3Adult Neurosurgery Which tumor is associated with hydrocephalus and sudden death? A. Colloid cyst B. Glioblastoma multiforme C. Lymphoma D. Pilocytic astrocytoma Complex regional pain syndrome type 2 (formerly known as causalgia) is defined by what symptoms? A. Burning pain, autonomic dysfunction, and trophic changes following obvious nerve damage B. Increased perspiration in excess of what is required for regulation of body temperature C. Burning pain, autonomic dysfunction, and trophic changes without obvious nerve damage D. An initial lack of sensation and tingling on one side of the body followed later by severe, chronic dysesthesias or allodynia E. Recurrent hospitalizations with dramatic, untrue, and extremely improbable tales of past experiences What factors contribute to the intracranial hemorrhage (ICH) score for a patient with a hemorrhagic stroke? A. Patient age, Glasgow Coma Scale (GCS) score, acuity of ICH B. ICH volume, GCS score, acuity of ICH C. Intraventricular hemorrhage (IVH), position of ICH, patient age D. Position of ICH, patient age, baseline Karnofsky Scale score E. Patient age, IVH, hemiplegia A patient with a history of intravenous drug use is seen in clinic with new-onset severe back pain. An MRI is obtained that demonstrates bony erosion and collapse of the L2/L3 disk. What is the next step in the management of this patient? A. Perform a lumbar puncture, and send spinal fluid cultures. B. Obtain a CT scan of the spine. C. Obtain blood cultures. D. Obtain a bone scan. E. Schedule follow-up with a repeat MRI in 4 to 6 weeks. How is mechanical back pain associated with activity? A. Improves with activity B. Worsens with activity C. Relieved by standing D. Worsens with axial unloading Where should the dissection take place during a transpsoas approach to the lumbar spine in order to minimize the risk of nerve injury? A. Anterior to the psoas major B. Posterior to the psoas major C. Through the bulk of the psoas major D. Along the medial aspect of the psoas major E. Along the lateral aspect of the psoas major A 17-year-old girl presents to the neuro-ophthalmology clinic with complaints of episodic diplopia that has been present for the past week. The episodes occur about every hour and last around 1 minute each time. The patient has a history of a transsphenoidal resection of a craniopharyngioma 3 years ago followed by radiation. Postoperative ophthalmologic exams including visual fields have been unremarkable. An MRI from 1 month ago demonstrated no evidence of recurrent disease. The patient is examined during one of these episodes and is found to have an exotropia of her right eye that resolves spontaneously. She is prescribed carbamazepine, and her symptoms improve. What is her most likely diagnosis? A. Craniopharyngioma recurrence B. Myasthenia gravis C. Ocular neuromyotonia D. Seizures A man presents to clinic with results from an electromyographic (EMG) study showing fibrillations and reduced motor unit potentials in his gluteus medius and extensor digitorum longus. He has no abnormal EMG findings in his biceps femoris (short head). Weakness of foot eversion and numbness on the dorsum of the foot are noted on his exam. What nerve(s) is/are being affected? A. L4 nerve root only B. L5 nerve root only C. S1 nerve root only D. Common peroneal nerve proximal to the fibular head only E. L5 nerve root and common peroneal nerve at the fibular head A malignant peripheral nerve sheath tumor is discovered in a patient’s left upper extremity. Where should screening first be focused to detect distant metastases? A. Brain B. Other extremities C. Axial skeleton D. Lungs E. Lymph nodes What type of spinal arteriovenous malformation typically is associated with low blood flow? A. Dural B. Juvenile C. Extramedullary/intradural D. Glomus Multiple sclerosis is a contraindication to what procedural treatment for trigeminal neuralgia? A. Microvascular decompression B. Percutaneous radiofrequency rhizotomy C. Percutaneous glycerol injection into the Meckel cave D. Percutaneous balloon microcompression E. Stereotactic radiosurgery What is the major complication of a stereotactic mesencephalotomy for medically intractable right upper extremity pain? A. Ipsilateral weakness B. Anesthesia dolorosa C. Memory deficits D. Diplopia E. Hypothalamic dysfunction A patient undergoing a craniotomy for resection of a vestibular schwannoma has a reasonable chance of losing serviceable hearing following surgery if the preoperative speech discrimination is below what percentage? A. 50% B. 65% C. 75% D. 85% E. 95% A woman with a known pituitary macroadenoma presents to the emergency room with a sudden, intense headache and a new-onset ophthalmoplegia with her chronic visual field cuts. She endorses photophobia. After imaging confirms the most likely diagnosis, what is the next step in her management? A. Sumatriptan administration B. Follow-up with repeat imaging in 6 