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ABPN Neurology practice questions

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Question 1Basic Neuroscience and Neuroanatomy

Isolated weakness of abduction of one eye is produced by a lesion of which cranial nerve?

  1. Facial nerve
  2. Trochlear nerve
  3. Abducens nerve Correct answer.
  4. Oculomotor nerve

Explanation

The lateral rectus is the only extraocular muscle that abducts the eye, and it is innervated solely by the abducens nerve (CN VI). A lesion therefore produces an isolated abduction deficit with horizontal diplopia that worsens on gaze toward the affected side. The other ocular motor nerves supply muscles that mediate adduction, elevation, depression, or intorsion.

Question 2Basic Neuroscience and Neuroanatomy

Synaptic transmission at the skeletal neuromuscular junction is mediated primarily by which neurotransmitter?

  1. Gamma-aminobutyric acid
  2. Acetylcholine Correct answer.
  3. Glutamate
  4. Norepinephrine

Explanation

Motor neuron terminals release acetylcholine, which binds nicotinic receptors on the motor end plate to produce the end-plate potential. Acetylcholinesterase then terminates the signal. This cholinergic arrangement is the basis for both depolarizing and nondepolarizing neuromuscular blockade.

Question 3Basic Neuroscience and Neuroanatomy

In most individuals, Broca area is located in which gyrus of the dominant hemisphere?

  1. Medial occipital cortex
  2. Angular gyrus of the parietal lobe
  3. Superior temporal gyrus
  4. Inferior frontal gyrus Correct answer.

Explanation

Broca area occupies the posterior part of the inferior frontal gyrus (pars triangularis and pars opercularis) of the language-dominant hemisphere. Damage there yields nonfluent output with relatively preserved comprehension. The lesion is supplied by branches of the middle cerebral artery.

Question 4Basic Neuroscience and Neuroanatomy

Primary visual cortex is located in which lobe of the brain?

  1. Temporal lobe
  2. Occipital lobe Correct answer.
  3. Parietal lobe
  4. Frontal lobe

Explanation

Primary visual cortex (V1) lies in the occipital lobe along the banks of the calcarine fissure, where geniculocalcarine fibers terminate. Lesions here produce contralateral homonymous field defects. Adjacent occipital association cortex handles higher-order visual processing.

Question 5Basic Neuroscience and Neuroanatomy

Cerebrospinal fluid is produced mainly by which structure?

  1. Choroid plexus Correct answer.
  2. Pia mater
  3. Ependymal canal of the spinal cord
  4. Arachnoid granulations

Explanation

The choroid plexus of the lateral, third, and fourth ventricles secretes most cerebrospinal fluid through an active transport process involving the choroid epithelium. Fluid then circulates through the subarachnoid space. Obstruction anywhere along this path produces hydrocephalus.

Question 6Basic Neuroscience and Neuroanatomy

Axons of the dorsal column-medial lemniscus pathway decussate at which level of the neuraxis?

  1. Spinal cord segment of entry
  2. Midbrain
  3. Pons
  4. Medulla Correct answer.

Explanation

Primary afferents ascend ipsilaterally in the fasciculus gracilis and cuneatus to the medulla, where they synapse on second-order neurons in the dorsal column nuclei. Those neurons cross as internal arcuate fibers to form the medial lemniscus. This contrasts with the spinothalamic pathway, which crosses near its segment of entry.

Question 7Basic Neuroscience and Neuroanatomy

A patient has a left homonymous hemianopia with sparing of the macula. Occlusion of which artery is most likely?

  1. Left middle cerebral artery
  2. Left posterior cerebral artery
  3. Right posterior cerebral artery Correct answer.
  4. Left anterior cerebral artery

Explanation

Posterior cerebral artery infarction affects the occipital cortex, producing a contralateral homonymous hemianopia; the macular representation at the occipital pole often survives because of collateral supply from the middle cerebral artery. A left-sided field defect requires a right-sided retrochiasmal lesion. The right posterior cerebral artery therefore is the implicated vessel.

Question 8Basic Neuroscience and Neuroanatomy

Activation of the indirect pathway of the basal ganglia ultimately does which of the following?

