100+ Free ABIM Neurocritical Practice Questions

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A 68-year-old woman presents 2 hours after sudden right-sided weakness and aphasia. NIHSS is 14. Non-contrast CT shows no hemorrhage, ASPECTS 9. BP is 168/92, glucose 140 mg/dL, INR 1.0. Per the AHA 2024 update, which IV thrombolytic regimen is preferred?

Tenecteplase 0.25 mg/kg single IV bolus (max 25 mg)

Alteplase 0.6 mg/kg with 15% as bolus over 1 minute

Streptokinase 1.5 million units over 60 minutes

Reteplase 10 units double bolus 30 minutes apart

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2026 Statistics

Key Facts: ABIM Neurocritical Exam

100

Exam Questions

ABIM 2026

8.5 hours

CBT Exam Day Length

ABIM 2026

~$2,840

Application + Exam Fee

ABIM 2026

Oct 2021

First ABIM Administration

ABIM

1 year

Neurocritical Care Fellowship Required

ACGME

10 years

MOC Cycle

ABIM MOC

The ABIM Neurocritical Care subspecialty exam certifies internists trained in critical care medicine to manage adults with primary neurologic and neurosurgical disease in dedicated neuro-ICUs. It is a 100-question single-best-answer MCQ exam delivered in an 8.5-hour CBT day at Pearson VUE centers. The application + exam fee is approximately $2,840. The credential is co-sponsored by ABA, ABEM, ABIM, ABNS, and ABPN — ABIM issues it to candidates who hold active ABIM Internal Medicine plus Critical Care Medicine certification and have completed a 1-year Neurocritical Care fellowship (or a 2-year combined Critical Care + Neurocritical Care fellowship). The first ABIM administration was October 2021. The 2026 blueprint emphasizes acute ischemic stroke (alteplase 0-4.5 hrs and tenecteplase 0.25 mg/kg per AHA 2024 update; mechanical thrombectomy 0-6 hrs and 6-24 hrs per DAWN/DEFUSE 3), ICH/SAH (BP control SBP <140 per INTERACT-2/ATACH-2; reversal with 4F-PCC, idarucizumab, andexanet alfa per ANNEXA-I 2023), status epilepticus (ESETT 2019), TBI and elevated ICP (Brain Trauma Foundation 4th ed., DECRA/RESCUE-ICP), brain death determination (AAN 2023), TTM 32-36°C per TTM2 (2021), and multimodality neuromonitoring. MOC is required every 10 years.

Sample ABIM Neurocritical Practice Questions

Try these sample questions to test your ABIM Neurocritical exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1A 68-year-old woman presents 2 hours after sudden right-sided weakness and aphasia. NIHSS is 14. Non-contrast CT shows no hemorrhage, ASPECTS 9. BP is 168/92, glucose 140 mg/dL, INR 1.0. Per the AHA 2024 update, which IV thrombolytic regimen is preferred?

A.Tenecteplase 0.25 mg/kg single IV bolus (max 25 mg)

B.Alteplase 0.6 mg/kg with 15% as bolus over 1 minute

C.Streptokinase 1.5 million units over 60 minutes

D.Reteplase 10 units double bolus 30 minutes apart

Explanation: The AHA/ASA 2024 update recommends tenecteplase 0.25 mg/kg as a single IV bolus (max 25 mg) as a reasonable alternative — and increasingly the preferred agent — for eligible adults within 4.5 hours of acute ischemic stroke onset, based on AcT (2022) showing non-inferiority to alteplase plus the operational advantages of a single bolus. Standard alteplase dosing is 0.9 mg/kg (10% bolus, remainder over 60 min), not 0.6 mg/kg.

2A patient receives IV alteplase for acute ischemic stroke. What is the recommended blood pressure target during and for 24 hours after thrombolysis?

A.<180/105 mmHg

B.<140/90 mmHg

C.<160/100 mmHg

D.<220/120 mmHg

Explanation: AHA/ASA recommends maintaining BP <180/105 mmHg during and for 24 hours after IV thrombolysis to minimize symptomatic intracerebral hemorrhage. Lowering pre-tPA BP to ≤185/110 is required before initiating thrombolysis. <140/90 is too aggressive in this setting and risks hypoperfusion of penumbral tissue.

