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Zakaria_87574_PTR_CH00_10-06-13_i-xx.indd ii 6/19/2013 8:43:22 PM
Neurocritical Care
Board Review
Questions and
Answers
Editor
Asma Zakaria, MD
Assistant Professor
Departments of Neurology and Neurosurgery
Fellowship Director, Neurocritical Care
Division of Neurocritical Care
University of Texas, Health Science Center at Houston
New York
Zakaria_87574_PTR_CH00_10-06-13_i-xx.indd iii 6/19/2013 8:43:22 PM

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ISBN: 978-1-936287-57-4
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Neurocritical care board review / [edited by] Asma Zakaria.
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To My Parents– For their support and patience
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Contents
Contributors xi
Preface xvii
PART I: NEUROLOGIC DISEASE STATES: PATHOLOGY, PATHOPHYSIOLOGY, AND THERAPY
Section I: Cerebrovascular Diseases

1. Infarction, Ischemia, and Hemorrhage 3
John J. Volpi
2. Subarachnoid Hemorrhage and Vascular Malformations 19
Bülent Yapicilar and Asma Zakaria
Section II: Neurotrauma

3. Neurotrauma 35
Scott R. Shepard
Section III: Disorders, Diseases, Seizures, and Epilepsy

4. Seizures and Epilepsy 51
Grant M. Warmouth
5. Neuromuscular Medicine 71
Suur Biliciler, Justin Kwan, and Cecile L. Phan
6. CNS Infections 79
Doris Kung
vii
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CONTENTS
7. Toxic–Metabolic Disorders 95
Elissa K. Fory
8. Inflammatory and Demyelinating Diseases 107
Flavia Nelson
9. Neuroendocrine Disorders 121
Matthew Flaherty and Howard J. Fan
10. Neuro-Oncology 131
Yoshua Esquenazi and Nitin Tandon
11. Encephalopathies 141
Corey E. Goldsmith
12. Clinical Syndromes 159
Howard J. Fan and Asma Zakaria
13. Perioperative Neurosurgical Care 175
Yoshua Esquenazi and Nitin Tandon
14. Pharmacology and Practical Use of Medications in Neurocritical Care 183
Teresa A. Allison and Sophie Samuel
PART II: GENERAL CRITICAL CARE: PATHOLOGY, PATHOPHYSIOLOGY, AND THERAPY

15. Cardiovascular Physiology 205
David J. Powner
16. Cardiovascular Diseases 217
Jean Onwuchekwa Ekwenibe, Francisco Fuentes, Siddharth Mukerji,
Husnu Evren Kaynak, Nicoleta Daraban, Charles Hebenstreit, and
Ketan Koranne
17. Pulmonary Physiology and Fundamentals of Mechanical Ventilation 239
David J. Powner
18. Respiratory Diseases 267
Imoigele P. Aisiku
19. Renal Diseases 285
Ala Abudayyeh and Maen Abdelrahim
20. Electrolyte and Endocrine Disorders 299
David J. Powner
21. Infectious Diseases 319
Safdar A. Ansari
viii
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CONTENTS
22. Acute Hematologic Disorders 333

Jitesh Kar and Hanh T. Truong
23. Acute Gastrointestinal and Genitourinary Disorders 349
Luis J. Garcia and Asad Latif
24. Diagnosis of Brain Death 361
David J. Powner
25. General Trauma and Burns 371
Sasha D. Adams and Amy R. Alger
26. Ethical and Legal Aspects of Critical Care Medicine 383
Nasiya Ahmed
27. Principles of Research in Critical Care 391
Suur Biliciler and Justin Kwan
28. Procedural Skills and Monitoring 397
George W. Williams
29. Clinical Cases 415
Asma Zakaria and Bülent Yapicilar
Index 433
ix
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Contributors
Maen Abdelrahim, MD, PhD

Resident
Department of Internal Medicine
Baylor College of Medicine
Houston, Texas
Ala Abudayyeh, MD
Assistant Professor
Department of General Internal Medicine
Division of Nephrology
University of Texas, MD Anderson Cancer Center
Houston, Texas
Sasha D. Adams, MD
Assistant Professor
Department of Surgery
Division of Trauma and Critical Care
University of North Carolina, School of Medicine
Chapel Hill, North Carolina
Nasiya Ahmed, MD
Assistant Professor
Division of Geriatric and Palliative Medicine
Houston, Texas
xi
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CONTRIBUTORS
Imoigele P. Aisiku, MD
Associate Professor
Department of Neurosurgery
Houston, Texas
Amy R. Alger, MD, FACS

Assistant Professor
Division of Trauma and Critical Care
University of North Carolina, School of Medicine
Chapel Hill, North Carolina
Teresa A. Allison, PharmD, BCPS

Neurosciences Clinical Pharmacy Specialist
Memorial Hermann–Texas Medical Center
Houston, Texas
Safdar A. Ansari, MD
Assistant Professor
University of Utah
Salt Lake City, Utah
Suur Biliciler, MD
Assistant Professor
Department of Neurology
Neuromuscular Diseases Section
Houston, Texas
Nicoleta Daraban, MD
Chief Cardiovascular Fellow
Houston, Texas
Jean Onwuchekwa Ekwenibe, MD

Cardiovascular Fellow
Houston, Texas
xii
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CONTRIBUTORS
Yoshua Esquenazi, MD
Chief Resident
Houston, Texas
Howard J. Fan, MD
Neurocritical Care Fellow
Ronald Reagan UCLA Medical Center
Los Angeles, California
Matthew Flaherty, MD
Neurocritical Care Fellow
Houston, Texas
Elissa K. Fory, MD
Department of Neurosciences
Winthrop University Hospital
Mineola, New York
Francisco Fuentes, MD
Professor
Division of Cardiology
Houston, Texas
Luis J. Garcia, MD
Division of Acute Care Surgery
Johns Hopkins University School of Medicine
Baltimore, Maryland
Corey E. Goldsmith, MD
Assistant Professor
Houston, Texas
xiii
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CONTRIBUTORS
Charles Hebenstreit, MD
Chief Resident
Houston, Texas
Jitesh K. Kar, MD, MPH

Chief Resident
Houston, Texas
Husnu Evren Kaynak, MD

Houston, Texas
Ketan Koranne, MD
Resident
Houston, Texas
Doris H. Kung, DO
Assistant Professor
Houston, Texas
Justin Kwan, MD
Assistant Professor
University of Maryland School of Medicine
Baltimore, Maryland
Asad Latif, MD, MPH

Assistant Professor
Department of Anesthesiology and Critical Care Medicine
Division of Adult Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland
xiv
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CONTRIBUTORS
Siddharth Mukerji, MD
Houston, Texas
Flavia Nelson, MD
Associate Professor
Multiple Sclerosis Research Group
Houston, Texas
Cecile L. Phan, MD, FRCPC

Assistant Professor
Neuromuscular and EMG Sections
Houston, Texas
David J. Powner, MD, FCCP, FCCM

Professor
Departments of Neurosurgery and Internal Medicine
Houston, Texas
Sophie Samuel, PharmD, BCPS

