The Greenberg Rapid Review 8E.pdf

The Greenberg Rapid Review

�Thieme

The Greenberg Rapid Review A

Companion to the

gth

Edition

Leonard I. Kranzler, MD, JD, FACS, FAANS Clinical Professor of Surgery (Neurosurgery) University of Chicago Chicago, Illinois jonathan G. Hobbs, MD Resident Neurosurgeon University of Chicago Chicago, Illinois

Thieme New York

•

Stuttgart

•

Delhi

•

Rio de Janeiro

Executive Editor: Timothy Y. Hiscock Managing Editor: judith Tomat Director, Editorial Services: Mary jo Casey Production Editor: Naamah Schwartz International Production Director: Andreas Schabert Vice President, Editorial and E-Product Development: Vera Spillner International Marketing Director: Fiona Henderson International Sales Director: Louisa Turrell Director of Sales, North America: Mike Roseman Senior Vice President and Chief Operating Officer: Sarah Vanderbilt President: Brian D. Scanlan

Library of Congress cataloging-in-Publication Data

Names: Kranzler, Leonard 1., author. I Hobbs, jonathan G., author. Title: The Greenberg rapid review: a companion to the 8th edition I Leonard I. Kranzler, MD, jD, RACS, FA ANS, Clinical Professor of Surgery (Neurosurgery), University of Chicago, Chicago, Illinois, jonathan G. Hobbs, MD, Resident Neurosurgeon, University of Chicago, Chicago, Illinois. Description: New York : Thieme, [2017]1 A companion to: Handbook of neurosurgery. 8th ed., c2017. I Includes bibliographical references and index. I Description based on print version record and CIP data provided by publisher; resource not viewed. Identifiers: LCCN 2016037898 (print) I LCCN 2016035166 (ebook) I ISBN 9781626232075 I ISBN 9781626232068 (pbk.) Subjects: LCSH: Nervous system-Surgery-Examinations, questions, etc. Classification: LCC RD593 (print) I LCC RD593 .G677 2017 Suppl. (ebook) I DOC 617.4l80076-dc23 LC record available at https:lllccn.loc.govl2016037898

© 2017 Thieme Medical Publishers, Inc.

Thieme Medical Publishers, Inc. 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, [email protected] Thieme Publishers Stuttgart Ri.idigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, [email protected] Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, [email protected] Thieme Publishers Rio de janeiro, Thieme Publica�oes Ltda. Edificio Rodolpho de Paoli, 25' andar Av. Nilo Pe�anha, 50 - Sala 2508, Rio de janeiro 20020-906 Brasil +55 21 3172-2297 1 +55 21 3172-1896 Cover design: Thieme Publishing Group Typesetting by Friedheim Hubner Electronic Publishing GmbH

Printed in The United States of America by Sheridan Press 5 4 3 2 1 ISBN 978-1-62623-206-8 Also available as an e-book: elSBN 978-1-62623-207-5

Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of Important note:

knowledge at the time of production of the book

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

!;j FSC

-Joe ...

MIX Paper from rea�nslble 10u�

Fsc• co12s21

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

In appreciation for their example of scholarship, tradition, and love of family, this book is dedicated to the memory of: Mr. Morris Kranzler Mr. Louis Weinberg Mr. Max Goldstein Dr. K. jeffery Kranzler Mr. Charles Kranzler Dr. Gershon Kranzler Rabbi Alex Weisfogel Mr. Nate Blum Mr. Henry Kranzler Mr. Harvey Goldstein Mrs. Luiza Anghelo Mr. Yerachmiel Kranzler Mrs. Ruth Yudkofsky

Mr. Ben Teichner Dr. David Kranzler Mr. Alex Angheluta Mr. Milton Saltzman Mr. David Hurwitz Mr. Kurt Loebenberg Mr. joseph Kranzler Mr. Walter Rosenbush Mr. Steve Rotter Mr. Tobey Friedman Mr. Python Anghelo Mr. Arthur Kranzler

In appreciation of my parents, Lillian ( obm) and George Kranzler ( obm). And to my wife Uliana and children, jenelle, justin, and jared. Leonard I. Kranzler

Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs.

Eva Teichner Ada Rotter Rina Rosenbush Dina Weinberg Chana Kranzler Rose Hurwitz Ruth Kranzler Helen Goldstein Betty Blum Rosalie Goldstein Eveline Kranzler Miriam Saltzman

No accomplishment would be possible without the unwavering and selfless love of my family, allowing me to pursue my aspirations and dreams without limits. They are the ones who made this possible. My friends and mentors who provide guidance, support, and an often needed voice of reason; I am grateful for all that you do. It is for my family, friends, and the countless others who are yet to be named, that I strive to be a better physician and most importantly, a better person. Thank you all. jonathan G. Hobbs Below is a quote from Walden, a book that has provided inspiration, fostered self-reflection and a deeper understanding of what my family and friends mean to me, and how I want to approach life. It is my hope that these words will speak to you too, even in some minute way, that may give you hope and reason in those dark times we all face during our journey to become the person we want to be. "I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived. I did not wish to live what was not life, living is so dear; nor did I wish to practice resignation, unless it was quite necessary. I wanted to live deep and suck out all the marrow of life, to live so sturdily and Spartan-like as to put to rout all that was not life, to cut a broad swath and shave close, to drive life into a corner, and reduce it to its lowest terms." - Henry David Thoreau, Walden: Or, Life in the Woods

Contents

Contents ............................................................................. viii Preface ................................................................................ xi Acknowledgments.................................................................... xiii Special Acknowledgment............................................................. xiv Part 1 2 3

1: Anatomy and Physiology Gross Anatomy, Cranial, and Spinal. Vascular Anatomy Neurophysiology and Regional Brain Syndromes

1 12 18

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 2: General and Neurology 4 Neuroanesthesia 5 Sodium Homeostasis and Osmolality 6 General Neurocritical Care 7 Sedatives, Paralytics, Analgesics 8 Endocrinology 9 Hematology 10 Neurology for Neurosurgeons 11 Neurovascular Disorders and Neurotoxicology

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28 31 36 38 44 48 53 64

Part 3: Imaging and Diagnostics 12 Plain Radiology and Contrast Agents 68 13 Imaging and Angiography..................................................................................... 73 14 Electrodiagnostics ................................................................................................ 78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 15 16 17

4: Developmental Anomalies Primary Intracranial Anomalies Primary Spinal Anomalies Primary Craniospinal Anomalies

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 5: Coma and Brain Death 18 Coma 19 Brain Death and Organ Donation

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 6: Infection 20 Bacterial Infections of the Parenchyma and Meninges and Complex lnfections 21 Skull, Spine, and Post-Surgical Infections 22 Other Nonbacterial lnfections

. . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 23 24 25

7: Hydrocephalus and Cerebrospinal Fluid (CSF) Cerebrospinal Fluid Hydrocephalus - General Aspects Treatment of Hydrocephalus

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 8: Seizures 26 Seizure Classification and Anti-Convulsant Pharmacology 27 Special Types of Seizures

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

81 88 95

102 108 111 121 128 132 138 146 152 160

Part 9: Pain 28 Pain

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

166

Part 10: Peripheral Nerves 29 Peripheral Nerves ................................................................................................ 173 30 Entrapment Neuropathies 185 31 Non-Entrapment Peripheral Neuropathies.............................................................. 194 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 11: Neurophthalmology and Neurotology 32 Neurophthalmology 204 33 Neurotology........................................................................................................ 217 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 12: Primary Tumors of the Nervous and Related Systems: Tumors of Neuroepithelial Tissue 34 General Information, Classification and Tumor Markers .......................................... 223 35 Syndromes Involving Tumors 230 36 Astrocytomas 234 37 Other Astrocytic Tumors 239 38 Oligodendroglia! Tumors and Tumors of the Ependyma, Choroid Plexus, and Other Neuroepithelial Tumors 243 39 Neuronal and Mixed Neuronal-Glial Tumors........................................................... 248 40 Pineal Region and Embryonal Tumors ................................................................... 251 41 Tumors of Cranial, Spinal and Peripheral Nerves 256 42 Meningiomas 266 43 Other Tumors Related to the Meninges. . . .. .... .. . . ....... . .. .. . . . . .. .. . . 271 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. .

.

.

.

.

. .

.

. . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

Part 13: Tumors Involving Non-Neural Origin: Metastases, Lymphomas, Chordomas 44 Lymphomas and Hematopoietic Neoplasms 275 45 Pituitary Tumors - General Information and Classification 278 46 Pituitary Adenomas - Evaluation and Nonsurgical Management 284 47 Pituitary Adenomas - Surgical Management, Outcome, and Recurrence Management 289 48 Cysts and Tumor-Like Lesions.... . . .. .... .. . . ....... . .. .. . . . . .. .. . . ..... . . 291 49 Pseudotumor Cerebri and Empty Sella Syndrome 294 50 Tumors and Tumor-Like Lesions of the Skull 295 51 Tumors of the Spine and Spinal Cord. .... .. . . ....... . . .. .... .. . . ....... . .. .. . . 297 52 Cerebral Metastases 299 53 Spinal Epidural Metastases 302 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. .

.

.

.

.

. .

.

. . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

.

. .

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

.

.

. .

.

.

. .

.

.

.

.

. .

.

. . . .

.

.

.

. .

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 14: Head Trauma 54 General Information, Grading, Initial Management.. . . .. .. . . . . .. .. . . ..... . . 305 55 Concussion, High Altitude Cerebral Edema, Cerebrovascular lnjuries 308 56 Neuromonitoring 314 57 Skull Fractures 320 58 Traumatic Hemorrhagic Conditions....... . .. .... . . . ..... . . .. .. . . . . .. .. . . 324 59 Gunshot Wounds and Non- Missile Penetrating Brain lnjuries 332 60 Pediatric Head Injury 334 61 Head Injury: Long-Term Management, Complications, Outcome 337 . . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

.

. .

.

. . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

.

.

. .

.

. .

.

.

. . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 15: Spine Trauma 62 General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries ... .. . . ....... . .. .... . . . ..... . . 340 63 Management of Spinal Cord Injury ....... . .. .... . . . ..... . . .. .. . . . . .. .. . . 349 64 Occipitoatlantoaxial Injuries (Occiput to C2 ) ..........................................................354 65 Subaxial (C3 through C7 ) Injuries I Fractures. .... . . . ..... . . .. .. . . . . .. .. . . 361 66 Thoracic, Lumbar and Sacral Spine Fractures . .... . . . ..... . . .. .. . . . . .. .. . . 366 67 Penetrating Spine Injuries and Long Term Management I Complications . .. .. . . 373 . . . .

.

.

.

. .

.

. . . .

.

.

. .

.

. .

.

.

. . . .

.

.

. .

.

. .

.

.

. . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

.

. .

.

. .

.

.

. . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

.

. .

.

. .

.

.

. . . .

.

.

.

. .

.

. .

.

.

.

. . . .

.

. .

.

.

.

. . . .

.

Part 16: Spine and Spinal Cord 68 Low Back Pain and Radiculopathy .........................................................................376 69 Lumbar and Thoracic Intervertebral Disk Herniation f Radiculopathy .......................383 70 Cervical Disc Herniation .......................................................................................393 71 Degenerative Cervical Disc Disease and Cervical Myelopathy ..................................397 72 Thoracic and Lumbar Degenerative Disc Disease ....................................................400 73 Adult Spinal Deformity and Degenerative Scoliosis .................................................404 74 Special Conditions Affecting the Spine ..................................................................407 75 Other Non-Spine Conditions with Spine Implications ..............................................412 76 Special Conditions Affecting the Spinal Cord .........................................................415 Part 17: SAH and Aneurysms 77 Introduction and General Information, Grading, Medical Management, Special Conditions ...............................................................................................419 78 Critical Care of Aneurysm Patients ........................................................................428 79 SAH from Cerebral Aneurysm Rupture ..................................................................432 80 Aneurysm Type by Location .................................................................................438 81 Special Aneurysms and Non-Aneurysmal SA H ....................................................... .444 Part 18: Vascular Malformations 82 Vascular Malformations ........................................................................................448 Part 19: Stroke and Occlusive Cerebrovascular Disease 83 General Information and Stroke Physiology ...........................................................454 84 Evaluation and Treatment for Stroke .....................................................................457 85 Special Conditions ...............................................................................................462 86 Cerebral Arterial Dissections .................................................................................468 Part 20: Intracerebral Hemorrhage 87 Intracerebral Hemorrhage ....................................................................................470 Part 21: Outcome Assessment 88 Outcome Assessment ..........................................................................................477 Part 22: Differential Diagnosis 89 Differential Diagnosis by Location or Radiographic Finding- Intracranial .................478 90 Differential Diagnosis by Location or Radiographic Finding - Spine .........................490 91 Differential Diagnosis (DDx) by Signs and Symptoms- Primarily lntracranial ............493 92 Differential Diagnosis (DDx) by Signs and Symptoms - Primarily Spine and Other 498 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Part 23: Procedures, Interventions, Operations 93 Procedures, Interventions, Operations: General lnformation ....................................509 94 Specific Craniotomies ..........................................................................................515 95 Spine, Cervical ....................................................................................................522 96 Spine, Thoracic and Lumbar .................................................................................527 97 Miscellaneous Surgical Procedures ........................................................................531 98 Functional Neurosurgery ......................................................................................534 99 Pain Procedures ..................................................................................................542 100 Seizure Surgery ...................................................................................................546 101 Radiation Therapy (XRT) .......................................................................................550 102 Endovascular Neurosurgery ..................................................................................555

Preface

This offering is a study and review aid. It is to

It is expected that the reader will review the

be used in conjunction with

material multiple times until

Neurosurgery, Eighth Edition,

Handbook of by Mark S.

success in

responding to the questions has been

Greenberg. It permits the user, after reading

achieved. The question formats take advan­

a page, section, or chapter in Greenberg, to

tage of the established ideas in learning

test retention of the details of that portion.

theory:

Every question is directly referenced to Greenberg's text, where background infor­ mation and context is readily available. An effort has been made to highlight

the

important facts in neurosurgical practice by posing questions to the reader that forces active involvement in the learning and re­

•

complex subjects broken into small bits

•

fill-in-the-gap exercises in sentences and

•

progressive withdrawal of cues forcing the

words user to recall more and more of the details •

view process. The purpose of this textbook is to make clinicians aware of what they should expect to know using a rapid review format. It will help identify for readers what they already

mnemonics or hints (some material has been arranged in "study charts" to aid mnemonic teaching techniques)

•

Humor

•

alternate arrangements of the material (the same facts presented in different formats)

•

repetition

know as well as what is not known and

Moreover, this study guide is designed with

provide a method by which an individual can

answers appearing directly after the ques­

verify the fact that has been learned. The

tions (we recommend that users cover the

reader can also have confidence that what

answers in the outer page margin) so that

has been highlighted as valuable has been

time is not wasted searching for correct

identified by peers and by an editor who has

answers at the back of the book. This format

been involved in neurosurgical education as

should further facilitate rapid review.

coordinator of the Chicago Review Course in

Neurological Surgery since 1974. Many ques­

Please note that literature references and the

tions were contributed by enrollees in the

index are present in the parent volume,

Chicago Review Course in Neurological Sur­ gery as well as by young neurosurgeons and neurologists. In a nutshell, individuals at all levels of neurosurgical and neurological sophistication have contributed to this book.

Handbook of Neurosurgery, Eighth Edition.

xii

Preface

Knowledge of this material demonstrated by

Note to the Reader

correct responses to the questions can give confidence to the reader that much of the

Please call to our attention any mistakes that

current scientific foundation of the specialty

you identify. Please suggest any additional

of neurosurgery has been mastered. This

mnemonic devices that might help others in

reassurance of a strong, up-to-date knowl­

the field of neurosurgery. Be aware that

edge base should be helpful to the resident,

medical knowledge is ever changing and that

the instructor, the neurosurgeon, and those

some items and opinions conveyed in these

who are planning to take written, oral, or

pages are controversial.

recertification examinations. Leonard I. Kranzler jonathan G. Hobbs

Contact the authors at [email protected] [email protected]

Acknowledgments

We acknowledge the cooperation and en­

We also thank our contributors and the team

couragement of Dr. Mark S. Greenberg. Our

of Thieme who helped us so much.

generation of neurosurgeons is fortunate that Dr. Greenberg has collated the literature of our field and presented it to us in such a concise, authoritative, well-balanced, and wise manner.

Special Acknowledgment

It has been a pleasure to work with and have the collective experience of our contributors. They have been insightful in their choice of questions, prompt and efficient, and fully cooperative. We thank each of you. For more details on the specific work of our contributors, please contact [email protected].

Uchenna Ajoku, MD

Ryan A. McDermott, MD

University of Port Harcourt Teaching Hospital

University of Texas at San Antonio

Port Harcourt, Nigeria

San Antonio, Texas

jason L. Choi, MD

jose M. Morales, MD MSc

University of Chicago

University of Chicago

Chicago, Illinois

Chicago, Illinois

Bhargav D. Desai, BS

Ramin A. Morshed, MD

University of Illinois-Chicago College of

University of California, San Francisco

Medicine

San Francisco, California

Chicago, Illinois

Andrew W. Platt, MD, MBA

j. Palmer Greene, BA

University of Chicago

University of Chicago Pritzker School of

Chicago, Illinois

Medicine Chicago, Illinois

Sean P. Polster, MD

University of Chicago Dominic A. Harris, MD

University of New Mexico Albuquerque, New Mexico

Chicago, Illinois Sophia F. Shalmr, MD

University of Chicago jordan Lebovic, BA

Chicago, Illinois

Harvard Medical School Boston, Massachusetts

jacob S. Young, BS

Yimo Lin, MD

Medicine

Oregon Health and Science University

Chicago, Illinois

University of Chicago Pritzker School of

Portland, Oregon Raisa C. Martinez Martinez, MD

University of Chicago Chicago, Illinois

1 Gross Anatomy, Cranial, and Spinal

•

Cortical Su rface Anatomy 1.

a. b.

Characterize the lateral cortical surface. T h e pre-centra l sulcus is not . The middle fronta l gyrus connects with the gyru s via a thin . The centra l sulcus is sepa rated from the sylvian fissu re _% of the time. The tissue separati ng them is ca l led the ___

___

c. d.

1 .1.1

complete precentra l , isth mus

__

e. The inferior and su perior pa rieta l lobules a re separated by the sulcus. f. The inferior pa rieta l lobule is com posed of i. the ii. and the g . The sylvian fissu re i. term i nates in the , ii. which is the Brod m a n n a rea #_ h . T h e su perior temporal gyrus i. term i nates in the , ii. which is the Brod m a n n a rea #_ _ _ __

__ __

___

__

98% su bcentra l gyrus intra pa rieta l

suprama rginal gyrus (SMG) a n g u l a r gyrus SMG 40 AG 39

2.

Complete the following regarding surface anatomy: a. The middle fronta l gyrus often connects with the b. The centra l sulcus joins the sylvia n fissu re i n on ly_%. c. A su b-centra l su lcus is present in_% of patients. d. The sylvia n fissu re term inates in the

supramarginal gyrus

e.

a n g u l a r gyrus

1 .1 .1

precentra l gyrus

__ __

The su perior tempora l sulcus is capped by the . ____

2 98

Part 1 : Anatomy and Physiology

2 3.

Matching. Match the following Brodmann cortical areas and their functional significance:

1 . 1 .2

Functional sign ifica nce:

CD primary motor cortex; 0 Broca 's a rea

a. b. c

d. e. f. g. h. 4.

a. b. c

d.

(motor speech); G) Wernicke's a rea in the dominant hemisphere; 0 pri mary a u d itory a rea; ® frontal eye fields; ® pri mary somatosensory a rea; (j) pre motor a rea; ® primary visual cortex Area : (a-h) below Area 3 , 1 , 2 Area 41 , 42 A�a 4 Area 6 Area 44 Area 1 7 Area 40, 39 Area 8

Complete the following regarding pars marginalis: Is t h e term inal part o f t h e sulcus. Is visible on axial view in_% of CTs and _% of M Ris. Is the of the middle paired g rooves straddling the midline. Extends into t h e hemispheres. On axial CT it is located just posterior to the widest It curves in lower slices. It cu rves i n higher slices. __

__

®

0 CD (j)

0 ® G) ®

1 . 1 .3

ci n g u l ate 95%, 97% most prom inent biparieta l diameter

_ __ _ _

e. f.

•

__

__

Central Sulcus on Axia l I maging 5 . Complete the following regarding central sulcus: a . Is visi ble in a l most_%. b. Does it reach the midli ne? Term inates in the c ___

•

posteriorly a nteriorly

1 .2

95% no paracentra l lobule

Surface Anatomy of the Cranium 6. True or False. The pterion is a region where each of the following bones comes together: a. frontal b. sphenoid (g reater wi ng) c pa rieta l d . tem pora l e. sphenoid (lesser wi ng)

1 .3 . 1

true true true true fa lse

Gross Anatomy, Cranial, and Spinal 7.

Matching. Match the bones/sutures that form t h e listed craniometric points. Bone/sutu re: CD l a m bdoid suture; 0 occi pitomastoid suture; ® pa rietomastoid suture; @ fronta l ; ® pa rieta l ; ® tem pora l ; (j) g reater wing sphenoid Cra n iometric point: a. asterion b. pterion True or False. The name of the junction o f lambdoid, occipitomastoid, and parietomastoid sutures is a . pterion b. asterion

1 .3 . 1

G), upper m a rg i n of the externa l a u d itory meatus

1 .3 . 1

1 0.

1 1 . The external landmark for the Sylvian fissure is a line from the lateral canthus to a spot three quarters of the way posterior along an arc running over the convexity in the to the midline from the --

1 .3.2

0 ®

CD nasion; i n ion

1 .3.2

3

Part 1 : Anatomy and Physiology

4

1 2. True or False. In relation to external landmarks the angular gyrus is a. one fi nger's breadth above the zygomatic a rch. b. just above the pinna.

c. d.

a th u m b's breadth behind the fronta l process of the zygomatic bone. at the junction of the l a m bdoid and sag itta l sutu re.

1 3. True or False. The motor strip of the motor cortex lies a . a t t h e level o f t h e coronal sutu re. b. within 2 em of the coronal sutu re. c. 3 to 4 em posterior to the coronal suture. d . 4 t o 5 .4 e m posterior t o t h e coronal suture. e. 2 em posterior to the mid-position of the nasion-inion a rc. f. 5 em straight u p from the externa l a u d itory m eatus. 1 4. True or False. In the nonhydrocephalic adult the lateral ventricles lie a . 2 t o 3 e m below t h e outer sku l l su rface. b. 3 to 4 em below the outer sku l l su rface. c. 4 to 5 em below the outer sku l l su rface. d. 5 to 6 em below the outer sku l l su rface. 1 5. True or False. In the nonhydrocephalic adult the anterior horns extend a . 1 t o 2 e m a nterior t o t h e fora men of Monro. b. 2.5 em a nterior to the fora men of Monro. c. 3 to 4 em a nterior to the fora men of Monro. 1 6. True or False. The fastigium is located at a. the mi dpoint of the Twining's line. b. the floor of the fou rth ventricle. c. the a pex of the fou rth ventricle with in the cerebe l l u m .

d.

1 t o 2 e m a nterior t o t h e coronal sutu re.

1 .3.2

fa lse true (The a n g u l a r gyrus is just a bove the pinna and im porta nt as part of Wernicke's a rea in the dominant hemisphere.) fa lse fa lse 1 .3.2

fa lse fa lse fa lse true true true 1 .3.3

fa lse fa lse true fa lse 1 .3.3

fa lse true fa lse 1 .3.3

fa lse fa lse true (The fastigium is the a pex o f t h e fou rth ventricle in the cerebe l l u m . ) fa lse

Gross Anatomy, Cranial, and Spinal 1 7.

a. b. c. d. 1 8.

list the surface landmarks of the following cervical levels: (3-4 C4-5 CS-6 (6-7 -- -----

----

-- --

Ta ble 1 .4

hyoid bone thyroid ca rti lage cricothyroid mem brane cricoid ca rti lage

Matching. Match the following surface landmarks and cervical levels:

1 .3.3

Surface landmark:

CD level of thyroid ca rti lage; @ cricoid

a. b. c. d. e. f.

•

carti lage; ® angle of mandible; @ cricothyroid mem brane; ® ca rotid tubercle; ® 1 em a bove thyroid cartilage (hyoid bone) Cervica l level: (a-f) below Cl -2 (3-4 C4-5 CS-6 C6 (6-7

® ®

CD @ ® @

Cranial Fora mina and their Contents 1 9.

a. b. c. d. e. f. g. h.

Matching. Match the foramen with contents (choices ma y b e used more than once). Contents: CD noth i n g ; @ middle meningeal a rtery; G) VII facia l ; @ V2 ; ® V3 ; @ Vl ; 0 IX, X, XI Foramen: (a-h) below su perior orbita l fissu re inferior orbita l fissure fora men laceru m fora men rotu n d u m fora men ova le fora men spinosum stylomastoid fora men j u g u l a r fora men

20. list the cranial nerves and the three branches o f o n e found within the superior orbital fissure (SOF). a. 0 b. t c. n d. f --

__

__

e. f.

a

1 .5.1

® @

CD

@ ® @ ® 0

1 .5.1

CN I l l ocu lomotor IV troch lear nasoci liary nerve fronta l nerve ophth a l m ic d ivision: a l l three bra n ches lacrimal nerve VI abducens nerve

5

Part 1 : Anatomy and Physiology

6 21 .

a. b. c. d. e.

list the other contents of the superior orbital fissure {SOF). s__ o v__ r__ m __ a __ which a rises from the I a rtery. o b of the m m a s p of the ICA ___

__

__

__

__

__

1 .5.1

su perior ophtha lmic vei n recu rrent meningeal a rtery lacri m a l orbita l branch o f t h e m i d d l e meningeal a rtery sym pathetic plexus of the ICA

22. Another name for the transverse crest is

crista fa lciformis

1 .5.2

23. Another name for the vertical crest is

Bill's bar

1 .5.2

_____ _

24.

Draw and label the nerves in the right porus acusticus.

1 .5.2

a. b. d e

c. d. e. f.

B i l l ' s bar Tra nsverse crest crista fa lciform is CN VII SV-su perior vestibular CN V I II IV-i nferior vestib u l a r

b

Fig. 1 . 1 25.

label the diagram of the right internal auditory canal. c

-------

1 .5.2

a. b.

F

D

A

B

Fig. 1 .2

E

c. d. e. f.

Tra nsverse crest Acoustic portion of CN VI I I CN V I I in facia l ca nal Su perior vesti bular nerve I nferior vestibular nerve Bill's bar-vertica l crest

Gross Anatomy, Cranial, and Spinal 26.

a. b. c. d. e. f. g. h.

•

Matching. Match the nerves of the lAC with the areas that they serve. Nerves: CD facia l n . ; @ nervus intermed ius; ® acoustic portion of VII I n . ; @ su perior branch of vestibular n.; ® inferior branch of vesti bular n. Areas served: (a-h) below facial m u scles hair fol l icles taste buds hearing utricle su perior semicircular ca nal latera l semicircu l a r ca nal saccu le

1 .5.2

CD

@ @ ® @ @ @ ®

I nternal Ca psule 27.

Most internal capsule lesions are caused by or . ___

throm bosis or hemorrhage

Name the vascular supply for the following components of the internal capsule: a . a nterior l i m b

28.

b.

posterior l i m b

c. ventra l posterior l i m b d. genu e. optic radiations

1 .6.2

latera l striate branches of MCA latera l striate branches of MCA a nterior choroidal di rect branches of ICA a nterior choroida l

29.

Name four thalamic peduncles and where their radiations go. ,f l a. a b. s ,p g c. p ,o &p a __

_

__

d.

i

__

,a

__

__

_

__

__

a

_

__

__

1 .6.1

___

__

1 .6.2

a nterior, fronta l lobe su perior, postcentra l gyrus posterior, occi pita l & pa rieta l a reas inferior, a u ditory a rea

7

Part 1 : Anatomy and Physiology

8 30.

Draw the internal capsule and label which blood vessel serves which area. H i nt: M I MA

1 .6.2

Anterior limb MCA lateral striate branches

Genu Internal carotid a branches Posterior MCA lateral striate branches and Anterior choroidal a.

oo Fig. 1 .3 31 .

Retro lenticular Anterior choroidal

a.

Matching. Match the area in the internal capsule with its function.

1 .6.2

Fig. 1 .4

Function: (a-d) below a. Movement of face b. Movement of foot c. Vision d. Hearing

C D F G

genu posterior l i m b latera l genicu late medial geniculate

Gross Anatomy, Cranial, and Spinal •

Occipitoatlantoaxiai-Complex Anatomy 32.

a. b. c. d. e. f. g. h. i. j. k.

Matching. Match the ligaments of the occipita-atlantoaxial complex with the statements below. Lig aments: CD apica l ; 0 alar; ® cruciate; 0 ascending portion ; ® descending portion; ® transverse portion; (f) posterior longitu d i n a l ; ® tectoria l ; ® anterior longitu d i n a l ; @) a nterior atla nta-occipita I Statements: (a-k) below Attaches t h e odontoid to t h e fora men magnum. Attaches the odontoid to the occipita l condyle. Attaches the odontoid to the latera l mass of Cl . Attaches Cl to t h e cl ivus and to C2. Attaches odontoid to clivus. Attaches Cl to C2. Tra ps t h e odontoid agai nst t h e atlas. Extends cephalad to become the tectori al. Is t h e cephalad extension o f t h e PLL. Extends cephalad t o become t h e anterior atlanta-occi pita l . The cephalad extension of the anterior longitudinal ligament.

The most important spinal ligaments in maintaining atlanta-occipital stability are the membrane a n d the a. b. liga ments.

1 .8

CD 0 0 ®

0

® ® (j) ® ® @)

33.

__

•

1 .8

tectorial alar

Spinal Cord Anatomy 34. The dentate ligament a . sepa rates __ b. from __ roots in the spinal nerves. 35. Which cranial nerve lies dorsal to the dentate ligament? 36.

a. b.

How is the lateral spinothalamic tract (LST) somatotopically organized? Cervica l i s Sacra l is

37. Which descending motor tract facilitates a . extensor tone? b. flexor tone?

1 .9 . 1

dorsa l ventra l CN XI spinal accessory

1 .9 . 1

Fig. 1 . 1 3

medial latera l Ta ble 1 . 7

vestibulospinal tract ru brospinal tract

9

Part 1 : Anatomy and Physiology

10

38. The very large ascending tract closest to the dentate ligament is the __

----

39.

a. b.

c. d. e.

f.

g.

h. i. 40.

a. b. c. d. e. f. g. h. i. j.

Matching. Match sensory function and anatomy. Sensory fu nction: CD pain and temperatu re: body; 0 fine touch, deep pressu re and proprioception : body; ® light (crude) touch: body Anatomy: (a-i) below Receptors i. Free nerve ending ii. Meissner's and Pacinian corpuscles Fi rst order neurons i. S m a l l ii. Heavily myelinated iii. Fi nely myelinated iv. Large Soma in dorsal root g a n g l ion Enter cord at i. zone of Lissa uer ii. ipsilatera l posterior col u m n s Syna pse in i. Rexed layer II ii. Rexed layer I l l and IV iii. Rexed layer VI and VII Second order neurons i. cross obliquely i n a nterior wh ite com m issure ii. form the intern a l a rcuate fibers and enter the i. latera l spino-thalamic tract. ii. medial lemniscus. iii. a nterior spi nothalamic tract. Second order neurons syna pse on the ventra l posterior latera l n ucleus of the thalamus. Third order neurons pass through IC to postcentra l gyrus. List the body area with the appropriate root. Nipple, root: U m iblicus, root: I n g u i n a l crease, root: Anterior thi g h , root: Posterior thig h , root: Latera l ca lf, root: Medial ca lf, root: Posterior calf, root: B i g toe, root: Little toe, root: ___

___

___

___

___

___

___

___

___

___

latera l spi nothalamic tract ( LST) (for pain and tem peratu re from the opposite side of the body)

Ta ble 1 . 9

1 .9.2

CD 0-® CD 0-® CD 0 CD-0-® CD 0-® CD 0 ® CD-® 0 CD 0 ® CD-0-® CD-0-® Fig. 1 . 1 4

T4 T1 0 T1 2 L2-L3 51 L5 L4 51 L5 51

Gross Anatomy, Cranial, and Spinal k. Sole of foot, root: I. Latera l shoulder, root: m . Latera l forearm, root: n . T h u m b , root: o. Middle fi nger, root: p. Little finger, root: q . Medial forea rm, root:

_ __ _ __

__ _

_ _ _

__ _

_ __ _ __

41 . Complete the following regarding upper extremity vs. trunk dermatomes. Trunk sensory level is reported at T3 on a trauma patient. the clavicle. a. This is a l ittle b. You m u st check the dermatomes. to a re not c. Dermatomes represented on the tru nk.

51 C5 C6 C6 C7 C8 Tl Fig. 1 . 1 4

below a rm C5 to T2

11

2 Vascular Anatomy

•

Cerebra l Vascular Territories 1 . Cerebral vascular territories: a . Anterior cerebral a rtery: fronta l lobe a n d

ca udate

b.

tha l a m u s

Posterior cerebral a rtery: occipital lobe and c. Anterior choroidal a rtery: internal ca psule, medial g lobus pa llidus, and

d.

•

a rtery suppl ies

the rest.

Fig. 2 . 1

optic tract Middle cerebra l

Cerebra l Arterial Anatomy 2. Circle of Willis: a. I ntact in %. b. Hypoplasia of at least one of the posterior com m u n icati ng a rteries occu rs in %. c. Absent or hypoplastic A 1 occu rs in %. --

-

--

3. Segments of t h e ICA: a. Name the 7 seg ments of the ICA. (Hi nt: ca n Peter la ugh ca n Charlie only clap) i. c ii. p iii. I iv. c v. c vi . 0 vii . c

2.2.2

1 8% 22-32% 25% 2.2.3

cervica l petrous laceru m cavernous clinoid ophtha l m ic com m u nicating

Vascular Anatomy b.

Now also name the main branches of each seg ment. i. Cl c , no ii. C2 p iii. C3 1 iv. C4 c m t a m a v. cs c vi . C6 o a 0 h a s p a c a vii . C7 c into A M

c

a

a

d ivides

2 . 2 .4

cervica l , branches petrous lacerum cavernous meningohypophysea l tru nk a nterior meningeal a rtery clinoida l ophth a l m ic ophthalmic a rtery su perior hypophyseal artery posterior com m u nicati ng a rtery anterior choroida l a rtery com m u n icating a rtery ACA MCA

4.

Name the branches of the meningohypophyseal trunk: ( H int: dit) a. d b. i c. t

Complete the following: Occl usion o f t h e i a rtery resu lts i n h necrosis. b. This a rtery suppl ies the c. It is a branch of the d . Occl usion usually occu rs in patients.

2 . 2 .4

dorsal meningeal inferior hypophysea l tentorial a rtery (a rtery of Bernasconi and Cassi nari)

5. a.

2.2.4

inferior hypophysea l ; Sheehan's a rtery.

Complete the following about the ophthalmic artery: a . I t a rises from the segment of the ICA. b. % dista l to cavernous seg ment. c. % within cavernous seg ment. d . Shape on latera l an giogra m i s

posterior lobe of pitu ita ry meningohypophysea l post-partum

6.

2.2.4

6th 89% 8% bayonet-like kin k

13

Part 1 : Anatomy and Physiology

14 7.

Complete the following about the anterior choroidal artery: a . N a m e t h e 7 structu res that i t supplies. {Hint: gogou pl) p i. g ii. 0 t of i iii. g c iv. 0 v. u of vi . p i c vii . I g b b. Occl usion may prod uce {H int: 3Hs) , a nd

8. a.

b. c. d.

e.

Posterior communicating artery: segment enters supracorn u a l to recess of the su pply Orig in is proxi m a l to a rtery. Larger than a rtery. Anterior choroidal a rtery h a s h u m p , or , where it passes to enter through the Travels between cranial nerves and

9. Carotid siphon: a . Beg ins a t t h e posterior bend o f the ICA and ends at the ICA

b. 1 0. a.

b.

It includes 3 seg ments: ca op , and co External carotid artery: and It l ies to the I CA. Name its branches from proxi mal to dista l . {Hint: salfopsmax) i. s ii. a iii. I iv. f v. 0 vi . p vii . s viii. i m

2 . 2 .4

g lobus pa llidus optic tract g e n u ; internal ca psule optic radiations u ncus posterior l i m b ; intern a l ca psule latera l genicu late body hemiplegia, hemihypesthesia; homonymous hemianopsia 2 . 2 .4

Plexa l ; tem pora l horn ; choroid plexus anterior choroidal anterior choroidal plexa l point; choroidal fissure; ventricle II, Ill 2.2.4

cavernous; bifu rcation cavernous, ophthal mic; com m u n icating 2.2.4

anterior; latera l

su perior thyroid ascending pharyngeal l in g ua l facial occipita l posterior a u ricu l a r superficial tem pora l internal maxillary

Vascular Anatomy 1 1 . Recurrent artery of Heubner: a. Typica lly a rises in a rea of j u n ction. of c b. Suppl ies h p , and a c 1 2. a.

b.

2.2.4

Al /2 head ; ca udate; putamen; anterior internal ca psule

Posterior circulation: % of patients have a circulation where PCA is su pplied via system . instead of the

1 3. Vertebral artery: a. The fi rst seg ment enters the fora men tra nsversari u m . with in b . T h e second ascends the fora mina tra nsversaria. as it exits c. The second tu rns the axis. and d. The third cu rves

e. The fou rth pierces the f. Right and left vertebra l a rteries join at the level of the I p to form the a rtery. g . N a m e its 6 bra n ches. ( H i nt: A postma n puts postcards away) i. a m ii. p m iii. m s iv. p v. p s vi . a PICA: It a rises m m dista l to the poi nt where the vertebra l a rtery becomes intradu ra l . %. b . Has a n extra d u ra l origin in c. Name the 5 seg ments. i. a m ii. I m iii. t , conta ins loop iv. t , conta ins loop s v. c d . N a m e its 3 bra n ches. i. c ii. t iii. v

1 4. a.

__

__

2.2.4

1 5-35%; feta l p-comm; vertebrobasi lar 2.2.4

sixth vertica lly latera l ly posteriorly; medially d u ra lower pons; basilar

anterior meningeal posterior meningeal med u l l a ry posterior spinal PICA anterior spinal 2.2.4

l O mm 5-8% anterior med u l l a ry latera l med u l l a ry tonsillomed u l l a ry; ca udal telovelotonsi l l a ry; cranial cortical seg ments choroidal tonsillohemispheric inferior verm ian

15

Part 1 : Anatomy and Physiology

16

e. The choroidal poi nt on an giogra phy is where the a rtery enters the to su pply the

choroid a l ; 4th ventricle; choroid plexus

f. The copu l a r point on angiog raphy is where the artery inflects

inferior vermian; inferiorly

1 5. a.

Posterior cerebral artery: Name the 3 seg ments. i. Pl p ii. P2 a iii. P3 q b. The medial posterior choroidal a rtery or arises from the seg ment. c. The latera l posterior choroidal a rtery a rises from the seg ment. d. Artery of Percheron is a a natomic va riant where a tru n k a rises from PCA to su pply paramedian tha l a m i and rostra l mid bra i n .

1 6. Persistent fetal anastomoses: types. a. There a re b. They result from a fai l u re to , 0 c. They include t h , and p d . T h e most com mon type i s e. The first type to invol ute is •

2.2.4

peduncular am bient q u a d rigeminal Pl , P2 P2 rare; sol itary; one; bilatera l 2.2.4

4 invol ute trigeminal, otic, hypog lossa l , proatlanta l trigeminal otic

Cerebra l Venous Anatomy 1 7. a.

Cerebral venous anatomy: Domina nce: intern a l jugular vein i. The is usually domina nt. ii. The tra nsverse sinus is usually domina nt. iii. The vertebral a rtery is usually domina nt. iv. The vein of La bbe is usually domina nt. b. The main contri butors to the vein of vein , Galen a re p c vein of R , a nd b i vein . c c . T h e joining o f t h e septa l vein a n d thala mostriate vein with the internal cerebral vei n forms a n an giogra p h ic lan dmark ca lled the v a at the fora men of

2.3.1

right right left left precentra l cerebellar; basal vein of Rosenth a l ; intern a l cerebral venous angle; Mon ro

Vascular Anatomy 1 8. Cavernous sinus anatomy: a . T h e cavernous s i n u s is a

2.3.1

____

of

b.

Draw the right and left cavernous sinus coronal view. On you r d rawing label the fol lowing: 1 . Oculomotor ( I l l } ; 2. Trochlear ( IV}; 3 . Pa rki nson triangle; 4. Ophth a l m ic (Vl ); 5 . Maxi l l a ry (V2 }; 6. Abd ucent (VI }; 7 . Carotid .

c.

Name 6 major contents o f t h e cavernous sinus. is the only Cranial nerve nerve of the cavernous sinus that doesn't exit sku l l through ; it exits through

d.

_ _ _ _ _ _ _ _ _

Fig. 2.1 CN Ill, CN IV, CN Vl , CN V2 , CN VI, ICA V2 ; su perior orbita l fissure; fora men rotu n d u m

_ _ _ _

____

Cranial nerve is the only nerve not attached to d u ra l wa l l . f. Parkinson triangle is bordered superiorly and and by inferiorly by and

e.

plexus; veins

____

VI; latera l CN I l l and IV; CN Vl and V2

_ _ __

•

Spinal Cord Vascu lature Spinal cord vasculature: Su pply o f t h e cervica l spinal cord comes from v a rtery, d c a rtery, and c t b. Artery of suppl ies spinal cord from T8 to conus. is located on the c. Artery of % a nd a rises between left in T9-L2 in %. d. region is considered a zone and is thus more to vascu lar insu lts.

1 9. a.

2.4

vertebra l deep cervica l ; costocervica l tru nk Ada m kiewicz Ada m kiewicz; 80%; 85% M idthoracic; watershed; suscepti ble

17

3 Neurophysiology and Regional Brain Syndromes

•

Neurophysiology 1 . Answer the following concerning the blood-brain barrier (BBB): a. What chemical opens the BBB? b. What chemical closes the BBB? c. Which sites have no BBB? ( H i nt: pppcta)

3.1 .1

2.

3.1 .1

M a n n itol Steroids Pituita ry, pinea l , preoptic recess, choroid plexus, tuber cinere um , a rea postrema d . What pathology inj u res BBB? ( H i nt: histt) Hepatic encepha lopathy, infections, stroke, tra u m a , tumor

a.

b.

Complete the following statements about cerebral edema: Cytotoxic i. occu rs with h ii. occu rs with h iii. shape is c iv. occu rs with C v. BBB is c Vasogenic i. shape is

ii. iii. iv. v.

occu rs with t occu rs with m treat with s with contrast it

vi .

BBB is o

and

Matching. Match the type of edema with the characteristics. Type of edema: CD cytotoxic; (I) vasogenic H i nt: cytotoxic-ea rly letters of alphabet vasogen ic-later letters of alphabet Cha racteristics: (a-1) below a . B B disru pted b. BBB closed c. Head inj u ry

head inj u ry hematoma circu l a r CVA closed V-sha ped (l ike fi ngers of wh ite matter edema) tu mors metastasis steroids enha nces on CT and M R open

3.

3.1 .1

0 CD CD

Neurophysiology and Regional Brain Syndromes d . Tumor e. Enhances f. Does not enha nce g . Not appropriate to u s e steroids h . Appropriate to u s e steroids i. Circu lar shape on MR j. V-sha ped finger like extensions on MR k. Occu rs with hematoma I . Occu rs with CVA

0 0 CD CD 0 CD 0 CD CD

4. True or False. Cytotoxic edema has: a . a disru pted B B B b. expansion of the extrace l l u l a r space c. enha ncement when contrast injected d. no protein extravasation

fa lse fa lse fa lse true

3.1 . 1

5. Study Sheet. a . Cytotoxic: i. Closed BBB ii. Head inj u ry iii. Hematoma iv. Circu l a r shape v. CVA vi . Cells swe l l then s h ri n k b . Vasogenic: i. Disru pted BBB ii. Tu mors iii. Metastasis iv. Steroids v. Protein extravasates vi . Enha nces on CT and MRI vii . Wide extrace l l u l a r space viii. Sta ble cells

3.1 . 1

h.

Fill in the blanks to complete the details of the Babinski reflex. (Hint: pcrstl pt) latera l sti m u lation originates as a a n d sti m u lates the dermatome in the that travel via the to the spi n a l cord seg ments n u mber ( l i m b) T h e efferent l i m b travels via the nerve to the

toe extensors

7. a. b. c. d.

Summarize the Babinski sign. receptor afferent l i m b cord efferent l i m b

Sl dermatome ti bial nerve L4-S2 peroneal nerve

6.

a. b. c. d. e. f. g.

3 . 1 .2

pla nta r cuta neous reflex receptors Sl tibial nerve L4-S2 ; afferent peroneal

3 . 1 .2

19

Part 1 : Anatomy and Physiology

20 8.

a. b. c. d. e. f. g.

Fill in the blanks to complete the details of eliciting the plantar reflex. Sti m u late t h e su rface and the in a movement that lasts __ seconds. Response consists of of the _ _ _ _ __

__ __ __ _ _ __ __ __

__

___

_______ _______

of the s m a l l toes is clinica l ly i m porta nt.

9. True or False. The Chaddock maneuver is described as a . scratching t h e latera l foot b. pinching the Achi l les tendon c. sliding kn uckles down shin d . momentarily squeezi ng lower gastrocnemius 1 0.

a. b.

Complete the following concerning Hoffman sign: letter H (from Hoffma n ) is the of the alphabet. If u n i l atera lly present, Hoffma n sign ind icates a lesion a bove

3.1 .2

latera l pla nta r tra nsverse a rch single 5 to 6 extension; g reat toe Fa nning not 3.1 .2

true fa lse fa lse fa lse 3.1 .2

eig hth C8

_ __

Complete the following concerning bladder physiology: a . T h e pri mary coord inating center for bladder fu nction is in the i. n I c. ii. of the p b. This center coord inates c (d i. b with (e ii. s s ).

11.

__ __ __ _

__ __ __ _

_ _ _

___

_ _ _

1 2. Voluntary cortical control a . i n h i bits t h e p c.

b.

It orig inates in the f i. a ii. and g ----.,. of the c and c c. travels via the p t d . to inhibit i. c of the and contraction ii. d s iii. of the e _____

nucleus locus coeruleus pons bladder contraction (detrusor) sphincter relaxation (external sphincter) 3 . 1 .3

_ __ ____

__

3 . 1 .3

__ __ , ___ _ _ _

ponti ne center-n ucleus locus coeru leus anterom edial fronta l lobes genu of the corpus ca l losum

_______

___

_ _ _

__ _

pyra m id a l tract contraction detrusor external sphincter

Neurophysiology and Regional Brain Syndromes 1 3.

Immaturity, infarct, or cortical lesions cause a . inability to s b. the m c. a n d resu lt in i

1 4. The efferents to the bladder portion a. travel in the d b. of the I c

1 7. Sympathetic nerve a. provides bladder neck b. travels via the i plexus.

3 . 1 .3

3 . 1 .3

contracts relaxes pelvic splanchnic 3 . 1 .3

contracts continence pudendal

nerve

3 . 1 .3

h

and

1 8. True or False. The detrusor muscle of the bladder contracts and the internal sphincter relaxes under a. PNS sti m u l ation

b. c. d.

suppress mictu rition reflex inconti nence dorsa l latera l col u m n s

1 5. Parasympathetic control a. detrusor b. intern a l sphincter s c. travels via the p nerves 1 6. Somatic nerve a. externa l sphincter b. maintains c c. travels via p

3 . 1 .3

somatic nerve sti m u l ation sympathetic nervous system sti m u l ation all of the a bove

1 9. True or False. The following can cause detrusor hyperreflexia: a . stroke b. spinal cord lesion (myelopathy) c. chronic bladder catheterization

d . m u lti ple sclerosis e. Parki nson disease f. hyd rocephalus g . dementia h. brain tumor 20. True or False. Interruption of the efferents results in a. atonic bladder b. overflow incontinence c. u n controllable voiding d . reflex bladder em ptyi ng e. voiding triggered by critical vol u m e

clos u re inferior hypog astric 3 . 1 .3

true (pa rasym pathetic nervous system sti m u l ation) fa lse fa lse fa lse 3 . 1 .3

true true fa lse (Detrusor hyperreflexia can result from interru ption of efferents a nywhere from cortex to sacra l cord . ) true true true true true 3 . 1 .3

fa lse-root lesion fa lse-root lesion true true true

21

Part 1 : Anatomy and Physiology

22 f. g. h. i. 21 .

true true fa lse-detrusor a reflexia fa lse-a utomatic neuropathy

prod uced by myelopathy prod uced b y head inj u ry prod uced b y certa in d rugs prod u ced by dia betes mellitus

pontine voiding reflex

loss of centrally mediated inhibition v r of the p is mediated by supraspinal lesions.

3 . 1 .3

_ _ _ _

22.

The s v c located in the c m and results from lesions above the spinal cord level, which vertebral correspond to bodies.

___

is

___

sacra l voiding center; con u s med u l l a ris; S1 ; T1 2 / L 1

23. After acute su prasacral spinal cord injuries, there may be s , and as a result d s a

spinal shock; detrusor a reflexia

24. When the spinal shock subsides, most develop

detrusor hyperreflexia

_ _ _ _

3 . 1 .3

3 . 1 .3

_ __

____ ,

3 . 1 .3

_ _ _ _ _ _ __

25. Match the injury to the etiology. I nj u ry: CD suprasacra l ; CD infrasacra l (below the 52 spinal cord level). Etiologies: (a-d) below a. ca uda equina b. conus med u l l a ris inj u ry c. tra nsverse myelitis d. peri pheral nerve inj u ries 26.

Interruption of the a r d a

p.____

____

may produce

3 . 1 .3

CD CD. CD CD CD peripheral reflex a rc; detrusor a reflexia

3 . 1 .3

_ _ _

27.

Spinal stenosis urologic symptoms vary (detrusor hyperactivity or detrusor underactivity) and depend on the spinal level involved and the type of involvement depending on whether there is compression of the i r t or m f involving the p

i n h i bitory reticulospinal tracts; myelopathy; posterior fu nicu l u s

Cauda equina syndrome usually r produces u although o may occur.

u rin a ry retention; overflow inconti nence

P n usually produce impaired detrusor activity.

peripheral neuropathies

3 . 1 .3

_ _ _

_ _ _

_ _ _

28.

_ __ _

29.

3 . 1 .3

3 . 1 .3

Neurophysiology and Regional Brain Syndromes 30.

N d patients have an areflexic bladder neck.

31 . True or False. Patients with multiple sclerosis develop voiding symptoms from demyelination primarily involving the a . posterior and latera l col u m n s o f l u m ba r spinal cord . b. latera l col u m n of cervica l spine. c. posterior col u m n of l u m ba r spine. d. latera l col u m n of l u m ba r spine. e. posterior and latera l col u m ns of cervical spinal cord . 32. True or False. Causes of urinary retention are a . u reth ra l strictu re b. prostatic enlargement c. d etrusor areflexia d . herpes zoster

neurospinal dysraphism

3 . 1 .3

3 . 1 .3

fa lse fa lse fa lse fa lse true ( posterior and latera l col u m n s of cervical spinal cord ) 3 . 1 .3

true true true true

33.

Evaluation of bladder function usually combines c or v with s m

cystometrog ra m ; videourodynamics; sphincter myelog ra phy

34.

Synthetic anticholinergics block s (m p a ) without blocking skeletal neuromuscular or autonomic ganglia (n ). j

postg a n g l ionic syna pses (m uscarinic action); nicoti nic junctions

35.

The most widely prescribed anticholinergic for detrusor , while hyperreflexia is 0 T is considered less effective.

Oxybutyn i n ; Tolterod ine

36.

B is indicated for post-op non-obstructive urinary retention and for neurogenic atony due to spinal cord injury or dysfunction.

Betha necol

3 . 1 .3

37.

Following acute cauda equina decompression, patients may start T to relieve urinary retention symptoms.

Ta msulosin

3 . 1 .3

3 . 1 .3

3 . 1 .3

3 . 1 .3

23

Part 1 : Anatomy and Physiology

24 •

Regional Brain Synd romes 38.

a. b. c. d. e. f. g. h. i. j. k. I. 39.

a. b. c. d. e.

Matching. Match region with deficit. Region: CD pre-fronta l lobes; 0 fronta l lobe; ® pa rieta l lobe-dominant; 0 pa rieta lnon dominant; ® occi pita l lobe; ® cerebe l l u m ; (j) brain ste m ; ® pinea l ; ® olfactory g roove Deficit: (a-1) below a pathy a b u l ia disorganized thoug hts contra latera l neglect language disorders a nosog nosia d ressing apraxia homonymous hemianopsia tru ncal ataxia ipsilatera l ataxia para lysis of u pward gaze poor planning unilatera l a nosmia Frontal eye fields for contra lateral gaze are located in the fronta l lobe. in Brod mann area With a destructive lesion there, the patient's eyes look the lesion. With a n irritative lesion there, the patient's eyes look the lesion. Usually the lesions a re

40. True or False. Gerstmann syndrome includes a . agraphia without a l exia b. left-rig ht confusion c. digit ag nosia d . tacti le ag nosia e. acalculia

3.2.1

0 CD ® or @ ®

0 0

® ® ® ® CD ®

3.2.1

posterior 8 towa rd ( H i nt: destructive=towa rd) away from ( H i nt: irritative=away) destructive 3.2.1

true true true fa lse true

41 . True or False. Gerstmann syndrome patients can read.

true

3.2.1

42. True or False. Gerstmann syndrome patients can write.

fa lse

3.2.1

43. True or False. Cortical sensory syndrome includes: a . loss o f position sense b. inability to loca l ize tacti le sti m u l i c. astereog nosis d . loss of pain and tem peratu re sense

3.2.2

true true true fa lse (Pain and temperatu re as wel l as vibration sense a re preserved.)

Neurophysiology and Regional Brain Syndromes 44. a. b. c. d.

