Neurological Emergencies — MCQs
In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :
Which of the following statements regarding hypertensive crisis is false?
Initial drug of choice in a child with status epilepticus:
A child with moderate to severe head injury is admitted in PICU. First line treatments are all except:
Which is not used in status epilepticus?
Which of the following is not a sign of cerebral compression?
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 35-year-old male presents with posterior epistaxis. Conservative management including nasal packing to stop the bleeding was unsuccessful. What is the next step in the management of this patient?
On conducting the autopsy on a victim of hanging, the ligature mark is seen at the lower 1/3rd of the neck. The victim is seen to have a protruded tongue. He was found with his head hanging to his left side with saliva dribbling from the left angle of his mouth. The right pupil appears constricted and there is ptosis (drooping) of the right eyelid. Compression of which of the following structures is the most probable reason for the unilateral ptosis in this case?
A 40-year-old man presents with sudden onset of unilateral facial paralysis. He is unable to close his eye or raise his eyebrow. What is the most likely diagnosis?
Neurological Emergencies Indian Medical PG Practice Questions and MCQs
Question 1: In patient of head injuries with rapidly increasing intracranial tension without hematoma, the drug of choice for initial management would be :
- A. 20% Mannitol (Correct Answer)
- B. Lasix
- C. Glycine
- D. Steroids
Explanation: ***20% Mannitol*** - **Mannitol** is an osmotic diuretic that reduces **intracranial pressure (ICP)** by creating an osmotic gradient, drawing water from the brain parenchyma into the intravascular space [1]. - Its rapid onset of action and significant ICP-reducing effects make it the drug of choice for acute management of elevated ICP in head injuries without hematoma. *Lasix* - **Furosemide (Lasix)** is a loop diuretic that can reduce ICP by decreasing cerebrospinal fluid production and promoting diuresis. - However, its effects are generally slower and less potent than mannitol for acute, rapidly increasing ICP. *Glycine* - **Glycine** is an amino acid and neurotransmitter; it has no direct role in the acute management of increased ICP. - It is sometimes used as an irrigating solution in urological procedures but is not indicated for brain injury. *Steroids* - **Steroids**, particularly **dexamethasone**, are effective in reducing vasogenic edema associated with brain tumors or abscesses. - They are generally **not recommended** for acute traumatic brain injury due to lack of benefit and potential for increased mortality or complications.
Question 2: Which of the following statements regarding hypertensive crisis is false?
- A. Hypertensive urgencies may be managed without extensive monitoring on an outpatient basis.
- B. Hypertensive emergencies require immediate reduction of blood pressure over hours to prevent end-organ damage. (Correct Answer)
- C. Hypertensive urgency is characterized by marked elevation of blood pressure without rapidly evolving end organ damage.
- D. None of the options.
Explanation: ***Hypertensive emergencies require immediate reduction of blood pressure over hours to prevent end-organ damage.*** - This statement is **false** because in a **hypertensive emergency**, blood pressure must be reduced gradually over **minutes to hours** (not over multiple hours) to prevent rapid drops in pressure that could lead to organ hypoperfusion and ischemia. [1] - The goal is to reduce the mean arterial pressure by no more than **25% within the first hour**, followed by a more gradual reduction to 160/100 mmHg over the next 2-6 hours. *Hypertensive urgencies may be managed without extensive monitoring on an outpatient basis.* - This statement is **true** because **hypertensive urgencies** lack acute end-organ damage, allowing for a more gradual reduction in blood pressure, often with oral medications. [1] - Patients can frequently be managed safely in an **outpatient setting** without the need for intensive monitoring or intravenous medications. *Hypertensive urgency is characterized by marked elevation of blood pressure without rapidly evolving end organ damage.* - This statement is **true** and precisely defines a **hypertensive urgency** where blood pressure readings are typically >180/120 mmHg but without acute signs of damage to organs like the brain, heart, or kidneys. - The absence of **acute end-organ damage** differentiates it from a hypertensive emergency. *None of the options.* - This option is incorrect because the first statement (regarding the management of hypertensive emergencies) is indeed **false**, making it the correct answer to the question. - There is a false statement identified among the given options, so "None of the options" cannot be the correct answer.
