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UKOM Sp.N (Neurology) study materials
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UKOM Sp.N (Neurology) practice questions

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Question 1Neuroanatomy, Neurophysiology and Basic Neuroscience

A patient has a lesion of the left optic tract. Which visual field defect is expected?

  1. Right superior quadrantanopia
  2. Left homonymous hemianopia
  3. Right homonymous hemianopia Correct answer.
  4. Bitemporal hemianopia

Explanation

Each optic tract carries fibres from the temporal retina of the ipsilateral eye and the nasal retina of the contralateral eye; these subserve the contralateral visual field. A left tract lesion therefore produces a right homonymous hemianopia, often with slight asymmetry. Chiasmal lesions instead give bitemporal defects, and temporal lobe lesions give superior quadrantanopia.

Question 2Neuroanatomy, Neurophysiology and Basic Neuroscience

Which structure forms the main efferent output of the basal ganglia to the thalamus?

  1. Ventral lateral thalamic nucleus
  2. Subthalamic nucleus
  3. Globus pallidus externus
  4. Globus pallidus internus and substantia nigra pars reticulata Correct answer.

Explanation

The internal segment of the globus pallidus and the substantia nigra pars reticulata are the major output nuclei, projecting tonically inhibitory GABAergic fibres to the thalamus. The external pallidum and subthalamic nucleus belong to the indirect pathway within the basal ganglia circuitry. The ventral lateral thalamic nucleus is a recipient, not a source, of this projection.

Question 3Neuroanatomy, Neurophysiology and Basic Neuroscience

A 60-year-old has sudden right arm and leg weakness with a right homonymous hemianopia and gaze deviation to the left. Where is the lesion most likely?

  1. Left internal capsule Correct answer.
  2. Right cervical spinal cord
  3. Right cerebral peduncle
  4. Left frontal eye field only

Explanation

Contralateral hemiparesis with homonymous hemianopia and ipsilateral gaze deviation localises to a large left hemispheric lesion involving corticospinal and corticobulbar fibres, typically the internal capsule with cortical involvement. Gaze deviation towards the lesion side reflects frontal eye field damage with unopposed contralateral drive. A peduncular or spinal lesion cannot explain the hemianopia or the eye deviation.

Question 4Neuroanatomy, Neurophysiology and Basic Neuroscience

Which cranial nerve carries parasympathetic fibres that constrict the pupil?

  1. Optic nerve
  2. Oculomotor nerve Correct answer.
  3. Abducens nerve
  4. Trigeminal nerve

Explanation

Preganglionic parasympathetic fibres travel with the oculomotor nerve to the ciliary ganglion, and postganglionic fibres innervate the sphincter pupillae to produce miosis. The optic nerve is purely sensory, the trigeminal is sensory and motor to muscles of mastication, and the abducens is motor to the lateral rectus. Loss of oculomotor parasympathetic supply produces a fixed dilated pupil.

Question 5Neuroanatomy, Neurophysiology and Basic Neuroscience

Dorsal column-medial lemniscus pathway fibres decussate at which level?

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

Explanation

First-order dorsal column fibres ascend ipsilaterally to the nucleus gracilis and cuneatus in the medulla, where second-order neurons decussate as internal arcuate fibres to form the medial lemniscus. Spinothalamic fibres decussate near the level of entry in the cord, which is why the two pathways differ in lesion effects. Thalamic and midbrain levels lie above the crossing.

Question 6Neuroanatomy, Neurophysiology and Basic Neuroscience

A lesion of the right cerebellar hemisphere most typically causes which finding?

  1. Bilateral loss of vibration sense
  2. Left-sided spastic weakness
  3. Right homonymous hemianopia
  4. Right-sided limb ataxia with intention tremor Correct answer.

Explanation

The cerebellar hemispheres control the ipsilateral limbs, so a right hemispheric lesion produces right-sided dysmetria, intention tremor and ataxia. Corticospinal lesions cause contralateral spastic weakness, and posterior column lesions impair vibration sense. Cerebellar lesions do not produce visual field defects.

Question 7Neuroanatomy, Neurophysiology and Basic Neuroscience

Which artery supplies the medial surface of the frontal and parietal lobes, including the leg motor area?

  1. Middle cerebral artery
  2. Posterior cerebral artery
  3. Anterior cerebral artery Correct answer.
  4. Anterior choroidal artery

Explanation

The anterior cerebral artery runs in the longitudinal fissure and supplies the medial frontal and parietal cortex, including the paracentral lobule where the leg is represented. The middle cerebral artery supplies most of the lateral convexity, and the posterior cerebral artery supplies the occipital lobe and inferomedial temporal lobe. Anterior choroidal branches supply deep structures such as the posterior limb of the internal capsule.

