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Category: Critical Care Medicine-Neurologic Disorders--->Neuro Monitoring and Diagnostic Modalities
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Question 1# Print Question

A 49-year-old female is admitted to the medical intensive care unit with sepsis due to pyelonephritis and acute kidney injury. Prior urinary tract infections have been due to extended-spectrum Blactamase Escherichia coli. Her initial pertinent lab values include creatinine 1.8 mg/dL, BUN 32 mg/dL, WBC 22.4 × 10 9 /L with elevated band percentage (24%). She was resuscitated with 6 L of IV fluids and started on norepinephrine to maintain a mean arterial pressure of 65. Empiric antibiotic therapy was started with imipenem and vancomycin. Over the course of 48 hours she has improvement in her lab values and vitals and was weaned from vasoactive medications. Despite improvement in the above, she has had ongoing alteration in her level of consciousness. She underwent a prolonged EEG monitoring (see figure tbelow).

Standard 10 to 20 electrode placement. This is a standard “double banana” montage with left over right. EEG demonstrates broad, generalized periodic discharges right greater than left hemispheric involvement.

What is the next best step in management?

A. Change of imipenem to different antibiotic given ongoing seizures
B. Continue with supportive care and no change to medications
C. Initiation of antiepileptic medication—levetiracetam 500 mg twice a day
D. Benzodiazepine trial—lorazepam 1 mg IV once

Question 2# Print Question

A 36-year-old female presents with worsening dyspnea, double vision, and dysarthria over the course of the last 3 days, which was preceded by an upper respiratory tract infection that cleared without any treatment. On examination she has mild labial and palatal dysarthria, limited right eye elevation, and abduction with horizontal double vision on right lateral gaze. She is admitted to the neurology service for workup. A nerve conduction study is completed and demonstrates 50% decrement with rapid stimulation. Laboratory workup reveals positive MuSK (muscle specific kinase) antibody.

What is the best treatment plan for this patient? 

A. Rapid therapy with IVIG and maintenance therapy with oral prednisone
B. Rapid therapy with plasmapheresis and maintenance therapy with oral prednisone
C. Rapid therapy with intravenous methylprednisolone and maintenance therapy with oral prednisone
D. Rapid therapy with plasmapheresis and maintenance therapy with rituximab
E. Rapid therapy with rituximab and maintenance therapy with rituximab

Question 3# Print Question

A 55-year-old female with lupus (on hydroxychloroquine) and hypertension was brought to the emergency department for obtundation. She was intubated in the field given agonal respirations. CT angiogram revealed diffuse subarachnoid hemorrhage and an anterior communicating artery aneurysm. The aneurysm was secured with endovascular coiling. On hospital day 8 the patient had worsening of her examination with weakness of the left face, arm, and leg, as well as mild dysarthria. Her transcranial Doppler ultrasound results are shown below. Angiography was done to evaluate for potential cerebral artery vasospasm. Mild-tomoderate right proximal anterior communicating artery vasospasm was found and treated with intra-arterial verapamil resulting in angiographic and clinical improvement of her symptoms.

Which of the comments is true regarding the use of transcranial Doppler ultrasound for cerebral artery vasospasm following aneurysmal subarachnoid hemorrhage?

A. The most reliable blood vessels for evaluating vasospasm via transcranial Doppler ultrasound is the anterior cerebral artery and vertebral artery
B. If there is vasospasm (defined as mean velocity >120 cm/s) present on transcranial Doppler, there will be clinical changes
C. Lindegaard ratio can help evaluate the etiology of elevated mean velocities by comparing the middle cerebral artery and ipsilateral extracranial carotid artery velocities
D. Following intra-aterial treatment with verapamil, transcranial Doppler velocities will typically increase due to hyperemia

Question 4# Print Question

A 73-year-old woman with schizophrenia on lithium was found unresponsive by her husband in the bathroom. EMS was called, and on arrival she was unresponsive, intubated in the field, and brought to the ED. Her initial vital signs were stable and within normal limits. Off sedation, her eyes remained closed, minimally reactive pupils, no corneal or cough but intact gag reflex, and no movement to painful stimulation. A head CT, and CTA head and neck were completed (see figures below).

What is the patient’s Hunt and Hess and modified Fisher grade?

A. Hunt and Hess score 0 and Fisher grade 1
B. Hunt and Hess score 5 and Fisher grade 4
C. Hunt and Hess score 5 and Fisher grade 3
D. Hunt and Hess score 0 and Fisher grade 4

Question 5# Print Question

A 68-year-old female is brought to the emergency department from home for increased confusion, nausea, and emesis. She was in her usual state of health until the morning of presentation. She was last known well at 9:15 am when her husband saw her getting dressed. He heard a thud at 9:30 am and found her on the ground in the bedroom confused. EMS was called and en route she had an episode of emesis. Her initial head CT demonstrated a cerebellar hemorrhage. A follow-up MRI was completed 5 days following admission (see figures below).

What is the most likely underlying etiology of her intraparenchymal hemorrhage?

A. Cerebral amyloid angiopathy
B. Hypertensive angiopathy
C. Autoimmune vasculitis
D. Infective endocarditis

Category: Critical Care Medicine-Neurologic Disorders--->Neuro Monitoring and Diagnostic Modalities
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