Neurology: Self-Assessment for MRCP(UK) Neurology SCE

By Osama Shukir Muhammed Amin

You will find 1080 questions of different formats, distributed into five chapters. The book’s questions were written in many formats; best of fives (one correct stem of out five, i.e., single best answer), best of many (two or three answers out of ten stems), a single line (filling in a blank space with your answer), serial best of fives (one to four best of five questions about one patient), and best of five questions with photographic materials. Chapter four contains 215 MCQs in a true/false format targeting neuroanatomy, neurophysiology, neuropharmacology, etc. as well as clinical neurology. The objective behind writing chapter four is to retrieve your information rapidly. The single-line format tests the candidate's skills in clinical decision-making and retrieving his medical knowledge. The last two formats are no longer used in many post-graduate exams all over the world. Comprising about 20% of this book, I included them here just for a diverse way of self-assessment. Chapters two and three were taken from my other books and MRCP courses; they include updates in neurology, and COVID-19 questions are also encompassed.

The first copy of this book, entitled “One Year of Har Work”, was in PDF format only and published in 2006; it was used by many postgraduate neurology bodies to examine their trainees. The work then progressed to an updated version, the first edition (published in 2016) was named “Neurology: Self-Assessment for MRCP(UK) and MRCP(I)” with 792 questions. Favorable and productive reviews and critiques made me write this second edition. As far as I know and have been informed about, many post-graduate neurology board candidates and diploma trainees in many countries have been using my book. I hope this updated edition will help strengthen your information and solidify your clinical approach.

• Language: English
• Publisher: Lulu.com
• Release date: Feb 12, 2023
• ISBN: 9781447844815

Book preview

Neurology:

Self-Assessment for MRCP(UK) Neurology SCE

Osama Shukir Muhammed Amin

MBChB, MD, MRCP, FRCP(Edin), FRCP(Glasg), FRCP(Ire), FRCP(Lond), FACP, FAHA, FCCP(USA), FRSA

- Senior Consultant Neurologist

- Formerly, Director of the Kurdistan Board of Neurology, Sulaymaniyah

- Formerly, Clinical Associate Professor

  School of Medicine, International Medical University

  Malaysia

Copyright © 2023. Osama Shukir Muhammed Amin.

Copyright © 2023. Osama Shukir Muhammed Amin.

Copyright Notice:

All rights reserved. No part of this publication may be reproduced or transmit3ted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the copyright owner in writing:

Email: [e-mail].

First Edition: 2016.

Second Edition: 2023.

ISBN: 978-1-4478-4481-5

Disclaimer:

This book was written depending on reliable sources. However, while every effort has been made to ensure its accuracy, no responsibility for loss, damage, or injury occasioned on any person acting or refraining from action as a result of information contained herein can be accepted by the author or publisher.

Distributed by Lulu Press, Inc., North Carolina, USA.

Dedication

To my lovely wife Sarah, daughter Awan, and baby girl Naz. Without their kind help and patience, this book would not have been published.

Osama

Acknowledgments

  I would like to thank my dear patients; their real clinical scenarios were used to formulate and generate these questions.

I’m very grateful to my post-graduate neurology trainees; their continuous feedback helped me tremendously when I decided to make this book.

Special gratitude goes to my other half, my wife Sarah, for her endless support and encouragement, and of course her extreme patience.

I would like to sincerely thank Dr. Umberto Benneli MD, Ph.D., an ophthalmologist from Italy. He kindly permitted me to use some of his photos; these images were used in the 1st 20 questions of chapter 3.   

Osama

Preface

It is much simpler to buy books than to read them and easier to read them than to absorb their contents, Sir William Osler (1849-1919).

You will find 1080 questions of different formats, distributed into five chapters. The book’s questions were written in many formats; best of fives (one correct stem of out five, i.e., single best answer), best of many (two or three answers out of ten stems), a single line (filling in a blank space with your answer), serial best of fives (one to four best of five questions about one patient), and best of five questions with photographic materials. Chapter four contains 215 MCQs in a true/false format targeting neuroanatomy, neurophysiology, neuropharmacology, etc. as well as clinical neurology. The objective behind writing chapter four is to retrieve your information rapidly. The single-line format tests the candidate's skills in clinical decision-making and retrieving his medical knowledge. The last two formats are no longer used in many post-graduate exams all over the world. Comprising about 20% of this book, I included them here just for a diverse way of self-assessment. Chapters two and three were taken from my other books and MRCP courses; they include updates in neurology, and COVID-19 questions are also encompassed.

I, a senior consultant Board-certified neurologist, found it difficult what topics to select and highlight. In writing this book, I tried to cover the most important examination themes of MRCP Part I, Part II, and Neurology SCE. Remember, this book is not an alternative to reading accredited textbooks. Read, self-assess, and fill in the gaps in your knowledge.

The first copy of this book, entitled One Year of Har Work, was in PDF format only and published in 2006; it was used by many postgraduate neurology bodies to examine their trainees. The work then progressed to an updated version, the first edition (published in 2016) was named Neurology: Self-Assessment for MRCP(UK) and MRCP(I) with 792 questions. Favorable and productive reviews and critiques made me write this second edition. As far as I know and have been informed about, many post-graduate neurology board candidates and diploma trainees in many countries have been using my book. I hope this updated edition will help strengthen your information and solidify your clinical approach.   

The book is not exclusive to the MRCP(UK) neurology SCE exams. Candidates preparing for the MRCP(UK) and MRCP(I) part I and II written exams, post-graduate exams (e.g., board certifications, FRACP, FRCPC, and diplomas), and medical licensing exam can also self-asses themselves using this book. Anyone interested in neurology can read it. 

Finally, according to the website of the Membership of Royal Colleges of Physicians of the United Kingdom’s website (www.mrcpuk.org), there are no entry requirements for the SCE (specialty certificate examination) in neurology, although trainees in UK training posts would normally take the SCE in their penultimate year of higher specialty training. This examination is a certificate in neurology. Trainees who hold MRCP(UK), have gained the certificate in neurology (SCE), and are recommended for a CCT (the certificate of completion of training awarded by the GMC) will be entitled to apply for the postnominal MRCP(UK) (Neurology). It is not equivalent to the MRCP(UK) or MRCP(I), it is not a diploma or fellowship, and does not grant you GMC registration. 

Good luck with your career and exams!

Osama S. M. Amin

February 2023

References and Recommended Readings

1. Ropper et al. Adams and Victor’s Principles of Neurology, 12th edition. New York: McGraw-Hill Education/Medical; 2023.

2. Greenberg et al. Clinical Neurology. 11th edition. New York: McGraw-Hill Education/Medical; 2020.

3. Hauser S, Josephson S. Harrison’s Neurology in Clinical Medicine. 4th edition. New York: McGraw-Hill Education; 2016.

4. Loscalzo et al. Harrison’s Principles of Internal Medicine, 21st edition. New York: McGraw-Hill Professional, 2022.

5. Goldman et al. Goldman-Cecil Medicine, 2-Volume Set (Cecil Textbook of Medicine), 26th Edition. New York: Elsevier; 2019.

