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ABEM Neurocritical Care study materials
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ABEM Neurocritical Care practice questions

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Question 1Cerebrovascular Disease and Stroke

A patient with acute ischemic stroke presents 3 hours after symptom onset. Intravenous alteplase is being considered. What is the maximum time from symptom onset for which alteplase is generally recommended?

  1. 24 hours
  2. 6 hours
  3. 12 hours
  4. 4.5 hours Correct answer.

Explanation

Intravenous alteplase is recommended for eligible patients within 4.5 hours of symptom onset. Treatment beyond that window is not routinely recommended without advanced imaging selection. Six hours is the classic thrombectomy window, and 12-24 hours applies to selected thrombectomy candidates.

Question 2Cerebrovascular Disease and Stroke

Before administering intravenous thrombolysis for acute ischemic stroke, which blood pressure threshold must be met?

  1. Systolic <160 mmHg and diastolic <100 mmHg
  2. Systolic <140 mmHg and diastolic <90 mmHg
  3. Systolic <185 mmHg and diastolic <110 mmHg Correct answer.
  4. Systolic <220 mmHg and diastolic <120 mmHg

Explanation

Current guidelines require blood pressure below 185/110 mmHg before IV thrombolysis and maintain it below 180/105 mmHg afterward. Higher pressures increase the risk of intracranial hemorrhage. Lowering to <140/90 is not required acutely and may compromise penumbral perfusion.

Question 3Cerebrovascular Disease and Stroke

Which medication is recommended for all patients with aneurysmal subarachnoid hemorrhage to improve neurologic outcome?

  1. Mannitol
  2. Heparin
  3. Dexamethasone
  4. Nimodipine Correct answer.

Explanation

Nimodipine 60 mg every 4 hours for 21 days is recommended for aneurysmal SAH to reduce delayed cerebral ischemia and poor outcome. It is a calcium channel blocker with cerebral selectivity. Mannitol, heparin, and dexamethasone are not routine for this indication.

Question 4Cerebrovascular Disease and Stroke

A patient presents with sudden right hemiparesis and a point-of-care glucose of 45 mg/dL. What is the most appropriate next step?

  1. Obtain CT angiography before treatment
  2. Give intravenous alteplase immediately
  3. Start dual antiplatelet therapy
  4. Administer intravenous dextrose and reassess Correct answer.

Explanation

Hypoglycemia is a common stroke mimic and must be corrected before deciding on reperfusion therapy. Dextrose administration is rapid and diagnostic. Alteplase should not be given until glucose is corrected and a true stroke is confirmed.

Question 5Cerebrovascular Disease and Stroke

Which best defines a transient ischemic attack?

  1. Complete recovery within 7 days
  2. Focal deficit lasting 24 hours with infarction
  3. Transient neurologic dysfunction without acute infarction Correct answer.
  4. Reversible seizure activity

Explanation

A TIA is now defined by tissue criteria as a transient episode of neurologic dysfunction without acute infarction on imaging. Symptoms typically resolve, but the risk of subsequent stroke is high. A deficit with infarction, even if transient, is classified as stroke.

Question 6Cerebrovascular Disease and Stroke

A noncontrast head CT shows a hyperdense collection in the basal ganglia. What is the most likely diagnosis?

  1. Acute ischemic stroke
  2. Subarachnoid hemorrhage
  3. Intracerebral hemorrhage Correct answer.
  4. Subdural hematoma

Explanation

Acute intraparenchymal blood appears hyperdense on noncontrast CT, commonly in the basal ganglia in hypertensive hemorrhage. Ischemic stroke is typically hypodense and may not be visible early. Subdural and subarachnoid blood have different distributions.

Question 7Cerebrovascular Disease and Stroke

In the acute management of ischemic stroke, which serum glucose range is generally targeted?

  1. 250-300 mg/dL
  2. 200-250 mg/dL
  3. 140-180 mg/dL Correct answer.
  4. 80-110 mg/dL

Explanation

Guidelines recommend treating hyperglycemia in acute stroke to a glucose range of about 140-180 mg/dL while avoiding hypoglycemia. Tight control to 80-110 has not improved outcomes and increases hypoglycemia risk. Very high glucose is associated with worse outcome.

Question 8Cerebrovascular Disease and Stroke

For a patient with acute ischemic stroke who did not receive thrombolysis, when should aspirin typically be started?