Question 3: Initial drug of choice in a child with status epilepticus:
- A. Phenobarbitone
- B. Lorazepam (Correct Answer)
- C. Phenytoin
- D. Valproate
Explanation: ***Lorazepam*** - **Lorazepam** is a benzodiazepine that rapidly crosses the blood-brain barrier and has a longer duration of action compared to other benzodiazepines, making it highly effective for acute seizure termination in children with **status epilepticus**. - Its rapid onset and sustained anticonvulsant effect reduce the risk of ongoing neuronal damage and provide a window for administering longer-acting antiepileptic drugs. *Phenobarbitone* - **Phenobarbitone** is a potent anticonvulsant but has a slower onset of action and a higher risk of **respiratory depression** and sedation compared to lorazepam. - It is typically considered a second-line or third-line agent in status epilepticus, after benzodiazepines have failed. *Phenytoin* - **Phenytoin** is a classic antiepileptic drug, but it has a slower onset of action when administered intravenously and carries risks of **cardiac arrhythmias** and **hypotension** with rapid infusion. - It's generally used as a second-line agent to maintain seizure control after the initial termination of status epilepticus with a benzodiazepine. *Valproate* - **Valproate** can be effective in status epilepticus, especially for generalized seizures, but its intravenous formulation also has a slower onset of action than lorazepam. - While it's a good broad-spectrum antiepileptic, it is not the **first-line choice** for immediate seizure termination due to its slower pharmacokinetics in acute settings.
Question 4: 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 5: 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 6: Which of the following is not a sign of cerebral compression?
- A. Papilloedema
- B. Vomiting
- C. Bradycardia
- D. Hypotension (Correct Answer)
Explanation: ***Hypotension*** - **Hypotension** (low blood pressure) is generally not a direct sign of cerebral compression; rather, **hypertension** (Cushing's triad) is associated with increased intracranial pressure. - While systemic hypotension can reduce cerebral perfusion pressure, it is not a primary compensatory mechanism against rising ICP. *Bradycardia* - **Bradycardia** (slow heart rate) is a key component of the **Cushing's reflex**, which is a physiological response to increased intracranial pressure (ICP) aiming to maintain cerebral perfusion. - It occurs alongside hypertension and irregular respiration in the Cushing's triad. *Papilloedema* - **Papilloedema** refers to swelling of the optic disc due to increased intracranial pressure (ICP), which impedes venous return from the retina. - It is a significant and often late sign of cerebral compression or sustained elevation of ICP. *Vomiting* - **Vomiting**, particularly without nausea and often described as **projectile vomiting**, is a common symptom of increased intracranial pressure. - It results from the stimulation of the vomiting center in the brainstem by the elevated pressure.
Question 7: 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.
Question 8: A 35-year-old male presents with posterior epistaxis. Conservative management including nasal packing to stop the bleeding was unsuccessful. What is the next step in the management of this patient?
- A. Internal carotid artery (ICA) ligation
- B. Maxillary artery ligation
- C. External carotid artery (ECA) ligation
- D. Endoscopic sphenopalatine artery ligation (Correct Answer)
Explanation: ***Endoscopic sphenopalatine artery ligation*** - **Sphenopalatine artery ligation** is the most common surgical intervention for **posterior epistaxis** that is refractory to conservative management (e.g., nasal packing). - It is highly effective because the sphenopalatine artery is the major blood supply to the **posterior nasal cavity**. *Internal carotid artery (ICA) ligation* - **ICA ligation** is rarely performed for epistaxis due to the risk of **neurological complications**, such as stroke. - The ICA primarily supplies the brain, and its contribution to nasal bleeding is indirect and not typically the primary source. *Maxillary artery ligation* - The **maxillary artery** is the parent artery of the sphenopalatine artery, but ligating it more proximally carries a higher risk of complications and is less precise. - Due to the deep anatomical location, this approach is more invasive and technically challenging than sphenopalatine artery ligation. *External carotid artery (ECA) ligation* - **ECA ligation** is a more proximal and less selective procedure than sphenopalatine artery ligation, meaning other vessels may be ligated unnecessarily. - While it can reduce blood flow, it may not be as effective as direct sphenopalatine artery ligation for controlling severe posterior epistaxis, as collateral blood flow can still occur.
Question 9: On conducting the autopsy on a victim of hanging, the ligature mark is seen at the lower 1/3rd of the neck. The victim is seen to have a protruded tongue. He was found with his head hanging to his left side with saliva dribbling from the left angle of his mouth. The right pupil appears constricted and there is ptosis (drooping) of the right eyelid. Compression of which of the following structures is the most probable reason for the unilateral ptosis in this case?
- A. Left vagus nerve
- B. Right internal jugular vein
- C. Right internal carotid artery
- D. Cervical sympathetic chain (Correct Answer)
Explanation: ***Cervical sympathetic chain*** - The combination of **unilateral ptosis**, **miosis** (constricted pupil), and sometimes **anhidrosis** (lack of sweating) is characteristic of **Horner's syndrome**, which results from damage to the **cervical sympathetic chain**. - Hanging can cause compression or injury to this chain, leading to the observed **Horner's syndrome** on the ipsilateral side of the injury. *Left vagus nerve* - Compression of the **vagus nerve** is associated with cardiac arrhythmias, bradycardia, or gastric disturbances, not directly with ptosis. - The symptoms observed are specific to sympathetic dysfunction, not parasympathetic vagal stimulation. *Right internal jugular vein* - Compression of the **internal jugular vein** would cause venous congestion and edema in the head and neck, not neurological signs like ptosis or miosis. - While it can be injured in hanging, it does not directly explain the specific neurological findings. *Right internal carotid artery* - Compression of the **internal carotid artery** could lead to cerebral ischemia or stroke symptoms, such as weakness or sensory deficits, but not typically isolated ptosis and miosis. - The observed symptoms point to a specific sympathetic pathway disruption rather than arterial occlusion.
Question 10: A 40-year-old man presents with sudden onset of unilateral facial paralysis. He is unable to close his eye or raise his eyebrow. What is the most likely diagnosis?
- A. Myasthenia gravis
- B. Trigeminal neuralgia
- C. Bell's palsy (Correct Answer)
- D. Stroke
Explanation: ***Bell's palsy*** - **Bell's palsy** presents as an **idiopathic, sudden-onset, unilateral facial nerve paralysis** affecting both the upper and lower face (inability to close eye or raise eyebrow). - This condition is thought to be due to **inflammation or compression of the facial nerve (CN VII)**, leading to a complete hemifacial weakness or paralysis [2]. *Myasthenia gravis* - **Myasthenia gravis** is an **autoimmune disorder** primarily affecting the **neuromuscular junction**, causing fluctuating muscle weakness that worsens with activity and improves with rest. - While it can affect facial muscles, it typically presents with **ptosis**, **diplopia**, and generalized weakness, not an acute unilateral paralysis of the entire hemiface. *Trigeminal neuralgia* - **Trigeminal neuralgia** is characterized by **brief, severe, electric shock-like pains** in the distribution of the **trigeminal nerve (CN V)**, often triggered by touch or movement. - It does not cause muscle weakness or paralysis, but rather sensory symptoms and pain. *Stroke* - A **stroke** causing facial paralysis typically results in **sparing of the forehead** (the patient can still raise their eyebrow) because the upper facial muscles receive bilateral cortical innervation [1]. - While a stroke can cause sudden unilateral weakness, the inability to raise the eyebrow is a key differentiating feature making Bell's palsy more likely [2].
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