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Neurosurgery Board Review

Questions and Answ ers for Self-Assessment

Third Edition

Cargill H. Alleyne Jr., MD


Professor an d Marshall Allen Dist inguish ed Ch airm an
Resid en cy Program Director
Depar t m en t of Neu rosu rger y
Medical College of Georgia at Georgia Regen t s Un iversit y
Augu st a, Georgia

M. Neil Wo o dall, MD
Ch ief Resident
Depar t m en t of Neu rosu rger y
Medical College of Georgia at Georgia Regen t s Un iversit y
Augu st a, Georgia

Jo nathan Stuart Citow , MD, FACS


Ch ief of Neurosurger y
Advocate Con dell Medical Cen ter
Liber t yville, Illin ois
Assist an t Clin ical Professor of Neu rosu rger y
Rosalin d Fran klin Un iversit y Medical Sch ool
Nor th Ch icago, Illinois
an d
President of th e Am erican Cen ter for Spin e an d Neurosurger y
Liber t yville, Illin ois

268 illu st rat ion s

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Neu rosurger y board review : quest ion s and an sw ers w h et h er th e d osage sch ed u les m en t ion ed t h erein or
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Th is book is dedicated to m y w ife, Audrey, an d ch ildren , Nath an an d Nicole, w h ose love
an d su p port keep m e grou n ded; m y paren ts, Cargill Sr. an d Lin n et te, an d sister, Carlin ,
w h o t augh t m e th e m ean ing of fam ily; an d to th e m any residen ts w ith w h om I h ave
w orked over th e years.

Cargill H. Alleyne Jr., MD

To m y w ife, An n eliese, m y son , Art , an d m y paren ts, Jam es an d Lin da, for th eir un con -
dit ion al love an d suppor t .

M. Neil W oodall, MD

Th is book is dedicated to m y th ree m ost in terest ing ch ildren , Benjam in Joseph , Em m a


Carolin e, an d Harrison At t icu s Ch am berlain . Hop efu lly w h en you each join th e clan of
n eu rosu rgeon s (n o p ressu re th ere...), you w ill correct any in accu racies w e h ave m ade
h ere in th is text , ju st as you are so w on t to do w ith anyth ing I tou ch at h om e.

Jonathan S. Citow , MD

v
Contents

Fo rew o rd to the Third Editio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix


Fo rew o rd to the Se co nd Editio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .x
Preface to the Third Editio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface to the Seco nd Editio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Preface to the First Editio n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

1A. Neurosurger y – 4C. Neu robiology –


Qu est ion s . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 An sw ers an d
Exp lan at ion s . . . . . . . . . . . . . . . . . . . . . . .189
1B. Neurosurger y –
An sw er Key . . . . . . . . . . . . . . . . . . . . . . . . . 25 5A. Neurop ath ology –
Qu est ion s . . . . . . . . . . . . . . . . . . . . . . . . . .207
1C. Neu rosu rger y –
An sw ers an d 5B. Neuropath ology –
Explan at ion s . . . . . . . . . . . . . . . . . . . . . . . . 28 An sw er Key . . . . . . . . . . . . . . . . . . . . . . . .248
2A. Clin ical Neu rology – 5C. Neu ropath ology –
Qu est ion s . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 An sw ers an d
Exp lan at ion s . . . . . . . . . . . . . . . . . . . . . . .251
2B. Clin ical Neu rology –
An sw er Key . . . . . . . . . . . . . . . . . . . . . . . . . 80 6A. Neuroradiology –
Qu est ion s . . . . . . . . . . . . . . . . . . . . . . . . . .294
2C. Clin ical Neurology –
An sw ers an d 6B. Neurorad iology –
Explan at ion s . . . . . . . . . . . . . . . . . . . . . . . . 84 An sw er Key . . . . . . . . . . . . . . . . . . . . . . . .330
3A. Neuroan atom y – 6C. Neu roradiology –
Qu est ion s . . . . . . . . . . . . . . . . . . . . . . . . . .110 An sw ers an d
Exp lan at ion s . . . . . . . . . . . . . . . . . . . . . . .332
3B. Neuroan atom y –
An sw er Key . . . . . . . . . . . . . . . . . . . . . . . .136 7A. Clinical Skills/Crit ical
Care – Quest ion s . . . . . . . . . . . . . . . . . . .368
3C. Neu roan atom y –
An sw ers an d 7B. Clinical Skills/Crit ical
Explan at ion s . . . . . . . . . . . . . . . . . . . . . . .140 Care – An sw er Key . . . . . . . . . . . . . . . . . .382
4A. Neurobiology – 7C. Clin ical Skills/Crit ical
Qu est ion s . . . . . . . . . . . . . . . . . . . . . . . . . .169 Care – An sw ers an d
Exp lan at ion s . . . . . . . . . . . . . . . . . . . . . . .385
4B. Neurobiology –
An sw er Key . . . . . . . . . . . . . . . . . . . . . . . .186 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Forew ord to the Third Edition
Board cert i cat ion h as been a rite of p as- diagnosis – including im age interpretat ion
sage in ou r specialt y sin ce Th e Am erican – and t reat m ents such as, but not lim ited
Board of Neu rological Su rger y (ABNS) to neurocrit ical intensive care and
w as app roved as a n ew exam in ing board rehabilitat ion) and operat ive m anagem ent
in 1940. Sin ce it s in cept ion , th e prim ar y w ith it s associated im age use and inter-
p u rp ose of th e ABNS h as been to con - pretat ion (e.g. endovascular surgery, func-
duct exam in at ion s of can didates w h o t ional and restorat ive surgery, stereotact ic
volu n t arily seek cert i cat ion , an d to is- radiosurgery, and spinal fusion – including
su e cert i cates to th ose w h o m eet th e its inst rum entat ion.”
requirem en t s of th e Board an d sat isfac-
torily com plete th ose exam in at ion s. Th e W h ile a residen t at Em or y Un iversit y,
rst o cial m eet ing of th e ABNS w as h eld Dr. Alleyn e created a p rod igiou s list of
in Ch icago on October 17, 1940. Tw en t y- quest ion s based upon preparat ion for h is
fou r can didates for cert i cat ion w ere w rit ten board exam in at ion . In an e or t
exam in ed . Th ose 24 m en w ere exam in ed to assist oth er residen t s, th at com p ilat ion
on a specialt y th at w as relat ively elem en - later becam e th e rst edit ion of Neuro-
t ar y by today’s st an dards. Neurosurger y surgery Board Review . Th at m on ograp h
w as sim p ly de n ed as a sp ecialt y focu sed an d th e secon d edit ion h ave becom e
on surgical t reat m en t of diseases of th e a t im e-h on ored an d popu lar m eth od
n er vou s system . As th e ABNS celebrates for residen ts to p repare for th eir w rit-
it s 75th an n iversar y, th at de n it ion of ten board exam in at ion . With advan ces
ou r specialt y h as been t ran sform ed. in th e n eu roscien ces in gen eral an d ou r
specialt y speci cally, h as com e th e n eed
“Neu r ologica l su r ger y const it utes a to u pdate th is w ork. Th is th ird edit ion
m edical discipline and surgical specialt y of Neurosurgery Board Review con tain s
that provides care for adult and pediat ric n ot on ly qu est ion s an d an sw ers bu t also
pat ient s in the t reat m ent of pain or explan at ion s of th ose correct an sw ers to
pathological processes that m ay m odify en h an ce th e overall kn ow ledge base of
the funct ion or act ivit y of the cent ral th e reader. I am con den t th is w ork w ill
nervous system (e.g. brain, hypophysis, con t in u e to provide a valuable resou rce
and spinal cord), the peripheral nervous for all n eu rosu rgeon s, bu t p art icu larly
system (e.g. cranial, spinal, and peripheral residen t s preparing for th e rst step to-
nerves), the autonom ic nervous system , w ard cer t i cat ion by th e ABNS.
the support ing st ruct ures of these system s
(e.g. m eninges, sk ull & sk ull base, and ver- Daniel L. Barrow , MD
tebral colum n), and their vascular supply Pam ela R. Rollins Professor and Chairm an
(e.g. int racranial, ext racranial, and spinal Depart m ent of Neurosurgery
vasculat ure). Director, Em ory MBNA St roke Center
Em ory Universit y School of Medicine
Treat m ent encom passes both non- Form er Director, Secretary, President
operat ive m anagem ent (e.g. prevent ion, Am erican Board of Neurological Surgery

ix
Forew ord to the Second Edition
Most learn ed p rofession s requ ire t h eir study guide for individuals preparing for
m em bersh ip to d em on st rate am in i- the prim ary exam ination of the Am erican
m al level of com p eten cy to be fu lly ac- Board of Neurological Surgeons. This e ort
cepted in to th at p u rsu it . Cer t i cat ion also provides an outstanding resource for
by t h e Am erican Board of Neu rological physicians involved in the neurosciences at
Su rgeon s (ABNS) is a rite of p assage in any level of their career w ho m ay be m o-
th e edu cat ion al p rocess of ou r ch osen tivated to assess their current know ledge.
p rofession . In addition to self-assessm ent this volum e
guides readers to appropriate resources
For the assiduous neurosurgical resident, to expand their know ledge in areas of
assem bly and organization of the m ate- de ciency.
rial necessary to study for Part I of the
ABNS exam ination can be an onerous task. Many factors in u en ce a n eu rosu rgeon’s
Dr. Alleyne has com piled a set of questions ch oice to pursue an academ ic career. A
he originally developed w hile studying passion for teach ing, h ow ever, is an essen -
for the oral boards during his residency at t ial feat ure of th e successful academ ian .
Em ory Universit y School of Medicine. Based Dr. Alleyn e h as dem on st rated h is p assion
in part on his outstanding perform ance on for teach ing th rough th e produ ct ion of
that exam ination, he was encouraged by th is valuable volum e.
his co-residents and colleagues to share his
e orts and eventually publish them . In do- Daniel L. Barrow , MD
ing so, Dr. Alleyne has provided a valuable Atlanta, Georgia

x
Preface to the Third Edition
Dr. Alleyn e w rote th e rst edit ion of h is classic book are th reefold: (1) in crease
board review book w h ile preparing to th e n um ber of quest ion s an d h igh -yield
t ake th e w rit ten por t ion of th e ABNS im ages to re ect th e ch anging scope of
exam as a residen t . Seven years later, in n eurosurger y; (2) correct any errors con -
2004, h e an d Dr. Citow im proved th e book tain ed in the secon d edit ion ; an d (3) m ost
w ith addit ion al quest ion s an d im ages. im p ort an tly, provide det ailed explan a-
Mu ch h as ch anged in n eu rosu rger y over t ion s for each quest ion . We h ope th at
th e past 10 years, in cluding the w ide- th e reader w ill be able to use th is text for
sp read u se of en d ovascu lar tech n iqu es self-assessm en t , bu t also to en h an ce h is
for th e t reat m en t of cerebral an eu r ysm s, or h er un derst an ding of th e m aterial. Th e
th e availabilit y of a n ew arm am ent arium form at of th e book h as also been ch anged
of advan ced im aging tech n iqu es, an d to m ake it m ore u ser-frien dly.
m ajor ch anges in th e t reat m en t of acu te
isch em ic st roke. Preparing for t h e ABNS prim ar y exam is
a su bst an t ial u n d er t aking. We h op e th at
Cert ain ly ever y residen t taking th e ABNS th is t h ird edit ion w ill aid in you r self-
p rim ar y exam w an t s to do h is or h er assessm en t , en h an ce you r u n d erst an d ing
ver y best , bu t a h igh score on th e exam of th e m aterial, an d give you con den ce
is n ot th e p rim ar y en dpoin t . Our goal as w h en you get ready to sit for th e boards.
st u den t s an d p ract it ion ers of n eu rosu r-
ger y is understanding of th e m aterial. Th e M. Neil W oodall, MD
goals of th is th ird iterat ion of Dr. Alleyn e’s Augusta, Georgia

xi
Preface to the Second Edition
In th e 7 years sin ce th e p u blicat ion of con t ribu ted by Jon ath an St uart Citow,
th e rst edit ion , th ere h ave been several MD. Several of th e excellen t an atom ic dis-
oth er review text s p u blish ed to aid in sect ion s by Dr. Al Rh oton are in clu ded in
th e review for th e w rit ten port ion of th e Neurosurger y sect ion . I w ould again
th e Neurosurger y Board Exam in at ion . like to th an k th e editorial an d p roduct ion
Th is secon d edit ion rem ain s a text to be sta at Th iem e for th eir excellen t w ork. I
u sed for self-assessm en t an d review to also th an k An dy Rekito, ou r illu st rator in
facilit ate, n ot replace, p rim ar y st u dy. Th e th e Depart m en t of Neurosurger y at th e
form at rem ain s th e sam e, bu t th e tot al Med ical College of Georgia, for h is su perb
n u m ber of qu est ion s h as been in creased art w ork.
to over 1,200. Th ese in clu de approxim ate-
ly 200 n ew quest ions, 100 of w h ich w ere Cargill H. Alleyne Jr., MD

xii
Preface to the First Edition
This work m aterialized as I was studying accom panied by answers that have been
for the w ritten portion of the Neurosurgery referenced to m ajor texts in the respective
Board Exam ination; it is based largely on subspecialt y areas. Unless the questions are
the question content areas revealed by deem ed self-explanatory, brief explana-
the Am erican Board of Neurological Sur- tions are also provided. Every attem pt was
gery over the last several years. As the m ade to ensure the clarit y of questions and
exam ination loom ed closer, I was able to the accuracy of answers, but the reader is
use the questions I had previously w rit- urged to refer to the references listed or to
ten to aid in the review process. The text other standard textbooks for further detail
should m ainly bene t neurosurgery resi- should the need arise. Sincere gratitude is
dents, but it m ay also appeal to residents expressed to the facult y on the editorial
in other neuroscience subspecialties. It is board for their critique of the m anuscript.
com posed of over 1,000 m ultiple choice I would also like to thank the editorial
questions in seven sections: Neurosurgery and production sta at Thiem e for their
(132 questions, including 3 photographs), excellent work. It is hoped that the use of
Clinical Neurology (214 questions), Neu- this text for self-assessm ent w ill facilitate
roanatomy (185 questions), Neurophysi- the arduous task of review for the w rit-
ology (146 questions), Neuropathology ten portion of the Neurosurgery Board
(134 questions, including 52 photographs), Exam ination.
Neuroradiology (83 questions, including
51 photographs), and Clinical Skills/Criti- Cargill H. Alleyne Jr., MD
cal Care (126 questions). The proportion Resident in Neurosurgery
of questions in each section approxim ately Em ory Universit y School of Medicine
m irrors that of the Neurosurgery w rit- 1997
ten Board exam ination. Each section is

xiii
1A Neurosurgery—Questions

For qu est ion s 1 to 9, iden t ify th e follow ing st ru ct u res. Th e gu re illu st rates a righ t
t ran scallosal approach to th e th ird ven t ricle.

1. Caudate n ucleus

2. Ch oroid plexus

3. Foram en of Mon ro

4. Colum n s of th e forn ix

5. Sept um pellucidum

6. Th alam ost riate vein

7. Th alam us

8. Body of th e forn ix

9. An terior caudate vein

1
Neurosurgery Board Review

10. Surgical procedures ut ilized in th e t reat m en t of spasm odic tor t icollis in clude
I. Up p er cer vical ven t ral rh izotom ies an d sp in al accessor y n eu rectom y
II. Stereot act ic th alam otom y
III. Microvascu lar decom pression of th e sp in al accessor y n er ve
IV. Myotom y
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

11. W h ich surgical approach for th oracic disk h ern iat ion s is associated w ith th e
h igh est rate of n eu rologic inju r y?
A. Costot ran sversectom y
B. Lateral ext racavit ar y
C. Midlin e lam in ectom y
D. Tran spedicular
E. Tran sth oracic

12. Most pat ien t s w ith in t rin sic brain stem gliom as in it ially presen t w ith
A. Cran ial n eu ropath ies
B. Headach e
C. Hydroceph alu s
D. Nausea an d vom it ing
E. Papilledem a

13. Each of th e follow ing is ch aracterist ic of com plex region al pain syn drom e II
(causalgia) except
A. At roph ic ch anges in th e lim b
B. Hypesth esia
C. In creased sw eat ing
D. Lack of m ajor m otor de cit
E. Good relief w ith sym path et ic block

For qu est ion s 14 to 18, m atch th e descript ion w ith th e st ru ct u re.


A. Derm oid cyst
B. Epiderm oid cyst
C. Both
D. Neith er

14. Bacterial m en ingit is

15. Asept ic m en ingit is

16. Associated congen it al m alform at ion s

17. Most often m idlin e

18. Respon sive to radiat ion th erapy

2
Neurosurgery—Questions

19. Ven t ricular en largem en t from ch oroid plexus papillom as can be secon dar y to
I. En t rap m en t of cerebrospin al u id (CSF)
II. Decreased absorpt ion of CSF from h em orrh age-in du ced arach n oidit is
III. Tu m or grow th
IV. Excessive produ ct ion of CSF
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

20. W h ich approach is favored for a pat ien t w ith an 8-m m acoust ic n eurom a in
w h ich h earing preser vat ion is a goal?
A. Middle fossa
B. Suboccipital
C. Tran slabyrin th in e

21. Un cin ate seizures t ypically produ ce


A. Auditor y h allucin at ion s
B. Gust ator y h allu cin at ion s
C. Olfactor y h allucin at ion s
D. Vert igin ous sen sat ion s
E. Visual seizures

For qu est ion s 22 to 25, m atch th e descript ion w ith th e st ru ct u re.


A. Calcarin e sulcus
B. Lateral m esen ceph alic sulcu s
C. Posterior com m un icat ing arter y
D. Tect al plate

22. Separates th e P1 an d P2A segm en t s of th e posterior cerebral ar ter y

23. Separates th e P2A an d P2P segm en t s of th e posterior cerebral ar ter y

24. Separates th e P2P an d P3 segm en t s of th e posterior cerebral ar ter y

25. Separates th e P3 an d P4 segm en t s of th e posterior cerebral ar ter y

26. Th e radial n er ve or on e of it s bran ch es in n er vates each of th e follow ing except th e


A. Abductor pollicis longus
B. Addu ctor pollicis
C. Brach ioradialis
D. Exten sor pollicis brevis
E. Supin ator

3
Neurosurgery Board Review

27. Each of th e follow ing is t rue of in t raven t ricu lar h em orrh age (IVH) in th e n ew born
except
A. Periven t ricu lar h em orrh agic in farct ion is on e sequela.
B. Posth em orrh agic hydroceph alus can result in persisten t bradycardia an d
ap n eic sp ells.
C. Th e capillar y bed of th e germ in al m at rix is com posed of large irregular
vessels.
D. Th e germ in al m at rix is th e m ost com m on site of IVH in th e full-term
n eon ate.
E. Th e risk of IVH is greater in th e preterm th an in th e term in fan t .

28. Th e ossi cat ion cen ters of th e odon toid con sist of
A. On e prim ar y an d t w o secon dar y cen ters
B. On e secon dar y an d th ree prim ar y cen ters
C. Th ree secon dar y an d on e prim ar y cen ter
D. Tw o prim ar y cen ters
E. Tw o prim ar y an d on e secon dar y cen ter

29. Th e m ost com m on single-su t ure syn ostosis is


A. Coron al
B. Lam bdoid
C. Metopic
D. Sagit t al
E. Sph en ozygom at ic

30. Th e m ost sen sit ive m eth od for detect ing carpal t un n el syn drom e is
A. Needle exam in at ion of th e abductor pollicis brevis
B. Needle exam in at ion of th e rst an d secon d lum bricals
C. Motor am plit ude of th e m edian n er ve
D. Motor distal laten cy of th e m edian n er ve
E. Palm ar sen sor y con duct ion t im e of th e m edian n er ve

31. Coup con t usion s m ost com m on ly occur at th e


A. Cerebral convexit ies
B. Fron t al an d tem poral poles
C. Orbit al surface of th e fron t al lobes
D. Posterior fossa
E. Ven t ral surface of th e tem poral lobe

For qu est ion s 32 to 36, m atch th e an eu r ysm w ith th e sign or sym ptom it is m ost likely
to produ ce. Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. An terior com m u n icat ing arter y an eur ysm
B. In t racavern ou s carot id ar ter y an eu r ysm
C. Middle cerebral ar ter y an eur ysm
D. Oph th alm ic ar ter y an eur ysm
E. Posterior com m un icat ing arter y an eur ysm

32. Pupil-involving th ird n er ve palsy

33. Seizu res

34. Diabetes in sipidus

4
Neurosurgery—Questions

35. In ferior n asal quadran t an opia

36. Exoph th alm os

37. Th e essen t ial di eren ce bet w een a syringom yelic an d a hydrom yelic cavit y is
th at th e cavit y in
A. Hydrom yelia is lin ed w ith epen dym al cells, an d in syringom yelia is n ot
B. Hydrom yelia is lin ed w ith ch oroid plexu s, an d in syringom yelia is n ot
C. Syringom yelia con t ain s CSF, an d in hydrom yelia con tain s seru m
D. Syringom yelia is focal, an d in hydrom yelia is m ore exten sive
E. Syringom yelia is an en largem en t of th e cen t ral can al, an d in hydrom yelia is
an en largem en t of th e an terior m ed ian sept u m

For qu est ion s 38 to 45, iden t ify th e follow ing st ru ct u res. Th e gu re illu st rates th e
st ru ct u res exposed th rough th e righ t opt icocarot id t riangle.

38. Basilar ar ter y

39. Pit uitar y st alk

40. Righ t ocu lom otor n er ve

41. Righ t posterior cerebral ar ter y

42. In tern al carot id arter y

43. Left duplicated superior cerebellar arter y

44. Righ t superior cerebellar ar ter y

45. Righ t an terior cerebral arter y (A1 segm en t)

46. Each of th e follow ing is t rue of basilar im pression except


A. Cerebellar an d vest ibular com plain t s t ypically oversh adow m otor an d
sen sor y com plain ts.
B. McGregor’s lin e is h elpful in rout in e screen ing.
C. McRae’s lin e is h elpful in clin ical assessm en t .
D. Sh ort n ecks an d tort icollis are com m on .
E. Vertebral ar ter y an om alies are com m on .

5
Neurosurgery Board Review

47. W h ich of th e follow ing fract ures h as th e poorest progn osis for h ealing w ith out
su rgical in ter ven t ion ?
A. Hangm an’s
B. Je erson’s fract u re w ith 4 m m displacem en t of lateral m asses
C. Type I odon toid
D. Type II odon toid
E. Type III odon toid

48. Sprengel’s deform it y refers to a(n )


A. Congen it al elevat ion of th e scap ula
B. Congen it al fusion of th e upper cer vical ver tebrae
C. In t raver tebral disk h ern iat ion
D. Postlam in ectom y kyph osis
E. Scoliosis result ing from teth ering of th e spinal cord

For qu est ion s 49 to 55, m atch th e fract u re t yp e w ith th e m ech an ism . Each respon se
m ay be u sed on ce, m ore th an on ce, or n ot at all.

Force Neck Post u re


A. Flexing exed
B. Com pressing exed
C. Com pressing n eut ral
D. Dist ract ing exten ded
E. Flexing axially rot ated
F. Com p ressing laterally ben t

49. Hangm an’s fract ure

50. Burst fract ure

51. Un ilateral facet dislocat ion

52. Teardrop fract ure

53. Bilateral facet dislocat ion

54. Horizon t al facet fract ure

55. Je erson’s fract u re

56. Lateral recess sten osis in spon dylosis is m ost com m on ly caused by
A. Disk h ern iat ion
B. Hyper t rophied pedicles
C. In ferior art icular facet hypert rophy
D. Ligam en t um avum hyper t rophy
E. Superior ar t icular facet hypert rophy

6
Neurosurgery—Questions

57. In th e t reat m en t of ch ron ic pain , th e u n desirable e ect(s) th at is/are m ore


com m on in st im ulat ion of th e periaqueductal gray th an th e periven t ricu lar gray
region is/are
I. Diplop ia
II. Oscillop sia
III. Redu ct ion of u pgaze
IV. Sen se of im p en ding doom
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

58. “Trilateral ret in oblastom a” describes bilateral ocular ret in oblastom as an d a(n )
A. Ast rocytom a
B. Medulloblastom a
C. Neuro brom a
D. Opt ic n er ve sh eath t um or
E. Pin eoblastom a

59. Carot id arter y ligat ion is absolutely con t rain dicated in pat ien ts w ith (a)
A. Bilateral in t racavern ous carot id an eu r ysm s
B. Gian t oph th alm ic arter y an eur ysm an d eviden ce of vasospasm on
ar teriogram
C. Gian t op h t h alm ic ar ter y an eu r ysm an d ext racran ial ath erosclerot ic
d isease
D. In t racavern ous carot id arter y an eur ysm an d sudden loss of ext raocular
m ot ilit y
E. Traum at ic dissect ing an eur ysm of th e pet rou s carot id ar ter y

60. Th e syn drom e of w eakn ess in on e upper ext rem it y follow ed by low er ext rem -
it y w eakn ess on th e sam e side, th en con t ralateral low er ext rem it y w eakn ess, is
m ost ch aracterist ic of a m en ingiom a involving th e
A. Clivus
B. Falx
C. Foram en m agn um
D. Olfactor y groove
E. Tuberculum sella

7
Neurosurgery Board Review

For qu est ion s 61 to 70, th e gu re illu st rates a lateral view of th e left cavern ou s sin u s.
Match th e follow ing t riangles w ith th e descript ion s/st ru ct u res. Each respon se m ay be
u sed on ce, m ore th an on ce, or n ot at all.

A. Clin oidal
B. Oculom otor
C. Suprat roch lear
D. In frat roch lear or Parkin son’s
E. An terom edial
F. An terolateral
G. Posterolateral or Glasscock’s
H. Posterom edial or Kaw ase’s

61. Clin oidal segm en t of th e in tern al carot id ar ter y

62. In t racavern ou s carot id arter y

63. In t rapet rou s carot id ar ter y

64. Men ingohypophyseal t run k origin

65. Opt ic st rut

66. Sph en oid sin us an d low er m argin of V1

67. Tw o m argin s of th is t riangle are form ed by th e an terior an d posterior pet rocli-


n oidal du ral folds.

68. Located bet w een V2 an d V3

69. Con t ain s th e foram en spin osum

70. Con t ain s th e coch lea

8
Neurosurgery—Questions

71. W h ich of th e follow ing n dings is m ost con sisten t w ith adh eren ce of a posterior
com m un icat ing ar ter y an eur ysm to th e tem poral lobe?
A. Loss of con sciousn ess
B. Absen ce of th ird n er ve palsy
C. Project ion of th e an eur ysm m edial to th e carot id on th e an teroposterior
(AP) angiogram
D. Th ird n er ve involvem en t
E. Seizures

72. Weakn ess of th e deltoid m uscle is caused by injur y to th e


A. Axillar y n er ve
B. Dorsal scapular n er ve
C. Musculocu tan eous n er ve
D. Suprascapular n er ve
E. Th oracodorsal n er ve

73. Subdural em pyem a result ing after m en ingit is in an in fan t m ost com m on ly devel-
ops w ith
A. Escherichia coli
B. Haem ophilus inf uenzae
C. Listeria
D. Neisseria
E. Staphylococcus

74. Sudeck’s at rophy, associated w ith re ex sym path et ic dyst rophy, refers to at ro-
p h ic ch anges occu rring in each of th e follow ing st ru ct ures except
A. Bon e
B. Join ts
C. Mu scle
D. Ner ve
E. Skin

For qu est ion s 75 to 79, m atch th e em br yologic even t w ith th e p ostovu lator y day. Each
resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.

Postovulator y Day Num ber


A. 13
B. 17
C. 22
D. 24
E. 26

75. Closure of th e caudal n europore

76. Closure of th e cran ial n eu ropore

9
Neurosurgery Board Review

77. Form at ion of th e n otoch ord

78. Form at ion of th e prim it ive st reak

79. Fusion of th e n eural folds to form th e n eural t ube

80. Factors th at predispose to th e subclavian steal syn drom e in clude


I. Occlu sion of th e left su bclavian ar ter y p roxim al to th e origin of th e
left vertebral ar ter y
II. Occlu sion of th e left su bclavian ar ter y dist al to th e origin of th e left
vertebral ar ter y
III. Act ive u se of th e left arm
IV. Occlu sion of th e left vertebral ar ter y
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

81. Th e art icu lar facet join t in th e upper th oracic region is orien ted
A. Axially
B. Coron ally
C. Obliquely
D. Sagit t ally

82. Th e m ost com m on presen t ing sym ptom of a th oracic h ern iated disk is
A. Back pain
B. Leg n um bn ess
C. Leg w eakn ess
D. Th oracic n um bn ess
E. Urin ar y in con t in en ce

83. Neurologic de cit s th ough t to result from occlusion of th e th alam ost riate vein
during th e subch oroidal t ran svelum in terposit um approach to th e th ird ven t ricle
in clud e
I. Drow sin ess
II. Hem ip aresis
III. Mu t ism
IV. Seizu res
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

10
Neurosurgery—Questions

For qu est ion s 84 to 88, th e gu re illu st rates th e righ t in tern al au ditor y can al th rough a
m id dle fossa app roach . Iden t ify th e follow ing n er ves.

84. Labyrin th in e segm en t of th e facial n er ve

85. Meat al segm en t of th e facial n er ve

86. Superior vest ibular n er ve

87. Greater super cial pet rosal n er ve

88. Gen iculate ganglion

89. In th e suboccipit al t ran sm eat al approach to an acoust ic n eurom a, th e locat ion of


th e facial n er ve in relat ion to th e t um or, in decreasing frequen cy of occurren ce, is
A. An terior, posterior, in ferior
B. An terior, superior, in ferior
C. Superior, an terior, posterior
D. Posterior, superior, an terior
E. An terior, posterior, superior

90. Each of th e follow ing feat ures is usu ally m in im al or absen t in pat ien t s w ith
t yp e 2 n eu ro brom atosis except
A. Axillar y freckles
B. Café au lait spot s
C. Lisch n odules
D. Mult iple, t ypical skin n euro brom as
E. Skin plaques

91. Th e single m ost im port an t factor in th e recurren ce of m en ingiom as is


A. Age of th e p at ien t
B. Bon e invasion
C. Histologic t ype of ben ign m en ingiom a
D. Postoperat ive t u m or residual
E. Sex of th e pat ien t

11
Neurosurgery Board Review

For qu est ion s 92 to 98, m atch th e cistern w ith th e st ru ct u re it con t ain s. Each respon se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Am bien t cistern
B. Cerebellopon t in e angle cistern
C. In terpedun cular cistern
D. Lateral cerebellom edu llar y cistern
E. Prepon t in e cistern
92. Con t ain s th e an teroin ferior cerebellar arter y (AICA)
93. Con t ain s th e origin of th e posteroin ferior cerebellar arter y (PICA)
94. Con t ain s th e superior cerebellar arter y
95. Con t ain s cran ial n er ve (CN) IV
96. Con t ain s CN V
97. Con t ain s th e basal vein of Rosen th al
98. Con t ain s th e ch oroid plexus at th e foram en of Lu sch ka
99. Th e t ran sverse crest separates th e
A. Coch lear, facial, an d sup erior vest ibu lar n er ves from th e in ferior vest ibu lar
n er ve
B. Coch lear an d in ferior vest ibular ner ves from th e facial an d superior ves-
t ibu lar n er ves
C. Facial an d coch lear n er ves from th e superior an d in ferior vest ibular n er ves
D. Facial, coch lear, an d in ferior vest ibular n er ves from th e superior vest ibu lar
n er ve
E. Facial an d in ferior vest ibu lar n er ves from th e coch lear an d superior
vest ibu lar n er ves
100. W h ich of th e follow ing is t ru e of h em ifacial spasm ?
A. Com pression of th e facial n er ve by th e su perior cerebellar ar ter y is th e
m ost com m on op erat ive n ding.
B. Deafn ess is m ore com m on th an perm an en t facial w eakn ess as a com plica-
t ion of m icrovascu lar decom pression .
C. Men are m ore frequen tly a ected th an w om en .
D. Sym ptom s t ypically begin in th e buccal m uscles an d m ove cran ially.
E. Th e cure rate at 1 m on th after m icrovascular decom pression is 95%.
101. Each of th e follow ing su rgical ap p roach es m ay be con sidered for an an eu r ysm of
th e ver tebrobasilar jun ct ion except th e
A. Exten ded ext rem e lateral in ferior t ran scon dylar approach
B. Lateral su boccipit al approach
C. Presigm oid t ran sten torial approach
D. Ret rolabyrin th in e t ran ssigm oid approach
E. Subtem poral approach
102. Th e m ost com m on p resen t ing sym ptom in p at ien ts w ith colloid cyst s is
A. Headach e
B. Dem en t ia
C. Seizures
D. Sudden at t acks of leg w eakn ess
E. Sudden death

12
Neurosurgery—Questions

For qu est ion s 103 to 106, th e gu re illu st rates th e n er ves occu pying th e righ t in tern al
au ditor y can al th rough a m iddle fossa ap proach . Iden t ify th eir relat ive posit ion s.

103. In ferior an d an terior


104. In ferior an d p osterior
105. Su p erior an d an terior
106. Su p erior an d p osterior
107. Th e m ost com m on presen t ing sym ptom of n eon ates w ith vein of Galen
an eu r ysm s is
A. Congest ive h ear t failu re
B. Hydroceph alus
C. In t racerebral h em orrh age
D. Seizu res
E. Subarach n oid h em orrh age
108. Th e m ost com m on u p p er th oracic sp in e inju r y is a
A. Bu rst fract ure
B. Com pression fract ure
C. Fract u re-dislocat ion
D. Seat belt injur y
109. W h ich is t ru e of th oracolu m bar sp in e fract u res?
A. Bu rst fract ures are th e m ost com m on .
B. Fract ure-dislocat ion s involve all th ree colu m n s.
C. Seat belt t ype injuries are gen erally st able.
D. Wedge com pression fract ures are gen erally un st able.
E. Wedge com pression fract ures involve th e m iddle colum n .
110. Each of th e follow ing is t ru e of di u se brain sw elling except th at it is
A. A result of cerebrovascular congest ion
B. A resu lt of cytotoxic edem a
C. Associated w ith a 50% m or talit y rate in ch ildren w ith severe h ead injuries
D. Man ifested on com puted tom ography (CT) scan by a com pression of th e
perim esen ceph alic cistern
E. More com m on in ch ildren th an in adults

13
Neurosurgery Board Review

111. W h ich of th e follow ing is least suggest ive of ch ild abu se?
A. Acu te an d h ealing long bon e fract ures
B. In terh em isph eric subdural h em atom a
C. Pariet al skull fract u re
D. Ret in al h em orrh ages
E. Ten torial subdu ral h em atom a

112. Trigon ocep h aly resu lts from p rem at u re closu re of th e


A. Coron al su t ure bilaterally
B. Coron al sut ure un ilaterally
C. Fron tosph en oidal sut ure
D. Lam bdoid sut ure
E. Metopic sut ure

113. Th e cleft in th e sp in al cord associated w ith diastem atom yelia is m ost com m on ly
located in th e
A. Cer vical region
B. Lum bar region
C. Sacral region
D. Th oracic region

114. Up to w h at p ercen tage of p at ien t s w ith bacterial ar terial (m ycot ic) an eu r ysm s
carr y an un derlying diagn osis of subacu te bacterial en docardit is?
A. 10%
B. 20%
C. 40%
D. 60%
E. 80%

115. Each is t ru e of bacterial in t racran ial an eu r ysm s except


A. In fected em boli lodge in th e vasa vasorum .
B. Th e m iddle cerebral arter y is m ost com m on ly a ected.
C. Th e periph erally located bran ch es are m ost com m on ly a ected.
D. Typical subarach n oid h em orrh age occurs in 18% of pat ien t s.
E. Staphylococcus aureus an d b -h em olyt ic st reptococci are m ost com m on ly
involved .

116. Each of th e follow ing is t ru e of grow ing sku ll fract u res except th at th ey
A. Can cross su t u re lin es
B. May be associated w ith un derlying brain inju r y
C. Occur if th e edges of th e in it ial fract ure are separated by m ore th an 3 m m
D. Occur m ost com m on ly in th e parietal bone
E. Occur m ost com m on ly bet w een th e ages of 2 an d 5 years

117. App roxim ately w h at p ercen t age of in fan t s w ith m yelom en ingocele h ave m ag-
n et ic reson an ce im aging (MRI) eviden ce of a Ch iari II m alform at ion ?
A. 20%
B. 40%
C. 60%
D. 80%
E. 100%

14
Neurosurgery—Questions

118. Cardiovascu lar disease involving th e h eart an d great vessels gives rise to w h ich of
th e follow ing t ypes of em boli in th e ret in a?
I. Ch olesterol
II. Calci c
III. Platelet- brin
IV. Fat
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

119. In th e in fraten torial su p racerebellar app roach to th e p in eal region , w h ich of th e


follow ing vein s are u su ally sacri ced?
I. Su perior verm ian vein
II. Posterior p ericallosal vein
III. Precen t ral cerebellar vein
IV. Basal vein of Rosen th al
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

120. Each of th e follow ing is ch aracterist ic of an acou st ic n eu rom a except


A. Békésy t ype III or IV audiogram
B. Loudn ess recruit m en t
C. Low sh ort-in crem en t sen sit ivit y in dex
D. Poor speech discrim in at ion
E. Pron oun ced ton e decay

For qu est ion s 121 to 128, th e gu re illu st rates th e righ t ret rosigm oid ap p roach . Id en t ify
th e follow ing st ruct ures.

121. Subarcu ate arter y

122. An teroin ferior cerebellar ar ter y

123. Coch lear n er ve

124. Facial n er ve

125. Glossoph ar yngeal n er ve

126. Spin al accessor y n er ve

127. Posteroin ferior cerebellar ar ter y

128. Vagus n er ve

H–Not labeled

15
Neurosurgery Board Review

129. W h ich of th e follow ing st ru ct u res provid es a m arker for th e m ost dorsal exten t
of th e in cision for an terolateral cordotom y for pain con t rol?
A. Den t ate ligam en t
B. Dorsal root en t r y zon e
C. Posterior in term ediate sulcus
D. Posterior m edian sulcus
E. Zon e of Lissauer

130. Occlu sion of th e an terior ch oroidal arter y resu lts in


I. Con t ralateral h em ip legia
II. Hem ihyp esth esia
III. Hom onym ou s h em ian opsia
IV. Im paired cogn it ion
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

131. W h ich of th e follow ing sym ptom s of Parkin son’s disease is m ost likely to resp on d
to a stereot act ic lesion in th e posterior ven t ral oval (VOP)/ven t ral in term ediate
(VIM) (ven t rolateral) th alam us?
A. Bradykin esia
B. Gait dist u rban ce
C. Rigidit y
D. Speech dist urban ce
E. Trem or

For qu est ion s 132 to 136, m atch th e descript ion w ith th e syn drom e or disease.
A. Aper t’s syn drom e
B. Crou zon’s disease
C. Both
D. Neith er

132. Au tosom al recessive in h eritan ce

133. Exorbit ism

134. Syn dact yly

135. Th e m ajorit y of p at ien t s h ave p reop erat ive in telligen ce qu ot ien t s (IQs) greater
th an 90

136. An terior open bite is com m on

For qu est ion s 137 an d 138, m atch th e descript ion w ith th e sym ptom .
A. Prim ar y em pt y sella syn drom e
B. Secondar y em pt y sella syn drom e
C. Both
D. Neith er

137. Occu rs p rim arily in w om en .

138. Visu al d ist u rban ce m ay occu r.

16
Neurosurgery—Questions

139. Th e m ost com m on et iology of os odon toideu m is


A. Congen it al
B. Iat rogen ic
C. In fect iou s
D. Neoplast ic
E. Traum at ic

140. Th e m ost com m on m ech an ism of t ran slat ion al C1–C2 su blu xat ion is
A. Axial loading
B. Dist ract ion
C. Exten sion
D. Flexion

141. Th e factor or su bstan ce w ith th e least im port an t role in th e p ath ogen esis of cere-
bral vasospasm is probably
A. Bilirubin
B. En doth elin
C. In t im al proliferat ion
D. Lipid peroxides
E. Oxyh em oglobin

For qu est ion s 142 to 148, th e gu re illu st rates th e righ t p resigm oid, ret rolabyrin th in e
ap p roach . Iden t ify th e follow ing st ru ct u res.

142. In tern al acou st ic m eat u s

143. Posterior in ferior cerebellar ar ter y

144. Ch orda t ym p an i n er ve

145. Facial n er ve

146. Su p erior cerebellar ar ter y

147. Trigem in al n er ve

148. Troch lear n er ve

For qu est ion s 149 to 155, m atch th e descript ion s w ith th e t ype of ar terioven ou s
m alform at ion (AVM).
A. Type I spin al AVMs
B. Type II spin al AVMs
C. Type III spin al AVMs
D. Type IV spin al AVMs
E. Types II an d III spin al AVMs

149. Most com m on t yp e of sp in al AVM

150. Et iology believed to be acqu ired

151. Also kn ow n as juven ile m alform at ion s

17
Neurosurgery Board Review

152. Also kn ow n as glom u s AVMs


153. Low ow an d h igh pressu re dyn am ics can be seen in t ype IV an d th is t ype
154. High ow an d h igh pressu re dyn am ics can be seen in t yp e IV an d th is t ype
155. Type IV an d th is t yp e t ypically p resen t w ith p rogressively w orsen ing sym ptom s
w ith ou t sign i can t clin ical im provem en t
156. W h ich of th e follow ing represen t s th e correct sequ en ce of rem oval of clam p s
from th e arteries follow ing carot id en dar terectom y?
A. Com m on carot id, extern al carot id, in tern al carot id
B. Com m on carot id, in tern al carot id, extern al carot id
C. Extern al carot id, com m on carot id, in tern al carot id
D. Extern al carot id, in tern al carot id, com m on carot id
E. In tern al carot id, com m on carot id, extern al carot id

For qu est ion s 157 to 163, th e gu re illu st rates th e su bch oroidal t ran svelu m in terp osi-
t um approach to th e th ird ven t ricle. Iden t ify th e follow ing st ruct ures.

157. An terior caudate vein

158. Colu m n of th e forn ix

159. In tern al cerebral vein

160. Sept al vein

161. Tela ch oroidea

162. Th alam ost riate vein

163. Th alam us

For qu est ion s 164 to 168, th e gu re illu st rates th e righ t ret rocon dylar, far lateral
ap p roach . Iden t ify th e follow ing st ru ct u res.

164. Dorsal ram us of C1

165. Glossoph ar yngeal n er ve

166. Hypoglossal ner ve

167. Sp in al accessor y n er ve

168. Vagu s n er ve

18
Neurosurgery—Questions

For qu est ion s 169 to 174, th e gu re illu st rates th e pterion al ap proach to an eu r ysm clip -
p ing. Iden t ify th e follow ing st ruct u res.

169. An terior cerebral ar ter y

170. An terior ch oroidal arter y

171. Middle cerebral ar ter y

172. Opt ic n er ve

173. Posterior com m un icat ing arter y

174. Superior hypop hyseal arter y

175. W h ich of th e follow ing is m ost im p ort an t in determ in ing th e p rop en sit y of a
dural AVM to an aggressive clin ical course?
A. Du rat ion of sym ptom s
B. Leptom en ingeal ven ou s drain age
C. Locat ion
D. Presen t at ion
E. Size

For qu est ion s 176 an d 177, refer to th e im age sh ow n .

176. Th e MRI sh ow n is th at of a 40-year-old p at ien t w ith bitem poral h em ian op ia an d


a prolact in level of 89. Th e best m an agem en t of th is lesion is
A. Brom ocript in e
B. Brom ocript in e, th en su rger y
C. Follow w ith serial MRIs
D. Radiat ion th erapy
E. Surger y

19
Neurosurgery Board Review

177. If th e p rolact in level of th e sam e pat ien t in qu est ion 176 w as fou n d to be 650,
th e best m an agem en t is
A. Brom ocript in e
B. Follow w ith serial MRIs an d prolact in levels
C. Radiat ion th erapy
D. Surger y
E. Surger y, th en radiat ion th erapy

178. Of th e follow ing, th e least com m on locat ion of in t racran ial m en ingiom as is (th e)
A. In t raven t ricular
B. Olfactor y groove
C. Posterior fossa
D. Sph en oid ridge
E. Tubercu lum sella

179. Each of th e follow ing st atem en t s is t ru e of AVMs except


A. High er pressures h ave been m easu red in th e feeding arteries of sm aller as
com pared w ith larger AVMs.
B. Sm aller AVMs are m ore likely to bleed th an larger AVMs.
C. Th e an n ual risk of death from a ru pt ured AVM is 1%.
D. Th e risk of bleeding from an un rupt u red AVM is 3 to 4% a year.
E. Th e risk of rebleed in th e rst year after h em orrh age is h igh est in th e rst
2 w eeks.

180. Th e m ost com m on com p licat ion of p ercu tan eou s radiofrequ en cy t rigem in al
gangliolysis is
A. An esth esia dolorosa
B. Decreased h earing
C. Kerat it is
D. Mast icator y w eakn ess
E. Paresth esias or dysesth esias

181. In th e tech n iqu e of percu t an eou s radiofrequ en cy t rigem in al gangliolysis, th e


n eed le is in serted in to th e
I. Foram en rot u n du m
II. Trigem in al cistern
III. Foram en sp in osu m
IV. Foram en ovale
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

20
Neurosurgery—Questions

For qu est ion s 182 to 189, th e gu re illu st rates a lateral view of th e con ten t s of th e righ t
orbit . Th e eyeball at t ach m en t of th e lateral rect us m uscle h as been divided. Iden t ify th e
follow ing st ru ct u res.

182. In ferior rect u s m u scle

183. In ferior division of th e ocu lom otor n er ve

184. Abdu cen s n er ve

185. Fron tal n er ve

186. Nasociliar y n er ve

187. Su p erior division of th e ocu lom otor n er ve

188. Opt ic n er ve

189. Troch lear n er ve

For qu est ion s 190 to 195, m atch th e con dit ion w ith th e m ost ap prop riate t reat m en t
opt ion . Each t reat m en t opt ion m ay be used on ce, m ore th an on ce, or n ot at all.
A. Cingu lotom y
B. Dorsal root en t r y zon e (DREZ) rh izotom y
C. Morph in e in fusion
D. Pallidotom y
E. Sym path ectom y
F. Ven t ral rh izotom y

190. Brach ial p lexu s avu lsion

191. Cau salgia

192. Obsessive-com pu lsive disorder

193. Nocicept ive can cer p ain above C5

194. Parkin son’s disease

195. Spasm odic tor t icollis

21
Neurosurgery Board Review

196. Don or n er ves th at m ay be u sed for n eu rot izat ion after brach ial p lexu s avu lsion
in clu de
I. In tercostal n er ves
II. Spin al accessor y n er ve
III. Cer vical p lexu s
IV. Ph ren ic n er ve
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

197. Th e pterion is form ed by w h ich of th e follow ing bon es?


A. Fron t al, greater w ing of th e sph en oid, p ariet al, an d squ am ous par t of th e
tem poral
B. Fron t al, lesser w ing of th e sph en oid, pariet al, an d squ am ous part of th e
tem poral
C. Fron t al, greater w ing of th e sph en oid, pariet al, an d zygom at ic arch
D. Fron t al, lesser w ing of th e sph en oid, pariet al, an d zygom at ic arch
E. Fron t al, lesser w ing of th e sph en oid, squam ous part of th e tem poral, an d
zygom at ic arch

198. Th e m ost com m on extern al beam radiat ion th erapy regim en for brain m etast a-
ses is
A. 30 Gy in 2 w eeks
B. 30 Gy in 4 w eeks
C. 60 Gy in 2 w eeks
D. 60 Gy in 4 w eeks
E. 45 Gy in 4 w eeks

199. Th e m ost app rop riate rad iat ion t reat m en t p rotocol for glioblastom a is
A. 8,000 cGY in 400 cGY daily fract ion s
B. 6,000 cGY in 200 cGy daily fract ion s
C. 6,000 cGy in 100 cGy daily fract ion s
D. 4,000 cGy in 400 cGy daily fract ion s
E. 4,000 cGy in 200 cGy daily fract ion s

200. Cerebral salt w ast ing an d syn drom e of in app rop riate an t idiu ret ic h orm on e
(SIADH) m ay best be dist inguish ed by m easu ring
A. Plasm a argin in e vasopressin (AVP)
B. Serum osm olalit y
C. Serum sodiu m
D. Urin e sodium
E. Volum e st at us

22
Neurosurgery—Questions

201. A p at ien t p resen t s st at u s p ost a h igh speed m otor veh icle collision w ith a cer vical
5/6 fract ure dislocat ion . Pow er in th e deltoid, biceps, an d w rist exten sors is 5/5,
an d all oth er m u scle grou ps are 2/5 in clu d ing t ricep s, grip s, an d low er ext rem i-
t ies. Rect al ton e an d perian al sen sat ion are in tact . W h at is th e appropriate grade
of th is acu te spin al cord injur y?
A. ASIA A
B. ASIA B
C. ASIA C
D. ASIA D
E. ASIA E

202. W h at is th e likelih ood th at th e pat ien t in th e p reviou s qu est ion (201) w ill be
am bu lator y at long-term follow -u p ?
A. , 3%
B. 50%
C. 75%
D. 95%
E. 100%

203. A pat ien t p resen t s w ith facial t rich ilem m om as, brom as of th e oral m u cosa,
h am artom as of th e GI t ract an d breast , an d a thyroid m ass. Fu rth er w orku p re-
veals Lh erm it te-Du clos disease in th is p at ien t , as w ell. W h at is th e m ost likely
gen et ic abn orm alit y?
A. CAG t rin ucleot ide repeat
B. m TOR am pli cat ion
C. p53 delet ion
D. PTEN m u t at ion
E. Trisom y 21

204. W h ich of th e follow ing best describes th e st an d ing rad iograp h seen h ere?

A. Major lu m bar dext roscoliosis an d m in or


th oracic levoscoliosis
B. Major lum bar levoscoliosis an d m ajor
th oracic dext roscoliosis
C. Major lum bar levoscoliosis an d m in or
th oracic dext roscoliosis
D. Min or lum bar dext roscoliosis an d m ajor
th oracic levoscoliosis
E. Min or lum bar levoscoliosis an d m ajor
th oracic dext roscoliosis

23
Neurosurgery Board Review

205. W h ich n er ve(s) is (are) at risk du ring h ar vest ing of iliac crest bon e graft via an
an terior ap proach ?
A. Iliohyp ogast ric n er ve
B. Ilioinguin al ner ve
C. Lateral fem oral cu tan eous n er ve
D. All of th e above
E. Non e of th e above

206. W h ich of th e follow ing feat u res is suggest ive of u ln ar n er ve com pression at th e
w rist (Guyon’s can al)?
A. Ach ing along th e m edial proxim al forearm
B. “Claw ” h an d
C. Paresth esias in an uln ar dist ribut ion
D. Sparing of dorsal h an d sen sat ion
E. Weakn ess of th e th ird an d fourth lu m bricals

207. All of th e follow ing are t ru e of SCIWORA except


A. Acronym for “spin al cord injur y w ith out radiograph ic abn orm alit y”
B. More com m on in ch ildren
C. MRI is alw ays un rem arkable
D. No eviden ce of spin al fract ure is seen
E. Th ough t to be due to ligam en tou s laxit y

208. A p at ien t p resen ts stat u s post fall w ith an acu te t ype II odon toid fract u re. Good
sp in al align m en t is m ain t ain ed. Th e p at ien t h as good bon e qu alit y, is oth er w ise
h ealthy, an d is n eu rologically in t act . An MRI reveals disru pt ion of th e t ran sverse
ligam en t . W h ich of th e follow ing is th e m ost appropriate t reat m en t?
A. C-collar im m obilizat ion
B. No t reat m en t
C. Occiput to C2 posterior fusion
D. Odon toid screw placem en t
E. Posterior C1–C2 in st rum en ted fusion

24
1B Neurosurgery—Answer Key

1. D 27. D
2. I 28. E
3. F 29. D
4. B 30. E
5. A 31. A
6. G 32. E
7. H 33. C
8. C 34. A
9. E 35. D
10. E 36. B
11. C 37. A
12. A 38. F
13. B 39. G
14. A 40. H
15. B 41. C
16. A 42. A
17. A 43. D
18. D 44. B
19. E 45. E
20. A 46. A
21. C 47. D
22. C 48. A
23. B 49. D
24. D 50. C
25. A 51. E
26. B 52. B

25
Neurosurgery Board Review

53. A 92. B
54. F 93. D
55. C 94. A
56. E 95. A
57. E 96. B
58. E 97. C
59. B 98. D
60. C 99. B
61. A 100. B
62. D 101. E
63. H 102. A
64. D 103. C
65. A 104. D
66. E 105. A
67. B 106. B
68. F 107. A
69. G 108. B
70. H 109. B
71. B 110. B
72. A 111. C
73. A 112. E
74. D 113. B
75. E 114. E
76. D 115. A
77. B 116. E
78. A 117. E
79. C 118. A
80. B 119. B
81. B 120. B
82. A 121. B
83. A 122. F
84. E 123. A
85. C 124. E
86. D 125. C
87. A 126. G
88. B 127. H
89. B 128. D
90. E 129. A
91. D 130. A

26
Neurosurgery—Answer Key

131. E 170. E
132. D 171. F
133. C 172. A
134. A 173. B
135. B 174. C
136. A 175. B
137. A 176. E
138. C 177. A
139. E 178. A
140. D 179. E
141. C 180. E
142. D 181. C
143. E 182. H
144. G 183. D
145. F 184. E
146. B 185. A
147. C 186. C
148. A 187. B
149. A 188. G
150. A 189. F
151. C 190. B
152. B 191. E
153. A 192. A
154. E 193. C
155. A 194. D
156. C 195. F
157. C 196. E
158. B 197. A
159. D 198. A
160. A 199. B
161. G 200. E
162. E 201. C
163. F 202. C
164. E 203. D
165. A 204. C
166. D 205. D
167. C 206. D
168. B 207. C
169. D 208. E

27
1C Neurosurgery—Answ ers
and Explanations

1. D – Caudate n ucleus

2. I – Ch oroid plexu s

3. F – Foram en of Mon ro

4. B – Colu m n s of th e forn ix

5. A – Sept um pellucidu m

6. G – Th alam ost riate vein

7. H – Th alam u s

8. C – Body of th e forn ix

9. E – An terior caudate vein

28
Neurosurgery—Answers and Explanations

Figu re 1.1 is a t ran scallosal view of th e righ t lateral ven t ricle. Th e left side
of th e im age is m edial, th e righ t side of th e im age is lateral, th e top of th e
im age is an terior, an d th e bot tom of th e im age is posterior. Th e septum
pellucidum (A) separates th e righ t lateral ven t ricle from th e left lateral ven t ri-
cle in th e m idlin e. Th e co lum ns o f the fo rnix (B) m ake u p th e an terior aspect
of th e fo ram e n o f Mo nro (F). Posteriorly, th e co lum ns o f the fo rnix (B) t u rn
in to th e bo dy o f the fo rnix (C), w h ich is separated from th e laterally sit u ated
thalam us (H) by a t uft of cho ro id plexus (I) an d th e superior ch oroidal vein
(n ot labeled). Th e caudate nucleus (D) can be ap preciated in th e an terolateral
w all of th e lateral ven t ricle. Th e anterio r caudate vein (E) drain s th is area
an d u lt im ately join s th e thalam o striate ve in (G). Un derst an ding of th ese an -
atom ical relat ion sh ip s is im port an t for t ran sch oroidal app roach es to th e th ird
ven t ricle. For qu est ion s 1–9, gu re u sed w ith p erm ission of Dr. Al Rh oton .1

10. E – All of th e above

Myotom y w as th e earliest su rgical p rocedu re u sed to t reat sp asm odic


tor t icollis. About 70% of pat ien t s im prove after m icrovascular decom pression
of th e spin al accessor y n er ve, an d 81 to 97% of pat ien t s im prove after upper
cer vical ven t ral rh izotom ies an d spin al accessor y den er vat ion procedu res.
Rough ly t w o-th irds of pat ien t s un dergoing stereotact ic th alam otom y obtain
a sat isfactor y resu lt .2

11. C – Midlin e lam in ectom y

Co stotransve rsecto m y (A), lateral extracavitary (B), transpe dicular (D),


an d transtho racic (E) app roach es all facilitate access to th e th oracic disk
sp ace w ith ou t th e n eed for ret ract ion on th e th ecal sac. Ap proach ing a th o-
racic disk h erniat ion th rough a sim ple lam inecto m y (C) w ou ld requ ire th ecal
sac ret ract ion an d risk resu ltan t n eu rologic inju r y. Posterior decom pression
alon e (lam inecto m y [C] w ith out diskectom y) is un likely to im prove sym p -
tom s as th e path ologic process involves ven t ral com pression across an already
kyph ot ic spin al segm en t . Th e risk of eith er n eurologic deteriorat ion or n o
ben e t w ith lam in ectom ies for th oracic disk h ern iat ion is 45%.3

12. A – Cran ial neuropath ies

Th e in it ial sym ptom s in m ost pat ien t s w ith brain stem gliom as are cranial
neuro pathies (A) follow ed by w eakn ess or ataxia. Headache (B), nausea and
vo m iting (D), an d papilledem a (E) usually occur later in th e course of th e
illn ess.4

29
Neurosurgery Board Review

13. B – Hyp esth esia

Com plex region al pain syn drom e t ype II (CRPS II, form erly causalgia) is
ch aracterized by atro phic changes in the a ected lim b (A), increase d
sw eating (C), absence o f a m ajo r m oto r de cit (D), go od respo nse to sym -
pathetic blo ckade (E), an d hyp eresth esia (in creased sen sit ivit y to st im u lu s).
CRPS II is diagn osed in th e set t ing of a kn ow n n er ve inju r y. Th e diagn osis
CRPS I (form erly re ex sym path et ic dyst rophy or Su deck’s at rophy) is m ade
on ly in th e absen ce of kn ow n n er ve injur y. Neith er con dit ion is associated
w ith hypesthesia (B), decreased sen se of tou ch or sen sat ion .3

14. A – Bacterial m en ingit is → derm oid cyst


15. B – Asept ic m en ingit is → epiderm oid cyst
16. A – Associated congen it al m alform at ion s → derm oid cyst
17. A – Most often m idlin e → derm oid cyst
18. D – Resp on sive to radiat ion th erapy → n eith er

In t racran ial derm o id cysts (A) com p rise 0.3% of brain t u m ors an d u su ally
p resen t in th e p ed iat ric p opu lat ion . Th ey occu r w h en cell rests w ith derm al
an d ep iderm al com p on en t s are in clu ded w ith in n eu ral ectoderm in th e m id-
lin e during n eu rulat ion . Com m un icat ion of th e derm oid cyst w ith th e exterior
via a sin u s t ract p redisp oses th e p at ien t to bacterial m en ingit is (qu est ion 14).
Congen it al m alform at ion s (qu est ion 16) m ay be associated w ith derm o id
cysts (A). In t racran ial epide rm o id cysts (B) com p rise 0.5 to 1.8% of brain
t um ors an d usu ally presen t in th e adult . Spillage of th e epiderm oid cyst
con ten t s can lead to asept ic m en ingit is (qu est ion 15). Epiderm o id cysts
(B) resu lt from ep id erm al cell rests an d are m ost often located eccen t rically
(e.g., th e cerebellopon t in e angle), w h ereas derm o id cysts (A) ten d to be
sit u ated in th e m id lin e (qu est ion 17). Radiat ion (qu est ion 18) is n ot rst-lin e
therapy for eith er of th ese lesion s.2

19. E – All of th e above

Ch oroid p lexu s p apillom as can cause ven t ricular en largem en t by en t rap -


m en t of cerebral sp in al u id (blocking CSF p ath w ays at th e foram en of Mon ro,
cerebral aqu educt , or foram in a of Lu sch ka an d Magen die), blocking CSF
absorpt ion at th e arach n oid gran u lat ion s d u e to h em orrh age-in du ced arach -
n oidit is, by t u m or grow th (cau sing ven t ricu lar exp an sion by th e t u m or it self),
an d by produ ct ion of excessive cerebrospin al u id.2

20. A – Middle fossa

Th is quest ion is based on th e assum pt ion th at an 8 m m acoust ic n eu-


rom a w ou ld be an in t racan alicu lar lesion . Sm all (, 1 cm ) in t racan alicu lar
acou st ic n eu rom as can easily be ap proach ed via th e m id dle fossa rou te. A
translabyrinthine (C) ap p roach w ou ld sacri ce h earing. Th e m iddle fossa
ap p roach is p referred to a subo ccipital (B), ret rosigm oid ap p roach for in t ra-
can alicular lesion s.

30
Neurosurgery—Answers and Explanations

21. C – Olfactor y h allu cin at ion s

Seizu re foci in th e m esial tem p oral lobe (u n cin ate seizu res) ten d to p rodu ce
o lfacto ry hallucinatio ns (C). Audito ry hallucinatio ns (A) in t u it ively w ou ld
seem to be associated w ith a focu s n ear Hesch l’s gyru s, bu t th e dat a do n ot
su pp ort th at assu m pt ion . Gustatory hallucinatio ns (B) are rare an d can be
brough t about by st im u lat ion of th e posterior in sula. Vertigino us sensatio ns
(D) are associated w ith foci in th e superoposterior tem poral lobe n ear th e
ju n ct ion w ith th e pariet al lobe. Visual seizures (E) suggest a focu s in th e
st riate cor tex of th e occip it al lobe.4,5

22. C – Posterior com m u n icat ing arter y (PCom A)


23. B – Lateral m esen cep h alic su lcu s
24. D – Tect al p late
25. A – Calcarin e sulcus

Th e posterior cerebral arter y is divided in to four segm en t s. Th e P1 segm en t


arises from th e basilar bifu rcat ion an d exten ds th rough th e in terpedu n cu -
lar cistern to th e jun ct ion w ith th e po sterio r co m m unicating artery (C).
Th e P2A (an terior) segm en t run s in th e cru ral cistern , exten ding from th e
PCo m A (C) to th e late ral m esence phalic sulcus (B) w h ere it becom es th e P2P
(p osterior) segm en t . Th e P2P segm en t ru n s in th e am bien t cistern , lateral to
the m idbrain . Th e P2P an d P3 segm en t s are separated by th e te ctal plate (D);
the P3 segm en t run s in th e quadrigem in al cistern . Th e P4 segm en t begin s at
the calcarine sulcus (A). (Qu est ion s 22–25 from th e m icrosu rgical an atom y
course; w ith perm ission of Dr. Al Rh oton .1 )

26. B – Addu ctor p ollicis

Th e adducto r po llicis (B) is in n er vated by th e u ln ar n er ve. Th e abducto r po l-


licis lo ngus (A), brachio radialis (C), exte nso r po llicis brevis (D), an d supi-
nato r (E) are in n er vated by th e radial n er ve or on e of its bran ch es.6

27. D – Th e germ in al m at rix is th e m ost com m on site of IVH in th e fu ll-term n eon ate
(false).

Th e ge rm inal m atrix is th e m o st com m on site o f IVH in the pr et er m infant,


n ot th e full-term in fan t as p resen ted in th e qu est ion (D). Th e m ost com m on
site of IVH in th e fu ll-term n eon ate is th e ch oroid p lexu s. Th e germ in al m at rix
is ch aracterized by a capillary bed o f large irregular vessels (C) an d begin s to
involu te at 43 w eeks. Th e risk o f IVH is greater in the preterm than the term
infant (E) an d can lead to periventricular hem o rrhagic infarctio n (A) as
w ell as po sthem o rrhagic hydro ce phalus leading to persiste nt bradycardia
and apne ic spells (B).7

28. E – Tw o prim ar y an d on e secon dar y cen ter

Th e odon toid con sists of tw o prim ary and o ne seco ndary o ssi catio n
ce nter. Th e t w o prim ar y cen ters lie in feriorly on eith er side of m idlin e. Th e
secon dar y ossi cat ion cen ter is apical.7

31
Neurosurgery Board Review

29. D – Sagit t al syn ostosis

Isolated sagittal syno sto sis (D) cau ses scaph oceph aly an d is th e m ost com m on
single-su t u re syn ostosis, accou n t ing for u p to 50%of cran iosyn ostosis pat ien t s
in som e series. Meto pic syno sto sis (C) cau ses t rigon oceph aly; co ro nal syn-
o sto sis (A) causes an terior plagioceph aly an d is less com m on th an sagit tal
syn ostosis. Lam bdo id an d sphe nozygo m atic syno sto sis (B, E) are both less
com m on th an sagit t al syn ostosis.8

30. E – Palm ar sen sor y con duct ion t im e of th e m edian n er ve

Eigh t y- ve to 90% of pat ien t s w ith carpal t un n el syn drom e m an ifest abn or-
m alit ies of th e n er ve con du ct ion velocit ies. Th e p alm ar sen sor y con du ct ion
t im e is th e m ost sen sit ive elect rical test for carpal t un n el syn drom e. Th e
abducto r po llicis brevis (A) an d the rst and second lum bricals (B) are in -
n er vated by th e m edian n er ve, bu t n eed le exam in at ion alon e is n ot as sen sit ive
as sen sor y con du ct ion t im e for diagn osis. Decreased m otor am plitude (C) is
m ore sen sit ive an d speci c for axon al loss. Mo to r latency (D) of th e m edian
n er ve is less sen sit ive th an palm ar senso ry co nductio n tim e (E) of th e
m edian n er ve for th e d iagn osis of carp al t u n n el syn d rom e.3

31. A – Cerebral convexit ies

Con t recoup con t usion s, produced by rot at ion al force, occur w h ere th e fro ntal
and tem po ral lo bes ru b along bony prom in en ces (B, C, E). Cou p con t u sion s
(th e least com m on t ype) are located over th e cerebral co nvexities (A).9

32. E – Posterior com m u n icat ing arter y an eur ysm


33. C – Middle cerebral arter y an eu r ysm
34. A – An terior com m un icat ing arter y an eur ysm
35. D – Op h th alm ic ar ter y an eu r ysm
36. B – In t racavern ou s carot id ar ter y an eu r ysm

Th e close proxim it y of an anterio r co m m unicating artery aneurysm (A) to


the hypoth alam us can lead to en docrin e abn orm alit ies, in cluding diabetes
in sipidu s. A ru pt ured intracave rno us aneurysm (B) produ ces a carot id-
cavern ous st u la, on e of th e h allm arks of w h ich is exoph th alm os. Com pres-
sion of th e m edial tem p oral lobe by a m iddle cerebral artery aneurysm (C)
m ay resu lt in seizu res. Ophthalm ic artery ane urysm s (D) m ay in it ially
p resen t w ith an in ferior n asal eld cut becau se of pressure on th e opt ic n er ve
from th e overlying falciform ligam en t (th e du ral fold bet w een th e an terior
clin oid processes). A pupil-involving th ird n er ve palsy is ext rem ely suggest ive
of a po ste rio r co m m unicating artery aneurysm (E).2

32
Neurosurgery—Answers and Explanations

37. A – Hydrom yelia is lin ed w ith epen dym al cells, an d syringom yelia is n ot

Hydrom yelia rep resen ts a dilat at ion of th e cen t ral can al of th e sp in al cord,
w h ich is lin ed by epen dym al cells. Syringom yelia dissect s th rough th e spin al
cord t issue out side of th e cen t ral can al an d is th erefore n ot lin ed by epen -
dym a (A, E). Neith er lesion is lin ed w ith cho ro id plexus (B). Both lesion s
con t ain CSF (C). Both syringom yelia an d hydrom yelia m ay be eith er fo cal o r
exte nsive (D), d ep en ding on th e in d ividu al pat ien t .9

38. F – Basilar ar ter y


39. G – Pit uitar y stalk
40. H – Righ t ocu lom otor n er ve
41. C – Righ t posterior cerebral arter y
42. A – In tern al carot id ar ter y
43. D – Left du p licated su p erior cerebellar arter y
44. B – Righ t su p erior cerebellar arter y
45. E – Righ t an terior cerebral arter y (A1 segm en t)

In th is gu re th e righ t opt icocarot id t riangle is exp osed. On th e left of th e


im age, th e opt ic ch iasm (un labeled) is being ret racted w ith an in st ru m en t .
Th e pituitary stalk (G) is n oted bet w een th e p aired opt ic n er ves (u n labeled).
Th e basilar artery (F) is n oted in th e cen ter of th e im age, as is its bifurcat ion
in to th e left an d right po sterio r cerebral arteries (C). A single right supe rio r
ce rebellar arte ry (B) takes o proxim al to th e basilar bifu rcat ion , an d a left
duplicated superio r cerebellar artery (D) t akes o on th e con t ralateral side.
Th e right o culo m oto r ne rve (H) can be seen crossing un dern eath th e right
SCA (B) on its w ay to th e su perior orbit al ssu re. Th e internal carotid artery
(A) is being ret racted laterally at its bifurcat ion . Th e right A1 segm ent (E) is
n oted distal to th e ICA bifu rcat ion . (For qu est ion s 38–45, gu re u sed w ith
perm ission of Dr. Al Rh oton .)

33
Neurosurgery Board Review

46. A – Cerebellar an d vest ibu lar com plain t s t ypically oversh adow m otor an d sen sor y
com plain ts (false).

In cases of basilar im pression , m otor an d sen sor y com plain ts are seen m ore
often than are cerebellar an d vest ibu lar sym ptom s. Th e lin es of McGrego r
(B) an d McRae (C) m ay be h elpful in th e radiograph ic assessm en t of pat ien ts
w ith basilar invagin at ion . Sho rt necks, to rtico llis (D), an d vertebral artery
ano m alies (E) are com m on in p at ien t s w ith basilar invagin at ion .10

47. D – Type II odon toid fract u re

Type II o dontoid (D) fract ures h ave th e w orst progn osis for h ealing of th e
ch oices presen ted. Type I (C) and type III (E) fract ures gen erally h eal w ell w ith
im m obilizat ion . The burst fracture o f C1 (Je erson’s fracture ) (B) u su ally
h eals by rigid im m obilizat ion u n less th e t ran sverse ligam en t is disru pted
(lateral m asses d isp laced m ore th an 7 m m ) or th e p at ien t is elderly.10

48. A – Congen it al elevat ion of th e scapula

Sprengel’s deform it y refers to a congen ital asym m et r y of th e scap u la, w ith


failu re of on e scap u la to com p letely descen d d u ring develop m en t . Sp rengel’s
deform it y is often associated w ith th e Klippel-Feil syn drom e (co nge nital fu-
sio n o f the upper cervical vertebrae [B]). Intrave rtebral disk he rniatio n (C)
is kn ow n as a Sch m orl’s n ode. Po stlam inecto m y k ypho sis (D) an d sco lio sis
resulting fro m tethe ring o f the spinal co rd (E) are in correct respon ses.11

49. D – Dist ract ing exten ded


50. C – Com pression n eut ral
51. E – Flexing axially rot ated
52. B – Com p ressing exed
53. A – Flexing exed
54. F – Com p ressing laterally ben t
55. C – Com pressing n eut ral

Con dit ion s of ext rem e exion (e.g., exing in the exed po sitio n [A]) m ay
resu lt in bilateral facet dislocat ion . Co m pressio n (axial loading) in the exe d
po sitio n (B) is th e m ech an ism of th e teardrop fract ure. Co m pressio n in the
neutral po sitio n (C) m ay lead to burst fract ures of th e subaxial spin e as w ell
as bu rst fract u res of th e C1 ring (Je erson’s fract u re). Distractio n w hile
in extensio n (D) is th e u n derlying m ech an ism of th e Hangm an’s fract u re.
Flexio n w ith axial rotatio n (E) m ay lead to un ilateral facet dislocat ion .
Co m pression w ith lateral bending (F) is th e m ech an ism of h orizon t al facet
fract u res.11

34
Neurosurgery—Answers and Explanations

56. E – Superior ar t icular facet hypert rophy

Th is qu est ion test s th e exam in ee’s un derstan ding of lum bar an atom y as w ell
as th e p ath ogen esis of lu m bar sten osis. Th e su p erior ar t icu lar facet is sit u ated
an terolaterally to th e in ferior art icu lar facet of th e level above, an d m akes u p
m u ch of th e p osterior lim it of th e lateral recess of th e lu m bar spin al can al.
Th erefore, superio r articular facet hypertro phy (E) is th e m ost com m on
cau se of lateral recess sten osis in spon dylosis. Disk herniatio n (A) an d liga-
m e ntum avum hype rtro phy (D) m ay con t ribu te to lateral recess sten osis
bu t are less likely to cause lateral recess sten osis th an superio r articular
facet hypertrophy (E). Inferio r articular facet hypertro phy (C) is in correct
because th e superio r articular facet is m ore closely associated w ith th e
lateral recess. Hypertro phy o f the pe dicles (B) does n ot con t ribute to lateral
recess sten osis.10

57. E – All of th e above

Diplo pia, o scillo psia, re ductio n o f upgaze, an d a sense o f im pe nding do o m


are all m ore com m on w ith st im u lat ion of th e p eriaqu ed u ct al gray th an w ith
st im u lat ion of th e p eriven t ricu lar gray region .2

58. E – Pin eoblastom a

Th e presen ce of bilateral ocular ret in oblastom as along w ith th e presen ce of a


pine o blasto m a (E) is kn ow n as “t rilateral ret in oblastom a.” An u n d erst an ding
of th is associat ion is facilit ated by th e recogn it ion th at th e pin eal glan d is a
p h otoreceptor organ . Astro cyto m a (A), m edullo blastom a (B), ne uro bro -
m a (C), an d o ptic ne rve sheath tum o r (D) are in correct resp on ses.2

59. B – Gian t oph th alm ic arter y an eu r ysm an d eviden ce of vasosp asm on arteriogram

Evide nce o f vaso spasm o n arteriogram (B) im plies th e p oten t ial for in ad-
equ ate collateral ow, w h ich w ou ld p u t th e pat ien t at risk for isch em ic n eu-
rologic de cits follow ing vessel sacri ce. W h ile the presen ce of bilateral
intracave rno us carotid aneurysm s (A) or extracranial athero sclerotic
disease (C) m ay be relat ive con t rain dicat ion s to carot id sacri ce in th is clin i-
cal scen ario, th ey do n ot represen t absolute con t rain dicat ion s. Carot id arter y
ligat ion is n ot con t rain dicated in th e set t ing of sudden lo ss o f extrao cular
m otility in the prese nce o f an intracave rno us carotid artery aneurysm (D)
or in th e set t ing of traum atic disse cting ane urysm o f the petro us carotid
artery (E).2

60. C – Foram en m agn um

Th e “clockw ise” progression of w eakn ess described in th e vign et te is


classically associated w ith lesion s at th e fo ram e n m agnum (C) su ch as
a m en ingiom a. Men ingiom as of th e clivus (A) m ay p resen t w ith cran ial
n er ve p alsies. Olfacto ry gro ove (D) an d tube rculum sella (E) m en ingiom as
m ay p resen t w ith visu al sym ptom s, beh avioral dist u rban ces, or sym ptom s
from in creased in t racran ial p ressu re. Parafalcine (B) m en ingiom as are n ot
associated w ith th e “clockw ise” p at tern of qu adrip aresis described .4

35
Neurosurgery Board Review

61. A – Clin oidal


62. D – In frat roch lear (Parkin son’s)
63. H – Posterom edial (Kaw ase’s)
64. D – In frat roch lear (Parkin son’s)
65. A – Clin oidal
66. E – An terom edial
67. B – Ocu lom otor
68. F – An terolateral
69. G – Posterolateral (Glasscock’s)
70. H – Posterom edial (Kaw ase’s)

Th e clin oidal, oculom otor, suprat roch lear, an d in frat roch lear t riangles are th e
fou r t riangles of th e cavern ou s sin u s. Th e clinoidal (A) t riangle lies bet w een
the opt ic n er ve an d oculom otor n er ve an d can be exposed by rem oval of th e
an terior clin oid process to reveal th e clin oidal segm en t of th e in tern al carot id
ar ter y. Th e o culo m oto r (B) t riangle is bordered by th e an terior an d posterior
p et roclin oidal du ral folds an d th e in t raclin oidal dural fold. Th e oculom otor
n er ve en ters th e cavern ou s sin u s in th e cen ter of th e o culo m oto r (B) t riangle.
Th e supratro chlear (C) t riangle lies bet w een th e in ferior m argin of th e ocu-
lom otor n er ve an d superior m argin of th e t roch lear n er ve—th is t riangle is
ver y sm all. Th e infratro chlear (D) t riangle, or Parkinso n’s (D) t riangle, lies
bet w een th e in ferior m argin of th e t roch lear n er ve an d superior m argin of th e
oph th alm ic n er ve (V1) an d con tain s th e in t racavern ous carot id arter y an d th e
m en ingohyp op hyseal t ru n k. Parkin son described a su rgical app roach th rough
th e infratro chlear (D) t riangle for th e t reat m ent of carot id-cavern ous st ulas.

36
Neurosurgery—Answers and Explanations

Th e an terolateral, an terom edial, posterolateral, an d posterom edial t riangles


are th e fou r t riangles of th e m idd le fossa. Th e ante ro m e dial (E) t riangle lies
bet w een th e low er m argin of th e oph th alm ic n er ve (V1) an d th e upper m argin
of th e m axillar y n er ve (V2). Drilling th e bon e in th e ante ro m edial (E) t riangle
open s in to th e sph en oid sin us. Th e antero lateral (F) t riangle lies bet w een
th e in ferior m argin of th e m axillar y n er ve (V2) an d th e upper m argin of th e
m an dibu lar n er ve (V3). Th e po stero lateral (Glassco ck’s) (G) t riangle op en s
laterally to th e m an dibu lar n er ve (V3), an terior to th e poin t at w h ich th e
greater su per cial pet rosal n er ve crosses V3, an d con tain s th e m id dle m en in-
geal ar ter y in foram en sp in osu m . Th e po stero m edial t riangle (Kaw ase’s) (H)
con t ain s th e coch lea in it s lateral apex, an d also con tain s th e pet rous carot id
ar ter y. Th e m edial port ion of Kaw ase’s t riangle can be drilled in an an terior
p et rosectom y for approach es to th e an terolateral brain stem an d low -riding
basilar bifurcat ion s.1 (For quest ion s 61–70, gure used w ith perm ission of
Dr. Al Rh oton .)

71. B – Absen ce of th ird n er ve p alsy

Pat ien t s w ith p osterior com m u n icat ion arter y an eu r ysm s w h o do not have
a third ne rve palsy (B) or w h ose angiogram reveals th e an eu r ysm p roject ing
laterally to th e carot id are m ore likely to h ave an eur ysm dom es th at are ad-
h eren t to th e tem p oral lobe. Ch oices C an d D are in correct because th ey con -
t radict th is st atem ent . Neith er lo ss o f co nscio usness (A) n or seizures (E)
p red ict an eur ysm adh eren ce to th e tem poral lobe.5

72. A – Axillar y n er ve

Weakn ess of th e deltoid m uscle could be caused by injur y to th e axillary


nerve (A), w h ich in n er vates th e d eltoid. Th e do rsal scapular nerve (B)
in n er vates th e rh om boid m uscles as w ell as th e levator scapulae. Th e m uscu-
lo cutaneo us nerve (C) in n er vates th e m uscles of th e an terior com part m en t
of th e arm in cluding th e biceps brach ii an d th e coracobrach ialis m uscles. Th e
suprascapular nerve (D) in n er vates th e su praspin at u s an d in frasp in at u s
m u scles. An inju r y to th e tho racodo rsal nerve (E) w ould cause w eakn ess of
the lat issim us dorsi m uscle.6

73. A – Escherichia coli

E. coli (A) is th e m ost com m on cause of su bdural em pyem a in th e in fan t fol-


low ing m en ingit is. St reptococcus pneum oniae m en ingit is m ay also lead to
su bdu ral em pyem as. List er ia (C), Neisser ia (D), an d St a ph ylococcu s (E) are
in correct respon ses.12

74. D – Ner ve

Th e m an ifest at ion s of Sudeck’s at rophy are late ch anges of re ex sym path et ic


dyst rophy (CPRS I, RSD). Th is con dit ion m ay involve at roph ic ch anges in th e
bo ne (A), jo ints (B), m uscle (C), and skin (E), bu t n ot th e nerve (D). Th e diag-
n osis of CRPS I, or re ex sym path et ic dyst rop hy, is m ade on ly in th e absen ce
of a kn ow n n er ve injur y (in con t rast w ith CRPS II, or causalgia, w h ich requ ires
a kn ow n n er ve inju r y for diagn osis).2

37
Neurosurgery Board Review

75. E – Closure of th e caudal n europore: Day 26


76. D – Closu re of th e cran ial n eu rop ore: Day 24
77. B – Form at ion of th e n otoch ord: Day 17
78. A – Form at ion of th e prim it ive st reak: Day 13
79. C – Fusion of th e n eural folds to form th e n eural t ube: Day 22

Prim ar y n eu rulat ion con sist s of th e follow ing even t s in th is order: Th e prim i-
t ive st reak form s on day 13 (A), n otoch ord form at ion occu rs on day 17 (B), th e
n eu ral folds fu se to form th e n eu ral t u be on day 22 (C), th e cran ial n eu rop ore
closes on day 24 (D), an d th e cau dal n eu ropore closes on day 26 (E). Abn or-
m alit ies du ring th is st age of em br yogen esis cau se n eu ral t u be defect s an d
Ch iari m alform at ion s.13,14

80. B – I, III

Th e subclavian steal syn drom e is associated w ith sym ptom s of vertebrobasi-


lar in su cien cy. It occu rs w h en in creased activity o f the left arm (III) resu lt s
in sh u n t ing of blood in to th e left subclavian th at is o ccluded proxim al to the
o rigin o f the left vertebral artery (I). Th e blood ow in th e vertebral ar ter y
is reversed, result ing in part ial brain stem isch em ia exacerbated by use of th e
left arm . Occlusio n o f the left subclavian artery distal to the o rigin o f the
left vertebral arte ry (II) w ou ld n ot cau se reversal of ow in th e left ver tebral
arter y, an d th erefore w ou ld n ot cau se su bclavian steal syn drom e. Occlusio n
o f the left vertebral arte ry (IV) m igh t cau se sym ptom s of vertebrobasilar
in su cien cy, bu t th is w ou ld n ot be an exam ple of su bclavian steal.3

81. B – Coron ally

Th e coron al orien t at ion of th e facets in th e upper th oracic spin e leads to sig-


n i can t resist an ce to an terior t ran slat ion bu t lit tle resistan ce to rot at ion . In
the low er th oracic spin e, th e facets becom e m ore sagit tally orien ted, an d less
resistan ce to an terior t ran slat ion is o ered.3

82. A – Back pain

W hile it is possible for a th oracic disk hern iat ion to cause either thoracic
m yelopathy, w hich m ay be characterized by leg num bness (B), leg w eak-
ness (C), o r urinary inco ntinence (E); or th oracic radicu lopathy, w h ich
could cause thoracic num bness (D); or th oracic pain in a derm atom al dis-
t ribut ion , th e m ost com m on present ing sym ptom of a herniated thoracic
disk is back pain (A). Back p ain is th e presen ting com plain t of 57 to 88% of
pat ient s w ith a thoracic h erniated disk.3

83. A – I, II, III

Occlu sion of th e th alam ost riate vein d u ring th e su bch oroidal t ran svelu m
in terp osit u m approach to th e th ird ven t ricle m ay result in drow siness (I),
he m iparesis (II), or m utism (III). Seizures (IV) h ave n ot been repor ted after
the ligat ion of th e th alam ost riate vein du ring th is approach .5

38
Neurosurgery—Answers and Explanations

84. E – Labyrin th in e segm en t of th e facial n er ve


85. C – Meat al segm en t of th e facial n er ve
86. D – Su p erior vest ibu lar n er ve
87. A – Greater super cial pet rosal n er ve
88. B – Gen icu late ganglion

Th is set of quest ion s tests relevan t an atom y for th e m iddle fossa approach to
the in tern al acoust ic m eat u s. Th e m eatal segm ent o f the facial nerve (C) is
n oted in it s su p eroan terior posit ion in th e in tern al acou st ic m eat u s w ith th e
superio r vestibular nerve (D) being located ju st lateral to it . Th e in ferior ves-
t ibular n er ve an d coch lear n er ve are obscu red from view. Th e labyrinthine
segm ent o f the facial nerve (E) is n oted ju st before th e facial n er ve en ters
th e geniculate ganglio n (B). Th e greate r super cial petro sal nerve (A) t u rn s
an terom edially to ru n along th e m iddle fossa oor. Th e coch lea is n oted in th e
angle form ed by th e facial n er ve an d greater su p er cial p et rosal n er ve.1 (For
quest ion s 84–88, gure used w ith perm ission of Dr. Al Rh oton .)

