Monday, 4 July 2016

M.Ch. Neurosurgery entrance examination in India

M.Ch. Neurosurgery is the superspeciality course for post doctoral training in General Neurosurgery in India. Many renowned academic medical institutions in India provide training in Neurosurgery.
M.Ch Neurosurgery makes life easy for the surgery post graduates who want to pursue further after passing M.S.Examination in General Surgery.
Obtaining M.Ch. Neurosurgery cuts lot of competition among large number of post graduates. Moreover, it is a new begining and an opportunity to focus your surgical career.
During Master in Surgery you gain experience of assisting and operating on different systems of the body. It is good to have a basic knowledge of surgery. But, career in general surgery is albeit challenging. One needs to have some experience after post graduation if he or she wishes to pursue an academic career or get respect among the peers. Further training adds to your competence and provides an opportunity to plan your career as surgeon.
M.Ch Neurosurgery is best way achieve your goal in a standard, well planned, and time bound manner. Once you get through you many problems are over. You become superspecialist and among few elite medical professionals. M.Ch. Neurosurgery training provides you a job for three years, opportunity to master the art of operating over the brain and spine, enhance your academic experience so that you are eligible to become Assistant Professor in Neurosurgery, without any further residency.
The preparation for M.Ch. Neurosurgery is easy but requires planning, perseverance and patience. Read all aspects of neurosurgery with interest: Neuroanatomy, Neurophysiology, Clinical neurological examination, Neuroradiology and neurosurgical conditions like Neuro-trauma, Neurooncology, Pediatric Neurosurgery, Vascular Neurosurgery, etc. One should join a center as a senior resident doctor in Neurosurgery  Department of any hospital where you will be able to learn basics of neurosurgery. This will help you get out of your previous love of general surgery.
You cannot become a Neurosurgeon by still boasting of being a good general surgeon during your post graduate training. Forget your past achievements, preparation for neurosurgery is entirely a new begining. 



Dare to be novice. 
Be hungry to learn more. 
Be grateful to your new colleagues especially the Neursurgery OT, ICU & ward Nursing staffs, OT & ICU technitians, Neuroanesthetists and seniors in the Neurosurgery department. Be open to listen to the patients and their relatives. Every event in Neurosurgery ward or OPD or OT will teach you something. Everyday adds to your experience and now you a superspecialist just by joining a hospital as a resident doctor. Everyday you are creating your impression and this the last and final opportunity for you.

Start with Neuro-anatomy. Learn to know about brain, spinal cord, cranial nerves, skull, spine. Proceed to learn about Neurophysiology like bood supply of brain, CSF formation, etc. 
Neurology learning begins with neurological examination. 
Neuro-radiology is interesting and includes acquanting yourself about the indications and interpretations of X-Ray images, CT scans, MRI, Angiography, PET CT, PET MRI, etc. It is nothing new to you has you might have seen such investigations during your medical graduation or during postgraduate training. Mastering Neuroradiology requires your interest and focus to see minute details and needs your sustained interest & fascination of looking towards such images. You may be surprised to see the pictures of neural structures which you might have thought that such structures are theoretical. A good MRI brain image will show yu the Fornix, Mamillary body, Pituitary talk, superior and inferior collculi. Substantia nigra in the midbrain is very well seen in MRI. So, create your interest in seeing neural structures. 
Any text book of Neurosurgery would provide you a bird eye view of all neurosurgical diseases and their management.
Illustrated Neurology & Neurosurgery by Lindsay Ian Bone is a good book to begin neurosurgery M.Ch preparation. Read each line with interest. Most of the questions of M.Ch. neurosurgery entrance examination can be answered by reading this book. Never underestimate the value of this book.
Clinical Neuroanatomy by Stephen G.Waxman ( 27th edition) by McGraw Hill education, Lange, international edition is another book which I would like to recommend to every aspirant who is preparing for M.Ch neurosurgery. Even this book should be read comprehensively.
Remember that all these books are assets for you as these books will also guide you through out your neurosurgical career.
Start appearing for M.Ch. Neurosurgery entrance examination of reputed institutions like All India Institute of Medical Sciences (AIIMS), Delhi, Govind Ballabh Pant Hospital ( G.B.Pant Hospital, University of Delhi) now G.B.Pant Post Graduate Institute Medical Institute, (GIPMER), Delhi,  Shree Chitra Institute, Trivendrum, P.G.I Chandigarh, NIMHANS Bangalore, Sanjay Gandhi Post Graduate Institute (SGPGI) Lucknow, Uttar Pradesh, Christian Medical College ( CMC ), Vellore and many other institutes who conduct M.Ch Neurosurgery entrance examinations. M.Ch.degree from any institute is of worth pursuing if it is recognized by Medical Council of India. One should not be scared of failing the M.Ch entrance examinations. It will provide you an opportunity to know what is expected from you.

One textbook of Neurosurgery will be required to have an overall concept of Neurosurgery. Ramamurthi & Tandon's Manual of Neurosurgery authored by PN Tandon, R Ramamurthi & PK JainN of Jaypee Publication provides a good concept of every aspect of neurosurgery. Similarly, Handbook of Neurosurgery by Mark S. Greenberg ( 7th Edition) of Thieme publication is an essential companion for all the neurosurgical aspirants & trainees.
Although, it seems very tedious to learn all aspects of neurosurgery theoretically and master the art of neurosurgery also. But, this is possible because this journey of becoming neurosurgeon is very interesting and self motivating. Everyday you add something to your neurosurgical experience. All notes & books will be your companion.

