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DVS Part VIII Neurosurgery > Pestana/Pre-Test/DVS > Flashcards

Flashcards in Pestana/Pre-Test/DVS Deck (15)
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1

Mgmt:

  1. Prolactinomas
  2. Acromegaly
  3. Pituitary apoplexy
  4. Trigem neuralgia
  5. Reflex sympathetic dystrophy (causalgia)
  6. GBM?

Mgmt:

  1. Prolactinomas: r/o pregnancy, hypothyroidism --> therapy with bromocriptine
  2. Acromegaly: surgical removal (trans-nasal or trans-sphenoidal)
  3. Pituitary apoplexy: urgent steroid replacement
  4. Trigem neuralgia: carbamazapine
  5. Reflex sympathetic dystrophy (causalgia): develops several months after a crushing injury... constant, burning, agonizing pain that does not respond to usual analgesics... extremity is cold, cyanotic, and moist --> sympathetic block = diagnostic --> surgical sympathectomy
  6. GBM: Combined surgical resection, external beam radiation, chemo w/ temozolomide

2

A 16 y/o adolescent boy sustains head trauma in a MVC. He has a GCS of 15 and an obvious depressed skull fracture with 1-cm displacement. During his hospital stay, he notices clear fluid draining from his nose. What is the best mgmt 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. Abx for sinusitis

c. Immediate dural repair

3

An 18 y/o man is admitted to the ER following a MVC. He is alert, fully oriented, but witnesses to the accident report an interval of unresponsiveness following the injury. Skull films disclose a fracture of the left temporal bone. Following x-ray, the pt suddently loses consciousness and dilation of the left pupil is noted. Which of the following is the most likely diagnosis?

 

a. A ruptured berry aneurysm

b. An acute subdural hematoma

c. An epidural hematoma

d. An intra-abdominal hemorrhage

e. A ruptured AVM

c. An epidural hematoma

 

Epidural hematomas are typically caused by a tear in the MMA and they may be associated with linear skull fractures, usually in the temporal region. The lesion appears as a hyperdense biconvex mass between the skull and the brain on CT scan. 

 

Typical hx is one of head trauma followed by a momentary alteration in consciousness and then a lucid interval lasting for up to a few hours. This is followed by a loss of consciousness, dilation of pupil on ipsilateral side, and then contralateral hemiparesis.

 

Treamtne: temporal craniectomy, evaluation of hemorrhage, control of bleeding vessel

4

A 42 y/o woman presents to the ER with the worst headache of her life. A noncontrast CT scan of the head is negative for lesions or hemorrhage. She then undergoes a lumbar puncture, which appears bloody. All 4 tubes collected have RBC counts greater than 100,000/mL. WHich of the following steps is the most appropriate mgmt of this patient?

 

a. Repeat head CT scan with IV contrast

b. Perform angiogram of aorta and lumbar branches for immediate embolization of injured vessel

c. Perform 4-vessel cerebral angiogram

d. Administer dose of mannitol

c. Perform 4-vessel cerebral angiogram

 

A CT scan w/o contrast will show hemorrhage... if CT scan is negative, then perform lumbar puncture to assess for xanthochromia. Workup should then proceed to a 4-vessel cerebral angiogram to assess for cerebral aneurysm

 

Surgical tx consists of craniotomy w/ clipping of aneurysm

5

An 18 y/o high school senior develops peripheral vision abnormalities. A 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. GH therapy

b. Cerebral angiography with tumor embolization

c. Transsphenoidal decompression of optic nerve and optic chiasm

d. Surgical resection

e. Radiotherapy

d. Surgical resection

 

Tx of craniopharyngiomas consists of complete subfrontal or transsphenoidal excision if possible. 

6

Following significant head trauma, a 34 y/o woman undergoes a CT scan that demonstrates bilateral frontal lobe contusions of the brain. There is no midline shift. She has a GCS of 14. Which of the following is the best initial mgmt of this pt?

 

a. Observation alone

b. Observation and administration of anticonvulsive medication for 1 week

c. Administration of 25 g mannitol

d. Placement of ICP monitor

b. Observation and administration of anticonvulsive medication for 1 week

 

Pts deemed to have a substantial contusion should receive anticonvulsive medication to prevent seizures in an early posttraumatic period. Mannitol not required in setting of mild TBI.

7

A middle-aged homeless man is brought to the ER by EMS for AMS, seizures, and vomiting. On exam, he has no fever, neck stiffness, or evidence of head trauma. He does, however, have multiple dental caries and a FND. Which of the following is the best next step in the patient's workup?

 

a. LP

b. Noncontrast head CT

c. Contrast-enhanced head CT

d. Placement of ICP monitor

c. Contrast-enhanced head CT

 

The pt's presentation is most consistent with a brain abscess, which is dx by contrast-enhanced CT or MRI. In this condition, fever, elevated WBC and signs of meningeal irritation are often absent. Brain abscesses develop by either contiguous spread from adjacent structures or hematogenous spread from a distant site. Common sites of infection include paranasal sinus infection, dental caries, and ear infection. 

 

Contrast-enhanced CT and MRI reveal ring-enhancing lesion usually at gray-white interface with surrounding edema. Tx involves ID-ing organism and appropriate abx therapy. 

