Vascular Neurosurgery Flashcards

Question

Fisher 2

Answer 1

Diffuse or thin layer of blood with all vertical layers \<1mm thick

Answer 2

\>1mm in vertical fissures or cisterns/localised clot

Answer 3

Diffuse or no subarachnoid blood but with intracerebral or intraventircular clots

Answer 4

Focal or diffuse thin SAH, no IVH

Answer 5

Focal or diffuse thin SAH with IVH

Answer 6

Focal or diffuse thick SAH with no IVH

Answer 7

Focal or diffuse thick SAH with IVH

Answer 8

Based on GCS

Answer 9

GCS 13-14 with no focal neurology

Answer 10

GCS 13-14 with focal neurological deficit

Answer 11

ISAT demonstrated that for a selected population (good grade, M/ACA suitable for both coiling and clipping) Coiling associated with lower risk of dependency or death at 1y. Difference not seen at 5y

Answer 12

Posterior circulation aneurysm- difficult access Poor-grade patients Elderly Presence of medical comorbidities Raised ICP

Answer 13

Wide necked aneurysm Aneurysm incorporating branching arteries Coexisting haematoma requiring evacuation Acute brainstem compression

Answer 14

This patient has left III nerve palsy.

Answer 15

Supplies LPS and extraocular muscles except LR and SO

Answer 16

Innervate the sphincter pupillae muscle in iris

Answer 17

Ptosis, mydriasis and down (unopposed SO) and out (unopposed LR) pupil

Answer 18

DDx includes any lesion affect CN III. History sudden onset headache, the priority is to exclude SAH from an aneursym compressing the third nerve. Another less common cause of III palsy is pituitary apoplexy

Answer 19

The intracavernous segment of the third nerve is compressed by the expanding pituitary mass.

Answer 20

95% Reduces to 70% after 3 days. After 6d, a CT scan is not sensitive enough to detect an SAH

Answer 21

It is a normal CTH LP to exclude SAH may be reasonable. An alternative would be to proceed directly to cerebral angiography as an aneurysm, if found, will require urgent treatment in this context, whether or not it has bled given it is symptomatic

Answer 22

Timing depends on which diagnostic test is used. Spectrophotometry rests on the detection of bilirubin and should be performed after 12h

Answer 23

She should receive standard medical treatment for SAH pending the results.

Answer 24

A- ICA B- Ophthalmic C- PCA D- Anterior choroidal artery E- Anterior cerebral artery F- aneurysm which arises from posterior communicating artery

Answer 25

The paired oculomotor nerves exit the midbrain anteriorly. They lie between the PCA above and the superior cerebellar artery below, either side of the basilar artery. They then pass forward via the lateral wall of the cavernous sinus to enter the orbit via the SOF. CN III passes by the point where the PCA branches off the internal carotid. The site of origin of most PCA aneurysms.

Answer 26

PCA Superior cerebellar artery Basilar tip

Answer 27

Common causes for neurological deterioration after SAH: Re-bleed from aneurysm (unlikely in this case as the aneurysm has been secured) Vasospasm Hyponatraemia Hydrocephalus Seizures Hospital-acquired infections

Answer 28

ABC Urgent CT scan Blood test to include electrolytes and inflammatory markers. Adequate hydration should be ensured as dehydration increases the risk of vasospasm.

Answer 29

Blood is seen in the interhemispheric fissure (A), both Sylvian fissures, left (B) more than the right (C) and both ambient cisterns (D). There is hydrocephalus indicated by enlargement of the temporal horns of the lateral ventricles (E) and the third ventricle (F)

Answer 30

The presence of subarachnoid blood confirms the patient has re-bled as the admission was normal. This may have occurred from the aneurysm that was treated or from a separate aneurysm that was not identified on initial imaging. The patient should have urgent repeat angiography to determine whether the treated aneurysm is secure and to look for additional aneurysms. The repeat angiogram in this patient showed that the treated aneurysm was apparently secure and no additional vascular abnormalities were demonstrated. The patient proceeded to a craniotomy and a small remnant of the aneurysm neck, which was not seen on angiography, was found. This was clipped.

Answer 31

The causes of neurological deterioration listed previously apply to any deteriorating patient with SAH. However, the presence of lateralizing signs in this scenario make hyponatraemia, hydrocephalus, and hospital-acquired infections relatively less likely. Additionally, a postoperative haematoma requires consideration in this scenario as the patient has just had a craniotomy, and an urgent CT scan should be performed to exclude this.

Answer 32

CT scan excludes post-operative haematoma and re-bleed. Likely diagnosis is delayed cerebral ischaemia due to vasospasm Treatment strategies are controversial and vary but have been traditionally based on volume resuscitation and induced hypertension.

Answer 33

Spasm or narrowing of the cerebral vasculature that may follow SAH. It is often seen in aneurysmal SAH but rare in non-aneurysmal SAH (including traumatic SAH, perimesencephalic SAH and SAH from vascular malformations).

