Neurocritical Care — MCQs
Which of the following is not a contraindication for the use of rtPA in stroke management?
Intravenous anaesthetic agent of choice in status epilepticus
Which anesthetic agent is safe to use in patients with elevated intracranial pressure (ICP)?
Which of the following medications is contraindicated in head trauma patients?
Which of the following drugs is contraindicated in a patient with raised intracranial pressure ?
What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?
Which inhalational agent increases intracranial pressure most significantly?
The position of the patient as shown below is favored for which of the following conditions?
During cardiopulmonary resuscitation in an adult, at what rate are chest compressions given?
Neurocritical Care Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not a contraindication for the use of rtPA in stroke management?
- A. BP >185/110 mm Hg
- B. Heparin in the past 24 hrs
- C. Lesion occupying >1/3 of middle cerebral artery territory
- D. Presence of coma (Correct Answer)
Explanation: ***Presence of coma*** - While a severe neurological deficit, **coma itself is not an absolute contraindication** for rtPA if the stroke is acute ischemic and within the treatment window, and other contraindications are absent. - The decision to administer rtPA in comatose patients is complex and based on careful assessment of neurological impairment due to **ischemia**, not just a state of reduced consciousness. *BP >185/110 mm Hg* - **Elevated blood pressure** above 185/110 mmHg is a **major contraindication** for rtPA because it significantly increases the risk of **intracranial hemorrhage**. - Blood pressure must be **controlled below this threshold** before rtPA can be safely administered. *Heparin in the past 24 hrs* - Recent use of **anticoagulants**, especially heparin, within 24 hours, indicates a higher **risk of bleeding** if rtPA is given. - This significantly raises the potential for **hemorrhagic transformation** of the ischemic stroke. *Lesion occupying >1/3 of middle cerebral artery territory* - A **large ischemic lesion** (e.g., >1/3 of MCA territory) on initial imaging is a **contraindication** due to increased risk of **hemorrhagic conversion** and **edema** after reperfusion [1]. - Giving rtPA to such large lesions is associated with poorer outcomes and higher mortality [1].
Question 2: Intravenous anaesthetic agent of choice in status epilepticus
- A. Thiopentone
- B. Etomidate
- C. Ketamine
- D. Propofol (Correct Answer)
Explanation: ***Propofol*** - **Propofol** is favored due to its rapid onset and short duration of action, allowing for quick titration to seizure control and rapid assessment of neurological function post-seizure. - Its potent GABAergic effects effectively **suppress seizure activity** in refractory status epilepticus. *Thiopentone* - While effective in terminating seizures due to its potent GABAergic action, **thiopentone** has a much longer context-sensitive half-time, leading to prolonged sedation and delayed neurological assessment. - Its use often necessitates **intubation and mechanical ventilation** due to significant respiratory depression. *Etomidate* - **Etomidate** is a potent sedative that can terminate seizures but is strongly associated with **adrenal suppression** due to inhibition of 11-β-hydroxylase, which limits its use in status epilepticus, particularly with prolonged infusions. - It has a short duration of action but lacks the neuroprotective properties of other agents and can cause **myoclonus**, which might be confused with ongoing seizure activity. *Ketamine* - **Ketamine** primarily acts as an NMDA receptor antagonist and is often used in refractory status epilepticus that fails to respond to GABAergic drugs (benzodiazepines, propofol, barbiturates). - It is not considered the **first-line intravenous anesthetic agent of choice** and is typically reserved for later stages of management due to its different mechanism of action and potential side effects like hallucinations and cardiovascular stimulation.
Question 3: Which anesthetic agent is safe to use in patients with elevated intracranial pressure (ICP)?
- A. Thiopentone (Correct Answer)
- B. Halothane
- C. Ketamine
- D. Ether
Explanation: ***Thiopentone*** - **Thiopentone** is a barbiturate that **decreases cerebral blood flow** and **metabolic rate**, leading to a reduction in intracranial pressure (ICP). - Its rapid onset and short duration of action make it suitable for inducing anesthesia in patients with elevated ICP. *Halothane* - **Halothane** is a potent **vasodilator** that can increase cerebral blood flow and consequently **elevate intracranial pressure**, making it unsuitable. - It also has a **slow onset and offset**, which can be problematic in emergent situations involving ICP. *Ketamine* - **Ketamine** is known to significantly **increase cerebral blood flow** and **intracranial pressure**, making it generally contraindicated in patients with elevated ICP. - It can also cause **dissociative states** and **emergence delirium**, which can further complicate neurological assessment. *Ether* - **Ether** is an older anesthetic agent known to cause **significant cerebral vasodilation** and an **increase in intracranial pressure**. - It is **highly flammable** and rarely used in modern clinical practice due to its side effects and safety profile.
Question 4: Which of the following medications is contraindicated in head trauma patients?
