MCQ bank · 11 questions · free
Neurosurgery MCQs with answers
11 single-best-answer questions on head injury, subdural and extradural haematoma, cauda equina and spinal cord compression. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 22-year-old was hit on the side of the head, lost consciousness briefly, was then lucid, and 3 hours later became drowsy with a dilated left pupil. CT shows a biconvex (lens-shaped) collection under the left temporal bone. What is the management?
- Steroids
- Lumbar puncture
- Mannitol only
- Emergency craniotomy and evacuation of the extradural haematoma
- Observation and repeat CT in 24 hours
Show the answer and explanation
Answer: D. Emergency craniotomy and evacuation of the extradural haematoma. Extradural haematoma usually comes from a torn middle meningeal artery under a temporal fracture. The “lucid interval” is classic but not always present. A symptomatic or large haematoma needs urgent evacuation; outcome is excellent with prompt surgery.
Why not the others? Lumbar puncture in raised intracranial pressure can cause brain herniation.
References
After a fall, a 60-year-old has a GCS of 9. CT shows a crescent-shaped acute subdural haematoma 14 mm thick with 8 mm of midline shift. What is the management?
- Burr holes 3 weeks later
- Antiplatelet therapy
- Conservative management only
- Lumbar drain
- Urgent surgical evacuation (craniotomy), because the haematoma is over 10 mm thick and the shift over 5 mm
Show the answer and explanation
Answer: E. Urgent surgical evacuation (craniotomy), because the haematoma is over 10 mm thick and the shift over 5 mm. Acute subdural haematomas over 10 mm thick or causing more than 5 mm of midline shift should be evacuated regardless of GCS. They arise from torn bridging veins and are often associated with underlying brain injury, so outcomes are worse than with extradural haematoma.
Why not the others? Smaller haematomas in stable patients may be observed with repeat imaging.
References
An 82-year-old on warfarin has had worsening confusion and a mild left-sided weakness over 3 weeks after a minor fall. CT shows a chronic subdural haematoma with mass effect. What is the treatment?
- Thrombolysis
- Dexamethasone as the main treatment
- Observation only
- Craniectomy for every patient
- Reverse the anticoagulation and perform burr-hole drainage
Show the answer and explanation
Answer: E. Reverse the anticoagulation and perform burr-hole drainage. Symptomatic chronic subdural haematoma is drained through burr holes, often with a subdural drain to reduce recurrence. The Dex-CSDH trial found that dexamethasone led to worse outcomes than placebo, so it is not recommended routinely.
Why not the others? Elderly patients with minor falls, especially on anticoagulants, are at high risk.
References
A 45-year-old has a sudden, severe “worst ever” headache reaching maximum intensity within a minute, with neck stiffness. What is the first investigation?
- EEG
- MRI of the spine
- Skull X-ray
- Discharge with analgesia
- Urgent non-contrast CT of the head; if negative and done more than 6 hours after onset, lumbar puncture at least 12 hours after onset
Show the answer and explanation
Answer: E. Urgent non-contrast CT of the head; if negative and done more than 6 hours after onset, lumbar puncture at least 12 hours after onset. A thunderclap headache suggests subarachnoid haemorrhage, most often from a ruptured aneurysm. CT within 6 hours of onset is highly sensitive. Confirmed SAH is managed with nimodipine, blood pressure control and urgent aneurysm treatment by coiling or clipping.
Why not the others? Missed SAH can lead to fatal rebleeding.
References
A 40-year-old with back pain now has numbness around the anus and perineum, difficulty passing urine and bilateral leg pain. What is the management?
- Analgesia and discharge
- Physiotherapy and review in 6 weeks
- Plain lumbar X-ray only
- Suspected cauda equina syndrome: emergency MRI of the lumbosacral spine and urgent surgical decompression if confirmed
- Wait until incontinence develops
Show the answer and explanation
Answer: D. Suspected cauda equina syndrome: emergency MRI of the lumbosacral spine and urgent surgical decompression if confirmed. Cauda equina syndrome is usually caused by a large central disc prolapse compressing the sacral nerve roots. Saddle anaesthesia and bladder or bowel dysfunction are red flags. Emergency MRI and early decompression offer the best chance of preserving bladder, bowel and sexual function.
Why not the others? Waiting for painless retention or incontinence means permanent damage is more likely.
References
A man with known prostate cancer has new thoracic back pain and progressive weakness of both legs. What is the immediate management?