Answer 34

Not clearly established though various endothelial mediators are thought to play a role

Answer 35

70% and may or may not lead to a clinically detectable neurological deficit

Answer 36

AP right internal carotid angiogram on admission (left) and after 4 days with evolving left hemiparesis (right) of a 41-year-old man with a subarachnoid haemorrhage. By day 4 there is severely reduced calibre of the terminal internal carotid artery which begins just proximal to the aneurysm (A, transition point; B, aneurysm). The proximal MCA (C) and ACA (D) are both very severely attenuated compared with the earlier angiogram. This is diagnostic of severe vasospasm

Answer 37

Used when vasospsm leads to a clinical neurological deficit

Answer 38

7-14d after ictus but may be up to 21/7 after haemorrhage. The deficit may be permanent if cerebral infarction occurs.

Answer 39

Administration of 60mg oral nimodipine every 4 hours, reduced the risk of cerebral infarction by 34% and poor outcomes by 40%

Answer 40

Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. Showed reduction in incidence of cerebral infarction by 34% Reduction in poor outcomes by 40%

Answer 41

The overall goal is to augment cerebral blood flow to the affected area Triple H therapy

Answer 42

Haemodilution Hypertension Hypervolaemia

Answer 43

Adequate hydration, which can be gauged by CVP monitoring. Inotropes to augment MAP. Endovascular therapies such as transluminal angioplasty and intra-arterial release of vasodilators have not been proved in RCTs but may be used in refractory cases.

Answer 44

The oblique muscles principally act when the eyeball is turned medially whereas the superior and inferior rectus muscles generally work when the eye is turned laterally.

Answer 45

Oculomotor (III)

Answer 46

Trochlear (IV)

Answer 47

Abducens (VI)

Answer 48

Number of RBCs in CSF will be uniformly raised in all bottles. A decreasing number in sequential bottles is more consistent with traumatic tap. Although the patient may also have had an SAH

Answer 49

If the red cell count is only mildly elevated (hundreds), SAH is less likely as the RBC count in SAH is usually in the thousands

Answer 50

The CSF is inspected after it has been centrifuged. The result is positive if it has an orange tinge (the sample is held against a white background). A traumatic tap may also produce a positive result.

Answer 51

93% , a specificity of 95% , a positive predictive value of 72% , and a negative predictive value of 99%

Answer 52

Differentiates between SAH and traumatic tap by detecting oxyhaemoglobin and bilirubin in the CSF. Any blood that enters the CSF (from SAH or truamatic tap) will convert to oxyhaemoblogin as this occurs both in vivo and in vitro. In contrast the breakdown of RBCs into bilirubin only occurs in vivo and takes at least 12h and thus cannot result from a traumatic tap. Therefore a CSF sample taken 12h after headache onset that is positive for bilirubin is consistent with SAH. High CSF protein or serum bilirubin may also result in raised CSF bilirubin.

Answer 53

If in any doubt- angiography. Vasospasm which suggests recent haemorrhage can also be detected. Alternatively MRI with gradient echo and MRA sequences can demontsrate the presence of blood and aneurysm.

Answer 54

DDx includes cardiac events, hypoxic brain injury Seizure activity suggests intracerebral event. He may have had a seizure and currently be post ictal though ICH must be excluded

Answer 55

1o survey IV access, bloods, ECG. Unless it is certain that he is improving neurologically after a seizure, he is likely to require intubation for safe ongoing management including transfer to CT.

Answer 56

Frequently see trop rise/ECG abnormalities Very rarely reflects primary coronary event but rather the sudden myocardial stress caused by an extreme surge in SNS associated with the ictus of SAH

Answer 57

BP may be raised in the context of chronic HTN or part of the autoregulation response. It should not be aggressively controlled in the acute setting. Anaesthetic may cause a drop in BP. Efforts to control BP using conventional antihypertensives should be deferred unless his BP settles at an unacceptable level, usually \>200mmHg

Answer 58

3 key findings: Diffuse SAH in keeping with an aneurysmal haemorrhage Large ICH arising in the left sylvian fissure extending into the temporal lobe. There is no midline shift and the ventricles are symmetrical. There is hydrocephalus Left sylvian fissure haemorrhage is highly suggestive of ruptured left MCA aneurysm

Answer 59

Usually arises at the junction between the proximal MCA (M1) and the first branches (M2).

Answer 60

The proximal MCA is M1 This usually splits into two branches- M2 a bifurcation. One of which then splits into two itself. Occasionally all three M2 branches arise from M1 (a trifurcation)

Answer 61

This man is a poor grade SAH His WFNS grade is 4 His Modified Fisher grade is 4 His Hunt and Hess grade is also 4

Answer 62

All of the grades have been shown to correlate with worse outcome in terms of death and major disability. The risk of vasospasm and ischaemia leading to irreversible stroke is higher Their complication rate from VAP, DVT and infection is also higher. Treatment to secure aneurysm may also be more challenging as endovascular surgery may be limited by vasospasm. Surgery to clip the aneurysm often finds a swollen brain, making clipping without resection of brain impossible.

