Fundamental skills Flashcards
Approximately what percentage of total body fluid is intravascular?
A. 3%
B. 8%
C. 25%
D. 50%
E. 75%
A. 3%
B. 8%
C. 25%
D. 50%
E. 75%
In a normal 70-kg man, approximately 67% of fluid is intracellular and 33% is extracellular. Of the extracellular fluid, a further 25% is interstitial, and the remaining approximately 8% is intravascular.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 300.
You evaluate a patient in the emergency department who has a history of avsyringopleural shunt and now is having difficulty breathing. Chest X-ray is shown. What treatment should you consider in this patient?
A. Diuretics
B. Needle decompression
C. Shunt externalization/removal
D. Antibiotics
E. Observation
A. Diuretics
B. Needle decompression
C. Shunt externalization/removal
D. Antibiotics
E. Observation
This patient has evidence of a large pleural effusion on the side where the syringopleural shunt has been placed. In this case, the shunt should be externalized or removed completely. General/thoracic surgery can address the pleural effusion, but further treatment of the syrinx will have to be performed via another approach.
Further Reading: Procedures: Syringopleural Shunting, Thieme eNeurosurgery.
What finding on invasive monitoring would a patient with cardiogenic pulmonary edema likely have?
A. Hypoxemia with a normal A–a gradient
B. PCWP > 18 mm Hg
C. PCWP < 18 mm Hg
D. PAO2/FiO2 255 mm Hg
E. Hypoventilation with normal A–a gradient
A. Hypoxemia with a normal A–a gradient
B. PCWP > 18 mm Hg
C. PCWP < 18 mm Hg
D. PAO2/FiO2 255 mm Hg
E. Hypoventilation with normal A–a gradient
In patients with cardiogenic pulmonary edema, the PCWP is elevated beyond 18 mm Hg. In acute or adult respiratory distress syndrome (ARDS), the PCWP is less than 18 mm Hg.
What medication can be used in patients with severe ARDS to improve oxygenation?
A. Diuretics
B. Dobutamine
C. Dexamethasone
D. Beta blocker
E. Nimodipine
A. Diuretics
B. Dobutamine
C. Dexamethasone
D. Beta blocker
E. Nimodipine
Of the listed medications, only dobutamine has positive effects in patients with severe ARDS. Its inotropic effects can increase cardiac output and thus oxygen delivery.
Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 503.
In treating what type of arrhythmia is adenosine useful?
A. Narrow complex tachycardia
B. Wide complex tachycardia
C. Ventricular fibrillation
D. Atrial fibrillation
E. Wolff–Parkinson–White syndrome
A. Narrow complex tachycardia
B. Wide complex tachycardia
C. Ventricular fibrillation
D. Atrial fibrillation
E. Wolff–Parkinson–White syndrome
Adenosine briefly interrupts transmission through the His–Purkinje system and causes asystole for several seconds. It can be useful for treating supraventricular tachycardia (a narrow complex tachycardia).
Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 498.
You are caring for a patient in the ICU who has suddenly developed a wide complex tachycardia. She is awake, conversive, and currently stable. What would be an appropriate treatment for her condition?
A. Defibrillation
B. Lidocaine infusion
C. Coronary angiogram
D. tPA administration
E. Adenosine
A. Defibrillation
B. Lidocaine infusion
C. Coronary angiogram
D. tPA administration
E. Adenosine
This patient has a stable, wide complex tachycardia. She could undergo elective, synchronized cardioversion, or infusion of lidocaine, which can treat wide complex tachycardia. The other options are not reasonable in a stable patient.
Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 498.
You are evaluating a new admission to the neuro-ICU. The patient was involved in a motor vehicle collision and currently demonstrates flexor posturing of the upper extremities, briefly opens his eyes to pain, and is nonverbal. What is his GCS score?
A. 15
B. 0
C. 3
D. 6
E. 9
A. 15
B. 0
C. 3
D. 6
E. 9
The GCS is a commonly used scale for neurotrauma. Points are assigned for motor, verbal and eye-opening responses. This patient gets 3 points for flexor posturing, 2 points for eye opening to pain, and 1 point for no verbal response.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, pages 3–5.
In the neuro-ICU, you are called by a nurse to evaluate a patient with pupillary abnormalities. When you see the patient, you observe rhythmic dilation and contraction of the pupillary sphincter muscles. What is causing this?
A. Normal physiologic response
B. Uncal herniation
C. Diabetic oculomotor palsy
D. Transient ischemic attacks
E. Shearing injury of the oculomotor nerve
A. Normal physiologic response
B. Uncal herniation
C. Diabetic oculomotor palsy
D. Transient ischemic attacks
E. Shearing injury of the oculomotor nerve
This patient is exhibiting hippus, a normal physiologic response where the pupils dilate and contract seemingly randomly. It can also be seen during recovery of oculomotor nerve injury.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 14.
You are caring for a patient in the neuro-ICU after an intracerebral hemorrhage. She has baseline progressive dementia. In the ICU, her delirium worsens significantly in the evening and at night. This condition is thought to be due to degeneration of what hypothalamic nucleus?
A. Anterior nucleus
B. Ventromedial nucleus
C. Suprachiasmatic nucleus
D. Supraoptic nucleus
E. Lateral nucleus
A. Anterior nucleus
B. Ventromedial nucleus
C. Suprachiasmatic nucleus
D. Supraoptic nucleus
E. Lateral nucleus
This patient is experiencing sundowning, where delirium worsens in the evening and at night. It is thought that this is at least partially due to degeneration of the suprachiasmatic nucleus of the hypothalamus, and dysregulation of melatonin release and the circadian rhythm.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 31.
Which of the following is not a type of opioid receptor?
A. Mu
B. Delta
C. Kappa
D. N/OFQ
E. Gamma
A. Mu
B. Delta
C. Kappa
D. N/OFQ
E. Gamma
Opioid receptors have four classes, mu, delta, kappa, and N/OFQ. Gamma is not an opioid receptor subtype. There is interest in the kappa receptor as a target for pain medication as it may also have neuroprotective effects in traumatic brain injury.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 150.
Which of the following coagulation cascade factors is inhibited by warfarin?
A. 3
B. 5
C. 8
D. 9
E. 12
A. 3
B. 5
C. 8
D. 9
E. 12
Warfarin inhibits vitamin K–dependent factors, including factors II, VII, IX, and X and proteins C and S.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 47.
Approximately how long will it take for IV vitamin K to normalize the INR in a patient who is anticoagulated with warfarin?
A. 4 hours
B. 8 hours
C. 12 hours
D. 18 hours
E. 24+ hours
A. 4 hours
B. 8 hours
C. 12 hours
D. 18 hours
E. 24+ hours
IV vitamin K has excellent bioavailability and a rapid onset; however, the vitamin K–dependent coagulation factors have long half-lives, with factor II having a half-life of 65 hours. Therefore, it can take between 24 to 72 hours for IV vitamin K to reverse the INR.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 48.
On what coagulation factor does the combination of heparin/antithrombin exert anticoagulant effects?
A. III
B. VII
C. IX
D. Xa
E. XII
A. III
B. VII
C. IX
D. Xa
E. XII
Heparin binds to antithrombin, and this combination has a high affinity for factor Xa, inhibiting its function and causing anticoagulation. It is monitored using activated partial thromboplastin time (aPTT).
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 52.
You are treating a patient in the ICU who is in acute renal failure and needs to have DVT prophylaxis initiated. Unfortunately, she has developed heparin-induced thrombocytopenia and you need another option. Which of the following anticoagulants would be contraindicated in her current condition?
