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Flashcards in INBR 7 - Neurosurgery Deck (100):
1

PIC (?)
Ny. X, 54 tahun dibawa ke UGD setelah jatuh pingsan saat bekerja . Dia tersadar dan dapat
berkomunikasi, dg sakit kepala berat, fotopobia, nuchal kaku dan pandangan buram. CT atas otak mengungkapkan adanya darah subaraknoid menyebar pada cistern basal, Hidrosepalus ringan dan tidak tampak hematoma intraparenkimal. Angiogram pasien di bawah ini (utk soal 1-5):

1. GRADE HUNT dan HESS klinis berapa pasien ini?
A. Gr I C. Gr III E. Gr V
B. Gr II D. Gr IV

B
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs. Frequent[

2

2. Beberapa aneurisma arteri komunikan posterior (PComA) tidak menimbulkan defisit saraf ketiga manapun. Mengapa perlu diberikan perhatian khusus kepada angiogram untuk kasus-kasus ini?
A. Jika aneurisme memproyeksi lebih secara posterolateral alih-alih pada posisi medial yanglebih lazim, ada peningkatan risiko cedera pembuluh-pembuluh perforasi dari PComA selama mikrosiseksi.
B. Sebuah aneurisma yang terproyeksi secara lateral kepada tepi tengah lobe temporal akan melawan retraksi prematur dari lobe temporal.
C. Angiogram ini mungkin saja lebih mengungkapkan aneurisma dinding karotid ventral alih-alih luka pada PcomA, yang sering lebih baik jika dikelola dengan perawatan.
D. Untuk mencari aneurisma lainnya dan/atau vasospasma terkait.
E. Mungkin dapat membantu rencana bedah, karena luka yang terproyeksi secara medial akan lebih baik didekati melalui Segitiga karotid-okulomotor.

B
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs. Frequent[

3

3. Pasien kemudian dibawa ke ruang bedah untuk kliping aneurisme. Kontrol terhadap bagian proksimal dan distal arteri karotis interna diperoleh dengan penempatan klip sementara sebelum diseksi leher aneurismal. Meskipun demikian, tetap terjadi ruptur saat dilakukan mikrodiseksi pada aneurisma dan terjadi perdarahan yang cukup banyak, sehingga menghalangi
pandangan. Tindakan preventif apa yang sebaiknya dilakukan saat sebelum terjadinya
ruptur agar jumlah perdarahan selama operasi berkurang ?
A. Mikrodiseksi bedah tumpul
B. Dapatkan kontrol dekat atas arteri karotid dalam di leher.
C. Lepaskan kubah aneurisma dari lobe temporal sebelum penempatan penjepit sementara untuk mencegah retaknya fundus.
D. Sedapat mungkin pastikan arteri komunikasi posterior medial dari arteri karotid interna untuk menempatkan penjepit sementara
E. Penempatan penjepit sementara pada arteri optalamik untuk mencegah pendarahan balik dari orbit.

D
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs. Frequent[

4

4. Pasca bedah, pasien sadar dalam kontralateral parese dan parestesi dan hemianopsia homonim. CT scan otak menunjukkan infark pada bagian belakang kapsul interna dan substansia alba di dekatnya (di atas kornu temporalis ventrikel lateral), Komplikasi ini kemungkinan bisa dihindari dengan :
A. Memastikan terlebih dahulu arteri koroidal sebelum penjepitan aneurismal untuk mencegah kerusakan atau menyatunya pembuluh ini ke dalam konstruk penjepit
B. Meningkatkan waktu oklusi sementara untuk mencegah mikrodiseksi yang tergesa-gesa.
C. Membatasi diseksi celah sylvian sampai ke bagian spenoidal untuk mencegah adanya diseksi yang tidak perlu di dekat perforator arteri PcomA, yang memasok batang tubuh belakang kapsul internal,
D. Mendapatkan angiogram pasca-bedah untuk meyakinkan kembali apakah penempatan penjepit sudah benar.
E. Memastikan dan mempertahankan arteri balik Heubner.

A
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs. Frequent[

5

5. Pasca-bedah, pasien menderita kerusakan pada cabang frontal nervus fasialis. Manakah yang menjadi penyebabpaling mungkin dari cedera cabang frontal nervus fasialis ini ?
A. Saraf supraorbital tidak dipastikan saat mengangkat kulit kepala dari rim supraorbital.
B. Insisi dimulai dengan jarak kurang dari satu cm ke sebelah depan tragus
C. Ada neuropraksia saraf karena robekan pasca-bedah.
D. Saraf pada bantalan lemak subgaleal cedera selama diseksi bedah.
E. Saraf antara lapisan luar dan dalam dari faskia temporalis cedera dengan monopolar cautery.

D
Patients with posterior communicating artery (PComA) aneurysms typically present with subarachnoid hemorrhage (SAH) and partial or complete third nerve palsies (ptosis, dilated pupil, extraocular muscle abnormalities) due to compression of the third nerve by the aneurysm. Another common presentation of PComA aneurysms is the development of a third nerve deficit in the absence of SAI-l. The appearance of an enlarged pupil with or without involvement of other third nerve functions should be taken as diagnostic of a PComA aneurysm until proven otherwise. After the aneurysm is clipped, it should be punctured not only to ensure complete obliteration but also to achieve maximal decompression of the third nerve. Most patients with third nerve palsies improve within 6 months and frequently sooner. Some PComA aneurysms will not produce any oculomotor nen•e deficit. Special care must be tal\en in interpreting the angiograms of these patients, since the aneurysms often project laterally onto the medial edge of the temporal lobe rather than in more common posterolateral or downward directions. This is relevant during operative planning, since early retraction of the temporal lobe may result in premature aneurysmal ruptureIt is important during surgerY to identify the distal PComA for temporary clip placement, if possible, because obtaining proximal and distal control of the internal carotid may not be enough to halt back bleeding from the PComA if intraoperative rupture occurs. Frequent[

6

Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:

6. Diagnosis mana yang paling mungkin?
A. Sindroma celah orbital atas
B. Meningioma incidental yang berasal dari aspek tengah dari tepi sphenoid
C. Fistula venus-arterial
D. Oklusi arteri karotid dalam di dekat origin arteri optalamik
E. Cavernous sinus thrombosis

C
Carotid-cm•ernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous t\•pes. They are direct shunts bet\\'een the ICA or EC.-\ and ca,•ernou: sinus and usual!" occur after trauma or spontaneous aneuJTsmal rupture. Traumatic CCFs often present in a dela\•ed fashion: like spontaneous fistulas, the,• often presem "•ith retro-o rhitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia, and r

7

Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:

7. Tanda-tanda / gejala-gejala dari proses penyakit ini hampir sepenuhnya tergantung
kepada:
A. Ukuran dan lokasi tumor dibandingkan dengan saraf optik
B. Arah drainase Venus dan kecepatan aliran darah melalui shunt
C. Sejauh mana reaksi peradangan di dekat cavernous sinus
D. Sejauh mana reaksi peradangan di dekat celah orbital atas
E. Sejauh mana aliran kolateral dari arteri karotid balik dan Pengumpan-pengumpan meningeal luar

B
Carotid-cm•ernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous t\•pes. They are direct shunts bet\\'een the ICA or EC.-\ and ca,•ernou: sinus and usual!" occur after trauma or spontaneous aneuJTsmal rupture. Traumatic CCFs often present in a dela\•ed fashion: like spontaneous fistulas, the,• often presem "•ith retro-o rhitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia, and r

8

Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:

8. Untuk pasien ini, pilihan terapi manakah yang seharusnya ditempuh?
A. Enam minggu pemberian antibiotika dan diikuti dengan angiografi ulangan
B. Embolisasi perekat dari Pengumpan-pengumpan arteri utama diikuti oleh reseksi tumor
C. Pembuangan arteri karotid
D. Embolisasi balon transarterial detachable
E. Infus heparin

D
Carotid-cm•ernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous t\•pes. They are direct shunts bet\\'een the ICA or EC.-\ and ca,•ernou: sinus and usual!" occur after trauma or spontaneous aneuJTsmal rupture. Traumatic CCFs often present in a dela\•ed fashion: like spontaneous fistulas, the,• often presem "•ith retro-o rhitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia, and r

9

Tn. X, 28 th mengalami kecelakaan motor. Setelah 1 mgg KRS, pasien mengalami demam, sakit kepala retro-orbital parah, diplopia dan proptosis mata kiri. Segera dibawa ke UGD, CT scan atas otak menunjukkan andanya kontusi frontal 2 x 3 cm kiri yg mengalami retak tulang depan dan sedikit bergeser dan bertahan sejak saat cedera awal. Tingkat sedimentasi eritrosit (ESR) dan protein C-reaktif (CRP) agak naik. Angiogram di bawah ini:

9. Jika strategi terapi yang dikehendaki ternyata gagal, apakah pilihan terapi lainnya ?
1. Debridemen bedah atas infeksi
2. Paking bedah langsung atas cavernous sinus dengan Gelfoam, Surgicel, kawat platina, atau serat katun.
3. Embolisasi perekat praoperasi yang dilanjutkan dengan reseksi tumor.
4. Prosedur endovaskuler untuk membuang arteri karotid dalam.

C
Carotid-cm•ernous fistulas ( CCFs ) can be divided into posttraumatic and spontaneous t\•pes. They are direct shunts bet\\'een the ICA or EC.-\ and ca,•ernou: sinus and usual!" occur after trauma or spontaneous aneuJTsmal rupture. Traumatic CCFs often present in a dela\•ed fashion: like spontaneous fistulas, the,• often presem "•ith retro-o rhitalpain, chemosis, pulsatile proptosis, ocular or cranial bruit, decreased visual acuity, diplopia, and r

10

PIC
10. Temuan proses patologis apakah yang tampak pada angiogram di bawah ini dan perlu terapi segera?
A. Drainase Vena kortikal retrograde
B. Pengumpan artero meningeal majemuk
C. Pasokan arteri karotid dalam dan luar berganda
D. stroke embolik
E. Oklusi sinus Venus

A.
The natural history of DAVF is variable and includes spontaneous resolution, recruitment of meningeal arterial feeders, and the development of intracranial hypertension. DAVF can present with pulsatile tinnitus, visual symptoms, papilledema, hydrocephalus, and intracranial hemorrhage. The presence of retrograde cortical venous drainage indicates the potential for intracranial hemorrhage and mandates urgent treatmen.t of the DAVF. Intracranial hemorrhage from a DAVF in the absence of retrograde cortical venous drainage has not been reported. Hemorrhage from a DAVF is associated with a high morbidity and mortality (approximately 30%). Ectatic dilation or venous occlusion of the invoked sinus, multiple or dual ICA/ECA arterial feeders, or embolic stroke, in the absence of retrograde cortical venous drainage has not been reported to increase hemorrhage rates of DA \'Fs ( Kaye and Black, pp. 1125-1135; Greenberg, p . 811; Youmans, p p . 2 1 7 1-2 173; Wilki ns, p p . 2523-2527).

11

Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.

11. Manuver bedah yang bisa menambah eksposure dari percabangan letak tinggi (high-riding) arteri karotid saat endarterektomi karotid meliputi semua hal di bawah ini, KECUALI
A. Mobilisasi medial dari servikalis ansa
B. Membagi perut belakang dari otot digastris
C. Osteotomi mandibular atau disartikulasi mandibel pada sendi temporomandibular
D. Judicious cautery dan lligasi pembuluh-pembuluh terpilih (arteri okipital, pembuluh wajah biasa) yang menghambat paparan
E. Diseksi trasversal kepala klavikular dari otot sternokleidomastoid pada setinggi tulang hyoid untuk memperoleh visualisasi yang lebih baik arteri karotid lateral dari vena jugular.

E
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves \'II, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .

12

Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.

12. Saraf kranial mana yang paling berisiko terkena cedera pada saat mengekspose pencabangan letak tinggi (highriding) arteri karotid ?
A. VII B. IX C. X
D. XI E. XII

E
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves \'II, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .

13

Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.

13. Bagaimana urutan penempatan klem pada arteri selama endarektomi karotid?
A. Luar, dalam, biasa
B. Internal, Utama, Eksternal
C. Luar, biasa, dalam
D. Biasa, luar, dalam
E. Biasa, dalam, luar

B
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves \'II, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .

14

Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.

