Intracranial Aneurysms and Subarachnoid Hemorrhage — WACS Viva & Clinical Scenarios (Cerebrovascular Disorders)

Exam-style intracranial aneurysms and subarachnoid hemorrhage viva scenarios with examiner probes and model answers for Neurosurgery candidates.

Scenarios covered

• SCENARIO 1: A 48-year-old woman presents to the emergency department with a sudden-onset, catastrophic headache described as the worst headache of her life, accompanied by vomiting, photophobia, and transient loss of consciousness. On examination, she is drowsy but opens eyes to voice, localizes pain, and speaks confused words (GCS 13). Blood pressure is 185/105 mmHg, heart rate is 58 beats per minute, and she demonstrates moderate neck stiffness without focal motor deficits. Outline your step-by-step emergency assessment, diagnostic imaging protocol, initial medical stabilization, clinical and radiologic
• SCENARIO 2: A non-contrast cranial CT confirms thick diffuse subarachnoid blood filling the basal cisterns with acute intraventricular hemorrhage in the third and lateral ventricles. CT angiography reveals a 7 mm saccular aneurysm of the anterior communicating artery (AComA) pointing anteriorly and superiorly. Describe the precise microvascular anatomy of the AComA complex, detail the surgical steps and anatomical landmarks of a right pterional craniotomy for aneurysm clipping, outline the sequence of proximal vessel control, and discuss the management of intraoperative aneurysm rupture.
• SCENARIO 3: Within 4 hours of admission, the patient deteriorates to GCS 9 (E2V2M5) with bilateral sluggish pupillary light reflexes. Repeat CT demonstrates acute obstructive triventricular hydrocephalus. Detail the emergency placement of an external ventricular drain (EVD), including anatomical landmarks (Kocher point), trajectory, depth, target opening pressure, and potential procedural complications. Formulate the post-procedural ICP and CSF drainage management protocol.
• SCENARIO 4: On post-bleed day 6 following successful microsurgical clipping, the patient develops progressive left hemiparesis and speech slowing. Formulate an evidence-based diagnostic approach to distinguish delayed cerebral ischemia (vasospasm) from rebleeding, hydrocephalus, metabolic derangements, and seizures. Detail the definitive medical protocol for delayed cerebral ischemia prevention and management, including oral nimodipine administration, hemodynamic targets, and the indications and techniques for rescue endovascular intervention.
• SCENARIO 5: A patient on day 8 post-aneurysmal subarachnoid hemorrhage develops severe hyponatremia with a serum sodium of 122 mmol/L and increasing lethargy. Differentiate the pathophysiology, clinical volume status, laboratory findings, and definitive management of Cerebral Salt Wasting (CSW) versus Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). State why fluid restriction is strictly contraindicated in this neurosurgical setting.