TBI MCQs Type A

A. According to the 4th edition of Brain Trauma Foundation guidelines for management of
traumatic brain injury, which of these is a level 1 recommendation?

A. Phenytoin is recommended to decrease the incidence of early post-traumatic seizures

B. Prolonged prophylactic hyperventilation with PaCO2 < 25 mmHg is not recommended
C. Early (within 2.5 h), short-term (48 h post-injury), prophylactic hypothermia is not
recommended to improve outcomes in patients with diffuse injury
D. The use of steroid is not recommended for improving outcome or reducing ICP in TBI

Answer: D
According to the results of CRASH (Corticosteroid Randomization After Significant Head
Injury) trial, high dose methylprednisolone was associated with high mortality in TBI
patients and is therefore contraindicated. GUDHIS (German Ultrahigh Dexamethasone
Head Injury Study) trial demonstrated no difference between placebo and high dose
dexamethasone in terms of efficacy and safety. Other RCTS that randomized severe TBI
patients to placebo vs varying doses of dexamethasone, triamcinolone and
methylprednisolone yielded similar results

B. Cerebral metabolic rate is decreased by all of the following agents except

A. Thiopentone
B. Propofol
C. Ketamine
D. Sevoflurane

Answer: C

All volatile agents except nitrous oxide and all intravenous anaesthetics except Ketamine
cause a reduction in cerebral metabolic rate and cerebral blood flow. Therefore the use of
nitrous oxide and ketamine for neurosurgical procedures in TBI is contraindicated.

C. What is the gold standard for intracranial pressure monitoring in TBI?

A. Subdural bolt
B. Intraventricular catheter
C. Subarachnoid catheter
D. Epidural catheter
 Answer: B

Intraventricular catheter or external ventricular drain or ventriculostomy catheter is

considered as the gold standard for monitoring of intracranial pressure. The major
advantage of EVD over other methods if the ability to drain CSF. The major disadvantage is
the risk of ventriculitis.

D. Epidural hematoma is commonly caused by injury to which vessels?

A. Vertebral artery
B. Middle meningeal artery
C. Middle cerebral artery
D. Dural venous sinuses

Answer: B

In vast majority of cases, epidural hematoma is caused by injury to the middle meningeal
artery. Some cases are caused by injury to dural venous sinuses. Epidural hematoma appears
as a lentiform opacity in the CT Scan of head and is more common in young patients with
TBI.

E. The universal measures for the control of ICP include

A. Normocarbia
B. Hyperthermia
C. Hyponatremia
D. Hypervolemia

Answer: A
The universal measures for the control of ICP include maintaining head elevation,
normocarbia, normothermia, euglycemia and avoiding hyponatremia, jugular venous
compression. Hyperventilation to PaCO2<25 mmHg is only used as a temporarizing measure
for reducing ICP and is not recommended by the Brain Trauma Foundation Guidelines for
prolonged use.
F. Which is the preferred resuscitation fluid in traumatic brain injury?

A. Hypertonic saline
B. Mannitol
C. 0.9% Sodium Chloride
D. Albumin

Answer: C

Current evidence suggests the efficacy and safety of isotonic intravenous fluids like 0.9%
Sodium Chloride and Hartmann’s solution for fluid resuscitation in TBI. Resuscitation with 4%
albumin in TBI patients in ICU worsens mortality, which may be mediated by increased ICP
during the first week after injury. Hypertonic saline and mannitol decrease ICP, but may not
improve survival or neurological outcomes. Sodium lactate may be a future therapy for
treatment and prevention of secondary brain injury.

G. Cushing’s sign seen in raised intracranial pressure comprises of all the following except:

A. Tachycardia
B. Hypertension
C. Irregular breathing
D. Bradycardia

Answer: A

An increase in blood pressure and a drop in pulse rate (Cushing’s response) are often found
in patients with trans-tentorial herniation due to an increase in ICP.

