Surgery - Neurosurgery

Question 1

Which clinical picture associates with the following symptoms? Sudden occipital headache, photophobia, fever, neck stiffness.

A) Acute subdural hemorrhage
B) Intracerebral hemorrhage
C) Posterior fossa tumor
D) Subarachnoid hemorrhage
E) Migraine

Answer 1

D) Subarachnoid hemorrhage

EXPLANATION
The acute subdural hemorrhage (A) generally caused by a high magnitude impact of the skull therefore this syndrome can not be spontaneous and it is followed by immediate black out. The intracerebral hemorrhage (B) starts with sudden headache, but not localizing to the occipital region, its causing diffuse, tensive pain, in most cases progressing to deep coma with sever neurological deficits. In principle posterior fossa tumors (C) can cause occipital headache but its not appears suddenly, and not associates with photophobia or fever. The migraine (D) could be the most similar to subarachnoid hemorrhage, but it`s not accompanied with fever. The correct answer is subarachnoid hemorrhage (D).

Question 2

What should be done with a patient with subarachnoidal bleeding?

A) Observation
B) Sending to inpatient provider institute
C) Sending to neurosurgery department
D) Asking MRI
E) Asking angiography

Answer 2

C) Sending to neurosurgery department

EXPLANATION
The subarachnoid hemorrhage is a neurosurgical type of disease, because in the background there is a treatable bleeding source. In the most cases the acute surgical treatment (acute aneurysm surgery) is the only possible choice, so the patient should be sent to the nearest neurosurgical department. Any other act is just unnecessary risk for the patient.

Question 3

The main pathologies causing trigeminal pain:

A) Intracranial tumors
B) Sclerotic plaque
C) Vascular compression of the nerve
D) Idiopathic

Answer 3

C) Vascular compression of the nerve

EXPLANATION
The leading cause of trigeminal neuralgia 90% of the cases is vascular compression. The remaining 10% is idiopathic, but there is 2% in sclerosis multiplex caused by sclerotic plaque localized in the pons. In some cases brainstem tumors, or skull base tumors can also cause trigeminal compression.

Question 4

In case of traumatic spine fracture the main purposes of the operation are the following, except for:

A) Decompression of neural elements
B) Restoration of spine statics
C) Stabilization
D) Spine stimulation

Answer 4

D) Spine stimulation

EXPLANATION
Like in the surgical treatment of one instabile segment, in the treatment of spine fracture there is also tree principle. Release of the nerve elements being under compression caused by fracture, or luxation of the vertebrae, restoration the spine statics, and stabilization of the spine.

Question 5

We need to think of a stenotic spinal canal when the patient’s walking is facilitated by bending, when there is neurogenic claudication, so occurring low back pain which can radiate to the legs during walking.

A) true
B) false

Answer 5

A) true

EXPLANATION
It is a clinical observation, that in the case of a spinal stenosis (narrowing of the spinal) canal, the patient is asymptomatic, however, when walking gradually worsening pain occurs in the waist radiating into the lower extremities. Furthermore, in many cases the patient tends to lean forward when walking in order to reduce pain.

Question 6

It is necessary to prepare brain MRI when cerebellar symptoms are noticed during or after upper respiratory tract infection in childhood because of the suspicion of scala posterior tumor:

A) true
B) false

Answer 6

A) true

EXPLANATION
In childhood, tumors located in the posterior cranial fossa can often remain unnoticed for a long time. Edema associated with upper respiratory tract infections or because the child is being more carefully examined over this period, may reveal symptoms (clumsiness, gait abnormalities) that are thought to be novel or have not been attributed beforehand. In many past medical histories frequent falls, balance disorders, etc. are mentioned at a later time. Although similar symptoms may be caused by infection-related inflammation of the nervous system, it is advisable to confirm or exclude the possibility posing greater risk (i.e. tumor), hence targeted therapy can be started as soon as possible. So performing an MRI scan is justified.

Question 7

The specific symptoms in case of elderly normal pressure hydrocephalus are the following, except for:

A) gait disturbance
B) blurred vision
C) incontinence
D) memory loss

Answer 7

B) blurred vision

EXPLANATION
Symptoms of normal pressure hydrocephalus (NPH) include abnormal gait, incontinence and memory disorder.

