IV.1. Which of the following examination findings is confirmative of
brain death?
a. Absent motor response, absent verbal response, and intact corneal
reflex
b. Presence of alpha waves on an electroencephalogram
c. During an apnea test, no breathing effort observed when PCO2 is
greater than 60 mm Hg or increases 20 mm Hg from baseline
d. Core body temperature less than 32°C
e. Presence of decerebrate posturing
IV.1. Answer c.
Brain death is the irreversible cessation of all brain and
brainstem function due to a known, irreversible injury.
When an apnea test is performed to confirm brain death, the
arterial blood gas test is considered positive if no breathing
effort occurs when the arterial PCO2 is greater than 60 mm
Hg or there is an increase of 20 mm Hg in PCO2 above a nor-
mal baseline value.
IV.2. In confirming brain death, which of the following should be cor-
rected before an apnea test?
a. Core body temperature greater than 36°C
b. Pulse rate less than 100 beats per minute
c. Head of bed elevated to 30°
d. Correction of coagulopathies
e. Absence of antipyretic medications
IV.2. Answer a.
Requirements for the apnea test, in addition to a general
brain death examination to exclude brain or brainstem
functioning, include a core temperature of more than 36°C,
a positive fluid balance and no recent polyuric episode,
PaCO2 of more than 40 mm Hg, and PaO2 of more than 200
mm Hg. Severe metabolic derangements should be cor-
rected with replacement or toxin removal as necessary;
there should be no effect of sedating or paralytic drugs.
Systolic blood pressure should be greater than 100 mm Hg.
No pulse rate requirements are noted.
IV.3. A 23-year-old farm worker is brought to the emergency depart-
ment after being found unresponsive. The patient is generally
weak with pinpoint pupils, diaphoresis, and excessive salivation.
Glucose is at the reference level. Naloxone results in no response.
Head computed tomography is negative. The most likely cause
of this patient’s coma is which of the following?
a. Methanol poisoning
b. Organophosphate poisoning
c. Hallucinogen overdose
d. Carbon monoxide exposure
e. Tricyclic antidepressant overdose
IV.3. Answer b.
Patients with organophosphate poisoning may present with
coma in addition to miosis, urination, diarrhea, diaphore-
sis, lacrimation, excitation, and salivation (mnemonic
MUDDLES).
IV.4. A comatose patient is intubated and triggers the ventilator.
Motor response is decorticate. Pupils are midposition and fixed.
The horizontal oculocephalic reflex is intact. The examination is
suggestive of a supratentorial lesion with transtentorial herni-
ation affecting which of the following structure(s)?
a. Midbrain
b. Midbrain and pons
c. Midbrain, pons, and medulla
d. Midbrain, pons, medulla, and cervicomedullary junction
e. Midbrain, pons, and cerebellum
IV.4. Answer a.
Midposition, fixed pupils indicate disruption of parasym-
pathetic and sympathetic tone and disruption of the effer-
ent pathway of the pupillary light reflex (cranial nerve III).
They can be indicative of severe midbrain dysfunction,
such as dysfunction from an infarct or transtentorial hernia-
tion. Normal horizontal oculocephalic reflex is suggestive
that the afferent limb (cranial nerve VIII) and efferent limb
(cranial nerve VI) of this pathway are intact. These cranial
nerves are at the level of the pons. Decorticate posturing is
generally seen with a lesion above the red nucleus. With all
pieces of the patient parameters taken together, the mid-
brain is dysfunctional, but the pons and medulla are intact.
IV.5. After assessment of airway, breathing (oxygen), and circulation,
what measure(s) should be considered immediately for a patient
with coma?
a. Urine toxin screen
b. Finger-stick glucose, thiamine, naloxone, and intravenous glucose
c. Head computed tomography without contrast medium
d. Point-of-care international normalized rate
e. Serum electrolytes and kidney and liver function
IV.5. Answer b.
