Download MH SAQ practice neurosurgery/eyes A 25 year old male was

MH SAQ practice neurosurgery/eyes
A 25 year old male was assaulted with a baseball bat. He had a witnessed LOC for
5 minutes and GCS was 10 when paramedics attended. On arrival to the ED, he
had a generalised seizure following which he became agitated and combative
with a GCS of 8. His left pupil is dilated and he has already vomited at scene and
the ED.
R
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1. Describe the 4 abnormalities on this CT (2 marks)
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midline shift
acute left subdural haemorrhage
acute right extradural haemorrhage
left frontal intracerebral haemorrhage
2. List 9 important initial steps in this patient’s initial primary survey, including
end points where appropriate (6 marks)
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secure the airway/ intubate
C-spine immobilisation
maintain normoxaemia PO2 100mmHg
ventilate to maintain PCO2 35-40mmHg
secure IV access, crystalloids to maintain MAP >65mmHg, SBP > 90mmHg
inotropes noradrenaline once fluid deficit corrected to maintatin MAP>65
maintain normoglycaemia
normothermia
phenytoin loading dose to minimise early seizures/ secondary brain injury
NB score 2 marks for each 3 steps named
3. Describe the methods of reducing intracranial pressure in this patient and the
rationale of each method (2 marks)
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hyperventilation – temporary vasoconstriction at the expense of cerebral perfusion
prior to theatre
mannitol – 0.25 1.0g/kg – osmotic gradient, can be detrimental with disrupted
blood brain barrier or cardiovascular instability
hypertonic saline
head elevation 30 degrees
optimise cerebral venous drainage
NB need to describe 4 methods to score 2 marks
A 45 year-old female has long standing low back pain was discharged the
preceding day by a JMO in your ED with a diagnosis of malingering. She now
presents to the ED with a sudden and severe lower back pain radiating down the
legs. In the department she was unable to control herself and was incontinent of
urine.
1. What 6 features would suggest cauda equina syndrome? (3 marks)
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sciatica
variable motor and sensory loss both lower limbs
urinary incontinence
bowel dysfunction
saddle anaesthesia
bilaterally absent ankle reflexes
need to score 2 correct answers for each 1 mark
2. List the essential test to aid the assessment of a patient with suspected cauda
equina syndrome (1 mark)

MRI
3. You investigate and find that the JMO did not examine the patient, wrote no
notes and was heard by the ED RN to tell the patient that there is nothing wrong
with them and they should not have come to the ED, again. You are the JMO’s
supervisor. Outline your approach to this situation (4 marks)
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Arrange to speak with the JMO privately
Assess if any drugs, alcohol, mental health issues with the JMO and if concern
escalate to ED Director and or medical board
Educate that not appropriate was of handling this situation
Document record of conversation
Inform JMO that patient may complain – should contact medical defence and write
contemporaneous notes
Review departmental protocol for JMO supervision
4. Outline the immediate steps in the management of this patient (2 marks)
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bedrest with pressure relieving mattress
bladder scan/ urinary catheter
analgesia
neurosurgical review discectomy/ laminectomy
Q1. A 57 years old male presented to ED with a sudden onset red painful right
eye. You suspect a diagnosis of acute glaucoma
1. What are the features of acute Glaucoma on examination? (4 marks)
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Fixed semi dilated pupils
Hazy cornea
shallow anterior chamber
increased intraocular pressure
2. How does glaucoma cause blindness? (1 mark)
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High intraocular pressure causes direct optic nerve damage
3. List the 5 most relevant topical medications used in primary open angle
glaucoma and explain why they are used: (5 marks)
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Prostaglandin analogues (e.g. Latanoprost): increase aqueous outflow: first line
Beta blockers e.g. Timolol; Reduces aqueous humour production by blocking Beta
receptor: first line
Alpha2 agonists: e.g. apraclonidine; increase aqueous outflow and decrease
aqueous production: second line agent.
Carbonic anhydrase inhibitors topical e.g. Brinzolamide, decrease aqueous
production ; second line agent
cholinergics (miotics) e.g.Pilocarpine 2%: Contracts ciliary muscle and facilitate
drainage of aqueous humour/ causes miosis (3rd line agent)
A 22 year old male with known cerebral palsy presented to ED with a seizure. He
complains of worsening headache and is known to have VP shunt. His
observations are stable and GCS15.