14. Setelah penempatan klem dan arteriotomi, ahli bedah melihat pendarahan terus menerus dari dinding belakang arteri karotid, yang sangat mengganggu penglihatan selama prosedur bedah. Apakah dasar utama terjadinya pendarahan terus menerus ini ?
A. Pemasangan klem yang tidak tuntas terhadap arteri karotid biasa
B. Pendarahan balik dari arteri temporal permukaan
C. Pendarahan dari arteri asending paringeal
D. Pendarahan Venus dari adventitia arteri karotid dalam
E. Kelainan penebalan dari infuse heparin

C
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves \'II, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .

15

Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.

15. Saat diseksi di sekitar arteri karotid, akhli anestesi melihat bahwa pasien menjadi hipotensi dan bradikardia. Langkah pengelolaan selanjutnya yang perlu ditempuh adalah:
A. Dapatkan gas arterial intermedier (ABG) untuk memastikan apakah pasien menderita embolus pulmonaris.
B. Periksa enzim jantung, karena sepertinya pasien menderita infarksi dinding miokardial depan.
C. Persarafan sinus karotid (saraf Hering) perlu dianestesi dengan 0,5mL dari lidokain 2%.
D. Memulai dubotamin, periksa tekanan pembuluh vena pusat, dan dapatkan kadar laktat, karena pasien sepertinya mengalami deplesi volume laktat
E. Perlu dilakukan infuse 100 IU/kg heparin secara intravena untuk mencegah berlanjutnya emboli.

C
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves \'II, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .

16

Tn X. 67 tahun dengan riwayat diabetes mellitus dan hipertensi dibawa ke UGD dg lengan kanan
lemah dan mati rasa. Ternyata dia memiliki stenosis >90% pada arteri karotid interna kiri dan difusi MRI terbatas pada bagian-bagian otak yang dipasok dari arteri serebral medial kiri. Pasien memilih melanjutkan bedah untuk stenosis karotidnya tetapi ternyata mengalami bifurkasi arteri karotid riding yang tinggi.

Pasca-bedah, pasien terbangun dengan hemiplegia sisi kanan dan letargi. Langkah pengelolaan logis selanjutnya perlu mencakup:

A. Segera lakukan CT Angiografi untuk menilai kemantapan arteri karotid kanan
B. Segera lakukan angiografi selektif atas arteri karotid kanan
C. Lakukan terapi antiplatelet selama satu minggu, yang diikuti oleh angiografi ulangan
D. Tempatkan stent pada lokasi arteriotomi untuk memperkuat penutupannya
E. Segera lakukan reeksplorasi bedah untuk dilakukannya trombektomi

E
Attempts to gain additional exposure for a high-riding carotid artery bifurcation include mobilization of the ansa cervicalis, sectioning the posterior belly of the digastric muscle, cautery and ligation of the occipital artery, and mandibular osteotomy or disarticulation of the j aw at the temporomandibular joint. This type oi exposure places the hypoglossal nen•e at particular risk. although segments of cranial nerves \'II, IX, X, and XI can also be injured during carotid endarterectomy (CEA) . Patients who become hypotensive and bradycardic during surgery often do so as a result of manipulation of the nerve of Hering near the carotid bulb. This is not uncommon with CEA and can often be addressed with lidocaine infusion adjacent to the carotid bulb. Placing the clamps on the internal carotid artery first, followed by the common and then the external carotid artery often ensures that the clot will pass through the external carotid artery instead of the internal carotid artery. The order for clamp removal should be just the opposite, as this should again ensure that any accumulated blood clot will be more likely to pass through the external rather than internal carotid circulation. It is not uncommon during CEA to have some backbleeding into the surgical field by the ascending pharyngeal artery after clamp placement on the major vessels. If the extent of bleeding is severe and hinders the operation, identification, clamping (aneurysm clip) , or ligation of this ,•esse] may drastically improve visibility. A patient who awakens with a major neurologic deficit is likely to have suffered thrombosis at the arteriotomy site, which usually warrants immediate attention (surgical exploration) rather than time-consuming diagnostic studies, as some case reports describe a significant neurologic imprm•ement if flo\\• is re-established within 4 5 minutes. For later-onset deficits, workup ( i . e . , C T , angiogram) m a y be indicated. CT m a v help t o identify hemorrhage and an angiogram may reveal whether the ICA is occluded or if the deficit is from another cause (emboli) that would not necessarily require surgical re-exploration ( Kaye and Black, p p . 1179-118 7 ; Greenberg, pp. 837-841 ; Youmans, p p . 1631-1645; Wilkins, p p . 2 113-2 114) .

17

Nn. X, 15 tahun menjalani reseksi tanpa komplikasi atas luka yang ditunjukan di bawah ini 4 hari kemudian dia menderita Letargi, demam, meningismus, dan fotopobia. Sampel cairan serebospinal (CSF) mengungkapkan kadar protein sebesar 86 mg/d (Rentang baku 12 - 60 mg/dL), gula darah 61 mg/dL (40 – 70 mg/dL), erytrosit 16/mL, dan lekosit 126/mL, dengan diferensial 11% netropil, 82% limposit dan 7% histiosit. Tes dan kultur grain dari CSF adalah steril dan tetap demikian untuk keberadaan organisme tersebut.

18. Manakah yang menjadi riwayat lazim
masalah di atas?
A. Pemberian antibiotika selama 10 hari, meski pun kulturnya negatif karena perlunya mencegah spesies-spesies bakterial yang pertumbuhannya lambat
B. Pasien seringkali memerlukan terapi steroid yang dilanjutkan dengan lumbar puncture ulangan
C. Biasanya pulih dengan sendirinya dan tidak perlu perawatan
D. Setelah shunting, pasien biasanya menunjukkan pemulihan yang drastis
E. Biasanya akan segera pulih setelah materi sintetis apa pun selama pembedahan (misalnya, dural graft) diangkat kembali.

B
Aseptic meningitis (AM) is a well-recognized complication after posterior fossa surgery but is typically self-limited and requires no treatment. It has generally been attributed to one or more irritants released into the subarachnoid space during surgery, including blood breakdown products, tumor, muscle, and brain . Lowering of i n tracranial pressure with lumbar puncture and dexamethasone is the mainstay of treatment in certain patients with continued, problems. Bacterial meningitis and postmeningitic syndrome are unlikely, considering that an organism was not isolated from the CSF, although this is not always the case. .\!orem•er. the CSF profile was more consistent with aseptic meningitis than bacterial meningitis. Hydrocephalus is unlike[,•. since fe,•er. meningismus, and photophobia rarely accompanv this diagnosis, and encephalitis would be very uncommon in this situation (Carmel et a l . , pp. 2 76-280; Youmans. pp. 3645, 3659; Kaye and Black, p . 868; Wilkins, p . 3965 ) 3227-3233).

18

Nn. X, 15 tahun menjalani reseksi tanpa komplikasi atas luka yang ditunjukan di bawah ini 4 hari kemudian dia menderita Letargi, demam, meningismus, dan fotopobia. Sampel cairan serebospinal (CSF) mengungkapkan kadar protein sebesar 86 mg/d (Rentang baku 12 - 60 mg/dL), gula darah 61 mg/dL (40 – 70 mg/dL), erytrosit 16/mL, dan lekosit 126/mL, dengan diferensial 11% netropil, 82% limposit dan 7% histiosit. Tes dan kultur grain dari CSF adalah steril dan tetap demikian untuk keberadaan organisme tersebut.

17. Diagnosis manakah yang paling mungkin?
A. Meningitis bakterial
B. Meningitis aseptic
C. Hidrosepalus
D. Sindroma pasca-meningitis
E. Sinus petrosal atas

C
Aseptic meningitis (AM) is a well-recognized complication after posterior fossa surgery but is typically self-limited and requires no treatment. It has generally been attributed to one or more irritants released into the subarachnoid space during surgery, including blood breakdown products, tumor, muscle, and brain . Lowering of i n tracranial pressure with lumbar puncture and dexamethasone is the mainstay of treatment in certain patients with continued, problems. Bacterial meningitis and postmeningitic syndrome are unlikely, considering that an organism was not isolated from the CSF, although this is not always the case. .\!orem•er. the CSF profile was more consistent with aseptic meningitis than bacterial meningitis. Hydrocephalus is unlike[,•. since fe,•er. meningismus, and photophobia rarely accompanv this diagnosis, and encephalitis would be very uncommon in this situation (Carmel et a l . , pp. 2 76-280; Youmans. pp. 3645, 3659; Kaye and Black, p . 868; Wilkins, p . 3965 ) .

19

19. NY. X, 62 tahun menjalani dekompresi mikrovaskuler karena spasme hemifasial. Pasca-bedah, pasien menderita ketulian ipsilateral total tanpa adanya defisit neurologis lainnya Penyebab yg paling memungkinkan dari defisit ini adalah cederanya salah satu pembuluh darah berasal dari
A. Arteri serebral belakang (PCA)
B. Arteri serebelar Atas (SCA)
C. Arteri serebellar Inferior Anterior (AICA)
D. Arteri serebellar bawah belakang (PICA)
E. Arteri vertebral

C.
Complications of microvascular decompression for hemifacial spasm in

20

20. Remaja puteri usia 14 tahun dengan hilang penglihatan progresif pada mata kanan baru baru ini didiagnosis 2.0 x 3.5 cm Glioma saraf optik kanan yang menjalar ke kiasme optik. Selama pembedahan, porsi tumor pada saraf optik berhasil dibuang tetapi tumor di dekat kiasme optik dibiarkan. Berapa dosis maksimal radiosurgeri fraksi tunggal yang dapat dijalankan dengan aman kepada kiasme optik ini?
A. 4 sampai dg 7 Gy
B. 9 sampai dg 10 Gy
C. 11 sampai dg 13 Gy
D. 14 sampai dg 16 Gy
E. 21 Gy

B.
The maximal safe dose of single-shot radiosurgery that the optic chiasm can tolerate is approximately 9 to 10 Gy (Alexander, p. 171).

21

21. Seorang dokter akhli bedah memutuskan untuk menggunakan koridor supraselebelar infratentorial untuk mendekati massa daerah pineal. Pembuluh darah manakah yang seringkali diberi kauterisasi dan dibagi agar diperoleh paparan yang lebih baik atas permukaan belakang dari tumor selama pendekatan ini?
A. Pembuluh Galen
B. Pembuluh basal ipsilateral dari Rosenthal
C. Arteri serebral belakang (PCA)
D. Pembuluh serebelar pra-sentral
E. Sinus Petrosal Atas

D.
Cauterizing and dividing the precentral cerebellar vein will often expose the posterior surface of pineal region tumors. The veins of Galen and Rosenthal should be preserved during this operation , as well as the vermian vein, which often can be spared in this approach. The choroidal arteries may supply feeders to the tumor but rarely need to be cauterized and ligated for adequate tumor resection ( Kaye and Black, pp. 815-824; Youmans; pp. 1017-1021, Wilkins, p . 1029) .

22

22. Selama paparan trans-labirintin untuk reseksi Neuroma akustik, dokter akhli bedah terpapar Segitiga Trautmann. Semua struktur di bawah ini akan menegaskan daerah Segitiga tersebut, KECUALI
A. Daerah Segitiga dura pada aspek belakang tulang temporal yang berhadapan dengan sudut serebelopontin
B. Lateralis sinus sigmoid
C. Sinus petrosal atas di atasnya
D. gelembung jugular di bawahnya
E. Foramen magnum di tengahnya

E.
There are two goals of the translabyrinthine approach for acoustic neuroma resection that may help achieve maximal tumor resection. The first is to remove enough bone to identify the nerves lateral to the tumor as they course through the IAC, and the second is to expose the dura of the posterior aspect of the temporal bone that faces the cerebellopontine angle (CPA). This triangular patch of dura facing the CPA is called Trautmann's triangle and extends from the sigmoid sinus laterally, the superior petrosal sinus above, and the j ugular bulb below. The foramen magnum is not included in Trautmann's triangle ( Kaye and Black, pp. 851-860; Youmans, pp. 1155-1156; Wilkins, pp. 1067- 1071) .

