A lesion selectively injures the most ventral brainstem region containing large corticospinal and corticobulbar fiber bundles. Which region is affected?

A. Brainstem basis
B. Brainstem tegmentum
C. Brainstem tectum
D. Reticular core

A. Brainstem basis

A rostral midbrain section shows red nuclei and oculomotor nuclei. Which landmark is present?

A. Inferior colliculi
B. Basis pontis
C. Superior colliculi
D. Pyramidal decussation

C. Superior colliculi

A caudal midbrain section contains trochlear nuclei and brachium conjunctivum. Which landmark is present?

A. Superior colliculi
B. Inferior colliculi
C. Ventral pons
D. Olivary complex

B. Inferior colliculi

The cerebral peduncles are composed of:

A. Tectum and tegmentum
B. Red nucleus and tectum
C. Substantia nigra and tegmentum
D. Substantia nigra and basis pedunculi

D. Substantia nigra and basis pedunculi

The superior and inferior colliculi are components of the:

A. Tegmentum
B. Basis
C. Peduncle
D. Tectum

D. Tectum

The ventral pons consists primarily of:

A. Tectum and tegmentum
B. Basis pontis and pontine nuclei
C. Olive and pyramids
D. Inferior olives and reticular formation

B. Basis pontis and pontine nuclei

The basis pontis contains which descending tracts?

A. Spinothalamic and gracile
B. Rubrospinal and tectospinal
C. Corticospinal and corticobulbar
D. Vestibulospinal and reticulospinal

C. Corticospinal and corticobulbar

Pontine nuclei are most directly involved in:

A. Taste relay
B. Visceral pain relay
C. Auditory decussation
D. Cerebellar function

D. Cerebellar function

The fourth ventricle begins within the:

A. Pons
B. Midbrain
C. Medulla
D. Cervical cord

A. Pons

The pyramidal decussation marks the:

A. Midbrain-pons junction
B. Pons-medulla junction
C. Medulla-spinal cord transition
D. Cervicomedullary nerve entry

C. Medulla-spinal cord transition

The spinal accessory nucleus is located in the:

A. Lower medulla only
B. Entire cervical cord
C. Upper thoracic cord
D. Upper five cervical segments

D. Upper five cervical segments

A tiny paramedian pontine lesion near the floor of the fourth ventricle most likely injures which nucleus first?

A. Facial nucleus
B. Abducens nucleus
C. Vestibular nucleus
D. Trigeminal motor nucleus

B. Abducens nucleus

The oculomotor nuclei are located in the:

A. Rostral midbrain, superior colliculus
B. Caudal midbrain, inferior colliculus
C. Rostral pons, facial colliculus
D. Caudal medulla, hypoglossal trigone

A. Rostral midbrain, superior colliculus

The trochlear nuclei are located in the:

A. Rostral midbrain, tectum
B. Pons, facial colliculus
C. Medulla, vestibular area
D. Caudal midbrain, inferior colliculus

D. Caudal midbrain, inferior colliculus

Internuclear ophthalmoplegia reflects damage to a tract interconnecting ocular motor nuclei with the:

A. Solitary nucleus
B. Facial nucleus
C. Vestibular nuclei
D. Nucleus ambiguus

C. Vestibular nuclei

The hypoglossal trigones form part of the:

A. Midbrain tectum
B. Floor of fourth ventricle
C. Pontine basis
D. Inferior cerebellar peduncle

B. Floor of fourth ventricle

Which set contains only branchial motor nuclei?

A. V motor, VII, ambiguus, XI
B. III, IV, VI, XII
C. Solitary, dorsal vagal, EW
D. Vestibular, cochlear, gracile, cuneate

A. V motor, VII, ambiguus, XI

The trapezoid body is best defined as:

A. Midbrain visual relay
B. Caudal pontine auditory decussation
C. Medullary corticospinal crossing
D. Rostral pontine taste relay

B. Caudal pontine auditory decussation

General and special visceral afferents terminate primarily in the:

A. Dorsal motor nucleus
B. Spinal trigeminal nucleus
C. Nucleus solitarius
D. Inferior salivatory nucleus

C. Nucleus solitarius

A patient loses taste from territories carried by CN VII, IX, and X. These afferents would normally terminate in the:

A. Caudal nucleus ambiguus
B. Main sensory trigeminal nucleus
C. Vestibular nuclear complex
D. Rostral nucleus solitarius

D. Rostral nucleus solitarius

The brachium conjunctivum is another name for the:

A. Superior cerebellar peduncle
B. Inferior cerebellar peduncle
C. Middle cerebellar peduncle
D. Medial longitudinal fasciculus

A. Superior cerebellar peduncle

A patient with impaired carotid sinus and visceral cardiorespiratory reflex input has a lesion of which nucleus?

A. Rostral nucleus solitarius
B. Caudal nucleus solitarius
C. Dorsal motor nucleus X
D. Nucleus ambiguus

B. Caudal nucleus solitarius

General visceral afferents from CN IX and X terminate primarily in the:

A. VPM
B. VPL
C. Rostral nucleus solitarius
D. Caudal nucleus solitarius

D. Caudal nucleus solitarius

Taste fibers ascend from the medulla to the thalamus through the:

A. Medial lemniscus
B. Solitary tract
C. Central tegmental tract
D. Dorsal longitudinal fasciculus

C. Central tegmental tract

Taste fibers from the nucleus solitarius synapse in which thalamic nucleus?

