NEURO TEST 3
Neurological Disease — Cumulative Practice Exam
Weeks 6 & 7 · 50-Question High-Yield Interleaved Exam
Diseases of the Neurological System · ATL 2026 · Neurocognitive Disorders · Closed Head Injuries · Vascular Disorders · Headaches · Cranial Nerve Palsies · Neuralgias · Hydrocephalus · Source-week tags appear in the Answer Key only
Questions are deliberately INTERLEAVED across both weeks — identify the domain before you answer. Source-week tags are withheld until the Answer Key so the stem cannot cue you.
1. An 84-year-old admitted for a UTI becomes agitated on hospital day 2, then withdrawn by afternoon, then agitated again overnight. Her daughter says she manages her own finances at home. Which feature most strongly supports delirium over dementia?
A. Her advanced age
B. Acute onset over hours to days with fluctuation, worse at night
C. The presence of agitation
D. Her baseline independence
2. A 33-year-old man has bouts of severe right orbital pain lasting about 2 hours with ipsilateral tearing, ptosis, and nasal congestion. He paces during attacks. What is the most common rescue therapy?
A. High-dose verapamil
B. Inhaled 100% oxygen at 12–15 L/min via non-rebreather
C. Oral topiramate
D. Amitriptyline
3. A 71-year-old has 2 years of fluctuating attention with vivid visual hallucinations. Rigidity and bradykinesia appeared 15 months after the cognitive changes. Which diagnosis, and what is first-line pharmacotherapy?
A. Parkinson's disease dementia; pimavanserin
B. Dementia with Lewy bodies; cholinesterase inhibitors
C. Alzheimer's disease; memantine
D. Frontotemporal dementia; mood stabilizers
4. A 29-year-old woman with BMI 33 and recent weight gain has headache, pulsatile tinnitus, and horizontal diplopia. Fundoscopy shows papilledema, and she cannot abduct the left eye. Which cranial nerve is affected and why?
A. CN III, from posterior communicating artery aneurysm
B. CN VI, because its course through the subarachnoid space makes it vulnerable to increased intracranial pressure
C. CN IV, from congenital palsy
D. CN VII, from postviral inflammation
5. A 68-year-old presents 3 hours after sudden onset of right facial droop, right arm weakness, and expressive aphasia. Which vascular territory, and what is the first imaging step?
A. Anterior cerebral artery; MRI brain first
B. Middle cerebral artery; non-contrast CT head first to exclude hemorrhage
C. Posterior cerebral artery; CTA first
D. Vertebrobasilar; carotid duplex first
6. A 26-year-old has 15 lifetime episodes of unilateral pulsating headache lasting 8–20 hours with nausea and photophobia, worsened by climbing stairs. Which criteria are met, and when should abortive therapy be taken?
A. Migraine without aura; at the earliest sign of an attack, even during aura
B. Migraine without aura; only once pain becomes severe
C. Chronic migraine; only at night
D. Tension headache; as needed
7. A 76-year-old on apixaban bumped her head 3 weeks ago. She now has progressive lethargy and confusion, and her family assumes she is developing dementia. Which diagnosis should be suspected?
A. Acute epidural hematoma
B. Chronic subdural hematoma
C. Subarachnoid hemorrhage
D. Alzheimer's disease
8. A 72-year-old has a magnetic, shuffling, wide-based gait, forgetfulness, and urinary incontinence. He was previously diagnosed with Alzheimer's disease. Which diagnosis must be excluded, and why does it matter?
A. Vascular dementia; it progresses stepwise
B. Normal pressure hydrocephalus; it is a REVERSIBLE cause of dementia
C. Frontotemporal dementia; it responds to donepezil
D. HIV-related dementia; it responds to antiretrovirals
9. A 79-year-old with newly diagnosed moderate Alzheimer's disease has second-degree AV block. Which statement about therapy is correct?
A. Start donepezil and memantine on the same day
B. Cholinesterase inhibitors are contraindicated in severe cardiac conduction abnormalities due to increased vagal tone
C. Memantine causes bradycardia
D. Cholinesterase inhibitors are contraindicated in all patients over 75
10. A 63-year-old describes brief attacks of electric right facial pain triggered by brushing her teeth, with complete relief between attacks. Which statement about evaluation and treatment is correct?
A. No imaging is needed; start gabapentin
B. It is a clinical diagnosis but all patients require neuroimaging (MRI, possibly MRA); first line is carbamazepine or oxcarbazepine
C. CT without contrast is the study of choice; first line is baclofen
D. Imaging is needed only if surgery is planned
11. A 52-year-old presents with the worst headache of her life, brief loss of consciousness, and nuchal rigidity. She had a similar milder severe headache 12 days ago. Non-contrast CT shows subarachnoid blood. Which statement is correct?
A. Order MRA immediately to characterize the aneurysm
B. The prior headache was likely a sentinel headache; since a bleed is identified on CT, do NOT order the MRA or CTA
C. Sentinel headaches follow the major bleed
D. Seizures occur in the majority of these patients
12. A 41-year-old with migraine has been taking sumatriptan and butalbital-containing analgesics nearly daily for 5 months and now has headache 20 days per month. What is the correct management?
A. Increase the triptan dose
B. Start a preventive migraine medication and wean the patient off the rescue medication
C. Add a muscle relaxant
D. Add an opioid for breakthrough pain
13. A 22-year-old arrives after a motor vehicle collision with a GCS of 7. Which classification applies, what airway decision follows, and which scale would be inappropriate here?
A. Moderate TBI; observe; MoCA inappropriate
B. Severe TBI; intubate; MMSE, MoCA, and CDR are all inappropriate in this setting
C. Mild TBI; discharge; GCS inappropriate
D. Severe TBI; intubate; GCS inappropriate
14. A 55-year-old presents with new-onset headache waking him from sleep, increasing in severity over 3 weeks. He takes warfarin. Which action is indicated?
A. Trial NSAIDs for 3 months
B. Obtain neuroimaging, preferably MRI brain — these are red flags and anticoagulant use is a secondary headache risk factor
C. Start a preventive migraine medication
D. Reassure and follow up in 6 months
15. A 58-year-old is brought in by his wife for 18 months of sexual disinhibition, loss of empathy, and socially inappropriate behavior, with relatively preserved memory. Which treatment statement is correct?
A. Donepezil is first line
B. Cholinesterase inhibitors and NMDA antagonists used for Alzheimer's are ineffective; treat behavioral symptoms with mood stabilizers
C. Memantine reverses the behavioral changes
D. Pimavanserin is FDA approved for this condition
16. A 61-year-old with diabetes has ptosis, a dilated pupil, diplopia, and the eye deviated down and out. What must be assumed until proven otherwise?
A. Microvascular disease, given his diabetes
B. Posterior communicating artery aneurysm, because the pupil is involved
C. Myasthenia gravis
D. Cavernous sinus thrombosis
17. A 38-year-old with HIV for 9 years and a low CD4 count has impaired processing speed, saccadic eye movements, increased tone, apathy, and social withdrawal, with intact memory. Which statement is correct?
