Neurology (Stroke, Epilepsy, Parkinson's, MS, MG, GBS, Meningitis) MCQs

Medicine · 191 free questions with answers & explanations.

1. A 70-year-old hypertensive man presents with sudden-onset right hemiplegia and aphasia lasting 3 hours, which then completely resolved. CT head is normal. MRI DWI shows no infarct. What is the most likely diagnosis and the single most important risk-reduction intervention?
2. A 45-year-old woman with relapsing-remitting multiple sclerosis presents with bilateral ascending weakness, areflexia, and albuminocytologic dissociation on CSF analysis (protein 120 mg/dL, cells 3/μL) 2 weeks after a respiratory infection. Nerve conduction studies show prolonged distal latencies and slowed conduction velocities. What is the most appropriate treatment?
3. A 30-year-old woman presents with bilateral ptosis and diplopia that worsen in the evening and with sustained use, and improve with rest. She has no atrophy. Ice pack test is positive. Repetitive nerve stimulation shows a decremental response at 3 Hz. Anti-acetylcholine receptor (anti-AChR) antibody is positive. Which pharmacological mechanism underlies the benefit of pyridostigmine in this condition?
4. A 68-year-old man with 3-year history of Parkinson's disease controlled on levodopa-carbidopa develops dyskinesias (involuntary writhing movements) 2 hours after each dose of levodopa, coinciding with peak drug levels. His motor symptoms worsen before the next dose. What is the most appropriate pharmacological adjustment?
5. A 68-year-old man presents with sudden onset left-sided weakness and neglect. MRI-DWI shows a right MCA territory infarct. He is 2 hours from symptom onset. NIHSS score is 14. CT angiography shows a right M1 occlusion. His BP is 188/100 mmHg and blood glucose is 142 mg/dL. He is on warfarin with INR 2.2 from atrial fibrillation. What is the most appropriate next step?
6. A 32-year-old woman presents with an episode of unilateral optic neuritis. MRI brain shows 3 periventricular T2 hyperintense lesions, one of which is Dawson's finger orientation. CSF shows oligoclonal bands in 8 fractions. She has had no prior neurological episodes. What is the diagnosis at this stage?
7. A 45-year-old man with known myasthenia gravis (AChR antibody positive) develops worsening ptosis, dysphagia, and progressive respiratory distress over 24 hours. He was recently started on azithromycin for a respiratory infection. On examination, deep tendon reflexes are intact. PFTs show FVC 1.1 L (26% predicted). What is the most critical immediate intervention?
8. A 35-year-old man with a 10-year history of focal onset epilepsy with secondary generalization, on carbamazepine 800 mg/day, develops breakthrough seizures. He is also started on valproate. Two weeks later he develops diplopia, ataxia, and drowsiness. Serum carbamazepine level is 18 μg/mL (therapeutic 4–12 μg/mL). What is the pharmacokinetic explanation?
9. A 45-year-old woman presents with rapidly progressive ascending weakness over 10 days, bilateral facial palsy, absent deep tendon reflexes, and dysautonomia. CSF shows albumin-cytological dissociation (protein 180 mg/dL, 3 cells). Nerve conduction studies show prolonged distal latencies, reduced conduction velocities, conduction block, and prolonged F-wave latencies. Which variant of GBS is this most consistent with?
10. A 35-year-old woman presents with a second demyelinating episode affecting the optic nerve and cervical spinal cord (transverse myelitis). MRI brain shows 4 T2/FLAIR lesions typical of demyelination. Criteria for MS diagnosis are now being applied. Which modification in the 2017 McDonald Criteria allows diagnosis of MS after a single clinical attack?
11. A 62-year-old man presents with resting tremor, rigidity, bradykinesia, and postural instability for 3 years. He now develops impulse control disorders (hypersexuality, compulsive gambling) after starting a new medication. Which recently started drug is most likely responsible?
12. A 40-year-old man presents with acute severe headache (thunderclap), nausea, and brief loss of consciousness. CT scan is normal. Lumbar puncture is performed 12 hours after symptom onset. What CSF finding would most specifically confirm subarachnoid haemorrhage (SAH)?
13. A 70-year-old hypertensive woman presents with sudden-onset pure motor hemiparesis affecting the face, arm, and leg equally, without sensory loss, cortical signs, or visual field defect. MRI DWI shows a small lacunar infarct in the internal capsule. Which small vessel syndrome is this?
14. The DWI-FLAIR mismatch on MRI is used clinically to identify stroke patients who may benefit from thrombolysis when the time of onset is unknown. A positive mismatch (DWI positive, FLAIR negative) indicates:
15. In Lambert-Eaton myasthenic syndrome (LEMS), antibodies against P/Q-type voltage-gated calcium channels (VGCC) at the presynaptic terminal cause impaired acetylcholine release. Which neurophysiological finding on repetitive nerve stimulation distinguishes LEMS from myasthenia gravis?
16. The McDonald criteria 2017 for multiple sclerosis require dissemination in space (DIS) and dissemination in time (DIT). DIT can now be fulfilled by simultaneous presence of symptomatic and asymptomatic contrast-enhancing and non-enhancing lesions. This change allows MS diagnosis after how many clinical attacks?
17. Neuromyelitis optica spectrum disorder (NMOSD) associated with anti-AQP4 antibodies targets aquaporin-4 water channels on astrocyte end-feet at the blood-brain barrier. The characteristic lesion pattern that distinguishes NMOSD from MS is:
18. In anti-NMDAR encephalitis (the most common autoimmune encephalitis), the characteristic CSF finding and initial clinical phase are:
19. A 72-year-old man with atrial fibrillation presents with left hemispheric ischaemic stroke. MRI DWI shows an infarct of 45 mL. NIHSS is 14. Time from symptom onset to hospital arrival is 3 hours. CT angiography shows left MCA M2 occlusion with excellent collaterals (ASPECTS 8). The BEST management strategy is:
20. A 35-year-old woman presents with relapsing-remitting MS confirmed on McDonald 2017 criteria. She is started on natalizumab. The risk of PML (progressive multifocal leukoencephalopathy) is determined by:
21. In myasthenia gravis, thymectomy is recommended in which clinical scenario according to current MGFA/AAN guidelines?
22. A 28-year-old develops rapidly ascending flaccid paralysis, areflexia, and albuminocytologic dissociation on CSF analysis 2 weeks after a diarrhoeal illness. Nerve conduction studies show prolonged distal latencies, reduced conduction velocities, and absent F-waves. The subtype and causative organism are:
23. A 45-year-old man presents with 4 days of high fever, severe headache, photophobia, and neck stiffness. CSF shows glucose 2.1 mmol/L (serum 6.8), protein 2.8 g/L, and WBC 2400 cells/μL (90% polymorphs). Gram stain shows gram-negative diplococci. The antibiotic of choice for treatment and the dose is:
24. A 67-year-old man presents with acute left-sided weakness 2 hours after onset. CT head is negative for hemorrhage. His BP is 185/100 mmHg. NIHSS score is 14. There is no contraindication to thrombolysis. He is given IV alteplase. Based on the DAWN and DEFUSE-3 trials, if the patient were presenting 8–24 hours after symptom onset with penumbra imaging mismatch, the recommended intervention would be:
25. A 24-year-old woman with relapsing-remitting multiple sclerosis (RRMS) has had 2 clinical relapses in 2 years and new T2 lesions on MRI. She is currently on interferon-beta 1a. Her neurologist considers switching to a high-efficacy therapy. The mechanism of action of natalizumab in MS is:
26. A 52-year-old woman presents with ptosis that worsens during the day, diplopia, and fatigable limb weakness. Single-fiber EMG shows increased jitter and blocking. Anti-AChR antibody is positive. Which paraneoplastic association must be ruled out in this patient?
