Question 1

A 25-year-old man falls while skateboarding and strikes the left side of his
head against a concrete retaining wall. On physical examination only a minor
scalp abrasion is present at the site of the impact, with minimal bleeding that
stops in 3 minutes. He is initially alert following this accident, but then
became unconscious 30 minutes later. A head CT scan reveals a convex, lensshaped area of hemorrhage centered over the left parietal region. These
events are most likely to be associated with damage to which of the following
parts of the intracranial vasculature?
A Bridging veins
B Cavernous sinus
C Great vein of Galen
D Inferior cerebellar artery
E Middle meningeal artery
F Ophthalmic branch of external carotid artery
Question 2
A 70-year-old man has a 2 day history of worsening generalized headache
and increasing obtundation. He now complains of stiffness in his neck. On
physical examination vital signs include T 38.7C, pulse 85/minute,
respirations 23/minute, and blood pressure 130/85 mm Hg. A CBC reveals a
WBC count of 16,850/microliter. Serum electrolytes include a glucose of 88
mg/dL. A lumbar puncture yields cloudy cerebrospinal fluid with a glucose of
32 mg/dL, protein 146 mg/dL, and cell count of 3800 WBCs (95% PMNs and 5
% mononuclears) and 122 RBCs. He receives antibiotic therapy and improves.
Which of the following long-term complications is most likely to develop from
this man's current disease?
A Cerebral infarction
B Cerebellar tonsillar herniation
C Encephalitis
D Hydrocephalus
E Subdural hematoma
Question 3
A 6-year-old girl develops visual loss within 3 days of consuming a clear liquid

she found in a bottle in her family's garage. On physical examination she has
intact motor and sensory function, except for blindness. Poisoning with which
of the following substances has most likely occurred?
A Mercury
B Methanol
C Lead
D Iron
E Arsenic
F Organophosphate
Question 4
A 73-year-old man is undergoing radical prostatectomy for prostatic
adenocarcinoma. During this procedure the anesthesiologist reports a drop in
blood pressure with hypotension that persists for 30 minutes despite
intervention with pressor agents. Which of the following pathologic lesions is
most likely to occur in his brain as a consequence of this prolonged
hypotensive episode?
A Hydranencephaly
B Linear parasagittal infarction
C Lacunar infarcts of basal ganglia
D Parietal lobe hemorrhagic infarction
E Anterior pituitary necrosis
Question 5
A 28-year-old man undergoes induction chemotherapy for acute myelogenous
leukemia. A week later he becomes severely pancytopenic, with WBC count
of 1320/microliter, Hgb 7.9 g/dL, and platelet count 72,000/microliter. Head
CT scan shows a right parietal hemorrhage. MR imaging and angiography
reveals a right middle cerebral arterial thrombosis with right parietal
hemorrhagic infarction. Which of the following infectious agents is most likely
to cause these findings?
A Herpes simplex virus
B Toxoplasma gondii
C Human immunodeficiency virus

D Cytomegalovirus
E Aspergillus flavus
Question 6
A 27-year-old G2 P1 woman gives birth following an uncomplicated
pregnancy at 29 weeks gestation to a girl infant. Her prior pregnancy resulted
in a normal term birth. She continued to smoke 1 pack of cigarettes per day
during the current pregnancy. Following the delivery, the baby receives
surfactant therapy and does not develop respiratory distress from hyaline
membrane disease. However, the infant has a seizure during the next day of
life. Which of the following conditions did this baby most likely develop?
A Intraventricular hemorrhage
B Intracerebellar hemorrhage
C Subdural hematoma
D Subgaleal hemorrhage
E Epidural hematoma
Question 7
Following an episode of severe head trauma incurred in a motorcycle
accident, an 18-year-old woman is noted to have decerebrate posturing.
Funduscopic examination reveals marked bilateral papilledema. A CT scan of
the head reveals marked diffuse cerebral edema from an increase in sodium
and water content. There is effacement of lateral ventricles. This edema is
most likely to be severest in which of the following parts of the brain?
A Gray matter
B Meninges
C White matter
D Dura
E Ependyma
Question 8
A 32-year-old woman has noted problems with writing for the past month.
She has difficulty controlling her hand movements, and the writing is nearly
illegible. On examination she has decreased strength in her right upper
extremity and decreased light touch sensation over her left lower extremity.
She has no decrease in mentation, and there is no reported seizure activity. A
lumbar puncture is performed, and the CSF contains elevated levels of IgG,