Question 8

In case of inactive pituitary tumor, without compressive symptoms and progressive growing, the chosen treatment is the following:

A) early tumor resection by using transsphenoidal approach
B) periodic ophthalmological examination and MRI control within the confines of endocrinology care
C) radiotherapy
D) hormone substitution

Answer 8

B) periodic ophthalmological examination and MRI control within the confines of endocrinology care

EXPLANATION
In patients with a hormonally inactive and non space-occupying pituitary gland tumor, i.e. compression of the optic nerve is not present, surgical treatment is unnecessary regardless of size, regular ophthalmic and MRI followup is sufficient as part of regular endocrinological care.

Question 9

A patient with isolated head injury is transferred to the hospital with the following parameters: GCS 7, BP 130/85 mmHg, HR 75/min, oxygen saturation 97%; no space-occupying lesion is detectable in the cranial CT scan. What is to be done?

A) only observation
B) intubation, placement of ventricular drain, measurement of intracranial pressure
C) decompressive craniectomy (DC)
D) induction of barbiturate coma

Answer 9

B) intubation, placement of ventricular drain, measurement of intracranial pressure

EXPLANATION
A patient who suffered traumatic brain injury and has a decreased level of consciousness with GCS ≤ 8 must be intubated, and it is recommended to measure the intracranial pressure and, if necessary, treat the increased intracranial pressure by placement of a ventricular drain and in certain cases by drainage of the cerebrospinal fluid (B).

Question 10

Spinal dysraphia (neural tube defect) can frequently present with hydrocephalus.

A) true
B) false

Answer 10

A) true

EXPLANATION
The statement is true because the neural tube defect is part of a complex developmental anomaly; therefore, the circulation and/or absorption of the cerebrospinal fluid may be disturbed. Consequently, hydrocephalus can develop, predominantly due to meningocele, meningomyelocele or Chiari malformation.

Question 11

Chronic subdural hematoma can be diagnosed based on the following symptoms: banal head injury, lack of serious headache, memory impairment and altered level of consciousness fluctuating from hour to hour:

A) true
B) false

Answer 11

A) true

EXPLANATION
The described features represent the typical signs indicating the development of a chronic subdural hematoma. This diagnosis should be taken into account even if the cerebral (or general) vascular condition of the patient raises the suspicion of a vascular origin underlying the symptoms. It should not be ignored that such patients are more likely to have frequently suffered minor head traumas without remembering those events, especially if the onset of the consequences are late.

Question 12

Spinal dysraphias (neural tube defects) are always associated with neurological signs.

A) true
B) false

Answer 12

B) false

EXPLANATION
Defects in neural tube closure do not necessarily associate with neurological symptoms. Just think of spina bifida, a pathology that is revealed in most of the cases as an incidental finding, affects exclusively the bony structure, and often to a minor extent.

Question 13

If the pain radiates to the medial part of the arm and the elevation or abduction of the arm leads to the disappearance of the radial pulse, we should think of the following pathology:

A) syringomyelia
B) coarctation of the aorta
C) cervical disc hernia
D) thoracic outlet syndrome
E) poliomyelitis

Answer 13

D) thoracic outlet syndrome

EXPLANATION
In the presence of the described features of cervicobrachial syndrome, it is essential for the differential diagnosis to take into account each of the possibilities listed. However, the loss of the radial pulse on elevation or abduction of the arm (a.k.a. Adson’s sign) is characteristic of only the scalenus syndrome (D).

Question 14

Acute epidural hematoma is half as dangerous as subdural hematoma considering mortality:

A) true
B) false

Answer 14

A) true

EXPLANATION
The statement is indeed true, because according to great international statistics, mortality of acute subdural hematomas is between 36-74%, while mortality of epidural hemorrhage is nowadays 9-36%. The difference is partly due to the fact that in the case of epidural hemorrhage, with modern imaging early diagnosis and rapid surgical intervention can provide a favorable outcome, partly because it doesn’t always involve severe and extensive brain damage. The development of acute subdural hematoma is a consequence of high force (speed) and in all cases involves severe brain contusion (in many cases the outcome is determined by the latter). This statement is intended to correct an earlier belief.