27. A 30-year-old man presents with ascending weakness after a Campylobacter gastroenteritis 3 weeks ago. NCS shows prolonged distal latencies, absent H-reflexes, and markedly reduced CMAP amplitudes with conduction block. CSF shows albuminocytological dissociation. Antibody testing shows anti-GM1 IgG. The NCS pattern suggests which variant of GBS?
28. A 68-year-old man with Parkinson's disease on levodopa-carbidopa develops unpredictable off periods, dyskinesias, and motor fluctuations despite optimized oral therapy. According to current movement disorder society guidelines, which intervention is specifically indicated for this scenario?
29. A 68-year-old man presents with right-sided weakness and aphasia with onset 90 minutes ago. NIHSS score is 16. Non-contrast CT head shows no hemorrhage. CT perfusion shows penumbra/core mismatch with salvageable tissue. He is eligible for IV thrombolysis. He also has a large vessel occlusion of the left MCA on CTA. What is the optimal treatment strategy?
30. A 32-year-old woman with relapsing-remitting MS is on natalizumab for 3 years. Her JC virus antibody index rises to 3.6 (high). She has experienced no PML. What is the most important risk management decision?
31. In Lambert-Eaton Myasthenic Syndrome (LEMS), the autoimmune target is the presynaptic voltage-gated calcium channel (VGCC). How does LEMS differ from Myasthenia Gravis (MG) in terms of clinical testing findings?
32. A 35-year-old woman develops rapidly progressive ascending weakness over 3 days following a respiratory tract infection. She has areflexia and cannot walk unaided. CSF shows albumino-cytological dissociation (protein 280 mg/dL, cells 4/μL). Nerve conduction studies show prolonged distal latencies and reduced conduction velocities. Which is the MOST specific electrodiagnostic finding distinguishing acute inflammatory demyelinating polyneuropathy (AIDP) from acute motor axonal neuropathy (AMAN)?
33. A 25-year-old man has focal epilepsy with secondary generalization not controlled by valproate and levetiracetam. MRI shows a focal cortical dysplasia in the right temporal lobe. EEG confirms concordant ictal onset zone. He is being considered for epilepsy surgery. Which factor most strongly PREDICTS good surgical outcome (Engel Class I)?
34. A 70-year-old man with atrial fibrillation has an ischaemic stroke with NIHSS 14. CT brain: no haemorrhage, ASPECTS score 8. He arrives 3.5 hours after symptom onset. CT angiography shows M1 segment MCA occlusion. What is the optimal treatment strategy?
35. A 45-year-old woman with relapsing-remitting multiple sclerosis has had two confirmed relapses in the past year despite interferon-beta-1a therapy. MRI shows five new T2 lesions. Which is the most appropriate next step per ECTRIMS/AAN treat-to-target recommendations?
36. A 30-year-old woman with myasthenia gravis (MG) is intubated with respiratory failure. She was recently started on ciprofloxacin for a urinary tract infection. Which mechanism explains this drug-related exacerbation?
37. A 68-year-old man is started on levodopa-carbidopa for Parkinson's disease. After 6 years he develops marked wearing-off and peak-dose dyskinesias. Which pharmacological addition is best supported for reducing off-time without worsening dyskinesia?
38. A 68-year-old hypertensive woman presents within 3 hours of onset of right hemiplegia and aphasia. CT head shows no hemorrhage. BP is 188/102 mmHg. She has no contraindications to thrombolysis. According to AHA/ASA guidelines, the BP threshold that must be achieved BEFORE IV alteplase can be administered is:
39. A 42-year-old man with relapsing-remitting multiple sclerosis (RRMS) on interferon beta-1a develops breakthrough disease: two relapses in 12 months and two new T2 lesions on MRI. He has no JC virus antibody. According to current EMA/FDA treatment escalation guidelines, the most appropriate high-efficacy DMT is:
40. A 72-year-old man presents with resting tremor, bradykinesia, and lead-pipe rigidity for 2 years. He has postural hypotension, rapid eye movement sleep behavior disorder (RBD), urinary incontinence, and his UPDRS motor score does NOT significantly improve with levodopa. The most likely diagnosis is:
41. A 25-year-old woman presents with progressive ascending weakness, areflexia, and CSF showing albumino-cytologic dissociation. Nerve conduction studies show prolonged distal latencies and absent F-waves. She is intubated due to declining forced vital capacity. The choice between IV immunoglobulin and plasma exchange in GBS is based on the following evidence:
42. A 35-year-old woman presents with bilateral ptosis worsening toward evening, diplopia, and fatigable proximal limb weakness. Repetitive nerve stimulation at 3 Hz shows 15% decremental response. Serum anti-AChR antibodies are positive. CT chest shows a 4 cm anterior mediastinal mass. The most appropriate definitive management of this mediastinal mass is:
43. A 72-year-old man with atrial fibrillation presents with sudden right-sided weakness, aphasia, and right facial droop. NIHSS score is 16. CT brain shows no hemorrhage. CT angiography reveals left MCA M1 segment occlusion. Time from symptom onset to hospital arrival is 3.5 hours. He has no contraindications. What is the optimal management?
44. A 25-year-old woman presents with bilateral ascending weakness over 3 weeks, areflexia, and albuminocytologic dissociation in CSF (protein 180 mg/dL, cells 4/µL). Nerve conduction studies show prolonged distal latencies, reduced conduction velocities, and conduction block. This pattern identifies which variant of GBS?
45. A 45-year-old woman with relapsing-remitting MS has had 2 relapses in 12 months and MRI shows 4 new T2 lesions despite being on interferon beta-1a. She is seronegative for anti-JC virus antibody. The best escalation therapy is:
46. A 60-year-old man presents with resting tremor, rigidity, bradykinesia, and postural instability over 3 years. His symptoms are predominantly asymmetric. He has poor response to high-dose levodopa. Which feature best distinguishes atypical parkinsonian syndrome (Parkinson plus) from idiopathic Parkinson disease?