A. VPL
B. VPM
C. VA
D. Pulvinar

B. VPM

In the rostral medulla, the nucleus solitarius surrounds the:

A. Solitary tract
B. Spinal trigeminal tract
C. Medial lemniscus
D. Inferior cerebellar peduncle

A. Solitary tract

Fibers from which cranial nerves course in the solitary tract?

A. III, IV, VI
B. V, VII, VIII
C. VII, IX, X
D. IX, X, XII

C. VII, IX, X

The spinal trigeminal tract carries sensory fibers from which cranial nerves?

A. V only
B. V and VII
C. V, VII, IX, X
D. VII, IX, X

C. V, VII, IX, X

The MLF interconnects oculomotor and trochlear nuclei with the:

A. Facial and cochlear nuclei
B. Abducens and vestibular nuclei
C. Solitary and ambiguus nuclei
D. Trigeminal and hypoglossal nuclei

B. Abducens and vestibular nuclei

The trigeminal nuclear complex consists of:

A. Mesencephalic, chief sensory, spinal trigeminal
B. Chief sensory, ambiguus, mesencephalic
C. Spinal trigeminal, vestibular, chief sensory
D. Mesencephalic, facial, spinal trigeminal

A. Mesencephalic, chief sensory, spinal trigeminal

The trigeminal nuclear complex extends from the:

A. Pons to medulla
B. Midbrain to upper cervical cord
C. Midbrain to thoracic cord
D. Medulla to lumbar cord

B. Midbrain to upper cervical cord

A lesion of the spinal trigeminal nucleus would most directly impair:

A. Jaw proprioception
B. Facial pain and temperature
C. Facial fine touch
D. Auditory localization

B. Facial pain and temperature

The chief sensory trigeminal nucleus primarily conveys:

A. Taste from tongue
B. Pain from face
C. Fine touch from face
D. Motor to mastication

C. Fine touch from face

Auditory pathways are unusual because they decussate:

A. Only in caudal pons
B. Only in midbrain
C. Only in medulla
D. At multiple levels

D. At multiple levels

All visceral afferents, both general and special, project to the:

A. Nucleus ambiguus
B. Dorsal motor nucleus X
C. Nucleus solitarius
D. Chief sensory nucleus V

C. Nucleus solitarius

The rostral nucleus solitarius receives primarily:

A. Gustatory afferents
B. Vestibular afferents
C. Somatic pain afferents
D. Auditory afferents

A. Gustatory afferents

The caudal nucleus solitarius receives primarily:

A. Gustatory and visual input
B. Cardiorespiratory and GI input
C. Facial touch and pain
D. Vestibular and auditory input

B. Cardiorespiratory and GI input

Which cranial nerves send taste afferents to the rostral nucleus solitarius?

A. V, VII, IX
B. VII, IX, X
C. IX, X, XII
D. V, IX, X

B. VII, IX, X

In the midbrain, corticospinal and corticobulbar fibers occupy which part of the cerebral peduncle?

A. Medial third
B. Lateral third
C. Dorsal third
D. Middle third

D. Middle third

The remaining portions of the cerebral peduncle carry predominantly:

A. Corticopontine fibers
B. Spinothalamic fibers
C. Medial lemniscus fibers
D. Vestibulospinal fibers

A. Corticopontine fibers

Medial lemniscus fibers synapse in which thalamic nucleus?

A. VPM
B. VPL
C. VL
D. VA

B. VPL

A patient is awake and cognitively intact but quadriplegic and anarthric. Vertical eye movements are spared. This syndrome is:

A. Medial medullary syndrome
B. One-and-a-half syndrome
C. Locked-in syndrome
D. Vegetative state

C. Locked-in syndrome

Locked-in syndrome classically results from infarction of the:

A. Dorsal midbrain
B. Ventral pons
C. Lateral medulla
D. Medial thalamus

B. Ventral pons

The major tracts bilaterally injured in classic locked-in syndrome are the:

A. Spinothalamic and sympathetic
B. Medial lemnisci and MLF
C. Corticospinal and corticobulbar
D. Solitary and trigeminothalamic

C. Corticospinal and corticobulbar

In locked-in syndrome, which function is classically preserved?

A. Limb movement
B. Facial expression
C. Horizontal gaze
D. Vertical eye opening

D. Vertical eye opening

A patient with classic locked-in syndrome can still blink and move the eyes vertically. Which structure is most likely spared?

A. Pontine gaze centers
B. Rostral midbrain tegmentum
C. Ventral medullary pyramids
D. Medial thalamic nuclei

B. Rostral midbrain tegmentum

Horizontal eye movements are usually lost in locked-in syndrome because they depend mainly on:

A. Midbrain tectal circuits
B. Cerebellar vermal circuits
C. Hypothalamic arousal nuclei
D. Pontine gaze circuits

D. Pontine gaze circuits

Patients with prolonged locked-in syndrome most commonly eventually die from:

A. Respiratory infection
B. Status epilepticus
C. Thalamic hemorrhage
D. Renal failure

A. Respiratory infection

The decussation of the superior cerebellar peduncles occurs at the:

A. Superior colliculi
B. Pontomedullary junction
C. Pyramidal decussation
D. Inferior colliculi

D. Inferior colliculi

The middle cerebellar peduncle is best described as the:

A. Smallest peduncle
B. Vestibular output tract
C. Largest cerebellar peduncle
D. Major cerebellar output

C. Largest cerebellar peduncle

The middle cerebellar peduncle receives massive input primarily from the:

