27 Neurosurgery MCQs Answers

Answer: E

Most intracranial aneurysms are congenital, evolving and developing during life. They are typically found at the bifurcation of major vessels of the circle of Willis with over 85% occurring in the carotid or anterior circulation. Up to 20% of patients with aneurysms will have multiple aneurysms. Patients with intracranial aneurysms most commonly present with signs and symptoms of subarachnoid hemorrhage. In fact, 80% of nontraumatic subarachnoid hemorrhages are caused by aneurysm rupture. The patient notes a sudden severe headache commonly followed by neck stiffness and photophobia due to associated meningeal irritation caused by subarachnoid blood. Transient loss of consciousness may occur. Some patients may develop a focal neurologic deficit or become comatose due to acute rise in ICP.

The diagnosis of subarachnoid hemorrhage is usually made clinically and confirmed either by noting blood within the subarachnoid spaces on CT scan or finding bloody CSF with xanthochromia on a lumbar puncture. The CT scan should be obtained first since it spares the patient an LP and also eliminates the potential risk of brain-stem compression from herniation if an unsuspected mass lesion is present. Complete cerebral angiography is then used to identify and delineate the aneurysm and, at the same time, rule out multiple aneurysms or an associated arterial venous malformation. Once the diagnosis of aneurysmal rupture is confirmed, the patient is placed on a medical regimen to reduce the risk of rebleeding. This includes strict bed rest with the head elevated. Blood pressure is tightly controlled below 150 mm Hg systolic.


Careful observation is necessary to watch for signs of raised ICP which may be attributable to delayed hydrocephalus. Anticonvulsants are started for seizure prophylaxis. The ultimate treatment of aneurysms is microsurgical dissection and obliteration, usually by placing a metallic clip on the aneurysm’s neck by way of a craniotomy. The timing of surgery depends on the clinical grade of the patient. Good grade (I and II) patients should undergo operation within 72 hours of rupture. Poor grade (III and IV) should continue intensive medical management until they improve to a lower grade because mortality is higher with higher grades. Surgically accessible unruptured aneurysms should be operated on electively to prevent rupture.

Category: Surgery MCQs