Question 8Neuroanatomy, Neurophysiology and Basic Neuroscience

In a patient with a complete left third nerve palsy, which combination is expected?

  1. Ptosis, dilated pupil and eye deviated down and out Correct answer.
  2. Diplopia only on downward gaze with a normal pupil
  3. Lid retraction, dilated pupil and eye deviated up and out
  4. Ptosis, constricted pupil and eye deviated down and in

Explanation

The oculomotor nerve supplies levator palpebrae, the pupillary sphincter and most extraocular muscles except the lateral rectus and superior oblique. Loss therefore gives ptosis, a fixed dilated pupil and unopposed lateral rectus and superior oblique action, deviating the eye down and out. Sparing of the pupil suggests a microvascular cause, but the complete palsy pattern is as described.

Question 9Neuroanatomy, Neurophysiology and Basic Neuroscience

Which neurotransmitter is released by lower motor neurons at the neuromuscular junction?

  1. GABA
  2. Acetylcholine Correct answer.
  3. Glutamate
  4. Dopamine

Explanation

Lower motor neurons release acetylcholine, which binds nicotinic receptors on the motor end plate to depolarise muscle fibres. Glutamate is the main excitatory transmitter in the central nervous system, GABA is inhibitory, and dopamine modulates basal ganglia circuits. Disorders of the neuromuscular junction, such as myasthenia gravis, target this cholinergic transmission.

Question 10Neuroanatomy, Neurophysiology and Basic Neuroscience

A patient cannot recognise objects by sight but can describe them by touch, with normal visual acuity and visual fields. This is most consistent with a lesion where?

  1. Bilateral parietal somatosensory cortex
  2. Right primary motor cortex
  3. Left optic nerve
  4. Bilateral occipitotemporal cortex Correct answer.

Explanation

Visual agnosia reflects failure of higher-order visual association cortex to link percepts with meaning, typically from bilateral occipitotemporal lesions. Preserved tactile recognition and normal acuity and fields distinguish it from sensory loss or a simple visual pathway defect. Optic nerve and somatosensory cortical lesions produce elemental deficits rather than agnosia.

Question 11Neuroanatomy, Neurophysiology and Basic Neuroscience

Which structure connects the third ventricle to the fourth ventricle?

  1. Foramen magnum
  2. Cerebral aqueduct Correct answer.
  3. Interventricular foramen
  4. Central canal

Explanation

The cerebral aqueduct runs through the midbrain and carries cerebrospinal fluid from the third to the fourth ventricle. The interventricular foramen connects the lateral ventricles to the third ventricle, and the central canal continues below the fourth ventricle into the cord. The foramen magnum is the skull opening for the medulla.

Question 12Neuroanatomy, Neurophysiology and Basic Neuroscience

A patient has a right-sided Horner syndrome. Which additional finding would suggest a central rather than preganglionic cause?

  1. Anhidrosis confined to the forehead
  2. Ipsilateral ptosis with miosis
  3. Dilation lag on light exposure
  4. Contralateral loss of pain and temperature sensation Correct answer.

Explanation

Central Horner syndrome arises from brainstem or hypothalamic lesions and may be accompanied by crossed spinothalamic sensory loss, as in lateral medullary infarction. Anhidrosis pattern and dilation lag occur in Horner syndrome of any level and do not discriminate central from peripheral. Ipsilateral ptosis and miosis are the defining features rather than localising clues.

Question 13Neuroanatomy, Neurophysiology and Basic Neuroscience

Which spinal cord tract carries pain and temperature sensation from the contralateral body?

  1. Dorsal columns
  2. Lateral spinothalamic tract Correct answer.
  3. Dorsal spinocerebellar tract
  4. Lateral corticospinal tract

Explanation

Nociceptive and thermal fibres synapse in the dorsal horn and cross within one or two segments to ascend in the lateral spinothalamic tract, so it carries contralateral information. The dorsal columns carry vibration and proprioception ipsilaterally, and the corticospinal tract is motor. Spinocerebellar fibres convey unconscious proprioception to the cerebellum.

Question 14Neuroanatomy, Neurophysiology and Basic Neuroscience

A patient shows flaccid weakness of the left leg with absent ankle jerk but normal tone and reflexes in the arms. This pattern most suggests disease at which level?