For any patient with coma, many tests are simultaneously
performed, and it may be important to get all the tests listed
above as choices. However, it will take time for the results of
serum and urine laboratory studies. Of importance are early
assessment of a finger-stick glucose level and use of intrave-
nous thiamine, naloxone, and glucose (50% dextrose),
which potentially reverse life-threatening causes of coma.
IV.6. Which of the following statements is true about Cheyne-Stokes
respiration?
a. It suggests a supratentorial mass as a cause
b. It is characterized by erratic, irregular bouts of respiration
c. It occurs in patients with medullary lesions
d. It is always due to a brain mass
e. It is consistent with a poor prognosis
IV.6. Answer b.
Cheyne-Stokes breathing is characterized by a progressive
increase in the respiratory volume and rate followed by a
gradual decrease in the rate and volume, and it may lead to
brief periods of apnea. It generally is nonlocalizing and can be
seen in patients with lesions in multiple locations and with
nonlesional coma (ie, toxic/metabolic or systemic illnesses).
IV.7. An intracranial pressure (ICP) monitor placed in a female patient
with a hemorrhage in a brain tumor shows an ICP of 30 mm Hg after
a ventriculostomy is positioned. The patient’s mean arterial pressure
(MAP) is 90 mm Hg. What is her cerebral perfusion pressure (CPP)?
a. 20 mm Hg
b. 60 mm Hg
c. 120 mm Hg
d. Cannot calculate CPP because the autoregulation curve has
shifted to the right
e. Cannot calculate CPP without cerebral blood flow
IV.7. Answer b.
The calculation CPP = MAP – ICP applies in this case: CPP
= 90 – 30, or 60 mm Hg. Typically, CPP is between 50 and
150 mm Hg in a normotensive patient.
IV.8. A patient with a rapidly expanding right frontal cortical mass
undergoes surgery and the mass is removed. On awakening from
surgery, the patient has reduced motivation to eat and speak and
seems to stare blankly. He can name items and comprehend sim-
ple commands. What is a potential cause of these new symptoms?
a. Subfalcine herniation
b. Downward herniation before surgery resulting in mutism from
brainstem injury
c. Tonsillar herniation with cerebellar mutism
d. Uncal herniation with resultant aphasia
e. Upward herniation
IV.8. Answer a.
Patients with frontal masses can have subfalcine herniation
that results in anterior cerebral artery infarction. This
infarction may cause contralateral leg paralysis. If the pre-
frontal cortex is affected, abulia is common.
IV.9. The Cushing reflex consists of which of the following items?
a. Cerebral perfusion pressure = mean arterial pressure – intracra-
nial pressure (ICP)
b. Total intracranial content volume = blood + cerebrospinal fluid
+ brain volume
c. Hypertension, tachycardia, and Cheyne-Stokes breathing
d. Increased ICP, reduced cerebral blood flow, and elevated P1
waveform
e. Irregular respirations, bradycardia, and hypertension
IV.9. Answer e.
The Cushing reflex consists of hypertension, bradycardia,
and abnormal breathing (which may include Cheyne-Stokes
breathing).
IV.10. Which of the following therapies could be used to treat refrac-
tory increased intracranial pressure (ICP) due to malignant cere-
bral ischemia?
a. High-dose corticosteroids
b. Prolonged hyperventilation
c. Hypertonic saline
d. Decompressive craniotomy
e. Propofol
IV.10. Answer d.
If ICP does not decrease with the simple interventions, a
large bone flap must be removed, allowing brain swelling to
occur without the confinement of the skull and thereby
reducing ICP.
IV.11. Which of the following statements about status epilepticus (SE)
is true?
a. The majority of SE episodes occur in patients with no history of
seizures
b. The highest incidence occurs within the first year of life and after
age 60 years
c. SE is diagnosed after 30 minutes of continued seizure activity
d. Most seizures, if untreated, lead to SE
e. The diagnosis of SE relies on electroencephalography
IV.11. Answer b.
SE is a medical and neurologic emergency defined as per-
sistent seizure activity lasting more than 5 minutes or recur-
rent seizures without recovery of consciousness in between.
The highest incidence of SE is within the first year of life
and after age 60.
