1
Q
A 33-year-old man suffered the sudden onset of double vision, right-sided body
numbness, and gait difficulties. Over the next 3 months, neurologic deficits resolved
completely. Ten months after the first event, he developed an abrupt recurrence of
double vision, gait incoordination, as well as a sudden onset of left numbness and
left-sided hearing loss.
On neurologic examination. the patient’s is He has left-sided
abducens (VI). facial (VII)and vestibulocochlear (VIII) cranial nerve deficits and has
right-sided motor and sensory deficits. Figure 1 shows serial magnetic resonance
imaging examinations in this patient.
1. Based on the patient’s history, physical, and the most likely diagnosis
is:
A. pontine glioma
B. cavernous malformation
C. Criptococcal abscess
D. giant basilar aneurysm
E. none of the above
A
B. Cavernous Malformation
2
Q
A 33-year-old man suffered the sudden onset of double vision, right-sided body
numbness, and gait difficulties. Over the next 3 months, neurologic deficits resolved
completely. Ten months after the first event, he developed an abrupt recurrence of
double vision, gait incoordination, as well as a sudden onset of left numbness and
left-sided hearing loss.
On neurologic examination. the patient’s is He has left-sided
abducens (VI). facial (VII)and vestibulocochlear (VIII) cranial nerve deficits and has
right-sided motor and sensory deficits. Figure 1 shows serial magnetic resonance
imaging examinations in this patient.
2. These brain stem lesions may present with of following EXCEPT:
A. hydrocephalus
B. cranial nerve deficits
C. progressive neurologic deficits
D. seizures
E. long tracts signs
A
D. Seizures
3
Q
A 33-year-old man suffered the sudden onset of double vision, right-sided body
numbness, and gait difficulties. Over the next 3 months, neurologic deficits resolved
completely. Ten months after the first event, he developed an abrupt recurrence of
double vision, gait incoordination, as well as a sudden onset of left numbness and
left-sided hearing loss.
On neurologic examination. the patient’s is He has left-sided
abducens (VI). facial (VII)and vestibulocochlear (VIII) cranial nerve deficits and has
right-sided motor and sensory deficits. Figure 1 shows serial magnetic resonance
imaging examinations in this patient.
3. The best therapeutic option for this patient at this time is:
A. observation
B. radiosurgery
C. surgery
D. aspiration
E. embolization
A
C. Surgery
4
Q
- A 6-month-old boy with hydrocephalus has a history of cardiac abnormalities and
seizures, and is blind. Computed tomographic scan of the head shows hypoplasia
of the cerebellar vermis with a posterior fossa cyst:in communication with the fourth
ventricle, hydrocephalus, and agenesis of the corpus callosum(Figure 4). You tell the
parents:
A. the child needs a VP shunt
B. after placement of a shunt, trapping of the fourth ventricle may occur, which would require a cystoperitoneal shunt
C. the child has a less than 5% chance of having normal intelligence
D. the child has an 87% chance of surviving to age 10 years
E. all above are true
A
E. All above are true
5
Q
- A 75-year-old white male with a medical history significant for coronary artery
disease, myocardial infarction, and hypertension presents to the emergency department
after a 2-hour episode of right arm and face numbness and weakness, as well as slurring
of speech. General physical and neurologic examination are normal, except for a loud
left carotid bruit. A noncontrasted CT of the head is normal.
After the CT scan, the patient has an identical episode which resolves in 15 minutes.
What is the MOST useful diagnostic test to order next?
A, noninvasive carotid Doppler studies
B. contrast head CT scan
C. cerebral Angiogram
D. Magnetic resonance imaging
E. MRA
A
C. Cerebral Angiogram
6
Q
- The patient in question 5 undergoes a carotid arteriogram(Figure 6) and is scheduled
for a carotid endarterectomy the following morning. That evening he becomes acutely
aphasic, with a right hemiplegia. His carotid bruit also disappears. What is the MOST
appropriate course of action?
A. emergency carotid endarterectomy - emergency head CT scan
C.emergency angiogram
D. heparinization
E. tissue plasminogen activator
A
A. Emergency Carotid Endarterectomy
7
Q
7. A 17 year-old white male presents with a history of severe, progressive headaches and seizures. His neurologic examination is normal. Contrast and non contrast CT scans of the head show an extraparenchymal mass that is large, nonclacified, nonenhancing and low density. The mass has a clearly defined smooth border located near the left Sylvian fissure. Which of the following diagnoses is MOST likely: A. chronic SDH B. arachnoid cyst C. neoplastic cyst secondary to a glioma D. Intracranial abscess E. Meningioma with cystic degeneration
A
B. Arachnoid Cyst
8
Q
- Which of the following are accepted treatments for arachnoid cysts?
A. shunting
B. excisionofthecystwall
C. establishment of communication with the subarachnoid space
D. observation
E. all of the above
A
E. All of the above
9
Q
- Which of the following statements about the neurosurgical treatment of cerebral palsy is FALSE :
A. Intrathecal baclofen and selective dorsal rhizotomy may have a common mechanism of action in reduction of spasticity
B. Spastic diplegic former prematures who are ambulatory without aids often benefit from selective dorsal rhizotomy
C. selective dorsal rhizotomy for children with spastic diplegia has been shown to reduce the requirements for subsequent orthopedic surgery
D. Athetoid patients do not often benefit from selective dorsal rhizotomy
E. Disturbances of bladder function can complicate selective dorsal rhizotomy
A
C. selective dorsal rhizotomy for children with spastic diplegia has been shown to reduce the requirements for subsequent orthopedic surgery
10
Q
10 A 2-month-oldchild is referred because of a bump on his forehead (Figure 10 A) The patient was exposed to phenytoin and valproate in utero. His delivery and his initial developmental and medical histories are unremarkable. The family brings with them a computed tomographic scan of the head (Figure 10B) Which of the following statements is TRUE?
A. This condition is infrequently associated with hypotelorism
B. The history of intrauterine drug exposure is irrelevant
C. The diagnosis is metopic synostosis
D. The condition is commonly associated with hypertelorism
E. Without treatment this condition commonly leads to mental retardartion
A
C. The diagnosis is metopic synostosis
11
Q
- A 30-year-old woman is referred to your clinic with pain. She notes that her pain began 1 month ago with a “strange feeling in the face,” followed rapidly by brief electric-like sensations radiating from the jaw to the eye on the right. One week later she noted an identical pain on the left, sometimes occuring simultaneously with right-sided pain. She was placed on 600 mg carbamazepin per day by her referring physician with partial pain control. Her examination is unremarkable except for weakness in the left arm and leg, which has a giveaway quality. The first studies you order would include all of the following EXCEPT:
A, magnetic resonance image with and without contrast enhancement
B. electroencephalogram
C. complete blood count
D. psychological testing
E. Serum carbamazepin level
A
B. electroencephalogram
12
Q
12. A 64-year-old male executive with diabetes controlled by oral medication comes to the emergency room on a Sunday morning with acutely increased pain in the right hip and thigh. The patient states that although he has had back pain for years, he has never experienced such severe pain in the leg. He was awakened that previous night with severe burning pain and lancinating jabs in the thigh associated with proximal leg weakness. Examination shows no atrophy but there is of hip flexion and knee extension. Straight leg raising is negative, but reverse straight leg raising (hip extension and knee flexion) is positive. Light touch and pinprick sensation are decreased on the anterior thigh. The knee jerk is absent. At this point the most likely diagnosis is: A. mononeuritis multiplex B. L3-4herniated nucleus pulposus C. acute herpetic neuralgia D. Guillain-Barre syndrome E. Diabetic amyotrophy