89. B – An terior, su perior, in ferior

In th e series of Sugita an d Kobayash i, th e facial n er ve w as an terior to th e


t um or in 50%, superior in 30%, an d in ferior in 15% of cases.15

90. E – Skin plaques (false)

Skin plaques (E) are th e m ost com m on skin lesion s seen in n euro brom ato-
sis t yp e 2. Th ey are w ell-circu m scribed, raised, rough areas of skin th at m ay
be associated w ith excess h air. Axillary freckles (A), café au lait spots (B),
Lisch no dules (C), an d m ultiple typical skin neuro bro m as (D) are all ch ar-
acterist ics of n eu ro brom atosis t yp e 1.6,12

39
Neurosurgery Board Review

91. D – Postop erat ive t u m or residu al

Of th e ch oices available, po sto perative tum o r residual (D) is th e m ost im -


p or tan t factor in m en ingiom a recurren ce. Bo ne invasio n (B) could in uence
recu rren ce rates as it m ay lim it th e exten t of t um or resect ion , part icularly for
lesion s at th e skull base. Histo logic type o f be nign m e ningio m a (C) is in cor-
rect becau se th is an sw er ch oice im plies th at th e lesion is W HO grade I. Cer-
t ain ly W HO grade II (at ypical) an d W HO grade III (an aplast ic) m en ingiom as
h ave a h igh er recu rren ce rate th an grade I (ben ign ) lesion s, bu t th is is n ot an
an sw er ch oice. Patient age (A) an d sex (E) are in correct resp on ses.3

92. B – Cerebellop on t in e angle cistern


93. D – Lateral cerebellom edu llar y cistern
94. A – Am bien t cistern
95. A – Am bien t cistern
96. B – Cerebellop on t in e angle cistern
97. C – In terpedun cular cistern
98. D – Lateral cerebellom edu llar y cistern

Th e am bient cistern (A) con tain s p ort ion s of th e su perior cerebellar arter y
an d th e t roch lear n er ve as it cou rses arou n d th e lateral brain stem . Th e cer-
ebello po ntine angle cistern (B) con t ain s th e an teroin ferior cerebellar arter y
an d th e t rigem in al n er ve. Th e inte rpe duncular cistern (C) con tain s th e basal
vein of Rosen th al. Th e late ral cerebello m edullary cistern (D) con tain s th e
ch oroid plexus at th e foram en of Lusch ka an d th e origin of th e posteroin ferior
cerebellar arter y (PICA). Non e of th e st ru ct ures listed are located in th e pre-
po ntine cistern (E).16

99. B – Coch lear an d in ferior vest ibu lar n er ves from th e facial an d su perior vest ibu lar
n er ves

Th is qu est ion test s th e exam in ee’s kn ow ledge of th e relat ion sh ips of th e


n er ves in th e in tern al acou st ic m eat u s. An teriorly, th e facial n er ve is su p e-
rior to th e coch lear n er ve (“7-u p, coke dow n ”). Posteriorly, th e su p erior an d
in ferior vest ibu lar n er ves are related to on e an oth er as th eir n am es im ply.
Th e t ran sverse crest run s h orizon t ally separat ing th e t w o superior st ru c-
t ures (facial n er ve an teriorly an d su perior vest ibu lar n er ve posteriorly) from
the t w o in ferior st ruct ures (coch lear n er ve an teriorly an d in ferior vest ibular
n er ve p osteriorly).2

100. B – Deafn ess is m ore com m on th an p erm an en t facial w eakn ess as a com p licat ion
of m icrovascular decom pression .

Hem ifacial sp asm is m ore com m on in fem ales (C is inco rrect); it t ypically
begin s in th e orbicularis m u scles an d progresses caudally (D is inco rrect).
At m icrovascu lar decom p ression th e m ost com m on n ding is com p ression
by the posteroin ferior cerebellar ar ter y (PICA) (A is inco rre ct); th e cure rate
at 1 m on th is 86% (E is inco rrect). Deafn ess occurs in 2.7% of pat ien ts, an d
perm an en t facial w eakn ess occurs in 1.5% of pat ien t s after m icrovascular
decom pression (B is co rrect).6

40
Neurosurgery—Answers and Explanations

101. E – Subtem poral approach

Possible approaches to an aneurysm of the vertebrobasilar junction include


the extended extrem e lateral inferior transcondylar approach (A), the lat-
eral suboccipital approach (B), the presigm oid transtentorial approach (C),
and the retrolabyrinthine transsigm oid approach (D). The subtem poral ap-
proach (E) is best suited for aneurysm s of the upper basilar trunk arising w ithin
2 cm below the tip of the posterior clinoid.3,5

102. A – Headach e

Headache (A) is the initial sym ptom in m ore than 75% of patients w ith col-
loid cysts, and alm ost all patients w ith this lesion experience headache. “Drop
attacks,” possibly secondary to acute hydrocephalus that suddenly stretches
corticospinal leg bers (sudden leg w eakness [D]), are associated w ith col-
loid cysts. Dem entia (B) m ay be prom inent, and seizures (C) occur in 20% of
patients. An association w ith sudden death (E) has been reported.3

103. C – In ferior an d an terior


104. D – In ferior an d posterior
105. A – Su p erior an d an terior
106. B – Su perior an d p osterior

This quest ion tests the exam in ee’s understan ding of the anatom y of th e in ter-
n al acou st ic m eat us view ed th rough a m iddle fossa app roach . Th e rst step is
get t ing orien ted by iden t ifying kn ow n st ru ct u res. Th e coch lea h as been ex-
posed in the angle created by th e facial n er ve (A) an d greater super cial pet ro-
sal n er ve (n ot labeled), w h ich w e kn ow is an terom edial to th e in tern al acou st ic
m eat u s. A port ion of th e labyrin th h as been exposed to reveal on e of th e sem i-
circular can als posterolaterally (closest to B). As such , w e kn ow th is is a view
of th e IAC from above (m iddle fossa approach ) on th e pat ien t’s righ t side. The
facial n er ve is n oted superio r and anterio r (A) cou rsing tow ard th e gen icu late
ganglion . Th e coch lear n er ve is sit u ated in an inferio r and anterio r (C) posi-
t ion on its w ay to th e coch lea. Th e superio r an d inferio r vest ibular n er ves are
sit u ated po sterio rly (B and D, respectively) en route to the labyrin th . (For
quest ion s 103–106, gure used w ith perm ission of Dr. Al Rh oton .)

41
Neurosurgery Board Review

107. A – Congest ive h ear t failu re

Neon ates w ith congestive heart failure (A) u su ally h ave m u lt ip le st u las,
an d over 25% of th eir cardiac ou t pu t is sh u n ted. Hydro cephalus (B) an d
seizures (D) are m ore com m on in infan t s, w hereas subarachno id hem o r-
rhage (E), decreased cogn it ion , an d intraparenchym al hem o rrhage (C) are
m ore com m on in older ch ildren an d adu lts.3

108. B – Com p ression fract u re

Th is t ype of fract u re is gen erally stable because th e m iddle colum n is in t act ,


by de n it ion (ut ilizing th e th ree-colum n spin e m odel). Posterior colum n
failu re can st ill occu r, h ow ever, if th e an terior body h eigh t is redu ced by m ore
than h alf. Th e resu lt ing kyph ot ic deform it y can lead to n eurologic de cit .3

109. B – Fract u re-dislocat ion s involve all th ree colu m n s.

Com pression fract ures are th e m ost com m on th oracolum bar spin e fract ure
(A is inco rre ct). Seat belt inju ries refer to exion -d ist ract ion t ype inju ries th at
are often u n stable (C is inco rrect). Wedge com pression fract u res gen erally
involve th e an terior colu m n an d are usually stable (D and E are inco rrect).3

110. B – A resu lt of cytotoxic ed em a (false)

Di u se brain sw elling is a vasoact ive p ost t rau m at ic p h en om en on occu rring


w ith in h ours of h ead injur y. It is th ough t to be a result of cerebrovascular
co ngestion (A) an d can be m an ifested on CT scan by a co m pressio n o f the
perim ese ncephalic cistern (D). Th is path ologic process is m o re co m m o n in
children than adults (E), an d m ay be asso ciated w ith a 50%m o rtality rate
in severely head injured children (C). It is dist in ct from th e vasogen ic or
cyto toxic edem a (B) th at occu rs later.7

111. C – Pariet al skull fract u re

Of th e ch oices listed, an isolated parietal skull fracture (C) is th e least sug-


gest ive of ch ild abu se, or n on acciden t al t rau m a. Acute and healing lo ng bo ne
fractures (A), retinal hem o rrhages (D), an d the presence of subdural he-
m atom as (B and E) sh ould be t reated as n on acciden t al t raum a un t il proven
oth er w ise. W h en associated w ith abu se, sku ll fract u res ten d to be m u lt iple or
com plex, depressed, an d n onpariet al.7,9

112. E – Metopic sut ure

Prem at ure closure of th e m eto pic suture (E) resu lt s in t rigon oceph aly. Th e
in ciden ce of t rigon oceph aly ranges from 10 to 16%.7

113. B – Lu m bar region

Th e cleft is located in th e lum bar regio n (B) in 47%, th oracolum bar region
in 27%, tho racic regio n (D) in 23%, an d sacral (C) or cervical region (A) in
1.5% of cases.3

42
Neurosurgery—Answers and Explanations

114. E – 80%

Up to 80% of pat ien t s w ith m ycot ic an eur ysm s carr y an u n derlying diagn osis
of subacute bacterial en docardit is.3

115. A – In fected em boli lodge in th e vasa vasoru m (false).

Bacterial (m ycot ic) in t racran ial an eu r ysm s are t yp ically located in th e periph-
eral branches (C) of th e m iddle cerebral artery territo ry (B). St a ph ylococcu s
a u r eu s and b -hem o lytic strepto co cci species (E) are th e m ost com m on of-
fen ding agen ts. Th e obser vat ion th at vasa vasoru m are fou n d on ly on th e rst
segm en t of th e in tern al carot id ar ter y (ICA), an u n u su al site of th e develop -
m en t of bacterial an eu r ysm s, h as d iscred ited th e n ot ion th at infected e m bo li
lo dge in the vasa vaso rum (A). Alth ough th ese an eu r ysm s h ave a h igh ten -
den cy to bleed, t ypical subarachno id he m o rrhage occurs in less than 20%
o f patie nts (D).3

116. E – Occur m ost com m on ly bet w een th e ages of 2 an d 5 years (false)

Grow ing sku ll fract u res m ay cro ss suture lines (A), m ay be asso ciated w ith
an underlying brain injury (B), ten d to occu r if th e initial fracture is sepa-
rated by m o re than 3 m m (C), an d occu r m o st co m m o nly in the parietal
bo ne (D). Up to 75% of p at ien ts w ith grow ing sku ll fract u res are , 1 year o ld
(E is false, and the refore the co rre ct answ er cho ice).7

117. E – 100%

One hundre d perce nt (E) of in fan t s w ith m yelom en ingocele h ave MRI
evid en ce of a Ch iari II m alform at ion , th e m ech an ism of w h ich is th ough t to
be due to CSF leaking th rough th e m yelom en ingocele during developm en t .3

118. A – I, II, III (ch olesterol, calci c, an d platelet- brin )

Cho lestero l em bo li (I) (Hollen h orst plaqu es) are associated w ith ulcerated
ath erom atou s plaques of th e ICA. Calci c em bo li (II) origin ate from th e car-
diac valves. Platelet- brin em bo li (III) are th ough t to arise from large-vessel
m u ral th rom bi. Fat em bo li (IV) resu lt after t rau m a to m arrow -con tain ing
bon es an d th erefore are n ot due to cardiovascular disease of th e h ear t an d
great vessels.4

119. B – I, III (su p erior verm ian vein , p recen t ral cerebellar vein )

Th e superio r ve rm ian vein (I) an d precentral cerebellar vein (III) are u su-
ally sacri ced du ring th e in fraten torial su pracerebellar app roach to th e p in eal
region . Th e basal vein o f Ro se nthal (IV) an d po ste rio r pericallo sal vein (II)
are n ot sacri ced du ring th is app roach .5

43
Neurosurgery Board Review

120. B – Lou dn ess recru it m en t (false)

An absen ce of lo udness recruitm ent (B is inco rrect) is ch aracterist ic of a


n er ve t ru n k lesion , in clu ding an acou st ic n eu rom a. Recru it ing deafn ess
occurs w ith a lesion in th e organ of Cort i (e.g., Mén ièreʼs disease). The oth er
respon ses (Béké sy type III or IV audiogram [A], low sho rt-increm ent
sensitivity index [C], po o r spee ch discrim inatio n [D], and pro no unced
to ne decay [E]) are all ch aracterist ic of a ret rococh lear (n er ve) lesion su ch as
an acou st ic n eu rom a.4

121. B – Su barcu ate ar ter y


122. F – An teroin ferior cerebellar arter y
123. A – Coch lear n er ve
124. E – Facial n er ve
125. C – Glossoph ar yngeal n er ve
126. G – Spin al accessor y n er ve
127. H – Posteroin ferior cerebellar arter y
128. D – Vagus n er ve

H–Not labeled

Th is gure illust rates th e st ru ct ures of th e righ t cerebellopon t in e angle as


view ed th rough a ret rosigm oid app roach . A Rh oton dissector in th e cen ter of
th e im age is ret ract ing th e in ferior vest ibular n er ve in feriorly an d is m aking
con t act w ith th e AICA (F). Th e co chlear nerve (A) is im m ediately an terior to
th e in ferior vest ibular n er ve. Th e subarcuate arte ry (B) com es o of AICA an d
t ravels tow ard th e subarcu ate fossa. Th e superior vest ibular n er ve is being
ret racted su periorly in th e upper righ t corn er of th e im age to reveal th e facial
nerve (E), w h ich is im m ediately an terior to th e su p erior vest ibu lar n er ve at
th e IAC. In th e low er h alf of th e im age, th e glo sso pharyngeal nerve (C), th e
vagus nerve (D), an d th e spinal accesso ry nerves (G) can be seen as th ey ap -
p roach th e jugular foram en to exit th e cran ial vau lt . Th e PICA vessel is n ot la-
beled but can be foun d in th e low er left quadran t of th e im age crossing cran ial
n er ves IX, X, an d XI.1 (For quest ion s 121–128, gure used w ith perm ission of
Dr. Al Rh oton .)

44
Neurosurgery—Answers and Explanations

129. A – Den t ate ligam en t

Th e dentate ligam ent (A) is a paired st ruct ure th at is an exten sion of pia
that conn ect s th e lateral aspect of th e spin al cord to th e dura bilaterally—
it m arks th e m ost dorsal exten t of th e in cision for an terolateral cordotom y,
a fu n ct ion al p rocedu re for ch ron ic pain . Lesion ing at th e do rsal ro ot entry
zo ne (B) is a u seful tech n iqu e par t icularly in cases of pain related to n er ve
root avu lsion . Th e po sterio r interm ediate sulcus (C) sep arates th e fascicu lu s
gracilis from th e fascicu lu s cu n eat u s. Th e po sterio r m edian sulcus (D) ru n s
in th e dorsal m idlin e separat ing th e righ t an d left dorsal colu m n s. A eren t
p ain bers en ter th e spin al cord an d m ay ascen d or descen d up to th ree spin al
levels in th e zo ne o f Lissauer (E) p rior to term in at ing in th e dorsal h orn .3,14

130. A – I, II, III (con t ralateral h em iplegia, h em ihypesth esia, h om onym ous h em ian opia)

Th e an terior ch oroidal arter y is an in t racran ial bran ch of th e in tern al carot id


ar ter y th at com es o th e ICA ju st dist al to th e origin of th e p osterior com m u -
n icat ing arter y. Th e an terior ch oroidal arter y can be th ough t of as th e m ost
m edial of th e lateral len t icu lost riate arteries, su pp lying th e globu s p allid u s
in tern a, th e p osterior lim b of th e in tern al capsule, an d th e opt ic t ract . Occlu-
sion of th e an terior ch oroidal arter y m ay lead to contralateral hem iplegia (I),
he m ihypesthesia (II), an d a ho m o nym o us hem iano psia (III). Cognitive
functio n (IV) is u n im p aired after occlu sion of th e an terior ch oroidal ar ter y.4

131. E – Trem or

Th e sym ptom of Parkin son’s disease th at is m ost likely to respon d to a stereo-


t act ic lesion of th e VIM of th e th alam us is trem o r (E).3

132. D – Neith er
133. C – Both
134. A – Ap er t’s syn d rom e
135. B – Crou zon’s d isease
136. A – Ap er t’s syn d rom e

Both Ap er t’s syn drom e an d Crou zon’s disease are au tosom al dom in an t
con dit ion s. Exorbit ism an d m idface de cien cy are seen in both . An terior open
bite an d syn dact yly are ch aracterist ic of Apert’s syn drom e. Alth ough develop -
m en tal d elay is u n com m on in p at ien t s w ith Crou zon’s disease, m en t al ret ar-
dat ion is seen in 50 to 85% of pat ien ts w ith Apert’s syn drom e.3,7

137. A – Prim ar y em pt y sella syn drom e


138. C – Secon dar y em pt y sella syn drom e

Prim ary em pty sella (A) syn drom e is an in t rasellar h ern iat ion of th e su b-
arach n oid sp ace occu rring w ith ou t p reviou s p it u it ar y su rger y or radiat ion
therapy. It t ypically occurs in m iddle-aged, obese w om en . Visual dist urban ce
m ay occu r in both th e p rim ar y an d secon dar y form s of th e syn d rom e.2

45
Neurosurgery Board Review

139. E – Traum at ic

Os od on toideu m is a segm en t of odon toid th at is w ell-cort icated an d is n ot


fu sed w ith th e body of th e den s. Th e con dit ion m ay be co ngenital (A) or
traum atic (E); t rau m a is th e m ore com m on cau se.14

140. D – Flexion

Tran slat ion al C1–C2 sublu xat ion is associated w ith exio n (D) inju ries, rh eu -
m atoid arth rit is, an d ton sillit is (Grisel’s syn drom e).14

141. C – In t im al proliferat ion

W h ile th e m ech an ism of cerebral vasospasm has yet to be elu cidated, st udies
in dicate th at intim al pro liferatio n (C) is too m ild an d occu rs too long after
su barach n oid h em orrh age to p lay a sign i can t role in vasospasm .2

142. D – In tern al acoust ic m eat us


143. E – Posterior in ferior cerebellar arter y
144. G – Ch orda t ym p an i n er ve
145. F – Facial n er ve
146. B – Su p erior cerebellar arter y
147. C – Trigem in al n er ve
148. A – Troch lear n er ve

Th is gure illu st rates th e righ t presigm oid, ret rolabyrin th in e approach . Th e


tro chlear nerve (A) is n oted at th e rost ral exten t of th e exp osu re, w ith th e
superio r cerebellar arte ry (B) ju st below it . Th e trigem inal ne rve (C) is
closely associated w ith th e superior pet rosal vein in th is im age (n ot labeled).
Th e VII–VIII com plex is seen en tering th e inte rnal aco ustic m eatus (D). Th e
tem poral bon e h as been drilled to expose th e course of th e facial (F) an d
cho rda tym pani ne rves (G).1 (For qu est ion s 142–148, gu re used w ith per-
m ission of Dr. Al Rh oton .)

149. A – Type I sp in al AVMs


150. A – Type I sp in al AVMs
151. C – Type III spin al AVMs
152. B – Type II sp in al AVMs
153. A – Type I sp in al AVMs
154. E – Types II an d III spin al AVMs

46
Neurosurgery—Answers and Explanations

155. A – Type I sp in al AVMs

Type I (A), or du ral, sp in al ar terioven ou s m alform at ion s (AVMs) are th e m ost


com m on t ype of spin al AVM, are believed to be acquired lesion s, an d m an i-
fest low ow bu t h igh p ressu re. Th ey t yp ically presen t w ith a slow ly p rogres-
sive cou rse w ith ou t sign i can t clin ical im provem en t . Th e et iology of t yp es
II, III, an d IV sp in al AVMs is believed to be congen it al. Type II (B), or glom u s,
AVMs are in t ram edullar y. Type III (C), or juven ile, AVMs are p redom in an tly
in t radu ral. Th ey are both t ru e AVMs w ith rapid blood ow an d are at risk
for su barach n oid or in t ram edu llar y h em orrh age. Type IV (D) AVMs var y in
size an d in rap idit y of blood ow. Th ey are in t radu ral, ext ram edu llar y, or
perim edullar y.2

156. C – Extern al carot id, com m on carot id, in tern al carot id

Th e correct sequen ce of rem oval of clam ps from th e arteries follow ing carot id
en darterectom y is th e extern al carot id arter y rst , follow ed by th e com m on
carot id ar ter y, w ith th e rem oval of th e clam p from th e in tern al carot id arter y
last . Th is sequen ce en su res th at any em bolic m aterial w ill be u sh ed in to th e
extern al carot id circu lat ion .2

157. C – An terior caudate vein


158. B – Colu m n of th e forn ix
159. D – In tern al cerebral vein
160. A – Septal vein
161. G – Tela ch oroid ea
162. E – Th alam ost riate vein
163. F – Th alam u s

Th e above gure represen ts a view of th e con ten ts of th e righ t lateral ven t ri-
cle th at are relevan t for th e subch oroidal t ran svelu m in terposit um approach
to th e th ird ven t ricle.5

47
Neurosurgery Board Review

164. E – Dorsal ram u s of C1


165. A – Glossoph ar yngeal n er ve
166. D – Hypoglossal n er ve
167. C – Spin al accessor y n er ve
168. B – Vagu s n er ve

Qu est ion s 164–168 test th e exam in ee’s kn ow ledge of th e relevan t an atom y


exp osed th rough th e far lateral ap p roach . A righ t-sided exp osu re is pict u red
h ere. Th e glo ssopharyngeal (A), vagus (B), an d spinal accesso ry nerves (C)
can be seen in t ran sit to th e jugu lar foram en in th e upper righ t por t ion of th e
im age. Th e hypo glo ssal nerve (D) h as been exposed in its can al. Th e do rsal
ram us o f C1 (E) is adjacen t to th e ver tebral arter y at th e low er m argin of th e
gu re. (For qu est ion s 164–168, gu re u sed w ith perm ission of Dr. Al Rh oton .)

169. D – An terior cerebral arter y


170. E – An terior ch oroidal ar ter y
171. F – Middle cerebral arter y
172. A – Opt ic n er ve
173. B – Posterior com m u n icat ing arter y
174. C – Superior hypophyseal arter y

Th e above gures sh ow th e su rgeon’s view of th e opt ic n er ve, carot id ar ter y,


an d it s bran ch es as seen th rough a righ t-sided pterion al cran iotom y. Th e ip -
silateral o ptic nerve is labeled A. Th e in tern al carot id arter y (ICA) bifu rcates
in to th e laterally project ing m iddle cerebral arte ry (F) an d m edially p roject-
ing ante rio r cerebral artery (D). Th e m ost p roxim al ICA bran ch in th is im -
age is th e po sterio r co m m unicating arte ry (B). Th e superio r hypo physeal
artery (C) can be seen project ing m edially un dern eath th e opt ic ch iasm . Th e
anterio r cho ro idal artery (E) t akeo is just proxim al to th e in tern al carot id
ar ter y bifu rcat ion .2

48
Neurosurgery—Answers and Explanations

175. B – Leptom en ingeal ven ou s d rain age

Th e risk of h em orrh age of dural AVMs seem s related to th e presen ce of


tor t uous an d an eur ysm al leptom en ingeal ar terialized vein s.2

176. E – Surger y
177. A – Brom ocript in e

A prolact in level of 89 probably represen t s th e “st alk e ect” from th is large pi-
t uitar y t u m or w ith suprasellar exten sion . A preoperat ive oph th alm ologic ex-
am in at ion sh ou ld be docu m en ted , an d su rger y probably sh ou ld be perform ed
because ch iasm al com pression is eviden t . A prolact in level of 650 suggests a
p rolact in om a th at sh ou ld be brom ocript in e respon sive.2,14

178. A – In t raven t ricu lar

Lateral ven t ricu lar m en ingiom as accou n t for 1 to 2% of in t racran ial m en in -


giom as. Olfacto ry gro ove (B), po sterio r fo ssa (C), spheno id ridge (D), an d
tuberculum sella (E) are all m ore com m on locat ion s.2

179. E – Th e risk of rebleed in th e rst year after h em orrh age is h igh est in th e rst
2 w eeks (false).

Th e risk of rebleed from an AVM in th e rst year after h em orrh age is as h igh
as 6 to 18%, bu t th is risk is even ly d ist ribu ted th rough ou t th e rst year.2

180. E – Paresth esias or dysesth esias

Paresthesias (E) occur in 20% of postoperat ive pat ien t s; dysesthesias (E)
occur in 5.2 to 24.2%.2

181. C – II, IV (t rigem in al cistern an d foram en ovale)

In th e tech n iqu e of percu t an eou s rad iofrequ en cy t rigem in al gangliolysis, th e


n eedle is in ser ted in to th e trigem inal cistern (II) via th e fo ram e n ovale (IV).
Th e fo ram en rotundum (I) does t ran sm it th e m axillar y d ivision of th e t ri-
gem in al n er ve, bu t is n ot u sed in th is p rocedu re. Th e fo ram en spino sum (III)
t ran sm it s th e m iddle m en ingeal arter y an d is n ot u sed in percut an eous t ri-
gem in al gangliolysis.2

49
Neurosurgery Board Review

182. H – In ferior rect u s m u scle


183. D – In ferior division of th e oculom otor n er ve
184. E – Abducen s n er ve
185. A – Fron t al n er ve
186. C – Nasociliar y n er ve
187. B – Su perior d ivision of th e ocu lom otor n er ve
188. G – Opt ic n er ve
189. F – Troch lear n er ve

Th e above gure represen t s a cross sect ion th rough th e righ t orbit (an terior
view ). Th e frontal nerve (A) an d superio r divisio n o f the o culo m oto r nerve
(B) are n oted su perolaterally. Th e sm all tro chlear nerve (F) is n oted supero-
m edially. Th e o ptic ne rve (G) is seen in its sh eath w ith th e naso ciliary nerve
(C) just lateral to it . In ferior to th e opt ic n er ve lies th e infe rio r divisio n o f
the o culo m oto r nerve (D) an d th e infe rio r rectus m uscle (H). Th e abdu-
ce ns nerve (E) is seen in ferolateral to th e op h th alm ic arter y (u n labeled).1 (For
quest ion s 182–189, gure u sed w ith perm ission of Dr. Al Rh oton .)

190. B – DREZ rh izotom y


191. E – Sym path ectom y
192. A – Cingu lotom y
193. C – Morph in e in fusion
194. D – Pallidotom y
195. F – Ven t ral rh izotom y

Cingulotom y (A) procedures are used in the treatm ent of obsessive-com pulsive
disorder. For patients w ith nociceptive cancer pain above C5, m orphine in-
fusion (C) and periven tricular gray m at ter stim ulation are options. If ch ronic
stim ulation fails in brachial plexus avulsion pain, a dorsal root entry zo ne
(DREZ) procedure (B) sh ould be considered. The pallidotom y (D) is ver y e ec-
tive in Parkinson’s disease, w hereas causalgia responds to sym pathecto m y (E).
Good results are obtained w hen spasm odic torticollis is treated w ith ventral
rhizotom y (F) com bined w ith spin al accessor y denervation procedures.2

50
Neurosurgery—Answers and Explanations

196. E – All of th e above

Th ese opt ion s (in tercostal n er ves, spin al accessor y n er ves, cer vical plexus,
an d p h ren ic n er ve) h ave all been u sed w ith var ying degrees of su ccess. In ter-
cost al n er ves are m ost com m on ly u sed for n eurot izat ion procedures involv-
ing th e u p per ext rem it y.2

197. A – Fron t al, greater w ing of th e sph en oid, p ariet al, an d squ am ou s p ar t of th e
tem poral

B is in correct; th e lesser w ing of th e sph en oid does n ot con t ribu te to th e


pterion . C is in correct; th e zygom at ic arch does n ot con t ribu te to th e pterion .
D and E are in correct becau se n eith er th e lesser w ing of th e sp h en oid n or th e
zygom at ic arch con t ributes to th e pterion .17

198. A – 30 Gy in 2 w eeks

Th e m ost com m on extern al beam radiat ion th erapy regim en for brain m etas-
t asis is 30 Gy given over 2 w eeks (A).14

199. B – 6,000 cGy in 200 cGy daily fract ion s

Th e m ost appropriate radiat ion protocol for glioblastom a is 6,000 cGy in


200 cGy daily fractio ns (B).14

200. E – Volum e st at us

Pat ien t s w ith cerebral salt w ast ing are volu m e d ep leted , w h ereas th ose w ith
syn drom e of in ap prop riate an t idiu ret ic h orm on e (SIADH) are euvolem ic or
volu m e expan ded.2

201. C – ASIA C

Th e ASIA im pairm en t scale is used for th e grading of acute spin al cord injuries.
ASIA A (A) represen t s a com p lete spin al cord inju r y w ith n o sen sor y or m otor
sp aring in th e sacral derm atom es. ASIA B (B) corresp on ds to a sen sor y in com -
p lete sp in al cord inju r y, w ith sparing of sen sat ion bu t n ot m otor fun ct ion dis-
t al to th e level of injur y—th is m ay in clude sen sat ion in th e sacral derm atom es
on ly (perian al sen sat ion or deep an al pressure). ASIA C (C) represen t s m otor
in com p lete inju ries w h ere . 50%of th e m u scles below th e level of inju r y h ave
, grade 3 pow er—such as th e pat ien t in th e vign et te. ASIA D (D) is ascribed
to pat ien ts w ith grade 3 p ow er in . 50% of th e m u scle grou p s below th e
n eu rologic level. ASIA E (E) correspon ds to pat ien t s w h o h ave su stain ed a
docum en ted spin al cord injur y, but are n ow n eurologically in tact .14

51
Neurosurgery Board Review

202. C – 75%

Th e ASIA im pairm en t scale can h elp to predict am bulator y ou tcom es. Th e


p at ien t in th e qu est ion stem h as an ASIA C spin al cord inju r y. Please see th e
t able below.14

Grade % Am bu lator y

A , 3

B 50

C 75

D 95

E 100

203. D – PTEN m u t at ion

Th e diagn osis for th e pat ien t in th e quest ion stem is Cow den’s syn drom e,
w h ich is ch aracterized by facial t rich ilem m om as, brom as of th e oral m u -
cosa, h am ar tom as of th e GI t ract an d breast , an d thyroid t um ors. Th ere is
also an associat ion w ith Lh erm it te-Du clos disease, a h am artom atou s lesion
of th e cerebellu m . Cow den’s disease is due to m ut at ion s of th e PTEN gene
o n chro m o so m e 10q (D). CAG trinucleotide re peats (A) are associated w ith
Hu n t ington’s disease. Th e m TOR pathw ay (B) h as been im plicated in th e
p ath ogen esis of t u berou s sclerosis. Germ lin e m utatio ns o f p53 (C) are seen
in th e Li-Fraum en i syn drom e. Triso m y 21 (E) is seen in Dow n’s syn drom e.14

204. C – Major lum bar levoscoliosis an d m in or th oracic dext roscoliosis

52
Neurosurgery—Answers and Explanations

The cur ve is nam ed based on the direct ion of the convexit y of th e cur ve. If the
convexit y of the cur ve is to the right , it is labeled dext roscoliosis. If the convex-
it y of th e cur ve is to th e left , it is labeled levoscoliosis (A and D are inco rrect).
The m ajor and m in or cur ves are determ ined by the Cobb angles; the cur ve
w ith the larger Cobb angle is the m ajor cur ve. Conversely, the cur ve w ith th e
sm aller Cobb angle is th e m in or cur ve (E is incorrect). In th is case, th e th oracic
cur ve has its convexit y pointed to the right w ith a Cobb angle of 33 degrees.
The lum bar cur ve has its convexit y pointed to the left an d has a Cobb angle of
48 degrees. Therefore, th e best descript ion is choice C, m ajo r lum bar levo sco -
lio sis and m ino r tho racic dextro sco lio sis.18

205. D – All of th e above

Iliac crest bon e graft is h ar vested from a p oin t at least 3 cm beh in d th e an terior
su perior iliac sp in e to avoid ilioingu in al ligam en t disru pt ion . Ner ves at risk
during th is procedure (from lateral to m edial) in clude th e ilio hypo gastric (A),
ilio inguinal (B), an d lateral fem o ral cutane o us ne rves (C). Th e correct an -
sw er is D, all o f the above.18

206. D – Sparing of dorsal h an d sen sat ion

A sen sor y de cit over th e dorsouln ar aspect of th e h an d is seen in uln ar


n er ve com pression at th e elbow. With u ln ar n er ve com p ression at th e w rist in
Guyon’s can al, th is dorsal sen sat ion is sp ared as th e dorsal sen sor y bran ch of
the uln ar n er ve bran ch es o proxim al to th e w rist . Th erefore, D is th e correct
respon se. Th e oth er feat u res can be seen in uln ar n er ve com pression at th e
elbow or th e w rist .8

207. C – MRI is alw ays un rem arkable (false)

SCIWORA refers to spinal co rd injury w itho ut radio graphic abno rm ality (A)
an d is m ore often see n in the pediatric po pulation (B). Pat ien t s w ill presen t
w ith sign s an d sym ptom s of spin al cord injur y w ith out radio graphic (X-ray
o r CT) evidence o f a fracture (D). SCIWORA w as rst described before MRI
w as rou t in ely u sed in th e evalu at ion of sp in e t rau m a, an d th e m ech an ism is
though t to be related to ligam ento us laxity in children (E). MRI scan s in ch il-
dren w ith SCIWORA m ay reveal disrupt ion of th e discoligam en tous com plex
an d inju r y to th e cord itself (C is false).19

208. E – Posterior C1–C2 in st rum en ted fusion

Type II odontoid fractures have a high rate of nonunion, and therefore, surgical in-
tervention is usually recom m ended (A and B are incorrect). Generally, odontoid
screw placem ent (D) and posterior C1– C2 fusion (E) either w ith transarticular
screws or a screw /rod construct are acceptable options. In this case, the transverse
ligam ent is disrupted, w hich is a contraindication to odontoid screw placem ent
(the patient would have ongoing atlantoaxial instability even if the odontoid was
stabilized due to ligam entous disruption between the dens and C1). Therefore, a
posterior C1– C2 fusion (E) is the m ost appropriate treatm ent for this patient.
Inclusion of the occiput would be unnecessary and introduces additional com -
plexity and m orbidity to the procedure (C is incorrect).18

53
Neurosurgery Board Review

References

1. Rh oton AL. Cran ial An atom y an d Su rgical Ap p roach es. Sch au m bu rg, IL: Lip pin cot t William s
& Wilkin s; 2003
2. Tin dall GT, Cooper PR, Barrow DL, eds. Th e Pract ice of Neu rosurger y. Balt im ore, MD:
William s & Wilkin s; 1995
3. Win n HR, ed-in -chief. Neurological Su rger y, 5th ed. Ph iladelph ia, PA: W.B. Saun ders; 2003
4. Ropper AH, Brow n RH. Prin ciples of Neu rology, 8th ed. New York: McGraw -Hill; 2005
5. Apuzzo MLJ. Brain Surger y. Com plicat ion Avoidan ce an d Man agem en t . New York: Ch urch ill
Livingston e; 1993
6. Green berg MS. Han dbook of Neurosurger y, 5th ed. New York: Th iem e Medical Pu blish ers;
2001
7. Ch eek W R, ed. Pediat ric Neu rosu rger y: Su rger y of th e Develop ing Ner vou s System , 3rd ed.
Ph iladelphia, PA: W.B. Sau n ders; 1994
8. Qu in on es-Hin ojosa A, ed. Sch m idek & Sw eet Op erat ive Neu rosu rgical Tech n iqu es, 6th ed .
Ph iladelphia, PA: Elsevier; 2012
9. Nelson JS, Men a H, Parisi JE, Sch ochet SS, eds. Prin ciples an d Pract ice of Neuropath ology,
2n d ed. New York: Oxford Un iversit y Press; 2003
10. Roth m an RH, Sim eon e FA, eds. Th e Spin e, 3rd ed . Ph ilad elph ia, PA: W B Sau n ders; 1992
11. Fr ym oyer JW, ed . Th e Adu lt Sp in e, Prin ciples an d Pract ice. Ph iladelp h ia, PA: Lip p in cot t-
Raven ; 1997
12. Row lan d LP, ed. Merrit t’s Textbook of Neurology, 9th ed. Balt im ore, MD: William s &
Wilkin s; 1995
13. Ch eek W R, ed. Pediat ric Neu rosu rger y: Su rger y of th e Develop ing Ner vou s System , 3rd ed.
Ph iladelphia, PA: W.B. Sau n ders; 1994
14. Citow JS, Macdon ald RL, Refai D, eds. Com preh en sive Neu rosu rger y Board Review. New
York: Th iem e Medical Pu blish ers; 2009
15. Youm an s JR, ed-in -ch ief. Neurological Surger y, 4th ed. Ph iladelph ia, PA: W.B. Saun ders;
1992
16. Yasargil MG, Kasdaglis K, Jain KK. An atom ic Obser vat ion s of th e Su barach n oid Cistern s of
th e Brain du ring Surger y. In : Selected papers of Professor Gazi Yasargil. Congress of Neuro-
logical Surger y. New York: Waverly Press; 1986
17. Moore KL, Dalley AF. Clin ically Orien ted An atom y, 5th ed. Balt im ore, MD: Lippin cot t
William s an d William s; 2006
18. Kim DH, ed . Su rgical An atom y an d Tech n iqu es to th e Sp in e, 2n d ed . Ph iladelp h ia, PA:
Elsevier; 2013
19. Borden NM, Forseen SE. Pat tern Recogn it ion Neuroradiology. New York: Cam bridge Un i-
versit y Press; 2011

54
2A Clinical Neurology—
Questions

For qu est ion s 1 to 7, m atch th e eye m ovem en t w ith th e descript ion . Each respon se m ay
be u sed on ce, m ore th an on ce, or n ot at all.
A. Convergen ce nyst agm us
B. Dissociated nyst agm us (in tern uclear oph th alm oplegia)
C. Dow n beat nyst agm u s
D. Im pairm en t of optokin et ic nyst agm us
E. Ocular bobbing
F. Seesaw nyst agm u s
G. Spasm u s m u t an s

1. A com m on sign of m ult iple sclerosis

2. Most often associated w ith large dest ruct ive lesion s of th e pon s

3. Seen exclusively in in fan t s

4. Associated w ith lesion s of th e cer vicom edullar y ju n ct ion

5. Associated w ith lesion s of th e parasellar region

6. Associated w ith lesion s of th e parietal lobe

7. Associated w ith lesion s of th e pin eal region

8. W h ich of th e follow ing is false of seizu re foci?


A. Epilept ic foci are slow er in bin ding an d rem oving acet ylch olin e th an n orm al
cor tex.
B. Firing of n euron s in th e focus is re ected by periodic spike disch arges in th e
elect roen ceph alogram (EEG).
C. If u n ch ecked, cor t ical excit at ion m ay spread to th e subcort ical n uclei.
D. Neu ron s surroun ding th e focus are in it ially hyperpolarized an d are
GABAergic.
E. Th e ch ange in seizure disch arge from th e ton ic ph ase to th e clon ic ph ase
resu lts from in h ibit ion from th e n eu ron s surroun ding th e focu s.

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Neurosurgery Board Review

9. An abn orm al optokin et ic respon se is m ore likely to be obtain ed by rot at ing th e


optokin et ic nystagm us drum
A. Aw ay from an occip ital lobe lesion
B. Aw ay from a parietal lobe lesion
C. Tow ard an occipit al lobe lesion
D. Tow ard a parietal lobe lesion
E. Tow ard a tem poral lobe lesion

For quest ion s 10 to 14, m atch th e EEG w ave w ith th e descript ion . Each resp on se m ay be
u sed on ce, m ore th an on ce, or n ot at all.
A. Alp h a
B. Beta
C. Delta
D. Th et a
E. 3-per-secon d spike an d w ave

10. 4 to 7 Hz

11. Norm ally m ay be presen t over th e tem poral lobes of th e elderly

12. Recorded from th e fron tal lobes sym m et rically

13. Associated w ith absen ce seizures

14. At ten uated or abolish ed w ith eye open ing or m en t al act ivit y

15. W h ich of th e follow ing drugs is least e ect ive in th e t reat m en t of t rigem in al
n eu ralgia?
A. Baclofen
B. Carbam azepin e
C. Clon azepam
D. Ph enytoin
E. Ketorolac t rom eth am in e (Toradol)

16. W h ich of th e follow ing is t rue of p ap illedem a?


A. Absen ce of ven ou s pu lsat ion s is a reliable in d icator of pap illedem a.
B. Pupillar y ligh t re exes rem ain n orm al.
C. Th e congested capillaries derive from th e cen t ral ret in al vein .
D. Un ilateral edem a of th e opt ic disk is n ever seen .
E. Visual acu it y usually decreases.

17. W h ich of th e follow ing can occur in glossoph ar yngeal n euralgia?


I. Pain in th e th roat
II. Syn cope
III. Pain in th e ear
IV. Bradycardia
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

56
Clinical Neurology—Questions

18. Feat ures of t risom y 13 (Pat au’s syn drom e) in clude


I. Microcep h aly
II. Hyp er ton ia
III. Cleft lip an d palate
IV. Dext rocard ia
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

19. W h ich of th e follow ing is not a feat u re of Parin au d’s syn drom e?
A. Dissociated ligh t–n ear respon se
B. Lid ret ract ion
C. Nystagm us ret ractorius
D. Paralysis of upgaze
E. Th ird n er ve palsy

20. W h ich of th e follow ing is t rue of t u bercu lou s m en ingit is?


A. Headach e is usu ally absen t .
B. If un t reated, th e clin ical course is self-lim ited.
C. Th e in am m ator y exudate is con n ed to th e su barach n oid space.
D. Th e in am m ator y exudate is foun d m ain ly at th e convexit ies.
E. Th e protein con ten t of th e cerebrospin al uid (CSF) is alm ost alw ays
elevated.

21. W h ich of th e follow ing CSF n dings is least suggest ive of acu te m ult iple sclerosis?
A. An IgG in dex greater th an 1.7
B. In creased m yelin basic protein
C. In creased protein to 200 m g/dL
D. Presen ce of oligoclon al bands
E. Sligh t to m oderate m on ocyt ic pleocytosis

22. Each of th e follow ing is t rue of m yasth en ia gravis except


A. A decrem en t ing resp on se to perip h eral n er ve st im ulat ion is t ypical.
B. Am in oglycoside an t ibiot ics m ay w orsen th e sym ptom s.
C. Fem ales are m ore frequen tly a ected in th e , 40 age grou p.
D. Fem ales predom in ate in th e subset of pat ien t s w ith a thym om a.
E. Ten to 15% of pat ien t s h ave n o an t ibodies to th e acet ylch olin e receptor.

23. A defect in m itoch on drial DNA is foun d in each of th e follow ing disorders except
A. Kearn s-Sayre syn drom e
B. Leber’s h eredit ar y opt ic at rophy
C. Leigh’s subacute n ecrot izing en ceph alopathy
D. Mitoch on drial m yopathy, en ceph alopathy, lact ic acidosis, an d st roke
(MELAS)
E. Men kes’ syn drom e

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Neurosurgery Board Review

24. Sym ptom s of spon t an eous carot id ar ter y dissect ion in clude
I. Dysgeu sia
II. Eye p ain
III. Tongu e w eakn ess
IV. Horn er’s syn drom e
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

25. Mem or y im pairm en t is cau sed by discrete bilateral lesion s of w h ich of th e


follow ing st ru ct u res?
I. Am ygdala
II. Hip p ocam p al form at ion
III. Mam m illar y bodies
IV. Dorsom edial n u clei of th e th alam u s
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

26. Ge n es resp on sib le for cave r n ou s m a lfor m at ion s h ave b e e n m a p p e d t o


ch rom osom es
A. 1 an d 3
B. 3 an d 5
C. 3 an d 7
D. 4 an d 5
E. 5 an d 7

27. Each of th e follow ing is ch aracterist ic of a diabet ic th ird n er ve palsy except


A. It develops over a few h ours
B. It spares th e pupil
C. It is u sually pain less
D. Th e lesion involves the cen ter of th e n er ve
E. Th e progn osis for recover y is good

For quest ion s 28 to 36, provide th e best m atch of th e toxicit ies w ith th e descript ion .
Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Arsen ic poison ing
B. Lead poison ing
C. Mangan ese poison ing
D. Mercur y poison ing
E. Ph osph orus poison ing

28. Tran sverse w h ite lin es in th e ngern ails

29. Black lin es at th e gingival m argin s

30. Later sym ptom s resem ble th ose of Parkin son’s disease

31. Treated w ith at ropin e

58
Clinical Neurology—Questions

32. Pen icillam in e is th e t reat m en t of ch oice in th e ch ron ic form

33. Ch aracterized by m ood ch anges, t rem ors, an d a cerebellar syn drom e

34. Treated w ith ethylen ediam in etet raacet ic acid (EDTA) an d dim ercaprol (BAL)

35. In creased excret ion of urin ar y coproporphyrin

36. Diagn osis can be m ade by th e exam in at ion of h air sam ples

37. W h ich of th e follow ing is not a ch aracterist ic of Ad ie’s syn drom e?


A. Degen erat ion of th e ciliar y ganglia an d postganglion ic parasym path et ics
B. More com m on in w om en th an in m en
C. No react ion to 0.1% pilocarpin e solut ion
D. Paralysis of segm en t s of th e pupillar y sph in cter
E. Pupil respon ds bet ter to n ear th an to ligh t

38. Ch aracterist ics of in fan t ile seizu res in clude


I. Lip sm acking
II. Hyp sarrhyth m ia
III. Gen eralized ton ic-clon ic act ivit y
IV. Myoclon ic h ead jerks
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

For qu est ion s 39 to 42, m atch th e disease w ith th e d escript ion . Each resp on se m ay be
u sed on ce, m ore th an on ce, or n ot at all.
A. Myasth en ia gravis
B. Eaton -Lam ber t m yasth en ic syn drom e
C. Both
D. Neith er

39. Muscles of th e t run k an d low er ext rem it ies are m ore frequen tly involved th an
th e ext raocular m uscles

40. Poor respon se to an t icholin esterase drugs

41. An in crem en t ing respon se (m arked in crease in th e am plit ude of th e act ion
p oten t ial w ith fast rates of n er ve st im u lat ion ) is t ypical

42. Associated w ith antibodies to the presynaptic voltage-dependent calcium channel

43. Th e dorsal scapular n er ve in n er vates th e


I. Su p rasp in at u s
II. Rh om boids
III. Su bscapu laris
IV. Levator scapu lae
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

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Neurosurgery Board Review

For qu est ion s 44 to 50, m atch th e perip h eral n er ve w ith th e m u scle it in n er vates. Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Axillar y n er ve
B. Dorsal scapular n er ve
C. Subscapular n er ve
D. Suprascapu lar n er ve
E. Non e of th e above

44. Teres m ajor

45. Teres m in or

46. Subscapularis

47. Levator scapulae

48. Supraspin at us

49. In fraspin at us

50. Rh om boids

51. Th e m otor u n it poten t ial in m yopathy is of


A. Decreased volt age an d decreased d urat ion
B. Decreased voltage an d in creased durat ion
C. Decreased volt age an d n orm al durat ion
D. Norm al volt age an d decreased durat ion
E. Norm al volt age an d in creased du rat ion

52. W h ich is t rue of m yoton ic dyst rophy?


A. Fron t al balding occu rs on ly in m en .
B. Len s abn orm alit ies are rare.
C. Th e congen it al form is in h erited on ly from th e m atern al lin e.
D. Th e in h erit an ce is autosom al recessive.
E. Weakn ess alw ays predates th e m yoton ia.

53. Subacute com bin ed degen erat ion of th e spin al cord is caused by a de cien cy of
A. Cobalam in
B. Folic acid
C. Nicot in ic acid
D. Pyridoxin e
E. Th iam in e

54. Th e m arker lin ked to the Hu n t ington gen e is localized to th e sh or t arm of


ch rom osom e
A. 4
B. 11
C. 17
D. 22
E. Non e of th e above

60
Clinical Neurology—Questions

55. Alexia w ith out agraph ia is m ost likely to occur w ith a lesion involving th e
A. Left gen iculocalcarin e t ract an d corpu s callosum
B. Left gen iculocalcarin e t ract an d Wern icke’s area
C. Left gen iculocalcarin e t ract , corpus callosu m , an d Wern icke’s area
D. Righ t gen iculocalcarin e t ract an d corpus callosu m
E. Righ t gen iculocalcarin e t ract an d Wern icke’s area

56. Deviat ion of th e eyes to th e righ t is m ost likely to occur w ith occlu sion of th e
A. Calcarin e arter y bilaterally
B. Calcarin e ar ter y on th e con t ralateral side
C. Con t ralateral param edian bran ch of th e basilar arter y
D. Ipsilateral superior cerebellar ar ter y
E. Superior division of th e con t ralateral m iddle cerebral ar ter y

57. W h ich of th e follow ing an t iepilept ic drugs h as th e sh ortest h alf-life?


A. Carbam azep in e
B. Eth osu xim ide
C. Ph en obarbit al
D. Ph enytoin
E. Valproate

For qu est ion s 58 to 60, m atch th e descript ion w ith th e d isease.


A. Am yot roph ic lateral sclerosis
B. Syringom yelia
C. Both
D. Neith er

58. Weakn ess an d at rophy of th e h an ds

59. Hypo- or are exia

60. Absen ce of sen sor y ch anges

61. Bioch em ical st udies of n euron s from a seizure focus h ave sh ow n all of th e
follow ing except
A. In creased levels of ext racellular p ot assiu m in glial scars n ear seizu re foci
B. Decreased rate of bin ding an d rem oving acet ylch olin e in th e foci
C. De cien cy of -am in obu t yric acid (GABA)
D. Decreased glycin e levels
E. Decreased t aurin e levels

62. The m ost reliable indicator of an intracellular cobalam in (vitam in B12 ) de ciency is
A. Low vit am in B12 on a m icrobiologic assay
B. Low vit am in B12 on a radioisotope dilu t ion assay
C. Low vit am in B12 on a Sch illing test
D. Th e n ding of hypersegm en ted polym orph on uclear n eut roph il leukocytes
(PMN) in bon e m arrow sm ears
E. Th e n ding of increased seru m con cen t rat ion of m ethylm alon ic acid an d
h om ocystein e

61
Neurosurgery Board Review

63. Each of th e follow ing is t rue of radiat ion m yelopathy (delayed progressive t ype)
except
A. Absen ce of p ain is t ypical early in th e course
B. It occurs 12 to 15 m on th s after radiat ion
C. Magn et ic reson an ce im aging (MRI) sh ow s abn orm al sign al in ten sit y;
decreased on T1 and in creased on T2
D. Sen sor y ch anges usually develop after m otor ch anges
E. Th e m ost severe paren chym al changes are t ypical of in farct ion

64. Fasciculat ion poten t ials in dicate


A. Motor n er ve ber irritabilit y
B. Motor n er ve ber dest ruct ion
C. Motor un it den er vat ion
D. Muscle at rophy
E. Rein n er vat ion of m u scle un its

For qu est ion s 65 to 70, m atch th e descript ion w ith th e poten t ial.
A. Fasciculat ion poten t ial
B. Fibrillat ion poten t ial
C. Both
D. Neith er

65. Di- or t riph asic pat tern

66. 5 to 15 m illisecon ds in durat ion

67. May t ake th e form of posit ive sh arp w aves

68. Seen in poliom yelit is

69. Usually develops 24 to 36 h ours after th e death of an a xon

70. May be visible th rough th e skin

71. W h at ch aracterist ics of m otor un it poten t ials are t ypical soon after rein n er vat ion ?
A. Prolonged, h igh am plit ude, an d polyph asic
B. Prolonged, low am plit ude, an d polyph asic
C. Sh orten ed, h igh am plit ude, an d polyph asic
D. Sh orten ed, low am plit ude, an d polyph asic
E. Non e of th e above

72. W h ich of th e follow ing ocular n dings is not seen in m yasth en ia gravis?
A. Abn orm al pupillar y respon se to accom m odat ion
B. Norm al pupillar y respon se to ligh t
C. Weakn ess of ext raocular m uscles
D. Weakn ess of eye closure
E. Weakn ess of eye open ing

62
Clinical Neurology—Questions

73. Risk factors for carpal t un n el syn drom e in clude


I. Acrom egaly
II. Am yloidosis
III. Hyp othyroidism
IV. Pregn an cy
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

74. W h ich of th e follow ing is t rue of n eu rologic n dings in sarcoidosis?


A. Cran ial n er ve VI is m ost frequen tly involved.
B. Sarcoidosis occurs in 25% of cases of sarcoid.
C. Polydipsia, polyu ria, som n olen ce, an d obesit y are com m on feat u res.
D. Th e gran ulom atous in lt rat ion is m ost prom in en t over th e h em isph eres.
E. Visual dist u rban ces are usually secon dar y to lesion s in th e occipit al cor tex.

75. All of th e follow ing are associated w ith n arcolepsy except


A. In creased tot al n um ber of h ours per day spen t sleeping
B. Cat aplexy
C. Hypn agogic h allucin at ion s
D. Sleep paralysis
E. Sleep pat tern s begin n ing w ith th e rapid eye m ovem en ts (REM) st age

76. W h ich of th e follow ing sign s or sym ptom s occurring in a young person is th e
m ost suggest ive of m u lt ip le sclerosis?
A. Bilateral in tern u clear oph th alm oplegia
B. Gait ata xia
C. Lh erm it te’s sign
D. Opt ic n eurit is
E. Vert igo

77. Th e m uscles m ost often involved in thyroid oph th alm opathy are th e
A. In ferior, superior, an d m edial rect i
B. In ferior rect us an d superior oblique
C. Lateral an d su perior rect i
D. Lateral rect us an d su perior oblique
E. Medial rect us an d in ferior obliqu e

78. Most cases of “idiopathic” h em ifacial spasm are th ough t to result from
A. Eph apt ic t ran sm ission
B. Hypersen sit ivit y of facial m uscles
C. Hypocalcem ia
D. Psych iat ric disorders
E. Recurren ce of laten t viral in fect ion

63
Neurosurgery Board Review

79. Th e diagn osis of n eurosarcoidosis is based on


A. Biopsy eviden ce of sarcoid gran ulom as in n on –cen t ral n er vous system
(CNS) t issue an d n eurologic n dings
B. Com puted tom ography (CT) scan sh ow ing m en ingeal involvem en t
C. In creased sedim en tat ion rate an d hyperglobulin em ia
D. In creased serum levels of angioten sin -convert ing en zym e
E. MRI n dings of periven t ricular an d w h ite m at ter ch anges

For qu est ion s 80 to 84, m atch th e paran eop last ic syn d rom e w ith th e d escript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Lim bic en ceph alit is
B. Eaton -Lam ber t syn drom e
C. Moersch -Wolt m an (st i -m an ) syn drom e
D. Opsoclon u s-m yoclon us
E. Sen sor y n europathy

80. Seen m ost often in ch ildren w ith n euroblastom a

81. An t i-Hu an t ibodies

82. An t i-Ri an t ibodies

83. Autoan t ibodies to voltage-gated calcium ch an n els

84. Autoan t ibodies to glut am ic acid decarboxylase

For qu est ion s 85 to 88, m atch th e vascu lar syn d rom e w ith th e descript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Basilar syn drom e
B. Lateral m edullar y syn drom e (vertebral arter y [VA] or posteroin ferior
cerebellar arter y [PICA] occlusion )
C. Lateral superior pon t in e syn drom e (superior cerebellar arter y [SCA]
occlusion )
D. Medial m edu llar y occlusion
E. Non e of th e above

85. Con t ralateral h em iparesis sparing th e face, con t ralateral loss of posit ion an d
vibrat ion sen se, ip silateral paralysis, an d at rop hy of th e tongu e

86. Con t ralateral pain an d tem perat u re loss in th e body, ipsilateral Horn er’s
syn drom e, ip silateral at axia, ip silateral p aralysis of th e palate an d vocal cords,
an d ipsilateral pain an d n u m bn ess in th e face

87. Ipsilateral cerebellar at axia, con t ralateral loss of pain an d tem perat ure in th e
body, part ial deafn ess, an d n au sea an d vom it ing

88. Bilateral m otor w eakn ess in all ext rem it ies, bilateral cerebellar at axia, an d
diplopia

89. Th e lesion in h em iballism us is localized to th e con t ralateral


A. Brach ium conjun ct ivum
B. Caudate n ucleus
C. Dorsom edial n ucleus of th e th alam us
D. Subst an t ia n igra
E. Subth alam ic n ucleus

64
Clinical Neurology—Questions

90. Th e long th oracic n er ve in n er vates th e


A. Lat issim u s dorsi
B. Levator scapulae
C. Rh om boids
D. Serrat u s an terior
E. Teres m in or

91. W h ich of th e follow ing is m ost con sisten t w ith Eaton -Lam bert syn drom e?
A. Abn orm al presyn apt ic vesicles
B. An t ibodies to th e acet ylch olin e receptor
C. Decreased n um bers of acet ylch olin e receptors
D. Defect in release of acet ylch olin e quan ta
E. Non e of th e above

92. Von Hippel-Lin dau disease h as been associated w ith all of th e follow ing except
A. A defect on ch rom osom e 3
B. Dom in an t in h eritan ce
C. Iris h am artom as
D. Pan creat ic cysts
E. Ren al cell carcin om a

93. Gerst m an n’s syn drom e classically involves a lesion in th e


A. Dom in an t fron tal lobe
B. Dom in an t parietal lobe
C. Dom in an t tem poral lobe
D. Non dom in an t pariet al lobe
E. Non dom in an t tem poral lobe

94. Each of th e follow ing is t rue of dopam in e ph arm acology except


A. Hom ovan illic acid is a m et abolite.
B. It is derived from ph enylalan in e.
C. It is m et abolized by m on oam in e oxidase (MAO).
D. Th e act ivat ion of th e D2 receptor decreases th e release of t ran sm it ter at
syn apt ic term in als.
E. Th e rate-lim it ing step in it s syn th esis is dopa decarboxylase.

For qu est ion s 95 to 99, m atch th e an t ip arkin son ian drug w ith th e d escript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Am an t adin e
B. Art an e (t rih exyph en idyl)
C. Brom ocript in e
D. Eldepr yl (selegilin e)
E. Sin em et (carbidopa-levodopa)

95. Con t ain s a dopa decarboxylase in h ibitor

96. Slow s progression of th e disease in it s early st ages

97. St im ulates D2 receptors

98. Dr yn ess of th e m ou th an d blurred vision are som e of th e side e ects

99. In h ibits in t racerebral m et abolic degradat ion of dopam in e

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Neurosurgery Board Review

100. Wern icke’s area corresp on d s m ost closely to Brodm an n’s area(s)
A. 17
B. 19
C. 22
D. 41 an d 42
E. 44

101. Com p licat ion s of diabetes gen erally th ough t to be vascu lar in origin in clu de
I. Op h th alm op legia
II. Acu te m on on eu ropathy
III. Mon on eu rit is m u lt iplex
IV. Dist al sen sorim otor p olyn eu rop athy
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

102. Each of th e follow ing is con sisten t w ith a ch olin ergic crisis in a p at ien t w ith
m yasth en ia gravis being t reated w ith pyridost igm in e (Mest in on ) except
A. Bradycardia
B. Diarrh ea
C. In creased st rength after th e Ten silon test
D. Miosis
E. Sw eat ing

103. Th e gen et ic t ran sm ission of th e MELAS syn drom e is


A. Autosom al dom in an t
B. Autosom al recessive
C. Matern al in h eritan ce
D. Sporadic
E. X-lin ked recessive

For qu est ion s 104 to 107, m atch th e cord syn drom e w ith th e descript ion . Each respon se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. An terior cord syn drom e
B. Brow n -Séqu ard syn drom e
C. Cen t ral cord syn drom e
D. A an d B
E. Non e of th e above

104. Acu te hyp erexten sion

105. Flexion inju r y

106. Dissociated sen sor y loss

107. Am ong th e in com p lete syn drom es, th is h as th e best p rogn osis

66
Clinical Neurology—Questions

For qu est ion s 108 to 113, m atch th e descript ion w ith th e sleep st age.
A. REM sleep
B. Non –rapid eye m ovem en t (NREM) sleep
C. Both
D. Neith er

108. Dream ing

109. Adu lt som n am bu lism

110. Desyn ch ron izat ion of th e EEG

111. K com plexes

112. Sleep sp in dles

113. Glu cose m etabolism in th e brain is in creased in com parison to th e w aking st ate

For qu est ion s 114 to 117, m atch th e descript ion w ith th e d isease.
A. Glycogen storage disease t ype II (acid m alt ase de cien cy)
B. Glycogen storage disease t ype V (McArdle’s disease)
C. Both
D. Neith er

114. Myop h osph or ylase d e cien cy

115. Large am ou n t s of glycogen are d ep osited in variou s organ s

116. Th ree clin ical form s are n oted

117. X-lin ked recessive in h eritan ce

118. Wilson’s disease is ch aracterized by


I. High u rin ar y cop per excret ion
II. High seru m copp er
III. Low ceru lop lasm in levels
IV. Hyp erden sit y of th e globu s p allid u s an d pu t am en on CT
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

119. Each of th e follow ing is t ru e of cen t ral pon t in e m yelin olysis except
A. A m arked in am m ator y respon se w ith dest ruct ion of n er ve cells in th e
p on s is seen .
B. It is associated w ith rapid correct ion of hypon at rem ia.
C. It is associated w ith ch ron ic alcoh olism .
D. Quadriplegia, pseu dobulbar palsy, an d a locked-in syn drom e can occur.
E. Som e pat ien ts h ave n o sign s or sym ptom s referable to th e pon t in e lesion .

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Neurosurgery Board Review

For quest ion s 120 to 122, m atch th e descript ion w ith th e d isease.
A. Hom ocyst in uria
B. Marfan’s syn drom e
C. Both
D. Neith er

120. Arach n odact yly

121. Men tal retardat ion

122. Brain in farct s

123. Dressing ap raxia is associated w ith a lesion in th e


A. Dom in an t fron tal lobe
B. Dom in an t parietal lobe
C. Non dom in an t fron t al lobe
D. Non dom in an t pariet al lobe
E. Non dom in an t tem poral lobe

124. Th e axillar y n er ve in n er vates th e


A. Coracobrach ialis
B. Rh om boids
C. Supraspin at us
D. Teres m ajor
E. Teres m in or

125. All of th e follow ing are seen in St u rge-Weber syn drom e except
A. Calci ed cort ical vessels
B. Facial n evus con t ralateral to seizure act ivit y
C. Hem isen sor y de cit con t ralateral to facial n evus
D. Men ingeal ven ous angiom as
E. Tram lin e calci cat ion s outlin ing th e convolut ion of th e parieto-occipital
cor tex

126. Th e n orm al sen sor y n er ve con du ct ion velocit y in th e m edian an d u ln ar n er ves is


ap p roxim ately
A. 10 m eters per secon d (m /s)
B. 25 m /s
C. 50 m /s
D. 100 m /s
E. 150 m /s

127. Each of th ese st atem en t s is t ru e of Ch arcot-Marie-Tooth disease except


A. Au tosom al d om in an ce is th e usu al m ode of in h erit an ce.
B. Distal m uscle at rophy is prom in en t .
C. It can a ect th e upper ext rem it ies.
D. Steroids h ave n o e ect on disease progression .
E. Th e au ton om ic n er vous system is usually involved.

68
Clinical Neurology—Questions

128. Cran ial n er ves th at m ay be a ected by a clival ch ordom a in clu d e


I. Cran ial n er ve XII
II. Cran ial n er ve V
III. Cran ial n er ve X
IV. Cran ial n er ve II
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

129. W h ich of th e follow ing CSF n dings is least con sisten t w ith t u bercu lou s
m en ingit is?
A. Glucose of 30 m g/dL
B. Lym ph ocyt ic predom in at ion after 1 w eek of illn ess
C. Open ing pressure of 200 m m CSF
D. Protein of 35 m g/dL
E. W h ite blood cell cou n t (W BC) of 200 cells/m m 3

130. Th e syn drom e of PICA occlu sion resu lt s in all of th e follow ing except
A. Con t ralateral Horn er’s syn drom e
B. Con t ralateral loss of pain an d tem perat ure over th e body
C. Ipsilateral at axia
D. Ipsilateral n um bn ess of th e lim bs
E. Ipsilateral paralysis of th e palate

131. St age 2 sleep is ch aracterized by


A. K com plexes
B. Delta w aves
C. Desyn ch ron izat ion of th e EEG
D. REM sleep
E. Som n am bulism

For qu est ion s 132 to 141, m atch th e m u scu lar dyst rop hy w ith th e d escript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Becker’s m uscu lar dyst rophy
B. Duch en n e’s m uscu lar dyst rophy
C. Em er y-Dreifuss m uscular dyst rophy
D. Lan dou zy-Dejerin e (facioscapuloh um eral) dyst rophy
E. Myoton ic dyst rophy

132. Th e p rotein dyst roph in is absen t

133. Th e p rotein dyst roph in is st ru ct u rally abn orm al

134. Th e m ost com m on adu lt form of m u scu lar dyst rophy

135. Prom in en t pseu dohyp ert rop hy of th e calves is seen in Becker’s an d in th is t ype

136. Con t ract u res of th e elbow exors an d n eck exten sors occu r early

137. Abn orm al gen e is on ch rom osom e 4

138. Len s opacit ies are fou n d in 90% of p at ien ts

69
Neurosurgery Board Review

139. Occasion ally associated w ith congen ital absen ce of an involved m u scle

140. Masseter at rop hy, ptosis, an d fron t al bald n ess are ch aracterist ic

141. Abn orm al gen e is on ch rom osom e 19

142. Mon op legia w ith ou t m u scu lar at rophy is m ost often secon dar y to a lesion in th e
A. Brain stem
B. Cor tex
C. In tern al capsule
D. Periph eral n er ve
E. Spin al cord

143. Th e t ran sm issible agen t of Creu t zfeldt-Jakob disease is in act ivated by


I. Form alin
II. Au toclaving at 132°C un der pressu re for 1 h our
III. Alcoh ol
IV. Im m ersion for 1 h ou r in bleach
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

144. Th e m ost com m on n ding on au diograp hy in p at ien t s w ith acou st ic n eu rom as is


A. Flat loss
B. High -frequen cy loss
C. Low -ton e loss
D. Norm al audiogram
E. Trough -sh aped loss

For quest ion s 145 to 149, m atch th e brach ial p lexu s lesion w ith th e descript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Lateral cord lesion
B. Low er t run k lesion
C. Medial cord lesion
D. Middle t run k lesion
E. Upper t run k lesion

145. Median sen sor y resp on ses from th e in d ex an d m id dle nger are low in am p lit u d e,
but m otor con duct ion velocit ies of th e h an d m uscles are n orm al.

146. Uln ar sen sor y respon se from th e lit tle nger is abn orm al; elect rom yograp h ic
exam of th e exten sor in dicis prop riu s an d abdu ctor pollicis longu s is abn orm al.

147. Uln ar sen sor y resp on se from th e lit tle nger is abn orm al; n orm al resp on ses are
seen from th e exten sor in dicis prop riu s.

148. Act ion poten t ials from th e deltoid an d bicep s are of low am plit u de.

149. Abn orm al m edian sen sor y resp on ses an d d en er vat ion are seen in th e bicep s an d
exor carpi radialis; n orm al respon se is seen from th e abd u ctor p ollicis brevis.

70
Clinical Neurology—Questions

150. Person s m igrat ing from a zon e w ith h igh risk of m u lt ip le sclerosis (MS) to on e of
low risk after age 15 sh ow a risk of developing MS th at is
A. Equ al to th at of th e h igh -risk zon e
B. Equal to th at of th e low -risk zone
C. In term ediate bet w een th e t w o zon es
D. Low er th an th at of th e low -risk zon e
E. Unpredict able

151. Eye n dings in bot u lism in clu de


I. Ptosis
II. St rabism u s
III. Diplop ia
IV. Un react ive pu pils
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

152. Rep et it ion is least likely to be a ected by a


A. Broca’s aph asia
B. Con duct ion aph asia
C. Global aph asia
D. Tran scor t ical sen sor y aph asia
E. Wern icke’s aph asia

153. W h ich stage of sleep is prom inen t on EEG at th e on set of n arcolept ic sleep at tacks?
A. St age 1
B. St age 2
C. St age 3
D. St age 4
E. REM

154. Th e m ost com m on cau se of viral m en ingit is is


A. En terovirus
B. Hum an im m un ode cien cy virus (HIV)
C. Leptospirosis
D. Lym ph ocyt ic ch oriom en ingit is
E. Mum ps

155. Su ccessive involvem en t of all cran ial n er ves on on e side h as been rep orted in
A. Men ingit is
B. Sarcoidosis
C. Tum ors of th e brain stem
D. Tum ors of th e cavern ous sin us
E. Tum ors of th e clivus

156. Each of th e follow ing is t ru e of Mén ière’s disease except


A. Disten t ion of th e en dolym ph at ic du ct occurs
B. Hearing loss is u sually un ilateral
C. High -ton e loss occurs early in th e disease
D. Horizon t al nyst agm u s occu rs during an acute at t ack
E. Low -pitch ed t in n it u s is t ypical

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Neurosurgery Board Review

157. Each of th e follow ing is t ru e of Eaton -Lam bert syn drom e except
A. Au ton om ic dist u rban ces are seen
B. Fasciculat ion s are n ot seen
C. It h as been associated w ith carcin om a of th e stom ach an d colon
D. Tem porar y in crease in m uscle pow er m ay occur during th e rst few
con t ract ion s
E. Wom en are m ore frequ en tly a ected th an m en

158. Type I (red) m u scle bers di er from t yp e II (w h ite) bers in all of th e follow ing
w ays except th at th ey
A. Are m ore fat igable
B. Fire m ore ton ically
C. Have slow er con t ract ion an d relaxat ion rates
D. Have m ore m itoch on dria
E. Have m ore oxidat ive en zym es

159. Historically, on e of th e t reat m en t m odalit ies of Parkin son’s disease w as su rgical


ligat ion of th e
A. An terior cerebral arter y
B. An terior ch oroidal ar ter y
C. Middle cerebral arter y
D. Posterior com m un icat ing arter y
E. Recurren t ar ter y of Hu ebn er

160. W h ich of th e follow ing is not ch aracterist ic of diabet ic m on on eu rit is m u lt iplex?


A. Low er ext rem it ies are m ore com m on ly a ected th an u pper ext rem it ies
B. Pain ful n eu ropathy
C. Proxim al ext rem it ies are m ore com m on ly a ected th an dist al ext rem it ies
D. Recover y is usual
E. Sym m et ric n europathy

For qu est ion s 161 to 165, p rovide th e best m atch of each an t iep ilept ic drug w ith th e
seizu re t yp e. Each resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Adren ocor t icot ropic h orm on e (ACTH)
B. Eth osu xim ide
C. Lorazepam
D. Tegretol
E. Valproic acid
F. D or E

161. St at u s ep ilept icu s

162. Absen ce seizu res

163. Com p lex part ial seizu res

164. In fan t ile seizu res

165. At ypical p et it m al syn d rom e of Len n ox-Gastau t

72
Clinical Neurology—Questions

166. Each of th e follow ing is t ru e of polym yosit is associated w ith carcin om a except
A. Carcin om a a ect s 9% of pat ien t s w ith polym yosit is.
B. It is m ost com m on ly associated w ith lung an d prostate can cer in m en .
C. It is usually pain ful.
D. Muscle biopsies sh ow n o eviden ce of t um or cells.
E. Proxim al m uscles are in it ially a ected m ore th an dist al on es.

167. W h ich of th e follow ing is least suggest ive of clu ster h eadach es?
A. Associated w ith lacrim at ion an d rh in orrh ea
B. Bilateral locat ion
C. Daily occurren ce for 2 m on th s
D. Male predom in an ce
E. Orbit al locat ion

168. Organ op h osp h ate poison ing is ch aracterized by all of th e follow ing except
A. Bron ch ial spasm s
B. Dr y m outh
C. Miosis
D. Sw eat ing
E. Vom it ing

169. On e of th e cerebral bioch em ical defects in Hu n t ington’s disease is


A. Decreased dopam in e
B. Decreased GABA
C. Decreased n orepin eph rin e
D. Decreased som atostat in
E. In creased acet ylch olin e

170. Prosopagn osia is associated w ith lesion s of th e


A. An terior corpu s callosu m
B. Bilateral an teroin ferior tem poral lobes
C. Bilateral m edial tem poro-occipital lobes
D. Occipital poles
E. Posterior corpus callosum

171. A lesion of th e su pp lem en t ar y m otor cor tex produ ces


A. Ech olalia
B. Palilalia
C. Povert y of spon tan eous speech
D. Recept ive aph asia
E. No speech abn orm alit ies

172. Lesion s of th e peron eal n er ve produ ce w eakn ess of th e


A. Abd uctor h allu cis an d gast rocn em ius
B. Exten sor digitorum longus an d brevis an d abductor h allucis
C. Gast rocn em ius an d exor h allu cis longus
D. Tibialis an terior an d exten sor digitorum longus an d brevis
E. Tibialis an terior an d exor digitorum brevis

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Neurosurgery Board Review

173. W h ich of th e follow ing is not ch aracterist ic of Tay-Sach s d isease?


A. Abn orm al startle respon se
B. Autosom al recessive in h erit an ce
C. Ch err y red spot s in th e ret in a
D. De cien cy of sph ingom yelin ase
E. Macroceph aly

174. W h ich of th e follow ing d e cit s is least ch aracterist ic of Alzh eim er’s disease?
A. Cort icospin al t ract dysfu n ct ion
B. Dysn om ia
C. Korsako ’s am n esic st ate
D. Person alit y ch ange
E. Spat ial disorien t at ion

175. Each of th e follow ing is t ru e of Gu illain -Barré syn drom e except


A. Dist urban ces of auton om ic fun ct ion are com m on
B. High -dose steroids form th e m ain stay of th erapy
C. Hypo- or are exia is ch aracterist ic
D. Th e m ort alit y rate is 3%
E. Th e peak severit y is 10 to 14 days after on set in 80% of cases

176. Th e secon d-order n eu ron in th e sym p ath et ic path w ay to th e p u p il arises


from th e
A. Ciliar y ganglion to th e iris
B. Edinger-West ph al n ucleu s to th e ciliar y ganglion
C. Hypoth alam us to th e lateral h orn cells at C8 to T3
D. Lateral h orn cells at C8 to T3 to th e superior cer vical ganglion
E. Superior cer vical ganglion to th e iris

177. Th e t reat m en t of ch oice for toxoplasm osis is


A. Pen icillin
B. Praziquan tel
C. Pyrim eth am in e an d sulfadiazin e
D. Rifam pin an d n afcillin
E. Th iaben dazole

178. W h ich of th e follow ing is t rue of su bacu te sclerosing p an en cep h alit is (SSPE)?
A. In t racytoplasm ic but n ot in t ran uclear in clusion s are foun d.
B. It is m ore com m on in pat ien t s . 18 years of age.
C. Lesion s are con n ed to th e w h ite m at ter.
D. Th e EEG sh ow s ch aracterist ic periodic w aves th at occu r ever y 2 to 3 secon ds.
E. Th e CSF protein is n orm al.

179. Th e t reat m en t of ch oice for opt ic n eurit is is


A. In t rath ecal predn isolon e
B. In t raven ous m ethylpredn isolon e follow ed by oral predn ison e
C. Oral predn ison e on ly
D. Oral predn ison e follow ed by in t raven ous m ethylpredn isolon e
E. Plasm aph eresis

74
Clinical Neurology—Questions

180. Sch ilder’s disease m ost closely resem bles


A. Du ch en n e’s m u scular dyst rophy
B. Krabbe’s disease
C. Mult iple sclerosis
D. Trisom y 13
E. Tuberous sclerosis

181. Th e cricothyroid m u scle is in n er vated by th e


A. Extern al bran ch of th e sup erior lar yngeal n er ve
B. In tern al lar yngeal bran ch of th e su perior lar yngeal n er ve
C. Nin th cran ial n er ve
D. Recurren t lar yngeal n er ve
E. Seven th cran ial n er ve

182. Korsako ’s syn drom e is best ch aracterized by (a)


A. Defect in learn ing an d loss of p ast m em ories
B. Global con fusion al st ate
C. Man ic-depressive st ate
D. Paran oid ideat ion
E. St upor or com a

183. Werdn ig-Ho m an n disease is n otable for all of th e follow ing except
A. Are exia
B. Autosom al recessive in h erit an ce
C. Hypoton ia
D. Involvem en t of ch rom osom e 5q
E. Men t al retardat ion

184. Tricyclic an t idep ressan t s


I. Block n orep in ep h rin e u pt ake
II. Block oxidat ive deam in at ion of m on oam in es
III. Block seroton in u pt ake
IV. Bin d to GABA receptors
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

For qu est ion s 185 to 189, m atch th e descript ion w ith th e disease.
A. Am yot roph ic lateral sclerosis (ALS)
B. Cer vical spon dylosis
C. Both
D. Neith er

185. Low er ext rem it y sp ast icit y

186. Hyp ore exia

187. Hyp erre exia

188. Absen ce or p au cit y of sen sor y sym ptom s

189. At rop hy of th e h an d m u scles

75
Neurosurgery Board Review

For qu est ion s 190 to 195, m atch th e vascu lit is w ith th e d escript ion . Each respon se m ay
be u sed on ce, m ore th an on ce, or n ot at all.
A. Cogan’s syn drom e
B. Polyarterit is n odosa
C. System ic lupus er yth em atosus
D. Takayasu’s syn drom e
E. Tem poral arterit is
F. Wegen er’s gran ulom atosis

190. An t in eu t rop h il cytop lasm ic an t ibodies

191. An t in u clear an t ibodies an d m alar rash

192. Visu al loss an d clau dicat ion w ith ch ew ing

193. Visu al loss an d loss of periph eral p u lses

194. Mon on eu rit is m u lt iplex, kidn ey involvem en t , an d skin pu rp u ra

195. Deafn ess an d kerat it is

196. Wern icke’s en cep h alop athy con sists of all of th e follow ing except
A. Defect in reten t ive m em or y ou t of p rop ort ion to oth er cogn it ive fun ct ion s
B. Gait ataxia
C. Gaze palsy
D. Men t al con fusion
E. Nyst agm us

197. W h ich of th e follow ing is least suggest ive of a parietal lobe lesion ?
A. Astereogn osis
B. Loss of posit ion sen se
C. Loss of tem perat ure sen sat ion
D. Loss of t w o-poin t discrim in at ion
E. Atopogn osia

198. Th e p u rest form of ach rom atop sia is cau sed by a lesion involving th e
A. Left calcarin e cor tex
B. Left su perior occipitotem poral region
C. Righ t in ferior occipitotem poral region
D. Righ t occipit al cor tex an d angular gyrus
E. Righ t superior calcarin e cor tex

199. Failu re of a m iot ic p u p il to dilate after in st illing 2 to 10% cocain e follow ed by


1% hydroxyam ph et am in e in dicates a
A. First-order Horn er’s syn drom e
B. Secon d-order Horner’s syn drom e
C. Th ird-order Horn er’s syn drom e
D. First- or secon d-order Horn er’s syn drom e
E. Second- or th ird-order Horn er’s syn drom e

76
Clinical Neurology—Questions

200. Som n am bu lism occu rs in w h ich stage of sleep ?


A. St age 1
B. St age 2
C. St age 4
D. REM
E. All of th e above

201. Th e m ost e ect ive t reat m en t of en u resis is


A. Klon opin
B. Clon idin e
C. Haloperidol (Haldol)
D. Im ipram in e (Tofran il)
E. Methylph en idate (Rit alin )

202. In m ost cases, sect ion of th e corpu s callosu m cau ses


A. Apraxia of both h an ds to com m an d
B. Apraxia of th e left han d to com m an d
C. Apraxia of th e righ t han d to com m an d
D. Object agn osia
E. No de cit

For qu est ion s 203 to 208, m atch th e ap h asia w ith th e descript ion . Each resp on se m ay
be used on ce, m ore th an on ce, or n ot at all.
A. Good com preh en sion , uen t speech , poor repet it ion
B. Good com preh en sion , n on uent speech , good repet it ion
C. Good com preh en sion , n on uen t speech , poor repet it ion
D. Poor com preh en sion , uen t speech , good repet it ion
E. Poor com preh en sion , uen t speech , poor repet it ion
F. Poor com preh en sion , n on uen t speech , poor repet it ion

203. Broca’s aph asia

204. Con du ct ion ap h asia

205. Global ap h asia

206. Tran scort ical m otor ap h asia

207. Tran scort ical sen sor y ap h asia

208. Wern icke’s ap h asia

For qu est ion s 209 to 215, m atch th e descript ion w ith th e disease.
A. Derm atom yosit is
B. Polym yosit is
C. Both
D. Neith er

209. May be associated w ith carcin om a

210. Men are m ore frequ en tly a ected th an w om en

211. Necrosis an d p h agocytosis of in d ividu al m u scle bers are th e prin cipal ch anges

212. Perifascicu lar m u scle degen erat ion an d at rophy are fou n d

77
Neurosurgery Board Review

213. Large n u m bers of T cells are fou n d in th e in t ram u scu lar in am m ator y exu dates

214. Im m u n e com p lexes are dep osited in th e w alls of arterioles an d ven u les

215. Cor t icosteroid s h ave n o e ect on sym ptom s

216. W h ich of th e follow ing an t iconvu lsan t s is associated w ith hypon at rem ia?
A. Carbam azep in e
B. Gabapen t in
C. Levet iracet am
D. Ph enytoin
E. Topiram ate

217. All of th e follow ing st atem en t s regarding th e u se of single-ph oton em ission


com puted tom ography (SPECT) an d posit ron em ission tom ography (PET) in
epilep sy are t ru e except
A. Both ict al an d in terict al SPECT st ud ies can be acquired an d com pared for
seizu re localizat ion
B. Ict al SPECT scan s are gen erally easier to acquire th an ictal PET scan s
C. Ict al SPECT scan s sh ow decreased t racer sign al in th e seizu re focus
D. Perfu sion follow s ch anges in m et abolism during seizures
E. Tracer n eeds to be injected w ith in 1–2 m inu tes of seizure on set for an ict al
SPECT st u dy

218. All of th e follow ing are associated w ith m on on eu rit is m u lt ip lex except
A. Diabetes
B. HIV
C. Neurocyst icercosis
D. Polyarterit is n odosa
E. Sarcoidosis

219. Th e U.S. Food an d Drug Adm in ist rat ion (FDA) in it ially ap proved in t raven ou s rtPA
(recom bin an t t issue plasm in ogen act ivator) for use in acute isch em ic st roke
u p to ___ h our(s) sin ce sym ptom on set , but in 2009 exten d ed th e w in dow to
___ h ours sin ce sym ptom on set .
A. 1, 3
B. 3, 4.5
C. 4.5, 6
D. 6, 8
E. 8, 10

220. Based on th e PROACT st u dy, in t ra-ar terial th rom bolyt ic th erapy is ap p rop riate
for p at ien t s w ith m id dle cerebral arter y occlu sion s w ith in ___ h ou rs of sym ptom
on set .
A. 3
B. 4.5
C. 6
D. 8
E. 12

78
Clinical Neurology—Questions

221. Based on th e MERCI st u dy, m ech an ical th rom bectom y is app rop riate for p at ien t s
w ith m iddle cerebral arter y occlusion s w ith in ___ h ou rs of sym ptom on set .
A. 3
B. 4.5
C. 6
D. 8
E. 12

222. All of th e follow ing are possible in d icat ion s for en dovascu lar th erapy in th e
set t ing of acu te isch em ic st roke except
A. Con t rain dicat ion to in t raven ou s tPA
B. Di usion -perfusion m ism atch
C. Failure to im prove w ith in t raven ous tPA
D. NIH st roke score of . 20
E. Pat ien t presen t s ou tside th e th erapeut ic w in dow for in t raven ous tPA

79
1B
2B Clinical Neurology—
Answ er Key

1. B 27. C
2. E 28. A
3. G 29. B
4. C 30. C
5. F 31. E
6. D 32. D
7. A 33. D
8. E 34. B
9. D 35. B
10. D 36. A
11. D 37. C
12. B 38. C
13. E 39. B
14. A 40. B
15. E 41. B
16. B 42. B
17. E 43. C
18. E 44. C
19. E 45. A
20. E 46. C
21. C 47. B
22. D 48. D
23. E 49. D
24. E 50. B
25. C 51. A
26. C 52. C

80
Clinical Neurology—Answer Key

53. A 92. C
54. A 93. B
55. A 94. E
56. C 95. E
57. E 96. D
58. C 97. C
59. B 98. B
60. A 99. D
61. D 100. C
62. E 101. A
63. D 102. C
64. A 103. C
65. B 104. C
66. A 105. A
67. B 106. A
68. C 107. B
69. D 108. C
70. A 109. B
71. B 110. A
72. A 111. B
73. E 112. B
74. C 113. A
75. A 114. B
76. A 115. A
77. A 116. A
78. A 117. D
79. A 118. B
80. D 119. A
81. E 120. C
82. D 121. A
83. B 122. A
84. C 123. D
85. D 124. E
86. B 125. A
87. C 126. C
88. A 127. E
89. E 128. E
90. D 129. D
91. D 130. A

81
Neurosurgery Board Review

131. A 170. C
132. B 171. C
133. A 172. D
134. E 173. D
135. B 174. A
136. C 175. B
137. D 176. D
138. E 177. C
139. D 178. D
140. E 179. B
141. E 180. C
142. B 181. A
143. C 182. A
144. B 183. E
145. D 184. B
146. B 185. C
147. C 186. D
148. E 187. C
149. A 188. A
150. A 189. C
151. E 190. F
152. D 191. C
153. E 192. E
154. A 193. D
155. E 194. B
156. C 195. A
157. E 196. A
158. A 197. C
159. B 198. C
160. E 199. C
161. C 200. C
162. B 201. D
163. F 202. B
164. A 203. C
165. E 204. A
166. C 205. F
167. B 206. B
168. B 207. D
169. B 208. E

82
Clinical Neurology—Answer Key

209. C 216. A
210. D 217. C
211. B 218. C
212. A 219. B
213. B 220. C
214. A 221. D
215. D 222. D

83
2C
Clinical Neurology—
Answ ers and Explanations

1. B – Dissociated nyst agm u s (in tern u clear op h th alm op legia)

2. E – Ocular bobbing

3. G – Spasm u s m u tan s

4. C – Dow n beat nyst agm u s

5. F – Seesaw nystagm u s

6. D – Im pairm en t of optokin et ic nyst agm u s

7. A – Convergen ce nyst agm us

84
Clinical Neurology—Answers and Explanations

Co nve rgence nystagm us (A) is a “rhyth m ic oscillat ion in w h ich a slow abdu c-
t ion of th e eyes w ith respect to each oth er is follow ed by a quick m ovem en t
of addu ct ion ,” an d m ay be accom pan ied by oth er sign s of Parin aud’s ph e-
n om en on , suggest ing a lesion of th e pin eal region or m idbrain tegm en t u m .
Disso ciated nystagm us (B) is h orizon tal nystagm u s th at occu rs on ly in th e
abdu ct ing eye—th is is a sign of in tern u clear op h th alm oplegia an d is associ-
ated w ith m u lt iple sclerosis. Dow nbeat nystagm us (C) h as been associated
w ith lesion s of th e cer vicom edullar y ju n ct ion in cluding Ch iari m alform at ion ,
syrin x, an d basilar invagin at ion . Im pairm ent o f o pto kinetic nystagm us (D)
is associated w ith lesion s to th e parietal lobe—“th e slow pu rsuit ph ase of th e
OKN m ay be lost . . . w h en a m oving st im u lu s . . . is rot ated tow ard th e side of
th e lesion .” Ocular bo bbing (E) involves a “spon tan eous fast dow nw ard jerk
of th e eyes follow ed by a slow upw ard drift to m idposit ion ,” an d h as been as-
sociated w ith large dest ru ct ive lesion s of th e p on s. Seesaw nystagm us (F) is
a “torsion al-ver t ical oscillat ion in w h ich th e in tor t ing eye m oves u p an d th e
opposite (extort ing) eye m oves dow n , th en both m ove in th e reverse direc-
t ion .” Seesaw nystagm us (F) h as been associated w ith ch iasm at ic bitem p oral
h em ian opsia du e to lesion s of th e parasellar region . Spasm us m utans (G) is
a pen du lar nyst agm u s of in fan cy th at is t yp ically idiop ath ic an d self-lim ited .1

8. E – Th e ch ange in seizu re disch arge from th e ton ic ph ase to th e clon ic ph ase


resu lts from in h ibit ion from th e n eu ron s su rroun ding th e focu s (false).

