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Flashcards in Neurosurgery Deck (16):
1

a severely traumatized woman is seen it he ER with decreased mental status. prior to intubation, she does not open her eyes, withdraws with all of her extremities, and makes incomprehensible sounds. what is her glasgow coma scale score
a. 3
b. 4
c. 5
d. 6
e. 7

E. 7

1 - no opening of eyes
2 - incomprehensible sounds
4 - withdrawing

13-15 = mild TBI
9-12 = moderate TBI
<8 = severe TBI

2

25yo unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head CT scan. he is agitated but hemodynamically stable, with a HR of 80 and MAP of 90. an ICP monitor is placed, and the initial ICP reading is 30mmHg. which of the following is the most appropriate management of his TBI over the next few days
a. hyperventilation, to maintain a cerebral PCO2 of 25-30mmHg
b. administration of neosynephrine to increase his MAP and consequently his cerebral perfusion pressure.
c. administration of mannitol (1g/kg) to reduce his ICP
d. placement of the pt in Trendelenburg position to increase cerebral perfusion
e. avoidance of all sedating drugs in the first 24-48h in order to accurately assess his neurologic status

C. increased ICP

Tx
1) hyperventilation [within first 24-48h] and mannitol = improve blood flow
2)elevation of bed (revere trendelenberg)
3) sedative to decrease pt agitation
4) fluid restriction / hypertonic saline

Want cerebral perfusion pressure > 70mmHg
ICP <20mmHg

3

50yo woman complains of HA and lateralizing weakness. A CT scan of the brain reveals an irregular mass in the R cerebral hemisphere. a biopsy documents that this is a glioblastoma. which of the following is the best treatment strategy for potential cure?
a. chemotherapy with temozolomide alone.
a. combination chemo with carmustin, cisplatin, ahd temozolomide
c external beam radiation alone
d. surgical resection alone
e. combo surgical resection, external beam radiation, and chemo with temozolomide

E. Glioblastoma = irregular lesion w/ hypodense central necrosis; pierpheral ring enhancement of highly cellular tumor tissue; surrounding edema & mass effect

glioblastoma doesn't have much treatment = do everything.

median survival = 1y

4

60o otherwise healthy woman presents to her physician with a 3w hx of severe HA. a contrast CT reveals a small, circular, hypodense lesion with ringlike contrast enhancement. which of the following is the most likely diagnosis?
a. brain abscess
b. high grade astrocytoma
c. parenchymal hemorrhage
d. metastatic lesion
e. toxoplasmosis

D. metastatic brain tumors are MORE common v. primary braintumors.

single enhancing ring = CNS lymphoma
multiple enhancing rings = toxo

she is young, healthy = likely some sort of cancer.

5

16yo adolescent boy sustains head trauma in a MVC. he has a GCS of 15 and an obvious depressed skull fracture with 1cm displacement. during his hospital stay, he notices clear fluid draining from his nose. what is the best management strategy for this pt?
a. immediate surgical elevation of the skull fracture
b. delayed surgical elevation of the skull fracture
c. immediate dural repair
d. elevation of the head & placement of a lumbar drain
e. antibiotic therapy for sinusitis.

C

leaking CSF d/t depressed skull fracture

1) coul wait to see if it dissipates
2) persistent CSF leak for >14d [likely d/t depressed / compound fractures] ==> surgical repair of torn dura
3) depressed skull fracture >1cm, fragment over motor strip, or with small, shart fragment ==> surgical elevation
4) open fracture ==> I&D, wound closed.

6

39yo man presents to his physician with the complaint of loss of peripheral vision. which of the following findings are demonstrated by the subsequent MRI scan, showing showing a mass at the optic chiasm - "saddle" (turnica sella) where the pituitary should be .
a. cerebral atrophy
b. pituitary adenoma
c. optic glioma
d. pontine hemorrhage
e. multiple sclerosis plaque

B

7

an 18yo man is admitted to the ER following a motorcycle accident. he is alert and fully oriented but witnesses to the accident report an interval of unresponsiveness following the injury. skull films disclose a fracture of the L temporal bone. following xray the pt suddenly loses consciousness and dilation of the L pupil is noted. Which of the following is the most likely diagnosis?
a. a ruptured berry anerysm
b. an acute subdural hematoma
c. an epidural hematoma
d. an intra-abdominal hemorrhage
e. a ruptured arteriovenous malformation

C

likely epidural hematoma - was looking fine, but did have LOC

herniation

8

42yo woman presents to the ER with the worst HA of her life. a noncontrast CT scan of the head is negative for lesions or hemorrhage. she then undergoes a lumbar procedure, which appears bloody. all 4 tubes collected have RBC count > 100,00. which of the following steps is the most appropriate management of this pt?
a. repeat the head CT with IV conttrast
b. perform an angiogram of the aorta and lumbar branches for immediate embolization of the injured of the injured vessel
c. perform a 4 vessel cerebral angiogram
d. administer a dose of mannitol
e. consult neurosurgery for immediate ventriculostomy

C

bleeding into spinal cord
subarachnoid hemorrhage

CT scan without contrast for hemorrhage --> will show a localized clot / diffusely distributed hemorrrhage, intraventricular hemorrhage, or intraparencymal hemorrahge