  1. Only after discharge
  2. After 7 days
  3. Within 24-48 hours Correct answer.
  4. Immediately before CT imaging

Explanation

Aspirin should be started within 24-48 hours after ischemic stroke once intracranial hemorrhage is excluded. Early antiplatelet therapy reduces recurrent stroke and mortality. It is not delayed for 7 days or until discharge.

Question 9Cerebrovascular Disease and Stroke

A 68-year-old presents 5 hours after onset with MCA syndrome, NIHSS 16, and CTA shows an M1 occlusion. ASPECTS is 8. What is the most appropriate treatment?

  1. Intravenous thrombolysis alone without thrombectomy
  2. Decompressive hemicraniectomy without reperfusion
  3. Aspirin monotherapy without reperfusion therapy
  4. Mechanical thrombectomy alone Correct answer.

Explanation

For anterior circulation large vessel occlusion presenting within 6 hours, mechanical thrombectomy is standard and improves functional outcome. At 5 hours, IV thrombolysis is outside the routine 4.5-hour window, so bridging thrombolysis is not given unless imaging-based selection applies. Aspirin alone or decompression without reperfusion is inadequate.

Question 10Cerebrovascular Disease and Stroke

After IV alteplase for acute ischemic stroke, blood pressure should be maintained below which threshold for at least 24 hours?

  1. <180/105 mmHg Correct answer.
  2. <160/100 mmHg
  3. <140/90 mmHg
  4. <220/120 mmHg

Explanation

After IV thrombolysis, blood pressure should be kept below 180/105 mmHg for at least 24 hours. This reduces the risk of hemorrhagic transformation. More permissive thresholds are used for patients who did not receive thrombolysis.

Question 11Cerebrovascular Disease and Stroke

A patient on warfarin with INR 3.2 has an acute intracerebral hemorrhage. Which is the best reversal strategy?

  1. Platelet transfusion alone without factor replacement
  2. Protamine sulfate alone without factor replacement
  3. Four-factor PCC plus IV vitamin K Correct answer.
  4. Fresh frozen plasma alone without vitamin K

Explanation

For warfarin-associated ICH, four-factor prothrombin complex concentrate plus IV vitamin K rapidly reverses the INR and is preferred over fresh frozen plasma. Vitamin K prevents rebound coagulopathy. Platelets and protamine do not reverse warfarin.

Question 12Cerebrovascular Disease and Stroke

In aneurysmal subarachnoid hemorrhage, what is the preferred timing for securing the ruptured aneurysm?

  1. Only if delayed cerebral vasospasm develops
  2. After 3 months of medical therapy
  3. After 2 weeks of strict bed rest and observation
  4. As early as possible within 24-72 hours Correct answer.

Explanation

Early aneurysm securing by coiling or clipping within 24-72 hours reduces rebleeding risk. Delayed treatment increases mortality from rebleeding. Vasospasm is not a reason to delay securing the aneurysm.

Question 13Cerebrovascular Disease and Stroke

A patient with spontaneous intracerebral hemorrhage presents with systolic blood pressure 210 mmHg. What is a reasonable systolic target?

  1. 200-220 mmHg
  2. 170-190 mmHg
  3. 130-150 mmHg Correct answer.
  4. 90-110 mmHg

Explanation

For spontaneous ICH, systolic blood pressure is commonly lowered to a target of 130-150 mmHg, often aiming for about 140 mmHg. Intensive lowering appears safe and may reduce hematoma expansion. Extreme lowering to 90-110 risks cerebral ischemia.

Question 14Cerebrovascular Disease and Stroke

A patient with cerebellar hemorrhage develops declining consciousness and brainstem compression. What is the most appropriate management?

  1. Intravenous thrombolysis
  2. Observation with repeat CT in 24 hours
  3. Lumbar puncture
  4. Emergent surgical decompression Correct answer.

Explanation

Cerebellar hemorrhage with brainstem compression or neurologic decline requires emergent surgical decompression, often with hematoma evacuation and sometimes ventricular drainage. Observation is unsafe once deterioration occurs. Thrombolysis and lumbar puncture are contraindicated.

Question 15Cerebrovascular Disease and Stroke

A 45-year-old with a large MCA infarct develops progressive drowsiness and midline shift at 36 hours. What intervention improves survival?