Neuroscience Clinical Pharmacy Specialist
Memorial Hermann–Texas Medical Center
Houston, Texas
Scott R. Shepard
Assistant Professor
Houston, Texas
Nitin Tandon, MD
Associate Professor
Departments of Neurosurgery and Pediatric Surgery
Director Epilepsy Surgery Program
Houston, Texas
xv
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CONTRIBUTORS
Hanh T. Truong, MD
Assistant Professor
Departments of Neurosurgery and Emergency Medicine
Houston, Texas
John J. Volpi, MD
Assistant Professor
The Methodist Hospital
Weill Cornell Medical College
Houston, Texas
Grant M. Warmouth, MD
Staff Neurophysiologist
St. Louis, Missouri
George W. Williams, MD
Assistant Professor
Departments of Anesthesiology and Neurosurgery
Houston, Texas
Bülent Yapicilar, MD
Assistant Professor
MetroHealth Medical Center
Case Western Reserve University
Cleveland, Ohio
Asma Zakaria, MD
Assistant Professor
Departments of Neurology and Neurosurgery
Houston, Texas
xvi
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Preface
In the last decade, Neurocritical Care has emerged from under the shadow of Stroke and
Critical Care Medicine into an entity on its own. In 2005 the United Council of Neurologic
Subspecialties (UCNS)* officially recognized neurocritical care as a subspecialty. Exhaustive
efforts by the Neurocritical Care Society resulted in recognition of the sub-specialty by
Leapfrog, and it has been established as standard of care in neuroscience centers across the
United States. This has led to a need for consistency in training and knowledge base among
practicing and future neuro-intensivists.
The first neurocritical care board examination was administered by UCNS in 2007. The
grandfathering period for the practice tract will end in December 2013, after which a two-year
neurocritical care fellowship will be mandatory to qualify for the boards. The test consists of
200 multiple-choice questions of which 50% will address neurologic disease states and the
remaining will assess competency in general critical care.
Neurocritical Care Board Review: Questions and Answers is intended to be a comprehensive
study guide for candidates sitting for the UCNS neurocritical care specialty board examina-
tion. It is a learning and self-assessment tool for practitioners and trainees who treat neuro-
logic patients in an emergent or critical care capacity, and for those who are preparing for the
UCNS board, or any other specialty examination that requires knowledge of neurologic or
general critical care.
In keeping with the original intent of this book, I approached physicians from various
medical and surgical specialties to author chapters based on the UCNS curriculum, frequently
encountered challenges or consults, and what they believed to be an appropriate level of
understanding that an intensivist should have on a given topic. Together, we compiled this
anthology of over 500 multiple-choice questions with answers, detailed explanations, and ref-
erences for further self study. The chapters are named and arranged in a similar format to the
UCNS curriculum to allow for easy review and organization when studying for the boards.
I encourage all candidates to visit www.ucns.org to peruse eligibility criteria in the grandfa-
thering period as well as information regarding examination format and content.
* The United Council for Neurologic Subspecialties did not participate in or contribute materials or advice in the
development of this book nor does UCNS endorse or recommend this book or any other texts or other teaching aids
for examination preparation purposes.
xvii
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PREFACE
Neurocritical Care is a ubiquitous subspecialty and is of clinical relevance to all inten-

sivists and emergency physicians in addition to general and vascular neurologists, cardiol-
ogists, nephrologists, internists, as well as vascular and trauma surgeons among others. By
no means an exhaustive reference, Neurocritical Care Board Review: Questions and Answers,
addresses many of the day-to-day clinical conundrums pertaining to neurologic and
general critical care patients encountered in all ICUs and ERs. The compilation includes
chapters on neurovascular catastrophes, neurotrauma, encephalopathies, epilepsy, and
neuromuscular emergencies as well as general trauma, respiratory, cardiovascular, renal,
hematologic, and infectious diseases. This broad range of topics makes it a handy tool for
medical students, residents, fellows, advanced care practitioners, and physicians working
in any acute care setting.
Assembling this book has been a labor of love for me. All credit goes to my students,
residents, and fellows for their exhaustive questions on rounds, to my mentors, (especially
Dr. Powner) for urging me to embark on this journey, and most of all, the friends and col-
leagues who participated as authors. This effort was meant to be an extension of my passion
for teaching, and as so often happens when dealing with bright minds, the teacher became
the student! I hope this text is as educational and enjoyable to its readers as it has been for me.
For those of you taking the Neurocritical Care Boards, I hope it serves its purpose of being a
quick and easy self-assessment tool, reference, and guide. Good Luck!
Asma Zakaria, MD
xviii
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Neurocritical Care
Board Review
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I
Neurologic Disease States:
Pathology, Pathophysiology,
and Therapy
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Section I: Cerebrovascular Diseases
1
Infarction, Ischemia,
and Hemorrhage
John J. Volpi
QUESTIONS
1. A 58-year-old man with long-standing hypertension has acute onset of right hemiplegia
and aphasia 6 hours prior to his arrival in the ED. He is obtunded, with a dense left gaze
deviation, and the left pupil is 6 mm and poorly reactive to light, while the right is 4 mm
and reacts to light. The patient vomits and is subsequently intubated and then taken to
CT scan, where he is found to have a large left hemisphere hypodensity with mass effect
and uncal herniation. Of the following steps, which is most proven to lead to a good
outcome?
A. Osmotherapy with 23.4% saline
B. Increase respiratory rate to 24
C. Hemicraniectomy
D. Administer intra-arterial thrombolysis
E. Elevate head of bed to 30°
ANSWERS TO THIS SECTION CAN BE FOUND ON PAGE 10 3

CEREBROVASCULAR DISEASES
2. A 32-year-old woman with a history of complex partial seizures is well controlled on car-
bamazepine for many years. She is found unresponsive in her bedroom. EMS transports
her to the ED where her blood pressure is 175/80, heart rate 110, respiratory rate 12, tem-
perature 37.0°C. She has mid-gaze pinpoint pupils that cannot be overcome with oculo-
cephalic maneuvers, and frequent extensor posturing. CT scan does not show any obvious
hypodensity. The best evaluation to carry out next is:
A. Lumbar puncture
B. Urine toxicology
C. EEG
D. Review CT for hyperdense vessel
3. A 78-year-old man with hypertension, tobacco use, and hyperlipidemia presents with an
episode of transient aphasia lasting 30 minutes and difficulty with right-arm coordination.
He is examined 1 hour later and found with no deficits. An MRI shows no acute stroke.
Carotid duplex suggests 70% to 90% stenosis of the proximal left internal carotid artery at
the bulb. He has no history of coronary artery disease, and his EKG is normal. The best
option for stroke prevention in this patient is:
A. High-dose statin therapy
B. Aspirin
C. Carotid stenting
D. Carotid endarterectomy
4. A 54-year-old woman with hypertension and hyperlipidemia experiences acute right

hemiparesis for 45 minutes. She has a blood pressure of 185/107, recovers, and under-
goes a workup that reveals a left middle cerebral artery stenosis of 75%, but no stroke or
other vessel disease. She is placed on aspirin, atorvastatin 80 mg, and hydrochlorothiazide
25 mg. She does well for 2 days, is discharged, and then experiences a similar episode last-
ing 1 hour. An initial blood pressure is 165/70, which later, when she is asymptomatic, is
145/72. Her repeat workup has no other findings different than prior evaluation. The next
best step proven to reduce her risk of subsequent stroke is:
A. Stop aspirin, start anticoagulation
B. Endovascular stenting of the left-middle cerebral artery
C. Stop hydrochlorothiazide
D. Start lisinopril 10 mg
5. A 21-year-old woman presents with brief right facial sensory loss and mild right upper
extremity incoordination. Her symptoms resolve without any residual deficit. The MRI
shows no infarct, but the magnetic resonance angiography suggests high-grade right-
middle cerebral artery stenosis. An angiogram confirms the stenosis and reveals exten-
sive hypertrophy and collateralization in the lenticulostriate vessels. Her blood pressure is
135/65, and her lipid profile reveals a total cholesterol of 236 and a low-density lipoprotein
of 112. The best option for subsequent management of this patient is:
A. High-dose statin therapy
B. Aspirin
C. Endovascular stenting of the right-middle cerebral artery
D. Surgical bypass of the right-middle cerebral artery

