Neurotrauma Flashcards
What parameter is the American Society of Anesthesiologists (ASA) class designed to assess?
a. Risk of postoperative ventilator dependence
b. Operative mortality
c. Severity of medical comorbidities
d. perative morbidity
e. Tolerable blood loss
c. Severity of medical comorbidities
A 56 year-old woman presents with diffuse traumatic subarachnoid hemorrhage on CT after a motor vehicle accident. On exam, she is flexor posturing, and initial ICP is 15mmHg. Her CPP is 50mmHg. What management strategy is recommended by the Brain Trauma Foundation Guidelines?
a. Maintain a minimum CPP of 60 mmHg
b. Maintain PCO2 less than 30 mm Hg
c. Maintain systolic blood pressure above 90mmHg
d. Maintain ICP less than 20 mm Hg
e. Monitor brain tissue oxygenation
a. Maintain a minimum CPP of 60 mmHg
10-year-old boy underwent resection of a craniopharyngioma. Postoperatively, he develops panhypopituitarism and delayed hydrocephalus. What medication will need
to be increased in preparation for his shunt placement?
a. Desmopressin
b. Levothyroxine
c. Testosterone
d. Hydrocortisone
e. Growth hormone
d. Hydrocortisone
A 36 year old woman with a known history of epilepsy treated with phenytoin presents in convulsive status epilepticus. After administration of lorazepam and
supplementation with IV phenytoin, convulsions cease. Two hours later she remains unresponsive despite a normal head CT and normal serum electrolyte levels and blood counts. What is the most appropriate next diagnostic test?
a. Lumbar puncture
b. MRI of the brain, including diffusion imaging
c. Electroencephalogram
d. Angiogram
e. Repeat serum sodium
c. Electroencephalogram
A patient initially presents after closed head injury with a GCS of 14. Head CT demonstrates a small amount of pneumocephalus. Two
hours later, the patient becomes unresponsive (GCS 4). A repeat head CT is obtained (Fig. 1). What is the most appropriate next step
in management?
a. Lumbar puncture to rule out meningitis
b. Repeat head CT with fine cuts to identify a basal skull fracture
c. Administer 1g/kg of mannitol
d. Treatment with high flow oxygen
e. surgical evacuation of pneumocephalus.
e. surgical evacuation of pneumocephalus.
A 35 year-old man was found down for an unknown period of time after a generalized seizure. In the emergency department, he complains of pain in his thighs,
shoulders, and calves. On exam, he is GCS 14 with confusion, and his imaging shows a small left frontal subarachnoid hemorrhage. Rhabdomyolysis is suspected.
What finding is most consistent with this diagnosis?
a. Normal serum creatinine
b. Hematuria
c. Hypokalemia
d. Normal CPK level
e. Myoglobinuria
e. Myoglobinuria
A 65-year-old male with a history of hypertension and diabetes presents to the emergency room after experiencing severe headache. The Glasgow Coma Scale (GCS)
is 14. On head CT scan, the patient was found to have a 2 cm acute cerebellar hematoma with no hydrocephalus. What is the most appropriate management?
a. Surgical evacuation
b. Posterior fossa craniectomy
c. Stereotactic aspiration and infusion of thrombolytic agents
d. External ventricular drainage
e. Medical management in an ICU setting
e. Medical management in an ICU setting
A 23 year-old man presents to the emergency department after an intoxicated fall and head injury. He has a moderate occipital
headache and nausea without vomiting. On exam, the patient has normal vital signs and no focal neurological deficits. His noncontrast head CT is shown (Figure 1). The volume of the hematoma is measured to be 35 cm3. What is the most appropriate
treatment for this patient?
a. External ventricular drain for CSF diversion and intracranial pressure monitoring
b. Posterior fossa craniotomy for evacuation of hematoma
c. Close neurological monitoring with serial head CT imaging
d. Embolization of the transverse sinus
e. Burr hole evacuation of hematoma
b. Posterior fossa craniotomy for evacuation of hematoma
In a patient with Guillain-Barre syndrome, what does the presence of significant cerebrospinal fluid pleocytosis suggest?
a. coexistent Epstein-Barr virus infection
b. preceding Campylobacter jejuni infection
c. preceding herpes virus infection
d. coexistent human immunodeficiency virus type 1 infection
e. preceding influenza vaccination
d. coexistent human immunodeficiency virus type 1 infection
This brain micrographof a 68 yo male nursing home resident who had a vague history of dementia and relatively rapid decline shows which of the following?
a. Jakob-Creutzfeldt Disease
b. Acute traumatic brain injury
c. Pick’s Disease
d. Chronic Traumatic Encephalopathy
e. Subacute brain degeneration
d. Chronic Traumatic Encephalopathy
What is the next appropriate step in management following resection of an epidermoid tumor?
a. Intracystic chemotherapy
b. Fractionated radiotherapy
c. Radiographic surveillance
d. Prophylactic antibiotics
e. Brachytherapy
c. Radiographic surveillance
A patient with severe closed head injury is suspected of having diabetes insipidus. What electrolyte and volume profile best fits this diagnosis?
a. Increased blood volume, hyponatremia.
b. Increased blood volume, hypernatremia.
c. Diminished blood volume, hyponatremia.
d. Diminished blood volume, hypernatremia.
d. Diminished blood volume, hypernatremia.