  1. Hypertonic saline alone
  2. Therapeutic hypothermia
  3. Decompressive hemicraniectomy Correct answer.
  4. Intravenous alteplase

Explanation

Decompressive hemicraniectomy within 48 hours reduces mortality in malignant MCA infarction with mass effect, especially in younger patients. Medical therapy alone is often insufficient once malignant edema develops. Thrombolysis is not appropriate at 36 hours.

Question 16Cerebrovascular Disease and Stroke

A patient with cerebral venous sinus thrombosis has a hemorrhagic infarct on imaging. What is the recommended treatment?

  1. Aspirin alone
  2. Immediate craniectomy
  3. Systemic anticoagulation with heparin Correct answer.
  4. No anticoagulation because of hemorrhage

Explanation

Anticoagulation with heparin is recommended for cerebral venous sinus thrombosis even when hemorrhagic infarction is present. The hemorrhage is usually venous and does not contraindicate anticoagulation. Cranial surgery and aspirin alone are not primary treatments.

Question 17Cerebrovascular Disease and Stroke

A patient with neck pain and Horner syndrome has a carotid dissection with ischemic stroke. Which treatment is recommended for secondary prevention?

  1. Antiplatelet or anticoagulant therapy Correct answer.
  2. Observation only with repeat ultrasound
  3. Intravenous thrombolysis with tenecteplase
  4. Carotid endarterectomy with patch angioplasty

Explanation

Cervical artery dissection with ischemic stroke is treated with antithrombotic therapy, either antiplatelet or anticoagulant, for secondary prevention. Surgery and thrombolysis are not routine for dissection itself. Observation alone risks recurrent stroke.

Question 18Cerebrovascular Disease and Stroke

After a minor ischemic stroke or high-risk TIA, dual antiplatelet therapy with aspirin and clopidogrel is generally continued for how long?

  1. 6 months
  2. 1 year
  3. 21 days Correct answer.
  4. 3 months

Explanation

Dual antiplatelet therapy with aspirin and clopidogrel for 21 days is recommended after minor stroke or high-risk TIA, followed by single antiplatelet therapy. Longer dual therapy increases bleeding without clear benefit. This regimen reduces early recurrent stroke.

Question 19Cerebrovascular Disease and Stroke

An elderly patient has recurrent lobar hemorrhages and probable cerebral amyloid angiopathy. Which medication should be avoided if possible?

  1. Levetiracetam
  2. Labetalol
  3. Acetaminophen
  4. Warfarin Correct answer.

Explanation

Cerebral amyloid angiopathy causes lobar microbleeds and recurrent lobar hemorrhage, and anticoagulation markedly increases hemorrhage risk. Warfarin should be avoided when possible. Acetaminophen, labetalol, and levetiracetam are not associated with this specific risk.

Question 20Cerebrovascular Disease and Stroke

A patient with severe hypertension and renal failure develops seizures and posterior white matter edema. What is the cornerstone of treatment?

  1. Intravenous thrombolysis with alteplase
  2. Therapeutic anticoagulation with heparin
  3. Blood pressure control Correct answer.
  4. Emergent decompressive craniectomy

Explanation

Posterior reversible encephalopathy syndrome is managed primarily by controlling blood pressure and removing offending triggers. Seizures and edema usually improve with treatment. Thrombolysis, anticoagulation, and craniectomy are not indicated.

Question 21Cerebrovascular Disease and Stroke

A patient presents 12 hours after last known well with MCA occlusion. Which finding best supports mechanical thrombectomy?

  1. Small core with large penumbra on perfusion imaging Correct answer.
  2. Large established infarct on noncontrast CT
  3. ASPECTS of 3 with a large established infarct
  4. NIHSS of 2 with a mild neurologic deficit

Explanation

Beyond 6 hours and up to 24 hours, thrombectomy selection relies on perfusion imaging showing a small infarct core and large penumbra. DAWN and DEFUSE-3 criteria use clinical-imaging mismatch. A large core or mild deficit does not support intervention.

Question 22Cerebrovascular Disease and Stroke

A patient with intracerebral hemorrhage took apixaban 4 hours ago. Which reversal agent is most specific?

  1. Vitamin K
  2. Protamine
  3. Idarucizumab
  4. Andexanet alfa Correct answer.

Explanation

Andexanet alfa is a specific reversal agent for factor Xa inhibitors such as apixaban and rivaroxaban. Idarucizumab reverses dabigatran, not apixaban. Vitamin K and protamine do not reverse direct factor Xa inhibitors.

