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ABPMR Brain Injury Medicine study materials
ABPMR Brain Injury Medicine study resources

ABPMR Brain Injury Medicine practice questions

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Question 1Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient opens the eyes only to painful stimulation, makes incomprehensible sounds, and withdraws the limb from pain. What is the Glasgow Coma Scale score?

  1. 11
  2. 6
  3. 8 Correct answer.
  4. 9

Explanation

The score is calculated as eye 2 (opening to pain), verbal 2 (incomprehensible sounds), and motor 4 (withdrawal from pain), which totals 8. This corresponds to a severe traumatic brain injury.

Question 2Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with traumatic brain injury is confused, agitated, and exhibits bizarre, non-purposeful behavior. Which Rancho Los Amigos level does this describe?

  1. Level II
  2. Level IV Correct answer.
  3. Level VIII
  4. Level VI

Explanation

Level IV is the confused-agitated level, characterized by disorientation, agitation, and inappropriate or bizarre behavior. Level II is a generalized response, level VI is confused-appropriate, and level VIII is purposeful-appropriate.

Question 3Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient has a lucid interval after head trauma followed by rapid neurologic decline, and CT shows a biconvex hyperdense extra-axial collection. What is the most likely diagnosis?

  1. Diffuse axonal injury
  2. Epidural hematoma Correct answer.
  3. Chronic subdural hematoma
  4. Subarachnoid hemorrhage

Explanation

A biconvex, lens-shaped hyperdense collection with a lucid interval is characteristic of an epidural hematoma, often from middle meningeal artery injury. Subdural hematomas are crescentic, and subarachnoid hemorrhage fills sulci and cisterns.

Question 4Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Ecchymosis over the mastoid process after head trauma is most suggestive of which injury?

  1. Basilar skull fracture Correct answer.
  2. Mandibular fracture
  3. Orbital fracture
  4. Zygomatic arch fracture

Explanation

Mastoid ecchymosis is the Battle sign, a delayed finding of basilar skull fracture. Periorbital ecchymosis (raccoon eyes) and cerebrospinal fluid rhinorrhea or otorrhea are other associated signs.

Question 5Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

According to current consensus, what should happen to an athlete who shows signs of concussion during a game?

  1. Returned after 10 symptom-free minutes
  2. Returned after brief sideline rest
  3. Removed from play for the day Correct answer.
  4. Returned if head CT is normal

Explanation

Current consensus states that any athlete with suspected concussion should be removed from play and not returned the same day. Same-day return is contraindicated because of the risk of worsening injury and second impact syndrome.

Question 6Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which brief cognitive screening instrument is more sensitive than the MMSE for detecting mild cognitive impairment and executive dysfunction?

  1. GCS
  2. MoCA Correct answer.
  3. NIHSS
  4. MMSE

Explanation

The Montreal Cognitive Assessment includes items for executive function, visuospatial ability, and abstraction, making it more sensitive to mild impairment than the MMSE. The NIHSS and GCS measure stroke severity and coma, respectively.

Question 7Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which treatment is first-line for focal spasticity affecting a single limb after traumatic brain injury?

  1. Selective dorsal rhizotomy
  2. Intrathecal baclofen
  3. Botulinum toxin injection Correct answer.
  4. Oral baclofen

Explanation

Focal spasticity is best treated with chemodenervation using botulinum toxin injected into the affected muscles. Oral baclofen is used for generalized spasticity, and intrathecal baclofen and rhizotomy are reserved for refractory or severe cases.

Question 8Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

What is the recommended approach to oral intake in a patient with a new stroke or traumatic brain injury?

  1. Start oral diet immediately
  2. Withhold all oral intake for 72 hours
  3. Screen for dysphagia before oral intake Correct answer.
  4. Obtain a barium swallow in every patient

Explanation

Patients should be screened for dysphagia before any oral intake, including medications, to reduce aspiration risk. Formal instrumental assessment is reserved for those who fail screening or have ongoing concerns.