23

23. Salah satu prosedur paling dini yang dilakukan untuk penyakit Parkinson adalah ligasi pembuluh darah yang mana?
A. Arteri koroidal anterior
B. Arteri koroidal belakang tengah
C. Arteri balik Heubner
D. Arteri tentorial Bernasconi dan Cassarini
E. Arteri lentikulostriata media

A.
Neurosurgical therapies for Parkinson's disease (PD) have been utilized in patients with progressi\•e disease despite maximal medical therapy. An early procedure performed for PD was ligation of the anterior choroidal artery, with subsequent infarction of the pallidum. Due to the variable distribution of this vessel outside the confines of the pallidum, results were too unpredictable and this procedure lost favor. In the 1 9 50s, anterodorsal pallidotomy became an accepted procedure, but the long-term benefits 11•ere mostly for rigidity, while tremor and dyskinesia did nor improve. Subsequently, the ventrolateral thalamus became the preferred target for lesioning, but this procedure also lost favor, as patients were often still left with bradykinesia ancl/or rigidity. Moreover, this procedure reduced tremor only in the contralateral half of the body, and bilateral thalamotomies were not recommended due to an unacceptably high risk of postoperative dysarthria and gait disturbances. Thalamotomy procedures fell off dramaticalh• in the late 1960s with the i ntroduction of L-DOPA. More recently, dramatic and beneficial effects of both -ubthalamic nucleus (STN) and globus pallidus interna CHAPTER 6 Neurosurgery Questions 2 0 1 (Gpi) deep brain stimulation (DBS) have been consistently observed. Both interventions appear to result in significant improvements in both motor fluctuations and dyskinesias. The DBS study group, in a large multicenter study, reported that on time without dyskinesia during the waking hours increased from 25 to 30% at baseline to 65 to 75% 6 months postoperatively. In a complementary fashion, these procedures also markedly decreased off time and on time without dyskinesia. Although some preliminary studies suggest STN DBS may be a superior intervention, no large randomized controlled trial comparing STN and Gpi DBS has been conducted to compare the efficacy of these treatments. The most consistent finding has been the reduction in antiparkinson medication following STN DBS compared to Gpi DBS. (Greenberg, p . 751; Tarsy, p . 191).

24

24. Stimulasi saraf vagal dicadangkan untuk memilih pasien dengan epilepsi. Mengapa dilakukannya pada sisi kiri?
A. Untuk menghindari kemungkinan cedera pada saraf laringeal balik, yang mengikui
jalur ke arah kanan yang lebah rawan kerusakan
B. Untuk menghindari kemungkinan rusaknya saraf laryngeal atas dominan di sisi kanan.
C. Untuk menghindari kemungkinan rusaknya saraf kranial X, yang memasok jantung terutama dari sisi kanan
D. Untuk menghindari kemungkinan cedera pada saluran torak
E. Lebih kecil peluang terjadinya paralisis dan seraknya urat suara dari kiri

C.
Vagal nerve stimulation must be performed on the left side so that the cardiac innervation of CN X is unaffected (Youmans, pp. 2644-2645 ) .

25

25. Perawatan manakah yang menjadi pilihan utama untuk luka avulsi pleksus brakial kronis dan yang membandel?
A. Kordotomi
B. Lesioning Zona Entri Akar Dorsal (DREZ)
C. Penempatan pompa morfin
D. Mielotomi garis tengah
E. Stimulasi otak dalam talamik lateral ventroposterior (VPL)

B.
Dorsal root entry zone ( DREZ) lesioning involves radiofrequency ablation along the dorsolateral sulcus of the spinal cord. The DREZ procedure is most effective in the treatment of brachial and lumbar plexus avulsion pain. Direct sectioning of the spinothalamic tract ( cordotomy) is very effective for unilateral pain below the upper chest region; however, it is associated with many complications and is usually performed only in terminally ill patients. Complications of cordotomy include hemiparesis , respiratory depression ( "Ondine's curse" with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract, and this can be quite effective in the treatment of chronic pelvic pain secondary to cancer. Intrathecal narcotic administration is typically used for the treatment of chronic pain associated with malignancy or failed low back syndrome. Deep brain stimulation of the VPL and VPM nuclei of the thalamus as well as the periaqueductal gray have been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Chronic low-threshold stimulation of the motor cortex is also utilized in the treatment of thalamic pain syndromes; it is thought to work by retrograde thalamic stimulation pathways ( Kaye and Black, pp. 1521- 153 7; Greenberg, pp. 365-370; You mans, pp. 3025-3030. 3045-3048, 3068-3070, 3 101, 3 125, 3128-3.129; Wilkins. pp. 4036-4038, 4055-4059 ) .

26

26. Berapa porsi kandungan eistern basal dari pembuluh Rosenthal?
1. Krural
2. Kuadrigeminal
3. Ambien
4. Kuadrigeminal

B.
The ambient a n d crural cisterns contain portions o f t h e basal vein o f Rosenthal (Youmans, pp. 36-39)

27

27. Bayi laki-laki umur 3 bulan dibawa ke kantor anda karena bentuk kepala yang abnormal. Sang anak tercatat memiliki bentuk kepala datar oksiput di sebelah kiri, telinga kiri lebih ke depan dibandingkan telinga kanan, dan dahi yang sangat menjorok serta eminensi malar di sebelah kiri. Manakah yang merupakan etiologi paling memungkinkan atas deformitas ini?
A. Sinostosis lambdoid kiri
B. Sinostosis lambdoid Kanan
C. Sinostosis sutur sagital
D. tengkorak molding
E. Sinostosis sutur koronal Kanan

D .
Lambdoid synostosis i s among the rarest forms of suture synostosis, while sagittal synostosis is the most common. After the American Academv of Pediatrics published itS recommendations that all children sleep on thei r back. the incidence of skull molding increased. lllosr i nfants sleep ontheir backs and spend the rest of the day sitting in a car seat or infant seat. Children with this condition are often noted to have a flat occiput, one ear that is anterior to the other in an axial plane, and a prominent forehead and malar eminence. Many infants may also have a mild torticollis due to a shortened sternocleidomastoid muscle on one side, as well as decreased range of motion in the neck. The skull deformity usually responds very well to behavioral modification, which includes having the parents turn the infant or child from side to side during sleep and reducing the amount of time spent in a car seat. If this is unsuccessful, a molding helmet or band is often helpful. For nonresponders, a variety of occipital remolding surgical procedures are available (Committee on Education in Neurological Surgery, pp. 43, 137; Pattisapu, pp. 178-179).

28

28. Semua hal di bawah ini merupakan kondisi suboptimal penempatan skrup odontoid,
KECUALI
A. Retakan lama (> 6 minggu)
B. Retakan diagonal melalui proses odontoid
C. Pasien dengan dada barrel
D. Retakan odontoid yang bergeser ke arah depan
E. Ligamen transversum intak

E.
An intact transverse ligament must be confirmed preoperatively prior to placement of an odontoid screw. Old fractures in which a nonunion has already formed, diagonal fractures through the odontoid process, and comminuted odontoid fractures do not allow for proper odontoid screw placement due to suboptimal arthrodesis rates and inadequate screw purchase and compression effects ( Kaye and Black, pp. 2048-2050; Youmans, pp. 4943- 4945; Benzel, pp. 225-228.) .

29

29. NY. X, 56 tahun menjalani penjepitan aneurisma sebagaimana ditunjukkan pada
angiogram di bawah ini. Setelah siuman dari bedah, tercatat bahwa pasien semakin
lemah pada lengan kiri dibandingkan dengan kaki kirinya. Alasan apakah yang paling memungkinkan dari defisit baru?


A. Cedera pada pembuluh darah yang berasal dari segmen A2 arteri serebral anterior
B. Infark pada pembuluh karena retraksi lobe frontal yang berlebihan
C. Cedera pembuluh darah perforasi halus yang berasal dari arteri komunikasi depan.
D. Infarksi kapsul dalam belakang dari mikroemboli yang berasal dari arteri karotid dalam
E. Retraksi lobe temporal mesial

A.
The recurrent artery of Heubner usuall

30

30. Retak tengkorak basilar dapat berasosiasi dengan palsi saraf kranial, ekimosis pra-
orbital bilateral, ekimosis mastoid, hemotimpanum dan rinoea. Drainase nasal yang tidak jelas CSF dapat diuji untuk…,yang khas untuk CSF dan…
A. α-Fetoprotein, ludah
B. β2-Transferrin, cairan vitrus mata
C. β2-Transferrin, air mata
D. hipoglikorakia, sekresi nasal
E. Sodium, cairan peritoneal

B.
transferrin is present in the CSF but absent in the tears, saliva. peritoneal fluid, nasal exudates, and serum ( except for newborns or those \Yith lh•er disease) . The only other source is the \"itreous humor of the eye. Other commonly employed tests include measuring the glucose level of the tluid ( CSF glucose > 30 mg %, whereas lacrimal and mucous secretions are

31

31. Bayi laki-laki umur 4 bulan terjatuh dari ayunannya, dan menderita growing fracture. Semua hal di bawah ini adalah benar untuk penyakit ini, KECUALI
A. Kemungkinan berasosiasi dengan defisit neurologis tertunda
B. Selalu ada laserasi dural
C. Kemungkinan terjadi kerusakan yang sedang berlangsung pada otak pokoknya karena terus menerus terjadinya herniasi otak melalui cacad tersebut
D. Seringkali diversi CSF hanya merupakan satu-satunya tindakan yang perlu dilakukan untuk fracture semacam ini.
E. Kemungkinan berasosiasi dengan tumbuhnya kiste leptomeningeal

D.
GrOwing skull fractures occur in children, are always associated ,,-ith underlying dural lacerations. and almost ahYays require surgical treatment. Early surgi.cal correction of growing iractures is often necessarv because these types of fractures almost never heal spontaneously and late neurologic deterioration can occur. The pathophysiology requires a fracture with enough force to cause a tear in the dura (which is always present) and an underlying constant force such as a growing brain, leptomeningeal cyst, hydrocephalus, or porencephaly. The precise etiology of late neurologic deficits remains unclear but is beli eved to occur by one of two mechanisms. There may be ongoing brain damage from brain herniation and pulsations of the brain against the bone edges. Alternatively, some have proposed that there may be \'ascular compromise of blood vessels at the bone edges. Although some authors have recommended a CSF diversion procedure for growing skull fractures, direct repair of the fracture is the definitive treatment (You mans, pp. 3468-3469; Wilkins, pp. 2757-2 761).

32

32. Ny. X, 54 tahun telah selesai menjalani terapi radiologi kanker Payudara. Pasien mengeluh lemah pada lengan kiri selama 3 bulan terakhir dan merasa khawatir bahwa kankernya kambuh. Bagaimana dokternya dapat membedakan nyata pleksopati akibat radiasi dengan serangan kanker pada pleksus braksial?
A. Pleksopati akibat radiasi seringkali disertai oleh rasa sakit dan tidak adanya edema
B. Serangan kanker atas pleksus braksial selalu dibarengi oleh limpedema, lemas tanpa rasa sakit, dan kehilangan indera peraba.
C. Pleksopati akibat radiasi seringkali dapat dipulihkan
D. Miokimia pada EMG akan menunjang pleksopati akibat radiasi
E. Latensi H yang lama hanya tampak pada pleksopati brakial yang merupakan sampingan dari kerusakan radiasi.

D
Myokymia (quivering of muscles) on E1!G strongly favors radiation-induced changes of the brachial plexus. L

33

Tn X, 42 th terjatuh dari ketinggian 25 kaki saat bekerja dan dibawa ke UGD dg GCS 5, pupil kanan dilatasi tanpa reaksi, dan rata-rata tekanan darah arteri 80. Setelah pengelolaan oksigen dan pemulihan cairan tubuh, GSC pasien naik menjadi 7, tapi hemiparesis kanan dan pupil non-reaktif pasien tetap tidak berubah. Pasien juga mengalami retak pelvik, retak humerus kanan, laserasi splenik dan liver, dan berbagai retak pada tulang servikal.

33. Pengelolaan awal untuk kondisi pasien semacam ini harus meliputi:
1. Mulailah Hiperventilasi untuk menurunkan pCO2.
2. Berikan manitol begitu tiba di bagian gawat darurat karena bukti klinis pemeriksaan asimetris
3. Selesaikan pemeriksaan primer, ambil film tulang servikal dan hasil Rontgen dada dan langsung lanjutkan dengan CT scan
4. Pasien harus segera diberi perlakuan pentobarbital untuk tekanan intrakranial tinggi begitu selesai pemeriksaan primer jika berdasarkan hasil CT scan tidak tampak adanya luka massa

B
Current head injury research guidelines suggest that manni tol and hvpen•entilation may exacerbate cerebral ischemia after head injurv. HO\YeYer, mannitol and hyperventilation are recommended for those patients with acute head injury as a temporary measure to control elevated intracranial pressure. Hvperventilation may be commenced immediatelv, but mannitol should be withheld until the primar

34

Tn X, 42 th terjatuh dari ketinggian 25 kaki saat bekerja dan dibawa ke UGD dg GCS 5, pupil kanan dilatasi tanpa reaksi, dan rata-rata tekanan darah arteri 80. Setelah pengelolaan oksigen dan pemulihan cairan tubuh, GSC pasien naik menjadi 7, tapi hemiparesis kanan dan pupil non-reaktif pasien tetap tidak berubah. Pasien juga mengalami retak pelvik, retak humerus kanan, laserasi splenik dan liver, dan berbagai retak pada tulang servikal.