some mononuclear cells, and oligoclonal bands on gel electrophoresis. Which

of the following pathologic findings in the CNS is she most likely to have?
A Loss of pigmented neurons in the substantia nigra
B Perivascular lymphocytes with demyelinated axons in white matter
C Increased neurofibrillary tangles and neuritic plaques in the neocortex
D Periventricular lymphoid aggregates with cells marking with CD19
E Foci of multinucleated cells and macrophages in grey and white matter
F Gliosis with atrophy of caudate and putamen

Question 9
A 23-year-old primigravida has noted minimal fetal movement. A fetal
ultrasound is performed at 17 weeks gestation and shows an intact fetal
cranial vault, mild ventriculomegaly, intact cerebral hemispheres, a "lemon
sign" (due to flattened frontal bones), a "banana sign" (due to effacement of
the cisterna magna), a normal foramen magnum, and head measurements
that are small for gestational age. The maternal serum alpha-fetoprotein is
increased. Which of the following fetal congenital abnormalities is most likely
to be present in this case?
A Meningocele
B Encephalocele
C Arnold-Chiari II malformation
D Lissencephaly
E Alobar holoprosencephaly

Question 10
A 26-year-old G3 P2 woman has had an uncomplicated pregnancy. A
screening ultrasound is performed at 16 weeks gestation, and the findings
prompt performance of maternal serum alpha-fetoprotein test, which is
elevated. Which of the following abnormalities of the CNS is most likely to be
present in this fetus?
A Holoprosencephaly
B Metachromatic leukodystrophy

C Encephalocele
D Germinal matrix hemorrhage
E Spina bifida occulta

Question 11
A 22-year-old primigravida has noted no fetal movement at 18 weeks
gestation. Fetal ultrasound examination shows marked hydrops fetalis and
organomegaly. There is extensive cerebral necrosis and periventricular
calcification. Infection with which of the following organisms is most likely to
produce these findings?
A Cytomegalovirus
B Herpes simplex virus
C Human immunodeficiency virus
D Epstein-Barr virus
E Rubeola

Question 12
A 50-year-old African-American man has had headaches for the past month.
On physical examination his blood pressure is 182/108 mm Hg. He cannot
afford to take any medications. He is admitted to the hospital after suddenly
losing consciousness 2 months later. When he is aroused, he cannot speak
and he cannot move his right leg. Which of the following intracranial
pathologic abnormalities is most likely to be present?
A Middle cerebral artery embolus
B Subfrontal meningioma
C Cerebral venous thrombosis
D Central pontine myelinolysis
E Basal ganglia hemorrhage

Question 13
A 54-year-old woman has 30 year history of alcohol abuse. She has

developed more severe and constant motor problems over the past 5 years.
Which of the following neurologic findings is she most likely to exhibit?
A Choreiform movements
B Lateral gaze nystagmus
C Gait ataxia
D Tremor at rest
E Hemiparesis

Question 14
A previously healthy 31-year-old woman experiences a sudden severe
headache and loses consciousness within an hour. An emergent head CT scan
reveals extensive subarachnoid hemorrhage at the base of the brain. She is
afebrile. A lumbar puncture yields cerebrospinal fluid with many red blood
cells, but no white blood cells. The CSF protein is slightly increased, but the
glucose is normal. Which of the following is the most likely diagnosis?
A Acute bacterial meningitis
B Ruptured berry aneurysm
C Progressive multifocal leukoencephalopathy
D Hypertensive hemorrhage
E Amyloid arteriopathy
Question 15
Several members of a large family are affected by the onset of decreasing
mental function and motor coordination when they reach middle age. Their
extremity movements are marked by choreoathetosis. Genetic testing reveals
increased trinucleotide CAG repeats. Which of the following intracranial
structures is most likely to appear grossly abnormal with radiologic imaging
of these affected persons?
A Caudate nucleus
B Midbrain
C Temporal lobe
D Locus ceruleus