An 18 year old man who was involved in a motor vehicle accident is admitted to the ICU and intubated and sedated on high dose continuous propofol infusion
(4mg/kg/h). Ten days later, he is following command in all four extremities. Suddenly, on hospital day 12, he becomes acutely altered. CT head is stable from admission.
Laboratory studies reveal a markedly profound hypertriglyceridemia, metabolic acidosis and rhabdomyolysis. Which one of the following is the next step in
management?
a. stop propofol infusion immediately
b.btain CT-angio of chest
c. Obtain 12 lead EKG and troponin
d. Start hemodialysis
e. Order MRI brain
a. stop propofol infusion immediately
Following transsphenoidal resection of a large craniopharyngioma, the manifestations of a classic triphasic response are which of the following?
a. Hyponatremia - Hypematremia - Hyponatremia.
b. Hyponatremia - Normonatremia or Hypernatremia - Hyponatremia.
c. Normonatremia - Hyponatremia - Normonatremia.
d. Hypernatremia - Normonatremia or Hyponatremia - Hypernatremia.
e. Normonatremia - Hypernatremia - Normonatremia.
d. Hypernatremia - Normonatremia or Hyponatremia - Hypernatremia.
A 25 year-old man presents after assault with bilateral contusions and subarachnoid hemorrhage. His admission GCS is 4T, and an ICP monitor is placed. ICP steadily
increases despite sedation, CSF diversion, hyperosmolar therapy, and hypothermia. What additional non-surgical intervention is most appropriate?
a. 10mg IV dexamethasone
b. Increase PEEP > 10 mmHg
c. Maintain CPP > 60mmHg
d. Hyperventilate with goal PCO2 <30mmHg
e. Acetazolamide
c. Maintain CPP > 60mmHg
After a motorcycle accident, a patient’s examination reveals eyes that open to stimulation, incomprehensible vocalization, and withdrawal to painful stimulus. Head CT scan demonstrates several punctate contusions and a 2mm right-sided subdural hematoma. After intubation, what is the next most appropriate step?
a. Hyperventilation
b. Craniotomy for evacuation of subdural
c. Administration of mannitol
d. Repeat head CT within 1 hour
e. Placement of ICP monitor
e. Placement of ICP monitor
A 26 year old male presents to the emergency room after a motor vehicle accident. He is orally intubated, does not open his eyes to verbal or painful stimuli but does localize briskly with his right upper extremity. What is this patient’s GCS?
a. 101
b. 6T
c. 5T
d. 3T
e. 7T
e. 7T
A 22 year-old woman presents after a motor vehicle collision with neck pain. She is neurologically intact. She has a non-displaced C4 lamina fracture. CTA of the neck shows a Biffl Grade 2 injury to the right internal carotid artery. What is the most appropriate next step in management?
a. MR of the brain
b. Initiation of aspirin
c. Transcranial Doppler with emboli detection
d. Diagnostic cerebral angiogram
e. Carotid Doppler
b. Initiation of aspirin
‘What monitoring modality has the greatest sensitivity for detection of a venous air embolus?
a. Precordial Doppler
b. Transvenous intracardiac echocardiography
c. Pulse oximetry
d. Pulmonary artery pressure
e. EKG
b. Transvenous intracardiac echocardiography
An ABG with PCO2 25 mmHg, pH 7.55, HCO3- 24 mEq/L is most consistent with which diagnosis?
a. Respiratory alkalosis with metabolic compensation
b. Metabolic alkalosis
c. Respiratory alkalosis
d. Metabolic alkalosis with respiratory compensation
c. Respiratory alkalosis
What characteristic imaging finding on MRI would best differentiate neuromyelitis optica from multiple sclerosis?
a. An intramedullary spinal cord lesion spanning 3 or more segments.
b. Presence of high burden of periventricular, juxtacortical and infratentorial demyelinating lesions.
c. Optic nerve enhancement.
d. Multiple non-enhancing intramedullary spinal lesions spanning 1-2 segments.
e. Multiple enhancing intramedullary spinal lesions spanning 1-2 segments.
a. An intramedullary spinal cord lesion spanning 3 or more segments.
Which of the following is most likely to DECREASE during the physiologic compensation for acute anemia?
a. systemic vascular resistance
b. Stroke volume
c. Oxygen extraction
d. Cardiac index
e. Oxygen consumption
a. systemic vascular resistance
A65-year-old man presents with one week history of agitation and confusion. He sustained a generalized tonic-clonic seizure and is hallucinating. On exam, he is febrile, confused and has a left pronator drift with hyper-reflexia. An MRI of the brain is shown (figure)
Which of the following is the most likely diagnosis?
a. Low grade glioma
b. Neurosyphilis
c. Herpes simlex virus
d. Sarcodosis
e. Hemorrhagic stroke
c. Herpes simlex virus
A high school football player gets speared by an opposing player. He never loses consciousness but is confused for approximately 30 minutes. The most appropriate recommendation regarding further play in the game is that the player:
a. Can immediately return to play.
b. Should be removed from the rest of the game.
c. Return to the game as soon as his confusion resolves.
d. Emergent head CT.
e. Should be excluded from play for the rest of the season.
b. Should be removed from the rest of the game.