weeks C. Repeat pituitary lab work as an outpatient D. Observation E. Preparation for transsphenoidal decompression immediately A woman is referred to you for treatment of a cerebellopontine angle tumor. She has obvious weakness of the right side of her face. She does have some motion but has no motor contraction over her forehead, she cannot close her eye completely, and she has noticeable asymmetry of her mouth when attempting to smile. What is her House-Brackmann classification grade? A. 2 B. 3 C. 4 D. 5 E. 6 What form of nicotine potentially will not decrease spinal fusion rates? A. Cigarette smoking B. Chewing tobacco C. Nicotine gum D. Nicotine patches E. No form of nicotine avoids the risk of decreased spinal fusion rates. What is the recommended torque used on a halo pin on an adult skull? A. 4 in-lbs B. 8 in-lbs C. 12 in-lbs D. 20 in-lbs E. 30 in-lbs Injury to the subthalamic nucleus during a functional lesioning procedure classically produces what type of movement disorder? A. Myoclonus B. Hemiballism C. Pill-rolling tremor D. Fixed posture of limbs E. Chorea Deep brain stimulation in the setting of Parkinson disease is expected to result in brief minimal improvement to what characteristic of the disease? A. Dyskinesia B. Balance C. Tremors D. Rigidity E. Cognitive impairment What electromyography/nerve conduction study finding supports a diagnosis of lumbar radiculopathy from a herniated disk? A. Paraspinal muscle fibrillations B. Abnormal sensory nerve action potentials (SNAPs) C. Increased motor fiber recruitment with volitional activity D. Absence of spontaneous sensory nerve activity A patient presents with a blunt cerebrovascular injury after a motor vehicle collision. The patient has no intracranial hemorrhage. CT angiogram reveals an internal carotid artery luminal irregularity with < 25% stenosis. What is the next step in the management of this patient? A. No acute intervention; repeat imaging in 4 to 6 weeks. B. Initiate a heparin drip if there are no contraindications. C. Perform endovascular stenting. D. Perform a ligation/occlusion of carotid artery. E. Initiate antiplatelet therapy if there are no contraindications. Halo bracing is least effective for what type of cervical fractures? A. Odontoid fractures B. Levine type 2 pars fractures C. Midcervical spine fractures D. C1 fractures with a type 3 odontoid fracture E. Teardrop fractures What artery often is associated with hemifacial spasm? A. Posterior inferior cerebellar artery B. Anterior inferior cerebellar artery C. Superior cerebellar artery D. Posterior cerebellar artery E. Vertebral artery For nonemergent neurosurgical procedures, it is recommended that a patient’s INR be less than or equal to what value? A. 1.0 B. 1.2 C. 1.4 D. 1.6 With pituitary tumors, what optic chiasm position is most associated with optic nerve compression? A. Prefixed chiasm B. Postfixed chiasm C. Chiasm superior to the sella turcica D. Neutral position chiasm Over 95% of vestibular schwannomas present with progressive unilateral or asymmetric sensorineural, high-frequency hearing loss. In general, what is considered the definition of serviceable hearing? A. Pure tone audiogram of 40 dB or less; speech discrimination score of at least 40% B. Pure tone audiogram of 60 dB or less; speech discrimination score of at least 60% C. Pure tone audiogram of 60 dB or less; speech discrimination score of at least 40% D. Pure tone audiogram of 40 dB or less; speech discrimination score of at least 60% E. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class C or D A 50-year-old woman presents with an acute onset of severe headache, bitemporal hemianopsia, and cranial nerve III palsy. She is alert and conversant. What is the most appropriate next step in this patient’s management? A. Rapid administration of corticosteroids B. Cerebral angiography C. Administration of nimodipine D. Obtaining an erythrocyte sedimentation rate, C-reactive protein concentration, and blood cultures E. Intracranial pressure monitoring A 19-year-old man presents following a motor vehicle collision complaining of lower extremity weakness. He is found to have a thoracic spine Chance fracture. He has full strength in his upper extremities. He has sensation in his lower extremities and perineum, and his motor strength in his lower extremities ranges from 4-/5 to 4/5. What is his American Spinal Injury Association (ASIA) impairment scale score? A. A B. B C. C D. D E. E What incomplete spinal cord injury syndrome is associated with a poor prognosis for recovery and dissociated sensory loss? A. Central cord syndrome B. Anterior cord syndrome C. Brown-Séquard syndrome D. Posterior cord syndrome E. Cauda equina syndrome When placing a C2 pedicle screw, what is the trajectory of the screw? A. Superior and medial B. Superior and lateral C. Inferior and medial D. Inferior and lateral E. Parallel to the spinous process What is a relative contraindication