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Question 1: Traumatic Brain Injury - Blood Pressure Management
A 45-year-old male presents to the emergency department following a motor vehicle accident with a Glasgow Coma Scale of 7. What is the minimum systolic blood pressure target that should be maintained in the prehospital and early hospital phase?
A) > 90 mmHg
B) > 100 mmHg
C) > 110 mmHg ✓
D) > 120 mmHg
Explanation: Mortality rates are markedly increased when systolic blood pressure drops below 110 mmHg at admission in severe traumatic brain injury patients. A single episode of hypotension (SBP < 90 mmHg) worsens neurological outcomes, but recent evidence demonstrates that maintaining SBP > 110 mmHg is the appropriate target before measuring cerebral perfusion pressure 1.
Question 2: Severe TBI - Initial Imaging
A 32-year-old patient arrives at the emergency department with severe head trauma and a GCS of 6. Which imaging study should be performed without delay?
A) MRI brain with contrast
B) CT brain and cervical spine ✓
C) CT angiography only
D) Skull X-rays
Explanation: Brain and cervical CT scan without delay is the standard of care for severe traumatic brain injury patients. CT scanning is the first choice for diagnosing primary brain lesions due to its availability and can guide neurosurgical procedures and monitoring techniques 1.
Question 3: TBI - Prehospital Ventilation Management
During prehospital management of a severe TBI patient requiring intubation, what is the recommended end-tidal CO2 (EtCO2) range before obtaining arterial blood gas samples?
A) 20-25 mmHg
B) 30-35 mmHg ✓
C) 40-45 mmHg
D) 45-50 mmHg
Explanation: An EtCO2 between 30-35 mmHg is recommended prior to obtaining arterial gas samples to adjust mechanical ventilation. Hypocapnia induces cerebral vasoconstriction and is a risk factor for brain ischemia, making end-tidal CO2 monitoring critical in intubated severe TBI patients 1.
Question 4: Acute Subdural Hematoma - Surgical Indication
Which of the following acute subdural hematomas requires surgical evacuation according to current guidelines?
A) 3 mm thickness with no midline shift
B) 6 mm thickness with 7 mm midline shift ✓
C) 4 mm thickness with 3 mm midline shift
D) 2 mm thickness with 5 mm midline shift
Explanation: Removal of a significant acute subdural hematoma is indicated when thickness is greater than 5 mm with displacement of the median line greater than 5 mm. This represents a neurosurgical indication at the early phase of severe TBI 1.
Question 5: High-Grade Glioma - Standard Radiotherapy Dose
What is the recommended total radiation dose for first-line external-beam radiotherapy in patients with high-grade glioma?
A) 45 Gy
B) 50 Gy
C) 60 Gy ✓
D) 70 Gy
Explanation: First-line external-beam radiotherapy should be offered to patients with high-grade glioma as it improves survival. A total dose of 60 Gy should be delivered, with fractionation from 1.8 to 2 Gy per fraction per day 1.
Question 6: Glioblastoma - Postoperative Chemotherapy
Which chemotherapy agent is the standard for mono-drug chemotherapy in patients with glioblastoma?
A) Temozolomide
B) Nitrosourea (BCNU) ✓
C) Carboplatin
D) Vincristine alone
Explanation: When chemotherapy is selected for glioblastoma, mono-drug chemotherapy with a nitrosourea should be offered as the standard treatment. This can be combined with radiotherapy as an option 1.
Question 7: TBI - CT Angiography Indication
Which of the following is a risk factor that should prompt CT angiography of supra-aortic and intracranial vessels in a TBI patient?
A) Isolated scalp laceration
B) Cervical spine fracture ✓
C) Simple nasal bone fracture
D) Isolated rib fractures
Explanation: Risk factors for traumatic dissection of supra-aortic and intracranial arteries include presence of cervical spine fracture, focal neurological deficit not explained by brain imaging, Claude Bernard-Horner syndrome, Lefort II or III facial fractures, basal skull fractures, and soft tissue neck lesions. These should lead to CT-angiography exploration 1.
Question 8: Intracranial Hypertension - CSF Drainage
In a severe TBI patient with persistent intracranial hypertension despite sedation and correction of secondary brain insults, which intervention should be considered?