E Spinal cord

Question 16
A 23-year-old man suffers a deep laceration to the forearm. On physical
examination there is loss of sensation over the lateral palm, including the
thumb and first two fingers of his left hand. Which of the following pathologic
changes will most likely result distally in the forearm structure that was
injured to produce his physical finding?
A Wallerian degeneration
B Fibrinoid necrosis
C Coagulative necrosis
D Segmental demyelination
E Chronic inflammation

Question 17
A 50-year-old man has been imbibing martinis for 3 hours while at the
blackjack table. He wanders off, and 5 minutes later is found down.
Paramedics arrive, and discover a bruise on his posterior occiput, but no
other signs of trauma. He is transported to the hospital in stable condition,
with vital signs showing temperature 36.9C., pulse 81/minute, respirations
20/minute, and blood pressure 115/80 mm Hg. On arrival, his blood ethanol is
330 mg/dL. He becomes progressively obtunded. His right pupil is 8 mm and
the left 4 mm. A head CT scan reveals a collection of blood in the right
subdural region. Damage to which of the following intracranial vascular
structures has most likely resulted in these findings?
A Middle meningeal artery
B Cavernous sinus
C Middle cerebral artery
D Dural bridging vein
E Great vein of Galen

Question 18
An 11-month-old infant was born at term with no apparent anomalies. The

infant has exhibited irritability, vomiting, and loss of appetite for the past 2
months. On physical examination there is macrocephaly with impaired
extraocular movements, hypertonia of the lower extremities, and generalized
hyperreflexia. A head CT scan reveals bilateral symmetrical ventriculomegaly.
Which of the following pathologic abnormalities is most likely to produce
these findings?
A Haemophilus influenzae meningitis
B Forking of the cerebral aqueduct
C Epidural hematoma
D Ruptured berry aneurysm
E Metachromatic leukodystrophy

Question 19
A 48-year-old woman has the sudden onset of a severe headache. On
physical examination there are no localizing neurologic signs, but she is
minimally responsive. A cerebral angiogram demonstrates marked narrowing
of cerebral artery branches near the base of the brain, consistent with
vasospasm, but no intraparenchymal hemorrhage is present. Laboratory
studies show a serum urea nitrogen of 50 mg/dL. An ultrasound scan of the
abdomen shows bilaterally enlarged cystic kidneys. Which of the following is
the most likely pathologic finding in this woman?
A Acute meningitis
B Severe atherosclerosis
C Arteriolosclerosis
D Cerebral edema
E Subarachnoid hemorrhage

Question 20
A 39-year-old woman with cough and fever for 10 days has had a worsening
headache for the past week, along with increasing obtundation. On physical
examination her temperature is 38.2C. A head CT scan reveals a solitary 3
cm diameter mass lesion with ring enhancement located in the right parietal
lobe. A stereotactic biopsy is performed and a frozen section shows
granulation tissue with adjacent collagenization, gliosis, and edema. Which of
the following is the most likely diagnosis?

A Bacterial abscess
B Aspergillosis
C Oligodendroglioma
D Toxoplasmosis
E Thromboembolic infarct

Question 21
A 66-year-old man is finding that he has more difficulty getting up and
moving about for the past year. He is annoyed by a tremor in his hands, but
the tremor goes away when he performs routine tasks using his hands. His
friends remark that he seems more sullen and doesn't smile at them, but only
stares with a fixed expression on his face. He has not suffered any loss of
mental ability. Which of the following conditions is he most likely to have?
A Amyotrophic lateral sclerosis (ALS)
B Huntington disease
C Parkinson disease
D Niemann-Pick disease
E Tuberous sclerosis

