TENC Neurocirurgia Practice Questions - TENC - Título De Especialista Em Neurocirurgia (Sociedade Brasileira De Neurocirurgia AMB) Exam

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A 48-year-old man undergoes successful endovascular coiling of a ruptured anterior communicating artery aneurysm within 18 hours of ictus. On post-bleed day 6, he develops new expressive aphasia and right arm weakness (4/5). Bedside Transcranial Doppler (TCD) ultrasonography reveals a mean flow velocity of 210 cm/s in the left middle cerebral artery with a Lindegaard ratio of 4.8. What is the most appropriate initial medical management for this delayed cerebral ischemia (DCI)?

Aggressive hypervolemic hemodilution using 5 liters of 0.45% saline daily and prophylactic placement of a balloon pump. Maintenance of euvolemia, continuous oral nimodipine (60 mg every 4 hours), and induction of hypertension using intravenous vasopressors (such as norepinephrine) to improve cerebral perfusion. Immediate intravenous administration of high-dose corticosteroids and low-dose unfractionated heparin bolus. Immediate surgical exploration for left carotid artery endarterectomy and bypass.

Correct Answer:

Maintenance of euvolemia, continuous oral nimodipine (60 mg every 4 hours), and induction of hypertension using intravenous vasopressors (such as norepinephrine) to improve cerebral perfusion.

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