1. List the 3 most likely causes of worsening headache in this man? (2 marks)
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developing hydrocephalus due to shunt blockade (shunt malfunction or infection)
intracranial trauma OR infection (either answer acceptable)
2. How do you interpret shunt function after locating and pressing the chamber?
(2 marks)
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Difficulty compressing the chamber indicates distal flow obstruction
slow refill, defined as refill requiring >3 seconds after compression, generally
indicates a proximal obstruction
NB compression is inaccurate in identifying shunt obstruction
3. What 2 radiological investigations will you arrange for a suspected blocked VP
shunt. Explain your rational for each (2 marks)
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
shunt series of plain from skull to abdomen (for ventriculoperitoneal shunts) will
identify kinking, migration, or disconnection of the shunt system.
Brain CT is required to evaluate ventricular size .Comparison with previous CT
scans is needed, because many patients with shunts have an abnormal baseline
ventricular size..
3. The neurosurgical registrar asks you to perform a shunt tap. Outline the steps
(2 marks)
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Consent/ explain to patient
Locate site over the valve system
PPE with sterile gloves and gown
Sterile field with antiseptic
A 23-gauge needle or butterfly attached to a manometer is inserted into the
reservoir
4. What are the possible outcomes of the shunt tap and what is their
significance? (2 marks)
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If no fluid returns or flow ceases, a proximal obstruction is likely.
The opening pressure should be measured while the reservoir outflow is occluded.
An opening pressure of ≥20 cm H2O (normal 12 ± 2 ) indicates a distal obstruction,
whereas low pressures indicate a proximal obstruction.
A 65 year old male attends complaining of loss of vision in his left eye.
a. Give six features you would enquire about in the history. (3 marks)
Visual acuity
Flashers/floaters/ amaurosis fugax
trauma
headache/temporal pain/ systemic upset
neurological signs or symptoms
eye pain
previous medical history e.g. AF, TIA
b. List 2 abnormalities of the fundus shown in the picture above. (2 marks)
Venous engorgement and widespread haemorrhage. Sunset
appearance
c. What is the diagnosis? (2 marks)
Central retinal vein occlusion
d. Give 6 associations of this condition. (3 marks)
Trauma- closed head
Vasculitis
Hypercoaguability states
Hypertension
DM
Alcohol
Glaucoma
A 28 year old man has been out kite surfing and was thrown into the water at
high speed. He is brought in on a spinal board with C-spine protection. He is
intubated and ventilated and put on a propofol infusion.
His observations are: Pulse 65 /min, BP 90/60 mmHg and he is warm and well
perfused.
The C-spine film and tomogram are shown below.
a. Describe 3 abnormalities on the x-ray. (3 marks)
# body C4, loss of space C3-4, probably soft tissue swelling
Burst fracture
b. Describe 2 aspects of his cardiovascular status. (2 marks).
Hypotensive and bradycardic/normocardic
c. What is the likely diagnosis? (2 marks)
Spinal shock
d. What 3 signs would support this? (3 marks)
priapism
Pink, well perfused peripheries,
flaccid paralysis below level C4,
increased tendon jerk reflexes below that level (might be absent
initially)
loss of sensation,
very weak respiratory effort,
. A 25 year old man is brought into your regional ED after a bicycle accident. He is
not moving his legs and has limited upper limb movement. He has a soft stridor.
His vitals are:
GCS
14
P
62
/min
BP
80/40 mmHg
Sats
95
% 10L O2
A CT neck is done as part of his assessment.
a. Describe the major abnormalities. (3 marks)
Bilateral facet dislocation atC6/7 with posterior displacement by one vertebral width
and spinal cord impingement. Large haematoma anterior to C5-T3 causing tracheal
and airway compression at subglottic and glottis level
b. Outline your management of his airway and breathing. (7 marks)
Needs airway soon but not NOW.
Potentially difficult ++
MILI and gentle technique mandatory
Careful planning
preO2 as much as possible
Support BP: fluids then pressors as likely neurogenic shock (must have pressor
available if not given pre induction). Induction drug must be HD Ok (eg ketamine
fentanyl, not big dose props)
Mandatory backup surgical option considered
Options depend on access in institution ; thus OT with fibreoptic/gas;
definitie trache primarily with ENT; glidescope in ED with bougie etc.
Consider other injuries in decision making
An 18 year old factory worker is rushed to ED having sustained a chemical burn
to his eye. He thinks the chemical had ammonia in it. It is now 20 minutes since
the accident.
His eye is pictured here.
a. Describe the picture. (3 marks)
There is marked clouding/opacification of the entire cornea, limbal
ischaemia (must note), conjunctival haemorrhage, swelling, inflammation,
inflammation of the eyelid tissues. These features are consistent with a
significant/severe alkali corneal chemical burn.
