[Control/Command + F] to find what you’re looking for (for now) until my site gets a bit more sophisticated.
Eventual plan will be advanced search features with posts organized by organ system. Thank you for your patience!
2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association
Question: A 68-year-old male with a history of atrial fibrillation on warfarin therapy presents to the emergency department with sudden onset, severe headache and loss of consciousness. A CT scan confirms the diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). In this patient, which of the following is the most appropriate immediate intervention to prevent rebleeding?
A. Maintain systolic blood pressure below 160 mmHg.
B. Administer antifibrinolytic therapy.
C. Perform an emergency reversal of anticoagulation.
D. Reduce blood pressure to the normal range immediately.
Answer: C. Perform an emergency reversal of anticoagulation.
Explanation:
Option A is incorrect. While it is beneficial to avoid severe hypertension and hypotension in patients with aSAH, there is no definitive BP target universally recommended in these patients. Guidelines suggest keeping systolic BP <160 mm Hg or <180 mm Hg, but these suggestions are based on limited evidence.
Option B is incorrect. Antifibrinolytic therapy is not routinely recommended for the management of patients with aSAH. The ULTRA trial, which investigated ultra-early antifibrinolytic therapy in patients with aSAH, found no significant reduction in the rate of rebleeding and no improvement in functional outcomes in patients treated with the antifibrinolytic agent, tranexamic acid.
Option C is correct. This patient is on anticoagulation therapy for atrial fibrillation. In patients with aSAH, it is strongly recommended to perform an emergency reversal of anticoagulation to prevent rebleeding. While this specific intervention has not been studied in aSAH, the benefit of anticoagulation reversal has been demonstrated in other forms of intracranial hemorrhage.
Option D is incorrect. Sudden, profound reduction of blood pressure should be avoided in patients with aSAH as it may compromise cerebral perfusion and induce ischemia. Instead, a gradual reduction of blood pressure is recommended in patients who are severely hypertensive, avoiding hypotension and maintaining a close monitoring of the neurological examination.
Question: A 45-year-old woman presents to the clinic with symptoms of dry cough and fatigue lasting for two months. On examination, she has bilateral hilar lymphadenopathy. The physician suspects sarcoidosis. Which of the following is the most appropriate next step in management?
A. Endobronchial ultrasound-guided lymph node sampling
B. Routine transthoracic echocardiography
C. Baseline serum calcium testing
D. Baseline serum transaminase testing
Answer: A. Endobronchial ultrasound-guided lymph node sampling
Explanation:
Option A is correct. For patients with suspected sarcoidosis and mediastinal and/or hilar lymphadenopathy for whom it has been determined that tissue sampling is necessary, the ATS suggests endobronchial ultrasound (EBUS)-guided lymph node sampling, rather than mediastinoscopy, as the initial mediastinal and/or hilar lymph node sampling procedure.
Option B is incorrect. The ATS suggests not performing routine baseline transthoracic echocardiography (TTE) for patients with extracardiac sarcoidosis who do not have cardiac symptoms or signs. These tests should be considered on a case-by-case basis.
Option C is correct but not the most appropriate next step in management in this patient with suspected sarcoidosis and mediastinal and/or hilar lymphadenopathy. For patients with sarcoidosis who do not have symptoms or signs of hypercalcemia, the ATS recommends baseline serum calcium testing to screen for abnormal calcium metabolism.
Option D is incorrect. The ATS makes no recommendation for or against baseline serum transaminase testing for patients with sarcoidosis who have neither hepatic symptoms nor established hepatic sarcoidosis.
Question: A 63-year-old woman presents to the emergency department within 4 hours of symptom onset of minor nondisabling acute ischemic stroke, with a National Institutes of Health Stroke Scale score of 2. In light of the ARAMIS Randomized Clinical Trial findings, which of the following treatment options is appropriate?
A) Intravenous alteplase only, as it is superior to dual antiplatelet therapy.
B) Dual antiplatelet therapy only, as it is inferior to intravenous alteplase.
C) Either intravenous alteplase or dual antiplatelet therapy, as the latter is noninferior to the former.
D) Neither intravenous alteplase nor dual antiplatelet therapy, as no significant difference in outcomes was found in the trial.
Answer: (C) Either intravenous alteplase or dual antiplatelet therapy, as the latter is noninferior to the former.
Explanations:
A) Incorrect. According to the ARAMIS trial, intravenous alteplase was not found to be superior to dual antiplatelet therapy in the treatment of minor nondisabling acute ischemic stroke.
B) Incorrect. Dual antiplatelet therapy was not found to be inferior to intravenous alteplase. In fact, the trial found it to be noninferior, meaning it was at least as effective as intravenous alteplase.
C) Correct. In the scenario given, the patient fits the criteria of the ARAMIS trial participants. Therefore, according to the trial findings, either intravenous alteplase or dual antiplatelet therapy could be appropriately administered, as dual antiplatelet therapy was found to be noninferior to intravenous alteplase. This provides a potential new therapeutic approach for minor nondisabling acute ischemic stroke.
D) Incorrect. The ARAMIS trial did find a difference in outcomes between intravenous alteplase and dual antiplatelet therapy. The difference was that dual antiplatelet therapy was not worse than intravenous alteplase by a prespecified amount, demonstrating noninferiority. The study did not show that they were exactly equally effective.
