may cause poor localiza-
tion of sound. Possible causes include stroke, tumor, and
multiple sclerosis.
I.42. Which of the following would not result from a lesion affecting
cranial nerve VII at the internal acoustic meatus?
a. Unilateral facial weakness sparing the forehead
b. Ipsilateral decrease in taste
c. Ipsilateral increase in sound
d. Ipsilateral change in tear production
e. Difficulty closing the ipsilateral eye
I.42. Answer a.
A lesion at the internal acoustic canal should result in lower
motor neuron weakness.
I.43. From which skull foramen does the third sensory division of cra-
nial nerve V enter?
a. Hypoglossal foramen
b. Foramen rotundum
c. Foramen spinosum
d. Foramen ovale
e. Foramen lacerum
I.43. Answer d.
The motor component of cranial nerve V and the third sen-
sory division of cranial nerve V traverse the foramen ovale.
I.44. Which finding might you see in a patient with decorticate
posturing?
a. Absent spontaneous respirations
b. Absent corneal reflex
c. Fixed, dilated pupils
d. Absent caloric reflex
e. Decreased level of consciousness
I.44. Answer e.
Patients with decorticate posturing may have a decreased level
of consciousness. Brainstem reflexes would still be intact.
I.45. A patient has skew diplopia that worsens with right head tilt and
improves with left head tilt. Where is the most likely lesion?
a. Right third nerve axon
b. Left third nerve nucleus
c. Right fourth nerve axon
d. Left fourth nerve axon
e. Right third nerve nucleus
I.45. Answer c.
Cranial nerve IV aids intorsion and depression of the eye. In
a patient with a fourth nerve palsy, head tilt functionally
intorts the eye. Thus, a right fourth nerve palsy would result
in skew double vision that improves with left head tilt.
I.46. If a patient presents with a right third nerve palsy and contralat-
eral hemiparesis, where is the lesion?
a. Right lateral midbrain
b. Right medial midbrain
c. Left lateral midbrain
d. Left medial midbrain
e. Tectal plate
I.46. Answer b.
A medial midbrain syndrome, also known as Weber syn-
drome, is characterized by ipsilateral third nerve palsy and
contralateral hemiparesis.
I.47. What is the result of a right nuclear third nerve palsy?
a. Right third nerve palsy and contralateral pupillary dilatation
b. Right third nerve palsy and left intranuclear ophthalmoplegia
c. Right third nerve palsy, contralateral superior rectus palsy, and
contralateral ptosis
d. Right third nerve palsy and pupillary sparing
e. Right third nerve palsy and ipsilateral facial weakness
I.47. Answer c.
A nuclear third nerve palsy causes ipsilateral third nerve
palsy, contralateral ptosis due to involvement of the central
caudal nucleus, and contralateral superior rectus palsy due
to the location of the superior rectus subnucleus.
I.48. Which extraocular muscles are innervated by cranial nerve III?
a. Superior rectus, superior oblique, inferior rectus, and inferior
oblique
b. Lateral rectus, superior rectus, inferior rectus, and medial rectus
c. Lateral rectus, inferior rectus, inferior oblique, and superior oblique
d. Inferior rectus, superior rectus, medial rectus, and inferior
e. Superior rectus, lateral rectus, inferior oblique, and superior
I.48. Answer d.
Cranial nerve III innervates the inferior, superior, and medial
rectus muscles and the inferior oblique muscle.
I.49. Which of the following does not describe the third nerve nuclear
complex?
a. The Edinger-Westphal subnucleus is rostral to the general somatic
efferent component of the third nerve
b. The medial rectus subnuclei on the right innervate the left medial
rectus muscle
c. The central caudal nucleus is midline and innervates bilateral
levator palpebrae muscles
d. This complex lies in the medial midbrain at the level of the red
nucleus and superior colliculus
e. The general visceral efferent component of the third nerve inner-
vates the pupillary constricting muscles
I.49. Answer b.
The superior rectus subnuclei (not the medial rectus subnu-
clei) innervate the contralateral superior rectus muscle.
I.50. A patient presents with acute right hemiparesis and gaze prefer-
ence toward the left. What will happen if you perform the ves-
tibuloocular reflex?
a. The vestibuloocular reflex will be intact
b. The vestibuloocular reflex will be impaired
c. The vestibuloocular reflex will indicate intranuclear
ophthalmoplegia
d. The vestibuloocular reflex will indicate one-and-a-half syndrome
e. The vestibuloocular reflex will indicate bilateral horizontal gaze
dysfunction
I.50. Answer a.
A supratentorial lesion would cause gaze preference toward
the side of the lesion and away from the hemiparesis. With a
supratentorial lesion, the vestibuloocular reflex is intact.
I.51. Which neurotransmitter is secreted by the locus ceruleus?
a. Serotonin
b. Norepinephrine
c. Epinephrine
d. Dopamine
e. Tryptophan
I.51. Answer b.
The locus ceruleus, which is important for wakefulness and
attention, secretes norepinephrine.
I.52. A patient presents with gradual, progressive difficulty with
upward gaze and headache. Upon attempted upgaze, he has
convergence-retraction nystagmus. His pupils do not react. What
is the most likely cause?
a. Pituitary tumor
b. Multiple sclerosis affecting the pons
c. Pineal tumor
d. Cavernous sinus meningioma
e. Acoustic neuroma
I.52. Answer c.
Parinaud syndrome is characterized by upward gaze palsy,
convergence-retraction nystagmus, and pupillary reaction to
accommodation but not light. Parinaud syndrome is due to a
dorsal midbrain lesion, such as a pineal tumor.
I.53. Which cranial nerves have parasympathetic components?
a. III, V, VI, and X
b. III, IV, V, and VI
c. III, VII, IX, and X
d. V, VII, IX, and X
e. V, VII, IX, and XII
I.53. Answer c.
Cranial nerves III, VII, IX, and X have parasympathetic (gen-
eral visceral efferent) components.
I.54. What innervates the submandibular and sublingual glands?
a. Cranial nerve IX through the otic ganglion
b. Cranial nerve X through the otic ganglion
c. Cranial nerve VII through the sphenopalatine ganglion
d. Cranial nerve V through the submandibular ganglion
e. Cranial nerve VII through the submandibular ganglion
I.54. Answer e.
Cranial nerve VII innervates the sublingual and submandib-
ular glands through the submandibular ganglion. Cranial
nerve VII also innervates the lacrimal gland through the
sphenopalatine ganglion.
I.55. Where do burst neurons for horizontal saccades originate?
a. Interstitial nucleus of Cajal
b. Nucleus raphe interpositus
c. Vestibular nucleus
d. Paramedian pontine reticular formation
e. Superior olive
I.55. Answer d.
Burst neurons from the paramedian pontine reticular forma-
tion are involved in horizontal saccadic eye movements.
I.56. While examining a 35-year-old woman referred for possible multiple
sclerosis, you observe eye movement abnormalities. Although right-
ward gaze is normal and conjugate, during leftward saccades the
right eye adducts slowly and incompletely, and the abducted left eye
shows a few beats of nystagmus. Both eyes adduct normally with
convergence. On the basis of these findings, where is the lesion?
a. Left vestibular nuclei
b. Left medial longitudinal fasciculus (MLF)
c. Left paramedian pontine reticular formation
d. Right MLF
e. Right rostral interstitial nucleus of the MLF
I.56. Answer d.
