A 21-year-old man presents to the emergency department after sustaining a stab wound to the neck at a local farmer's market. The patient is otherwise healthy and is complaining of pain. The patient is able to offer the history himself. His temperature is 97.6°F (36.4°C), blood pressure is 120/84 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam demonstrates a 3 cm laceration 1 cm inferior to the mastoid process on the right side. The patient's breath sounds are clear and he is protecting his airway. No stridor or difficulty breathing is noted. Which of the following is the most appropriate next step in the management of this patient?

Observation and blood pressure monitoring

A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

CT head without intravenous contrast

Doppler ultrasound of the carotids

CT head with intravenous contrast

MRI head without intravenous contrast

MRI head with intravenous contrast

A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below: Serum: Na+: 130 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.7 mg/dL Urine: Appearance: dark Glucose: negative WBC: 0/hpf Bacterial: none Na+: 320 mEq/L/24 hours His temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

Continue conservative management

A 48-year-old woman is brought to the emergency department because of a 1-hour history of sudden-onset headache associated with nausea and vomiting. The patient reports she was sitting at her desk when the headache began. The headache is global and radiates to her neck. She has hypertension. She has smoked one pack of cigarettes daily for the last 10 years. She drinks alcohol occasionally. Her father had a stroke at the age 58 years. Current medications include hydrochlorothiazide. She is in severe distress. She is alert and oriented to person, place, and time. Her temperature is 38.2°C (100.8°F), pulse is 89/min, respirations are 19/min, and blood pressure is 150/90 mm Hg. Cardiopulmonary examination shows no abnormalities. Cranial nerves II–XII are intact. She has no focal motor or sensory deficits. She flexes her hips and knees when her neck is flexed while lying in a supine position. A CT scan of the head is shown. Which of the following is the most appropriate intervention?

Administer intravenous alteplase

Administer intravenous vancomycin and ceftriaxone

Perform decompressive craniectomy

A 52-year-old man is brought to the emergency department with a 2-hour history of severe, sudden-onset generalized headache. He has since developed nausea and has had one episode of vomiting. The symptoms began while he was at home watching television. Six days ago, he experienced a severe headache that resolved without treatment. He has hypertension and hyperlipidemia. The patient has smoked two packs of cigarettes daily for 30 years. His current medications include lisinopril-hydrochlorothiazide and simvastatin. His temperature is 38.1°C (100.6°F), pulse is 82/min, respirations are 16/min, and blood pressure is 162/98 mm Hg. The pupils are equal, round, and reactive to light. Fundoscopic examination shows no swelling of the optic discs. Cranial nerves II–XII are intact. He has no focal motor or sensory deficits. Finger-to-nose and heel-to-shin testing are normal. A CT scan of the head shows no abnormalities. Which of the following is the most appropriate next step in management?

Administer 100% oxygen and intranasal sumatriptan

Place ventriculoperitoneal shunt

A 56-year-old woman presents with sudden-onset severe headache, nausea, vomiting, and neck pain for the past 90 minutes. She describes her headache as a ‘thunderclap’, followed quickly by severe neck pain and stiffness, nausea and vomiting. She denies any loss of consciousness, seizure, or similar symptoms in the past. Her past medical history is significant for an episode 6 months ago where she suddenly had trouble putting weight on her right leg, which resolved within hours. The patient denies any history of smoking, alcohol or recreational drug use. On physical examination, the patient has significant nuchal rigidity. Her muscle strength in the lower extremities is 4/5 on the right and 5/5 on the left. The remainder of the physical examination is unremarkable. A noncontrast CT scan of the head is normal. Which of the following is the next best step in the management of this patient?

Diffusion-weighted magnetic resonance imaging of the brain

Placement of a ventriculoperitoneal (VP) shunt

A 48-year-old woman undergoes awake craniotomy for resection of a left frontal glioma near Broca's area. Intraoperatively, cortical mapping identifies eloquent tissue, but the tumor extends into functionally critical regions. The surgeon achieves 70% resection when the patient develops expressive aphasia during mapping. Frozen section shows low-grade astrocytoma. The family previously expressed desire for maximal resection. Evaluate the intraoperative decision-making.

