Neurosurgery

Question 1

Epidural Hematoma

Answer 1

Path: Usually fracture tearing middle meningeal artery

Symptoms: Trauma resulting in LOC, lucid interval, then deterioration and death

Diagnosis: Noncontrast CT head with biconcave hematoma

Management: Craniotomy or even craniectomy

Complications:

Specialist and role: Neurosurgery

Question 2

Subdural Hematoma

Answer 2

Path: Tearing of bridging veins. Usually after a fall that gradually worsens

Symptoms: Focal neuro deficit or AMS

Diagnosis: Noncontrast CT head with crescent hematoma. Acute is lighter than parenchyma, chronic is darker, subacute is same

Management: Burr holes? Craniotomy may be necessary but often not needed, reverse anticoagulation

Complications:

Specialist and role: Neurosurgery

Question 3

Aneurysmal Subarachnoid Hemorrhage

Answer 3

Path: Aneurysmal involves circle of willis from atherosclerosis/HTN. Happens and seals off. Can happen in ehler danlos and ADPKD. Trauma involves focal trauma site

Symptoms: Thunderclap headache very quickly, meningitis like sx

Diagnosis: Noncontrast CT head if Ottawa SAH criteria suggest headache concerning for SAH. Will be blood in sulci and basal cistern. If CT head is negative and still concern, can get LP if it has been 6 hours looking for xanthochromia and bilirubin. If CT head is positive get CTA looking for aneurysm

Management: Endovascular angiogram with coil or craniectomy and clipping. Systolic BP < 140 using non nitrate IV medications. Anticoagulation reversal. Nimodipine within 48h. If seizures treat seizures but not prophlacticlaly. Maintain euglycemic, euvolemic, euthermic

Complications: Rebleeding, delayed cerebral ischemia from vasospasm up to 6 weeks, seizures, obstructive hydrocephalus

Specialist and role: Neurosurgery

Question 4

Cerebral contusion

Answer 4

Path: Rapid deceleration results in small intraparenchymal hematomas from brain contact with skull. It’s like a concussion with a positive CT

Symptoms: LOC

Diagnosis: CT non contrast will show small intraparenchymal hematomas (punctate hematomas) anterior or posteriorly with surrounding vasogenic edema

Management: Do not require craniectomy unless expanding. Can increase in size after craniectomy

Complications:

Specialist and role: Neurosurgery

Question 5

Intraparenchymal hematoma

Answer 5

Path: Involves lenticulostriate arteries that feed basal ganglia and internal capsule

Symptoms: Motor and Sensory deficits like ischemic stroke

Diagnosis: Noncontrast CT head. Cerebral perfusion pressure = MAP - intracranial pressure

Management: Surgery if herniation or cerebellar involvement > 3cm. Systolic < 160 with titratable antihypertensive, not nitrates. Elevate head to control bleeding. q1h neuro checks. Reverse anticoagulation. Pharmacologic DVT PPX 24h after hematoma is stable

Complications: Herniation

Specialist and role: Neurosurgery

Question 6

Hydrocephalus

Answer 6

Path:

Symptoms: Wet, wobbly, wacky

Diagnosis: Test of choice is MRI

Management: Lumbar tap test to see if VP shunt will help, if so, VP shunt

Complications:

Specialist and role: Neurosurgery

Question 7

Intraventricular hemorrhage

Answer 7

Path: Usually after a intraparenchymal hemorrhage or SAH

Symptoms:

Diagnosis: CT head shows blood in ventricles

Management: Extraventricular drain

Complications:

Specialist and role: Neurosurgery

Question 8

Brain cancer

Answer 8

Path: Majority metastatic, some primary

Symptoms: Focal neurologic deficit, seizure, headaches, nausea, vomiting

Diagnosis: MRI preferred over CT, followed by biopsy

Management: Resection, radiation, and/or chemo. Seizure ppx and steroids

Complications:

Specialist and role: Neurosurgery

Question 9

Pituitary tumors

Answer 9

Path: Usually prolactinoma, acromegaly, and craniopharyngioma

Symptoms:

Diagnosis: Pregnancy test, TSH, prolactin, CT/MRI head

Management: Dopamine for prolactinomas, sometimes resection required

Complications:

Specialist and role:

Question 10

Meningioma

Answer 10

Path:

Symptoms: Focal deficits at site of compression

Diagnosis: Imaging shows cancer on dura mater

Management: Resection

Complications:

Specialist and role:

Question 11

Gliblastoma Multiforme

Answer 11

Path:

Symptoms:

Diagnosis: Intraparenchymal. Ring enhancing lesion/bat’s wing

Management:

Complications:

Specialist and role:

Question 12

Astrocytoma

Answer 12

Less dismal gliblastoma

Question 13

Schwannoma

Answer 13

Path:

Symptoms: N, V, hearing loss, vertigo, tinnitus

Diagnosis:

Management: Resection

Complications:

Specialist and role:

Question 14

Vertebral compression fracture

Answer 14

Path:

Symptoms:

Diagnosis:

Management: Pain control or vertebral augmentation with vertebroplasty or kyphoplasty if severe

Complications:

Specialist and role:

Question 15

Spinal tumors

Answer 15

Path:

Symptoms:

Diagnosis:

Management:

Complications:

Specialist and role:

Question 16

Spinal stenosis

Answer 16

Path: Occurs from degenerative spondylosis

Symptoms: Bilateral sensory loss, weakness, or pain

Diagnosis:

Management: Pain control, physical therapy, and laminectomy if disabling

Complications:

Specialist and role:

Question 17

Herniated Disc

Answer 17

Path:

Symptoms: Radicular pain

Diagnosis:

Management: Discectomy/microdiscectomy

Complications:

Specialist and role:

Question 18

Spondylosis/Degenerative arthritis of spine

Answer 18

Path:

Symptoms:

Diagnosis:

Management: Lumbar fusion

Complications:

Specialist and role:

Question 19

Degenerative disc disease

Answer 19

Path:

Symptoms:

Diagnosis:

Management: Disc replacement, fusion

Complications:

Specialist and role: