Neurosurgery Lecture Flashcards
(189 cards)
1
Q
SCALP pneumonic for what all the scalp consists of
A
Skin Connective tissue aponeurosis loose connective tissue periosteum
2
Q
Brain anatomy terms
A
Scalp Skull Dura mater Arachnoid Pia Brain (Gray matter and white matter)
3
Q
what brain anatomy has nerve endings
A
scalp and Dura
4
Q
Intraparenchymal means what
A
in the brain area
5
Q
extraaxial
A
inside of scalp but outside of brain tissue
6
Q
breast milk does what to brain
A
myelinates neurons and gives you white matter
7
Q
myelin and brain tissue in relation to seizures
A
myelinated tissue is not as excitable
8
Q
neonates and gray matter/white matter
A
does not have as much white matter. colostrum has cholesterol which helps to myelinate the brain to develop the white matter
9
Q
brain stem is made up of how many parts
what are they
A
3
midbrain
pons
medulla
10
Q
supratentorial
A
above posterior fossa
11
Q
drooling, not managing secretions - from a neuro stand point, what part of the brain should you think about
A
think brain stem
12
Q
how many ventricles do you have
A
4
13
Q
CSF is being absorbed through what layer of the brain
A
arachnoid
14
Q
80% of the CSF is produced where
A
Choroid plexus (in the 3rd ventricle)
15
Q
part of brain controls balance or movement (coordination)
A
cerebellum
16
Q
lobe that controls personality motor emotions problem solving reasoning
A
frontal lobe
17
Q
lobe that controls
sensory
A
parietal lobe
18
Q
lobe that controls
hearing
language
speech
A
temporal lobe
19
Q
lobe that controls
vision
A
occipital lobe
20
Q
CN in midbrain
A
3 -oculomotor
4 - trochlear
21
Q
CN pons
A
5 - trigeminal
6- abducens
7- facial
8- vestibulocochlear
22
Q
CN medulla
A
9- glossopharyngeal
10- vagus
11 - accessory
23
Q
definition of brain death by the American academy of neurology (AAN) in 1995 and updated in 2010
A
“irreversible cessation of all functions of the entire brain, including the brain stem”
each facility will have their criterion
24
Q
cant call Brain death if there is
A
- contribution of depressant drugs
- hypothermic
- metabolic/endocrine disturbance
- breathing on own
-patient condition must be compatible with irreversible brain damage
25
Brain death tests
pupil response
corneal reflex
vestibulo-ocular reflex (ear drum must be intact - inject cold water into ear while some one is holding the eyes open...eyes will shoot over to opposite side and produce nystagmus) (Dolls eyes test)
gag reflux (If intubated must be at the carina)
motor response (Train of 4 (TOF)) (needs to be central ie) sternal rub)
resp movements
each institution varies on who, repetition/timing
26
labs needed prior to neurosurgery
CBC (H&H and platelets - needs to be 100,000) - Hgb (10), HCT (30)
Coags (pt/inr/ptt)
BMP/Chem10 (sodium, potassium, BUN, creatinine)
type and screen
27
an impact, penetration or rapid movement of the brain within the skull that results in altered mental state
Traumatic brain injury
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an insult to the brain, not of a degenerative or congenital nature, but caused by external physical force that may produce a diminished or altered state of consciousness
Traumatic brain injury
29
GCS associated with mild TBI
13-15 (brief change in mental status/consciousness)
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GCS associated with moderate TBI
10-12
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GCS associated with severe TBI
9 and below - extended period of unconsciousness or memory loss...death
32
results when the brain moves rapidly within the skull (coup - impact and contrecoup - non-impact (physiological due to force))
Traumatic brain injury
33
what lab that there are studies with brain injury
| serial ____ levels
lactate
34
Changes in ionic fluxes after TBI
| what's going on
body is trying to repair itself
| sodium and potassium will be depleted
35
when does frontal sinus develop
7-10 years old
36
sagittal view is
side view
37
when you see a bleed on a CT - bright white vs dull white
bright white is clotted blood, dull is fresh- still bleeding
38
when have a TBI, still have swelling. What electrolyte is important to follow and make sure they are keeping up?
sodium
39
what age is it that they have a better chance of the other parts of the brain taking over those functions
younger than 7 y.o.
