A
Gynecology
Alfred S. Guirguis, D.O., M.P.H.
1 A 53-year-old G3P3 (three pregnancies [gravida] with three births [para]) postmenopausal woman was found to have a right adnexal mass during a routine examination. The patient denies any pain, nausea, vomiting, or postmenopausal bleeding. Her past medical history is significant for borderline diabetes and hypertension. Her family history is significant for a first-degree relative with ovarian cancer diagnosed at the age of 39 years. Her initial work-up should include all of the following except:
A Transvaginal ultrasound
B Blood tumor markers, including CA 125
C Magnetic resonance imaging (MRI) of the pelvis and abdomen
D Genetic counseling and possible testing of the patient for BRCA1 and BRCA2 mutations
E National Comprehensive Cancer Network (NCCN) guidelines
Ref.: 1-10
Comments
Common ovarian masses include functional cysts, hemorrhagic cysts, paraovarian or paratubal wolffian remnants, endometrioma, and benign or malignant tumors (epithelial, germ cell, stromal). The single most effective and efficient modality for assessing pelvic anatomy and pathology is real-time ultrasonography, especially with a transvaginal transducer. In addition, the tumor marker CA 125 is a glycoprotein that is produced by certain tumors, however, it is not specific for ovarian cancer. In postmenopausal women with a pelvic mass and elevated CA 125 (normal, <35 U/mL), ovarian cancer is diagnosed in 80% of these patients. MRI rarely provides additional information in patients with benign pelvic pathology. First-degree relative (i.e., mothers, sisters, and daughters) of patients with breast and ovarian cancers have a two- to threefold excess risk for the disease. Women should be considered for genetic testing only if their chance of having a deleterious BRCA mutation is at least 10%. The U.S. Preventive Services Task Force currently recommends that genetic testing be considered for women who have a family history that suggests inherited BRCA1 and BRCA2 mutations. Criteria for identifying individuals with at least a 10% risk of having a genetic mutation for referral to a genetic counselor and possible testing were also developed by the Kaiser Permanente Health Plan, NCCN, Family History Risk Assessment Tool, and the American College of Medical Genetics.
Answer
C
2 For the patient in Question 1, what ultrasound finding is not associated with higher risk for malignancy?
A Simple cyst and increased resistive index of ovarian vessels on Doppler ultrasound
B Cystic and solid components
C Low resistive indices of ovarian vessels
D Thickened septations
E Hyperechoic solid component
Ref.: 1-10
Comments
High-risk ultrasonographic features include (1) a solid component that is not hyperechoic and is often nodular or papillary; (2) septations or papillae, if present, that are thick (>2 mm); (3) color or power Doppler demonstration of flow in the solid component; (4) decreased resistive index of ovarian vessels, probably occurring as a result of neovascularization; (5) bilaterality; and (6) presence of ascites.
Answer
A
3 The patient in Question 1 was found to have a 3-cm simple cyst on transvaginal ultrasound and a CA 125 level of 15 U/mL. What is the most appropriate next step in her management?
A Exploratory laparotomy and a right salpingo-oophorectomy
B Computed tomography (CT) of the abdomen and pelvis
C Oral contraceptive prescription
D Repeated CA 125 determination and pelvic ultrasound in 2 to 3 months
E MRI of the pelvis
Ref.: 1, 8
Comments
Follow-up with serial ultrasound examinations and CA 125 measurements is appropriate for women who meet all the following criteria: simple unilateral ovarian cyst on ultrasound and Doppler imaging, asymptomatic pelvic examination not suggestive of malignancy, and normal cervical cytology and CA 125 concentration.
Answer
D
4 If the patient in Question 1 was considered to be at high risk for ovarian and breast cancers, what type of close surveillance should be recommended?
A Annual mammograms and pelvic ultrasound starting at 20 years of age
B Monthly breast self-examination (BSE) beginning at 25 years of age and annual mammography beginning at age 35
C Annual MRI for BRCA mutation carriers and other high-risk women
D Monthly BSE beginning at 18 years of age, annual mammography and MRI beginning at age 25, and ovarian cancer screening with ultrasound and serum CA 125 levels beginning age 35
E None of the above
Ref.: 5, 6
Comments
Unfortunately, the efficacy of early and increased surveillance for breast and ovarian cancer mortality is not known for women with genetic mutations. Although most guidelines recommend conventional annual mammography, there is no consensus regarding the optimal frequency of breast imaging screening for asymptomatic BRCA carriers. More frequent mammography (e.g., every 6 months) is sometimes considered because of the frequent development of interval malignancies. Nevertheless, the following screening strategies are typically recommended for women with BRCA1 or BRCA2 mutations who have not undergone risk-reducing surgery: monthly BSE beginning at age 18; clinical breast examination two to four times annually; annual mammography; and twice-yearly ovarian cancer screening with ultrasound and serum CA 125 levels beginning at age 35. In addition to a malignancy, benign findings such as leiomyomas, endometriosis, menstruation, pregnancy, pelvic inflammatory disease (PID), and liver cirrhosis may elevate CA 125 levels.
Answer
D
5 A 65-year-old woman was undergoing a routine abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. Intraoperatively, the gynecologist noted ascites, a 3-cm adnexal mass, and lesions on her omentum. Initially, a gynecologic oncologist was not available to assist on this surgery. Her past medical history was significant for an unintentional 20-lb weight loss, night sweats, abdominal bloating, early satiety, and pelvic pain over the last 2 months. Of note, the patient emigrated from Asia approximately 2 years earlier. What is the differential diagnosis for this patient?
A Ovarian cancer
B Meigs syndrome
C Uterine cancer
D Tuberculosis
E All except B
Ref.: 8, 11-15
Comments
Seventy-five percent of women with epithelial ovarian cancer are initially found to have tumor that has spread throughout the peritoneal cavity or involves the para-aortic or inguinal lymph nodes (stage III) or tumor that has spread to more distant sites (stage IV). The association of ovarian fibroma with ascites or pleural effusion (or both) is termed Meigs syndrome. Papillary serous adenocarcinoma of the endometrium behaves more like an ovarian carcinoma than an endometrial cancer. Most cases of tuberculous peritonitis result from reactivation of latent peritoneal disease. The illness often develops insidiously, with patients having had symptoms for several weeks to months at the time of initial evaluation. Abdominal swelling secondary to ascites formation is the most common symptom, with most patients complaining of a nonlocalized, vague abdominal pain. Constitutional symptoms such as low-grade fever and night sweats, weight loss, anorexia, and malaise are reported in about 60% of patients. CT can demonstrate the thickened and nodular mesentery with mesenteric lymphadenopathy and omental thickening.
Answer
E
6 Upon exploration of the patient in Question 5, a biopsy of an accessible lesion is submitted for frozen section and reads as adenocarcinoma, most likely of gynecologic origin. What is not the most appropriate surgical strategy?
A Operable resection of all visible disease, including possible splenectomy and bowel resections if necessary, with no disease greater than 1 cm in diameter remaining
B Total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and paraaortic lymph node dissection, omentectomy, and optimal cytoreduction
C Recommendation for ending the surgery given her advanced disease status and arranging follow-up with a medical oncologist for possible chemotherapy
D Consultation with a gynecologic oncologist
E None of the above
Ref.: 1, 3, 13-15
Comments
Treatment of invasive epithelial ovarian cancer includes hysterectomy; bilateral salpingo-oophorectomy; omentectomy; peritoneal biopsy of the diaphragm, bilateral paracolic gutters, bilateral pelvis, and cul-de-sac; and lymph node sampling. If the cell type is mucinous, an appendectomy is also performed to rule out a metastasis from the appendix. Optimal debulking/cytoreduction is defined as residual disease no greater than 1 cm in diameter. Studies have consistently shown that surgical treatment by non-gynecologic oncologists and low-volume providers contributes to suboptimal surgical management and shorter median survival.
Answer
C
7 For the patient in Question 5, what would have been the appropriate work-up preoperatively if a pelvic mass and ascites were noted on pelvic examination and ultrasound?
A CT of the chest, abdomen, and pelvis
B Tumor markers such as CA 125, carcinoembryonic antigen (CEA), CA 19-9, and HE4
C Colonoscopy
D PPD and chest radiograph
E All of the above
Ref.: 8, 11-13
Comments
The single most effective and efficient modality for assessing pelvic anatomy and pathology is real-time ultrasound, especially with a transvaginal transducer. In addition, the tumor marker CA 125 is a glycoprotein that is produced by certain tumors. It is unfortunately not specific for ovarian cancer. In postmenopausal women with a pelvic mass and elevated CA 125 (normal, <35 U/mL), ovarian cancer is diagnosed in 80% of these patients. CEA is probably the most studied cancer tumor marker and is predominantly used clinically in patients with cancers of the colon and rectum. Carbohydrate antigen 19-9 (CA 19-9) is widely used as a serum marker for pancreatic cancer, but it can also be elevated in women with colon and ovarian cancers. Recommendations for screening include annual fecal occult blood testing and flexible sigmoidoscopy every 5 years (with full colonoscopy for patients with positive occult blood or adenomatous polyps on flexible sigmoidoscopy) or colonoscopy every 5 to 10 years. Peritoneal tuberculosis often develops insidiously, with patients having had symptoms for several weeks to months at initial evaluation. Abdominal swelling secondary to ascites formation is the most common symptom and occurs in more than 80% of instances. Similarly, most patients complain of a nonlocalized, vague abdominal pain. Constitutional symptoms such as low-grade fever and night sweats, weight loss, anorexia, and malaise are reported in about 60% of patients. CT will demonstrate the thickened and nodular mesentery with mesenteric lymphadenopathy and omental thickening.
Answer
E
8 What is the most common histologic subtype of ovarian cancer?
A Epithelial tumors
B Papillary serous carcinoma
C Germ cell carcinoma
D Endometrioid adenocarcinoma
E Transitional cell carcinoma
Ref.: 8, 16, 17
Comments
Of all ovarian epithelial tumors, papillary serous carcinoma accounts for 30.7% to 52.7%, mucinous for 23.7% to 31.1%, endometrioid for 6.1%, clear cell for 2.6%, and transitional cell for 3.2%.
Answer
B
9 What is one of the most common causes of death in patients with ovarian cancer?
A Uremia
B Anemia
C Liver failure
D Bowel obstruction
E Respiratory failure
Ref.: 8, 17-19
Comments
One of the most common problems faced by women with recurrent advanced ovarian cancer is bowel obstruction. Rectosigmoid resection was the most common bowel operation overall, particularly in the primary surgery group (65%). Colostomy was performed at primary surgery in 30% of patients who underwent rectosigmoid resection. Small bowel resection was most common in the women treated surgically for recurrence or palliation.
Answer
D
10 A 49-year-old G0P0 perimenopausal woman was undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy for abnormal uterine bleeding lasting more than 1 year. Intraoperatively, on frozen section the uterus was found to have a deeply invasive adenocarcinoma. Of note, her past medical history is significant for diabetes and hypertension. What is the most appropriate surgical staging for endometrial cancer?
A Total abdominal hysterectomy and bilateral salpingo-oophorectomy
B Pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymph node sampling or dissection
C Pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic lymph node dissection
D Total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic and para-aortic lymph node dissection
E Pelvic washings, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy
Ref.: 8
Comments
According to the International Federation of Gynecologists and Oncologists (FIGO) Surgical Staging, optimal staging for endometrial cancer requires the steps outlined in answer B. All other options are incomplete.
Answer
B
11 What is the most common histologic subtype of endometrial cancer?
A Squamous cell carcinoma
B Papillary serous carcinoma
C Germ cell carcinoma
D Endometrioid adenocarcinoma
E Clear cell carcinoma
Ref.: 8, 17, 20
Comments
The most common type of endometrial cancer is epithelial endometrioid adenocarcinoma. However, there are other types of epithelial carcinoma, including papillary serous, squamous, clear cell, mucinous, and neuroendocrine. Papillary serous, clear cell, and neuroendocrine tumors behave aggressively with a high risk for recurrence of disease.
Answer
D
12 Which of the following is not a risk factor for endometrial cancer?
A Obesity
B Smoking
C Unopposed estrogen use
D Nulliparity
E Diabetes
Ref.: 17, 20
Comments
Patients who have complex hyperplasia with atypia have a 20% to 30% chance for the development or presence of a coexisting adenocarcinoma. Risk factors for hyperplasia include obesity, hypertension, diabetes, anovulation, and unopposed estrogen use.
Answer
B
13 What is the single most important prognostic indicator for endometrial cancer?
A Stage
B Depth of invasion
C Uterine size
D Lymphovascular invasion
E Histologic subtype
Ref.: 16, 17, 20
Comments
Stage and histology are the most important prognostic factors for endometrial cancer, especially the presence of extrauterine disease, particularly pelvic and para-aortic lymphadenopathy.
Answer
A
14 For the patient in Question 10 with endometrial cancer, what preoperative work-up should have been done initially?
A CT of the chest, abdomen, and pelvis
B Endometrial biopsy or dilation and curettage
C Pelvic transvaginal ultrasound
D All of the above
E Only B and C
Ref.: 8, 15, 16, 19
Comments
Ultrasound measurement of the thickness of the endometrial stripe can assist in avoiding unnecessary biopsies. A postmenopausal woman with an endometrial stripe of less than 5 mm and no an irregularity in the cavity is very unlikely to have a carcinoma. Endometrial biopsy or dilation plus curettage is the procedure for the evaluation and possible therapeutic treatment of menorrhagia, menometrorrhagia, and abnormal uterine bleeding.
Answer
E
15 A 63-year-old woman was undergoing a hysterectomy and debulking for a uterine sarcoma that appeared to be extending into the pelvic side walls. You were called in to assist with the intraoperative hemorrhage that occurred after the hysterectomy was performed. The estimated blood loss at this time was approximately 2 L, she was normothermic, and her total operative time was 3 hours. Her hemoglobin level dropped from 10 to 7 g/dL. However, her platelet count is still 175,000/mm3. Intraoperatively, brisk bleeding appeared to be coming from near the uterine vessels that were coated with tumor. As the surgeon, what options would appear to decrease the bleeding?
A Administration of platelets
B Bilateral ligation of the anterior division of the hypogastric artery
C Ligation of the internal iliac vein
D Use of fibrin sealant
E Bilateral ligation of the anterior and posterior branches of the hypogastric artery
Ref.: 8, 16, 17
Comments
Bilateral hypogastric artery ligation can reduce pulse pressure by 85% and blood flow by 50%. It is important to ligate only the anterior division of the hypogastric artery and not the posterior division. In addition, fibrin sealant can be used to stop bleeding from small and inaccessible blood vessels. These sealants mimic the last step of the coagulation cascade.
Answer
B
16 For the patient in Question 15, after the aforementioned was done and on further investigation, she has already received 8 units of packed red blood cells and a large volume of crystalloid and continues to have small but diffuse venous bleeding. What is the best next step in the management of this hemorrhage?
A Continuation of the operation and finishing the surgery
B Replacement of coagulation factors
C Pelvic packing and reoperation in 24 to 48 hours
D Only B and C
E None of the above
Ref.: 8, 16, 17
Comments
By now the patient most probably has a dilutional coagulopathy, and therefore replacement of clotting factors and pelvic pressure should be the next step. Application of pelvic pressure with tight packing plus reoperation when the patient is fully resuscitated in 24 to 48 hours has also been shown to help in multiple case series.
Answer
D
17 A 40-year-old G4P3 woman comes to the emergency department complaining of vaginal bleeding, pelvic pain, flank pain, foul-smelling discharge, and disorientation. Her past medical history is significant for three normal vaginal deliveries and one miscarriage. In addition, she did have a history of abnormal Papanicolaou smears approximately 3 years earlier. What initial laboratory work-up must be done?
A Complete metabolic panel
B Complete blood count
C β-Human chorionic gonadotropin (β-hCG)
D Urine analysis
E All of the above
Ref.: 16, 17, 20
Comments
A good history and physical examination, including a pelvic examination, is an absolute in any patient with abnormal vaginal bleeding and can usually determine the origin of this bleeding. This patient’s differential diagnosis includes PID, miscarriage, dysfunctional uterine bleeding, cervical lesions including cervical cancer, and urinary tract infections leading to pyelonephritis. A complete metabolic panel and a complete blood count are important in this patient because she is disoriented, which could be caused by electrolyte abnormalities or severe anemia. In addition, all patients younger than 50 years should have urine hCG determined to rule out a miscarriage. Finally, urine analysis and culture will determine whether this patient has a urinary tract infection and possibly pyelonephritis, as well as hematuria.
Answer
E
18 Assuming that the patient in Question 17 is not pregnant and was found to have cervical cancer extending to the side wall on pelvic examination, what is the most likely minimal stage of her cervical cancer?
A Stage IB2
B Stage IIB
C Stage IIIA
D Stage IIIB
E Stage IV
Ref.: 5, 8, 16
Comments
Cervical cancer stage IIIB includes T3b or T1-3, any N or N1, and M0, extension onto the pelvic side wall and/or causes hydronephrosis and/or a nonfunctional kidney (Figure 31-1).
Figure 31-1 AJCC Cervix Uteri Cancer Staging Poster.
(Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer Science and Business Media LLC, www.springer.com.)
Answer
D
19 Which of the following risk factors have the strongest association with cervical cancer?
A Multiple sexual partners
B Early onset of intercourse
C Human papillomavirus (HPV)
D Human immunodeficiency virus (HIV)
E Smoking
Ref.: 8, 21
Comments
Squamous cell carcinoma of the cervix is a disease of sexually active women. Infection with specific high-risk strains of HPV is central to the pathogenesis of cervical cancer. Risk factors that predispose to infection with HPV include early onset of intercourse, multiple sexual partners over time, and sexual partners who themselves have had multiple sexual partners. Cigarette smoking increases the risk for cervical cancer up to fourfold. Immunosuppression also significantly increases risk for the development of cervical cancer. Squamous cell carcinoma accounts for approximately 80% of cervical cancers, adenocarcinoma for 15%, and adenosquamous carcinoma for 3% to 5%.
Answer
C
20 Which is the most appropriate next step after an abnormal Papanicolaou smear?
A Simple hysterectomy
B Cold knife cone
C Loop electrosurgical excision procedure
D Colposcopy and possibly biopsy
E Radical hysterectomy
Ref.: 8, 17, 20
Comments
Pap smears are a screening test for dysplasia and malignancy. Abnormal Pap smears require further evaluation with colposcopy to exclude glandular lesions and atypical cells from low- and high-grade squamous intraepithelial lesions. Biopsy at the time of colposcopy can confirm the histologic diagnosis of mild, moderate, or severe dysplasia.
Answer
D
21 A patient in whom cervical cancer was diagnosed underwent CT that showed disease confined to her pelvis. Which of the following treatment modalities would be most appropriate?
