1.D. (For questions 1–9 figure used with permission of Dr. Al Rhoton.)

2.I.

3.F.

4.B.

5.A.

6.G.

7.H.

8.C.

9.E.

10.E. GTT pp. 3236–3237. Myotomy was the earliest surgical procedure used to treat spasmodic torticollis. About 70% of patients improve after microvascular decompression of the spinal accessory nerve, and 81 to 97% of patients improve after upper cervical ventral rhizotomies and spinal accessory denervation procedures. Roughly two thirds of patients undergoing stereotactic thalamotomy obtain a satisfactory result.

11.C. Y p. 4497. The risk of either neurologic deterioration or no benefit with laminectomies for thoracic disk herniation is 45%.

12.A. V&A p. 718. The initial symptoms in most patients with brainstem gliomas are cranial nerve palsies followed by weakness or ataxia. Headache, vomiting, and papilledema usually occur later in the course of the illness.

13.B. Y pp. 3094, 3820–3821. Hyperesthesia, not hypesthesia, occurs in causalgia (complex regional pain syndrome [CRPS] type II). CRPS II differs from CRPS I reflex sympathetic dystrophy (RSD) in that the former is diagnosed with a known nerve injury.

15.B. comprise 0.3% of brain tumors and usually present in the pediatric popu-

16.A. lation. They occur when cell rests with dermal and epidermal components

17.A. are included within neural ectoderm in the midline during neurulation.

18.D. Communication of the cyst with the exterior via a sinus tract predisposes the patient to bacterial meningitis. Congenital malformations may be associated. Intracranial epidermoid cysts comprise 0.5 to 1.8% of brain tumors and usually present in the adult. These result from epidermal cell rests and are most often located eccentrically (e.g., the cerebellopontine angle). Spillage of the cyst contents can lead to aseptic meningitis.

19.E. GTT pp. 842–843.

20.A. Apuzzo p. 1753, Fig. 61–1. The translabyrinthine approach would sacrifice hearing. Small (<1 cm) acoustic neuromas are intracanalicular and can easily be approached via the middle fossa.

21.C. V&A pp. 338, 481.

22.C. (Questions 22–25 from the microsurgical anatomy course; with permission of

23.B. Dr. Al Rhoton.)

24.D.

25.A.

26.B. HndbkNS p. 521. The adductor pollicis is innervated by the ulnar nerve.

27.D. PNS pp. 242–244. The germinal matrix is the site of IVH in the preterm infant. This region begins to involute at 43 weeks. The most common site of IVH in the full-term neonate is the choroid plexus.

28.E. PNS pp. 45–46, Fig. 2–10. The secondary center is apical, and the primary centers lie inferiorly on either side of midline.

29.D. PNS p. 115. Isolated sagittal synostosis accounts for 50% of craniosynostosis patients in some series.

30.E. Y p. 3891. Eighty-five to 90% of patients with carpal tunnel syndrome manifest abnormalities of the nerve conduction velocities. The palmar sensory conduction time is the most sensitive electrical test.

31.A. Nelson p. 148. Contrecoup contusions, produced by rotational force, occur where the frontal and temporal lobes rub along bony prominences. Coup contusions (the least common type) are located over the convex and lateral cerebral surfaces.

32.E. For questions 32–36 see GTT pp. 2019, 2036, 2040, 2047, 2061. The close proxi-

33.C. mity of an anterior communicating artery aneurysm to the hypothalamus

34.A. can lead to endocrine abnormalities, including diabetes insipidus. A ruptured

36.B. hallmarks of which is exophthalmos. Compression of the medial temporal lobe by a middle cerebral artery aneurysm may result in seizures. Ophthalmic artery aneurysms usually initially present with an inferior nasal field cut because of pressure on the optic nerve from the overlying falciform ligament (the dural fold between the anterior clinoids). A pupil-involving third nerve palsy is extremely suggestive of a posterior communicating artery aneurysm.