Th e ch ange from th e ton ic to th e clon ic ph ase results from dien ceph alic
in h ibit ion of th e ring cor tex, n ot from in h ibit ion of th e n euron s surroun ding
the focus as described in (E). Th e oth er st atem en t s are t ru e: Ep ilept ic foci
are slow er in bin ding an d rem oving acet ylch olin e th an n orm al cor tex (A);
ring of n eu ron s in th e focu s is re ected by p eriodic sp ike disch arges in th e
elect roen ceph alogram (B); if u n ch ecked, cor t ical excitat ion m ay sp read to
the subcort ical n uclei (C); an d n eu ron s su rrou n ding th e focu s are in it ially
hyperpolarized an d are GABAergic (D).1

9. D – Tow ard a parietal lobe lesion

An abn orm al optokin et ic respon se (loss of th e slow pursuit ph ase) is m ore


likely to be obt ain ed by rot at ing th e optokin et ic nystagm us drum tow ard a
parietal lo be lesio n (D).1

10. D – Th et a
11. D – Th et a
12. B – Beta
13. E – 3-per-secon d spike an d w ave

85
Neurosurgery Board Review

14. A – Alph a

Alpha w aves (A) are 8–12 Hz w aves th at are presen t in th e occipital an d pa-
riet al region an d are at ten u ated or abolish ed w ith eye op en ing or m en tal
act ivit y. Beta w aves (B) are of faster frequ en cy (. 12 Hz) an d low er am pli-
t ude th an a w aves an d are recorded from th e fron t al areas sym m et rically.
Theta w aves (D) are 4–7 Hz, an d m ay be p resen t over th e tem p oral region s—
especially in th e elderly. Delta w aves (C) are 1–3 Hz an d are n ot p resen t in
the n orm al w aking adult . A 3-pe r-seco nd spike and w ave (E) EEG pat tern is
associated w ith absen ce seizu res.1

15. E – Ketorolac t rom eth am in e (Toradol)

Of th e opt ion s listed , keto ro lac (To rado l [E]), a n on steroidal an t i-in am m ator y
drug (NSAID), is th e least e ect ive in relieving th e pain of t rigem in al
n eu ralgia. An t iconvu lsan ts su ch as carbam azepine (B), clo nazepam (C), and
phe nyto in (D) are often useful. Baclo fen (A) is m ost h elpful as an adjun ct to
on e of th e an t iconvulsan t drugs.1

16. B – Pu p illar y ligh t re exes rem ain n orm al

Venous pulsations are absent in 10 to 15% of norm al individuals (A is


incorrect). The congested capillaries are derived from th e sh ort ciliary ar-
teries (C is incorrect). Unilateral edem a can occur w ith optic ner ve t um ors
(D is incorrect). Visual acuit y is usually n orm al in papilledem a (E is incorrect).
Pupillary light re exes t ypically rem ain norm al in papilledem a (B).1

17. E – All of th e above

Glossoph ar yngeal n eu ralgia is less com m on th an t rigem in al n eu ralgia an d


is ch aracterized by pain in the thro at (I) th at is often exacerbated by sw al-
low ing, talking, or yaw n ing. Pain m ay also radiate to the ear (III). Abn orm al
a eren t inp u t s to card ioregu lator y cen ters m ay t rigger synco pe (II) or
bradycardia (IV), w h ich are n ot associated w ith t rigem in al n eu ralgia or h em i-
facial spasm .1

18. E – All of th e above

Trisom y 13, or Patau’s syn drom e, is ch aracterized by m icrocephaly (I),


hyperto nia (II), cleft lip and palate (III), and dextro cardia (IV). Oth er feat u res
of th is dysgen et ic syn drom e in clude corn eal opacit ies, polydact yly, im paired
h earing, an d severe m en t al retardat ion . Death u su ally occu rs in early ch ild-
h ood. Trisom y 18, Edw ard s’ syn drom e, is ch aracterized by low -set ears,
m icrogn ath ia, m en t al ret ardat ion , an d rocker-bot tom feet .1

19. E – Th ird n er ve palsy

Parin au d’s syn drom e (dorsal m idbrain syn drom e) is a con stellat ion of sym p -
tom s th at in clude paralysis o f upgaze (D), m ydriasis an d lid retractio n (B),
nystagm us retracto rius (C), an d a disso ciated light-near respo nse (A).
Third nerve palsy (E) is n ot associated w ith Parin au d ’s syn drom e.1

86
Clinical Neurology—Answers and Explanations

20. E – Th e protein con ten t of CSF is alm ost alw ays elevated.

Headach e occu rs in m ore th an h alf of cases (A is inco rrect). Con fu sion , com a,
an d death u su ally resu lt if th e p at ien t is u n t reated (B is inco rrect). Th e in -
am m ator y exu date occu rs m ain ly in th e basal m en inges an d frequ en tly in -
vades th e u n d erlying brain by sp reading via p ial vessels (C is inco rre ct). Th e
CSF p rotein is alw ays elevated to 100 to 200 m g/dL or h igh er (E).1

21. C – In creased protein to 200 m g/dL

Th e CSF protein is sligh tly in creased in 40% of pat ien t s w ith m ult iple
sclerosis (MS). A con cen t rat ion of . 100 m g/d L is rare (C). If th e rat io of
CSF IgG/seru m IgG to CSF albu m in /seru m albu m in is m ore th an 1.7, th e
diagn osis of MS is probable (A). Th is rat io is kn ow n as th e IgG in d ex. Test ing
for o ligo clo nal bands (D) in CSF is th e m ost w id ely u sed test for MS. In -
creased CSF m yelin basic prote in (B) can be p resen t in acu te MS exacerba-
t ion s an d is th erefore con sisten t w ith a diagn osis of MS; h ow ever, in creased
MBP m ay be p resen t in any p rocess w h ere m yelin is dest royed. A slight to
m o derate m o no cytic pleo cyto sis (E) is p resen t in ap proxim ately on e-th ird
of MS pat ien t s.1

22. D – Fem ales p redom in ate in th e su bset of p at ien t s w ith a thym om a (false)

Th e m ajorit y of pat ien t s w ith m yasth en ia gravis h arboring a thym om a are


older (50–60 years) an d m ale (D is false). Th e disease is t w o to th ree t im es
m ore com m on in w om en th an m en in p at ien ts , 40 years of age (C is true).
A decrease in m uscle act ion poten t ial w ith n er ve st im ulat ion at 3 Hz (a dec-
rem en t ing resp onse) is seen (A is true). Cer tain am in oglycoside an t ibiot ics
can im pair t ran sm it ter release by in h ibit ing calcium ion u xes at th e n euro-
m u scu lar ju n ct ion (B is true). Ten to 15%of p at ien ts h ave n o an t ibod ies to th e
acet ylch olin e receptor (E is true).1

23. E – Men kes’ syn drom e (false)

Me nkes’ (kink y hair) syndro m e (E) is a rare sex-lin ked recessive disease ch ar-
acterized by severe cop per de cien cy du e to failu re of in test in al absorpt ion of
copper. Th e oth er disorders (Kearns-Sayre syndro m e [A], Leber’s he reditary
o ptic atro phy [B], Leigh’s subacute necrotizing e ncephalo pathy [C], and
m itocho ndrial m yo pathy, encephalo pathy, lactic acidosis, and stro ke
[MELAS; D]) h ave poin t m u t at ion s or d elet ion s of m itoch on drial DNA as p art
of th eir path ogen esis.1

24. E – All of th e above

Sym ptom s of spon t an eous carot id arter y dissect ion m ay in clude eye pain (II)
or un ilateral h eadach e as w ell as th e presen ce of a Ho rner’s syndro m e (IV)
that is due to th e disrupt ion of sym path et ic n er ves run n ing along th e carot id
ar ter y. Sign s of isch em ia in th e territor y of th e a ected in tern al carot id ar ter y
m ay be p resen t . Sm all bran ch es o of th e carot id arter y m ay su p p ly th e cran ial
n er ves ext racran ially; isch em ia to th ese bran ch es m ay lead to cran ial n er ve
dysfu n ct ion such as dysgeusia (im paired taste, I) or tongue w eakness (III).1

87
Neurosurgery Board Review

25. C – II, IV (h ippocam pal form at ion an d dorsom edial n uclei of th e th alam us)

Discrete, bilateral lesion s in th e hippo cam pus (II) an d do rso m edial


thalam us (IV) im pair m em or y an d learn ing out of proport ion to oth er
cognit ive funct ions. Stereotactic lesion s of th e am ygdala (I) an d m am m illary
bo dies (III) h ave failed to produ ce th ese sym ptom s.1

26. C – 3 an d 7

Th e gen e (CCM1) respon sible for fam ilial cavern ous m alform at ion s h as been
m ap p ed to 7q11.2– q21. In add it ion , CCM2 (7p13–15) an d CCM3 (3q25.2–27)
h ave been iden t i ed in pat ien t s w ith cavern ou s m alform at ion s.2

27. C – It is usually pain less (false)

Diabet ic th ird n er ve p alsy develo ps over a few ho urs (A), an d ten d s to be


pupil-sparing (B) because it involves in farct ion of th e cente r o f the nerve (D).
Recove ry is typical (E) but m ay take m on th s. Diabet ic th ird n er ve palsy is
u su ally painful (C is false).1

28. A – Arsen ic poison ing


29. B – Lead poison ing
30. C – Mangan ese poison ing
31. E – Ph osph orus poison ing
32. D – Mercu r y poison ing
33. D – Mercu r y poison ing
34. B – Lead poison ing
35. B – Lead poison ing
36. A – Arsen ic poison ing

Arsenic po isoning (A) m ay be du e to pest icide exposure, m ay cau se


transverse w hite lines in the nge rnails, an d m ay be diagn osed based
on exam inatio n o f the hair or urin e. Lead po iso ning (B) is less com m on
in adu lt s th an in ch ildren an d m ay presen t w ith an em ia or periph eral n eu -
ropathy. Lead po iso ning (B) m ay cause black lines at the gingival m argins,
increase d urinary excretio n o f co pro po rphyrin, an d m ay be treated w ith
ethyle ne diam inetetraacetic acid (EDTA) and dim ercapro l (BAL). Ch ron ic
m anganese po iso ning (C) m ay result in ext rapyram idal sym ptom s rem in is-
cen t of dyston ia or parkinso nism . Mercury po iso ning (D) m ay p resen t w ith
m o o d changes, tre m o rs, and a cerebellar syndrom e an d is t reated w ith
penicillam ine. Pho spho ro us po iso ning (E) is t ypically due to exposure to
organ oph osph ate in sect icides an d is m an ifested by an t i ch olin esterase e ects
in th e acu te set t ing. Sym ptom s of pho spho ro us po iso ning (E) can be t reated
w ith at ropin e an d pralidoxim e.1

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Clinical Neurology—Answers and Explanations

37. C – No react ion to 0.1% pilocarpin e solu t ion

Adie’s syn d rom e or Adie’s ton ic p u p il resu lts from degeneratio n o f the ciliary
ganglia and po stganglio nic parasym pathetics (A) th at are respon sible for
p u pillar y con st rict ion . Adie’s pu pil respo nds better to near (acco m m o da-
tio n) than to light (E). Th e con dit ion is m o re com m o n in w om en (B) an d
involves paralysis o f segm ents o f the pupillary sphincter (D). An Adie’s
pupil w ill respo nd to 0.1% pilo carpine, w h ereas a n orm al p u p il w ou ld n ot
(den er vat ion hypersen sit ivit y). C is false.1

38. C – II, IV (hypsarrhyth m ia, m yoclon ic h ead jerks)

In fan t ile seizu res or sp asm s (West’s syn drom e) u su ally begin before 6 m on th s
of age an d are ch aracterized by sudden exor or exten sor spasm s o f the
head, t ru n k, an d lim bs an d an elect roen ceph alogram (EEG) p ict u re of
bilateral h igh -volt age, slow -w ave act ivit y (hypsarrhythm ia). Lip sm acking
an d generalized tonic-clo nic activity are n ot feat u res.1

39. B – Eaton -Lam ber t m yasth en ic syn drom e


40. B – Eaton -Lam ber t m yasth en ic syn drom e
41. B – Eaton -Lam ber t m yasth en ic syn drom e
42. B – Eaton -Lam ber t m yasth en ic syn drom e

In Eato n-Lam bert m yasthenic syndro m e (B), m u scles of th e t ru n k an d


low er ext rem it ies are m ost frequ en tly involved, th ere is an in crem en t-
ing respon se to st im uli, an d th ere is a p oor respon se to an t ich olin esterase
drugs. Eato n-Lam be rt syndro m e (B) is associated w ith an t ibodies to th e
p resyn apt ic volt age-depen den t calcium ch an n el. Th ese are all feat ures of
Eato n-Lam be rt syndro m e (B) an d st an d in con t rast to th e feat u res of classic
m yasthenia gravis (A).1

43. C – II, IV (rh om boids, levator scapulae)

Th e dorsal scapular n er ve arises from th e an terior ram us of C5 an d pierces th e


m id dle scalen e to in n er vate th e rho m bo id m uscles (II) an d levato r scapulae
m uscle (IV). Th e supraspinatus m uscle (I) is in n er vated by th e suprascapu lar
n er ve, w h ich arises from th e su perior t ru n k of th e brach ial p lexu s an d re-
ceives con t ribut ion s from C5, C6, an d C4. Th e subscapularis m uscle (III) is
in n er vated by th e up per an d low er subscapular n er ves th at are bran ch es of
th e posterior cord receiving bers from C5 an d C6, respect ively.3

44. C – Subscapular n er ve
45. A – Axillar y n er ve
46. C – Subscapular n er ve
47. B – Dorsal scap u lar n er ve
48. D – Su p rascapu lar n er ve
49. D – Su p rascapu lar n er ve

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Neurosurgery Board Review

50. B – Dorsal scap u lar n er ve

Th e axillary nerve (A) is on e of th e t w o term in al bran ch es of th e p osterior


cord an d in n er vates th e te res m inor an d deltoid m u scles. Th e do rsal
scapular nerve (B) arises from th e an terior ram u s of C5 an d in n er vates th e
levato r scapulae an d rho m bo id m uscles. Th e subscapular ne rve (C) h as
u pper an d low er com pon en ts th at com e o th e posterior cord to in n er vate
the te res m ajo r an d subscapularis m uscles. Th e suprascapular nerve (D)
arises from th e su perior t ru n k to in n er vate th e supraspinatus an d infraspi-
natus m uscles.3

51. A – Decreased volt age an d decreased durat ion

Th e m otor un it poten t ial of m yopathy ten ds to be of decreased voltage an d


decreased durat ion because in th ese con dit ion s th ere is a reduced n um ber of
m otor bers p er m otor u n it .1

52. C – Th e congen it al form is in h erited on ly from th e m atern al lin e.

Fron t al balding occurs in both m en an d w om en a icted w ith m yoton ic


dyst rophy (A is false). Len s op acit ies are fou n d by slit lam p in 90% of p at ien ts
(B is false). Th e in h erit an ce is au tosom al dom in an t , an d th e defect ive gen e
segregates on ch rom osom e 19 (D is false). Myoton ia m ay p recede w eakn ess
by several years (E is false). An sw er C is correct: In th e congen it al (n eon at al)
form of m yoton ic dyst rophy, th e a ected p aren t is alw ays th e m oth er.1

53. A – Cobalam in

Su bacu te com bin ed de cien cy of th e cord occu rs from failu re to t ran sfer
cobalam in (vit am in B12 ) across th e in terst it ial m ucosa because of lack of
in t rin sic factor. Folic acid de cien cy t ypically causes h em atologic e ects,
an d w h ile folic acid is involved in B12 m et abolism , it is rarely im plicated in
n eu rologic d isease st ates (B is incorrect). Nicot in ic acid de cien cy h as been
associated w ith en cep h alop athy (C is inco rre ct). Pyridoxin e (vitam in B6 )
de cien cy is associated w ith ison iazid th erapy for t u berculosis an d causes
p olyn eu ropathy (D is inco rrect). Th iam in e d e cien cy is associated w ith th e
Wern icke-Korsako syn drom e seen in ch ron ic alcoh olism (E is inco rre ct).1

54. A – Ch rom osom e 4

Th e m arker lin ked to th e Hun t ington gen e is localized to th e sh ort arm of


ch rom osom e 4 (A). Neu ro brom atosis t yp e I is lin ked to ch rom osom e 17
(C is incorrect). Neu ro brom atosis t yp e II is lin ked to ch rom osom e 22 (D is
inco rre ct).1

55. A – Left gen iculocalcarin e t ract an d corpus callosum

Th e lesion described in A w ou ld ren der th e p at ien t blin d in th e righ t h alf of


the visual eld. Visual in form at ion reach es on ly th e right occipit al lobe but
can n ot be t ran sferred to Wern icke’s area across th e callosum . Th us th e abilit y
to read aloud an d to un derst an d th e w rit ten w ord is lost , but th e abilit y to un -
derst an d th e spoken language, speak, w rite, dict ate, an d converse is retain ed.1

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Clinical Neurology—Answers and Explanations

56. C – Con t ralateral param edian bran ch of th e basilar arter y

Deviat ion of th e eyes aw ay from th e lesion occu rs in brain stem syn drom es, for
exam ple, th e m ed ial m id pon t in e syn drom e (o cclusion o f the param edian
branch o f the m idbasilar artery [C]). An sw ers B, D, an d E w ou ld cau se devia-
t ion of th e eyes to th e left .1

57. E – Valproate

Of th e an t iep ilept ic drugs listed, pheno barbital (C) h as th e longest h alf-life of


96 6 12 h ours, follow ed by etho su xim ide (B), 40 6 6 h ours; phenyto in (D),
24 6 12 h ours; carbam azepine (A), 12 6 4 h ours; an d valpro ate (E), 8 6 2 h ou rs.1

58. C – Both
59. B – Syringom yelia
60. A – Am yot roph ic lateral sclerosis

Desp ite th e at rop hy of th e h an ds an d forearm s in am yot roph ic lateral sclerosis


(ALS), di u se hyp erre exia is seen , w ith absen ce of sen sor y ch ange.1

61. D – Decreased glycin e levels (false)

In creased glycin e levels h ave been fou n d in n eu ron s in seizu re foci (D is false).1

62. E – Th e n ding of in creased serum con cen t rat ion of m ethylm alon ic acid an d
h om ocystein e

Alth ough m icro bio lo gic assay (A) is th e m ost accu rate w ay to m easu re
seru m cobalam in (B12 ) levels, th e serum level is n ot a m easure of total body
cobalam in (B12 ). High serum co nce ntratio ns of co balam in (B12 ) m etabo lites
(m ethylm alonic acid and ho m o cyste ine [E]) are th e m ost reliable in dicators
of an in t racellular cobalam in de cien cy.1

63. D – Sen sor y ch anges u su ally develop after m otor ch anges (false)

In radiat ion m yelop athy, sen sor y ch anges u su ally p recede th e w eakn ess
(D is false). Th e oth er resp on ses are ch aracterist ics of rad iat ion m yelop athy
(delayed progressive t ype).1

64. A – Motor n er ve ber irrit abilit y

Fasciculat ion poten t ials are a sign of m oto r nerve ber irritability (A).
Fibrillat ion poten t ials are associated w ith m oto r ne rve ber destruction (B).
In ser t ion al act ivit y is t yp ically seen w ith denervating pro cesses (C). Muscle
atro phy (D) result s in m otor u n it poten t ials of low er volt age an d sh orter du-
rat ion . Reinnervatio n o f m uscle units (E) m ay resu lt in “gian t” m otor u n it
poten t ials of u n usually h igh am plit ude.1

65. B – Fibrillat ion poten t ial


66. A – Fasciculat ion poten t ial
67. B – Fibrillat ion poten t ial
68. C – Both
69. D – Neith er

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Neurosurgery Board Review

70. A – Fasciculat ion poten t ial

Fibrillat ion potent ials last from 1 to 5 m illiseconds, m ay take th e form of posi-
t ive sharp w aves, and are seen 10 to 25 days after th e death of an axon . Fascic-
u lat ion potent ials h ave th ree to ve p hases. Both can be seen in poliom yelit is.1

71. B – Prolonged, low am plit u de, an d p olyph asic

In early den er vat ion , m otor u n it poten t ials m ay in crease in size an d am p lit u d e
an d becom e longer in du rat ion an d p olyp h asic (A). Th ese so-called “gian t”
p oten t ials are a resu lt of m otor un its con tain ing m ore th an th e usual n um ber
of m otor bers. In early rein n er vat ion th e m otor un its are low in am plit ude,
p rolonged, an d polyp h asic (B), rep resen t ing a t ran sit ion al con gu rat ion .1

72. A – Abn orm al pupillar y respon se to accom m odat ion

Norm al pu p illar y resp on se to ligh t an d accom m odat ion (A is false, B is true),


togeth er w ith ext raocular (C) an d orbicu laris oculi (D) m u scle w eakn ess, is
h igh ly suggest ive of m yasth en ia gravis.1

73. E – All of th e above

Acrom egaly (I), am yloidosis (II), hyp othyroidism (III), an d pregn an cy (IV) are
all risk factors for th e carpal t u n n el syn drom e (m edian n er ve en t rap m en t
n eu ropathy at th e w rist).1

74. C – Polyopsia, polyuria, som n olen ce, an d obesit y are com m on feat ures.

Neu rologic involvem en t in sarcoidosis occu rs in 5% of cases (B is false). A


gran u lom atou s in am m ator y resp on se m ost prevalen t at th e base of th e
brain is seen (D is false). Visu al d ist u rban ces (du e to lesion s in an d arou n d th e
opt ic n er ves an d ch iasm [E is false ]) an d polydipsia, polyuria, som n olen ce,
or obesit y (du e to involvem en t of th e pit uit ar y an d hypoth alam us) are th e
u su al feat u res (C is true). Th e facial n er ve is th e m ost com m on cran ial n er ve
involved (A is false).1

75. A – In creased total n u m ber of h ours per day spen t sleeping

Th e n oct urn al sleep of a n arcolept ic is often redu ced, but frequen t n aps are
t aken during th e day; h en ce, th e tot al n um ber of h ours spen t sleeping is
sim ilar to a n orm al in dividu al (A is false). Th e oth er resp on ses are associated
w ith n arcolepsy.1

76. A – Bilateral in tern uclear oph th alm oplegia

Th e in it ial m an ifestat ion of MS in 25%of all pat ien t s is o ptic neuritis (D), an d
50%of pat ien t s w h o presen t w ith opt ic n eurit is w ill even t ually develop MS.
Bilateral internuclear o phthalm o plegia o ccurring in a yo ung perso n (A),
h ow ever, is virt u ally diagn ost ic of MS.1

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Clinical Neurology—Answers and Explanations

77. A – In ferior, su perior, an d m edial rect i

Upgaze or dow ngaze is usually m ore lim ited th an lateral gaze. Th ese de cit s
are cau sed by an in am m ator y in lt rat ion of th e in ferior an d m ed ial rect i,
leading to con t ract u res of th ese m u scles.1

78. A – Eph apt ic t ran sm ission

Th e spasm is th ough t to be caused by n er ve root com pression an d segm en tal


dem yelin at ion , w h ich leads to im pu lses con ducted in on e m otor ber being
t ran sm it ted to n eigh boring bers (eph apt ic t ran sm ission [A]).1

79. A – Biopsy eviden ce of sarcoid gran ulom as in n on - CNS t issue an d n eurologic


n dings

Alth ough all of th e opt ion s are seen in act ive n eurosarcoidosis, th e diagn osis
is m ade on th e basis of an sw er A.1

80. D – Op soclon u s-m yoclon u s


81. E – Sen sor y n europathy
82. D – Op soclon u s-m yoclon u s
83. B – Eaton -Lam ber t syn drom e
84. C – Moersch -Wolt m an (st i -m an ) syn drom e

Th e IgG an t ibody in pat ien t s w ith Eato n-Lam bert syndro m e (B) (associated
w ith sm all-cell carcin om a of th e lung) react s w ith presyn apt ic volt age-
gated calciu m ch an n els. Th e Mo e rsch-Wo ltm an syndro m e (C) is ch ar-
acterized by involu n tar y m u scle rigidit y an d sp asm s, an d 60% of pat ien t s
h ave au toan t ibodies to glu t am ic acid decarboxylase. Un derlying t u m ors are
often foun d. Most cases of paraneo plastic senso ry ne uro pathy (E) are as-
sociated w ith sm all-cell carcin om a of th e lu ng or lym p h om a, an d an an t i-
n u clear an t ibody (an t i-Hu ) is fou n d in 70% of th ese p at ien ts. Paraneo plastic
o pso clo nus (D) in ad u lt s is associated w ith breast can cer an d an an t in eu ron al
an t ibody (an t i-Ri).4

85. D – Medial m edu llar y occlu sion


86. B – Lateral m edu llar y syn d rom e (VA or PICA occlu sion )
87. C – Lateral su perior pon t in e syn drom e (SCA occlusion )
88. A – Basilar syn drom e

Me dial m edullary o cclusio n (D) is associated w ith con t ralateral h em ip aresis


sp aring th e face, con t ralateral loss of p osit ion an d vibrat ion sen se, ip silateral
p aralysis, an d at rop hy of th e tongue. Lateral m edullary syndro m e (VA o r PICA
o cclusio n [B]) is associated w ith con t ralateral pain an d tem perat u re loss in
the body, ipsilateral Horn er’s syn drom e, ipsilateral at axia, ipsilateral paralysis
of th e palate an d vocal cords, an d ipsilateral pain an d n um bn ess in the face.
Late ral superio r po ntine syndro m e (SCA o cclusio n [C]) is associated w ith
ip silateral cerebellar at axia, con t ralateral loss of pain an d tem perat ure in th e
body, par t ial deafn ess, an d n au sea an d vom it ing. Basilar syndro m e (A) is as-
sociated w ith bilateral m otor w eakn ess in all ext rem it ies, bilateral cerebellar
at axia, an d dip lopia.1

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Neurosurgery Board Review

89. E – Subth alam ic n ucleus

Th e lesion in h em iballism us is localized to th e co ntralate ral subthalam ic


nucleus (E). Cerebellar in coordin at ion an d in ten t ion t rem or are associated
w ith dam age to th e brachium co njunctivum (A). Hun t ington’s ch orea is
associated w ith dam age to th e caudate nucleus (B). Dysfu n ct ion of th e
substantia nigra (D) is involved in th e p ath ogen esis of Parkin son’s disease.1

90. D – Serrat u s an terior

Th e long th oracic n er ve arises from th e posterior aspect of th e an terior


ram i of C5, C6, an d C7 an d in n er vates th e serratus anterior m uscle (D);
lesion s to th e long th oracic n er ve resu lt in w inging of th e scapula. Th e
levato r scapulae (B) an d rho m bo ids (C) are in n er vated by th e dorsal scapu-
lar n er ve, w h ich is a bran ch o th e posterior aspect of th e an terior ram u s of
C5. The latissim us dorsi (A) is in n er vated by th e th oracodorsal n er ve, a side
bran ch of th e posterior cord. The teres m ino r (E) is in n er vated by th e axillar y
n er ve along w ith th e deltoid m u scle.3

91. D – Defect in release of acet ylch olin e qu an ta

In Eaton -Lam bert syn drom e, th e presyn apt ic vesicles are n orm al (A is false),
an t ibod ies to th e acet ylch olin e receptor are n ot presen t (B is false), an d th e
exten t of receptor su rface is act u ally in creased (C is false). Th ere is, h ow ever,
a defect in th e release of acet ylch olin e qu an t a from th e n er ve term in als (D).1

92. C – Iris h am artom as (false)

Von Hip p el-Lin dau disease is associated w ith a defe ct o n chro m o so m e


3 (A), do m inant inheritance (B), pancreatic cysts (D), an d renal cell
carcino m as (E). Iris ham arto m as (Lisch no dules [C]) are seen in n euro -
brom atosis t ype 1.1

93. B – Dom in an t p ariet al lobe

Gerst m ann’s syn drom e con sists of nger agn osia, left–right confusion , acalcu-
lia, and agraphia. It is associated w ith lesions of the do m inant parietal lo be (B),
usually in the inferior parietal lobule, angular gyrus, or subjacen t w hite m at ter.1

94. E – Th e rate-lim it ing step in it s syn th esis is dopa decarboxylase (false)

The rate-lim iting step in dopam ine synth esis is t yrosine hydroxylase (converts
L-t yrosine to L-hydroxyphenylalanine [L-dopa]). The oth er responses regarding
dopam in e pharm acology are t rue.1,5

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Clinical Neurology—Answers and Explanations

95. E – Sin em et (carbidopa-levodopa)


96. D – Eldep r yl (selegilin e)
97. C – Brom ocript in e
98. B – Art an e (t rih exyp h en idyl)
99. D – Eldep r yl (selegilin e)

Am antadine (A) is an antiviral agent that m ay release dopam ine from st riatal
n euron s. Artane (trihexyphenidyl [B]) is an anticholinergic agent w ith side ef-
fects th at include dr y m outh and blurred vision. Bro m o criptine (C) is an ergot
derivative that agonizes D2 receptors. Eldepryl (selegiline [D]) is a m onoam ine
oxidase B in hibitor an d slow s progression of disabilit y. Sinem et (carbido pa-
levodo pa [E]) com bin es L-dopa w ith a dopa decarboxylase in h ibitor.1

100. C – Area 22

Wern icke’s area correspon ds m ost closely to Brodm an n’s area 22 (C).
Area 17 (A) correspon ds to prim ar y visual cortex located on th e ban ks of th e
calcarin e ssure. Area 19 (B) represen t s tert iar y visu al fu n ct ion . Areas 41
and 42 (D) represen t prim ar y an d secon dar y auditor y cor tex in Hesch l’s gyri
an d th e su perior tem p oral gyru s. Area 44 (E) correspon ds to Broca’s area lo-
cated in th e fron t al operculum .1,6

101. A – I, II, III

Th e progressive sensorim oto r po lyne uro pathy (IV) associated w ith diabetes
m ellit u s is gen erally (bu t n ot u n iversally) th ough t to be m et abolic in origin . Th e
p ath ophysiology of o phthalm o plegia (I), acute m o no neuro pathy (II), an d
m o no neuritis m ultiplex (III) are gen erally th ough t to be vascu lar in origin .1,4

102. C – In creased st rength after th e Ten silon test

In a m yasth en ic pat ien t presen t ing w ith acu tely w orsen ing w eakn ess an d
respirator y failure, th e di eren t ial in clu des m yasth en ic crisis an d ch olin ergic
crisis (due to an t ich olin esterase th erapy). Muscarin ic sym ptom s in clude
bradycardia (A), diarrhea (B), m io sis (D), an d sw eating (E). Increase d
strength fo llow ing the adm inistratio n o f Tensilo n (e dro pho nium [C])
does n ot support th e diagn osis of ch olin ergic crisis. Edroph on ium is an
an t ich olin esterase drug, w h ich w ou ld in crease th e availabilit y of acet ych o-
lin e on adm in ist rat ion . Th e w eakn ess of a ch olin ergic crisis is u n a ected by
Ten silon (edroph on ium ).1

103. C – Matern al in h erit an ce

Th e MELAS syn drom e (m itoch on drial m yopathy, en ceph alopathy, lact ic aci-
dosis, an d st rokelike episodes) is a m itoch on drial disease associated w ith a
m atern al in h erit an ce.1

104. C – Cen t ral cord syn drom e


105. A – An terior cord syn drom e
106. A – An terior cord syn drom e

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Neurosurgery Board Review

107. B – Brow n -Séqu ard syn drom e

Th e anterio r co rd syndro m e (A) is associated w ith hyp esth esia an d hyp -


algesia du e to inju r y of th e an terior an d lateral spin oth alam ic t ract s an d is
associated w ith hyp er exion inju ries. Posterior colu m n fu n ct ion is gen erally
p reser ved. Th e Brow n-Séquard syndro m e (B) is associated w ith cont ralat-
eral pain an d tem p erat u re loss, ip silateral dorsal colu m n dysfu n ct ion , an d
ip silateral h em iplegia. It is usu ally due to pen et rat ing t raum a an d h as th e
best progn osis of th e in com plete syn drom es. Central co rd syndrom e (C) is
though t to be due to hyperexten sion in th e set t ing of cer vical sten osis. Cen -
t ral cord injuries cause decreased sen sat ion over th e upper lim bs an d sh oul-
ders an d decreased m otor fun ct ion th at is w orse in th e upper ext rem it ies.2

108. C – Both
109. B – Non -REM sleep
110. A – REM sleep
111. B – Non -REM sleep
112. B – Non -REM sleep
113. A – REM sleep

Alth ough m ost dream s occur in rapid eye m ovem ent (REM) slee p (A), th ey
can also occur in no n–REM (NREM) sle ep (B). Adu lt som n am bu lism , K
com plexes, an d sleep spin dles all occur in NREM slee p (B) (th e lat ter t w o
in stage 2). Glu cose m et abolism in th e brain is in creased in REM (A) an d de-
creased in NREM sleep (B) in com p arison to th e w aking st ate.1

114. B – Glycogen storage d isease t yp e V (McArdle’s disease)


115. A – Glycogen storage disease t ype II (acid m alt ase de cien cy)
116. A – Glycogen storage disease t ype II (acid m alt ase de cien cy)
117. D – Neith er

Glycogen storage disease type II (A) results from acid m altase (a -1,4-glucosidase)
de ciency and has three form s: infantile (classic Pom pe’s disease), juve-
nile, and adult form s. Glycogen accum ulates in lysosom es throughout the
body. Glycogen storage disease type V (McArdle’s disease [B]) results from m yo-
phosphorylase de ciency. Glycogen cannot be converted to glucose-6-phosphate,
and the blood lactate does not rise after ischem ic exercise. Both t ypes are autoso-
m al recessive. Rarely, t ype V m ay be autosom al dom inant.1

118. B – I, III (h igh u rin ar y copp er excret ion an d low ceru loplasm in levels)

Wilson’s disease is ch aracterized by an increased urinary co pper excretio n (I),


low seru m copper levels (II is false), an d low cerulo plasm in levels (III). Th e
com pu ted tom ography (CT) scan som et im es sh ow s hypoden se areas in th e
len t icu lar n uclei (IV is false).1

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Clinical Neurology—Answers and Explanations

119. A – A m arked in am m ator y respon se w ith dest ru ct ion of n er ve cells in th e pon s


is seen (false)

Cen t ral pon t in e m yelin olysis (CPM) occu rs in th e set t ing of rapid co rrectio n
o f chro nic hypo natrem ia (B), as is som et im es seen in chronic alco ho lism (C).
Quadriplegia, pse udo bulbar palsy, and lo cked-in syndro m e (D) can occu r
w ith CPM. Microscopically, dest ruct ion of th e m edullated sh eath s w ith rela-
t ive sparing of th e axis cylin ders an d preser vat ion of n er ve cells in th e pon s is
seen . An in am m ator y resp on se is absen t (A is false).1

120. C – Both
121. A – Hom ocyst in u ria
122. A – Hom ocyst in u ria

Pat ien t s w ith ho m o cystinuria (A) an d th ose w ith Marfan’s syndro m e (B)
h ave a t all, th in fram e an d arach n odact yly. Pat ien t s w ith h om ocyst in u ria
(cystath ion e syn th ase de cien cy) also sh ow eviden ce of m en t al ret ardat ion
an d are pron e to st rokes.1

123. D – Non dom in an t pariet al lobe

Dressing ap raxia is a sp ecial t yp e of an osogn osia th at is t yp ically at t ribu ted to


dysfu n ct ion of th e no ndo m inant parietal lo be (D).1

124. E – Teres m in or

Th e axillar y n er ve in n er vates th e teres m ino r (E) an d deltoid m uscles.


Co raco brachialis (A) is in n er vated by th e m u scu locu t an eou s n er ve. Th e
rho m bo ids (B) are in n er vated by th e dorsal scapu lar n er ve. Th e su p rascap u -
lar n er ve in n er vates th e supraspinatus (C) an d in fraspin at us m uscles. Th e
su bscapu lar n er ves in n er vate th e te res m ajo r (D) an d subscapularis m u scles.3

125. A – Calci ed cort ical vessels (false)

St u rge-Weber syn d rom e is ch aracterized by a facial vascular nevus (B) th at


is presen t at birth , w ith seizures, hem isensory de cit (C), an d h em ip are-
sis contralateral to th e side of th e n evu s. Me ningeal veno us angio m as (D)
are also p resen t ip silateral to th e skin lesion . Sku ll lm s m ay reveal tram line
calci catio n is present in the parieto -o ccipital cortical substance (E), n ot
the vessels (A is false).1

126. C – 50 m /s

Th e n orm al sen sor y con duct ion velocit y in th e m edian an d uln ar n er ves is
ap p roxim ately 50 m /s (C). Th e oth er an sw er ch oices are in correct .1

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Neurosurgery Board Review

127. E – Th e au ton om ic n er vous system is usu ally involved (false)

Ch arcot-Marie-Tooth disease, or peron eal m uscu lar at rophy, is a slow ly pro-


gressive, sym m et ric, in h erited dem yelin at ing con dit ion of th e perip h eral n er-
vou s system . Th e u su al p at tern of in h erit an ce is auto so m al do m inant (A), an d
the disease m ay cause w eakn ess, at rophy, an d at axia of both th e uppe r and
low er extrem ities (C), part icu larly of th e distal m uscle gro ups (B)—foot
drop is com m on . No speci c m edical th erapy is available at th is t im e, an d
stero ids do not appear to have an e ect o n disease pro gressio n (D). Th e
au ton om ic n er vou s system is u su ally n ot involved in Ch arcot-Marie-Tooth
disease (E is false ).1

128. E – All of th e above

Clival ch ordom as m ay cause palsies of m ult iple cran ial n er ves. All of th e cra-
n ial n er ves listed cou ld poten t ially be a ected by a dest ru ct ive lesion of th e
sku ll base (II, V, X, an d XII).1

129. D – Protein of 35 m g/dL

Lum bar punct ure and CSF ndings in t uberculous m eningitis t ypically include
glucose less than 40 m g/dL (A), although glucose levels are t ypically n ot as low
as th ose foun d in pyogen ic m en ingitis. CSF tends to be under increased pres-
sure (C), an d a leuko cytosis is usually present (E) w ith a predo m inance o f
lym phocytes after several days of the illness (B). Th e protein level is elevat-
ed in tuberculo us m eningitis and is usually 100 to 200 m g/dL (D is false).1

130. A – Con t ralateral Horn er’s syn drom e (false)

PICA occlu sion m ay resu lt in Wallen berg’s lateral m ed u llar y syn drom e, w h ich
is ch aracterized by co ntralate ral pain and tem perature lo ss over the body
(due to disruptio n o f spinothalam ic bers [B]), ip silateral n u m bn ess over
h alf of th e face (du e to d escen ding t ract an d n u cleu s of th e t rigem in al n er ve),
ipsilateral ataxia (etio lo g y uncertain [C]), ipsilateral num bness o f the
lim bs (due to injury to the cuneate and gracile nuclei [D]), ipsilateral pa-
ralysis o f the palate (E), an d ipsilateral Ho rne r’s syndro m e (due to injury
o f descending sym pathetic be rs; A is inco rrect).1

131. A – K com p lexes

K co m plexes (A) are a ch aracterist ic of st age 2 sleep. Delta w aves (B) are
p revalen t in st age 3 an d 4 sleep. Desynchro nizatio n o f the EEG (C) oc-
cu rs in REM sleep (A), an d som nam bulism (E) occu rs alm ost exclu sively in
st age 4 sleep .1

132. B – Du ch en n e’s m u scu lar dyst rop hy


133. A – Becker’s m u scu lar dyst rop hy
134. E – Myoton ic dyst rophy
135. B – Du ch en n e’s m u scu lar dyst rop hy
136. C – Em er y-Dreifuss m uscular dyst rophy
137. D – Lan dou zy-Dejerin e (facioscapuloh um eral) dyst rophy
138. E – Myoton ic dyst rophy

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Clinical Neurology—Answers and Explanations

139. D – Lan dou zy-Dejerin e (facioscapuloh um eral) dyst rophy


140. E – Myoton ic dyst rophy
141. E – Myoton ic dyst rophy

Duche nne’s (B) and Becker’s (A) m uscu lar dyst roph ies are X-lin ked reces-
sive d isorders ch aracterized by th e absen ce of th e gen e p rod u ct dyst rop h in
in th e form er an d th e presen ce of a st ru ct u rally abn orm al form of th e p rod-
u ct in th e lat ter. Weakn ess an d pseu do-hypert rop hy of cer tain m u scles (n o-
t ably th e calf) occur. Th e on set is later an d th e course m ore ben ign in th e
Becker’s type (A). Myoto nic dystro phy (E) is th e m ost com m on adu lt form of
m u scu lar dyst rophy an d is ch aracterized by an au tosom al dom in an t in h eri-
t an ce, w ith th e defect ive gen e localized to ch rom osom e 19q. Feat ures in clude
dyst roph ic ch anges in n on m uscular t issues (e.g., len s opacit ies) an d a ch ar-
acterist ic facies. Lando uzy-Dejerine dystro phy (D) is u sually t ran sm it ted
by autosom al dom in an t in h erit an ce, an d th e abn orm al gen e h as been local-
ized to ch rom osom e 4. Congen it al absen ce of a p ectoral, brach ioradialis, or
biceps fem oris m uscle occasion ally occurs. Ch aracterist ics of Em ery-Dreifuss
dystro phy (C), a ben ign X-lin ked dyst rop hy, in clu de con t ract u res of th e elbow
exors, n eck exten sors, an d p osterior calf m u scles.1

142. B – Cor tex

Mon op legia w ith ou t m u scu lar at rop hy is m ost often du e to a lesion of th e


ce rebral co rtex (B).1

143. C – II, IV (autoclaving at 132°C u n der p ressure for 1 h ou r an d im m ersion for


1 h our in bleach )

Su bacu te sp ongiform en cep h alop athy, or Creu t zfeldt-Jakob disease, is a


p rogressive n eurologic illn ess ch aracterized by d em en t ia an d m yoclon ic
jerks. Th e disease is th ough t to be du e to a prion protein th at is resistant to
fo rm alin (I), alco ho l (III), boiling, an d u lt raviolet radiat ion . Th e p rotein can
be inactivated by auto claving at 132°C unde r pressure fo r 1 ho ur (II), or by
im m ersio n in bleach fo r 1 ho ur (IV).1

144. B – High -frequ en cy loss

Hearing loss cau sed by acou st ic n eu rom as is m ost often high-freque ncy (B),
or h igh -ton e, h earing loss.6

145. D – Middle t run k


146. B – Low er t ru n k
147. C – Medial cord
148. E – Upper t run k

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Neurosurgery Board Review

149. A – Lateral cord

Alth ough low er trunk lesio ns (B) resem ble m edial co rd lesio ns (C), abn or-
m alit ies of rad ially in n er vated C8 m u scles are seen w ith th e form er, bu t n ot
w ith th e lat ter. Low -am plit u de act ion poten t ials in th e deltoid an d biceps are
seen in upper trunk lesio ns (E). Median sen sor y resp on ses from th e in dex
an d m iddle nger are abn orm al, an d m otor con d u ct ion velocit ies of th e h an d
m u scles are n orm al in m iddle trunk lesio ns (D). Lateral co rd lesio ns (A)
cau se w eakn ess of th e m uscles supplied by th e m usculocut an eous n er ve an d
the lateral root of th e m edian n er ve (in n er vates th e forearm m uscles). Th e
in t rin sic h an d m uscles in n er vated by th e m ed ial root of th e m edian n er ve
are sp ared.7

150. A – Equ al to th at of th e h igh -risk zon e

Several st u d ies in dicate th at a p erson m igrat ing from a h igh -risk to a low -risk
zon e of MS before age 15 w ill develop a risk th at is sim ilar to the low -risk
zo ne (B). If th e m igrat ion t akes p lace after age 15, th e risk is sim ilar to that
o f natives o f the high-risk zo ne (A).1

151. E – All of th e above

Bot u lism is a disease of th e n eu rom u scu lar ju n ct ion cau sed by a bacterial
exotoxin . Th e bot u lin u m toxin preven t s th e p resyn apt ic release of acet ylch o-
lin e from periph eral m otor n eu ron s. Early sym ptom s often in clude blu rred vi-
sion an d diplo pia (III). Th e p resen ce of pto sis (I), strabism us (II), an d palsies
of ext raocular m uscles can som et im es con fuse th e diagn osis w ith m yasth e-
n ias gravis. Th e p u p ils are often unreactive (IV) in bot ulism , w h ich h elps to
clarify th e diagn osis.1

152. D – Tran scort ical sen sor y aph asia

Transco rtical m oto r and senso ry aphasias (D) are m an ifested by preser ved
repet it ion . Bro ca’s aphasia (A) is ch aracterized by a disrupt ion of expressive
sp eech w ith relat ive p reser vat ion of com p reh en sion —rep et it ion is im p aired.
We rnicke’s aphasia (E) is ch aracterized by uen t , ar t iculate speech th at
lacks m ean ing w ith sign i can t im p airm en t of com preh en sion —repet it ion is
im paired . Co nductio n aphasia (B) is ch aracterized by uen t speech an d a
relat ive p reser vat ion of com preh en sion , bu t w ith sign i can t im pairm en t of
repet it ion . Glo bal aphasia (C) is ch aracterized by im pairm en t of speech , com -
preh en sion , an d repet it ion .1

153. E – REM

Narcolept ic sleep at tacks ten d to begin w ith REM sleep (E), rath er th an w ith
no n-REM (A–D) sleep as in th e gen eral p op u lat ion . Th is n ding suggest s th at
n arcolep sy is n ot a con dit ion of excessive dayt im e drow sin ess, bu t rath er a
“gen eralized disorder of sleep –w ake fu n ct ion .”1

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Clinical Neurology—Answers and Explanations

154. A – En teroviru s

Th e enteroviruses (A), w h ich in clu d e ech oviru s, Coxsackie, an d polio, rep -


resen t th e m ost com m on cau se of viral m en ingit is. HIV (B) m ay cau se a
m on on u cleosis-like syn drom e, an d m um ps (E) can be associated w ith
m en ingit is, alth ough th is is n ot as com m on as en teroviru s m en ingit is.
Lepto spiro sis (C) is a spiroch ete an d th erefore n ot a cause of viral m en ingit is.1

155. E – Tum ors of th e clivus

Garcin’s (h em ibasal) syn drom e h as been reported w ith ch on drom as or ch on -


drosarcom as of th e clivu s.1

156. C – High -ton e loss occu rs early in th e disease (false)

Mén ière's d isease is ch aracterized by recu rren t at t acks of ver t igo an d uni-
lateral tinnitus and deafness (B). Distentio n o f the endo lym phatic duct
is a ch aracterist ic path ologic ch ange (A). Ho rizo ntal nystagm us m ay o ccur
during an acute attack (D), an d low -pitched tinnitus is typical (E). Early
in Mén ière's d isease, d eafn ess a ect s m ain ly th e low ton es an d uct uates in
severit y. Later in th e disease, h igh ton es are a ected (C is false ).1

157. E – Wom en are m ore frequen tly a ected th an m en (false)

Th e Eaton -Lam bert syn drom e is due to decreased calcium -depen den t release
of acet ylch olin e quan ta at th e n eurom u scular jun ct ion . A te m po rary increase
in m uscle pow er m ay be o bse rved during the rst few co ntractio ns (D), in
con t rast to m yasth en ia gravis. Th e disease process h as been associated w ith
carcino m a o f the sto m ach and co lo n (C); auto no m ic disturbances are
o fte n o bserved (A), bu t fasciculatio ns are not a presenting feature (B). Men
are m ore often a ected th an w om en (5:1; E is false).1

158. A – Are m ore fat igable

Type I (red) m uscle bers are rich er in oxidat ive en zym es (E), p oorer in gly-
colyt ic en zym es, con tain m ore m itoch on dria (D) an d m yoglobin , re m ore
ton ically (B), h ave slow er rates of con t ract ion an d relaxat ion (C), an d are less
fat igable (A is false) th an t ype II (w h ite) bers.1

159. B – An terior ch oroidal ar ter y

In farct ion of th e an terior ch oroidal ar ter y m ay resu lt in con t ralateral h em i-


p legia, h em ihypesth esia, an d h om onym ous h em ian opia w ith sparing of
cogn it ive an d language fun ct ion s. Historically, ligat ion of th e anterio r cho -
ro idal artery (B) w as an early su rgical t reat m en t for pat ien t s w ith un ilateral
t rem or an d rigidit y from Parkin son’s disease.1

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Neurosurgery Board Review

160. E – Sym m et ric n europathy

Mon on eu rop athy m u lt ip lex of diabetes is classically asym m et ric (E is false).


In p ract ice, h ow ever, a con u en ce of m u lt ip le m on on eu ropath ies m ay lead to
a sym m et ric p ict u re. Th e oth er an sw er ch oices are ch aracterist ics of diabet ic
m on on eu rit is m u lt ip lex: low e r extre m ities are m o re co m m o nly a ecte d
than upper extrem ities (A), neuro pathy tends to be painful (B), proxim al
extrem ities are m o re co m m o nly a e cted than distal extrem ities (C), an d
recovery is usual (D).1

161. C – Lorazepam
162. B – Eth osu xim id e
163. F – Tegretol or valp roic acid
164. A – ACTH
165. E – Valproic acid

Ben zod iazepin es su ch as lo razepam (C) are th e rst-lin e agen t s for th e


t reat m en t of stat u s epilept icus. Ethosu xim ide (B) is t ypically used for th e
t reat m en t of absen ce seizu res. ACTH (A) is em ployed in th e t reat m en t of in -
fan t ile sp asm s. Tegretol (D) an d valpro ic acid (E) are accept able altern at ives
for th e t reat m en t of com p lex part ial seizu res. Valpro ic acid (E) is som et im es
u sed in th e at ypical pet it m al syn drom e of Len n ox- Gast aut .1

166. C – It is usually pain ful (false)

Pain w ith polym yosit is occu rs in on ly 15%of patien ts an d often suggests an ad-
dit ional disorder, such as rheum atoid arth ritis (C is false). Th e oth er respon ses
regarding polym yositis associated w ith carcinom a are t rue: carcinom a a ects
9%of patients w ith polym yositis (A), it is m ost com m only associated w ith
lung and pro state cancer in m en (B), m uscle biopsies show no evidence
o f tum o r cells (D), an d proxim al m uscles are initially a ected m o re than
distal o nes (E).1

167. B – Bilateral locat ion

Cluster h eadach es t ypically are re current fo r 6 to 12 w eeks (C) in a uni-


lateral (B is false) o rbital (E) locat ion . Th e m ale-to -fem ale ratio is
4.5:1 to 6.7:1 (D). Lacrim atio n, rhinorrhea (A), u sh ing of th e face, an d oth er
su ch p arasym p ath et ic-t yp e resp on ses often accom pany th e h eadach e.1

168. B – Dr y m ou th

Th e acute an t ich olin esterase e ect of organ oph osph ate poison ing results
in increase d salivatio n (B is false), bro nchial spasm s (A), m io sis (C),
sw eating (D), abdom in al cram p s, an d vo m iting (E). Th e m ain st ay of ph arm a-
cologic t reat m en t con sist s of at ropin e an d pralidoxim e.1

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Clinical Neurology—Answers and Explanations

169. B – Decreased GABA

Decreased glutam ic acid decarboxylase (hence, de crease d g-am ino butyric


acid [GABA] [B]) an d cho line acetyltransferase (hence, decreased acetyl-
cho line ; E is false) h ave been fou n d in th e st riat u m an d lateral p allid u m in
Hu n t ington’s disease. Also rep or ted h as been increased no repinephrine and
som ato statin in the striatum (C and D are false). An excess of dopam ine
o r an increase d sensitivity o f striatal do pam ine recepto rs h as been p ost u -
lated in th e path ogen esis of Hun t ington’s disease (A is false ).1

170. C – Bilateral m edial tem poro-occipital lobes

Prosopagn osia refers to th e in abilit y to iden t ify a fam iliar face w h ile retain -
ing th e abilit y to id en t ify it s feat ures an d is associated w ith inju r y to th e
bilate ral m edial te m po ro -o ccipital lo bes (C).1

171. C – Povert y of spon tan eous speech

Inju ries to th e su pp lem en tar y m otor cor tex are associated w ith m utism , con -
t ralateral m otor n eglect , an d im pairm en t of coordin at ion (C is co rrect).1

172. D – Tibialis an terior an d exten sor digitorum longus an d brevis

Lesion s of th e peron eal n er ve produ ce w eakn ess of th e tibialis anterio r and


extenso r digito rum lo ngus and brevis (D). Th e t ibialis an terior is in n er vated
by th e deep peron eal n er ve, w h ile th e exor digitorum brevis is in n er vat-
ed by th e m edial plan t ar n er ve, a bran ch of th e t ibial n er ve (E is inco rre ct).
Th e abductor h allucis is in n er vated by th e m edial plan t ar n er ve (a bran ch
of th e t ibial n er ve), an d th e gast rocn em iu s is in n er vated by th e t ibial n er ve
(A is inco rrect). Th e exten sor digitoru m longu s an d brevis are in n er vated by
the deep peron eal n er ve, w h ereas th e abductor h allucis is in n er vated by a
bran ch of th e t ibial n er ve (B is inco rrect). C is inco rre ct becau se th e gast roc-
n em iu s an d exor h allu cis longu s are in n er vated by th e t ibial n er ve.3

173. D – De cien cy of sph ingom yelin ase

Tay-Sach s disease is ch aracterized by m acro cephaly (E), abno rm al startle


respo nse (A), an d cherry red spots in the retina (C). It is t ran sm it ted via
auto so m al re cessive inheritance (B). De cien cy of hexo am inidase A char-
acterizes Tay-Sachs disease (D is false), w h ile sp h ingom yelin ase de cien cy
is presen t in Niem an n -Pick disease t ypes A an d B.1

174. A – Cort icosp in al t ract dysfu n ct ion

Co rticospinal and co rtico senso ry functio ns, visu al acu it y, an d visu al


elds are relat ively preser ved th rough ou t th e cou rse of Alzh eim er’s disease
(A is false ).1

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Neurosurgery Board Review

175. B – High -dose steroid s form th e m ain stay of th erapy

Neith er conventional dose n or high -dose steroids have been show n to be


helpful in the treatm ent of Guillain-Barré syndrom e (B is false). The oth er
statem ents regarding th e Guillain -Barré syn drom e are true: disturbances of
autonom ic function are com m on (A), hypo - o r are exia is characteristic (C),
the m ortality rate is 3%(D), an d the peak severity is 10 to 14 days after onset
in 80%of cases.1

176. D – Lateral h orn cells at C8 to T3 to th e superior cer vical ganglion

Th e path w ay from th e lateral ho rn cells at C8 to T3 to the superio r


ce rvical ganglio n (D) con st it u tes th e secon d-ord er n eu ron (preganglion ic) in
the sym path et ic path w ay to th e pu pil. Neuron s from th e hypo thalam us to the
lateral ho rn cells at C8 to T3 (C) con st it ute th e rst-order n euron s (cen t ral),
an d n eu ron s p roject ing from th e superio r cervical ganglio n to the iris (E)
con st it ute th e th ird-order n euron s (postganglion ic) in th e sym path et ic in n er-
vat ion of th e pu pil. Project ion s from th e Edinger-Westphal nucleus to the
ciliary ganglio n (B) rep resen t th e p arasym p ath et ic system .1

177. C – Pyrim eth am in e an d sulfadiazin e

Th e t reat m en t of ch oice for toxoplasm osis is oral sulfadiazine and


pyrim etham ine (C) for at least 4 w eeks. Leucovorin is som et im es given as
an adjuvan t to cou n teract th e an t ifolate e ects of pyrim eth am in e. Pe nicillin
and nafcillin (A and D) are b -lactam an t ibiot ics an d are n ot an app ropriate
t reat m en t for toxoplasm osis. Praziquantel (B) is used for th e t reat m en t of
cyst icercosis; alben dazole is an oth er opt ion for cyst icercosis t reat m en t . Th ia-
ben dazole (E) is m ost com m on ly em p loyed in th e t reat m en t of t rich in osis.1

178. D – Th e EEG sh ow s ch aracterist ic periodic w aves th at occur ever y 2 to 3 secon ds.

Su bacu te sclerosing pan en cep h alit is (SSPE), ch aracterized by a p rogressive


m en tal declin e w ith seizu res, m yoclon u s, an d at axia, m ainly a ects children
and ado lescents (B is false ). SSPE is th ough t to be th e resu lt of ch ron ic m ea-
sles in fect ion . Th e lesion s are fou n d in bo th the cerebral co rtex and w hite
m atte r (C is false). Eosin op h ilic in clu sion s are fou n d in both th e cyto plasm
and nuclei o f ne uro ns and glial cells (A is false). Elevated gam m a globu lin in
the CSF is t ypical—th at is, CSF prote in tends to be increased (E is false). Th e
EEG sh ow s characteristic 2 to 3 per se co nd w aves (D is true).1

179. B – In t raven ou s m ethylp red n isolon e follow ed by oral p redn ison e

Treat m en t w ith o ral predniso ne (C) alo ne act u ally in creased th e risk of n ew
episodes of opt ic n eu rit is in a large ran dom ized con t rolled st u dy of opt ic n eu -
rit is t reat m en t . Intraveno us m ethylpredniso lo ne the rapy fo llow ed by o ral
predniso ne spe eds re cove ry o f visual lo ss (B is co rrect).1

104
Clinical Neurology—Answers and Explanations

180. C – Mult iple sclerosis

Schilder’s disease (C) is a dem yelin at ing illn ess of ch ildren an d you ng adult s
that h as several feat ures in com m on w ith ch ron ic relapsing MS.1

181. A – Extern al bran ch of th e su p erior lar yngeal n er ve

Th e cr icot hyroid, su p plied by th e exte rnal laryngeal n e rve (A), is th e on ly


in t rin sic lar yngeal m u scle n ot su p plied by th e re curre nt laryngeal ne rve
(D). Cranial ne rves VII (E) and IX (C) d o n ot p rovid e m otor in n er vat ion to
th e lar yn x.3

182. A – Defect in learn ing an d loss of p ast m em ories

In Korsako ’s p sych osis, reten t ive m em or y is im p aired ou t of p roport ion to


oth er cogn it ive fu n ct ion s in an oth er w ise aler t pat ien t .1

183. E – Men t al retardat ion (false)

Werdn ig-Ho m an n disease is in fan t ile spin al m uscu lar at rophy, or SMA
t ype I. SMA t ype I is ch aracterized by n eon atal hypoto nia (C) an d are exia (A).
In h eritan ce is auto so m al recessive (B) an d h as been lin ked to chrom o -
som e 5q (D). Mental retardatio n is not a feature o f the spinal m uscular
atro phy o f infancy and childho o d (E), bu t m ay be associated w ith late-on set
variet ies of sp in al m u scu lar at rop hy.1

184. B – I, III (block n orep in ep h rin e an d seroton in reu ptake)

Tricyclic an t idepressan t s su ch as im ipram in e an d am it ript ylin e block th e


reuptake o f both no repine phrine and seroto nin (I and III). Select ive sero-
ton in reupt ake in h ibitors such as citalopram or uoxet in e preven t th e reup-
take o f seroto nin o nly (III). Mon oam in e oxidase in h ibitors su ch as ip ron iazid
an d p h en elzin e p reven t th e oxidative deam inatio n o f m o no am ines (II).5

185. C – Both
186. D – Neith er
187. C – Both
188. A – Am yot roph ic lateral sclerosis
189. C – Both

Desp ite th e m u scle w eakn ess an d at rop hy seen in ALS, hyperre exia an d m ild
low er ext rem it y spast icit y are ch aracterist ic. Low er ext rem it y spast icit y an d
h an d at rophy can be seen in both con dit ion s. Cer vical sp on dylot ic m yelop a-
thy ten ds n ot to presen t as a pu rely m otor syn drom e.1

190. F – Wegn er’s gran u lom atosis


191. C – System ic lupus er yth em atosus
192. E – Tem poral arterit is
193. D – Takayasu’s syn drom e
194. B – Polyarterit is n odosa

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Neurosurgery Board Review

195. A – Cogan’s syn drom e

Cogan’s syndro m e (A) rep resen t s a n on syph ilit ic in terst it ial kerat it is th at
even t u ally leads to deafn ess th at m ay be accom pan ied by a system ic vas-
culit is resem bling polyarterit is n odosa. Po lyarte ritis no do sa (B) is a sys-
tem ic vasculit is th at causes in am m ator y n ecrosis of arteries an d arterioles
th rough out th e body, but spares th e lungs (con t rast w ith Ch urg-St rauss).
Involvem en t of th e vasa n er voru m m ay lead to m on on eu rit is m u lt iplex in
po lyarteritis no do sa (B)—kidn ey involvem en t an d skin p u rpu ra are com -
m on . System ic lupus erythem ato sus (C) m ay also cau se a n on in fect iou s vas-
cu lit is an d is associated w ith posit ive an t in uclear an t ibody t iters an d a m alar
rash . Takayasu’s syndro m e (D) is a vascu lit is involving th e aor t ic arch an d its
p roxim al bran ch es—a ected arteries becom e pulseless; blu rring of vision is
com m on . Te m po ral arte ritis (E) t yp ically p resen ts w ith h eadach e an d m ay
lead to blin dn ess du e to occlu sion of oph th alm ic ar ter y bran ch es. Wegener’s
granulom ato sis (E) is a rare gran ulom atou s vascu lit is th at is ch aracterized by
involvem en t of th e respirator y t ract s accom p an ied by a n ecrot izing glom eru -
lon eph rit is. Th e presen ce of an t in eu t rop h il cytoplasm ic an t ibodies (c-ANCA)
is relat ively sen sit ive an d speci c for Wegner’s granulo m ato sis (E).1

196. A – Defect in retentive m em ory out of proportion to other cognitive functions (false)

Defects in learn ing an d m em or y ou t of prop ort ion to oth er cogn it ive fu n ct ion s
(A) are feat u res of Korsako ’s psych osis, n ot Wern icke’s en ceph alopathy. Th e
oth er resp on ses are feat u res of Wern icke’s en cep h alop athy: gait ataxia (B),
gaze palsy (C), m etal co nfusio n (D), an d nystagm us (E).1

197. C – Loss of tem perat ure sen sat ion

Pariet al lobe lesion s are ch aracterized by lo ss o f po sitio n sense (B), im -


p aired abilit y to lo calize to uch and pain stim uli (ato po gno sia [E]),
aste reo gno sis (A), an d im pairm ent o f tw o -po int discrim inatio n (D).
Pe rceptio n o f pain, to uch, pressure, vibrato ry, and therm al stim uli is
relatively intact (C).1

198. C – Righ t in ferior occipitotem poral region

A lesion in th e righ t in ferior occipitotem poral region sparing th e opt ic radia-


t ion an d st riate cortex causes th e purest form of achrom atopsia.1

199. C – Th ird-order Horner’s syn drom e

Horn er’s syn drom e can be con rm ed by th e failu re of th e m iot ic p u p il to d ilate


in respon se to 2 to 10%cocain e drops. If th e later applicat ion of th e adren ergic
m ydriat ic hydroxyam p h et am in e h as n o e ect , th en th e lesion localizes to th e
third-o rder neuro n (po stganglio nic part [C]). A rst- or secon d-order lesion
(A o r B) is in dicated by a failu re of th e m iot ic p u p il to d ilate to cocain e drops,
follow ed by dilat ion (after 24 h ou rs) w ith 1% hydroxyam p h etam in e.1

106
Clinical Neurology—Answers and Explanations

200. C – St age 4

Som n am bu lism , or sleep -w alking, occu rs alm ost exclu sively in stage 4 (no n-
REM) sleep (C).1

201. D - Im ipram ine

Noct u r n al en u resis w it h dayt im e con t in en ce occu rs frequ en t ly d u r in g


ch ild h ood . Th e m ost e ect ive m ed ical t h erapy is im ipram in e (D), a t r icy-
clic an t id ep ressan t .1

202. B – Apraxia of th e left h an d to com m an d

Sect ion ing of th e corp u s callosu m cau ses a discon n ect ion syn drom e by isolat-
ing th e language fun ct ion of th e left h em isph ere from th e righ t h em isph ere.
Th erefore, w h en given a verbal com m an d (processed by th e left h em isph ere),
the pat ien t w ill be able to execute th e com m an d w ith th e righ t h an d (con -
t rolled by left h em isph ere), but w ill h ave di cu lt y execut ing th e com m an d
w ith th e left h an d (con t rolled by righ t h em isph ere). Th erefore, th e best
an sw er is B, apraxia o f the left hand to co m m and.1

203. C – Good com preh en sion , n on uen t speech , poor repet it ion
204. A – Good com p reh en sion , u en t speech , p oor repet it ion
205. F – Poor com p reh en sion , n on u en t sp eech , p oor rep et it ion
206. B – Good com p reh en sion , n on u en t sp eech , good rep et it ion
207. D – Poor com preh en sion , uen t speech , good repet it ion
208. E – Poor com preh en sion , uen t speech , poor repet it ion

Con duct ion aph asia is sim ilar to We rnicke’s aphasia (E) in th at th ere is a
u en t parap h asic sp eech w ith im p aired repet it ion . In con t rast to p at ien ts
w ith Wern icke’s aph asia, h ow ever, th ose w ith co nductio n aphasia (A) h ave
lit tle or n o di cu lt y in com preh en sion . Bro ca’s aphasia (C) is ch aracterized
by n on u en t agram m at ical speech w ith relat ively preser ved com preh en sion ;
repet it ion is im paired . Th e transco rtical aphasias (B and D) are ch aracter-
ized by good repet it ion . Glo bal aphasia (F) is ch aracterized by im paired
sp eech , im paired com p reh en sion , an d im p aired rep et it ion .1

209. C – Both
210. D – Neith er
211. B – Polym yosit is
212. A – Derm atom yosit is
213. B – Polym yosit is
214. A – Derm atom yosit is

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Neurosurgery Board Review

215. D – Neith er

Both idiopath ic po lym yo sitis (PM [B]) and derm ato m yo sitis (DM [A]) are
m ore com m on in w om en . Abou t 9%of pat ien t s w ith PM an d 15%of th ose w ith
DM h ave an u n derlying carcin om a. Single- ber n ecrosis is seen in PM (B),
w h ereas a perifascicular m uscle ber degen erat ion and at rophy are seen in
DM (A). IgG, IgM, com plem en t , an d m em bran e at t ack com p lexes are deposited
in th e sm all vessels in DM (A), w h ereas in PM (B) th e en dom ysial in am m a-
tor y exudate cont ain s a large n um ber of T cells an d few B cells. Both disorders
are readily resp on sive to cort icosteroids an d oth er im m u n osu ppressan t s.1

216. A – Carbam azep in e

Carbam azepine (A) is a sodiu m ch an n el m odu lator th at m ay lead to SIADH


an d hyp on at rem ia. Gabapentin (B) cau ses som n olen ce as a m ajor sid e e ect .
Levetiracetam (C) h as a low risk of side e ect s, but m ay cause som n olen ce,
p ar t icu larly in th e elderly. Phe nyto in (D) h as a m yriad of side e ects including
allergy, at axia, d ip lopia, st u p or, h irsu t ism , gingival hyp erp lasia, cerebellar d e-
gen erat ion , perip h eral n eu ropathy, an d decreased vit am in K. To piram ate (E)
h as cogn it ive im p airm en t , dizzin ess, an d at axia as it s m ajor side e ect s.

217. C – Ict al SPECT scan s sh ow decreased t racer sign al in th e seizure focus (false)

Single-p h oton em ission com p uted tom ograp hy (SPECT) is u sed in seizure lo-
calizat ion for pat ient s w ith par t ial epilepsy. Both ict al an d in terict al SPECT
st u dies can be acqu ired an d com pared for seizu re localizat ion (A). Perfu sion
follow s ch anges in m et abolism du ring seizu res (D), an d th erefore th ere ten ds
to be in creased SPECT t racer sign al in a ected brain t issue on an ict al SPECT
st u dy (C is false). PET scan s ten d to be in terictal st u d ies; ictal SPECT scan s
are gen erally easier to acqu ire th an ict al PET scan s (B). Th e m ajor lim itat ion
of ictal SPECT scan n ing is th at t racer n eeds to be injected w ith in 1–2 m in utes
of seizure on set (E).8

218. C – Neurocyst icercosis (false)

Mon on eu rit is m u lt ip lex is a con dit ion th at involves th e acu te or su bacu te


involvem en t of m ult iple periph eral n er ves. Com m on cau ses of m on on eu-
rit is m u lt ip lex in clu d e po lyarte ritis no do sa (D), Wegn er’s gran u lom atosis,
diabetes (A), cr yoglobu lin em ia, sarco ido sis (E), Lym e disease, an d HIV (B).
Rare cau ses in clu de sarco ido sis (E), paran eop last ic syn d rom es, am yloidosis,
lep rosy, lu pu s, rh eu m atoid arth rit is, an d Sjögren’s syn drom e.

219. B – 3, 4.5

Th e FDA in it ially approved in t raven ous r tPA for use in acu te isch em ic st roke
w ith in 3 h ours of sym ptom on set follow ing th e NINDS t rial in 1995. In 2009,
th e FDA approved th e use of in t raven ous rtPA in pat ien ts u p to 4.5 h ours from
sym ptom on set . Ch oice B is correct .8

108
Clinical Neurology—Answers and Explanations

220. C – 6 h ours

In th e PROACT II st u dy, p at ien ts w ith MCA occlu sion s w ith in 6 ho urs (C) of
sym ptom on set t reated w ith in t ra-arterial recom bin an t prou rokin ase h ad im -
p rovem en ts in recan alizat ion an d fun ct ion al in dep en d en ce in com parison to
p at ien t s receiving p lacebo.8

221. D – 8 h ours

Ben e t w ith m ech an ical th rom bectom y h as been dem on st rated u p to


8 ho urs (D) from sym ptom on set . Th is o ers an advan t age over th e
4.5-ho ur (B) w in dow of in t raven ou s tPA an d th e 6-hour (C) w in dow of in t ra-
ar terial th rom bolyt ic th erapy.8

222. D – NIH st roke score of . 20

Pat ien t s eligible for in t raven ou s t PA sh ou ld be t reated before p u rsu ing en d o-


vascu lar t h erapy. If t h e p at ien t fails to im prove w ith in trave n o us tPA (C),
p resen t s o utside th e th e rape utic w in do w fo r in trave n o us tPA (E), or h as
a co n train dicatio n to in trave n o us tPA (A), en d ovascu lar t h erapy m ay be
con sid ered . A di usio n-pe rfusio n m ism atch (B) suggest s t h at t h ere is sal-
vageable t issu e p resen t in t h e isch em ic p en u m bra, w h ich is d esirable for
en d ovascu lar t h erapy. An NIH stro ke sco re o f . 20 (D) suggest s a severe
st roke an d m ay be a relat ive con t rain d icat ion to en d ovascu lar t h erapy.8

References

1. Ropper AH, Brow n RH. Prin ciples of Neurology, 8th ed. New York: McGraw -Hill; 2005
2. Win n HR, ed-in -ch ief. Neu rological Surger y, 5th ed. Ph iladelph ia, PA: W.B. Saun ders; 2003
3. Moore KL, Dalley AF. Clinically Orien ted An atom y, 5th ed. Balt im ore, MD: Lippin cot t
William s an d William s; 2006
4. Row lan d LP, ed. Merrit t’s Textbook of Neu rology, 9th ed. Balt im ore, MD: William s &
Wilkin s; 1995
5. Brun ton LL, Lazo JS, Parker KL, eds. Goodm an & Gilm an’s th e Ph arm acological Basis of Th era-
peu t ics, 11th ed . New York: McGraw -Hill; 2006
6. Citow JS, Macdon ald RL, Refai D, eds. Com preh ensive Neurosurger y Board Review.
New York: Th iem e Medical Publish ers; 2009
7. You m an s JR, ed-in -ch ief. Neurological Surger y, 4th ed. Ph iladelphia, PA: W.B. Saun ders; 1992
8. Quin on es-Hin ojosa A, ed. Schm idek & Sw eet Operat ive Neurosurgical Tech n iques, 6th ed.
Ph iladelph ia, PA: Elsevier; 2012

109
3A Neuroanatomy—Questions

For qu est ion s 1 to 4, m atch th e follow ing st ru ct u res w ith th e descript ion . Each resp on se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Dorsal longit u din al fasciculus
B. Lateral lem n iscu s
C. Medial lem n iscus
D. Medial longit udin al fasciculus

1. Con n ect ion of posterior colum n s to th alam us

2. Carries bers involved w ith eye m ovem en ts an d h as vest ibu lar input

3. A par t of th e auditor y path w ay

4. Con n ect s th e periven t ricular hypoth alam us an d m am m illar y bodies to th e m id -


brain’s cen t ral gray m at ter

5. St im ulat ion of cau dal regions of th e param edian pon t in e ret icular form at ion
(PPRF) produces
A. Conjugate h orizon t al deviat ion of th e eyes to th e op posite side
B. Conjugate h orizon tal deviat ion of th e eyes to th e sam e side
C. Deviat ion of on ly th e con t ralateral eye to th e sam e side
D. Deviat ion of on ly th e ipsilateral eye to th e opposite side
E. Deviat ion of on ly th e ipsilateral eye to th e sam e side

For quest ion s 6 to 9, m atch th e descript ion w ith th e eye m ovem en t s.


A. Conjugate h orizon t al deviat ion to th e op posite side
B. Conjugate h orizon tal deviat ion to th e sam e side
C. Vert ical eye m ovem en t s
D. Non e of th e above

6. St im ulat ion of th e caudal PPRF

7. St im ulat ion of th e rost ral PPRF

8. St im ulat ion of th e superior colliculus

9. St im ulat ion of th e m iddle fron t al gyrus

110
Neuroanatom y—Questions

10. W h ich of th e follow ing is t rue of th e occip it al eye eld?


A. It is localized to a relat ively sm all area.
B. It su bser ves pursuit eye m ovem en t s th at are largely volun tar y.
C. Lesion s in th is area are associated w ith t ran sien t deviat ion of th e eyes aw ay
from th e sid e of th e lesion .
D. Th e th resh old for excit at ion in th is area is low er th an in th e fron t al
eye elds.
E. With lesion s in th is area, th e pat ien t can direct th e eyes to a par t icular
locat ion on com m an d.
11. Th e in t racran ial dura is in n er vated by
I. Cran ial n er ve V
II. Up p er cer vical spin al n er ves
III. Cran ial n er ve X
IV. Cran ial n er ve VII
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above
12. Descen ding bers of th e m edial longit udin al fasciculus (MLF) arise from all of th e
follow ing st ru ct u res except th e
A. In ferior colliculus
B. Cajal’s in terst it ial n u cleus
C. Medial vest ibu lar n ucleus
D. Pon t in e ret icular form at ion
E. Superior colliculus
13. W h ich st ruct ure does not pass th rough th e orbit al ten din ous ring (Zin n’s an ulus)?
A. Fron t al n er ve
B. Superior division of III
C. Abducen s n er ve
D. Nasociliar y n er ve
E. In ferior division of III
14. All of th e follow ing can be seen in uln ar n er ve en t rapm en t at th e w rist except
A. Motor de cit s in th e adductor pollicis
B. Motor de cit s in th e deep h ead of th e exor pollicis brevis
C. Motor de cit s in th e th ird an d fourth lum bricals
D. Sen sor y de cit s in th e dorsum of th e h an d
E. Sen sor y de cit s in th e palm ar surface of th e hypoth en ar em in en ce
15. Th e thalam us is fed by (th e)
I. Medial p osterior ch oroidal arter y
II. An terior ch oroidal ar ter y
III. Basilar ar ter y bran ch es
IV. Middle cerebral ar ter y bran ch es
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

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Neurosurgery Board Review

16. Th e an terior ch oroidal arter y supplies por t ion s of each of th e follow ing st ruc-
t ures except th e
A. Am ygdala
B. Globu s pallidus
C. Hippocam pus
D. Hypoth alam us
E. In tern al capsule

For qu est ion s 17 to 21, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Cen t ral tegm en t al t ract
B. Lam in a term in alis
C. Medial forebrain bun dle
D. St ria m edu llaris
E. St ria term in alis

17. Con n ect s th e am ygdala to th e hypoth alam us

18. Th e closed rost ral en d of th e n eural t ube

19. Con n ect s th e gust ator y brain stem n u cleus to th e th alam us

20. Con n ect s th e septal area, hypoth alam us, olfactor y area, an d an terior th alam us to
th e h aben ula

21. Con n ect s th e septal area, hypoth alam us, olfactor y area, and h ippocam pus to th e
m id brain , pon s, an d m ed u lla

22. E eren t bers from th e den t ate n u clei


A. Are som atop ically arranged in th e th alam u s w ith th e h ead represen ted lat-
erally an d cau dal body p ar ts m edially
B. In uen ce act ivit y of m otor n euron s in th e con t ralateral cerebral cor tex
C. Leave th e cerebellum via th e m iddle cerebellar pedun cle
D. Main ly term in ate in th e red n u cleus
E. Project to th e ipsilateral ven t ral lateral th alam ic n uclei

23. Th e pulvin ar h as w ell-de n ed project ion s to th e


I. Occipit al cortex
II. Parietal cortex
III. Tem poral cortex
IV. Fron t al cortex
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

24. Each of th e follow ing is t rue of th e forn ix except


A. It is th e m ain e eren t ber system of th e h ippocam pus.
B. Postcom m issu ral bers of th e forn ix project to th e m am m illar y bodies.
C. Th e colum n s of th e forn ix lie an terior to th e an terior com m issu re.
D. Th e body of th e forn ix run s to th e rost ral m argin of th e th alam us.
E. Th e forn ical com m issure (psalterium ) is rost ral to th e an terior com m issure.

112
Neuroanatom y—Questions

25. Th e e eren t project ion s of th e arcu ate nu cleus are m ost closely associated
w ith th e
A. Mam m illar y bodies
B. Median em in en ce
C. Nucleus of th e diagon al ban d
D. Posterior hypophysis
E. Supraopt ic n ucleu s

26. Region s of th e st riate cortex th at do n ot con tain ocular dom in an ce colum n s are
th ose represen t ing th e
I. Fovea
II. Blin d spot of th e ret in a
III. Macu la
IV. Mon ocu lar tem p oral crescen t of th e visu al eld
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

27. Each of th e follow ing is t rue of th e supplem en tal m otor cor tex (MII) except
A. Som e of th e n eu ron s project directly to th e spin al cord.
B. Th e body is som atopically represen ted.
C. Th e n eu ron s in th is area exh ibit m ovem en t-related act ivit y on ly if th e m o-
tor t ask is perform ed w ith th e con t ralateral lim bs.
D. Th e th resh old for st im ulat ion is h igh er th an for th e prim ar y m otor
cor tex (MI).
E. Un ilateral ablat ion s produce n o perm an en t de cit in th e m ain ten an ce of
p ost u re or capacit y for m ovem en t .

