Neurosurgery Flashcards
- You are evaluating an 82-year-old man who takes 325 mg of aspirin daily for coronary artery disease. He presented to the emergency department with a headache and sleepiness. CT is shown below. What is the most likely diagnosis? Use the following figure to answer questions 1 through 5:
A. Epidural hematoma
B. Subdural hematoma
C. Intraparenchymal hematoma
D. Traumatic subarachnoid hemorrhage
A. Epidural hematoma
B. Subdural hematoma
C. Intraparenchymal hematoma
D. Traumatic subarachnoid hemorrhage
B. Subdural hematoma
This CT scan demonstrates an acute subdural hematoma, as evident by the hyperdense blood collection crossing the suture lines. A significant midline shift is associated. Blood remains hyperdense on CT scan for 1 to 3 days.
Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 895.
You are evaluating an 82-year-old man who takes 325 mg of aspirin daily for coronary artery disease. He presented to the emergency department with a headache and sleepiness. Refer to CT shown in Question 1. How long has this bleed likely been present?
A. 1 to 3 days
B. 4 days to 2 weeks
C. 2 weeks to 3 months
D. > 3 months
A. 1 to 3 days
B. 4 days to 2 weeks
C. 2 weeks to 3 months
D. > 3 months
This CT scan demonstrates an acute subdural hematoma, as evident by the hyperdense blood collection crossing the suture lines. A significant midline shift is associated. Blood remains hyperdense on CT scan for 1 to 3 days.
Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 895.
You are evaluating an 82-year-old man with a history of a mechanical aortic valve. He presented to the emergency department with a headache and sleepiness. His GCS is 13 (E3, V4, M6). Refer to CT shown in Question 1. What is the next best step?
A. Intubate
B. Bedside burr hole evacuation
C. Start levetiracetam
D. Check INR
A. Intubate
B. Bedside burr hole evacuation
C. Start levetiracetam
D. Check INR
This CT scan demonstrates an acute subdural hematoma, as evident by the hyperdense blood collection crossing the suture lines. This patient has a history of a mechanical aortic valve and is likely on chronic anticoagulation. Before you choose to intervene you should know the coagulation status of the patient and reverse if necessary. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 895.
You are evaluating an 82-year-old man with a history of a mechanical aortic valve. He presented to the emergency department with a headache and sleepiness. His GCS is 13 (E3, V4, M6). Refer to CT shown in Question 1. You decide to intervene. What procedure would you recommend?
A. EVD insertion
B. Burr hole evacuation
C. Decompressive hemicraniotomy/ectomy
D. Posterior fossa decompression
A. EVD insertion
B. Burr hole evacuation
C. Decompressive hemicraniotomy/ectomy
D. Posterior fossa decompression
This CT scan demonstrates an acute subdural hematoma, as evident by the hyperdense blood collection crossing the suture lines. This patient will require surgery and due to the acute nature of this clot, the patient will likely not be adequately drained with burr holes. A decompressive hemicraniotomy/ectomy is recommended. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 895.
You are evaluating an 82-year-old man with a history of a mechanical aortic valve. He presented to the emergency department with a headache but is otherwise neurologically intact with a GCS of 15. What would you recommend?
A. EVD insertion
B. Admission/observation
C. Decompressive hemicraniotomy/ectomy
D. Discharge home from ED with 1 month follow-up head CT
A. EVD insertion
B. Admission/observation
C. Decompressive hemicraniotomy/ectomy
D. Discharge home from ED with 1 month follow-up head CT
This CT scan demonstrates an acute subdural hematoma, as evident by the hyperdense blood collection crossing the suture lines. According to practice guidelines in the management of acute subdural hematoma, any time the acute hematoma is > 10 mm in maximum diameter or there is > 5 mm of associated midline shift, evacuation should be performed regardless of presenting GCS. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 896.
You see a 40-year-old man who was out drinking with friends and was involved in a car accident as an unrestrained passenger. He is sleepy in the trauma bay and his head CT is demonstrated below. What is the most likely diagnosis?
A. Chronic subdural hematoma
B. Acute subdural hematoma
C. Epidural hematoma
D. Traumatic subarachnoid hemorrhage
A. Chronic subdural hematoma
B. Acute subdural hematoma
C. Epidural hematoma
D. Traumatic subarachnoid hemorrhage
This CT scan demonstrates evidence of an acute epidural hematoma, as evident by the hyperdense fluid collection that does not cross the suture lines. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 892.
You see a 40-year-old man who was out drinking with friends and was involved in a car accident as an unrestrained passenger. He is sleepy in the trauma bay and his head CT is demonstrated in Question 6. The injured vessel in this setting enters the skull through what foramen?
A. Foramen ovale
B. Foramen rotundum
C. Foramen spinosum
D. Foramen lacerum
A. Foramen ovale
B. Foramen rotundum
C. Foramen spinosum
D. Foramen lacerum
This CT scan demonstrates evidence of an acute epidural hematoma, as evident by the hyperdense fluid collection that does not cross the suture lines. It is often caused by damage to the middle meningeal artery, which enters the skull through the foramen spinosum. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 892.
ou see a 40-year-old man who was out drinking with friends and was involved in a car accident as an unrestrained passenger. He is sleepy in the trauma bay and his head CT is demonstrated in Question 6. What is the next best step?
A. EVD placement
B. Observation
C. Operative Evacuation
D. Bedside burr hole drainage
A. EVD placement
B. Observation
C. Operative evacuation
D. Bedside burr hole drainage
This CT scan demonstrates evidence of an acute epidural hematoma, as evident by the hyperdense fluid collection that does not cross the suture lines. This is a large EDH and should be evacuated emer- gently if possible via open surgery. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 892.
You see a 40-year-old man who was involved in a car accident as an unrestrained passenger. He is awake and responsive in the trauma bay (GCS 15) and his head CT is demonstrated below. What is the next best step?
A. EVD placement
B. Observation/rescan
C. Operative evacuation
D. Bedside burr hole drainage
A. EVD placement
B. Observation/rescan
C. Operative evacuation
D. Bedside burr hole drainage
This CT scan demonstrates evidence of an acute epidural hematoma, as evident by the hyperdense fluid collection that does not cross the suture lines. This is a small epidural hematoma (< 15 mm) with less than 30 cm 3 of total volume in an awake patient with an exam to follow. This patient can be observed with an early rescan to demonstrate stability in the size of the epidural hematoma. If there is significant expansion or worsening of the exam, the patient should undergo operative evacuation. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 893.
You see a 40-year-old man who was involved in a car accident as an unrestrained passenger. He initially lost consciousness but EMTs reported that he woke up and was talking to them through transport. When you see him in the trauma bay he is no longer responding verbally and opens his eyes only to deep central stimulation. His head CT is demonstrated in Question 6. What is the next best step?
A. EVD placement
B. Observation/rescan
C. Operative evacuation
D. Intubate
A. EVD placement
B. Observation/rescan
C. Operative evacuation
D. Intubate
This CT scan demonstrates evidence of an acute epidural hematoma, as evident by the hyperdense fluid collection that does not cross the suture lines. This patient had a lucid interval and has now deteriorated. Ultimately he will need operative evacuation emergently, but securing his airway should be the first priority. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 893.
You are evaluating a 55-year-old woman who was involved in a car accident where she hit her head and she thinks she lost consciousness. On CT scan you see small hyperdensities in both frontal lobes concerning for small intraparenchymal hemorrhages. She has a GCS of 15. What should you recommend in your consult note?
A. Discharge home
B. Rescan in 6 hours
C. Rescan now
D. Start levetiracetam
A. Discharge home
B. Rescan in 6 hours
C. Rescan now
D. Start levetiracetam
This patient has bifrontal contusions likely from deceleration injury to the brain parenchyma. At this point she has an exam that can be followed, but a rescan should happen after at least several hours to look for expansion of the intraparenchymal hemorrhages. They can expand in a delayed fashion and become symptomatic. A rescan should occur earlier if she deteriorates clinically. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 891.
You are evaluating an 82-year-old man who takes 325 mg of aspirin daily for coronary artery disease. He presented to the emergency department with a headache and sleepiness. MRI is shown below. How long has this bleed likely been present?
A. 1 day
B. 3 days
C. 1 week
D. > 3 weeks
A. 1 day
B. 3 days
C. 1 week
D. > 3 weeks
This MRI scan demonstrates a chronic subdural hematoma. It is uniform and has a fluid appearance. This likely has been present for > 3 weeks. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 895.
You are evaluating an 82-year-old man who takes 325 mg of aspirin daily for coronary artery disease. He presented to the emergency department with a headache and sleepiness. CT is shown below. What procedure would you recommend?
A. EVD placement
B. Burr hole evacuation
C. Decompressive hemicraniotomy/ectomy
D. Posterior fossa decompression
A. EVD placement
B. Burr hole evacuation
C. Decompressive hemicraniotomy/ectomy
D. Posterior fossa decompression
This CT scan demonstrates a chronic subdural hematoma. It is uniform and dark in appearance. This likely has been present for > 3 weeks, and very likely can be completely drained via burr hole evacuation. It will likely not require a full craniotomy. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 895.
You are seeing a 78-year-old man in your office who underwent drainage of a large, right-sided chronic subdural hematoma approximately 40 days ago. He has evidence of a residual subdural fluid collection. Approximately how many patients will still have a fluid collection after subdural drainage at 40 days?
A. 3%
B. 15%
C. 35%
D. 60%
E. 90%
A. 3%
B. 15%
C. 35%
D. 60%
E. 90%
Approximately 15% of patients who undergo subdural fluid evacuation have a residual fluid collection at 40 days. Often times these residual collections do not require repeat surgery and can be managed with observation and serial CT examinations.
Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 901.
When evaluating patients with gunshot wounds to the head, bullet trajectory is important for prognostication. What trajectory has been found to be uniformly fatal in the civilian population?
A. Bifrontal trajectory
B. Holohemispheric trajectory
C. Biventricular trajectory
D. Transverse cerebellar trajectory
A. Bifrontal trajectory
B. Holohemispheric trajectory
C. Biventricular trajectory
D. Transverse cerebellar trajectory
Dating back to initial research done by Harvey Cushing and further studied recently, it has been demonstrated that biventricular trajectory through the third ventricle is uniformly fatal in the civilian literature. Bifrontal, holohemispheric, and isolated cerebellar trajectories have not been found to be uniformly fatal. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 911.
You are asked to evaluate a 65-year-old patient who was discharged from the hospital 1 week ago after undergoing decompression of a right-sided subdural hematoma. She has noticed some clear drainage from her incision and has had a persistent, severe headache all day. Head CT is demonstrated below. What is the diagnosis?
A. Subdural hematoma
B. Epidural hematoma
C. Tension pneumocephalus
D. Subdural empyema
A. Subdural hematoma
B. Epidural hematoma
C. Tension pneumocephalus
D. Subdural empyema
This CT scan demonstrates tension pneumocephalus, the classic “Mount Fuji” sign. This is not a fluid collection given how dark the findings are on CT scan and can only be air. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 888.
You are asked to evaluate a 65-year-old patient who was discharged from the hospital 1 week ago after undergoing decompression of a right-sided subdural hematoma. She has noticed some clear drainage from her incision and has had a persistent, severe headache all day. She prefers to keep her eyes closed and responds with one-word answers only. Head CT is demonstrated in Question 16. What is the next best step?
A. Decompression
B. Lumbar drain
C. Discharge home
D. 100% FiO2 via nonrebreather
A. Decompression
B. Lumbar drain
C. Discharge home
D. 100% FiO2 via nonrebreather
This CT scan demonstrates tension pneumocephalus, the classic “Mount Fuji” sign. This patient is symptomatic from this air collection and while the CSF leak certainly needs to be repaired, the patient should have some form of decompression of the pressurized gas within the skull, followed shortly thereafter by repair of the CSF leak. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 889.