- A. Furosemide
- B. Thiopentone
- C. Mannitol
- D. Corticosteroids (Correct Answer)
Explanation: ***Corticosteroids*** - While previously used, **corticosteroids** are now contraindicated in traumatic brain injury (TBI) due to evidence suggesting they may increase mortality. - **CRASH trial** showed that corticosteroids increased the risk of death in patients with head injury, possibly by exacerbating secondary brain injury. *Furosemide* - **Furosemide** can be used in certain situations to reduce intracranial pressure by inducing diuresis and reducing cerebral edema, especially when combined with mannitol. - It works by inhibiting the Na-K-2Cl cotransporter in the thick ascending limb of the loop of Henle, leading to increased water excretion. *Thiopentone* - **Thiopentone** (a barbiturate) can be used in severe head trauma to reduce cerebral metabolic rate, thereby decreasing cerebral blood flow and intracranial pressure. - It induces a **pharmacological coma** and provides neuroprotection by scavenging free radicals and stabilizing cell membranes. *Mannitol* - **Mannitol** is an osmotic diuretic commonly used to reduce intracranial pressure in head trauma by creating an osmotic gradient that draws water out of the brain parenchyma. - It is administered intravenously and works rapidly to decrease brain volume and improve cerebral perfusion pressure.
Question 5: Which of the following drugs is contraindicated in a patient with raised intracranial pressure ?
- A. Ketamine (Correct Answer)
- B. Midazolam
- C. Propofol
- D. Thiopentone
Explanation: ***Ketamine*** - **Ketamine** typically causes an increase in **cerebral blood flow** and **intracranial pressure (ICP)**, making it contraindicated in patients with raised ICP. - This effect is due to its action as a **dissociative anesthetic** which can lead to cerebral vasodilation. *Midazolam* - **Midazolam**, a benzodiazepine, can decrease **cerebral metabolic rate** and **cerebral blood flow**, thereby reducing ICP, making it a suitable option for sedation in patients with raised ICP. - It provides **sedation** and **anxiolysis** without significantly increasing ICP. *Propofol* - **Propofol** is a common choice for sedation in patients with raised ICP because it significantly reduces **cerebral blood flow**, **cerebral metabolic rate**, and thus **intracranial pressure**. - Its rapid onset and offset allow for precise control of depth of sedation and neurological assessment. *Thiopentone* - **Thiopentone**, a barbiturate, effectively reduces **cerebral blood flow** and **cerebral metabolic rate**, leading to a decrease in **intracranial pressure**. - It is often used for inducing anesthesia and as a neuroprotective agent in situations with acute brain injury.
Question 6: What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
- A. 2,1,4,3
- B. 1,3,2,4
- C. 2,1,3,4
- D. 1,2,3,4 (Correct Answer)
Explanation: ***1,2,3,4*** - This sequence follows the **ATLS (Advanced Trauma Life Support)** protocol, prioritizing immediate life threats in order. - **Cervical spine stabilization** is the **first action upon patient contact** to prevent secondary neurological injury in any trauma patient. - **Airway management (intubation)** is then performed **with maintained in-line c-spine stabilization** - these occur nearly simultaneously but c-spine protection is instituted first. - **IV cannulation (circulation)** follows to establish vascular access for resuscitation and medications. - **CECT (imaging)** is performed last, once the patient is stabilized after addressing immediate life threats. - This follows the **ATLS Primary Survey: Airway (with c-spine protection) → Breathing → Circulation → Disability → Exposure**. *2,1,4,3* - This incorrectly places intubation **before** cervical spine stabilization is initiated. - In ATLS, **c-spine protection must be applied immediately upon patient contact** before any airway manipulation. - Delaying IV cannulation until after CECT is inappropriate as circulatory access is critical for early resuscitation. *1,3,2,4* - While this correctly starts with cervical spine stabilization, it incorrectly places **IV cannulation before intubation**. - In the ATLS primary survey, **Airway comes before Circulation** - securing the airway takes priority over establishing IV access. - This sequence could delay critical airway management in a patient with respiratory compromise. *2,1,3,4* - This sequence places **intubation before cervical spine stabilization**, which violates ATLS principles. - **C-spine stabilization must be the first action** upon approaching any trauma patient to prevent secondary spinal cord injury. - While intubation with in-line stabilization is possible, the c-spine protection must be instituted first, not after beginning airway manipulation.
Question 7: An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?
- A. Reduce BP
- B. NCCT (Correct Answer)
- C. MRI
- D. Aspirin 300mg and anticoagulants
Explanation: ***NCCT*** - A **non-contrast CT (NCCT) scan of the brain** is the most crucial initial step to differentiate between **ischemic stroke** and **hemorrhagic stroke** [1]. - This distinction is vital because management, especially the use of thrombolytics or anticoagulants, differs significantly based on stroke type [1]. *Reduce BP* - While blood pressure management is important in stroke, immediate and aggressive lowering of BP in acute ischemic stroke can **worsen cerebral perfusion** and **increase infarct size**. - In hemorrhagic stroke, BP control is often necessary, but the decision to lower BP and by how much depends on the cause and extent of the bleed, and this can only be determined after imaging [1]. *MRI* - **MRI** is more sensitive for detecting acute ischemic changes than CT, especially in the posterior fossa [1]. - However, **MRI is not typically the first-line imaging** in an emergency setting for an acute stroke due to its longer acquisition time and potential contraindications (e.g., pacemakers, metallic implants) [1]. *Aspirin 300mg and anticoagulants* - These medications are indicated for **ischemic stroke** (aspirin is an antiplatelet, anticoagulants may be used in specific cases like cardioembolic stroke). - Administering these agents in the event of a **hemorrhagic stroke** would be contraindicated and could significantly worsen the bleeding, leading to severe neurological damage or death [1].