True or False. Broca aphasia includes: dysa rthria lesion is in a rea 44 "apraxia" of motor sequencing similar to cond u ction aphasia

45. True or False. Wernicke's aphasia includes: a . fl uent a phasia b. lesion is in Brod mann a reas 41 and 42

c. speech devoid of meaning d . normal intonation 46. Alexia without agraphia a. means that the patient ca n b. but ca nnot c. Su rprisi ng ly, such patients can usually do what with n u m bers? d . Lesion is located i n the lobe. e. On which side? f. Serves to disconnect and g. h. also known as

i. This is contrasted with what synd rome? j. Where patient ca n k. but ca n't I . also known as 47.

a. b. c. d.

Matching. Match the numbered syndromes with the lettered phrases. Synd rome: CD Gerstm a n n ; 0 pure word blind ness Phase: (a-d) below alexia without agraphia agraphia without a l exia where patient can 't read where patient can 't write

48. True or False. Regarding FosterKennedy syndrome: a . usually from olfactory g roove or medial third sphenoid wing tu mor b. contra latera l a nosmia

3.2.2

true true true fa lse (Broca is a motor aphasia-fa lteri ng dysa rth ric speech. Conduction a phasia is fl uent speech with para phasias.) 3.2.2

true fa lse {The lesion is in Brod m a n n 39 and 40 .} true true 3.2.2

write read read and name them pa rietooccipita l dom inant left a n g u l a r gyrus occipital lobe p u re word blind ness Gerstmann's read write a g raphia without alexia 3.2.2

0 CD 0 CD 3.2.3

true fa lse { I psi latera l not contra latera l a nosmia is part of the classic triad.)

25

Part 1 : Anatomy and Physiology

26 c. d. e.

ipsilatera l centra l scotoma contra latera l papilledema contra latera l optic atrophy

f.

usually from meningioma

49. True or False. Regarding Weber syndrome: a . Weber synd rome incl udes CN I l l palsy with contra latera l hemiparesis. b. Weber synd rome incl udes CN VII palsy with contra latera l hemiparesis. c. Weber synd rome incl udes CN I l l palsy with ipsilatera l hemiparesis. d. Weber synd rome incl udes CN VI and VII palsy with contra latera l hemiparesis. e. Weber synd rome incl udes i. CN I l l palsy ii. contra latera l hemiparesis iii. a rm hyperki nesis iv. ataxia v. intention tremor 50. True or False. Benedict's syndrome is due to disruption of a . cerebra l ped u ncle b. issuing fibers of CN I l l c. red n ucleus 51 . True or False. Millard-Gubler syndrome is due to disruption of a . n ucleus o f VI I b. n ucleus of VI c. corticospinal tract 52. True or False. Regarding Parinaud syndrome: a . Parinaud's syn d rome includes downgaze palsy. b. Parinaud's synd rome includes lid retraction . c . Pa rinaud's synd rome includes nystagmus retractorius. d. When Parinaud's synd rome is com bined with downgaze palsy it is known as the synd rome of the

true true fa lse (ipsilatera l optic atrophy) true 3.2.4

true fa lse fa lse fa lse true true fa lse fa lse fa lse 3.2.4

true true true 3.2.4

true true true 3.2.5

fa lse true fa lse Sylvian aqueduct

Neurophysiology and Regional Brain Syndromes •

Jugular Foramen Synd romes 53. True or False. Regarding jugular foramen syndromes: a . tra nsverse sinus b. CN IX, X, a ndXI c. CN X, XI, and XII d. sig moid sinus e. petrosa l sinus f. branches from the ascending pharyngeal a rtery g . branches from the occipital a rtery Matching. Match the following numbered syndromes with the lettered lesions. Also indicate the nerves involved and the results of the lesion. Synd rome: CD Vernet's; 0 Col l et-Sica rd ; ® Vil l a ret's Lesion: (a-c) below a . Which j u g u l a r fora men synd rome i s most likely due to a n intracranial lesion?

3.3.1

fa lse true fa lse true true true true

54.

b. c.

extracranial lesion? retropharyngeal lesion?

55. True or False. A jugular foramen syndrome that spares CN IX is a. Vernet's b. Col l et-Sica rd c. Vi lla ret's d. Ta pia

3.3.2

CD involves CN, IX, X , XI taste, vocal cords and SCM (sternocleido mastoid muscle) 0 a bove plus XII tongue ® a bove plus Horner 3.3.2

fa lse fa lse fa lse true (Ta pia X, XII vocal cords and tongue )

27

4 Neuroanesthesia

•

General I nformation Provide general information on neuroanesthesia. a . N a m e t h e most potent cerebral vasod ilator b. Effect of hyperventi lation on: i. PaC02 ii. CBV iii. CBF iv. Goa l is end tida l C02 of ( ETC02) mmHg. v. Correlates with PaC02 of _ - _ mmHg. c. For every degree Celsius change i n tem perature, d. there is a change i n cerebral meta bolic rate of oxygen by %. e. Hyperg lycemia ca n __ ischemic deficits. f. Head of the bed elevation wil l have the i. a rterial blood flow ii. ICP iii. venous blood outflow

1.

4.1

C02 red uces decreases decreases 2 5-30 mm Hg

__

30 to 3 5 m m Hg

__

7%

__

•

worsen decrease red u ce decrease

Drugs Used in Neuroa nesthesia 2.

a. b. c. d. e.

Inhaled agents have the following effects on: cerebra l meta bolism cerebra l vessels cerebra l blood vol u m e ICP C02 reactivity

3. What anesthetic drug may come out of solution and aggravate pneumocephalus?

4.2.1

red uce dilate increase increase increase nitrous oxide

4.2.1

Neuroanesthesia 4. To reduce the risk of tension a. b. c.

4.2.1

pneumocephalus you would fil l any space with and turn off m i n utes before closing the d u ra . __

__

___

5. Complete the following regarding barbiturates: a . They produce dose-dependent EEG b. They cause peripheral vaso c. which may result in t h e CPP. d. and

__

__

___

6. Which barbiturate can decrease seizure threshold? 7. True or False. Etomidate a. has a n a lgesic properties. b. can prod uce myoclonic activity. c. ca n i m pair renal fu nction. d . may produce adrenal insufficiency. 8.

Ketamine is a antagonist.

__

receptor

9. True or False. Morphine a. significantly crosses BBB b. releases histamine which c. produces hypotension d . causes vasodilation e. increases ICP f. comprom ises CPP

fl uid agent 10 4.2.2

suppression d i latation hypotension red uce methohexita l

4.2.2

4.2.2

fa lse true true true N M DA

4.2.2

4.2.2

fa lse true true true true true

Characterize synthetic narcotics: Have the adva ntage that they don't cause h An exam ple is f

fentanyl

11.

Benzodiazepines are

GABA

4.2.3

1 2.

Dexmedetomidine ( Precedex) is an receptor agonist.

a l pha-2 adrenergic

4.2.3

1 0. a.

b.

__

agonists.

4.2.2

histamine release

1 3. What is the only depolarizing paralytic succinylchol ine agent?

4.2.4

29

Part 2: General and Neurology

30 •

Anesthetic Requirements for I ntra-Operative Evoked Potential Monitoring 1 4. Answer the following questions concerning anesthesia requirements for evoked potential monitoring: a . What tech nique is preferred? b. Second best is c. Are m u scle relaxa nts perm itted? _ ___

1 5.

•

How should fentanyl be infused?

4.3

tota l IV a nesthesia nitrous/na rcotic yes continuously, not interm ittently

4.3

Malig nant Hyperthermia 1 6. a.

Regarding malignant hyperthermia: Due to block o f re-entry into sarcoplasmic reticu l u m . i n end­ b . Earl iest possible s i g n is tidal pC02. c. Treatment with IV is u s u a l ly effective. shou ld be d . I n patients a t risk avoided . __

__

__

__

4.4. 1

ca lci u m

4.4.2

increase da ntrolene

4.4.3

succinylchol ine

4.4.4

5 Sodium Homeostasis and Osmolality

•

Serum Osmolality and Sodium Concentration is 1 . A serum osmolality of associated with risk of renal failure. __

•

>

320

Ta ble 5 . 1

Hyponatremia 2 . The diagnosis i s hyponatremia i f the serum sodium is less than mEq/l.

1 35

5.2.1

__

3. Two common etiologies for hyponatremia are a. s

5.2.1

SIADH

__

b.

c__

csw

4. Minimal work-up for hyponatremia should include: a. seru m b. seru m c. u rine d . assessment of e. u rine f. T

5.2.1

[ N a+] osmolal ity osmola l ity vol u m e status [ N a+] TSH

__

__

5. The syndrome is SIADH a . i f t h e seru m osmola l ity is less than mOsm/L b . and the u rine osmola lity is more than mOsm/L.

5.2.1

275

__

1 00

__

6.

Pseudohyponatremia occurs when active solutes draw from the cells and the water fraction of plasma and produce artificially values.

___

__

__

___

osmotical ly; water; red uce; low sod i u m

5.2.1

Part 2: General and Neurology

32 7.

a. b. c. d. 8.

9.

a. b. c. d. e. f. g. h. i.

Name osmotically active solutes that may cause pseudohyponatremia. g m h h _ __

_ _ _

_ _ _

Complete the equation to calculate serum osmolality Effective seru m osmolality = [BUN](mq/d l) measure d osmo I a l .t 1 y Matching. Match the symptoms with severity of hyponatremia. Hyponatremia: CD m i l d , < 1 30 m Eq/L: 0 severe, < 1 2 5 m Eq/L Sym ptoms: (a-i) below headache cerebral edema a norexia nausea vomiti ng muscle weakness m u scle twitching seizu res respi ratory a rrest difficu lty concentrati ng

1 0. SIADH is a . t h e release o f sti m u l i b. without c. resu lting in i. natremia ii. volemia iii. with ina ppropriately osmolality.

5.2.1

g l u cose mannitol hyperlipidemia hyperproteinemia 5.2.2

2.8

5.2.3

CD 0 CD 0 CD 0 0 0 CD 5.2.5

ADH osmotic

___

__

__

__

u rine

Complete the following regarding treatment of hyponatremia: a. Avoid correction . b. Avoid correction . m E q / L p e r hour. c . D o not exceed m Eq/L per 24 d. Do not exceed hours. e. Do not exceed m Eq/L per 48 hou rs.

hypo hyper high

11.

___

__

___

5.2.5

ra pid over 1 8 18

Sodium Homeostasis and Osmolality 1 2.

Matching. Diagnosis of SIADH depends on three diagnostic criteria. Match the laboratory value with the appropriate test. Hyponatremia: G) seru m N a ; @ seru m K; ® serum osmolal ity; @ u ri n ary osmolality; ® u ri n ary N a ; ® urinary K; 0 blood u rea nitrogen ( B U N ) creati nine 1 8 m Eq/L 50-1 50mEq/L 10 normal 5.2.5

osmotic demyel ination ra pid correction pontine wh ite matter

_ __

d.

__

_ _ _

___

___

flaccid quadriplegia menta l status cranial nerve pseudobulbar

1 5.

Features common in patients who develop CPM are a. r c c b. o for more than in c. d hours. d . increase in Na b y more than mEq/L within hours. __

_ __

__

_ __

___

__

__

5.2.5

ra pid correction over correction delay in diag nosis; 48 25; 48

1 6. Treatment of SIADH includes: a. f b. s

fl uid restriction salt

1 7. a. b. c. d.

ren a l ; Na intracranial hypo decrease

_ _

_ _ _

__

Cerebral salt wasting (CSW) is r loss of as a res u lt of i d isease prod ucing natremia and a in extrace l l u l a r fl uid vol ume. __

__

5.2.5

5.2.6

33

Part 2: General and Neurology

34 1 8.

a.

list the expected patient laboratory result when comparing SIADH with csw. Water: in SIADH , in CSW

b.

Na (seru m): in SIADH

c. d.

__

__

osmol (seru m ) : in SIADH

, in CSW

__

csw

osmol ( u rine): in SIADH

e.

Na ( u rine): in SIADH

f.

Hct: in SIADH

, in

, in CSW

__

___

, in

__

, i n CSW

csw__

1 9. What is the treatment of CSW? a . Hyd rate i. with _% saline ii. at ccf h r. b. Use furosemide (yes or no?) c. Avoid correction __

•

Ta ble 5 . 5

SIADH: hypervolemic, CSW: hypovolemic SIADH : low, CSW: low SIADH: low, CSW: high SIADH : high, CSW: high SIAD H : high, CSW: high SIAD H : low, CSW: high 5.2.6

0.9% normal 1 00-1 2 5 no ra pid

Hypernatremia 2 0 . In neurosurgical patients hypernatremia is seen in a. d i __ b. Defi ne hypernatremia

dia betes insipidus Na > 1 50 m Eq/L

21 . a. b. c. d. e.

ADH 200 1 .005 high high

5.3.1

_

Characterize diabetes insipidus Due t o low level of Urine output is < ccf h r. Specific g ravity of u rine is < Seru m osmola rity is normal or Serum sod i u m is ___

_ _ _ __ _

_ _ _

In diabetes insipidus is the following low or high? a. ADH is . b. Urine specific g ravity is c. Urine output is d . Seru m osmolality is _ e. Serum sod i u m is

5.3.2

22.

___

_ _ _

_ _

_ _ __

23. The etiology of diabetes insipidus can be a . Neu b. Nep _ _ _

_ _ _

5.3.2

low low high high high 5.3.2

neurogenic nephrogenic

Neurosurgery Books

Sodium Homeostasis and Osmolality 24.

a. b. c. d.

Diagnosis of diabetes insipidus occurs when u rine output is above u rine osmol is below specific g ravity is below adrenal fu nction is _ _ _

_ _ _

_ __

_ _ _ _

25. Treatment of diabetes insipidus in conscious ambulatory patient is to instruct patient to d only when

5.3.2

2 50ccf h r 200 mOsm/L 1 .003 normal d rink; thi rsty

5.3.2

___

26. Treatment of diabetes insipidus in comatose patient: a. IV fl uid management with at appropriate rate (75-1 OOccf h r). a bove base IV rate m l b. Replace for m l with -,-c. If unable to keep up with fl uid loss use i. v ii. d __ __

____

5.3.2

D5 1 /2 N S + 20 m Eq/L u rine output; 1 /2 NS vasopressin desmopressin

35

6 General Neurocritical Care

•

Parenteral Agents for Hypertension 1 . True or False. Nicardipine a . is a ca lci u m channel blocker. b. does not raise ICP. c. d ecreases heart rate.

true true fa lse

ICP. 2. Nitroglycerins can a. It is a vaso b. acts on v more than a c. which LV fi lling pressures.

ra ise di lator vei ns, a rteries decrease

6.1

__

--

--

__

3.

alpha- 1 ; beta

labetalol is a selective blocker and non selective blocker.

4. list the effects of labetalol on the a. b. c. d. e.

•

6.1

6.1

6.1

following: ICP pulse ca rdiac output coronary ischemia renal fa i l u re

no change decrease or no change no change no change no change

Hypotension {Shock) 5. What is the first sign of hypovolemic shock?

tachyca rd ia

6.2.1

6.

negative

6.2.1

constrictor

6.2.2

Septic shock is most often due to gram sepsis. __

7.

Dopamine is primarily a vaso

___

.

8. Characterize the effect of dopamine at these doses a . 0.5-2.0 meg/kg/min b. 2 - 1 0 meg/kg/min c . > 1 0 meg/kg/min

Ta ble 6 . 1

dopaminerg ic beta - 1 a l p h a , beta , dopami nergic

Acid Inhibitors 9. True or False. Dobutamine a. b. c.

1 0.

6.2.2

is prima rily a vasod ilator by beta - 1 . increases ca rdiac output by inotropy. may exacerbate myoca rd ial ischemia.

true true true

Phenylephrine blood pressure by SVR, and causes reflex in parasympathetic tone resulting in pulse.

elevates; increasin g ; increase; decreased

___

___

___

11.

For the listed pressors complete the following statements to describe the cautions required. a . Phenylephrine: avoid in s c i b. Dopa mine: may cause h . c. Dobuta m ine: may cause dysfu nction of p . ___

___

___

6.2.2

6.2.2

spinal cord i nj u ry hyperg lycemia platelets

__

•

Acid Inhibitors 1 2. True or False. Extra CNS risk factor that increase t h e odds o f stress ulcers are the following: a . bu rns covering > 2 5 % o f body su rface a rea b. hypotension c. ren a l fai l u re d . coa g u lopathies

6. 3 . 1

true true true true

1 3. When is the peak time for acid and pepsin production after head injury?

3-5 days after inj u ry

6. 3 . 1

1 4.

Should prophylactic use of H2 blocker be given when steroids are used?

no-usually not wa rra nted

6.3.2

1 5.

Gastric pH > 4 may risk of pneumonia from aspiration.

increase

6.3.3

1 6.

Omeprazole may the effectiveness of prednisone and the clearance of warfarin and phenytoin due to of hepatic P450 enzymes.

decrease; decrease; i n h ibition

__

___

6.3.5

__

1 7.

Sucralfate may the incidence of lower pneumonia and mortality more than agents that affect gastric pH. ___

6.3.6

37

7 Sedatives, Paralytics, Analgesics

•

Sedatives and Para lytics 1 . The Richmond Scale: RASS quantitates and levels. a. Positive n u m bers for b. N egative n u m bers for

ag itation and sedation

7. 1 . 1

____

__

2. True or False. Indicate whether the following statements are true or false: a . Methohexita l (Brevita l) is more potent and shorter acti ng than thiopenta l . b. Remifenta n i l ra pidly crosses B B B . c. Fentanyl causes dose-dependent respi ratory depression. d . Propofol has better neuroprotection than ba rbitu rates ( du ring aneurysm surgery). e. Precedex can be used to red uce shiveri ng.

ag itation sedation 7 . 1 .2, 7 . 1 .3

true true true fa lse (ba rbitu rates a re better) true

3 . True or False. T h e following sedatives may induce seizure: a. Thiopenta l b. Methohexita l c. Fentanyl d. Propofol e. Precedex

fa lse true fa lse fa lse fa lse

4. T

Thiopenta l

may cause necrosis when injected intraarterially.

5.

a.

Complete the following statements about propofol infusion syndrome: Cha racterized by i. ka lemia ii. megaly iii. m a iv. r v. r f f vi . m vii . h __ __

__

__

_ _ _ _

___

_ __

_ _ _

_ _ _ _

7 . 1 .3

7 . 1 .3

7 . 1 .3

hyperkalemia hepatomegaly metabolic acidosis rhabdomyolysis ren a l fai l u re myoca rd ial fa i l u re hypertrig lyceridemia

Sedatives, Paralytics, Analgesics 6.

a.

Complete the following statements about Precedex. Mechanism o f action

b. Acts in i. I c ii. d c. Has both properties. d . Side effects: h

and g

__

and

Succinylcholine

c.

Rocu ron i u m

d . Vecu roni u m

•

a l pha-2-adrenoreceptor agonist locus ceru leus dorsal root g a n g l ia sedative and ana lgesic hypotension, bradyca rdia

,b

7. Choose the correct order from longacting to short-acting for the following neuromuscular agents: a . Pa ncu ron i u m

b.

7 . 1 .3

Ta ble 7 . 2

Pa ncuron i u m : 60 to 1 80 m i n utes Vecuronium: 40 to 60 min utes Rocu roni u m : 40 to 60 m i n utes (but shorter onset) Succinylcholine: 20 min utes

Para lytics (Neuromuscular Blocking Agents) is always required in a 8. s conscious patient simultaneously with the use of a paralytic agent and as ventilation is being established.

9. True or False.

7.2.1

Ta ble 7.2

a . Pa ncu ron i u m is l o n g acti ng. b. Rocuronium is short acti ng. c. Succinylcholine is a com petitive blocker and is short acti ng.

d.

Sedation

Sedation is req u i red for conscious patients.

1 0. Which is the only depolarizing ganglionic blocker among the following paralytics: a . Succinylcholine b. Ra pacuronium c. M ivacuronium d . Rocuronoium

true true fa lse (Succinylcholine is noncom petitive blocker and is considered the only depolarizi ng gang lionic blocker. It has been l i n ked to malignant hyperthermia) true a. Succinylcholine

Neurosurgery Books

7.2.1

39

Part 2: General and Neurology

40 11.

a. b. c. d.

Complete the following regarding possible side effects of succinylcholine I ncreases seru m potassi u m b y . Ca uses severe hyperka lemia in patients with pathology. It is contraindicated in which acute phase i nju ries? M a y cause dysrhythmias, especi ally ___

7.2.1

0 . 5 mEq/mL neuronal or neurom uscu lar pathology Major bu rns, m u lti pletra u m a sinus bradyca rdia

--- ---

1 2. Which of the following paralytic is contraindicated in the acute phase of injury because of the risk of hyperkalemia? a . Succinylcholine b. Metocurine c. Doxacurium d. Pa ncuronium e. Vecuronium

a . Succinylcholine

7.2.1

1 3. Which of these is the shortest acting nondepolarzing blocking agent? a . M ivacuri u m b . Rocuronium c. Vecuronium d . Metocurine e. Doxacuri u m

c. Vecuronium

7.2.4

1 4. Which nondepolarzing paralytic does not affect ICP or CPP? a . Vecuronium b. Pa ncuronium c. Succinylcholine d. Ra pacuronium e. Rocu ron i u m

a. Vecu ron ium

7.2.4

d. Cistracuri u m does not 1 5. What is the main difference between cistracrium and its isomer atracurium? release histamine a . cost b. onset of action c. d u ration d . Cistracuri u m does not release hista m ine. e. none of the a bove 1 6.

a. b. c.

State if pancuronium increases or decreases the following: cardiac output pulse rate ICP

7.2.4

7.2.4

increases increases increases

Sedatives, Paralytics, Analgesics Complete the following statements about reversal of competitive muscle blockade: a. Reversa l is not attem pted u ntil patient has at least twitch t o sti m u lus. % m u scle b. A response of Y4 ind icates blockade. c. What medication is used for reversa l?

1 7.

7.2.5

1 twitch to tra i n of fou r

___ _

__

d . What medications c a n b e added to prevent bradyca rd ia? i. a _ _ _

ii.

•

g

__ _

90 neostigmine (2.5 m g to 5 mg IV) atropine (0.5 mg for each mg of neostigmine) g lycopyrrolate (0.2 mg for each mg of neostig mine)

Ana lgesics 1 8.

a. b. c. d.

Metastatic cancer pain can be desensitized by which of these analgesics? steroids aspirin nonsteroidal a nti-inflammatory d rugs aceta m inophen

1 9. How do NSAIDs work? a . They i n h i bit b. which thereby interferes with the synthesis of p c. a n d t d . This i n h i bits t h e fu nction o f e. and prolongs f. They may a lso cause __ _

a , b, c

7.3.3

7.3.4

cyclooxygenase prostaglandins

___ _

_ __

_ __

_ _ _ ___ _ ____ _

Complete the following concerning NSAIDS and platelet function: a. The N SAI D that resu lts in irreversible binding is b. Which N SAID resu lts in reversi ble i n h i bition of platelet fu nction? c. The N SAI D that does not interfere with platelet fu nction is

throm boxa nes platelets bleed ing time neph rotoxicity

20.

7.3.4

aspirin

_ _ _ _

most N SAI DS Relafen (nabu metone)

___

21 .

a.

List the doses of the following substances: N SAI D to use i. Naprosyn loa d i n g : then every to hours. ii. Motrin no loading: Sta rt dose to mg then times per day. ___

__

___

___

__

__

___

Ta ble 7 . 4

500 mg; then 250 mg; 6 to 8 400 to 800; then 4 times per day

41

Part 2: General and Neurology

42 b.

Opioid to use (moderate to severe pain) i. Percoda n no loading: Sta rt dose pill(s) every to hours. to ii. Vicod in no load i n g: Sta rt dose pill(s) every hours. Limit to every hours per day. Opioids use (mild to moderate pain) i. Codeine loading? Sta rt dose __ to __ mg at hours, to mg at hours to ___

___

___

c.

___

___

_ _ _

___

1 to 2 pills; 3 to 4 hours 1 pill; every 6 hours 8 pills every 24 hours no load i n g ; 30 t o 60 mg at 3 hours; 60 mg at 3 to 5 hours

___

22. a.

How much Tylenol is safe? Comes in dosages o f or mg. Safe u p t o mgfday mgfday Has a ceiling effect at Has hepatic toxicity a bove ,mgfday ___

Ta ble 7 . 3

650 or 1 000 mg

___

b. c. d.

4000 mgfday 1 300 mgfday 1 0,000 mgfday

___

23. A serious side effect of acetaminophen hepatotoxicity is

Ta ble 7 . 3

_____ ,

24.

Complete the following regarding ketorolac (Toradol). N SAI D approved for use i n a. Only p a i n control in t h e U.S. effect is more potent than its b. A effect. c. H a lf-l ife is hours ___

____

25. True or False. Regarding opioid analgesics: a . They have no ceiling effect. b. With chronic use, tolerance develops. c. Overdose is possi ble with severe respi ratory depression. d. Treatment of overdose includes admin istration of naloxone. e. Fl u m a nezil helps in treatment of overdose. 26. True or False. Regarding narcotics: a . Some opioids m a y cause seizu res. b. Physical and psychologica l tolera n ce develops with chronic use. c. There is a ceiling effect with increasing dosage. d. Overdose can cause respi ratory depression.

7.3.4

parentera l ana lgesic; a nti-infl a m matory 6 7.3.5

true true true true fa lse (Fi u m a nezi l is usefu l on treatment overdose from benzod iazepines.) 7.3.5

true true true true

Sedatives, Paralytics, Analgesics 27.

a. b.

Complete the following mnemonic about opioids: 0

p

c. d. e.

0

f. d 28. To what type of opioid receptor subtype does tramadol (Uitram) bind? 29.

a. b.

Ultram acts centrally to inhibit reuptake of n and s

30. True or False. OxyContin tablets should never be taken crushed, divided or chewed. 31 . What is the intramuscular:per os (IM:PO) potency ratio for morphine? a . single dose b. chronic dosing Indicate the following adjuvant medications' characteristic actions: a . Tricyclics b. Tryptophan c. Antihista m i nes d . Phenothiazine

7.3.5

overdose is possi ble potentia l for respiratory depression i ncrease dosage = increase effect - no ceiling effect small pupils - miosis intoxication - treat with N a rcan develops tolera n ce with chronic use 1-1-opioid receptor

7.3.5

norepinephrine serotonin true

34.

Chronic use of tryptophan may cause

Ta ble 7 . 6

Ta ble 7 . 7

1 :6 1 :2 to 3

32.

33. What craniofacial pain syndromes are responsive to carbamazepine? n a. t b. g n n c. p

7.3.5

7.3.6

blocks serotonin inta ke precursor of serotonin a nxiolytic tra n q u i l izing 7.3.6

trigeminal neuralgia g l ossopharyngea l neuralgia post-herpetic neuralgia Vita m i n B6 depletion

7.3.6

43

8 Endocrinology

•

Corticosteroids 1.

Cortisol is released by the a d renal glands; and i s stimulated by pitu ita ry; adrenocorticotrophic hormone (ACTH) hypothalamus which in turn is from the stimulated by corticotropin releasing hormone (CRH) from the . __

8. 1 . 1

___

___ ,

__

2. True or False. The following has to be replaced in adrenal failure: a . M ineralocorticoids b. G l u cocorticoids 3. True or False. The following has to be replaced in pituitary failure: a . Mineralocorticoids b. G l u cocorticoids 4. True or False. The following medications have mineralocorticoid potency: a . Cortisone b. Cortisol c. Sol u-Cortef d . Prednisone e. Methyl pred nisolone f. Dexa m ethasone Hypothalamic-pituitary-adrenal suppression can occur if a dose a . o f 4 0 mg o f pred nisone is g iven for __ days. b. is g iven for 7 to 1 4 days ta per over

8.1 .2

true true 8.1 .2

fa lse true Ta ble 8 . 1

true true true true fa lse fa lse

5.

c. After a month of steroids, H PA axis may be depressed for as long as .

8 . 1 .3

>7 1 -2 weeks 1 yea r

___

Neurosurgery Books

Endocrinology 6. When withdrawal problems develop a.

conservative steroid ta per includes small decrements eq u iva lent to mg of pred nisone every days.

8.1 .3

2 . 5-5

___

b.

___

7. list the possible deleterious effects of steroids in alphabetical order. a. a

b. c.

b c

d.

d

e. e f. f g.

g

h.

h

i. j. j k. k I. I m. m n.

n

0.

0

p.

p

q. r. s.

q r s

t. t u. u v. v w. w 8. What is the best way to test for hypocortisolism?

3-7 8.1 .4

a l ka losis, a menorrhea, avascular necrosis (hip) bone loss cushing noid featu res cata racts, com p ression fractures, chicken pox reactivation diverticu lar perforation, diabetes epid u ra l lipomatosis fu ngal infections, feta l adrenal hypoplasia g rowth s u ppression in children, G l bleed , g l a u coma hypertension, hypokalemia, hyper coa g u lopathy, hiccu ps, hirsutism, hyperlipidemia i m m u nosuppression lipomatosis menta l ag itation, m u scle wea kness, myopathy non-ketotic com a , nitrogen meta bolism is distu rbed obesity prog ressive m u ltifoca l leukoencephalopathy (PML), pseudotu mor cerebri, pancreatitis reactivation of TB sod i u m retention, steroid psychosis tissue plasminogen activator i n h ibition water retention 8 a . m . cortisol level

8.1 .5

45

Part 2: General and Neurology

46

9. What are the symptoms of Addisonian crisis? { H int: CLAW) a. c Confusion b. L Letha rgy c. A Ag itation Wea kness d. w

8.1 .5

--

--

--

1 0. What are the signs of Addisonian crisis? Sta rt you r answers with hypo- or hypera . blood pressu re b. g l u cose c. sod i u m d. tem peratu re e. potassi u m

•

8.1 .5

hypotension hypog lycemia hyponatremia hyperthermia hyperka lemia

Hypothyroidism 11.

levothyroxine is almost pure and contains no T3 because most T3 is from T4. produced __

T4; periphera l ly

8.2.3

___

1 2. Signs of myxedema coma include a. h b. h c. h d. h e. b f. s

•

8.2.3

hypotension hyponatremia hypog lycemia hypoventilation bradyca rd ia seizu res

Pituitary Embryology and Neuroendocrinology 1 3.

The posterior pituitary derives from the downward evagination of from the floor of the

__

-- --

neura l crest cells; third ventricle

8.3.1

--

--

The anterior pituitary gland develops from evagination of , which is also called

epithelial ectoderm Rath ke's pouch

1 5.

The pituitary gland is functionally the blood-brain barrier.

outside

1 6.

The pituitary gland releases hormones, from the anterior pituitary and from the posterior pituitary.

8; 6; 2

1 4.

__ __

__

__

__

8.3.1

8.3.1

8.3.2

Endocrinology 1 7.

a. b. c. d. e. f. g. 1 8.

Match the hormone and the portion of the pituitary where it is produced CD a nterior; 0 posterior Thyrotropin releasing hormone CD Corticotropin releasing hormone CD Oxytocin 0 Antidiu retic hormone 0 Somatostati n CD Prolactin release inhibitory factor CD Gonadotropin releasing hormone CD Prolactin is the only pituitary hormone i n h ibitory predominantly under control from the hypothalamus.

Fig. 8 . 1

8.3.2

___

Describe the side effects of ADH. the permeabil ity of the dista l tubu les. b. __ rea bsorption of water. c. __ circu lating blood. u rine. d . Prod uces

1 9. a.

__

8.3.2

increases i ncreases d i l utes concentrated

20. What is the most powerful physiologic seru m osmolal ity stimulus for ADH release?

8.3.2

47

9 Hematology

•

Blood Component Therapy 1.

For a n adult, 1 unit of packed red blood cells (PRBCs) should raise the hematocrit by %.

3-4%

9.2.2

__

Complete the following concerning platelets: a . Normal platelet count is t o __ . b. Rega rding tra nsfusion of platelets: or i. Tra nsfu se if su rgery is ii. patient is on __ or and ca n 't wait _ to _ days. of iii. Usual tra nsfusion is platelets. iv. One u n it ra ises platelets by . v. Platelet count can be checked in hours. vi . Retra nsfusion wi l l be needed in __ days.

2.

__

__

__

__

Complete the following concerning fresh frozen plasma: a . O n e b a g eq uals __ cc. b. Risk of acq u i red i m m u n odeficiency synd rome (AI DS) or hepatitis is the same as c. Use to reverse Cou madin: i. Proth rom bin time (PT) g reater than

9.2.3

1 50 k-400 k/m m 3 u rgent ASA or Plavix; 5 to 7 an eight pack (=6- 1 0 U) 10 k 2 3-5

3.

ii.

I nternational normalized ratio ( I N R) g reater than __ . iii. Von Wi l lebrand 's d isease u n responsive to __ . iv. M u lti ple coa g u lation dysfu nction such as i n : h v D

9.2.4

200-2 50 a u n it of blood

1 8 seconds 1 .6 DDAVP

hepatic dysfu nction; vita m i n I< deficiency; DIC

Hematology 4. True or False. Regarding Prothrombin complex concentrate {PCC): a . Contains clotti ng factors I I , VI I , I X , X . b. Contains protein C & S. c. Pri mary ind ication is to be given for wa rfa rin reversa l . d . Req uires higher volume than FFP to work. 5.

a.

9.2.4

true true true fa lse (lower vol u m e)

In regard to the use of anticoagulation in a patient who has ok a n u n ru ptu red aneurysm < 4 m m , a nticoa g u lation is . Plavix a d rug el uti ng ca rd iac stent - continue

9.2.5

___

b.

c. At onset of SAH , we wou l d a nticoag ulation. d. Post-operative craniotomy may sta rt to days after surgery. __

reverse 3 to 5

__

6. Regarding anticoagulation in a.

9.2.5

preparation for surgery. If a patient has: a mechanical heart va lve i. stop wa rfa rin days before su rgery ii. and begin . chronic atrial fibril lation i. stop wa rfa rin days before su rgery. __

__

b.

__

3 Loven ox 4 to 5

Complete the following regarding anticoagulation: days a . M a y resume a nticoa g u lation 3 to 5 after craniotomy. b. An n u a l risk of com p lications while not anticoagulated for a patient with i. mechanical heart va lve is % per 6% yea r. ii. chronic atrial fibri l l ation is % per 4-6% yea r

9.2.5

Complete the following regarding neurosurgical procedures: a . PT should b e below seconds. b . I N R s h o u l d not b e above c. For emergencies g ive d. and

9.2.5

7.

__

__

__

8.

___

9.

Both Plavix and ASA inhibit platelet function for how long?

Plavix is more dangerous drug than ASA because it remains a. for u p to b. after the last dose and c. ca n i n h i bit even those g iven treatm ent.

< 1 3.5 1 .4 2 U FFP vita m i n K permanently

1 0.

__

--- ---

9.2.5

9.2.5

active severa l days tra nsfused platelets

Neurosurgery Books

49

Part 2: General and Neurology

50 11.

a. b. c. d.

Name the commonly used herbal products that may affect platelet aggregation. g g g f ___

__

___

_ __

9.2.5

garlic g i n kgo ginseng fish oil

1 2.

Complete the following concerning warfarin (Coumadin): a. Don 't sta rt Cou madin u ntil a has been ach ieved on heparin b. to red u ce the risk of c. For the first 3 days of Cou madin thera py patients a re actua l ly d . therefore patients should b e with or ___

9.2.5

thera peutic partial throm boplastin time {PTT) Cou madin necrosis hypercoagulable

_ _ _

_ __

___

1 3. Possible heparin side effects include a. t b. t c. These side effects a re due to in heparin induced i. throm bosis or ii. formed agai nst heparin platelet. _ _ _

__

1 4. low molecular weight heparins should a . have fewer com p l ications. b. have more predicta ble __ levels. biologic c. elimi nate the need to activity. d . have a longer l ife. e. req u i re __ doses per day. f. have a lower incidence of g. be more effective i n prophylaxis than wa rfarin. ___

___

___

____

___

"bridged"; Lovenox or heparin 9.2.5

throm bosis th rom bocytopen ia consum ption antibodies 9.2.5

hemorrhagic plasma monitor half fewer thrombocytopenia DVT

1 5. A serious side effect could be spinal

epid u ra l hematoma

1 6. a. b.

direct thrombin i n h ibitor ldaru cizu m a b

Regarding dabigatran (Pradaxa). It is a d t i Ca n be reversed with __

__

___

__ _

1 7. Regarding fondaparineux (Arixtra) a. It factor Xa i n h ibition b. without affecti ng Factor . c. U n l ike hepari n , it does not cause h t __

__

__

__

9.2.5

9.2.5

9.2.5

increases Factor lla (th rombin) heparin-i n d uced throm bocytopenia

Hematology 1 8.

a.

Complete the following concerning coagulopathy: To reverse Cou madin a nticoa g u l ation in a patient who is at the usual therapeutic level, use . For severely prolonged coag ulation use

9.2.5

2 to 3 u n its FFP

___

b.

c. To reverse PT from Cou madin use i. ii. Ad m i nistered by what route? iii. Ad ministration may be fata l if given iv. Why? _ h

6 u n its FFP vita m i n K aqua mephyton IM IV hypotension; ana phylaxis

__

a, ____

Matching. Use the numbers of the listed terms to complete the following statements. CD proth rombin complex concentrate; 0 protamine su lfate; G) vita min K; 0 Aq uaMephyton a . Cou madin is reversed by i. ii. iii. b. Heparin is reversed by

1 9.

9.2.5

__ _ ___

20. a.

b.

Regarding protamine sulfate. 1 mg o f protamine reverses __ of heparin. % of Lovenox can be reversed with 1 mg of prota mine for every mg of Loven ox with in the last hours.

__

9.2.5

1 00

u

60%; 8

21 .

Significantly elevated pre-op PTT is commonly due to d a. f a b. l __

__

22.

a. b.

__

__

Complete the following concerning thromboembolism: Risk o f embolism from calf-deep-vein throm bosis is _% Extends to proxi mal deep veins in %. Embolism from thigh veins is %. Morta l ity of DVT in legs is __%. DVTs in neurosurgical patients occur in %.

9.2.5

factor d eficiency l u pus a nticoa g u lant 9.2.5

1% 30 to 50%

___

c. d. e.

___

40 to 50% 9 to 50% 1 9-50%

___

23. Conditions that make neurosurgical patients prone to DVTs are a. c b. I c. o fd d . t. _ __ _ _ __

_

__ __

__ __

_ ___

_ ___ ___

9.2.5

concom ita nt sludging long-time immobility operating room/dehyd ration throm boplastin release

51

Part 2: General and Neurology

52

24. The best prophylaxis against DVT is a . PCB, which is t h e abbreviation for

b.

25.

a. b. c. d.

low

_ _ __

Matching. One can diagnose DVT with the following tests. Match the finding with its appropriate diagnostic value. CD gold sta ndard ; 0 associated with PE and DVT; G) only 50% accu rate; 0 99% specific Hot swollen tender calf with positive Homan sign Contrast venography Doppler u ltrasonog raphy D-d imer

9.2.5

G) CD 0 0

26. What is the treatment of DVT? a. b i leg b. e c. h or l. d . c. f e. Consider G f. a to days g . after h . wea r i. For how long?

bed rest elevate involved leg hepari n ; Lovenox Cou madin G reenfield filter a m b u l ate 7 to 1 0 a nti-embolic stockings indefi nitely

27. a.

1 0 to 1 4 days

_ ___

__

__

_ _ _

_ __

_ _ _

_ _ __

__

__

__

_ _ _ __ _ _ _ _

Regarding pulmonary embolism. Genera l ly occu rs __ to fol l owing s u rgery. b. Common findings include i. t. ii. t. iii. f iv. h c. Classic EKG finding is -e d. Test of choice is c c__ c

_ _ _ _

_ _ _ _ _ _

_ _ _

_ __

__

_

•

9.2.5

pneumatic compression boots dose heparin {5000 1 U su bcutaneous every t o 8 to 1 2 hours first postop day)

9.2.5

9.2.5

tachypnea tachyca rdia fever hypotension S 1 Q3T3 contrast-enha nced chest CT

_ _

Extramed u l lary Hematopoiesis 28.

a.

Extramedullary hematopoiesis can result in abnormal sku l l x-ray ca lled

hair on end

b.

spinal cord compression due to

vertebral body thickening

__

9.3 . 1

--- -- --

Extramedullary hematopoiesis can be treated with a. r a nd/or b. s

29.

9.3.3

radiothera py su rgery

10 Neurology for Neurosurgeons

•

Dementia 1 . What is the definition of dementia? a. Loss of i abil ities b. severe enough to interfere with __ fu nctioning. c. or o d _ d. Ca rdinal featu re is m e. plus at least one additional i f. Affects _ - _% of persons over 6 5 .

_

__

_ _

_ _ __

2 . True or False. T h e following are risk factors for dementia: a. Adva nced age b. Fa m i ly history c. Apolipoprotein E2 3. True or False. Regarding dementia vs. delirium: a . Patients with dementia a re a t increased risk of developing deliri u m . b . Fifty percent o f patients with deliri u m die with in 2 years. c. U n l ike dementia , deliri u m has acute onset.

•

1 0. 1

i ntel lectua l social occu pational memory deficit im pairment 3 to 1 1 % 1 0. 1

true true fa lse (apolipoprotein E4) 1 0. 1

true true true

Headache 4.

Regarding unilateral headache. If it persists a . for > 1 yea r a n is recommended b. beca use this is for migraine c. and may be a hint of an underlyi ng __ __

1 0. 2 . 1

M RI sca n atypical AVM

Part 2: General and Neurology

54 5.

a. b. c. d. e. f.

Matching. Match symptoms with category of migraine. Sym ptoms: CD episodic H/A; 0 N/V; ® photophobia; @ a u ra ; ® foca l neurologic deficit; (a) that resolves with in 24 hours; (b) slow march-like progression of deficit; (c) that resolves within 30 days; ® no headache; (j) mostly seen in childre n ; ® hemiplegia; ® mostly seen in adolescents; @ vertigo, ataxia , dysa rthria , severe H A Category o f migraine: (a-f) below Common migraine Classic migraine Com p l icated migraine Migraine equiva lent Hemiplegic migraine Basi lar artery migraine

1 0.2.2

CD-0-® CD-0-®-@-®-®a-®b ®-®c-®

0-@-(j) CD-® ®-@

6. True or False. Neurological deficits seen in classic migraine typically resolve within a. 1 hour b. 1 day c. 1 week d. 1 month e. They a re permanent 7. True or False. Regarding cluster headaches: a . M a y include partial Horner's synd rome and a utonomic (ptosis, m iosis, tea ri ng) symptoms, nasal stuffiness. b. Are more common in women. c. Occur a l m ost daily. d . Last 30 t o 9 0 mi n utes. e. Conti n u e for 6 to 9 month period. 8. Treatment of acute attacks of cluster headache includes: a. 0 b. e c. s d. s 9. True or false. Basilar artery migraines are essentially restricted to a . geriatric patients b. postmenopausal women c. adolescents d . men 1 0. True or False. Patients suffering from basilar artery migraine usual ly have a family history of migraine.

1 0.2.2

fa lse true fa lse fa lse fa lse 1 0.2.2

true fa lse (5 men to 1 woman) true true fa lse ( 1 to 3 months) 1 0.2.2

oxygen 1 00% by face mask ergota mine sumatri pta n SQ steroids 1 0.2.2

fa lse fa lse true fa lse true (Fa m i ly history of migraine is present in 86%.)

Neurosurgery Books

1 0.2.2

Neurology for Neurosurgeons •

Parkinsonism Matching. Match the symptoms with type of parkinsonism. Sym ptoms: CD g radual onset of bradykinesia; 0 asym metric tremor; G) responds wel l t o levodopa ; @ ra pid progression of symptoms; ® equ ivoca l response to levodopa; ® early midline sym ptoms (i.e., ataxia, gait, ba lance); 0 ea rly dementia ; ® orthostatic hypotension; ® extraocu lar movement abnormal ities Types of parkinsonism: (a-b) below a . Pri mary idiopathic pa ralysis agita ns ( I PA) b. Secondary parkinsonism

11.

In parkinsonism, degeneration of substantia nigra cells (pars compacta) results in a. in 02 dopamine receptors projecting to the globus pallidus interna (GPi) b. i n 0 1 receptors projecting to the globus pa llid us externa (GPe) and subthalamic n ucleus (STN )

1 0.3.2

CD-0-G:l @-®-®-0-®-®

1 2.

1 3.

a. b. c. 1 4.

a. b. c. d.

The effects noted in question 1 2 result in increased activity by ca using of the thalam us, which then suppresses activity i n the

___

The effects noted in question 1 3 increase activity by degeneration o f pigmented neurons of the pars compacta of the This red u ces the levels of in the neostriatu m ; that is the: i. c ii. p P,......,.- iii. g This red uces inhibitory 02 receptors to ___

_ _ _ _

____

_ _ _

_ _ _ ___

e. f.

and ca uses the loss of i n h ibitory 0 1 receptors t o and the s n i n activity The net resu lt is a n of G Pi has i n h ibitory projections to the t. I n h i biti ng the tha l a m u s also suppresses the s m c

1 0.3.2

decrease increase

1 0.3.2

GPi i n h ibition su pplementa l motor cortex 1 0.3.2

dopaminerg ic su bsta ntia nigra dopamine ca udate putamen globus pa llidus GPi GPe

_ __

g. h. i. j.

___

_ _ _

_ _ _

s u bthalamic nucleus increase G Pi tha l a m u s

_ _ _ _

k.

_ _ _

supplementa l motor cortex

55

Part 2: General and Neurology

56

1 5. A hallmark of Parkinson's disease a. a re b. which are i. e ii. h _ _ ____ __

_ _ _

_ _ _ _

a. b.

list secondary parkinsonism examples 4 {Hint: p secondary) p p

c. d.

p p

e.

s

f.

e

g. h.

c

i.

n

1 6.

0

j. d k. a I. r m. y 1 7.

a. b. c. 1 8.

a. b. c. 1 9.

a. b.

Multisystem atrophy (i.e., Shy-Drager syndrome) is parkinsonism plus

dysfu nction plus hypotension. Most don't respond to

_ ___

list the distinguishing features of the progressive supranuclear palsy triad (vertical gaze) dystonia palsy Characteristics of the early stage of progressive supranuclear palsy (PSP) include: Fa l l i n g due to palsy (ca n 't see the floor). Difficu lty eati ng due to and gaze palsy (ca n't see plate).

__

1 0.3.2

Lewy bodies eosi nophilic intraneuronal hyaline incl usions 1 0.3.3

phenothiazine a ntiemetics prog ressive su pran uclear palsy {PSP) poisoning CO, manga nese parkinson-dementia complex of Gua m strial nigra l degeneration, Shy-Drager synd rome post-encephaletic parkinsonism Com pazine olivo-ponto-cerebel lar degeneration neoplasms near su bsta ntia nigra dementia pugilistica a nti-psychotic d rugs Reg l a n , Reserpi ne H u nti ngton's Disease (young people) 1 0.3.3

a utonomic nervous system orthostatic d rug therapy 1 0.3.3

opth a l moplegia axial pseudobu lbar 1 0.3.3

downward gaze downward and vertical gaze

Neurology for Neurosurgeons 20.

a. b.

c.

d. e.

•

Regarding surgical treatment for Parkinson's disease. The ta rget site was True or Fa lse. The surgery worked better for i. bradyki nesia ii. tremor True or Fa lse. The more disabling symptom is i. bradyki nesia ii. tremor The procedure can not be done bi latera l ly beca use of risk of Cu rrent treatment site is the p ___

-- ---

57

1 0.3.3

ventrolatera l nucleus fa lse true true fa lse speech distu rba nce posteroventra l pa l l i d u m

M ultiple Sclerosis 21 .

a. b. 22. a. b. c.

Prevalence of multiple sclerosis { MS) per 1 00,000 is variable. N e a r t h e equ ator i t i s per 1 00,000. I n Ca nada and the northern Un ited States it is per 1 00,000. Multiple sclerosis. Study chart M

u

L

d. T e. I f.

p

g. h. i. j. k.

L E

I. m. n. 0.

p. q.

s

c

L

E R 0 s

s

23. The most common category is r -r

1 0 .4.2

___

___

__

a. b. c. d. e. f. 26.

a. b. c. d. e. f. g.

relapsing-rem itting secondary-prog ressive

___

primary-prog ressive

__

prog ressive-relapsing

__ _

25.

Ta ble 1 0. 2

Matching. Match the multiple sclerosis signs and symptoms with anatomic location. Sym ptoms: CD visual acu ity; 0 d i plopia; ® extremity wea kness; @ quadriplegia; ® spasticity; ® scanning speech; (!) loss of proprioception Anatomic location: (a-f) below optic nerve retro-bulbar region M LF pyramidal tract cerebe l l u m posterior col u m n s Matching. Match anatomic location with multiple sclerosis signs and symptoms. Anatomic location: CD optic nerve; 0 retro-b u l ba r reg ion; ® M LF; @ pyra m id a l tract; ® cerebe l l u m ; ® posterior col u m n s Anatomic location: ( a - g ) below visual acu ity di plopia extrem ity weakness q u a d riplegia spasticity scanning speech loss of proprioception

Provide the frequency of multiple sclerosis signs and symptoms. a . Visual sym ptoms a re among the presenti ng sym ptoms of m u lti ple sclerosis in % b. and occur in m u ltiple sclerosis patients d u ring the cou rse of i l l ness in approxi mately __%. c. In additio n , abdominal cutaneous reflexes a re lost in __%.

>

6 months

1 0.4.3 1 0.4.4

CD CD 0 ®-@-® ® 0 1 0.4.4

CD-0 ® @ @ @ ® ®

27.

1 0.4.4

1 5% 50% 70 to 80%

Neurology for Neurosurgeons 28. A multiple sclerosis plaque in the medial longitudinal fascicu lus {M LF) will cause a. , which wi l l resu lt i n

1 0.4.4

intern uclear ophthalmoplegia (INO) di plopia INO

b. c. This is im porta nt beca use rarely occurs in other diseases. 29.

Indicate the presence or absence of the following reflexes in MS: a . hyperactive m u scle stretch reflexes b. Babinski c. abdominal cutaneous reflexes

1 0.4.4

present present a bsent

30. Conditions found in the differential diagnosis of multiple sclerosis include a. __ __ __ , genera l ly monophasic and b. CNS

acute disseminated encephalomyelitis (AD EM) lym phoma

31 . True or False. In multiple sclerosis the more M RI Iesions, the higher the likelihood of a MS diagnosis.

true ( M RI is very specific for MS plaq ues; specificity is 94%.)

32. Provide M RI criteria for MS. a . Gadol i n i u m : acute lesions in dia meter b. Size: at least c . White matter abnorm a l ities: d. T2-weig hted image: e. Periventricu l a r lesions best seen on f. Criterion for dissemi nation is a

enha nce 3mm 80% lesions a re high sig n a l proton density new enhancing lesion

g.

1 0.4.5

1 0 .4.6

1 0 .4.6

%

or a

Il

new T2 WI lesion

33. True or False. Focal tumefactive demyelination lesions {TDL) can be mistaken for neoplasms because a . they enha nce b. they show perilesional edema c. they can be solita ry d . they can b e in patients known t o have MS e. they can be distinguished from MS f. a biopsy may be necessary g . a biopsy resu lts m a y be confusing Regarding CSF analysis for MS. I t should include q testing. b. I n 90% of MS patients the CSF high.

34. a.

59

1 0 .4.6

true true true true fa lse true true 1 0 .4.6

q u a litative lgG

__

is

lgG

Neurosurgery Books

Part 2: General and Neurology

60 •

Acute Disseminated Encepha lomyelitis 35. True or False. Regarding acute disseminated encephalitis. a . Associated with recent history of vacci nation. b. May demonstrate oligoclona l bands in CSF. c. Is genera l ly monophasic. d. Has good response to high dose IV corticosteroids.

•

1 0.5

true true true true

Motor Neuron Diseases 36.

a. b. c. d. e. f.

Complete the following regarding amyotrophic lateral sclerosis: a ka m n disease a ka L G disease a m ixed and d isease m n, degeneration of a h cells and c t__ in the cervica l spine and med u l l a _ _ _ _

____

___

1 0.6.2

motor neuron Lou Gehrig u pper and lower motor neuron anterior horn corticospinal tracts

37. True or False. Regarding clinical characteristics of ALS. a. There is no cog nitive, sensory, or true a utonomic dysfu nction. b. Spa res vol u nta ry eye m u scles and u ri n ary true sphincter. c. Presents i n itia lly with weakness and true atrophy of hands, spasticity and hyperreflexia . 38.

The common condition that must be distinguished from ALS is

cervica l myelopathy

R inhibits presynaptic release of g , and increases tracheostomy-free survival at and months.

Riluzole; g l uta mate; 9 and 1 2 months

1 0.6.2

1 0.6.2

__ _

39.

__

1 0.6.2

Neurology for Neurosurgeons •

Guillain-Ba rre Synd rome 40.

Regarding Guillain-Barre Syndrome (GBS}. onset o f peripheral a . I nvolves a neu ropathy with b. p m u scle wea kness with a days to _ c. Reaches maxi m u m over weeks. involvement. d . Little or no __

___

___

__

1 0. 7 . 1

acute prog ressive; a rreflexia 3 days to 3 weeks sensory (but paresthesias a re not u ncom mon)

41 . What is albuminocytologic dissociation?

Elevated CSF protein without pleocytosis

42. What infectious organism is commonly involved?

Ca m pylobacter jej u n i

43.

a. b. c. d. e. 44.

a.

Featu res casting doubt on the diagnosis asym metry o f dysfu nction of more than 50 in CSF any i n CSF sharp level ___

___

Complete the following about Miller­ Fisher variant of GBS: Describe the triad i. a ii. a iii. o iv. Seru m bioma rker: a ntia ntibodies _ __

_ __

_ _ _

__

45. Complete the following about Cl OP: a . Sta nds for c d P· _ _ _

_ _ _ __

----

b.

Symptoms m u st be present for more than Cranial nerves are usually Bala nce difficu lties a re Electrodiagnostic and nerve biopsy findings a re indicative of d CSF findings a re similar to Most respond to and _ _ _

_ __

weakness bladder monocytes PMNs sensory 1 0.7.3

ataxia arreflexia ophthal moplegia anti-GQ 1 b 1 0.7.4

chronic i m m u n e demyelinati ng polyradicu loneu ropathy 2 months spared common demyelination

__ _ _

f. g.

_ _ _ _

1 0. 7 . 1

1 0. 7 . 1

___ ___

c. d. e.