A Simple hysterectomy
B Radical hysterectomy
C Pelvic exenteration
D Pelvic irradiation as well as brachytherapy
E Chemoradiation therapy directed to the pelvis with brachytherapy
Ref.: 8, 16, 17, 19, 20
Comments
For stages IIB to IVA tumors, treatment is a combination of extended field radiation therapy with cisplatin-based chemotherapy. Radical hysterectomy involves removal of the uterus, resection of parametrial tissue lateral to the ureter, ligation of the uterine arteries at their origin on the hypogastric arteries, transection of the uterosacral ligaments near the rectum, and removal of the upper third of the vagina. Pelvic lymphadenectomy is commonly done at the time of radical hysterectomy. The ovaries are preserved if they appear normal. This is usually done in conjunction with pelvic lymph node dissection for early cervical cancer stages IA2 to IB2. Extrafascial hysterectomy can be performed for stage IA1 cervical cancer; it involves removal of the uterus, preservation of the parametrium, ligation of the uterine vessels at the level of the cervical os, transection of the uterosacral ligaments at the uterus, and preservation of the vaginal cuff. Because of the more extensive and lateral dissection done during radical hysterectomy, there is a higher incidence of ureteral and bladder complications than with extrafascial hysterectomy.
Answer
E
22 The patient from Question 21 had initially been treated nonsurgically and is now seen 2 years later with a pelvic recurrence of her cervical cancer. All of the following are acceptable criteria for surgical intervention except:
A Central recurrence
B Disease extending to the side wall
C Disease invading the bladder and causing a vesicovaginal fistula
D Disease invading the rectum and causing a rectovaginal fistula
E Both B and C
Ref.: 8, 16, 17, 20
Comments
Once there is evidence of local recurrence on pelvic examination, distant disease must be ruled out by imaging studies. After this has been completed, side wall involvement must be ruled out by examining the patient under anesthesia. Patients with central recurrence of cervical cancer who have previously undergone radiation therapy can be cured with pelvic exenteration.
Answer
B
23 One year after the patient underwent pelvic radiation therapy, she began having symptoms of bowel obstruction. Which segment of bowel is most commonly affected?
A Terminal ileum
B Cecum
C Sigmoid colon
D Rectum
E None of the above
Ref.: 8, 17
Comments
Patients treated by external radiation therapy, brachytherapy, and possibly extended field irradiation are at risk for bowel complications, particularly when the terminal ileum and other segments of bowel are fixed in place either physiologically or from previous surgery.
Answer
A
24 Two years after completing pelvic radiation therapy she started having rectal bleeding. All of the following are acceptable treatment options for hemorrhagic proctitis except:
A Transfusions if necessary
B Colonoscopy, biopsy to rule out recurrence, and focal cautery
C Colonoscopy and focal cautery
D Cortisone enemas
E Colostomy with resection of the affected bowel
Ref.: 8, 16, 17
Comments
Hemorrhagic proctitis can be managed with cortisone enemas and transfusion. Colonoscopy with focal cautery can also be performed. However, biopsies are avoided because of the risk for fistula formation. In some cases, colostomy with resection of the affected bowel may be indicated.
Answer
B
25 Regarding endometriosis, which of the following is not true?
A Total abdominal hysterectomy with bilateral salpingo-oophorectomy is considered definitive surgical therapy.
B Adenomyosis is a clinical variant of the disease.
C Laparoscopy is considered the “gold standard” for diagnosis.
D Minimal and mild stages of the disease can be associated with infertility.
E Symptoms include pelvic pain and dysmenorrhea.
Ref.: 20, 22
Comments
Endometriosis is defined as endometrial tissue outside the uterus. Symptoms can include pelvic pain, dysmenorrhea, and infertility. Minimal and mild stages of the disease have been associated with infertility. The diagnosis can be made empirically if the patient’s symptoms are ameliorated after a short (3-month) trial of a gonadotropin-releasing hormone agonist and after all other causes have been ruled out. Laparoscopy, however, is considered the gold standard for diagnosis. Definitive surgery for endometriosis consists of total abdominal hysterectomy with bilateral salpingo-oophorectomy. Bilateral salpingo-oophorectomy is the key component because it results in surgical menopause. Adenomyosis, which refers to endometrial tissue within the myometrium, is not considered a variant of the disease. Symptoms of adenomyosis include abnormal uterine bleeding and dysmenorrhea. Medical therapy for adenomyosis is usually ineffective, and surgery (hysterectomy) is generally required for persistent symptoms.
Answer
B
26 Which ovarian tumor is correctly matched with the most appropriate characteristic?
A Masculinizing—Endodermal sinus tumor (yolk sac)
B α-Fetoprotein (AFP)—Sertoli-Leydig cell tumor
C hCG—Choriocarcinoma
D Elaborates estrogen—Granulosa-theca cell tumor
E None of the above
Ref.: 16, 23, 24
Comments
Ovarian tumors are frequently characterized by their ability to produce hormones or biologic markers. Sertoli-Leydig cell tumors produce androgens and frequently cause masculinization. Granulosa-theca cell tumors frequently produce estrogen and have been associated with precocious puberty in young patients and endometrial cancer in older patients. Endodermal sinus tumor (yolk sac tumor), which is the second most common germ cell ovarian tumor, secretes AFP. Choriocarcinoma produces hCG, which can be used as a marker to gauge response to treatment.
Answer
C
27 All of the following statements are true except:
A Clear cell carcinoma—Seen in adolescents or young adult females
B Sarcoma botryoides—Seen in infants
C Squamous cell carcinoma—Most common primary vaginal cancer
D Vaginal cancer—Most are secondary to direct spread from other organs
E Primary upper-third vaginal cancer—Should be treated as vulvar cancer
Ref.: 16, 17, 23
Comments
Squamous cell carcinoma is the most common primary vaginal malignancy. Most vaginal cancers are direct extensions from cancers arising in adjacent organs. Sarcoma botryoides is a bulky polypoid sarcoma commonly found in infants or young children. Clear cell carcinoma can develop in adolescent or adult children of mothers who took diethylstilbestrol during pregnancy.
Answer
E
28 Regarding vaginal cancer, which of the following is not true?
A It is rare.
B Tumor extending to the pelvic side wall is considered stage II disease.
C Primary vaginal cancer involving the upper third of the vagina should be treated as though it were cervical cancer.
D It is predominantly a disease of older women.
E All of the above are true.
Ref.: 8, 16, 17
Comments
Primary vaginal cancer is predominantly a disease of older women but is rare overall. Primary vaginal cancers involving the upper third of the vagina generally behave as cervical cancer and are treated as such. Similarly, tumors involving the lower third of the vagina are treated as vulvar cancer. Management of tumors involving the middle third of the vagina is challenging. Vaginal carcinoma is staged clinically. The tumor may be limited to the vaginal wall (stage I), extend to subvaginal tissue (stage II), extend to the pelvic side wall (stage III), spread to adjacent organs or to areas outside the true pelvis (stage IVA), or spread to distant organs (stage IVB).
Answer
B
29 Which of the following vulvar abnormalities is not considered a risk factor for invasive malignancy?
A Vulvar intraepithelial neoplasia (VIN) type III
B Paget disease
C Lichen sclerosis
D Hypertrophic dystrophy without atypia
E All of the above are risk factors
Ref.: 17, 20
Comments
Suspicious vulvar lesions should undergo biopsy to rule out malignancy. There are numerous risk factors for vulvar cancer, including a history of vulvar dysplasia, smoking, hypertension, diabetes, and chronic steroid use. Vulvar lichen sclerosis has an approximately 5% risk of progressing to invasive squamous cell carcinoma. Hypertrophic dystrophy without atypia of the vulva is a nonneoplastic epithelial disorder that is not considered a risk factor for malignancy. Paget disease is an intraepithelial lesion of the vulva associated with vulvar adenocarcinoma. Untreated VIN can progress to vulvar cancer in 5% of cases. VIN is commonly multifocal, and multiple biopsies are needed to determine the extent of the disease. Acetic acid can be used to help identify dysplastic vulvar lesions. Treatment of VIN consists of observation, wide local excision, skinning vulvectomy, laser ablation, or topical 5-fluorouracil (5-FU). Most lesions that undergo spontaneous regression do so within 6 months. Wide local excision requires removal of a full thickness of skin with a 2- to 3-cm cancer-free margin. Laser treatment to a depth of 1 mm in non–hair-bearing areas and 3 mm in hair-bearing areas is required for effective treatment. Topical 5-FU can be very effective but requires good compliance on the part of the patient and is associated with significant skin reactions.
Answer
D
30 Regarding vulvar carcinoma, which of the following is false?
A Squamos cell cancer is the most common type.
B There is an association with HPV infection in young patients.
C Pruritus is one of the most common symptoms.
D The disease is staged clinically.
E Ulceration lesion is one of the common initial complaints.
Ref.: 17, 20
Comments
Squamous cell cancer is the most common vulvar malignancy. Pruritus and the presence of an abnormal or ulcerating lesion are common initial complaints. High-risk subtypes of HPV have been associated with vulvar cancer in younger patients. Patients often have a history of cervical or vulvar dysplasia. Vulvar cancer, unlike cervical cancer, is staged surgically. Staging assists in guiding treatment and determining prognosis.
Answer
D
31 Which is the correct match for clinical pelvic organ prolapse with the appropriate description?
A Rectocele—Uterosacral ligament defect
B Cystocele—Defect in the pubocervical fascia
C Enterocele—Defect in the rectovaginal septum
D Uterovaginal prolapse—Herniation of the pouch of Douglas between the uterosacral ligaments
E All of the above are matched correctly
Ref.: 20, 22
Comments
Damage to endopelvic fascial support structures can lead to prolapse of pelvic organs. The pubocervical fascia provides major support to the urethra and bladder. Damage to this support structure can lead to a cystocele, which causes protrusion of the bladder through the anterior vaginal wall. The rectovaginal septum lies between the posterior vagina wall and the anterior part of the rectum. Damage to this septum results in a rectocele, which is a herniation of the rectum anteriorly. In addition to distressing symptoms from the bulge itself, rectoceles can cause a sensation of obstructed defecation from trapping of stool. The uterosacral ligaments, along with the cardinal ligaments, provide major support to the cervix and upper part of the vagina. Weakened or damaged uterosacral ligaments can lead to uterovaginal prolapse. The uterosacral ligaments also prevent the development of an enterocele, or herniation of small bowel into the pouch of Douglas.
Answer
B
32 Potential sites for ureteral injury during abdominal hysterectomy with bilateral salpingo-oophorectomy include all of the following except:
A Transection of the round ligaments
B Transection of the uterine arteries
C Transection of the cardinal ligaments
D Transection of the infundibulopelvic ligaments
E All are potential sites of injury
Ref.: 19, 20
Comments
Anatomic knowledge of the course of the ureters in the pelvis is essential for preventing ureteral injury. The ureters travel in the retroperitoneal space in the abdominal and pelvic segments. In the abdomen, they run downward and medially along the anterior surface of the psoas muscle. The iliopectineal line serves as the marker for the pelvic segment of the ureter. The ureters cross the iliac vessels as they enter the pelvis and travel in the medial leaf of the parietal peritoneum. They course near the ovarian and uterine vessels. Thus, they are susceptible to injury during transection of the infundibulopelvic ligaments and uterine arteries. The ureters travel through the cardinal ligaments about 1 to 2 cm lateral to the cervix.
Removal of the cervix during hysterectomy places the ureter at risk for injury. In general, the ureters do not travel near the round ligaments. In a pelvis with normal anatomy, this is not regarded as a common site for ureteral injury.
Answer
A
33 Regarding menopause, which of the following is false?
A The average age at onset in the United States is 51.4 years.
B It occurs as result of gradual depletion of functional ovarian follicles.
C Unopposed estrogen is acceptable therapy for women with a uterus and vasomotor symptoms.
D Vaginal atrophy, vasomotor symptoms, and osteoporosis are sequelae.
E All of the above are true.
Ref.: 20
Comments
The average age at menopause in the United States is 51.4 years. A gradual decrease in the number of ovarian follicles usually precedes its onset. The result is diminished estrogen production. This hypoestrogenic state may lead to vasomotor symptoms, vaginal atrophy, and osteoporosis. Menopausal hormone therapy is usually highly effective in ameliorating all of these symptoms. For patients who have contraindications to menopausal hormone therapy, alternative therapies exist for each of these symptoms. If menopausal hormone therapy is prescribed, it should never be given as an unopposed oral estrogen formulation in women with a uterus. Unopposed estrogen has been associated with an increased incidence of endometrial hyperplasia with atypia, the precursor to endometrial cancer. Combination oral menopausal hormonal therapy has been reported in a recent randomized controlled trial to be associated with increased risk for breast cancer, coronary heart disease, dementia, and venous thromboembolic events.
Answer
C
34 Regarding pelvic inflammatory disease (PID), which of the following is true?
A Neisseria gonorrhoeae is the most common causative organism.
B Physical examination is considered the gold standard for diagnosis.
C Chronic pelvic pain and ectopic pregnancy are common sequelae.
D It should initially be treated with parenteral antibiotics.
E CT scan of the pelvis should be done routinely.
Ref.: 25
Comments
Treatment of pelvic inflammatory disease is the most common reason for gynecologic hospital admissions in the United States. PID is a spectrum of inflammatory disorders of the upper genital tract in women that include salpingitis, endometritis, and tubo-ovarian abscess (TOA). Bacterial organisms involved include N. gonorrhoeae, Chlamydia trachomatis, endogenous aerobic and anaerobic bacteria, and Mycoplasma. C. trachomatis is the causative organism more often than N. gonorrhoeae. Although physical examination is frequently used to diagnose PID, laparoscopy is considered the gold standard for diagnosis. Patients who meet the diagnostic criteria can be treated as outpatients with broad-spectrum antibiotics, but a follow-up evaluation should be scheduled for 48 hours later. Patients who fail outpatient therapy should be admitted and treated with intravenous broad-spectrum antibiotics. Imaging studies are required if one suspects TOA. All patients with PID should be counseled about the common sequelae of the disease, which include chronic pelvic pain, infertility, and increased risk for ectopic pregnancies.
Answer
C
35 Regarding TOAs, which of the following is false?
A Initial outpatient oral antibiotic therapy is currently considered suboptimal treatment.
B Initial therapy should be nonsurgical.
C TOAs are present in approximately 50% of patients with PID.
D Unilateral removal can be used as conservative therapy for women desiring fertility.
E None of the above.
Ref.: 19, 20
Comments
Tubo-ovarian abscesses are present in 10% of women with PID. They are more common in women with concurrent bacterial vaginosis or HIV infection. TOAs contain a mixture of anaerobic and facultative or aerobic organisms. Therefore, antibiotic therapy should cover a wide range of organisms, including N. gonorrhoeae and C. trachomatis. Initial therapy with oral antibiotics does not appear to provide sufficient serum antibiotic levels to treat TOAs. In general, broad-spectrum intravenous antibiotics should be used as initial therapy. If the patient’s symptoms do not improve over a 24- to 48-hour period, alternative interventions such as surgery should be considered. TOAs can be drained laparoscopically or under radiologic guidance. There appears to be no difference in outcome between these approaches. Midline pelvic TOAs may be drained through a posterior colpotomy. Frequently, a temporary intraperitoneal catheter is left in place for drainage. For patients who are not candidates for conservative procedures, resection of TOAs via laparotomy is commonly done. TOAs involving both ovaries or the uterus are treated with hysterectomy and bilateral salpingo-oophorectomy. Unilateral TOAs can be treated with unilateral adnexectomy for patients desiring fertility. The abdominopelvic cavity should be irrigated extensively. Ideally, the vaginal cuff should be left open or an intraperitoneal catheter placed for postoperative drainage. Ruptured TOAs are surgical emergencies. Patients should undergo prompt surgical treatment via laparotomy after they are hemodynamically stabilized. These patients usually have acute and progressive pelvic pain, and they may be hemodynamically unstable. The mortality rate associated with a ruptured TOA is 5% to 10%. Delay in diagnosis and treatment results in higher mortality rates. Most patients undergo hysterectomy with bilateral salpingo-oophorectomy. Conservative surgeries for ruptured TOAs have not been well studied. Broad-spectrum intravenous antibiotics are continued until the patient is able to tolerate oral intake, and oral antibiotics are continued until the patient is afebrile.
Answer
C
References
1 ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Obstet Gynecol. 2002;100:1413-1416.
2 American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol. 2003;21:2397-2406.
3 Kaiser Permanente Guideline. BRCA1 genetic screening, 1998.
4 Myers ER, Bastian LA, Havrilesky LJ, et al. Management of adnexal mass. Evid Rep Technol Assessment. 2006;130:1-145.
5 . National Comprehensive Cancer Network (NCCN) Guidelines for Hereditary Breast and/or Ovarian Cancer. available online at www.nccn.com/physician_gls/index.html
6 Scheuer L, Kauff N, Robson M, et al. Outcome of preventive surgery and screening for breast and ovarian cancer in BRCA mutation carriers. J Clin Oncol. 2002;20:1260-1268.
7 Statement of the American Society of Clinical Oncology: genetic testing for cancer susceptibility, Adopted on February 20, 1996. J Clin Oncol. 1996;14:1730-1736. discussion 1737–1740
8 Townsend CMJr, Beauchamp RD, Evers BM, et al, editors. Sabiston textbook of surgery: the biological basis of modern surgical practice, ed 18, Philadelphia: WB Saunders, 2004.
9 Genetic risk assessment and BRCA mutation testing for breast and ovarian cancer susceptibility: recommendation statement. Ann Intern Med. 2005;143:355-361. 6
10 Hampel H, Sweet K, Westman JA, et al. Referral for cancer genetics consultation: a review and compilation of risk assessment criteria. J Med Genet. 2004;41:81-91.
11 Sanai FM, Bzeizi KI. Systematic review. Tuberculous peritonitis: presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther. 2005;22:685-700.
12 Shakil AO, Korula J, Kanel GC, et al. Diagnostic features of tuberculous peritonitis in the absence and presence of chronic liver disease: a case control study. Am J Med. 1996;100:179-185.
13 Mullholland MW, Lillemoe KD, Doherty GM, et al, editors. Greenfield’s surgery: scientific principles and practice, ed 4, Philadelphia: Lippincott Williams & Wilkins, 2006.
14 Petignat P, Vajda D, Joris F, et al. Surgical management of epithelial ovarian cancer at community hospitals: a population-based study. J Surg Oncol. 2000;75:19-23.
15 Schrag D, Earle C, Xu F, et al. Associations between hospital and surgeon procedure volumes and patient outcomes after ovarian cancer resection. J Natl Cancer Inst. 2006;98:163-171.