PIC

34.Tampak hasil CT scan otak. Mengapa pasien yg bersangkutan mengalami hemiparesis
pada sisi yg sama dg hematoma?

A. Bergesernya brainstem dari landas yang mengakibatkan tekanan pedunkel serebral kontralateral terhadap tentorium.
B. Pasien kemungkinan mengalami hemorase Dural.
C. Ada kemungkinan kontusi di dalam korteks motorik utamanya yang ada pada sisi kontralateral tetapi tidak terdeteksi pada CT scan awal
D. Ada kemungkinan bahwa pasien menjalani diseksi arteri karotid dalam kiri yang kemudian menyapu emboli ke vaskulatur jauh.
E. Ada retakan terkait dari foramen melintang di kiri, yang mengakibatkan diseksi arteri vertebral dan infark kecil di dalam pons ventral

A
Current head injury research guidelines suggest that manni tol and hvpen•entilation may exacerbate cerebral ischemia after head injurv. HO\YeYer, mannitol and hyperventilation are recommended for those patients with acute head injury as a temporary measure to control elevated intracranial pressure. Hvperventilation may be commenced immediatelv, but mannitol should be withheld until the primar

35

Tn X, 42 th terjatuh dari ketinggian 25 kaki saat bekerja dan dibawa ke UGD dg GCS 5, pupil kanan dilatasi tanpa reaksi, dan rata-rata tekanan darah arteri 80. Setelah pengelolaan oksigen dan pemulihan cairan tubuh, GSC pasien naik menjadi 7, tapi hemiparesis kanan dan pupil non-reaktif pasien tetap tidak berubah. Pasien juga mengalami retak pelvik, retak humerus kanan, laserasi splenik dan liver, dan berbagai retak pada tulang servikal.

35. Komplikasi manakah yang paling mungkin timbul akibat diberikannya manitol
1. Mengganasnya edema vasogenik
2. Berkembangnya keadaan nonketotik hyperosmolar
3. Nekrosis tubular akut
4. Hipotensi

E
Current head injury research guidelines suggest that manni tol and hvpen•entilation may exacerbate cerebral ischemia after head injurv. HO\YeYer, mannitol and hyperventilation are recommended for those patients with acute head injury as a temporary measure to control elevated intracranial pressure. Hvperventilation may be commenced immediatelv, but mannitol should be withheld until the primar

36

Tn X, 42 th terjatuh dari ketinggian 25 kaki saat bekerja dan dibawa ke UGD dg GCS 5, pupil kanan dilatasi tanpa reaksi, dan rata-rata tekanan darah arteri 80. Setelah pengelolaan oksigen dan pemulihan cairan tubuh, GSC pasien naik menjadi 7, tapi hemiparesis kanan dan pupil non-reaktif pasien tetap tidak berubah. Pasien juga mengalami retak pelvik, retak humerus kanan, laserasi splenik dan liver, dan berbagai retak pada tulang servikal.

36. Setelah pengangkatan bedah atas hematoma subdural kanan, dilakukan angiogram CT untuk memastikan cedera arteri vertebral akibat banyaknya retakan pada tulang servikal yang memanjang melalui foramen transversum. Hasil pemeriksaan ini tidak konklusif, dan kemudian dilakukan angiografi tindak lanjut dengan hasil angiogram di bawah ini pada malam harinya setelah hematoma diangkat. Strategi perawatan manakah yang paling masuk akal pada titik ini, untuk pasien multi-trauma ini? Pertimbangkanlah bahwa pasien cukup memperoleh pengisian sirkulasi belakang dari arteri vertebral kanan

PIC

1. Jalankan pemberian infuse heparin dengan tujuan menjadi PTT sekitar dua kali kadar normalnya
2. Terapi antiplatelet
3. t-PA intrevanus
4. Pembuangan endovascular dari arteri vertebral yang teroklusi

C
Current head injury research guidelines suggest that manni tol and hvpen•entilation may exacerbate cerebral ischemia after head injurv. HO\YeYer, mannitol and hyperventilation are recommended for those patients with acute head injury as a temporary measure to control elevated intracranial pressure. Hvperventilation may be commenced immediatelv, but mannitol should be withheld until the primar

37

Tn X, 45 tahun dibawa ke UGD dalam keadaan demam, mual, muntah, dan sakit kepala hebat.
Lumbar puncture mengungkapkan eritrosit sedikit mengalami kenaikan, tapi jumlah protein,
glukosa dan lekosit semuanya normal, termasuk tidak xanthochromia. Angiogram di bawah ini
PIC
37. Etiologi dari kelainan yang ditunjukkan pada angiogram
A. Trauma kepala
B. Infeksi
C. Pradisposisi genetika
D. Penyakit vaskular kolagen
E. Hipertensi

B
M

38

Tn X, 45 tahun dibawa ke UGD dalam keadaan demam, mual, muntah, dan sakit kepala hebat.
Lumbar puncture mengungkapkan eritrosit sedikit mengalami kenaikan, tapi jumlah protein,
glukosa dan lekosit semuanya normal, termasuk tidak xanthochromia. Angiogram di bawah ini
PIC
38. Temuan ini paling sering terjadi pada kondisi…
A. Kecanduan alcohol
B. Penyakit echlers – dantos
C. Endokarditis bakterial sub-akut
D. Sindroma marfan
E. Penyakit ginjal polikistik

C
M

39

Tn X, 45 tahun dibawa ke UGD dalam keadaan demam, mual, muntah, dan sakit kepala hebat.
Lumbar puncture mengungkapkan eritrosit sedikit mengalami kenaikan, tapi jumlah protein,
glukosa dan lekosit semuanya normal, termasuk tidak xanthochromia. Angiogram di bawah ini
PIC
39. Bagaimana masalah ini seharusnya ditangani?
A. Observasi, dilanjutkan dengan angiografi
ulangan dalam jangka waktu enam bulan
B. Pemberian antibiotika dilanjutkan oleh angiografi ulangan
C. Segera dilakukan pembedahan
D. Stent/coiling yang dilanjutkan dengan kontrol tekanan darah
E. Steroid

B
M

40

Nn.X, 15 tahun dibawa ke UGD dalam keadaan lemas, mual-mual, dan muntah-muntah dan ternyata menderita stenosis akueduktal berdasarkan hasil MRI ada otak.

40. Strategi manakah yang paling baik untuk pasien ini?
A. Observasi
B. Penempatan shunt subgaleal
C. Penempatan shunt ventrikuloperitoneal yang dilanjutkan dengan ventrikulostomi ketiga endoskopik jika pemasangan shunt gagal
D. ventrikulostomi ketiga endoskopik
E. ventrikulostomi ketiga endoskopik yang dilanjutkan oleh septostomi


D
ETV is a commonly performed procedure for patients with aqueductal stenosis (AS ) . Although there is some controversy about the age at which this procedure should first be employed, results indicate high success rates for properly selected patients. Complications of shunting mav include slit ventricle syndrome, intracranial hypotension, subdural hematomas, craniosynostosis, microcephal

41

Nn.X, 15 tahun dibawa ke UGD dalam keadaan lemas, mual-mual, dan muntah-muntah dan ternyata menderita stenosis akueduktal berdasarkan hasil MRI ada otak.

41. Semua hal di bawah ini adalah kelebihan-kelebihan third ventrikulostomi endoskopik (ETV) dibandingkan shunting, KECUALI
A. ETV memiliki tingkat formasi hematoma subdural yang lebih rendah
B. ETV memiliki tingkat kraniosonostosis yang lebih tinggi
C. ETV memiliki tingkat infeksi yang lebih rendah
D. ETV memiliki diversi CSF psikologis
E. Penempatan shunt memiliki peluang over-drainase yang lebih tinggi

B
ETV is a commonly performed procedure for patients with aqueductal stenosis (AS ) . Although there is some controversy about the age at which this procedure should first be employed, results indicate high success rates for properly selected patients. Complications of shunting mav include slit ventricle syndrome, intracranial hypotension, subdural hematomas, craniosynostosis, microcephal

42

Nn.X, 15 tahun dibawa ke UGD dalam keadaan lemas, mual-mual, dan muntah-muntah dan ternyata menderita stenosis akueduktal berdasarkan hasil MRI ada otak.

42. Yang benar tentang perencanaan pra-bedah ETV, KECUALI
A. Adalah relatif untuk menentukan secara pasti fungsi mendatang dari jalur subaraknoid dan patensi ETV selama hasil sisternogram MR resolusi tinggi diperoleh sebelum pelaksanaan memastikan tingkat sumbatannya.
B. MRI dapat secara pasti menjelaskan anatomi foramen Monro, ventrikel ketiga, dan landas
intermedier
C. Posisi dari arteri basilar dan ketebalan lantai ventricular ketiga dapat diverifikasi oleh hampir semua MRI yang dijalankan sebelum pembedahan
D. Riwayat infeksi CSF sebelumnya mungkin akan menurunkan tingkat keberhasilan dari ETV
E. Riwayat penempatan shunt sebelumnya bukanlah merupakan kontraindikasi mutlak bagi ETV

A
ETV is a commonly performed procedure for patients with aqueductal stenosis (AS ) . Although there is some controversy about the age at which this procedure should first be employed, results indicate high success rates for properly selected patients. Complications of shunting mav include slit ventricle syndrome, intracranial hypotension, subdural hematomas, craniosynostosis, microcephal

43

Nn.X, 15 tahun dibawa ke UGD dalam keadaan lemas, mual-mual, dan muntah-muntah dan ternyata menderita stenosis akueduktal berdasarkan hasil MRI ada otak.

43. Mana yang merupakan lokasi optimal untuk fenetrasi lantai ventrikel ke 3 selama ETV?
A. Di belakang batang mamillaris
B. Di depan reses infundibular, di belakang ruang prakiasmatis
C. Pada hampir semua daerah transluken dari lantai ventrikel ketiga
D. Di anterior badan mamillaris, di posterior reses infundibular
E. Di depan denyut dari arteri basilar

D
ETV is a commonly performed procedure for patients with aqueductal stenosis (AS ) . Although there is some controversy about the age at which this procedure should first be employed, results indicate high success rates for properly selected patients. Complications of shunting mav include slit ventricle syndrome, intracranial hypotension, subdural hematomas, craniosynostosis, microcephal

44

44. Batas resesus lateral meliputi semua hal di bawah ini, KECUALI:
A. Pedikel
B. Faset artikular atas
C. Faset artikular inferior
D. Batang vertebral
E. saluran tulang/ kantung tekal

C
Compression of nerve roots in the lateral recess (lateral recess syndrome) can occur between a hypertrophied superior articular facet (dorsally), the pedicle (laterally), and the inferior vertebral body (ventrally). Medially, the lateral recess opens toward the spinal canaVthecal sac. The characteristic feature of lateral recess syndrome is that of radicular symptoms that occur mainly when the patient is walking or standing and are relieved by sitting, squatting forward, lying on either side, and/or postures that accentuate lumbar kyphosis. This is opposite to what is seen with patients harboring discogenic disease. who are uncomfortable while sitting. With the lateral recess syndrome, adequate decompression involves laminectomY with resection of the medial third of the hypertrophied facet (medial facetectomy), which is usually the superior articular process (Wi l kins, pp. 3841-3845).

45

45. Penyebab utama stenosis resesus lateral adalah pembentukan Osteopit yang berasal dari…
A. Proses artikular dalam
B. Pedikel
C. Prosesus artikular superior
D. Hipertropi ligamentum flavum
E. Batang vertebral

C
Compression of nerve roots in the lateral recess (lateral recess syndrome) can occur between a hypertrophied superior articular facet (dorsally), the pedicle (laterally), and the inferior vertebral body (ventrally). Medially, the lateral recess opens toward the spinal canaVthecal sac. The characteristic feature of lateral recess syndrome is that of radicular symptoms that occur mainly when the patient is walking or standing and are relieved by sitting, squatting forward, lying on either side, and/or postures that accentuate lumbar kyphosis. This is opposite to what is seen with patients harboring discogenic disease. who are uncomfortable while sitting. With the lateral recess syndrome, adequate decompression involves laminectomY with resection of the medial third of the hypertrophied facet (medial facetectomy), which is usually the superior articular process (Wi l kins, pp. 3841-3845).

