ICP Flashcards
ICP pathophysiology
A 62-year-old patient with a history of hypertension is brought to the emergency department after a severe headache and vomiting. A noncontrast CT scan reveals an intracranial hemorrhage. Based on the Monro-Kellie doctrine, which of the following best describes the compensatory mechanism that initially prevents a significant rise in ICP?
A. Increased absorption of glucose by brain cells
B. Reduction of CSF and/or cerebral blood volume
C. Vasodilation of cerebral arteries
D. Increased production of CSF to buffer excess blood
B. Reduction of CSF and/or cerebral blood volume
Which of the following statements about normal intracranial pressure (ICP) is correct?
A. ICP > 40 mmHg is considered mild elevation
B. Sneezing and coughing do not affect ICP
C. Normal ICP ranges between 10–15 mmHg
D. An elevated ICP always returns to baseline within seconds
C. Normal ICP ranges between 10–15 mmHg
A patient’s ICP rises from 15 mmHg to 28 mmHg with minimal stimulation. Which explanation best describes this phenomenon?
A. The cerebral vessels are vasodilating in response to decreased PaCO₂
B. The brain’s compliance is low, leading to steep ICP increases
C. There is excessive vasoconstriction of cerebral arteries
D. There is a compensatory increase in venous outflow
B. The brain’s compliance is low, leading to steep ICP increases
Which factor most directly causes vasodilation and a subsequent rise in cerebral blood flow and ICP?
A. High serum sodium concentration
B. Elevated PaCO₂ (hypercapnia)
C. Low PaCO₂ (hypocapnia)
D. Increased systemic blood pressure alone
B. Elevated PaCO₂ (hypercapnia)
A 35-year-old with a suspected traumatic brain injury has the following vital signs: MAP = 80 mmHg, ICP = 20 mmHg. What is this patient’s cerebral perfusion pressure (CPP), and how should it be interpreted?
A. CPP = 60 mmHg; this is within acceptable range
B. CPP = 60 mmHg; this indicates dangerously high cerebral perfusion
C. CPP = 100 mmHg; this is too high
D. CPP = 40 mmHg; this indicates inadequate cerebral perfusion
A. CPP = 60 mmHg; this is within acceptable range
Question 6 (Scenario-Based)
A 50-year-old patient arrives with confusion, severe headache, and repeated vomiting over the past hour. On exam, you note irregular respirations, bradycardia, and a systolic pressure significantly higher than diastolic pressure. Which life-threatening complication is most likely occurring?
A. Status epilepticus
B. Cushing’s triad, indicating impending herniation
C. Intracranial infection
D. Hyperglycemic crisis
B. Cushing’s triad, indicating impending herniation
In a patient with increased ICP, which of the following is the gold standard for both monitoring ICP and draining excess cerebrospinal fluid?
A. Subdural drain
B. Intraparenchymal fiber optic bolt
C. Ventriculostomy
D. Lumbar puncture
C. Ventriculostomy
On a noncontrast CT scan of a patient with elevated ICP, you see evidence of midline shift and compressed basal cisterns. These findings most likely indicate:
A. Early hydrocephalus with no immediate concern
B. Significant mass effect and risk of herniation
C. Low ICP states
D. Enlargement of ventricles due to atrophy
B. Significant mass effect and risk of herniation
When evaluating a patient with potential increased ICP, which of the following early symptoms is most commonly encountered?
A. Coma
B. Decerebrate posturing
C. Altered mental status (confusion, lethargy)
D. Absent pupillary reflexes
C. Altered mental status (confusion, lethargy)
A 28-year-old patient with a severe headache and blurred vision is found to have increased ICP. The team obtains an arterial blood gas (ABG) showing a PaCO₂ of 50 mmHg. What is the most likely effect of this ABG finding on cerebral blood flow?
A. Vasoconstriction leading to reduced cerebral blood flow
B. No change in cerebral blood flow
C. Vasodilation leading to increased cerebral blood flow
D. Enhancement of CSF absorption
C. Vasodilation leading to increased cerebral blood flow
Question 11
A key nonpharmacologic management step for a patient with elevated ICP is to:
A. Lower the head of the bed to 0°
B. Elevate the head of the bed to at least 30°
C. Restrict sedation to improve neurological assessments
D. Encourage the patient to hyperventilate spontaneously
B. Elevate the head of the bed to at least 30°
Which nonpharmacologic measure helps prevent spikes in ICP by decreasing metabolic and oxygen demands?
A. Frequent neurological stimulation
B. Keeping the room temperature elevated
C. Providing adequate sedation and pain control
D. Administering high PEEP during mechanical ventilation
C. Providing adequate sedation and pain control
A 60-year-old with a large intracerebral hemorrhage is intubated and sedated. The ICU nurse notes an elevated ICP of 35 mmHg. The respiratory therapist asks if they should increase the respiratory rate to acutely lower PaCO₂. According to current guidelines, what is the recommended approach to ventilation?
A. Always hyperventilate to PaCO₂ < 30 mmHg
B. Brief, controlled hyperventilation only if there are signs of herniation
C. Maintain PaCO₂ > 55 mmHg to ensure vasodilation
D. Avoid adjusting ventilator settings; high ICP will self-correct
B. Brief, controlled hyperventilation only if there are signs of herniation
Which of the following is a critical goal in managing increased ICP?
A. Maintain ICP <40 mmHg
B. Keep serum osmolarity >350 mOsm/L
C. Maintain CPP ≥60 mmHg
D. Provide high-dose steroids for all TBI patients
C. Maintain CPP ≥60 mmHg
In caring for a patient with elevated ICP, what is the primary rationale for maintaining normothermia?
A. To avoid vasospasm in cerebral vessels
B. To reduce metabolic demand and prevent additional increases in ICP
C. To promote vasodilation and raise cerebral blood flow
D. To directly reduce the volume of CSF production
B. To reduce metabolic demand and prevent additional increases in ICP
You are caring for a patient with known increased ICP secondary to a brain tumor. Which medication would be most appropriate to reduce vasogenic edema in this scenario?
A. Mannitol
B. Dexamethasone
C. 3% Hypertonic Saline
D. Pentobarbital
B. Dexamethasone
Steroids are indicated for vasogenic edema from tumors or infections,
but contraindicated in TBI.)
Mannitol is administered to a patient with increased ICP. Which laboratory parameter must be closely monitored to prevent complications?
A. Serum potassium levels only
B. Serum osmolarity (<320 mOsm/L) and electrolytes
C. White blood cell count
D. Thyroid hormone levels
B. Serum osmolarity (<320 mOsm/L) and electrolytes
A patient in the neuro ICU is receiving mannitol for severely elevated ICP. Over the past hour, the nurse notes a drop in blood pressure and increased urine output. Which adverse effect of mannitol is most likely responsible?
A. Excess intravascular fluid retention
B. Cytotoxic edema
C. Rebound hypoglycemia
C. Rebound hypoglycemia
Hypertonic saline (3%) is being used to manage a patient’s refractory ICP. Which of the following complications should the healthcare provider be most vigilant about?
A. Hyponatremia
B. Central pontine myelinolysis
C. Uncontrolled hypothermia
D. Excess sedation
B. Central pontine myelinolysis
A patient with severe traumatic brain injury and uncontrollable elevated ICP is placed into a barbiturate (pentobarbital) coma. What is the primary therapeutic goal of this intervention?
A. To increase PaCO₂ and improve cerebral blood flow
B. To reduce cerebral metabolic demand and ICP
C. To promote vasogenic edema
D. To permanently lower blood pressure
B. To reduce cerebral metabolic demand and ICP
Which herniation syndrome is characterized by downward displacement of the brainstem through the foramen magnum, often resulting in cardiopulmonary arrest?
A. Transtentorial (Uncal) herniation
B. Central herniation
C. Cingulate herniation
D. Tonsillar herniation
D. Tonsillar herniation
A 45-year-old patient in the ICU with an ICP of 42 mmHg for the past hour suddenly becomes bradycardic, hypertensive, and has irregular respirations. This presentation should raise immediate concern for:
A. Cerebral venous sinus thrombosis
B. Imminent transtentorial herniation
C. Basilar skull fracture
D. Simple migraine headache
B. Imminent transtentorial herniation
A patient with a ventriculostomy placed for elevated ICP is at increased risk for which potentially harmful complication?