  1. Motor cortex
  2. Internal capsule
  3. Lumbosacral plexus or nerve roots Correct answer.
  4. Cervical spinal cord

Explanation

Lower motor neuron signs confined to one leg point to damage of the anterior horn cells, roots or peripheral nerves supplying that limb, such as a lumbosacral plexopathy. Upper motor neuron lesions of the cord, capsule or cortex would give increased tone and hyperreflexia. Preserved arm function argues against a diffuse or cervical process.

Question 15Neuroanatomy, Neurophysiology and Basic Neuroscience

In Parkinson disease, the pathological hallmark in the substantia nigra is loss of which neuronal population?

  1. Dopaminergic neurons projecting to the striatum Correct answer.
  2. Noradrenergic neurons of the locus coeruleus only
  3. Cholinergic neurons of the pedunculopontine nucleus
  4. GABAergic neurons of the globus pallidus externus

Explanation

Parkinson disease is characterised by degeneration of dopaminergic neurons in the substantia nigra pars compacta, with Lewy bodies, leading to striatal dopamine depletion. Other brainstem nuclei can be involved, but the cardinal motor features relate to the nigrostriatal dopaminergic loss. Cholinergic and pallidal populations are not the primary site of degeneration.

Question 16Neuroanatomy, Neurophysiology and Basic Neuroscience

A patient with a right middle cerebral artery stroke has dense left face and arm weakness with relative sparing of the leg. Why is the leg spared?

  1. Leg motor cortex is supplied mainly by the anterior cerebral artery Correct answer.
  2. The leg is represented in the cerebellum
  3. The thalamus relays only face and arm fibres
  4. Leg fibres cross at a different spinal level

Explanation

The homunculus places the leg representation on the medial surface and superior convexity, which is supplied by the anterior cerebral artery, while the face and arm lie laterally in middle cerebral territory. This vascular anatomy explains the characteristic pattern of arm-predominant weakness. Crossing sites and thalamic relay do not differ between face, arm and leg.

Question 17Clinical Neurology: History Taking, Neurological Examination and Localization

A 62-year-old man is brought to the clinic with word-finding difficulty. On examination he can follow two-step commands, repeat sentences accurately, and name objects, but his speech is halting and effortful with distorted sounds. Where is the lesion most likely located?

  1. Bilateral medial temporal lobes
  2. Left posterior superior temporal gyrus (Wernicke area)
  3. Left inferior frontal gyrus (Broca area) Correct answer.
  4. Left arcuate fasciculus

Explanation

Effortful, distorted speech with preserved comprehension and repetition points to a motor (non-fluent) aphasia from a lesion of the dominant inferior frontal gyrus. Repetition is intact because the arcuate fasciculus and posterior language areas are spared. Naming may be mildly impaired but comprehension remains good.

Question 18Clinical Neurology: History Taking, Neurological Examination and Localization

Which cranial nerve is tested by asking the patient to shrug the shoulders against resistance?

  1. Accessory nerve (XI) Correct answer.
  2. Glossopharyngeal nerve (IX)
  3. Hypoglossal nerve (XII)
  4. Facial nerve (VII)

Explanation

The spinal accessory nerve supplies the trapezius and sternocleidomastoid, so shoulder shrug and head turning against resistance test it. Hypoglossal testing involves tongue movement, glossopharyngeal testing involves gag and swallow, and facial testing involves facial muscles.

Question 19Clinical Neurology: History Taking, Neurological Examination and Localization

During the neurological examination you strike the biceps tendon and observe a brisk contraction. Which spinal segments mediate this reflex?

  1. S1-S2
  2. L3-L4
  3. C5-C6 Correct answer.
  4. C7-C8

Explanation

The biceps jerk is a myotatic reflex carried by the musculocutaneous nerve with its arc at C5-C6. Knowing segmental levels allows localization of radiculopathy or myelopathy. The other listed levels correspond to the triceps, knee, and ankle jerks respectively.

Question 20Clinical Neurology: History Taking, Neurological Examination and Localization

A patient is asked to walk heel-to-toe along a straight line. Which function is being assessed most directly?

  1. Truncal and gait ataxia Correct answer.
  2. Cortical sensation such as graphaesthesia
  3. Proprioception at the great toe
  4. Distal lower limb power

Explanation

Tandem gait stresses balance and coordination and is sensitive to midline cerebellar and vestibular dysfunction. It is not a test of joint position sense, cortical sensation, or strength. Abnormal sway suggests ataxia rather than weakness.

Question 21Clinical Neurology: History Taking, Neurological Examination and Localization

On fundoscopy the optic disc margin is blurred and the cup is preserved, with the veins engorged. Which finding does this most suggest?

  1. Papilloedema Correct answer.
  2. Optic atrophy
  3. Glaucomatous cupping
  4. Retinitis pigmentosa

Explanation

Swollen, blurred disc margins with venous engorgement and a preserved cup indicate papilloedema, usually from raised intracranial pressure. Optic atrophy produces a pale disc, while glaucoma produces cupping with a high cup-to-disc ratio. Retinitis pigmentosa shows pigmentary retinal changes rather than disc swelling.

Question 22Clinical Neurology: History Taking, Neurological Examination and Localization

A patient reports that a bright light shone in one eye causes discomfort in the other eye. Which structure is responsible for this consensual response?

  1. Trigeminal ophthalmic branch
  2. Facial nerve motor fibres
  3. Unilateral optic nerve only
  4. Optic tract and pretectal nucleus with bilateral Edinger-Westphal connections Correct answer.

Explanation

Light input travels via the optic nerve and tract to the pretectal nucleus, which projects bilaterally to both Edinger-Westphal nuclei, producing consensual constriction. This is why a relative afferent pupillary defect can be detected by the swinging flashlight test. The facial and trigeminal nerves do not mediate the light reflex.

Question 23Clinical Neurology: History Taking, Neurological Examination and Localization

A 70-year-old woman has sudden-onset right hemiparesis and dense non-fluent speech after a left middle cerebral artery stroke. Which bedside finding would best distinguish an upper from a lower motor neuron facial weakness?

  1. There is isolated weakness of eye closure only
  2. Forehead wrinkling is preserved on the affected side Correct answer.
  3. The whole face including the forehead is weak on the affected side
  4. There is ptosis with a dilated pupil

Explanation

Upper motor neuron lesions spare the forehead because the frontalis receives bilateral corticobulbar input, whereas lower motor neuron lesions paralyse the whole hemiface. This distinction localizes the lesion above or below the facial nucleus. Ptosis with a dilated pupil suggests a third nerve lesion rather than facial weakness.

Question 24Clinical Neurology: History Taking, Neurological Examination and Localization

A patient describes episodes of vertigo triggered by rolling over in bed, lasting under a minute, with no hearing loss. Which examination finding best supports the diagnosis?

  1. Unilateral sensorineural hearing loss with a positive Rinne test
  2. Downbeat nystagmus on primary gaze
  3. Positional nystagmus with a latency and fatigability on the Dix-Hallpike manoeuvre Correct answer.
  4. Direction-changing nystagmus on lateral gaze without vertigo

Explanation

Benign paroxysmal positional vertigo produces positional nystagmus that appears after a brief latency, is torsional-upbeating, and fatigues on repetition of the Dix-Hallpike manoeuvre. Gaze-evoked direction-changing nystagmus suggests cerebellar disease, and downbeat nystagmus suggests a central lesion. Hearing loss is absent in typical BPPV.

Question 25Clinical Neurology: History Taking, Neurological Examination and Localization

A 55-year-old man has a 6-month history of progressive right hand wasting and fasciculations, with brisk reflexes and an extensor plantar response in the same limb. What is the most likely localization?

  1. Right C6 root only
  2. Right median nerve at the wrist
  3. Right brachial plexus lower trunk
  4. Anterior horn cell and corticospinal tract involvement Correct answer.

Explanation

The combination of lower motor neuron signs (wasting, fasciculation) and upper motor neuron signs (brisk reflexes, extensor plantar) in the same limb suggests combined anterior horn cell and corticospinal tract disease, as in motor neuron disease. Plexopathy or a single root lesion would not produce upper motor neuron signs. Median neuropathy causes distal sensory and thenar motor deficits without brisk reflexes.

Question 26Clinical Neurology: History Taking, Neurological Examination and Localization

A patient has a right homonymous hemianopia with macular sparing. Where is the lesion most likely?

  1. Left occipital cortex Correct answer.
  2. Optic chiasm
  3. Right optic nerve
  4. Right optic tract

Explanation

A homonymous hemianopia localizes behind the chiasm, and macular sparing is characteristic of occipital cortex lesions because the macula has a dual blood supply from the posterior and middle cerebral arteries. Optic nerve lesions cause monocular visual loss, chiasmal lesions cause bitemporal defects, and optic tract lesions typically produce a homonymous hemianopia without macular sparing, often with other signs.

Question 27Clinical Neurology: History Taking, Neurological Examination and Localization

A 30-year-old woman has horizontal binocular diplopia that worsens when looking to the left and is absent when either eye is covered. Which examination step best identifies the affected muscle?