6. Barrett et al. Ganong’s Review of Medical Physiology, 26th edition. New York: McGraw-Hill Education/Medical; 2019.

7. Salmon JF. Kanski's Clinical Ophthalmology: A Systematic Approach. New York: Elsevier; 2019.

Chapter One – Questions

Best of Five (choose one stem out of 5)

Best of Many (choose 2 or 3 correct stems out of 10)

Single Line (fill in the space with your answer)

1) A 32-year-old female presents with a 6-day history of progressive failing vision and painful eye movements. Her right-sided visual acuity is 6/60 and you find a normal-looking optic disc and retina. You detect right-sided Marcus-Gunn pupil. Where is the lesion?

a. Central retinal artery

b. Posterior ciliary arteries

c. Optic nerve head

d. Retro-orbital portion of the optic nerve

e. Retina-choroid interface

2) A 67-year-old man has a 2-month history of throbbing headaches and jaw claudication. Today, he presents with a sudden loss of his right-sided vision. Fundoscopy reveals a swollen and somewhat pale right optic disc; otherwise, the rest of the retina is normal-looking. He has an upper altitudinal visual field defect. Where is the lesion that is responsible for this sudden visual loss?

a. Right temporal artery

b. Right posterior ciliary arteries

c. Right central retinal artery

d. Right anterior choroidal artery

e. Right ophthalmic artery

3) A 33-year-old man who was diagnosed with relapsing-remitting multiple sclerosis visits the physician’s office for a scheduled follow-up. He states that he has a shock-like electrical sensation in his neck and down his spine when attempting to flex the neck. Where is the anatomical site of the lesion that is responsible for his new complaint?

a. The lower medulla oblongata

b. The posterior column of the dorsal cord

c. The posterior column of the cervical cord

d. The anterior-lateral column of the cervical cord

e. The anterior 2/3rd of the dorsal cord

4) A 68-year-old right-handed man who has chronic atrial fibrillation presents with a 4-hour history of dense left-sided hemiplegia, hemianesthesia, and homonymous hemianopia. His speech is somewhat slurred but is understandable; you detect intact comprehension, repetition, and naming. Which artery is responsible for this man’s ischemic stroke?

a. Right middle cerebral artery main stem

b. Left internal carotid artery

c. Right anterior cerebral artery

d. Right posterior cerebral artery

e. Left lenticulo-striate perforating arteries

5) A 34-year-old female presents with painless easy fatigability and difficulty swallowing. She has bilateral partial ptoses, variable diplopia, and normal pupillary size and reactivity. Deep tendon reflexes are normal. Repetitive EMG reveals a decremental response. Where is the lesion that is responsible lesion for this woman’s presentation?

a. Motor end-plate, post-synaptic area

b. Motor end-plate, pre-synaptic area

c. Motor end-plate, pre- and post-synaptic areas

d. Skeletal muscle capillaries

e. Skeletal muscle tendons

6) A 17-year-old male presents with dysarthria and dysphagia. You find resting tremors and dystonic posturing. Slit-lamp eye examination discloses the presence of the Kayser-Fleischer ring. Where is the anatomical location of this ring?

a. Corneal epithelial layer

b. Corneal stromal layer

c. Corneoscleral junction

d. Corneal Descemet’s membrane

e. Anterior surface of the iris

7) A 34-year-old woman presents with optic neuritis. She has spastic paraparesis. Her final diagnosis is multiple sclerosis. Which one of the following is the anatomical target of this disease?

a. Brain and spinal cord white matter

b. Schwann cells

c. Brain venules

d. Proximal spinal roots

e. Cerebral cortex

8) A 26-year-old man presents with repetitive staring, picking at clothes movements, and lip-smacking. The history was taken from his older sister but the patient himself denies such movements. Further evaluation reveals a diagnosis of complex partial epilepsy. From where does this type of epilepsy arise?

a. Occipital lobe

b. Parietal lobe

c. Temporal lobe

d. Frontal lobe

e. Both thalami

9) A 56-year-old man has a history of head trauma. Today, he presents with repetitive jerky movements of the left hand which lasted for 1 minute and then disappeared spontaneously. This type of seizure generates from? 

a. Occipital lobe

b. Parietal lobe

c. Temporal lobe

d. Frontal lobe

e. Both thalami

10) A 55-year-old man was diagnosed with complex partial seizures 3 months ago. He states that he sees certain faces and landscapes every now and then. What is the origin of these formed visual hallucinations?

a. Right basal ganglia

b. Left thalamus

c. Upper midbrain

d. Occipital lobe

e. Temporal lobe

11) A 45-year-old man presents with rapidly ascending flaccid paraparesis. He demonstrates normal peripheral sensory examination. A preliminary diagnosis of Guillain-Barrè syndrome was made. What is the primary pathology of this syndrome?

a. Central demyelination

b. Peripheral demyelination

c. Peripheral axonal degeneration

d. Simultaneous peripheral demyelination and axonal loss

e. Simultaneous central demyelination and axonal loss

12) A 66-year-old man, who has small cell lung cancer, presents with easy fatigability, dry mouth, and impotence. His reflexes are hypoactive but improve upon repetition. Repetitive EMG reveals an incremental response. Which one of the following is dysfunctional in this neurological condition?

a. Motor end-plate, post-synaptic area

b. Motor end-plate, pre-synaptic area

c. Motor end-plate, pre- and post-synaptic areas

d. Dorsal root ganglia

e. Anterior horn cells

13) A 69-year-old female has a rock-hard mass in her right ovary and ascites. She presents with a 7-week history of unsteady reeling gait, slurred speech, and down-beating nystagmus. Brain MRI with gadolinium is unremarkable. Serum anti-Yo antibodies are positive. What is the anatomical target of this antibody?

a. Midbrain red nuclei

b. Deep cerebellar nuclei 

c. Pontine vestibular complex

d. Medullary pyramid

e. Cerebellar cortex

14) A 74-year-old man presents with easy forgetfulness and anxiety. There is a prominent impairment of recent memories with relative preservation of remote ones. His mini-mental status examination score is 20. You consider Alzheimer's disease. What is the primary anatomical target of this disease?

a. Brain stem

b. Thalami

c. Cerebral Cortex

d. Subcortical white matter

e. Basal ganglia

15) A 55-year-old man presents with vague personality changes and subtle cognitive deficits. His memory testing is reasonable. Further evaluation, including brain biopsy, reveals Pick's type of dementia. What is the primary area affected by this dementia?

a. Parieto-occipital lobes

b. Mesial frontal lobes

c. Mesial temporal lobes

d. Frontotemporal lobes

e. Both lateral surfaces of the parietal lobes

16) A 50-year-old heavy drinker man is brought to the Emergency Room in an agitated confusional state. You find nystagmus, gait ataxia, and global confusion. There is a prominent disorder of immediate recall and recent memory. You are thinking of Wernicke's encephalopathy. This disorder does not affect one of the following central nervous system areas:

a. Medial thalami

b. Periaqueductal gray matter

c. Mammillary bodies

d. Cerebellar vermis

e. Spinal cord

17) A 57-year-old man presents with sudden severe occipital headache and drowsiness. A brain CT scan reveals blood in the basal cisterns. No history of trauma was obtained. There is no family history of note. What is the most likely cause behind this man’s presentation?

a. Ruptured arteriovenous malformation

b. Occluded middle meningeal artery

c. Ruptured Berry's aneurysm

d. Cerebral venous sinus thrombosis

e. Ruptured cavernous angioma

18) A 33-year-old woman presents with double vision. While you examine the eye movements, you find an inability to adduct the right eye with nystagmus in the abducting left eye. Both eyes adduct well and symmetrically upon convergence and move well upon looking to the right. Where is the lesion that is responsible for this presentation?

