171. A 65-year-old right-handed woman began having neurological problems about 1 week ago. She began experiencing nausea, vomiting, and numbness in the left hand and left foot. Today she had a generalized convulsion, and since then she has had a throbbing headache that is worse when she bends forward. On examination, the only deficits she has are loss of double simultaneous tactile stimulation and left lower facial droop when smiling. MRI reveals a lesion suggestive of a primary brain tumor. Which of the following is the most common source of primary brain tumors?
a. Glial cells
b. Neurons
c. Meningeal cells
d. Lymphocytes
e. Endothelial cells
172. A previously healthy 31-year-old man collapses in the kitchen of his home while sitting at the table talking. His wife witnessed a convulsion that lasted about 2 minutes. He seems to recover fully within an hour. The history taken in the emergency room reveals that he has been having new headaches in the early morning hours over the past few weeks. A brain magnetic resonance imaging (MRI) indicates that there is an enhancing right frontal lesion that is most likely a primary brain neoplasm. Which of the following is the most common type of primary brain tumor?
a. Meningioma
b. Astrocytoma
c. Lymphosarcoma
d. Oligodendroglioma
e. Medulloblastoma
173. A 7-year-old girl has been diagnosed with a brain tumor. The parents are both well educated with a scientific background and have many questions. During the course of the discussion, you might tell them that most brain tumors in children are which of the following?
a. Metastatic lesions from outside the central nervous system (CNS)
b. Oligodendrogliomas
c. Glioblastomas multiforme
d. Meningiomas
e. Infratentorial
174. As you provide the parents of the patient (see question 173) with some information, it prompts many more questions. The overall incidence of primary brain tumors in children is approximately 1-to-5 per 100,000 per year. Which of the following account for the majority?
a. Meningiomas and neurofibromas
b. Astrocytomas and medulloblastomas
c. Melanomas and choriocarcinomas
d. Gliomas and adenomas
e. Colloid cysts of the third ventricle
175. A 72-year-old woman has a head computed tomography (CT) performed because of headaches. It is significant for a left hemisphere mass with an overlying hyperostosis of the skull. She most likely has which of the following?
a. Meningioma
b. Pituitary adenoma
c. Astrocytoma
d. Schwannoma
e. Hemangioblastoma
176. Upon routine examination by her pediatrician, a 9-year-old girl is discovered to have precocious puberty. More careful examination discovers the presence of papilledema. This patient is most likely to have which of the following?
a. A pineal region tumor
b. An oligodendroglioma
c. A Kernohan class II astrocytoma
d. A brainstem glioma
e. An ependymoma
177. A 15-year-old boy has multiple angiomatoses of the retina and cysts of the kidney and pancreas. Which of the following brain tumors is most likely to develop in this child?
a. Glioblastoma multiforme
b. Meningioma
c. Hemangioblastoma
d. Ependymoma
e. Pinealoma
178. A 56-year-old right-handed woman who had breast cancer 1 year ago began having neurological problems about 1 week ago. She began experiencing nausea, vomiting, and numbness in the right hand and foot. Today she is experiencing crescendo pain in the left retroorbital area. Her headache is throbbing and positional, particularly when she tries to bend forward. The headache was intense in the morning, and at times it woke her up last night. On examination, the only deficits are loss of double simultaneous tactile stimulation and right lower facial droop when smiling. Which of the following is the most appropriate next action?
a. Administer intravenous prochlorperazine
b. Give the patient a prescription for zolmitriptan
c. Make a follow-up appointment for next month
d. Order an electroencephalogram (EEG) to rule out seizures
e. Get a brain MRI
179. A 60-year-old woman presents to her internist with 2 months of new headaches and some difficulty walking. Further evaluation reveals multiple brain masses. Which of the following is the most common source of meta-static tumors to the brain in patients without a known primary tumor?
a. Breast
b. Lung
c. Kidney
d. Skin
e. Uterus
180. A 29-year-old woman with a history of malignant melanoma presents to her primary care doctor with a new type of headache. Examination is normal, and a head CT is ordered. Multiple small brain hemorrhages are revealed by the scan. Metastatic lesions to the brain most often appear in which of the following locations?
a. At the gray–white junction
b. In the thalamus
c. In the posterior fossa
d. In the caudate
e. In the sella turcica
181. The shortest life expectancy with metastatic disease to the brain will be found in the patient with which of the following metastatic cancers?
a. Malignant melanoma
b. Breast cancer
c. Lung cancer
d. Renal cancer
e. Prostate cancer
182. A 30-year-old, normally developed, and generally healthy man has had new intermittent headaches for 1 year. Over the past several months they have been becoming more frequent and were twice accompanied by syncope. The patient has an MRI performed, and a colloid cyst of the third ventricle is identified. Which of the following is the most common complication of this lesion?
