March 2014

Pass Rate 32.9%

A 64-year-old man is scheduled for a stereotactic brain biopsy. He is taking dual antiplatelet therapy following the insertion of a drug- eluting coronary artery stent six months earlier.

a) Explain the issues that may arise from antiplatelet therapy in this patient. (30%)

b) Summarise the perioperative strategies to minimise the above issues. (40%)

c) What are the specific contraindications (15%) and complications (15%) of a stereotactic brain biopsy under sedation?
Pass Rate 32.9%

There was a low pass rate because candidates misread or misinterpreted the question. Most did not appreciate that the management of anti-platelet therapy requires a balance of risks in a patient for whom intra-operative bleeding could be a critical event. Many candidates mentioned stent thrombosis and intracranial / extracranial haemorrhage but did not explain why these events would be important even though the question specifically asks for these details. In part (b) the question asks for strategies to avoid the risk issues, but many candidates only described administration of neuroanaesthesia. Contraindications and complications were answered marginally better than the other two sections.
September 2013

A 34-year-old man is scheduled for a posterior fossa tumour excision.

a) List patient positions that might be employed for this operation. (10%)

b) What potential intraoperative problems are associated with posterior fossa craniotomy? (25%)

c) What monitoring techniques can specifically detect the presence of venous air embolism during surgery and for each method used, give the features that would indicate the diagnosis? (40%)

d) How would you manage a significant venous air embolism in this patient? (25%)
48.4% pass rate.

Section b) was poorly answered. Clearly, inexperience in anaesthesia for this type of surgery was apparent.
The model answer to b) included:
Problems associated with positioning: including hypotension from pooling of blood, spinal cord injury and peripheral nerve damage.
Brain stem damage: including the respiratory /cardiovascular centre and cranial nerve nuclei.
Knowledge of the diagnosis and management of an intraoperative air embolism was satisfactory.
September 2012

a) What are the symptoms (10%) and signs (20%) of raised intracranial pressure (ICP) in an adult?

b) Describe the physiological principles underlying the management of raised ICP. (40%)

c) What methods are used to manage or prevent acute rises in ICP? (30%)
Question 10: Raised intracranial pressure (symptoms and signs)/physiological basis/management.

56% pass rate.

Many candidates failed to attempt to answer b) Physiological mechanisms of raised intracranial pressure instead wrote about areas of clinical management only then to repeat the same points in section c). Key points are never repeated in any question.

A number of candidates advised a 30-degree head-up tilt rather than the 15-20 degrees recommended in this question. Perhaps there was confusion with the head-up tilt to avoid ventilator-associated pneumonia.
September 2009

A 20 year old is admitted to the Emergency Department having been involved in a road traffic accident. His Glasgow Coma Score (GCS) is 12. He has a closed fracture of his left femur. No other injuries are evident. A CT scan of his head has revealed a right subdural haematoma, and it has been agreed to transfer him to the regional neurosurgical unit 60 miles away.

a) What are your clinical priorities prior to transfer of this patient? (50%)

b) What are the indications for intubation and ventilation prior to transfer following a brain injury of this nature? (30%)

c) Who should accompany this patient for transfer to the neurosurgical unit? (10%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2006

An adult patient requires angiography and interventional radiology for a cerebral aneurysm.
(a) What potential problems may be encountered anaesthetising a patient in the Angiography Suite? (30%)
(b) What are the key Principles of Anaesthesia in this patient? (60%)
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
October 2004

A comatose, ventilated patient who has a head injury has an intracranial pressure of 35 mmHg. His CT scan excludes a surgically reversible cause.
What immediate steps would you take to assess and treat the patient?
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question
May 2003

A 4 year old child who has been knocked unconscious by a blow from a cricket bat arrives at a paediatric neurosurgical centre. After initial appropriate management a CT scan shows an extradural haematoma. There are no other injuries. Discuss the subsequent management.
Question11 Critical care/management of airway problem/tracheostomy

76.6% pass rate

In the main was a well-answered question