Neurosurgery, C75 P721-743 Flashcards
(201 cards)
1
Q
HEAD TRAUMA
What is the incidence?
P721
A
70,000 fatal injuries/year in the United
States, 500,000 head injuries per year
2
Q
HEAD TRAUMA What percentage of trauma deaths result from head trauma? P721
A
50%
3
Q
HEAD TRAUMA
Identify the dermatomes:
P721 (picture)
A
(see Picture)
4
Q
HEAD TRAUMA
What is the Glasgow Coma
Scale (GCS)?
P721
A
GCS is an objective assessment of the
level of consciousness after trauma
5
Q
HEAD TRAUMA
GCS SCORING SYSTEM
Eyes?
P721
A
Eye Opening (E)
4—opens spontaneously
3—opens to voice (command)
2—opens to painful stimulus
1—does not open eyes
(Think: “4 eyes”)
6
Q
HEAD TRAUMA
GCS SCORING SYSTEM
Motor?
P722
A
Motor Response (M)
6—obeys commands
5—localizes painful stimulus
4—withdraws from pain
3—decorticate posture
2—decerebrate posture
1—no movement
(Think: 6-cylinder motor)
7
Q
HEAD TRAUMA
GCS SCORING SYSTEM
Verbal?
P722
A
Verbal Response (V)
5—appropriate and oriented
4—confused
3—inappropriate words
2—incomprehensible sounds
1—no sounds
(Think: Jackson 5 = verbal 5)
8
Q
HEAD TRAUMA GCS SCORING SYSTEM What indicates coma by GCS score? P722
A
< 8 (Think: “less than eight—it may be
too late”)
9
Q
HEAD TRAUMA GCS SCORING SYSTEM What does unilateral, dilated, nonreactive pupil suggest? P722
A
Focal mass lesion with ipsilateral
herniation and compression of CN III
10
Q
HEAD TRAUMA GCS SCORING SYSTEM What do bilateral fixed and dilated pupils suggest? P722
A
Diffusely increased ICP
11
Q
HEAD TRAUMA GCS SCORING SYSTEM What are the four signs of basilar skull fracture? P722
A
1. Raccoon eyes—periorbital
ecchymoses
2. Battle’s sign—postauricular
ecchymoses
3. Hemotympanum
4. CSF rhinorrhea/otorrhea
12
Q
HEAD TRAUMA GCS SCORING SYSTEM What is the initial radiographic neuroimaging in trauma? P722
A
- Head CT scan (if LOC or GCS 15)
- C-spine CT
- T/L spine AP and lateral
13
Q
HEAD TRAUMA GCS SCORING SYSTEM Should the trauma head CT scan be with or without IV contrast? P722
A
Without!
14
Q
HEAD TRAUMA
GCS SCORING SYSTEM
What is normal ICP?
P722
A
5 to 15 mm H(2)O
15
Q
HEAD TRAUMA GCS SCORING SYSTEM What is the worrisome ICP? P723
A
>20 mm H(2)O
16
Q
HEAD TRAUMA GCS SCORING SYSTEM What determines ICP (Monroe-Kelly hypothesis)? P723
A
- Volume of brain
- Volume of blood
- Volume of CSF
17
Q
HEAD TRAUMA
GCS SCORING SYSTEM
What is the CPP?
P723
A
Cerebral Perfusion Pressure = mean
arterial pressure—ICP (normal CPP is
>70)
18
Q
HEAD TRAUMA
GCS SCORING SYSTEM
What is Cushing’s reflex?
P723
A
Physiologic response to increased ICP:
1. Hypertension 2. Bradycardia 3. Decreased RR
19
Q
HEAD TRAUMA GCS SCORING SYSTEM What are the three general indications to monitor ICP after trauma? P723
A
- GCS 9
- Altered level of consciousness or
unconsciousness with multiple system
trauma - Decreased consciousness with focal
neurologic examination abnormality
20
Q
HEAD TRAUMA
GCS SCORING SYSTEM
What is Kocher’s point?
P723 (picture)
A
Landmark for placement of ICP monitor
bolt:
21
Q
HEAD TRAUMA GCS SCORING SYSTEM What nonoperative techniques are used to decrease ICP? P724
A
1. Elevate head of bed (HOB) 30
(if spine cleared)
2. Diuresis-mannitol (osmotic diuretic),
Lasix®, limit fluids
3. Intubation (PCO2 control)
4. Sedation
5. Pharmacologic paralysis
6. Ventriculostomy (CSF drainage)
22
Q
HEAD TRAUMA GCS SCORING SYSTEM What is the acronym for the treatment of elevated ICP? P724
A
“ICP HEAD”:
INTUBATE
CALM (sedate)
PLACE DRAIN (ventriculostomy)/
PARALYSIS
HYPERVENTILATE TO PCO2 35
ELEVATE head
ADEQUATE BLOOD PRESSURE
(CPP 70)
DIURETIC (e.g., mannitol)
23
Q
HEAD TRAUMA GCS SCORING SYSTEM Can a tight c-collar increase the ICP? P724
A
Yes (it blocks venous drainage from
brain!)