17 year old sustains a gunshot wound to the head. On examination, he has decorticate posturing on the right and he localizes on the
left. His left pupil is 2 mm larger than the right but is sill reactive. His non-contrast head CT (see figures) demonstrates metal and bone fragments within the left frontal region with an associated subdural hematoma with midline shift. What is the most appropriate management of this patient?
a. Right frontal ventriculostomy placement
b. Expectant care
c. Superficial debridement of wound
d. Craniotomy, hematoma evacuation, removal of all bone and metal fragments
e. Craniotomy, hematoma evacuation, superficial debridement
e. Craniotomy, hematoma evacuation, superficial debridement
A 50-year old man admitted to the neuro-ICU with severe traumatic brain injury develops multi-organ failure, including acute kidney injury (Cr 7.5). He is afebrile and his vital signs are normal. On exam, he is lethargic, but arousable to verbal commands. He is disorientated with diffuse myoclonus and asterixis, without any other focal cranial nerve or motor deficits. A repeat CT brain is unchanged from baseline. What is the most appropriate next step?
a. Dialysis
b. Lumbar puncture
c. EEG
d. MRI brain
e. Oral stimulants
a. Dialysis
Ahead trauma patient on your service for the past 12 days has been in a coma. You notice that that his sleep-wake cycles have retumed. However, he does not exhibit
evidence of cognitive function. What term best describes this patient’s level of consciousness?
a. Stupor
b. Obtundation
c. Vegetative state
d. Lethargy
e. Minimally conscious state
c. Vegetative state
An 18 year-old college basketball player suffers from transient disorientation, dizziness, and imbalance following a hard foul. Her symptoms resolve after approximately 1 minute. What is the most appropriate management for this athlete regarding retum-to-play?
a. Refrain from all physical activity and external stimulation for 1 week before full return to play.
b. Return to full physical and cognitive activity in 24 hours if asymptomatic.
c. Brief period of rest with graduated increase in physical activity, followed by return to play if asymptomatic at each activity level.
d. Emergent head CT.
e. Return to play immediately since symptoms have resolved.
c. Brief period of rest with graduated increase in physical activity, followed by return to play if asymptomatic at each activity level.
A 27-year-old pregnant female presents to the ER with acute confusion, headaches and biurry vision. While in the ER she is found to have acute fetal distress and a blood pressure of 210mmHg/110mmHg. After expedited delivery of the baby, a CT is performed, revealing patchy areas of hypodensity in the posterior parietal and occipital lobes. An MRI is shown (figure). Which of the following is
the most likely diagnosis?
a. Posterior Reversible Encephalopathy Syndrome (PRES)
b. Infiltrating neoplasm
c. Demyelination, likely mutiple sclerosis
d. Acute infarction of the posterior cerebral arteries
e. Progressive multifocal leukoencephalopathy
a. Posterior Reversible Encephalopathy Syndrome (PRES)
58 year old male is in coma from a stroke. The intensivist wants to begin feeding. What is the best plan for early feeding of this patient (first 7 days after stroke)?
a. Intravenous isotonic solution with electrolyte replacement
b. Nasogastric tube
c. Gastrostomy tube
d. Total parenteral nutrition
e. Peripheral parenteral nutrition
b. Nasogastric tube
A 25 year old patient is involved in a motor vehicle accident and is intubated and sedated in the field before a complete neurological examination can be obtained. His non-contrast head CT is shown. (figure 1) What is the appropriate next step in management?
a. Take to the OR for an emergent craniotomy for evacuation of hematoma
b. Place an intracranial pressure monitor and admit to ICU
c. Awaken the patient for neurological examination
d. Obtain an urgent MRI with Diffusion weighted imaging
a. Take to the OR for an emergent craniotomy for evacuation of hematoma
What is usually the earliest sign of developing malignant hyperthermia?
a. Decreased body temperature.
b. Increased oxygen saturation.
c. Increased end-tidal CO2.
d. Decreased heart rate.
e. Decreased muscle tone.
c. Increased end-tidal CO2
Based on the Guidelines for the Acute Management of Severe Traumatic Brain Injury, in patients with severe head injury, what should the cerebral perfusion pressure (CPP, mmHg) should be maintained between?
a. 10-30
b. 30-50
c. 70-90
d. 50-70
e. 90-110
d. 50-70
A 24 year-old man is brought to the emergency department following a single midline gunshot wound to the forehead. On arrival, he is GCS 7T with bilateral sluggishly reactive pupils and localizing in the left upper extremity to noxious stimulus. His non-contrast head CT
is depicted (Figure 1). This patient is most at risk for what acute complication of penetrating brain injury?
a. Arteriovenous malformation
b. Traumatic intracranial aneurysm
c. Traumatic arterial dissection
d. Cavernous-carotid fistula
e. Venous sinus thrombosis
b. Traumatic intracranial aneurysm
After a fall, a 20 year old skateboarder is asymptomatic but is found to have a non-displaced fracture involving the petrous portion of the left temporal bone. What is the most appropriate management of this fracture?
a. Conservative management.
b. Prophylactic antibiotics.
c. Steroid therapy.
d. Surgical repair.
e. Lumbar drainage.
a. Conservative management.
