BCCCP: Subarachnoid Hemorrhage Critical Care Questions

Question 1 of 10

1. Question

A 68-year-old woman presents with sudden-onset headache and loss of consciousness. Imaging confirms an aneurysmal subarachnoid hemorrhage. During the initial evaluation, which of the following findings would most strongly suggest that aneurysm treatment is unlikely to be beneficial?

Hunt and Hess grade of 5
Presence of acute hydrocephalus on CT requiring external ventricular drainage
Absent brainstem reflexes
Advanced age (78 years)

Question 2 of 10

2. Question

A 62-year-old female presents with a sudden, severe “thunderclap” headache followed by rapid decline in consciousness. Computed tomography confirms aneurysmal subarachnoid hemorrhage. Which of the following is the primary parameter quantified by clinical grading scales, such as the Hunt and Hess or World Federation of Neurological Surgeons scales, to assess initial severity and predict outcome in patients with aSAH?

Extent of cerebral vasospasm and risk of delayed cerebral ischemia
Volume and distribution of subarachnoid blood
Degree of neurological impairment and level of consciousness
Presence of acute hydrocephalus and need for cerebrospinal fluid diversion

Question 3 of 10

3. Question

A 45-year-old man presents to the emergency department after collapsing at home. He experienced a sudden, severe headache immediately before losing consciousness. On arrival, his Glasgow Coma Scale score is 7 (E1V2M4). Examination reveals nuchal rigidity and left-sided facial weakness. His blood pressure is 180/95 mm Hg. Which of the following clinical features is most characteristic of an aneurysmal subarachnoid hemorrhage (aSAH)?

Sudden, severe headache reaching maximal intensity within seconds (“thunderclap” headache)
Focal neurologic deficits such as facial droop or hemiparesis
Sensitivity to light (photophobia)
Nausea and vomiting

Question 4 of 10

4. Question

A 62-year-old woman is admitted with aneurysmal subarachnoid hemorrhage confirmed by head CT. The team needs to grade her initial clinical severity and predict her outcome. Which of the following scales is most appropriate?

Hunt and Hess scale
World Federation of Neurological Surgeons (WFNS) scale
Fisher scale
VASOGRADE score

Question 5 of 10

5. Question

A 72-year-old man is admitted to the neurocritical care unit after sudden collapse. He is comatose, localizes only to pain, has absent brainstem reflexes (including oculocephalic reflexes), fixed and dilated pupils, and CT shows diffuse subarachnoid hemorrhage with intraventricular extension and global cerebral edema. The neurointerventional team is considering immediate endovascular coiling of the ruptured aneurysm. Which of the following is the MOST critical consideration before proceeding?

Absent brainstem reflexes and global cerebral edema indicate irreversible neurological injury, making aneurysm repair likely futile.
Aggressive neuroprotective measures (e.g., optimizing cerebral perfusion pressure) should be completed first to potentially improve neurological status.
Immediate administration of nimodipine is essential to reduce vasospasm risk and should precede aneurysm coiling.
Advanced age (>70 years) is the primary predictor of poor outcome and justifies delaying coiling until further assessment.

Question 6 of 10

6. Question

A 62-year-old man with a history of hypertension and hyperlipidemia and baseline independent function is admitted to the neurocritical care unit after a sudden, severe headache and collapse. He is intubated on assist-control ventilation and receiving norepinephrine to maintain a mean arterial pressure above 70 mmHg. Noncontrast head CT shows diffuse subarachnoid hemorrhage in the basal cisterns with acute hydrocephalus, for which an external ventricular drain has been placed. Neurologic examination reveals absent brainstem reflexes and no response to noxious stimuli. There is no known advance directive. CT angiography identifies a 6-mm anterior communicating artery aneurysm. When evaluating this patient’s candidacy for aneurysm repair, which consideration should be addressed first?