47. A 28-year-old woman presents with status epilepticus. She had a prodrome of psychiatric symptoms for 2 weeks before seizures. MRI brain is normal. CSF shows mild lymphocytosis. EEG shows extreme delta brush pattern. Which autoantibody is most likely responsible?
48. A 68-year-old man presents with sudden onset left-sided weakness 90 minutes ago. NIHSS is 14. Non-contrast CT brain is normal. BP is 178/96 mmHg. No contraindications to thrombolysis are identified. What is the appropriate BP management before IV alteplase administration?
49. A 22-year-old woman has had two unprovoked generalised tonic-clonic seizures. EEG shows generalised spike-and-wave discharges at 3 Hz. She plans pregnancy within 2 years. Which antiseizure medication should be avoided due to highest teratogenic risk in this context?
50. A 45-year-old woman with relapsing-remitting multiple sclerosis has been on interferon-beta for 2 years with two clinical relapses and new MRI lesions. She asks about escalation of therapy. Which of the following high-efficacy disease-modifying therapies carries risk of PML (progressive multifocal leukoencephalopathy) due to JC virus reactivation?
51. A 35-year-old woman presents with ascending weakness over 3 weeks following a Campylobacter jejuni diarrhoeal illness 4 weeks earlier. NCS shows reduced CMAP amplitudes with normal conduction velocities and no demyelination. Anti-GM1 ganglioside antibodies are positive. What subtype of GBS does this represent?
52. A 60-year-old man with Parkinson's disease on levodopa-carbidopa 250/25 mg TDS develops involuntary writhing movements of his limbs and trunk occurring about 60 minutes after each dose, at peak plasma levodopa levels. What is this complication called and what is the most appropriate first management step?
53. A 72-year-old man presents with sudden right hemiplegia and global aphasia. Non-contrast CT brain at 2 hours is normal. NIHSS score is 14. He is not on anticoagulants. Last known well was 90 minutes ago. What is the CORRECT reperfusion strategy?
54. A 28-year-old woman has a 6-month history of relapsing-remitting episodes of optic neuritis, transverse myelitis, and area postrema syndrome (intractable hiccups and vomiting). MRI brain shows no demyelinating plaques typical of MS. She is anti-AQP4 antibody positive. The CORRECT diagnosis and recommended acute treatment is:
55. A 55-year-old man has Parkinson's disease treated with levodopa-carbidopa for 6 years. He now develops involuntary writhing movements of his limbs occurring 60–90 minutes after each dose. These represent:
56. In Guillain-Barré syndrome (GBS), the CSF finding of albuminocytological dissociation (raised protein with normal cell count) is typically seen from which day of illness onwards?
57. A 35-year-old woman with myasthenia gravis has positive anti-AChR antibodies and CT chest reveals a 4 cm anterior mediastinal mass. The MOST appropriate next steps are:
58. A 68-year-old hypertensive man presents with sudden-onset aphasia and right hemiplegia at 11 AM. The last known well time was 10:30 AM. CT brain shows no haemorrhage or established infarct, and CT perfusion shows a large penumbra. What is the extended time window for IV alteplase administration per current guidelines (AHA/ASA 2019)?
59. A 25-year-old woman has relapsing-remitting MS with two relapses in the past year, new enhancing lesions on MRI. She wants highly effective therapy. Per McDonald 2017 criteria and EAN/ECTRIMS guidelines, which disease-modifying therapy (DMT) is classified as high-efficacy first-line?
60. Lambert-Eaton myasthenic syndrome (LEMS) differs from myasthenia gravis in which key clinical and electrophysiological feature?
61. Herpes simplex encephalitis (HSE) preferentially involves which brain regions, and what is the cornerstone of diagnosis?
62. A 72-year-old patient with Parkinson's disease on carbidopa-levodopa develops unpredictable off episodes despite multiple daily doses. Which adjunct therapy targets the COMT enzyme to extend levodopa's half-life and reduce off time?
63. A 72-year-old man presents with sudden left-sided hemiplegia and hemianopia 3.5 hours after symptom onset. NIHSS score is 18. CT head shows no hemorrhage and no established infarct core. Which intervention provides the greatest additional benefit over IV thrombolysis alone in this patient with proximal M1 occlusion?
64. A 25-year-old woman has two unprovoked generalised tonic-clonic seizures 6 months apart. MRI brain is normal. EEG shows 3 Hz spike-and-wave discharge. Which antiepileptic drug is FIRST-LINE for juvenile absence epilepsy / generalised epilepsy with this EEG pattern?
65. A 35-year-old woman presents with optic neuritis and sensory loss in her right arm two years after an episode of internuclear ophthalmoplegia. MRI shows periventricular T2 lesions perpendicular to the corpus callosum (Dawson fingers) and two lesions disseminated in time. This is relapsing-remitting MS. Per current NICE/EAN guidelines, the mechanism of action of natalizumab (a high-efficacy DMT) is:
66. A 55-year-old man with Parkinson's disease on levodopa/carbidopa develops dyskinesias and wearing-off phenomenon. Which deep brain stimulation (DBS) target is the most commonly used and proven effective for motor fluctuations in PD?
67. A 30-year-old woman presents with ascending flaccid paralysis 10 days after a gastroenteritis. CSF shows albumin-cytological dissociation (protein 2.4 g/L, cells 2/mm³). NCS shows absent F-waves and prolonged distal motor latency. Which serological finding is most commonly associated with axonal GBS (AMAN subtype)?
68. A 72-year-old man with atrial fibrillation presents with sudden onset left hemiplegia and hemisensory loss. CT head at 90 minutes shows no hemorrhage. NIHSS score is 14. He is on aspirin. What is the MOST appropriate immediate management?
69. A 25-year-old woman develops bilateral lower limb weakness, urinary retention, and a sensory level at T6 over 48 hours. MRI spine shows a longitudinally extensive transverse myelitis (LETM) spanning 3 vertebral segments. MRI brain is normal. Serum AQP4-IgG (NMO-IgG) is positive. Which diagnosis is most likely?
70. A 32-year-old woman with myasthenia gravis (generalized, AChR antibody positive) is poorly controlled on pyridostigmine and azathioprine. CT chest is normal (no thymoma). Which immunotherapy has been approved as add-on for AChR antibody-positive generalized MG?
71. A 70-year-old man with Parkinson's disease has been on levodopa/carbidopa for 8 years and now experiences predictable 'wearing-off' and unpredictable 'on-off' fluctuations. Which pharmacological strategy is MOST appropriate to address wearing-off?
72. A 19-year-old presents with fever, neck stiffness, and petechial rash. CSF shows: glucose 32 mg/dL (serum 92), protein 240 mg/dL, WBC 1800 cells/µL (90% neutrophils). Gram stain shows Gram-negative diplococci. What is the empiric antibiotic of choice and the most important adjunctive therapy?