24
Q
HEAD TRAUMA GCS SCORING SYSTEM Why is prolonged hyperventilation dangerous? P724
A
It may result in severe vasoconstriction
and ischemic brain necrosis!
Use only for very brief periods
25
```
HEAD TRAUMA
GCS SCORING SYSTEM
What is a Kjellberg?
(pronounced “shellberg”)
P724
```
Decompressive bifrontal craniectomy
with removal of frontal bone frozen for
possible later replacement
26
```
HEAD TRAUMA
GCS SCORING SYSTEM
How does cranial nerve
examination localize the
injury in a comatose patient?
P724
```
CNs proceed caudally in the brain stem
as numbered: Presence of corneal reflex
(CN 5 + 7) indicates intact pons; intact
gag reflex (CN 9 + 10) shows functioning
upper medulla (Note: CN 6 palsy is often
a false localizing sign)
27
```
HEAD TRAUMA
GCS SCORING SYSTEM
What is acute treatment of
seizures after head trauma?
P724
```
Benzodiazepines (Ativan®)
28
```
HEAD TRAUMA
GCS SCORING SYSTEM
What is seizure prophylaxis
after severe head injury?
P724
```
Give phenytoin for 7 days
29
```
HEAD TRAUMA
GCS SCORING SYSTEM
What is the significance of
hyponatremia (low sodium
level) after head injury?
P725
```
SIADH must be ruled out; remember,
| SIADH = Sodium Is Always Down Here
30
```
HEAD TRAUMA
EPIDURAL HEMATOMA
What is an epidural
hematoma?
P725
```
Collection of blood between the skull and
| dura
31
HEAD TRAUMA
EPIDURAL HEMATOMA
What causes it?
P725
Usually occurs in association with a skull
fracture as bone fragments lacerate
meningeal arteries
32
```
HEAD TRAUMA
EPIDURAL HEMATOMA
Which artery is associated
with epidural hematomas?
P725
```
Middle meningeal artery
33
```
HEAD TRAUMA
EPIDURAL HEMATOMA
What is the most common
sign of an epidural
hematoma?
P725
```
>50% have ipsilateral blown pupil
34
```
HEAD TRAUMA
EPIDURAL HEMATOMA
What is the classic history
with an epidural hematoma?
P725
```
LOC followed by a “lucid interval”
| followed by neurologic deterioration
35
```
HEAD TRAUMA
EPIDURAL HEMATOMA
What are the classic CT scan
findings with an epidural
hematoma?
P725 (picture)
```
Lenticular (lens)-shaped hematoma
| Think: Epidural = LEnticular
36
```
HEAD TRAUMA
EPIDURAL HEMATOMA
What is the surgical treatment
for an epidural hematoma?
P725
```
Surgical evacuation
37
```
HEAD TRAUMA
EPIDURAL HEMATOMA
What are the indications for
surgery with an epidural
hematoma?
P725
```
Any symptomatic epidural hematoma;
| any epidural hematoma >1 cm
38
HEAD TRAUMA
SUBDURAL HEMATOMA
What is it?
P726
Blood collection under the dura
39
HEAD TRAUMA
SUBDURAL HEMATOMA
What causes it?
P726
```
Tearing of “bridging” veins that pass
through the space between the cortical
surface and the dural venous sinuses or
injury to the brain surface with resultant
bleeding from cortical vessels
```
40
```
HEAD TRAUMA
SUBDURAL HEMATOMA
What are the three types of
subdurals?
P726
```
```
1. Acute—symptoms within 48 hours of
injury
2. Subacute—symptoms within 3 to 14 days
3. Chronic—symptoms after 2 weeks or
longer
```
41
```
HEAD TRAUMA
SUBDURAL HEMATOMA
What is the treatment of
epidural and subdural
hematomas?
P726
```
Mass effect (pressure) must be reduced;
craniotomy with clot evacuation is usually
required
42
```
HEAD TRAUMA
SUBDURAL HEMATOMA
What classic findings appear
on head CT scan for a
subdural hematoma?
P726 (picture)
```
Curved, crescent-shaped hematoma
| Think: sUbdural = cUrved
43
HEAD TRAUMA
TRAUMATIC SUBARACHNOID HEMORRHAGE
What is it?
P726
Head trauma resulting in blood below the
| arachnoid membrane and above the pia
44
HEAD TRAUMA
TRAUMATIC SUBARACHNOID HEMORRHAGE
What is the treatment?
P726
Anticonvulsants and observation
45
HEAD TRAUMA
CEREBRAL CONTUSION
What is it?