INFARCTION, ISCHEMIA, AND HEMORRHAGE: Questions
6. An 11-year-old boy is admitted with a left putamen hemorrhage. His peripheral blood
smear reveals sickle cell disease. He undergoes appropriate acute management and reha-
bilitation and has no long-term deficits. His discharge blood pressure is 125/66. To prevent
future strokes, the best strategy is:
A. Start blood pressure–lowering medications
B. Encourage the patient to drink plenty of fluids
C. Monitor routine transcranial doppler (TCD)
D. Perform weekly complete blood counts (CBCs) for the first month
7. An 85-year-old woman with mild dementia but no significant vascular disease presents to
the ED within 1 hour of abrupt onset of nausea and altered mental status. Her blood pres-
sure is 135/76, heart rate is 104, respiratory rate 16, and temperature 36.8°C. Her exam is
notable for dense left hemineglect. Her motor exam is limited by her neglect but appears
normal. A CT scan of the brain shows a 4-cm right parietal intracerebral hemorrhage (ICH).
Which of the following treatments could significantly worsen her outcome?
A. Placement of an intraventricular catheter to measure intracranial pressure (ICP)
B. Surgical evacuation of the hematoma within 4 hours
C. Prophylactic seizure therapy with levetiracetam
D. Early nutrition support with tube feeds
8. A 45-year-old man with poorly controlled hypertension presents with new onset ataxia
and dysarthria with a systolic blood pressure of 225/115. A noncontrast head CT shows
a 4-cm right cerebellar hemisphere hemorrhage with near compression of the fourth ven-
tricle and dilation of the lateral and third ventricles. The next best step in management is:
A. Target mean arterial pressure (MAP) of less than 100 mmHg with labetalol push and
nicardipine drip
B. Insert intraventricular drain and normalize intracranial pressure (ICP)
C. Surgical evacuation of the cerebellar hematoma
D. Perform a cerebral angiogram to evaluate for aneurysm
9. A 35-year-old man with poorly controlled hypertension presents to the ED with acute dys-
arthria. His initial blood pressure is 175/110. A noncontrast head CT shows a 1-cm pontine
hemorrhage. He is placed on a nicardipine drip, but before his blood pressure responds, he
becomes obtunded and a follow-up CT shows significant hematoma expansion to involve
3 cm of the mid pons. He is intubated and moved to the ICU with a Glasgow Coma Scale
(GCS) score of 6. Upon arrival to the ICU, the nursing staff comments that this patient has
a poor prognosis and asks you to discuss do-not-resuscitate (DNR) status with the family.
The most appropriate next step is to:
A. Explain to the family that the patient will likely not survive to a functional status and
they should consider no CPR if he worsens overnight
B. Call an ethics consult to evaluate elements of the case for futility of care
C. Notify the family of the severity of the injury but strongly urge them to allow CPR and
full code status for the next 24 hours
D. Notify the case manager that the patient will likely need long-term care, and plan for
early tracheotomy and a gastrostomy tube

10. A 60-year-old woman has a severe headache followed by left hemiplegia. She is brought
to the ED and a noncontrast head CT shows a right thalamic hemorrhage with intra-
ventricular extension. Her blood pressure is 187/100, heart rate is 20, respiratory rate
is 20, and temperature is 37.2°C. She is awake and cooperative but is slowly becoming
more lethargic. Her blood pressure is cautiously lowered with labetalol to a mean arterial
pressure (MAP) of 120 mmHg. She has an intraventricular drain placed that allows the
intracranial pressure (ICP) to be lowered from 25 to 10 cm H2O. She continues to slowly
decline and a follow-up CT shows stability of the bleed but progression of the surround-
ing edema. In addition to continuing ICP drainage, which of the following therapies has
been shown in preliminary trials to reduce perihematoma edema?
A. Induced hypothermia
B. High-dose methylprednisolone
C. Recombinant factor VII
D. Intraventricular tissue plasminogen activator (tPA)
11. A 23-year-old woman is postpartum day 2 from a normal vaginal delivery for which she
received an epidural anesthetic, which was a “wet tap” with spinal leak. She is scheduled
to be discharged home but has a lingering headache and mild nausea, which has been
attributed to a spinal headache. She then has a generalized seizure and becomes difficult
to arouse. Her sclera are injected. She is intubated and taken for noncontrast CT, which
shows diffuse cerebral edema with multiple dilated vessels in the vertex. There are two
small cortical hemorrhages, one 1 cm in the left frontal region, and the other 6 mm in the
right parietal region. What is the likely diagnosis?
A. Ruptured arteriovenous malformation
B. Ruptured left-middle cerebral artery aneurysm
C. Cerebral venous thrombosis
D. Brainstem infarction
12. For the same patient, what is the best initial management?
A. Heparin drip
B. Interventional thrombolysis
C. Mannitol
D. Hemicraniectomy
13. A 45-year-old woman is an unrestrained passenger in a motor vehicle accident where she
sustains a blow to the right side of her head. Other than a brief loss of consciousness and
head pain, she has no deficits. She has a negative noncontrast head CT in an ED after the
event and is discharged home. Over the next several weeks, she notices occasional diplo-
pia and eye redness, prompting further evaluation. Upon seeing her in your office, the
most useful diagnostic test is:
A. Brain MRI with contrast
B. Cerebral angiogram
C. Optic nerve sheath ultrasound
D. Formal visual field assessment

14. A 13-year-old girl has a fall while horseback riding. She has no loss of consciousness, but
complains of left-sided posterior neck pain. She is referred to the ED, where an MRI of the
cervical spine is unremarkable. While she has no motor or sensory deficits, the ED physi-
cian detects a left lid lag and pupil asymmetry and calls for a neurological evaluation. The
pupil asymmetry will be most noticeable:
A. In the dark
B. In direct light
C. During the swinging flash light test
D. When examined with a red lens
15. A 26-year-old nurse has frequent nausea and vomiting during pregnancy. After an epi-
sode of vomiting, she becomes aphasic and has difficulty moving her right arm. She is
brought to the ED, where her symptoms begin to improve, but on exam, she remains
impaired in language fluency and has a right-arm drift. Initial CT is normal, but subse-
quent MRI shows an infarction in the left insula and pre-central gyrus. She undergoes MR
angiogram of the neck, which shows a 6-cm dissection of the carotid artery originating
from the carotid bulb. The lumen is reduced in diameter to approximately 70%. She has
been improving with no further symptoms. The best treatment at this point is:
A. Endovascular stenting
B. Aspirin
C. Warfarin
D. Endarterectomy
16. Which of the following statements regarding blood pressure management in stroke
patients is true?
A. There is significant class-specific evidence for the superiority of calcium channel block-
ers in stroke patients over other blood pressure–reducing medications
B. Stopping blood pressure medications in hospitalized acute stroke patients leads to
worse outcomes
C. Careful blood pressure lowering in the hospital was demonstrated to lead to better
outcomes in the SCAST trial
D. Two-drug therapy is indicated as an initial strategy in patients with an observed blood
pressure of 160/100
17. A 75-year-old man presents with a right facial droop that is apparent at rest and does not
improve with grimace. He is able to elevate his forehead symmetrically. His speech is
slurred but understandable, and he has mild sensory loss on the right with a right-arm
drift, but no other deficits. What would his National Institutes of Health (NIH) Stroke
Scale be?
A. 4
B. 5
C. 6
D. 7

18. A 60-year-old woman with hypertension but no prior stroke or other disease presents to
the hospital via EMS after being found down by her son. Her son had dinner with her
the evening before and she said goodnight to him around 11 p.m. He saw her walking
normally from her bedroom at 8 a.m., but they did not talk. At 10 a.m., she called him at
work and was difficult to understand so he came home and found her on the floor. It is
now 11:30 a.m. Her blood pressure is 175/100, heart rate is 74 and regular, and tempera-
ture is 36.9°C. The patient has a right gaze with dense left hemiplegia. CT of the brain
shows blurring of the gray–white junction in the right-middle cerebral artery territory,
but no definite hypodensity. Her NIH Stroke Scale is calculated to be 22. The right-middle
cerebral artery is hyperdense. Is this patient a candidate for thrombolysis?
A. No, her last-known normal was the prior evening, which is outside the tissue plasmi-
nogen activator (tPA) window
B. No, her last-known normal was 8 a.m., which is outside the approved 3-hour window
for tPA
C. Yes, her time of onset was 10 a.m., which is within the approved 3-hour window for
tPA
D. Yes, her last-known normal was 8 a.m., which is within the 4.5-hour window for tPA
19. A 45-year-old man is on hospital day 2 after a large left-middle cerebral artery infarc-
tion. He develops a temperature of 39.2°C and has a pulmonary infiltrate in the right-
middle lobe of the lung. Which of the following strategies is most effective in achieving
euthermia?
A. Early initiation of broad-spectrum antibiotics
B. Scheduled oral acetaminophen
C. Scheduled IV diclofenac infusions
D. Surface cooling device
20. An 89-year-old woman who lives alone has acute onset of left hemiparesis and dysarthria.
She is brought to the ED, receives IV tissue plasminogen activator (tPA), and improves
to her baseline despite evidence of a 3-cm infarction in the right insula on MRI. The MRI
otherwise shows age-appropriate atrophy without a significant amount of white matter
disease. During her evaluation, she is found to be in atrial fibrillation. What regimen
should be recommended for secondary stroke prevention?
A. Aspirin
B. Aspirin plus clopidogrel
C. Warfarin
D. Amiodarone without anticoagulation
21. In which scenario is anticonvulsant therapy recommended?