(3 marks) – Must include limbal ischaemia or whitening around cornea,
conclude a severe or significant alkali burn.
b. What is your immediate management? (4 marks)
1. Copious Irrigation – water, normal saline, continuous, high volume, aim
for pH <8 (may say 7.5) on litmus paper.
2. Analgesia – topical amethocaine or equiv, systemic titrated to pain
score
(3. Treat associated burns (skin, other eye))
4. Refer Opthalmology given severity of burn
c. Name 3 things you would do to assess this injury, including prognostic
indicators. (3 marks)
1.Hx – collateral history, confirm chemical involved – industrial alkali?
2. Exam – slit lamp -assess for limbal ischaemia (prognostic indicator),
depth of burn
(pH if not mentioned above, litmus paper)
3. Visual acuity
A 65 year old man with insulin dependent diabetes mellitus presents to the ED
with a marked sudden decrease in vision.
a. What are your top 6 differential diagnoses? (3 marks)
Central retinal artery occlusion - mandatory
Central retinal vein occlusion - mandatory
Retinal detachment - mandatory
Vitreous haemorrhage - mandatory
Optic neuritis
Loss of contact lens
Cranial nerve palsy causing diplopia
Giant Cell arteritis
Toxic metabolic neuropathy/any post chiasmal cause e.g. CVA, acute
glaucoma/local trauma etc
b. What are the key historical features you would ask for to help differentiate
between these? (7 marks)
Monocular vs binocular
- Moncular – ophthalmologic cause
- Binocular- central cause – need stroke workup
Painful vs painless visual loss
- Painful favors acute glaucoma, optic neuritis and iritis
Sudden onset profound loss in CRAO
- often preceded by episodes of amaurosis fugax
- occurs over seconds
Spectrum of loss in CRVO
- variable extent: blurring to complete monocular vision loss
- more gradual onset than CRAO
Photopsiae/floaters
- with retinal detachment and vitreous haemorrhage
- associated with underlying diabetic retinopathy
- decreased central/peripheral deficit e.g. dark curtain in visual
field
Diplopia
- with diabetic cranial nerve palsy
- vascular compromise of cranial nerves to EOM
- direction of gaze producing symptom gives clue to nerve affected
A 60 year old female presents to ED with a painful red eye. There is no history of
trauma.
a. What features on history and examination would you expect in acute closed
angle glaucoma? (3 marks)
History
-
Severe unilateral pain
Nausea +/- Vomiting
Reduced vision and halo’s
Known Glaucoma
Absence of trauma
Presence of risk factors; e.g anticholinergic drugs, mydriatics,
age, family history, known shallow anterior chamber
b. You diagnose acute closed angle glaucoma. Outline your management. (7
marks)
Antiemetic e.g ondansetron 4mg IV - mandatory
Analgesia likely opiate - mandatory
Acetazolamide 500mg IV then 250mg PO tds – mandatory
Pilocarpine 2% every 5 min for 1hr
Timoptol 0.5% every 30-60mins
Consider mannitol
Urgent Opthalmology consultation – mandatory
. A 48 year old man is brought by ambulance to your tertiary ED following a
collapse at home. GCS on arrival is 3. He is immediately intubated and ventilated
before CT scanning of his head and neck. CT reveals a massive intraparenchymal
haemorrhage with obstructive hydrocephalus. The neck CT scan is normal. He
was previously well on no medication. His partner is present and requests
information about his treatment and prognosis.
His observations are:
HR
60
/min
BP
180/110 mmHg
O2 sats 100
%
Temp
36.3
°C
Old Format Question
Describe your management (100%)
No model answer provided
New Format questions
a. What are your management priorities?
No model answer provided
b. List and justify 4 other investigations you would perform.
No model answer provided
c. Describe 5 urgent interventions you would perform.
No model answer provided
d. What are the principles for gaining consent for organ donation?
No model answer provided
A 29 year old man has been brought to your hospital after being hit to the head by a baseball
bat.
He has no prior medical history.
His vital signs on arrival to the ED are:
GCS 11 E2 V2 M5
Pulse 110 /min
BP 110/65 mmHg
O2 sats 99% 6L O2 via mask
A CT scan of his head has been performed.
1. List 5 abnormalities on the CT slice. (5 marks)
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2. List your treatment priorities in the ED. Where appropriate, give end-points. (9 marks)
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1.