A. Aspirin
B. Dabigatran
C. Argatroban
D. Warfarin
E. Clopidogrel
A. Aspirin
B. Dabigatran
C. Argatroban
D. Warfarin
E. Clopidogrel
Dabigatran is in the class of direct thrombin inhibitors, which can be used for anticoagulation in patients with HIT. Dabigatran is cleared by the kidney, however, and it should be avoided in patients with renal failure. Argatroban is cleared by the liver, and would be a better choice.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 54.
What is the approximate half-life of aspirin?
A. 30 minutes
B. 6 hours
C. 24 hours
D. 7 days
E. 1 month
A. 30 minutes
B. 6 hours
C. 24 hours
D. 7 days
E. 1 month
The half-life of aspirin is very short, only 30 minutes. It has lasting effects, however, due to the irreversible inhibition of platelets, which survive for 7 days. The effect of aspirin will no longer be evident in most patients by 5 to 7 days after the last dose.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 55.
Via what mechanism does clopidogrel exhibit an antiplatelet effect?
A. Inhibition of thromboxane synthesis via COX 1 inhibition
B. P2Y12 receptor binding inhibiting ADP mediated platelet aggregation (GPIIb/IIIa)
C. Thienopyridine-mediated ADP receptor blockade
D. Factor IIa inhibition
E. Binds antithrombin III
A. Inhibition of thromboxane synthesis via COX
1 inhibition
B. P2Y12 receptor binding inhibiting ADP mediated platelet aggregation (GPIIb/IIIa)
C. Thienopyridine-mediated ADP receptor
blockade
D. Factor IIa inhibition
E. Binds antithrombin III
Clopidogrel (plavix) inhibits platelet function by binding to the P2Y12 receptor and inhibiting ADP-mediated GPIIb/IIIa complex formation. It is irreversible and its effects last until new platelets are formed.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 56.
What level of urine output suggests adequate volume replacement?
A. 0.1 to 0.5 mL/kg/h
B. 0.5 to 1.0 mL/kg/h
C. 1.0 to 1.5 mL/kg/h
D. 1.5 to 2.0 mL/kg/h
E. 2.0 to 2.5 mL/kg/h
A. 0.1 to 0.5 mL/kg/h
B. 0.5 to 1.0 mL/kg/h
C. 1.0 to 1.5 mL/kg/h
D. 1.5 to 2.0 mL/kg/h
E. 2.0 to 2.5 mL/kg/h
Urine output can be a useful determining factor of overall volume status in the postoperative patient. Often, volume resuscitation is targeted to a urine output of 0.5 to 1.0 mL/kg/h.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 89.
What is the best immediate reversal agent of a patient with an elevated INR and ICH who also has coexistent heart failure?
A. Prothrombin complex concentrates
B. Fresh frozen plasma
C. IV vitamin K
D. Transexamic acid
E. Protamine
A. Prothrombin complex concentrates
B. Fresh frozen plasma
C. IV vitamin K
D. Transexamic acid
E. Protamine
In this patient with heart failure and a need for immediate reversal, PCCs should be used to decrease the overall fluid volume utilized during resuscitation as to not worsen the heart failure.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 49.
You are about to discharge a hospitalized patient who is now at POD 3 from a lumbar laminectomy. Her hospital course was complicated by development of an unprovoked left lower extremity DVT. It has been recommended that she discharge on oral anticoagulation for treatment of her DVT. How long should she be on anticoagulation for this event?
A. 1 week
B. 1 month
C. 3 months
D. 6 months
E. 1 year
A. 1 week
B. 1 month
C. 3 months
D. 6 months
E. 1 year
For patients with an unprovoked deep vein thrombosis (DVT) who are on anticoagulation, the recommended initial treatment period is 3 months. After 3 months, further imaging will be performed to determine if treatment needs to be extended.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 129.
You are caring for a 33-year-old woman who is on oral contraceptive pills and intermittently smokes. She developed a severe headache and has the findings demonstrated in the images below. What is the best initial management of her condition?
A. Intravenous heparin
B. Observation
C. Aspirin
D. TransarterialtPA
E. Dabigatran administration
A. Intravenous heparin
B. Observation
C. Aspirin
D. TransarterialtPA
E. Dabigatran administration
This patient has evidence of a cerebral venous sinus thrombosis. Regardless of the presence of intracerebral hemorrhage (ICH), this patient should receive IV heparin administration in an attempt to dissolve the clot. The presence of hemorrhage is not a contraindication for heparin.
Further Reading: Hamilton, Golfinos, Pineo, Couldwell. Handbook of Bleeding and Coagulation for Neurosurgery, 2015, page 190.
What brain tissue partial pressure of oxygen level is thought to be the threshold below which anaerobic respiration takes over and secondary injury via lactic acidosis occurs?
A. 50 mm Hg
B. 40 mm Hg
C. 30 mm Hg
D. 20 mm Hg
E. 10 mm Hg
A. 50 mm Hg
B. 40 mm Hg
C. 30 mm Hg
D. 20 mm Hg
E. 10 mm Hg
It is thought that with a brain tissue partial pressure of oxygen below 20 mm Hg, anaerobic respiration predominates, which can lead to secondary brain injury.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 329.
According to the guidelines for the management of severe traumatic brain injury, a GCS of what is considered severe head injury?
A. 12 or less
B. 10 or less
C. 8 or less
D. 6 or less
E. 3
A. 12 or less
B. 10 or less
C. 8 or less
D. 6 or less
E. 3
According to these guidelines, a GCS of 8 or less is considered severe head injury, and these patients should be considered for intubation if there is clinical concern for airway protection
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 330.
You are asked to evaluate a patient with a severe head injury in the ED after a motor vehicle collision. As you are arriving to the ED, you see the ED resident starting to intubate. You are told that the patient was given rocuronium for paralytic just prior to intubation. How long will you likely have to wait before you can get an adequate neurologic exam?
A. 15 minutes
B. 30 minutes
C. 90 minutes
D. 6 hours
E. 24 hours
A. 15 minutes
B. 30 minutes
C. 90 minutes
D. 6 hours
E. 24 hours
Rocuronium is a paralytic agent used for intubation. The duration can be 30 to 90 minutes.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 333.
Via what mechanism can hyperventilation of the intubated patient with elevated ICP decrease ICP?
A. Decreased pH
B. Increased pH
C. Increased CSF production
D. Decreased CSF production
E. Decreased cardiac output
A. Decreased pH
B. Increased pH
C. Increased CSF production
D. Decreased CSF production
E. Decreased cardiac output
Hyperventilation increases the pH in the brain due to increased ventilation and blowing off of CO2 . This increase in pH causes vasoconstriction, which can decrease blood volume in the brain and subsequently decrease ICP.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 335.
You are evaluating a patient who has suffered a severe brain injury and unfortunately no measures have led to improvement of the patient’s condition. He is currently on comfort cares and as you observe, his breathing pattern consists of a prolonged pause at full inspiration. Where does this breathing pattern localize the injury?
A. Diffuse forebrain
B. Thalamus
C. Pons
D. Medulla
E. Upper cervical spine
A. Diffuse forebrain
B. Thalamus
C. Pons
D. Medulla
E. Upper cervical spine
This breathing pattern is apneustic breathing, suggestive of destruction to the pons.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 340.
What is the average cerebral blood flow to the brain in the normal, healthy adult?