Alcohol withdrawal syndromes in the intensive care unit
Question: A 42-year-old man is admitted to the ICU after sustaining a severe traumatic brain injury from a fall. His Glasgow Coma Scale score is 7. He is intubated for airway protection. On postoperative day two, he becomes acutely agitated and is tremulous. His vital signs are: temperature 38.5°C (101.3°F), blood pressure 175/115 mm Hg, heart rate 140 beats/min, and respiratory rate 30 breaths/min. On examination, he is trying to get out of bed and is diaphoretic. He is not responding appropriately to commands. Pupils are equal and reactive; lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in management?
A) Administer a bolus of hypertonic saline
B) Immediate repeat head CT
C) Administer lorazepam IV
D) Administer thiamine and folate
E) Administer levetiracetam for seizure prophylaxis
Answer: C) Administer lorazepam IV
Explanation:
A) Administer a bolus of hypertonic saline – This intervention is appropriate for managing elevated ICP, but the patient’s symptoms suggest acute agitation rather than increased ICP.
B) Immediate repeat head CT – A head CT can be useful to rule out neurological causes of agitation such as hemorrhage or edema, but it’s not the immediate step in this case.
C) Administer lorazepam IV – The patient’s agitation, tremors, and autonomic instability suggest alcohol withdrawal syndrome, which should be managed with benzodiazepines like lorazepam.
D) Administer thiamine and folate – While these supplements are often given to patients suspected of having alcohol withdrawal syndrome to prevent Wernicke-Korsakoff syndrome, they won’t directly treat the acute symptoms the patient is experiencing.
E) Administer levetiracetam for seizure prophylaxis – Prophylactic anticonvulsants are often used in TBI, but they won’t treat the acute agitation and possible alcohol withdrawal syndrome this patient is experiencing.
Question: A 63-year-old man with a history of congestive heart failure presents to the intensive care unit with sepsis-induced hypotension. You’re considering several management strategies: early vasopressor use with conservative fluid management, liberal fluid resuscitation prior to initiating vasopressor use, or an aggressive fluid resuscitation strategy given the patient’s cardiac history. Based on the findings of a recent randomized controlled (CLOVERS) trial, which of the following statements best guides your treatment plan?
A. Early vasopressors reduce mortality.
B. Liberal fluids before vasopressors reduce mortality.
C. Both strategies have similar 90-day mortality rates.
D. Aggressive fluid resuscitation is needed due to heart failure.
E. Strategy should depend on initial hemodynamic response.
Answer:
C. Both strategies have similar 90-day mortality rates.
Explanation:
A. Early use of vasopressors in the treatment of sepsis-induced hypotension did not lead to a reduction in mortality, according to the findings of the CLOVERS trial.
B. The study also found that liberal fluid resuscitation before initiating the use of vasopressors did not lead to a reduction in mortality.
C. The CLOVERS trial demonstrated no difference in 90-day mortality rates between the strategies of early vasopressor use and conservative fluid management versus liberal fluid resuscitation before vasopressor initiation. Therefore, both strategies could be considered for this patient.
D. Aggressive fluid resuscitation due to the patient’s history of congestive heart failure may not necessarily be the best course of action, as the CLOVERS trial did not find a mortality benefit with liberal fluid resuscitation.
E. While the strategy should consider the initial hemodynamic response, the choice between the two strategies should not be solely dependent on it. Neither approach was found to be superior in the CLOVERS trial, and the treatment plan should be based on the patient’s overall clinical status. Further research might reveal patient subgroups for whom one strategy might be more beneficial.
Question: A 60-year-old man with a recent diagnosis of depression presents to your clinic with a 3-month history of rapidly progressive cognitive decline, myoclonus, and ataxia. His neurologic examination is remarkable for a positive startle response. His mental status examination reveals memory impairment, disorientation, and decreased attention span. Brain MRI shows high signal intensity in the pulvinar and dorsomedial thalamic nuclei bilaterally on DWI and FLAIR sequences, the so-called “hockey stick” sign. An EEG shows periodic sharp wave complexes. Lumbar puncture isperformed, and CSF analysis reveals an elevated level of 14-3-3 protein.
Despite these findings, the patient’s family requests a definitive diagnosis. Which of the following would provide the highest diagnostic certainty in this scenario?
Answer Choices:
A. Brain biopsy
B. Genetic testing for PRNP mutations
C. Autoantibody panel to rule out autoimmune encephalitis
D. PET scan of the brain
E. Repeat CSF analysis in 6 weeks
Correct Answer: (A) Brain biopsy
Answer Explanation:
A. While CJD can often be diagnosed based on clinical criteria and supportive investigations, definitive diagnosis can only be established with brain biopsy or autopsy showing spongiform changes and PrPSc aggregates.
B. Genetic testing for PRNP mutations is useful in suspected genetic prion diseases but does not exclude sporadic CJD, which represents the majority of cases.
C. An autoantibody panel can help rule out autoimmune encephalitis, but it won’t definitively diagnose CJD.
D. A PET scan of the brain can reveal metabolic changes in CJD, but it is less specific and sensitive than MRI and CSF analysis.
E. Repeat CSF analysis may not provide additional information to what has already been established and hence does not contribute to increased diagnostic certainty.
Neurointensvist 