CNS CNS Neurocritical Care and Emergency Neurology 2 — Questions and Answers
Question 1: Which finding on CT angiography is the strongest predictor of hematoma expansion in spontaneous intracerebral hemorrhage?
- Hematoma volume >30 mL
- The 'spot sign' (contrast extravasation within the hematoma) (Correct answer)
- Perilesional edema on initial scan
- Midline shift >5 mm
Correct answer: The 'spot sign' (contrast extravasation within the hematoma)
The CT angiography spot sign, representing active contrast extravasation into the hematoma, is the strongest independent predictor of subsequent hematoma expansion.
Question 2: A patient in the neurological ICU develops fever, neck stiffness, photophobia, and CSF showing >1000 WBC with predominantly neutrophils and low glucose. The MOST appropriate immediate intervention is:
- Await culture results before starting antibiotics
- Start empirical IV antibiotics and dexamethasone immediately (Correct answer)
- Order MRI before lumbar puncture
- Administer acyclovir only pending PCR results
Correct answer: Start empirical IV antibiotics and dexamethasone immediately
Bacterial meningitis is a medical emergency; empirical broad-spectrum antibiotics plus dexamethasone must be started immediately without waiting for cultures.
Question 3: Which neuroprotective intervention has the STRONGEST evidence for improving neurological outcomes after out-of-hospital cardiac arrest?
- High-dose corticosteroids
- Targeted temperature management (TTM) to 32–36°C (Correct answer)
- Prophylactic anticonvulsants
- High-flow oxygen supplementation throughout
Correct answer: Targeted temperature management (TTM) to 32–36°C
TTM prevents secondary neuronal injury after cardiac arrest by reducing metabolic demand and inflammatory cascades, with the strongest evidence base for post-cardiac arrest neuroprotection.
Question 4: A patient with myasthenia gravis develops rapidly worsening dysphagia and respiratory distress. The CNS specialist recognizes this as:
- Cholinergic crisis from anticholinesterase overdose
- Myasthenic crisis requiring ICU monitoring and possible intubation (Correct answer)
- Autonomic neuropathy progression
- Intercurrent Guillain-Barré exacerbation
Correct answer: Myasthenic crisis requiring ICU monitoring and possible intubation
Myasthenic crisis is life-threatening deterioration of neuromuscular transmission causing respiratory failure and requires urgent ICU care, plasmapheresis, or IVIG.
Question 5: In a patient with acute spinal cord injury, neurogenic shock presents with hypotension and which cardiovascular finding that distinguishes it from hemorrhagic shock?
- Tachycardia and vasoconstriction
- Bradycardia and warm, vasodilated extremities (Correct answer)
- Pulsus paradoxus
- Narrow pulse pressure
Correct answer: Bradycardia and warm, vasodilated extremities
Loss of sympathetic tone in neurogenic shock produces bradycardia and peripheral vasodilation, contrasting with the compensatory tachycardia seen in hemorrhagic shock.
Question 6: Which electroencephalographic pattern is MOST concerning for non-convulsive status epilepticus in a comatose neurocritical care patient?
- Diffuse theta slowing
- Burst suppression pattern
- Continuous spike-and-wave discharges at 3 Hz (Correct answer)
- Alpha coma pattern
Correct answer: Continuous spike-and-wave discharges at 3 Hz
Continuous or near-continuous spike-and-wave activity on cEEG in a comatose patient without overt motor signs is the hallmark of non-convulsive status epilepticus.
CNS CNS Neurocritical Care and Emergency Neurology 2
Which finding on CT angiography is the strongest predictor of hematoma expansion in spontaneous intracerebral hemorrhage?