A. 20 mL/100 g/min
B. 35 mL/100 g/min
C. 50 mL/100 g/min
D. 75 mL/100 g/min
E. 100 mL/100 g/min
A. 20 mL/100 g/min
B. 35 mL/100 g/min
C. 50 mL/100 g/min
D. 75 mL/100 g/min
E. 100 mL/100 g/min
CBF in the normal, healthy adult is thought to be around 50 mL/100 g/min.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 424.
What is the normal cerebral blood flow in a normal, healthy 4-year-old?
A. 20 mL/100 g/min
B. 35 mL/100 g/min
C. 50 mL/100 g/min
D. 75 mL/100 g/min
E. 100 mL/100 g/min
A. 20 mL/100 g/min
B. 35 mL/100 g/min
C. 50 mL/100 g/min
D. 75 mL/100 g/min
E. 100 mL/100 g/min
Pediatric patients have elevated cerebral blood flow, and it can be as high as 108 mL/100 g/min and it can stay this elevated through the teenage years.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 424.
Which of the following tumors is associated with hyponatremia?
A. Bronchogenic carcinoma
B. Small cell lung cancer
C. Medullary thyroid cancer
D. Neuroblastoma
E. Medulloblastoma
A. Bronchogenic carcinoma
B. Small cell lung cancer
C. Medullary thyroid cancer
D. Neuroblastoma
E. Medulloblastoma
Small cell lung cancer has the ability to form peptide hormones, including antidiuretic hormone (ADH), which can lead to syndrome of inappropriate antidiuretic hormone secretion (SIADH) and hyponatremia.
urther Reading: Bernstein, Berger. Neuro- Oncology: The Essentials, 3rd edition, 2015, page 451.
You are evaluating a 38-year-old woman who has severe migraines, several seizure episodes, and a recent subclinical stroke that was demonstrated on MRI. She also has an associated mood disorder. Dilutional testing is suggestive of an inhibitor present. You suspect lupus. How do you confirm the diagnosis of neuropsychiatric SLE?
A. Skin biopsy
B. CSF antineuronal antibodies
C. CSF anti-Jo antibodies
D. CSF anti-RI antibodies
E. CSF glucose
A. Skin biopsy
B. CSF antineuronal antibodies
C. CSF anti-Jo antibodies
D. CSF anti-RI antibodies
E. CSF glucose
Neuropsychiatric SLE can manifest with multiple symptoms. The diagnosis can be made by testing for ANA in the cerebrospinal fluid (CSF).
Further Reading: Kanekar. Imaging of Neurodegenerative Disorders, 2016, page 221.
You are evaluating a 64-year-old woman with left arm and leg weakness. MRI has the following findings. Genetic testing demonstrates an abnormality on chromosome 19. What is the diagnosis? 30. You are evaluating a 64-year-old woman with left arm and leg weakness. MRI has the following findings. Genetic testing demonstrates an abnormality on chromosome 19. What is the diagnosis?
A. Alexander’s disease
B. CADASIL
C. PML
D. Symptomatic carotid stenosis
E. Multiple embolic infarcts
A. Alexander’s disease
B. CADASIL
C. PML
D. Symptomatic carotid stenosis
E. Multiple embolic infarcts
This MRI demonstrates findings classic for cerebral autosomal dominant arteriopathy with subcortical infarcts. This is thought to occur due to regional hypometabolism due to a genetic abnormality on chromosome 19. Patients have a progressive declining course and often die between 50 and 70 years of age.
Further Reading: Kanekar. Imaging of Neurodegenerative Disorders, 2016, page 220.
You are evaluating a 76-year-old man who presents with persistent temporal headaches, jaw claudication, and tenderness of the temporal artery. If this patient were to go on to develop blindness, what mechanism underlies the ischemic optic neuropathy?
A. Inflammation
B. Thrombosis
C. Embolic infarct
D. Arterial rupture
A. Inflammation
B. Thrombosis
C. Embolic infarct
D. Arterial rupture
This patient has giant cell arteritis, also known as temporal arteritis. Blindness is a feared complication when this condition is left untreated, and it occurs via inflammation and progression of disease to include the ciliary arteries and central retinal artery. When inflamed, they can lead to ischemic optic neuropathy and blindness.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 249.
You are caring for a patient with giant cell arteritis, newly diagnosed. You are concerned about the development of blindness in this patient. What should be your initial management?
A. Clopidogrel
B. Heparin
C. Prednisone
D. Hydroxychloroquine
E. Infliximab
A. Clopidogrel
B. Heparin
C. Prednisone
D. Hydroxychloroquine
E. Infliximab
Giant cell arteritis is an inflammatory vasculitis and blindness can be a complication of this condition. These patients should be treated with prednisone initially.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 249.
What serum osmolality represents a threshold after which mannitol administration is contraindicated due to an elevated risk of acute tubular necrosis?
A. 300
B. 310
C. 320
D. 330
E. 340
A. 300
B. 310
C. 320
D. 330
E. 340
Mannitol should no longer be administered in patients who have a serum osmolality of 320 or greater as the risk of ATN increases substantially.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 762.
You are asked to review the CT scan of a 7-week-old newborn with a head mass. What is the diagnosis?
A. Epidermoid cyst
B. Eosinophilic granuloma
C. Growing skull fracture
D. Calcified cephalohematoma
E. Nonaccidental trauma
A. Epidermoid cyst
B. Eosinophilic granuloma
C. Growing skull fracture
D. Calcified cephalohematoma
E. Nonaccidental trauma
This CT scan demonstrates evidence of a calcified cephalohematoma, a bleed located between the periosteum and the skull. It becomes bound by suture lines. In the majority of cases, these resolve in 1 to 3 days; however, they can persist and calcify, sometimes requiring surgery.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 798.
You are asked to evaluate a 5-day-old newborn who has a cephalohematoma that has not resolved at this point. It does not appear to have increased in size; the child remains afebrile and stable both neurologically and systemically. What treatment should you recommend?
A. Further observation
B. Surgical decompression
C. Needle aspiration
D. Serial CT scans
E. Tight head wrap
A. Further observation
B. Surgical decompression
C. Needle aspiration
D. Serial CT scans
E. Tight head wrap
At this point, the child is stable and more observation should be recommended. The hematoma may continue to resolve over time. Needle aspiration should be avoided unless there is concern for infection due to the risk of iatrogenic infection.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 799.
Retinal hemorrhages are a classic symptom of severe, abusive pediatric head trauma, occurring in up to 80% of patients. How often are retinal hemorrhages present in cases of confirmed accidental trauma?
A. 5%
B. 15%
C. 35%
D. 55%
E. 75%
A. 5%
B. 15%
C. 35%
D. 55%
E. 75%
Retinal hemorrhages are very common in non- accidental trauma, and very rare in accidental brain trauma, occurring in 5% or less of accidental traumas.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 803.
You are seeing a patient in the ED. You were called emergently as this patient has evidence of an epidural hematoma and has now developed pupillary anisocoria. You decide to go emergently to the OR for evacuation. Based on current evidence, after the onset of pupillary changes, within what time interval should you achieve decompression of the hematoma to promote a good outcome?
A. < 10 minutes
B. < 70 minutes
C. < 120 minutes
D. < 6 hours
E. < 24 hours
A. < 10 minutes
B. < 70 minutes
C. < 120 minutes
D. < 6 hours
E. < 24 hours
According to current evidence, decompression should be achieved within 70 minutes of the onset of pupillary changes in patients with EDH, highlighting the emergent nature of this condition.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 749.