16 DiSaia PJ. Clinical gynecologic oncology, ed 6. St. Louis: CV Mosby; 2002.
17 Hoskins WJ. Principles and practice of gynecologic oncology, ed 3. Philadelphia: Lippincott Williams & Wilkins; 2000.
18 Tamussino KF, Lim PC, Webb MJ, et al. Gastrointestinal surgery in patients with ovarian cancer. Gynecol Oncol. 2001;80:79-84.
19 Thompson JD, Rock AR. Te Linde’s operative gynecology, ed 9. Philadelphia: Lippincott Williams & Wilkins; 2003.
20 Herbst AL, Mishell DR, Stenchever MA, et al. Comprehensive gynecology, ed 4. St. Louis: Mosby–Year Book; 2001.
21 Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189:12-19.
22 Bent AE. Ostergard’s urogynecology and pelvic floor dysfunction, ed 5. Philadelphia: Lippincott Williams & Wilkins; 2003.
23 Berek JS. Practical gynecologic oncology, ed 3. Philadelphia: Lippincott Williams & Wilkins; 2000.
24 Briasoulis E, Karavasilis V, Pavlidis N. Megestrol activity in recurrent adult type granulosa cell tumour of the ovary. Ann Oncol. 1997;8:811-812.
25 Available online at www.cdc.gov/STD/treatment/2006/updated-regimens.htm
B Neurosurgery
Adam P. Smith, M.D., Richard W. Byrne, M.D.
1 Which of the following statements regarding diagnostic procedures used to evaluate the central nervous system (CNS) is false?
A MRI is the most useful initial test for the evaluation of spinal cord compression.
B Magnetic resonance angiography eliminates some of the risk associated with cerebral angiography.
C Water-soluble contrast material has decreased the incidence of arachnoiditis following myelography.
D CT is the best available radiographic test for soft tissue evaluation.
E MRI does not expose the patient to radiation.
Ref.: 1-5
Comments
In evaluating intracranial processes, magnetic resonance imaging is superior to computed tomography in many cases. MRI is associated with minimal bone artifact, yields high-grade differentiation of gray-white matter, can directly scan multiple planes (although CT reconstructions can be useful), and does not expose the patient to radiation. In the case of spinal cord compression, MRI will identify the degree of soft tissue or bone impingement on the spinal cord, hematoma within or around the spinal cord, and any changes in signal within the cord itself. CT identifies bone structures well, along with some indications of canal or foraminal stenosis, but it provides poor delineation of soft tissues or the degree of actual neural tissue compression. Angiography is the main method for identifying and evaluating vascular lesions, for preoperative evaluation and possible treatment of tumors, and for identifying vascular involvement in trauma to the brain and spinal cord. The risks involved in angiography are predominately vessel rupture, embolus formation, and vessel spasm, all of which could lead to stroke. Adverse reactions to contrast material may also occur. These risks may be obviated by the use of magnetic resonance angiography, but the images obtained are of slightly inferior quality. With the advent of higher-power MRI (i.e., 3-T or greater MRI), angiography is still believed to be superior. The use of water-soluble contrast media during myelography has decreased the incidence of postprocedure arachnoiditis. Most institutions use CT scanning in conjunction with myelography. Computed tomographic myelography is most commonly used to evaluate intervertebral disk disease, but it is also useful for patients with contraindications to MRI. Following trauma, CT myelography may identify nerve root avulsion. CT is at present the most useful diagnostic tool for identifying acute hemorrhage or fracture intracranially and for identifying spine fractures or subluxations. Modern units perform axial cuts of approximately 5 mm and provide resolution in the range of 1 mm. The major disadvantage of CT is the artifact created by bone and the poor resolution of neural tissue.
Answer
D
2 Which of the following statements regarding scalp injuries is true?
A The blood supply to the scalp lies between the periosteum and the galea.
B Most scalp laceration hemorrhages can be controlled by applying direct pressure.
C Subgaleal hematomas must be drained to avoid abscess formation and extensive scalp elevation.
D If a scalp laceration extends below the zygoma, facial weakness may result from damage to the ipsilateral trigeminal nerve.
E The scalp consists of two layers: the skin and the subcutaneous tissue.
Ref.: 2, 3
Comments
The scalp consists of five layers: skin, subcutaneous tissue, galea aponeurotica, loose areolar tissue, and periosteum (SCALP). The skin and galea are the layers of surgical importance, with the blood supply lying between the skin above and the galea below. Because the blood supply to the scalp is rich, lacerations can be accompanied by significant blood loss. When the underlying skull is intact, this blood loss can be controlled by simple pressure. If the skull is fractured, however, direct pressure may be hazardous to the underlying brain tissue. Pulling the retracted galea back over the wound edge with forceps often controls such hemorrhage. Contusions causing subgaleal hemorrhagecan lead to the formation of large subgaleal hematomas that can elevate extensive portions of the scalp off the skull. In this instance, compression dressings can reduce the extent of hematoma formation. If the overlying scalp is viable and there is no evidence of infection, subgaleal hematomas may be left alone to resolve naturally over a period of several weeks. If the hematoma is infected, it is necessary to evacuate it. The occipitalis and frontalis muscles insert on the galea, and contraction of these muscles tends to separate areas of galeal disruptions. Therefore, even small lacerations of the galea should be closed. Regarding nonoperative treatment of subgaleal hematomas, large lacerations with significant loss of galeal or subgaleal tissue may be treated with compression dressings after appropriate débridement and closure to minimize the chance of residual subgaleal hematoma, infection, or both. The largest arteries supplying the scalp originate from the external carotid arteries and are the superficial temporal and occipital arteries. The facial nerve (cranial nerve VII) runs below the zygoma and may be injured if a laceration extends into the face. This may result in facial weakness, depending on which branch or branches are injured. As the facial nerve exits the cranium through the stylomastoid foramen, it penetrates the parotid gland and lies in a plane that separates the deep and superficial lobes of the parotid. It then divides into five main branches as it leaves the gland to innervate the muscles of facial expression. The temporal branch of the facial nerve lies within the deep temporal fascia, between the superficial layer of the deep temporal fascia and the superficial temporal fat pad. The superficial temporal fat pad splits the superficial and deep layers of the deep temporal fascia. Lacerations through this area may also damage the nerve. The trigeminal nerve supplies sensation to the face, and although scalp lacerations may also damage this nerve, such lacerations would not result in weakness of the muscles of facial expression.
Answer
B
3 Which of the following statements regarding hydrocephalus is the most accurate?
A It represents a primary process in up to two thirds of patients.
B It is classified as communicating or noncommunicating, depending on where the obstruction to cerebrospinal fluid (CSF) flow occurs.
C With proper, timely shunting, patients with hydrocephalus usually have intelligence equal to that of matched control groups without hydrocephalus.
D Hydrocephalus ex vacuo is more common in the young.
E Clinical signs of hydrocephalus are manifested the same ways in all age groups.
Ref.: 2, 3, 5
Comments
Hydrocephalus is a secondary, not a primary problem. Causes of hydrocephalus include aqueductal stenosis, dysfunction of arachnoid granulations, subarachnoid scarring, blockage of cerebrospinal fluid by blood clot or tumor, or rarely excess production by some choroid plexus tumors. These causes may be classified as communicating or noncommunicating. With communicating hydrocephalus, obstruction to flow is outside the ventricular system, most commonly at the arachnoid granulations. Noncommunicating, or obstructive, hydrocephalus is caused by obstruction of CSF flow at any point within the ventricular system. The most common cause of congenital hydrocephalus is aqueductal stenosis. The clinical features of infantile hydrocephalus include diastasis of the cranial sutures, enlarging head circumference, bulging anterior fontanelle, and weakness of upward gaze (the “setting sun” sign). Clinical features of hydrocephalus past 1 year of age (when the cranial sutures are closed) include headache, nausea, vomiting, visual loss, and lethargy. In some cases, this progresses to coma and death without proper treatment of the increased intracranial pressure (ICP). Most cases of hydrocephalus are treated with pressure-activated shunts, the most common being a ventriculoperitoneal shunt. Other common distal catheter targets are the pleura, cardiac atrium, and gallbladder. Although treated patients usually attain acceptable levels of intelligence overall, patients with shunts do not commonly do as well intellectually as nonhydrocephalic matched control groups. The outcome largely depends on the cause of the hydrocephalus and how quickly and successful the hydrocephalus is treated. Hydrocephalus ex vacuo refers to enlarged ventricles secondary to loss of cerebral tissue, commonly following a cerebral insult or atrophy. It occurs most commonly in the elderly.
Answer
B
4 Which of the following statements regarding ICP monitoring is false?
A Ventricular pressure catheters are the reference standard for ICP monitoring.
B ICP monitoring should be performed in salvageable patients with a Glasgow Coma Scale (GCS) score of 3 to 8 after resuscitation and an abnormal findings on head CT.
C Risk factors for elevated ICP after head injury include age younger than 40 years, open basal cisterns on CT, and systolic blood pressure higher than 90 mm Hg.
D Normal ICP is 0 to 15 mm Hg or 0 to 20 cm H2O.
E ICP can be measured with either an intraparenchymal or ventriculostomy monitor.
Ref.: 5-9
Comments
Because of the approximate 1% risk for hemorrhage and 5% risk for infection with intracranial pressure monitoring, this procedure is not appropriate for all patients with head injury (especially those with coagulopathy or thrombocytopenia). ICP monitoring is appropriate in patients with a Glasgow Coma Scale score of 3 to 8 and abnormal findings on head CT or for selected patients with normal findings on CT and risk factors for elevated ICP, such as age older than 40 years, systolic blood pressure lower than 90 mm Hg, decerebrate or decorticate posturing on motor examination, or a suspicious mechanism of injury. CT may not show overt hemorrhage or lesions, but edema may still develop quickly and lead to high ICP. Common signs of brain swelling with high ICP on CT are slit ventricles, flattening or loss of normal cortical sulci patterns, blurring of normal gray-white junctions, and effacement of the basal cisterns. Ventricular catheters are an accurate, low-cost, and reliable method to monitor ICP, thus making them preferred over parenchymal, subarachnoid, subdural, or epidural devices. They have the additional ability to be recalibrated without replacement. The risk for hemorrhage associated with different ICP monitoring devices has not been clearly defined and it is rarely of clinical consequence. The presence of actual infection versus device colonization is difficult to assess with any ICP monitoring device without associated clinical signs. Colonization rates do appear to be related to the type of device, however, with parenchymal monitors carrying the highest rates. Recently, more advanced techniques such as cerebral oxygenation, cerebral blood flow, microdialysis, and electrophysiologic monitors are being studied. Normal ICP is 0 to 15 mm Hg, but ICP is not usually treated in most centers until it rises to 20 mm Hg or higher.
Answer
C
5 Which of the following is true regarding neurogenic shock?
A First-line therapy consists of repetitive fluid boluses with crystalloids.
B Pure α-adrenergic sympathomimetics are the vasopressor drugs of choice.
C Tachycardia and hypotension are pathognomonic signs of neurogenic shock.
D The absence of a cervical collar can be used to rule out neurogenic snock.
E Dopamine is the preferred vasopressor agent.
Ref.: 1, 5, 6
Comments
Neurogenic shock should be suspected in any patient with cervical spinal cord trauma. It is characterized by the sudden loss of sympathetic tone and the predominance of parasympathetic tone. Sympathetic control starts in the hypothalamus and is carried down the brainstem through the spinal cord, where it exits to target organs at the thoracic and high lumbar levels. Therefore, any damage to the cervical cord may disrupt descending sympathetic neurons. Common features of neurogenic shock include hypotension, bradycardia, warm and dry extremities, peripheral vasodilation, venous pooling with decreased cardiac output, poikilothermia, and priapism. In contrast to other forms of shock, loss of sympathetic tone in patients with neurogenic shock leads to both hypotension and bradycardia. As smooth muscle in the vasculature relaxes and blood pressure decreases, cardiac drive is also lost and reflexive tachycardia cannot be accomplished. First-line therapy is similar to that for other forms of shock and may involve placing the patient in the Trendelenburg position, fluid resuscitation, or administration of vasopressor agents, but a few key points differ. Because of loss of vasomotor tone, massive fluid boluses with crystalloids may result in flash pulmonary edema. Pressor agents are often useful, but an agent with only α-adrenergic properties may lead to unopposed reflexive bradycardia, which may worsen cardiovascular dynamics. An agent such as dopamine with both α- and β-adrenergic properties will combat any reflexive bradycardia and is the preferred medication. In any trauma with suspected cervical injury, a cervical collar is recommended until the spine is cleared. However, the pure absence of a cervical collar should never be used to rule out either cervical trauma or neurogenic shock.
Answer
E
6 Which of the following is true regarding cervical trauma?
A The mortality associated with atlanto-occipital dislocation is 100%.
B Most mortality in cervical trauma is not the direct result of neural compression.
C With the advent of CT, no other imaging is needed for evaluation of the cervical spine.
D In a neurologically intact patient with neck pain, the cervical spine can be cleared immediately with normal findings on plain cervical radiographs.
E Methylprednisolone should be started immediately in any trauma patient suspected of having cervical trauma, regardless of the findings on neurologic examination or the time of injury.
Ref.: 1-3, 5, 10-16
Comments
Evaluating, treating, or possibly clearing the cervical spine in a trauma patient is a procedure that can be complex at times. In fact, the spine trauma guidelines state that there is insufficient evidence to even support treatment guidelines. Initial immobilization of a trauma victim’s cervical spine is commonplace with most emergency medical service systems. The neck continues to be immobilized until the spine can be cleared by clinical assessment or radiographic imaging. The process of evaluating begins with a careful history and physical examination. In the absence of any suspicious mechanism of injury and with an asymptomatic patient (awake, alert, neurologically intact, not intoxicated, without neck pain/tenderness, and without other injuries that prevent appropriate assessment of the spine or that distract the patient), imaging is unlikely to be necessary. However, a symptomatic patient requires imaging. A three-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended, sometimes supplemented by computed tomography to better define suspicious or poorly visualized areas on plain cervical radiographs. The diagnostic performance of helical CT scanners has a sensitivity approaching 99% and specificity approaching 93%. Because of this, many trauma centers have proposed relying exclusively on CT to evaluate the cervical spine. However, the CT-generated artifact, especially in coronal and sagittal reconstructions, may distort the true anatomy of the cervical spine. Nonetheless, missed injuries on CT are extremely rare and the majority are ligamentous. In an awake and neurologically intact patient with neck pain, three-view plain cervical radiographs and CT are recommended to evaluate bony pathology. If pain is still present despite normal findings on radiography and CT, either magnetic resonance imaging or dynamic flexion/extension films are recommended. Atlanto-occipital dislocation, or craniocervical junction dislocation, occurs in approximately 1% of patients with cervical spine trauma and has been noted in 18% to 19% of patients with fatal cervical spine injuries at autopsy. Although the entity was previously perceived as an infrequent injury resulting in death, improved emergency management has recently provided increased survivors. Most mortality in patients with cervical spine trauma results from anoxia secondary to respiratory arrest from other injuries. The use of steroids, in particular methylprednisolone, after spinal cord injury is a matter of great debate. The original studies performed involved patients with known neurologic deficits seen within 8 hours of injury. A 30-mg/kg bolus, followed by a 23-hour infusion of 5.4 mg/kg/h, is the usual protocol. Even in this scenario, the degree of functional motor improvement is questionable, and side effects such as sepsis and pneumonia may occur. Therefore, no level I evidence exists to support the use of methylprednisolone for spinal cord injury, although many physicians still follow the protocol based on levels II and III data. However, in the setting of a neurologically intact patient or a patient with spinal cord injury but outside the 8-hour window, data suggest that steroids should not be administered.
Answer
B
7 Which of the following statements regarding traumatic CSF leaks is false?
A Most are caused by basilar skull fractures and close spontaneously.
B The risk for infection is greater with rhinorrhea than with otorrhea.
C They often do not require immediate surgical repair to avert infection.
D They may be observed for up to 14 days if there is no evidence of infection.
E The presence of a traumatic CSF leak mandates the use of prophylactic broad-spectrum antibiotic coverage.
Ref.: 2, 3, 5, 17, 18
Comments
The overall incidence of traumatic cerebrospinal fluid leak is 0.25% to 0.50%. It occurs secondary to a skull fracture that tears the dura. If a CSF leak is suspected, the fluid may be sent for determination of β2-transferrin because this protein only exists in CSF and the vitreous of the eye. Imaging studies may then be useful in identifying the site of leakage after one is suspected. Most traumatic cerebrospinal fluid fistulas close spontaneously within a few days, but they may be managed in the hospital under close supervision. Placement of a lumbar drain to divert the fistula can be helpful if spontaneous resolution does not occur. The risk for persistent drainage and infection is greater with rhinorrhea than with otorrhea. If left untreated, both rhinorrhea and otorrhea may eventually lead to infection, but some patients can go for years without sequelae. Initial treatment involves bed rest, elevation of the head of the bed, and stool softeners to prevent straining. The use of prophylactic antibiotics remains a controversial issue. Proponents believe that CSF leaks are exposed to upper respiratory tract and skin pathogens and are therefore at high risk for infection. Opponents argue that despite the exposure, prophylactic antibiotics contribute to antibiotic resistance and, moreover, that prophylactic antibiotics do not decrease the risk for meningitis. The evidence available does not support the use of prophylactic antibiotics, whether a skull fracture exists in isolation or with a CSF leak. However, if meningitis is confirmed, antibiotic therapy is started based on sensitivity of the organism. Surgical exploration may be indicated for leaks refractory to observation and lumbar drainage to repair the torn dura if the site of CSF leak can be found.
Answer
E
8 Which of the following statements regarding brain injury is false?
A The extent of brain injury is a function of the mechanism of injury.
B Contusions tend to involve the anterior portions of the frontal and temporal lobes.
C Diffuse axonal injury (DAI) is usually an incidental and asymptomatic finding.
D The effects of secondary edema and hematoma enlargement may be delayed for several days.
E Not all brain contusions are clinically apparent on neurologic examination.