  1. Excites thalamocortical neurons
  2. Facilitates initiation of voluntary movement
  3. Inhibits thalamocortical neurons Correct answer.
  4. Increases cortical motor output

Explanation

The indirect pathway runs from striatum to external globus pallidus, then subthalamic nucleus, then internal globus pallidus and substantia nigra pars reticulata, whose inhibitory output to the thalamus is increased. The net effect is suppression of thalamocortical drive and restraint of unwanted movements. Loss of this pathway, as in Huntington disease, produces hyperkinesia.

Question 9Basic Neuroscience and Neuroanatomy

A patient has dysmetria, intention tremor, and past-pointing of the right arm. The lesion most likely involves which structure?

  1. Right primary motor cortex
  2. Left dorsal column nuclei
  3. Left cerebellar hemisphere
  4. Right cerebellar hemisphere Correct answer.

Explanation

Cerebellar circuitry is doubly crossed, so a hemispheric lesion produces ipsilateral limb incoordination, including dysmetria and intention tremor. The right arm findings therefore localize to the right cerebellar hemisphere. Weakness and sensory loss are not features of a pure cerebellar lesion.

Question 10Basic Neuroscience and Neuroanatomy

Somatosensory information from the contralateral foot relays through which thalamic nucleus?

  1. Ventroposteromedial nucleus
  2. Ventroposterolateral nucleus Correct answer.
  3. Lateral geniculate body
  4. Pulvinar

Explanation

The ventroposterolateral nucleus receives the medial lemniscus and spinothalamic fibers representing the contralateral trunk and limbs and projects to the primary somatosensory cortex. The ventroposteromedial nucleus handles the face through trigeminothalamic input. This topographic division explains the segregated face and body representations.

Question 11Basic Neuroscience and Neuroanatomy

The principal efferent tract leaving the hippocampus is which structure?

  1. Fornix Correct answer.
  2. Mammillothalamic tract
  3. Stria terminalis
  4. Anterior commissure

Explanation

Hippocampal output travels through the fornix to the mammillary bodies, septal region, and anterior thalamus. This projection belongs to the Papez circuit subserving memory consolidation. Interruption of the circuit, for example by lesions of the mammillary bodies or anterior thalamic nuclei, produces amnesia.

Question 12Basic Neuroscience and Neuroanatomy

A patient has right facial and arm weakness together with nonfluent speech. Occlusion of which artery is most likely?

  1. Right middle cerebral artery
  2. Left middle cerebral artery Correct answer.
  3. Right anterior cerebral artery
  4. Left anterior cerebral artery

Explanation

Nonfluent aphasia localizes to the language-dominant frontal operculum, and face and arm weakness follow involvement of the adjacent motor strip, a classic middle cerebral artery pattern. Because the right face and arm are weak, the lesion lies in the left hemisphere. The left middle cerebral artery is therefore the occluded vessel.

Question 13Basic Neuroscience and Neuroanatomy

Fast anterograde axonal transport of vesicles is driven mainly by which protein?

  1. Dynamin
  2. Dynein
  3. Kinesin Correct answer.
  4. Myosin II

Explanation

Kinesin motors move cargo along microtubules toward the plus ends, which are oriented distally in the axon, thereby supporting fast anterograde transport. Dynein moves cargo in the retrograde direction. Interference with these motors produces axonal swellings and distal degeneration.

Question 14Basic Neuroscience and Neuroanatomy

The lateral corticospinal tract travels in which region of the spinal cord white matter?

  1. Anterior funiculus
  2. Lateral funiculus Correct answer.
  3. Dorsal columns
  4. Lissauer tract

Explanation

After decussating in the medullary pyramids, corticospinal fibers descend in the lateral funiculus, just dorsal to the lateral horn, and synapse on internuncial and motor neurons. This tract mediates voluntary movement of the contralateral limbs. A small uncrossed component travels in the anterior funiculus.

Question 15Basic Neuroscience and Neuroanatomy

The barrier that restricts solute movement from blood into brain parenchyma is formed chiefly by which structure?

  1. Fenestrated endothelium
  2. Endothelial tight junctions Correct answer.
  3. Perivascular macrophages
  4. Choroid plexus epithelium

Explanation

Brain capillary endothelial cells are joined by tight junctions that prevent paracellular diffusion, and they are supported by pericyte and astrocyte end-foot investment. This arrangement constitutes the anatomic blood-brain barrier and limits entry of large or polar molecules. Circumventricular organs lack these tight junctions and thus sense blood-borne signals.

