Block 5 Neuro Reglodi Case Reviews W Expl
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- 1.
- A.
Diagnosis: acute disseminating encephalomyelitis, resulting from the viral infection she had. This spread to orbital infection manifesting in blurry vision.
- B.
Diagnosis: Viral meningitis, leading to severe neck pain when looking downwards (nuchal rigidity), inhibiting her from seeing the play from the upper row. Later meningeal plaques led to the involvement of the optic nerve around the sellar region.
- C.
Multiple system degeneration, a neurodegenerative disease affecting long tracts along ventricles. The first attack was due to the optic radiation involvement along the border of the lateral ventricle. The viral infection she had before triggered the autoimmune disease. The second attack was due to the degenerating optic nerve on one side.
- D.
Diagnosis: carotid aneurism. The first attack was caused by the forced position of the head to see the play and so the aneurism was pushed against the optic chiasm from the side. The second attack was caused by slow further growth of the aneurism, compressing the optic nerve.
- E.
Diagnosis: multiple sclerosis. The first attack affected her optic radiation in the occipital lobe, resulting in inferior sectoranopia (not seeing well from the upper rows of the theater). Second attack affected her optic nerve, which is a very common symptom of this disease.
Correct Answer
E. Diagnosis: multiple sclerosis. The first attack affected her optic radiation in the occipital lobe, resulting in inferior sectoranopia (not seeing well from the upper rows of the theater). Second attack affected her optic nerve, which is a very common symptom of this disease.Explanation
Multiple sclerosis is a demyelination disease, can start with a wide variety of
symptoms. It mainly affects first long fiber tracts, like the dorsal column of the spinal
cord (leading to gait instability), optic nerve (visual blurriness with pain –optic
neuritis), optic tract and optic radiation with different symptoms depending on the
exact location. The age of the patient in this case is also very typical: it is most
common in young women. The interval between the two attacks is also characteristic,
usually quite a long time passes between two attacks. Many times, just like in this
case, the first attack is not even recognized, patients often remember only at the
second time, that they already experienced something similar in the past.Rate this question:
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- 2.
- A.
Inferior vestibular nucleus
- B.
Ventral cochlear nucleus
- C.
Superior olivary nucleus
- D.
Inferior colliculus
- E.
Lateral geniculate nucleus
Correct Answer
C. Superior olivary nucleus -
- 3.
- A.
A sebum plug was swollen due to repeated water exposure, leading to a conductive hearing loss
- B.
Using Weber`s test, he could hear the sound better on his right side
- C.
Using Rinne`s test, he could hear the sound better when the fork was moved to his ear.
- D.
Middle ear infection is the most probable cause, resulting in sensorineural hearing loss
- E.
Applying the Epley`s maneuver, his condition got better
Correct Answer
A. A sebum plug was swollen due to repeated water exposure, leading to a conductive hearing lossExplanation
This is a typical case, especially if one cleans his ears by pushing the sebum inwards
with the ear cleaning tips. Webers test in this case would cause better hearing on the
left side (affected), while in Rinne test he would not hear the fork when placed in
front of his ear (conductive hearing loss). Middle ear infection is also possible, but
this also leads to conductive hearing loss, not sensorineural. Epleys maneuver is
applied in vertigo, has nothing to do with hearing.Rate this question:
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- 4.
Which statement is true for visual transmission?
- A.
Rod bipolar cells transmit information when light is on
- B.
On bipolar cells are hyperpolarized when light is on in the center of the receptive field
- C.
Off ganglion cells are depolarized when on bipolar cells are depolarized
- D.
On ganglion cells increase their firing rate when their on bipolar cells are depolarized
- E.
Depolarization of a cone in the periphery of the receptive field leads to hyperpolarization of the on bipolar cell in the periphery
Correct Answer
D. On ganglion cells increase their firing rate when their on bipolar cells are depolarizedExplanation
On ganglion cells increase their firing rate when their on bipolar cells are depolarized. This statement is true for visual transmission. Ganglion cells are the output cells of the retina and they respond to the activity of bipolar cells. When the on bipolar cells are depolarized, it indicates the presence of light in the receptive field, and this leads to an increase in firing rate of the on ganglion cells.Rate this question:
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- 5.
