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MCQ 1. A 67-year-old right-handed retired teacher suddenly develops language difficulty. She speaks fluently with normal articulation but produces frequent semantic and phonemic paraphasias. She cannot repeat “No ifs, ands, or buts.” Naming is impaired. Auditory comprehension is relatively preserved for simple commands but deteriorates with syntactically complex sentences. Reading aloud is impaired. The lesion most likely involves: A. Left inferior frontal gyrus (pars opercularis) B. Left posterior superior temporal gyrus extending into inferior parietal lobule C. Left supplementary motor area D. Left angular gyrus only.
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Answer 1. Answer: B Explanation: This is Wernicke aphasia. Fluent speech with paraphasias, impaired repetition, impaired naming, and impaired comprehension for complex syntax localize to the dominant posterior superior temporal gyrus extending into the inferior parietal region. Why others are incorrect: A. Broca area → non-fluent aphasia. C. SMA → transcortical motor aphasia. D. Angular gyrus alone more typically causes alexia/agraphia and Gerstmann syndrome. References: Mesulam MM. Principles of Behavioral and Cognitive Neurology, 3rd ed. Bradley's Neurology in Clinical Practice, 9th ed..
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MCQ 2. A 58-year-old man presents with acute inability to speak. He follows complex commands, nods appropriately, and writes complete grammatically correct sentences. He cannot voluntarily produce speech except for occasional stereotyped utterances. Oral musculature is normal. Repetition cannot be assessed because of severe speech output impairment. The most likely diagnosis is: A. Broca aphasia B. Apraxia of speech C. Transcortical motor aphasia D. Aphonia.
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Answer 2. Answer: C Explanation: Preserved comprehension and writing with markedly reduced spontaneous speech suggest transcortical motor aphasia due to disruption of frontal initiation pathways while sparing the perisylvian language network. References: Mesulam MM. Principles of Behavioral and Cognitive Neurology, 3rd ed. Adams & Victor's Principles of Neurology, 12th ed..
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MCQ 3. A patient is shown a pen. He says: “Well...it's the thing...you write with...the school thing...” He cannot name it but immediately identifies it among multiple objects when asked. This deficit is best classified as: A. Semantic memory impairment B. Visual agnosia C. Lexical retrieval failure (anomia) D. Loss of conceptual knowledge.
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Answer 3. Answer: C Explanation: The patient has preserved semantic knowledge but cannot retrieve the lexical label, consistent with anomia (lexical retrieval failure). References: Blumenfeld H. Neuroanatomy through Clinical Cases, 3rd ed. Mesulam MM. Principles of Behavioral and Cognitive Neurology, 3rd ed..
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MCQ 4. A patient has fluent spontaneous speech, excellent repetition, preserved grammar, but is unable to comprehend spoken language. He echoes examiner's questions verbatim without understanding them. Which vascular territory is MOST likely involved? A. Superior division of left MCA B. Inferior division of left MCA sparing perisylvian cortex C. Watershed infarction between MCA and PCA D. PCA infarction involving occipital cortex.
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Answer 4. Answer: C Explanation: This is transcortical sensory aphasia. Repetition is preserved because the perisylvian language network is spared, while posterior watershed lesions disconnect semantic association cortex. References: Bradley's Neurology in Clinical Practice, 9th ed. DeJong's The Neurologic Examination, 8th ed..
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MCQ 5. A 61-year-old right-handed woman develops fluent aphasia after stroke. MRI demonstrates infarction involving the left posterior temporal cortex. During examination she is asked: “Point to the ceiling before touching your left ear.” She consistently fails. Which additional bedside test would MOST help distinguish impaired syntactic comprehension from impaired auditory attention? A. Boston Naming Test B. Token Test C. Oral diadochokinesis D. Ideomotor praxis examination.
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Answer 5. Answer: B Explanation: The Token Test evaluates comprehension of increasingly complex verbal commands and is useful for detecting subtle receptive aphasia while minimizing attentional confounders. References: DeJong's The Neurologic Examination, 8th ed. Mesulam MM. Principles of Behavioral and Cognitive Neurology, 3rd ed..