Question 16Basic Neuroscience and Neuroanatomy

The rapid upstroke of the neuronal action potential results mainly from which conductance change?

  1. Decreased sodium conductance
  2. Increased potassium conductance
  3. Increased sodium conductance Correct answer.
  4. Increased chloride conductance

Explanation

Depolarization to threshold opens voltage-gated sodium channels, and the resulting sodium influx drives the membrane potential toward the sodium equilibrium potential. Repolarization follows as sodium channels inactivate and potassium conductance rises. This sequence underlies the all-or-none character of the spike.

Question 17Basic Neuroscience and Neuroanatomy

A patient has impaired adduction of the right eye and nystagmus of the left eye on attempted leftward gaze. Which structure is most likely damaged?

  1. Right medial longitudinal fasciculus Correct answer.
  2. Left medial longitudinal fasciculus
  3. Right abducens nucleus
  4. Left oculomotor nucleus

Explanation

Internuclear ophthalmoplegia reflects interruption of the fibers connecting the contralateral abducens nucleus to the ipsilateral oculomotor nucleus. A right medial longitudinal fasciculus lesion prevents the right medial rectus from receiving the command to adduct during leftward gaze, while the left eye shows abducting nystagmus. Multiple sclerosis and brainstem infarction are common causes.

Question 18Basic Neuroscience and Neuroanatomy

A patient develops vertigo, right facial numbness, hoarseness, and loss of pain and temperature sensation over the left body. Occlusion of which vessel is most likely?

  1. Right posterior inferior cerebellar artery Correct answer.
  2. Right anterior inferior cerebellar artery
  3. Right superior cerebellar artery
  4. Right paramedian pontine perforators

Explanation

These findings describe a right lateral medullary syndrome, in which vestibular nuclei, the spinal trigeminal nucleus, and nucleus ambiguus are involved ipsilaterally while the spinothalamic tract produces contralateral body sensory loss. The territory is supplied by the posterior inferior cerebellar artery, usually from the vertebral artery. Dysphagia and Horner syndrome are common accompaniments.

Question 19Basic Neuroscience and Neuroanatomy

Occlusion of the anterior choroidal artery classically produces which combination of deficits?

  1. Aphasia, apraxia, and contralateral sensory loss
  2. Contralateral hemiplegia, hemianesthesia, and hemianopia Correct answer.
  3. Bitemporal hemianopia with optic disc pallor
  4. Ipsilateral ataxia, Horner syndrome, and dysarthria

Explanation

The anterior choroidal artery supplies the posterior limb of the internal capsule, the medial pallidum, and the lateral geniculate body. Infarction therefore damages corticospinal, sensory, and optic radiation fibers together, giving the triad of contralateral hemiplegia, hemianesthesia, and homonymous hemianopia. The syndrome can mimic a lacunar motor-sensory stroke with the added visual field defect.

Question 20Basic Neuroscience and Neuroanatomy

Long-term potentiation at hippocampal synapses depends critically on which receptor?

  1. NMDA receptor Correct answer.
  2. GABA-B receptor
  3. Metabotropic glutamate receptor
  4. AMPA receptor

Explanation

The NMDA receptor is blocked by magnesium at resting membrane potential and conducts calcium only when glutamate binding coincides with sufficient postsynaptic depolarization. This coincidence detection triggers calcium-dependent kinases that strengthen the synapse, the cellular basis of long-term potentiation. Blocking this receptor impairs spatial learning in animals.

Question 21Behavioral Neurology and Dementia

Which medication is a cholinesterase inhibitor approved for the treatment of Alzheimer disease?

  1. Quetiapine
  2. Memantine
  3. Valproate
  4. Donepezil Correct answer.

Explanation

Donepezil reversibly inhibits acetylcholinesterase, increasing synaptic acetylcholine, and is approved across Alzheimer disease stages. Memantine is an NMDA receptor antagonist, whereas quetiapine and valproate are not cognitive enhancers.

Question 22Behavioral Neurology and Dementia

A 72-year-old man has 2 years of progressive short-term memory loss. Brain MRI shows disproportionate medial temporal and parietal atrophy. Which diagnosis is most likely?