You have been asked to act as the sideline physician for a local high school football game. One of the players takes a big hit and appears to initially walk to the wrong sideline. When you evaluate him he says that he doesn’t remember the previous play. Should he be allowed to go back into the game?
A. Yes
B. No
B. No
This player has evidence of a concussion, including disorientation and amnesia to the event. Based on current concussion guidelines, this player should be removed from the game and not allowed to return until evaluated further by a licensed healthcare provider trained in evaluating concussions. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 844.
What is the normal range of intracranial pressure in adults (mm Hg)?
A. 1 to 4
B. 5 to 9
C. 10 to 15
D. 16 to 20
A. 1 to 4
B. 5 to 9
C. 10 to 15
D. 16 to 20
Normal ICP range for adults and older children is 10 to 15 mm Hg. Young children generally range from 3 to 7 mm Hg, and infants range from 1.5 to 6 mm Hg. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 857.
How is cerebral perfusion pressure calculated?
A. CPP = CMRO2 + ICP
B. CPP = SBP − ICP
C. CPP = MAP − ICP
D. CPP = CBF − ICP
A. CPP = CMRO2 + ICP
B. CPP = SBP − ICP
C. CPP = MAP − ICP
D. CPP = CBF − ICP
Cerebral perfusion pressure is calculated by subtracting the intracranial pressure from the mean arterial pressure. Based on autoregulation, the brain can maintain normal cerebral blood flow at a wide range of CPP, generally between 50 and 150 mm Hg. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 857.
A 33-year-old man is attempting to perform BMX tricks on a bicycle and is not wearing a helmet. He goes over the handlebars and hits his head on a concrete surface. He loses consciousness at the scene but regains consciousness in the trauma bay and is GCS 15. CT is shown below. What is the next best step?
A. Observation
B. IV antibiotics
C. Operative elevation/debridement
D. Discharge home
A. Observation
B. IV antibiotics
C. Operative elevation/debridement
D. Discharge home
This patient has evidence of a depressed skull fracture with an underlying hematoma. Given the concerning underlying hematoma and depth of the depressed skull fracture segment, this fracture should be elevated and the hematoma should be addressed surgically. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 882.
What is the most common type of temporal bone fracture?
A. Longitudinal
B. Transverse
C. Anterior
D. Lateral
A. Longitudinal
B. Transverse
C. Anterior
D. Lateral
There are two types of temporal bone fractures, longitudinal and transverse. Longitudinal fractures are parallel to the EAC and are the most common type of temporal bone fractures. The longitudinal fracture does not tend to put stretch forces on the geniculate ganglion and therefore is less likely to lead to VII nerve injury. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 884.
What type of temporal bone fracture is associated with VII nerve injury?
A. Longitudinal
B. Transverse
C. Anterior
D. Lateral
A. Longitudinal
B. Transverse
C. Anterior
D. Lateral
There are two types of temporal bone fractures, longitudinal and transverse. Longitudinal fractures are parallel to the EAC and are the most common type of temporal bone fractures. The longitudinal fracture does not tend to put stretch forces on the geniculate ganglion and therefore is less likely to lead to VII nerve injury. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 884.
You are seeing a patient in the trauma bay who was involved in a motor vehicle accident leading to a skull base fracture that appears to be a transverse temporal bone fracture. There is blood coming from the EAC and significant bruising around the ear/mastoid tip. On exam the patient is GCS 15, but has House-Brackmann grade VI left facial nerve function. What is the next best step?
A. Immediate surgical decompression
B. IV antibiotics
C. Start steroids
D. Repeat head CT
A. Immediate surgical decompression
B. IV antibiotics
C. Start steroids
D. Repeat head CT
With a transverse temporal bone fracture, VII nerve injury can occur. While efficacy is currently unproven, many surgeons will start glucocorticoids in the presence of facial nerve dysfunction in the setting of a transverse temporal bone fracture. ENT consultation should be considered as decompression may be required if facial nerve function does not improve. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 884.
You are seeing a patient in the trauma bay who was involved in a motor vehicle accident leading to a skull base fracture that appears to be a transverse fracture of the clivus. All of the following should be performed except?
A. CBC/Electrolyte panel
B. NG tube insertion
C. CT angiogram head and neck
D. Cervical spine CT
A. CBC/Electrolyte panel
B. NG tube insertion
C. CT angiogram head and neck
D. Cervical spine CT
Clival fractures are severe injuries that are often fatal. They can be associated with cranial nerve deficits, diabetes insipidus, and anterior/posterior circulation vascular injury. NG tube insertion should be avoided as there have been reports of intracranial NG tube insertion through a diastased fracture of the clivus. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 885.
What type of Lefort facial fracture has a high incidence of associated brain injury?
A. Type I
B. Type II
C. Type III
D. Type IV
A. Type I
B. Type II
C. Type III
D. Type IV
There are three types of Lefort facial fractures, and of these, type III involves the zygomatic arches, the nasofrontal suture, and orbital floors. Given the type of fracture and the forces required, there is a high incidence of brain injury with type III Lefort fractures. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 887.
You are asked to see a 6-month-old infant who sustained a skull fracture after his older brother accidentally pulled down the flat screen TV that landed on the infant’s head. CT scan is demonstrated below. The child is neurologically intact with no focal deficits. How would you manage this fracture?
A. Operative elevation
B. Observation
A. Operative elevation
B. Observation
In a neurologically normal infant, this fracture should be managed nonoperatively. This is the classic “ping-pong” fracture, and over time the CSF pulsations will remodel the bone and heal this fracture. Operative intervention is generally not required. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 915.
You are asked to see a 6-month-old infant who sustained a skull fracture after his older brother accidentally pulled down the flat screen TV that landed on the infant’s head. Follow-up CT scan is demonstrated below. What is the diagnosis? Use the following figure to answer questions 28 and 29:
A. Growing skull fracture
B. Arachnoid cyst
C. Intraparenchymal hemorrhage
D. Normal bone healing
A. Growing skull fracture
B. Arachnoid cyst
C. Intraparenchymal hemorrhage
D. Normal bone healing
This CT scan demonstrates widening of the skull fracture with evidence of fluid below the fracture. This is consistent with a growing skull fracture, and is often seen with a dural laceration and CSF leak that goes unrepaired. It is different than an arachnoid cyst and should be managed operatively with dural closure. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 915.
You are asked to see a 6-month-old infant who sustained a skull fracture after his older brother accidentally pulled down the flat screen TV that landed on the infant’s head. Follow-up CT scan is demonstrated in Question 28. What is the next best step?
A. Observation
B. Percutaneous drainage
C. Cranioplasty
D. Circumferential craniotomy and dural repair
A. Observation
B. Percutaneous drainage
C. Cranioplasty
D. Circumferential craniotomy and dural repair
This CT scan demonstrates widening of the skull fracture with evidence of fluid below the fracture. This is consistent with a growing skull fracture, and is often seen with a dural laceration and CSF leak that goes unrepaired. It is different than an arachnoid cyst and should be managed operatively with dural closure. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 915.
You are asked to see a 6-month-old infant who is being worked up for suspected non-accidental trauma. What is the most common intracranial manifestation of non-accidental trauma?
A. Diffuse axonal injury
B. Bilateral subdural hematomas
C. Intraparenchymal hemorrhage
D. Epidural hematoma
A. Diffuse axonal injury
B. Bilateral subdural hematomas
C. Intraparenchymal hemorrhage
D. Epidural hematoma
Suspected non-accidental trauma workup should include some form of intracranial injury. When a child is shaken, bilateral subdural hematomas can develop due to shear forces exerted on the brain leading to tearing of bridging veins. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 916.
What is the most common reason for retinal hemorrhages on fundoscopy in an infant?
A. Nonaccidental trauma
B. Benign subdural effusion in infants
C. Acute high altitude sickness
D. Acute ICP increase
A. Nonaccidental trauma
B. Benign subdural effusion in infants
C. Acute high altitude sickness
D. Acute ICP increase
While all options listed can cause retinal hemorrhages, nonaccidental trauma is the most common cause seen in an infant. 16/26 battered children < 3 years of age had RH on fundoscopy, while 1/32 nonbattered children with head injury had RH. The single false positive was due to traumatic parturition. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 916.
You are seeing a 25-year-old man who was involved in a car accident where he hit his head on the windshield and lost consciousness. What marker has been shown to be associated with acute traumatic brain injury?
A. PTEN
B. GFAP
C. Amyloid precursor protein
D. Tau protein
A. PTEN
B. GFAP
C. Amyloid precursor protein
D. Tau protein
GFAP, a marker of neurons, has been shown to be associated with acute traumatic brain injury and may be used in the future to determine which patients need to undergo CT scan of the brain. Further Reading: Brain injury biomarkers may improve the predictive power of the IMPACT outcome calculator. J Neurotrauma. 2012, 1770–1778.
You have been following a 55-year-old man with severe traumatic brain injury and depressed GCS for the last 48 hours. A bolt was placed, and over the last 6 hours ICP has been elevated to 30 despite aggressive medical management. According to the DECRA trial, what is the best next step?
A. Continued medical management
B. Withdrawal of care
C. Decompressive hemicraniectomy
D. Posterior fossa decompression
A. Continued medical management
B. Withdrawal of care
C. Decompressive hemicraniectomy
D. Posterior fossa decompression
According to the initial results of the DECRA trial, decompressive hemicraniectomy in the setting of elevated ICP in patients < 60 years of age within 72 hours of injury refractory to first line medical management was associated with a higher rate of unfavorable outcome than the control group who did not undergo surgery. In a subgroup analysis, there was no difference when patients who had bilaterally unreactive pupils were controlled for (initial analysis had significantly higher rate of bilaterally unreactive pupils in the surgical arm). While some providers would perform a decompression, strictly according to the results of the DECRA trial, this will lead to unfavorable outcomes. Further surgical trials are underway, and results depend on the definition of favorable outcome. Further Reading: Kolias AG. Traumatic brain injury in adults. Pract Neurol. 2013, 228–235.
You are performing a decompressive hemicraniectomy for a patient with evidence of impending herniation. What is the most important aspect of the craniectomy to decrease the risk of uncal herniation?
A. AP diameter > 12 cm
B. Drilling to the edge of the sagittal sinus
C. Drilling to the floor of the middle fossa
D. Intraoperative EVD placement
A. AP diameter > 12 cm
B. Drilling to the edge of the sagittal sinus
C. Drilling to the floor of the middle fossa
D. Intraoperative EVD placement
It is important to ensure that a decompressive craniectomy is large enough to not only decompress the cerebral hemisphere, but to also avoid complications that have been shown to occur when the AP diameter of the craniectomy is < 12 cm. Subsequent herniation of the brain can, through the craniectomy defect, lead to vascular injury and further infarction of the brain. When uncal herniation is suspected, making sure the craniectomy reaches the floor of the middle fossa is important to fully decompress the temporal lobe. Further Reading: Wagner S. Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the MCA. J Neurosurg. 2001, 693–696.
Which of these options is not a part of Cushing’s triad (signs of acute increased intracranial pressure)?
A. Hypotension
B. Hypertension
C. Bradycardia
D. Irregular respirations
A. Hypotension
B. Hypertension
C. Bradycardia
D. Irregular respirations
Cushing’s triad is seen often during terminal elevation of ICP immediately before herniation. It consists of bradycardia, hypertension, and breathing irregularities. If these findings are seen together in a patient with elevated ICP, action should be taken immediately to decrease ICP as the patient is likely about to herniate. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 858.