1) CT without contrast
2) lumbar puncture
3) 4-vessel angiogram --> to assess for cerebral aneurysm
4) 2nd 4-vessel angiogram within first 7-10 days

tx (aneurysm)
1) counteract vasospasm
2) BP control
3) anticonvulsant therapy
4) craniotomy with clipping of aneurysm

9

a trauma pt with a closed-head injury is being monitored in the neurosurgical ICU. his ICP measurement is seen to rise precipitously. an acute increase in ICP is characterized by which of the following clinical findings
a. respiratory irregularities
b. decreased BP
c. tachycardia
d. papilledema
e. compression of 5th cranial nerve

A

symptom of increased ICP
1) irregular respirations (hypoperfusion of brainstem), bradycardia, HTN (decreased cerebral hypoperfusion)
2) herniation / compression of brainstem - CN3 [chronic increases in ICP]

10

24yo pt with known neurofibromatosis type 2 undergoes an MRI for ringing in his ears. the MRI demonstrates lesions in b/l auditory canals. which of the following is the most likely diagnosis?
a. gangioneuroma
b. schwannoma
c. ependymoma
d. meningioma
e. pituitary adenoma

B

NF2 = vestibular schwanomma, meningioma, ependymoma

tx
= surgical excision of benign schwanomma
= surgery + radiation for malignant schwannoma

sxs = hearing loss, tinnitus, vertigo

11

18yo high school senior develops peripheral vision abnormalities. CT scan of the brain reveals a cystic suprasellar mass with some calcification noted. clinically this is compatible with a craniopharyngioma. what is the best next step in treatment?
a. growth hormone therapy
b. cerebral angiography with tumor embolization
e. transsphenoidal decompression of the optic nerve and optic chiasm
d. surgical resection
e. radiotherapy

D. complete subfrontal / transsphenoidal excision
OR
partial resection + adjuvant radiotherapy

craniopharyngioma = common cancer in children (in optic chiasm)

12

following significant head trauma, a 34yo woman undergoes a CT scan that dmeonstrates b/l frontal lobe contusions of the brain. there is no midline shift. she has a GCS of 14. which of teh following is the best initial management of this pt?
a. observation alone
b. observation and administration fo anticonvulsive meds for 1w
c. placement of an ICP monitor
d. administration of 25g of mannnitol
e. intubation and hyperventilation

B. substantial cranial contusion

tx = observation + q4 neuro checks + mannitol to decrease ICP (for CONTUSION)

13

45yo woman presents with L sided weakness. CT scan of the head demonstrates a well-circumscribed mass abutting the skull in the R hemishpere. workup of the mass reveals a meningioma. which of the following is the best next step in treatment?
a. cerebral angiography with tumor embolization
b. preoperative radiation therapy followed by surgical excision
c. surgical excision
d. chemotherapy with adriamycin
e. chemoradiation

C

meningioma = slow growwing, mostly benign

tx
- complete surgical excision
- partial surgical excision + adjuvant radiation therapy

14

middle-aged homeless man is brought to the ED by EMS for altered mental status, seizures, and vomiting. on exam, he has no fever, neck stiffness or evidence of head trauma. he does, however, have multiple dental caries and focal neurologic deficit. which of the following is the best next step in the pt's workup?
a. lumbar puncture
b. noncontrast head CT
c. contrast-enhanced head CT
d. placement of ICP monitor
e. placement of ventriculoperitoneal shunt

C

mass effect - possible abscess in the brain

dx = CT with contrast to help it light up + surrounding edema

tx = Abx + aspiration or abscess
OR
surgery

15

select the type of vascular event with which it is most likely to be associated.
a. subdural hematoma
b. epidural hematoma
c. carotid dissection
d. brain contusion
e. ruptured intracranial aneurysm
while watching a golf tournament, a 37yo man is struck on the side of the head by a golf ball. he is conscious and talkative after the injury, but several days later he is noted to be increasingly lethargic, somewhat confused, and unable to move his R side.

A

(minor head injury)slow bleed --> due to tears in the bridging veins from cerebral cortex to dura / venous sinuses

CT non contrast --> crescent shaped + mass effect

tx = drainage through burr hole

16

select the type of vascular event with which it is most likely to be associated.
a. subdural hematoma
b. epidural hematoma
c. carotid dissection
d. brain contusion
e. ruptured intracranial aneurysm
42yo woman complains of the sudden onset of a severe HA, stiff neck, and photophobia. she loses consciousness. she is later noted to have a dilated pupil.

E

subarachnoid hemorrhage (SAH) --> due to ruptured intracranial aneurysm [@ bifurcation of circle of Willis], AVM

sxs
- sudden onset of excruciating HA
- stiff neck, photophobia [~meningitis]
- LOC or coma

dx
1) CT --> blood in ventricles at base of brain & around brainstem
2) CTA --> to confirm diagnosis; localize aneurysm

tx
- surgical ligation of aneurysm
- aggressive management of posthemorrhage vasospasm ==> CCB (Nimodipine) --> reduce ischemic complications