P726
Hemorrhagic contusion of brain parenchyma
46
```
HEAD TRAUMA
CEREBRAL CONTUSION
What are coup and
contrecoup injuries?
P727
```
Coup—injury at the site of impact
Contrecoup—injury at the site opposite
the point of impact
47
HEAD TRAUMA
CEREBRAL CONTUSION
What is DAI?
P727
Diffuse Axonal Injury (shear injury
to brain parenchyma) from rapid
deceleration injury; 33% mortality;
long-term coma
48
```
HEAD TRAUMA
CEREBRAL CONTUSION
What is the best diagnostic
test for DAI?
P727
```
MRI
49
```
HEAD TRAUMA
CEREBRAL CONTUSION
What can present after blunt
trauma with neurological
deficits and a normal brain
CT scan?
P727
```
DAI, carotid artery injury
50
```
HEAD TRAUMA
SKULL FRACTURE
What is a depressed skull
fracture?
P727
```
Fracture in which one or more fragments
of the skull are forced below the inner
table of the skull
51
```
HEAD TRAUMA
SKULL FRACTURE
What are the indications for
surgery?
P727
```
```
1. Contaminated wound requiring
cleaning and débridement
2. Severe deformity
3. Impingement on cortex
4. Open fracture
5. CSF leak
```
52
```
HEAD TRAUMA
SKULL FRACTURE
What is the treatment for
open skull fractures?
P727
```
1. Antibiotics
2. Seizure prophylaxis (phenytoin)
3. Surgical therapy
53
```
HEAD TRAUMA
SPINAL CORD TRAUMA
What are the two general
types of injury?
P727
```
1. Complete—no motor/sensory function
below the level of injury
2. Incomplete—residual function below
the level of injury
54
HEAD TRAUMA
SPINAL CORD TRAUMA
Define “spinal shock.”
P727
Loss of all reflexes and motor function,
| hypotension, bradycardia
55
HEAD TRAUMA
SPINAL CORD TRAUMA
Define “sacral sparing.”
P728
Sparing of sacral nerve level: anal sphincter
| intact, toe flexion, perianal sensation
56
```
HEAD TRAUMA
SPINAL CORD TRAUMA
What initial studies/
intervention are important?
P728
```
```
1. ABCs—obtain airway and ventilate if
needed
2. Maintain BP (IVF, pressors if refractory
to fluids)
3. NG tube—prevents aspiration
4. Foley
5. High-dose steroids—proven to
improve outcome if given 8 hours
post injury
6. Complete cervical x-rays and those of
lower levels as indicated by examination
```
57
```
HEAD TRAUMA
SPINAL CORD TRAUMA
What are the diagnostic
studies?
P728
```
Plain films, CT scan, MRI
58
```
HEAD TRAUMA
SPINAL CORD TRAUMA
What are the indications for
emergent surgery with
spinal cord injury?
P728
```
Unstable vertebral fracture
Incomplete injury with extrinsic
compression
Spinal epidural or subdural hematoma
59
```
HEAD TRAUMA
SPINAL CORD TRAUMA
What is the indication for
IV high-dose steroids with
spinal cord injury?
P728
```
```
Controversial: Blunt spinal cord injury with
neurologic deficit (methylprednisolone:
high-dose bolus [30 mg/kg] followed
by continuous infusion [5.4 mg/kg] for
23 hours)
```
60
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Have steroids been proven to
help after PENETRATING
spine injury?
P728
```
No
61
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Describe the following
conditions:
Anterior cord syndrome
P728 (Picture)
```
Affects corticospinal and lateral
spinothalamic tracts, paraplegia, loss of
pain/temperature sensation, preserved
touch/vibration/proprioception
62
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Describe the following
conditions:
Central cord syndrome
P729 (Picture)
```
Preservation of some lower extremity
motor and sensory ability with upper
extremity weakness
63
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Describe the following
conditions:
Brown-Séquard syndrome
P729 (Picture)
```
Hemisection of cord resulting in
ipsilateral motor weakness and touch/
proprioception loss with contralateral
pain/temperature loss
64
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Describe the following
conditions:
Posterior cord syndrome
P729
```
Injury to posterior spinal cord with loss
| of proprioception distally
65
```
HEAD TRAUMA
SPINAL CORD TRAUMA
How can the findings
associated with Brown-
Séquard syndrome be
remembered?