Ref.: 2, 3, 5, 6, 8, 9
Comments
Localized force can damage the scalp, skull, and underlying brain tissue in the immediate area of injury. The resulting neurologic deficit is related to the area of the brain directly involved and usually produces brief or no loss of consciousness. The application of generalized force to the skull, such as that caused by impact of the head against an immovable object, allows diffuse transmission of energy and thus causes injury to the entire brain. In such a case the brain insult is generalized, with altered consciousness often being produced, and its severity is related to the mechanism of injury. For example, the injury may be the result of linear or rotational acceleration-deceleration of the brain against the cranium, such as when the head hits an immovable object. When the brain strikes the rigid skull, contusions occur in the area where the force is applied (coup injury), as well as against the opposite inner surface of the skull (contrecoup injury). The undersurface of the frontal lobes, the anterior portions of the temporal lobes, the posterior portions of the occipital lobes, and the upper portion of the midbrain are most likely to suffer contusions because they are relatively more confined by rough bone and dural shelves. The contusion may be clinically silent initially if the involved area of brain has no demonstrable clinical function. These injuries often become most apparent days after the injury as edema accumulates and creates the effects of an intracranial mass. Occasionally, a hematoma accumulates in the area of contusion 24 to 72 hours after initial injury despite having initial normal-appearing findings on CT. This situation occurs more often in elderly persons. Rotation of the brain within the skull may cause tearing of axons and result in diffuse axonal injury within the white matter, a so-called shearing injury, which is often severe. Some estimate that more than 90% of patients with severe DAI remain in a persistent vegetative state. DAI most commonly affects the subcortical white matter (centrum semiovale), corpus callosum, superior cerebellar peduncle, and dorsal rostral brainstem. The severity of DAI is based on (1) the distance from the center of rotation, (2) the arc of rotation, and (3) the duration and intensity of force. Gunshot brain injuries are frequently severe because of damage caused by the bullet and the associated shock wave that travels along the path. The primary injury, bleeding, swelling, and infection result in high mortality rates.
Answer
C
9 Which of the following is true regarding brain death?
A Neurosurgical evaluation is required for proper determination of brain death.
B Once the patient demonstrates no functional neurologic findings, including loss of all cranial nerves and reflexes, brain death can be pronounced.
C If toxicology studies show the presence of opiates in blood or urine, brain death may still be pronounced if all other criteria are met and if the opiates were given in known low concentrations.
D If while performing a brain death examination the patient becomes cardiovascularly unstable, the examiner should finish quickly to pronounce brain death without delay.
E Confirmation with electroencephalography (EEG) is not required to pronounce brain death.
Ref.: 1, 6, 19
Comments
Brain death is a confusing topic for many individuals, even within the realm of health care. Brain death is a clinical diagnosis, and the exact criteria may vary from one hospital to another. It may be legally performed by any physician, although many centers recommend either neurologic or neurosurgical consultation. The diagnostic criteria for brain death are (1) clinical or neuroimaging evidence of CNS dysfunction that is compatible with the clinical diagnosis of brain death, (2) exclusion of confounding medical conditions, (3) no drug intoxication or poisoning (the brain death examination may be performed only after laboratory-verified absence of any sedating drugs), and (4) core temperature higher than 32° C (febrile patients can be tested). Regarding the clinical criteria, findings must show (1) coma or unresponsiveness, including no cerebral motor response to pain; (2) absence of all brainstem reflexes, including absence of the pupillary response, oculocephalic reflex, cold caloric testing, corneal reflex, jaw reflex, cough reflex, or gag reflex; and (3) apnea testing. Usually, the brain death examination consists of two examinations separated in time, which is often at least 6 hours. Because the apnea test can destabilize an already potentially unstable patient, it is generally performed only after the second brain death examination when brain death is highly suspected. Prerequisites for the apnea test are (1) a core temperature higher than 36.5°C, (2) systolic blood pressure higher than 90 mm Hg, (3) euvolemia, (4) normal PCO2, and (5) normal serum electrolyte levels. The apnea test is usually performed as follows: The patient is given 100% O2 by nasal or tracheal cannula to maintain adequate oxygen saturation and prevent cardiovascular collapse. Baseline arterial blood gas studies are performed. The ventilator is disconnected, arterial blood gas studies are performed at variable intervals throughout the test, and the examiner assesses for respiratory movements. If no respiratory movements are observed and PCO2 is greater than 60 mm Hg or has increased more than 20 mm Hg from baseline at the end of the test, the apnea test supports the clinical diagnosis of brain death. One caveat is that the patient must remain cardiovascularly stable during the examination as described in the prerequisite criteria. If at any time the blood pressure falls below the criteria, the test should be stopped and repeated. Vasopressor agents may be used during the examination. After the apnea test, confirmatory tests are optional but do not replace the three core diagnostic criteria. Some examples of confirmatory tests are cerebral angiographyshowing no intracerebral filling at the level of the circle of Willis, confirmation of no electrical activity via electroencephalography, transcranial Doppler ultrasonography, technetium-99m hexamethylpropyleneamine oxime brain scan showing no uptake of isotope, or somatosensory evoke potentials showing no activity. Each of these confirmatory tests has flaws, including EEG, and may not appear to demonstrate brain death despite the other diagnostic criteria already having been fulfilled. This is why they are purely optional. Of note, some research now recommends monitoring pH levels rather than PCO2 during the apnea test.
Answer
E
10 Which statement is true regarding elevated ICP and brain herniation syndromes?
A The pupils are always dilated in the setting of brain herniation.
B After the pupils become fixed and dilated, no functional recovery is possible.
C Cortical sulci effacement may not be observed in the setting of increased posterior fossa pressure from a cerebellar hematoma.
D In a patient with a unilateral supratentorial mass and increased ICP, weakness will always be observed on the contralateral side of the body.
E Compression of the occulomotor nerve during brain herniation causes pupillary constriction.
Ref.: 1, 5, 6, 9, 12, 17, 20
Comments
In the setting of sustained elevated intracranial pressure, the brain will seek lower pressure and “herniate” across various dural attachments and bony prominences inside the cranium. Uncal herniation is one of the most recognized and is caused by elevated pressure in the supratentorial compartment with downward pressure on the brain. This forces the medial temporal lobe or lobes, including the uncus, through the incisura. The occulomotor nerve is compressed, thus impairing the parasympathetic fibers running superficially along the nerve, and dilation of either one or both pupils ensues. Of note, some studies suggest that brainstem ischemia from raised ICP may also be responsible for at least some cases of pupillary dilation when uncal herniation was not present. The overall mortality rate associated with herniation syndromes leading to fixed and dilated pupils has been reported to be as high as 75%. However, if medical therapy is instituted immediately and the pupils return to normal, a small chance of survival may exist, but often with low chance for a favorable outcome. If the pupils do not respond to therapy, few patients improve to more than a vegetative state. Not all brain herniation syndromes result in dilated pupils. Herniation of the frontal lobes into and beneath the falx may not affect the pupils at all. Similarly, pressure from a pontine hemorrhage may disrupt the descending sympathetic fibers and result in pinpoint pupils (myosis) from unopposed parasympathetic tone. Elevated ICP in the posterior fossa is unique in that it may cause either downward pressure through the foramen magnum or upward pressure into the tentorium cerebelli. In either case, the supratentorial compartment is often “protected” from the majority of the elevated pressure by the tentorium. Therefore, despite a resultant comalike state from brainstem compression, the supratentorial compartment may appear relatively unaffected on imaging studies with normal cortical sulci patterns. “Kernohan notch” refers to a transtentorial brain herniation scenario in which elevated supratentorial pressure pushes the contralateral cerebral peduncle into the tentorium. This is manifested as weakness ipsilateral to the side of pressure formation because the descending corticospinal fibers have not yet decussated.
Answer
C
11 Which of the following is true regarding the management of elevated ICP?
A Hemicraniectomy is first-line therapy for elevated ICP.
B Hypertonic saline is superior to mannitol for osmotherapy.
C Prolonged hyperventilation is a benign method for lowering elevated ICP.
D Maintenance of elevated cerebral perfusion pressure (CPP) may be more important in improved neurologic outcome at the expense of high ICP.
E Persistent hyperventilation is a terrific method to sustain alkalization and combat acidosis in the brain for long periods.
Ref.: 5, 6, 9, 21, 22
Comments
Cerebral perfusion pressure is calculated by the formula CPP = MAP − ICP, where MAP is mean arterial pressure. Therefore, as intracranial pressure rises to malignant levels, CPP falls. This is problematic in the treatment of elevated ICP, because attempts to continue perfusing the brain (elevating CPP) can occur only by elevating blood pressure (MAP). Increasing blood pressure with already elevated ICP leads to loss of the brain’s normal autoregulatory mechanisms, which eventually results in even higher ICP. Much debate exists over whether to focus treatment on CPP or ICP. Early studies indicated that greater than a 20-mm Hg elevation in ICP for sustained intervals was associated with poor neurologic outcome. Later studies indicated that CPP less than 60 mm Hg was also associated with worse outcome. Recent preliminary studies, however, have shown that aggressive maintenance of CPP at a level higher than 60 mm Hg, even with prolonged ICP higher than 50 mm Hg for more than 48 hours, may still lead to a good neurologic outcome. Further randomized trials need to be performed before definitive recommendations can be made. Unfortunately, there are no level I studies indicating an optimal CPP threshold or ICP limit on which to base CPP-guided therapy. The initial steps in controlling elevated ICP include medical therapies such as raising the head of the bed, maintaining the patient’s head straight, hyperventilation, and hyperosmolar therapy. Hyperventilation is a quick and easy way to lower ICP in theory, for lowering PCO2 will decrease cerebral blood flow and reverse brain parenchymal and CSF acidosis. However, hyperventilation is not without consequence. Disadvantages include induced vasoconstriction to a point where ischemia develops. The alkalization of cerebrospinal fluid is also very short-lived with hyperventilation. In a direct comparison of hyperventilation and no hyperventilation in patients with severe head injury, some studies have shown a statistically significant worse outcome in the hyperventilation group, mainly because of ischemia induced by the prolonged therapy. However, temporary hyperventilation is still a useful tool to lower ICP until other measures can be instituted. The usual hyperosmolar agents used in the setting of traumatic brain injury are mannitol and hypertonic saline. Mannitol has three postulated effects: (1) plasma expansion, which improves cerebral rheology; (2) antioxidant effect, which improves the cerebral reaction to ischemia; and (3) osmotic diuresis, which lowers MAP and then ICP in a slightly delayed fashion. This third mechanism, however, could be detrimental if diuresis decreases MAP to a point of reduced CPP. Regardless, a level III randomized controlled trial has shown improved outcome with mannitol therapy. Hypertonic saline, in contrast, reduces ICP while preserving or improving CPP. Although it is questioned whether the reduction in ICP by hypertonic saline is greater than that by mannitol, few studies have directly compared the two, and they are rarely compared in equimolar doses. Additionally, despite hypertonic saline’s proved effect on control of ICP, no evidence of improved outcome exists. As a result, there is insufficient evidence to support the use of hypertonic saline over mannitol for osmotherapy in adults. Hemicraniectomy has an important role in the treatment of elevated ICP; however, it is rarely used as first-line therapy except in some cases of malignant stroke.
Answer
D
12 Which of the following statements regarding the evaluation and care of head-injured patients is the most accurate?
A Hypotension is often the direct result of intracranial trauma.
B Decerebrate posturing is a common response to diffuse cortical injury.
C A score of 5 on the GCS is associated with a poor prognosis.
D The syndrome of inappropriate antidiuretic hormone secretion (SIADH) should be suspected when the serum sodium level exceeds 150 mEq/L.
E Brain injury takes predominance over any other injury, and therefore initial evaluation and management should focus only on the neurologic examination.
Ref.: 2, 3, 8, 9
Comments
Initial care of a head-injured patient must focus on maintenance of ventilation, control of hemorrhage, and maintenance of the peripheral circulation as in any trauma scenario. Continued hypotension and tachycardia are rarely the direct results of head trauma and should alert the examiner to the existence of a systemic hemorrhage. Normal intracranial volume is only 1300 cm3 in adult females and 1500 cm3 in adult males, which makes severe blood loss intracranially nearly impossible. Instead, severe intracranial trauma more commonly leads to the Cushing triad (hypertension, bradycardia, and irregular respirations). As soon as possible, careful neurologic examination and documentation of the level of consciousness should be undertaken as a baseline for later comparison as the patient progresses. Decerebrate posturing (extension and internal rotation of the extremities, neck extension, and arching of the back) implies compression of or damage to the brainstem below the level of the red nucleus (midbrain). The Glasgow Coma Scale measures motor, verbal, and eye responses on scales of 1 to 6, 1 to 5, and 1 to 4, respectively. It is recorded as a sum of the highest score in each category, and the lowest possible total score is 3. Coma is defined by a GCS score of 8 or less. Patients with a score lower than 5 have a mortality rate higher than 50%. Scores of 3 are associated with mortality approaching 100%. The syndrome of inappropriate antidiuretic hormone secretion should be suspected when serum osmolality and sodium levels fall in association with an increase in urinary osmolality. Restriction of water intake or the use of solute diuretics may be necessary to control this problem. SIADH sometimes needs to be differentiated from cerebral salt wasting (CSW), in which brain trauma induces the active secretion of sodium. Although the resultant hyponatremia and low serum osmolality are similar to SIADH, treatment of CSW focuses more on serum sodium replacement with hypertonic saline as opposed to fluid restriction.
Answer
C
13 Which of the following statements regarding cerebral edema caused by head injury is the most accurate?
A CT should be performed to exclude the diagnosis of intracranial hemorrhage or a mass lesion before starting therapy.
B Cerebral edema caused by head injury is vasogenic and not cytotoxic in origin.
C Steroids are useful for the treatment of head trauma.
D Hypercapnia induces cerebral vasoconstriction and is useful for decreasing intracerebral blood volume.
E Within a few hours (1 to 3 hours) after injury, maximal cerebral edema has already formed, so further monitoring is unnecessary if the patient is clinically stable.
Ref.: 2, 3, 6, 9, 23
Comments
According to the Monro-Kellie doctrine, the intracranial contents normally consist of brain tissue, intravascular blood, and CSF. If any of these components increase in volume, the others must reciprocally decrease to avoid increasing pressure. In the setting of injury, neuronal injury and death occur and lead to cytotoxic edema, which results in increased pressure and a compensatory reduction in blood flow and the production of cerebrospinal fluid. As the pressure is further elevated to high levels and cerebral perfusion continues to decrease, further neuronal death and edema occur. The onset of edema is usually slow and reaches its maximal level within 48 to 72 hours after injury. Therefore, these patients should be monitored closely, often in an intensive care unit, over the following few days because the true neurologic sequelae of edema may not initially be obvious early after injury. The progress of cerebral edema may be monitored by neurologic examination, computed tomography, and sometimes the use of intracranial pressure–monitoring devices. These devices are commonly used to monitor patients with altered consciousness following head injury or patients with Glasgow Coma Scale scores lower than 8. A baseline CT is initially obtained to identify intracranial hemorrhage or a mass lesion that may need to be evacuated surgically. Once these entities are ruled out, medical treatment is started to counter the progress of edema. This may be accomplished, but not necessarily in this order, by (1) elevating the head of the bed 15 to 30 degrees; (2) maintaining the patient’s head in a straight position to facilitate cerebral venous drainage; (3) temporary hyperventilation to PCO2 levels of 30 to 35 mm Hg; (4) hyperosmolar therapy and sometimes fluid restriction to minimize edema; (5) intermittent drainage of CSF through a pressure-monitoring catheter placed in the ventricular system; (6) paralytic agents to minimize patient agitation or elevated blood pressure, which may further increase ICP; and (7) neuronal burst-suppressive medications to minimize cerebral metabolism and counter neuronal distress from low perfusion. Finally, and in rare circumstances, decompressive hemicraniectomy may be indicated if enough swelling occurs from the edema and the high ICP is refractory to the aforementioned medical therapies. Frequently, the first few therapies are performed and the later, more invasive therapies are pursued only in refractory cases. Exciting experimental animal models using neuroprotective agents have not shown the same beneficial effects in humans when translated to clinical trials. New research on induced hypothermia has demonstrated promise in small case studies, but larger randomized trials have not yet been performed. Steroids are believed to decrease vasogenic edema by limiting the permeability of the vasculature, but they have not been shown to impede cell death from trauma or limit cytotoxic edema. No meta-analysis has been performed, but the largest trial to date on traumatic brain injury demonstrated an increase in mortality with steroids, and therefore steroids are not recommended.
Answer
A
14 Which of the following statements regarding subarachnoid hemorrhage (SAH) is the most accurate?
A Normal findings on CT of the brain exclude the possibility of SAH.
B Aneurysms occur most frequently on the basilar artery.
C Surgical or endovascular treatment is recommended for patients who are neurologically intact and have an uncomplicated aneurysmal SAH.
D The use of hypertension, hypervolemia, hemodilution (triple-H therapy), and calcium channel blockers is contraindicated for the treatment of vasospasm.
E Aneurysms are the most common cause of SAH.
Ref.: 4, 5
Comments
Trauma is the most common cause of subarachnoid hemorrhage, although aneurysms are the most common “nontraumatic” etiology. In the traumatic setting, patients commonly complain of only mild headache, and the neurologic sequelae are rarely as profound as observed in those with aneurysmal subarachnoid hemorrhage. Sudden severe headache followed by altered consciousness is the usual clinical pattern following aneurysmal SAH. Focal neurologic deficits may occur, but they are less common than those seen after occlusion of major intracranial arteries. The sequelae vary, depending on the size of the hemorrhage, and range from headache to death. Although CT is the diagnostic method of choice to confirm SAH, approximately 15% to 20% of patients with documented hemorrhage have normal findings on CT within 24 hours of the onset of SAH. It is therefore important to perform a lumbar puncture when SAH is suspected and CT is negative for SAH. Maintenance of a high red blood cell count (often >100,000/mm3) in the first and last tube is indicative of SAH rather than traumatic lumbar puncture. Furthermore, the presence of xanthochromia indicates hemorrhage, although xanthochromia may not be present if the hemorrhage occurred in the preceding few days. Angiography is helpful to confirm the presence of an aneurysm and is the gold standard for diagnosis. Computed tomographic angiography and magnetic resonance angiography are also helpful but may miss smaller aneurysms because of their limited resolution. Most intracranial aneurysms arise from the large intracranial arteries of the circle of Willis and at the origin of the vertebrobasilar arteries. The most common sites of aneurysm, in decreasing order of prevalence, are the anterior communicating artery and posterior communicating artery (nearly equal prevalence), middle cerebral artery, and vertebrobasilar system. Not all aneurysms rupture. Autopsy studies of the population as a whole indicate an approximately 4% to 5% prevalence of aneurysms. The risk for rupture and need for treatment of aneurysms found incidentally (no SAH) are much debated topics. Recent studies have used the size and location of incidentally found nonruptured aneurysms to stratify the risk for rupture, and the necessity for and type of treatment must be discussed with the patient based on the individual risk for rupture. Multiple aneurysms are present 20% of the time and tend to be symmetrical in distribution or arise from the same parent artery on opposite sides of the circulation. Aneurysms are congenital in nature (not caused by hypertension), but risk factors, predominately hypertension, are believed to induce rupture. The incidence of rupture is highest in patients between the ages of 40 and 60 years. Most aneurysms are “false” aneurysms, as opposed to “true” aneurysms, which contain all three layers of the vessel, or “pseudoaneurysms,” which contain no layers and are simply surrounded by previous blood clot. They most commonly have a saccular or berry-like shape, hence the name berry aneurysm. The goal of treatment is to isolate the aneurysm from the force of systolic blood flow. This should be attempted as early as possible. After initial rupture the aneurysm thromboses, but if left untreated, it may rerupture at an incidence of 4% on the first day and 1.5% every subsequent day to a risk of approximately 20% at 2 weeks and about 50% at 6 months. It is commonly recommended that surgical correction be performed within 48 to 72 hours, if possible. Antifibrinolytics, such as ε-aminocaproic acid, have been found to decrease the rate of rebleeding during the time preceding treatment. Current options for definitive treatment involve either craniotomy for clipping or endovascular coiling (with or without stenting) of the aneurysm. Vasospasm, or delayed ischemic neurologic deficit, is a common entity in patients with SAH. Symptomatic vasospasm occurs in approximately 15% of patients with SAH, results in the highest morbidity in patients surviving the initial hemorrhage, and can be aggressively treated after the ruptured aneurysm is secured by either clips or coils. It often occurs in delayed fashion after the initial hemorrhage (usually after the third day) and is seen most commonly between the sixth and eighth days after hemorrhage up until 2 weeks. There is no definitive way to predict whether or when vasospasm will occur. A calcium channel blocker (nimodipine) and relative hypertension, hypervolemia, and hemodilution (triple-H therapy) are the medical therapies most commonly recommended for combating vasospasm.
