CNS Surgery (Tumors, Cerebrovascular Disease) MCQs

Surgery · 58 free questions with answers & explanations.

1. A 55-year-old man develops a sudden-onset 'thunderclap' headache described as the worst of his life. CT head is normal. Lumbar puncture performed 12 hours later shows xanthochromia. The most likely diagnosis is:
2. A 40-year-old woman with neurofibromatosis type 2 (NF2) is found on surveillance MRI to have bilateral vestibular schwannomas. Her right-sided tumor is 2.5 cm with mild sensorineural hearing loss and no brainstem compression. The management strategy that best balances hearing preservation with tumor control is:
3. A 55-year-old man presents with progressive headache, papilloedema, and gait ataxia. MRI shows a posterior fossa midline mass with cystic component and a mural nodule. The nodule enhances brightly. Histology shows a highly vascular tumour with Weibel-Palade bodies on electron microscopy and negative for S100 and GFAP. The most likely diagnosis is:
4. A 65-year-old man presents with a ruptured intracranial saccular aneurysm confirmed by CT and CTA showing a 9 mm posterior communicating artery aneurysm with an irregular bleb. GCS is 14, no focal deficits (Hunt and Hess Grade I-II). Based on the ISAT trial evidence, the preferred intervention modality is:
5. The Cushing reflex (vasopressor response) is a physiological response to acute raised intracranial pressure. Which triad characterizes it, and what is its clinical significance?
6. A 45-year-old man presents with a sudden severe 'thunderclap' headache reaching maximum intensity within 60 seconds. CT head is performed within 6 hours and is negative for subarachnoid haemorrhage. What is the most appropriate immediate next investigation?
7. A 58-year-old man presents with headache, confusion, and a ring-enhancing lesion in the right frontal lobe on MRI with significant perilesional edema. He has no fever, no immunocompromise, and no history of known malignancy. Spectroscopy shows high choline:creatine ratio with reduced N-acetyl aspartate. The most likely diagnosis and primary next investigation is:
8. The ISAT trial (International Subarachnoid Aneurysm Trial) compared endovascular coiling with neurosurgical clipping for ruptured intracranial aneurysms. Its main conclusion was:
9. A 45-year-old patient with IDH-mutant, 1p/19q co-deleted grade 3 oligodendroglioma undergoes maximal safe resection. Which adjuvant treatment protocol is currently supported by the CATNON and CODEL trials?
10. A 45-year-old woman presents with progressive headache, left-sided hemiparesis, and papilloedema. MRI brain shows a ring-enhancing lesion with surrounding oedema in the right parietal lobe. CSF shows elevated protein, lymphocytosis, and low glucose. No known primary malignancy. HIV negative. The lesion is single. Which diagnosis most requires immediate empirical treatment while awaiting definitive confirmation?
11. A 45-year-old man presents with progressive right leg weakness over 3 months. MRI shows a 3 cm intradural extramedullary mass at the T5 level. The mass is isointense on T1, enhances uniformly with gadolinium, and has a 'dural tail' sign. The most likely diagnosis is:
12. A 58-year-old patient presents with sudden thunderclap headache ('worst headache of life') with meningism and photophobia. CT brain is negative for blood. Lumbar puncture is performed at 12 hours post-symptom onset. The CSF finding MOST consistent with subarachnoid hemorrhage is:
13. A 45-year-old man presents with new-onset seizures. MRI shows a ring-enhancing lesion with central necrosis and surrounding oedema in the right temporal lobe. Stereotactic biopsy confirms IDH-wild-type glioblastoma multiforme (GBM), MGMT promoter methylated. According to EORTC 26981/22981 (Stupp protocol) and current ESMO guidelines, the standard treatment is:
14. A 45-year-old man presents with progressive headaches and seizures. MRI shows a 3 cm ring-enhancing lesion in the left temporal lobe with surrounding edema and mass effect. The radiological finding that most strongly suggests glioblastoma multiforme (GBM) rather than a brain metastasis is:
15. A 60-year-old hypertensive patient presents with sudden severe 'thunderclap' headache. CT brain is negative for haemorrhage. Lumbar puncture shows xanthochromia (yellow CSF supernatant) at 12 hours. The most important next investigation is:
16. A 60-year-old man undergoes craniotomy for a right temporal glioblastoma (GBM). Post-operatively, O6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status is reported as methylated. Per EORTC-NCIC and subsequent trials, what is the significance of MGMT methylation in GBM treatment?
17. A 55-year-old patient presents with a subarachnoid hemorrhage (SAH) secondary to a ruptured middle cerebral artery aneurysm. CT confirms Fischer Grade 3 (thick diffuse subarachnoid blood). On day 7, the patient develops hemiplegia and confusion. TCD shows mean flow velocity in MCA of 160 cm/s. What is this complication and first-line treatment?