46

46. Meski pun cukup mirip dg gejala Radikulopati yg sifatnya sekunder dari penyakit diskogenik, stenosis resesus lateral; dapat dibedakan dari penyakit diskogenik melalui…
A. Nyeri pada sindroma resesus lateral semakin menjadi setiap berjalan atau berdiri
B. Pada penyakit diskogenik, batuk atau bersin yang gagal akan memperhebat rasa sakit.
C. Pada sindroma reses lateral, menaikkan kaki lurus-lurus akan positif
D. Pada sindroma reses lateral, rasa sakit akan hilang melalui lordosis lumbar Aksentuasi postur
E. Pada stenosis reses lateral, kejadian inkonsistensi kandung empedu sedikit lebih tinggi.

A
Compression of nerve roots in the lateral recess (lateral recess syndrome) can occur between a hypertrophied superior articular facet (dorsally), the pedicle (laterally), and the inferior vertebral body (ventrally). Medially, the lateral recess opens toward the spinal canaVthecal sac. The characteristic feature of lateral recess syndrome is that of radicular symptoms that occur mainly when the patient is walking or standing and are relieved by sitting, squatting forward, lying on either side, and/or postures that accentuate lumbar kyphosis. This is opposite to what is seen with patients harboring discogenic disease. who are uncomfortable while sitting. With the lateral recess syndrome, adequate decompression involves laminectomY with resection of the medial third of the hypertrophied facet (medial facetectomy), which is usually the superior articular process (Wi l kins, pp. 3841-3845).

47

47. Strategi bedah manakah yang paling baik untuk pasien dengan stenosis resesus lateral?
A. Laminektomi
B. Laminektomi dengan reseksi 1/3 tengah faset hipertropi (fasetektomi medial)
C. Mikrodisektomi
D. Laminektomi dan fusi
E. A, B, C dan D salah.

B
Compression of nerve roots in the lateral recess (lateral recess syndrome) can occur between a hypertrophied superior articular facet (dorsally), the pedicle (laterally), and the inferior vertebral body (ventrally). Medially, the lateral recess opens toward the spinal canaVthecal sac. The characteristic feature of lateral recess syndrome is that of radicular symptoms that occur mainly when the patient is walking or standing and are relieved by sitting, squatting forward, lying on either side, and/or postures that accentuate lumbar kyphosis. This is opposite to what is seen with patients harboring discogenic disease. who are uncomfortable while sitting. With the lateral recess syndrome, adequate decompression involves laminectomY with resection of the medial third of the hypertrophied facet (medial facetectomy), which is usually the superior articular process (Wi l kins, pp. 3841-3845).

48

48. Disartria dan penurunan kognitif
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

E
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

49

49. Hemiparesis, hemanopia homonimus
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

F
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

50

50. “Kutukan Ondine”
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

A
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

51

51. Gangguan pergerakan mata, pupil dilatasi, rasa takut
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

B
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

52

52. Sindroma HORNER
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

D
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

53

53. Anestesia dolorosa
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

C
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

54

54. Lemah kaki, disestesia, disfungsi kandung Kemih
A. Kordotomi
B. Stimulasi gray periakueduktal
C. Elektrokauteri trigeminal prakutanus
D. Simpatektomi
E. Talamotomi bilateral
F. Palidotomi
G. Mielotoni komisural

G
Direct sectioning of the spinothalamic tract (cordotomy) is very effecti,•e ior unilateral pain below the upper chest region, however. it is associated with many complications and is usually performed only in terminal patients. Complications of cordotomy includehemiparesis, respiratory depression (Ondine's curse with bilateral procedures), and dysesthesias. Midline myelotomies can also be performed to interrupt the decussating fibers of the spinothalamic tract. This can be quite effective in the treatment of chronic pelvic pain secondary to cancer but is associated with leg weakness, dysesthesias, and bladder dysfunction. Chronic deep brain stimulation of the VPL and VP!vl nuclei of the thalamus as well as the periaqueductal gray (PAG) has been performed in the treatment of thalamic pain states, postherpetic neuralgia, and causalgia. Stimulation of the PAG has been associated with eye movement disorders, pupillary dilation, and the feeling of fear. Complications of pallidotomy include injury to the adjacent internal capsule (hemiparesis) and optic tract (homonymous hemianopsia), while complications of bilateral thalamotomy include speech problems and congnitiYe decline. Horner's syndrome, pneumothorax, intercostal neuralgias, and spinal cord injur

55

Tn. X, 58 tahun dengan artrisis rheumatoid dibawa ke UGD dengan sakit leher yang tidak tertahankan dan Mielopati servikal. Hasil MRI menunjukkan bahwa pasien mengalami proses migrasi atas odontoid (SMO) ke foramen magnum ( cranial settling ) dan tekanan pada brainstem oleh proses odontoid itu sendiri.

B.
Peripheral alcohol injection, glvcerol rhizolysis, radiofrequency thermocoagulation, and micro,•ascular decompression are all established procedures for the treatment of trigeminal neuralgia. Peripheral balloon compression instead of decompression is a modification of the observation that open surgical decompression of the ganglion could lead to significant pain relief in trigeminal neuralgia ( Kaye and Black, pp. 1616-1633; Greenberg, pp. 373 -380 ) .

56

Tn. X, 58 tahun dengan artrisis rheumatoid dibawa ke UGD dengan sakit leher yang tidak tertahankan dan Mielopati servikal. Hasil MRI menunjukkan bahwa pasien mengalami proses migrasi atas odontoid (SMO) ke foramen magnum ( cranial settling ) dan tekanan pada brainstem oleh proses odontoid itu sendiri.

56. Semua informasi di bawah ini perlu dihimpun sebelum pembedahan untuk pasien dengan kelainan persendian kranioservikal (CGJ), KECUALI
A. Evaluasi stabilitas kranioservikal
B. Pemeriksaan-pemeriksaan EMG dan konduksi saraf untuk memastikan sampai sejauh mana terjadinya kerusakan pada saraf periferal
C. Apakah terdapat syrinx terkait
D. Sampai sejauh mana tekanan ventral-nya
E. Adanya pusat-pusat osifikasi dan lempeng-lempeng pertumbuhan epifisieal abnormal pada anak, karena hal ini bisa mengubah prosedur-prosedur perawatannya.

B
Craniocervical junction (CC.J ) abnormalities can often be very difficult to manage, with the primary goal being to relieve the compression at the cervicomedullary junction. They are commonly seen in patients with Chiari malformation or rheumatoid arthritis. With reducible lesions, stabilization is essential to maintain neural decompression, while for irreducible lesions, decompression at the site of encroachment (\•entral or posterior) as well as stabilization are often required. Patiems with rheumatoid arthritis are at risk for developing atlantoa:dal instability (Ai\.l) ; superior migration of the odomoid process ( Slv!O), also known as cranial settling; and subaxial subluxations ( SAS) . For rheumatoid patients with reducible lesions, immobilization alone with posterior spinal or craniospinal fusion without decompressive procedures is the mainstay of treatment. Late-onset deterioration in patients with rheumatoid arthritis or Chiari malformations in the pattern seen in this patient is concerning for syrinx or syringomyelia formation (Kaye and Black, pp. 1755-1770; Wilkins, pp. 3789-3790; Youmans, p p . 4569-4580) .

57

Tn. X, 58 tahun dengan artrisis rheumatoid dibawa ke UGD dengan sakit leher yang tidak tertahankan dan Mielopati servikal. Hasil MRI menunjukkan bahwa pasien mengalami proses migrasi atas odontoid (SMO) ke foramen magnum ( cranial settling ) dan tekanan pada brainstem oleh proses odontoid itu sendiri.

57. Pemeriksaan pencitraan dinamis atas persendian kranioservikal mengungkapkan adanya ketidakstabilan. Akhli bedah saraf memutuskan untuk menerapkan traksi servikal lembut selama 3 hari dan berhasil menurunkan kelainan tersebut. Setelah 3 hari traksi, rasa sakit pada leher pasien mengalami pemulihan yang berarti, dan hasil MRI mengungkapkan tekanan minimal pada brainstem dengan posisi yang menurun.
Langkah pengelolaan yang selanjutnya perlu ditempuh...
A. Laminektomi servik belakang
B. Laminektomi servik belakang, kraniektomi sub-okipital, dan fusi
C. Traksi servik selama seminggu berikutnya dalam upaya untuk semakin menurunkan kelainan tersebut sebelum memusatkan perhatian kepada prosedur bedah apa pun.
D. Hanya imobilisasi saja dengan fusi servikal belakang tanpa dekompresi
E. Odontektomi transoral yang dilanjutkan dengan dekompresi servik belakang, kraniektomi sub-okipital dan fusi.

D
Craniocervical junction (CC.J ) abnormalities can often be very difficult to manage, with the primary goal being to relieve the compression at the cervicomedullary junction. They are commonly seen in patients with Chiari malformation or rheumatoid arthritis. With reducible lesions, stabilization is essential to maintain neural decompression, while for irreducible lesions, decompression at the site of encroachment (\•entral or posterior) as well as stabilization are often required. Patiems with rheumatoid arthritis are at risk for developing atlantoa:dal instability (Ai\.l) ; superior migration of the odomoid process ( Slv!O), also known as cranial settling; and subaxial subluxations ( SAS) . For rheumatoid patients with reducible lesions, immobilization alone with posterior spinal or craniospinal fusion without decompressive procedures is the mainstay of treatment. Late-onset deterioration in patients with rheumatoid arthritis or Chiari malformations in the pattern seen in this patient is concerning for syrinx or syringomyelia formation (Kaye and Black, pp. 1755-1770; Wilkins, pp. 3789-3790; Youmans, p p . 4569-4580) .

58

Tn. X, 58 tahun dengan artrisis rheumatoid dibawa ke UGD dengan sakit leher yang tidak tertahankan dan Mielopati servikal. Hasil MRI menunjukkan bahwa pasien mengalami proses migrasi atas odontoid (SMO) ke foramen magnum ( cranial settling ) dan tekanan pada brainstem oleh proses odontoid itu sendiri.

58. Satu tahun kemudian pasien mengalami kelemahan pada kaki yang semakin parah, ataksia, dan inkonsistensi kantung empedu, tapi kekuatan pada ujung-ujung tubuh bagian atasnya tetap, dan tidak ada bukti kelainan saraf kranial. Hasil film datar dan CT scan persendian kranioservik tidak begitu tampak. Test diagnostik apakah yang selanjutnya perlu dilakukan?
A. CT pada otak untuk menjajagi kemungkinan Hidrosepalus
B. EMG dan NCS untuk memastikan sampai sejauh mana rusaknya saraf periferal
C. Screening tulang dengan MRI
D. Uji urodinamis kantung empedu.
E. Film dinamis tulang servik untuk menilai kemungkinan pseudoartrosis dan ketidakstabilan.

C
Craniocervical junction (CC.J ) abnormalities can often be very difficult to manage, with the primary goal being to relieve the compression at the cervicomedullary junction. They are commonly seen in patients with Chiari malformation or rheumatoid arthritis. With reducible lesions, stabilization is essential to maintain neural decompression, while for irreducible lesions, decompression at the site of encroachment (\•entral or posterior) as well as stabilization are often required. Patiems with rheumatoid arthritis are at risk for developing atlantoa:dal instability (Ai\.l) ; superior migration of the odomoid process ( Slv!O), also known as cranial settling; and subaxial subluxations ( SAS) . For rheumatoid patients with reducible lesions, immobilization alone with posterior spinal or craniospinal fusion without decompressive procedures is the mainstay of treatment. Late-onset deterioration in patients with rheumatoid arthritis or Chiari malformations in the pattern seen in this patient is concerning for syrinx or syringomyelia formation (Kaye and Black, pp. 1755-1770; Wilkins, pp. 3789-3790; Youmans, p p . 4569-4580) .

59

Seorang dokter bedah menggunakan pendekatan fossa infratemporal untuk mengangkat tumor besar yang menyebar dari landas kranial. Dia terbentur kepada struktur yang diarsir pada tanda panah di bawah ini.

pic
59. Berapa banyak otot yang melekat pada struktur ini?
A. 2 B. 3 C. 4 D. 5 E. 6

B
The styloid process gives rise to the stylohyoid (VI I ) , styloglossus (XII ) , and stylopharyngeal muscles ( IX) of the visceral neck as well as the stylomandibular and stylohyoid ligaments. It is a remnant of the second brachial arch (Youmans, p . 36).