Answer
C
15 Which of the following statements regarding subdural hematomas (SDHs) is false?
A Acute SDHs are generally unilateral and have a poorer prognosis than chronic SDHs do.
B Adequate treatment of an acute SDH usually consists of drainage through bur holes.
C Chronic SDHs frequently recur.
D Chronic SDHs should be suspected in elderly patients with progressive changes in mental status, even without a definite history of trauma.
E SDHs carry a worse prognosis than do epidural hematomas (EDHs).
Ref.: 5-7, 12
Comments
Subdural hematomas are caused by rupture of veins traversing the subdural space or by arterial bleeding from parenchymal lacerations. Their symptoms and treatment depend on the rapidity of hematoma formation. All types of SDH (acute, subacute, or chronic) have in common the presence of a decreased level of consciousness out of proportion to the observed focal neurologic deficit. Acute subdural hematomas cause progressive neurologic deficit within 48 hours of injury. They usually follow severe head trauma, are unilateral, often have both arterial and venous sources of bleeding, and can progress rapidly. The diagnosis should be considered in any patient with a severe head injury who exhibits deteriorated neurologic status or who is unresponsive with a focal neurologic deficit. The hematomas are solid and easily visualized on CT as a hyperdense collection or sometimes a hypodense collection in the hyperacute setting with active bleeding. In contrast to epidural hematomas, they are crescent shaped, cross suture lines, but do not cross dural reflections. They can be bilateral, and adjacent intracerebral hematomas are often present. Treatment requires formal craniotomy with removal of solid clot and control of bleeding points. Subacute subdural hematomas are defined as those more than 48 hours but less than 2 weeks old. Patients are usually less severely injured than those with acute SDHs, and marked fluctuation of the level of consciousness or headache should alert surgeons to the diagnosis. With large hematomas, third-nerve palsy with dilation of the pupils is a warning sign that midbrain compression secondary to temporal lobe herniation is occurring. CT may not identify the collection because the hematoma becomes isodense 10 to 12 days after its formation, and bilateral hematomas may be present. If the clot is completely liquefied, two bur holes may be placed followed by copious irrigation. Otherwise, formal craniotomy may be required if the hematoma is more solid than liquid. Chronic subdural hematomas most often develop in the elderly, frequently without a clear history of antecedent trauma. They can occur months after the initial injury and should be suspected in patients with decreasing or fluctuating mental status out of proportion to the focal neurologic deficit. The hematoma is commonly liquid, and drainage via bur holes is often adequate. However, chronic SDHs frequently recur when associated with subdural membranes, which may then require formal craniotomy to strip the superficial membrane. Subdural-peritoneal shunting may also eventually be necessary. Because of the tremendous mass effect on the brain from an SDH, mortality may be as high as 60% and can approach 90% in patients older than 80 years without surgical treatment. The mortality associated with untreated EDHs is approximately 50%, lower than that for SDHs because the dural attachments prevent the EDH from compressing the brain to the degree observed with SDH. Patients with EDH may sometimes initially have a “lucid interval,” with temporary clinical improvement after the trauma followed by deterioration as the blood accumulates epidurally.
Answer
B
16 Which of the following statements regarding intracranial vascular malformations is the most accurate?
A Arteriovenous malformations (AVMs) are the most common vascular malformations in the brain.
B Venous angiomas commonly bleed and surgical removal is usually required.
C AVM rupture and aneurysm rupture may cause spontaneous SAH at nearly equal frequency.
D AVMs have a 2% to 4% incidence of hemorrhage per year.
E Capillary telangiectases are the least common vascular malformations in the brain.
Ref.: 2, 5, 7
Comments
Vascular malformations in the brain include venous angiomas, cavernomas, capillary telangiectases, and arteriovenous malformations. AVMs receive more attention than the other, more common lesions because of their propensity to cause seizures or life-threatening hemorrhage. AVMs are irregular connections of arteries to veins with irregular walls and a nidus in the center. Ten percent are associated with aneurysms, most commonly on the feeding artery. These irregularities lead to a 2% to 4% incidence of hemorrhage per year. Intracranial hemorrhage is the most common initial symptom, and it is mostly intraparenchymal, although subarachnoid hemorrhage may also occur. AVMs are the second most common cause of spontaneous SAH (4% to 10%), with aneurysms being the most common (75% to 80%). Most AVMs are symptomatic when found, whereas the other vascular malformations are commonly incidental findings. In fact, CT or MRI is necessary to detect cavernomas or capillary telangiectases, which are both angiographically occult lesions. However, capillary telangiectases are often missed on MRI as well. Cavernomas hemorrhage at a rate of about 0.7% per year. They are most commonly identified radiographically after a small hemorrhage that was manifested clinically as a headache or seizure. Capillary telangiectases and venous angiomas rarely hemorrhage but are the first and second most common vascular malformations overall, respectively. Neither require treatment.
Answer
D
17 Which of the following statements regarding peripheral nerve injuries is false?
A Neurapraxic injury does not require surgical resection of the nerve root involved to eliminate pain.
B Axonal regeneration progresses at a rate of 1 mm/day after a 10- to 20-day lag period.
C Denervation atrophy of muscles becomes irreversible after 12 to 15 months.
D Restoration of sensory loss is not possible after muscle atrophy secondary to denervation is complete.
E Recovery is influenced by the cause of the injury, the patient’s age, the type of nerve injured, and the severity of injury to nearby vessels and bone.
Ref.: 2, 3, 8
Comments
There are several classifications of nerve injuries. The Seddon classification uses three terms to classify nerve injuries: neurapraxia, axonotmesis, and neurotmesis. With neurapraxia, anatomic continuity of the nerve is preserved, and there is often incomplete motor paralysis with little muscle atrophy and considerable sparing of sensory and autonomic function. Neurapraxia, in simplified terms, is a bruise. Operative repair is not indicated, and the quality of recovery is excellent. Axonotmesis is the loss of axonal continuity without interruption of the investing myelin tissue. There is complete motor, sensory, and autonomic paralysis and progressive muscle atrophy. Operative repair is not indicated, and recovery occurs at a rate of about 1 mm/day. Neurotmesis is a more severe injury, with significant disorganization within the nerve or actual disruption of continuity of the nerve and its investing myelin tissues. It is common with penetrating trauma and less common with compression injury, such as that seen with surgical positioning. Recovery is impossible without operative repair. After disruption, axonal sprouting begins within 10 to 20 days. After operative repair, distal growth occurs at a rate of 1 mm/day after the initial 10- to 20- day lag period. The degree of recovery is a function of the patient’s age (with greater recovery in younger patients), type of nerve involved (pure motor or sensory nerves recover better than do mixed motor and sensory nerves), level of nerve injury (distal is better), and duration of denervation (shorter tends to be better). Early repair of the severed nerve has the advantage of clearer anatomy and a longer period for regeneration, but late repair also has advantages. If more than 12 to 15 months is required for regenerating axons to reach a denervated muscle, a significant degree of denervation atrophy will have occurred and is irreversible. In contrast, sensory loss may be recovered after prolonged periods of denervation, and thus a nerve repair can provide protective sensory function in the atrophied distal extremity. With peripheral nerve injury, the site of injury and nerve activity can be detected by electromyography only after 2 to 3 weeks. A rare late consequence of peripheral nerve injury is causalgia, a painful condition causing burning sensations, swelling, and skin changes in the distribution of a partially injured mixed peripheral nerve. It is believed to be caused by “sensitization” of the traumatized nerve with sympathetic hyperactivity. Treatment consists of medications or sympathectomy in intractable cases. The role of corticosteroids in the treatment of peripheral nerve injury is unclear, and level III evidence suggesting a beneficial role is lacking and mostly anecdotal.
Answer
D
18 Which of the following is false regarding brain and spine tumors?
A Intracranial schwannomas most commonly arise from the eighth cranial nerve, and spinal schwannomas are most commonly found in the intradural and extramedullary space on sensory nerves.
B Spinal cord ependymomas are the most common primary adult spinal cord tumors and are commonly found in the cervical cord.
C Most intracranial tumors are benign.
D Meningiomas arise from the arachnoid layer of the brain, as opposed to the brain tissue itself.
E Glioblastoma multiforme (GBM) is the most common primary brain tumor and carries the worst prognosis.
Ref.: 2, 3, 7, 8, 10
Comments
CNS tumors can be classified in many ways, such as the tissue of origin or even location. The main types include astrocytic tumors (including pilocytic astrocytoma, anaplastic astrocytoma, glioblastoma multiforme, oligodendroglioma, and ependymoma), neuroectodermal tumors (including ganglioglioma and dysembryoplastic neuroepithelial tumor), embryonal neuroepithelial tumors (including medulloblastoma, neuroblastoma, and pineoblastoma), choroid plexus tumors, pineal region tumors, peripheral nerve sheath tumors (including neurofibroma and schwannoma), meningiomas, parasellar tumors (including pituitary tumors, craniopharyngiomas, and Rathke cleft cysts), blood-based tumors (including lymphoma), germ cell tumors, and miscellaneous tumors (including dermoids, epidermoids, and colloid cysts). In both the brain and spinal cord, metastases are the most common tumors. The most common brain metastases are from lung, breast, skin, and kidney cancers. Approximately one fourth of patients who die of cancer have brain metastases on autopsy. One half of all patients with brain metastases will have a single metastasis. If it is a solitary lesion, the patient has an approximately 6-month expected longevity from systemic cancer. The lesion may be primarily surgically resected if accessible, followed by radiation therapy in certain circumstances. Whole-brain irradiation versus focused beam irradiation, along with possibly chemotherapy, is determined on an individual basis and tumor sensitivity. The spine is also a common target for metastases, most commonly from a large epidural venous system called the Batson plexus. Up to 40% of patients who die of cancer have spine metastases on autopsy. In the brain, gliomas are the most common primary tumor, with GBM being the most frequent. The World Health Organization (WHO) developed a grading system for CNS tumors in which grade I is the most benign and grade IV is the most malignant. GBMs are grade IV tumors. The prognosis of patients with GBM is poor, with median survival being 3 months without treatment. With surgery, radiation therapy, and chemotherapy, survival averages 14 months. Of the more common brain tumors, meningiomas arise from the arachnoid cap cells of the brain coverings and are most commonly located parasagittally. Schwannomas arise from sensory nerves, with the eighth cranial nerve being the most common. Ependymomas arise in the ventricles. Oligodendrogliomas arise in the cerebral hemispheres, usually in the frontal lobe. Medulloblastoma is one of the most common primary pediatric tumors, and it arises in the cerebellum of the posterior fossa. In the spinal cord, ependymomas and astrocytomas are the most common primary tumors, with ependymomas being more common in adults and astrocytomas more common in children. Although primary brain tumors tend to be malignant, primary spinal cord tumors tend to be benign. Spine tumors may be extradural (most commonly metastases), intradural and extramedullary (most commonly schwannomas, neurofibromas, or meningiomas), or intradural and intramedullary (most commonly ependymomas and astrocytomas). Because spinal ependymomas often have a dissectible plane and tend to not diffusely infiltrate the nervous tissue itself, they may be resected while maintaining stable neurologic function. They, like spinal cord astrocytomas, are commonly found in the cervical region.
Answer
C
19 Which of the following myotome and dermatome distributions is correct?
A C1 has a myotome distribution as part of the ansa cervicalis with supply to the neck “strap muscles,” but no dermatome distribution.
B T4 has a myotome distribution to the intercostal muscles and a dermatome distribution to the nipple area.
C L1 has a myotome distribution to the iliopsoas muscle and a dermatome distribution to the inguinal area.
D L5 has a myotome distribution to the extensor hallucis longus and anterior tibialis muscles and a dermatome distribution to the lateral aspect of the calf and foot.
E All of the above.
Ref.: 5, 7, 10
Comments
Thirty-one paired spinal nerves provide afferent and efferent innervation to the body, except C1, which has only motor function. Compression of a spinal nerve can lead to pain, numbness, or weakness in the distribution of that spinal nerve. This is known as radiculopathy. When radiculopathy is manifested as pain only, certain ones mimic common medical conditions. A left-sided midthoracic radiculopathy can be mistaken for cardiac disease, a right-sided lower thoracic radiculopathy can mimic gallbladder disease, and an L1 or L2 radiculopathy can be mistaken for hernia symptoms. Fortunately, disk herniations at these levels are uncommon. Common levels for disk herniation are C5-6, C6-7, L4-5, and L5-S1. The disk herniation usually causes a radiculopathy in the nerve root paired with the lower vertebra (i.e., C5-6 causes a C6 radiculopathy). In the cervical spine, a nerve roots exits above its number-associated pedicle, and the intervertebral disk space is located near the inferior portion of the pedicle. Therefore, the herniated disk compresses the lower nerve as it exits because the higher nerve is protected by the pedicle. In the lumbar region, the given nerve root exits below and in close proximity to its number-associated pedicle, but the intervertebral disk space is located far below the pedicle. Therefore, a herniated lumbar disk often still spares the nerve exiting at that interspace (even though the pedicle is not protecting it as in the cervical spine) and instead compresses the lower nerve root heading toward the interspace below.
Answer
E
20 Regarding spinal cord injury, which of the following incorrectly describes the syndrome listed?
A In anterior spinal artery syndrome, bilateral loss of motor and pain sensation occurs with preservation of position and vibratory sensation.
B In posterior spinal artery syndrome, bilateral loss of position and vibration sensation occurs with preservation of motor and pain sensation.
C In central cord syndrome, bilateral motor and pain sensation is lost, worse in the lower extremities than the upper extremities and worse in the proximal ends of extremities than in the distal ends of extremities.
D In Brown-Sequard syndrome, ipsilateral motor and position sensation is lost along with contralateral pain and temperature sensation.
E In cauda equina syndrome, unilateral or bilateral loss of motor and sensory function occurs in the distribution of multiple nerve roots, including bladder areflexia and stool incontinence.
Ref.: 2, 10, 11
Comments
The syndromes of spinal cord injury are named according to the area of injury and have deficits related to the tracts running in that area of the spinal cord. The anterior two thirds of the spinal cord holds the corticospinal tracts and the spinothalamic tract. Injury to this area via compression or infarction of the anterior spinal artery leads to paralysis and loss of pain and temperature sensation below the level of the lesion, with sparing of proprioception, which runs in the dorsal columns. The posterior spinal cord holds the dorsal columns, which are involved in position and vibratory sense and are supplied by the paired posterior spinal arteries. Lesions in this area result in loss of these modalities below the level of the lesion, with sparing of motor and pain/temperature sensation. The cervical central spinal cord consists of gray matter, crossing fibers of the spinothalamic tract, and motor fibers to the upper extremities. Injury here causes central cord syndrome. Most common in the elderly with preexisting cervical stenosis, injury is caused by neck hyperextension in which hypertrophied perispinal ligaments compress the already stenosed cervical cord. This leads to weakness and loss of pain sensation in the arms more than in the legs and distally worse than proximally. Central cord syndrome was originally thought to occur as a result of somatotopy of the corticospinal tract and ischemia from cord impingement, but this theory has recently been questioned. Axial hemisection of the spinal cord from penetrating trauma leads to Brown-Sequard syndrome. Deficits associated with this syndrome are loss of ipsilateral motor, position, and vibratory sensation and contralateral pain and temperature sensation because of the crossing fibers of the spinothalamic tracts. The nerve roots of the cauda equina arise from the distal spinal cord at L1-2. Compression of nerve roots of the cauda equina leads to variable loss of all functions of the nerve roots involved, along with radicular pain.
Answer
C
21 Which of the following statements regarding brain abscesses is false?
A The brain is resistant to infection despite its high glucose content.
B The brain is extremely effective in walling off infections.
C Brain abscesses are classified as acute, subacute, and chronic.
D Prompt drainage is indicated for all types of brain abscesses.
E Corticosteroids may be useful in treating this type of infection.
Ref.: 2, 3, 7
Comments
The brain is generally resistant to infection because of the blood-brain barrier unless previously damaged by trauma, hemorrhage, or anoxia. Once infected, the brain is effective in walling off the infection and is capable of isolating the abscess from the uninvolved brain and systemic circulation, thus making sterilization by systemic antibiotics difficult. The three major sources of brain abscesses include (1) direct extension from middle ear, mastoid, and nasal sinus infections (commonly affecting the temporal lobe and cerebellar hemispheres); (2) hematogenous spread (as occurs with cyanotic heart defects or pulmonary AVMs with right-to-left shunts); and (3) direct trauma. The most common organisms are Streptococcus and Staphylococcus. Brain abscesses are classified as acute, in which they follow a course similar to and difficult to differentiate from subdural empyema; subacute, with a picture in between acute and chronic; and chronic, often with progressive neurologic deficit and an expanding mass with a longer history (2 weeks to 2 months). MRI is the most accurate indirect means of making the diagnosis and is helpful before performing surgical drainage. Treatment consists of medical measures (antibiotics) or surgical evacuation. Medical therapy requires 6 to 8 weeks of intravenous antibiotics and the use of corticosteroids if severe edema and mass effect are present. On follow-up imaging, if an increase in size occurs, surgical drainage should be considered. Surgery is also necessary if the abscess is causing enough mass effect to induce focal symptoms or if identification of the organism is needed to select appropriate antibiotics. Even with surgical drainage, antibiotics are still required for at least 6 to 8 weeks, and it may take longer than 10 weeks for significant resolution of the capsule and its enhancement to be observed on imaging. Seizures are a common sequelae of brain abscess. Brain abscess recurs in 8% to 10% of patients.