18. A 35-year-old presents with headaches and MRI shows a 3 cm WHO Grade 2 IDH-mutant, 1p/19q co-deleted oligodendroglioma in the left frontal lobe. He is neurologically intact. What is the current WHO 2021 classification and significance of 1p/19q co-deletion?
19. A 45-year-old woman is found to have a 7 mm unruptured intracranial aneurysm at the middle cerebral artery bifurcation as an incidental finding on MRI done for headache. She is otherwise well with no prior haemorrhage. Which scoring system and which annual rupture risk estimate best guides the management decision?
20. A 38-year-old woman presents with progressively worsening headaches and bitemporal hemianopia. MRI shows a sellar mass with suprasellar extension, cystic and solid components, calcification ('machine oil' contents on aspiration), and Rathke's pouch origin. Histology shows 'wet keratin' (adamantinomatous type). This is consistent with which tumor?
21. A 65-year-old man with a 7 mm unruptured intracranial aneurysm of the middle cerebral artery (MCA) bifurcation is evaluated for management. Per ISUIA (International Study of Unruptured Intracranial Aneurysms) and current guidelines, which factor most strongly predicts rupture risk?
22. A 55-year-old presents with sudden-onset thunderclap headache reaching peak intensity within 60 seconds. CT head is negative. The next diagnostic step and the gold standard for subarachnoid haemorrhage diagnosis when CT is negative is:
23. The ISAT trial (International Subarachnoid Aneurysm Trial) compared neurosurgical clipping versus endovascular coiling for ruptured intracranial aneurysms. What was its primary finding regarding dependency and death at 1 year?
24. A 45-year-old woman presents with progressive headache, bitemporal hemianopia, and galactorrhoea despite normal prolactin levels. MRI shows a large suprasellar mass with calcification. The most likely diagnosis and the treatment of choice are:
25. A 60-year-old hypertensive man presents with sudden-onset thunderclap headache ('worst headache of my life'). CT head (plain) is performed within 6 hours of onset and is normal. The next diagnostic step is:
26. A 55-year-old man presents with sudden-onset thunderclap headache. CT brain is performed 2 hours after onset and is negative for haemorrhage. What is the MOST appropriate next investigation to exclude subarachnoid haemorrhage (SAH)?
27. The Monro-Kellie doctrine states that the total volume of the intracranial contents (brain, blood, CSF) is fixed. In raised intracranial pressure (ICP), the first compensatory mechanism that is exhausted before ICP rises exponentially is:
28. A 50-year-old woman presents acutely with severe headache ('thunderclap'), neck stiffness, and photophobia. CT brain is negative. LP shows xanthochromic CSF with >2000 red blood cells in tubes 1 and 4. CT angiography confirms a 7 mm posterior communicating artery (PCoA) aneurysm. The most appropriate definitive treatment within 24 hours is:
29. A 45-year-old man presents with progressive headache, nausea, and bilateral papilledema. MRI brain shows a heterogeneously enhancing mass in the corpus callosum with involvement of both hemispheres producing a 'butterfly pattern.' What is the most likely diagnosis?
30. A 60-year-old woman presents with sudden-onset severe headache described as 'thunderclap' — the worst headache of her life — with meningism. CT brain is performed within 6 hours and appears normal. What is the immediate next investigation?
31. The Cushing reflex (Cushing response) is a late and ominous sign of raised intracranial pressure and consists of which triad?
32. Regarding epidural haematoma following head injury, the classic 'lucid interval' is caused by:
33. A 45-year-old man presents with headaches and personality changes over 3 months. MRI brain shows a right frontal mass with minimal enhancement, T2 hyperintensity, no midline shift. Stereotactic biopsy reveals IDH1-mutant, 1p/19q co-deleted oligodendroglioma. According to WHO 2021 classification, this is:
34. A 60-year-old woman with a subarachnoid hemorrhage (SAH) from a ruptured anterior communicating artery aneurysm has a Hunt and Hess grade III. When is the optimal timing for aneurysm clipping or coiling?
35. The Monroe-Kellie doctrine describes intracranial pressure regulation. According to this doctrine, initial compensation for an expanding intracranial lesion is achieved primarily by:
36. A 65-year-old man presents with sudden onset severe headache ('thunderclap headache'), neck stiffness, and photophobia. CT head is normal. Lumbar puncture reveals xanthochromic CSF. This presentation is consistent with subarachnoid haemorrhage (SAH). The MOST common cause of non-traumatic SAH is:
37. The World Health Organization (WHO) 2021 classification of CNS tumours incorporates molecular parameters alongside histology. Grade II diffuse astrocytoma in an adult is now classified as IDH-mutant. The presence of IDH mutation in a glioma confers:
38. Cushing's triad (Cushing response) is a late sign of raised intracranial pressure indicating imminent transtentorial herniation. What are the three components?
