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Category: Critical Care Medicine--->Cerebrovascular Diseases
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Question 1#Print Question

A 49-year-old man with no past medical history is admitted to the medicine service for 2 weeks of intermittent night sweats, myalgia, and progressive headache. Other than febrile, his vital signs are normal at the time of admission. His neurologic examination at the time of admission is normal, and basic laboratory workup is unrevealing. A lumbar puncture is performed with a normal opening pressure, pleocytosis with 41 white blood cells/microL (94% polymorphonuclear cells), 5 red blood cells/microL, glucose 58 mg/dL, and protein 53 mg/dL. There was concern for potential infectious meningitis, so vancomycin, ceftriaxone, and acyclovir were started. One day following the lumbar puncture, the patient had acute onset of marked expressive aphasia and right facial weakness. A head computed tomography (CT) was completed and demonstrated in the figure that follows.

Additional workup was completed to determine the etiology of his stroke, and he was found to have a mobile target on the anterior leaflet of the mitral valve, concerning for endocarditis (shown in the figure below), and the mitral valve has severe mitral valve regurgitation.

What is the next best step in management of the patient’s possible endocarditis?

a. The patient should undergo urgent (within 5 days) mitral valve replacement
b. The patient should undergo urgent (within 5 days) mitral valve repair
c. The patient should undergo delayed (∼4 weeks) mitral valve replacement
d. The patient should undergo delayed (∼4 weeks) mitral vale repair
e. Only antibiotics therapy is needed, and current antibiotics should remain the same


Question 2#Print Question

A 53-year-old woman is postbleed day 8 from a subarachnoid hemorrhage (SAH) from a, now secured, right middle cerebral artery (MCA) aneurysm. Since admission, the patient has been closely watched and the data from her external ventricular drain (EVD), brain tissue oxygenation monitor, and microdialysis catheter are all monitored. Recordings from the previous day shows PbtO2 (partial pressure of brain tissue O2 ) to be consistently greater than 25 and lactate/pyruvate (L/P) ratio less than 35, while her most recent readings from this morning are noted in the table that follows:

 What is the best next step in management to reduce the patient’s risk of delayed cerebral ischemia?

a. Continue to maintain increased cerebral perfusion pressure (CPP)
b. Targeted temperature management
c. Transfuse one unit of packed red blood cells
d. Start continuous electroencephalogram (cEEG) monitoring


Question 3#Print Question

A 47-year-old male with untreated hypertension was brought to the emergency department for loss of consciousness while at home and an episode of emesis. A head CT demonstrated a diffuse SAH with intraventricular extension and early signs of hydrocephalus. A CT angiogram demonstrated a 6 mm fusiform aneurysm from the distal right posterior inferior cerebellar artery (PICA). He was admitted to the intensive care unit for ongoing management. Over the course of the evening, there was progressive somnolence and an EVD was placed with an elevated opening pressure. Once placed, the EVD remained clamped. Given the need to delay definitive management of the aneurysm, transexamic acid (TXA) was started. Within 8 hours of admission, there was acute worsening of the examination and an acute increase in the intracranial pressure (ICP), and on opening the EVD, blood actively drained.

What of the following is MOST true of aneurysmal rerupture? 

a. Aneurysm rerupture does not change functional outcome of those who survive
b. Posterior circulation aneurysms are more common to have rerupture than anterior circulation aneurysms
c. The use of TXA decreases the risk of rebleeding and improves clinical outcomes
d. Placement of an EVD increases the risk of rebleeding
e. Rerupture more commonly occurs within the first 3 to 5 days, following the initial aneurysm rupture


Question 4#Print Question

A 67-year-old female has had progressive tinnitus over the last 4 years. Initial laboratory workup has been unrevealing, so additional workup with brain imaging was completed. The CT angiogram is shown in the figure that follows:

Which of the following is MOST true regarding incidentally discovered aneurysms?

a. Saccular aneurysms are most amenable to treatment with intraarterial coiling
b. Incidentally discovered aneurysms without any symptoms do not warrant further evaluation or intervention
c. Aneurysms located in the posterior circulation have a higher risk of rupture than the anterior circulation
d. The average annual rupture rate of all incidentally discovered aneurysm is around 10%


Question 5#Print Question

A 69-year-old male, who has not seen a doctor in at least 10 years, presents to the emergency department for left-sided numbness and weakness. He initially had symptoms 1 day before presentation that lasted for 30 minutes with complete recovery. A head CT did not demonstrate any ischemic changes. A magnetic resonance imaging (MRI) did not demonstrate any infarction. A magnetic resonance angiogram (MRA) of the intracranial and neck vessels demonstrated severe stenosis of the right MCA.

What is the next best step management?

a. Consultation to endovascular service for angioplasty and placement of a stent across the right MCA stenosis
b. Start intravenous (IV) heparin infusion with bolus of heparin
c. Start dual antiplatelet therapy with aspirin and clopidogrel
d. Start single antiplatelet therapy with aspirin following a loading dose




Category: Critical Care Medicine--->Cerebrovascular Diseases
Page: 1 of 2