37.A. Nelson p. 35.

38.F. (For questions 38–45 figure used with permission of Dr. Al Rhoton.)

39.G.

40.H.

41.C.

42.A.

43.D.

44.B.

45.E.

46.A. Rothman pp. 263–264. In a basilar impression, in contrast to the Chiari’s malformation, motor and sensory symptoms are more frequent than cerebellar and vertebral symptoms.

47.D. Rothman pp. 1013, 1015–1016. Type II odontoid fractures have a poor prognosis for healing. Type I and III fractures generally heal well with immobilization. The burst fracture of C1 (Jefferson’s fracture) usually heals by rigid immobilization unless the transverse ligament is disrupted (lateral masses displaced more than 7 mm) or the patient is elderly.

48.A. Frymoyer p. 1215. Sprengel’s deformity is often associated with the Klippel-Feil syndrome (congenital fusion of the upper cervical vertebrae).

49.D. For questions 49–55 see Frymoyer p. 1086.

50.C.

51.E.

52.B.

53.A.

54.F.

55.C.

56.E. Rothman pp. 831–832.

57.E. GTT pp. 3085, 3087.

58.E. GTT p. 744. An understanding of this association is facilitated by the recognition that the pineal gland is a photoreceptor organ.

59.B. GTT p. 2114. Evidence of vasospasm implies the potential for inadequate collateral flow. Responses A and C are relative contraindications.

61.A. (For questions 61–70 figure used with permission of Dr. Al Rhoton.)

62.D.

63.H.

64.D.

65.A.

66.E.

67.B.

68.F.

69.G.

70.H.

71.B. Apuzzo p. 962. Patients with posterior communicating artery aneurysms who present without third nerve palsies or whose angiogram reveals the aneurysm projecting lateral to the carotid are more likely to have aneurysmal domes that are adherent to the temporal lobe.

72.A. HndbkNS p. 521.

73.A. Mer 106. Streptococcus pneumoniae meningitis also leads to subdural empyemas.

74.D. GTT p. 2828. The manifestations of Sudeck’s atrophy are late changes of causalgia.

75.E. For questions 75–79 see PNS pp. 7–10.

76.D.

77.B.

78.A.

79.C.

80.B. Y p. 1694. The subclavian steal syndrome is associated with symptoms of vertebrobasilar insufficiency. It occurs when increased activity of the left arm results in shunting of blood into the left subclavian that is occluded before the origin of the vertebral. The blood flow in the vertebral artery is reversed, resulting in partial brainstem ischemia.

81.B. Y p. 4953. The coronal orientation of the facets in the upper thoracic spine leads to significant resistance to anterior translation but little resistance to rotation. In the lower thoracic spine, the facets become more sagittally oriented, and less resistance to anterior translation is offered.

82.A. Y p. 4491. Back pain is the presenting complaint of 57 to 88% of patients with a thoracic herniated disk.

83.A. Apuzzo p. 548. Seizures have not been reported after the ligation of the thalamostriate vein during this approach.

85.C.

86.D.

87.A.

88.B.

89.B. Y4 p. 2847. In the series of Sugita and Kobayashi, the facial nerve was anterior to the tumor in 50%, superior in 30%, and inferior in 15% of cases.

90.E. HndbkNS pp. 477–478, Mer pp. 587–589. The most frequent skin lesion seen in type 2 neurofibromatosis is a well-circumscribed, raised, rough area of skin that is sometimes associated with excess hair.

91.D. Y p. 1109.

92.B. For questions 92–98 see Yas pp. 97–100.

93.D.

94.A.

95.A.

96.B.

97.C.

98.D.

99.B. GTT p. 190.

100.B. HndbkNS pp. 358–360. Hemifacial spasm is more common in females; it typically begins in the orbicularis muscles and progresses caudally. At microvascular decompression the most common finding is compression by the posteroinferior cerebellar artery (PICA); the cure rate at 1 month is 86%. Deafness occurs in 2.7% of patients, and permanent facial weakness occurs in 1.5% of patients after microvascular decompression.

