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Key Facts: ABIM Neurocritical Exam

270

Exam Questions

ABPN

320 min

Scheduled Testing Time

ABPN

$2,995

Initial Certification Fee

ABIM 2026

Oct 2021

First ABIM Administration

ABIM

12 months

Accredited NCC Training Required

ABIM

MOC Program

Certification Maintained Through

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 270-question single-best-answer MCQ exam (five 54-question sections) delivered by ABPN in 320 scheduled minutes at Pearson VUE centers. The initial certification fee is $2,995. The credential is co-sponsored by ABA, ABEM, ABIM, ABNS, and ABPN, with ABPN administering one jointly developed exam to all five boards' candidates at the same time; ABIM issues it to candidates who were previously certified by ABIM in Critical Care Medicine and have completed 12 months of accredited Neurocritical Care fellowship training. The first administration was October 2021, and the exam is now offered every other year (next 2028). The blueprint's five official domains are Principles of Neurocritical Care (42-48%), Diagnostic Studies and Procedural Skills (13-17%), Neurocritical Care Diseases (27-33%), Neurosurgical and Perioperative Complications (3-7%), and Ethics, Research, and Practice-Based Learning (3-7%). Current-guideline anchors include the 2026 AHA/ASA stroke guideline (tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg, both Class 1, within 4.5 hours), the 2022 AHA/ASA ICH guideline (SBP target 140 within 130-150 mmHg for mild-to-moderate ICH presenting at SBP 150-220; cerebellar ICH ≥15 mL → immediate evacuation), 4F-PCC as the main US factor Xa-inhibitor reversal option (off-label; COR 2b) since Andexxa's US withdrawal, the 2023 AAN/AAP/CNS/SCCM brain death guideline (apnea test PaCO2 ≥60 and ≥20 above baseline, SBP ≥100 and MAP ≥75), the 2025 AHA post-cardiac-arrest temperature control statement (32-37.5°C for ≥36 hours), and the 2024 AO Spine/Praxis spinal cord injury MAP target (75-80 to 90-95 mmHg for 3-7 days). Certification is maintained through ABIM's MOC Program.

Sample ABIM Neurocritical Practice Questions

Try these sample questions to review concepts for the ABIM Neurocritical exam. Each question includes a detailed explanation. Start the interactive quiz above for the full 198+ 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 2026 AHA/ASA acute ischemic stroke guideline, which of these IV thrombolytic regimens is recommended?

A.Tenecteplase 0.25 mg/kg 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.Tenecteplase 0.4 mg/kg IV bolus (max 40 mg)

Explanation: The 2026 AHA/ASA guideline for early management of acute ischemic stroke (Prabhakaran et al., Stroke, published online 2026-01-26, doi 10.1161/STR.0000000000000513) gives tenecteplase 0.25 mg/kg as a single IV bolus (max 25 mg) a Class 1 recommendation, on equal footing with alteplase, for eligible adults within 4.5 hours of onset, citing practical advantages from 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: The 2026 AHA/ASA acute ischemic stroke guideline keeps BP <180/105 mmHg for the first 24 hours after IV thrombolysis (COR 1) to limit symptomatic intracerebral hemorrhage; BP must first be brought below 185/110 mmHg before the bolus is given. Intensive systolic lowering to <140 mmHg after IVT in mild-to-moderate stroke is not recommended (COR 3: No Benefit) because trials showed no functional gain.

3A 72-year-old presents 8 hours after last known well with NIHSS 18 from a left M1 occlusion. CT perfusion shows an ischemic core of 18 mL and a total hypoperfused (Tmax >6 s) volume of 90 mL. Per DAWN and DEFUSE 3, what is the most appropriate next step?