A. Pontine nuclei
B. Red nucleus
C. Inferior olive
D. Vestibular nuclei

A. Pontine nuclei

Corticopontine fibers that ultimately influence the cerebellum travel first to the:

A. Vestibular nuclei
B. Pontine nuclei
C. Dentate nucleus
D. Fastigial nucleus

B. Pontine nuclei

The inferior cerebellar peduncle primarily carries afferents from the:

A. Spinal cord
B. Basal forebrain
C. Cerebral cortex
D. Thalamus

A. Spinal cord

The red nucleus receives major cerebellar input through the:

A. Inferior cerebellar peduncle
B. Middle cerebellar peduncle
C. Medial lemniscus
D. Superior cerebellar peduncle

D. Superior cerebellar peduncle

Palatal myoclonus is characterized by:

A. Intermittent jaw deviation
B. Continuous clicking palate
C. Episodic tongue fasciculations
D. Rhythmic eyelid flutter

B. Continuous clicking palate

The central core of nuclei extending through the entire brainstem is the:

A. Olivary complex
B. Reticular formation
C. Trigeminal complex
D. Vestibular complex

B. Reticular formation

Within the brainstem, the reticular formation lies primarily in the:

A. Basis
B. Tectum
C. Tegmentum
D. Pyramid

C. Tegmentum

Rostrally, the reticular formation is continuous with certain:

A. Cerebellar nuclei
B. Diencephalic nuclei
C. Basal ganglia nuclei
D. Septal nuclei

B. Diencephalic nuclei

The rostral reticular formation is most important for maintaining:

A. Cortical alertness
B. Fine motor control
C. Visual acuity
D. Language output

A. Cortical alertness

The caudal reticular formation is most associated with:

A. Episodic memory consolidation
B. Visual reflex suppression
C. Motor, reflex, autonomic functions
D. Olfactory discrimination

C. Motor, reflex, autonomic functions

The consciousness system is formed mainly by the rostral reticular arousal system plus the:

A. Primary motor cortices
B. Occipital association cortices
C. Medial temporal cortices
D. Frontoparietal association cortices

D. Frontoparietal association cortices

A lesion most likely to produce coma would involve the:

A. Unilateral cerebellar hemisphere
B. Upper brainstem reticular formation
C. Primary visual cortex
D. Unilateral frontal operculum

B. Upper brainstem reticular formation

Bilateral thalamic lesions causing coma most characteristically involve the:

A. Medial intralaminar regions
B. Pulvinar
C. Geniculate bodies
D. Ventral posterior nuclei

A. Medial intralaminar regions

The ascending reticular activating system is located mainly in the:

A. Ventral pons and medulla
B. Cerebellar vermis and fastigium
C. Basal forebrain and amygdala
D. Rostral midbrain, medial diencephalon

D. Rostral midbrain, medial diencephalon

Stimulation of the ascending reticular activating system during deep anesthesia would most likely produce:

A. Arousal
B. Decerebrate rigidity
C. Aphasia
D. Hemianopia

A. Arousal

Cell bodies contributing prominently to reticular alerting systems are concentrated in the:

A. Midbrain and rostral pons
B. Medulla and upper cervical cord
C. Basal forebrain and amygdala
D. Thalamus and hypothalamus

A. Midbrain and rostral pons

Which description best matches the intralaminar thalamic nuclei?

A. GABAergic to cerebellum only
B. Glutamatergic to cortex and striatum
C. Cholinergic to spinal cord
D. Dopaminergic to hippocampus

B. Glutamatergic to cortex and striatum

Which description best matches the midline thalamic nuclei?

A. GABAergic to basal ganglia
B. Serotonergic to cortex
C. Glutamatergic to cortex
D. Dopaminergic to amygdala

C. Glutamatergic to cortex

Diffuse projections from the locus ceruleus and lateral pontomedullary tegmentum regulate attention, mood, and sleep-wake state. ADD medications often enhance:

A. Dopaminergic transmission
B. Cholinergic transmission
C. Serotonergic transmission
D. Noradrenergic transmission

D. Noradrenergic transmission

Neurons of the locus ceruleus and lateral tegmental area primarily release:

A. Serotonin
B. Histamine
C. Norepinephrine
D. Dopamine

C. Norepinephrine

A pharmacologic strategy often helpful in narcolepsy is enhancement of:

A. GABAergic signaling
B. Histaminergic signaling
C. Cholinergic signaling
D. Noradrenergic signaling

D. Noradrenergic signaling

Dopaminergic cell bodies are found mainly in the:

A. Ventral midbrain
B. Lateral medulla
C. Basal forebrain
D. Posterior thalamus

A. Ventral midbrain

The two major ventral midbrain dopaminergic nuclei are the:

A. Raphe and locus ceruleus
B. Tuberomammillary and VTA
C. Substantia nigra and VTA
D. Red nucleus and VTA

C. Substantia nigra and VTA

Dopamine projects prominently to all of the following except the:

A. Striatum
B. Prefrontal cortex
C. Nucleus accumbens
D. Cerebellar cortex

D. Cerebellar cortex

Which combination best matches core dopaminergic functions?