101.E. Y pp. 2015–2018; Apuzzo p. 1887. The subtemporal approach is best suited for aneurysms of the upper basilar trunk arising within 2 cm below the tip of the posterior clinoid.

102.A. Y p. 3688. Headache is the initial symptom in more than 75% of patients with colloid cysts, and almost all patients with this lesion experience headache. “Drop attacks,” possibly secondary to acute hydrocephalus that suddenly stretches corticospinal leg fibers, are asssociated with colloid cysts. Dementia may be prominent, and seizures occur in about 20% of patients. An association with sudden death has been reported.

103.C. (For questions 103–106 figure used with permission of Dr. Al Rhoton.)

104.D.

105.A.

106.B.

108.B. Y pp. 4961–4962. This type of fracture is generally stable because the middle column is intact, by definition (utilizing the three-column spine model). Posterior column failure can still occur, however, if the anterior body height is reduced by more than half. The resulting kyphotic deformity can lead to neurologic deficit.

109.B. Y pp. 4992–4993.

110.B. PNS p. 271. This is a vasoactive posttraumatic phenomenon occurring within hours of head injury. It is distinct from the vasogenic or cytotoxic edema that occurs later.

111.C. PNS pp. 284, 273; Nelson p. 478. When associated with abuse, skull fractures tend to be multiple or complex, depressed, and nonparietal.

112.E. PNS p. 132. The incidence of trigonocephaly ranges from 10 to 16%.

113.B. Y p. 3270. The cleft is located in the lumbar region in 47%, thoracolumbar region in 27%, thoracic region in 23%, and sacral or cervical region in 1.5% of cases.

114.E. Y p. 2101.

115.A. Y pp. 2101–2106. The observation that vasa vasorum are found only on the first segment of the internal carotid artery (ICA), an unusual site of the development of bacterial aneurysms, has discredited this theory. Although these aneurysms have a high tendency to bleed, typical subarachnoid hemorrhage occurs in less than 20% of patients.

116.E. PNS p. 297. Up to 75% of patients with growing skull fractures are <1 year old.

117.E. Y p. 3349.

118.A. V&A 255. Cholesterol emboli (Hollenhorst plaques) are associated with ulcerated atheromatous plaques of the ICA. Calcific emboli originate from the cardiac valves. Platelet fibrin emboli are thought to arise from large-vessel mural thrombi. Fat emboli result after trauma to marrow-containing bones.

119.B. Apuzzo pp. 469–470.

120.B. V&A p. 307. An absence of loudness recruitment is characteristic of a nerve trunk lesion, including an acoustic neuroma. Recruiting deafness occurs with a lesion in the organ of Corti (e.g., Meniere’s disease). The other responses are characteristic of a retrocochlear (nerve) lesion.

122.A.

123.F.

124.E.

125.C.

126.G.

127.H.

128.D.

129.A. Y p. 3063.

130.A. V&A p. 837. Cognitive function is unimpaired after occlusion of the anterior choroidal artery.

131.E. Y pp. 2775–2776.

132.D. For questions 132–136 see Y p. 3318; PNS p. 126. Both Apert’s syndrome and

133.C. Crouzon’s disease are autosomal dominant conditions. Exorbitism and mid-

134.A. face deficiency are seen in both. Anterior open bite and syndactyly are chara-

135.B. cteristic of Apert’s syndrome. Although developmental delay is uncommon

136.A. in patients with Crouzon’s disease, mental retardation is seen in 50 to 85% of patients with Apert’s syndrome.

137.A. For questions 137–138 see GTT pp. 1191–1192. Primary empty sella

138.C. syndrome is an intrasellar herniation of the subarachnoid space occurring without previous pituitary surgery or radiation therapy. It typically occurs in middle-aged, obese women. Visual disturbance may occur in both the primary and secondary forms of the syndrome.