Large extradural haematoma – high density bi convex lesion left temporal region
Hyperacute extradural with “swirl sign” mixed density
Large scalp haematoma left temporal region
Parietal cerebral contusion left
Significant midline shift to right
Loss of sulci and gyri consistent with raised intracranial pressure
Pass 3 of 5
2.
Immediate neurosurgical referral for surgical drainage of haematoma
Intubation for airway control and management of CO2
Maintain MAP >80 (accept approx.) mmHg with IV N/S +/- noradrenaline infusion
Maintain oxygenation sats >95%
Ventilate for low normal CO2 (35 – 40)
Other neuroprotective measures (max 4 marks)
Well sedated, paralysed
Slightly head-up position
Loosen ties / restriction to venous return
Na high normal range
Normothermia
normoglycaemia
pass 5 of 9
total pass 8 of 14 corrects to 5.5/10_
A 65 year old man has presented to the ED with a painful left eye. The pain developed over
30
minutes while he was at the movie theatre.
A clinical photo of his right eye is given.
1. List 3 abnormalities in the clinical photo. (3 marks)
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2. Give your clinical impression of the photo. (2 marks)
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3. List 3 specific treatment steps for this patient. (3 marks)
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4. List 2 supportive treatment steps for this patient. (2 marks)
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1.
Cloudy cornea
Mid-sized pupil
Ciliary injection, especially laterally
Pass 2 of 3
2.
Acute angle closure glaucoma
Pass 2 of 2
3.
Early ophthalmological review - laser
IV acetazolamide
Topical pilocarpine to constrict pupil
Topical apraclonidine
Topical beta blocker
Pass 2 of 3
4.
Analgesia
Anti-emetic
Pass 1 of 2
Total pass 7/10
Question 7:
Whist restraining a 47yo male with a convulsive seizure a nurse was kneed in
the cheek, including the orbit and nose. She experienced immediate epistaxis,
facial pain and visual blurring. (photo)
(a) Assuming that this is an isolated facial injury without loss of consciousness, list
six potential immediate ocular complications that you would exclude. (25%)
(b) What non-occular complications would you seek to exclude? (25%)
(c) Describe your management of a probable acutely fractured nose. (25%)
(d) What are the clinical signs of orbital compartment syndrome? What is the
immediate management? (25%)
Answers
7a.
Globe rupture, hyphaema, retinal tear and detachment, vitreous
haemorrhage and detachment, choroidal tear/rupture, iris injury, traumatic
iritis, lens detachment, corneal abrasion, commotion retinae, orbital fracture,
orbital compartment syndrome, orbital content entrapment in the fractured
orbital floor.
7b. Inferior orbital nerve injury (sensory loss), nasal septal haematoma
(fractured nose), depressed fractured maxilla), orbital floor fracture and
entrapment of orbital fat (enophthalmos) and inferior rectus (diplopia). Pass = 4
complications
7c.
Analgesia, control epistaxis, exclude/drain septal haematoma,
only image in the context of surveying for facial fractures, exclude orbital
injury and inferior orbital nerve injury, no evidence for antibiotics but argued
for and given by many on risk of severe infection (divided debate), Pass must be
reasonable and include exclude/drain septal haematoma, no imaging unless
excluding facial fractures
A 70yo female attends with acute, non-traumatic painless right unioccular
blindness.
(a)
(b)
(c)
(d)
List 5 potential aetiologies for this presentation (50%)
What are the clinical features that would suggest Giant Cell Arteritis? (30%)
What is the treatment for Giant Cell Arteritis? (10%)
What are the complications of delayed treatment of Giant Cell Arteritis?
(10%)
Answers (9)
9a.
Complications: Includes, central retinal artery thrombosis,
Ischaemic Central Retinal vein Thrombosis, Optic neuritis (MS,
autoimmune, HSV), Retinal detachment, vitreous haemorrhage,
ischaemic optic neuropathy, Giant Cell/temporal arteritis, Drugs
(phosphodiesterase-5 inhibitors such as Viagra), migraine
Marking (a) : 10% each up to
50%
9b.
Clinical features:
Rare under 50yo, peaks in 8th decade, median age of onset 75.
3.7 female: 1male.
Increased risk (x6) in smokers
Usually has prodromal symptoms days to weeks: headaches
(72%), polymyalgia (neck, shoulder girdle, pelvis, malaise, weight
loss, jaw and oropharyngeal claudication, limb claudication.