73. A 68-year-old hypertensive man presents with sudden-onset aphasia and right hemiplegia. NIHSS is 14. Non-contrast CT head shows no haemorrhage. Time from symptom onset to hospital arrival is 2.5 hours. CT perfusion shows a core infarct of 30 mL and penumbra of 80 mL. The mismatch ratio is 2.7. What is the appropriate reperfusion strategy?
74. A 28-year-old woman with relapsing-remitting MS has had two clinical relapses in the past year plus one new T2 lesion on MRI. She wants the most effective disease-modifying therapy. Which agent is classified as a high-efficacy therapy with evidence of superior relapse rate reduction compared to injectable therapies?
75. A 24-year-old woman presents with bilateral lower limb weakness, ascending over 3 days, absent deep tendon reflexes and facial diplegia, preceded by a campylobacter gastroenteritis 2 weeks earlier. CSF shows albuminocytological dissociation. Nerve conduction studies show prolonged distal motor latencies, reduced CMAP amplitudes with conduction block. The MOST appropriate immediate treatment is:
76. A 62-year-old man with Parkinson's disease on levodopa/carbidopa develops dyskinesias during peak dose and 'wearing off' before the next dose. Which medication can be added to extend the ON time and reduce wearing off by inhibiting peripheral COMT?
77. A 25-year-old woman has focal impaired awareness seizures and one secondarily generalised tonic-clonic seizure. MRI shows a left mesial temporal sclerosis. She is started on levetiracetam but continues to have 2–3 seizures per month despite optimal dosing. This pattern is best described as:
78. A 72-year-old man presents with sudden right hemiplegia and aphasia. CT head shows no hemorrhage. NIHSS score is 14. Time from symptom onset is 2.5 hours. MRI DWI shows a left MCA territory infarct. He has no contraindications to thrombolysis. BP is 168/95 mmHg. What is the next critical step?
79. A 30-year-old woman with relapsing-remitting MS (RRMS) has had 2 relapses in the past year, one involving optic neuritis and one brainstem relapse. MRI shows 5 new T2 lesions and 2 gadolinium-enhancing lesions compared to 12 months ago. This disease activity pattern defines:
80. A 25-year-old woman presents with ptosis and diplopia worse in the evenings, positive ice-pack test, and positive repetitive nerve stimulation (3 Hz) showing >10% decrement. Anti-AChR antibodies are elevated. CT chest shows an anterior mediastinal mass. What intervention, in addition to pyridostigmine, is most important for long-term remission?
81. A 60-year-old man with Parkinson disease on levodopa/carbidopa develops involuntary writhing movements of the trunk and limbs that occur 1–2 hours after each dose. These movements are absent just before the next dose. This is classified as:
82. A 22-year-old man presents with ascending paralysis, absent deep tendon reflexes, and albuminocytological dissociation on CSF analysis 2 weeks after a Campylobacter jejuni gastroenteritis. Nerve conduction studies show absent F-waves and reduced CMAP amplitudes with relatively preserved conduction velocities. This variant of GBS is:
83. A 35-year-old woman develops focal onset impaired awareness seizures that are refractory to two adequate antiseizure medications (ASMs) at therapeutic doses. She is referred for pre-surgical evaluation. MRI shows left hippocampal sclerosis. EEG confirms left temporal lobe ictal onset. This patient has:
84. A 72-year-old man with atrial fibrillation develops sudden right-sided hemiplegia, aphasia, and right homonymous hemianopia. Brain CT (non-contrast) is normal. The NIHSS score is 18. Time of symptom onset is confirmed at 2 hours ago. He is not on anticoagulation. The most appropriate acute intervention is:
85. A 35-year-old woman presents with episodic neurological symptoms over 2 years: an episode of right optic neuritis that resolved over weeks, and now left arm tingling and weakness. Brain MRI shows periventricular T2/FLAIR hyperintense lesions perpendicular to the corpus callosum (Dawson's fingers). CSF shows oligoclonal bands in CSF not in serum. The McDonald 2017 criteria for diagnosis requires:
86. A 60-year-old man with Parkinson's disease has adequate motor control but is troubled by frequent episodes of sudden-onset sleep at the wheel (sleep attacks). He is on pramipexole 1.5 mg/day and levodopa 600 mg/day. Which medication is most likely responsible for the sleep attacks?
87. A 25-year-old woman develops progressive ascending weakness over 10 days, starting in the feet and reaching the thighs. Deep tendon reflexes are absent. CSF shows protein 220 mg/dL with WBC 4 cells/µL (albumin-cytological dissociation). Anti-ganglioside antibody testing is positive for anti-GQ1b. What is the likely diagnosis and its distinctive clinical feature?
88. A 40-year-old woman presents with bilateral ptosis worse in the evening, diplopia, and fatigable proximal weakness. Edrophonium (Tensilon) test is positive. Anti-AChR antibodies are positive. CT chest shows a 4 cm anterior mediastinal mass. The most appropriate next step after diagnosis is confirmed is:
89. A 71-year-old man presents 2.5 hours after onset of right-sided hemiplegia and aphasia. NIHSS score is 14. Non-contrast CT shows no haemorrhage or early infarct signs. BP is 178/96 mmHg. He has no contraindications to thrombolysis. What is the MOST appropriate immediate treatment?
90. A 55-year-old woman with relapsing-remitting MS develops acute unilateral optic neuritis. She has had two relapses in the past year. MRI shows 12 T2 lesions. She is currently on interferon beta-1a. What would be the MOST appropriate change to disease-modifying therapy?
91. A 28-year-old woman with myasthenia gravis presents with progressive dyspnoea, inability to count above 6 in a single breath, and paradoxical abdominal movement. Forced vital capacity is 1.2 L (predicted 3.4 L). What is the MOST appropriate immediate management?
92. A 38-year-old patient with Parkinson's disease has been on levodopa/carbidopa for 4 years and now develops wearing-off episodes and dyskinesias. Which mechanism BEST explains levodopa-induced dyskinesias?
93. A 22-year-old presents with ascending flaccid paralysis 2 weeks after a diarrhoeal illness. CSF shows albumin-cytological dissociation (protein 180 mg/dL, cells 2/mm³). Nerve conduction studies show prolonged distal latencies, slow conduction velocities, and conduction blocks. Which antibody is MOST commonly associated with acute inflammatory demyelinating polyneuropathy (AIDP)?
94. A 68-year-old woman with atrial fibrillation presents with sudden onset left hemiplegia and hemianopia. CT brain at 90 minutes is normal. She is within 4.5 hours of symptom onset. What is the most appropriate treatment?
95. A 45-year-old woman presents with subacute progressive limb weakness, bilateral leg paraesthesias, and is found to have oligoclonal bands in CSF but not serum. MRI brain shows periventricular T2 lesions perpendicular to the corpus callosum (Dawson fingers). Visual evoked potentials are delayed. What is the mechanism of first-line disease-modifying therapy (DMT) with interferon beta-1a in this condition?