Just to give you an idea about the common questions which are usually asked in entrance exams, I am mentioning some facts for your revision:

Quincke , in 1891, first reported the measurement of intracranial pressure ( ICP) through the lumbar puncture ( LP). So, if question is asked who performed L.P. for the first time? Answer is Quincke.

Quckenstedt established the normal range of normal ICP and demonstrated the effect of changes in ICP with respiration.

Lundberg, in 1960, published his work on the continuous recording of ICP  using indwelling intraventricular catheter and described 3 waveforms: A,B,C.

Cranium is like a rigid sphere & 3 main components inside are brain, blood & CSF occupying 1400 mL, 75 mL & 75 mL of space, respectively. Therefore , any change in the volume of the brain causes reciprocal change in the volume of either blood or CSF.This is the basis of the modified Monro-Kellie doctrine introduced into neurosurgery by Cushing.

Each day in your neurosurgical practice will make you stronger, wiser & confident.


Some commonly asked questions in M.Ch. entrance examinations are mentioned below:

1. Commonest cause of spontaneous intracerebral hematoma in adults?                            

Hypertension

2. Commonest site of spontaneous intracerebral hematoma in adults due to hypertension?

Basal ganglia

3. Commonest cause of subarachnoid haemorrhage (SAH)?                                               
             
             Trauma ( Head Injury)

4. Commonest cause of spontaneous subarachnoid haemorrhage ( SAH) in adults?           
                  
                               Rupture of intracranial aneurysm

5. Maximum incidence of rebeed or re-haemorrhage following aneurysm ruture is
   A. within 24 hour
  B. within 1 week
    C. within 2 weeks
D. First month

The patient who survives the initial haemorrhage of an intracranial aneurysm is at significant risk of 2nd haemorrhage from the aneurysm.
If left untreated, at least 4 percent of patients will experience haemorrhage within the first 24 hour and 19 percent will have re haemorrhage within 2 weeks following the initial haemorrhage. The second haemorrhage has 50 percent. In the first 28 days ( if untreated patient) approximately 30% of patients would re-bleed , of these 70% die.  In the following few months the risk gradually falls off but it never drops below 3.5 per year.



6. Commonest brain tumor?                                                                                                
    Brain metastases are the most common brain tumor.


7. On CT scan of brain , Hounsfield units for fat is about                                                   
-90

Hounsfield unit on CT scan indicates the nature of the structure inside the skull, and relative density of the tissue as compared to brain. On CT scan , Hounsfield unit of water is treated as 0 and it looks black on CT scan.
CSF density is about  +10 to +16. It also looks black as compared to brain tissue.
Fat is about -90. It is more black as compared to CSF.
Hounsfield unit of Bone is approximately more than +300 to +1000. 
Metals look very white on CT scan and a metallic foreign body looks hyperdense +3000. Example is gun shot bullet injury in the brain tissue.
So, about 5 structures look black ( Hypodense ) as compared to brain tissue like Fat, CSF, Air, Pus.


8. Commonest primary brain tumor                                                                                   
Glioma

9. Length of the spinal cord?                                                                                              

           45 centimetre

10. Commonest site of intracranial aneurysm                                                                        

Anterior communicating artery

11. Commonest type of pituitary tumor?                                                                 

 Prolactinoma 

12. What is the size of pituitary Microadenoma                                                    

Less than 1 centimeter 

13.  What is the size of pituitary Macroadenoma                                                     

Size of the pituitary tumor more than 1 cm

14. Positive end expiratory pressure ( PEEP) ventilation is beneficial in of the following situations
A. Head Injury
B. Adult Respiratory Distress Syndrome
B. Both of the above
C. None of the above

Answer is B. In fact PEEP is contraindicated in head injury because it decreases venous return and increases intracranial pressure. Positive end expiratory pressure means pressure in the alveoli at the end of the expiration. It helps to open up the collapsed alveoli in edematous lung of ARDS, and in turn, increases the gaseous exchange at the level of alveoli.

15. Who is regarded as "Father of Modern Neurosurgery"
Harvey Cushing

16. Who invented Bone Wax for stopping bleed from the diploic spaces of skull bones
Victor Horsley

17. Which of the following is the second branch of intracranial part of Internal carotid Artery ( ICA)
      A. Anterior cerebal artery
B. Ophthalmic artery
                                      C. Posterior Communicating artery ( P Com)
             D. Anterior Choroidal artery

Answer is Posterior communicating artery

18. What is the location of Basilar artery to Pons                                                          
                         A. It lies anterior to Pons
     B. Posterior
C. Lateral
D. None

Answer is A, i.e., it lies just anterior to the Pons.




19. Triad of Normal Pressure Hydrocephalus?                                                              

                                                  Gait Apraxia ( Gait Ataxia or gait disturbance) : Difficulty in walking without any weakness of the limbs

Dementia 

and

Urinary incontinence

                                                                                                                                      
                                                                                                                                            



As Neurosurgeon you get lot of respect not because of you are special but because of your consistent endeavour to improve yourself for improving quality of life of many patients who will benefit from your expertize.

                                         

                                                                                   


                                                                              














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