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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 76 OF 100
A 32-year-old man with no known medical problems is brought to the emergency department by EMS after being struck by a car. Upon arrival, his Glasgow Coma Scale score decreases from 13 to 6, and examination reveals a new blown” right pupil. He is immediately intubated for airway protection, and his vital signs are otherwise stable. Which of the following studies should be ordered immediately to identify the etiology of his worsening neurologic examination?
A. Transcranial Doppler ultrasound to assess blood flow in the middle cerebral arteries
B. Head CT, with consideration of CT angiography to rule out intracerebral hemorrhage **
C. MRI of the brain to rule out acute ischemic stroke
D. Continuous EEG and administration of a loading dose of fosphenytoin 10 mg/kg
E. Four-vessel cerebral angiography to rule out arteriovenous malformation
** = Your answer
A patient with deteriorating neurologic signs,including a pupillary change, requires emergent intracranial imaging studies if the airway, breathing, and circulation are stable. Head CT is the fastest, most efficient imaging study for acute evaluation of intracerebral hemorrhage (intraparenchymal, subarachnoid, subdural, or epidural). Acute ischemic stroke is less of a concern in this scenario; thus, transcranial Doppler ultrasound and MRI of the brain are not the best first studies in the emergent period. Cerebral angiography and continuous EEG may be necessary at some point during the evaluation, but not in the emergent setting.
* Gentry LR. Imaging of closed head injury. Radiology. 1994 Apr;191(1):1-17.