39. A 28-year-old female presents with sudden-onset severe headache ('thunderclap headache', 'worst headache of her life'). CT head is negative. LP is performed and shows xanthochromia. What is the most likely diagnosis and next most appropriate investigation?
40. A 45-year-old man presents with a chronic subdural haematoma (CSDH) causing midline shift of 10 mm and progressive hemiplegia. He is on aspirin. What is the definitive surgical treatment?
41. A 30-year-old woman presents with progressive headaches, papilloedema, and bitemporal hemianopia. MRI pituitary shows a 3 cm suprasellar mass with calcification and signal heterogeneity. What is the MOST likely diagnosis?
42. A 55-year-old man presents with a sudden-onset severe headache 'like a thunderclap', and CT head performed within 6 hours of symptom onset is negative. What is the next appropriate investigation?
43. A 62-year-old man with a WHO grade IV glioblastoma (GBM) undergoes maximal safe resection followed by standard Stupp protocol. What does the Stupp protocol consist of?
44. A 65-year-old man presents with sudden-onset severe headache ('thunderclap headache'), neck stiffness, and photophobia. CT brain is normal. Lumbar puncture shows xanthochromia and elevated red cell count that does not decrease in successive tubes. The most common cause of spontaneous subarachnoid haemorrhage is:
45. A 45-year-old woman has a CT showing a well-circumscribed dural-based extra-axial mass with homogeneous contrast enhancement and a 'dural tail' sign. She has mild headache only. The 2021 WHO CNS tumour classification grade most often assigned to most meningiomas is:
46. A 35-year-old man presents with headache and focal seizures. MRI brain shows a 4 cm ring-enhancing lesion in the right temporal lobe with mass effect and midline shift. He is immunocompetent with no systemic cancer history. Stereotactic biopsy shows IDH-mutant, MGMT promoter-methylated glioblastoma. According to the EORTC 26981/NCIC CE3 trial (Stupp protocol), what is the standard of care?
47. A 60-year-old hypertensive man presents with sudden onset severe headache ('thunderclap headache'), neck stiffness, and a normal CT head. Lumbar puncture at 12 hours shows xanthochromia. What does xanthochromia specifically indicate?
48. A spinal meningioma is found at the T4 level in a 55-year-old woman presenting with progressive spastic paraparesis and a sensory level. MRI confirms an intradural, extramedullary mass with homogeneous enhancement. Which surgical approach is most appropriate?
49. The ISAT trial (International Subarachnoid Aneurysm Trial) compared endovascular coiling to neurosurgical clipping for ruptured intracranial aneurysms. The primary outcome at 1 year showed:
50. Cushing's reflex (triad) is an ominous late sign of raised intracranial pressure representing impending brainstem herniation. The triad consists of:
51. The ISUIA (International Study of Unruptured Intracranial Aneurysms) identified which factor as most predictive of aneurysm rupture risk?
52. The ISAT trial compared endovascular coiling to neurosurgical clipping for ruptured intracranial aneurysms. Its primary finding at 1 year was:
53. The WHO 2021 CNS tumour classification has incorporated molecular markers into glioma grading. IDH-mutant astrocytoma is now graded 2–4 based on which molecular feature that upgrades a grade 3 IDH-mutant astrocytoma to grade 4?
54. In the surgical management of aneurysmal subarachnoid haemorrhage (SAH), the ISAT trial compared endovascular coiling versus neurosurgical clipping for ruptured intracranial aneurysms. The primary finding at 1 year was:
55. The ISAT trial (International Subarachnoid Aneurysm Trial) compared endovascular coiling versus surgical clipping for ruptured intracranial aneurysms. Which statement best reflects the key finding?
56. A 55-year-old man presents with sudden severe headache ('worst headache of his life'), neck stiffness, and photophobia. CT brain is negative. What is the NEXT diagnostic step and the MOST common cause of this presentation?
57. A 45-year-old man presents with progressive headache for 3 months, papilloedema, and a ring-enhancing lesion with surrounding oedema on contrast MRI. He is HIV-positive with CD4 count 80 cells/μL. What is the MOST likely diagnosis?
58. A 60-year-old man has an intracranial meningioma found incidentally on MRI (2 cm, asymptomatic, no oedema). Which management is MOST appropriate based on current evidence?