Answer
D
22 Which of the following is true regarding pediatric trauma?
A Spinal cord injury without radiologic abnormality (SCIWORA) is a diagnosis made after neurologic symptoms are present despite normal findings on MRI.
B Because of their inability to speak, the GCS cannot be used in infants.
C Age younger than 3 years, nonparietal skull fractures, isolated SDH in the absence of witnessed trauma, retinal hemorrhages, and long-bone fractures at varying stages of healing are all signs arguing against the diagnosis of nonaccidental trauma.
D Spinal cord injuries are relatively uncommon in young children.
E Interpretations of pediatric spinal radiographs are similar to those of adults, and pathologic fractures and subluxations are often easily identified.
Ref.: 5, 7, 9, 11
Comments
Spinal cord injury without radiologic abnormality is an injury originally described in children in the 1980s before the advent of MRI. Signs of myelopathy were present in pediatric patients after known cervical spine trauma, but plain radiography and CT showed no pathology. Therefore, the current definition does not necessarily include the complete absence of imaging abnormalities because abnormal MRI findings may very well be present. The incidence has been reported to be as high as 36% in children with traumatic myelopathy. Because MRI has become a mainstay imaging modality in the evaluation of cervical trauma, children in whom SCIWORA has been diagnosed have been shown to exhibit ligamentous or disk injury, complete spinal cord transection, spinal cord hemorrhage, or occasionally, normal findings on MRI. SCIWORA most commonly results from hyperflexion or hyperextension movements. Because the adult Glasgow Coma Scale assessment is not appropriate for the functional level of infants, particularly in its verbal and motor aspects, a modified version known as the Pediatric Glasgow Coma Scale has been developed. It still uses the eye, verbal, and motor components, but to an age-appropriate level for infants. Nonaccidental trauma is most common in children younger than 3 years. Nonparietal skull fractures, isolated subdural hematomas without witnessed trauma, retinal hemorrhages, and long-bone fractures at various stages of healing are common inclusion signs for this diagnosis. Spinal cord injuries account for less than 5% of all childhood spinal injuries. The spinal ligaments are lax and the facet joints are oriented more horizontally in children, thus making vertebral body subluxation and ligamentous injury more common than fractures or cord injuries. Because of incomplete fusion of ossification centers in a pediatric patient’s spine, radiolucencies may falsely appear to be fractures and make interpretation of pediatric spine imaging challenging. Such radiolucencies may occur in the anterior arch of C1 and the junction of the dens with the body of C2, a finding representing persistent synchondrosis that may mimic a fracture. In similar fashion, the tip may fail to fuse with the peg body of the dens, a condition called ossiculum terminale persistens (differs from os odontoideum), which can appear similar to an odontoid fracture. Laxity in ligaments may also allow normal movement in the pediatric spine that would be considered pathologic in adults. The high cervical levels may move up to 3 to 4 mm with flexion, which is considered a normal variant in the pediatric spine. The atlantodens interval may be particularly prominent with motion as well and be mistakenly diagnosed as instability.
Answer
D
23 Which of the following is true regarding brain metastases?
A More than 75% of patients who die of cancer have intracranial metastasis on autopsy.
B The most common primary malignancies from which brain metastases arise are lung, breast, and prostate cancers.
C Melanoma, colorectal, and renal carcinoma are extremely sensitive to whole-brain radiation therapy (WBRT).
D Patients with a single metastasis and good prognostic features often benefit from surgery followed by WBRT.
E Most brain metastases are chemosensitive.
Ref.: 2, 3, 5, 7, 8, 11, 24
Comments
Brain metastases are the most common brain tumors in adults. They occur in 10% to 30% of adults with systemic disease and are found at autopsy in 25% of patients who have died of systemic disease. The most common primary sources are lung cancer (40% to 50%), breast cancer (15% to 25%), and melanoma (5% to 20%). Prostate carcinomas rarely metastasize to the brain. As with any cancer, treatment options for brain metastases are surgery, radiotherapy (whole-brain radiotherapy and stereotactic radiosurgery), and chemotherapy. Management is based on the extent of systemic disease and the number, size, location, and histology of the brain metastases. The patient’s initial performance status is also crucial and is rated by the Karnofsky performance scale (KPS). Simplified, a good KPS score is one greater than 80, which describes a patient who is able to carry out normal daily activity and work without special assistance. WBRT has long been the most frequently used therapeutic modality for brain metastases. Currently, it is used for patients with multiple metastases (usually more than three), for metastases too large for radiosurgery (usually >2 to 3 cm), and for patients with disease progression after previous treatment. Radiosensitive tumors are lung and breast tumors, whereas melanoma, colon tumors, and renal tumors are fairly resistant. Commonly, WBRT is used in addition to surgery or radiosurgery, although it may be used alone, predominately in the scenario of active systemic disease with multiple large metastases. Cognitive decline following WBRT is of concern and factors into the overall treatment decision. Stereotactic radiosurgery may also be very useful in carefully selected patients. Surgery for brain metastases obtains tissue for diagnosis, provides therapy by resecting at least some of the tumor burden, and may be used to deliver brachytherapy. Like WBRT, surgery is commonly used in addition to other therapies such as WBRT, radiosurgery, or chemotherapy. Several studies have shown that patients with a single metastasis and good prognosis benefit from surgery followed by radiation therapy. Brain metastases are relatively resistant to chemotherapy. It is usually reserved for recurrence after standard therapy.
Answer
D
References
1 Kandel ER, Schwartz JH, editors. Principles of neural sciences, Part II. London: Edward Arnold, 1981.
2 Schwartz SI, Shires GT, Spencer FC. Principles of surgery, ed 7. New York: McGraw-Hill; 1999.
3 Sabiston DCJr. Textbook of surgery, ed 15. Philadelphia: WB Saunders; 1997.
4 Ross JS, Masaryk TJ, Modic MT, et al. Intracranial aneurysms: evaluation of MR angiography. AJR Am J Roentgenol. 1990;155:159-165.
5 Greenberg MS. Handbook of neurosurgery. New York: Thieme Medical Publishers; 2001.
6 Narayan RK, Rosner MJ, Pitts LH, et al. Guidelines for the management of severe head injury. Chicago: Brain Trauma Foundation; 1995.
7 Schmidek HH, Sweet WH. Operative neurosurgical techniques, ed 3. Philadelphia: WB Saunders; 1995.
8 Greenfield LJ. Surgery, ed 3. Philadelphia: Lippincott, Williams & Wilkins; 2001.
9 Bullock MR, Povlishock JT. Guidelines for the management of severe traumatic brain injury. Editor’s Commentary. J Neurotrauma. 2007;24(Suppl 1):2.
10 Way LW. Current surgical diagnosis and treatment, ed 10. Norwalk, CT: Appleton & Lange; 1994.
11 Menezes AH, Sonntag VK, Benzel EC, et al. Principles of spinal surgery. New York: McGraw-Hill; 1991.
12 Atlas SW. Magnetic resonance imaging of the brain and spine. New York: Raven Press; 1991.
13 Sciubba DM, Dorsi MJ, Kretzler R, et al. Computed tomography reconstruction artifact suggesting cervical spine subluxation. J Neurosurg Spine. 2008;8:84-87.
14 Doran SE, Papadopoulos SM, Ducker TB, et al. Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation. J Neurosurg. 1993;79:341-345.
15 Bracken MB, Shepard MJ, Collins WF, et al. A randomized controlled trail of methylprednisolone or naloxone in the treatment of acute spinal cord injury. N Engl J Med. 1990;322:1405-1411.
16 Hadley MN, Walters BC, Grabb PA, et al. Guidelines for the management of acute cervical spine and spinal cord injuries. Clin Neurosurg. 2002;49:407-498.
17 Ritter AM, Muizelaar JP, Barnes T, et al. Brain stem blood flow, pupillary response, and outcome in patients with severe head injuries. Neurosurgery.. 1999;44:941-948.
18 Aston S, Seasley R, Thorne C, editors. Grabb and Smith’s plastic surgery, ed 5, Philadelphia: Lippincott-Raven, 1997.
19 Greer DM, Varelas PN, Haque S, et al. Variability of brain death determination guidelines in leading U.S. neurologic institutions. Neurology. 2008;70:284-289.
20 Clusmann H, Schaller C, Schramm J. Fixed and dilated pupils after trauma, stroke, and previous intracranial surgery: management and outcome. J Neurol Neurosurg Psychiatry. 2001;71:175-181.
21 Young JS, Blow O, Turrentine F, et al. Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained? Neurosurg Focus. 2003;15(6):E2.
22 Muizelaar JP, Marmarou A, Ward JD, et al. Adverse effects of prolonged hyperventilation in patients with severe head injury: a randomized clinical trail. J Neurosurg. 1991;75:731-739.
23 Alderson P, Roberts I: Corticosteroids for acute traumatic brain injury, Cochrane Database Syst Rev 1:CD000196, 2005.
24 Ranjan T, Abrey L. Current management of metastatic brain disease. Neurotherapeutics. 2009;6:598-603.
C Urology
Michael R. Abern, M.D., Kalyan C. Latchamsetty, M.D.
1 Regarding the management of blunt renal trauma, which of the following is true?
A Contusions are best treated by observation until the gross hematuria subsides.
B Parenchymal lacerations secondary to blunt trauma require routine exploration because of the risk for secondary hemorrhage or infection.
C Nonexpanding retroperitoneal flank hematomas encountered during laparotomy should be explored.
D On exploring a perinephric hematoma, the fascia of Gerota is opened first to facilitate control of the vessels.
E Nonvisualization of the kidneys, on CT requires immediate operative exploration.
Ref.: 1
Comments
As with any visceral organ, a spectrum of renal injuries may occur following blunt trauma. Renal contusions are the most common renal injury and are managed conservatively with bed rest and observation. Parenchymal lacerations confined to the renal cortex may also be treated nonoperatively if the patient is stable. Deeper lacerations extending into the calyceal system may require primary surgical repair. When an expanding retroperitoneal hematoma is encountered, it should be explored. However, when a nonexpanding perinephric hematoma is encountered, high-dose intravenous urographic studies should be done if no other imaging study is available to evaluate the potentially injured kidney and to confirm the presence of a contralateral functioning kidney. Preoperative CT provides accurate staging, thereby allowing one to determine the best treatment modality and to manage the majority of patients by observation. The key surgical principle in the approach to an injured kidney is to obtain control of the vascular pedicle first. If the fascia of Gerota is incised first, the tamponade effect may be released, and a significant hemorrhage could occur and possibly lead to nephrectomy. Moreover, if nephrectomy is necessary, the presence of a functioning contralateral kidney is verified via intravenous pyelography (IVP) or CT before exploration. Penetrating renal injury usually requires exploration, but some patients may be managed nonoperatively, provided that adequate imaging staging is done and they are not undergoing laparotomy for associated injury. Traditionally, nonvisualization of the kidneys has been further evaluated with renal angiographic studies. Recently, spiral CT has provided adequate evaluation of the renal vessels. Nonvisualization of the renal artery may be caused by total avulsion of the renal artery and vein, renal artery thrombosis, absence of the kidney, or severe contusion resulting in major vascular spasm. If a kidney cannot be visualized on arteriography, exploration and revascularization are indicated if salvage of the kidney is possible.
Answer
A
2 Which of the following statements is true regarding renal vascular anatomy?
A Solitary renal arteries are seen in approximately 20% to 30% of patients.
B The right renal artery usually crosses ventral to the vena cava.
C The left renal vein usually crosses dorsal to the aorta.
D The right adrenal and gonadal veins typically empty into the right renal vein.
E The renal arteries are end arteries.
Ref.: 2
Comments
Approximately two thirds of normal kidneys are supplied by a single renal artery arising from the aorta, near the upper aspect of the second lumbar vertebra. Each renal artery has approximately five segmental branches that are end arteries. Occlusion of the segmental vessels therefore causes infarction. Renal arterial anomalies are more often present in abnormally located kidneys. Venous drainage of the kidneys often involves collateral vessels, particularly on the left side, via the gonadal, adrenal, and lumbar veins. The renal vein itself is usually singular on the left side but multiple on the right side approximately 10% of the time. Because the aorta in normal individuals lies to the left side of the vena cava, the right renal artery crosses behind the vena cava and the left renal vein crosses ventral to the aorta. This is consistent with the general anatomic principle that major systemic veins pass ventral to their associated arteries. The longer length of the left renal vein is advantageous when the left kidney is used as a donor organ during renal transplantation. The right adrenal and gonadal veins empty directly into the inferior vena cava.
Answer
E
3 Which of the following findings occurs in most patients with renal cell carcinoma?
A Hypertension
B Erythrocytosis
C Hematuria
D Acute varicocele
E Palpable flank mass
Ref.: 3
Comments
Among the many symptoms that have been associated with renal cell carcinoma, hematuria, pain, and an abdominal mass are the most common. Only 10% of patients have the classic triad of hematuria, pain, and an abdominal mass. Hypertension (37.5% of cases) may result from renal vascular compression but is more commonly seen with Wilms tumor. Fever (17%) is believed to result from tumor necrosis. A small percentage of patients exhibit erythrocytosis (1% to 5%), which has been related to the production of erythropoietin-like substances by the tumor. It is more common, however, for patients with renal cell carcinoma to have anemia (36%) than erythrocytosis. Renal vein thrombosis and a subsequent acute varicocele (3%) develop in a small percentage of patients with renal tumors. Hematuria occurs in about 60% of patients. Renal cell carcinomas occur in an approximate 2 : 1 male-to-female ratio. In most patients it is diagnosed during the sixth and seventh decades of life. More than 50% of renal cell carcinomas are now detected incidentally because of the increased use of imaging for a variety of abdominal symptoms. Thus, masses are rarely palpable on physical examination. The TNM staging system classifies a T1/T2 tumor as being confined to the kidney, with tumors larger than 7.0 cm classified at a higher stage (T2). T3 tumors involve the renal veins, inferior vena cava, or perinephric tissues that are confined by the fascia of Gerota. T4 tumors extend beyond this fascia. Nodal status is stratified by size, number of nodes, and whether metastatic disease is present or absent. Lesions that involve the inferior vena cava may still be cured with surgical therapy, and such involvement is not considered a contraindication to surgery.
Answer
C
4 Transitional cell cancers of the renal pelvis are best treated by which of the following?
A Nephrectomy
B Nephroureterectomy with excision of the ureter to the level of the bladder
C Nephroureterectomy with excision of the bladder cuff
D Nephroureterectomy and total cystectomy
E Radiotherapy
Ref.: 4
Comments
Transitional cell cancers of the renal pelvis and ureter are notable for their multicentricity and tendency to spread by direct extension to other parts of the urothelium. Approximately 30% of patients have a recurrence in the ureteral stump. For this reason, nephroureterectomy with excision of a cuff of bladder at the ureteral orifice is the preferred treatment. There is no specific role for radiotherapy in the primary treatment of these lesions. Long-term cystoscopic surveillance is necessary postoperatively because in approximately 25% of patients, a subsequent bladder tumor arises. In selected cases (e.g., solitary kidney or chronic renal disease), endoscopic or percutaneous resection or ablation of small, low-grade noninvasive tumors of the renal pelvis or ureters has produced long-term survival. Meticulous long-term postoperative surveillance, including cystoscopic studies, periodic IVP or CT, and urine cytologic examination, is essential in these circumstances.
Answer
C
5 Regarding treatment of renal cell carcinoma, which of the following statements is true?
A Induction chemotherapy followed by nephrectomy yields the best overall results.
B Radical nephrectomy involves removal of the kidney, adrenal gland, perinephric fat, fascia of Gerota, and regional lymph nodes.
C Regional lymphadenectomy for lesions extending outside the kidney improves postoperative survival.
D CT- or ultrasound-guided biopsy of the renal mass should be performed before nephrectomy.
E Percutaneous cryoablation or radiofrequency ablation may be used for large unresectable tumors.
Ref.: 3
Comments
Treatment of renal cell carcinoma and the subsequent prognosis are determined by the anatomic extent of the disease. Treatment of local disease focuses on tumor removal by radical nephrectomy. Solid renal masses are rarely subjected to biopsy, and they are diagnosed after pathologic examination of the kidneys. Surgery alone offers an excellent prognosis in patients with early lesions confined within the renal cortex. Percutaneous ablation of renal masses is indicated for small masses generally less than 3 cm. A survival advantage for those undergoing regional lymphadenectomy has not been established. Metastases frequently occur by hematogenous routes as well, which may negate any theoretical advantage of even more radical local surgery, although the presence of a limited volume of tumor thrombus in the vena cava with right-sided carcinomas may not adversely affect long-term outcome if the thrombus is removed completely. In the presence of distant metastases, nephrectomy may still be appropriate to control bleeding, pain, or infection. A randomized controlled study revealed that survival is increased (from 9 to 12 months) in patients who undergo nephrectomy in the face of metastatic disease versus chemotherapy with interleukin-2 alone. Recent studies have established tyrosine kinase inhibitors as the adjuvant treatment of choice for metastatic renal cell carcinoma after nephrectomy. Phase III trials have shown a 3-month survival advantage over placebo. Immunotherapy may result in remission of the cancer in a small percentage of patients. In select circumstances, patients with isolated metastases have benefited from resection of their metastatic disease.
Answer
B
6 A 64-year-old woman with symptoms typical of cholelithiasis undergoes ultrasound of the abdomen, which detects an asymptomatic, solid left renal mass. Which of the following should be the next examination?
A Excretory urographic studies
B Renal angiographic studies
C CT of the abdomen
D Radionuclide scanning of the urinary tract
E Renal biopsy
Ref.: 3
Comments
CT of the abdomen is the single most useful examination for the work-up of patients suspected of having renal cell carcinoma. In addition to confirming the solid nature of a renal mass, it can demonstrate local extension, venous and caval involvement, and distant metastases to the liver, adrenal gland, and visualized skeleton. Calcification is present in 8% to 18% of renal cell carcinomas, in contrast to about 1% of simple renal cysts. Small asymptomatic renal cell carcinomas are frequently discovered during abdominal ultrasonography and CT performed for other reasons (incidentalomas). Renal cell carcinoma, which probably arises from the proximal tubular epithelium, is the most common primary renal cancer; it accounts for approximately 86% of all primary malignant renal cancers. Of the remainder, 12% are Wilms tumor and 2% are renal sarcoma. The foregoing comments refer to primary renal tumors, but the most common asymptomatic renal masses are metastatic, with the lung being the most frequent primary site. A calcified renal artery aneurysm demonstrates opacification of the lumen on postinfusion scans. Calcified metastases to the kidney are extremely uncommon and have been reported only in patients with primary osteosarcoma elsewhere. A calcified simple cyst demonstrates a radiolucent center with peripheral ring calcification.
