chapter 6 neurosurgery cont'd

Question 1

QUESTIONS 1-5

Scenario: A 54-year-old female was taken to an emergency room after collapsing at work. She was alert and communi¬cative, with a severe headache, photophobia, nuchal rigidity, and blurry vision. Computed tomography (CT) of the brain revealed diffuse subarachnoid blood in the basal cisterns, mild hydrocephalus, and no intraparenchymal hematoma. Her angiogram is depicted below (Figure 6.1-6.5Q)

1. What is the clinical Hunt and Hess grade of this patient?

A. Grade I
B. Grade II
C. Grade III
D. Grade IV
E. Grade V

Answer 1

B. Grade II

Question 2

QUESTIONS 1-5

Scenario: A 54-year-old female was taken to an emergency room after collapsing at work. She was alert and communi¬cative, with a severe headache, photophobia, nuchal rigidity, and blurry vision. Computed tomography (CT) of the brain revealed diffuse subarachnoid blood in the basal cisterns, mild hydrocephalus, and no intraparenchymal hematoma. Her angiogram is depicted below (Figure 6.1-6.5Q)

2. Some posterior communicating artery (PGomA) aneurysms do not produce any third nerve deficit. Why should special attention be given to the angiogram in these cases?

A. If the aneurysm is projecting posterolaterally rather
than in a more common medial position, there is an
increased risk of injuring the perforating vessels from
the PComA during microdissection
B. An aneurysm projecting laterally onto the medial edge of the temporal lobe argues against premature retraction of the temporal lobe
C. The angiogram may reveal a ventral carotid wall
aneurysm instead of a PGomA lesion, which is often
better managed with coiling
D. To look for any other associated aneurysms and/or
vasospasm
E. It may help with surgical planning, as medially projecting lesions are better approached through the carotidoculomotor triangle

Answer 2

B. An aneurysm projecting laterally onto the medial edge of the temporal lobe argues against premature retraction of the temporal lobe

Question 3

QUESTIONS 1-5

Scenario: A 54-year-old female was taken to an emergency room after collapsing at work. She was alert and communi¬cative, with a severe headache, photophobia, nuchal rigidity, and blurry vision. Computed tomography (CT) of the brain revealed diffuse subarachnoid blood in the basal cisterns, mild hydrocephalus, and no intraparenchymal hematoma. Her angiogram is depicted below (Figure 6.1-6.5Q)

3. The patient is taken to the operating room for aneurysm clipping. Proximal and distal control of the internal carotid artery is obtained with temporary clip placement prior to aneurysmal neck dissection. Despite this maneuver, the aneurysm ruptures during microdissection and significant bleeding is encountered, which significantly hinders visual-
   ization. What preventative maneuver could have been
   employed prior to aneurysmal rupture to decrease the
   amount of intraoperative bleeding?

A. Blunt surgical microdissection
B. Obtaining proximal control of the internal carotid
artery in the neck
C. Releasing the dome of the aneurysm from the temporal lobe prior to temporary clip placement to prevent traction on the fundus
D. Identifying the distal posterior communicating artery medial to the internal carotid artery for temporary clip placement if possible
E. Temporary clip placement on the ophthalmic artery to prevent retrograde bleeding from the orbit

Answer 3

D. Identifying the distal posterior communicating artery medial to the internal carotid artery for temporary clip placement if possible

Question 4

QUESTIONS 1-5

Scenario: A 54-year-old female was taken to an emergency room after collapsing at work. She was alert and communi¬cative, with a severe headache, photophobia, nuchal rigidity, and blurry vision. Computed tomography (CT) of the brain revealed diffuse subarachnoid blood in the basal cisterns, mild hydrocephalus, and no intraparenchymal hematoma. Her angiogram is depicted below (Figure 6.1-6.5Q)

4. Postoperatively, the patient wakes up with contralateral weakness, numbness, and homonymous hemianopia. A GT scan of the brain shows an infarct in the posterior limb of the internal capsule and in the adjacent white matter (above the
   temporal horn of the lateral ventricle). This complication might possibly have been avoided by

A. Identifying the anterior choroidal artery prior to
aneurysm clipping in order to prevent damage or
incorporation of this vessel into the clip construct
B. Increasing temporary occlusion time to prevent hasty microdissection
C. Limiting the sylvian fissure dissection to the sphe-
noidal portion in order to prevent unnecessary
dissection adjacent to PComA artery perforators,
which supply the posterior limb of the internal capsule
D. Obtaining an intraoperative angiogram to confirm
proper clip placement
E. Identifying and preserving the recurrent artery of
Heubner