- A.
The chemotherapy damaged the vestibulocochlear nerve on both sides.
- B.
Cisplatin led to toxic damage of the outer hair cells.
- C.
Due to chemotherapy, one of the metastatic sites at the internal acoustic meatus got edemic, compressing the cochlear nerves.
- D.
Chemotherapy made the patient more susceptible to infections, and he had a severe middle ear infection, leading to hearing loss.
- E.
Metastatic spot in the rhomboid fossa in the vestibular area compressed one of the cochlear nuclei.
Correct Answer
B. Cisplatin led to toxic damage of the outer hair cells.Explanation
Cisplatin is one of the most well-known drug to cause ototoxicity, killing the hair
cells. although the other causes listed could also occur, the induced ototoxicity is the
far most common complication of this treatment.Rate this question:
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- 6.
What is true for adaptation when you enter from sunlight into a dark room?
- A.
Retinal pigment is bleached and it needs time to recover
- B.
Sensitivity is very high and it will decrease only after a few minutes
- C.
Vision has to switch from scotopic to photopic vision
- D.
Rods are not active in sunlight and they need some time to be reactivated
- E.
11-‐cis retinal has to be reconverted into all trans retinal to be able to sense light in a dark room
Correct Answer
A. Retinal pigment is bleached and it needs time to recoverExplanation
When you enter from sunlight into a dark room, the retinal pigment in your eyes is bleached due to the sudden change in light intensity. This bleaching process takes time to recover, meaning that your eyes need some time to adjust and regain their sensitivity to light. This explains why it takes a few moments for your vision to fully adapt to the darkness after coming from a bright environment.Rate this question:
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- 7.
- A.
Frontal lobe tumor involving the cortical eye field
- B.
Parietal lobe tumor leading to visual agnosia
- C.
Craniopharyngioma
- D.
Temporal lobe tumor with the involvement of the Meyer`s loop
- E.
Occipital lobe tumor around the calcarine sulcus
Correct Answer
C. CraniopHaryngiomaExplanation
Craniopharyngeoma is a tumor of the pituitary, most common onset is childhoodearly
adulthood. In young patients, visual field deficit can be hidden for a long time.
In children, headache can be very characteristic, much more than in adults, but still,
tumors can reach an enormous size before they cause any symptoms.Rate this question:
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- 8.
Which statement is true for color blindness?
- A.
The most common form affects the rods
- B.
Blue color blindness is more common in men, because blue pigment gene is coded on the X chromosome
- C.
Red-‐green color blindness is more common in men, because these genes are coded on the X chromosome
- D.
Achromatopsia is the most common form of color blindness
- E.
Lack of red or green pigment alone leads only to mild color blindness
Correct Answer
C. Red-‐green color blindness is more common in men, because these genes are coded on the X chromosomeExplanation
Because blue cone pigment is coded on another chromosome (not X), it is equally
common in men and women, but altogether it is very rare (duplicate encoding). Red
green pigments are encoded on the X chromosome, so it is much more common in
men.Rate this question:
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- 9.
- A.
Occipital lobe tumor, with macular sparing. Because his high acuity vision was intact, he did not notice the visual problem.
- B.
Prostate cancer spreading in the brain and giving metastasis in different parts, explaining the variety of symptoms. The visual pathway was not affected.
- C.
Craniopharyngioma combined with ocular albinism. In ocular albinism, the nasal retinal fibers do not cross, that is why he did not have any visual deficits.
- D.
Pituitary tumor (causing acromegaly) growing downwards toward the sphenoid sinus instead of upwards, therefore not causing visual deficits.
- E.