A. Smell, language, posture
B. Movement, initiative, working memory
C. Hearing, satiety, analgesia
D. Vision, arousal, swallowing

B. Movement, initiative, working memory

The three major dopamine projection systems are:

A. Nigrostriatal, mesolimbic, mesocortical
B. Reticulospinal, rubrospinal, corticospinal
C. Spinocerebellar, olivary, tectal
D. Raphe, hypothalamic, striatal

A. Nigrostriatal, mesolimbic, mesocortical

The mesostriatal pathway is also called the:

A. Nigrostriatal pathway
B. Mesothalamic pathway
C. Rubrostriatal pathway
D. Spinostriatal pathway

A. Nigrostriatal pathway

The mesostriatal pathway arises mainly from the:

A. Ventral tegmental area
B. Substantia nigra pars compacta
C. Raphe nuclei
D. Locus ceruleus

B. Substantia nigra pars compacta

The principal targets of the mesostriatal pathway are the:

A. Amygdala and hippocampus
B. Cingulate and insula
C. Caudate and putamen
D. Thalamus and cortex

C. Caudate and putamen

Dysfunction of the mesostriatal pathway most classically causes:

A. Parkinson disease
B. Narcolepsy
C. OCD
D. SIDS

A. Parkinson disease

The mesolimbic pathway arises mainly from the:

A. Raphe nuclei
B. Ventral tegmental area
C. Substantia nigra reticulata
D. Tuberomammillary nucleus

B. Ventral tegmental area

The mesolimbic pathway projects predominantly to:

A. Limbic structures
B. Spinal cord
C. Cerebellar nuclei
D. Primary visual cortex

A. Limbic structures

Which structure is a key mesolimbic target?

A. VPL
B. Nucleus ambiguus
C. Nucleus accumbens
D. Dentate nucleus

C. Nucleus accumbens

The mesolimbic pathway is most strongly linked to:

A. Respiration and arousal
B. Reward and addiction
C. Temperature and pain
D. Taste and salivation

B. Reward and addiction

Overactivity of the mesolimbic pathway is most associated with the positive symptoms of:

A. Major depression
B. Parkinson disease
C. Bipolar disorder
D. Schizophrenia

D. Schizophrenia

The mesocortical pathway arises mainly from the:

A. Ventral tegmental area
B. Substantia nigra pars reticulata
C. Raphe nuclei
D. Caudate nucleus

A. Ventral tegmental area

The principal target of the mesocortical pathway is the:

A. Putamen
B. Prefrontal cortex
C. Amygdala
D. Hypothalamus

B. Prefrontal cortex

Mesocortical dopamine is most associated with:

A. Fine touch perception
B. Working memory, motor initiation
C. Auditory localization
D. Thermoregulation, pain

B. Working memory, motor initiation

Damage to the mesocortical pathway may contribute to cognitive defects and hypokinesia in:

A. Schizophrenia
B. Narcolepsy
C. Parkinson disease
D. OCD

C. Parkinson disease

Mesocortical dopamine dysfunction is implicated in the negative symptoms of:

A. Parkinson disease
B. Schizophrenia
C. Depression
D. SIDS

B. Schizophrenia

Serotonergic cell bodies are located mainly in the:

A. Raphe nuclei
B. Basal nuclei
C. Red nuclei
D. Inferior olives

A. Raphe nuclei

A neurotransmitter system arising from midbrain, pons, and medulla and projecting throughout the CNS is most likely:

A. Histamine
B. Serotonin
C. Dopamine
D. Acetylcholine

B. Serotonin

Which set best matches major serotonin functions?

A. Alertness, mood, breathing, pain modulation
B. Movement, reward, appetite, memory
C. Vision, hearing, smell, language
D. Salivation, chewing, blinking, gait

A. Alertness, mood, breathing, pain modulation

Which condition is associated with defective serotonin neurons causing impaired arousal to hypoventilation?

A. Cataplexy
B. Parkinson disease
C. Sudden infant death syndrome
D. Locked-in syndrome

C. Sudden infant death syndrome

Histaminergic neurons are found prominently in the:

A. Tuberomammillary nucleus
B. Locus ceruleus
C. Raphe magnus
D. Substantia nigra

A. Tuberomammillary nucleus

A first-generation antihistamine causes drowsiness primarily by blocking CNS histamine receptors. Which parallel alerting system, arising from the posterior lateral thalamus and projecting widely, also promotes alertness and food intake?

A. Orexin
B. Dopamine
C. Serotonin
D. Acetylcholine

A. Orexin

A neurotransmitter system sends widespread projections from a single origin to many targets throughout the nervous system. This best defines:

A. Corticobulbar tract
B. Segmental interneuron loop
C. Diffuse projection system
D. Medial lemniscus pathway

C. Diffuse projection system

Which pair contains basal forebrain cholinergic nuclei?

A. Nucleus basalis, medial septal
B. Raphe, locus ceruleus
C. VTA, substantia nigra
D. Olive, red nucleus

A. Nucleus basalis, medial septal

Pontomesencephalic cholinergic neurons are found mainly in the:

A. Raphe and olive
B. Basalis and septum
C. VTA and accumbens
D. Pedunculopontine and laterodorsal nuclei

D. Pedunculopontine and laterodorsal nuclei

Which combination best matches CNS acetylcholine function?