Answer 63

Management of the hydrocephalus. This should be undertaken as soon as possible with EVD Neurological state must then be reassessed with weaning of sedation

Answer 64

They do not distinguish between coma due to high blood load and coma due to hydrocephalus.

Answer 65

There is a left MCA aneurysm. Smaller unruptured AComm aneurysm, There is diffuse vasospasm causing attenuation of the visualised anterior circulation settings bilaterally.

Answer 66

Should be secured ASAP to reduce the risk of re-bleed which is likely to be fatal. Surgery will be challenging and may itself pose an unacceptably high risk. Coiling is likely to be lower risk procedure though there is a much higher chance of recurrence of MCA aneurysm with coiling as the neck cannot be completely secured

Answer 67

Clinical grading system to grade the severity of SAH

Answer 68

Asymptomatic, mild headache, slight nuchal rigidity

Answer 69

Moderate to severe headache, nuchal rigidity. No neurological deficit other than CN palsy

Answer 70

Drowsiness/confusion, mild focal neurologic deficit

Answer 71

Stupor, moderate-severe hemiparesis

Answer 72

Coma, decerebrate posturing

Answer 73

There are two areas of hyperdenisty in the sylvian fissures bilaterally. SAH is possible given the history and these would be suspicious for MCA aneurysms. It is also possible that the aneurysms have not bled and there is another cause for her headache. An LP would be reasonable to establish whether she has suffered an LP. This is important as it informs how she should subsequently be managed if an aneurysm is confirmed

Answer 74

There are bilateral MCA aneurysms. Which are approximately the same size. Mirror aneurysms in this configuration are seen occasionally. There is vasospasm of the right MCA M1 segment which is narrowed and irregular.

Answer 75

It is important to establish which aneurysm has bled and therefore requires treatment. Sometimes more than one aneurysm may be treated in the same session. If a PCom and ACom aneurysm in a favourable configuration they could be coiled in the same session or clipped in the same operation on the same side.

Answer 76

Not possible when either of the aneuryssm will require separate approach via right or left ICA or if neither can be coiled e.g. in bilateral MCA aneurysms clipping would need to happen via bilateral craniotomies.

Answer 77

Possible but more than doubles the risk to the patient of a single proceudre due to bilateral brain retraction. It is thus necessary to make a concerted effort to establish which aneurysm has bled.

Answer 78

Most commomn method is to review the pattern of SAH bleed on the presenting CT scan. The location of blood at presentation corresponds to aneurysm in around 80% of SAH.

Answer 79

MRI can be used to look for asymmetric blood with greater sensitivity than CT There may also be signs of recent bleed at angiography e.g. Murphy's teat, localised vasospam around one more than another.

Answer 80

Aneurysm morphology associated with a secondary bleb points to a higher rupture risk. This is more commonly seen at surgery but can be identified at angiography.

Answer 81

FLAIR (fluid attenuated inversion recovery)

Answer 82

Axial MRI flair sequence showing high signal on the right around the site of MCAA suggesting this is the aneurysm responsible for the bleed.

Answer 83

There is a large high density lesion in the region of the thalamus representing acute harmorrhage The blood extends into the third ventricle, the frontal and occiptal horns of the lateral venticles. The frontal horns are dilated, indicating hydrocephalus

Answer 84

The hemiplegia is due to the invovlement of the internal capsule, which lies adjacent to the thalamus and basal ganglia

Answer 85

The pateint has suffered a spontaneous intracerebral haemorrhage. The DDx includes hypertensive haemorrhage, bleeding from underlying lesion suvch as AVM or tumour or coagulopathy. Hypertensive haemorrahge is most frequently seen in this location in a patient of this age.

Answer 86

The most common location for spontaneous ICH is the BG \> cerebrum (lobar haemorrhage)\> cerebellum. These areas are susceptible because they are supplied by small arteries that directly branch off major arteries e.g. the lenticulostriate arteries supplying the basal ganglia and the thalamoperforating arteries supplying the thalamus. The walls of these susceptible arteries have been found to contain fat cells and fibrin-like material, a process termed lipohyalinosis and they develop microaneurysms (Charcot-Bouchard)

Answer 87

Charcot–Bouchard aneurysms (also known as miliaryaneurysms or microaneurysms) are aneurysms of the brain vasculature which occur in small blood vessels (less than 300 micrometre diameter). Develop as a consequence of lipohyalinosis

Answer 88

Patients with spontaneous subcortical haemorrahge should be admitted to a stroke unit and receive IV fluids, DVT prophlyaxis and NGT as required. Surgery for spontaenous ICH is contraversial but is generally not recommended when the haemorrhage is subcortical and the deficit from the haemtoma is unlikely to impove. Treatment of the hydrocephalus may lead to a neurological improvment.

