Prometric Exam Questions for Neurosurgery Specialists 2026: 20 MCQs with Answers on Head Injury, Intracranial Pressure, Subarachnoid Haemorrhage, Brain Tumours, Spinal Cord Injury, Degenerative Spine, Hydrocephalus and Paediatric Neurosurgery

The specialist neurosurgery paper (NEU5311 at DHA, and the equivalent SCFHS, QCHP and NHRA papers) is 100 to 150 single-best-answer questions in up to three hours with a pass mark of about 60%. Candidates with an MCh, DNB, FCPS, FRCS (SN) or Arab Board sit it after the authority confirms the specialist title. The Gulf has some of the world's highest road traffic injury rates, so trauma dominates the paper, followed by vascular, tumour, spine and paediatric neurosurgery. This set covers what recurs. The licensing route is in the neurosurgeon guide.

Head injury

Question 1

A motorcyclist opens his eyes only to painful stimulus, makes incomprehensible sounds and withdraws from pain. His Glasgow Coma Scale score and injury category are:

1. GCS 10, moderate
2. GCS 8 (E2 V2 M4), severe traumatic brain injury, requiring airway protection by intubation and a CT head
3. GCS 6, severe
4. GCS 12, mild

Answer: B. Mild is 13 to 15, moderate 9 to 12, severe 8 or less. The motor score is the most prognostic component; document each component, not just the total.

Question 2

A 20-year-old is briefly unconscious after a fall, recovers and talks normally, then two hours later becomes drowsy with a dilated right pupil and left hemiparesis. CT shows a biconvex hyperdense lesion in the right temporal region. The diagnosis and management are:

1. Acute subdural haematoma; observation
2. Extradural (epidural) haematoma, usually from middle meningeal artery injury with a temporal bone fracture; emergency craniotomy and evacuation, with an excellent prognosis if evacuated before secondary brain injury
3. Diffuse axonal injury; ICU care
4. Contusion; steroids

Answer: B. The lucid interval is classic; a crescentic lesion crossing suture lines would indicate a subdural haematoma, which carries a worse prognosis because of underlying brain injury.

Question 3

Which patient with a head injury needs a CT head within one hour according to standard guidance?

1. A patient with GCS 15, one episode of vomiting and no other features
2. A patient with GCS below 13 at any point, a suspected open or depressed skull fracture, signs of basal skull fracture, a post-traumatic seizure, a focal deficit, or more than one episode of vomiting
3. Any patient over 50
4. A patient with a headache only

Answer: B. Anticoagulant use, amnesia over 30 minutes and a dangerous mechanism justify CT within 8 hours even without the one-hour criteria.

Question 4

An intubated patient with severe traumatic brain injury has an intracranial pressure of 28 mmHg and a mean arterial pressure of 80 mmHg. First-tier measures to lower intracranial pressure include:

1. Hyperventilation to a PaCO₂ of 3 kPa for 24 hours
2. Head elevation to 30 degrees with neutral neck, adequate sedation and analgesia, normothermia, PaCO₂ 4.5 to 5.0 kPa, hyperosmolar therapy (mannitol or hypertonic saline), CSF drainage if a ventricular catheter is in place, and maintaining cerebral perfusion pressure of 60 to 70 mmHg
3. Prophylactic high-dose steroids
4. Fluid restriction to dehydrate the brain

Answer: B. Steroids increase mortality in traumatic brain injury (CRASH trial). Prolonged hyperventilation causes ischaemia; decompressive craniectomy and barbiturate coma are second-tier options.

Question 5

A patient with a basal skull fracture has clear fluid dripping from the nose. The appropriate management is:

1. Pack the nose tightly and start prophylactic antibiotics
2. Confirm CSF rhinorrhoea (beta-2 transferrin), head elevation and avoidance of nose blowing or straining, no nasogastric tube, observation, with lumbar drainage or surgical repair if the leak persists beyond about a week; prophylactic antibiotics are not routinely recommended
3. Immediate craniotomy
4. Nasal decongestants

Answer: B. Nasal tubes are contraindicated with basal skull fracture; meningitis risk is managed by closing the leak, and pneumococcal vaccination is advised.

Vascular neurosurgery

Question 6

A 50-year-old woman has a sudden severe headache, vomiting and neck stiffness. CT shows blood in the basal cisterns. She is drowsy but obeys commands, with no focal deficit. The grade and the key next steps are:

1. WFNS grade 5; palliative care
2. WFNS grade 2 to 3; CT angiography to find the aneurysm, nimodipine 60 mg every 4 hours for 21 days, euvolaemia, blood pressure control before securing, and early aneurysm treatment by endovascular coiling or clipping within 24 to 72 hours
3. Lumbar puncture first
4. Therapeutic anticoagulation

Answer: B. Rebleeding is the early killer and securing the aneurysm prevents it; nimodipine reduces poor outcome from delayed cerebral ischaemia.

