Neurology 4 mrcp answers book - part 8 pptx

a-false, the 1
st
division of the trigeminal nerve when involved ,may cause a lost
corneal reflex, neuropathic corneal ulcerations, and visual loss. Remember that
impaired vision may be due to a previously associated zoster ophthalmitis including:
anterior uveitis, chorioditis, optic neuritis.
b-true, loss of corneal sensation.
c-true, with hypo-pigmentation .
d-true, and detected only by carful testing.
e-true, due to many reasons mentioned above.
Q24:
Answer: d
a-true, Aciclovir has been shown to reduce the intensity and duration of the zoster
rash and associated acute pain but NO effect at reducing the incidence of post herpetic
neuralgia. Prednisolone has been shown to reduce the intensity and incidence of the
acute pain but NO effect on post herpetic neuralgia.
b-true, but usually large dosed are needed ( up to 250 mg/ day ). Carbamazepin ,
phenytoin , and gabapentin are less effective.
c-true , or a xylocain-prilocain cream.
d-FALSE, may be very effective by depleting the pain-mediating peptides from the
peripheral nerve endings and sensory neurons, but unfortunately it is rarely tolerated.
e-true, at weekly intervals.
Q25:
Answer: d
a-true, for which no cause can be found.
b-true, and it is not paroxysmal.
c-true, and from intracranial extension of squamous cell carcinoma, or an infection at
the site of a tooth extraction.
d-false, treated by amitryptiline with or without phenelzine.
e-true, when tricyclics are not effective.
Q26:

Answer: d
a-true, at least in onset. It may be bilateral or alternating. Cluster headache is always
(100%) unilateral.
b-true, but not in all cases.
c-true, and photo and phnophobias and lassitude.
d-false, visual or other neurological abnormalities accompanying headache are seen in
up to 10%.
e-true, 75% of patients are women. A family history of migraine is seen in 50% of
cases( unlike cluster headache where a family history of a similar problem is not
seen).
Q27:
Answer: e
a-true, although a consistent mendelian pattern of inheritance has not been found
among the collective group of familial migraineurs.
b-true, and predicts a significant environmental contribution.
c-true, chromosome 19p13( associated with miss-sense mutation in a brain expressed
voltage gated P/Q calcium channel gene ) and 2 neighboring loci on chromosome 1q.
d-true, an possibly with multiple modes of inheritance and variable degrees of
penetrance.
e-false, migraine is considered a multi-genetic and multi-factorial disease.
Q28:
Answer: e
a-true, and the commonest are hemianpoic field defects,

Chapter XI / Neurology
Subchapter E:
Q1:
Answer: e
Apart from sedative drug intoxication, all other items cause confusional state+fever
(not hypothermia ) .Alcohol and sedative drug withdrawal cause fever but intoxication

with them is the cause of low body temperature Other causes of hypothermia with a
confusional state: hypothyroidism, hepatic encephalopathy, hypoglycemia.
Q2:
Answer: e
Bleeding peptic ulcer is the cause of hypotension (not hypertension). Don’t forget
hypertensive encephalopathy and sedative drug withdrawal.
Q3:
Answer: c
Apart from opioid intoxication (which produces pinpoint reactive pupils), all others
can be the cause of her presentation.
Q4:
Answer: b
Hepatic encephalopathy (and prominent hyperglycemia) can be a cause of
hyperventilation not hypoventilation.
Q5:
Answer: e
Wernick's encephalopathy can cause confusional state with ophthalmoplegia and
ataxia (not a hemiparesis state) .Keep in mind that metabolic causes of
encephalopathy (like hypo or hyperglycemia, hepatic, uremic…etc) can cause focal or
multifocal neurological signs that are usually fluctuating or ALTERNATING between
the right and left sides of the body.
Q6:
Answer: e
This question highlights the importance of any associated illnesses.
a-true, and hence EEG should be done which will reveal an ongoing seizure activity
in one of the temporal lobes .
b-true, always think of this possibility. A variety of intracranial hemorrhages might
occur and can precipitate a catastrophic status epilepticus.
c-true. A prolonged post-ictal confusional state is seen in the presence of underlying
metabolic or structural encephalopathy. Hence the recovery might be long giving a