Answer 89

LP Lumbar drain EVD

Answer 90

This patient has haemorrahge into the ventricles and performing an LP/drain in this situation carries the risk of coning. He underwent placement of an EVD

Answer 91

A blocked EVD can lead to an acutely raised ICP and is a potential emergency. Urgent assessment of the patient and the EVD apparatus is required. If the CSF swings in the drain when it is lowered obstruction is unlikely and the non-drainage is probably due to the EVD being set higher than CSF pressure. If the CSF does not swing, the drain is likely obstructed.

Answer 92

This depends on whether ventricular drainage is still required and will be informed by a CTH to assess ventricular size

Answer 93

The ventricles have decompressed and has clinically improved. Another EVD is not necessary. The patient requires ongoing stroke rehabilitation and an interval CT to check for recurrence of hydrocephalus and haemorrhage evolution

Answer 94

This is a superficial lobar haemorrhage. There is no associated intraventricular blood or hydrocephalus. There may be an unproven benefit in these cases to relieve local mass effect and improve associated deficit. If the patient is otherwise medically well, direct evacuation of the haematoma would often be appropriate. Evacuation of the haematoma depends on whether the clot is thought to have caused the deficit by direct damage to eloquent brain or by local mass effect. In the latter situation, surgery is likely to have more benefit

Answer 95

Cerebellar haematomas are more often treated surgically than supratentorial haematomas because the local mass effect can cause distortion of the fourth ventricle and obstructive hydrocephalus, the prevention of which results in a much better outcome. Many people will rehabilitate better from a bleed in the cerebellum rather than eloquent brain. This patient has early hydrocephlus and the surgical options are to treat the hydrocephalus only with an EVD, to evacuate the clot and anticipate the hydrocephalus will settle, or to evacute the clot and place an EVD at the same time with gradual wean over the next few days. Evacuation of clot would be preferred in this case as there is radiological evidence of brainstem compression which would not be relieved by EVD placement.

Answer 96

Showed no significant difference in outcome in conservative vs surgical management of spontaneous intracerebral haematomas in which the clinician was unsure as to management

Answer 97

Mass lesions or obstructive hydrocephalus

Answer 98

Reintroduce CSF or saline to the subarachnoid space

Answer 99

It involves placing a catheter within a ventricular cavity, most often the frontal horn of the lateral ventricle on the right side to minimise risk to the language area which is externalised through the skin and connected to a drainge device.

Answer 100

The zero level of the manometer is placed at the level of the foramen Monro (external auditory meatus).

Answer 101

The height of the manometer can be used. CSF will drain when intracranial pressure exceeds that level. At intracranial pressures less than this, CSF will swing in the tubing without draining ICP. A port is provided for sampling and antibiotic administration

Answer 102

Treatment of hydrocephalus: provides controlled, continuous drainge of CSF Treatment of ventriculitis: allows intrathecal Abx administration Continuous measurement of ICP

Answer 103

Bleeding Malposition of drain Rarely, stroke (through drain malposition)

Answer 104

Infection (skin, ventriculitis) CSF leak Blockage of drain Seizures

Answer 105

Infection Blockage CSF leak

Answer 106

Most frequent complication: leads to ventriculitis. The catheter should be replaced and intrathecal and IV Abx commenced

Answer 107

Check patency by lowering drain, if CSF swings, drain is patent. Check apparatus for disconnection or leaks Check tubing for debris Consider CT to check position of drain Consider aspiration Consider flushing drain with saline If you can flush but not aspirate from a drain that is not draining, the drain may be left in situ if it is being used for administration of Abx, otherwise it should be removed. If you cannot flush or aspirate from the drain which is not draining, it should be removed. Any manipulation of the EVD apparatus should be performed under sterile conditions

Answer 108

Occurs where the drain exits scalp. Check drain length to see whether it has been displaced. Place a suture to tighten the space between the drain and scalp or lower drain level to drain more CSF through drain. A CSF leak must not be left to continue as it will result in ventriculitis

Answer 109

There is a large right temporo-occipital intracerebral haematoma which has ruptured into the ventricles. There is moderate hydrocephalus. This is not a typical location for hypertensive haemorrahge. He is relatively young and is BP is not elevated. An underlying malformation is possible, most commonly an AVM. Haemorrhage from a tumour or cavernoma is possible but unlikely as typically these are more confined. The haemorrhage is parenchymal without any blood in the sylvian fissure so ruptured aneursym is unlikely. Early management is supportive. He is likely to need an EVD given the degree of hydrocephalus, intraventricular blood and neurological impairment. Surgery for the haematoma can be conisdered but the underlying cause should ideally be identified first so that intraoperative problems can be anticpated e.g. haemorrhage from an AVM

Answer 110

Many centres employ CTA for patients with SAH to look for intracranial aneurysms. if this patient has vascular pathology it is more likely to be an AVM\> Catheter angiography is preferred for AVM as it offers dynamic information during contrast injection and allows better visualisation of the feeding arteries supplying the AVM nidus as well as showing which veins drain the AVM. However, it is invasive and time-consuming to perform if the patient requires emergency surgery. In this case, a CTA should show abnormal vasculature prior to emergency surgery though it may not be sufficient for definitive elective treatment.

