Cerebrovascular Neurosurgery - exam-focused guide
Cerebrovascular Neurosurgery covers aneurysms, arteriovenous malformations, cavernomas, moyamoya and stroke surgery. The exam tests acute SAH management, treatment selection and complication prevention.
Core rules
- Aneurysmal SAH presents with thunderclap headache. Grade with WFNS or Hunt–Hess; CT and LP establish diagnosis, CTA/DSA locate the aneurysm.
- Nimodipine 60 mg every 4 hours for 21 days improves outcome after SAH; it is prophylactic and does not reverse established vasospasm. Maintain euvolemia; avoid routine triple-H therapy.
- Secure the aneurysm early by clipping or coiling based on anatomy, age, grade and team expertise. Hydrocephalus may require EVD; vasospasm is monitored clinically and with TCD/CTA.
- AVM grading uses Spetzler–Martin size, venous drainage and eloquence. Cavernomas are angiographically occult; surgery is for symptomatic hemorrhage or epilepsy.
- Moyamoya is progressive stenosis of distal ICA and proximal circle vessels; revascularization (EDAS or STA–MCA bypass) reduces stroke risk.
- Malignant MCA infarction with swelling may warrant decompressive hemicraniectomy, especially in younger patients within 48 hours.
Worked example: A 50-year-old WFNS grade 2 after SAH has a 7-mm anterior communicating aneurysm. The aneurysm is secured within 72 hours. Nimodipine is started, euvolemia maintained, and hydrocephalus excluded. A new drowsiness or focal deficit prompts CT and vascular imaging for hydrocephalus or vasospasm.
Traps: using nimodipine to treat established vasospasm; assuming all unruptured aneurysms need treatment; operating on a cavernoma expecting angiographic filling; delaying hemicraniectomy in a deteriorating malignant MCA infarct.