40
general changes in brain function, such as confusion, amnesia, loss of alertness, disorientation (not cognizant of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions and disruptions in perception, psychomotor skills and behavior.
altered mental status
41
Pediatric decreased mental status differentials
```
acute demyelinating encephalomyelitis (ADEM)
fever
electrolyte disturbance
sepsis/meningitis
Respiratory
head injury
hydrocephalus
abscess of brain
seizure
ruptured AVM/aneurysm
narcotics
benzo
```
42
focal brain injury is a
contusion
43
2 types of diffuse brain injury
concussion
| DAI (direct axonal injury)
44
types of hemorrhages
epidural
subdural
subarachnoid
intracerebral (in brain tissue)
45
4 major causes of brain injury
falls
MVA
bicycle accident
child abuse
46
what does intraparenchymal hemorrhage mean
bleeding inside the brain
47
where is bleeding for a subdural hemorrhage
between the arachnoid mater and dura mater - irritates the brain faster, may cause seizures faster
48
where is bleeding for a subarachnoid hemorrhage
bleeding in the subarachnoid space
49
where is bleeding for epidural hemorrhage
between the dura mater and the skull
50
if bleeding does not clear during LP (from tube 1 to tube 4)
subarachnoid hemorrhage
if it clears its a dirty lp
51
subarachnoid hemorrhage think what on differential causes
subarachnoid hemorrhage
52
what type of bleed is confined by sutures
subdural
53
where does blood accumulate in an epidural
between skull and dural membrane
54
what artery tear is most common cause of epidural hematoma
middle meningeal artery
55
R pupil is fixed and dilating, what side of the brain is the bleed
R
56
clotted blood, up to 48 hours (subdural hematoma classification)
acute
57
2-3 days to 2-weeks, clot lyses (subdural hematoma classification)
subacute
58
> 3 weeks, fluid mass (subdural hematoma classification)
chronic
59
stroke - what is the hour time frame to be able to see on MRI
immediately
60
narcotic use in head injury - pros and cons
decrease agitation and pain so the blood pressure and ICP doesn't increase
works as a CNS depressant by slowing down neural activity in the brain and body (PNS)
downside - no effect on cerebral metabolic rate of oxygen (CMRO2) or cerebral blood flow but they have been reported to increase ICP in some cases
CNS depressants
61
cautious alert to think about for when you are ordering benzos for treating seizure (What should you be double checking before giving a benzo for seizure
treating a seizure with benzo has major effects on the CNS. Are you treating a seizure? or could this be posturing?
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Benzos and ICP
no effect on ICP
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downside of Benzos
have a coupled reduction in cerebral metabolic rate of oxygen and cerebral blood flow and no effect on ICP
CNS depressant
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what stage of sleep has highest ICP
REM
65
normal ICP ranges
1-15mm Hg
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causes of increased ICP
trauma (contusion, EDH, SDH), infection, neurosurgery/neurosurgical procedures, overdose of/toxic reactions from meds, disease that affect nervous system, stroke, hydrocephalus (malfunctioning shunt/ETV)
67
signs symptoms of Increased ICP
lethargy/change in LOC
bradycardia
HTN
unequal pupils (esp if one is not reactive at all)
68
ICP mgmt
```
decompressive craniectomy (most invasive)
pentobarbital coma
EVD
Mannitol/hypertonic saline
sedatives, paralytics, hyperventilation
general measures (least invasive)
```
69
why would you give 23% mannitol/hypertonic saline vs 3%
less volume
70
ICP general measures
elevate HOB (enhances venous outflow)
Loosen C-collar (if present), keep neck midline which enhances venous outflow, prevents "kinking"
maintain euvolemia
avoid hypotension
control pain/agitation
71
CSF production vs CSF absorption
not consistent over time and among individuals
Production not affected by ICP
but as ICP increases (usually >14cm H20) -> absorption increases
72
most common etiologies for hydrocephalus
```
intraventricular hemorrhage (IVH) of newborn
chiari II (myelomeningocele)
aqueductal stenosis
post infectious
tumors
congenital brain malformations
```
73
types of hydrocephalus
obstructive
Communicating
over-production
74
what type of hydrocephalus can bacterial meningitis cause
communicating Hydrocephalus (HCP)
75
flow of CSF is blocked along one or more of the narrow pathways connecting the ventricles
Obstructive hydrocephalus