A. Memory loss is the earliest feature
B. Memory, visuospatial reasoning, and language are largely spared until later; this is the most common dementia worldwide under age 40
C. The CNS damage comes directly from HIV infecting neurons
D. Antiretroviral therapy does not alter the course
18. A 40-year-old develops acute unilateral facial weakness including inability to wrinkle the forehead, loss of taste on the anterior tongue, and hyperacusis. She presents 40 hours after onset. Which finding distinguishes this from a central stroke, and what is first-line treatment?
A. Forehead sparing distinguishes it; treat with aspirin
B. Forehead INVOLVEMENT distinguishes the peripheral lesion; treat with corticosteroids within 72 hours
C. Loss of taste distinguishes it; treat with antivirals alone
D. Hyperacusis distinguishes it; treat with surgical decompression
19. A 70-year-old scores 22 on the MMSE. Her provider wants a more sensitive test for subtle executive and visuospatial dysfunction. Which instrument, and what education adjustment does it make?
A. Mini-Cog; no adjustment
B. MoCA; grants an additional point for patients with fewer than 12 years of education
C. CDR; adjusts for occupation
D. GCS; adjusts for age
20. A 34-year-old has a 5-year history of recurrent headaches with typical primary-headache features, a normal neurologic exam, and no red flags. Which statement is correct?
A. Neuroimaging is required annually
B. Neuroimaging is not indicated in this scenario
C. MRA is required to exclude aneurysm
D. Lumbar puncture is indicated
21. A 65-year-old had 20 minutes of left arm numbness and slurred speech that fully resolved. Exam is now normal. Which statement is correct?
A. This is benign and needs no workup
B. It is a clinical diagnosis with no confirmatory test, and 15% have a stroke within 90 days
C. MRI confirms the diagnosis
D. Symptoms lasting 48 hours are still consistent with TIA
22. A 27-year-old has attacks of vertigo, dysarthria, tinnitus, and ataxia with decreased level of consciousness accompanying headache, without any motor weakness. Which variant is this?
A. Hemiplegic migraine
B. Migraine with brainstem aura
C. Retinal migraine
D. Vestibular migraine
23. A patient with severe TBI is in the ICU. Which statement about secondary brain injury is correct?
A. Secondary injury occurs instantaneously at impact
B. Secondary injury develops over hours to days; avoid hypotension and hypoxia, since CPP equals MAP minus ICP
C. CPP equals ICP minus MAP
D. Hypotension is protective in TBI
24. A patient with suspected IIH is scheduled for lumbar puncture. Which sequence and value set is correct?
A. LP first, then image if abnormal; normal pressure 30–40 cm H2O
B. Neuroimaging FIRST because elevated ICP risks herniation; normal CSF pressure 5–25 cm H2O, elevated above 25 in an adult
C. LP and imaging simultaneously; normal pressure under 5 cm H2O
D. Imaging is unnecessary in IIH
25. A patient has an affected right eye that deviates upward in primary gaze with diplopia, and tilts the head to the left to compensate. Which nerve, and how is the responsible muscle isolated on exam?
A. CN III; test adduction
B. CN IV; ask the patient to adduct the eye and then depress it
C. CN VI; test abduction
D. CN VII; test forehead wrinkling
26. A 20-year-old soccer player is struck in the head, is confused for 20 minutes, then returns to baseline with amnesia for the event. CT is normal. Which statement is correct?
A. Normal CT excludes concussion
B. Concussion is a mild TBI with transient altered mental status under 6 hours; only about 5% have abnormal CT or MRI
C. Loss of consciousness is required for diagnosis
D. Concussion is a structural injury visible on routine imaging
27. A patient with hydrocephalus has an obstructing tumor blocking CSF flow between the ventricles. Which type is this, and what is the preferred procedure if the tumor cannot be removed?
A. Communicating; VP shunt
B. Obstructive (non-communicating); third ventriculostomy
C. Hypersecretory; choroid plexus coagulation
D. Normal pressure; serial lumbar punctures
28. An 80-year-old with hypertension, diabetes, and atrial fibrillation has an abrupt cognitive decline with motor deficits. MRI shows an acute infarct timed to symptom onset. Which statement about this dementia is correct?
A. It progresses steadily like a neurodegenerative proteinopathy
B. It is non-degenerative; symptoms typically do not progress unless another stroke occurs, and memory loss is less prominent than in Alzheimer's
C. Memory loss is more prominent than in Alzheimer's
D. A remote infarct is sufficient for the diagnosis
29. A 38-year-old office worker has recurrent bilateral pressure-like head pain radiating to the neck, about 10 days per month, without nausea or photophobia, unaffected by climbing stairs. Which diagnosis and chronic-phase treatment apply?
A. Migraine; triptans
B. Episodic tension headache; NSAIDs episodically, amitriptyline if it becomes chronic
C. Cluster headache; verapamil
D. Chronic migraine; onabotulinumtoxin A
30. A 32-year-old presents with sudden severe headache, vomiting, and seizure. Imaging shows a tangle of poorly formed vessels with hemorrhage. Which statement is correct?
A. This is the most common cause of intracranial bleeding
B. It is the second most common cause of intracranial bleeding after aneurysm; 40–80% present with hemorrhage and angiography is the gold standard
C. CT without contrast is the gold standard for imaging it
D. Fewer than 5% ever hemorrhage
31. A 55-year-old develops acute unilateral facial palsy preceded by severe ear pain. Which diagnosis and treatment apply?
A. Bell's palsy; corticosteroids alone
B. Ramsay Hunt syndrome from herpes zoster; corticosteroids AND acyclovir
C. Benign hemifacial spasm; botulinum toxin
D. Recurrent laryngeal nerve palsy; voice therapy
32. A patient with an acute ischemic stroke is admitted. Which statement about complications is correct?
A. Hemorrhagic conversion occurs only in patients who received thrombolytics
B. Hemorrhagic conversion typically occurs within 4 days of infarction, or within 24 hours of treatment if thrombolytics were given
C. Cerebral edema does not raise intracranial pressure
D. Seizures do not complicate ischemic stroke
33. A patient reports episodes of painful monocular vision loss lasting about 40 minutes with headache. Which variant is this, and what prior-course diagnosis should it recall?
A. Vestibular migraine; Meniere disease
B. Retinal migraine; amaurosis fugax
C. Hemiplegic migraine; TIA
D. Ophthalmoplegic neuropathy; Horner syndrome
34. A 71-year-old has memory testing abnormal for age and education, some difficulty with daily activities but remains independent, and does not meet dementia criteria. Which workup and prognosis apply?
A. CSF biomarkers in all patients; 90% convert to dementia
B. CBC, CMP, thyroid panel, B12, folate; 10–25% convert to dementia while the remainder resolve or stay stable
C. Genetic testing in all patients; all convert within 2 years
D. No workup; conversion is universal
35. A patient presents with severe unilateral periorbital headache, painful decreased eye movements, and paralysis of CN III, IV, and VI, with orbital inflammation of unknown origin. Which syndrome and treatment?