  1. Test the corneal reflex
  2. Test tandem gait
  3. Perform the swinging flashlight test
  4. Assess the separation of the images in the direction of maximal diplopia and identify the outer image Correct answer.

Explanation

In binocular diplopia the image from the paretic eye is projected further in the direction of action of the weak muscle, so the outer image belongs to the affected eye. This allows the examiner to identify the involved extraocular muscle. The swinging flashlight test assesses the pupillary pathway, and corneal reflex and gait testing do not localize diplopia.

Question 28Clinical Neurology: History Taking, Neurological Examination and Localization

A patient has a spastic paraparesis with a sensory level at T8, and vibration sense is lost below the level while pain and temperature are preserved. Which spinal cord structure is most likely affected?

  1. Dorsal columns Correct answer.
  2. Spinothalamic tracts
  3. Dorsal root ganglia
  4. Anterior horn cells

Explanation

Preserved pain and temperature with loss of vibration and proprioception below a level indicates dorsal column dysfunction, which can occur in tabes dorsalis or subacute combined degeneration. The spinothalamic tracts carry pain and temperature, and anterior horn involvement would produce lower motor neuron weakness rather than a sensory dissociation.

Question 29Clinical Neurology: History Taking, Neurological Examination and Localization

A patient is unable to identify a coin placed in the hand with the eyes closed, although light touch and pinprick are intact. Which term describes this finding?

  1. Agraphaesthesia
  2. Astereognosis Correct answer.
  3. Allochiria
  4. Anosognosia

Explanation

Astereognosis is the inability to recognize an object by touch despite intact primary sensation, reflecting parietal cortical dysfunction. Agraphaesthesia is the inability to identify numbers traced on the skin, anosognosia is denial of illness, and allochiria is mislocalization of a stimulus to the opposite side.

Question 30Clinical Neurology: History Taking, Neurological Examination and Localization

A 45-year-old man has a 3-week history of ascending symmetrical numbness and weakness, areflexia, and mild facial weakness after a diarrhoeal illness. Which examination feature best fits the likely diagnosis?

  1. Unilateral extensor plantar response with a sensory level
  2. Proximal muscle weakness with preserved reflexes and a rash
  3. Distal burning pain with preserved reflexes and normal power
  4. Symmetric flaccid weakness with absent reflexes and minimal sensory loss Correct answer.

Explanation

The subacute ascending symmetric weakness with areflexia after a gastrointestinal infection suggests Guillain-Barre syndrome, in which the examination shows flaccid weakness and absent reflexes. A sensory level with an extensor plantar suggests spinal cord disease, and preserved reflexes argue against a widespread peripheral neuropathy.

Question 31Clinical Neurology: History Taking, Neurological Examination and Localization

A patient has a right-sided ptosis, a dilated unreactive right pupil, and the right eye is deviated down and out. Which additional finding would most support a cavernous sinus lesion rather than an isolated nerve palsy?

  1. Impaired sensation over the right forehead Correct answer.
  2. Downbeat nystagmus
  3. Contralateral hemiparesis
  4. Bitemporal hemianopia

Explanation

A third nerve palsy with a dilated pupil suggests compression, and involvement of the ophthalmic division of the trigeminal nerve indicates a cavernous sinus lesion. Isolated oculomotor palsy would not affect facial sensation. Hemiparesis and bitemporal hemianopia localize elsewhere, and downbeat nystagmus suggests a cerebellar lesion.

Question 32Clinical Neurology: History Taking, Neurological Examination and Localization

A 68-year-old man has a resting tremor of the right hand that improves when he reaches for a cup, together with cogwheel rigidity and bradykinesia. Which examination finding would best support the diagnosis?

  1. Loss of vibration sense at the ankles
  2. Asymmetric onset with a unilateral resting tremor Correct answer.
  3. Bilateral intention tremor with dysmetria
  4. Proximal weakness with fasciculations

Explanation

Parkinsonism is characterised by asymmetric resting tremor, rigidity, and bradykinesia, with tremor improving on voluntary movement. Intention tremor with dysmetria suggests cerebellar disease, and fasciculations suggest lower motor neuron disease. Sensory loss is not a feature of idiopathic Parkinson disease.

Question 33Clinical Neurology: History Taking, Neurological Examination and Localization

A patient has a left homonymous superior quadrantanopia. Which structure is most likely damaged?

  1. Right parietal lobe
  2. Left optic nerve
  3. Optic chiasm
  4. Right temporal lobe (Meyer loop) Correct answer.

Explanation

Superior homonymous quadrantanopia results from damage to the temporal lobe, where Meyer loop fibres subserving the superior visual field run. Parietal lesions produce inferior quadrantanopia, chiasmal lesions produce bitemporal defects, and optic nerve lesions produce monocular loss.