Answer
C
7 A 45-year-old man complains of severe flank pain and gross hematuria. Urinalysis reveals 200 red blood cells per high-power field, and his creatinine level is normal. What should the next test be?
A Imaging of the kidney, ureter, and bladder (KUB)
B IVP
C Ultrasonography
D CT of the abdomen and pelvis
E MRI
Ref.: 5
Comments
CT of the abdomen and pelvis is currently the best test for diagnosing nephrolithiasis. It is controversial whether the use of intravenous contrast material is necessary in patients with nephrolithiasis. The benefits of evaluating renal function and better assessing the degree of obstruction must be weighed against the disadvantages of using contrast material. The preferred CT protocol for the diagnosis of nephrolithiasis or other genitourinary pathology includes three phases: plain, venous phase (to visualize the renal parenchyma and vasculature), and 5- to 10-minute delay (to visualize the collecting system). The use of oral contrast material is not necessary and it may obscure the visibility of stones. IVP and ultrasound are acceptable but are not the preferred choices. To complete the work-up for gross hematuria, lower tract evaluation with cytologic and cystoscopic studies should be performed.
Answer
D
8 For which of the following types of renal calculi is growth not affected by manipulation of urinary pH?
A Cystine
B Uric acid
C Ammonium magnesium phosphate (struvite)
D Calcium oxalate
E Carbonate apatite
Ref.: 6
Comments
Renal calculi result from a variety of metabolic conditions. Determination of stone composition is important for both recognition of the underlying abnormality and institution of appropriate therapy aimed at removing the stone and preventing recurrence. Most urinary calculi (up to 75%) are calcium oxalate stones, and approximately one half of them are mixtures of calcium oxalate and phosphate. The serum calcium level should be checked in patients with these stones, and if elevated, the parathyroid hormone level should be determined as well, Calcium phosphate and calcium oxalate stones are not generally altered by variations in urinary pH within the normal range. Ammonium magnesium phosphate (struvite) stones are next in frequency and are usually associated with infection. They form in alkaline urine, and their solubility is increased by acidic urine. Because urea-splitting organisms form ammonia and alkaline urine in the presence of infection, adequate pH manipulation cannot be obtained without control of the infection. Uric acid stones are typically radiolucent, and their solubility is increased by alkalinization. The solubility of cystine is increased in alkaline urine. However, because cystine stones are not crystalline in nature but are composed of amino acids, they are not easily pulverized by extracorporeal shock wave lithotripsy (ESWL). Stone composition is related to the ability to visualize stones on plain radiographs. Calcium-containing stones in particular are radiopaque. Ammonium magnesium phosphate (struvite) and cystine stones may also be visualized.
Answer
D
9 Which of the following is an indication for expectant management of renal calculi?
A Progressive renal damage
B Intractable pain
C Persistent or progressive obstruction
D Intractable urinary tract infection
E Detection of any calculi
Ref.: 7
Comments
The simple presence of a renal or ureteral calculus alone is not an indication for intervention by invasive techniques. Medical management, including analgesics, antibiotics, and appropriate urinary pH adjustments, often result in the spontaneous passage of stones. Smaller stones (<4 mm), in particular, can be expected to pass 90% of the time. There is no evidence that excessive hydration facilitates the passage of renal or ureteral calculi. Indeed, it may increase pain. α-Antagonist and calcium channel blocker medications have been shown to significantly decrease the time to passage of distal ureteral stones. Surgical management is indicated when calculi produce persistent obstruction, intractable pain, or a stone associated with impaired renal function. Techniques for stone removal include ureteroscopic manipulation, percutaneous nephrolithotomy, open nephrolithotomy, and ESWL.
Answer
E
10 Resection of a sigmoid cancer necessitates excision of a segment of the left pelvic ureter, with the specimen extending 3 cm distal to the bifurcation of the common iliac artery. Possible options for reconstruction include which of the following?
A Ileal substitution
B Ureteroneocystostomy
C Nephrectomy
D Psoas bladder hitch ligatures
E Renal autotransplantation
Ref.: 1
Comments
In this situation, simple in situ ureteroneocystostomy is not possible. An end-to-side anastomosis of the severed ureter to the opposite ureter (transureteroureterostomy) may be successful but may jeopardize the contralateral ureter. This approach is contraindicated in patients with a history of nephrolithiasis, transitional cell carcinoma, or recurrent pyelonephritis. A broad U-shaped flap (Boari flap) can be rotated off the bladder, fashioned in the shape of a cylinder, and anastomosed to the severed ureter. Another solution is to mobilize the bladder extensively and hitch it to the psoas muscle as high as possible, at which point ureteral implantation is performed (psoas hitch). With this technique, the bladder can often be brought as high as the common iliac artery. Mobilization of the kidney may provide 2 to 3 cm of ureteral length distally. Autotransplantation or ileal substitution of the ureter is reserved for large mid or proximal ureteral injuries. Nephrectomy may be considered for a nonfunctioning kidney with differential function consisting of less than 20% of the total glomerular filtration rate as quantified on a nuclear medicine study; however, every effort should be made to preserve the renal unit.
Answer
D
11 Which of the following is not a principle of repair of an intraoperative ureteral injury?
A Use of nonabsorbable suture material
B Spatulation of the transected ends
C Foley catheter drainage
D Drainage
E Intraureteral stent
Ref.: 1
Comments
Ureteral injuries are usually iatrogenic and occur during the course of retroperitoneal dissection for various abdominal and pelvic conditions. In cases of transection, repair should be carried out with absorbable suture material and an indwelling intraureteral stent. Nonabsorbable sutures should be avoided because they may serve as a nidus for calculus formation. Extensive ureteral dissection should be avoided to preserve the segmental blood supply. Spatulation reduces the incidence of anastomotic stricture in the severed ureter. Drains should be placed to accommodate any anastomotic leak. When injury involves the pelvic ureteral segment, ureteroneocystostomy may be preferable. Percutaneous (or open) nephrostomy serves to divert urine from the repair site, thereby facilitating healing at the anastomotic site. Foley catheter drainage is important in the immediate postoperative period because an intraureteral stent allows reflux of bladder urine to the anastomosis.
Answer
A
12 A properly constructed cutaneous ureteroileostomy (ileal conduit) should do which of the following?
A Provide an adequate reservoir for storage of urine
B Prevent ureteral reflux
C Require catheterization for emptying
D Separate the urinary and fecal streams
E Allow urinary continence
Ref.: 8
Comments
The use of an isolated segment of ileum to serve as a conduit between the ureters and the skin has become the most common form of urinary diversion and is the standard against which all other diversions are measured. Ileal conduits are used for patients after cystectomy, as well as for those with other indications for supravesical diversion. Large bowel is useful as a conduit because of the ease of creating an antireflux ureterointestinal anastomosis. Continent urinary reservoirs are fashioned from colon or small bowel (or both) and require periodic catheterization if anastomosed to skin. Continent reservoirs offer patients even greater control of urinary function and are well accepted. In selected cases, complete neobladders, fashioned from bowel, may be attached directly to the urethral remnant to eliminate the need for catheterization. The purpose of constructing an ileal conduit is to create a route (unidirectionally within the conduit) for transport of urine. It is not a reservoir for storage. Stasis in the bowel segment predisposes to infections, stone formation, and ureteral reflux. Stasis also promotes the absorption of electrolytes and may result in hyperchloremic metabolic acidosis. Some degree of ureteral reflux can normally be expected with an ileal conduit.
Answer
D
13 The preferred treatment of muscle-invasive bladder cancer involves which of the following?
A Radical cystectomy
B Preoperative irradiation and radical cystectomy
C Preoperative chemotherapy and radical cystectomy
D Radiation therapy alone
E Intravesical chemotherapy
Ref.: 9
Comments
In the United States, radical cystectomy is the preferred treatment of muscle-invasive bladder cancer. Preoperative radiation therapy has not been shown to increase survival after radical cystectomy. The role of partial cystectomy with muscle invasion is limited because of a high local recurrence rate (approximately 50%). Lesions confined to the mucosa can be treated by transurethral resection, fulguration, or intravesical chemotherapy. A careful surveillance program must then be maintained. Treatment of lesions with submucosal invasion has been controversial with regard to whether intravesical chemotherapy is appropriate and the necessary extent of surgical resection. Certainly, intravesical therapy is of no value for high-grade invasive cancer. In the United States, radical cystectomy is the preferred treatment. The 5-year survival rate of patients with muscle invasion following cystectomy is only 50%, and the major cause of death is distant metastatic disease. Recent studies have shown a modest survival benefit with neoadjuvant chemotherapy for locally advanced tumors that may otherwise be unresectable. Because combination chemotherapy (with methotrexate, vinblastine, Adriamycin [doxorubicin], and cisplatin [MVAC]) in patients with advanced disease has yielded response rates of 50% to 70%, these agents now are being considered before cystectomy when muscle invasion is present. Complete response rates with MVAC alone, however, have been disappointing (10% to 15%).
Answer
A
14 In a male patient with a pelvic fracture secondary to blunt trauma, retrograde urethrographic examination demonstrates disruption of the membranous urethra. Which of the following constitutes appropriate initial treatment?
A Passage of a transurethral catheter
B Suprapubic cystostomy
C Urethrostomy
D Retropubic repair
E Percutaneous nephrostomy tubes
Ref.: 10, 11
Comments
Blunt pelvic trauma is the most common cause of urethral injury. Urethral disruption may cause the classic triad of blood at the meatus, a palpable bladder, and inability to urinate. Approximately 10% of pelvic fractures in males result in urethral injury. Urethral injuries are classified as posterior (proximal to the urogenital diaphragm) or anterior (distal to the membranous urethra). Disruption usually occurs at or above the membranous portion of the urethra because the anterior prostatic and membranous portions are relatively fixed by the puboprostatic ligaments and the urogenital diaphragm. Urethral injury should be suspected if blood is noted at the meatus or if the patient is unable to void clear urine. Passage of a catheter should not be attempted under these circumstances. Instead, a retrograde urethrogram should be obtained. In select cases, a urologist may attempt passing a catheter retrogradely in patients with minimal disruption. The risk of inserting the catheter is that partial disruption may be converted to complete disruption. In most cases, if urethral injury is confirmed, treatment should initially be accomplished with suprapubic cystotomy. A punch cystostomy can be performed if the bladder is palpable and no contraindications exist, such as extreme obesity, suprapubic surgical scars, or the presence of an abdominal hernia. Perineal urethrostomy does not divert the urine proximal to the site of injury and is of no value in such a situation. Immediate retropubic surgical realignment has a place in selected clinical situations, such as major bladder neck laceration, prostatic fragmentation, or severe dislocation of the prostate with severely displaced bone fragments. In most cases, however, current results suggest that the complications of incontinence, stricture, and impotence are minimized by performance of suprapubic cystostomy and delayed repair. Percutaneous nephrostomy tubes will not decompress the bladder and therefore leave the patient at risk for bladder rupture. Penetrating urethral injuries, in contrast, can often be treated by initial repair and urinary diversion.
Answer
B
15 Regarding bladder trauma, which of the following statements is true?
A Rupture is usually extraperitoneal when associated with pelvic fracture.
B A single-view retrograde cystogram in the emergency department demonstrates most significant bladder injuries.
C Primary closure is generally indicated for extraperitoneal ruptures.
D Intraoperative injury usually requires repair with a suprapubic cystostomy.
E Injuries at the dome of the bladder are typically extraperitoneal.
Ref.: 10, 11
Comments
Bladder injury may result from blunt or penetrating trauma or may occur during pelvic operations. When associated with pelvic fracture, the site of injury is usually extraperitoneal because it has been caused by the shearing force of the pelvic fracture. Extraperitoneal rupture without pelvic fracture is an infrequent occurrence. Isolated extraperitoneal bladder rupture is treated with 7 to 10 days of Foley catheter drainage. Blunt injury without pelvic fracture is associated with intraperitoneal rupture, particularly if the bladder is full at the time of injury, and results in perforation, typically at the dome of the bladder. Bladder injury should be suspected in any patient with lower abdominal trauma if there is any hematuria or the patient is unable to void. Single-view cystography may miss a significant injury. Anterior, posterior, lateral, oblique, and in particular, postvoid films are necessary. Alternatively, a CT cystogram may be performed by injecting 300 to 400 ml of contrast material through a Foley catheter followed by CT of the pelvis. The usual treatment of intraperitoneal rupture involves a two-layer, watertight closure with absorbable suture and transurethral or suprapubic bladder drainage. Iatrogenic injury recognized at the time of an operation does not generally require suprapubic cystotomy but does require repair with absorbable suture and urethral catheter drainage for 5 to 7 days. It is also necessary to be vigilant that the Foley catheter does not become obstructed, such as with blood, and cause the bladder to become distended.
Answer
A
16 Which of the following is true regarding the management of a patient with benign prostatic hyperplasia (BPH)?
A All patients with complaints of prostatism should undergo therapy.
B Patients with BPH have an increased risk for prostate cancer.
C Initial therapy usually consists of nonoperative therapy.
D Surgery is indicated only in patients who fail medical management.
E The disease arises from the peripheral zone of the prostate.
Ref.: 12
Comments
Unlike prostate cancer, which arises in the periphery of the gland, benign prostatic hyperplasia arises in the transitional zone of the prostate gland. The incidence of BPH is approximately 50% at 50 years of age and increases to approximately 80% in men entering their eighth decade of life. Patients are traditionally treated with medical therapy first, if the symptoms warrant it, and then undergo surgical therapy in the event of medical failure. Most patients are treated initially with medical therapy consisting of 5α-reductase inhibitors or α-adrenergic blocking agents that act on prostatic smooth muscle. 5α-Reductase inhibitors inhibit the conversion of testosterone to dihydrotestosterone, which is the active agent responsible for BPH. Indications for surgical management include recurrent urinary tract infection, recurrent gross hematuria, worsening renal function, failure of medical management, or the presence of bladder stones. The presence of a normal-sized prostate on rectal examination does not exclude obstruction by BPH. BPH occurs in most men, and the incidence increases with advancing age. It is not a risk factor for the development of prostate cancer. It should be noted, however, that the usual transurethral prostatectomy or open surgery does not remove all the prostate tissue, and prostate cancer can occur following removal of the prostate for benign disease.
Answer
C
17 Regarding prostate-specific antigen (PSA), which of the following statements is true?
A PSA is a better serum marker for prostate cancer than acid phosphatase.
B PSA is produced by both benign and malignant prostate tissue.
C As an immunohistochemical marker, determination of the PSA level has been able to establish whether a metastatic adenocarcinoma is of prostatic origin.
D A PSA level greater than 10 ng/dL in a patient with prostate cancer may be cured surgically.
E All of the above.
Ref.: 13
Comments
Prostate-specific antigen is the best marker for prostate cancer and the first organ-specific marker in all of cancer biology. It is produced by both benign and malignant prostate tissue. Although age-specific reference ranges have been proposed, most would consider a normal PSA level to be less than 4 ng/mL. As an immunohistochemical marker, the PSA level is much more accurate and specific than the prostatic acid phosphatase level, which can be elevated in association with nonprostatic cancers, bone disorders, and liver abnormalities. In addition, the acid phosphatase level is not generally elevated with early prostate cancer. An elevated PSA level does not necessarily imply escape beyond the capsule and surgical incurability, although high values are often associated with bulky lesions. In contradistinction, an elevated acid phosphatase level in an individual with prostate cancer usually signifies extensive local or metastatic disease.
Answer
E
18 One hour after a prolonged transurethral resection of the prostate (TURP), a 70-year-old man with mild coronary artery disease experiences bradycardia, hypertension, confusion, nausea, and headache. What is the most likely cause?
A Hyperkalemia
B Hypokalemia
C Hypernatremia
D Hyponatremia
E Anemia
Ref.: 14, 15
Comments
The patient is most likely suffering from transurethral resection (TUR) syndrome, which is caused by excessive absorption of irrigating solution and results in hyponatremia. The usual irrigation fluid is 1.5% glycine, which has an osmolarity of 200 mOsm/L, as compared with the normal serum osmolarity of 290 mOsm/L. Excessive systemic absorption of the irrigating solution can result in a dilutional hyponatremia, hypoproteinemia, and ultimately, decreased serum osmotic pressure. Extremely low sodium levels (<110 mEq/L) may result in severe cerebral edema and subsequent seizures. Treatment of transurethral resection syndrome traditionally consists of terminating the procedure as rapidly as possible, administration of furosemide (Lasix) intraoperatively or postoperatively, and instillation of a 0.9% NaCl (and in severe cases 3% NaCl) solution over a 3- to 6-hour period. Newer bipolar resecting equipment allows irrigation with 0.9% normal saline, which has drastically decreased the probability of TUR syndrome occurring. However, these patients may still suffer from fluid overload as a result of absorption of isotonic fluid.
Answer
D
19 A 60-year-old man in good general health has an asymptomatic prostate nodule. His PSA level is 9 ng/mL, and biopsy confirms adenocarcinoma (Gleason III + III) on one side. Bone scanning does not reveal any evidence of metastatic disease. Which of the following therapies is appropriate?
A Transurethral prostate resection
B Radical prostatectomy
C Orchiectomy
D Diethylstilbestrol
E Injection of luteinizing hormone–releasing hormone (LHRH) agonist
Ref.: 16
Comments
Carcinoma of the prostate is the most common non–skin-related cancer in men older than 65 years and is the second most common cause of cancer death in the male population. Histologically, most of these lesions are adenocarcinomas. Squamous cell carcinoma and sarcomas of the prostate are rare. No definite etiologic factors have been established, but age, race, and family history are important predictors. Most prostate cancers arise in the periphery of the gland and are asymptomatic until urinary obstruction or symptoms of metastases develop. More than one half of the prostate nodules detected on examination are malignant. When a prostatic nodule is detected, a PSA level should be obtained, followed by transrectal ultrasound imaging and biopsy. If prostate cancer is found, a bone scan may be obtained to rule out evidence of metastatic disease. In addition, a chest radiograph and possibly a serum acid phosphatase level are obtained preoperatively. Treatment of localized prostate cancer consists of radical prostatectomy or external beam or interstitial implanted radiotherapy, depending on the physician’s and patient’s preference. Watchful waiting or active surveillance has been studied for men with low-grade and low-stage prostate cancer, but men undergoing definitive surgical or radiation therapy enjoy a significant improvement in overall and prostate cancer–specific survival. Many new experimental and investigational modalities are being used for the treatment of prostate cancer. Radical prostatectomy consists of removing the entire prostate and seminal vesicles and may be done through the retropubic or perineal route. Staging pelvic lymph node dissection is often performed before prostatectomy. If the lymph nodes are grossly enlarged, they are sent for frozen section, and the operation is usually terminated if cancer has spread to the lymph nodes. Tables have been established that predict the likelihood of positive margins and lymph node involvement based on the clinical stage, PSA level, and Gleason score. Hormonal therapy with estrogens or LHRH agonists is indicated for metastatic disease but is not appropriate primary therapy.