Question 7

On day 7 after coiling of a ruptured anterior communicating aneurysm, the patient develops new confusion and left arm weakness. The most likely cause and management are:

1. Rebleeding; repeat coiling
2. Delayed cerebral ischaemia from vasospasm; exclude hydrocephalus and rebleed on CT, confirm with transcranial Doppler or CT perfusion, induce hypertension if the aneurysm is secured, maintain euvolaemia, and consider endovascular rescue (intra-arterial vasodilators or angioplasty) if refractory
3. Seizure; phenytoin
4. Hyponatraemia; fluid restriction

Answer: B. Vasospasm peaks at days 4 to 14. Hyponatraemia after SAH is usually cerebral salt wasting, treated with salt and volume, not fluid restriction.

Question 8

A 65-year-old hypertensive patient has a 35 mL putaminal haemorrhage with GCS 13 and no hydrocephalus. The most appropriate management is:

1. Immediate craniotomy and clot evacuation
2. Medical management: intensive blood pressure lowering to a systolic of about 140 mmHg, reversal of any anticoagulation, neurological monitoring and seizure management, with surgery reserved for deterioration, cerebellar haematomas over 3 cm with brainstem compression or hydrocephalus, and selected superficial lobar clots
3. Thrombolysis
4. Steroids

Answer: B. Routine surgery for deep supratentorial haemorrhage does not improve outcome (STICH trials); cerebellar haemorrhage with compression is a surgical emergency.

Tumours

Question 9

A 60-year-old presents with two months of headache, personality change and a first seizure. MRI shows a ring-enhancing, irregular, necrotic right frontal mass crossing the corpus callosum. The most likely diagnosis and management are:

1. Meningioma; observation
2. Glioblastoma (IDH-wildtype grade 4 glioma); maximal safe resection, then radiotherapy with concurrent and adjuvant temozolomide, with dexamethasone for oedema and anticonvulsants for seizures, and molecular testing including MGMT methylation status
3. Brain abscess; antibiotics alone
4. Metastasis; whole-brain radiotherapy

Answer: B. The 2021 WHO classification is molecular: IDH mutation, 1p/19q codeletion and MGMT status guide prognosis and treatment. Prophylactic anticonvulsants are not given without seizures.

Question 10

A 55-year-old woman has an incidental 2 cm dural-based, homogeneously enhancing convexity lesion with a dural tail and no oedema or symptoms. The best management is:

1. Urgent craniotomy
2. Serial MRI surveillance for a probable meningioma, with surgery (Simpson grading of resection) or radiosurgery reserved for growth, symptoms or oedema
3. Chemotherapy
4. Biopsy via lumbar puncture

Answer: B. Most incidental meningiomas grow slowly; progesterone receptor positivity and female predominance are features.

Question 11

A 35-year-old woman has galactorrhoea, amenorrhoea and a 1.5 cm pituitary lesion with a prolactin of 4,500 mIU/L. The first-line treatment is:

1. Transsphenoidal surgery
2. A dopamine agonist such as cabergoline, which normalises prolactin and shrinks most prolactinomas; surgery is reserved for intolerance, resistance, CSF leak or acute visual compromise
3. Radiotherapy
4. Observation only

Answer: B. Prolactinomas are the one pituitary adenoma treated medically first; non-functioning macroadenomas with visual field defects and acromegaly or Cushing's disease are surgical.

Question 12

After transsphenoidal surgery, a patient passes 400 mL/h of dilute urine with a rising serum sodium of 150 mmol/L. The nurse and surgeon should recognise and treat:

1. Cerebral salt wasting; hypertonic saline
2. Diabetes insipidus from posterior pituitary dysfunction; replace losses, monitor sodium and osmolality closely and give desmopressin when criteria are met, watching for the triphasic response
3. SIADH; fluid restriction
4. Normal post-operative diuresis

Answer: B. The triphasic response is DI, then transient SIADH from stored ADH release, then permanent DI; hydrocortisone cover is also checked post-operatively.

Spine

Question 13

A 40-year-old man has severe low back pain radiating to both legs, saddle anaesthesia, urinary retention with overflow and reduced anal tone. The management is:

1. Analgesia and physiotherapy referral
2. Emergency MRI of the lumbar spine and urgent surgical decompression of cauda equina syndrome, ideally within 24 to 48 hours of symptom onset, because bladder and bowel recovery depends on the speed of decompression
3. Outpatient MRI in two weeks
4. Epidural steroid injection

Answer: B. Painless retention and perineal numbness are the red flags; a post-void residual bladder scan is documented at presentation.

Question 14

A 70-year-old has gradual clumsiness of the hands, gait unsteadiness, hyperreflexia in the legs, a positive Hoffmann sign and up-going plantars. MRI shows multilevel cervical cord compression with T2 signal change. The management is:

1. Cervical collar and observation
2. Surgical decompression (anterior or posterior depending on alignment and levels) for moderate to severe degenerative cervical myelopathy, because the natural history is stepwise deterioration and surgery halts progression
3. Steroids
4. Cervical traction

Answer: B. Lower motor neuron signs at the level of compression and upper motor neuron signs below it are the pattern; the modified JOA score grades severity.