1 0. 7 . 1

GBS pred nisone and plasmapharesis

61

Part 2: General and Neurology

62 •

Myelitis 46. True or False. Regarding Acute Transverse Myelitis a . T h e most common sensory level in acute true (68% thoracic sensory tra nsverse myelitis is thoracic. level in ATM } true (66% reach maximal b . ATM prog resses ra pid ly. deficit by 24 hours) c. CSF ca n be normal in the acute phase. true (38%, remainder can have elevated protein or pleocytosis or both ) d . A n emergency M RI is the first test of true (if not available a choice myelogram with CT to fol low) True or False. Regarding treatment of ATM. a. No treatment has been studied in a ra ndom ized controlled tri al. b . High do s e IV methylprednisolone for 3-5 days can be administered . c. Plasma exchange can be given for those who do not respond to steroids.

47.

48. True or False. Regarding prognosis of ATM. a. There is 1 5% morta l ity. b. 62% of survivors a re a m bulatory. c. Recovery occu rs between 1 month to 2 yea rs d . No i mp rovement occu rs after 3 months.

•

1 0.8.3

1 0.8.5

true true true 1 0.8.6

true true fa lse ( 1 to 3 months) true

Neurosarcoidosis Regarding sarcoidosis. Complete the following: a . T h e most common man ifestation i s

dia betes insipidus

b. Treat with

corticosteroids

CNS sarcoidosis involves the I -e a. M may occur as wel l as b. b m may c. T ventricle and h a lso be involved .

leptomeninges

49.

50.

---

---

--

1 0 .9. 1

meningo-encephalitis basal meningitis Third ; hypotha l a m u s

1 0 .9. 1

Neurology for Neurosurgeons 51 .

a.

Complete the following statements about neurosarcoidosis Microscopica l ly w e see featu res of n g, Clinical findings include n p i. c n ii. p iii. m iv. h Dia betes insipidus from involvement of the

1 0.9.2, 1 0.9.4

non-caseating g ra n u lomas

__ __ __ _

b.

_____

______

______

_ _ _

_ _ _

c.

cranial nerve palsies peri phera l neu ropathy myopathy hyd rocephalus hypothalamus

___ _

52.

a. b. c. d. e.

Regarding laboratory findings in neurosarcoidosis. Seru m test that is positive in 8 3 % of cases is CSF test that is helpfu l is H ow frequently is it positive? CSF suggests ACE sta nds for ___

____ _

__ __ __ _ _ __

53. List the test performed with the results in sarcoidosis. a. Chest X-ray a i. H ii. M I n b. M RI i. Enha ncement of I ii. Enhancement of o n iii. Best seen on seq uence c. G a l l i u m sca n (nuclear medicine). Usefu l i n neurosu rgery for: i. s ii. c o v __ _

__ _

___ _ _____

_____

___

______

_ _ _

63

1 0.9.5

ACE ACE 55% meningitis ang iotensin converti ng enzyme 1 0.9.6

hilar adenopathy mediastinal lym ph nodes leptomeninges optic nerve FLAIR sarcoidosis chronic vertebral osteomyelitis

11 Neurovascular Disorders and Neurotoxicology

•

Posterior Reversible Encephalopathy Synd rome ( PRES) 1. a.

PRES: PRES sta nds for

Cha racterized by v e on CT or M RI b with some predomina nce in and regions. c. Associated conditions include h ,e s ' , a nd a d t d . Treatment involves control of and of underlyi ng ca use. b.

posterior reversi ble encephalopathy synd rome vasogenic brain edema ; pa rieta l ; occipita l hypertension, ecla m psia, sepsis, a utoi m m u n e disease, transpla ntation

1 1 .1 .1

1 1 . 1 .2

____

•

blood pressu re

1 1 . 1 .3

Vasculitis and Vascu lopathy 2. Giant cell arteritis: a. Also known as b. I nvolves branches of the a rtery. c. Seen a l m ost exclusively in older than , with a fema le:male ratio of d . T h e most common presenting sym ptom is e. Most serious conseq uence is % a nd is not which occu rs in

f. The wa rning sym ptom that precedes perma nent visual loss is , which occu rs in %. g . Giant cel l a rteritis is associated with which is disease. h. ESR >

times as l i kely in this m m / h r is suspicious.

1 1 .3 . 2

temporal a rteritis external ca rotid ca ucasians; 50; 2:1 headache blind ness; 7%; reversi ble a m a u rosis fugax; 44% thoracic aortic aneurysms; 1 7 times 40

Neurosurgery Books

Neurovascular Disorders and Neurotoxicology i. j. k. I.

m. n. 3.

a. b. c. d. e.

ESR > m m f h r is highly suggestive. ESR may be normal in % with giant cel l a rteritis. Diagnosed via biopsy. Optimal length o f STA biopsy i s em. branch Spare and of STA d u ring biopsy. for M a n a g e with months. ____

Behcet's syndrome consists of the following: (Hint: Behcet's) B. ____

e h c e

____ __ __

, c.____

___ _

f. t g.

s

, t.

___ _

____

,s

_ _ _ _

4. Fibromuscular dysplasia: a . T h e most common vessel involved is the r a rtery, %. b. The second most common vessel involved is the c a rtery. c. The incidence of aneurysms with FM D is %. d . Presenti ng symptoms include: i. H % in ii. u iii. ca n be mistaken for t m iv. s in % v. d u e to involvement of the s c changes in vi . T % vii . d u e t o involvement o f the a c syn d rome in viii. H %. or i ix. T in u p to %. e. Gold sta ndard for diagnosis is where the most common fi nding is " " a ppeara n ce. f. The recommended treatment is

80 22.5% tem poral artery 4-6 cm main tru nk; pa rieta l steroids; 6-24 months 1 1 .3 . 6

Behcet eye lesions headache cerebel l a r signs, CSF pleocytosis erosions of mouth and genita ls thro m bophlebitis, throm bosis of d u ra l sinuses skin lesions, seizu res 1 1 .3 . 9

ren a l , 85% ca rotid 20-50% headache; 78% unilatera l ly typical migraine syncope; 3 1 % ca rotid sinus T-wave; 33% coronary a rteries Horner's; 8% TIA; infarction; 50% DSA; "stri ng of pearls" aspirin

65

Part 2: General and Neurology

66 5. a.

CADASI L: CADASI L sta nds for

1 1 .3 . 6 _ _ __

____ ____ ____ ____ ____

•

and

with

_ _ _ _

b.

inherita nce pattern ma pped to chromosome

c.

M RI findings similar to m u ltiple su bcortica l infa rcts from hypertension, except there is no evidence of

Cerebra l a utosom a l dominant a rteriopathy with su bcortical infa rcts and leukoencephalopathy Autosom a l domina nt; 19 hypertension

Neu rotoxicology 6. Ethanol toxicity:

1 1 .4 . 1

a . T h e pri mary effect o f ethanol on t h e CNS is depression of n i e c ' and n r b. Mellanby effect: the severity of intoxication is g reater when blood alcohol level is c. Blood alcohol level of 2 5 mg/dl ca uses

neuronal excita bil ity, i m pu lse con d uction, neu rotra nsm itter release

d.

Blood a lcohol level o f 1 00 mg/dl causes

cerebel l a r dysfu nction

e.

Blood a lcohol level of 500 mg/dl causes

respiratory depression

f.

Lega l intoxication in most j u risdictions is a blood a lcohol level of may g . A s alcohol levels fa l l , occur as a compensation for the effects of chronic alcohol use. h. Mainstay of treatment for a lcohol withd rawa l synd rome a re h i. They red u ce a and or and may prevent s j. k. I.

m. n. 0.

For a lcohol withd rawa l a lso use for days and for seizu res. Deliri u m tremens occu rs within days of a lcohol withd rawa l . Sym ptoms i n c l u d e a c , and a i Morta l ity i s % if u ntreated . Treatm ent incl udes Classic triad of Wernicke's encephalopathy is e , and a 0

rising mild intoxication

1 00 mg/dl hyperactivity; CNS depressant Benzod iazepines a utonomic hyperactivity; seizures; deliri u m tremens Thiamine; 3 days; Dilantin 4 days ag itation, confusion, a utonomic insta bil ity 5 - 1 0% benzod iazepines encephalopathy, ophtha l m oplegia, ataxia

Neurovascular Disorders a n d Neurotoxicology p. q. r. s.

deficiency. Due to Eye signs occur i n %. Gait distu rbance occu rs in Memory d istu rba nce is ca lled synd rome and occu rs in %. t. Atrophy of the may be seen on M RI . u . It is a med ica l emergency and s h o u l d b e treated with mg daily for days. v. Thia mine administration i mproves but not synd rome.

7. a.

thiamine 96% 87% l< orsa koff' s; 80% m a m m i l l a ry bodies thiamine, 1 00 m g ; 5 days eye signs; Korsa koff's

Opioid toxicity: Opioids include h and d rugs. pupils. b . Prod uce c . Reversa l of toxicity is achieved with

heroi n ; prescri ption small Na loxone

8. a.

norepinephrine

1 1 .4 . 2

Cocaine: Prevents reu pta ke of the neu rotra nsm itter pupils. b . Prod uces c . Ca n be associated with

l a rge stroke

9. Amphetamines: a . Toxicity is similar to b . Their use can resu lt in stroke due to

cocaine vascu litis

1 0. Carbon monoxide poisoning: a . The largest source of death from poisoning i n the U.S. is from

b. c. d. e. f. g.

It poisons by binding to thereby displacing " color of blood occurs in %. In severe cases, CT sca n may show a I i n the g p % die. % have persistent seq uelae. % ma ke fu l l recovery.

1 1 .4.3

1 1 .4.4

1 1 .4 . 5

carbon monoxide hemog lobin; oxygen Cherry-red ; 6% low atten uation; globus pallidus 40% 1 0-30% 3 0-40%

67

12 Plain Radiology and Contrast Agents

•

C-Spine X-rays 1 . A lateral C-spine x-ray has four contour lines: a. along a nterior su rface of vertebral bodies: a m l_ b. along the back su rface of the vertebral bodies: p m l_ c. along the posterior marg i n of the spinal ca n a l : s l l_ d . a l o n g t h e posterior m a rg i n o f the spinous process: p s I_ ___

___

__

__

___

1 2. 1 . 1

a nterior m a rginal line posterior marginal line spino-laminar line

___

___

posterior spinous line

___

2.

Complete the following about spine films: a . Cervica l spine norm a l ca n a l diameter is mm. b . Stenosis is present when the anteroposterior diameter is less than mm.

3.

a. b. c.

Complete the following about normal prevertebral soft tissue: a nterior C1 mm anterior C2 , 3 ,4 mm a nterior C5-C6 mm ___

1 2 . 1 .4

1 7 +/- 5 m m 1 2 mm

1 2 . 1 .4

10 7 22

4 . Interspinous distances: a. Are a bnormal if it is times the adjacent level on AP fil m . b . True or fa lse. I f present they represent: i. fractu re ii. dislocation iii. liga ment disruption on latera l x-ray. c. This is ca lled

true true true fa nning

5 . Cl has how many ossification centers?

3

1 2. 1 .5

6. C2 has how many ossification centers? 4

1 2. 1 .5

1 2 . 1 .4

1 .5

Plain Radiology and Contrast Agents •

Lum bosacral ( LS) Spine X-rays Complete the following regarding lumbosacral spine films. a. The disc space with the g reatest height is at b. AP view. Look for "owl eyes." i. These correspond to the ii. Ca n be eroded in disease. c. Oblique views. Look for the neck of the scotty dog. i. It corresponds to the ii. Disconti n u ity occu rs in a

7.

•

1 2.2

L4-5 pedicles metastatic pars intera rticu laris fractu re

Sku l l X-rays Matching. Match the following skull film findings with their characteristics: CD enlarged sel l a ; 0 ]-sha ped sel l a ; ® symmetrica l ba llooni n g ; @ erosion of posterior clinoids a. cra n iopharyngioma b. pitu ita ry adenoma c. optic glioma d . em pty sella

8.

9.

a. b. c. d. e.

True or False. On a skull x-ray, erosion of the posterior clinoids would most often be seen in the setting of cra n iopharyngioma em pty sella synd rome pitu ita ry adenoma H u rler synd rome optic g l ioma

1 0. True or False. The most common congenital anomaly of the craniocervical junction is: a . Chiari ma lformation b. basi l a r i mpression c. os odontoideum d. incomplete a rch Cl e. Cl -C2 subl uxation 1 1 . What are the types of basilar invagination? a . Type 1 :

b. Type I I : 1 2. a.

b.

Regarding basilar invagination: I n Type I % ca n be red u ced with traction. I n Type II, f m d is appropriate. __

__

1 2.3.1

@ CD 0 ® 1 2.3.1

true fa lse fa lse fa lse fa lse 1 2.3.1

fa lse true fa lse fa lse fa lse 1 2.3.2

Bl without Chiari ma lformation Bl with Chiari ma lformation 1 2.3.2

85% fora men m a g n u m de com pression

Neurosurgery Books

69

Part 3: Imaging and Diagnostics

70

1 3. True or False. In the evaluation of basilar invagination, in the normal patient, no part of the odontoid should be above the McRae line. 1 4. True or False. A line used in the evaluation of the craniocervical junction is a . McRae line b. Cha m berlain line c. Wackenheim line d . Maginot line e. Fischgold line 1 5. True or False. Basilar invagination is seen in a . hypoparathyroidism b. Paget's d isease c. osteogenesis i m perfecta d. osteoma lacia e. hyperpa rathyroidism

•

true

1 2.3.2

1 2.3.2

true true true fa lse true 1 2.3.2

fa lse true true true true

Contrast Agents in Neuroradiology 1 6.

Characteristics of iodinated contrast agents a . m a y delay excretion of b. which is an agent c. used in d . and can be associated with I a e. and r f f. It should be held for hours before and after administration of contrast agent. ____

1 2 .4. 1

metformin oral hypog lycemic dia betes type 2 lactic acidosis

___

_ _ __

1 7. The primary approved agent for , trade name intrathecal use is

Use Omnipaque cautiously in patients who have a. s h �_ b. c -v d c. c a d. m s _ medications at least e. and stop hours before procedure.

ren a l fa i l u re 48

iohexo l ; Omnipaque

1 8.

__

___

__

___

___

___

1 2 .4. 1

1 2 .4. 1

seizu re history cardio-vascular disease chronic alcoholism mu ltiple sclerosis neuroleptic; 48

Plain Radiology and Contrast Agents 1 9.

a.

b.

c.

20.

a.

Complete the following regarding iodinated contrast allergy prep: Prednisone i. Pretest ti ming in hours

ii. Dose in mg iii. Route Benadryl i. Pretest ti ming in hours ii. Dose in mg iii. Route Cimetidine i. Pretest ti ming in hours ii. Dose in mg iii. Route may increase the risk of contrast media reactions and m a y m a s k manifestations of a reaction.

1 2 .4. 1

20 to 24 hours, 8 to 1 2 hours, 2 hours 50 PO 1 50 IM 1 300 PO or IV Beta blockers anaphylactoid

21 .

Describe some idiosyncratic reactions to contrast media. a. Anaphylactoid reaction i. h ii. t b. Vasovagal reaction i. h ii. b c. Facia l or l a ryngeal ang ioedema i. Treat with

ii.

•

If respi ratory distress, i

1 2 .4.2

1 2 .4.2

hypertension tachyca rdia hypotension bradyca rd ia epinephrine (0.3 - 0 . 5 ml of 1 : 1 000 SQ} i ntu bate

Radiation Safety for Neurosurgeons 2 2 . Characterize radiation safety. a. Rem is the a bsorbed dose in rads mu ltipl ied by . b. Q "is the q u a l ity factor": the Q of x-ray is

1 2.5.2

Q

__

cases of cancer in 1 rem causes every 1 million people. d. Spine x-rays with obliq ues is rem . rem . e . Cerebral ang iogram i s f. Cerebral embolization is rem . c.

23.

a. b.

Complete the following regarding occupational radiation exposure: It is advised t o keep below rem per yea r, averaged over a yea r period. ___

___

300

1 2.5.3

5 1 0 to 20 34 1 2.5.4

2 5

71

Part 3: Imaging and Diagnostics

72 24. a.

b. c.

Provide the precautions advised. I ncrease the from the rad iation source. Expos u re is proportional to the of the dista nce. Stay at least feet, prefera bly feet away. Dou ble the dista nce and get of the radiation . What is better: l e a d "doors" or lead aprons? ___

d. e.

1 2.5.4

d ista nce inverse sq uare 6· 10 1 /4 doors

13 Imaging and Angiography

•

CAT Sca n (AKA CT Scan) For measurement o n a CT scan Give Hounsfield u n its for i. air ii. water iii. bone iv. blood clot v. ca lcium vi . disc material vii . theca l sac b. Effect of anemia on a n acute subdura l hematoma ( S D H ) i n a patient with less than 23% HCT wi l l look 1. a.

1 3. 1 . 1

1 000 0 + 1 000 7 5-80 1 00-300 55-70 20-30 isodense

___

2.

a.

Indications for Non-contrast vs. IV contrast enhanced CT scan (CECT): Noncontrast: i . Excels in demonstrati ng a b ,f ,f b , p and h _ _ _

__

__

__

__

ii.

Weak in demonstrating a s and has poor signal quality in the p f . CECT: Excels in demonstrati ng n and v m _ __

_

b.

__

__

__

_

__

_ __

3. Abnormalities that can be demonstrated by CT perfusion (CTP): s s a. f i. decreased c _ & c_ ii. increased M and T_ __

__

__

b. s_: after A_ c

__

i. ii.

,

decreased c _ & c_ increased c c M __

__

t

__

&

1 3. 1 .2

acute blood, fractu res, foreign bod ies, pneumocephalus and hyd rocephalus acute stroke; posterior fossa neoplasms and vascu l a r ma lformations 1 3 . 1 .4

flow significa nt stenosis decreased CBV & CBF increased MTI (mean transit time) and TIP (time to peak) stea l : after ACZ (acetazolamide) challenge decreased CBV & CBF increased correspond ing contra latera l territory and MTI

Part 3: Imaging and Diagnostics

74 •

Magnetic Resonance I maging ( M RI ) Matching. Match the best completion for each of the following: CD short TE, short TR; 0 short TE, long TR; ® long TE, short TR; @ long TE, long TR a. T1 -weig hted MRI has , b. T2-weig hted image has ,

4.

__

__

__

___

Complete the following about magnetic resonance imaging (M RI): a. List the fou r materials that appear white on T1 -weig hted imaging (T1 WI) M R I . b. What color is pathology on T1 WI? c. What color is pathology on T2WI?

1 3.2.1

CD @

5.

1 3.2.2

fat, melanin, and su bacute blood (3- 1 4 days), Onyx low signal on T1 (dark) high sig nal on T2 (white)

6. Matching. Match the phrases with the appropriate signal. CD high signal (bright); (?) low signal (dark); ® intermed iate sig nal a . Fat on T1 i s b. Fat on T2 is c. 7- to 1 4-day-old blood on T2-weig hted M RI is d. 7- to 1 4-day-old blood on T1 -weig hted M RI is

7. Complete the following about M RI: a. The best seq uence for CVA is which sta nds for

b. c. d.

Cerebrospinal fl uid (CSF) is Most lesions appear seq uence. Most lesions a re more

i n this

1 3.2.2, 1 3.2.3

CD 0 CD CD On T1 both fat and 7 -to 1 4day-old blood a re high sig nal (white). On T2 fat d rops out (i.e., is dark); blood remains wh ite. 1 3.2.5

FLAIR; fl uid-atten u ated inversion recovery black bright conspicuous

8. The best M RI sequence for a . acute SAH i s b. old blood is

FLAI R g radient echo

9. Gradient echo: a. a ka b. aka c. CSF and flowi ng blood appear d . I n cervical spine prod uces a effect. e. I m p roves deli neation of

f. Also shows small old g. It is the most sensitive M RI seq uence for b

1 3.2.5 1 3.2.7 1 3.2.7

T2 sta r g rass white myelographic bone spurs hemorrhage intraparenchyma l blood

--

Neurosurgery Books

Imaging and Angiography 1 0. Complete the following about M RI: a. An M RI sequence that s u m mates Tl and T2 signals and causes fat to be suppressed is ca l l ed the seq uence. b. STI R sta nds for

c. 11. a.

Use it to see tissues that a reas of fat.

in

Name two contraindications to M RI. or Patients who contain

b. A relative contra indication to M RI is 1 2.

a. b. 1 3.

a. b. c. 1 4.

Complete the following regarding programmable valves and M RI: Ca n such patients have M RI studies? You may need to check the after the M R I .

a. b. c.

1 3.2.8

STI R

short tau inversion recovery (sum mates Tl and T2 images) enhance 1 3.2.9

ferro meta ls or cobalt (i.e., ca rdiac pacemaker, impla nted neurosti m u lators, coch lear im plants, ferromagnetic aneurysm clips, foreign bodies with a large component of iron or cobalt, meta l l i c fragments in the eye, placement of stent, coi l , or fi lter withi n past 6 weeks) claustrophobia 1 3.2.9

yes pressu re setti ng

Hemorrhage on M RI. Related to time.

1 3.2. 1 0

Tl .

H i nt: George Washington Bridge acute g su bacute w chronic b

g ray white black

Hemorrhage on MRI. Related to time.

1 3.2. 1 0

T2.

H i nt: layers of Oreo cookie a . acute b b. su bacute w c. chronic b 1 5.

75

Hemorrhage on MRI. Related to time. H i nt: i - baby, i - d i , bi - d i , ba - by, da - da hyper-acute i. Tl : i ii. T2 : b acute i. Tl : i ii. T2 : d su bacute ea rly i. Tl : b ii. T2 : d

black white black 1 3.2. 1 0

isodense bright isodense dark brig ht dark

1!1

Part 3: Imaging and Diagnostics

76 d.

su bacute late i. T1 : b ii. T2 : b chronic i. T1 : d ii. T2 : d

d a rk dark

1 6. a. b. c. d. e.

Age of hemorrhage hyper acute: acute: su bacute ea rly: su bacute late: chronic:

1 4 days

1 7.

If M RI contrast is given to patients with severe renal failure, a rare condition called n s f may occur.

1 8.

Complete the following regarding diffusion weighted images (DWI): Its primary use is to detect i. MS p ii. and a It fi rst generates on map. On DWI , freely diffusible water is

e.

a. b. c.

d . Restricted diffusion i s e. Which is a bnormal?

brig ht bright

1 3.2. 1 0

nephrogenic systemic fibrosis

1 3.2. 1 3

ischemia active; plaq ues ADC dark bright restricted diffusion

Characterize DWI. Restricted perfusion usually ind icates

cel l death

b.

DWI abnorma l ly will be present for

1 month

c.

DWI abnorm a l ities can light u p withi n of ischemia.

m i n utes

1 9. a.

20. The most sensitive study for ischemia of the brain i s the DWI and PWI mismatch identifies penumbra. H i nt: DWI death PWI pen u m bra a . Which modal ity shows i rreversible cel l inj u ry (death)? b. Which modality shows reversi ble cel l inj u ry (penum bra)?

1 3.2. 1 3

PWI {Perfusion Weig hted Imaging)

21 .

22. The important peaks in MRS are: H i nt: li-la-N a-crea-chol a. li b. Ia c. N a d . crea e. chol

1 3.2.1 1

1 3.2. 1 3

1 3.2. 1 3

DWI PWI 1 3.2. 1 4

lipid lactate N acetyl aspartate creati ne choline

Imaging and Angiography 23. The significance of important peaks in M RS are a . hypoxia b. a cou plet pea k c. nerve and axons d . a reference for choline e. mem brane synthesis f. increased in tumor g. increased in developing bra i n h . red uced in CVA 24. The test that may help distinguish hemangiopericytoma a . from meningioma is the b. specifica lly the presence of a large peak. 25. The test that may help a surgeon avoid critical white matter a . tracts d u ring bra i n su rgery i s b . which sta nds for d t

•

1 3.2. 1 4

lactate lactate NAA creatinine choline choline choline choline 1 3.2. 1 4

M RS inositol 1 3.2. 1 5

DTI diffusor tensor imaging

Myelogra phy 26. True or False. The risk of postlumbar puncture headache is higher with a . water-sol uble contrast. b. non-water-soluble contrast.

1 3 .4

fa lse true

27.

Matching. Match each of the following two statements with answers G), @, @, or @. G) 1 0%; @ 3 5%; ® 65%; @ 90% a . I n l u m ba r d i s c d isease, what percentage 0 of free fragments move inferiorly? b. I n l u m ba r disc d isease, what percentage ® of free fragments move superiorly?

•

1 3 .4

Radionuclide Scanning 28. Applications for bone scans include: a. b. t__ c. d __ involvi ng a __ b__ m d . c. _ e. s__ or s__ f__ f. " I __ b__ p__ " __ _

29. Applications for Gallium scan are a . s__ b. c__ v__ o__

1 3.5.1

infection tumor diseases involvi ng abnormal bone meta bolism era n iosynostosis spine or sku l l fractu res " l ow back problems" 1 3.5.2

sarcoidosis chronic vertebral osteomyel itis

77

14 Electrod iag nosties

•

Electroencepha log ram ( EEG) 1 . True or False. Periodic epileptiform discharges (PLEDs) may b e produced by a . herpes simplex encephalitis b. bra i n a bscess c. e m bolic infa rct d . bra i n tumor e. any acute foca l cerebral insult

•

1 4. 1 . 1

true true true true true

2.

Matching. Match the following EEG patterns a n d their probable diagnostic pathology: (j) Creutzfeldt-jakob disease; 0 hepatic encephalopathy, post anoxia and hyponatremia; ® SS PE-su bacute sclerosing panencephalitis a . tri phasic waves 0 b. body jerks plus high-voltage period icity ® with 4-1 5 second sepa ration ; no change with pain c. myoclonic jerks, bilatera l sharp waves (j) 1 . 5-2/sec, react to painfu l sti m u lation

1 4. 1 . 1

3. What is the frequency of the following EEG rhythms? a . Delta b. Theta c. Alpha d . Beta

Ta ble 1 4. 1

0-3 Hz 4-7 Hz 8-1 3 Hz > 1 3 Hz

Evoked Potentials 4.

a.

Complete the following statements about evoked potentials: Evoked potentia ls offer lim ited usefu l ness in avoiding intraoperative i nj u ry beca use they a re __

1 4. 2 . 3

acute; delayed

Electrodiagnostics b.

Criteria for sign ificance: i. I ncreased latency of %. ii. Decreased a m plitude of %. __

__

5.

Intraoperative SSEP may localize the primary sensory cortex by potential across the central sulcus.

1 0% 50% phase reversa l

1 4. 2 . 3

___

6. When testing brainstem auditory a.

__

b.

_

7.

a. b. 8.

a. b. c. d. e. f. g.

___

_

Evoked potentials during spine surgery: M a y remain u nchanged b y inj u ry t o the cord but a re sensitive to inj u ry to the col u m n s of the cord .

___

True or false. Regarding transcranial (i.e., motor evoked) potentials: Too painfu l to do on the awake patient. Feedback is prom pt, a l m ost im mediate. Ca n't record conti n u ously beca use of m u scle contractions. Usefu l for cervical spine surgery. Usefu l for thoracic spine s u rgery. Usefu l for l u m ba r spine surgery. Have more special a nesthetic req u i rements.

9. Provide the SSEP deterioration plan. a. R b. R c. R d. s e. s f. s g. T h. A i. H j. E __ __

--

--

---

__

--

--

•

Ta ble 1 4. 5

evoked responses (BAER): Prolongation in peak 1-1 1 1 suggests lesion pons and inferior col licu l u s between p and i c Prolongation in peak 1 1 1-V suggests lesion lower p o n s and mid brain between I p and m 1 4. 2 . 3

a nterior posterior, dorsa l 1 4. 2 . 3

true true true true true fa lse true 1 4. 2 . 4

remove ha rdwa re reposition patient release retraction sixty Hz steroids stop surgery tem peratu re anemia hypotension electrode contact

NCS/ EMG 1 0.

Name the parts of the EMG examination. a. l a b. s a c. v a ___

__

___

___

__

_ _ _

1 4. 3 . 2

insertional activity sponta neous activity volitional activity

Neurosurgery Books

79

Part 3: Imaging and Diagnostics

80

How long following denervation of muscle after nerve injury do you want to see fibrillation potentials on electromyography { EMG)? a. The earliest is __ , but b. relia bly not u nti l c. Therefore, don't order EMG u ntil at least ___weeks after the inj u ry.

11.

_ _ _ _

1 2. a. b. c.

SNAP: a ka ___ action potenti al. Ganglion lies with in the Hern iated disc is preganglion; therefore, S NAP is

_ _ _ _ _ _ _

1 4. 3 . 2

1 0 days 3 to 4 weeks 4 weeks 1 4. 3 . 2

sensory nerve neura l foramen not affected

__ __

1 3. a.

b. 1 4. a.

b.

F wave: May b e___ in m u ltilevel radiculopathy. Most hel pfu l in eva l uating slowing.

___

1 4. 3 . 2

prolonged root

H reflex: Is practica l only rega rding t h e __ root. Has similar information to the

proxi m a l 1 4. 3 . 2

51 Ankle jerk

1 5. True or False. Regarding EMG: true a . Is low yield for radiculopathy. b. Best reserved for patients with wea kness. true true c. Pa in without wea kness, EMG has low yield.

1 4. 3 . 2

1 6. True or False. Radiculopathy EMG is: a. Reliable if negative

1 4. 3 . 2

b. 1 7.

Reliable if positive The earliest possible finding in EMG for radiculopathy is

red uced recruitment (2-3 days)

Findings with healing radiculopathy: potentia l s retu rn fi rst. If lost, retu rn last or may not retu rn.

Motor Sensory

_ _ _

1 8. a. b.

fa lse - EMG is not sensitive for radiculopathy true - when positive very specific.

___

___

1 4. 3 . 2

1 4. 3 . 2

15 Primary Intracranial Anomalies

•

Arachnoid Cysts, Intracranial 1.

a. b. c. d. e. f. g.

Characterize intracranial arachnoid cysts. Orig i n : c Arise from splitti ng o f a m Conta in fl uid identica l to Incidence p e r 1 000 a utopsies: More common in male or fema le? Most a re a I f sym ptomatic, typical sym ptoms a re: h i. i ii. s ---

2. True or False. Acute deterioration in patients with known arachnoid cysts usually signifies a . ra pid i ncrease in cyst size. b. posticta l state. c. ru ptu re into subd u ra l space. d. ru ptu re of bridging veins and cyst bleed . 3.

a. b. c. d.

Complete the following about arachnoid cysts: T h e location o f t h e only extra d u ra l type of a rachnoid cyst is in the __ cyst. A retrocerebellar a rachoid cyst might m1m1c a -___ synd rome. The most common location for an a rachnoid cyst is t h e __ ___ . T h e next most common location is the -- ---

e. They a re associated with ventricu lomegaly in __%. f. The best treatment is probably c___ s

1 5. 1 . 1

congenita l a rachnoid membrane CSF 5 male asym ptomatic intracranial hypertension seizures 1 5 . 1 .4

fa lse fa lse fa lse true

intrasellar

1 5. 1 .3

Dandy-Wa l ker Sylvian fissu re

Ta ble 1 5 . 1

cerebel lopontine angle 64%

1 5. 1 .5

cyst s h u nting

1 5. 1 .6

Part 4: Developmental Anomalies

82 •

Craniofacia l Development Complete the following about craniofacial development: a . T h e anterior fonta nelle closes b y age

2 . 5 years

b.

1 yea r

4.

1 5.2.1

Head size is 90% of a d u lt size at age

c. The head stops enlarging by age a t birth . d . T h e sku l l i s e. Diploe a ppears by the __ yea r and f. Reaches a maxi m u m at age . g . Diploic veins form a t age h. Air cel l s in the mastoid occur in year.

___

.

___

5. True or False. Craniosynostosis a. has been proven to occur after s h u nti ng. b. of one sutu re does not cause increased ICP.

7 yea rs u n ilaminar 4th 35 35 6th 1 5.2.2

fa lse fa lse ( 1 1 % have high ICP)

6. Complete the following about

1 5.2.2

craniofacial development: a . T h e most common cra n iosynostosis i s

b. The male to female ratio is c. The resu lti ng sku l l shape is Su rgery should be done within the age ra nge of e. The stri p cra n iectomy should be em wide.

d.

___

7.

a. b. 8.

a. b. c. d.

Complete the following regarding coronal synostosis Incidence o f patients with cra n iosynostosis who have coronal synostosis is __%. I n which is it more com mon, males or fema les? Complete the following regarding coronal suture synostosis {CSS ) : P l u s syndactyly is ca l l ed synd rome. Unilatera l CSS is ca l led CSS plus hypoplasia of the face is ca l led d isease. Plag iocephaly i. Forehead on affected side is or ii. Supraorbita l ridge has a marg i n . ___

___

9.

Regarding harlequin eye sign

sag itta l 80:20 dol ichocepha lic/ sca phocephalic/ boat shape 3 to 6 months 3 cm 1 5.2.2

1 8% females 1 5.2.2

Apert's synd rome plag iocephaly Crouzon 's disease flattened ; concave higher 1 5.2.2

Primary Intracranial Anomalies a.

Occu rs in u c___ sutu re closure b. seen on c. The abnormal bony structu re is the ___ ___

d . which is

than the normal side.

Complete the following about craniofacial development: a . What suture is closed t o prod uce trigonoceha ly? b. It is usually associated with an abnormality of the chromosome.

u n i latera l coronal anteroposterior sku l l X-ray supraorbita l marg i n higher

1 0.

1 5.2.2

metopic 19 p

_ __

1 1 . Characterize lambdoid synostosis. a . M a l e t o female ratio is b. Side involved most frequently is ___ . c. The frequency of involvement is ___ % rig ht. d . Does i t have a ridge or a n indentation to pal pation? 1 2. a.

Considering lambdoid synostosis: Differentiate from positional flattening by looking at the ears from the

b.

I n l a m bdoid synostosis you wi l l see the ipsilatera l ear In position a l flattening you wi l l see the ipsilatera l ear is __ ___ .

1 5.2.2

4:1 right side 70% indentation (Not a ridge like the sag itta l or coronal synostosis) 1 5.2.2

top of the head lags behind

__ ___

c.

1 3. Answer the following concerning lambdoid synostosis treatment: a . True or Fa lse. A l l req u i re surgery.

b.

True or Fa lse. Surgery is ind icated ea rly (i.e., 3 to 6 months).

c.

Ideal age for su rgery is to months. Early su rgery is ind icated for s d and e

d.

___

__

_ _ _

___

__ _

pushed forwa rd (If flat side of occipita l bone is same side as the posteriorly positioned ear it is a case of lam boid synostosis; if not it is a case of position a l flattening) 1 5.2.2

Fa lse ( 1 5% won't respond to repositioning.) Fa lse (one ca n observe for 3 to 6 months for im provement) 6 to 1 8 severe disfi g u rement and elevated intracranial pressure

P· ---

1 4.

a.

Complete the following about encephalocele: I ncidence o f basa l form o f encephalocele is %. May exit the sku l l via a defect in ___

b.

1 5.2.3

1 . 5%

83

Part 4: Developmental Anomalies

84

i. c ii. f iii. s

•

___

p c

_ _ _ _ ___

f

__ _

0

cribriform plate fora men cecum su perior orbita l fissu re

Da ndy Wa lker Malformation 1 5. To differentiate DWM from retrocerebellar arachnoid cyst observe for a. v a verm ian agenesis fou rth ventricle v b. cyst opens i nto f c. enlarged p f posterior fossa torcu l a r herophili d . elevation o f t h e t h

1 5.3.2

1 6. What is Dandy-Walker pathogenesis? a. D b. A c. N ( m ) d. D e. Y

1 5.3.3

_ _ _ _

___

_ _ _

___

___

_ _ _ _

1 7. Complete the following regarding Dandy-Walker malformation (DWM): of the f a. It is cau sed by a of M and L ___

___

b.

___

_ _ _

di lation of 4th ventricle agenesis of vermis mem brane of 4th ventricle dysembryo genesis hyd rocephalus

atresia of the fora m i n a ; M a g e n d i e and Lusch ka (old theory)

Resu lts i n verm is i. agenesis of ii. large which posterior fossa cyst comm u nicates with the fou rth ventricle; , which becomes iii. enlarged

1 5.3.5

1 5.3.3

___ ___

1 8. What is Dandy-Walker pathogenesis? a . Hyd rocephalus is present in % b. and __% of hyd rocephalus patients have DWS. c. A common associated abnormality is c i. a of the c

70 to 90% 2 to 4%

1 5.3.5

agenesis of the corpus ca llosum %. 1 7% ii. in ca rdiac abnormalities a and c If treatment is necessa ry, you m ust s h u nt cyst the ventricle, the cyst, or both? If aqueducta l stenosis you should s h u nt ventricle a lso. But shu nti ng the latera l ventricle alone i . is contraindicated ii. beca use it might cause u pwa rd herniation ___

1 5.3.3

___

___

d. e. f.

___

_ _ _ _

1 5.3.6

___

g.

___

___

h . To avoid herniation, a lone. i. you m u st not s h u nt the ___

1 9.

u pwa rd ventricle

What is the prognosis of DWM?

Neurosurgery Books

1 5.3.7

Primary Intracranial Anomalies a. b. c. •

Seizu res occur in Morta lity occu rs in Norma i iQ is

%. ___

%.

to

___

%

1 5% 1 2 to 50% 50%

Aqueductal Stenosis 20. True or False. Aqueductal stenosis is seen only in children. 21 . What are the causes of aqueductal stenosis? a. A b. Q c. E(i) d. c e. T f. A g. L 22. Complete the following concerning aqueductal stenosis: a . It is associated with congenita l hyd rocephalus in %. b. M RI may show a bsence of f in the v i. n ii. a of S c. M RI with contrast should be used to rule out d . Fol l ow- u p s h o u l d be for a t least e. I n order to ru le out

Fa lse (Ad u lts can present with sym ptoms as wel l . )

1 5 .4. 1

1 5 .4.2

astrocytoma o f brain stem quadrigeminal plate mass inflam mation infection congenital atresia tumor a rachnoid cyst l i poma 1 5 .4.3

70%

1 5 .4.4

___

___

___

_ __

23. True or False. A patient with aqueductal stenosis of adulthood may have the following symptoms: a . Headache b. Visu a l disturbances c. Decl ine of menta l fu nction d . Gait distu rbance e. Pa pilledema (sig n) f. Ataxia g . Urinary incontinence 24. What are the treatment options for aqueductal stenosis? a. Ventriculoperitoneal b. T c. ETV = _ __ _ _ _ _

___ ____ ___ _ __ _ _ _ _ _ _ _ _ _ __

•

normal flow void aqueduct of Sylvius tu mor 2 yea rs tumor 1 5 .4.4

true true true true true true true 1 5 .4.4

CSF shu nti ng Torki ldsen s h u nt in adu lts endoscopic third ventriculostomy

Agenesis of the Corpus Cal losum 2 5 . Agenesis o f the corpus callosum forms after conception and at age forms from to __ _

2 weeks; rostru m to splenium

1 5.5.1

85

Part 4: Developmental Anomalies

86

26. Complete the following concerning the bundles of Probst: a . They a re aborted beginnings o f the

b.

bulging into the

1 5.5.3

corpus ca llosum latera l ventricles

27. Complete the following regarding agenesis of the corpus callosum: a. Does it a lways have clinica l significance?

b.

•

1 5.5.4

No, it may be an incidenta l finding Underlyi ng cause may be a n abnormality chromosome of a

Absence of the Septum Pel l ucidum 28. One possible cause of absence of septum pellucidum is a. s -o d b. a ka of o c. which prod uces h n d . and o c as wel l as e. p __

_ _ _

_ _ _ _ _ _ __

__ _

1 5.6

septa-optic dysplasia de Morsier synd rome hypoplasia of optic nerve

_ _ _

___

____

•

___

-----

optic chiasm pitu ita ry infundibu l u m

I ntracranial Lipomas 29. lntracranial lipomas a. a re usually found in the

1 5.7.2 __ _

midsag itta l plane

b. especia lly in the c. They a re freq uently associated with

corpus ca llosum agenesis

d. of the e. They may less freq uently involve the i. t c ii. and the

corpus ca l losum

___ ___ _

___

___

30. True or False. Characteristics of intracranial lipomas include a bnormalities a . association with b. on CT they have a density. c. Differential diag nosis is c. i. d ii. t iii. g-,-----,-intensity on d . On M RI they have a Tl . intensity on e. On M RI they have a T2 .

tuber cinereum q u a d rigeminal plate 1 5.7.3

congenital low

___

dermoid cyst teratoma germinoma high

___

low

___ _

___ _

Primary Intracranial Anomalies 31 .

a. b. c. d.

•

Intracranial lipomas may present clinically with s h d. h m _ _ _

_ _ _

_ _ _

_ _ _

_ _ _

1 5.7.4

seizu res hypothalamic dysfu nction hyd rocephalus menta l reta rdation

Hypothalamic Hamartomas 32. Hypothalamic hamartomas a . a re freq uent or ra re? b. a re neoplastic or nonneoplastic? c. consist of a mass of d . that a rises from the h or i. in ii. t c 33. a.

b. c. d. e.

Hypothalamic hamartomas clinically may present with a special type of seizu re ca l led , which means seizure. may also have attacks. may also present with p p d u e t o release o f g h formed within the cells.

1 5.8.1

rare nonneoplastic neuronal tissues inferior hypothalamus tuber cinereum 1 5.8.2

gelastic; laughing rage precocious puberty gonadotropin releasing hormone hamartoma

87

16 Primary Spinal Anomalies

•

Spinal Dysraphism (Spina Bifida) 1 . Study sheet. Spinal bifida occulta a. B b. I c. F d. I e. D f. A g. 0 h. c i. c j. u k. L I. T m. A

1 6.2.2

bifid a incidental foot deformity in nocuous diastematomyelia atrophy of leg occu rs in 20 to 30% cutaneous stig mata clinical im porta nce nil u rin a ry incontinence lipoma leg wea kness tethered cord a bsent spinous process

2.

Complete the following regarding myelomeningocele (MM): a . T h e anterior neuropore closes a t gestational age d a y . b. The posterior neuropore closes at gestational age day .

1 6.2.3

25

__

28

__

3.

a.

Complete the following regarding myelomeningocele (MM): Incidence i f no previous c h i l d has M M eq uals % or p e r 1 000. One previous M M child: % or per l OOO. Two previous MM children: __% or __ per l OOO. Associated hyd rocephalus: incidence of %. Associated Chiari I I occurs in children with M M . __

b.

1 6.2.3

0 . 2 % or 2 %

__

__

2%, 20

__

c. d. e.

6%, 60 80% most

Primary Spinal Anomalies 4. Answer the following about myelomeningocele: a . What is t h e incidence o f meningocele o r myelomeningocele? b. Does the risk increase i n fa mi lies with one affected child?

c. Does the risk increase i n fa mi lies with two affected children?

89

1 6.2.3

1 t o 2 / 1 000 l ive births (0.2%) Yes (The risk does increases to 2 to 3% i n fa mil ies with one previous myelomeningocele child.) Yes (It fu rther increases to 6 to 8% in fa mil ies with two previous affected children.)

5. True or False. All children born with myelomeningocele have an associated Chiari I I malformation.

fa lse (Not a l l , but most, have Chiari I I . )

6. True or False. Closure of

true

1 6.2.3

latex

1 6.2.3

1 6.2.3

myelomeningocele may result in the need for CSF shunting. 7.

Meningomyelocele patients develop allergy to

8. True or False or Uncertain. Intrauterine closure of mm defect reduces a . Chiari I I defect b. hyd rocephalus c. neurological dysfu nction 9.

a. b. c.

Complete the following concerning myelomeningocele: (n I f ru ptu red , sta rt and g ). Perform surgery within to hours. Better fu nctional outcome occu rs if of children have sponta neous

d . D o m u ltiple anoma lies occur in myelomeningocele? Complete the following about myelomeningocele and early closure: a . True or Fa lse. Resu lts in i mprovement of neurolog ica l fu nctions. b. True or Fa lse. Resu lts in lower infection rate. c. Myelomeni ngocele should be closed with in 1 2 , 24, or 36 hou rs?

1 6.2.3

true u n certain fa lse 1 6.2.3

a ntibiotics (nafci l l i n and genta m icin) 24 to 36 hours movement of lower extremities Yes (average 2 to 2.5 additional anomalies in myelomeningocele)

1 0.

1 6.2.3

fa lse true 24 hours

Il Neurosurgery Books

Part 4: Developmental Anomalies

90 11.

a.

Considering late problems in myelomeningocele repair. Possible late problems include: bra i n :

b. cervicomed u l l a ry j u n ction: c. cord : d . ca uda: 1 2.

a.

Characterize myelomeningocele outcome without treatment and with treatment. S u rvive infa n cy without treatment _ ­ _%; with treatment %. Normai iQ without treatment %; % with treatment Ambulatory without treatment %; with treatment % Conti nence without treatment with treatment %.

1 6.2.3

hyd rocephalus ­ malfu n ctioning s h u nt Chiari I I com pressing med u l l a Syri nx tethered cord 1 6.2.3

1 5 to 30%; 85%

__

b. c. d. 1 3.

__

__

__

__

__

__

___ ,

a. b. c. d. e.

For each of the following, what are the facts to know concerning lipomeningocele? age for su rgery band conus d u ra epid u ra l fat versus

f. g. h.

placode neuro exa m sensory loss

i. j.

stigm ata u rologic exa m

_ _ _

1 4. True or False. Lipomyelomeningocele is associated with tethered cord. 1 5. a.

Study Chart. Lipomeningocele: Steps in surgical ma nagement (Co u rtesy of Dr. David Frim):

70%; 80% 50%; 40 to 85% ra re; 3 to 1 0% 1 6.2.4

2 months is appropriate thick fi brovascu lar band is split is deh iscent lipoma (is disti nct from epid u ra l fat) attached to neura l placode is normal in 50% most com mon neurological a bnormality cutaneous should be done pre-op true

1 6.2.4

1 6.2.4

1 . Untether the cord using Xomed CUSA and recording from a n a l sphincter 2. Free u p sides from attachment to d u ra . 3 . Red u ce t h e b ul k o f fat using CUSA in the midline. 4. Tie d u ra open to sides. 5 . Place bovine perica rd ia! g raft as d u ra l substitute.

Primary Spinal Anomalies 1 6. True or False. The most common location of a dermal sinus tract is the: a . occi pita l reg ion b. cervica l region c. thoracic reg ion d. l u m bosacra l reg ion 1 7. What is the most likely cause of dermal sinus? a . Fai l u re o f the ectoderm b. to -ectoderm c. from the d . a t t h e time of e. of the 1 8. a.

b.

Dermal sinus facts to know include: Most com monly located in the a rea. of of Resu lts from

c. from d . Appea rs as a i. Hair? ii. Midli ne? iii. Skin stigmata? e. Fi rst m a nifestation is f. Tract a lways cou rses l u m bosacra l a rea.

from

1 9. True or False. An epidermoid cyst contains hair follicles and sweat glands. 20. What is the major difference between epidermoid cyst and dermoid cyst? a . Epidermoid cyst i s s i. lined with s e ii. and contains only b. Dermoid cyst is i. lined with such ii. and contains as iii. hair fol licles? iv. sebaceous g l a nds? ---

21 . True or False. A dermal sinus tract is a potential pathway for intradural infection such as meningitis or abscess. 22. Radiologic evaluation of dermal sinus. a . I f seen a t births do b. If first seen later do _ _ _ _

1 6.2.5

fa lse fa lse fa lse true 1 6.2.5

cuta neous sepa rate neuro closure neura l g roove 1 6.2.5

l u m bosacra l fa i l u re of separation of cutea nous ectoderm neura l ectoderm d i m ple With or without Close to midline yes bladder dysfu nction cephalad fa lse

1 6.2.5

1 6.2.5

stratified squamous epithelium kerati n dermis skin appendages yes yes true

1 6.2.5

1 6.2.5

u ltrasound MRI

91

Part 4: Developmental Anomalies

92

23. Given the above, indicate whether the dermal sinus tract should be excised at the given locations. a. l u m ba r yes b. sacra l yes no c. coccygeal

1 6.2.5

24.

1 6.2.5

Complete the following concerning the cranial dermal sinus: a . T h e track extends b. If the dermal sinus tract enters the sku l l t o t h e torcu la. i t does s o _ __

•

ca u d a l ly ca udal

Klippei-Feil Synd rome 25. True or False. Klippei-Feil syndrome results from failure of a. pri m a ry neuru lation b. secondary neu ru lation c. dysj u n ction d. seg mentation 26. Klippei-Feil syndrome of a . Resu lts from fa i l u re of at gestational age of weeks. to b. c. Clinical triad i. Hairline is ii. N eck is iii. Motion is d . Lim itation o f ra nge o f motion o f the neck occu rs only if more than seg ments a re fused. e. True or fa lse. Other congen ita l abnormalities may a lso be present. f. True or fa lse. Klippei-Feil causes sym ptoms related to fused vertebrae. ___

_ __

_ _ _ _

1 6. 3 . 1

fa lse fa lse fa lse true 1 6. 3 . 1

seg mentation of cervical so m ites 3 to 8 weeks 1 6.3.2

low short l i m ited 3

_ __

27. True or False. Anomalies seen associated with Klippei-Feil include a. Sprengel deformity b. webbing of the neck c. basilar i m pression d . unilatera l a bsence o f t h e kidney 28.

a.

Possible systemic congenital abnormalities include g

b.

c.____

_ _ _ _

true fa lse 1 6.3.2

true true true true 1 6.3.2

genitourinary - a bsence of one kid ney ca rdiopulmonary

Primary Spinal Anomalies •

93

Tethered Cord Syndrome 29.

a. b. c. d. e. f.

List the six presenting signs and symptoms of tethered cord syndrome. c cutaneous {54%) s scoliosis {29%) b bladder {40%) s sensations {70%) g gait {93%) p pain {37%)

Ta ble 1 6. 2

30. True or False. Regarding tethered cord syndrome. a . Prog ressive scoliosis is not seen in fa lse conj u n ction with tethered cord synd rome. b. Early u ntethering may res u lt in true i mp rovement in scol iosis.

1 6 .4.4

31 . True or False. The following is associated with adult tethered cord syndrome: a . Foot deform ities b. Pain c. Leg wea kness d . U rological symptoms

1 6 .4.5

fa lse true true true

32. True or False. Urological symptoms are not common in the adult tethered cord syndrome.

fa lse

1 6 .4.5

33. True or False. A tethered conus lies distal to L2 on radiographic evaluation.

true

1 6 .4.5

Complete the following concerning tethered cord syndrome: a . N a m e two criteria. i. Conus below level ii. Thick fil u m g reater than b. A preop test that is strongly recomm ended is a

34.

35.

a. b.

Indicate the characteristics used to identify the filum. The vessel on the su rface is The color of the fi l u m is than nerve roots

--- ---

Complete the following outcome from tethered cord: a . I n meningomyelocele i t is usually to permanently b. Repeated u ntethering is advised til l patient stops

1 6 .4.5

L2 2 m m diameter cystometrogram

1 6 .4.6

1 6 .4.6

squiggly more wh ite

36.

1 6 .4.6

im possible; u ntether g rowing

Il

Part 4: Developmental Anomalies

94 37.

Symptoms of untethering are especially likely during the a g s

adolescent g rowth spurt

1 6 .4.6

__ _

___

38. a. b.

•

_ _ _

Surgical release in an adult is good for and poor for return of

__ __ _

1 6 .4.6

pain relief bladder fu nction

Split Cord Malformation 39. True or False. Diastematomyelia is fa lse (septu m is rig id) associated with nonrigid bony septum that separates two durally unsheathed hemicords. 40.

Complete the following concerning diastematomyelia: a . Cuta neous stigmata a re h tuft or hypertrichosis. b. True or fa lse. There are foot abnormalities, c. specifica l ly n h -a __ f __

__

1 6.5.2

1 6.5.2

hair true neurogenic high-arched foot

_ _ _

Neurosurgery Books

Ii

17 Primary Craniospinal Anomalies

•

Chiari Malformations 1. a.

Compare Chiari types I and II. med u l la-ca udal d islocation

b.

into cervical ca nal

c.

myelomeningocele

d.

hyd rocephalus

e.

med u l l a ry kink

f.

cervica l nerves

g . a g e a t presentation h.

sym ptoms

2.

Complete the following about Chiari malformation: Chiari I has how many a bnormal ities? List fou r names this abnorm a l ity has been ca lled. i. t h of c ii. c d

a. b.

iii. p iv. c 3. a. b.

e e

of t

Chiari I has how many deform ities? is known by the following names i. e ii. e iii. d iv. h

Ta ble 1 7 . 1

Chiari I, no; Chiari I I , yes Chiari I , tonsils; Chiari II, verm is, med u l l a , fou rth ventricle Chiari I , no; Chiari II, yes Chiari I , no; Chiari I I , yes Chiari I , no; Chiari II, 55% Chiari I, norm a l ; Chiari I I , u pwa rd Chiari I , a d u lt; Chiari I I , infa nt Chiari I , neck pain; Chiari II, hyd rocephalus, respiratory distress 1 7. 1 .2

1 -with many names tonsi l l a r hern iation ca udal displacement of cerebe l l u m peg like elongation of tonsil cerebellar ectopia 1 7. 1 .2

ectopia elongation displacement herniation

Part 4: Developmental Anomalies

96 c.

symptoms i. 0 ii. c

h p

occipita l headaches cervica l pain

4. What is the particular eye sign associated with Chiari I?

Downbeat nysta g m u s is considered a cha racteristic of this cond ition in 47%, but it ca n also occur in Chiari I I .

5. What percentage of Chiari I patients have hydrosyringomyelia?

20 to 30% of Chiari I patients have a syri nx.

6. Characterize the location of tonsils a.

b.

c. d. 7.

a. b. c. d.