Question 23Cerebrovascular Disease and Stroke

After a large cardioembolic stroke in a patient with atrial fibrillation, when is it generally safest to start anticoagulation?

  1. After 2-4 weeks depending on infarct size Correct answer.
  2. Immediately on day 1 regardless of infarct size
  3. Never because of hemorrhagic risk
  4. After 6 months of antiplatelet therapy

Explanation

Anticoagulation timing after cardioembolic stroke is individualized by infarct size and hemorrhagic risk, often starting within 2-4 weeks. Large infarcts may warrant delayed initiation. Immediate anticoagulation increases hemorrhagic transformation risk.

Question 24Cerebrovascular Disease and Stroke

A patient has recurrent thunderclap headaches and segmental cerebral artery narrowing after sumatriptan use. What is the most appropriate treatment?

  1. High-dose intravenous corticosteroids
  2. Intravenous thrombolysis with alteplase
  3. Nimodipine and trigger avoidance Correct answer.
  4. Therapeutic anticoagulation with heparin

Explanation

Reversible cerebral vasoconstriction syndrome presents with recurrent thunderclap headaches and segmental arterial narrowing, often triggered by serotonergic drugs. Treatment is nimodipine and avoidance of triggers. Thrombolysis and anticoagulation are not indicated.

Question 25Cerebrovascular Disease and Stroke

A child with sickle cell disease has an acute ischemic stroke. What therapy is indicated beyond supportive care?

  1. Hypertonic saline
  2. Decompressive craniectomy
  3. Aspirin
  4. Exchange transfusion Correct answer.

Explanation

Acute ischemic stroke in sickle cell disease is treated with exchange transfusion to rapidly lower hemoglobin S and improve oxygen delivery. This is recommended in addition to supportive care. Hypertonic saline, aspirin, and craniectomy do not address the underlying sickling.

Question 26Cerebrovascular Disease and Stroke

A 62-year-old man develops sudden right-sided weakness and numbness. Examination shows pure motor and sensory loss involving the face, arm, and leg on the right, without aphasia, neglect, or visual field deficit. Which stroke syndrome is most likely?

  1. Left posterior cerebral artery infarct
  2. Left internal capsule lacunar infarct Correct answer.
  3. Left middle cerebral artery cortical infarct
  4. Right anterior cerebral artery infarct

Explanation

Lacunar infarcts in the internal capsule produce pure motor or sensorimotor deficits without cortical signs such as aphasia, neglect, or hemianopia. Cortical signs point instead to a large-vessel cortical infarct.

Question 27Cerebrovascular Disease and Stroke

Which description best matches the current tissue-based definition of a transient ischemic attack?

  1. Focal neurologic symptoms that resolve completely within 24 hours, regardless of imaging
  2. Any sudden neurologic deficit that resolves after thrombolytic therapy
  3. A transient focal neurologic deficit caused by ischemia without acute infarction Correct answer.
  4. A brief episode of global cerebral hypoperfusion causing syncope

Explanation

The tissue-based definition requires a transient focal deficit caused by ischemia with no acute infarction on imaging. The older 24-hour time cutoff is no longer the defining criterion.

Question 28Cerebrovascular Disease and Stroke

A patient has an isolated contralateral homonymous hemianopia with macular sparing. Which artery is most likely occluded?

  1. Basilar artery
  2. Left anterior cerebral artery territory
  3. Left posterior cerebral artery Correct answer.
  4. Left middle cerebral artery territory

Explanation

The posterior cerebral artery supplies the occipital cortex, so occlusion causes a contralateral homonymous hemianopia. Macular sparing occurs because the occipital pole also receives collateral supply from the middle cerebral artery.

Question 29Cerebrovascular Disease and Stroke

In a patient with aneurysmal subarachnoid hemorrhage, which medication is recommended to reduce the risk of delayed cerebral ischemia?

  1. Nimodipine Correct answer.
  2. Dexamethasone
  3. Phenytoin
  4. Mannitol

Explanation

Oral or enteral nimodipine is standard therapy after aneurysmal subarachnoid hemorrhage and improves neurologic outcomes by reducing delayed cerebral ischemia. It is not used primarily to lower blood pressure.