Question 9Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which score on the Galveston Orientation and Amnesia Test indicates resolution of post-traumatic amnesia?

  1. 25 or higher
  2. 50 or higher
  3. 100 only
  4. 76 or higher Correct answer.

Explanation

The GOAT is scored from 0 to 100, and a score of 76 or higher on two consecutive days indicates that post-traumatic amnesia has resolved. Scores below that reflect ongoing disorientation and memory impairment.

Question 10Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which finding best distinguishes the minimally conscious state from the unresponsive wakefulness syndrome?

  1. Presence of sleep-wake cycles
  2. Consistent command following Correct answer.
  3. Normal electroencephalogram
  4. Intact brainstem reflexes

Explanation

The minimally conscious state requires reproducible evidence of awareness, such as consistent command following, visual pursuit, or intentional communication. Sleep-wake cycles and intact brainstem reflexes are preserved in both conditions.

Question 11Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with severe traumatic brain injury develops recurrent episodes of tachycardia, hypertension, tachypnea, diaphoresis, and extensor posturing triggered by turning. What is the most likely diagnosis?

  1. Paroxysmal sympathetic hyperactivity Correct answer.
  2. Severe sepsis with delirium
  3. Nonconvulsive status epilepticus with autonomic features
  4. Neuroleptic malignant syndrome

Explanation

Paroxysmal sympathetic hyperactivity is characterized by episodic sympathetic surges, including tachycardia, hypertension, hyperthermia, diaphoresis, and posturing, typically triggered by routine care. It occurs after severe acquired brain injury and is distinct from seizures and infection.

Question 12Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

How long should prophylactic antiseizure medication be continued to prevent early post-traumatic seizures after severe traumatic brain injury?

  1. 7 days Correct answer.
  2. 6 months
  3. 3 months
  4. Until the EEG normalizes

Explanation

Prophylaxis with levetiracetam or phenytoin is recommended for 7 days after severe traumatic brain injury to reduce early seizures. Prolonged prophylaxis has not been shown to prevent late post-traumatic epilepsy.

Question 13Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which finding most suggests heterotopic ossification in a patient recovering from traumatic brain injury?

  1. Painless joint contracture without overlying warmth or swelling
  2. Diffuse osteopenia on plain radiographs
  3. Warm, swollen joint with reduced range of motion Correct answer.
  4. Hypercalcemia with nephrolithiasis

Explanation

Heterotopic ossification typically presents with localized warmth, swelling, pain, and decreased joint range of motion, most often at the hips, knees, or shoulders. Bone scan or CT confirms the diagnosis before radiographic changes become evident.

Question 14Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which anterior pituitary hormone deficiency is most common after moderate to severe traumatic brain injury?

  1. Growth hormone Correct answer.
  2. Thyroid-stimulating hormone
  3. Adrenocorticotropic hormone
  4. Prolactin

Explanation

Growth hormone deficiency is the most frequently reported anterior pituitary deficit after traumatic brain injury, followed by gonadotropin deficiency. Deficiencies can be subtle and may present as fatigue, altered body composition, or delayed recovery.

Question 15Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

What is the most appropriate venous thromboembolism prophylaxis for a patient with a stable intracranial hemorrhage 48 hours after traumatic brain injury?

  1. Placement of an inferior vena cava filter
  2. Low-molecular-weight heparin once stable Correct answer.
  3. Aspirin 325 mg daily
  4. No prophylaxis for the first two weeks

Explanation

Pharmacologic prophylaxis with low-molecular-weight heparin can be started once repeat imaging confirms that the intracranial hemorrhage is stable, typically within 24 to 72 hours. Mechanical prophylaxis is used before that point.

Question 16Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which imaging finding best distinguishes post-traumatic hydrocephalus from ex vacuo ventricular enlargement?