A
A. Mononeuritis Multiplex
13
Q
13. The most significant risk factor for hemorrhage from a arteriovenousfistula is: A. size B. location C. venous outflow restriction D. drainage to cortical veins E. patient age
A
D. drainage to cortical veins
14
Q
- An endovascular approach can be effective as primary or adjunctive therapy for all dural AV-fistulas EXCEPT for lesions involving the:
A. superior sagittal sinus
B. inferior petrosal sinus
C. anterior cranial fossa or ethmoidal groove
D. lateral sinus
E. none of the above
A
C. anterior cranial fossa or ethmoidal groove
15
Q
15. A 14-year-old female presents with complaints of slowly progressive exophthalmus and mild diplopia. Examination revealed a palpable mass along the left supraorbital rim that is not tender or supple. The patient has full extraocular movements. A nonenhancing lesion is identified on cranial tomographic (CT) scan (Figure15).The most likely diagnosis is: A. optic nerve glioma B. Meningioma C. dermoid tumor D. pseudotumor E. sarcoma
A
C. dermoid tumor
16
Q
- When resecting a mass involving the cavernous sinus, it is frequently important to obtain proximal control of the internal carotid artery. Although exposure of the internal carotid can be performed via neck dissection, exposure of the petrous carotid can be more advantageous, especially a vascular by pass is contemplated. Which of the followlng statements are FALSE regarding extradual exposure of petrous carotid after pterional craniotomy ?
A. The carotid canal, tensor tympani muscle, and eustachian tube are covered by a thin layer of bone and parallel to the greater superficial petrosal nerve.
B. The Greater superficial petrosal nerve is usually 4-6 mm medial to the foramen spinosum.
C. Occasionally, a portion of the petrous internal carotid lies uncovered by bone near the posterior border of V3
D. The petrous internal carotid artery lies medial to the tensor tympani muscle
E. Since excessive retraction of the be greater superficial petrosal nerve can be transmitted to V3, resulting in facial sensory deficits, the greater superficial petrosal nerve is cut when exposing the petrous carotid
A
E. Since excessive retraction of the be greater superficial petrosal nerve can be transmitted to V3, resulting in facial sensory deficits, the greater superficial petrosal nerve is cut when exposing the petrous carotid
17
Q
- Optic nerve resection often is considered when removing an optic nerve glioma or optic nerve sheath meningiorna. After frontal craniotomy and removal of the orbital roof, optic nerve exposure invoIves dissection through the annulus Zinn. Due to the arrangement of cranial nerves, the optic nerve related tumor usually is approached through the medial orbital compartment ( between the levator paIpebrae muscle and medial rectus). Which nerve is MOST likely to be injured when annulus of Zlnn is
opened through the medial orbital compartment?
A. Superior oculomotor branch
B. Inferior oculomotor branch
C. Trochlear nerve
D. Branches of ophthalmic nerve
E. Abducens nerve
A
C. Trochlear nerve
18
Q
18. Intracranial taumatic aneurysms occur in all the locations listed below, EXCEPT: A. pericallosal artery B. Middle meningeal artery C. distal MCA D. basilar bifurcatio E. SCA
A
D. basilar bifurcatio
19
Q
- A 51-year-old male developed burning pain and dysesthesiss in the aterior shin, medial calf, and medial ankle areas after a femord-popliteal bypass operation 3 years earlier. On examination there was numbness and hyperesthesia in the area of pain distribution; there were no motor Or reflex abnormalities. Which of the following conditions is this patients MOST likely to have ?