Question 30Cerebrovascular Disease and Stroke

A 70-year-old has a minor ischemic stroke in the left MCA territory. Carotid imaging shows 80% stenosis of the left internal carotid artery. He has no major disability. What is the most appropriate management?

  1. Carotid artery stenting only if symptoms recur
  2. Carotid endarterectomy within 2 weeks Correct answer.
  3. Carotid endarterectomy after 3 months of medical therapy
  4. Medical therapy alone because stenosis is asymptomatic

Explanation

Symptomatic severe carotid stenosis benefits from carotid endarterectomy, and the benefit is greatest when surgery is performed within 2 weeks of the index event. Antiplatelet and statin therapy should continue, but they do not replace timely revascularization.

Question 31Cerebrovascular Disease and Stroke

A 58-year-old presents with fluctuating consciousness, quadriparesis, and pinpoint pupils. CT angiography shows a basilar artery occlusion. He is 8 hours from symptom onset. What is the most appropriate next step?

  1. Start intravenous thrombolysis only if within 4.5 hours
  2. Give aspirin and admit for observation
  3. Transfer for mechanical thrombectomy evaluation Correct answer.
  4. Perform lumbar puncture to exclude subarachnoid hemorrhage

Explanation

Basilar artery occlusion is a devastating large-vessel stroke, and mechanical thrombectomy can be considered in selected patients beyond the 6-hour window. Urgent transfer to a thrombectomy-capable center is therefore appropriate.

Question 32Cerebrovascular Disease and Stroke

A patient with acute ischemic stroke is not eligible for thrombolysis. Blood pressure is 184/102 mmHg. What is the most appropriate blood pressure management?

  1. Give IV nicardipine to keep systolic <120 mmHg
  2. Lower systolic BP to 140-160 mmHg immediately
  3. No routine lowering unless BP is >220/120 mmHg Correct answer.
  4. Start oral lisinopril and target MAP <65 mmHg

Explanation

In acute ischemic stroke without thrombolysis, permissive hypertension is standard unless blood pressure exceeds 220/120 mmHg or another indication requires lowering. Aggressive reduction can compromise perfusion of ischemic tissue.

Question 33Cerebrovascular Disease and Stroke

A patient with a spontaneous lobar intracerebral hemorrhage has no clinical or electrographic seizures. What is the recommended approach to antiseizure medication?

  1. Start levetiracetam for 7 days in all patients
  2. Start phenytoin for 30 days in all patients
  3. Do not start routine prophylactic antiseizure medication Correct answer.
  4. Start prophylactic medication only if the hemorrhage is lobar

Explanation

Routine prophylactic antiseizure medication is not recommended for spontaneous intracerebral hemorrhage without clinical or electrographic seizures. Antiseizure drugs are reserved for treating documented seizures.

Question 34Cerebrovascular Disease and Stroke

A patient with aneurysmal subarachnoid hemorrhage develops serum sodium 126 mmol/L. Which treatment is preferred to avoid worsening cerebral vasospasm?

  1. Hypertonic saline Correct answer.
  2. Intravenous furosemide
  3. Desmopressin
  4. Fluid restriction

Explanation

Hyponatremia after subarachnoid hemorrhage is often related to cerebral salt wasting or SIADH, and fluid restriction can worsen vasospasm by reducing intravascular volume. Hypertonic saline corrects sodium while preserving volume.

Question 35Cerebrovascular Disease and Stroke

A pregnant woman at 30 weeks gestation has an acute ischemic stroke with disabling deficit and presents 2 hours from onset. Which treatment is most appropriate after excluding hemorrhage?

  1. Consider IV alteplase despite pregnancy Correct answer.
  2. Withhold all reperfusion therapy until after delivery
  3. Give aspirin 325 mg and avoid thrombolysis
  4. Give intravenous alteplase only after cesarean delivery

Explanation

Pregnancy is not an absolute contraindication to intravenous alteplase, and reperfusion should be considered when the maternal benefit outweighs risk. Management should involve obstetrics and stroke specialists.

Question 36Cerebrovascular Disease and Stroke

A 38-year-old has a cryptogenic ischemic stroke. Echocardiography shows a patent foramen ovale. He has no other identified stroke mechanism. Which finding most strongly favors percutaneous PFO closure over antiplatelet therapy alone?