A. Infections such as ventriculitis
B. Permanent resolution of ICP issues
C. Development of subarachnoid hemorrhage
D. Complete elimination of seizure risk
A. Infections such as ventriculitis
A 30-year-old patient is recovering from a severe TBI. The nurse reports multiple episodes of brief tonic-clonic movements that coincide with a sharp rise in ICP. What best explains how this might harm the patient?
A. Seizures reduce cerebral metabolic demand
B. Seizures can increase metabolic demands and further raise ICP
C. Seizures trigger immediate vasoconstriction and lower ICP
D. Seizures do not affect ICP
B. Seizures can increase metabolic demands and further raise ICP
Cushing’s triad (systolic hypertension with wide pulse pressure, bradycardia, and irregular respirations) is a classic late sign of:
A. Respiratory alkalosis
B. Herniation
C. Pending seizure activity
D. Glucose imbalance
B. Herniation
Which electrolyte abnormality is commonly seen in patients receiving hypertonic therapy for elevated ICP?
A. Hyponatremia
B. Hyperkalemia
C. Hypernatremia
D. Hypocalcemia
C. Hypernatremia
In a patient with increased ICP, which type of cerebral edema involves increased capillary permeability and is often responsive to steroids if caused by a tumor or infection?
A. Cytotoxic edema
B. Vasogenic edema
C. Osmotic edema
D. Interstitial edema
B. Vasogenic edema
A 55-year-old patient with a large ischemic stroke develops sudden neurological deterioration. A stat CT scan shows massive swelling and signs of midline shift. The ICP is measured at >40 mmHg. This prolonged, severe elevation in ICP is most likely to:
A. Spontaneously resolve without harm
B. Cause irreversible ischemia and potentially death
C. Indicate a need to reduce sedation
D. Be a sign of early mild ICP elevation
B. Cause irreversible ischemia and potentially death
Question 29 (Scenario-Based)
An 18-year-old male with a severe TBI is brought to the ICU. He has an ICP of 32 mmHg. Despite mannitol, hypertonic saline, and ensuring adequate sedation, the ICP remains elevated. The team is considering advanced options. Which of the following is the next reasonable step to manage refractory ICP according to the study guide?
A. High-dose steroid therapy
B. Bolus of intravenous normal saline
C. 23.4% hypertonic saline or barbiturate coma
D. Aggressive fluid restriction
C. 23.4% hypertonic saline or barbiturate coma
A patient presents with confusion and lethargy (early signs of increased ICP). When asked about your management priorities, you recall the three fundamental questions: “What will kill my patient, what might harm my patient, and what is really common?” Which of the following interventions best addresses all three concerns?
A. Administer prophylactic steroids for every cause of elevated ICP
B. Monitor for seizure activity, maintain adequate perfusion (ABCs), and watch for electrolyte imbalances
C. Perform repeated lumbar punctures for any ICP elevation
D. Keep the head of the bed flat to stabilize intracranial contents
B. Monitor for seizure activity, maintain adequate perfusion (ABCs), and watch for electrolyte imbalances
ICP complications
Herniation, refractory ICP)
What will kill your patient?
seizures, infections, improper sedation/ventilation
What will harm your patient?
cerebral edema, electrolyte imbalances, increased ICP with TBI
What is really common?
A 12-year-old patient with a history of hydrocephalus and a ventriculoperitoneal (VP) shunt is brought in with severe headache, nausea, and lethargy. His mother reports that he has been more irritable for the past 48 hours. Vital signs show a widened pulse pressure and bradycardia. Which of the following is the most likely cause of his presentation?
A. Blocked or malfunctioning VP shunt leading to increased ICP
B. Simple migraine triggered by stress C. Acute bacterial meningitis
D. Spinal cord compression
Blocked or malfunctioning VP shunt leading to increased ICP
A 47-year-old trauma patient has elevated ICP and is on mechanical ventilation. Which ventilation strategy is most appropriate to avoid adding to intracranial pressure?
A. Increasing PEEP to 15 cm H₂O to improve oxygenation
B. Maintaining low to moderate PEEP and avoiding excessive hyperventilation
C. Hyperventilating to maintain PaCO₂ below 25 mmHg
D. Discontinuing sedation to allow for spontaneous breathing
- B – Maintain low to moderate PEEP, avoid excessive hyperventilation
Hint: Remember, excessive PEEP can raise intrathoracic pressure, impeding venous return from the brain, thus raising ICP.
A 30-year-old patient with a confirmed large ischemic stroke is brought to the ICU. Over 24 hours, his neurological status worsens, and a repeat CT scan shows significant edema with midline shift. His ICP is now 38 mmHg. Which initial measure is most appropriate to urgently address his elevated ICP?
A. Start high-dose dexamethasone for any stroke
B. Begin IV mannitol bolus and elevate the head of bed
C. Administer prophylactic antibiotics D. Hyperventilate for an extended period to PaCO₂ of 25 mmHg
B. Begin IV mannitol bolus and elevate the head of bed
A patient with increased ICP needs sedation to control agitation. Which agent is commonly used for sedation in neuro patients because it provides rapid onset and can help control ICP by reducing metabolic demand?
A. Propofol
B. Midazolam
C. Dexmedetomidine
D. Haloperidol
A. Propofol
(rapid onset, reduces metabolic demand)
A 55-year-old with a brain tumor presents with focal neurological deficits and imaging findings consistent with vasogenic edema. According to the study guide, what is the best initial medication to reduce this type of edema?
A. Mannitol
B. Dexamethasone
C. 3% Hypertonic saline
D. Acetazolamide
Dexamethasone for vasogenic edema from tumors
In a patient with traumatic brain injury (TBI), which of the following statements regarding steroids is accurate based on the provided content?
A. Steroids are indicated for all TBI to reduce cytotoxic edema
B. Steroids are contraindicated in TBI because they have not shown benefit and may cause harm
C. Steroids are only given in TBI when ICP is <20 mmHg
D. Steroids cannot cross the blood-brain barrier, so they are never used in neurologic cases
C. Steroids are only given in TBI when ICP is <20 mmHg
– Steroids are contraindicated in TBI
A 68-year-old with severe TBI has had persistently elevated ICP (>35 mmHg) despite mannitol and hypertonic saline. The team decides to place him in a barbiturate coma. Which desired physiologic effect are they trying to achieve?
A. Increased cerebral metabolic rate to improve arousal
B. Decreased cerebral metabolic demand to lower ICP
C. Elevated blood pressure to improve CPP
D. Permanent cessation of seizures, regardless of ICP levels
- B – Decreased metabolic demand to lower ICP
A common issue in patients receiving osmotherapy (mannitol or hypertonic saline) for elevated ICP is:
A. Respiratory alkalosis
B. Hypernatremia and shifting electrolyte levels
C. Immediate hypothermia
D. Bradycardia and hypotension in all patients
B – Hypernatremia and electrolyte imbalances
A 52-year-old patient in the ICU for elevated ICP suddenly becomes extremely restless and starts pulling at IV lines. The nurse notes that the patient’s ICP values spike from 22 to 38 mmHg. Which immediate intervention is most appropriate to prevent further ICP elevation?
A. Allow the patient to continue moving to self-stimulate neurologically
B. Use restraints and avoid sedation to maintain accurate neuro exams
C. Provide adequate sedation and analgesia to reduce agitation
D. Lower the head of the bed to horizontal to stabilize ICP
Provide adequate sedation/analgesia
In which situation is hyperventilation to acutely lower PaCO₂ most justified in the management of increased ICP?
A. Long-term control of ICP in all traumatic brain injuries
B. Routine prophylactic measure for minor head injuries
C. Emergency rescue therapy for acute herniation signs
D. Standard practice to keep PaCO₂ below 25 mmHg indefinitely
- C – Emergency rescue therapy for acute herniation
A 50-year-old patient has an intracranial pressure (ICP) measured at 28 mmHg after a severe headache and confusion. According to the provided definitions, this value best fits which category?
A. Normal ICP (10–15 mmHg)
B. Mild elevation (20–30 mmHg)
C. Severe elevation (>40 mmHg)
D. No clinical significance
- B – Mild elevation (20–30 mmHg)
A patient sneezes multiple times, causing a sudden transient spike in ICP from 12 mmHg to 25 mmHg. What is the most likely outcome under normal physiologic circumstances?
