Neurosurgery Prometric exam questions with answers

1. Question 1Cerebrovascular Neurosurgerymedium

   A 40-year-old had a sudden severe headache 14 hours ago. Non-contrast CT of the head is normal and she is neurologically intact. What is the next step?

   1. ADischarge with oral analgesia
   2. BMRI of the brain in 2 weeks
   3. CLumbar puncture for xanthochromia
   4. DRepeat non-contrast CT tomorrow
   Show answer and explanation▾

   Answer: C. Lumbar puncture for xanthochromia

   CT sensitivity for subarachnoid haemorrhage falls after 6 hours, so a lumbar puncture at least 12 hours after onset to look for xanthochromia is needed. Discharging her risks missing a sentinel bleed from an aneurysm.

2. Question 2Cerebrovascular Neurosurgeryhard

   A 68-year-old with a spontaneous cerebellar haemorrhage becomes drowsy. CT shows fourth ventricle effacement, brainstem compression and early hydrocephalus. What is the best management?

   1. AExternal ventricular drain alone
   2. BBlood pressure control and observation
   3. CSuboccipital decompression and evacuation
   4. DIntravenous mannitol and repeat CT
   Show answer and explanation▾

   Answer: C. Suboccipital decompression and evacuation

   Cerebellar haemorrhage causing neurological deterioration, brainstem compression or hydrocephalus should be surgically evacuated. A ventricular drain alone is not recommended because it does not relieve brainstem compression and risks upward herniation.

3. Question 3Functional Neurosurgery and Epilepsymedium

   According to the ILAE, when is epilepsy defined as drug-resistant?

   1. AAfter failure of one drug at its maximum tolerated dose
   2. BAfter failure of four or more drugs
   3. CAfter failure of two appropriate tolerated drugs
   4. DAfter seizures persist for 5 years
   Show answer and explanation▾

   Answer: C. After failure of two appropriate tolerated drugs

   The ILAE defines drug resistance as failure of adequate trials of two tolerated, appropriately chosen and used antiseizure drug schedules. Such patients should be referred for surgical evaluation rather than waiting years.

4. Question 4Neuro-oncologymedium

   A 72-year-old has a 9 mm intracanalicular vestibular schwannoma with mild hearing loss and no brainstem compression. What is the most appropriate initial management?

   1. ATranslabyrinthine resection
   2. BSerial MRI surveillance
   3. CWhole-brain radiotherapy
   4. DVentriculoperitoneal shunt
   Show answer and explanation▾

   Answer: B. Serial MRI surveillance

   Small, minimally symptomatic vestibular schwannomas often grow slowly or not at all, so observation with serial MRI is appropriate, especially in older patients. Surgery or radiosurgery is considered if the tumour grows or symptoms progress.

5. Question 5Paediatric Neurosurgery and CSF Disorderseasy

   A 74-year-old has progressive gait apraxia, memory decline and urinary incontinence. CT shows ventriculomegaly out of proportion to atrophy. Which test best predicts shunt response?

   1. AHigh-volume lumbar tap test
   2. BEEG recording
   3. CSerum vitamin B12 level
   4. DCarotid Doppler study
   Show answer and explanation▾

   Answer: A. High-volume lumbar tap test

   In suspected normal pressure hydrocephalus, improved gait after removing 30-50 mL of CSF (tap test) or extended lumbar drainage predicts benefit from shunting. EEG and B12 testing do not predict shunt response.

6. Question 6Neurocritical Care, Perioperative Care and Safetymedium

   A patient with catastrophic brain injury is being assessed for brain death. Which finding means the clinical examination must be postponed?

   1. ASystolic blood pressure of 110 mmHg
   2. BCore temperature of 33 C
   3. CSerum sodium of 142 mmol/L
   4. DAbsent corneal reflexes
   Show answer and explanation▾

   Answer: B. Core temperature of 33 C

   Hypothermia is a confounder that must be corrected (to a core temperature of at least 36 C) before brain death determination. Absent corneal reflexes are part of the expected examination findings, not a reason to delay.

7. Question 7Spine and Peripheral Nervehard

   A 58-year-old with metastatic renal cell carcinoma has single-level T8 cord compression and has been paraparetic for 24 hours. Expected survival is over 6 months. What is the best treatment after dexamethasone?

   1. ADecompressive surgery then radiotherapy
   2. BConventional radiotherapy alone
   3. CSystemic chemotherapy alone
   4. DHigh-dose steroids without other therapy
   Show answer and explanation▾

   Answer: A. Decompressive surgery then radiotherapy

   Direct decompressive surgery followed by radiotherapy improved ambulation over radiotherapy alone in selected patients with single-level compression and reasonable prognosis. Renal cell carcinoma is relatively radioresistant, which makes radiotherapy alone less attractive.

8. Question 8Spine and Peripheral Nerveeasy

   A 70-year-old with cervical spondylosis falls forward and hyperextends his neck. He has weakness much worse in the arms than the legs. Which syndrome is most likely?