P729
```
```
Think: CAPTAIN Brown-Séquard =
“CPT”:
Contralateral
Pain
Temperature loss
```
66
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Jefferson’s fracture
P729
```
Fracture through C1 arches from axial
| loading (unstable fracture)
67
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Hangman’s fracture
P729
```
Fracture through the pedicles of C2 from
hyperextension; usually stable
Think: A hangman (C2) is below stature of
President T. Jefferson (C1)
68
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Odontoid fracture
P729
```
Fracture of the odontoid process of C2
| view with open-mouth odontoid x-ray
69
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Priapism
P729
```
Penile erection seen with spinal cord
| injury
70
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Chance fracture
P730
```
Transverse vertebral fracture
71
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Clay shoveler’s fracture
P730
```
Fracture of spinous process of C7
72
```
HEAD TRAUMA
SPINAL CORD TRAUMA
Define the following terms:
Odontoid fractures
P730 (picture)
```
```
A: Type I—fracture through tip of dens
B: Type II—fracture through base of
dens
C: Type III—fracture through body
of C2
```
73
```
TUMORS
GENERAL
What is the incidence of
CNS tumors?
P730
```
≈1% of all cancers; third leading cause of
cancer deaths in people 15 to 34 years of
age; second leading cause of cancer
deaths in children
74
```
TUMORS
GENERAL
What is the usual location of
primary tumors in adults/
children?
P730
```
In adults, 66% of tumors are
supratentorial, ≈33% are infratentorial;
the reverse is true in children (i.e.,
≈66% infratentorial)
75
```
TUMORS
GENERAL
What is the differential
diagnosis of a ringenhancing
brain lesion?
P730
```
Metastatic carcinoma, abscess, GBM,
| lymphoma
76
```
TUMORS
GENERAL
What are the adverse effects
of tumors on the brain?
P730
```
1. Increased ICP
2. Mass effect on cranial nerves
3. Invasion of brain parenchyma,
disrupting nuclei/tracts
4. Seizure foci
5. Hemorrhage into/around tumor mass
77
```
TUMORS
GENERAL
What are the signs/symptoms
of brain tumors?
P730
```
1. Neurologic deficit (66%)
2. Headache (50%)
3. Seizures (25%)
4. Vomiting (classically in the morning)
78
TUMORS
GENERAL
How is the diagnosis made?
P731
CT scan or MRI is the standard
| diagnostic study
79
```
TUMORS
GENERAL
What are the surgical
indications?
P731
```
1. Establishing a tissue diagnosis
2. Relief of increased ICP
3. Relief of neurologic dysfunction
caused by tissue compression
4. Attempt to cure in the setting of
localized tumor
80
```
TUMORS
GENERAL
What are the most common
intracranial tumors in adults?
P731
```
Metastatic neoplasms are most common;
among primaries, gliomas are #1 (50%)
and meningiomas are #2 (25%)
81
```
TUMORS
GENERAL
What are the three most
common in children?
P731
```
1. Medulloblastomas (33%)
2. Astrocytomas (33%)
3. Ependymomas (10%)
82
TUMORS
GLIOMAS
What is a glioma?
P731
General name for several tumors of
neuroglial origin (e.g., astrocytes,
ependymal, oligodendrocytes)
83
```
TUMORS
GLIOMAS
What are the characteristics
of a LOW-grade astrocytoma?
P731
```
Nuclear atypia, high mitotic rate,
high signal on T2 weighted images,
nonenhancing with contrast CT scan
84
```
TUMORS
GLIOMAS
What is the most common
primary brain tumor in
adults?
P731
```
Glioblastoma multiforme (GBM)
(Think: GBM = Greatest Brain
Malignancy)
85
TUMORS
GLIOMAS
What are its characteristics?
P731
Poorly defined, highly aggressive tumors
occurring in the white matter of the cerebral
hemispheres; spread extremely rapidly
86
```
TUMORS
GLIOMAS
What is the average age of
onset?
P731
```
Fifth decade
87
TUMORS
GLIOMAS
What is the treatment?
P731
Surgical debulking followed by radiation
88
TUMORS
GLIOMAS
What is the prognosis?
P731
Without treatment, 90% of patients
die within 3 months of diagnosis; with
treatment, 90% die within 2 years
89
```
TUMORS
MENINGIOMAS
What is the layer of
origination?
P732
```
Arachnoid cap cells
90
TUMORS
MENINGIOMAS
What are the risk factors?
P732
Radiation exposure
Neurofibromatosis type 2
Female gender
91
```
TUMORS
MENINGIOMAS
What are the associated
histologic findings?
P732
```
Psammoma bodies (concentric
calcifications), whorl formations
(“onion skin” pattern)
92
```
TUMORS
MENINGIOMAS
What is the histologic
malignancy determination?
P732
```
Brain parenchymal invasion
93
```
TUMORS
MENINGIOMAS
What is the peak age of
occurrence?
P732
```
40 to 50 years
94
TUMORS
MENINGIOMAS
What is the gender ratio?
P732
Females predominate almost 2:1
95
```
TUMORS
MENINGIOMAS
What is the clinical
presentation?