3A 72-year-old presents 8 hours after last known well with NIHSS 18 from a left M1 occlusion. CT perfusion shows infarct core 18 mL and penumbra 90 mL. Per DAWN and DEFUSE 3, what is the most appropriate next step?

A.Mechanical thrombectomy

B.IV alteplase only

C.Aspirin and admit to neuro ICU

D.Decompressive hemicraniectomy

Explanation: DAWN (6-24 hr, clinical-core mismatch) and DEFUSE 3 (6-16 hr, perfusion-core mismatch with core ≤70 mL and mismatch ratio ≥1.8) extended mechanical thrombectomy windows for LVO with favorable imaging. This patient has a small core (18 mL) and large penumbra (90 mL, mismatch ratio 5) — a clear thrombectomy candidate even at 8 hours. IV alteplase is outside the 4.5-hour window. The HERMES meta-analysis showed NNT ~3 for functional independence with thrombectomy.

4Which NIHSS score is generally considered the threshold above which acute ischemic stroke is severe enough to warrant strong consideration of reperfusion therapy?

A.≥6

B.≥2

C.≥20

D.≥30

Explanation: The NIHSS (0-42) is the standard stroke severity scale. Scores <6 represent minor stroke (treatment decisions individualized), ≥6 is generally considered worth treating with reperfusion when otherwise eligible, and ≥16-21 represents severe stroke with high disability risk if untreated. NIHSS strongly correlates with infarct volume and outcome.

5Which ASPECTS score on non-contrast CT generally predicts a favorable outcome from mechanical thrombectomy in MCA territory stroke?

A.≥6

B.≥3

C.≤2

D.Exactly 5

Explanation: ASPECTS (Alberta Stroke Program Early CT Score) is a 10-point CT score for early ischemic changes in MCA territory; 1 point is subtracted for each affected region. ASPECTS ≥6 generally identifies patients likely to benefit from mechanical thrombectomy, while scores ≤5 suggest extensive established infarct with reduced benefit. Recent trials (RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT) suggest possible benefit even with ASPECTS 3-5, but ≥6 remains the high-confidence threshold.

6The HERMES collaboration meta-analysis of mechanical thrombectomy trials demonstrated which approximate number-needed-to-treat for functional independence (mRS 0-2) at 90 days?

A.~3

B.~30

C.~100

D.No benefit demonstrated

Explanation: HERMES (pooled analysis of MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, EXTEND-IA — 1287 patients) showed an absolute increase in functional independence at 90 days from 26.5% to 46.0% with mechanical thrombectomy plus standard care vs standard care alone, NNT ~3 (one of the largest treatment effects in modern medicine). Benefit was consistent across age, sex, and timing within the 0-6 hour window.

7A 60-year-old man develops acute ischemic stroke 3 hours after onset. NIHSS 9. He took apixaban 5 mg this morning. Which is the most appropriate decision regarding IV alteplase?

A.Withhold IV alteplase if last DOAC dose was within 48 hours and no specific reversal demonstrating absent anticoagulant effect

B.Give full-dose alteplase regardless because apixaban is short-acting

C.Give half-dose alteplase

D.Give tenecteplase but not alteplase

Explanation: AHA/ASA recommends against IV thrombolysis in patients on a direct oral anticoagulant who have taken a dose within the prior 48 hours, unless laboratory testing (e.g., calibrated anti-Xa, dabigatran ECT/dilute thrombin time) shows no clinically relevant anticoagulant effect or specific reversal has been demonstrated. The bleeding risk outweighs benefit. Mechanical thrombectomy remains a reasonable option.

8Which imaging modality is the most sensitive for detecting hyperacute (within 30 minutes) cerebral ischemia?

A.MRI diffusion-weighted imaging (DWI)

B.Non-contrast CT

C.CT perfusion mean transit time

D.T2-weighted MRI

Explanation: MRI DWI is the most sensitive sequence for hyperacute ischemia, detecting cytotoxic edema (restricted diffusion) within minutes of arterial occlusion — far before changes appear on non-contrast CT (which becomes sensitive at hours) or T2/FLAIR (which lag behind DWI by hours). CT perfusion identifies penumbra/core mismatch but DWI alone is the most sensitive single sequence for early ischemia.

9A 64-year-old undergoes successful mechanical thrombectomy for left M1 occlusion. NIHSS improved from 18 to 6. Six hours post-procedure, NIHSS is 22 and head CT shows new parenchymal hematoma. The most likely diagnosis is:

A.Symptomatic intracerebral hemorrhage (sICH)

B.Reperfusion seizure

C.Contrast staining mimicking hemorrhage

D.Recurrent embolic stroke

Explanation: Symptomatic intracerebral hemorrhage (sICH, defined as neurologic deterioration plus new hemorrhage on imaging) complicates ~5-7% of thrombolysis and ~2-7% of thrombectomy cases. The clinical picture (significant NIHSS worsening + parenchymal hematoma) defines sICH. Contrast staining is hyperdense on early post-thrombectomy CT but typically resolves on dual-energy CT or repeat imaging within 24 hours and lacks mass effect or hematoma morphology.

10A 75-year-old woman presents 12 hours after last known well with right hemiparesis and aphasia from left M1 occlusion. NIHSS 22, ASPECTS 8. CT perfusion shows core 25 mL, penumbra 110 mL. Per DAWN, which clinical-core mismatch criterion supports thrombectomy?

A.Age ≥80 with NIHSS ≥10 and core <21 mL; or age <80 with NIHSS ≥10 and core <31 mL; or age <80 with NIHSS ≥20 and core <51 mL

B.Any patient with NIHSS ≥4 within 24 hours regardless of core

C.Only patients with core 0 mL on perfusion imaging

D.Only patients with NIHSS ≤6

Explanation: DAWN inclusion criteria for 6-24 hr thrombectomy used clinical-core mismatch in three age/severity strata: (1) age ≥80 + NIHSS ≥10 + core <21 mL; (2) age <80 + NIHSS ≥10 + core <31 mL; (3) age <80 + NIHSS ≥20 + core <51 mL. This 75-year-old with NIHSS 22 and core 25 mL meets criteria. DEFUSE 3 used a different perfusion-core mismatch (≥1.8 ratio, mismatch volume ≥15 mL, core ≤70 mL).

About the ABIM Neurocritical Exam

The ABIM Neurocritical Care subspecialty certification is co-sponsored by ABA, ABEM, ABIM, ABNS, and ABPN — ABIM issues the credential for internal medicine diplomates. The exam covers acute ischemic stroke (alteplase 0-4.5 hrs, tenecteplase 0.25 mg/kg per AHA 2024 update, mechanical thrombectomy 0-24 hrs per DAWN/DEFUSE), intracerebral and subarachnoid hemorrhage with anticoagulant reversal (4F-PCC, idarucizumab, andexanet alfa per ANNEXA-I 2023), status epilepticus (ESETT 2019), TBI and elevated ICP (Brain Trauma Foundation 4th ed.), spinal cord and neuromuscular emergencies, brain death determination per AAN 2023, neuropharmacology, anoxic brain injury and post-arrest care (TTM2 2021), and multimodality monitoring. Eligibility requires active ABIM Internal Medicine + Critical Care Medicine certification plus a 1-year Neurocritical Care fellowship (or 2-year combined). The first ABIM administration was October 2021.

Questions

100 scored questions

Time Limit

8.5 hours (CBT)

Passing Score

Scaled by ABIM

Exam Fee

~$2,840 (American Board of Internal Medicine (ABIM))

ABIM Neurocritical Exam Content Outline

15%

Acute Ischemic Stroke

Alteplase 0-4.5 hrs (NINDS), tenecteplase 0.25 mg/kg single bolus per AHA 2024 + AcT 2022, post-tPA BP <180/105, hemorrhagic transformation; mechanical thrombectomy 0-6 hrs (HERMES NNT ~3, MR CLEAN), 6-24 hrs with imaging selection (DAWN, DEFUSE 3); NIHSS 0-42 cutoffs; ASPECTS ≥6

15%

Intracerebral & Subarachnoid Hemorrhage

ICH BP control SBP <140 (INTERACT-2, ATACH-2); reversal: 4F-PCC for warfarin, idarucizumab for dabigatran, andexanet alfa per ANNEXA-I 2023 for FXa inhibitors; cerebellar ICH >3 cm evacuation; SAH Hunt-Hess/WFNS/Modified Fisher, coiling vs clipping (ISAT), nimodipine 60 mg q4h x 21 d, EVD

10%

Status Epilepticus & EEG Monitoring

Convulsive SE = ≥5 min continuous seizure or ≥2 seizures without recovery; benzodiazepine first-line; ESETT 2019: fosphenytoin = levetiracetam = valproate equivalent for benzo-refractory; refractory and super-refractory definitions; cEEG ≥24-48 hrs for non-convulsive SE detection

15%

TBI & Cerebral Edema

Brain Trauma Foundation 4th ed. (2017): ICP >22 mmHg threshold, CPP 60-70 mmHg, hyperosmolar (3% saline bolus, mannitol 0.25-1 g/kg), hyperventilation only as bridge (PaCO2 30-35, avoid <25); DECRA + RESCUE-ICP for decompressive craniectomy; cytotoxic vs vasogenic vs interstitial edema

10%

Spinal Cord & Neuromuscular Emergencies

Neurogenic shock vs spinal shock; NASCIS II/III steroids controversial — most centers no longer use; MAP ≥85 mmHg x 7 days for SCI; GBS (ascending paralysis, areflexia, albuminocytologic dissociation, IVIG 0.4 g/kg/d x 5 or PLEX, FVC <20 mL/kg or NIF >-30); MG crisis (cholinergic vs myasthenic)

10%

Brain Death Determination & Organ Donation

AAN 2023 update: prerequisites (cause known, exclude reversible, T ≥36°C, SBP ≥100); brainstem reflex absence (pupillary, corneal, oculocephalic, vestibulo-ocular cold caloric, pharyngeal, tracheal cough); apnea test PaCO2 ≥60 or 20+ above baseline; ancillary studies only when exam unreliable; pediatric 2-exam protocol; UNOS, DBD vs DCD

10%

Neuropharmacology

Anticoagulant reversal: vitamin K + 4F-PCC for warfarin; idarucizumab/Praxbind for dabigatran; andexanet alfa/Andexxa per ANNEXA-I 2023 for apixaban/rivaroxaban; PCC off-label for FXa inhibitors; ICU sedation (propofol, dexmedetomidine, midazolam, ketamine); vasoactives in neuro-ICU

10%

Anoxic Brain Injury & Post-Cardiac Arrest

Targeted Temperature Management — TTM2 2021 showed 33°C = 36°C, ERC 2021 + AHA 2023 recommend TTM 32-36°C ≥24 hrs with fever avoidance; multimodal neuro-prognostication delayed ≥72 hrs after ROSC (clinical exam, EEG, SSEP N20 absence, NSE ≥60 ng/mL, neuroimaging)

Multimodality Monitoring & Neuroimaging

ICP (parenchymal vs EVD); CPP = MAP - ICP; PbtO2 ≥20 mmHg; SjvO2 55-75%; microdialysis lactate/pyruvate >40 anaerobic; TCD vasospasm Lindegaard ratio MCA/ICA >3 mild, >6 severe; CT for acute hemorrhage; MRI DWI hyperacute ischemia; CT/MR perfusion (penumbra vs core); DSA gold standard

How to Pass the ABIM Neurocritical Exam

What You Need to Know

Passing score: Scaled by ABIM
Exam length: 100 questions
Time limit: 8.5 hours (CBT)
Exam fee: ~$2,840

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ABIM Neurocritical Study Tips from Top Performers

1Memorize stroke reperfusion windows cold: alteplase 0-4.5 hrs (NINDS) with post-tPA BP <180/105; tenecteplase 0.25 mg/kg single bolus is now preferred over alteplase per the AHA 2024 update based on AcT 2022 and subsequent trials. Mechanical thrombectomy is standard 0-6 hrs for LVO (HERMES NNT ~3, MR CLEAN), and extended 6-24 hrs with imaging selection — DAWN uses clinical/core mismatch, DEFUSE 3 uses perfusion mismatch. Know NIHSS cutoffs (≥6 stroke worth treating, ≥16-21 severe) and ASPECTS ≥6 generally favorable for thrombectomy.

2For ICH, drive SBP to <140 mmHg per INTERACT-2 and ATACH-2 (avoid overshoot to <110-120 in ATACH-2). Reverse anticoagulants by drug class: 4F-PCC + vitamin K for warfarin, idarucizumab (Praxbind) for dabigatran, andexanet alfa (Andexxa) per ANNEXA-I 2023 for apixaban/rivaroxaban (superior to usual care for hematoma expansion but with thromboembolic risk; 4F-PCC remains an off-label alternative). Cerebellar ICH >3 cm or with brainstem compression needs neurosurgical evacuation.

3For SAH, use Hunt-Hess and WFNS for clinical grading and Modified Fisher for vasospasm risk. ISAT favored coiling over clipping for suitable aneurysms. Give nimodipine 60 mg PO q4h x 21 days for ALL aneurysmal SAH — it improves outcomes regardless of whether vasospasm develops. Replace 'triple H therapy' with euvolemia plus induced hypertension if vasospasm occurs. Place an EVD for acute hydrocephalus from intraventricular blood.

4For status epilepticus: ≥5 minutes of continuous seizure or ≥2 seizures without recovery is the modern definition. Lorazepam or IM midazolam first; per ESETT (2019), fosphenytoin, levetiracetam, and valproate are all equivalent for benzo-refractory SE. Place continuous EEG within 24-48 hrs in any persistently obtunded ICU patient — non-convulsive status is missed without it.

5Brain death determination per AAN 2023: confirm prerequisites (cause known, exclude reversible factors including drugs/sedation/paralytics/severe acidosis/hypothermia/hemodynamic instability; T ≥36°C; SBP ≥100 mmHg). Document coma plus absent brainstem reflexes (pupillary, corneal, oculocephalic, vestibulo-ocular cold caloric, pharyngeal, tracheal cough). Apnea test requires PaCO2 ≥60 mmHg or ≥20 above baseline. Use ancillary testing (EEG, cerebral angiography, TCD, nuclear scan) only when clinical exam or apnea test cannot be reliably completed.

Frequently Asked Questions

Who can take the ABIM Neurocritical Care subspecialty exam?

Candidates must hold active ABIM Internal Medicine certification AND active ABIM Critical Care Medicine subspecialty certification, plus satisfactory completion of a 1-year Neurocritical Care fellowship (or a 2-year combined Critical Care + Neurocritical Care fellowship). Physicians from anesthesiology, emergency medicine, neurosurgery, or neurology pursue the same Neurocritical Care credential through their parent boards (ABA, ABEM, ABNS, ABPN) under the co-sponsored ABMS pathway. A separate UCNS Neurocritical Care credential exists as an alternative pathway.

How is the ABIM Neurocritical Care exam structured?

The Neurocritical Care exam is approximately 100 single-best-answer multiple-choice questions delivered in an 8.5-hour computer-based testing day at Pearson VUE centers. Questions are case-based and emphasize current guidelines including the AHA/ASA stroke recommendations (with the 2024 tenecteplase update), Brain Trauma Foundation 4th edition, ESETT 2019 for status epilepticus, AAN 2023 brain death determination, TTM2 (2021), and ANNEXA-I 2023 for FXa inhibitor reversal.

When was the first ABIM Neurocritical Care administration?

The first ABIM administration of the Neurocritical Care subspecialty exam was in October 2021. The credential is co-sponsored by ABA, ABEM, ABIM, ABNS, and ABPN, with each Member Board administering the exam to its own diplomates under a shared content blueprint. Before this ABIM pathway opened, physicians earned Neurocritical Care certification through the United Council for Neurologic Subspecialties (UCNS), which remains an alternative pathway.

What is the passing score for the ABIM Neurocritical Care exam?

ABIM uses a criterion-referenced scaled passing score established through standard-setting methodology and reports results as pass/fail. The threshold is not publicly disclosed as a percentage. ABIM does not routinely publish first-time pass rates for the Neurocritical Care subspecialty given its relatively recent launch (October 2021) and small candidate volume.

How much does the ABIM Neurocritical Care exam cost?

The application fee plus exam fee is approximately $2,840 for initial certification. Costs are subject to change — always confirm directly on the ABIM website. Total preparation cost including the Neurocritical Care Society Practice Update, Continuum Neurocritical Care issues, a board review course, and a high-yield question bank typically ranges from $3,500 to $5,500.

How do I maintain ABIM Neurocritical Care certification?

ABIM Neurocritical Care diplomates maintain certification on a 10-year MOC cycle. ABIM offers the Longitudinal Knowledge Assessment (LKA) — an open-book quarterly question set — for many subspecialties, with the traditional 10-year recertification exam as an alternative. Diplomates must also complete MOC activity requirements and hold an unrestricted medical license.