Visual : amorous fujax, diplopia, blurring,
Clinically inflamed temporal artery
Carotid tenderness (15%)
Fundoscopic changes of retinal ischaemia delayed 36hrs
Occasional diplopia and, ptosis and miosis
Marking (b) 30% of total score for this
question: Pass (15%) but must include
both ophthalmic and non-ophthalmic
features, including headache,
oropharyngeal claudication. Add 5%
for each additional feature up to 30%
total
9(c).
Tx:
Prednisolone initiate at 1mg per Kg (or equivalent dose
methylprednisolone) prior to
histological confirmation by
Temporal artery biopsy.
Marking (c) 10% of total score for this
Pass/Fail only: Early
question.
high dose steroid
9d.
Complications
(i) Ophthalmic complications
-
Visual loss (retinal/optic infarction)
(ii) Non-ophthalmic complications:
-
Cerebral ischaemia,
mesenteric ischaemia,
limb ischaemia,
aortic rupture,
renal infarction,
death.
Marking (d) 10% of total score for this
question: Pass (5%) must include
visual loss, and two others, add 3% for
another and another 2% for a 5th
Overall pass = Total >60%
A 22yo female attends with a sudden onset severe unilateral headache.
(a) What features on history and examination support the diagnosis of Acute Subarachnoid Haemorrhage? (20%)
(b) What features support the diagnosis of hemicrania? (20%)
(c) What is the optimal timing for an LP to exclude the diagnosis of SAH? (10%)
(d) Describe your procedure/technique for lumbar puncture. (30%)
The LP result (after a negative CT for SAH) follow:
(e) What is the next step in the diagnostic work up given this result? (20%)
Answers
(a) What features on history and examination support the diagnosis of Acute Subarachnoid Haemorrhage? (20%)
Marking. 20% of the total for
question 15
Past history of SAH
Pregnancy
Polycystic kidneys
Family history
Abrupt onset
Syncope at onset
New neurological deficit
Severe
Occipital/nuchal
Evidence of meningism (photophobia, neck stiffness)
Marking. 20% of the total for question
15
2% per feature up to 20%
(b) What features support the diagnosis of hemicrania? (20%)
Past history of hemicranias
Severe
Unilateral, Ophthalmic division of trigeminal nerve
Epiphoria and corneal injection
Highly responsive to Indomethacin
Multiple episodes per day
Marking. 20% of the total for question
15
4% per feature up to 20%
(c) What is the optimal timing for an LP to exclude the diagnosis of SAH? (10%)
After 11 hours from symptom onset to allow for development of
xanthochromia
Marking. 10% of the total for
question 15
(d) Describe your procedure/technique for lumbar puncture. (30%)
Essential items : Consent, sterile technique, patient positioning,
landmarks, at least 3 numbered tubes in sequence, reinsert stylete prior to
withdrawal of LP needle, time-out, local anaesthetic, manometry, tests
requested.
Marking. 30% of the total for
question 15
Pass = 15% which requires all
of the bold.
Add 5% for each extra item as
above, up to
30%
(e) What is the next step in the diagnostic work up given this result? (20%)
question 15
Refer to neurosurgery & CT angiography
Marking. 20% of the total for
10% for each
Overall pass = 60%
You have intubated a patient with a severe head injury from an assault.
His CT is attached.
(a) List the abnormalities on this CT (50%)
(b) Would you provide seizure prophylaxis? (20%)
(c) Outline your management and define your physiological targets in the initial
resuscitation for this presentation. (30%)
Answers
(a) List the abnormalities on this CT (50%)
Penetrating head injury right parietotemporal
Depressed skull fracture at the site of the penetrating injury
Air within the cranium
Effacement of the right lateral ventricle
Overlying scalp laceration/defect
question 17
Marking. 25% of the total for
(b) Would you provide seizure prophylaxis? (20%)
Yes. Penetrating head injury. Depressed skull fracture.
question 17
Marking. 25% of the total for
Pass/fail (zero)
(c) Outline your management and define your physiological targets in the initial
resuscitation for this presentation. (30%)
Normalize CO2, PaO2, BP, BSL, temperature
Nurse at 30degrees head up
C-spine precautions
and clearance by CT
Tetanus prophylaxis
IV antibiotics eg Cefazolin and gentamicin
Analgesia and sedation (eg midazolam and morphine or morphine and propofol)
Anticonvulsant eg levetiracetam, valproate, phenytoin
Marking. 25% of the total for
question 17
Pass = 15% (must include bolded
item) plus 2% for each
5% per
additional
Overall pass = 60%