Question 15

Arteriovenous malformations are congenital lesions, which have lifelong bleeding risk without treatment.

A) true
B) false

Answer 15

A) true

EXPLANATION
Arteriovenous malformations are congenital, they tend to grow in the course of life and cause lifelong bleeding risk without treatment.

Question 16

All the unconscious patient who have suffered head injury should be potentially considered to have spine injury (thus immobilized) till detailed medical examination rules it out.

A) true
B) false

Answer 16

A) true

EXPLANATION
All the unconscious patient who have suffered head injury must be considered to have spine injury at the same time till proper spine imaging tests exclude it.

Question 17

One of the following locations considered as the most frequent level of herniated disc disease:

A) LIII–IV
B) LIV–V
C) CIV–V
D) CVI–VII
E) ThXI–XII

Answer 17

B) LIV–V

EXPLANATION
Herniated disc disease most commonly occurs in the lumbar spine. Because of the forces associated with movement and load are the greatest here, and providing the “ideal location” for disc damage. From the list above the most frequent location for herniation is LIV-V intervertebral disc (B), the rarest location is lower thoracic spine.

Question 18

Acupuncture or physiotherapy may expressly worsen radiating pain of herniated disc disease initially:

A) true
B) false

Answer 18

A) true

EXPLANATION
The statement is based on observation. Herniated disc disease is causing pain by local spatial disproportionateness, making radicular tension or compression of the surrounding structures. The listed therapies in the statement are causing local plethora at the beginning, and as a result spatial disproportionateness will be increased, thus – in case of herniated disc – the pain will worsen usually as the treatment begins. Practical experience can be helpful if we are uncertain about the concrete spatial disproportionateness and the initially given treatment increasing the pain, then surgical treatment should be considered to solve the spatial disproportionateness.

Question 19

In case of so-called silent carotid stenosis, no surgical solution is recommended because the results of medication treatment are better than the surgical solution:

A) true
B) false

Answer 19

B) false

EXPLANATION
Today it is a fact has been proven by international studies that in case of certain carotid stenosis (significant, higher than 75%) endarterectomy results in better outcome with lower risk of stroke than only drug therapy. It should be considered separately if the silent but narrowed carotid artery has a serious collateral role in the blood supply of the opposing hemisphere (e.g., contralateral carotid occlusion). In case of such so-called tandem lesions endarterectomy is also recommended. Therefore, the 15-year-old professional opinion that “in the case of mute carotid stenosis, no surgical solution is to be considered” is to be changed.

Question 20

Which is the most common central nervous system tumor?

A) pituitary adenoma
B) glioblastoma multiforme
C) metastasis
D) meningioma

Answer 20

C) metastasis

EXPLANATION
The most common type of tumor in the central nervous system is metastatic tumor, far above the primary tumor rate.

Question 21

If the patient is in deep coma, their pupils are dilated and they do not respond to light, there isn’t spontaneous breathing and any response to painful stimuli, brain death can be stated.

A) true
B) false

Answer 21

B) false

EXPLANATION
The listed symptoms and test findings actually meet the criteria for brain death according to physical examination. Nevertheless, in this form, the statement is considered false, caused by ignoring an important consideration. In all case of symptoms correspond to brain death; the key phrase must also be that “findings can’t be related to drug effects”. However, the findings listed correspond to the clinical condition of deep barbiturate coma, which we sometimes need to use as a therapeutic solution.

Question 22

What is your treatment recommendation if your patient suddenly experiences a lumbar pain that radiates into the lower limb on its outer surface towards the old finger?