Hypophyseal sclerosis due to the early head trauma. In this case, the hypophysis is shrinking instead of growing, so no visual deficit is caused.
Correct Answer
D. Pituitary tumor (causing acromegaly) growing downwards toward the spHenoid sinus instead of upwards, therefore not causing visual deficits.Explanation
already in childhood. Later he continued to overproduce GH, so he developed
acromegaly (looking like Shrek). Later all organs can enlarge, so he had cardiac
problems, liver and spleen enlargement, and other symptoms related to increased GH
production (diabetes). For an unknown reason (possible relation to his childhood head
trauma and infection) the tumor is growing downwards, toward the sphenoid sinus, and
then towards the nasal cavity blocking his nasal breathing. The lack of chiasmal
compression (which is usually associated with pituitary tumors) explains why he did not
have visual field deficit.Rate this question:
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- 10.
- A.
Retinal detachment
- B.
Optic neuritis
- C.
Cataract
- D.
Glaucoma
- E.
Retinal hemorrhage
Correct Answer
A. Retinal detachmentExplanation
Marfan syndrome patients have a lot of complications, including ocular ones. One can
be retinal detachment, which, in this case is obvious based on the symptoms (painless
blurry vision, occasional lightning sensation).Rate this question:
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- 11.
- A.
ROP
- B.
Retinitis pigmentosa
- C.
Macular degeneration
- D.
Oculocutaneous albinism
- E.
Papilla edema
Correct Answer
D. Oculocutaneous albinismExplanation
Although very little information is given, but the hypopigmented retina and the lack
of focusing are signs of albinism. Most commonly, albino babies have blue eyes and
very white skin (even white hair), which might not be suspicious at first, given the
age of the baby (2 months old), especially if parents are also very white with blond
hair (common in northern europe for example). The lack of ability to focus can result
in continuous searching movements of the eyes, later nystagmus.Rate this question:
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- 12.
- A.
Bitemporal hemianopia
- B.
Inferior quadrantanopia
- C.
Superior quadrantanopia
- D.
Homonymous hemianopia
- E.
Nasal hemianopia
Correct Answer
B. Inferior quadrantanopiaExplanation
Periventricular leukomalacia is a white matter lesion, characteristic in premature
babies with complications. Often it affects the optic radiation around the occipital
horn of the lateral ventricle, thus, resulting in inferior quadrantanopia.Rate this question:
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- 13.
- A.
Craniopharyngioma
- B.
Medulloblastoma
- C.
Meningioma
- D.
Retinoblastoma
- E.
ROP
Correct Answer
D. RetinoblastomaExplanation
Retinoblastoma, most characteristically appearing at this age, can be suspected when
the tumor reflects light in a strange opalescent way, when light is shed onto the eye
(like when taking a picture with flash) and there is a clear difference between the two
eyes.Rate this question:
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- 14.
- A.
Pituitary tumor
- B.
Temporal lobe epilepsy
- C.
Occipital lobe stroke
- D.
Acoustic neurinoma
- E.
Periventricular leukomalacia
Correct Answer
A. Pituitary tumorExplanation
bitemporal hemianopia is one of the most common first symptoms in pituitary tumors
(he could not see people approaching from the side). Adults usually notice if there is a
visual field loss, it may be hidden for longer times in children. A tumor anywhere in
the brain can present itself by triggering a seizure, in which case it is obligatory to
perform brain imaging. The weight loss can be explained by compression of the
hypothalamus or interfering with pituitary hormones (no information in this case).Rate this question:
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- 15.
- A.
Left Homonymous hemianopia
- B.
Bitemporal hemianopia
- C.
Left upper quadrantanopia
- D.
Lower right quadrantanopia
- E.
Right upper quadrantanopia
Correct Answer
D. Lower right quadrantanopiaExplanation
The tumor was above the calcarine sulcus, where the lower visual field is presented,
so the patient has lower contralateral quadrantanopia.Rate this question:
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- 16.
- A.