28. Each of th e follow ing is t rue of dorsolateral bers en tering th e dorsolateral spin al
cord except
A. Root bers of spin al ganglia separate in to a m edial an d lateral bu n dle.
B. Th e cen t ral processes of each dorsal root ganglion divide in to both
ascen ding an d d escen ding bran ch es.
C. Th e lateral bun dle conveys im pulses from free n er ve en dings.
D. Th e m edial bun dle con sist s of th in ly m yelin ated or un m yelin ated bers,
w h ereas th e lateral bun dle is th ickly m yelin ated.
E. Th e m edial bun dle conveys im pulses from Golgi ten don organ s.

29. W h ich of th e follow ing does th e uln ar n er ve in n er vate?


I. Pron ator qu adrat u s
II. Flexor p ollicis longu s
III. Op pon en s pollicis
IV. Addu ctor p ollicis
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

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For qu est ion s 30 to 40, m atch th e th alam ic n u cleu s w ith th e cor t ical area(s) to w h ich it
p roject s. Each resp on se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Areas 1, 2, 3
B. Area 4
C. St riat um
D. Areas 5, 7
E. Area 17
F. Areas 18, 19
G. Areas 41, 42
H. Cingu late gyru s
I. Prefron tal cortex

30. An terior n uclear group

31. Lateral dorsal n u cleus

32. Lateral gen iculate n ucleus

33. Lateral posterior n u cleus

34. Medial gen iculate n ucleus

35. Mediodorsal n ucleu s

36. Pulvin ar

37. Cen t rom edian n ucleu s

38. Ven t ral lateral n ucleus

39. Ven t ral posterolateral n ucleus

40. Ven t ral posterom edial n ucleu s

For quest ion s 41 to 43, m atch th e descript ion w ith th e st ru ct u re.


A. Su p raopt icohypophysial t ract
B. Tuberoin fun dibular t ract
C. Both
D. Neith er

41. E eren t bers project to th e n eurohypophysis.

42. E eren t bers project to th e an terior pit uitar y.

43. E eren t bers project to th e hypophyseal port al vessels.

For qu est ion s 44 to 49, m atch th e follow ing st ru ct u res w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. An sa len t icularis
B. Fasciculus ret ro exu s
C. Len t icular fasciculus (FF H2)
D. Postcom m issural forn ix
E. Precom m issural forn ix
F. Th alam ic fasciculus (FF H1)

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Neuroanatom y—Questions

44. Con n ect s th e globu s pallidus in tern a to th e th alam us (t ravels arou n d th e in tern al
capsule)

45. Con n ect s th e globus pallidus in tern a to th e th alam us (t ravels th rough th e in ter-
n al cap su le)

46. Com bin at ion of th e an sa len t icularis, len t icular fasciculus, an d cerebelloth alam ic
t ract

47. Con n ect s th e h aben ula to th e m idbrain an d in terpedun cular n uclei

48. Con n ect s th e h ippocam pu s to th e sept al n uclei

49. Con n ect s th e h ippocam pus to th e hypoth alam us, m am m illar y bodies, an terior
th alam us, septal n uclei, an d cingulate gyrus

50. W h ich of th e follow ing st ruct ures is not p resen t on a t ran sverse sect ion of th e
m edu lla t aken at m idolive?
A. Accessor y cun eate n u cleu s
B. Dorsal n ucleus of X
C. Nucleus am biguus
D. Nucleus of th e solitar y t ract
E. Superior vest ibular n u cleus

51. W h ich of th e follow ing ber t ract s is not a p art of th e lim bic system ?
A. Diagon al ban d of Broca
B. Forn ix
C. Mam m illoth alam ic t ract
D. Medial forebrain bun dle
E. Th alam ic fasciculus

52. Th e secon dar y som at ic sen sor y area (SII) is located on th e


A. Medial surface of th e superior fron t al gyrus
B. Medial surface of th e su perior pariet al lobu le
C. Superior ban k of th e lateral sulcus
D. Ven t ral posterolateral n ucleus of th e th alam us
E. Sam e area as th e prim ar y som at ic sen sor y area

53. W h ich of th e follow ing is not seen w ith a lesion of th e facial n er ve im m ediately
distal to th e gen icu late ganglion ?
A. Hyp eracu sis
B. Im pairm en t of lacrim at ion
C. Im pairm en t of salivar y secret ion s
D. Loss of t aste in th e an terior t w o-th irds of th e tongu e
E. Paralysis of ipsilateral facial m uscles

54. Th e extern al ureth ral sph in cter is in n er vated by


A. Parasym path et ic pelvic n er ves
B. Som at ic puden dal n er ves
C. Sym path et ic hypogast ric n er ves
D. A an d B
E. B an d C

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55. Region s of th e brain devoid of a blood–brain barrier (circum ven t ricular organ s)
in clu de each of th e follow ing except
A. In du siu m griseum
B. Median em in en ce
C. Organ um vasculosum of th e lam in a term in alis
D. Pin eal glan d
E. Subforn ical organ

56. Uncrossed bers of the optic tract term inate on w hich layers of the lateral geniculate?
A. 1, 3, an d 5
B. 1, 4, an d 6
C. 2, 3, an d 5
D. 2, 4, an d 6
E. 2, 5, an d 6

57. Subst an ces can cross th e blood–brain barrier via


I. Act ive t ran sp ort
II. Carrier-m ed iated t ran sp or t
III. Di u sion
IV. Vesicu lar t ran sport
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

For qu est ion s 58 to 61, m atch th e follow ing st ru ct u res w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Arcu ate fascicu lus
B. Diagon al ban d of Broca
C. Tapet um
D. Un cin ate fasciculus

58. Con n ects sept al n uclei to th e am ygdala

59. Con n ects Wern icke’s area to Broca’s area

60. Con n ects tem poral an d occipital lobes

61. Con n ects th e tem poral lobe to th e fron t al lobe

For qu est ion s 62 to 67, m atch th e descript ion w ith th e st ru ct u re.


A. Paraven t ricular n ucleus
B. Supraopt ic n ucleus
C. Both
D. Neith er

62. Located in th e supraopt ic region

63. Located in th e t uberal region

64. Con sists of several dist in ct cell groups

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Neuroanatom y—Questions

65. Com posed m ain ly of un iform ly large cells

66. Im m un oh istocytoch em ically large cells in th is n ucleus con t ain eith er vasopres-
sin or oxytocin .

67. Region s of th is n ucleus give rise to descen ding a xon s project ing to th e brain stem
an d all levels of th e spin al cord.

68. Each of th e follow ing is t rue of cort icobulbar bers except


A. Fibers project ing to th e p osterior colu m n n u clei leave th e pyram ids an d
en ter th ese n u clei via th e m edial lem n iscu s or ret icu lar form at ion .
B. Fibers project ing to t rigem in al sen sor y n uclei an d th e n ucleus solitarius are
derived predom in an tly from fron topariet al cor t ical areas.
C. Pseudobulbar palsy can result from un ilateral lesion s involving cor t icobu l-
bar bers.
D. Th e supran uclear in n er vat ion of m otor cran ial n er ve n uclei is largely bilat -
eral.
E. Un ilateral lesion s involving cor t icobulbar bers produce paralysis of con -
t ralateral low er facial m uscles on ly.

69. Th e palm ar in terosseus m uscles


A. Abduct th e ngers
B. Addu ct th e ngers
C. Exten d th e m et acarpoph alangeal join ts an d ex th e in terph alangeal join ts
D. Flex th e m etacarpoph alangeal join ts an d exten d th e in terph alangeal join t s
E. Perform n on e of th e above

70. The sciatic nerve supplies each of the follow ing m uscles in part or in w hole except the
A. Adductor m agn us
B. Biceps fem oris (sh or t h ead)
C. Gluteus m axim us
D. Sem im em bran osus
E. Sem iten din osus

71. Th e syn drom e of posteroin ferior cerebellar arter y (PICA) occlu sion con sists of
each of th e follow ing except
A. Con t ralateral loss of pain an d tem perat ure in th e body
B. Con t ralateral loss of pain an d tem perat ure in th e face
C. Ipsilateral paralysis of th e ph ar yn x an d lar yn x
D. Ipsilateral Horn er’s syn drom e
E. Persisten t h iccup

For qu est ion s 72 to 77, m atch th e region of th e in tern al cap su le w ith th e descript ion .
Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. An terior lim b of th e in tern al capsule
B. Gen u of th e in tern al capsule
C. Posterior lim b of th e in tern al capsule
D. Non e of th e above

72. Locat ion of th e cor t icobu lbar bers

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73. Locat ion of cort icospin al bers

74. Locat ion of an terior th alam ic radiat ion

75. Locat ion of superior th alam ic radiat ion

76. Locat ion of m edial forebrain bun dle bers

77. Locat ion of cort icofugal bers

For quest ion s 78 to 85, m atch th e follow ing ganglia w ith th e descript ion . Each ch oice
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Ciliar y ganglion
B. Gasserian ganglion
C. Gen iculate ganglion
D. Ot ic ganglion
E. Scarpa’s ganglion
F. Sph en opalat in e ganglion
G. Spiral ganglion
H. Su bm an dibu lar ganglion

78. Auditor y system

79. Vest ibular system

80. Parot id glan d

81. Parasym path et ic to eye

82. Majorit y of facial sen sat ion

83. Taste

84. Lacrim at ion

85. Salivat ion (n onparot id)

86. Each of th e follow ing ch aracterizes a path w ay involved in th e pupillar y ligh t


re ex except
A. Crossed an d u n crossed bers of th e opt ic t ract term in ate on th e lateral
gen icu late body.
B. E eren t bers from th e pretectal olivar y n u cleus cross in th e posterior
com m issure an d en d in visceral cell colum n s of th e oculom otor n er ve
com plex.
C. E eren t bers from th e pretectal olivar y n u cleus cross ven t ral to th e
cerebral aqueduct an d en d in th e visceral cell colum n s of th e oculom otor
com plex.
D. Postganglion ic bers from th e ciliar y ganglion project to th e sph in cter of
th e iris.
E. Preganglion ic bers from th e n uclei of th e ocu lom otor com plex t ravel w ith
bers of th e th ird n er ve an d syn ap se in th e ciliar y ganglion .

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Neuroanatom y—Questions

87. Th e ch oroid plexus of th e fou rth ven t ricle can be fou n d


I. In th e cau dal aspect of th e roof (in ferior m edu llar y velu m )
II. In th e cran ial aspect of th e roof (su p erior m edu llar y velu m )
III. In th e lateral recess (of Lu sch ka)
IV. On th e oor
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above
88. Th e m edian n er ve in n er vates each of th e follow ing m uscles except th e
A. Adductor pollicis
B. Flexor carpi radialis
C. Oppon en s pollicis
D. Palm aris longus
E. Pron ator teres
89. A eren t sou rces of ber path w ays to th e sept al n uclei in clude th e
I. Am ygdala
II. Haben u lar n u clei
III. Hipp ocam pu s
IV. Basal ganglia
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above
90. Th e an terior ch oroidal ar ter y supplies part s of th e
I. Cau date n u cleu s
II. Opt ic t ract
III. Th alam u s
IV. An terior lim b of th e in tern al cap su le
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above
91. A lesion a ect ing th e left opt ic t ract w ill be m an ifested by a de cit in th e
A. Nasal h alf of th e visual eld of both eyes
B. Nasal h alf of th e righ t visual eld an d tem poral h alf of th e left visual eld
C. No de cit un less th e righ t opt ic t ract w as also a ected
D. Tem poral h alf of th e visual eld of both eyes
E. Tem poral h alf of th e righ t visual eld an d n asal h alf of th e left visual eld
92. W h ich of th e follow ing is not an a eren t con n ect ion of th e basal ganglia?
A. Cerebral cor tex to globus pallidus
B. Cerebral cor tex to put am en
C. Subst an t ia n igra to caudate n ucleus
D. Subthalam ic n ucleus to globus pallidu s
E. Th alam us to caudate n ucleus

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93. Most of th e bers of th e st ria term in alis origin ate from th e


A. Am ygdala
B. An terior hypoth alam us
C. Arcuate n ucleu s
D. Haben ula
E. Septal n uclei

For qu est ion s 94 to 96, m atch th e follow ing st ru ct u res w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Trapezoid body
B. Probst’s com m issure
C. In ferior collicular com m issure

94. Con n ects in ferior collicu li

95. Con n ects n u clei of lateral lem n iscu s

96. Con n ects ven t ral coch lear n u cleu s to su perior olive

For qu est ion s 97 to 103, m atch th e region of th e hypoth alam u s w ith th e descript ion .
Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. An terior hypoth alam us
B. Lateral hypoth alam u s
C. Posterior hypoth alam us
D. Ven t rom edial hypoth alam us

97. Bilateral lesion s h ere produ ce hyp erp h agia.

98. Bilateral lesion s h ere produ ce poikiloth erm ia.

99. Tu m ors in th is region can resu lt in hyper th erm ia.

100. Togeth er w ith th e lateral region , th is area con t rols sym path et ic resp on ses.

101. Lesion s h ere produce em ot ion al leth argy an d sleepin ess.

102. Th e feeding cen ter

103. Togeth er w ith th e m edial region , th is area con t rols parasym path et ic respon ses.

For qu est ion s 104 to 107, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Nodose ganglion
B. Jugular ganglion
C. Pet rosal ganglion
D. Superior ganglion of cran ial n er ve (CN) IX

104. Ear sen sat ion to CN IX

105. Ear sen sat ion to CN X

106. Carot id sin u s an d body inp ut

107. Visceral inp u t to CN X

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Neuroanatom y—Questions

108. Th e telen ceph alon gives rise to each of th e follow ing except th e
A. Am ygdala
B. Caudate
C. Claust rum
D. Globus pallidus
E. Put am en
109. Weakn ess of th e coracobrach ialis m u scle resu lt s from im p airm en t of th e
A. Axillar y n er ve
B. Dorsal scapular n er ve
C. Median n er ve
D. Muscu locut an eous n er ve
E. Suprascapular n er ve
110. Cells th at give rise to com m issu ral bers th at in tercon n ect h om ologou s cor t ical
areas via th e corp u s callosu m are fou n d in layer
A. I
B. II
C. III
D. IV
E. V
111. Neu ral crest derivat ives in clu de all of th e follow ing except th e
A. Adren al m edu lla
B. Dorsal root ganglion of cran ial an d spin al n er ves
C. Neuron s of th e cerebral cortex
D. Pigm en ted layers of th e ret in a
E. Sym path et ic ganglia of th e auton om ic n er vous system
112. W h ich of th e follow ing progression s from p rim ar y vesicle to secon dar y vesicle to
ad u lt derivat ive is correct?
A. Mesen ceph alon to rh om ben cep h alon to m edulla
B. Prosen ceph alon to dien ceph alon to m idbrain
C. Prosen ceph alon to telen ceph alon to th alam i
D. Rh om ben ceph alon to m eten ceph alon to cerebellu m
E. Rh om ben ceph alon to m yelen ceph alon to pon s
113. Major st riat al e eren t p roject ion s in clu de
A. Am ygdala an d globu s p allid us
B. Globu s pallidus an d su bst an t ia n igra
C. Substan t ia n igra an d am ygdala
D. Substan t ia n igra an d th alam us
E. Th alam us an d globus pallidus
114. Fibers from th e n u cleu s am bigu u s m ake con t ribu t ion to
I. Cran ial n er ve IX
II. Cran ial n er ve XI
III. Cran ial n er ve X
IV. Cran ial n er ve VII
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

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115. Fu n ct ion al com p on en t s of th e facial an d in term ed iate n er ves in clu de


I. Gen eral som at ic a eren t bers
II. Gen eral visceral a eren t bers
III. Special visceral a eren t bers
IV. Special visceral e eren t bers
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above
116. Th e in fu n dibu lar recess of th e th ird ven t ricle is located
A. Dorsal to th e m am m illar y bodies
B. Dorsal to th e h aben ula
C. Lateral to th e in fun dibulu m
D. Ven t ral to th e in fun dibulu m
E. Ven t ral to th e m am m illar y bodies
117. Lesion s of th e lateral lem n iscu s produ ce
A. Bilateral com plete deafn ess
B. Bilateral part ial deafn ess, greater in th e con t ralateral ear
C. Bilateral part ial deafn ess, greater in th e ipsilateral ear
D. Un ilateral, con t ralateral deafn ess
E. Un ilateral, ipsilateral deafn ess
118. Th e su perior orbital ssu re is t raversed by w h ich com bin at ion of cran ial n er ves?
A. III, IV, an d VI on ly
B. III, IV, VI, an d V1 on ly
C. III, IV, VI, V1, an d V2 on ly
D. II, III, IV, VI, V1, an d V2 on ly
E. II, III, IV, VI, an d V1 on ly

For qu est ion s 119 to 123, m atch th e n er ve w ith th e foram en or ssu re it t raverses. Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. In ferior orbit al ssure
B. Foram en m agn um
C. Foram en ovale
D. Superior orbit al ssure
E. Non e of th e above
119. Nasociliar y n er ve
120. Lacrim al n er ve
121. Maxillar y n er ve
122. Man dibu lar n er ve
123. Sp in al accessor y n er ve

For qu est ion s 124 to 126, m atch th e follow ing st ru ct u res w ith th e d escript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Puden dal n er ve
B. Splan ch n ic n er ve
C. Ner vi erigen tes

122
Neuroanatom y—Questions

124. Parasym p ath et ic

125. Sym p ath et ic

126. Som at ic

For qu est ion s 127 to 130, m atch th e st ru ct u re involved in au dit ion w ith th e descript ion .
Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Coch lear n ucleu s
B. In ferior colliculu s
C. Lateral lem n iscus
D. Medial gen iculate
E. Superior olivar y n ucleus

127. Fibers arising h ere are grou ped in to th ree acou st ic st riae.

128. Th e m ost p roxim al sou rce of ter t iar y au ditor y bers

129. Projects bers in to th e lateral lem n iscu s

130. Fibers from th is st ru ct u re p roject bilaterally to st ap ediu s m otor n eu ron s.

131. Th e bers of th e st ria m edu llaris of th e th alam u s arise in th e


I. Hyp oth alam u s
II. Lateral preopt ic region
III. Septal n u clei
IV. Am ygdala
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

132. Each of th e follow ing is t ru e of st riatal a eren t s except


A. Cells in th e cen t rom edian n ucleus project to th e caudate.
B. Cort icost riate project ion s use glutam ate as th eir t ran sm it ter.
C. Nigrost riat al bers arise from cells in th e pars com pacta.
D. Seroton ergic project ion s arise from th e dorsal n ucleu s of th e raph e.
E. Th alam ost riate bers arise largely from cells in th e cen t rom edian
p arafascicular n u cleu s

For qu est ion s 133 to 139, m atch th e t rigem in al n u cleu s w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Mesen ceph alic n u cleus
B. Motor n ucleus
C. Prin cipal sen sor y n ucleus
D. Spin al t rigem in al n ucleu s
E. Trigem inal ganglion

133. Con sist s of a p ars oralis, pars in terp olaris, an d p ars cau dalis

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134. Lesion s in th is st ru ct u re can resu lt in a loss of pain an d tem p erat u re sen se.

135. A eren t bers of th is n u cleu s convey p rop riocept ive in form at ion .

136. Secon d -order n eu ron s of th e ven t ral t rigem in oth alam ic t ract are fou n d in th e
p rin cipal sen sor y n ucleu s an d h ere.

137. Secon d -order n eu ron s of th e d orsal t rigem in oth alam ic t ract are fou n d h ere.

138. Th is n u cleu s an d th e m otor n u cleu s are involved in th e jaw jerk.

139. Cells h ere h ave large recept ive eld s an d resp on d to a w ide range of p ressu re
st im u li.

140. W h ich is t rue of den tate n u cleu s project ion s?


A. Th ey in directly p roject to th e ipsilateral cerebellar cor tex.
B. Th ey in directly project to th e ipsilateral prim ar y m otor cortex.
C. Th ey leave th e cerebellu m via th e m iddle cerebellar pedun cle.
D. Th ey project som atotopically on th e ven t ral an terior th alam ic n ucleus.
E. Th ey project to th e ipsilateral red n u cleus.

For qu est ion s 141 to 144, m atch th e follow ing n er ves w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Su p erior gluteal n er ve
B. In ferior gluteal n er ve
C. Sciat ic n er ve
D. Fem oral n er ve

141. Addu ctor m agn u s

142. Sartoriu s

143. Ten sor fascia lata

144. Glu teu s m axim u s

For qu est ion s 145 to 149, m atch th e com p on en t of th e brach ial p lexu s w ith th e descrip -
t ion . Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Lateral cord
B. Medial cord
C. Posterior cord
D. Radial ner ve
E. Uln ar n er ve

145. Th e n er ve th at su p plies th e teres m ajor origin ates h ere.

146. Th e m edial cu tan eou s n er ve of th e forearm origin ates h ere.

147. Th e axillar y n er ve is a bran ch of th is st ru ct u re.

148. Th e m u scu locu t an eou s n er ve is a bran ch of th is st ru ct u re.

149. Th e m id dle an d low er t ru n ks both con t ribu te to th is st ru ct u re.

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Neuroanatom y—Questions

150. Each of th e follow ing is t ru e of ber t racts leaving th e cerebellu m an d term in at-
ing in th e th alam u s except
A. Fibers term in ate on th e ven t ral lateral an d ven t ral posterolateral th alam ic
n u clei.
B. In th e th alam u s, th e ext rem it ies are represen ted dorsally an d th e back
ven t rally.
C. In th e th alam us, th e h ead is represen ted m edially an d th e cau dal th orax
laterally.
D. Som e bers project to th e rost ral in terlam in ar n uclei.
E. Th ese bers origin ate from both th e den tate an d th e in terposed n u clei.

151. All of th e follow ing su bcort ical n uclei are con sidered part of th e lim bic system
except th e
A. Am ygdala
B. Cen t rom edian n ucleus of th e th alam u s
C. Epith alam us
D. Hypoth alam us
E. Sept al n uclei

152. Cen t ral n er vou s system m elan ocytes are con cen t rated in th e
A. Ch oroid plexus
B. Red n uclei
C. Region of th e am ygdala
D. Sept um pellu cidu m
E. Ven t ral m edulla

153. A lesion in th e m edial lem n iscus produ ces


A. Con t ralateral loss of pain an d tem perat ure
B. Con t ralateral loss of posit ion an d vibrat ion
C. Ipsilateral loss of pain an d tem perat ure
D. Ipsilateral loss of posit ion an d vibrat ion
E. Loss of pain an d tem perat ure bilaterally

154. Each of th e follow ing is con sidered a par t of th e dien ceph alon except th e
A. Forn ix
B. Hypoth alam us
C. Mam m illar y bodies
D. Pin eal glan d
E. St ria m edullaris th alam i

For qu est ion s 155 to 162, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Ma xillar y bran ch of CN V
B. Nasopalat in e n er ve
C. Man dibular bran ch of CN V
D. Abducen s n er ve
E. Men t al n er ve
F. Middle m en ingeal arter y

155. In ferior orbit al ssu re

156. Su p erior orbital ssu re

125
Neurosurgery Board Review

157. Foram en sp in osu m

158. Foram en rot u n du m

159. Foram en ovale

160. Dorello’s can al

161. In cisive foram en

162. Men tal foram en

For qu est ion s 163 to 170, m atch th e vest ibu lar n u cleu s w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. In ferior vest ibular n ucleu s
B. In terst it ial n ucleus of th e vest ibular n er ve
C. Lateral vest ibular n ucleus
D. Medial vest ibular n ucleus
E. Superior vest ibular n u cleus

163. Th e largest of th e vest ibu lar n u clei

164. Cells of th e su p erior vest ibu lar ganglion , w h ich in n er vate th e u t ricu lar m acu le,
p roject to th is n u cleus.

165. Cells of th e in ferior vest ibu lar ganglion , w h ich in n er vate th e p osterior p ar t of th e
saccu lar m acu le, project to th is n u cleu s.

166. Gives rise to th e vest ibu lospin al t ract

167. Ascen ding bers from th is n u cleu s are p redom in an tly crossed an d project bilat-
erally to th e ext raocu lar n er ve n u clei.

168. Gives rise to th e u n crossed ascen ding bers in th e m edial longit u din al fascicu lu s
p roject ing to th e oculom otor an d t roch lear n u clei

169. Cells of th is n u cleu s lie am ong bers of th e vest ibu lar root .

170. Secon dar y vest ibu locerebellar p roject ion s arise from th e cau dal asp ect of th e in -
ferior vest ibu lar n u cleu s an d th is n u cleu s.

For qu est ion s 171 to 175, m atch th e t rigem in al n u cleu s w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Mesen ceph alic n u cleu s
B. Motor n ucleus
C. Prin cipal sen sor y n ucleus
D. Spin al t rigem in al n ucleu s
E. Trigem inal ganglion

171. Th e m ost rost ral of th e n u clei

172. Exten ds th e m ost cau dally

173. A eren t bers of th is n u cleu s convey p ressu re an d kin esth et ic sen se from
th e teeth .

174. Cen t ral p rocesses from th e t rigem in al ganglion cells ascen d to th is n u cleu s.

126
Neuroanatom y—Questions

175. Cen t ral p rocesses from th e t rigem in al ganglion cells descen d to th is n u cleu s.

176. Th e solitar y t ract is form ed from bers of cran ial n er ve(s)


I. IX
II. X
III. VII
IV. XII
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

177. A fem oral n er ve inju r y resu lt s in w eakn ess of


A. Hip exten sion
B. Hip exion
C. Kn ee exion
D. Th igh abduct ion
E. Th igh adduct ion

178. Th e p ars t u beralis is a p ar t of th e


A. An terior lobe of th e pit uitar y
B. Diaph ragm a sellae
C. In term ediate lobe of th e pit uit ar y
D. Pit uit ar y stalk
E. Posterior lobe of th e pit uitar y

179. The dentate n uclei project to each of the follow ing, directly or in directly, except the
A. Cerebellar cor tex
B. In ferior olive
C. Red n ucleus
D. Ret icu lotegm en t al n ucleu s
E. Subth alam ic n ucleus

180. Fibers in th e su p erior cerebellar p ed u n cle syn apse in w h ich of th e follow ing th a-
lam ic n u clei?
I. Ven t ral an terior
II. Ven t ral lateral
III. Rost ral in terlam in ar n u clei
IV. Ven t ral lateral p osterior (VLp )
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

181. Th e lim bic lobe is com posed of all th e follow ing except th e
A. Am ygdala
B. Cingulate gyrus
C. Den tate gyrus
D. Parah ippocam pal gyrus
E. Subcallosal gyrus

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Neurosurgery Board Review

182. Th e m ost sign i can t con t ribu t ion to th e n asal sept u m is m ade by th e
A. Eth m oid and fron tal bon es
B. Eth m oid an d sph en oid bon es
C. Eth m oid an d vom er bon es
D. Fron tal an d vom er bon es
E. Sph en oid an d vom er bon es

183. Th e p osterior in terosseu s n er ve in n er vates th e


A. Abd u ctor p ollicis brevis
B. Abdu ctor pollicis longus
C. Addu ctor pollicis
D. Flexor pollicis longus
E. Oppon en s pollicis

184. Th e in tern al cerebral vein receives each of th e follow ing vein s except th e
A. Ch oroidal vein
B. Epith alam ic vein
C. Great cerebral vein of Galen
D. Sept al vein
E. Th alam ost riate vein

185. Th e st riate cor tex corresp on d s to area


A. 17
B. 18
C. 19
D. 41
E. 42

186. Th e in tern al cap su le is su p p lied by bran ch es of th e


I. Middle cerebral arter y
II. An terior cerebral arter y
III. In tern al carot id ar ter y
IV. Posterior cerebral arter y
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

For qu est ion s 187 to 191, m atch th e associat ion or com m issu ral ber bu n dle w ith th e
descript ion . Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. An terior com m issure
B. Arcuate fasciculus
C. Cingulate fasciculus
D. Corpus callosum
E. Un cin ate fasciculu s

187. Con n ects th e orbit al fron tal gyri w ith an terior p art s of th e tem poral lobe

188. Con n ects th e m edial fron t al an d p ariet al lobes w ith th e p arah ip pocam pal region

128
Neuroanatom y—Questions

189. Con n ect s th e su p erior an d m iddle fron tal gyri to th e tem p oral lobe

190. Th e t ap et u m is derived from th ese bers.

191. In tercon n ects region s of th e m iddle an d in ferior tem p oral gyri bet w een h em i-
sp h eres

For qu est ion s 192 to 194, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Rest iform body
B. Ju xt arest iform body
C. Brach ium conjun ct ivum
D. Brach ium pon t is

192. Su p erior cerebellar p ed u n cle

193. Mid dle cerebellar pedu n cle

194. Port ion of th e in ferior cerebellar pedu n cle con tain ing on ly a eren t bers from
th e in ferior olive an d pon s

195. A discrete u n ilateral lesion of th e abdu cen s n u cleu s p rodu ces p aralysis of m ove-
m en t of
A. Both eyes aw ay from th e lesion
B. Both eyes tow ard th e lesion
C. Th e con t ralateral eye tow ard th e lesion
D. Th e ipsilateral eye aw ay from th e lesion
E. Th e ipsilateral eye tow ard th e lesion

196. Postganglion ic p arasym path et ic bers d est in ed for th e lacrim al glan d are d e-
rived from th e
A. Gen icu late ganglion
B. Ot ic ganglion
C. Pter ygopalat in e ganglion
D. Sublingual ganglion
E. Subm an dibular ganglion

197. Fibers origin at ing in th e su bst an t ia n igra syn ap se on each of th e follow ing st ru c-
t ures except th e
A. Cau date
B. Globu s pallidus
C. Put am en
D. Superior colliculus
E. Th alam us

198. Th e blood–brain barrier is form ed by (th e)


A. Ast rocyt ic foot processes
B. Basem en t m em bran e
C. Epen dym al lin ing cells
D. Microglia
E. Tigh t jun ct ion s of th e capillar y en doth eliu m

129
Neurosurgery Board Review

199. W h ich of th e follow ing ligam en ts is a con t in u at ion of th e p osterior longit u din al
ligam en t?
A. An terior atlan to-occipit al m em bran e
B. Apical ligam en t
C. Cruciate ligam en t
D. Tectorial ligam en t
E. Tran sverse ligam en t

For quest ion s 200 to 204, m atch th e p ercen t age of cort icosp in al bers w ith th e descrip -
t ion . Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. 3%
B. 30%
C. 40%
D. 60%
E. 90%

200. Bet z cells accou n t for th is prop or t ion of th e cort icosp in al bers.

201. Th e ap p roxim ate p ercen t age of cort icosp in al bers arising from area 4

202. Th e ap p roxim ate p ercen t age of cort icosp in al bers arising from area 6

203. Th e ap p roxim ate p ercen tage of cort icosp in al bers arising from th e p ariet al lobe

204. Th e ap p roxim ate p ercen t age of cort icosp in al bers th at are p oorly m yelin ated

205. Th e facial n er ve in n er vates all of th e follow ing m u scles except th e


A. An terior belly of th e digast ric
B. Bu ccin ator
C. Plat ysm a
D. St apediu s
E. St ylohyoid

206. Th e n u cleu s pu lposu s of th e in ter ver tebral disk is form ed from th e


A. Ch on dri cat ion of th e cen t rum of th e ver tebral body
B. Myotom e
C. Notoch ord
D. Prim it ive st reak
E. Sclerotom e

207. Th e p rim ar y olfactor y cor tex is located in th e


A. An terior perforated subst an ce
B. En torh in al cortex
C. Mediodorsal n ucleu s of th e th alam us
D. Orbitofron t al cor tex
E. Pyriform cortex

208. Each of th e follow ing cell grou p s is derived from th e alar plate except th e
A. Nu cleu s am bigu us
B. Prin cipal sen sor y n ucleus of CN V
C. Solitar y n u cleus
D. Spin al t rigem in al n ucleu s
E. Vest ibular n ucleus

130
Neuroanatom y—Questions

209. A u n ilateral lesion of th e t roch lear n er ve p rod u ces m axim al d ip lopia on


A. Dow ngaze to th e op posite side
B. Dow ngaze to th e sam e side
C. Upgaze to th e opposite side
D. Upgaze to th e sam e side
E. Lateral gaze to th e opposite side

For qu est ion s 210 an d 211, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Sup erior olive
B. In ferior olivar y com plex
C. Both
D. Neith er

210. Par t of th e au d itor y system

211. Par t of th e cerebellar system

For qu est ion s 212 to 216, m atch th e follow ing st ru ct u res w ith th e descript ion .
A. Sup erior salivator y n u cleu s
B. In ferior salivator y n ucleu s
C. Both
D. Neith er

212. Gen eral visceral e eren t bers arise h ere.

213. Preganglion ic parasym p ath et ic bers from th is n u cleu s t ravel w ith th e in term e-
diate n er ve.

214. Preganglion ic p arasym p ath et ic bers from th is n u cleu s t ravel w ith th e lesser
p et rosal n er ve.

215. Located in th e ret icu lar form at ion

216. Fibers origin at ing h ere even t u ally divid e in to t w o grou p s th at p ass to th e pter y-
gopalat in e an d su bm an dibu lar ganglia, respect ively.

For qu est ion s 217 an d 218, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Parasym path et ic
B. Sym path et ic
C. Both

217. Sh ort ciliar y n er ves

218. Long ciliar y n er ves

For qu est ion s 219 to 225, m atch th e ascen d ing sp in al t ract w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. An terior sp in oth alam ic t ract
B. Cun eocerebellar t ract
C. Dorsal spin ocerebellar t ract
D. Lateral spin oth alam ic t ract
E. Ven t ral spin ocerebellar t ract

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Neurosurgery Board Review

219. Arises from th e dorsal n u cleu s of Clarke

220. Th e u p per lim b equ ivalen t of th e dorsal spin ocerebellar t ract

221. Tran sm it s ligh t tou ch

222. Crossed; cells of origin receive inp u t from grou p Ib a eren ts

223. Crossed w ith in on e or t w o sp in al segm en t s; cells in lam in ae I, IV, an d V give rise


to m ost of th e axon s in th is t ract

224. En ters th e cerebellu m via th e su p erior cerebellar p edu n cle

225. First-order n eu ron s are fou n d from L1 to S2.

For qu est ion s 226 to 230, m atch th e descen ding sp in al t ract w ith th e d escript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Cort icosp in al t ract
B. Ret iculospin al t ract
C. Rubrospin al t ract
D. Tectospin al t ract
E. Vest ibulospin al t ract

226. Th e m ajorit y of bers d escen d on ly to cer vical levels.

227. Cells of origin reside in th e p on t in e tegm en t u m an d m edu lla.

228. Divides in to th ree t racts at th e spin om edu llar y ju n ct ion

229. Associated w ith th e con t rol of ton e in exor m u scle grou ps

230. Associated w ith th e con t rol of ton e in exten sor m u scle grou ps

For qu est ion s 231 to 240, m atch th e p eriph eral n er ve w ith th e m u scle it in n er vates.
Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Deep p eron eal E. Sciat ic
B. Fem oral F. Super cial peron eal
C. In ferior gluteal G. Superior gluteal
D. Obt urator H. Tibial

231. Addu ctor brevis

232. Bicep s fem oris

233. Exten sor h allu cis longu s

234. Glu teu s m ediu s

235. Glu teu s m axim u s

236. Gast rocn em iu s

237. Iliop soas

238. Flexor digitoru m longu s

239. Peron eu s longu s an d brevis

240. Qu adriceps

132
Neuroanatom y—Questions

241. Movem en t of m olecu les across th e blood–brain barrier involves


A. Act ive t ran sp ort requiring en ergy
B. Carrier-m ediated t ran sport
C. Both
D. Neith er

242. W h ich of th e follow ing m ost closely ch aracterizes th e t u berohyp op hysial t ract?
A. Arcu ate n ucleu s to m edian em in en ce
B. Arcuate n ucleus to posterior hypophysis
C. Dorsom edial n ucleus to posterior hypophysis
D. Supraopt ic n ucleu s to m edian em in en ce
E. Supraopt ic n ucleu s to posterior hypophysis

For qu est ion s 243 to 250, m atch th e follow ing st ru ct u res w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Apical ligam en t
B. Alar ligam en ts
C. Den t ate ligam en ts
D. Tectorial m em bran e
E. Superior cru ciate ligam en t s
F. In ferior cru ciate ligam en ts
G. An terior atlan to-occipital m em bran e
H. Tran sverse ligam en t

243. Den s to basion

244. Den s to lateral foram en m agn u m

245. Pia to du ra

246. Con t in u ou s w ith p osterior longit u din al ligam en t

247. Con t in u ou s w ith an terior longit u din al ligam en t

248. Bet w een C1 lateral m asses

249. Tran sverse ligam en t to basion

250. Tran sverse ligam en t to axis

251. W h ich hyp oth alam ic n u cleu s is th e p rin cip le sou rce of hyp oth alam ic d escen ding
bers resp on sible for au ton om ic con t rol?
A. Mam m illar y n ucleu s
B. Medial preopt ic n u cleus
C. Paraven t ricular n ucleus
D. Periven t ricular n ucleus
E. Supraopt ic n ucleu s

252. All of th e follow ing t arget s of descen ding hypoth alam ic au ton om ic bers part ici-
p ate in parasym path et ic con t rol except
A. Dorsal m otor n ucleu s of the vagus
B. Edinger-West ph al n u cleus
C. S2-S4 n ucleu s
D. Superior an d in ferior salivator y n u clei
E. T1-L2 of th e spin al cord

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Neurosurgery Board Review

For quest ion s 253 to 259, m atch th e follow ing st ru ct u res to th e app rop riate an sw er
ch oice.
A. Sym p ath et ic system
B. Parasym path et ic system
C. Both
D. Neith er

253. An terior an d m edial hypoth alam u s

254. Dorsal m otor n u cleu s of th e vagu s

255. Edinger-West p h al n u cleu s

256. Posterior an d lateral hyp oth alam u s

257. Preganglion ic n eu ron s from T1-L2 of th e spin al cord

258. S2-S4 parasym p ath et ic n u cleu s

259. Su p erior an d in ferior salivator y n u clei

260. W h ich of th e follow ing an sw er ch oices best describes th e decu ssat ion of th e dor-
sal colu m n –m edial lem n iscal system ?
A. Secon d -order n eu ron s as th e an terior w h ite com m issure
B. Secon d-order n eu ron s as th e in tern al arcuate bers
C. Second-order n euron s as th e lateral lem n iscus
D. Second-order n euron s as th e m edial lem n iscu s
E. Second-order n euron s as th e pyram idal decussat ion

261. Melan ocytes are m ost often fou n d in w h ich of th e follow ing an atom ical locat ion s?
A. Basal forebrain
B. Leptom en inges of th e cerebral convexit ies
C. Leptom en inges of th e ven t ral m edu lla
D. Substan t ia n igra
E. Non e of th e above

262. All of th e follow ing feat u res are associated w ith inju r y to th e n on dom in an t h em i-
sp h ere except
A. An osogn osia
B. Con t ralateral h em in eglect
C. Disorien t at ion to t im e an d direct ion
D. Global aph asia
E. Visuospat ial de cit s

263. W h ich of th e follow ing st atem en t s is t rue regard ing th e an terolateral system ?
A. First-order bers decu ssate in th e an terior w h ite com m issure of th e spin al
cord.
B. Project ion s of rst-order n euron s form Lissauer’s t ract (dorsolateral
fascicu lu s).
C. Secon d-order in tern euron s project to Clarke’s colum n conveying pain an d
tem perat ure sen sat ion .
D. Th in ly m yelin ated C bers are fast con duct ing bers.
E. Un m yelin ated A-delta bers are slow con duct ing bers.

134
Neuroanatom y—Questions

264. Propriocept ion from th e low er ext rem it ies is m ed iated by


A. Dorsal colu m n –m edial lem n iscal system
B. Clarke’s colum n an d dorsal spin ocerebellar t ract
C. Nucleus cun eat us an d cu n eocerebellar t ract
D. Nucleus gracilis an d dorsal spin ocerebellar t ract
E. Nucleus of Clarke h om ologue an d rost ral spin ocerebellar t ract

265. All of th e follow ing statem en t s regarding th e m am m illoth alam ic t ract are t ru e
except th at it
A. Is also kn ow n as th e t ract of Vicq d’Azyr
B. Is a part of th e proposed Papez circuit
C. Is a th in bun dle of un m yelin ated bers
D. Projects from th e m am m illar y body to th e an terior n uclear group of th e
th alam us
E. Ser ves as a lan dm ark for deep brain st im u lat ion im plan t at ion

266. The m em brane of Liliequist separates w hich of the follow ing subarachnoid cisterns?
A. Am bien t cistern an d cru ral cistern
B. Am bien t cistern an d quadrigem in al cistern
C. In terpedun cular an d ch iasm at ic cistern
D. In terpedun cular an d prepon t in e cistern
E. Lam in a term in alis cistern an d in terpedun cular cistern

For qu est ion s 267 to 271, m atch th e p air of st ru ct u res w ith th e st ru ct u re th at sepa-
rates th em .
A. Ch oroid ssure
B. Foram en of Lu sch ka
C. Foram en of Magen die
D. Lam in a term in alis
E. Velum in terposit um

267. Lam in a term in alis cistern an d th ird ven t ricle

268. Cru ral cistern an d tem poral h orn of lateral ven t ricle

269. Velu m in terp osit u m cistern an d th ird ven t ricle

270. Lateral recess of fou r th ven t ricle an d lateral cerebellom edu llar y cistern

271. Fou r th ven t ricle an d cistern a m agn a

135
3B Neuroanatomy—
Answ er Key

1. C 27. C
2. D 28. D
3. B 29. D
4. A 30. H
5. B 31. H
6. B 32. E
7. C 33. D
8. A 34. G
9. A 35. I
10. E 36. F
11. A 37. C
12. A 38. B
13. A 39. A
14. D 40. A
15. A 41. A
16. D 42. D
17. E 43. B
18. B 44. A
19. A 45. C
20. D 46. F
21. C 47. B
22. B 48. E
23. A 49. D
24. C 50. E
25. B 51. E
26. C 52. C

136
Neuroanatom y—Answer Key

53. B 92. A
54. B 93. A
55. A 94. C
56. C 95. B
57. A 96. A
58. B 97. D
59. A 98. C
60. C 99. A
61. D 100. C
62. C 101. C
63. D 102. B
64. A 103. A
65. B 104. D
66. C 105. B
67. A 106. C
68. C 107. A
69. B 108. D
70. C 109. D
71. B 110. C
72. B 111. C
73. C 112. D
74. A 113. B
75. C 114. A
76. D 115. E
77. C 116. E
78. G 117. B
79. E 118. B
80. D 119. D
81. A 120. D
82. B 121. A
83. C 122. C
84. F 123. B
85. H 124. C
86. A 125. B
87. B 126. A
88. A 127. A
89. A 128. E
90. A 129. E
91. E 130. E

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Neurosurgery Board Review

131. A 170. D
132. A 171. A
133. D 172. D
134. D 173. A
135. A 174. C
136. D 175. D
137. C 176. A
138. A 177. B
139. C 178. A
140. A 179. E
141. C 180. C
142. D 181. A
143. A 182. C
144. B 183. B
145. C 184. C
146. B 185. A
147. C 186. A
148. A 187. E
149. C 188. C
150. B 189. B
151. B 190. D
152. E 191. A
153. B 192. C
154. A 193. D
155. A 194. A
156. D 195. B
157. F 196. C
158. A 197. B
159. C 198. E
160. D 199. D
161. B 200. A
162. E 201. B
163. D 202. B
164. C 203. C
165. A 204. C
166. C 205. A
167. D 206. C
168. E 207. E
169. B 208. A

138
Neuroanatom y—Answer Key

209. A 241. C
210. A 242. A
211. B 243. A
212. C 244. B
213. A 245. C
214. B 246. D
215. C 247. G
216. A 248. H
217. C 249. E
218. B 250. F
219. C 251. C
220. B 252. E
221. A 253. B
222. E 254. B
223. D 255. B
224. E 256. A
225. E 257. A
226. D 258. B
227. B 259. B
228. A 260. B
229. C 261. C
230. E 262. D
231. D 263. B
232. E 264. B
233. A 265. C
234. G 266. C
235. C 267. D
236. H 268. A
237. B 269. E
238. H 270. B
239. F 271. C
240. B

139
3C Neuroanatomy—Answ ers
and Explanations

1. C – Medial lem n iscu s


2. D – Medial longit u d in al fascicu lu s
3. B – Lateral lem n iscu s
4. A – Dorsal longit u din al fasciculus

Th e do rsal lo ngitudinal fasciculus (A), or dorsolateral fascicu lu s, carries -


bers from th e hypoth alam us to th e auton om ic n uclei an d ret icular form at ion
of th e brain stem ’s cen t ral gray m at ter to in uen ce act ivit ies such as ch ew -
ing, sw allow ing, an d sh ivering. Th e lateral le m niscus (B) is par t of th e audi-
tor y path w ay, carr ying secon d-order bers arising from th e coch lear n ucleus
that ascen d to th e in ferior colliculus. Th e m edial lem niscus (C) con n ect s th e
secon d-order n eu ron s of n u cleu s gracilis an d cu n eat u s (dorsal colu m n s) to
the ven t ral posterior lateral n ucleus of th e th alam us. Th e m e dial lo ngitudi-
nal fasciculus (D) carries p roject ion s from th e su perior collicu lu s to th e ocu -
lom otor, t roch lear, an d abducen s n u clei an d con t ributes to re ex m ovem en t s
of th e eyes in respon se to visual, auditor y, an d som at ic st im uli.1

5. B – Conjugate h orizon t al deviat ion to th e sam e side

Th e param edian pon t in e ret icular form at ion (PPRF) m ediates h orizon t al eye
m ovem en t s in resp on se to h ead m ovem en t . St im u lat ion of th e cau dal PPRF
cau ses co njugate ho rizo ntal deviation o f the eyes to the sam e side (B).1,2

6. B – Conjugate h orizon t al deviat ion to th e sam e side


7. C – Vert ical eye m ovem en t s
8. A – Conjugate h orizon t al deviat ion to th e opposite side

140
Neuroanatom y—Answers and Explanations

9. A – Conjugate h orizon t al deviat ion to th e opposite side

Th e cen ter for h orizon t al gaze (th e abdu cen s n ucleus) an d th e cen ter for ver-
t ical gaze (th e rost ral in terst it ial n ucleus of th e m edial longit udin al fascicu-
lu s [RiMLF]) are join ed physiologically by th e param edian pon t in e ret icular
form at ion (PPRF), w h ich lies rost ral to th e abdu cen s n u cleu s. St im u lat ion of
the caudal an d rost ral PPRF produces co njugate horizontal eye deviatio n (B)
an d vertical eye m ovem ents (C), resp ect ively. Fibers from th e cau dal PPRF
project to th e ipsilateral abducen s n ucleus, an d bers from th e rost ral PPRF
project u ncrossed bers to th e RiMLF, w h ich in t u rn project s to th e ipsilateral
oculom otor n uclear com plex. Lesion s of th e caudal PPRF m ay cause paralysis
of h orizon t al eye m ovem en t s, w h ereas lesion s of th e rost ral PPRF can cause
paralysis of ver t ical eye m ovem en ts. Exten sive lesion s m ay a ect both t ypes
of eye m ovem en ts. St im ulat ion of th e fron t al eye eld, located in th e caudal
part of th e m iddle fron t al gyrus, usually result s in co njugate deviation o f the
eyes to the o ppo site side (A). St im u lat ion of th e su p erior collicu lu s resu lt s in
co ntralate ral co njugate deviatio n o f the eyes (A).1,2

10. E – With lesion s of th is area, th e pat ien t can direct th e eyes to a part icular locat ion
on com m an d.

Th e occipital eye elds are n ot as w ell de n ed as th e fron t al eye elds an d


con t ribute to sm ooth pu rsuit m ovem en t s w h en t racking object s. With lesion s
of th e occipit al eye elds, w h ich are located n ear th e jun ct ion of th e occipit al
lobes w ith th e posterior tem p oral an d p ariet al lobes, th e pat ien t can dire ct
the eyes to a particular lo catio n on co m m and (E).2

11. A – I, II, III (cran ial n er ve V, upper cer vical spin al n er ves, an d cran ial n er ve X)

Th e supraten torial du ra is in n er vated by CN V. V1 su p p lies th e an terior


cran ial fossa, V2 su pplies th e m iddle fossa, an d V3 supplies th e supraten torial
p osterior fossa. Th e in fraten torial du ra is in n er vated by th e upper cervical
ro ots (C2, C3) an d CN X.3

12. A – In ferior colliculus (false)

Th e MLF carries bers arising from Cajal’s interstitial nucle us (B), th e m edial
vestibular nucleus (C), th e param edian po ntine reticular fo rm atio n (D), as
w ell as th e superio r co lliculus (E). Project ion s from th e infe rio r co lliculus
(A) do n ot con t ribu te th e MLF.1,2

13. A – Fron t al n er ve

Th e an n u lar ten don of Zin n divides th e superior orbit al ssure (SOF) in to


lateral, cen t ral, an d in ferior segm en ts. Th e lateral sector con tain s th e t roch -
lear, fro ntal (A), an d lacrim al n er ves, w h ich all p ass ou tsid e th e an n u lar ten-
don of Zin n . The superior oph th alm ic vein also passes in ferior to th e n er ves
in th is p ort ion of th e ssu re to reach th e cavern ous sin u s. Th e cen t ral p ort ion
of th e SOF (oculom otor foram en ) con t ain s th e o culo m o to r ne rve (B and E),
naso ciliary ne rve (D), abduce ns nerve (C), an d root s of th e ciliar y ganglion —
all of w h ich pass th rough th e an n u lu s of Zin n . Th e opt ic n er ve an d op h th al-
m ic ar ter y cou rse m edially to th e ocu lom otor foram en th rough p ar t of th e
an n u lar ten don th at is at tach ed to th e opt ic foram en .4

141
Neurosurgery Board Review

14. D – Sen sor y de cit s in th e dorsu m of th e h an d

The sensory branch to the dorsum of the hand leaves the ulnar ner ve in the
forearm and is n ever involved in uln ar nerve entrapm ent at the w rist. The su-
per cial head of the abductor pollicis brevis is inner vated by the m edian ner ve.5

15. A – I, II, III (m edial posterior ch oroidal ar ter y, an terior ch oroidal arter y, an d
basilar ar ter y bran ch es)

Th e th alam us is also fed by th alam operforators arising from th e posterior


com m un icat ion (PCom m ) arteries. Th ere is gen erally n o con t ribut ion to th a-
lam ic blood su pply by th e m idd le cerebral arter y or its bran ch es.3

16. D – Hyp oth alam u s (false)

Th e an terior ch oroidal ar ter y is a bran ch of th e in tern al carot id ar ter y th at


arises 2–4 m m d ist al to th e PCom m arter y. It cou rses p osterom edially to su p -
p ly several st ruct u res in cluding th e am ygdala (A), hippo cam pus (C), inter-
nal capsule (E), an d globus pallidus (B). Th e an terior ch oroidal ar ter y does
n ot p rovide blood su p ply to th e hypothalam us (D), w h ich is su p plied by p er-
forators arising from th e an terior cerebral arter y an d an terior com m u n icat ing
(ACom m ) arteries.3

17. E – St ria term in alis


18. B – Lam in a term in alis
19. A – Cen t ral tegm en t al t ract
20. D – St ria m edu llaris
21. C – Medial forebrain bun dle

Th e central tegm ental tract (A) con n ect s th e gu stator y brain stem n ucleu s
(rost ral n u cleus solitariu s) to th e th alam us. Th e m e dial fo rebrain bundle (C)
is a bidirect ion al path w ay bet w een th e hyp oth alam us/sept al area an d th e
m id brain , p on s, an d m edu lla th at is th ough t to be involved in m ot ivat ion an d
sen se of sm ell. Th e stria m e dullaris thalam i (D) con n ects th e hyp oth alam u s,
septal area, an d olfactor y area to th e h aben u la. Th e bers of th e stria
term inalis (E) p roject from th e am ygdala to th e hyp oth alam u s. Th e lam ina
term inalis (B) rep resen ts th e rost ral bou n dar y of th e n eu ral t u be.1,3

22. B – In u en ce act ivit y of m otor n eu ron s in th e con t ralateral cerebral cor tex

Th e bulk of th e bers from th e den t ate n ucleu s pass aroun d th e red n ucleus
an d project to th e con t ralateral th alam u s via th e su perior cerebellar p edu n -
cle, w h ereas th e bu lk of bers from th e in terposed n uclei project to th e caudal
t w o th irds of th e red n u cleus. In th e th alam ic n u clei, th e h ead is represen ted
m edially an d th e cau dal p ar ts of th e body laterally.1

23. A – I, II, III (occipit al, pariet al, an d tem poral cor tex)

Th e pulvin ar of th e th alam us is involved in th e in tegrat ion of visu al, auditor y,


an d som atosen sor y in form at ion . For th is reason , it n ecessarily sh ares projec-
t ion s w ith th e associat ion areas of th e occipital, parietal, an d tem poral lobes.
Th ey in clude project ion s to th e occipit al cortex (areas 17, 18, an d 19), th e
in ferior p ariet al lobu le (areas 39 an d 40), an d th e superior tem poral gyru s.1,2

142
Neuroanatom y—Answers and Explanations

24. C – Th e colum n s of th e forn ix lie an terior to th e an terior com m issure (false)

Th e forn ix is th e m ain e erent pathw ay fro m the hippo cam pal


fo rm atio n (A). At th e level of th e an terior com m issu re, th e forn ix is divid-
ed in to a precom m issu ral an d postcom m issu ral p ar t , w h ich lie an terior an d
p osterior to th e an terior com m issure, respect ively (C is false). Th e p recom -
m issu ral bers arise p rim arily from th e pyram idal cells of th e h ip p ocam p u s
an d project to th e sept al area an d basal forebrain w h ile th e po stco m m issural
bers arise fro m the subiculum and project prim arily to the m am m illary
bo dies (B). Th e bo dy o f the fo rnix runs to the ro stral m argin o f the thala-
m us (D); th e crura of th e forn ix m eet in th e m idlin e at th e fo rniceal co m -
m issure (psalte rium ), w hich is ro stral to the ante rior com m issure (E).1,2

25. B – Median em in en ce

Th e e eren t project ion s of th e arcuate n ucleu s h ave been t raced to th e ex-


tern al layer of th e m edian em in en ce. Ch em ical subst an ces from th e arcu ate
n u cleu s (in clu ding dopam in e) p lay a m ajor role in th e regu lat ion of h orm on al
out put from th e an terior pit uitar y.2

26. C – II, IV (blin d spot of th e ret in a an d m on ocu lar tem poral crescen t)

Th e blin d spot of th e ret in a an d th e m on ocular tem poral crescen t , both receiv-


ing on ly m on ocu lar visu al inpu t , do n ot con t ain ocular dom in an ce colu m n s.2

27. C – Th e n eurons in th is area exh ibit m ovem en t-related act ivit y on ly if th e m otor
t ask is perform ed w ith th e con t ralateral lim bs (false)

Motor t asks p erform ed w ith eith er th e ip silateral or th e con t ralateral lim bs


can elicit m ovem en t-related act ivit y in th e supplem en t ar y area (C is false).
Th e oth er respon ses are correct: so m e ne uro ns o f the SMA project directly
to the spinal co rd (A), the bo dy is so m ato pically represented (B), the
thresho ld fo r stim ulatio n is highe r than fo r prim ary m oto r co rtex (D), an d
unilateral ablatio ns pro duce no perm anent de cit in the m aintenance o f
po sture o r capacity fo r m ovem ent (E).2

28. D – Th e m edial bu n dle con sists of th in ly m yelin ated bers or u n m yelin ated bers,
w h ereas th e lateral bun dle is th ickly m yelin ated (false)

Th e do rsal ro ots se parate into a lateral and m e dial bundle (A). Th e m ed ial
bu n dle of dorsal root a eren ts en tering th e dorsolateral spin al cord con sist s
of large m yelin ated bers w h ile the lateral bundle co nsists o f thin, unm y-
elinated be rs (D is false). Th e late ral bundle co nveys info rm atio n fro m
fre e ne rve e ndings (C) w h ile th e m edial bundle transm its im pulses fro m
encapsulated re cepto rs, such as Go lgi tendo n o rgans (E), to th e p osterior
colum n s.2,3

29. D – IV (ad du ctor pollicis)

Th e pron ator quadrat us an d exor pollicis longus are in n er vated by th e an -


terior in terosseous n er ve (a purely m otor bran ch of th e m edian n er ve). Th e
oppon en s pollicis (a th en ar m uscle) is in n er vated by th e m edian n er ve. Th e
ad du ctor pollicis is in n er vated by th e u ln ar n er ve.6

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Neurosurgery Board Review

30. H – Cingu late gyru s


31. H – Cingu late gyru s
32. E – Area 17
33. D – Areas 5, 7
34. G – Areas 41, 42
35. I – Prefron tal cortex
36. F – Areas 18, 19
37. C – St riat um
38. B – Area 4
39. A – Areas 1, 2, 3
40. A – Areas 1, 2, 3

Th e ven t ral posterom edial (VPM) an d ven t ral posterolateral (VPL) n uclei of
the th alam us are par t of th e lateral t ier of th e lateral th alam ic n uclei an d are
p ar t of th e sen sor y th alam u s. Th ey receive input from th e t rigem in oth alam ic
(VPM) an d lateral spin oth alam ic t ract s (VPL) an d relay th is in form at ion to
the prim ar y sen sor y cortex in th e postcen t ral gyrus of th e pariet al lobe,
Bro dm ann’s areas 1, 2, and 3 (A). Th e ven t ral lateral n u cleu s of th e th alam u s
(VL) is also part of th e ven t ral t ier of th e lateral n uclear group an d receives
a eren t s from th e basal ganglia an d cerebellu m . Th e VL n u cleu s in u en ces
som at ic m otor act ivit y via p roject ion s to th e su p plem en t ar y m otor area
(Brodm an n’s area 6) as w ell as th e prim ary m oto r co rtex, Bro dm ann’s
area 4 (B). Th e cen t rom edian n u cleu s is classi ed w ith th e in t ralam in ar
n u clei of th e th alam u s, w h ich represen t th e rost ral con t in u at ion of th e brain -
stem ret icu lar act ivat ing system in to th e th alam u s. Th e cen t rom edian n u cle-
u s is p rim arily con cern ed w ith sen sorim otor in tegrat ion receiving a eren ts
from th e globu s p allidu s, p rem otor, an d prim ar y m otor area an d sen ding th e
m ajorit y of it s p roject ion s to th e striatum (C). Th e lateral p osterior n u cleu s
(LP) of th e th alam us is part of th e dorsal t ier of th e lateral n uclear group, is
closely related to th e pulvin ar, an d is involved w ith sen sor y in tegrat ion . Th e
LP sen ds p roject ion s prim arily to th e superio r parietal lobule, Bro dm ann’s
areas 5 and 7 (D). Th e lateral gen icu late n u cleu s (LGN) receives bers of th e
opt ic t ract an d project s to prim ary visual co rtex, Bro dm ann’s area 17 (E).
Th e pulvin ar of th e th alam us is a m em ber of th e dorsal t ier of th e lateral
n u clear grou p an d in tegrates visu al, au ditor y, an d som atosen sor y in form a-
t ion , project ing to asso ciatio n areas o f the o ccipital, te m po ral, and parietal
lo bes—Bro dm ann’s areas 18 and 19 (F). Th e m edial gen icu late n u cleu s
(MGN) receives auditor y path w ay input an d project s to prim ary audito ry
co rtex, Bro dm ann’s areas 41 and 42 (G). Th e an terior n u clear grou p of th e
thalam us is closely associated w ith th e lim bic system , an d as such sen ds its
p roject ion s to th e cingulate g yrus (H). Th e lateral dorsal (LD) n u cleu s of th e
thalam us is part of th e dorsal t ier of th e lateral n u clear group, but represen ts
the caudal con t in uat ion of th e an terior n uclear grou p, an d m ay be involved
in th e expression of em ot ion s, p roject ing to th e cingulate gyrus (H) of th e
lim bic system . Th e m edial dorsal (MD) or dorsom edial (DM) n ucleus of th e
thalam us is a m em ber of th e m edial n uclear group an d fun ct ion s in th e pro-
cessing of em ot ion . Th e MD n ucleus sen ds it s project ion s prim arily to th e
prefro ntal co rtex (I).1

41. A – Supraopt icohypophyseal t ract

144
Neuroanatom y—Answers and Explanations

42. D – Neith er
43. B – Tu beroin fu n dibu lar t ract

Axons of the tuberoinfundibular tract (B) project to the m edian em inence near
the sinusoids of the hypophyseal portal system ; their products are carried to the
anterior pituitary and in uence horm one production at the adenohypophysis
(anterior pituitary gland). The supraopticohypophyseal (A) tract consists of
neurosecretory projections from the supraoptic and paraventricular nuclei that
produce antidiuretic horm one and oxytocin, w hich are released directly into the
bloodstream , constituting the neurohypophysis or posterior pituitary gland.1

44. A – An sa len t icularis


45. C – Len t icular fasciculus (FF H2)
46. F – Th alam ic fascicu lu s (FF H1)
47. B – Fascicu lu s ret ro exu s
48. E – Precom m issural forn ix
49. D – Postcom m issu ral forn ix

Th e ansa lenticularis (A) represen t s a bu n dle of p allid oth alam ic bers th at


courses posteriorly, looping aroun d th e posterior lim b of th e in tern al capsule
from th e globu s pallidu s to th e th alam u s. An oth er grou p of p allid oth alam ic
bers, th e lenticular fasciculus (C), p rojects from th e globu s p allidu s an d
t raverses th e posterior lim b of th e in tern al capsule to reach th e th alam us. Th e
thalam ic fasciculus (F) represen ts th e con uen ce of th e ansa lenticularis (A)
an d th e lenticular fasciculus (C) as th ey reach th e thalam us. Th e fasciculus
retro exus (B) con n ects th e h aben u la to th e m id brain an d in terp edu n cu lar
n u clei.

Th e forn ix is th e m ain e eren t path w ay from th e h ippocam pal form at ion .


At th e level of th e an terior com m issu re, th e forn ix is divided in to a
p recom m issural an d postcom m issural part , w h ich lie an terior an d posterior
to th e an terior com m issure, respect ively. Th e preco m m issural bers (E)
arise p rim arily from th e pyram idal cells of th e h ip pocam p u s an d p roject to
the septal area an d basal forebrain w h ile th e po stco m m issural bers (D)
arise from th e su bicu lu m of th e h ip pocam p u s an d p roject p rim arily to th e
m am m illar y bod ies an d hyp oth alam u s.1,3

50. E – Superior vest ibular n ucleus

Th e superior vest ibu lar n ucleus is foun d at th e level of th e pon s.2

51. E – Th alam ic fasciculus

Th e th alam ic fasciculus con tain s pallidoth alam ic bers an d ascen ding bers
from th e con t ralateral deep cerebellar n u clei. It is n ot a com p on en t of th e
lim bic system .1,2

52. C – Superior ban k of th e lateral sulcus

Th e secon dar y som atosen sor y cortex (SII, Brodm an n’s area 43) is located on
the superior ban k of th e lateral ssure at th e in ferior exten t of th e prim ar y
m otor an d sen sor y areas.1

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Neurosurgery Board Review

53. B – Im pairm en t of lacrim at ion

Fibers in n er vat ing th e lacrim al glan d arise from postganglion ic bers from
the pter ygopalat in e ganglion , w h ich is lin ked to th e gen icu late ganglion via
the greater super cial pet rosal n er ve. A lesion distal to th e gen iculate ganglion
w ou ld n ot im pair lacrim atio n (B is false). A lesion to th e facial n er ve ju st
distal to th e gen icu late ganglion w ould cause paralysis o f ipsilateral facial
m uscles due to disrupt ion of som at ic m otor n eurons (E), hyperacusis due
to disru pt ion of th e facial n er ve proxim al to th e t ake-o of th e n er ve to th e
st ap ediu s m u scle (A), an d im pairm ent o f salivary se cretio ns an d lo ss o f
taste in the anterio r tw o -thirds o f the to ngue du e to disru pt ion of th e facial
n er ve p roxim al to th e t ake-o of th e ch orda t ym p an i n er ve (C and D).1

54. B – Som at ic p u den dal n er ves

Th e extern al ureth ral sph in cter is in n er vated by som at ic m otor bers supplied
by th e puden dal n er ve (S2–S4). Th e in tern al urin ar y sph in cter is in n er vated
by sym path et ic bers su pplied by th e vesical (pelvic) n er ve plexus.6

55. A – In dusium griseum (false)

Region s of th e brain devoid of a blood–brain barrier in clude th e m edian


em ine nce (B), the o rganum vasculo sum o f the lam ina term inalis (C),
the pineal gland (D), the subfo rnical o rgan (E), th e area p ost rem a, an d th e
n eu rohyp ophysis. Th e in du siu m griseu m (or su pracallosal gyru s) is a vest igial
convolut ion of th e den tate gyrus.1,2,3

56. C – 2, 3, an d 5

Uncrossed bers of the optic tract term inate in layers 2, 3, and 5 (C) of the lat-
eral geniculate nucleus w hile crossed bers term inate in layers 1, 4, and 6 (B).2,3

57. A – I, II, III (act ive t ran spor t , carrier-m ediated t ran sport , an d di usion )

Su bstan ces can cross th e blood–brain barrier (form ed by cap illar y en doth elial
t igh t jun ct ion s) via act ive t ran spor t , carrier-m ediated t ran sport , or di usion .
Su bstan ces do n ot cross th e blood–brain barrier via vesicu lar t ran sport
m ech an ism s.2,3

58. B – Diagon al ban d of Broca


59. A – Arcuate fasciculus
60. C – Tapet um
61. D – Un cin ate fascicu lu s

Th e arcuate fasciculus (A) con n ect s Wern icke’s to Broca’s area. Th e diago nal
band o f Bro ca (B) con n ect s th e sept al (p araolfactor y) area to th e am ygdala.
Th e tapetum (C) is a p osterior sect ion of th e corp u s callosu m con n ect ing
the tem poral an d occipit al lobes. Th e uncinate fasciculus (D) con n ect s th e
an terior tem p oral lobe to th e orbitofron tal gyru s.3

62. C – Both
63. D – Neith er

146
Neuroanatom y—Answers and Explanations

64. A – Paraven t ricular n ucleu s


65. B – Su p raopt ic n u cleu s
66. C – Both
67. A – Paraven t ricular n ucleu s

Th e supraoptic (B) an d paraventricular (A) n u clei of th e hyp oth alam u s are


both located in th e supraopt ic region an d syn th esize vasopressin (an t idiuret ic
h orm on e [ADH], argin in e vasopressin [AVP]) an d oxytocin . Th e su p raopt ic
n u cleu s is com prised of u n iform ly large cells (m agn ocellu lar). Th e p araven -
t ricular n ucleu s con t ain s a diverse group or n euron s, som e of w h ich project
to th e brain stem an d spin al cord. Neith er of th ese st ruct ures is located in th e
t uberal region , w h ich con tain s th e arcuate n u cleus, th e dorsom edial n ucleus,
the ven t rom edial n u cleus, an d th e lateral hypoth alam ic n ucleus.1

68. C – Pseu dobulbar palsy can resu lt from un ilateral lesion s involving cort icobulbar
bers (false)

Pseu dobulbar palsy (ch aracterized by w eakn ess of th e m uscles involved in


ch ew ing, sw allow ing, breath ing, an d speaking, w ith loss of em ot ion al con t rol)
resu lts from bilateral lesion s of th e cor t icobulbar bers.1

69. B – Addu ct th e ngers

Adductio n of the ngers (B) is perform ed by th e p alm ar in terosseu s m u s-


cles, in n er vated by th e deep bran ch of th e uln ar n er ve. Finge r abductio n (A)
is perform ed by th e dorsal in terossei, also in n er vated by th e uln ar n er ve. Th e
lu m bricals (m edian n er ve) ex the m etacarpo phalangeal jo ints w hile ex-
tending the interphalangeal jo ints (D) of th e 2n d–5th digit s.6

70. C – Glu teus m axim us

Th e glute us m axim us (C) is in n er vated by th e in ferior gluteal n er ve. A por-


t ion of th e adducto r m agnus (A) is also in n er vated by th e obt u rator n er ve.
Th e sciat ic n er ve in n er vates all m u scles of th e p osterior com par t m en t
of th e th igh in clu ding bice ps fe m o ris (B), sem im e m brano sus (D), an d
se m ite n din o sus (E).6

71. B – Con t ralateral loss of p ain an d tem perat u re in th e face 2

Th e syn drom e of PICA occlusion , or Wallen berg lateral m edullar y syn drom e,
is ch aracterized by co ntralate ral pain and tem pe rature lo ss over the body
(A), ipsilate ral Ho rner’s syndro m e (D), ipsilateral paralysis o f the pharynx
and larynx (C), an d hiccup (E). Ipsilateral, n ot con t ralateral, loss of p ain an d
tem perat ure in th e face occu rs in th e syn drom e of posteroin ferior cerebellar
ar ter y (PICA) occlu sion (B is false ).7

72. B – Gen u of th e in tern al cap su le


73. C – Posterior lim b of th e in tern al capsule
74. A – An terior lim b of th e in tern al capsu le
75. C – Posterior lim b of th e in tern al capsule
76. D – Non e of th e above

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77. C – Posterior lim b of th e in tern al capsule

The anterio r lim b o f the internal capsule (A) contains the anterior thalam ic
radiation and th e prefron tal corticopontine tract. The genu o f the internal cap-
sule (B) con tain s cort icobulbar an d corticoret icular bers. Th e posterio r lim b
o f the internal capsule (C) con tain s th e superior th alam ic radiation , th e fron -
topon tin e tract , cort icospin al bers, as w ell as cort icoru bral an d corticotectal
project ions. The m edial forebrain bundle is not part of the internal capsule.3

78. G – Spiral ganglion


79. E – Scarpa’s ganglion
80. D – Ot ic ganglion
81. A – Ciliar y ganglion
82. B – Gasserian ganglion
83. C – Gen iculate ganglion
84. F – Sph en opalat in e ganglion
85. H – Su bm an dibular ganglion

The ciliary ganglion (A) receives parasym path etic bers of CN III an d projects
to th e pupillar y con strictor an d ciliar y m uscle m ediating th e e eren t lim b of
the pupillar y light and accom m odation re exes. The gasserian ganglion (B) is
also kn ow n as th e sem ilun ar or trigem in al ganglion an d is associated w ith CN
V, w hich provides sensor y innervation to the face. The geniculate ganglio n (C)
is associated w ith the facial ner ve, and transm its inform at ion regarding taste
(chorda t ym pani) and visceral sensation from the m iddle ear, nasal cavit y, and
soft palate, as w ell as a sm all area of skin over th e extern al auditor y m eat us.
The otic ganglion (D) conveys parasym pathetic m essages transm it ted by CN IX
to the parotid glan d. Scarpa’s ganglio n (E) includes the superior and inferior
vest ibular ganglia and is involved in equilibrium . Th e spheno palatine gangli-
o n (F) is also know n as the pter ygopalatine ganglion and transm its parasym -
pathetics from the facial ner ve (via the greater super cial petrosal ner ve and
vidian n er ve) to th e lacrim al glan d an d glands of th e n asal cavit y an d palate.
The spiral ganglio n (G) is associated w ith th e organ of Corti an d tran sm its in-
form ation regarding sound to the dorsal and ventral cochlear nuclei via CN XIII.
The subm andibular ganglion (H) t ran sm its parasym path et ic sign als from the
facial ner ve (ch orda t ym pan i) to th e subm an dibular an d sublingual glan ds.1

86. A – Crossed an d un crossed bers of th e opt ic t ract term in ate on th e lateral ge-
n icu late body (false)

Th e lateral gen iculate body is n ot involved in th e pupillar y ligh t re ex.1

87. B – I, III (in th e cau dal asp ect of th e roof an d in th e lateral recess)

Choroid plexus is located in the caudal aspect of the roof of the fourth ventricle
near the m idline, and laterally extends through the lateral recesses of Luschka.4

88. A – Addu ctor pollicis (false)

Th e adducto r po llicis (A) is in n er vated by th e uln ar n er ve. Th e oth er


st ru ct u res listed are in n er vated by th e m ed ian n er ve: exo r carpi radialis (B),
o ppo ne ns po llicis (C), palm aris lo ngus (D), an d pro nato r te res (E).6

148
Neuroanatom y—Answers and Explanations

89. A – I, II, III (am ygdala, h aben ular n uclei, an d h ippocam pu s)

Th e am ygdala p ar t icip ates in lim bic m odu lat ion of th e hyp oth alam u s by t w o
m ajor p ath w ays th at p roject to th e septal n u clei: th e st ria term in alis an d th e
ven t ral am ygdalofugal path w ay. Th e habe nular nuclei sen d project ion s to
the sept al n uclei via th e st ria m edullaris th alam i. Th e hippo cam pus p rojects
to th e septal area via th e forn ix.1

90. A – I, II, III (cau date n ucleu s, opt ic t ract , an d th alam us) 2

Th e an terior ch oroidal arter y supplies ven t rolateral part s of th e posterior


lim b of th e in tern al capsu le an d th e ret rolen t icular in tern al cap sule, n ot th e
anterio r lim b. Th e an terior lim b of th e in tern al capsu le is su pp lied by th e
lateral st riate bran ch es of th e m iddle cerebral arter y an d th e m edial st riate
ar ter y. Th e an terior ch oroidal arter y m ay su p p ly a port ion of th e tail of th e
caudate an d a port ion of th e thalam us as w ell as th e o ptic tract. Th e syn -
drom e of an terior ch oroidal ar ter y in farct ion con sist s of con t ralateral h em i-
p legia, h em ihypesth esia, an d h om onym ous h em ian opia.3,7

91. E – Tem poral h alf of th e righ t visu al eld an d n asal h alf of th e left visual eld

A lesion to th e opt ic t ract result s in a con t ralateral h om onym ous h em ian op -


sia (E), w h ich w ou ld a ect th e tem poral h alf of th e con t ralateral visu al eld
an d th e n asal h alf of th e ipsilateral visu al eld . B describes a left-sided h om -
onym ous h em ianopsia, w h ich w ould occur w ith a lesion to th e righ t opt ic
t ract . D describes a bitem p oral h em ian op sia as t ypically occu rs w ith ch iasm al
lesion s w ith com pression of crossing bers from th e n asal ret in a (tem poral
eld). A lesion of th e occip it al cor tex t yp ically resu lts in a h om onym ou s h em i-
an op sia w ith m acu lar sp aring.1

92. A – Cerebral cortex to globus pallidu s

The striat um (caudate and putam en) represent the m ajor input centers for the
basal ganglia. There are no direct cortical projections from the cerebral cortex
to th e globus pallidus (A is false). Cortical inputs to the basal ganglia (cor-
tico striate bers) term inate in the caudate and putam en (B) and represent
the principle input to the basal ganglia. Thalam ostriate bers are the second
m ajor input to th e basal ganglia arising in the intralam inar nucleus of the
thalam us and projecting to the striatum (E). Subcortical struct ures such as
the subthalam ic nucleus project to the glo bus pallidus (D). Dopam in ergic n i-
grostriatal bers project from th e substantia nigra to the caudate nucleus (C)
an d h ave been im plicated in th e pathophysiology of Parkin son’s disease.1

93. A – Am ygdala

Th e am ygdala (A) project s to th e hyp oth alam u s via t w o p ath w ays, th e st ria
term in alis an d th e ven t ral am ygdalohypoth alam ic t ract . Th is is n ot to be con-
fu sed w ith th e st ria m edu llaris w h ich p rojects from th e habe nula (D) to th e
septal n u clei an d an terior hyp oth alam u s.1

94. C – In ferior collicular com m issure


95. B – Probst’s com m issu re

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96. A – Trapezoid body

The trapezoid body (A) connects the ventral cochlear nuclei to the contralateral
superior olive. Pro bst’s com m issure (B) connects the n uclei of the lateral lem -
niscus. The inferior collicular com m issure (C) connects th e in ferior colliculi.3

97. D – Ven t rom edial hypoth alam u s


98. C – Posterior hypoth alam us
99. A – An terior hypoth alam u s
100. C – Posterior hypoth alam us
101. C – Posterior hypoth alam us
102. B – Lateral hypoth alam u s
103. A – An terior hyp oth alam u s

Th e preopt ic an d an terior hypoth alam us is involved in regulat ion of body


tem perat ure. Lesion s to th e ante rio r hypothalam us (A) can result in
hyper th erm ia. Lesion s to th e anterio r hypo thalam us (A) can also result in
decreased parasym path et ic ton e. Th e lateral hypothalam us (B), or “feeding
cen ter,” causes an in crease in appet ite w h en st im ulated. Th e po sterio r
hypothalam us (C) is respon sible for sym path et ic ton e; lesion s to th is area
can result in in abilit y to regulate tem perat ure (poikiloth erm ia), decreased
sym p ath et ic ton e, leth argy, an d sleep in ess. Th e ventro m edial nucleus (D)
of th e hypoth alam u s is respon sible for sat iet y—lesion s h ere m ay produce
hyperphagia an d w eigh t gain .1

104. D – Superior ganglion of CN IX


105. B – Jugu lar ganglion
106. C – Pet rosal ganglion
107. A – Nodose ganglion

Th e in ferior ganglion of CN IX is called th e petro sal ganglio n (B) an d receives


input from th e carot id sin u s an d body as w ell as from taste receptors in th e
p osterior on e-th ird of th e tongu e. Th e supe rio r ganglio n o f CN IX (D) con -
t ain s th e cell bodies of n eurons th at provide gen eral som at ic sen sor y in n er va-
t ion to th e pin n a of th e ear an d a por t ion of th e extern al acou st ic m eat us. Th e
in ferior ganglion of cran ial n er ve CN X is called th e no do se ganglio n (A) an d
receives taste an d oth er visceral in form at ion . Th e superior ganglion of CN X is
called th e jugular ganglio n (B) an d h ou ses th e cell bodies of gen eral som at ic
a eren t n eu ron s in n er vat ing a p ort ion of th e extern al acou st ic m eat u s an d
t ym pan ic m em bran e via th e vagus n er ve. Both superior ganglia are involved
w ith som at ic sen sat ion .1,3

108. D – Globus pallidus (false)

Th e telen ceph alon is th e an terior-m ost port ion of th e prosen ceph alon an d
gives rise to th e cerebral h em isp h eres. Th e h ip p ocam p al form at ion , cerebral
h em isp h eres an d cor tex, as w ell as th e am ygdala (A), caudate (B), putam en
(E), an d claustrum (C) are telen cep h alic st ru ct u res. Th e cau dal p ort ion of th e
p rosen cep h alon , th e dien ceph alon , gives rise to th e th alam us, glo bus pallidus
(D), p osterior hypop hysis, in fu n d ibu lu m , opt ic n er ve, ret in a, p osterior com -
m issu re, an d h aben u lar com m issu re.1,3

150
Neuroanatom y—Answers and Explanations

109. D – Musculocut an eous n er ve

The m usculocutaneous nerve (D) inn er vates the m uscles of th e an terior com -
partm ent of the arm including the coracobrachialis, biceps brachii, and bra-
chialis m uscles. The axillary nerve (A) innervates the teres m inor and deltoid
m uscles. Th e do rsal scapular nerve (B) innervates th e rhom boids. The m edian
nerve (C) inner vates the m uscles of the anterior com partm ent of the forearm
except the exor carpi ulnaris and the ulnar half of the exor digitorum profun-
dus, as w ell as ve hand intrinsics on the thenar aspect of the hand. The supra-
scapular nerve (E) in nervates the supraspin at us an d in fraspin atus m uscles.6

110. C – III

Cells that give rise to com m issural bers that interconnect hom ologous cortical
areas via th e corpus callosum are foun d in layer III (C) of th e cerebral cortex
(the external pyram idal layer). Layer I (A) is th e plexiform m olecular layer an d
con sists m ainly of n er ve cell processes. Layer II (B) is th e extern al gran ular lay-
er com prised m ostly of sm all gran ule cells. Layer IV (D), th e in tern al gran ular
layer, is im portant for a erent signaling and is thicker in the prim ar y sensor y
area. Layer V (E), th e in tern al pyram idal layer, is the source of th e m ajorit y of
out put bers for the cerebral cortex. Layer VI is the fusiform layer and lies adja-
cent to underlying w hite m at ter and consists prim arily of association neurons.1

111. C – Neuron s of th e cerebral cortex

Th e n eural crest is a n arrow st rip of cells at th e edge of th e developing n eu ral


p late th at gives rise to several st ru ct ures in clud ing, n euron s of th e do rsal ro o t
ganglia of cranial and spinal nerves (B), adrenal m edulla (A), m elanocytes
o f the retina (D), Sch w an n cells, m en inges, as w ell as th e sym pathetic and
parasym pathetic ganglia (E). Co rtical ne uro ns (C) are derived from n euro-
ectod erm th at form s from th e n eu ral t u be.1

112. D – Rh om ben ceph alon to m eten ceph alon to cerebellu m

Th e prim ar y brain division s in clude th e rh om ben ceph alon (h in dbrain ), m es-


en ceph alon (m idbrain ), an d prosen cep h alon (forebrain ). Th e rh om ben ceph a-
lon gives rise to th e m yelen ceph alon an d m eten ceph alon . Th e prosen ceph alon
gives rise to th e d ien ceph alon an d telen cep h alon . Th e m yelen cep h alon gives
rise to th e m edu lla an d in ferior cerebral p edu n cles. Th e m eten cep h alon gives
rise to th e p on s, cerebellu m , an d m idd le an d su perior cerebellar pedu n cles.
Th e m esen ceph alon gives rise to th e cerebral pedun cles, m idbrain tect um ,
an d tegm en t u m . Th e dien cep h alon gives rise to th e epith alam u s, th alam u s,
an d hypoth alam u s. Th e telen cep h alon gives rise to th e cerebral h em isp h eres
in clu ding th e corpus st riat u m an d rost ral aspect of th e hypoth alam us. D is th e
on ly correct respon se.1

113. B – Globu s p allidu s an d su bst an t ia n igra

E erent t ran sm ission from th e st riat um is lim ited to on ly t w o targets: the


glo bus pallidus and substantia nigra (B) via th e st riatopallidal bers an d
st riaton igral bers. Th e st riat u m d oes n ot h ave any direct project ion s to th e
am ygdala (A, C) o r thalam us (D, E).1

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Neurosurgery Board Review

114. A – I, II, III (cran ial n er ves IX, X, an d XI)

Th e n ucleus am biguous con t ributes bers to cran ial n er ves IX, X, an d XI, but
n ot VII. Th e con t ribu t ion of th e n u cleu s am bigu ou s to th e glo sso pharyngeal
nerve (IX) is special visceral e eren t bers to th e st yloph ar yngeu s an d ph a-
r yngeal con st rictor m u scles as w ell as receiving gen eral visceral a eren t inpu t
from th e m iddle ear, ph ar yn x, tongu e, an d carot id sin u s. Th e n u cleu s am bigu-
ous provides special visceral e eren t bers to th e vagus nerve (X) for m u scles
of th e lar yn x an d ph ar yn x. Th e n ucleus am biguou s provides special visceral
e eren t bers to th e spinal accesso ry nerve (XI) for the con t rol of lar yngeal
m u scles. Th e facial nerve (VII) is n ot associated w ith th e n u cleu s am bigu ou s.1