Answer 4

A. Identifying the anterior choroidal artery prior to
aneurysm clipping in order to prevent damage or
incorporation of this vessel into the clip construct

Question 5

QUESTIONS 1-5

Scenario: A 54-year-old female was taken to an emergency room after collapsing at work. She was alert and communi¬cative, with a severe headache, photophobia, nuchal rigidity, and blurry vision. Computed tomography (CT) of the brain revealed diffuse subarachnoid blood in the basal cisterns, mild hydrocephalus, and no intraparenchymal hematoma. Her angiogram is depicted below (Figure 6.1-6.5Q)

5. Postoperatively, the patient sustained damage to the frontal branch of the facial nerve. What is the most likely reason for the frontal branch facial nerve injury?
   A. The supraorbital nerve was not identified in detaching
   the scalp from the supraorbital rim
   B. The incision was started less than 1 cm anterior to the
   tragus
   C. There was nerve neuropraxia from postoperative
   swelling
   D. The nerve in the subgaleal fat pad was injured during
   surgical dissection
   E. The nerve between the superficial and deep layers of
   the temporalis fascia was injured with monopolar
   cautery

Answer 5

D. The nerve in the subgaleal fat pad was injured during
surgical dissection

Question 6

Scenario: A 28-year-old male was involved in a motorcycle accident. About 1 week after being discharged from the hospital he began experiencing fevers, severe retroorbital headaches, diplopia, and left eye proptosis, which prompted a visit to the emergency department. A computed tomography (GT) scan of the brain showed a resolving 2- by 3-cm left frontal contusion underlying a minimally displaced frontal bone fracture, which was sustained at the time of initial injury. His erythrocyte sedimentation rate (ESR) and G-reactive protein (GRP) were mildly elevated. The angiogram is depicted below (Figures 6.6-6.9QA, B).

6. What is the most likely diagnosis?
   A. Superior orbital fissure syndrome
   B. Incidental meningioma originating from the medial
   aspect of the sphenoid ridge
   C. Arterial-venous fistula
   D. Occlusion of the internal carotid artery proximal to the
   ophthalmic artery origin
   E. Cavernous sinus thrombosis

Answer 6

C. Arterial-venous fistula

Question 7

Scenario: A 28-year-old male was involved in a motorcycle accident. About 1 week after being discharged from the hospital he began experiencing fevers, severe retroorbital headaches, diplopia, and left eye proptosis, which prompted a visit to the emergency department. A computed tomography (GT) scan of the brain showed a resolving 2- by 3-cm left frontal contusion underlying a minimally displaced frontal bone fracture, which was sustained at the time of initial injury. His erythrocyte sedimentation rate (ESR) and G-reactive protein (GRP) were mildly elevated. The angiogram is depicted below (Figures 6.6-6.9QA, B).

7. The signs/symptoms of this disease process depend
   mostly upon
   A. The size and location of the tumor relative to the optic
   nerve
   B. The direction of venous drainage and rate of blood flow through the shunt
   C. The extent of the inflammatory reaction adjacent to
   the cavernous sinus
   D. The extent of the inflammatory reaction adjacent to
   the superior orbital fissure
   E. The extent of collateral flow from the opposite internal
   carotid artery and external meningeal feeders

Answer 7

B. The direction of venous drainage and rate of blood flow through the shunt

Question 8

Scenario: A 28-year-old male was involved in a motorcycle accident. About 1 week after being discharged from the hospital he began experiencing fevers, severe retroorbital headaches, diplopia, and left eye proptosis, which prompted a visit to the emergency department. A computed tomography (GT) scan of the brain showed a resolving 2- by 3-cm left frontal contusion underlying a minimally displaced frontal bone fracture, which was sustained at the time of initial injury. His erythrocyte sedimentation rate (ESR) and G-reactive protein (GRP) were mildly elevated. The angiogram is depicted below (Figures 6.6-6.9QA, B).