A. ICP will remain elevated indefinitely
B. ICP will drop below 5 mmHg
C. ICP will rapidly return to baseline
D. Brain herniation is inevitable
- C – ICP will rapidly return to baseline
Question 3
Which statement best describes the Monro-Kellie Doctrine?
A. Each intracranial component can increase without affecting the others
B. Increases in one intracranial component must be offset by decreases in others
C. Only brain tissue volume matters; CSF and blood volume are negligible
D. The skull can expand to accommodate increases in ICP
- B – Increases in one component must be offset by decreases in the others
A 60-year-old with a newly diagnosed brain tumor has an MRI showing a growing mass. Initially, their ICP remains near normal because:
A. The tumor does not affect intracranial pressure
B. The body compensates by shunting blood and/or CSF to maintain stable ICP
C. The tumor is in a non-compliant portion of the brain
D. The tumor creates negative pressure within the skull
- B – The body compensates by shunting blood or CSF to maintain stable ICP
Question 5
Cerebral perfusion pressure (CPP) is calculated as:
A. ICP + MAP
B. MAP - ICP
C. Systolic BP - Diastolic BP
D. PaCO₂ + ICP
- B – CPP = MAP - ICP
A patient in the ICU has low PaCO₂ levels due to overzealous hyperventilation. Which direct effect on cerebral blood flow is most likely?
A. Vasoconstriction leading to decreased CBF
B. Vasodilation leading to increased CBF
C. No effect on cerebral blood flow
D. Rapid increase in ICP
- A – Low PaCO₂ causes vasoconstriction and decreased CBF
Which minimum CPP (cerebral perfusion pressure) is considered generally acceptable to maintain adequate brain perfusion in an adult?
A. <40 mmHg
B. ≥60 mmHg
C. Approximately 100 mmHg
D. 15–20 mmHg
- B – CPP ≥60 mmHg
A 30-year-old patient sustains a traumatic brain injury (TBI) in a motor vehicle collision. On CT scan, there is evidence of cerebral swelling. Which of the following is not a common cause of increased ICP?
A. Hydrocephalus
B. Intracranial hemorrhage
C. Brain tumors
D. Hypoglycemia
- D – Hypoglycemia (not a direct cause of increased ICP listed)
types of cerebral edema
. Cerebral Edema Types
Question 9
Which type of cerebral edema is primarily caused by ischemia and hypoxia that lead to irreversible cell damage?
A. Vasogenic edema
B. Cytotoxic edema
C. Interstitial edema
D. Hydrostatic edema
- B – Cytotoxic edema
A patient with chronic hydrocephalus presents with elevated CSF pressure on imaging. The patient’s ventricles are notably enlarged, exerting pressure on surrounding brain tissue. This clinical picture is most consistent with which type of cerebral edema?
A. Vasogenic
B. Cytotoxic
C. Interstitial
D. Hemorrhagic
- C – Interstitial edema
A 40-year-old patient has an ICP reading of 42 mmHg following a severe headache and confusion. According to standard definitions provided, how would you classify this ICP elevation?
A. Normal ICP (10–15 mmHg)
B. Mild elevation (20–30 mmHg)
C. Moderate elevation (30–40 mmHg)
D. Severe elevation (>40 mmHg)
- D – Severe elevation (>40 mmHg)
Monro-Kellie Doctrine
According to the Monro-Kellie Doctrine, which factor most commonly compensates first when an intracranial mass or lesion starts to increase in volume?
A. Brain tissue shrinking via atrophy
B. CSF displacement or reabsorption changes
C. Blood vessel expansion to accommodate volume
D. Skull expansion to reduce intracranial pressure
CSF displacement or reabsorption changes
A patient is found hyperventilating with a PaCO₂ of 25 mmHg. Which immediate effect on cerebral blood flow (CBF) is expected if this state continues?
A. Pronounced vasodilation, raising ICP
B. Minimal or no effect on CBF
C. Vasoconstriction leading to reduced CBF
D. Increased metabolic demand in cerebral tissue
- C – Vasoconstriction leading to reduced CBF
Causes of Increased ICP
Which of the following is a primary cause of increased intracranial pressure?
A. Systemic hypotension
B. Hepatic encephalopathy
C. Traumatic brain injury (TBI)
D. Hyperglycemia
- C – Traumatic brain injury (TBI)
Types of Cerebral Edema
A patient presents with swelling of the brain tissue after a severe ischemic event. Brain imaging and labs indicate cellular injury due to lack of oxygen, leading to intracellular fluid accumulation. This pattern best fits which type of cerebral edema?
A. Vasogenic edema
B. Cytotoxic edema
C. Interstitial edema
D. Osmotic edema
- B – Cytotoxic edema
: Early Clinical Presentation of ICP
A 35-year-old patient presents to the emergency department after a minor car accident. Initially, they are alert but complain of a persistent headache and increasing nausea. Over the past two hours, the patient has become more lethargic and confused, though vital signs remain relatively stable.
* What does this clinical change most likely represent regarding ICP, and what additional early symptom might you anticipate?
A. Elevated ICP with early signs; you might also see unilateral dilated pupils
B. Elevated ICP with early signs; you might also see diplopia or blurred vision
C. Normal ICP with isolated post-concussive symptoms; no concern unless vomiting occurs
D. Normal ICP; bradycardia is typically the first sign of trouble
- B – Elevated ICP with early signs; you might also see visual disturbances like diplopia.
Late Clinical Presentation of ICP
A 60-year-old patient with a known intracranial mass experiences sudden deterioration. Over the last 24 hours, confusion has worsened to the point of near unresponsiveness. The nurse notes extensor posturing (decerebrate) and minimal pupillary response to light.
* Which statement best explains these findings in relation to increased ICP?
A. These are early, nonspecific signs of mild intracranial pressure elevation
B. These are late signs indicating significantly raised ICP and potential herniation risk
C. These findings suggest a migraine variant and are not ICP-related
D. These findings are unrelated to mass lesions and are caused by electrolyte imbalance
A 60-year-old patient with a known intracranial mass experiences sudden deterioration. Over the last 24 hours, confusion has worsened to the point of near unresponsiveness. The nurse notes extensor posturing (decerebrate) and minimal pupillary response to light.
* Which statement best explains these findings in relation to increased ICP?
A. These are early, nonspecific signs of mild intracranial pressure elevation
B. These are late signs indicating significantly raised ICP and potential herniation risk
C. These findings suggest a migraine variant and are not ICP-related
D. These findings are unrelated to mass lesions and are caused by electrolyte imbalanceIC
ICP imaging
A 50-year-old patient presents with severe headache, vomiting, and confusion. A noncontrast CT scan of the head shows compressed basal cisterns and evidence of a 1 cm midline shift.
* How should these CT findings be interpreted?
A. They are typical findings of normal aging and do not explain the symptoms
B. They suggest significant intracranial hypertension and a risk for herniation
C. They indicate a normal intracranial pressure; further imaging is unnecessary
D. They confirm a subarachnoid hemorrhage unrelated to ICP changes
- B – Compressed basal cisterns and midline shift suggest significant intracranial hypertension.
ICP monitoring
A 45-year-old patient with hydrocephalus has a ventriculostomy placed to monitor and manage ICP. The ICP readings fluctuate between 25–30 mmHg. Over several hours, you note the ICP trending upward to 35 mmHg with no immediate changes in the patient’s exam, although the drain is in place.
* Which immediate action is most appropriate?
A. Remove the ventriculostomy and opt for an intraparenchymal monitor
B. Check the ventriculostomy system for obstructions or kinks, and verify its level
C. Assume the monitor is malfunctioning; no further intervention is needed
D. Perform an urgent lumbar puncture to reduce CSF volume
- B – Check for mechanical issues (kinks/leveling) before concluding other causes.
Cushing’s Triad
A 70-year-old patient hospitalized with a large hemispheric stroke suddenly develops a widened pulse pressure, bradycardia, and an irregular respiratory pattern.
* What is the significance of this triad, and what immediate concern does it raise?