A. Pain, taste, temperature
B. Alertness, memory, learning
C. Vision, hearing, smell
D. Hunger, satiety, thirst

B. Alertness, memory, learning

Cholinergic projections to the hippocampal formation arise mainly from the:

A. Raphe and locus ceruleus
B. Pedunculopontine and laterodorsal nuclei
C. Medial septal and diagonal band
D. VTA and substantia nigra

C. Medial septal and diagonal band

Hippocampal theta rhythm is thought to contribute mainly to:

A. Memory functions
B. Auditory localization
C. Bladder control
D. Pain modulation

A. Memory functions

The predominant cholinergic receptor type in the CNS is:

A. Nicotinic
B. Glycinergic
C. Adrenergic
D. Muscarinic

D. Muscarinic

Pharmacologic blockade of central cholinergic transmission most classically causes:

A. Coma and apnea
B. Delirium, memory deficits
C. Hemiballismus, aphasia
D. Deafness, anosmia

B. Delirium, memory deficits

Degeneration of basal forebrain cholinergic neurons is strongly linked to memory decline in:

A. Alzheimer disease
B. Huntington disease
C. Narcolepsy
D. SIDS

A. Alzheimer disease

Lesions or blockade of cholinergic or histaminergic systems usually cause:

A. Immediate brain death
B. Flaccid quadriplegia
C. Confusion and drowsiness
D. Profound coma only

C. Confusion and drowsiness

Adenosine receptors important for alertness modulation are located mainly in the:

A. Brainstem, spinal cord
B. Thalamus and cortex
C. Cerebellum and retina
D. Amygdala and striatum

B. Thalamus and cortex

Caffeine increases alertness primarily by:

A. Blocking adenosine receptors
B. Activating glycine receptors
C. Inhibiting histamine release
D. Blocking muscarinic receptors

A. Blocking adenosine receptors

Sleep-promoting regions are postulated to lie in the:

A. Medullary reticular formation and solitarius
B. Basal ganglia and cerebellum
C. Optic tract and pulvinar
D. Corpus callosum and fornix

A. Medullary reticular formation and solitarius

Galanin contributes mainly to:

A. Visual dream imagery
B. Reward-related learning
C. Inhibitory sleep pathways
D. Dopamine synthesis

C. Inhibitory sleep pathways

The ventrolateral preoptic area promotes non-REM sleep by releasing:

A. Glutamate and histamine
B. Dopamine and glycine
C. Serotonin and norepinephrine
D. GABA and galanin

D. GABA and galanin

Which transmitters progressively decrease firing during stages 1–4 non-REM and are silent during REM?

A. Norepinephrine, serotonin
B. Acetylcholine, dopamine
C. Histamine, orexin
D. GABA, glycine

A. Norepinephrine, serotonin

Which transmitter increases during REM sleep?

A. Serotonin
B. Histamine
C. Acetylcholine
D. Norepinephrine

C. Acetylcholine

PGO waves are thought to contribute primarily to:

A. Postural tone
B. Dream visual imagery
C. Taste processing
D. Corticospinal decussation

B. Dream visual imagery

REM sleep behavior disorder most likely results from:

A. Locus ceruleus lesions
B. Orexin deficiency
C. Damage to REM-on inhibition
D. Bilateral hippocampal injury

C. Damage to REM-on inhibition

According to this material, melanin levels are:

A. Unchanged across states
B. Higher during wakefulness
C. Higher during sleep
D. Absent during REM

C. Higher during sleep

The suprachiasmatic nucleus is crucial because it:

A. Sets circadian rhythms
B. Generates muscle tone
C. Mediates taste
D. Drives saccades

A. Sets circadian rhythms

Coma is best defined as:

A. Sleep with easy arousal
B. Reflex eye opening only
C. Awake without awareness
D. Unarousable, eyes closed

D. Unarousable, eyes closed

Coma most commonly results from trauma or anoxia causing dysfunction of:

A. Cerebellum and basal ganglia
B. Cortex and arousal systems
C. Retina and tectum
D. Spinal cord only

B. Cortex and arousal systems

Which finding favors coma rather than brain death?

A. Only spinal reflexes persist
B. No brainstem reflexes
C. Preserved brainstem reflexes
D. No forebrain function

C. Preserved brainstem reflexes

A patient regains sleep-wake cycles, opens the eyes, and turns toward sound but remains unconscious for 6 weeks. This is:

A. Persistent vegetative state
B. Brain death
C. Narcolepsy
D. Delirium

A. Persistent vegetative state

The earliest sign that a severely impaired patient may be emerging from a vegetative state is often:

A. Purposeful speech
B. Visual tracking
C. Command following
D. Withdrawal to pain

B. Visual tracking

Akinetic mutism, abulia, and catatonia all involve dysfunction of circuits linking the:

A. Cerebellum and medulla
B. Frontal lobes and diencephalon
C. Occipital cortex and pons
D. Hippocampus and amygdala

B. Frontal lobes and diencephalon

Which additional projection system is commonly implicated in akinetic mutism, abulia, and catatonia?

A. Ascending cholinergic
B. Descending corticospinal
C. Ascending dopaminergic
D. Spinothalamic

C. Ascending dopaminergic

The syndrome in which a patient appears awake, tracks visually, but remains unresponsive is:

A. Abulia
B. Akinetic mutism
C. Brain death
D. Status epilepticus

B. Akinetic mutism

Akinetic mutism is best viewed as an extreme form of:

A. Cataplexy
B. Delirium
C. Abulia
D. Aphasia

C. Abulia

Abulia is defined as an inability to:

A. Sleep or dream
B. Act or decide
C. Maintain posture
D. Recognize faces

B. Act or decide

Which medication class may reverse abulia or akinetic mutism in some patients?