IV.12. For a patient with status epilepticus (SE), what is the next step
after assessment of airway, breathing, and circulation?
a. Establish intravenous access
b. Administer fosphenytoin 20 mg/kg intramuscularly
c. Assess a finger-stick glucose and oxygen saturation
d. Administer 2 mg of lorazepam intramuscularly
e. Obtain an arterial blood gas
IV.12. Answer c.
Although many activities occur simultaneously during sta-
bilization of a patient with SE, immediate assessment of a
finger-stick glucose and oxygen saturation may help iden-
tify a potentially reversible cause of SE. While these initial
assessments are occurring, establishment of intravenous
access is crucial.
IV.13. A 60-kg patient with generalized convulsive status epilepticus
receives 6 mg of lorazepam and 20 mg/kg of intravenous fos-
phenytoin. The patient is intubated with etomodate, fentanyl,
and recuronium, and an electroencephalography monitor is
placed showing frequent generalized seizures. The next best
choice of therapy is which of the following?
a. Lacosamide
b. Levetiracetam
c. Inhalation anesthetic
d. Vagal nerve stimulation
e. Midazolam
IV.13. Answer e.
If seizures persist after adequate doses of benzodiazepine and
of fosphenytoin or valproic acid, consideration should be
given to intubation, patient transfer to an intensive care unit,
infusion of an anesthetic agent (midazolam, propofol,
ketamine, or pentobarbital), and continuous electroencepha-
lography. Alternative antiepileptic agents, including lacos-
amide and levetiracetam, are currently not recommended as
third-line agents for control of convulsive SE. Although they
are widely used, their effectiveness and safety are not clearly
established in this clinical setting. Inhalation anesthetic or
surgical procedures are reserved for selected cases of super
refractory SE.
IV.14. Which of the following medications should be avoided as an
antiepileptic agent for aneurysmal subarachnoid hemorrhage
because of its potential systemic adverse effects?
a. Levetiracetam
b. Phenytoin
c. Lacosamide
d. Lamictal
e. Phenobarbital
IV.14. Answer b.
Phenytoin should be avoided in patients with aneurysmal
subarachnoid hemorrhage because some evidence suggests
that worse functional and cognitive outcomes at 14 to 30 days
are associated with its use. Additional studies have suggested
a higher adverse effect profile and more drug-to-drug interac-
tions than levetiracetam. In addition, phenytoin induces the
metabolism of nimodipine, which may decrease its effect.
IV.15. Abrupt, early hydrocephalus typically presents as which of the
following conditions?
a. Cranial nerve VII palsy
b. Nystagmus
c. Impaired consciousness
d. Horner’s syndrome
e. Hemiparesis
V.15. Answer c.
One of the first signs of abrupt-onset hydrocephalus is a reduced
level of consciousness. Patients may also have diplopia, vomit-
ing, and vertical gaze restriction.
IV.16. The percentage of patients who regain functional independence
within the first year after aneurysmal subarachnoid hemor-
rhage is approximately which of the following ranges?
a. 1% to 2%
b. 5% to 10%
c. 10% to 20%
d. 30% to 50%
e. 60% to 70%
IV.16. Answer d.
Within the first year after aneurysmal subarachnoid hemor-
rhage, 30% to 50% of patients regain independence.
IV.17. For a patient with aneurysmal subarachnoid hemorrhage and
hyponatremia, all of the following steps are indicated except
which step?
a. Free water restriction
b. Use of fludrocortisone acetate
c. Use of hypertonic saline solution
d. Use of normal saline
e. Liberal free water intake
IV.17. Answer e.
Hyponatremia due to cerebral salt wasting occurs in
approximately 20% to 40% of patients with aneurysmal
subarachnoid hemorrhage. Free water intake will worsen
the hyponatremia. The use of fludrocortisone acetate and
hypertonic saline is reasonable for prevention and correc-
tion of hyponatremia.
