Craniotomies—General Information and Cortical Mapping

Question 1

Intraoperative brain swelling etiologies include all of the following except?
● A. Extraparenchymal bleeding: from a vessel or intraoperative aneurysm rupture
● B. Intracerebral hemorrhage
● C. Venous outflow obstruction
● D. Vasodilatation induced by hypocarbia
● E. Severe diffuse cerebral edema

Answer 1

D. Vasodilatation induced by hypocarbia

Question 2

What is the last life-saving measure for uncontrollable intraoperative brain swelling?
● A. Reverse Trendelenburg position
● B. Removal of swollen brain
● C. Decompressive craniectomy
● D. Apply pressure on the brain
● E. Place the head in neutral position

Answer 2

B. Removal of swollen brain

Question 3

Cranioplasty following posterior fossa surgery for vestibular schwannoma reduced the incidence of postoperative headache to how much?
● A. 4%
● B. 17%
● C. 50%
● D. 70%
● E. 100%

Answer 3

A. 4%

Question 4

What is the incidence of postoperative headache after posterior fossa surgery?
● A. 100%
● B. 80%
● C. 95%
● D. 97%
● E. 90%

Answer 4

B. 80%

Question 5

A patient who underwent tumor resection and awake craniotomy develops lethargy, confusion, severe headache, nausea, vomiting, and seizures. For awake craniotomy, skull block is being done for which local anesthetic agents injection must be applied at many regions?
● A. 1 region
● B. 2 regions
● C. 3 regions
● D. 4 regions
● E. 5 regions

Answer 5

D. 4 regions

Question 6

Definitive treatment of syndrome of trephination is indicated if headache does not settle within how long?
● A. 2 months
● B. 3 months
● C. 4 months
● D. 5 months
● E. 6 months

Answer 6

B. 3 months

Question 7

During awake craniotomies, what is the maximum current that can be used to stimulate any area of cortex?
● A. 2 mA
● B. 4 mA
● C. 6 mA
● D. 8 mA
● E. 10 mA

Answer 7

E. 10 mA

Question 8

Which of the following nerves must not be anesthetized during awake craniotomies?
● A. Supraorbital nerve
● B. Facial nerve
● C. Postauricular nerve
● D. Lesser occipital nerve
● E. Third occipital nerve

Answer 8

B. Facial nerve

Question 9

During awake craniotomy, total speech arrest occurs by stimulating which area of nondominant hemisphere?
● A. Pars opercularis
● B. Frontal operculum
● C. Posterior middle temporal gyrus
● D. Anterior supramarginal gyrus
● E. None of the above

Answer 9

A. Pars opercularis

Question 10

Which of the following is a contraindication of awake craniotomy?
● A. Thalamic tumor
● B. Epileptic foci in eloquent brain area
● C. Removal of brainstem tumors
● D. Tumor near motor strip
● E. Significant speech/motor deficits

Answer 10

E. Significant speech/motor deficits

Question 11

The FDA released a number of recommendations for use of drill to reduce injury during craniotomy which are the following?
● A. Selection of appropriate perforator based on the skull thickness (pediatric vs. adults)
● B. Keeping the perforator perpendicular to the skull throughout the drilling process
● C. Do on rock, rotate, or change the angel of the device during drilling
● D. Avoid using excessive pressure on the drill
● E. Use caution when drilling through areas of irregular bone contour, curvature, or variations in thickness or drilling where bone might be diseased or incompetent
● F. All of the above

Answer 11

F. All of the above

Question 12

All of the following are etiologies of intraoperative brain swelling except?
● A. Extraparenchymal bleeding from a vessel or intraoperative aneurysm rupture
● B. Intracerebral hemorrhage
● C. Venous outflow obstruction
● D. Vasoconstriction induced by hypercapnia
● E. Severe diffuse cerebral edema following stroke or traumatic brain injury

Answer 12

D. Vasoconstriction induced by hypercapnia

Question 13

Management of intraoperative brain swelling include finding out the cause and treating that cause. Other measures that should be taken for decreasing brain swelling include which of the following?
● A. Elevation of head of bed
● B. Making sure the jugular veins are not kinked
● C. Ruling out hypercarbia, making sure that endotracheal tube is not kinked, and checking the patient’s end tidal pCO2
● D. Measures to lower ICP are adopted, which includes giving mannitol, draining CSF, tapping and draining ventricle, having the anesthesiologist hyperventilate the patient’s pCO2 to 30 to 35 mmHg
● E. Emergency intubation for patients are undergoing awake craniotomy and intraoperative ultrasound or CT of brain
● F. All of the above

Answer 13

F. All of the above

Question 14

The overall risk of postoperative hemorrhage is 0.8 to 1.1%. Which hematomas constitute 43 to 60% of these?
● A. Intraparenchymal
● B. Epidural
● C. Subdural
● D. Intrasellar
● E. Mixed

Answer 14

A. Intraparenchymal

Question 15

What are the postoperative medications that are given to a patient after craniotomy for brain tumor?
● A. Dexamethasone and H2 antagonist
● B. Antiepileptic drugs
● C. Cardene drip to keep systolic BP less than 160 mmHg and diastolic BP less than 100 mmHg
● D. Prophylactic antibiotics are continued
● E. Acetaminophen and codeine are also given for pain relief
● F. All of the above

Answer 15

F. All of the above

Question 16

All of the following are causes of postoperative deterioration of patients after craniotomy except?
● A. Hematoma or cerebral infarction (from compromise of normal arteries or veins)
● B. Postoperative seizures or acute hydrocephalus
● C. Syringomyelia formation
● D. Pneumocephalus or brain edema
● E. Persistent anesthetic effect or vasospasm

Answer 16

C. Syringomyelia formation

Question 17

What are the causes of postoperative headache in a patient after craniotomy?
● A. Traction of the dura when the bone is not replaced
● B. Traction on dura due to tight dural closure
● C. Temporalis or nuchal muscle dissection
● D. Nerve entrapment in the closing suture or healing scar
● E. Intradural blood and/or CSF leak
● F. All of the above

Answer 17

F. All of the above

Question 18

Phase reversal technique can be used to see primary sensory or motor cortex. What is the use of intraoperative cortical mapping in a patient undergoing craniotomy?
● A. Motor strip localization
● B. Sensory cortex localization
● C. Speech centers determination
● D. All of the above

Answer 18

D. All of the above

Question 19

Indications of awake craniotomy include surgery in eloquent brain area, removal of brain stem tumors, or for some seizure surgery to look for seizure focus. All of the following are contraindications of awake craniotomy except?
● A. Patients who are unable to cooperate
● B. Very young or very elderly patients
● C. Confused patients
● D. Those with significant speech deficit already present
● E. Those with no language barrier

Answer 19

E. Those with no language barrier

Question 20

What is the typical sequence of anesthesia in case of awake craniotomy?
● A. In the preoperative holding area, precedex is started
● B. Induction of anesthesia is given using propofol and skull block is applied
● C. Inhalational anesthesia is started and continued until dura starts to open, at which point inhalational anesthesia is stopped
● D. Remifentanil is given for pain control with neurophysiologic resting performed at this time
● E. Once the intracranial part of the operation is complete, general anesthesia is given again and the operation is completed
● F. All of the following

Answer 20

F. All of the following