  1. Prominent cortical sulci
  2. Age greater than 65 years
  3. Periventricular edema with effaced sulci Correct answer.
  4. Presence of a ventriculoperitoneal shunt

Explanation

Post-traumatic hydrocephalus is suggested by ventriculomegaly with periventricular interstitial edema, effaced cortical sulci, and ballooned frontal horns, often with clinical deterioration. Ex vacuo enlargement shows enlarged ventricles but prominent, not effaced, sulci.

Question 17Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which screening instrument is most commonly recommended for depression in patients with traumatic brain injury?

  1. PHQ-9 Correct answer.
  2. MMSE
  3. Glasgow Outcome Scale
  4. ASIA scale

Explanation

The Patient Health Questionnaire-9 is a validated and widely recommended screening tool for depression in traumatic brain injury. Somatic items can overlap with neurologic symptoms, so clinical confirmation is needed.

Question 18Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which medication has the strongest evidence for improving recovery in patients with disorders of consciousness after traumatic brain injury?

  1. Haloperidol
  2. Diphenhydramine
  3. Baclofen
  4. Amantadine Correct answer.

Explanation

Amantadine has been shown to accelerate the rate of functional recovery in patients with vegetative or minimally conscious states after traumatic brain injury. Dopaminergic and stimulant agents are used to support arousal and attention.

Question 19Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which pharmacologic class is most appropriate for persistent attention and processing-speed deficits three months after a mild traumatic brain injury?

  1. Stimulant Correct answer.
  2. Acetylcholinesterase inhibitor
  3. Atypical antipsychotic
  4. Opioid antagonist

Explanation

Stimulant medications such as methylphenidate are used to treat persistent attention and processing-speed deficits after traumatic brain injury. Acetylcholinesterase inhibitors are used primarily for memory impairment, and antipsychotics may worsen cognition.

Question 20Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with traumatic brain injury and aneurysmal subarachnoid hemorrhage develops hyponatremia with high urine output, a negative fluid balance, and high urine sodium. What is the most appropriate initial management?

  1. Demeclocycline
  2. Fluid restriction
  3. Hypertonic saline for seizures only
  4. Isotonic saline resuscitation Correct answer.

Explanation

These findings indicate cerebral salt wasting, which is treated with volume resuscitation using isotonic saline. Fluid restriction would worsen the hypovolemia and is the treatment for syndrome of inappropriate antidiuretic hormone.

Question 21Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

During apnea testing for brain death, which arterial partial pressure of carbon dioxide confirms the absence of respiratory drive?

  1. 40 mm Hg or higher
  2. 50 mm Hg or higher
  3. 60 mm Hg or higher Correct answer.
  4. 30 mm Hg or higher

Explanation

The apnea test is positive when no respiratory effort occurs after the arterial PaCO2 rises to at least 60 mm Hg, or at least 20 mm Hg above the baseline. A lower threshold is inadequate to stimulate the respiratory center.

Question 22Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with subarachnoid hemorrhage is stuporous and has a moderate hemiparesis. What is the Hunt and Hess grade?

  1. Grade II
  2. Grade V
  3. Grade IV Correct answer.
  4. Grade III

Explanation

Hunt and Hess grade IV is assigned to patients with stupor and moderate to severe hemiparesis. Grade III is drowsiness with mild focal deficit, and grade V is coma with decerebrate posturing.

Question 23Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

What is the most appropriate reversal for a warfarin-associated intracranial hemorrhage?

  1. Fresh frozen plasma alone
  2. Recombinant factor VIIa without vitamin K
  3. Four-factor PCC plus vitamin K Correct answer.
  4. Platelet transfusion

Explanation

Four-factor prothrombin complex concentrate rapidly replaces vitamin K-dependent factors and is combined with intravenous vitamin K for sustained reversal. Fresh frozen plasma is slower and associated with volume overload.

Question 24Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which finding most reliably predicts a poor neurologic outcome after cardiac arrest?

