Free Neurology mock test

Neurology sample questions with answers

10 more original exam-style Neurology questions, worked in full. They are not real or recalled exam questions, and none of them is in the mock above or on the bank page, so sit the mock first if you have not.

1. Question 1 · Epilepsy and Paroxysmal Disorders

   A 47-year-old man has a first unprovoked generalised tonic-clonic seizure. He sustained a severe traumatic brain injury 6 years ago; MRI now shows right frontal encephalomalacia and gliosis, and his routine EEG demonstrates right frontal sharp waves. He is otherwise well and works as a schoolteacher. What is the most appropriate management?

   1. AWithhold antiseizure medication and review in 12 months, as a single seizure does not define epilepsy
   2. BRepeat the EEG after sleep deprivation before making any treatment decision
   3. CStart an antiseizure medication now, because his recurrence risk is high enough to diagnose epilepsy after one seizure
   4. DStart an antiseizure medication only if a second seizure occurs within the next 6 months
   Show answer and explanation

   Correct answer: C. Start an antiseizure medication now, because his recurrence risk is high enough to diagnose epilepsy after one seizure

   The ILAE definition allows a diagnosis of epilepsy after one unprovoked seizure when the risk of further seizures over 10 years is at least 60%, comparable to the risk after two unprovoked seizures. A remote symptomatic lesion plus epileptiform discharges places this man well above that threshold, so treatment is indicated now rather than deferred. A repeat sleep-deprived EEG will not change management when epileptiform activity is already documented, and waiting for a second seizure exposes him to avoidable injury and driving restriction.

   Reference: Fisher RS et al., ILAE practical clinical definition of epilepsy, Epilepsia 2014; NICE NG217 Epilepsies in children, young people and adults, 2022

2. Question 2 · Neuro-oncology, Neuro-ophthalmology, Neuro-otology and Sleep Neurology

   A 47-year-old woman develops seizures with olfactory auras. Perimetry shows a left superior homonymous quadrantanopia that is incongruous between the two eyes. Which structure is most likely involved?

   1. ARight temporal lobe optic radiation (Meyer loop)
   2. BRight parietal optic radiation (dorsal fibres)
   3. CLeft lateral geniculate nucleus
   4. DRight optic nerve
   Show answer and explanation

   Correct answer: A. Right temporal lobe optic radiation (Meyer loop)

   Inferior retinal fibres, which carry the superior visual field, sweep anteriorly around the temporal horn as Meyer loop, so a right temporal lesion produces a contralateral superior quadrantanopia, classically incongruous and accompanied by temporal-lobe seizure phenomena such as olfactory auras. Dorsal parietal radiation lesions cause an inferior quadrantanopia ('pie on the floor'). A left geniculate lesion would cause a right-sided defect, and an optic nerve lesion causes monocular loss with a relative afferent pupillary defect.

   Reference: Brazis, Masdeu & Biller, Localization in Clinical Neurology, 7th ed. (2021); AAN Continuum: Neuro-ophthalmology

3. Question 3 · Neuro-Immunological and Demyelinating Disorders

   A 52-year-old hypertensive smoker is referred with multiple T2 white matter hyperintensities found on MRI and possible demyelination. Which single imaging finding would most strongly support multiple sclerosis rather than chronic small-vessel ischaemic disease?

   1. AConfluent periventricular caps around the frontal horns
   2. BScattered punctate lesions in the deep white matter of the centrum semiovale
   3. CT2 hyperintensities involving the basal ganglia and thalami
   4. DA single vein running through the centre of the majority of the lesions on susceptibility-weighted imaging
   Show answer and explanation

   Correct answer: D. A single vein running through the centre of the majority of the lesions on susceptibility-weighted imaging

   The central vein sign reflects the perivenular inflammatory pathology of MS and is present in a high proportion of MS lesions but in relatively few microangiopathic, migrainous or NMOSD lesions; a threshold of about 40% of lesions (or the simplified 'rule of six') gives good discrimination. Periventricular caps, punctate deep white matter lesions and basal ganglia hyperintensities are all common in small-vessel disease and are non-specific.

   Reference: Sati P et al. The central vein sign and its clinical evaluation for the diagnosis of multiple sclerosis: a NAIMS consensus statement. Nature Reviews Neurology 2016

4. Question 4 · Movement Disorders

   A 69-year-old man with clearly levodopa-responsive Parkinson disease has disabling peak-dose dyskinesia and motor fluctuations. Neuropsychological testing shows mild executive dysfunction without dementia, and he has a history of recurrent depression currently in remission. Both subthalamic and pallidal targets are technically feasible. Which option is most appropriate?