8. What should be the initial treatment of choice for this
   patient?
   A. Six weeks of antibiotics followed by repeat angiography
   B. Glue embolization of major arterial feeders followed by
   tumor resection
   C. Carotid artery sacrifice
   D. Transarterial detachable balloon embolization
   E. Heparin infusion

Answer 8

C. Carotid artery sacrifice

Question 9

Scenario: A 28-year-old male was involved in a motorcycle accident. About 1 week after being discharged from the hospital he began experiencing fevers, severe retroorbital headaches, diplopia, and left eye proptosis, which prompted a visit to the emergency department. A computed tomography (GT) scan of the brain showed a resolving 2- by 3-cm left frontal contusion underlying a minimally displaced frontal bone fracture, which was sustained at the time of initial injury. His erythrocyte sedimentation rate (ESR) and G-reactive protein (GRP) were mildly elevated. The angiogram is depicted below (Figures 6.6-6.9QA, B).

9. If the desired treatment strategy fails, what would be
   another potential treatment option?
10. Surgical debridement of the infection
11. Direct surgical packing of the cavernous sinus with either Gelfoam, Surgicel, platinum coils, or strands of cotton
12. Preoperative glue embolization of arterial feeders followed by tumor resection
13. Endovascular procedure for internal carotid artery sacrifice
    A. 1, 2, and 3 are correct
    B. 1 and 3 are correct
    C. 2 and 4 are correct
    D. Only 4 is correct
    E. All of the above

Answer 9

C. 2 and 4 are correct

Question 10

Scenario: A 28-year-old male was involved in a motorcycle accident. About 1 week after being discharged from the hospital he began experiencing fevers, severe retroorbital headaches, diplopia, and left eye proptosis, which prompted a visit to the emergency department. A computed tomography (GT) scan of the brain showed a resolving 2- by 3-cm left frontal contusion underlying a minimally displaced frontal bone fracture, which was sustained at the time of initial injury. His erythrocyte sedimentation rate (ESR) and G-reactive protein (GRP) were mildly elevated. The angiogram is depicted below (Figures 6.6-6.9QA, B).

10. What finding in the pathologic process depicted by the angiogram below (Figure 6.10Q.) would mandate urgent treatment?

A. Retrograde cortical venous drainage
B. Multiple meningeal artery feeders
C. Dual internal and external carotid artery supply
D. Embolic stroke
E. Venous sinus occlusion

Answer 10

A. Retrograde cortical venous drainage

Question 11

QUESTIONS 11-16

Scenario: A 67-year-old male with a history of diabetes mellitus and hypertension presents to the emergency depart¬ment with right arm weakness and numbness. He is found to have > 90% stenosis of the left internal carotid artery and restricted MR diffusion in portions of the brain supplied by the left middle cerebral artery. He elects to proceed with surgery for his carotid stenosis but is found to have a high-riding carotid artery bifurcation.

11. Surgical maneuvers that may increase surgical exposure of a high-riding carotid artery bifurcation during carotid endarterectomy include all of the following EXCEPT?
    A. Medial mobilization of the ansa cervicalis
    B. Dividing the posterior belly of the digastric muscle
    C. Mandibular osteotomy or disarticulation of the mandible at the temporomandibular joint
    D. Judicious cautery and ligation of select vessels (occipital artery, common facial vein) hindering exposure
    E. Transverse sectioning of the clavicular head of the
    sternocleidomastoid muscle at the level of the hyoid
    bone for better visualization of the carotid artery
    lateral to the jugular vein

Answer 11

E. Transverse sectioning of the clavicular head of the
sternocleidomastoid muscle at the level of the hyoid
bone for better visualization of the carotid artery
lateral to the jugular vein

Question 12

QUESTIONS 11-16

Scenario: A 67-year-old male with a history of diabetes mellitus and hypertension presents to the emergency depart¬ment with right arm weakness and numbness. He is found to have > 90% stenosis of the left internal carotid artery and restricted MR diffusion in portions of the brain supplied by the left middle cerebral artery. He elects to proceed with surgery for his carotid stenosis but is found to have a high-riding carotid artery bifurcation.

12. What cranial nerve is at most risk of injury when exposing a high-riding carotid artery bifurcation?

A. VII
B. IX
C. X
D. XI
E. XII

Answer 12

E. XII

Question 13

QUESTIONS 11-16

Scenario: A 67-year-old male with a history of diabetes mellitus and hypertension presents to the emergency depart¬ment with right arm weakness and numbness. He is found to have > 90% stenosis of the left internal carotid artery and restricted MR diffusion in portions of the brain supplied by the left middle cerebral artery. He elects to proceed with surgery for his carotid stenosis but is found to have a high-riding carotid artery bifurcation.