   1. AAnterior cord syndrome
   2. BBrown-Sequard syndrome
   3. CCentral cord syndrome
   4. DPosterior cord syndrome
   Show answer and explanation▾

   Answer: C. Central cord syndrome

   Central cord syndrome typically follows hyperextension in a spondylotic canal and affects the arms more than the legs, because the arm fibres sit medially in the corticospinal tract. Anterior cord syndrome causes paralysis with loss of pain and temperature but preserved proprioception.

9. Question 9Neurocritical Care, Perioperative Care and Safetymedium

   On day 1 after transsphenoidal pituitary surgery, a patient passes 300 mL per hour of dilute urine (osmolality 120 mOsm/kg) and serum sodium rises to 149 mmol/L. What is the most appropriate treatment?

   1. AFluid restriction
   2. BHydrochlorothiazide
   3. CDesmopressin
   4. DHypertonic saline
   Show answer and explanation▾

   Answer: C. Desmopressin

   Polyuria with dilute urine and rising serum sodium indicates central diabetes insipidus, which is treated with desmopressin and fluid replacement. Fluid restriction would worsen the hypernatraemia.

10. Question 10Neurotraumamedium

    In severe traumatic brain injury, above what intracranial pressure does the 4th edition Brain Trauma Foundation guideline recommend treatment?

    1. A15 mmHg
    2. B30 mmHg
    3. C40 mmHg
    4. D22 mmHg
    Show answer and explanation▾

    Answer: D. 22 mmHg

    The 4th edition guideline recommends treating ICP above 22 mmHg because values above this are linked to higher mortality. The older threshold of 20 mmHg was revised; 30 and 40 mmHg are far too permissive.

11. Question 11Paediatric Neurosurgery and CSF Disordersmedium

    A 6-year-old with a ventriculoperitoneal shunt has 1 day of headache, vomiting and increasing drowsiness. What is the most appropriate next step?

    1. AOral antiemetic and review in clinic tomorrow
    2. BUrgent CT, shunt series and neurosurgical review
    3. CLumbar puncture to measure opening pressure
    4. DElective outpatient MRI within the next week
    Show answer and explanation▾

    Answer: B. Urgent CT, shunt series and neurosurgical review

    Headache, vomiting and reduced consciousness in a shunted child suggest shunt malfunction, which is an emergency. Lumbar puncture is unsafe with possible obstructive hydrocephalus.

12. Question 12Paediatric Neurosurgery and CSF Disordersmedium

    On MRI, how far must the cerebellar tonsils descend below the foramen magnum to meet the usual radiological definition of Chiari I malformation in adults?

    1. AAt least 1 mm
    2. BAt least 15 mm
    3. CAt least 25 mm
    4. DAt least 5 mm
    Show answer and explanation▾

    Answer: D. At least 5 mm

    Tonsillar descent of 5 mm or more below the foramen magnum is the usual adult radiological criterion for Chiari I malformation. Descent of 3-5 mm is called tonsillar ectopia and is often asymptomatic.

13. Question 13Spine and Peripheral Nervemedium

    A 62-year-old has progressive hand clumsiness, a broad-based gait and positive Hoffmann signs. MRI shows multilevel cervical cord compression. His modified JOA score is 12. What is recommended?

    1. ASupervised physiotherapy trial
    2. BSurgical decompression
    3. CSoft cervical collar
    4. DObservation with annual MRI
    Show answer and explanation▾

    Answer: B. Surgical decompression

    Moderate (mJOA 12-14) and severe degenerative cervical myelopathy should be treated with surgical decompression to stop further neurological decline. A structured non-operative trial is an option only for mild disease.

14. Question 14Spine and Peripheral Nervemedium

    When a patient grips paper between thumb and index finger, the thumb interphalangeal joint flexes (positive Froment sign). Which nerve is affected?

    1. AUlnar nerve
    2. BMedian nerve
    3. CRadial nerve
    4. DMusculocutaneous nerve
    Show answer and explanation▾

    Answer: A. Ulnar nerve

    A positive Froment sign shows weakness of adductor pollicis, which is supplied by the ulnar nerve. The patient compensates with flexor pollicis longus, which is supplied by the median (anterior interosseous) nerve.

15. Question 15Spine and Peripheral Nervemedium

    A 35-year-old who injects drugs has fever, severe thoracic back pain and new leg weakness. What is the most important investigation?

    1. AMRI of the whole spine with gadolinium
    2. BPlain radiographs of the thoracic spine
    3. CBone scan with technetium
    4. DLumbar puncture and CSF culture
    Show answer and explanation▾

    Answer: A. MRI of the whole spine with gadolinium

    Suspected spinal epidural abscess needs urgent contrast-enhanced MRI of the whole spine, because skip lesions occur and surgery may be needed. Lumbar puncture can spread infection and is not diagnostic.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.