Ischemic Cerebrovascular Disease and Surgical Revascularization — WACS Viva & Clinical Scenarios (Cerebrovascular Disorders)

Exam-style ischemic cerebrovascular disease and surgical revascularization viva scenarios with examiner probes and model answers for Neurosurgery candidates.

Scenarios covered

• SCENARIO 1: A 46-year-old male presents to the emergency department 18 hours after sudden onset of left-sided hemiplegia and neglect. Initial non-contrast head CT demonstrates early ischemic changes across greater than 60 percent of the right middle cerebral artery territory with 6 mm of midline shift at the septum pellucidum. His Glasgow Coma Scale score has dropped from 13 to 9 over the last 3 hours. Discuss the pathophysiology of malignant middle cerebral artery infarction, evaluate the indications and timing for decompressive hemicraniectomy quoting relevant landmark trial evidence, and outline the te
• SCENARIO 2: Outline the physiological determinants of cerebral blood flow (CBF) and cerebral autoregulation. Describe the cellular ischemic cascade during focal cerebral ischemia and explain the perfusion imaging parameters used to differentiate the ischemic core from the ischemic penumbra.
• SCENARIO 3: A 68-year-old female presents with recurrent episodes of amaurosis fugax and transient left upper limb weakness. Carotid duplex ultrasonography and digital subtraction angiography demonstrate an 80 percent stenosis of the right internal carotid artery by NASCET criteria. Discuss the criteria for surgical intervention versus best medical therapy, describe the anatomical exposure and cranial nerve hazards during a right carotid endarterectomy, and explain the pathophysiology and emergency management of postoperative cerebral hyperperfusion syndrome.
• SCENARIO 4: A 9-year-old child presents with recurrent transient ischemic attacks triggered by hyperventilation and crying. Digital subtraction angiography reveals progressive bilateral terminal internal carotid artery stenosis with a prominent basal collateral vascular network consistent with Moyamoya disease (Suzuki Stage III). Discuss the pathophysiology and clinical staging of Moyamoya disease. Contrast direct extracranial-intracranial bypass (STA-MCA) with indirect revascularization techniques (such as EDAS and EMS), justifying your selection of surgical approach in this pediatric patient.
• SCENARIO 5: A 55-year-old hypertensive female is admitted with a massive right posterior inferior cerebellar artery (PICA) territory infarction. Over 12 hours, she develops worsening lethargy, sixth nerve palsy, and respiratory irregularity. Explain the biomechanical consequences of space-occupying cerebellar infarction in the posterior fossa. Describe the clinical and radiologic triggers for suboccipital decompressive craniectomy, the sequence of operative steps including management of obstructive hydrocephalus, and the key neurointensive care parameters required postoperatively.