A.Meralgia paresthetica
B. iatrogenic saphenous neuropathy
C.Radiculopathy involving the L4 nerve root
D. reflex sympathetic dystrophy
E. ischemia of the involved bextremity
A
B. iatrogenic saphenous neuropathy
20
Q
20. A 52-year-old female presents with back pain that worsens at night The pain is nonradiating Her neurologic exam is unremarkable. The magnetic resonance image of the thoracolumbar region is shown Figure 20. The differential diagnosis of this lesion includes all of the following EXCEPT : A. idiopathic syringomyelia B. drop metastasis C.myxopapillary ependymoma D. schwannoma E.paraganglioma
A
A. idiopathic syringomyelia
21
Q
- A 28-year-old female presents with right shoulder pain after a lymph node biopsy in her neck 6 months ago. On examination she has a right shoulder drop, with wasting of the trapezius muscle side. She is unable to abduct the right shoulder beyond 80 degrees. She has a small, well-healed incision in the posterior triangle of the neck. An EMG
study reveals increased insertional activity, positive sharp waves and fibrillation potential in the upper and middle regretions of the trapezius muscle. Which of the following statements is TRUE?
A. Shoulder pain is a common symptom accompanying iatrogenic accessory nerve palsy.
B. There is no role for surgical management in this patient.
C. Accessory nerve palsy is not associated with surgery in the posterior triangle of the neck
D. The accessory nerve courses superficial to the SCM muscle.
E. The sternocleidomastoidmuscle is always affected by an accessory nerve injury.
A
A. Shoulder pain is a common symptom accompanying iatrogenic accessory nerve palsy.
22
Q
- A 59-year-old presents with left sided focal seizures. Magnetic resonance imaging evaluation is shown in Figure 22. Which of the following statements is TRUE?
A. Dural enhancement adjacent to tumors is a nonspecific phenomenon that can be seen in any dural based tumor
B. Dural enhancement adjacent to tumors. the so-called “meningeal tail” sign, is always associated with tumor invasion of dura
C. The “meningeal tail” sign commonly accompanies meningiomas is pathognomonic of this tumor.
D. Evidence of surrounding brain edema rules out meningioma
E. The homogeneous enhancement of the tumor rules out a malignant neoplasm.
A
A. Dural enhancement adjacent to tumors is a nonspecific phenomenon that can be seen in any dural based tumor
23
Q
- A 26-year-old male fell approxirnateIy 10 feet off scaffolding and experienced immediate severe back pain. Examination revealed marked focal tenderness in the upper lumbar region and no abnormal neurologic findings. Plain films and computed tomography revealed a fracture, with the L.2 body circumferentially enlarged, 20%canal encroachment, 25% loss of vertebral height with minimal anterior wedging, 3-mm widening of the interpeduncular distance, and intact posterior bony elements. The MOST appropriate management of this patient would be:
A. posterior midline surgical approach for distraction instrumentation of the fracture and transverse process fusion without decompression
B. posterolateral or transpedicular decompression with anterior interbody fusion and posterior distraction instrumentation
C. brief course of bed rest analgesics and muscle relaxants for pain control, external bracing, subsequent ambulation with serial plain films
D. prolonged course of bedrest (12-16 weeks) followed by gradual weight bearing in a thoracolumbar sacral orthosis with serial radiographic monitoring
E.retroperitoneal surgical approach for ventral decompression, interbody strut graft, and anterior plate fixation
A
C. brief course of bed rest analgesics and muscle relaxants for pain control, external bracing, subsequent ambulation with serial plain films
24
Q
- A stab wound through the anterior wall of the axilla results in paralysis of the biceps and flexor carpi radialis and loss of sensation in the thumb, index, and middle fingers, but the abductor is preserved. The lack of local swelling is taken as an indication there has not been a vasular injury. Which element of the brachial plexus has been damaged, and what is the BEST management?
A. lateral cord; delayed (2-3 months) operation
B. lateral cord; early (primary)operation
C. musculocutaneous nerve; operation
D. medial head of median nerve; early operation
E. upper trunk; early operation
A
B. lateral cord; early (primary)operation
25
25. The risk of symptomatic vasospasm following aneurysmal subarachnoid hemorrhage is MOST closely correlated with which one of the following factors? .
A. hydrocephalus
B. clinical grade
C. location of aneurysm
D. amount of subarachnoid blood
E. presence of intraventricular hemorrhage
D. amount of subarachnoid blood
26
```
26. Critical factors related to the surgical morbidity of removing an intracranial arteriovenous malformation (AVM) include which of the following?