115. E – All of th e above

Fun ct ion al com pon en t s of th e facial n er ve an d n er vus in term ediu s in clude


special visceral e e rent be rs to th e m u scles of facial exp ression an d st ape-
diu s m uscles, gen eral visceral e eren t (parasym path et ic) bers to th e lacri-
m al an d su blingu al glan ds, special visce ral a erent inp ut from th e an terior
t w o-th irds of th e tongu e, general visce ral a erent inp u t s from th e m iddle
ear, n asal cavit y, an d soft p alate, as w ell as general so m atic a erents from
th e extern al auditor y m eat us an d posterior auricular area.1

116. E – Ven t ral to th e m am illar y bodies

Th e in fun dibu lar recess of th e th ird ven t ricle is located in th e oor of th e th ird
ven t ricle ve ntral to the m am illary bo dies (E).3

117. B – Bilateral p ar t ial deafn ess, greater in th e con t ralateral ear

Th e m ajorit y of second-order n euron s from th e coch lear n uclei decu ssate


in th e t rap ezoid body to th e con t ralateral superior olivar y n ucleus, w h ile a
sm aller n u m ber of bers ascen d to th e ipsilateral su p erior olivar y n u cleu s.
Th is bilateral inpu t to th e superior olivar y n uclei con t ributes to sou n d
localizat ion an d determ in at ion of direct ion al in ten sit y. Th e lateral lem n iscus
is th e m ain ascen ding p ath w ay of th e auditor y system in th e brain stem . Due
to th e presen ce of both crossed an d un crossed bers, a lesion to th e lateral
lem n iscu s causes bilateral partial deafness, w o rse in the co ntralateral
ear (B).1

118. B – III, IV, VI, an d V1 on ly

Th e lateral sector of th e superior orbit al ssu re (SOF) con tain s th e tro chlear
(IV), fro ntal (branch o f V1), an d lacrim al nerves (branch o f V1), w h ich all
p ass ou t side th e an n ular ten d on of Zin n . Th e superior oph th alm ic vein also
p asses in ferior to th e n er ves in th is por t ion of th e ssu re to reach th e cavern -
ous sin us. Th e cen t ral por t ion of the SOF (oculom otor foram en ) con tain s th e
o culo m oto r nerve (III), naso ciliary nerve (branch o f V1), abducens nerve
(VI), an d root s of th e ciliar y ganglion —all of w h ich p ass th rough th e an n u lu s
of Zin n . Th e opt ic n er ve an d oph th alm ic arter y course m edially to th e oculo-
m otor foram en p assing th rough th e opt ic foram en . Th e m axillar y n er ve (V2)
exit s th e cran ial vau lt via foram en rot u n du m before en tering th e orbit via th e
in ferior orbit al ssu re, n ot th e superior orbital ssu re.4

152
Neuroanatom y—Answers and Explanations

119. D – Superior orbit al ssure


120. D – Superior orbit al ssure
121. A – In ferior orbit al ssu re
122. C – Foram en ovale
123. B – Foram en m agn u m

Th e supe rio r o rbital ssure (D) t ran sm its cran ial n er ves (CN) III, IV, V1, an d
VI. Th e infe rio r o rbital ssure (A) t ran sm it s CN V2 (m axillar y n er ve) in to
the orbit after it h as exited th e skull via th e foram en rot un dum . Th e fo ram en
ovale (C) t ran sm it s CN V3 (m an dibu lar n er ve), an d th e foram e n m agnum (B)
t ran sm it s CN XI as it ascen ds to join th e vagus n er ve prior to exit ing th e skull
through th e jugular foram en .1

124. C – Ner vi erigen tes


125. B – Splan ch n ic n er ve
126. A – Pu den dal n er ve

Th e pude ndal nerve (A) arises from S2, 3, an d 4 an d provides som at ic in n er-
vat ion to th e skin of th e p erin eu m an d of th e m u scles of th e p erin eu m an d
p elvic oor in clu ding th e extern al ureth ral an d an al sph in cters. Th e sacral
splanchnic ne rves (B) provide sym path et ic in n er vat ion to th e p elvis. Th e
nervi erige ntes (C), or p elvic sp lan ch n ic n er ves, p rovide p arasym p ath et ic in -
n er vat ion to th e st ru ct u res of th e p elvis.6

127. A – Coch lear n u cleu s


128. E – Superior olivar y n ucleus
129. E – Superior olivar y n ucleus
130. E – Superior olivar y n ucleus

First-order n eu ron s of th e auditor y path w ay project from th e spiral ganglion


an d term in ate in th e ip silateral co chlear nucle us (A). Secon d-order bers
from th e coch lear n u cleu s m ay eith er ascen d to th e ip silateral su p erior oli-
var y n u cleu s or decu ssate in th e t rap ezoid body to form th ree acou st ic st riae:
the dorsal, in term ediate, an d ven t ral acou st ic st riae. Th e superio r o livary
nucleus (E) p rojects th ird-order n eu ron s in to both th e ip silateral an d bilat-
eral lateral le m niscus (C). Th e inferio r co lliculus (B) receives inp u t from th e
lateral lem n iscus an d is involved in sou n d localizat ion . Th e in ferior colliculu s
th en project s to th e ipsilateral m edial geniculate nucleus (D) via th e bra-
ch ium of th e in ferior collicu lus. Th e m edial gen iculate n ucleus gives o th e
au d itor y rad iat ion s, w h ich p roject to th e au ditor y cortex.1

131. A – I, II, III (hyp oth alam u s, lateral p reopt ic region , sept al n u clei)

Th e st ria m edullaris th alam i is a bidirect ion al path w ay th at con nect s th e


hypoth alam us, preopt ic region , an d sept al n uclei w ith th e h aben ula. Th e st ria
m edu llaris does n ot con t ain bers from th e am ygdala.1

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Neurosurgery Board Review

132. A – Cells in th e cen t rom ed ian n u cleu s p roject to th e cau date (false)

Cells in th e cent rom edian n ucleus project to th e put am en (A is false), an d


cells in th e parafascicu lar n ucleus project to th e caudate. Th e oth er respon ses
are t ru e. Cort icost riate p roject ion s u se glu tam ate as th eir t ran sm it ter, n igros-
t riat al bers arise from cells in th e pars com pact a, seroton ergic project ion s
arise from th e dorsal n u cleu s of th e rap h e, an d th alam ost riate bers arise
largely from cells in th e cen t rom edian parafascicu lar n ucleus.1,2

133. D – Spin al t rigem in al n ucleu s


134. D – Spin al t rigem in al n ucleu s
135. A – Mesen ceph alic n u cleu s
136. D – Spin al t rigem in al n ucleu s
137. C – Prin cipal sen sor y n ucleus
138. A – Mesen ceph alic n u cleu s
139. C – Prin ciple sen sor y n ucleus

Th e m esencephalic nucleus (A) is un ique because it is a sen sor y ganglion


con t ain ing th e cell bodies of pseudoun ipolar n euron s th at are respon sible
for conveying p ropriocept ive in form at ion from th e m u scles of th e face. Th e
m oto r nucleus o f the trigem inal nerve (B) con t ain s th e cell bodies of th e
n eu ron s th at in n er vate th e m u scles of m ast icat ion . The principle se nso ry
nucleus (C) is h om ologou s to th e n ucleu s gracilis an d n ucleu s cun eat us an d
sen d s th e dorsal t rigem in oth alam ic t ract to th e ip silateral VPM of th e th ala-
m u s, conveying t act ile an d p ressu re sen se. Th e spinal trigem inal nucle us
(D) is th e largest of th e t rigem in al sen sor y n uclei, an d con sist s of a pars ora-
lis, pars in terpolaris, an d p ars caudalis. Th e ven t ral t rigem in oth alam ic t ract
carries project ion s from th e m ain sen sor y n ucleus to th e th alam us regarding
t act ile an d pressure sen se, an d carries project ion s from th e spinal trigem inal
nucleus (D) regarding p ain an d tem p erat u re sen se. Th e trigem inal ganglio n
(E) h ouses cell bodies of pseu doun ipolar sen sor y n euron s; it lies in Meckel’s
cave in th e pet rous tem poral bon e.1

140. A – Th ey in directly p roject to th e ipsilateral cerebellar cor tex.

E erent bers from th e den t ate n ucleu s leave via th e su perior cerebellar
p edu n cle (C is false), decu ssate in th e cau dal m esen ceph alon , an d p roject
to th e con t ralateral red n ucleus (B and E are false) an d ven t ral lateral an d
ven t ral posterolateral th alam ic n u clei (D is false). Th ese th alam ic n u clei th en
p roject to th e prim ar y m otor cortex. Fibers form ing th e descen ding part of
the su perior cerebellar pedun cle project to ret icu lar n uclei an d th e in ferior
olivar y n ucleus, w h ich in t urn projects back to th e ipsilateral cerebellar cor tex
(A is true).1

141. C – Sciat ic n er ve
142. D – Fem oral n er ve
143. A – Su p erior glu teal n er ve

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Neuroanatom y—Answers and Explanations

144. B – In ferior glu teal n er ve

Th e superio r gluteal nerve (A) in n er vates gluteus m edius, gluteus m in im us,


an d th e ten sor of th e fascia lat a, w h ich add u ct an d m edially rot ate th e th igh .
Th e inferio r gluteal ne rve (B) in n er vates gluteus m axim u s, w h ich exten ds
the th igh at th e h ip. Th e sciatic ne rve (C) in n er vates n o glu teal m u scles,
all m u scles of posterior th igh , an d all th e m u scles of th e leg an d foot . Th e
ad du ctor m agn u s is in th e m edial com p ar t m en t of th e th igh an d is con sidered
to be on e of th e ve addu ctors of th e th igh . Th e m edial com par t m en t of th e
thigh is in n er vated prim arily by th e obt urator n er ve. Th e adductor part of
ad du ctor m agn u s is in n er vated by th e obt u rator n er ve, bu t th e h am st rings
p ar t of ad du ctor m agn us is in n er vated by th e sciatic nerve (C). Th e fe m o ral
nerve (D) in n er vates th e m u scles of th e an terior th igh , w h ich con sist
p rim arily of h ip exors an d kn ee exten sors such as pect in eus, iliacus, sarto-
riu s, an d qu adricep s fem oris (rect u s fem oris, vast u s lateralis, vast u s m ed ialis,
an d vast u s in term ed iu s).6

145. C – Posterior cord


146. B – Medial cord
147. C – Posterior cord
148. A – Lateral cord
149. C – Posterior cord

Th e lateral co rd (A) is form ed by th e an terior division s of th e su p erior an d


m id dle t ru n ks an d gives rise to th e lateral p ectoral n er ve, th e m u scu locu t a-
n eou s n er ve, an d th e lateral root of th e m edian n er ve. Th e m edial co rd (B)
con sist s of th e an terior division of th e in ferior t run k an d gives rise to th e
m edial p ectoral n er ve, th e m ed ial cu t an eou s n er ve of th e arm , an d th e m ed ial
cut an eous n er ve of th e forearm ; th e m edial co rd (B) u lt im ately term in ates
in to th e u ln ar n er ve an d th e m ed ial root of th e m edian n er ve. Th e po sterio r
co rd (C) receives con t ribu t ion s from th e p osterior division s of th e su p erior,
m id dle, an d in ferior t ru n ks, an d u lt im ately bran ch es in to th e a xillar y an d ra-
dial n er ves. Th e po ste rio r co rd (C) gives o th e u p p er an d low er su bscap u lar
n er ves (teres m ajor m u scle) an d th e th oracodorsal n er ve (lat issim u s dorsi
m u scle). Th e radial ne rve (D) is th e larger term in al bran ch of th e p osterior
cord an d in n er vates th e exten sor com part m en t s of th e arm an d forearm . Th e
ulnar nerve (E) is th e larger term in al bran ch of th e m edial cord an d in n er-
vates exor carp i u ln aris, th e u ln ar h alf of exor digitoru m profu n du s, an d
m ost of th e in t rin sic m u scles of th e h an d.6

150. B – In th e th alam u s, th e ext rem it ies are rep resen ted dorsally an d th e back ven-
t rally (false)

Th e ext rem it ies are represen ted ven t rally an d th e back dorsally in th e th ala-
m u s (B is false). Th e oth er st atem en t s regarding cerebellar p roject ion s to th e
th alam us are t rue. Fibers term in ate on th e ven t ral lateral an d ven t ral postero-
lateral th alam ic n uclei (A), in th e th alam u s th e h ead is rep resen ted m ed ially
an d th e cau dal th orax represen ted laterally (C), som e bers p roject to th e
rost ral in terlam in ar n u clei (D), an d th ese bers origin ate from th e den tate
an d in terposed n u clei (E). Fibers from th e fast igial n u cleu s p roject to eith er
th e lateral or in ferior vest ibular n u clei or th e brain stem ret icular form at ion .1

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151. B – Cen t rom edian n u cleu s of th e th alam u s 2

Th e centro m edian nucleus o f the thalam us (B) is m ost closely related to


m otor fu n ct ion s in th at it receives inp u t from th e m otor an d p rem otor cortex
an d from th e globu s pallidu s an d project s m ain ly to th e st riat u m . Th e oth er re-
sp on ses are con sidered p art of th e lim bic system in clu ding th e am ygdala (A),
epithalam us (C), hypothalam us (D), an d septal nucle i (E).1

152. E – Ven t ral m edulla

Melan ocytes are located in th e pia m ater an d are con cent rated in the region of
the ventral m edulla and upper spinal cord. These m ay represent the cells of ori-
gin for m elan om as seen in patien ts w ith n o h istory of prim ar y skin m elan om a.8

153. B – Con t ralateral loss of p osit ion an d vibrat ion

Inform ation regarding position an d vibration is carried in the dorsal colum ns


via rst-order sensor y neurons th at then syn apse in the n ucleus gracilis or nu-
cleus cuneatus. These second-order neuron s decussate in th e caudal m edulla
as the intern al arcuate bers before ascen ding in the m edial lem niscus before
syn apsing in th e ventral posterior lateral n ucleus of th e thalam us. A lesion to
the m edial lem niscus w ould cause contralateral loss of position and vibration
sense (B). A lesion to the dorsal colum ns at the level of the spin al cord w ould
cause an ipsilateral loss of position and vibration sense (D). The decussation
for th e spinothalam ic tract (pain and tem perat ure) occurs in the anterior com -
m issure of th e spinal cord, so a unilateral lesion to th e spinal cord or brain stem
w ould cause contralateral loss of pain and tem perature sensation (A).9

154. A – Forn ix (false)

Th e dien ceph alon is th e cau dal port ion of th e prosen ceph alon (forebrain ) an d
gives rise to th e ep ith alam u s (habenula [D], stria m edullaris [E], an d pineal
gland [D]), th alam u s, an d hypothalam us (B). Th e telen ceph alon is th e rost ral
port ion of th e prosen ceph alon an d gives rise to th e cerebral h em isph eres
in clu ding th e h ip pocam pal form at ion an d fo rnix (A).1

155. A – Maxillar y bran ch of CN V


156. D – Abducen s n er ve
157. F – Middle m en ingeal arter y
158. A – Maxillar y bran ch of CN V
159. C – Man dibular bran ch of CN V
160. D – Abducen s n er ve
161. B – Nasop alat in e n er ve
162. E – Men t al n er ve

Th e superior orbit al ssure t ran sm its cran ial n er ves (CN) III, IV, V1, an d VI (D).
Th e in ferior orbital ssure t ran sm it s CN V2 (m axillary ne rve [A]) in to th e
orbit after it h as exited th e skull via foram en rot un dum . The foram en ova-
le t ran sm its CN V3 (m andibular nerve [C]). Th e naso palatine ne rve (B)
t raverses th e in cisive foram en an d th e m ental ne rve (E) t raverses th e m en tal
foram en . Th e m iddle m eningeal artery (F) en ters th e sku ll via foram en
sp in osu m . Th e abducens (D) n er ve t raverses Dorello’s can al as p ar t of it s long
in t racran ial cou rse.1

156
Neuroanatom y—Answers and Explanations

163. D – Medial vest ibular n ucleus


164. C – Lateral vest ibular n ucleus
165. A – In ferior vest ibu lar n u cleu s
166. C – Lateral vest ibular n ucleus
167. D – Medial vest ibular n ucleus
168. E – Superior vest ibular n ucleus
169. B – In terst it ial n u cleu s of th e vest ibu lar n er ve
170. D – Medial vest ibular n ucleus

Th e inferio r vestibular nucle us (A) receives bers from th e in ferior vest ibular
ganglion an d sen ds p roject ion s to th e ret icu lar form at ion an d cerebellu m .
The inte rstitial nucleus o f the vestibular ne rve (B) con sist s of cell bodies
that lie am ong bers of th e vest ibular root . Th e late ral vestibular nucleus (C),
Deiter’s n u cleu s, receives inp u t from th e su p erior vest ibu lar ganglion an d
form s th e lateral vest ibu losp in al t ract , w h ich p rojects to all spin al levels
an d is respon sible for exten sor ton e. Th e m e dial vestibular nucle us (D),
Sch w albe’s n u cleu s, is th e largest of th e vest ibu lar n u clei an d sen ds p rojec-
t ion s to con t ralateral ext raocular n uclei via th e MLF. Th e superio r vestibular
nucleus (E), Bech terew ’s n u cleu s, gives rise to u n crossed ascen ding bers to
the oculom otor an d t roch lear n uclei t raveling in th e MLF. Secon d-order ves-
t ibu locerebellar project ion s arise from th e caudal aspect of th e in ferior cer-
ebellar n u cleu s an d th e m edial vestibular nucle us (D).1,2

171. A – Mesen ceph alic n u cleu s


172. D – Spin al t rigem in al n ucleu s
173. A – Mesen ceph alic n u cleu s
174. C – Prin cipal sen sor y n ucleus
175. D – Spin al t rigem in al n ucleu s

Th e m esencephalic nucleus (A) is un ique because it is a sen sor y ganglion


con t ain ing th e cell bodies of pseudoun ipolar n euron s th at are respon sible
for conveying p ropriocept ive in form at ion from th e m u scles of th e face; it is
the m ost rost ral of th e n uclei listed. Th e m oto r nucle us o f the trigem inal
nerve (B) con t ain s th e cell bodies of th e n eu ron s th at in n er vate th e m u scles of
m ast icat ion . The principal se nso ry nucleus (C) is h om ologou s to th e n u cleu s
gracilis an d n u cleu s cu n eat u s an d sen ds th e d orsal t rigem in oth alam ic t ract
to th e ipsilateral VPM of th e th alam u s, conveying t act ile an d pressure sen se;
it receives ascen ding processes from t rigem in al ganglion cells. Th e spinal
trigem inal nucleus (D) is th e largest of th e t rigem in al sen sor y n uclei an d
con sist s of a pars oralis, pars in terpolaris, an d pars caudalis. Th e pars caudalis
of th e spinal trigem inal nucleus (D) is th e m ost cau dal of th e n u clei listed
an d receives descen d ing bers from th e t rigem in al ganglion cells. Th e ven t ral
t rigem in oth alam ic t ract carries project ion s from th e m ain sen sor y n ucleus
to th e th alam us regarding t act ile an d pressure sen se, an d carries project ion s
from th e spinal trigem inal nucle us (D) regarding pain an d tem perat ure
sen se. Th e trigem inal ganglio n (E) h ou ses cell bodies of p seu dou n ipolar sen -
sor y n eu ron s. It lies in Meckel’s cave in th e p et rou s tem poral bon e.1

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Neurosurgery Board Review

176. A – I, II, III (IX, X, an d VII)

Th e solit ar y t ract is form ed by visceral a eren t bers from th e vagus, glosso-


p h ar yngeal, an d facial (in term ediate) n er ves. Th e hypoglossal n er ve (CN XII) is
associated w ith th e hypoglossal n u cleu s, n ot th e n u cleu s of th e solitar y t ract .1

177. B – Hip exion

Th e fem oral n er ve in n er vates th e m uscles of th e an terior th igh , w hich con sist


p rim arily of hip exo rs (B) an d kn ee exten sors such as pect in eu s, iliacus,
sartoriu s, an d qu adricep s fem oris (rect u s fem oris, vast u s lateralis, vast u s m e-
dialis, an d vast us in term edius).6

178. A – An terior lobe of th e pit u it ar y

Th e pars t uberalis, a part of th e an terior pit uit ar y (aden ohypophysis),


su rrou n ds th e low er p or t ion of th e p it u it ar y st alk an d is derived from
Rath ke’s pou ch , along w ith p ars d ist alis an d p ars in term edia. Th e n eu rohy-
p op hysis (m edian em in en ce, pit uitar y stalk, an d p ars n er vosa) arises from
the in fun dibulum .1

179. E – Subth alam ic n ucleus

Th e m ajor out put from th e den t ate n ucleu s is via th e brach ium conjun ct i-
vum to th e con t ralateral VL n ucleu s of th e th alam us. Th e VL sen ds projec-
t ion s to th e m otor an d prem otor areas of th e cerebral cortex, w h ich th en
p roject back to th e cerebellar co rtex (A). A p or t ion of th e bers leave th e
den t ate n ucleus via th e brach ium conjun ct ivum , decussate an d syn apse on
the red nucleus (C). Th e red n u cleu s th en sen ds p roject ion s to th e ip silateral
inferio r o livary nucleus (B). In direct project ion s also arrive in th e reticulo -
tegm ental nucleus (D), so th e den t ate m ay part icipate in regu lat ion of sac-
cadic eye m ovem en t s. Th e den t ate n ucleu s does n ot sen d project ion s to th e
subthalam ic nucleus (E).1,2

180. C – II, IV (ven t ral lateral an d ven t ral lateral posterior)

Th e superior cerebellar pedun cle con t ain s m ostly e eren t bers from th e cer-
ebellu m in clu ding th e den torubroth alam ic, in terpositoru broth alam ic (both in
the brach ium conjun ct ivum ), fast igioth alam ic, an d fast igiovest ibular t ract s.
Th e ventral late ral (VL) an d ve ntral anterio r (VA) n u clei ser ve as m otor relay
st at ion s. Th e VL n u cleu s is d ivid ed in to an an terior an d p osterior p or t ion :
ven t ral lateral an terior (VLa) an d ventral lateral po ste rio r (VLp). Th e VLp
receives p roject ion s from th e con t ralateral den t ate n ucleus via th e brach iu m
conjun ct ivum . Th e VLp sh ould n ot be con fused w ith th e ven t ral posterior
lateral n u cleu s (VPL), w h ich is a sen sor y relay st at ion th at receives spin oth a-
lam ic inpu t s. Th e ven t ral an terior n u cleu s of th e th alam us (VA) receives input
from th e su bst an t ia n igra an d th e globu s p allidu s, n ot th e cerebellu m . The
ro stral intralam inar nuclei receive th eir inpu t from th e ascen ding sen sor y
system s an d basal ganglia prim arily, n ot th e cerebellu m .1

158
Neuroanatom y—Answers and Explanations

181. A – Am ygdala

Th e am ygdala (A) is part of th e lim bic system but n ot th e lim bic lobe. Th e lim -
bic system con sist s of th e lim bic lobe plus all subcort ical n uclei an d path w ays.
Th e lim bic lobe con sists of th e cingulate gyrus (B), subcallo sal gyrus (E),
parahippo cam pal g yrus (D), an d h ip pocam p al form at ion . Th e h ipp ocam -
p al form at ion in clu des th e dentate g yrus (C), th e h ipp ocam p u s prop er, an d
th e subiculum .1

182. C – Eth m oid an d vom er bon es

Th e n asal sept um is com prised of a bony par t an d a cart ilagin ous part . Th e
bony n asal sept um is com prised prim arily of perpen dicular plate of th e eth -
m oid bon e an d th e vom er bon e.6

183. B – Abdu ctor p ollicis longu s

Th e posterior in terosseous n er ve (PIN) is th e m otor bran ch of th e radial


n er ve in th e forearm provid ing in n er vat ion to all m u scles located in th e
p osterior com par t m en t of th e forearm in clu ding th e abducto r po llicis
lo ngus (B). The abducto r pollicis brevis (A) an d o ppo nens po llicis (E) are
th en ar m u scles in ner vated by th e recurren t bran ch of th e m edian n er ve. Th e
adducto r po llicis (C) is a th en ar m u scle in n er vated by th e deep bran ch of th e
u ln ar n er ve. Th e an terior in terosseou s n er ve, a bran ch of th e m edian n er ve,
in n er vates th e exo r po llicis longus (D), th e radial h alf of th e exor digito-
ru m p rofu n du s, an d th e p ron ator qu adrat u s.6

184. C – Great cerebral vein of Galen

Th e paired in tern al cerebral vein s are form ed by th e un ion of th e thala-


m o striate (E), cho roidal (A), septal (D), e pithalam ic (B), an d lateral ven -
t ricu lar vein s. Th ey run in th e tela ch oroidea in th e roof of th e th ird ven t ricle
before coursing over th e th alam us in to th e qu adrigem in al cistern w h ere th ey
join to con t ribute to th e vein o f Galen (C).3

185. A – 17

Th e st riate cortex refers to th e prim ar y visual cor tex, Bro dm ann’s area 17 (A).
Areas 18 (B) and 19 (C) are visu al associat ion cor tex. Areas 41 (D) and 42 (E)
are prim ar y au ditor y cortex.1

186. A – I, II, III (an terior cerebral arter y, m iddle cerebral arter y, in tern al carot id arter y)

Th e in tern al capsu le receives blood supply from th e ante rio r ce rebral artery
via th e recu rren t arter y of Hu ebn er, th e m iddle cerebral arte ry via len -
t icu lost riate perforators, an d th e internal carotid artery via th e an terior
ch oroidal arter y. Th e po sterio r cerebral artery does n ot con t ribute to th e
in tern al capsule.3

187. E – Un cin ate fasciculus


188. C – Cingulate fasciculus
189. B – Arcu ate fascicu lu s
190. D – Corpus callosum

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Neurosurgery Board Review

191. A – An terior com m issu re

Th e anterio r co m m issure (A) con n ects th e tem poral lobes of th e t w o h em i-


sp h eres. Th e arcuate fasciculus (B) lin ks Broca’s area to Wern icke’s area. Th e
cingulate fasciculus (C) con n ects th e an terior perforated subst an ce to th e
p arah ipp ocam pal gyru s. Th e co rpus callosum (D) con n ect s th e bilateral ce-
rebral h em isph eres; th e t ap et um is a subset of bers con n ect ing th e tem poral
an d occip it al lobes. Th e uncinate fasciculus (E) con n ects th e an terior tem p o-
ral lobe to th e orbitofron t al gyru s.1,3

192. C – Brach ium conjun ct ivum


193. D – Brach ium pon t is
194. A – Rest iform body

Th e restifo rm (A) an d ju xtarestifo rm (B) body m ake u p th e in ferior cerebel-


lar pedu n cle. Th e restifo rm bo dy (A) con t ain s a eren t bers from th e spin al
cord an d brain stem . Th e ju xtarestifo rm bo dy (B) con t ain s m ostly a eren t
bers bu t also som e e eren t bers from th e cerebellu m . Th e brachium co n-
junctivum (C) t ravels in th e superior cerebellar pedun cle an d represen t s
the prin ciple e eren t path w ay from th e cerebellum (den torubroth alam ic
an d in terp ositoru broth alam ic path w ays). Th e brachium po ntis (D) is th e
m idd le cerebellar pedu n cle an d con sist s of a eren t bers from th e p on s—
pon tocerebellar bers.1,3

195. B – Both eyes tow ard th e lesion

Th e abducen s n ucleus con tain s t w o subset s of n eu ron s. On e set is m ade u p


of m otor n euron s an d projects to th e ipsilateral lateral rect us m uscle, an d th e
oth er p op u lat ion is m ade u p of in tern eu ron s th at p roject to th e con t ralateral
oculom otor n ucleus via th e MLF. Th erefore, dam age to th e abducen s n ucleus
cau ses lateral gaze paralysis ipsilateral to the side o f the lesio n (B). A le-
sion to th e abdu cen s n er ve cau ses an ipsilateral lateral rectus palsy (E). It is
th e on ly cran ial n er ve in w h ich lesion s of th e root bers an d n ucleus do n ot
produ ce th e sam e e ect s.1

196. C – Pter ygopalat in e ganglion

Postganglion ic p arasym p ath et ic bers dest in ed for th e lacrim al glan d are de-
rived from th e pte rygo palatine ganglio n (C). Preganglion ic parasym path et ic
bers from th e su p erior salivator y n u cleu s ru n in th e n er vu s in term ediu s
(along w ith pseudoun ipolar SVA t aste bers from th e tongue an d GSA bers
from th e ear). Th e p arasym p ath et ics for th e lacrim al glan d ru n w ith th e great-
er su per cial p et rosal n er ve, w h ich bran ch es in th e facial can al p roxim al to
th e gen iculate ganglion . Th e bers of th e GSPN join th e bers of th e n er ve of
th e pter ygoid can al (vidian n er ve) an d syn apse in th e pterygo palatine gan-
glio n (C). Th ese bers reach th e lacrim al glan d via th e lacrim al n er ve. Th e
geniculate ganglio n (A) is associated w ith gen eral an d special visceral a er-
en t an d gen eral som at ic a eren t bers t raveling w ith th e facial n er ve an d m e-
diates t aste an d n asoph ar yngeal sen sat ion . Th e otic ganglio n (B) t ran sm it s
p arasym path et ic sign als from th e glossoph ar yngeal n er ve (IX) to th e parot id
glan d. Th e subm andibular (D) an d sublingual (E) ganglia convey p arasym -
p ath et ics t ran sm it ted from CN VII via th e ch orda t ym pan i n er ve.1

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Neuroanatom y—Answers and Explanations

197. B – Globu s p allidu s (false)

The substan t ia n igra sen ds project ion s to th e thalam us (E), th e st riat u m (cau-
date [A] and putam en [C]), th e superio r co lliculus (D), an d tegm en tal area. Th e
su bstan t ia n igra does n ot sen d direct project ion s to th e globus pallidus (B).1

198. E – Tigh t jun ct ion s of capillar y en doth elium

Th e blood–brain barrier is form ed by t igh t jun ct ion s of capillar y en doth elium .1

199. D – Tectorial ligam en t

Th e tectorial ligam ent (D) is th e rost ral exten sion of th e p osterior longit u -
din al ligam en t . Th e ante rio r atlanto -o ccipital m em brane (A) is th e rost ral
exten sion of th e an terior longit u din al ligam en t . Th e apical ligam e nt (B) ex-
ten ds from th e t ip of th e den s to the basion . Th e transverse ligam ent (E)
exten d s bet w een th e t u bercles of th e lateral m asses of C1 an d h old s th e den s
again st th e an terior arch of C1. Th e cruciate ligam ents (C) em erge from th e
t ran sverse ligam en t , con n ect ing th e t ran sverse ligam en t to th e posterior ba-
sion an d p osterior body of C2.3

200. A – 3%
201. B – 30%
202. B – 30%
203. C – 40%
204. C – 40%

Gian t pyram idal cells, or Bet z cells, m ake up approxim ately 3% of cor-
t icospin al bers an d are located exclu sively in prim ar y m otor cortex.
Approxim ately 30% arise from area 4, 30% from area 6, an d th e rem ain der
(40%) arise from th e p ariet al lobe. Ap p roxim ately 40% of cor t icosp in al t ract
axon s are p oorly m yelin ated.1

205. A – An terior belly of th e digast ric m u scle (false)

Th e facial n er ve in n er vates all of th e m uscles of facial expression in clu ding


the buccinato r (B) an d platysm a (C). Th e facial n er ve also in n er vates th e pos-
terior belly of th e digast ric, th e stylo hyo id (E), an d m ylohyoid m u scles. Th e
n er ve to th e stapedius (D) leaves CN VII in th e facial can al to in n er vate th e
st ap ediu s m u scle. CN V in n er vates th e anterio r belly o f the digastric (A) an d
th e m uscles of m ast icat ion .3

206. C – Notoch ord

Th e n u cleus pulposu s of th e in ter ver tebral disks are form ed by noto -


cho rd rem nants (C). Notoch ord rem n an t s are also th ough t to be th e cells of
origin for ch ordom as.3

207. E – Pyriform cortex

The pyrifo rm co rtex (E) (lateral olfactor y gyrus) an d periam ygdaloid area
con st it ute th e prim ar y olfactor y cortex, an d th e ento rhinal co rtex (B) con -
st it u tes th e secon dar y olfactor y cor t ical area.1

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Neurosurgery Board Review

208. A – Nu cleu s am bigu u s 2,6

Th e ven t ral basal plate an d dorsal alar plate are divided by th e sulcus lim i-
t an s. Th e basal plate ten ds to di eren t iate tow ard m otor fun ct ion s an d th e
alar p late ten ds to di eren t iate tow ard sen sor y fu n ct ion s (Alar 5 A eren t).
Th e nucleus am biguus (A) con tain s special visceral e eren t m otor bers in -
volved in th e sw allow ing re ex an d is a basal p late d erivat ive. Th e basal plate
of th e m eten ceph alon gives rise to th e n ucleus of th e abducen s n er ve, para-
sym p ath et ics of th e facial n er ve, an d m otor n u clei of t rigem in al an d facial
n er ves. Th e alar p late of th e m eten cep h alon gives rise to th e n eu ron s of th e
trigem inal (B, D) an d vestibulo co chlear (E) n er ves. Basal p late of th e m es-
en cep h alon gives rise to th e red n u cleu s, su bst an t ia n igra, ocu lom otor, an d
t roch lear n uclei. The nucleus o f the tractus so litarius (C) receives a eren t
bers an d is a p rodu ct of th e alar p late.1

209. A – Dow ngaze to th e op posite side

Th e t roch lear n er ve is un ique because it is th e on ly cran ial n er ve to origin ate


tot ally from th e con t ralateral n u cleus an d th e on ly cran ial n er ve to em erge
from th e dorsal asp ect of th e brain stem . A lesion to th e t roch lear n er ve cau ses
an ip silateral su p erior obliqu e palsy, w h ile a lesion to th e t roch lear n u cleu s
cau ses a con t ralateral superior oblique palsy. Norm al con t ract ion of th e su-
p erior obliqu e m u scle resu lt s in in torsion w ith sim ultan eous depression an d
lateral m ovem en t of th e eye (dow n an d out). Th is diplopia is exacerbated by
dow nw ard, m edial (con t ralateral) gaze, part icularly w h en descen ding st airs
or reading.1

210. A – Su p erior olive


211. B – In ferior olivar y com p lex

Th e superio r olivary nuclear co m plex (A) is involved in th e processing of


au ditor y in form at ion an d h elp s determ in e th e direct ion th at a sou n d is com -
ing from an d th e soun d’s in ten sit y. Th e inferio r o livary nucleus (B) is a relay
n u cleu s of th e cor t ico-olivocerebellar path w ay, fu n ct ion s as a cerebellar relay
n u cleu s, an d is im p or tan t for learn ing n ew m otor t asks.1

212. C – Both
213. A – Su p erior salivator y n u cleu s
214. B – In ferior salivator y n u cleu s
215. C – Both
216. A – Su p erior salivator y n u cleu s

Th e superio r (A) an d inferio r (B) salivato ry nuclei both t ran sm it gen eral
visceral e eren t p arasym p ath et ic bers an d are located in th e brain stem re-
t icu lar form at ion . Th e superio r salivatory nucle us (A) sen ds its bers via th e
n er vu s in term ediu s of th e facial n er ve; a port ion of it s bers t ravel to th e
pter ygopalat in e ganglion via th e GSPN an d vidian n er ve, an d an oth er por-
t ion t ravels to the subm an dibular ganglion via th e ch orda t ym pan i n er ve. Th e
infe rio r salivato ry nucleus (B) sen ds it s bers w ith th e lesser pet rosal n er ve
of th e glossoph ar yngeal n er ve (IX) to u lt im ately reach th e ot ic ganglion an d
parot id glan d.1

162
Neuroanatom y—Answers and Explanations

217. C – Both
218. B – Sym path et ic

Th e sh ort ciliar y n er ves are m ain ly com posed of parasym path et ic bers from
the ciliar y ganglion to th e eye, but som e sym path et ic bers are also presen t . Th e
long ciliar y n er ves carr y sym path et ic bers th at m ediate pu pillar y dilatat ion .1

219. C – Dorsal spin ocerebellar t ract


220. B – Cu n eocerebellar t ract
221. A – An terior sp in oth alam ic t ract
222. E – Ven t ral spin ocerebellar t ract
223. D – Lateral spin oth alam ic t ract
224. E – Ven t ral spin ocerebellar t ract
225. E – Ven t ral spin ocerebellar t ract

Th e lateral spinothalam ic tract (D) arises from cells in lam in ae I, IV, an d V,


an d t ran sm its p ain an d tem p erat u re sen sat ion . Fibers in th is t ract cross in th e
an terior w h ite com m issu re, u su ally w ith in on e spin al segm en t . Th e ante rio r
spinothalam ic tract (A) also arises from cells in lam in ae I, IV, an d V, an d cross-
es in a decu ssat ion th at involves several segm en t s. It t ran sm it s ligh t tou ch . Th e
do rsal spino cerebellar tract (C) is u n crossed an d arises from cells of th e dor-
sal n u cleu s of Clarke (from C8 to L2). Th e ven t ral spino cerebellar tract (E) is
crossed, w h ereas th e cuneo ce rebellar (B) t ract is un crossed. Th e lat ter th ree
t ract s t ran sm it un con scious exterocept ive im pulses con cern ed w ith m ove-
m en t an d p ost u re. Th e cuneo cerebellar tract (B) t ransm its im pulses from
th e u pper ext rem it y, w h ereas th e do rsal spino ce rebellar tract (C) t ran sm it s
im p u lses from th e low er ext rem it y.2

226. D – Tectospin al t ract


227. B – Ret icu losp in al t ract
228. A – Cort icosp in al t ract
229. C – Rubrospin al t ract
230. E – Vest ibulospin al t ract

Th e co rtico spinal tract (A) divides in to a large crossed lateral cort icosp i-
n al t ract , sm all u n crossed an terior cor t icospin al t ract , an d a m in u te ( 2%
of bers) un crossed an terolateral cor t icospin al t ract at th e jun ct ion of th e
m edu lla an d spin al cord. Th e tecto spinal tract (D) arises from cells in th e
su perior collicu lu s, term in ates in th e u p per fou r cer vical levels, an d m edi-
ates re ex post u ral m ovem en t s in resp on se to visual st im u li. Th e rubro -
spinal tract (C) arises from th e m agn ocellular region of th e red n ucleus,
an d its m ost im p or tan t fu n ct ion is in th e con t rol of exor m u scle ton e. Th e
vestibulo spinal tract (E) arises m ain ly from th e lateral vest ibular n ucleus.
Th is t ract facilitates spin al re ex act ivit y an d spin al m ech an ism s th at con -
t rol exten sor ton e. Th e tectospin al an d rubrospin al t racts are both crossed,
w h ereas th e vest ibulospin al t ract is un crossed. Th e reticulo spinal tracts
(B) arise from th e pon t in e tegm en t um (pon t in e ret iculospin al t ract) an d th e
m edu lla (m edu llar y ret icu losp in al t ract). Th e form er is u n crossed, w h ereas
the lat ter con sist s of crossed and u n crossed com pon en t s. St im ulat ion of th e
brain stem ret icular form at ion can facilitate an d in h ibit volun t ar y m ovem en t ,
cor t ically in duced m ovem en t , an d re ex act ivit y, am ong oth er e ect s.2

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Neurosurgery Board Review

231. D – Obt urator n er ve


232. E – Sciat ic n er ve
233. A – Deep p eron eal n er ve
234. G – Su p erior glu teal n er ve
235. C – In ferior gluteal n er ve
236. H – Tibial n er ve
237. B – Fem oral n er ve
238. H – Tibial n er ve
239. F – Su p er cial p eron eal n er ve
240. B – Fem oral n er ve

Th e superio r gluteal nerve (G) in n er vates gluteus m edius, gluteus m in i-


m u s, an d th e ten sor of th e fascia lat a, w h ich add u ct an d m edially rot ate th e
thigh . Th e inferio r gluteal ne rve (C) in n er vates gluteus m axim us, w h ich
exten d s th e th igh at th e h ip . Th e sciatic nerve (E) in n er vates n o gluteal
m u scles, all m u scles of p osterior th igh , an d all th e m u scles of th e leg an d
foot (via it s bran ch es). Th e add u ctor m agn u s is in th e m edial com p art-
m en t of th e th igh an d is con sidered to be on e of th e ve addu ctors of th e
thigh . Th e m edial com part m en t of th e th igh is in n er vated prim arily by th e
o bturato r ne rve (D). Th e addu ctor part of addu ctor m agn u s is in n er vated by
the obt urator n er ve, but th e h am st rings part of addu ctor m agn us is in n er-
vated by th e sciatic nerve (E). Th e fem o ral nerve (B) in n er vates th e m uscles
of th e an terior th igh , w h ich con sist prim arily of h ip exors an d kn ee exten -
sors su ch as iliop soas, pect in eu s, iliacu s, sartoriu s, an d qu adriceps fem oris
(rect us fem oris, vast us lateralis, vast us m edialis, an d vast us in term edius). A
p or t ion of th e addu ctor m agn us is also in n er vated by th e obt urator n er ve. Th e
sciat ic n er ve bran ch es in to th e tibial nerve (H), w h ich su p plies th e m u scles of
the posterior com par t m en t of th e leg such as gast rocn em ius an d exor digi-
toru m longus, an d th e pero neal ne rve. Th e peron eal n er ve h as a su p er cial
an d a d eep bran ch . Th e super cial pero neal ne rve (F) su pplies th e m uscles
of th e lateral com part m en t of th e leg such as peron eus longu s an d brevis. Th e
de ep pero neal ne rve (A) su p plies th e m u scles of th e an terior com part m en t
of th e leg in cluding th e exten sor h allucis longus.6

241. C – Both

Molecu les also m ove across th e blood–brain barrier by di u sion . Su bst an ces
that cross th e blood–brain barrier by di usion in clude w ater an d alcoh ol.
D-glu cose an d large n eu t ral am in o acids are t ran sported in to th e brain by
carrier-m ediated t ran spor t . Act ive t ran sport is used to m ove w eak organ ic
acids, h alides, an d ext racellu lar K1 from th e brain an d cerebrosp in al u id
in to plasm a.2

242. A – Arcu ate n u cleu s to m edian em in en ce

Th e t uberohypophysial or t uberoin fun dibular t ract arises from th e t u-


beral region (m ain ly th e arcuate n ucleus) an d can be t raced to th e
m e dian em inence (A) an d in fu n dibu lar stem w h ere h orm on es are released
in to th e hyp ophyseal p or t al system . Th e su praopt icohypophyseal t ract car-
ries oxytocin or vasop ressin from th e suprao ptic and pe riventricular nuclei
to the po sterio r hypo physis (E).1

164
Neuroanatom y—Answers and Explanations

243. A – Ap ical ligam en t


244. B – Alar ligam en ts
245. C – Den t ate ligam en ts
246. D – Tectorial m em bran e
247. G – An terior atlan to-occipit al m em bran e
248. H – Tran sverse ligam en t
249. E – Superior cru ciate ligam en t s
250. F – In ferior cru ciate ligam en t s

Th e te cto rial m e m brane (D) is th e rost ral exten sion of th e p osterior longi-
t udin al ligam en t . Th e anterio r atlanto -o ccipital m em brane (G) is th e ros-
t ral exten sion of th e an terior longit u din al ligam en t . Th e apical ligam ent (A)
exten d s from th e t ip of th e den s to th e basion . Th e alar ligam ent (B) exten d s
from th e den s to th e lateral foram en m agn u m . Th e transverse ligam ent (H)
exten d s bet w een th e t u bercles of th e lateral m asses of C1 an d h olds th e
den s again st th e an terior arch of C1. Th e cruciate ligam e nts em erge from
th e t ran sverse ligam en t , con n ect ing th e t ran sverse ligam en t to th e posterior
basion (superio r cruciate ligam ents [E]) an d posterior body of C2 (infe rio r
cruciate ligam ents [F]). Th e dentate ligam ents (C) are bilateral exten sion s
of pia con n ect ing th e lateral spin al cord to th e dura.3

251. C – Paraven t ricular n ucleu s

Descen ding hyp oth alam ic au ton om ic bers arise from m u lt iple hyp oth alam ic
n u clei, bu t th e p rin cip le sou rce of th ese d escen ding au ton om ic bers is
the par vocellular part of th e paraventricular nucle us (C). Som e of th e
p araven t ricu lar n euron s project to both sym path et ic an d parasym path et ic
t arget s. Th e m am m illary nucle us (A) is associated w ith th e processing of in -
form at ion related to em ot ion al exp ression . Th e m edial preo ptic nucleus (B)
regu lates th e release of rep rod uct ive h orm on es from th e aden ohypophysis.
Th e periventricular nucle us (D) p rodu ces hyp oth alam ic releasing an d in h ib -
it ing h orm on es. Th e supraoptic nucleus (E) con t ribu tes to th e produ ct ion of
ADH an d oxytocin .1

252. E – T1-L2 of th e spin al cord (false)

Th e hypoth alam u s sen ds descen ding auton om ic project ion s to a variet y of


st ru ct u res. Fibers from th e posterior an d lateral hyp oth alam u s p roject to th e
p reganglion ic sym path et ic n eu ron s from T1-L2 of th e spin al cord to provide
sym p ath et ic con t rol (E is false). Fibers from th e an terior an d m edial hyp o-
th alam us project to th e Edinger-Westphal nucle us (B), th e superio r and
infe rio r salivato ry nucle i (D), th e do rsal m oto r nucleus o f vagus (A), an d
th e S2-S4 parasym pathetic nucleus (C) to drive parasym p ath et ic con t rol.1

253. B – Parasym p ath et ic system


254. B – Parasym p ath et ic system
255. B – Parasym p ath et ic system
256. A – Sym p ath et ic system
257. A – Sym p ath et ic system
258. B – Parasym p ath et ic system

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Neurosurgery Board Review

259. B – Parasym p ath et ic system

Th e hypoth alam u s sen ds descen ding auton om ic project ion s to a variet y of


st ru ct u res. Fibers from th e posterior an d lateral hyp oth alam u s p roject to th e
p reganglion ic sym path et ic n eu ron s from T1-L2 of th e spin al cord to p rovide
sym pathetic co ntrol (A). Fibers from th e an terior an d m edial hyp oth alam u s
p roject to th e Edinger-West p h al n ucleu s, th e superior an d in ferior salivator y
n u clei, th e dorsal m otor n u cleu s of vagu s, an d th e S2-S4 parasym path et ic
n u cleu s to d rive parasym pathetic co ntro l (B).1

260. B – Secon d-order n eu ron s as th e in tern al arcu ate bers

In th e d orsal colu m n –m edial lem n iscal system , rst-order n eu ron s term in ate
in th e n ucleu s gracilis an d cu n eat us, w h ere th e cell bodies of secon d-order
n eu ron s are located. Th ese secon d-ord er n eu ron s form th e internal arcuate
bers (B) th at cu r ve ven t rom edially an d decussate th rough th e ret icular
form at ion . Th ese sam e secon d-order n eu ron s th en ascen d in th e cau dal
m edu lla as th e m edial lem niscus (D), u lt im ately syn ap sing w ith th ird -order
n eu ron s in th e ven t ral p osterior lateral n u cleu s of th e th alam u s. Fibers of th e
sp in oth alam ic t ract d ecu ssate as secon d-order n eu ron s in th e anterio r w hite
co m m issure (A) of th e sp in al cord. Th e lateral lem niscus (C) con t ain s both
secon d- an d th ird-order n eu ron s, an d is th e m ajor ascen ding au ditor y p ath -
w ay in th e brain stem . Th e pyram idal de cussatio n (E) is associated w ith th e
descen ding m otor system .1

261. C – Leptom en inges of ven t ral m edulla

Melan ocytes are m ost often fou n d in th e lepto m eninges o f the ve ntral
m e dulla (C) an d cer vical cord. Th ese are th e p resu m ed cells of origin for focal
or dissem in ated CNS m elan om a w h en th ere is n o h istor y of a prim ar y skin
lesion . Th e pigm en tat ion in th e substantia nigra (D) is due to accum ulat ion
of n eu rom elan in , a catech olam in e w aste product , in dopam in ergic n eurons.
Th e oth er respon ses are in correct .

262. D – Global aph asia (false)

Th e de cit s seen in injuries to th e n on dom in an t h em isph ere m ay be due, in


p ar t , to de cit s of p ercept ion an d at ten t ion . Th ese pat ien ts m ay be un aw are
of th eir de cit (ano so gno sia [A]). Th ey m ay also n eglect object s an d person s
on th e con t ralateral side of th eir body or con t ralateral visual eld (con-
tralateral he m i-neglect [B]). Diso rientatio n to tim e and directio n (C) is
ch aracterist ic, an d m ay even occur w h en th e pat ien t is orien ted to person an d
p lace. Visuospatial pro blem s (E) are com m on in clu ding di cult y rem em -
bering sh apes an d even faces (prosopagn osia). True aph asias are associated
w ith injur y to th e dom in an t h em isph ere (D is false).7

166
Neuroanatom y—Answers and Explanations

263. B – Project ion s of rst-order n euron s form Lissauer’s t ract (dorsolateral fasciculus)

Th e an terolateral system t ran sm its in form at ion about pain , tem perat ure, an d
crude touch to th e brain . Th e rst-order bers con sist m ain ly of thinly m y-
elinated, fast co nducting A-delta bers (E is false) an d unm yelinated, slow
co nducting C bers (D is false). Th ese rst-ord er p seu dou n ipolar n eu ron s
en ter th e dorsal h orn an d fo rm the tract o f Lissauer o r do rso lateral fascicu-
lus (B), w h ich ascen d or descen d on e to th ree sp in al levels. Th e se co nd-o rde r
neuro ns the n de cussate in the anterio r w hite co m m issure (A is false) be-
fore ascen ding to th eir targets. Th e antero lateral system do es not interact
w ith Clarke’s co lum n (nucleus do rsalis), w h ich is located in lam in a VII of
sp in al cord levels C8-L2,3 an d is involved in prop riocept ion (C is false).1

264. B – Clarke’s colu m n an d dorsal sp in ocerebellar t ract

Propriocept ive inform at ion from th e t run k an d low er lim b is carried by rst-
order pseudoun ipolar n eu ron s to th e nucle us do rsalis (Clarke’s co lum n),
w h ich is located in lam in a VII of spin al cord levels C8-L2,3. Clarke’s colum n
con t ain s secon d-order n eu ron s th at project rost rally to form th e do rsal spi-
no cerebellar tract (B). Low er lim b p ropriocept ion is carried in th e lateral
Clarke’s colu m n n euron s, n ot in th e po sterio r co lum ns (A). Th e nucleus cu-
neatus and cuneo cerebellar tract (C) carr y prop riocept ive in form at ion from
th e n eck an d upper lim bs to th e cerebellum . Th e nucleus o f Clarke ho m o -
lo gue in the ce rvical re gio n and the ro stral spino cerebellar tract (E) carr y
propriocept ive in form at ion from th e h ead an d upper lim b to th e cerebellu m .
Cho ice B is a bet ter an sw er th an cho ice D.1,3

265. C – Is a th in bun dle of un m yelin ated bers (false)

Th e m am m illoth alam ic t ract , also kn ow n as th e tract o f Vicq d’Azyr (A), is a


heavily m yelinated (C is false) bu n dle of bers th at p roject s from th e m edial
an d lateral m am m illar y n u cleu s of th e m am m illary bo dy to the anterio r
nuclear gro up o f the thalam us (D). Th e Papez circuit (B) con sist s of th e
h ip p ocam p u s, forn ix, m am m illar y body, m am m illoth alam ic t ract , an terior
n u cleu s of th e th alam u s, an d cingu lated gyru s. Th e m am m illoth alam ic t ract
can be a useful landm ark during planning fo r subthalam ic nucleus target-
ing (E), as it is u su ally sit u ated at th e level of th e an terior border of th e STN.1,5

266. C – In terpedun cular an d ch iasm at ic cistern

On p n eu m oen ceph alogram , air is preven ted from ascen ding in th e su barach -
n oid space arou n d th e opt ic ch iasm by a th ick layer of arach n oid, Liliequ ist’s
m em bran e. Th e t w o cistern s sep arated by th e m em bran e of Liliequ ist are th e
chiasm atic cistern and the inte rpe duncular cistern (C).10

267. D – Lam in a term in alis


268. A – Ch oroid ssu re
269. E – Velum in terposit um
270. B – Foram en of Lu sch ka

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Neurosurgery Board Review

271. C – Foram en of Magen die

Th is is a list of st ruct ures th at separate port ion s of th e ven t ricular system


from th e su barach n oid cistern s. Th e cru ral cistern an d tem p oral h orn of th e
lateral ven t ricle m eet at th e ch oroid ssu re (A), w h ere th ey are sep arated by
the arach n oid an d a single pial layer—th e an terior an d lateral posterior ch o-
roidal ar teries t raverse th e ch oroid ssure to su pp ly th e ch oroid plexus. Th e
lateral recess of th e fou r th ven t ricle op en s in to th e lateral cerebellom edul-
lar y cistern th rough th e fo ram en o f Luschka (B); a n e in com p lete arach -
n oid m em bran e is presen t h ere. Th e fou r th ven t ricle op en s in th e m idlin e
in to th e cistern a m agn a via th e fo ram en o f Magendie (C). A th in m em bran e
con t ain ing n eural elem en ts, th e lam ina term inalis (D), sep arates th e lam in a
term in alis cistern from th e an terior par t of th e th ird ven t ricle. Th e cistern of
th e velu m in terposit um an d th ird ven t ricle are separated by arach n oid and
ep en dym a (the velum interpo situm [E]). Th e velu m in terposit u m cistern
con t ain s th e m edial posterior ch oroidal arteries an d in tern al cerebral vein s.10

References

1. Patest as MA, Gar t n er LP. A Textbook of Neuroanatom y. Malden , MA: Blackw ell Publish ing;
2006
2. Carpen ter MB. Core Text of Neu roan atom y, 4th ed. Balt im ore, MD: William s & Wilkin s;
1991
3. Citow JS, Macdon ald RL, Refai D, eds. Com preh en sive Neu rosu rger y Board Review. New
York: Th iem e Medical Pu blish ers; 2009
4. Rh oton AL. Cran ial An atom y an d Su rgical Ap proach es. Ph ilad elph ia: Lip p in cot t , William s,
and Wilkin s; 2013
5. Qu in on es-Hin ojosa A, ed. Sch m idek & Sw eet Op erat ive Neu rosu rgical Tech n iqu es, 6th ed .
Ph iladelphia, PA: Elsevier; 2012
6. Moore KL, Dalley AF. Clin ically Orien ted An atom y, 5th ed. Balt im ore, MD: Lippin cot t
William s an d William s; 2006
7. Ropper AH, Brow n RH. Prin ciples of Neu rology, 8th ed. New York: McGraw -Hill; 2005
8. Miller DC. Modern Surgical Neuropathology. New York: Cam bridge Un iversit y Press; 2009
9. Blu m en feld H. Neu roan atom y th rough Clin ical Cases, 2n d ed . Su n d erlan d, MA: Sin au er
Associates; 2011
10. Yasargil MG. Micron eurosurger y, Volum e I. New York: Th iem e; 1984

168
4A Neurobiology—Questions

For qu est ion s 1 to 5, m atch th e su bst an ces w ith th e descript ion .


A. Bon e grow th factors
B. Recom bin an t h um an bon e m orph ogen ic protein s
C. Both
D. Neith er

1. A st rong m itogen

2. A poten t in du cer of bon e cell di eren t iat ion

3. Act on di eren t iated m esen chym al cells of th e ch on dro-osseous lin eage

4. Act on un di eren t iated m esen chym al cells

5. Polypept ides

6. W h ich of th e follow ing is th e correct represen tat ion of th e subu n it s of th e acet yl-
ch olin e (ACh ) receptor at th e n eu rom uscular jun ct ion ?
A. a b gd
B. a 2b gd
C. a b 2gd
D. a b g2d
E. a b gd2

7. W h ich of th e follow ing is t ru e of th e a subu n it of th e n icot in ic acet ylch olin e


receptor?
A. It con t ain s four hydroph obic t ran sm em bran e por t ion s.
B. Th e bin ding site is n ot located on th e a su bu n it .
C. Th e cytoplasm ic loop is th e m ost h igh ly con ser ved por t ion of th e subun it .
D. Th e N term in al is ext racellu lar, an d th e C term in al is in t racellu lar.
E. Th e t ran sm em bran e port ion is th e least con ser ved segm en t .

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8. Th e n um ber of bin ding sites on th e n icot in ic acet ylch olin e receptor is


A. 1
B. 2
C. 3
D. 4
E. 5

For quest ion s 9 an d 10, m atch th e descript ion w ith th e receptor.


A. a su bu n it of GABAA receptor
B. b su bu n it of GABAA receptor
C. Both
D. Neith er

9. Bin ds g-am in obu t yric acid (GABA)

10. Bin ds ben zodiazepin es

For qu est ion s 11 to 16, m atch th e receptor w ith th e descript ion . Each resp on se m ay be
used on ce, m ore th an on ce, or n ot at all.
A. GABA receptor
B. Glut am ate receptor
C. Glycin e receptor
D. Nicot in ic ACh receptor
E. Seroton in (5-HT) receptor

11. Most closely lin ked w ith syn apt ic plast icit y an d cell death

12. GABA an d th is receptor are perm eable to ch loride ion s

13. Bin ds st r ych n in e

14. Bin ds ben zodiazepin e

15. On e t ype of th is receptor is both ligan d an d voltage regulated

16. On e t ype of th is receptor is blocked by m agn esiu m ion s

For qu est ion s 17 to 21, m atch th e descript ion w ith th e receptor.


A. Kain ate receptor only
B. N-m ethyl- d -asp art ate (NMDA) receptor on ly
C. Quisqualate/a -am in o-3-hydroxy-5-m ethyl-4-isoxazoleprop rion ic acid
(AMPA) receptor on ly
D. A an d B
E. A, B, an d C

17. Sign i can tly perm eable to calcium ion s

18. Perm eable to m on ovalen t cat ion s

19. Ligan d-gated

20. Volt age-gated

21. Blocked by m agn esium ion s

170
Neurobiology—Questions

22. W h ich of th e follow ing is t ru e of acet ylch olin e (ACh ) release from th e n eurom us-
cular jun ct ion ?
A. On e m olecule of ACh equ als 10,000 quan ta
B. On e quan ta con t ain s 10,000 m olecules of ACh
C. On e quan t a equals 1 m olecule of ACh
D. On e vesicle con tain s 10,000 quan t a
E. On e vesicle con tain s 10 m olecu les

23. Pro-opiom elan ocort in is a precursor of


I. Adren ocort icot rop ic h orm on e (ACTH)
II. a -m elan ocyte-st im u lat ing h orm on e (MSH)
III. b -en dorp h in
IV. b -lip ot rop in
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

24. Rem oval of calcium ion s from the cytosol in a presyn apt ic n er ve term in al
follow ing an act ion p oten t ial is th ough t to occu r by
I. Act ive t ran sp or t
II. Bin ding to cytosolic p rotein s
III. Tran sp or t in to in t racellu lar calciu m storage vesicles
IV. Reversal of ow th rough voltage-gated calciu m ch an n els
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

25. Each of th e follow ing occurs in ph otot ran sduct ion except
A. Act ivated rh odop sin act ivates a G protein .
B. Act ivat ion of cyclic guan osin e m on oph osph ate (cGMP) ph osphodiesterase
in creases hydrolysis of cGMP to 59-GMP.
C. Curren t th rough a cGMP-act ivated sodiu m ch an n el decreases.
D. Rh odopsin is act ivated w h en ligh t convert s boun d 11-cis-ret in al to all-
t rans-ret in al.
E. Th e decreased con cen t rat ion of cGMP result s in depolarizat ion of th e
p lasm a m em bran e.

26. Each of th e follow ing is t rue of G protein s except


A. Each G protein is regu lated by on ly on e t ype of receptor.
B. Each G protein m ay regulate m u lt iple e ectors.
C. Th e a su bu n it bin ds gu an osin e t rip h osph ate (GTP).
D. Th e b an d g su bu n its h elp an ch or th e a su bu n it to th e p lasm a m em bran e.
E. Th e b an d g su bu n it s m odu late gu an osin e dip h osph ate (GDP)/GTP
exch ange.

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Neurosurgery Board Review

For qu est ion s 27 to 33, m atch th e secon d m essenger w ith th e descript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Calcium
B. 1,2-Diacylglycerol (DAG)
C. Cyclic aden osin e m on oph osph ate (cAMP)
D. Cyclic guan in e m on oph osph ate (cGMP)
E. In ositol-1,4,5-t risph osph ate (IP3)
F. B an d E

27. D1 receptors act by th is secon d m essenger

28. In creased by n it ric oxide

29. Gen erated by th e act ion of ph osph olipase C

30. Syn ergist ically act ivates protein kin ase C w ith calcium

31. Bin ds to calm odulin

32. Ph otorecept ion ut ilizes th is secon d m essenger

33. Open s a calcium ch an n el in th e en doplasm ic ret iculum , releasing free calcium


in to th e cytosol

34. Each of th e follow ing is t rue of th e Na 1 /K1 p u m p except th at it


A. Con t ributes to th e rest ing poten t ial of th e cell
B. Hyperpolarizes th e m em bran e
C. Is elect rogen ic
D. Tran spor t s th ree Na 1 ion s ou t for t w o K1 ion s in
E. Ut ilizes t w o m olecules of aden osin e t riphosph ate (ATP) for ever y th ree Na 1
ion s t ran spor ted

35. Each of th e follow ing is t rue of even t s occurring during th e act ion poten t ial
except
A. A sudden in crease in con duct an ce of Na results in depolarizat ion .
B. Ch loride perm eabilit y in creases during depolarizat ion .
C. During hyperpolarizat ion , th e con duct an ce of Na is low er th an n orm al, an d
th e con duct an ce of K is h igh er th an n orm al.
D. Th e decrease in Na perm eabilit y, occurring as th e act ion poten t ial reach es
a peak, resu lt s from in act ivat ion of Na ch an n els.
E. Th e presen ce of volt age-depen den t K ch an n els is to allow faster
repolarizat ion .

36. Th e velocit y of an act ion poten t ial in creases w ith a


A. High tran sm em bran e resistan ce, low in tern al resistan ce, an d h igh m em -
brane capacitan ce
B. High t ran sm em bran e resist an ce, low in tern al resist an ce, an d low m em -
bran e capacitan ce
C. Low t ran sm em bran e resistan ce, h igh in tern al resist an ce, an d h igh m em -
bran e capacit an ce
D. Low t ran sm em bran e resistan ce, low in tern al resistan ce, an d h igh m em -
bran e capacit an ce
E. Low t ran sm em bran e resistan ce, low in tern al resist an ce, an d low m em -
bran e capacit an ce

172
Neurobiology—Questions

37. W h ich of th e follow ing is t rue of m yelin at ion ?


A. It h as n o e ect on t ran sm em bran e resist an ce bu t in creases m em bran e
cap acit an ce.
B. It decreases both t ran sm em bran e resistan ce an d m em bran e capacit an ce.
C. It decreases t ran sm em bran e resist an ce an d in creases m em bran e
capacit an ce.
D. It in creases t ran sm em bran e resist an ce an d decreases m em bran e
capacit an ce.
E. It in creases both t ran sm em bran e resist an ce an d m em bran e capacit an ce.

For qu est ion s 38 to 40, m atch th e descript ion w ith th e poten t ial.
A. En d-plate poten t ial
B. Min iat ure en d-plate poten t ial
C. Both
D. Neith er

38. Usually depolarizes m u scle cells past th resh old

39. Occurs in un st im u lated cells

40. Produces a m in iat ure act ion poten t ial

41. In h ibitor y post syn apt ic poten t ials are produ ced w h en a t ran sm it ter open s ch an -
n els p erm eable to
A. Cl2 on ly
B. Cl2 or K1
C. Na 1 on ly
D. Na 1 or Cl2
E. Na 1 or K1

42. W h ich of th e follow ing is t rue of axon al t ran spor t?


A. Dyn am in does n ot use ATP.
B. Dyn ein is th e m otor for an terograde fast axon al t ran sport .
C. Fast axon al t ran sport occu rs prim arily along n euro lam en t s.
D. Kin esin is th e m otor for ret rograde fast axon al t ran sport .
E. Slow axon al t ran spor t occurs at 200 to 400 m m /day.

For qu est ion s 43 to 52, m atch th e descript ion w ith th e st ru ct u re.


A. Golgi ten don organ
B. Muscle spin dle
C. Both
D. Neith er

43. Disch arge in creases w ith passive st retch

44. Disch arge in creases w ith act ive con t ract ion

45. In series w ith ext rafusal bers

46. In parallel w ith ext rafusal bers

47. Sen sit ive to m u scle ten sion

48. Sen sit ive to m u scle length an d velocit y of length ch ange

49. In n er vated by group I (large m yelin ated) bers

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Neurosurgery Board Review

50. In n er vated by group II (sm all m yelin ated) bers

51. Con duct ion velocit y of a eren t bers is . 120 m /s.

52. Con t ain s dyn am ic n uclear bag, stat ic n uclear bag, an d n uclear chain bers

53. Each of th e follow ing is t rue of decerebrate rigidit y except


A. It resu lt s from ton ic act ivit y in th e vest ibulospin al an d pon t in e ret icu lospin al
n eu ron s.
B. It is reduced by cut t ing dorsal roots.
C. It is redu ced by dest ruct ion of th e an terior lobe of th e cerebellum .
D. It occurs w ith t ran sect ion bet w een th e colliculi.
E. Th ere is in creased gam m a m otor n euron act ivit y.

For qu est ion s 54 to 59, m atch th e re ex or resp on se w ith th e descript ion . Each an sw er
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Clasp -kn ife respon se
B. Flexion re ex
C. F respon se
D. H respon se
E. M respon se
F. St retch re ex

54. An an t idrom ic w ave in m otor bers t raveling to an terior h orn cells

55. Has ph asic an d tonic com pon en t s

56. A protect ive re ex involving polysyn apt ic re ex path w ays

57. Th e elect rical equivalen t of th e ten don re ex

58. Th e direct m otor respon se obt ain ed by st im ulat ing a m ixed m otor sen sor y n er ve

59. A length -depen den t ch ange in m uscle force w h en th e lim b is passively m oved

60. Con t ract ion of th e det ru sor m uscle of th e bladder is ach ieved th rough
act ivat ion of
A. Parasym path et ic bers from T9 to L1
B. Parasym path et ic bers from S2 to S4
C. Sym path et ic bers from T9 to L1
D. Sym path et ic bers from S2 to S4
E. Puden dal n er ves

61. W h ich is t rue of even t s occurring after a t ypical axon is severed?


A. Ch rom atolysis is alw ays associated w ith decreased protein syn th esis.
B. Ret ract ion bu lbs form on ly at th e proxim al en d of th e cut n er ve.
C. Term in al degen erat ion leads to th e loss of presyn apt ic term in als.
D. Wallerian degen erat ion occurs before term in al degen erat ion .
E. Wallerian degen erat ion leads to loss of th e proxim al axon segm en t .

174
Neurobiology—Questions

62. Agen t s th at in crease th e form at ion of cerebrospin al uid (CSF) in clude


I. Carbon dioxide
II. Norepin eph rin e
III. Volat ile an esth et ic agen t s
IV. Carbon ic an hydrase in h ibitors
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

63. Th e m ain n eurot ran sm it ter of th e Ren sh aw cell is th ough t to be


A. Acet ylch olin e
B. GABA
C. Glutam ate
D. Glycin e
E. Histam in e

For qu est ion s 64 to 68, m atch th e w ave in th e brain stem au ditor y evoked respon se w ith
th e st ruct ure w ith w h ich it is m ost closely associated. Each respon se m ay be used on ce,
m ore th an on ce, or n ot at all.
A. Wave I
B. Wave II
C. Wave III
D. Wave IV
E. Wave V

64. Auditor y n er ve

65. Coch lear n uclei

66. In ferior colliculus

67. Lateral lem n iscus

68. Superior olivar y n ucleus

For qu est ion s 69 to 72, m atch th e w ave in th e som atosen sor y evoked poten t ial w ith th e
descript ion . Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Erb’s poin t
B. N11
C. N13/P13
D. N19
E. P22

69. Absen ce or delay im plies cer vical cord disease

70. Absen ce or delay im plies periph eral n er ve disease

71. Absen ce or delay im plies a lesion in th e low er m edulla

72. Is fou n d at the sh oulder

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Neurosurgery Board Review

For qu est ion s 73 to 75, m atch th e rate of cerebral blood ow w ith th e descript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. 75 m L/100 g/m in
B. 55 m L/100 g/m in
C. 23 m L/100 g/m in
D. 17 m L/100 g/m in
E. 8 m L/100 g/m in

73. Crit ical th resh old below w h ich fu n ct ion al im pairm en t occurs

74. Irreversible in farct ion occurs below th is ow rate

75. Norm al cerebral blood ow

For qu est ion s 76 to 83, m atch th e cerebellar cort ical cell w ith th e descript ion . Each
respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Basket cells
B. Golgi cells
C. Gran ule cells
D. Purkinje cells
E. Stellate cells

76. Axon s of th ese cells m ain ly com pose th e m olecular layer

77. Reside in th e gran ular layer togeth er w ith gran u le cells

78. Excitator y

79. Mossy bers syn apse h ere

80. Clim bing bers syn apse h ere

81. Th e only cerebellar cort ical out put

82. Directly in h ibit Purkinje cells togeth er w ith stellate cells

83. Ut ilize glut am ate

84. W h ich is t rue of th e m acule of th e u t ricle an d saccule w h en th e h ead is h eld


erect?
A. Th e u t ricu lar m acu le is orien ted h orizon tally, an d th e saccular m acu le is
orien ted ver t ically.
B. Th e ut ricular m acule is orien ted ver t ically, an d th e saccular m acule is ori-
en ted h orizon t ally.
C. Th ey are both orien ted h orizon tally.
D. Th ey are both orien ted ver t ically.
E. Non e of th e above is t rue.

85. Th e sen sat ion of sh arp, pricking pain is m ediated by


A. Aa bers
B. Ab bers
C. Ag bers
D. Ad bers
E. C bers

176
Neurobiology—Questions

86. W h ich is t rue of syn apt ic t ran sm ission in autom at ic ganglia?


A. Neuron al ACh receptors con t ain fou r t ypes of subun its.
B. Th e slow excitator y post syn apt ic poten t ial (EPSP) is produced by m usca-
rin ic receptors closing Na 1 an d Ca 21 ch an n els w h ile op en ing K1 ch an n els.
C. Th e slow in h ibitor y postsyn apt ic poten t ial (IPSP) is m ediated by act ivat ion
of m uscarin ic receptors th at close K1 ch an n els.
D. Th e fast EPSP is m ediated by n icot in ic ACh receptors.
E. Pept ides are n ever co-released w ith ACh .

87. Each of th e follow ing is t rue of th e n eural in n er vat ion of th e bladder except
A. In creased postganglion ic sym path et ic act ivit y resu lt s in bladder w all
con t ract ion .
B. In creased postganglion ic sym path et ic act ivit y results in a -adren ergic
in h ibit ion of p arasym path et ics in th e p elvic ganglion .
C. Motor n eu ron s in th e ven t ral h orn of th e sacral spin al cord in n er vate th e
extern al sp h in cter.
D. Parasym path et ic act ivit y prom otes bladder em pt ying.
E. Th e in tern al sph in cter is in n er vated by sym path et ic bers.

88. Fibers from th e superior salivator y n ucleus syn apse in th e


I. Pter ygop alat in e ganglion
II. Gen icu late ganglion
III. Su bm an d ibu lar ganglion
IV. Trigem in al ganglion
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of the above

89. Ipsilateral cor t ico-cort ical associat ion bers arise from cells in cort ical layers
A. I an d II
B. II an d III
C. III an d IV
D. IV an d V
E. V an d VI

90. As th e m em bran e of a m otor n eu ron becom es in creasingly depolarized,


A. Both EPSP an d IPSP decrease
B. Both EPSP an d IPSP in crease
C. EPSP decreases an d IPSP in creases
D. EPSP in creases an d IPSP decreases
E. Th ere is n o ch ange in IPSP, but EPSP in creases

91. Each of th e follow ing is t rue of Ren sh aw cells except th at


A. Th ey are part of a n egat ive feedback loop to th e m otor n eu ron s.
B. Th ey facilit ate Ia in h ibitor y in tern euron s th at act on an tagon ist m otor
n eu ron s.
C. Th ey in h ibit m otor n euron s th at in n er vate syn ergist m uscles.
D. Th ey m ake divergen t con n ect ion s to m otor n euron s.
E. Th ey receive input from descen ding path w ays.

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Neurosurgery Board Review

For qu est ion s 92 to 96, m atch th e n u cleu s w ith th e descript ion . Each respon se m ay be
u sed on ce, m ore th an on ce, or n ot at all.
A. In ferior vest ibular n ucleu s
B. Lateral vest ibular n ucleu s
C. Medial vest ibular n ucleus
D. Superior vest ibular n u cleus
E. Non e of th e above

92. Involved in th e con t rol of p ost u re


93. Th is n u cleu s an d th e m edial vest ibu lar n u cleu s are involved in m ediat ing
vest ibu lo-ocu lar re exes
94. Also kn ow n as Deiters’ n u cleu s
95. In tegrates inpu t from th e vest ibu lar labyrin th an d th e cerebellu m
96. Decerebrate rigidit y is du e to th e u n op posed excitator y e ect of th e ret icu losp in al
t ract an d th e t ract origin at ing from th is n ucleu s
97. W h ich of th e follow ing m odi cat ion s of p rotein s d oes n ot occu r in th e Golgi
com plex?
A. At tach m en t of fat t y acids
B. Form at ion of O-lin ked sugars
C. In it iat ion of N-lin ked glycosylat ion
D. Sugar ph osph or ylat ion
E. Sulfat ion of t yrosin e residues

For qu est ion s 98 to 104, m atch th e toxin w ith th e descript ion . Each resp on se m ay be
u sed on ce, m ore th an on ce, or n ot at all.
A. Bin ds to th e ACh receptor
B. Blocks reupt ake of dopam in e
C. Blocks volt age-gated K1 ch an n els
D. Blocks volt age-gated Na 1 ch an n els
E. Depletes n orepin eph rin e (NE) from vesicles
F. In h ibits GTP hydrolysis
G. Preven ts p resyn apt ic release of qu an t a of ACh
98. a -bu ngarotoxin
99. Bot u lin u m
100. Ch olera
101. Cocain e
102. Reserpin e
103. Tet raethylam m on iu m (TEA)
104. Tet rodotoxin
105. At th e equ ilibriu m p oten t ial of p ot assiu m ,
A. Th e elect rical force equals th e ch em ical force
B. Th e n et elect rical force is zero
C. Th e n et ch em ical force is zero
D. Th ere is n o m ovem en t of K1 ion s across th e m em bran e
E. Non e of th e above

178
Neurobiology—Questions

106. Each of th e follow ing is t ru e of G p rotein act ivat ion an d deact ivat ion except
A. Act ivat ion of any G protein w ill in h ibit th e act ivat ion of oth er G protein s in
th e m em bran e
B. Hydrolysis of boun d GTP to GDP in act ivates a G protein
C. Th e b g su bu n it stabilizes th e bin ding of GDP
D. Th e b g su bu n it stabilizes th e bin ding of GTP
E. W h en act ivated, th e a su bu n it’s a n it y for th e b g su bu n it decreases
107. Th e e ect of su ccinylch olin e at th e n eu rom u scu lar ju n ct ion is
A. Am pli ed by in creased m uscle tem perat ure
B. Hyperpolarizat ion
C. Not reversed by an t ich olin esterase agen t s
D. Not sim ilar to th at of decam eth on ium
E. Sim ilar to th at of D-t ubocurarin e

For qu est ion s 108 to 111, m atch th e area in th e som at ic sen sor y cor tex w ith th e recep -
tors. Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Area 1
B. Area 2
C. Area 3a
D. Area 3b

108. Mu scle st retch receptors in deep t issu e

109. Pressu re an d join t posit ion in deep t issu e

110. Slow ly an d rap idly adapt ing receptors in th e skin

111. Rap idly adapt ing receptors in th e skin

112. Each of th e follow ing is t ru e of th e d orsal colu m n m edial lem n iscal system except
A. Propriocept ion from th e leg is relayed in th e dorsal colum n s
B. Secon d-order n euron s cross th e m idlin e in th e m edial lem n iscus
C. Th alam ic n euron s project to th e prim ar y som at ic sen sor y cortex (SI)
D. Th alam ic n euron s project to th e secon dar y som at ic sen sor y cortex (SII)
E. Touch an d vibrat ion sen se from th e arm is relayed in th e dorsal colum n s

For qu est ion s 113 to 121, m atch th e region of th e cerebellu m w ith th e clin ical sign or
sym ptom . Each resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Cerebellar h em isph ere, in term ediate part (in terposed n u clei)
B. Cerebellar h em isph ere, lateral part (den t ate n uclei)
C. Flocculon odular (lateral vest ibular n ucleus)
D. Verm is (fast igial n ucleus)
E. Non e of th e above

113. Tru n cal ata xia

114. Ap p en d icu lar ata xia

115. Term in al t rem or

116. Nyst agm u s

117. Scan n ing sp eech

118. Hyp erton ia

179
Neurosurgery Board Review

119. Hyp oton ia is seen in lesion s of th e in terp osed n u clei or of th is p ort ion

120. Decom p osit ion of m u lt ijoin t m ovem en ts

121. Delay in in it iat ing m ovem en t s

122. In th e form at ion of n it ric oxid e, n it ric oxide syn th etase act s on th e su bst rate
A. Argin in e
B. Cit rullin e
C. Lysin e
D. Orn ith in e
E. Tyrosin e

123. Th e p in eal glan d syn th esizes m elaton in from


A. Acet ylch olin e
B. Dopam in e
C. Hist idin e
D. Norepin eph rin e
E. Seroton in

For qu est ion s 124 to 128, m atch th e receptor w ith th e descript ion . Each respon se m ay
be u sed on ce, m ore th an on ce, or n ot at all.
A. Mu scarin ic receptor
B. Nicot in ic receptor
C. Both
D. Neith er

124. Bin ds ACh

125. Fou n d in skelet al m u scle

126. Fou n d in sym p ath et ic n eu ron s

127. Blocked by h exam eth on iu m

128. Act ivates a secon d m essenger system via G p rotein s

129. Th e EPSP in sp in al m otor n eu ron s resu lt s from th e op en ing of


A. Cl2 ch an n els on ly
B. Cl2 an d Na 1 ch an n els
C. K1 ch an n els on ly
D. Na 1 an d K1 ch an n els
E. Na 1 an d Cl2 ch an n els

130. Th e respon se of th e carot id sin u s to an in crease in blood p ressu re is a


I. Decrease in p erip h eral resistan ce
II. Decrease in h eart rate
III. Decrease in force of con t ract ion
IV. Decrease in blood pressu re
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

180
Neurobiology—Questions

For qu est ion s 131 to 137, m atch th e descript ion w ith th e st ru ct u re.
A. Th ick lam en t s
B. Th in lam en t s
C. Both
D. Neith er

131. Con t ain s act in

132. Con t ain s m yosin

133. Con t ain s t rop om yosin

134. Con t ain s t rop on in

135. Bin ds ADP du ring rest

136. Sarcom eres con t ain th em

137. At t ach ed to th e Z disks

138. W h ich of th e follow ing is t ru e of skelet al m u scle con t ract ion ?


A. Calciu m bin ds to t rop om yosin .
B. Rot at ion of m yosin h eads pulls th in lam en t s tow ard th e cen ter of th e
sarcom ere.
C. Th e det ach m en t of cross bridges does n ot require ATP.
D. Th e dissociat ion of act in from m yosin uses en ergy from th e hydrolysis of
GTP.
E. W h en m uscle relaxes, calcium di uses in to th e sarcoplasm ic ret icu lum
from th e in t racellu lar sp ace.

139. Th e rest ing poten t ial of a n eu ron is ap p roxim ately


A. 2 90 m V
B. 2 65 m V
C. 2 50 m V
D. 1 50 m V
E. 1 65 m V

140. Each of th e follow ing agen ts or st ates prom otes an t idiu ret ic h orm on e (ADH)
release except
A. Alcoh ol
B. Angioten sin II
C. Decreased blood volum e
D. Vom it ing
E. In creased plasm a osm olalit y

141. Each of th e follow ing is a criterion th at a ch em ical m essenger sh ou ld fu l ll to be


con sidered a t ran sm it ter except
A. A sp eci c m ech an ism exist s for rem oving it from it s site of act ion
B. It is presen t in th e presyn apt ic term in al an d is released in am oun t s suf-
cien t to exert it s act ion on th e p ostsyn apt ic n eu ron or e ector organ
C. It is syn th esized in th e n euron
D. Th e en zym es th at cat alyze th e steps in it s syn th esis are cytoplasm ic
E. Th e exogen ously applied subst an ce sh ould m im ic th e act ion of th e en dog-
en ou sly released t ran sm it ter

181
Neurosurgery Board Review

142. Each of th e follow ing is con sidered a n eu rot ran sm it ter except
A. Ep in eph rin e
B. Glycin e
C. Histam in e
D. Seroton in
E. Vasoact ive in test in al polypept ide (VIP)

143. Each of th e follow ing organ s is in n er vated by both th e sym path et ic an d p arasym -
p ath et ic system s except th e
A. Gast roin test in al t ract
B. Heart
C. Lungs an d bron ch i
D. Salivar y glan ds
E. Sw eat glan ds

144. Each of th e follow ing is t ru e of gam m a m otor n eu ron s except


A. Th eir act ivat ion du ring act ive m u scle con t ract ion allow s m u scle spin dles to
sen se ch anges in length
B. Th eir act ivit y is in creased after lesion s of th e spin ocerebellu m
C. Th ey in n er vate in t rafu sal bers
D. Dyn am ic gam m a m otor n euron s in n er vate dyn am ic n uclear bag bers on ly
E. St at ic gam m a m otor n eu ron s in ner vate n uclear ch ain bers an d st at ic n u-
clear bag bers

145. Neu rot ran sm it ters th at are fou n d in m ajor descen ding pain p ath w ays from th e
p on s an d m edulla are
I. Dop am in e
II. Norepin ep h rin e
III. Acet ylch olin e
IV. Seroton in
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

146. Cell grou p s th at h ave con cen t ric recept ive elds in clu de
I. Ret in al ganglion cells
II. Sim ple cells of th e p rim ar y visu al cor tex
III. Lateral gen icu late cells
IV. Com p lex cells of th e p rim ar y visu al cor tex
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

182
Neurobiology—Questions

For qu est ion s 147 to 151, m atch th e sen sor y receptor w ith th e descript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Free n er ve end ings
B. Meissn er’s corpuscles
C. Merkel’s receptors
D. Pacin ian corpuscles
E. Ru n i’s corpuscles
147. A su bcu t an eou s, slow ly adapt ing receptor
148. A rap id ly adapt ing receptor fou n d in th e derm al p ap illae
149. A receptor su bser ving pressu re an d w ith a sm all recept ive eld
150. A rapidly adapt ing receptor m ore sen sit ive to h igh -frequ en cy st im u lat ion th an
low -frequen cy st im u lat ion
151. A n ociceptor
152. A m an in h is early 40s p resen ts w ith th e in sid iou s on set of p ersisten t sp asm s
of th e proxim al low er lim bs an d lum bar spin al m uscles th at in it ially caused
di cu lt y w alking, but n ow h ave left h im bed boun d w ith th e legs locked in an
exten ded p osit ion . His spast icit y abates du ring sleep an d during gen eral an es-
th esia. His EMG is n orm al. He h as n o h istor y, sign s, or sym ptom s of can cer. W h at
is th e m ost likely au toan t ibody resp on sible?
A. An t i-am ph iphysin
B. An t i-gephyrin
C. An t i-glut am ic acid decarboxylase
D. An t i-Yo
E. An t i-Ri
153. A 3-year-old ch ild p resen ts w ith abn orm al eye m ovem en t s an d is diagn osed
w ith an opt ic t ract gliom a. W h at oth er n ding m igh t you expect in th is pat ien t?
A. Bilateral vest ibu lar sch w an n om as
B. Gain of fun ct ion m utat ion in a t u m or prom oter
C. Mut at ion associated w ith ch rom osom e 22
D. Mut at ion a ect ing th e RAS sign al-t ran sduct ion path w ay
E. Mut at ion of th e h am art in gen e locus on ch rom osom e 9
154. W h ich of th e follow ing cell cycle t ran sit ion s rep resen t s th e “poin t of n o ret u rn ”
in th e cell cycle?
A. G0 /G1
B. G1 /S
C. G1 /G0
D. G2 /M
E. S/G2
155. Th e m ain advan t age of Ki-67 or MIB1 labeling over t radit ion al h em atoxylin an d
eosin (H&E) st ain ing is
A. MIB1 labeling in dex allow s for th e m ore accu rate diagn osis of glioblastom a
B. MIB1 labeling in dex does n ot provide any advan t age over H&E st ain ing
C. MIB1 labels cells proliferat ing in m ult iple st ages of th e cell cycle
D. Mitoses are m ore obvious w ith MIB1 stain ing
E. World Health Organizat ion (W HO) grading of brillar y ast rocytom as de-
pen ds on MIB1 labeling in dex

183
Neurosurgery Board Review

For qu est ion s 156 to 163, m atch each solu te w ith th e ap p ropriate respon se. Each
an sw er m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Value is h igh er in CSF th an plasm a.
B. Value is h igh er in plasm a th an CSF.
C. Value is equal in plasm a an d CSF.