  1. Dementia with Lewy bodies
  2. Behavioral variant frontotemporal dementia
  3. Alzheimer disease Correct answer.
  4. Normal pressure hydrocephalus

Explanation

Alzheimer disease typically presents with insidious episodic memory loss and prominent medial temporal and hippocampal atrophy, with parietal involvement as disease advances. The other disorders have different early clinical and imaging profiles.

Question 23Behavioral Neurology and Dementia

Which APOE genotype carries the greatest risk for late-onset Alzheimer disease?

  1. APOE ε3/ε3
  2. APOE ε4/ε4 Correct answer.
  3. APOE ε2/ε2
  4. APOE ε2/ε3

Explanation

The ε4 allele is the strongest common genetic risk factor for late-onset Alzheimer disease, and homozygosity confers the highest risk among these genotypes. The ε2 allele is generally considered protective relative to ε3.

Question 24Behavioral Neurology and Dementia

Which clinical feature is most characteristic of dementia with Lewy bodies?

  1. Early personality change with hyperorality and compulsions
  2. Stepwise decline with focal motor and sensory deficits
  3. Prominent early anomia with preserved repetition
  4. Visual hallucinations with parkinsonism Correct answer.

Explanation

Dementia with Lewy bodies is characterized by fluctuating cognition, recurrent well-formed visual hallucinations, REM sleep behavior disorder, and spontaneous parkinsonism. These core features help distinguish it from other dementias.

Question 25Behavioral Neurology and Dementia

Which bedside task most directly assesses executive function?

  1. Three-word delayed recall
  2. Double simultaneous stimulation
  3. Confrontation naming
  4. Letter verbal fluency Correct answer.

Explanation

Letter fluency requires self-generated strategy, cognitive flexibility, and response inhibition, making it a practical bedside executive measure. Recall, naming, and double simultaneous stimulation test memory, language, and sensory integration, respectively.

Question 26Behavioral Neurology and Dementia

A 55-year-old man with chronic alcohol use disorder presents with confusion, ataxia, and horizontal nystagmus. Which condition is most likely?

  1. Hepatic encephalopathy
  2. Marchiafava-Bignami disease
  3. Wernicke encephalopathy Correct answer.
  4. Central pontine myelinolysis

Explanation

The triad of encephalopathy, ataxia, and oculomotor dysfunction in a patient with alcohol use disorder suggests thiamine deficiency, or Wernicke encephalopathy. Prompt parenteral thiamine is required to prevent progression to Korsakoff syndrome.

Question 27Behavioral Neurology and Dementia

A 66-year-old woman develops rapidly progressive dementia, myoclonus, and periodic sharp wave complexes on EEG. Which diagnosis is most likely?

  1. Sporadic Creutzfeldt-Jakob disease Correct answer.
  2. Alzheimer disease with rapid progression
  3. Vascular dementia with strategic infarcts
  4. Neurosyphilis with general paresis

Explanation

Rapidly progressive dementia with myoclonus and periodic sharp wave complexes is classic for sporadic Creutzfeldt-Jakob disease. MRI may show cortical ribboning or basal ganglia hyperintensity on diffusion-weighted imaging, and CSF RT-QuIC supports the diagnosis.

Question 28Behavioral Neurology and Dementia

Which feature best distinguishes behavioral variant frontotemporal dementia from Alzheimer disease early in the course?

  1. Presence of limb apraxia on examination
  2. Low CSF amyloid-beta with elevated tau
  3. Impaired delayed recall on episodic memory testing
  4. Disinhibition with preserved memory Correct answer.

Explanation

Behavioral variant frontotemporal dementia typically presents with early personality change, disinhibition, loss of empathy, and compulsive behaviors while episodic memory remains relatively preserved. Alzheimer disease usually begins with prominent episodic memory impairment and later apraxia.

Question 29Behavioral Neurology and Dementia

Mild cognitive impairment differs from dementia primarily because patients with mild cognitive impairment:

  1. Lack any biomarker evidence of disease
  2. Have no subjective cognitive complaints
  3. Remain independent in daily activities Correct answer.
  4. Always have a normal MMSE score

Explanation

Mild cognitive impairment denotes cognitive decline beyond normal aging with preserved functional independence, whereas dementia requires impairment in instrumental or basic activities of daily living. Subjective complaints, MMSE scores, and biomarkers may be abnormal in mild cognitive impairment.

