Skull Fractures and Cranial Base Injuries — WACS Viva & Clinical Scenarios (Neurotrauma and Craniofacial Emergency Surgery)

Exam-style skull fractures and cranial base injuries viva scenarios with examiner probes and model answers for Neurosurgery candidates.

Scenarios covered

• SCENARIO 1: A 28-year-old construction worker presents to the emergency department following an impact from a falling steel bar. Examination reveals an 8 cm scalp laceration over the left parietal region with palpable bony step-off, active bleeding, and focal right-sided motor weakness. A non-contrast cranial CT confirms an open compound depressed skull fracture displaced by 12 mm with indriven bony fragments and an underlying cortical contusion. Outline your immediate emergency resuscitation, surgical indications, operative strategy, and perioperative management for this patient.
• SCENARIO 2: A 34-year-old motorcyclist involved in a road traffic collision sustains polytrauma. On examination, he has a Glasgow Coma Scale score of 14, right mastoid ecchymosis (Battle sign), blood behind the right tympanic membrane, and immediate complete right-sided lower motor neuron facial weakness. High-resolution thin-slice temporal bone CT reveals a transverse petrous fracture. Discuss the classification of temporal bone fractures, the clinical differentiation between longitudinal and transverse patterns, the pathophysiological basis and timing of facial nerve exploration, and the protocol for ma
• SCENARIO 3: A 22-year-old unrestrained driver presents 4 days post-injury with clear fluid dripping from his left nostril that worsens on leaning forward. He exhibits bilateral periorbital ecchymosis (raccoon eyes) and anosmia. Detail your diagnostic approach to confirm and localize the cerebrospinal fluid (CSF) fistula, discuss the rationale and evidence surrounding prophylactic antimicrobial therapy, and outline the conservative and definitive surgical management algorithms.
• SCENARIO 4: A 40-year-old male sustains severe frontal impact during an assault. Non-contrast cranial CT reveals a comminuted fracture involving both the anterior and posterior tables of the frontal sinus with a posterior displacement exceeding one table width, pneumocephalus, and disruption of the nasofrontal outflow tract. Explain the classification system for frontal sinus fractures, the indications and operative steps for frontal sinus cranialization versus obliteration, and potential long-term complications if left untreated.
• SCENARIO 5: An 8-month-old infant is brought to the paediatric neurosurgery clinic with a progressively enlarging, pulsatile scalp swelling along the line of a linear parietal skull fracture sustained 3 months earlier. Cranial imaging confirms post-traumatic craniocerebral erosion (growing skull fracture). Describe the underlying pathophysiology, essential diagnostic imaging modalities, operative principles of repair, and strategies to prevent neurological sequelae.