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Category: Critical Care Medicine-Neurologic Disorders--->Increased Intracranial Pressure
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Question 1#Print Question

A 79-year-old female with history of hypertension and right-sided subdural hemorrhage status-post right hemicraniectomy and cranioplasty presented to the emergency department with progressive head and focal right arm twitching concerning for a focal seizure. A head CT was obtained and is shown in the figure below:

What type of herniation is demonstrated on the head CT and what are the anticipated neurologic findings on examination?

a. Fungating herniation—contralateral > ipsilateral weakness
b. Subfalcine herniation—contralateral > ipsilateral leg weakness
c. Transtentorial (uncal) herniation—contralateral weakness and anisocoria
d. Tonsillar herniation—marked depressed level of consciousness and bulbar dysfunction


Question 2#Print Question

A 22-year-old male has an external ventricular drain placed for intracranial pressure monitoring following a traumatic brain injury. The patient continues to have a poor neurologic examination. There are episodes of time when he has an elevation in his intracranial pressure to 20 mm Hg that will last for 10 to 20 minutes at a time. During this time there are no changes to other vital signs. A tracing of the external ventricular drain (EVD) is shown below.

What is the phenomenon depicted?

a. Lundberg A wave
b. Lundberg B wave
c. Lundberg C wave
d. Autonomic storming


Question 3#Print Question

An 18-year-old male is brought in to the emergency department after a motor vehicle crash. He was on a motorcycle and was found 30 feet away from his vehicle in unconscious state without a helmet. He has noted trauma to his left forearm, active bleeding from the left posterior portion of his scalp. He was intubated in the field with EMS. On arrival he is tachycardic (heart rate 120s), blood pressure 110/62. He was recently paralyzed for intubation and does not have twitches present on train of four testing. A head CT is completed which demonstrates a large left-sided subdural hematoma with 6 mm midline shift. In the interval, as neurosurgery team is taking the patient to the OR, hyperventilation is started to decrease cerebral edema.

How does hyperventilation decrease intracranial pressure?

a. Change in CSF pH results in constriction of vascular smooth muscle
b. Change in intracranial blood pH results in constriction of vascular smooth muscle
c. Change in CSF pH results in electrical quiescence of neurons, decreased metabolic demand, and decreased cerebral blood flow
d. Change in pCO2 sensed by carotid body chemoreceptors results in vasoconstriction
e. A drop in pCO2 leads to a large osmotic gradient and worsening interstitial edema


Question 4#Print Question

A 32-year-old female with chronic alcoholism and cirrhosis was brought to the emergency department following a night of binge drinking. She was found unresponsive at home and EMS was called. On arrival to the emergency department she was intubated for airway protection. She did not require sedation for intubation and is not currently on any sedation. A head CT was completed and demonstrated diffuse cerebral edema with effacement of the sulci and ventricular system. Her lab results were remarkable for an elevation in AST and ALT (2000, 1000 units/L respectively), total bilirubin 5.6 mg/dL, and ammonia 3642 µm/L. Her examination remains poor, with only extensor posturing to motor stimulation. Her pupils are 5 mm and sluggishly reactive to light.

Given the findings on head CT what is the next best step in management?

a. Hyperventilate the patient with goal pCO2 20 mm Hg
b. Start sedation with a midazolam infusion at 1 mg/h
c. Placement of an intraparenchymal monitor for intracranial pressure monitoring and guidance of therapy
d. Infusion of mannitol at 1 g/kg and if needed repeat every 6 hours
e. Emergent liver transplantation


Question 5#Print Question

A 62-year-old male was admitted with diffuse subarachnoid hemorrhage, intraventicular extension of the hemorrhage, and early signs of hydrocephalus. An EVD was placed without complication. The EVD has functioned well and following placement the patient’s examination improved. The figure that follows is the waveform produced.

What occurs during the P3 peak?

a. P3 represents the arterial pulse
b. P3 represents the cerebral compliance
c. P3 represents the respiratory ICP wave
d. P3 represents the dicrotic notch




Category: Critical Care Medicine-Neurologic Disorders--->Increased Intracranial Pressure
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