Question 30Behavioral Neurology and Dementia

Which clinical pattern is most consistent with vascular dementia?

  1. Insidious decline with prominent amnesia
  2. Fluctuating cognition with visual hallucinations
  3. Stepwise decline with focal deficits Correct answer.
  4. Early personality change with hyperorality

Explanation

Vascular dementia often follows a stepwise course with focal neurologic deficits corresponding to infarct locations, and imaging shows relevant cerebrovascular disease. The other patterns suggest Alzheimer disease, Lewy body dementia, and behavioral variant frontotemporal dementia, respectively.

Question 31Behavioral Neurology and Dementia

A patient has effortful, agrammatic speech with impaired repetition but preserved single-word comprehension. Which primary progressive aphasia variant is most likely?

  1. Logopenic variant with impaired phonological loop
  2. Nonfluent/agrammatic variant Correct answer.
  3. Mixed transcortical variant with preserved grammar
  4. Semantic variant with impaired word comprehension

Explanation

The nonfluent/agrammatic variant of primary progressive aphasia is characterized by apraxia of speech, agrammatism, and effortful output, with relatively preserved single-word comprehension early. Semantic variant features impaired word comprehension, and logopenic variant features impaired repetition with relatively preserved grammar.

Question 32Behavioral Neurology and Dementia

Which cerebrospinal fluid profile is most supportive of Alzheimer disease?

  1. Elevated opening pressure with lymphocytic pleocytosis
  2. Low Aβ42 with high phospho-tau Correct answer.
  3. Elevated 14-3-3 protein with normal tau
  4. Normal amyloid-beta with elevated total tau

Explanation

Alzheimer disease classically shows reduced CSF amyloid-beta-42, reflecting amyloid deposition, and elevated phosphorylated tau, reflecting neurofibrillary pathology. This profile is used as a supportive biomarker when the diagnosis is uncertain.

Question 33Behavioral Neurology and Dementia

A patient shows agraphia, acalculia, right-left disorientation, and finger agnosia. The responsible lesion is most likely in which area?

  1. Bilateral occipital cortex
  2. Right parietal cortex
  3. Left angular gyrus Correct answer.
  4. Left frontal operculum

Explanation

Gerstmann syndrome-agraphia, acalculia, right-left confusion, and finger agnosia-localizes to the dominant angular gyrus in the inferior parietal lobule. Right parietal lesions more often produce hemispatial neglect.

Question 34Behavioral Neurology and Dementia

Which cognitive profile is most typical early in Huntington disease?

  1. Executive dysfunction with inattention Correct answer.
  2. Severe cortical sensory loss
  3. Dense amnesia with confabulation
  4. Fluent aphasia with preserved repetition

Explanation

Huntington disease is a striatal degeneration that produces a dysexecutive syndrome with impaired attention, processing speed, and cognitive flexibility before frank dementia. Chorea and psychiatric symptoms often accompany these changes.

Question 35Behavioral Neurology and Dementia

A patient develops severe anterograde amnesia with preserved intelligence and working memory after bilateral medial temporal lobe damage. Which structures are most implicated?

  1. Parietal lobes and posterior cingulate
  2. Mammillary bodies and anterior thalamus
  3. Frontal lobes and basal ganglia
  4. Hippocampi and entorhinal cortices Correct answer.

Explanation

Bilateral hippocampal and entorhinal damage impairs consolidation of new declarative memories while leaving working memory and general intellect relatively intact. Mammillary body and thalamic damage can also cause amnesia, but the medial temporal pattern is the classic description.

Question 36Behavioral Neurology and Dementia

Which feature best helps distinguish delirium from dementia?

  1. Acute onset with fluctuating attention Correct answer.
  2. Gradual onset over many months
  3. Stable level of alertness throughout the day
  4. Presence of memory impairment on testing

Explanation

Delirium is an acute, fluctuating disturbance of attention and awareness, often with an identifiable medical trigger. Dementia is typically chronic and progressive, although the two frequently coexist.