A) pain relief and bed rest
B) pain relief and acupuncture treatment
C) pain relief and neurosurgical consultation
D) Medication and orthopedic examination
E) Pain relief and physiotherapy

Answer 22

A) pain relief and bed rest

EXPLANATION
The decision has to be made based on an important consideration in the statement that is the sudden emergence of a symptom, a radiating pain, without paresis. Because of the latter, we do not have to necessarily suppose such lesion that may warrant deliberation of an urgent surgical solution. The first and most important task is pain relief and bed rest (A) to reduce acute, tortuous complaints. Only if this treatment does not produce results (within a few days) it is advisable to turn to other methods or tests.

Question 23

Surgical treatment is more often than endovascular treatment among ruptured or unruptured aneurysms.

A) true
B) false

Answer 23

B) false

EXPLANATION
The treatment of cerebral aneurysms has been changed in the latest decades, since development of endovascular intervention (aneurysms has been excluded from circulation by stuffing with coils) means less preoperative strain and accompanied by as many complication as , it had effaced the opened-cranial surgery. Surgeries didn’t loose their significance, because in many cases (e.g. aneurysms with wide neck, a part of giant-aneurysms, severe atherosclerosis, kinking of carotid artery, etc.), that may exclude or accompanied by higher risk of intervention, so the surgical management is preferable.

Question 24

Cerebral vasopasm is a condition that takes after subarachnoid hemorrhage:

A) 12-24 hours
B) 1-3 days
C) 3-14 days
D) 0-48 hours

Answer 24

C) 3-14 days

EXPLANATION
Cerebrals vasopasm may occur after subarachnoid hemorrhage on the third days after bleeding, and reaches the peak of it between the 6th and 10th days and ceases after the 14th days.

Question 25

Mortality of acute subdural haemorrhage is at least two-times higher than diffuse axonal injury:

A) true
B) false

Answer 25

A) true

EXPLANATION
According to international data, mortality of diffuse axonal injury is 13-51%, but mortality of acute subdural hematoma (that always accompanied by sever contusion of brain) 26-74%. Based on this data mortality rate is less in diffuse axonal injury then in acute subdural hematoma. We would like to revise the illusion, diffuse axonal injury has the highest mortality rate.

Question 26

Which anatomical location has been injured, if patient has psychomotoric attacks and temporarily sensory aphasia?

A) left fronto-parietal region
B) right limbic lobe
C) left temporal lobe
D) right central region
E) left thalamus

Answer 26

C) left temporal lobe

EXPLANATION
Psychomotoric attack is a condition with temporal lobe background. Thus frontal, central, fronto-parietal location can be excluded. Temporary sensors aphasia means affected dominant hemispheric angular gyrus or supra marginal location.Thus the correct answer is left temporal lobe.

Question 27

How long bleeding ruptured aneurysms in subarachonoidal room?

A) approx. 1–2 minutes
B) approx. half hour
C) approx. a week
D) while artery systolic pressure higher than intracranial pressure
E) while perfusion pressure higher than 40 Hgmm

Answer 27

D) while artery systolic pressure higher than intracranial pressure

EXPLANATION
Ruptured aneurysms may lead with subarachnoid hemorrhage (mainly in this case), and instantaneous. Bleeding that takes minutes (A) or lasts much time (B and C) leads to death. Sudden onset of increased intracranial pressure after bleeding of aneurysm ,that leads to loss of consciousness, stops bleeding(D). Other factors with affect on stopping bleeding were absent among answers.

Question 28

Most common signs of arteriovenous malformations are:

A) headache, epilepsy
B) dementia, neurological focal symptom
C) subarachnoid haemorrhage, intracerebral haemorrhage bruit, cardiac failure

Answer 28

A) headache, epilepsy

EXPLANATION
In case of arteriovenous malformation (AVM) all combination of events can occur. Headache in 50%, and epileptic attack is present in 1/3 of cases. Epileptic attack may developed based on ischemic areas around the AVM. Dementia is not a typical sign of AVM, but it may be present in certain location ( frontal lobe, thalamus), like neurological focal symptom’s development too ( mainly based on steel of blood or small cerebral bleeding. 50%of cases with subarachnoid hemorrhage may cause by AVM, and more rarely in intracerebral hemorrhage. Bruit may present in case of AVM with high blood-flow, and cardiac failure may present if AVM with high blood-flow accompanied by venous black-flow in infancy and childhood , that mean extra load on the heart (in these cases bruit can auscultate on heart and big vessels)

Question 29

A 50-year-old, regularly smoking male patient complains about weakness of his right limbs and has a problem with verbal self expressing, though he understands verbal communication. There is a contrast-enhancing tumorous lesion with a diameter of 2 cm with perifocal oedema in the superficial area of the left frontal lobe on the skull CT scans. There is no midline shift. What should you do?