A lesion in the right MLF would result in diplopia predomi-
nantly with left gaze because the connection between the
right medial rectus subnucleus and left lateral rectus would
be impaired.
I.57. In the ocular motor system, what is the purpose of a neural
integrator?
a. To prolong the duration of the vestibular system response to sus-
tained rotation
b. To improve the accuracy of saccades
c. To convert a velocity (pulse) to the position (step) command in
order to hold the eyes in an eccentric position and prevent gaze-
holding nystagmus
d. To prevent excitatory burst neurons from unintended firing that
would result in ocular flutter or opsoclonus
e. To relay visual input to the ocular motor system during smooth
pursuit
I.57. Answer c.
The neural integrator helps the “step” of tonic innervation to
hold the eyes in the new position.
I.58. A 62-year-old woman is referred to you for slowly progressive gait
impairment. On examination you observe spontaneous downbeat
nystagmus in primary position, gaze-evoked nystagmus, and
choppy pursuit in all directions. What is the most likely diagnosis?
a. Parkinson disease
b. Progressive supranuclear palsy
c. Pontine cavernous angioma
d. Posterior cortical atrophy
e. Cerebellar degeneration
I.58. Answer e.
Spontaneous central vestibular nystagmus that is predomi-
nantly downbeating in the straight-ahead gaze position is
often associated with cerebellar degeneration.
I.59. Through which thalamic nucleus does the olfactory pathway
relay before reaching the olfactory cortex?
a. Pulvinar
b. Medial dorsal
c. Lateral geniculate body
d. Anterior nucleus
e. None
I.59. Answer e.
The olfactory pathway is the only sensory pathway that does
not relay through the thalamus.
I.60. To which part of the visual pathway would bitemporal visual loss
localize?
a. Optic nerve
b. Optic chiasm
d. Optic radiation to the parietal lobe
e. Occipital cortex
I.60. Answer b.
A lesion at the optic chiasm would result in bitemporal
visual loss because the fibers carrying information from each
temporal field cross to the opposite side of the chiasm.
I.61. If a patient reports detecting unusual odors that no one else
perceives, where might a lesion be located?
a. Orbitofrontal cortex
b. Piriform cortex
c. Lingual gyrus
d. Fusiform gyrus
e. Angular gyrus
I.61. Answer b.
The olfactory pathway terminates in the piriform cortex of
the temporal lobe. Patients with phantosmia (perception of
an odor that is not truly present) may have a temporal lobe
seizure disorder or a temporal lobe lesion.
I.62. What would a patient likely experience with an ischemic stroke
involving the anterior nucleus of the thalamus?
a. Contralateral homonymous hemianopsia
b. Ipsilateral hemiataxia
c. Short-term memory loss
d. Aphasia
e. Disinhibited behavior
.62. Answer c.
The anterior nucleus of the thalamus is involved in limbic
relay with input from the mammillary bodies. Lesions of the
anterior thalamus often result in short-term memory loss
without alteration of consciousness.
I.63. Which of the following thalamic nuclei is involved in executive
function and multitasking?
a. Dorsomedial
b. Lateral geniculate body
c. Ventral lateral
d. Ventral anterior
e. Pulvinar
I.63. Answer a.
The dorsomedial nucleus receives input from the prefrontal
cortex and projects back to the prefrontal cortex, which is
involved in executive function and the ability to multitask.
I.64. Which thalamic nucleus receives blood supply from the anterior
circulation?
c. Ventral posterior lateral
d. Pulvinar
e. Anterior nucleus
I.64. Answer e.
The anterior nucleus of the thalamus receives blood supply
from a perforating artery off the proximal portion of the pos-
terior communicating artery.
I.65. A 60-year-old woman has clinical signs and symptoms consistent
with a diagnosis of Cushing syndrome. This condition is likely due
to prolonged exposure to high levels of which of the following?
a. Thyrotropin
b. Prolactin
c. Insulinlike growth factor 1
d. Follicle-stimulating hormone
e. Cortisol
I.65. Answer e.
Cushing syndrome occurs with prolonged exposure to
inappropriately high levels of cortisol that result in excess
levels of cortisol, corticotropin, or corticotropin-releasing
hormone.
I.66. Which of the following inhibits the secretion of growth hormone?
a. Somatostatin
b. Dopamine
c. Cortisol
d. Triiodothyronine
e. Testosterone
I.66. Answer a.
Somatostatin, also known as growth hormone release–inhib-
iting hormone, is produced in the periventricular nucleus
and inhibits the secretion of growth hormone.
I.67. A 45-year-old man has difficulty with food intake and the sleep-
wake cycle. Which nucleus of the hypothalamus is most likely
affected?
a. Paraventricular (magnocellular neurons)
b. Paraventricular (parvocellular neurons)
c. Medial preoptic
d. Posterolateral
e. Dorsomedial
I.67. Answer d.
Posterolateral hypothalamic neurons secrete orexin, which
regulates the switch between wakefulness and sleep. Orexin
neurons also stimulate food intake and are part of the reward
circuit involved in drug addiction through projections to
dopaminergic neurons of the ventral tegmental nucleus.
I.68. Which part of the limbic system is most critical for the encoding
and retrieval of declarative (explicit) memory?
a. The posterior limbic circuit, centered in the posterior cingu-
late cortex
b. The anterior limbic circuit, centered in the hippocampus
c. The posterior limbic circuit, centered in the hippocampus
d. The anterior limbic circuit, centered in the amygdala
e. The orbitomedial prefrontal cortex
I.68. Answer c.
The posterior limbic circuit is critical for learning, storage, and
retrieval of declarative memory, including details about auto-
biographical events (episodic memory), places and locations
(visuospatial memory), and general facts (semantic memory).
I.69. Which component of the limbic system is responsible for asso-
ciative memory linking the perception of odors with emotional
and behavioral responses?
a. Basolateral amygdala
b. Basal forebrain
c. Entorhinal cortex
d. Olfactory amygdala
e. Centromedial amygdala
.69. Answer d.
The olfactory amygdala receives information from the olfac-
tory bulb and primary olfactory cortex and is involved in
associative memory for odors and the resulting emotional
and behavioral responses.
I.70. A 38-year-old man is dismissed from the hospital after receiving
antiviral therapy for herpes simplex virus encephalitis. A few
months later, family members bring him to you for evaluation
because the patient has been displaying inappropriate sexual
behavior and a tendency to explore objects with his mouth, and he
has had memory loss, weight gain due to nearly compulsive eating,
and a submissive, “docile” affect. What syndrome is most likely?
a. Behavioral variant frontotemporal dementia
b. Kleine-Levin syndrome
c. Herpes simplex virus reinfection syndrome
d. Early-onset Alzheimer disease
e. Klüver-Bucy syndrome
I.70. Answer e.
Klüver-Bucy syndrome, due to bilateral damage to the
medial temporal lobes, including the amygdala, may occur
through various insults and result in amnesia, hypersexual-
ity, hyperorality, hyperphagia, and docility.