You are seeing a patient in the trauma bay with evidence of acute increased ICP who has subsequently been intubated. You are taking the patient to the OR for decompression. In order to temporize the situation, you sit up the patient’s head of bed and tell the anesthesiologist to hyperventilate in order to decrease intracranial pressure. How long will this technique work?
A. ~ 1 minute
B. ~ 30 minutes
C. ~ 12 hours
D. ~ 24 hours
E. ~ 48 hours
A. ~ 1 minute
B. ~ 30 minutes
C. ~ 12 hours
D. ~ 24 hours
E. ~ 48 hours
CO2 is a potent vasodilator and hyperventilation can be used to decrease intracranial pressure by decreasing CO2 . The brain is able to buffer efficiently, and therefore this technique may only transiently decrease ICP as the brain will adjust to new levels of CO2 within 20 to 30 minutes. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 868.
You are seeing a patient in the trauma bay with evidence of acute increased ICP who has subsequently been intubated. You are taking the patient to the OR for decompression. In order to temporize the situation, you sit up the patient’s head of bed and tell the anesthesiologist to hyperventilate in order to decrease intracranial pressure. What is the target PaCO2 you are aiming for?
A. 16 to 20 mm Hg
B. 21 to 25 mm Hg
C. 26 to 30 mm Hg
D. 31 to 35 mm Hg
E. 36 to 40 mm Hg
A. 16 to 20 mm Hg
B. 21 to 25 mm Hg
C. 26 to 30 mm Hg
D. 31 to 35 mm Hg
E. 36 to 40 mm Hg
CO2 is a potent vasodilator and hyperventilation can be used to decrease intracranial pressure by decreasing CO2 . The brain is able to buffer efficiently, and therefore this technique may only transiently decrease ICP as the brain will adjust to new levels of CO2 within 20 to 30 minutes. You are aiming for a PaCO2 of 31 to 35 mm Hg. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 868.
You are medically managing a patient with persistent increased intracranial pressure using scheduled mannitol, 0.5 g/kg Q6H. You are appropriately checking serum osmolality during this treatment. What serum osmolality measurement would make you stop giving mannitol?
A. 306
B. 312
C. 318
D. 324
A. 306
B. 312
C. 318
D. 324
Mannitol is a very effective osmotic diuretic that is often used to decrease intracranial pressure. When utilized in a scheduled fashion, monitoring of serum osmolality should take place. When serum osmolality is greater than 320, other options should be considered for medical treatment of raised ICP. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 868.
You have been emergently consulted by neurology in a patient with a subarachnoid hemorrhage who has evidence of acute hydrocephalus and you feel that an EVD is warranted. What is a good approximation of where you should perform your bedside burr hole?
A. 8 cm back from the nasion, mid-pupillary line
B. 11 cm back from the nasion, mid-pupillary line
C. 14 cm back from the nasion, mid-pupillary line
D. 3 cm up from the pinna, 3 cm posterior
A. 8 cm back from the nasion, mid-pupillary line
B. 11 cm back from the nasion, mid-pupillary line
C. 14 cm back from the nasion, mid-pupillary line
D. 3 cm up from the pinna, 3 cm posterior
Kocher’s point is thought to be located generally between 10.5 and 11.5 cm back from the nasion and roughly 3 to 3.5 cm lateral, or in the mid-pupillary line. Generally speaking this is a good location to place a burr hole for an EVD placement for acute hydrocephalus. In many situations, simply placing the EVD perpendicular to the skull will lead to ventricular puncture, depending on ventricular size. Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 473.
You are taking care of a patient with persistently elevated intracranial pressure despite mannitol administration. You decide to utilize hypertonic saline, but the patient currently only has a peripheral IV. What is the highest concentration of hypertonic saline you can safely give through a peripheral IV?
A. 1.5%
B. 3%
C. 7%
D. 23.4%
A. 1.5%
B. 3%
C. 7%
D. 23.4%
Hypertonic saline can be used for ICP management either as a first line agent or in patient’s refractory to mannitol administration. The patient can be given 3% saline as a continuous infusion through a peripheral IV, but 7% and 23.4% given as a bolus should be administered through a central line to avoid deleterious effects to the extremities. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 875.
What is the approximate volume of CSF within the ventricular system at any given time?
A. 100 mL
B. 150 mL
C. 200 mL
D. 250 mL
A. 100 mL
B. 150 mL
C. 200 mL
D. 250 mL
The approximate volume of CSF in the system is 150 mL at any given time. Roughly 450 to 500 mL of CSF is produced each day, and the CSF turns over 3 times daily. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 856.
You see a patient in the trauma bay that opens his eyes to painful stimulation, localizes to that painful stimulation, and mutters incomprehensible words. What is the GCS?
A. 8
B. 10
C. 12
D. 14
E. 15
A. 8
B. 10
C. 12
D. 14
E. 15
This patient has a GCS of 10. E = 2, V = 3, M = 5. Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 496.
You see a patient in the trauma bay that was intubated during transport for airway concerns, does not open his eyes to painful stimulation, and externally rotates/extends both upper extremities during that painful stimulation. What is the GCS?
A. 4t
B. 6t
C. 8t
D. 3t
E. 14t
A. 4t
B. 6t
C. 8t
D. 3t
E. 14t
This patient has a GCS of 4t. E = 1, V = 1t, M = 2. This patient is decerebrate posturing (M = 2), is not opening his eyes (E = 1), and is intubated (V = 1t). Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edi- tion, 2010, page 496.
. You are managing the care of a patient who has elevated ICP, hydrocephalus, and has had an EVD placed. Your staff wants you to move the EVD to 10 mm Hg, but the EVD catheter only has markings for cm H2O. What should you set the EVD height to?
A. 8.7 cm H2O
B. 17.4 cm H2O
C. 13.6 cm H2O
D. 21.4 cm H2O
A. 8.7 cm H2O
B. 17.4 cm H2O
C. 13.6 cm H2O
D. 21.4 cm H2O
There is a lack of convention among neurosurgeons as to what system should be utilized, mm Hg or cm H2 O. 1 mm Hg = 1.36 cm H2 O, meaning that 10 mm Hg = 13.6 cm H2 O. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 861.
What type of ICP waves are associated with elevations of ICP > 50 mm Hg for 5 to 20 minutes accompanied by elevations in mean arterial pressure?
A. Lundberg A waves
B. Lundberg B waves
C. Lundberg C waves
D. Lundberg D waves
E. Lundberg E waves
A. Lundberg A waves
B. Lundberg B waves
C. Lundberg C waves
D. Lundberg D waves
E. Lundberg E waves
There are three types of Lundberg waves seen during ICP monitoring: A, B, and C. Lundberg A (plateau waves) are associated with extremely high elevation of ICP that plateaus for 5 to 20 minutes and then decreases to ~ 20 mm Hg for 30 to 45 minutes followed by another elevation. MAP increases can be seen as well. These waves are not often seen in the ICU setting as active ICP management is taking place. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 865.
Which peak of the ICP waveform gives you information about the compliance of the ventricular system?
A. P1
B. P2
C. P3
D. P4
E. P5
A. P1
B. P2
C. P3
D. P4
E. P5
The second ICP wave, P2, represents the pressure when the aortic pulse bounces off the ventricular wall (P1 is the aortic pulse itself). When the ventricular walls are stiffened due to hydrocephalus and lack compliance, the P2 wave will be greatly increased and will lead to the classic ICP waveform that is indicative of elevated ICP. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 864.
In patients with elevated ICP, what should be the goal cerebral perfusion pressure?
A. > 20
B. > 50
C. > 100
D. > 150
E. > 200
A. > 20
B. > 50
C. > 100
D. > 150
E. > 200
Cerebral perfusion pressure is calculated by subtracting ICP from the mean arterial pressure. The brain can autoregulate CPP to maintain stable cerebral blood flow at 55 to 60 mL/100 mg/min. This autoregulation curve in a normal brain keeps flow stable between CPPs of 50 and 150. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 869.
In a patient with elevated ICP (25 mm Hg) in the setting of severe traumatic brain injury, what should be the goal mean arterial pressure?
A. 45
B. 85
C. 115
D. 145
E. 165
A. 45
B. 85
C. 115
D. 145
E. 165
Cerebral perfusion pressure is calculated by subtracting ICP from the mean arterial pressure. The brain can autoregulate CPP to maintain stable cerebral blood flow at 55 to 60 mL/100 mg/min. This autoregulation curve in a normal brain keeps flow stable between CPPs of 50 and 150. It is thought during severe TBI that autoregulation fails and that CBF matches CPP much more closely. In this setting, an MAP of 85 with an ICP of 25 will give you a CPP of 60, exactly matching the standard CBF of the brain in normal conditions. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 869.
You are asked to evaluate a patient in the trauma bay that is unresponsive. He is intubated, does not open his eyes, and exhibits no movement of the upper or lower extremities even to deep painful stimulation of the nail bed. What is the GCS?
A. 0
B. 3
C. 6
D. 9
E. 12
A. 0
B. 3
C. 6
D. 9
E. 12
This patient has a GCS of 3t. E = 1, V = 1t, M = 1. GCS of 0 is not possible. You get 3 points just for showing up. Further Reading: Citow, Macdonald, Refai. Comprehensive Neurosurgery Board Review, 2nd edition, 2010, page 496.
What medical therapy is thought to provide the maximum drop in CMRO2 and CBF in patients with severely increased ICP in the setting of trauma?
A. Mannitol
B. Hypertonic saline
C. Propofol
D. Pentobarbital
E. Ketamine
A. Mannitol
B. Hypertonic saline
C. Propofol
D. Pentobarbital
E. Ketamine
Pentobarbital is a last resort medical management strategy for reducing raised ICP. It provides maximal reduction in CMRO2 and CBF when compared to other agents, but should be used as a last resort. It should be titrated to burst suppression on EEG. It can cause severe hypotension and paralytic ileus. It also stores within fat deposits so dosing should be adjusted. It can confound any attempts at brain death examination until it has been completely metabolized from the system, which can take days. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 875.
You are evaluating a 33-year-old man who experienced a first-time seizure; subsequent MRI was performed and is demonstrated below. If you decided to operate on this patient, what operative adjunct would be useful in this case? Use the following figure to answer questions 51 and 52:
A. Motor mapping
B. Diffusion tensor imaging
C. Awake language mapping
D. Somatosensory evoked potentials
E. EMG
A. Motor mapping
B. Diffusion tensor imaging
C. Awake language mapping
D. Somatosensory evoked potentials
E. EMG
This imaging demonstrates a left frontal likely low grade astrocytoma of the frontal region. This should concern you for potential involvement of Broca’s area, and may make you consider performing the procedure awake with language mapping. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 160.
You are evaluating a 33-year-old man who experienced a first-time seizure; subsequent MRI was performed and is demonstrated in Question 51. What further imaging study might be helpful in this case?
A. PET scan
B. Diffusion tensor imaging
C. Functional MRI
D. Perfusion MRI
E. Perfusion C
A. PET scan
B. Diffusion tensor imaging
C. Functional MRI
D. Perfusion MRI
E. Perfusion C
This MRI demonstrates a left frontal likely low grade astrocytoma frontal region. This should concern you for potential involvement of Broca’s area, and you could consider performing an fMRI to localize language structures prior to surgical decision making. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 160.
You are evaluating a 45-year-old man who experienced a first-time seizure; subsequent MRI was performed and is demonstrated below. What would be useful during surgical resection of this mass? Use the following figure to answer question 53:
A. Motor mapping
B. Awake language mapping
C. Somatosensory evoked potentials
D. EMG
A. Motor mapping
B. Awake language mapping
C. Somatosensory evoked potentials
D. EMG
This MRI demonstrates a likely anaplastic astrocytoma of the posterior frontal lobe on the right. There is concern that this tumor involves the motor strip and thus intraoperative motor mapping could be useful during this resection. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 160.