A) Neurosurgical concilium, acute operation, irradiation
B) Neurosurgical concilium, skull MRI, further investigation for other tumors (staging), operation and acute oncological therapy by the decision of the neuro-oncology team
C) Irradiation of the whole skull and decreasing of the oedema
D) Chemotherapy

Answer 29

B) Neurosurgical concilium, skull MRI, further investigation for other tumors (staging), operation and acute oncological therapy by the decision of the neuro-oncology team

EXPLANATION
According to the datas and imaging studies written in the question and to the statistical incidence of tumors the lesion is most likely a metastatic tumor or a glioblastoma multiforme. The tumor and the surrounding oedema cause the problems in the motor cortex and motor speech area. For further diagnostics, there is a need for skull MRI scans to search for other possible metastatic tumors not seen on the CT scans. With these informations and the knowledge of the patient’s other diseases, general and neurological status the neuro-oncology team’s decision gives the direction of the treatment: biopsy or tumor removal, or depending on the histological examination there might be oncological treatment.

Question 30

The patient has regular events like TIA and the ultrasound and angiography certified an ulcerous and sclerotic plaque causing a stenosis of 50%. In this case is it preferred to do endarterectomy?

A) yes
B) no

Answer 30

B) no

EXPLANATION
Today, based on large international studies, it is considered acceptable that the symptom causing carotid artery stenoses are operated only when the rate of the stenosis is significant (above 75%) from the haemodynamic point of view. In the case of a stenosis of 50% or less, medication is certainly more beneficial, and this has been confirmed by the aforementioned studies. In case of an ulcerated plaque, which does not cause hemodynamic disorders, it is not advisable to think about surgical solution until antiaggregation treatment has not been applied. If symptoms persist beside the embolism preventing anticoagulant therapy, then the surgical solution is only to be discussed (the more favorable effect of which is not yet demonstrated in international studies).

Question 31

There is no need for hospitalization for every patient with traumatic skull injury, you can let a patient under the influence of alcohol with traumatic skull injury to go home after examination and wound treatment in case he does not have neurological symptoms.

A) true
B) false

Answer 31

B) false

EXPLANATION
The state of being drunk implies a condition in which the consequences of the trauma are difficult to be detected or investigated. That is the reason why professional advice has been given that it is advisable to keep a drunken skull injured patient hospitalized, even if for a short time, until it is possible to judge the condition of the patient properly. (The advice is the same for babies and elderly people.)

Question 32

The most obvious cause of a gradually forming hemiparesis:

A) rupture on an aneurysm
B) hemispheric tumor
C) obstruction of the internal carotid artery
D) problem with the circulation of cerebrospinal fluid
E) tumor of the posterior fossa

Answer 32

B) hemispheric tumor

EXPLANATION
From the causes of the progressive hemiparesis caused by aneurysmaruptura (A) and internal carotid artery blockage (C) are eliminated, as both of these are ictal-like diseases, so one-sided paralysis develops suddenly and not gradually. Disruption of liquor circulation (D) is never in the background of hemiparesis. Tumors of the posterior fossa (E) causes one-sided paralysis only in those very rare cases, when it is located in the brainstem or craniocervical transition and is definitely half-side localized. Therefore, the most probable cause is a hemispheric tumor (B).

