Neurological Emergencies in ICU — MCQs
Thrombolysis can be considered in all of these conditions, except:
Which of the following is not a contraindication for the use of rtPA in stroke management?
Signs of increased intracranial tension are all except:
The Monro-Kellie doctrine is used in?
Glasgow coma scale of a patient with head injury who is confused, localizes to pain on the right side but shows abnormal flexion on the left side, and opens eyes only to painful stimuli on sternum:
A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:
What is the drug of choice for managing status epilepticus?
Which is not used in status epilepticus?
Intracranial pressure may be increased by all of the following drugs except -
A previously healthy 45-year-old laborer suddenly develops acute lower back pain with right-leg pain and weakness of dorsiflexion of the right great toe. Which of the following is TRUE?
Neurological Emergencies in ICU Indian Medical PG Practice Questions and MCQs
Question 1: Thrombolysis can be considered in all of these conditions, except:
- A. Blood pressure of more than 185/110 mmHg (Correct Answer)
- B. Ischemic stroke within 2 hours
- C. Onset of symptoms <4 hours
- D. MRI showing density in less than 1/3rd of the area supplied by MCA
Explanation: ***Blood pressure of more than 185/110 mmHg*** - A **blood pressure** greater than **185/110 mmHg** is an absolute contraindication for thrombolysis due to the significantly increased risk of developing **hemorrhagic transformation**. - **Aggressive blood pressure control** is necessary to reduce the risk of intracranial hemorrhage before considering thrombolytics. *Ischemic stroke within 2 hours* - This is within the **therapeutic window** for thrombolysis, which typically extends up to **4.5 hours** from symptom onset [1]. - Earlier administration of thrombolytics within this window generally leads to **better outcomes** and reduced disability [1]. *Onset of symptoms <4 hours* - An onset of symptoms less than **4.5 hours** is a primary **inclusion criterion** for intravenous thrombolysis in acute ischemic stroke [1]. - This timeframe allows for the maximum benefit from **clot dissolution** while minimizing the risk of adverse events. *MRI showing density in less than 1/3rd of the area supplied by MCA* - A **diffusion-weighted MRI** showing an infarct core of less than one-third of the **Middle Cerebral Artery (MCA)** territory is an indicator that the amount of **irreversibly damaged tissue** is small. - This suggests a larger volume of **salvageable penumbra**, making thrombolysis more likely to be beneficial.
Question 2: 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 3: Signs of increased intracranial tension are all except:
- A. Headache
- B. Seizures
- C. Papilledema
- D. Tachycardia (Correct Answer)
Explanation: ***Tachycardia*** - **Tachycardia** is generally *not* a sign of increased intracranial pressure (ICP); rather, **bradycardia** (Cushing's reflex) is a classic finding. - While other systemic responses may occur, a direct, consistent increase in heart rate due to elevated ICP is uncommon. *Papilledema* - **Papilledema** is a swelling of the **optic disc** due to increased ICP, a critical diagnostic sign [1]. - The increased pressure impedes venous return from the retina, causing the optic nerve head to bulge. *Headache* - **Headache** is a common and often early symptom of increased ICP due to the stretching of pain-sensitive meningeal and vascular structures [1]. - It is typically described as a dull, throbbing pain, often worse in the morning or with straining. *Seizures* - **Seizures** can result from increased ICP as the pressure on brain tissue can lead to electrical instability and abnormal neuronal discharge [2]. - This symptom indicates significant cortical irritation or dysfunction caused by the elevated pressure.
Question 4: The Monro-Kellie doctrine is used in?
- A. Cervical injury
- B. Pelvic injury
- C. Head injury (Correct Answer)
- D. Aortic injury
Explanation: ***Head injury*** - The **Monro-Kellie doctrine** states that the sum of volumes of brain, cerebrospinal fluid (CSF), and intracranial blood is constant within the rigid skull. - In **head injury**, any increase in one component (e.g., hematoma, edema) must be compensated by a decrease in another to maintain intracranial pressure (ICP), otherwise, ICP rises, leading to potential herniation. *Cervical injury* - This doctrine applies to the **closed intracranial compartment**, not the spinal canal or cervical spine. - Cervical injuries primarily involve the vertebrae, spinal cord, and surrounding tissues, which do not have the same rigid, fixed-volume characteristics. *Pelvic injury* - The **pelvic cavity** is not a closed, rigid system like the cranium. - It accommodates changes in volume (e.g., from fluid, blood, or organ displacement) without the same direct impact on pressure seen in the skull. *Aortic injury* - **Aortic injuries** concern cardiovascular trauma and blood loss, typically presenting as hypovolemic shock or hemorrhage. - These conditions do not involve the intracranial compartment, and thus, the Monro-Kellie doctrine is irrelevant to their pathophysiology.