You are operating on a 55-year-old man with a low-grade astrocytoma of the posterior frontal lobe and you are utilizing motor mapping to identify the motor structures. What monitoring finding alerts you to the location of the motor strip
A. Doubling of signal amplitude
B. Signal dampening
C. Phase reversal
D. Phase doubling
A. Doubling of signal amplitude
B. Signal dampening
C. Phase reversal
D. Phase doubling
When motor mapping for tumor resection near the motor strip, you are looking for phase reversal of the signal on monitoring. This shows the change from the sensory cortex to the motor cortex. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 160.
You are operating on a 55-year-old man with a low-grade astrocytoma of the posterior frontal lobe and you are utilizing motor mapping to identify the motor structures. Intraoperative recordings are demonstrated below. What electrode is located on the motor strip in this image?
A. 2
B. 3
C. 4
D. 5
E. 6
A. 2
B. 3
C. 4
D. 5
E. 6
These intraoperative recordings demonstrate phase reversal between electrodes 3 and 5. This means that in this scenario the motor strip is likely located under electrode 5. Electrode 4 is very likely located directly over the central sulcus, given the lack of response. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 160.
What is the most common tumor of the central nervous system?
A. Meningioma
B. Metastases
C. Glioblastoma
D. Lymphoma
E. Low-grade glioma
A. Meningioma
B. Metastases
C. Glioblastoma
D. Lymphoma
E. Low-grade glioma
Metastases are the most common tumor of the central nervous system, and account for just over 50% of intracranial tumors. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 451.
What is the most common metastatic tumor to the brain?
A. Lymphoma
B. Lung
C. Colorectal
D. Melanoma
E. Renal
A. Lymphoma
B. Lung
C. Colorectal
D. Melanoma
E. Renal
Overall, lung cancer has the highest incidence of brain metastases based on autopsy data currently available. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 801. Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 451.
What is the most common metastatic tumor to the brain in females?
A. Melanoma
B. Lung
C. Colorectal
D. Breast
E. Renal
A. Melanoma
B. Lung
C. Colorectal
D. Breast
E. Renal
Breast cancer metastases are the most common metastatic tumor to the brain in females. Further Reading: Schouten LJ. Incidence of brain metastases in a cohort of patients with carcinoma of the breast, colon, kidney, lung and melanoma. Cancer. 2002.
A 66-year-old woman presents to your clinic with a first-time seizure and an MRI was performed which is demonstrated below. What is the next best step?
A. Total spine MRI
B. CT chest, abdomen, and pelvis
C. Gamma knife
D. Whole brain radiation
A. Total spine MRI
B. CT chest, abdomen, and pelvis
C. Gamma knife
D. Whole brain radiation
This MRI demonstrates evidence of metastatic disease. In a patient with no prior history of primary cancer, workup should proceed with a CT CAP to look for primary disease. Further Reading: Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 451.
Which of these metastatic tumor types has a higher risk of presenting with hemorrhage?
A. Lymphoma
B. Renal cell carcinoma
C. Squamous cell lung carcinoma
D. Ductal carcinoma in situ
E. Colon adenocarcinoma
A. Lymphoma
B. Renal cell carcinoma
C. Squamous cell lung carcinoma
D. Ductal carcinoma in situ
E. Colon adenocarcinoma
Renal cell carcinoma has a higher propensity for hemorrhagic conversion of a cerebral metastatic lesion. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 805. Bernstein, Berger. Neuro-Oncology: The Essentials. 3rd edition, 2015, page 451.
Which of these metastatic lesions is considered radiosensitive?
A. Multiple myeloma
B. Thyroid
C. Malignant melanoma
D. Renal cell carcinoma
A. Multiple myeloma
B. Thyroid
C. Malignant melanoma
D. Renal cell carcinoma
Of the tumor types listed here, multiple myeloma is radiosensitive. The other lesions are highly resistant. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 809.
Which of these metastatic lesions is considered highly resistant to radiation?
A. Multiple myeloma
B. Breast cancer
C. Small cell lung cancer
D. Renal cell carcinoma
A. Multiple myeloma
B. Breast cancer
C. Small cell lung cancer
D. Renal cell carcinoma
Of the tumor types listed here, renal cell carcinoma is highly resistant to radiation. The other lesions are considered radiosensitive to varying degrees. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 809.
What Karnofsky performance status score is a patient considered able to care for himself or herself without assistance?
A. 70
B. 80
C. 90
D. 100
E. 110
A. 70
B. 80
C. 90
D. 100
E. 110
KPS is used to determine patient function in ollow-up for many tumor resections. A KPS of 70 or greater means the patient is able to at least care or himself or herself without assistance. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1358.
You are evaluating a patient with a single, right frontal brain metastasis with no known primary who has a KPS of 100. What should you offer the patient?
A. Surgical resection
B. Gamma knife
C. Observation
D. Biopsy
A. Surgical resection
B. Gamma knife
C. Observation
D. Biopsy
In patients with a single brain met (of any type) with a KPS > 70 and no evidence of extra cranial disease, surgery plus radiation increased median survival by 25 weeks. Surgical resection should be offered in this case in order to obtain tissue diagnosis if no primary can be found. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 804.
Primary CNS melanoma commonly arises from melanocytes located where?
A. Pachymeninges
B. Leptomeninges
C. Virchow-Robin spaces
D. Pia mater
A. Pachymeninges
B. Leptomeninges
C. Virchow-Robin spaces
D. Pia mater
Melanocytes are found in the leptomeninges and are thought to be the probable origination point for primary CNS melanoma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 701.
What percentage of incidentally discovered meningiomas will exhibit no growth over 3-year follow-up?
A. 10%
B. 33%
C. 66%
D. 90%
E. 100%
A. 10%
B. 33%
C. 66%
D. 90%
E. 100%
Nearly 33% of patients with incidentally discovered meningiomas will exhibit no growth over a 3-year follow-up period. Many of these patients can simply be observed depending on symptomatology. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 690.
Where do meningiomas arise from?
A. Oligodendrocytes
B. Arachnoid cap cells
C. Pachymeninges
D. Pia mater
A. Oligodendrocytes
B. Arachnoid cap cells
C. Pachymeninges
D. Pia mater
Meningiomas arise from arachnoid cap cells of the CNS. They can arise from wherever these arachnoid cap cells are found, including between the brain and skull, ventricles, and surrounding the spinal cord. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 690.
What is the overall incidence of meningiomas?
A. ~ 1 to 3%
B. ~ 8 to 10%
C. ~ 13 to 15%
D. ~ 18 to 20%
E. ~ 21 to 23%
A. ~ 1 to 3%
B. ~ 8 to 10%
C. ~ 13 to 15%
D. ~ 18 to 20%
E. ~ 21 to 23%
Meningiomas are thought to have roughly 1 to 3% incidence in the general population > 60 years of age based on autopsy studies. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 690.
What is the most common location for a meningioma?
A. Sphenoid wing
B. Parasagittal
C. Convexity
D. Planum sphenoidale
E. Petrous apex
A. Sphenoid wing
B. Parasagittal
C. Convexity
D. Planum sphenoidale
E. Petrous apex
Parasagittal meningiomas are thought to be the most common location, followed by convexity meningiomas, based on a series of 336 cases. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 691.
Foster-Kennedy syndrome classically was caused by what tumor?
A. Medulloblastoma
B. Frontal glioblastoma
C. Olfactory groove meningioma
D. Clival chordoma
A. Medulloblastoma
B. Frontal glioblastoma
C. Olfactory groove meningioma
D. Clival chordoma
Foster-Kennedy syndrome (anosmia, ipsilateral optic atrophy, and contralateral papilledema) was classically described in the setting of an olfactory groove meningioma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 691.
What is the most common type of WHO grade II astrocytoma?
A. Anaplastic
B. Gemistocytic
C. Protoplasmic
D. Fibrillary
A. Anaplastic
B. Gemistocytic
C. Protoplasmic
D. Fibrillary
Fibrillary astrocytoma is the most common subtype of WHO grade II astrocytoma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 615.
What is considered the principal treatment for low-grade gliomas?
A. Observation
B. XRT alone
C. Chemotherapy + XRT
D. Surgical resection
A. Observation
B. XRT alone
C. Chemotherapy + XRT
D. Surgical resection
Surgical resection is considered the principal treatment for low-grade gliomas to both establish the diagnosis and for cytoreduction. More aggressive surgical excision has been shown to be associated with better outcome and further time to malignant transformation. XRT and chemotherapy may follow later in the disease course. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 620.
In patients with subtotally resected low-grade gliomas, early radiotherapy (54 Gy) has been associated with what results?
A. No difference in progression-free survival
B. 2-year increase in progression-free survival
C. 5-year increase in progression-free survival
D. 8-year increase in progression-free survival
A. No difference in progression-free survival
B. 2-year increase in progression-free survival
C. 5-year increase in progression-free survival
D. 8-year increase in progression-free survival
In subtotally resected low-grade gliomas, 54 Gy XRT has been associated with an increased PFS from 3.4 to 5.3 years and is recommended as an early adjuvant treatment. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 620.
In patients with gross total resection of a lowgrade glioma, early radiotherapy (54 Gy) has been associated with what results?
A. No difference in progression-free survival
B. 2-year increase in progression-free survival
C. 5-year increase in progression-free survival
D. 8-year increase in progression-free survival
A. No difference in progression-free survival
B. 2-year increase in progression-free survival
C. 5-year increase in progression-free survival
D. 8-year increase in progression-free survival
In gross totally resected low-grade gliomas, 54 Gy XRT has been associated with no increase in PFS and should be deferred until progression occurs. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 620.
In patients with glioblastoma, what percentage of resection has been associated with increased overall survival?
A. > 50%
B. > 70%
C. > 85%
D. > 95%
E. > 97%
A. > 50%
B. > 70%
C. > 85%
D. > 95%
E. > 97%
Extent of resection matters when undergoing attempted gross total resection of a GBM. Extent of resection > 97% has been shown to be associated with prolonged overall survival. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 621.
The classic Stupp regimen of chemoradiation following glioblastoma resection consists of what?
A. 60 Gy XRT + PCV chemotherapy
B. 25 Gy XRT + temozolomide chemotherapy
C. 25 Gy XRT + PCV chemotherapy
D. 60 Gy XRT + temozolomide chemotherapy
A. 60 Gy XRT + PCV chemotherapy
B. 25 Gy XRT + temozolomide chemotherapy
C. 25 Gy XRT + PCV chemotherapy
D. 60 Gy XRT + temozolomide chemotherapy
The Stupp regimen of chemoradiation for GBM consists of 60 Gy XRT in fractions along with concurrent TMZ and adjuvant chemotherapy. PCV chemotherapy was attempted, but showed no benefit in an RCT prior to publication of the Stupp regimen. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 622.
Giving 60 Gy XRT and temozolomide chemotherapy (Stupp) after resection of a glioblastoma is associated with a median overall survival of how many months?
A. 11.5 months
B. 14.6 months
C. 12.1 months
D. 18.3 months
E. 20.7 months
A. 11.5 months
B. 14.6 months
C. 12.1 months
D. 18.3 months
E. 20.7 months
The Stupp regimen of chemoradiation for GBM consists of 60 Gy XRT in fractions along with concurrent TMZ and adjuvant chemotherapy. In the classic article, median survival increased from 12.1 months to 14.6 months. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 622.
MGMT promoter methylation in glioblastoma is associated with what median survival benefit compared to non-methylated tumors after utilization of the Stupp regimen of chemoradiation?