A. size of the AVM nidus
B. location of the AVM
C. pattern of venous drainage
D. amount of flow through the AVM
E. all the above
```
E. all the above
27
27. During carotid endarterectomy in normothermic a lightly anesthetized patient, flattening of the ipsilateral electroencephalogram during carotid clamping signifies which of the following?
A. Cortical blood flow has been reduced from the normal to 50 mm/100g/min to less than 20 mm/100g/min, the ischemic threshold of synaptic transmission.
B. The ischemic threshold for membrane integrity has been reached.
C. These changes do not correlate with postoperative outcome.
D. Cortical blood flow has been reduced below the normal 100 mm/100g/min to below 50mm/100g/min
E. Stroke inevitably occur.
Cortical blood flow has been reduced from the normal to 50 mm/100g/min to less than 20 mm/100g/min, the ischemic threshold of synaptic transmission
28
28. Which of the following statements regarding Crouzon's disease is TRUE?
A. Craniosynostosis, maxillary hypoplasia, ocular proptosis characterize the syndrome
B. It has an autosomal recessive mode of genetic transmission.
C. Syndactaly is a common associated finding.
D. Exotropia is rare.
E. Surgery to repair synostosis must be performed by 3 months of age.
A. Craniosynostosis, maxillary hypoplasia, ocular proptosis characterize the syndrome
29
29. In the pediatric age group, which of the following signs and symptoms is commonly associated with arachnoid cysts?
A. head enlargement
B. headache
C. local bulging of the skull over the region of the cyst
D. convulsive seizures
E. all of the above
E. All of the above
30
30. Immuno conjugate (toxins or radioisotopes)currently utilized for the treatment of clinical central nervous system metastases and primary CNS neoplasms are directed to which of the following cell surface molecules?
A. epidermal growth factor and transferrin receptors
B. transforming growth factor and ciliary neuronotrphic factor receptors
C. fibroblast and nerve growth factor receptors
D. tumor necrosis factors
E. none of the above
A. epidermal growth factor and transferrin receptors
31
```
31. For symptomatic vertebral artery atherosclerotic disease involving the intradural vessel proximal to the posterior inferior cerebellarartery (PICA) origin, which of the following treatments cannot be utilized?
A. anticoagulation
B. occipital artery - PICA bypass
C. vertebral endarterectomy
D. vertebral-carotid transposition
E. carotid endarterectomy
```
D. vertebral-carotid transposition
32
32. Which of the following statements regarding chemodectomas (glomus tumors,paragangliomas) is FALSE?
A. The two primary sites occurrence of are in the carotid body and in the temporal bone.
B. some of this lesions are similar to pheochromocytomas and carcinoid tumors in that they can also produce neurotransmitters.
C. Common therapeutic options for these tumors include surgical resection,radiotherapy, and a combination of these modalities.
D. Multiple or bilateral lesions occur, especially in familial cases
E. These tumors commonly metastasize from their primary locus.
E. These tumors commonly metastasize from their primary locus
33
```
33. Similar to their counterparts in the dorsal spine, nasal midline defects result from
abnormal embryologic development and may commonly present with all of the
lesions. EXCEPT:
A. anterior encephaloceles
B. nasal gliomas
C. dermoid tumors
D. aesthesioneuroblastomas
E. all of the above
```
D. aesthesioneuroblastomas
34
34, Septic cavernous sinus thrombosis:
A. may be difficult to differentiatefrom orbital cellulitis in early stages
B. is readily dianosed with carotid angiography
C. responds rapidly to antibiotic treatment, compared to orbital celluilitis
D. is rarely associated with sinus infection
E. All of above
A. may be difficult to differentiatefrom orbital cellulitis in early stages
35
35. A 58-year-old man has been aggressively treated for a soft tissue sarcoma of the leg for nearly 3 years. He now presents with progressive, intractable bilateral lower extremity pain. MRI studies reveal extensive involvement of pelvic viscera with diffuse invasion into the lumbosacral plexus. Medical management of his pain has proven futile, including morphine administration. Which of the following surgical options would be MOST likely to provide pain relief?