P732
```
Variable depending on location; lateral
cerebral convexity tumors can cause focal
deficits or headache; sphenoid tumors
can present with seizures; posterior fossa
tumors with CN deficits; olfactory groove
tumors with anosmia
96
TUMORS
MENINGIOMAS
What is the treatment?
P732
Preoperative embolization and surgical
| resection
97
```
TUMORS
CEREBELLAR ASTROCYTOMAS
What is the peak age of
occurrence?
P732
```
5 to 9 years
98
TUMORS
CEREBELLAR ASTROCYTOMAS
What is the usual location?
P732
Usually in the cerebellar hemispheres;
| less frequently in the vermis
99
```
TUMORS
CEREBELLAR ASTROCYTOMAS
What are the signs/
symptoms?
P732
```
Usually lateral cerebellar signs occur:
ipsilateral incoordination or dysmetria
(patient tends to fall to side of tumor) as
well as nystagmus and ataxia; CN deficits
are also frequently present, especially in
CNs VI and VII
100
```
TUMORS
CEREBELLAR ASTROCYTOMAS
What are the treatment and
prognosis?
P733
```
Completely resectable in 75% of cases,
which usually results in a cure; overall
5-year survival rate exceeds 90%
101
```
TUMORS
MEDULLOBLASTOMA
What is the peak age of
occurrence?
P733
```
First decade (3 to 7 years)
102
TUMORS
MEDULLOBLASTOMA
What is the cell of origin?
P733
External granular cells of cerebellum
103
```
TUMORS
MEDULLOBLASTOMA
What is the most common
location?
P733
```
Cerebellar vermis in children; cerebellar
| hemispheres of adolescents and adults
104
```
TUMORS
MEDULLOBLASTOMA
What are the signs/
symptoms?
P733
```
Headache, vomiting, and other signs of
| increased ICP; also usually truncal ataxia
105
```
TUMORS
MEDULLOBLASTOMA
What are the treatment and
prognosis?
P733
```
Best current treatment includes surgery
to debulk the tumor, cranial and spinal
radiation, and chemotherapy; 5-year
survival rate is >50%
106
```
TUMORS
PITUITARY TUMORS
What is the most common
pituitary tumor?
P733
```
Prolactinoma
107
```
TUMORS
PITUITARY TUMORS
What is the most common
presentation of a
prolactinoma?
P733 (picture)
```
```
Bitemporal hemianopsia (lateral visual
fields blind)
```
108
```
TUMORS
PITUITARY TUMORS
What are the blood prolactin
levels with a prolactinoma?
P734
```
>300 mg/L is diagnostic for prolactinoma
| 100 mg/L is abnormal
109
```
TUMORS
PITUITARY TUMORS
Medical treatment of a
prolactinoma?
P734
```
Bromocriptine
110
```
TUMORS
PITUITARY TUMORS
Surgical treatment for a
prolactinoma?
P734
```
Transsphenoidal resection of the pituitary
| tumor (in cases refractory to bromocriptine)
111
```
TUMORS
PITUITARY TUMORS
What is the treatment of a
recurrent prolactinoma after
surgical resection?
P734
```
Radiation therapy
112
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What are the usual causes?
P734
Most cases are due to trauma; of
nontraumatic SAH, the leading cause is
ruptured berry aneurysm, followed by
arteriovenous malformations
113
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What is a berry aneurysm?
P734
Saccular outpouching of vessels in the
| circle of Willis, usually at bifurcations
114
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What is the usual location of
a berry aneurysm?
P734
```
Anterior communicating artery is #1 (30%),
followed by posterior communicating
artery and middle cerebral artery
115
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What medical disease
increases the risk of berry
aneurysms?
P734
```
```
Polycystic kidney disease and connective
tissue disorders (e.g., Marfan’s syndrome)
```
116
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What is an Arterio-Venous
Malformation (AVM)?
P734
```
Congenital abnormality of the vasculature
with connections between the arterial
and venous circulations without
interposed capillary network
117
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
Where do they occur?
P734
>75% are supratentorial
118
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What are the signs/
symptoms of SAH?
P734
```
```
Classic symptom is “the worst headache
of my life”; meningismus is documented
by neck pain and positive Kernig’s and
Brudzinski’s signs; occasionally LOC,
vomiting, nausea, photophobia
```
119
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What comprises the workup
of SAH?
P735
```
```
If SAH is suspected, head CT should
be the first test ordered to look for
subarachnoid blood; LP may show
xanthochromic CSF, but is not necessary
if CT scan is definitive; this test should
be followed by arteriogram to look for
aneurysms or AVMs
```
120
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What are the possible
complications of SAH?
P735
```
1. Brain edema leading to increased ICP
2. Rebleeding (most common in the first
24 to 48 hours posthemorrhage)
3. Vasospasm (most common cause of
morbidity and mortality)
121
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What is the treatment for
vasospasm?
