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UCSM-SURGERY2 > SCHWARTZ Ch42 - Neurosurgery > Flashcards

SCHWARTZ Ch42 - Neurosurgery Flashcards

1
Q

Neurologic and Neurosurgical Emergencies

A

1) Raised ICP
2) Brain Stem Compression
3) Stroke
4) Seizure

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2
Q

Normal ICP

A

4-14mmHg

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3
Q

Sustained ICP level that can injure the brain

A

20 mmHg

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4
Q

3 normal contents of the

cranial vault:

A

1) Brain tissue (80%)
2) Blood (10%)
3) CSF (10%)

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5
Q

Brain’s content expand due to:

A

1) swelling from traumatic brain injury (TBI)
2) Stroke
3) reactive edema

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6
Q

Blood volume can increase by:

A

1) Extravasation to form hematoma

2) reactive vasodilation in a hypoventilating, hypercarbic patient

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7
Q

CSF volume increases by:

A

Hydrocephalus

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8
Q

Temporal lesions push

the uncus medially and compress the midbrain.

A

uncal herniation

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9
Q

Masses higher up in the

hemisphere can push the cingulate gyrus under the falx cerebri

A

subfalcine herniation

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10
Q

passes between the uncus and midbrain and may be

occluded, leading to an occipital infarct.

A

posterior cerebral artery

PCA

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11
Q

the branches of this artery run along the medial surface of

the cingulate gyrus

A 
anterior
cerebral artery (ACA)
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12
Q

posterior cerebral artery

PCA

A

leading to an occipital infarct.

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13
Q 
anterior
cerebral artery (ACA)
A

leading to

medial frontal and parietal infarcts.

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14
Q

Cushing’s triad

A

hypertension, bradycardia, and irregular respirations.

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15
Q

increased ICP, or intracranial hypertension,

often will present with..

A
  • headache
  • nausea
  • vomiting and
  • progressive mental status decline
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16
Q

Initial management of intracranial hypertension

A

airway protection and adequate ventilation

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17
Q

a characteristic “crashing patient,”

A
  • rapidly loses airway protection,
  • becomes apneic,
  • and herniates.
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18
Q

The cingulate gyrus shifts across midline

under the falx cerebri

A

Subfalcine herniation

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19
Q 
The uncus (medial temporal lobe gyrus) shifts medially and compresses the midbrain and
cerebral peduncle
A

Uncal herniation

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20
Q

The diencephalon and midbrain shift caudally through the tentorial incisura.

A

Central transtentorial herniation

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21
Q

The cerebellar tonsil shifts caudally

through the foramen magnum.

A

Tonsillar herniation.

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22
Q

posterior fossa

A

brain stem and cerebellum

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23
Q

Symptoms of brain stem

compression include:

A

-hypertension
-agitation
-progressive
obtundation
-followed rapidly by brain death

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24
Q

brain stem compression management:

A

emergent neurosurgical

evaluation for possible ventriculostomy or suboccipital craniectomy

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25
Q

defined as an uncontrolled synchronous organization of neuronal electrical activity

A

seizure

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26
Q

three main areas of neurosurgical

focus for trauma are:

A

1) traumatic brain injury (TBI)
2) spinal cord injury (SCI)
3) peripheral nerve injury

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27
Q

most common type of cerebral hernia

A

Subfalcine hernia

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28
Q

Subfalcine hernia

A

also known as midline shift or cingulate hernia

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29
Q

caused by unilateral frontal, parietal, or temporal lobe disease that creates a mass effect with medial direction, pushing the ipsilateral cingulate gyrus down and under the falx cerebri

A

Subfalcine hernia

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30
Q

the movement of brain tissue from one intracranial compartment to another. This includes uncal, central, and upward herniation

A

Transtentorial herniation

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31
Q

Neurological signs that reflect dysfunction distant or remote from the expected anatomical locus of pathology

A

false localizing signs

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32
Q

The initial assessment of the

trauma patient includes

A
  • primary survey
  • resuscitation
  • secondary survey
  • definitive care
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33
Q

GCS Motor score

A

1 to 6

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34
Q

GCS Verbal score

A

1 to 5

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35
Q

GCS eye score

A

1 to 4

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36
Q

Normal GCS range

A

3-15

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37
Q

this fracture

is covered by intact skin

A

closed fracture

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38
Q

fracture is

associated with disrupted overlying skin

A

An open, or compound, fracture

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39
Q

The fracture lines may

be

A
  • single (linear);
  • multiple and radiating from a point (stellate);
  • multiple, creating fragments of bone (comminuted)
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40
Q