A 76 year-old undergoes a craniotomy for evacuation of a subdural hematoma. Three days later, the patient is noted to have increased confusion and a heart rate of
102 bpm. His blood pressure is 83/52, and his respiratory rate is 31 breaths per minute. The nurse measures a temperature of 38.5 degrees C. He has coarse breath sounds and his urine output was 15cc/hr over the prior 6 hours. His symptoms do not respond to a saline bolus. What is the most appropriate next step?
a. Send the patient for a STAT repeat head CT
b. Administer a diuretic
c. Obtain a CT chest to rule out pulmonary embolus
d. Send blood cultures and start broad spectrum antibiotics
e. Obtain EKG and send cardiac enzymes
d. Send blood cultures and start broad spectrum antibiotics
The Food and Drug Administration (FDA) has issued limits on the per dose and daily dose recommended for acetaminophen to prevent what
complication?
a. Aplastic anemia
b. Myositis
c. Kidney toxicity
d. Steven-Johnson syndrome
e. Liver toxicity
e. Liver toxicity
A 21 year-old-man sustained blunt force trauma to his head, had brief loss-of-consciousness and was GCS 15 at initial evaluation, complaining of headaches, nausea and visual disturbance. CT is shown in figures. What is the best management of this patient?
a. Take to the OR emergently for a combined Supra- and infratentorial approach
b. Place ICP monitor and observe in the ICU
c. Evacuation of hematoma with placement of burr holes
d. Manage conservatively in the ICU with a f/u CT in 6 hrs.
e. Cerebral angiogram and embolization of sinus
a. Take to the OR emergently for a combined Supra- and infratentorial approach
A 70-year-old man presents with new onset progressive confusion, expressive dysphasia, and right hemiparesis. MRI shows multiple enhancing intracerebral masses with surrounding edema that resolve after a short course of steroids. What is the most likely diagnosis of these lesions?
a. central nervous system sarcoidosis.
b. primary central nervous system lymphoma.
c. multiple metastases.
d. multifocal glioma.
e. multiple sclerosis.
b. primary central nervous system lymphoma.
A 17-year old man presents with severe traumatic brain injury with a Glasgow Coma Scale score of 7 and reactive pupils. A head CT indicates a thin subdural
hematoma on the right side with 6 mm shift of the midline structures with visible but tight ambient cisterns. Despite sedation, intubation, hypertonic saline and external ventricular drainage, his ICPs remain elevated. What is the next best step in the management of this patient?
a. Mannitol infusion
b. Decompressive hemicraniectomy
c. Hypothermia
d. Pentobarbital coma
e. Insert brain tissue oxygen monitoring device
b. Decompressive hemicraniectomy
Following aneurysmal subarachnoid hemorrhage, which cardiac complication is the most significant independent predictor of mortality?
a. Myocardial stunning
b. Cardiac failure
c. Tachyarrhythmias
d. Heart block
e. Myocardial infarction
b. Cardiac failure
A hypertensive 50 year-old man is found to have a blood pressure of 230/110 mmHg with a heart rate of 50 bpm. Physical exam reveals a fixed and dilated right pupil,
and CT scan shows a large right subdural hematoma with midline shift. What is the most likely cause of the hypertension?
a. Exacerbation of baseline hypertension due to pain
b. Failure to comply with antihypertensive regimen
c. Peripheral vasoconstriction and catecholamine release
d. Decreased blood flow to the medulla
e. Shunting of blood flow from the myocardium to the brain
c. Peripheral vasoconstriction and catecholamine release
What is the MOST common organism isolated in ventilator associated pneumonia (VAP)?
a. staphylococcus aureus
b. Pseudomonas aeruginosa
c. Klebsiella pneumoniae
d. Acinetobacter
e. Haemophilus
a. staphylococcus aureus
What is the most likely appearance of a chronic subdural hematoma on MRI?
a. Hyperintense on T1 and hypointense on T2
b. Hypointense on T1 and hyperintense on T2
c. Isointense on both T1 and T2
d. Hypointense on both T1 and T2
e. Hyperintense on both T1 and T2
e. Hyperintense on both T1 and T2
A 23 year old male sustains a gunshot wound to the head. On examination, his GCS is 3T, his pupils are bilaterally fixed and dilated, he has a weak gag and cough reflex, and he intermittently draws a spontaneous respiration. His non-contrast head CT demonstrates a transventricular bullet tract and a 3 mm right subdural hematoma. What is the most appropriate management for this patient?
a. Evacuation of subdural hematoma
b. Debridement of bullet tract
c. Ventriculostomy
d. Expectant care
e. Decompressive hemicraniectomy
d. Expectant care
A 25-year old female presents with new onset weakness and vision difficulties which worsen as the day progresses. Nerve conduction and EMG testing shows improvement after the administration of edrophonium. What is the diagnosis?
a. Dermatomyositis
b. Guillain-Barre syndrome
c. Myasthenia gravis
d. Lambert-Eaton syndrome
e. Polymyositis
c. Myasthenia gravis
Seven days ago a 3 year old boy developed a low-grade fever which resolved and was followed by a vesicular rash (see Figures).
Two days ago, he had sudden onset of truncal ataxia and horizontal nystagmus. He has moderate dysmetria of both arms when reaching for toys, cannot stand or walk, and his speech is slurred. His mental status is fully intact. Fundi show sharp disc margins. His strength is full and deep tendon reflexes are present. What is the MOST likely diagnosis?
a. Post-infectious cerebellar ataxia
b. Posterior fossa mass
c. Opsoclonus myoclonus syndrome
d. Guillain-Barre Syndrome
e. Acute disseminated encephaloymyelitis
a. Post-infectious cerebellar ataxia
You are called about a 14 year old girl with severe intractable spasticity in whom you placed a baclofen pump 6 months ago. She presents with increase in tone and agitation due to severe itching. Pump interrogation reveals normal telemetry and indicates it is not due for a refill. Her
temperature is 40.0 C. She is confused and hypertonic. Pump X-rays do not show evidence of a disconnection. What is the next appropriate step in management?