  1. Absent bilateral N20 SSEP responses at 72 hours Correct answer.
  2. Absent corneal reflexes at 24 hours
  3. Persistent myoclonic status epilepticus at 24 hours
  4. Elevated serum lactate

Explanation

Bilateral absence of the N20 cortical response on somatosensory evoked potentials at 72 hours or later is a robust predictor of poor outcome. Prognostication should be multimodal, incorporating examination, EEG, biomarkers, and imaging.

Question 25Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

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

  1. 40 to 50 mm Hg
  2. 60 to 70 mm Hg Correct answer.
  3. 100 to 110 mm Hg
  4. 80 to 90 mm Hg

Explanation

Current Brain Trauma Foundation guidelines recommend a cerebral perfusion pressure target of 60 to 70 mm Hg for adults with severe traumatic brain injury. Higher targets may increase the risk of acute respiratory distress syndrome.

Question 26Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient sustains a frontal head injury and reports complete loss of smell. Which cranial nerve is most likely injured?

  1. Olfactory nerve Correct answer.
  2. Optic nerve
  3. Glossopharyngeal nerve
  4. Facial nerve

Explanation

The olfactory nerve (CN I) passes through the cribriform plate and is vulnerable to shearing injury after frontal trauma. Injury produces anosmia, which may be permanent. The other listed nerves mediate vision, facial movement/taste, and pharyngeal sensation, respectively.

Question 27Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which clinical scale grades spasticity by quantifying resistance to passive joint movement?

  1. Modified Ashworth Scale Correct answer.
  2. ASIA Impairment Scale
  3. Fugl-Meyer Assessment
  4. Brunnstrom stages

Explanation

The Modified Ashworth Scale grades resistance to passive stretch on a 0 to 4 scale and is widely used to quantify spasticity. The Brunnstrom stages describe motor recovery patterns, the Fugl-Meyer Assessment measures motor impairment, and the ASIA scale classifies spinal cord injury.

Question 28Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which instrument is designed to quantify agitation in patients recovering from traumatic brain injury?

  1. Rancho Los Amigos Scale
  2. Agitated Behavior Scale Correct answer.
  3. Glasgow Coma Scale
  4. Disability Rating Scale

Explanation

The Agitated Behavior Scale contains 14 items rated for severity and is specifically designed to measure agitation during brain injury recovery. The Glasgow Coma Scale assesses consciousness, the Rancho Los Amigos Scale describes global cognitive and behavioral recovery, and the Disability Rating Scale measures overall disability.

Question 29Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with a recent traumatic brain injury and atrial fibrillation on dabigatran develops an acute intracranial hemorrhage. Which reversal agent is most specific?

  1. Vitamin K
  2. Protamine sulfate
  3. Fresh frozen plasma
  4. Idarucizumab Correct answer.

Explanation

Idarucizumab is a monoclonal antibody fragment that specifically binds and neutralizes dabigatran. Vitamin K reverses warfarin, protamine reverses heparin, and fresh frozen plasma provides nonspecific coagulation factor replacement.

Question 30Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with severe traumatic brain injury develops polyuria, serum sodium of 152 mmol/L, urine osmolality of 120 mOsm/kg, and urine specific gravity of 1.002. Which test best confirms central diabetes insipidus?

  1. Water deprivation test
  2. Desmopressin challenge Correct answer.
  3. Pituitary MRI
  4. Serum antidiuretic hormone level

Explanation

Central diabetes insipidus results from deficient antidiuretic hormone release and responds to desmopressin with an increase in urine osmolality. A water deprivation test is hazardous in the acute setting with existing hypernatremia. Serum antidiuretic hormone levels are unreliable, and MRI does not confirm the functional diagnosis.

Question 31Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

According to Brain Trauma Foundation guidelines, which patient with severe traumatic brain injury meets criteria for intracranial pressure monitoring?