A. It is a normal physiologic variant with no bearing on ICP
B. It indicates sympathetic overactivity, suggesting a seizure focus
C. It represents Cushing’s Triad, signaling possible impending herniation
D. It suggests metabolic derangements in the liver, requiring hepatic function tests5. C – Cushing’s Triad indicates impending herniation and requires urgent intervention.
- C – Cushing’s Triad indicates impending herniation and requires urgent intervention.
A 55-year-old patient with suspected rising ICP presents with progressive drowsiness, headache, and intermittent vomiting. A noncontrast CT scan shows midline shift, and the neurosurgeon places an intraparenchymal ICP monitor that reads 28 mmHg. Over the next few hours, the patient’s pupils become sluggish, and they exhibit a trend toward systolic blood pressure increases and bradycardia.
* Based on this scenario, which combination of diagnostic findings best reflects the evolution of dangerous intracranial hypertension?
A. Early mental status changes, normal CT scan, stable ICP reading
B. Compressed ventricles on CT, symmetrical pupils, tachycardia
C. Midline shift on CT, ICP > 20 mmHg, sluggish pupils, Cushing’s Triad signs
D. Clear scan with normal ICP, mild confusion, tachycardia
- C – Midline shift, ICP above 20 mmHg, and emerging Cushing’s Triad (widened pulse pressure, bradycardia) are hallmark signs of dangerous ICP elevation.
(ventriculostomy vs. intraparenchymal monitor)
ICP Monitoring
Signs of Herniation
(Cushing’s triad)
ICP Early vs. Late Signs
- Which of the following is considered an early sign of increased intracranial pressure?
A. Coma
B. Decerebrate posturing
C. Confusion or lethargy
D. Bradycardia
C. Confusion or lethargy
- A patient with a suspected rise in ICP presents with headache, blurred vision, and nausea. Over the next several hours, they develop bilateral extensor posturing. How would you categorize this posturing sign?
A. Early sign of increased ICP
B. Late sign of increased ICP
C. Not related to ICP
D. A benign finding indicating improvement
B. Late sign of increased ICP
- Which clinical presentation typically appears first in the evolution of increasing ICP?
A. Coma
B. Fixed, dilated pupils
C. Hypertensive crisis
D. Altered mental status (e.g., mild confusion)
D. Altered mental status (e.g., mild confusion)
- A 55-year-old patient presents with severe headache, nausea, and vomiting. Vital signs are relatively stable, but the neurological exam reveals progressive drowsiness. This presentation most likely aligns with:
A. Early signs of increased ICP
B. Immediate signs of herniation
C. Late irreversible changes
D. Normal intracranial dynamics
A. Early signs of increased ICP
- Diplopia (double vision) in a patient with suspected increased ICP is primarily caused by:
A. Excess tear production
B. Pressure on the oculomotor nerves or cranial nerve VI dysfunction
C. Elevated blood sugar
D. Liver enzyme abnormalities
B. Pressure on the oculomotor nerves or cranial nerve VI dysfunction
- Which of the following best describes a late sign of increased ICP?
A. Nausea and vomiting
B. Mild confusion
C. Coma or posturing
D. Headache
C. Coma or posturing
- A patient’s pupils become asymmetric and respond sluggishly to light. What does this suggest in the context of increased ICP?
A. Early sign of mild ICP elevation with no concern
B. Potential cranial nerve involvement indicating rising ICP
C. Normal finding with sedation
D. A primary sign of hepatic encephalopathy
B. Potential cranial nerve involvement indicating rising ICP
- Which of the following signs or symptoms is not typically associated with increased ICP?
A. Projectile vomiting
B. Diplopia
C. Hemoptysis
D. Headache
C. Hemoptysis
- A patient with moderate TBI appears increasingly drowsy and less responsive. In the context of ICP, this drowsiness is most likely:
A. An early clinical finding of rising ICP
B. Unrelated to intracranial pressure
C. A guaranteed sign of seizures
D. A late, irreversible sign
A. An early clinical finding of rising ICP
- What is the most common initial indicator that a patient’s ICP may be rising?
A. Unilateral dilated pupil
B. Cushing’s triad
C. Subtle changes in mental status
D. Full decorticate posturing
C. Subtle changes in mental status
- A patient with suspected increased ICP undergoes a noncontrast CT scan. Which of the following findings would indicate significantly elevated intracranial pressure?
A. Normal-sized ventricles and no midline shift
B. Evidence of mass effect with midline shift
C. Bilateral pleural effusions
D. Enlarged sinuses
B. Evidence of mass effect with midline shift
- On a noncontrast CT, which finding is commonly associated with increased ICP due to hydrocephalus?
A. Narrowed ventricles
B. Enlarged ventricles with compressed sulci
C. Completely normal intracranial structures
D. No changes unless MRI is done
B. Enlarged ventricles with compressed sulci
- The “mass effect” seen on a CT scan of a patient with a large intracranial hemorrhage refers to:
A. The effect of subcutaneous swelling on scalp tissues
B. Displacement of brain structures leading to potential herniation
C. A benign tumor expansion with no clinical consequences
D. Excess fluid in the subarachnoid space without risk
B. Displacement of brain structures leading to potential herniation
- When evaluating a noncontrast CT scan for increased ICP, which specific sign is critical to identify promptly?
A. Displacement of nasal septum
B. Midline shift or compressed basal cisterns
C. Bilateral pneumonia
D. Enlarged pituitary gland
B. Midline shift or compressed basal cisterns
- Which imaging modality is the first-line, rapid evaluation for suspected acute increased ICP?
A. Contrast-enhanced MRI
B. Ultrasound of the temporal artery
C. Noncontrast CT scan
D. PET scan
C. Noncontrast CT scan
- A noncontrast head CT shows markedly compressed basal cisterns. This finding often suggests:
A. Low intracranial pressure
B. Elevated ICP and risk of herniation
C. Normal variation of cistern size
D. Brain atrophy
B. Elevated ICP and risk of herniation
- Which of the following best describes the rationale for choosing a noncontrast CT over a contrast CT in suspected intracranial hemorrhage or increased ICP?
A. Contrast is necessary to visualize old hemorrhages
B. Noncontrast CT avoids masking acute bleeding and is faster
C. Contrast CT always provides better detail for acute bleeds
D. Contrast does not cross the blood-brain barrier
B. Noncontrast CT avoids masking acute bleeding and is faster
- A patient arrives with signs of severely raised ICP. The noncontrast head CT shows a “compressed ventricle” appearance, consistent with:
A. Abnormal accumulation of subdural fluid
B. Pressure from surrounding brain edema pushing inwards
C. Normal variations in ventricular shape
D. Chronic atrophy making ventricles appear smaller
B. Pressure from surrounding brain edema pushing inwards
- If a patient with raised ICP also has a CT finding of blood in the ventricles, the most likely immediate cause is:
A. Meningitis
B. Intracerebral hemorrhage that has extended into the ventricles
C. Chronic hydrocephalus
D. Simple sinus congestion
B. Intracerebral hemorrhage that has extended into the ventricles
- In the context of increased ICP, the term “hydrocephalus” on imaging refers to:
A. Swelling of brain tissue only
B. Excess CSF accumulation leading to enlarged ventricles
C. A malignant tumor in the posterior fossa
D. A normal process of aging
B. Excess CSF accumulation leading to enlarged ventricles
- Which ICP monitoring technique is considered the gold standard for both measuring ICP and draining CSF?
A. Lumbar puncture
B. Intraparenchymal (bolt) monitor
C. Ventriculostomy
D. Epidural sensor
C. Ventriculostomy
- An intraparenchymal monitor (bolt) measures ICP via a fiber optic transducer placed:
A. In the lateral ventricle
B. In a peripheral vein
C. Directly into brain tissue parenchyma
D. Within the epidural space
C. Directly into brain tissue parenchyma
- One advantage of a ventriculostomy over an intraparenchymal monitor is the ability to:
A. Monitor ICP more accurately
B. Drain CSF and relieve pressure
C. Place it at bedside without imaging guidance
D. Avoid infection risk
B. Drain CSF and relieve pressure
- An intraparenchymal ICP monitoring device typically does not allow for:
A. Continuous ICP waveform readings
B. CSF drainage
C. Early detection of ICP surges
D. Fiber optic-based measurements
B. CSF drainage
- For a patient with acute hydrocephalus and elevated ICP, which monitoring technique is often preferred for both diagnostic and therapeutic purposes?