A. 6.3 months
B. 10.8 months
C. 23.4 months
D. 35.5 months
E. 40.2 months
A. 6.3 months
B. 10.8 months
C. 23.4 months
D. 35.5 months
E. 40.2 months
The Stupp regimen of chemoradiation for GBM consists of 60 Gy XRT in fractions along with concurrent TMZ and adjuvant chemotherapy. In the classic article, median survival increased from 12.1 months to 14.6 months. When a subgroup of patients with MGMT promoter methylation was studied, it was found that these patients had a median survival of 23.4 months compared to 12.6 in non–MGMT methylated patients, leading to a median overall survival benefit of 10.8 months. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 622.
What is the main side effect of temozolomide chemotherapy?
A. Peripheral neuropathy
B. Myelosuppression
C. Cardiomyopathy
D. Leukocytosis
E. Seizures
A. Peripheral neuropathy
B. Myelosuppression
C. Cardiomyopathy
D. Leukocytosis
E. Seizures
The main side effect of TMZ chemotherapy is myelosuppression, and it is an otherwise well tolerated chemotherapeutic. Patients undergo routine neutrophil testing and should have a neutrophil count of > 1.5 × 10^9/L and a platelet count > 100. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 622.
You are seeing a 55-year-old patient back in follow- up 3 months after a gross total resection of a glioblastoma of the right frontal lobe. She has undergone 60 Gy XRT and TMZ chemotherapy. Her tumor demonstrated MGMT promoter methylation. On her MRI there is evidence of a contrast enhancing nodule in the resection cavity. What is the likely cause of this finding?
A. Postoperative blood products
B. Tumor recurrence
C. Pseudoprogression
D. Ischemic stroke
A. Postoperative blood products
B. Tumor recurrence
C. Pseudoprogression
D. Ischemic stroke
In MGMT promoter methylated GBM patients, contrast enhancement can be seen at roughly 3 months post gross total resection and Stupp regimen. It is consistent with pseudoprogression and often decreases on subsequent imaging and symptoms can resolve with steroids. It is associated with radiation kill of the tumor. At this time there are no definitive imaging studies that can prove pseudoprogression vs tumor recurrence, but this is an active area of research. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 623.
You are seeing a patient with recurrent glioblastoma who is currently undergoing treatment with bevacizumab (Avastin). All of the following are side effects of bevacizumab except?
A. Hypertension
B. Arterial thromboembolism
C. Hemorrhage
D. Myelosuppression
A. Hypertension
B. Arterial thromboembolism
C. Hemorrhage
D. Myelosuppression
Bevacizumab is a monoclonal antibody against VEGF and is FDA approved for the treatment of recurrent GBM. Its side effect profile consists of hypertension, arterial thromboembolism, hemorrhage, GI perforations, wound healing complications, and fistula formation. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 624.
Approximately 75% of pilocytic astrocytomas present in what age group?
A. 1 to 20 years
B. 21 to 40 years
C. 41 to 60 years
D. 61 to 80 years
E. 81 to 100 years
A. 1 to 20 years
B. 21 to 40 years
C. 41 to 60 years
D. 61 to 80 years
E. 81 to 100 years
Pilocytic astrocytoma is a WHO grade I tumor with a predilection for younger patients. Approximately 75% of these tumors present in patients less than 20 years of age. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 630.
What is the preferred postoperative treatment regimen for incompletely resected pilocytic astrocytomas in the pediatric population?
A. Observation
B. Early XRT
C. Temozolomide chemotherapy
D. Gamma knife
A. Observation
B. Early XRT
C. Temozolomide chemotherapy
D. Gamma knife
Pilocytic astroyctomas in the pediatric population that are incompletely resected should be initially observed as the rate of growth over 5, 10, or even 20 years can be minimal. Radiation and chemother- apy should be saved for obvious recurrence with growth demonstrated on serial imaging studies. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 631.
Collins’ law suggests that a pediatric patient with pilocytic astrocytomas can be considered cured if no recurrence happens in what time interval?
A. 5 years
B. 10 years
C. Patient’s age at diagnosis + 5 years
D. Patient’s age at diagnosis + 9 months
A. 5 years
B. 10 years
C. Patient’s age at diagnosis + 5 years
D. Patient’s age at diagnosis + 9 months
Collins’ law suggests that pediatric patients with pilocytic astrocytomas can be considered cured if there is no recurrence after enough time has passed adding the patient’s age at time of diagnosis + 9 months. It is controversial, but often quoted. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 631.
A 16-year-old boy with a known history of NF-1 presents with painless proptosis. What is the most likely diagnosis?
A. Sphenoid wing meningioma
B. Optic glioma
C. Thyrotoxicosis
D. Orbital neurofibroma
A. Sphenoid wing meningioma
B. Optic glioma
C. Thyrotoxicosis
D. Orbital neurofibroma
Optic gliomas are found in patients with neurofibromatosis and often present with unilateral painless proptosis. Visual loss occurs when the glioma has reached the chiasm or is causing significant mass effect on the optic nerve. These lesions can be cured if complete excision of the optic nerve and eye occur before the tumor has invaded the optic chiasm. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 632.
A 12-year-old girl presents with headache, nausea/ vomiting, and diplopia. MRI is demonstrated below. What management should you recommend to the parents?
A. Surgical resection
B. Biopsy
C. Chemotherapy
D. Observation
E. Radiation
A. Surgical resection
B. Biopsy
C. Chemotherapy
D. Observation
E. Radiation
This MRI demonstrates diffuse enlargement of the brainstem consistent with a diffuse intrinsic pontine glioma. Diagnosis can often be made based on MRI scans and surgical resection/biopsy should be avoided unless an obvious exophytic component is present. Children with this diagnosis die within 6 to 12 months, and XRT may not prolong survival. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 634.
Pleomorphic xanthoastrocytomas often present where?
A. Frontal lobe
B. Temporal lobe
C. Brainstem
D. Cerebellum
E. Occipital lobe
A. Frontal lobe
B. Temporal lobe
C. Brainstem
D. Cerebellum
E. Occipital lobe
PXAs tend to occur in the temporal lobe, are cystic with an enhancing nodule, and present with seizures. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 636.
You perform a subtotal resection of a tumor confirmed to be an oligodendroglioma based on final pathology. What is the recommended postoperative treatment?
A. 60 Gy XRT + temozolomide chemotherapy
B. 60 Gy XRT + PCV chemotherapy
C. PCV chemotherapy alone
D. Temozolomide chemotherapy alone
A. 60 Gy XRT + temozolomide chemotherapy
B. 60 Gy XRT + PCV chemotherapy
C. PCV chemotherapy alone
D. Temozolomide chemotherapy alone
For pathology proven oligodendrogliomas, postoperative PCV chemotherapy has shown to be beneficial. XRT is controversial, and often saved for malignant transformation or recurrent growth. At this time immediate XRT post-resection is not often recommended.
Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 640.
You are evaluating a 33-year-old woman with what appears to be an ependymoma on MRI. If she were to present with a cranial nerve deficit, what deficit would you expect to see?
A. Visual loss
B. Medial rectus palsy
C. Facial weakness
D. Tongue weakness
A. Visual loss
B. Medial rectus palsy
C. Facial weakness
D. Tongue weakness
Ependymomas often present in the fourth ventricle, originating from the floor of the fourth ventricle. Given their invasiveness, they may involve the facial colliculus which is located in the floor of the fourth ventricle, making facial weakness a likely cranial nerve deficit. Lateral rectus palsy (CN VI involvement) can be seen as well. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 643.
You are evaluating a 33-year-old woman with what appears to be an ependymoma on MRI of the brain. What other imaging should be performed?
A. Whole body PET CT
B. CT chest/abdomen/pelvis
C. MRI spinal axis
D. Technetium bone scan
A. Whole body PET CT
B. CT chest/abdomen/pelvis
C. MRI spinal axis
D. Technetium bone scan
Ependymomas often present in the fourth ventricle, originating from the floor of the fourth ventricle. They can cause drop metastases within the spinal canal, and thus MRI imaging of the entire neuraxis should be performed prior to intervention. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 644.
You resect an ependymoma of the fourth ventricle in a 33-year-old woman. MRI of the spinal axis does not demonstrate any evidence of drop metastases. What postoperative treatment would you recommend?
A. XRT + temozolomide chemotherapy
B. XRT + PCV chemotherapy
C. XRT alone
D. Temozolomide alone
A. XRT + temozolomide chemotherapy
B. XRT + PCV chemotherapy
C. XRT alone
D. Temozolomide alone
Ependymomas often present in the fourth ventricle, originating from the floor of the fourth ventricle. They tend to be radiosensitive and have not been shown to benefit from added chemotherapy. Traditional XRT therapy included 45 to 48 Gy to the tumor bed with 15 to 20 Gy reserved for recurrence. With the development of 3D conformal XRT, doses of 59.4 Gy to the tumor bed have been given. Prophylactic spinal XRT is usually given only if there is evidence of drop metastases on imaging. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 644.
What tumor type is often found attached to the septum pellucidum?
A. Glioblastoma
B. Central neurocytoma
C. Intraventricular meningioma
D. Intraventricular lymphoma
E. Pleomorphic xanthoastrocytoma
A. Glioblastoma
B. Central neurocytoma
C. Intraventricular meningioma
D. Intraventricular lymphoma
E. Pleomorphic xanthoastrocytoma
Central neurocytomas are WHO grade II neuronal tumors often found attached to the septum pellucidum in the frontal horn of the lateral ventricles. Further Reading: Greenberg. Handbook of Neuro- surgery. 8th edition, 2016, page 645.
Gelastic seizures are often seen with a mass located where?
A. Frontal lobe
B. Mesial temporal lobe
C. Third ventricle
D. Anterior temporal pole
E. Fourth ventricle
A. Frontal lobe
B. Mesial temporal lobe
C. Third ventricle
D. Anterior temporal pole
E. Fourth ventricle
Gelastic seizures are characterized by inappropriate laughter and are often seen with hypothalamic hamartomas or hypothalamic gliomas with a mass in the third ventricle. Further Reading: Baltuch, Villemure. Operative Techniques in Epilepsy Surgery, 2009, page 83.
You have just resected a dysembryoplastic neuroepithelial tumor of the anterior temporal pole in a 22-year-old man with intractable epilepsy. Postoperative imaging suggests gross total resection. What do you recommend for postoperative management?
A. XRT + temozolomide chemotherapy
B. XRT alone
C. Temozolomide chemotherapy alone
D. Observation
A. XRT + temozolomide chemotherapy
B. XRT alone
C. Temozolomide chemotherapy alone
D. Observation
DNETs are often seen in the temporal lobe and appear to have nodular enhancement on MRI. They are WHO grade I tumors and are associated with medically intractable epilepsy. After gross total resection, observation is recommended as XRT and chemotherapy have not shown any benefit in these benign tumors. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 647.
During surgery for a paraganglioma, manipulation of the tumor can lead to what intraoperative complication?
A. Cardiac arrhythmia
B. Life-threatening hemorrhage
C. Seizure
D. Stroke
A. Cardiac arrhythmia
B. Life-threatening hemorrhage
C. Seizure
D. Stroke
Paraganglioma (glomus tumors) can secrete epinephrine and norepinephrine based on histologic subtype, and therefore aggressive manipulation can lead to release of these catecholamines and hypertension/cardiac arrhythmias may occur. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 653.
Which of the following is the most common type of paraganglioma?
A. Glomus tympanicum
B. Glomus jugulare
C. Glomus intravagale
D. Carotid body tumor
A. Glomus tympanicum
B. Glomus jugulare
C. Glomus intravagale
D. Carotid body tumor
Carotid body tumor is the most common paraganglioma of the ones listed here. Overall, pheochromocytoma is the most common paraganglioma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 653.
Neuroblastomas arise from what element of the nervous system?