A. Dopaminergic agonists
B. Cholinergic antagonists
C. GABA agonists
D. Serotonergic antagonists

A. Dopaminergic agonists

Catatonia may appear as an akinetic state in advanced cases of:

A. Parkinson disease
B. Narcolepsy
C. Schizophrenia
D. Alzheimer disease

C. Schizophrenia

Which dysfunction has been implicated in catatonia?

A. Occipital and vestibular
B. Frontal and dopaminergic
C. Cerebellar and serotonergic
D. Temporal and cholinergic

B. Frontal and dopaminergic

Status epilepticus is best defined as:

A. Recurrent syncopal episodes
B. Continuous seizure activity
C. Repeated transient ischemia
D. Intermittent myoclonus only

B. Continuous seizure activity

A patient is comatose from brainstem dysfunction. A common mechanism is:

A. Optic nerve compression
B. Cerebellar mass compression
C. Unilateral temporal sclerosis
D. Basal ganglia calcification

B. Cerebellar mass compression

Intrinsic brainstem lesions causing coma most commonly include:

A. Infarct or hemorrhage
B. Migraine or seizure
C. Demyelination or abscess
D. Tumor or hydrocephalus

A. Infarct or hemorrhage

Before laboratory results return in an undifferentiated coma, a standard empiric treatment set includes:

A. Thiamine, dextrose, naloxone
B. Heparin, insulin, calcium
C. Atropine, mannitol, phenytoin
D. Epinephrine, bicarbonate, magnesium

A. Thiamine, dextrose, naloxone

Flumazenil is most appropriate when coma is suspected to be due to:

A. Opiate overdose
B. Hypoglycemia
C. Benzodiazepine overdose
D. Wernicke encephalopathy

C. Benzodiazepine overdose

A unilateral or bilateral “blown” pupil in coma suggests a lesion affecting the:

A. Oculomotor parasympathetics
B. Trigeminal motor nucleus
C. Abducens fascicle
D. Vestibulospinal tract

A. Oculomotor parasympathetics

Midbrain or transtentorial lesions classically produce pupils that are:

A. Pinpoint and fixed
B. Small but reactive
C. Blown and dilated
D. Irregular but miotic

C. Blown and dilated

A pontine lesion classically produces pupils that are:

A. Large and fixed
B. Small and reactive
C. Unilateral and blown
D. Alternating in size

B. Small and reactive

Automatic respiratory rhythms are generated mainly by the:

A. Medulla
B. Thalamus
C. Midbrain
D. Cerebellum

A. Medulla

Voluntary control of respiration arises mainly from the:

A. Medulla
B. Forebrain
C. Pons
D. Spinal cord

B. Forebrain

The pre-Bötzinger complex is located in the _____ and functions as a respiratory _____.

A. pons; relay
B. medulla; pacemaker
C. midbrain; oscillator
D. thalamus; integrator

B. medulla; pacemaker

The lower motor neurons driving the diaphragm are located mainly in:

A. T1–T4
B. C3–C5
C. C1–C2
D. L1–L3

B. C3–C5

Thoracic respiratory muscles are controlled primarily by motor neurons in the:

A. Sacral cord
B. Lumbar cord
C. Thoracic cord
D. Cervical cord only

C. Thoracic cord

Ataxic respiration is an ominous pattern characterized by:

A. Crescendo-decrescendo cycling
B. Inspiratory breath-holding
C. Very irregular breathing
D. Deep rapid breathing

C. Very irregular breathing

Ataxic respiration most strongly localizes to a lesion in the:

A. Midbrain
B. Medulla
C. Upper cervical cord
D. Frontal cortex

B. Medulla

A patient shows 2–3 second pauses at full inspiration after a rostral pontine lesion. This is:

A. Ataxic respiration
B. Cheyne-Stokes breathing
C. Central hyperventilation
D. Apneustic respiration

D. Apneustic respiration

Central neurogenic hyperventilation is most associated with lesions of the:

A. Midbrain
B. Medulla
C. Cerebellum
D. Basal forebrain

A. Midbrain

Presympathetic neurons essential for maintaining normal blood pressure are located in the:

A. Nucleus ambiguus
B. Caudal raphe nuclei
C. Rostral ventrolateral medulla
D. Dorsal motor nucleus X

C. Rostral ventrolateral medulla

Cheyne-Stokes breathing is most likely with bilateral lesions:

A. Below the medulla
B. At or above upper pons
C. Limited to cerebellum
D. In lumbar cord

B. At or above upper pons

Cheyne-Stokes respiration may also occur in:

A. Cardiac failure, high altitude
B. Asthma, myasthenia gravis
C. Pulmonary embolism only
D. Parkinson disease, ALS

A. Cardiac failure, high altitude

The nucleus solitarius is especially important for:

A. Vision and hearing
B. Circulation and respiration
C. Memory and learning
D. Motor planning only

B. Circulation and respiration

Baroreceptor input from the carotid body and aortic arch reaches the nucleus solitarius via:

A. V and VII
B. VII and VIII
C. IX and X
D. X and XII

C. IX and X

Which set contains only functions heavily dependent on pontomedullary reticular formation?