60

Seorang dokter bedah menggunakan pendekatan fossa infratemporal untuk mengangkat tumor besar yang menyebar dari landas kranial. Dia terbentur kepada struktur yang diarsir pada tanda panah di bawah ini.

pic
60. Saraf-saraf kranial manakah yang menginervasi otot-otot tersebut?
A. VII, IX B. VII, IX, XII C. IX, X, XII
D. V, VII, IX E. X, XII

B
The styloid process gives rise to the stylohyoid (VI I ) , styloglossus (XII ) , and stylopharyngeal muscles ( IX) of the visceral neck as well as the stylomandibular and stylohyoid ligaments. It is a remnant of the second brachial arch (Youmans, p . 36).

61

Seorang dokter bedah menggunakan pendekatan fossa infratemporal untuk mengangkat tumor besar yang menyebar dari landas kranial. Dia terbentur kepada struktur yang diarsir pada tanda panah di bawah ini.

pic
61. Berapa jumlah ligamen yg melekat pada struktur

A. 1 B. 2 C. 3 D. 4 E. 5

B
The styloid process gives rise to the stylohyoid (VI I ) , styloglossus (XII ) , and stylopharyngeal muscles ( IX) of the visceral neck as well as the stylomandibular and stylohyoid ligaments. It is a remnant of the second brachial arch (Youmans, p . 36).

62

PIC
62. Paling mungkin menyebabkan kelemahan otot ekstensor dari pergelangan dan tangan, ekstensi lengan depan biasanya tidak terpengaruh sensasi tangan dorsal terpengaruh.

B
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

63

PIC
63. Mungkin akan menyebabkan kelemahan pada teres minor

A
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

64

PIC
64. Kelemahan fleksi dan aduksi pergelangan, lumpuh otot hipotenar, dan hampir semua otot dalam dari tangan, beberapa kelemahan pada otot-otot tenar

C
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

65

PIC
65. Kelemahan abduksi bahu

A
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

66

PIC
66. Kemungkinan tinggi hanya untuk cedera saraf ulnar saja

C
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

67

PIC
67. Kerusakan saraf medianus, lumpuh otot hipotenar, beberapa otot tenar, dan hampir semua otot dalam dari tangan, fleksi dan adduksi pergelangan terganggu.

F
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

68

PIC
68. Bisa berasosiasi dengan cedera-cedera pleksus brakial

A
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

69

PIC
69. Paling mungkin menyebabkan kombinasi cedera saraf radial medial dan ulnar

D
Fracture of the proximal humerus (A) can result in injury to the axillary nerve (CS-6), which innervates the teres minor and deltoid muscles. This can result in sensory loss at the shoulder as well as shoulder abduction weakness. There is also a chance of concomitant brachial plexus injury with such a fracture due to the proximity of the proximal humerus to the brachial plexus. The radial nerve runs down the posterior aspect of the arm and is at risk for injury during fractures of the midhumeral shaft as it winds around the spiral groove ( B ) . This could cause paralysis o f the wrist a n d hand extensor muscles. Since the fibers that innervate the triceps muscle often arise proximal to the spiral groo\•e, extension of the forearm may not be affected by midhumeral fractures, and some supination is possible due to an intact biceps brachii muscle. Fracture in the vicinity of the medial epicondyle may result in ulnar neJTe damage onl\• ( C ) , \Yhich can produce weakness of flexion and adduction of wrist, paralvsis of hypothenar muscles and most deep muscles of the h and, as well as some weakness in select thenar muscles. Injury of the ulnar nerve by fracture of the distal ulna can result in weakness or paralysis of h

70

70. Seorang anak perempuan berusia 9 tahun dibawa ke dokter anaknya dengan sakit kepala
dan field-cut bitemporal. Hasil MRI atas pasien ditunjukkan pada Gambar. Manakah diantara hal-hal di bawah ini yang akan tepat jika dihubungkan dengan hasil endokrin setelah reseksi bedah atas tumor ini?

PIC

A. Peluang bahwa dia akan mengidap diabetes insipidus adalah 30%
B. Masalah yang paling serius dan parah adalah berkembangnya obesitas, yang terjadi sekitar 50% pasien setelah mengalami pembedahan sejenis.
C. Sekitar 90% pasien tidak akan memerlukan perawatan terapi kortikosteroid dan penggantian tiroid.
D. Sekitar 10% dari pasien akan memerlukan terapi penggantian hormon pertumbuhan
E. Hasil endoktrin pasca bedah sangat tidak dapat diprediksikan

B.
A significant number of children with craniopharyngiomas will have a significant endocrine abnormality after surgery, which is quite predictable . The most serious complication appears to be obesity, which develops in about SO% of patients. These patients are unable to control their appetite secondary to damage to the hypothalamic satiety center. Growth hormone may benefit these patients, as it appears to reduce body fat and increase lean body mass. Nearly SO% of patients will require GI-l-replacement therapy. Diabetes insipidus occurs in about 90% of patients and is often permanent. Moreover, about 90% of patients will require hydrocortisone and thyroid replacement therapy after surgery ( Kaye and Black, p p . 7 41-7 48; Com m ittee on Education in Neurological Surgery, pp. 26, 116; Curtis et a l . , p p . 24-2 7 ) .

71

71. Ny. X, 42 tahun baru-baru ini didiagnosis hipotensi intrakranial spontan, Semua hal di bawah ini sering berasosiasi dengan masalah ini, KECUALI
A. Sakit kepala yang dirasakan seringkali mirip dengan sakit kepala pasca lumbar puncture
B. Pemindaian lemah dengan kontras bisa mengungkapkan penguatan pada dura atas Konveksitas serebral dan serebelar.
C. Jarang tampak adanya pemulihan spontan, karena kebocoran CSF sering dipastikan tampak di dekat akar-akar saraf.
D. Cairan tulang mungkin bisa mengungkapkan naiknya protein dan pleositosis
E. Analgesik yang mengandung kafein mungkin bisa membantu.

C .
The headaches o f spontaneous intracranial hypotension often resemble post-lumbar puncture headaches. Headaches are usually worse in the upright position and are generally relieved when the patient is lying down. The diagnosis is established by lumbar puncture, which reveals low opening pressure or dry tap . It is not uncommon to have elevated protein and pleocytosis. It is postulated that this syndrome results from leakage of CSF to the outside neuraxis, often around nerve roots. :rviR cisternography is often capable of demonstrating the leak. Jugular compression will elevate intracranial pressure but usually makes the headache worse, suggesting that low pressure may not be the only factor responsible for the headaches. MRI scans often reveal dural enhancement over the cerebral and cerebellar com•exities, tentorium, and falx, which usually resolves with resolution of the symptoms. Treatment should be consen•ati\•e. since there is often spontaneous improvement. Analgesics containing caffeine and adequate hydration seem to help. In some cases an epidural patch may be required; surgical closure of the fistula is rarely required (Committee on Education in Neurological Surgery, pp. 1 7 , 105; Kosmosky, pp. 79 -83 ) .

72

72. Semua luka di bawah ini cocok untuk radiosurgeri stereostatis, KECUALI
A. Malformasi Arteriovenus 3 – cm3 pada brainstem.
B. Karsinoma metastatis 1-cm frontal kanan dan 2-cm parietal kiri dari paru-paru.
C. Glioblastoma kambuhan pada lobe temporal kiri (2 cm3)
D. Kavermoma 1-cm dari inti kaudatus kanan yang sebelumnya mengalami perdarahan.
E. Malformasi Arteriovenus talamik bilateral ( 3 cm3)

D.
A long history of radiosurgical treatment ior arteriovenous malformations exists. The best responses are oiten obtained for lesions with volumes less than 4 cnr' .

73

73. Semua hal di bawah ini akan menurunkan penyebaran rasa sakit atau reaksi pasien
terhadap rasa sakit, KECUALI
A. stimulasi gray periakueduktal
B. Lobotomi pra-frontal
C. Singulotomi
D.Hipokampektomi
E. Kordotomi ventrolatera

D.
Prefrontal lobectomy, cingulotomy, ventrolater.al cordotomy, and periaqueductal gray stimulation may interrupt pain pathways or the response to painful stimuli. Hippocampectomy does not interrupt these pathways but may decrease the severity of complex partial seizures (Youmans, pp. 3025-3030; Greenberg, pp. 364-370).

74

74. Ny. X, 34 tahun mengalami kecelakaan tabrakan kendaraan bermotor dan mengalami
cedera memar kepala tertutup parah, dan menderita tremor pasca-trauma berat pada lengan kanan. Meski pun tremor pasca-trauma biasanya sulit dikelola, prosedur bedah manakah yang bisa membantu mengendalikan tremor, yang jika tidak dilakukan maka tremor akan tidak beraksi terhadap terapi medis?
A. Stimulasi talamik
B. Stimulasi nukleus subtalamik
C. Stimulasi korteks motorik
D.Kapsulotomi
E.Transeksi suppial majemuk

A .
Traumatic injury to the brainstem including the superior cerebellar peduncles and their connections can result in severe tremor that may be delayed by weeks to months following the brain injury. In some cas

75

75. Ny. X, 36 tahun mengalami aneurisma kompleks yang mengharuskan penghentian jantung dan hipotermia selama pembedahan. Semua hal di bawah ini merupakan kemungkinan dampak psiologis dari hipotermia, KECUALI
A. Naiknya kekentalan darah
B. Hiperglisemia
C. Menurunnya pelepasan kortikosteroid
D. Pneumonitis termediasi komplemen
E. Keadaan hiperkoagulasi

E.
Profound hypothermia during circulatory arrest can result in various physiologic effects including increasing blood viscosity, metabolic acidosis ( underperfused tissue ) , hyperglycemia (secondary t o hypoinsulinemia), decreased corticosteroid secretion, complement-mediated pneumonitis, renal failure (due to transient decrease in glomerular fil tration rate, hemolysis, and bl0od product reactions), hepatic failure, and hypothermia-induced coagulopathy ( due to platelet dysfunction and slowing of the enzymatic clotting cascade) (Youmans, p. 153 2 ) .

76

76. Manakah yang merupakan manifestasi fisik yang paling lazim dari kelainan yang ditunjukkan pada angiogram di bawah ini ?

PIC

A. Sakit leher
B. Servikal bruit
C. Kelemahan atau mati rasa pada lengan
D. Disestesia
E. Kehilangan penglihatan sekejap

B.
The most common physical manifestation of extracranial carotid artery disease is a cervical bruit. The degree oi stenosis necessary to produce a bruit has been reported w be as lo\\' as 25%, but in various studies its presence has been found to indicate a significant level (> SO%) of stenosis on angiography in at least 70% of patients. False-positi\•e rates of 10 to 40% and false-negative rates of 30 to 70% hm•e been reported for cervical bruits. The Framingham Study found that the risk of stroke and T!As in patients with bruits "•as two to three times the risk for patients \\'ithout bruits. Such patients were also about 2 . 5 times more likely to ha\•e a hean attack and 1. 9 times more like!