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occurs when the flow of CSF is blocked after it exits from the ventricles
communicating hydrocephalus
77
mongolian spot, hair, tissue are all what type of markers
cutaneous
78
what age should you have head circumferences
2 years and younger
79
hydrocephalus signs/symptoms
abnormal enlargement of head
AF (anterior Fontenelle) tense/bulging when child is sitting up and quiet
scalp appears thin and glistening
scalp veins prominent
separated suture lines
vomiting, sleepiness, irritability, sunsetting eyes
seizures
difficulty feeding
80
position child should be in when checking fontanelle
upright
81
what week gestation is the germinal matrix max size
23 weeks (2.3mm)
82
common mistake with assessing eye movement tracking
signs without sound
83
what week gestation is the germinal matrix 1.15mm
32 weeks
84
what week gestation is the germinal matrix involuted
36 weeks
85
what week gestation is the germinal matrix gone
39 weeks
86
what grade (intracranial hemorrhage)
hemorrhage limited to subpendymal matrix
grade 1
87
toddler specific hydrocephalus s/s
if sutures not closed, head enlargement
sutures closed -s/s increased ICP
HA, vomiting, nausea, blurred or double vision, irritable, tired
balance problems, delayed walking, talking, poor coordination
loss of previous abilities
seizures
88
eye signs for hydrocephalus
setting sun (Parinaud's syndrome)
nystagmus
VI nerve paresis
89
higher risk time frame for infection with shunt
6 months after insertion or manipulation of any sort
90
a small catheter is passed into a ventricle of the brain. A pump is attached to the catheter to keep the fluid away from the brain. Another catheter is attached to the pump and tunneled under the skin, behind the ear, down the neck and chest and into the peritoneal cavity. The CSF is absorbed in the peritoneal cavity
Ventriculoperitoneal shunt (VP shunt)
91
a typical shunt infection lowers IQ by how many points
10
92
testing for meningitis in an shunted pt
still need to
93
labs for shunt infection
CRP
Procalcitonin
CSF esosinophilia (>7% suggests infection)
94
procalcitonin is an inflammatory marker that checks for what
bacterial infection
95
what inflammatory marker checks for viral infection
CRP
96
what hour marker does vancomycin reach steady state
24 hour
97
when do you start drawing vanc trough levels
24 hour mark
so if you are vanc q 8 draw 30 min prior to 3 rd dose
if you are vanc q 6 hours draw 30 min prior to 4th dose
98
what vanc trough level do you want to maintain for shunt infection treatment
>15-20
| 10-15 without shunt
99
other than shunt placement for treatment of hydrocephalus (surgical)
cranial morcellation
100
what type of bleed
"thunderclap headache/worst headache of life"
subarachnoid and can be intraventricular as well
101
star of death pattern on CT
aneurysm
102
work up for aneurysms
Labs
CTA or MRA/MRV
may get diagnostic angiogram as well
103
Treatment for aneurysms
usually involves clipping or open case
TIGHT BLOOD PRESSURE CONTROL WITH ARTERIAL LINE
High risk for stroke
High risk for vasospasm ->leads to stroke
104
Post aneurysm how many days are critical risk for stroke, in ICU
21 days
105
clinical presentation of brain injury - shift/herniation
progressive loss of consciousness
coma
irregular breathing
resp arrest
irregular pulse
cardiac arrest
loss of all brainstem reflex (blink, gag, pupillary reaction to light)
106
hydrocortisone and Decadron -whats better for treating adrenal insufficiency
hydrocortisone
107
tumor that grows slow
benign
108
tumor that grows fast
malignant
109
what type of tumor does chemo and radiation target
targets mitosis
| malignant
110
posterior fossa tumors - what CN deficits
Primarily V, VI, VII, VIII
V - ptosis, moves mandible chewing
VI - eyes cant abduct
VII - facial palsy
VIII - balance and hearing
111
amount of contrast they use for a contrasted CT (Isovue300)
2cc/kg: max of 100cc
>50kg - max of 100cc
>75kg - case dependent, may choose to use Isovue 370
112
imaging that demos intracranial vessels in 2D/3D
CTA (Computed Tomography Angiography)
113
gold standard for evaluating
Vessel occlusion/stenosis
aneurysm/AVM
Abnormal tumor circulation
Angiography
114
why are they ordering an MRI
stroke
evaluation of ETV (CINE)
Tumor/post surgery
AVM/aneurysm
Non-bony items
Ligamentous injury
Brain anatomy (any plane)
115
MRI vs CT
no radiation with MRI
more detailed for MRI
116
isotonic IV solution
what is it?
what does it do to the cells?
what does it do to the vascular volume?