13. What is the order of clamp placement on the arteries
    during carotid endarterectomy?

A. External, internal, common
B. Internal, common, external
C. External, common, internal
D. Common, external, internal
E. Common, internal, external

Answer 13

B. Internal, common, external

Question 14

QUESTIONS 11-16

Scenario: A 67-year-old male with a history of diabetes mellitus and hypertension presents to the emergency depart¬ment with right arm weakness and numbness. He is found to have > 90% stenosis of the left internal carotid artery and restricted MR diffusion in portions of the brain supplied by the left middle cerebral artery. He elects to proceed with surgery for his carotid stenosis but is found to have a high-riding carotid artery bifurcation.

14. After clamp placement and arteriotomy, the surgeon
    notices continued bleeding from the back wall of the carotid artery, which severely hinders visualization during the surgical procedure. What is the most likely reason for the continued bleeding?

A. Incomplete clamping of the common carotid artery
B. Backbleeding from the superficial temporal artery
C. Backbleeding from the ascending pharyngeal artery
D. Venous bleeding from the adventitia of the internal
carotid artery
E. Clotting abnormality from heparin infusion

Answer 14

C. Backbleeding from the ascending pharyngeal artery

Question 15

QUESTIONS 11-16

Scenario: A 67-year-old male with a history of diabetes mellitus and hypertension presents to the emergency depart¬ment with right arm weakness and numbness. He is found to have > 90% stenosis of the left internal carotid artery and restricted MR diffusion in portions of the brain supplied by the left middle cerebral artery. He elects to proceed with surgery for his carotid stenosis but is found to have a high-riding carotid artery bifurcation.

15. During surgical dissection adjacent to the carotid
    artery, the anesthesiologist notices that the patient becomes hypotensive and bradycardic. The next course of management should include

A. Obtain an immediate arterial blood gas (ABG) to
determine if the patient is suffering from a pulmonary
embolus
B. Check cardiac enzymes, as the patient is likely suffering from an anterior myocardial wall infarction
C. The nerve to the carotid sinus (nerve of Hering) should be anesthetized with 0.5 mL of 2% lidocaine
D. Begin dobutamine, check central venous pressures, and obtain a lactate level, as the patient is likely to be volume-depleted
E. 100 IU/kg of heparin should be infused intravenously to prevent further emboli

Answer 15

C. The nerve to the carotid sinus (nerve of Hering) should be anesthetized with 0.5 mL of 2% lidocaine

Question 16

QUESTIONS 11-16

Scenario: A 67-year-old male with a history of diabetes mellitus and hypertension presents to the emergency depart¬ment with right arm weakness and numbness. He is found to have > 90% stenosis of the left internal carotid artery and restricted MR diffusion in portions of the brain supplied by the left middle cerebral artery. He elects to proceed with surgery for his carotid stenosis but is found to have a high-riding carotid artery bifurcation.

16. Postoperatively, the patient awoke with right-sided hemiplegia and lethargy. The next logical course of management should include

A. Immediate CT angiography to assess the patency of the right carotid artery
B. Immediate selective angiography of the right carotid
artery
C. Antiplatelet therapy for 1 week, followed by repeat
angiography
D. Stent placement across the arteriotomy site to re-
inforce the closure
E. Immediate surgical reexploration for thrombectomy

Answer 16

E. Immediate surgical reexploration for thrombectomy

Question 17

QUESTIONS 17-18
A 15-year-old female undergoes uncomplicated resection of the lesion depicted below (Figure 6.17-6.18Q). Four days later she develops lethargy, fever, meningismus, and photo¬phobia. A cerebrospinal fluid (CSF) sample reveals a protein level of 86 mg/dL (reference range, 12 to 60 mg/dL), a glu¬cose level of 61 mg/dL (reference range, 40 to 70 mg/dL), 16 red blood cells/mL, and 126 white blood cells/mL with a differential of 11% neutrophils, 82% lymphocytes, and 7% histiocytes. Gram stain and culture of CSF were sterile and remained so for the presence of organisms.