wrong impression of a continued seizure activity (ie status epilepticus).
d-true , either iatrogenic (like adding an enzyme blocking medication like
Clarithromycin for a simple chest infection and enhancing phenytoin toxicity) ,or
might be self poisoning to suicide.
e-False… always take a complete history of any recent or OLD illnesses.
Q7:
Answer: c
a-or a sulphonylurease-induced hypoglycemia
b-or post traumatic epilepsy
c-false. Alcohol intake can cause: acute intoxication (with alcohol or other materials
like methyl alcohol), hypoglycemia, head injury, decompensated hepatic
encephalopathy, Wernick's encephalopathy, post-ictal state. Don't forget alcohol
withdrawal.
d-or may suggest an organic cause like hypothyroidism, Wilson's disease and
decompensated cirrhosis, B12 deficiency or a functional state. Don't forget
neuroleptic malignant syndrome in those taking conventional neuroleptics like
schizophrenic patients.
e-it may cause a variety of CNS and extra-CNS causes of confusional state.
Q8:
Answer: a
a-false, think of AIDS-dementia complex.
b-true, might be a cause of multi-infarct dementia
c-true, like bradycardia in hypothyroidism or atrial fibrillation in multi-infarct
dementia .
d-true, like hypothermia in hypothyroidism
e-true, might be due to brain tumor or subdural hematoma causing a dementing
illness.
Q9:
Answer: c
a-true, an acute confusional state which is mainly seen in non-chronic alcoholics.

b-true, although the severity and clinical features of encephalopathy correlate roughly
with blood ethanol levels. Chronic heavy alcoholics may have a very high blood level
although they don't appear to be intoxicated.
c-false, it is characteristically raised . The plasma osmolality roughly increases by 22
mOsm/L for every 100 mg/ dl of ethanol presents .
d-true. Can be differentiated by presence of ethanol odor, increased plasma osmolality
(in ethanol poisoning it is raised), blood and urinary toxicology.
e-true. Also predisposes to head injury, lung aspiration, seizures. Chronic alcoholism
increases the risk of bacterial meningitis.
Remember that the treatment is supportive only. All alcoholics should receive 100 mg
of thiamin intravenously to prevent Wernick's encephalopathy.
Q10:
Answer: d
Item d is false because confusion, IF PRESENT, is usually mild. Illusions and
hallucinations, usually visual, are seen up to 25% of cases. It usually responds to
diazepam 5-20 mg or chlordiazepoxide 20-25 mg orally every 4 hours.
Q11:
Answer: a
a-false. Usually seen within 48hours; however, in 70% of cases they occur within 7-
24 hours of abstinence.
b-true, and the interval between the first and last seizure is usually 6-12 hours up to
85% of cases . Up 40 % of patients will have ONE seizure only.
c-true. They abate spontaneously; however, diazepam or chlordiazepoxide is given
prophylactically because up to 30% of patients will develop delirium tremens.
d-unusual and atypical features are: focal fits, prolonged duration of the fits ( > 6-12
hours ), more than 6 fits, status epilepticus or a prolonged post-ictal phase. In these
cases, a prompt search for pathology is required.
e-true. Always look for such an association.
Q12:
Answer: c

a-true. It is the most aggressive type with a high mortality rate, usually seen with 3-5
of abstinence and may last up to 72 hours.
b-true. Also tachycardia and sweating.
c-false. The mortality rate is 15% and mostly due to concomitant : infection ,
pancreatitis, cardiovascular collapse, or trauma .
d-true, the total requirement to produce a calm patient may exceed 100 mg/ HOUR.
e-true, like atenolol 50-100 mg/ day.
Q13:
Answer: d
a-true, with respiratory depression , hypotension, reactive pupils and hypothermia.
b-true, a characteristic feature. However, very large doses of phenobarbitone or
glutethimide may result in LARGE FIXED pupils.
c-true, with ataxia, dysarthria and hyporeflexia.
d-false. The mortality rate is low and mostly due to aspiration pneumonia (with or
without systemic sepsis, or due to iatrogenic fluid overload and pulmonary edema
).Despite severe intoxication, a patient who arrives at the hospital with adequate
cardio-pulmonary function and support should survive without any sequelae.
Remember the treatment is mainly supportive while the drug is being eliminated.
e-true, it is mainly used to increase the urinary clearance of Phenobarbital., but in
general should be avoided as it can lead to fluid overload. Hemodialysis may be used
in severe resistant cases of barbiturate poisoning or when drug elimination is impaied
by renal failure.
Q14:
Answer: d
a-true, intermediate or short acting agents are more likely to produce an withdrawal
syndrome when stopped abruptly. The syndrome is seen within 1-3 days (for short
acting agents ) and may take up to 1 week or even more to appear ( for long acting
agents ).
b-true, with confusion, agitation, seizures.
c-true, if positive , the patient should receive long acting phenobarbital orally to