A. Laughing, crying, swallowing
B. Hearing, vision, smell
C. Memory, language, praxis
D. Saccades, vergence, tracking

A. Laughing, crying, swallowing

A medullary structure on the lateral wall of the fourth ventricle contains a chemoreceptor trigger zone with an incomplete blood-brain barrier. This structure is the:

A. Nucleus ambiguus
B. Area postrema
C. Inferior olive
D. Solitary tract

B. Area postrema

Release of which transmitter from stomach and small-intestinal cells can provoke nausea and vomiting?

A. Glycine
B. GABA
C. Serotonin
D. Dopamine

C. Serotonin

Vagal afferents carrying emetogenic input from the gut project mainly to the:

A. Nucleus solitarius
B. Red nucleus
C. Edinger-Westphal nucleus
D. Ventral posterior nucleus

A. Nucleus solitarius

A patient develops nausea after chemotherapy. Gut enteroendocrine signaling most likely reaches the brainstem via:

A. Sympathetics to hypothalamus
B. Vagus to solitarius
C. Spinothalamics to VPL
D. Trigeminals to pons

B. Vagus to solitarius

Urethral and anal sphincter control in the brainstem depends most on the:

A. Pontine micturition center
B. Superior colliculus
C. Area postrema
D. Nucleus cuneatus

A. Pontine micturition center

In addition to the pontine micturition center, continence is influenced by other regions of the:

A. Tectum
B. Olive
C. Reticular formation
D. Cerebellar vermis

C. Reticular formation

Which brainstem region most strongly modulates pain transmission?

A. Pontine basis
B. Periaqueductal gray
C. Medial lemniscus
D. Solitary nucleus

B. Periaqueductal gray

Blood supply to the posterior fossa arises primarily from the:

A. Carotid siphon
B. External carotid system
C. Anterior cerebral system
D. Vertebrobasilar system

D. Vertebrobasilar system

Before piercing the dura and entering the foramen magnum, the vertebral arteries ascend through the last cervical vertebra at:

A. C1
B. C2
C. C6
D. C7

B. C2

The basilar artery bifurcates at the _____ to form the _____.

A. Pontomedullary junction; SCAs
B. Inferior colliculus; PCAs
C. Pontomesencephalic junction; PCAs
D. Foramen magnum; vertebrals

C. Pontomesencephalic junction; PCAs

The posterior inferior cerebellar artery usually arises from the vertebral artery at the level of the:

A. Medulla
B. Midbrain
C. Rostral pons
D. Upper cervical cord

A. Medulla

The PICA most classically supplies the:

A. Medial medulla only
B. Lateral medulla, inferior cerebellum
C. Medial pons, inner ear
D. Midbrain, bilateral thalami

B. Lateral medulla, inferior cerebellum

The AICA arises from the proximal basilar artery near the level of the:

A. Midbrain
B. Medulla
C. Rostral pons
D. Caudal pons

D. Caudal pons

The AICA most classically supplies the:

A. Lateral caudal pons
B. Medial medulla
C. Medial thalamus
D. Upper midbrain only

A. Lateral caudal pons

The superior cerebellar artery arises near the top of the basilar artery at the level of the:

A. Rostral pons
B. Caudal medulla
C. Inferior olive
D. Internal capsule

A. Rostral pons

The SCA most classically supplies the:

A. Inferior cerebellum
B. Midbrain tectum
C. Superior cerebellum
D. Medial medulla

C. Superior cerebellum

The posterior cerebral artery supplies all of the following except the:

A. Medial occipital lobe
B. Midbrain
C. Most of thalamus
D. Lateral frontal convexity

D. Lateral frontal convexity

In the caudal medial medulla, the principal blood supply is from paramedian branches of the:

A. PICA
B. Basilar artery
C. Anterior spinal artery
D. AICA

C. Anterior spinal artery

In more rostral medial medulla, the paramedian blood supply comes chiefly from the:

A. Vertebral arteries
B. SCAs
C. PCAs
D. AICAs

A. Vertebral arteries

Lateral medullary structures are supplied primarily by branches of the:

A. Basilar and SCA
B. Vertebral and PICA
C. Anterior spinal only
D. PCA and basilar apex

B. Vertebral and PICA

The medial pons is supplied mainly by branches of the:

A. Basilar artery
B. Vertebral artery
C. Posterior cerebral artery
D. Anterior spinal artery

A. Basilar artery

The lateral pons is supplied mainly by circumferential basilar branches and the:

A. PCA
B. PICA
C. AICA
D. ASA

C. AICA

The inner ear is usually supplied by the:

A. Recurrent artery of Heubner
B. Internal auditory artery
C. Thalamogeniculate artery
D. Lateral medullary artery

B. Internal auditory artery

The internal auditory artery most commonly arises from the:

A. PICA
B. SCA
C. AICA
D. PCA

C. AICA

The rostral pons is supplied chiefly by:

A. Lenticulostriate arteries
B. Lateral pontine branches
C. Anterior choroidal branches
D. Callosomarginal branches

B. Lateral pontine branches

The thalamus is supplied chiefly by branches from the basilar apex and proximal:

A. PCA
B. AICA
C. SCA
D. Vertebral artery

A. PCA

Crossed neurologic findings are more suggestive of a lesion in the:

A. Cerebral cortex
B. Basal ganglia
C. Brainstem
D. Cerebellar vermis

C. Brainstem

Vertebral or basilar stenosis may produce waxing and waning deficits because brainstem signs can be sensitive to changes in:

A. Serum glucose
B. Intracranial pressure
C. Blood pressure
D. Body temperature

C. Blood pressure

Vertebral or basilar thrombosis is especially life-threatening because it may cause:

A. Bilateral retinal ischemia
B. Widespread brainstem infarction
C. Isolated facial weakness
D. Unilateral temporal necrosis

B. Widespread brainstem infarction

A patient presents with vertigo, hearing loss, and lateral pontine signs. Which vessel is most likely involved?