A. Prophylaxis in ischemic stroke patients with large cortical infarcts
B. Prophylaxis in hemorrhagic lobar stroke patients with significant edema
C. Prophylaxis in ischemic stroke patients, post hemicraniectomy
D. Ischemic stroke patients who have an isolated, brief seizure 2 weeks after initial
stroke

22. A 31-year-old woman with no significant medical problems experienced a severe headache
while jogging. She went to the ED and was alert but had a severe, throbbing headache and
no focal neurologic symptoms. Her blood pressure was 173/105, and noncontrast head CT
was normal. She went home from the ED, and the following day, she experienced aphasia
while speaking to a friend on the phone. She returned to the ED, where her symptoms
resolved, but a repeat CT scan showed a small, distal, right parietal convexity subarachnoid
hemorrhage. Lumbar puncture (LP) was normal with no inflammation. Cerebral angiog-
raphy showed no aneurysm or arteriovenous malformation (AVM), but multiple areas of
vasoconstriction. She was treated with fluids, and an extensive autoimmune workup was
negative. On follow-up imaging 3 months later, one would expect to find:
A. Complete resolution of the vasoconstriction
B. Mycotic aneurysms
C. Hypertrophy of the lenticulostriates
D. Diffuse white matter disease
23. A 49-year-old woman with no significant past medical history is staying at a hotel on a
business trip abroad when she has acute onset of dysarthria and left-side weakness with
sensory loss. She is found to have a moderate-sized right-middle cerebral artery infarc-
tion on MRI, but no sign of large vessel disease. Her hypercoaguable workup is negative,
EKG and telemetry are normal, and transthoracic echocardiogram (TTE) is normal, but
transesophageal echocardiogram (TEE) shows a right-to-left shunt across a patent fora-
men ovale (PFO) during the Valsalva maneuver. The patient is very interested in “fixing
the problem” and would like to have the PFO closed. The most appropriate next step in
management is:
A. Refer the patient to a cardiologist for PFO closure
B. Start aspirin and counsel the patient that her future stroke risk is negligible
C. Start anticoagulation for life
D. Refer the patient for a clinical trial in PFO closure
24. A 73-year-old woman with hyperlipidemia and hypertension experiences a 30-minute

episode of dysarthria and right-side weakness. She comes to the ED and is fully recov-
ered. Her initial blood pressure is 163/102. CT is normal, and EKG shows normal sinus
rhythm. What is her ABCD2 score, and should she be admitted to the hospital?
A. 3, no admission required
B. 4, no admission required
C. 4, yes admission required
D. 5, yes admission required
25. A 69-year-old man has chest pain and is found to have an aortic dissection requiring
emergent OR repair. Postoperatively, he is noted to be paraplegic. Which of the following
strategies is worthwhile in this patient?
A. Reduction of mean arterial pressure to target less than 100 mmHg
B. Placement of a lumbar drain
C. Avoid bypass methods during surgery for distal reperfusion
D. Prolong ICU sedation to avoid oxygen consumption

1
ANSWERS
1. The answer is C. Hemicraniectomy is a life-saving remedy in the setting of massive

hemispheric infarct. The results of the HAMLET–DESTINY–DECIMAL pooled analysis of
hemicraniectomy versus medical management provide strong evidence for this therapy. A
total of 93 patients were included in the pooled analysis. More patients in the decompres-
sive-surgery group than in the control group had a modified Rankin Score (mRS) less than
or equal to 4 (75% vs. 24%; pooled absolute risk reduction 51%), an mRS ≤ 3 (43% vs. 21%;
23%), and survived (78% vs. 29%; 50%); with numbers needed to treat of two for survival
with mRS ≤ 4, four for survival with mRS ≤ 3, and two for survival irrespective of functional
outcome (1). In this scenario, the patient is an ideal candidate for surgery based on his age
and the early nature of the edema. Osmotherapy is an important temporizing measure to
reduce edema for 2 to 6 hours, but it is not the best answer as it is not a therapy that has
been subjected to a large, randomized trial to show better outcomes in the absence of defini-
tive management. Similarly, raising the head of the bed or increasing the respiratory rate
will produce a decrease in intracranial pressure (ICP) but will not be expected to provide
sufficient benefit to lead to a better outcome. Intra-arterial thrombolysis would be poorly
tolerated in a patient with a large hypodensity on CT and signs of herniation. It would most
likely worsen the patient’s outcome based on analysis of the PROACT II trial (2).
2. The answer is D. This is an abrupt coma with a reportedly normal CT. In this case, the dif-
ferential diagnosis would include a post-ictal state, meningitis, intoxication, subarachnoid
hemorrhage, or brainstem stroke. All are realistic possibilities in this patient, although the
absence of fever makes meningitis the least likely. In terms of the proper steps in carry-
ing out the evaluation for these conditions, basilar thrombosis presents the most morbid
possibility and one that requires prompt recognition in order to consider thrombolysis. A
hyperdense basilar artery is often the only sign of basilar thrombosis on initial CT because
10