77

77. Perhatikan Gambar di bawah ini. Diagnosis manakah yang paling mungkin?
A. Infeksi echinococcus
B. Neukrosistiserkosis
C. Infeksi Cryptococcus
D. Infeksi cytomegalovirus
E. Trichinosis

B
Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system (CNS) worldwide. Humans are the definitive host for the adult tapeworm Taenia solium, which thrives in the small intestine without consequence. Fecal shedding of eggs usually leads to ingestion of eggs in contaminated water or food by an intermediate host, typically humans or pig. Once inside the intestine, the eggs are released and produce primary larvae that enter the circulatory system. Hematogenous spread to muscular, ocular, and neural tissue then occurs. Once inside the brain, the primary larvae develop into secondary larvae, the cysticerci. Clinical manifestations of the neural form of the disease are varied and nonspecific. This pleomorphism is related to the number, size, and topography of the lesions. Parenchymal disease (as in this case) is most common and presents with seizures in 50 to 80% of patients. Treatment typically includes antiepileptics, albendazole, or praziquantel, as well as a short course of steroids to reduce the inflammatory reaction during antihelminthic t reatment. Niclosamide may be given orally to treat adult tapeworms in the GI tract. Fluconazole is an antifungal and not used to treat this disease process. The colonization of the ventricular system often presents with rapid clinical deterioration clue to increased intracranial pressure from obstructive hydrocephalus. There is still controversy about the best treatment for this form of the disease, but most authors advocate either a trial of antihelminthic medication, endoscopic cyst resection , or microsurgery. Subarachnoid disease is usually more difficult to manage because the cysts are usually multiple, attain larger sizes, and produce severe basal meningitis, but antihelminthic medications are typically first-line therap

78

8. Pasien ini paling mungkin mengeluh?
A. Sakit kepala
B. Obtundation
C. Lumpuh saraf cranial
D. Demam
E. Kejang-kejang

E
Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system (CNS) worldwide. Humans are the definitive host for the adult tapeworm Taenia solium, which thrives in the small intestine without consequence. Fecal shedding of eggs usually leads to ingestion of eggs in contaminated water or food by an intermediate host, typically humans or pig. Once inside the intestine, the eggs are released and produce primary larvae that enter the circulatory system. Hematogenous spread to muscular, ocular, and neural tissue then occurs. Once inside the brain, the primary larvae develop into secondary larvae, the cysticerci. Clinical manifestations of the neural form of the disease are varied and nonspecific. This pleomorphism is related to the number, size, and topography of the lesions. Parenchymal disease (as in this case) is most common and presents with seizures in 50 to 80% of patients. Treatment typically includes antiepileptics, albendazole, or praziquantel, as well as a short course of steroids to reduce the inflammatory reaction during antihelminthic t reatment. Niclosamide may be given orally to treat adult tapeworms in the GI tract. Fluconazole is an antifungal and not used to treat this disease process. The colonization of the ventricular system often presents with rapid clinical deterioration clue to increased intracranial pressure from obstructive hydrocephalus. There is still controversy about the best treatment for this form of the disease, but most authors advocate either a trial of antihelminthic medication, endoscopic cyst resection , or microsurgery. Subarachnoid disease is usually more difficult to manage because the cysts are usually multiple, attain larger sizes, and produce severe basal meningitis, but antihelminthic medications are typically first-line therap

79

79. Gangguan ini disebabkan oleh

A. Borrelia burgdorferi
B. Echinococcus granulosa
C. Toxoplasma Gondii
D. Treponema pallidum
E. Taenia solium

E
Neurocysticercosis (NCC) is the most common parasitic infection of the central nervous system (CNS) worldwide. Humans are the definitive host for the adult tapeworm Taenia solium, which thrives in the small intestine without consequence. Fecal shedding of eggs usually leads to ingestion of eggs in contaminated water or food by an intermediate host, typically humans or pig. Once inside the intestine, the eggs are released and produce primary larvae that enter the circulatory system. Hematogenous spread to muscular, ocular, and neural tissue then occurs. Once inside the brain, the primary larvae develop into secondary larvae, the cysticerci. Clinical manifestations of the neural form of the disease are varied and nonspecific. This pleomorphism is related to the number, size, and topography of the lesions. Parenchymal disease (as in this case) is most common and presents with seizures in 50 to 80% of patients. Treatment typically includes antiepileptics, albendazole, or praziquantel, as well as a short course of steroids to reduce the inflammatory reaction during antihelminthic t reatment. Niclosamide may be given orally to treat adult tapeworms in the GI tract. Fluconazole is an antifungal and not used to treat this disease process. The colonization of the ventricular system often presents with rapid clinical deterioration clue to increased intracranial pressure from obstructive hydrocephalus. There is still controversy about the best treatment for this form of the disease, but most authors advocate either a trial of antihelminthic medication, endoscopic cyst resection , or microsurgery. Subarachnoid disease is usually more difficult to manage because the cysts are usually multiple, attain larger sizes, and produce severe basal meningitis, but antihelminthic medications are typically first-line therap

80

80. Manakah yang merupakan diagnosis yang paling mungkin dari angiogram di bawah ini

A. Sindroma blue rubber bleb nevus
B. Aneurisma vena Galen
C. Fistula kavernus-karotid
D. Hemangiblastoma intracranial pada infant
E. Sinus pericranii

B.
A neonate suffering high-output cardiac failure, hyperdynamic precordium, dilated cervical and cranial ,•eins, and a rteries with a "machine-like" bruit heard over the head and neck is most likely harboring a vein of Galen aneurysm. \"ascular tumors, CC fistula, blue rubber bleb nents syndrome. and sinus pericranii do not typicallv present with this constellation of problems. Although transcranial ultrasonography is an excellent way to diagnose these lesions. the "gold standard" is cerebral angiography. In infants, a transarterial and transvenous route to eliminate the high-tlo"• shunt is often employed. This technique mav not lead to complete obliteration but often converts highoutput cardi:tc failure to a persistent fis tula . In an older child or adul t, the treatment is frequently gradual and entails graded elimination of the shunt with endovascular surgery, usually via a transarterial route ( Kaye and Black, pp. 17 4- 176; Youmans, pp. 3433-3445).

81

81. Saraf interoseus posterior memasok semua hal di bawah ini KECUALI
A. Supinator
B. Extensor carpi ulnaris
C. Abductor pollicis longus
D. Extensor Digitorum
E. Pronator quadratus

E .
The deep branch of the radial nerve passes through a slit in the supinator muscle (arcade of Frohse) to the posterior forearm. After passing this slit, the nerve is called the posterior interosseous nerve and supplies the supinator, extensor carpi radialis bre,•is, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensors pollicis longus and breYis, and extensor indicis muscles. The anterior interosseous nerve, a branch of the median nen•e, supplies the pronator quadratus (Greenberg, pp. 523, 542-543).

82

82. Kemampuan menciptakan bentuk tak beraturan sangat penting untuk mencapai iradiasi konformal jaringan target. Diantara teknik di bawah ini, manakah yang dapat dilakukan untuk menciptakan rancangan tersebut?
A. Gabungkan berbagai isosenter iradiasi pada bidang-bidang yang berbeda
B. Masing-masing isosenter dapat dibobot secara variabel untuk mengubah bentuk relatifnya
C. Masing-masing sinar radiasi dapat dihambat untuk membatasi dosis jauh dari struktur-struktur kritis, seperti kiasme optik
D. Hanya A dan B
E. Jawaban A, B, C dan D semuanya benar.

E.
The ability to create irregularly shaped rac\iosurgical volumes is important to achieve conformal irradiation of target tissue, as all tumors or lesions are rarely perfect spheres. The following techniques can be used to create an irregularly shaped plan during radiosurgerY. First. combine multiple isocenters of irradiation in different planes. For example, a series of 4-mm isocentors of irradiation is often used to tailor radiation to the porus acusticus for schwannomas. Second, individual isocenters can be weighted variably to change their relative shape. Finally, indiYidual radiation beams can be blocked to restrict dose away from critical structures, such as the optic chiasm (Youmans, pp. 4118-4119).

83

83. Ny. X, 45 tahun menjalani disektomi dan fusi servikal anterior C5-6 dan C5-7. Pasca bedah pasien siuman dan mengalami sindroma Horner. Etiologi yang paling mungkin dari temuan ini berkaitan dengan kerusakan pada struktur yang mana?
A. Saraf simpatetik yang berjalan sepanjang arteri karotid selama diseksi leher
B. Cedera pada akar syarat T1 selama disektomi
C. Interupsi rantai simpatetik yang terletak pada permukaan anterior dari otot longus colli
D. Cedera urat tulang selama bedah
E. Infark hipotalamik kecil selama bedah

C
A rare complication after anterior cervical procedures is the development of a Horner's syndrome (anhidrosis, miosis, ptosis) from interruption of the sympathetic chain located on the anterior surface of the longus colli muscle. The thoracic duct enters the subclm•i nn vein on the left and is particularly vulnerable to injurv during left-sided anterior cervical procedures (Youmans, pp. 4442-4443 , 4451).

84

83. Ny. X, 45 tahun menjalani disektomi dan fusi servikal anterior C5-6 dan C5-7. Pasca bedah pasien siuman dan mengalami sindroma Horner. Etiologi yang paling m84. Pendekatan sisi kiri menurunkan risiko kambuhnya lumpuh saraf laryngeal selama prosedur-prosedur servikal depan, tetapi dengan tingkatan yang lebih rendah, pendekatan sisi kiri ini akan berisiko cedera pada struktur mana?
A. Saraf laryngeal bawah
B. Arteri tiroservik
C. Saluran torak
D. Akar saraf C5
E. Saraf akselelator jantung dominan
ungkin dari temuan ini

C
A rare complication after anterior cervical procedures is the development of a Horner's syndrome (anhidrosis, miosis, ptosis) from interruption of the sympathetic chain located on the anterior surface of the longus colli muscle. The thoracic duct enters the subclm•i nn vein on the left and is particularly vulnerable to injurv during left-sided anterior cervical procedures (Youmans, pp. 4442-4443 , 4451).

85

85. Spondilolistetis degeneratif paling lazim pada tingkat tulang pada tulang lumbar yang
mana?
A. L.1-2
B. L.1-3
C. L.1-4
D. L4-5
E. L5-S1

D.
Degenerative spond

86

mengalami dislokasi atlantaoaksial yang tereduksi, setelah 36 traksi servikal. Tampak tekanan ventral menimal dari formasi pannus, tidak tampak cranial settling, dan tidak stenosis magnum foramen pada hasil MR scan. Strategi perawatan apakah yang terbaik bagi pasien ini?
A. Fiksasi dan fusi skrup trans-artikular jika massa atlantal lateral intak dengan mutu tulang baik
B. Odontektomi ransoral yang dilanjutkan dengan dekompresi dan fusi servik okipital belakang
C. Laminektomi
D. Odontektomi Transoral yang dilanjutkan dengan observasi
E. Penempatan Halo

A.
I rreducible pathologic conditions affecting the cervicomedullarv junction in patiems "•ith rheumatoid a rthri tis frequently require an anterior cen•ical procedure to remove the offending patholog,• ( trequeml

87

87. Graft tulang yang ideal memberikan semua unsur penyembuhan yang sukses di bawah ini ,KECUALI
A. Matriks osteokonduktif
B. Faktor osteokonduktif
C. Untuk menopang sel-sel osteogenik yg masih baik
D. Penopang struktur
E. Osteoblas untuk penyembuhan tulang.

E .
The ideal bone graft provides t h e follmYing elements for successful healing: osteoconductive matrix, osteoinductive factors, viable osteogenic cells, and structural support. Only fresh autografts contribute viable osteogenic cells to the developing fusion. Processed allografts frequently have no living cellular elements and are mainly derived from the tissues of the recipient bed (Youmans, pp. 4615-4616). ) .

88

88. Intervensi pada uptake ion mana ke dalam sel-sel selama cedera kepala tertutup yang
mengakibatkan manfaat klinis?
A. Ca2+
B. Na+
C. Cl-
D. K+
E. A, B, C dan D salah


E.
Although traumatic brain injury ( TBI) has been shown to result in increases of calcium flux into cells with subsequent cell injury, no clinical benefit has been observed in clinical trials attempting to attenuate this response in patients with TBI. A subset of patients with subarachnoid hemorrhage, however, did show a benefit. Calcium may enter cells via ion channels influenced by excitatory amino acids (glutamate, aspartat e ) . Unfortunately clinical trials to antagonize these receptors have been discouraging in TBI (Youmans, p p . 5025-502 7

89

89. Terapi-terapi bedah yang digunakan untuk Distonia biasanya meliputi semua hal di bawah ini, KECUALI
A. Denervasi periferal
B. Pallidotomi
C. Talamotomi
D. Stimulasi kolom dorsal
E. Stimulasi korteks motorik

E .
Surgical therapies including cerebellar stimulation, dorsal column stimulation, peripheral denen•ation, thalamotomy, and pallidotomy have been used in the past to treat various forms of dystonia. Although the thalamus has been the primary target for years, more recently many surgeons are targeting the globus pallidus with good results. :Medications such as anticholinergics, muscle relaxants, and benzodiazepines are of limited use to patients. Botulism toxin is a safe and effective therapy for many focal dystonias but has not proven effecti,•e for patients \\•ith segmental dystonia, hemidystonia, or generalized dystonia (Youmans, pp. 2 795-2801 ) .

90

90. Semua prosedur bedah di bawah ini telah dilakukan untuk merawat penyakit neuropsikiatris dan gangguan-gangguan keperilakuan, KECUALI
A. Faskikulotomi arkuate
B. Traktotomi subkaudate
C. Leukotomi limbik
D. Kapsulotomi depan
E. Singulotomi depan

A .
The surgical management o f psychiatric disease can be helpful for select patients \\'ith treatment-refractory major affective disorders. obsessh•e-compulsi,•e disorder, and chronic anxiety states. Surgical inten•entions hm•e included anterior capsulotomy, limbic leukotomY. subcaudate tractotomy, and anterior cingulotomy but not arcuate fasciculotomy (Youmans, pp. 2853-2862 ) .