156. Beta-2 t ran sferrin

157. Calciu m

158. Ch loride

159. Glu cose

160. Osm olalit y

161. Potassiu m

162. Sodiu m

163. Uric acid

164. Hu n t ington’s disease is associated w ith all of th e follow ing except


A. Cau date at rophy
B. Gen et ic abn orm alit y localizes to ch rom osom e 4
C. In creased acet ylch olin e t ran sferase act ivit y
D. Progressive ch oreoath etosis
E. Trin ucleot ide CAG repeat

165. W h at is th e equ ilibriu m poten t ial for sodiu m ?


A. 2 94 m V
B. 2 90 m V
C. 2 86 m V
D. 1 61 m V
E. 1 267 m V

166. All of th e follow ing st atem en t s regarding th e O6 -m ethylgu an in e-DNA m ethyl-


t ran sferase (MGMT) gen e in glioblastom a are t rue except
A. Methylat ion of th e MGMT gen e’s prom oter region u pregu lates MGMT gen e
exp ression
B. MGMT m ethylat ion predict s im p roved su r vival
C. MGMT m ethylat ion predict s im proved ben e t from tem ozolom id e
D. Th e MGMT gen e en codes a DNA repair p rotein
E. Th e MGMT gen e p rom otes ch em oth erapy resist an ce

For qu est ion s 167 to 171, m atch th e rate of cerebral blood ow to th e ap proxim ate t im e
to cell death . Each an sw er m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. , 4 m in u tes
B. 15 m in utes
C. 40 m in utes
D. 80 m in utes
E. In n ite

184
Neurobiology—Questions

167. 0 m L/100 g/m in

168. 10 m L/100 g/m in

169. 15 m L/100 g/m in

170. 18 m L/100 g/m in

171. 55 m L/100 g/m in

For qu est ion s 172 to 176, m atch th e descript ion or sign s an d sym ptom s to th e ap prop ri-
ate au toan t ibody.
A. An t i-glu t am ic acid decarboxylase
B. An t i-Hu
C. An t i-Ma
D. An t i-Ri
E. An t i-Yo

172. Associated w ith lim bic en ceph alit is

173. Cerebellar degen erat ion , associated w ith ovarian an d breast can cer

174. Sen sor y n eu rop athy, en cep h alit is, an d cerebellar degen erat ion , associated w ith
p u lm on ar y carcin om a an d lym ph om a

175. Op soclon u s, associated w ith breast can cer

176. St i -m an syn d rom e

185
4B Neurobiology—
Answ er Key

1. A 27. C
2. B 28. D
3. A 29. F
4. B 30. B
5. C 31. A
6. B 32. D
7. A 33. E
8. B 34. E
9. C 35. B
10. A 36. B
11. B 37. D
12. C 38. A
13. C 39. B
14. A 40. D
15. B 41. B
16. B 42. A
17. B 43. C
18. E 44. A
19. E 45. A
20. B 46. B
21. B 47. B
22. B 48. B
23. E 49. C
24. A 50. B
25. E 51. D
26. A 52. B

186
Neurobiology—Answer Key

53. C 92. B
54. C 93. D
55. F 94. B
56. B 95. A
57. D 96. B
58. E 97. C
59. A 98. A
60. B 99. G
61. C 100. F
62. B 101. B
63. D 102. E
64. A 103. C
65. B 104. D
66. E 105. A
67. D 106. D
68. C 107. C
69. B 108. C
70. A 109. B
71. C 110. D
72. A 111. A
73. C 112. A
74. E 113. D
75. B 114. A
76. C 115. B
77. B 116. C
78. C 117. D
79. C 118. E
80. D 119. D
81. D 120. B
82. A 121. B
83. C 122. A
84. A 123. E
85. D 124. C
86. D 125. B
87. A 126. C
88. B 127. B
89. B 128. A
90. C 129. D
91. B 130. E

187
Neurosurgery Board Review

131. B 154. B
132. A 155. C
133. B 156. A
134. B 157. B
135. A 158. A
136. C 159. B
137. B 160. C
138. B 161. B
139. B 162. C
140. A 163. B
141. D 164. C
142. E 165. D
143. E 166. A
144. B 167. A
145. C 168. C
146. B 169. D
147. E 170. E
148. B 171. E
149. C 172. C
150. D 173. E
151. A 174. B
152. C 175. D
153. D 176. A

188
4C Neurobiology–Answ ers
and Explanations

1. A – Bon e grow th factors


2. B – Recom bin an t h u m an bon e m orph ogen ic protein s
3. A – Bon e grow th factors
4. B – Recom bin an t h u m an bon e m orph ogen ic protein s
5. C – Both

Bo ne grow th facto rs (A) are st rong m itogen s an d act on di eren t iated m es-
en chym al cells of th e ch on dro-osseou s lin eage. Reco m binant hum an bo ne
m o rpho genic prote ins (B) are poten t in ducers of bon e cell di eren t iat ion
an d m ay act on u n di eren t iated m esen chym al cells. Both bo ne grow th
facto rs (A) an d bo ne m o rpho genic prote ins (B) are polyp ept ides.1

6. B – a 2b gd

Acet ylch olin e receptors can be divided in to m u scarin ic an d n icot in ic t yp es.


Th e m uscarin ic acet ylch olin e receptors are presen t in all postganglion ic para-
sym p ath et ic term in als an d in th e postganglion ic sym p ath et ic term in als in -
n er vat ing sw eat glan d s. Th e m u scarin ic acet ylch olin e receptor is a G-p rotein -
coupled receptor an d th erefore t ran sm its its sign als via a secon d m essenger
system . Nicot in ic acet ylch olin e receptors fu n ct ion as cat ion -select ive ion
ch an n els. Nicot in ic acet ylch olin e receptors are presen t at th e n eurom uscular
ju n ct ion an d at th e preganglion ic term in als of sym p athet ic an d parasym pa-
thet ic bers. Auton om ic n icot in ic acet ylch olin e receptors con sist of a an d b
su bu n it s on ly, i.e., a 2b 2 o r a 3b 3. How ever, th e n icot in ic acet ylch olin e recep -
tor at th e n eurom uscular jun ct ion is a pen t am er con sist ing of t w o a , on e b ,
on e γ, an d on e δ su bun it , i.e., a 2b g d (B).2,3,4

7. A – It con t ain s four hydroph obic t ran sm em bran e protein s.

Th e ligand bin ding site is located on th e a su bu n it (B is false), th e t ran sm em -


bran e segm en t is th e m ost h igh ly con ser ved (E is false ), an d th e cytoplasm ic
loop con n ect ing M3 an d M4 is th e least h igh ly con ser ved (C is false ). Both th e
N an d th e C term in als are ext racellu lar (D is false ). Resp on se A is correct .2,5

189
Neurosurgery Board Review

8. B – 2

Each n icot in ic acet ylch olin e receptor com plex h as tw o extracellular ace-
tylcho line binding sites (B) th at are p rim arily com posed of six am in o acids
located on the a su bu n its.2,6

9. C – Both
10. A – a su bu n it of GABAA receptor

Th e GABAA receptor fu n ct ion s as a ch loride ion ch an n el an d is act ivated by


m u lt ip le ligan ds in clu ding ben zodiazep in es, barbit u rates, an d zolpidem . Th e
bin ding site for GABA on th e GABAA receptor is located bet w een th e a and b
subunits (C). Th e bin ding site for ben zodiazep in es is located bet w een th e a
and gam m a subunits (A).4

11. B – Glu tam ate receptor


12. C – Glycin e receptor
13. C – Glycin e receptor
14. A – GABA receptor
15. B – Glu tam ate receptor
16. B – Glu tam ate receptor

GABA re ceptors (A) h ave been ch aracterized as th e site of act ion of ben zodi-
azep in es. Ligan d-gated glutam ate re cepto rs (B) can be divided in to NMDA
an d n on -NMDA receptors. Th e N-m ethyl- d -asp art ate (NMDA) receptor is
volt age regu lated in th at th e op en ch an n el is occlu ded at n orm al rest ing p o-
ten t ial by Mg 21 . Dep olarizat ion drives Mg 21 ou t of th e cell, allow ing oth er ion s
to pass. High con cent rat ion s of glut am ate m ay in duce n euron al cell death
via act ivat ion of NMDA an d AMPA (a n on -NMDA glutam ate receptor [B]),
allow ing calciu m in u x in to th e cell. Glycin e receptors sh are m any feat u res of
th e GABAA receptor. Both fun ct ion as ligan d-gated ch loride ion ch an n els an d
are presen t th rough ou t th e brain stem an d sp in al cord. Th e glycine rece pto r
(C) is an tagon ized by st r ych n in e. Nicot in ic acet ylch olin e receptors fu n ct ion as
cat ion -select ive ion ch an n els. Nicotinic acetylcho line recepto rs (D) are p res-
en t at th e n eu rom u scu lar ju n ct ion an d at th e p reganglion ic term in als of sym -
path et ic and parasym path et ic bers. Se roto nin rece pto rs (E) can be fou n d at
m u lt ip le sites an d are p rom in en t in th e dorsal raph e n u cleu s.5

17. B – NMDA receptor on ly


18. E – A, B, an d C
19. E – A, B, an d C
20. B – NMDA receptor on ly
21. B – NMDA receptor on ly

Th e ligan d-gated glut am ate receptors can be grouped in to N-m ethyl- d -


aspartate (NMDA) recepto rs (B) an d n on -NMDA receptors, all of w h ich in -
crease cat ion con duct an ce w h en act ivated. Th e n on -NMDA receptors in clude
th e a -am ino -3-hydroxy-5-m ethyl-4-isoxazo lepro prio nic acid (AMPA)
recepto r (C) an d th e kainic acid (A) re cepto r. Th e NMDA recepto r (B) can be
blocked by m agn esium at rest ing m em bran e poten t ials an d is th erefore both
ligan d an d volt age gated. NMDA recepto rs (B) are part icularly perm eable to

190
Neurobiology—Answers and Explanations

calcium ion s, part icipate in long-term poten t iat ion , an d are th ough t to be im -
p or tan t for n euron al plast icit y, learn ing, an d m em or y.4,5

22. B – On e qu an ta con t ain s 10,000 m olecu les of Ach

Qu an t a refers to th e acet ych olin e qu an t it y of on e syn apt ic vesicle an d h as


been est im ated in th e range of 1,000 to 50,000 m olecu les of Ach per vesicle
(p er qu an t a).5

23. E – All of th e above

Pre-proopiom elan ocort in (POMC) is an opioid precursor pept ide along w ith
p re-p roen keph alin an d pre-prodyn orph in . Th e m ajor opioid pept ide derived
from POMC is b -e ndo rphin. POMC is also conver ted in to th e n on opioid
p ept ides adreno co rticotro pic ho rm o ne (ACTH), m elanocyte-stim ulating
ho rm o ne (a -MSH), an d b -lipotro pin.5

24. A – I, II, III (act ive t ran sport , bin ding to cytosolic protein s, an d t ran spor t in to
in t racellular calcium storage vesicles)

Rem oval of calciu m ion s from th e cytosol in a presyn apt ic n er ve term in al


follow ing an act ion poten t ial is th ough t to occu r by active transpo rt, bind-
ing to cyto so lic prote ins, and transpo rt into intracellular calcium sto rage
vesicles. Reversal of ow th rough volt age-gated ch an n els is n ot a m ech an ism
of rem oval of Ca 21 from th e cytosol.5

25. E – Th e decreased con cen t rat ion of cGMP results in depolarizat ion of th e plasm a
m em bran e (false)

In p h otot ran sdu ct ion , a p h oton of ligh t lead s to th e iso m erizatio n o f 11-cis-
retinal to an all-t r a n s fo rm , activating rho do psin (D). Activate d rho do psin
then stim ulates a G-protein-co upled re ceptor, transducin (A), activating a
cyclic GMP-speci c pho spho diesterase (PDE [B]). Th e decreased cGMP level
(caused by in creased cGMP PDE) leads to a decrease d Na co nductance by
cGMP-gated io n channels (C) lead ing to hyp erp olarizat ion of th e m em bran e.
In su m m ar y, light leads to hyperpo larizatio n o f the cell m em brane via
reduced levels o f cGMP (E is false).5

26. A – Each G protein is regulated by on ly on e t ype of receptor (false)

G protein s bin d to th e cytoplasm ic face of a given receptor; each G protein


m ay be regulated by separate receptors (A is false ). Agon ist s prom ote th e
binding o f GTP to the a subunit (C), w h ich can th en act ivate a variety o f
e ecto r proteins (B). Th e G p rotein rem ain s act ive u n t il GTP is hydrolyzed
to GDP. Th e b an d γ su bu n it s h elp to ancho r the G protein to the m e m brane
(D), participate in m o dulatio n o f GDP/GTP exchange (E), an d con fer local-
izat ion via m yristolizat ion .2,5

27. C – Cyclic aden osin e m on oph osph ate (cAMP)


28. D – Cyclic gu an in e m on oph osph ate (cGMP)
29. F – 1,2-d iacylglycerol (DAG) an d in ositol-1,4,5-t risp h osph ate (IP3)
30. B – 1,2-d iacylglycerol (DAG)

191
Neurosurgery Board Review

31. A – Calcium
32. D – Cyclic gu an in e m on oph osph ate (cGMP)
33. E – In ositol-1,4,5-t risph osph ate (IP3)

Cytosolic calcium (A) levels are regu lated by several di eren t factors, an d cal-
cium (A) m ay exert its in uen ce via m ult iple m ech anism s—calcium is the on ly
choice listed, how ever, that bin ds to calm odulin. Gq act ivates ph ospholipase
C w h ich hydrolyzes ph osphatidylinositol-4,5-bisphosphate to ino sito l-1,4,5-
trispho sphate (IP3 [E]) and diacylglycero l (DAG [B]). IP3 (E) binds to recep -
tors on th e en doplasm ic ret icu lu m th at cause a tran sien t in crease in cytosolic
calcium concent rat ions. DAG (B) binds protein kinase C (PKC), low ering PKC’s
requirem ent for act ivat ion by calcium . Cyclic AMP (cAMP [C]) is gen erated
by adenylyl cyclase, st im ulated by Gs , an d in h ibited by Gi. D1 receptors are an
exam ple of a receptor th at u ses cAMP (C) as a secon d m essenger. Nit ric oxide
gen erates cyclic GMP (cGMP [D]) via act ivation of soluble guanylyl cyclase.
Ph otorecept ion ut ilizes cGMP (D) as a second m essenger. Recall th at light leads
to hyperpolarizat ion of th e cell m em bran e via reduced levels of cGMP (D).5

34. E – Ut ilizes t w o m olecules of ATP for ever y th ree Na 1 ion s t ran sp or ted (false)

Th e sodium potassium ATPase con t ributes to th e resting po tential o f the cell


(A); hyperpo larizing the m e m brane (B) by p u m ping thre e Na 1 io ns into the
cell fo r eve ry tw o K1 io ns it transpo rts o ut o f the cell (D). Th is act ion gen er-
ates both a ch em ical an d an electrical gradient (C) across th e cell m em bran e.
Th e Na 1 /K1 pu m p u ses o ne m o lecule of adeno sine tripho sphate (ATP) for
ever y three Na 1 io ns transpo rted (E is false).5

35. B – Ch loride p erm eabilit y in creases du ring dep olarizat ion (false)

An act ion poten t ial con sist s of t w o p h ases, th e rst of w h ich is du e to an


in creased p erm eabilit y to Na cau sed by t h e o pe n ing o f vo ltage-gate d Na
chan nels (A). Th u s th ere is rap id d ep olarizat ion of th e cell d u e to sod iu m
in u x. Th e secon d ph ase is d u e to fast activatio n o f Na chan nels (D) an d
d elayed op en in g of K ch an n els th at allow K to leave the cell an d te rm in ate
de po larizatio n (C, E). Ch lorid e p erm eabilit y d oes n ot ch ange d u ring t h e
act ion p oten t ial (B is false ).5

36. B – High t ran sm em bran e resist an ce, low in tern al resist an ce, an d low m em bran e
capacit an ce

Th e velocit y of an act ion poten t ial in creases w ith high transm em brane re-
sistance, low internal resistance, and low m em brane capacitance (B). Th e
con du ct ion velocit y is depen den t on th e diam eter of th e axon an d m yelin a-
t ion st at us. In creased axon al diam eter leads to low er in tern al resist an ce an d
h igh er con du ct ion velocit ies. Myelin at ion leads to in creased velocit ies via
in creased t ran sm em bran e resistan ce an d decreased m em bran e capacitan ce,
an d th erefore h igh er con du ct ion velocit ies.7

37. D – It in creases t ran sm em bran e resistan ce an d decreases m em bran e capacit an ce.

Myelin at ion in creases t ran sm em bran e resist an ce an d decreases m em bran e


capacit an ce, leading to in creased con duct ion velocit ies.6

192
Neurobiology—Answers and Explanations

38. A – En d-plate poten t ial


39. B – Min iat u re en d-plate p oten t ial
40. D – Neith er

End-plate potential (A) refers to th e dep olarizing p rocess th at occu rs at th e


n eu rom u scu lar ju n ct ion , t riggering a m u scle act ion p oten t ial, an d th erefore
leading to m u scle con t ract ion . Miniature e nd-plate potentials (B) result
from ran dom release of qu an ta of acet ylch olin e cau sing m in or region al m em -
bran e depolarizat ion s (excit ator y en d-plate poten t ials) but do n ot reach th e
thresh old n ecessar y to produce an act ion poten t ial. Act ion poten t ials are an
all-or-n oth ing ph en om en on (D).5

41. B – Cl2 or K1

Localized dep olarizat ion s of th e cell m em bran e are u su ally du e to in creased


Na 1 perm eability (C) an d are called excitator y p ost syn apt ic p oten t ials
(EPSPs). Th e sum m at ion of m ult iple EPSPs can cause an act ion poten t ial to
occur if th e depolarizat ion reach es th resh old. Th is e ect can be blocked by
in h ibitor y post syn apt ic poten t ials (IPSPs) th at represen t region al hyperpolar-
izat ion m ediated by in creased p erm eabilit y to Cl 2 o r K1 io ns (B).5

42. A – Dyn am in does n ot use ATP.

Dyn am in u ses GTP as an energy so urce (A). Dyn ein is th e m otor protein for
ret rograde fast axon al t ran spor t (B and E are false). Slow axon al t ran sp or t
occurs at several m illim eters per day (E is false); fast axon al t ran sp or t occu rs
at 200 to 400 m m /day an d ut ilizes m icrot ubules (C is false).2,6

43. C – Both
44. A – Golgi ten don organ
45. A – Golgi ten don organ
46. B – Mu scle spin dle
47. B – Mu scle spin dle
48. B – Mu scle spin dle
49. C – Both
50. B – Mu scle spin dle
51. D – Neith er
52. B – Mu scle spin dle

Both Go lgi tendo n o rgans (A) an d m uscle spindles (B) are propriocept ive
receptors th at are act ivated by passive st retch an d are in n er vated by group I
(large m yelin ated) bers. Golgi tendo n o rgans (A) are arranged in series w ith
the m uscle in th e ten don an d are act ivated m axim ally by m u scle con t rac-
t ion . Muscle spindles (B) are arranged in parallel w ith th e m uscle bers an d
con sist of a dyn am ic n uclear bag, st at ic n uclear bag, an d n uclear ch ain bers.
Mu scle sp in dles are sen sit ive to m u scle st retch an d length . Motor in n er va-
t ion to th e m uscle spin dle via gam m a m otor n euron s allow s for th e length of
the m uscle spin dle to ch ange it s sen sit ivit y to length an d velocit y of length
ch ange.6,8

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Neurosurgery Board Review

53. C – It is reduced by dest ruct ion of th e an terior lobe of th e cerebellu m (false)

Decerebrate rigid it y, or exten sor p ost u ring, resu lt s from ton ic act ivit y of th e
lateral vestibular and po ntine reticular nuclei (A) prom ot ing un opposed
exten sor ton e of th e u p per an d low er ext rem it ies, an d m ay be in du ced by
transe ctio n betw een the co lliculi (D). Decerebrate rigid it y is associated
w ith increase d gam m a m o to r neuro n activity (E) an d m ay be reduced by
sectio ning o f the do rsal ro ots (B). Dest ru ct ion of th e an terior lobe of th e
cerebellum releases th e cells of origin of th e lateral vest ibular t ract from in -
h ibit ion by Pu rkinje’s cells, th ereby facilit at ing exten sor m otor n eu ron s (C is
false).3,8

54. C – F respon se
55. F – St retch re ex
56. B – Flexion re ex
57. D – H resp on se
58. E – M respon se
59. A – Clasp -kn ife respon se

Th e H re ex (Ho m an’s [D]) is th e elect rical equivalen t of th e ten don re ex


circuit an d represen ts th e act ivat ion of a m uscle con t ract ion w ith subm axi-
m al st im u lat ion in su cien t to illicit a direct m otor respon se—th e resp on se
is m ediated by th e act ivat ion of m u scle spin dles an d involves both th e dorsal
an d ven t ral h orn s. Th e H re ex (D) is p ar t icu larly u sefu l in th e diagn osis of
S1 radicu lopathy. Th e F w ave (C) is evoked by su pram axim al st im ulus of a
m ixed m otor-sen sor y n er ve an d con sists of a sm all m u scle act ion poten t ial
recorded after the d irect m otor respon se. Th e F w ave resu lt s from an t idrom ic
im p u lses t raveling u p th e m otor n er ve to th e an terior h orn causing an or th o-
drom ic respon se recorded in dist al m uscle. A n orm al F w ave an d absen t H
re ex occu r in diseases of sen sor y n er ves an d roots. Th e M w ave (E) is th e
direct m otor respon se caused by st im ulat ion of a m otor n er ve. A clasp -kn ife
respon se con sist s of th e follow ing: if m uscles are briskly st retch ed, th e lim b
m oves freely for a sh or t dist an ce follow ed by rap id resistan ce—w ith in creas-
ing p assive st retch , th e resist an ce disappears. Th e spinal exio n (B) re ex-
es resu lt in exion across m u lt ip le join t s to w ith draw from pain fu l st im u li
an d m ay be exaggerated in st ates of sp ast icit y. Th e stretch re ex (F) is th e
fam iliar m yotact ic re ex (ten don jerk) as occu rs w ith t ap ping on th e kn ee
w ith a h am m er. Th e stretch re ex occu rs du e to th e act ivat ion of th e m u scle
sp in dle an d n u clear bag bers cau sing re ex con t ract ion of skelet al m u scle
bers via a m on osyn apt ic p ath w ay—th e st retch re ex h as both a p h asic an d
ton ic com pon en t .3,8,9

60. B – Parasym p ath et ic bers from S2 to S4

Th e det rusor m uscle of th e bladder is in n er vated by parasym pathetic bers


from the S2-S4 (B) n er ve root s.9

194
Neurobiology—Answers and Explanations

61. C – Term in al degen erat ion leads to loss of presyn apt ic term in als.

Ch rom atolysis is associated w ith increased pro tein synthesis (A is false).


Ret ract ion bulbs, from th e buildup of t ran spor ted m aterials, occu r at both
the proxim al and the distal e nds o f the cut nerve (B is false). Wallerian
degen erat ion begins in the distal e nd o f the axo n 1 w eek afte r initial
degenerative changes begin in the axo n term inal (D and E are false).
Term in al degen erat ion does lead to th e lo ss o f presynaptic term inals (C).8

62. B – I, III (carbon dioxide an d volat ile an esth et ic agen ts)

Carbo n dioxide an d vo latile anesthetic agents in crease cerebrosp in al u id


(CSF) product ion , w h ereas carbo nic anhydrase inhibito rs an d no repine ph-
rine in h ibit CSF produ ct ion .10

63. D – Glycin e

Ren sh aw cells are in h ibitor y in tern euron s located in th e ven t ral h orn an d
are resp on sible for a n egat ive feedback re ex called recu rren t in h ibit ion .
Ren sh aw cells use glycin e as th eir prin ciple n eurot ran sm it ter.6

64. A – Wave I
65. B – Wave II
66. E – Wave V
67. D – Wave IV
68. C – Wave III

St im u lat ion of th e coch lear n er ve by clicks delivered to th e ear causes th e


ap p earan ce of seven w aves as record ed by scalp elect rodes—brain stem au di-
tor y evoked respon ses (BAERs). Wave I represen t s act ivat ion of th e au ditor y
n er ve. Wave II represen t s act ivat ion of th e coch lear n u cleus. Wave III rep -
resen t s act ivat ion of th e su perior olivar y n u cleu s. Wave IV represen t s act i-
vat ion of th e lateral lem n iscu s. Wave V rep resen t s act ivat ion of th e in ferior
colliculus. Wave VI corresp on ds to th e m edial gen icu late n u cleu s. Wave VII
correspon ds to th e auditor y radiat ion s.9

69. B – N11
70. A – Erb’s poin t
71. C – N13/P13
72. A – Erb’s poin t

Som atosen sor y evoked p oten t ials (SSEPs) involve th e app licat ion of 5-p er-
secon d t ran scu tan eou s st im u li to th e m edian , p eron eal, an d t ibial n er ves, an d
recording th e evoked poten t ials as th ey pass th e brach ial plexu s 2–3 cm above
the clavicle (Erb’s po int [A]), over th e C2 ver tebra, an d over th e con t ralateral
p ariet al cor tex. A delay bet w een th e periph eral st im u lu s an d Erb’s po int (A)
suggest s a periph eral lesion . Absen ce or delay in N11 (B) im plies cer vical cord
disease. Th e sum m ated w ave th at is recorded at th e cer vicom edullar y ju n c-
t ion is N13/P13 (C). Th e cor t ical p oten t ial record ed at th e cor tex from m edian
n er ve st im u lat ion is N19/P22 (D and E). Th e cort ical w ave after t ibial or p ero-
n eal st im u lat ion is N/P 37.9

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Neurosurgery Board Review

73. C – 23 m L/100 g/m in


74. E – 8 m L/100 g/m in
75. B – 55 m L/100 g/m in

Norm al cerebral blood ow is 55 m L/100 g/m in (B). Flow redu ct ion below
8–10 m L/100 g/m in (E) results in irreversible cerebral in farct ion . Fun ct ion al
im p airm en t occu rs at a cerebral blood ow of 23 m L/100 g/m in (C). Th e bio-
ch em ical abn orm alit ies, in cluding deplet ion of ATP an d creat in e ph osph ate
an d in crease of K1 level (from inju red cells), can be reversed if adequ ate blood
ow is restored in a t im ely fash ion .9

76. C – Gran ule cells


77. B – Golgi cells
78. C – Gran ule cells
79. C – Gran ule cells
80. D – Pu rkinje cells
81. D – Pu rkinje cells
82. A – Basket cells
83. C – Gran ule cells

Th e cerebellar cortex con sist s of th ree layers th at con tain ve cell t ypes. Th e
m olecu lar layer (ou term ost) is com p osed of th e a xon s of th e granule cells
(C) (parallel bers), stellate (E) an d basket cells (A) (in tern euron s), an d den -
drites of th e u n derlying Purkinje cells (D). Th e Pu rkinje cell layer (m iddle)
con t ain s th e cell bodies of th e Purkinje n euron s. Th ey are th e sole out put
of th e cerebellar cortex an d are in h ibitor y. Th e gran ular (in n erm ost) layer
con t ain s n u m erous granule cells (C, excitatory; utilize glutam ate), a few
Go lgi cells (B), an d glom eru li (w h ere cells in th e gran u lar layer form com plex
syn apt ic con t act s w ith th e in com ing m ossy bers). A eren ts to th e cor tex
term in ate eith er in th e gran ule cell layer as m ossy bers or on th e den drites
of Purkinje cells as clim bing bers. Both m ossy an d clim bing ber input s are
excitator y to both th e deep cerebellar n u clei an d th e cortex. Stellate (E) an d
basket cells (A) directly in h ibit Purkinje (D) an d Go lgi cells (B), an d Golgi
cells in h ibit granule cells (C).8

84. A – Th e ut ricular m acule is orien ted h orizon t ally an d th e saccular m acule is


orien ted ver t ically.

W h en th e h ead is uprigh t , th e ut ricular m acule is orien ted in th e h orizon -


t al plan e an d can be act ivated by lin ear forces in th e h orizon t al plan e. Th e
saccu lar m acu le is orien ted in th e ver t ical p lan e an d can be st im u lated by
lin ear forces in th e ver t ical plan e (A is co rrect).7

85. D – Ad bers

Nocicept ion is m ediated p rim arily by ligh tly m yelin ated free n er ve en dings
of t ype Ad bers (D) or u n m yelin ated C bers (E). Th e sen sat ion of sh arp
p ain is m ediated by Ad bers (D). C bers (E) relay in form at ion regarding
m ech an ical, th erm al, or ch em ical st im u li.7

196
Neurobiology—Answers and Explanations

86. D – Th e fast EPSP is m ediated by n icot in ic ACh receptors.

Un like th e ACh receptors at th e n eurom uscu lar jun ct ion , th e ACh receptors in
au ton om ic ganglia con t ain on ly t w o t ypes of su bu n its (A is false). Th e fast ex-
cit ator y post syn apt ic poten t ial (EPSP) is m ediated by n icot in ic ACh receptors
(D is true), th e slow EPSP is m ed iated by m u scarin ic receptors op en ing Na 1
an d Ca 21 ch an n els an d closing K1 ch an n els (B is false ), an d th e slow in h ibitor y
post syn apt ic poten t ial (IPSP) is m ediated by m uscarin ic receptors th at open
K1 ch an n els (C is false ). A variet y of pept id es th at ap pear to be m odu lator y in
act ion m ay be co-released w ith Ach (E is false).8

87. A – In creased postganglion ic sym path et ic act ivit y result s in bladder w all con t rac-
t ion (false)

In creased sym path et ic act ivit y resu lts in bladder w all relaxat ion (A is false).
Th e oth er respon ses are t ru e regarding in n er vat ion of th e urin ar y system .
In creased p ostganglion ic sym path et ic act ivit y resu lt s in a -adren ergic in h i-
bit ion of parasym path et ics in th e pelvic ganglion (B), m otor n eu ron s in th e
ven t ral h orn of th e sacral spin al cord in n er vate th e extern al sph in cter (C),
parasym path et ic act ivit y prom otes bladder em pt ying (D), an d th e in tern al
sp h in cter is in n er vated by sym p ath et ic bers (E).7

88. B – I, III (pter ygopalat in e ganglion , su bm an dibu lar ganglion )

Fibers from th e su perior salivator y n ucleu s t ravel w ith th e facial n er ve


reach ing eith er th e pter ygop alat in e ganglion via th e GSPN an d vidian n er ve
or th e subm an dibu lar ganglion via th e ch orda t ym pan i n er ve. Th e gen iculate
ganglion con t ain s th e cell bodies of pseu dou n ip olar n eu ron s carr ying a eren t
in form at ion in th e facial n er ve. Th e t rigem in al ganglion h ouses th e cell bodies
of pseu doun ipolar n euron s carr ying a eren t in form at ion in th e t rigem in al
n er ve.7

89. B – II an d III

Ip silateral cort ico-cor t ical associat ion bers arise from cells in cort ical
layers II and III. Cells th at give rise to com m issu ral bers th at in tercon n ect
h om ologou s cort ical areas via th e corpu s callosu m are fou n d in laye r III of
the cerebral cortex (th e external pyram idal layer). Layer I is th e plexiform
m olecu lar layer an d con sist s m ain ly of n er ve cell p rocesses. Laye r II is th e
extern al gran u lar layer com p rised m ostly of sm all gran u le cells an d p rojects
p rim arily to local or dist an t cor t ical areas as associat ion bers. Layer IV, th e
in tern al gran ular layer, is im por tan t for a eren t sign aling an d is th icker in th e
p rim ar y sen sor y area. Layer V, th e in tern al pyram idal layer, is th e sou rce of
the m ajorit y of out put bers for th e cerebral cor tex. Layer VI is th e fu siform
layer an d lies adjacen t to un d erlying w h ite m at ter an d con sist s prim arily of
associat ion n eu ron s.7

90. C – EPSP decreases an d IPSP in creases

As th e m em bran e of a m otor n euron becom es in creasingly depolarized,


excitator y post syn apt ic poten t ials decrease w h ile in h ibitor y post syn apt ic p o-
ten t ials in crease. Choice C is correct .8

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Neurosurgery Board Review

91. B – Th ey facilit ate Ia in h ibitor y n eu ron s th at act on an t agon ist m otor n eu ron s
(false)

Ren sh aw cells are located in th e an terior h orn an d part icipate in a n egat ive
feedback loop to th e m otor n eu ron s (A). Th ey receive input from descen ding
p ath w ays (E), m ake divergen t con n ect ion s to m otor n eu ron s (D), an d in h ibit
m otor n eu ron s th at in h ibit syn ergist ic m u scles (C). Du ring develop m en t ,
Ren sh aw cells receive input from Ia a eren ts, but th ey project to a m otor
n eu ron s (B is false ).3,6,8

92. B – Lateral vest ibu lar n u cleu s


93. D – Su p erior vest ibu lar n u cleu s
94. B – Lateral vest ibu lar n u cleu s
95. A – In ferior vest ibular n ucleus
96. B – Lateral vest ibu lar n u cleu s

Par t of th e late ral vestibulo spinal nucleus (De ite rs’ n ucle us [B]) receives
d irect in h ibitor y inp u t from Pu rkinje cells in th e cerebellar verm is. Decer-
ebrate rigid it y is exacerbated if th e p or t ion of th e cerebellu m con n ected to
De ite rs’ nucle us (B) is in terrupted becau se of rem oval of th is in h ibitor y
act ion . Th e lateral vestibulo spinal tract (B) h as a facilit ator y e ect on both
a an d γ n eu ron s th at in n er vate m uscles in th e lim bs; th is ton ic excit at ion of
th e exten sors of th e leg an d th e exors of th e arm h elps in th e m ain ten an ce
of post u re. Th e supe rio r and m e dial vestibular nuclei (D) receive sen sor y
inp u t from th e sem icircu lar can als via th e vest ibular n er ve an d p roject to th e
m edial longit u d in al fascicu lu s an d m edial vest ibu losp in al t ract to m ed iate
re exes of both ocu lar an d h ead m ovem en t s in respon se to vest ibular st im u li.
Th e infe rio r vestibular nucleus (A) receives a eren t s from th e sem icircular
can als an d u t ricle an d sen ds it s project ion s to th e ret icular form at ion an d
cerebellum , act ing as an in tegrat ion cen ter for th e vest ibular labyrin th an d
cerebellum .7,8

97. C – In it iat ion of N-lin ked glycosylat ion

Th e Golgi apparat us ser ves t w o m ajor fu nct ion s for th e processing of m em -


bran e protein s: sor t ing an d target ing of protein s, an d post-t ran slat ion al
m od i cat ion s—part icu larly of oligosacch aride ch ain s th at h ave already been
ad ded in th e rough en dop lasm ic ret icu lu m . (The initial ste ps o f N-linked
glyco sylatio n take place in the endo plasm ic reticulum ; C is false.) Th e
oth er ch oices listed take place in th e Golgi ap parat u s: attachm e nt o f fatty
acids (A), fo rm atio n o f O-linke d sugars (B), sugar pho spho rylation (D), an d
sulfatio n o f tyro sine residues (E).2,6

98. A – Bin ds to th e ACh receptor


99. G – Preven ts presyn apt ic release of quan t a of ACh
100. F – In h ibits GTP hydrolysis
101. B – Blocks reu pt ake of dopam in e
102. E – Depletes n orepin eph rin e from vesicles
103. C – Blocks volt age-gated K1 ch an n els

198
Neurobiology—Answers and Explanations

104. D – Blocks volt age-gated Na 1 ch an n els

a -Bungarotoxin (A) is a n eu rotoxin fou n d in sn ake ven om th at is select ive for


th e n icot in ic acet ylch oline receptor at th e m uscle en d-plate. Botulinum toxin
(G) blocks th e release of acet ylch olin e quan ta at th e presyn apt ic m em bran e.
Cho le ra toxin (F) in h ibits GTP hydrolysis leading to con st it u t ive act ivit y of
ad enylyl cyclase an d in creased in t racellu lar cAMP levels. Co caine (B) act s on
th e dopam in e t ran spor ter (DAT) in h ibit ing dopam in e reuptake. Rese rpine (E)
in teracts w ith adren ergic storage vesicles an d in h ibit s th eir capacit y to con -
cen t rate an d store n orepin eph rin e an d dopam in e. Tetraethylam m o nium (C)
is an am m on iu m salt sim ilar to h exam eth on ium th at fun ct ion s as a “n icot in e
p aralyzing” ganglion blocker, act ing prim arily via blockade of volt age-gated
K1 ch an n els. Tetro dotoxin (D) is a sh toxin th at blocks Na 1 ch an n els in excit-
able cells.2,5,8

105. A – Th e elect rical force equ als th e ch em ical force

At th e equ ilibriu m p oten t ial, th e ch em ical an d elect rical forces are equ al, bu t
opposite (A). Th ere is n o net m ovem en t of K ion s across th e m em bran e (D is
false ). Neith er th e n et ch em ical n or th e n et elect rical force equ al zero at th e
equ ilibriu m p oten t ial of potassiu m (B and C are false ).2,11

106. D – Th e b g su bu n it stabilizes th e bin ding of GTP (false)

Upon bin ding of a ligan d to a G-protein -coupled receptor, GDP on th e a su b-


u n it is converted to GTP an d th e G protein d issociates from th e receptor. Th e a
an d b g su bun its th en dissociate (the a subunit’s a nity fo r the b g subunit
decreases [E]). Both su bu n it s are th en free to exert th eir e ect s on dow n -
st ream e ectors, in clu ding th e in h ibit ion of oth er G protein s in th e m em -
bran e (A). Th e a subu n it th en cat alyzes hydrolysis of GTP to GDP, prom ot ing
reassem bly of th e t rim er an d receptor in act ivat ion (B). At rest , th e b g su bu n it
in h ibit s act ivat ion by both st abilizing th e bin ding of GDP (C) an d in h ibit ing
the bin ding of GTP (D is false ).2,11

107. C – Not reversed by an t ich olin esterase agen t s

Su ccinylch olin e an d decam eth on iu m cau se depolarizing n eu rom u scu lar


blockade (B and D are false). Th e e ect is n ot reversed by an t ich olin esterase
agen t s (C) an d is am pli ed by decreased m u scle tem perat u re (A is false).
Su ccinylch olin e is resistan t to th e act ion of acet ylch olin esterase (C is true).5

108. C – Area 3a
109. B – Area 2
110. D – Area 3b
111. A – Area 1

Th e prim ar y som atosen sor y area con sists of Brodm an n’s areas 1, 2, an d 3.
Area 1 (A) receives inpu t from rapidly adapt ing receptors in th e skin . Area 2
(B) deals w ith p ressu re an d join t p osit ion in deep t issu es. Area 3a (C) receives
m u scle, ten don , an d join t st retch receptors. Area 3b (D) receives inp u t from
both slow ly an d rapidly adapt ing receptors in th e skin .3,8

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Neurosurgery Board Review

112. A – Propriocept ion from th e leg is relayed in th e dorsal colu m n s (false)

Propriocept ion from th e leg is relayed in th e lateral colum n by axon s of n eu-


ron s in Clarke’s colum n (A is false). Th e oth er resp on ses regarding th e dorsal
colum n m edial lem n iscal system are t ru e. In addit ion to sen ding axon s to th e
p rim ar y som at ic sen sor y cortex (SI [C]), th alam ic n euron s sen d a sparse pro-
ject ion to th e secon dar y som at ic sen sor y cortex (SII [D]). Touch an d vibrat ion
sen se from th e arm are relayed in th e d orsal colu m n s (E). Secon d-order n eu -
ron s cross th e m idlin e in th e m edial lem n iscus (B).8

113. D – Verm is (fast igial n ucleus)


114. A – Cerebellar h em isp h ere, in term ediate p ar t (in terposed n u clei)
115. B – Cerebellar h em isph ere, lateral p ar t (den tate n u clei)
116. C – Flocculon odu lar (lateral vest ibular n ucleu s)
117. D – Verm is (fast igial n ucleus)
118. E – Non e of th e above
119. D – Verm is (fast igial n ucleus)
120. B – Cerebellar h em isph ere, lateral p ar t (den tate n u clei)
121. B – Cerebellar h em isph ere, lateral p ar t (den tate n u clei)

Th e cells of th e in terposed n uclei are associated w ith th e paraverm al cortex


an d sp in ocerebellu m , w h ich con t ribu tes to p ost u re, m u scle ton e, an d m u scle
act ivit y of th e t ru n k an d lim bs du ring stereot yp ed act ivit ies—inju ries to th e
interpo sed nucle i and asso ciated co rtex (A) m ay lead to appen dicular at axia.
Th e cells of th e den tate n ucleus are associated w ith th e lateral cerebellar cor-
tex an d cerebrocerebellum , w h ich par t icipate in plan n ing an d coordin at ion of
skilled m ovem en t . Lesion s to th e de ntate nucle us and asso ciate d co rtex (B)
can result in term in al t rem or, decom posit ion of m u lt ijoin t m ovem en t s, an d
delay in in it iat ing m ovem en t s. Lesion s to the o cculo no dular lo be and lat-
eral vestibular nucleus (C) m ay lead to nyst agm u s; gen erally, th e occu lo-
n odu lar lobe is involved in balan ce, p ost u re, an d th e coord in at ion of h ead an d
n eck m ovem en t s via it s recip rocal con n ect ion s w ith th e vest ibu lar system .
Th e verm is is par t of th e spin ocerebellum an d is largely respon sible for th e
m ain ten an ce an d coordin at ion of axial an d girdle m u scu lat u re an d th e fast i-
gial n u cleu s is associated w ith th e vest ibu locerebellu m . Inju ries to th e verm is
and fastigial nucleus (D) m ay lead to t run cal at axia, scan n ing speech , an d
hypoton ia. Lesion s to th e cerebellum are n ot kn ow n to cau se hyper ton ia (E).7,8

122. A – Argin in e

Nit ric oxide p rodu ct ion in n eu ron s is from l -arginine (A) an d m olecu lar
oxygen by n it ric oxid e syn th et ase act ing in conju n ct ion w ith th e cofactor,
redu ced n icot in am ide aden in e din ucleot ide ph osp h ate (NADPH), an d Ca 21
ion s. Th e arginine (A) is conver ted to citrulline (B).5

123. E – Seroton in

Th e pin eal glan d syn th esizes m elaton in from serotonin (E) by th e act ion of
t w o en zym es sen sit ive to variat ion s of diu rn al ligh t . Th e rhyth m ic u ct ua-
t ion s in m elaton in syn th esis are directly related to th e daily ligh t cycle.10

200
Neurobiology—Answers and Explanations

124. C – Both
125. B – Nicot in ic receptor
126. C – Both
127. B – Nicot in ic receptor
128. A – Mu scarin ic receptor

Th e n icot in ic an d m uscarin ic receptors both (C) bin d acet ylch olin e an d are
fou n d in sym p ath et ic n eu ron s, w h ereas th e directly gated receptors in skele-
t al m uscle are nicotinic (B). Hexam eth on iu m select ively blocks nicotinic ACh
recepto rs (B). Muscarinic re cepto rs (A) act ivate secon d m essenger system s
via G p rotein s, w h ereas n icot in ic receptors are ligan d-gated ion ch an n els.4,8

129. D – Na 1 an d K1 ch an n els

Th e excitator y postsynaptic poten tial in spinal m otor neurons is m ediated by


the act ion of acet ylch oline on th e acet ylcholin e receptor (a nonselective cat ion
channel), w h ich in creases m em brane perm eabilit y to both Na 1 and K1 (D).4,11

130. E – All of th e above

In creased m ean arterial pressure leads to increased stretch across the barore-
ceptors located in the carotid sinus (carried to the brainstem w ith the glosso-
pharyngeal nerve) leading to re ex vasodilat ion and bradycardia. These e ects
are m ediated by decreased sym path etic ton e an d in creased vagal ton e, w h ich
leads to a decrease in heart rate and cardiac contractilit y, as w ell as system ic
vasodilation , low ering system ic vascular resistan ce as w ell as blood pressure.8,11

131. B – Th in lam en t s
132. A – Th ick lam en t s
133. B – Th in lam en t s
134. B – Th in lam en t s
135. A – Th ick lam en t s
136. C – Both
137. B – Th in lam en t s

Thin lam ents (B) con sist of act in , t rop om yosin , an d t rop on in an d are
at tach ed to th e Z disks. Thick lam e nts (A) are com p osed of m u lt iple m yosin
m olecu les an d bin d ADP du ring rest . A sarcom ere is th e bu ilding block of a
m yo bril an d exten ds from on e Z disk to th e n ext . A sarcom ere is com posed
of bo th (C) thick and thin lam ents.8,11

138. B – Rot at ion of m yosin h eads p u lls th in lam en t s tow ard th e cen ter of th e
sarcom ere.

Du ring skelet al m u scle con t ract ion , calciu m bin ds to t rop on in (A is false).
Both th e associat ion an d det ach m en t of cross bridges requ ire ATP (not GTP;
C and D are false). Du ring relaxat ion , Ca 21 is act ively p u m p ed ou t of th e in t ra-
cellular space an d back into th e sarcoplasm ic ret icu lum (E is false ).8,11

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Neurosurgery Board Review

139. B – 2 65 m V

Th e rest ing poten t ial of a n euron is approxim ately 2 65 m V (B). Th e oth er


respon ses are in correct .8

140. A – Alcoh ol

An tidiu retic h orm on e, or argin in e vasopressin , is secreted by th e posterior


pit uitar y glan d an d inhibits renal excret ion of free w ater. Increased plasm a
o sm o lality (E) st im ulates osm oreceptor cells in the hypothalam us, w hich leads
to th e release of ADH. Volum e con traction , or decreased blo o d vo lum e (C),
prom otes ADH release via three m ech anism s: (1) At a xed osm olalit y, volum e
cont ract ion in creases the rate of ADH release—during a low -volum e state, a
low plasm a osm olalit y th at w ould n orm ally inh ibit th e release of ADH w ould
allow ADH secret ion to con t in u e. (2) Low left atrial pressure decreases th e r-
ing of vagal a erents, leading to in creased ADH secret ion. (3) Low circulat ing
blood volum e leads to renin product ion by th e ju xtaglom erular apparat us in
the kidneys. Renin is converted to angiotensin II (B), w h ich acts on th e sub -
fornical organ an d organ um vasculosu m of the lam in a term inalis to st im ulate
ADH release. Pain an d nausea (D) ten d to prom ote ADH secret ion . Alcohol (A)
in h ibits th e release of ADH from the posterior pit uitar y gland.5,8,11

141. D – Th e en zym es th at cat alyze th e steps in it s syn th esis are cytoplasm ic (false)

Th e en zym es th at catalyze th e syn th esis of th e low -m olecular-w eigh t t ran s-


m it ters are u su ally cytop lasm ic (dopam in e-b -hyd roxylase is an except ion ),
bu t th is is n ot a criterion th at m ust be ful lled for a ch em ical to be con sidered
a t ran sm it ter (D is false).8

142. E – Vasoact ive in test in al polypept ide (VIP) (false)

VIP (E) is con sidered a n euroact ive pept ide, n ot a n eurot ran sm it ter. Th e
oth er ch oices listed are con sidered to be n eu rot ran sm it ters: epinephrine (A),
glycine (B), histam ine (C), an d se roto nin (D).8,11

143. E – Sw eat glan ds

In gen eral, p ostganglion ic sym p ath et ic n eu ron s release n orep in eph rin e.
Sw eat glands (E) are an except ion to th is ru le, h ow ever. Sw eat glands are
in n er vated by sym path et ic n eu ron s th at release acet ylch olin e an d act via
m u scarin ic receptors. Th e sw eat glands are in n er vated by th e sym path et ic
system on ly.8,11

144. B – Th eir act ivit y is in creased after lesion s of th e sp in ocerebellu m (false)

Upon st im ulat ion of ext rafusal m uscle bers in n er vated by a m otor n euron s,
the m uscle spin dles (in t rafusal bers) w ould h ave a ten den cy to go slack,
w h ich w ould m ake th em in sen sit ive to fu rth er ch anges in length . g m otor
n eu ron s innervate intrafusal bers (C), cau sing in t rafu sal bers to con t ract
to sen se ongoing changes in length o f the m uscle (A). Th e act ivit y of g m otor
n eu ron s is p rofou n dly reduced by lesio ns in the ce rebellum (B is false).8,11

202
Neurobiology—Answers and Explanations

145. C – II, IV (n orepin eph rin e an d seroton in )

Descen ding seroto nergic path w ays (from rost roven t ral m edu llar y n eu ron s)
an d no radre ne rgic path w ays (from th e pon s) are im port an t lin ks in th e
su praspin al m od u lat ion of n ocicept ive t ran sm ission .7,8

146. B – I, III (ret in al ganglion cells an d lateral gen icu late cells)

Cells of th e retina an d lateral ge niculate nucleus h ave con cen t ric recept ive
elds th at fall in to t w o classes: on -cen ter or o -cen ter. Sim p le cells of th e vi-
su al cor tex h ave rect angu lar recept ive elds. Th e recept ive eld of a com p lex
cell in th e prim ar y visual cor tex h as n o clearly dist in ct excit ator y or in h ibi-
tor y zon es. Orien t at ion but n ot posit ion of th e ligh t st im u lus is im por tan t .8

147. E – Ru n i’s corpuscles


148. B – Meissn er’s corpu scles
149. C – Merkel’s receptors
150. D – Pacin ian corpuscles
151. A – Free n er ve en d ings

Me issner’s co rpuscles (B) an d Merkel’s recepto rs (C) are both fou n d su p er -


cially in th e derm al papillae an d h ave sm all recept ive elds. Pacinian (D) an d
Ru ni’s (E) corp u scles are fou n d in th e deeper su bcu t an eou s t issu e an d h ave
large recept ive elds. Both Merkel’s re cepto rs (C) an d Ru ni’s co rpuscles
(E) are slow ly adapt ing an d su bser ve p ressu re sen sat ion . Pacinian co rpuscles
(D) are m ore sen sit ive to low - th an h igh -frequ en cy st im u li an d t ran sm it u t-
ter. Pain sen sat ion is t ran sm it ted by free nerve e ndings (A).8,11

152. C – An t i-glut am ic acid decarboxylase

Th e diagn osis in th e case is “st i -m an ” or “st i -person” syn drom e. Most cases
of th is disorder sh ow circulat ing autoan t ibodies again st glutam ic acid de car-
boxylase (C), w h ich is th e en zym e respon sible for syn th esizing GABA. Th e st i -
person syn drom e can occur rarely as a paran eoplast ic syn drom e in associat ion
w ith breast cancer; in th ose cases, it is associated w ith an anti-am phiphysin
(A) or an anti-gephyrin (B) autoan t ibody. Th e anti-Yo (D) an t ibody occurs
w ith ovarian , lung, an d Hodgkin t um ors an d causes cerebellar degen erat ion .
The anti-Ri (E) an t ibody is respon sible for th e opsoclonus-m yoclon us-ataxia
seen w ith som e breast an d sm all-cell lu ng can cers.9

153. D – Mut at ion a ect ing th e RAS sign al-t ran sduct ion path w ay

Th is young pat ien t presen t ing w ith an opt ic t ract gliom a m ay carr y a diagn o-
sis of n eu ro brom atosis t yp e 1 (NF1). NF1 is associated w ith n eu ro brom as,
opt ic n er ve an d t ract gliom as, pigm en ted n odu les of th e iris, an d hyperpig-
m en ted cu t an eou s m acu les. Th e NF1 gen e is located on ch rom osom e 17 an d
en codes th e p rotein n eu ro brom in . Ne uro bro m in is tho ught to be a tum o r
suppresso r gene (B is false) th at h as som e st ru ct u ral h om ology to th e RAS
superfam ily o f GTPases. Th erefore, cho ice D is co rrect. Neu ro brom atosis
t ype 2 is associated w ith bilateral vestibular schw anno m as (A) an d is cau sed
by a m utatio n o n chro m oso m e 22 (C). Tu berou s sclerosis is associated w ith
m u t at ion s of th e ham artin gene o n chro m o so m e 9 (E).12

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Neurosurgery Board Review

154. B – G1 /S

The G1 /S transitio n (B) represen t s th e poin t of n o ret urn in th e cell cycle. At


th is poin t , DNA is ch ecked for accuracy prior to en tering th e S ph ase. If DNA
repair is n ot p ossible, apoptot ic m ech an ism s are act ivated. An oth er ch eck-
p oin t exist s at th e G2 /M transitio n (D), w h ich is p ar t icu larly im p ort an t for
cells exposed to ion izing radiat ion .12

155. C – MIB1 labels cells proliferat ing in m ult iple st ages of th e cell cycle

Tradit ion al H&E st ain ing tech n iques rely on th e iden t i cat ion of m itoses for
the detect ion of proliferat ing cells. Th e key advan tage of MIB1 labeling is th e
ability to detect pro life rating cells in m ultiple stages o f the cell cycle (C),
even th ose n ot cu rren tly in th e M p h ase of th e cell cycle. MIB1 labeling does
ad d dat a th at st an dard tech n iqu es can n ot provide, so choice B is inco rrect.
Mitoses are t yp ically cou n ted on th e H&E p rep arat ion , an d w h ile cells
u n dergoing m itosis are p osit ive for MIB1, cho ice D is not the best answ er.
W h ile MIB1 labeling m ay be useful in determ in ing th e proliferat ive in dex of
a t u m or, it is not a part o f the WHO criteria fo r the grading o f brillary
astro cyto m as (A and E).13

156. A – Valu e is h igh er in CSF th an p lasm a.


157. B – Valu e is h igh er in p lasm a th an CSF.
158. A – Valu e is h igh er in CSF th an p lasm a.
159. B – Valu e is h igh er in p lasm a th an CSF.
160. C – Value is equal in plasm a an d CSF.
161. B – Valu e is h igh er in p lasm a th an CSF.
162. C – Value is equal in plasm a an d CSF.
163. B – Valu e is h igh er in p lasm a th an CSF.

CSF con t ain s a h igh er con cen t rat ion of ch loride th an th e blood p lasm a. Bet a-2
t ran sferrin is a com pon en t th at is u n ique to CSF an d can be h elpful in th e
diagn osis of CSF leak (A). Osm olalit y an d sodiu m con cen t rat ion are equ al
bet w een CSF an d plasm a (C). Th e con cen t rat ion s of p ot assiu m , calciu m , u ric
acid, an d glu cose are low er in CSF th an in plasm a (B).3

164. C – In creased acet ylch olin e t ran sferase act ivit y (false)

Hu n t ington’s disease is a fat al, au tosom al dom in an t , pro gressive cho reo ath-
eto sis (D) th at involves a trinucleotide CAG (E) repeat on chro m oso m e 4 (B).
Brain im aging reveals atro phy o f the caudate heads (A) w ith a ch aracterist ic
ap p earan ce of hydrocep h alu s ex vacu o. W h ile th e p ath ophysiology is n ot
w ell u n derstood, th ere is believed to be decreased acet ylch olin e t ran sferase
act ivit y in p at ien ts w ith Hu n t ington’s disease (C is false ).3,12

204
Neurobiology—Answers and Explanations

165. D – 1 61 m V

Th e equilibriu m poten t ial is th e m em bran e poten t ial at w h ich n o n et di u-


sion of an ion occu rs becau se of balan ced elect rical an d ch em ical gradien t s.
Th e rest ing m em bran e poten t ial for sodium is 1 61 m V (D), potassiu m is
2 94 m V (A), ch loride is 2 86 m V (C), an d calciu m is 1 267 m V (E). Th e rest ing
m em bran e poten t ial of large, m yelin ated p erip h eral n er ves is ap p roxim ately
2 90 m V (B). Th e rest ing m em bran e p oten t ial is determ in ed largely by th e
equ ilibriu m p oten t ial of potassiu m (2 94 m V) because pot assium is 100 t im es
m ore p erm eable th an sodiu m .3

166. A – Methylat ion of th e MGMT gen e’s prom oter region u pregulates MGMT gen e
exp ression

Th e O6 -m ethylgu an in e-DNA m ethylt ran sferase (MGMT) gen e codes for a DNA
repair protein (D) th at represen t s an im po rtant m echanism fo r chem o -
therapy resistance (E) in glioblastom a. Methylat ion of th e gen e’s p rom oter
region leads to silencing o f the MGMT gene (A is false). MGMT m ethylat ion
is an inde pende nt predicto r o f im proved survival (B) as w ell as a pre dicto r
o f survival be ne t fro m tem ozo lom ide (C) in p at ien t s w ith glioblastom a.3

167. A – , 4 m in u tes
168. C – 40 m in u tes
169. D – 80 m in u tes
170. E – In n ite
171. E – In n ite

Norm al cerebral blood ow (CBF) is 50–55 m L/100 g/m in (E). Cells can com -
p en sate at a CBF of 18 m L/100 g/m in inde nitely (E). CBF in th e isch em ic
p en u m bra is th ough t to be 8–23 m L/100 g/m in . At less than 8 m L/100 g/m in,
there is rapid cell death fro m io n pum p failure (A). At 10 m L/100 g/m in , cell
death occurs after approxim ately 40 m inutes (C). At 15 m L/100 g/m in cell
death occurs after 80 m inute (D).3

172. C – An t i-Ma
173. E – An t i-Yo
174. B – An t i-Hu
175. D – An t i-Ri
176. A – An t i-glu t am ic acid decarboxylase

Lim bic en cep h alit is is a su bacu te en cep h alit is th at t ypically involves th e m esi-
al tem p oral lobes, cingu late gyri, an d in su la. Lim bic en cep h alit is is associated
w ith test icular can cer, lung can cer, an d anti-Ma (C) an t ibod ies. Anti-Yo (E)
an t ibodies are associated w ith ovarian an d breast can cer an d lead to cerebel-
lar degen erat ion . Anti-Hu (B) an t ibodies are associated w ith oat cell pu lm o-
n ar y carcin om a an d lym ph om a an d are associated w ith sen sor y n eu rop athy,
en cep h alit is, an d cerebellar degen erat ion . Anti-Ri (D) an t ibodies are associ-
ated w ith breast can cer an d lead to opsoclon us. St i -m an syn drom e is associ-
ated w ith an t ibodies to glutam ic acid decarboxylase (A) in . 60% of cases.3

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Neurosurgery Board Review

References

1. Win n HR, ed. Neu rological Surger y, 5th ed. Ph iladelph ia, PA: W.B. Saun ders; 2003
2. Hall ZW, ed. An In t roduct ion to Molecular Neurobiology. Sun derlan d, MA: Sin auer
Associates, In c.; 1992
3. Citow JS, Macdon ald RL, Refai D, eds. Com preh en sive Neu rosu rger y Board Review. New
York: Th iem e Medical Pu blish ers; 2009
4. Kat zung BG, ed. Basic an d Clin ical Ph arm acology, 9th ed. New York: McGraw -Hill; 2004.
5. Bru n ton LL, Lazo JS, Parker KL, eds. Goodm an & Gilm an’s th e Ph arm acological Basis of
Th erap eu t ics, 11th ed . New York: McGraw -Hill; 2006
6. Squ ire LR, Berg D, Bloom FE, du Lac S, Gh osh A, Spit zer NC, eds. Fu n dam en t al Neu roscien ce,
4th ed. New York: Elsevier; 2013
7. Patest as MA, Gar t n er LP, eds. Textbook of Neuroanatom y. Malden , MA: Blackw ell
Pu blish ing; 2006
8. Kan d el ER, Sch w art z JH, Jessel TM, eds. Prin cip les of Neu ral Scien ce, 4th ed. New York:
McGraw -Hill; 2000
9. Ropper AH, Brow n RH, eds. Prin ciples of Neurology, 8th ed. New York: McGraw -Hill; 2005
10. Carpen ter MB. Core Text of Neu roan atom y, 4th ed. Balt im ore, MD: William s & Wilkin s;
1991
11. Boron W F, Boulparp EL, eds. Medical Physiology. A Cellular an d Molecular Approach .
Ph iladelphia, PA: Elsevier; 2005
12. Ku m ar VK, Abbas AK, Fau sto N, ed s. Robbin s an d Cot ran : Path ologic Basis of Disease, 7th ed.
Ph iladelphia, PA: Elsevier; 2005
13. Dabbs DJ, Th om p son LDR. Diagn ost ic Im m u n oh istoch em ist r y: Th eran ost ic an d Gen om ic
Ap plicat ion s. Philadelph ia: W. B. Sau nders; 2010

206
5A Neuropathology—
Questions

1. Th e organ ism m ost frequ en tly iden t i ed in brain abscesses is


A. Bacteroides
B. Candida
C. Cit robacter
D. Microaeroph ilic St reptococcus
E. Staphylococcus

For qu est ion s 2 to 9, m atch th e m et al w ith th e toxicit y or descript ion . Each resp on se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Arsen ic
B. Lead
C. Mercur y
D. Mangan ese

2. Mees’ t ran sverse w h ite lin es on ngern ails

3. Psych ological dysfun ct ion (“m ad as a h at ter”)

4. Parkin son’s sym ptom s

5. Red blood cell basoph ilic st ippling

6. Brain levels in creased by dim ercaprol (BAL)

7. Sym ptom s im prove w ith L-dopa

8. In creased urin e coproporphyrin

9. Both pen icillam in e an d BAL are used in t reat m en t

For qu est ion s 10 to 14, m atch th e st ru ct u re w ith th e descript ion . Each resp on se m ay be
u sed on ce, m ore th an on ce, or n ot at all.
A. Neu ro brillar y t angles
B. Neurit ic plaques
C. Both
D. Neith er

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Neurosurgery Board Review

10. In t ran uclear

11. Core com posed of a p rotein

12. Con t ain s paired h elical lam en t s

13. Im m un oreact ive for t protein

14. Revealed w ith silver stain s

15. Most m en ingiom as express im m un oreact ivit y for


A. Cytokerat in
B. Desm in
C. Glial brillar y acidic protein (GFAP)
D. S-100 protein
E. Vim en t in

16. Each of th e follow ing is t rue of gangliogliom as except


A. Th e ast rocytes are GFAP posit ive
B. Th e ganglion cells are syn aptophysin posit ive
C. Th ey con tain n eu ropept ides
D. Th ey are usually di usely in lt rat ive
E. Th ey are m ost com m on in th e tem poral lobes

17. W h ich of th e follow ing is not associated w ith t risom y 13?


A. Holoprosen ceph aly
B. Hyper telorism
C. Microceph aly
D. Microph th alm ia
E. Polydact yly

18. W h ich of th e follow ing is not ch aracterist ic of ep en dym om as?


A. Bleph aroplast s in th e basal cytop lasm
B. In term ediate lam en t s th at are im m un oh istoch em ically iden t ical to glial
lam en t s of ast rocytes
C. Perivascular pseudoroset tes
D. Surface m icrovilli
E. True roset te form at ion

For qu est ion s 19 to 28, m atch th e vit am in w ith th e descript ion of its de cien cy or
toxicit y. Each respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Th iam in e
B. Niacin
C. Vitam in B12
D. Vitam in A
E. Vitam in D

19. Wern icke’s en ceph alopathy

20. Korsako ’s psych osis

21. Pellagra

22. Beriberi

23. Seen in rice eaters

208
Neuropathology—Questions

24. Seen in corn eaters

25. Rickets

26. Pern icious an em ia

27. Subacute com bin ed degen erat ion

28. Pseudot um or

29. W h ich of th e follow ing is t rue of lym ph om as (n on -Hodgkin’s m align an t


lym ph om as) of th e cen t ral n er vous system (CNS)?
A. All exh ibit a di u se h istologic p at tern .
B. Men ingeal lesion s are m ore com m on in prim ar y lym ph om as.
C. Most are of T cell lin eage.
D. Paren chym al lesion s are m ore com m on in secon dar y lym ph om as.
E. Th ey are radioresist an t .

30. W h ich of th e follow ing is not seen in St u rge-Weber syn drom e?


A. Cort ical ar terioven ou s m alform at ion s
B. Facial n evus
C. In t racort ical calci cat ion
D. Men ingeal angiom a
E. Seizu res

31. Each of th e follow ing is t rue of th e cord path ology in pern icious an em ia except
A. Dem yelin at ion occurs
B. Lum bar levels are m ost severely a ected
C. Lesion s m ay occu r in th e m edu lla
D. Vacuolar disten t ion of m yelin sh eath s occurs
E. Wallerian degen erat ion occurs

32. W h ich of th e follow ing is associated w ith progressive m ult ifocal en ceph alopathy?
A. Bacterial in fect ion
B. Dem yelin at ion
C. In creased n um bers of oligoden droglial cells
D. In ten se in am m ator y in lt rate
E. Sh run ken oligoden droglial n uclei at th e periph er y of th e lesion

33. W h ich of th e follow ing is associated w ith von Hippel-Lin dau disease?
I. Hepat ic cyst s
II. Hem angioblastom a of th e sp in al cord
III. Ren al cyst s
IV. Ren al cell carcin om a
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

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Neurosurgery Board Review

For qu est ion s 34 to 38, m atch th e t u m or w ith th e d escript ion . Each respon se m ay be
u sed on ce, m ore th an on ce, or n ot at all.
A. Neu ro brom a
B. Sch w an n om a
C. Both
D. Neith er

34. An ton i A areas

35. An ton i B areas

36. Verocay bodies

37. Axon s are presen t bet w een t um or cells

38. Th e plexiform t ype is st rongly associated w ith n euro brom atosis t ype 1

39. W h ich on e of th e follow ing cerebral m et ast ases h as th e greatest ten den cy to
h em orrh age?
A. Breast
B. Ch oriocarcin om a
C. Gast roin test in al (GI) t ract
D. Ovarian
E. Prost ate

For quest ion s 40 to 44, m atch th e t im e p eriod after a cerebral in farct w ith th e h istologic
ap p earan ce. Each resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. 12–24 h ou rs
B. Days 1–2
C. Days 5–7
D. Days 10–20
E. More th an 3 m on th s

40. Lipid-laden m acroph ages rst appear

41. Fibrillar y ast rocytes presen t at th e periph er y of th e lesion

42. Gem istocyt ic ast rocytes presen t at th e periph er y of th e lesion

43. Polym orph on uclear in lt rate

44. Neuron al n ecrosis is rst apparen t

45. Hepat ic failu re is m ost closely associated w ith


A. En doth elial proliferat ion
B. Gliosis localized to th e globus pallidus an d h ippocam pu s
C. Gliosis localized to th e w h ite m at ter
D. Alzh eim er’s t ype II ast rocytes
E. Loss of oligoden droglial cells

46. Each of the follow ing has been associated w ith central pont ine m yelinolysis except
A. Alcoh olism
B. Severe burn s
C. Rapid correct ion of hypon at rem ia
D. Serum hyperosm olarit y
E. Vitam in A excess

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Neuropathology—Questions

47. Rosen th al bers are associated w ith


I. Ast rocytosis
II. Alexan der’s disease
III. Pilocyt ic ast rocytom a
IV. Pick’s d isease
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

48. W h ich of th e follow ing is not t yp ically seen in n eu ro brom atosis t yp e 2?


A. Acou st ic n eurom as
B. Café-au-lait spot s
C. Cu tan eous n euro brom atosis
D. Lisch n odules
E. Plexiform n eu ro brom as

49. W h ich of th e follow ing is not associated w ith h epat ic en cep h alop athy?
A. Th iam in e de cien cy
B. Asterixis
C. Alzh eim er’s t ype II ast rocytes
D. In creased serum am m on ia

50. In am yot roph ic lateral sclerosis, th e cran ial n er ve n ucleus th at t ypically does not
exh ibit cell loss is
A. III
B. V
C. VII
D. IX
E. XII

51. W h ich of th e follow ing vascular m alform at ion s h ave n o in ter ven ing brain paren -
chym a bet w een blood vessels?
A. Ar terioven ous m alform at ion s
B. Capillar y telangiectasias
C. Cavern ous m alform at ion s
D. Cr ypt ic arterioven ous m alform at ion s
E. Ven ous angiom as

For qu est ion s 52 to 57, m atch th e sites of dam age in th e a xon al t ran sp ort ap parat u s
w ith th e toxin . Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Microt ubules
B. Oxidat ive ph osph or ylat ion
C. Tran script ion
D. Tran slat ion
E. Turn aroun d t ran spor t

52. Diabetes

53. Vin crist in e

54. Mercur y

211
Neurosurgery Board Review

55. Act in om ycin D

56. Din it roph en ol

57. Vin blast in e

58. Catech olam in e product ion can occur in w h ich of th e follow ing t um ors?
A. Ch oriocarcin om as
B. Glom us jugu lare t u m ors
C. Oligoden drogliom as
D. Pin eocytom as
E. Pleom orph ic xan th oast rocytom as

59. Th e viral in clu sion s seen in h erpes sim plex en ceph alit is are
A. Basop h ilic
B. Called Cow dr y t ype B bodies
C. Fou n d in n eu ron s on ly
D. In t ran u clear
E. On ly eviden t several w eeks after th e in fect ion

60. High levels of a -fetoprotein are associated w ith


A. En doderm al sin us t u m ors
B. Ch oriocarcin om as
C. Germ in om as
D. Pin eoblastom as
E. Teratom as

61. Th e m ost com m on sites of hyper ten sive h em orrhage, in decreasing order of fre-
quen cy, are
A. Lobar, put am en , cerebellum , th alam u s, p on s
B. Put am en , lobar, th alam us, cerebellum , pon s
C. Put am en , th alam us, pon s, lobar, cerebellum
D. Th alam us, cerebellu m , lobar, putam en , pon s
E. Th alam us, lobar, putam en , cerebellum , pon s

For qu est ion s 62 to 65, m atch th e sou rce of th e m et ast at ic brain lesion to th e descrip -
t ion . Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Breast
B. Ch oriocarcin om a
C. Lu ng
D. Lym ph om a
E. Prost ate

62. Most com m on

63. Greatest ten den cy to h em orrh age

64. Men ingeal involvem en t is m ost com m on .

65. Least propen sit y to involve th e brain

212
Neuropathology—Questions

For qu est ion s 66 to 69, m atch th e m ech an ism of act ion to th e disease. Each resp on se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Presyn apt ic in h ibit ion at th e n eu rom uscular jun ct ion
B. In h ibit ion of Ren sh aw cells
C. Post syn apt ic in h ibit ion

66. Bot ulism

67. Myasth en ia gravis

68. Eaton -Lam ber t syn drom e

69. Tet an us

70. Tuberous sclerosis is m ost closely associated w ith


A. Acou st ic n eu rom as
B. Cor t ical calci cat ion
C. Gian t-cell ast rocytom as
D. Opt ic gliom as
E. Ren al cysts

71. High levels of h um an ch orion ic gon adot roph in are seen in


A. Ch oriocarcin om a
B. Em br yon al carcin om a
C. En doderm al sin us t um or
D. Germ in om a
E. Teratom a

72. Cush ing’s disease is m ost often associated w ith a(n )


A. Acid op h ilic p it u it ar y ad en om a
B. Basoph ilic pit u it ar y aden om a
C. Ch rom oph obic pit uitar y aden om a
D. Ectopic sou rce of adren ocort icot ropic h orm on e (ACTH)
E. Non fun ct ion ing pit u it ar y aden om a

For qu est ion s 73 to 83, m atch th e sp h ingolip id osis w ith th e descript ion . Each respon se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Fabr y’s disease
B. Gauch er’s disease
C. Niem an n -Pick disease
D. San dh o ’s disease
E. Tay-Sach s disease

73. Sph ingom yelin ase de ciency

74. Hexosam in idase A an d B de cien cy

75. Glu cocerebrosidase de cien cy

76. Hexosam in idase A de cien cy on ly

77. a -galactosidase de cien cy

78. Abn orm al accum ulat ion of ceram ide t rih exosides

79. Tay-Sach s an d th is disorder are form s of th e GM2 gangliosidoses

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Neurosurgery Board Review

80. Supran uclear paresis of ver t ical gaze is h igh ly ch aracterist ic

81. Episodes of pain occur

82. X-lin ked recessive

83. Ch err y-red spots are foun d in vir t ually all pat ien t s w ith San dh o ’s an d th is
disorder

For qu est ion s 84 to 88, m atch th e m u cop olysacch aridosis (MPS) w ith th e d escript ion .
Each respon se m ay be used on ly on ce.
A. Hu n ter’s syn drom e (MPS II)
B. Hurler’s syn drom e (MPS I H)
C. Morqu io’s syn drom e (MPS IV)
D. San lippo’s syn drom e (MPS III)
E. Sch eie’s syn drom e (MPS I S)

84. De cien cy of a -L-idu ron idase

85. Ch aracterized by severe skelet al deform it ies an d ligam en tous laxit y

86. Heparan sulfate on ly is excreted in th e urin e

87. De cien cy of iduron ate sulfat ase; pebbling of th e skin m ay occur; X-lin ked
recessive

88. All form s of Morquio’s an d th is disorder are ch aracterized by n orm al in telligen ce

For quest ion s 89 to 95, m atch th e leu kodyst rop hy w ith th e descript ion . Each resp on se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Adren oleu kodyst rophy
B. Alexan der’s disease
C. Can avan’s disease
D. Krabbe’s disease
E. Met ach rom at ic leukodyst rophy

89. De cien cy of galactocerebrosidase

90. De cien cy of peroxisom es

91. Rosen th al bers are prom in en t

92. De cien cy of ar ylsulfat ase

93. X-lin ked recessive in h eritan ce

94. Accu m ulat ion of sm all qu an t it ies of psych osin e, a h igh ly toxic com poun d

95. Accu m ulat ion of long-chain fat t y acids

96. Each of th e follow ing is ch aracterist ic of Wilson’s disease except


A. Alzh eim er’s t yp e II ast rocytes
B. At rophy an d brow n ish discolorat ion of th e globus pallidus an d put am en
C. Autosom al dom in an t t rait
D. Decreased serum ceruloplasm in
E. Decreased serum copper

214
Neuropathology—Questions

For qu est ion s 97 to 100, m atch th e descript ion w ith th e d isease or syn drom e.
A. Idiop ath ic Parkin son’s disease
B. Shy-Drager syn drom e
C. Both
D. Neith er

97. Loss of cells in th e zon a com p acta of th e su bstan t ia n igra

98. Loss of cells in th e in term ediolateral h orn cells

99. Lew y bodies p resen t

100. Prom in en t loss of n eu ron s in th e p u t am en

101. Th e m ost com m on n eu rologic com p licat ion of acqu ired im m u n ode cien cy
syn drom e (AIDS) is
A. Dem en t ia
B. In am m ator y polym yosit is
C. Lym ph om a
D. Myelopathy
E. Toxoplasm osis

102. Each of th e follow ing lesion s is ch aracterist ic of t u berou s sclerosis except


A. Aden om a sebaceum
B. Ren al cell carcin om a
C. Rh abdom yom as of th e h eart
D. Subepen dym al gian t-cell ast rocytom a
E. Subu ngual brom as

103. Each of th e follow ing is seen in n eu ro brom atosis t yp e 1 except


A. Axillar y freckling
B. Café-au-lait m acu les
C. Neu ro brom as of th e iris
D. Opt ic gliom as
E. Sph en oid dysplasia

104. Each of th e follow ing is t ru e of am yloid angiopathy except


A. Am yloid b p rotein is th e m ajor p rotein seen
B. An eur ysm al dilat ion s are seen in involved vessels
C. It occu rs prim arily in vessels of deep n uclear st ruct ures of th e brain
D. It occurs prim arily in pat ien t s over 70 years of age
E. A yellow -green dich rom ism is seen un der polarized ligh t w h en th e am yloid
is stain ed w ith Congo red

105. Ch aracterist ic p ath ologic n dings in Gu illain -Barré syn drom e in clu d e each of th e
follow ing except
A. In creased cerebrospin al uid (CSF) protein at 5 w eeks after on set of illn ess
B. Lym ph ocyt ic pleocytosis in 90% of pat ient s
C. Norm al CSF pressures
D. Perivascular lym ph ocyt ic an d in am m ator y cell in lt rate
E. Periven ular an d segm en tal dem yelin at ion

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Neurosurgery Board Review

For quest ion s 106 to 162, m atch th e gu re w ith th e m ost ap prop riate resp on se.

106.
A. Rarely m ult ip le
B. Associated w ith im m u n osuppression in older m en
C. Associated w ith im m un osuppression in younger m en
D. Resist ant to steroids

107. Note in set at top righ t .

A. Hiran o bodies
B. In clusion bodies of h erpes sim plex virus-1 (HSV-1)
C. Lew y bodies
D. Pick bodies
E. Rabies

216
Neuropathology—Questions

108.

A. Hiran o bodies
B. In clusion bodies of subacute sclerosing pan enceph alit is (SSPE)
C. Lew y bodies
D. Pick bodies
E. Rabies

109.

A. In clu sion bodies of HSV-1


B. Lew y bodies
C. Pick bodies
D. Rabies
E. In clusion bodies of SSPE

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Neurosurgery Board Review

110.

A. In clu sion bodies of HSV-1


B. Lew y bodies
C. Pick bodies
D. Rabies
E. In clusion bodies of SSPE

111.

A. Gangliogliom a
B. Hepat ic en ceph alopathy
C. HSV-1
D. Parkin son’s disease
E. Norm al cor tex

218
Neuropathology—Questions

112.

A. Fibrillar y ast rocytom a


B. Gem istocyt ic ast rocytom a
C. Glioblastom a m ult iform e
D. Hem angioblastom a
E. Oligoden drogliom a

113.

A. An eur ysm al subarach n oid h em orrh age


B. Bacterial m en ingit is
C. Con t u sion
D. HSV-1
E. Subdu ral h em atom a

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Neurosurgery Board Review

114.

A. AIDS en ceph alopathy


B. Gian t-cell glioblastom a m ult iform e (GBM)
C. Hem angioblastom a
D. Creut zfeldt-Jakob disease
E. Progressive m ult ifocal leukoen ceph alopathy

115.

A. AIDS en ceph alopathy


B. Gian t-cell GBM
C. Hem angioblastom a
D. Creut zfeldt-Jakob disease
E. Progressive m ult ifocal leukoen ceph alopathy

220
Neuropathology—Questions

116. Th e p at ien t in th is ph otograp h is m ost likely to h ave

A. Met astat ic disease


B. Neuro brom atosis t ype 1 (NF-1)
C. NF-2
D. Tuberous sclerosis
E. von Hippel-Lindau disease

117.

A. HIV en ceph alopathy


B. Gian t-cell GBM
C. Hem angioblastom a
D. Creut zfeldt-Jakob disease
E. Progressive m ult ifocal leukoen ceph alopathy

221
Neurosurgery Board Review

118.

A. An ap last ic ast rocytom a


B. Epen dym om a
C. Gangliogliom a
D. Men ingiom a
E. Oligoden drogliom a

119.

A. An ap last ic ast rocytom a


B. Men ingiom a
C. Norm al pit uit ar y glan d
D. Oligoden drogliom a
E. Pit uitar y aden om a

222
Neuropathology—Questions

120.

A. Ch oroid plexu s p ap illom a


B. Epen dym om a
C. Medulloblastom a
D. Men ingiom a
E. Pit uitar y aden om a

121.

A. Ch oroid plexu s p ap illom a


B. Cran ioph ar yngiom a
C. Hem angioblastom a
D. Met ast at ic t um or
E. Myxopapillar y epen dym om a

223
Neurosurgery Board Review

122.

A. Ch oroid plexu s papillom a


B. Cran ioph ar yngiom a
C. Hem angioblastom a
D. Met ast at ic t um or
E. Myxopapillar y epen dym om a

123.

A. Ch oroid plexu s papillom a


B. Cran ioph ar yngiom a
C. Hem angioblastom a
D. Met ast at ic t um or
E. Myxopapillar y epen dym om a

224
Neuropathology—Questions

124.

A. Bu t ter y gliom a
B. Carbon m on oxide poison ing
C. Fat em boli
D. Lipom a
E. Lipofuscin deposit ion

125.

A. Carbon m on oxide poison ing


B. Fat em boli
C. Haller vorden -Spat z disease
D. Miliar y t uberculosis
E. Wilson’s disease

225
Neurosurgery Board Review

126.

A. Ep en dym om a
B. Glioblastom a
C. Medulloblastom a
D. Men ingiom a
E. Sch w an n om a

127. Th e p at ien t in th is ph otograp h is m ost likely to h ave

A. Met astat ic disease


B. NF-1
C. NF-2
D. Tuberous sclerosis
E. von Hippel-Lindau disease

226
Neuropathology—Questions

128.

A. An ap last ic ast rocytom a


B. Medulloblastom a
C. Men ingiom a
D. Met ast at ic t um or
E. Oligoden drogliom a

129.

A. Glioblastom a
B. Malign ant periph eral n er ve sh eath t um or
C. Men ingiom a
D. Neuro brom a
E. Sch w an n om a

227
Neurosurgery Board Review

130.

A. Glioblastom a
B. Malign ant periph eral n er ve sh eath t um or
C. Men ingiom a
D. Neuro brom a
E. Sch w an n om a

131.

A. Glioblastom a
B. Malign ant periph eral n er ve sh eath t um or
C. Men ingiom a
D. Neuro brom a
E. Sch w an n om a

228
Neuropathology—Questions

132.

A. Glioblastom a
B. Malign ant periph eral n er ve sh eath t um or
C. Men ingiom a
D. Neuro brom a
E. Sch w an n om a

133. Th is lesion is associated w ith (th e)

A. Filu m term in ale


B. Kidn ey
C. Notoch ord
D. Pit uitar y
E. von Hippel-Lindau disease

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Neurosurgery Board Review

134.

A. Alzh eim er’s disease


B. HSV-1
C. Hun t ington’s disease
D. Parkin son’s disease
E. Pickʼs disease

135. Dou ble arrow s corresp on d to

A. Bacterial m en ingit is
B. Can didiasis
C. Neurit ic plaques
D. Neuro brillar y t angles
E. Pick bodies

230
Neuropathology—Questions

136.

A. Acu te dissem in ated en ceph alom yelit is


B. Adren oleukodyst rophy
C. Alexan der’s disease
D. Krabbe’s disease
E. Met ach rom at ic leukodyst rophy

137.

A. Am yloid angiopathy
B. Duret’s h em orrh age
C. Glioblastom a
D. Hyper ten sive h em orrh age
E. Melan om a

231
Neurosurgery Board Review

138.

A. Cen t ral n eurocytom a


B. Colloid cyst s
C. Glioblastom a
D. Hem angioblastom a
E. Sch w an n om a

139.