a. Pontine horizontal gaze center

b. Midbrain up-gaze center

c. Brainstem medial longitudinal fasciculus

d. Oculomotor subnuclei

e. Abducens nucleus 

19) A 34-year-old man sustained a minor head trauma after which he developed double vision upon reading or descending downstairs. He demonstrates an inability to depress the adducted left eye. There is vertical diplopia. Where is the lesion causing this presentation?

a. Left oculomotor nerve

b. Left trochlear nerve

c. Right trochlear nerve

d. Right oculomotor nerve

e. Combined left abducens and oculomotor nerves

20) A 67-year-old diabetic woman presents with a sudden onset of double vision. She has right-sided orbital pain and lid drooping. She denies a recent or remote history of headaches. Examination reveals near total right-sided ptosis. Elevation of the ptotic lid shows that the right globe is depressed towards the outer canthus. Diplopia occurs in all directions of gaze except upon looking to the right side. The right pupil has normal size and reactivity. Where is the lesion that is responsible for this woman’s painful ophthalmoplegia?

a. Right abducens in the orbit

b. Right oculomotor nerve in the orbit

c. Right oculomotor compression by an expanding intracranial aneurysm

d. Right abducens and oculomotor nerves in the cavernous sinus

e. Right trochlear nerve in the superior oblique fissure

21) A 60-year-old woman presents with a 6-month history of severe episodic lancinating pains in her right cheek. You find nothing on examination. Where is the lesion?

a. Right facial nerve

b. Left facial nerve

c. Right trigeminal nerve

d. Left trigeminal nerve

e. Combined right and left trigeminal nerves

22) A 34-year-old man presents with sudden onset of low back pain and inability to walk. You detect tenderness and stiffness in the lower back and an inability to dorsiflex the right foot and big toe. Deep tendon reflexes are normal. Which spinal root is responsible for this man’s presentation?

a. L4

b. L5

c. S1

d. S2

e. L4,5 and S1

23) A 44-year-old man is brought by an ambulance to the Acute and Emergency Department in a coma. No history is obtainable as there is no accompaniment. You notice an ataxic type of breathing. Where does this type of respiration localize the lesion?

a. Right cerebral hemisphere

b. Both cerebral hemispheres

c. Ponto-medullary area

d. Both thalami

e. High spinal cord

24) A 32-year-old woman is brought by her boyfriend to the Acute and Emergency Department in a deep coma state. The boyfriend is shocked and perplexed and is unable to give any history. You find a right-sided mid-sized fixed pupil with gaze deviation to the same side of the right hemiparesis. Her breathing is gasping. Where is the site of the lesion?

a. Left frontal lobe

b. Posterior fossa

c. High spinal cord

d. Both parieto-occipital lobes

e. Anterior temporal lobes

25) A 32-year-old man presents with a 3-day history of fever, headache, and vomiting. The examination reveals drowsiness, severe neck stiffness, and a positive Kerning's sign. You are thinking of pyogenic meningitis. While he is sleeping, you notice that his right eye is not closed, and the right globe is turned up. What is the reason for his eye appearance?

a. Right-sided facial palsy

b. Right-sided Horner's syndrome

c. Right-sided proptosis

d. Right-sided abducens palsy

e. Right-sided oculomotor palsy

26) A 34-year-old woman, who has a history of idiopathic optic neuritis, presents with a burning sensation in the trunk, paraparesis, and urinary incontinence. There is nystagmus and slurred speech. What is the likely nature of the new lesion?

a. Vascular occlusion

b. Degenerative

c. Demyelinating

d. Compressive

e. Infective

27) A 68-year-old diabetic man presents with sudden onset of vertigo, nausea and vomiting, dysphagia, dysarthria, and hiccough. Examination reveals absent sensation in the right side of the face and left side of the body, right-sided Horner's syndrome, and right upper limb ataxia. No pyramidal signs were found. Which one of the following areas is damaged?

a. Ventral surface of the medulla oblongata

b. Wedge-shaped lateral area of the medulla oblongata

c. Basis pontis

d. Cerebral peduncles

e. Posterior surface of the pontomedullary junction

28) A 45-year-old woman has been experiencing a pancephalic headache for the past 6 months. The examination reveals astereognosis and agraphesthesia. There are normal power and deep tendon reflexes. Brain MRI reveals a brain tumor. Where is the likely location of this tumor?

a. Occipital lobe

b. Parietal lobe

c. Temporal lobe

d. Frontal lobe

e. Brainstem

29) A 43-year-old right-handed man sustains head trauma after falling from a tree. He develops a depressed skull fracture and is brought by his family to your office. The family states that the patient eats only food on the right side of the plate and fails to properly clothe and groom the left side of the body. Where is the anatomical location of the lesion that is responsible for these vague behaviors?

a. Right parietal lobe

b. Left parietal lobe

c. Right frontal lobe

d. Left frontal lobe

e. Both cerebral hemispheres

30) A 54-year-old man has a recent history of a road traffic accident and now presents with an inability to walk properly. You notice that he compensates by exaggerated elevation of the flexed left hip and knee to allow the left foot to clear off the ground while walking. Where is the lesion causing this type of gait?

a. Right femoral nerve

b. Left common peroneal nerve

c. Left posterior tibial nerve

d. Right deep peroneal nerve

e. Both sciatic nerves

31) A 14-year-old boy presents with three attacks of generalized tonic-clonic seizures. His work-up is normal and he has a family history of the same problem. The final diagnosis is idiopathic grand mal epilepsy. You put him on sodium valproate and he becomes seizure-free after 1 week. Regarding sodium valproate, which one of the following is the correct statement?

a. It can worsen myoclonic epilepsy

b. It is given 5 times daily

c. It is a potent enzyme inducer

d. It is a broad-spectrum antiepileptic medication

e. Can cause gallstones

32) A 34-year-old woman presents with repeated attacks of rising sensation in the epigastrium lasting for minutes. Her husband states that she sometimes has repetitive lip-smacking and swallowing movements and she is not responsive during these attacks. These episodes last for about 2 minutes. You are thinking of complex partial seizures and you are considering carbamazepine therapy. Which one is the correct statement regarding this medication?

a. It is useless in generalized epilepsies

b. Can cause auto-induction of its metabolism

c. Safe in severe renal failure

d. Safe during pregnancy

e. It is given once daily

33) A 50-year-old woman presents with right-sided repetitive jerky hand movements over the past 1 week. Her left-sided frontal meningioma was removed surgically 1 month ago. You tell her that these are simple motor seizures. You prescribe phenytoin. All of the following statements are incorrect regarding this medication, except:

a. Is usually given as an add-on therapy

b. Very effective in petit mal epilepsy

c. Has a very short half-life

d. A potent enzyme inhibitor

e. Can cause pseudo-lymphoma

34) A 6-year-old boy is being treated with ethosuximide for absence attacks. His mother is concerned about its side effects. Which one is not a recognized side effect of this medication?

a. Night terrors

b. Hyperactivity

c. Weight gain

d. Gum hyperplasia

e. Tongue swelling

35) A 37-year-old female receives daily carbamazepine as medical therapy for her complex partial seizures but she is not responding well. You are thinking of shifting towards gabapentin. Which one of the following is the correct statement about gabapentin?