Question 37Behavioral Neurology and Dementia

Which exposure is most strongly associated with chronic traumatic encephalopathy?

  1. Chronic hypertension
  2. Obstructive sleep apnea
  3. Vitamin B12 deficiency
  4. Repetitive head trauma Correct answer.

Explanation

Chronic traumatic encephalopathy is a tauopathy associated with repetitive head impacts, including contact sports and military blast exposure. The other factors are risk factors for vascular cognitive impairment or reversible metabolic encephalopathy, not chronic traumatic encephalopathy.

Question 38Behavioral Neurology and Dementia

A patient has simultanagnosia, optic ataxia, and ocular apraxia. This triad indicates which syndrome?

  1. Klüver-Bucy syndrome
  2. Gerstmann syndrome
  3. Balint syndrome Correct answer.
  4. Anton syndrome

Explanation

Balint syndrome reflects bilateral parieto-occipital damage and consists of simultanagnosia, optic ataxia, and ocular motor apraxia. It is often caused by posterior cortical atrophy or bilateral infarcts.

Question 39Behavioral Neurology and Dementia

In suspected normal pressure hydrocephalus, which finding best predicts improvement after ventricular shunting?

  1. Severe hippocampal atrophy on coronal MRI
  2. Improvement after lumbar puncture Correct answer.
  3. Long duration of symptoms before evaluation
  4. Prominent cortical atrophy on volumetric MRI

Explanation

A positive response to large-volume lumbar puncture or external lumbar drainage supports disturbed cerebrospinal fluid dynamics and predicts better shunt response. Severe cortical or hippocampal atrophy suggests an alternative neurodegenerative cause.

Question 40Behavioral Neurology and Dementia

A patient with frontotemporal dementia develops compulsive eating and inappropriate social behavior. Which brain regions are most implicated?

  1. Parietal association cortex
  2. Cerebellar vermis and hemispheres
  3. Orbitofrontal and temporal cortex Correct answer.
  4. Occipital visual cortex

Explanation

Behavioral variant frontotemporal dementia involves degeneration of frontal and anterior temporal networks, including orbitofrontal and insular regions that regulate social conduct, reward, and eating behavior. This produces disinhibition, loss of empathy, and hyperorality.

Question 41Cerebrovascular Disease

A 68-year-old man presents 2 hours after the sudden onset of right hemiparesis and aphasia. Noncontrast head CT shows no hemorrhage and his blood pressure is 170/95 mmHg. Which is the most appropriate immediate treatment?

  1. Oral aspirin 325 mg immediately
  2. Intravenous heparin bolus
  3. Intravenous alteplase 0.9 mg/kg Correct answer.
  4. Observation with repeat CT in 6 hours

Explanation

Intravenous thrombolysis is indicated for disabling acute ischemic stroke when treatment can begin within 4.5 hours of onset and hemorrhage has been excluded by imaging. Blood pressure below 185/110 mmHg is acceptable for treatment. Immediate anticoagulation and immediate antiplatelet therapy are avoided in this setting.

Question 42Cerebrovascular Disease

A patient has a focal neurologic deficit that resolves completely within 3 hours, but diffusion-weighted MRI shows a small area of restricted diffusion in the cortex. This event is best classified as which of the following?

  1. Amaurosis fugax
  2. Transient ischemic attack
  3. Ischemic stroke Correct answer.
  4. Reversible ischemic neurologic deficit

Explanation

Current practice uses a tissue-based definition: a transient episode of neurologic dysfunction without acute infarction is a TIA, whereas documented acute infarction makes the event an ischemic stroke regardless of symptom duration. The presence of restricted diffusion confirms tissue injury.

Question 43Cerebrovascular Disease

Chronic hypertension most characteristically produces spontaneous intracerebral hemorrhage in which location?

  1. Corpus callosum
  2. Putamen Correct answer.
  3. Cerebellar cortex
  4. Lobar white matter

Explanation

Hypertensive hemorrhage arises from rupture of small penetrating arteries damaged by arteriolosclerosis. The putamen is the most common site, followed by the thalamus, pons, and cerebellum. Lobar hemorrhage in an older normotensive patient instead suggests cerebral amyloid angiopathy.

Question 44Cerebrovascular Disease

Which item is assessed as part of the NIH Stroke Scale?

