Neurologic Emergencies

Question 1

Normally, ___ accounts for up to 85% of the contents of the cranial vault

Answer 1

Brain parenchyma

Question 2

CSF pH that can produce cerebral ischemia

Answer 2

Increase in pH

Question 3

Hallmark of severe TBI

Answer 3

Coma (GCS 3-8)

Question 4

GCS indicating moderate TBI

Answer 4

9-12

Question 5

In TBI, ICP should be maintained at

Answer 5

<20mmHg

Question 6

Reasonable indications for CT imaging in TBI

Answer 6

LOC or amnesia >5 min, persistent dizziness, mental status changes, focal neurologic defects, depressed skull fracture, signs of a basilar skull fracture, drug or alcohol use, age <2, suspected child abbuse, falls from >3m, high speed injuries

Question 7

MCC of death from TBI in infants

Answer 7

Abusive head trauma

Question 8

Leading cause of hypoxic-ischemic insults leading to HIE in infants and children

Answer 8

Asphyxia arrest

Question 9

These define the need for neuroprotective interventions in perinatal asphyxia (3) e.g. therapeutic hypothermia

Answer 9

1) Fetal acidosis 2) 5-min APGAR of 0-3 3) Neurologic dysfunction and/or abnormal EEG findings

Question 10

First goal in HIE

Answer 10

Optimize cardiac output and cerebral perfusion

Question 11

Seizure of sufficient duration to provide an enduring epileptic focus

Answer 11

Status ep

Question 12

Diagnosis of status ep is made with

Answer 12

EEG

Question 13

Development of epilepsy after status ep occurs in up to ___% of children

Answer 13

30

Question 14

Predominant causes of ischemic stroke in children responsibble for ~50% of strokes after the neonatal period

Answer 14

1) Sickle cell disease 2) Heart disease

Question 15

Ischemic strokes in children are generally the result of

Answer 15

Damage to the intima of cerebral arteries which can form a thrombotic nidus

Question 16

Predominant presentation of children with stroke

Answer 16

Abrupt onset of focal neurologic deficits

Question 17

Predominant presentation of children with intracerebral hemorrhage

Answer 17

Coma

Question 18

Major complication of stroke

Answer 18

Hemorrhagic transformation

Question 19

Major complication of aneurysmal SAH

Answer 19

Vasospasm

Question 20

The only approved acute therapy for stroke

Answer 20

rTPA within 3 hours IV or within 6 hours intrarterially into the occlusion

Question 21

Guidelines for the management of pediatric stroke

Answer 21

1) ICP monitoring 2) RBC exchange/transfusion therapy for children with sickle cell disease 3) Anticoagulation and/or thrombolytics IF ICP MANAGEMENT IS NOT WARRANTED 4) Continuous EEG monitoring for children with tracheal intubation 5) Thrombolytics for children with cerebral venous sinus thrombosis

Question 22

Herniation syndromes: Supratentorial to infratentorial

Answer 22

Transtentorial or uncal

Question 23

Herniation syndromes: Increased ICP in one hemisphere

Answer 23

Subfalcine

Question 24

Herniation syndromes: Cerebellar mass or edema

Answer 24

Foramen magnum

Question 25

Herniation syndromes: Compression of the cerebral peduncles

Answer 25

Transtentorial or uncal

Question 26

Herniation syndromes: Compression of the anterior cerebral artery

Answer 26

Subfalcine

Question 27

Herniation syndromes: Compression of the midbrain

Answer 27

Transtentorial/uncal

Question 28

Herniation syndromes: Compression of the cerebellar tonsils

Answer 28

Foramen magnum

Question 29

Herniation syndromes: Compression of CN III

Answer 29

Transtentorial/uncal

Question 30

Herniation syndromes: Compression of the posterior circulation

Answer 30

Transtentorial/uncal

Question 31

Herniation syndromes: Compression of the medulla oblongata

Answer 31

Foramen magnum

Question 32

Herniation syndromes: Dilated ipsilateral pupil

Answer 32

Transtentorial/uncal

Question 33

Herniation syndromes: Hemiparesis

Answer 33

Transtentorial/uncal

Question 34

Herniation syndromes: Bladder incontinence

Answer 34

Subfalcine

Question 35

Herniation syndromes: Bradycardia, bradypnea, htn, death

Answer 35

Foramen magnum

Question 36

Herniation syndromes: Hemiparesis

Answer 36

Transtentorial/uncal

Question 37

Herniation syndromes: Cushing triad

Answer 37

Transtentorial/uncal

Question 38

Herniation syndromes: Decerebrate posturing

Answer 38

Transtentorial/uncal

Question 39

In children, brain death most commonly follows

Answer 39

TBI or asphyxia

Question 40

Standard for diagnosis of brain death

Answer 40

Repeat clinical exam (it is a CLINICAL DIAGNOSIS)

Question 41

3 key components of clinical brain death

Answer 41

1) Irreversible coma/unresponsiveness 2) Absence of brainstem reflexes 3) Apnea

Question 42

Extension of the upper extremities followed by flexion of the arms with the hands reaching to midsternal level

Answer 42

Lazarus sign

Question 43

What does the apnea test assess

Answer 43

Function of the medulla in driving ventilation

Question 44

How do you do the apnea test

Answer 44

Preoxygenate with 100% O2 ~10mins > adjust ventilation to achieve pCO2 of about 40 > CPAP > assess for breathing efforts through observation and auscultation > ABG 10 mins into the test and every 5 mins thereafter until target pCO2 is surpassed

Question 45

Positive apnea test

Answer 45

Absence of respiratory efforts with pCO2 >60 or more than 20 from baseline

Question 46

To establish diagnosis of brain death, findings must remain consistent over a period of observation: For 7 days to 2 mos

Answer 46

2 exams separated by at least 48 hours

Question 47

To establish diagnosis of brain death, findings must remain consistent over a period of observation: For 2 mos to 1 year

Answer 47

2 exams separated by at least 24 hours

Question 48

To establish diagnosis of brain death, findings must remain consistent over a period of observation: Older than 1 y/o

Answer 48

2 exams separated by at least 12 hours

Question 49

Confirmatory testing of brain death should be performed on what population

Answer 49

All children <1 y/o

Question 50

Confirmatory testing of brain death

Answer 50

EEG, nuclear medicine cerebral flow scans etc.

Question 51

EEG finding that supports diagnosis of brain death

Answer 51

Electrocerebral silence