Question 22
A 52-year-old man has had headaches and difficulty concentrating for the
past 2 months. He then begins to exhibit odd behavior, including shooting his
rifle in his back yard, which the neighbors find disconcerting. He then suffers
a grand mal seizure, and is admitted to the hospital. MR imaging of the brain
reveals a large mass with extensive necrosis in the left cerebral hemisphere
extending across corpus callosum into the right hemisphere. Which of the
following neoplasms is he most likely to have?
A Meningioma
B Glioblastoma
C Medulloblastoma
D Metastatic adenocarcinoma
E Pilocytic astrocytoma

Question 23
A 27-year-old man comes to his physician because of recurrent headaches,
averaging one episode per week for the past year. He describes a slowly
building, dull, aching, band-like pain accompanied by tight neck muscles. The
pain lasts for 4 to 10 hours. Exertion does not worsen the headache. On
physical examination there are no abnormal findings. Which of the following
types of headache is he most likely to have?
A Brain tumor
B Cluster
C Migraine
D Temporomandibular joint dysfunction
E Tension-type

Question 24
A 30-year-old G2 P1 woman delivers a stillborn male infant at 28 weeks
gestation. Her previous pregnancy resulted in a normal term birth. At
autopsy, the cerebrum of the fetus demonstrates extensive diffuse
periventricular areas of necrosis with dystrophic calcifications. Infection in
utero with which of the following organisms is most likely to have caused
these findings?
A Taenia solium
B Toxoplasma gondii
C Poliovirus
D Candida albicans
E Treponema pallidum
F Group B Streptococcus

Question 25
A 74-year-old man has exhibited memory problems for the past 7 months,
and he is noted by his immediate family to confabulate. He dies as a
consequence of a hepatocellular carcinoma. At autopsy, his brain
demonstrates bilaterally small mamillary bodies that show brown

discoloration. Microscopically, there is gliosis and vascular proliferation and

hemosiderin deposition in the mamillary bodies and periaqueductal gray
matter. Which of the following is the most likely diagnosis?
A Multiple sclerosis
B Parkinson disease
C Amyotrophic lateral sclerosis
D Wernicke-Korsakoff syndrome
E Huntington disease

Question 26
A 50-year-old man was involved in a vehicular accident in which he was not
wearing any restraint device and struck his head against the windshield of his
van. He did not lose consciousness at that time or at any point thereafter.
Physical examination showed a minor contusion to his forehead. However, a
month later he begins complaining of headaches, becoming irritable and
acting strangely. Which of the following intracranial vascular abnormalities
most likely developed in this man?
A Epidural hematoma
B Subdural hematoma
C Cerebral contusions
D Subarachnoid hemorrhage
E Intracerebral hematoma
Question 27
A previously healthy 42-year-old former major league baseball player
develops progressive, symmetric muscular weakness of his upper extremities
along with fasciculations over the course of 3 years. Then he develops
difficulty speaking and swallowing. He does not have myalgias or arthralgias.
He remains afebrile. His mental function has not become diminished. Which
of the following is his most likely diagnosis?
A Amyotrophic lateral sclerosis
B von Recklinghausen disease
C Multiple sclerosis

D Werdnig-Hoffman disease
E Guillain-Barr syndrome
Question 28
A 20-year-old man has recently been inducted into the army. Four weeks into
basic training, he experiences a severe headache for an entire day. He had
been healthy prior to this, noting only a mild sore throat the prior day. His
vital signs are: T 39.2C, P 90/minute, RR 24/minute, and BP 110/70 mm Hg.
A lumbar puncture is performed and examination of the cerebrospinal fluid
shows 2 RBC's/microliter, 4,000 WBC's/microliter, glucose of 20 mg/dL (serum
75 mg/dL), and CSF protein of 105 mg/dL. Which of the following additional
laboratory tests on the CSF would be the most helpful for diagnosis in this
man?
A Cryptococcal antigen assay
B Acid fast stain
C India ink preparation
D Herpes simplex virus serology
E Gram stain
F VDRL