  1. Best language and aphasia Correct answer.
  2. Modified Rankin score
  3. Glasgow Coma Scale motor score
  4. Barthel index

Explanation

The NIH Stroke Scale quantifies deficit severity across items including level of consciousness, gaze, visual fields, facial palsy, motor function, ataxia, sensation, language, dysarthria, and extinction. Language is scored as part of the scale. The other instruments measure consciousness or functional independence rather than acute deficit severity.

Question 45Cerebrovascular Disease

A patient with nonvalvular atrial fibrillation and a prior ischemic stroke is to start a direct oral anticoagulant. Which of these agents is a direct factor Xa inhibitor?

  1. Dabigatran
  2. Argatroban
  3. Apixaban Correct answer.
  4. Warfarin

Explanation

Apixaban directly inhibits factor Xa and is approved for stroke prevention in nonvalvular atrial fibrillation. Dabigatran is a direct thrombin inhibitor, warfarin reduces synthesis of vitamin K-dependent factors, and argatroban is a parenteral thrombin inhibitor.

Question 46Cerebrovascular Disease

A patient with acute ischemic stroke does not receive thrombolysis or thrombectomy. When should aspirin be started?

  1. Only if atrial fibrillation is present
  2. After 7 days of bed rest
  3. After 72 hours
  4. Within 24 to 48 hours Correct answer.

Explanation

Aspirin is recommended within 24 to 48 hours of ischemic stroke onset for patients not treated with thrombolysis, because early antiplatelet therapy reduces recurrent stroke and mortality. When thrombolysis is given, antiplatelet therapy is deferred for about 24 hours.

Question 47Cerebrovascular Disease

A 45-year-old woman describes a sudden severe headache that peaked within seconds. Noncontrast head CT performed 8 hours after onset is normal. Which is the most appropriate next step?

  1. MRI of the cervical spine
  2. Lumbar puncture for xanthochromia Correct answer.
  3. Repeat noncontrast CT in 24 hours
  4. Carotid duplex ultrasound

Explanation

CT sensitivity for subarachnoid hemorrhage is very high in the first 6 hours but declines thereafter, so a normal CT at 8 hours does not exclude the diagnosis. Lumbar puncture performed at least 12 hours after onset should be examined for xanthochromia.

Question 48Cerebrovascular Disease

A 60-year-old hypertensive man has pure motor weakness of the right face, arm, and leg without sensory loss, aphasia, or visual field deficit. Which lesion best explains this syndrome?

  1. Left superior MCA division
  2. Left occipital cortex
  3. Left internal capsule Correct answer.
  4. Left lateral medulla

Explanation

A lacunar infarct in the posterior limb of the internal capsule interrupts corticospinal and corticobulbar fibers, producing pure motor hemiparesis without cortical features. Small-vessel disease from hypertension is the usual cause. Cortical signs such as aphasia or hemianopia indicate a larger territorial infarct instead.

Question 49Cerebrovascular Disease

A patient has right hemiplegia, right homonymous hemianopia, and global aphasia. Which artery is most likely occluded?

  1. Left posterior cerebral artery
  2. Left anterior cerebral artery
  3. Left middle cerebral artery Correct answer.
  4. Basilar artery

Explanation

The left MCA supplies the lateral frontal and temporal cortex, including the dominant language areas, plus the optic radiations and motor cortex. Occlusion therefore produces contralateral face and arm-predominant hemiparesis, a homonymous hemianopia, and aphasia. ACA and PCA infarcts spare the language cortex in most patients.

Question 50Cerebrovascular Disease

A 70-year-old with atrial fibrillation has a moderate-sized cardioembolic stroke and receives IV alteplase. Which approach to anticoagulation is most appropriate?

  1. Start warfarin immediately with heparin bridging
  2. Start a DOAC within 6 hours of thrombolysis
  3. Withhold anticoagulation permanently
  4. Delay anticoagulation by several days Correct answer.

Explanation

After a cardioembolic stroke, anticoagulation is generally restarted after a delay that depends on infarct size and hemorrhagic transformation risk, ranging from about 1 day for small infarcts to 2 weeks or more for large ones. Early intense anticoagulation increases symptomatic hemorrhagic transformation.