A. Intraparenchymal bolt
B. Ventriculostomy
C. Serial lumbar punctures
D. No monitoring required
B. Ventriculostomy
- Which statement is true regarding ICP monitoring devices?
A. A lumbar puncture is the gold standard for ICP measurement
B. Ventriculostomy can help drain excess CSF and directly measure ICP
C. Intraparenchymal monitors provide CSF samples for laboratory analysis
D. Epidural monitors are the most accurate for long-term ICP measurement
B. Ventriculostomy can help drain excess CSF and directly measure ICP
- When placing an ICP monitor, which of the following is a key clinical concern?
A. Cost of the monitoring device
B. Risk of infection (e.g., ventriculitis)
C. Necessity for sedation for more than a week
D. Overnight hospital stay for monitoring
B. Risk of infection (e.g., ventriculitis)
- A patient with a functioning ventriculostomy for ICP monitoring has persistently high ICP readings (>30 mmHg). The most appropriate immediate step in diagnosis would be:
A. Remove the ventriculostomy immediately
B. Check for kinks or obstructions in the catheter and ensure the drain is leveled appropriately
C. Order a PET scan of the brain
D. Increase intravenous fluids
B. Check for kinks or obstructions in the catheter and ensure the drain is leveled appropriately
classic signs of Cushing’s triad is classically
- Cushing’s triad is classically characterized by:
A. Bradycardia, systolic hypertension with widened pulse pressure, altered respirations
B. Tachycardia, hypotension, hyperventilation
C. Normal blood pressure, bradycardia, rapid respirations
D. Palpitations, chest pain, normal mental status
A. Bradycardia, systolic hypertension with widened pulse pressure, altered respirations
- A 52-year-old patient with a known mass lesion develops sudden bradycardia, irregular respirations, and a widening pulse pressure. This constellation of signs most urgently suggests:
A. Pulmonary embolism
B. Sepsis with shock
C. Cushing’s triad indicating impending herniation
D. Simple anxiety and panic
C. Cushing’s triad indicating impending herniation
A B C ICO management
- A 36-year-old with a severe traumatic brain injury (TBI) is hemodynamically unstable (systolic BP <90 mmHg) and has an ICP of 22 mmHg. Which immediate priority best aligns with management guidelines?
A. Aggressively reduce ICP below 10 mmHg, regardless of blood pressure
B. Focus on raising the blood pressure to maintain CPP ≥60 mmHg
C. Disregard blood pressure until ICP is normalized
D. Initiate barbiturate coma to rapidly lower ICP
B. Focus on raising the blood pressure to maintain CPP ≥60 mmHg
- A patient with a large hemispheric stroke has an ICP of 25 mmHg and a mean arterial pressure (MAP) of 80 mmHg. What is the most appropriate initial management goal?
A. Maintain ICP below 30 mmHg to avoid herniation
B. Increase MAP to at least 100 mmHg
C. Ensure CPP is at least 60 mmHg by maintaining MAP or lowering ICP
D. Keep the head of the bed flat to improve jugular venous return
C. Ensure CPP is at least 60 mmHg by
circulation -preventing hypotension
Preventing Hypotension
3. A 55-year-old with cerebral edema from a brain tumor is hypotensive due to sepsis, and ICP is borderline elevated at 18 mmHg. Which action aligns with best practice?
A. Prioritize fluid resuscitation and vasopressor support to maintain MAP
B. Aggressively lower ICP with mannitol regardless of blood pressure
C. Restrict all IV fluids to limit edema
D. Delay antibiotic therapy until ICP is <10 mmHg
A. Prioritize fluid resuscitation and vasopressor support to maintain MAP
- A 42-year-old’s ICP is consistently 22–25 mmHg. Which positioning intervention is most appropriate to help reduce ICP?
A. Keep the head of the bed at 0°
B. Elevate the head of the bed to ≥30° with neutral neck alignment
C. Turn the patient’s neck sharply to the side to enhance jugular drainage
D. Lower the foot of the bed to promote central blood flow
B. Elevate the head of the bed to ≥30° with neutral neck alignment
- A nurse elevates the head of the bed to 45° for a patient with increased ICP. After 10 minutes, the ICP reading drops from 25 mmHg to 18 mmHg. Which explanation best accounts for the improvement?
A. The elevated position decreases venous outflow obstruction
B. ICP always drops after any random position change
C. Laying flat compresses the ventricles, forcing fluid out
D. This effect is incidental; bed position does not affect ICP
A. The elevated position decreases venous outflow obstruction
Avoiding Hyperventilation Unless Necessary
- A 60-year-old patient has an ICP of 38 mmHg and shows signs of impending herniation. Which ventilation strategy is recommended?
A. Prolonged hyperventilation to maintain PaCO₂ below 25 mmHg indefinitely
B. Brief, controlled hyperventilation to lower PaCO₂ and acutely decrease ICP
C. Maintain high PaCO₂ (50–60 mmHg) to promote cerebral vasodilation
D. Avoid any changes in ventilation because it may worsen ICP
B. Brief, controlled hyperventilation to lower PaCO₂ and acutely decrease ICP
Nonpharmacologic Management
Temperature Control
- A patient’s temperature is 39.2°C (102.6°F) following a traumatic brain injury. ICP is trending upward at 28 mmHg. Why is prompt treatment of fever critical?
A. Fever promotes vasoconstriction and lowers ICP
B. Reducing temperature prevents increased metabolic demand, helping control ICP
C. Hyperthermia always resolves spontaneously in TBI
D. High temperature improves cerebral blood flow, reducing ICP
B. Reducing temperature prevents increased metabolic demand, helping control ICP
Seizure Prophylaxis
- A 22-year-old with severe TBI is at high risk for seizures. How does seizure prophylaxis help manage ICP?
A. Seizures reduce metabolic demand, stabilizing ICP
B. Avoiding seizures reduces metabolic spikes and potential ICP elevations
C. Prophylaxis only helps if the patient already had seizures
D. There is no link between seizures and ICP elevations
B. Avoiding seizures reduces metabolic spikes and potential ICP elevations
- A 48-year-old in the ICU with increased ICP becomes agitated whenever turned or suctioned. Which intervention best addresses this issue?
A. Increase stimulation to keep the patient alert
B. Provide adequate sedation and analgesia to minimize ICP spikes
C. Withhold all sedation for more frequent neurological checks
D. Discontinue mechanical ventilation to reduce patient distress
B. Provide adequate sedation and analgesia to minimize ICP spikes
- Which outcome is most directly achieved by properly managing pain and anxiety in patients with elevated ICP?
A. Lower risk of bacterial meningitis
B. Prevention of cardiovascular collapse
C. Reduced sympathetic responses that can spike ICP
D. Guarantee of normal pupillary reflexes
C. Reduced sympathetic responses that can spike ICP
- A patient with increased ICP is on mechanical ventilation with a PEEP of 15 cm H₂O. ICP remains above 25 mmHg despite sedation and head elevation. What might be a next step?
A. Increase PEEP further to 20 cm H₂O
B. Lower PEEP to avoid increasing intrathoracic pressure
C. Stop ventilator support and allow spontaneous breathing
D. Obtain a CT scan immediately, as PEEP does not affect ICP
B. Lower PEEP to avoid increasing intrathoracic pressure
- Which statement best explains why low PEEP is typically preferred in managing high ICP?
A. Low PEEP reduces alveolar oxygenation but helps venous return
B. High PEEP can increase intrathoracic pressure and impede cerebral venous outflow
C. High PEEP exclusively reduces arterial CO₂, thus lowering ICP
D. Low PEEP has no effect on cerebral physiology
B. High PEEP can increase intrathoracic pressure and impede cerebral venous outflow
Pharmacologic Management
Osmotherapy: Mannitol & Hypertonic Saline
- A 34-year-old with elevated ICP is given mannitol (0.5 g/kg IV). What best describes its mechanism?
A. Beta-blockade reducing heart rate and systemic blood pressure
B. Osmotic diuresis pulling fluid out of brain tissue, reducing ICP
C. Calcium channel blockade improving cerebral vasoconstriction
D. Direct sedation of cortical neurons
B. Osmotic diuresis pulling fluid out of brain tissue, reducing ICP
- After administering a bolus of mannitol for increased ICP, which lab value is most important to monitor?