- Wait for urinary retention
- Physiotherapy
- Suspected metastatic spinal cord compression: lie flat if spinal instability is suspected, give dexamethasone 16 mg, and arrange MRI of the whole spine within 24 hours, then radiotherapy or surgery
- Oral analgesia and review next month
- Plain X-ray only
Show the answer and explanation
Answer: C. Suspected metastatic spinal cord compression: lie flat if spinal instability is suspected, give dexamethasone 16 mg, and arrange MRI of the whole spine within 24 hours, then radiotherapy or surgery. Metastatic spinal cord compression is an oncological emergency. Function at the time of treatment largely determines whether patients walk afterwards. Urgent MRI, steroids and definitive treatment (radiotherapy or surgical decompression and stabilisation) are coordinated by a specialist team.
Why not the others? Delays lead to permanent paralysis.
References
After a head injury, a patient opens his eyes only to pain, makes incomprehensible sounds and localises to pain. What is his Glasgow Coma Scale score?
- 13
- 11
- 9 (E2 V2 M5)
- 7
- 5
Show the answer and explanation
Answer: C. 9 (E2 V2 M5). GCS: eye opening to pain = 2; incomprehensible sounds = 2; localising to pain = 5, giving 9. A GCS of 8 or less generally indicates the need for airway protection. The individual components should always be reported, not just the total.
Why not the others? Localising (5) is different from withdrawal (4) and abnormal flexion (3).
References
A 55-year-old with a known pituitary macroadenoma has a sudden severe headache, double vision, drooping eyelid and reduced vision, with low blood pressure. What is the immediate treatment?
- Levothyroxine first
- Paracetamol and discharge
- Thrombolysis
- Lumbar puncture
- Suspected pituitary apoplexy: intravenous hydrocortisone, urgent MRI and neurosurgical and endocrine assessment
Show the answer and explanation
Answer: E. Suspected pituitary apoplexy: intravenous hydrocortisone, urgent MRI and neurosurgical and endocrine assessment. Pituitary apoplexy is haemorrhage or infarction of a pituitary tumour. Acute ACTH deficiency causes adrenal crisis, so hydrocortisone is given immediately. Surgery is considered for severe or worsening visual loss or reduced consciousness.
Why not the others? Giving thyroxine before steroids can precipitate adrenal crisis.
References
An adult with a head injury has a GCS of 12 when first assessed in the emergency department, and has vomited twice. When should a CT of the head be done?
- The next day
- Within 8 hours
- Not needed
- Only if the GCS falls below 8
- Within 1 hour
Show the answer and explanation
Answer: E. Within 1 hour. NICE recommends CT within 1 hour for adults with a GCS below 13 on initial assessment, or below 15 two hours after injury, suspected open or depressed skull fracture, signs of basal skull fracture, a post-traumatic seizure, a focal neurological deficit, or more than one episode of vomiting.
Why not the others? Anticoagulated patients without other features need CT within 8 hours.
References
A 25-year-old has an acute incomplete cervical spinal cord injury. Is high-dose methylprednisolone recommended?
- Yes; for 1 month
- Yes; for every patient
- Only if the injury is complete
- Only oral prednisolone
- No; high-dose methylprednisolone is not routinely recommended because of the lack of clear benefit and the risk of complications
Show the answer and explanation
Answer: E. No; high-dose methylprednisolone is not routinely recommended because of the lack of clear benefit and the risk of complications. Trials of high-dose methylprednisolone did not show convincing neurological benefit, and steroids increase infection and other complications. Management focuses on immobilisation, avoiding hypotension and hypoxia, early decompression and stabilisation where appropriate, and rehabilitation.
Why not the others? Maintaining spinal cord perfusion (mean arterial pressure 85–90 mmHg) is part of care.
References
A man with a complete T4 spinal cord injury develops a severe pounding headache, flushing above the injury and a blood pressure of 210/120 during a rectal examination. What is happening and what do you do?
- Give a beta-blocker and continue
- Autonomic dysreflexia: sit him up, stop the stimulus, check for a full bladder or faecal impaction, and give a fast-acting antihypertensive (such as nitrate or nifedipine) if pressure stays high
- Lie him flat and continue the examination
- Give more fluids
- Ignore it; it is anxiety
Show the answer and explanation
Answer: B. Autonomic dysreflexia: sit him up, stop the stimulus, check for a full bladder or faecal impaction, and give a fast-acting antihypertensive (such as nitrate or nifedipine) if pressure stays high. In spinal cord injury at or above T6, a stimulus below the injury (bladder distension, bowel procedures, pressure sores, haemorrhoidectomy) triggers uncontrolled sympathetic activity, causing dangerous hypertension that can cause stroke or seizures. Removing the trigger is the key treatment.
Why not the others? Bradycardia is common because of the vagal response above the injury.
References