  1. Large shunt with atrial septal aneurysm Correct answer.
  2. Small-vessel disease on MRI
  3. A history of migraine with aura
  4. Age older than 60 years with hypertension

Explanation

PFO closure is favored in younger patients with cryptogenic stroke and high-risk PFO features such as a large right-to-left shunt or atrial septal aneurysm. Antiplatelet therapy alone is generally preferred when such features are absent.

Question 37Cerebrovascular Disease and Stroke

A patient with a large MCA infarct develops sudden headache and vomiting on day 3. Noncontrast CT shows a new parenchymal hematoma within the infarct. He is not on anticoagulation. What is the most appropriate immediate management?

  1. Supportive care and reverse coagulopathy Correct answer.
  2. Start dual antiplatelet therapy with aspirin and clopidogrel
  3. Perform immediate lumbar puncture to exclude infection
  4. Give intravenous alteplase immediately

Explanation

Symptomatic hemorrhagic transformation is managed with supportive care, control of blood pressure and intracranial pressure, and reversal of any coagulopathy. Thrombolysis and antiplatelet escalation are contraindicated in this setting.

Question 38Cerebrovascular Disease and Stroke

A 55-year-old presents with sudden coma, vertical gaze palsy, and bilateral thalamic infarcts on MRI. Which vascular territory is most likely involved?

  1. Bilateral posterior cerebral arteries
  2. Basilar artery apex
  3. Bilateral anterior cerebral arteries
  4. Artery of Percheron Correct answer.

Explanation

The artery of Percheron is a variant that supplies both paramedian thalami from a single trunk. Its occlusion causes bilateral thalamic infarcts with altered consciousness and vertical gaze palsy.

Question 39Cerebrovascular Disease and Stroke

A patient with acute ischemic stroke undergoes CT perfusion. Which pattern best identifies salvageable penumbra?

  1. Increased cerebral blood volume throughout the ischemic territory
  2. No perfusion abnormality despite clinical deficit
  3. A large core with matched reduction in cerebral blood flow and cerebral blood volume
  4. Reduced cerebral blood flow with preserved cerebral blood volume Correct answer.

Explanation

Penumbra is hypoperfused tissue with reduced cerebral blood flow but preserved cerebral blood volume, indicating that autoregulatory vasodilation is still maintaining tissue viability. Matched profound reductions in both CBF and CBV indicate core infarction.

Question 40Cerebrovascular Disease and Stroke

In the penumbra of an acute ischemic stroke, why is excessive blood pressure lowering potentially harmful?

  1. It increases cerebral metabolic oxygen demand substantially
  2. It increases cerebrospinal fluid production
  3. Impaired autoregulation makes perfusion pressure-dependent Correct answer.
  4. It directly promotes hemorrhagic transformation

Explanation

Cerebral autoregulation is impaired in ischemic tissue, so blood flow becomes more dependent on mean arterial pressure. Excessive lowering can reduce perfusion to the penumbra and extend infarction.

Question 41Traumatic Brain Injury and Spinal Cord Injury

A patient with a traumatic brain injury opens the eyes only after firm pressure is applied to the nail bed. What score is assigned for the eye-opening component of the Glasgow Coma Scale?

  1. 4
  2. 3
  3. 1
  4. 2 Correct answer.

Explanation

Eye opening is scored 4 for spontaneous, 3 for opening to sound, 2 for opening to pressure, and 1 for no opening. Nail-bed pressure is a pressure stimulus, so the score is 2. The best response observed is the one recorded.

Question 42Traumatic Brain Injury and Spinal Cord Injury

According to the Monro-Kellie doctrine, which intracranial component is displaced first when an expanding traumatic hematoma increases intracranial volume?

  1. Cerebrospinal fluid Correct answer.
  2. Brain parenchyma
  3. Cerebral arterial blood
  4. Cerebral venous blood

Explanation

The doctrine holds that the cranium is a fixed container holding brain, blood, and cerebrospinal fluid. When an expanding mass adds volume, CSF is displaced into the spinal subarachnoid space first and venous blood is expressed next. Arterial blood and brain tissue are relatively preserved until compensatory reserve is exhausted.

Question 43Traumatic Brain Injury and Spinal Cord Injury

Which set of vital-sign changes constitutes the Cushing triad of raised intracranial pressure?