I.71. What is the effect of the globus pallidus interna (GPi) on thala-
mocortical outflow?
a. Tonic excitation
b. Oscillatory excitation
c. Tonic inhibition
d. Oscillatory inhibition
e. No direct outflow is present
I.71. Answer c.
The GPi and the substantia nigra pars reticularis are the out-
put nuclei of the basal ganglia and provide tonic γ-aminobu-
tyric acid (GABA)ergic inhibition of motor pattern generators
in the motor cortex (by relay through the ventral anterior
and ventral lateral nuclei of the thalamus), the pedunculo-
pontine nucleus (locomotor pattern generator), and the
superior colliculus (saccadic pattern generator).
I.72. For facilitation of movement, which of the following must occur?
a. Facilitation of the subthalamic nucleus
b. Inhibition of the globus pallidus interna (GPi)
c. Inhibition of the supplementary motor area
d. Increased γ-aminobutyric acid (GABA)ergic transmission
e. Inhibition of thalamocortical projections
I.72. Answer b.
The direct pathway involves cortical input to medium spiny
neurons that express dopamine D1 receptors and send a
GABAergic projection to the GPi and the subthalamic
nucleus. This pathway transiently inhibits the GPi and the substantia nigra pars reticularis. The resultant “go” signal
from the basal ganglia facilitates movement.
I.73. Which disease is associated with decreased activity of the direct
pathway dopamine D1 receptors and increased activity of the
indirect pathway dopamine D2 receptors?
a. Hemiballismus
b. Huntington disease
c. Basal ganglia stroke
d. Parkinson disease
e. Fahr disease
I.73. Answer d.
Parkinson disease results from the loss of dopaminergic
neurons of the substantia nigra pars compacta (SNc) and
affects first the ventrolateral portion of the SNc targeting
the putamen. This creates an imbalance between the
direct and indirect pathways, with hypoactivity of the
dopamine D1 receptor–activated direct pathway and
hyperactivity of the dopamine D2 receptor–inhibited
indirect pathway, resulting in the motor manifestations of
Parkinson disease.
I.74. A female patient presents with acute mild weakness of the right
arm and leg. She has superimposed ataxia on the right side with
the finger-to-nose and heel-to-shin tests. She also has reduced
sensation to pain and temperature on the right side. Where is
the most likely localization of this syndrome?
a. Basis pontis
b. Lateral thalamus and internal capsule
c. Medial midbrain
d. Ventral medulla
e. Parietal cortex
I.74. Answer b.
Ataxic hemiparesis is a classic lacunar syndrome that can be
localized to the cortex, internal capsule and lateral thala-
mus, or basis pontis. However, when the patient also has
sensory involvement, the most likely localization is the lat-
eral thalamus and internal capsule.
I.75. Which artery supplies the dentate nucleus?
a. Vertebral artery
b. Basilar artery
c. Posterior inferior cerebellar artery
d. Anterior inferior cerebellar artery
e. Posterior cerebral artery
I.75. Answer d.
The ventral aspect of the dentate nucleus is supplied by the
anterior inferior cerebellar artery. The rostral part of the den-
tate nucleus is supplied by the superior cerebellar artery.
I.76. If a patient has gait ataxia without limb ataxia, where might the
lesion be located?
a. Vermis of the cerebellum
b. Flocculus of the cerebellum
c. Anterior lobe of the cerebellum
d. Decussation of the left superior cerebellar peduncle
e. Lateral hemisphere of the cerebellum
I.76. Answer a.
A lesion of the vermis of the cerebellum may result in iso-
lated gait ataxia.
I.77. Which of the following describes the output of the dentate nucleus?
a. The fibers travel ipsilaterally in the spinal cord as the reticulospi-
nal tracts
b. The fibers travel to the contralateral spinal cord as the reticulo-
spinal tracts
c. The fibers travel through the superior cerebellar peduncle, cross to
the contralateral side, and synapse in the ventral lateral thalamus
d. The output fibers from the dentate nucleus travel to the contra-
lateral basis pontis, where they synapse
e. The fibers travel to the ipsilateral ventromedial thalamus
I.77. Answer c.
Output fibers from the dentate nucleus travel to the contra-
lateral cortex through the ventral lateral thalamus (see
Figure 18.9).
I.78. Autoimmune autonomic ganglionopathy (AAG) most often
results from autoantibodies against the ganglionic subtype of
nicotinic acetylcholine receptors. Which of the following would
not be an expected manifestation of AAG?
a. Atonic bladder
b. Early satiety
c. Excessive sweating
d. Impaired night vision
e. Orthostatic hypotension
I.78. Answer c.
Blockade of ganglionic nicotinic acetylcholine receptors would
impair preganglionic neurotransmission at sympathetic and
parasympathetic pathways. The result related to sweating
would be anhidrosis, not excessive sweating.
I.79. Which of the following correctly pairs a lesion with a feature of
the type of neurogenic bladder that would result from that lesion?
a. Aqueductal stenosis and retention of large volumes of urine
b. Cauda equina compression and detrusor-sphincter dyssynergia
c. Diabetic neuropathy and uninhibited bladder
d. Lateral medullary infarction and atonic bladder
e. Transverse myelitis and urinary frequency with urgency
I.79. Answer e.
A lesion in the spinal cord would disrupt the pontine mictu-
rition reflex that coordinates detrusor contraction and
sphincter relaxation during bladder emptying. The result is
a spastic bladder characterized by frequency, urgency, detru-
sor-sphincter dyssynergia, and small-volume incontinence.
I.80. A patient’s pupils measure OD 2 mm and OS 4 mm in bright light
and OD 3 mm and OS 7 mm in dim light. With instillation of
dilute cocaine drops, the pupils measure OD 8 mm and OS 9 mm.
Which of the following is a possible location of the lesion result-
ing in pupil asymmetry?
a. Right oculomotor nerve
c. Right superior cervical ganglion
d. Left oculomotor nuclei
e. Right pupillary dilator muscle
I.80. Answer c.
The exaggerated response of the right pupil to dilute cocaine
is consistent with denervation hypersensitivity, which
results only from postganglionic (peripheral) autonomic
lesions. Of the given answer choices, only choice c describes
a postganglionic neuronal structure on the right side.
I.81. In which lobe of the brain is the angular gyrus located?
a. Frontal
b. Temporal
c. Parietal
d. Occipital
e. Limbic
I.81. Answer c.
The angular gyrus is located in the parietal lobe.
I.82. A 34-year-old patient with a history of recent traumatic brain
injury was found urinating on his front lawn. He made inappro-
priate comments when police arrived. In which portion of the
brain is the injury most likely located?
a. Anterior cingulate gyrus
b. Paracentral lobule
c. Cuneus
d. Orbitofrontal cortex
e. Dorsolateral prefrontal cortex
I.82. Answer d.
Patients with injury to the orbitofrontal cortex often display
disinhibition. The orbitofrontal cortex is prone to injury in
coup-contrecoup trauma.
I.83. Where in the cortex are primary visceral sensory, taste, and pain
information projected?
a. Dorsolateral prefrontal cortex
b. Cuneus
c. Inferior temporal lobe
d. Precuneus
e. Insular cortex
I.83. Answer e.
Primary visceral sensory, taste, and pain information project
to the insular cortex.