It is indeed unnecessary because temporal lobe surgery cannot cause visual problems, only occipital lobe surgery can.
- B.
Tractography would be indeed unnecessary because they have to remove the whole sclerotic lesion anyway, independent from the fibers of the optic tract passing through, leading to inferior quadrantanopia after surgery.
- C.
This examination is unnecessary because the optic tract runs at approximately the same position in everyone and conventional MRI can reveal subtle individual differences.
- D.
It is an additional technique to reveal the exact position of the optic tract fibers and combined with electrophysiological examination to determine the focus of epilepsy, they can indeed minimize the risk of visual deficit, which would be contralateral superior quadrantanopia
- E.
Tractography visualizes the long tracts and so the optic tract is visible. Thus, it is suitable for determining the extent of the surgical intervention to avoid lesion of the Meyer`s loop, which would result in contralateral inferior sectoranopia.
Correct Answer
D. It is an additional technique to reveal the exact position of the optic tract fibers and combined with electropHysiological examination to determine the focus of epilepsy, they can indeed minimize the risk of visual deficit, which would be contralateral superior quadrantanopiaExplanation
Although still not used everywhere, tractography is a very useful tool in the surgeon’s
hand to see the exact borders of the future surgery. Especially useful when very impartant
brain areas are involved in/around the tumor (like pyramidal tract, visual pathway).
Temporal lobe epilepsy often leads to temporal lobe sclerosis, which is often resistant to
antiepileptic treatments. So surgery can be necessary. Questioning patients, one of the
most undesired side effects is visual field deficits, which can prevent them from obtaining
driver’s licence, affecting their quality of life in great deal. Therefore, it is necessary to
remove as small area as possible and to avoid visual field deficit due to surgery. The
Meyer’s loop loops around exactly the temporal lobe, and many people forget that
temporal lobe processes can also lead to visual field deficits (most people remember only
the occipital lobe in relation to the visual pathway).Rate this question:
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- 17.
The following case report was published in Neurol. Med. Chir. 2010 (Tokyo) Solitary metastatic tumor within the optic chiasm –case report
- A.
Nasal hemianopia
- B.
Bitemporal hemianopia
- C.
Contralateral homonymous quadrantanopia
- D.
Contralateral homonymous hemianopia
- E.
Ipsilateral nasal sectoranopia
Correct Answer
B. Bitemporal hemianopiaExplanation
It is a very obvious case, but a rare complication of this type of cancer.Rate this question:
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- 18.
Which statement is true for photoreceptors in darkness?
- A.
Sodium channels are closed
- B.
CGMP levels are high
- C.
Phosphodiesterase is activated
- D.
Transducin is activated
- E.
Retinal detaches from opsin
Correct Answer
B. CGMP levels are highExplanation
In darkness, photoreceptors are not receiving any light stimulus. This causes sodium channels in the photoreceptor cell membrane to close, preventing the influx of sodium ions. As a result, cGMP levels remain high because there is no activation of phosphodiesterase, which is responsible for breaking down cGMP. This high level of cGMP allows for the continuous opening of cGMP-gated ion channels, maintaining the photoreceptor in a depolarized state. Therefore, the correct statement is that cGMP levels are high in photoreceptors in darkness.Rate this question:
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- 19.
- A.
CN VI
- B.
CN III
- C.
CN V/1
- D.
CN VII
- E.
CN IV
Correct Answer
E. CN IVExplanation
CN IV refers to the fourth cranial nerve, also known as the trochlear nerve. This nerve is responsible for controlling the superior oblique muscle of the eye, which is responsible for downward and inward eye movement. CN IV is unique among the cranial nerves because it is the only one that exits from the dorsal side of the brainstem. Dysfunction of CN IV can lead to weakness or paralysis of the superior oblique muscle, resulting in difficulty with downward and inward eye movement, double vision, and tilting of the head to compensate.Rate this question:
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- 20.
- A.
Increased diplopia and asymmetry when looking to the right
- B.