a. Treatment with IV benzodiazepines and admission to ICU
b. Replacement of baclofen via intrathecal administration and admission to ICU
c. Replacement of baclofen via oral administration and admission to ward
d. Replacement of baclofen via oral administration and discharge with clinic follow up
e. Emergent surgery for pump exploration and replacement
b. Replacement of baclofen via intrathecal administration and admission to ICU
A 24-year-old gravida 1 para 0 abortus 0 woman presents in her third trimester with hypertension, proteinuria, hemolysis, elevated liver enzymes, low platelets and
seizure. What is the most definitive treatment for this patient?
a. Intravenous blood pressure medication
b. Bedrest
c. Deliver the baby
d. Corticosteroids
e. Magnesium sulfate
c. Deliver the baby
A 45 year old man presents with sudden onset of vomiting, dysarthria and ataxia and a CT scan demonstrating a cerebellar infarction. Thirteen hours after onset of
symptoms, he develops abducens nerve palsy and depressed mental status. What is the most appropriate definitive management of this patient?
a. High dose Dexamethasone
b. Hypertonic saline
c. suboccipital craniectomy
d. Barbiturate coma
e. Intravenous tPA
c. suboccipital craniectomy
What finding on head CT is consistent with a mild concussion?
a. Hemorrhages within the corpus callosum.
b. Subarachnoid hemorrhage.
c. Loss of grey-white distinction.
d. Normal study.
e. Diffuse edema.
d. Normal study.
A 47 year old man presents with confusion, agitation, fatigue, fever (104F), hyponatremia, hypoglycemia, and hypotension after resection of a right frontal metastasis
lesion 3 weeks ago. Phenytoin and steroids were discontinued at 2.5 weeks post-operatively. Head CT reveals no acute abnormality. What is the most appropriate
management of this patient?
a. Fosphenytoin
b. Haloperidol
c. Heparin
d. Fludricortisone
e. Hydrocortisone
e. Hydrocortisone
What tumor histology is associated with highest risk of cerebral hemorrhage in patients receiving therapeutic anticoagulation for deep vein thromboses and pulmonary
emboli?
a. Non-Small Cell Lung Carcinoma
b. Glioma
c. Choriocarcinoma
d. Renal Carcinoma
e. Melanoma
b. Glioma
A50 year old male is admitted to the ICU after a fall from a scaffolding with severe diffuse TBI. ICP and BtpO2 monitors are placed. Despite sedation, pain control and
hyperosmolar therapy, ICP remains at 25 mmHg and BtpO2 is 22 mmHg. His PaCO2 is 38 mmHg. The trauma service would like to hyperventilate the patient with a
goal PaC0O2 30 mmHg. When is hyperventilation indicated?
a. Only in conjunction with barbiturate coma
b. Within the first 24 hours
c. When brain oxygen is low
d. As temporizing measure
e. Never
d. As temporizing measure
A 24 year old patient with a gunshot wound to C2 is resuscitated after a PEA code and found to have fixed and dilated pupils, absent comeal reflexes, and absent
cough and gag reflex. A head CT reveals diffuse cerebral edema with loss of grey-white differentiation. He is normothermic and normotensive and his urine toxicology
screen and electrolyte panels are within normal limits. Which component of the brain death examination cannot be used in this patient to evaluate for brain death?
a. Cold caloric testing
b. EEG
c. Apnea testing
d. Transcranial Doppler ultrasonography
e. Nuclear cerebral blood flow study
c. Apnea testing
What change in the intracranial pressure waveform is an early sign of elevated intracranial pressure?
a. When P2 is higher than P1
b. When P2 is higher than P3
c. When P1 is higher than P2
d. When P3 is higher than P1
e. When P1 is higher than P3
a. When P2 is higher than P1
A 21 year-old man was admitted following a motorcycle crash with diffuse axonal injury. An ICP monitor and brain tissue oxygenation monitor are placed. After 24 hours,
his brain partial pressure of oxygen decreases from 20mmHg to 10mmHg. What threshold for treatment of brain hypoxia is recommended by the most recent Brain
Trauma Foundation Guidelines (4th edition)?
a. 15 mmHg
b. 10 mmHg
c. There is no recommended threshold for treatment
d. 20mmHg
e. 25 mmHg
c. There is no recommended threshold for treatment
A patient with a severe closed head injury exhibits a decreasing serum sodium over a 48 hour period to 125 mEq/l. Serum osmolality is diminished, urine sodium is
elevated. What parameter is critical to understand in the ensuing management of this patient?
a. Blood pressure
b. Circulating blood volume
c, Urine Osmolality
d. Hematocrit
e. Serum potassium
b. Circulating blood volume
A 25 year old male is brought to the emergency department after a motor vehicle crash. His blood pressure is low, requiring pressors. His Glasgow Coma Scale score is 5. A ventriculostomy is inserted and his intracranial pressure is found to be 35 mm Hg. What is the most appropriate immediate treatment for lowering his ICP?
a. Mannitol
b. Barbiturate Coma
c. Hyperventilation
d. CSF Drainage
e. Calcium Channel Blocker
d. CSF Drainage
A 72 year-old man with no medical history or history of trauma presents with chronic headache and mild confusion. He has no focal neurological deficits. A non-contrast
head CT demonstrates cerebral atrophy, and a right convexity 1.3 cm thick chronic subdural hematoma with 4 mm of midline shift and non-effaced basal cisterns. What
medical management option has the best evidence to support use?