   1. ASubthalamic nucleus stimulation, because it abolishes dyskinesia without any change in medication
   2. BSubthalamic nucleus stimulation, because cognitive and mood adverse effects are less frequent than with pallidal stimulation
   3. CDeep brain stimulation is absolutely contraindicated by the mild executive dysfunction
   4. DGlobus pallidus internus stimulation, because it has a direct antidyskinetic effect and carries a lower risk of cognitive and neuropsychiatric adverse effects than the subthalamic target
   Show answer and explanation

   Correct answer: D. Globus pallidus internus stimulation, because it has a direct antidyskinetic effect and carries a lower risk of cognitive and neuropsychiatric adverse effects than the subthalamic target

   Both targets give comparable motor benefit, but subthalamic stimulation permits greater dopaminergic dose reduction at the cost of more frequent cognitive decline, depression, apathy and impulsivity, whereas pallidal stimulation has a direct antidyskinetic effect and a more favourable neuropsychiatric profile, making it preferable when dyskinesia dominates and there are cognitive or mood concerns. Subthalamic stimulation reduces dyskinesia mainly through medication reduction rather than directly, and mild executive dysfunction without dementia is a relative rather than absolute contraindication.

   Reference: Odekerken VJJ et al. Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson's disease (NSTAPS study). Lancet Neurology, 2013; Follett KA et al. Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. New England Journal of Medicine, 2010

5. Question 5 · Clinical Neurophysiology, Neuroanatomical Localization and Neuroimaging

   A 22-year-old woman with recurrent syncope has an EEG showing bursts of sharply contoured 6 Hz activity over the midtemporal regions occurring only in drowsiness, running for 1-2 seconds, with no after-going slow wave and no disruption of the background. Which is the most appropriate interpretation?

   1. AFocal interictal epileptiform discharges supporting temporal lobe epilepsy
   2. BTemporal intermittent rhythmic delta activity
   3. CElectrographic seizure activity
   4. DRhythmic midtemporal theta of drowsiness, a benign normal variant
   Show answer and explanation

   Correct answer: D. Rhythmic midtemporal theta of drowsiness, a benign normal variant

   Rhythmic midtemporal theta of drowsiness (psychomotor variant) is a benign pattern of sharply contoured or notched 5-7 Hz rhythms confined to drowsiness, without evolution, after-going slow waves or background disruption, and it has no epileptogenic significance. True interictal discharges disrupt the background and are usually followed by a slow wave. Electrographic seizures evolve in frequency, morphology and field, and TIRDA is a delta-frequency pattern.

   Reference: Ebersole & Pedley, Current Practice of Clinical Electroencephalography, 4th ed. (2014); Tatum, Handbook of EEG Interpretation, 3rd ed. (2021)

6. Question 6 · Patient Safety and Quality in Neurological Care

   A 68-year-old man taking dabigatran, with his last dose four hours ago, develops an expanding traumatic subdural haematoma requiring urgent evacuation. Which intervention provides the most rapid and specific reversal?

   1. AAndexanet alfa by bolus and infusion
   2. BIdarucizumab 5 g intravenously
   3. CFour-factor prothrombin complex concentrate 50 units/kg
   4. DUrgent haemodialysis before transfer to theatre
   Show answer and explanation

   Correct answer: B. Idarucizumab 5 g intravenously

   Idarucizumab is the licensed specific monoclonal antibody fragment reversal agent for dabigatran and normalises dilute thrombin time within minutes. Andexanet alfa reverses factor Xa inhibitors such as apixaban and rivaroxaban, not dabigatran. Prothrombin complex concentrate is only a non-specific fallback if idarucizumab is unavailable, and although dabigatran is dialysable, haemodialysis is far too slow and impractical for a patient needing immediate craniotomy.

   Reference: ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants (2020); RE-VERSE AD trial, NEJM 2017

7. Question 7 · Cerebrovascular Disorders

   In the CREST trial comparing carotid endarterectomy with carotid artery stenting, which periprocedural pattern was observed?

   1. AStenting had fewer strokes but more myocardial infarctions than endarterectomy
   2. BStenting had a higher periprocedural stroke rate, whereas endarterectomy had a higher periprocedural myocardial infarction rate
   3. CBoth stroke and myocardial infarction were more frequent after stenting
   4. DThere was no difference in any individual outcome between the two procedures
   Show answer and explanation

   Correct answer: B. Stenting had a higher periprocedural stroke rate, whereas endarterectomy had a higher periprocedural myocardial infarction rate

   CREST found similar composite outcomes but a clear divergence in components: periprocedural stroke was more common with stenting, particularly in patients over about 70, while periprocedural myocardial infarction was more common with endarterectomy. This drives the practice of favouring endarterectomy in older patients with suitable anatomy and reserving stenting for those with hostile necks, restenosis or high surgical cardiac risk.