Question 34Clinical Neurology: History Taking, Neurological Examination and Localization

A patient has a right sixth nerve palsy. Which clinical sign best distinguishes it from an internuclear ophthalmoplegia?

  1. Impaired adduction of the right eye with nystagmus of the abducting left eye
  2. Impaired abduction of the right eye with normal convergence Correct answer.
  3. Downbeat nystagmus on upward gaze
  4. Bilateral ptosis with normal eye movements

Explanation

A sixth nerve palsy impairs abduction of the affected eye, whereas internuclear ophthalmoplegia impairs adduction on the side of the medial longitudinal fasciculus lesion with nystagmus of the abducting eye. Convergence is typically preserved in a sixth nerve palsy. The other options describe findings unrelated to abducens or internuclear lesions.

Question 35Clinical Neurology: History Taking, Neurological Examination and Localization

A patient has a left-sided Horner syndrome. Which combination of findings would you expect on examination?

  1. Mild ptosis, miosis, and facial anhidrosis on the left Correct answer.
  2. Severe ptosis, mydriasis, and preserved facial sweating
  3. Severe ptosis, miosis, and a dilated unreactive pupil
  4. Mild ptosis, mydriasis, and facial anhidrosis on the left

Explanation

Horner syndrome results from disruption of the sympathetic pathway and produces mild ptosis from Muller muscle weakness, miosis, and anhidrosis on the affected side. A third nerve palsy causes severe ptosis with mydriasis, and a dilated unreactive pupil suggests a compressive third nerve lesion or Adie pupil rather than Horner syndrome.

Question 36Clinical Neurology: History Taking, Neurological Examination and Localization

A 58-year-old woman reports brief electric-shock sensations down the back and legs when she flexes her neck. Which examination sign is being described?

  1. Babinski sign
  2. Lhermitte sign Correct answer.
  3. Kernig sign
  4. Romberg sign

Explanation

Lhermitte sign is an electric-shock sensation radiating down the spine or limbs on neck flexion, reflecting dorsal column or cervical cord pathology such as demyelination. Romberg sign tests proprioceptive balance with eyes closed, Babinski sign indicates an upper motor neuron lesion, and Kernig sign indicates meningeal irritation.

Question 37Cerebrovascular Disease and Neurocritical Care

A 68-year-old man is brought to the emergency department 90 minutes after sudden onset of right hemiparesis and global aphasia. Non-contrast CT shows no haemorrhage and an Alberta Stroke Program Early CT Score of 9. Blood pressure is 168/94 mmHg and there are no contraindications. According to current thrombolysis guidance, which treatment should be given?

  1. No reperfusion therapy because the CT score is not 10
  2. Intravenous thrombolysis only after blood pressure falls below 140/90 mmHg
  3. Intravenous alteplase or tenecteplase within the 4.5-hour window Correct answer.
  4. Immediate intravenous thrombolysis followed by prophylactic mannitol

Explanation

Patients with disabling ischaemic stroke within 4.5 hours of onset and no contraindication are eligible for intravenous thrombolysis, either alteplase or tenecteplase depending on local protocol. The blood pressure threshold for treatment is below 185/110 mmHg, so 168/94 mmHg does not preclude therapy. A score of 9 reflects minimal established infarction and does not exclude treatment.

Question 38Cerebrovascular Disease and Neurocritical Care

Which large-vessel occlusion pattern most commonly produces a syndrome of conjugate eye deviation toward the lesion, contralateral hemiparesis and contralateral hemianopia?

  1. Proximal middle cerebral artery occlusion Correct answer.
  2. Recurrent artery of Heubner infarction
  3. Anterior choroidal artery occlusion
  4. Posterior cerebral artery occlusion

Explanation

A proximal middle cerebral artery occlusion affects the frontal eye field and descending motor pathways, giving gaze deviation toward the hemisphere of the lesion with contralateral weakness and visual field loss. This combination is the classic malignant middle cerebral artery syndrome. Smaller perforator infarcts produce restricted deficits rather than this full triad.

Question 39Cerebrovascular Disease and Neurocritical Care

A 54-year-old woman has a subarachnoid haemorrhage from a ruptured anterior communicating aneurysm, confirmed on CT angiography. She is alert with no focal deficit. Which measure most reduces the risk of rebleeding?