Answer
B
20 An asymptomatic 76-year-old man has a hard, irregular prostate, an elevated acid phosphatase level, a PSA level of 53 ng/mL, and multiple osteoblastic lesions in the lumbosacral spine. Biopsy of the prostate reveals a moderately differentiated adenocarcinoma. Which of the following therapies is indicated?
A Transurethral prostate resection
B Radical prostatectomy
C Hormonal therapy
D Radiation therapy
E Cytotoxic chemotherapy
Ref.: 17
Comments
The treatment of locally advanced or metastatic prostate cancer is palliation. The primary method of therapy is hormonal manipulation, which consists of bilateral orchiectomy or the administration of LHRH agonists (e.g., leuprolide) and possibly testosterone-blocking agents (e.g., flutamide). Exogenous estrogens, such as diethylstilbestrol, are not used often because of their associated increased incidence of thromboembolic disease. Hormonal therapy is the primary means of palliating bone pain, obstructive uropathy, and the general debility of metastatic disease. Use of early versus delayed hormonal therapy is controversial, and a survival benefit for initiating hormonal therapy before the onset of symptoms has yet to be proved but may benefit select patients with positive nodes. When hormonal treatment fails to palliate, TURP is performed to relieve obstruction or local radiotherapy is used to palliate painful or bulky metastasis. Chemotherapy is not particularly useful, although protocols are forthcoming for hormone-refractory prostate cancer. Radical prostatectomy is not indicated in men with metastatic disease.
Answer
C
21 An 11-year-old boy complains of scrotal swelling and pain. His parents note that the size of his scrotum seems to fluctuate. What is the probable diagnosis?
A Testicular tumor
B Spermatocele
C Chronic epididymitis
D Acute or subacute epididymitis
E Hydrocele
Ref.: 11, 18
Comments
Hydrocele can be idiopathic or secondary to a process such as epididymitis, trauma, mumps, or tuberculosis. Typically, it is a nontender, translucent mass. It can obscure palpation of the testes, and it is important to be aware of this in young men because as many as 20% of acute hydroceles are secondary to testicular tumors. If a mass with all the characteristics of a hydrocele empties when the patient is in the supine position, there is probably a patent processus vaginalis. In patients who have a fluctuating hydrocele or are younger than 12 years, an inguinal approach is necessary to perform high ligation of the hydrocele. Hydroceles in adults require treatment only when symptomatic, but in children they may require treatment if persistent. A spermatocele is a simple or multiloculated cyst at the head of the epididymis and usually requires no treatment unless it is symptomatic. It transilluminates and can be palpated as being discrete from the testes. Epididymitis, if acute, leaves the patient with an exquisitely tender scrotum whose skin may be red and edematous. There may be a mass, but this is often difficult to appreciate because the patient does not permit a deliberate examination. With chronic epididymitis, the mass is nontender and firm and can cause beading of the entire vas deferens. If a draining sinus tract is also present, the most likely cause is tuberculosis. Testicular cancer is the most serious condition in the scrotum, and a solid mass arising from the testicle is considered cancer. The mass is usually firm, cannot be transilluminated, and is not tender. If it is tender, it may be so as a result of bleeding of a tumor into the testicle. Ultrasonic examination of the testicle, along with determination of tumor markers, has greatly facilitated making a diagnosis in such a clinical setting.
Answer
E
22 A 14-year-old boy is brought to the emergency department with a 4-hour history of acute, severe left scrotal pain. Examination reveals a high-riding left testicle with severe pain on palpation. Urinalysis does not reveal any evidence of red or white blood cells. Which of the following is the treatment of choice at this point?
A Heat, scrotal elevation, and antibiotics
B Manual attempt at detorsion
C Analgesics and re-examination
D Doppler examination to assess testicular blood flow
E Surgical exploration
Ref.: 11
Comments
When examining the acutely painful scrotum, one should attempt to differentiate epididymitis from testicular torsion, but it may not be possible. Doubtful cases should be treated as testicular torsion until proved otherwise. Because irreversible testicular ischemia occurs within 4 hours when there is complete torsion, prompt surgical exploration is indicated even if the diagnosis is uncertain. Doppler examination may be helpful for assessing testicular blood flow. Nuclear medicine scans also are reliable and must be used judiciously. Manual detorsion is not usually successful but can be done when the scrotum is not swollen. It may relieve pain, but exploration is still necessary because residual torsion may still exist. At the time of exploration, the involved testis should be anatomically fixated and detorsion performed. The contralateral testis should undergo a similar procedure prophylactically because the same anatomic abnormality may be found in both testes.
Answer
E
23 The anatomic abnormality found with torsion of the testicle in adolescents most commonly involves which of the following?
A Intravaginal torsion of the spermatic cord
B Extravaginal torsion of the spermatic cord
C Torsion of the appendix testis
D Torsion of the appendix epididymis
E Torsion of the contralateral testis
Ref.: 11, 19
Comments
There are two types of torsion of the testicle. In neonates, torsion of the spermatic cord occurs before attachment of the gubernaculum, which allows torsion of the entire testicle and tunica vaginalis. This is called extravaginal torsion. The second type of torsion usually occurs in adolescents and older men and is called intravaginal torsion of the spermatic cord. By this time, the tunica vaginalis is fixed to the dartos fascia and cannot twist. Intravaginal torsion is most commonly associated with a long mesenteric attachment between the cord and the testes and epididymis, which allows the testicle to rotate (producing the “bell clapper” deformity), and torsion can therefore occur within the tunica vaginalis. This deformity is often bilateral, and fixation of the contralateral testis should be performed at the time that the testicular torsion is corrected. Nonetheless, bilateral torsion is exceedingly rare at initial evaluation. Regarding the appendix testis and the appendix epididymis, torsion of these appendages can produce acute pain and swelling similar to torsion of the spermatic cord, but it does not result in testicular infarction. Transillumination may reveal the “blue dot” sign representing the infarcted structure. Exploration is sometimes required to exclude testicular torsion.
Answer
A
24 Which of the following is true regarding varicocele?
A Varicoceles occur more commonly on the right side.
B Varicoceles are associated with infertility.
C Varicoceles occur in about 40% of men.
D Varicoceles are often associated with testicular tumors.
E Varicoceles are not usually palpable on physical examination.
Ref.: 20
Comments
Varicoceles are seen in approximately 15% to 20% of the male population but in up to 40% of infertile men. Varicoceles have not been found to be associated with testicular tumors. They are much more common on the left side—because the gonadal vein drains into the renal vein, it usually maintains higher pressure than the right side. They have been associated with diminished sperm count, decreased sperm motility, and abnormal sperm morphology. In infertile patients with abnormal findings on semen analysis, varicocelectomy often improves the semen analysis. Physical examination of the scrotum reveals a large group of veins palpable within the scrotum, which has been described as a “bag of worms.”
Answer
B
25 A 65-year-old man is unable to void after an abdominoperineal resection. Postvoid residuals have been 600 to 800 mL. The treatment of choice is which of the following?
A Chronic Foley catheterization
B TURP
C Clean intermittent catheterization
D Transurethral sphincterotomy
E α-Blockers alone
Ref.: 21
Comments
Bladder dysfunction has been reported in 10% to 50% of patients following abdominal perineal resection or other major pelvic surgery. The type of voiding dysfunction that occurs is dependent on the specific nerve involved and the degree of injury. Patients with urinary retention are best treated by clean intermittent catheterization. Most (>80%) resolve over a period of 3 to 6 months. The use of a chronic indwelling catheter is a reasonable choice in some patients, but the risk for infection is higher with chronic catheterization than with intermittent catheterization. The use of α-blockers alone or TURP is unlikely to be successful. Transurethral sphincterotomy does not treat the underlying problem and may result in incontinence.
Answer
C
26 Which of the following are not treatments or characteristics of nonseminomatous germ cell tumors of the testis?
A Radiation therapy
B Retroperitoneal lymph node dissection
C Elevated α-fetoprotein (AFP)
D Elevated hCG
E Chemotherapy for advanced disease
Ref.: 22
Comments
The most common solid tumor in a young male is a seminoma. About 95% of testicular masses are of germ cell origin. Germ cell tumors are divided into seminomatous and nonseminomatous germ cell tumors. Nonseminomatous germ cell tumors include tumors of the following histologic types: embryonal cell carcinoma, yolk sac tumor, choriocarcinoma, and teratoma. Clinically, stage I seminomas (confined to the testis) are treated with prophylactic radiotherapy of the retroperitoneal lymph nodes to eliminate any chance of failure in the retroperitoneum. Select patients are now treated by surveillance alone. Higher-stage seminomas (visible adenopathy in the retroperitoneum or lung metastasis) are best treated with chemotherapy. An elevated hCG level is seen in 5% to 10% of patients with seminomas, but if an elevated AFP level is found, the tumor is considered nonseminomatous. Treatment of clinical stage I nonseminomatous germ cell tumors is controversial but consists of either retroperitoneal lymph node dissection, primary chemotherapy, or surveillance. Elevated AFP and β-hCG levels may be seen in patients with nonseminomatous germ cell tumors. For patients with bulky retroperitoneal disease or visceral metastasis, treatment consists of combination chemotherapy.
Answer
A
27 Appropriate treatment of a painless solid testicular mass in a 28-year-old man includes which of the following?
A Preoperative CT for staging
B Incisional biopsy via a scrotal incision
C Incisional biopsy via an inguinal incision
D Orchiectomy via a scrotal incision
E Orchiectomy via an inguinal incision
Ref.: 22
Comments
During the work-up of a patient with a testicular tumor, serum should be obtained for determination of AFP and β-hCG levels because these tumor markers are elevated in many patients with testicular cancer. CT of the abdomen and pelvis for staging is performed after the diagnosis is made and should not delay orchiectomy The primary diagnostic and therapeutic maneuver is orchiectomy, and it should be carried out via an inguinal incision with early clamping of the vessels. If the presence of a testicular mass is confirmed, an orchiectomy should be performed. Rarely, the testicle suspected of being involved with cancer may be affected by a benign condition. Yet even in this situation, the best treatment is often orchiectomy. A scrotal approach is contraindicated because it does not permit control of the testicular vessels before manipulation of the testicle, which may dislodge tumor cells into the venous drainage. In addition, with such an approach, cells from the biopsy specimen may spill into the scrotum and subsequently spread tumor via the scrotal lymphatic drainage to the superficial inguinal nodes, or they may seed locally.
Answer
E
28 A 32-year-old man arrives at the emergency department with an exquisitely painful and “woody”-feeling penile erection of 18 hours’ duration. Which of the following is not a therapeutic option?
A Aspiration of blood from the corpora cavernosa
B Irrigation of the corpora cavernosa with a dilute solution of papaverine
C Creation of a communication between the glans penis and a corporal body with a biopsy needle or scalpel blade
D Side-to-side anastomosis between the corpus spongiosum and corpus cavernosum
E Exchange transfusions
Ref.: 23
Comments
Priapism is a prolonged pathologic penile erection in the absence of sexual stimulation, and there are two major types: ischemic (or “low flow”) and nonischemic (“high flow”). Blood gas analysis of aspirated corporal blood shows acidosis and hypoxemia in ischemic priapism, and the patient experiences pain. Nonischemic priapism is not usually painful and requires only conservative management and reassurance, but ischemic priapism requires emergency treatment. Most cases of priapism are idiopathic. Some known causes are sickle cell disease, leukemic infiltration of veins draining the penis, and certain medications, such as anticoagulants and antidepressants. Frequently, simple aspiration of blood from the corpus cavernosum alone can cause lasting detumescence. If this fails, irrigation of the corpus with a dilute solution of epinephrine or norepinephrine may work. This has the dual effect of decompressing the corpus and the venous obstruction that goes with it, as well as diminishing arterial flow. Papaverine is used to treat impotence. It increases penile blood flow by directly relaxing vascular smooth muscle. The glans penis is an extension of the corpus spongiosum and is not usually affected by priapism. Shunts between it and the corpus cavernosa created with biopsy needles or scalpel blades or removal of a portion of the glandular corporal septum may provide a path of egress for blood trapped in the penis. If all else fails, formal spongiosum-to-cavernosum shunts may be created. There is a high incidence of impotence after priapism lasting 24 hours or longer. When priapism is secondary to sickle cell anemia, exchange transfusions and other medical therapies, including oxygenation, hydration, and alkalinization, may be indicated.
Answer
B
29 A 40-year-old man with a history of alcoholism comes to the emergency department with changes in mental status and scrotal pain. Physical examination reveals a temperature of 102.2°F and an ecchymotic and exquisitely tender scrotum with palpable crepitus. What are the immediate next steps in management?
A CT of the pelvis to the midthigh
B Incision and drainage of the scrotal skin and culture of the retrieved fluid
C Plain radiograph of the pelvis
D Duplex ultrasonography of the scrotum
E Wide débridement of the affected tissues
Ref.: 21
Comments
This patient has evidence of a necrotizing infection of the scrotal tissue consistent with Fournier gangrene. It is a necrotizing fasciitis that arises from urethral, rectal, or perineal skin flora. The etiology is usually polymicrobial, including aerobic and anaerobic bacteria. It is characterized by subcutaneous crepitus, tenderness, and foul-smelling necrotic tissue. This life-threatening infection must be widely débrided without delay, and broad-spectrum antibiotic therapy and aggressive fluid resuscitation are necessary. Imaging studies may confirm the presence of subcutaneous gas, but surgery should not be delayed because the diagnosis is clinical.
Answer
E
30 Which of the following events is necessary for normal micturition?
A Increase in sympathetic tone to the detrusor resulting in bladder contraction
B Increased activity of cholinergic nerves in the lower urinary tract
C Stimulation of α-adrenergic receptors at the bladder neck
D Cerebellar coordination of voiding reflex
E Increase in intra-abdominal pressure
Ref.: 11, 24
Comments
Normal micturition is a complex process requiring coordination of the autonomic and voluntary nervous systems. Voluntary relaxation of the external urinary sphincter (innervated by the sacral spinal nerve roots) initiates normal urination. When the bladder fills, autonomic afferent nerves transmit a signal to the pons that coordinates relaxation of the bladder neck and contraction of the bladder via an increase in parasympathetic tone and inhibition of sympathetic tone in the lower urinary tract. α-Adrenergic receptors mediate closure of the bladder neck and therefore facilitate urine storage. α-Blockers facilitate voiding by relaxing smooth muscle in the bladder outlet. Some patients with detrusor areflexia may void via maneuvers such as the Valsalva or Credé maneuver, which increases intraabdominal pressure.
Answer
B
31 Which of the following matches a layer of the scrotum with its corresponding fascial layer in the abdominal wall:
A Cremasteric fascia—Internal oblique muscle
B Tunica vaginalis—External oblique fascia
C Dartos fascia—Transversalis fascia
D External spermatic fascia—Scarpa fascia
E Internal spermatic fascia—Peritoneum
Ref.: 25, 26
Comments
As the testes descend, the scrotal wall is formed from layers of the abdominal wall. The Scarpa fascia is continuous with the dartos fascia. The external oblique aponeurosis corresponds to the external spermatic fascia and is attached to the external inguinal ring. The internal oblique muscle gives rise to the cremasteric muscle and fascia. The transversalis fascia is continuous with the internal spermatic fascia. The transversus abdominis muscle terminates superior to the triangle of Hesselbach and therefore does not have a scrotal counterpart. The tunica vaginalis is a bilayered scrotal structure that is continuous with the peritoneum. They are connected by the processus vaginalis, which normally closes in infancy. Persistence of the processus vaginalis may result in a hydrocele.
Answer
A
32 Which of the following is true regarding circumcision?
A It is protective against penile cancer
B It may increase HIV transmission
C It decreases penile sensation
D The fascia of Buck must be closed before skin closure
E Hypospadias is a contraindication
Ref.: 27, 28
Comments
Circumcision is removal of the preputial skin. The fascia of Buck is deep to the dartos fascia and should not be entered during circumcision. No reports have definitively proved any decrease or increase in penile sensation after circumcision. Penile cancer is most commonly squamous cell carcinoma, occurs in men with phimosis as a result of chronic irritation of the underlying skin, and is virtually nonexistent in circumcised men. At the time of circumcision the glans penis should be inspected carefully for suspicious lesions and the surgical specimen analyzed. In high-risk young adult populations in Africa, circumcision has been shown to reduce the rate of acquiring HIV by 50%. It has been shown that the inner prepuce has a high concentration of Langerhans cells that contain receptors for HIV. Hypospadias is not a contraindication to circumcision; however, because the preputial skin is often used for urethral reconstruction, circumcision should be deferred until the hypospadias is repaired.
Answer
A
33 Which of the following is true regarding enterovesical fistulas?
A Barium enema is the most sensitive imaging test.
B An oral charcoal test will localize a fistula to the small bowel.
C Pneumaturia is the most common initial sign/symptom.
D A definitive diagnosis can be made 90% of the time with cystoscopy.
E Inflammatory bowel disease is the most common cause.
Ref.: 29
Comments
Enterovesical fistulas are abnormal connections between the bowel and bladder. The sigmoid colon is the most common site, and sigmoid diverticulitis accounts for 70% of cases. Patients are initially seen with pneumaturia or air in the urine 50% to 80% of the time and fecaluria or symptoms of urinary tract infection 40% of the time. CT of the abdomen and pelvis with oral contrast enhancement is the most sensitive imaging modality for detecting an enterovesical fistula. The classic triad of findings on CT are a thickened bladder wall adjacent to a thickened loop of bowel, air in the bladder in the absence of instrumentation, and colonic diverticula. Barium enema has low sensitivity for the detection of fistulas; however, the first voided specimen after the test may be centrifuged and examined radiographically to increase its diagnostic yield. Oral charcoal administration and subsequent blackening of the urine will make the diagnosis of enterovesical fistula but will not provide anatomic information. Cystoscopy will reveal changes in the bladder mucosa, but a fistula tract is identified only approximately 35% of the time. Any endoscopically identified fistula tract in the setting of previous malignancy should undergo biopsy to evaluate for a malignant fistula.
Answer
C
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