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Neurosurgery Flashcards

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1
Q

mild concussion is loc for:

A

30 sec to 5 min
less than 24 hours
gcs of 13-15
ct neg

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2
Q

moderate concussion:

A

6hours or less of loc
7 days or less of amnesia
9-12 on gcs scale
neg or mostly neg on ct

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3
Q

clinical exam is combined with ct if you have:

A 
CT brain if LOC and:
GCS <15
Seizure
Focal neurologic deficit
Alteration in memory
Worsening headache
Vomiting (repeated vomiting in kids)
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4
Q

after possible concussion you can return to playing contact sports when:

A

symptom free for 7 days, problem is that this is very broad: need baseline neuro cognitive testing, step wise working them back up for 7 days

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5
Q

post concussive symptoms:

A

Physical
HA, N/V, dizziness, fatigue, blurred vision, sleep disturbance, loss of appetite, sensitivity to light/noise, balance problems

Cognitive
Impaired attention, concentration, memory, speed of processing, judgment, executive function

Behavioral/emotional
Depression, anxiety, agitation, irritability, impulsivity, aggression

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6
Q 
6 y/o boy fell out of shopping cart
2 minute LOC
No amnesia
Vomited on scene
Complaining of mild headache
Large tender bump in right parietal 
Normal neurologic exam
A

Alert and oriented

Confusion

Agitation FIRST SIGN OF ICP

Lethargy: you can arouse them with voice where as stupor you have to pinch them, etc

Stupor: responsive to vigorous stimulation

Coma: Unarousable to physical stimuli

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7
Q

gcs may not be 100% accurate if :

A

bp is less than 90 (fully recussitated) ox sat at 90%

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8
Q

most important cn to test:

A

2, 3 (extra occular motion) most important pupillary constriction (blown nerve if 3 is out)
6 bc it has the longest course so you can test for hydrocephalus
facial droop: 7,

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9
Q

if you have a _____ you have the ____ of the brain pushing _____ into the _____ and it impinges on the ______

A

subdural hematoma, uncus, down, foramen, cn 3

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10
Q

with subdural hematoma, the brain is pressed down and the midbrain on ct will show ____ because the _______

A

hemorrage of the small vessels off the basilar as they rip off:
Duret haemorrhages are small lineal areas of bleeding in the midbrain and upper pons of the brainstem. They are caused by a traumatic downward displacement of the brainstem.[1]

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11
Q

Bilaterally fixed and dilated

A

Death; hypovolemic shock; drugs (atropine, ecstasy)

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12
Q

Unilaterally fixed and dilated

A

Head injury; stroke

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13
Q

Bilateral pinpoint constriction

A

Opiate overdose

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14
Q

Bilateral constriction

A

Brain stem stroke

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15
Q

Irregular pupil

A

Trauma; previous eye surgery: cateract surgery will give you an irregular pupil

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16
Q

motor exam:

A

0- No muscle activity
1- Muscular contraction without limb movement
2- Can move the limb with gravity eliminated
3- Can move limb against gravity
4- Can move limb against resistance
5- Full strength

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17
Q

note: if a pt has just had an l3 surgery and you ask them to move their iliopsoas:

A

they might not be able to, you may have to hold their leg and let them do the rest

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18
Q

imparied loc on motor exam: if they’ve broken all their extremities and you ask them to move something and they do:

A

they get a 6 because they’ve done everything they can and followed directions

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19
Q

testing with noxious stimuli to check impared loc: testing peripheral is usually done by pushing with a pen on their big toe and having them withdrawl is:

A

triple flexion resonse, and this is just pulling your leg away, NOT A GOOD MOTOR RESPONSE for a test: better to test central!

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20
Q

testing central:

A

pushing on supra orbital, squeezing trapezeus, sternal rub, etc

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21
Q

what is localization for a central noxious stimuli test?