Question 29
A 14-year-old boy is brought to the emergency room following an accident in
which he hit his head against a concrete wall. He was initially unconscious
but then "came to" 5 minutes later. However, an hour later in the emergency
room, he is comatose, and skull radiograph reveals a linear skull fracture of
the temporal-parietal region on the left. Which of the following is the most
likely develop in this boy?
A Subdural hematoma
B Epidural hematoma
C Ruptured berry aneurysm
D Cerebral edema with herniation
E Contusion of frontal lobes
F Sagittal sinus thrombosis

Question 30
A 45-year-old man has had a severe, intractable headache for a week.
Physical examination reveals papilledema on the right. A head CT scan shows
marked right to left midline shift. MR imaging shows a 6 cm enhancing mass
lesion in the right parietal region with marked surrounding edema. He then
develops a dilated pupil on the right. Which of the following vascular lesions
is he most likely to have?
A Superior sagittal sinus thrombosis
B Right cerebellar hemispheric hemorrhage
C Pontine hemorrhages
D Thrombosis of the posterior cerebral artery
E Diffuse subarachnoid hemorrhage

Question 31
A 43-year-old woman develops progressive, ascending motor weakness over
the past 4 days. She is afebrile. She is hospitalized and requires intubation
with mechanical ventilation. A lumbar puncture is performed and normal
opening pressure is noted. The CSF is clear and colorless with glucose of 65
mg/dL (serum 100 mg/dL), protein 95 mg/dL, and cell count 5/microliter, all
lymphocytes. She gradually recovers over the next month. Which of the
following conditions most likely preceded the onset of her neurologic disease?
A Ketoacidosis
B Viral pneumonia
C Drug allergy
D Systemic lupus erythematosus
E Vitamin B12 deficiency

Question 32
A 50-year-old woman suddenly loses consciousness. On examination in the
emergency department, her temperature is 37C, pulse 79/minute,
respirations 18/minute, and blood pressure 160/95 mm Hg. A head CT scan
shows a 4 cm area of bright attenuation in the left basal ganglia region. There
is effacement of the lateral ventricles and a shift of the midline to the right.
Through which of the following mechanisms is death in the patient most likely

to occur?
A Cerebellar tonsillar herniation
B Intraventricular hemorrhage
C Widespread metastases
D Dissemination of infection
E Extensive watershed infarction
Question 33
The mother of a 5-year-old girl realizes that her child has spent all of
Saturday in bed. The girl is listless and not arousable. At the emergency
department the examining nurse practitioner notes a temperature of 38.8C
and nuchal rigidity. A lumbar puncture yields slightly cloudy CSF with a
protein of 61 mg/dL and glucose 19 mg/dL (serum glucose 83 mg/dL). A
culture of CSF is most likely to yield which of the following organisms?
A Streptococcus pneumoniae
B Cryptococcus neoformans
C Aspergillus fumigatus
D Mycobacterium tuberculosis
E Cytomegalovirus

Question 34
A 46-year-old woman is bothered by tinnitus in her left ear that has
progressed over 5 weeks to unilateral hearing loss. On physical examination
she has a marked decrease in hearing on the left, with Rinne test indicating
air conduction better than bone conduction. The other cranial nerves I - VII
and IX - XII are intact. Brain MR imaging reveals a solitary, circumscribed 3
cm mass located in the region of the left cerebellopontine angle. Which of the
following statements is most appropriate to tell the patient and her family
regarding the course of her disease?
A Survival more than a year is unlikely
B Remissions and exacerbations will occur in coming years
C Other family members should undergo brain MR imaging
D Resection without recurrence is likely

E HIV-1 infection must be treated

Question 35
A 66-year-old man has had general paresis with increasing loss of higher
mental functions for the past 3 years. On physical examination he walks with
a widened gait, and he has a positive Romberg test. Laboratory studies show
that a VDRL is positive on cerebrospinal fluid obtained by lumbar puncture.
The CSF protein and glucose are normal, and there is 1 mononuclear cell
present. Which of the following pathologic findings is most likely to be
present in his spinal cord?
A Anterior horn cell loss
B Hemorrhage
C Plaques of demyelination
D Vacuolar myelopathy
E Dorsal column atrophy
Question 36
A 53-year-old woman has had transient ischemic attacks (TIAs) for 3 years.
She then has the sudden onset of a left hemiparesis. Four months later, brain
MR imaging shows a 4 cm diameter cystic area in the right frontal-parietal
region. Which of the following underlying conditions is she most likely to
have?
A Coronary atherosclerosis
B Chronic meningitis
C Alzheimer disease
D Anaplastic astrocytoma
E Cerebral arterial vasculitis