96. A 55-year-old man with Parkinson's disease on levodopa-carbidopa develops troublesome wearing-off and peak-dose dyskinesias. Adjusting the levodopa timing has not helped. Which pharmacological strategy specifically targets wearing-off by inhibiting peripheral COMT enzyme?
97. A 27-year-old woman presents with acute-onset diplopia and fatigable ptosis worsening towards the end of the day. Edrophonium (Tensilon) test is positive. Anti-AChR antibodies are detected. CT thorax shows a 4 cm anterior mediastinal mass. What is the significance of the thoracic mass in this setting?
98. A 24-year-old man presents with ascending weakness and areflexia progressing over 10 days following a Campylobacter jejuni enteritis 3 weeks ago. CSF shows albuminocytological dissociation. Nerve conduction studies show marked reduction in CMAP amplitude with relative preservation of conduction velocity. Which subtype of Guillain-Barré syndrome does this suggest?
99. A 67-year-old man presents with sudden-onset left hemiplegia and aphasia 2.5 hours after symptom onset. CT head rules out haemorrhage. NIHSS score is 16. CT angiography shows a right M1 segment MCA occlusion. He is eligible for both IV thrombolysis and mechanical thrombectomy. According to AHA/ASA 2019 guidelines, the management is:
100. A 28-year-old woman presents with two episodes of optic neuritis separated by 3 months, and MRI brain shows periventricular white matter lesions. CSF shows oligoclonal bands and elevated IgG index. She is diagnosed with relapsing-remitting multiple sclerosis. Which disease-modifying therapy is classified as high-efficacy and is a monoclonal antibody targeting CD20?
101. A 24-year-old man develops rapidly ascending weakness over 10 days, progressing from legs to arms. Deep tendon reflexes are absent bilaterally. CSF shows protein 180 mg/dL with cell count of 4 cells/µL (albuminocytological dissociation). Nerve conduction study shows reduced CMAP amplitudes with absent F-waves but preserved sensory nerve action potentials. This electrophysiological pattern suggests:
102. A 35-year-old woman with myasthenia gravis generalised (MGFA class III) has anti-AChR antibody titre 42 nmol/L. CT chest shows thymoma. After thymectomy, she still has incomplete response on pyridostigmine. According to MGTX trial and MGFA guidelines, the next immunosuppressive drug of choice is:
103. A 70-year-old man presents with bradykinesia, cogwheel rigidity, unilateral resting tremor, and postural instability. He has a poor response to levodopa after 18 months. MRI shows 'hummingbird sign' (midbrain atrophy with relative pontine preservation). The most likely diagnosis is:
104. A 72-year-old man arrives at the emergency department 4.5 hours after onset of left-sided hemiparesis. NIHSS is 14; NCCT head shows no haemorrhage or early ischaemic changes. DWI-MRI shows infarct core of 40 mL with penumbra of 90 mL. He is haemodynamically stable. According to EXTEND-IA and DAWN/DEFUSE-3 trial evidence, what is the most appropriate intervention?
105. A 25-year-old woman with known multiple sclerosis on natalizumab for 30 months tests JC virus antibody positive with an index of 3.2. She develops rapidly progressive cognitive decline, aphasia, and a new large white matter lesion on MRI (T2-hyperintense, no enhancement). Which complication is most likely?
106. A 52-year-old woman presents with ptosis, diplopia, and proximal limb weakness that worsens during the day. Repetitive nerve stimulation at 3 Hz shows a 20% decremental response. Anti-AChR antibodies are positive. CT chest reveals a thymoma. Which treatment is indicated as an early-stage disease-modifying measure alongside pyridostigmine?
107. In Guillain-Barré syndrome, albuminocytological dissociation on CSF analysis refers to:
108. A 40-year-old man with Parkinson's disease on levodopa/carbidopa for 5 years develops sudden involuntary writhing movements of the face and limbs 45 minutes after each dose, lasting 30–60 minutes. Which is the most likely phenomenon and its mechanism?
109. A 68-year-old man presents with acute right hemiplegia and aphasia. CT head shows no haemorrhage. NIHSS score is 14. He was last seen normal 3.5 hours ago. CT angiography reveals M1 occlusion. What is the OPTIMAL management?
110. A 35-year-old woman with relapsing-remitting MS (2 relapses in 2 years, one lesion enhancing on MRI) is currently on interferon beta-1a. She has remained on this for 2 years with continued disease activity. Which high-efficacy DMT is most appropriate as an escalation option with a favorable safety profile?
111. A 25-year-old woman with a 6-month history of diplopia, ptosis worsening throughout the day, and fatigable limb weakness. Anti-AChR antibodies are positive. CT chest reveals thymoma. Which statement about thymectomy is CORRECT per the MGTX trial (2016)?
112. A 60-year-old man presents with progressive tremor at rest in right hand, cogwheel rigidity, masked facies, and micrographia over 2 years. He fails a trial of levodopa. DaTscan is negative. Which alternative diagnosis should be strongly suspected?
113. A 22-year-old man is diagnosed with new-onset focal epilepsy with secondary generalisation. MRI is normal. EEG shows left temporal spikes. Which anti-seizure medication has the BEST evidence as monotherapy for focal epilepsy with fewest drug interactions?
114. A 68-year-old hypertensive man presents with sudden left hemiplegia and hemisensory loss at 2 hours. NIHSS score is 14. CT head shows no haemorrhage. CT perfusion shows ischaemic core 28 mL and penumbra 110 mL (mismatch ratio 3.9). He receives IV alteplase at 2.5 hours. Which additional intervention should be offered?
115. A 32-year-old woman with MS (relapsing-remitting) has had 2 relapses in the past year despite being on interferon beta-1a. MRI shows 4 new T2 lesions and 2 gadolinium-enhancing lesions. What is the appropriate escalation strategy?
116. A 25-year-old woman with myasthenia gravis (generalised, anti-AChR antibody positive, MGFA Class IIb) has thymoma found on CT thorax. She is currently on pyridostigmine with incomplete control. What is the management sequence?
117. Which specific CSF finding distinguishes Guillain-Barré syndrome from acute transverse myelitis when both present with acute ascending weakness?
118. A 55-year-old man with Parkinson's disease on levodopa-carbidopa for 6 years develops involuntary writhing movements of his limbs and trunk approximately 1 hour after each dose. These movements are most problematic at peak medication levels. What is this phenomenon called and what is the most appropriate management?
119. A 67-year-old man develops sudden-onset severe headache ('thunderclap'), photophobia, and neck stiffness. CT head is normal. Lumbar puncture shows xanthochromia with 1200 RBCs/mm³ (same count in tubes 1 and 4). The most likely diagnosis is:
120. A 70-year-old man with AF is found to have a left MCA territory ischemic stroke. He is within the thrombolysis window but has a large territory infarction (>1/3 MCA territory on CT). His NIHSS score is 22. Regarding IV alteplase, which statement is correct per current AHA/ASA guidelines?