A. Am yot rop h ic lateral sclerosis


B. Friedreich’s at axia
C. Mult iple sclerosis
D. Radiat ion m yelopathy
E. Subacu te com bin ed degen erat ion

232
Neuropathology—Questions

140.

A. Am yot rop h ic lateral sclerosis


B. Friedreich’s at axia
C. Mult iple sclerosis
D. Radiat ion m yelopathy
E. Subacu te com bin ed degen erat ion

141.

A. Am yot rop h ic lateral sclerosis


B. Friedreich’s at axia
C. Mult iple sclerosis
D. Radiat ion m yelopathy
E. Subacu te com bin ed degen erat ion

233
Neurosurgery Board Review

142.

A. Am yot rop h ic lateral sclerosis


B. Friedreich’s at axia
C. Mult iple sclerosis
D. Radiat ion m yelopathy
E. Subacu te com bin ed degen erat ion

143.

A. Am yot rop h ic lateral sclerosis


B. Friedreich’s at axia
C. Mult iple sclerosis
D. Radiat ion m yelopathy
E. Subacu te com bin ed degen erat ion

234
Neuropathology—Questions

144.

A. Gliom atosis cerebri


B. Hun t ington’s disease
C. Krabbe’s disease
D. Mult iple sclerosis
E. Tuberous sclerosis

145.

A. Ch oroid plexu s p ap illom a


B. Epen dym om a
C. Lym ph om a
D. Medulloblastom a
E. Men ingiom a

235
Neurosurgery Board Review

146.

A. Ch ordom a
B. Derm oid
C. Met astat ic t u m or
D. Myxopapillar y epen dym om a
E. Teratom a

147. Th is p at ien t is m ost likely to h ave

A. Advan ced age an d lobar h em orrh ages


B. Alcoh olism an d pron e to falls
C. Port-w in e n evus on th e face
D. Ret inal h am ar tom as
E. Subungu al brom as

236
Neuropathology—Questions

148.

A. Acou st ic n eu rom a
B. An aplast ic ast rocytom a
C. Medulloblastom a
D. Melan om a
E. Men ingiom a

149.

A. Carbon m on oxide poison ing


B. Cerebral con t usion s
C. Herpes en ceph alit is
D. Men ingeal carcin om atosis
E. Melan om a

237
Neurosurgery Board Review

150.

A. Acou st ic n eu rom a
B. An aplast ic ast rocytom a
C. Medulloblastom a
D. Melan om a
E. Men ingiom a

151.

A. An ap last ic ast rocytom a


B. In farct
C. Met ach rom at ic leukodyst rophy
D. Mult iple sclerosis
E. Radiat ion n ecrosis

238
Neuropathology—Questions

152.

A. An ap last ic ast rocytom a


B. In farct
C. Met ach rom at ic leukodyst rophy
D. Mult iple sclerosis
E. Radiat ion n ecrosis

153.

A. Epiderm oid
B. Lipom a
C. Met astat ic t u m or
D. Mult iple sclerosis
E. Teratom a

239
Neurosurgery Board Review

154.

A. Ast rocytom a
B. Lym ph om a
C. Melan om a
D. Oligoden drogliom a
E. Pit uitar y aden om a

155.

A. Men ingiom a
B. Neuro brom a
C. Pilocyt ic ast rocytom a
D. Pleom orph ic xan th oast rocytom a
E. Sch w an n om a

240
Neuropathology—Questions

156.

A. An eur ysm al subarach n oid h em orrh age


B. Bacterial m en ingit is
C. Con t u sion
D. HSV-1
E. Subdu ral h em atom a

157.

A. Am yloid angiopathy
B. Arterioven ous m alform at ion
C. Capillar y telangiectasia
D. Em bolism
E. Ven ous angiom a

241
Neurosurgery Board Review

158.

A. Alzh eim er’s disease


B. Ast rocytom a
C. Hun t ington’s disease
D. Krabbe’s disease
E. Pick’s disease

159.

A. Ast rocytom a
B. Glioblastom a
C. Hem angioblastom a
D. Medulloblastom a
E. Met astasis

242
Neuropathology—Questions

160.

A. Ast rocytom a
B. Glioblastom a
C. Neuro brom a
D. Pit uitar y aden om a
E. Sch w an n om a

161.

A. Dejerin e-Sot t as disease


B. Krabbe’s disease
C. Met ach rom at ic leukodyst rophy
D. Norm al periph eral n er ve
E. Ch arcot-Marie-Tooth disease

243
Neurosurgery Board Review

162. Th e gross sp ecim en seen h ere is m ost con sisten t w ith

A. Cyst icercosis
B. Hem angioblastom a
C. Juven ile pilocyt ic ast rocytom a
D. Ren al cell carcin om a
E. Toxoplasm osis

For quest ion s 163 to 168, m atch th e m et al toxicit y w ith th e m ost ap prop riate feat u re or
descript ion . Each respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Arsen ic toxicit y
B. Lead toxicit y
C. Mangan ese toxicit y
D. Mercur y toxicit y

163. En ceph alopathy, p erip h eral n eu rop athy, abdom in al pain , n au sea, vom it ing, diar-
rh ea, an d sh ock

164. Malaise, t ran sverse w h ite lin es, p igm en tat ion an d hyp erkeratosis of th e p alm s
an d soles

165. Irrit abilit y, seizu res, abdom in al p ain , at axia, com a, an d in creased ICP

166. Dem yelin at ing m otor p olyn eu rop athy (w rist drop), an em ia, gingival lin e

167. Psych ological dysfu n ct ion , t rem or, m ovem en t disorders, p eriph eral n eu rop athy,
cerebellar sign s

244
Neuropathology—Questions

168. Parkin son’s t yp e sym ptom s an d h eadach e

169. W h ich of th e follow ing st atem en t s regarding p rim ar y CNS lym p h om a is t ru e?


A. Herp es zoster viru s h as been im plicated in th e p ath ogen esis.
B. It is often periven t ricular an d brigh tly en h an cing.
C. Steroid th erapy sh ould be in it iated im m ediately.
D. It is t ypically of T cell lin eage.
E. It is an un likely diagn osis in im m u n ocom prom ised pat ien t s.

170. Th e p h otom icrograp h seen h ere

is m ost con sisten t w ith w h ich of th e follow ing diagn oses?


A. Cen t ral n eurocytom a
B. Dysem br yoplast ic n euroepith elial t um or
C. Lym ph om a
D. Men ingiom a
E. Sch w an n om a

171. W h ich of th e follow ing gen et ic abn orm alit ies are u su ally obser ved in “p rim ar y”
glioblastom as?
A. Ch rom osom e 10 delet ion s (PTEN)
B. Epiderm al grow th factor receptor (EGFR) am pli cat ion
C. p53 delet ion
D. Non e of th e above
E. All of th e above
F. A an d B
G. B an d C

245
Neurosurgery Board Review

172. Th is p h otom icrograp h

is an exam ple of w h ich of th e follow ing?


A. Ch on drosarcom a
B. Ch ordom a
C. Glioblastom a
D. Gliosarcom a
E. Sch w an n om a

173. At least h alf of all m en ingiom as h ave delet ion s involving w h ich of th e follow ing?
A. Ch rom osom e 3
B. Ch rom osom e 10
C. Ch rom osom e 17
D. Ch rom osom e 22
E. All of th e above

174. Men ingiom as ten d to sh ow im m u n oposit ivit y for w h ich of th e follow ing?
A. Ep ith elial m em bran e an t igen (EMA)
B. Vim en t in
C. Progesteron e receptor
D. All of th e above
E. Non e of th e above

175. W h ich of th e follow ing is t ru e regarding dem en t ia p ugilist ica?


A. Di u se deposits of b -am yloid are som et im es presen t .
B. Lew y bodies are prom in ent .
C. N-acet ylasp ar t ate con ten t in th e p u t am en an d p allid u m is in creased.
D. Th e clin ical syn drom e is presen t in up to on e-h alf of profession al boxers.
E. Th ere is a reduced in ciden ce of cavum sept um pellucidum in th is disorder.

176. W h ich of th e follow ing feat u res of m edu lloblastom a is associated w ith a w orse
p rogn osis?
A. Age , 3 years at diagn osis
B. Desm oplast ic subt ype on h istology
C. Exten sive n odu larit y on h istology
D. Less th an 1.5 cm 2 p ostoperat ive resid u al t u m or
E. Nuclear posit ivit y for b -caten in

246
Neuropathology—Questions

177. W h ich of th e follow ing is t ru e regarding th e lesion seen h ere?

A. Th ey are usu ally lled w ith kerat in .


B. Th ey ten d to be dorsally located.
C. Th ey ten d to occur in th e m idlin e.
D. All of th e above
E. Non e of th e above

247
5B Neuropathology—
Answer Key

1. D 27. C
2. A 28. D
3. C 29. A
4. D 30. A
5. B 31. B
6. C 32. B
7. D 33. E
8. B 34. B
9. B 35. B
10. D 36. B
11. D 37. A
12. C 38. A
13. A 39. B
14. C 40. C
15. E 41. E
16. D 42. D
17. B 43. B
18. A 44. A
19. A 45. D
20. A 46. E
21. B 47. A
22. A 48. D
23. A 49. A
24. B 50. A
25. E 51. C
26. C 52. E

248
Neuropathology—Answer Key

53. A 92. E
54. D 93. A
55. C 94. D
56. B 95. A
57. A 96. C
58. B 97. C
59. D 98. B
60. A 99. A
61. B 100. B
62. C 101. A
63. B 102. B
64. D 103. C
65. E 104. C
66. A 105. B
67. C 106. C
68. A 107. B
69. B 108. B
70. C 109. C
71. A 110. B
72. B 111. B
73. C 112. B
74. D 113. D
75. B 114. E
76. E 115. D
77. A 116. B
78. A 117. A
79. D 118. C
80. C 119. D
81. A 120. C
82. A 121. E
83. E 122. B
84. B 123. C
85. C 124. D
86. D 125. A
87. A 126. B
88. E 127. D
89. D 128. C
90. A 129. C
91. B 130. D

249
Neurosurgery Board Review

131. B 155. C
132. E 156. C
133. C 157. A
134. C 158. E
135. C 159. C
136. C 160. D
137. D 161. D
138. A 162. A
139. B 163. A
140. E 164. A
141. D 165. B
142. C 166. B
143. A 167. D
144. E 168. C
145. B 169. B
146. E 170. B
147. C 171. F
148. A 172. D
149. E 173. D
150. B 174. D
151. D 175. A
152. C 176. A
153. A 177. C
154. B

250
5C Neuropathology—Answ ers
and Explanations

1. D – Microaerop h ilic St reptococcus

W h ile brain abscesses ten d to con sist of m ixed ora, m icroaeroph ilic an d
an aerobic st reptococci are th e m ost frequ en tly iden t i ed organ ism s in brain
abscesses.1,2

2. A – Arsen ic
3. C – Mercu r y
4. D – Mangan ese
5. B – Lead
6. C – Mercu r y
7. D – Mangan ese
8. B – Lead
9. B – Lead

Arsenic toxicity (A) can be caused by in sect icides. Ch ron ic exposure to arsen ic
causes m alaise, hyperkeratosis, and pigm en tat ion of th e palm s and soles, as
w ell as Mees’ t ran sverse w h ite lin es in th e ngern ails. Arsen ic toxicit y is t reated
w ith dim ercaprol (BAL). Lead po iso ning (B) cau ses en ceph alit is in ch ildren ,
but in adult s causes a dem yelin at ing m otor polyn europathy an d anem ia. Lead
toxicity leads to basophilic st ippling of the er yth rocytes and in creases excre-
t ion of urinar y coproporphyrin . Lead toxicity can be t reated w ith EDTA, BAL,
an d p en icillam in e. Mercury (C) can be foun d in con tam in ated sh an d in felt
h at dyes. Mercury poison ing m ay cau se psych ological dysfu n ct ion (“m ad as
a h at ter”) as w ell as cerebellar sign s an d ren al t u bu lar n ecrosis. Pen icillam in e
is th e t reat m en t of choice for m ercury toxicit y; BAL increases brain levels of
m ercury an d sh ould be avoided. Manganese toxicity (D) prim arily a ects
m in ers an d is ch aracterized by Parkin son’s-t ype sym ptom s. Neu ron al loss is
obser ved in th e basal ganglia, an d sym ptom s gen erally respond to L-dopa.3

10. D – Neith er
11. D – Neith er
12. C – Both

251
Neurosurgery Board Review

13. A – Neuro brillar y t angles


14. C – Both

Neuro brillary tangles (A) an d ne uritic plaques (B) are both in t racytoplas-
m ic; both con t ain paired h elical lam en ts an d are revealed w ith silver st ain s.
Th e cen t ral core of th e neuritic plaque (B) is com posed of b /A4, n ot a protein .
Th e neuro brillary tangles (A) are im m u n oreact ive for t protein .1

15. E – Vim en t in

Vim entin (E) is an interm ediate lam ent protein and is usually expressed by
m eningiom as. Vim entin (E) expression is not terribly useful in m eningiom a
diagnosis, as the histopathologic di erential diagnostic considerations include
m any other tum ors that m ay also be vim entin positive such as carcinom as (pos-
itive for cytokeratins [A]), m elanom as (positive for m yelin A, HMB45, and S-100
[D]), gliom as (positive for S-100 [D]), and schwannom as (positive for S-100 [D]).
Epithelial m em brane antigen (EMA) is also expressed by the m ajorit y of m enin-
giom as and is a re ection of their epithelial character. Metastatic carcinom as
m ay also express EMA; however, EMA positivit y helps to rule out schw annom as,
m elanom as, and hem angioblastom as. GFAP (C) staining is generally negative for
m eningiom as but has been reported in papillary m eningiom as.1,2

16. D – Th ey are u su ally d i u sely in lt rat ive (false)

Gangliogliom as are usually w ell circum scribed an d can be part ially cyst ic
(D is false). Th e oth er resp on ses regarding gangliogliom as are t ru e: th e
ast rocytes are GFAP p osit ive (A), th e ganglion cells are syn aptop hysin posit ive
(B), th ey con t ain n eu rop ept ides (C), an d th ey m ost com m on ly occu r in th e
tem poral lobes (E).1,2

17. B – Hyp er telorism

Trisom y 13, Pat au ʼs syn drom e, is associated w ith hypotelorism , ho lo pro sen-
cephaly (A), m icro ce phaly (C), m icro phthalm ia (D), cleft palate, po lydac-
tyly (E), dext rocardia, an d ocu lar abn orm alit ies. Pat ien t s t ypically su r vive n o
m ore th an 9 m on th s. Hyp otelorism , n ot hype rtelo rism (B), is associated w ith
t risom y 13.3,4

18. A – Bleph aroplast s in th e basal cytoplasm

Epen dym om as are CNS n eoplasm s th at resem ble th e st ruct u re of th e brain’s


epen dym a. Th e m ost de n it ive eviden ce of epen dym om a is th e presen ce
of true ro settes (E), also called “Flexn er-Win terstein er roset tes.” Most ep -
en dym om as con t ain pe rivascular pseudo ro settes (C) involving t u m or cells
su rrou n ding an en doth elial-lin ed lu m en . Ep en dym om as ten d to st ain for
GFAP and vim e ntin (B), p ar t icu larly in th e p erivascu lar p seu doroset tes. On
elect ron m icroscopy, exten sive surface m icrovilli (D) form ing both in t ra- an d
ext racellu lar lu m en s can be seen . Blep h arop last s (ciliar y basal bodies) are
fou n d in th e apical, n ot basal, cytoplasm (A is false).1,2

19. A – Th iam in e
20. A – Th iam in e

252
Neuropathology—Answers and Explanations

21. B – Niacin
22. A – Th iam in e
23. A – Th iam in e
24. B – Niacin
25. E – Vitam in D
26. C – Vitam in B12
27. C – Vitam in B12
28. D – Vitam in A

Diet s h eavy in corn lack t r yptop h an th at is u sed to syn th esize niacin (B);
n iacin d e cien cy cau ses p ellagra—derm at it is, diarrh ea, an d dem en t ia. Diet s
h eavy in re n ed rice are m ore likely to lack su cien t thiam ine (A). Th iam in e
de cien cy is associated w ith Wern icke’s en ceph alopathy an d Korsako ’s psy-
ch osis, as seen in ch ron ic alcoh olism , an d is also associated w ith beriberi—
ch aracterized by periph eral polyn europathy, dem yelin at ion , an d auton om ic
dysfu n ct ion . Vitam in A (D) toxicit y m ay cau se cerebral ed em a w ith a pseudo-
t um or presen t at ion . Pern icious an em ia can lead to a vitam in B12 (C) de cien cy
w ith m egaloblast ic an em ia an d subacute com bin ed degen erat ion of th e spi-
n al cord. Vitam in D de ciency (E) causes ricket s, w h ich is associated w ith
decreased parathyroid h orm on e an d brit tle bon es.3

29. A – All exh ibit a di use h istologic pat tern .

Men ingeal in lt rat ion is th e m ost com m on lesion in secon dar y lym ph om as
(B is false), an d p aren chym al lesion s are th e m ost com m on lesion in prim ar y
lym ph om as (D is false). Most are of B cell lin eage an d are radiosen sit ive
(C and E are false). Nod u lar lym p h om as are n ot seen in th e cen t ral n er vou s
system (CNS); all sh ow a d i u se h istology (A is true ).1,2

30. A – Cort ical ar terioven ou s m alform at ion s

St u rge-Weber syn drom e is ch aracterized by a usu ally un ilateral po rt-w ine


nevus (B) th at t ypically involves th e orbit or upper eyelid, un ilateral m enin-
geal angiom a (D), calci catio ns con n ed to th e secon d an d th ird layers of
ce rebral co rtex (C), an d seizure activity (E). Th e abn orm al m en ingeal vessels
are t ypically vein s an d are n ot w ell-visu alized on angiograp hy—a feat u re th at
is n ot con sisten t w ith ar terioven ous m alform at ion s. Arterioven ous m alfor-
m at ion s (AVMs) are n ot ch aracterist ic of th e St u rge-Weber syn drom e (A).5

31. B – Lu m bar levels are m ost severely a ected (false)

Th e dem yelinatio n (A), spo ngio sis (D), an d gliosis seen in vit am in B12
de cien cy are m ost com m on at low er cer vical an d th oracic levels (B is false).1

32. B – Dem yelin at ion

Progressive m ult ifocal leukoen ceph alopathy is caused by a papovavirus (no -


tably the JC virus; A is false). Lesion s occu r m ain ly in th e w h ite m at ter an d
con sist of foci of m yelin an d oligoden droglial cell loss w ith m in im al in am m a-
tor y in lt rate (C and D are false). Hyp erch rom at ic en larged oligoden droglial
n u clei are fou n d at th e m argin of th e lesion s (E is false ). Dem yelinatio n is
present (B); som e early cases w ere th ough t to rep resen t at ypical MS.1,2

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Neurosurgery Board Review

33. E – All of th e above

von Hippel-Lindau (VHL) disease is an autosom al dom inant disorder linked to the
VHL gene on chrom osom e 3—a tum or suppressor gene. The disease is associated
w ith hem angioblastom as of the brain and spinal cord (II), retinal hem angio-
blastom as, renal cell carcinom as and renal cysts (III, IV), pheochrom ocytom a,
pancreatic tum ors and cysts, hepatic cysts (I), and polycythem ia vera.5,6

34. B – Sch w an n om a
35. B – Sch w an n om a
36. B – Sch w an n om a
37. A – Neuro brom a
38. A – Neuro brom a

Schw anno m as (B) are ch aracterized by a biphasic cellular pat tern com posed
of com pact spindle cells (Antoni A areas) and loosely arranged stellate cells (An -
ton i B areas). Also seen are Verocay bodies, w h ich result from th e palisading of
elongated nuclei alternating w ith anuclear brillar m aterial. Neuro brom as
(A) in corporate the paren t ner ve and h ence have axons in their m idst. The
plexiform t ype is considered pathognom onic for neuro brom atosis t ype 1.1,2

39. B – Ch oriocarcin om a

Of th ese ch oices, cho rio carcino m a (B) h as th e greatest ten d en cy to h em -


orrh age. Hem orrh age is also com m on in m elan om a, ren al cell carcin om a,
co lo rectal carcinom a (C), an d lu ng carcin om a. Can cers of breast o rigin (A)
are u n likely to h em orrh age.1,2

40. C – Days 5–7


41. E – More th an 3 m on th s
42. D – Days 10–20
43. B – Days 1–2
44. A – 12–24 h ou rs

Irreversible isch em ic inju r y is eviden t at th e cellu lar level w ith in 6 h ou rs w ith


m icrovacu olizat ion of th e cells an d cytop lasm ic bu lging. Neu ron al n ecrosis
becom es apparen t w ith in 12–24 ho urs (A). Polym orp h on u clear (PMN) leu-
kocytes begin to accu m u late 24 h ou rs after th e in su lt an d PMN accu m u lat ion
p eaks at 48 hours (B). Macrop h ages begin to arrive on day 3; by day 5–7 (C)
lip id-laden m acroph ages becom e ap paren t . Bet w een days 10 an d 20 (D) gem -
istocyt ic ast rocytes begin to ap pear at th e periph er y of th e lesion , an d en -
h an cem en t begin s to occu r on con t rasted im ages. Fibrillar y ast rocytes d o n ot
ap p ear at th e perip h er y of th e lesion for m o re than 3 m onths (E).1,3

45. D – Alzh eim er’s t yp e II ast rocytes

Acqu ired h ep atocerebral d egen erat ion is associated w ith gliosis w ith a p redi-
lect ion for th e cortex (C is false). It ten ds to sp are th e h ip p ocam p u s, globu s
p allidu s, an d deep folia of th e cerebellar cor tex (B is false). Widesp read hy-
perplasia of protoplasm ic ast rocytes (Alzh eim er’s t ype II ast rocytes) is visible
in th e d eep layers of th e cerebral an d cerebellar cortex an d in deep n uclear
st ru ct u res (D).5

254
Neuropathology—Answers and Explanations

46. E – Vitam in A excess (false)

“Th e ou tstan ding ch aracterist ic of CPM is its invariable associat ion w ith som e
oth er seriou s, often life th reaten ing disease.” Cen t ral p on t in e m yelin olysis is
an acu te d em yelin at ing con dit ion of th e brain stem th at h as been at t ribu ted
to rapid correct ion of hypon at rem ia. Th e disorder h as been associated w ith
alco ho lism (A), severe burns (B), an d serum hypero sm o larity (D). Th e
com m on path w ay of all of th ese disease processes seem s to involve eith er th e
rap id correct ion of hypo natrem ia (C) or severe acute hype ro sm o larity (D)
(as in burn vict im s). Vitam in A excess h as n ot been associated w ith cen t ral
p on t in e m yelin olysis (E is false).5

47. A – I, II, an d III: (ast rocytosis, Alexan der’s disease, an d pilocyt ic ast rocytom a)

Rosen th al bers, eosin oph ilic m asses obser ved in ast rocyt ic processes, are
associated w ith pilo cytic astro cyto m as (III, neo plastic), astrocyto sis (I),
an d Alexander’s disease (II, no nne oplastic). Pick’s disease (IV) is associated
w ith Pick bodies, w h ich are rou nd, in t racytoplasm ic eosin oph ilic in clusion s
th at are posit ive w ith silver st ain s an d w ith an t ibodies to tau .1,2,3

48. D – Lisch n odu les

Neuro bro m as (E) an d café-au-lait spots (B) occu r less com m on ly in n eu ro-
brom atosis t ype 2 (NF-2) th an in NF-1. Bilateral aco ustic neuro m as (A) are
the h allm ark of NF-2. Lisch no dules (D) are rare in NF-2.1,5

49. A – Th iam in e de cien cy

Asterixis (B) can ap pear in a variet y of m et abolic en ceph alop ath ies bu t is
m ost com m on in h ep at ic en cep h alop athy. Th e serum am m o nia (D) level
u su ally exceed s 200 m g/dL. Th e m ost st riking n europath ologic n ding in pa-
t ien ts w h o die in a st ate of h epat ic en ceph alopathy is th e presen ce of a large
am ou n t of large p rotop lasm ic ast rocytes w ith glycogen -con t ain ing in clu-
sion s. Th ese Alzhe im erʼs type II astro cytes (C) can be foun d th rough out th e
deep cerebral cor tex, len t icular n u clei, th alam us, subst an t ia n igra, cerebellar
cor tex, red, den t ate, an d pont in e n uclei. Th iam in e de ciency is n ot associated
w ith h epat ic en ceph alopathy.5

50. A – III

Th e m otor n uclei of cran ial n er ves V (B), VII (C), IX (D), an d XII (E) as w ell as
the m otor cor tex m ay be a ected.1

51. C – Cavern ous m alform at ion s

Cave rno us m alfo rm atio ns (cave rno us hem angio m as [C]) are com posed of
large, th in -w alled vessels w ith out in terposed brain paren chym a. Typically
AVMs (A and D) t raverse d isordered brain t issu e th at lies bet w een th e abn or-
m al vessels. Capillary telangiectasias (B) con tain in ter ven ing brain paren -
chym a; so do develo pm e ntal veno us ano m alies (veno us angio m as [E]).1,2,3

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Neurosurgery Board Review

52. E – Turn arou n d t ran sport


53. A – Microt ubules
54. D – Tran slat ion
55. C – Tran script ion
56. B – Oxidat ive p h osph or ylat ion
57. A – Microt ubules

Th is quest ion focuses on causes of toxic n europath ies. Both vin crist in e an d
vin blast in e in terfere w ith m icrotubule (A) fun ct ion , alth ough th rough sligh tly
di eren t m ech an ism s. Din it roph en ol is th ough t to disrupt oxidative phos-
pho rylatio n (B). Act in om ycin D is an an t ibiot ic p rodu ced by st reptom yces
that is used in can cer th erapy. It s ph en oxazon e ring in tercolates w ith DNA
an d in terferes w ith DNA transcriptio n (C). Mercu r y in act ivates su lfhydr yl
grou p s of en zym es in terfering w ith cellu lar m etabolism an d fu n ct ion —
translatio n (D), in part icu lar. En d-organ glycosylat ion m ay disru pt turn-
aro und transpo rt (E), as seen in diabetes.1,3,7

58. B – Glom u s jugu lare t u m ors

Glo m us jugulare tum ors (B) origin ate from foci of paraganglion ic t issue
arou n d th e jugu lar bu lb (th ey are p aragangliom as of th e glom u s jugu lare).
Th ese invasive t um ors con tain n eurosecretor y gran ules sim ilar to th ose in
the carot id body. Som e of th em produ ce clin ically detect able am oun t s of
catech olam in e. Th e m ost com m on paragangliom a is th at of th e adren al glan d
an d goes by an oth er n am e: p h eoch rom ocytom a. Non e of th e oth er opt ion s
listed are kn ow n to secrete catech olam in es.2,8

59. D – In t ran u clear

Th e viral in clu sion s of h erpes sim plex t ype 1 (Cow dr y t ype A) are den se, in -
t ran u clear, eosin oph ilic bodies foun d in n euron s, ast rocytes, an d oligoden -
drocytes. Th ey are m ore likely to be foun d early in the course of th e disease.1

60. A – En doderm al sin us t um ors

High levels of h u m an ch orion ic gon adot rop h in (HCG) are associated w ith
cho rio carcino m as (B), an d h igh levels of a -fetop rotein (AFP) are associated
w ith e ndo de rm al sinus tum o rs (yo lk sac tum ors [A]). Fifteen p ercen t of
germ ino m as (C) m ay be associated w ith in creased HCG. Em br yon al carcin o-
m as w ill sh ow elevat ion s in both AFP an d HCG. Terato m as (E) m ay cau se a
rise in seru m CEA levels.1,3

61. B – Pu t am en , lobar, th alam u s, cerebellu m , p on s

Th e m ost com m on sites of hyperten sive cerebral h em orrh age are (1) puta-
m en an d in tern al cap su le (50%); (2) lobar h em orrh ages of th e cen t ral w h ite
m at ter of th e tem p oral, p ariet al, or fron t al lobes; (3) th alam u s; (4) cerebellar
h em isp h ere; an d (5) pon s.5

62. C – Lung
63. B – Ch oriocarcin om a
64. D – Lym p h om a

256
Neuropathology—Answers and Explanations

65. E – Prost ate

Lung (C) m et ast asis is th e m ost com m on in t racran ial m et ast at ic t u m or.
Cho rio carcino m a (B) h as th e greatest propen sit y to h em orrh age. Secon dar y
(m et ast at ic) CNS lym pho m a (D) ten ds to involve th e m en inges, w h ile
p rim ar y CNS lym ph om a ten ds to involve th e paren chym a. Of th e opt ion s
listed, pro state (E) h as th e low est p rop en sit y to m et astasize to brain .1

66. A – Presyn apt ic in h ibit ion at th e n eu rom uscular jun ct ion


67. C – Post syn apt ic in h ibit ion
68. A – Presyn apt ic in h ibit ion at th e n eu rom uscular jun ct ion
69. B – In h ibit ion of Ren sh aw cells

Both bot u lism an d Eaton -Lam ber t syn drom e cau se presynaptic inhibitio n
at the neuro m uscular junctio n (A), albeit via di eren t m ech an ism s. Bot u li-
n u m toxin p reven t s bin ding of syn apt ic vesicles to th e p resyn apt ic m em bran e
in h ibit ing acet ylch olin e release. Eaton -Lam bert syn drom e is caused by an t i-
bodies directed again st volt age-gated calcium ch an n els located at th e presyn -
apt ic term in al; in terferen ce w ith th ese volt age-gated Ca 21 ch an n els causes
decreased release of ACh qu an t a, as syn apt ic vesicle bin ding is a calcium -
depen den t process. Tetan us toxin causes excit at ion of agon ist an d an t ago-
n ist m u scles by inhibiting the release o f glycine fro m Renshaw cells (B)
(sim ilar to st r ych n in e poison ing). Myasth en ia gravis is caused by an t ibodies
to acet ych olin e receptors located on th e po stsynaptic end-plate (C).3

70. C – Gian t-cell ast rocytom as

Tuberous sclerosis is an autosom al dom in an t con dit ion localized to ch rom o-


som es 9 an d 16 th at is associated w ith a classic t riad of m en tal retardat ion , sei-
zures, an d aden om a sebaceum . Subepe ndym al giant-cell astro cyto m as (C)
are p resen t in 15% of cases. Aco ustic ne uro m as (A) are associated w ith NF-2.
Co rtical calci cations (B) are associated w ith St urge-Weber syn drom e. Optic
gliom as (D) are associated w ith NF-1. Re nal cysts (E) are associated w ith VHL
disease.1,3

71. A – Ch oriocarcin om a

High levels of h u m an ch orion ic gon adot rop h in (HCG) are associated w ith
cho rio carcino m as (A), an d h igh levels of a -fetop rotein (AFP) are associated
w ith endo derm al sinus tum o rs (yo lk sac tum o rs [C]). Fifteen percen t of
ge rm ino m as (D) m ay be associated w ith in creased HCG. Em bryo nal carci-
no m as (B) w ill sh ow elevat ion s in both AFP an d HCG. Te rato m as (E) m ay
cause a rise in serum carcin oem br yon ic an t igen levels.1,3

72. B – Basop h ilic pit u it ar y ad en om a

Cu sh ing’s d isease is hypercor t isolem ia cau sed by an ACTH-secret ing pit uit ar y
t um or (D is false ). Cu sh ing’s syn d rom e is a hypercort isol state th at m ay
be du e to a variet y of causes. Acido philic (A) p it u itar y cells m ay produ ce
p rolact in , grow th h orm on e, or FSH/LH. Baso philic (B) p it u it ar y cells m ay
p rodu ce ACTH or TSH. Th erefore, Cu sh ing’s disease, by de n it ion , is m ost
often associated w ith a baso philic pituitary adeno m a (B).1,3

257
Neurosurgery Board Review

73. C – Niem an n -Pick disease


74. D – San dh o ’s disease
75. B – Gau ch er’s disease
76. E – Tay-Sach s disease
77. A – Fabr y’s disease
78. A – Fabr y’s disease
79. D – San dh o ’s disease
80. C – Niem an n -Pick disease
81. A – Fabr y’s disease
82. A – Fabr y’s disease
83. E – Tay-Sach s disease

Th e ve opt ion s listed are sph ingolipidoses, lysosom al storage disorders th at


resu lt in abn orm al accum u lat ion of lipids. All of th e ch oices are in h erited in an
au tosom al recessive fash ion except for Fabry’s disease (A), w h ich is X-lin ked
recessive. Tay-Sachs (E) an d Sandho ’s disease (D) are th e t w o GM2 ganglio-
sidoses, an d both h ave ch err y-red spots in th e m acu la as a prom in en t feat u re.
Nie m ann-Pick disease (C) is cau sed by sp h ingom yelin ase de cien cy w ith an
accu m u lat ion of sp h ingom yelin an d ch olesterol. Su p ran u clear p aresis of ver-
t ical gaze is h igh ly ch aracterist ic of th is disease. Fabry’s disease (A) is cau sed
by a de cien cy of a -galactosidase w ith accu m u lat ion of ceram ides. Pain fu l
dysesth esias are prom in en t in th is disorder. Gaucher’s disease (B) is caused
by a glucocerebrosidase de cien cy w ith accum ulat ion of glu cocerebrosides.
Sandho ’s disease (D) is cau sed by h exosam in idase A an d B de cien cy
w ith accu m u lat ion of GM2 gangliosides. Tay-Sachs disease (E) is cau sed by
a de cien cy of h exosam in idase A w ith accu m u lat ion of GM2 gangliosides.1,3

84. B – Hu rler’s syn drom e


85. C – Morqu io’s syn drom e
86. D – San lip po’s syn drom e
87. A – Hun ter’s syn drom e
88. E – Sch eie’s syn drom e

Th e opt ion s listed are m ucopolysacch aridoses (MPS), w h ich produce lipid
accu m u lat ion in th e lysosom es of th e gray m at ter an d p olysacch arid e
accu m u lat ion in con n ect ive t issu e. All of th ese opt ion s are in h erited in an
au tosom al recessive fash ion , w ith th e except ion of Hunter’s syndro m e (A),
w h ich is in h erited in an X-lin ked recessive fash ion . Hunter’s syndrom e (A) is
cau sed by a de cien cy of iduron idase sulfat ase w ith h eparan and derm atan
excret ion in th e u rin e—skin p ebbling an d p eriph eral n er ve en t rap m en t are
com m on . Hurler’s syndro m e (B) is caused by an a -L-idu ron idase de cien cy
w ith h eparan an d derm at an sulfate excret ion in th e u rin e. Sche ie’s syndro m e
(E) is a m ilder form of Hurler’s disease th at is also caused by a d e cien cy of
a -L-idu ron idase. It is ch aracterized by n orm al in telligen ce. Mo rquio’s syn-
dro m e (C) is cau sed by b -galactosidase an d galactose-6-su lfat ase de cien cy
w ith kerat in excret ion in th e urin e. Ligam en tous laxit y, skelet al deform it ies,
an d atlan toaxial su blu xat ion are ch aracterist ic. San lippo’s syndro m e (D) is
caused by sulfam idase de cien cy w ith h eparan excret ion in th e urin e.1,3

258
Neuropathology—Answers and Explanations

89. D – Krabbe’s disease


90. A – Adren oleukodyst rophy
91. B – Alexan d er’s disease
92. E – Met ach rom at ic leukodyst rophy
93. A – Adren oleukodyst rophy
94. D – Krabbe’s disease
95. A – Adren oleukodyst rophy

Th e ch oices listed are leukodyst roph ies, a group of disorders involving en zym e
de cien cies causing abn orm al m yelin syn th esis, degradat ion , or m ain te-
n an ce. Adrenoleukodystrophy (A) is an X-lin ked recessive disorder resu lt -
ing from abn orm al lipid oxidat ion in peroxisom es leading to accum ulat ion
of long-ch ain fat t y acids accom pan ied by adren al in su cien cy. Alexander’s
disease (B) is a sp oradically in h erited disease resu lt ing from a defect in th e
GFAP gen e. Psych om otor ret ardat ion an d seizu res are com m on , an d Rosen th al
bers are p resen t on h istologic sect ion s. Canavan’s disease (C) is an autoso-
m al recessive disorder cau sed by a de cien cy of asp artoacylase w ith spongy
vacu olizat ion p referen t ially a ect ing su bcort ical U- bers. Krabbe’s disease
(D) is an autosom al recessive disorder of th e en zym e b -galactosidase w ith
accu m u lat ion of galactocerebrosid e as w ell as psych osin e, w h ich is toxic for
oligoden droglial cells. In Krabbe’s disease, th ere is vacuolizat ion of th e w h ite
m at ter w ith sparing of su bcor t ical U- bers.1,3

96. C – Autosom al dom in an t t rait (false)

Wilson’s disease is t ran sm it ted as an auto so m al recessive trait (C is false),


an d involves th e ATP7B gen e, w h ich cau ses t w o dist u rban ces of cop p er
m et abolism . Th ere is redu ced in corp orat ion of cop p er in to ceru lop lasm in ,
an d th ere is redu ct ion in biliar y excret ion of cop p er. Decrease d serum co p-
per levels (E), decrease d serum cerulo plasm in levels (D), an d in creased
u rin ar y excret ion of copper are t yp ical laborator y n d ings. Cavitatio n and
disco lo ratio n (B) o f the le ntifo rm nucle i (h en ce, “h epatolen t icu lar degen -
erat ion ”) are t yp ical on p ath ologic exam in at ion . Th ere is m arked hyp erp lasia
of protoplasm ic ast rocytes (Alzheim er’s type II astro cytes [A]) in both cort i-
cal an d su bcor t ical st ruct u res.5

97. C – Both
98. B – Shy-Drager syn drom e
99. A – Idiopath ic Parkin son’s disease
100. B – Shy-Drager syn drom e

Both idiop ath ic Parkinso n’s disease (A) an d th e Shy-Drager syndro m e


(a fo rm o f striato nigral degeneratio n [B]) are ch aracterized by loss of cells in
the zon a com pact a of th e subst an t ia n igra, bu t in Shy-Drager syndro m e (B),
sign i can t cell loss in th e pu t am en an d th e in term ediolateral colu m n is also
fou n d. Lew y bodies are n ot fou n d in th e Shy-Drager syndro m e (B). Pat ien t s
w ith th is syn drom e su er from parkin son ian sym ptom s an d or th ost at ic
hypoten sion .5

259
Neurosurgery Board Review

101. A – Dem en t ia

Dem e ntia (A), ch aracterized by cogn it ive dysfu n ct ion , beh avioral dist u rban ce,
an d m otor im p airm en t , occu rs in on e-th ird to t w o-th ird s of p at ien ts w ith
AIDS. Myelo pathy (D) occu rs in less th an 10%, in am m ato ry po lym yo sitis
(B) in 20%, toxo plasm o sis (E) in 10%, an d lym pho m a (C) in 5% of AIDS
p at ien ts.1,5

102. B – Ren al cell carcin om a

Th e t riad of ade no m a sebaceum (A) (act u ally angio brom as), epilep sy, an d
m en tal retardat ion ch aracterizes t u berou s sclerosis. Alth ough ben ign t u m ors
(angiom yolipom as) of th e kidn ey an d oth er organ s are seen , re nal cell car-
cino m as (B) are n ot (ren al cell carcin om a is associated w ith VHL). Rhabdo -
m yo m as o f the heart (C), subepe ndym al giant-cell astro cyto m a (D), an d
subungual bro m as (E) are all seen in t u berou s sclerosis.5

103. C – Neuro brom as of th e iris (false)

Neu ro brom atosis t yp e 1 (NF of von Recklingh au sen , perip h eral or classic NF)
is an au tosom al dom in an t disord er localized to ch rom osom e 17 (n euro bro-
m in gen e) ch aracterized by areas of skin hyp erp igm en tat ion an d cu tan eou s
an d su bcu t an eou s n eu ro brom as. Café-au-lait spots (B) are presen t on th e
skin , an d th e presen ce of six or m ore . 1.5 cm lesion s is in dicat ive of th e
diagn osis. Th e presen ce of axillary freckling (A) in conju n ct ion w ith café-au -
lait m acu les is n early p ath ogn om on ic of NF-1. NF-1 is also associated w ith th e
grow th of m u lt ip le perip h eral n eu ro brom as, bon e cysts, scoliosis, spheno id
dysplasia (E), an d o ptic glio m a (D) form at ion . Th e Lisch n odu les of NF-1
represen t h am ar tom as of th e iris, n ot n eu ro brom as of th e iris (C is false).5

104. C – It occurs prim arily in vessels of deep n uclear st ruct ures of th e brain (false)

Cerebral am yloid angiopathy is con n ed to in t racran ial ar teries an d ar terioles


in th e leptom en inges an d su per cial cor tex (C is false ). Th e oth er resp on ses
are t ru e st atem en ts regarding am yloid angiop athy.1

105. B – Lym p h ocyt ic pleocytosis in 90% of p at ien t s (false)

Th e CSF in Guillain -Barré syn drom e is un der no rm al pressure (C), is acel-


lular in 90%o f patie nts (B is false ), an d dem on st rates an increased prote in
level that peaks at 4 to 6 w eeks after o nset (A). Presen ce of a pe rivascular
lym pho cytic in am m ato ry in ltrate (D) an d pe rive nular and se gm e ntal
de m yelinatio n (E) are ch aracterist ic n dings.5

260
Neuropathology—Answers and Explanations

106. C – Associated w ith im m un osuppression in younger m en

Th is is lym ph om a w ith di use perivascular lym ph ocyt ic in lt rat ion in to


th e Virch ow -Robin space aroun d a blood vessel. Such lym ph om as are o fte n
m ultiple (A is false), respo nd initially to stero ids (D is false), bu t invariably
recu r, an d are associated w ith im m uno suppressio n in yo unge r m e n (C).
Th ey also occur in im m un ocom peten t m ales over 60 years.3

107. B – In clu sion bodies of h erpes sim plex viru s-1 (HSV-1)

Th is h em atoxylin an d eosin H&E-st ain ed sect ion represen ts HSV-1 e ncepha-


litis (B) an d sh ow s lym p h ocyt ic p erivascu lar cu ng on th e m ain slide. Th e
in set at th e top righ t of th e im age sh ow s a Cow dr y t ype A body, th e eosin o-
ph ilic in t ran uclear in clusion w ith a surroun ding h alo t ypical for HSV-1.3

261
Neurosurgery Board Review

108. B – In clu sion bodies of SSPE

Th is H&E-st ain ed sect ion is an exam ple of subacute sclero sing panencepha-
litis (B) as is seen som et im es follow ing m easles in fect ion (1 in 1,000 cases).
Th e in clusion bodies of HSV (den se, eosin oph ilic, an d surroun ded by a clear
h alo) an d SSPE are in t ran u clear. Th e in clu sion bodies seen in th e oth er
respon ses are in t racytoplasm ic. Sm aller eosin oph ilic in t racytoplasm ic in clu -
sion s m ay also be seen in SSPE.3

109. C – Pick bodies

Th is silver st ain sh ow s an exam ple of Pick bo dies (C), rou n ded in t racytoplas-
m ic m asses. On H&E stain ing, it m igh t be di cu lt to dist ingu ish cor t ical Pick
bodies from cort ical Lew y bo dies (B), both of w h ich w ou ld app ear as rou n d
eosin oph ilic in t racytop lasm ic in clu sion s. Lew y bodies of th e brain stem an d
n u cleu s basalis t yp ically h ave a h alo, w h ich can h elp w ith th e dist in ct ion . Pick
bodies are m arked w ith silver stain s (Lew y bodies are n ot). Pick bodies are
im m un op osit ive w ith an t i-t au an t ibodies.2

262
Neuropathology—Answers and Explanations

110. B – Lew y Bodies

Th is is an H&E-stain ed sect ion sh ow ing an exam ple of a Lew y bo dy (neuro nal


intracyto plasm ic inclusio n w ith an eo sino philic co re surro unded by a
clear halo [B]), w h ich can be seen in th e n eu ron s of th e su bstan t ia n igra in
Parkin son’s disease pat ien t s.3

111. B – Hepat ic en cep h alop athy

Th is H&E-st ain ed sect ion sh ow s an exam ple of Alzh eim er’s t ype II ast rocytes,
large vesicu lar n u clei, an d lit tle visible cytoplasm . Th ese react ive protoplasm ic
ast rocytes are fou n d in he patic e ncephalo pathy (B) an d Wilson’s disease.3

263
Neurosurgery Board Review

112. B – Gem istocyt ic ast rocytom a

Th is H&E-st ain ed sect ion sh ow s an exam ple of a ge m istocytic astro cytom a


(B). Th e cells of th is varian t of ast rocytom a h ave p rom in en t eosin op h ilic cyto-
p lasm , sh ort processes, an d eccen t ric n u clei (com p rised of gem istocyt ic ast ro-
cytes). Gem istocyt ic ast rocytes can be seen in th e set t ing of react ive gliosis,
bu t th e crow ding an d overlapping of cells in th is slide suppor t th e diagn osis of
n eop lasm . Gem istocyt ic ast rocytom as ten d to beh ave m ore aggressively th an
oth er W HO grade II ast rocytom as; for th is reason , gem istocyt ic ast rocytom as
are som et im es graded W HO grade III becau se of gem istocyt ic feat u res.1,2

113. D – HSV-1

Th e h em orrhagic appearan ce of th e m edial tem poral lobe is ch aracterist ic of


HSV-1 (D).1,2

264
Neuropathology—Answers and Explanations

114. E – Progressive m u lt ifocal leukoen ceph alopathy

Th is H&E-st ain ed sect ion is an exam ple of pro gressive m ultifo cal e ncepha-
lo pathy (E, asso ciated w ith the JC virus and an im m uno co m pro m ised
state). Dem yelin at ion an d oligod en d roglial cell loss are seen . Residu al oligo-
den droglial n uclei (arrow s) are large an d bizarre.3

115. D – Creut zfeldt-Jakob disease

Th is is a represen tat ive H&E-st ain ed sect ion from a pat ien t w ith Creutzfeldt-
Jako b disease (D), a p rion disease cau sing vacu olizat ion an d sp ongiform
ch anges.3

265
Neurosurgery Board Review

116. B – NF-1

Th e iris h am artom as (Lisch n odules) of NF-1 (B) are seen in th is ph otograph .3

117. A – HIV en ceph alopathy

Th is Lu xol fast blue H&E-st ain ed sect ion is an exam ple of HIV ence phalo pathy
(A). Microglial n odu les w ith foci of dem yelin at ion , n eu ron al loss, an d reac-
t ive ast rocytosis are t ypical. Th e ch aracterist ic m ult in ucleated gian t cell is
seen h ere.3

266
Neuropathology—Answers and Explanations

118. C – Gangliogliom a

Th is is an H&E-stain ed sect ion from a ganglioglio m a (C), w h ich con tain s both
n eop last ic n eu ron s an d ganglion cells. Th e n ding of abn orm al ganglion cells
(in clu ding bin u cleate form s) is key to th e diagn osis of gangliogliom a.3

119. D – Oligoden drogliom a

Th is is an H&E-stain ed sect ion of an o ligo dendro glio m a (D). 1p an d 19q


co-delet ion s in th ese t um ors are associated w ith im proved progression -free
an d overall su r vival. A ch aracterist ic “ch icken w ire” vascu lar p at tern an d a
m on oton ou s “fried egg” n u clear array are seen .3

267
Neurosurgery Board Review

120. C – Medulloblastom a

Th is H&E-st ain ed sect ion s sh ow s den se, hyperch rom at ic cells th at are radially
arranged in Hom er-Wrigh t roset tes w ith cen t ral gran u lo brillar m aterial.
Th ese n dings are m ost con sisten t w ith a prim it ive n euroectoderm al t um or
(m e dullo blasto m a [C]), n eu roblastom a, etc.).3

121. E – Myxopapillar y epen dym om a

Th is H&E-st ain ed sect ion of a m yxo papillary ependym om a (E) sh ow s


coh esive epen dym al cells term in at ing aroun d perivascular accum ulat ion s of
m u cin ou s m aterial. Myxopap illar y ep en dym om as ten d to occu r at th e lu m
(con us m edullaris).3

268
Neuropathology—Answers and Explanations

122. B – Cran iop h ar yngiom a

Qu est ion 122 sh ow s an H&E-st ain ed sect ion from a cranio pharyngio m a (B)
th at dem on st rates an adam an t inom atou s pat tern w ith a basal layer of colum -
n ar cells sep arated by loosely arranged stellate cells. Palisad ing ep ith elial cells
w ith kerat in izat ion an d calci cat ion are prom in en t . Th e papillar y varian t is
m ore often seen in adu lt s an d con t ain s p ap illae of w ell-di eren t iated squ a-
m ou s ep ith eliu m (n ot pict u red h ere).3

123. C – Hem angioblastom a

An H&E-stain ed sect ion of hem angio blasto m a (C) is pict ured h ere. Th ey
are m ost com m on ly fou n d in th e p osterior fossa, an d 60% presen t as a cyst
w ith a m u ral n odule. Mult iple h em angioblastom a are associated w ith VHL.
On H&E st ain ing th ey are di cu lt to dist ingu ish from ren al cell carcin om a
(p art icu larly p roblem at ic in VHL p at ien ts w h o are at risk for ren al cell carci-
n om a also). Th e d iagn ost ic d ist in ct ion can be m ad e by im m u n oh istoch em is-
t r y. Vacuolated “st rom al” cells in a com plex capillar y n et w ork are seen in th is
p h otom icrograph .3

269
Neurosurgery Board Review

124. D – Lipom a

Th is gross an atom ical specim en sh ow s an exam ple of a lipo m a (D) of th e


corpus callosum .3,9

125. A – Carbon m on oxide p oison ing

Th is gross an atom ic specim en sh ow s select ive n ecrosis of th e globu s pallidus,


m ost con sisten t w ith carbo n m o noxide po iso ning (A).1,3

270
Neuropathology—Answers and Explanations

126. B – Glioblastom a

Th is is an H&E-stain ed sect ion sh ow ing a sect ion represen t at ive of glio blas-
to m a (B). Eith er m icrovascu lar p roliferat ion or n ecrosis is requ ired for an
ast rocyt ic t u m or to qu alify as glioblastom a (W HO grade IV). Necrosis w ith
p seu dop alisading is w ell illu st rated in th is p h otom icrograp h .3

127. D – Tuberous sclerosis

Th e aden om a sebaceum of tubero us sclero sis (D) is seen in th is ph otograph .


Tuberous sclerosis is an autosom al dom in an t con dit ion lin ked to ch rom o-
som es 9 an d 16 ch aracterized by th e classic t riad of aden om a sebaceu m ,
seizu res, an d m en t al ret ardat ion . Pat ien ts w ith t u berou s sclerosis are pron e
to develop cort ical t ubers, subepen dym al gian t cell ast rocytom as, cardiac
rh abdom yom a, ret in al h am artom a, an d ren al angiom yolipom a.3

271
Neurosurgery Board Review

128. C – Men ingiom a

Th is H&E-st ain ed ph otom icrograph is an exam ple of a m en ingoth eliom atou s


(syn cyt ial) t ype of m eningio m a (C). A psam m om a body is n oted as w ell.3

129. C – Men ingiom a

Th is H&E-st ain ed sect ion is an oth er exam ple of m e ningio m a (C). Note th e
p rom in en t w h orls.3

272
Neuropathology—Answers and Explanations

130. D – Neuro brom a

Th is is an H&E-st ain ed sect ion of a neuro bro m a (D). Bu n dles of elongated


Sch w an n cells w ith ch aracterist ic w avy n u clei in a loose m u cin ou s or collag-
en ou s m at rix are feat u res of th e n eu ro brom a.3

131. B – Malign an t p eriph eral n er ve sh eath t u m or

Malignant peripheral nerve sheath tum o rs (B) are com posed of sp in dle
cells in fascicles w ith occasion al m itoses an d foci of n ecrosis (H&E).3

273
Neurosurgery Board Review

132. E – Sch w an n om a

This H&E-stained section show s Verocay bodies, palisading elongated nuclei en-
circling anuclear brillary m aterial, w hich are hallm arks of schw annom as (E).3

133. C – Notoch ord

Th is H&E-st ain ed sect ion sh ow s “physaliph orous” or “bubbly” cells surroun d-


ing pools of m u cin , con sisten t w ith th e diagn osis of ch ordom a. Ch ordom as
are th ough t to arise from noto cho rd (C) rem n an t s, u su ally occu rring in th e
clivu s or sacrum .3

274
Neuropathology—Answers and Explanations

134. C – Hun t ington’s disease

Huntingto n’s disease (C) is an autosom al dom in an t h eredit ar y m ovem en t


disorder th at localizes to ch rom osom e 4 an d involves a CAG t rin ucleot ide
repeat . Th e clin ical syn drom e involves ch oreiform m ovem en ts of th e t run k
an d u pp er lim bs w ith su bcort ical d em en t ia. At rop hy of th e h ead of th e
cau date w ith “boxcar” ven t ricles is ch aracterist ic an d can be seen in th is gross
p ath ologic sp ecim en .1,3

135. C – Neurit ic plaques

Neuritic (“senile”) plaques (com posed of degen erat ing n er ve cell processes
su rrou n ding a cen t ral core of am yloid com p osed of b /A4 p rotein , dou ble ar-
row s [C]) an d ne uro brillary tangles (single arrow s [D]) are seen (silver
st ain ).3

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Neurosurgery Board Review

136. C – Alexan der’s disease

Alexander’s disease (C) is on e of the leukodyst roph ies an d is caused by a


defect in th e GFAP gen e leading to h em isph eric dem yelin at ion an d m itoch on -
drial dysfun ct ion . Num erou s Rosen th al bers (eosin oph ilic m aterial in cell
p rocesses, likely from GFAP degradat ion product s) in areas of ast rocytosis are
n oted (H&E). Alexan der’s disease is an exam p le of a n on n eoplast ic process
w h ere Rosen th al bers m ay occu r.1,3

137. D – Hyper ten sive h em orrh age

A m assive basal ganglia hypertensive hem o rrhage (D) is n oted on th is gross


p ath ologic specim en .1

276
Neuropathology—Answers and Explanations

138. A – Cen t ral n eu rocytom a

A den se array of un iform un di eren t iated cells w ith sm all blue n uclei an d
p erin u clear h alos is fou n d in ce ntral neuro cyto m as (A). Th e n d ings are
sim ilar to oligod en d rogliom as an d can be di cu lt to di eren t iate on H&E
st ain ing. Cen t ral n eu rocytom as st ain w ith syn aptop hysin an d n eu ron -sp eci c
en olase (NSE).3

139. B – Friedreich’s at axia

Th is Lu xol fast blue st ain sh ow s dem yelin at ion of th e posterior colum n s an d


ven t ral sp in ocerebellar t racts. Cor t icosp in al t racts are also a ected .3

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Neurosurgery Board Review

140. E – Subacute com bin ed degen erat ion

Th is Lu xol fast blue st ain reveals a spongiform an d gliot ic appearan ce of th e


cord prim arily a ect ing th e posterior an d lateral colum n s con sisten t w ith
subacute co m bined dege ne ratio n (E). Su bacu te com bin ed d egen erat ion
occurs in th e set t ing of vit am in B12 de cien cy an d leads to im p aired
p rop riocept ive sen se an d paraplegia.3,9

141. D – Radiat ion m yelopathy

Th ere is an irregu lar area of coagulat ive n ecrosis involving both gray an d
w h ite m at ter con sisten t w ith radiatio n m yelo pathy (D).3,9

278
Neuropathology—Answers and Explanations

142. C – Mult iple sclerosis

Well-de n ed plaques are seen involving both gray an d w h ite m at ter in th is


Lu xol fast blu e st ain ed sect ion . Th ese n dings su pport a diagn osis of m ultiple
sclero sis (C).3

143. A – Am yot roph ic lateral sclerosis

Th is ph otom icrograph of a Lu xol fast blue st ain ed sect ion sh ow s degen erat ion
of th e an terior h orn an d cor t icospin al t racts, con sisten t w ith am yotro phic
lateral sclero sis (A).3

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Neurosurgery Board Review

144. E – Tuberous sclerosis

Cor t ical t ubers are seen in th e fron t al an d tem poral lobes of th is gross
p ath ologic sp ecim en as seen in . 95% of pat ien ts w ith tubero us sclero sis
(D). Tu berou s sclerosis is an au tosom al dom in an t con dit ion lin ked to ch ro-
m osom es 9 an d 16 ch aracterized by th e classic t riad of aden om a sebaceu m ,
seizu res, an d m en t al ret ardat ion . Pat ien ts w ith t u berou s sclerosis are pron e
to develop cort ical t ubers, subepen dym al gian t cell ast rocytom as, cardiac
rh abdom yom a, ret in al h am artom a, an d ren al angiom yolipom a.1,3

145. B – Ep en dym om a

Th e h istologic appearan ce of epen dym om as is h igh ly variable. A cellular vari-


et y w ith sh eetlike grow th of oval to polygon al cells arranged in a p erivascu lar
p seu doroset te is illust rated (H&E). Epen dym om as are CNS n eop lasm s th at
resem ble th e st ruct u re of th e brain’s epen dym a. Th e m ost de n it ive eviden ce
of epen dym om a is th e presen ce of t rue roset tes, also called “Flexn er-
Win terstein er roset tes.” Most ep en dym om as con tain p erivascu lar pseu do-
roset tes involving t u m or cells surroun ding an en doth elial-lin ed lum en (as
seen h ere). Ep en dym om as ten d to st ain for GFAP an d vim en t in , p art icu larly
in th e perivascular pseu doroset tes. On elect ron m icroscopy exten sive surface
m icrovilli form ing both in t ra- an d ext racellu lar lu m en s can be seen .1,2,3

280
Neuropathology—Answers and Explanations

146. E – Teratom a

Teratom as are th e m ost di eren t iated of th e germ cell n eoplasm s an d con t ain
elem en ts of all th ree germ layers: ectoderm , m esoderm , an d en doderm .
Car t ilage, m u cin -p rodu cing ep ith eliu m , an d im m at u re sp in d le cell st rom a are
all p ar t of th is im m at u re terato m a (E)—a low -grade m align an cy (H&E).1,2

147. C – Port-w in e n evus on th e face

At rop hy of th e h em isp h ere an d leptom en ingeal ven ou s angiom a are p resen t


in th is specim en w ith St u rge-Weber syn drom e. St u rge-Weber syn drom e is
ch aracterized by a usually u n ilateral po rt-w ine nevus (C) th at t yp ically in -
volves th e orbit or u p per eyelid, u n ilateral m en ingeal angiom a, calci cat ion s
con n ed to th e second an d th ird layers of cerebral cortex, an d seizure act ivit y.
Advanced age and lo bar hem orrhage (A) are associated w ith am yloid angi-
opathy. Retinal ham arto m as (D) an d subungual bro m as (E) are associated
w ith t uberous sclerosis. Choice B, alco ho lism and pro ne to falls, w ou ld be a
bet ter an sw er if th e gross specim en sh ow ed cerebellar at rophy.5,9

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Neurosurgery Board Review

148. A – Acou st ic n eu rom a

Th is low -pow er view (H&E) sh ow s den se An ton i A areas (w ith com pact spin -
dle cells) an d looser An ton i B areas (w ith stellate cells) con sisten t w ith acous-
t ic n eurom a (sch w an n om a).3

149. E – Melan om a

Melano m a (E) ten ds to be com posed of cells w ith epith eloid or spin dle
cell con gu rat ion s. Epith eloid cells w ith m elan in in clu sion s are seen in th is
H&E-stain ed sect ion , con sisten t w ith th e d iagn osis of m elan om a. Prim ar y
CNS m elan om as are m ore likely to be pigm en ted th an m et astat ic m elan o-
m as, w h ich ten d to be am elan ot ic. Am elan ot ic m etast at ic m elan om as m ay
be di cult to dist inguish from m et ast at ic carcin om a, but th is dist in ct ion can
be m ade w ith im m u n oh istoch em ical stain s. Th e presen ce of duct s or glan ds
ru les ou t m elan om a.2,3

282
Neuropathology—Answers and Explanations

150. B – An ap last ic ast rocytom a

Th e anaplastic astro cyto m a (B, WHO grade III) is a di u se t um or w ith low


to m oderate cell den sit y an d m oderate pleom orph ism . Th ere m ay be focal
areas of in creased cell den sit y an d in creased p leom orph ism ; h ow ever, it
m u st n ot con tain areas of m icrovascu lar p roliferat ion or n ecrosis (if eith er
of th ese feat ures are presen t , th e diagn osis is glioblastom a—W HO grade IV).
Th is H&E-st ain ed sect ion sh ow s cellular pleom orph ism , hypercellularit y, an d
m itot ic act ivit y con sisten t w ith th e diagn osis of an ap last ic ast rocytom a.2,3

151. D – Mult iple sclerosis

Th is gross anatom ical specim en show s a periven tricular dem yelinat ing plaque.
Th is n ding is con sistent w ith the diagn osis of m ultiple sclero sis (D).3

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Neurosurgery Board Review

152. C – Met ach rom at ic leukodyst rophy

Metachro m atic leuko dystro phy (C) is cau sed by a de cien cy of ar ylsu lfat ase
A leading to th e accum u lat ion of sulfat ides in lysosom es. In h erit ance is auto-
som al recessive—it is th e m ost com m on of th e leu kodyst roph ies. Large con u -
en t areas of dem yelin at ion w ith U- ber sp aring are seen in th e H&E-st ain ed
p h otom icrograp h an d are t yp ical of m et ach rom at ic leukodyst rophy.3

153. A – Ep iderm oid

A large cerebellopon t in e angle epide rm o id (A) w ith w h ite aky, kerat in ou s


debris is illust rated in th is gross specim en . Epiderm oid cyst s con sist of a cyst
w all m ade u p of st rat i ed squ am ou s ep ith eliu m w ith ou t glan du lar st ru ct u res.
Th e cyst con t ain s desquam ated kerat in . Derm oid cyst s can be dist inguish ed
h istop ath ologically from epiderm oid cyst s based on th e p resen ce of h air
follicles, adn exal glan ds, an d th e begin n ings of p ap illar y derm is form at ion in
derm oid cyst s. Som e auth ors argue th at derm oid cyst s m ay represen t ben ign
teratom as.2,9

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Neuropathology—Answers and Explanations

154. B – Lym p h om a

Th is is an exam ple of lym pho m a (B) w ith di u se p erivascu lar lym ph ocyt ic
in lt rat ion in to th e Virch ow -Robin space aroun d a blood vessel. Such lym -
p h om as are often m u lt iple, respon d in it ially to steroids, but invariably recur,
an d are associated w ith im m u n osu p pression in you nger m en . Th ey also occu r
in im m u n ocom p eten t m ales over age 60 years.3

155. C – Pilocyt ic ast rocytom a

Com pact fascicles of elongated cells and spongiform foci w ith stellate form s and
m icrocystic ch ange are noted in this exam ple of pilo cytic astrocytom a (C).3

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Neurosurgery Board Review

156. C – Con t usion

Exten sive bilateral con t recou p con t usion s of th e orbit al surfaces an d fron tal
p oles are illust rated in th is gross p ath ologic specim en .1

157. A – Am yloid angiopathy

Th e ar terioles of th e leptom en inges an d super cial cortex are dilated, an d


am orp h ou s m aterial in lt rates th e w all in th is H&E-st ain ed sect ion from a
p at ien t w ith am ylo id angio pathy (A).3

286
Neuropathology—Answers and Explanations

158. E – Pickʼs disease

Pickʼs disease (E) is a form of cerebral degen erat ion ch aracterized by at rophy
of th e fron tal an d tem poral lobes involving both th e gray and w h ite m at ter
(lobar at rop hy). Select ive at rop hy of th e fron tal an d tem p oral lobes con sisten t
w ith Pickʼs disease is n oted in th is gross path ologic specim en . In Alzheim er’s
disease (A), at rop hy is m ore m ild an d di u se. Huntingto n’s disease (C) is
associated w ith at rop hy of th e cau date.1,5

159. C – Hem angioblastom a

Hem angioblastom a (C) accou n ts for ~10% of p osterior fossa t u m ors. Th e


m ajorit y of h em angioblastom as are cyst ic w ith a m u ral n odu le. In th is gross
sp ecim en , a vascu lar m u ral n odu le in th e left cerebellar h em isp h ere an d
an associated cyst (m idlin e) are con sisten t w ith th e diagn osis of cerebellar
h em angioblastom a.3,9

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Neurosurgery Board Review

160. D – Pit uitar y aden om a

Th is H&E-st ain ed sect ion sh ow s an exam ple of a pit u it ar y aden om a (D). Th e


n orm al acin ar, h eterogen eou s app earan ce of th e pit u it ar y is rep laced by a
di u se sh eet of polygon al cells.2,3

161. D – Norm al periph eral n er ve

A sect ion from n orm al su ral n er ve is illust rated.3

288
Neuropathology—Answers and Explanations

162. A – Cyst icercosis

Th e lesion seen h ere is an exam ple of cyst icercosis (A). Th is sp ecim en w as


excised from th e fou r th ven t ricle. Th e oth er resp on ses are in correct .2

163. A – Arsen ic toxicit y (acu te)


164. A – Arsen ic toxicit y (ch ron ic)
165. B – Lead toxicit y (in ch ildren )
166. B – Lead toxicit y (in adu lts)
167. D – Mercur y toxicit y
168. C – Mangan ese toxicit y

Arsenic toxicity (A) is associated w ith in sect icides an d is m an ifested in its


acu te form by en cep h alop athy, p erip h eral n eu ropathy, abdom in al p ain , n au-
sea, vom it ing, diarrh ea, an d sh ock. Ch ron ic arsenic toxicity (A) causes m alaise,
Mees’ t ran sverse w h ite lin es on th e ngern ails, an d in creased p igm en tat ion
an d hyp erkeratosis of th e palm s an d soles. Lead po iso ning (B) in ch ildren
cau ses irrit abilit y, seizures, abdom in al pain , at axia, an d com a. In adult s, lead
po iso ning (B) cau ses a p u re m otor dem yelin at ing p olyn eu ropathy often asso-
ciated w ith w rist drop, an em ia, an d a gingival lead lin e. Manganese toxicity
(C) occu rs in m in ers an d cau ses Parkin son’s t yp e sym ptom s th at t yp ically re-
sp on d to levodop a. Neu ron al loss an d gliosis are obser ved in th e p allidu m an d
st riat u m . Me rcury po iso ning (D) is associated w ith sh ingest ion an d expo-
su re to felt h at dyes. Mercu r y p oison ing leads to p sych ological dysfu n ct ion ,
t rem or, m ovem en t disorders, periph eral n eu ropathy, an d cerebellar signs.3

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Neurosurgery Board Review

169. B – It is often p eriven t ricu lar an d brigh tly en h an cing.

Prim ar y CNS lym ph om a is usually o f B cell o rigin (D is false) an d ten d s to


occur in a periventricular lo catio n (B). Prim ar y CNS lym ph om a is m o re
co m m o n in im m uno co m prom ise d patie nts (E is false), an d Epstein-
Barr virus has been im plicate d in the patho physio lo g y o f the disease in
im m uno co m pro m ised patients (A is false). Gen erally, an e ort is m ade to
w ith h old steroid t reat m en t un t il a t issue diagn osis is m ade, as steroids can
decrease the diagno stic yield o f tissue bio psy (C is false).10

170. B – Dysem br yop last ic n eu roep ith elial t u m or

Th is H&E-stain ed sect ion is an exam ple of dysem bryo plastic neuro epithelial
tum o r (B). Note th e “ oat ing n eu ron ” in a m icrocyst su rrou n d ed by sm aller
n eu rocyt ic cells. Th e oth er an sw er ch oices are in correct .2

171. F – A an d B

Prim ar y glioblastom as are th ough t to arise de n ovo w ith out any h istor y of a
p rior kn ow n low er grade t u m or. Prim ar y glioblastom as ten d to h ave n orm al
p53 genes (C), overexp ression of th e epide rm al grow th facto r re cepto r
(EGFR [B]), an d p ar t ial delet ion s of ch rom osom e 10 n ear th e pho sphatase
and te nsin ho m o lo gue (PTEN) gene (A). Secon dar y glioblastom as ten d to
lack overexp ression of EGFR, bu t t ypically h ave a loss of h eterozygosit y of
ch rom osom e 17p leading to decreased p53 (C).2

290
Neuropathology—Answers and Explanations

172. D – Gliosarcom a

Th is H&E-stain ed ph otom icrograph sh ow s an exam ple of gliosarcom a (D)


w ith a m osaic pat tern of sarcom atous an d gliom atous foci. Cells in th e glial
p or t ion ten d to be GFAP p osit ive, w h ile cells in th e sarcom atous areas ten d to
be GFAP n egat ive.2

173. D – Ch rom osom e 22

At least h alf of all m en ingiom as h ave delet ion s or m u t at ion s involving ch ro-
m osom e 22 (D) involving th e NF-2 gen e. A w ide variet y of gen et ic aberra-
t ion s h ave been described in m en ingiom as, but a reliable pat tern h as yet to
be iden t i ed.

174. D – All of th e above

Men ingiom as ten d to be st rongly im m u n op osit ive for th e in term ed iate la-
m en t protein vim entin (B), w h ich is a re ect ion of th e m esen chym al ch aracter
of m en ingiom as. Th is is n ot part icularly useful diagn ost ically as oth er t um ors
in th e di eren t ial are often vim en t in p osit ive, su ch as m et ast at ic carcin om a,
gliom a, m elan om a, sch w an n om a, an d h em angioblastom a. Th e epith elial
n at u re of m en ingiom as is re ected by th eir im m u n oposit ivit y to EMA (A),
w h ich h elps to rule out sch w an n om as, m elan om as, an d h em angioblastom as.
Th e vast m ajorit y of m en ingiom as sh ow pro gestero ne re cepto r (C) im m u -
n oposit ivit y in th eir n u clei, bu t th is ten d s n ot to be h elpfu l diagn ost ically. Th e
correct an sw er is D, all o f the above.2

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Neurosurgery Board Review

175. A – Di u se d ep osits of b -am yloid are som et im es presen t .

Dem en t ia p ugilist ica, or “p u n ch -dru n k” en ceph alopathy, is a clin ical syn-


drom e ch aracterized by dysarth ric speech , slow n ess in th in king, an d forget -
fu ln ess, along w ith slow, st i m ovem en ts an d a w ide-based gait . A large series
fou n d th at th e syn drom e occu rs in ap proxim ately 17%o f pro fessional boxers
(D is false), alth ough radiograph ic ch anges m ay occu r in u p to on e-h alf of
boxers. Radiograph ic n dings in clu de ven t ricular dilat at ion , su lcal w iden ing,
an d an increased incide nce o f cavum se ptum pellucidum (E is false ). Dif-
fuse depo sitio n o f b -am ylo id (A) is a n ot u n com m on n ding in th e brain s of
pat ien t s w ith dem en t ia pugilist ica. Lew y bo dies are not present, how eve r
(B is false ). MRI sp ect roscopy reveals de crease d levels o f N-acetylaspartate
in the putam en and pallidum th at m ay be a result of n euron al loss in these
region s (C is false).5

176. A – Age , 3 years at diagn osis

Medu lloblastom as are th e m ost com m on m align an t brain t u m or in ch ildren .


High -risk pat ien t s are cu rren tly de n ed as ch ildren w ith m o re than 1.5 cm 2
po sto perative tum o r residual (D), th ose presenting at , 3 years o f age (A),
an d th ose w ith m et ast ases. Desm o plastic m edullo blasto m a (B) an d m edul-
lo blasto m a w ith extensive no dularity (C) are th ough t to h ave a bet ter prog-
n osis. Large-cell an d an ap last ic m ed u lloblastom a are associated w ith a p oor
progn osis. Nuclear po sitivity fo r b -catenin (E) is a m arker of Wn t p ath w ay
act ivat ion , w h ich h as been associated w ith a bet ter progn osis. High exp res-
sion of th e m yc an d erbB2 on cogen es is associated w ith w orse ou tcom es.10

177. C – Th ey tend to occur in th e m idlin e.

Th e lesion seen h ere is an exam ple of a n euren teric cyst . Neuren teric cyst s
likely rep resen t develop m en tal abn orm alit ies involving en t rapm en t of devel-
oping foregut t issue in th e developing leptom en inges. Th ey h ave a colum n ar
epith eliu m th at u su ally p rod u ces a m ucino us (PAS po sitive) m ate rial into
the cyst lum en (A is false). Typ ically th ey occu r ventrally (B is false), in th e
m idline (C).2

292
Neuropathology—Answers and Explanations

References

1. Nelson JS, Men a H, Parisi JE, Sch ochet SS, eds. Prin ciples an d Pract ice of Neu ropath ology,
2n d ed. New York: Oxford Un iversit y Press; 2003
2. Miller DC. Modern Surgical Neuropathology. New York: Cam bridge Un iversit y Press; 2009
3. Citow JS, Macdon ald RL, Refai D, ed s. Com p reh en sive Neu rosu rger y Board Review.
New York: Thiem e Medical Publish ers; 2009
4. Friede R. Developm en t al Neu ropath ology, 2n d ed. New York: Springer-Verlag; 1989
5. Ropper AH, Brow n RH. Prin ciples of Neu rology, 8th ed . New York: McGraw -Hill; 2005
6. Row land LP, ed. Merrit t’s Textbook of Neu rology, 9th ed. Balt im ore, MD: William s
& Wilkin s; 1995
7. Br u n ton LL, Lazo JS, Parker KL, eds. Good m an & Gilm an’s th e Ph arm acological Basis of
Th erap eu t ics, 11th ed. New York: McGraw -Hill; 2006
8. Bu rger PC, Sch eith au er BW, Vogel FS. Su rgical Path ology of th e Ner vou s System an d it s
Coverings, 4th ed . New York: Ch u rch ill Livingston e; 2002
9. Okazaki H. Fu n dam en t als of Neu rop ath ology: Morp h ologic Basis of Neu rologic Disord ers,
2n d ed. New York, Tokoyo: Igaku-Sh oin ; 1989
10. Qu in on es-Hin ojosa A, ed. Sch m idek & Sw eet Op erat ive Neu rosu rgical Tech n iqu es, 6th ed .
Ph iladelph ia, PA: Elsevier; 2012

293
6A Neuroradiology—Questions

1. W h ich of th e follow ing is a risk factor for clin ically eviden t n eurologic com plica-
t ion s in th e rst 24 h ours after cerebral angiography?
I. Age over 70 years
II. Du rat ion of angiogram over 90 m in u tes
III. Histor y of t ran sien t isch em ic at tack (TIA) or st roke
IV. Histor y of system ic hyp erten sion
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

2. Th e m ost com m on n on n eurologic com plicat ion of cerebral angiography via a


fem oral ar ter y ap proach is
A. Angin a
B. Allergic react ion
C. Hem atom a
D. Myocardial in farct ion (MI)
E. Pseu doan eur ysm

3. Bran ch es of th e m en ingohypophysial t run k in clu de th e


I. Ten torial ar ter y
II. In ferior hyp op hysial arter y
III. Dorsal m en ingeal arter y
IV. Su p erior hyp ophysial arter y
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

294
Neuroradiology—Questions

For qu est ion s 4 to 6, m atch th e p ersisten t an astom oses w ith th e descript ion . Each
respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Cer vical in tersegm en t al ar ter y
B. Proatlan t al in tersegm en t al ar ter y
C. Prim it ive hypoglossal ar ter y
D. Prim it ive ot ic arter y
E. Prim it ive t rigem in al ar ter y

4. Th e m ost com m on of th e persisten t an astom oses

5. Pet rou s in tern al carot id arter y to th e basilar ar ter y

6. Proxim al cavern ou s in tern al carot id arter y to basilar arter y

7. Th e precen t ral cerebellar vein usually drain s in to th e


A. In tern al cerebral vein
B. Lateral m esen ceph alic vein
C. Posterior m esen ceph alic vein
D. St raigh t sin us
E. Vein of Galen

8. An terior tem poral lobe m asses ch aracterist ically displace th e


A. An terior ch oroidal ar ter y laterally
B. An terior ch oroidal ar ter y m edially
C. An terior ch oroidal ar ter y u pw ard
D. Posterior ch oroidal arter y dow nw ard
E. Posterior ch oroidal arter y upw ard

For qu est ion s 9 to 14, m atch th e blood p rodu ct s w ith th eir ap p earan ce on m agn et ic res-
on an ce im aging (MRI). Each respon se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Isoin ten se on T1, isoin ten se to hyperin ten se on T2
B. Hyperin ten se on T1 an d T2
C. Hypoin ten se on T1 an d T2
D. Isoin ten se on T1, hypoin ten se on T2
E. Hyperin ten se on T1, hypoin ten se on T2
F. Hyp oin ten se on T1, hyperin ten se on T2

9. Oxyh em oglobin (0–24 h ours)

10. Deoxyh em oglobin (1–3 days)

11. In t racellular m eth em oglobin (3–6 days)

12. Ext racellular m eth em oglobin (6 days–2 m on th s)

13. Nonparam agn et ic h em e pigm en t s

14. Hem osiderin arou n d periph er y

295
Neurosurgery Board Review

For qu est ion s 15 to 23, m atch th e bran ch of th e in tern al carot id ar ter y w ith th e st ate-
m en t th at best describes it .
A. Carot icot ym pan ic ar ter y
B. In ferior hypophysial arter y
C. In ferolateral t run k
D. Man dibulovidian arter y
E. McCon n ell’s capsular vessels
F. Ten torial ar ter y

15. Poten t ial supply to vascular t um ors of th e m iddle ear

16. Vest igial hyoid arter y

17. Com m on supply to juven ile angio brom as

18. Also called th e arter y of Bern ascon i an d Cassin ari

19. Togeth er w ith th e in ferior hypophysial arter y, th ese vessels supply th e pit uitar y
glan d

20. Togeth er w ith th e carot icot ym pan ic ar ter y, it is a bran ch of th e pet rou s in tern al
carot id arter y

21. An astom oses w ith th e superior hypophysial arter y

22. Rem n an t of th e em br yon ic dorsal oph thalm ic arter y

23. Provides im port an t bran ch es to som e of th e cran ial n er ves

24. Th e correct order of th e n am ed segm en ts of th e an terior ch oroidal ar ter y is


A. Cistern al segm ent , plexal poin t , p lexal segm en t
B. Cistern al segm en t , plexal segm en t , plexal poin t
C. Plexal poin t , cistern al segm en t , plexal segm en t
D. Plexal poin t , plexal segm en t , cistern al segm en t
E. Plexal segm en t , plexal poin t , cistern al segm en t

25. In th e m ost com m on an atom ic variat ion , th e n am ed bran ch es of th e proxim al


righ t su bclavian arter y from proxim al to distal are
A. Internal m am m ary artery, thyrocervical trunk, vertebral artery, costocervical
trunk
B. Internal m am m ary artery, vertebral artery, thyrocervical trunk, costocervical
trunk
C. Vertebral artery, internal m am m ary artery, costocervical trunk, thyrocervical
trunk
D. Vertebral artery, internal m am m ary artery, thyrocervical trunk, costocervical
trunk
E. Vertebral artery, thyrocervical trunk, internal m am m ary artery, costocervical
trunk

26. Th e m ost com m on site of origin of th e recurren t ar ter y of Heubn er is th e


A. A1 segm en t
B. A2 segm en t
C. In tern al carot id ar ter y
D. M1 segm en t
E. M2 segm en t

296
Neuroradiology—Questions

27. In t racran ial hypoten sion related to leakage or rem oval of cerebrospin al uid
(CSF) is m ost closely associated w ith w h ich m agn et ic reson an ce n ding?
A. Di u se du ral en h an cem en t
B. Epen dym al en h an cem en t
C. Pn eum oceph alus
D. Slitlike ven t ricles
E. Ven t ricu lom egaly

28. W h ich of th e follow ing im aging ch aracterist ics is least likely for p leom orp h ic
xan th oast rocytom a?
A. Calci cat ion
B. Cyst form at ion
C. Mult iple lesion s
D. Super cial locat ion
E. Tem poral lobe locat ion

29. Ch oroid plexus papillom as in ch ildren are m ost com m on in th e


A. Fou rth ven t ricle
B. Left lateral ven t ricle
C. Righ t lateral ven t ricle
D. Th ird ven t ricle

30. Ch oroid plexus papillom as in adult s occur m ost com m on ly in th e


A. Fou rth ven t ricle
B. Left lateral ven t ricle
C. Righ t lateral ven t ricle
D. Th ird ven t ricle

31. W h ich of th e follow ing w h ite m at ter lesion s usually in it ially involves th e parieto-
occipit al region s?
A. Adren oleukodyst rop hy
B. Can avan’s disease
C. Met ach rom at ic leukodyst rophy
D. Mult iple sclerosis
E. Sch ilder’s disease

For qu est ion s 32 to 37, m atch th e descript ion w ith th e m alform at ion .
A. Ch iari I m alform at ion
B. Ch iari II m alform at ion
C. Both
D. Neith er

32. Cau dal displacem en t of cerebellar ton sils

33. Beaking of th e m idbrain tect um is ch aracterist ic

34. A m en ingom yelocele is virt ually alw ays presen t

35. Medullar y kin king is seen

36. Occipital or h igh cer vical en ceph alocele is presen t

37. Usually presen t s in young adulth ood

297
Neurosurgery Board Review

38. Th e term bovine arch refers to


A. Bi-in n om in ate ar teries
B. Left com m on carot id ar ter y origin from the aort ic arch
C. Left com m on carot id ar ter y origin from th e righ t brach ioceph alic t run k
D. Righ t aor t ic arch
E. Righ t subclavian arter y dist al to th e left subclavian ar ter y

39. Th e di eren t ial diagn osis of colpoceph aly, or dilatat ion of th e posterior por t ion
of th e lateral ven t ricles, in cludes
I. Agen esis of th e corp u s callosu m
II. Leigh’s disease
III. Periven t ricu lar leu kom alacia
IV. Pan toth en ate kin ase-associated n eu rod egen erat ion
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

40. Sch izen ceph aly is essen t ially a


A. Dem yelin at ing illn ess
B. Disease th at rst develops in th e elderly
C. Disorder of n euron al m igrat ion
D. Neurodegen erat ive disorder
E. Psych iat ric disorder

41. Th e di eren t ial diagn osis of opt ic n er ve th icken ing in cludes


I. Opt ic n er ve sh eath m en ingiom a
II. Orbit al p seu dot u m or
III. Opt ic n er ve gliom a
IV. Graves’ disease
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

42. Th e m ost com m on prim ar y ben ign t u m or of th e adult orbit is (a)


A. Cavern ous h em angiom a
B. Derm oid cyst
C. Lym ph angiom a
D. Opt ic n er ve gliom a
E. Sarcoidosis

43. W h ich of th e follow ing is a bran ch of th e oph th alm ic arter y?


A. An terior eth m oidal arter y
B. Posterior eth m oidal ar ter y
C. Both
D. Neith er

298
Neuroradiology—Questions

44. W h ich of th e follow ing set s of n dings on a lum bar MRI scan perform ed im m edi-
ately after con t rast inject ion is m ost ch aracterist ic of a recurren t disk hern iat ion
an d epidu ral brosis, resp ect ively?
A. A rim of en h an cem en t in th e recu rren t disk, di use en h an cem en t in th e
brosis
B. A rim of en h an cem en t in th e brosis, di use en h an cem en t in th e recurren t
disk
C. A rim of en h an cem en t in th e recurren t disk, n o en h an cem en t in th e brosis
D. Di use en h an cem en t in th e recurren t disk, n o en h an cem en t in th e brosis
E. No en h an cem en t of eith er th e recurren t disk or brosis

45. Lesion s in di use axon al inju r y are com m on ly fou n d in th e


I. Corp u s callosu m
II. Gray-w h ite ju n ct ion
III. Rost ral brain stem
IV. Tem poral lobe
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

46. Acute subarach n oid h em orrh age is m ore di cu lt to diagn ose on T1- an d T2-
w eigh ted MRI sequ en ces th an on com p u ted tom ograp hy (CT) becau se
A. Ext racellular m eth em oglobin is isoin ten se on T1 an d T2
B. Hem osiderin is isoin ten se on T1 an d T2
C. Most radiologist s are n ot fam iliar w ith th e appearan ce of acute subarach -
n oid h em orrh age on MRI
D. The h igh oxygen ten sion in th e subarach n oid space preven ts conversion of
oxyh em oglobin to d eoxyh em oglobin
E. The low oxygen ten sion in th e subarach n oid space preven t s conversion of
deoxyh em oglobin to oxyh em oglobin

47. W h ich of th e follow ing is t rue of th e ch oroidal blu sh ?


A. It is an in dicator of th e ch oroidal plexus in th e lateral ven t ricle.
B. It is best seen on th e an teroposterior project ion .
C. It is from th e posterior eth m oidal bran ch es of th e oph th alm ic arter y.
D. It s con gurat ion is usu ally a th in , den se crescen t .
E. It s presen ce usu ally in dicates an elevated in t raocular pressure.