A

I recognize there is a noxious stimuli here and I’m going to try to do something about it

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22
Q

*diff between localization and withdrawl:
if you push above nipple line and patient moves up past nipple line, it is__ if they cannot get past nipple line it is considered_____

A

localization, withdrawl

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23
Q

decortication you have taken away ____ but still have _____

A

cortex input, basil ganglia input, any separation above red nucleus

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24
Q

decerebrate:

A

you have taken the whole brain away

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25
*patients don't have strength to really posture so you have to put their hands on their hips: if they come up and _____ it is decorticate, if ____ decerebrate
flex wrist, bend elbow, straight wrist and lock elbow extended
26
signs of herniation:
bp spikes into 200s (hypothalamus triggers increased heart contractility) Bradycardia: hr drops (baroreceptors register increased sbp) apneusis/neurogenic breathing (loss of vagal and pneumotaxic center stimulation)
27
ICP and CPP
``` Normal ICP <15mmHg High >20mmHg sustained for >10min CPP=MAP-ICP (normal is 70-100 mmHg) CPP of 70 is needed to provide adequate blood supply to brain ```
28
first sign of increased ICP?
agitation (20-25 mmHg)
29
agitation____ lethargy _____ coma_____
20-25, 25-30, 40s
30
decrease icp?
``` Positioning Hyperventilation Hypertonic therapy (steroids not useful except in tumor swelling) CSF drainage Decrease brain metabolism Surgical decompression ```
31
locations of hemmorhage:
``` subgaleal epidural subdural subarachnoic intracerebral intraventricular ```
32
SUBGALEAL HEMATOMA
``` DDX: Caput succedaneum Potential complications Anemia/shock due to small circulating volume in infants Potential calcification- cosmesis Management: goes away on its own Nonoperative Cosmesis concerns usually resolve Monitor CBC ```
33
``` 54 y/o man hit a tree while skiing Transient loss of consciousness Amnestic Worsening headache Normal neurologic exam what is it's a 1 inch lens? what about huge lens? ```
watch for 3-4 hr intervals if only 1 inch, if huge, operate asap, they end up fine
34
epidural hematoma:
Etiology Skull fracture with laceration of middle meningeal artery Skull fracture with dural venous sinus laceration High suspicion for early imaging Lucent period prior to deterioration Without associated injuries, 100% good outcome with prompt care Any mortality is a system failure or delay in care True neurosurgical emergency
35
``` 65 y/o male who fell backward off the back of a golf cart while drinking On ASA for CAD PE: Confused and combative, yelling Opens eyes to voice Follows commands all extremities what about his GCS? ```
opens eyes to voice: 3 confused: 4 follows commands all extremities: 6
36
how do sub dural surgeries turn out?
not nearly as well, ripped off bridging veins, confusion
37
in ____ the dura peels off of the skull and in _____ the dura is stuck to the skull
epidural hematoma, subdural hematoma
38
subdural hematoma:
Associated with underlying brain injury Worse prognosis If asymptomatic, may watch if <1cm in diameter Treatment Acute- Hyperintense- craniotomy Subacute- Isointense- bur holes Chronic- Hypointense- SEPS (twist drill/suction)
39
``` 83 y/o man s/p drug eluting coronary stent On Plavix and ASA Tripped in the driveway 4 weeks ago (No LOC) Now with HA and difficulty walking PE: Awake with mild STM deficit PERRLA, EOMI 5/5 all extremities, left drift what do they have? ```
chronic or sub acute subdural which is common with people on BLOOD THINNER MEDS and OLD (rip bridging veins and it'll build up)
40
on ct acute blood looks ____ while chronic blood looks _____
white, dark subacute in the middle looks gray
41
24 y/o male fell off bike Seizure at the scene Normal neurologic exam on arrival
subarachnoid space (fills up all the sulci and gyri- esecially on the sides)
42
``` 45 y/o male pedestrian hit by car +LOC PE: PERRLA Moaning No eye opening Withdrawing ```
contusion: coup and contracoup especially frontal lobe, and sections across from each other, anterior fossa and middle fossa have lots of little ridges
43
contusions
``` Parenchymal damage from the bony ridges at base of the skull Associated with edema Worse prognosis Potential for “blossoming” Repeat CT within 4-6 hours ```
44
of the herniation types: ____ is not as bad, and ____ is BAD
Subfalcine- not that dangerous Transtentorial Foramen magnum patient dies Risk with GCS <8 Place ICP monitor
