CEN Neurological Emergencies 2 — Questions and Answers
Question 1: Which clinical sign differentiates a herniation syndrome from a metabolic cause of coma?
- Bilateral pinpoint pupils
- Unilateral fixed and dilated pupil (Correct answer)
- Symmetric sluggish pupils
- Small reactive pupils bilaterally
Correct answer: Unilateral fixed and dilated pupil
A unilateral fixed and dilated pupil (blown pupil) indicates compression of cranial nerve III from uncal herniation, a structural cause, unlike the symmetric findings seen in metabolic coma.
Question 2: A patient with increased intracranial pressure (ICP) is being managed. Which intervention is most appropriate as a temporizing measure?
- Administer normal saline bolus 1L
- Elevate head of bed to 30 degrees and hyperventilate to PaCO2 35 mmHg (Correct answer)
- Administer morphine for pain
- Lower blood pressure to below 120/80 mmHg
Correct answer: Elevate head of bed to 30 degrees and hyperventilate to PaCO2 35 mmHg
Head-of-bed elevation to 30 degrees improves venous drainage, and mild hyperventilation (PaCO2 35 mmHg) causes cerebral vasoconstriction to temporize elevated ICP.
Question 3: What is the NIH Stroke Scale (NIHSS) primarily used for in the emergency setting?
- Determining eligibility for surgery
- Quantifying neurological deficits and guiding thrombolysis decisions (Correct answer)
- Predicting long-term functional outcome only
- Classifying hemorrhagic vs. ischemic stroke
Correct answer: Quantifying neurological deficits and guiding thrombolysis decisions
The NIHSS quantifies neurological deficits on a standardized scale and helps guide tPA eligibility and treatment decisions in acute ischemic stroke.
Question 4: A patient post-trauma has a GCS of 8. According to current guidelines, what intervention is most appropriate?
- Observe with serial neuro checks only
- Intubate to protect the airway (Correct answer)
- Administer mannitol empirically
- Perform immediate lumbar puncture
Correct answer: Intubate to protect the airway
A GCS ≤8 is the clinical threshold for airway compromise; endotracheal intubation is indicated to protect the airway and provide controlled ventilation.
Question 5: Which medication is first-line for treatment of an acute hypertensive encephalopathy with a BP of 240/140 mmHg?
- Oral nifedipine
- IV labetalol or nicardipine with goal of 20–25% MAP reduction in 1 hour (Correct answer)
- Furosemide 80 mg IV push
- Sublingual nitroglycerin
Correct answer: IV labetalol or nicardipine with goal of 20–25% MAP reduction in 1 hour
Hypertensive encephalopathy requires controlled BP reduction of 20–25% in the first hour using IV agents like labetalol or nicardipine to prevent cerebral hypoperfusion.
Question 6: A patient presents with sudden onset severe vertigo, nausea, and inability to walk. Head impulse test is negative and there is direction-changing nystagmus. What diagnosis should be suspected?
- Benign paroxysmal positional vertigo (BPPV)
- Cerebellar stroke (Correct answer)
- Labyrinthitis
- Vestibular neuritis
Correct answer: Cerebellar stroke
A negative head impulse test with direction-changing nystagmus and inability to walk are central (not peripheral) signs suggesting cerebellar stroke requiring urgent MRI.
CEN Neurological Emergencies 2
Which clinical sign differentiates a herniation syndrome from a metabolic cause of coma?