A. Serum osmolarity and electrolytes
B. Hemoglobin A1c
C. Liver function tests
D. Blood urea nitrogen (BUN) only
Serum osmolarity and electrolytes
- A patient’s ICP briefly decreases after mannitol but rises again to 30 mmHg within an hour. Which explanation best fits this phenomenon?
A. Mannitol is ineffective for intracranial pressure management
B. Rebound intracranial hypertension can occur once mannitol wears off
C. The elevated ICP reading must be inaccurate
D. Mannitol has a half-life of weeks, so the rebound is unrelated
B. Rebound intracranial hypertension can occur once mannitol wears off
- Hypertonic saline (3%) is administered to a patient with refractory ICP. Which adverse effect is most critical to monitor?
A. Hypoglycemia
B. Hypernatremia leading to osmotic demyelination
C. Urinary retention
D. Excess sedation
B. Hypernatremia leading to osmotic demyelination
- You are caring for a patient on 3% saline for increased ICP. The goal serum sodium is around 155–165 mEq/L. Why might the team accept a higher serum sodium than normal in this scenario?
A. Elevated sodium has no real side effects
B. The hyperosmolar environment pulls fluid from brain tissue, lowering ICP
C. Intracellular fluid shifts into RBCs, preventing stroke
D. High serum sodium counteracts sedation
B. The hyperosmolar environment pulls fluid from brain tissue, lowering ICP
- A 65-year-old with a brain tumor and vasogenic edema has high ICP. Which pharmacologic treatment is specifically indicated for this edema type?
A. Steroids (e.g., dexamethasone)
B. Mannitol for cytotoxic edema
C. Hypertonic saline for all TBI patients
D. Acetazolamide for aqueductal stenosis
A. Steroids (e.g., dexamethasone)
- Steroids are generally contraindicated in which situation related to high ICP?
A. Vasogenic edema due to metastases
B. Intracranial infections
C. Traumatic brain injury (TBI)
D. Brain tumor post-surgery
C. Traumatic brain injury (TBI)
- A 55-year-old patient has refractory ICP (>35 mmHg) despite head-of-bed elevation, sedation, and standard osmotherapy. Which agent might be used for a more aggressive osmotic effect?
A. 0.9% Normal Saline
B. 23.4% Hypertonic Saline
C. Acetazolamide
D. Antibiotic prophylaxis
B. 23.4% Hypertonic Saline
C. Acetazolamide
patient with severe TBI and persistent ICP of 38 mmHg is placed into a pentobarbital coma. What is the primary rationale for this intervention?
A. Induce vasogenic edema to reduce ICP
B. Lower cerebral metabolic rate and thereby lower ICP
C. Improve patient consciousness to perform better neuro exams
D. Stabilize systemic blood pressure without sedation
B. Lower cerebral metabolic rate and thereby lower ICP
- Which intervention is most appropriate for truly refractory elevated ICP when all other measures (e.g., sedation, osmotherapy) have failed?
A. High-dose steroid therapy in TBI
B. Inhaled nitric oxide
C. High-concentration hypertonic saline (23.4%) or barbiturate coma
D. Large-volume lumbar punctures
C. High-concentration hypertonic saline (23.4%) or barbiturate coma
Complications
Recognizing Life-Threatening Scenarios
- A patient’s ICP remains at 45 mmHg for one hour despite maximal interventions. This prolonged elevation puts the patient at highest risk for:
A. Sinus congestion
B. Cerebral herniation and potential brain death
C. Rebound hypotension
D. Spontaneous resolution after 24 hours
B. Cerebral herniation and potential brain death
- Which complication falls under the category of “What Will Kill Your Patient”?
A. Mild hypothermia
B. Refractory ICP > 40 mmHg leading to ischemia and death
C. Hyperglycemia from stress response
D. Localized scalp infection
B. Refractory ICP > 40 mmHg leading to ischemia and death
What will harm the patient
- A patient with an ICP monitor (ventriculostomy) is at risk for:
A. Daily migraines
B. Local site bruising only
C. Infections such as ventriculitis
D. Intracranial pressure dropping to zero
C. Infections such as ventriculitis
- Uncontrolled seizures in a patient with increased ICP are particularly dangerous because they:
A. Lower metabolic demand and quickly reduce ICP
B. Can spike metabolic demand, further elevating ICP
C. Have no effect on cerebral perfusion
D. Only occur in hypothermic patients
B. Can spike metabolic demand, further elevating ICP
Common/typical findings in ICP
- Which electrolyte disturbance is commonly seen in patients receiving aggressive osmotherapy?
A. Hyponatremia
B. Hypernatremia
C. Hypercalcemia
D. Hypophosphatemia
B. Hypernatremia
- Cerebral edema in brain injuries is often:
A. Exclusively vasogenic in nature
B. Exclusively cytotoxic in nature
C. A mixture of vasogenic and cytotoxic
D. Independent of oxygenation status
C. A mixture of vasogenic and cytotoxic
Comprehensive Management and Prevention of Secondary Injury
- A 40-year-old with increased ICP is being managed with both mannitol and sedation. Arterial blood pressure is stable. Which best practice aligns with preventing secondary injury?
A. Avoid unnecessary hyperventilation to keep PaCO₂ near normal
B. Always keep PaCO₂ <25 mmHg for indefinite periods
C. Restrict all fluids to avoid any risk of edema
D. Elevate the foot of the bed higher than the head
A. Avoid unnecessary hyperventilation to keep PaCO₂ near normal
- Which combination of strategies reflects a comprehensive approach to managing elevated ICP?
A. Head elevation, maintain normothermia, sedation, mannitol or hypertonic saline as needed
B. Flat bed positioning, prolonged hyperventilation, high-dose steroids for all TBI patients
C. Frequent deep suctioning without sedation, minimal fluid resuscitation
D. Restrictive sedation to enable continuous neuro checks, no osmotherapy
A. Head elevation, maintain normothermia, sedation, mannitol or hypertonic saline as needed
- Per Sacco & Delibert (2018), prolonged use of mannitol in ICP management increases the risk of:
- A) Fluid overload
- B) Renal failure
- C) Hypoglycemia
- D) Hyponatremia
Answer: B) Renal failure
- A patient presents with altered mental status, vomiting, and a systolic BP of 180 with a diastolic BP of 80. His HR is 35. What is the most likely diagnosis?
A) Ischemic stroke
B) Cushing’s triad indicating increased ICP
C) Myasthenia gravis crisis
D) Brain abscess
Answer: B) Cushing’s triad indicating increased ICP
Rationale: Cushing’s triad (hypertension, bradycardia, and irregular respirations) suggests impending herniation due to increased ICP
- What is the gold standard for monitoring ICP in a patient with severe traumatic brain injury?
A) Intraparenchymal brain tissue monitor
B) Ventriculostomy catheter
C) Lumbar puncture
D) CT angiography
Answer: B) Ventriculostomy catheter
Rationale: A ventriculostomy catheter is the gold standard for ICP monitoring and allows for CSF drainage.
- Which intervention is appropriate for a patient with an ICP of 25 mmHg?
A) Hyperventilation to decrease CO2
B) Head positioning at 15 degrees
C) Administering mannitol
D) Increasing PEEP to optimize oxygenation
Answer: C) Administering mannitol
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by drawing fluid from brain tissue
- A patient with traumatic brain injury has an ICP of 30 mmHg despite initial treatment. What is the next best step?
A) Increase PEEP to improve oxygenation
B) Initiate pentobarbital coma
C) Administer corticosteroids
D) Start dopamine infusion
Answer: B) Initiate pentobarbital coma
Rationale: Barbiturate coma is used for refractory ICP elevation when standard treatments fail.
- A patient presents with confusion, nausea, and headache following a head injury. A non-contrast CT shows midline shift and compressed cisterns. What is the most likely diagnosis?
A) Epidural hematoma
B) Subdural hematoma
C) Concussion
D) Diffuse axonal injury
Answer: B) Subdural hematoma
Rationale: Subdural hematomas cause brain shift and can result in elevated ICP.