8.

a. b. c. d. e.

and Chiari I. Normal ra nge related t o fora men magnum i. high ii. low iii. mean Chiari I ra nge is i. high ii. low iii. mean Sym ptoms can occur with tonsils at mm below. U s u a l level considered cutoff for diagnosis is m m below. Possible better correlation with symptoms of tonsillar herniation is the degree of brain stem compression a t the as seen on the T W1 M R I . T h e best resu lts from su rgery occur if treated withi n yea rs o f onset of symptoms. Complete the following concerning Chiari 1 : The most common postop complication is in %. Occurs within how m a ny days of surgery? Occu rs mostly at what time of day? Death can occur from s a Other risks of surgery include f I i. c ii. inj u ry to p a c of c iii. h h

1 7. 1 .2

1 7. 1 .2

Ta ble 1 7 .4

8 m m a bove 5 mm below 1 m m a bove 3 m m below 29 mm below 1 3 m m below 2 5 1 7. 1 .2

fora men m a g n u m axial 2 2

1 7. 1 .2

respi ratory depression i n 1 5% 5 night sleep a pnea cerebrospinal fl uid leak posterior inferior cerebel l a r artery (PICA) herniation of cerebel l a r hemispheres

Primary Craniospinal Anomalies 9.

Complete the following concerning Chiari 1 : a . Operative resu lts i . Main benefit m a y b e t o a p ii. Best resu lts in patients with synd rome iii. which consists of a t I a n d b. Which responds better: pain or weakness? ___

__ _

1 7. 1 .2

arrest progression cerebellar

___

__ _

__ _

__ _ __ _

1 0. Factors that correlate with a worse outcome are a. a b. s c. sym ptoms that a re lasting more than _ __

__ _

1 1 . Which Chiari malformation is associated with myelomeningocele? 1 2.

Study Chart. Chiari II anatomical abnormalities: A to Z.

tru nca l ataxia l i m b ataxia nystagmus dysarthria pain 1 7. 1 .2

atrophy scoliosis 2 yea rs Chiari I I atlas assi milation beaking of tectu m , bony a bnormalities cerebel lar folia poorly myelinated, cervica l med u l l a ry junction compression, cra niolacu nia, corpus ca llosum agenesis degenerated lower CN nuclei enlarged massa intermedia fa lx hypoplasia, fou rth ventricle trapped, fusion of cervica l vertebrae gyri min iatu rized hyd rocephalus, heterotopia, hyd romyelia Kl ippei-Feil deformity low attachm ent of tentori u m massa interm edia enlarged med u l l a oblongata "z" bend microgyria nuclei of lower CN degenerated platybasia, peg of cerebellar tonsils septu m pel l u cid u m a bsent, syringomyelia tectum bea king, tentori u m low attachment Z-sha ped bend of med u l la

1 7. 1 .3

1 7. 1 .3

97

Ii

Part 4: Developmental Anomalies

98 1 3.

a. b. c. d. e. f. g.

Findin � on presentation of Chiari II. H i nt: n chiari two n n c h i a r

h. i i. t j. w k. 0 1 4.

a.

Complete the following regarding Chiari II. The most common cause of morta l ity is

The mortal ity at 6 years follow- u p is %. c. Ra nge of morta l ity i. I nfa nts in poor cond ition (i.e., ca rdiopulmonary a rrest, vocal cord para lysis, and /or a rm weakness morta l ity) is %. d . I f there is g radual onset o f symptoms, morta l ity is %. e. The worst prog nostic factor for response to surgery is b v c p b.

•

1 7 . 1 .3

nystag m u s-down beat nasal reg u rgitation cya nosis hoa rseness im paired venti latory d rive a pneic spells, aspiration reg u rgitation, respi ratory a rrest inspiratory stridor tenth nerve (vag us) voca l cord para lysis wea k a rm-weak cry opisthotonus 1 7 . 1 .3

respi ratory arrest 40% 71%

23% bilatera l voca l cord para lysis

Neural Tube Defects 1 5.

With neural tube defects there are classification systems. Give examples of a . neuru lation defects i. a ii. m b. postneurulation defects i. m ii. h iii. h iv. I v. s c. spinal defects i. d ii. s

1 7.2.1

anencephaly myelomeningocele microcephaly hyd ranencephaly holoprosencephaly lissencephaly schizencephaly diastematomyelia syringomyelia

Primary Craniospinal Anomalies Complete the following about neural tube defects: a . Fai l u re t o fuse t h e a nterior neuropore resu lts in b. Fai l u re to fuse the posterior neuropore resu lts in c. The definition of microcephaly is head circu mference below the mean. d. I n hyd ra nencephaly the cortex is replaced by e. Fai l u re to cleave ca n result in

1 6.

Complete the following about neural tube defects: a . Give exa m ples o f neuru lation defects. i. a ii. c iii. m of b. These defects are due to the neura l tube.

1 7.2.1

anencephaly myelomeningocele 2 sta ndard deviations CSF holoprosencephaly

1 7.

Complete the following about neural tube defects: a . N a m e five postne u ru l ation defects. i. h ii. I iii. h of iv. a v. d b. Which is the most severe?

1 7.2.1

anencephaly era n iorach ischisis myelomeningocele nonclosure

1 8.

1 7.2.1

hyd ranencephaly lissencephaly (most severe) holoprosencephaly agenesis of corpus ca l losum diastematomyelia l issencephaly

b.

Complete the following regarding lissencephaly: I t is a n example o f a n a bnormality of neuronal It resu lts in a n abnormality of the

cortica l convol utions

c.

ca l led

a gyri a

1 9.

a.

20.

a.

___

Name the key features of schizencephaly. which com municates with

b. lined with c. Two types are i. 0 ii. c

1 7.2.1

migration

1 7.2.1

cleft; ventricle g ray matter open li pped close l i pped

21 .

Complete the following about neural tube defects: a . I n schizencepha ly, t h e cleft wa l l is lined with cortica l b. I n porencepha ly, the cystic lesion is lined or tissue. with

1 7.2.1

g ray matter connective or glial

Neurosurgery Books

99

Ii

Part 4: Developmental Anomalies

1 00 22. a. b. c. d.

Hydranencephaly is a defect. Cra n i u m is fi lled with Is there a small or large head? Most common etiology i s

e. Angiography i. of anterior circu lation shows ii.

of posterior circulation shows

1 7.2.2

post-neuru lation CSF l a rge (macrocrania) bilatera i iCA infa rcts no flow normal flow

23.

Complete the following about neural tube defects: a . What a re t h e th ree types of holoprosencepha ly? Please list in order of decreasing severity. i. a

ii. s iii. I b. They occur beca use of i. fa i l u re to ii. of the 24.

a. b. c.

list the risk factors for neural tube defects. B c D

d. f e. f f. h g.

a e

0

h. v

a

i. v 25. What are the tests for prenatal detection of neural tube defects? a . Seru m

b. u c. which ca n detect what % of spina bifida cases? d. a

1 7.2.2

alobar (single ventricle, most severe) semi lobar lobar (least severe) cleave telencephalic vesicle 1 7.2.3

B l 2 insufficiency cocaine-maternal use Depa kene-use d u ring preg nancy folic acid insufficiency fever i n first trimester heat exposu re-maternal hot tub, sa u n a obesity before and d u ring preg nancy va l proic acid use d u ring preg nancy vita mins-prenatal lack of folic acid and B l 2 1 7.2.4

a lfa fetoprotein (If high at 1 5 to 20 weeks be suspicious for neura l tube d efects. ) u ltrasonography 90% a m niocentesis

Primary Craniospinal Anomalies 26.

Regarding prenatal detection of neural tube defects. a . Test mother's seru m for alpha fetoprotein

•

b. which has a sensitivity rate for spina bifida % and for anencephaly %. c. Closed spinal dysraphism

9 1 %; 1 00%

d . A n overestimate o f gestational a g e wil l make us think that a high alpha fetoprotein level is e. Rea l-ti me imaging through f. Identifies % of s b g . Obtaining fl uid from the wom b is ca lled

normal

a m niocentesis

h.

6%

It ca rries a risk of feta l loss of %.

1 7.2.4

may be missed

u ltrasonography 90% of spinal bifida

Neurenteric Cysts 27.

Complete the following about neurenteric cysts: a . A neurenteric cyst is a centra l nervous system ( CNS ) cyst lined with b. resembling the or tract. c. Reg ions affected a re usually the or a reas. d. H istologica l ly, cyst lined with e -c c e . with m g -s c

1 7.3.1

endothelium gastrointesti nal or respi ratory cervica l or thoracic cu boidal-co l u m n a r epitheli u m muci n-secreti ng goblet cells

1 7.3.2

1 01

Ii

18 Coma

•

General I nformation 1 . Write out the Glascow Coma Scale (GCS) and indicate the score assigned to each point on the scale. a . Eyes i. e ii. y_ iii. e iv. s b. Verbal i. v_ ii. 0 iii. i iv. c v. e c. Motor i. m ii. 0 iii. v_ iv. i v. n vi . g_ -

-

-

-

-

-

-

1 8. 1

4 sponta neous 3 to speech 2 to pain 1 nil 5 oriented 4 confused 3 inappropriate 2 incoherent 1 nil 6 obeys 5 loca lizes 4 withd rawa l 3 decorticate 2 decerebrate 1 nil

2. True or False. A patient with a GCS score E2 Vl M2 (GCS 5) is in a coma.

fa lse (Whereas 9 0 % of patients with GCS < 8 a re in a com a , coma is defined as the inability to obey com mands, speak or open the eyes even to pain.)

3.

A GCS less than 8 is a genera l ly accepted operation a l defi n ition of com a .

Define coma.

4.

list the three locations of brain lesions that produce coma. u pper p o n s and midbra i n and m a. u __ p diencephalic b. d c. b__ c bi latera l cerebral hemisphere h __

___

_ _ _

_ __

1 8. 1

1 8. 1

1 8. 1

Coma •

Posturing 5.

Disinhibition by removal of the corticospinal pathways above the midbrain typically results in (f ) posturing.

decorticate (flexion)

1 8.2.2

decerebrate (extension)

1 8.2.3

__

__

6. Disinhibition by removal of the vestibulospinal tract and pontine reticular formation by removing inhibition of medullary reticular formation typically results in (e ) posturing.

_ _ _

7.

a.

Complete the following about coma in general: I n a decorticate postu ring . flexion i. the u pper extremities a re in ii. the lower extrem ities a re in extension

1 8.2.3

___

b.

•

I n decerebrate posturing i. the u pper extremities a re in ii. the lower extremities a re in

___

.

extension extension

Etiologies of Coma 8.

A patient is brought to the ER in a coma after being found down. Pupils are equal and reactive. Painful stimulus elicits no movement. No signs of trauma are evident. Studies show Na 1 30, K 4.9. C 1 -1 00, HC03 21 5, BUN 30, Cr 1 .2, Glu 440. The likely cause of coma is

dia betic ketoacidosis

1 8. 3 . 1

___ _ _ _

Indicate the effect of midline shift on level of consciousness. a. 0 to 3 mm: b. 3 to 4 m m : c. 6 to 8.5 mm: d. 8 to 13 mm:

9.

1 0. The three categories of disorders in the different diagnosis of pseudocoma are: -i s and v a. 1 p i b. p d ,c , and __

___

___

__

n g B

___

__

c.____

c.

___

___

__ _

w ,G s

____

_ _ _ ___

and m

__ _

Ta ble 1 8 . 3

alert d rowsy stu porous comatose 1 8.3.3

locked-in syn d rome; ventra l pontine infract psych iatric disorders, catatonia; conversion reaction neuromuscu l a r wea kness; myasthenia g ravis; G u i l lain­ Ba rre synd rome

1 03

1 04

Part 5: Coma and Brain Death

1 1 . A patient presents with coma. Your first move is to assess and secure the

airway

1 2.

Complete the following about approach to the comatose patient: a . What percentage o f patients with Wernicke's encephalopathy present with coma? b. You wou l d i n itia l ly treat those patients with

Matching. Match the respiratory pattern with the location of the lesion. CD med u l l a ry; 0 pontine; ® bilatera l cerebral hemisphere; 0 high med u l la or lower pons a. Cheyne-Stokes b. hyperventilation c. cluster breathing d . apneustic e. ataxic

1 8.3.4

3% thiamine

1 3.

1 8.3.4

® 0

0

0 CD

1 4. What is the significance of equal, reactive pupils in a comatose patient?

Indicates toxic metabolic ca use.

1 5. What is the most useful sign in distinguishing metabolic from structural coma?

the light reflex

1 6.

The only metabolic causes of fixed/dilated pupils are a. a e b. g t u c. a __

d.

b

t

p

1 7. In a third nerve palsy a. the pupil is b. and the eye looks __ and ___ . 1 8. True or False. The following ocular finding can be seen in comatose patients with pontine lesions: a . pin point pupils b. period ic a lternating gaze

c. ocu lar bobbing d . bilatera l conjugate d eviation t o cold caloric

1 8.3.4

1 8.3.4

1 8.3.4

1 8.3.4

a n oxic encephalopathy g l utethimide toxicity a nticholi nergic use (i.e., atropine) botu l i n toxin poison ing 1 8.3.4

dilated down and out 1 8.3.4

true fa lse (usually ind icates bilatera l cerebra l dysfu nction) true fa lse

Neurosurgery Books

Coma In frontal lobe lesions patient looks t h e side o f t h e destructive lesions that is __from the hemiparesis. from the side of the irritative b. lesions (seizu res) that is __ the jerki ng side.

1 9. a.

20.

In a pontine lesion the eyes deviate towards the side.

1 8.3.4

towa rd ; away away; towa rd hemiparetic

21 .

Name three causes of bilateral downward gaze deviation. a . t___ l l b. m __ p c. b. _ _ _

__

__

_ _ _

22.

a.

Complete the following concerning internuclear opthalmoplegia: Is d u e t o a lesion i n t h e

b.

Fibers a re interru pted that go to the

c.

Resu Its in i. loss of ii. of the ___ eye iii. on iv. or in response to

_ _ _ _ _ _

__ _

___ _ _ _ _ _ _ ___

v.

and convergence is

__ _ _ _ _

1 8.3.4

1 8.3.4

thalamic lesion mid bra i n pretecta l lesion ba rbitu rates 1 8.3.4

medial longitudinal fascicu l u s contra latera l 3 rd nerve nucleus add uction ipsi latera l sponta neous eye movement reflex movement (doll's, ca lories) not i m paired

Complete the following regarding oculo-vestibular reflex: a . A comatose patient with an intact tonic; towa rds brainstem wi l l have conjugate eye deviation the side of the cold sti m u lus, b. which may be delayed u p to mi n ute. No c. Will there be nystagm us?

23.

1 8.3.4

__

__

24.

In a normal ciliospinal reflex, the pupil to noxious cutaneous stimulus.

dilates

1 8.3.4

___

25.

True or False. The ciliospinal reflex is indicative of a. pa rasym pathetic pathways b. spinothalamic pathways c. i nteg rity of the periaqueducta l g ray d. sym pathetic pathway

1 8.3.4

fa lse fa lse fa lse true

1 05

1 06 •

Part 5: Coma and Brain Death

Herniation Synd romes 26. True or False. Subfalcine herniation is of concern because: a . Anterior cerebral a rtery territory infa rcts may occur. b. Tra nstentorial herniation may occur. c. There is no obvious concern.

true fa lse

27. True or False. Decreased consciousness occurs early in uncal herniation.

fa lse (It occurs l ate in u ncal and early in centra l herniation.)

28. True or False. Uncal herniation rarely gives rise to decorticate posturing.

true

1 8 .4.2

true

29. Upwards cerebellar herniation a . c a n occl ude the b. resu lti ng in infa rction

SCA cerebel l a r

30. Tonsillar herniation a . c a n compress t h e b. resu lti ng in

med u l la respiratory a rrest

31 . Central herniation a . c a n occl ude the b. resu lti ng in c. It can shear the basilar a rtery a n d cause D ___ hemorrhages.

PCA cortical blind ness perforators; Duret

__ ,

True or False. This stage of central herniation is reversible. a. med u l l a ry stage b. diencephalic stage c. lower pons d. u pper pons

1 8 .4.3

1 8 .4.4

1 8 .4.4

fa lse true fa lse fa lse

33.

__

__

34. True or False. Internuclear ophthalmoplegia is prominent at the "lower pons" stage of central herniation.

1 8 .4.2

1 8 .4.3

32.

List the distinguishing features of pupils and respiratory rate in the following injuries. a . I nj u ry at t h e diencepha lon: i. Pupils to ii. Respi ratory pattern is ___ . b. I nj u ry at the mid bra i n : i. Pupils a re in ___ . ii. Respi ratory pattern is ___ . c. I nj u ry at the pons: i. Pupils ii. Respi ratory pattern is___ . d. I nj u ry at the med u l la oblongata : i. Pupils a re ___ . ii. Respi ratory pattern is

1 8 .4.2

1 8 .4.4

react to light Cheyne-Stokes mid position hyperventilation pin-point apneustic di lated , fixed ataxic fa lse (at the u pper pons stage)

1 8 .4.4

Coma 35. Why does injury to the pons result in pinpoint pupils?

Sym pathetics a re lost.

36. Why does injury of midbrain herniation result in moderately dilated, fixed pupils?

Sym pathetics and parasym pathetics a re lost.

37. What percentage of patients with central herniation symptoms had: a . good outcome? b. fu nctional outcome? c. died?

39. What shape is the suprasellar cistern?

pentagonal

1 8 .4.4

40.

c. ca using hemiplegia. d . Kernahan's phenomenon is desig nated as a __ loca lizing sign

•

1 8 .4.4

9% 1 8% 60%

fa lse true

During uncal herniation, Kernahan's phenomenon occurs a . when the cerebra l ped u ncle b. is com p ressed against the ___

1 8 .4.4

1 8 .4.4

38. True or False. Regarding uncal herniation: a . T h e earliest consistent s i g n i s i. i m pa i red consciousness ii. u n i l atera l dilated pupil

1 8 .4.4 1 8 .4.4

contra latera l tentoria l edge ipsilatera l fa lse

Hypoxic Coma 41 .

a. b.

Regarding the most vulnerable cells in anoxic encephalopathy. Cortex i. ___ cortical layer horn ii. Basal ganglia p i. g ii. c iii. p Cerebel l u m i. p ce lls ii. d n ucleus iii. i 0 What tissue is more sensitive t o a n oxia , g ray or white matter? Are steroids usefu l after ca rdiac a rrest? __

c.

d. e.

__

1 8.5

3 rd Ammon 's globus pallidus ca udate putamen Pu rkinje dentate inferior olive g ray (has g reater 0 2 req u i rement) no

1 07

1!1

19 Brain Death and Organ Donation

•

Brain Death in Adu lts 1 . True or False. According to the Uniform Determination of Death Act of 1 980, an individual is dead if they have sustained a . irreversible cessation o f circu latory a n d respiratory fu nctions. b. irreversible cessation of all fu nctions of the enti re brain, including bra i n stem.

•

1 9. 1

true true

Brain Death Criteria 2. The basic requirements and clinical findings that may be used in determining brain death include: . a . Core tem peratu re b. Systolic blood pressu re __ . c. Blood a lcohol level r d . Absence of b c p . e. No response to d f. Failed a c __

_ _ _

__

__

__

__

__ _

3. When testing oculovestibular reflex you should a. insti l l _ - _ m l of ice water into one ear b. with HOB at , c. wait _ m i n ute for response and d . > _ min utes before testing the opposite side. __

4. The apnea test: of m a . Assesses f b. to be va lid test for bra i n death, the PaC02 m u st reach __ without any respirations. c. This usually takes m i n utes. __

__

Ta ble 1 9. 1

> 36 C (96.8F} > 1 00 m m H g < 0.08 % brainstem reflexes deep centra l pain a pnea challenge 1 9.2.3

60- 1 00 30 degrees 1 5 1 9.2.3

fu nction of med u l l a > 60 mmHg 6

Brain Death and Organ Donation 5. True or False. The apnea test should be aborted if: a . t h e patient h a s chest or abdominal movement. b. SBP < 90 m m H g c . S a 0 2 d rops < 8 0 % for > 30 seconds.

1 9.2.3

true true true

6. True decerebrate or decorticate posturing or seizures are with the diagnosis of brain death.

incom patible

1 9.2.3

7.

com patible

1 9.2.3

___

Spinal cord mediated reflex with the movements are diagnosis of brain death.

Name five complicating conditions that must not be present to declare an adult brain dead. a. h

8.

_ _ _

b. c.

p

d. e.

s

9.

_ _ _ _

P· --_ _ _

Cerebral angiography is compatible with brain death when there is of intracranial flow at the level of the c b or the c of ___

1 9.2.3

hypothermia: core tem peratu re < 3 2 . 2 (90F) intoxication (i.e. para lytics, ba rbitu rates, benzod iazepines) post-resuscitation (i.e., cou l d be in shock, or atropine may have been used in resuscitation, ca using fixed dilated pupils) pentoba rbita l (> 1 0 u g f m l) shock (SBP < 90 m m H g ) a bsence; ca rotid bifu rcation; circle of Willis

1 9.2.5

__

w__

1 0. True or False. Regarding the use of EEG as an ancillary confirmatory test. a . I t is a b l e t o detect brainstem activity. b. It does not exclude the possibil ity of reversi ble coma. c. It req uires electro-cerebral silence. 1 1 . When performing a cerebral radionuclide angiogram for brain death confirmation, the finding of no uptake in brain parenchyma is also called h s p . __

__

1 9.2.5

fa lse true true (no electrica l activity > 2mcV) hol low sku l l phenomenon

__

Neurosurgery Books

1 9.2.5

1 09

110 •

Part 5: Coma and Brain Death

Brain Death in Children 1 2.

Current guidelines for diagnosis of brain death in children are not supported for infants week gestational age due to insufficient data.

< 37

1 9. 3 . 1

__

Recommended observation periods to declare brain death in children: a. Term newborn - 30 days of age b. I nfa nts and children

1 3.

•

1 9.3.2

24 hours 1 2 hours

Organ and Tissue Donation 1 4.

a. b. c.

Brain death can result in the following physiologic aberration: h h d

1 5. True or False. Candidates for organ donation by cardiac death: a . Are venti lator dependent. b. Their fa m i ly has decided to withd raw support. c. Further treatment wou l d improve outcome.

1 9 .4.3

hypotension hypothermia dia betes insipidus 1 9 . 4. 5

true true fa lse (it wou l d be futi le)

20 Bacterial Infections of the Parenchyma and Meninges and Complex Infections

•

Meningitis 1 . True o r false. Regarding meningitis. a . Com m u n ity acq u i red meningitis i s typica l ly more fu l m i n ant than meningitis fol lowing a neurosurgical procedure or tra u m a . b . Foca l neurological s i g n s a re common in acute meningitis 2. What syndrome describes large petechial hemorrhages i n the skin and mucous membranes, fever, septic shock, adrenal failure, and DIC in children with disseminated meningococcal infection? 3. a.

Regarding treatment of meningitis. What is empiric a ntibiotic coverage for post-neurosurgical proced u re meningitis?

b.

If the patient has a severe PCN allergy, what a ntibiotics can be used instead?

c. What a re the three phases of a ntifu n g a l treatment for cryptococca l meningitis?

20. 1 . 1

true

fa lse Waterhouse-Friderichsen synd rome

20. 1 . 1

20. 1 .2

Va ncomyci n (M RSA coverage), 1 5 mgfkg q 8 - 1 2 h rs to achieve a trough level of 1 5 - 20 mgfdl + cefepime 2 g m IV q 8 h rs Aztreonam 2gm IV q 6 - 8 h rs or Ciprofloxacin 400 mg IV q 8 h rs I n d u ction thera py: l i posoma l amphotericin B 3-4 mgfkg IV daily + fl ucytosine 2 5 mgfkg PO Q I D for at least two weeks followed by Consolidation therapy: fl uconazole 400mg PO daily for at least 8 weeks followed by Chronic mai ntena nce therapy: fl uconazole 200mg PO daily

112

Part 6: Infection

4. What are the most common causal organisms in post-neurosurgical procedure meningitis? a. c -n s __ _

b. c. d. e.

s__

E P P

a

__ __ __ __ __ ___

sp.

__ __ __ ____

In immunocompromised patients, what additional organisms must be considered in the differential diagnosis? n a. C b. M t a m c. H d. L m

20. 1 . 2

Coa g u lase-negative sta phylococci S. a u reus Enterobacteriaceae Pseudomonas sp. Pneumococci (usually with basilar sku l l fractu res and otorh inologic surgery)

5.

___ _

_ __

_____

_ __ __ __

__ _ _ _ _

6. True or false. Regarding post­ traumatic meningitis. a . Most cases wil l have a basal sku l l fractu re. b. Most patients have obvious CSF rhinorrhea . c. Most infections are from organisms i n digenous to the nasal cavity. d. Surgical treatment is preferred to conservative management. e. Ciprofloxacin or l m ipenem is the treatment for gram-negative orga nisms. f. Penici l l i n is the treatment of choice for g ram-positive orga nisms. g. Antibiotics should be contin ued for 1 week after CSF is sterilized. Patients with recurrent meningitis must be evaluated for the presence of the following etiologies of an abnormal communication between the environment and the intraspinal/intracranial compartment. a. d s b. C_ f c. n c

20. 1 . 2

Cryptococcus meningitis Mycobacteri u m tu berculosis HIV aseptic meningitis Listeria Monocytogenes 20. 1 .3

true true true fa lse true fa lse true

7.

__

__

__

______

8.

a. b. c. d. e.

_

Differential diagnosis for chronic meningitis: t. f n s m c _ _ _ ___

__

___

___ _ __

_ ___

_ _ _ _ _

2 0 . 1 .4

dermal sinus CSF fistula neu roenteric cyst 20. 1 . 5

tu bercu losis fu ngal infections neu rocysticercosis sarcoidosis meningeal ca rcionmatosis

Bacterial and Complex Infections list the favored antibiotic for each of the following organisms: a. S. pneumonia b. N . meningitidis c. H. infl uenza

9.

d. Group B Strep e. L. monocytogenes f. S. a u erus g. h. i.

•

aerobic g ra m negative baci l l i P. aeru g inosa Ca ndida spp.

20. 1 .6

PCN G PCN G a m pici l l i n (beta lacta mase neg) or ceftriaxone (beta lacta mase pos) am pici l l i n am pici l l i n ± IV genta micin oxaci l l i n (M SSA) or va ncomyci n ± rifampin (M RSA) ceftriaxone ceftazid ime or cefepime Liposomal a m photericin B + fl ucytosine

Cerebra l Abscess 1 0. True or false. Regarding brain abscesses. a . Are most commonly polymicrobia l . b . Sta phylococcus is t h e most common organism isolated. c. CRP is typica lly norma l . d . Sym ptoms a re similar o f other mass lesions by prog ress ra pid ly. 1 1 . The incidence of brain abscesses is in developing countries.

20.2.1

true fa lse fa lse true higher

20.2.2

__

1 2. What are the risk factors for a brain abscess? a. p a b. c c h d c. b e d. p h __ t s e. c f. o m g. h ____ __ __ _

___

__ __ __

_______

__ __ __ __ __

___

_____

__ __ __

___

______

1 3.

a. b. c. d. e.

__

Complete the following about sources of brain abscesses: For what percentage o f cerebral a bscesses is no source found? Where is the most common orig in for hematogenous spread? Eth moidal and fronta l sinu sitis leads to an a bscess in which lobe? Why a re infa nts less likely t o develop a bra i n a bscess fol lowi ng p u rulent sinusitis? After penetrati ng tra u m a , open surgical debridement is req u i red to _ _ _

20.2.3

pul monary a bnormalities congenita l cya notic heart disease bacteria l endocarditis penetrati ng head tra u m a chronic sinusitis otitis media i m m u n ocom p rom ised host 20.2.4

25% of cases chest fronta l lobe Lack of aerated sinuses and air cells. remove foreign matter and devita l ized tissue

113

B

1 14

Part 6: Infection

1 4.

Complete the following about causative pathogens of brain abscesses: a . What percentage o f cerebral a bscesses fai l to g row a n organism on cultu re? b. The most common organism is

20.2.5

25% Streptococcus

c. The most common orgamisms in fronta l- Streptococcus m i l leri and eth moid sinusitis a re and Streptococcus a n g i nosus --- ---

d . T h e most common organism in tra u m atic ca uses is

Streptococcus a u erus

e. The most common organisms in transplant patients are

fu ngal infections

f. The most common organisms fol lowing neurosurgical proced u res a re and g . T h e most common type o f organism i n infa nts is h . T h e most common organism from a dental source is i. The most common organisms in AIDS patients a re

Sta phylococcus epidermidis and Sta phylococcus a u reus

1 5.

The symptoms of a brain abscess in adults are largely the result of?

1 6.

Describe the four stages of a cerebral abscess. Stages i. stage 1 e c c ii. stage 2 I iii. stage 3 e c iv. stage 4 1 c N u m ber of days i. stage 1 ii. stage 2 iii. stage 3 iv. stage 4 H istologic cha racteristics i. stage 1 ii. stage 2 iii. stage 3

a.

b.

c.

d.

iv. stage 4 Resista nce to need le aspiration i. stag e 1 ii. stage 2 iii. stage 3 iv. stage 4

g ra m negative acti nomyces toxoplasmosis nocardia Edema surrounding the lesion ca using increased ICP (headache, nausea/vom iti ng, lethargy) and a ra pid progression of sym ptoms

20.2.6

20.2.7

ea rly cerebritis late cerebritis ea rly ca psule late ca psule 1 to 3 4 to 9 1 0 to 1 3 > 14 inflammation developing necrotic center neovascula rity, reticular network gliosis around collagen capsule intermed iate resista nce no resista nce no resista nce firm resista nce

Neurosurgery Books

Bacterial and Complex Infections 1 7.

a.

Indicate the value of the following diagnostic tests in the work up for a brain abscess? blood work

b.

l u m ba r puncture ( LP}

c. d.

com puted tomogra phy (CT} M RI

e.

M RS

f.

leu kocyte scan

g.

effect of ste ro i d s

1 8.

How long should antibiotics be used for treating brain abscesses?

Medical therapy alone is more successful for the treatment of abscesses if: a . i t is in t h e stage.

20.2.8

WBC may be normal or m i l d ly elevated ; blood cu ltu res should be obtained but a re often negative ; ESR may be normal or elevated ; CRP is typica lly elevated very d u bious and not routinely done - may cause herniation excel lent (sensitivity 1 00%} good for staging cerebral a bscesses presence of amino acids and either acetate or lactate a re diag nostic for a bscess excel lent a lthough infreq uently used tests become less positive ­ may mislead "'

Often IV x 6-8 wks followed by oral x 4-8 wks, although d u ration should be g u ided by clinical and radiographic response (note: CT im p rovement may lag behind clinical im provement (neovascula rity remains) so it is okay to dfc antibiotics even if the CT a bnormalities persist.

1 9.

____

b. the a bscess is less than em in diameter. c. symptom d u ration is less than _ wks. 20. What antibiotics are used in AIDS patients with Toxoplasma gondii? 21 .

a. b. c. d.

General management of brain abscesses includes: b c e a a s _____

______

_____

____ __

__ __ __ __ __

__

20.2.9

20.2.9

cerebritis stage (before complete encapsu lation) 3 2 Su lfad iazine + pyrimethamine + leucovorin

20.2.9

20.2.9

blood cu ltu res empiric antibiotics a nticonvu lsa nts (optional) steroids (controversial)

115

116

Part 6: Infection

22. The surgical mainstay of treatment for a brain abscess is

need le aspiration

20.2.9

_ _ __

23.

Complete the following regarding outcomes for patients with brain abscesses? a . morta lity ( i n t h e C T era) b. neurologic disability c. late foca l or genera l ized seizu res d. hemiparesis e. morta lity for transplant patients with fu ngal a bscesses?

•

20.2. 1 0

0 - 1 0% 45% 27% 29% a pproaches 1 00%

Subdural Empyema 24. Why is a subdural empyema (SDE) typically more emergent than a brain abscess?

No a natomic ba rrier to spread of a SDE, no su rrou nding tissue reaction to conta in the infection, and poor a ntibiotic penetration into the space

25. Where are SDE typically located?

70-80% over the convexity, 1 0-20% a re parafa lcine

26.

a.

List the most common etiologies of SDE: p s (especia l ly f__) __

o m c. p d. t

b.

__

__

(usually c__ o__ ) (neuro or ENT)

__

__

s. ____

__

27. Causative organisms in SDE: a . Associated with sinusitis? a and a s b. Fol lowi ng tra u m a or procedures? s and g_-n c. Sterile cultures a re more common following

20.3 . 1

20.3.2

20.3.3

para nasal sinusitis (esp. fronta l ) otitis (usually chronic otitis media) post surgical tra u m a 20.3.4

aerobic and a naerobic strep

__

__

sta ph and g ram-negatives

__

previous a nti biotic exposu re

_ __

28. a. b. c. d. e. f. g. h. i.

Neurological findings in SDE include: f__ h m h a m __ s s s t. n /v h h ___

_ _ _ __

_ _ _ _

___

__

_ _ _ _

__

_ ___

__ _ _

20.3.5

fever headache meningismus hemiparesis a ltered mental status seizu res (usually occur late) sinus tenderness nausea/vomiting homonymous hemia nopsia

Bacterial and Complex Infections 29. True or False. Evaluating SDE with a LP true is potentially hazardous and rarely positive.

true 30. True or False. Burr holes are more effective for SDEs early in the course when the pus tends to be more fluid and fewer loculations have developed. 31 .

Fatal cases of SDE have been associated with v b . __

___

venous infa rction of the brain

20.3.6

20.3.7

20.3.8

of the

__

•

Neurologic I nvolvement in H IV/AI DS 32. Regarding patients with AIDS. a . What percentage wil l present initia l ly with a neurological com plaint? b. How many patients that die with AIDS have a normal bra i n at autopsy? 33. The most common conditions producing focal CNS lesions in AIDS are: a. t. C_ I b. p c. p m, I _ d . c. e. t. _ _ _ _ _ _

___

__

_ _ __

__ _ _

_ ____

____

Infection with HIV itself can have direct neurological involvement such as: a. A e

20.4. 1

33% 5% 20.4. 1

toxoplasmosis prim a ry CNS lym phoma prog ressive m u ltifoca l leukoencephalopathy (PML) cryptococcus tuberculoma (TB)

34.

__ _ _ _ _

__

d b. A c. a m d . c___ n

___

__

__ _ _

__ __ __ _

e. A f. p

___

35.

a. b. c. d.

-r

____

m

__ __ __ _

n, ___

Complete the following about CNS diseases in AI DS: Does C N S toxoplasmosis occur ea rly o r late in t h e cou rse o f H IV infection? What causes PML? What vi rus is associated with pri mary CNS lym phoma (PCNSL)? How q u ickly c a n AIDS patients develop neurosyphil is?

20.4. 1

AI DS encephalopathy (most common) AIDS dementia aseptic meningitis cranial neuropathies (e.g. Bell's palsy) AIDS-related myelopathy peripheral neuropathy 20.4. 1

late (typica l ly CD4 cou nts < 200 cellsf m m 3) JC vi rus EBV as little as 4 months followi ng infection

117

B

Part 6: Infection

118

36. Complete the following chart by listing the CT and M RI findings in each of the following: a. Toxo i. n u m ber ii. enha nce iii. location

iv. mass effect v. miscella neous b. PCN SL i. n u m ber ii. enha nce iii. location iv. mass effect v. miscella neous c. PM L i. n u m ber ii. enha nce iii. location iv. mass effect v. miscella neous 37.

a.

b. c. d.

Complete the following about the management of AIDS-related intracerebral lesions: Treatment for toxoplasmosis i. p ii. s iii. I How prom ptly should we see i mp rovement clinica lly and radiological ly? If successfu l , how long should toxoplasmosis be treated? biopsy should be considered i f there i s no response in . True or fa lse. Toxo can not be radiologica l ly disti n g u ished from i. PCNSL. ii. PM L. For diag nosis, check: i. for toxo ii. for lym phoma

20.4.2

> S lesions ring basa l ganglia and g rey-white j u n ction mild-moderate surrou nded by edema < S lesions homogenous su bependym a l mild may cross corpus ca llosum may be m u lti ple none wh ite-matter none-m inimal high sig nal on T2WI , low sig nal on Tl Wl 20.4.3

pyri metha mine su lfadiazine leucovorin 2 to 3 weeks Patients need l ifetime meds 3 weeks

___ ___

e.

f.

true usually seru m toxo titers OP of LP and cytology; PCR a m p l ification of EBV DNA

Bacterial and Complex Infections 38.

Considerations for performing a biopsy of a brain lesion in an H IV+ patient? a . I f toxo titers a re b. If no response to toxo meds in c. True or fa lse. Biopsy is equally va luable in lesions that enha nce or don't enha nce. _ _ _ _

_ _ _ _

d . Tech nique for biopsy: e. What two a reas should be sampled? f. Positive biopsy ca n be expected i n %

20.4.3

negative 3 weeks fa lse (m ore va luable in enha ncing lesions to differentiate toxo from lym phoma) stereotactic enha ncing ri m and center 96

__

Indicate the survival times for AIDS patients with the following conditions: a . C N S toxo b. PML c. lym phoma

39.

__ _

_ _ _

___ _

d.

lym phoma in nonimmu nosuppressed patients

20.4.4

1 5 months 1 5 months 3 months ( 1 month wfo treatment) 1 3 . 5 months

_ _ _ _

•

Lyme Disease - Neurologic Manifestations 40.

Lyme disease is caused by and transmitted by the

_ _ _ _

___

41 .

a. b.

Regarding clinical findings of Lyme disease. classic rash e___ c. m ___

__

clinical triad of neurolog ica l manifestations i. c n __

___

ii. m iii. r --,---- --,-,-----,neurolog ica l findings frequently m cardiac c___ d and m ----,----,-in the late stage: a ___ and c n s __ _

c.

Borrelia spirochetes; Ixodes

20.5.1

tick. 20.5.2

erythema chron icu m migrans ("bul ls-eye" rash) cranial neu ritis (bilatera l "Bell 's palsy") meningitis radiculopathy migrate

_ _ _ _

d. e.

__

__

__ _

42. True or false. Regarding diagnosis of Lyme disease. a . No test is indicative o f active infection. b. Antibodies can be seen on serology im med iately after initia l infection.

c. CSF stud ies may be com patible with aspectic meningitis or MS.

conduction defects; myoperica rditis a rth ritis; chronic neurological synd romes 20.5.3

true fa lse (typica l ly req u i res 2-3 weeks for a ntibodies to be detected in untreated patients) true (oligoclonal bands may be seen)

Neurosurgery Books

1 19

1 20 •

Part 6: Infection

Nocardia Brain Abscess 43.

a. b. c. 44.

Complete the following regarding Nocardia: I t a rises from the It is a Seen in patients with c___ d i_.

__

Nocardia is typically diagnosed with a b b. __

20.6. 1

soil bacteria (not a fu ngus) chronic debil itati ng i l l ness brain biopsy

20.6.2

_ _ _

45. The treatment regimen for Nocardia is: a. T_-S_ b. i c. D u ration? ___

20.6.3

TM P-SMX i m i penem > one yea r or l ife-long

21 Skul l, Spine, and Post-Surgical Infections

•

Shunt I nfection 1 . Regarding shunt infection. a . Accepta ble infection rate? b. Risk of ea rly infection after surgery? c. _% of Sta ph infections occur within 2 mos. d. Most common sou rce is

< 5 - 7% 7% 70% (> 50% within the first two weeks) patients' skin

2.

1 0 to 1 5%

___

3. a. b. c. 4. a.

Mortality ranges from to % for children after a shunt infection. _

_

Risk factors for shunt infection: a_ of p l of p _ o n t d

y__ __ __

2 1 . 1 .3

_ _

__

__

Causal pathogens of shunt infections: Ea rly infection i. S e (most common) ii. S. a iii. g_-n b iv. in neonates: E c_ and S h Late infection (> 6 months after procedure) i. risk? ii. most com mon orga nism? Fu ngal infections spp. i. most com mon: C __

__

__

__

b.

c.

__

5. What are the common characteristics of shunt nephritis? a. v v s h u nt l_ l infection b. c c. ___ c deposition i n g d. p and h __

__

___

2 1 . 1 .4

Sta ph. epidermidis Sta ph. a u reus g ra m-negative baci l l i E. c o l i and Strep. hemoliticus

2.7 - 3 1 % (typica l ly 6%) Sta p h . epidermidis Ca ndida 2 1 . 1 .5

ventriculovascular chronic low level i m m u n e complex; g lomeru li

___

_ _ _

2 1 . 1 .2

young age of patient length of proced u re open neura l tube defect

___

__

21.1.1

proteinuri a ; hematu ria

1 22 6.

a. b.

Part 6: Infection Gram negative bacillus (GNB) shunt infection compared with gram positive bacillus (GPB): morbid ity Fol lowing a shunt ta p i. G ram stains

ii. protein iii. g l u cose iv. neutrophils 7. True or False. Regarding treatment of shunt infections. a . Remove s h u nt. b. Treatment with a ntibiotics without s h u nt remova l is o n ly recommended when patients a re term inally i l l , is a poor anesthetic risk, or has ventricles that may be d ifficult to catheterize. c. Place EVD. d . Intraventricu l a r injection o f preservativefree a ntibiotics in addition to IV thera py is never indicated . e. Anti biotics should be contin ued 7 days after steril ization of the CSF. f. Patients with peritonitis and a VP s h u nt will often have ascending i nfection into the CNS. g. VP s h u nts must be im mediately removed fol lowing peritonitis.

•

2 1 . 1 .5

higher in G N B more than 90%+ G ram sta in (in contrast to only 50% in GPB) higher in G N B lower in G N B higher in G N B 2 1 . 1 .5

true true

true fa lse fa lse {1 0-1 4 days) fa lse fa lse

External Ventricular Drain ( EVD)-Related I nfection The diagnosis of an EVD-related infection is suggested by: a. h

8.

b. c. d.

c > p in t h e presence o f p c r

___

__

___

c_

___

c_

21 .2.1

hypog lycorrhea {CSF g l u cose/ blood g l u cose < 0.2) rising cel l index CSF pleocytosis > 1 000 positive CSF cu ltu res

___

9.

1 0.

a. b.

What is the formula for cell index?

Contamination in the context of EVDinfection is P CSF c and/or g s or s No attri butable s __

__

__

--

--

Cel l index = CS Fle!JkQ•�teslCS Fer�thrQ•�es Blood leukocytes / Biood erythrocytes

2 1 .2.2

2 1 .2.2

positive CSF cultu re and/or g ram stain No attri butable sym ptoms or signs

Skull, Spine, and Post-Surgical I nfections 11. a. b. c. d.

Risk factors for EVD infections: d of EVD s I b in CSF ( IVH and SAH) and f

1 2.

The usual organisms that cause EVD­ related infections are s f

a. b. c.

_ _ _

__

_ _ _

__

__

present in the h e May form a b that increases a ntim icrobial resista nce.

_ _ _ _

__

1 3. a.

Management of an EVD infection: empiric a nti biotics: + i. v ii. c or c. b. r -- catheter --:-: a c. add i d . b y clamping for mi n utes e. wait at least days after CSF steril izes to im plant new s h u nt ____

_ _ _ _

___

___

_ _ _ _

___

__

__

1 4. a. b.

c.

2 1 .2.3

d u ration site leakage blood irrigation and fl ushing 2 1 .2.4

skin flora (coagu lase-negative sta ph, P. acnes) hea lthcare environ ment biofi l m 2 1 .2.7

vancomyci n ceftazidime or cefepime remove (if it is safe to do so) intratheca l a ntibiotics EVD ; 1 5 - 60 min 7 - 1 0 days

Prevention of EVD infections. tunneling away from the burr hole > 5 em a c c a ntibiotic coated catheters (rifa m ipin+ minocycline) do NOT the catheter at day 5 i. e exchange a p ii. g ive p prolonged a ntibiotic prophylaxis

2 1 .2.7

__

___

__

___

___

•

__

_ _ __

Wound I nfections 1 5.

a.

laminectomy superficial wound infection management: H i nt: bcdefg h b. ___

b. c c. d d. e

__ ___ ___

e. f f. g

w use v

__ ___

+c

__ _ _ _ _ _

g.

h

_ _ _ _ _ _

_____ __

_ __

2 1 .3.1

bacitracin (ha lf-strength) followed by normal saline culture debride wound empirical ly; vancomyci n + cefepime fil l with iodoform Y4 inch g ra d u a l ly tri m 0 . 5 - 1 inch of packi ng with each d ressi ng change change q8 h rs for hospital ized patients, B I D for patients at home

1 23

llJ

1 24

Part 6: Infection

Regarding post-operative discitis. Sta ph a u reus is t h e most common pathogen. % present by 3 weeks post-op b. 80% at the site of the operation is back pain c. the most common sym pto m . d . Ma nagement includes: i. a analgesics + muscle relaxa nts +m ii. a a ntibiotics iii. a r activity restriction iv. c culture if radiographs a re suspicious

1 6. a.

2 1 .3.1

_

__ ___

---

---

___

•

Osteomyelitis of the Sku l l Complete the following concerning Pott's puffy tumor: a . Treatment i. f ii. d weeks. for iii. a ntibiotics for fi rst week iv. wait approx. months for cra n ioplasty b. Most common organism is

1 7.

__

__

•

2 1 .4.4

fla p remova l debridement 6 to 1 2 ; IV 6 Sta ph lococcus a u reus

2 1 .4.2

Spine I nfections 1 8. What are the main categories of spine infections? a. v o b. d a c. s e s e d. s e. m f. s c a ___ _

__

__

___

___

___ _

____

___

___

__

Describe a spinal epidural abscess. Most common site for spinal epid u ra l a bscess is t h e at % b. The next most common is at %, followed by at % c. Sym ptoms include: i. s t ii. f iii. b p d . Co-morbid cond itions i. d m a ii. I d iii. a, iv. c r f v. i c.

1 9. a.

___ ___

__

__

__

_ _ __

__ __

__

__ _

_ _ __

_

__

___

___

_ _ _ _

2 1 .5

vertebra l osteomyel itis discitis spinal epid u ra l a bscess spinal subdura l em pyema meningitis spinal cord a bscess 21 .5.1

thoracic leve l ; 50%

__

__

l u m ba r; 35%; cervica l ; 1 5% spine tenderness fever back pain dia betes mellitus IV d rug abuse alcoholism chronic ren a l fai l u re i m m u n e comprom ised

Neurosurgery Books

Skull, Spine, and Post-Surgical I nfections e.

is the most common organism cu ltu red. f. is the imaging study of choice. g . Treatment consists o f + __

___ _

_ _ _ _

____

20. Describe the pathophysiology of spinal cord dysfunction. a . Com p ression by i. m of a ii. b by c of o v b t b. I nfa rction by v c. Di rect spread to the cord can cause m __

__

___

__ _

__

__

____ _

Sta ph. a u reus M RI s u rgical evacuation + a ntibiotics 21 .5.1

mass of a bscess bone by colla pse of osteomyelitic vertebral body venous thrombophlebitis myelitis

21 .

Complete the following regarding causes of spinal epidural abscess: a . Hematogenous - most com monly from i. f -___,. a ii. IV d b. d e ___

_ _ _

c.

Spinal proced u res i. d

fu ru ncle IV d rug a buse d i rect extension (e.g. psoas a bscess) d iscectomy (incidence of SEA is 0.67%) needles (catheters)

__ _

ii.

21 .5.1

n

Cultures from spinal epidural abscess patients can be expected to show the following: a. Sta phlococcus a u reus: _% b. no g rowth: _ to _% c. Streptococcus (freq uency)

22.

d. e.

TB associated with d isease: _% m u ltiple orga nisms: _%

Complete the following regarding spinal epidural abscess (SEA): a . I f d u ring a spinal ta p you encou nter pus, what should you do? b. Empiric antibiotics for SEA i. c___

21 .5.1

50 - most common organism 3 0 to 50% second most common organism Pott's disease; 25% 1 0%

23.

21 .5.1

Stop adva ncing the need le and cu ltu re the pus.

iii. m iv. ±r_ .,--c. The length of time IV antibiotics shou ld be administered for SEA is d. Morta lity is % e. Recovery of severe neurologic deficit is

ceftriaxone or cefepime (if pseudomonas is a concern) vancomycin (u ntil M RSA ca n be ruled out) metronidazole rifa m pin PO min. 6 weeks with immobilization 4 to 3 1 % very rare

f. An exception to this ru le is i mp rove neurological ly.

Pott's d isease - 50% im p rove neurologica l ly

_

ii.

v

_

_ _

_ _ _ __ _ _

__

__

- _%

1 25

1 26

Part 6: Infection

24. Complete the following regarding vertebral osteomyelitis: a. Risk factors i. d ii. d iii. h iv. a b. What cond ition in ren a l patients ca n mimic infection on M RI? c. Sou rces of i nfection a re never found in %. __

d.

N e u rologic d eficits occur i n to % of Pott's disease patients How long does it take for plain x-rays to demonstrate changes? Best imaging test? __

2 1 .5.2

d rug abuse dia betes mel litus hemodia lysis advanced age destructive spondyloarth ropathy 37% (consider urinary tract infection (UTI; most common source), respiratory tract, teeth) 1 0 to 47%

__

e. f.

25. True or False. Regarding the treatment of vertebral osteomyelitis. a. Instru mented fu sion is contraind icated . b. It is perm itted even in pyogenic infections. c. 90% of cases ca n be successfu l ly managed nonoperatively. d. TLSO brace has no role in nonoperative management. One differentiates spinal destruction from a . infection: i the d the d b. metastases: m

2 to 8 weeks M RI with and without contrast 2 1 .5.2

fa lse true true fa lse

26.

__

__

___

__

27. What is the M RI triad of infection in discitis? p p a. a b. b m c. d s __

__

__

__

___ _

_ _ _ _

28. What is the CT triad of infection in discitis? p f a. e s b. p a c. p __

__ _

_ _ _ _ _ ___

Complete the following regarding discitis: a. Cultures a re positive %. i. from the disc space in %. ii. from the blood in b. The usual pathogen is c. Special staining is req u i red to d etect , and should be done in _ cases.

2 1 .5.3

involves the disc miss the d isc and i nvolve the vertebral body 2 1 .5.3

a n n u l u s posterior portion bone ma rrow disc space 2 1 .5.3

end plate fragmentation pa ravertebra l swelling pa ravertebral a bscess

29.

__

__

__ _

__

2 1 .5.3

60% 50% Sta phlococcus a u reus TB; all

Skull, Spine, and Post-Surgical I nfections 30. a.

b.

Complete the following about discitis: I n children, discitis m a nifests itself b y t h e child's refusal to or or Postop discitis is sugg ested when the and does not i. ESR is raised to c o m e down . ii. CRP is a bove _ mg/L at wks post-op. Interva l between s u rgery and radiological changes in d iscitis: weeks i. plain x-rays: ii. polytomography: _ weeks __

c.

__

31 . Regarding the treatment of discitis. a. a b. i c. Approaches for surgery (only needed in 2 5% of cases) i. a in the cervica l or thoracic reg ions in l u m ba r l ii. p reg ion __ _

_ _ _ _

___

___

____

32. Complete the following concerning psoas abscess: a. Psoas extends from to b. Psoas is the primary h i p c. innervated by . d . Pai n on h i p of psoas shadow e. CT shows f. inside the wi ng. __

___

_ _ _

__ __

wa l k or sta nd or sit

2 1 .5.3

2 1 .3.1

20 m m / h r 1 0; 2

1 2 ( 1 to 8 months ra nge) 3 to 8 weeks 2 1 .5.3

a ntibiotics im mobilization anterior posterior laminectomy 2 1 .5.4

T1 2 VB to LS VB flexor L2-4 flexion enlargement iliac

1 27

22 Other Nonbacterial lnfections

•

Viral Encepha litis 1.

a.

Complete the following regarding herpes simplex: H S E sta nds for

b. It has a pred ilection for the t I and I s c. Defi nitive diag nosis req u i res b and v b d . Treat prom ptly with b.

0

2. a. b.

22. 1 . 1

herpes simplex encephalitis tempora l , orbitofronta l lobes and l i m bic system brain biopsy and virus isolation Acyclovir

HSE has the following characteristics: CSF: EEG : p e discharges on electroencephalogra phy. I in t c. CT: e d . Hemorrhage o n means

leu kocytosis-monocytes period ic latera l izing epileptiform edema in tem pora l lobes CT; poorer prog nosis

e. f.

tra nssylvian sign HSE

M RI shows t s Significa nce: If bilatera l it is highly suggestive of

3. Transsylvian sign a . ind icates tem poral lobe e b. that extends across the s f General treatment for intracranial pressure (ICP) elevation involves the following: h a. e of b b. m c. h

22.1 .1

22.1 .1

edema Sylvian fissu re

4.

22.1 .1

elevate head of bed mannitol hyperventilate

Other Nonbacterial lnfections 5.

Complete the following concerning acyclovir treatment: a . T h e dose i s

22. 1 . 1

30 mg/kgfday ( i s divided every 8 hours) b. for a d u ration of days. 1 4 to 2 1 c. If you identify HSE before GCS d rops, you limit morta lity ca n l m _ _ _

Which inclusion body identifies VZV on brain biopsy? z a . VZV sta nds for v v

6.

___

Cowd ry type A

22. 1 .2

va ricella zoster virus

__ _

•

Creutzfeldt-Jakob Disease 7.

a.

Complete the following about Creutzfeldt-jakob disease: CJ D sta nds for

_ _ _ _ _ _ _ _

b. The prog nosis is c. The EEG shows

_ _ _ _ _ _ _ _

_ _ _

d.

Prion sta nds for

e.

Classic histologic triad i. n I ii. a p s. iii. s Diag nostic triad i. d ii. E. iii. m

_ _ _ _ _ _ _ _

inva ria bly fata l cha racteristic bilatera l sharp waves 0.5 to 2 . 0 per second proteinaceous infectious particles 22.2.8

_ _ _

_ _ _ _

22.2. 1 0

dementia EEG myoclonus

_ _ _

_ _ _ _ _ __

8.

Creutzfeldt-jakob d isease

neuronal loss astrocytic prol iferation status spongiosus

__ _

f.

22.2.1

Detection of protein in the CSF 1 4-3-3 ; has % sensitivity and specificity 96% for CJD among patients with dementia. ___

22.2. 1 0

__

9. What is the biopsy procedure in suspected CJD? a . Use a cranial saw b. to avoid of the infection. with the saw. c. Avoid cutting the d. Clea rly conta i ners. e. Fix in % phenolized form a l i n .