Question 5: Glasgow coma scale of a patient with head injury who is confused, localizes to pain on the right side but shows abnormal flexion on the left side, and opens eyes only to painful stimuli on sternum:
- A. 11 (Correct Answer)
- B. 12
- C. 6
- D. 7
Explanation: ***11*** - The Glasgow Coma Scale (GCS) score is calculated by summing the scores for **Eye Response**, **Verbal Response**, and **Motor Response**. - In this case: **Eye Response = 2** (opens eyes to painful stimuli), **Verbal Response = 4** (confused), and **Motor Response = 5** (localizes to pain on the right side). - **Key principle**: When there is **asymmetric motor response**, the **best motor response** is used for GCS calculation, not the worse response or an average. - Right side localizes to pain (M5) and left side shows abnormal flexion (M3), so we use M5. - **Total GCS = E2 + V4 + M5 = 11** *12* - This score would require a better response in at least one GCS component than what is described. - For a GCS of 12, the patient would need either: eyes opening to voice (E3), or obeys commands for motor (M6), or no confusion (V5). - The given patient has E2 + V4 + M5, which totals to 11, not 12. *6* - A score of 6 indicates **severe neurological impairment**, much worse than the described patient. - A GCS of 6 might include: no eye opening (E1) + incomprehensible sounds (V2) + abnormal flexion (M3) = 6. - This is significantly worse than the patient's current state with localizing response and confused speech. *7* - A GCS of 7 also represents **severe neurological deficit**, though not as profound as a score of 6. - This score would typically involve lower responses such as: E1 + V2 + M4 (withdrawal to pain) = 7, or E2 + V1 + M4 = 7. - The described patient has better responses (E2 + V4 + M5 = 11) than this would indicate.
Question 6: A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:
- A. Analgesia and sedation
- B. Hypothermia
- C. Controlled mechanical ventilation
- D. IV mannitol (Correct Answer)
Explanation: ***IV mannitol*** - While **intravenous mannitol** is used in the management of head injury to reduce **intracranial pressure (ICP)**, it is **not a first-line treatment**. - It is a **second-line therapy** reserved for documented or suspected elevated ICP despite initial supportive measures. - First-line management focuses on maintaining adequate oxygenation, ventilation, and cerebral perfusion, while mannitol is used for specific ICP management when needed. *Analgesia and sedation* - **Analgesia and sedation** are essential **first-line treatments** to reduce pain, anxiety, and agitation, which can increase **intracranial pressure (ICP)**. - These therapies ensure patient comfort, decrease metabolic demand, facilitate mechanical ventilation, and prevent secondary brain injury. *Hypothermia* - **Therapeutic hypothermia** is **NOT routinely recommended** as a first-line treatment in pediatric traumatic brain injury. - Current evidence (including the Cool Kids trial) has not demonstrated benefit, and it may be associated with adverse effects. - It is considered **investigational** and not part of standard first-line management protocols. - **Note**: While this is also not first-line, the question specifically tests knowledge that mannitol is second-line therapy for ICP management. *Controlled mechanical ventilation* - **Controlled mechanical ventilation** is a fundamental **first-line treatment** for severe head injury to secure the airway and ensure adequate oxygenation and ventilation. - Prevents secondary brain injury from **hypoxia** and **hypercapnia**, which can worsen outcomes. - Maintaining appropriate **PaCO2 levels** is critical to control cerebral blood flow and intracranial pressure.
Question 7: What is the drug of choice for managing status epilepticus?
- A. Propofol
- B. Thiopentone
- C. Phenytoin
- D. Lorazepam (Correct Answer)
Explanation: ***Lorazepam*** - **Lorazepam** is the preferred first-line agent for status epilepticus due to its rapid onset of action and relatively long duration of anticonvulsant effect (12-24 hours), making it highly effective in stopping ongoing seizures. - Its **lipophilicity** allows it to quickly cross the blood-brain barrier while having less redistribution than diazepam, providing sustained seizure control. - Dose: **0.1 mg/kg IV** (typically 4 mg) administered at 2 mg/min. *Propofol* - **Propofol** is an anesthetic agent used in **refractory status epilepticus** when first and second-line agents have failed. - It carries risks of **hemodynamic instability**, **propofol infusion syndrome** with prolonged use, and requires ICU monitoring with intubation. - Reserved for third-line therapy, not appropriate as initial management. *Thiopentone* - **Thiopentone** is a barbiturate used for **refractory status epilepticus** as a third-line agent. - It has a longer half-life and recovery time compared to benzodiazepines, with significant **cardiovascular depression** and respiratory suppression. - Requires ICU setting with mechanical ventilation and hemodynamic support. *Phenytoin* - **Phenytoin** (or fosphenytoin) is a **second-line agent** used after benzodiazepines if seizures persist. - It has a **slower onset of action** (15-30 minutes) compared to benzodiazepines and requires cardiac monitoring due to risk of arrhythmias. - Loading dose: **20 mg/kg IV** at maximum rate of 50 mg/min to avoid cardiovascular complications.
Question 8: Which is not used in status epilepticus?