Question 33

These are the next compensating mechanisms in case of an intracranial space occupying lesion:

1) decrease of the intracranial blood volume
2) decrease of the subdural liquid volume
3) decrease of the cerebrospinal fluid volume
4) decrease of the brain’s water content
5) thinning of the skull bones

A) all of the answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 5th answers are correct
D) none of the answers are correct

Answer 33

B) 1st and 3rd answers are correct

EXPLANATION
In the case of intracranial space occupying lesion the following gives opportunities for compensation (in order): reduction in the amount of liquor (3), reduction in intracranial blood volume (1), while the water content of the brain increases due to oedema (4). There is no subdural fluid in that virtual space, so it can not be mentioned in the theme of compensation. Thinning of the skull bones may occur only in childhood, usually in the case of chronic intracranial pressure increase. This is a consequence, not a mark of compensation, as in the same case the suture removal. Version B is the correct answer.

Question 34

The most common symptomes of the suprasellar tumors:

1) ophtalmoplegia
2) endocrine disorders
3) facial palsy
4) visual field defect
5) dementia

A) all of the answers are correct
B) 1st, 3rd and 5th answers are correct
C) 2nd and 4th answers are correct
D) none of the answers are correct

Answer 34

C) 2nd and 4th answers are correct

EXPLANATION
Endocrin disorders (2) are typical consequencies of the supreasellar tumors either because they origin directly from the hypophysis or because they directly compress it. Similarly, the hypothalamo-pituitary system can be damaged. Due to a compressing or a stressing effect on one or more segment (oprtic nerv, optic chiasm, optic tract) of the visual system, visual field defect (4) is also characteristic in this disease. Eye movement disorders, sometimes even complete ophtalmoplegia can accompany the previously mentioned symptoms, becuse the tumor infiltrates the cavernous sinus. Facial palsy doesn’t develop (extreme rare??) (/The incidence of facial palsy as a symptom of a suprasellar tumor is close to 0.) If the tumor very rarely reaches a size big enough, when it severely compresses the frontal cortex on both sides, dementia can occur. Because the question is about “the most common symptoms”, the correct answer is “C”.

Question 35

Elements of the Glagow Coma Scale:

1) consciousness
2) verbal response
3) size of the pupil
4) motor response
5) eye opening response
6) Babinski-sign

A) all of the answers are correct
B) 1st and 3rd answers are correct
C) 3rd and 6th answers are correct
D) 2nd, 4th and 5th answers are correct
E) 1st, 3th and 6th answers are correct

Answer 35

D) 2nd, 4th and 5th answers are correct

EXPLANATION
With the help of the Glasgow Coma Scale, the status of a patient with head injury is assessed through the verbal, the motor and the eye opening responses. Although, it is recommended to frequently evaluate and document the level of conciousness, the size of the pupil (and the change of it) and the Babinksi-sign, they are not elements of this scale. Hence, the correct answer is „D”.

Question 36

Choose the correct statements.

1) Each and every head trauma patient has to be transported to a trauma surgery department.
2) In the case of a posttraumatic pupillary inequality(/anisocosia/ unequal pupils) an immidiate transport to neurosurgery is required.
3) By a suspected impression fracture of the skull, the patient has to be transported to the nearest trauma clinic.
4) A polytraumtic patient with skull injury needs an immidiate transport to neurosurgery.
5) A prompt transport to neurosurgery in a case of a severe (traumatic) skull injury is mandatory

A) only 1st and 2nd answers are correct
B) only 3rd answer is correct
C) only 4th and 5th answers are correct
D) all of the answers are correct

Answer 36

C) only 4th and 5th answers are correct

EXPLANATION
It is not correct to state that each and every head trauma patient has to be transported to a trauma surgery department because some minor head injuries do not even require any treatment, but some severe ones should be treated in neurosurgery. Posttraumatic pupillary inequality can be a consequence of direct eye-ball (bulbus) or orbit (orbita) injury, which is primarily a subject of an ophthalmological treatment. Thus, neurosurgical intervention is not always part of the cure. By a suspected impression fracture of the skull, the patient has to be transported not to the nearest trauma clinic, but to a neurosurgery. Polytrauma patients with skull injury or patients with severe (traumatic) skull injury indeed have to be transported to neurosurgery. Considering these, the correct answer is „C’.