299
Neurosurgery Board Review

For quest ion s 48 to 109, m atch th e gu re w ith th e m ost ap prop riate resp on se.

48. Th e m ost likely et iology of th is n eon ate’s path ology is

A. Ast rocytom a
B. Metast at ic t um or
C. Staphylococcus aureus
D. Cit robacter

For quest ion s 49 to 54, iden t ify th e lesion s.


A. Eosin oph ilic gran u lom a
B. Epiderm oid cyst
C. Fibrou s dysplasia
D. Hem angiom a
E. Mult iple m yelom a
F. Osteom a

49.

300
Neuroradiology—Questions

50.

51.

52.

301
Neurosurgery Board Review

53.

54.

55.

A. Hem angioblastom a
B. Juven ile pilocyt ic ast rocytom a
C. Cyst icercosis
D. Medulloblastom a

302
Neuroradiology—Questions

56.

A. Fet al origin of th e posterior cerebral ar ter y


B. Moyam oya disease
C. Persisten t acou st ic ar ter y
D. Persisten t hypoglossal ar ter y
E. Persisten t t rigem in al arter y

57.

A. Corp us callosu m lip om a


B. Cran ioph ar yngiom a
C. Gian t an eur ysm
D. Glioblastom a m ult iform e
E. Grow ing skull fract ure

303
Neurosurgery Board Review

58.

A. Cyst icercosis
B. In farct
C. Low -grade ast rocytom a
D. Mycot ic an eur ysm
E. Neurocytom a

59.

A. Mu lt ifocal glioblastom a m u lt iform e (GBM)


B. Mult iple sclerosis
C. Met astat ic carcin om a
D. Neurocytom a
E. Tuberous sclerosis

304
Neuroradiology—Questions

60.

A. Gangliogliom a
B. S. aureus
C. Herpes sim plex virus
D. Lym ph om a

61.

A. Aqu edu ctal sten osis


B. Brain stem ast rocytom a
C. Ch iari m alform at ion
D. Pit uitar y t um or
E. Polym icrogyria

305
Neurosurgery Board Review

62. Th is pat ien t is m ost likely to presen t w ith

A. Congest ive h ear t failu re


B. Fever an d ch ills
C. Headach es
D. Hem iparesis
E. Subarach n oid h em orrh age

63.

A. Arterioven ous m alform at ion (AVM)


B. Cavern ous h em angiom a
C. GBM
D. Met astat ic carcin om a
E. Tubercu lom a

306
Neuroradiology—Questions

64.

A. Ast rocytom a
B. Ch iari m alform at ion
C. Diskit is
D. Met astat ic disease
E. Syringom yelia

65. Associated w ith all but

A. Ren al cell carcin om a


B. Ash -leaf m acules
C. Sh agreen patch es
D. Cardiac rh abdom yom a

307
Neurosurgery Board Review

66.

A. Ast rocytom a
B. Epen dym om a
C. Men ingiom a
D. Myelom en ingocele
E. Tubercu losis

67.

A. An eu r ysm al bon e cyst


B. Hem angiom a
C. Met astat ic disease
D. Osteom yelit is
E. Radiat ion ch ange

308
Neuroradiology—Questions

68. Th e m ost appropriate t reat m en t for a pat ien t w ith m ult iple isch em ic even ts an d
th e accom panying angiogram is

A. Carot id en darterectom y
B. En ceph alom yosyn angiosis
C. Heparin izat ion
D. Super cial tem poral ar ter y to m iddle cerebral arter y bypass
E. No t reat m en t

69.

A. AVM
B. Low -grade ast rocytom a
C. Mult iple sclerosis
D. Norm al CT
E. Sagit t al sin us th rom bosis

309
Neurosurgery Board Review

70.

A. Ast rocytom a
B. Arach n oid cyst
C. Abscess
D. Met astat ic t u m or

71. A pat ien t w ith low back pain on ly an d th e accom panying radiograph sh ould
u n dergo (a)

A. CT-gu ided biopsy


B. Met ast at ic w orkup
C. Mult ilevel decom pressive lam in ectom y
D. Radiat ion th erapy
E. Serum an t igen test ing

310
Neuroradiology—Questions

72.

A. Calci ed d isk h ern iat ion


B. Epidural h em atom a
C. Men ingiom a
D. Met astat ic t u m or
E. Ossi cat ion of th e posterior longit u din al ligam en t

73.

A. Disk h ern iat ion


B. Diskit is
C. Epen dym om a
D. Men ingiom a
E. Met astat ic t u m or

311
Neurosurgery Board Review

74.

A. Ast rocytom a
B. Diastem atom yelia
C. Ependym om a
D. Lipom a
E. Men ingiom a

75.

A. Cran ioph ar yngiom a


B. Ch ordom a
C. Pit uitar y aden om a
D. Rath ke’s cleft cyst

312
Neuroradiology—Questions

76.

A. Arach n oid cyst


B. Dan dy-Walker m alform at ion
C. Epiderm oid cyst
D. Poren ceph aly
E. Vein of Galen an eur ysm

77.

A. Arach n oid cyst


B. Epen dym om a
C. Lipom yelom en ingocele
D. Men ingiom a
E. Neuren teric cyst

313
Neurosurgery Board Review

78. Th e pat ien t w h ose m yelogram is sh ow n probably

A. Has developm en tal cyst s


B. Has m u lt iple café-au-lait lesion s
C. Is asym ptom at ic
D. Was recen tly diagn osed w ith lung can cer
E. Was th row n from a m otorcycle

79.

A. AVM
B. Carot id occlusion
C. Dural AVM
D. Men ingiom a
E. Moyam oya disease

314
Neuroradiology—Questions

80.

A. Glioblastom a
B. Lym ph om a
C. Fahr’s disease
D. Herpes sim plex virus

81.

A. Disk h ern iat ion


B. Epidural abscess
C. Men ingiom a
D. Met astat ic disease
E. Radiat ion ch ange

315
Neurosurgery Board Review

82. Th e lesion sh ow n is associated w ith

A. Eh lers-Dan los disease


B. En docardit is
C. Fibrom u scular dysplasia
D. Radiat ion th erapy
E. Ren al cyst s

83.

A. Du ral AVM
B. Moyam oya disease
C. Sagit t al sin us th rom bosis
D. Subdural h em atom a
E. Vein of Galen m alform at ion

316
Neuroradiology—Questions

84.

A. Ch ordom a
B. Diskit is
C. Met astat ic disease
D. Neuro brom a
E. Norm al lum bosacral radiograph

85.

A. Hu m an im m u n ode cien cy viru s (HIV)


B. Gliom a
C. Rapid correct ion of hypon at rem ia
D. Meth ot rexate toxicit y

317
Neurosurgery Board Review

86. Th e et iology of th e process sh ow n is

A. Develop m en tal
B. Iat rogen ic
C. In fect ious
D. Neoplast ic
E. Traum at ic

87.

A. AVM
B. Fusiform an eur ysm
C. Misplaced sh un t cath eter
D. Sch izen ceph aly
E. Ven ous m alform at ion

318
Neuroradiology—Questions

88. Th is 8-year-old boy w h o presen ted w ith h eadach es, n ausea, an d vom it ing is
m ost likely to h ave a(n )

A. Ast rocytom a
B. Dan dy-Walker cyst
C. Hem angioblastom a
D. Medulloblastom a
E. Met astat ic t u m or

89.

A. Acou st ic n eu rom a
B. Ch ordom a
C. Gian t-cell t um or
D. Glom us jugulare
E. Men ingiom a

319
Neurosurgery Board Review

90.

A. No in ter ven ing n orm al brain


B. Usually m ult iple
C. Often associated w ith cavern ous m alform at ion
D. Frequen tly h em orrh age

For qu est ion s 91 to 99, id en t ify th e an atom ical st ru ct u res. Each resp on se m ay be u sed
on ce, m ore th an on ce, or n ot at all.

A. An terior caudate vein


B. At rial vein
C. Basal vein of Rosen th al
D. In tern al cerebral vein
E. Septal vein
F. Term in al vein
G. Th alam ost riate vein
H. Vein of Galen
I. Ven ous angle

320
Neuroradiology—Questions

91. St ru ct ure 1

92. St ru ct ure 2

93. St ru ct ure 3

94. St ru ct ure 4

95. St ru ct ure 5

96. St ru ct ure 6

97. St ru ct ure 7

98. St ru ct ure 8

99. St ru ct ure 9

100.

A. Hem angioblastom a
B. Lym ph om a
C. Men ingiom a
D. Myxopapillar y epen dym om a
E. Sch w an n om a

321
Neurosurgery Board Review

101. Th e axial postcon t rast MRI sh ow n w as obt ain ed in a p at ien t w ith

From Yoch DH. Magnet ic Resonance Im aging of


CNS Disease: A Teaching File, 2n d ed. St . Louis, MO:
C.V. Mosby, Inc., 2002. Used w ith perm ission from
Elsevier Ltd., Oxford, UK.

A. Acqu ired im m un ode cien cy syn drom e (AIDS)


B. Ch iari m alform at ion
C. Disk disease
D. Neuro brom atosis
E. Severe spin al cord t raum a

102.

A. Gian t-cell t um or
B. Osteoblastom a
C. An eur ysm al bon e cyst
D. Osteoid osteom a

322
Neuroradiology—Questions

103. Th is p ostcon t rast T1-w eigh ted MRI illu st rates

A. Abscesses
B. Gliom atosis cerebri
C. Met astat ic disease
D. Mult iple in farct s
E. Neuro brom atosis t ype 2

104. Th is p ostcon t rast T1-w eigh ted MRI illu st rates a(n )

A. An eur ysm
B. Colloid cyst
C. GBM
D. Men ingiom a
E. Met astasis

323
Neurosurgery Board Review

105.

From Yoch DH. Magnetic Resonance Im aging of


CNS Disease: A Teaching File, 2nd ed. St. Louis,
MO: C.V. Mosby, Inc., 2002. Used w ith perm is-
sion from Elsevier Ltd., Oxford, UK.

A. Abscess
B. Art ifact
C. Hem angioblastom a
D. In farct
E. Met astasis

106.

A. An eu r ysm
B. AVM
C. In farct
D. Norm al angiogram
E. Persisten t t rigem in al arter y

324
Neuroradiology—Questions

107. W h ich st atem en t is t ru e regarding th e fract u re seen h ere?

A. Type II fract ure


B. Usually requires surger y
C. Requ ires t ract ion
D. Treated w ith extern al or th osis

108.

A. Abscess
B. Lym ph om a
C. Mult iple sclerosis
D. Periven t ricular leukom alacia
E. Tuberous sclerosis

325
Neurosurgery Board Review

109.

A. Acu te in farct ion


B. Ch ron ic subdural h em atom a
C. Epiderm oid cyst
D. In t racran ial hypoten sion
E. St urge-Weber syn drom e

For qu est ion s 110 to 114, m atch each of th e follow ing m agn et ic reson an ce (MR) spec-
t roscopy peaks w ith th e best an sw er.
A. Has t w o peaks; involved in storage of m em bran ou s ph osph oin osit ides
B. Involved in m ain ten an ce of en ergy system s an d often used as a referen ce
C. Predecessor of brain lipids an d part icipates in coen zym e A in teract ion s
D. St ru ct ural com pon en t of cell m em bran es
E. Typical doublet located aroun d 1.32 ppm

110. N-acet ylasp ar t ate (NAA)

111. Ch olin e

112. Creat in e

113. Myo-in ositol (MI)

114. Lactate

115. W h ich of th e follow ing MR spect roscopy n dings are con sisten t w ith glioblas-
tom a?
A. In creased NAA, in creased ch olin e, in creased lact ate
B. In creased NAA, reduced ch olin e, in creased lactate
C. In creased NAA, reduced ch olin e, reduced lact ate
D. Redu ced NAA, in creased ch olin e, in creased lactate
E. Redu ced NAA, reduced ch olin e, reduced lactate

326
Neuroradiology—Questions

116. Th e im age seen h ere is an exam ple of

A. An kylosing spon dylit is


B. Di use idiopath ic skelet al hyperostosis
C. No path ologic process is presen t
D. Osteoporosis
E. Vertebral osteopet rosis

117. Th e st ru ct u re seen h ere m ost likely rep resen t s

A. At rial vein
B. In tern al cerebral vein
C. Median prosen ceph alic vein
D. St raigh t sin us
E. Vein of Galen

327
Neurosurgery Board Review

118. Th e im ages seen h ere are con sisten t w ith w h ich of th e follow ing?

A. Agen esis of th e corpus callosu m


B. Colpoceph aly
C. Septo-opt ic dysplasia
D. All of th e above
E. Non e of th e above

119. Th e follow ing im age is m ost con sisten t w ith

A. Arach n oid cyst


B. Epiderm oid
C. Lipom a
D. Low -grade gliom a
E. Men ingiom a

328
Neuroradiology—Questions

120. W h ich of th e follow ing MRI sequ en ces is th e m ost sen sit ive for blood p rodu ct s?
A. Di u sion -w eigh ted im ages
B. Fast spin ech o
C. Fluid-at ten uated inversion recover y
D. Gradien t ech o
E. MR spect roscopy

121. W h ich of th e follow ing is (are) t ru e of th e lesion seen h ere?

A. Associated w ith cor t ical dysplasia


B. Con t ain s abn orm al n euron s an d abn orm al oligoden drocytes an d ast rocytes
C. Typically presen t s w ith seizu res
D. A an d C on ly
E. All of th e above

329
6B Neuroradiology—
Answ er Key

1. E 27. A
2. C 28. C
3. A 29. B
4. E 30. A
5. D 31. A
6. E 32. C
7. E 33. B
8. B 34. B
9. A 35. B
10. D 36. D
11. E 37. A
12. B 38. C
13. F 39. B
14. C 40. C
15. A 41. E
16. A 42. A
17. D 43. C
18. F 44. A
19. E 45. A
20. D 46. D
21. B 47. D
22. C 48. D
23. C 49. C
24. A 50. A
25. D 51. D
26. B 52. F

330
Neuroradiology—Answer Key

53. E 88. A
54. B 89. D
55. C 90. C
56. A 91. E
57. A 92. A
58. A 93. F
59. E 94. G
60. C 95. B
61. B 96. C
62. C 97. H
63. B 98. D
64. A 99. I
65. A 100. C
66. B 101. A
67. B 102. D
68. C 103. E
69. E 104. D
70. B 105. D
71. E 106. C
72. E 107. D
73. A 108. B
74. B 109. E
75. C 110. C
76. B 111. D
77. C 112. B
78. E 113. A
79. D 114. E
80. B 115. D
81. B 116. E
82. E 117. C
83. E 118. D
84. B 119. B
85. C 120. D
86. A 121. D
87. E

331
6C Neuroradiology—Answ ers
and Explanations

1. E – All of th e above

Risk factors for clinically eviden t neurologic com plications in th e rst 24 h ours
after cerebral angiography include age over 70 years (I), duration of angio -
gram . 90 m inutes (II), history of TIA or stroke (III), an d histo ry of sys-
tem ic hypertension (IV). Other risk factors include patients w ith m ore th an
50 to 70%stenosis of the cerebral vessels, patients w hose angiogram s require a
higher volum e of contrast, and patients referred for subarachnoid hem orrhage
or w ho are im m ediately postoperative.1

2. C – Hem atom a

Sign i can t hem ato m a (C) form at ion occu rs at a rate of 6.9 to 10.7%. Angina
(A), alle rgic reactio n (B), an d m yocardial infarctio n (MI [D]) all occur w ith
an in ciden ce of less th an 1 to 2%. Pseu doan eu r ysm s are rare, occu rring 0.05
to 0.55% of th e t im e.1

3. A – I, II, an d III (ten torial ar ter y, in ferior hypophysial arter y, an d dorsal m en ingeal
ar ter y)

Th e m en ingohypophyseal t ru n k, th e largest an d m ost proxim al bran ch of th e


cavern ous carot id ar ter y, t ypically h as th ree bran ch es: th e te nto rial artery
(o f Be rnasco ni and Cassinari [I]), th e do rsal m e ningeal artery (III), an d
the infe rio r hypo physeal artery (the infero lateral trunk [II]). Th e superio r
hypo physeal artery (IV) is a bran ch of th e su praclin oid carot id arter y.2

4. E – Prim it ive t rigem in al ar ter y


5. D – Prim it ive ot ic arter y

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Neuroradiology—Answers and Explanations

6. E – Prim it ive t rigem in al ar ter y

Th e prim itive trige m inal artery (E) is th e m ost com m on persisten t fetal
an astom osis (except for th e fetal p osterior com m u n icat ing arter y, w h ich is
n ot an an sw er ch oice). Th e prim itive trigem inal arte ry (E) con n ects th e cav-
ern ou s in tern al carot id arter y (ICA) to th e basilar arter y. Th e prim itive otic
artery (D) is rare an d con n ects th e p et rou s ICA to th e basilar ar ter y via th e
in tern al aud itor y m eat u s. Th e prim itive hypo glo ssal arte ry (C) is th e sec-
on d m ost com m on persisten t fetal circulat ion , con n ect ing th e cer vical ICA to
the basilar ar ter y via th e hypoglossal can al. Th e pro atlantal inte rsegm ental
artey (B) con n ect s th e extern al carot id ar ter y (ECA) or cer vical ICA w ith th e
vertebral ar ter y, cou rsing bet w een th e arch of C1 an d th e occip u t .3,4

7. E – Vein of Galen

Th e precen t ral cerebellar vein is a m idline vessel th at courses m edially over


the brach ium pon t is, parallels th e roof of th e fourth ven t ricle, an d cur ves
u pw ard beh in d th e in ferior colliculus an d precen t ral lobu le of th e verm is to
drain into th e vein o f Galen (E).2

8. B – An terior ch oroidal ar ter y m edially

An terior tem poral lobe m asses ch aracterist ically displace th e ante rio r cho -
ro idal arte ry m edially (B).2

9. A – Isoin ten se on T1, isoin ten se to hyperin ten se on T2


10. D – Isoin ten se on T1, hyp oin ten se on T2
11. E – Hyperin ten se on T1, hypoin ten se on T2
12. B – Hyp erin ten se on T1 an d T2
13. F – Hyp oin ten se on T1, hyp erin ten se on T2
14. C – Hypoin ten se on T1 an d T2

Blood products can be staged by th eir appearan ce on m agnet ic resonan ce im -


aging (MRI). Hyperacute blood cont ain s oxyhem oglobin an d is iso intense o n
T1 and hyperintense o n T2 (A). Acute blood (1–3 days) con t ain s deoxyh em o-
globin an d is iso intense o n T1 and hypo intense o n T2 (D). Th e early su bacu te
ph ase is associated w ith in t racellular m eth em oglobin and appears hyperin-
tense on T1 and hypo intense on T2 (E). Th e late su bacu te ph ase is associated
w ith ext racellular m ethem oglobin and appears hyperintense o n both T1 and
T2 w eighted im ages (B). Th e ch ron ic ph ase con t ain s h em osiderin aroun d th e
periph er y an d appears hypo intense o n both T1 and T2 (C). Nonparam agn et ic
h em e pigm en ts ap pear hypo intense o n T1 and hyperintense o n T2 (F).4,5

15. A – Carot icot ym pan ic ar ter y


16. A – Carot icot ym pan ic ar ter y
17. D – Man dibu lovidian arter y
18. F – Ten torial ar ter y
19. E – McCon n ell’s capsular vessels
20. D – Man dibu lovidian arter y
21. B – In ferior hyp op hysial ar ter y
22. C – In ferolateral t run k

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Neurosurgery Board Review

23. C – In ferolateral t run k

Th e caroticotym panic artery (A) is a vest igial hyoid ar ter y rem n an t th at su p -


plies th e m iddle an d inn er ear; it can provide blood supply to vascular t um ors
of th e m iddle ear (i.e., glom us t ym pan icum ). The m en ingohypophysial t run k
gives rise to th ree vessels, th e tentorial artery (F) of Bern ascon i an d Cassin ari,
the inferio r hypo physial artery (B), an d th e dorsal m en ingeal arter y. Th e in-
fero lateral trunk (C), or th e arter y of th e in ferior cavern ou s sin u s, is a rem -
n an t of th e em br yon ic dorsal op h th alm ic ar ter y an d provides bran ch es to
cran ial n er ves III, IV, V, an d VI. Th e m andibulovidian artery (D) is a bran ch
of th e pet rous in tern al carot id arter y an d is a com m on supply to juven ile an -
gio brom as. Th e m edial t ru n k, or McCo nnell’s capsular vessels (E), p rovides
blood supply to th e pit uit ar y glan d.1,4

24. A – Cistern al segm en t , plexal poin t , plexal segm en t

Th e an terior ch oroidal ar ter y (ACh A) is best seen on th e an teroposterior


angiogram arising from th e m edial in tern al carot id arter y. Th e cistern al ACh A
cur ves m edially an d posteriorly aroun d th e u n cus. An abrupt “kin k” is seen at
the plexal poin t w h ere th e ACh A en ters th e ch oroidal ssure. Th e plexal ACh A
then courses th rough th e tem poral h orn .2

25. D – Vertebral ar ter y, in tern al m am m ar y arter y, thyrocer vical t ru n k, costocer vical


t run k

Alth ough th is is th e m ost com m on variat ion , oth ers in clude th e in ferior thyroid
ar ter y sh aring a com m on t ru n k w ith th e vertebral ar ter y, th e ver tebral arter y
from th e thyrocer vical t ru n k, th e vertebral arter y from th e proxim al com m on
carot id arter y, an d th e vertebral arter y from th e subclavian artery distal to
the thyrocervical trunk.1

26. B – A2 segm en t

Th e recurren t arter y of Heubn er (on e of th e m edial st riate arteries) t akes ori-


gin from th e A2 segm ent (B) 34 to 50% of th e t im e, from th e A1 segm ent (A)
17 to 45% of th e t im e, an d from th e an terior com m un icat ing ar ter y 5 to 20%
of th e t im e.2

27. A – Di use dural en h an cem en t

Th is e nhance m ent (A) is th ough t to rep resen t an in crease in blood volu m e


in th e dura. In ferior displacem en t of th e st ru ct ures in th e p osterior fossa m ay
accom p any th is n ding in su ch cases of in t racran ial hyp oten sion .6

28. C – Mult iple lesion s (false)

Pleom orp h ic xan th oast rocytom a u su ally presen t s as a large single m ass in
a you ng pat ien t w ith a long h istor y of seizu res. Typ ical n dings in clu de cyst
fo rm atio n (B), calci catio n (A), supe r cial lo catio n (D), an d te m po ral lo be
lo catio n (E).6

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Neuroradiology—Answers and Explanations

29. B – Left lateral ven t ricle

Th e propen sit y for th e lateralizat ion of ch oroid plexus papillom as to th e left


lateral ventricle (B) h as n ot been explain ed. Th ese large bu lky t u m ors usu-
ally arise in th e t rigon e.6

30. A – Fou rth ven t ricle

Ch oroid plexus papillom as in th e ad ult populat ion are often foun d at th e cau-
dal aspect of th e fo urth ventricle (A) an d frequ en tly calcify.6

31. A – Adren oleukodyst rophy

Th e lesion s of adre no leuko dystro phy (A) are u su ally sym m et rical, begin in
the parieto-occipit al region , an d spread an teriorly.6

32. C – Both
33. B – Ch iari II m alform at ion
34. B – Ch iari II m alform at ion
35. B – Ch iari II m alform at ion
36. D – Neith er
37. A – Ch iari I m alform at ion

Chiari I m alfo rm atio ns (A) con sist of in ferior displacem en t of th e cerebellar


ton sils through th e foram en m agn u m . Th ey usually presen t in early adult-
h ood. In Chiari II m alfo rm atio ns (B), th e cau dal disp lacem en t of th e h in d-
brain is m ore severe, w ith beaking of th e tect um an d m edullar y kin king often
seen . Myelom en ingoceles are virt u ally alw ays p resen t . Chiari II m alfo rm a-
tio ns (B) u su ally p resen t in in fan cy. Ch iari III m alform at ion s disp lay th e m ost
severe displacem en t of p osterior fossa st ru ct u res an d are often associated
w ith a h igh cer vical or occipital m en ingocele.6

38. C – Left com m on carot id ar ter y origin from th e righ t brach ioceph alic t ru n k

Th e left com m on carot id ar ter y u sually arises from th e aort ic arch distal to
the righ t brach ioceph alic arter y. In th e bovin e arch varian t , th e left co m m o n
carotid artery arises fro m the proxim al right brachio cephalic artery (C).
Th e presen ce of bi-inno m inate arte ries (A) is rare. A right ao rtic arch (D)
m ay be in ciden tal or associated w ith congen it al h eart disease. A right sub-
clavian arte ry take-o distal to the left subclavian artery (E) is associated
w ith Dow n ʼs syn drom e.1

39. B – I, III (agen esis of th e corp u s callosu m , p eriven t ricu lar leu kom alacia)

Agenesis o f the co rpus callo sum (I) an d periventricular leuko m alacia (III)
can both result in colpoceph aly. Le igh’s disease (II) and pantothenate kinase-
asso ciate d neuro degeneratio n (fo rm erly Halle rvo rde n-Spatz disease [IV])
can both cause sym m et ric lesion s of th e globus pallidus bu t are n ot associated
w ith colpoceph aly.6

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Neurosurgery Board Review

40. C – Disorder of n euron al m igrat ion

Th e cleft of sch izen ceph aly can be un ilateral or bilateral, but it u sually in -
volves th e region n ear th e cen t ral su lcu s. Pat ien t s can presen t w ith seizu res
or focal de cit s. It is a diso rder o f ne uro nal m igratio n (C).6

41. E – All of th e above

Opt ic n er ve th icken ing m ay be cau sed by n on n eop last ic processes like Graves’
disease (IV), o rbital pseudotum o r (II), opt ic n eu rit is, papilledem a, an d
vascu lar m alform at ion s, or by t u m ors like glio m as (III), m eningio m as (I),
lym ph om as, leukem ia, an d m et astases.6

42. A – Cavern ous h em angiom a

Cave rno us hem angio m as (A) of th e orbit are u sually w ell-dem arcated, vas-
cular, in t racon al lesion s w ith sm ooth or lobulated borders.7

43. C – Both

Th e ethm o idal arteries (C) are bran ch es of th e oph th alm ic ar ter y. Th ey


su p ply a p ort ion of th e an terior cran ial fossa an d th e m u cosa of th e n asal
sept u m . Du ring em bolizat ion of th e in tern al m axillar y ar ter y, dangerou s
p oten t ial an astom oses from th e sph en opalat ine bran ch es of the in tern al
m axillar y ar ter y to bran ch es of th e op h th alm ic arter y m ay be presen t .1

44. A – A rim of en h an cem en t in th e recurren t disk, di use en h an cem en t in th e


brosis

Scar t issu e con t ain s vascu lar gran u lat ion t issu e th at en h an ces m ore di u sely
than a residual or recurren t disk.6

45. A – I, II, an d III (corpu s callosum , gray-w h ite jun ct ion , an d rost ral brain stem )

Lesion s in di u se axon al inju r y are com m on ly fou n d in th e corp u s callosu m ,


gray-w h ite ju n ct ion , an d rost ral brain stem .8

46. D – Th e h igh oxygen ten sion in th e su barach n oid sp ace p reven ts conversion of
oxyh em oglobin to deoxyh em oglobin

Acu te su barach n oid h em orrh age is m ore di cu lt to d iagn ose on MRI th an


com pu ted tom ography (CT) because th e high oxygen tensio n in the sub-
arachno id space preve nts the co nve rsio n o f oxyhem o glo bin to deoxyhe-
m o glo bin (D). Hyperacu te-ap pearing blood con tain ing oxyh em oglobin ap -
pears isoin ten se on T1 an d hyperin ten se on T2, sim ilar to cerebrospin al uid
(CSF) sign al. Suscept ibilit y w eigh ted im ages, such as gradien t ech o sequ en ces,
are qu ite sen sit ive for blood p rod u ct s in all stages, h ow ever.4,8

336
Neuroradiology—Answers and Explanations

47. D – It s con gu rat ion is u su ally a th in , den se crescen t .

Th e ch oroidal blush sign i es th e ch oroidal plexus of th e eye (A is false ) an d


is su pp lied by th e ciliar y bran ch es of th e op h th alm ic arter y (C is false ). It is
ch aracterist ically seen as a th in crescen t on th e lateral project ion (B is false)
of th e in tern al carot id angiogram . It s absen ce (E is false) can be an in direct
sign of elevated in t raorbital or in t raocu lar pressu re.1

48. D – Cit robacter

Large n eon atal brain abscesses are u su ally cau sed by Cit r oba ct er (D), Bacte-
roides, Proteus, an d variou s gram -n egat ive bacilli.4

49. C – Fibrou s dysplasia

Sclerosis an d th icken ing of th e left orbit is presen t in th is X-ray of a pat ien t


w ith bro us dysplasia (C).4,9 (Cou r tesy of Dr. Joh n A. Goree, Du rh am , NC.)

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Neurosurgery Board Review

50. A – Eosin oph ilic gran ulom a

A discrete radiolucen t area is seen th at does n ot h ave sclerot ic m argin s, con -


sisten t w ith eo sino philic granulo m a (A).4,9 (Courtesy of Dr. Joh n A. Goree,
Du rh am , NC.)

51. D – Hem angiom a

Th e h on eycom b or su n burst pat tern is ch aracterist ic of a calvarial hem an-


gio m a (D).4,10

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Neuroradiology—Answers and Explanations

52. F – Osteom a

A discrete h igh -den sit y lesion w ith sm ooth con tours is seen , m ost con sisten t
w ith o steo m a (F).4,10

53. E – Mult iple m yelom a

Mu lt ip le rou n d discrete p u n ch ed-ou t lesion s are ch aracterist ic of m ultiple


m yelo m a (E).4,10

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Neurosurgery Board Review

54. B – Ep iderm oid cyst

Th e scalloped border an d sclerot ic rim are ch aracterist ic of a skull epider-


m o id (B).4,10 (Cou r tesy of Dr. Joh n A. Goree, Du rh am , NC.)

55. C – Cyst icercosis

Th e sm ooth an d th in -w alled in t raven t ricular cyst w ith a m u ral n odule is clas-


sic for cysticerco sis (C).4

340
Neuroradiology—Answers and Explanations

56. A – Fet al origin of th e posterior cerebral ar ter y

A fetal o rigin o f the po ste rio r cerebral artery (A) from th e in tern al carot id
circu lat ion is seen in 20% of an atom ical dissect ion s.4

57. A – Corpus callosum lipom a

Periph eral calci cat ion is n oted in th is cu r vilin ear lipo m a o f the co rpus
callo sum (A).4

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Neurosurgery Board Review

58. A – Cyst icercosis

A sm all ring-en h an cing lesion surroun ded by a zon e of low den sit y is t ypical
of cysticerco sis (A).4

59. E – Tuberous sclerosis

Sh ow n are m u lt iple calci ed su bep en dym al t u bers of tubero us sclero sis (E).
Th e appearan ce of th ese h am artom atous lesion s in th e subepen dym al region
is som et im es referred to as “can d le gu t tering.”4

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Neuroradiology—Answers and Explanations

60. C – Herpes sim plex virus

The in am m ation of the m esial tem poral lobe w ith di use edem a is m ost char-
acteristic of herpes encephalitis (C). There is often associated hem orrhage.4

61. B – Brain stem ast rocytom a

An expan sile lesion of th e pon s is seen m ost con sisten tly w ith po ntine glio -
m a (brainstem astro cyto m a [B]).4

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Neurosurgery Board Review

62. C – Headach es

Th e sign al in ten sit y of colloid cysts is variable on eith er T1- or T2-w eigh ted
MRI. Sh or t T1 valu es (hyperin ten se im ages) re ect protein aceou s m aterial.
Th ese m asses arise from th e an terior roof of th e th ird ven t ricle.4

63. B – Cavern ou s h em angiom a

Th e dark h alo of decreased sign al is caused by iron in h em osiderin in th is


T2-w eigh ted MRI. Th is is an alm ost diagn ost ic im age of a caverno us he m an-
gio m a (i.e., cavernous m alfo rm atio n [B]).4

344
Neuroradiology—Answers and Explanations

64. A – Ast rocytom a

Th e di use fusiform w iden ing of th e cord w ith variable sign al in ten sit y is
con sisten t w ith a di u se or brillar y astro cyto m a (A).4

65. A – Ren al cell carcin om a (false)

Th e en h an cing in t raven t ricular m ass n ear th e foram en of Mon ro is a sub -


epen dym al gian t-cell ast rocytom a th at is associated w ith t u berou s sclero-
sis. Th e righ t ven t ricu lar calci ed m ass is a su bepen dym al t u ber. Renal cell
carcino m a (A) is associated w ith von Hippel-Lin dau syn drom e, n ot t uberous
sclerosis. Th e oth er opt ion s listed are associated w ith t u berou s sclerosis.4

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Neurosurgery Board Review

66. B – Ep en dym om a

Th e discrete lobulated appearan ce of th e m yxopapillar y e pendym o m a (B)


is illust rated . Th ese t u m ors origin ate from th e con us m edu llaris or lum
term in ale.4

67. B – Hem angiom a

Th e t ypical polka dot , or salt-an d-pepper, appearan ce of a hem angio m a (B)


of th e vertebral body is seen .4,8

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Neuroradiology—Answers and Explanations

68. C – Heparin izat ion

Th e angiogram illust rates a carot id dissect ion . Th e in tern al carot id gradu ally
t apers distal to its origin : th e “st ring sign .”4

69. E – Sagit t al sin us th rom bosis

Th is con t rast CT scan illust rates th e “em pt y delta sign ” suggest ive of sagittal
sinus thro m bo sis (E). Th e t riangle d evelop s becau se of en h an cem en t of vas-
cular ch an n els aroun d th e occlu ded sin us.11

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Neurosurgery Board Review

70. B – Arach n oid cyst

Th is low -in ten sit y ext ra-axial m ass w ith out surroun ding edem a is con sisten t
w ith an arachno id cyst (B). Th e m ost com m on locat ion is th e m iddle fossa.4

71. E – Serum an t igen test ing

Th e radiograph sh ow s th e classic “bam boo spin e” con gurat ion of an kylos-


ing spon dylit is. Alth ough HLA-B27 test ing is in dicated, th e result s sh ould be
in terp reted w ith caut ion . Alth ough 90% of pat ien t s w ith clin ical an kylosing
sp on dylit is are HLA-B27 posit ive, , 2% of HLA-B27 pat ien t s even t ually de-
velop an kylosing sp on dylit is.8

348
Neuroradiology—Answers and Explanations

72. E – Ossi cat ion of th e posterior longit u din al ligam en t

Ossi catio n o f the po sterio r lo ngitudinal ligam ent (E) is a com m on cau se
of cer vical m yelopathy in pat ien t s of Asian descen t . Fibrosis an d hyperplasia
develop in it ially, follow ed by calci cat ion . Th e ossi cat ion m ay be di use or
localized an d m ay involve th e d ura.4

73. A – Disk h ern iat ion

Th is post m yelogram CT illust rates a righ t-sided, part ially calci ed herniated
disk (A).

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Neurosurgery Board Review

74. B – Diastem atom yelia

The split cord m alform ation (diastem atom yelia [B]) and cartilaginous septum
can be seen. Patients m ay present w ith signs of a tethered cord or kyphoscoliosis.8

75. C – Pit uitar y aden om a

Th is pituitary ade no m a (C) lls an d expan ds th e sella an d also exten ds to


th e suprasellar space. Cranio pharyngio m as (A) are m ore likely to be m ain ly
su prasellar. Rathke’s cleft cysts (D) sh ould be cyst ic an d are n ot usually th is
large w ith u pw ard exten sion (th ough th ey m ay be). Cho rdo m as (B) u su ally
involve m ore bony invasion of th e clivu s.4

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Neuroradiology—Answers and Explanations

76. B – Dan dy-Walker m alform at ion

A hypoplast ic verm is, h igh t ran sverse sin us, an d cyst ic dilat at ion of th e fourth
ven t ricle are ch aracterist ic of th e Dandy-Walke r m alfo rm atio n (B).4

77. C – Lipom yelom en ingocele

A subcut an eous lipom a that exten ds in to th e low -lying teth ered spin al cord
is seen .4

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Neurosurgery Board Review

78. E – Was th row n from a m otorcycle

Th e classic appearan ce of pseudom en ingoceles from low er cer vical n er ve root


avulsion is seen in th is m yelogram .8

79. D – Men ingiom a

Th is lateral ph ase angiogram sh ow s th e t um or blush of a m e ningio m a (D),


w ith a prom in en t con t ribut ion from th e ten torial arter y.4

352
Neuroradiology—Answers and Explanations

80. B – Lym p h om a

Bilateral p er iven t ricu lar en h an cin g m asses are m ost con sisten t w it h lym -
pho m a (B). Th ey u su ally en h an ce qu ite brigh t ly. Fah r’s disease (C) is
id iop at h ic basal ganglia calci cat ion an d sh ou ld be low -in ten sit y on MRI.
He rpes sim plex virus (HSV [D]) in fect ion u su ally involves th e tem poral
lobes. Glio blasto m a (A) m ay be m u lt icen t r ic, bu t th is p ict u re is m ost likely
a lym p h om a.4

81. B – Ep idu ral abscess

An e pidural infe ction (B) is iso- or hypoin ten se to th e cord on T1-w eigh ted
MRI an d hyperin ten se on T2-w eigh ted an d p roton den sit y u n en h an ced MRIs.
With con t rast , th e solid p or t ion of th e abscess or th e perip h er y of a liqu id
collect ion en h an ces.4

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Neurosurgery Board Review

82. E – Ren al cyst s

Cerebellar h em angioblastom as (t u m or blush is seen in th is arterial ph ase) are


associated w ith re nal cysts (E) an d pan creat ic cyst s.4

83. E – Vein of Galen m alform at ion

Lateral basilar arter y angiogram sh ow s early lling of th e vein of Galen . Vein


o f Galen m alfo rm atio ns (E) usu ally presen t w ith h igh -ou t put cardiac fail-
u re in th e n eon ate. Th ey also m ay presen t w ith hydrocephalus in th e in fan t ,
or subarach n oid h em orrh age, epilepsy, or m en t al ret ardat ion in th e older
ch ild (or adult).4

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Neuroradiology—Answers and Explanations

84. B – Diskit is

Erosion of th e in ferior an terior L2 en d plate is n oted. Plain lm abn orm alit ies
in diskitis (B) m ay n ot becom e eviden t for w eeks. Th ey in clu de irregu larit ies
of th e en d plate, loss of disk space h eigh t , an d bony sclerosis.4

85. C – Rapid correct ion of hypon at rem ia

Cen t ral pon t in e m yelin olysis is associated w ith th e rapid co rre ctio n o f
hypo natre m ia (C) an d u su ally occu rs in m aln ou rish ed or alcoh olic p at ien t s.4

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Neurosurgery Board Review

86. A – Developm en tal

Th is T2-w eigh ted axial MRI sh ow s th e split cord of diastem atom yelia, a devel-
o pm ental (A) con dit ion . 4

87. E – Ven ous m alform at ion

A lin ear or cur vilin ear st ru ct ure w ith a n idus from w h ich em an ates n u-
m erou s sm all vein s is th e t yp ical MRI ap p earan ce of a veno us angio m a (E)
(i.e., d evelop m en tal ven ou s an om aly). Th e angiograph ic ap pearan ce is th at of
a cap u t m ed u sae.4

356
Neuroradiology—Answers and Explanations

88. A – Ast rocytom a

Th e brigh tly en h an cing m ural n odule in a large cyst is th e t ypical appear-


an ce of th e juven ile p ilocyt ic astro cyto m a (A) in th is age group. A cerebellar
he m angio blasto m a (C), w h ich w ou ld be m ore com m on in an adu lt , m ay also
h ave th is ap p earan ce on MRI.4

89. D – Glom u s jugu lare

Th e h eterogen eous “salt-an d-pepper” appearan ce of th e glo m us jugulare (D)


t um or is appreciated. Th ese relat ively rare t um ors arise from rest s of para-
ganglion ic t issu e along th e jugu lar bu lb. Glom u s t ym p an icu m t u m ors occu r
in th e m iddle ear.8

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Neurosurgery Board Review

90. C – Often associated w ith cavern ous m alform at ion

Ven ou s m alform at ion s (developm en t al ven ou s an om alies) con sist of a


large drain ing cort ical vein receiving a collect ion of m edullar y vein s (caput
m edu sae). Th ere u su ally is in ter ven ing n orm al brain (A is false ), u n like w ith
ar terioven ou s m alform at ion s (AVMs) an d cap illar y telangiect asias. Th ey
are usually single (B is false), u n like cap illar y telangiectasias. Th ey rarely
he m o rrhage (D is false) an d are o fte n fo und in asso ciatio n w ith caverno us
m alfo rm atio ns (C).4

91. E – Septal vein

92. A – An terior caudate vein


93. F – Term in al vein
94. G – Th alam ost riate vein
95. B – At rial vein
96. C – Basal vein of Rosen th al

358
Neuroradiology—Answers and Explanations

97. H – Vein of Galen


98. D – In tern al cerebral vein
99. I – Ven ou s angle

For qu est ion s 91 to 99, see referen ces 2 an d 4.

100. C – Men ingiom a

Th is sagit t al MRI sh ow s a dural-based m ass m ost con sisten t w ith m eningi-


o m a (C). Large schw anno m as (E) u su ally sh ow m ore h eterogen eou s con t rast
en h an cem en t .4

101. A – Acqu ired im m u n ode cien cy syn drom e (AIDS)

From Yoch DH. Magnet ic Resonance Im aging of


CNS Disease: A Teaching File, 2n d ed. St . Louis, MO:
C.V. Mosby, Inc., 2002. Used w ith perm ission from
Elsevier Ltd., Oxford, UK.

Cytom egalovirus (CMV) is a frequ en t cause of polyradiculit is an d m yelit is in


p at ien t s w ith acquire d im m uno de ciency syndro m e (AIDS [A]). Th e pial
en h an cem en t seen is ch aracterist ic of th is con dit ion .6

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Neurosurgery Board Review

102. D – Osteoid osteom a

Th e lyt ic lesion w ith surrou n ding sclerosis an d a cen t ral n idus is classic for
o steo id o steo m a (D). Th ese u sually presen t w ith pain th at resolves w ith
asp irin .4

103. E – Neuro brom atosis t ype 2

Th e bilateral acoust ic n eurom as an d m ult iple m en ingiom as are con sisten t


w ith neuro bro m ato sis type 2 (E).4

360
Neuroradiology—Answers and Explanations

104. D – Men ingiom a

A parafalcin e m eningio m a (D) is sh ow n .6

105. D – In farct

From Yoch DH. Magnetic Resonance Im aging of


CNS Disease: A Teaching File, 2nd ed. St. Louis,
MO: C.V. Mosby, Inc., 2002. Used w ith perm is-
sion from Elsevier Ltd., Oxford, UK.

A gyriform pat tern of con t rast en h an cem en t in th e dist ribut ion of th e left
an terior cerebral ar ter y (ACA) is suggest ive of su bacu te in farct ion .6

361
Neurosurgery Board Review

106. C – In farct

Th e cen t ral sulcus arter y (bran ch of th e m iddle cerebral arter y) is n ot lling


on th is lateral ICA inject ion angiogram . Th ese n dings are con sisten t w ith
isch em ic in farct ion .2

107. D – Treated w ith extern al or th osis

Type III odon toid fract ures usually heal w ell w ith an external o rtho sis (D)
(e.g., h alo, Som i, Min er va). Type II fractures (A) w ill m ore often require sur-
gical st abilizat ion , especially if th ere are m ore th an 6 m m of disp lacem en t .4

362
Neuroradiology—Answers and Explanations

108. B – Lym p h om a

Periven t ricu lar involvem en t by p rim ar y cen t ral n er vou s system lym pho m as
(B) is com m on .6

109. E – St urge-Weber syn drom e

Th e layer of en h an cem en t covering th e hypoplast ic righ t h em isph ere repre-


sen t s th e m en ingeal angiom a on th is postcon t rast coron al MRI.4

110. C – Predecessor of brain lipids an d par t icipates in coen zym e A in teract ion s
111. D – St ru ct ural com pon en t of cell m em bran es
112. B – Involved in m ain ten an ce of en ergy system s an d often u sed as a referen ce
113. A – Has t w o peaks; involved in storage of m em bran ou s p h osp h oin osit ides

363
Neurosurgery Board Review

114. E – Typical doublet located aroun d 1.32 ppm

N-acet ylasp ar t ate (NAA) is t ypically th e m ost visible peak an d occu rs at


2 ppm . Th e NAA peak con tain s a com bin at ion of m acrom olecu les con t ain ing
N-acet yl grou ps. NAA is th ough t to fu n ct ion as a predecesso r o f brain lipids
and participate in co en zym e A interactio ns (C). Th e ch olin e p eak occu rs at
3.21 ppm an d is a structural co m po nent o f cell m em branes (D). Ch olin e
in h ealthy m em bran es m ay n ot be detected in th e ch olin e p eak, but th e
ch olin e peak in creases in sit uat ion s w h ere m em bran es are being dest royed
(m align an t t um ors an d degen erat ive disease). Th e creat in e peak occurs at
3.03 ppm an d is involved in th e m ainte nance of energy system s (B). Th e
creat in e peak is th ough t to be relat ively st able, so it is often used as a refer-
en ce. Myo-in ositol (MI) h as p eaks at 3.56 an d 4.06 p p m an d is a re ect ion
of the sto rage o f m e m brano us phospho ino sitides, se co nd m essengers o f
cell m em branes (A). MI is located prim arily in glial cells. Th e lactate do ublet
o ccurs at 1.32 ppm (E).12

115. D – Redu ced NAA, in creased ch olin e, in creased lactate

For ast rocytom as (in gen eral), an in creased ch olin e peak, reduct ion of th e
NAA p eak, an d ap pearan ce of a lact ate p eak are t ypical. In cases of glioblas-
tom a, a full reduct ion of th e NAA peak an d a sh arp in crease in th e lact ate
p eak often occur, w h ich correlate w ith th e presen ce of n ecrosis. Ch oice D is
the correct an sw er.12

116. E – Vertebral osteopet rosis

Th is sagit t al CT scan sh ow s an exam ple of vertebral o steo petro sis (E), a pro-
cess ch aracterized by de cien t osteoclast ic reabsorpt ion leading to in creased
bon e m in eral den sit y. Di use sclerosis an d cort ical th icken ing are seen h ere.
Th e oth er ch oices are in correct .13

364
Neuroradiology—Answers and Explanations

117. C – Median prosen ceph alic vein

Th is lateral angiogram sh ow s an exam ple of a vein of Galen m alform at ion ,


a t yp e of arterioven ou s st u la th at u su ally p resen t s du ring ch ildh ood. Th e
arrow is p oin t ing to a persisten t m edian pro se ncephalic vein (C), th e preser-
vat ion of w h ich m ay be th e u n derlying m ech an ism of th e st u la. Th e arrow is
p oin ted at a locat ion too d ist al for th e st ruct u re to represen t an atrial vein (A),
th e internal cerebral vein (B), or th e vein o f Galen (E). Th e straight sinus
(D) w ould be at th e level of th e ten torium ; th is st ruct ure is clearly above th e
ten torium .12

118. D – All of th e above

Th e MRI im ages sh ow n h ere dem on st rate septo -o ptic dysplasia (C). Th is


con dit ion is con sidered by som e to represen t th e m ildest form of h olopros-
en ceph aly. Th ere is absen ce of th e sept u m p ellu cid u m an d hyp op lasia of th e
opt ic n er ves. Th e absen ce of th e sept um pellucidum gives th e box-sh aped
con gurat ion to th e ven t ricles (co lpo cephaly [B]). Th is pat ien t also h as age n-
esis o f the co rpus callo sum (A), con t ribu t ing to th e parallel con gu rat ion of
th e ven t ricles. Th e correct an sw er is D, all o f the above.13

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Neurosurgery Board Review

119. B – Ep iderm oid

Th is postcon t rast T1-w eigh ted MRI im age sh ow s an exam ple of a cerebello-
p on t in e angle epiderm o id cyst (B). An arachno id cyst (A) w ou ld also ap p ear
hypoin ten se on T1; h ow ever, th is locat ion is m ore t ypical for an epiderm oid
lesion . A lipo m a (C) w ould ap pear hyperin ten se on T1. A low -grade glio m a
(D) w ou ld be in t ra-axial, n ot ext ra-axial. A m eningio m a (E) w ou ld m ost like-
ly sh ow h om ogen ous en h an cem en t on th is postcon t rast im age.4

120. D – Gradien t ech o

Gradient echo se que nces (D) are sen sit ive to th e m agn et ic eld created by
the iron in h em oglobin , an d are th erefore th e m ost sen sit ive sequen ce for th e
detect ion of blood product s of th e ch oices listed. Di usio n-w eighted im ages
(A) are u sefu l in th e diagn osis of acu te st roke. Fast spin echo (B) sequ en ces
gen erate t radit ion al T1- an d T2-w eigh ted im ages. Fluid-attenuated inver-
sio n recovery se que nces (C) elim in ate CSF sign al an d are u sefu l for lesion s
adjacen t to th e ven t ricu lar system . MRI spe ctro sco py (E) is less sen sit ive
than gradien t ech o for th e detect ion of blood produ cts. 4

366
Neuroradiology—Answers and Explanations

121. D – A an d C on ly

Th e lesion seen in th is axial MRI is an exam ple of a dysem br yoplast ic n euro-


epith elial t u m or (DNET). Th ese lesion s u su ally present w ith seizures (C) an d
are asso ciate d w ith co rtical dysplasia (A). Th e lesion con tain s abn orm al oli-
goden drocytes an d ast rocytes, bu t n orm al n eu ron s (B is false). Gangliogliom a,
n ot DNET, co ntains both abno rm al neuro ns and glial cells (B). D is th e cor-
rect an sw er.4,13

References

1. Morris P. Pract ical Neuroangiography. Balt im ore, MD: William s & Wilkin s; 1997
2. Osborn AG. Diagn ost ic Cerebral Angiography. Ph iladelph ia, PA: Lippin cot t William s
& Wilkin s; 1998
3. Apuzzo MLJ. Brain Surger y. Com plicat ion Avoidan ce an d Man agem en t . New York: Ch urch ill
Livingston e; 1993
4. Citow JS, Macdon ald RL, Refai D, ed s. Com p reh en sive Neu rosu rger y Board Review.
New York: Thiem e Medical Publish ers; 2009
5. Am erican College of Radiology Neu roradiology Learn ing File. Osborn e AG, Sm irn iotop ou los
JG, ed s. Videod isc Version 1.0. Mish kin , MM.
6. Yock DH Jr. Magn et ic Reson an ce Im aging of CNS Disease: A Teach ing File, 2n d ed . St . Lou is,
MO: Mosby; 2002
7. Win n HR, ed-in -chief. Neurological Su rger y, 5th ed. Ph iladelph ia, PA: W.B. Saun ders; 2003
8. Tin dall GT, Cooper PR, Barrow DL, eds. Th e Pract ice of Neu rosurger y. Balt im ore, MD:
William s & Wilkin s; 1995
9. Bu rger PC, Sch eith au er BW, Vogel FS, ed s. Su rgical Path ology of th e Ner vou s System an d It s
Coverings, 4th ed . New York: Ch u rch ill Livingston e; 2002
10. Bu rger PC, Sch eith au er BW, Vogel FS. Su rgical Path ology of th e Ner vou s System an d It s
Coverings, 3rd ed. New York: Ch u rch ill Livingston e; 1991
11. McKh an n II GM, Kitch en ND, Manju H. Qu est ion s an d An sw ers Color Review of Clin ical
Neu rology an d Neurosu rger y. New York: Thiem e Medical Publish ers; 2003
12. Kornien ko VN, Pron in IN. Diagn ost ic Neuroradiology. Moscow : Springer; 2009
13. Borden NM, Forseen SE. Pat tern Recogn it ion Neuroradiology. New York: Cam bridge
Un iversit y Press; 2011

367
7A Clinical Skills/
Critical Care—Questions

For quest ion s 1 to 6, m atch th e an esth et ic agen t w ith th e descript ion . Each resp on se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. En u ran e
B. Etom idate
C. Haloth an e
D. Iso uran e
E. Ket am in e
F. Th iopen t al

1. In creases cerebral blood ow (CBF) an d cerebral m et abolic rate of oxygen con -


su m pt ion (CRMO2 )

2. Of th e volat ile an esth et ics, it in creases CBF th e least .

3. In duces seizu re disch arges

4. Dissociat ive an esthet ic

5. Decreases CBF an d CRMO2 an d p rodu ces cardiovascu lar dep ression

6. Decreases CBF an d CRMO2 an d su p p resses adren ocor t ical respon se to st ress

7. W h ich an t iem et ic m edication low ers seizu re th resh old?


A. Ph en ergan
B. Droperidol
C. Tigan
D. Zofran
E. Reglan

8. Th e m ost appropriate drug to adm in ister to a st able pat ien t w ith a n arrow com -
p lex su p raven t ricu lar t achycardia (n o serious sign s or sym ptom s) after vagal
st im u lat ion is
A. Aden osin e
B. Digoxin
C. Procain am ide
D. Qu in idin e
E. Verapam il

368
Clinical Skills/Critical Care—Questions

9. Each is t ru e of fat em bolism except


A. Cerebral m an ifest at ion s frequ en tly occur in th e absen ce of pu lm on ar y
m an ifest at ion s.
B. In creased serum lipase occurs in up to h alf of all pat ien t s.
C. Petech ia over the sh oulders an d ch est is a classic n ding.
D. Sym ptom s t ypically occur 12 to 48 h ours after t raum a.
E. Tachycardia an d t achypn ea are ch aracterist ic.

10. Gam m a irradiat ion of blood h elps preven t


A. Graft-versus-h ost disease
B. Hem olyt ic t ran sfusion react ion s
C. Hepat it is B t ran sm ission
D. Non h em olyt ic t ran sfusion react ion s
E. Tran sfusion siderosis

11. Cit rate toxicit y from m assive t ran sfu sion s results from th e
A. Bin ding of free ion ized Ca 21
B. Decrease of 2,3-diph osph oglyceric acid (DPG) levels
C. In act ivat ion of factors 5 an d 8
D. In teract ion w ith platelets, ren dering th em dysfu n ct ion al
E. Precipit at ion of autoim m un e h em olyt ic an em ia

For qu est ion s 12 to 14, m atch th e descript ion w ith th e d isease.


A. Cush ing’s disease
B. Ectopic adren ocort icot ropic h orm on e (ACTH) produ ct ion
C. Both
D. Neith er

12. Cor t isol is su ppressed w ith low -dose dexam eth ason e.

13. Cor t isol is su ppressed w ith h igh -dose dexam eth ason e.

14. In crease in urin ar y 17-hydroxycor t icosteroids after a m et yrapon e test

15. W h ich of th e follow ing scen arios re ect s an iron de cien cy an em ia?
A. Decreased m ean corpuscu lar volu m e (MCV) an d decreased tot al iron bin d -
ing cap acit y (TIBC)
B. Decreased MCV an d in creased TIBC
C. Decreased MCV an d n orm al TIBC
D. In creased MCV an d decreased TIBC
E. In creased MCV an d in creased TIBC

16. Prolongat ion of bleeding t im e usu ally occurs in


I. von Willebran d’s disease
II. Use of n on steroidal an t i-in am m ator y agen ts
III. Urem ia
IV Factor VII de cien cy
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

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Neurosurgery Board Review

17. Drugs th at an t agon ize th e an t icoagulan t e ect of w arfarin (Cou m adin ) in clude
I. Ch olest yram in e
II. Ph en obarbit al
III. Rifam pin
IV Cim et idin e
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

18. Side e ect s of th iazide diuret ics in clu de


I. In su lin resist an ce
II. Hyp on at rem ia
III. Hyp okalem ia
IV. Flu sh ing
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

19. Plasm a levels of ph enytoin (Dilan t in ) are in creased by all of th e follow ing except
A. Carbam azepin e
B. Cim et idin e
C. Coum adin
D. Ison iazid
E. Sulfon am ides

20. Th e m ost com m on elect rocardiogram (EKG) n ding(s) in pat ien ts w ith pulm o -
n ar y em boli is
A. A peaked T w ave
B. An S1-Q3-T3 pat tern
C. Righ t w ard sh ift of th e QRS axis
D. Sin us t achycardia (ST) an d T w ave ch anges
E. Bradycardia

21. W h ich of th e follow ing disorders leads to hypern at rem ia?


A. Addison’s disease
B. Hyperaldosteron ism
C. Hypothyroidism
D. Ren al failure
E. Syn drom e of in appropriate an t idiuret ic h orm on e (SIADH)

22. Th e m ost com m on acid–base dist urban ce in m ild to m oderately inju red pat ien t s
w ith out severe ren al, circulator y, or pulm on ar y decom pen sat ion is
A. Respirator y acidosis an d m et abolic alkalosis
B. Respirator y alkalosis an d m et abolic acidosis
C. Respirator y or m et abolic acidosis
D. Respirator y or m et abolic alkalosis

370
Clinical Skills/Critical Care—Questions

23. Th e reabsorpt ion of Na 1 ion s in th e th in ascen ding Hen le’s loop


A. Is by act ive t ran sport
B. Is by a Na 1 –K1 exch ange p u m p
C. Passively follow s th e act ive t ran spor t of Cl2 ion s
D. Passively follow s th e act ive t ran sport of w ater m olecules

For qu est ion s 24 to 27, m atch th e an t iplatelet agen t w ith th e descript ion . Each resp on se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Abcixim ab (ReoPro)
B. Aspirin
C. Clopidogrel (Plavix)
D. Ept i bat ide (In tegrilin )
E. Ticlopidin e (Ticlid)

24. Of th e t w o prodrugs th at block th e Gi-coupled platelet aden osin e diph osph ate
(ADP) receptor, it h as a sligh tly m ore favorable toxicit y pro le.

25. Is th e Fab fragm en t of a m on oclon al an t ibody directed again st th e IIb/IIIa receptor

26. Is a cyclic pept ide in h ibitor of th e argin in e-glycine-aspart ate (RGD) bin ding site
on th e glycoprotein IIb/IIIa

27. Blocks product ion of th rom boxan e A2

28. W h ich laborator y n ding in dissem in ated in t ravascu lar coagulat ion (DIC) cor-
relates m ost closely w ith bleeding?
A. Decreased brin ogen
B. In creased brin degradat ion product s
C. In creased proth rom bin t im e (PT)
D. In creased part ial th rom boplast in t im e (PTT)
E. In creased th rom bin t im e (TT)

29. Th e de n it ion of oxygen sat urat ion is th e


A. Am ou n t of oxygen dissolved in plasm a
B. Fract ion al con cen t rat ion of in spired oxygen
C. Part ial pressure of oxygen in th e blood
D. Percen t age of h em oglobin th at is boun d to oxygen
E. Rat io of u n boun d to boun d h em oglobin

30. Met abolic respon ses to t raum a in clude each of the follow ing except
A. Hyp oglycem ia
B. In creased rate of lipolysis
C. In creased Na 1 reabsorpt ion
D. In creased w ater reabsorpt ion
E. Met abolic alkalosis

31. A n orm al PT, a prolonged PTT, an d a bleeding disorder w ould resu lt from a de -
cien cy of factor
A. II
B. V
C. VIII
D. X
E. XII

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Neurosurgery Board Review

For qu est ion s 32 to 37, m atch th e coagu lat ion factor w ith th e d escript ion . Each respon se
m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Factor II
B. Factor VII
C. Factor VIII
D. Factor IX
E. Factor X

32. Sh ortest h alf-life

33. Re ect s th e ext rin sic path w ay

34. De cien t or abn orm al in h em oph ilia A (classic)

35. De cien t in h em oph ilia B (Ch rist m as disease)

36. All except th is factor are vit am in K–depen den t factors.

37. De cien cy of factor II or th is factor resu lt s in prolonged PT an d PTT.

For qu est ion s 38 to 45, m atch th e com bin at ion of laborator y valu es w ith th e h em ato-
logic d iagn osis. Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. Abn orm al PT, PTT, an d bleeding t im e
B. Abn orm al PT, n orm al PTT an d bleeding t im e
C. Norm al PT, PTT, an d bleeding t im e
D. Norm al PT, abn orm al PTT an d bleeding t im e
E. Hypercoagulable state
F. Norm al PT, abn orm al PTT, n orm al bleeding t im e

38. An t ith rom bin III de cien cy

39. DIC

40. von Willebran d’s disease

41. Dys brin ogen em ia

42. Maln ut rit ion

43. Factor VII de cien cy

44. Factor XIII de cien cy

45. Factor VIII de cien cy

For qu est ion s 46 to 52, m atch th e acid–base dist u rban ce w ith th e descript ion or
diagn osis. Each respon se m ay be used on ce, m ore th an on ce, or n ot at all.
A. In creased an ion gap m etabolic acidosis
B. Non -an ion gap m et abolic acidosis
C. Met abolic alkalosis
D. Respirator y acidosis
E. Respirator y alkalosis

46. Often occurs w ith hypokalem ia

47. Addison’s disease

372
Clinical Skills/Critical Care—Questions

48. Salicylate overdose (early st age)

49. Myasth en ia gravis

50. Ethylen e glycol overdose

51. Cush ing’s disease

52. Prim ar y aldosteron ism

53. Th e form ula for m ean arterial pressure is (DBP, diastolic blood pressure; SBP,
systolic blood p ressu re)
A. (DBP 1 SBP)/2
B. DBP 1 (SBP 2 DBP)/2
C. DBP/2 1 SBP/3
D. DBP 1 (SBP 2 DBP)/3
E. DBP/2 1 (SBP 2 DBP)/3

For qu est ion s 54 to 60, m atch th e descript ion w ith th e syn d rom e.
A. Mu lt ip le en docrin e n eop lasia (MEN) t yp e I (Wern er’s syn drom e)
B. MEN t ype IIA (Sipple’s syn drom e)
C. Both
D. Neith er

54. Parathyroid hyperplasia or aden om a

55. Pan creat ic islet cell hyperplasia, aden om a, or carcin om a

56. Pit uitar y hyperplasia or aden om a

57. Ph eoch rom ocytom as are com m on .

58. Medullar y thyroid carcin om as are com m on .

59. Mucosal an d gast roin test in al n eurom as

60. Marfan oid feat ures

61. Ch aracterist ics of prim ar y hyperaldosteron ism in clude each of th e follow ing
except
A. Edem a
B. Hypokalem ia
C. In creased diastolic blood pressure
D. Met abolic alkalosis
E. Suppression of plasm a ren in act ivit y

62. Adequacy of pulm on ar y ven t ilat ion is assessed by


A. FiO2
B. Oxygen sat u rat ion
C. PaCO2
D. Par t ial pressure of O2 in blood
E. Tidal volum e

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Neurosurgery Board Review

For quest ion s 63 to 68, m atch th e abn orm alit y in th e EKG w ith th e diagn osis. Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. At rial brillat ion
B. J-poin t elevat ion
C. Peaked T w ave
D. Prolonged QT in ter val
E. U w ave

63. Hypocalcem ia

64. Hypokalem ia

65. Hyperkalem ia

66. Hypoth erm ia

67. Hyper thyroidism

68. Quin idin e toxicit y

69. W h ich of th e follow ing is false of m align an t hyper th erm ia?


A. Calcium is released from th e m u scle cell’s sarcop lasm ic ret iculum .
B. En d-t idal pCO2 in creases
C. It is precipit ated by th e use of in h alat ion al an esth et ics.
D. Treat m en t is w ith dan t rolen e.
E. Use of succinylch olin e can h elp preven t it .

70. Of th e follow ing, th e best ch oice for Clost ridium di cile en terocolit is is
A. Clin dam ycin orally
B. Met ron idazole (Flagyl) orally
C. Pen icillin G orally
D. Pen icillin VK int raven ously
E. Van com ycin in traven ously

For qu est ion s 71 to 73, m atch th e descript ion w ith th e p rocess.


A. Cardiac t am ponade
B. Ten sion pn eu m oth orax
C. Both
D. Neith er

71. Pulsus paradoxus

72. In creased ven ous pressure

73. In creased pulse pressure

74. Men ingit is occu rring w ith in 72 h ours after a basilar skull fract ure is m ost com -
m on ly secon dar y to
A. Haem ophilus inf uenzae
B. Neisseria m eningit idis
C. Staphylococcus aureus
D. Staphylococcus epiderm idis
E. St reptococcus pneum oniae

374
Clinical Skills/Critical Care—Questions

75. Postoperat ive sh un t in fect ion s are m ost com m on ly caused by


A. Coagu lase-n egat ive staphylococci
B. H. inf uenzae
C. Pseudom onas sp ecies
D. S. aureus
E. S. pneum oniae

76. Th e m ost likely cause of a fever occurring in th e rst 24 h ours after surger y is
A. Atelect asis/postop erat ive in am m at ion
B. Deep vein th rom bosis
C. Pn eum on ia
D. Urin ar y t ract in fect ion
E. Woun d in fect ion

For qu est ion s 77 to 81, m atch th e descript ion w ith th e d rug.


A. Dobu t am in e
B. Dopam in e
C. Both
D. Neith er

77. A posit ive in ot ropic agen t

78. Has ver y lit tle e ect on a -adren ergic receptors

79. Is th e drug of ch oice in sept ic sh ock

80. Has n o e ect on b 2 receptors

81. Has a dose-related e ect

82. Of th e follow ing, th e m ost com m on cause of n eon at al m en ingit is is


A. H. inf uen zae
B. Listeria species
C. N. m eningit idis
D. St aphylococci
E. Group B st reptococci

83. Each of th e follow ing is t rue of n it roprusside except


A. Cyan ide accum ulat ion m ay lead to m et abolic acidosis
B. Th e cyan ide is reduced to th iocyan ate in th e liver
C. Th e h alf-life of th iocyan ate is 3 to 4 days
D. Th iocyan ate is excreted in th e gast roin test in al (GI) t ract
E. With prolonged adm in ist rat ion , accum ulat ion of th iocyan ate m ay cau se an
acu te toxic psych osis

84. Isoproteren ol
A. Act s alm ost exclusively on a -receptors
B. Decreases SBP
C. In creases DBP
D. In creases periph eral vascu lar resist an ce (PVR)
E. Relaxes sm ooth m u scle

375
Neurosurgery Board Review

85. Splen ectom y for h eredit ar y sph erocytosis


A. Corrects th e an em ia
B. Corrects th e defects in red blood cells
C. Has n o e ect on red blood cell su r vival
D. Sh ould n ot be preceded by vaccin at ion
E. Sh ould be perform ed before age 3

For quest ion s 86 to 92, m atch th e t im e p eriod after creat ion of a w ou n d w ith th e even t
occurring during w oun d h ealing. Each respon se m ay be u sed on ce, m ore th an on ce, or
n ot at all.
A. 12 h ours
B. 5 days
C. 17 days
D. 42 days
E. 2 years

86. Epith elial m igrat ion occurs.

87. In crease in ten sile st rength occu rs at least up to th is poin t .

88. Woun d con t ract ion begin s.

89. Maxim um am ou n t of tot al collagen occu rs at th is t im e.

90. Visible collagen syn th esis begin s.

91. Sign i can t gain in ten sile st rength begin s at th is t im e.

92. Th e rapid in crease in collagen con ten t slow s con siderably at th is poin t .

93. Each of the follow ing is consistent w ith the Zollinger-Ellison syndrom e except a(n )
A. Decrease in seru m gast rin w ith secret in inject ion
B. Duoden al ulcer
C. Duoden al w all gast rin om a
D. Pan creat ic gast rin om a
E. In creased serum gast rin level

For quest ion s 94 to 99, m atch th e descript ion w ith th e d isease.


A. Type I (distal) ren al t ubu lar acidosis (RTA)
B. Type II (proxim al) RTA
C. Both
D. Neith er

94. Non -anion gap acidosis

95. Hyperkalem ia

96. Neph rocalcin osis com m on ly occurs.

97. Urin e pH . 5.5

98. Defect in reabsorpt ion of bicarbon ate

99. Hypokalem ia

376
Clinical Skills/Critical Care—Questions

100. The percentage of extracellular uid represented by plasm a volum e is approxim ately
A. 5%
B. 15%
C. 20%
D. 40%
E. 60%

101. Each of th e follow ing occu rs in ven ou s air em bolism except a(n )
A. Decrease in cardiac out pu t
B. In crease in en d-t idal pCO2
C. In crease in pulm on ar y ar ter y pressure
D. In crease in pulm on ar y vascular resistan ce
E. Ven t ilat ion -perfu sion m ism atch

102. Th e m ost sen sit ive n on invasive m on itor of ven ous air em bolism is
A. Au scu ltat ion of th e ch est w ith a steth oscope
B. En d-t idal pCO2
C. En d-t idal pN2
D. Precordial Doppler
E. Pulm on ar y ar ter y cath eterizat ion

103. W h ich EKG ch ange in th e an terior leads is th e m ost ch aracterist ic n d ing in su b -


en docardial isch em ia?
A. Hyp eracu te T w ave
B. Q w ave
C. ST depression
D. ST elevat ion
E. T w ave inversion

104. W h ich set of laborator y values is m ost con sisten t w ith hypothyroidism of hypo-
th alam ic or pit uitar y origin ?
A. Decreased thyroid-st im ulat ing h orm on e (TSH) an d decreased free thyroxin e
(T4)
B. Decreased TSH an d in creased free T4
C. Decreased TSH an d n orm al free T4
D. In creased TSH an d decreased free T4
E. In creased TSH an d in creased free T4

105. Of th e follow ing t reat m en t opt ion s for hyperkalem ia, w h ich on e does not alter
seru m potassiu m ?
A. Calciu m
B. Cat ion -exch ange resin s
C. Hem odialysis
D. In sulin
E. Sodium bicarbon ate

377
Neurosurgery Board Review

For qu est ion s 106 to 111, m atch th e acid–base d ist u rban ce w ith th e arterial blood gas
resu lt . Each resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Respirator y acidosis
B. Respirator y acidosis an d m etabolic acidosis
C. Met abolic acidosis
D. Met abolic acidosis an d com pen sator y respirator y alkalosis
E. Respirator y alkalosis
F. Resp irator y alkalosis an d com p en sator y m et abolic acidosis
G. Un in terp ret able

106. p H 5 7.5, p CO2 5 30, HCO3 5 19

107. p H 5 7.3, p CO2 5 52, HCO3 5 29

108. p H 5 7.35, p CO2 5 17, HCO3 5 9

109. pH 5 7.55, pCO2 5 32, HCO3 5 12

110. pH 5 7.22, pCO2 5 55, HCO3 5 22

111. pH 5 7.25, pCO2 5 28, HCO3 5 12

112. If Qs an d Qt are pu lm on ar y sh u n t an d total blood ow, resp ect ively, an d Cc, Ca,
an d Cv are th e oxygen conten t s of en d-capillar y, arterial, an d m ixed ven ous
blood, respect ively, th en th e sh un t fract ion Qs/Qt 5
A. Cc/(Cc 2 Cv)
B. (Ca 2 Cv)/Cv
C. (Cv 2 Ca)/Cc
D. (Cc 2 Ca)/(Cc 2 Cv)
E. (Ca 1 Cv)/(Ca 1 Cc 1 Cv)

113. At rop in e toxicit y p rodu ces each of th e follow ing except


A. Blurred vision
B. Decreased in test in al peristalsis
C. Dr y m outh
D. In creased pu lse
E. In creased sw eat ing

114. Each of th e follow ing is t ru e of hyperosm olar com a except


A. Free fat t y acid con cen trat ion is low er th an in ketoacidosis
B. Glucose con cen t rat ion is h igh er th an in ketoacidosis
C. It is m ore com m on in t ype 1 diabetes m ellit us th an in t ype 2 diabetes
m ellit u s
D. Mort alit y is m ore th an 50%
E. Volum e deplet ion is usually severe

For qu est ion s 115 to 119, m atch th e au ton om ic drug w ith th e descript ion . Each
resp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Clon idin e
B. Isoproteren ol
C. Ph en oxyben zam in e
D. Ph en tolam in e
E. Prazosin

378
Clinical Skills/Critical Care—Questions

115. b agon ist

116. Pu re a 1 an t agon ist

117. Non com pet it ive a an tagon ist

118. Com p et it ive, n on select ive a an t agon ist

119. Cen t ral a 2 agon ist

120. Th e m ost app rop riate ch olin ergic agen t to be u sed in u rin ar y reten t ion is
A. Acet ylch olin e
B. Beth an ech ol
C. Carbach ol
D. Ch olin e
E. Meth ach olin e

121. W h ich of th e follow ing is false of p olycyth em ia vera?


A. Bu dd- Ch iari syn drom e is com m on .
B. Hyperuricem ia can com plicate th e disorder.
C. It is th e m ost com m on of th e m yeloproliferat ive disorders.
D. Massive splen om egaly is usually th e presen t ing sign .
E. Th e use of alkylat ing agen t s sh ould be avoided.

122. Th e seru m osm olarit y of a pat ien t w ith a sodiu m level of 130 m eq/L, K of
4.0 m eq/L, glucose of 126 m g/dL, an d blood u rea n it rogen (BUN) of 28 m g/dL is
A. 276
B. 285
C. 296
D. 304
E. 310

123. Each of th e follow ing is a resu lt of th e u se of p osit ive en d-exp irator y p ressu re
(PEEP) in th e ven t ilated pat ien t except
A. Decreased cerebral perfu sion pressu re
B. Decreased physiologic dead space
C. Decreased w ork of breath ing
D. Im proved lung com plian ce
E. Predisposit ion to barot raum as

124. Th e oxyh em oglobin dissociat ion cu r ve is sh ifted to th e righ t (decreased oxygen


a n it y) by
I. Acidosis
II. Decreased 2,3-diph osp h oglyceric acid (2,3-DPG)
III. Fever
IV Ban ked blood
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

379
Neurosurgery Board Review

125. Gast roin test in al carcin oid t u m ors are m ost frequ en tly fou n d in th e
A. Ap pen dix
B. Colon
C. Ileum
D. Rect um
E. Stom ach

126. Alkalin izat ion of th e u rin e prom otes excret ion of


I. Salicylates
II. Tricyclic an t id ep ressan t s
III. Ph en obarbit al
IV. Am p h et am in es
A. I, II, III
B. I, III
C. II, IV
D. IV
E. All of th e above

For qu est ion s 127 an d 128, m atch th e descript ion w ith th e su bst an ce.
A. Cr yoprecipit ate
B. Fresh frozen plasm a
C. Both
D. Neith er

127. Reliably e ect ive in von Willebran d’s disease

128. Used in th e t reat m en t of h em oph ilia B

129. Th e free w ater d e cit in a dehydrated 70-kg m an w ith an Na 1 of 160 is


A. 2L
B. 4L
C. 6L
D. 7L
E. 8L

For qu est ion s 130 to 134, m atch th e au ton om ic d rug w ith th e d escript ion . Each re-
sp on se m ay be u sed on ce, m ore th an on ce, or n ot at all.
A. Am rin on e
B. Dopam in e
C. Epin eph rin e
D. Neo-Syn eph rin e
E. Norepin eph rin e

130. Pu re a agon ist

131. Does n ot in teract w ith a or b receptors

132. E ect s var y sign i can tly w ith dose adm in istered.

133. Prim arily an a agon ist w ith m ild b 1 act ivit y

134. Balan ced a an d b agon ist prop ert ies

380
Clinical Skills/Critical Care—Questions

135. Th alliu m in toxicat ion cau ses each of th e follow ing except
A. Cardiac dysfun ct ion
B. GI dist urban ce
C. Hirsut ism
D. Low er ext rem it y join t pain
E. Periph eral n europathy

136. W h ich of th e follow ing sym ptom s is least ch aracterist ic of acute interm it ten t
p orphyria?
A. Abd om in al pain
B. Hypoten sion
C. Polyn europathy
D. Psych osis
E. Tachycardia

137. A p at ien t on h is th ird h osp it al day in th e n eu ro in ten sive care u n it abru ptly de-
velops bradycardia, hyp erlipidem ia, an d rh abdom yolysis w h ile on th e ven t ilator.
Th e m ost appropriate n ext step is
A. Acqu ire cardiology consultat ion
B. Discon t in ue th e o en ding agen t
C. In it iate broad-spect rum an t ibiot ics
D. In sulin adm in ist rat ion
E. Ren al dialysis

138. W h ich of th e follow ing descript ion s best describes Ch eyn e-Stokes resp irat ion ?
A. Breath ing is irregularly in terrupted, an d each breath varies in rate an d
depth
B. Few rapid deep breath s altern ate w ith apn eic cycles (2–3 secon d pause in
fu ll in sp irat ion ) in sh ort cycles
C. In crease in rate an d depth of respirat ion leading to respirator y alkalosis
D. Waxing an d w an ing hyperpn ea regularly altern ates w ith sh orter apn eic
p eriods
E. Non e of th e above

139. Cu sh ing’s re ex refers to


A. In creased h ear t rate in respon se to in creased in t racran ial pressu re
B. In creased systolic arterial pressure in respon se to in creased in t racran ial
p ressu re
C. Parasym path et ic out ow in respon se to in creased in t racran ial pressu re
D. All of th e above
E. Non e of th e above

381
7B Clinical Skills/
Critical Care—Answ er Key

1. E 27. B
2. D 28. A
3. A 29. D
4. E 30. A
5. F 31. C
6. B 32. B
7. A 33. B
8. A 34. C
9. A 35. D
10. A 36. C
11. A 37. E
12. D 38. E
13. A 39. A
14. A 40. D
15. B 41. A
16. A 42. B
17. A 43. B
18. A 44. C
19. A 45. F
20. D 46. C
21. B 47. B
22. D 48. E
23. C 49. D
24. C 50. A
25. A 51. C
26. D 52. C

382
Clinical Skills/Critical Care—Answer Key

53. D 92. D
54. C 93. A
55. A 94. C
56. A 95. D
57. B 96. A
58. B 97. A
59. D 98. B
60. D 99. C
61. A 100. C
62. C 101. B
63. D 102. D
64. E 103. C
65. C 104. A
66. B 105. A
67. A 106. E
68. D 107. A
69. E 108. D
70. B 109. F
71. A 110. B
72. C 111. C
73. D 112. D
74. E 113. E
75. A 114. C
76. A 115. B
77. C 116. E
78. A 117. C
79. D 118. D
80. D 119. A
81. B 120. B
82. E 121. D
83. D 122. B
84. E 123. B
85. A 124. B
86. A 125. A
87. E 126. A
88. B 127. A
89. D 128. D
90. B 129. C
91. B 130. D

383
Neurosurgery Board Review

131. A 136. B
132. B 137. B
133. E 138. D
134. C 139. B
135. C

384
7C Clinical Skills/Critical Care—
Answ ers and Explanations

1. E – Ket am in e
2. D – Iso u ran e
3. A – En uran e
4. E – Ket am in e
5. F – Th iop en t al
6. B – Etom idate

Iso urane (D), en urane (A), an d halothane (C) are all in h alat ion al (vola-
t ile) an esth et ics. All in h alat ion al an esth et ics reduce th e m et abolic rate of th e
brain , but also in crease cerebral blood ow (CBF), w h ich m ay lead to in creases
in in t racran ial pressu re (ICP). At low doses all h alogen ated an esth et ics h ave
a sim ilar e ect on cerebral blood ow, bu t at h igh er doses en u ran e an d iso-
u ran e in crease CBF less th an h aloth an e. A com bin at ion of n it rou s oxid e an d
h aloth an e in creases CBF m ore th an h aloth an e alon e. Of th e volat ile an esth et -
ics listed, iso urane (D) in creases cerebral blood ow th e least . En urane
(A), at h igh d oses, h as cerebral irrit an t e ects th at can lead to spike-an d -w ave
elect roen ceph alogram (EEG) pat tern s. Eto m idate (B) is a carboxylated im id-
azole th at is som et im es u sed for in du ct ion of an esth esia—its u se is associated
w ith adren al su ppression , even after a single dose. Ketam ine (E) is a dissocia-
t ive an esth et ic th at in creases cerebral blood ow, cerebral oxygen con sum p -
t ion , an d ICP. Thiope ntal (F) is a sh ort-act ing barbit urate th at is used for in -
d u ct ion of gen eral an esth esia—it rapidly crosses th e blood–brain barrier an d
causes reduct ion s in both CMRO2 an d CBF; th e reduct ion in CMRO2 is greater
th an th e reduct ion in CBF, h ow ever. Thio pental (F) is associated w ith a m yo-
cardial depressan t e ect an d in creased ven ous pooling, w h ich m ay lead to
decreased blood pressu re, st roke volu m e, an d cardiac out pu t .1,2

7. A – Ph en ergan

Phenergan (A), a ph en oth iazin e an t iem et ic, h as been sh ow n to low er th e sei-


zure th resh old.3

385
Neurosurgery Board Review

8. A – Aden osin e

Ade no sine (A) at an in it ial d ose of 6 m g over 1 to 3 secon d s, follow ed by a


repeat of 12 m g in 1 to 2 m in utes as n eeded, is th e in it ial drug of ch oice. If
lidocain e is in e ect ive, procain am id e at a dose of 20 to 30 m g/m in for a m axi-
m u m of 17 m g/kg is given .4,5

9. A – Cerebral m an ifest at ion s frequ en tly occur in th e absen ce of pulm on ar y m an i-


festat ion s (false)

Fat em bolism syn drom e m ay occur after long bon e fract ures or soft t issue
inju r y an d bu rn s. Th e syn drom e is ch aracterized by pulm o nary insu -
ciency (E), n eu rologic sym ptom s, an em ia, an d th rom bocytop en ia. On set of
sym ptom s t yp ically occu rs w ith in th e rst 1–2 days fo llow ing traum a (D).
A pete chial rash (C) in n on depen den t areas is presen t in up to 50% of cases.
Neu rologic involvem en t does n ot develop in th e absen ce of pu lm on ar y ab -
n orm alit ies u n less th ere is th e rare even t of a p arad oxical em bolu s th rough a
paten t foram en ovale (A is false).6,7

10. A – Graft-versu s-h ost disease

Graft-versu s-h ost disease m ay occu r w h en blood don or lym ph ocytes at t ack
the n orm al t issues of th e t ran sfusion recipien t (part icularly in im m un ocom -
p rom ised pat ien t s). Tran sfusion -associated graft-versus-h ost disease m ay re-
su lt if viable lym ph ocytes in blood are n ot irradiated.8

11. A – Bin ding of free ion ized Ca 21

An t icoagulant s such as h eparin , cit rate, an d EDTA bind calcium (A). Ban ked
blood con tain s th e an t icoagulan t cit rate. Massive t ran sfusion s can lead to
acu te hyp ocalcem ia in th e crit ically ill pat ien t .5,6

12. D – Neith er
13. A – Cush ing’s disease
14. A – Cush ing’s disease

Cush ing’s syn drom e is th e con d it ion of over t glucocor t icoid exposure regard-
less of th e et iology. Cushing’s disease (A) is Cu sh ing’s syn d rom e cau sed by
an ACTH-p rod u cing p it u it ar y aden om a. Th e dexam eth ason e su p pression test
is u sed to di eren t iate Cush ing’s syn drom e of various et iologies. Gen erally,
ACTH p rod u ct ion an d cort isol secret ion are n ot su p p resse