Question 37
A 50-year-old man has a history of falling multiple times over the past 4
years. Today he fell and on examination is noted to have a 2 cm contusion on
the scalp at his occiput. Funduscopic examination shows no papilledema. His
blood ethanol is 0.29 gm% (290 mg/dL). In which of the following intracranial
locations are hemorrhages most likely to be found in this man?

A Putamen
B Gyrus rectus
C Pons
D Thalamus
E Lateral ventricle
Question 38
A 54-year-old woman has noted changes in sensation in her legs for the past
5 months. On physical examination she has a distal, symmetric, primarily
sensory polyneuropathy. She also has a non-healing ulceration on the ball of
her left foot. She had a myocardial infarction last year but recovered and is
doing well following angioplasty. Which of the following laboratory test
findings would you most likely expect to be present in this woman?
A CSF protein of 110 mg/dL
B Positive herpes simplex virus serology
C Blood lead of 50 micrograms/dL
D Plasma cobalamin of 5 pg/mL
E Serum glucose of 195 mg/dL
Question 39
A 17-year-old primigravida has a screening fetal ultrasound performed at 19
weeks gestation. Major fetal internal thoracic and abdominal organs are
identified, with no major abnormalities. However, one abnormality is
detected, but it is considered to have minimal significance for the fetus.
Laboratory studies show that the maternal serum alpha-fetoprotein is not
elevated. Which of the following neural tube defects is most likely to be
present in this fetus?
A Meningocele
B Anencephaly
C Spina bifida occulta
D Meningomyelocele
E Encephalocele

Question 40
A 50-year-old man is noted by his wife to have undergone personality
changes over the last year. In the past, he was noted to be obsessivecompulsive, but he became slovenly and now does not appear to take an
interest in his work. He has become more forgetful. On physical examination
he has frontal release signs and memory loss. He appears unconcerned about
his illness. MR imaging of the brain is performed and shows a 3 cm diameter
left frontal lobe mass with areas of calcification. Which of the following
diagnoses is most likely to be made on microscopic examination of this mass?
A Vascular malformation
B Oligodendroglioma
C Meningioma
D Schwannoma
E Organizing abscess
F Remote infarct
Question 41
A 53-year-old woman has experienced recurring headaches for the past 16
years. These headaches always occur on the right, have a pulsatile quality,
and are accompanied by nausea, photophobia, tingling in her left arm, and
dizziness. The headache increases in intensity over 6 hours and remains for a
day, unless she is able to fall asleep. On physical examination there are no
abnormal findings. Which of the following drugs is most likely to be useful in
treating her headaches?
A Acetylsalicylic acid
B Carbamazepine
C Oxazepam
D Oxycodone
E Phenytoin
F Sumatriptan
Question 42
A 10-month-old infant is failing to reach developmental milestones. On
physical examination there is a prominent 2 cm lumbar meningomyelocele.
MR imaging of the brain shows downward extension of the cerebellar vermis