P735
```
Nimodipine (calcium channel blocker)
122
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What is the treatment of
aneurysms?
P735
```
Surgical treatment by placing a metal
clip on the aneurysm is the mainstay of
therapy; alternatives include balloon
occlusion or coil embolization
123
```
VASCULAR NEUROSURGERY
SUBARACHNOID HEMORRHAGE (SAH)
What is the treatment of
AVMs?
P735
```
```
Many are on the brain surface and
accessible operatively; preoperative
embolization can reduce the size of the
AVM; for surgically inaccessible lesions,
radiosurgery (gamma knife) has been
effective in treating AVMs <3 cm in
diameter
```
124
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
What is it?
P735
Bleeding into the brain parenchyma
125
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
What is the etiology?
P735
```
#1 is hypertensive/atherosclerotic disease
giving rise to Charcot-Bouchard
aneurysms (small tubular aneurysms
along smaller terminal arteries); other
causes include coagulopathies, AVMs,
amyloid angiopathy, bleeding into a
tumor, and trauma
```
126
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
Where does it occur?
P735
66% occur in the basal ganglia; putamen
| is the structure most commonly affected
127
```
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
How often does blood
spread to the ventricular
system?
P736
```
66% of cases
128
```
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
What is the usual
presentation?
P736
```
```
66% present with coma; large
putamen bleeding classically presents
with contralateral hemiplegia and
hemisensory deficits, lateral gaze
preference, aphasia, and homonymous
hemianopsia
```
129
```
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
What is the associated
diagnostic study?
P736
```
CT scan
130
```
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
What are the surgical
indications?
P736
```
CN III palsy, progressive alteration of
| consciousness
131
VASCULAR NEUROSURGERY
INTRACEREBRAL HEMORRHAGE
What is the prognosis?
P736
Poor, especially with ventricular or
| diencephalons involvement
132
SPINE
LUMBAR DISC HERNIATION
What is it?
P736
```
Extrusion of the inner portion of the
intervertebral disc (nucleus pulposus)
through the outer annulus fibrosis,
causing impingement on nerve roots
exiting the spinal canal
```
133
SPINE
LUMBAR DISC HERNIATION
Which nerve is affected?
P736
Nerve exiting at the level below (e.g., an
L4–L5 disc impinges on the L5 nerve
exiting between L5–S1)
134
SPINE
LUMBAR DISC HERNIATION
Who is affected?
P736
Middle-aged and older individuals
135
SPINE
LUMBAR DISC HERNIATION
What is the usual cause?
P736
Loss of elasticity of the posterior
longitudinal ligaments and annulus
fibrosis as a result of aging
136
```
SPINE
LUMBAR DISC HERNIATION
What are the most common
sites?
P736
```
L5–S1 (45%)
| L4–L5 (40%)
137
```
SPINE
LUMBAR DISC HERNIATION
What is the usual presenting
symptom?
P736
```
Low back pain
138
```
SPINE
LUMBAR DISC HERNIATION
What are the signs:
L5–S1?
P737
```
```
Decreased ankle jerk reflex
Weakness of plantar flexors in foot
Pain in back/midgluteal region to
posterior calf to lateral foot
Ipsilateral radiculopathy on straight leg
raise
```
139
```
SPINE
LUMBAR DISC HERNIATION
What are the signs:
L4–L5?
P737
```
Decreased biceps femoris reflex
| Weak extensors of foot
140
```
SPINE
LUMBAR DISC HERNIATION
What are the signs:
L3–L4?
P737
```
```
Decrease or absence of knee jerks,
weakness of the quadriceps femoris,
pain in lower back/buttock, pain in
lateral thigh and anterior thigh
Pain in hip/groin region to posterolateral
thigh, lateral leg, and medial toes
```
141
SPINE
LUMBAR DISC HERNIATION
How is the diagnosis made?
P737
CT scan, CT myelogram, or MRI
142
SPINE
LUMBAR DISC HERNIATION
What is the treatment?
P737
Conservative—bed rest and analgesics
Surgical—partial hemilaminectomy and
discectomy (removal of herniated disc)
143
```
SPINE
LUMBAR DISC HERNIATION
What are the indications for
emergent surgery?
P737
```
1. Cauda equina syndrome
| 2. Progressive motor deficits
144
```
SPINE
LUMBAR DISC HERNIATION
What is cauda equina
syndrome?
P737
```
```
Herniated disc compressing multiple
S1, S2, S3, S4 nerve roots, resulting in
bowel/bladder incontinence, “saddle
anesthesia” over buttocks/perineum, low
back pain, sciatica
```
145
SPINE
LUMBAR DISC HERNIATION
What is “sciatica”?
P737
Radicular or nerve root pain
146
SPINE
CERVICAL DISC DISEASE
What is it?
