Neurocritical Care
Answer: C
Answer C is correct because midazolam (together with
lorazepam) is recommended by the status epilepticus
guidelines. Answers A, B, and D are incorrect because
phenytoin is less effective than lorazepam as the initial
agent. Although valproic acid and levetiracetam have
not been formally compared with lorazepam as the ini-
tial agent for status epilepticus, their use is supported by
less clinically rigorous evidence.
Answer B is correct because clinical evidence supports
the safety and efficacy of osmotherapy as a first-line
therapy in this situation. Hypertonic saline would be
more appropriate than mannitol because of the patientβs
relatively low serum sodium concentration and elevated
SCr (mannitol is cleared renally and is thus not optimal
for patients with renal dysfunction, making Answer A
incorrect). Answers C and D (pentobarbital and mid-
azolam) are not ideal for this patient because of the
likelihood of hypotension.
Answer: B
Answer B is correct because warfarin is well reversed by
4F-PCC products in a much more timely and complete
manner than vitamin K in the acute setting. Answer A is
incorrect; although blood pressure control is important
for this patient, amlodipine is unlikely to have timely
effects immediately after ICH. Answer C is incorrect
because platelets are minimally effective for reversing
ibuprofen. Answer D is incorrect; rFVIIa is not recom-
mended for reversal of warfarin because of thrombosis
risks.
Answer: B
Answer B is correct because nicardipine is recommended
for reducing blood pressure after ICH, and the threshold
for treatment is correct according to the INTERACT-2
and ATACH-2 studies. Answer A is incorrect; although
clevidipine may be considered in this case, the typical
goal blood pressure target after ICH is a SBP 140-150
mm Hg. Answers C and D are incorrect; although labet-
alol and esmolol also reduce blood pressure, the optimal
SBP goal after ICH 140-150 mm Hg.
Answer: A
Answer A is correct because nimodipine is the only agent
with an FDA indication for preventing ischemic compli-
cations related to SAH. Answer B is incorrect because
prophylactic Triple-H therapy or variants thereof do not
prevent ischemic complications; rather, hyperperfusion
therapies are used when vasospasm develops. Answer
C is incorrect because in clinical trials, the efficacy of
statins for preventing vasospasm has failed. Answer
D is incorrect because aminocaproic acid may in fact
increase the risk of stroke in patients with SAH.
Answer: A
Answer A is correct because induction of hypertension
with a vasopressor such as norepinephrine appears to
improve cerebral perfusion. Titrating the infusion to
MAP values that result in improved neurologic symp-
toms is often necessary. Answer B is incorrect because
data analyses are limited to support transfusing blood
to a high hemoglobin (in fact, blood transfusion appears
to be a risk factor for vasospasm). In addition, fluid
resuscitation to hypervolemic levels is not beneficial.
Answer C is incorrect because when hypervolemia is
compared with euvolemia, neurologic outcomes are no
different, but patients receiving hypervolemia develop
more pulmonary edema. Answer D is incorrect because
milrinone is not first-line therapy for vasospasm.
Answer: B
Answer B is correct because the anti-Xa activity concen-
tration is the laboratory value that best correlates with
rivaroxaban activity. Answers A and C are incorrect
because neither INR nor activated partial thrombo-
plastin time is typically affected by rivaroxaban alone.
Answer D is incorrect because the VerifyNow PRU test
measurement is more specific to antiplatelet agents such
as aspirin or clopidogrel.
Answer: A
Answer A is correct because the most consistent reversal
effects, although with low-quality evidence, occur with
4F-PCCs. Answer B is incorrect because the appropriate
bolus dose of andexanet would be 400 mg followed by
a 2-hour continuous infusion, given the dose and time
of the last dose. In addition, available data are currently
limited regarding the periprocedural use of andexanet.
Answer C is incorrect because fresh frozen plasma does
not reverse factor Xa inhibitors reliably. Answer D is
incorrect; although factor VII may have some useful-
ness, reversal is incomplete, and factor VII is associated
with an increased risk of thrombosis.