Closed

skull fractures do not normally require specific treatment

A

Open

fractures require repair of the scalp and operative debridement

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41
Q

Indications for craniotomy

A 
-depression greater than the
cranial thickness, 
-intracranial hematoma, 
-frontal sinus
involvement
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42
Q

Depressed skull fractures may result from

A

a focal injury

of significant force

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43
Q

GCS range for intubated patients

A

3T to 10T

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44
Q

simple laceration

A

copiously irrigated and closed primarily

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45
Q

laceration is short, a single-layer

A

percutaneous suture closure

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46
Q

laceration is long or has multiple arms

A

patient may need debridement and closure in the operating room, with its superior lighting and wider selection of instruments and suture materials

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47
Q

Extravasation of

blood results in ecchymosis behind the ear,

A

Battle’s sign

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48
Q

fracture of the anterior skull base can result in

A

1) anosmia (loss of smell from damage to the olfactory nerve), 2) CSF drainage from the nose (rhinorrhea),
3) periorbital ecchymosis,
(raccoon eyes)

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49
Q

A fracture of the temporal bone, for
instance, can damage the facial or vestibulocochlear nerve,
resulting in

A

vertigo, ipsilateral deafness, or facial paralysis

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50
Q

a carbohydrate-free isoform of transferrin exclusively found in
the CSF

A

β-2 transferrin testing

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51
Q

this test assesses for a double ring when a drop of the fluid is allowed to fall on an absorbent surface

A

The “halo” test

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52
Q

when the CSF leak is

in the lumbar thecal sac

A

the head of the bed should be flat so as to maximize hydrostatic pressure of the CSF fluid column at the cranial vault, away from the site of the defect

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53
Q

When

there is a contraindication, to lumbar drain placement

A

an extraventricular

drain should be used for CSF diversion

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54
Q

The initial impact, defined as the immediate injury to

neurons from transmission of the force of impact

A

primary injury

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55
Q

Subsequent neuronal damage due to the sequelae of trauma is referred to as

A

secondary injury

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56
Q

mechanisms of secondary injury

A
  • Hypoxia,
  • hypotension,
  • hydrocephalus,
  • intracranial hypertension,
  • thrombosis,
  • intracranial hemorrhage
57
Q

ABCD of resucitation

A

airway
breathing
circulation
disability

58
Q

severe head injury

A

GCS score is 3 to 8

59
Q

moderate head injury

A

GCS score is 9 to 12

60
Q

mild head injury

A

GCS score is 13 to 15

61
Q

TBI patients who are asymptomatic, who have only

headache, dizziness, or scalp lacerations, and who did not lose consciousness

A

low risk for intracranial injury

62
Q

Patients with a history of altered consciousness, amnesia, progressive headache, skull or facial fracture, vomiting, or
seizure

A

moderate risk for intracranial injury

63
Q

Patients with depressed consciousness, focal neurologic
deficits, penetrating injury, depressed skull fracture, or changing
neurologic examination

A

high risk for intracranial injury

64
Q

may be discharged home without a head CT scan

A

low risk for intracranial injury

65
Q

undergo a prompt head CT

A

moderate risk for intracranial injury

66
Q

Types of Closed Head Injury

A

Concussion
Contusion
Diffuse Axonal Injury
Penetrating Injury

67
Q

Colorado grading system

A

Concussion

68
Q

Colorado grading system:

Head trauma patients with confusion

A

grade 1

69
Q

Colorado grading system: patients with amnesia

A

grade 2

70
Q

Colorado grading system: patients who lose consciousness

A

grade 3

71
Q

The brain is also much more susceptible to injury from
even minor head trauma in the first 1 to 2 weeks after concussion. Patients should be informed that, even after mild head injury, they might experience memory difficulties or persistent headaches.

A

second-impact syndrome

72
Q

temporary neuronal

dysfunction following nonpenetrating head trauma; head CT is normal, and deficits resolve over minutes to hours

A

concussion

73
Q

defined as:

  • transient loss of consciousness,
  • alteration of mental status.
  • Memory difficulties
  • amnesia of the event
A

concussion

74
Q

a bruise of the brain, and occurs when the force from trauma is sufficient to cause breakdown of small vessels and extravasation of blood into the brain

A

contusion

75
Q

frontal, occipital, and temporal poles are most often involved

A

contusion

76
Q

Contusions also may occur in brain tissue opposite the site of impact. These contusions result from deceleration of the brain against the skull

A

contre-coup injury.