- A. Lorazepam
- B. Phenytoin
- C. Phenobarbitone
- D. Metformin (Correct Answer)
Explanation: ***Metformin*** - **Metformin** is an **oral hypoglycemic agent** used to treat **type 2 diabetes mellitus** and has no role in the management of seizures or status epilepticus. - Its primary mechanism involves decreasing **hepatic glucose production** and improving **insulin sensitivity**. *Lorazepam* - **Lorazepam** is a first-line treatment for **status epilepticus** due to its rapid onset of action and efficacy in terminating seizures. - It enhances the effect of **GABA** (gamma-aminobutyric acid) at the GABA-A receptor, leading to neuronal hyperpolarization and reduced excitability. *Phenytoin* - **Phenytoin** is a common second-line agent used in status epilepticus, administered after benzodiazepines, to maintain seizure control. - It works by blocking **voltage-gated sodium channels**, thereby stabilizing neuronal membranes and preventing repetitive firing. *Phenobarbitone* - **Phenobarbitone** (phenobarbital) is an effective antiepileptic drug, often considered as a second or third-line agent in status epilepticus, especially when other treatments fail. - It acts primarily by enhancing the activity of **GABA** at the GABA-A receptor, similar to benzodiazepines, but with a longer duration of action.
Question 9: Intracranial pressure may be increased by all of the following drugs except -
- A. Quinolones
- B. Aminoglycosides (Correct Answer)
- C. Vitamin A
- D. Corticosteroids
Explanation: ***Aminoglycosides*** - **Aminoglycosides** are not typically associated with increasing intracranial pressure. Their primary toxicities include **ototoxicity** and **nephrotoxicity**. - There is no established physiological mechanism by which aminoglycosides directly elevate ICP. *Vitamin A* - **Vitamin A toxicity**, particularly the chronic form of hypervitaminosis A, is a known cause of **idiopathic intracranial hypertension (pseudotumor cerebri)**, which directly increases ICP. - This occurs due to an unknown mechanism that leads to impaired CSF absorption or increased CSF production. *Corticosteroids* - While corticosteroids are often used to reduce cerebral edema and ICP, their **withdrawal**, particularly after prolonged use, can lead to rebound increases in ICP. - In certain susceptible individuals, or with paradoxical reactions, corticosteroids can also induce **pseudotumor cerebri**, leading to elevated ICP. *Quinolones* - **Quinolones** (fluoroquinolones) have been implicated in cases of **drug-induced intracranial hypertension (pseudotumor cerebri)**. - The mechanism is not fully understood but is thought to involve effects on **cerebrospinal fluid dynamics**.
Question 10: A previously healthy 45-year-old laborer suddenly develops acute lower back pain with right-leg pain and weakness of dorsiflexion of the right great toe. Which of the following is TRUE?
- A. If the neurological signs fail to resolve within 1 week, lumbar laminectomy and excision of any herniated nucleus pulposus should be done.
- B. Immediate treatment should include analgesics, muscle relaxants, and back strengthening exercises.
- C. If the neurological signs resolve within 2 to 3 weeks but low back pain persists, the proper treatment would include fusion of affected lumbar vertebrae.
- D. The appearance of the foot drop indicates consideration for earlier surgical intervention if conservative management fails. (Correct Answer)
Explanation: ***The appearance of the foot drop indicates consideration for earlier surgical intervention if conservative management fails.*** - The sudden onset of **foot drop** (weakness of dorsiflexion of the great toe, indicating L5 nerve root compression) in the context of acute low back pain represents a **significant motor deficit**. - While **cauda equina syndrome** (bladder/bowel dysfunction, saddle anesthesia) is an absolute indication for emergency surgery, **progressive or severe motor deficits** like foot drop warrant closer monitoring and consideration for **earlier surgical intervention** if there is no improvement with conservative management. - The typical approach is a trial of **4-6 weeks of conservative management** first, but the presence of foot drop may shorten this window if weakness progresses or fails to improve, as prolonged nerve compression can lead to permanent damage. - This differs from purely sensory radiculopathy or mild motor weakness, where longer conservative management is more appropriate. *If the neurological signs fail to resolve within 1 week, lumbar laminectomy and excision of any herniated nucleus pulposus should be done.* - A **1-week timeline** is too aggressive for routine motor deficits including foot drop, unless there is **rapidly progressive weakness** or cauda equina syndrome. - Standard practice involves **4-6 weeks** of conservative management before considering surgery for most cases of radiculopathy with motor involvement. *Immediate treatment should include analgesics, muscle relaxants, and back strengthening exercises.* - While **analgesics** and **muscle relaxants** are appropriate for immediate symptom relief, **back strengthening exercises** should NOT be initiated in the acute, painful phase with neurological deficits. - Initial treatment focuses on **rest, pain control**, and avoiding activities that worsen symptoms, followed by gradual physical therapy and rehabilitation after the acute phase. *If the neurological signs resolve within 2 to 3 weeks but low back pain persists, the proper treatment would include fusion of affected lumbar vertebrae.* - **Lumbar fusion** is a major surgical procedure reserved for **spinal instability**, **severe degenerative disease**, failed prior surgeries, or intractable pain unresponsive to extensive conservative measures. - It is NOT the standard treatment for persistent mechanical back pain after resolution of neurological deficits—**physical therapy**, activity modification, and other conservative measures are tried first.
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