I.84. Which statement is false about cortical organization?
a. The number of layers in the cortex varies by cortex type
b. Idiotypic isocortex contains 6 layers
c. Homotypic isocortex contains 6 layers
d. The primary motor cortex is an example of idiotypic isocortex
e. Allocortex has no consistent lamination
I.84. Answer e.
The allocortex has 3 identifiable layers.
I.85. Which is not an example of mesocortex?
a. Parahippocampal gyrus
b. Cingulate gyrus
c. Basal forebrain
d. Insula
e. Temporal pole
I.85. Answer c.
The mesocortex includes the parahippocampal gyrus, cingu-
late gyrus, orbitofrontal cortex, insula, and temporal pole. The
basal forebrain is corticoid with no consistent lamination.
I.86. Which term is not related to the neocortex?
a. Isocortex
b. Corticoid
c. Primary cortex
d. Heteromodal association cortex
e. Unimodal association cortex
I.86. Answer b.
The neocortex (also known as idiotypic isocortex and homo-
typic isocortex) contains 6 layers. The corticoid structures
have no consistent lamination and include the basal forebrain (septal area, diagonal band of Broca, and substan-
tia innominata).
I.87. Which of the following is true about the default mode net-
work (DMN)?
a. The DMN consists of a series of interconnected unimodal cortices
b. The orbitofrontal cortex is a large component of the DMN
c. Neurodegenerative diseases may impair the DMN, leading to
impairment of autobiographic memory and poor spatial navigation
d. The DMN is active during coma
e. The DMN is associated with lesions in the thalamus
I.87. Answer c.
The DMN is a distributed neural network of heteromodal
association cortices, including the posterior cingulate, precu-
neus, lateral parietal, middle temporal, and medial prefrontal
cortices. The DMN maintains a continuous background and
will deactivate during some cognitive tasks. Neurodegenerative
diseases such as Alzheimer disease may damage medial tem-
poral lobe structures of the DMN, leading to impaired auto-
biographic memory and poor spatial navigation.
I.88. Which of the following is a function of the anterior limbic circuit?
a. Hunger
b. Autobiographic memory
c. Visual spatial awareness
d. Sensory integration
e. Taste
I.88. Answer a.
The anterior limbic circuit is involved in coordinating
behavioral drives (eg, hunger, thirst, procreation, and emo-
tion) and complex cognitive processes with motor plans to
satisfy those drives through certain behaviors.
I.89. Why is the parietal heteromodal cortex important?
a. For identifying and labeling a visual object
b. For identifying the color of a visual object
c. For integrating the location of a visual object to direct motor (eye
and limb) movement toward the object
d. For identifying the texture of an object
e. For initiating a motor response to an emotion
I.89. Answer c.
The dorsal visuospatial processing stream (the “where”
pathway) is located in the posterior parietal cortex and then
spreads to the medial and superior parietal regions. The
superior parietal and intraparietal sulcal portions of the dor-
sal stream are functionally connected to the premotor cortex
and particularly to the frontal eye fields, which are impor-
tant for coordinating hand and eye movements directed
toward the environment with visual-spatial knowledge.
I.90. A 75-year-old patient presents with stroke affecting the left
hemisphere. He has nonfluent speech with poor naming but
intact comprehension and repetition. What would be the best
classification for this type of aphasia?
a. Broca aphasia
b. Wernicke aphasia
d. Transcortical sensory aphasia
e. Transcortical motor aphasia
I.90. Answer e.
Transcortical motor aphasia is similar to Broca aphasia
except that repetition is intact. Patients are nonfluent and
have difficulty naming, but they have intact repetition and
comprehension.
I.91. Soon after a patient was involved in a motor vehicle accident,
the patient began to laugh inappropriately during church ser-
vices, interrupt conversations, and make poor financial deci-
sions. Where is the most likely localization of the brain injury?
b. Ventrolateral prefrontal cortex
c. Orbitofrontal cortex
d. Bilateral temporal cortices
e. Bilateral parietal cortices
I.91. Answer c.
The orbitofrontal cortex and medial prefrontal cortex modu-
late emotional behavior and decision making. Injury to these
regions may result in behavioral disinhibition, inappropri-
ate social behavior, impaired insight, and lack of empathy.
I.92. A patient with stroke cannot recognize her son visually, but
when he speaks, she recognizes his voice. Where is the stroke
most likely localized?
a. Left prefrontal cortex
b. Right prefrontal cortex
c. Left parietal cortex
d. Right occipitotemporal cortex
e. Left occipital lobe
I.92. Answer d.
Prosopagnosia is the inability to recognize faces. This condi-
tion localizes bilaterally or to the right occipitotemporal
cortex.
I.93. A patient has sudden difficulty with adding and subtracting,
identifying his thumb, right-left disorientation, and writing.
Where is this process localized?
a. Left orbitofrontal cortex
b. Left premotor cortex
c. Left anterior thalamus
d. Left angular gyrus
e. Left superior parietal lobule
I.93. Answer d.
Gerstmann syndrome is characterized by right-left disorien-
tation, finger agnosia, agraphia, and acalculia. This syn-
drome localizes to the left angular gyrus.
I.94. Which factor increases the speed of action potential propagation?
a. Sensory nerve rather than motor nerve
b. Cold
c. Location in the central nervous system
d. Absence of myelin
e. Larger axonal diameter
I.94. Answer e.
The speed of action potential propagation along an axon is
determined by several factors: axonal diameter (larger is
faster), temperature (warmer is faster), and myelination
(myelinated is faster).
I.95. Which of the following describes the neurotransmitter glutamate?
a. Ondansetron acts on glutamate receptors
b. Glutamate is an inhibitory neurotransmitter
c. α-Amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA)
and N-methyl-D-aspartate (NMDA) are receptors for glutamate
d. The locus ceruleus manufactures glutamate
e. Glutamate acts on nicotinic and muscarinic receptors
I.95. Answer c.
Glutamate is an excitatory neurotransmitter when acting on
AMPA and NMDA receptors.
I.96. Which of the following is produced by the raphe nuclei?
a. Dopamine
b. Acetylcholine
c. Serotonin
d. Adrenaline
e. Oxytocin
I.96. Answer c.
The raphe nuclei, which are present throughout the brain-
stem, produce serotonin.
I.97. Which of the following statements about neuronal transmem-
brane potentials is most correct?
a. Usually the neuronal resting membrane potential is approxi-
mately +70 mV
b. The resting membrane potential is maintained primarily through
passive membrane ion transport
c. The depolarizing phase of the action potential is mediated primar-
ily by voltage-gated sodium channels that have a fast activation
d. The speed of action potential propagation is entirely indepen-
dent of axonal diameter
e. The equilibrium potential of potassium is highly positive (approx-
imately +90 mV) and therefore does not contribute meaningfully
to the resting membrane potential
I.97. Answer c.
The nerve action potential is an all-or-none phenomenon
that occurs within the axon and propagates along the axon to
its target. The depolarizing phase of the action potential is
driven by the voltage-gated sodium channel. As the mem-
brane potential becomes depolarized, delayed activation of
voltage-gated potassium channels helps the potential
become more negative (hyperpolarization), moving it toward
the potassium equilibrium potential (−90 mV).
