EDAIC Neuroanesthesia and Neuromonitoring 5 — Questions and Answers
Question 1: A patient undergoes carotid endarterectomy under regional cervical plexus block. During carotid clamping they become confused and agitated. The BEST immediate management is:
- Convert to general anesthesia with rapid sequence intubation
- Administer IV midazolam for sedation
- Request the surgeon to place a carotid shunt (Correct answer)
- Increase FiO2 via face mask
Correct answer: Request the surgeon to place a carotid shunt
New neurological symptoms during carotid clamping in an awake patient indicate inadequate cerebral perfusion; immediate shunt placement restores blood flow.
Question 2: Which drug reduces the incidence of cerebral vasospasm after subarachnoid hemorrhage and is given for 21 days?
- Verapamil
- Nimodipine (Correct answer)
- Amlodipine
- Diltiazem
Correct answer: Nimodipine
Oral nimodipine (60 mg every 4 hours for 21 days) is the only proven pharmacological intervention to reduce neurological deficits from vasospasm after SAH.
Question 3: When performing lumbar puncture, which position optimizes CSF flow and is preferred in obese patients?
- Prone with pillow under the abdomen
- Lateral decubitus with knees flexed to chest
- Sitting upright leaning forward (Correct answer)
- Supine with 30-degree Trendelenburg
Correct answer: Sitting upright leaning forward
The sitting upright position widens interlaminar spaces and is preferred in obese patients where the lateral position makes midline identification unreliable.
Question 4: Which ICP waveform component, when dominant (P2 > P1), indicates reduced intracranial compliance?
- P1 (percussion wave)
- P2 (tidal wave) (Correct answer)
- P3 (dicrotic wave)
- C wave
Correct answer: P2 (tidal wave)
Normally P1>P2>P3; when P2 exceeds P1, intracranial compliance is reduced and the brain cannot buffer volume changes, indicating impending decompensation.
Question 5: In a patient with a Glasgow Coma Scale (GCS) of 7 following head trauma, which airway management decision is most appropriate?
- Nasopharyngeal airway insertion and supplemental oxygen
- Bag-mask ventilation until CT scan results available
- Rapid sequence intubation with cricoid pressure (Correct answer)
- Supraglottic airway device placement
Correct answer: Rapid sequence intubation with cricoid pressure
GCS ≤8 indicates inability to protect the airway; RSI with cricoid pressure (modified if basal skull fracture suspected) provides definitive airway control.
Question 6: The 'triple H therapy' (hypertension, hypervolemia, hemodilution) for cerebral vasospasm after SAH has largely been replaced by which approach?
- Induced normothermia and tight glucose control
- Induced hypertension with normovolemia (Correct answer)
- Prophylactic nimodipine plus magnesium
- Endovascular balloon angioplasty for all patients
Correct answer: Induced hypertension with normovolemia
Current evidence supports induced hypertension with normovolemia rather than hypervolemia/hemodilution, as fluid loading can cause pulmonary edema without added cerebral benefit.
Question 7: Which brainstem reflex is LAST to disappear as intracranial hypertension progresses to herniation?
- Pupillary light reflex
- Corneal reflex
- Oculocephalic (doll's eye) reflex
- Cough and gag reflex (Correct answer)
Correct answer: Cough and gag reflex
The cough and gag reflex, mediated by the medulla (CN IX/X), is the most caudal brainstem reflex and the last to be lost as herniation progresses rostrocaudally.
EDAIC Neuroanesthesia and Neuromonitoring 5
A patient undergoes carotid endarterectomy under regional cervical plexus block.
During carotid clamping they become confused and agitated.
The BEST immediate management is: