CNS CNS Neurocritical Care and Emergency Neurology 1 — Questions and Answers
Question 1: A patient arrives with sudden onset worst headache of life. CT head is negative. What is the NEXT priority step to rule out subarachnoid hemorrhage?
- Repeat CT in 6 hours
- Lumbar puncture for xanthochromia (Correct answer)
- MRI brain with gadolinium
- Empirical nimodipine administration
Correct answer: Lumbar puncture for xanthochromia
When CT is negative but SAH is clinically suspected, lumbar puncture to detect xanthochromia (yellow CSF discoloration) is mandatory to rule out subarachnoid hemorrhage.
Question 2: Which blood pressure target is recommended during the acute phase of ischemic stroke in a patient NOT receiving thrombolysis?
- <140/90 mmHg immediately
- Allow up to 220/120 mmHg unless end-organ damage is present (Correct answer)
- <160/90 mmHg within 1 hour
- <180/105 mmHg at all times
Correct answer: Allow up to 220/120 mmHg unless end-organ damage is present
For non-thrombolyzed acute ischemic stroke, permissive hypertension up to 220/120 is recommended to maintain penumbral perfusion unless end-organ damage is present.
Question 3: A 45-year-old presents with ascending weakness beginning in the legs over 3 days, areflexia, and albuminocytologic dissociation on LP. Which diagnosis is MOST likely?
- Myasthenia gravis
- Guillain-Barré syndrome (Correct answer)
- Transverse myelitis
- Multiple sclerosis relapse
Correct answer: Guillain-Barré syndrome
GBS classically presents with ascending flaccid paralysis, areflexia, and elevated CSF protein with normal cell count (albuminocytologic dissociation).
Question 4: Which monitoring parameter is MOST critical in a neurocritical care patient with severe traumatic brain injury to guide management?
- Continuous EEG only
- Intracranial pressure monitoring with cerebral perfusion pressure targets (Correct answer)
- Hourly pupillary checks alone
- Serial CT scans every 2 hours
Correct answer: Intracranial pressure monitoring with cerebral perfusion pressure targets
ICP monitoring with CPP targets (typically 60–70 mmHg) is the standard of care in severe TBI to prevent secondary brain injury from herniation or ischemia.
Question 5: A patient with known epilepsy presents with continuous seizure activity lasting 30 minutes. After benzodiazepines fail, which second-line agent is preferred per US guidelines?
- Diazepam rectal gel
- Valproate, fosphenytoin, or levetiracetam IV (Correct answer)
- Oral carbamazepine loading
- Ketamine infusion immediately
Correct answer: Valproate, fosphenytoin, or levetiracetam IV
After benzodiazepine failure in status epilepticus, IV valproate, fosphenytoin, or levetiracetam are recommended second-line agents per AES/NCS guidelines.
Question 6: Cushing's triad—hypertension, bradycardia, and irregular respirations—signals which life-threatening neurological emergency?
- Acute ischemic stroke with penumbra
- Impending transtentorial herniation from raised ICP (Correct answer)
- Severe autonomic dysreflexia
- Hypertensive encephalopathy
Correct answer: Impending transtentorial herniation from raised ICP
Cushing's triad is a late sign of severely elevated intracranial pressure threatening brainstem compression and herniation, requiring immediate intervention.
CNS CNS Neurocritical Care and Emergency Neurology 1
A patient arrives with sudden onset worst headache of life.
CT head is negative.
What is the NEXT priority step to rule out subarachnoid hemorrhage?