Another random document with
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boots not to inquire, with the beautiful daughter of the Laird o’ the
Haugh. I felt it through every vein of my body, and every fibre of my
heart, and I fondly imagined from sundry stealthy glances and sweet
suggestive smiles that the dear creature had perceived and
reciprocated my attachment. The golden silence of love is the highest
eloquence, and the most entrancing song. As good luck and
favouring fortune would have it, I had no sooner left the dining-hall
than the object of my adoration came tripping down stairs alone. In
looking over the drawing-room window a rich flower from her
lustrous hair had fallen to the ground, and the lovely creature was
now hastening to secure the lost treasure. Here was an opportunity
little anticipated, but long remembered. It was impossible that I
could be so ungallant as allow her to search for the fallen flower by
herself, and we therefore went out into the open air together. There
was no moon, but the stars were shining full and brilliant in the
firmament. Tall holly bushes and other shrubs surrounded the house
within the outer circle of trees. The only two sounds I distinctly
heard were the beating of my heart, and the humming sound of the
minister’s voice as he narrated the incidents of his pilgrimage to the
Eternal City. I blessed the good man for his unconscious kindness in
granting me this opportunity. Jessie and I proceeded to the place
where the flower was supposed to be. I saw it at once, and she saw it
at once; but both of us pretended that we had not seen it, and so the
sweet search continued. Need I describe, O amiable reader! how in
searching and stooping I felt the touch of her ringleted hair, the
warmth of her breath, the delicate softness of her cheek, and imbibed
the honey-balm of her lips? At last the flower was found,—I blessed it
unaware,—and, under the starlight, replaced it on that lovely head
from which it had not been untimely plucked, but had most
opportunely fallen.
We returned to the house undiscovered. The Laird, I knew, was in
that pleased and placid state when he could have listened for many
hours to the Man of the Moon describing the incidents of his celestial
travels and the wonders he had seen from his specular tower. I
parted with Jessie at the foot of the staircase, pressed her soft warm
hand, and re-entered the room which I had rather unceremoniously
left. The minister had got upon the Pope, and all the symptoms of
“tired nature” were apparent on the faces of most of the listeners.
They had the look of a congregation when the thirteenth “head” is
being propounded with due deliberation from the pulpit. The Laird
had not seen me depart, but he saw me enter. He evidently placed in
me the most implicit reliance, and there was no suspicion in his look.
“Hae ye been snuffin’ the caller air, doctor?” he inquired.
I answered in the affirmative with a look of perfect innocence, and
then the Laird added, wishing apparently to cut short the minister’s
harangue, “Ay, weel, let’s join the leddies noo.”
After that evening I was a frequent and welcome visitor at the
Haugh. Prince Charlie soon knew the way to his own stall in the
Laird’s stables. Some golden opportunities occurred when the Laird
was absent for interviews and conversations with Jessie. We plighted
our mutual troth, and were devoted to each other heart and soul. The
one grand difficulty in the way of our happiness was the removal of
the Laird’s scruples with regard to the marriage of his daughter. At
last, when jogging leisurely homeward to Oakbank one evening, I hit
upon a scheme which ultimately resulted in complete success, and
gave me possession of the being whom I loved dearer than life.
A wealthy and winsome widow lady resided in the neighbourhood
of St Dunstan, and the project entered my brain to make her believe
that Laird Ramsay had some notions of her, and also to make him
believe that she had a warm side of her heart to him. If I could only
get the Laird to marry the widow, I knew that Jessie would soon
thereafter be mine. The Laird was open to flattery; he was fond of
what Mr Barlas called “butter;” and I did not despair of being able to
make him renew his youth. Tact was required in such a delicate
undertaking, and I resolved to do my spiriting gently. I began with
the Laird first one evening when he was in his mellow after-dinner
state. I praised the graces and winsome ways of Mrs Mackinlay, and
drew from the Laird the confession that he thought her a “very gude
and sociable-like leddy.” I then tried a few dexterous passes before
hinting that she had a warm side to the Laird o’ the Haugh.
“Ye dinna mean to say that Mrs Mackinlay is castin’ a sheep’s e’e at
me, do ye, doctor?”
“I can assure you, Mr Ramsay,” I rejoined, “that she speaks of you
always with great respect, and seems to wonder why you do not
honour her with a visit occasionally.”
“Ay, doctor, it’s queer what way I never thocht o’ that. She’s a
sensible leddy after a’, Mrs Mackinlay. I think I could do worse than
look ower at her hoose some o’ these days.”
“It’s the very thing you ought to do, Mr Ramsay,” I replied. “You
will find her company highly entertaining. She has an accumulated
fund of stories and anecdotes.”
“Has she, doctor?—has she? Weel, I’ll gang; but what would Jessie
say, I wunner?”
I had now put the Laird on the right scent, and I tried my best also
with Mrs Mackinlay. I made her aware of the Laird’s intended visit,
and hinted tenderly its probable object. After a lengthened
conversation, in which I exercised all the ingenuity I possessed, I left
her with the impression on my mind that Laird Ramsay’s addresses
when he called would be met half-way. The meeting did take place—
it was followed by another and another—and the upshot of the
matter was that the eccentric Laird and the wealthy widow were duly
wedded, to the astonishment of the whole district. I allowed six
months of their wedded bliss to slip past before I asked the Laird’s
consent to have Jessie removed from the Haugh to Oakbank. A sort
of dim suspicion of the whole affair seemed to cross the Laird’s mind
when I addressed him. A pawky twinkle lit up his eye as he replied,
“Ah, ye rogue!—tak her, an’ my blessin’ alang wi’ her. Ye ken whaur
to look for a gude wife, an’ I daursay ye’ll no mak the warst o’
gudemen.” Thus I won the Laird’s daughter, and the paradise of
Oakbank, in the village of St Dunstan, was complete in happiness.
MOSS-SIDE.
By Professor Wilson.
Gilbert Ainslie was a poor man; and he had been a poor man all
the days of his life, which were not few, for his thin hair was now
waxing gray. He had been born and bred on the small moorland farm
which he now occupied; and he hoped to die there, as his father and
grandfather had done before him, leaving a family just above the
more bitter wants of this world. Labour, hard and unremitting, had
been his lot in life; but, although sometimes severely tried, he had
never repined; and through all the mist and gloom, and even the
storms that had assailed him, he had lived on from year to year in
that calm and resigned contentment which unconsciously cheers the
hearthstone of the blameless poor. With his own hands he had
ploughed, sowed, and reaped his often scanty harvest, assisted, as
they grew up, by three sons, who, even in boyhood, were happy to
work along with their father in the fields. Out of doors or in, Gilbert
Ainslie was never idle. The spade, the shears, the ploughshaft, the
sickle, and the flail, all came readily to hands that grasped them well;
and not a morsel of food was eaten under his roof, or a garment worn
there, that was not honestly, severely, nobly earned. Gilbert Ainslie
was a slave, but it was for them he loved with a sober and deep
affection. The thraldom under which he lived God had imposed, and
it only served to give his character a shade of silent gravity, but not
austere; to make his smiles fewer, but more heartfelt; to calm his
soul at grace before and after meals, and to kindle it in morning and
evening prayer.
There is no need to tell the character of the wife of such a man.
Meek and thoughtful, yet gladsome and gay withal, her heaven was
in her house; and her gentler and weaker hands helped to bar the
door against want. Of ten children that had been born to them, they
had lost three; and as they had fed, clothed, and educated them
respectably, so did they give them who died a respectable funeral.
The living did not grudge to give up, for a while, some of their daily
comforts for the sake of the dead; and bought, with the little sums
which their industry had saved, decent mournings, worn on Sabbath,
and then carefully laid by. Of the seven that survived, two sons and a
daughter were farm-servants in the neighbourhood, while two
daughters and two sons remained at home, growing, or grown up, a
small, happy, hard-working household.
Many cottages are there in Scotland like Moss-side, and many such
humble and virtuous cottagers as were now beneath its roof of straw.
The eye of the passing traveller may mark them, or mark them not,
but they stand peacefully in thousands over all the land; and most
beautiful do they make it, through all its wide valleys and narrow
glens—its low holms, encircled by the rocky walls of some bonny
burn—its green mounts, elated with their little crowning groves of
plane-trees—its yellow corn-fields—its bare pastoral hill-sides, and
all its heathy moors, on whose black bosom lie shining or concealed
glades of excessive verdure, inhabited by flowers, and visited only by
the farflying bees. Moss-side was not beautiful to a careless or hasty
eye; but, when looked on and surveyed, it seemed a pleasant
dwelling. Its roof, overgrown with grass and moss, was almost as
green as the ground out of which its weather-stained walls appeared
to grow. The moss behind it was separated from a little garden, by a
narrow slip of arable land, the dark colour of which showed that it
had been won from the wild by patient industry, and by patient
industry retained. It required a bright sunny day to make Moss-side
fair, but then it was fair indeed; and when the little brown moorland
birds were singing their short songs among the rushes and the
heather, or a lark, perhaps lured thither by some green barley-field
for its undisturbed nest, rose ringing all over the enlivened solitude,
the little bleak farm smiled like the paradise of poverty, sad and
affecting in its lone and extreme simplicity. The boys and girls had
made some plots of flowers among the vegetables that the little
garden supplied for their homely meals; pinks and carnations,
brought from walled gardens of rich men farther down in the
cultivated strath, grew here with somewhat diminished lustre; a
bright show of tulips had a strange beauty in the midst of that
moorland; and the smell of roses mixed well with that of the clover,
the beautiful fair clover that loves the soil and the air of Scotland,
and gives the rich and balmy milk to the poor man’s lips.
In this cottage, Gilbert’s youngest child, a girl about nine years of
age, had been lying for a week in a fever. It was now Saturday
evening, and the ninth day of the disease. Was she to live or die? It
seemed as if a very few hours were between the innocent creature
and heaven. All the symptoms were those of approaching death. The
parents knew well the change that comes over the human face,
whether it be in infancy, youth, or prime, just before the departure of
the spirit; and as they stood together by Margaret’s bed, it seemed to
them that the fatal shadow had fallen upon her features. The surgeon
of the parish lived some miles distant, but they expected him now
every moment, and many a wistful look was directed by tearful eyes
along the moor. The daughter who was out at service came anxiously
home on this night, the only one that could be allowed her; for the
poor must work in their grief, and servants must do their duty to
those whose bread they eat, even when nature is sick—sick at heart.
Another of the daughters came in from the potato-field beyond the
brae, with what was to be their frugal supper. The calm, noiseless
spirit of life was in and around the house, while death seemed
dealing with one who, a few days ago, was like light upon the floor,
and the sound of music, that always breathed up when most wanted;
glad and joyous in common talk—sweet, silvery, and mournful, when
it joined in hymn or psalm. One after the other, they all continued
going up to the bedside, and then coming away sobbing or silent, to
see their merry little sister, who used to keep dancing all day like a
butterfly in a meadowfield, or, like a butterfly with shut wings on a
flower, trifling for a while in the silence of her joy, now tossing
restlessly on her bed, and scarcely sensible to the words of
endearment whispered around her, or the kisses dropped with tears,
in spite of themselves, on her burning forehead.
Utter poverty often kills the affections; but a deep, constant, and
common feeling of this world’s hardships, and an equal participation
in all those struggles by which they may be softened, unite husband
and wife, parents and children, brothers and sisters, in thoughtful
and subdued tenderness, making them happy indeed, while the circle
round the fire is unbroken, and yet preparing them every day to bear
the separation, when some one or other is taken slowly or suddenly
away. Their souls are not moved by fits and starts, although, indeed,
nature sometimes will wrestle with necessity; and there is a wise
moderation both in the joy and the grief of the intelligent poor,
which keeps lasting trouble away from their earthly lot, and prepares
them silently and unconsciously for heaven.
“Do you think the child is dying?” said Gilbert, with a calm voice,
to the surgeon, who, on his wearied horse, had just arrived from
another sick-bed, over the misty range of hills, and had been looking
steadfastly for some minutes on the little patient. The humane man
knew the family well, in the midst of whom he was standing, and
replied, “While there is life there is hope; but my pretty little
Margaret is, I fear, in the last extremity.” There was no loud
lamentation at these words; all had before known, though they would
not confess it to themselves, what they now were told; and though
the certainty that was in the words of the skilful man made their
hearts beat for a little with sicker throbbings, made their pale faces
paler, and brought out from some eyes a greater gush of tears, yet
death had been before in this house, and in this case he came, as he
always does, in awe, but not in terror. There were wandering and
wavering and dreamy delirious fantasies in the brain of the innocent
child; but the few words she indistinctly uttered were affecting, not
rending to the heart, for it was plain that she thought herself herding
her sheep in the green silent pastures, and sitting wrapped in her
plaid upon the lown and sunny side of the Birk-knowe. She was too
much exhausted—there was too little life, too little breath in her
heart—to frame a tune; but some of her words seemed to be from
favourite old songs; and at last her mother wept, and turned aside
her face, when the child, whose blue eyes were shut, and her lips
almost still, breathed out these lines of the beautiful twenty-third
Psalm:—
The Lord’s my shepherd, I’ll not want.
He makes me down to lie
In pastures green: He leadeth me
The quiet waters by.
The child was now left with none but her mother by the bedside,
for it was said to be best so; and Gilbert and his family sat down
round the kitchen fire, for a while, in silence. In about a quarter of an
hour, they began to rise calmly, and to go each to his allotted work.
One of the daughters went forth with the pail to milk the cow, and
another began to set out the table in the middle of the floor for
supper, covering it with a white cloth. Gilbert viewed the usual
household arrangements with a solemn and untroubled eye; and
there was almost the faint light of a grateful smile on his cheek, as he
said to the worthy surgeon, “You will partake of our fare, after your
day’s travel and toil of humanity?” In a short silent half-hour, the
potatoes and oat-cakes, butter and milk, were on the board; and
Gilbert, lifting up his toil-hardened but manly hand, with a slow
motion, at which the room was as hushed as if it had been empty,
closed his eyes in reverence, and asked a blessing. There was a little
stool, on which no one sat, by the old man’s side. It had been put
there unwittingly, when the other seats were all placed in their usual
order; but the golden head that was wont to rise at that part of the
table was now wanting. There was silence—not a word was said—
their meal was before them—God had been thanked, and they began
to eat.
While they were at their silent meal a horseman came galloping to
the door, and, with a loud voice, called out that he had been sent
express with a letter to Gilbert Ainslie; at the same time rudely, and
with an oath, demanding a dram for his trouble. The eldest son, a lad
of eighteen, fiercely seized the bridle of his horse, and turned its head
away from the door. The rider, somewhat alarmed at the flushed face
of the powerful stripling, threw down the letter and rode off. Gilbert
took the letter from his son’s hand, casting, at the same time, a half-
upbraiding look on his face, that was returning to its former colour.
“I feared,”—said the youth, with a tear in his eye,—“I feared that the
brute’s voice, and the trampling of the horse’s feet, would have
disturbed her.” Gilbert held the letter hesitatingly in his hand, as if
afraid at that moment to read it; at length he said aloud to the
surgeon:—“You know that I am a poor man, and debt, if justly
incurred, and punctually paid when due, is no dishonour.” Both his
hand and his voice shook slightly as he spoke; but he opened the
letter from the lawyer, and read it in silence. At this moment his wife
came from her child’s bedside, and, looking anxiously at her
husband, told him “not to mind about the money, that no man who
knew him would arrest his goods, or put him into prison. Though,
dear me, it is cruel to be put to thus, when our bairn is dying, and
when, if so it be the Lord’s will, she should have a decent burial, poor
innocent, like them that went before her.” Gilbert continued reading
the letter with a face on which no emotion could be discovered; and
then, folding it up, he gave it to his wife, told her she might read it if
she chose, and then put it into his desk in the room, beside the poor
dear bairn. She took it from him, without reading it, and crushed it
into her bosom: for she turned her ear towards her child, and
thinking she heard it stir, ran out hastily to its bedside.
Another hour of trial passed, and the child was still swimming for
its life. The very dogs knew there was grief in the house, and lay
without stirring, as if hiding themselves, below the long table at the
window. One sister sat with an unfinished gown on her knees, that
she had been sewing for the dear child, and still continued at the
hopeless work, she scarcely knew why; and often, often putting up
her hand to wipe away a tear. “What is that?” said the old man to his
eldest daughter. “What is that you are laying on the shelf?” She could
scarcely reply that it was a riband and an ivory comb that she had
brought for little Margaret, against the night of the dancing-school
ball. And at these words the father could not restrain a long, deep,
and bitter groan; at which the boy, nearest in age to his dying sister,
looked up weeping in his face; and, letting the tattered book of old
ballads, which he had been poring on, but not reading, fall out of his
hands, he rose from his seat, and, going into his father’s bosom,
kissed him, and asked God to bless him: for the holy heart of the boy
was moved within him; and the old man, as he embraced him, felt
that, in his innocence and simplicity, he was indeed a comforter.
“The Lord giveth, and the Lord taketh away,” said the old man;
“blessed be the name of the Lord!”
The outer door gently opened, and he whose presence had in
former years brought peace and resignation hither, when their hearts
had been tried even as they now were tried, stood before them. On
the night before the Sabbath, the minister of Auchindown never left
his manse, except, as now, to visit the sick or dying bed. Scarcely
could Gilbert reply to his first question about his child, when the
surgeon came from the bedroom, and said—“Margaret seems lifted
up by God’s hand above death and the grave: I think she will recover.
She has fallen asleep; and, when she wakes, I hope—I—believe—that
the danger will be past, and that your child will live.”
They were all prepared for death; but now they were found
unprepared for life. One wept that had till then locked up all her
tears within her heart; another gave a short palpitating shriek; and
the tender-hearted Isobel, who had nursed the child when it was a
baby, fainted away. The youngest brother gave way to gladsome
smiles; and calling out his dog Hector, who used to sport with him
and his little sister on the moor, he told the tidings to the dumb
irrational creature, whose eyes, it is certain, sparkled with a sort of
joy. The clock for some days had been prevented from striking the
hours; but the silent fingers pointed to the hour of nine; and that, in
the cottage of Gilbert Ainslie, was the stated hour of family worship.
His own honoured minister took the Book,—
He waled a portion with judicious care,
And, “Let us worship God,” he said, with solemn air.
A chapter was read—a prayer said; and so, too, was sung a psalm;
but it was sung low, and with suppressed voices, lest the child’s
saving sleep might be broken; and now and then the female voices
trembled, or some one of them ceased altogether; for there had been
tribulation and anguish, and now hope and faith were tried in the joy
of thanksgiving.
The child still slept; and its sleep seemed more sound and deep. It
appeared almost certain that the crisis was over, and that the flower
was not to fade. “Children,” said Gilbert, “our happiness is in the love
we bear to one another; and our duty is in submitting to and serving
God. Gracious, indeed, has He been unto us. Is not the recovery of
our little darling, dancing, singing Margaret, worth all the gold that
ever was mined? If we had had thousands of thousands, would we
not have filled up her grave with the worthless dross of gold, rather
than that she should have gone down there with her sweet face and
all her rosy smiles?” There was no reply, but a joyful sobbing all over
the room.
“Never mind the letter, nor the debt, father,” said the eldest
daughter. “We have all some little thing of our own,—a few pounds,—
and we shall be able to raise as much as will keep arrest and prison at
a distance. Or if they do take our furniture out of the house, all
except Margaret’s bed, who cares? We will sleep on the floor; and
there are potatoes in the field, and clear water in the spring. We need
fear nothing, want nothing; blessed be God for all His mercies!”
Gilbert went into the sick-room, and got the letter from his wife,
who was sitting at the head of the bed, watching, with a heart blessed
beyond all bliss, the calm and regular breathings of her child. “This
letter,” said he, mildly, “is not from a hard creditor. Come with me
while I read it aloud to our children.” The letter was read aloud, and
it was well fitted to diffuse pleasure and satisfaction through the
dwelling of poverty. It was from an executor to the will of a distant
relative, who had left Gilbert Ainslie £1500.
“The sum,” said Gilbert, “is a large one to folks like us, but not, I
hope, large enough to turn our heads, or make us think ourselves all
lords and ladies. It will do more, far more, than put me fairly above
the world at last. I believe that, with it, I may buy this very farm, on
which my forefathers have toiled. But God, whose providence has
sent this temporal blessing, may He send us wisdom and prudence
how to use it, and humble and grateful hearts to us all.”
“You will be able to send me to school all the year round now,
father,” said the youngest boy. “And you may leave the flail to your
sons, now, father,” said the eldest. “You may hold the plough still, for
you draw a straighter furrow than any of us; but hard work for young
sinews; and you may sit now oftener in your arm-chair by the ingle.
You will not need to rise now in the dark, cold, and snowy winter
mornings, and keep threshing corn in the barn for hours by
candlelight, before the late dawning.”
There was silence, gladness, and sorrow, and but little sleep in
Moss-side, between the rising and the setting of the stars, that were
now out in thousands, clear, bright, and sparkling over the
unclouded sky. Those who had lain down for an hour or two in bed
could scarcely be said to have slept; and when about morning little
Margaret awoke, an altered creature, pale, languid, and unable to
turn herself on her lowly bed, but with meaning in her eyes, memory
in her mind, affection in her heart, and coolness in all her veins, a
happy group were watching the first faint smile that broke over her
features; and never did one who stood there forget that Sabbath
morning on which she seemed to look round upon them all with a
gaze of fair and sweet bewilderment, like one half conscious of
having been rescued from the power of the grave.
MY FIRST FEE.
A Chapter from the Autobiography of an Advocate.