a. Cannot be used as an add-on therapy

b. Pregabalin is related to it

c. Is given once daily

d. A potent enzyme inhibitor

e. Is not useful in neuropathic pains

36) A 26-year-old female currently receives phenytoin for idiopathic grand mal epilepsy. Today, she visits you saying that she does not want to get pregnant and that she takes daily oral contraceptive pills. Her friend is a registered nurse who told her that phenytoin makes the pills useless. You agree with the nurse and educate the patient about the possible contraceptive alternatives. Which one of the following is a suitable alternative to phenytoin?

a. Fosphenytoin

b. Carbamazepine

c. Lamotrigine

d. Topiramate

e. Phenobarbitone

37) Because of Lennox-Gastaut seizures, a 4-year-old child has been given lamotrigine. The mother says her child still experiences seizures. You think the addition of topiramate may produce better seizure control. Which one is the wrong statement regarding topiramate?

a. After long-term use, it can be withdrawn suddenly

b. Dehydration should be avoided during the period of therapy 

c. Acute myopia is a risk during treatment

d. Can precipitate acute angle-closure glaucoma

e. Choroidal effusion is a side effect 

38) A 19-year-old female has been prescribed lamotrigine for her idiopathic generalized tonic-clonic seizures. She has been receiving this medication for 4 years but recently her seizures are getting worse. She denies non-compliance or co-medication ingestion. You tell her that lamotrigine daily doses should be increased to control her seizures. Which one is the correct statement regarding this antiepileptic medication?

a. Sodium valproate decreases plasma lamotrigine level

b. Concomitant use of sodium valproate decreases the risk of developing Stevens-Johnson syndrome

c. Can be used to treat seizures of Lennox-Gastaut syndrome

d. No need to withdraw if a flu-like illness develops

e. Safe in aplastic anemia

39) A 62-year-old man takes phenytoin for post-hemorrhagic stroke epilepsy. He still experiences at least one seizure a day. You are thinking of adding a second anti-epileptic medication but you are concerned about the resulting interactions. Phenytoin raises the blood level of which one of the following?

a. Phenobarbital

b. Carbamazepine

c. Clonazepam

d. Sodium valproate

e. Topiramate 

40) A 17-year-old female presents with continuous seizures for 45 minutes without regaining full consciousness. All of the following can be given parenterally in this status epilepticus, except:

a. Midazolam

b. Paraldehyde

c. Fosphenytoin

d. Sodium valproate 

e. Ethosuximide

41) A 64-year-old man has idiopathic Parkinson's disease for which he takes Sinemet®(carbidopa-levodopa). Levodopa (L-dopa) is contraindicated in all but one of the following:

a. Malignant melanoma

b. Pregnancy

c. Breast-feeding

d. Angle-closure glaucoma

e. Basal cell carcinoma

42) A 57-year-old woman has been recently diagnosed with idiopathic Parkinson's disease. She states that she has many chronic illnesses. You are thinking of giving a carbidopa-levodopa preparation. You should be cautious when prescribing this medication in the presence of all of the following, except:

a. Peptic ulcer

b. Open-angle glaucoma

c. Diabetes insipidus

d. Severe psychosis

e. Osteomalacia

43) A 64-year-old man is compliant with his Sinemet® (carbidopa-levodopa) which has been prescribed for idiopathic Parkinson's disease. The patient is intolerant to this medication. All of the following are side effects of this L-dopa preparation, except:

a. Nausea

b. Labile hypertension

c. Greenish discoloration of urine

d. Insomnia

e. Cardiac arrhythmia

44) Because of right-hand pill-rolling resting tremor and hypokinesia, a 38-year-old man was diagnosed with early-onset Parkinson's disease. You are considering a dopamine receptor agonist as a treatment option. All of the following are dopamine receptor agonists, except:

a. Pramipexole

b. Ropinirole

c. Entacapone

d. Lisuride

e. Cabergoline

45) A 64-year-old man visits the physician’s office with a 3-year history of idiopathic Parkinson's disease. His general practitioner prescribed cabergoline tablets at the time of diagnosis. The patient is compliant with it. The patient reports shortness of breath upon exertion. His work-up has revealed raised ESR, blood urea, and serum creatinine. Blood counts and blood film are normal. Which one is the most likely explanation for his new presentation?

a. Ischemic heart disease

b. Retroperitoneal fibrosis

c. Congestive heart failure

d. Hypernephroma

e. Multiple myeloma

46) A 67-year-old man with a long-standing history of idiopathic Parkinson's disease is being considered to be given apomorphine therapy. Which one of the following is incorrect regarding this mode of therapy?

a. It is highly emetogenic

b. Usually given for refractory motor fluctuations

c. Should be avoided in respiratory depression

d. It can cause dyskinesia

e. Decreases the cognitive impairment

47) Amantadine is an anti-viral agent that can be used for other purposes. Regarding its use in Parkinson’s disease, which one is the correct statement?

a. It is useful in drug-induced Parkinsonism

b. Safe in congestive heart failure

c. Can be withdrawn suddenly in Parkinson's disease

d. Livedo reticularis is a side effect

e. Dehydration results from its long-term use

48) A 19-year-old woman presents to the Emergency Room with a severe unilateral throbbing headache for one hour. She has a migraine without aura. You give her a sumatriptan injection. Which one is the wrong statement regarding this anti-migraine medication?

a. It is a 5HT1 agonist

b. Useful in migraine prophylaxis

c. Better to be avoided in coronary heart disease

d. Can cause throat and chest tightness

e. Contraindicated in severe hypertension

49) A 21-year-old college student has had migraine without aura since he was 15 years. On average, he has 4 attacks per month. He asks if there is any way to lessen these attacks. All of the following can be used in migraine prophylaxis, except:

a. Sodium valproate

b. Amitriptyline

c. Cyproheptadine

d. Ergotamine

e. Propranolol

50) A 66-year-old man presents with hand clumsiness and leg cramps. He has spastic paraparesis, bilateral extensor planter responses, as well as upper and lower motor neuron signs in his upper limbs. EMG is suggestive of motor neuron disease. You consider starting riluzole. Which one is the correct statement regarding this medication?

a. Safe in hepatic failure

b. Can cause neutrophilia

c. Can cause perioral paresthesia

d. It is useful in any spasticity

e. Bradycardia is a side effect

51) A 68-year-old man has been recently diagnosed with Alzheimer's disease. His wife asks you if there is any medication that can be given to her husband to improve his cognitive function. Donepezil comes into your mind. Which one is the correct statement regarding this medication?

a. It is an irreversible inhibitor of peripheral acetylcholinesterase

b. Is given three times daily

c. Use with caution in sick sinus syndrome

d. Safe for asthma

e. Improves extra-pyramidal features

52) Memantine hydrochloride is a licensed medication that can be used for Alzheimer's disease. Which one is the correct statement regarding this medication?

a. It is a reversible inhibitor of central acetylcholinesterase

b. Used in mild Alzheimer's disease only

c. Decreases libido

d. Use it with caution in the presence of convulsions

e. Safe in renal failure

53) A young man complains of memory disturbances after sustaining head trauma. His neurological examination is non-focal and his brain MRI is normal. Regarding head trauma-associated amnesia, which one is the wrong statement?