45
treatment of ICP
Elevate head of bed to 30 degrees Maintain head and neck in straight alignment Prevent compression of jugular veins by circumferential ETT tape, trach ties or cervical collar Minimize ETT suction and gagging
46
*Hyperventilation
Mechanism: CO2 is a vasodialator, so when you blow off co2, it causes vasoconstriction this causes decrease the blood volume of the brain *Maintain CO2 30-35 for <24 hrs to prevent ischemia Never drop CO2 below 30
47
ideally the CO2 level can be kept approximately around:
30-35
48
*what is normal na level?
140 | you would want to get it up to 150-155
49
why is it a challenge to get young people to increase their na level to 150s?
kidneys are still working well and ridding body of na
50
never increase the na concentration too fast bc:
chance of central pontine myelinolisis (common in patients who are hyponeutremic and/or alcoholics)
51
hyponeutrimic alcoholics never get icp bc:
atrophy
52
it can be necessary to ____ in healthy people, but:
increase na rapidly; hypotonic fluid (1/2ns or d5w) it is easy to accidentally kill them
53
you want to avoid _____ because when _____ it ______
dextrose, it is in fluids, decrases glutamate production (it can be neurotoxic)
54
to decrease cerebral metabolic rate, you want to:
Sedation (propofol or precedex for continual neuro assessment) Paralytics Barbituate coma Control Seizures, Fever, Restlessness, Pain Normothermia this is to fix icp
55
with _____ no one will be completely normal afterwards:
DAI
56
with DAI, you have :
Deceleration injury- usually high speed MVA Shear-strain forces on the axons during rotation/deceleration of head rips the blood supply at the base of the skull Poor prognosis 35% of all TBI deaths Most common cause of coma and severe disability ct has all microhemorrhages
57
Skull Fractures include:
Linear: do nothing! Depressed- Surgical elevation if cortical compression or cosmetic deformity Open– Surgical Debridement have to be careful of osetomyelitis Frontal Sinus- Surgery if through inner and outer tables with pneumocephalus Skull Base Temporal Bone- CN7 palsy Carotid Canal- Vascular Injury CSF Leak
58
if your kid is hit in the head and you don't want to go to ed?
check on them for 4 hours
59
tbi outcomes:
EDH: 5-43% mortality depending on location, age, pupils, ICP, LOC Acute SDH Mortality: 20% <40 yrs, 65% over 40 yrs Timing of operation: 60% lower mortality if OR within 4 hours DAI: 51% mortality rate, 14% severely disabled, 8% vegetative, 26% good recovery GSW– 70 % die at scene, 25% favorable outcome (GCS 13-15)
60
58 yo woman Lifelong smoker, HTN, DM Sudden onset of right sided weakness and word finding difficulty it is a central white spot by thalamus so it is: what do you do?
hemorrhage, central, so hypertensive hemorrhage most found with people that have HTN monitor to see if patient changes and becomes more lathargic if less than 30 cc, no way to operate
61
location is important in considering surgery because:
if you are lateral to internal capsule, should be fine if medial to internal capsule, the patient will remain hemipalegic in this case you would insert a catheter, use tpa and let the clot dissolve and drip out
62
*Why is a cerebellar hematoma different than any other type of hematoma?
if you take out a cerebellar hematoma, your patient will be fine, maybe will have ataxia but that will improve with time, and most important is that the mass effect will press on the brainstem and kill you
63
cerebellar hemorrhage also will kill you bc:
mass effect wiil push on brainstem area and eventually close off 4th ventrical and cause a hydrocephalus
64
*cerebellar hemorrhage: 1st thing to go: then: bc:
potential space, causes hydrocephalus patient gets aggitated they start hyperventillating to blow off co2
65
*cerebellar hemorrhage is also dangerous because it pushes and closes off 4th ventrical and at the base of the 4th ventrical is:
6 and 7, so patient first gets aggitated and then develops a 6th and 7th nerve palsey simultaneously, usually on 1 side, and at that point you have 30 min to get to or
66
*why are temporal hemorrhages dangerous?
they cause uncal herniation, so there is no rise in icp, no lethargy, no change or decline in patient, just fine then dead
67
``` 43 y/o woman Sudden onset of severe headache during intercourse last night PMH: Smoker, HTN FH: Mother died of “stroke” PE: Drowsy but arousable PERRLA 5/5 strength, no drift right around basal ganglia and circle of willis star of death ```