“Fee him, father, fee him.”
Seven long yearning years had elapsed since, with the budding
anticipation of youthful hope, I had assumed the lugubrious insignia
of the bar. During that dreadful time, each morn, as old St Giles told
the hour of nine, might I be seen insinuating my emaciated figure
within the penetralia of the Parliament House, where, begowned and
bewigged, and with the zeal of a Powell or a Barclay, I paced about
till two. These peripatetic practices had well-nigh ruined me in
Wellingtons, and latterly in shoes. My little Erskine was in pawn;
while my tailor and my landlady threw out unmistakable and
ominous hints regarding their long bills and longer credit. I dared
not understand them, but consoled myself with the thought, that the
day would come when my tailor would cease his dunning, and my
landlady her clamour.
I had gone the different circuits, worn and torn my gown, seated
myself in awful contemplation on the side benches, maintained
angry argument on legal points with some more favoured brother,
within earshot of a wily writer. In fine, I had resorted to every means
that fancy could suggest, or experience dictate; but as yet my eyes
had not seen, nor my pocket felt—a Fee. Alas! this was denied. I
might be said to be, as yet, no barrister: for what is a lawyer without
a fee? A nonentity! a shadow! To my grief, I seemed to be fast verging
to the latter; and I doubt much whether the “Anatomie vivant” could
have stood the comparison—so much had my feeless fast fed on my
flesh!
I cannot divine the reason for this neglect of my legal services. In
my own heart, I had vainly imagined the sufficiency of my tact and
subtlety in unravelling a nice point; neither had I been wanting in
attention to my studies; for Heaven and my landlady can bear
witness, that my consumption of coal and candle would have sufficed
any two ordinary readers. There was not a book or treatise on law
which I had not dived into. I was insatiable in literature; but the
world and the writers seemed ignorant of my brain be-labouring
system, and sedulously determined that my fee-ling propensities
should not be gratified.
Never did I meet an agent either in or out of Court, but my heart
and hand felt a pleasing glow of hope and of joy at the prospect of
pocketing a fee; but how often have they turned their backs without
even the mortifying allusion to such a catastrophe! How often have I
turned round in whirling ecstacy as I felt some seemingly patronising
palm tap gently on my shoulders with such a tap as writers’ clerks are
wont to use; but oh, ye gods! a grinning wretch merely asked me how
I did, and passed on!
Nor were my non-legal friends more kind. There was an old
gentleman, who, I knew (for I made it my business to enquire), had
some thoughts of a law-plea. From him I received an invitation to
dinner. Joyfully, as at all times, but more so on this occasion, was the
summons obeyed. I had laid a train to introduce the subject of his
wrongs at a time which might suit best, and with this plan I
commenced my machinations. The old fox was too cunning even for
me; he too had his plot, and had hit upon the expedient of obtaining
my opinion without a fee—the skinflint! Long and doubtful was the
contest; hint succeeded hint, question after question was put, till at
last my entertainer was victorious, and I retired crestfallen and
feeless from the field! By the soul of Erskine, had it not been for his
dinners, I should have cut him for ever! Still I grubbed with this one,
cultivated an acquaintance with that, but all to no purpose; no one
pitied my position. My torments were those of the lost! Hope (not the
President) alone buoyed me up; visions of future sovereigns,
numerous as those which appeared to Banquo of old, but of a better
and more useful kind, flitted before my charmed imagination. Pride,
poverty, and starvation pushed me on. What! said I, shall it be hinted
that I am likely neither to have a fee nor a feed? Tell it not in the First
Division; publish it not in the Outer House! All my thoughts were
riveted to one object—to one object all my endeavours were bent, and
to accomplish this seemed the ultimatum of bliss.
Often have I looked with envy upon the more favoured candidates
for judicial fame—those who never return to their domicile or their
dinner, but to find their tables groaning with briefs! How different
from my case! My case? What case? I have no case! Not one fee to
work its own desolateness! Months and months passed on, still
success came not! The hoped-for event came not; resolution died
within me; I formed serious intentions of being even with the
profession. As the profession had cut me, I intended to have cut the
profession. In my wants, I would have robbed, but my hand was
withheld by the thought that the jesters of the stove might taunt me
thus: “He could not live, so he died, by the law.” I have often thought
that there is a great similarity between the hangman and the want of
a fee; the one is the finisher of the law, the other of lawyers!
Pondering on my griefs, with my feet on the expiring embers of a
seacoal fire, the chair in that swinging position so much practised
and approved in Yankee-land,—the seat destined for a clerk occupied
by my cat, for I love everything of the fe-line species,—my cogitations
were disturbed by an application for admittance at the outer door. It
was not the rat-tat of the postman, nor the rising and falling attack of
the man of fashion, but a compound of both, which evidently
bespoke the knockee unaccustomed to town. I am somewhat curious
in knocks; I admire the true principles of the art, by which one may
distinguish the peer from the postman—the dun from the dilettante
—the footman from the furnisher. But there was something in this
knock which baffled all my skill; yet sweet withal, thrilling through
my heart with a joy unfelt before. Some spirit must have presided in
the sound, for it seemed to me the music of the spheres.
A short time elapsed, and my landlady “opened wide the infernal
doors.” Now hope cut capers—(Lazenby, thou wert not to blame, for
of thy delicacies I dared not even dream!)—now hope cut capers
within me! Heavy footsteps were heard in the passage, and one of the
lords of the creation marched his calves into the apartment. With
alacrity, I conveyed my corpus juris to meet him, and, with all
civility, I requested him to be seated. My landlady with her apron
dusted the arm-chair (I purchased it at a sale of Lord M——’s effects,
not causes,—expecting to catch inspiration). In this said chair my
man ensconced his clay.
I had commenced my survey of his person, when my eyes were
attracted by a basilisk-like bunch of papers which the good soul held
in his hand. In ecstasy I gazed—characters were marked on them
which could not be mistaken; a less keen glance than mine might
have discovered their import. My joy was now beyond all bounds,
testifying itself by sundry kickings and contortions of the body. I
began to fear the worthy man might think me mad, and repent him
of his errand; I calmed myself, and sat down. My guest thrust into
my hands the papers, and then proceeded to issue letters of open
doors against his dexter pocket. His intentions were evident; with
difficulty could I restrain myself. For some minutes he “groped about
the vast abyss,” during which time my agitation increased so much
that I could not have answered one question, even out of that
favourite chapter of one of our institutional writers, “On the
Institution of Fees.” But let me describe the man to whom I owe so
much.
He was a short, squat, farmer-looking being, who might have
rented some fifty acres or so. Though stinted in his growth upwards,
Dame Nature seemed determined to make him amends by an
increase of dimension in every other direction. His nose and face
spoke volumes—ay, libraries—of punch and ale; these potations had
also made themselves manifested lower down, by the magnitude of
the belli-gerent powers. There was in his face a cunning leer, in his
figure a knowing tournure, which was still further heightened by his
dress; this consisted of a green coat, which gave evident signs of its
utter incapability of ever being identified with Stultz; cords and
continuations encased the lower parts of his carcase; a belcher his
throat; while the whole was surmounted by a castor of the most
preposterous breadth of brim, and shallow capacity. But in this
man’s appearance there was something that pleased me; something
of a nature superior to other mortals. I might have been prejudiced,
but his face and figure seemed to me more beautiful than morning.
Never did I gaze with a more complacent benevolence on a
breeches-pocket. At last he succeeded in dragging from its depths a
huge old stocking, through which “the yellow-lettered Geordie’s
keeked.” With what raptures did I look on that old stocking, the
produce, I presumed, of the stocking of his farm. It seemed to
possess the power of fascination, for my eyes could not quit it. Even
when my client (for now I calculated upon him) began to speak, my
attention still wandered to the stocking. He told me of a dispute with
his landlord about some matters relating to his farm, that he was
wronged, and would have the law of the laird, though he should
spend his last shilling (here I looked with increased raptures at the
stocking). On the recommendation of the minister (good man!), he
had sought me for advice. He then opened wide the jaws of his
homely purse—he inserted his paw—now my heart beat—he made a
jingling noise—my heart beat quicker still—he pulled forth his two
interesting fingers—oh, ecstasy! he pressed five guineas into my
extended hand—they touched the virgin palm, and oh, ye gods! I was
Fee’d!!!—Edinburgh Literary Journal.
THE KIRK OF TULLIBODY.
The parish of Tullibody, in Clackmannanshire, now united with