A. Cavernous sinus syndrome; treat the neoplasm
B. Tolosa-Hunt syndrome; glucocorticoids
C. Cluster headache; oxygen
D. IIH; acetazolamide
36. A comatose patient is examined. Which pairing of brainstem reflex to anatomic level is correct?
A. Corneal reflex — medulla; gag — pons
B. Pupillary response — midbrain; corneal — pons; gag — medulla
C. Pupillary response — medulla; gag — midbrain
D. All brainstem reflexes localize to the midbrain
37. A 52-year-old develops sudden dysphonia, dyspnea, and difficulty swallowing following anterior cervical spine surgery. Which statement about this palsy is correct?
A. Thyroidectomy accounts for nearly all cases
B. Thyroidectomy accounts for only about 35%; management is ENT referral with watchful waiting about 9 months plus voice therapy
C. Immediate surgical reinnervation is always required
D. Diagnosis is by MRI alone
38. A 25-year-old sustained a concussion 6 weeks ago and still has headache, dizziness, insomnia, irritability, and poor concentration. Neurologic exam and MRI are normal. Which statement is correct?
A. Normal imaging excludes a post-concussive process
B. Patients may be severely disabled despite a normal neurologic exam and normal neuroimaging; ICD-10 defines this as symptoms beyond 3 weeks
C. Symptoms beyond 2 weeks indicate structural injury
D. This requires urgent neurosurgical referral
39. A patient is diagnosed with IIH. Which is first-line treatment, and why does the medication matter early?
A. CSF shunting; it works fastest
B. Weight reduction and acetazolamide; acetazolamide works almost immediately with most benefit in the first 4–6 weeks while weight loss takes longer
C. Optic nerve sheath fenestration; first line in all patients
D. Topiramate monotherapy
40. A 64-year-old with poorly controlled hypertension has acute headache progressing to aphasia and hemiparesis. Which statement about diagnosis and outpatient management is correct?
A. MRI is the gold standard; lower BP rapidly to 110/70
B. Non-contrast CT is the gold standard; hypertension is the most common cause, and BP should be gradually decreased to 150/90
C. Prophylactic antiepileptics are recommended in all patients
D. Statins are contraindicated after hemorrhagic stroke
41. A patient starting topiramate for migraine prevention asks when to expect benefit. Which counseling is correct, and at what frequency is prevention indicated?
A. Full relief in 48 hours; prevention at 15+ days per month only
B. Some relief in 2–4 weeks with complete relief up to 3 months, starting low and titrating slowly; prevention at about 4–6 migraine days per month
C. Discontinue if no benefit in 1 week; prevention at 1–2 days per month
D. Preventives work immediately and are not titrated
42. A 22-year-old struck in the temple with a bat had brief LOC, awoke with headache, and 2 hours later became lethargic and began vomiting. Which lesion, vessel, and management timeline apply?
A. Subdural; bridging veins; conservative management
B. Epidural; middle meningeal artery; neurosurgical emergency with evacuation ideally within 1–2 hours
C. Subarachnoid; anterior communicating artery; nimodipine
D. Intraparenchymal; lenticulostriate arteries; BP control
43. A 16-year-old has headache, fever, and nuchal rigidity, then develops a petechial rash. CSF shows glucose 4 mg/dL, protein 82 mg/dL, and 119 leukocytes with 72% polymorphonuclear cells. Which organism is most likely?
A. Streptococcus pneumoniae
B. Neisseria meningitidis
C. Listeria monocytogenes
D. West Nile virus
44. A patient with delirium is managed on the medical floor. Which approach is correct?
A. Prophylactic haloperidol in all patients
B. Treat the underlying cause with supportive and protective measures; avoid environmental change and restraints when possible
C. Apply restraints early to prevent falls
D. Move the patient to a new room daily for stimulation
45. A patient with HSV encephalitis is suspected based on subacute fever, headache, and altered mental status with focal findings. Which management is correct?
A. Withhold treatment until viral serology returns
B. Treat empirically with acyclovir immediately while awaiting serology
C. Start antibiotics only
D. Corticosteroids alone
46. Which statement about the pathology and genetics of Alzheimer's disease is correct?
A. 95% of cases are genetically inherited
B. Extracellular beta amyloid plaques and intraneuronal neurofibrillary tau tangles; 95% sporadic; trisomy 21 is a risk factor for early onset
C. Alpha-synuclein aggregates in the basal ganglia; APOE guarantees disease
D. Tau deposition with astrocytosis; onset typically 45–65
47. A patient is being followed 6 months after a severe TBI. Which prognostic statement is correct?
A. Recovery plateaus at 6 weeks
B. Re-evaluate at 6 months, when about 85% of recovery has occurred; GCS under 4 on admission carries an 80% chance of death or remaining in a coma
C. GCS on admission has no prognostic value
D. Nearly all patients return to their prior employment within 2 years
48. How are trigeminal autonomic cephalalgias defined as a group, and which condition responds characteristically to indomethacin?
A. Bilateral pain without autonomic features; migraine
B. Trigeminal distribution pain with IPSILATERAL autonomic features; hemicrania continua and chronic paroxysmal hemicrania
C. Contralateral autonomic features; cluster headache
D. Exertional headache; tension headache
49. A patient asks how migraine aura is distinguished from a TIA. Which statement is correct?
A. Aura produces permanent deficits; TIA is transient
B. Aura is transient with full return to baseline, typically under 1 hour, and TIA/ischemic stroke are LESS likely to feature nausea, vomiting, photophobia, phonophobia, or paresthesia
C. TIA always lasts longer than 24 hours
D. Both produce identical features and cannot be distinguished clinically
50. Which timing rule correctly distinguishes dementia with Lewy bodies from Parkinson's disease dementia?
A. DLB — Parkinson diagnosis precedes dementia by at least 1 year; PDD — dementia precedes extrapyramidal symptoms by at least 1 year
B. DLB — dementia precedes extrapyramidal symptoms by at least 1 year; PDD — Parkinson diagnosis precedes dementia by at least 1 year
C. Both require simultaneous onset
D. Timing is irrelevant to the distinction
ANSWER KEY & CLINICAL RATIONALES
All 50 Answers with Source-Week Tags and High-Yield Rationales
1. [Week 6] Answer: B. Acute onset over hours to days with fluctuation, worse at night
Rationale: Delirium is ACUTE onset over HOURS TO DAYS — NOT MONTHS — that FLUCTUATES and is TYPICALLY WORSE AT NIGHT, with altered attention and awareness. Dementia is insidious over months to years with chronic slow decline. Delirium may be HYPERACTIVE (agitated) or HYPOACTIVE (withdrawn), and this patient shows both — the fluctuation itself is the diagnostic feature. Delirium affects 1 IN 3 ED ARRIVALS and ~80% OF ICU PATIENTS, is a MEDICAL EMERGENCY, and carries HIGH MORTALITY — about 14% at 1 month, 22% at 6 months, 40% at 1 year.