aneurysmal subarrachnoid hemorrhage= star of death | traumatic subarrachnoid hemorrhage: slightly detectable blood on side of brain
68
*cereberal aneurysms
``` Prevalence – 5% Ruptured: Unruptured Ratio 1:1 SAH Morbidity/Mortality 33% functional 33% dependent 33% mortality when small, very little chance of rupture, larger=more likely ```
69
arterial bp____ venous bp ____
120-80, 0-5
70
aneurysm management:
``` Prevent rerupture Surgical clipping Endovascular coiling/remodeling Observation Manage complications Hydrocephalus Vasospasm ```
71
avm:
Arteriovenous shunts without intervening capillary bed Congenital Risk of hemorrhage: 2- 4%/year – 25% morbidity and mortality after hemorrhage ``` Increased Risk Flow related aneurysm: 10-15% Intranidal aneurysm: 50% Venous outflow obstruction/stenosis Vascular steal ```
72
what do you do with avm?
``` Surgery Grade 1-2: 2% complication rate Immediate results Embolization Cure is rare, only 10-15% Radiosurgery 80% occluded at 3 years ```
73
every 30 min that passes with no blood flow to the brain you have ____
10% less chance of having a functional outcome
74
back pain, we get concerned with?
``` Weakness Radicular numbness/pain Bowel or Bladder changes Urinary retention, NOT incontinence Saddle anesthesia/erectile dysfunction Rectal exam- Volitional tone Severe, localized midline pain Night time pain (tumor ```
75
severe localized midline pain that gets worse at night, can be made better with aspirin, sit up in a chair:
tumor
76
dermatomes:
t1 medial arm (from armpit) | l3 inner thigh, l4 inner calf, l5 outer calf
77
dermatome testing:
``` C5 Deltoid C6 Biceps is a waste of time, just check Wrist extension C7 Triceps C8 IO don't test grip, it's a waste of time L3 Iliopsoas L4 Quadriceps, patellar reflex L5 EHL S1 Plantar flexion, achilles ```
78
disk dessication is ____ and is characerized by:
arthritis: Loss of water in the disks Loss of disk height disk bulge
79
*disk bulge is caused by:
Loss of water leads to bulging against the annulus TEARING ANNuLUS HURTS! Car tire analogy Rarely surgical the water is now in the bone and shows white on t2 image disk not doing its job so you go to physical therapy
80
treatment for disk herniation:
Good explanation of the musculoskeletal basis of their disease, what to expect, and how to control it Paraspinal muscle conditioning Physical therapy Daily home exercise, Pilates, Water aerobics, Water therapy, Biofeedback NSAIDs Smoking Cessation Weight loss
81
disk herniation has to correspond to the _____ or else :
dermatome location, surgery won't help If active participation in conservative measures for 6-12 weeks fail, then consider surgical intervention ``` Interventional Pain Decompression Fusion Disk replacement Spinal cord stimulation ```
82
the explanation of arthritis spinal pain includes:
there are 4 columns of muscles around the spine and if they stop doing their job and atrophy and start spasming, then it hurts like crazy, it's more muscle problem from muscles spasing
83
surgical treatment for spinal surgery disk herniation procedures
If active participation in conservative measures for 6-12 weeks fail, then consider surgical intervention ``` Interventional Pain Decompression Fusion Disk replacement Spinal cord stimulation ```
84
*Lumbar stenosis neurogenic claudication presents as: vascular claudication presents in: how to tell the difference?
crampy end organ pain associated with stenosis the feet in neurogenic claudication, leaning forward will open up the pinched area and relieve pain, vascular it won't help not associated with incontinence, bowel problems
85
a problem associated with osteoperosis:
``` compression fractures Treat conservatively if <50% height loss, <11 degrees of angulation Semi-rigid brace Analgesia Begin PT at 6 wks Consider Kyphoplasty/Vertebroplasty at 6 wks if still with unresponsive pain ```
86
*cervical stenosis:
``` Same progression as lumbar, with bigger neurologic consequences Myelopathy Hyperreflexia Proprioceptive loss Wide based gait +Hoffmans/Babinskiif ```
87
if problem coming from lumbar to nerve roots, you will be: | from spinal cord:
hyporeflexic | hyperreflexic
88
hoffmans sign:
is a finding elicited by a reflex test which verifies the presence or absence of problems in the corticospinal tract if thumb flicks IN, not normal
89
what are you testing with romberg?
vision, vestibular, proprioception | vestibular there to keep you balanced, vision is there in case vestibular is not working,
90
important things to ask about for stenosis:
bladder retention in women, ed in men

jK NEURO (35 decks)

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