  1. Glasgow Coma Scale 12 with normal CT
  2. Glasgow Coma Scale 9 with normal CT and no risk factors
  3. Glasgow Coma Scale 3 to 8 with abnormal CT Correct answer.
  4. Glasgow Coma Scale 14 with linear skull fracture

Explanation

Intracranial pressure monitoring is recommended for severe traumatic brain injury, defined as a Glasgow Coma Scale score of 3 to 8, when the CT scan is abnormal. Monitoring is also considered with a normal CT if risk factors such as age over 40, hypotension, or motor posturing are present.

Question 32Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which medication is considered first-line for central post-stroke pain?

  1. Carbamazepine
  2. Ibuprofen
  3. Oxycodone
  4. Amitriptyline Correct answer.

Explanation

Central post-stroke pain is a neuropathic pain syndrome that responds to tricyclic antidepressants, gabapentinoids, and serotonin-norepinephrine reuptake inhibitors. Amitriptyline is a standard first-line agent. Nonsteroidal anti-inflammatory drugs and opioids are not first-line, and carbamazepine is primarily used for trigeminal neuralgia.

Question 33Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

Which MRI finding is most characteristic of diffuse axonal injury after traumatic brain injury?

  1. Enlarged ventricles with effaced sulci
  2. Cortical contusion with surrounding edema
  3. Biconvex extra-axial hematoma
  4. Punctate gray-white junction hemorrhages Correct answer.

Explanation

Diffuse axonal injury results from shearing forces and produces punctate hemorrhages in the white matter, corpus callosum, and brainstem, best seen on susceptibility-weighted imaging. Cortical contusions and extra-axial hematomas reflect focal impact or vascular injury, and ventricular enlargement with effaced sulci suggests hydrocephalus.

Question 34Assessment, Diagnosis, and Ongoing Medical Management of Brain Injury

A patient with traumatic brain injury has clear rhinorrhea after a basilar skull fracture. Which test most reliably confirms that the fluid is cerebrospinal fluid?

  1. Gram stain
  2. Glucose oxidase
  3. Beta-2 transferrin Correct answer.
  4. Protein electrophoresis

Explanation

Beta-2 transferrin is highly specific for cerebrospinal fluid and is the preferred confirmatory test for a cerebrospinal fluid leak. Glucose testing is nonspecific because nasal secretions and tears also contain glucose. Gram stain and protein electrophoresis do not reliably confirm cerebrospinal fluid.

Question 35Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Post-traumatic amnesia (PTA) is best defined as which of the following?

  1. The time from injury until Glasgow Coma Scale score is 15
  2. The duration of retrograde amnesia before the injury
  3. The interval between injury and return of continuous memory Correct answer.
  4. The period of unconsciousness immediately after injury

Explanation

PTA is the period after traumatic brain injury during which new memories are not formed reliably, ending when continuous memory returns. It is distinct from loss of consciousness and from normalization of the Glasgow Coma Scale. PTA duration is a useful marker of injury severity and predicts functional outcome.

Question 36Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which statement about major depression after traumatic brain injury is most accurate?

  1. It rarely responds to treatment.
  2. It is unrelated to injury severity.
  3. It occurs in about 10% of patients within the first year.
  4. It is among the most common psychiatric sequelae. Correct answer.

Explanation

Major depression is one of the most frequent psychiatric complications of traumatic brain injury and affects a substantial minority of patients. Its development reflects a mix of neurobiologic and psychosocial factors rather than a single severity marker. It is treatable with psychotherapy and antidepressant medication, although treatment response can be complicated by cognitive and somatic symptoms.

Question 37Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Dense anterograde amnesia after bilateral medial temporal lobe injury is most closely associated with damage to which structure?

  1. Cerebellum
  2. Caudate nucleus
  3. Amygdala
  4. Hippocampus Correct answer.

Explanation

Bilateral hippocampal injury impairs the formation of new declarative memories and produces prominent anterograde amnesia. The amygdala contributes to emotional learning, while the caudate and cerebellum support other aspects of procedural and motor learning. The hippocampus is the key medial temporal structure for encoding new episodic information.