a. Head traumas causing loss of consciousness always result in an amnesic syndrome

b. Features of transient global amnesia may be seen

c. Retrograde amnesia may occur

d. Anterograde amnesia is against the diagnosis

e. After the head injury, the patient may behave normally in an automatic fashion

54) A 69-year-old woman who has cardiac conduction defects sustained a prolonged Stokes-Adams attack. After recovery, she starts to experience memory difficulties. All of the following statements about cerebral ischemia-associated amnesia are correct, except: 

a. Such amnesia tends to occur in those who are in a coma for more than 12 hours

b. Mainly attributed to damage in the pyramidal neurons of the hippocampus in the Sommer sector of the hippocampus

c. There is severe impairment in the formation of new memories with relative preservation of registration

d. Patient may sometimes confabulate

e. Characteristically, retrograde amnesia is not seen

55) A 54-year-old heavy smoker man sustains an ST-segment elevation myocardial infarction that is complicated by prolonged but failed cardiac arrest. You are assessing him neurologically and he seems to have memory problems. With respect to cerebral ischemia-associated amnesia, which one of the following is an inconsistent statement?

a. It may be the sole manifestation following a cardiac arrest event

b. Following a cardiac arrest, this syndrome may coexist with cerebral watershed syndromes

c. Recovery from this amnesic syndrome often occurs within several days

d. Carbon monoxide poisoning associated-amnesic syndromes are frequently associated with prominent affective disturbances

e. In carbon monoxide poisoning associated-amnesic syndromes, the brain CT scan usually shows hyperdense areas in the frontal cortex

56) A 58-year-old man with a history of ischemic heart disease has a posterior circulation stroke complicated by memory impairment. He denies weakness. His speech and language examinations are intact. Bilateral posterior cerebral artery occlusion-associated amnesia is characterized by all of the following, except:

a. Bilateral cerebral artery occlusion associated-amnesic syndrome may be a transient or a permanent one

b. Usually caused by emboli to the internal carotid arterial system

c. The resulting amnesic syndrome may be associated with unilateral or bilateral hemianopia

d. Signs of upper midbrain dysfunction may be prominent

e. Recent memory tends to be affected with relative preservation of remote memory and registration

57) The Acute and Emergency physician is consulting you about an old man who was found wandering in the streets and is pretending not to remember anything. No signs of head injury can be found. After a proper assessment, you tell the physician that you suspect transient global amnesia. Regarding transient global amnesia (TGA), which one is the wrong statement?

a. It is an acute memory loss seen in middle-aged and old people

b. Most patients will have recurrent attacks

c. During the attack, knowledge of personal identity is characteristically preserved

d. Retrograde amnesia preceding the attack for a variable period may be seen

e. During the attack, new memories cannot be formed

58) The psychiatry department consults you about a middle-aged man who is suspected to have a hysterical fugue. After a thorough interview with the patient, you disagree with their diagnosis, and you are thinking of transient global amnesia. Regarding transient global amnesia (TGA), which is the wrong statement?

a. During the spell, the patient appears to be perplexed

b. Unfortunately, the condition may be diagnosed as a psychogenic disturbance

c. All patients are completely healthy before the spells

d. Brain CT scan may show abnormalities in the temporal lobes during the spells

e. Diffusion-weighted MRI may show signal abnormalities during the spells

59) A 22-year-old unemployed man started to drink heavily lately. He admits to forgetting many details after waking in the morning and after a night full of drinking. Regarding these alcoholic blackouts, which one of the following statements is the wrong one?

a. Caused by short-term consumption of a large amount of ethanol by chronic alcoholics

b. Defined as an acute amnesic syndrome that is not due to global confusion, seizures, head trauma, or Wernicke's encephalopathy

c. There is a prominent inability to form new memories

d. May result from ethanol-induced depression of synaptic neurotransmission

e. Necessitates treatment with long-term chlordiazepoxide tablets

60) A 16-year-old female who was admitted into the psychiatry department pretends to forget her school's name. She remembers her name and the name of her city and district. You consider a conversion reaction. All of the following about dissociative amnesia are correct but one: 

a. Characterized by an isolated or a disproportionate loss of traumatic or stressful personal memories

b. Usually localized in time to the immediate aftermath of a traumatic experience

c. In some cases, the patients may be unable to remember their own name

d. Recent memory is prominently affected

e. Examination under hypnosis may help in establishing that the amnesia is psychogenic in origin

61) A middle-aged man is brought to you by his wife who states that her husband has difficulty forming new memories. He used to drink a lot, she says. Alcoholic Korsakoff's amnesic syndrome is characterized by all of the following, except:

a. Usually preceded by one or more episodes of Wernicke's encephalopathy

b. The associated memory disorder is thought to be due to degeneration of the dorsomedial thalami

c. Often associated with peripheral polyneuropathy

d. The classical defect is an impairment of recent memory and failure to form new ones

e. The patient is characteristically agitated and has an insight into his illness

62) A young man is recovering from viral encephalitis. You notice that he has many memory disturbances and his family confirms your initial impression. Regarding post-encephalitic amnesia, choose the incorrect statement?

a. Following encephalitis, the patient may be left with a permanent and static and amnesic syndrome

b. Confabulation is never seen

c. Symptoms of limbic system disease may be prominent

d. Complex partial seizures may occur 

e. The commonest cause of this syndrome is herpes simplex encephalitis

63) A 44-year-old woman, who has a brain tumor, starts to forget simple daily details. She demonstrates difficulty forming new memories. Regarding brain tumor-associated amnesic syndrome, which is the wrong statement?

a. It is a very common type of amnesic syndrome

b. Tumors that produce this syndrome include those that are located within the third ventricle

c. The amnesic syndrome resembles that of alcoholic Korsakoff's syndrome 

d. Deep midline tumors often produce prominent lethargy and headache

e. Treatment depends on the underlying tumor type and location

64) A 65-year-old man is being treated for cancer with chemotherapy and radiotherapy. However, he has started to demonstrate memory difficulties and attacks of complex partial seizures. Serum anti-Hu antibodies are positive. Regarding paraneoplastic limbic encephalitis, which one is the wrong statement?

a. It is an autoimmune inflammatory and degenerative disease that affects the gray matter of the limbic system

b. Usually associated with small cell carcinoma of the lung

c. Neuropathologically, there is neuronal loss, reactive gliosis, microglial proliferation, and perivascular lymphocytic cuffing

d. Affective symptoms, such as depression or anxiety, are rare late features

e. The amnesic syndrome resembles that of alcohol Korsakoff's one

65) An old woman has features of paraneoplastic limbic encephalitis, but you are trying to detect the associated tumor by running a battery of investigations. Regarding paraneoplastic limbic encephalitis, which one is the wrong statement?

a. The CSF may show an elevated protein and mild mononuclear pleocytosis

b. EEG may show diffuse slowing or bi-temporal slow-wave and spikes

c. Brain MRI may show signal abnormalities in the occipital lobes

d. 60% of patients have anti-neuronal antibodies in the serum and CSF

e. The paraneoplastic syndrome can be static

66) A 67-year-old retired college professor is referred to you for further assessment. He is anxious and declines to be examined. His daughter says that her father forgets many things, such as what was on breakfast and what he did yesterday. The patient denies these events. He scored 18 on the mini-mental status examination. Routine blood tests, including serum vitamin B12 and serum TSH, are normal. Brain CT scan reveals mild cortical atrophy with compensatory hydrocephalus; no space-occupying lesion is seen after contrast administration. You are considering Alzheimer's disease. Regarding Alzheimer's disease, which one is the wrong statement?