for the placement of an anterior odontoid screw that may make surgery technically very difficult? A. Type 2 odontoid fracture B. Combined 5-mm overhang of the lateral masses of C1 on C2 C. Acute fracture D. Reducible fracture E. Barrel chest A patient presents in the emergency room with a cervical spine fracture and the following radiographic findings: a triangular bone fragment fractured off the anterior inferior vertebral body, retrolisthesis of the caudal vertebrae, and disruption of the facet joints and the disk space. What type of fracture is suspected? A. Avulsion fracture B. Clay-shoveler fracture C. Jefferson fracture D. Teardrop fracture E. Locked facets A patient presents after a significant fall from a ladder with an L2 burst fracture that has a 70% loss of height, 50% canal stenosis due to retropulsion, and 15 degrees of angulation. How would you reduce this fracture with ligamentotaxis? A. Removing ligaments such as the ligamentum flavum that would allow for easier manipulation of the fracture B. Distracting pedicle screws to reduce indirectly the retropulsed segment by putting tension on the posterior longitudinal ligament C. Compressing pedicle screws to reduce the retropulsed fragment by releasing tension on the posterior longitudinal ligament D. Placing a strut or cage to reduce the loss of height of the vertebral body E. Positioning the patient to utilize the anterior longitudinal ligament to reduce the kyphotic angulation associated with the fracture In what zone is a sacral fracture that occurs in the region of the sacral foramina? A. Zone 1 B. Zone 2 C. Zone 3 (vertical) D. Zone 4 (transverse) E. Zone 5 Fisher grade 3 is differentiated from Fisher grade 2 for aneurysmal subarachnoid hemorrhage by what characteristic? A. Greater than 1 mm of blood B. Presence of hydrocephalus C. Intracerebral or intraventricular clot D. Presence of vasospasm E. Greater than 1 cm of blood A 37-year-old man presents with a sudden onset of the “worst headache of my life.” The CT shows intraventricular hemorrhage that you suspect resulted from hemorrhage entering through the lamina terminalis. You are suspicious of an aneurysm at what location? A. Middle cerebral artery bifurcation B. Posterior communicating artery C. Internal carotid artery terminus D. Anterior communicating artery E. Basilar artery tip A patient presents with subacute bacterial endocarditis. Evaluation and workup includes a CT angiogram followed by a cerebral angiogram that demonstrates two small aneurysms on distal left middle cerebral artery branches. What treatment modality is indicated? A. Endovascular coiling B. Surgical clipping C. Antibiotics and serial imaging D. Observation Following the standard of care, what role does brachytherapy play as an adjunctive treatment for high-grade gliomas? A. Brachytherapy is a viable alternative to whole brain radiation. B. Brachytherapy is superior to stereotactic radiosurgery. C. Brachytherapy has no role as an adjuvant to whole brain radiation. D. Brachytherapy can be useful in addition to whole brain radiation. E. Brachytherapy can substitute for whole brain radiation. Following resection of a low-grade oligodendroglioma, what is the next step in adjuvant therapy? A. Intravenous chemotherapy B. Focused radiation C. Whole brain radiation D. Intrathecal chemotherapy What is the complication rate for shunting a patient with normal pressure hydrocephalus? A. 5 to 10% B. 10 to 25% C. 25 to 40% D. 40 to 55% A woman is referred to your office for symptoms consistent with carpal tunnel syndrome. She has had a nerve conduction study showing that the proximal median nerve latency is shorter than the distal median nerve latency. What is the explanation for this finding? A. Poor quality/erroneous nerve conduction study B. Lesion of the proximal median nerve C. Presence of a Martin-Gruber anastomosis D. Marinacci syndrome E. Diabetic neuropathy A 17-year-old boy is brought to the emergency room following a motor vehicle collision with multiple fatalities. He is alert, awake, and oriented. He denies neck pain, has no midline tenderness, and does not have any other injuries. The neurologic exam is unremarkable. He has not used alcohol or drugs. What is the minimum radiographic study needed to clear the cervical spine? A. Radiographs are not indicated B. Upright lateral and AP X-rays C. Flexion-extension X-rays D. Lateral and AP X-rays with CT imaging of areas that are suspicious or not easily seen on plain films E. Thin-cut axial CT scan from the occiput to T1 with sagittal and coronal reconstructions A 63-year-old diabetic man with a remote history of vertebral osteomyelitis presents to the hospital with low back pain and pain down the anterior part of the thigh for the past 3 weeks. Neurologic exam is unremarkable. MRI suggests a psoas and epidural abscess without severe compression. What is the next appropriate step in this patient’s management? A. Discharge