I.98. Which of the following is the primary neurotransmitter synthe-
sized by alpha motor neurons in the spinal cord?
b. Serotonin
c. Norepinephrine
d. Acetylcholine
e. Glutamate
I.98. Answer d.
Alpha motor neurons in the spinal cord synthesize acetyl-
choline.
I.99. Which statement is true about anterograde axonal transport?
a. It is accomplished by the dynein-dynactin complex
b. Anterograde transport shuttles cellular cargo toward the cell body
c. The kinesin family of proteins is involved in this process
d. The rate of transport is approximately 100 mm/d
e. Transport occurs along neurofilaments
I.99. Answer c.
Anterograde transport (away from the cell body) is accom-
plished by the kinesin family of proteins. Anterograde trans-
port may be fast (200-400 mm/d) or slow (1-10 mm/d) and
occurs along microtubules. Retrograde transport (toward the
cell body) is performed by the dynein-dynactin complex.
I.100. Which cellular component or process is dysfunctional in lyso-
somal storage diseases?
a. Anterograde axonal transport
b. Apoptosis
c. Transcription
d. Mitochondria
e. Protein processing
I.100. Answer e.
Proteins are degraded primarily by 2 processes: 1) endo-
somal and lysosomal destruction or 2) ubiquitination and
proteasome removal. Lysosomal storage diseases are a
broad array of primarily pediatric disorders caused by dys-
functional lysosomal function.
I.101. Which of the following is required for transport of long-chain
fatty acids into the mitochondria?
a. L-carnitine and carnitine palmitoyltransferases
b. Nicotinamide adenine dinucleotide
c. Adenosine triphosphate
d. Methylmalonic acid
e. Coenzyme Q10
I.101. Answer a.
Long-chain fatty acids are dependent on L-carnitine and
carnitine palmitoyltransferases I and II for transport into
the mitochondria.
I.102. Which of the following best decribes the cause of necrosis, an
acute process of cellular injury and death?
a. Formation of autophagosomes
b. Energy depletion, ion pump failure, and cellular swelling and lysis
c. Cellular shrinkage and chromatin condensation
d. Self-aggregation of misfolded proteins
e. Release of cytochrome c through mitochondrial pores
I.102. Answer b.
The biochemical hallmark of necrosis is the sudden loss of
cellular energy due to acute mitochondrial dysfunction.
Depletion of adenosine triphosphate and phosphocreatine
leads quickly to the failure of energy-dependent ion pumps
(eg, Na+,K+-ATPase; also called the sodium-potassium
pump), causing loss of osmotic and electrolyte gradients.
Ion pump failure thus leads to an influx of water and neu-
ronal depolarization.
I.103. What is the culmination of intrinsic and extrinsic apoptotic
pathways?
a. A profound inflammatory response caused by apoptotic bodies
b. Cellular lysis releasing toxic and proinflammatory intracellular
contents
c. Mitochondrial pore formation, cytochrome c release, and cas-
pase 3 activation, which causes DNA fragmentation
d. Large membrane vesicles fusing with lysosomes
e. Cell membrane pore formation, which accelerates permeability,
swelling, and lysis
I.103. Answer c.
The final effectors of cell death in the intrinsic and extrin-
sic apoptotic pathways are 1) the formation of a mitochon-
drial pore (by B-cell lymphoma 2 [Bcl-2]-associated X
protein [Bax] and Bcl-2 homologous antagonist/killer
[Bak]); 2) the mitochondrial release of cytochrome c and
other mediators (eg, caspase 9, an initiator caspase) that
activate caspase 3 (an executioner caspase); and 3) DNA
fragmentation by activated caspase 3.
I.104. What is the morphologic hallmark of autophagy?
a. Cytoplasmic and mitochondrial swelling
b. Formation of apoptotic bodies
c. Nuclear chromatin rarefaction and karyolysis
d. An abundance of intracellular vesicles, autophagosomes, and
lysosomes
e. Cellular shrinkage, membrane blebs, and nuclear compaction
I.104. Answer d.
The morphologic hallmark of autophagy is an abundance of
intracellular vesicles, autophagosomes, and lysosomes,
which can also be seen in the late stages of necrotic and
apoptotic cell death.
I.105. In the presynaptic neuron, which vitamin is required for the
conversion of glutamate to γ-aminobutyric acid (GABA)?
a. Vitamin B1
b. Vitamin E
c. Vitamin D
d. Vitamin A
e. Vitamin B6
I.105. Answer e.
Glutamic acid decarboxylase converts glutamate to GABA
in a reaction that requires vitamin B6. GABA is then stored
in presynaptic vesicles.
I.106. Phenytoin is highly protein bound. In which instance would a
patient most likely show signs of toxicity with a normal level of
serum total phenytoin?
a. Chronic kidney disease
b. Concurrent levetiracetam use
c. Obesity
d. Type 2 diabetes mellitus
e. Pregnancy
I.106. Answer a.
Chronic illness, malnutrition, and advanced age are all
associated with decreased serum protein. When less phen-
ytoin is bound to protein, the amount of free phenytoin is
higher. Although the level of serum total phenytoin may be
normal, if the level of free phenytoin is high, a patient can
show signs of toxicity.
I.107. How do calcitonin gene–related peptide (CGRP) receptor anti-
body medications exert their action on migraine?
a. By acting as selective agonists of serotonin 1B and 1D receptors
b. By increasing glutamatergic inhibition
c. By decreasing intrasynaptic dopamine reuptake
d. By modulating nociceptive pathways in the trigeminovascu-
lar system
e. By inhibiting norepinephrine production
I.107. Answer d.
CGRPs are central to migraine pathophysiology, which
involves nociceptors in the trigeminovascular system and
allows for targeted therapy with CGRP receptor antibodies.
I.108. How do monoamine oxidase B (MAO-B) inhibitors improve
symptoms of Parkinson disease?
a. By directly activating dopamine receptors
b. By blocking degradation of dopamine
c. By enhancing dopamine release from presynaptic terminals
d. By causing anticholinergic effects
e. By inhibiting dopa decarboxylase
I.108. Answer b.
Treatment of Parkinson disease focuses on increasing the
production of dopamine in the central nervous system or
activating dopamine receptors. MAO-B breaks down dopa-
mine, so MAO-B inhibitors increase the availability of
dopamine.
I.109. A patient in the sleep laboratory has low-amplitude, mixed-fre-
quency changes on electroencephalography (EEG) with K com-
plexes and sleep spindles in addition to decreased muscle tone.
The patient is most likely in which of the following stages of sleep?
a. Non–rapid eye movement (NREM) sleep stage N1
b. NREM sleep stage N2
c. NREM sleep stage N3
d. NREM sleep stage N4
e. Rapid eye movement sleep
I.109. Answer b.
NREM sleep stage N2 is characterized by decreased muscle
tone, reduced eye movements, and low-amplitude, mixed-
frequency changes on EEG. Sleep spindles and K com-
plexes may be present. See also Table 28.1.
I.110. Which stage of sleep is represented in the sleep study shown in the figure below?
I.110. Answer e.