2. [Week 7] Answer: B. Inhaled 100% oxygen at 12–15 L/min via non-rebreather
Rationale: Cluster headache: unilateral trigeminal pain lasting 15–180 MINUTES with IPSILATERAL AUTONOMIC FEATURES, in a young male who drinks or smokes, who FEELS BETTER WALKING AROUND. RESCUE is INHALED 100% OXYGEN 12–15 L/MIN VIA NON-REBREATHER, plus SC sumatriptan or intranasal zolmitriptan. VERAPAMIL and TOPIRAMATE are PREVENTIVE — the rescue-versus-preventive swap is the most common trap on this topic. PREVENTIVE options are HIGH-DOSE VERAPAMIL, TRANSITIONAL STEROIDS, and GALCANEZUMAB — the only injectable CGRP FDA approved for cluster headache.
3. [Week 6] Answer: B. Dementia with Lewy bodies; cholinesterase inhibitors
Rationale: In DLB, COGNITIVE IMPAIRMENT PRECEDES EXTRAPYRAMIDAL SYMPTOMS BY AT LEAST ONE YEAR, with FLUCTUATING ATTENTION and EARLY VISUAL HALLUCINATIONS. CHOLINESTERASE INHIBITORS (donepezil, rivastigmine) ARE FIRST LINE. In PDD the Parkinson diagnosis comes FIRST by at least a year. Pathology for both: ALPHA-SYNUCLEIN in the BASAL GANGLIA. Atypical antipsychotics such as quetiapine carry a BLACK BOX WARNING for sudden cardiac death in dementia.
4. [Week 7] Answer: B. CN VI, because its course through the subarachnoid space makes it vulnerable to increased intracranial pressure
Rationale: CN VI (abducens) supplies the LATERAL RECTUS; palsy causes ESOTROPIA with INABILITY TO ABDUCT and BINOCULAR HORIZONTAL DIPLOPIA. CN VI IS AFFECTED BY INCREASED INTRACRANIAL PRESSURE because of its course through the SUBARACHNOID SPACE, with associated headache, nausea, vomiting, and PAPILLEDEMA. In IIH, DIPLOPIA IS OFTEN A CN VI PALSY — the false localizing sign of raised ICP.
5. [Week 6] Answer: B. Middle cerebral artery; non-contrast CT head first to exclude hemorrhage
Rationale: MCA is the most commonly affected vessel in ischemic stroke, producing CHANGes — CONTRALATERAL HEMIPARESIS, HOMONYMOUS HEMIANOPSIA, APHASIA, NEGLECT, GAZE PREFERENCE TOWARD THE LESION. CT HEAD WITHOUT CONTRAST IS FIRST (within ~20 minutes) to RULE OUT HEMORRHAGIC STROKE before thrombolytics. VESSEL IMAGING AND MRI MUST NOT DELAY THROMBOLYTIC THERAPY. Ischemic stroke is 80% of all strokes.
6. [Week 7] Answer: A. Migraine without aura; at the earliest sign of an attack, even during aura
Rationale: MIGRAINE WITHOUT AURA: AT LEAST FIVE ATTACKS lasting 4–72 HOURS plus TWO of UNILATERAL, PULSATING, MODERATE-SEVERE, NAUSEA/VOMITING, PHOTOPHOBIA/PHONOPHOBIA. RESCUE MEDICATIONS START AT THE EARLIEST SIGN OF A MIGRAINE, EVEN IN THE AURA STAGE. Options: high-dose NSAIDs, triptans (rizatriptan and sumatriptan favored, usable WITH NSAIDs), and CGRP inhibitors. TRIPTANS ARE LIMITED TO 9 DOSES PER MONTH.
7. [Week 6] Answer: B. Chronic subdural hematoma
Rationale: CHRONIC subdural presents with LETHARGY, IRRITABILITY, and CONFUSION MORE THAN 2 WEEKS after injury — also called a CHRONIC HYGROMA. It is more common in OLDER ADULTS WITH BRAIN ATROPHY ON BLOOD THINNERS, grows slowly, and its SYMPTOMS ARE OFTEN MISTAKEN FOR DEMENTIA, DELIRIUM, TUMORS, OR STROKE. Mechanism: SHEARING FORCES RUPTURE BRIDGING VEINS. The subdural lucid interval CAN BE WEEKS; the epidural lucid interval is UNDER 4 HOURS.
8. [Week 7] Answer: B. Normal pressure hydrocephalus; it is a REVERSIBLE cause of dementia
Rationale: NPH is a COMMUNICATING hydrocephalus with abnormal CSF accumulation but NORMAL intracranial pressure, and is the MOST COMMON FORM OF HYDROCEPHALUS IN ADULTS. TRIAD: GAIT INSTABILITY, COGNITIVE DEFICITS, URINARY INCONTINENCE. It MIMICS ALZHEIMER'S AND PARKINSON'S BUT IS A REVERSIBLE CAUSE OF DEMENTIA and is frequently misdiagnosed as an irreversible dementia. Risk factors: AGE OVER 65 and NEURO TRAUMA.
9. [Week 6] Answer: B. Cholinesterase inhibitors are contraindicated in severe cardiac conduction abnormalities due to increased vagal tone
Rationale: Cholinesterase inhibitors block acetylcholine degradation; INCREASED VAGAL TONE can cause BRADYCARDIA, CARDIAC CONDUCTION DEFECTS, and SYNCOPE, so they are CONTRAINDICATED in SEVERE CARDIAC CONDUCTION ABNORMALITIES. Donepezil is first line at ALL STAGES; memantine (NMDA antagonist) is added for moderate-to-severe disease — NEVER START BOTH THE SAME DAY, or you cannot tell which is causing side effects.
10. [Week 7] Answer: B. It is a clinical diagnosis but all patients require neuroimaging (MRI, possibly MRA); first line is carbamazepine or oxcarbazepine
Rationale: Trigeminal neuralgia is INTERMITTENT ATTACKS OF SEVERE UNILATERAL FACIAL PAIN in the trigeminal distribution, PAIN FREE BETWEEN ATTACKS, triggered by touch, eating, talking, brushing teeth, shaving, cold weather. It is a CLINICAL DIAGNOSIS, BUT ALL PATIENTS REQUIRE NEUROIMAGING — MRI AND POSSIBLY MRA. FIRST LINE: CARBAMAZEPINE OR OXCARBAZEPINE. Second line: gabapentin, lamotrigine, baclofen. Surgery may relieve pain but LEAVE NUMBNESS. Differential includes TMJ DYSFUNCTION — chewing trigger, CLICKING of the jaw, treated with BOTULINUM TOXIN — versus the light-touch triggers and electric paroxysmal pain of trigeminal neuralgia.
