Cerebrovascular Neurosurgery
What the candidate must own
Know the natural history and management of unruptured and ruptured intracranial aneurysms, the Hunt and Hess and World Federation of Neurosurgical Societies grading scales, and the complications of subarachnoid haemorrhage: rebleeding, vasospasm (days 3-14), hydrocephalus, and hyponatraemia. Understand the ISAT and BRAT evidence comparing clipping and coiling, and when each is preferred (wide-necked, middle cerebral artery, and young patients favour clipping; posterior circulation and poor-grade patients favour coiling). For AVMs, know the Spetzler-Martin grading and the treatment options - microsurgery, radiosurgery, embolisation - and the concept of normal perfusion pressure breakthrough. Know moyamoya disease and its revascularisation strategies, and the role of surgery in intracerebral haemorrhage and malignant middle cerebral artery infarction.
Traps that appear in questions
- Attributing deterioration after SAH to rebleeding when vasospasm is the more likely cause in the day 3-14 window.
- Forgetting that nimodipine improves outcome without necessarily reversing angiographic vasospasm.
- Assuming all AVMs should be treated - small, unruptured, deep lesions may be observed.
- Missing the indication for decompressive hemicraniectomy in malignant MCA infarction (large infarct, mass effect, within 48 hours).
Rule of thumb
Match the treatment to the lesion and the patient: location, size, neck morphology, age, and grade. Worked example: a 30-year-old with a ruptured middle cerebral artery bifurcation aneurysm and a wide neck - clipping is preferred over coiling because of durability and the wide neck, and the timing is early to prevent rebleeding.