The electroencephalogram (EMG) shows a low-voltage,
mixed-frequency pattern with rapid eye movements in the
eye channels. Normal muscle atonia is evident in the chin,
arm, and leg EMG channels (30-second epoch). (The mon-
tage and the abbreviations are the same as in Figure 28.3.)
I.111. Where are hypocretinergic (orexinergic) nuclei located?
a. Basal forebrain
b. Pineal gland
c. Posterolateral hypothalamus
d. Anterior thalamus
e. Supraoptic nucleus of the hypothalamus
I.111. Answer c.
The wakefulness stabilizing system consists of the hypo-
cretinergic (also known as orexinergic) neurons of the peri-
fornical area and posterolateral hypothalamus.
I.112. What type of inheritance is most likely represented by the pedigree in the figure below?
a. Autosomal dominant
b. Autosomal recessive
c. Mitochondrial
d. X-linked dominant
e. X-linked recessive
I.112. Answer a.
An autosomal dominant disorder is one in which the
mutant allele, located on an autosome, is expressed in the
heterozygote. The pedigree pattern of transmission is verti-
cal, with successive generations affected.
I.113. Which statement is true about mitochondrial DNA or mitochon-
drial inheritance?
a. Mitochondrial DNA contains 48 genes
b. An individual cell contains approximately 5 copies of the mito-
chondrial DNA
c. Transmission of mitochondrial diseases is through maternal
inheritance
d. Mitochondrial diseases are never inherited in a mendelian fashion
e. The phenotype of patients with mitochondrial disease is almost
identical to that of the parent
I.113. Answer c.
Mitochondrial DNA is a double-stranded circular molecule
that contains 37 genes. Most cells contain thousands of
mitochondrial DNA molecules. Mitochondrial inheritance
has the following unique features: maternal inheritance,
mitotic segregation, homoplasmy, heteroplasmy, and
threshold effect. The risk and severity of mitochondrial dis-
ease in children of mothers with mitochondrial DNA muta-
tions depend on the fraction of mutant mitochondria in
their mother and in their tissues and on the random chance
of inheriting mutant mitochondria.
I.114. Which of the following terms refers to the degree or severity to
which a disease phenotype is expressed among persons with
the same mutation?
a. Allelic heterogeneity
b. Expressivity
c. Locus heterogeneity
d. Penetrance
e. Phenotypic heterogeneity
I.114. Answer b.
Expressivity is the degree or severity to which a disease
phenotype is expressed among persons with the same
mutation.
I.115. Adults with Down syndrome have an increased risk for which of
the following neurologic conditions?
a. Ataxia
b. Parkinson disease
c. Alzheimer dementia
d. Spastic paraparesis
e. Multiple system atrophy
I.115. Answer c.
Adults with Down syndrome have an increased risk for
Alzheimer dementia due to triplication of the gene for amy-
loid-β precursor protein.
I.116. Which diagnostic test may be helpful in the diagnosis of
Angelman syndrome?
a. Cerebrospinal fluid analysis
b. Electroencephalography
c. Electromyography
d. Magnetic resonance imaging of the brain
e. Auditory evoked potentials
I.116. Answer b.
Angelman syndrome is characterized by severe intellectual
disability, marked impairment of language acquisition,
ataxia, a seizure disorder with a characteristic electroen-
cephalogram, subtle but distinctive facial features (wide
smiling mouth, prominent chin, and deep-set eyes), and a
happy, sociable disposition. Molecular genetic testing
(methylation analysis and UBE3A sequencing) identifies
alterations in approximately 90% of patients. The electro-
encephalogram is characteristic with 1) persistent rhythmic
activity (4-6/s); 2) runs of triphasic activity (2-3/s) that is
maximal over the frontal regions and is mixed with spikes
and sharp waves; and 3) posterior spikes mixed with waves
(3-4/s) provoked by eye closure.
I.117. Which of the following syndromes is the most common single-gene cause of intellectual disability?
a. Prader-Willi syndrome
b. Angelman syndrome
c. Williams syndrome
d. Fragile X syndrome
e. Down syndrome
I.117. Answer d.
Fragile X syndrome is the most common inherited cause of
intellectual disability and the most common single-gene
cause of autism. Classic clinical features in a male include
intellectual impairment, a characteristically long face with
prominent ears, autistic behavior, postpubertal macro-
orchidism, connective tissue abnormalities (mitral valve
prolapse or aortic dilatation), and seizures (in 20% of
patients).
I.118. Repetitive, stereotypic hand movements are characteristic for
which of the following intellectual disabilities?
a. Rett syndrome
b. Fragile X syndrome
c. Down syndrome
d. Prader-Willi syndrome
e. Angelman syndrome
I.118. Answer a.
Rett syndrome is an X-linked disorder. Classically, affected
girls are often considered to have had normal development
for the first 6 to 18 months of life before their development
slows and arrests. These girls then enter a period of regres-
sion and social withdrawal that may persist for months.
Loss of purposeful hand use and loss of spoken language
are important features. The presence of nonspecific hand rubbing or hand-mouth movements and of truncal instabil-
ity or ataxia may also suggest a diagnosis of Rett syndrome.
I.119. What stage of sleep is shown in the electroencephalographic (EEG) epoch in the figure below?
a. N1
b. N2
c. N3
d. Rapid eye movement (REM)
e. Awake
I.119. Answer b.
Sleep spindles (in the middle of the EEG) and K complexes
(toward the right side of the EEG) are key components of N2
sleep. V waves, also present, can be seen in N1 sleep, but the
other components would not be present. There is no delta
activity to suggest N3 sleep. All the sleep architecture present
would not be found in REM sleep. The patient is not awake.
I.120. A 43-year-old man had an episode of confusion. An electroencephalogram (EEG) during drowsiness is shown in the figure
below. What is its clinical importance?
a. It shows a normal variant
b. It indicates an increased risk of seizures
c. It shows a temporal lobe seizure
d. It indicates that a brain injury occurred
e. It is typical after a craniotomy
I.120. Answer a.
The figure shows a brief run of wicket waves, which are a
normal variant, over the left temporal head region. These
are not sharp waves that would indicate a seizure risk, and
they are not consistent with a temporal lobe seizure.
Persistent or frequent focal slowing throughout the EEG—
but not wicket waves—may be expected after a brain injury.
This is not a breach rhythm, which is seen after craniotomy.
I.121. From slowest to fastest, what is the correct order of electroen-
cephalographic (EEG) frequencies?
a. Alpha, beta, delta, theta
b. Delta, theta, alpha, beta
c. Beta, alpha, theta, delta
d. Theta, alpha, beta, delta
e. Delta, alpha, theta, beta
I.121. Answer b.
The EEG frequencies from slowest to fastest are delta (<4
Hz), theta (4-7 Hz), alpha (8-13 Hz), and beta (>13 Hz).
I.122. A 17-year-old high school senior presents after having a generalized tonic-clonic seizure. She describes a history of quick jerks that have usually occurred in the morning and have sometimes caused her to drop things. You suspect juvenile myoclonic epilepsy. What
finding might be expected on electroencephalography?
a. Electrodecrement with myoclonic jerks
b. Generalized 3-Hz spike-and-wave pattern
c. Generalized slow spike-and-wave pattern
d. Generalized atypical polyspike-and-wave pattern
e. Focal right temporal sharp waves
I.122. Answer d.