a. It is the commonest cause of dementia with a prevalence of 10-20 million cases worldwide

b. Men and women are affected with equal frequency

c. Abnormal metabolism and deposition of beta-amyloid protein appear to be closely linked to its pathogenesis

d. It is usually inherited on a genetic basis

e. Neuropathologically, there are neuritic plaques and neurofibrillary tangles

67) A 45-year-old TV show host is consulting you about the possibility of contracting sporadic Alzheimer's disease. He says that his deceased father had Alzheimer's disease. He is quite sure that he will get the same disease when he reaches the 7th decade. He is desperate to hear anything positive from you. You discuss the matter with him. Which one is the wrong statement with respect to Alzheimer's disease?

a. Patients with Down's syndrome have a very high incidence of developing Alzheimer's disease

b. Familial Alzheimer's diseases are autosomal dominant and linked to chromosomes 1 and 14

c. The number of APOE4 alleles on chromosome 19 may influence the disease development

d. Abnormal cleavage of amyloid precursor protein (APP) by alpha, beta, and, gamma secretases is one of the presumed pathophysiological mechanisms

e. Choline acyltransferase is markedly increased in the cortex and hippocampus of patients with Alzheimer's disease

68) You are attending a national conference about the genetics of Alzheimer's disease, the recent advances in gene research, and possible future interferences. You have learned many facts about this disease. Which one is the wrong statement about Alzheimer's disease?

a. There is prominent degeneration of the nucleus basalis of Myenert and the cholinergic septal hippocampal tract

b. APOE4 polymorphism increases the susceptibility to Alzheimer's disease

c. Various missense mutations in the APP gene on chromosome 21 may cause familial Alzheimer's disease

d. Various missense mutations in the PS2 gene on chromosome 1 are responsible for the development of early-onset Alzheimer's disease

e. Down's syndrome patients are protected against the development of Alzheimer's disease

69) A 69-year-old man is brought to you by his wife because of easy forgetfulness. He neither smokes cigarettes nor drinks alcohol. He denies any history of head trauma. You interview the patient and examine him and you think that he has an early Alzheimer's disease. Regarding early manifestations of Alzheimer's disease, which one is the wrong statement?

a. Impairment of recent memory is typically the first sign of the disease

b. Gradually, the patient becomes disoriented to time

c. Aphasia, anomia, and acalculia are very rare

d. A frontal gait disorder may be seen early

e. Visuospatial disorientation can occur early in the course

70) Your psychiatry colleague consults you to assess their Alzheimer's disease patient, who has an advanced stage. The family is concerned about their patient's death. Regarding late manifestations of Alzheimer's disease, which is the wrong statement?

a. Seizures occur in some cases

b. There might be frank psychosis with paranoia and hallucinations

c. Rigidity and bradykinesia are late features

d. Mutism, incontinence, and a bed-ridden state indicate a terminal situation

e. Death typically occurs 1-2 years after the onset of symptoms

71) A 73-year-old woman was recently diagnosed with early-onset Alzheimer's disease. You are thinking of prescribing some medications to help her cope with her life. Regarding the medical treatment of Alzheimer's disease, which is the wrong statement?

a. Nowadays, many medications can reverse or arrest the progression of the disease

b. Acetylcholinesterase inhibitors have been shown to produce a small improvement in the tests of cognitive function

c. Of all acetylcholinesterase inhibitors, donepezil is the agent of choice

d. Alpha-tocopherol and selegiline are of small benefit in Alzheimer's disease

e. Behavioral disturbances can be controlled by antipsychotics, antidepressants, or anxiolytics

72) A young woman asks you about the future of her father who has Alzheimer's disease and his possibility of living without suffering. She seems to be very irritable and anxious and does not know what to do. She is desperate for your help. The prognosis of Alzheimer's disease includes all of the following true statements, except: 

a. Early in the course, the patient can usually remain at home

b. In advanced cases, the patient usually needs special care in nursing facilities

c. The patient should be protected from injuring himself and his family

d. Death usually occurs 5-10 years after the onset of symptoms

e. The usual cause of death is myocardial infarction

73) A 52-year-old woman is referred to you by her general practitioner as having Alzheimer's disease. After taking a proper history, you think that she has Pick's dementia, not Alzheimer’s disease. Pick's frontotemporal dementia, rather than Alzheimer's disease, is suggested by all of the following, except: 

a. Earlier age of onset

b. More prominent behavioral than cognitive dysfunction at presentation

c. MRI showing preferential atrophy of anterior temporal frontal lobes

d. Presence of Pick's cells and inclusion bodies on the brain biopsy specimen

e. Presence of prominent neuritic plaques and neurofibrillary tangles

74) A 65-year-old woman has rapidly progressive dementia and startle myoclonus. Her brain EEG and CSF analysis are consistent with Creutzfeldt-Jacob disease (CJD). Which one is the wrong statement with respect to CJD?

a. An invariably fatal transmissible disorder of the central nervous system

b. The annual incidence is 1:1 000 000 populations

c. The naturally acquired disease occurs in patients 16-82 years of age

d. Affects both sexes equally

e. More than one member of a family is affected in up to 90% of cases

75) A 69-year-old man has a new-onset myoclonus and severe impairment of recent and old memories. You suspect Creutzfeldt-Jacob disease and you order a battery of investigations to confirm this clinical impression. His CSF analysis is positive for protein 14-3-3. All of the following statements regarding Creutzfeldt-Jacob disease are true, except?

a. Transmission from humans to animals has been demonstrated

b. The infectious agent is present in all body fluids

c. Familial cases are due to mutation in the prion protein-cellular isoform

d. The normal prion protein-cellular isoform differs from the abnormal prion protein-scrapie-isoform in the secondary folding structure only

e- Prominent autonomic and endocrine disorders are against the diagnosis

76) A 67-year-old male underwent an open brain biopsy for an unexplained rapidly progressive dementia. The histopathological result is consistent with the spongiform changes of Creutzfeldt-Jacob disease (CJD). With respect to CJD, which one of the following is the incorrect statement?

a. Dementia is present virtually in all cases

b. Focal cortical signs, such as aphasia and apraxia, may be seen early

c. Psychiatric, behavioral, and personality changes are common

d. Aside from cognitive abnormalities, the most frequent clinical manifestation is myoclonus

e. Progression to akinetic mutism or coma typically ensues over many years

77) A 62-year-old woman is referred to you by her general practitioner as a suspected case of Creutzfeldt-Jacob disease (CJD), and you are about to conduct many investigations for her to confirm or refute the provisional diagnosis.  With respect to the diagnosis of CJD, which one is the inconsistent statement?

a. The EEG may show periodic sharp waves or spikes in 65% of cases

b. MRI of the brain may show hyper-intense lesions in the basal ganglia

c- The levels of protein 14-3-3 are markedly decreased in the CSF

d. In familial cases, a definitive diagnosis can be made by detection of the mutant form of PrPc in DNA from peripheral blood lymphocyte

e. The CSF protein may be elevated

78) A 63-year-old man is referred to the neurology department from the general medical ward as having degenerative brain disease. After obtaining a proper history and doing a neurological examination, you consider Creutzfeldt-Jacob disease (CJD). Regarding CJD, which is the wrong statement?