Assessment of clinical severity using Hunt and Hess and WFNS grading scales.
Assessment and correction of potentially reversible factors (e.g., electrolyte disturbances, seizures, hypothermia).
Assessment of vasospasm risk using the Fisher CT scale.
Assessment of timing for invasive angiography to localize the aneurysm for definitive repair.

Question 7 of 10

7. Question

A 65-year-old man is admitted to the neurocritical care unit after a sudden, severe headache followed by rapid loss of consciousness. Non-contrast head CT confirms aneurysmal subarachnoid hemorrhage (aSAH). He is comatose (GCS 4: E1 VTM3), intubated, on assist-control ventilation, with decerebrate posturing. Pupillary and corneal reflexes are sluggish but present. He receives a norepinephrine infusion to maintain cerebral perfusion pressure. Neurosurgery is planning definitive aneurysm management. Which of the following is the most appropriate consideration regarding treatment of his aneurysm?

Proceed with early aneurysm repair (surgical clipping or endovascular coiling), since no clear evidence of irreversible brainstem injury is present.
Defer aneurysm repair solely because of his low GCS (≤4), as outcomes in high-grade aSAH are uniformly poor.
Initiate oral nimodipine for vasospasm prophylaxis and delay aneurysm repair until after the vasospasm risk period subsides.
Administer short-term antifibrinolytic therapy (e.g., tranexamic acid) to prevent early rebleeding and postpone definitive aneurysm repair.

Question 8 of 10

8. Question

A 72-year-old female is admitted to the critical care unit after a sudden, severe headache followed by rapid neurological decline. She is intubated and on mechanical ventilation, with a continuous infusion of nicardipine via a central line for blood pressure control. A CT scan confirms a large aneurysmal subarachnoid hemorrhage (aSAH) with significant intraventricular hemorrhage. On examination, she is stuporous, responds only to painful stimuli with decorticate posturing, and exhibits moderate right-sided hemiparesis. Her Glasgow Coma Scale (GCS) score is 7. Given this high-grade aSAH, which of the following is the most critical immediate consideration?

Initiate nimodipine 60 mg PO every 4 hours to reduce delayed cerebral ischemia (Class I, Level A).
Engage family in early discussion of prognosis and appropriateness of definitive aneurysm securing (Class IIa, Level C).
Administer tranexamic acid infusion to prevent rebleeding (Class III: Not recommended, Level B).
Schedule repeat non-contrast head CT in 6 hours to monitor hemorrhage expansion (Class IIb, Level C).

Question 9 of 10

9. Question

A 68-year-old woman is admitted to the ICU after a sudden, severe headache described as “the worst of her life,” followed by rapid decline in consciousness. She is intubated and on mechanical ventilation with a propofol infusion; a central venous catheter is in place. Neurologic exam shows GCS E1V1M3 with decorticate posturing, 4 mm sluggish pupils bilaterally, and absent oculocephalic reflexes. Head CT confirms extensive aneurysmal subarachnoid hemorrhage (aSAH). Which initial assessment is most important for guiding prognosis and the overall management strategy?

Aggressively lowering systolic blood pressure to <140 mm Hg to reduce rebleeding risk.
Starting nimodipine immediately to prevent delayed cerebral ischemia.
Determining the clinical severity using Hunt and Hess or WFNS grading.
Obtaining CT angiography to localize the aneurysm before further assessment.

Question 10 of 10

10. Question

A 48-year-old woman presents to the neurocritical care unit after a sudden, severe headache and transient loss of consciousness. CT angiography confirms an aneurysmal subarachnoid hemorrhage. On initial neurologic examination, she opens eyes to speech (E4), is oriented but confused (V4), localizes pain (M5) for a Glasgow Coma Scale score of 13, and has right upper extremity weakness (4/5). Which of the following scales is most appropriate for initial clinical severity stratification and outcome prediction in this patient?

Hunt and Hess grade
National Institutes of Health Stroke Scale (NIHSS)
Modified Rankin Scale (mRS)
Fisher grade