CEN Neurological Emergencies 1 — Questions and Answers
Question 1: A 58-year-old patient presents with sudden-onset 'worst headache of my life.' CT head is negative. What is the next most important diagnostic step?
- MRI brain with gadolinium
- Lumbar puncture for xanthochromia (Correct answer)
- Repeat CT in 6 hours
- Cerebral angiography immediately
Correct answer: Lumbar puncture for xanthochromia
A negative CT does not rule out subarachnoid hemorrhage; lumbar puncture looking for xanthochromia (yellow discoloration) is essential to confirm or exclude the diagnosis.
Question 2: A patient presents with right-sided facial droop, left arm weakness, and slurred speech that started 45 minutes ago. CT shows no hemorrhage. The patient has no contraindications. What is the priority treatment?
- Anticoagulation with heparin drip
- IV alteplase (tPA) within the 3–4.5 hour window (Correct answer)
- Aspirin 325 mg and admit for observation
- Emergent carotid endarterectomy
Correct answer: IV alteplase (tPA) within the 3–4.5 hour window
IV alteplase is the standard of care for ischemic stroke presenting within 3–4.5 hours of symptom onset when there are no contraindications.
Question 3: Which of the following is a contraindication to administering IV tPA for acute ischemic stroke?
- Age over 80 years
- Blood pressure 175/95 mmHg after treatment
- Recent ischemic stroke within the last 3 months (Correct answer)
- Blood glucose of 110 mg/dL
Correct answer: Recent ischemic stroke within the last 3 months
A prior ischemic stroke within 3 months is an absolute contraindication to IV tPA due to significantly increased risk of hemorrhagic transformation.
Question 4: A patient is brought in seizing continuously for 10 minutes. Lorazepam has been given twice without effect. What is the next drug to administer?
- Phenobarbital 20 mg/kg IV
- Levetiracetam or fosphenytoin IV (Correct answer)
- Propofol infusion
- Midazolam 10 mg IM
Correct answer: Levetiracetam or fosphenytoin IV
For benzodiazepine-refractory status epilepticus, second-line agents include fosphenytoin, valproate, or levetiracetam IV per current guidelines.
Question 5: A patient with bacterial meningitis should receive which treatment combination as soon as possible?
- Ceftriaxone alone
- Ceftriaxone + dexamethasone + acyclovir
- Vancomycin + ceftriaxone + dexamethasone (Correct answer)
- Acyclovir alone until cultures return
Correct answer: Vancomycin + ceftriaxone + dexamethasone
Empiric treatment for bacterial meningitis includes vancomycin (for resistant organisms) plus ceftriaxone (broad coverage) plus dexamethasone (to reduce inflammation and neurological sequelae).
Question 6: The Glasgow Coma Scale (GCS) assesses which three components?
- Pupil reactivity, verbal response, motor response
- Eye opening, verbal response, motor response (Correct answer)
- Eye opening, pupil reactivity, verbal response
- Respiratory effort, eye opening, motor response
Correct answer: Eye opening, verbal response, motor response
The GCS evaluates eye opening (1–4), verbal response (1–5), and motor response (1–6) for a maximum score of 15 and minimum of 3.
CEN Neurological Emergencies 1
A 58-year-old patient presents with sudden-onset 'worst headache of my life.' CT head is negative.
What is the next most important diagnostic step?