Specialist & Consultant Neurosurgery oral assessment prep

Knowledge: This is an acute extradural haematoma, usually from the middle meningeal artery beneath a temporal fracture, with a lucid interval then deterioration. The dilating ipsilateral pupil and the Cushing response of hypertension with bradycardia indicate uncal herniation. It meets every operative criterion: volume over 30 mL, thickness over 15 mm, shift over 5 mm and GCS below 9 with anisocoria. Isolated extradural haematomas evacuated promptly often do well, so minutes matter. I would still look for a subdural, contusions, a contralateral lesion and vascular injury. Hypoxia, hypotension, hypercarbia, fever and glucose derangement each worsen outcome.

Management: I call theatre now for emergency craniotomy, keeping spinal precautions. Meanwhile: head up 30 degrees, neck neutral, sedation, saturation above 94 percent, PaCO2 35 to 40 mmHg and systolic pressure at least 110 mmHg. As a bridge I give mannitol 0.5 to 1 g/kg or hypertonic saline, with brief hyperventilation only until the incision. I send coagulation, platelets and crossmatch and reverse any anticoagulant. In theatre I perform a trauma craniotomy rather than burr holes alone, evacuate the clot, control the middle meningeal artery and place dural hitch stitches. He then goes to neuro-ICU with a repeat CT within 24 hours or on deterioration, ICP monitoring if contusions or swelling were present, phenytoin for 7 days against early seizures, and chemical VTE prophylaxis once the scan is stable. I would not give corticosteroids, which increased mortality in CRASH. Follow-up includes rehabilitation and cognitive review.

Ethics and communication: He lacks capacity and delay would harm him, so I operate under the emergency exception to consent in Federal Decree-Law No. 4 of 2016 on Medical Liability, recording reasons and times. When the family arrives I explain what was done and that recovery is uncertain, without false reassurance. Police enquiries go through the facility's formal channel only.

Reference: Guidelines for the Management of Severe Traumatic Brain Injury, 4th edition, Brain Trauma Foundation, 2016; American College of Surgeons, Advanced Trauma Life Support (ATLS) Student Course Manual, 10th ed, 2018

Knowledge: This is aneurysmal subarachnoid haemorrhage, WFNS grade 2, with early hydrocephalus. The main early threat is rebleeding, highest in the first 24 hours and often fatal, so the 2023 AHA/ASA guideline recommends securing the aneurysm within 24 hours, not on Monday. Later threats are delayed cerebral ischaemia from about day 3 to 14, hyponatraemia, seizures and cardiac dysfunction. ISAT showed better disability-free survival with coiling for aneurysms suitable for both, with more retreatment, so the choice rests on anatomy, patient factors and expertise, decided with interventional neuroradiology. Oral nimodipine is the only drug shown to improve outcome.

Management: I admit her to neuro-critical care, give analgesia and antiemetics, and keep systolic pressure at or below 160 mmHg with titratable agents while avoiding hypotension. I start oral nimodipine 60 mg every 4 hours for 21 days, splitting the dose if hypotension occurs, and maintain euvolaemia. If consciousness falls I place an external ventricular drain, avoiding over-drainage before the aneurysm is secured. The same day I review the angiogram with interventional neuroradiology and secure the aneurysm within 24 hours, coiling if anatomy suits or clipping for a wide neck or associated haematoma. I do not use routine antifibrinolytics, prophylactic hypervolaemia or fluid restriction for hyponatraemia. Over the next two weeks I monitor for delayed cerebral ischaemia clinically and with transcranial Doppler, treating it with induced hypertension and endovascular rescue if refractory. Follow-up includes angiographic surveillance, blood pressure control, smoking cessation and screening for cognitive and mood problems.

Ethics and communication: She has capacity, so consent covers the risk of rebleeding if untreated, procedural stroke and retreatment, with a professional interpreter if needed. I would not let scheduling delay a time-critical treatment and would escalate firmly but politely. If both options are reasonable I say so honestly rather than steering her to the one I perform, and I document the multidisciplinary decision.

Reference: AHA/ASA Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage, 2023; Greenberg, Handbook of Neurosurgery, 10th ed, 2023

Knowledge: This is suspected cauda equina syndrome, most likely from a large central L4/5 or L5/S1 disc prolapse. With saddle anaesthesia and a 620 mL residual he is either incomplete with retention or progressing, and outcome is better if decompression precedes established painless retention. Clinical signs are unreliable in both directions, so MRI is mandatory. Differentials include conus lesions, epidural abscess or haematoma, tumour and analgesic-related retention. The SBNS and BASS standards expect emergency MRI at the receiving hospital at any hour once the syndrome is suspected, and decompression without avoidable delay once compression is confirmed.

Management: Immediately I would document a full neurological examination including perianal sensation, anal tone and a post-void residual, then catheterise and record the volume. I would not accept morning imaging: I escalate through the on-call radiology consultant and management to obtain MRI tonight, and if that is impossible arrange urgent transfer to a centre that can scan and operate. If MRI shows significant compression, I consent him and perform decompression, usually a laminectomy or wide discectomy, as soon as theatre and an experienced team are available, rather than as an unsupervised night case by a junior. Afterwards I monitor bladder function with trial without catheter, residual scans and urology input, and document sensory recovery. I provide written information about bladder, bowel and sexual function and arrange early pelvic floor physiotherapy. Follow-up at six weeks and later includes urodynamics if bladder symptoms persist and psychological support.

Ethics and communication: Consent must state that surgery aims to stop deterioration and that bladder, bowel and sexual function may not fully recover. Delay is a leading cause of claims, so I record the time of each step and escalation. I offer a private discussion of sexual function, with a professional interpreter rather than a relative if needed. If delay caused harm, I disclose it and report it through the incident system.