maintain a calm state without signs of intoxication. In most patients it is possible to
stop it gradually after progressive decrement in the daily doses within 2 weeks.
d-false. Seizures especially the myoclonic ones should be treated aggressively with
anticonvulsants.
e-true, mainly seen in those taking very high frequent doses.
Q15:
Answer: d
a-true, as an iatrogenic overdose. Also seen as an accidental overdose in addicts, and
in suicidal attempts.
b-true, and pontine hemorrhage is a differential diagnosis .Although needle tracks and
marks might be seen, they are not diagnostic .
c-true, the test is positive if the pupils dilates and the patient regains his full
consciousness; however, when very large doses of opioids are taken or multiple drug
ingestion is present the pupils may slightly dilate.
d-false, with appropriate treatment , patients should recover uneventfully .
e-true, because nalaxone is a short acting agent.
Q16:
Answer: d
a-true, or with antidepressants and antihistamine overdose.
b-true, also flushing, urinary retention and tachycardia.
c-true, mainly used in antipsychotics or antidepressants overdose.
d-false. Symptoms usually resolve spontaneously.
e-true, although rarely needed . Physostigmine can produce severe bradycardia,
seizures and hypersalivation. Specific treatment is required when there is life
threatening cardiac dysrrythmias.
Q17:
Answer: d
a-true. Their mechanism of action involves a variable combination of inhibiting the
reuptake and or increasing the release of noradrenalin and or dopamine and thus
producing a central stimulant and peripheral sympathomimetic effects.

b-true, and cocaine can produce myocardial infarction.
c-true, either due to sudden severe hypertension, drug induced vasculitis, or rupture of
AVMs.
d-false, should be avoided , especially in cocaine induced myocardial infarctions.
Alpha blockers are useful to attack hypertension.
e-true, and thus attacking the psychotic manifestations of overdose. Because
amphetamines are longer acting than cocaine, amphetamine intoxication is more
likely to require treatment.
Q18:
Answer: c
a-true, and prominent insomnia.
b-true, changes in the mental status are usually the most striking feature. Alterations
in affect and mood may predominate the clinical picture.
c-FALSE, very rare. The presence of a prominent seizure activity should prompt a
search for another pathology or to revise the diagnosis.
d-true, there is prominent sympathetic overactivity.
e-true, and when this fails, treatment with diazepam may be of benefit.
Q19:
Answer: c
a-true, unlike other hallucinogens( eg LSD ).
b-true, also large or small pupils, horizontal and vertical nystagmus, hypertonia,
hyper-reflexia and myoclonus. There may analgesia to a surprising degree.
c-false, phenothiazines reduce seizure threshold and may produce severe hypotension.
Haloperidol can be used safely in such cases. Diazepam can be used for sedation and
treating muscle spasms.
d-true, although in some patients it may take days or even weeks.
e-true, this is especially seen in poisoning with large doses .