A) Hyperventilation to PaCO2 of 25 mmHg
B) External ventricular drainage ✓
C) Prophylactic decompressive craniectomy
D) High-dose barbiturates immediately
Explanation: External ventricular drainage should be performed to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults. Drainage of cerebrospinal fluid from normal or small volume ventricles is a therapeutic option to control intracranial pressure 1.
Question 9: Severe TBI - Transfer Destination
A patient with severe traumatic brain injury (GCS 6) should be transferred to which type of facility?
A) Nearest community hospital
B) Specialized center with neurosurgical facilities ✓
C) Trauma center without neurosurgery
D) Rehabilitation facility
Explanation: Severe TBI patients should be managed by a prehospital medicalized team and transferred as soon as possible to a specialized centre including neurosurgical facilities. Mortality rates are lower in neurosurgical centers compared to non-specialized centers, even for patients who do not require neurosurgical procedures 1.
Question 10: Anaplastic Oligodendroglioma - Chemotherapy Regimen
Which chemotherapy regimen has been shown to be efficacious in patients with oligodendroglioma?
A) BCNU alone
B) PCV (Procarbazine, Lomustine, Vincristine) ✓
C) Temozolomide alone
D) Cisplatin-based regimen
Explanation: Chemotherapy with PCV (procarbazine, lomustine, and vincristine) has been shown to be efficacious in patients with oligodendroglioma. A combination of radiotherapy and chemotherapy can be considered for anaplastic oligodendroglioma and oligoastrocytoma 1.
Question 11: Subdural Hygroma - Initial Imaging
What is the recommended first-line imaging investigation for a patient with suspected subdural hygroma?
A) CT head without contrast
B) MRI brain with contrast and whole spine MRI ✓
C) CT angiography
D) Plain skull radiographs
Explanation: MRI of the brain with intravenous contrast and whole spine MRI are recommended as first-line investigations to identify subdural hygroma and investigate for spontaneous intracranial hypotension as the underlying cause 2, 3.
Question 12: Subdural Hygroma with SIH - Initial Treatment
What is the recommended initial treatment for subdural hygromas associated with spontaneous intracranial hypotension?
A) Immediate surgical drainage
B) Epidural blood patch ✓
C) High-dose steroids
D) Lumbar puncture
Explanation: Epidural blood patch should be prioritized as initial treatment for subdural hygromas associated with spontaneous intracranial hypotension. This is recommended with a high level of evidence 2, 3.
Question 13: Intracerebral Hemorrhage - Blood Pressure Target
In acute intracerebral hemorrhage, what is the proven safe systolic blood pressure target according to recent randomized trials?
A) < 120 mmHg
B) < 140 mmHg ✓
C) < 160 mmHg
D) < 180 mmHg
Explanation: Intensive lowering of systolic blood pressure to < 140 mmHg is proven safe by two recent randomized trials in the management of intracerebral hemorrhage 4.
Question 14: Intraventricular Hemorrhage - Hydrocephalus Management
A patient with intraventricular hemorrhage develops acute obstructive hydrocephalus with neurologic decline. What is the most immediate appropriate intervention?
A) Lumbar puncture
B) External ventricular drainage ✓
C) Intraventricular tPA immediately
D) Observation for 24 hours
Explanation: The most immediate threat to life posed by intraventricular hemorrhage is acute obstructive hydrocephalus. If contributing to neurologic decline, it must be treated emergently with external ventricular drainage through an intraventricular catheter 5.
Question 15: Intracranial Mycotic Aneurysm - Endovascular vs Surgery
Which patients with intracranial mycotic aneurysm are best suited for neurosurgical intervention rather than endovascular therapy?
A) Multiple distal aneurysms
B) Ruptured aneurysm with increased ICP and mass effect ✓
C) Proximal circulation aneurysms
D) Patients requiring urgent cardiac surgery
Explanation: Neurosurgery is reasonable for patients with ruptured intracranial mycotic aneurysm with mass effect who require urgent neurosurgery to evacuate hematoma, reduce intracranial pressure, and control bleeding. Endovascular therapy is not suitable with rupture and increased ICP with mass effect 1.