Which of the following measurements of an acute subdural hematoma meets criteria for evacuation regardless of GCS?
A. 7-mm thick/4-mm midline shift
B. 12-mm thick/6-mm midline shift
C. 3-mm thick/3-mm midline shift
D. 9-mm thick/2-mm midline shift
E. 13-mm thick/1-mm midline shift
A. 7-mm thick/4-mm midline shift
B. 12-mm thick/6-mm midline shift
C. 3-mm thick/3-mm midline shift
D. 9-mm thick/2-mm midline shift
E. 13-mm thick/1-mm midline shift
According to current guidelines, any acute subdural hematoma that measures greater than 10 mm in thickness and is associated with greater than 5 mm of midline shift should be surgically evacuated regardless of GCS.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 753.
You are caring for a patient who has developed postsurgical brachial neuritis (Parsonage–Turner syndrome). She is experiencing significant shoulder girdle pain. What medication should you use to help her symptoms?
A. Prednisone
B. NSAIDs
C. Ketamine
D. Methotrexate
E. Temozolomide
A. Prednisone
B. NSAIDs
C. Ketamine
D. Methotrexate
E. Temozolomide
There is currently no role for steroids in the treatment of brachial neuritis. These patients are managed conservatively and NSAIDs can be used for shoulder pain.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 736.
In patients with nonhereditary brachial neuritis (Parsonage–Turner syndrome), what is the expected rate of full recovery at 3 years?
A. 50%
B. 60%
C. 70%
D. 90%
E. 100%
A. 50%
B. 60%
C. 70%
D. 90%
E. 100%
Brachial neuritis is managed conservativelyand most patients experience a full recovery at 3 years. The rate of recovery is around 90%. Supportive care and extensive physical therapy should be utilized in this condition.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 736.
Which of the following is a known side effect of dexmedetomidine use for sedation in the neuro-ICU?
A. Seizures
B. Agitation
C. Bradycardia
D. Hypertension
E. Tachycardia
A. Seizures
B. Agitation
C. Bradycardia
D. Hypertension
E. Tachycardia
Precedex is an alpha-2 agonist in the CNS that can be used for sedation. It has dose-dependent effects on blood pressure and heart rate, specifically causing hypotension and bradycardia.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 160.
What brainstem nucleus is thought to be mediated by administration of dexmedetomidine?
A. Raphe nucleus
B. Nucleus accumbens
C. Periaqueductalgray
D. Locus coeruleus
E. Solitary tract
A. Raphe nucleus
B. Nucleus accumbens
C. Periaqueductalgray
D. Locus coeruleus
E. Solitary tract
Precedex is a central alpha-2 agonist that is thought to exert its effects on the locus coeruleus in the brainstem, mediating arousal and sleep–wake cycles. Decreasing transmission of the neurons in this nucleus that are primarily noradrenergic causes sedation and diminishes agitation.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 161.
Only for what time frame is continuous infusion of dexmedetomidine approved by the FDA?
A. 1 hour
B. 6 hours
C. 12 hours
D. 24 hours
E. 48 hours
A. 1 hour
B. 6 hours
C. 12 hours
D. 24 hours
E. 48 hours
Currently, the FDA has only approved continuous infusion of Precedex for 24 hours given the risk of rebound hypertension and tachycardia after cessation of administration.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 161.
What might you see as an initial symptom of propofol infusion syndrome in a patient who has received high doses of propofol for the last 72 hours?
A. Hypertension
B. New right bundle branch block
C. Seizures
D. Metabolic alkalosis
E. Hypokalemia
A. Hypertension
B. New right bundle branch block
C. Seizures
D. Metabolic alkalosis
E. Hypokalemia
Propofol infusion syndrome is thought to occur in patients receiving high-dose propofol infusion for more than 48 hours. The exact mechanism is unknown but thought to be due to metabolic derangements in the mitochondria. Initial find- ings can include a right bundle branch block. It can go on to include hypotension, bradycardia, metabolic acidosis, rhabdomyolysis, and hypokalemia. Propofol should be stopped.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 159.
Which of the following anesthetic agents inhibits the formation of ACTH?
A. Propofol
B. Etomidate
C. Ketamine
D. Pentobarbital
E. Isoflurane
A. Propofol
B. Etomidate
C. Ketamine
D. Pentobarbital
E. Isoflurane
Etomidate is an anesthetic agent that decreases CMRO2 and cerebral blood flow. It also causes adrenocortical axis suppression and decreases the concentration of ACTH.
Further Reading: Albright, Pollack, Adelson. Prin- ciples and Practice of Pediatric Neurosurgery, 3rd edition, 2015, page 740.
Which of the following conditions would be a contraindication to performing a supracerebellar, infratentorial approach to a pineal region tumor in the sitting position?
A. Patent foramen ovale
B. Pre-existing DVT
C. Restrictive lung disease
D. History of cervical fusion
E. Ongoing cervical radiculopathy
A. Patent foramen ovale
B. Pre-existing DVT
C. Restrictive lung disease
D. History of cervical fusion
E. Ongoing cervical radiculopathy
The sitting position can be useful in neurosurgery, but there is an increased risk of venous air embolism. A patient with a PFO is a relative contraindication for the use of the sitting position due to the risk of a right-sided air embolism becoming a left-sided embolism.
Further Reading: Albright, Pollack, Adelson. Principles and Practice of Pediatric Neurosurgery, 3rd edition, 2015, page 142.
Which of the following anesthetic medications can lower the seizure threshold?
A. Propofol
B. Pentobarbital
C. Etomidate
D. Midazolam
E. Methohexital
A. Propofol
B. Pentobarbital
C. Etomidate
D. Midazolam
E. Methohexital
Methohexital is an anesthetic agent that lowers the seizure threshold. It is sometimes used during electrocorticography for surgical treatment of epilepsy.
Further Reading: Baltuch, Villemure. Operative Techniques in Epilepsy Surgery, 2009, page 48.
You are evaluating a 38-year-old man with right-sided temporal lobe epilepsy from presumed hippocampal sclerosis. According to the landmark controlled trial focusing on temporal lobe epilepsy, what percentage of surgical patients will be completely seizure free at 1 year?
A. ~ 25%
B. ~ 33%
C. ~ 40%
D. ~60%
E. ~ 90%
A. ~ 25%
B. ~ 33%
C. ~ 40%
D. ~ 60%
E. ~ 90%
In patients with refractory temporal lobe epilepsy (TLE), surgical treatment can lead to 60% seizure freedom at 1 year post-op, compared to 8% seizure freedom in patients undergoing medical management alone.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 269.
You are evaluating a 52-year-old man with medically refractory epilepsy that appears to be located in eloquent cortex (motor cortex) on the right side. There are no other options and you and the patient are considering a procedure to perform multiple pial transections in attempt to control the epilepsy. What should you council this patient about during the postoperative course?
A. Permanent motor deficit
B. Temporary motor deficit
C. Initial seizure worsening
D. High risk of infection
E. High risk of postoperative hemorrhage
A. Permanent motor deficit
B. Temporary motor deficit
C. Initial seizure worsening
D. High risk of infection
E. High risk of postoperative hemorrhage
Multiple subpial transections can be performed as a palliative epilepsy surgery in patients with medically refractory epilepsy. It severs the horizontal intracortical connections, but preserves neurons due to the vertical columnar orientation. These patients should expect to have transient neurologic deficit for several months postoperatively.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 272.
You are seeing a patient in clinic with drug- resistant epilepsy who is being considered for surgical treatment. She describes her seizure onset including a rising epigastric sensation just prior to initiation of her seizure episode. Where is the most likely location of her epilepsy?