Q20:
Answer: e

a-true, whether accidental or intentional .
b-true, thus such patients may be wrongly diagnosed as having a serious CNS illness.
c-true, like renal or hepatic failures.
d-true. Dementia patients are very susceptible.
e-false, one of the prominent causes especially in old people.
Q21:
Answer: d
a-true, and also a "reversible" dementia.
b-true, bilateral ptosis is seen up to 65 % of cases due to low sympathetic tone of
levators.
c-true, also agitation and even frank psychosis is seen.
d-false, the most characteristic neurological finding is a delayed relaxation of tendon
reflexes, typically seen at the ankles.
e-true, and CSF pressure is occasional increased.
Q22:
Answer: e
a-true, so-called " activated crisis ".
b-true, so-called " apathetic crisis ".
c-true, because of the prominent hyper-adrenergic manifestations.
d-true, and exaggerated action tremor and hyper-reflexia are usually seen.
e-false, very rare and when prominent should cast a doubt on the diagnosis.
Q23:
Answer: e
a-true, especially in those with recurrent "hypos", or the presence of associated
autonomic neuropathy, or concomitant treatment with beta blockers.
b-true, flaccid quadriparesis is an advanced feature. Focal , multifocal or generized
seizures and myoclonus may be seen.
c-true, although a prolonged hypoglycemia at levels of 30 mg/ dl or lower invariably
leads to irreversible brain damage.
d-true, with coma, bilateral extensor planters and decorticate or decerebrate posturing.

e-false, somnolence might be seen. Tachycardia is seen with agitated delirium, but
bradycardia is seen with somnolence.
Q24:
Answer: c
a-true, while the degree of systemic acidosis does not.
b-true, focal neurological signs, focal or generalized seizures that are not responsive
to antiepileptics are commonly seen.
c-false, the mortality rate is unfortunately between 40-70% and is largely due to
failure to recognize the condition in elderly patients without prior history of diabetes
or who present who present with stroke or seizures, and to coexistent diseases.
d-true, in contrast to diabetic ketoacidosis.
e-true, impairment in consciousness ranges between very mild and subtle drowsiness
to deep and profound coma.
NB: hypersomolar non-ketotic hyperglycemia is a presenting feature of up to 40% of
cases of type II diabetes mellitus.
Q25:
Answer: d
a-true, and hyponatremia may produce focal signs by unmasking preexisting
structural brain lesions such as infarcts.
b-true, "central pontine myelinolysis syndrome" in which no treatment is available,
thus prevention is very important by avoiding rapid correction of hyponatremia.
c-true, but the tendon reflexes are usually normal .
d-false, they are very rare ( unlike hypocalcemia in which seizures are very common
and might be the only presenting feature).
e-true, the overall clinical picture is due to calcium-induced increase in the
depolarization threshold of nerve and muscle with consequent under-excitability.
Q26:
Answer: e
a-true, thus, hypocalcemic patients demonstrate a positive Chvostek's sign and
Trousseau's sign both of which indicate a hyperexcitability state.

b-true, this is especially seen in children. Hypocalcemic fits can sometimes be very
resistant to anticonvulsants.
c-true, also basal ganglia calcification and Parkinsonian features.
d-true, or induced by Trousseau's sign.
e-false, chorea may be seen. Also, irritability, depression, hallucinations, frank
psychosis all might be seen.
NB: The following 3 questions highlight the importance of knowing what Wernicke's
encephalopathy is. Every few days, the A/E department consults us to see certain
patients with a variety of neurological findings, these patients then prove to have
Wernicke's, although they give thiamine BLINDLY and the patient usually improves,
we noticed that many junior and senior house officers lack much information about
Wernicke's. I tried to cover some useful aspects about this VERY COMMON
neurological disease (we see it almost every day in the A/E department). You should
also know the prognosis if it.
Q27:
Answer: c
a-true, there is also small blood vessel proliferation and small petechial hemorrhages.
The most commonly affected areas are: mammilary bodies, periaqueductal grey
matter, cerebellar vermis, and occulomotor, abducens and vertibular nuclei. How
thiamine deficiency produces these effects is still not clear.
b-true, the commonest ocular manifestations are nystagmus and unilateral or bilateral
lateral rectus weakness or paralysis.
c-FALSE, ataxia primarily affects GAIT, limb ataxia is highly uncommon, as is
dysarthria.
d-true, up to 80%; remember alcoholism can attack many targets ( some are
asymptomatic).
e-true, it is uncommon cause of coma, but a very common cause an acute confusion.
Mental status examination reveals GLOBAL confusion with a prominent impairment
of immediate recall and recent memory.
NB: CSF analysis is usually NORMAL, although mild increase in protein (<90 mg/dl)