121. A 45-year-old woman presents with ascending limb weakness over 2 weeks. She recently had Campylobacter jejuni gastroenteritis. CSF shows albuminocytologic dissociation. Nerve conduction studies reveal prolonged distal motor latencies, absent F-waves, and low-amplitude motor responses. The most likely subtype of Guillain-Barré syndrome is:
122. A 35-year-old woman has recurrent episodes of unilateral arm weakness lasting 20 minutes, with MRI showing a periventricular white matter lesion. CSF shows 3 oligoclonal bands not present in serum. Her visual evoked potential is delayed on the right. To confirm a diagnosis of multiple sclerosis (MS), the McDonald 2017 criteria require demonstration of:
123. A 62-year-old man with Parkinson's disease on levodopa/carbidopa develops sudden-onset episodes where his medications 'wear off' before the next dose, with increasing off-time despite dose adjustments. Which strategy is specifically approved to EXTEND ON-time in Parkinson's motor fluctuations?
124. A 40-year-old woman with relapsing-remitting MS is being considered for high-efficacy disease-modifying therapy. Which of the following is associated with the highest risk of progressive multifocal leukoencephalopathy (PML) due to JC virus reactivation?
125. A 67-year-old man presents 3.5 hours after onset of right hemiplegia and aphasia. NIHSS score is 14. NCCT brain shows no haemorrhage or early ischaemic changes. BP is 168/94 mmHg. Which intervention is appropriate?
126. A 32-year-old woman with relapsing-remitting MS develops a new optic neuritis episode despite being on interferon-beta-1a for 2 years. MRI shows 3 new T2 lesions in 12 months. What is the most appropriate next step?
127. A 24-year-old woman presents with diplopia, ptosis worsening through the day, and weakness that improves with rest. Anti-AChR antibody is positive. CT chest shows a 3.5 cm anterior mediastinal mass. What is the most important immediate diagnostic test and management decision?
128. A 58-year-old man with Parkinson's disease on levodopa-carbidopa 25/100 mg four times daily develops predictable 'wearing-off' phenomena. Which pharmacological strategy most specifically targets motor fluctuations from wearing-off?
129. A 19-year-old student presents with acute meningitis: fever, neck stiffness, photophobia, and petechial rash. CSF shows: WBC 1800 (predominantly neutrophils), glucose 1.8 mmol/L (blood glucose 5.2 mmol/L), protein 2.4 g/L. Gram stain shows Gram-negative diplococci. What is the empirical antibiotic and corticosteroid strategy?
130. A 35-year-old woman develops ascending weakness starting in the legs over 2 days after a diarrheal illness 2 weeks ago. She now has bilateral facial diplegia, areflexia, and sensory loss. CSF shows albumino-cytological dissociation (protein 180 mg/dL, cells 3/µL). Nerve conduction studies show reduced CMAP amplitudes with prolonged distal latencies and absent F waves. Which antibody is associated with the most severe axonal variant of GBS?
131. A 50-year-old man with advanced Parkinson's disease on levodopa/carbidopa 250/25 mg four times daily develops involuntary writhing movements of the face, trunk, and limbs appearing 60-90 minutes after each dose. These are absent at trough. What is this phenomenon and how should it be managed?
132. A 25-year-old woman has relapsing-remitting multiple sclerosis (RRMS). She has had 2 clinical relapses in the past year and a new T2 lesion on MRI. She is concerned about treatment efficacy. Which first-line disease-modifying therapy has the highest relapse rate reduction (approximately 68%) with parenteral administration?
133. A 40-year-old woman presents with recurrent episodes of sudden-onset unilateral periorbital pain lasting 15-45 minutes, occurring up to 8 times per day, associated with ipsilateral conjunctival injection, lacrimation, nasal congestion, and ptosis/miosis. Episodes cluster for 6-8 weeks. What is the diagnosis and the drug of choice for acute attacks?
134. A 68-year-old man presents 1.5 hours after onset of acute left MCA territory ischaemic stroke (NIHSS 12). CT head shows no haemorrhage. His BP is 175/95 mmHg, blood glucose 8.4 mmol/L. He was on warfarin for AF with a recent INR of 2.8 two weeks ago; today's INR is 1.6. The MOST appropriate immediate management is:
135. A 25-year-old woman with relapsing-remitting MS (RRMS) has had 2 relapses in the past year and new MRI lesions on low-efficacy therapy. Anti-JCV antibody index is 0.4. Which high-efficacy disease-modifying therapy (DMT) has the HIGHEST risk of progressive multifocal leucoencephalopathy (PML) and should be used cautiously?
136. A 40-year-old man presents with ptosis, diplopia, and fatigable proximal limb weakness worse in the evening. Edrophonium (Tensilon) test is positive. Anti-AChR antibodies are positive. CT chest reveals a 3 cm anterior mediastinal mass. The NEXT most important step in management after starting pyridostigmine is:
137. A 22-year-old woman with generalised epilepsy (myoclonic jerks, absence, and occasional tonic-clonic seizures) starting at age 14 is MOST likely to have which epilepsy syndrome, and what is the MOST appropriate first-line drug?
138. In Guillain-Barré syndrome (GBS), the anti-GQ1b antibody is MOST associated with which clinical variant?
139. A 65-year-old man with AF presents with acute left hemiparesis and dysarthria. CT head is normal. MRI DWI shows an infarct in the right posterior limb of the internal capsule. His NIHSS is 8. He is 2.5 hours from symptom onset. His INR is 1.1 (on no anticoagulation). What is the MOST appropriate immediate management?
140. A 30-year-old woman has a 3-year history of relapsing-remitting MS. Her last two relapses were while on dimethyl fumarate. MRI shows 4 new T2 lesions with 1 gadolinium-enhancing lesion. This represents high disease activity on a moderate-efficacy DMT. According to escalation vs induction strategies, the MOST appropriate next step is:
141. A 55-year-old man has Parkinson's disease with wearing-off and on-off fluctuations despite optimised levodopa-carbidopa regimen. An 'off' state UPDRS motor score is 42/108. His neurologist considers adjunct therapy. Which agent acts by inhibiting catechol-O-methyltransferase (COMT) peripherally AND centrally, allowing better central levodopa bioavailability?
142. A 40-year-old woman with myasthenia gravis (anti-AChR antibody positive, Osserman class IIb) has failed to achieve remission with pyridostigmine and prednisolone. She has no thymoma on CT. Which biologic mechanism correctly describes the action of eculizumab in refractory generalised MG?
143. A 28-year-old woman presents with progressive ascending weakness over 10 days, areflexia, and bilateral facial diplegia. CSF shows cytoalbuminous dissociation (protein 280 mg/dL, cells 4/mm³). Nerve conduction studies show prolonged distal motor latencies, absent F waves, and dispersed CMAPs. Which GBS variant does this pattern represent?