8

A 32 y/o man presents with progressive frontal headaches. His symptoms started 2 months ago and often wake him from his sleep. His VS are stable, and neurologic examination reveals no focal deficits. MRI brain imaging reveals a mass lesion, and subsequent biopsy is consistent with a type IV astrocytoma. Which of the following is true regarding this patient's illness?

 

a. Considered most common primary malignant brain tumor

b. Prognosis is good since tumor is slow growing

c. Biopsy should demonstrate psammoma bodies

d. Tumor does not cross corpus callosum

e. IFN-beta and glatiramer acetate used in mgmt of this tumor

a. Considered most common primary malignant brain tumor

 

GBM = type IV astrocytoma

 

Life expectancy estimated to be <1 year from time of dx

9

Which of the following is true regarding diffuse axonal injury?

 

a. Often associated w lucid interval

b. Blurring of gray-white jxns is commonly found on imaging

c. Occurs following tensile force

d. Persistent vegetative state is rare

e. Pts often have hyperdense fluid in ventricles, sulci, and cisterns

b. Blurring of gray-white jxns is commonly found on imaging

 

Pts with DAI following rapid deceleration trauma typically suffer instantaneous LOC followed by persistent vegetative state. Prognosis is very poor.

 

CT scan will show numerous minute punctate hemorrhages with blurring of gray-white jxns.

10

Which of the following findings would be expected in a patient presenting with a transtentorial (uncal) herniation?

 

a. Loss of gag reflex

b. Diplopia on attempted lateral gaze

c. MR palsy on attempted lateral gaze

d. Ptosis and "down and out" eye

d. Ptosis and "down and out" eye

 

The uncus is part of the medial temporal lobe and can herniate through tentorium and compress midbrain and brainstem during significant brain swelling --> local compression of nearby structures by herniated uncus (e.g., mydriasis or "blown pupil," ipsilateral ptosis, and "down and out" eye).

11

In a pt with an isolated head injury and concerns for increased ICP, which of the following would have the most potential to benefit the patient?

 

a. Hypertonic (3%) saline sol'n

b. Ventilation with permissive hypercapnia

c. Trendelenburg position of bed

d. Intermittent D50 boluses

e. Nitroprousside drip

a. Hypertonic (3%) saline sol'n

 

Act as osmotic force to draw fluid out of tissues and into the blood and thus decrease ICP

12

A 20 y/o female arrives to the ED after slipping and hitting her head on ice and briefly losing consciousness. In the ED, she vomits twice. She denies amnesia. BP is 110/80. Pulse is 80/min. GCS = 15. Exam is normal with no papilledema. What is the most appropriate next step in mgmt? 

 

a. Admit for observation and order CT scan of head only if she develops neurologic deficit. 

b. Admit for observation and start corticosteroids.

c. Order CT scan of head w/o contrast now

d. Discharge home w/ tapered dose of corticosteroids

c. Order CT scan of head w/o contrast now

 

Head CT indicated following minor head trauma and more than one episode of emesis, GCS <15 at 2 h after injury, evidence of basilar skull fracture (Battle's sign, raccoon eyes), FND, age >65, suspected skull fracture

13

A 29 y/o M with no PMHx presents to ED with worst headache of his life. He was watching television when the headache started and is unlike any headache he has experienced before. It is located near the back of his head. He reports that his father had a kidney transplant at a young age. He is managed appropriately for his acute condition. His recovery is complicated by progressive lethargy, agitation, and eventual coma. Which of the following would most likely explain this condition?

 

a. Nephrogenic DI

b. Neurogenic DI

c. Poor oral intake

d. Cerebral salt-wasting syndrome

d. Cerebral salt-wasting syndrome

 

Pts with SAH can have multiple complications after their initial presentation including rebleeding, hyperglycemia, and electrolyte abnormalities. Pts are at risk for symptomatic hyponatremia 2/2 cerebral salt-wasting syndrome. THis is thought to occur b/c of inappropriate secretion of vasopressin resulting in water retention. In addition, these patients have increased levels of ANP and BNP which contribute to salt wasting. 

14

HIV pts with ring-enhancing lesion... best next step in mgmt?

 

a. Radiation

b. Chemo and radiation

c. Pyrimethamine and sulfadiazine

d. Stereotactic brain biopsy

c. Pyrimethamine and sulfadiazine

 

Either have toxoplasmosis or CNS lymphoma

 

Treat first with pryimethamine/sulfa for toxo... and then stereotactic brain biopsy

15

61 y/o man with PMHx opioid dependence and diabetes presents with focal back pain and R leg weakness. Does not recall any recent trauma. He reports having "back surgery" nearly 20 years ago but does not remember why. 

 

Physical exam significant for focal pain on palpation of his lower lumbar spine. Lab exam significant for elevated ESR. Imaging is obtained. What is the best mgmt approach for this condition?

 

a. NSAID

b. High-dose IV corticosteroids

c. Long-term abx

d. Long-term abx with surgical drainage

d. Long-term abx with surgical drainage

 

Epidural abscess from previous spinal surgery

MRI = imaging modality to confirm