might be seen. An increased opening pressure or pleocytosis or low glucose should
prompt a search for other or additional disease.
Q28:
Answer: d
Wernicke's encephalopathy can have many ocular findings which can easily escape
detection. Medicine books usually mention " ophthalmoplegia and nystagnmus", but
there is no further details regarding these findings.
There are 9 ocular findings in general:
1-External rectus weakness or paralysis ( uni- or bilateral ).
2-Nystagmus, horizontal or a combined horizontal and vertical one.
3-Internuclear ophthalmoplegia, a common finding!
4-Conjugate gaze palsy or weakness.
5-Ptopsis.
6-Retinal hemorrhages.
7-Optic neuropathy.
8-Involvement of vestibular focusing mechanisms.
9-Small miotic reactive pupils ( a very rare finding but worthy to mention). Very
subtle anisocoria and sluggish pupillary reaction might be seen. However, the pupils
are usually spared.
Q29:
Answer: e
a-true, a very important thing tot remember.
b-true, together with confusion , should start to improve within 1 week.
c-true, they totally disappear in 40% only, others (60%) will be left with residual gait
ataxia and horizontal nystagmus.
d-true, up to 75 % of cases after recovery from Wernicke's, thus long term follow ups
are important.
e-FALSE, external ophthalmolegia, VERETICAL nystagmus and confusion
SHOULD BE ENTIRELY REVERSIBLE. Failure of these to reverse back to normal
should prompt a search for other or additional disease.

Q30:
Answer: c
a-true, can produce confusion, depression ,aggression, agitation, frank psychosis with
hallucinations.
b-true, but clear cut sensory LEVEL is against the diagnosis. Also, Lhermitte 's sign,
distal paresthesias, gait ataxia, all might be the presenting feature.
c-FALSE, loss of ankle jerk indicates peripheral neuropathy. Remember both might
present together and can cause a combination of exaggerated knee jerks, up going
planters with loss of ankle jerks.
d-true, any other abnormal profile should cast a doubt on the diagnosis.
e-true, vitamin b12 should assessed in the differential diagnosis of any unexplained:
cognitive impairment , myelopahty, and peripheral neurpatrhy, whether anemia is
present or not.
NB: Neurological abnormalities present for more than a year are less likely to correct
with treatment. Encephalopathy may begin to clear within 24 hours after the first
vitamin B12 injection, but full neurological recovery, when it occurs, may take
several months.

Q31:
Answer: e
a-true, that might gradually progress to stupor and coma.
b-true, as in other organ failure, asterixis ( which is actually a negative myoclonus)
indicates impairment of the parietal postural control mechanism.
c-true, and focal or multi-focal neurological signs that might fluctuate in severity and
type might occur.
d-true, it is the most SPECIFIC CSF finding. Also, an elevated opening pressure, mild
pleocytosis, and increased protein all might be seen Xanthochromia is seen when the
total serum bilirubin exceeds 4-6 mg/dl.
d-false, as in any metabolic encephalopathy, the EEG shows diffuse slowing with
triphasic complexes

NB: The prognosis in hepatic encephalopathy is most closely correlated with the
severity of hepatpocellular damage than neurological dysfunction.
Q32:
Answer: d
a-true. CSF acidosis is rare and cerebral edema is NOT a factor.
b-true, adding more confusion to the clinical picture. Motor manifestations are: coarse
tremor, asterixis, myoclonus and tetany. Focal or generalized seizures or focal signs
all are common.
c-true, and this may wrongly suggest an infectious meningitic process.
d-false, as in any severe encephalopathy ,and which may be diagnosed as seizures.
e-true, should always be kept in mind. The treatment should be directed against the
renal failure in its cause. Control of seizures and hypertension is very important.
Q33:
Answer: d
a-true, it may begin during hemodialysis or as long as 24 hours after hemodialysis. It
is a rare complication of maintenance hemodialysis in patients with chronic stable
renal failure.
b-true and a rapid correction of systemic acidosis may also exacerbate CSF acidosis
as CO2 diffuses into the CSF.
c-true, sometimes before any clinical change has occurred and showing paroxysmal
activities with spikes and sharp waves.
d-false, fortunately these severe abnormalities are uncommonly seen.
e-true, and prevention is much more important by correcting uremia more gradually
or using briefer periods of dialysis at reduced rate of blood flow.
Q34:
Answer: d
a-true, the confusional state ranges from mild drowsiness to deep coma.
b-true, unlike other encephalopathies complicating other organ failures.
c-true, hypereflexia is uncommon.
d-false, one of the commonest mistakes in clinical practice. Bicarbonate infusion