Reference: SBNS and BASS Standards of Care for Investigation and Management of Cauda Equina Syndrome, 2018; Greenberg, Handbook of Neurosurgery, 10th ed, 2023

Knowledge: This is wrong-level spinal surgery, a never event and one of the commonest wrong-site errors in neurosurgery. Contributors include transitional anatomy, obesity, poor fluoroscopic views, counting from one end only and no correlation with the pre-operative MRI. Prevention rests on the WHO Surgical Safety Checklist, the Universal Protocol of marking, time-out and verification, and an intraoperative level check correlated with pre-operative imaging, using whole-spine views when anatomy is atypical. The clinical problem remains an L4/5 prolapse plus an unnecessary L3/4 discectomy. Calling the error staging would be dishonest.

Management: First I confirm the facts from the MRI and intraoperative images. Today, with the registrar present, I meet the patient and the family member he chooses, explain that the wrong level was operated on, apologise and set out the plan, then document the conversation. I examine him for new deficits. I offer corrective L4/5 discectomy at the earliest safe opportunity, performed by me, after fresh consent and a rigorous level check correlated with full-length imaging. I report the event through the incident system the same day and inform the head of department, who manages any regulatory notification. Over the following weeks I contribute to a root cause analysis focused on the level-check process and support changes such as a mandatory imaging protocol for transitional anatomy. I follow him up personally, including for instability at L3/4.

Ethics and communication: Open disclosure is a professional and legal expectation, and concealment would compound the harm and the liability under Federal Decree-Law No. 4 of 2016 on Medical Liability. I decline the registrar's suggestion clearly but arrange support and supervised learning rather than blame. As supervising consultant I share responsibility. If he wants a second opinion or to complain, I facilitate it.

Reference: WHO Guidelines for Safe Surgery, World Health Organization, 2009; The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery

Knowledge: This is probable shunt infection, most occurring within months of surgery from skin flora such as coagulase-negative staphylococci and Staphylococcus aureus, with Cutibacterium acnes and Gram-negative organisms less often. Track erythema, fever and abdominal pain suggest infection with distal involvement, and larger ventricles suggest malfunction. Differentials include intercurrent infection with a coincidental block, abdominal pseudocyst and appendicitis. Diagnosis rests on CSF from a shunt tap, with cultures held long enough for slow-growing organisms. The IDSA 2017 guideline recommends removing all infected hardware, external drainage and intravenous antibiotics, then reimplantation once CSF is sterile.

Management: I resuscitate, take blood cultures and perform a sterile reservoir tap before antibiotics if this causes no delay. I start intravenous vancomycin with an anti-pseudomonal beta-lactam such as cefepime or meropenem, dosed by weight and adjusted to levels, and request abdominal ultrasound. Within hours I remove the whole shunt and insert an external ventricular drain, sending all components for culture. Over the following days I monitor CSF cell count and cultures, tailor antibiotics, and consider intraventricular antibiotics only if response is poor. Once CSF is sterile for the period appropriate to the organism, I reimplant a new shunt, often at a fresh site, using a standardised infection-reduction protocol. I would not treat with antibiotics alone or merely externalise the distal catheter. Follow-up includes developmental review and teaching the family the signs of malfunction.

Ethics and communication: As he is under 18, his guardian consents. I explain honestly why one operation is less likely to succeed and what a drain stay involves, and help with the practical burden of distance. I explain things to him at his level. Infection after a recent revision is reviewed through surgical site infection surveillance, not hidden.

Reference: IDSA Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis, 2017; Greenberg, Handbook of Neurosurgery, 10th ed, 2023

Knowledge: The likely diagnosis is glioblastoma, IDH-wildtype, CNS WHO grade 4, given age, necrosis and callosal spread. Differentials are metastasis, primary CNS lymphoma, abscess and tumefactive demyelination, and diffusion, perfusion and spectroscopy help separate them. Steroids can make lymphoma vanish and spoil the biopsy, so they are withheld if lymphoma is suspected and he is safe. The 2021 WHO classification integrates histology with markers such as IDH, MGMT promoter methylation, TERT, EGFR and chromosome 7 and 10 changes. Maximal safe resection is preferred over biopsy when feasible, and the Stupp regimen of radiotherapy with temozolomide improves survival, with MGMT methylation predicting benefit.

Management: I start levetiracetam and, if lymphoma is unlikely, dexamethasone at the lowest effective dose, for example 4 to 8 mg daily, with gastric protection and glucose monitoring. Within days he is discussed at the neuro-oncology multidisciplinary meeting and I plan surgery with tractography and neuronavigation, using 5-aminolevulinic acid fluorescence where available. Given callosal spread I aim for maximal safe resection of the enhancing tumour, or biopsy if resection is unsafe. Post-operative MRI within 72 hours documents residual tumour. After integrated diagnosis he is referred for radiotherapy, 60 Gy in 30 fractions with temozolomide, or a shorter course if frail. I would not delay surgery for weeks or stop steroids abruptly. Follow-up includes MRI surveillance, seizure review, rehabilitation and early palliative care input.

Ethics and communication: I acknowledge the son's concern, but the patient has capacity and needs the diagnosis to consent. I ask the patient how much he wants to know and who should be present, then share information at his pace. Consent includes specific risks of weakness and cognitive change. His employer is told nothing without his agreement.

Reference: EANO Guidelines on the Diagnosis and Treatment of Diffuse Gliomas of Adulthood, 2021; WHO Classification of Tumours of the Central Nervous System, 5th ed, 2021