A.Mechanical thrombectomy for LVO with favorable imaging

B.IV alteplase alone as the reperfusion strategy

C.Aspirin and neuro ICU admission only

D.Decompressive hemicraniectomy first-line

Explanation: DAWN (6-24 h, clinical-core mismatch) and DEFUSE 3 (6-16 h; core <70 mL, mismatch ratio ≥1.8, mismatch volume ≥15 mL) established thrombectomy beyond 6 hours for anterior LVO with favorable imaging; the number needed to treat for functional independence was about 2.8 in DAWN and 3.6 in DEFUSE 3. Here the mismatch ratio is 90/18 = 5.0 and the mismatch volume is 90 - 18 = 72 mL, so he meets DEFUSE 3 criteria (and DAWN: age <80, NIHSS ≥10, core <31 mL). The 2026 AHA/ASA guideline gives EVT in the 6-24 hour window a Class 1 recommendation for ICA/M1 occlusion with NIHSS ≥6 and ASPECTS ≥6.

4Per the 2026 AHA/ASA acute ischemic stroke guideline, a patient with an ICA or M1 occlusion presenting within 6 hours (prestroke mRS 0-1, ASPECTS 3-10) has a Class 1 recommendation for thrombectomy when the NIHSS score is at least:

A.6

B.2

C.10

D.20

Explanation: Section 4.7.2 of the 2026 AHA/ASA guideline recommends EVT (COR 1, LOE A) for anterior-circulation ICA or M1 occlusion within 6 hours when NIHSS is ≥6, prestroke mRS is 0-1, and ASPECTS is 3-10. The NIHSS ≥10 threshold belongs to basilar artery occlusion (COR 1 with PC-ASPECTS ≥6; NIHSS 6-9 is COR 2b). IV thrombolysis, by contrast, is not tied to an NIHSS cutoff: disabling deficits are treated within 4.5 hours regardless of score.

5Per the 2026 AHA/ASA guideline, an 84-year-old with an M1 occlusion presents 10 hours after last known well (NIHSS 16, prestroke mRS 0, no significant mass effect). Thrombectomy carries a Class 1 recommendation if the ASPECTS is:

A.≥6

B.≥3

C.≥0, with no lower limit

D.≥8

Explanation: ASPECTS is a 10-point CT score in which a point is subtracted for each MCA-territory region with early ischemic change. In the 6-24 hour window, the 2026 AHA/ASA guideline recommends EVT for ICA/M1 occlusion with NIHSS ≥6, prestroke mRS 0-1, and ASPECTS ≥6 (COR 1, LOE A). Large-core trials (SELECT2, ANGEL-ASPECT) extended a Class 1 recommendation to ASPECTS 3-5 in this window only for patients younger than 80 without significant mass effect. Within 6 hours, ASPECTS 3-10 is Class 1 at any age, and ASPECTS 0-2 is COR 2a for selected patients under 80. For an 84-year-old at 10 hours, the Class 1 threshold is therefore ASPECTS ≥6.

6The HERMES individual-patient meta-analysis of five early thrombectomy trials reported approximately what number needed to treat to reduce disability by at least one modified Rankin Scale level at 90 days?

A.~2.6

B.~8

C.~14

D.No significant benefit over medical therapy

Explanation: HERMES (Goyal et al., Lancet 2016; 1,287 patients from MR CLEAN, ESCAPE, REVASCAT, SWIFT PRIME, and EXTEND-IA) found an adjusted common odds ratio of 2.49 for improvement on the mRS, giving an NNT of 2.6 to reduce disability by at least one level. Functional independence (mRS 0-2) rose from 26.5% to 46.0%, an absolute difference of 19.5% (NNT about 1/0.195 = 5). Symptomatic ICH and 90-day mortality did not differ between groups, and the benefit was consistent across subgroups.

7A 60-year-old man presents 3 hours after onset of an acute ischemic stroke with NIHSS 9. He took apixaban 5 mg 4 hours ago, and no drug-specific anti-Xa assay is available. Which is the most appropriate decision regarding IV thrombolysis?