H. In cerebral physiology, which of the following variable has a sigmoid relationship with
cerebral blood flow?

A. Partial pressure of oxygen

B. Partial pressure of Carbon dioxide
C. Intracranial pressure
D. Cerebral perfusion pressure
 Answer: B
At PaCO2 of 80mmHg, the CBF is doubled beyond which there is no further increase in CBF
as maximal vasodilation is achieved. At PaCO2 of 20mmHg, flow is halved beyond which
there is no further reduction possible as the cerebral vasculature is maximally
vasoconstricted. The relationship between CBF on y axis and PaCO2 on x axis is essentially a
sigmoid curve.

I. Periorbital hematoma, Battle’s sign and CSF otorrhoea/rhinorrhoea are classical findings of
which type of injury?

A. Subdural hematoma
B. Sub-arachnoid Hemorrhage
C. Base of skull fracture
D. Maxillofacial trauma

Answer: C
Battle’s sign or mastoid echhymosis, Raccoon eyes or periorbital hematoma, CSF
rhinorrhoea, hemotympanum, cranial nerve palsy and bleeding from nose and ears are some
physical signs of base of skull fracture. These patients carry a high risk of meningitis.

J. Which of the following is correct with regards to ICP waveform?

A. A waves are called plateau waves

B. C waves are always associated with pathology
C. B waves have amplitude of 20mm and frequency of 4-8 Hz
D. None of the above

Answer: A

A waves or “Plateau waves” have amplitudes of 50–100 mmHg, lasting 5–20 min. These
waves are always associated with intracranial pathology.B waves have amplitudes up to 50
mmHg with a frequency 0.5–2/min and are thought to be due to vasomotor tone instability.
C waves are up to 20 mmHg in amplitude and have a frequency of 4–8/min. These waves
have been documented in healthy individuals and are thought to occur because of
interaction between cardiac and respiratory cycles.
11. All of the following are brainstem reflexes except

A. Gag reflex
B. Pupillary light reflex
C. Babinski reflex
D. Doll’s eye reflex

Answer: C
Brainstem includes the midbrain, pons and medulla. The brainstem reflexes include corneal ,
pupillary, cough, gag, caloric or doll’s eye reflexes. These are used during brainstem testing.
The plantar reflex is a reflex elicited when the sole of the foot is stimulated with a blunt
instrument. The reflex can take one of two forms. In normal adults, the plantar reflex causes a
downward response of the hallux. An upward response of the hallux is known as the Babinski
response or Babinski sign.

12. Which is the most frequent intra-axial or extra-axial hematoma in patients with TBI?

A. Intracerebral
B. Subdural
C. Epidural
D. Subarachnoid

Answer: A

Parenchymal lesions are by far the most frequent lesion in TBI. Bleeding can occur within
this area in a variable manner, from none to ‘salt and pepper’ appearance on CT, to larger
lesions.

13. In a patient with TBI with neurological deterioration, all of the following are signs of
raised ICP on a CT scan of head except:

A. Obliteration of third ventricle

B. Presence of unilateral hydrocephalus
C. Increase in mass shift
D. Enlargement of ventricular horns

Answer: D
The CT Head of patients with raised ICP shows obliteration of the third ventricle,
compression of basal cisterns, enlargement of the mass lesion, an increase of mass shift,
distortion of the ipsilateral peri-mesencephalic cisterns, compression of ventricular horns, or
the presence of unilateral hydrocephalus.
14. Which of these is an exclusion criteria for placement of ICP monitor in a patient with TBI?

A. Patients with reactive pupils

B. Difficult to manage extracranial lesion
C. Absence of coagulopathy
D. Treatable lesions at CT

Answer : C
Criteria of exclusion for ICP monitor placement : patients with bilateral unreactive mydriasis,
untreatable lesions at CT, advanced age and comorbidities, extracranial lesion difficult to
manage, coagulopathy and high GCS motor score (≥5).