Alloa, was, before the Reformation, an independent ecclesiastical
district. The manner in which it lost its separate character is curious.
In the year 1559, when Monsieur D’Oysel commanded the French
troops on the coast of Fife, they were alarmed by the arrival of the
English fleet, and thought of nothing but a hasty retreat. It was in the
month of January, and at the breaking of a great storm. William
Kirkaldy of Grange, commander of the congregational forces,
attentive to the circumstances in which his enemies were caught,
took advantage of this situation, and marched with great expedition
towards Stirling, and cut the bridge of Tullibody, which was over the
Devon, to prevent their retreat. By this manœuvre, the French found
themselves completely enclosed. They were driven to an extremity
which obliged them to resort to an extraordinary expedient to effect
their escape. They lifted the roof off the church of Tullibody, and laid
it along the broken part of the bridge, by which means they effected a
safe retreat to Stirling.
Such a dilapidation of the church caused the Tullibodians to
proceed to the adjacent kirk of Alloa, and in a short time the parish
ceased to be independent. The burying-ground round the ancient
place of worship, now repaired, still remains; and on the north side
of it, where there had been formerly an entry, there is a stone coffin,
with a niche for the head, and two for the arms, covered with a thick
hollowed lid like a tureen. The lid is a good deal broken, but a
curious tradition is preserved of the coffin. It is related that in early
times a young lady of the neighbourhood had declared her affection
for the minister, who, either from his station or want of inclination,
made no returns. So vexed was the lady on perceiving his
indifference, that, in a short while, she sickened, and at last died of
grief. While on her deathbed, she left it as her last request, that she
should not be buried in the earth, but that her body should be placed
in a stone coffin, and laid at the entry to the church; which was done,
and to this day, the stone retains the name of the “Maiden’s Stone.”—
Chambers’ Edinburgh Journal, 1832.
THE PROGRESS OF INCONSTANCY;
OR, THE SCOTS TUTOR.
“Sweet, tender sex! with snares encompassed round,