and displacement of the medulla from a small posterior fossa into the
foramen magnum. There is tenting of the tectum of the midbrain. The
cerebral ventricles are enlarged. The spinal cord has hydromyelia. Which of
the following is the most likely diagnosis?
A Dandy-Walker malformation
B Viral meningoencephalitis
C Arnold-Chiari malformation
D Maternal folate deficiency
E Werdnig-Hoffman disease
Question 43
A 46-year-old woman has experienced severe headaches, worsening over the
past 2 months. She has noted difficulty moving her left arm during the past
day. On physical examination papilledema is present, worse on the right. A
lumbar puncture is performed, and the CSF reveals a protein of 190 mg/dL,
glucose of 68 mg/dL (serum glucose is 100 mg/dL), and a cell count of 5
WBCs/microliter (4 mononuclears and 1 PMN) and 6 RBCs/microliter. Through
which of the following mechanisms are these findings most likely to be
produced?
A Blockage of lymphatics by metastatic tumor
B Overproduction of cerebrospinal fluid
C Storage disease with neuronal cell loss
D Hyperosmolar coma with diabetes mellitus
E Edema adjacent to a primary neoplasm
Question 44
A 22-year-old man has recently emigrated from Mexico City. He has the
sudden onset of a seizure disorder while working as a chef in a restaurant. On
physical examination he is afebrile. No papilledema is noted. MR imaging of
his brain reveals a 2 cm rounded cyst in the right temporal lobe cortex and
another 1.5 cm cyst in the subarachnoid space over the left parietal lobe.
Both lesions are non-enhancing. A lumbar puncture yields colorless CSF under
normal pressure. The CSF protein and glucose are normal, and there are 5
WBCs/microliter (4 monos, 1 PMN). Which of the following conditions most
likely to cause these findings?
A Metastatic adenocarcinoma

B HIV encephalopathy
C Left atrial mural thrombosis
D Cysticercosis
E Hypertension

Question 45
A 32-year-old man has noted episodic headaches for the past 6 years. The
headaches occur over a month, and then do not recur from another 2 or 3
months. The headaches begin with periorbital pain on the left that increases
in intensity for 5 minutes, then persists for an hour before diminishing. The
pain is accompanied by lacrimation, drooping of the right eyelid, nasal
congestion, and nausea. Which of the following forms of headache is he most
likely to have?
A Brain tumor
B Cluster
C Migraine
D Temporal arteritis
E Tension
Question 46
A 61-year-old man has had a chronic cough for 6 years as a result of smoking
2 packs of cigarettes per day for 45 years. He has noted the onset of
headaches over the past 2 weeks. On neurologic exam there are no localizing
signs. MR imaging of his brain reveals a solitary 3.5 cm lesion that is located
at the grey-white junction in the posterior left frontal lobe. There is no ring
enhancement. A stereotactic biopsy of this lesion is performed. Which of the
following microscopic appearances is most likely to be present in this biopsy?
A Organizing abscess
B Viral inclusions
C Plaque of demyelination
D Neuronal loss with gliosis
E Metastatic carcinoma

Question 47
A 48-year-old woman has had headaches for the past 4 months. On
examination she is afebrile. The only neurologic deficit is loss of cranial nerve
I function on the right. A head CT scan shows a 6 cm circumscribed solid
mass in the right anterior fossa. What is the most likely cell of origin for this
mass?
A Microglial cell
B Neuron
C Neuroblast
D Meningothelial cell
E Breast ductal epithelial cell

Question 48
A 9-year-old boy has had the new onset of headaches for the past 4 months.
The headaches are associated with dull pain and seem diffuse, but they are
becoming more frequent and prolonged. On physical examination he has no
focal neurologic deficits. MR imaging reveals enlargement of the lateral
ventricles. There is a 4 cm homogenous, well-circumscribed mass within the
fourth ventricle. Which of the following is the most likely diagnosis?
A Astrocytoma
B Choroid plexus papilloma
C Ependymoma
D Meningioma
E Metastatic bronchogenic carcinoma
F Schwannoma
Question 49
A 36-year-old woman has noted increasing numbers of disfiguring nodular
masses involving the skin of her trunk and extremities. She has experienced
frequent headaches over the past month. On physical examination these 0.5
to 2 cm subcutaneous masses are firm and non-tender. MR imaging of the
brain shows an ill-defined 4 cm mass of the right parietal lobe. An abdominal
CT scan shows a 3 cm mass involving the left adrenal gland. Laboratory
studies show increased urinary free catecholamines. No other family
members are affected by these problems. A mutation involving which of the
following genes is most likely to be present in this woman?