a. Should be differentiated from Alzheimer's disease

b. Might be confused with Parkinson's disease or progressive supranuclear palsy

c. Intra-cerebral mass lesion may simulate it

d. It is invariably a fatal disease

e. Death usually occurs within 5 years after the onset of symptoms

79) A 65-year-old woman has features of dementia, incontinence, and gait apraxia. Brain CT scan shows communicating hydrocephalus with no mass lesion. Her CSF opening pressure and other parameters are normal. You are thinking of normal pressure hydrocephalus. Regarding normal pressure hydrocephalus, which is the incorrect statement?

a. A potentially reversible cause of dementia

b. It might be idiopathic

c. Dementia is usually severe and rapidly progressive

d. Aphasia and agnosia are rare

e. It is supposed to be due to impaired absorption of the CSF at the level of arachnoid granulations over the cerebral convexities

80) An old woman has cognitive impairment. Her funduscopic examination is normal and CT brain scanning reveals dilated ventricles as the referral letter states. You take a thorough history from her daughter and perform a neurological examination. The patient’s mini-mental status examination score is 21. Normal pressure hydrocephalus is your preliminary diagnosis. Regarding normal pressure hydrocephalus, which is the wrong statement?

a. Usually develops over weeks to months

b. The initial abnormality is usually gait apraxia

c. Urinary incontinence is a late development

d. Pyramidal signs are very common

e. Motor perseveration and grasp reflex in the hands and feet may occur

81) A 57-year-old male with a history of non-traumatic subarachnoid hemorrhage presents with dementia, incontinence, and gait apraxia. You are suspecting normal pressure hydrocephalus (NPH). All but one of the following statements about normal pressure hydrocephalus are correct:

a. The CSF opening pressure is usually elevated

b. Brain CT scan usually shows dilated ventricles without cortical atrophy

c. Radionuclide cisternography classically reveals isotope accumulation in the ventricles

d. Transient improvement following removal of 50 ml of CSF at lumbar puncture is a predictor of a favorable clinical response to shunting

e. Complications of shunting occur in 1/3rd of cases

82) A 66-year-old man presents with a cortical type of dementia, Parkinsonian features, and formed visual hallucinations. Routine blood tests, including syphilis serology, serum TSH, and vitamin B12 levels are normal. Brain CT scan reports normal images for his age. You discuss the matter with your colleagues and you consider the Lewy body type of dementia. Regarding this type of dementia, which one is the incorrect statement?

a. It is the second most common cause of dementia

b. Lewy bodies are present in the cerebral cortex and brain stem

c. Lewy bodies contain alpha-synuclein only

d. Dementia with Lewy bodies is found in a patient with and without histological features of Alzheimer's disease

e. It is characterized by cognitive decline without a prominent early loss of recent memory

83) A 71-year-old man is referred from the polyclinic as a suspected case of Lewy body dementia. All of the following are characteristic features of dementia with Lewy bodies, except:

a. Fluctuating cognitive function

b. Visual hallucinations

c. Parkinsonism

d. No favorable response to donepezil

e. High response rate to antipsychotics

84) A 54-year-old woman presents with vague personality and behavioral changes as well as impaired recent memory and recollection. Her mini-mental status examination score is 23. The routine work up turns out to be negative, but her brain MRI reveals a large brain mass. You think that her cognitive decline is due to this brain mass. Regarding brain tumors-associated dementia, which one is the incorrect statement?

a. Might be due to brain edema, compression of adjacent brain structures, raised intracranial pressure, and impairment of cerebral blood flow

b. The tumor most likely producing this picture is of the pituitary gland

c. This type of dementia is characterized by mental slowness and apathy

d. There might be associated agnosia or aphasia

e. Seizures might occur

85) A 34-year-old homosexual singer presents with features of dementia and personality changes. He is not receiving any anti-HIV medication. His CD4+ lymphocyte count is very low. A brain CT scan reveals diffuse cortical atrophy with compensatory hydrocephalus but there is no mass lesion. You are thinking of the AIDS-dementia complex. AIDS-dementia complex is characterized by all of the following, except: 

a. It is the commonest neurological complication of AIDS

b. It might be the presenting feature of AIDS

c. It results from invasion of the brain with HIV-1 early in the course after the acquisition of the virus

d. HIV-1 replicates in neurons and glia of the brain with resulting neuronal death

e. Might be preceded by a history of symptomatic HIV-1 meningitis

86) A 32-year-old hemophiliac male has easy forgetfulness, apathy, and an unsteady gait. He is HIV positive and his brain imaging shows global brain atrophy. You consider AIDS-dementia complex. With respect to the AIDS-dementia complex, which one is the wrong statement?

a. The onset is usually rapidly progressive with prominent agitation

b. Examination may reveal cerebellar ataxia and extensor planters

c. Fecal and urinary incontinence are late features

d. Organic psychosis is common lately in the course

e. Myoclonus and seizures can be prominent

87) A middle-aged HIV-positive man with cognitive decline is being assessed for AIDS-dementia complex. His CD4+ cell count is 87 cells/µL and he takes daily co-trimoxazole as a secondary prophylaxis regimen against P. jirovecii. This AIDS-dementia complex is characterized by all, but one of the following statements:

a. MRI may reveal diffuse cortical atrophy

b. In 20% of cases, there is mild mononuclear pleocytosis in the CSF

c. CSF oligoclonal bands might be seen

d. CSF opening pressure is normal 

e. CSF protein is elevated in 10% of the cases 

88) A 45-year-old antisocial prisoner has an abnormal gait, pupillary light-near dissociation, and personality and behavioral changes. Serological tests for syphilis are positive in blood and CSF. Brain CT scanning shows prominent atrophy of the frontal lobes. You tell the prison manager that this patient has general paresis of insane. Regarding general paresis of insane (GPI), which is the wrong statement?

a. It is a chronic meningoencephalitis caused by active spirochetal infection of the brain

b. The onset is usually gradual with memory loss, altered affect, or vague personality changes

c. Incontinence, seizures, and stroke are very common early feature

d. There is trombone tremor of the face and tongue

e. Pyramidal signs and paucity of facial features are common

89) An old man is asking you about his son who has neurosyphilis. This young man has memory loss, irritability, and trombone tremor of the tongue. You start penicillin injections and you discuss the outlook with his father. Regarding the prognosis of general paresis of insane (GPI) after receiving penicillin, which is the wrong statement?

a. The clinical condition may improve

b. Asymptomatic patients with persistent CSF abnormalities should not be re-treated

c. Patients with symptomatic progression should be re-treated

d. Patients with reactive CSF syphilis serology but without pleocytosis are unlikely to respond to penicillin

e. Patients with reactive CSF syphilis serology but without pleocytosis should receive treatment

90) A middle-aged HIV-positive drug addict female has had visual field defect, weakness, and speech problems for the last 2 months. Her brain CT scan reveals no mass lesion. You put progressive multifocal leukoencephalopathy (PML) at the top of your differential diagnosis list. Regarding PML, which one of the following statements is the wrong one?

a. Results from infection with Papovavirus

b. Most healthy adults are seropositive for Papovavirus

c. The virus infects the cortical neurons

d. The course of the disease is sub-acute

e. The disease is rarely symptomatic in those with intact immune functions

91) A young HIV-positive male has progressive cognitive decline. His brain CT scan is inconclusive but a brain MRI with contrast suggests progressive multi-focal leuko-encephalopathy (PML). Regarding PML, which is the incorrect statement?

