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19-Surgical-Specialties-Neurosergery-19Qs.pdf
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MyPasTest: MRCS A Online - Jan Exam 201519. Surgical Specialties- Neurosergery (19Qs)
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01. Theme: Management options in a patient with head injury-
A Admit for neuro-observations
B Craniotomy
C Computed tomography (CT) scan
D Discharge
E Discharge and head injury instructions
F Elective burr hole Page |
G Emergency burr hole
H Emergency laparotomy 1258
I Endotracheal intubation
J Intracranial pressure monitoring
K Mannitol
L Mannitol and transfer to Neurosurgical Unit
M Skull X-ray.
The following patients have all sustained head injuries. From the list above, select the most
appropriate plan of management. The items may be used once, more than once, or not at all.
Scenario 1
A 70-year-old woman attends The Emergency Department having fallen at home. She is unclear of the events
surrounding the fall, and as she lives alone, no collateral history is available. She has vomited three times
since arrival in the department. Her Glasgow Coma Scale (GCS) is currently 15. All other observations are
normal. There is no evidence of focal neurological deficit.
A - Admit for neuro-observations « YOUR ANSWER
C - Computed tomography (CT) scan« CORRECT ANSWER
Despite the apparently trivial mechanism of injury and the normal Glasgow Coma Scale (GCS), this
lady has two clinical features that indicate risk of a clinically significant brain injury (age > 64 years
and more than one episode of vomiting). The Canadian Head CT Rule was derived from a cohort of
more than 3000 patients using multivariate analysis of several risk factors, and has identified the
following clinical features that indicate that there is a clinically significant brain injury requiring
neurosurgical intervention:
1. GCS < 13 at any point since injury
2. GCS 13 or 14 with failure to regain GCS 15 within 2 h
3. suspected open or depressed skull fracture
4. any sign of basal skull fracture (Battle’s sign, haemotympanum etc)
5. more than one episode of vomiting
6. age > 64 years
7. post-traumatic seizure
8. coagulopathy (including anti-coagulant therapy)
9. focal neurological deficit.
CT scan should be performed within 1 h in all such patients. Two further features in the absence of the
above indicate a risk of clinically significant brain injury that does not require neurosurgical
intervention: retrograde amnesia of > 30 min and dangerous mechanism of injury (pedestrian hit by
vehicle, fall from a height etc). CT scan in such patients may be delayed for up to 8 h.
Scenario 2
A 24-year-old gentleman presents to The Emergency Department with a history of head injury while playing
rugby. He was involved with a ‘clash of heads’ with another player during a ‘ruck’. He remembers the events
surrounding the event well, and has no amnesia. Collateral history from his friends confirms that there was no
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
19. Surgical Specialties- Neurosergery (19Qs)
--------------------------------------------------------------------------------------------------------------------------------------------------
loss of consciousness. On examination he is fully orientated, GCS is 15 and all other observations are normal.
There is no evidence of focal neurological deficit.
B - Craniotomy « YOUR ANSWER
E - Discharge and head injury instructions« CORRECT ANSWER
Patients with trivial head injury, and who are fully orientated, have no history of loss of consciousness
or amnesia, nor any other clinical risk factors, as described above, have a negligible risk of a clinically Page |
important brain injury and do not require imaging. The risk of complications requiring hospital care is
low enough to warrant discharge to the care of a responsible adult with head injury instructions. All 1259
patients with a head injury must receive such instructions before discharge. Similarly, patients with a
normal CT scan and no other social or clinical risk factors may be discharged with head injury
instructions.
Scenario 3
A 38-year-old gentleman has been involved in a road traffic accident and brought to The Emergency
Department as a ‘trauma call’. The ambulance staff inform you that he was a pedestrian hit by a car travelling
at approximately 40 mph. He has sustained a significant head injury but the paramedic crew report that he
was alert at the scene and that his pupils were equal and reactive. Having completed the primary survey, your
examination reveals a GCS of 8, and a fixed dilated left pupil. There is no evidence of hemiparesis. No other
significant injuries are apparent, and the patient is stable, and has a pulse rate of 50/min and a blood pressure
of 160/80 mmHg. You request an urgent CT scan, but are informed that this will not be possible in your unit as
the scanner is undergoing repair.
