Cerebrovascular Neurosurgery
Core concepts
Understand aneurysmal subarachnoid hemorrhage: presentation, grading (Hunt and Hess, WFNS, modified Fisher), vasospasm timing, and management of hydrocephalus and rebleeding. Know the decision between clipping and coiling based on aneurysm location, morphology, and patient factors. Cover arteriovenous malformations, cavernous malformations, moyamoya disease, and the surgical versus endovascular approach to carotid stenosis and intracranial atherosclerosis. Also know the classification and management of intracerebral hemorrhage, including the role of blood pressure control and surgical indications.
Traps
- Vasospasm peaks at days 3–14 and is not the cause of the initial hemorrhage; rebleeding is highest in the first 24 hours.
- Assuming all aneurysms need treatment; small incidental aneurysms may be observed.
- Confusing the modified Fisher scale (which predicts vasospasm) with Hunt and Hess (which grades clinical severity).
- Forgetting that anticoagulation reversal is urgent in intracerebral hemorrhage.
Worked example / rule of thumb
A sudden "worst headache of life" with neck stiffness and a normal CT within 6 hours in a high-risk patient still warrants lumbar puncture for xanthochromia if suspicion is high. Rule of thumb: the modified Fisher grade predicts vasospasm risk, while Hunt and Hess and WFNS grade the clinical condition at presentation.