Answer 111

The images are an axial maximal intensity projection of the CTA An AP and lateral projection of the right ICA and an AP of the left vertebral artery angiogram

Answer 112

1- haematoma with some abnormal blood vessels posterolateral to the haematoma bed (2). There appears to be some supply to them from the right PCA. The carotid angiogram shows the abnormal tangle of vessels coming through a fetal PComm (4) which partly feeds the PCA (5). The vertebral angiogram also shows supply from the PCA and in addition during the arterial phase as shown there is filling from the veins draining the AVM before the normal cerebral venous phase. Early venous filling is the hallmark of arteriovenous shunting. Overall the nidus is around 2.5cm in diameter

Answer 113

The arterial supply and venous drainage of the AVM are the most important features along with the overall size. If endovascular therapy is to be attempted, either prior to surgical resection or radiosurgery, the vessels supplying the AVM must be wide enough to allow catheter access. Similarly, if these vessels also supply eloquent brain close to the AVM nidus, achieving safe catheter position for embolisation will be more difficult and the risk of embolisation causing stroke higher.

Answer 114

Requires knowledge of the arterial supply so that appropriate vessels can be ligated in turn before nidus excision

Answer 115

Venous drainage must be established and ligated before nidus excision otherwise intranidal pressures will rise and this may cause severe intraoperative harmorrahge

Answer 116

AVM \<3cm in diameter may be treated with stereotactic radiosurgery.

Answer 117

There is usually a lag between 2 and 5y before radiosurgery results in obliteration, it is a treatment with low morbidity and therefore is preferred for smaller AVMs in eloquent brain areas

Answer 118

Conservative Embolisation alone with curative intent Surgery alone Radiosurgery alone Embolisation followed by surgery or radiosurgery

Answer 119

Embolisation alone is not usually curative and should be performed for larger AVMs prior to surgery. It may be tried with curative intent in surgically inaccessible lesions. following failed radiosurgery or with palliative intent for large AVMs presenting with unusual features (e.g. steal phenomena or hydrocephalus)

Answer 120

Spetzler-Martin scale

Answer 121

Eloquence of surrounding brain Presence of deep draining veins Size of nidus

Answer 122

Eloquent (1) Non-eloquent (0)

Answer 123

Present 1 Absent 0

Answer 124

\<3cm, 1 3-6cm 2 \>6cm 3

Answer 125

Scores range from 1-5. For grade 1 AVMs, the surgical morbidity and mortality should be very low and surgery is the treatment of choice. For larger AVMs in non-eloquent brain, embolisation should be performed prior to surgery Smaller, eloquent AVMs should be managed with radiosurgery, possibly in combination with prior embolisation. High grade (4/5) are considered inoperable and should be treated with embolisation to reduce the size of the nidus and then be re-evaluated

Answer 126

Far lower than for aneursyms, 5-17% per year compared with 2% per day and therefore there is not the same mandate for urgent excision. If the patient is sufficently well there is a strong argument for early surgery in AVM.

Answer 127

The signs point to a lesion in the upper thoracic spinal cord. This is supported by the UMN signs in the lower limbs, T3 sensory level and extensor plantars. Impaired proprioception in this context suggests dorsal column involvement

Answer 128

It can interfere with the central micturition pathway which runs in the spinal cord.

Answer 129

This gentleman requires an urgent MRI scan of the spine. He also requires a pre and post-void bladder scan. If a residual volume is found, urologoy opinion should be sought

Answer 130

There is an area of diffuse high signal in the spinal cord extending from T3/4 to T12 (A) Prominent vessels are present around the cord between these levels indicated by small areas of hypointensity or flow voids on the cord surface (B). These appearances are highly suggestive of a spinal vascular malformation. A mild disc bulge is also present (C) which is not compressing the spinal cord and therefore unrelated to the presenting symptoms

Answer 131

The spinal cord is supplied by an arterial anastomotic network consisting of the anterior spinal artery, paired posterior spinal arteries and anterior and posterior segmental arteries arising from the vertebral, posterior intercostal, lumbar or sacral arteries depending on the SC level which enter the spinal canal through the intervertebral foramina. Segmental arteries supply the spinal nerve roots and may extend intradurally to anastomose with the anterior or posterior spinal arteries. The spinal veins have a similar configuration to the arteries. There are usually 3 anterior and 3 posterior spinal veins that lie on the surface of the SC and drain into the epidural venous plexus. This drains into segmental veins but also communicates with the intracranial venous sinuses through the foramen magnum

Answer 132

Kim-Speltzer classficiation

Answer 133

SCDAVF Dural AVF in which a segmental artery forms a fistula with a draining vein at the dural sleeve of a nerve root

Answer 134

SCAVM (Glomus) Lesions consist of a compact intramedullary nidus

Answer 135

Juvenile SCAVM Juvenile lesions are large intramedullary lesions which may extend extradurally or extraspinally.