C - Computed tomography (CT) scan« YOUR ANSWER
I - Endotracheal intubation« CORRECT ANSWER
This patient has several risk factors for significant brain injury requiring urgent neurosurgical
intervention. Clearly, he requires a CT scan, but this is currently unavailable in the receiving Unit. A
skull X-ray is unlikely to provide sufficient information relating to the degree of brain injury sustained,
and therefore this patient should be transferred to a Neurosurgical Unit where clinical and radiological
assessment may be performed. In addition, there is a clear indication to administer an intravenous
bolus of mannitol (1 g /kg) in this case, because there is a history of deterioration in consciousness
level and pupil changes, secondary to rising intracranial pressure.
The creation of an emergency burr hole performed by a general surgeon is not generally
recommended or supported, and can only be justified in patients with rapidly expanding intracranial
haematomas that are imminently life-threatening, and when definitive neurosurgical care is
unavailable. Neither criteria are met, as the diagnosis is not yet clear, and neurosurgical care is
available. However, before mannitol and transfer (which you might have been tempted to choose), he
will require intubation, ‘A’ being before ‘D’.
The primary aim of clinical and radiological assessment of patients with head injury is to identify
those patients with clinically important brain injury and, most crucially, those with an intracranial
haematoma requiring urgent neurosurgical management. The vast majority of head injuries are
classified as ‘mild’ with a low-risk of intracranial haematoma.
Previously, skull X-ray has been heavily relied upon to triage patients with mild head injury but the
sensitivity of this investigation may be as low as 38%. Therefore, it is currently only justified if
computed tomography (CT) is not available, or when non-accidental injury in children is suspected. By
contrast, CT scanning has a sensitivity and specificity approaching 100%, and so the Royal College of
Surgeons Guidelines state that 24-h CT is required in all centres receiving head-injured patients.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
19. Surgical Specialties- Neurosergery (19Qs)
--------------------------------------------------------------------------------------------------------------------------------------------------
02. A 14-year-old girl fell off her scooter. She was not wearing a helmet. Her mum says that she lost
consciousness for a few minutes and vomited several times. On arrival in A&E, she seemed drowsy
and could not remember the events leading to the accident. What is the most appropriate investigation
in her management?
CT head« YOUR ANSWER
CT head and spine Page |
No images required 1260
Skeletal survey
Skull X rays.
This girl has several signs of intracranial head injury. NICE recommends immediate CT head in this
scenario.
CT spine in conscious patients is requested only if the patient complains of pain or there is an
abnormality on plain C Spine x-rays or restricted active movements, because children have an
increased risk from irradiation.
Skull X rays and skeletal survey are considered if Non Accidental Injury (NAI) is suspected.
03. Theme: Head injury (types)
A Basal skull fracture
B Depressed skull fracture
C Diffuse axonal injury
D Extradural haematoma
E Intracerebral haemorrhage
F Intraventricular haemorrhage
G Le Fort I fracture
H Le Fort II fracture
I Le Fort III fracture
J Linear vault fracture
K Subarachnoid haemorrhage
L Subdural haematoma.
The following patients have all sustained head injuries. Please select the most appropriate clinical
description from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 26-year-old man is assaulted with a baseball bat. On examination, he has multiple lacerations and bruises
on his face. There is blood in the left external auditory meatus and bilateral black eyes with a left
subconjunctival haematoma. Glasgow Coma Scale (GCS) is 15.
A - Basal skull fracture « CORRECT ANSWER
Skull fractures may be of the vault or base. Basal skull fractures usually require computed
tomography (CT) scanning (bone windows) for identification. The clinical signs include, however,
‘racoon’ or ‘panda’ eyes (as in this case), retroauricular eccymosis (ie mastoid bruising = Battle’s
sign), subconjunctival haemorrhage and blood in the external auditory meatus.
Such fractures rarely require intervention but may be associated with cerebrospinal fluid leaks from
ear or nose, or with cranial nerve palsies (as well as neurological injury). All should have 24-h
neurological observation. Antibiotics are not now administered.
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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