Today we will discuss another Q69 Neurology PLAB 1/ UKMLA exam question. This is a common topic that has appeared in the past PLAB 1 exam.

A 61-year-old woman presents to the emergency department with morning headaches, nausea, and vomiting. An urgent CT head reveals a mass within the right frontal lobe, and an MRI head confirms the presence of a glioblastoma surrounded by oedema. The neurosurgery team is consulted, and the patient is scheduled for surgical intervention. Which of the following management strategies is most appropriate to help prevent complications during surgery?

A. Preoperative administration of hypertonic saline

B. Preoperative initiation of dexamethasone therapy

C. Preoperative administration of mannitol

D. Immediate administration of chemotherapy

E. Preoperative administration of furosemide

The correct answer is B

Explanation

In patients with glioblastoma or other brain tumours, preoperative management with dexamethasone (option B) is often employed to reduce cerebral oedema and the associated mass effect, helping to minimize the risk of complications during surgery. Dexamethasone is a potent glucocorticoid steroid that effectively treats vasogenic oedema by reducing the breakdown of the blood-brain barrier.

Preoperative administration of hypertonic saline (option A) is not the standard approach for reducing cerebral oedema in brain tumour patients. Hypertonic saline may be used in the context of acute neurological emergencies to decrease intracranial pressure rapidly but is not the preferred choice in this scenario.

Mannitol (option C) is an osmotic diuretic commonly used to treat elevated intracranial pressure in acute settings, such as traumatic brain injury. However, in the context of preoperative management for brain tumours, dexamethasone is preferred due to its specific effects on vasogenic oedema.

Immediate administration of chemotherapy (option D) is not appropriate for preoperative management of glioblastoma. Chemotherapy is typically administered postoperatively, sometimes in conjunction with radiation therapy, as part of a multimodal treatment approach.

Furosemide (option E) is a loop diuretic that is not routinely used to treat cerebral oedema in brain tumour patients. While it can be helpful in managing fluid overload, it does not specifically target vasogenic oedema associated with brain tumours, making dexamethasone a more appropriate choice.

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Reference:  

NICE guideline on brain tumours (primary) and brain metastases in over 16s, covers the diagnosis, monitoring and management of any type of primary brain tumour or brain metastases in adults. It includes recommendations on the use of corticosteroids, such as dexamethasone, to reduce cerebral oedema and improve symptoms.

The Alberta Health Services that provides recommendations on the use of dexamethasone in patients with high-grade gliomas and cerebral oedema. It covers the indications, dosage, duration, monitoring, and adverse effects of dexamethasone therapy. It states that treatment with the lowest possible dexamethasone dose is recommended for symptom relief in patients with primary high-grade gliomas and cerebral oedema, and that following surgery, a maximum dose of 16 mg daily, administered in twice-daily doses is recommended for symptomatic patients.

Neurosurgery Clinics of North America that reviews the perioperative management of patients with glioblastoma. It discusses the role of awake brain mapping, neoadjuvant modalities, and multidisciplinary teams in achieving optimal surgical outcomes. It also mentions that preoperative dexamethasone therapy is recommended to provide temporary symptomatic relief of symptoms related to increased intracranial pressure and oedema secondary to brain tumours.