17. What is the most likely diagnosis?

A. Bacterial meningitis
B. Aseptic meningitis
C. Hydrocephalus
D. Postmeningitis syndrome
E. Viral encephalitis

Answer 17

B. Aseptic meningitis

Question 18

QUESTIONS 17-18
A 15-year-old female undergoes uncomplicated resection of the lesion depicted below (Figure 6.17-6.18Q). Four days later she develops lethargy, fever, meningismus, and photo¬phobia. A cerebrospinal fluid (CSF) sample reveals a protein level of 86 mg/dL (reference range, 12 to 60 mg/dL), a glu¬cose level of 61 mg/dL (reference range, 40 to 70 mg/dL), 16 red blood cells/mL, and 126 white blood cells/mL with a differential of 11% neutrophils, 82% lymphocytes, and 7% histiocytes. Gram stain and culture of CSF were sterile and remained so for the presence of organisms.

18. What is the natural history of this problem?

A. Requires a 10-day course of antibiotics despite negative cultures to cover for slow-growing bacterial species
B. Patients frequently require steroid therapy followed
by repeat lumbar punctures
C. Usually self-limited and requires no treatment
D. Patients show drastic improvement with shunting
E. Usually favorable once any synthetic material placed
during surgery (e.g., dural graft) is removed

Answer 18

C. Usually self-limited and requires no treatment

Question 19

19. A 62-year-old female undergoes microvascular decompression for hemifacial spasm. Postoperatively, she has complete ipsilateral deafness but no other neurologic deficits. The most likely cause of this deficit was injury to one of the blood vessels that originated from which artery?

A. Posterior cerebral artery (PCA)
B. Superior cerebellar artery (SCA)
C. Anterior inferior cerebellar artery (AICA)
D. Posterior inferior cerebellar artery (PICA)
E. Vertebral artery

Answer 19

C. Anterior inferior cerebellar artery (AICA)

Question 20

20. A 14-year-old girl with progressive loss of vision in her right eye was recently diagnosed with a 2.0- by 3.5-cm right optic nerve glioma extending to the optic chiasm. During surgery, the portion of the tumor on the optic nerve was successfully resected, but the tumor adjacent to the optic chiasm was left behind. What is the maximal dose of single fraction radiosurgery that can safely be employed to the optic chiasm?

A. 4 to 7 Gy
B. 9tolOGy
C. 11 to 13 Gy
D. 14 to 16 Gy
E. 21 Gy

Answer 20

B. 9tolOGy

Question 21

21. A surgeon decides to utilize an infratentorial-
    supracerebellar corridor to approach a pineal region mass. What blood vessel is frequently cauterized and divided for better exposure of the posterior surface of the tumor during this approach?

A. Vein of Galen
B. Ipsilateral basal vein of Rosenthal
C. Posterior cerebral artery (PGA)
D. Precentral cerebellar vein
E. Superior petrosal sinus

Question 22

22. During translabyrinthine exposure for acoustic neuroma resection, surgeons find themselves exposing Trautmann’s triangle. All of the following structures delineate this area EXCEPT?

A. A triangular patch of dura on the posterior aspect of
the temporal bone facing the cerebellopontine angle
B. The sigmoid sinus laterally
C. The superior petrosal sinus above
D. The jugular bulb below
E. The foramen magnum medially

Answer 22

D. The jugular bulb below

Question 23

23. One of the earliest procedures performed for Parkinson’s disease was ligation of what blood vessel?

A. Anterior choroidal artery
B. Medial posterior choroidal artery
C. Recurrent artery of Heubner
D. Tentorial artery of Bernasconi and Cassarini
E. Medial lenticulostriate artery

Answer 23

E. Medial lenticulostriate artery

Question 24

24. Vagal nerve stimulation is reserved for select patients
    with epilepsy. Why is it performed on the left side?

A. To avoid injuring the recurrent laryngeal nerve, which
follows a more torturous route on the right
B. To avoid damage to the dominant superior laryngeal
nerve on the right
C. To avoid damage to cranial nerve X, which supplies the heart mainly from the right
D. To avoid injuring the thoracic duct
E. Less chance of vocal cord paralysis and hoarseness
from the left

Answer 24

A. To avoid injuring the recurrent laryngeal nerve, which
follows a more torturous route on the right

Question 25

25. What is the treatment of choice for chronic, intractable
    brachial plexus avulsion injury?

A. Cordotomy
B. Dorsal root entry zone (DREZ) lesioning
C. Morphine pump placement
D. Midline myelotomy
E. Ventroposterior lateral (VPL) thalamic deep brain
stimulation

Answer 25

C. Morphine pump placement

Question 26

26. What basal cistern(s) contain portions of the vein ofRosenthal?
27. Crural
28. Quadrigeminal
29. Ambient
30. Quadrigeminal

A. 1, 2, and 3 are correct

B. 1 and 3 are correct

C. 2 and 4 are correct

D. Only 4 is correct

E. All of the above

Answer 26

B. 1 and 3 are correct

Question 27

27. A 3-month-old boy is brought to your office for an
    abnormally shaped head. The child is noted to have a flat
    occiput on the left, a left ear that is anterior to the right, and a prominent forehead and malar eminence on the left. What is the most likely etiology of this deformity?