Answer 136

SCAVF Intradural, extramedullary AV fistulas with a direct connection between the vascular supply of the spinal cord and a vein

Answer 137

In Type 1 spinal AVMs, AV shunting leads to chronic venous hypertension in the intradural venous system. This leads to slower flow in the arterial system, impaired oxygenation and subsequent ischaemic myelopathy. Spinal cord oedema begins in the most dependent part of the cord, hence symptoms are usually of an ascending nature. In extradural AVMs, myelopathy may occur due to compression of the cord due to engorged extradural veins.

Answer 138

The patient has progressive symptoms and therefore should be offered treatment to obliterate the fistula. The options are surgical divison or endovascular embolisation

Answer 139

Offers the highest rate of sucess though with associated risks of open surgery

Answer 140

The endovascular option is associated with an appreciable recurrence rate, approximately 50%

Answer 141

DDx includes vascular events such as SAH Other types of intracranial haemorrhage should be considered though they would more frequently be associated with neurological deficits. Non haemorrhagic causes such as migraine and cluster headache should be considered though typically patients will have a prior history

Answer 142

There is a well-circumscribed subcortical hyperdensity in the right parietal region with an appreciable amount of surrounding oedema. This is an acute haemorrhage The location and age of the patient mandate a search for an underlying abnormality that may have bled such as a tumour or vascular malformation. If no structural lesion is found the patient should be investigated for medical causes such as vasculitis or amyloid angiopathy

Answer 143

The management should initialy be conservative given the good neurological condition. If he deteriorates repeat imaging should be performed to look for further haemorrhage. In planning further Ix the underlying cause should be considered. The bleed has none of the features of an aneurysmal haemorrhage and further investigation is probably not necessary. MRI scanning should be delayed for 6/52 to allow the haematoma to involute to increase diagnostic certainty. Angiography may be required depending on MRI findings

Answer 144

General advice about what to do if there were recurrence of symptoms and the need to return to hospital. He must not drive due to the presence of supratentorial haemorrhage of unknown aetiology and the associated risks of seizures. For the same reason he should be counselled about swimming alone and working in dangerous situations

Answer 145

The coronal T1, axial T2 and axial T1 post contrast scans are shown. The abnormality and an associated fluid-filled cavity within it are seen. The mass has high signal elements on T1 and low signal elements with a black rim on T2. It does not enhance. These are charactersitic findings of a cavernoma however a metastasis is still possible. An angiogram is not reuqired, it would probably be normal although a late venous blush may be seen reflecting the venous nature of the vascular channels in the cavernoma. The near-normal angiographic appearances of cavernomas has led them to being described as angiographically occult vascular malformations

Answer 146

High signal elements on T1, low signal on T2. No appreciable enhancement. May have a black rim which represents haemosiderin deposts after acute haemorrhage

Answer 147

Cavernomas are characterised by recurrent haemorrhages that are typically small as they are under venous pressure. A cavernoma in the parietal lobe is unlikely to be life-threatening. Surgery is typically curative and depending on the location may carry low morbidity. The principle risks of surgery would be epilepsy and focal neurological deficits. The risks of not treating a patient such as the one in the case discussed is low. Surgery may not be offered unless patients have difficulty with the uncertainty of conservative management.

Answer 148

Problems with spatial perception, classically getting lost in an otherwsie familiar location. Dressing apraxia

Answer 149

Has been used extensively with safety and good long term results for intracranial AVMs. It has also been used for cavernomas with equivocal results. It appears to be safe and thus may be given if there is no alternative and conservative management is not acceptable. It is more appropriate for surgically inaccessible lesions such as those in the thalamus or brainstem.

Answer 150

The patient should be told of the diagnosis but reassured that the risks of recurrent haemorrhage are statistically low but that this may be more clinically apparent in eloquent areas of the brain such as the brainstem. A gradual recovery is to be expected and rehabilitation with ophthalmological follow up if the diplopia doesn't resolve. He may be disqualified from driving because of his diplopia. Surgery would only be considered for brainstem cavernomas with recurrent bleeds, progressive deficits with a lesion that is surgically accessible. Radiosurgery may be the only option though outcomes are equivocal.

Answer 151

His GCS is E4, VD, M6= 10 He is unable to speak, presumably due to damage to the language areas in the lest hemisphere. His verbal score is therefore recorded as D (dysphasic)

Answer 152

This patient has an expressive dysphasia as he is obeying commands, indicating that his comprehension is intact

Answer 153

There is a large area of low attenuation in the left frontal, temporal and parietal regions and in the posterior basal ganglia. This is an acute infarct and it involves the entire left MCA. There is also some early haemorrhagic transformation as evidenced by high density in the left putamen. The caudate head is spared as it is supplied by the ACA perforators. There is effacement of the frontal horn of the left lateral ventricle with midline shift. There is also contralateral compartmental hydrocephalus of the trigone of the right lateral ventricle

Answer 154

Thrombolysis would be considered for acute ACA but this is not appropriate as the presentation is too late and there is evidence of haemorrhage. The patient should receive aspirin, IVF, thromboprophylaxis with IPB, swallowing assessment and NG tube if necessary for feeding and medication. A) Management of BP B) Management of AF with FVR C) Ix to establish the underlying aetiology of the stroke

Answer 155

In general hypertension in the immediate period after stroke is best left alone. If antihypertensives are used an IV infusion that can be stopped readily should be used

Answer 156

Carotid doppler Echo for thrombi, valve disease, septal defets Routine bloods including CV risk profile

Answer 157

There are three randomised trials, DESTINY, DECIMAL, HAMLET comparing decompressive hemicraniectomy with medical management for malignant MCA infarction. None of the studies showed a difference in primary outcome though a meta-analysis of the three studies appears to show that surgery reduces mortality in patients under the age of 60 who undergo surgery withn 48h. Many although not all patients who are salvaged with surgery are left with a signfiicant disability

Answer 158

Made on an individual basis taking into account the patient's neurological status, previous level of functioning and comorbidities

Answer 159

Note the brain herniating through the craniectomy defect and the resolution of the midline shift. The outcome without surgery would have been transtentorial herniation. After surgery, this patient remained hemiplegic and aphasic and was transferred to a neuro-rehab centre. If he regians independence a cranioplasty will be required at a future data, the bone window CT scan shown was used to plan the prosthesis

Answer 160

The scan shows a circular hyperdense area adjacent to the right MCA which is likely to be an aneurysm. Note that the density is the same as the adjacent blood vessels. There is no subarachnoid blood suggesting that this is an incidental finding. There are small low-density areas in the left side of the pons which may be due to small vessel disease. It was felt her symptoms were more likely explained by a TIA

Answer 161

The initial management is to investigate the TIA in a conventional manner with echo, carotid doppler and risk factor control The subsequent risk of aneurysm rupture should be weighed against the risks of the procedure to secure the aneurysm. The rupture risk of an aneurysm of this size is about 0.5-1% per year. The patient does not have to be admitted to hospital

Answer 162

More people are undergoing high resolution brain imaging for smyptoms in the past that would not have warranted imaging of sufficient quality to show an aneurysm. Increased education of the relatives of patients with SAH is resulting in more screening investigations for first-degree relatives

Answer 163

Visual disturbance, typically a CN3 palsy due to PComm or SCAA or reduced acuity in one eye due to optic nerve compression by an ophthalmic artery or terminal carotid aneuryms.

Answer 164

Can occasionally present with cortical deficits due to mass effect. Large aneurysms are usually lined with thrombus and if there is turbulent flow within the aneurysm this thrombus may act as a source of emboli. Aneurysms may thus present with TIAs in the downstream territory

Answer 165

Treated specifically to prevent rupture. Large aneurysms are difficult to clip or coil and may require complex vascular surgical procedures including bypass.

Answer 166

What is the life expectancy of the patient? What is the annual risk of rupture? What are the consequences of aneurysmal rupture likely to be e.g. cavernous carotid aneurysms may cause a carotid-cavernous fistula which is a more benign problem than SAH. How can the aneurysms be treated, is it suitable for coiling, what are the risks associated for surgery if it is suitable for clipping?

Answer 167

The International Study of Unruptured Intracranial Aneurysms

Answer 168

Anterior- ICA, ACA, AComm, MCA or Posterior PCom, basilar, PCA

Answer 169

Risk of recurrence is increased fourfold if they continue to smoke

Answer 170

Follow up is not to detect imminent rupture but rather to detect recurrence of the aneurysm neck which might over time result in an unstable aneurysm with a risk of re-rupture. CTA is the modality of choice for diagnosis of ruptured aneurysm initially but there will be too much artefact from the coils to make it of any value in the surveillance of a coiled aneurysm. MR angiography or catheter angiography can be used instead.

Answer 171

Arterial puncture Stroke

Answer 172

When MRA is unclear

Answer 173

An early post-procedure MRA may be done to offer baseline comparison for the next scan which may be done at 6/12 assuming the coiling is deemed satisfactory. If scans at 6/12 and 12/12 show stable appearances, the follow up interval is increased

Answer 174

Should be offered to any individual with two first-degree relatives with aneurysmal SAH. Patients with associated disease e.g. ADPKD may be offered a screening CTA or MRA. There are emerging groups of patients with lesser indications for screening angiography for example those with relatives with unruptured aneurysms. They may be offered screening but should be counselled that small aneurysms in difficult locations to access surgically may be left or monitored and that the act of screening may provoke more anxiety than assurances.