15. Which of these is a first line therapy for the control of ICP in neurointensive care setting?

A. Mechanical ventilation with appropriate sedation

B. Hyperventilation
C. Hypothermia
D. Steroids

Answer: A
As first line therapy, appropriate sedation and analgesia is critical since stress and pain may
cause a rise in ICP. Mechanical ventilation is also mandatory, at least during the initial
stages.The patient’s head should be elevated at 15-30 degrees. Care should be taken to
ensure that wound dressings and collars do not compress the jugular veins.
Hyperventilation, hypothermia, barbiturate coma and decompressive craniectomy can be
used as second line therapies when there is failure of first line therapies or further
neurological deterioration.

16. The commonest cause of Sub-arachnoid haemorrhage is :

A. AV malformation
B. Trauma
C. Non-aneurysmal SAH
D. Ruptured Intracranial aneurysm

Answer : D
By far the most common cause of SAH is rupture of intracranial aneurysm which accounts
for almost 85% of the cases. Other non-aneurysmal causes of SAH are trauma, AV
malformation, occult aneurysm and perimesencephalic non-aneurysmal SAH.
17. What is the gold standard diagnostic modality for detection of vasospasm after surgical
management of SAH?

A. Contrast-enhanced CT Head
B. CT angiography
C. MRI with contrast
D. Formal cerebral angiography

Answer: D
Formal cerebral angiography is the gold standard for detection of vasospasm which usually
occurs between 4-11 days after the initial management of SAH. 50% of the patients are
symptomatic and usually present with decreased levels of consciousness.

18. After endovascular coiling for a Fisher Grade IV SAH, decrease in level of consciousness
on the second day is suggestive of:

A. Hydrocephalus
B. Vasospasm
C. Re-bleed
D. Encephalitis

Answer : A
Decreased levels of consciousness on second day post-coiling in SAH is suggestive of
hydrocephalus in Fisher Grade IV SAH (presence of intra-ventricular blood on CT scan).
Vasospasm usually occurs 4-11 days post-procedure.

19. Which of the following is not a pre-condition for testing brain stem death ?

A. Hypothermia
B. Complete Neuromuscular blockade
C. Deep sedation
D. Normal metabolic and electrolyte levels

Answer: D
The preconditions for testing brain stem death include absence of hypothermia, absence of
effects of sedatives, absence of severe metabolic or electrolyte abnormalities, intact
neuromuscular function, intact eye/ear (at least one) to examine the reflexes and possibility
of doing an apnea test.
20. What is the Glasgow Coma Scale motor score for a patient with TBI who exhibits
decerebrate posturing?

A. 1
B. 2
C. 3
D. 4

Answer : B
The motor scoring for GCS is : 6 for following commands, 5 for localizing pain, 4 for
withdrawing from painful stimuli, 3 for flexing upperextremities and extending lower
extremitis in response to pain (decorticate posturing), 2 for extending all extremities in
response to pain (decerebrate posturing) and 1 for lack of any motor response.

21. Which of these is a correct physiological target for patients with TBI?

A. CPP 70-90 mmHg

B. ICP >20 mmHg
C. MAP < 65mmHg
D. None of the above

Answer: A
As per the latest brain trauma guidelines, maintaining CPP in the range of 70-90mmHg is
essential to prevent cerebral ischaemia in TBI patients. ICP> 20 mmHg should be aggressively
treated with CSF drainage or craniectomy depending on the patient characteristics. MAP
should be maintained at a higher level to maintain CPP between 70-90mmHg. These patients
will benefit from ICP monitoring, invasive Blood Pressure monitoring and Jugular venous
oximetry.

22. What is the most common side effect of using mannitol to treat raised ICP?

A. Decreased respiratory drive

B. Hypervolemia
C. Hypovolemia
D. Vasoconstriction leading to ischaemia

Answer: C
Mannitol is an osmotic diuretic which causes marked diuresis resulting in hypovolemia and
hypotension which may compromise cerebral perfusion pressure hence causing cerebral
ischaemia and aggravating secondary injury.