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Type 2 Diabetes-Initial Management — USMLE Step 2 CK MCQ

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ModerateEndocrinologyType 2 Diabetes-Initial ManagementUSMLE Step 2 CK

A 52-year-old woman presents with a sudden severe headache and meningismus. CT shows diffuse subarachnoid blood, and angiography identifies a ruptured anterior communicating artery aneurysm. The aneurysm is successfully coiled within 12 hours. She is awake, euvolemic, and receiving care in a neurocritical-care unit. Which intervention should now be initiated to improve neurologic outcome?

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Correct answer: D — Start enteral nimodipine early in the hospital course

Early enteral nimodipine is recommended after aneurysmal subarachnoid hemorrhage because it reduces delayed cerebral ischemia and improves functional outcomes. It should be started early and continued with blood-pressure monitoring; dose adjustment may be needed if hypotension develops. Securing the ruptured aneurysm promptly addresses the immediate risk of rebleeding but does not eliminate the later risk of delayed cerebral ischemia. Routine statin therapy and intravenous magnesium have not improved outcomes and are not recommended for this purpose. Maintaining euvolemia is appropriate, whereas prophylactic hypervolemia or hemodynamic augmentation can cause harm and is not used before symptomatic delayed ischemia. Antifibrinolytic therapy may have a limited short-term role only when aneurysm treatment will be unavoidably delayed. Continuing it after successful coiling adds thrombotic risk without the intended benefit.

Reference: American Heart Association/American Stroke Association. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage. https://professional.heart.org/en/science-news/2023-guideline-for-the-management-of-patients-with-aneurysmal-subarachnoid-hemorrhage/top-things-to-know