Right eye does not adduct when looking to the left
- C.
Left eye does not abduct when looking to the left
- D.
Right eye abduction is impaired
- E.
Right eye is positioned down and out
Correct Answer
B. Right eye does not adduct when looking to the left -
- 21.
- A.
Argyll Robertson syndrome
- B.
Parinaud syndrome
- C.
Internuclear ophthalmoplegia
- D.
Horner syndrome
- E.
One-‐and-‐a-‐half syndrome
Correct Answer
E. One-‐and-‐a-‐half syndromeExplanation
One-and-a-half syndrome is a neurological disorder characterized by a combination of horizontal gaze palsy in one direction and internuclear ophthalmoplegia in the other direction. This means that the person is unable to move their eyes horizontally in one direction, and has impaired adduction and nystagmus in the other direction. This syndrome is caused by a lesion in the brainstem, specifically in the area where the abducens and medial longitudinal fasciculus (MLF) pathways cross.Rate this question:
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- 22.
- A.
Abducent nucleus
- B.
Trochlear nucleus
- C.
Pontine reticular formation
- D.
Oculomotor nucleus
- E.
Medial longitudinal fascicle
Correct Answer
E. Medial longitudinal fascicle -
- 23.
- A.
Left trochlear nerve palsy with Marcus Gunn pupil
- B.
Left oculomotor nerve palsy with Horner syndrome
- C.
Left abducent nerve palsy with Argyll Robertson pupil
- D.
Left abducent nerve palsy with Marcus Gunn pupil
- E.
Left MLF lesion with midriasis
Correct Answer
C. Left abducent nerve palsy with Argyll Robertson pupilExplanation
The lack of abduction of the left eye indicates left abducent nerve palsy. The lack
of pupillary constriction can be due to different lesions, and there was no
information given whether the constriction is preserved upon convergence (which
is necessary for the diagnosis of Argyll Robertson pupil). However, given the
patient`s history (AIDS with various other accompanying infections), this can be
assumed. AIDS patients often have neuro-ophthalmological complications,
including cranial nerve palsy, pupil disorders and optic neuritis. Argyll Robertson
pupil was classically described in syphilis, which is again more common,
especially in HIV-infected patients.Rate this question:
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- 24.
A 52-year-old man struck his occiput. A few hours later, he became aware of vertical diplopia. Brain CT disclosed no intracranial hemorrhage; however, MRI demonstrated a lesion.
- A.
CN VI
- B.
CN III
- C.
CN IV
- D.
MLF
- E.
PPRF
Correct Answer
C. CN IVExplanation
This is a case of isolated trochlear nerve palsy, due to a contusion at the trochlear
nerve exit zone, at the midbrain tegmentum (arrow). Trochlear nerve is the only
nerve exiting on the dorsal side, has a long intracranial course, is very thin, so it is
vulnerable in traumatic injuries. This patient had complete recovery after 1 monthRate this question:
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- 25.
- A.
Increased intracranial pressure and vertical gaze palsy
- B.
Optic neuritis and CN VI lesion
- C.
Optic neuritis and CN IV lesion
- D.
Compression of the central retinal artery and Parinaud syndrome
- E.
Macular degeneration and horizontal gaze palsy
Correct Answer
A. Increased intracranial pressure and vertical gaze palsyExplanation
A pineal tumor would typically compress the cerebral aqueduct and the midbrain
center for vertical gaze (Parinaud syndrome). In this case, the boy did not have the
expected vertical gaze palsy in spite of the huge size of the tumor. But he did have
increased intracranial pressure, severe hydrocephalus, which led to the edematous
papilla and vomiting.Rate this question:
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.JPG "The following case report was published in Neurol. Med. Chir. 2010 (Tokyo) Solitary metastatic tumor within
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.JPG "A 52-year-old man struck his occiput. A few hours later, he became aware of vertical diplopia. Brain CT disclosed no intracranial hemorrhage; however, MRI demonstrated a lesion.")
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