Question 8: Which inhalational agent increases intracranial pressure most significantly?
- A. Halothane (Correct Answer)
- B. Sevoflurane
- C. Isoflurane
- D. Desflurane
Explanation: ***Halothane*** - **Halothane** causes a greater increase in **cerebral blood flow** and thus **intracranial pressure (ICP)** compared to newer volatile anesthetics due to its more potent cerebral vasodilation. - Its use has largely declined due to concerns about its effects on ICP and potential for **hepatotoxicity**. *Sevoflurane* - While sevoflurane can cause **cerebral vasodilation** and increase ICP, its effect is generally less pronounced than halothane, especially when normocapnia is maintained. - It is often favored in neuroanesthesia due to its rapid onset and offset, allowing for quicker adjustments in anesthetic depth. *Isoflurane* - Isoflurane causes less cerebral vasodilation and a smaller increase in ICP compared to halothane, particularly at lower concentrations. - It maintains **cerebral vascular autoregulation** better than halothane, helping to preserve a more stable ICP. *Desflurane* - Desflurane also causes cerebral vasodilation and can increase ICP, but its effect is typically less significant than halothane. - Rapid increases in desflurane concentration can lead to sympathetic stimulation and transient increases in blood pressure, which can indirectly affect ICP.
Question 9: The position of the patient as shown below is favored for which of the following conditions?
- A. CHF
- B. Air embolism
- C. Neurosurgery
- D. Raised ICP (Correct Answer)
Explanation: ***Raised ICT*** - The image depicts the patient in a **reverse Trendelenburg position** (head elevated). This position is often used to reduce **intracranial pressure (ICP)** by promoting venous drainage from the brain. - Elevating the head above the trunk aids in gravity-assisted drainage of cerebral venous blood and cerebrospinal fluid, thereby lowering ICP and preventing complications like brain herniation. *CHF* - Patients with **congestive heart failure (CHF)** often prefer a **Fowler's position** (sitting upright) to ease breathing and reduce pulmonary congestion, not the reverse Trendelenburg as shown. - Lying flat or with feet elevated in CHF can worsen dyspnea and increase cardiac workload due to increased venous return. *Air embolism* - For suspected **air embolism**, the patient is typically placed in the **Trendelenburg position** (head down, feet up) with a left lateral tilt to trap air in the right ventricle and prevent it from entering the pulmonary circulation. - This position helps prevent air from crossing into the left side of the heart thereby reducing the risk of systemic arterial air embolization. *Neurosurgery* - While neurosurgery often involves specific patient positioning, the depicted position isn't uniquely favored for neurosurgery in general. Positioning depends on the surgical site. - The **reverse Trendelenburg** is specifically used when reducing ICP is a primary goal during or after neurosurgical procedures, but not all neurosurgeries.
Question 10: During cardiopulmonary resuscitation in an adult, at what rate are chest compressions given?
- A. 72 compressions/min
- B. 90 compressions/min
- C. 100 compressions/min (Correct Answer)
- D. 120 compressions/min
Explanation: **Explanation:** The correct answer is **C. 100 compressions/min**. **Medical Concept:** According to the latest American Heart Association (AHA) and ERC guidelines for Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS), the recommended rate for chest compressions in adults is **100 to 120 compressions per minute**. High-quality CPR is essential to maintain coronary and cerebral perfusion. A rate of at least 100 bpm ensures sufficient cardiac output, while exceeding 120 bpm is discouraged as it reduces the time for ventricular filling and decreases the quality of recoil. **Analysis of Options:** * **A (72/min) & B (90/min):** These rates are too slow. Inadequate compression frequency fails to generate the necessary intrathoracic pressure and arterial perfusion pressure required to restart the heart or protect the brain. * **D (120/min):** While 120 is the upper limit of the recommended range, standard medical examinations (like NEET-PG) traditionally prioritize the baseline "at least 100/min" as the gold standard answer when a range is not provided. **High-Yield Clinical Pearls for NEET-PG:** * **Compression Depth:** 2 to 2.4 inches (5 to 6 cm) in adults. * **Compression-to-Ventilation Ratio:** 30:2 for adults (single or dual rescuer). * **Recoil:** Allow complete chest recoil after each compression to allow the heart to fill. * **Minimize Interruptions:** Keep pauses in compressions to less than 10 seconds. * **EtCO2 Monitoring:** A capnography reading of <10 mmHg during CPR indicates poor quality compressions.
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