  1. A 21-day course of oral nimodipine
  2. Serial lumbar punctures to clear blood from the subarachnoid space
  3. Early securing of the aneurysm by endovascular coiling or surgical clipping Correct answer.
  4. Strict bed rest with maintenance of systolic pressure above 160 mmHg

Explanation

Rebleeding carries high mortality and occurs most often in the first 24 to 72 hours, so the aneurysm should be secured as early as possible by coiling or clipping. Blood pressure control and antifibrinolytic therapy are only temporising measures. Nimodipine improves outcome by reducing delayed cerebral ischaemia but does not prevent rebleeding.

Question 40Cerebrovascular Disease and Neurocritical Care

Which finding on non-contrast CT most reliably distinguishes an acute intracerebral haemorrhage from an ischaemic infarct?

  1. Hyperdense extravasated blood within the parenchyma Correct answer.
  2. Hypodensity in the lentiform nucleus
  3. Loss of the insular ribbon
  4. Sulcal effacement over the affected hemisphere

Explanation

Fresh extravasated blood appears hyperdense on non-contrast CT because of its high protein and iron content, and this is the defining feature of intracerebral haemorrhage. The other listed signs are early ischaemic changes of the middle cerebral artery territory. They indicate infarction rather than haemorrhage.

Question 41Cerebrovascular Disease and Neurocritical Care

A 72-year-old man with atrial fibrillation has a cardioembolic stroke. After 24-hour imaging shows no haemorrhagic transformation and he is clinically stable, when should anticoagulation generally be started?

  1. Never, because anticoagulation is contraindicated after cardioembolic stroke
  2. Within 4 to 14 days of onset, depending on infarct size and bleeding risk Correct answer.
  3. Only after 3 months of dual antiplatelet therapy
  4. Immediately on day 0 alongside thrombolysis

Explanation

Current guidance supports early initiation of direct oral anticoagulation, typically within 4 to 14 days, with the exact timing individualised to infarct size, haemorrhagic transformation and comorbidity. Starting immediately after thrombolysis is unsafe because of bleeding risk. Anticoagulation is the mainstay of secondary prevention in atrial fibrillation.

Question 42Cerebrovascular Disease and Neurocritical Care

A 60-year-old man has a right middle cerebral artery infarct with a National Institutes of Health Stroke Scale score of 18. He remains drowsy with worsening right-sided weakness 24 hours after onset. CT shows a large infarct with midline shift but no haemorrhage. Which intervention is most appropriate?

  1. Intravenous thrombolysis
  2. Therapeutic anticoagulation with heparin
  3. Decompressive hemicraniectomy Correct answer.
  4. Hyperbaric oxygen therapy

Explanation

Malignant middle cerebral artery infarction with mass effect and clinical deterioration is treated with decompressive hemicraniectomy, which reduces mortality and improves functional outcome in selected patients. Surgery is most beneficial when performed early, generally within 48 hours of onset. Reperfusion therapies are outside their time window at this stage.

Question 43Cerebrovascular Disease and Neurocritical Care

Which statement best describes cerebral autoregulation in a healthy adult?

  1. Cerebral blood flow is maintained relatively constant across a mean arterial pressure range of roughly 60 to 150 mmHg Correct answer.
  2. Cerebral blood flow depends entirely on arterial oxygen content rather than perfusion pressure
  3. Cerebral blood flow rises linearly with every increase in mean arterial pressure
  4. Cerebral blood flow is highest during sleep and lowest during wakefulness

Explanation

Myogenic and metabolic mechanisms keep cerebral blood flow near constant over a mean arterial pressure range of about 60 to 150 mmHg, protecting the brain from hypo- and hyperperfusion. Outside this range, flow becomes pressure-passive, which is why both hypotension and severe hypertension are dangerous. The curve is shifted in chronic hypertension and after acute brain injury.

Question 44Cerebrovascular Disease and Neurocritical Care

A 45-year-old woman presents with sudden severe headache and neck stiffness. CT is normal but lumbar puncture 12 hours after onset shows uniformly blood-stained cerebrospinal fluid that does not clear between tubes. Which diagnosis is most likely?

  1. Bacterial meningitis
  2. Subarachnoid haemorrhage Correct answer.
  3. Cerebral venous sinus thrombosis
  4. Migraine with aura

Explanation

Thunderclap headache with meningism, a normal early CT and uniformly bloody cerebrospinal fluid that fails to clear between collection tubes indicates subarachnoid haemorrhage; xanthochromia may confirm it. CT sensitivity falls with time after onset, so lumbar puncture remains important when imaging is negative. Meningitis and venous thrombosis do not produce uniformly blood-stained fluid.