IV.18. Which of the following might confer a better prognosis in
anoxic-ischemic injury?
a. Burst suppression pattern on electroencephalography
b. Localization to painful stimuli
c. Serum neuron-specific enolase of 80 μ/L at day 1 to day 3 after
cardiac arrest
d. Sustained upward gaze
e. Status myoclonus
IV.18. Answer b.
A localizing motor response may confer a better prognosis,
whereas the other options may be predictive of a poor neu-
rologic prognosis after cardiac arrest.
IV.19. Man-in-the-barrel syndrome localizes to which of the following
areas?
a. The watershed distribution between the middle and posterior
cerebral artery territories
b. The middle cerebral artery territory
c. The anterior cerebral artery territory
d. The posterior fossa
e. The watershed distribution between the anterior and middle
IV.19. Answer e.
The man-in-the-barrel syndrome clinically presents as bilat-
eral proximal upper-extremity weakness and localizes to the
watershed distribution between the anterior and middle
cerebral artery vascular territories. Hypoperfusion, often in
the setting of bilateral carotid disease, may cause infarction
in this territory.
IV.20. Which of the following statements is true regarding the utility of
tests in the assessment of prognosis for patients with anoxic
encephalopathy?
a. Neuroimaging is not useful in prognostication
b. Somatosensory-evoked potential (SSEP) may be influenced by
hypothermia and medications used in an intensive care unit and
should not be used for prognostication
c. Computed tomographic scan of the brain is 85% sensitive and
90% specific in identification of anoxic brain injury
d. A neuron-specific enolase (NSE) value greater than 33 μg/L at day
1 is uniformly predictive of a poor prognosis
e. An electroencephalography (EEG) showing burst suppression is
suggestive of a poor prognosis
IV.20. Answer e.
A highly malignant pattern on EEG such as burst suppres-
sion suggests a poor prognosis. Magnetic resonance imaging can document the extent of anoxic-ischemic injury with
diffusion-weighted sequences and has some value in prog-
nostication. SSEPs are not influenced by drugs, tempera-
ture, or acute metabolic derangements. The absence of both
N20s implies an invariably poor prognosis, and the patient
likely will never regain consciousness. A serum NSE level
greater than 33 μg/L at day 1 through day 3 after cardiac
arrest was traditionally a predictor of poor outcome.
However, several studies have confirmed that this cutoff
level for NSE is not reliable for patients who have under-
gone hypothermia protocols. (See also Table 59.2.)
A 15-year-old boy is struck on the left side of the head by an 80-
mile-per-hour baseball pitch. Although initially he dropped to
the ground, he got up and was able to walk to the ambulance. On
arrival to the emergency department, his level of consciousness
deteriorates. A computed tomographic (CT) scan is shown in the
image below. The best course of action is which of the following?
a. Burr hole evacuation
b. Emergent craniotomy and evacuation
c. No surgery; admission to the neuroscience intensive care unit
and administration of mannitol
d. No surgery; admission to the general neurology floor service for
close observation
e. No surgery; admission to the general neurology floor service and
administration of intravenous corticosteroids
IV.21. Answer b.
CT scan of the brain shows an acute epidural hemorrhage on
the left side with overlying soft tissue swelling. The condition
of such patients may deteriorate rapidly, and emergent craniot-
omy and evacuation of the epidural hemorrhage are warranted.
IV.22. A 37-year-old man involved in a motor vehicle crash sustains
facial trauma and a brief loss of consciousness. He now reports
headache, nausea, and clear nasal drainage. To determine
whether the nasal drainage is due to cerebrospinal fluid (CSF)
leak, which of the following tests can be used on the fluid?
a. Vascular endothelial growth factor
b. β-2 Transferrin
c. Neuron-specific enolase
d. Glial fibrillary acidic protein
e. Xanthochromia
IV.22. Answer b.
The fluid can be tested for β-2 transferrin. This protein is
found only in CSF and perilymph.
IV.23. Which of the following statements is true about concussion?
a. By definition of concussion, patients must lose consciousness,
even if briefly
b. A direct head strike is required
c. Patients must have associated nausea and vomiting
d. The Glasgow Coma Scale (GCS) score must be 15
e. Concussion can occur in a patient who sustains body trauma that
transmits an impulsive force to the head
IV.23. Answer e.