A. Bilateral multilevel dorsal root rhizotomies
B. pecutaneous unilateral cervical cordotomy
C. anterior commisural myelotomy
D. decompression of the lumbosacral plexus bilaterally
E. hypophysectomy
C. anterior commisural myelotomy
36
```
36. A 28-year-old man with severe and intractable left arm pain sustained a brachial plexus injury after a motorcycle accident 3 years prior to admission. All conservative forms treatment have failed to remedy his pain. His examination reveals a flaccid and asensate left arm but he is otherwise neurologically intact. A myelogram reveal evidence of nerve root avulsion from C5-T1. Which pain procedure would be MOST likely succeed in this clinical situation?
A. DREZ lesion
B. Percutaneus cordotomy
C. Mesencephalotomy
D. Thalamotomy
E. sympathectomy
```
A. DREZ lesion
37
37. A 42-year-old man has undergone 7 lumbar for degenerative disc disease and over the past fifteen years at another institution. Over the past year, he has had a recurrence of mid low back pain with left leg pain and numbness. His exam shows loss of pin prick and light touch sensation in the L4-S1 dermatome on the left, with some weakness in plantar and dorsifelxion of his left ankle. The pain in his leg is much worse that in his back and has been unresponsive to physical therapy, medical management, and conservative pain clinic approaches, including epidural steroids and facet blocks. Recent radiographic studies reveal no evidence of spinal instability, disc herniation or nerve root impingement. Matting of the nerve roots within the intrathecal sac was as as epidural scar. The diagnosis of arachnoiditis was made. An epidural spinal cord stimulator was considered as an option for treatment. Which of the following statements is TRUE?
A. If a trial of temporary stimulation provides satisfactory pain relief. A permanently implanted device could considered.
B. A temporary device not be considered - the permanent should be placed under general anesthesia.
C. The patient should understand that spinal cord stimulation is generally of more value for back pain for extremity pain.
D. The chances of spinal cord stimulation providing satisfactory pain relief are less than 20%
E. For optimal results, the electrode should be placed in the cervical region, along the midline.
A. If a trial of temporary stimulation provides satisfactory pain relief. A permanently implanted device could considered
38
38. A 68-year-old hypertensive woman suffered a right internal capsule and thalamic infarction 1 year ago. This resulted in a dense left numbness and numbness on left side of her body. Shortly after her infarction, she developed severe pain in her left arm, leg, and face. Medical management has failed to remedy her pain. Surgical for options for management of her pain syndrome include:
A. an implanted intrathecal drug delivery device
B. frontal topectomy, parietal cortectomy, or cingulotomy
C . stereotactic thalamotomy
D. deep brain stimulation
E. all of the above
E. all of the above
39
39. A 16-year-old male is struck on the head with a baseball bat during an altercation. We is judged to be in coma on the basis of the Glasgow Coma Scale when he is examined in the emergency room. Which of the following findings is consistent with that conclusion?
A. He makes unidentifiable sounds.
B. He does not open his eyes spontaneously
C . He is breathing spontaneously.
D. He doesn't follow commands.
E. all of the above
E. all of the above
40
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40. A 45-year-old female is involved in a motor vehicle accident in which she strikes the side of her head against the windshield. She is transiently unconscious. When examined in the emergency room she is felt to be fully conscious. On her return from the Radiology Department, though, she arouses only to vigorous stimulation. The "lucid interval" she has experienced is MOST characteristic of which of the following ?
A. subarachnoid hemorrhage
B. extradural hemorrhage
C. subdural hemorrhage
D. traumatic inhacerebral hemorrhage
E. ischemic stroke
```
B. extradural hemorrhage
SANS V
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