increases the production of CO2 which subsequently diffuses into the CSF and
worsens the CSF acidosis leading t paradoxical clinical deterioration while systemic
acidosis is improving.
e-true. Treatment involves intubation and mechanical ventilation.
Q35:
Answer: e
a-true, a very aggressive process.
b-true, and on the surface of the brain.
c-true, and their surface may show ependymal exudate or granular ependymitis
d-true, and thus focal signs like hemiparesis can be seen.
e-false, cranial nerve palsies are in general either due to vasculitis or nerve
compression due to basal fibrosis, both of which are very common.
Q36:
Answer: d
a-true, surprisingly such history is usually absent, thus the diagnosis needs a high
index of suspicion.
b-true, but ALL might be ABSENT.
c-true, and can wrongly be attributed to a mass lesion.
d-false, can be a prominent feature.
e-true, and thus increasing the already increased morbidity.
Q37:
Answer: c
a-true, but may show a clot upon standing due to high protein content.
b-true, this early polymorphonuclear pleocytosis may wrongly suggest a pyogenic
cause.
c-false, it may reach very high levels ,especially in those with spinal subarachnoid
block.
d-true, it was used in the past, but nowadays it has been shown that it is too non-
specific.
e-true, unlike pyogenic meningitis (where the CSF glucose might reach ZERO mg/dl

!).
Q38:
Answer: c
a-true, the inflammatory response is associated with the release of inflammatory
cytokines like IL-1, LL-6 and TNF alpha and thus promoting the permeability of the
blood brain barrier, vasogenic cerebral edema , changes in cerebral blood flow and
perhaps direct neuronal toxicity.
b-true, and more marked in the basal cisterns with N. meningitides.
c-FALSE, actual bacterial invasion of the underlying brain is very rare. The burden of
the pathological process is within the leptomeninges with secondary changes in the
underlying brain.
d- true, and thus many complications can alter the clinical course.
e-true, that is why meningitis is an aggressive disease.
Q39:
Answer: d
a-true, and few may presents as a stroke like pattern within 1 day .
b-true, it is usually absent in neonates and old people and in those with deep coma.
Thus its absence is NOT against the diagnosis.
c-true, and may be easily mistaken for a brain abscess.
d-FALSE, it is seen in 50-60% of cases of N. meningitidis infections.
e-true, but in clinical practice the full syndrome is often NOT present.
Q40:
Answer: b
a-true, leucopenia may indicate and immune suppressed state or an over-whelming
infections and hence portending a very bad prognosis.
b-FALSE, fortunately, it can be isolated in 40-90% of cases ( while CSF culture is
positive in 80% of cases only ! ).
c-true, indicating a wide spread inflammatory process. Granular ependymitis may be
seen.
d-true, and focal changes may indicate the presence of focal cerebritis, brain abscess

or scarring.
e-true, always look for a parameningeal focus of infection and remote sites of
infection like pulmonary abscess.
Q41:
Answer: d
a-true, and the CSF appearance ranges from slightly turbid to grossly purulent.
b-true, predominantly polymorphonuclear. The presence of predominantly
mononuclear pleocytosis is consistent with Listeria infections. CSF white cell count
more than 50000 cells/ ml almost always indicates the presence of a burst brain
abscess as cause.
c-true, and may be immeasurably low ie almost ZERO mg/ dl.
d-FALSE, it is positive in 60-80% of cases. In TB meningitis , acid fast smears are
positive in 20% of cases only.
e-true, a useful tool. CSF culture is positive in 80% of cases only.
Q42:
Answer: d
a-true, and is based upon the patient's age and predisposing factors.
b-true, although it is suggested to be given to children less than 2 months of age and
to adults with positive CSF gram stain and features of raised intracranial pressure.
Steroids has been shown to decrease hearing loss and neurological sequelae in
children with H. influenzae meningitis.
c-true, and the CSF pleocytosis and the proportion of polymorphonuclear cells should
decrease with 3 days.
d-FALSE, 20mg /kg once daily for 4 days. In N. meningitides meningitis it is given as
20mg/kg twice daily for 2 days. You should know these as they are totally different.
e-true, and a vaccine is also available for certain strains of N. meningitides and is
recommended for military recruits, college students and travelers to areas of ongoing
epidemics.
Q43:
Answer: d

