Viva 5

You are managing a 45-year-old male who had elective surgery 2 days ago for removal of an arachnoid cyst. This was complicated by a localized posterior fossa haemorrhage requiring an emergency craniotomy and evacuation of the clot within 6 hours of the original surgery. Prior to the emergency surgery, he had fixed dilated pupils. His sedation (propofol and morphine) has now been off for 24 hours and on examination he has a GCS of 3, no cough or gag, and fixed dilated pupils.

CT Report (prior to emergency craniotomy) is shown below:

Findings:

Evidence of occipital craniotomy. Posterior fossa arachnoid cyst has been removed. There is a large acute, posterior fossa haemorrhage that compresses the brain stem. There is mild inferior displacement of the cerebellar tonsils through the foramen magnum. Basal cisterns are intact. The fourth ventricle remains normal in size as do the remainder of the ventricles. Supra-tentorial structures appear normal.

Conclusion: Acute posterior fossa haemorrhage with compression of the brain stem and early cerebellar tonsil herniation.

What would be your approach to prognostication?

This viva focussed on the diagnosis of brain death.

Disclaimer: the viva stem above may be an original CICM stem, acquired from their publicly available past papers. Or, perhaps it is a slightly altered version of the original CICM stem. Or, it is a completely original viva stem, concocted by the monstrously amoral author of Deranged Physiology for nothing more than his own personal amusement. In either case, because the college do not make the main viva text or marking criteria available, almost everything here has been confabulated. It might sound like a plausible viva and it could be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.