On others hang thy comforts and thy rest.”—Hogg.
Nature has made woman weak, that she might receive with
gratitude the protection of man. Yet how often is this appointment
perverted! How often does her protector become her oppressor!
Even custom seems leagued against her. Born with the tenderest
feelings, her whole life is commonly a struggle to suppress them.
Placed in the most favourable circumstances, her choice is confined
to a few objects; and unless where singularly fortunate, her fondest
partialities are only a modification of gratitude. She may reject, but
cannot invite: may tell what would make her wretched, but dare not
even whisper what would make her happy; and, in a word, exercises
merely a negative influence upon the most important event of her
life. Man has leisure to look around him, and may marry at any age,
with almost equal advantage; but woman must improve the fleeting
moment, and determine quickly, at the hazard of determining rashly.
The spring-time of her beauty will not last; its wane will be the signal
for the flight of her lovers; and if the present opportunity is
neglected, she may be left to experience the only species of
misfortune for which the world evinces no sympathy. How cruel,
then, to increase the misery of her natural dependence! How
ungenerous to add treachery to strength, and deceive or disappoint
those whose highest ambition is our favour, and whose only safety is
our honesty!
William Arbuthnot was born in a remote county of Scotland, where
his father rented a few acres of land, which his own industry had
reclaimed from the greatest wildness to a state of considerable
fertility. Having given, even in his first attempts at learning, those
indications of a retentive memory, which the partiality of a parent
easily construes into a proof of genius, he was early destined for the
Scottish Church, and regarded as a philosopher before he had
emerged from the nursery. While his father pleased himself with the
prospect of seeing his name associated with the future greatness of
his son, his mother, whose ambition took a narrower range, thought
she could die contented if she should see him seated in the pulpit of
his native church; and perhaps, from a pardonable piece of vanity,
speculated as frequently upon the effect his appearance would have
upon the hearts of the neighbouring daughters, as his discourses
upon the minds of their mothers. This practice, so common among
the poorer classes in Scotland, of making one of their children a
scholar, to the prejudice, as is alleged, of the rest, has been often
remarked, and sometimes severely censured. But probably the
objections that have been urged against it, derive their chief force
from the exaggerations upon which they are commonly founded. It is
not in general true that parents, by bestowing the rudiments of a
liberal education upon one of the family, materially injure the
condition or prospects of the rest. For it must be remembered that
the plebeian student is soon left to trust to his own exertions for
support, and, like the monitor of a Lancastrian seminary, unites the
characters of pupil and master, and teaches and is taught by turns.
But to proceed with our little narrative. The parish schoolmaster
having intimated to the parents of his pupil, that the period was at
hand when he should be sent to prosecute his studies at the
university, the usual preparations were made for his journey, and his
departure was fixed for the following day, when he was to proceed to
Edinburgh under escort of the village carrier and his black dog
Cæsar, two of the eldest and most intimate of his acquaintance.
Goldsmith’s poetical maxim, that little things are great to little men,
is universally true; and this was an eventful day for the family of
Belhervie, for that was the name of the residence of Mr Arbuthnot.
The father was as profuse of his admonitions as the mother was of
her tears, and had a stranger beheld the afflicted group, he would
have naturally imagined that they were bewailing some signal
calamity, in place of welcoming an event to which they had long
looked forward with pleasure. But the feelings of affectionate regret,
occasioned by this separation, were most seasonably suspended by

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Acquisitions Editor: Beth Barry

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America by Bradford and Bigelow.

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PART I: NEUROLOGIC DISEASE STATES: PATHOLOGY, PATHOPHYSIOLOGY, AND THERAPY

Section I: Cerebrovascular Diseases

Section II: Neurotrauma

Section III: Disorders, Diseases, Seizures, and Epilepsy

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PART II: GENERAL CRITICAL CARE: PATHOLOGY, PATHOPHYSIOLOGY, AND THERAPY

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22. Acute Hematologic Disorders 333

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Amy R. Alger, MD, FACS

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Cecile L. Phan, MD, FRCPC

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Neurocritical Care is a ubiquitous subspecialty and is of clinical relevance to all inten-

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ANSWERS TO THIS SECTION CAN BE FOUND ON PAGE 10 3

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4. A 54-year-old woman with hypertension and hyperlipidemia experiences acute right

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21. In which scenario is anticonvulsant therapy recommended?

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24. A 73-year-old woman with hyperlipidemia and hypertension experiences a 30-minute

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1. The answer is C. Hemicraniectomy is a life-saving remedy in the setting of massive

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A Chapter from the Autobiography of an Advocate.

The parish of Tullibody, in Clackmannanshire, now united with

“Sweet, tender sex! with snares encompassed round,