22.2. 1 0

manual aerosol ization d u ra label 1 5%

Neurosurgery Books

1 29

Part 6: Infection

1 30 •

Parasitic I nfections of the CNS 1 0. Regarding cysticercosis. a. Cau sed by which organism? b . A t which life cycle stage? c. The l ife cycle stages (4) include the followin g : i. e ii. a iii. e iv. I d . T h e cu rrent best test i s Complete the following statements about parasitic infections of the CNS: a . Cysticercosis is caused by t i. the p ii. T s b . Ech inococcus is caused by t i. the d g ii. E c. What is hydatid sand?

22.3.2

Taenia sol i u m l a rva l stage embryo a d u lt eggs l a rva enzyme-linked i m m u noelectrotra nsfer blot

11.

__

__

d.

Caution is advised d u ring remova l not to

1 2. a.

Describe the life cycle of cysticercosis. Pig contains in its flesh. with H u m a n s eat undercooked in it. Embryo matu res to a n The prod uces eggs. of the Eggs a re released in the human. The same or a different h u m a n the

b. c. d. e. f.

g . Eggs in this host release h . which bu rrow through the to i. La rva lands and develops a j. k.

a n d becomes a n in months.

22.3.2

pork ta peworm Taenia sol i u m 22.3.3

dog ta peworm Ech inococcus g ra n u losa germinating parasitic scoleces ru ptu re the Echinococcus cyst and conta m inate adjacent tissues 22.3.2

encysted embryo pork; embryo a d u lt a d u lt feces ingests t h e e g g s (from conta m i nated fi ngers, vegeta bles, or water) l a rvae small bowel wa l l to circu lation cyst wa l l encysted embryo 4

1 3. Answer the following concerning neurocysticercosis a . What is t h e perma nent host for t h e a d u lt h u m a n tapeworm? b. What is the intermed iate host? h u m a n or animal (pig)

22.3.2

Other Nonbacterial lnfections 1 4. Answer the following concerning neurocysticercosis a . What is t h e significa nce o f C T sca n with i. low-density cysts with eccentric punctate hig h-density spots in a n enha ncing ring? ii. a bove plus edema? iii. intra parenchymal punctate ca lcifications? b. What may soft tissue x-rays show?

c. What might M RI show? 1 5.

a. b.

Complete the following regarding CT in cysticercosis: Ri ng-enha ncing cysts suggest

l ntraparenchyma l punctate calcifications suggest Ring-enha ncing cyst with edema suggests or d i. r d with p ii.

22.3.2

livi ng cysticerci dyi ng cysticerci dead pa rasites calcifications in thigh or shoulder intraventricu l a r or cisternal cysts

l ivi ng cysticerci

22.3.2

dead parasites

___

c.

___

---

__

•

Fungal I nfections of the CNS 1 6. What organism can cause a cerebral abscess in an organ transplant patient? 1 7.

a. b.

Asperg i l l u s fu migatus

Name the most common fungal cryptococcosis infection of the CNS diagnosed in the living patient. Lumbar punctu re usually shows elevated, 75% open ing pressu re in % of patients. Seru m cryptococca l a ntigen is elevated with CNS involvement. ____

•

recently dead or dying pa rasite infl a m matory reaction

2 2 .4. 1

22.4.2

__

_ _ _

Amoebic I nfections of the CNS 1 8.

a. b. c. d. e. f.

Describe amoebic infections of the CNS. T h e only amoeba known t o cause infection is Infection occurs 5 days after exposu re in warm The amoeba gains entry to the CNS via m 0 9 5 % fata l with in due to Treat with

22.5.1

Naegleria fowleri freshwater olfactory mu cosa 1 week i iCP a m photericin B

1 31

23 Cerebrospinal Fluid

•

General I nformation 1 . The volume (ml) of cerebrospinal fluid (CSF) in a. a newborn is 5 b. an a d u lt is 1 50 2. What is the intracranial:spinal ratio of distribution of CSF in adults?

E •

50:50

Ta ble 2 3 . 1

Ta ble 2 3 . 1

Production 3. What percentage of CSF is produced in 80% t h e lateral ventricles? 4. Where is CSF produced other than in t h e choroid plexus? a. i s I of the v b. e

c.

d s

of n in s

5. The amount of CSF volume produced per day for a . a d u lts i s b. newborns is 6. What is the rate of CSF formation ml/min in adults? What is the CSF pressure in a patient in lateral decubitus position in the following age groups? a . newborn b. 1 to 1 0 yea rs old c. young a d u lt d. a d u lt

23.2 . 1

interstitia l space ependyma l lining of the ventricles d u ra of nerve root sleeves in spine 23.2.2

4 5 0 t o 750 m l/d 2 5 mL/d 0.3 to 0 . 5

7.

Complete the following concerning CSF: a . What is t h e rate o f CSF prod uction? b. That equals how m a ny m l per day?

23.2 . 1

23.2.2

Ta ble 2 3 . 1

9 to 1 2 em H20 < 15 < 1 8 to 20 < 1 8 (7 to 1 5 )

8.

23.2.2

0.3 to 0.5 ml/min 450 to 750

Cerebrospinal Fluid c.

d. e. f. g. 9.

•

Normal CSF has i. lym phocytes polymorphonuclear ii. leucocytes (PM N) iii. red blood cel l s ( RBCs) White blood cel l s (WBCs) a bove is suspicious. WBCs above is definitely abnorm a l . WBC for every Su btract RBCs. mg protein for every Su btract RBCs. Does intracranial pressure { ICP) have any effect on CSF formation?

0 to 5 0 0 5 to 1 0 1 0 WBCs per cubic m m 1 ; 700 1 ; 1 000 no (The rate of formation is pressu re except if the ICP is so high that it ca uses reduction in cerebra l blood flow [CBF) . )

Absorption 1 0.

Complete the following concerning CSF: a . True or Fa lse. CSF a bsorption is a pressu re-dependent phenomenon. b. Where does it take place? i. a, ____ v __ _

ii. c____ p iii. I

_ _ _ _

_ _ _

•

23.2.2

independen t of CSF

23.3

true a rachnoid vi l l i -+ d u ra l venous sinuses choroid plexus lym phatics

CSF Constituents 1 1 . True or False. The composition of CSF is exactly the same in the ventricles as in the lumbar subarachnoid space. 1 2. True or False. The following are normally found in CSF: a . lym phocytes b. mononuclear cells c. polymorphonuclear leucocytes d . RBCs 1 3. True or False. CSF osmolarity and plasma osmolarity are equal, with a ratio 1 :1 . What is the other constituent that is also equal among the following? a . Na b. K+ c. Cl d . lgG

fa lse (It d iffers slig htly. )

23.4. 1

23.4. 1

true true fa lse fa lse 23.4.2

true fa lse fa lse fa lse

1 33

1 34

Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF)

1 4. True or False. CSF proteins a . a re eq ual in a d u lts and children .

b.

in prematures a re - 60 mg/dl.

c.

i n newborn a re -40 mg/dl.

d.

norma lly rise - 1 mg/dl/yr o f a g e i n a d u lts.

2 3 .4.4

fa lse (30 mg/dl in a d u lts and 20 mg/dl in children) fa lse (in prematures 1 50 mg/dL) fa lse (a bout 80 mg/dl in newborn ) true

1 5.

How do you differentiate true leukocytosis from normal white blood cell count incl uded in the traumatic tap? a . ratio of to b. normal is c . or su btract 1 W B C for every

1 6. What conditions would affect the WBC:RBC ratio of 1 :700? a. a b. p

Ta ble 2 3 . 4

RBC to WBC 700 : 1 700 RBCs Ta ble 23.4

anemia periphera l leu kocytosis

1 7.

How would you estimate the correct protein in the CSF of a traumatic tap? mg of protein a . Su btract RBCsf mm3 . b. for every

1 8. Answer the following about subarachnoid hemorrhage: a . How l o n g does i t ta ke for R B C to disappear? b. How long does it ta ke for xa nthoch romia to d isappear?

•

Ta ble 2 3 . 4

1 1 000 Ta ble 23.4

2 weeks many weeks

Cranial CSF Fistula 1 9.

Rosenmuller's fossa is located just to the

inferior to the cavernous sinus ( Rose n m u l ler's fossa is located just inferior to the cavernous sinus exposed by drilling the anterior clinoid in a paraclinoid aneurysm . Upper latera l pharyngeal recess. Lim ited a bove by the sphenoid and occipita l bone com m u nicates with the nasal cavities.)

20. True or False. The following are characteristics of traumatic CSF fistula: a. They occur i n 2 to 3% of all patients with true head inj u ry. b. 60% a re noted with in days of tra u m a . true c. 95% occur within 3 months of tra u m a . true

Neurosurgery Books

23.5.2

23.5.3

Cerebrospinal Fluid d . < 5% o f cases o f CSF rhinorrhea stop within 1 week. e. Ad u lt:child ratio is 1 : 1 0. f. Occu rrence is common before age 2 years. g. Anosmia is com mon. h . Most C S F otorrhea ceases in 5 t o 1 0 days. 21 .

a. b.

Complete the following concerning posttraumatic CSF fistula: Rhinorrhea stops withi n week in %. Otorrhea stops with in to days in to %. __

__

fa lse (70% of cases stop within 1 week.) fa lse (adu lt:child ratio is 1 0: 1 ) fa lse (occu rrence u n common prior to 2 yea rs of age) true (78% have a nosm ia.) true 23.5.3

1 ; 70% 5 to 1 0; 80 to 85%

__

22. True or False. Regarding CSF fistulas. a . Anosmia is com mon i n tra u m atic leaks. b. Anosmia is com mon i n sponta neous leaks. 23. Study Chart. a . Regarding sponta neous CSF fistu la: ( H i nt: spontaneous fistula h)

23.5.3

true (78% in tra u m atic leaks) fa lse (ra re insponta neous leaks; approxi mately 5%} 23.5.3

sense of smell preserved pneumocephalus is not common otitis media neck stiffness tu mor-pitu ita ry-mening ioma allergic rh initis meningitis em pty sella synd rome otitis media may result in CSF leak undeveloped floor of anterior fossa sense of smell preserved cri briform plate agenesis sinusitis (paranasal sinusitis) foot plate of sta pes is dehiscent-CSF into eustachian tube facia l ca nal fistula i nto middle ear insidious, /CP is high interm ittent serous effusion tra nssphenoidal surgery conseq uence unable to hear d u e to M u nd in i dysplasia labyri nthine anomalies adenoma of pituita ry hyd rocepha I us

1 35

Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF)

1 36 •

Meningitis in CSF Fistula 24. The infection rate for a . penetrating inju ries and C S F fistu las i s %. b. penetrati ng inj u ries without fistula is %. 25.

a.

Complete the following concerning meningitis in CSF fistula: Posttra u m atic CSF leak has a n incidence of meningitis of to %. Does CSF leakage after surgery have a higher or lower incidence of meningitis? If the leakage site is not identified before su rgery, fai l u re to close CSF leaks is %. T h e most common pathogen i s and its percentage is %. __

b. c. d.

•

23.7

50% 4.6% 23.7

5 to 1 0%

__

higher 30% (recu rrent leak postop) Pneumococcus; 83%

Eval uation of the Patient with CSF Fistula 26. What are the characteristics of the fluid suggesting the presence of rhinorrhea or otorrhea resulting from a CSF fistula? a . CSF fl uid i s

b. True or Fa lse. Fluid ca uses excoriation. c. d.

Fluid tastes G l u cose is g reater than

e.

It contains a special chemical ca lled

mg %.

23.8.1

as clear as water ( u n less infected or blood present). fa lse (Fluid doesn't cause excoriation of the nose.) salty (in rhinorrhea). normal CSF g l u cose > 30 mg %. �rtra nsferrin (present i n CSF)

f. The special sign when it d rops on a sheet ring sign (An old but is ca lled a u n reliable sign. Described as a ring of blood surrounded by a larger concentric ring of clear fl uid [suggests the presence of CSF) seen when blood-tinged fl uid a l l owed to d rip onto linen [sheet or pillowcase] . ) 27.

Name five characteristics of fluid that suggest the presence of CSF fistula. H i nt: bcsfg a. B b. c c. s d. f e. g

23.8.1

�rtra nsferrin clear sa lty taste fl uid does not excoriated g l u cose

Cerebrospinal Fluid •

Treatment for CSF Fistula 28. True or False. The procedure of choice to localize the site of CSF fistula is a . mag netic resonance imaging b. iohexol cisternography c. computed tomography with intravenous contrast d . plain x-ray

•

23.9.2

fa lse true fa lse fa lse

I ntracranial Hypotension (Sponta neous) 29.

Spontaneous intracranial hypotension i s characterized by h a. 0 c p b. I e c. d p __

___

30. Characteristics on imaging that suggest intracranial hypotension ( H int: SEEPS) a. s b b. E

c. d. e.

E

v h f

p

s

31 . True or False. Epidural blood patch provides relief for the majority of patients. 32.

a. b. c. d. e.

Conservative management for intracranial hypotension incl udes b r h a c a b __

__

2 3 . 1 0. 1

orthostatic headache low CSF pressu re diffuse pachymeningial enha ncement 2 3 . 1 0. 1

sagging bra i n enha ncement (pachymeningeal) engorged vei ns pitu ita ry hyperemia subdura l fl uid true

2 3 . 1 0. 1

2 3 . 1 0. 1

bed rest hydration analgesics caffeine abdom i n a l binder

1 37

B

24 Hydrocephalus - General Aspects

•

Etiologies of Hyd rocephalus 1.

a. b. c.

Complete the following statements about hydrocephalus: Incidence of congenita l hyd rocepha l u s is %. Due to either CSF resorption or CSF ___

2. True or False. Indicate if the following are considered "true" hydrocephalus: a. hyd rocephalus ex vacuo b. obstructive hyd rocephalus c. com m u n icating hyd rocephalus Regarding the characteristics of the etiology of hydrocephalus. a. True or Fa lse. There is excess prod uction of CSF. b. True or Fa lse. There is impaired a bsorption of CSF. c. True or Fa lse. It is congenita l without myelomeningocele. d . Congenita l with myelomeningocele usually occu rs with e. Chiari I, if a cause, has

24.3 . 1

0.2% su bnorm a l overprod uction 24.3 . 1

fa lse true true

3.

f. Aq ueducta l stenosis presents sym ptom s in g . Secondary aqueducta l stenosis is d u e to , or h. Atresia of foramina of Luschka and Magendie is ca l led

24.3 . 2

true true true Chiari I I fou rth ventricle outlet obstruction infancy intrauteri ne infection, hemorrhage, or tumor Dandy-Wa l ker synd rome

Hydrocephalus - General Aspects 4.

Complete the following concerning etiologies of hydrocephalus: a. % of post-op pediatric postfossa tumor patients develop hyd rocephalus and need a s h u nt. b. This may be delayed for u p to c. Dandy-Wa l ker ma lformation occu rs in what percentage of patients with hyd rocephal us?

_ _ _

•

1 39

24.3 . 2

20% 1 yea r 2 .4%

Sig ns and Symptoms of HCP 5.

a. b. c. d. e. f.

list the signs a n d symptoms o f active hydrocephalus in older children/adults with rigid cranial vault. h headache n nausea vom iting v gait; bladder control changes in g and b c p papilledema u g p u pwa rd gaze palsy ___

__

__

list signs and symptoms of hydrocephalus in young children. ( H i nt: hyd rocephal usss) a. h b. y c. d

6.

d. e.

0

f.

c

g. h.

e p

i. j.

h a

k. I. m. n. 0.

7.

24.4. 1

r

u s s s Occipital frontal circumference (OFC) in the normal child should equal the distance from crown to

24.4.2

hyd roceph a l u s young (children) di plopia (on latera l gaze; abd ucens palsy) respi ratory pattern (irreg u l a r) outwa rd protrusion of fontanelle cracked pot sou nd of Macewen enlargement of cra n i u m poor h e a d control, Parinaud synd rome hyperactive reflexes a pneic spells, abducens nerve palsy l a rge head u pward gaze palsy sca l p veins prominent setti ng s u n sign splaying of cranial sutu res (seen on plain sku l l x-rays) ru m p

Neurosurgery Books

24.4.2

FDI

B

1 40

Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF)

For the indicated ages give the expected normal head circumference pattern. { H int: At 33 weeks the circu mference is 33 em . In a child younger than 33 weeks the head circu mference is g reater in em than the age of the child in weeks old. After 33 weeks head circu mference g rowth slows so that at 40 weeks of age the head circu mference is 36 em.) a . Prematu re (ages in weeks) i. 28 ii. 29 iii. 3 0 iv. 3 1 v. 3 2 vi . 3 3 vii . 3 4 viii. 3 5 ix. 36 X. 37 xi . 3 8 xii. 3 9 xiii. 4 0 b. Fu l l term (ages in months) {Hint: Note the pattern; with each month head circu mference increases by 1 em.) i. 1 ii. 2 iii. 3 iv. 4 v. 5 vi . 6 c. What is the u pper limit of head circu mference for a ba by? i. 28 weeks gestational age ii. 3 3 weeks gestational age iii. 2 months old iv. 3 months old v. 4 months old vi . 6 months old

Fig. 24. 1

8.

a.

Blindness in hydrocephalus may be due to: {Hint: pop) p

b.

0

c

c

p

c

a

9.

c.

0

29 cm 30 cm 3 1 em 3 1 . 5 cm 32 e m 33 e m 33.5 em 34 cm 34.5 em 35 em 3 5 em 35.5 em 36 cm

40 cm 42 em 43 em 44 cm 45 em 46 cm 29 cm 33 em 42 em 43 em 44 cm 46 cm 24.4.3

papilledema (chronic-optic atrophy-damage to optic d isc) optic chiasm compression (due to dilation of third ventricle) posterior cerebral a rtery occlusion (compressed at tentorial edge d u e to downward herniation)

Hydrocephalus - General Aspects 1 0.

a.

b.

Types of blindness from hydrocephalus are and Cha racteristics for pre b n i. 0 a s ii. p -p iii. d u e to p ,h a Cha racteristics for post b n a i. 0 m ii. p -n or iii. d u e to

Cortical blindness may be associated with of a . Anton 's synd rome = d d v of b. Ridoch 's phenomenon = a m , but n_ 0 a of s 0

pregeniculate blind ness and postgeniculate blind ness

•

optic nerve atrophy-severe pupillary reflexes-poor pressure, hypotension, anemia postgeniculate blind ness optic nerve atrophy-m inimal pupillary reflexes-norm a l hypoxia or trauma (macular sparing in PCA occlusion, no macu lar sparing in tra u m a to occi put) 24.4.3

denial of visual deficit

FDI

appreciation of movi ng objects, but no appreciation of stationary objects

CT/ M RI Criteria for Hyd rocephalus 1 2. Hydrocephalus-radiologic criteria: mm. a . Tempora l horns' width is > b. Fronta l horns ballooning look l i ke M M c. Tra nsependymal d. Ratio of fronta l horns to internal dia meter of brain. e. Anteroposterior {AP) view shows

f. Third ventricle on AP view shows g. h. i.

•

24.4.3

pregeniculate blind ness

11.

---

Eva ns ratio > Corpus ca llosum is and shows

and

24. 5 . 2

2 mm Mickey Mouse edema 50% disproportion of ventricle size and cortical su lci bowing latera lly 0.3 thin/atrophic stretching and u pwa rd bowi ng

Chronic HCP 1 3. a. b. c.

Characteristics of chronic HCP: Inner ta ble shows Sella shows --,-Corpus callosum shows .

____ _ _ _ _

___

1 41

24.7

beaten copper cra n i u m erosion atrophy

1 42 •

Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF)

External Hyd rocephalus (AKA Benign External Hyd rocephalus) 1 4.

a. b. c. d. e. 1 5.

Complete the following about external hydrocephalus: Malignant or benign? spaces over the Enlarged s f poles in the f yea r o f life. Resolves by age . __

__

External hydrocephalus may be distinguished from subdural hematoma by the presence of c v s __

1 6.

24.8 . 1

benign subarachnoid frontal first 2 yea rs of age cortical vein sign

24.8 . 1

vei ns; inner ta ble

24.8 . 1

hyd rocephalus; inherited

24.9 . 1

__ __ _

The cortical vein sign shows extending from the brain to the i t of the skull on a or MRI.

__ __

__

•

X-linked Hydrocepha lus 1 7. X-linked hydrocephalus that is a. is a type of h

b.

occu rs in % of patients with hyd rocephalus. c. Gene is located on d . I t causes abnormality in m r and l e. prod uces classical synd romes ( H i nt: crash) h i. c c. ii. iii. a, t iv. s p v. h __ __

_ _ _

__

____

_____

_____

__ _ _

__ __

__ _ _

_ _ _

Complete the following regarding radiographic finding of l1 syndrome: a. Large i. p h ii. m iii. q p b. Small (hypoplastic) i. c c. ii. c v c. Rippled i. v w d . Which featu re is pathog nomon ic? i. r v w e. Available treatment for reta rdation?

2% Xq28 mem brane receptor and Ll CAM

24.9.2

24.9.3

corpus ca llosum hypoplasia reta rdation adducted th u m bs spastic pa ralysis hyd rocephalus

1 8.

_ _ _

_ _ _

__ _

_ __ _

___

_ __ _

___

__ _

__ _

_ _ _

24.9.3

posterior horn massa interm edia quadrigeminal plate corpus callosum cerebellar vermis ventricu lar wa l l ri ppled ventricu l a r wa l l none

Hydrocephalus - General Aspects •

"Arrested Hydrocephalus" 1 9. True or False. With regard to "arrested hydrocephalus": a. It is interchangeable with the term "u ncom pensated hyd rocephalus." b. Arrested hyd rocephalus satisfies the fol lowing criteria in the a bsence of a cerebrospinal fl uid (CSF} shu nt: i. ventriculomegaly nonprog ressive ii. normal head g rowth curve iii. contin ued psychomotor development 20. True or False. When deemed "arrested," no further follow-up is needed. 21 . True or False. Shunt dependency is likely in hydrocephalus due to a . aqueducta l stenosis b. spina bifida c. com m u n icating hyd rocephalus (i.e., secondary to arachnoidal ad hesions

24. 1 0. 1

fa lse

true true true fa lse (deterioration can sti l l occu r)

24. 1 0 . 2

24. 1 0 . 2

true true fa lse (shunt independence more l i kely to occur)

22. True or False. With respect to a disconnected or nonfunctioning shunt: a . A disconnected s h u nt m a y conti n u e to true fu nction by CSF flow through a su bcuta neous fibrous tract. b. If in doubt, better to watch, not s h u nt. fa lse c. Patients with a nonfu nctioning s h u nt fa lse should not be fol l owed with serial CT scans but possi bly with serial neuropsychological eva l uations.

•

1 43

24. 1 0.3

Entra pped Fourth Ventricle 23.

a. b. c. d.

Complete the following about entrapped fourth ventricle. Usually seen with c s of the I v Possibly d u e to a Occu rs in _ to _% of patients with shu nts. True or Fa lse. M a y b e treated with a sepa rate VP s h u nt or by l i n king into a n existing s h u nt.

chronic s h u nting of the latera l ventricles adhesions 2 to 3% true

24. 1 1 . 1

24. 1 1 . 3

FDI

1 44 •

Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF)

Normal Pressure Hyd rocepha lus ( N PH ) 24. What are the symptoms of normal pressure hydrocephal us? (Hint: dig) a. d b. c. g _ __

_ _ _ _

24. 1 2 . 1

dementia (wacky) incontinence of u rine (wet) gait distu rba nces (wobbly)

25. What is the etiology? (Hint: mista pa) a. m b. c. s d . t. e. a f. pg. A

meningitis id iopathic subarachnoid hemorrhage tra u m a aqueducta l stenosis posterior fossa surgery Alzheimer's disease

26.

In clinical triad, which symptom precedes the others?

gait distu rbance

27.

Note the clinical features of NPH as expected {+) or not expected {-). wide-based gait shuffling steps u nsteadiness on turning difficult in itiati ng steps feel g l u ed to the floor ataxia of l i m bs slowness of thought u nwitting u rinary incontinence papilledema seizu re headaches

24. 1 2 . 1

_ _ _ _

__ _

__ _

__ _

__ _

__ _

a. b. c. d. e. f. g. h. i. j. k.

Ta ble 24.3

+ + + + +

+

28. What is the upper limit opening pressure suggested for the definition of NPH?

24 em H20

29. What is the tap test?

LP with remova l of CSF and assessment of response. 40 to 50 m l of CSF

a.

How m u c h C S F is withd rawn?

30. What is the procedure of choice for treatment of NPH? a. Com p l ication rates may be as high as %. b. Com p lications include: i. s h or h

VP shunt 35%

___

_ __

ii. s iii. i iv. s

i

h

_ _ _

_ _ _ _

24. 1 2 . 3

subdura l hematoma or hyg roma s h u nt infection intracerebral hemorrhage seizu res

Neurosurgery Books

24. 1 2 . 5

24. 1 2 . 5

24. 1 2 . 8

Hydrocephalus - General Aspects 31 .

a. b. c.

•

In NPH what is the sequence in which symptoms are likely to improve with shunting? H i nt: igd

g d

__ _ __ _

1 45

24. 1 2 . 9

incontinence gait dementia

Hyd rocephalus and Preg nancy 32.

a. b. c.

d. e. f. 33.

a. b.

34. a. b.

c. d.

Patients with shunt for hydrocephalus should, prior t o conception, or have u p-to-date have assessment of a ny m If prospective mother's hyd rocephalus is accom pan ied by a neura l tube defect (NTD), her child cou l d be born with a n to N T D incidence of %. have genetic c sta rt ta king v avoid excessive h If shunt malfunctions during pregnancy, shunt revision is performed in t h e first two trimesters using a

in the third trimester using a or a shu nt. During labor and delivery use p a If patient is asymptomatic, del ivery is performed . If patient is symptomatic, deliver via

I n li ght o f increased cranial pressu re avoid

24. 1 3 . 1

CT or M RI med ications 2 to 3%

cou nseling vita mins heat 24. 1 3 . 3

revised VP s h u nt ventriculo-atrial or ventriculopleura l 24. 1 3 . 4

prophylactic a ntibiotics vaginal cesa rea n epid u rals

FDI

25 Treatment of Hydrocephalus

•

Medical Treatment of Hyd rocephalus Answer the following about the treatment of hydrocephalus: a. True or Fa lse. Hyd rocepha l u s is a medica l ly treated condition . b. Diu retic thera py ca n include a and f c. Be sure to watch for the complication of 1.

__ _

_ _ _

d.

Role o f spinal ta ps in hyd rocephalus is to t. _ _ _

e.

•

Critica l protein level of CSF is

__ _

fa lse (mainly to be treated surgical ly) acetazolamide and fu rosemide electrolyte imbala nces tem porize ( Hyd rocepha l u s after intraventricu lar hemorrhage may be only tra nsient, and serial ta ps [ventricu lar or l u m bar] may tem porize until resorption resu mes, but l u m ba r taps ca n be performed only for com m u nicating hyd rocephalus.) 1 00 mg/dl (If rea bsorption does not resume when protein content of CSF is 90% pregna ncies have favora ble outcomes. true c . Status epilepticus poses serious risk to the mother and to the fetus. Considering seizures, AEDs, and birth defects, describe the following: a . Effect of seizu re history on incidence of fetal ma lformations. b . Phenobarbita l and ma lformations

43.

c . Teratogenic properties in i. Phenytoin ii. Ca rba mazepine iii. Va l p roate d . Therefore, d u ring preg nancy i. first choice is ii. second choice is iii. add iv. use

1 59

26.2.6

!I 26.2.6

double 4 to 5% the worst, 9. 1 % - hig hest rate of ma lformation feta l hydantoin syn d rome, low iQ neura l tube defects - ra re neura l tube defects 1 -2% carbamazepine (lowest dose possi ble) va l proic acid folate monotherapy

Neurosurgery Books

27 Special Types of Seizures

•

New Onset Seizu res 1.

Incidence of new-onset seizures per 1 00,000 person years is .

44

27.1 . 1

___

2.

a. b. c. d. e. 3.

Neurologic insults resulting in first time seizure include. s h t c i f b a

stroke head trauma CNS infection fever birth asphyxia

In patients with stroke, % had a seizure within days of a stroke.

4.2%; 14

__

__

__

__

__

__

__

__ _

__

__

4. What metabolic disturbances can cause first-time seizure? a. u b. natremia c. g lycemia _ __

__

5.

In pediatric patients the most common etiology of first-time seizure is

27. 1 .2

27. 1 .2

27. 1 .2

u remia hypo hypo febrile seizu res

27. 1 .2

_ _ __

6.

a. b.

In patients with new-onset unprovoked seizure, % had recu rrent seizu res d u ring follow-up. If seizu re-free for 3 years, had recu rrence.

___

__

For new-onset seizure in an adult what should be done? a. s w b. c c. M d. E i . If a l l studies negative, you should repeat study at ii. If two EEGs are norma l , the 2 yea r recu rrence rate is %.

27. 1 .2

27% none

7.

___

_ _ _

_ _ _

_ _ _

_ _ _

____ _

__

27. 1 .3

systemic work-up CT M RI EEG 6 and 1 2 (and possibly 24) months 1 2%

Special Types of Seizures •

Posttrau matic Seizures What are the two categories of posttraumatic seizure? a. within days after tra u m a . b. beyond .days after tra u m a .

8.

___

9. True or False. Regarding posttraumatic seizures. a . AEDs m a y be used t o prevent ea rly post­ tra umatic seizures in high risk patients. b. Prophylactic AEDs red uce the frequency of late posttra u m atic seizu res. c. AEDs ca n be d isconti n ued after 1 week. 1 0.

a. b. 11.

Incidence of seizures in early posttrauma period ( 1 to 7 days) is % i n severe head inj u ries % i n mild to moderate head inju ries.

___ ___

true fa lse true 27.2.2

30% 1% 1 0- 1 3%

The incidence of posttraumatic seizures is higher in head head injuries than with injuries. Occur in % of penetrati ng tra u m a cases fol lowed for 1 5 years.

penetrati n g ; closed

__

1 3. True or False. High risk criteria for posttraumatic seizures include: a. acute S D H , EDH, or ICH b. seizu re within 24 hours after i nj u ry c. G lasgow coma scale > 1 0 d . a lcohol a buse e. penetrati ng inj u ry 1 4.

27.2.1

27.2.3

_

___

a.

Early, within 7 days after tra u m a Late, beyond 7 days after tra u m a

Incidence of late seizures (> 7 days) is % over a 2-year period.

_

1 2.

27.2 . 1

27.2.4

50% Ta ble 2 7 . 1

true true fa lse (GCS < 1 0) true true

Phenytoin has adverse when given long-term as prophylaxis against posttraumatic seizures.

cogn itive effects

27.2.5

Using AEDs after head trauma can result in % reduction of early posttraumatic seizures.

73%

27.2.5

In appropriate patients AEDs should be tapered after except in: p b i I p s p s h

1 week

27.2.5

_ _ _ _

____

1 5.

__

1 6.

__ ,

a. b. c. d.

__

__

__

__

__

c.___

__

__

_ __

penetrati ng bra i n inj u ry late posttra u m atic seizu re prior seizu re history cra n iotomy

1 61

1 62

Part 8: Seizures

1 7.

In patients not meeting criteria to discontinue AEDs after 1 week, a . AEDs should b e mainta ined for _ _ months. b. should be done before disconti n u i n g .

•

27.2.5

6-1 2 months EEG

Alcohol Withd rawal Seizures 1 8. True or False. Ethanol withdrawal seizures are seen in % of habitual drinkers within to of stopping or reducing ethanol intake.

33%; 7 to 30 hours

27.3.1

__

_ ___

1 9.

Regarding alcohol withdrawal patients. a . What occu rs fi rst: deliri u m tremens o r seizu res? b. Risk of onset of seizu res lasts for c. Risk of onset of DTs lasts for d . Risk persists for _ to _ days. e. Are AEDs recommended: i . For prophylaxis? ii. For treatement?

20. True or False. The following patients should be admitted for observation for additional seizures or DT's: a . Those with their first EtOH withd rawa l seizu re b. Those with foca l fi ndings c. Those with more than 6 seizu res in 6 hours d . Those with evidence o f tra u m a 21 . True or False. Patients with ethanol withdrawal seizures should receive long-term anti epileptic drugs if they have: a . A history o f prior ethanol withd rawa l seizu res b. Recu rrent seizu res c. H istory of prior seizu re d isorder u n related to ethanol d . Risk factors for seizu res (e.g . , subdura l hematoma)

27.3.1

seizu res 48 hours 96 hours 1 to 3 days yes no, (because seizure is usually brief, and self-limited . AEDs a re not indicated once seizu res have occu rred . ) 27.3.2

true true true true 27.3.3

true true true true

Special Types of Seizures •

Nonepileptic Seizu res 22. Answer the following about nonepileptic seizures a . a ka pse b. a ka psy c. True or False i. They a re rea l events ii. The may not be under vol u nta ry control iii. They a re hel ped by AEDs 23. What are features suggestive of nonepileptic seizures? a . T h i s featu re is 9 0 % specific for N ES: a b. Another highly specific featu re is w c. Forced eye d . Bi latera l shaking with preserved

27.4.1

pseudoseizu res psychogenic true true fa lse 27.4.2

a rching back weeping

___

clos u re awa reness

e. Va riable f. Clonic U E or LE movements that a re

seizu re types out of phase

g. Pelvic h . Altered b y

thrust distraction

.

__

latera l tong u e laceration

24. A feature strongly suggestive of epileptic seizure is I t I 25. True or False. Which serum hormone may be used to confirm a true seizure versus nonepileptic seizures: a . TSH b. ACTH c. Cortisol d. GH e. Prolactin 26. Regarding serum prolactin a. Transient elevations occu r in genera l ized motor seizu res. b. Pea k levels a re reached in mi n utes.

27.4.2

fa lse fa lse fa lse fa lse true 27.4.2

--

-

27.

27.4.2

% of

-

Overall accuracy of prolactin levels in predicting true seizures is %. __

80% 1 5-20 72%

27.4.2

1 63

1 64 •

Part 8: Seizures

Febrile Seizures 28. True or False. The most common type of seizure is a. ethanol withd rawa l b. tumor induced c. posttra u matic d . febrile e. epileptic Regarding treatment of febrile seizures. a. Recurrence rate ca n be by b. administering c. every _ hours and hours after the d . conti n u ing until fever su bsides.

27.5.2

fa lse fa lse fa lse true fa lse

29.

_ _ __

__

•

27.5.3

red uced diazepa m (0.33 mgfkg ) 8 24

Status Epilepticus 30. Status epilepticus is defined as a. seizu re lasting more than b. or persistent seizu re after

27.6.1

__ _ __ _

5 m i n utes 1 st and 2nd line AEDs

31 . What is the most common etiology for low AED levels status epilepticus? Complete the following about status epilepticus a. The mean d u ration is hours. %. b. The morta l ity for SE is c. The morta l ity from underlying acute event is _ _%. d . I rreversible changes from repetitive electrical discharges beg in to a ppear in neurons as ea rly as m i n utes. e. Cel l death may occ u r after m i n utes.

32.

___

27.6. 1

27.6.5

1 .5 2% 1 0- 1 2% 20 min utes

__

___

For a patient in status epilepticus, the work-up includes the following a. a b. b c. c. d. e e. f.

60 m i n utes

33.

__ _

__ _

_ _ _ __

34.

a. b.

If a lumbar puncture is done after a seizure, w c , it may show e which may be b p p and should be treated as __

__

__

__

27.6.6

a i rway blood pressu re CPR EKG, EEG, electrolytes IV l u m ba r puncture 27.6.6

elevated wh ite cou nt benign posticta l pleocytosis

__ _

c.

__ _

infection (u ntil cultures negative)

Neurosurgery Books

Special Types of Seizures 35. What is the first line drug for status? 36.

If seizures persist after first dose of benzodiazepine, load with f or p Loading dose for fosphenytoin i s at Loading dose for phenytoin is at If no response to load ing dose, a n additiona l c a n be given after m i n ute.

benzodiazepine

27.6.6

fosphenytoin, phenytoin

27.6.6

_ __

__ _

a.

___

b.

1 5-20 mgfkg at 1 50 mg/min

__ __ ____

__ __ __ _

1 5-20 mgfkg at 50 mg/min

_ ___

c.

_____

1 0 mgfkg; 20 min utes

37. What medication should be avoided in status epilepticus? a. n na rcotics phenothiazines b. p b a c. n neurom uscu lar blocking agents

27.6.6

38. True or False. The drug of choice for myoclonic status is a. Lorazepam b. Benzodiazepine c. Dila nti n d . Phenoba rbita l e. Diazepa m

27.6.8

__ _ __

_ __

_____

39.

a. b. c. d. e.

___

__ __ __ _

True or False. The drug of choice for absence status is Va l p roic acid Benzodiazepine Dila nti n Phenoba rbita l Diazepa m

true fa lse fa lse fa lse fa lse 27.6.8

true fa lse fa lse fa lse fa lse

1 65

28 Pai n

•

General I nformation Complete the following statements about pain: a . T h e th ree types o f p a i n a re i. n ii. d iii. s m b. Two types of nociceptive pain a re: i. s ii. v

1.

_ _ _

_ __

__ _

__ _

_ __

•

nociceptive deafferentation sym pathetica l ly mediated somatic viscera l

Neuropathic Pain Synd romes 2. Answer the following about the use of tricyclics to treat neuropathic pain: a. Use is l i m ited by and effects, and by b. Which is more effective: serotonin reu ptake blockers, or norepinephrine reu ptake blockers? ___

•

28.1

___

28.2.2

a nticholinergic; centra l ; lim ited pain relief serotonin reu pta ke blockers

Craniofacia l Pain Syndromes 3 . Complete t h e following statements about craniofacial pain syndromes: a . Tic convu lsif is g neura l g ia plus spasm. h b. Ra msay H u nt synd rome is p n g c. Tolosa-Hunt synd rome is s f 0 d . Raeder neuralgia is p n

2 8 .3 . 1

geniculate; hemifacia l postherpetic gen icu late neuralgia su perior orbita l fissu re inflammation pa ratrigeminal neuralgia

Pain 4. Characterize the craniofacial pain a. b. c. d. e. f. g. h. i.

syndrome known as SUNCT s u n c t brief-a bout near the per day occu rs affects

2 8 .3 . 1

short lasting u n i latera l neura l g iform headache conj u n ctiva l i njection tea ring 2 min utes eye m u ltiple times males

Complete the following regarding primary otalgia: a . I t m a y have its orig in from which nerves? fifth, seventh , ninth, tenth , and occipita l nerves b. Coca in ization of the pharynx, prod ucing g lossopharyngeal neuralgia pain relief, suggests instead of primary otalgia. c. Treatment includes Teg reto l , Dilantin , and i. Medicines: T ,D baclofen and b ii. S u rgical proced u res: of m microvascular decompression or sectioning the (MVD); d i nervus intermed ius; n , the C N , and the u pper two ninth; fi bers of the CN tenth

5.

6.

a. b.

c.

Characterize trigeminal neuralgia (TGN}. The incidence is , but higher (2%) i n patients with It is pathophysiologica l ly caused by what?

Pathogenesis may be due to vascu l a r compression from what a rteries?

d . T h e neurologic exa m in a patient with trigeminal neuralgia should be Complete the following statements about treatment of trigeminal neuralgia: %. a . Teg retol provides p a i n rel ief i n b. What if Teg retol has no effect?

c. What is the second d rug of choice for trigeminal neuralgia? d . T h e two specia l preca utions needed with the use of this medication a re as follows: i. It may be ii. Don't

28.3.2

28.3.3

4/ 1 00,000; MS ephaptic transm ission from l a rge myeli nated A fibers to poorly myelinated A delta and C fibers su perior cerebel lar a rtery (SCA) , persistent prim itive trigeminal a rtery, or dolichoectatic basi l a r a rtery entirely norm a l , or with very m il d sensory loss

7.

__

1 67

FDI 28.3.3

69% The d iag nosis of trigeminal neuralgia is suspect. baclofen ( Lioresal)

teratogenic stop abru ptly

1 68 8.

a. b. c. d. e. f. g. h. i. j.

Part 9: Pain Medicines for trigeminal neuralgia include the following: ®) a (E (L ®) b ®) (B b ®) (Z c ®) (T c ®) (K c ®) (N g ®) I (L ®) (D p (T ®) o

28.3.3

a m itri ptyl ine; Elavi l® baclofen; Lioresal® botu l i n u m toxi n ; Botox® capsaici n ; Zostrix® carbamazepine; Teg retol® clonazepa m ; Klonopin® gabapenti n ; Neurontin® lamotrigine; Lam icta l® phenytoin; Dila nti n® oxca rbazepine; Trilepta l®

nociceptive fibers (A-delta 9. The basis upon which percutaneous trigeminal rhizotomy treats trigeminal a n d C fi bers); touch fi bers (A­ neuralgia is the destruction of alpha and A-beta) fibers and while preserving fibers.

28.3.3

____

1 0. When treating trigeminal neuralgia, percutaneous trigeminal rhizotomy (PTR) is recommended for whom? a . Patients with p r for genera l anesthesia. b. Patients who wish to avoid m , s c. have u t , d . have m s.____ e. have i h on the other side, I e f. or have I __

__

28.3.3

poor risk major surgery

___

_ _ _ _

_ _ _ _ _

___

___

11.

a. b. c. d. e.

__

_ _ _ _

State the considerations when choosing radiofrequency rhizotomy ( RFR) versus percutaneous microcompression (PMC) rhizolysis for trigeminal neuralgia. Recu rrence rates and incidence of dysesthesias a re across the va rious lesioning tech niq ues. Occu rrences of intraoperative hypertension a re with PMC than with radiofrequency. Bradyca rd ia occu rs reg u l a rly with . req u i res a patient who can cooperate; can be done with the patient asleep. Pa ra lysis of the ipsilatera l trigeminal motor root is more common with __

1 2. Answer the following concerning trigeminal neuralgia (TGN) and microvascular decompression (MVD): a. True or Fa lse. It is appropriate for patients with 90 degrees. c. is innervated by the axillary nerve. d . rotates the a rm out. 8. True or False. The abductor pollicis longus a. is innervated by the median nerve. b. is innervated by the posterior interosseous nerve. c. is innervated by the u l n a r nerve. d . is innervated b y t h e radial nerve.

9. True or False. The median nerve is responsible for the following movements of the thumb: a . adduction b. abduction c. extension d . flexion e. opposition Complete the following about the movements of the thumb: a. Plane of movement for the th u m b i. extension: ii. flexion: iii. adduction: iv. abduction: v. opposition: b. Action of nerves to the th u m b i. median nerve, H i nt: FAO F-action, f muscle, f p b root, A-action, a muscle, a p b root, 0-action, o p muscle, o root,

29.2 . 1

adductor-together with pectora lis thoracodorsal (5,6,7,8 29.2 . 1

true fa lse true fa lse (i nfraspinatus m u scle) 29.2 . 1

fa lse true fa lse true (The posterior interosseous nerve is a conti n uation of the radial nerve in the forea rm.) 29.2.2

fa lse ( u l n a r) true fa lse (rad ial) true true

1 0.

_ _ _

_ _ _

_ _ _ _

___

_ _ _

_ _ _

_ ___

___

_ _ _

_ _ _

___

_ _ _

_ _ _

29.2.2

plane of palm plane of palm perpendicu lar to pa l m perpendicu lar from palm across the pa l m flexion; flexor poll icis brevis; C8, Tl ; abduction; abductor poll icis brevis; C8, Tl ; opposition ; opponens pollicis; C8, Tl

1 75

B

1 76

Part 1 0: Peripheral Nerves ulnar nerve action, a m u scle, a root, iii. radial nerve action, e m u scle, e and I b root, ii.

___

p

___

p.___

___

Complete this list of the peripheral nerves of the lower extremities: H i nt: fosis pdstp (Follow our sig n . It says, "please don't spoil the plants. " ) a. f b. 0 c. s d. i e. s f. p g. d h. s i. t j. p

adduction; adductor pollicis; C8, Tl extension; extensor pollicis brevis and long us; C7, C8

11.

Now name the nerves of the lower extremities along with the roots that form them a. f b. 0 c. s d. i e. s f. d g. s h. t i. p

29.2.3

femora l obtu rator su perior g l uteal i nferior g l uteal sciatic (tru nk) peroneal (tru n k) deep peroneal su perficial peroneal tibial pudendal

1 2.

1 3.

a.

b.

Finally, name the nerves of the lower extremities along with the muscles and their function. nerve, f i. muscle, i ,q s f ' ii. fu nction,

nerve, o i. muscle, a 0

ii.

fu nction,

e

,g

29.2.3

femora l , L2 ,3,4 obtu rator, L2 ,3,4 su perior g l utea l , L4, 5 , Sl i nferior g l utea l , LS, S l ,2 sciatic, LS, S 1 ,2 deep peronea l , L4, 5 , Sl su perficial peronea l , LS, S l tibia l , L4, 5 , S l , 2 , 3 pudend a l , 52,3,4 29.2.3

femoral il iopsoas, quadriceps femoris, sartorius flex h i p and leg extension (quad riceps femoris) obtu rator adductor, g racilis, obtu rator extern us adduct thigh (all), and latera l rotation (obtu rator externus)

Peripheral Nerves c.

d. e.

nerve, s i. muscle, g f t p ii. fu nction,

nerve, i i. m u scle, g ii. fu nction, nerve, s i . muscle, b s ii.

f.

g.

h.

i.

m I

m

'

f

s

fu nction,

nerve, d i. muscle, t e e e ii. fu nction,

d h d

a I I b

nerve, s i. muscle, p b ii. fu nction, nerve, t i. muscle, p g f f f f ii. fu nction,

nerve, p i. muscle, p ii. fu nction,

and

t

,p h d d h

'

s

,s I I b b

___

,

1 77

su perior g l utea l g l uteus mediusf m i n i m u s , tensor fasciae lata, piriformis abduct thigh (gl uteus), thigh flexion (tensor fasciae lata), latera l thigh rotation (pi riformis) inferior g l uteal g l uteus maxim us thigh abduction sciatic tru n k biceps femoris, semitendi nosus, semimembra nosus leg flexion (and assist thigh extension) deep peroneal ti bialis anterior, extensor digitorum longus, extensor hall ucis longus, extensor digitorum brevis foot dorsiflexion (all but EDB), foot supination (TA), extension toes 2-5 (EDL, EDB), extension g reat toe (EHL, EDB) su perficial peroneal peroneus longus and brevis pla nta rflex pronated foot and eversion ti bial posterior tibia lis, gastrocnemius, planta ris, soleus, flexor h a l l ucis longus, flexor digitorum longus, flexor digitoru m brevis, flexor hall ucis brevis pla nta rflex supinated foot (PA, FDL, FHL), pla nta rflex a n kle (gastroc, pla nta ris, soleus), inversion (PA), flex term inal phalanx toes 2-5 (FDL), flex terminal phalanx g reat toe (FHL ) , flex mid pha lanx toes 2-5 ( FDB ) , flex proxim a l phalanx g reat toe ( FHB ) , knee flexion (gastroc, pla ntaris) pudendal perinea l , sphincters vol u nta ry contraction of pelvic floor

FDI

1 78

Part 1 0: Peripheral Nerves

1 4. True or False. The gluteus maximus muscle a . abducts thigh

b.

adducts thigh

c.

medially rotates thigh

d. e.

latera l ly rotates thigh is innervated by su perior g l uteal nerve

1 5. True or False. The tibialis anterior muscle is responsible for foot a . dorsiflexion b. pla nta rflexion c. eversion

d.

supination

Complete the following about the function of peripheral nerves: a . T h e fu nction o f extension o f t h e g reat toe is served by h i. muscle, e I and e d b ii. root, b . T h e fu nction o f foot dorsiflexion i s served by a i. muscle, t e d and e h I ii. root,

29.2.3

true (abducts thigh in a prone position) fa lse (obtu rator externus and pecti neus) fa lse (gl uteus medius and g l uteus minimus) fa lse (obtu rator externus) fa lse (i nferior g l uteal nerve) 29.2.3

true fa lse (soleus, gastrocnemius) fa lse (peroneus longus and brevis) true

1 6.

c. Which is the best L5 m u scle to test clinica l ly? (Hint: E is the 5th letter of the a l p h a bet) 1 7. True or False. The extensor hallucis longus muscle a . extends g reat toe b. dorsiflexes foot c. is innervated by the deep peroneal nerve

B •

29.2.3

extensor h a l l ucis long us and extensor digitorum brevis L5 , S l ti bialis a nterior, EDL, and EHL

L4,5 (TA); L4, 5 , 51 (EDL and EHL) extensor h a l l ucis longus

29.2.3

true true true

Peripheral Nerve I njury/Surgery Complete the following regarding timing of surgical repair of nerves: a . I f t h e nerve must regenerate a long dista nce, repa ir should be done

1 8.

months of denervation, b. After most m uscles ca nnot recover.

29.3.3

ea rly 24

Peripheral Nerves 1 9. True or False. The brachial plexus is formed by the dorsal rami of C5-Tl .

20.

fa lse (It is formed by the ventra l ra m i of CS-Tl . The dorsa l ra mi innervate the paraspi nal m u scles.)

Draw a diagram of the brachial plexus.

1 79

29.3.4

29.3.4

Fig. 29.1 21 .

On your diagram of the brachial plexus, label the following: CD roots C4-T1 ; 0 organ ization RTDCN (roots, tru n ks, divisions, cords, nerves); Q) names of tru n ks-S M I (su perior, middle, inferior); @ add names of cords-LM P (latera l , medial, posterior)

29.3.4 D

N

Fig. 29.2 22. On your outline of the brachial plexus, add the nerves. Hint: Dona ld says somewhat loud ly, " M ickey Mouse, you a re rig ht to so sincerely love M i n n ie Mouse madly."

29.3.4

MC

"

A

Fig. 29.3

Neurosurgery Books

1 80 23.

Part 1 0: Peripheral Nerves Draw the left brachial plexus-outline.

29.3.4

Fig. 29.4 24. Complete the following about the brachial plexus: a. Name the roots (6). b. Name the seg ments (5). ( H i nt: Run to do Cindy's needs.) c. Name the nerves ( 1 6). ( H i nt: Dona ld says somewhat loudly Mickey Mouse you a re rig ht to so sincerely love M i n n ie Mouse mad ly)

d. e.

Name t h e tru n ks (3). Name the cords (3).

25. Trace, using the brachial plexus diagram, the theoretically possible root contribution to each nerve and then compare with the actual root contribution in each nerve. a . nerve, d ___ s___ i. theoretica l , __ ii. actu a l , __ b. nerve, s___ i. theoretica l , ___ ii. actu a l , ___ c. nerve, s___ i. theoretica l , ___ ii. actu a l , ___

29.3.4

C4, 5,6,7,8, Tl roots, tru n ks, divisions, cords, nerves dorsal sca p u l a r; su prascapular; su bclavi us; latera l pectora l ; muscu locuta neous; median; u l n a r; axillary; radia l ; thoracodorsal; su bsca p u l a r u pper; su bsca p u l a r lower; long thoracic; medial pectora l ; medial brach ial cutaneous; medial antebrach ial cutaneous su perior, middle, inferior latera l , media l , posterior (Without rote memorization, this wi l l g ive accu rate answers 83% of the time. Only 8 of 49 theoretica l root contributions a re not actua l ized . ) dorsal sca p u l a r C4, 5 C4, 5 su bsca p u l a r C4, 5,6 C4, 5,6 su bclavi us C6 C6

Fig. 29. 1

Peripheral Nerves d.

nerve, I i. theoretica l , ii. actu a l , nerve, m i. theoretica l , ii. actu a l , nerve, m i. theoretica l , ii. actu a l , nerve, u i. theoretica l , ii. actu a l , nerve, a i. theoretica l , ii. actu a l , nerve, r i. theoretica l , ii. actu a l , nerve, t i. theoretica l , ii. actu a l , nerve, s u i. theoretica l , ii. actu a l , nerve, s l i. theoretica l , ii. actu a l , nerve, I t i. theoretica l , ii. actu a l , nerve, m t i. theoretica l , ii. actu a l , nerve, m b i. theoretica l , ii. actu a l , nerve, m a i. theoretica l , ii. actu a l ,

___

___

e.

___

___

___

f.

___

___

___

g.

___

___

___

h.

___

___

___

i.

___

___

___

j.

___

___

___

k.

___

___

___

___

I.

___

___

___

___

m.

--

___

___

n.

___

___

___

0.

___

---

___

___

p.

___

___

___

latera l pectora l C4, 5 ,6,7 C4, 5,6,7 musculocuta neous C5,6,7 C5,6,7 median C5,6,7, Tl C5,6,7, Tl ulnar C8, Tl C7 , 8 , Tl axillary C4, 5,6,7,8, Tl C4, 5,6,7,8, Tl radial C4, 5,6,7,8, T1 C4, 5,6 thoracodorsa I C5,6,7,8, T1 C6,7,8 su bsca p u l a r upper C5,6, 7 ,8, T1 C5,6,7 su bsca p u l a r lower C5,6,7,8,T1 C5,6,7 long thoracic C5,6,7 C5,6,7 med ial thoracic ( pectora l ) C8, T1 not listed medial brachial C8, T1 not listed medial a ntebrachial C8, T1 not listed

26.

list the brachial plexus nerves (except for median, ulnar, and radial), the muscles they serve, and the action of the muscles. s a . nerve, d s i. muscle 1 , I ii. action, iii. m u scle 2 , r iv. action, b. nerve, s i. muscle 1 , s ii. action, iii. m u scle 2 , i iv. action,

29.3.4

dorsa l sca p u l a r levator sca pulae elevate sca pulae rhomboids adduct and elevate sca p u l a suprasca pular supraspinatus adduct a rm 1 5 to 30 degrees infraspinatus exorotation of h u merus

1 81

1 82

Part 1 0: Peripheral Nerves

nerve, m i. muscle 1 , ii. action, iii. m u scle 2 , iv. action, v. muscle 3 , vi . action, d . nerve, a i. muscle 1 , ii. action, iii. m u scle 2 , iv. action, c.

___ _

b

b

_ _ _ _

___ _

c

___ _

___ _

b

___ _

___ _

_ _ _ _

d

_ _ _ _

___ _

t

m, ____

___ _

e.

nerve, s. i. muscle 1 , ii. action, iii. m u scle 2 , iv. action, nerve, t i. muscle, ii. action, nerve, I i. m u scle, ii. action,

_ _ _ _ ___ _

___ _ ___ _

___ _

f.

