CPEN Neurological Emergencies 2 — Questions and Answers
Question 1: A 3-year-old presents with sudden onset of left-sided hemiplegia and facial droop. Which condition should be highest on the differential?
- Hemiplegic migraine
- Arterial ischemic stroke (Correct answer)
- Todd's paralysis post-seizure
- Conversion disorder
Correct answer: Arterial ischemic stroke
Arterial ischemic stroke in children presents with acute focal neurological deficits and requires immediate neuroimaging to guide treatment.
Question 2: Which finding on CT head is MOST concerning for non-accidental trauma in a 6-month-old with altered mental status?
- Epidural hematoma
- Bilateral subdural hematomas in different stages (Correct answer)
- Single linear skull fracture
- Subarachnoid hemorrhage
Correct answer: Bilateral subdural hematomas in different stages
Bilateral subdural hematomas in varying stages of evolution are a classic and highly concerning finding for non-accidental trauma (abusive head trauma).
Question 3: A 7-year-old with known VP shunt presents with headache and vomiting for 24 hours. His temperature is 38.8°C. What is the priority intervention?
- Administer acetaminophen and observe
- Obtain immediate neurosurgical consultation for shunt evaluation (Correct answer)
- Perform lumbar puncture to rule out meningitis
- Start empiric antibiotics and discharge
Correct answer: Obtain immediate neurosurgical consultation for shunt evaluation
Fever with VP shunt malfunction symptoms requires urgent neurosurgical evaluation because shunt infection or obstruction can be life-threatening.
Question 4: During lumbar puncture in a child with suspected bacterial meningitis, CSF opening pressure is 38 cmH2O. Which action is MOST appropriate?
- Collect all four tubes of CSF as planned
- Remove the needle immediately and give mannitol
- Collect minimal CSF, remove needle promptly, and initiate ICP management (Correct answer)
- Administer furosemide before collecting CSF
Correct answer: Collect minimal CSF, remove needle promptly, and initiate ICP management
Elevated opening pressure signals increased ICP; collect minimal CSF and remove the needle quickly to reduce herniation risk, then manage ICP.
Question 5: An 8-year-old is brought in after a diving accident with complaints of neck pain and inability to move his arms. Which initial action takes highest priority?
- Obtain cervical spine X-rays
- Establish IV access and draw labs
- Maintain spinal immobilization and secure the airway (Correct answer)
- Administer high-dose methylprednisolone
Correct answer: Maintain spinal immobilization and secure the airway
Airway and spinal immobilization are the immediate priorities in suspected cervical spinal cord injury to prevent secondary injury.
Question 6: A 5-year-old presents with acute onset ataxia, nystagmus, and dysarthria 2 weeks after a varicella infection. The MOST likely diagnosis is:
- Guillain-Barré syndrome
- Acute cerebellar ataxia (Correct answer)
- Brainstem encephalitis
- Posterior fossa tumor
Correct answer: Acute cerebellar ataxia
Acute cerebellar ataxia is a post-infectious complication most commonly seen 1–3 weeks after varicella, presenting with sudden gait unsteadiness.
Question 7: Which pupillary finding is the EARLIEST sign of uncal herniation?
- Bilateral fixed and dilated pupils
- Unilateral dilated and non-reactive pupil ipsilateral to the lesion (Correct answer)
- Pinpoint pupils bilaterally
- Unilateral miosis with ptosis
Correct answer: Unilateral dilated and non-reactive pupil ipsilateral to the lesion
Uncal herniation compresses CN III, causing ipsilateral pupillary dilation that is non-reactive — this is an early and critical sign.
CPEN Neurological Emergencies 2
A 3-year-old presents with sudden onset of left-sided hemiplegia and facial droop.
Which condition should be highest on the differential?