139.E. PNS p. 151.

140.D. Y pp. 3541–3542.

141.C. GTT pp. 1972–1974. Studies indicate that intimal proliferation is too mild and occurs too long after subarachnoid hemorrhage to play a significant role in vasospasm.

142.D. (For questions 142–148 figure used with permission of Dr. Al Rhoton.)

143.E.

144.G.

145.F.

146.B.

147.C.

148.A.

149.A. For questions 149–155 see GTT pp. 2273–2276. Type I (dural) spinal arteri-

150.A. ovenous malformations (AVMs) are the most common type of spinal AVM,

152.B. They typically present with a slowly progressive course without significant

153.A. clinical improvement. The etiology of types II, III, and IV spinal AVMs is

154.E. believed to be congenital. Type II (glomus) AVMs are intramedullary. Type III

155.A. (juvenile) AVMs are predominantly intradural. They are both true AVMs with rapid blood flow and are at risk for subarachnoid or intramedullary hemorrhage. Type IV AVMs vary in size and in rapidity of blood flow. They are intradural, extramedullary, or perimedullary.

156.C. GTT p. 1836. This sequence ensures that any embolic material will be flushed into the external carotid circulation.

157.C. For questions 157–163 see Apuzzo Fig. 15-7B, p. 346.

158.B.

159.D.

160.A.

161.G.

162.E.

163.F.

164.E. (For questions 164–168 figure used with permission of Dr. Al Rhoton.)

165.A.

166.D.

167.C.

168.B.

169.D. For questions 169–174 see GTT Fig. 134.5, p. 2041.

170.E.

171.F.

172.A.

173.B.

174.C.

175.B. GTT p. 2215. The risk of hemorrhage of dural AVMs seems related to the presence of tortuous and aneurysmal leptomeningeal arterialized veins.

176.E. For questions 176–177 see GTT p. 1157; CNBR Fig. 3–114-A. A prolactin level

177.A. of 89 probably represents the “stalk effect” from this large pituitary tumor with suprasellar extension. A preoperative ophthalmologic examination should be documented, and surgery probably should be performed because chiasmal compression is evident. A prolactin level of 650 suggests a prolactinoma that should be bromocriptine responsive.

178.A. GTT p. 692. Lateral ventricular meningiomas account for 1 to 2% of intracranial meningiomas.

180.E. GTT p. 3048. Paresthesias occur in 20% of postoperative patients; dysesthesias in 5.2 to 24.2%.

181.C. GTT pp. 3045–3047.

182.H. (For questions 182–189 figure used with permission of Dr. Al Rhoton.)

183.D.

184.E.

185.A.

186.C.

187.B.

188.G.

189.F.

190.B. For questions 190–195 see GTT pp. 3124, 3126, 3232, 3237. Cingulotomy proc-

191.E. edures are used in the treatment of obsessive-compulsive disorder. For

192.A. patients with nociceptive cancer pain above C5, morphine infusion and

193.C. periventricular gray matter stimulation are options. If chronic stimulation

194.D. fails in brachial plexus avulsion pain, a dorsal root entry zone (DREZ) proce-

195.F. dure should be considered. The pallidotomy is very effective in Parkinson’s disease, whereas causalgia responds to sympathectomy. Good results are obtained when spasmodic torticollis is treated with ventral rhizotomy combined with spinal accessory denervation procedures.

196.E. GTT pp. 2910–2913. These options have all been used with varying degrees of success. Intercostal nerves are most commonly used for neurotization procedures involving the upper extremity.

197.A. Moore pp. 836, 838.

198.C. GTT p. 726.

199.B. GTT p. 673.

200.E. GTT pp. 342–343. Patients with cerebral salt wasting are volume depleted, whereas those with syndrome of inappropriate antidiuretic hormone (SIADH) are euvolemic or volume expanded.