144. A 70-year-old man with AF presents with left hemiplegia and hemisensory loss at 3.5 hours from symptom onset. NIHSS is 14. MRI-DWI shows a right MCA territory infarct (1/3 MCA territory involvement), no hemorrhage on MRI-GRE/SWI. BP is 165/90. He takes rivaroxaban 20 mg daily, last dose was 18 hours ago. What is the correct management regarding IV thrombolysis?
145. A 32-year-old woman with relapsing-remitting MS (RRMS) has had 2 relapses in 12 months and 2 new T2 lesions on MRI despite interferon-beta therapy for 18 months. She is otherwise healthy, planning pregnancy in 2 years. Which disease-modifying therapy best balances high efficacy and safety during future pregnancy planning?
146. A 55-year-old man with Parkinson's disease on levodopa/carbidopa 6 times daily has 3-4 hours of 'off' time per day despite optimized levodopa dosing. He has developed dyskinesias in 'on' state. Which add-on therapy is most appropriate to extend 'on' time without worsening dyskinesia?
147. A 25-year-old woman develops ascending paralysis, areflexia, and autonomic instability 2 weeks after Campylobacter jejuni gastroenteritis. CSF shows albuminocytologic dissociation. Nerve conduction studies (NCS) show low amplitude CMAPs with relatively preserved conduction velocities and minimal sensory involvement. Anti-GM1 antibodies are positive. What subtype of GBS does this represent?
148. A 40-year-old woman with myasthenia gravis (acetylcholine receptor antibody positive, thymoma present) is admitted with worsening weakness, ptosis, and dysarthria. She is on pyridostigmine 60 mg 5 times daily. FVC is 1.8 L (30% predicted). What is the immediate next step?
149. A 70-year-old man presents with sudden onset aphasia and right hemiplegia at 9 AM. Last seen well at 10 PM the previous night. Non-contrast CT brain shows no haemorrhage. MRI DWI shows early restricted diffusion in the left MCA territory with FLAIR mismatch (DWI lesion without FLAIR change). What does this finding suggest and what is its therapeutic implication?
150. A 28-year-old woman is diagnosed with relapsing-remitting multiple sclerosis after her second clinical attack and MRI showing dissemination in space and time. She requests the most effective disease-modifying therapy. Which agent has the highest efficacy in preventing relapses and disability progression in RRMS?
151. A 65-year-old woman with known Myasthenia Gravis (MG) presents to the ICU with respiratory failure. She was started on ciprofloxacin 3 days ago for a UTI. She is intubated. Which aspect of her management is MOST critical?
152. In Guillain-Barré Syndrome (GBS), which electrodiagnostic and clinical finding MOST reliably predicts a severe motor axonopathy subtype (AMAN) rather than AIDP?
153. A 55-year-old man with a 3-day history of fever, confusion, and focal seizures. CSF analysis: glucose 45 mg/dL (serum 90), protein 120 mg/dL, WBC 120/μL with predominantly lymphocytes. CSF HSV-1 PCR is positive. EEG shows periodic lateralised epileptiform discharges (PLEDs) over the left temporal region. The preferred duration of IV acyclovir treatment is:
154. In the management of status epilepticus (SE), if first-line benzodiazepines fail after 20 minutes, which IV agent is recommended as second-line per current guidelines?
155. In myasthenia gravis (MG), the MG-ADL score is used for clinical monitoring. Which antibody subtype predicts a significantly BETTER response to thymectomy compared to seronegative MG?
156. In Guillain-Barré syndrome (GBS), the EGOS (Erasmus GBS Outcome Scale) is used to predict outcomes. Which electrophysiological subtype is associated with the WORST short-term prognosis with slowest recovery?
157. A 38-year-old woman with multiple sclerosis (MS) has relapsing-remitting disease with 2 relapses in 2 years and active MRI lesions. According to current treatment algorithms, she qualifies for which category of disease-modifying therapy (DMT)?
158. In the DAWN trial, mechanical thrombectomy for ischemic stroke was extended to 24 hours from symptom onset. What selection criterion was used (beyond clinical-imaging mismatch) to identify eligible patients?
159. A 67-year-old man with AF presents with acute right hemiplegia and aphasia. CT shows no haemorrhage and early ischaemic changes in less than one-third of the MCA territory. NIHSS score is 14. Time from symptom onset is 90 minutes. He is on warfarin with INR of 1.3. What is the best management?
160. A 28-year-old woman with relapsing-remitting MS has two relapses in the past year. MRI shows three new T2 lesions and one gadolinium-enhancing lesion. Her neurologist considers escalation to high-efficacy disease-modifying therapy (HE-DMT). Which agent has the mechanism of action described as anti-CD20 monoclonal antibody that depletes B cells and is approved for RRMS?
161. A 50-year-old man with Parkinson's disease has been on levodopa/carbidopa for 8 years. He now has disabling motor fluctuations with 'off' periods of 4–5 hours daily despite optimised oral dosing. Which intervention has the strongest evidence for reducing 'off' time in this scenario?
162. In Guillain-Barré syndrome, which electrodiagnostic finding on nerve conduction studies suggests the acute motor axonal neuropathy (AMAN) subtype rather than the classic acute inflammatory demyelinating polyradiculoneuropathy (AIDP)?
163. A 68-year-old man is brought in 2.5 hours after onset of right hemiplegia and aphasia. CT brain shows no haemorrhage. NIHSS is 14. CT angiography shows left M1 MCA occlusion. BP is 168/92 mmHg. What is the correct management sequence according to current AHA/ASA 2019 guidelines?
164. A 29-year-old woman with relapsing-remitting MS (2 relapses in past year, one new T2 lesion on MRI) is being considered for disease-modifying therapy. She is pregnant and planning to breastfeed. Which DMT approach is most appropriate according to ECTRIMS/EAN 2023 guidelines?
165. A 42-year-old woman with known myasthenia gravis (MuSK antibody-positive) on pyridostigmine develops acute respiratory failure. She has been taking ciprofloxacin for a urinary infection. Her Tensilon test is equivocal. The most appropriate immediate investigation to differentiate myasthenic crisis from cholinergic crisis is:
166. A 25-year-old patient develops ascending weakness 3 weeks after Campylobacter jejuni diarrhoea. NCS shows markedly reduced CMAP amplitudes, near-normal sensory responses, and absent F-waves. Anti-GM1 antibodies are strongly positive. Which GBS subtype does this represent?
167. A 38-year-old man with Parkinson's disease has been on levodopa-carbidopa 100/25 mg TDS for 4 years. He now experiences wearing-off, peak-dose dyskinesias, and unpredictable on-off fluctuations. Which addition to his regimen specifically targets the non-dopaminergic adenosine A2A receptor mechanism implicated in basal ganglia output regulation?