a. Fever and systemic features are absent

b. Dementia is prominent

c. Hemiparesis, visual field defects, and aphasia are very common

d. Ataxia and headache are uncommon

e. Seizures commonly occur 

92)  A middle-aged bisexual woman with AIDS is being investigated for progressive multifocal leukoencephalopathy (PML) after having cognitive decline, right-sided weakness, and visual field defects over the past 6 weeks. Regarding PML, which one is the wrong statement?

a. The CSF is usually normal

b. Brain MRI study usually shows diffuse white matter abnormalities

c. Definitive diagnosis is usually done by brain biopsy

d. The disorder is fortunately rarely fatal

e. Treatment with cytosine arabinoside is unsuccessful

93) A young vagrant man developed a coma and eventually died. Autopsy reveals features of Marchiafava-Bignami syndrome. Regarding Marchiafava-Bignami syndrome, which one is the least correct statement?

a. Characterized by necrosis of the corpus callosum and subcortical white matter in malnourished alcoholics

b. The course could be acute, subacute, or chronic

c. Characterized by dementia, spasticity, and gait disorders

d. No specific treatment is available

e. Virtually all patients will die

94) A 33-year-old male, who was diagnosed with end-stage renal disease, presents with progressive cognitive decline and personality changes. He is on renal replacement therapy. His workup is negative for brain masses or infections. His serum levels of vitamin B12 and TSH are within their normal reference range. You are considering dialysis dementia. Dialysis dementia is characterized by all of the following, except:

a. It is seen in uremic patients on chronic long-term hemodialysis

b. Caused by the gradual accumulation of aluminum in the body

c. The classical features are dementia, myoclonus, seizures, and dysarthria

d- The EEG shows paroxysmal high-voltage slowing with intermixed spikes and slow waves

e. The incidence is gradually increasing world-wide

95) You are attending a symposium about the recent advances in the management of non-Wilsonian hepatocerebral degeneration. Regarding this type of brain degenerative disease, which is the incorrect statement?

a. It is an uncommon complication of hepatic cirrhosis

b. The syndrome is usually fluctuating but progressive over one to nine years

c. Dementia is characterized by mental slowness, apathy, impaired concentration, and memory disturbance

d. Pyramidal, extra-pyramidal, and cerebellar signs are common

e. CSF polymorphonuclear pleocytosis is striking

96) A 66-year-old male presents with memory disturbance, impaired concentration, and apathy. He reports headaches and left-sided weakness. He denies any history of head trauma. He takes daily warfarin for non-rheumatic permanent atrial fibrillation. Brain CT scan reveals bilateral crescent-shaped extra-axial hypodense lesions. Regarding chronic subdural hematoma-associated dementia, which one is the wrong statement?

a. Usually seen in elderly people following a minor head trauma

b. The hematoma is bilateral in 1/6th of cases

c. The symptoms may be delayed for several weeks or months after the development of hematoma

d. Headache is usually the last symptom

e. The classical presentation is with cognitive disturbance, hemiparesis, papilledema, and extensor planters

97) A 64-year-old man with ischemic heart disease and peripheral vascular disease presents with a somewhat abrupt onset of cognitive impairment. He has a history of repeated anterior circulation transient ischemic attacks and two completed strokes. Examination reveals dysfunction in many cognitive domains and focal sensorimotor signs. You think of multi-infarct dementia. Regarding vascular dementia, which one is the wrong statement?

a. It is the third most common cause of dementia

b. Those patients have either multiple large cortical infarcts or multiple small deep lacunar infarcts

c. The relationship between cerebrovascular disease and the development of dementia is poorly characterized

d. The majority of patients are normotensive

e. The onset may be more or less abrupt

98) An old woman with multi-infarct dementia is being assessed by you and by a vascular physician. You examine the patient and order some tests. Regarding vascular types of dementia, which is the incorrect statement?

a. Pseudo-bulbar palsy is very common

b. There are focal sensorimotor deficits with ataxia and gait apraxia

c. Brain MRI is less sensitive than a CT scan in detecting brain abnormalities

d. A search for vasculitis and meningovascular syphilis should be done in younger patients

e- Anti-platelet agents are usually given

99) A 72-year-old man is referred to you because of low mood and irritability. He is uncooperative with the mini-mental status examination, and he reports prominent vegetative symptoms with difficult concentration and impaired memory. You are considering dementia or depressive pseudo-dementia. Regarding depressive pseudo-dementia, which one is the wrong statement?

a. Depression is the most common disorder mistaken for dementia

b. Depression can be a feature of dementia and both disorders often coexist

c. Prominent vegetative symptoms are in favor of dementia

d. Somatic complaints are uncommon in dementia

e. Cognitive impairment that is more prominent at night is in favor of dementia

100) A 61-year-old office manager presents with a 6-week history of impaired mentation, headache, and vomiting. He admits to having some weakness when using his left hand and leg. Brain MRI with contrast is suggestive of glioblastoma multiforme (GM). All of the following statements regarding GM are wrong, except?

a. It constitutes about 80% of all intracranial neoplasms

b. Never seen before the age of 20 years

c. The incidence is higher in women than in men

d. Usually has a familial predilection

e. In the majority of adults, it occurs supratentorially

101) A 59-year-old journalist is referred to you for further evaluation because of new-onset seizures. Examination reveals florid papilledema, left-sided pyramidal weakness and extensor planter response. His brain imaging is consistent with glioblastoma multiforme (GM). All of the following statements regarding GM are true, except?

a. Most tumors arise in the deep white matter of the brain

b. The tumor may extend to the meningeal surface

c. Extra-neural metastases are common

d. Around 50% of tumors are bilateral

e. About 30-60% of cases show multicentric foci of growth

102) A 60-year-old housewife presents with an 8-week history of easy forgetfulness and vague personality changes. Examination reveals blurred hyperemic disc margins. Further work-up documents the presence of large glioblastoma multiforme (GM) at the right frontoparietal lobes. All of the following statements regarding GM are true, except:

a. Macroscopically, the tumor has a variegated appearance

b. Microscopically, areas of necrosis, hemorrhage, and thrombosis of small blood vessels are characteristic

c. The tumor arises from meningothelial cells

d. Cystic areas are common

e. The tumor vasculature may undergo sarcomatous changes

103) A 58-year-old pub owner is referred to you for further management. He is suspected to have a grade IV malignant glioma of the right frontoparietal area of the brain after undergoing brain MRI imaging with gadolinium. Which one is the correct statement with respect to this man's brain tumor?

a. Surgery is curative

b. Intrathecal methotrexate should be given routinely

c. Chemotherapy greatly improves the mortality figure

d. Whole brain irradiation improves survival by an average of 5 years

e. Generally, apart from palliation, little can be done to alter the natural history of grade IV malignant glioma of the brain

104) A 25-year-old taxi driver wants to consult you about his seizures. He reports infrequent attacks that are consistent with focal motor seizure with secondary generalization. He also admits to having a headache but denies vomiting or visual symptoms. Brain MRI with gadolinium is suggestive of low-grade glioma. All of the following statements regarding low-grade gliomas are wrong, except:

a. Those in the 6th decade are the usual victims

b. Are rapidly progressive tumors

c. The location of the tumor is usually influenced by the age of the patient

d. The presence of calcification on brain imaging should cast doubt