   Reference: Brott et al., CREST, NEJM 2010

8. Question 8 · Cephalgia and Headache Disorders

   A 70-year-old man with biopsy-proven giant cell arteritis has relapsed twice during prednisolone tapering and has developed steroid-induced hyperglycaemia and vertebral osteopenia. Which additional agent has randomised trial evidence for sustained remission and steroid sparing in giant cell arteritis?

   1. ARituximab
   2. BInfliximab
   3. CTocilizumab
   4. DHydroxychloroquine
   Show answer and explanation

   Correct answer: C. Tocilizumab

   The GiACTA trial showed that tocilizumab, an interleukin-6 receptor antagonist, achieves significantly higher sustained steroid-free remission rates and lowers cumulative corticosteroid exposure in giant cell arteritis, and it is recommended for relapsing disease or where steroid toxicity is a concern (noting that it suppresses CRP and ESR, so relapse must be judged clinically). Methotrexate has more modest evidence; rituximab, infliximab and hydroxychloroquine have not shown benefit in giant cell arteritis trials.

   Reference: Stone JH et al. Trial of Tocilizumab in Giant-Cell Arteritis (GiACTA). New England Journal of Medicine, 2017; ACR/VF Guideline 2021

9. Question 9 · Neuromuscular Disorders

   A 58-year-old woman treated 6 years ago with mastectomy and axillary radiotherapy for breast cancer develops slowly progressive numbness and weakness of the right arm over 12 months. Which combination of features most strongly favours radiation-induced brachial plexopathy rather than neoplastic infiltration of the plexus?

   1. ASevere early pain, lower trunk predominance and an ipsilateral Horner syndrome
   2. BRapidly progressive hand wasting with a supraclavicular mass
   3. CRelatively painless upper trunk weakness with lymphoedema and myokymic discharges on needle EMG
   4. DAcute onset with fever and raised inflammatory markers
   Show answer and explanation

   Correct answer: C. Relatively painless upper trunk weakness with lymphoedema and myokymic discharges on needle EMG

   Radiation plexopathy characteristically presents with paraesthesiae and relatively painless weakness in an upper trunk (C5-C6) distribution, often with arm lymphoedema and skin changes, and needle EMG shows myokymic discharges, a highly specific marker of radiation injury. Neoplastic plexopathy typically causes severe early pain, lower trunk (C8-T1) involvement and Horner syndrome, often with a palpable mass. Acute febrile presentations suggest infection rather than either diagnosis.

   Reference: Bradley and Daroff's Neurology in Clinical Practice, 8th edition (2022), plexopathy chapter; Jaeckle KA, Seminars in Neurology (2010), Neurologic manifestations of neoplastic and radiation-induced plexopathies

10. Question 10 · Neuro-Infectious Disorders

    The same patient's diagnosis of invasive meningococcal disease is confirmed. A neurology resident performed bag-mask ventilation without a mask during intubation, and the patient's flatmates are asking for advice. Which action is correct?

    1. ANo chemoprophylaxis is needed for anyone, because the patient has already received antibiotics
    2. BChemoprophylaxis should be offered to all ward staff who entered the room, but the case need not be notified
    3. CNotify the public health authority urgently as a notifiable disease, and offer chemoprophylaxis (for example ciprofloxacin, rifampicin or ceftriaxone) to household or equivalent close contacts and to the healthcare worker with direct unprotected exposure to respiratory secretions
    4. DOffer only vaccination to close contacts, as chemoprophylaxis is ineffective
    Show answer and explanation

    Correct answer: C. Notify the public health authority urgently as a notifiable disease, and offer chemoprophylaxis (for example ciprofloxacin, rifampicin or ceftriaxone) to household or equivalent close contacts and to the healthcare worker with direct unprotected exposure to respiratory secretions

    Invasive meningococcal disease is a statutorily notifiable condition in GCC states and internationally, and prompt notification allows public health contact tracing. Chemoprophylaxis is indicated for household and equivalent close contacts and for healthcare workers with direct unprotected exposure to respiratory secretions, such as during airway management, ideally within 24 hours. Casual ward contact does not warrant prophylaxis, treatment of the index case does not protect contacts, and vaccination is a complementary measure for certain serogroups but does not replace prompt chemoprophylaxis.

    Reference: CDC Meningococcal Disease chemoprophylaxis recommendations, MMWR ACIP (2020); WHO meningitis outbreak response guidance