A. Medial frontal lobe
B. Occipital lobe
C. Temporal lobe
D. Lateral frontal lobe
E. Parietal lobe
A. Medial frontal lobe
B. Occipital lobe
C. Temporal lobe
D. Lateral frontal lobe
E. Parietal lobe
The rising epigastric sensation and déjà vu can be associated with TLE.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 264.
Which of the following factors is more consistent with type II or atypical trigeminal neuralgia?
A. Lancinating pain
B. Pain-free intervals
C. Unilateral
D. Throbbing pain
Which of the following factors is more consistent
with type II or atypical trigeminal neuralgia?
A. Lancinating pain
B. Pain-free intervals
C. Unilateral
D. Throbbing pain
Type I, or classic TN, usually presents with sharp, lancinating unilateral pain with pain-free intervals. In studies on the subject, type I patients were more likely to have arterial compression at surgery as well as better long-term outcomes than type II patients, which tend to have persistent, burning/aching/throbbing pain that can be bilateral, and may be associated with other pathologies, such as multiple sclerosis.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 294.
What percentage of patients with classic type I trigeminal neuralgia pain will have “excellent to good” pain relief long term with microvascular decompression?
A. 25%
B. 65%
C. 75%
D. 85%
E. 95%
A. 25%
B. 65%
C. 75%
D. 85%
E. 95%
According to current literature, up to 84% of patients with type I TN pain will experience excellent to good pain control with microvascular decompression surgery.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 294.
What percentage of patients with atypical type II trigeminal neuralgia pain will have “excellent to good” pain relief long term with microvascular decompression?
A. 25%
B. 65%
C. 75%
D. 85%
E. 95%
A. 25%
B. 65%
C. 75%
D. 85%
E. 95%
Patients with atypical type II TN may still benefit from microvascular decompression. Up to 65% of these patients will have “excellent to good” pain control long term.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 294
You are asked to see a patient who is having severe, episodic pain in the right lower jaw. She describes lancinating pain that is worsened by brushing her teeth. You suspect trigeminal neuralgia. What is the best initial management of her condition?
A. Balloon compression
B. Radiofrequency rhizotomy
C. Microvascular decompression
D. Medical management
E. Glycerol rhizotomy
A. Balloon compression
B. Radiofrequency rhizotomy
C. Microvascular decompression
D. Medical management
E. Glycerol rhizotomy
This patient has TN and has not yet undergone any treatment. Initial management should be with carbamazepine, as 80% of patients will experience nearly immediate relief (within 24–48 hours) with this medication. The pain relief diminishes over time, and over the long term, only 50% of patients may have continued relief on carbamazepine. Up to 10% of patients may not tolerate carbamazepine.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 295.
What is the mechanism of action for trigeminal neuralgia pain relief via administration of the medication oxcarbazepine?
A. Voltage-gated sodium channel blockade
B. Voltage-gated calcium channel blockade
C. Mu opioid receptor agonist
D. NMDA receptor agonist
E. GABA agonist
A. Voltage-gated sodium channel blockade
B. Voltage-gated calcium channel blockade
C. Mu opioid receptor agonist
D. NMDA receptor agonist
E. GABA agonist
Oxcarbazepine is a sodium channel blocking pain medication that works in a similar fashion to carbamazepine. It can be used in some patients that cannot tolerate standard carbamazepine.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 295.
You are performing a balloon compression of the trigeminal nerve in a patient with TN. If the patient has primarily V3 distribution pain, where in the foramen ovale should you attempt to place the catheter?
A. Superior
B. Inferior
C. Lateral
D. Medial
E. Intermediate
A. Superior
B. Inferior
C. Lateral
D. Medial
E. Intermediate
The distribution of the V1, V2, and V3 divisions of the trigeminal nerve is oriented in the foramen ovale in a superomedial to inferolateral direction. Therefore, to best treat V3 pain, the catheter should be placed lateral within the foramen.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 297.
Which of the following patients is most likely to have the findings on MRI demonstrated below?
A. A 67-year-old woman with breast cancer
B. A 55-year-old male alcoholic
C. A 42-year-old male IV drug user
D. An 18-year-old woman with lymphoma
E. An 80-year-old woman with carotid stenosis
A. A 67-year-old woman with breast cancer
B. A 55-year-old male alcoholic
C. A 42-year-old male IV drug user
D. An 18-year-old woman with lymphoma
E. An 80-year-old woman with carotid stenosis
This image demonstrates central pontine myelinolysis (CPM), also known as osmotic demyelination syndrome. Patients with alcoholism can experience severe alterations in electrolytes, which could lead to CPM.
Further Reading: Rohkamm. Color Atlas of Neurology, 2007, page 310.
Which of the following conditions causes peaked T waves on ECG?
A. Hypokalemia
B. Hyperkalemia
C. Hypomagnesemia
D. Hypercalcemia
E. Hypernatremia
A. Hypokalemia
B. Hyperkalemia
C. Hypomagnesemia
D. Hypercalcemia
E. Hypernatremia
Hyperkalemia can cause tall, peaked or spiked T waves on ECG
Further Reading: Citow, Macdonald, Refai. Comprehensive
Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 519.
You are reading an ECG that demonstrates prolongation of the PR interval. What electrolyte abnormality can cause this finding on ECG
A. Hyponatremia
B. Hypocalcemia
C. Hyperkalemia
D. Hypernatremia
E. Hypermagnesemia
A. Hyponatremia
B. Hypocalcemia
C. Hyperkalemia
D. Hypernatremia
E. Hypermagnesemia
Hypocalcemia can be associated with lengthening of the PR interval on ECG.
Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 520.
Hypomagnesemia can lead to what changes on ECG?
A. Prolonged PR interval
B. ST elevation
C. Multifocality
D. QRS prolongation
E. Bundle branch block
A. Prolonged PR interval
B. ST elevation
C. Multifocality
D. QRS prolongation
E. Bundle branch block
Hypomagnesemia can cause multifocality on ECG.
Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 520.
Which of the following is a contraindication to the use of IV rtPA in the treatment of acute ischemic stroke?
A. Cortical-based tumor
B. Symptoms for 4 hours
C. History of seizures
D. Age of 18 years
E. Platelet count of 115,000
A. Cortical-based tumor
B. Symptoms for 4 hours
C. History of seizures
D. Age of 18 years
E. Platelet count of 115,000
The presence of an intracranial tumor, aneurysm or arteriovenous malformation (AVM) is absolute contraindication to the administration of IV rtPA for acute ischemic stroke.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 10.
Occlusion of the PICA proximal to what point will likely result in a lateral medullary syndrome?
A. Caudal loop
B. Choroidal point
C. Cranial loop
D. Spinal point
E. Extradural segment
A. Caudal loop
B. Choroidal point
C. Cranial loop
D. Spinal point
E. Extradural segment
PICA originates from the vertebral artery and supplies the brainstem and cerebellum. After the choroidal point, PICA is supplying only cerebellum and if needed could be taken with minimal side effects. Proximal to this point, a medullary infarct will likely occur.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 16.
What is the first branch of the external carotid artery?
A. Superior thyroid
B. Ascending pharyngeal
C. Lingual
D. Facial
E. Occipital
A. Superior thyroid
B. Ascending pharyngeal
C. Lingual
D. Facial
E. Occipital
The superior thyroid artery is the first branch of the external carotid artery. It is commonly seen and needs to be controlled during carotid endarterectomy.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 32.