168. A 65-year-old man presents to the ED 3.5 hours after sudden-onset left hemiparesis and dysarthria. NIHSS is 12. CT brain shows no hemorrhage. CT angiography reveals right MCA occlusion. Blood pressure is 165/90 mmHg. What is the MOST appropriate treatment?
169. A 25-year-old woman with relapsing-remitting MS (3 relapses in 2 years, EDSS 3.5) is being counselled about high-efficacy disease-modifying therapy. Which mechanism characterizes natalizumab's mode of action?
170. A 55-year-old man with Parkinson's disease develops 'on-off' fluctuations despite optimized levodopa and a dopamine agonist. He experiences painful 'off-period' dystonia. Which add-on therapy works by inhibiting catechol-O-methyltransferase (COMT) to prolong levodopa duration?
171. A 40-year-old woman presents with myasthenia gravis (generalized, anti-AChR positive). She fails pyridostigmine and prednisolone and requires multiple PLEX cycles. Thymectomy is planned. Which finding on CT chest would provide the STRONGEST indication for thymectomy?
172. A patient with suspected bacterial meningitis presents with fever, neck stiffness, and photophobia. Lumbar puncture is delayed due to papilledema on fundoscopy. Which antibiotic should be given IMMEDIATELY before LP or CT brain?
173. A 67-year-old man with atrial fibrillation presents 3.5 hours after onset of right-sided weakness and aphasia (NIHSS score 14). CT head shows no haemorrhage. CT perfusion shows a mismatch ratio of 2.0 with ischaemic core of 18 mL and penumbra of 95 mL. He is on apixaban, last dose 14 hours ago. He is otherwise eligible for thrombolysis. What is the CORRECT management?
174. A 28-year-old woman with known multiple sclerosis (relapsing-remitting MS, EDSS 2.5) on interferon beta-1a develops a severe relapse with optic neuritis and new T2 lesions on MRI. She is considering switching to high-efficacy therapy. Which of the following is classified as a high-efficacy disease-modifying therapy (DMT) for MS with demonstrated reduction in annual relapse rate > 60%?
175. A 52-year-old man with myasthenia gravis (acetylcholine receptor antibody positive, generalised MG, MGFA Class IIb) fails pyridostigmine monotherapy. Prednisone is being considered for immunosuppression. Which of the following is the mechanism of benefit of pyridostigmine in MG?
176. A 65-year-old woman is being evaluated for Parkinson's disease. She has asymmetric rest tremor, cogwheel rigidity, and bradykinesia for 2 years (Hoehn & Yahr stage 2). She also complains of constipation and anosmia preceding motor symptoms by 5 years. Which Braak stage of Parkinson disease pathology does the clinical sequence of anosmia and constipation PRECEDING motor symptoms suggest?
177. A 24-year-old woman presents with ascending weakness starting in the legs over 8 days after a GI illness. Examination reveals areflexia, symmetric proximal and distal weakness, and diminished proprioception. CSF shows albumino-cytological dissociation (protein 180 mg/dL, WBC 2 cells/µL). Nerve conduction studies show absent F-waves, prolonged distal motor latencies, and reduced CMAP amplitudes with normal sensory action potentials. Which subtype of GBS does this electrophysiology suggest?
178. A 70-year-old hypertensive man presents with sudden onset left hemiplegia, hemisensory loss, and left hemineglect. MRI DWI shows acute infarct in the right MCA territory. He is brought to the ER at 3.5 hours from symptom onset. NIHSS is 12, no haemorrhage on CT. He is on aspirin. What is the next BEST treatment?
179. A 25-year-old woman presents with recurrent episodes of bilateral tonic-clonic seizures that always begin with visual aura (flickering lights). MRI is normal. EEG shows generalised 3 Hz spike-and-wave discharges. She is planning pregnancy. Which antiepileptic drug should be AVOIDED as monotherapy in her?
180. A 35-year-old woman has relapsing-remitting MS. She is starting natalizumab. Which investigation MUST be done before initiation to stratify risk of a potentially fatal complication?
181. A 60-year-old woman develops proximal limb weakness that worsens throughout the day, ptosis, and diplopia. She also has a 5 cm anterior mediastinal mass on CT. Repetitive nerve stimulation at 3 Hz shows a decremental response of 20%. Which additional finding would specifically suggest Lambert-Eaton myasthenic syndrome (LEMS) rather than myasthenia gravis?
182. The MOST important determinant of outcome in bacterial meningitis that justifies not delaying antibiotics while awaiting CT head is:
183. A 72-year-old woman presents 3.5 hours after sudden onset left-sided hemiplegia and dysphasia. NIHSS is 12. Non-contrast CT brain shows no haemorrhage and no early infarct signs. BP is 170/95 mmHg. She has no contraindications to thrombolysis. What is the CORRECT BP target before administering IV alteplase?
184. A 25-year-old man presents with ascending weakness over 2 weeks, areflexia, and autonomic instability. CSF shows albumino-cytological dissociation. Nerve conduction studies show prolonged F-wave latencies and reduced CMAP amplitudes. Which treatment is MOST appropriate?
185. A 40-year-old woman with relapsing-remitting MS (RRMS) has had 2 relapses in the past year and a new T2 lesion on MRI. She is considering disease-modifying therapy. Which agent has the highest efficacy in reducing relapse rate but carries risk of progressive multifocal leukoencephalopathy (PML) due to JC virus?
186. A 50-year-old woman presents with fatigable diplopia, ptosis worsening throughout the day, and limb weakness. Acetylcholine receptor antibodies are positive. CT chest shows a 3 cm anterior mediastinal mass. What is the RECOMMENDED treatment for her thymic pathology?
187. A 30-year-old man presents with fever, severe headache, and neck stiffness. LP shows WBC 2,200 cells/mm³ (90% neutrophils), protein 180 mg/dL, glucose 28 mg/dL (serum glucose 90 mg/dL). Gram stain shows gram-negative diplococci. Which finding is MOST likely on examination and indicates POOR prognosis?
188. A 45-year-old woman presents with ptosis, diplopia, and fatigable proximal muscle weakness worse in the evening. Edrophonium (Tensilon) test is positive. Anti-AChR antibodies are positive. CT chest reveals a 3.5 cm anterior mediastinal mass. Management includes:
189. A 70-year-old man with bacterial meningitis (CSF: protein 280 mg/dL, glucose 22 mg/dL, WBC 1800/µL — 92% PMN, gram-positive diplococci) is started on ceftriaxone. Adjunctive dexamethasone should be given to reduce the risk of which primary complication?
190. A 55-year-old man with hypertension wakes up with a right hemiplegia and homonymous hemianopia without any cortical signs (aphasia, agnosia, neglect). The lesion is most likely located in which structure?
191. Which of the following antiepileptic drugs is associated with a DOSE-DEPENDENT worsening of tremor and pancreatitis, and requires monitoring of serum levels due to non-linear pharmacokinetics?