a. Mannitol
b. Angiotensin Receptor Blocker
c. Corticosteroids
d. Aspirin
e. Beta blockers
c. Corticosteroids
A 29 year old female presents after a motor vehicle accident with left hemiplegia, weak localization on right, and a dilated unreactive
right pupil. Her head CT is shown. What is the most appropriate surgical management?
a. Placement of brain tissue oxygenation and ICP probe
b. Decompressive right hemicraniectomy.
c. Craniotomy and hematoma evacuation
d. Temporal burr hole and hematoma drainage
e. Placement of ventriculostomy.
c. Craniotomy and hematoma evacuation
Four days after aneurysmal subarachnoid hemorrhage, a 49 year old female develops hyponatremia (serum Na = 129mmol/L). She is not on diuretics. Her lab work
shows the following: serum Osm = 265mOsm/kg, urine Osm = 210mOsm/kg, and urine Na = 50mmol/L. Her fluid balance has been negative for the past 3 days; her
creatinine and hemoglobin have increased since yesterday. What is most likely the cause of her hyponatremia?
a. Extrarenal fluid loss
b. Renal failure
c. Adrenal insufficiency
d. Cerebral salt wasting
e. Syndrome of inappropriate anti-diuretic hormone ( SIADH)
d. Cerebral salt wasting
A patient presents after a MVA with the head CT shown in the figure. His GCS is 14. His blood alcohol level is 0.31%. What is the most appropriate initial management?
a. Bifrontal decompressive craniectomy
b. Intubate, sedate, and monitor ICP
c. Placement of ventriculostomy
d. Admit to ICU for observation
e. Bifrontal craniotomy and evacuation of SDH
d. Admit to ICU for observation
A 50 year old man who was intubated for acute respiratory distress syndrome develops flaccid and symmetric weakness in the lower greater than upper extremities and
more distally than proximally. There is no cranial nerve involvement. What is the most likely diagnosis for the weakness?
a, Acute intermittent porphyria
b. Poliomyelitis
c. Critical illness myopathy and neuropathy
d. Myasthenia gravis
e. Guillain-Barré syndrome
c. Critical illness myopathy and neuropathy
A 23-year-old male involved in motor vehicle accident exhibits neurological decline from an initial GCS of 15 to 8, with a neurological exam notable for left hemiparesis and right dilated pupil. What is the most appropriate initial step in management of this patient?
a. Right temporal burr hole placement
b. Hypertonic (3%) saline 250 mL bolus.
c. Mannitol 1 mg/kg IV bolus.
d. Fosphenytoin 15-18 mg/kg IV rapid infusion
e. Intubation and Hyperventilation
e. Intubation and Hyperventilation
A 30-year-old male with no prior medical history presents with four days of rapidly progressive bilateral lower extremity weakness, reduced sensation below the level of the umbilicus, and urinary retention. See figure for MRI of the thoracic spine T2 and T1 with contrast. Spinal fluid evaluation including NMO IgG are unremarkable. Which of the following is the most effective first line
management of this patient’s condition?
a. Interferon
b. Excisional biopsy with subsequent radiation and chemotherapy
c. T10-T12 laminectomy for spinal cord decompression
d. High dose intravenous glucocorticoid therapy
e. Supportive care including maintenance of MAP > 80 mmHg
d. High dose intravenous glucocorticoid therapy
A 25 year-old man presents to the emergency room with a GCS of 3 after a high-speed motor vehicle accident. He undergoes a hemicraniectomy and evacuation of a
large left hemispheric subdural hematoma. On postoperative day 4, he develops a fever with increasing oxygen requirements on the ventilator. Chest X-ray shows
bilateral lung opacities. What finding best supports the diagnosis of acute respiratory distress syndrome?
a. Lung biopsy showing interstitial fibrosis
b. Brain natriuretic peptide level 600 pg/mL
c. Pa02/Fi02 ratio >500 mm Hg
d. Bronchoalveolar lavage (BAL) specimen showing 45% eosinophils
e. Ejection fraction of 55-60% consistent with normal cardiac function
e. Ejection fraction of 55-60% consistent with normal cardiac function
‘What combination of findings is most consistent with the diagnosis of central diabetes insipidus?
a. Urine output of 300 cc/hr, urine specific gravity of 1.030 and serum sodium of 145.
b. Urine output of 40 cc/hr, urine specific gravity of 1.010, and serum sodium of 145.
c. Urine output of 100 cc/hr, urine specific gravity of 1.030 and serum sodium of 135.
d. Urine output of 40 cc/hr, urine specific gravity of 1.002 and serum sodium of 135.
e. Urine output of 300 cc/hr, urine specific gravity of 1.002, and serum sodium of 145.
e. Urine output of 300 cc/hr, urine specific gravity of 1.002, and serum sodium of 145.