A.Withhold IVT; obtain CTA and assess for thrombectomy

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

C.Give half-dose alteplase to offset bleeding risk

D.Give tenecteplase instead, as it is fibrin-specific

Explanation: Patients taking anticoagulants were excluded from the pivotal thrombolysis trials. The 2026 AHA/ASA guideline lists recent DOAC exposure (<48 hours) among relative contraindications (Table 8): the safety of IVT is unknown, and IVT may be considered only after an individualized benefit-risk analysis that weighs the timing of the last dose, renal function, stroke severity, availability of thrombectomy, and access to reversal agents and drug-specific anti-factor Xa or thrombin assays. Here apixaban was taken 4 hours ago (near peak effect), no calibrated anti-Xa assay can show negligible drug activity, and thrombectomy is an alternative if CTA shows a large vessel occlusion, so the balance favors withholding IVT and proceeding immediately to vascular imaging and thrombectomy evaluation.

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 alone

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

B.Reperfusion seizure

C.Contrast staining mimicking hemorrhage

D.Recurrent embolic stroke

Explanation: Symptomatic intracerebral hemorrhage (sICH) is neurologic deterioration attributable to new hemorrhage on imaging; depending on the definition used, it complicates roughly 2-7% of patients treated with thrombolysis or thrombectomy. A large NIHSS worsening with a new parenchymal hematoma defines sICH. Contrast staining can look hyperdense on early post-thrombectomy CT, but it lacks hematoma morphology and mass effect and typically clears on dual-energy CT or repeat imaging within about 24 hours.

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 NIHSS ≥10 core <21; or age <80 NIHSS ≥10 core <31

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 and any core size

Explanation: DAWN selected patients 6-24 hours from last known well using clinical-core mismatch in three strata: (A) age ≥80, NIHSS ≥10, core <21 mL; (B) age <80, NIHSS ≥10, core <31 mL; (C) age <80, NIHSS ≥20, core 31 to <51 mL. This 75-year-old with NIHSS 22 and a 25 mL core meets group B. DEFUSE 3 instead used perfusion mismatch (ratio ≥1.8, mismatch volume ≥15 mL, core <70 mL) in the 6-16 hour window.

About the ABIM Neurocritical Exam

The ABIM Neurocritical Care subspecialty certification is co-sponsored by ABA, ABEM, ABIM, ABNS, and ABPN — ABPN administers a single jointly developed exam to candidates from all five boards at the same time, and ABIM issues the credential for internal medicine diplomates. The exam covers acute ischemic stroke (2026 AHA/ASA: tenecteplase 0.25 mg/kg max 25 mg or alteplase 0.9 mg/kg max 90 mg, both Class 1, within 4.5 hours; extended thrombolysis/thrombectomy windows), intracerebral and subarachnoid hemorrhage (mild-to-moderate ICH target SBP 140 within 130-150 mmHg, cerebellar ICH ≥15 mL evacuation; reversal now mainly 4F-PCC (off-label; COR 2b) following Andexxa's 2025-12-22 US withdrawal), status epilepticus (ESETT 2019), TBI and elevated ICP (Brain Trauma Foundation 4th ed.), spinal cord and neuromuscular emergencies (2024 AO Spine/Praxis SCI MAP targets), brain death determination per AAN 2023, neuropharmacology, anoxic brain injury and post-arrest temperature control (2025 AHA), and multimodality monitoring. Eligibility requires prior ABIM certification in Critical Care Medicine plus 12 months of accredited Neurocritical Care fellowship training. The first ABIM administration was October 2021.

Exam sponsor: ABPN administers the jointly developed exam; ABIM registers internists and issues the certificate. The requirements and fees below concern the certification or admission exam, separate from our free practice resources.

Questions

270 questions

Time Limit

320 minutes scheduled (310 minutes for 270 questions plus 10 minutes for the NDA/tutorial and survey), plus up to 40 minutes of optional pooled breaks

Passing Score

Scaled by ABPN

Exam / Certification Fees

$2,995 (+$400 late registration; +$500 international test center)

Exam sponsor website

Fees, eligibility, and exam policies can change. Confirm them with the exam sponsor before applying or paying.

Official sources

Our practice resources: topics covered

We aim to reflect publicly available exam outlines and topic information in our study resources. Coverage, format, and difficulty may differ from the actual exam, and we cannot guarantee that every detail is accurate or current. Confirm exam requirements, fees, and policies with the official exam sponsor.

42-48%

Principles of Neurocritical Care

Neuro-ICU exam and cerebral physiology, CSF physiology, and neuropharmacology (osmotherapy per NCS 2020 osmolar-gap guidance, sedation/analgesia, antiseizure loading, anticoagulant reversal - 4F-PCC the main US option for FXa-inhibitor bleeds (off-label; COR 2b) since Andexxa's 2025-12-22 US withdrawal). Airway/mechanical ventilation, hemodynamic support (IABP/VAD/ECMO), shock, nutrition, temperature control, ICU prophylaxis, general trauma, and organ-system complications (pulmonary, cardiovascular, renal, infectious, endocrine incl. DI/SIADH/cerebral salt wasting, GI, hematologic)

13-17%

Diagnostic Studies and Procedural Skills

Neuroimaging, EEG, ICP monitoring, transcranial Doppler, multimodality/PbtO2 monitoring, EMG, CSF analysis, vascular access, thoracic/lung ultrasound. Brain death determination per 2023 AAN/AAP/CNS/SCCM: prerequisites (T ≥36°C, SBP ≥100 AND MAP ≥75 mmHg); apnea test (no respiratory effort, pH <7.30, PaCO2 ≥60 AND ≥20 above baseline; abort for SBP <100, MAP <75, or SpO2 <85%)

27-33%

Neurocritical Care Diseases

Coma/anoxic brain injury and post-cardiac-arrest temperature control (32-37.5°C ≥36 hrs, 2025 AHA); intracranial hypertension (BTF: ICP >22, CPP 60-70); acute ischemic stroke (2026 AHA/ASA: tenecteplase 0.25 mg/kg max 25 mg or alteplase 0.9 mg/kg max 90 mg, both Class 1); ICH (mild-to-moderate, SBP 150-220: target 140 within 130-150 mmHg, <130 potentially harmful; cerebellar ICH ≥15 mL → immediate evacuation; 4F-PCC as the main US reversal option (COR 2b)) and SAH (grading, nimodipine, avoid fluid restriction); spinal cord injury (2024 AO Spine/Praxis MAP 75-80 to 90-95 mmHg x3-7d); status epilepticus; acute neuromuscular emergencies; CNS infections

3-7%

Neurosurgical and Perioperative Complications

Post-neurosurgical seizures, pneumocephalus, hemorrhage, ischemia, infections, CSF leak, complications of EVD and lumbar drains, hyperperfusion syndrome

3-7%

Ethics, Research, and Practice-Based Learning

Communication with families and conflict resolution, advance directives and DNR orders, uncertainties of prognostication and the self-fulfilling prophecy, palliative and end-of-life care, withdrawal/withholding of care, futility, determining decision-makers, donation after cardiac death, care of the organ donor

Preparing for the ABIM Neurocritical Exam

What You Need to Know

Passing score: Scaled by ABPN
Exam length: 270 questions
Time limit: 320 minutes scheduled (310 minutes for 270 questions plus 10 minutes for the NDA/tutorial and survey), plus up to 40 minutes of optional pooled breaks
Exam / certification fees: $2,995 (+$400 late registration; +$500 international test center) Official sources

Using Our Practice Resources

Work through all 198 available questions
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ABIM Neurocritical: Suggested Study Strategy

1Memorize stroke reperfusion per the 2026 AHA/ASA guideline: tenecteplase 0.25 mg/kg single bolus (max 25 mg) or alteplase 0.9 mg/kg (max 90 mg, 10% bolus + 60-min infusion) are both Class 1 options within 4.5 hours. Extended thrombolysis and thrombectomy windows use imaging selection. After reperfusion, avoid reflexively lowering BP below 140 systolic — the guideline finds no benefit after thrombolysis and harm after successful thrombectomy.

2For mild-to-moderate ICH presenting with SBP 150-220 mmHg, target SBP 140 mmHg within a 130-150 mmHg range (2022 AHA/ASA, COR 2b); lowering below 130 is potentially harmful (COR 3: Harm), and intensive lowering is not established for large or severe ICH. Reverse anticoagulants by drug class: 4F-PCC + vitamin K for warfarin, idarucizumab (Praxbind) for dabigatran, and 4F-PCC for factor Xa inhibitors — andexanet alfa (Andexxa) is no longer available in the US after its 2025-12-22 withdrawal, after FDA judged its thromboembolic risks outweighed its benefits (ANNEXA-I, NEJM 2024). Cerebellar ICH ≥15 mL, or with deterioration/brainstem compression/hydrocephalus, needs immediate evacuation.

3For SAH, use Hunt-Hess, WFNS, and Modified Fisher for grading. Give nimodipine 60 mg PO q4h x 21 days for all aneurysmal SAH. Maintain euvolemia and avoid fluid restriction regardless of whether hyponatremia is from SIADH or cerebral salt wasting — restricting fluids raises delayed cerebral ischemia risk either way.

4For status epilepticus: ≥5 minutes of continuous seizure, or ≥2 seizures without recovery, is the modern definition. First-line benzodiazepines (AES 2016): IM midazolam, IV lorazepam, or IV diazepam. Per ESETT (2019), fosphenytoin, levetiracetam, and valproate are equivalent for benzodiazepine-refractory SE.

5Brain death determination per 2023 AAN/AAP/CNS/SCCM: confirm prerequisites (T ≥36°C; SBP ≥100 mmHg AND MAP ≥75 mmHg; exclude reversible causes). Document coma plus absent brainstem reflexes. The apnea test is consistent with brain death if there is no respiratory effort, pH <7.30, and PaCO2 ≥60 mmHg AND ≥20 mmHg above baseline; abort for SBP <100, MAP <75, or SpO2 <85%.

Frequently Asked Questions

Who can take the ABIM Neurocritical Care subspecialty exam?

Candidates must have been previously certified by ABIM in Critical Care Medicine, plus satisfactory completion of 12 months of accredited Neurocritical Care fellowship training (ACGME-accredited if started on/after July 1, 2026; earlier training must be affiliated with a UCNS- or CAST-accredited program). 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 270 one-best-answer multiple-choice questions in five 54-question sections, per ABPN's Content Specifications and Format and Scoring documents. Scheduled testing time is 320 minutes (310 minutes for the questions plus 10 minutes for the nondisclosure agreement/tutorial and end-of-exam survey), with up to 40 additional minutes of optional pooled break time. Questions are case-based and emphasize current guidelines.

When was the first ABIM Neurocritical Care administration, and how is the exam delivered?

The Neurocritical Care Certification Examination is jointly developed by ABA, ABEM, ABIM, ABNS, and ABPN. ABPN administers one exam to candidates from all five boards at the same time, in the same Pearson VUE testing centers. The first administration was October 2021; it is now offered every other year (2022, 2024, 2026; next 2028). Before this 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?

ABPN sets a criterion-referenced standard score through an established process; results are reported pass/fail without a fixed norm-referenced rate. ABPN publishes first-time pass rates for its own examinees: 91% (2021), 94% (2022), and 96% (2024). A separate ABPN-authored report on the first (2021) administration across all five boards found an overall pass rate of 72.7% among 1,011 candidates (Lewis et al., 2022).

How much does the ABIM Neurocritical Care exam cost?

ABIM's current Exam Fees & Refund Policies page lists $2,995 for Neurocritical Care initial certification. A $400 late-registration fee and $500 international test-center fee can apply. 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 through ABIM's Maintenance of Certification (MOC) Program requirements, which include an unrestricted medical license and completion of ABIM's ongoing MOC activities.

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