a. Bitemporal hemianopsia
b. Hydrocephalus
c. Hemiparesis
d. Optic atrophy
e. Oscillopsia
183. A 45-year-old right-handed man who has been human immunodeficiency virus (HIV) positive for the past 3 years has noticed some sort of visual change over the past 1 to 2 months. It is difficult for him to describe, but it is some sort of distortion of part of his right visual field. There is a 4-cm rim-enhancing lesion in the left occipital lobe that is revealed by MRI. Which of the following tumor types is common in the brain of patients with acquired immune deficiency syndrome (AIDS), but otherwise extremely rare?
a. Lymphocytic leukemia
b. Metastatic lymphoma
c. Primary lymphoma
d. Kaposi sarcoma
e. Lymphosarcoma
184. A 37-year-old man presents with visual impairment. Examination reveals a bitemporal hemianopsia. Which of the following tumors is most likely responsible for this finding?
a. Optic glioma
b. Occipital astrocytoma
c. Brainstem glioma
d. Pituitary adenoma
e. Sphenoid wing meningioma
185. A 9-year-old developmentally delayed girl has precocious puberty and poorly controlled seizures. Her seizures are typically preceded by episodes of uncontrollable laughter. Which of the following mass lesions might explain her symptoms?
a. Craniopharyngioma
b. Choroid plexus papilloma
c. Giant aneurysm
d. Metastatic carcinoma
e. Hypothalamic hamartoma
186. A 35-year-old woman has worsening intermittent headaches and “dizzy spells” over the course of several months. Examination in between attacks is normal. An MRI reveals a mass in the posterior fossa suggestive of an ependymoma. This patient is potentially at risk of dying because of which of the following?
a. Transforaminal herniation
b. Emboli from the tumor
c. Vascular occlusion by the tumor
d. Hemorrhagic necrosis of the tumor
e. Status epilepticus
Questions 187 to 191
Match each clinical scenario with the appropriate type of tumor. Each lettered option may be used once, more than once, or not at all.
a. Medulloblastoma
b. Oligodendroglioma
c. Optic glioma
d. Carcinomatous meningitis
e. Vestibular schwannoma
f. Choriocarcinoma
g. Metastatic carcinoma
h. Pineocytoma
i. Primary CNS lymphoma
187. A 30-year-old man with AIDS develops headaches and left hemiparesis and is found to have a right frontal white matter homogeneously enhancing lesion.
188. A 4-year-old boy presents with ataxia, lethargy, and obstructive hydrocephalus.
189. A 16-year-old boy with café au lait spots and cutaneous nodules has a gradual decrease of vision in his left eye.
190. A 55-year-old woman presents with mild unsteadiness, tinnitus, and hearing loss.
191. A 13-year-old girl has headaches and diplopia. On examination, she has impaired upward gaze, lid retraction, and convergence-retraction nystagmus. Her pupils react on convergence but not to light.
Questions 192 to 195
Match each clinical scenario with the most likely causative disorder. Each lettered option may be used once, more than once, or not at all.
a. Paraneoplastic cerebellar degeneration
b. Limbic encephalitis
c. Dorsal root ganglionopathy
d. Hypercalcemia
e. Cancer-associated retinopathy
f. Pseudotumor cerebri
g. Motor neuron disease
h. Guillain-Barré syndrome
i. Paraproteinemic neuropathy
j. Opsoclonus-myoclonus
k. Stiff man syndrome
l. Lambert-Eaton myasthenic syndrome
m. Myasthenia gravis
192. A 67-year-old woman has a 2-month history of progressive gait disturbance. On examination, she has dysmetria of the limbs; a wide-based, unsteady gait; and hypermetric saccades. A hard, firm breast lump is discovered.
193. A 70-year-old man with a history of lung cancer develops nausea and vomiting and then becomes lethargic. On examination, he is lethargic but arousable, disoriented, and inattentive. He is weak proximally and has diminished reflexes.
194. A 57-year-old woman with a history of smoking has a 3-month history of hip and shoulder weakness. She also complains of xerostomia. There are no sensory symptoms, and she is cognitively intact. On examination, she is orthostatic. There is proximal muscle weakness, but she has increasing muscle strength with repetitive activity of her muscles. Eye movements are normal.
195. A 65-year-old woman develops pain and paresthesias in her feet. On examination, she has loss of reflexes, stocking distribution sensory loss, and mild distal weakness. Serum protein electrophoresis reveals a monoclonal gammopathy, and bone marrow biopsy reveals plasma cell dyscrasia.