Intracranial Hematomas and Emergency Cranial Decompression — WACS Viva & Clinical Scenarios (Neurotrauma and Craniofacial Emergency Surgery)

Exam-style intracranial hematomas and emergency cranial decompression viva scenarios with examiner probes and model answers for Neurosurgery candidates.

Scenarios covered

• SCENARIO 1: A 28-year-old male is brought to the emergency department following a road traffic collision with a temporal scalp contusion. Initial GCS was 14, but over the next two hours it deteriorates to 7 with a sluggishly reactive, dilated ipsilateral pupil and contralateral hemiparesis. Non-contrast brain CT demonstrates a 45 cm3 biconvex hyperdense temporal extra-axial collection with 8 mm of midline shift. Describe the surgical anatomy, immediate resuscitation, preoperative decision-making, and step-by-step operative technique for emergency evacuation of this lesion.
• SCENARIO 2: A 35-year-old female presents after an assault with a GCS of 6. Emergency brain CT demonstrates a 14 mm thick crescentic hyperdense frontotemporoparietal extra-axial collection crossing cranial sutures with 11 mm of midline shift and effacement of the basal cisterns. Outline the surgical indications, anatomical boundaries of the trauma flap, intraoperative management of acute intraoperative brain swelling, and the technical execution of a standard decompressive hemicraniectomy.
• SCENARIO 3: An 82-year-old male with a history of atrial fibrillation on warfarin therapy presents with progressive cognitive decline, gait ataxia, and left-sided hemiparesis over three weeks. Brain CT demonstrates a large hypodense crescentic right subdural collection causing 9 mm of midline shift. Discuss the pathophysiology of this condition, emergency reversal of coagulopathy, comparative surgical strategies (burr hole craniostomy versus twist drill craniostomy versus craniotomy), and postoperative protocols.
• SCENARIO 4: In a peripheral district hospital lacking neuroimaging capabilities, a patient with severe head trauma develops progressive anisocoria, decerebrate posturing, and rapid coma. Detail the anatomical landmarks and systematic sequence for performing emergency diagnostic and therapeutic exploratory burr holes, including the specific management of identified extra-axial hematomas.
• SCENARIO 5: A 40-year-old patient undergoes an expansive frontotemporoparietal decompressive hemicraniectomy for malignant traumatic brain swelling. Describe the postoperative management, potential surgical and physiological complications (including external herniation, subdural hygroma, and syndrome of the trephined), bone flap preservation methods, and the principles governing delayed cranioplasty reconstruction.