11. [Week 6] Answer: B. The prior headache was likely a sentinel headache; since a bleed is identified on CT, do NOT order the MRA or CTA
Rationale: 30–50% of patients with major SAH report a sudden severe headache 6–20 DAYS PRIOR — the SENTINEL HEADACHE, a minor hemorrhage or WARNING LEAK. IF A BLEED IS IDENTIFIED ON THE INITIAL CT OR MRI, YOU DO NOT ORDER THE MRA OR CTA — those are for suspected UNRUPTURED aneurysm. Ruptured aneurysm is a surgical EMERGENCY; RUPTURE IS FATAL IN 50%. SEIZURES ARE RARE (under 10%). NIMODIPINE prevents ischemia from vasospasm.
12. [Week 7] Answer: B. Start a preventive migraine medication and wean the patient off the rescue medication
Rationale: MEDICATION OVERUSE HEADACHE: 15 OR MORE HEADACHE DAYS after OVERUSING ACUTE THERAPIES FOR MORE THAN 3 MONTHS — the MOST COMMON secondary headache disorder. Culprits: OPIOIDS, BUTALBITAL, NSAIDs, TRIPTANS, ERGOTAMINES. Management: START A PREVENTIVE AND WEAN OFF THE RESCUE MEDICATION. This is precisely why rescue therapies carry monthly fill limits. Butalbital is no longer recommended due to MOH and seizure on withdrawal.
13. [Week 6] Answer: B. Severe TBI; intubate; MMSE, MoCA, and CDR are all inappropriate in this setting
Rationale: GCS: SEVERE = 8 OR LESS · MODERATE = 9–12 · MILD = 13–15. INTUBATE IF GCS IS 8 OR LESS. The GCS and NIHSS are the EMERGENCY AND HOSPITAL scales; MMSE, MoCA, RUDAS, and CDR are OUTPATIENT neurocognitive instruments and are NOT used for acute TBI. Prognostically, GCS UNDER 4 ON ADMISSION carries an 80% CHANCE OF DEATH OR REMAINING IN A COMA.
14. [Week 7] Answer: B. Obtain neuroimaging, preferably MRI brain — these are red flags and anticoagulant use is a secondary headache risk factor
Rationale: RED FLAGS: INCREASING SEVERITY, WORST HEADACHE OF LIFE, HEADACHE WAKING FROM SLEEP, DIZZINESS OR INCOORDINATION, NEW ONSET IN THE ELDERLY, NEW PERSISTENT HEADACHE — obtain neuroimaging, preferably MRI BRAIN. Secondary headache risk factors: AGE OVER 50, NEOPLASM HISTORY, ANTICOAGULANT USE, TRAUMA, PREGNANCY, IMMUNOSUPPRESSION. This patient carries three separate indications.
15. [Week 6] Answer: B. Cholinesterase inhibitors and NMDA antagonists used for Alzheimer's are ineffective; treat behavioral symptoms with mood stabilizers
Rationale: Frontotemporal dementia: YOUNGER ONSET (45–65), frontal and temporal atrophy, with BEHAVIOR VARIANT (disinhibition, no empathy, decline in social cues) and LANGUAGE VARIANT. PERSONALITY changes predominate in FTD; MEMORY changes predominate in AD. CHOLINESTERASE INHIBITORS AND NMDA ANTAGONISTS ARE INEFFECTIVE — use MOOD STABILIZERS and supportive care. These younger patients are often MISDIAGNOSED WITH PSYCHIATRIC DISEASE. Survival ~7.5 years.
16. [Week 7] Answer: B. Posterior communicating artery aneurysm, because the pupil is involved
Rationale: CN III palsy: PTOSIS, DOWN AND OUT DEVIATION, DILATED PUPIL, DIPLOPIA. Most common cause overall is MICROVASCULAR DISEASE (diabetes, hypertension), but PUPIL-INVOLVING CN III PALSY = POSTERIOR COMMUNICATING ARTERY ANEURYSM UNTIL PROVEN OTHERWISE. Most common is not most urgent. Down-and-out reflects unopposed LATERAL RECTUS (CN VI) and SUPERIOR OBLIQUE (CN IV) — recall LR6(SO4)3. About 60% resolve spontaneously.
17. [Week 6] Answer: B. Memory, visuospatial reasoning, and language are largely spared until later; this is the most common dementia worldwide under age 40
Rationale: HIV-related dementia is a LATE complication with a TRIAD of COGNITIVE (impaired processing, executive dysfunction), MOTOR (saccadic eye movements, slow RAM, increased tone), and BEHAVIORAL (withdrawn, apathetic, irritable, blunted affect) findings. MEMORY, VISUOSPATIAL REASONING, AND LANGUAGE ARE LARGELY SPARED UNTIL LATE. Damage comes from NEUROTOXIC HIV PROTEINS and immune/inflammatory mediators, NOT the virus infecting neurons directly. Untreated, death occurs within months.
18. [Week 7] Answer: B. Forehead INVOLVEMENT distinguishes the peripheral lesion; treat with corticosteroids within 72 hours
Rationale: THE DIFFERENCE BETWEEN A FACIAL PALSY AND A CENTRAL ISCHEMIC STROKE IS FOREHEAD INVOLVEMENT — the peripheral CN VII lesion weakens BOTH UPPER AND LOWER FACE. Bell's palsy is idiopathic but usually POST-VIRAL. FIRST LINE: CORTICOSTEROIDS WITHIN 72 HOURS, with ANTIVIRALS ADDED IN SEVERE CASES. Add eye protection — artificial tears, taping the lid at night. 90% IMPROVE; about 10% RECUR. Note taste loss is ANTERIOR 2/3 of the tongue.
19. [Week 6] Answer: B. MoCA; grants an additional point for patients with fewer than 12 years of education
Rationale: MMSE (30 points): above 24 normal · 18–23 MCI · 21–23 mild dementia · 15–20 moderate · below 14 severe. The MoCA is more sensitive for MCI and BETTER DISTINGUISHES executive function, complex visuospatial function, and language, and GRANTS AN ADDITIONAL POINT FOR LESS THAN 12 YEARS OF EDUCATION. MoCA: 26 or above normal · 18–25 mild · 10–17 moderate · below 10 severe.
20. [Week 7] Answer: B. Neuroimaging is not indicated in this scenario
Rationale: Clinical pearl: NEUROIMAGING IS NOT INDICATED in recurrent headache with CLINICAL FEATURES OF A PRIMARY HEADACHE DISORDER, NORMAL NEUROLOGIC EXAM, and NO RED FLAG SYMPTOMS. You still must RULE OUT SECONDARY HEADACHE before diagnosing a primary disorder — but by history and exam, not reflexive imaging. Contrast with trigeminal neuralgia, where ALL patients require imaging.