Question 38Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Reduced processing speed after moderate-severe traumatic brain injury most often manifests as which of the following?

  1. Difficulty keeping up with rapid conversation Correct answer.
  2. Inability to recognize familiar faces
  3. Fluent but irrelevant speech
  4. Loss of knowledge of object names

Explanation

Slowed processing speed makes it hard to keep pace with quickly presented information, such as rapid conversation or timed tasks. Word knowledge and face recognition depend on language and perceptual systems rather than processing speed alone. Fluent but irrelevant speech suggests a different problem, such as disinhibition or language disorder.

Question 39Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which anxiety disorder is particularly common after traumatic brain injury?

  1. Pyromania
  2. Body dysmorphic disorder
  3. Generalized anxiety disorder Correct answer.
  4. Hoarding disorder

Explanation

Generalized anxiety disorder, panic disorder, and post-traumatic stress disorder are among the anxiety-related conditions frequently seen after traumatic brain injury. Hoarding disorder, body dysmorphic disorder, and pyromania are not classified as anxiety disorders and are not typical post-injury sequelae. Persistent worry and autonomic arousal after injury warrant direct assessment and treatment.

Question 40Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which statement best characterizes persistent post-concussive symptoms?

  1. They resolve within 48 hours in most patients.
  2. They may persist for months with normal neuroimaging. Correct answer.
  3. They occur only when intracranial hemorrhage is present.
  4. They are limited to a single symptom domain.

Explanation

Persistent post-concussive symptoms can last for weeks to months or longer despite normal structural neuroimaging. They commonly span physical, cognitive, emotional, and sleep domains rather than being confined to one symptom type. The presence of normal imaging does not exclude clinically meaningful persistent symptoms.

Question 41Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

The primary goal of cognitive rehabilitation after traumatic brain injury is best described as which of the following?

  1. Improving function with strategies and compensation Correct answer.
  2. Restoring premorbid IQ in all patients
  3. Replacing behavioral therapy with medication
  4. Preventing all future neurodegenerative disease

Explanation

Cognitive rehabilitation aims to improve everyday functioning through strategy training, environmental supports, and compensation for persistent deficits. It does not guarantee restoration of premorbid IQ or prevent all late neurodegenerative disease. Medication may treat specific symptoms but does not replace rehabilitative skill-building.

Question 42Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Apathy after traumatic brain injury is best characterized by which of the following?

  1. Fluctuating level of consciousness
  2. Repetitive involuntary movements
  3. Reduced goal-directed behavior and motivation Correct answer.
  4. Heightened emotional reactivity

Explanation

Apathy refers to diminished motivation and reduced goal-directed activity, often with flattened affect and limited initiative. It differs from agitation or emotional lability, which involve heightened or labile emotional expression. Fluctuating consciousness suggests delirium, and repetitive movements suggest a movement disorder.

Question 43Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

A 72-year-old man with a recent mild traumatic brain injury becomes acutely confused at night, with fluctuating attention and visual hallucinations. Which diagnosis is most likely?

  1. Post-traumatic stress disorder
  2. Psychotic depression
  3. Delirium Correct answer.
  4. Major neurocognitive disorder

Explanation

Acute onset, fluctuating attention, and visual hallucinations strongly suggest delirium, which is common in older adults after injury or hospitalization. Delirium is a medical emergency that requires evaluation for causes such as infection, medication effects, or metabolic disturbance. Major neurocognitive disorder is typically chronic and progressive, while PTSD and psychotic depression do not usually present with fluctuating attention.

Question 44Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

After dangerous causes of acute post-traumatic agitation have been excluded, which medication strategy is most appropriate?

  1. Environmental modification plus targeted pharmacotherapy Correct answer.
  2. Physical restraint without medication
  3. Immediate high-dose benzodiazepine monotherapy
  4. Anticholinergic agents as first-line

Explanation

Initial management of post-traumatic agitation combines environmental modification, routine building, and safety measures with cautiously targeted pharmacotherapy when needed. Benzodiazepines can worsen confusion and agitation, especially in patients with brain injury. Physical restraint alone is not a treatment strategy, and anticholinergics can exacerbate cognitive impairment.