Juvenile myoclonic epilepsy is associated with generalized
atypical spike-and-wave and polyspike-and-wave patterns.
Electrodecrement is seen with infantile spasms, not myo-
clonic seizures. A 3-Hz spike-and-wave pattern is a hall-
mark of absence seizures. A slow spike-and-wave pattern
appears in Lennox-Gastaut syndrome. Juvenile myoclonic
epilepsy is a generalized epilepsy, so focal right temporal
sharp waves would not be an expected finding.
I.123. Which of the following is an electroencephalographic (EEG) cri-
terion to evaluate brain death?
a. Interelectrode distance of at least 20 cm
b. Impedance of 10 to 20,000 Ω
c. Recording with a sensitivity of 2 μV/mm for at least 30 minutes
d. Core body temperature less than 36°C
e. A high-frequency filter setting of less than 30 Hz
1.123. Answer c.
The EEG must remain absent of activity at a sensitivity of 2
μV/mm for at least 30 minutes to be consistent with electro-
cerebral silence supportive of brain death. The minimum
interelectrode distance to support brain death is 10 cm. The
impedance should be less than 10,000 Ω. The core body
temperature needs to be normal (around 36°C). The high-
frequency filter must be at least 30 Hz.
1.124. A 46-year-old woman presents to the emergency department
after a witnessed seizure. She had progressive confusion for the
day preceding the seizure. In the emergency department, she is
encephalopathic and febrile. With polymerase chain reaction,
her spinal fluid is positive for herpes simplex virus (HSV). Which
of the following would electroencephalography (EEG) most
likely show?
a. Lateralized periodic discharges
b. Normal EEG
c. Generalized atypical spike-and-wave discharges
d. Burst suppression pattern
e. Frontal intermittent rhythmic delta activity (FIRDA)
1.124. Answer a.
Lateralized periodic discharges are often found after brain
injury and are known to occur with HSV encephalitis. A
normal EEG would be unlikely for a patient with HSV
encephalitis. Generalized atypical spike-and-wave dis-
charges would be seen with a generalized epilepsy. The
patient in the question is encephalopathic rather than
comatose, so a burst suppression pattern would not be
expected. FIRDA can be seen with cerebral dysfunction for
any reason, but lateralized periodic discharges are much
more likely with this clinical picture.
I.125. Which is not an electromyographic feature of muscle disorders
(myopathy and muscular dystrophy)?
a. Fibrillation potentials
b. Fasciculation potentials
c. Small motor unit action potentials
d. Rapid recruitment of motor units
e. Myotonia
I.125. Answer b.
Fasciculation potentials are characteristic of motor neu-
rons, motor roots, and motor nerves. Fibrillation potentials
may be seen in some myopathies, including those that are
inflammatory. Myopathic disorders are characterized by
small motor unit action potentials and rapid recruitment of
motor units. Myotonia is present in select muscle disor-
ders, including myotonic muscular dystrophy.
I.126. A 32-year-old man presents with numbness and weakness in the
feet and ankles. The peroneal conduction velocity is 22 m/s; the
tibial motor conduction velocity is 24 m/s. Temporal dispersion
and conduction block are not present. Which is most likely?
a. A myopathy
b. A neuromuscular junction disorder
c. An axonal peripheral neuropathy (likely acquired)
d. A demyelinating peripheral neuropathy (likely acquired)
e. A demyelinating peripheral neuropathy (likely hereditary)
I.126. Answer e.
Slowed conduction velocities are suggestive of a demyelin-
ating process. Patients with acquired demyelinating neu-
ropathies may also have temporal dispersion or conduction
block (or both), but those findings are atypical for heredi-
tary neuropathies.
I.127. A patient presents with numbness and tingling of the right
fourth and fifth fingers. The intrinsic muscles of the hand are
slightly weak. Which of the following electromyographic (EMG)
findings would not fit with the diagnosis?
a. Low-amplitude ulnar motor compound muscle action poten-
tial (CMAP)
b. Low-amplitude ulnar sensory CMAP
c. Decreased amplitude with an inching study of the ulnar nerve
across the elbow
d. Needle EMG changes in the abductor pollicis brevis muscle
e. Needle EMG changes in the first dorsal interosseous muscle
I.127. Answer d.
Numbness of the fourth and fifth fingers is suggestive of an
ulnar distribution. The interosseous or intrinsic hand muscles are also supplied by the ulnar nerve. The abductor pollicis
brevis muscle, however, is innervated by the median nerve.
I.128. A patient is evaluated in the electromyography laboratory for fatigue. What finding would help support a diagnosis of myas-
thenia gravis?
a. Low-amplitude motor compound muscle action potential (CMAP)
b. Slowed sensory conduction velocities
c. A decrement immediately after exercise that improves with time
d. A decrement at rest that improves after exercise
e. A decrement of 5% at all times
I.128. Answer d.
In myasthenia gravis, the hallmark electrophysiologic find-
ing is a decrement before exercise that improves immedi-
ately after exercise. Routine nerve conduction study results,
such as CMAP amplitudes and conduction velocities, are
not usually affected. A decrement of 5% can be normal.
I.129. A low-amplitude motor compound muscle action potential (CMAP)
is least likely to be seen in which of the following disorders?
a. Motor neuropathy
b. Proximal myopathy
c. Lambert-Eaton syndrome
d. Amyotrophic lateral sclerosis
e. Sensory motor axonal neuropathy
I.129. Answer b.
Since nerve conduction studies record from distal muscles,
a proximal process such as a myopathy would not be
expected to lead to abnormalities in CMAP amplitudes. All
the other conditions listed can affect distal muscles or
nerves and result in lower CMAP amplitudes.
I.130. Which of the following would not be expected to increase the
protein level in cerebrospinal fluid (CSF) to more than 500 mg/dL?
a. Tuberculous meningitis
b. Spinal block (Froin syndrome)
c. Subarachnoid hemorrhage
d. Meningeal involvement by a malignancy
e. Viral meningitis
I.130. Answer e.
Bacterial and viral meningitis cause relatively small increases
in the CSF protein level, but the other choices increase the
CSF protein to values that often exceed 500 mg/dL.
I.131. Which of the following would be most helpful for reducing the
likelihood of headache after lumbar puncture (LP)?
a. Have the patient premedicate with caffeine before the procedure
b. Use a smaller LP needle
c. Have the patient rest supine for 30 minutes after the procedure
d. Remove less than 10 mL of fluid
e. Withdraw the spinal needle when the cerebrospinal fluid pres-
sure reaches 10 mm Hg
I.131. Answer b.
Post-LP headaches are more common when a larger needle is
used or the puncture results in a larger dural hole. No studies
have shown a relationship with the volume of fluid removed
or benefit from lying supine after LP. No studies have shown
that premedication before the procedure is helpful.
I.132. Which of the following conditions most commonly cause a low
glucose level in cerebrospinal fluid (CSF)?
a. Meningeal carcinomatosis
b. West Nile viral meningitis
c. Aseptic meningitis
d. Isolated central nervous system vasculitis
e. Diabetes mellitus
I.132. Answer a.
Box 34.1 lists common causes of a low CSF glucose level.