  1. Hypertension, bradycardia, and irregular respirations Correct answer.
  2. Hypertension, tachycardia, and hyperthermia with diaphoresis
  3. Hypotension, tachycardia, and tachypnea with warm extremities
  4. Hypotension, bradycardia, and hypothermia with apnea

Explanation

The Cushing triad consists of hypertension, bradycardia, and irregular respirations. It reflects brainstem ischemia from raised intracranial pressure and is a late, ominous sign of herniation.

Question 44Traumatic Brain Injury and Spinal Cord Injury

An epidural hematoma after blunt head trauma most commonly results from tearing of which vessel?

  1. Dural venous sinuses
  2. Middle meningeal artery Correct answer.
  3. Cortical pial arteries
  4. Bridging cortical veins

Explanation

Epidural hematomas classically arise from arterial bleeding when the middle meningeal artery is torn, often by a temporal bone fracture, creating a biconvex collection that does not cross suture lines. Bridging veins are the source in subdural hematomas.

Question 45Traumatic Brain Injury and Spinal Cord Injury

A crescent-shaped, hyperdense collection that crosses suture lines on CT after trauma is most consistent with which injury?

  1. Cerebral contusion
  2. Subarachnoid hemorrhage
  3. Epidural hematoma
  4. Subdural hematoma Correct answer.

Explanation

Subdural hematomas arise from torn bridging veins, spread diffusely over the hemisphere, and produce a crescentic collection that crosses suture lines. Epidural hematomas are biconvex and are limited by cranial sutures.

Question 46Traumatic Brain Injury and Spinal Cord Injury

Ecchymosis over the mastoid process after blunt head trauma, known as Battle sign, most strongly suggests which injury?

  1. Basilar skull fracture Correct answer.
  2. Cervical spine fracture
  3. Epidural hematoma
  4. Orbital blowout fracture with entrapment

Explanation

Battle sign is mastoid ecchymosis that, together with raccoon eyes and hemotympanum, indicates a basilar skull fracture. The finding usually appears hours after the injury as blood tracks through tissue planes.

Question 47Traumatic Brain Injury and Spinal Cord Injury

Which hemodynamic pattern is characteristic of neurogenic shock after a complete cervical spinal cord injury?

  1. Hypotension with reflex tachycardia
  2. Hypertension with reflex bradycardia
  3. Hypotension with bradycardia Correct answer.
  4. Hypertension and tachycardia

Explanation

Neurogenic shock results from loss of sympathetic outflow after cervical or high thoracic injury, producing hypotension from vasodilation and bradycardia from unopposed vagal tone. Hypotension with tachycardia instead suggests hemorrhage.

Question 48Traumatic Brain Injury and Spinal Cord Injury

Cerebral perfusion pressure is calculated using which formula?

  1. Mean arterial pressure plus intracranial pressure
  2. Mean arterial pressure minus intracranial pressure Correct answer.
  3. Systolic blood pressure minus intracranial pressure
  4. Intracranial pressure minus mean arterial pressure

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure and represents the gradient driving cerebral blood flow. Guidelines target a cerebral perfusion pressure of roughly 60 to 70 mm Hg in adults with severe traumatic brain injury.

Question 49Traumatic Brain Injury and Spinal Cord Injury

According to the Brain Trauma Foundation guidelines, which cerebral perfusion pressure target is recommended for adults with severe traumatic brain injury?

  1. 50 to 60 mm Hg
  2. 80 to 90 mm Hg
  3. 60 to 70 mm Hg Correct answer.
  4. 40 to 50 mm Hg

Explanation

The Brain Trauma Foundation recommends a cerebral perfusion pressure target of 60 to 70 mm Hg. Higher targets achieved with fluids and vasopressors increase the risk of pulmonary complications without clear benefit.

Question 50Traumatic Brain Injury and Spinal Cord Injury

Which property of hypertonic saline makes it attractive compared with mannitol for a hypotensive patient with elevated intracranial pressure?

  1. It produces a slower onset of action than mannitol
  2. It expands plasma volume without causing osmotic diuresis Correct answer.
  3. It crosses the blood-brain barrier more readily
  4. It requires central venous access for administration

Explanation

Hypertonic saline draws water out of the brain while expanding intravascular volume, avoiding the osmotic diuresis that can worsen hypotension with mannitol. Mannitol may precipitate hypovolemia and renal injury in a hemodynamically unstable patient.