Mock Neurology Module 1

An elderly man with dementia presents with his daughter, who reports sudden deterioration in his level of function over and above his usual level of confusion.

On examination, he has difficulty copying a clock face; he draws a full circle and then places all the numbers on one side of the clock. He also has difficulty putting on his coat.

What is the most likely cause of his deterioration?

A 65-year-old man was brought to the emergency department after his wife heard grunting noises in bed. She noticed a left facial droop and a dense left hemiplegia. An urgent MRI was performed.

An acute ischaemic lesion in the right parietal region was detected on diffusion-weighted imaging (DWI) but not on fluid-attenuated inversion recovery (FLAIR) imaging.

What is the significance of this finding?

Which of the following drugs could potentially lead to lamotrigine toxicity?

Levetiracetam is frequently used as add-on therapy for epilepsy.

What is a major concern regarding its use?

A 40-year-old patient presents with intense vertigo, tinnitus, and a sense of fullness in the right ear.

Examination during an attack shows fine rotatory nystagmus that is maximal on gaze to the left. The remainder of the neurological examination is unremarkable.

An audiogram shows low- to mid-frequency sensorineural hearing loss in the right ear, with recruitment but no tone decay.

What is the most likely diagnosis?

A 64-year-old man with hypertension and type 2 diabetes presents with 3 days of ongoing vertigo associated with spontaneous nystagmus.

Which clinical finding would be most concerning for a central cause?

Deep brain stimulation (DBS) is an established treatment modality for selected patients with Parkinson disease.

Which of the following symptoms is most likely to respond to this treatment?

Which of the following clinical features would suggest a stroke mimic rather than a true stroke?

A 56-year-old man, otherwise fit and well, develops sudden-onset right arm and leg weakness with a right facial droop at 9 am on a Saturday. His NIHSS score is 12 and routine bloods are unremarkable.

An urgent CT head shows early ischaemic changes in the left middle cerebral artery territory. The time is now 12 pm.

What is the best treatment to reduce his disability and mortality?

A 56-year-old man, otherwise fit and well, develops sudden-onset right arm and leg weakness with a right facial droop at 9 am on a Saturday. His NIHSS score is 12 and routine bloods are unremarkable.

An urgent CT head shows an acute left middle cerebral artery territory infarct. The time is now 3 pm. CT angiography shows an occlusive clot in the left middle cerebral artery, and CT perfusion shows a favourable core–penumbra mismatch.

What is the best treatment to achieve functional independence following his stroke?

A 57-year-old woman presents within one hour of onset of an acute ischaemic stroke. CT angiography demonstrates an occlusion in the right middle cerebral artery, and she is eligible for endovascular thrombectomy.

Which thrombolytic agent is most appropriate to administer prior to thrombectomy to optimise her outcome?

A 35-year-old man who abuses alcohol presents with unsteadiness of gait.

Examination reveals diminished deep tendon reflexes, absent proprioception and vibration sense in both legs, extensor plantar responses, and a cerebellar (intention) tremor in the hands.

Which condition is most likely responsible for his presentation?

The following descending motor tracts are predominantly responsible for axial and proximal limb control EXCEPT:

A 40-year-old woman with no significant past medical history presents with 3 days of ascending numbness. Tingling began bilaterally in the feet and ascended to the waist over 72 hours. She now drags her right leg and has difficulty emptying her bladder.

Cranial nerve examination is normal; upper limbs have normal power. Lower-limb power is 4/5 to 3/5 on the right with a T10 sensory level to pinprick and temperature, preserved proprioception, absent ankle and knee reflexes, and a right foot drop.

Brain MRI is normal; thoracic spine MRI shows increased T2 signal at T9.

CSF shows a pleocytosis with elevated IgG index; oligoclonal bands are present.

All of the following treatments could be helpful EXCEPT:

A 30-year-old man presents with a painful right eye. Examination reveals reduced visual acuity and a relative afferent pupillary defect (RAPD) in the right eye.

What is the most likely diagnosis?

The McDonald diagnostic criteria for multiple sclerosis incorporate clinical and MRI findings, with the core requirement being objective demonstration of dissemination of lesions in space and in time.

For dissemination in space, MRI must demonstrate one or more T2 lesions in at least two of the characteristic CNS regions.

Which of the following is NOT one of these regions?

Which of the following clinical features is LEAST suggestive of multiple sclerosis?

Which of the following conditions is most characteristically and reliably responsive to glucocorticoids?

A 50-year-old woman with relapsing-remitting multiple sclerosis has been treated with natalizumab for the past 6 months and now presents with symptoms concerning for progressive multifocal leukoencephalopathy (PML).

Which of the following features would favour PML rather than an MS relapse?

Ocrelizumab is a humanised monoclonal antibody that selectively depletes CD20-expressing B cells.

For which of the following conditions is it most notably indicated?

A 55-year-old woman reports 2 weeks of dizziness. Several times a day she experiences severe spinning triggered by head movements such as rolling over in bed or looking upward.

Each episode lasts about 15 seconds with transient nausea and resolves spontaneously, without hearing change, tinnitus, headache, fever, or other neurological symptoms.

On performing the Dix-Hallpike manoeuvre with the head turned to the right, after a latency of two seconds she develops severe vertigo with mixed torsional and upbeating nystagmus.

Which treatment is most likely to be effective?

If a patient with myasthenia gravis undergoes repetitive nerve stimulation, what change would be expected in the recorded compound muscle action potential?

Which of the following disabilities in Parkinson disease is unresponsive to levodopa?

Which of the following features is LEAST consistent with a diagnosis of essential tremor?

A neurologist assesses a 65-year-old man with worsening bilateral hand tremor.

Which feature makes Parkinson disease tremor more likely than essential tremor?

A 67-year-old man who smokes 20 cigarettes daily presents with sudden painless loss of vision in the right eye, described as a curtain descending, which resolved after about 5 minutes (amaurosis fugax).

There were no other neurological symptoms. MRI brain is normal. Carotid imaging shows 70% stenosis of the right internal carotid artery.

Which intervention will give the greatest reduction in his risk of stroke or death over the next year?

In patients presenting with acute idiopathic facial nerve palsy (Bell palsy), which patient group is LEAST likely to derive additional benefit from early corticosteroids because they already have a favourable prognosis?

Which antiepileptic drug would reduce the serum levels and effects of lamotrigine?

A patient develops a right (non-dominant) parietal lobe infarct. In addition to a left hemiparesis, which combination of clinical signs would you most expect?

Posterior reversible encephalopathy syndrome (PRES) is associated with all of the following EXCEPT:

In acute ischaemic stroke, which arterial occlusion has the best chance of recanalisation following intravenous thrombolysis with alteplase?

A 65-year-old man has a permanent pacemaker for complete heart block. His background includes hypertension and diet-controlled type 2 diabetes.

A routine pacemaker interrogation records a low burden of atrial high-rate episodes (subclinical atrial fibrillation) lasting less than 10 minutes over a 6-month period. He is asymptomatic. His CHA₂DS₂-VASc score is 3.

Which medication is most likely to reduce his future risk of stroke?

A 56-year-old man with hypertension treated with enalapril presents with an acute ischaemic stroke and receives intravenous alteplase.

Within an hour he develops severe swelling of the right side of his tongue, requiring emergent intubation.

Imaging confirms an acute-to-subacute infarct in the left posterior cerebral artery (occipital) territory.

Which of the following interventions should be AVOIDED in this situation?