I.133. What is the ideal time frame for detection of xanthochromia in
a patient with suspected subarachnoid hemorrhage?
a. 1 hour to 2 weeks
b. 1 hour to 12 weeks
c. 6 hours to 2 weeks
d. 6 hours to 12 weeks
e. 24 hours to 12 weeks
I.133. Answer c.
With bleeding, cerebrospinal fluid becomes xanthochromic
(yellow) from oxyhemoglobin (4-6 hours after bleeding). It
generally remains xanthochromic for up to 2 weeks. Some
patients may have detectable xanthochromia at 4 weeks.
I.134. A patient presents with headache and fever for 2 days.
Computed tomography of the head does not show any abnor-
malities. The cerebrospinal fluid (CSF) has a white blood cell
count of 100 cells/mcL (mostly lymphocytes), a protein level of
60 mg/dL, and a glucose level that is 50% of the serum glucose
level. What is the most likely diagnosis?
a. Sarcoidosis
b. Viral meningitis
c. Streptococcus pneumoniae meningitis
d. Cytomegalovirus ventriculitis
e. Blastomyces fungal meningitis
.134. Answer b.
The values suggest a viral meningitis. Patients with sar-
coidosis, fungal meningitis, or cytomegalovirus ventriculi-
tis may have low CSF glucose levels. Patients with bacterial
meningitis would typically have a higher white blood cell
count with a predominance of polymorphonuclear cells.
I.135. Which of the following structures is not assessed with somato-
sensory evoked potentials (SSEPs)?
a. Medial lemniscus
b. Arcuate fasciculus
c. Cuneate fasciculus
d. Ventral posterolateral nucleus of the thalamus
e. A-beta primary afferent peripheral axons
I.135. Answer b.
SSEPs assess the functional integrity of the peripheral and
central components of the proprioceptive (posterior col-
umn–medial lemniscal) sensory pathways. The arcuate fas-
ciculus is not a sensory structure but rather a connection
between the Broca and Wernicke areas of the brain.
I.136. Which structure correlates with wave V of the brainstem audi-
tory evoked potential?
a. Cochlea
b. Proximal auditory nerve
c. Dorsal cochlear nucleus
d. Midbrain tectum
e. Primary auditory cortex
I.136. Answer d.
Wave V correlates with the inferior colliculus at the level of
the midbrain. (See Table 35.2 for details.)
I.137. If a patient had visual evoked potential (VEP) P100 prolonga-
tion with full-field pattern reversal stimulation from both eyes,
where would demyelination be localized?
a. Bilateral optic nerves anterior to the optic chiasm
b. The optic chiasm
c. Bilateral optic tracts posterior to the optic chiasm
d. Bilateral temporoparietal optic radiations
e. Bilateral P100 prolongation is not localizable
I.137. Answer e.
VEPs are most commonly performed with a reversing check-
erboard pattern. This visual stimulation is provided to 1 eye at
a time. Recording electrodes are placed over Oz and refer-
enced to Cz (according to the International 10-20 System) or
the ear. The VEP waveform is generated by the visual cortex
and occurs usually 100 milliseconds after the stimulus. The
nerve fibers innervating the nasal field of the retina pass
through the optic nerve, cross over through the optic chiasm,
and pass posteriorly to the visual cortex on the contralateral
side; the nerve fibers innervating the temporal field of the ret-
ina pass through the optic nerve but remain ipsilateral as they
pass posteriorly to the visual cortex. Therefore, when 1 eye is
stimulated (both the nasal and the temporal retinal fields), the
activated visual pathways include the optic nerve on the stim-
ulated side and the bilateral visual pathways posterior to the optic chiasm. If both eyes have prolonged P100 latencies, the
process causing the problem cannot be further localized.
I.138. Which of the following is not a contraindication to magnetic
resonance imaging (MRI) of the brain with and without a con-
trast agent?
a. Patient’s creatinine level is 3.4 mg/dL
b. Patient is pregnant
c. Patient has a pacemaker but is not pacemaker dependent
d. Patient had an aneurysm clip placed in 1975
e. Patient has a history of metal lodged in his eye
I.138. Answer c.
If a patient is not pacemaker dependent and a specific pace-
maker protocol is followed, MRI can be performed with
appropriate staffing. An elevated creatinine level limits the
use of gadolinium because of the risk of nephrogenic sys-
temic fibrosis. Use of gadolinium is not recommended in a
patient who is pregnant or lactating. The presence of early
aneurysmal surgical clips and metal are contraindications
for MRI. Contrast agents are evolving to overcome issues
with nephrogenic systemic fibrosis.
I.139. Which of the following is true regarding diffusion-weighted
imaging (DWI)?
a. DWI is sensitive and specific for acute cerebral ischemia
b. If patients have cerebral ischemia, MRI shows increased attenu-
ation on DWI and the apparent diffusion coefficient (ADC) map
c. DWI will be abnormal for up to 6 weeks after cerebral ischemia
d. DWI cannot be used to distinguish between cytotoxic and vaso-
genic edema
e. DWI is helpful in distinguishing acute cerebral ischemia from
chronic cerebral infarction
I.139. Answer e.
DWI and ADC sequences provide unique information based
on the microscopic motion of water. Restricted diffusion is
demonstrated when lesions are bright on DWI and dark on
the ADC map. After an ischemic stroke, DWI sequences show
restricted diffusion immediately and for up to 10 to 14 days.
Subacute strokes begin to demonstrate enhancement (contin-
gent on the degree of disruption of the blood-brain barrier) at
about the same time that DWI stops showing restriction.
Thus, DWI is helpful in distinguishing acute stroke from
chronic stroke, which is often better demonstrated on fluid-
attenuated inversion recovery sequences. DWI can be helpful
in distinguishing cytotoxic edema from vasogenic edema.
DWI may be abnormal in cerebral ischemia, but other lesions
may also show abnormalities on DWI (see also Box 36.7).
I.140. Which of the following imaging sequences best demonstrates
cerebral microhemorrhage?
a. T2-weighted magnetic resonance imaging (MRI)
b. Short tau inversion recovery (STIR) MRI
c. Susceptibility-weighted imaging (SWI) MRI
d. Gradient-recalled echo (GRE) MRI
e. Computed tomography of the head
I.140. Answer c.
GRE and SWI are helpful for diagnosing cerebral micro-
hemorrhages; however, SWI has higher sensitivity than
GRE. T2-weighted MRI is insensitive for detecting microhe-
morrhage. STIR images are more helpful for assessing
edema. CT of the head is highly sensitive for acute hemor-
rhage but not cerebral microbleeds.
I.141. Which imaging is most useful for a patient who presents with
right hemiplegia and aphasia 12 hours after the patient was
last observed to be acting normally?
a. Computed tomography (CT) of the head without a contrast agent
b. CT and CT angiography (CTA) of the head
c. CT and CTA of the head and neck
d. CT and CTA of the head and neck and CT perfusion
e. Cerebral angiography
I.141. Answer d.
For patients with a probable ischemic stroke in the previ-
ous 6 to 24 hours, CT and CTA of the head and neck and CT
perfusion are generally considered. Please also see Chapter
50 (“Acute Ischemic Stroke Evaluation and Treatment”).
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