home on oral antibiotics with follow-up with an infectious disease specialist. B. Admit to the floor, place on antibiotics, and consult interventional radiology for culture and biopsy of the epidural abscess. C. Consult interventional radiology for culture and biopsy of the epidural space prior to starting antibiotics. D. Admit to the floor, obtain blood cultures, and consult interventional radiology for biopsy of the psoas abscess prior to administering antibiotics (if the biopsy can be done in a timely manner). E. Perform a decompressive laminectomy with evacuation of the abscess. An 82-year-old woman presents to the neurosurgery clinic with typical trigeminal neuralgia. She has substantial medical comorbidities and would like to avoid surgery. The patient opts for stereotactic radiosurgery. What factor would predict a favorable outcome? A. Absence of atypical pain B. Using a radiation dose less than 60 Gy C. Prior successful surgical microvascular decompression D. Decreased sensation in the affected nerve prior to treatment E. Trigeminal neuralgia related to multiple sclerosis What is the most effective surgical option for the treatment of glossopharyngeal neuralgia in the absence of vascular compression? A. Cranial nerve IX rhizotomy alone B. Cranial nerve X rhizotomy alone C. Cranial nerve IX rhizotomy with sectioning the upper one third of cranial nerve X D. Extracranial nerve ablation of cranial nerve IX E. Cranial nerve XI rhizotomy alone A teenager suffering from a defect in his L5 pars interarticularis as a result of an insufficiency fracture of the pars can be characterized as having what type of spondylolisthesis? A. Dysplastic B. Isthmic C. Degenerative D. Traumatic E. Pathological You perform a stereotactic-guided biopsy of a thalamic lesion. You notice bleeding from the cannula. What is the next step? A. Perform an emergent craniotomy and exploration. B. Immediately abort the procedure, and obtain a CT. C. Abort the procedure, wake the patient, and obtain a neurologic exam. D. Elevate the head of the bed, decrease the blood pressure, and irrigate the cannula. E. Insert a Fogarty catheter into the cannula, inflate the balloon, and obtain a CT. What is the most common location of mycotic aneurysms? A. Distal middle cerebral artery branches B. Proximal anterior cerebral artery C. Distal anterior cerebral artery D. Basilar tip E. Posterior inferior cerebellar artery A 35-year-old woman presents with spontaneous neck pain. A noncontrast head CT demonstrates subarachnoid hemorrhage, and an angiogram reveals a lesion suspicious for an intradural vertebral artery dissection. What is the appropriate treatment for this finding? A. Observation if asymptomatic B. Immediate heparinization followed by oral anticoagulation C. Immediate surgery or endovascular treatment D. Delayed surgery to allow for swelling resolution E. Nonoperative treatment followed by a delayed angiogram in 5 to 7 days to assess healing A 32-year-old man presents with slurred speech and a hypoglossal palsy. He reported that he was involved in a motor vehicle collision 3 weeks prior for which he did not pursue medical evaluation. He reports that he has had neck pain since the accident. What is the suspected diagnosis? A. Atlanto-occipital dislocation B. Vertebral artery dissection with stroke C. Odontoid fracture D. Clival fracture E. Condyle fracture A 43-year-old woman presents to the neurosurgery clinic complaining of hand clumsiness. A neurologic exam reveals wasting and weakness of the abductor pollicis brevis and hand intrinsics. There is sensory loss over the medial forearm, but sensation in the hand is normal. According to the above findings, what is the next appropriate test for diagnosis? A. MRI of the brain B. Cerebrospinal fluid studies C. Chest radiograph D. MRI of the cervical spine E. Cervical spine radiographs with oblique and apical lordotic views What tumor often arises from the ‘roof’ of the fourth ventricle? A. Ependymoma B. Juvenile pilocytic astrocytoma C. Brainstem glioma D. Choroid plexus papilloma E. Medulloblastoma A 38-year-old man presents with seizures, and workup reveals an arteriovenous malformation that is 6.4 cm in size, involves the posterior frontoparietal and occipital lobes, and drains into the galenic system. What is the preferred treatment option for this lesion? A. Embolization alone B. Stereotactic radiosurgery alone C. Surgical resection D. Observation E. Embolization and stereotactic radiosurgery After elective clipping of an unruptured anterior communicating artery aneurysm, the patient wakes up with dysarthria and contralateral paresis of his face and arm. What vessel likely is incorporated into the aneurysm clip? A. Anterior choroidal artery B. Recurrent artery of Heubner C. Middle cerebral artery D. Distal anterior cerebral artery The most common primary, intra-axial posterior fossa tumor in adults is associated with what condition? A. Smoking