NS
nothing to cells
increases volume
117
hypertonic saline
what is it?
what does it do to the cells?
what does it do to the vascular volume?
3%
so this adds sodium to the vascular
pulls water out of the cells into the vascular
shrinks cells
increases vascular volume
118
hypotonic saline
what is it?
what does it do to the cells?
what does it do to the vascular volume?
.45%
this pulls water from the vascular to the cells
enlarges cells
119
what color is blood and bone on a CT
White
120
What color is tissue on CT
black
121
decreased density on a CT means...
presence of surrounding edema
122
increased density on a CT means...
tumors with high nuclear to cytoplasmic ratio
123
CT Head with contrast will show what
areas of increased vascularity and breakdown of blood -brain barrier
124
A standard plane for Brain CT is selected to avoid excessive radiation to the ______
lens of the eye (retina)
125
Isovue 300: Contrast max dose rules
2cc/kg: max of 100cc
>50kg: max of 100cc
>75kg: case dependent, may choose to use Isovue 370
This is what they have to give to get a contrast study. If they have had one contrasted study, must wait 24 hours to get another study
126
Does MRI use Radiation
no
127
imaging type characterized by altered attenuation
CT
128
Imaging type characterized by signal intensity
MRI
129
what color is air and bone on MRI
black
130
What is the stronger/more detailed MRI magnet
3T
131
Renal precautions for MRI contrast
MRI Gadolinium can not be dialyzed
If GFR <60 (stage 3 or 4 renal disease, no gadolinium)
If they are a dialysis pt, you cant do this...
There is another med for off label use (Ferumoxytol (Feraheme)
132
Off label med as an alternative to Gadolinium for contrast for MRI in pt on dialysis
Ferumoxytol (Faraheme)
| IV 2-5mg/kg (max reported dose: 510mg)
133
for US (sonography) ______ stops the frequency beam completely
Bone
134
Imaging type that uses high frequency sound
Ultrasound
135
CTA and MRA
which imaging type requires contrast
CTA (Computed Tomography Angiography)
MRA (Magnetic Resonance Angiography) does not require contrast.
136
what imaging type uses signals that demonstrate vessels, aneurysms, and AVM
MRA
137
Imaging type that evaluates intra and extracranial vessels
- Vessel occlusion/stenosis
- Aneurysms/AVM
- Abnormal tumor circulation
**This can be diagnostic and interventional
Angiography (Angiogram)
-catheter inserted into femoral artery and maneuvered up to carotid or vertebral origin (guidewire/image intensifier)
Iodinated contrast used
138
After an AVM that has ruptured and pt has stabilized, 7 days later what are you looking to do imaging/interventional
MRA to view
| Angiogram to intervene
139
why do you want to use MRI instead of CT for stroke protocol
It takes a min of 6 hours to be able to see a stroke on CT, but can take 12 hours to show
140
If your worried about a head bleed, what do you order?
CT Head without contrast
141
what does MRI evaluate
```
Stroke
Evaluation of ETV (CINE)
Tumor/post surgery
AVM/aneurysm
Non-bony items
Ligamentous injury
Brain anatomy (any plane)
```
142
stroke protocol vs Rapid MRI
Stroke protocol - T1, T2
| Rapid - T2 only
143
what imaging is used to evaluate vessel injury/abnormality but uses less radiation than angiography
CTA
144
what imaging is used to
- evaluate blood supply to/from region
- evaluate anatomy of vessels looking for stenosis, occlusion, dissection
MRA/MRV
145
What imaging is the gold standard for aneurysm/AVM
Angiogram
146
what are the risks with MRI
sedation risks
| if kidney problem - metals in contrast
147
How is an MRI diff then CT
MRI is less radiation
| MRI is more detailed....the CT showed that something that was wrong but the MRI is going to give us more information
148
Headache
subjective fever
Abdominal pain
Vomiting
What lab do you need to draw?
What are you looking for?