A. Sympathetic ganglion
B. Peripheral nerve
C. Dorsal root ganglion
D. Free nerve endings
A. Sympathetic ganglion
B. Peripheral nerve
C. Dorsal root ganglion
D. Free nerve endings
Neuroblastomas are aggressive tumors that arise from the sympathetic ganglion. They often present in the adrenal gland (40%), but can present anywhere along the sympathetic chain and in certain presentations can cause a Horner’s syndrome. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 657.
You are seeing a patient with a pineal region tumor. CSF markers are ordered and demonstrated below. What is the most likely diagnosis? B-HCG (+), AFP (−), PLAP (−)
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
CSF markers are important for pineal region tumors. In this case there is an isolated elevation of B-HCG which leads to the diagnosis of choriocarcinoma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 660.
You are seeing a patient with a pineal region tumor. CSF markers are ordered and demonstrated below. What is the most likely diagnosis? B-HCG (+), AFP (−), PLAP (+)
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
CSF markers are important for pineal region tumors. In this case there is elevation of both B-HCG and placental alkaline phosphatase (PLAP), which is suggestive of germinoma. While PLAP is often positive in germinomas, B-HCG has been shown to be positive in 10 to 50% of cases based on the microarchitecture of the tumor and whether or not syncytiotrophoblasts are present. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 660.
You are seeing a patient with a pineal region tumor. CSF markers are ordered and demonstrated below. What is the most likely diagnosis? B-HCG (−), AFP (−), PLAP (−)
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
CSF markers are important for pineal region tumors. In this case, the markers are all negative, and this can be the case with a mixed germ cell tumor or a mature teratoma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 660.
You are seeing a patient with a pineal region tumor. CSF markers are ordered and demonstrated below. What is the most likely diagnosis? B-HCG (−), AFP (+), PLAP (−)
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
A. Germinoma
B. Choriocarcinoma
C. Embryonal carcinoma
D. Mature teratoma
CSF markers are important for pineal region tumors. In this case, AFP is elevated while the other markers are negative. This is suggestive of embryonal carcinoma, yolk sac carcinoma, or immature teratoma. Further Reading: Greenberg. Handbook of Neuro- surgery. 8th edition, 2016, page 660.
Patients with vestibular schwannomas are most likely to present with which of the symptoms listed below?
A. Facial weakness
B. Facial numbness
C. Taste changes
D. Otalgia
A. Facial weakness
B. Facial numbness
C. Taste changes
D. Otalgia
Patients with vestibular schwannomas are actually more likely to present with facial numbness than weakness. Often times the facial nerve is distorted by the tumor but no weakness is present. However, with fairly minor compression of the trigeminal nerve, facial numbness can occur. This is likely due to resiliency of motor nerves compared to sensory nerves. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 671.
What is the most common presentation of a vestibular schwannoma?
A. Facial weakness
B. Facial numbness
C. Taste changes
D. Hearing loss
A. Facial weakness
B. Facial numbness
C. Taste changes
D. Hearing loss
Unilateral hearing loss is overall the most common presentation of vestibular schwannomas. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 672.
You see a 34-year-old woman with an asymptomatically discovered 1.3-cm vestibular schwannoma. Her hearing tests demonstrate intact hearing. What is the next best step?
A. Surgical resection
B. Stereotactic radiosurgery
C. Observation
D. Chemotherapy
A. Surgical resection
B. Stereotactic radiosurgery
C. Observation
D. Chemotherapy
In patients with a vestibular schwannoma < 15 mm in size with intact hearing, observation with serial scans every 6 months should be the initial next step. If/when tumor growth is documented > 2 mm, treatment is recommended. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 676.
What direction is the facial nerve most often displaced by a vestibular schwannoma?
A. Anterior
B. Posterior
C. Superior
D. Inferior
E. Lateral
A. Anterior
B. Posterior
C. Superior
D. Inferior
E. Lateral
The facial nerve is displaced anteriorly in up to 75% of cases, but can also be seen superiorly displaced. It can be completely thinned out over the surface of the tumor, so monitoring is recommended. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 679.
What percentage of hemangioblastomas occur as part of von Hippel-Lindau disease?
A. 20%
B. 40%
C. 60%
D. 80%
E. 100%
A. 20%
B. 40%
C. 60%
D. 80%
E. 100%
Hemangioblastomas can be associated with VHL, but can also occur sporadically. They seem to be associated with VHL approximately 20% of the time. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 701.
All of these tumor types are associated with von Hippel-Lindau disease except?
A. Hemangioblastoma
B. Pheochromocytoma
C. Paraganglioma
D. Renal cell carcinoma
A. Hemangioblastoma
B. Pheochromocytoma
C. Paraganglioma
D. Renal cell carcinoma
VHL is a disease associated with abnormalities on chromosome 3. It is associated with multiple tumor types including hemangioblastomas, retinal hemangioblastomas, pheochromocytomas, renal cell carcinoma, cystadenomas, pancreactic neuroendocrine tumors, and endolymphatic sac tumors. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 705.
You are seeing a patient with biopsy proven, nonAIDS–related primary CNS lymphoma. What is the best treatment?
A. Surgical resection followed by XRT and methotrexate
chemotherapy
B. XRT + methotrexate chemotherapy
C. XRT + temozolomide chemotherapy
D. Surgical resection followed by XRT and temozolomide
chemotherapy
A. Surgical resection followed by XRT and methotrexate chemotherapy
B. XRT + methotrexate chemotherapy
C. XRT + temozolomide chemotherapy
D. Surgical resection followed by XRT and temozolomide chemotherapy
Primary CNS lymphoma that is non-AIDS related and biopsy proven is best treated with XRT and methotrexate chemotherapy. There is no role for surgical debulking as this has demonstrated no improvement in survival in this patient population. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 713.
What is the approximate 5-year survival of patients with biopsy proven primary CNS lymphoma?
A. 3 to 4%
B. 15 to 16%
C. 30 to 31%
D. 48 to 49%
E. 55 to 56%
A. 3 to 4%
B. 15 to 16%
C. 30 to 31%
D. 48 to 49%
E. 55 to 56%
Primary CNS lymphoma that is non-AIDS related and biopsy proven is best treated with XRT and methotrexate chemotherapy. There is no role for surgical debulking as this has demonstrated no improvement in survival in this patient population. Approximate 5-year survival is 3 to 4%. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 713.
A pituitary tumor is considered a macroadenoma after it has crossed what size threshold?
A. > 5 mm
B. > 1 cm
C. > 2 cm
D. > 3 cm
E. > 3.5 cm
A. > 5 mm
B. > 1 cm
C. > 2 cm
D. > 3 cm
E. > 3.5 cm
Pituitary adenomas are considered macroadenomas after they have grown to >1 cm in size. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 718.
Approximately what percentage of pituitary adenomas are functioning?
A. 15%
B. 35%
C. 50%
D. 65%
E. 80%
A. 15%
B. 35%
C. 50%
D. 65%
E. 80%
Approximately 65% of pituitary tumors secrete an active hormone, with prolactin being the most commonly secreted hormone (48%), followed by growth hormone (10%), ACTH (6%), and TSH (1%). Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 719.
What type of visual field deficit would a large pituitary macroadenoma cause?
A. Right homonymous hemianopia
B. Left superior quadrant hemianopia
C. Central scotoma
D. Bitemporal hemianopia
A. Right homonymous hemianopia
B. Left superior quadrant hemianopia
C. Central scotoma
D. Bitemporal hemianopia
Pituitary macroadenomas cause compression of the optic chiasm and given their midline location lead to bitemporal hemianopia. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 720.
What serum marker might help lead you to a diagnosis of suprasellar germinoma?
A. B-HCG
B. AFP
C. Sodium
D. Hematocrit
A. B-HCG
B. AFP
C. Sodium
D. Hematocrit
Suprasellar germinomas can lead to compression of the pituitary stalk and lead to diabetes insipidus. With elevated serum sodium in a suprasellar mass, germinoma should be considered. Further Reading: Schwartz, Anand. Endoscopic Pituitary Surgery, 2012, page 53.
You are taking care of a patient that you suspect has pituitary apoplexy. What finding would lead you to perform emergent decompression of the sella?
A. Hypotension
B. Visual field cut
C. Hypernatremia
D. Elevated urine output
A. Hypotension
B. Visual field cut
C. Hypernatremia
D. Elevated urine output
Pituitary apoplexy occurs when a pituitary tumor hemorrhages into the sella. These patients often need emergent corticosteroid administration, but progressive visual field deficit is a reason to emergently decompress the sella. This should ideally be performed within 7 days of onset to promote full recovery. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 721.
You see a patient with evidence of hypercortisolism. There appears to be a functioning pituitary adenoma. What is the diagnosis?
A. Cushing’s disease
B. Cushing’s syndrome
C. Nelson’s syndrome
D. Pituitary apoplexy
A. Cushing’s disease
B. Cushing’s syndrome
C. Nelson’s syndrome
D. Pituitary apoplexy
Cushing’s syndrome describes the general features of hypercortisolism, whereas Cushing’s disease is Cushing’s syndrome caused by an ACTH secreting pituitary adenoma. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 723.
You are evaluating a patient who has had both adrenal glands removed as a treatment for her primary disease. She has noticed some worsening of her peripheral vision and states that her skin appears darker than usual. What is the diagnosis?
A. Cushing’s disease
B. Cushing’s syndrome
C. Nelson’s syndrome
D. Pituitary apoplexy
A. Cushing’s disease
B. Cushing’s syndrome
C. Nelson’s syndrome
D. Pituitary apoplexy
Nelson’s syndrome occurs when ACTH producing pituitary adenoma cells remain after bilateral adrenalectomy for Cushing’s disease. Given the cross-reactivity between ACTH and melanocyte stimulating hormone, patients notice hyperpigmentation and signs/symptoms of an enlarging pituitary mass. She should undergo surgical resection of the mass. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 725.
Patients with growth hormone-secreting pituitary adenomas have an elevated risk of what other type of cancer?
A. Lung cancer
B. Colon cancer
C. Pancreatic cancer
D. Hepatocellular carcinoma
A. Lung cancer
B. Colon cancer
C. Pancreatic cancer
D. Hepatocellular carcinoma
Patients with growth hormone–secreting tumors and acromegaly have a two times increased risk of colon cancer compared to the normal population. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 726.
You see a patient with a large pituitary tumor and bitemporal hemianopia. Prolactin level is 356. You decide to attempt medical management. The main medication used in this case works on what receptor?
A. D1 dopamine receptor
B. D2 dopamine receptor
C. GABA receptor
D. Glutamate receptor
A. D1 dopamine receptor
B. D2 dopamine receptor
C. GABA receptor
D. Glutamate receptor
The main medication used for prolactinomas currently is cabergoline, a D2 receptor agonist, compared to bromocriptine which is a nonselective (D1 and D2) dopamine agonist. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 740.
You see a patient with a large pituitary tumor and bitemporal hemianopia. Prolactin level is 356. You decide to attempt medical management. You decide to use cabergoline. What is a worrisome side effect from the use of cabergoline?
A. Seizures
B. Diarrhea
C. Mitral regurgitation
D. Diabetes insipidus
A. Seizures
B. Diarrhea
C. Mitral regurgitation
D. Diabetes insipidus
The main medication used for prolactinomas currently is cabergoline, a D2 receptor agonist, and it can lead to cardiac valve regurgitation. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 740.
You are treating a patient with acromegaly and a growth hormone-secreting pituitary tumor. You elect to start the patient on medication using octreotide. How does this medication work?
A. GH receptor antagonist
B. Dopamine agonist
C. Somatostatin analogue
D. Adrenal steroid synthesis inhibitor
A. GH receptor antagonist
B. Dopamine agonist
C. Somatostatin analogue
D. Adrenal steroid synthesis inhibitor
While many growth hormone–secreting pituitary adenomas can be treated with surgery, occasionally medical management is attempted using octreotide, which is a somatostatin analogue. Tumor volume decreases in approximately 30% of patients. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 742.