21. [Week 6] Answer: B. It is a clinical diagnosis with no confirmatory test, and 15% have a stroke within 90 days
Rationale: A TIA produces deficits lasting LESS THAN 24 HOURS with return to baseline and NO residual deficits. NO IMAGING OR LABS CONFIRM IT — it is CLINICAL. It is NOT benign: 15% HAVE A STROKE WITHIN 90 DAYS; a true TIA is a WARNING SIGN. High-risk patients get DUAL ANTIPLATELET THERAPY FOR 21 DAYS plus MRI, vessel imaging, and ECHO. TIAs produce NEGATIVE features (loss of function); seizures produce POSITIVE features.
22. [Week 7] Answer: B. Migraine with brainstem aura
Rationale: MIGRAINE WITH BRAINSTEM AURA (basilar migraine) produces BRAINSTEM SYMPTOMS WITHOUT WEAKNESS — vertigo, dysarthria, tinnitus, ataxia, decreased LOC. THE ABSENCE OF WEAKNESS separates it from HEMIPLEGIC MIGRAINE, which features UNILATERAL MOTOR WEAKNESS with aphasia, lethargy, and paresthesia and mimics stroke. Triptans are CONTRAINDICATED in hemiplegic migraine.
23. [Week 6] Answer: B. Secondary injury develops over hours to days; avoid hypotension and hypoxia, since CPP equals MAP minus ICP
Rationale: PRIMARY injury is immediate tissue damage. SECONDARY BRAIN INJURY DEVELOPS OVER HOURS TO DAYS with hypoxia, hypovolemia, cerebral edema, hematoma expansion, and cytokine release. Per the MONRO-KELLIE hypothesis, CPP = MAP − ICP, so rising ICP lowers perfusion and causes ischemia. Goals: life-saving care and hemodynamic stability first, then PREVENT SECONDARY INJURY by AVOIDING HYPOTENSION AND HYPOXIA.
24. [Week 7] Answer: B. Neuroimaging FIRST because elevated ICP risks herniation; normal CSF pressure 5–25 cm H2O, elevated above 25 in an adult
Rationale: GET NEUROIMAGING FIRST — elevated ICP is a contraindication to LP because of herniation risk. Diagnosis of IIH: clinical symptoms with PAPILLEDEMA AS KEY, MRI BRAIN, NO IDENTIFIABLE CAUSE, and CONFIRMATORY LP OPENING PRESSURE. NORMAL = 5–25 cm H2O; ELEVATED = ABOVE 25 cm H2O IN AN ADULT (above 20 in children). Note 250 mm H2O = 25 cm H2O.
25. [Week 7] Answer: B. CN IV; ask the patient to adduct the eye and then depress it
Rationale: CN IV (trochlear) supplies the SUPERIOR OBLIQUE. Palsy causes the AFFECTED EYE TO DEVIATE UP IN PRIMARY GAZE — a PARALYTIC STRABISMUS — with the patient TILTING THE HEAD AWAY FROM THE AFFECTED EYE to reduce diplopia. The SUPERIOR OBLIQUE IS THE ONLY MUSCLE THAT LOWERS THE EYE WHEN ADDUCTED, so isolate it by ASKING THE PATIENT TO ADDUCT THEN DEPRESS. Most CN IV palsies are CONGENITAL.
26. [Week 6] Answer: B. Concussion is a mild TBI with transient altered mental status under 6 hours; only about 5% have abnormal CT or MRI
Rationale: Concussion IS a MILD TBI with TRANSIENT ALTERED MENTAL STATUS UNDER 6 HOURS, ranging from confusion to LOC (under 10% are completely out). Most common cause: ACCELERATION/DECELERATION. Most common symptoms: MEMORY AND ORIENTATION. It is a PHYSIOLOGIC injury — ONLY 5% HAVE ABNORMAL CT OR MRI, which is why it is underdiagnosed. Treatment: RELATIVE REST 24–48 HOURS then gradual symptom-limited return.
27. [Week 7] Answer: B. Obstructive (non-communicating); third ventriculostomy
Rationale: OBSTRUCTIVE (non-communicating) hydrocephalus = flow BLOCKED BETWEEN THE VENTRICLES, most often at the foramina of Monro, aqueduct of Sylvius, fourth ventricle, or foramen magnum; usually from an OBSTRUCTING TUMOR or POST-INFECTIOUS. Remove the tumor if possible; otherwise the PREFERRED METHOD IS THIRD VENTRICULOSTOMY. Match mechanism to intervention: blocked flow → third ventriculostomy; impaired absorption → shunt; overproduction → choroid plexus coagulation.
28. [Week 6] Answer: B. It is non-degenerative; symptoms typically do not progress unless another stroke occurs, and memory loss is less prominent than in Alzheimer's
Rationale: Vascular dementia is NON-DEGENERATIVE and the LEADING NONDEGENERATIVE CAUSE of dementia. Onset is ABRUPT and symptoms DO NOT PROGRESS unless another stroke occurs. MEMORY LOSS IS LESS PROMINENT THAN AD. The RADIOGRAPHIC FINDING MUST BE ASSOCIATED WITH THE ONSET OF COGNITIVE CHANGES — NOT a remote or old infarct. Life expectancy 3–5 years.
29. [Week 7] Answer: B. Episodic tension headache; NSAIDs episodically, amitriptyline if it becomes chronic
Rationale: Tension headache is BILATERAL, NON-PULSATING PRESSURE/TIGHTENING, MILD-MODERATE, NOT EXACERBATED BY PHYSICAL ACTIVITY, without nausea or vomiting, with rare photophobia/phonophobia. FREQUENT EPISODIC = 1–14 days/month; CHRONIC = 15 or more. STRESS is the most common trigger, and TENSION HEADACHE IS THE MOST COMMON HEADACHE DISORDER. EPISODIC → NSAIDs; CHRONIC → AMITRIPTYLINE. SYSTEMIC MUSCLE RELAXANTS HAVE NOT BEEN SHOWN TO BE BENEFICIAL.
30. [Week 6] Answer: B. It is the second most common cause of intracranial bleeding after aneurysm; 40–80% present with hemorrhage and angiography is the gold standard
Rationale: An AVM is a TANGLE OF POORLY FORMED BLOOD VESSELS and the SECOND MOST COMMON CAUSE OF INTRACRANIAL BLEEDING, SECOND TO ANEURYSM. 40–80% PRESENT WITH INTRACRANIAL HEMORRHAGE. ANGIOGRAPHY IS THE GOLD STANDARD for imaging AVMs. Only 12% become symptomatic; many are incidental. Mortality with hemorrhage is 10–15%.
31. [Week 7] Answer: B. Ramsay Hunt syndrome from herpes zoster; corticosteroids AND acyclovir
Rationale: RAMSAY HUNT SYNDROME is ACUTE UNILATERAL FACIAL PALSY CAUSED BY HERPES ZOSTER in which FACIAL WEAKNESS IS PRECEDED BY SEVERE PAIN IN THE EAR — treat with CORTICOSTEROIDS AND ACYCLOVIR. The antecedent severe ear pain is the discriminator from Bell's palsy, where antivirals are optional and reserved for severe cases. BENIGN HEMIFACIAL SPASM is continuous twitching WITHOUT weakness, treated with botulinum toxin.
32. [Week 6] Answer: B. Hemorrhagic conversion typically occurs within 4 days of infarction, or within 24 hours of treatment if thrombolytics were given
Rationale: Life-threatening complications: HEMORRHAGIC CONVERSION, BRAIN EDEMA, SEIZURES, COMA, DEATH. Conversion typically occurs WITHIN 4 DAYS OF INFARCTION REGARDLESS OF THROMBOLYTIC USE, and within 24 HOURS OF TREATMENT if given. Cerebral edema raises ICP and can lead to HERNIATION. Follow-up imaging is obtained within 24 hours of admission.
33. [Week 7] Answer: B. Retinal migraine; amaurosis fugax
Rationale: RETINAL MIGRAINE is MONOCULAR BLINDNESS UNDER 1 HOUR WITH HEADACHE — painful monocular vision loss should call back to AMAUROSIS FUGAX. Other variants: RECURRENT PAINFUL OPHTHALMOPLEGIC NEUROPATHY (pain with ptosis and double vision, lasting weeks) and VESTIBULAR MIGRAINE (dizziness more pronounced than pain, lasting weeks, often with BILATERAL hearing loss — versus Meniere, which is typically UNILATERAL and short lasting).
34. [Week 6] Answer: B. CBC, CMP, thyroid panel, B12, folate; 10–25% convert to dementia while the remainder resolve or stay stable
Rationale: MCI is decline ABNORMAL FOR AGE AND EDUCATION with DIFFICULTY WITH ADLs BUT STILL INDEPENDENT — the border between normal aging and dementia, in which THE PATIENT IS USUALLY MORE CONCERNED THAN ANYONE ELSE. Labs: CBC, CMP, THYROID PANEL, B12, FOLATE. 10–25% CONVERT TO DEMENTIA; the other ~75% RESOLVE OR REMAIN STABLE. AMNESTIC MCI risks progression to Alzheimer's. NO approved pharmacologic agents.
35. [Week 7] Answer: B. Tolosa-Hunt syndrome; glucocorticoids
Rationale: TOLOSA-HUNT SYNDROME: severe periorbital headache with DECREASED AND PAINFUL EYE MOVEMENTS, typically unilateral, with paralysis of CN III, IV, and/or VI from ORBITAL INFLAMMATION OF UNKNOWN ORIGIN. It may SPONTANEOUSLY RESOLVE (~8 weeks) and MAY RELAPSE; TREAT WITH GLUCOCORTICOIDS. Contrast CAVERNOUS SINUS SYNDROME: ophthalmoplegia, PROPTOSIS, trigeminal sensory loss, and HORNER SYNDROME, usually from a NEOPLASM.
36. [Week 6] Answer: B. Pupillary response — midbrain; corneal — pons; gag — medulla
Rationale: Coma results from dysfunction of the RETICULAR ACTIVATING SYSTEM or BILATERAL HEMISPHERES. Brainstem reflexes localize: PUPILLARY = MIDBRAIN (fixed dilated pupils suggest herniation) · CORNEAL = PONS · OCULOCEPHALIC (doll's eye) and OCULOVESTIBULAR (cold caloric) = BRAINSTEM · GAG = MEDULLA. Management follows ABCDE with INTUBATION IF GCS IS 8 OR LESS.
37. [Week 7] Answer: B. Thyroidectomy accounts for only about 35%; management is ENT referral with watchful waiting about 9 months plus voice therapy
Rationale: The RECURRENT LARYNGEAL NERVE (branch of CN X) innervates the intrinsic laryngeal muscles except cricothyroid, including the POSTERIOR CRICOARYTENOID which OPENS THE VOCAL FOLDS. THYROIDECTOMY CAUSES ONLY ABOUT 35%; the other 65% is non-thyroid procedures (25% idiopathic). Diagnosis: HISTORY AND DIRECT LARYNGOSCOPY. Management: ENT REFERRAL, WATCHFUL WAITING ~9 MONTHS WITH VOICE THERAPY, then surgery. The LEFT RLN loops under the AORTIC ARCH, the RIGHT under the RIGHT SUBCLAVIAN.
38. [Week 6] Answer: B. Patients may be severely disabled despite a normal neurologic exam and normal neuroimaging; ICD-10 defines this as symptoms beyond 3 weeks
Rationale: POST-CONCUSSION SYNDROME requires 3 OF: headache, dizziness, fatigue, insomnia, blurry vision, tinnitus, irritability, restlessness, poor concentration, memory trouble. PATIENTS MAY BE SEVERELY DISABLED WITH A NORMAL EXAM AND NORMAL IMAGING. ICD-10 defines PCS as symptoms LONGER THAN 3 WEEKS; PERSISTENT PCS is beyond 3 MONTHS, and 15% HAVE SYMPTOMS BEYOND A YEAR. Risk factors include NUMBER OF TIMES INJURED and pre-existing psychiatric conditions.
39. [Week 7] Answer: B. Weight reduction and acetazolamide; acetazolamide works almost immediately with most benefit in the first 4–6 weeks while weight loss takes longer
Rationale: FIRST LINE for IIH is WEIGHT REDUCTION AND ACETAZOLAMIDE, with TOPIRAMATE as an ADJUNCT (reduces migraine symptoms and suppresses appetite). ACETAZOLAMIDE IS EFFECTIVE ALMOST IMMEDIATELY with MOST BENEFIT IN THE FIRST 4–6 WEEKS, whereas weight loss takes longer to achieve. ESCALATION: optic nerve sheath fenestration, CSF shunting, venous sinus stenting. Goals: treat underlying disease, PROTECT VISION, minimize headache morbidity.
40. [Week 6] Answer: B. Non-contrast CT is the gold standard; hypertension is the most common cause, and BP should be gradually decreased to 150/90
Rationale: CT HEAD WITHOUT CONTRAST IS THE GOLD STANDARD for hemorrhagic stroke. HYPERTENSION IS THE MOST COMMON RISK FACTOR AND CAUSE of all types; for intraparenchymal bleeds, HTN is #1 followed by alcohol abuse and smoking. Outpatient: antihypertensives and STATINS (neuroprotective), with BP GRADUALLY DECREASED TO 150/90. PROPHYLACTIC ANTIEPILEPTICS ARE NOT RECOMMENDED. Only about 20% of survivors achieve independence.
41. [Week 7] Answer: B. Some relief in 2–4 weeks with complete relief up to 3 months, starting low and titrating slowly; prevention at about 4–6 migraine days per month
Rationale: MOST PREVENTIVES TAKE UP TO 3 MONTHS FOR COMPLETE RELIEF with SOME RELIEF IN THE FIRST 2–4 WEEKS; START LOW AND TITRATE SLOWLY. Prevention is indicated at 4–6 MIGRAINE DAYS PER MONTH (text says 6+, clinically 4+). Options: beta blockers or CCBs, topiramate, injectable SQ CGRP inhibitors, TCAs, venlafaxine, and ONABOTULINUMTOXIN A — approved ONLY for CHRONIC MIGRAINE.