77
Q

caused by damage to axons throughout the brain, due to rotational acceleration and then deceleration

A

Diffuse axonal injury (DAI)

78
Q

considered to be a severe

form of a concussion, often with irreversible consequence.

A

Diffuse axonal injury (DAI)

79
Q

due to bullets or fragmentation devices

A

missile (Penetrating Injury)

80
Q

due to knives or ice picks

A

nonmissile (Penetrating Injury)

81
Q

Traumatic Intracranial Hematomas

A

1) Epidural Hematoma
2) Acute Subdural Hematoma
3) Intraparenchymal Hemorrhage
4) Pneumocephalus

82
Q

accumulation of blood

between the skull and the dura

A

Epidural Hematoma

83
Q

results from arterial disruption, especially of the middle meningeal artery

A

Epidural Hematoma

84
Q

Epidural Hematoma on head CT

A

the blood clot is bright,
biconvex in shape (lentiform), and has a well-defined border
that usually respects cranial suture lines

85
Q

result of an accumulation of blood between the arachnoid membrane and the dura

A

Acute Subdural Hematoma

86
Q

results from venous bleeding, typically from tearing of a bridging vein running from the cerebral cortex to the dural sinuses

A

Acute Subdural Hematoma

87
Q

Acute Subdural Hematoma on head CT

A

the clot is bright or mixed-density, crescent-shaped (lunate), may have a less distinct border, and does
not cross the midline due to the presence of the falx

88
Q

Open craniectomy for evacuation of the congealed clot and

hemostasis generally is indicated for EDH.

A
  • clot volume <30 cm3

- maximum thickness <1.5 cm, –GCS score >8

89
Q

Open craniotomy for evacuation of acute SDH is indicated

for any of the following:

A

-thickness >1 cm
-midline shift >5 mm
-GCS drop by two or more points from the time of injury to
hospitalization

90
Q

a collection of blood breakdown products that is at least 2 to 3 weeks old

A

Chronic Subdural Hematoma

91
Q

Chronic Subdural Hematoma on head CT

A

Acute hematomas are bright white (hyperdense) on CT scan for approximately 3 days, after which they fade to isodensity with brain, and then to hypodensity after 2 to 3 weeks. A true chronic SDH will be nearly as dark as CSF on CT

92
Q

Traces of white
are often seen due to small, recurrent hemorrhages into the collection. These small bleeds may expand the collection enough
to make it symptomatic

A

acute-on-chronic SDH

93
Q

often occur in patients without a clear history of head trauma as they may arise from minor head injury.
Alcoholics, the elderly, and patients on anticoagulation are at
higher risk for developing chronic SDH

A

Chronic Subdural Hematoma (CSDHs)

94
Q

consists of a viscous fluid

with the texture and dark brown color reminiscent of motor oil.

A

Chronic Subdural Hematoma (CSDHs)

95
Q

Isolated hematomas within the brain parenchyma are most often associated with hypertensive hemorrhage or arteriovenous malformations (AVMs)

A

Intraparenchymal Hemorrhage

96
Q

Intraparenchymal Hemorrhage - Indications for craniotomy include:

A

-any clot volume >50 cm3
-clot volume >20 cm3 with referable neurologic deterioration
(GCS 6–8)
-associated midline shift >5 mm or basal cistern
compression

97
Q

defect in the skull that allows air to enter the intracranial cavity. This may occur following may represent an
iatrogenic defect created following cranial surgery or following head trauma

A

Pneumocephalus

98
Q

occurs when the intracranial
air pocket is under tension which can result in life threatening
herniation if left untreated

A

tension pneumocephalus

99
Q

Two radiographic features have been associated with a tension pneumocephalus

A

1) “Mount Fuji” sign

2) “air bubble” sign

100
Q

where the air pocket separates the frontal lobes and widens the inter-hemispheric fissure

A

“Mount Fuji” sign

101
Q

where there are multi-focal pockets of air throughout the subarachnoid cisterns, putatively within the subarachnoid space

A

“air bubble” sign

102
Q

two major mechanisms by which pneumocephalus develops

A

1) “ball valve”

2) “inverted bottle”

103
Q

involves the passage of air into the intracranial cavity during periods of positive pressure, whereby the defect in the skull acts as a one-way valve

A

“ball valve”

104
Q

management involves avoiding positive pressure ventilation,
and laying the head of the bed flat to minimize air traveling
upwards into the cranial cavity

A

“ball valve”

105
Q

mechanism involves air entering the intracranial space due to a negative pressure gradient created by the drainage of CSF

A

“inverted bottle”

