Neurocritical Care

Answer: B

Answer B is correct because sodium supplementation

is effective for treating hypovolemic and euvolemic

hyponatremia. Although inducing hypervolemia is no

longer advocated, ensuring euvolemia is important.

Answers A and C are incorrect because water restric-

tion or tolvaptan is undesirable in a patient who is 4 days

after ictus for SAH because of the importance of main-

taining adequate cerebral perfusion. Hyponatremia may

be harmful in a patient with a new stroke such as SAH

caused by cerebral edema, making Answer D incorrect.

Answer A is correct because vancomycin effectively

covers MRSE, and the intraventricular dose of 10 mg

daily is appropriate. Answer B is incorrect because gen-

tamicin is less likely to be effective alone for MRSE and

is more associated with seizures than other aminoglyco-

sides. Answer C is incorrect because ampicillin (or other

penicillins) should not be given by the intraventricular

route, given the risk of seizures. Answer D is incorrect

because this patient has a treatment-refractory, device-

related CNS infection. In this instance, intraventricular

antimicrobials may be considered.

Answer: B

Answer B is correct; although the optimal CPP varies

with each individual, the typical recommended target

range is 60–70 mm Hg. Patients with a TBI have gas-

tric intolerance but benefit greatly from early enteral

nutrition, making Answer A incorrect. Answer C is

incorrect because dextrose-containing fluids may

increase cerebral edema in TBI and lower the serum

sodium concentration. Answer D is incorrect because

high-dose methylprednisolone therapy increases mor-

tality in patients with a TBI.

Answer: B

Answer B is correct because this patient meets the

criteria for receiving alteplase and has no obvious

contraindications. The more timely the alteplase admin-

istration, the more likely the patient will benefit (and the

less risk). Answer A is incorrect because aspirin should

be initiated within the first 24–48 hours after stroke,

but not necessarily immediately. Answer C is incor-

rect because the blood pressure may be slightly elevated

(SBP less than 185 mm Hg, DBP less than 110 mm Hg)

before alteplase administration or immediately after

stroke in general (so-called permissive hypertension

to ensure adequate cerebral perfusion). Nicardipine is

not necessary for this patient at this point. Answer D is

incorrect because reversal of warfarin with vitamin K is

not recommended for an acute thrombosis in the brain.

Answer: C

Answer C is correct; the current guidelines do not recom-

mend high-dose methylprednisolone therapy because of

the inconsistency in beneficial effects and the relatively

consistent risk of adverse effects (GI bleeding, infection)

shown in clinical trials. Answer B is incorrect because

high-dose methylprednisolone does not augment spinal

perfusion. Answers A and D are incorrect; although the

NASCIS-III study showed some potential benefit for

patients who received a bolus and a 47-hour infusion

when high-dose methylprednisolone therapy was initi-

ated 3–8 hours after injury, particularly for incomplete

injuries, the therapy is no longer recommended.

Answer: A

Answer A is correct; of the agents listed, buspirone is

the only one that increases CNS serotonin concentra-

tions. Answers B–D would not be expected to increase

CNS serotonin concentrations. Cyproheptadine is a

potential therapeutic agent for patients with serotonin

syndrome.

Answer: B

Answer B is correct; given this patient’s change in neu-

rologic status, vital signs, and monitoring values, she is

likely having a cerebral vasospasm with increased ICP.

Therapy should be targeted at optimizing cerebral per-

fusion (fluid bolus or increase in MAP) and reducing

ICP. Hypertonic saline will address both issues, causing

an increase in intravascular volume to improve perfu-

sion and possibly an increase in blood pressure while

lowering ICP through osmotic effects. Answer A is

incorrect because verapamil must be given superselec-

tively in the angiography suite. One possible adverse

effect of verapamil is cerebral vasodilation, which could

lead to increased ICP, and ICP would be undesirable in

this patient right now. Answer C is incorrect; although

mannitol may decrease ICP, it also causes diuresis,