You are treating a patient with acromegaly and a growth hormone-secreting pituitary tumor. You elect to start the patient on medication using pegvisomant. How does this medication work?
A. GH receptor antagonist
B. Dopamine agonist
C. Somatostatin analogue
D. Adrenal steroid synthesis inhibitor
A. GH receptor antagonist
B. Dopamine agonist
C. Somatostatin analogue
D. Adrenal steroid synthesis inhibitor
While many growth hormone–secreting pituitary adenomas can be treated with surgery, occasionally medical management is attempted using pegvisomant, which is a growth hormone receptor antagonist. In patients treated for 12 months, normal IGF levels are seen in 97% of patients, but tumor size remains the same. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 742.
A patient presents to you with known colonic polyposis and evidence of multiple cranial osteomas in X-ray of the skull. What is the diagnosis?
A. Turcot’s syndrome
B. Garnder’s syndrome
C. McCune-Albright syndrome
D. Paget’s disease
A. Turcot’s syndrome
B. Garnder’s syndrome
C. McCune-Albright syndrome
D. Paget’s disease
Gardner’s syndrome is comprised of colonic polyposis, multiple cranial osteomas, and soft tis- sue tumors. Osteomas of the skull consist of oste- oid tissue within osteoblastic tissue with reactive bone formation around that region. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 775.
You are seeing a patient with a single abnormal protrusion of the skull in the right parietal region. X-rays demonstrate trabeculated bone. They decide they would like it removed and during surgery you observe a blue colored mass underneath the pericranium. What is the most likely diagnosis?
A. Osteoid osteoma
B. Hemangioma
C. Metastasis
D. Multiple myeloma
A. Osteoid osteoma
B. Hemangioma
C. Metastasis
D. Multiple myeloma
Hemangiomas of the skull can cause areas of skull protrusion with evidence of trabeculated bone on X-ray. During surgery they appear bluish in color underneath the pericranium. They should be excised completely to avoid recurrence. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 776.
The Hand-Schüller-Christian triad is comprised of exophthalmos (from intraorbital tumor), lytic bone lesions (of the cranium), and what?
A. Diabetes insipidus
B. Seizures
C. Papilledema
D. Facial weakness
A. Diabetes insipidus
B. Seizures
C. Papilledema
D. Facial weakness
The Hand-Schüller-Christian triad is a series ofclinical symptoms caused by an underlying diagnosis of Langerhans cell histiocytosis. When thisoccurs in the suprasellar region, a mass emanatingfrom the pituitary stalk can cause diabetes insipidus. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 777.
Fibrous dysplasia is associated with what syndrome?
A. Turcot’s syndrome
B. Garnder’s syndrome
C. McCune-Albright syndrome
D. Paget’s disease
A. Turcot’s syndrome
B. Garnder’s syndrome
C. McCune-Albright syndrome
D. Paget’s disease
Fibrous dysplasia is a benign condition where bone is replaced by fibrous connective tissue, and it is seen commonly in McCune-Albright syndrome along with endocrine dysfunction, café au lait spots on one side of the midline, and precocious puberty. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 781.
You are operating on a cerebellar hemangioblastoma with a large associated cystic component. You open the dura and the cerebellum begins to herniate through the dural defect. What will be the most effective means to decrease posterior fossa pressure?
A. Hyperventilation
B. Mannitol
C. Dexamethasone
D. Needle aspiration of cystic contents
A. Hyperventilation
B. Mannitol
C. Dexamethasone
D. Needle aspiration of cystic contents
While all of the above options are reasonable to decrease intracranial pressure, when a mass has a large cystic component, simple drainage of the cyst can lead to rapid decompression of the posterior fossa.
You resect a pathology proven cerebellar hemangioblastoma with a large cystic component. You have removed the mural nodule. Should you attempt to excise the entire cyst wall?
A. Yes
B. No
B. No
Generally, the wall of the associated cyst cavity within a hemangioblastoma does not need to be resected, unless there is a portion that enhances. Removal of the enhancing mural nodule should lead to sufficient resection.
You resect a pathology proven cerebellar pilocytic astrocytoma with a large cystic component. You have removed the mural nodule. Should you attempt to excise the entire cyst wall?
A. Yes
B. No
A. Yes
Generally, the wall of the associated cyst cavity should be resected if it can be done safely. Certain pilocytic astrocytomas can have pseudocysts that are really more tumor tissue and attempts should be made to resect the wall if possible. Certainly any areas that are enhancing should be resected if it can be done safely.
During endoscopic third ventriculostomy, aggressive manipulation of the endoscope within the third ventricle should be avoided to prevent injury to what structure?
A. Mamillary bodies
B. Caudate head
C. Fornix
D. Thalamus
A. Mamillary bodies
B. Caudate head
C. Fornix
D. Thalamus
When the endoscope is advanced through the foramen of Monro, care should be taken to avoid significant manipulation if possible given that the fornix can be easily compressed on the superior aspect of the foramen by a rigid endoscope. Further Reading: Torres-Corzo, Rangel-Castilla, Nakaji. Neuroendoscopic Surgery, 2016, page 232.
Approximately what length of temporal lobe can be resected safely during a temporal lobectomy on the dominant side?
A. 1 to 2.5 cm
B. 3 to 4.5 cm
C. 5 to 5.5 cm
D. 6 to 6.5 cm
A. 1 to 2.5 cm
B. 3 to 4.5 cm
C. 5 to 5.5 cm
D. 6 to 6.5 cm
Approximately 3 to 4.5 cm of dominant temporal lobe can be resected safely. Further posterior and risk to language function increases. Further Reading: Baltuch, Villemure. Operative Techniques in Epilepsy Surgery, 2009, page 40.
You are seeing a patient in the emergency department who had the worst headache of her life. She opens her eyes to voice, does not know the date or where she is, but is able to follow commands reliably with good strength x4. Subarachnoid hemorrhage is confirmed on imaging. What is her WFNS grade?
A. 1
B. 2
C. 3
D. 4
E. 5
A. 1
B. 2
C. 3
D. 4
E. 5
The WFNS grade is a way to evaluate clinical symptoms after SAH. A patient with a GCS of 13 to 14 without major motor deficit would be considered a WFNS grade 2. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1163.
You are seeing a patient in the emergency department who had the worst headache of her life. On imaging she has evidence of SAH in the basal cisterns that is >3 mm in diameter but no evidence of intra-ventricular hemorrhage. Based on the modified Fisher scale for SAH, what is her risk of vasospasm?
A. 0%
B. 24%
C. 33%
D. 40%
E. 50%
A. 0%
B. 24%
C. 33%
D. 40%
E. 50%
The modified Fisher scale rates the amount and location of SAH to predict risk of vasospasm. Grade 1 is thin (< 3 mm) clot only with no IVH–24% risk. Grade 2 is thin (< 3 mm) clot with IVH–33% RISK. Grade 3 is thick (> 3 mm) clot with no IVH–33% risk, and grade 4 is thick clot with IVH–40% risk. Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, page 471.
After a ruptured intracranial aneurysm, what is the approximate risk of rebleed per day while the aneurysm remains unsecured?
A. 1.5%
B. 5%
C. 25%
D. 33%
A. 1.5%
B. 5%
C. 25%
D. 33%
After aneurysmal rupture there is an approximately 1.5% per day risk of rebleeding up to 13 days postbleed. At 6 months there is a risk of 50%. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1168.
You are taking care of a patient who suffered a
rupture of a carotid bifurcation aneurysm. It is
postbleed day 5 and she is experiencing new left
arm weakness. What is the most likely underlying
mechanism?
A. Subclinical seizures
B. Hyponatremia
C. Vasospasm
D. Intracerebral hemorrhage
A. Subclinical seizures
B. Hyponatremia
C. Vasospasm
D. Intracerebral hemorrhage
This patient is likely experiencing a vasospasm, which occurs usually between postbleed days 3 and 14. It is rare for vasospasm to occur < 3 days. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1178.
What is the single most common location for an intracranial aneurysm?
A. Anterior communicating artery
B. Posterior communicating artery
C. Carotid bifurcation
D. Posterior inferior cerebellar artery
A. Anterior communicating artery
Anterior communicating artery aneurysms are the most common location for intracranial aneurysms (30%). Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1191.
You are evaluating a 55-year-old woman with a history of hypertension and smoking who has evidence of a third nerve palsy. Where is the aneurysm?
A. Anterior communicating artery
B. Posterior communicating artery
C. Carotid bifurcation
D. Posterior inferior cerebellar artery
A. Anterior communicating artery
B. Posterior communicating artery
C. Carotid bifurcation
D. Posterior inferior cerebellar artery
Posterior communicating artery aneurysms classically present with a non-pupil sparing third nerve palsy (due to compression and not microvascular disease, which would be pupil sparing). While only 9% of posterior communicating artery aneurysms will present this way, given the location of the posterior communicating artery to the third nerve, it is a commonly tested subject. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1192.
What is the most important step in aneurysm surgery prior to clip placement?
A. Dissecting the dome free
B. Releasing CSF
C. Proximal control
D. ICG administration
A. Dissecting the dome free
B. Releasing CSF
C. Proximal control
D. ICG administration
Obtaining proximal control prior to dissecting the aneurysm or placing a clip. When proximal control is obtained, further dissection can take place. If the aneurysm ruptures, temporary clips can be applied to the areas of proximal control in order to decrease bleeding. Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, page 1106.
You are seeing a patient with a right sided ophthalmic segment aneurysm that is growing and causing compression of the optic nerve from the aneurysm itself. What symptoms would you expect him to report?
A. Right inferior nasal quadrantanopsia
B. Right superior nasal quadrantanopsia
C. Right superior temporal quadrantanopsia
D. Right inferior temporal quadrantanopsia
A. Right inferior nasal quadrantanopsia
B. Right superior nasal quadrantanopsia
C. Right superior temporal quadrantanopsia
D. Right inferior temporal quadrantanopsia
Ophthalmic segment aneurysms can grow and cause compression of the optic nerve. Given that they will compress the nerve from the inferior temporal side, you would expect him to have an ipsilateral superior nasal quadrantanopsia. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1214.
You are seeing a patient with a right sided ophthalmic segment aneurysm that is growing and causing compression of the optic nerve. This initially led to an ipsilateral superior nasal quadrantanopsia. Now he reports that he is developing an inferior nasal quadrantanopsia. What structure is causing further compression of the optic nerve?
A. Falciform ligament
B. Tuburculum sellae
C. Anterior clinoid process
D. Middle clinoid process
A. Falciform ligament
B. Tuburculum sellae
C. Anterior clinoid process
D. Middle clinoid process
The falciform ligament is a dural fold overlying the superior aspect of the optic nerve. When an aneurysm pushes the optic nerve superiorly, compression can occur from above as the nerve is pressed against the falciform ligament. After an anterior clinoidectomy, opening of the falciform ligament can decompress the optic nerve. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1214.
You are seeing a patient with a right sided ophthalmic segment aneurysm that is growing and causing compression of the optic nerve. In order to gain access to the aneurysm neck you decide to perform an anterior clinoidectomy. What imaging modality might help you ensure that this procedure is safe in this patient’s case?
A. Conventional cerebral angiogram
B. MRI brain
C. CT head
D. Carotid ultrasound
A. Conventional cerebral angiogram
B. MRI brain
C. CT head
D. Carotid ultrasound
Occasionally patients can have bridging bone between the anterior and posterior clinoid processes, so called the “middle clinoid process.” If the surgeon is unaware of the presence of this middle clinoid process bridging bone, aggressive removal of the anterior clinoid process can lead to transection of the carotid artery as the bridging bone often encases the carotid artery to some degree. A CT scan of the head can rule out the presence of the middle clinoid bridging bone. Further Reading: Spetzler, Kalani, Nakaji. Neurovascular Surgery, 2nd edition, 2015, page 17.