42. [Week 6] Answer: B. Epidural; middle meningeal artery; neurosurgical emergency with evacuation ideally within 1–2 hours
Rationale: Epidural hematoma is blood between the DURA AND SKULL, 95% FROM SKULL FRACTURES AND BLUNT TRAUMA, most commonly from the MIDDLE MENINGEAL ARTERY in the TEMPOROPARIETAL region. Course: INITIAL LOC → LUCID INTERVAL UNDER 4 HOURS → RAPID DETERIORATION. It is a NEUROSURGICAL EMERGENCY — intervene WITHIN 1 TO 2 HOURS. PROGNOSIS IS EXCELLENT IF DETECTED AND TREATED EARLY, in contrast to subdural (30–80% mortality).
43. [Week 7] Answer: B. Neisseria meningitidis
Rationale: The CSF pattern — LOW GLUCOSE, ELEVATED PROTEIN, ELEVATED WBC WITH NEUTROPHIL PREDOMINANCE — indicates BACTERIAL meningitis. A PETECHIAL RASH with fever, headache, and nuchal rigidity is presumptive evidence of MENINGOCOCCAL disease. Bacterial causes by age: INFANTS UNDER 1 MONTH — Listeria, E. coli, group B strep; CHILDREN/ADOLESCENTS — NEISSERIA MENINGITIDIS; ADULTS — Streptococcus pneumoniae; consider LISTERIA over 50 or immunocompromised.
44. [Week 6] Answer: B. Treat the underlying cause with supportive and protective measures; avoid environmental change and restraints when possible
Rationale: There are NO FDA-APPROVED MEDICATIONS for delirium or its prevention. Diagnose it, then IDENTIFY AND TREAT THE CAUSE with a DRUG-SPARING APPROACH. The patient should NEVER BE LEFT ALONE (family preferred over a sitter), OPEN BLINDS for sleep-wake orientation, and AVOID CHANGE IN ENVIRONMENT AND RESTRAINTS — both increase agitation. Medications (haldol, lorazepam, quetiapine, risperidone) only if the patient threatens self or others.
45. [Week 7] Answer: B. Treat empirically with acyclovir immediately while awaiting serology
Rationale: VIRAL causes account for 70% of encephalitis, with HSV 1 AND 2 MOST COMMON (HSV-1 in adults, HSV-2 in infants). IF HSV IS SUSPECTED, TREAT WITH ACYCLOVIR IMMEDIATELY WHILE AWAITING SEROLOGY — early acyclovir significantly decreases mortality and morbidity. MRI with contrast shows inflammation primarily in the TEMPORAL AND FRONTAL LOBES; CSF shows elevated protein and lymphocytes. Remember to IMAGE BEFORE LP to assess for raised ICP.
46. [Week 6] Answer: B. Extracellular beta amyloid plaques and intraneuronal neurofibrillary tau tangles; 95% sporadic; trisomy 21 is a risk factor for early onset
Rationale: AD pathology: EXTRACELLULAR BETA AMYLOID PLAQUES and INTRANEURONAL NEUROFIBRILLARY TAU TANGLES, with atrophy in the HIPPOCAMPUS, TEMPORAL, and PARIETAL lobes. 95% IS SPORADIC. Autosomal dominant genes: PRESENILIN 1 (chr 14), PRESENILIN 2 (chr 1), APP (chr 21). APOE (chr 19) INCREASES RISK but does not guarantee disease. TRISOMY 21 IS A RISK FACTOR FOR EARLY-ONSET AD because APP sits on chromosome 21. Choice C describes Lewy body disease, D describes FTD. Note that DEFINITIVE DIAGNOSIS OF ANY DEMENTIA IS ONLY MADE AT AUTOPSY — all clinical diagnoses are probable — and no cognitive score alone diagnoses major neurocognitive disorder, since decline in daily function is also required.
47. [Week 6] Answer: B. Re-evaluate at 6 months, when about 85% of recovery has occurred; GCS under 4 on admission carries an 80% chance of death or remaining in a coma
Rationale: Re-evaluate 6 MONTHS after injury — 85% OF RECOVERY OCCURS BY THEN. Prognosis weighs GCS ON ADMISSION AND DISCHARGE, CT FINDINGS, and AGE. GCS UNDER 4 ON ADMISSION = 80% CHANCE OF DEATH OR REMAINING IN A COMA. EARLY cognitive, physical, and occupational therapy improves outcomes. In one study ONLY 46% RETURNED TO WORK AFTER 2 YEARS, and not to the same position.
48. [Week 7] Answer: B. Trigeminal distribution pain with IPSILATERAL autonomic features; hemicrania continua and chronic paroxysmal hemicrania
Rationale: TACs feature TRIGEMINAL DISTRIBUTION PAIN WITH IPSILATERAL AUTONOMIC FEATURES: conjunctival injection, lacrimation, nasal congestion, rhinorrhea, eyelid edema, forehead/facial sweating, MIOSIS, PTOSIS. HEMICRANIA CONTINUA and CHRONIC PAROXYSMAL HEMICRANIA are the INDOMETHACIN-RESPONSIVE entities. SUNCT/SUNA are very brief attacks treated with anticonvulsants (lamotrigine, gabapentin, topiramate). Cluster is the TAC you must know.
49. [Week 7] Answer: B. Aura is transient with full return to baseline, typically under 1 hour, and TIA/ischemic stroke are LESS likely to feature nausea, vomiting, photophobia, phonophobia, or paresthesia
Rationale: Migraine aura is TRANSIENT NEUROLOGIC DEFICITS WITH FULL RETURN TO BASELINE, TYPICALLY UNDER 1 HOUR — visual, auditory, somatosensory, or motor. About 25% of migraineurs have aura. Both migraine and TIA are transient, reversible, sudden onset with unremarkable imaging, but TIA AND ISCHEMIC STROKE ARE LESS LIKELY TO HAVE NAUSEA, VOMITING, PHOTOPHOBIA, PHONOPHOBIA, VISUAL DISTURBANCE, OR PARESTHESIA. Differentiate by onset and duration, nature of symptoms, persistent focal deficits, and patient age.
50. [Week 6] Answer: B. DLB — dementia precedes extrapyramidal symptoms by at least 1 year; PDD — Parkinson diagnosis precedes dementia by at least 1 year
Rationale: The highest-yield timing rule in the neurocognitive material. DLB: DEMENTIA PRECEDES EXTRAPYRAMIDAL SYMPTOMS BY AT LEAST ONE YEAR. PDD: PARKINSON'S DIAGNOSIS PRECEDES DEMENTIA BY AT LEAST ONE YEAR — cardinal signs of rigidity, bradykinesia, tremor, and postural instability come first. 20–40% of PD patients develop dementia. PIMAVANSERIN is the ONLY FDA-approved agent for hallucinations and delusions in PD and PDD.
Diseases of the Neurological System · Weeks 6 & 7 · ATL 2026 · For educational use only