Which of these treatments influences the incidence of chronic subdural hematoma (cSDH) recurrence?
a. Craniotomy
b. Burr hole drainage
c. Amount of irrigation
d. External subdural drain
e. Tranexamic Acid
d. External subdural drain
A 50 year old patient presenting to the ICU with 2 days of severe vomiting. The ABG reveals a PCO2 40 mmHg, pH 7.55, and HCO3- 30 mEq/L. With which condition is
this ABG most consistent?
a. Metabolic alkalosis with respiratory compensation
b. Respiratory alkalosis with metabolic compensation
c. Respiratory alkalosis
d. Metabolic alkalosis
d. Metabolic alkalosis
A 30-year-old male is brought to the emergency department after a motor vehicle crash. His Glasgow Coma Scale score is 13. He begins to have seizure activity in the
emergency department and the seizure is continuing after several minutes. What is the pharmacologic treatment of choice for the seizure?
a. Pancuronium
b. Phenobarbital
c. Lorazepam
d. Phenytoin
e. Paraldehyde
c. Lorazepam
A 36 year old victim of a motor vehicle accident with a normal neurological examination is found to have a closed femur fracture and a small, focal area of subarachnoid hemorrhage without other cranial injury. After repair of his femur fracture, the patient does not arouse from anesthesia. A brain CT shows bilateral diffuse small hypodense lesions. What is the most likely etiology of the patient’s change in clinical status?
a. Diffuse axonal injury
b. Carotid dissection with emboli
c. Fat emboli
d. Cerebral edema
e. Intraoperative hypotension
c. Fat emboli
A 30-year-old male cyclist presents wtih complete C5 quadriplegia after a motor vehicle collision. Work up reveals right wrist fracture and C5 fracture involving the left transverse foramen associated with a large spinal cord contusion. CT angiography of the neck is negative for vascular injury. Two hours after presentation, the patient
becomes confused, bradycardic, and hypotensive. Which of the following is the most likely explanation for these findings?
a. Fat embolism from the patient’s bony injuries.
b. Occult dissection of the vertebral artery with associated brain stem infarction.
c. Disruption of spinal sympathetic outflow due to spinal cord injury.
d. Delayed hemothorax due to thoracic trauma.
e. Pulmonary contusion resulting respiratory failu
c. Disruption of spinal sympathetic outflow due to spinal cord injury.
A 64-year old woman with multiple comorbidities undergoes emergent craniotomy after a fall. On post-operative day 4, she develops worsening tachypnea, tachycardia, hypotension, and fever of 101.5°F. Chest X-ray shows a new opacity in the right lower lobe. Bronchoscopy reveals thick, purulent secretions. What is the most appropriate next step in management?
a. Broad-spectrum antimicrobial therapy
b, Vancomycin
c. Await culture results prior to antibiotics
d. Rifampin
e. Daptomycin
a. Broad-spectrum antimicrobial therapy
Which symptomatic hormone deficiency is most common after pediatric moderate-to-severe traumatic brain injury?
a. Prolactin
b. Gonadotropic Hormones
c. Cortisol
d. Growth Hormone
e. Thyroid Hormone
d. Growth Hormone
Which cranial nerve injury is most likely to be associated with transvenous embolization of a cavernous-carotid fistula?
a. Abducens
b.Trochlear
c.Optic
d.Oculomotor
e. Trigeminal
a. Abducens
According to randomized control trials of hemicraniectomy for malignant MCA infarction, what is the time frame for the performance of hemicraniectomy associated with reduced mortality?
a. 3hours
b. 6 hours
c. 48 hours
d. 12 hours
e. 24 hours
c. 48 hours
A 5-month-old infant was a passenger in a car seat in a high-speed crash resulting in ejection. On exam, she only demonstrates right parietal scalp swelling. A head CT scan shows separation of the lambdoid suture and faint hypodensity in the subjacent brain (Figure 1). CT scanning of the cervical spine and other routine trauma investigations were negative. She was discharged in stable condition
after 1 day. Which of the following is the most active concemn for outpatient follow-up?
a. Traumatic meningoencephalocele
b. chronic subdural hematoma
c. Hypopituitarism
d. Atlanto-occipital instability
e. Hydrocephalus
a. Traumatic meningoencephalocele
A 58-year-old male dies from respiratory failure after battling a disease for 3 years. Microscopic examination of the spinal cord is shown below. Which disease lead to the death of patient?
a. Vitamin B12 deficiency
b. Guillain-Barre syndrome
c. Spinal muscular atrophy (SMA)
d. Spinal muscular bulbar atrophy (SMBA)
e. Amyotrophic lateral sclerosis
e. Amyotrophic lateral sclerosis
A 40 year old obese patient with a history of diabetes mellitus presents unresponsive to the ER and is subsequently intubated and admitted to the ICU. The patient’s
basic metabolic panel reveals a glucose level of 500. The ABG reveals a PCO2 40 mmHg, pH 7.25, and HCO3- 18 mEg/L. With which condition is this ABG most
consistent?
a Respiratory acidosis
b. Respiratory acidosis with metabolic compensation
c. Metabolic acidosis
d. Metabolic acidosis with respiratory compensation
c. Metabolic acidosis
What is the indication for repair of anterior wall frontal sinus fractures?
a. Acute and/or chronic sinusitis.
b. Repair of cosmetic deformity.
c. CSF leak and resulting meningitis
d. Al of the above.
e. Formation of mucocele.
b. Repair of cosmetic deformity.
