NBME Clinical Neurology 2 — Questions and Answers
Question 1: A 68-year-old man develops sudden right-sided weakness and aphasia. CT head is negative for hemorrhage. Which artery territory is most likely affected?
- Posterior cerebral artery
- Left middle cerebral artery (Correct answer)
- Right middle cerebral artery
- Anterior communicating artery
Correct answer: Left middle cerebral artery
Left MCA territory ischemia classically presents with contralateral (right) hemiplegia plus aphasia when the dominant hemisphere is involved.
Question 2: A 24-year-old woman has stereotyped episodes of lip smacking, hand automatisms, and postictal confusion lasting ~2 minutes. EEG shows left temporal spikes. What seizure type is this?
- Absence seizure
- Focal aware seizure
- Focal impaired awareness seizure (Correct answer)
- Generalized tonic-clonic seizure
Correct answer: Focal impaired awareness seizure
Automatisms with impaired awareness and postictal confusion from a temporal focus define focal impaired awareness (complex partial) seizures.
Question 3: A 72-year-old man with Parkinson's disease on levodopa develops end-of-dose wearing off. What pharmacologic strategy best addresses this?
- Add an anticholinergic agent
- Switch to immediate-release levodopa only
- Add a COMT inhibitor (Correct answer)
- Initiate amantadine
Correct answer: Add a COMT inhibitor
COMT inhibitors (entacapone, tolcapone) extend levodopa half-life by blocking peripheral dopamine metabolism, reducing wearing-off fluctuations.
Question 4: A 34-year-old woman presents with ptosis and diplopia that worsen throughout the day. Ice pack test is positive. Which antibody is most likely elevated?
- Anti-voltage-gated calcium channel (VGCC)
- Anti-acetylcholine receptor (AChR) (Correct answer)
- Anti-Jo-1
- Anti-MOG
Correct answer: Anti-acetylcholine receptor (AChR)
Fatigable ptosis and diplopia with a positive ice pack test are classic for myasthenia gravis, caused by anti-AChR antibodies in ~85% of generalized cases.
Question 5: A 38-year-old man presents with progressive chorea, personality changes, and cognitive decline. His father died of a similar illness at 45. CAG repeat expansion is confirmed. What is the inheritance pattern?
- X-linked recessive
- Autosomal recessive
- Autosomal dominant with anticipation (Correct answer)
- Mitochondrial
Correct answer: Autosomal dominant with anticipation
Huntington's disease is autosomal dominant with CAG trinucleotide repeat expansion in HTT; anticipation occurs with paternal transmission.
Question 6: A 55-year-old woman with chronic subdural hematoma is found to have midline shift on CT. She is increasingly drowsy. What is the most appropriate acute intervention?
- IV mannitol alone
- Oral dexamethasone and observation
- Urgent surgical evacuation (Correct answer)
- Lumbar puncture to reduce ICP
Correct answer: Urgent surgical evacuation
Symptomatic chronic subdural hematoma with midline shift and deteriorating consciousness requires urgent surgical drainage (burr hole or craniotomy).
Question 7: A 19-year-old has brief myoclonic jerks on awakening and a generalized tonic-clonic seizure while sleep-deprived. EEG shows 4-6 Hz generalized spike-and-wave. What syndrome is most likely?
- Lennox-Gastaut syndrome
- Childhood absence epilepsy
- Juvenile myoclonic epilepsy (Correct answer)
- West syndrome
Correct answer: Juvenile myoclonic epilepsy
Juvenile myoclonic epilepsy presents in adolescents with morning myoclonus, GTC seizures triggered by sleep deprivation, and 4-6 Hz generalized spike-wave on EEG.
NBME Clinical Neurology 2
A 68-year-old man develops sudden right-sided weakness and aphasia.
CT head is negative for hemorrhage.
Which artery territory is most likely affected?