P737
```
Basically the same pathology as lumbar
disc herniation, except in the cervical
region; the disc impinges on the nerve
exiting the canal at the same level of the
disease (e.g., a C6–C7 disc impinges on
the C7 nerve root exiting at the C6–C7
foramen)
```
147
```
SPINE
CERVICAL DISC DISEASE
What are the most common
sites?
P738
```
C6–C7 (70%)
C5–C6 (20%)
C7–T1 (10%)
148
```
SPINE
CERVICAL DISC DISEASE
What are the signs/symptoms:
C7?
P738
```
Decreased triceps reflex/strength,
weakness of forearm extension
Pain from neck, through triceps and into
index and middle finger
149
```
SPINE
CERVICAL DISC DISEASE
What are the signs/symptoms:
C6?
P738
```
Decreased biceps and brachioradialis
reflex
Weakness in forearm flexion
Pain in neck, radial forearm, and thumb
150
```
SPINE
CERVICAL DISC DISEASE
What are the signs/symptoms:
C8?
P738
```
Weakness in intrinsic hand muscles, pain
| in fourth/fifth fingers
151
SPINE
CERVICAL DISC DISEASE
How is the diagnosis made?
P738
CT scan or MRI
152
SPINE
CERVICAL DISC DISEASE
What is the treatment?
P738
Anterior or posterior discectomy with
| fusion PRN
153
```
SPINE
CERVICAL DISC DISEASE
What are the symptoms
of central cervical cord
compression from disc
fragments?
P738
```
Myelopathic syndrome with LMN signs
at level of compression and UMN signs
distally; e.g., C7 compression may cause
bilateral loss of triceps reflex and bilateral
hyperreflexia, clonus, and Babinski signs
in lower extremities
154
SPINE
CERVICAL DISC DISEASE
What is Spurling’s sign?
P738
Reproduction of radicular pain by having
the patient turn his head to the affected
side and applying axial pressure to the
top of the head
155
SPINE
SPINAL EPIDURAL ABSCESS
What is the etiology?
P738
Hematogenous spread from skin infections
is most common; also, distant abscesses/
infections, UTIs, postoperative infections,
spinal surgery, epidural anesthesia
156
```
SPINE
SPINAL EPIDURAL ABSCESS
What is the commonly
associated medical condition?
P738
```
Diabetes mellitus
157
```
SPINE
SPINAL EPIDURAL ABSCESS
What are the three most
common sites?
P739
```
1. Thoracic
2. Lumbar
3. Cervical
158
```
SPINE
SPINAL EPIDURAL ABSCESS
What is the most common
organism?
P739
```
Staphylococcus aureus
159
```
SPINE
SPINAL EPIDURAL ABSCESS
What are the signs/
symptoms?
P739
```
```
Fever; severe pain over affected area
and with flexion/extension of spine;
weakness can develop, ultimately leading
to paraplegia; 15% of patients have a back
furuncle
```
160
SPINE
SPINAL EPIDURAL ABSCESS
How is the diagnosis made?
P739
MRI = test of choice
161
```
SPINE
SPINAL EPIDURAL ABSCESS
Which test is
contraindicated?
P739
```
LP, because of the risk of seeding CSF
| with bacteria, causing meningitis
162
SPINE
SPINAL EPIDURAL ABSCESS
What is the treatment?
P739
Surgical drainage and appropriate
| antibiotic coverage
163
SPINE
SPINAL EPIDURAL ABSCESS
What is the prognosis?
P739
Depends on preop condition; severe
neurologic deficits (e.g., paraplegia) show
little recovery; 15% to 20% of cases are
fatal
164
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is it?
P739
Abnormal condition consisting of an
increased volume of CSF along with
distension of CSF spaces
165
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What are the three general
causes?
P739
```
1. Increased production of CSF
2. Decreased absorption of CSF
3. Obstruction of normal flow of CSF
(90% of cases)
166
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is the normal daily
CSF production?
P739
```
≈500 mL
167
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is the normal volume
of CSF?
P739
```
≈150 mL in the average adult
168
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
Define “communicating”
versus “noncommunicating”
hydrocephalus.
P740
```
Communicating—unimpaired connection
of CSF pathway from lateral ventricle
to subarachnoid space
Noncommunicating—complete or
incomplete obstruction of CSF flow
within or at the exit of the ventricular
system
169
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What are the specific causes
of hydrocephalus?
P740
```
```
Congenital malformation
Aqueductal stenosis
Myelomeningocele
Tumors obstructing CSF flow
Inflammation causing impaired
absorption of fluid
Subarachnoid hemorrhage
Meningitis
Choroid plexus papilloma causing
↑ production of CSF
```
170
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What are the signs/
symptoms?
P740
```
Signs of increased ICP: HA, nausea,
vomiting, ataxia, increasing head
circumference exceeding norms for age
171
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
How is the diagnosis made?