Question 37

Which are the characteristics of the hangman’s fracture

1) the peculiar fracture of the C2
2) A complete spinal cord injury occurs instantly in most cases
3) Typical injury of motorcyclists
4) the point is: traumatic spondylolisthesis

A) All of the answers are correct
B) 1st, 2nd and 4th answers are correct
C) only 3rd answer is correct
D) None of the answers are correct

Answer 37

B) 1st, 2nd and 4th answers are correct

EXPLANATION
The Hangman’s fracture is the peculiar fracture of C2, which is in most cases go hand in hand with a complete spinal cord injury. The essence of the injury is a traumatic spondylolisthesis. It is a false allegation, that it is a typical injury of the motorcyclists. In this way, the „B” is the right answer.

Question 38

Clinical sings of the basilar skull fracture:

1) blood or liquor discharge from the ear
2) nose-bleeding
3) bilateral periorbital ecchymoses (raccoon’seyes)
4) presence of air within the cranial cavity
5) trauma related anosmia
6) hemotympnaum
7) trauma related vertigo

A) only 1st answer is correct
B) 2nd and 5th answers are correct
C) 5th and 7th answers are correct
D) 1st, 3rd, 4th and 6th answers are correct
E) All of the answers are correct

Answer 38

D) 1st, 3rd, 4th and 6th answers are correct

EXPLANATION
The skull base fractures cannot always be recognized on X-ray pictures or on CT-scans. To confirm the suspition of this diagnosis the clinical signs must be thoroughly evaluated. Blood or cerebrospinal fluid discharge (1) from the ear unequivocally points to a skull base fracture, specifically to a pyramid fracture. Nose bleeding is a symptom of many diseases ergo it is not a characteristic sign of this kind of fracture. The raccoon’s eyes (3) and air in the cranial cavity (4) indicate a skull base fracture (anterior cranial fossa). As follows, trauma related anosmia is not a specific attendant phenomenon of a skull base fracture. Olfactory fila is prone to tear when a shift in the position of the brain happens. Blood in the tympanic cavity is a clear sign of this fracture too. Trauma related vertigo is a common symptom in head trauma cases. The correct answer is “D”.

Question 39

The possible complications of a subarachnoid hemorrhage:

1) hydrocephalus
2) vasospasm
3) memory impairment
4) epidural hemorrhage
5) cerebral abscess
6) cerebral edema

A) all of the answers are correct
B) only 1st answer is correct
C) 1st, 2nd, 3rd and 6th answers are correct
D) 4th and 5th answers are correct

Answer 39

C) 1st, 2nd, 3rd and 6th answers are correct

EXPLANATION
Acute (20-40%) or chronic (10%) hydrocephalus (1) may be a consequence of a subarachnoid hemorrhage (SAH) when the circulation or reabsorption of the cerebrospinal fluid is hampered. Vasospasm (2) usually develops in 2-3 days after the SAH and lasts for 3-4 weeks thereafter causing ischemic damage. Memory impairment (3) points to some particular locations of the damage. SAH is not associated with epidural hemorrhage and neither causes it brain abscess. Cerebral edema often accompanies SAH or vasospasm, especially in extensive hemorrhaging forms.

Question 40

The main principles of the management of the spine injuries:

1) Principally the primary spinal cord injury is to be treated.
2) The most important is to prevent the secondary injury of the spinal cord.
3) By a suspected spinal cord injury immobilization is required.
4) In a case of a spinal cord injury above the C4 segment an acute respiratory failure is expected, therefore the patient has to be intubated.

A) all of the answers are correct
B) only 1st answer is correct
C) 2nd, 3rd and 4th answers are correct

Answer 40

C) 2nd, 3rd and 4th answers are correct

EXPLANATION
Today it is still not yet possible to actually influence the primary spinal cord injury as part of the injury management, because the damage occurs at the time of the trauma. The aim of the therapy is to prevent the development of the secondary lesions of the spinal cord (2). When the suspicion of spinal cord injury is raised the immobilization of the patient (3) is an appropriate instruction. Because the diaphragm innervating phrenic nerve sprouts from the C4 level, when the damage affected site is the cervical segment above the C4 level acute respiratory failure is expected. Thus, intubation is inevitable. “C” is the correct answer.