- Which of the following is an early sign of increased ICP?
A) Decerebrate posturing
B) Cushing’s triad
C) Headache and nausea
D) Fixed, dilated pupils
Answer: C) Headache and nausea
Rationale: Early signs of ICP include headache, nausea, and altered mental status. Late signs include Cushing’s triad and herniation
A patient presents with altered mental status, vomiting, and a systolic BP of 180 with a diastolic BP of 80. His HR is 35. What is the most likely diagnosis?
A) Ischemic stroke
B) Cushing’s triad indicating increased ICP
C) Myasthenia gravis crisis
D) Brain abscess
Answer:B) Cushing’s triad indicating increased ICP
*Rationale: Cushing’s triad (hypertension, bradycardia, and irregular respirations) suggests impending herniation due to increased ICP.
Which intervention is appropriate for a patient with an ICP of 25 mmHg?**
A) Hyperventilation to decrease CO2
B) Head positioning at 15 degrees
C) Administering mannitol
D) Increasing PEEP to optimize oxygenation
Answer: C) Administering mannitol
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by drawing fluid from brain tissue.
A patient with a severe traumatic brain injury has an ICP of 35 mmHg. What is the most appropriate initial management strategy?
A) Lower the head of the bed to 10 degrees
B) Administer corticosteroids for cerebral edema
C) Initiate osmotherapy with mannitol or hypertonic saline
D) Hyperventilate the patient immediately to decrease CO2 levels
Answer: C) Initiate osmotherapy with mannitol or hypertonic saline
A 65-year-old patient presents with hydrocephalus and a suspected increase in ICP. What is the gold standard for monitoring ICP in this patient?
A) Non-contrast head CT
B) Intraparenchymal fiber optic transducer
C) Ventriculostomy with external transducer
D) Bolt monitor at the bedside
Answer: C) Ventriculostomy with external transducer
A nurse practitioner is caring for a patient with a closed head injury and signs of increased ICP. What is an appropriate non-pharmacologic intervention?
A) Keeping the patient’s head and neck in a neutral position
B) Elevating the head of the bed to 10 degrees
C) Administering high doses of corticosteroids
D) Encouraging frequent suctioning
Answer: A) Keeping the patient’s head and neck in a neutral position
Which of the following clinical findings would suggest that a patient with increased ICP is experiencing brain herniation?
A) Bradycardia, hypertension, and irregular breathing
B) Hypotension, tachycardia, and hyperthermia
C) Tachypnea, hypertension, and pupil dilation
D) Irregular pulse, fever, and nausea
Answer: A) Bradycardia, hypertension, and irregular breathing
A patient with increased ICP due to cerebral edema is being considered for hypertonic saline therapy. What is a potential complication of this treatment?
A) Hypochloremic alkalosis
B) Central pontine myelinolysis
C) Metabolic acidosis
D) Respiratory alkalosis
Answer: B) Central pontine myelinolysis
Which factor is most likely to increase cerebral blood flow and exacerbate elevated ICP?
A) Hypocapnia
B) Hypertension
C) Hypoxia
D) Hyperthermia
Answer: C) Hypoxia
A patient has refractory ICP elevation despite initial treatment efforts. What is the next appropriate step?
A) Continue supportive care and reassess in 24 hours
B) Initiate pentobarbital coma
C) Increase the patient’s PEEP to improve oxygenation
D) Increase the patient’s hydration with normal saline
Answer: B) Initiate pentobarbital coma
A 54-year-old male with a severe traumatic brain injury has an ICP of 28 mmHg. Despite proper positioning, sedation, and osmotherapy, his ICP remains elevated. What is the next best step?
A) Increase PEEP to enhance oxygenation
B) Hyperventilate the patient to maintain PaCO2 < 25 mmHg
C) Consider initiating a pentobarbital coma
D) Administer corticosteroids
Answer: C) Consider initiating a pentobarbital coma
A patient with hydrocephalus requires ICP monitoring, but their ventricles appear collapsed on imaging. What is the most appropriate method for ICP monitoring in this case?
A) Ventriculostomy
B) Brain tissue (intraparenchymal) monitor
C) Jugular venous bulb oximetry
D) Lumbar puncture
Answer: B) Brain tissue (intraparenchymal) monitor
A 70-year-old patient presents with an acute ischemic stroke. What type of cerebral edema is most likely to develop in this patient?
A) Cytotoxic edema
B) Vasogenic edema
C) Interstitial edema
D) Osmotic edema
Answer: A) Cytotoxic edema
A patient with increased ICP is receiving mechanical ventilation. Which setting should be carefully adjusted to avoid worsening ICP?
A) Tidal volume
B) FiO2
C) PEEP
D) Respiratory rate
Answer: C) PEEP
Which of the following clinical signs suggests brainstem herniation?
A) Unilateral fixed and dilated pupil
B) Symmetrical limb weakness
C) Nausea and vomiting
D) Neck stiffness
Answer: A) Unilateral fixed and dilated pupil
A patient with a traumatic brain injury and increased ICP is being treated with hypertonic saline. Which laboratory value requires immediate intervention?
A) Serum sodium 162 mEq/L
B) Serum sodium 140 mEq/L
C) Serum osmolality 340 mOsm/L
D) Serum potassium 4.2 mEq/L
Answer: C) Serum osmolality 340 mOsm/L
What is the rationale for elevating the head of the bed to at least 30 degrees in a patient with increased ICP?
A) It decreases cerebral metabolism
B) It promotes venous drainage from the brain
C) It increases cerebral perfusion pressure (CPP)
D) It enhances cerebrospinal fluid (CSF) production
Answer: B) It promotes venous drainage from the brain
A 60-year-old patient presents with altered mental status, vomiting, and severe headache. A non-contrast CT shows hydrocephalus and a midline shift. What is the most immediate intervention?
A) Administer high-dose corticosteroids
B) Start IV mannitol
C) Place an external ventricular drain (EVD)
D) Initiate therapeutic hypothermia
Answer: C) Place an external ventricular drain (EVD)
A patient has a sustained ICP of 25 mmHg. Which intervention is most appropriate to reduce ICP?
A) Maintain blood pressure at a systolic of 100 mmHg
B) Keep the head in a flexed position
C) Administer a bolus of 0.9% normal saline
D) Ensure proper sedation and pain control
Answer: D) Ensure proper sedation and pain control
A patient receiving mannitol for ICP control develops hypotension. What is the most likely cause?
A) Increased cerebral edema
B) Hypovolemia due to osmotic diuresis
C) Hyperkalemia
D) Overcorrection of sodium
Answer: B) Hypovolemia due to osmotic diuresis
Which patient is at highest risk for developing interstitial cerebral edema?
A) A patient with ischemic stroke
B) A patient with hydrocephalus
C) A patient with a brain tumor
D) A patient with traumatic brain injury
Answer: B) A patient with hydrocephalus
A patient with increased ICP has an MAP of 80 mmHg and an ICP of 25 mmHg. What is their cerebral perfusion pressure (CPP)?
A) 105 mmHg
B) 55 mmHg
C) 60 mmHg
D) 25 mmHg
Answer: B) 55 mmHg
A patient with refractory ICP > 30 mmHg for 20 minutes is considered for second-line treatment. Which option is most appropriate?
A) IV corticosteroids
B) Induced hypothermia
C) Craniotomy with decompression
D) Increasing IV fluids
Answer: C) Craniotomy with decompression
A patient with ICP monitoring shows a waveform where P2 is higher than P1. What does this indicate?
A) Normal ICP compliance
B) Impaired brain compliance
C) A need for increased PEEP
D) Normal autoregulation
Answer: B) Impaired brain compliance
. Which of the following is a contraindication to using mannitol in ICP management?
A) Hyponatremia
B) Hypotension
C) Hypernatremia
D) Respiratory acidosis
Answer: B) Hypotension
A patient with increased ICP is found to have a Glasgow Coma Scale (GCS) score of 3, nonreactive pupils, and absent brainstem reflexes. What does this indicate?
A) Potential brain death
B) Mild traumatic brain injury
C) Hydrocephalus with increased CSF production
D) Reversible brain ischemia
Answer: A) Potential brain death
In a patient with increased ICP, why should hyperventilation be used cautiously?