P740
CT scan, MRI, measurement of head
| circumference
172
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is the treatment?
P740
1. Remove obvious offenders
2. Perform bypass obstruction with
ventriculoperitoneal shunt or
ventriculoatrial shunt
173
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is the prognosis if
untreated?
P740
```
50% mortality; survivors show decreased
IQ (mean = 69); neurologic sequelae:
ataxia, paraparesis, visual deficits
174
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What are the possible
complications of treatment?
P740
```
1. Blockage/shunt malfunction
| 2. Infection
175
```
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is hydrocephalus ex
vacuo?
P740
```
Increased volume of CSF spaces from
brain atrophy, not from any pathology
in the amount of CSF absorbed or
produced
176
PEDIATRIC NEUROSURGERY
HYDROCEPHALUS
What is a “shunt series”?
P740
Series of x-rays covering the entire shunt
length—looking for shunt disruption/
kinking to explain malfunction of shunt
177
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What is the incidence?
P741
≈1/1000 live births in the United
| States
178
```
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What are the race/gender
demographics?
P741
```
More common in white patients and
| female patients
179
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
Define spina bifida occulta.
P741
Defect in the development of the
| posterior portion of the vertebrae
180
```
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What are the signs/
symptoms?
P741
```
Usually asymptomatic, though it may be
associated with other spinal abnormalities;
usually found incidentally on x-rays
181
```
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What is the most common
clinically significant defect?
P741
```
Myelomeningocele: herniation of nerve
roots and spinal cord through a defect in
the posterior elements of the vertebra(e);
the sac surrounding the neural tissue may
be intact, but more commonly is ruptured
and therefore exposes the CNS to the
external environment
182
```
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What are the three most
common anatomic sites?
P741
```
1. Lumbar region
2. Lower thoracic region
3. Upper sacral region
183
```
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What are the signs/
symptoms?
P741
```
Variable from mild skeletal deformities to
a complete motor/sensory loss; bowel/
bladder function is difficult to evaluate,
but often is affected and can adversely
affect survival
184
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What is the treatment?
P741
With open myelomeningoceles, patients
are operated on immediately to prevent
infection
185
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
What is the prognosis?
P741
≈95% survival for the first 2 years,
compared with 25% in patients not
undergoing surgical procedures
186
```
PEDIATRIC NEUROSURGERY
SPINAL DYSRAPHISM/NEURAL TUBE DEFECTS
Which vitamin is thought to
lower the rate of neural
tube defects in utero?
P741
```
Folic acid
187
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
What is it?
P742
Premature closure of one or more of the
| sutures between the skull plates
188
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
What is the incidence?
P742
1/200 live births in the United States
189
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
What are the types?
P742
Named for the suture that is fused (e.g.,
sagittal, coronal, lambdoid); sagittal
craniosynostosis accounts for 50% of all
cases; more than one suture can be
fused, and all or part of a suture may be
affected
190
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
How is the diagnosis made?
P742
```
Physical examination can reveal ridges
along fused sutures and lessened suture
mobility; plain x-rays can show a lack of
lucency along the fused suture, but are
rarely required
```
191
```
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
What are the indications for
surgery?
P742
```
```
Most often the reasons are cosmetic, as
the cranial vault will continue to deform
with growth; occasionally, a child will
present with increased ICP secondary to
restricted brain growth
```
192
```
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
What is the timing of
surgery?
P742
```
Usually 3 to 4 months of age; earlier
surgery increases the risk of anesthesia;
later surgeries are more difficult because
of the worsening deformities and
decreasing malleability of the skull
193
```
PEDIATRIC NEUROSURGERY
CRANIOSYNOSTOSIS
What is the operative
mortality?
P742
```
<1%
194
```
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What is the most
common bacteria causing
postneurosurgery meningitis?
P742
```
Staphylococcus aureus (skin flora)
195
```
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What classically presents as
the “worst headache of my
life”?
P742
```
Spontaneous subarachnoid hemorrhage
196
```
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What classically has a “lucid
interval”?
P742
```
Epidural hemorrhage
197
```
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What is the most common
location of a hypertensive
intracerebral hemorrhage?
P743
```
Putamen
198
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What is Horner’s syndrome?
P743
```
Cervical sympathetic chain lesion;
Think: “MAP”:
Miosis
Anhydrosis of ipsilateral face
Ptosis
```
199
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What is a third-nerve palsy?
P743
Think: Third nerve does three things:
1. Diplopia
2. Ptosis
3. Mydriasis
200
```
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What is Millard-Gubler
syndrome?
P743
```
Pons infarction:
1. VI nerve palsy
2. VII nerve palsy
3. Contralateral hemiplegia
201
PEDIATRIC NEUROSURGERY
MISCELLANEOUS
What is syringomyelia?
P743
Central pathologic cavitations of the
| spinal cord