A. Left lambdoid synostosis
B. Right lambdoid synostosis
C. Sagittal suture synostosis
D. Skull molding
E. Right coronal suture synostosis

Answer 27

B. Right lambdoid synostosis

Question 28

28. All of the following are suboptimal conditions for placement of an odontoid screw EXCEPT?

A. Old fractures (> 6 weeks)
B. Diagonal fractures through the odontoid process
C. Barrel-chested patient
D. Odontoid fracture that is displaced anteriorly
E. An intact transverse ligament

Answer 28

D. Odontoid fracture that is displaced anteriorly

Question 29

29. A 56-year-old female underwent clipping of the aneurysm depicted on the angiogram below (Figure 6.29Q). Upon awakening from surgery, she was noted to have greater weakness in her left arm than in her left leg. What is the most likely reason for this new deficit?

A. Injury of a blood vessel originating from the A2 seg-
ment of the anterior cerebral artery
B. Venous infarct from excessive frontal lobe retraction
C. Injury to the small perforating blood vessels originat-
ing from the anterior communicating artery
D. Posterior internal capsule infarction from microemboli
originating from the internal carotid artery
E. Mesial temporal lobe retraction

Answer 29

E. Mesial temporal lobe retraction

Question 30

30. Basilar skull fractures can be associated with cranial
    nerve palsies, bilateral periorbital ecchymosis, mastoid
    ecchymosis, hemotympanum, and rhinorrhea. Nasal
    drainage that is not clearly CSF can be assayed for
    , which is unique to CSF and .

A. a-Fetoprotein, saliva
B. p-Transferrin, vitreous fluid of the eye
C. (A-Transferrin, tears
D. Hypoglycorrhachia, nasal secretions
E. Sodium, peritoneal fluid

Answer 30

A. a-Fetoprotein, saliva

Question 31

31. A 4-month-old male fell from his crib and suffered a
    growing skull fracture. All of the following are true of this
    disease entity EXCEPT?

A. May be associated with late neurologic deficits
B. A dural laceration is always present
C. There may be ongoing damage to underlying brain
from continued herniation of brain through the defect
D. CSF diversion is often the only treatment required for
this fracture pattern
E. May be associated with leptomeningeal cyst develop-
ment

Answer 31

B. A dural laceration is always present

Question 32

32. A 54-year-old female completed radiation therapy for breast cancer. She has been complaining of weakness in her left arm over the past 3 months and is concerned there may be recurrence of her cancer. How can her physician distinguish between radiation-induced plexopathy and cancerous invasion of the brachial plexus?

A. Radiation-induced plexopathy is frequently accom-
panied by pain and lack of edema
B. Cancerous invasion of the brachial plexus is accompanied by lymphedema, painless weakness, and sensory loss
C. Radiation-induced plexopathy is frequently reversible
D. Myokymia on EMG favors radiation-induced plexopathy
E. Prolonged H latency is typically seen only with brachial plexopathy secondary to radiation damage

Answer 32

D. Myokymia on EMG favors radiation-induced plexopathy

Question 33

QUESTIONS 33-36

Scenario: A 42-year-old male falls 25 feet while at work and arrives at the emergency department with a Glasgow Coma Scale (GGS) score of 5, a dilated and nonreactive right pupil, and a mean arterial blood pressure of 80. After airway management and fluid resuscitation, his GGS improves to 7, but his right hemiparesis and nonreactive pupil remain unchanged. The patient also sustained a pelvic fracture, a left humeral fracture, splenic and liver lacerations, and multiple fractures of the cervical spine.

33. Initial management of this patient should include
34. Begin hyperventilation to decrease the pG02
35. Administer mannitol on arrival to the emergency department because of clinical evidence of an asym¬metric exam
36. Complete the primary survey, obtain cervical spine films and chest x-ray, and then move directly to CT scan
37. The patient should be started on pentobarbital for elevated intracranial pressure immediately after completion of the primary survey if no mass lesion is found on CT

A. 1, 2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above

Answer 33

D. Only 4 is correct