106
Q

management should be focused on minimizing CSF drainage through the defect

A

“inverted bottle”

107
Q

the head of bed must be elevated so as to reduce hydrostatic pressure in the ventricular CSF fluid column, and controlled CSF diversion can be performed using an extraventricular or lumbar drain

A

“inverted bottle”

108
Q

Peptic ulcers occurring in patients with head injury or high ICP are referred to as

A

Cushing’s ulcers

109
Q

refers to violation of the vessel wall intima

A

dissection

110
Q

Blood at arterial pressures can then open a plane between the intima and media, within the media, or between the media and adventitia. The newly created space within the vessel wall is referred to as

A

false lumen

111
Q

Traumatic dissection may occur in the carotid artery

A

(anterior circulation)

112
Q

Traumatic dissection may occur in the vertebral or basilar arteries

A

(posterior circulation)

113
Q

result from neck extension combined with lateral bending to the opposite side, or trauma from an incorrectly placed shoulder belt tightening across the neck in a motor vehicle accident

A

Carotid Dissection

114
Q

Symptoms of cervical carotid dissection

A

-contralateral neurologic deficit from brain ischemia
-headache
-ipsilateral Horner’s syndrome from disruption of the sympathetic tracts ascending from the stellate ganglion on the surface
of the carotid artery
-bruit

115
Q

result from sudden rotation or flexion/extension of the neck,
chiropractic manipulation, or a direct blow to the neck.

A

Vertebrobasilar Dissection

116
Q

Symptoms of vertebrobasilar dissection

A
  • neck pain
  • headache
  • brain stem stroke
  • SAH
117
Q

absence of signs of brain stem function or motor response to deep central pain in the absence of pharmacologic or systemic medical conditions that could impair brain function

A

Brain Death

118
Q

Documentation of no brain stem function requires the following:

A
  • nonreactive pupils
  • lack of corneal blink,
  • oculocephalic (doll’s eyes)
  • oculovestibular (cold calorics) reflexes
  • loss of drive to breathe (apnea test)
119
Q

TUMORS OF THE CENTRAL NERVOUS SYSTEM

A

1) Intracranial Tumors
2) Metastatic Tumors
3) Glial Tumors
4) Neural & Mixed Tumors
5) Neural Crest Tumors
6) Miscellaneous Tumors
7) Embryologic Tumors
8) Spinal Tumors

120
Q

commonly present with focal neurologic deficit, such as contralateral limb weakness, visual field deficit, headache, or seizure

A

Supratentorial tumors

121
Q

cause increased ICP due to hydrocephalus from compression of the fourth ventricle, leading to
headache, nausea, vomiting, or diplopia

A

Infratentorial tumors

122
Q

result in ataxia, nystagmus, or cranial nerve palsies

A

Cerebellar hemisphere

or brain stem dysfunction

123
Q

Initial management of a patient with a symptomatic brain tumor generally includes

A

dexamethasone for reduction of vasogenic edema, and phenytoin or levetiracetam if the patient has seized

124
Q

most common type of intracranial tumor

A

Metastatic Tumors

125
Q

The sources of most cerebral metastases are (in

decreasing frequency):

A

lung, breast, kidney, GI tract, and melanoma

126
Q

Meningeal involvement may result in carcinomatous meningitis

A

leptomeningeal carcinomatosis

127
Q

Metastatic cells usually travel to the brain hematogenously and frequently seed the gray-white junction due to characteristic blood vessel caliber change

A

Metastatic Tumors

128
Q

Glial Tumors

A

1) Astrocytoma
2) Oligodendroglioma
3) Ependymoma
4) Choroid Plexus Papilloma

129
Q

provide the anatomic and physiologic support for

neurons and their processes in the brain

A

Glial cells

130
Q

most common primary CNS

neoplasm

A

Astrocytoma

131
Q

The term _____ often is used to refer to astrocytomas specifically, excluding other glial tumors

A

glioma

132
Q

low-grade astrocytoma or low grade glioma

A

Grades I and II

133
Q

anaplastic astrocytoma

A

grade III

134
Q

glioblastoma multiforme (GBM)

A

grade IV

135
Q

Median survival is 8 years after diagnosis

A

low-grade tumor

136
Q

Median survival is 2 to 3 years after diagnosis

A

anaplastic astrocytoma

137
Q

Median survival is 1 year after diagnosis

A

GBM

138
Q

Histologic features associated with higher grade astrocytoma

A
  • hypercellularity
  • nuclear atypia
  • endovascular hyperplasia
  • **Necrosis is present only with GBMs

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