B. Tumor suppressor gene inactivation on chromosome 9q34 C. Tumor suppressor gene inactivation on chromosome 7q21 D. Tumor suppressor gene inactivation on chromosome 3p25 A 21-year-old man presents with a brachial plexus avulsion type injury. What is the recommended treatment option? A. Periodic electromyography/nerve conduction studies starting 3 to 12 weeks following the injury with consideration of surgical neurotization at 3 to 6 months if there is no improvement B. Periodic electromyography/nerve conduction studies starting 3 to 12 weeks following the injury with consideration of surgical neurolysis at 3 to 6 months if there is no improvement C. Periodic electromyography/nerve conduction studies starting 3 to 12 weeks following the injury with consideration of a spinal cord stimulator if pain remains after 3 to 6 months D. Exploration and surgical repair within 3 days E. Exploration at 2 to 3 weeks What type of basal skull fracture is associated with an increased risk of mortality? A. Longitudinal temporal bone fracture B. Transverse temporal bone fracture C. Fracture through the planum sphenoidale D. Clival fracture During decompression of an ulnar nerve, the surgeon wishes to ensure that the nerve is decompressed distally. The ulnar nerve can be found entering the forearm in relation to what structure? A. Deep to the pronator teres B. Deep to the flexor carpi radialis C. Deep to the flexor digitorum profundus D. Lateral to the ulnar artery E. Between the two heads of the flexor carpi ulnaris During a carotid endarterectomy, what is the correct order of vessel occlusion? A. External, common, and then internal carotid artery B. Internal, common, and then external carotid artery C. Common, internal, and then external carotid artery D. Internal, external, and then common carotid artery E. External, internal, and then common carotid artery A 63-year-old woman presents with ruptured anterior communicating artery aneurysm and an intracranial hemorrhage in the gyrus rectus. What is her Fisher grade? A. 0 B. 1 C. 2 D. 3 E. 4 What approach characterizes a far lateral craniotomy? A. Suboccipital craniotomy including opening of the foramen magnum and drilling of the occipital condyle B. Suboccipital craniotomy with exposure of the transverse and sigmoid sinus C. Suboccipital craniotomy with pre- and post- sigmoid exposure D. Subtemporal craniotomy with removal of the petrous apex E. Retrosigmoid craniotomy with removal of the lamina of C1 and C2 What characteristics (location and size) of a cerebral abscess are a surgical indication? A. Subcortical location; 2.5 cm in diameter B. Brainstem location; 1.0 cm in diameter C. Small lesion in the early cerebritis stage; 0.5 cm in diameter D. Periventricular location; 2.0 cm in diameter A patient presents with subarachnoid hemorrhage due to a ruptured aneurysm. What is the approximate risk of rerupture over the next 14 days if the aneurysm is not treated? A. 1 to 2% B. 5 to 10% C. 15 to 20% D. 50% E. 75% What is the most definitive treatment for atonic seizures? A. Ethosuximide B. Adrenocorticotropic hormone C. Multiple subpial transections D. Hemispherectomy E. Corpus callosotomy What is the most effective thalamic target during deep brain stimulation to control tremor associated with Parkinson disease? A. Medial nucleus B. Ventralis intermedius nucleus C. Nucleus accumbens D. Anterior nucleus E. Pedunculopontine nucleus How is the C7 plumb line measured? A. Originates at the posterior vertebral body of C7 and is measured from the anterior vertebral body of S1 B. Originates at the mid-vertebral body of C7 and is measured from the mid-vertebral body of S1 C. Originates at the mid-vertebral body of C7 and is measured from the posterior superior corner of S1 D. Originates at the anterior vertebral body of C7 and is measured from the mid-vertebral body of S1 E. Originates at the anterior vertebral body of C7 and is measured from the anterior vertebral body of S1 A patient with L4/L5 degenerative spondylolisthesis presents with radiculopathy. The L4 vertebral body is approximately 60% anterolisthesed. What grade is this spondylolisthesis according to the Meyerding grading scale? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4 E. Grade 5 A middle-aged woman presents to the emergency room with complaints of a sudden onset of the “worst headache of my life.” She complains of photophobia and nuchal rigidity. The head CT was negative for subarachnoid hemorrhage, and the CT angiogram did not reveal an aneurysm. What would be the most reasonable next step in this patient’s management? A. Discharge the patient home with pain medications. B. Admit the patient with aneurysm precautions, and repeat the CT angiogram in 5 to 7 days. C. Obtain a lumbar puncture. D. Repeat the head CT in 4 to 6 hours. E. Obtain a brain MRI. This diagram attempts to define which parameter?
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