A) It can increase cerebral blood flow
B) It can cause cerebral vasoconstriction and ischemia
C) It can worsen cerebral edema
D) It can lead to metabolic alkalosis
Answer: B) It can cause cerebral vasoconstriction and ischemia
Which medication is NOT recommended for ICP management in traumatic brain injury?
A) Mannitol
B) Hypertonic saline
C) Corticosteroids
D) Sedatives
Answer: C) Corticosteroids
A patient with ICP monitoring has a P1>P2>P3 waveform pattern. What does this indicate?
A) Impaired cerebral compliance
B) Normal ICP waveform
C) Increased cerebral blood flow
D) Brainstem herniation
Answer: B) Normal ICP waveform
. What is the major concern with prolonged use of hypertonic saline for ICP management?
A) Hypokalemia
B) Hyponatremia
C) Central pontine myelinolysis
D) Cerebral vasodilation
Answer: C) Central pontine myelinolysis
A patient with suspected elevated ICP undergoes a non-contrast head CT. What finding is most concerning for brain herniation?
A) Midline shift > 5 mm
B) Loss of gray-white differentiation
C) Enlarged ventricles
D) Subarachnoid hemorrhage
Answer: A) Midline shift > 5 mm
. A patient presents with lethargy, vomiting, and anisocoria (unequal pupils). What is the most appropriate initial diagnostic step?
A) Non-contrast CT scan
B) MRI brain with contrast
C) Lumbar puncture
D) EEG
Answer: A) Non-contrast CT scan
What is a key clinical sign of impending brainstem herniation?
A) Cushing’s triad (hypertension, bradycardia, irregular respirations)
B) Severe headache with nausea and photophobia
C) Gradual decline in cognitive function
D) Unilateral limb weakness
Answer: A) Cushing’s triad (hypertension, bradycardia, irregular respirations)
What is the gold standard for direct measurement of ICP?
A) Ventriculostomy (External Ventricular Drain)
B) Intraparenchymal pressure monitoring
C) Lumbar puncture
D) Transcranial Doppler
Answer: A) Ventriculostomy (External Ventricular Drain)
. A patient with a suspected brain mass has increased ICP and papilledema. Why is a lumbar puncture contraindicated in this patient?
A) Risk of brain herniation due to rapid CSF drainage
B) Risk of infection spread
C) Potential worsening of vasogenic edema
D) Poor diagnostic yield
Answer: A) Risk of brain herniation due to rapid CSF drainage
When should hyperventilation be used in ICP management?
A) Only in cases of acute brain herniation
B) As a first-line treatment to lower ICP
C) For all patients with TBI and increased ICP
D) Only when PaO2 levels are low
Answer: A) Only in cases of acute brain herniation
A patient with a GCS of 6 and refractory ICP elevation is intubated and sedated. What is the next best step in management?
A) Consider pentobarbital coma
B) Administer high-dose corticosteroids
C) Perform therapeutic lumbar drainage
D) Increase PEEP to improve oxygenation
Answer: A) Consider pentobarbital coma
What is the primary mechanism of action of mannitol in ICP management?
A) Increases plasma osmolarity to pull fluid from brain tissue into circulation
B) Causes cerebral vasoconstriction to reduce blood flow
C) Inhibits CSF production to decrease ICP
D) Increases cerebral metabolism to reduce ischemia
Answer: A) Increases plasma osmolarity to pull fluid from brain tissue into circulation
Which electrolyte must be closely monitored when using hypertonic saline for ICP control?
A) Sodium
B) Calcium
C) Magnesium
D) Phosphate
Answer: A) Sodium
What is the most life-threatening complication of increased ICP?
A) Brain herniation
B) Chronic hydrocephalus
C) Post-concussion syndrome
D) Seizure disorder
Answer: A) Brain herniation
What is the most fatal type of brain herniation?
A) Tonsillar herniation
B) Uncal herniation
C) Subfalcine herniation
D) Upward cerebellar herniation
Answer: A) Tonsillar herniation
. What adverse effect should be closely monitored in prolonged use of mannitol?
A) Rebound increased ICP
B) Respiratory alkalosis
C) Increased risk of seizures
D) Hyperkalemia
Answer: A) Rebound increased ICP
Which infection is a common and deadly complication of ventriculostomy placement?
A) Ventriculitis
B) Bacterial meningitis
C) Brain abscess
D) Encephalitis
Answer: A) Ventriculitis
A patient with increased ICP develops a systolic BP of 200 mmHg, bradycardia (HR 40), and irregular respirations. What is the immediate concern?
A) Imminent brain herniation
B) Normal physiologic response to increased ICP
C) Early-stage cerebral perfusion improvement
D) Early recovery from cerebral edema
Answer: A) Imminent brain herniation
A patient with severe traumatic brain injury (TBI) has a sustained ICP of 30 mmHg for 20 minutes despite initial interventions. What is the next step in management?
A) Continue current management and monitor for changes
B) Administer 23.4% hypertonic saline
C) Initiate a lumbar puncture to drain CSF
D) Increase PEEP to improve oxygenation
Answer: B) Administer 23.4% hypertonic saline
A patient with suspected brain herniation has a fixed, dilated right pupil and left-sided hemiparesis. What type of herniation is most likely?
A) Uncal herniation
B) Tonsillar herniation
C) Subfalcine herniation
D) Upward cerebellar herniation
Answer: A) Uncal herniation
A patient with refractory ICP elevation is placed into a pentobarbital coma. What is the primary goal of this therapy?
A) Reduce metabolic demand and cerebral oxygen consumption
B) Induce cerebral vasodilation to lower ICP
C) Increase cardiac output to maintain cerebral perfusion
D) Enhance CSF absorption to lower ICP
Answer: A) Reduce metabolic demand and cerebral oxygen consumption
A patient with increased ICP and a ventriculostomy drain develops fever, altered mental status, and purulent CSF drainage. What is the most likely diagnosis?
A) Ventriculitis
B) Hydrocephalus
C) Sepsis from a systemic infection
D) Subarachnoid hemorrhage
Answer: A) Ventriculitis
In a patient with increased ICP, why should hyperventilation be used cautiously?
A) It can increase cerebral blood flow
B) It can cause cerebral vasoconstriction and ischemia
C) It can worsen cerebral edema
D) It can lead to metabolic alkalosis
Answer: B) It can cause cerebral vasoconstriction and ischemia
A patient with a suspected brain mass has increased ICP and papilledema. Why is a lumbar puncture contraindicated in this patient?
A) Risk of brain herniation due to rapid CSF drainage
B) Risk of infection spread
C) Potential worsening of vasogenic edema
D) Poor diagnostic yield
Answer: A) Risk of brain herniation due to rapid CSF drainage
When should hyperventilation be used in ICP management?
A) Only in cases of acute brain herniation
B) As a first-line treatment to lower ICP
C) For all patients with TBI and increased ICP
D) Only when PaO2 levels are low
Answer: A) Only in cases of acute brain herniation
What is the most life-threatening complication of increased ICP?
A) Brain herniation
B) Chronic hydrocephalus
C) Post-concussion syndrome
D) Seizure disorder
Answer: A) Brain herniation
What is the most fatal type of brain herniation?
A) Tonsillar herniation
B) Uncal herniation
C) Subfalcine herniation
D) Upward cerebellar herniation
Answer: A) Tonsillar herniation
What adverse effect should be closely monitored in prolonged use of mannitol?
A) Rebound increased ICP
B) Respiratory alkalosis
C) Increased risk of seizures
D) Hyperkalemia
Answer: A) Rebound increased ICP
A patient with increased ICP develops a systolic BP of 200 mmHg, bradycardia (HR 40), and irregular respirations. What is the immediate concern?
A) Imminent brain herniation
B) Normal physiologic response to increased ICP
C) Early-stage cerebral perfusion improvement
D) Early recovery from cerebral edema
Answer: A) Imminent brain herniation
13. As described in Sacco & Delibert (2018), when should corticosteroids
Answer: B) In vasogenic edema from brain tumors
- What complication is most likely in a patient receiving hypertonic saline for refractory ICP?
o A) Hypernatremia
o B) Central pontine myelinolysis
o C) Rebound intracranial hypertension
o D) Hypokalemia
Answer: B) Central pontine myelinolysis