Stop resection to preserve language function

Use awake testing to define exact limits of safe resection

Obtain family consultation intraoperatively about acceptable deficits

Convert to asleep anesthesia and use anatomic landmarks for resection

Continue resection since low-grade tumors justify aggressive surgery

Cerebral aneurysm management for USMLE Step 2 CK: High-Yield Surgery Lessons

🧠 Pathophysiology - Weak Walls, Big Trouble

Origin: Congenital weakness at arterial bifurcations, primarily in the Circle of Willis.
- Defect: Focal absence of internal elastic lamina and thinned tunica media.
Growth & Rupture: Governed by the Law of Laplace, $T = (P \times r) / 2h$.
- As radius ($r$) ↑, wall tension ($T$) ↑, increasing rupture risk.
Key Risk Factors:
- Chronic Hypertension (HTN)
- Smoking
- Autosomal Dominant Polycystic Kidney Disease (ADPKD)
- Connective tissue disorders (Marfan, Ehlers-Danlos)

⭐ 85-95% of cerebral aneurysms are saccular ("berry") type, most commonly at the Anterior Communicating Artery (ACom) junction.

🤯 Clinical Manifestations - The Worst Headache

Classic Presentation: Sudden, explosive "thunderclap" headache, reaching maximum intensity within seconds.
- Patient often describes it as the "worst headache of my life."
Key Associated Symptoms:
- Nausea/Vomiting
- Meningismus (nuchal rigidity, photophobia) due to blood in CSF.
- Loss of consciousness (LOC).
- Focal deficits (e.g., CN III palsy from PComm aneurysm).
⚠️ Sentinel Headache: A less severe, warning headache may precede rupture by days/weeks in ~30-50% of patients.

⭐ The hallmark of a ruptured aneurysm is a "thunderclap headache" from subarachnoid hemorrhage (SAH).

CT head showing subarachnoid hemorrhage

🧠 Diagnosis - Finding the Bubble

Initial Test (Suspected Rupture/SAH):
- 1st: Non-contrast head CT to detect subarachnoid blood.
- 2nd (if CT negative, high suspicion): Lumbar Puncture (LP).
Localization Imaging (Post-SAH confirmation):
- CT Angiography (CTA): Rapid, first-line for locating the aneurysm.
- Digital Subtraction Angiography (DSA): Gold standard; invasive, for definitive diagnosis/planning.

⭐ Xanthochromia (yellow CSF from bilirubin) on LP is diagnostic for SAH if the initial CT is negative. It appears 6-12 hours after the bleed.

🧠 Management - To Clip or Coil?

The primary goal is to exclude the aneurysm from circulation to prevent (re)rupture. The choice between open surgery and endovascular methods depends on aneurysm and patient factors.

Cerebral Aneurysm Rerupture: Clipping vs. Coiling

Feature	Surgical Clipping	Endovascular Coiling
Approach	Open craniotomy	Catheter-based (femoral a.)
Best For	Wide-neck, MCA aneurysms	Narrow-neck, posterior circ.
Durability	More durable, ↓ re-bleed	↑ Retreatment rate
Risk	↑ Peri-procedural risk	↓ Peri-procedural risk
Ideal Pt	Young, good surgical candidate	Elderly, poor surgical candidate

💥 Complications - Post-Pop Problems

Rebleeding: Highest risk in first 24 hrs. Often fatal. Secure aneurysm early.
Cerebral Vasospasm: Onset 3-14 days post-SAH, causing delayed cerebral ischemia (DCI).
- Prophylaxis: Nimodipine (oral CCB) for all SAH patients.
- Dx: Transcranial Doppler (TCD), CTA.
Hydrocephalus: Blood obstructs arachnoid granulations → communicating hydrocephalus.
Hyponatremia: SIADH vs. Cerebral Salt Wasting (CSW).
Seizures: Risk is highest initially.

⭐ Vasospasm is the main cause of delayed morbidity/mortality. Its delayed onset (3-14 days) is a classic exam point.

CTA brain showing cerebral vasospasm after SAH

⚡ Biggest Takeaways

Ruptured aneurysm presents as a "worst headache of life" (thunderclap headache) from subarachnoid hemorrhage (SAH).

Initial diagnosis is a non-contrast CT scan. If negative, a lumbar puncture showing xanthochromia is diagnostic.

Cerebral angiography (CTA/MRA/DSA) is required to locate the aneurysm, most commonly at the ACom artery.

Nimodipine is essential to prevent vasospasm, a major cause of delayed ischemia (days 3-10 post-SAH).

Prevent rebleeding (highest risk <24h) with endovascular coiling or surgical clipping.

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