Although the exact definition of concussion differs across
medical societies, the American Academy of Neurology
defines traumatic brain injury concussion as “trauma-
induced alteration in mental status that may or may not
involve loss of consciousness.” Concussions do not require
loss of consciousness or a direct head strike. The GCS score
is generally 15 but can range from 13 to 15.
IV.24. Which of the following statements is true regarding assessment
of concussion in the emergency department?
a. Patients younger than 15 years should be admitted and observed
for postconcussion brain swelling
b. Patients should undergo neurologic evaluation that includes
assessment of cognition and a computed tomographic (CT) scan
of the head
c. Blood should be drawn for serum biomarkers to determine
which patients should be admitted and observed
d. Selected patients should undergo CT scan of the brain
e. Seizure prophylaxis for 3 days should be implemented
IV.24. Answer d.
Not all patients with concussion require a CT scan of the brain.
The New Orleans Criteria (see Box 60.1, “Clinical
Characteristics in the New Orleans Criteria”) are highly sensi-
tive and specific for identifying patients with concussion or
with mild traumatic brain injury who may have clinically
important intracranial lesions. This model includes 7 vari-
ables. If all 7 variables are absent, a head CT scan is not needed.
IV.25. A herniated disk at the L5-S1 interspace is compressing the con-
tents of the spinal canal. Which of the following characteristics
would not be typically associated with this lesion?
a. Asymmetrical weakness
b. Upgoing plantar responses
c. Back pain (lumbago)
d. Reduced ankle (Achilles) reflexes
e. Saddle anesthesia
IV.25. Answer b.
Cauda equina syndrome does not produce upper motor
neuron signs.
IV.26. A man is stabbed in the chest near his axilla and has arm weak-
ness. What is the best course of action?
a. Cast immobilization
b. Nonsteroidal anti-inflammatory drug therapy
c. Urgent surgical consultation
d. Physical therapy
e. Traction
IV.26. Answer c.
Clean, sharp, lacerating injuries to brachial plexus or termi-
nal nerve branches should be explored and repaired end to
end within 24 to 48 hours because with time, the nerve end-
ings become more edematous and difficult to suture.
Ultimately, they scar and degenerate, requiring more
advanced and less effective surgical interventions.
IV.27. A man who fell from a grain elevator had a complete spinal cord
injury at the T1 level (American Spinal Cord Injury Association
A). Twenty years later, he has progressive bilateral hand weak-
ness first and then has arm weakness. Which of the following is
the most likely cause of his new symptoms?
a. Ligamentous laxity
b. Scoliosis
c. Cervical radiculopathies due to spine instability
d. Syringomyelia
e. Amyotrophic lateral sclerosis
IV.27. Answer d.
Syringomyelia can develop proximally in the spinal cord in
up to 30% of patients after a major spinal cord injury and
can cause further neurologic deficits. It can cause unilateral
or bilateral symptoms, but bilateral symptoms are more spe-
cific for a spinal cord lesion.
IV.28. Which of the following statements about Guillain-Barré syn-
drome (GBS) is not true?
a. The presence of deep tendon reflexes in the initial evaluation
rules out GBS
b. The combination of intravenous immunoglobulin (IVIG) and
plasma exchange (PLEX) is superior to either treatment alone
c. Noninvasive ventilation should be avoided in the treatment of
respiratory failure
d. High cellularity in the cerebrospinal fluid should prompt ques-
tioning of the diagnosis of GBS
e. After the patient is intubated, bedside pulmonary function tests
should be measured daily to evaluate disease progression and
readiness for extubation
IV.28. Answer b.
IVIG and PLEX are accepted treatment choices for patients
who cannot walk unassisted. Both treatments are consid-
ered efficacious, but the combination of the 2 treatments is
not known to be beneficial.