Question 45Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which factor complicates the diagnosis of post-traumatic stress disorder after moderate-severe traumatic brain injury?

  1. PTSD never occurs after traumatic brain injury
  2. Hyperarousal is absent in all TBI patients
  3. Amnesia may obscure criterion A recall Correct answer.
  4. Patients cannot experience trauma-related fear

Explanation

Traumatic brain injury can produce amnesia for the precipitating event, making it difficult to establish the exact trauma exposure required for PTSD criterion A. PTSD can still occur after traumatic brain injury, and patients may show hyperarousal, avoidance, and intrusive symptoms. Diagnosis often relies on collateral information and careful longitudinal assessment.

Question 46Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which feature best distinguishes apathy from depression in a patient with traumatic brain injury?

  1. Lack of distress about reduced motivation Correct answer.
  2. Sleep disturbance
  3. Loss of pleasure in activities
  4. Presence of suicidal ideation

Explanation

Apathy is characterized by reduced motivation and initiative without the prominent dysphoria or distress typical of depression. Patients with depression often report sadness, guilt, hopelessness, or suicidal ideation and are distressed by their loss of function. Loss of pleasure and sleep disturbance can occur in both conditions and are less discriminating on their own.

Question 47Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

A patient with frontal lobe injury can perform a daily routine but cannot plan a novel multi-step task. This deficit most reflects impairment in which domain?

  1. Episodic memory
  2. Executive function Correct answer.
  3. Language comprehension
  4. Visuospatial perception

Explanation

Executive function encompasses planning, organization, sequencing, and cognitive flexibility, which are needed for novel multi-step tasks. Episodic memory concerns learning and recalling personal events, language comprehension concerns understanding language, and visuospatial perception concerns spatial analysis. Preserved routines with impaired novel planning is a classic dysexecutive pattern.

Question 48Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which statement about pseudobulbar affect after traumatic brain injury is most accurate?

  1. It consists of mood-congruent sadness
  2. It is a form of epileptic seizure
  3. It indicates deliberate malingering
  4. It causes affect incongruent with mood Correct answer.

Explanation

Pseudobulbar affect involves involuntary episodes of laughing or crying that are disproportionate to or incongruent with the patient's underlying mood. It reflects disrupted regulation of emotional expression rather than a primary mood disorder or seizure. Recognizing it is important because it can be socially disabling and may respond to specific pharmacologic treatment.

Question 49Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which approach is recommended for a patient with traumatic brain injury and comorbid alcohol use disorder?

  1. Delay all substance treatment until cognition fully recovers
  2. Integrate substance treatment with TBI rehabilitation Correct answer.
  3. Prescribe benzodiazepines long-term
  4. Use confrontational therapy as first-line

Explanation

Substance use treatment should be integrated with brain injury rehabilitation rather than delayed until cognitive recovery is complete. Integrated care addresses motivation, cognitive deficits, relapse risk, and family or environmental factors simultaneously. Confrontational approaches and long-term benzodiazepines are generally avoided because they can worsen engagement and cognition.

Question 50Neurobehavioral, Cognitive, and Psychiatric Sequelae of Brain Injury

Which sleep disturbance after traumatic brain injury most directly worsens daytime attention and memory?

  1. Restless legs syndrome
  2. Narcolepsy
  3. Sleepwalking
  4. Insomnia with fragmented sleep Correct answer.

Explanation

Insomnia with frequent awakenings reduces restorative sleep and commonly produces daytime fatigue, inattention, and memory difficulty. Restless legs syndrome and narcolepsy can affect alertness but are less common direct drivers of fragmented sleep after traumatic brain injury. Sleepwalking primarily poses safety risks and does not usually cause persistent daytime cognitive impairment.