91

91. Proyeksi kanalis semisirkularis superior ke arah lantai fossa media kranial, yang seringali tampak pada pendekatan subtemporal untuk reseksi Neuroma akustik?
A. Eminens arkuate
B. Timpani tegmen
C. Vestibula
D. Jambul vertikal
E. Prominensi vestibular

A.
The superior semicircular canal projects i nto the tloor of the middle cranial fossa as the arcuate eminence (Tew, pp. 48-49; Wilkins, pp. 1071-1073)

92

Tn. X, 45 tahun menjalani pendekatan Subtemporal untuk reseksi tumor dengan elevasi dura dari lantai fossa media dan tulang Petrosum.

92. Struktur-struktur yang dapat terlihat pada lantai fossa kranial tengah selama paparan tersebut mungkin meliputi hal-hal di bawah ini, KECUALI
A. Arteri meningeal tengah
B. Saraf trigeminal (V3)
C. Saraf petrosal luar halus
D. Saraf hipoglosal
E. Saraf petrosal luar besar

D
Structures often visible on the middle fossa floor during subtemporal approach include the middle meningeal artery (often sacrificed by cautery and packing of the foramen spinosum) , trigeminal nerve (V3), lesser superficial petrosal nerve, greater superficial petrosal nerve, ICA (if there is a small dehiscence in the bone) , as well as the arcuate eminence, which overlies the superior semicircular canal. Decreased tearing after surgery most likely resulted from injury of the greater superficial petrosal nenre, which provides parasympathetic supplv to the lacrimal and nasal gland. Additional exposure to the posterior fossa during a subte"mporal approach may be gained by removing the bone of Kawase's quadrilateral located in the medial petrous apex, medial to Glasscock's triangle . Kawase's quadrilateral is bounded laterally by the greater superficial petrosal nerve, medially by the petrous ridge and V3 of the trigeminal nerve, and at its base by the arcuate eminence. Glasscock's trianglt; is bounded laterally bY a line from the foramen spinosum to the facial hiatus, medially bv the GSPN , and at its base by the mandibular di,•ision of the trigeminal nerve (Tew, pp. 48-49, 385-395) .

93

Tn. X, 45 tahun menjalani pendekatan Subtemporal untuk reseksi tumor dengan elevasi dura dari lantai fossa media dan tulang Petrosum.

93. Pasca-bedah, pasien mengalami penurunan lakrimasi pada sisi ipsilateral. Etiologi manakah yang paling mungkin untuk masalah ini?
A. Cedera saraf petrosal halus
B. Cedera saraf petrosal besar
C. Cedera ganglion genikulate
D. Cedera timpani korda
E. Cedera saraf Jacobson

B
Structures often visible on the middle fossa floor during subtemporal approach include the middle meningeal artery (often sacrificed by cautery and packing of the foramen spinosum) , trigeminal nerve (V3), lesser superficial petrosal nerve, greater superficial petrosal nerve, ICA (if there is a small dehiscence in the bone) , as well as the arcuate eminence, which overlies the superior semicircular canal. Decreased tearing after surgery most likely resulted from injury of the greater superficial petrosal nenre, which provides parasympathetic supplv to the lacrimal and nasal gland. Additional exposure to the posterior fossa during a subte"mporal approach may be gained by removing the bone of Kawase's quadrilateral located in the medial petrous apex, medial to Glasscock's triangle . Kawase's quadrilateral is bounded laterally by the greater superficial petrosal nerve, medially by the petrous ridge and V3 of the trigeminal nerve, and at its base by the arcuate eminence. Glasscock's trianglt; is bounded laterally bY a line from the foramen spinosum to the facial hiatus, medially bv the GSPN , and at its base by the mandibular di,•ision of the trigeminal nerve (Tew, pp. 48-49, 385-395) .

94

Tn. X, 45 tahun menjalani pendekatan Subtemporal untuk reseksi tumor dengan elevasi dura dari lantai fossa media dan tulang Petrosum.

94. Selama bedah, diperlukan paparan tambahan untuk mengakses daerah petroklival atas untuk reseksi tumor. Manuver manakah yang dapat membantu melaksanakan tugas ini?
A. Terus menggali Segitiga Glasscock
B. Paparan tambahan melalui kuadrilateral Kawase
C. Terus melubangi eminensi arkuate
D. Memastikan Segitiga Trautman dan memapar bagian tengahnya ke bidang ini
E. Memodifikasi bedah dengan memanfaatkan koridor pra-sigmoid

B
Structures often visible on the middle fossa floor during subtemporal approach include the middle meningeal artery (often sacrificed by cautery and packing of the foramen spinosum) , trigeminal nerve (V3), lesser superficial petrosal nerve, greater superficial petrosal nerve, ICA (if there is a small dehiscence in the bone) , as well as the arcuate eminence, which overlies the superior semicircular canal. Decreased tearing after surgery most likely resulted from injury of the greater superficial petrosal nenre, which provides parasympathetic supplv to the lacrimal and nasal gland. Additional exposure to the posterior fossa during a subte"mporal approach may be gained by removing the bone of Kawase's quadrilateral located in the medial petrous apex, medial to Glasscock's triangle . Kawase's quadrilateral is bounded laterally by the greater superficial petrosal nerve, medially by the petrous ridge and V3 of the trigeminal nerve, and at its base by the arcuate eminence. Glasscock's trianglt; is bounded laterally bY a line from the foramen spinosum to the facial hiatus, medially bv the GSPN , and at its base by the mandibular di,•ision of the trigeminal nerve (Tew, pp. 48-49, 385-395) .

95

95. Mekanisme penjelasan manakah yang paling mungkin untuk response Cushing?
A. Herniasi tonsil serebelar melalui magnum foramen
B. Distorsi brainstem
C. Gangguan hemisperik besar
D. Hipoksia brainstem
E. Landas fossa belakang

D .
The Cushing response consists o f t h e triad o f hypertension, bradvcardia, and an irregular breathing pattern . According to manv authors, the most likely mechanism accounting for this response is reduction in oxygenation in an area j ust rostral to the medulla. For this reason it is also called the ischemic response ( G reenberg, p . 642 ; Committee on Education in Neurological S u rgery, p p . 58, 155 ) .

96

pic
96. Manifestasi klinis manakah yang paling lazim untuk kelainan yang ditunjukkan pada angiogram di bawah ini :

A. Serak
B. Dispagia
C. Atropi lidah sepihak
D. Palpasi massa leher
E. Hipertensi

D
The most common clinical presentation o f carotid body tumors is a palpable neck mass in the high cervical region. Less commonly patients present with hoarseness, dvsphagia, and unilateral tongue atrophy and weakness due to the tumors' proximity to the vagus and hypoglossal nerves. These tumors are generally benign, although they do tend to locally invade adjacent tissue , which can make their resection difficult. An evaluation of the endocrine system may be warranted, especially in patients with hypertension and tachycardia. Some patients may harbor a pheochromocytomalike lesion that secretes excess catecholamines. In such patients, a-adrenergic blockade must be started about 2 weeks preoperatively to control hypertension, tachycardia, and the potential for arrhythmia. Preoperative planning is critical in these patients to reduce comorbidity. Some may require preoperative embolization to reduce the amount of bleeding during surgery (Youmans, pp. 1677 -1681) . 98. D. Multiple subpial transection (lvlST) was developed as a procedure to address seizure activity that extends beyond the area of resection and into eloquent cortex. The cerebral cortex has functional vertical columns, with i ts vertical orientation of incoming and outgoing fibers. Seizures, however, arc believed to spread horizontally through the cortex. MST involves disconnecting the vertical columns of the cerebral cortex, which inhibits synchronization and spread of theseizure focus with minimal injury to the cortex. The most common problem faced by patients after this procedure includes subtle, transient deficits corresponding to the area of resection that typically improve. Permanent complication rates after this procedure are in the order of 5% (Youmans, pp. 2635-2642) .

97

pic
97. Para ahli klinis seharusnya waspada akan komorbiditas endokrin yang mana dalam menilai pasien dengan tumor ini?
A. Diabetes insipidus
B. Peokromositoma
C. Hiperprolaktinemia
D. Penilketonuria
E. A, B, C dan D, salah

B
The most common clinical presentation o f carotid body tumors is a palpable neck mass in the high cervical region. Less commonly patients present with hoarseness, dvsphagia, and unilateral tongue atrophy and weakness due to the tumors' proximity to the vagus and hypoglossal nerves. These tumors are generally benign, although they do tend to locally invade adjacent tissue , which can make their resection difficult. An evaluation of the endocrine system may be warranted, especially in patients with hypertension and tachycardia. Some patients may harbor a pheochromocytomalike lesion that secretes excess catecholamines. In such patients, a-adrenergic blockade must be started about 2 weeks preoperatively to control hypertension, tachycardia, and the potential for arrhythmia. Preoperative planning is critical in these patients to reduce comorbidity. Some may require preoperative embolization to reduce the amount of bleeding during surgery (Youmans, pp. 1677 -1681) . 98. D. Multiple subpial transection (lvlST) was developed as a procedure to address seizure activity that extends beyond the area of resection and into eloquent cortex. The cerebral cortex has functional vertical columns, with i ts vertical orientation of incoming and outgoing fibers. Seizures, however, arc believed to spread horizontally through the cortex. MST involves disconnecting the vertical columns of the cerebral cortex, which inhibits synchronization and spread of theseizure focus with minimal injury to the cortex. The most common problem faced by patients after this procedure includes subtle, transient deficits corresponding to the area of resection that typically improve. Permanent complication rates after this procedure are in the order of 5% (Youmans, pp. 2635-2642) .

98

98. Tn X., 45 tahun memiliki riwayat panjang epilepsi dari foci kejang yang berawal dari korteks pra-motorik kanan dan menjalar ke dalam korteks motorik di sekitarnya. Kejang-kejangnya tetap refraktoris kepada berbagai obat antiepilepsi, dan pasien telah dirujuk kepada akhli bedah saraf untuk membahas mengenai pilihan-pilihan pembedahan. Catatan hasil EEG mengungkapkan fokus kejang pada daerah pra-motorik yang menjalar ke korteks motorik di sekitarnya. prosedur-prosedur pembedahan manakah di antara prosedur-prosedur di bawah ini yang dapat dilaksanakan secara berbarengan selama lesionektomi untuk menghindari cedera berat atas korteks motorik dan membantu mengendalikan kejang-kejang pada pasien?
A. Topektomi
B. Lesionektomi terbatas
C. Stimulasi korteks motorik
D. Transeksi subpial multiple
E. Stimulasi saraf vagal

C.
The most common surgical complication after vagal nerve stimulator (VNS) placement is infection. Transient vocal cord paralysis with hoarseness and swallowing problems is the second most common surgical complication of VNS. Temporary lower face numbness and weakness occur in about 0. 7% of patients, likely related to high cervical incisions and superficial nerve injury (Youmans, pp. 2649-2650) .

99

99. Manakah yang merupakan komplikasi yang secara neurologi paling berkaitan setelah penempatan stimulator saraf vagal?
A. Mati rasa pada wajah
B. Bradikardia
C. Disponia
D. Hipotensi
E. Aritmia dengan durasi pendek

C.
The most common surgical complication after vagal nerve stimulator (VNS) placement is infection. Transient vocal cord paralysis with hoarseness and swallowing problems is the second most common surgical complication of VNS. Temporary lower face numbness and weakness occur in about 0. 7% of patients, likely related to high cervical incisions and superficial nerve injury (Youmans, pp. 2649-2650) .

100

100. Di antara pernyataan-pernyataan mengenai stabilisasi tulang lumbal dengan fiksasi segmental memakai pedicel screw di bawah ini, pernyataan manakah yang paling benar?
A. Stabilitas lateral akan banyak meningkat jika
sudut sekrup pedikel adalah 300 atau lebih
B. Penggunaan transfiksasi akan meningkatkan stabilitas beban putar tapi bukan beban
mendatar dari konstruk tersebut.
C. Tanpa adanya transfiksator, kolom vertebral akan stabil pada beban datar.
D. Bukan salah satu jawaban di atas
E. Jawaban A, B, dan C.

A.
The internal stabilization of two adjacent segments of the lumbar spine with a pedicle screw construct having a pedicle-to-pedicle screw angle of zero and no transfixitor is not stable in lateral or rotational load, as each of the screws are free to turn in their screw holes in the body. Stability can be enhanced by the application of a transfixitor or angling the screws inward to form a pedicle-to-pedicle screw angle of 30 degrees (Carson, pp. 893- 901; Committee on Education i n Neurological Surgery, p p . 36, 128).