A. Anterior spinal artery
B. AICA territory vessel
C. Paramedian vertebral branch
D. Artery of Percheron

B. AICA territory vessel

A patient presents 2 hours after abrupt hemiparesis from an acute thrombotic ischemic stroke. Which therapy is most appropriate?

A. Aspirin only
B. IV tPA
C. Heparin infusion
D. Clopidogrel only

B. IV tPA

A patient presents 7 hours after clearly witnessed onset of ischemic stroke symptoms. Which treatment is generally given after the tPA window has passed?

A. Aspirin
B. Alteplase
C. Warfarin
D. Nitroglycerin

A. Aspirin

Pontine hemorrhage is most commonly associated with:

A. Chronic hypertension
B. Atrial fibrillation
C. Carotid dissection
D. Migraine aura

A. Chronic hypertension

Sudden dizziness, vertigo, and nausea from posterior circulation ischemia most strongly suggest involvement of the:

A. Basal ganglia or cerebellum
B. Vestibular nuclei or cerebellum
C. Frontal eye fields or cerebellum
D. Medial thalamus or cerebellum

B. Vestibular nuclei or cerebellum

Dysarthria and dysphagia in posterior circulation ischemia most strongly implicate the:

A. Corticobulbar pathways or CN nuclei
B. Medial lemniscus or CN nuclei
C. Superior colliculus or CN nuclei
D. Spinocerebellar tracts or CN nuclei

A. Corticobulbar pathways or CN nuclei

Bilateral or perioral numbness most strongly suggests ischemia affecting the:

A. Corticospinal system
B. Trigeminal or somatosensory pathways
C. Visual association cortex
D. Inferior olivary complex

B. Trigeminal or somatosensory pathways

Hemiparesis or quadriparesis from brainstem ischemia most directly localizes to the:

A. Vestibular nuclei
B. Reticular formation
C. Corticospinal tract
D. Solitary tract

C. Corticospinal tract

Somnolence in posterior circulation ischemia most strongly suggests dysfunction of the:

A. Pontomesencephalic reticular formation
B. Cerebellar dentate nucleus
C. Lower medullary olives
D. Facial motor nucleus

A. Pontomesencephalic reticular formation

A patient has third-nerve palsy, dilated pupils, ataxia, impaired consciousness, and decorticate posturing. This pattern most strongly indicates:

A. Medullary dysfunction
B. Midbrain dysfunction
C. Cerebellar dysfunction
D. Peripheral vestibulopathy

B. Midbrain dysfunction

Ocular bobbing, horizontal gaze palsy, irregular respirations, and decerebrate posturing most strongly localize to the:

A. Pons
B. Midbrain
C. Medulla
D. Occipital lobe

A. Pons

Vertigo, nystagmus, nausea, vomiting, hiccups, autonomic instability, and possible respiratory arrest most strongly suggest dysfunction of the:

A. Midbrain
B. Pons
C. Medulla
D. Thalamus

C. Medulla

Medial basis pontis infarcts are most commonly caused by:

A. Vertebral dissection
B. Cardioembolism
C. Lacunar disease
D. PICA thrombosis

C. Lacunar disease

A patient has contralateral limb weakness, contralateral loss of vibration/proprioception, and ipsilateral tongue weakness. Which syndrome is most likely?

A. Lateral pontine syndrome
B. Medial medullary syndrome
C. Wallenberg syndrome
D. Top-of-basilar syndrome

B. Medial medullary syndrome

Medial medullary syndrome is usually caused by occlusion of paramedian branches of the:

A. AICA or basilar
B. SCA or PCA
C. PICA or AICA
D. Anterior spinal or vertebral

D. Anterior spinal or vertebral

In classic lateral medullary syndrome, decreased pain and temperature on the ipsilateral face reflects involvement of the:

A. Medial lemniscus
B. Hypoglossal fascicles
C. Spinal trigeminal tract
D. Corticospinal tract

C. Spinal trigeminal tract

Hoarseness or loss of taste sensation in a posterior circulation stroke most strongly localizes the lesion to the:

A. Midbrain
B. Medulla
C. Thalamus
D. Internal capsule

B. Medulla

A patient has vertigo, dysphagia, hoarseness, ipsilateral facial pain/temperature loss, contralateral body pain/temperature loss, and ipsilateral Horner syndrome. Which syndrome is most likely?

A. Medial medullary syndrome
B. Millard-Gubler syndrome
C. Wallenberg syndrome
D. Claude syndrome

C. Wallenberg syndrome

A patient has slurred speech with contralateral weakness, but the key clue is pure motor dysarthria-hemiparesis without prominent sensory loss. Which syndrome is most likely?

A. Dysarthria-hemiparesis
B. Ataxic hemiparesis
C. Foville syndrome
D. Benedikt syndrome

A. Dysarthria-hemiparesis

A patient has contralateral hemiparesis, ipsilateral facial weakness, and horizontal gaze palsy. Which syndrome is most likely?

A. Millard-Gubler syndrome
B. Weber syndrome
C. Foville syndrome
D. SCA syndrome

C. Foville syndrome