Question 45Cerebrovascular Disease and Neurocritical Care

Which finding on transcranial Doppler most suggests vasospasm after subarachnoid haemorrhage?

  1. Diffuse slowing on electroencephalography
  2. Elevated mean flow velocity in the middle cerebral artery with a Lindegaard ratio above 3 Correct answer.
  3. Reduced pulsatility index with normal flow velocity
  4. Absent flow in the middle cerebral artery with a Lindegaard ratio below 1

Explanation

Vasospasm raises blood flow velocity in the insonated artery, and a Lindegaard ratio above 3 distinguishes true vasospasm from hyperaemia. Serial transcranial Doppler is used to monitor for delayed cerebral ischaemia after subarachnoid haemorrhage. Absent flow or low ratios do not indicate spasm.

Question 46Cerebrovascular Disease and Neurocritical Care

A 30-year-old woman has a first seizure 3 weeks after an ischaemic stroke. Which statement about post-stroke epilepsy is most accurate?

  1. Late seizures after stroke carry a high risk of recurrence and usually warrant long-term antiepileptic treatment Correct answer.
  2. Seizures after stroke are unrelated to cortical involvement
  3. Prophylactic anticonvulsants are recommended for all stroke patients
  4. Early seizures within 7 days always require lifelong anticonvulsants

Explanation

Seizures occurring more than 7 days after stroke define post-stroke epilepsy and carry a high recurrence risk, so long-term antiepileptic therapy is generally indicated. Early seizures are provoked and do not by themselves justify lifelong treatment. Cortical and haemorrhagic lesions increase risk.

Question 47Cerebrovascular Disease and Neurocritical Care

Which clinical feature most strongly suggests basilar artery occlusion rather than a hemispheric stroke?

  1. Contralateral homonymous hemianopia alone
  2. Isolated Wernicke aphasia
  3. Fluctuating consciousness with quadriparesis and pupillary abnormalities Correct answer.
  4. Dense hemiparesis with gaze deviation toward the lesion

Explanation

Basilar artery occlusion produces brainstem ischaemia with fluctuating or reduced consciousness, quadriparesis, cranial nerve palsies and pupillary abnormalities. The presentation may evolve in a stuttering fashion and is easily mistaken for metabolic encephalopathy. Hemispheric signs such as gaze deviation or aphasia point to the anterior circulation.

Question 48Cerebrovascular Disease and Neurocritical Care

A patient with acute ischaemic stroke is being considered for endovascular thrombectomy. Which combination best defines the core eligibility criteria used in current practice?

  1. Intracerebral haemorrhage with a spot sign on CT angiography
  2. Transient ischaemic attack with complete resolution within 1 hour
  3. Large vessel occlusion with a small infarct core and a significant penumbra on perfusion imaging Correct answer.
  4. Any ischaemic stroke regardless of vessel status or imaging

Explanation

Thrombectomy is indicated for large vessel occlusion, typically of the internal carotid or proximal middle cerebral artery, with a small ischaemic core and salvageable penumbra. Advanced imaging selects patients likely to benefit, including those presenting beyond 6 hours. Vessel status and tissue viability are central to the decision.

Question 49Cerebrovascular Disease and Neurocritical Care

A 55-year-old man has a cerebellar haemorrhage 3 cm in diameter with progressive drowsiness and brainstem compression. What is the most appropriate management?

  1. Urgent surgical evacuation of the haematoma Correct answer.
  2. Immediate lumbar puncture
  3. Intravenous thrombolysis
  4. Observation with serial imaging only

Explanation

Cerebellar haemorrhage larger than about 3 cm, or associated with brainstem compression, hydrocephalus or clinical deterioration, warrants urgent surgical evacuation. Without surgery, deterioration from brainstem compression can be rapid and fatal. Observation is appropriate only for small haemorrhages without mass effect.

Question 50Cerebrovascular Disease and Neurocritical Care

Which mechanism best explains the benefit of permissive hypertension in the first days after acute ischaemic stroke?

  1. Increasing oxygen delivery through systemic vasodilation
  2. Maintaining perfusion pressure to the ischaemic penumbra where autoregulation is impaired Correct answer.
  3. Preventing rebleeding by increasing platelet aggregation
  4. Reducing cerebral oedema by raising capillary hydrostatic pressure

Explanation

In the ischaemic penumbra, autoregulation is lost and perfusion becomes pressure-dependent, so modest hypertension helps maintain collateral flow. Blood pressure is therefore lowered cautiously, generally only above 220/120 mmHg, or below 185/110 mmHg if thrombolysis is planned. Aggressive reduction can extend the infarct.