An immunocompromised patient presents with fever, encephalopathy and a hemorrhagic abscess. The microscopic appearance of a
biopsy specimen is shown below. What is the most likely organism?
a. Mucor and Rhizopus species
b. Candida albicans
c. Aspergillus fumigatus
d. Coccidomycosis
e. Cryptococcus neoformans
c. Aspergillus fumigatus
A 21-year-old male presents to the emergency department after being involved in a gunfight. His GCS is 15 with a non-focal
examination but several bullet holes are noted in his scalp with protruding cerebral tissue. His CT scan of the head is shown in the figure. What is the BEST definitive management strategy for this injury?
a. Cranioplasty and removal of accessible fragments
b. 14-day course of antibiotics
c. Surgical durotomy repair
d. Bedside laceration repair
e. Surgical removal of all bullet fragments
a. Cranioplasty and removal of accessible fragments
56 year old male suffered severe TBI after a MVA. Has refractory ICP and the decision was made to induce a pentobarbital coma. Which of the following is a potential
mechanism of neuropotection from pentobarbital coma?
a. Increased intracerebral calcium
b.Free radical scavenging
c. Decreased cerebral blood volume and decreased cerebral metabolic rate (CMRO2)
d. Increased nitrogen excretion
e. Decreased in intracerebral glucose energy store
c. Decreased cerebral blood volume and decreased cerebral metabolic rate (CMRO2)
You are consulted about a patient who suffered a cardiac arrest secondary to an asthma attack. Hypothermia to 33° C has been initiated. CT reveals diffuse edema with slit ventricles, sulcal effacement, and obliteration of the basal cisterns. You suggest assessing median nerve somatosensory evoked potentials for aid in prognostication. Which SSEP component is most commonly measured to identify patients with a probable poor neurological outcome?
a. N13(C5s)
b. Wave V
c. EP (Erb’s point)
d. Wave Il
e. N20
e. N20
An open, comminuted, and depressed skull fracture over what region of the dural venous sinus system has the lowest risk of venous infarct?
a. Posterior 1/3 of the superior sagittal sinus
b. Left transverse sinus
c. Right sigmoid sinus
d. Anterior 1/3 of the superior sagittal sinus
e. Middle 1/3 of the superior sagittal sinus
d. Anterior 1/3 of the superior sagittal sinus
Which of the following is the most effective sedative for pediatric trauma with severe traumatic brain injury and increased intracranial pressure?
a. Propofol
b. Dexmedetomidine
c. Sevoflurane
d. Fentanyl
e. Thiopental
d. Fentanyl
A chronic alcoholic presents in acute withdrawal with hypoglycemia and altered mental status. Administraton of glucose must be preceded by which of the following?
a. Labetaolol
b. Thiamine
c. Insulin
d. Fosphenytoin
e. Ativan
b. Thiamine
A patient with a baclofen pump presents with a temperature of 104 degrees F and hyperreflexia. What is the next appropriate treatment?
a/ Intravenous acetaminophen
b. Broad spectrum antibiotics
c. Cooling blanket
d. Intrathecal baclofen administration
e. Intravenous dantrolene
d. Intrathecal baclofen administration
A 55 year old man presents with a headache and tendemess to palpation of his right temporal artery. Which is the most likely vasculitic cause of his headache?
a. Behget disease
b. Polyarteritis nodosa
c. Churg-Strauss syndrome
d. Wegener’s granulomatosis
e. Giant cell arteritis
e. Giant cell arteritis
A 28 year-old healthy woman who delivered her second child 10 days ago presents with new onset headache, lethargy, and confusion
She has no focal deficits. A non-contrast head CT is obtained and shown below. What is the most appropriate definitive treatment for
this patient?
a. Recombinant activated Factor VIl
b. Endovascular embolization
c. Intravenous heparin infusion
d. Craniotomy for hematoma evacuation
e. Observation only
c. Intravenous heparin infusion
A 40 year old male develops left facial droop and left hemiparesis 48 hours after a motor vehicle accident despite initially being neurologically intact after the accident. A non-contrast head CT at the time of deterioration is negative. The most appropriate next diagnostic evaluation is:
a. ICP monitoring.
b. Cerebral perfusion study.
c. Flexion Extension C-spine XRay
d. CT angiogram of the cervical spine.
e. CT of the cervical spine.
d. CT angiogram of the cervical spine.
In addition to the negative effects on cerebral blood flow, hyperventilation should be avoided in the management of severe closed head injury for which of the following
reasons?
a. Right shift of hemoglobin-oxygen dissociation curve and potential oxygen delivery impairment
b. Right shift of hemoglobin-oxygen dissociation curve and potential CO2 removal impairment
c. Left shift of the hemoglobin-oxygen dissociation curve and potential oxygen delivery impairment
d. Increased pH and potential for increased oxygen delivery
e. Left shift of the hemoglobin-oxygen dissociation curve and potential CO2 removal impairment
c. Left shift of the hemoglobin-oxygen dissociation curve and potential oxygen delivery impairment
Decompressive craniectomy has been shown to have what effect in adult patients with severe traumatic brain injury and elevated intracranial pressure (ICP) values that are refractory to first-tier therapies?
a. Increase mortality
b. Increase number of days in the ICU stay
c. Reduce ICP
d. Improved the rate of good outcome as assessed by the Extended Glasgow Outcome Scale at 6 months
e. Decrease rates of vegetative state
c. Reduce ICP
The nurse calls you to see an intubated postoperative patient noting worsening oxygenation with oxygen saturation of 85%. ABG shows PaO2 of 50 and PaCO2 of 43. While the patient was previously following commands, he has stopped responding to the nurse. Upon your arival, the patient’s blood pressure drops suddenly from 110/62 to 76/40, with a CVP of 1, and his oxygen saturation drops further to 79%. What is the next most appropriate step in management of this unstable patient?
a.Increase the patient’s FiO2 and ventilator rate
b. Initiate norepinephrine for pressor support
c. Take the patient for a STAT head CT
d. Initiate heparin for presumed pulmonary embolism
e. Take the patient for a STAT CT of the Chest, PC protocol
a.Increase the patient’s FiO2 and ventilator rate
