Spontaneous Intracerebral Hemorrhage — WACS Viva & Clinical Scenarios (Cerebrovascular Disorders)

Exam-style spontaneous intracerebral hemorrhage viva scenarios with examiner probes and model answers for Neurosurgery candidates.

Scenarios covered

• SCENARIO 1: Single Best Answer (SBA): A 62-year-old male with long-standing poorly controlled hypertension presents to the emergency department with sudden onset right hemiplegia, aphasia, and declining consciousness (Glasgow Coma Scale score 10). Urgent non-contrast cranial CT reveals a 45 mL hyperdense hematoma centered in the left putamen with 6 mm midline shift and intraventricular extension into the left lateral ventricle. Which parameter is the most significant independent predictor of 30-day mortality in this patient using the validated intracerebral hemorrhage (ICH) score? A. Age >80 years B. Init
• SCENARIO 2: Clinical Viva / Operative Case Scenario: A 58-year-old female presents with sudden severe occipital headache, persistent vomiting, ataxia, and progressive drowsiness over 4 hours. Cranial CT demonstrates an acute 3.8 cm diameter hematoma in the right cerebellar hemisphere causing compression of the fourth ventricle and early supratentorial ventriculomegaly. Outline your immediate emergency resuscitation, surgical decision-making, choice of operative approach, and perioperative management plan.
• SCENARIO 3: Structured Essay / Membership Part I Written: Discuss the pathophysiology, diagnostic criteria, and management of cerebral amyloid angiopathy (CAA) associated lobar intracerebral hemorrhage in the elderly, contrasting its clinicopathological features and recurrence risk with hypertensive arteriopathy.
• SCENARIO 4: Objective Structured Clinical Examination (OSCE) Station: You are asked to manage a 70-year-old man who sustained an acute spontaneous intracerebral hemorrhage while on therapeutic warfarin for non-valvular atrial fibrillation. His international normalized ratio (INR) is 3.4, and his blood pressure is 195/110 mmHg. Formulate and defend your immediate medical resuscitation protocol, detailing pharmacological reversal strategies, target blood pressure parameters, and monitoring protocols over the first 24 hours.
• SCENARIO 5: Clinical Case Defense: Critically evaluate the landmark clinical trial evidence (including STICH I, STICH II, and MISTIE III) regarding the surgical evacuation of supratentorial spontaneous intracerebral hematomas. Specify the subgroup of patients who derive definitive functional benefit from surgical intervention.