What artery is the primary vascular supply to the nasal cavity?
A. Ophthalmic
B. Anterior ethmoidal
C. Posterior ethmoidal
D. Sphenopalatine
E. Vidian
A. Ophthalmic
B. Anterior ethmoidal
C. Posterior ethmoidal
D. Sphenopalatine
E. Vidian
The sphenopalatine artery is the primary vascular supply to the nasal cavity.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 35.
You are caring for a 42-year-old smoker who has suffered an aneurysmal subarachnoid hemorrhage. The CT findings are demonstrated below. What is the approximate risk of aneurysm rebleeding in the first 24 hours?
A. 4%
B. 8%
C. 12%
D. 20%
E. 33%
A. 4%
B. 8%
C. 12%
D. 20%
E. 33%
Patients with aneurysmal subarachnoid hemorrhage (SAH) with an unsecured aneurysm are at risk of rebleed, which can have devastating consequences. The risk in the first 24 hours is roughly 4%.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 45.
What is the approximate risk of aneurysmal rebleed in the first 2 weeks after aneurysmal subarachnoid hemorrhage?
A. 10 to 15%
B. 15 to 20%
C. 20 to 25%
D. 25 to 30%
E. 30 to 35%
A. 10 to 15%
B. 15 to 20%
C. 20 to 25%
D. 25 to 30%
E. 30 to 35%
There is an elevated risk of aneurysm rebleed in the first 2 weeks after rupture if the aneurysm remains unsecured. That risk is approximately 15 to 20%. The mortality of aneurysm rebleed is near 75%.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 45.
Neurogenic pulmonary edema after aneurysmal subarachnoid hemorrhage is thought to occur due to what mechanism?
A. Iatrogenic fluid overload
B. Catecholamine surge
C. Heart failure
D. Pulmonary embolism
E. Prolonged mechanical ventilation
A. Iatrogenic fluid overload
B. Catecholamine surge
C. Heart failure
D. Pulmonary embolism
E. Prolonged mechanical ventilation
Neurogenic pulmonary edema can occur after aneurysmal SAH and close pulmonary monitoring should occur in these patients. While pulmonary edema can occur from iatrogenic fluid overload, neurogenic pulmonary edema is thought to be due to an acute catecholamine surge experienced after the bleeding event.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 46.
What is the most common electrolyte derangement after aneurysmal subarachnoid hemorrhage?
A. Hyponatremia
B. Hypernatremia
C. Hypocalcemia
D. Hyperkalemia
E. Hypokalemia
A. Hyponatremia
B. Hypernatremia
C. Hypocalcemia
D. Hyperkalemia
E. Hypokalemia
The most common electrolyte disturbance in SAH is hyponatremia, which can occur via two mechanisms, either cerebral salt wasting (CSW) or SIADH. It is important to determine volume status to differentiate between SIADH and CSW.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 47.
You are caring for a patient with the subarachnoid hemorrhage demonstrated in the CT scans in the Question 65. If the patient had hypernatremia, where would you suspect the underlying aneurysm to be arising from?
A. Posterior communicating artery
B. MCA bifurcation
C. Anterior communicating artery
D. Basilar tip
E. Posterior inferior cerebellar artery
A. Posterior communicating artery
B. MCA bifurcation
C. Anterior communicating artery
D. Basilar tip
E. Posterior inferior cerebellar artery
Occasionally patients with SAH can present with hypernatremia, caused by diabetes insipidus. This may be suggestive of an anterior communicating artery aneurysm due to destruction of hypothalamic pathways involved in the production and release of ADH.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 47.
Which of the following helps decrease stress ulcer formation in ventilated patients with subarachnoid hemorrhage?
A. Aggressive glucose control
B. Decreasing IV infusions
C. TPN administration
D. Early enteral nutrition
E. Regular sedation holidays
A. Aggressive glucose control
B. Decreasing IV infusions
C. TPN administration
D. Early enteral nutrition
E. Regular sedation holidays
Intubated SAH patients have high rates of gastrointestinal (GI) stress ulcer formation and should all be placed on GI prophylactic medications. Early enteral nutrition via either percutaneous gastrostomy or nasogastric tube can allow for early feeding, thus decreasing stress ulcer formation.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 47.
You are evaluating a 24-year-old woman who was an unrestrained passenger in a motor vehicle collision and she struck her head on the windshield. She was transferred to the neuro-ICU and has been intubated since admission for a depressed GCS. A pressure monitor was placed and she has evidence of refractory ICP elevations. According to the Decompressive Craniectomy in Diffuse Traumatic Brain Injury (DECRA) trial, what is the most likely outcome of decompressive hemicraniectomy in this patient?
A. Mortality
B. Continued refractory ICP elevation
C. Good outcome and decreased ICP
D. Poor outcome and decreased ICP
E. Good outcome but increased ICP
A. Mortality
B. Continued refractory ICP elevation
C. Good outcome and decreased ICP
D. Poor outcome and decreased ICP
E. Good outcome but increased ICP
The DECRA trial was performed in Australia in 2011 and demonstrated that patients who underwent decompressive craniectomy (DC) had improvement in their ICP and shorter intensive care unit (ICU) stays, but overall had poorer outcomes than standard care. The trial has been criticized for having too aggressive a surgical arm with ref- ractory ICP defined as 20 mm Hg for more than 15 minutes. This may have led to more patients being operated than necessary. The Randomised Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) trial is ongoing and has increased the time frame required to determine refractory ICP elevation.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 776.
You are admitting an 80-year-old man to the neuro-ICU after he suffered a right-sided basal ganglia ICH with no intraventricular extension. His admission SBP is 206. According to the intensive blood pressure reduction in acute cerebral hemorrhage trial (INTERACT), intensive blood pressure control (SBP goal of 140 or less) will have what effect on this patient?
A. No change
B. Decreased hematoma volume; no clinical effect
C. Decreased hematoma volume; improved clinical course
D. Increased hematoma volume; no clinical effect
E. Increased hematoma volume; improved clinical course
A. No change
B. Decreased hematoma volume; no clinical effect
C. Decreased hematoma volume; improved clinical course
D. Increased hematoma volume; no clinical effect
E. Increased hematoma volume; improved clinical course
The INTERACT trial aimed to determine if intensive blood pressure control had significant effects on clinical outcome. Intensive blood pressure control (systolic blood pressure [SBP] < 140) decreased overall hematoma size, but it did not have any effect on clinical course. INTERACT 2 is ongoing.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 229.
You are caring for a patient who has significant hypertension at baseline. Her averaged systolic blood pressure is 178 in the office. You are concerned that her blood pressure remains greater than 160, and that she has a higher risk of spontaneous ICH. What is the increased risk of ICH in patients with SBP > 160?
A. 2 times
B. 5 times
C. 10 times
D. 50 times
E. 100 times
A. 2 times
B. 5 times
C. 10 times
D. 50 times
E. 100 times
According to current literature, baseline hypertension with SBP > 160 leads to a 5.5 times higher risk of spontaneous ICH compared to patients with good blood pressure control.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 231.
What is the rate of functional independence at 3 months in patients who suffer a spontaneous ICH?
A. 0%
B. 20%
C. 50%
D. 75%
E. 100%
A. 0%
B. 20%
C. 50%
D. 75%
E. 100%
ICH can be a devastating event, and many patients develop neurologic deficits following this event. The rate of functional independence 3 months after the bleeding event occurs is roughly 20%.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 231.