a-true, case fatality rate may exceed 25%.
b-true, Waterhouse-Friderichsen syndrome.
c-true, as is a delay at initiating treatment.
d-false, BAD prognosis.
e-true.
Q44:
Answer: a
a-false, it is seen within 2 years of a primary syphilitic infections and affects men
more than women.
b-true, it is usually asymptomatic.
c-true. The cranial nerves most frequently affected in descending order are: facial,
acoustic, oculomotor, trigeminal, abducens and optic, but other cranial nerves may be
involved as well.
d-true.
e-true, even when asymptomatic to prevent the development of more serious CNS
complications.
Q45:
Answer: a
a-false, although CSF VDRL is positive in 50% of cases only, the blood FTA
treponemal tests are almost always positive.
b-true. These are not present in normal CSF.
c-true, and the opening pressure may be normal or slightly elevated.
d-true, although acute syphilitic meningitis is a self limiting illness with littile or no
swquelae, it is should be treated to prevent the future development of tertiary
neurosyphylis.
e-true, and another course of treatment should be given if the CSF cell count or
protein remains elevated.
Q46:
Answer: d
a-true, there is no seasonal variation. The mortality rate ranges between 40-70% and

depends on many factors.
b-true, the age group is higher than that of other causes of viral encephalitides in
general.
c-true, while HSV type II affects neonates when passing through an infected birth
canal. HSV type II in adults usually produces viral meningitis rather than viral
encephalitis.
d-FALSE, characteristically involves the medial temporal and inferior frontal lobes(
unilateral or bilateral affection) .
e-true, intranuclear inclusions may beseen in neurons and glia. Patients who recover
may shoe cystic necrosis of the involved areas.
Q47:
Answer: d
a-true, but does NOT reliably implicate HSV as a cause of encephalitis .
b-true, may cause coma with few days.
c-true, the diagnosis can be easily missed early and may be wrongly diagnosis as an
acute psychosis.
d-false. May be seen
e-true, reflecting the predilection of HSV for LIMBIC structures.
Q48:
Answer: c
a-true, CSF white cell count usually between 50-100 cell/ml.
b-true, it is one of the causes of hemorrhagic CSFs. The glucose is usually NORMAL.
c-FALSE, the virus generally can not be isolated form the CSF but the virus DNA can
be detected in the CSF by PCR in some cases.
d-true, and focal paroxysmal activity in the form of spikes and waves might be seen.
e-true, but usually they show abnormalities in one or both temporal lobes and the
changes may extend to frontal and parietal lobes.
NB; the CSF is totally normal in 2% of cases.
Q49:
Answer: e

a-true, it can complicate many systemic cancers, in descending order: ALL, non-
Hodgkin's lymphoma, malignant melanoma, AML, breast carcinoma , Hodgkin's
lymphoma , lung carcinoma, GIT carcinomas and sarcomas .
b-true, but may be the presenting manifestation or occur after many years of illness (
sometimes in apparently cured patients ).
c-true, with nausea , vomiting , seizures, and gait abnormalities.
d-true, indicating involvement at multiple levels of the neuraxis.
e-false, primary brain tumors may be associated with meningeal gliomatosis , and
medulloblastomas and pineal tumors have a particular propensity for meningeal
dissemination.

Q50:
Answer: b
a-true, and the cytology is positive in 55 % of cases in general.
b-false, large volumes of fluid and repeated CSF samples increase the diagnostic
yield. The detection of malignant cells by cytological examination is the objective.
c-true, beta2 microglobulin, beta glucuronidase and LDH isozyme-V are sensitive
markers.
d-true, should always be kept in mind.
e-true, and pleocytosis is present in 60% of cases .
NB: Untreated , neoplastic meningitis typically results in death within 2 months.
NB: In neoplastic meningitis: ophthalmopleagia(30%),facial weakness(25%),
papileodema (10%),
Q51: