100+ Free ABPN Neurocritical Care Practice Questions

Cerebrovascular Emergencies (Ischemic & Hemorrhagic Stroke)

Acute ischemic stroke — IV alteplase 0-4.5 h (0.9 mg/kg max 90 mg; 10% bolus then 90% over 60 min), tenecteplase 0.25 mg/kg, large vessel occlusion thrombectomy DAWN (6-24 h, clinical-core mismatch) and DEFUSE-3 (6-16 h, perfusion mismatch), SELECT2/RESCUE-Japan LIMIT/ANGEL-ASPECT large core 2023, basilar occlusion (ATTENTION/BAOCHE 2023). Malignant MCA infarction with midline shift → decompressive hemicraniectomy <48 h (DESTINY/HAMLET/DECIMAL pooled). Spontaneous ICH — INTERACT-2 SBP <140 within 6 h, ICH Score, anticoagulant reversal (4F-PCC + vit K for warfarin, idarucizumab for dabigatran, andexanet alfa for Xa inhibitors). Cerebellar ICH >3 cm with brainstem compression or hydrocephalus → suboccipital craniectomy and EVD.

Aneurysmal Subarachnoid Hemorrhage & DCI

Hunt-Hess 1-5 and modified Fisher 1-4 grading, CTA/DSA for aneurysm characterization, early aneurysm securement <72 h by coiling vs clipping (ISAT 2002 — coiling better at 1 yr in amenable lesions, durable at long-term follow-up). Nimodipine 60 mg PO q4h × 21 days for DCI prevention (works via neuroprotection, NOT prevention of angiographic vasospasm). TCD monitoring — mean MCA velocity >120 cm/s suspicious, >200 cm/s severe; Lindegaard ratio MCA/ICA >3 distinguishes vasospasm from hyperemia. Vasospasm peaks days 4-14; treatment of symptomatic DCI with permissive/induced hypertension (triple-H abandoned), intra-arterial vasodilators (verapamil, nicardipine), balloon angioplasty. EVD for acute hydrocephalus. Hyponatremia from cerebral salt wasting (hypovolemic — give salt) vs SIADH (euvolemic — restrict fluids).

Traumatic Brain Injury & ICP/CPP Management

Brain Trauma Foundation 4th edition — treat ICP >22 mm Hg, CPP target 60-70 mm Hg (avoid CPP <60 worsening ischemia or >70 with vasopressors causing ARDS). Severe TBI GCS ≤8 with abnormal CT requires invasive ICP monitoring (intraparenchymal Camino/Codman or EVD permitting CSF drainage). Tiered ICP management — head of bed 30°, normothermia, deep sedation/analgesia, hyperosmolar therapy (3% saline 250 mL bolus or mannitol 0.25-1 g/kg, monitor serum osm <320 and osm gap <20), CSF drainage, brief hyperventilation to PaCO2 30-35 only as bridging measure, decompressive craniectomy as Tier 3 (RESCUEicp 2016 — 6-month mortality benefit but more vegetative survival; DECRA 2011 negative for early bifrontal craniectomy). Avoid hypotonic fluids and steroids (CRASH 2004 — steroids worsen TBI mortality).

Status Epilepticus & Continuous EEG Monitoring

NCS staged algorithm — Stage 1 (0-5 min) IV lorazepam 0.1 mg/kg up to 4 mg or IM midazolam 10 mg if no IV (RAMPART). Stage 2 (5-20 min, established SE) IV fosphenytoin 20 mg PE/kg, levetiracetam 60 mg/kg up to 4500 mg, or valproate 40 mg/kg up to 3000 mg — ESETT 2019 showed all three approximately equipotent (~46% efficacy at 60 min). Stage 3 (refractory SE >20-40 min) — continuous infusion midazolam (0.2 mg/kg load then 0.05-2 mg/kg/h), propofol (watch PRIS at >4 mg/kg/h or >48 h — metabolic acidosis, lactate >5, rhabdomyolysis, triglycerides >500), or pentobarbital titrated by continuous EEG to seizure suppression or burst suppression. Super-refractory SE (>24 h) — ketamine, inhaled anesthetics (isoflurane), hypothermia, and immunotherapy if NORSE/FIRES suspected. Nonconvulsive SE on cEEG diagnosed by Salzburg criteria.

Brain Death Determination

AAN/AAP 2023 pediatric and adult brain death/death by neurologic criteria consensus update. Prerequisites — irreversible catastrophic brain injury with established etiology, no confounders (core temp ≥36 °C, SBP ≥100 mm Hg, no sedatives/paralytics/severe metabolic or endocrine derangement). Clinical examination — coma, absent brainstem reflexes (pupillary, corneal, oculocephalic, oculovestibular cold caloric, gag, cough), no motor response except spinal reflexes. Apnea test — preoxygenate FiO2 100%, disconnect ventilator with passive O2, target PaCO2 ≥60 mm Hg or ≥20 mm Hg above baseline with no respiratory effort (8-10 min). Ancillary testing (cerebral angiography is gold standard, nuclear perfusion, TCD, EEG) only if exam or apnea cannot be completed. 2023 update: one exam suffices in adults; pediatrics still requires two exams with age-based interval (24 h for term newborn-30 d; 12 h for 30 d-18 y).

Post-Cardiac Arrest Care & Neuroprognostication

Targeted temperature management — TTM2 trial (2021) showed normothermia (37.5 °C) non-inferior to hypothermia (33 °C) in shockable OHCA at 6 months. Current AHA 2020 still recommends TTM 32-36 °C × 24 h with strict fever avoidance after rewarming. Multimodal neuroprognostication ≥72 h after ROSC (or ≥72 h after rewarming for hypothermia) — bilaterally absent N20 SSEP, absent pupillary/corneal reflexes at 72 h, status myoclonus within 72 h, NSE >60 mcg/L at 48-72 h, malignant EEG (suppression, burst-suppression with identical bursts, nonconvulsive SE on flat background), diffuse cortical or deep gray DWI restriction, loss of gray-white differentiation on CT. Avoid prognostication <72 h or with confounders (sedation, hypothermia, paralytics, hepatic/renal failure).

Neuromuscular Respiratory Failure

Myasthenic crisis — bulbar weakness, dyspnea, FVC <15-20 mL/kg or NIF less negative than -30 cm H2O triggers intubation (single breath count <20 also predicts). Treat with IVIG 2 g/kg over 5 days or plasma exchange 5 sessions; bridge with high-dose corticosteroids cautiously (transient steroid-induced worsening day 5-10). Cholinesterase inhibitors withheld during mechanical ventilation to reduce secretions. GBS (AIDP) — ascending areflexic weakness preceded by GI/respiratory infection; albuminocytologic dissociation on LP. Treat with IVIG 2 g/kg over 5 days OR plasma exchange (steroids NOT effective in GBS). Intubate by 20/30/40 rule — FVC <20 mL/kg, NIF less negative than -30, or peak expiratory pressure <40. Autonomic dysfunction (BP swings, arrhythmia, ileus) requires telemetry.

Multimodal Neuromonitoring

ICP monitoring — intraparenchymal probes (Camino, Codman) provide continuous ICP but cannot drain CSF; ventriculostomy/EVD allows therapeutic CSF drainage and zeroing but higher infection rate. Brain tissue oxygen (PbtO2 Licox/Neurovent) goal >20 mm Hg; BOOST-3 trial 2024 evaluating PbtO2-targeted vs ICP-only therapy in severe TBI. Cerebral microdialysis — lactate/pyruvate ratio >40 indicates anaerobic metabolism/ischemia or mitochondrial dysfunction; glucose <0.7 mM indicates substrate deficit. Continuous EEG (cEEG) in SAH (DCI detection by alpha-delta ratio), TBI, ICH, and post-arrest patients (high yield for nonconvulsive seizures ~10-30%). NIRS (regional cerebral oxygenation) limited by extracranial contamination. Transcranial Doppler for vasospasm and microembolic signal detection.

Sedation, Analgesia & Pharmacology in NeuroICU

Light sedation preferred to allow neurologic exam (analgesia first per ABCDEF bundle). Fentanyl 25-100 mcg/h infusion for analgesia. Propofol 5-50 mcg/kg/min — watch for propofol infusion syndrome (PRIS) at doses >4 mg/kg/h beyond 48 h: metabolic acidosis, lactate >5, rhabdomyolysis, triglycerides >500, cardiac failure. Dexmedetomidine 0.2-1.5 mcg/kg/h — alpha-2 agonist with no respiratory depression, useful for ventilator weaning and reducing delirium (MENDS, SEDCOM). Avoid benzodiazepine infusions (associated with delirium and ICU-acquired weakness — PAD/PADIS guidelines). Ketamine increasingly used for refractory SE and analgesia (no longer contraindicated for elevated ICP per current evidence). VTE prophylaxis with mechanical IPC then LMWH 24-48 h after stable ICH/SAH/TBI per consensus.

Neurosurgical & Spinal Cord Emergencies

Decompressive hemicraniectomy for malignant MCA infarction <48 h (DESTINY 2007, HAMLET 2009, DECIMAL — pooled NNT 2 for survival, NNT 4 for mRS ≤4; age <60 strongest benefit). Cerebellar ICH or infarct >3 cm with brainstem compression or 4th ventricle obstruction → suboccipital craniectomy and EVD. Acute hydrocephalus → EVD. Cervical spinal cord injury — MAP goal 85-90 mm Hg × 7 days (2013 AANS/CNS guidelines), early surgical decompression <24 h supported by STASCIS, high-dose methylprednisolone NOT recommended (NASCIS reanalyzed — lacks benefit and increases harm). Acute spinal epidural abscess or hematoma — emergent decompression. Spinal shock with neurogenic shock requires vasopressors (norepinephrine first-line for both alpha and beta) and atropine for symptomatic bradycardia.

NeuroICU Systemic & Other Topics

Cerebral salt wasting (hypovolemic hyponatremia, true volume depletion — treat with isotonic/hypertonic saline and fludrocortisone) vs SIADH (euvolemic — fluid restriction or salt tabs). Central diabetes insipidus after pituitary surgery, brain death progression, severe TBI (treat with desmopressin/DDAVP, replace urine output, monitor serum sodium). Sodium correction limit — chronic hyponatremia <8-10 mEq/L per 24 h to avoid osmotic demyelination (formerly central pontine myelinolysis). Paroxysmal sympathetic hyperactivity post-TBI (gabapentin, propranolol, clonidine, opioids). Neurogenic pulmonary edema and stunned myocardium (Takotsubo) post-SAH. Anti-NMDA receptor encephalitis (ovarian teratoma in young women) and other autoimmune causes of refractory SE — first-line steroids/IVIG/PLEX, second-line rituximab/cyclophosphamide.