IV.29. A 70-kg patient comes into the emergency department with
ascending weakness over the past 3 days and shortness of
breath. Respiratory rate is about 25 breaths per minute. Pulse is
100 beats per minute. Chest radiography is negative for con-
cerns. The patient’s vital capacity is 1,050 mL; inspiratory pres-
sure, –20 cm H2O; and expiratory pressure, 30 cm H2O. What is
important in the next steps of treatment of this patient?
a. Spine imaging
b. Admission to general floor with daily assessment of vital capac-
ity, inspiratory, and expiratory pressures
c. Spinal fluid evaluation
d. Arterial blood gas and consideration of intubation
e. Assessment of urine toxicology screen
IV.29. Answer d.
For a patient with suspected neuromuscular respiratory fail-
ure, the airway, breathing, and circulation should take prior-
ity to diagnostic imaging and testing. The 20-30-40 rule is a
useful predictor of respiratory failure in Guillain-Barré syn-
drome. A patient is likely to require endotracheal intubation
if vital capacity is <20 mL/kg; maximal inspiratory pressure,
<–30 cm H2O; and maximal expiratory pressure, <40 cm H2O.
IV.30. Which of the following characteristics might distinguish a cho-
linergic crisis from a myasthenic crisis?
a. Respiratory failure
b. Generalized weakness, including distal muscles
c. Presence or absence of excessive salivation and diarrhea
d. Presence or absence of reflexes
e. Presence or absence of ptosis
IV.30. Answer c.
Table 62.4 lists some clinical and examination findings that
may help distinguish cholinergic crisis from myasthenic crisis.
IV.31. Which of the following complications is not common in Guillan-
Barré syndrome (GBS)?
a. Takotsubo cardiomyopathy
b. Arrhythmia
c. Deep vein thrombosis
d. Paroxysmal fluctuations in blood pressure
e. Respiratory failure
IV.31. Answer a.
Patients with GBS may have serious cardiac complica-
tions—most commonly tachyarrhythmias and fluctuating
blood pressure—due to autonomic dysfunction. Heart fail-
ure is less common, and takotsubo cardiomyopathy has
been associated with GBS only in case reports. Deep vein
thrombosis, respiratory failure, adynamic ileus, urinary
retention, and pain are common complications of GBS.
IV.32. Which of the following drugs could increase the risk of sero-
tonin syndrome in a patient already taking a selective serotonin
reuptake inhibitor (SSRI)?
a. Quetiapine
c. Tramadol
d. Marijuana
e. Levetiracetam
IV.32. Answer c.
Many substances (see Box 63.1, “Drugs and Medications
Sometimes Associated With Serotonin Syndrome”) may
contribute to serotonin syndrome. Of the list provided, tra-
madol can increase the risk of serotonin syndrome in a
patient already taking an SSRI.
IV.33. A 75-year-old patient with advanced Parkinson disease is admit-
ted with abdominal pain, nausea, and vomiting. He receives the
diagnosis of small-bowel obstruction and is administered noth-
ing by mouth (NPO). On the second day of admission, the patient
has hyperthermia, rigidity, and mental status changes. The most
likely cause of these symptoms is which of the following?
a. Concomitant pneumonia
b. Reaction to the antiemetic
c. Abrupt withdrawal of dopamine
d. Malignant hyperthermia
e. Ischemic stroke
IV.33. Answer c.
A patient with advanced Parkinson disease is likely taking
levodopa/carbidopa. When the patient has the clinical
order for NPO, the abrupt withdrawal of dopamine may
result in a neuroleptic malignant–type clinical picture.
Resumption of the medication would be recommended.
IV.34. Which of the following statements is true about the cause of
malignant hyperthermia?
a. Abrupt withdrawal of dopamine may cause this syndrome
b. A mutation in the ryanodine receptor in combination with suc-
cinylcholine use may cause this syndrome
c. Cocaine use may result in this syndrome
d. Intramuscular haloperidol treatment may result in this syndrome
e. This disorder may result from severe head trauma
IV.34. Answer b.
Malignant hyperthermia is a muscle disorder caused by a
mutation in the ryanodine receptor. In susceptible patients,
it can be triggered by certain inhaled anesthetics or
succinylcholine.
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