A APC
B CFTR
C K-RAS
D NF-1
E N-MYC
F TP53
G RB

Question 50
A A 70-year-old man has had increasing difficulty with movement, starting
with his feet and ascending to involve legs, trunk, and now arms, over the
past 10 days. On physical examination there are variable sensory changes
noted. He is afebrile. He does not lose consciousness and remains mentally
alert. He becomes ventilator dependent a week after the onset of this illness.
A lumbar puncture is performed and the CSF demonstrates a protein of 86
mg/dL, glucose 63 mg/dL (serum 89 mg/dL), and only 3 mononuclear
cells/microliter. He gradually recovers over the ensuing 4 weeks. Which of the
following conditions most likely preceded the onset of this man's illness?
A Exposure to a toxin
B Recent viral infection
C Severe hypotension
D Bacterial septicemia
E Radiation therapy

Question 51
A 33-year-old HIV-positive woman has had increasing inability to think clearly,
with forgetfulness, over the past 3 weeks. She now has trouble doing
everyday tasks. She has no history of seizures, headaches, nausea, vomiting,
fever, chills or diarrhea. On examination she is oriented to time, place and
date. She is indifferent to her surroundings. She is unable to perform
calculations and has difficulty in word finding. MR imaging of her brain shows
an irregular ring-enhancing lesion involving left frontal lobe white matter. Her
CD4 count is 90/microliter. Which of the following is the most likely diagnosis?

A Infarction
B Toxoplasmosis
C Contusion
D Astrocytoma
E Cysticercosis
Question 52
A 28-year-old man swerves to avoid an oncoming vehicle while riding his
motorcycle. He falls and rolls along the pavement for 100 m. On physical
examination his vital signs include temperature 37C, pulse 78/minute,
respirations 20/minute, and blood pressure 120/80 mm Hg. He has multiple
contusions and abrasions involving the skin of his torso and extremities, but
none on his head because he was wearing a helmet. He is unconscious. There
is no decerebrate posturing. A head CT scan shows no intracranial
hemorrhage or edema and no skull fractures. He remains in a persistent
vegetative state. Which of the following pathologic findings is most likely to
be present?
A Central pontine myelinolysis
B Cerebral venous sinus thrombosis
C Demyelination
D Diffuse axonal injury
E Meningoencephalitis
F Neuronal degeneration
Question 53
A 58-year-old man has an episode of hemoptysis. Over the next week, he
becomes progressively obtunded. He has a blood pressure of 110/70 mm Hg,
pulse 90/minute, respirations 25/minute, and temperature 36.8C. A chest xray shows a right hilar lung mass. Serum chemistries reveal a sodium of 108
mmol/L, potassium 3.9 mmol/L, chloride 85 mmol/L, and CO2 19 mmol/L. He
is given intravenous saline, and the serum sodium is 135 mmol/L two days
later. He then becomes comatose. Which of the following lesions is most likely
to be found in his brain?
A Metastases to the cerebral hemispheres
B Central pontine myelinolysis

C Multiple watershed infarctions

D Hemorrhages in the basal ganglia
E Periventricular plaques of demyelination
Question 54
A 68-year-old man has experienced periodic headaches for the past 3 years
since retiring from his job. He feels the pain over his temple on the right. On
physical examination there is tenderness on palpation over his face anterior
to his right ear. During the examination he is noted to be grinding his teeth in
response to questions. Which of the following conditions is he most likely to
have?
A Faulty dentures
B Meningioma
C Migraine
D Temporal arteritis
E Trigeminal neuralgia
Question 55
An 18-month old girl exhibits poor psychomotor development since birth,
along with seizures. On examination her muscle strength and tone are poor.
Brain MR imaging shows multifocal abnormalities with loss of tissue in
periventricular regions of midbrain, pons, thalamus, and hypothalamus.
Laboratory studies show plasma lactate of 4.2 mmol/L. Which of the following
is the most likely diagnosis?
A Leigh disease
B Cytomegalovirus infection
C Wernicke disease
D Herpes simplex encephalitis
E Metachromatic leukodystrophy