CBC
low platelets
ORDER CT! This is the start of alot of neuro bleeds....(remember sepsis case study)
This set of symptoms is very common for early symptom of a severe neuro problems
149
Platelet requirement for neurosurgery to take pt to OR
100,000
150
white matter is what
myelinated tissue
151
myelin is made up of what
cholesterol
152
white matter and gray matter
| what is on outside and what is on inside of brain
White matter is inside
| gray matter is outside
153
cranial nerves that arise from the midbrain
```
CN III (oculomotor)
CN IV (trochlear)
```
154
cranial nerves that arise from the pons
```
CN V (trigeminal)
CN VI (abducens)
CN VII (facial)
CN VIII (vestibulocochlear)
```
155
cranial nerves that arise from the medulla
```
CN IX (glossopharyngeal)
CN X (vagus)
CN XI (accessory)
```
156
part of the brain that controls balance and coordination
cerebellum
157
Part of brain that regulates basic body functions
Brainstem - breathing, digestion, heart rate, blood pressure, being awake and alert
158
what cranial nerve is eyes moving side to side
6th
| if your L eye does not move to the side then that is a L sided CNVI palsy
159
what CN is eye conversion (when you have them follow finger follow to their nose)
4th
160
What CN controls eyelid movement
3rd
161
Brain death exams and problems with insurance
To declare someone brain dead, it requires 2 examinations. Sometimes there is a requirement for time in between the 2 exams. After 2nd one is done, pt is declared dead. Most insurance companies won't pay after this. So if they change their mind...this can have significant implications.
162
There is only one organ that can be donated even if your cold and not producing urine
Cornea
163
Shunt problem Neurosurgery will have to have what imaging first
CT
164
CBC number requirements for Neurosurgery
must be at least
Hgb - 10
HCT - 30
platelets - 100,000
165
surgical prep product info
Hibiclens is preferred
Chloraprep is flammable (hair catches fire)
Hibiclens is not safe for meninges so for LP needs to be iodine or chloraprep
166
In a brain bleed situation, when is a reasonable time to re-scan if no changes
4-6 hours
167
Bright or Dark
| MRI - T1
Dark
168
Bright or Dark
| MRI-T2
Bright (white)
169
The deeper in the brain the injury, the _______amount of force that caused it
Greater
170
what type of bleed
accumulation of blood between skull & dural membrane
Epidural hematoma
171
What is the most common cause of an epidural hematoma
Epidural hematoma
172
unilateral pupil dilatation - 2 potential causes
compression of a 3rd nerve
think seizure or bleed
if it goes away...seizure....
173
on CT there is a hematoma that is described as a well-defined mass, maintains boundaries within cranial sutures
Epidural hematoma
174
collection of blood below dura but external to the brain and arachnoid membrane
Subdural hematoma
175
Subdural hematoma classification:
| clotted blood - up to 48 hours
Acute
176
Subdural hematoma classification:
| 2-3 d to 2-3 wks, clot lyses
subacute
177
Subdural hematoma classification:
| >3 weeks, fluid mass
Chronic
178
the displacement of brain tissue, cerebrospinal fluid and blood vessels outside the compartments in the head that they normally occupy
Herniation
179
shaken baby syndrome is now called
Abusive head trauma
180
other reasons for shaken baby symptomes
underlying hematologic or metabolic problem
181
Osmotic therapy for ICP management with doses
Hypertonic saline
3% (3-5ml/kg)
23% (0.5.1ml/kg)
182
what can decrease CSF production
infection
183
Does Increased ICP affect CSF production
no, but as ICP increases (usually >14cm H20) absorption
184
germinal matrix is at its max size at how many weeks gestation
23 weeks (2.3 mm)
at 32 weeks (1.15 mm)
Involuted at 36 weeks
Gone at 39 weeks
185
hydrocephalus eye signs
Setting sun (Parinaud's syndrome)
VI nerve palsy/paresis (means same as palsy) (can't look up)
nystagmus (from pressure to the cerebellum)
186
95% of shunt infections occur within the first ______ months of operation
3 (very unlikely in a fever in a child that had a shunt infection more than a year ago)
187
Fever in a shunt pt ...what labs need to be drawn
CBC
ESR
CRP
188
Treatment in a pt with shunt infection
Broad spectrum abx (including vanc), replaced by organism specific antibiotics
Shunt needs to be replaced with an external ventricular drain (EVD) and a new shunt be replaced after CSF sterile
189
Posterior Fossa Tumor Work up
MRI brain and spine w and w/o contrast
Start Dexamethasone: (symptomatic reasons- vasodemic edema): 0.25-0.5mg/kg/day divided q 6 hours
PPI
If decompensating due to HCP - may need EVD placement prior to OR/MRI
labs