Question 15

A patient with a complete C6 spinal cord injury after a diving accident has a blood pressure of 80/50 mmHg, heart rate 48 and warm peripheries. The diagnosis and management are:

1. Haemorrhagic shock; massive transfusion
2. Neurogenic shock from loss of sympathetic tone; judicious fluids then vasopressors to maintain mean arterial pressure of 85 to 90 mmHg for the first week, atropine for bradycardia, strict spinal immobilisation, and early surgical decompression and stabilisation where indicated
3. Sepsis; antibiotics
4. Spinal shock, which is the same as neurogenic shock

Answer: B. Spinal shock is the transient loss of reflexes below the lesion, distinct from neurogenic (haemodynamic) shock. High-dose methylprednisolone is no longer recommended.

Question 16

A 45-year-old with an L4/5 disc herniation has six weeks of right leg sciatica, no weakness and no sphincter symptoms despite analgesia and physiotherapy. The appropriate advice is:

1. Immediate discectomy is mandatory
2. Most sciatica improves within 6 to 12 weeks; continue conservative care with a transforaminal epidural steroid injection as an option, and offer microdiscectomy for persistent disabling pain beyond that period or for progressive neurological deficit
3. Bed rest for a month
4. Spinal fusion

Answer: B. Surgery gives faster relief but similar long-term outcomes to conservative care in uncomplicated sciatica.

Hydrocephalus, paediatrics and end of life

Question 17

A 3-year-old with a ventriculoperitoneal shunt has two days of vomiting, headache, irritability and new drowsiness. The management is:

1. Oral rehydration and review in 48 hours
2. Urgent assessment for shunt malfunction or infection: CT or rapid MRI comparing ventricular size with previous imaging, shunt series radiographs, and neurosurgical review for shunt tap or revision, with blood cultures and CSF sampling if infection is suspected
3. Antibiotics for gastroenteritis
4. Lumbar puncture

Answer: B. Shunt failure is a time-critical emergency; infection is commonest in the first six months after insertion. Lumbar puncture is avoided with possible obstructive hydrocephalus.

Question 18

A 68-year-old has gait apraxia (magnetic gait), urinary incontinence and cognitive decline over a year. CT shows ventriculomegaly out of proportion to sulcal atrophy. The diagnosis and the test that predicts surgical benefit are:

1. Alzheimer's disease; no test
2. Normal pressure hydrocephalus; a high-volume lumbar tap test or extended lumbar drainage with timed gait assessment before and after, with ventriculoperitoneal shunting for responders
3. Parkinson's disease; levodopa trial
4. Vascular dementia; antiplatelets

Answer: B. Gait improves most reliably after shunting; cognition least.

Question 19

A newborn has a lumbosacral open myelomeningocele. The management priorities are:

1. Discharge for outpatient review
2. Cover the lesion with sterile saline-soaked non-adherent dressing, nurse prone, latex-free precautions, assess for hydrocephalus and Chiari II malformation, and close surgically within 48 to 72 hours, with shunting if hydrocephalus develops; folic acid counselling for future pregnancies
3. Immediate shunt before closure in all cases
4. Antibiotics only

Answer: B. Neural tube defects remain relatively common in parts of the region; periconceptional folic acid reduces recurrence by about 70%.

Question 20

Which set of findings is required for the clinical diagnosis of brain death in an adult after a devastating brain injury?

1. A flat EEG alone
2. An established irreversible cause, exclusion of confounders (hypothermia, sedatives, neuromuscular blockers, severe metabolic derangement), absence of all brainstem reflexes (pupillary, corneal, oculovestibular, gag, cough), no motor response to central pain, and a positive apnoea test with PaCO₂ rising above the threshold without respiratory effort, performed by qualified physicians per national law
3. Absence of pupillary reflex only
4. A GCS of 3 for 24 hours

Answer: B. Gulf states have brain death laws and organ donation programmes (for example Saudi Arabia's SCOT and the UAE's national programme); spinal reflexes may persist and do not exclude the diagnosis.

How to practise

• Learn the trauma algorithms: GCS, CT criteria, ICP tiers, cerebral perfusion pressure targets, what not to give (steroids, prolonged hyperventilation).
• Know the time-critical conditions: extradural haematoma, cauda equina, shunt failure, SAH rebleed, cerebellar haemorrhage.
• Learn the molecular tumour classification and pituitary endocrinology.
• Practise under time in the Neurosurgery bank with the error-log method.

Related sets: neurology, orthopaedic surgery and emergency medicine. The exam structure for all specialties is in specialist practice questions online.

Frequently asked questions

How many questions are in the Prometric neurosurgery specialist exam?

Typically 100 to 150 single-best-answer MCQs in up to three hours, with a pass mark of about 60%, varying by authority.

Which neurosurgery topics come up most?

Traumatic brain injury and intracranial pressure, subarachnoid haemorrhage, brain tumours, spinal cord injury and cauda equina, degenerative spine and hydrocephalus.

Does the exam include paediatric neurosurgery?

Yes, at the level of hydrocephalus and shunts, spina bifida, craniosynostosis and common paediatric tumours.

Which guidelines does the exam follow?

Current Brain Trauma Foundation, AHA/ASA stroke and SAH guidance, the WHO 2021 tumour classification and standard spine guidance.

Are these real exam questions?

No. They are original practice questions written to the published blueprint. Real exam content is confidential.