_ _ _ _ _ _ _ _

___ _

g.

t

_ _ _ _

_ _ _ _

___ _

a. b. c. d. e. f. g. h.

list the branches of the radial nerve cascade in proper sequence. (H int: rest in peace, retbes in peeeeeae) r e t b e s i n

i. j. k.

p e e

I. m. n. o. p.

e e e a e

27.

__ _

__

_ _ _

__

_ _ _

__

___

__

___

__ __

__ _ _ _ _ _ _

__

28. True or False. The radial nerve a . is formed b y C5-8. b. innervates triceps. c. i n nervates supinator. d. innervates brachioradialis. e. contin u es into forearm as posterior interosseous nerve.

muscu locuta neous biceps brachii flex and supi nate forea rm coracobrachialis flex hu merus at shoulder brachia lis flex forea rm axi l l a ry deltoid abduct a rm 30 to 90 deg rees teres minor exorotate and adduct hu merus su bsca p u l a r teres major adduct a rm su bsca p u l a ris adduct a rm thoracodorsa I latissimus dorsi adduct a rm long thoracic serratus a nterior forwa rd shoulder thrust 29.3.4

radial extensor triceps brachioradialis extensor carpi radialis supi nator i n posterior interosseous nerve p extensor carpi u l n a ris extensor digitorum com m u n is extensor digiti m i n i m i extensor poll icis brevis extensor pollicis longus abductor pollicis longus extensor indicis 29.3.4

true true true true true

Peripheral Nerves 29. What muscle is innervated by the axillary nerve? list the branches of the median nerve cascade. {Hi nt: pfpf3 pfaol) a. p t b. f c I c. p d. f d s e. f p d

teres minor, deltoid

30.

f. f g. p h. f i. a j. 0 k. I

p q p p p

b b

Now list the function of the muscles of the median nerve cascade: (Hi nt: pfpf3 pfaol) a. pronator teres: fu nction b. flexor carpi radialis: fu nction c. palmaris longus: fu nction d. flexor digitoru m su perficial is: fu nction

f. flexor pollicis longus: fu nction g . flexor poll icis brevis: fu nction h.

abductor poll icis brevis: fu nction

i. opponens pollicis: fu nction j. l u m brica ls 1 and 2 : fu nction

32. Which muscles of the hand are innervated by the median nerve? H i nt: loaf a. I b. 0 p b c. a p b d. f p

29.3.4

29.3.4

pronator teres flexor carpi radialis pa l m a ris longus flexor digitoru m su perficia l is flexor digitoru m profu ndus I & II flexor pollicis longus pronator quadratus flexor pollicis brevis abductor pollicis brevis opponens pollicis l u m brica ls 1 and 2

31 .

e. flexor digitorum profu ndus: fu nction

1 83

29.3.4

forearm pronator radial flexion of hand wrist flexion flex middle phalanx fi ngers 2 to 5 , flex wrist flex dista l phalanx fi ngers 2 and 3 , flex wrist flex dista l phalanx of th u m b flexes proximal phalanx of th u m b abducts thumb metaca rpa l and radial wrist extension opposes th u m b metaca rpa l flex proxim a l phalanx and extend 2 dista l phala nges Dig 2-3 29.3.4

l u m brica ls 1 and 2 opponens pollicis abductor pollicis brevis flexor poll icis brevis

FDI

B

Part 1 0: Peripheral Nerves

1 84 33.

list the muscles served by the ulnar nerve cascade in proper order, as well as the function of the muscles. (H i nt: '' Ffafner I Love H i m )

29.3.4

"

a. b.

c. d.

e.

f.

g.

i. ii.

f c fu nction:

u

flexor carpi u l n a ris ulnar flexion of hand

i. ii.

f d fu nction:

p

flexor digitoru m profundus flex dista l phalanx of fi ngers 4 and 5

i. ii.

a fu nction:

i.

d e e p part of f b fu nction:

ii.

p

adductor pollicis th u m b adductor flexor poll icis brevis

p

flex proxi mal phalanx th u m b

i. i ii. fu nction (dorsa l): iii. fu nction (pa l m a r):

interossei abducts adducts, flex proxi mal phala nges at metacarpophalangeal joints

i. ii.

l u m brica ls 3 & 4 extends two dista l phala nges of fi ngers 3 and 4 at interphalangeal joints

fu nction:

hypothenar m uscles i. a d ii. fu nction: iii. f d iv. fu nction: v. 0 d vi . fu nction: b h. p

m m m

Complete the following about anatomic variants with Martin-Gruber anastomosis: and a . Con n ections between the nerves b . in the % o f cadavers. c. found i n

abductor digiti minimi abduction of little fi nger flexor digiti m i n i m i flex l ittle fi nger opponens digiti minimi opposition digit 5 palmaris brevis

34.

29.3.4

media n ; ulnar forearm 23

Neurosurgery Books

30 Entrapment Neuropathies

•

General I nformation 1.

a. b. c. d.

list medical etiologies of entrapment neuropathies. d m h a a

e. c f. p g. r h. g

•

r a

30.1

dia betes mel litus hypothyroidism acromegaly amyloidosis (primary or secondary) ca rci nomatosis polymya lgia rheu matica rheu matoid a rth ritis gout

Mecha nism of I njury myeli nated 2. Does brief compression primarily affect myelinated fibers, unmyelinated fibers, or both?

•

30.2

Occipital Nerve Entrapment 3. True or False. Occipital nerve entrapment a . is d u e t o compression o f a sensory branch of C3. b. presents pain in the occi put with a trigger point near the su perior nuchal line. c. is more common in men. 4. Answer the following about nonsurgical treatment of occipital nerve entrapment: a . G reater occipita l nerve block may provide rel ief lasting b. I nject at

30.3 . 1

fa lse (sensory branch of C2) true fa lse 30.3.4

1 month trigger point

Il

1 86 c. d.

Part 1 0: Peripheral Nerves If the case is disabling, and pain doesn't respond to medication, what else may be tried? Is a col l a r indicated?

5. Answer the following about surgical treatment of occipital nerve entrapment: nerve root a . decompression of b. Occi pita l neu rectomy ca n consist of avu lsion of the g reater occi pita l nerve as it exits between the and the m u scle. c. Another option is release of nerve within m u scle. the i. rel ief in % ii. im provement in %

•

surgery, a lcohol neurolysis no 30.3.4

C2 transverse process of C2 and inferior oblique m u scle trapezi us 46 36

Median Nerve Entrapment 6.

a. b.

Name the two most common syndromes of median nerve entrapment. t s c p t s

30.4. 1

carpa l tu nnel synd rome pronator teres synd rome

7.

Complete the following about the course of the median nerve: a . T h e median nerve passes u n d e r the

b. The motor branch either goes or the ligament m u scles, c. and serves the d . which consist of i. ii. iii. iv. 8.

a.

b.

Complete the following about the median nerve: Describe t h e sensory distribution o f the median nerve. i. thumb: aspect ii. fingers: , a nd half of iii. eminence and adjacent iv. pa l m Pa lmar cutaneous branch (PCB) crosses tra nsverse carpal ligament.

9. Answer the following about the transverse carpal ligament {TCL): a . T h e TCL extends how fa r beyond the dista l wrist crease?

30.4.2

tra nsverse carpal liga m ent u nder; pierces LOAF l u m brica ls 1 and 2 opponens poll icis abductor pollicis flexor poll icis brevis 30.4.2

pa l m a r index, middle, and half of ring thenar radial above 30.4.2

3 cm

Entrapment Neuropathies b. What is the name of the sensory nerve spared in carpal tunnel synd rome? c. This nerve a rises em proxi m a l t o t h e wrist, d. passes the tra nsverse carpa l ligament e. and serves the sensation. ___ _ _ _ _

1 0.

a. b.

Describe main trunk median nerve compression. above el bow d u e t o at el bow i. I f ____

_ _ _

ii. p t. b iii. s c. H oneymoon para lysis is due to -,-d . Bened iction hand is d u e t o wea kness in what m u scle? _ _ _ _

_ _ _

palmar cutaneous bra nch 5.5 above thenar emi nence 30.4.3

Struther's liga ment lacertus fibrosus (bicipital aponeurosis) pronator teres sublimis bridge external pressure flexor digitorum profu ndus I and I I

11.

Characterize pronator teres syndrome (PTS). a . It com p resses t h e nerve b. where it dives between the two heads of the c. Sym ptoms: i. Pa in in disti n gu ishes it from carpa l tu nnel synd rome ii. d u e to the bra nch exiti ng before the TCL. iii. Also presents with weakness i n the and and iv. paresthesias in the

30.4.3

median pronator teres

___ __ _

_ _ _ _ _ _

pa lm median pa l m a r cuta neous

___

g rip

___

____

v.

Noctu rnal exacerbation is

_ _ _

1 2. What are the key features of anterior interosseous neuropathy? a. Presents with i. loss of f ii. of the d p iii. of the iv. and b. d u e to i. weakness of the f d and the p ii. f p I c. No loss of d . Patient ca n't e. treatment i. e m __ _

__ _

_ _ _

_ _ _ _

_ _ _

th u m b and index fi nger a bsent 30.4.3

flexion dista l phala nges th u m b index finger flexor digitorum profundus

___

_ _ _

_ _ _

__ _

___

ii.

s

___

__ _

e

_ _ _ _

flexor poll icis longus sensation make "OK" sig n expecta nt management 8-1 2 weeks surgical exploration (if no improvement)

1 87

1 88

Part 1 0: Peripheral Nerves

1 3. Describe carpal tunnel syndrome. median nerve a . The entra pment neu ropathy. b. It is due to

c. Where? d . Usually occu rs in what popu lation? e. M ale/female ratio: f. Bi latera l in % of cases g . Worse in of h . Phalen s i g n performed by the wrist i. and is positive i n 1 4. Answer the following about carpal tunnel syndrome: a . What is t h e most sensitive electrod iagnostics test for carpal tu nnel synd rome? b. Which should be faster, median sensory conduction velocity or u l n a r sensory conduction velocity? c. By how much? Complete the following about carpal tunnel syndrome: a . Describe treatment. i. sp ii. st iii. su b. Incision should be slig htly to the s i d e o f t h e interthenar crease c. to avoid c b i. p a nd/or r ii. a t b m

30.4.4

most common compression of the median nerve distal to wrist crease middle-aged patients 4: 1 >50% dominant hand forced flexion 8 0 % o f cases 30.4.4

sensory latency nerve con d uction velocity (NCV) median sensory conduction velocity 4mfs

1 5.

•

30.4.4

splint steroids su rgery ulnar pa l m a r cutaneous branch anomalous recu rrent thenar motor branch

Ulnar Nerve Entrapment 1 6.

a. b.

c.

Complete the following about the ulnar nerve: N a m e t h e roots. Motor findings of entra pment a re: i. wasti ng of the ii. w sign iii. F sign deformity of hand iv.

30.5.1

C7 , 8 , Tl interossei Wa rtenberg ' s Froment's claw

i.

d istu rba nce of sensation in

little finger

ii.

and

u l n a r half of ring fi nger

Entrapment Neuropathies 1 7. Describe Wartenberg's sign. a . I t affects t h e b. which rests in c. due to weakness of the t. p i m d . Which nerve is involved?

30.5.1

_ _ _

_ _ _

___ _ _ _ _

1 8. Describe Froment's sign. a . Test b y havi ng t h e patient g b. using their t and i f nerve is wea k the c. If the b d . th u m b b e. beca use u l nar-innervated is weak; f. therefore, the body su bstitutes it for the stronger g . which is innervated b y the nerve. branch of the ___ _

___ _

little fi nger abduction third palmar i nterosseous muscle ulnar 30.5.1

g rasp a piece o f paper th u m b and index fi ngers

_ _ _

____

_ _ _

_ _ _

ulnar bends backwards adductor pollicis

____

flexor poll icis longus

_ _ _ _ _ _ _ _ __ _ _ _

Describe injury to the ulnar nerve above the elbow. a . C a n be d u e t o inj u ry t o t h e cord of the brachial plexus. b. Ki n king may be ca used by the a of S c. which is a thin, flat

a nterior interosseous; median

1 9.

___ _

30.5.2

medial a rcade of Struthers

_ __

___ _ _ _

20. Answer the following about ulnar nerve entrapment at the elbow: a . May present as t u.

_ _ _ _

P· ---

mfs N CV is less than or there is a d rop of more than mfs between the AE and BE segments. d . Early symptoms may b e p u rely b. c.

___

motor

____

_ _ _ _

____

tardy ulnar palsy 50 10

____

___

30.5.3

_ _ _

21 . What are surgical options for treatment of ulnar compression at the elbow? a . nerve d without t. b. nerve d with e____ c. m of n. ____ d . Sometimes e and possibly j g may be req u i red. e. tra nsposition may be to , with in the , or a ____

aponeurotic band

__ _ __ _

_ _ _ _ __

30.5.3

decompression, tra nsposition decompression, tra nsposition medial epicondylectomy excision of neuroma; j u m p g raft su bcuta neous tissue, withi n t h e flexor carpi u l n a ris, or a submuscu lar position

Neurosurgery Books

1 89

1 90 22. a.

Part 1 0: Peripheral Nerves Describe the borders of Guyon's canal. roof f i. p ii. p b floor i. f of the p ii. p Below the floor lies the t. I c Contains only t h e and _ _ _

_ _ _ _

b.

_ _ _

___

c.

----

_ _ _ _

30.5.5

palmar fascia pa l m a ris brevis flexor retinacu l u m of the pa lm pisohamate ligament tra nsverse carpal liga ment

_ _ _

d.

___ ___

u l n a r nerve and u l n a r a rtery

23.

Describe the types of ulnar nerve lesions in Guyon's canal. a . Type I i. location of com pression

ii.

weakness

iii. sensory deficit b. Type I I i. location o f com pression ii. weakness

just proxi mal to or withi n Guyon 's ca nal a l l intrinsic hand m u scles innervated by u l n a r n. palmar u l n a r distri bution along deep branch muscles innervated by deep branch none

iii. sensory deficit c. Type l l l i. location o f compression ii. wea kness iii. sensory deficit

•

30.5.5

distal end of G uyon 's ca nal none palmar u l n a r distri bution

Radial Nerve I njuries 24.

a.

Complete the following regarding radial nerve injuries: Sensation loss in t h e web space o f the th u m b ind icates inj u ry in the Pain at the latera l epicondyle ind icates compression of the Wrist d rop ind icates inj u ry to , where the nerve is in the of the h u merus. Triceps plus a l l dista l m u scle weakness ind icates i nj u ry at the Weakness of the a bove, plus the deltoid and latissimus dorsi ind icates i nj u ry to the

30.6.3

hand

_ _ _ _

b.

supinator tunnel at the el bow

_ _ _ _

c.

__

-- __

mid-u pper arm; spira l g roove

____ ____

d.

axilla

_ _ _ _

e.

_ ___ _ _

posterior cord

Entrapment Neuropathies 25.

a.

Describe mid-upper or forearm radial nerve compression. Radial nerve compression in mid-u pper a rm prod uces i. w (w d ii. w n iii. beca use it compresses and I nj u ry to the posterior interosseous nerve of fingers. (PI N ) prod uces I nj u ry at the supi nator tu nnel prod uces but no ___

___

_ __

_ __

_ _ _

_ _ _ _ _ _ _ _ _ __ _

b. c.

a. b. c.

weakness (wrist d rop) wrist n u m bness PI N ; superficia l radial nerve wea kness pain; wea kness

__ _

____

26.

30.6.3

Complete the following about radial nerve anatomy. P I N refers t o t h e _ ___ __

a conti n u ation of the which serves the of the fingers i. p ii. and the a I

nerve,

_ _ _

30.6.3

posterior interosseous nerve radial extensors abductor pol licis longus

_ _ _

27.

a.

Describe management of radial nerve injury. posterior i nterosseous syn d rome i. e _ __

c

ii.

_ _ _ _

b.

supinator tu nnel synd rome

c.

hand inj u ry of i. Clinical finding is loss at the d, w s of the th u m b i i . often caused b y __ __

___

_ _ _ _

_ _ _ _

•

30.6.3

exploration (if case doesn't respond to 4-8 weeks expecta nt management) lyse constrictions (including arcade of Frohse) Su rgery ra rely req u i red, but responds to nerve decompression. small a rea of sensory loss; dorsal web space of the th u m b handcuffs

Axillary Nerve I njuries 28. List possible etiologies of axillary nerve neuropathy. a. s d b. sleeping in the position with arms c. compression from a i- -d. i ---.,-e. entra pment in the ___ _

_ _ _ ___ __ ___ _ _ _

_ _ _ _

30.7

shoulder dislocation prone; abducted a bove the head thoracic ha rness injection inj u ry quadrilatera l space

1 91

1 92 •

Part 1 0: Peripheral Nerves

Suprascapular Nerve 29. a. b.

Describe suprascapular nerve injury. Nerve formed from roots Entra pped at s n beneath the ---- ----

30.8

C5,6 suprasca p u l a r notch beneath the tra nsverse sca p u l a r ligament c. Sensory symptoms: deep, poorly local ized (referred) shoulder pain d . Motor sym ptoms: weakness a n d atrophy supraspinatus and of and infraspinatus rotator cuff inj u ry e. May be d ifficult to disti n g u ish from inj u ry. f. Differentiate from CS cervica l rhomboid and deltoid radiculopathy and u pper brachial plexus lesion by testi ng and _ _ __

_ _ _ _

__ _

_ _ _

---- ----

•

Meralgia Paresthetica 30. Define meralgia paresthetica. a . Also known a s , or b. c . Hyperpathia located a t t h e I t u f d . Entra pment o f t h e I c nerve. e. True or Fa lse. I nvolves both motor and sensory fibers. 31 . Answer the following regarding differential diagnosis of meralgia paresthetica: a . Femoral neuropathy sensory changes tend to be more b. L2 or L3 radiculopathy: look for

___

c.

Nerve com pression by abdominal or pelvic tumor suspected if

Describe treatment options for meralgia paresthetica. a . Nonsurgical measu res achieve relief in % of cases. b. True or Fa lse. Centra l ly acting pain med ications are often effective. c. Neu rectomy may be (more/less) effective than decompression, but risks

30.9.2

Bern h a rdt-Roth synd rome "swashbuckler's disease" latera l u pper thigh (burning pain) latera l femoral cuta neous fa lse (sensory on ly) 30.9.4

a nteromed ial motor weakness (thigh flexion or knee extension) concomitant G l or GU sym ptom s

32.

d . I f neu rectomy instead o f neurolysis i s elected , what should b e d o n e prior to sectioning?

30.9.5

91 fa lse more; denervation pain electrical sti m u lation to ru le out a motor component

Entrapment Neuropathies •

1 93

Common Peronea l Nerve Palsy Complete the following about common peroneal nerve palsy: a . True or Fa lse. T h e peroneal nerve is the most com mon nerve to develop acute compression palsy. b. At what location?

33.

Describe the clinical findings in peroneal nerve palsy. a . True or Fa lse. T h e a nterior tibia lis is the most com monly involved m u scle in peroneal nerve palsy. b. Resu lts in i m pa i rment of i. motor fu nction : ii. sensory loss in

30. 1 2 . 1

true fi bular head

34.

30. 1 2.3

fa lse (EHL)

foot d rop, wea k foot eversion dorsum of foot and latera l calf superficial peroneal

c. The peroneus longus and brevis a re innervated by the bra nch of the common peroneal nerve. d . T h e d e e p peroneal bra n ch innervates the EHL, a nterior ti bialis, and EDL , a nd (extensor digitoru m longus) m u scles. ___ ___

35.

•

If EMG stimulation is absent, both above and below fibular head, prognosis is

poor

3 0 . 1 2 .4

Tarsa l Tu nnel 36. True or False. The posterior tibial nerve may be a . fou n d in t h e tarsal tu nnel. b. fou n d posterior and inferior to the medial m a l leolus. c. tra pped at the retinacu l a r ligament. d . classica l ly responsible for nocturnal pain and paresthesia at the heel. 37. Answer the following about clinical findings of posterior tibial nerve entrapment: a . Percussion o f t h e nerve a t prod uces paresthesias that radiate b. Exacerbated by

c.

Dorsiflexion-eversion test: Examiner maxi m a l ly everts and dorsiflexes the a n kle while for 5 - l 0 seconds.

30. 1 3. 1

true true true fa lse (heel is spared) 30. 1 3.2

medial m a l leolus; dista l ly maximal inversion and eversion of foot dorsiflexing the toes at MTP joi nts

Il

31 Non-Entrapment Peripheral Neuropathies

•

•

Definitions 1. a.

Define: peripheral neuropathy

b.

mononeuropathy

c.

mononeuropathy m u ltiplex

31.1

d iffuse lesions of periphera l nerves prod ucing wea kness, sensory d istu rba nce, and/or reflex changes d isorder of a single nerve, often due to tra u m a or entra pment involvement of 2 or more nerves, usually d u e to a systemic abnormality

Etiologies of Periphera l Neuropathy 2.

a. b. c. d. e. f. g. h. i. j. k.

list the etiologies of non-entrapment peripheral neuropathies. (Hint: G rand Thera pist) G R A N D T H E R A or A p or P or __

p

I. I m. s n. T

3 1 .2

G u i l lain-Barre Renal ( u remic neu ropathy) Alcoholism N utritional Diabetes Tra u m atic Hered ita ry Endocrine or Entra pment Radiation Amyloid or AIDS Psychiatric or Pa ra neoplastic or Pseudoneuropathy Infectious Sa rcoidosis Toxins

Neurosurgery Books

Non-Entrapment Peripheral Neuropathies •

Classification 3.

a.

Complete the following regarding peripheral neuropathy: The most common periphera l neu ropathy that is an inherited disorder is C -M -T Psychogenic somatoform disorders or malingeri ng with sym ptoms of pains, pa resthesias, hyperalgesia, wea kness, a n even objective changes in temperatu re are associated with p ___

b.

3 1 .3

Charcot-Ma rie-Tooth

___

pseudoneu ropathy

_ ____

•

Clinical Regarding peripheral neuropathy. Sym ptoms o f peripheral neuropathies include: of s i. I ii. p iii. w iv. i a v. d b. Work-up includes: i. H -A ii. T iii. E iv. v B v. E

4. a.

--

__

-

-

--

--

---

-

--

•

3 1 .4. 1

loss of sensation pain wea kness incoord ination difficu lty a m b u l ating 3 1 .4.2

Hg b-A 1 C TSH ESR Vita m i n B l 2 EMG

Synd romes of Peripheral Neuropathy 5. True or False. Regarding critical illness polyneuropathy (CIP). a. Most often affects proxim a l m u scles. b. Occu rs in the presence of sepsis or m u ltiorg a n fa i l u re. c. Abnorm a l EMG is seen. d . Serum CPK may b e norm a l . e. Treatment is supportive. f. Complete recovery ra rely occurs. 6. Which syndrome is associated with a pure sensory neuropathy? 7. True or False. Alcohol neuropathy includes: a . motor neuropathy b. sensory neu ropathy c. a bsent Achi l les reflex d . intense pain

3 1 .5.1

fa lse (d ista l m uscles) true true true true fa lse (occurs in 50% of patients) paraneoplastic synd rome (also associated with pyridoxine therapy)

3 1 .5.2

3 1 .5.3

fa lse true true fa lse

1 95

Part 1 0: Peripheral Nerves

1 96 8. a. b.

c. d. e. f. g.

Brachial neuritis: a ka P -T synd rome a ka i brach ial plexus neu ropathy Etiology: Prog nosis: Predominant sympto m : in Followed by: % Confined t o shoulder girdle in % __

True or False. The most important study in the diagnosis of lumbosacral plexus neuropathy is a . M RI b. CT c. EMG

3 1 .5.4

Parsonage-Tu rner id iopathic u nclear good pain wea kness in 96% 50%

9.

d.

ESR

3 1 .5.5

fa lse fa lse true (EMG in l u m bosacra l neuropathy - ru le out dia betic neuropathy) fa lse

EMG in lumbosacral neuropathy shows what in regards to: a . Fibri l l ation potentials in n u m ber decreased

1 0.

b.

Motor u n it potentials in n u m ber

decreased

c.

Motor u n it potentia ls i n a m plitude

increased

d.

Motor u n it potentia ls in d u ration

increased

e.

Motor u n it potentials that a re

polyphasic

f.

Have changes involving at least seg ments. t h e paraspi n a l muscles is highly

2

g.

Spari n g ; diag nostic

Complete the following about diabetic neuropathy: a . Dia betic patients show neu ropathy o r 50% EMG changes _%. neuropathy b. The fi rst symptom of dia betes may be

11.

c. 1 2.

a. b. c. d.

3 1 .5.5

3 1 .5.6

N e u ropathy might be red uced by control sugar of blood Complete the following about druginduced neuropathy: H i nt: CDEF c

D E F

3 1 .5.7

Chemothera py d rugs Dilantin (Phenytoin) Elavil (Am itri ptyl ine) Flagyl (Metronidazole)

Non-Entrapment Peripheral Neuropathies 1 3. True or False. Femoral neuropathy includes: a . weakness o f t h e q u a d riceps and il iopsoas b. patellar reflex - red u ced c. femoral stretch - positive d. sensation over latera l ca lf red uced

1 4. Answer the following regarding femoral neuropathy: a . N a m e t h e muscle responsible for i. knee extension ii. hip flexion b. To distinguish L4 radicu lopathy from femora l neuropathy, L4 radiculopathy wou l d not involve the c. Femoral neuropathy is caused by i. d ii. c

3 1 .5.8

true true true fa lse (femora l neu ropathy includes l sensation over a nterior thigh a n d medial calf.) 3 1 .5.8

q u a d riceps femoris il iopsoas i l iopsoas

dia betes compression

1 5. True or False. The most frequent cause of femoral neuropathy is fa lse a. intrabdominal tumor fa lse b. retroperitoneal hematoma c. dia betes true (Al l other options can cause femoral neuropathy. ) fa lse d . entra pment due t o i n g u i n a l hernia fa lse e. tra u m a

3 1 .5.8

1 6. True or False. Regarding AI DS neuropathy. a . I t u s u a l ly presents as proxi m a l sym metric polyneu ropathy. b. H IV+ only patients do not develop it. c. It never includes sensory elements.

3 1 .5.9

d . I t h a s a n infectious etiology. e. It may be caused by lym phomatous invasion of the meni nges or nerves. f. Drugs used to treat H IV can also cause neuropathies, most com monly N RTis and protease i n h ibitors.

fa lse (d ista l , sym metric polyneu ropathy) true fa lse (usually includes n u m bness and tingling) true true true

1 97

1 98 1 7.

a.

Part 1 0: Peripheral Nerves Complete the following about monoclonal gammopathy: Incl uded entities such a s i. m ii. Wa ldenstrom iii. M Responsible for % of neuropathies. Patient risk factors for anesthesia-related u l n a r neu ropathy include: g i. m ii. o r iii. prolonged post-op b ___ _

_____ _

b. c.

__

___

__

___

__

___

Complete the following about perioperative ulnar neuropathies: a . Avoid el bow flexion o f g reater than degrees. b. It tightens the retinacu l u m .

3 1 .5. 1 0

myeloma macrog lobulinemia MGUS 1 0% male gender obesity {BMI > 38} bed rest

1 8.

31 .5.1 1

1 10

__

_ _ __ ____

1 9.

a.

Complete the following about lower extremity neuropathy:

% i. common peroneal i n ii. risk is position Femoral neu ropathy where there is hemorrhage in the muscle. Meralgia pa resthetica i. tends to occur ii. in young slender iii. positioned hours iv. in operations lasting v. recovers in approxi mately ___

__

b. c.

_ _ __

___

_ __

___

__

20. What is the management of lower extremity neuropathy? a. Ca l l neurolog ist if not better in days. weeks. b. Do EMG not earlier than

__

21 .

a.

cu bita l tu nnel 31 .5.1 1

81 % l ithotomy psoas bilatera l ly males prone 6 to 1 0 6 months 31 .5.1 1

5 3

Complete the following about amyloid neuropathy and uremic neuropathy: Amyloid neu ropathy peri pheral nerves i. Amyloid can be deposited in

ii.

It prod uces a neu ropathy. iii. It can prod uce pressu re on nerves, i.e., Uremic neu ropathy i. occu rs in patients. ii. symptoms include and iii. ca n be relieved by _ _ __

sensory carpal tu nnel

_ _ _ __ _

b.

_ _ _ _ _ _

chronic renal fai l u re

___

_ _ _

____ ___ _

_ _ _

"Charlie horses" and " restless legs" dia lysis

3 1 .5. 1 2

Non-Entrapment Peripheral Neuropathies 22.

a. b.

•

Complete the following about postcardiac catheterization neuropathy: nerve. I t involves the It usually involves

3 1 .5. 1 2

femora l hematomas

Periphera l Nerve I njuries Describe the anatomy of the peripheral nerve. a . T h e connective tissue mem brane that surrounds individ ual axons is the

23.

surrounds g roups of axons (i.e. fascicles). su rrounds g roups of c. fascicles ( i . e . nerves).

b.

Complete the following regarding injury and regeneration of nerve: a . T h e regeneration rate = b. Su nderland system i. first deg ree: anatomy

3 1 .6.1

endoneurium Perineurium Epineuri u m

24.

ii.

second degree: axon con nective tiss ue is

___

iii. third-degree: axon and endoneurium d

25.

a.

Complete the following about peripheral neuropathies: Fou rth-deg ree axon inj u ry involves of a l l the elements but is intact.

Fifth-deg ree axon inj u ry: endo-, peri-, and epineurium is com pletely t c. Sixth-deg ree axon inj u ry: mixed thro u gh degree i nj u ries

b.

3 1 .6.1

1 m mfday (i.e. 1 inch/month) preserved ; cond uction block, compression, or ischemia inj u ried; endo-, peri-, epineuri u m intact (endoneuri u m provided tube for regeneration) disru pted (g rossly normal a ppearance, recovery related to the extent of intrafascicu l a r fibrosis) 3 1 .6.1

interru ption of a l l elements but epineurium is intact (nerve is i n d u rated and enlarged) tra nsected

____

first through fou rth

___

Describe injury classification of peripheral nerves and regeneration prognosis. a . Axon compressed

26.

Two classifications: Seddon and Su nderland Fi rst deg ree = Seddon neuropraxia; conduction block from com pression or ischemia, a n atomy preserved

Neurosurgery Books

3 1 .6.1

1 99

200

Part 1 0: Peripheral Nerves

b. Axon inj u red

c. Axon and endoneurium disrupted

d . Axon, endoneurium a n d perineurium disru pted e. Axon endo-, peri-, and epineurium disru pted

27.

What are the etiologies of brachial plexus injuries? H i nt: CPT

a. c b. P c. T

_ _ _

_ __

_ _ _ _

28.

a. b.

Second-deg ree = Seddon axonotmesis; inj u ry to axon and Wa lleria n degeneration ; endo-, peri-, epineurium intact; endoneurium provides "tu be" to optim ize successfu l rei nnervation of ta rget muscle Third degree = axon and endoneurium disrupted ; recovery inversely related to interfascicu l a r fibrosis; g ross normal a ppearance Fou rth-degree = i nterruption of axon, en do- and per­ neuri u m ; g ross reveals i n d u rated enlarged nerve Fifth-degree = Sed don neu rotmesis; complete tra nsection of axon, endo-, peri-, and epineuri u m 3 1 .6.2

com p ression penetration traction

Complete the following about traction (stretch) inju ries of the brachial plexus selectively: Spare the medial cord i. median nerve ii. I nj u re the posterior cord i. latera l cord ii.

Complete the following about the pre­ and post-ganglionic injuries: a . What nerve i nj u ry ca nnot b e repa ired? proxim a l to the dorsal root g a n g l ion (i.e. preganglionic) b. What is the evidence for such a n inj u ry? (Hint: prEH ms) pain i. p rhomboids ii. r EMG iii. E. Horner's synd rome iv. H v. m meningocele vi . s scapula

29.

_ _ __

_ _ _ _ _ _ _ _

___ _

_ _ _ _

_ _ __

3 1 .6.2

3 1 .6.2

Non-Entrapment Peripheral Neuropathies Describe upper and lower brachial plexus injury. a . U pper brach ial plexus inj u ry i. E_-D palsy ii. C_-C_ iii. f s of h h from s iv. i a_ with e e or v. Com monly shoulder d m c vi . B t

30.

__

___

___

3 1 .6.2

__

__ _

___

___

__ _

Bellhop's tip, hand not affected

__

b.

Lower brachial plexus inj u ry: palsy i. a ka I< ii. C_-T_ iii. s a p of a t iv. f or P v. c h_ with w of s h m vi . s h __

__

__

in

__

__

__

__

__

31 .

a.

i. most com mon is ii. consisti ng of C5-C6 iii. C5, C6-C7 % % iv. lower C8-T1 Com bined is % % Bilatera l Sponta neous recovery is

__

% and

__

__

32.

a. b.

l50mm Hg 320 mOSm/L 56.4.4

cytotoxic edema; vasogenic edema med ica l and surgical hypotension b u rst suppression on EEG

Neurosurgery Books

56.4.4

31 9

57 Skull Fractures

•

Depressed Skull Fractures 1.

a.

Indications for surgery i n open skull fractures: Depressed sku l l fractu re that causes a n d c s f l i p i f depression is g reater than _ e m or i s g reater than the I nvolvement of the f s c d

5 7 .3 . 1

neurological deficit

__

b. c. d.

__

__

___

_

__

__

_ _ _ _ _ _ _ _

e. f. 2.

a.

__

__

Indications for surgery in depressed skull fractures: Depression g reater t h a n em o r g reater t h a n t h e t of c i or g c _

__

b. 3.

__

__

__

__

57.3.2

1 em ; thickness of calvaria infection or g ross conta m i nation

For contaminated fractures, when excision of depressed bone is necessary, it is recommended to soak fragment in p i .

povidone iodine

57.3.2

The superior sagittal sinus is often to the of the sagittal suture.

rig ht

57.3.2

__

4.

_

__

cerebra l spinal fl uid leak i ntra d u ra l pneumocepha l u s 1 em; thickness o f the calvari u m frontal sinus cosmetic deform ity

_

__

•

Basal Skull Fractures 5. Temporal bone fracture considerations: a . More common temporal bone fractu re i s longitudinal fracture; petro­ squamosal sutu re the I fractu re, through the p -s suture and parallel to and through the EAC. transverse petrous fractu re; b. Periphera l facia l nerve palsy may be associated with t p fractu re geniculate gang lion d u e to stretching of the g g __

__

__

__

_ _ _

__

57.4.2

Skull Fractures c. Which fracture damages hearing?

tra nsverse fractu re (horizonta l )

6.

72 hours

Facial EMG's after posttraumatic unilateral peripheral facial nerve palsy often takes hours to become abnormal.

7. True or False. Glucocorticoids have fa lse been proven to improve the functional outcome of traumatic facial nerve palsy. 8. Clival fracture considerations: a c a n occur with basa l sku l l a. T fractu res involving t h e clivus. c vessels may be affected in b. A __

__

c. d. e. f. 9.

__

__

Cranial nerve deficits _ thro u gh _ h and b Pituita ry s h e a r d a m a g e associated with d ___

__

c__

b.

__

---

____

' ----

Most sensitive test for detecting skull base fractures is

57.4.2

57.4.2

57.4.2

Tra u m atic aneurysms Anterior circu lation, transverse fractures CN I l l thro ug h VI; bitem pora l hemianopsia dia betes insipid us CSF leak brainstem infa rctions CT sca n

57.4.3

true

57.4.3

Battle's sign

57.4.4

__

1 0.

Complete the following regarding basal skull fractures: a . True or Fa lse. Pneumocephalus m a y be seen on plain sku l l x-rays. b. Posta u ricu lar ecchym osis is ca lled

c. True or Fa lse. Anosmia ca n be associated with tem poral bone fractures. d. Sixth nerve palsy can occur with fractu re.

fa lse (with fronta l bone fractu re) cliva l

____

1 1 . True or False. The following are clinical signs of basal skull fracture: a . CSF otorrhea or rhinorrhea b. hemotym panum c. depressed level of consciousness d . Battle's sign e. inj u ry to cranial nerve VII

57.4.4

true true fa lse true true

321

322 1 2. a.

Part 1 4: Head Trauma Management considerations: D o NOT place n _ t_, which c a n be fata l in % of cases if passed intracra n i a l ly. Surgery should be considered for i. t a_ ii. posttra u m atic c c f __

b.

__

__

__

__

iii. CSF f iv. c d v. posttra u m atic f_ p_ __

___

•

_ _ _

57.4.5

nasogastric tube; 64% tra umatic aneurysms posttra u m atic cavernous ca rotid fistula CSF fistula cosmetic deform ities posttra u matic facia l palsy

Craniofacial Fractu res 1 3. Frontal sinus fractures a . Anesthesia o f t h e forehead m a y b e d u e nerve to s and/or s involvement. b. M u cocele formation is due to obstruction of the f d or chronic infla m mation. c. O n ly packing the sinus increases the risk of i or m formation ___

57.5.1

supratrochlear and/or supraorbita l nerve frontonasal d u ct infection or m ucocele formation

1 4.

Matching. Match the type of LeFort fracture with the structures involved. Type of fracture: G) LeFort I ; 0 LeFort I I ; @ LeFort I l l Structu res involved : (a-g) below a. maxilla b. inferior orbita l ri m c. orbita l floor d. nasofronta l sutu re e. zygomatic a rches f. zygomaticofronta l suture g . pterygoid plates

•

57.5.2

Pneumocephalus 1 5.

a. b. c. d. e. 1 6.

Compartments where pneumocephalus can be located in: e s s __

__

__

57.6.2

epid u ra l subdura l su barachnoid intraparenchymal i ntrave ntricu Ia r

Craniotomy: risk is higher when sitti ng patient is operated with surgery in the s position. __

57.6.2

Skull Fractures 1 7.

Congenital skull defects may result in pneumocephalus especially if the defect includes the t t __

1 9. True or False. The presence of intracranial air may produce a characteristic sign known as a . em pty delta sign b. Mt. Hashimoto sign c. Dawson sign d. Mt. Fuji sign e. gas gap 20. Treatment of pneumocephalus. %0 for significa nt or a. symptomatic post-op pneumocephalus b. e of tension pneumocepha l u s __

__

57.6.2

__

1 8. Tension pneumocephalus might occur if a. n a nesthetic is 0 used. b. c a i r is tra pped . v c. b opening occurs. organisms a re d. g -p present.

__

teg men tym pani

57.6.5

nitrous oxide cool ba l l va lve gas-prod ucing 57.6.6

fa lse fa lse fa lse true fa lse 57.6.7

1 00% 02 evacuation

323

58 Traumatic Hemorrhagic Conditions

•

Posttrau matic Parenchymal I njuries 1.

Bifrontal decompressive craniectomy within hours of injury is a treatment option with diffuse, medically refractory posttraumatic cerebral edema and associated ICHTN.

48 hours

58. 1 . 1

__

•

Hemorrhagic Contusion 2. Surgical evacuation indications: r IC-HTN or mass effect a. m b. TICH vol u m e ml , with f or t c. GCS contusions with m m M LS and or c b c __

__

__

__

__

___

__

58.2.2

medica l ly refractory SOml 6-8; fronta l or tempora l ; > 5 ; compressed basal cisterns

__

3. True or False. Regarding delayed traumatic intracerebral hemorrhage (DTICH}. a. The patient typica l ly has GCS � 8. b. Incidence is "' 1 0%. c. Most DTICHs occur within 72 hours of tra u m a . d . Some patients initia l ly a ppear wel l a n d then deteriorate. e. Coa g u lopathy contributes to DTICH. 4. The following factors contribute to formation of delayed traumatic intracerebral hemorrhage: a. systemic b. hemorrhage i nto a n a rea of n __ b_ c. coalescence of extravasated m __ _

__

58.2.3

true true true true true 58.2.3

coag u lopathy necrotic brain m icrohem atomas

Neurosurgery Books

Traumatic Hemorrhagic Conditions •

325

Epidura l Hematoma 5. a.

Complete the following: Incidence o f epid u ra l hematoma i s % of a l l head inj u ries. b. Incidence of subdura l hematoma is % of a l l head inj u ries. c. Epid u ra l hematoma male to female ratio is d. Epid u ra l hematoma a rise from a rteria l bleeding i n %. e. Epidural hematoma patients develop a dilated pupil in %. f. % a re ipsilatera l . % h a d no loss o f consciousness. g. % had no lucid intern a l . h. i. Morta l ity of epid u ra l hematoma is __

6. True or False. Regarding epidural hematomas ( EDHs). a. The sou rce of bleed ing is a rterial 99% of the ti me. b. Women a re more commonly affected.

c.

EDHs a re rare before age 2.

d. The anterior meningeal a rtery is the most com mon cause of the bleeding. e. Patients with epid u ra l hematomas can present with a n ipsilatera l hemiparesis. 7. What is Kernohan notch phenomenon? a . Com p ression of the b. cerebral ped u ncle on the c. which ca n prod uce hemiparesis to the intracranial mass lesion . 8.

a. b. c. d. e.

True or False. Concerning epidural hematomas. A dilated p u p i l is not a good loca l izing sign as to the hematoma location. It occu rs in more than 1 5% of head tra u m a adm issions. No i n itial loss of consciousness occu rs in 60%. No l u cid interva l occu rs i n 20%. I n pediatric head tra u m a , EDH should be suspected if there is a 1 0% d rop in hematocrit after admission.

58.3 . 1

1% 2% 4: 1 85% 60% 85% 60% 20% 20-55% 58.3.2

fa lse (85% of the time) fa lse (Men a re more com monly affected-4: 1 .) true (EDHs are ra re before yea rs or g reater than 60 yea rs.) fa lse (middle meningeal a rtery) true 58.3.2

contra latera l tentorial notch ipsilatera l hemipa resis

fa lse (It is a good sig n . )

58.3.2

fa lse 1 %

58.3 . 1

true

58.3.2

true true

g

Part 1 4: Head Trauma

326

9. True or False. A 5-year-old girl presents to the emergency room ( ER) with a chief complaint of brief posttraumatic loss of consciousness after several hours of playing with her siblings. While she is being worked up in the ER, you get a call from your frantic intern who reports that the patient is now obtunded. You would expect the following signs and symptoms and would include the following statistics in your presumed diagnosis: a. ea rly bradyca rdia

b.

Kernahan 's notch phenomenon

c.

85% occu rrence of associated ipsilatera l pupillary dilation

d.

a crescent-sha ped h i g h density lesion o n CT

1 0.

What is the mortality rate of EDH?

11. a.

Nonsurgical treatment: is possi ble i f size is less t h a n and patient's sym ptoms a re What may ha ppen between days 5 a n d 1 6? A n epid u ra l hematoma thicker than em should have surgery. To document resol ution repeat CT in _ months. to A vol u m e of less than cc.

b. c. d.

_ _ __

_ _ _

58.3.2

fa lse (Ea rly bradyca rd ia is included in the d ifferential diag nosis of posttra u m atic disorder described by Den ny­ Brown . Late bradyca rd ia may be seen in you r presumed diag nosis, epid u ra l hematoma.) true { I psilatera l hemiparesis has been described in EDH.) true (60% of patients with EDH have a dilated pupil and 85% wi l l be ipsilatera l to the hematoma.) true

58.3.4

20 to 55%

58.3.5 58.3.6

1 em mild increase in size of the hematoma 1 cm

____

e. f.

1 to 3 30

1 2.

Complete the following about delayed epidural traumatic hematoma (DEPTH): a. It may occur in as many as _ % of epid u ra l hematomas. b. It may be related to increasing the patient's - -,-c. or red ucing the patients d . especi ally fol lowi ng s u rgical remova l of another e. is a n other pred isposing factor. __

__ _

58.3.7

9-1 0% BP ICP epid u ra l

_ _ _ _

____

Coa g u lopathy

Traumatic Hemorrhagic Conditions 1 3. True or False. Regarding posterior fossa epidural hematoma. a. Nea rly 85% wi l l have an occi pita l sku l l fractu re in a d u lts. b. D u ra l sinus tea rs a re com mon. c. Abnormal cerebel lar signs are com mon. d . Overa l l morta l ity is over 2 5%. e. They represent - 5% of EDH.

•

58.3.7

true true fa lse true true

Acute Subd u ral Hematoma 1 4.

Regarding acute subdural hematomas (ASDH). a . There is more l i kely to be a n underlying brain inj u ry with a n ASDH than with an EDH. b. On CT, a n ASDH typica l ly a ppears crescentic in shape. c. One ca use of ASDH is the accu m u lation of blood around a parenchymal laceration. d . A " l ucid interva l " may be present.

1 5.

a.

Complete the following about acute subdural hematomas: Patient on a nticoa g u lation thera py has a g reater cha nce of ASDH fold i. if the patient is male: fold ii. if the patient is female: iii. H ow many days u ntil the subdura l mem brane begins t o form? __

__

1 6. a. b. c. d.

a scan in ASDH and time frame acute: - _ - _ days su bacute: -- days to _ - _ wks chron ic: wks to _ _ months lenticular shaped: _ - _ months

1 7. a.

SDH Treatment Surgical ind ications i. ASDH thickness m m or M LS ii. Do a c not a b_ h_ b. Surgical ind ications for smaller ASDH i. GCS d rops by or fixed and ii. a nd/or pupils a re dilated . iii. ICP is c. Timing of Su rgery i. Ideally should be operated on with in hours. __

__

58.4. 1

true true true true 58.4.2

7 26 4 Ta b l e 5 8 . 1

1 -3 days 4 days to 2-3 weeks > 3 weeks and 1 0m m or >5 cra n iotomy not a b u rr hole 2 poi nts asym metric > 20 4 hours

327

328

Part 1 4: Head Trauma

1 8. True or False. Regarding mortality from ASDH. a. Morta l ity from a n acute subdura l hematoma (AS DH ) ra nges from 50 to 90%. b. Morta l ity is from the

c.

Mortal ity is higher i n young people.

d.

Med ication that i ncreases morta l ity is

1 9. a. b.

Interhemispheric subdural hematomas I n children, consider c a . I n a d u lts, usually due to t and can also occur with r a c. What is fa lx synd rome? __

__

__

__

___

d . What sym ptoms c a n i t man ifest? (Hint: psadlo) i. p ii. s iii. a iv. d d ifficu lties v. I vi . 0 palsies

true underlyi ng brain inj u ry (and not from the extraaxial bleed ) fa lse (Morta l ity thought to be higher in elderly patients.) a nticoagula nts 58.4.5

child abuse tra u m a ; ru ptu red aneurysms paresis or focal seizu res contra latera l to the hematoma paresis seizu res ataxia dementia language ocu lomotor

20. True or False. Regarding infantile acute subdural hematoma. a . Often involves loss o f consciousness with fa lse initia l inj u ry. fa lse b. Sku l l fractures are often seen. c. Often presents with g s after general ized seizu re i nj u ry.

58.4.5

21 . Treatment of IASDH a . For mi n i m i mally symptomatic cases, you can consider p s t .

58.4.5

__

___

•

58.4.4

__

__

percuta neous subdura l ta p

__

Chronic Subdural Hematoma 22. What are the risk factors for chronic SDH? (Hi nt: catss fa lls) a. c b. a c. t d. s e. s f. f

58.5.1

coa g u lopathies a lcohol abuse tra u m a shu nts seizu res fa l l s

Traumatic Hemorrhagic Conditions 23. Techniques that promote continued drainage after immediate procedure and prevent re-accumulation: a. Lay the patient f . b. Place generous b u rr hole under the t m d c. Use of a s d . Possi ble I s __

__

58.5.4

flat tem pora lis m u scle

__

__

__

___

subdura l d rain l u m ba r subarach noid infusion

24.

For twist drill craniotomies for chronic subdurals, a. a ventricu l a r catheter is placed into the s space. b. ventriculostomy bag is placed below the c. Catheter is removed when at least of col lection is d rained and when patient shows signs of improvement which occurs within days.

58.5.4

subdura l

__

__

_ _ _ _ __

20 em ; craniotomy site - 20%; 1 -7 days

__

25.

Complete the following regarding chronic subdurals: a. Repeat surgery is needed in %. b. Is the use of a d ra i n recommended? c. With a d rain the need to repeat su rgery is red uced to %.

26.

a. b. c. d.

Complete the following about chronic subdural hematoma outcomes: % Persistent fl uid at 1 0 days: % Persistent fl uid at 40 days: H ow long ti l l fu l l resol ution? O n e operation is successfu l i n % of patients Two operations a re successfu l in % of patients.

58.5.4

1 9% Yes 1 0% 58.5.5

78% 1 5% May ta ke 6 months 80%

____

e.

90%

____

27. What are the complications of surgical treatment of chronic SDH? (Hint: hherps) hemorrhage a. h hyperemia b. h e m pyema c. e reexpa nsion fa i l u re d. r pneumocephalus e. P· seizu res f. s _ _ _

___

_ _ _

_ _ _ _

---

_ _ _

Neurosurgery Books

58.5.5

329

Part 1 4: Head Trauma

330 •

Spontaneous Subdural Hematoma 28. What are the risk factors for spontaneous subdural hematomas? a. h b. v m c. n d. a e. s f. h g. c h h. i __

__

__

__

__

_ _ _

_ _ _

_ _ _

__

29.

_ _ _

In spontaneous SDH, bleeding sites were often a , often involving c branch of _ __

58.6. 1

hypertension vascu l a r ma lformations neoplasms infection su bsta nce a buse hypovita m inosis coa g u lopathies intracranial hypotension a rteri a l ; cortical bra nch o f MCA

58.6.3

__

•

Traumatic Subdural Hygroma 30.

a. b. c. d. e.

Complete the following regarding formation of subdural hygromas: Are they associated with trauma? Do sku l l fractu res occu r? Do they have membranes? Fluid on CT is similar t o They are created by t and i. a ii. b v f Can be associated post-meningitis often by (species). Recurrent subdura l hyg romas may benefit from a s p s . __ _

_ _ _

__

__

__

f.

__

__

__

g.

__

•

__

yes yes; 39% no CSF

58.7 . 1

58.7.4 58.7.2

arachnoid tea r ba l l va lve fla p haemophi l u s influenzae meningitis effusion subdural-peritoneal s h u nt

58.7.5

__

Extraaxial Fluid Collections in Children a.

list the differential diagnosis of extraaxial fluid collections in children. a s

b.

b

s

c.

c

s

d.

c

a

e. f.

c e

d h

31 .

32. What is the mean age of presentation of extraaxial fluid collections of infancy?

58.8. 1

acute SDH in a child with low Hct benign subdura l (extraaxial) collections of infancy chronic sym ptomatic extraaxial fl uid col lections cerebral atrophy external hyd rocephalus (EH) cra niocerebra l disproportion external hyd rocephalus 4 months

58.8.2

Traumatic Hemorrhagic Conditions 33. What is the treatment of benign extraaxial fluid collections of infancy? a. o _ _ _ _

b.

p.___

p

c.

h

c

d. e.

Most wi l l by

____

__

e. ___

__ _

_ _ _ _

_ __

34. What are the treatment options for symptomatic chronic extra-axial fluid collections in children? ( H int: otb sp) a. o _ _ _ _

•

b.

t.

c.

b- ___

d.

s

_ _ _

___

p

___

s __

_

58.8.2

observation ( Most cases resolve sponta neously withi n 8 t o 9 months and req u i re no treatment.) periodic physica l exa m i nation ( Repeat physica l exa m to identify development of symptoms.) head circu mference every 3 to 6 months (Orbita l-fronta l head circu mference [OFC) should be done at 3- to 6month interva ls to monitor head g rowth that should parallel normal g rowth and approach normal at 1 to 2 years. resolve 1 -2 yea rs 58.8.3

observation with serial orbita l fronta l head circu mferences, u ltrasound at least one percuta neous ta p should be done to rule out infection bu rr-hole d rainage ± externa l d rainage s u bd u ra l to peritoneal s h u nt (unilatera l with extremely low pressure va lve)

Traumatic Posterior Fossa Mass Lesions 35.

a. b. c. d.

Complete the following about traumatic posterior fossa mass lesions: Head inj u ry that involves t h e posterior fossa is less than %. h The majority a re e Parenchym a l hemorrhages can be ma naged nonsu rgica l ly if they a re less than em in dia meter. Posterior fossa lesions meeti ng surgical criteria should be evacuated

58.9

3% epid u ra l hematoma 3 asap

331

59 Gunshot Wounds and Non-Missile Penetrating Brain Injuries

•

Gunshot Wounds to the Head 1 . True or False. Regarding gunshot wounds (GSWs). a . GSWs represent 3 5 % o f a l l deaths from brain inj u ry i n the older population (> 45). b. GSWs a re the most leth a l type of head inj u ry; one fou rth die at the scene. c. 90% of victi ms die.

59 . 1 . 1

fa lse (35% under 45 die) fa lse (2/3 die) true

2.

For GSWs to the head, the mechanisms of injury include (Hint: Capone g a n g shooti ngs l a n d in the East River) a. c cavitation, cou p-contrecoup b. g gas shock waves c. s d. I low pressu re e. i im pact f. e explosive g. r ricochet

3.

Cerebral abscess from penetrating wounds can occur from r c m and p c with n s __

__

__

__

__ __

__

4.

General initial management in penetrating head injuries

a. c b. eva luation for a c. s i p r d. f __

_ _

__

__

5.

__

__

__

__

Patients with little CNS function in absence of s are unlikely to benefit from craniotomy. __

reta ined conta m inated materia l , persistent com m u nications with nasal sin uses

59. 1 . 2

59. 1 . 4

59 . 1 . 6

CPR additional inju ries spine inj u ry preca utions fl uid resuscitation shock

59 . 1 . 6

Gunshot Wounds and Non-Missile Penetrating Brain Injuries If surgical intervention is necessitated, devita l ized tissue a round entry and exit wou n d should be e . b. air sinuses should have mucosa e c . c. ensure tight d d . cra n ioplasty should b e delayed _ - _ months.

6. a.

59 . 1 . 6

excised

__

exenterated

___

__

•

__

d u ra l clos u re 6-1 2 months

Non-Missile Penetrating Tra u ma 7. True or False. a . I t is appropriate t o remove the protruding foreig n body as soon as possi ble. b. Consider pre-op ang iography if object passes near a large named artery or the d u ra l sin uses. c. They have a higher risk of contamination than missile i nj u ries. d. Prophylactic a ntibiotics a re recommended. e. Post-operative a rteriog ra ms are recom mended .

59.2.3

fa lse (sta bilize object and only consider remova l i n the O R) true true true true (to ru le out tra u m atic aneurysm)

333

60 Pediatric Head Injury

•

General I nformation Complete the following regarding children hospitalized for trauma: 75% a . What percentage have head inj u ry? 1 0- 1 3% b. The overa l l morta l ity is _ - _%. c. If presenti ng with decerebrate postu rin g , 7 1 % morta lity is %.

1.

•

60. 1

Home Observation 2. A child with a GCS 1 4, who is neurologically stable with a negative a, may be appropriate for h o .

home observation

60.2.2

__

__

•

Cephalhematoma 3.

a. b. c. d.

Indicate i f cephalohematoma is more consistent with subgaleal hematoma or subperiosteal hematoma. Bleeding is l i mited b y sutu res. Do not calcify. May lead to significa nt loss of circu lati ng blood vol u me. More com monly seen in a newborn , associated with partu rition .

60.4. 1

su bperiosteal hematoma subga leal hematoma subgaleal hematoma su bperiosteal hematoma

Neurosurgery Books

Pediatric Head Injury 4. True or False. A mother brings a 5-dayold baby, born via vaginal delivery, with a large, right-sided, soft scalp swelling that stops at the suture. You should a . percutaneously aspirate the lesion . fa lse (Cephalohematoma is most com monly seen associated with partu rition. 80% resorb usually with in 2 to 3 weeks. Avoid the tem ptation of puncturing the lesions beca use the risk of infection exceeds cosmetic benefits.) b. tel l the mother that 50% of these calcify. fa lse

c. tel l the mother that the baby may develop jaund ice as late as age 1 0 days.

d.

surgica l ly excise t h e lesion.

e.

consider child a buse.

f. treat this differently if the soft a rea crosses sutu res.

•

60.4. 1

true (I nfants may develop hyperbilirubinemia and jaundice as blood is resorbed from this cephalohematoma [subperiostea l hematoma] as late as 1 0 days after onset. ) fa lse (Surgery is considered only after 6 weeks if a CT demonstrates ca lcifications.) true (Child a buse needs to be considered a lways.) fa lse (ca lled subgaleal hematoma)

Sku l l Fractures in Pediatric Patients Complete the following regarding growing skull fracture: a . Leptom eningeal cysts result from a combination of two inju ries: i. s f ii. d t. b. Why does it g row?

5.

_ _ _ _

_ _ _ _

c.

If ea rly g rowth of a fractu re line with no subgaleal mass, do in _ - _ f___ months to rule out p d . What is a treatment for true PTLMC? __

What are the surgical indications for pediatric simple depressed skull fracture? p a. d b. c d n d c. f

60.5.2

sku l l fractu re d u ra l tea r intact a rachnoid pulsates and eventua l ly expands X-ray; 1 -2 months; pseudo-g rowi ng fractu re surgery

6.

__

__

__

__

__

__

__

60.5.3

d u ra l penetration cosmetic defect foca l neurologic deficit consistent with the site of fractu re

335

336 7.

a. b.

•

Part 1 4: Head Trauma Fill in the blank regarding ping pong ball fractures Usually seen in . newborns Often no treatment necessa ry in a bsence tem poropa rieta l region of underlyi ng bra i n inj u ry when it occu rs reg ion in the t

60.5.3

__

Nonaccidental Trauma ( NAT) Answer the following regarding child abuse: a . True or Fa lse. There a re pathog nomonic findings in child abuse. b. Suspicious findings a re i. r h ii. b c s h iii. s f

8.

___ _

___ _

_ _ _

_ _ __

9.

a. b.

Retinal hemorrhage differential diagnosis: c_ a b s e___ in ----:i a h a s a increase i n I P r ____

_ _

c. d. e. 1 0.

__

__

____

_

__

__

__

_ _ _

In skull fractures, the most common bone affected is the p bone, and can be missed in clinical exam due to o h __

__

__

60. 6 . 1

fa lse reti nal hemorrhage bi latera l chronic subdura l hematomas sku l l fractu res 60.6.3

child abuse benign subdura l effusion in infa nts acute high a ltitude sickness acute increase in ICP Purtscher's retinopathy pa rieta l bone; overlying hematoma

60.6.4

61 Head Injury: Long-Term Management, Complications, Outcome

•

Airway Management 1.

Early tracheostomy can reduce the days of m v but does not reduce m,

mechanical venti lation; morta lity

61 .1

_ _ _

•

Deep-Vein Throm bosis ( DVT) Prophylaxis 2. The risk of developing DVT in untreated severe TBI is %.

20%

61 .2

__

•

N utrition in the Head-Injured Patient 3.

Nutritional replacement should begin within hours of post-trauma patients with full caloric replacement by .

72 hours; by day 7

IV nutrition has increased risk of and i h compared to enteral nutrition.

hyperg lycemia and infection

61 .3.3

1 2%

6 1 .4. 1

__

61 .3.1

__

4.

•

Posttrau matic Hyd rocephalus 5. What is the incidence of clinically symptomatic hydrocephalus after traumatic SAH? 6.

Hydrocephalus ex vacuo is v e due to atrophy secondary to in TBI patients. __

__

__ ___ __

ventricu l a r enlargement; diffuse axonal inj u ry

6 1 . 4. 2

338

Part 1 4: Head Trauma

7. When should a shunt be considered in posttraumatic hydrocephalus? a. e p on 1 or more LPs b. p c. t a __

__

__

___

•

_ __

elevated press u re papilledema transependymal a bsorption

Outcome from Head Trauma 8.

The basal cisterns is evaluated on axial a scan at the level of the m , and 3 limbs, which are

midbra i n ; quadrigeminal cistern, 2 latera l l i m bs (posterior portion of the am bient cisterns)

Compression of the basal cisterns is associated with a fold risk of

3 fold risk; increased ICP

Midline shift measurements are done at the level of the f of M .

fora men of Monro

___

___.

9.

1 0.

___

61 .5.2

61 .5.2

61 .5.2

__

1 1 . Complete the following: a . What is t h e genotype associated with head inj u ry? b. It is also a risk factor for A d __

•

6 1 .4.3

__

61 .5.2

apoli poprotein E4 a l lele Alzheimer's disease

Late Complications from Trau matic Brain I njury 1 2.

a. b. c.

The three most common symptoms associated with postconcussive syndrome are: h d m d __

__

6 1 .6.2

headache dizzi ness memory difficu lty su pportive

1 3. Treatment for postconcussive syndrome is generally s .

6 1 .6.2

__

Neuropathology in chronic traumatic encephalopathy shows a. n and t b. a a c. These changes a re similar to A. d isease, however the n t in CTE. a re more s

1 4.

_ _ ___

_ _ ___ _ _ _

6 1 .6.3

neu rofibri l l a ry ta ngles a myloid angiopathy Alzheimer's d isease; neu rofibri l l a ry ta ngles; su perficia l

Head Injury: Long-Term Management, Complications, Outcome 1 5. True or False. Chronic traumatic encephalopathy is more likely in boxers who a . have more t h a n 20 fig hts. b. fig ht for more than 1 0 yea rs. c. have the apolipoprotein E4 a l lele d . have cerebral atrophy. e. have cavu m septu m pel l u cid u m .

f.

It is also known as d

_ _ _ _

6 1 .6.3

true true true true true { 1 3%, may be acq u i red condition) dementia pugil istica

P· ---

Neurosurgery Books

339

62 General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries

•

I ntroduction 1. a.

b.

•

Complete the following: What m u st you look for in a patient with a major spinal inj u ry? It occurs in %.

62.1

a second spinal inj u ry 20%

Terminology 2. a.

b.

Complete the following: I n spinal cord i nj u ry, a ny residual motor or sensory fu nction more than three seg ments below the level of inj u ry represents an lesion. Signs of this being the case include i. s __ _

ii.

v

___

m, ___

s

___

s, ___

c. Types of this lesion include these synd romes: i. c c -S ii. B iii. a c iv. p c

62.2.3

incomplete

sensation (include position sense) vol u nta ry movement in the lower extrem ities; sacra l sparing (Preserved sacra l reflexes alone do not q u a lify as incomplete inj u ry. Also req u i res preserved sensation around the a n us or vol u nta ry recta l sphincter contraction, or vol u nta ry toe flexion . ) centra l cord synd rome Brown-Seq u a rd synd rome anterior cord synd rome posterior cord synd rome

Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 341 3. A complete spinal cord lesion a . is defined as n o or i. m ii. s fu nction iii. t levels below lesion. b. What percentage of patients with no fu nction on i n itia l exa m wil l develop some recovery with in 24 hou rs? c. A complete spinal cord inj u ry that persists for 72 hours ind icates what? 4.

a.

b. c.

Complete the following regarding spinal shock: hypotension: i. interru ption of s a ii. loss of v t iii. im plies inj u ry a bove which level? bradyca rd ia: u n opposed p activity relative hypovolemia: i. loss of

ii. res u lting in d . true hypovolemia: loss of e. neurogenic spinal shock is: i. tra nsient loss of ii. res u lting in iii. loss of •

reflex

62.2.3

motor sensory th ree 3% No dista l recovery wil l occur. 62.2.3

sym pathetic activity vascu lar tone Tl pa rasym pathetic muscle skeleta l tone below inj u ry venous pooling blood neurological fu nction flaccid para lysis, loss of reflexes bul bocavernosus

Whiplash-Associated Disorders 5.

What is the most common nonfatal automobile injury?

6.

Describe the five grades of whiplash­ associated disorders and clinical evaluation of each. G rade 0 i. clinica l ii. radiological studies iii. treatment G rade 1 i. clinica l ii. radiological stud ies iii. treatment

a.

b.

c.

G rade 2 i. clinica l ii. radiological stud ies iii. treatment

whiplash

6 2 .3 . 1

Ta ble 62 . 1 , Ta ble 6 2 . 2 , Ta ble 6 2 . 3 .

no com plaint none req uired none neck pain no x-rays optional col l a r/ rest (not more tha n 72 hours) red u ced ROM/ point tenderness flexion-extension x-rays optional col l a r/ rest (not more tha n 96 hours)

g

a

342

Part 1 5: Spine Trauma

d.

G rade 3 i. clinica l ii. radiological studies iii. treatment e. G rade 4 i. clinica l ii. radiological studies iii. treatment f. What percentage of whiplash inju ries recover with in 1 year?

•

neurological deficits CT/ M R treatment as SCI fractu re/d islocation CT/ M R treatment as SCI 76%

Ta ble 6 2 . 4

Pediatric Spine I njuries 7.

a.

b. c.

Complete the following about pediatric spine injuries: Due t o ligamentous laxity together with ligamentous i mmatu rity of paraspi nal m u scles and underdeveloped u n cinate processes, ped iatric spinal inj u ry tends to involve inju ries. I n the age g roup ::;; 9 yea rs, the cervica l spine is the most vu l nerable seg m ent. Of all cervical spine inj u ries in the u pper 3 pediatric popu lation, 67% occur in the seg ments of the cervica l spine.

8. Complete the following about pediatric spine injuries: a . "Pseudospread o f t h e atlas" is a phenomenon occu rri ng in children - but it cou l d be confused with what kind of fractu re? b. Normal tota l offset of the tota l overlap of 2 C1 latera l masses on C2 on AP open mouth view is i. m m at 1 yea r of age ii. m m at 2 yea rs of age iii. m m at 3 yea rs of age iv. and should never be more than mm __

__

__

9 . Answer the following about Jefferson fractures: a . True or Fa lse. jefferson fractu res a re common in pediatric cervica l spine inj u ry. b. They are more com mon d u ring the years.

62.4. 1

62.4.3

62.4.3

jefferson fractu re

2 4 6 8 62.4.3

fa lse teenage

Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 343 •

Sports-Related Cervical Spine I nju ries Complete the following about football-related cervical spine injuries: a . sti nger i. involves ii. represents b. burning hands i. involves ii. represents c. neuropraxia i. involves ii. represents iii. m u st ru le out iv. by performing an

1 0.

1 1 . Complete the following: a. A football player who uses his helmet as a battering ra m is ca lled a b. What evidence may be present on his spine x-rays? i. loss of ii. evidence of i i i . presence of c. When may the ath lete resu me play? 1 2. True or False. Contact sports are permitted in a. Klippei-Feil with symptoms b. Klippei-Feil without symptoms c. spina bifida d. status post-a nterior cervical d iscectomy and fusion (ACDF) 1 level e. status post-ACDF 2 levels f. status post-ACDF 3 levels

•

62.7.2

one extremity compression of root bi latera l u pper extrem ities mild centra l cord synd rome a l l fou r extrem ities cervica l cord inj u ry cervical stensosis M RI 62.7.2

spea r tackler

lordosis prior tra u m a cervica l spinal stenosis when lordosis returns Ta ble 6 2 . 7

fa lse true true true fa lse fa lse

Neurologica l Assessment 1 3. a.

b. c.

Complete the following: Cervica l nerves exit their liken u m bered vertebra. Thoracic and l u m ba r nerves exit their like-n u m bered vertebra . For a segment of cord that lies under a g iven vertebra , T2 to T1 0 add

62.8 . 1

above below two cord levels

d . U n d e r T1 1 , T1 2 , L 1 lie the

lowest 1 1 spinal seg ments

e. The con u s lies at

Ll -2

g

a

344 1 4.

a. b. c. d. e. f. g. h. i. j. k. I. m. n. 0.

p. q. r. s. 1 5.

a.

b. c. d.

e.

Part 1 5: Spine Trauma Give the location of the key sensory landmarks. occi pita l protu bera nce supraclavicu l a r fossa shoulders latera l s i d e o f antecu bita l fossa th u m b middle finger little fi nger medial side of a ntecubital fossa nipples xyphoid u m bilicus inguinal ligament medial femoral condyle medial maleolus g reat toe latera l maleolus popliteal fossa in midline ischial tuberosity peria nal a rea Write out the American Spinal Injury Association (ASIA} motor scoring system-upper extremity-for the indicated root, muscle, and action to test. root C 5 or b i. m u scle: d a or ii. action: s e f root C6 e i. m u scle: w ii. action: e w root C7 i. m u scle: t e ii. action: e root C8 d i. muscle: f p ii. action: s h root Tl i. muscle: h i I ii. action: a f

Ta ble 62 . 1 1

C2 C3 C4 C5 C6 C7 C8 Tl T4 T6 Tl O T1 2 L3 L4 L5 51 52 53 54-5 Ta ble 62 . 1 0

deltoid or biceps shoulder abduction; el bow flexion wrist extension extend wrist triceps extend el bow flexor digitorum profundus squeeze hand hand intri nsics abduct little finger

Neurosurgery Books

Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 345 Write out the American Spinal Injury Association {ASIA) motor scoring system-lower extremity-for the indicated root, muscle, and action to test. a . root L2 i. muscle: i ii. action: f h b. root L3 i. m u scle: q k ii. action: s c. root L4 i. muscle: t a f ii. action: d d. root L5 i. muscle: e h I ii. action: d g t e. root Sl i. muscle: g f ii. action: p f

1 6.

Name the main nerve root responsible for the following motor action: a. g reat toe extension b. a n kle dorsiflexion c. knee extension d. a n kle pla nta r flexion

Ta ble 62 . 1 0

i l iopsoas flex hip quadriceps straight knee tiba lis a nterior dorsiflexion extensor h a l l ucis longus dorsiflex g reat toe gastrocnemius pla nta r flex foot

1 7.

1 8.

a. b.

Complete the following regarding Beevor's sign: It tests the level of spinal cord inj u ry at about T It is performed by i. flexi ng the

ii.

Note that the cepha lad.

moves

Complete the following regarding the abdominal cutaneous reflex: a . What is it?

Ta ble 62 . 1 0

L5 L4 L3 Sl Ta ble 62 . 1 0

T9 neck - patient activates rectus abdom i n u s um bilicus

1 9.

Ta ble 62 . 1 0

b . T h e u p p e r quadrant is served by

Stroking q u a d ra nts of a bdomen causes abdominal m u scle contraction, u m bilicus deviation towa rds q u a d rant of sti m u l u s T8-9

c. The lower quadra nt is served by

Tl 0-1 2

d.

spinal cord

Its presence indicates ( a t least some) fu nction of the

g

346

Part 1 5: Spine Trauma

e. There is inj u ry f. beca use the reflex and then abdominal m u scles.

___ ___

___

____

spinal cord

no complete

to the to the

ascends to the cortex and descends

20. There is a sensory region that is not represented on the trunk. a . I t j u m ps from C to T b. These levels a re distributed exclusively e on the u

__ _

62.8.3

C4 to T2 u pper extrem ity

_ _ __

21 .

a. b.

c.

d.

e.

•

Give the motor and sensory descriptions for each class in the ASIA impairment scale as modified from the Frankel neurologic performance scale. class A Com p l ete cord inj u ry: no motor or sensory fu nction preserved class B I ncomplete cord inj u ry: sensory but no motor fu nction preserved below the neurological level (includes sacral seg ments 54-5) I ncomplete cord i nj u ry: motor class C fu nction preserved below the neurologic level (more than half of key m u scles below the neurologic level have a muscle strength g rade mm retrotracheal space > m m in a d u lt or > mm i n pediatrics atla ntodenta l interva l (AD I ) > mm in a d u lt > mm in pediatrics In the neurologica l ly intact patient, mm may be subl uxation up to norm a l . T o prove i t is normal do

Ta ble 6 3 . 2

__ _

__ _

7mm 1 4 mm 22 m m 3mm 4mm 3.5 mm flexion-extension views

1 6. When should we order anteroposterior (AP) and lateral views of the thoracic and lumbosacral spine? back pain a. clinical sym ptoms? b. mechanism of inj u ry? high g rade: MVA, fa l l > 6 feet, LOC

63.4.3

1 7. a.

63.4.3

Complete the following: How ca n w e tel l a n o l d i nj u ry from a n acute one? and b. We should test between days. c. Test wi l l remain abnormal for

bone scan 2 and 2 1

___

__ _

1 8.

a. b. c. d.

During evaluation of occult cervical spine trauma, what are the contra indications for flexion-extension cervical spine x-rays? patient who is not im pairment patient who has subl uxation of mm or more neurologic deficit o f _ _ _ _

_ _ _ _

1 yea r 63.4.3

cooperative/awake cog n itive 3.5 a ny deg ree

351

352

Part 1 5: Spine Trauma

1 9. True or False. A normal flexiontrue extension of the cervical spine x-ray may demonstrate slight anterior subluxation distributed over all cervical levels with preservation of the normal contour lines. Complete the following: Lumbar puncture (for myleog ra m ) i s dangerous in complete spinal block and may cause deterioration in %. b. Avoid this with a or

20. a.

Indications for emergent myelogram or magnetic resonance imaging (M RI) in spinal cord injury includes neurologic deficit a . that is not b. after closed c. after surgery.

63.4.3

1 4% latera l cervica l punctu re or MRI

21 .

22. Complete the following about M RI in spine: a. It is appropriate when i. CT of spine is ii. patient has neurological b. It shou ld be done with in hours. c. Most usefu l seq uences a re and i. ii. •

63.4.3

63.4.3

explained red uction spinal 63.4.3

inconclusive deficits 48-72 T2 STI R

Traction / Red uction of Cervical Spine I njuries 23.

Contraindications to traction/reduction of cervical spine injuries include a. atla nta-occipita l disassociation or type I IA or I l l hangman 's b. types of axis fractu res ca l led fractu res c. a defect in the sku l l at pin site d . the patient is less than yea rs o f age. 3

63 . 5 . 1

__

24. Complete the following: a . After placing t h e patient in tongs we must obtain a b. and measure the d ista nce between the and the i . which s h o u l d be less t h a n m m in a d u lts ii. and less than mm in children.

63.5.2

latera l c-spine x-ray

___ _

____

basion; odontoid

__ _

_ _ _ _

___

1 2mm 1 Omm ( u n reliable < 1 3 yrs beca use of va riable ossification/fusion of odontoid tip)

Ta ble 64. 1

Management of Spinal Cord Injury 25. What is considered proper pin care? a . Clean with

_ _ _ _ _ _ _ _ _ _

b. Apply c. This may red uce the incidence of ___

26. a.

Complete the following: Closed red u ction o f cervical dislocations may be associated with neurologic deterioration, and this may be d u e to a r c d If neurologic deterioration occurs after closed red uction what tests m ust you do im med iately?

63.5.2

half strength hyd rogen peroxide povidone-iod ine osteomyel itis 63.5.2

retropulsed cervica l disc

__ _

b.

•

M RI

Indications for Emergency Decompressive Surgery 27. Complete the following: a . True or Fa lse. Patient with recent onset of loss of fu nction due to spinal cord inj u ry should have a decompressive laminectomy. b. If su rgery is done, it is usually com bined with Contraindications to emergent operation for acute spinal cord injury include: a . complete for more than 24 hours without evidence of b. u nsta ble c. centra l

63.6. 1

fa lse (May worsen inj u ry.)

sta bil ization procedure

28.

--- ---

63.6. 1

spinal cord i nj u ry; spinal shock med ica lly cord synd rome (controversial)

353

a

64 Occipitoatlantoaxial lnjuries (Occiput to C2)

•

Atlanta-Occipital Dislocation Complete the following: Incidence in spinal inj u ry i s approxi mately %. b. Are they more common in pediatrics or in a d u lts? c. Mortal ity resu lts from

1. a.

64. 1 . 1

1%

__

d . They m a y demonstrate what type of para lysis?

pediatrics respi ratory a rrest (bulbar cervica l disassociation) cruciate

2.

Complete the following about the three types of atlanto-occipital dislocation: a . Type 1 : occiput in relation t o atlas i s dislocated b. Type I I : occiput in relation to atlas is dislocated c. Type I l l : occiput in relation to atlas is dislocated

3.

a.

Name the ligaments at the following sites: atlas t o occiput a i. a -0 m ii. p a -0 m iii. a (of c b I ) axis to occi put (via dens) i. t m ii. a I iii. a I atlas to axis i. t __

__

b.

c.

ii. a iii. d I

__

)

I b

(of c

__

64. 1 . 1

a nteriorly su periorly posteriorly 1 .8

anterior atla nta-occipital mem brane (ALL) posterior atla nta-occi pita l mem brane ascending band (cruciate ligament) tectorial mem brane a l a r ligaments a pical ligament tra nsverse liga ment (part of cruciate) alar liga ment descending band (cruciate ligament)

Neurosurgery Books

Occipitoatlantoaxial lnjuries (Occiput to C2) 4. Complete the following:

1 .8

a . What structu re is t h e cephalad extension of the i. a nterior longitudinal ligament? a nterior atla nta-occipita l mem brane ii. posterior longitudinal ligament? tectoria l mem brane b. Which structures a re most im porta nt in maintaining atla nta-occipita l sta bil ity? i. t m tectorial mem brane I ii. a a l a r ligaments Complete the following: N a m e t h e horizonta l component o f the cruciate ligament. b. What does it hold together? c. What is the strongest liga m ent in the spine?

5. a.

Complete the following: What is the best method by which to measure AOD? b. It is considered normal if each is less than mm. c . Another method is ca l l ed the

6. a.

d . Traction m a y b e used but patients deteriorate.

It is considered normal if below It is definitely a bnormal if above

8.

Power's ratio greater than diagnostic of atlanta-occipital dislocation.

% of

9. AOD is suspected if a . t h e atla nta-occipital interva l is g reater than m m and/or b. there is blood in the

64. 1 . 3

12 Powers' ratio

64. 1 .4

1 0%

64. 1 . 5

Power's ratio

64. 1 .4

posterior arch of the atlas

by dista nce from opisth ion to

b. c.

odontoid and atlas transverse liga ment

BAI-BDI

7. Complete the following: a. A measurement used in eva l uati ng atla nta-occipita l dislocation (AOD) is ca l led i. d ivide dista nce from basion to

ii.

1 .8

transverse liga ment

anterior arch of the atlas 0.9 1 is

Ta ble 64.2

Ta ble 64.2

2 mm

Ta ble 64. 1

basilar cistern

64. 1 . 3

355

a

356 •

Part 1 5: Spine Trauma

Occipital Condyle Fractu res 1 0. Complete the following: a . C a n they involve t h e hypog lossa l nerve? b. List the types. i. I is a fractu re. ii. II has a fractu re.

iii. I l l has an fractu re. c. Treatment is with d . What are the indications for h a l o o r fusion? e. I n cidence in tra u m a patients is %. __ _

yes

64. 2 . 1 Ta ble 64.4

com min uted (axial loading) linear (extension of basi lar sku l l fracture) avu lsion (traction) col lar craniocervica l misalign ment, occi put-Cl interva l > 2 m m 0.4%

64. 2 . 1

____

•

Atlantoaxial Subluxation/ Dislocation 1 1 . Answer the following about atlantoaxial dislocation: a. True or Fa lse. It has less morbid ity and morta l ity tha n atla nta-occipita l dislocation. b. Name and describe the three types. i. rotatory atla nto-axia l dislocation type I tra nsverse liga ment facet capsule treatment type I I tra nsverse liga ment facet capsule treatment type I l l tra nsverse liga ment facet capsule treatment ii. a nterior atla nto-axial dislocation f 0 c h d of t 1 2.

a.

b.

Complete the following regarding atlanto-axial rotatory subluxation: N a m e fou r causes. H i nt: stu r i. s ii. t iii. u

iv. r Com petence of the m ust be assessed.

true

64.3 . 1

rotatory, anterior, posterior

Ta ble 64.5

intact bilatera l inj u red soft col l a r inj u red unilatera l inj u ry fusion, halo inj u red bilatera l inj u ry fusion, halo odontoid fractu re congenita l hypoplasia disruption of transverse ligament 64.3 . 2

spontaneous tra u m a u pper respi ratory tract infection {Grisel synd rome) rheumatoid a rth ritis transverse liga ment

Occipitoatlantoaxial lnjuries (Occiput to C2) c. What is the cha racteristic head position?

d. e.

Patients a re usually It can occl ude the

arteries.

"cock robi n " (20 deg rees latera l tilt, 20 deg rees rotation opposite, slight flexion) you n g vertebra l

1 3.

Complete the following regarding the rule of Spence: a . I t is designed t o determ ine i f the tra nsverse liga ment b. If disru pted what effect does it have on treatment?

c. It is performed by studyi ng what view? d . T o assess what structu res? e. The critica l reference n u m ber is sum o f both sides.

•

mm

is disru pted req uires immobil ization (surg ica l , halo, or col l a r, based on type of disruption) open-mouthed AP latera l masses of C 1 -C2 overhang 7mm

Atlas (Cl ) Fractures 1 4. a. b. c. d.

Complete the following: isolated fractu re: % com bined with C2 fractu re: additional spine fractu re: combined with head inj u ry:

64.4 . 1

%

% %

1 5. True or False. Regarding a jefferson fracture: a . I t involves a single fractu re through the ring of C1 . b. It is genera l ly a sta ble fracture.

c. "Rule of Spence" assesses displacement. d. Treatment is genera l ly s u rgical (fusion).

•

64.3 . 3

56% 44% 9% 21% 64.4.3

fa lse (at least 2 fractu re sites) fa lse (But without neurologic deficit.) fa lse fa lse (usua l ly col l a r/halo)

Axis (C2) Fractures 1 6.

Complete the following about acute fractures of the axis: a . Represent % of cervical fractu res. %. b. N e u rologic deficit occurs in

64. 5 . 1

20% 1 0%

357

a

358

Part 1 5: Spine Trauma

1 7. Complete the following: a. True or Fa lse. Regarding hangman's fractu re: In contrast to jud icial hanging, i. modern-day hangman's fractu res result from hyperextension and distraction. ii. This is usually a sta ble fractu re. b. There is a common occu rrence of nonunion, hence the need for surgery. c. Hangman's fractu re resu lts in a fractu re . It is also known thro u gh the as

64. 5 . 3

fa lse - hyperflexion, axial load ing true fa lse (usually heal with col l a r) pars of C2; tra u m atic spondylolisthesis of the axis

Complete the following regarding hangman's fracture: a . Subl uxation o f C 2 on C 3 b y more than 3 ; disc m m indicates disruption . and usually insta bil ity; su rgery b. This is a marker for req u i res

1 8.

1 9. Classify hangman's fractures a . Type 1 : i. subl uxation: ii. a n g u lation: iii. treatment b. Type lA: i. subl uxation: ii. a n g u lation: iii. treatment c. Type II:

i. subl uxation: ii. a n g u lation: iii. treatment d . Type I IA: i. subl uxation: ii. a n g u lation: iii. treatment e. Type I l l : i. subl uxation: ii. a n g u lation: iii. treatment f. A special caution for Type I lA and I l l fractu res is to avoid the use of g. What is the name of the classification system? 20. a. b.

Most hangman's fracture patients present neurologica l ly and need MRI to assess d isc.

64. 5 . 3

Ta ble 64.7

vertical pars fractu res 3 m m sign ifica nt traction/halo vs surgery type II with oblique fractures >3 m m > 1 5 deg NO TRACTIO N . Halo. type I I + bilat C2-3 facets disru pted yes facets locked NO TRACTION. S u rgery traction Effendi 64. 5 . 3

i ntact C2-3

Occipitoatlantoaxial lnjuries (Occiput to C2) It can be treated with weeks. d. Average time to heal is c.

___

for

___

weeks

immobilization; 1 2 1 1 .5

21 .

Describe the radiologic criteria of good fusion. a . Across t h e fractu re site w e should see

tra becu lations

b.

movement

Flexion-extension radiographs should show no

64. 5 . 3

_ _ _

22.

Complete the following about odontoid fractures: a. Odontoid fractu res represent approxi mately % of a l l cervica l s p i n e fractures. b. Mechanism of inj u ry is usually %. c. They a re fata l in about d. Major deficits in type II is %. e. I n Type I l l it is to have neurologic deficit. f. A displacement mm i. of ii. resu lts in a nonu nion rate of %. iii. Therefore, the treatment advised is __

64. 5 . 4

1 0- 1 5%

__

__

__

flexion 2 5 -40% 1 0% rare 6mm 70%

___

23. True or False. Regarding odontoid fractures: a. They a re a hyperflexion inj u ry in most insta nces. b. Most patients have presenting neurolog ica l d eficit. c. N eck pain is infrequent. 24. Complete the following: a. Regarding odontoid fractu res: i. Type I is fractu re through the

64. 5 . 4

true fa lse fa lse Ta ble 64.9

__

Type I I is fractu re through the of iii. Type Ill is fractu re through the of b. True or Fa lse. The spinal cord occu pies 50% of the ca nal at C1 . c. True or Fa lse. The ossicu l u m term inale resu lts from posttra u matic fractu re of the a pica l dens. ii.

surgical

__

apical dens base of dens body of C2 fa lse ( 1 /3) fa lse - from nonunion

Neurosurgery Books

64. 5 . 4

359

a

Part 1 5: Spine Trauma

360

25. Complete the following: a. List indications for s u rgical treatment of Type II odontoid fractu res. i. displacement of dens more than mm ii. despite halo there is iii. despite immobilization there is

iv. patient is older than v. disruption of the b. True or False. Most odontoid type I l l fractures should be treated surgica l ly d u e to low u n ion rate by rigid externa l immobilization (halo). 26. The appearance of os odontoideum is a. a bone borders b. with odontoid peg . c. near a d . I t m a y fuse with the e. It may mimic a fractu re. 27.

a. b. c. d. e. f.

•

Complete the following about os odontoideum: Postu lated etiolog ies i. c ii. a Does treatment depend on the etiology? Myelopathy correlates with an AP ca n a l dia meter o f less than mm. Wi l l im mobilization result in fusion? Treatment i. p w ii. t s Do we need a halo with each of these procedu res?

64. 5 . 4

5mm insta bil ity nonunion 50 tra nsverse liga ment fa lse

-

90% heal

64. 5 . 4

sepa rate smooth short clivus type II odontoid 64. 5 . 4

congenita l avu lsion of a l a r liga ment no 1 3 mm no posterior wiring transarticu l a r screw Not with transarticu lar screws

Combination Cl -2 I njuries 28. Complete the following about combined C1 and C2 fractures: a . Treatment is d ecided based on type of fractu re. b. An odontoid fractu re type I I that is m m is displaced more than considered c. Treatment is

C2 5mm; u nsta ble posterior fusion

64. 6 . 2

Ta ble 64. 1 3

65 Subaxial (C3 throug h C7 ) Injuries I Fractures

•

Classification Systems 1.

a. b. c. d. 2.

a. b.

Matching. For the following conditions, choose the most appropriate mechanism producing the cervical fracture. Mechanism: CD hyperextension; 0 vertical compression ; ® hyperflexion; @ flexion plus rotation bu rst fractu re unilatera l locked facet bilatera l locked facet laminar fractu re Guidelines for determining clinical instability include: Com p rom ise o f t h e anterior elements prod uces more i nsta bil ity in Com p rom ise of the posterior elements prod uces more i nstabil ity in

3. Give radiographic criteria for clinical instability. a . a sag itta l p l a n e displacement of m m and b. relative sag itta l plane an gu lation of degrees(on neutra l position latera l C-spine fi lms)

•

Ta ble 65.3

0 @ ® CD 6 5 . 1 .4

extension flexion Ta ble 6 5 . 4

>3 . 5 m m >1 1

Clay Shoveler's Fracture 4.

Clay shoveler's fracture usually involves the spinous process of

C7

65.2

a

Part 1 5: Spine Trauma

362 •

Flexion I njuries of the Subaxial Cervica l Spine 5 . True or False. The following i s true of teardrop fractures: a . They usually result from i. hyperflexion inju ries ii. compression flexion inj u ry iii. hyperextension inj u ry b. They are sta ble fractu res. c. The fractu red vertebra is usually displaced posteriorly into the spinal ca n a l . d . They a re often associated with a fractu re through the sag itta l plane of the vertebral body. e. The patient is often quadripleg ic. f. A "tea rd rop" chip of bone is at the a nterior-su perior edge of the vertebral body. 6. Complete the following: a. A teardrop fractu re m u st be disti n g u ished from a n

i.

req u i res

is u nsta ble and

ii. is sta ble. How ca n we disti n g u ish them? A teardrop will have: i. size of fractu re ii. a l i g n ment iii. neurological iv. soft tissue v. fractu re vi . height of disc vii . height o f vertebral body c. If i n dou bt, perform views. in d. If negative, repeat _ days. e. The fractu red vertebra is displaced b.

___

f. True teardrop fractu res should be treated with c a and f p Quadrangular fractures have four features. a . Featu re 1 : a n fracture i. from ii. to b. Featu re 2: subl uxation of su perior vertebral body (VB) on the i nferior VB

65.4.3

true true fa lse fa lse true true true fa lse - anterior-inferior

65.4.3

avu lsion fracture Tea rd rop fracture; su rgery avu lsion fractu re small chip displaced deficits swelling through vertebra red u ced red uced/wedged flexion-extension flexion-extension; 4-7 days posteriorly combined anterior and posterior fusions.

7.

c.

Featu re 3 : with a n g u l a r

65.4.5

oblique anterior-su perior inferior end plate posteriorly kyphosis

Subaxial (C3 through C7) Injuries I Fractures d.

Featu re 4: disruption of i. ii. iii. e. Treat with

___ _ _ _ __ _

•

disc ALL PLL com bined anterior and posterior fusions.

Distraction Flexion I njuries 8. a.

Describe distraction flexion injuries. Flexion inju ries include

b. Which liga ment is inj u red ea rly? c. X-rays demonstrate this by showing d. We may need to test by perform ing If sym ptoms persist 1 to 2 weeks we should f. Lig amentous insta bil ity is confirmed if there is a m m or i. subl uxation of a n g u lation of ii. degrees.

e.

9. Describe locked (aka jumped) facets. a . Norm a l ly t h e inferior facet o f t h e level above is to the su perior facet of the level below. of the b. I n locked facets there is facet c. Flexion and rotation prod uces d.

Hyperflexion prod uces

stra i n , subl uxation, locked facets posterior ligamentous com plex widening of interspinous dista nce flexion-extension views or M RI repeat flexion-extension views

65.5.1

65.5.2

65.5.3

3.5 11 65.5.4

posterior d isru ption; ca psule unilatera l locked facets bilatera l locked facets

e.

N e u rological inj u ry is for cord freq uent and/or root i nj u ry. f. In patients with locked facets the inferior anterior facet of the level above is to the su perior facet of the level below.

1 0.

Describe evidence of locked facets on x-ray. a . I n u n i latera l locked facets t h e spinous process is rotated to the side of the

b. Facets look l i ke a c. I nterspinous space is d. N e u ra l fora men is e. Articu lar surfaces of the facets a re

65.5.4

locked facet bow tie widened blocked on the wrong side

363

Part 1 5: Spine Trauma

364

a

11.

a.

Complete the following regarding locked facets: When t h e a rticu lating s u rfaces o f the facets a re on the wrong side, this is sig n . " ca l led the " I n bilatera l locked facets tra u matic disc herniation is fou n d in %. Attem pt at closed red uction of locked facets by traction m u st not exceed l b per vertebral leve l . Disc space height m u st not exceed mm. If neurologic worsening occu rs, you and should suspect plan for u ntil M RI Closed red u ction is assesses for

65.5.4

na ked facet

___ ___

b. c.

80% 10

__

d. e. f.

1 2. Answer the following about locked facets: a . True or Fa lse. Sta bil ization is more l i kely to be successfu l in halo if there a re i. m u ltiple fractu res of the facets. ii. no fractu res of the facets. b. Halo alone is successfu l for good anatom ica l resu lt in %. c. Fa i l u re of good anatomical resu lt occu rs in %. d . True or Fa lse. Surgical fusion is therefore clea rly ind icated in cases without facet fractu re fragments. -

•

10 disc hernation; su rgery contraind icated ; disc hernation 65.5.4

true fa lse 23% 77% true

Extension I njuries of the Subaxia l Cervical Spine Complete the following about subaxial (C3 - C7) injuries/fractures: a . Extension inju ries c a n prod uce i. in a d u lts and in children. ii. b. The liga ment that is most often inj u red in extension inju ries is the c. Is disc inj u ry possible? d. What vascu l a r inj u ry can occu r?

1 3.

___ ___ ___

65.6. 1

centra l cord synd rome SCIWORA ALL

__ _

yes ca rotid a rtery dissection

Neurosurgery Books

Subaxial (C3 through C7) Injuries I Fractures •

Treatment of Su baxia l Cervical Spine Fractures 1 4. a.

Complete the following: When combined a nterior and posterior a nterior cervica l fusion is needed which should be done fi rst? b. When the mechanism of inj u ry is flexion posterior fusion what is the procedure of choice? c. When the mechanism of inj u ry is extension what is the proced u re of choice for i. tea rd rop fractu re com bined a nterior/posterior fusion ii. b u rst fractu re com bined a nterior/posterior fusion

65.7.3

Complete the following about cervical carpectomy: a . Decompression of the cord usually req u i res carpectomy that is at least ___ m m wide. b. It is advised to note position of .

65.7.3

1 5.

•

1 6m m vertebral a rteries

Spinal Cord I njury Without Radiogra phic Abnormality (SCIWORA) 1 6. True or False. Answer the following about SCIWORA {spinal cord injury without radiographic abnormality): a . There is a higher incidence in a g e ::; 9 years. b. There is a risk of SCIWORA among young children with asym ptomatic Chiari I. c. Dynamic flexion/extension films a re norm a l . d . 54% o f children have a delay between inj u ry and the onset of objective sensori m otor dysfu nction.

65.8 . 1

true true true true

365

-'-! �

66 Thoracic, Lumbar and Sacral Spine Fractures

•

Assessment and Management of Thoracolumba r Fractures 1.

a. b. c. d. e. f. g. h. i. j. k. I. m.

Matching. Match the following structures with the appropriate Denis column: CD a nterior; 0 middle; ® posterior a nterior half of disc posterior half of disc posterior a rch a nterior half o f vertebra l body posterior half of vertebra l body facet joi nts and ca psule a nterior a n u l u s fi brosus posterior a n u lus fi brosus interspinous ligament supraspinous liga ment a nterior longitudinal liga ment posterior longitudinal liga ment ligamentu m flavu m

2. True or False. The following are considered minor fractures of the lumbar spine: a . fractu re o f transverse process b. fractu re of spinous process c. fractu re of su perior a rticu l a r process d . fractu re o f i nferior a rticu l a r process e. fractu re of su perior end plate of vertebral body 3. True or False. Major injuries of the spine include: a . compression fracture b. b u rst fractu re c. seat belt fractu re d . fractu re o f a rticu l a r process e. fractu re dislocation

66 . 1 . 2

CD 0 ® CD 0 ® CD 0 ® ® CD 0 ® 66. 1 . 2

true true true true fa lse 66. 1 . 2

true true true fa lse true

Thoracic, Lumbar and Sacral Spine Fractures 4. True or False. Subtypes of burst fracture include the following: a. fractu re of both end plates b. fractu re of su perior end plate c. fractu re of inferior end plate d . fractu re o f pars i ntera rticu l a ris e. bu rst rotation 5. True or False. Regarding burst fracture. a . I t occurs mainly at thoraco l u m ba r j u n ction. b. Mecha nism-axial load c. Mechanism-flexion and compression d . I t is a consequence o f fractu re o f the a nterior and middle col u m n . e . T h e most common su btype is fractu re of the su perior end plate. 6. True or False. Radiographic evaluation of burst fracture might show the following: a. latera l x-ray-cortica l fractu re of posterior vertebral wa l l b . AP x-ray-i ncrease in interped icu l a r dista nce c. latera l x-ray-loss of posterior vertebral height d. CT-fractu re posterior wa l l with retropulsed bone e. myelogram-large centra l defect 7. True or False. Seat belt fracture has all of the following subtypes: a . cha nce fractu re, one-level throug h bone b. one-level throug h ligaments c. two-leve l , bone in middle col u m n , ligaments in a nterior and posterior col u m n s d . pedicle fractu re e. two-level thro u gh ligaments in a l l th ree col u m ns State which of the following are stable or unstable fractures of the spine: a . th ree or more consecutive compression fractu res b. a single compression fractu re with loss of > 50% of height with a n g u lation c. kyphotic a n g u lation > 40 degrees at one level or > 2 5% d . prog ressive kyphosis

367

66. 1 . 2

true true true fa lse true

B 66. 1 . 2

true true fa lse - usually p u re axial load true true 66. 1 . 2

true true true true true 66 . 1 . 2

true true true fa lse true

8.

66 . 1 . 2

u n sta ble u nsta ble u n sta ble u nsta ble

a

368

Part 1 5: Spine Trauma

9. State whether the following are stable or unstable fractures of the spine: a . middle col u m n fractu re above T 8 below sta ble Tl if ribs and stern u m intact b. middle col u m n fractu re below L4 if sta ble posterior col u m n is intact c. posterior col u m n fractu re sta ble acutely, as long as middle col u m n intact d . com pression fractu re in three u n sta ble consecutive seg ments 1 0. True or False. Regarding burst fractures. a . Surgical treatment is recommended if a n g u l a r deformity > 20 deg rees. b. Surgical treatment is recommended for patients with neurologic deficit. c. S u rgical treatment is recommended for a nterior body height red uction c. After admin istering tPA, a nticoa g u l ation and a nti platelets a re held for hours. d . There is increased risk for s i h with use of tPA, but no increased risk of m =

___ _

_ _ _ _

_ _ _ _

___ _

_ _ _ _

mechanical throm bectomy; perfusion Posterior; agg ressively 84. 3 . 2

tPA intracerebral hem orrhage aneurysm or AVM internal bleed ing a nticoag u l ation < l OOK head tra u m a , stroke, bra i n surgery; 3 months

____

_ _ _ _

1 85 mmHg 2 4 hours

_ _ _ _

_ _ _

_ _ _

symptomatic intracerebral hemorrhage; mortal ity

Evaluation and Treatment for Stroke 8. Blood pressure guidelines: a.

b.

84.3.4

I f no prior history o f hypertension, do not lower SBP below _ _ a nd DBP below _ _ If prior history of hypertension, do not lower SBP below _ _ a nd DBP below _ _

9. Anticoagulation in ischemic stroke: a . American Heart Association recommended the use of heparin by the remains a matter of p treati ng physician. b. Effectiveness of heparin is u n p roven except with c stroke. c. Stop wa rfa ri n after months. d. A should be admin istered to most patients. •

1 60-1 70; 95- 1 05 1 80-1 8 5 ; 1 05 - 1 1 0 84.3.4

preference

ca rdioembolic 6 Aspirin 3 2 5 mg

Carotid Endarterectomy Symptomatic carotid stenosis: A__ NASCET sta nds for N S C E__ T b. Ca rotid endarterectomy (CEA) for symptomatic ca rotid stenosis % red uces strokes by % at 1 8 months and red u ces death by % at 1 8 months. days after c. O n ly need to wa it acute stroke to perform CEA.

1 0. a.

_

_

North America n Sym ptomatic Ca rotid Endarterectomy Trial

84.4 . 1

_ _ __

>70%; 1 7%; 7%

____ ____

1 1 . CEA surgery complications: a. days before surgery patient , which should be sta rted on a should be c the day of s u rgery. 24-48 hours b. Aspirin should be h postop. c. Morbid ity a bsol ute u pper limit is %. %. d. In-hospita l morta lity is e. List postop com p lications: (H int: ch 4 a rm2s2) n i. c ii. h iii. h iv. h v. h vi . a d vii . r viii. m ix. m X. s xi. s

7 days

84.4.4

5· aspirin 3 2 5 m g ; contin ued held 3%

____

____

84.4.2

1% cranial nerve inj u ry headache hoarseness hyperperfusion hypertension arteriotomy disru ption restenosis morbid ity morta l ity seizures stroke

Neurosurgery Books

459

Part 1 9: Stroke and Occlusive Cerebrovascular Disease

460 f.

I n cidence of hypog lossal nerve inj u ry is %. Tongue deviates t the i Hoarseness is most commonly ca used by e and not n i U n i latera l voca l cord para lysis is due to v or r I nerve inj u ry. Lip asym metry is d u e to m b of f nerve inj u ry. Hypertension may occur as a result of s loss of the c b reflex. I ntracerebral hemorrhage occu rs in % and is related to c h I n cidence o f post-op ischemic stroke i s %. Post-op liAs a re usually due to c o but may a lso be d u e to m Late restenosis occu rs in _% at , within 2 yea rs postop it is d u e to f a n d after 2 yea rs it h is d u e to a If liAs occur i n recovery room, then obtain C _ If fixed deficit occu rs in recovery room , then d n obta in CT; instead r ind icated . If a rteriotomy clos u re is disru pted, then fi rst to e o w clot, then have anesthesia i patient, and finally revise endarterectomy in o

1%

____

g. h.

_ _ _

__ _

towa rds the inj u ry edema; nerve inj u ry

_ _ _ _

i. j. k.

_ __

vag u s ; recu rrent laryngea l mandibular branch of facia l ca rotid sinus ba roreceptor

_ _ _ _

I.

_ _ _

____

0.6%; cerebral hyperperfusion

___

m.

5%

____

n.

_ __

ca rotid occl usion; microemboli

_ _ _ _

o.

___

25% at 1 yea r; fi brous hyperplasia; atherosclerosis

_ _ _

p.

CT

__

q. r.

_ _ _

_ _ _

do not; reexploration open wou n d ; evacuate; i ntu bate; OR

_ _ _ _

1 2. CEA surgery technique: d between a. There is n and g the use of I anesthesia. b. Use a s h u nt if there is h to clamping or if s pressu re is c. C f vei n crosses over the ca rotid bifu rcation. nerve is in vicin ity of d. H f v e. S a rtery is fi rst t bra nch of E and helps differentiate E from I f. Place tempora ry clip on s, a t g . Order o f occl usion o f vessels is I C E (H int: ICE). _ __

___ _

____

_ _ _

___ _

_ _ _

_ _ _ _

_ _ _

84.4 . 5

no difference; loca l ; genera l hemodynamic intolerance; stu mp; 80 yea rs-old

461

B

85 Special Conditions

•

Totally Occluded I nternal Carotid Artery 1 . Totally occluded internal carotid artery: a. % of patients with ca rotid territory stroke o r TIA have ipsilatera l ca rotid occl usion. b. Patients with mild deficit have stroke rate of % per yea r related to the occluded ca rotid . % of patients with acute c. occl usion and profound deficit make a good recovery. d. c -occluded ca rotid has p patency rate and I gain from re-opening. e. R fil l i n g of ICA to pretrous or cavernous segment from ECA or from sign of contra latera i iCA is a g operability. _

_

_

_

•

1 0- 1 5%

85. 1 . 1

3-5%

85. 1 .3

_

_

2 - 1 2% Chronica l ly; poor; l ittle

85. 1 . 5

Retrog rade; good

Cerebellar I nfarction 2 . Cerebellar infarction: a. % of patients developing signs of b c wi l l die within hours to days. b. Sym ptoms genera l ly increase with in _ - _ hours fol l owing onset. c. Operation of choice is s d d . Avoid using v d alone as this may cause u h and does not relieve b c

80%; brainstem com pression

85.2.1

1 2-96 hours su boccipital decompression ventricu l a r d rainage; u pwa rd herniation; brainstem com pression

85.2.3

85.2.6

Special Conditions •

Malig nant Middle Cerebral Artery Territory I nfa rction 3.

a. b. c.

Malignant middle cerebral artery territory infarction: % of stroke Occu rs in up to patients. Ca rries a morta l ity of u p to %. T herniation occu rs within days of stroke. H can red uce morta l ity to % a m ong a l l comers. Better resu lts if su rgery performed b a ny signs of herniation. 3r c t. found that hemicra n iectomy with hours of stroke onset decreased m and increased o favora ble f ____

____

d.

____

e. f.

_ _ _ _

____

___

___

•

1 0% 80% Tra nstentoria l ; 2-4 days Hem icra niectomy; 37% before

8 5 .3 . 1

85.3.2

ra ndom ized controlled trials; 48 hours; morta l ity; fu nctional outcome

___

Cardiogenic Brain Embolism 4 . Cardiogenic brain embolism: is a. stroke in cardioembolic. % of patients wil l have a b. stroke with in _ - _ weeks of a n acute M l , and t h e risk is h i g h e r with a wa l l M I . % c . Patients with A-fi b have a rate of stroke per yea r without treatment. d. Ischemic stroke rate per yea r for patients with mechanical heart valves who a re on % per yea r a nticoa g u lation is % per yea r for for mitra l and aortic va lves. e. P embolism ca n occur with a p f o which is present in % of the general population.

1 in 6 2 . 5%; 1 -2 ; a nterior 4.5% 3% per year; 1 . 5% per yea r

8 5 .4. 1

85.4.2

8 5 .4.3

8 5 .4.4

____

___ _

_

•

_

Pa radoxica l ; patent fora men ova le; 1 0- 1 8%

85.4.5

Vertebrobasilar I nsufficiency 5. Vertebrobasilar insufficiency: a . Six o f t h e sym ptoms o f V B I beg in with the letter " d . " They are: i. d r ii. d i iii. dy iv. de v. diz. vi . de b _ _ _ _ _ _ __

_ _ _ _

___ _

_ _ _ _ ____ ___ _ _ _ _ _

_ _ _ _

85.5.2

d rop attack d i plopia dysa rth ria defect in vision d izziness deficit bilatera l ly

463

B

464

Part 1 9: Stroke and Occlusive Cerebrovascular Disease

b. c. d.

e. f.

•

2 hemodynamic insufficiency

85.5.3

Su bclavian stea l ; reversed; vertebra l ; proxi m a l ; su bclavian 4.5-7% Anticoag u lation

85.5.4 85.5.6

Bow H unter's Stroke 6. a.

b. c. d. e. f.

•

Clinica l diag nosis of VBI req u i res or more of the sym ptoms listed above. The most common cause of VBI is h i s ca uses s flow in the v r artery d u e to p stenosis of the s a rtery. Stroke rate is _ - _% per yea r. A is the mai nstay of med ica l management.

Bow hunter's stroke: Bow h u nter's stroke is caused by occlusion of the v a rtery resu lti ng from h to the The vessel occluded is c direction of head rotation. It is more likely in patients with incom petent p c a rteries. A n appropriate test for this condition i s a d c of The treatment of choice is d the v a rtery at C If sym ptoms persist, then perform f c

vertebra l ; head rotation

85.6. 1

contra latera l posterior com m u nicati ng dynamic cerebral ang iogra phy decompression; vertebra l ; C1 -2 C1 -2 fusion

85.6.3

85.6.4

Cerebrovascu lar Venous Thrombosis 7. a.

Cerebrovascular venous thrombosis: Hypercoa � u l a ble states include: (Hint: ip rs) I l l deficiency i. a antibodies ii. a C deficiency iii. p S deficiency iv. p n v. p hemoglobi n u ria deficiency vi . p vii . r to activated protein C viii. s l u pus erythematosis b. Occu rs in mothers with incidence of , and the highest risk is f weeks post-partu m . c. Freq uency of d u ra l sinus involvement: % su perior sag itta l sinus i. ii. % left tra nsverse sinus iii. % m u ltiple sinuses

85.7.2

a ntithrom bin anti phospholipid protein protein pa roxysmal noctu rnal plasminogen resista nce systemic 1 / 1 0,000 births; fi rst 2 weeks 85.7.3

70% 70% 71%

Neurosurgery Books

Special Conditions d.

e.

f. g.

h. i. j. k. I.

m. n.

Cli nical sym ptoms associated with su perior sag itta l sinus thrombosis: i. Anterior 1 /3 n s ii. m 1 /3 increased muscle tone iii. p 1 /3 cortica l blind ness or edema/death j u g u lar bulb throm bosis may prod uce the fol l owing symptoms: ( H i nt: bash) i. b ii. a iii. s d iv. h The best way to diag nose venous sinus or throm bosis is b y M D CT findings: i. May be normal in _ - _%. ii. H sinuses and vei ns, sign, is d u bbed the c pathog nomonic. iii. Petech ial "flame" h iv. S m a l l ventricles in %. d sign seen v. E on CT sca n with c vi . Wh ite matter e vii . Above findings occur b is the treatment of choice for H venous sinus throm bosis, even when associated with i h M u st not treat with s beca use they red uce f and thereby increase t Should a lso correct u a and control h Conti nue a nticoa g u lation for _ - _ months. If medical management fails, ca n perform d c d s , or t e c r Morta l ity is approxi mately %. Poor prog nosticators a re e a ,c 0 n d r and d v involvement.