You are asked to consult on an 82-year-old woman with a large cerebellar hematoma from a presumed spontaneous cerebellar hemorrhage. Her admission GCS was 6 and there is evidence of intraventricular hemorrhage. The hematoma volume is measured to be 31 mL and there is brainstem compression. What is her 30-day mortality according to the ICH score?
A. 13%
B. 26%
C. 72%
D. 97%
E. 100%
A. 13%
B. 26%
C. 72%
D. 97%
E. 100%
This patient has suffered a devastating cerebellar hemorrhage that will have a 100% 30-day mortality according to the ICH score. Points are awarded for age older than 80 years, infratentorial location, IVH, hematoma volume greater than 30 mL, and 1 point for GCS 5 to 12. This gives her 5 of a total of 6 points. Patients with an ICH score of 5 or 6 have a 100% 30-day mortality. Patients with a score of 4 have a 97% 30-day mortality.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 231.
You are evaluating a 76-year-old woman who has suffered a right-sided spontaneous cerebral hemorrhage. The neurointensivist is asking if you would consider surgically resecting the hematoma. According to the original surgical treatment for intracerebral hemorrhage (STICH) trial subgroup analysis, what hematoma characteristic might demonstrate a benefit from surgical resection?
A. Right hemisphere location
B. Age younger than 80 years
C. Superficial cortical (< 1 cm from the surface) location
D. No midline shift
E. Intraventricular extension
A. Right hemisphere location
B. Age younger than 80 years
C. Superficial cortical (< 1 cm from the surface) location
D. No midline shift
E. Intraventricular extension
In the initial STICH trial, there was no benefit from surgical resection of spontaneous cerebral hemorrhage when compared to standard medical therapy. Upon subgroup analysis, there may be a benefit to resecting a cerebral hemorrhage with a superficial location and significant mass effect. STICH II examined cases of lobar hemorrhage, however, and found no improvement in outcome between the surgical and medical arms of treatment.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 232.
You are asked to evaluate the CT image of an 83-year-old woman with the following findings. What is the most common underlying cause of the findings on the CT scan?
A. Hypertension
B. Age older than 80 years
C. Metastatic disease
D. Smoking
E. Drug use
A. Hypertension
B. Age older than 80 years
C. Metastatic disease
D. Smoking
E. Drug use
This CT scan demonstrates a cerebellar hemorrhage with intraventricular extension. The most common underlying cause for this disorder is uncontrolled hypertension.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 235.
You are asked to discuss possible surgical outcomes with the family of a patient with the CT scan demonstrated in Question 77. When you discuss the possibility of surgical resection and decompression of the posterior fossa, they ask what chance there is that their family member can live without daily assistance. According to current literature, what is the rate of good outcome (Glasgow Outcome Score 4 or 5) in patients treated surgically for this condition?
A. 0%
B. 25%
C. 50%
D. 75%
E. 100%
A. 0%
B. 25%
C. 50%
D. 75%
E. 100%
This patient has a spontaneous cerebellar hemorrhage and the data suggest that there is a 50% chance of good outcome (Glasgow Outcome Score 4 or 5, meaning no requirement for assistance in activities of daily living) in patients treated surgically for this condition.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 236.
According to guidelines, which of the following factors present on admission should make you surgically decompress and resect the hematoma demonstrated in the CT scan in Question 77?
A. Hypertension (SBP > 160)
B. Hematoma enlargement on serial CT scan
C. GCS 15
D. Hydrocephalus
E. Elevated INR
A. Hypertension (SBP > 160)
B. Hematoma enlargement on serial CT scan
C. GCS 15
D. Hydrocephalus
E. Elevated INR
According to American Heart Association (AHA)/American Stroke Association (ASA) ICH guidelines, the presence of neurological deterioration, brainstem compression and/or the presence of hydrocephalus should make you strongly consider surgical resection of the hematoma and decompression of the posterior fossa. CSF diversion should also be utilized during the surgery. EVD placement alone without hematoma resection is not recommended.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 237.
What size threshold has been identified for spontaneous cerebellar hemorrhage under which most patients are less likely to deteriorate and require surgical decompression?
A. 1 cm
B. 2 cm
C. 3 cm
D. 4 cm
E. 5 cm
A. 1 cm
B. 2 cm
C. 3 cm
D. 4 cm
E. 5 cm
Three centimeters has been identified as a rough cutoff whereby patients with a hematoma smaller than 3 cm in dimension are less likely to deteriorate and require surgical intervention compared to patients with a hematoma greater than 3 cm. This is not a hard and fast rule, however, and many other factors, including location, brainstem compression, medical comorbidities, and other systemic characteristics, play into the surgical AU2 n making from patient to patient.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 237.
You performed a stereotactic needle biopsy on a 56-year-old woman who initially presented with headache and MRI demonstrated multifocal enhancement throughout the cortex. Her condition had started to worsen, and she developed cognitive impairment. The results of the biopsy are demonstrated below. What is the most likely diagnosis?
A. Glioblastoma
B. Hypertension
C. Vasculitis
D. Metastatic disease
E. Ischemic stroke
A. Glioblastoma
B. Hypertension
C. Vasculitis
D. Metastatic disease
E. Ischemic stroke
This pathologic specimen demonstrates arterial wall necrosis and monocytic infiltration of the vessel walls. There is associated granuloma formation. These findings are consistent with vasculitis. Conventional angiogram may demonstrate arterial nicking.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 253.
What is thought to be the underlying mechanism of normal pressure hydrocephalus?
A. CSF overproduction
B. Arachnoid granulation dysfunction
C. Aqueductal stenosis
D. Multiple subclinical hemorrhages
E. Decreased ventricular compliance
A. CSF overproduction
B. Arachnoid granulation dysfunction
C. Aqueductal stenosis
D. Multiple subclinical hemorrhages
E. Decreased ventricular compliance
NPH is characterized by ambulatory difficulties, cognitive impairment, and urinary incontinence in patients with ventriculomegaly but normal CSF pressure. The full underlying mechanism is not well understood, but thought to be due to poor craniospinal compliance of the ventricular system, at least in part.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 324.
What diagnostic test can increase the rate of favorable response to ventriculoperitoneal (VP) shunting in patients with normal pressure hydrocephalus from approximately 50 to 80% or more?
A. Ventriculomegaly on MRI
B. Adequate CSF flow on cine MRI
C. Leukocytosis
D. Improved gait after high-volume LP
E. Perceived cognitive improvement after high-volume LP
A. Ventriculomegaly on MRI
B. Adequate CSF flow on cine MRI
C. Leukocytosis
D. Improved gait after high-volume LP
E. Perceived cognitive improvement after highvolume LP
In patients with suspected NPH, high-volume lumbar puncture (LP) should be performed (30–50 mL removed), and gait analysis should be performed immediately after this procedure. Patients who had gait improvement after LP had the highest rate of overall symptom improvement after permanent VP shunt placement.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 326.
What is the diagnosis in this 18-year-old girl who presents with intermittent, right-sided holohemispheric headaches and the following MRI?
A. Pilocytic astrocytoma
B. Optic glioma
C. Epidermoid cyst
D. Arachnoid cyst
E. Metastatic disease
A. Pilocytic astrocytoma
B. Optic glioma
C. Epidermoid cyst
D. Arachnoid cyst
E. Metastatic disease
This patient has an arachnoid cyst of the right sylvian fissure. The cyst contents have the same signal intensity as CSF and this is helpful for the diagnosis.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 349.
You are caring for a 3-year-old boy who has been admitted to the pediatric ICU after nonaccidental trauma by the father that has caused severe TBI. He has elevated ICP and a poor clinical exam. The pediatric team asks you about the administration of steroids in an attempt to improve his cerebral edema. What effect do steroids have on severe pediatric TBI?
A. Improvement in ICP and clinical outcome, no systemic complications
B. Improvement in ICP and clinical outcome, increased systemic complications
C. No improvement in ICP, improved clinical outcome, increased Systemic complications
D. Improvement in ICP, no clinical improvement, increased systemic complications
E. No improvement in ICP, no clinical improvement, increased systemic complications
A. Improvement in ICP and clinical outcome, no
systemic complications
B. Improvement in ICP and clinical outcome, increased systemic complications
C. No improvement in ICP, improved clinical outcome, increased systemic complications
D. Improvement in ICP, no clinical improvement,
increased systemic complications
E. No improvement in ICP, no clinical improvement, increased systemic complications
Similar to adult TBI, there is no role for systemic steroids in pediatric patients that have severe TBI. Clinical and ICP outcomes show no difference and patients are exposed to systemic risk with steroid administration.
Further Reading: Harbaugh, Shaffrey, CouldwellBerger. Neurosurgery Knowledge Update, 2015, page 398.
Intrauterine fetal surgery for the repair of myelomeningocele is undertaken at what time?
A. 18 to 20 weeks of gestation
B. 24 to 26 weeks of gestation
C. 30 to 32 weeks of gestation
D. 36 to 38 weeks of gestation
E. 40+ weeks of gestation
A. 18 to 20 weeks of gestation
B. 24 to 26 weeks of gestation
C. 30 to 32 weeks of gestation
D. 36 to 38 weeks of gestation
E. 40+ weeks of gestation
Currently, fetal surgery for the repair of myelomeningocele occurs at 24 to 26 weeks of gestation.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 403.
You are asked to evaluate a 22-year-old woman in the ED who developed a sudden headache with some mild word-finding difficulties and admission CT is demonstrated below. She does not have any history of drug use or other systemic disease process that the ED team is currently aware of. Her INR is 1.0. What is the next best step in management?
A. ICU admission and observation
B. Intensive blood pressure management
C. Intensive glucose management
D. Further imaging
E. PMR assessment
A. ICU admission and observation
B. Intensive blood pressure management
C. Intensive glucose management
D. Further imaging
E. PMR assessment
This is a young patient with no significant risk factors for spontaneous ICH. The age, lack of risk factors, and odd location of this hemorrhage should make you concerned for an underlying vascular malformation or aneurysm. A CT angiogram (CTA) should be obtained as a start, and likely a formal catheter angiogram to follow depending on the CTA findings.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 422.
You are caring for a 33-year-old man with the following lesion on cerebral angiogram. What genetic condition might predispose him to development of this lesion?
A. Neurofibromatosis type I
B. Kennedy’s disease
C. Hereditary hemorrhagic telangiectasia
D. Ataxia-telangiectasia
E. Von Hippel–Lindau disease
A. Neurofibromatosis type I
B. Kennedy’s disease
C. Hereditary hemorrhagic telangiectasia
D. Ataxia-telangiectasia
E. Von Hippel–Lindau disease
The catheter angiogram demonstrates a cerebral AVM. Of the listed choices, HHT is associated with AVM formation.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 424.
You are caring for a 38-year-old man who has been diagnosed with bilateral moyamoya disease. He has been counseled that his rate of stroke over 5 years is between 67 and 90% without treatment. He was referred to you for potential indirect or direct bypass. If your surgery is successful, what will his new rate of stroke over the next 5 years be?
A. < 10%
B. 11 to 20%
C. 21 to 30%
D. 31 to 40%
E. 41 to 50%
A. < 10%
B. 11 to 20%
C. 21 to 30%
D. 31 to 40%
E. 41 to 50%
With successful indirect or direct bypass in patients with moyamoya disease, the 5-year rate of stroke drops from 67 to 90% to less than 10%.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 424.
You are evaluating a 5-year-old boy with known neurofibromatosis type I who has developed visual loss in the right eye. Imaging demonstrates a suspected right optic pathway glioma. What charac- teristic will determine if you are able to surgically cure this patient?
A. Baseline visual field tests
B. Optic chiasm involvement
C. Enhancement pattern on MRI
D. Location (right vs. left)
E. Patency of retinal artery on angiogram
A. Baseline visual field tests
B. Optic chiasm involvement
C. Enhancement pattern on MRI
D. Location (right vs. left)
E. Patency of retinal artery on angiogram
Optic gliomas in patients with NF1 can be surgically resected en bloc (or nearly en bloc) if it is obvious that there is normal optic nerve on either side of the involved area. In these cases, the tumor can be resected with the optic nerve (and orbit); however, if there is tumor invasion into the optic chiasm, the mass cannot be completely excised without unacceptable risk of bilateral blindness postop.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 429.
You are asked to evaluate a patient in the ED who has suffered a severe leg injury after being involved in a motorcycle accident. The laceration is just above the knee in the posterior aspect of the leg. What nerve are you worried could be severed in this location?
A. Sciatic
B. Superficial peroneal
C. Common peroneal
D. Femoral
E. Obturator
A. Sciatic
B. Superficial peroneal
C. Common peroneal
D. Femoral
E. Obturator
In this posterior location, the sciatic, common peroneal, and tibial nerves are at risk. When the laceration is just above the knee in a lateral position, it would be more likely for the patient to have suffered a common peroneal nerve injury as the peroneal and tibial nerves have bifurcated from the sciatic.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 655.
You have evaluated a patient in the ED with a severe leg laceration and foot drop. This occurred earlier today in a motorcycle accident. The image of the laceration is demonstrated. You are considering proceeding to the OR for washout of the wound and identification of the nerve injury. What should you obtain before going to the OR?
A. Infectious disease consult
B. Neurology consult
C. Vascular surgery consult
D. PMR consult
E. Social work consult
A. Infectious disease consult
B. Neurology consult
C. Vascular surgery consult
D. PMR consult
E. Social work consult
With a confirmed nerve injury in a sharp lacer- ation such as depicted above, you should strongly consider a vascular surgery consult given that nerves often run in close approximation with major blood vessels. There is also an associated hematoma apparent in the wound. You would not want to expose the nerve and discover a major vascular injury that you were not prepared for.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 565.
You are working in the neuro-ICU and have admit- ted a patient with the following MRI scan who also has severe encephalopathy. What other conditions would this patient likely present with?
A. SIADH
B. Motor deficit
C. Seizures
D. Intraparenchymal hemorrhage
E. Aphasia
A. SIADH
B. Motor deficit
C. Seizures
D. Intraparenchymal hemorrhage
E. Aphasia
This patient has posterior reversible encephalopathy syndrome (PRES), and along with significant encephalopathy, these patients have high rates of seizures and hypertension.
Further Reading: Harbaugh, Shaffrey, Couldwell, Berger. Neurosurgery Knowledge Update, 2015, page 851.
This EEG may be recorded in a patient on what medication?
A. Levetiracetam
B. Pentobarbital
C. Carbamazepine
D. Lorazepam
E. Ketamine
A. Levetiracetam
B. Pentobarbital
C. Carbamazepine
D. Lorazepam
E. Ketamine
This EEG demonstrates a burst-suppression pattern. Of the listed medications, pentobarbital is the most likely to be utilized in a patient to achieve this EEG pattern.
Further Reading: Siddiqi. Neurosurgical Intensive Care, 2017, page 177.