You are evaluating an angiogram in a patient with an AVM. The characteristics are: size = 3.6 cm; drainage = internal cerebral vein; location = right frontal. What is the Spetzler-Martin grade of this AVM?
A. 2
B. 3
C. 4
D. 5
E. 6
A. 2
B. 3
C. 4
D. 5
E. 6
The Spetzler-Martin grading system applies to AVMs and takes into account size of the nidus (< 3 cm, 3–6 cm, > 6 cm), venous drainage (deep/ superficial), and location (eloquent/noneloquent cortex). The scale is 1 to 5. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1243.
You are evaluating an angiogram in a patient with an AVM. The characteristics are: size = 3.6 cm; drainage = internal cerebral vein; location = right frontal. Based on Spetzler-Martin grade, what is the rate of good surgical outcome (no deficit postop)?
A. 95%
B. 84%
C. 73%
D. 69%
E. 53%
A. 95%
B. 84%
C. 73%
D. 69%
E. 53%
Based on the Spetzler-Martin grading system, grade 3 AVMs have an 84% chance of good outcome after surgical resection (grade 1 = 100%, grade 2 = 95%, grade 3 = 84%, grade 4 = 73%, grade 5 = 69%). Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1243.
What is the approximate annual risk of hemorrhage in S-M grade 1 to 3 AVMs?
A. 0%
B. 3.5%
C. 10%
D. 17.5%
E. 25%
A. 0%
B. 3.5%
C. 10%
D. 17.5%
E. 25%
The approximate annual risk of hemorrhage for grade 1 to 3 AVMs is 3.5%. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1240.
You are operating on a 35-year-old man with a brainstem cavernous malformation that has hemorrhaged twice. You successfully resect the cavernoma, but there appears to be a venous malformation deep in the resection cavity. True or false, you should coagulate and cut this venous malformation?
A. True
B. False
B. False
Many cavernous malformations of the brain are associated with developmental venous anomalies. It is important to remember that these venous channels can drain normal brain tissue and should not be resected to avoid risk of postoperative venous stroke. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1245.
You are operating on a 35-year-old man with a left temporal cavernous malformation that is thought to be causing his medically intractable epilepsy. As you approach to the cavernous malformation, you notice yellow discoloration of the surrounding brain parenchyma. True or false, you should resect this surrounding tissue?
A. True
B. False
A. True
When cavernous malformations hemorrhage they can cause hemosiderin staining of the surrounding brain parenchyma which gives it a yellowish color. Many surgeons believe that this hemosiderin stained brain can be a seizure focus and should be resected if it can be done safely. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1250.
What is the most common presentation of a dural arteriovenous fistula?
A. Hemorrhagic stroke
B. Seizure
C. Ischemic stroke
D. Pulsatile tinnitus
A. Hemorrhagic stroke
B. Seizure
C. Ischemic stroke
D. Pulsatile tinnitus
The vast majority of dural arteriovenous fistulae present with pulsatile tinnitus. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1251.
A Cognard grade II a + b dural arteriovenous fistula has what characteristic venous drainage?
A. Direct cortical venous drainage without
ectasia
B. Direct cortical venous drainage with ectasia
C. Retrograde sinus and retrograde cortical venous drainage
D. Anterograde sinus and retrograde cortical venous drainage
A. Direct cortical venous drainage without
ectasia
B. Direct cortical venous drainage with ectasia
C. Retrograde sinus and retrograde cortical venous drainage
D. Anterograde sinus and retrograde cortical venous drainage
There are two major classification systems for dural arteriovenous fistulae, the Borden classification and the Cognard classification. The Cognard classification consists of type I (anterograde drainage through a sinus), type IIa (retrograde sinus drainage only), type IIb (anterograde sinus drainage with retrograde cortical venous reflux), type II a + b (retrograde sinus and retrograde cortical venous reflux), type III (direct cortical venous drainage without ectasia), type IV (direct cortical venous drainage with ectasia), and type V (direct drainage into spinal perimedullary veins). Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1254.
What Cognard grade carries the highest risk of hemorrhage when grading a dural fistula?
A. Type II a + b
B. Type III
C. Type II b
D. Type II a
A. Type II a + b
B. Type III
C. Type II b
D. Type II a
Type II a + b (retrograde sinus and cortical venous reflux) carries the highest risk of hemorrhage, approximately 66%. Next is type IV with direct cortical venous drainage with ectasia, at 65%. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1254.
What is the most common presenting symptom of a vein of Galen malformation?
A. Hemorrhage
B. Seizure
C. Heart failure
D. Ischemic stroke
A. Hemorrhage
B. Seizure
C. Heart failure
D. Ischemic stroke
Vein of Galen malformations present in neonates with evidence of high output heart failure. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1256.
You are evaluating a 44-year-old woman in the emergency department who was just involved in a motor vehicle accident where she was unrestrained and hit her face on the dashboard. Since the accident she has noticed blurry vision out of the right eye only. You notice that she appears to have a VI nerve palsy on the right, chemosis, and some proptosis. What is the diagnosis?
A. Intraparenchymal contusion
B. Orbital blowout fracture
C. Ophthalmic artery dissection
D. Carotid-cavernous fistula
A. Intraparenchymal contusion
B. Orbital blowout fracture
C. Ophthalmic artery dissection
D. Carotid-cavernous fistula
Traumatic carotid-cavernous fistulae can occur after motor vehicle accidents or other intracranial trauma. They present with orbital pain, chemosis, proptosis, ophthalmoplegia, and visual loss. Patients should undergo vascular imaging and may require interventional or surgical treatment of the fistula. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1257.
A hypoxic cell is more sensitive to radiation than an oxygenated cell, true or false?
A. True
B. False
B. False
Radiation therapy damages cells by firing particles into an atom and releasing free electrons causing damage downstream. In fully oxygenated cells, oxygen combines with unpaired free electrons to form peroxides, which are more stable and lethal than free radicals, and therefore an oxygenated cell is more sensitive to damage by radiation therapy. Further Reading: Greenberg. Handbook of Neurosurgery, 8th edition, 2016, page 1566.
Generally speaking, how old should a child be before they are able to receive cranial radiation therapy?
A. > 1 year
B. > 3 years
C. > 5 years
D. > 7 years
E. > 10 years
A. > 1 year
B. > 3 years
C. > 5 years
D. > 7 years
E. > 10 years
Children less than 3 years of age are particularly sensitive to cranial radiation and can have severe developmental side effects. Children should be greater than 3 years of age to be eligible for cranial radiation. There may be demonstrable changes in IQ (decrease by 25 points) in children who receive radiation up to 7 years of age. Further Reading: Keating, Goodrich, Packer. Tumors of the Pediatric Central Nervous System, 2nd edition, 2013, page 138.
Gamma knife radiosurgery is used for tumors of what diameter?
A. 1 cm or less
B. 3 cm or less
C. 5 cm or less
D. 7 cm or less
E. 10 cm or less
A. 1 cm or less
B. 3 cm or less
C. 5 cm or less
D. 7 cm or less
E. 10 cm or less
Gamma knife radiosurgery can be useful for cranial masses, but should be reserved for patients with brain tumors that are 3 cm or less in maximum diameter. This size cutoff decreases the risk of harmful radiation side effects to surrounding brain structures. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1564.
What is the maximum safe dose of radiation to the optic apparatus?
A. 6 Gy
B. 10 Gy
C. 14 Gy
D. 18 Gy
E. 20 Gy
A. 6 Gy
B. 10 Gy
C. 14 Gy
D. 18 Gy
E. 20 Gy
Safe doses of radiation to the optic apparatus are generally thought to be 8 to 10 Gy. Doses beyond this can lead to visual loss. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1567. Lunsford, Sheehan. Intracranial Stereotactic Radiosurgery, 2016, page 52.
What is a standard stereotactic radiosurgery dose that gives good tumor control for vestibular schwannomas but preserves facial nerve function?
A. 10 Gy or less
B. 13 Gy or less
C. 16 Gy or less
D. 19 Gy or less
E. 22 Gy or less
A. 10 Gy or less
B. 13 Gy or less
C. 16 Gy or less
D. 19 Gy or less
E. 22 Gy or less
SRS doses for vestibular schwannomas have changed based on recent literature, and currently 12 to 13 Gy to the facial nerve seems to be a dose of radiation that causes good tumor control but greatly decreases the side effects to the seventh and eighth nerve. Further Reading: Lunsford, Sheehan. Intracranial Stereotactic Radiosurgery, 2016, page 150.
What is the maximum safe dose of radiation to the lens of the eye?
A. 6 Gy or less
B. 8 Gy or less
C. 10 Gy or less
D. 12 Gy or less
E. 15 Gy or less
A. 6 Gy or less
B. 8 Gy or less
C. 10 Gy or less
D. 12 Gy or less
E. 15 Gy or less
The lens of the eye can tolerate 10 Gy or less radiation with minimal side effects. Cataract formation will occur with doses up to 50 Gy. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1567 Lunsford, Sheehan. Intracranial Stereotactic Radiosurgery, 2016, page 52.
At the 10-year post-treatment mark, what percentage of patients who received standard sellar radiation for a residual pituitary tumor will experience side effects including hypopituitarism?
A. 10 to 20%
B. 20 to 30%
C. 30 to 40%
D. 40 to 50%
E. 50 to 60%
A. 10 to 20%
B. 20 to 30%
C. 30 to 40%
D. 40 to 50%
E. 50 to 60%
At 10 years posttreatment, approximately 40 to 50% of patients who receive sellar radiation will experience hypopituitarism as a side effect from radiation. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 744. Lunsford, Sheehan. Intracranial Stereotactic Radiosurgery, 2016, page 107.
What is considered the mean safe dose of radiation to the cochlea?
A. < 2 Gy
B. 4 to 6 Gy
C. 7 to 9 Gy
D. 10 to 12 Gy
E. 13 to 15 Gy
A. < 2 Gy
B. 4 to 6 Gy
C. 7 to 9 Gy
D. 10 to 12 Gy
E. 13 to 15 Gy
Based on current literature, the mean safe radiation dose to the cochlea is considered to be approximately 4.2 Gy, but has also been shown to range from 4 to 6 Gy. There is some controversy on this topic currently, but based on data available, doses from 4 to 6 Gy should be considered optimal.
Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1570.
You are seeing a 56-year-old man with a single brain metastasis which is proven to be a radiosensitive tumor based on histology. You elect to perform stereotactic radiosurgery for this mass that measures approximately 1.8 cm in maximum diameter. What dose of radiation should you plan to deliver to the tumor?
A. 10 Gy
B. 18 Gy
C. 24 Gy
D. 30 Gy
E. 40 Gy
A. 10 Gy
B. 18 Gy
C. 24 Gy
D. 30 Gy
E. 40 Gy
For tumors that are 10 to 20 mm, SRS doses up to 24 Gy can be used with acceptable risk of side effects. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1570.
You are seeing a 56-year-old man with a single brain metastasis which is proven to be a radiosensitive tumor based on histology. You elect to perform stereotactic radiosurgery for this mass that measures approximately 2.8 cm in maximum diameter. What dose of radiation should you plan to deliver to the tumor?
A. 10 Gy
B. 18 Gy
C. 24 Gy
D. 30 Gy
E. 40 Gy
A. 10 Gy
B. 18 Gy
C. 24 Gy
D. 30 Gy
E. 40 Gy
For tumors that are 21 to 30 mm, SRS doses up to 18 Gy can be used with acceptable risk of side effects. Further Reading: Greenberg. Handbook of Neurosurgery. 8th edition, 2016, page 1570.