Answer 175

There is appreciable recurrence of the neck of the aneursym due to compaction of coils into the dome

Answer 176

The options are again endovascular or surgical management. The aim of treatment is now very different from the aim of the original coiling, the aim is now to protect the patient from rupture during the rest of her life. The aim before was to prevent early re-rupture which is most common during the first few weeks after the bleed. Open surgery for previously coiled aneurysm can be challenging as the coil ball may prevent a good closure of the aneurysm clip. It may be necessary to exclude the patent vessel temporarily, open the sac and remove the coils before clipping the aneurysm and then remove the temporary clips from the parent vessel. These manoeuvres increase the risk of surgical morbidity. Given that the patient has had aneurysm recurrence after endovascular intervention and the different aims of this secondary treatment, surgical management would be reasonable

Answer 177

Double vision can be monocular or binocular. Binocular diplopia is more frequently seen in neuroglocial disease and occurs when the two eyes do not move in synchrony. This may be due to dysfunction of the extra-ocular msucles themselves or their nerve supply, or the central pathways involved in conjugate eye movements. Monocular diplopia occurs due to problems within the eye iteself e.g. damage to the cornea, iris or lens

Answer 178

A left CN6 palsy leads to failure of abduction of the left eye and therefore diplopia on looking to the left. Diplopia on looking right may also occur in this situation because the balance of the globe is maintained by the tone of all the extra-ocular muscles. An alternative explanation is that she may also have a partial left CN4 palsy

Answer 179

If a carotid aneurysm is wholly or partially within the cavernous sinus, as it expands it can compress structures in the lateral wall of the cavernous sinus, the nearest to it being the 6th nerve. If the aneurysm expands further it will compress more lateral structures- CN III, IV V1, 2

Answer 180

Numbness on one side of the face though not in the jaw or lower teeth, complete ophthalmoplegia. You may expect the lateral rectus to be involved first due to its close association with the internal carotid in the medial wall of the cavernous sinus

Answer 181

Complete ophthalmoplegia

Answer 182

Enlarging intracavernous carotid aneurysm.

Answer 183

Carotid aneurysm rupture causing a carotico-cavernous fistula. If there is an intradural segment to the aneurysm, a rupture of this section would lead to SAH which is potentially life-threatening

Answer 184

The MRI shows a left-sided 30mm mass located medial to the left temporal lobe and arising in the region of the carotid artery. The angiogram confirms this to be a cerebral aneurysm arising from the proximal intradural ICA. The posterior rim of the aneurysm does not fill with intra-arterial contrast and shows low signal on the MRI where the previously inserted coils were placed

Answer 185

This would be considered a giant aneurysm, with the prognosis being poor even if unruptured. The risk of rupture death or serious permanenet neurological deficit being \>50% within 1y. Giant aneurysms can be symptomatic if they rupture or they can cause ischaemic infarction by throwing off thrombotic emboli into their distal arterial territory.

Answer 186

Operative clipping can sometimes be undertaken but often has a higher risk of stroke and may have to be considered under cardiac bypass and hypothermic cerebral circulatory arrest. Coiling and stenting can sometimes be an option but still carry appreciable risks of stroke or death. Balloon occlusion of the feeding artery into a giant aneurysm can often be the best option provided that it is tolerated during a test occlusion without inducing a neurological deficit. This usually allows complete occlusion of the aneurysm with no risk of recurrence and a minimal physiological insult to the patient as the procedure is endovascular. If the cerebral collateral circulation is not enough to tolerate this and the patient develops a temporary deficit when performing a test occlusion, it is possible to perform surgical extracranial to intracranial bypass procedure to augment the cerebral blood flow to the affect distal circulation of the brain Patient can then subsequently undergo delayed balloon occlusion 1/12 later

Answer 187

Usually the superficial temporal artery or a segment of radial artery joint to the caroid artery in the neck can be anastomosed onto a branch of the MCA The CTA shows the presence of a superficial temporal artery branch transversing through a craniotomy defect and joining onto a vessel on the cerebral surface

Answer 188

Can be used to treat chronic cerebral haemodynamic insufficiency as a result of ICA occlusion causing haemodynamic TIAs or progressive strokes in patients with proven low blood flows in the ischaemic territory. Such patients typically develop a stereotyped neurological deficit when their cerebral perfusion might be reduced fro example when dehydrated or experiencing a postural drop. Patients with high-grade carotid stenosis could have an endarterectomy or carotid stenting to help improve CBF if they are developing haemodynamic TIAs. Can also be considered for moyamoya disease

Answer 189

Rare, idiopathic progressive cerebrovascular disease seen in children or young adult patients. Initially causes ischaemic stroke but later develops an increased risk of intracerebral bleeds as new abnormal fragile perforator arteries enlarge and attempt to supply the ischaemic regions of the brain

Answer 190

Fluid attenuation inversion recovery Special inversion recovery sequence with a long inversion time. Removes signal from CSF from the resulting images. Brain tissue on FLAIR images therefore appears similar to T2 weighted images with grey matter brighter than white but CSF is dark instead of bright.

Vascular Neurosurgery Flashcards

(223 cards)