465

85.7.5

no sym ptoms middle posterior

breath lessness a phonia swa llowing difficu lty hoarseness M RI ; DSA

g 85.7.6

1 0-20% Hyperdense; cord hemorrhages 50% Em pty delta ; contrast edema bi latera l ly Hepari n ; intracerebra l hemorrhage

85.7.7

steroids; fi brinolysis; throm bosis underlyi ng abnorm a l ity; hypertension 3-6 months decompressive cra n iectomy, di rect surgical treatment; endovascular clot retrieva l 30% extremes of age, com a , ra pid neurological deterioration; deep venous

85.7.8

B

Part 1 9: Stroke and Occlusive Cerebrovascular Disease

466 •

Moyamoya Disease 8. a.

b. c. d.

e. f. g.

h. i. j. k. I.

Moyamoya disease: Cha racterized b y p s or usually occlusion of o ICAs and their major b b , with secondary formation of collatera ls that have a p s a ppeara nce. 0 or The 2 types a re p s Pri mary moya moya is neither a nor i i n orig i n . Ca n be associated with a in 3 locations {C of W ), and c v , M with increased frequency of v aneurysms. or a 2 age peaks: j decades. Presentation in children is with i attacks and in adu lts with h Prog nosis is p with % rate of major deficit or death within yea rs of diag nosis. Diag nose with M and D Med ica l treatment has n proven benefit. S u rgical treatment incl udes d or i revascu l a rization. The d irect revascu l a rization treatment of -M choice is S b Indirect revascu larization is reserved for patients and include EMS y ) , and ) , EDAS ( ( ). OPT (

prog ressive spontaneous; one; both; branches; puff of smoke primary; secondary atherosclerotic; infl a m matory aneurysms; Circle of Wi l l is, choroidals, Moya moya vessels; vertebrobasilar juvenile; a d u lt, 3 rd/4th decades ischemic; hemorrhage poor; 73%; 2 yea rs M RI/A; DSA no di rect; indirect STA-MCA bypass

you nger; encephalomyosynangiosis; encephalodu roa rteriosyna ngiosis; omental pedicle tra nsposition m . With surgical treatment, the prog nosis i s good g in 58%. n. G u ideli nes for ma nagement of not asym ptomatic moya moya have n been esta blished.

85.8.1

85.8.2

85.8.3

85.8.4

85.8.5

85.8.6

85.8.7

Special Conditions •

467

Extracranial-l ntracra nial ( EC/ IC) Bypass 9. a.

EC/ IC bypass: EC/ IC bypass study was publ ished in

b. Study critics highlight study's fai l u re to disti n g u ish between h vs. t ca uses of stroke. c. Imaging technolog ies introd uced si nce the study can now identify f d ischemia. d. Misery perfusion o e f increases when a u n a ble to mai nta in adequate c b f to meet m d e. Cu rrent ind ications for EC/ IC bypass include patients with m p , certain a t disease. , and m f. Bypass g rafts: i. Ped icled a rterial g rafts include: s a rteries and o that a re considered I flow. ii. R a rtery g raft that is flow. m to h iii. s vein g raft that is h flow and associated with I g raft patency rates. =

85.9. 1

1 985 hemodynamic; throm boembolic flow-dependent oxygen extraction fraction; a utoreg u latio n ; cerebral blood flow; meta bolic demands misery perfusion; aneurysms, tumors; moya moya STA; occi pita l ; low Rad i a l ; moderate to high Saphenous; high; lowest

g

86 Cerebral Arterial Dissections

•

General I nformation 1. a.

B

b. c.

Key concepts: Hemorrhage between i and layers of vessel wa l l . m Ca n present with p H , or ,T s

Ca uses include s t ' or i d. Extracranial d issections usually treated m e. I ntracranial dissections with S a re treated with s

•

SAH ; su rgery

Sites of Dissection Sites of dissection: Most common site is v a %. b. Basilar/ICA/ M CA %. c. ACA/ PCA/ PICA %.

2. a.

'

•

86. 1

intim a ; media pa i n , Horner's synd rome, TIA/stroke; SAH sponta neous, tra u m a ; iatrogenic medica l ly

86.5

vertebral a rtery, 60% 30% 1 0%

Eval uation Imaging: CTA m a y obviate need for D D is the defi nitive diag nostic study. c. Pathog nomonic sign on DSA is d I s d . Most helpfu l M R I sequence is T s with f

3. a. b.

86.7

DSA DSA double l u m en sign Tl WI with fat suppression

Cerebral Arterial Dissections •

Overal l Outcome 4 . Outcomes: a. Overa l l morta lity is %. % have a favora ble outcome. b. c. Mortal ity is higher i n I lesions ( %) than in v lesions ( %).

•

469

86.8

26% 70% ICA (49%); vertebral (22%)

Vessel Specific I nformation Complete the following about carotid dissections: a . Most com monly caused b y t b. The most common i n itia l symptom is i h c. May also present with H synd rome.

5.

6. Complete the following about vertebral dissections: a . Most com m only caused b y t and so most com monly located within e portion of vertebral a rtery. b. I ntracranial dissection can present with s

c. Treatment is genera l ly medical with a a re equally effective. d. A or s treatment is e. E recommended for i dissections. f. Endovascu lar treatment is indicated is when m t ineffective, medical thera py is c , or when there is s -I s f

86. 9 . 1

tra u m a ipsilatera l headache

B

Horner's 86.9.2

tra u m a ; extracranial SAH a nticoag u l ation Anti platelets Endovascu l a r; surgica l ; intracranial medical therapy; contraind icated ; sym ptomatic flow-limiting stenosis

Neurosurgery Books

87 Intracerebral Hemo rr hage

•

I ntracerebral Hemorrhage in Adu lts 1.

a. b.

Intracerebral hemorrhage key concepts: Accou nts for % o f strokes. Presentation d iffers from ischemic infa rct beca use it inclu des h , a nd a v Hem atoma v correlates with morbid ity and morta l ity. Hematoma enlarges in at least % of cases with in fi rst hours of onset. Angiography is recom mended except in patients older than yea rs old and with preexisti ng h ,p hematoma in t f or p _

_

_ __ _

87.2

1 5-30% headache, vomitin g ; a ltered consciousness

_ __ _

c. d.

vol u m e 33%; 3

____ ____

e.

_ _ _ _

45; hypertension; tha l a m us, putamen; posterior fossa

_ _ _

•

Epidemiology 2. Risk factors: a . Incidence increases sign ifica ntly after age and d with each decade of age u ntil age 80. b. Preventable risk factors include a c ,c d ___

___

_ _ _

___ _

87.3.2

55; doubles a lcohol consumption, ciga rettes, d rugs

Intracerebral Hemorrhage •

Locations of Hemorrhage within the Brain 3.

a.

Locations of intracerebral hemorrhage: Hypertensive hemorrhage sites of pred ilection a re: i. b g % % ii. t iii. p , _% iv. c % v. c w m , _ - _% vi . b , _ - _% Most common location for deep and is due to hematoma is p ru ptu re of I a _ I n cidence of lobar hemorrhages is _ ­ _% Compared with deep hemorrhages, lobar hemorrhages have a b prog nosis. _ _ _ _

87.4. 1

basal ganglia; 50%

____

____

____

____

b.

____ -

_ _ _ _

thalamus; 1 5% pons; 1 0-1 5% cerebe l l u m ; 1 0% cerebra l white matter; 1 020% brainste m ; 1 -6% putamen; lenticu lostriate a rteries

_ _

c. d.

1 0-30%

87.4.2

better

_ _ _

•

Etiologies 4.

a. b. c. d.

List the causes of lobar hemorrhage: ( H int: teach it) t. e of d ___ __ a a c m _ _ _ _

_

____

_ _ _

__ _

e. h f. i g . t.

____

c

__ _

___ _ ___ _

Hemorrhagic transformation of an ischemic infarct: a . Estimated t o occur in % b. within the fi rst m c. and may occur with in hours.

87.5.2

tumor extension of deep ICH amyloid a n g iopathy cerebrovascu lar ma lformation hemorrhagic conversion idiopathic tra u m a

5.

____

6 . Coagulation disorders and intracerebral hemorrhage: a . Incidence o f symptomatic I C H with in 36 hours of treatment with rtPA is _%. b. Aspirin is associated with increased risk of ICH at a rate of I than % per yea r. ____

87.5.2

43% month 24 87.5.2

2-4% less than 1 %

47 1

E

472 7.

a.

8.

a. b. c.

Part 20: Intracerebral Hemorrhage Infection and intracerebral hemorrhage: 3 types o f infection that pred ispose to ICH: i. f ii. g iii. h s Hypertension and intracerebral hemorrhage: Hypertension is a risk factor for hemorrhage in what 2 locations? It is not a risk factor for at least % of basa l ganglia hemorrhages. a -B c a re the sou rce of some hypertensive hemorrhages.

9. Amyloid angiopathy: a. Present in % of patients over yea rs old, but most do not h b. Accou nts for % of ICH cases. c. Should be suspected in patients with hemorrhages in the location . d . Associated with deposition o f b a that a ppears on pola rized a g light as b E. e. Genetic link is a f. Is not associated with s a 1 0. a.

b.

Hemorrhagic brain tumors: Pri mary bra i n tumors associated with ICH include g m and I Metastatic tumors associated with ICH include I ,c m , and r c

1 1 . Anticoagulation and intracerebral hemorrhage: a . Incidence o f bleeding compl ications in patients on a nticoa g u lation is % per yea r. b. Incidence of intracerebra l hemorrhage is % per yea r. c. Mortal ity in the intracerebral hemorrhage g roup is %. _

87.5.2

fu ngal g ra n u lomas herpes simplex

pons; cerebe l l u m

87.5.4

35% Cha rcot-Bouchard aneurysms

87.5.5

87.5.6

50%; 70; hemorrhage 1 0% recu rrent; lobar beta a myloid; birefringent apple g reen Apolipoprotein E systemic a myloidosis 87.5.7

g lioblastoma m u ltiforme; lym phoma l u n g , chorioca rci noma, melanoma; renal cel l 87.5.8

1 0% 0.3- 1 .8%

_

65%

Intracerebral Hemorrhage •

Clinical 1 2.

a.

Clinical presentation of intracerebral hemorrhage: U n l ike embol ic/ischemic stroke, the neurolog ica l deficit with ICH has p onset over m to h Thalamic ICH is usually associated with h loss, m loss if i c is compressed , and e signs with upper b extension. Thalamic ICH > em has high morta lity. Cerebel l a r I C H prod uces c before h d u e to b compression.

prog ressive; m i n utes; hours

87.6. 1

___

b.

c. d.

_ ___

__ _

1 3. a.

b. c. d. e. f.

Rebleeding: Rebleed ing is more com mon with g ICH than b I ICH. I n cidence d with time. _% in first 1 -3 hours. % in 3 - 6 hours. sign on CTA correlated with S increased risk of ICH expa nsion. I n cidence of late rebleed ing is _ ­ _%. ____

Edema and intracerebral hemorrhage: Edema can cause delayed d after ICH. b. The component that is released by clot and presu med to be the most likely cause of s u rrounding delayed edema is t

1 4. a.

hemisensory; motor; interna l capsule; eye; brainstem

87.6.3

3.3 com a ; hemiparesis; brainstem 87.6.4

basal ganglia; lobar decreases 33-38% 1 6% Spot 1 . 8-5.3% 87.6.4

deterioration thrombinin

___ _

•

Eval uation 1 5.

a. b. c. d.

Evaluation of intracerebral hemorrhage: I C H vol u m e is approximated b y the e method. Form u l a is On average, clot size decreases .m m/day Density decreases Hounsfield u n its/day ___ _

ellipsoid (AP x LAT x HT)/2 0.75

____

____

2

87.7 . 1

473

Part 20: Intracerebral Hemorrhage

474

e. With I

change for the fi rst weeks. f. List the seq uence of hemoglobin evol ution after ICH: {Hint: On days my mom's home) i. 0 0 to 1 day ii. d 1 to 3 days iii. m 3 to 7 days 7 to 1 4 days iv. m v. h 1 4 plus days

little; 2 Ta ble 8 7 . 4

oxyhemoglobin deoxyhemoglobin methemoglobin methemoglobin hemosideri n

1 6. a.

ICH score: Give t h e n u m ber o f points for the fol lowing factors: i. GCS 3-4: poi nts ii. GCS 5-1 2 : points poi nts iii. GCS 1 3- 1 5 : iv. Age > 80: points v. Age < 80: points vi . lnfratentorial location: points vii . Supratentorial location: points poi nts viii. Vol u m e > 30 cc: ix. Vol u m e < 30 cc: poi nts IVH present: X. poi nts b. Give the 30-day morta l ity based on ICH score: % i. 0 points % ii. 1 points % iii. 2 points % iv. 3 points % v. 4 points % vi . 5 poi nts vii . 6 poi nts %

E

•

Ta ble 8 7 . 5

2 1 0 1 0 0 1 0 1 Ta ble 8 7 . 6

0% 1 3% 26% 72% 97% 1 00% 1 00%

Initial Management of ICH 1 7. a.

b. c. d. e.

Medical management: Red u ce M A P t o pre-morbid level if % if u n known . known or by Sugg ested ta rget BP is Platelet goal is > Most studies suggest that resu mption of a nticoa g u lation after ICH is s Proba bil ity of ischemic stroke 30 days fol lowing cessation of wa rfa rin for 1 0 days: i. % for those treated for prosthetic heart valve ii. % for AFi bb % for ca rdioembolic iii. stroke

20% 1 40/90 l OO K safe

2.9% 2 .6% 4.8%

Neurosurgery Books

87. 8 . 1

87.8.2

87.8.4

Intracerebral Hemorrhage •

475

Surgica l Treatment 1 8. a.

Surgical management: Indications for surgery: ICH with significant m i. e ii. ICH with s iii. ICH vol u m e iv. I and c locations age v. y b. Surgery is recommended for cerebellar ICH if GCS is , size is and h present. _ _ _ _

87.9.2

mass effect symptoms 1 0-30 cc lobar, cerebel l a r you n g 1 3 or less; 4 em or more, hyd rocephalus

____

•

ICH in Young Ad ults Name the top 5 causes of nontraumatic ICH in young adults (other than " undetermined" which accounts for - 1 /4): H i nt: AHadt % a. A % b. H % c. a % d. d % e. t

1 9.

•

Ta ble 8 7 . 7

II

AVM , 30% HTN , 1 5% aneurysm , 1 0% d rugs, 7% tumor, 4%

I ntracerebral Hemorrhage in the Newborn 20. a.

b. c. d. e. f.

ICH in the newborn: m prog ressively G u ntil i weeks gestational age. Matrix may persist i n p infa nts and cause hemorrhage. Site of hemorrhage depends on a Between 24-28 weeks, I C H located in of c b 29 weeks or more, ICH located in of c h List the risk factors: ( H int: vespacc) e i. v ii. E iii. s iv. p v. a d vi . c h a by m vii . c

Germinal matrix; involutes; 36

87. 1 2.2

prematu re age body of ca udate head of ca udate vol u m e expa nsion ECMO seizures pneumothorax asphyxia cya notic heart disease coca ine abuse by mother

8 7 . 1 2 .4

E

Part 20: Intracerebral Hemorrhage

476 g.

h. i. j. k.

I. m.

G rading system o f P i. G rade I = s ii. G rade I I = I without v d iii. G rade I l l = I with v d with p iv. G rade IV = I I Hyd rocephalus develops in _ - _% about weeks after ICH. imaging. Diagnosed using u Medical treatments a re n effective. S u rgical options include serial I p ,v v t t ' d a ,s Prerequ isites before s h u nt insertion include infant weight of and CSF protein of Outcomes: i. Mortal ity _ - _% with severe ICH. ii. Hyd rocephalus _ - _% with severe ICH. % a m b u l atory with g rade iii. I I ICH. % IQ normal ra nge with iv. g rade I I ICH. -

-

Pa pile su bependyma l IVH ; ventricle dilation

Ta ble 8 7 . 8

IVH ; ventricle dilation IVH ; pa renchym a i iCH 20-50%; 1 -3 weeks u ltrasound not

87. 1 2.7

8 7 . 1 2 .9 87 . 1 2 . 1 0

l u m ba r puncture, ventricu lar ta p, temporary ventricu l a r access device, s h u nt 2000 g rams or more; less than 1 00 mgfdl 50-65%

Ta ble 8 7 . 9

65-1 00% 1 00% 75%

87 . 1 2 . 1 1

88 Outcome Assessment

•

Cancer. Head I njury. Cerebrovascular Events. Spinal Cord I njury 1.

a. b. c. d.

Matching. Match the following outcome scores with the condition they are designed to assess. Outcome scores: CD Karnofsky; 0 Rancho Los Amigos; G) G lasgow Outcome; @ Mod ified Ra nkin; ® Ba rthel ; ® Functional Independence Measu re; (j) WHO performance score cerebrovascu l a r s p i n a l cord cancer head inj u ry

2. True or False. A higher number indicates better function. a. Karnofsky sca le b. WHO Performance Scale c. Rancho Los Amigos scale d . G lasgow Outcome scale e. Mod ified Ra nkin scale f. Barthel scale g . Functional Independence Measure 3.

On the Karnofsky scale, which score represents the transition from being able to engage in normal activity to only caring for self?

a . 80% b. 85% c. 75% d . 70%

@. ® ® CD. 0 0 . 0)

true fa lse true true fa lse true true d. 70%. There a re no 7 5 or 8 5 scores. 70 ca res for self, unable to ca rry on normal activity or work; 50 req u i res considerable care; and 40 is disabled.

88. 3 . 1 88.4 88.1 88.2

88.1

88.2

88.3

88.4 Ta ble 8 8 . 1

g •

IB

89 Differential Diagnosis by Location or Radiographic Finding I ntracrania I

•

Posterior Fossa Lesions 1.

If a solitary intraparenchymal lesion in the p-fossa i n an adult i s seen, a m must be ruled out.

metastasis (from an extracranial primary maligna ncy)

2.

The most common primary intra-axial p-fossa tumor in adults is h

hemangioblastoma

Complete the following about hemangioblastomas: a . Account for % of p-fossa tumors. on M RI . b. Usually see s v

3.

_ _

5.

a. b.

Multiple lesions in the cerebellum can be suggestive of: m h associated with v a c m

89.2 . 1

89. 2 . 1

7 - 1 2% sig nal voids (serpentine appeara n ce)

4.

Besides embolism and thrombosis of a plaque, 2 other etiologies for a cerebellar stroke are: a. v a d b. v h

89.2 . 1

89. 2 . 1

vertebral a rtery dissection vertebrobasilar hypoplasia 89. 2 . 1

metastases hemang ioblastomas; VHL

_

c. d.

are the 6. As a group, a most common pediatric brain tumors in the p-fossa.

a bscesses cavernous ma lformations astrocytomas

89.2 . 1

-

Differential Diagnosis by Location or Radiographic Finding - Intracranial 479 7. The following 3 types of tumors account for the majority of infratentorial tumors in patients less than 1 8 years of age: a. P including m : _% (of infratentorial tumors) including p b. a a % _% c. b g, ___

_ _ _ _

______ ____

8.

a. b.

__

____

The following facts help differentiate medulloblastomas and ependymomas: "Banana sig n " is seen with G row from a nterior aspect of 4th ventricle Tend to g row from floor of 4th ventricle. Tend to be i n homogeneous on Tl WI M RI . Ca lcification i s com mon. _ _ _ _ _

89.2 . 1

PN ET; med u l loblastoma: 27% astrocytomas; pilocytic astrocytom a : 27% brainstem g l iomas: 28% 89.2 . 1

med u l loblastoma med u l loblastoma

_ ____

c. d. e.

ependymomas ependymomas ependymomas

9. Complete the following about CPA lesions: a . Acoustic neuromas a re more accu rately vestibular schwa n nomas; known as v 80-90% s. and occur i n to _% of CPA lesions. 5 - 1 0% b. Meningioma occu rs in _ to _% of CPA lesions. c. Epidermoid occurs in _ to _% of CPA 5-7% lesions.

89.2.2

_ _ _ _ _

1 0.

a. b. c. d. e. f.

Match the tumor with the characteristic finding: CD vestibular schwannoma; 0 meningioma Cha racteristic: (a-f) below Hearing loss occurs ea rly. Facial weakness occu rs ea rly. I ntern a l a u d itory ca n a l is enlarged. Calcifications seen more com mon ly. Represents 90% of CPA tumors. Homogeneous signal and enhancement.

Match the cystic lesions of the CPA which its characteristic findings: CD a rachnoid cyst; 0 epidermoid cyst; G) dermoid cyst; 0 cholesterol g ra n u loma Cha racteristic: (a-d) below a . H i g h sig nal on Tl WI and h i g h sig n a l o n T2WI and associated with bone destruction. b. Cystic component has same intensity as CSF.

89.2.2

CD 0 CD 0 CD 0

11.

89.2.2

CD

Neurosurgery Books

IB

480

Part 22: Differential Diagnosis

c.

High sig n a l on DWM RI d ifferentiates this from a rachnoid cyst. d . Tl W I i ntensity similar t o fat a n d usually midline. 1 2. What are some differentiating features that distinguish neuromas of the V, VII, and VIII cranial nerves? a . N e u romas o f C N _ ca n pass through the tentoria l hiatus medial ly. b. N e u romas of CN ca n cross into the middle fossa via the petrous a pex. c. N e u romas of CN can cross the mid petrosal bone. 1 3.

a. b. c. d.

•

Complete the following about foramen magnum lesions: (extra-axial vs. Most a re intra-axial.) A mass behind the dens com pressing the u ntil proven spinal cord is a c otherwise. The second most common site of orig in of posterior fossa meningiomas is the a I _ of the fora men magnum c p is u s u a l ly a n ea rly symptoms of lesions i n this location. __

0 ® 89.2.2

CN VI I I CN V CN VI I 89.2.4

extra-axia I chordoma a nterior lip Craniocervica l pain

M ultiple I ntracranial Lesions on CT or M RI Infectious causes of multiple intracranial lesions on imaging include: a. t b. fu ngal etiologies including: i. a ii. c iii. c iv. c c. Pa rasitic etiolog ies including: i. e ii. s iii. p

1 4.

Complete the following about multiple intracranial lesions on imaging: a . What percentage o f g liomas are mu lticentric? b. HSV usually occu rs in the t lobe. c. MS lesions a re located i n the a rea. p

89.3

toxoplasmosis asperg i l losis coccidiomycosis cryptococcus ca ndid iasis ech inococcus schistosom iasis paragonimiasis

1 5.

____

89.3

6% tem poral periventricu l a r

Differential Diagnosis by Location or Radiographic Finding - Intracranial 481 d.

D u ra l s i n u s throm bosis ca n cause i, mu ltiple v M u ltiple "hypertensive" hemorrhages is a likely due to a

venous infa rcts

_ _ _ _

e.

amyloid angiopathy

__ _ _ _

•

Ring-Enha ncing Lesions on CT/ M RI 1 6. What are the classic etiologies for ring-enhancing lesions on imaging? (hint: MAG I C DR. L) a. M b. A c. G d . 1. e. c f. D g . R. h . L. _ _ _ _ _

_ _ __ __

_ __ _

_ _ _ _ _

_ _ _ _ _

_ __ _ _

_ _ _ _

•

M etastases Abscess GBM I nfa rction Contusion Demyelination Radiation Lym phoma (primary vs. metastatic)

White Matter Lesions 1 7.

a. b. c. d. e.

•

89.4.3

List conditions that can affect the corpus callosum: m G I I a d

89.5.2

m u ltiple sclerosis GBM lym phoma lipoma diffuse axonal inj u ry

Sellar, Suprasellar and Parasellar Lesions 1 8.

The most common enhancing pituitary lesion in adults is a a p

pitu ita ry adenoma

1 9.

The most common sellar and parasellar lesions in children are and c g

craniopharyngiomas and germinomas

20. Regarding pituitary tumors. a . Adenohypophysea l tumors include and pitu ita ry a c b. N e u rohypophyseal tumors include , a nd ,p m a c. What is the most common tu mor found i n the posterior pitu ita ry?

89. 6 . 1

89. 6 . 1

89.6.2

adenomas, ca rcinomas metastases, pituicytomas, and astrocytomas metastases (most common primaries a re l u n g and breast)

482

Part 22: Differential Diagnosis

21 . The pituitary gland can normally be slightly enlarged in w of age. c

women of child bearing age

89.6.2

_______

22.

a. b. c.

Complete the following about pituitary hyperplasia: Thyrotroph hyperplasia is most likely d u e to Gonadotroph hyperplasia is most likely due to Somatotroph hyperplasia is most l i kely due to Lactotroph hyperplasia is most l i kely d u e to _ __ _

d.

89.6.2

primary hypothyroidism primary hypogonadism ectopic G H - RH secretion

_ ___

preg nancy

__

23. a.

Suprasellar germ cell tumors are: more common in (men vs. women) b. triad of d p , a nd v d _ __ _

____

_ _ _ _ _

__ _ _ _

89.6.2

women (pineal reg ion more common in men) dia betes insipidus, pan hypopitu ita ris m ; visu a l deficits

Complete the following about juxtasellar masses: a . Craniopharyngiomas account for _% of 20%; 54% tumors in this reg ion in adu lts and _% in childre n . gadolinium b . T o d ifferentiate mening iomas from pitu ita ry adenomas, use g c. On imaging, meningiomas demonstrate: i. Enha ncement? bright homogenous enha ncement ii. Epicenter is s. suprasel l a r t d u ra l tai l iii. May see d iv. Is sel l a r enlarged or not enlarged? Usually n o t enlarged ca rotid a rteries v. Tend to encase

24.

89.6.2

_ __ _

___ _

__

_ ___ _ _ _

25.

a.

Pituitary hypophysitis and adenomas can be distinguished by the following: (hypophysitis vs. adenoma) Sym metric enlargement is most often seen with Sel l a r floor may be eroded with . Enha ncement more intense with Pitu ita ry sta lk thickened with Associated with preg nancy

hypophysitis

Ta ble 8 9 . 2

adenoma hypophysitis hypophysitis hypophysitis

89.6.4

_ _ _

b. c. d. e.

__

__ _

26. True or False regarding lymphocytic hypophysitis: a. May cause hypopitu ita rism. b. Most cases a re seen in men.

c.

Req u i res su rgery for treatment.

d.

May prod uce dia betes insipidus.

89.6.6

true fa lse - in women in late preg nancy or ea rly post­ partum period fa lse - treatment with steroids true

Differential Diagnosis by Location or Radiographic Finding - Intracranial 483 •

I ntracranial Cysts 27.

a. b. c. d.

Complete the following about arachnoid cyst: a ka l c Due to a d of the a Reach maxi m u m size in _ month(s). N eed su rgery in about _% of cases. ______

_ _ _

Complete the following about cavum septum pellucidum: a . Present in all p b and 97% of n b. Present in _% of a d u lts. c. What is it?

89 . 7 . 1

leptomeningeal cyst d u plication ; arachnoid 1 month 30%

28.

____ _ __

__ __ __ __ __

d.

Seen in c t e

_______

_____

suffering from

__ _ ____

__ __ __ __ __ ____

29.

Cavum vergae is located posterior to and communicates with c._____ s p_________

prematu re babies; newborns 1 0% Va ria ble sl it- l ike fl uid-fil led space between the leaflets of the left and right septu m pel l u cid u m . boxers; chronic tra u m atic enceph a lopathy cavu m septu m pel l u cid u m (CSP)

Ta ble 89.3

89.7.3

Ta ble 89.3

______

Complete the following about cavum velum interpositum: of the a. Due to separation of the c f b. between the t and the t _v c. Present in _% of chi l d ren less than 1 yea r of age. d . Present in % of children between 1 and 1 0 years old

30.

_____

___

___

•

_ _ _ _

Ta ble 89.3

cru ra ; fornix tha l a m i ; third ventricle 60% 30%

Orbital Lesions 31 .

cavernous hemangioma; The most common benign primary melanoma intraorbital neoplasm is c h . The most common primary intraocular malignancy in adults is m

89.8.2

__ __ __ __ _

Complete the following about orbital and ocular lesions: a . T h e most common orbita l lesion in children is a d c b. The most common malig n a nt tumor of the orbit in this age g roup is r c. The most common primary intraocular maligna ncy in children is r

32.

_ __ __

_ __ __ __ __ __ __ ____

__ __ __ ___

89.8.3

dermoid cyst rhabdomyosa rcoma reti noblastoma

IB

Part 22: Differential Diagnosis

484 33.

a. b. c. d. e. •

Match the orbital lesions with their characteristics. (multiple answers may be correct for a given characteristic) CD ca pillary hemangioma; (?) lymphangioma; ® lym phoma; @ thyroid ophthalmoplegia Cha racteristic: (a-e) below infantile proptosis reg ress sponta neously do not reg ress pain less proptosis bilatera l 80% of the time

89.8.2

CD. 0 CD 0 ®. @ @

Sku l l Lesions Complete the following about skull lesions: a . T h e most common benign tumors o f the and h sku l l a re o b. The most common malignancy of the sku l l is o s

34.

35.

a. b. c. d. e. f.

Complete the following about characteristics of skull lesions: M u lti pl icity suggests m Expa nsion of di ploe suggests a b lesion. Peripheral sclerosis suggests a b lesion . Fu ll-thickness lesions suggest m M u ltiple sharply demarcated and punched-out defects suggest m m Presence of peripheral vascu lar channels lesions. is highly suggestive of

36. Complete the following: a . Which sku l l lesion demonstrates a i. tra becu lar pattern? ii. s u n b u rst pattern? iii. islands of bone pattern? iv. tenderness to pal pation?

b.

Eosinophilic g ra n u loma is the mildest form of L c h

89 . 1 0. 1

osteomas, hemangiomas osteogenic sarcoma 89 . 1 0. 1

maligna ncy benign benign maligna ncy mu ltiple myeloma benign 89 . 1 0. 1

hemangioma hemangioma fi brous dysplasia La ngerhans cel l histiocytosis lesion La ngerha ns cel l histiocytosis

--

37. The following can cause diffuse demineralization or destruction of the skull: a. h b. m c. m m d. 0

89. 1 0. 3

hyperpa rathyroidism metastases m u lti ple myeloma osteoporosis

Neurosurgery Books

Differential Diagnosis by Location or Radiographic Finding - Intracranial 485 38. The following can cause diffuse or generalized increased skull density: a. a b. f d c. h g m d. 0

e.

p

d

39. A pneumocele is an enlargement of an (has that s a vs. does not have) bone erosion. Pneumosinus dilatans is an enlargement of an a_ s___ that (has vs. does not have) bone erosion.

•

Can intra-axial lesions grow out of the skull?

air sinus; has; air sinus; does not have

89. 1 0.9

Typical ly, no. However, a fu ngating malig nant glioma may do this.

89 . 1 1

I ntracranial Hyperdensities 41 . What can cause an intra-axial structure to appear hyperdense with respect to normal brain tissue on a non-contrast CT? a. a b b. c. f v c. I d. m _ __

___ _

__

__

_ _ _

____ _

•

anemia fi brous dysplasia hyperostosis interna generalisata osteoblastic metastases (prostate and breast) Paget's d isease

Com bined l ntracrania i / Extracranial Lesions 40.

•

89 . 1 0 . 5

89. 1 2

acute blood ca lci u m low flow vessels melanoma (melanin ca n appear hyperdense)

I ntracranial Calcifications 42. The following are physiologic causes of localized intracranial calcifications: a. c p b. a g s c. d d. d e. p g __

--

89 . 1 3 . 1

choroid plexus a rachnoid g ra n u l ation diaphragma sel lae d u ra pineal gland

43.

Choroid plexus calcifications have the following features: a . _% of patients by 5th decade of life demonstrate calcifications. b. Ca lcifications a re ra re under age _.

89 . 1 3 . 2

75% age 3

486 c.

Part 22: Differential Diagnosis If ca lcifications present under age 1 0, consider c p

choroid plexus papilloma

_ _ _ _

P· ----

d . I f ca lcified , choroid plexus in the tem pora l horn, then consider n

neurofibromatosis

____ _

44.

a. b.

Complete the following about basal ganglia calcifications: Common in e Ca uses include: i. h use ii. a iii. F disease Correlated with psychiatric diseases if > em. __ _

_ _ _ _ _ _ _

___

c. 45.

Fahr's disease involves progressive of the idiopathic c g b , s. of cerebral cortex, and d d n. _ _ _

89 . 1 3 . 2

elderly hyperpa rathyroidism a nticonvu lsant use Fa h r's disease 0.5 em ca lcification; basal ganglia (medial portions), su lca l depths; dentate nuclei

89 . 1 3 . 2

___ _

•

I ntraventricu lar Lesions 46.

a. b. c. d. e. f. g. h. i. 47. a.

Complete the following about intraventricular lesions: What is t h e most common lesion? Lesion at the fora men of Monro? 3 rd ventricle lesion with punctate ca lcifications? Fil l s the 4th ventricle with "banana sign"? Most common low density 4th ventricle lesion? Free-floati ng fat in ventricles? H a s fat and calcifications? At t h e septum pel l u cid um? Densely enhancing with calcifications?

Intraventricular meningiomas are: Usually a rterial su pply from a c a rtery b. Less com mon a rterial su pply from p m c artery and I p c a rtery. c. Tumor thought to a rise from cells.

_ _ _ _

_ _ _ _

_ _ _ _

89. 1 4. 2

astrocytoma col loid cyst cra niopharyngioma med u l loblastoma epidermoid dermoid with cyst ru ptu re teratoma centra l neu rocytoma meningioma 89. 1 4. 2

a nterior choroidal artery medial posterior choroidal a rtery, latera l posterior choroidal a rtery a rachnoid cap cel l s

Differential Diagnosis by Location or Radiographic Finding - Intracranial 487 48.

a. b. c. d. e.

Match the tumor that is found most often in the following ventricles: CD astrocytoma; 0 med u l l oblastoma ; ® meningioma; 0 ependymoma; ® col loid cyst; ® epidermoid; (j) dermoid ; ® teratoma Ventricle: (a-e) below 3 rd ventricle 4th ventricle atri u m of latera l ventricle fronta l horn o f latera l ventricle body of latera l ventricle

49. The following are lesions that can be found in the posterior of the 3rd ventricle: a. p b. m c c. a of G of v d. a __

50. Which masses within the lateral ventricles do not enhance? a. c b. d c. e d. s ___

•

Ta ble 89.4

® 0 ® CD

0 89. 1 4. 3

pinealoma meningioma a rachnoid cyst aneurysm of vein of Galen 89. 1 4. 3

cysts dermoids epidermoids su bependymomas

g

Periventricular Lesions 51 . What is the differential for a periventricular solid enhancing lesion? lym phoma a. I ependymoma b. e c. m metastases med u l loblastoma d. m in child e. p pineal tumor t f. G GBM

89 . 1 5 . 1

52. What are some etiologies of lowdensity periventricular lesions? e a. t s b. m a c. s e

89 . 1 5 . 2

--

d.

transependymal edema m u ltiple sclerosis su bacute a rteriosclerotic encephalopathy (aka Binswa nger's disease) leukoara iosis

488 •

Part 22: Differential Diagnosis

Ependymal and Su bependymal Enhancement 53. What is the differential for ependymal and subependymal enhancement? (Hint: some overlap with periventricu lar lesions) a. v b. c m __ _ _ _

_ _ _ _ _ _

c. m d . t.

____

____

54.

•

s

_____

_____

a.

In immunocompromised patients, what do the following patterns suggest? thin linear enhancement

b.

nod u l a r enhancement

a.

Complete the following about intraventricular hemorrhage: Most occur as a result of of

I n the a d u lt, this may orig inate in the t or p ii. I n a newborn, this may orig inate in the s b. Aneu rysms account for a bout _% of IVH in a d u lts. c. What a re the typical locations of an i nvolved aneurysm? i.

•

ventricu l itis ca rci nomatous meningitis (would see meningeal enha ncement as wel l ) m u ltiple sclerosis tuberous sclerosis (su pependymal hamartomas) 89. 1 7

vira l infection (CMV, va ricella­ zoster) CNS lym phoma

I ntraventricular Hemorrhage 55.

IB

s

89. 1 7

89 . 1 8

extension of intra parenchym a l hemorrhage tha lamus, puta men su bependym a l reg ion 25% a-co m m , dista l basilar a rtery, ca rotid term in us, vertebral a rtery, distal PICA

Medial Temporal Lobe Lesions 56. The most common medial temporal lobe lesions are: a. h b. m t s c. g _ _ _ _ __

_ _ _ _ _

89 . 1 9

hamartoma mesial temporal sclerosis

__ _ _ _ _ _ _

g l ioma

Differential Diagnosis by Location or Radiographic Finding - Intracranial 489 •

I ntranasa l / I ntracranial Lesions 57.

a. b. c.

d.

e.

Complete the following about intranasal/intracranial lesions: is a fu ngal infection M seen primarily i n dia betics or i m m u n ocom p rom ised patients. Nasopharyngeal carcinomas a re associated with infectio n . As u c (aka ) is a n agg ressive ca rcinoma that may invade i nto the frontal fossa and cavernous sinus. a rises from crest E cells of the nasal va u lt a n d often demonstrates intracranial invasion. Typica lly presents with e or n o A nasal polypoid mass i n a newborn should be considered an e u ntil proven otherwise. It ca n be disti n gu ished by a nasal g l ioma beca use it is often and s with the p Va lsa lva maneuver. _ __ _

__ _ _ __

89.22

M u cormycosis EBV sinonasal und ifferentiated ca rci noma; SNUC

Esthesioneuroblastoma; epistaxis; nasal obstruction encephalocele; pulsatile; swells

_____

Neurosurgery Books

90 Differential Diagnosis by Location or Radiographic Finding Spine

•

Atlantoaxial Subluxation 1 . What are the disease processes causing atlantoaxial subluxation? a . incom petence o f t h e ligament i. r a ii. t. iii. c _ _ _ _

90.2

tra nsverse atlanta l liga ment

_____

_ ____

___

___

_ _ _ _

use iv. chronic v. chronic b. incom petence of the ___

______

infections

_ _ _ _ _

i. f ii. 0_ 0 iii. r a iv. erosion by t. v. M synd rome _ _ _ _ _

_ ____ _ ____

_ _ _

__

d

vi . c vii .

_ _ _ _

2 . Complete the following about atlantoaxial subluxation: a . Incom petence o f t h e liga ment interva l . b. resu lts in increased _ _ _

rheumatoid a rth ritis tra u m a congen ita l laxity (esp. with Down synd rome) steroid retropharyngeal odontoid process fractu re os odontoideum rheumatoid a rth ritis tumor Morquio syn d rome (hypoplasia of dens) congenita l dysplasia infection 90.2

tra nsverse atlanta !

___

3 . Complete the following regarding differential diagnosis by location: a . Morquio synd rome is hypoplasia o f the

b. c.

d u e to a m It may resu lt in

_ _ _ _ _ _ _ _ ___

subl uxation.

atlantodental 90.2

dens m u copolysaccharidosis atla ntoaxial

Differential Diagnosis by Location or Radiographic Finding - Spine •

Abnormalities in Vertebral Bodies 4. What are 8 malignancies that have a tendency to metastasize to the vertebral bodies? 5.

a.

General differential for vertebral body lesions: n ___ _

b. c. f d. d e. m P and a

_ _

___

changes diseases including disease, o s

______

•

_ ____

_ ____

90.3

90.3

neoplasm (metastatic vs. primary) infection (osteomyelitis vs. discitis) fatty infi ltration degenerative changes meta bolic; Paget's d isease, osteoporosis, a n kylosing spondyl itis

Pathologic Fractures of the Spine 6. What are the 6 criteria for vertebra plana? What are 3 etiologies that may lead to this phenomenon? a. Criteria :

b.

•

prostate, breast, l u n g , ren a l cel l , thyroid , lym phoma, melanoma, and m u lti ple myeloma

Etiologies:

90.5.3

1 . u n iform colla pse of vertebral body into flat thin disc 2 . increased density of vertebra 3. spares neura l arches 4. normal disc and intervertebral disc space 5 . intervertebral vacu u m cleft sign (pathog nomonic) 6. no kyphosis 1 . La ngerhans cel l histiocytosis 2 . Ca lve-Ku m mei-Verneuil disease (avascu lar necrosis of the vertebral body) 3. hemangioma

Destructive Lesions of the Spine infection (often involves at 7 . I f vertebral body destruction is associated with destruction of the disc least two adjacent vertebra l space, what general etiology is this levels) suggestive of?

90.7.2

491

492 •

Part 22: Differential Diagnosis

Vertebra l Hyperostosis 8. What is the differential diagnosis of vertebral body hyperostosis? a. P b. m including I as wel l as p c i n men and b c in women _ _ _ _____

_ _ _ _

•

a.

Complete the following about sacral agenesis: Sacra l agenesis is also known as

___

b. _-_% have c. I ncreased incidence of a bnorm a l ities.

mothers. ____

90.9

ca udal reg ression synd rome 1 6-20%, dia betic mothers spinal

Enhancing Nerve Roots 1 0. What is the differential for an enhancing nerve root? a. t s u c h as m or l c b. especia l ly if patient has ___

___ _

__ _ _

c.

_____ ____

•

Paget's disease Metastases (osteoblastic); lym phoma; prostate ca ncer; breast cancer

Sacral lesions 9.

•

90.8

or

including

___

__ _ _ _

90 . 1 0

tumor; meningeal ca rcinomatosis; lym phoma infection ; AIDS (consider CMV) infl a m matory; G u i l lain-Ba rre, sarcoidosis

I ntraspinal Cysts 1 1 . What is the differential for an intraspinal cyst? a. s m c n b. c c. e d. s e. dilated c c ---

---

___

---

90 . 1 2

spinal meningeal cysts cystic neu rofi broma ependymoma syri ngomyelia dilated centra l ca nal

91 Differential Diagnosis (DDx) by Signs and Symptoms ­ Primarily Intracranial

•

Syncope and Apoplexy 1.

a. b. c.

d.

Complete the following about the causes of syncope: Preva lence o f syncope is a bout _% a n d is higher in the e I n a bout _% of cases, no cause can be diag nosed. Cerebrovascu lar causes include: i. s h infa rction ii. b iii. v

iv. p a Disorder o f AV n o d e conduction leading to syncope with bradyca rd ia is ca l led

e. Syncope while wearing a tight col lar or while shaving may be due to f.

g.

50%; elderly 40%

91 .3.1

91 .3.2

subarachnoid hemorrhage (most commonly aneurysmal) brainstem infa rction vertebrobasilar insufficiency pitu ita ry apoplexy Stokes-Adams synd rome ca rotid sinus syncope

M ictu rition or cou g h ca using syncope is triggered; syncope and is usually intrathoracic ca l led t associated with elevation in i pressu re. Orthostatic hypotension is defined as a 20; d rop in systolic BP of at least mm 1 0 Hg or diastolic BP of at least mm Hg on standing. __

__

2. When ar e neurodiagnostic tests ( EEG, a scan, M RI, carotid Doppler) warranted in the setting of syncope?

seizu res, a ltered menta l status, Todd 's para lysis, known history of cerebrovascu l a r compromise, new foca l deficits, new language deficits

9 1 .3.3

494 •

Part 22: Differential Diagnosis

Transient Neurologic Deficit 3.

a. b. c. d.

Complete the following about transient neurological deficits (TIA}: B y defi n ition, lasts less than _ hours. Sym ptoms wil l usually subside within (min utes vs. hours) They a re a resu lt of i. Differential for a tra nsient neurologic deficit includes: a i. t ii. m iii. s followed by _____

_ _ _ _

9 1 .4

24 20 m in utes ischemia

transient ischemic attack migraine seizure; Todd's para lysis iv. c s h chronic subdura l hematoma e. TIA-Iike sym ptoms from cerebral anti platelet; amyloid ang iopathy req u i re avoidance of anticoa g u lant a or a medications. __ _ _

_____

______

_____

•

Diplopia 4.

a.

Complete the following regarding the etiology of diplopia secondary to VI nerve palsy:

p b. s c. t.

_ _ _ _ __

____

s

_ _ _ _ __

_ _ _ _

5. The differential for diplopia includes: a. c n p b. i m disease c. G d. m g c a, e. g f. b. g . secondary t o t __ _ _

_ _ _ _

__ _

___

__

_ _ _ __

____ _

___

•

9 1 .6

increased intracranial pressu re sphenoid sinusitis tu mor 9 1 .6

cranial nerve palsies intraorbita l mass G raves' disease myasthenia g ravis giant cel l a rteritis botu lism tra u m a

Anosmia 6.

a. b. c.

Complete the following about anosmia: Most common cause is a severe u

___

Second most common cause is h with a _-_% t occu rrence in severe cases. I ntracranial neoplasms such as g 0 can be a cause. m Congenita l a n osmia is also known as synd rome. K _ _ _ _ _

d.

9 1 .7

u pper respi ratory infection head tra u m a ; 7 - 1 5% olfactory g roove meningiomas Ka l l m a n n synd rome

Neurosurgery Books

Differential Diagnosis (DDx) by Signs and Symptoms - Primarily Intracranial 495 •

Multiple Cranial Nerve Palsies (Cranial Neuropathies) 7.

a.

Complete the following about cranial neuropathies: Congenita l facia l d i plegia is a lso known as M s. It affects which half of the face more? Which other cranial nerves may be i nvolved? Lyme disease ca n cause CN palsy. Affects which half of the face? True or Fa lse. It may also involve other cranial nerves. Tubercu lous meningitis usually i nvolves which cranial nerve first and most frequently? Weber's synd rome involves CN _ a nd c h M i l l a rd-Gubler synd rome involves CN and CN as wel l as c h, A mass in the ventricle may com p ress the f c. causing facial diplegia.

Mobius synd rome

91 .8.1

_ _ _

b. c. d. e. f. g. h.

u pper half CN VI, Ill, or XII CN VII ( u n i latera l or bi latera l ) lower half Fa lse CN VI CN Ill and contra latera l hemiparesis

_ _ _ _ _ _ _

i.

CN VI and VII; contra latera l hemiparesis

____ __ __ __ _

j.

___

____ __ __

8. Complete the following about cavernous sinus syndrome: a . Which cranial nerves ca n b e involved with a lesion in the cavernous sinus? _ b. Clinica l symptoms include d d u e to o c. With CN _ palsy in cavernous sinus synd rome, the pupil (wi l l vs. wi l l not) b e dilated . ____

______________

___

9.

a. b. c. d.

Complete the following about osteopetrosis: Also known as m b It is a g disorder involving defective o resorption of bone. Patients wi l l have (increased vs. decreased) bone density. Most common neurologic man ifestation is b Treatment consists of bi latera l o n decompression . _____

_______

___

4th ventricle; facial col liculus

9 1 .8.2

CN Ill, IV, Vl , V2 , and VI d iplopia ; optha l moplegia CN I l l ; wil l not 9 1 .8.2

marble bone genetic; osteoclastic increased blindness

_ _____

e.

____

_______

91 .8.2

optic nerve

496 •

Part 22: Differential Diagnosis

Binocu lar Blind ness 1 0. What is the differential diagnosis for new onset binocular blindness? I a . bilatera l o dysfu nction secondary to either t or i b. s c. m d. p 0 n e. bilatera l v h such as f. f disorder _ _ __

_ _ _ _

___ _

--

•

9 1 .9

occi pita l lobe; tra u m a ; ischemia seizures {Epileptic blind ness) migrai nes posterior ischemic optic neuropathy vitreous hem orrhage fu nctional; conversion

Monocular Blind ness Complete the following about temporal arteritis: a. Also known as g c. a b. Usually d u e to ischemia of the: i. 0 n ii. 0 t r a iii. c (less likely)

11.

__ _

91 . 1 0

giant cel l a rteritis

___ _

•

optic nerve optic tract centra l reti nal a rtery

Exophthal mos 1 2.

Complete the following about exophthalmos: a . Also known as p b. If history of tra u m a , d ifferential should f include c c c. If fol lowing fronta l-orbita l surgery, differential should include o defect. _ __

___

proptosis ca rotid cavernous fistula

91 .1 1 . 1 91 . 1 1 .2

_ _ _ _

orbita l roof defect

___

____

1 3. What is the differential of pulsatile exophthalmos? f a. c c b. o r d with tra nsm itted intracranial pu lsations c. v t

_ _ _ _

__ _ _

91 . 1 1 .2

ca rotid cavernous fistula orbita l roof defect vascu lar tumor

Differential Diagnosis (DDx) by Signs and Symptoms - Primarily Intracranial 497 •

Ptosis 1 4. What is the differential diagnosis for etiologies causing ptosis? a. c. _ _ __

b. t to eyelid palsy or seen in H c. CN synd rome d. m g e. b f. mechanical obstruction secondary to t or extension of m from fronta l sinus g. d induced __

_ _ _ _

__

_ _ _

_ _ __

__

•

91 . 1 2

congenita l (often a utosomal dominant inherita nce) tra u m a CN I l l ; Horner's synd rome myasthenia g ravis botu lism tumor; mucocele d rug (alcohol, opi u m , etc.)

Tinnitus Complete the following about pulsatile tinnitus: a . Most cases o f pu lsati le ti nnitus a re d u e to v lesions. b. Worku p incl udes: M and a

1 5.

___

_ _ _ _

1 6. What is the differential for nonpulsatile tinnitus? a . occlusion o f e e m, b. o c. M d d. I e. e tumors f. Drugs such as s q , and a ____

__

_ _ _ _

_ _ _ __

_ _ _ _ _ ____ _

__ _ _ _ _

__ _ _ _ _ _ _

•

91 . 1 5.2

vascu l a r M RI (with and without enhancement); ang iogram 9 1 . 1 5.3

external ear otitis media Men iere's disease la byrinthitis endolym phatic sac salicylates, q u i n ine; am inog lycosides

La nguage Disturbance Complete the following about language distu rbances: a . Wernicke's a phasia is a f aphasia. b. Con du ction a phasia is associated with f speech and p (are vs. are not) awa re Patients of their deficits. c. Bilatera l fronta l lobe dysfu nction is associated with a, m

1 7.

__ _

_ _ _ _ _ _

_ _ __

_ _ _ _

91 . 1 7

fl uent fl uent; para phasias; a re not a kinetic m utism

E

92 Differential Diagnosis (DDx) by Signs and Symptoms ­ Primarily Spine and Other

•

Myelopathy 1 . True or False. The following are potential causes of myelopathy: a . cervica l or thoracic spinal stenosis b. chronic anemia c. Cushing's disease d . Lyme disease e. acq u i red i m m u nodeficiency synd rome (AI DS} 2.

a. b.

How does anemia produce myelopathy? Chronic anemia c a n lead t o b m hypertrophy and c c Pern icious anemia ca n lead to s d c

92.2

true true true true true 92.2

bone ma rrow; cord compression su bacute combined degeneration Epid u ra l lipomatosis

3.

is seen in E Cushing's disease and can produce myelopathy.

4.

Order the following location of neoplastic masses causing myelopathy in order of most common to least common: extra d u ra l , intramedullary intra d u ra l extra med u llary, extra d u ra l intramedullary i ntra d u ra l extramed u l l a ry

a. b. c.

5. What are the frequencies of spinal cord tumors in the following locations? a . extra d u ra l : % b. intra d u ra l extramed u l l a ry: _% c. i ntra d u ra l intra med u l l a ry: _% -

92.2

92.2

92.2

55% 40% 5%

Differential Diagnosis (DDx) - Primarily Spine and Other 6. Complete the following about spinal cord infarction: a . Although u ncommon, spi n a l cord infa rction most often occu rs in the s territory of the a a rtery and most com monly at the level of b. This occu rs beca use this reg ion is a w a rea. c c. This spares the p d . Cau ses o f infa rction include: i. h ii. a, iii. e iv. a d v. s s,

92.2

a nterior spinal artery; T4

_ _ __

___

_ _ _ _ _

_ _ _ _ __ _____ _

__

_ _ _ _ _ _

_ _ _ _ _

7.

Necrotizing myelopathy associated with spontaneous thrombosis of a spinal cord AVM that presents as spastic to flaccid paraplegia with ascending sensory level is called F -A __

8.

a. b. c.

e. f.

posterior col u m n s hypotension atherosclerosis em bol ization aortic d issection spinal stenosis Foix-Aiajouanine d isease

92.2

____ _

Regarding acute (idiopathic) transverse myelitis: True or Fa lse. Clinical onset is ind isti n g u ishable from acute spinal cord compression. (Abnormal vs. Norma l) imaging is expected on CT, myelogra m and M RI . Cerebrospinal fl uid (CSF) a n a lysis shows and h p The t region is the most common leve l . True or Fa lse. The most com mon onset is 20 to 40 yea rs of age. True or Fa lse. Usually resu lts in a diagnosis of m u lti ple sclerosis. _ _ _ _ _ _

d.

watershed

9. Abdominal cutaneous reflexes are almost always absent in m

92.2

true Normal pleocytosis and hyperproteinemia thoracic fa lse - most common d u ring fi rst 2 decades of l ife fa lse - MS is diagnosed i n only 7% m u ltiple sclerosis

92.2

_ _ _

s, _____ .

Regarding Devic's syndrome: Cha racterized by acute bilatera l o n and m b. True or Fa lse. The tra nsverse myelitis can be a cause of complete block on myelography. c. True or Fa lse. More common in Asia than i n the United States. d . True or Fa lse. I t is a va riant o f m u ltiple sclerosis.

1 0. a.

___

92.2

optic neuritis; myelopathy true true true

Neurosurgery Books

499

500

Part 22: Differential Diagnosis

11.

N o is another name for Devic's syndrome.

1 2.

The following are part of the mechanism responsible for pernicious anemia: mala bsorption of B 1 2 in the d i lack of secretion of intrinsic factor by g p c

a.

Neu romyelitis optica

92.2

92.2

dista l ileum

___ _

b.

__

1 3.

a. b. c.

gastric parieta l cel l s

__

Complete the following about viral causes of myelopathy: Herpes varicella-zoster ca n rarely cause n m HSV type 2 may cause a m CMV may cause t m _ _ _ _ _ _

_ _ _ _

_ _ _ _ __

_ _____

92.2

necrotizing myelopathy ascending myelitis tra nsverse myelitis

_ _ _ _ __

1 4. AI DS can produce myelopathy via v of the spinal cord. 1 5.

a. b. c. d. e. f. g. h. i. j. k. I. m.

Match the disease with the important feature: CD pernicious anemia; 0 G u i l l a in-Ba rre; @ ALS Features: (a-m) below ascending wea kness atrophic weakness of hands sym metrica l paresthesias posterior col u m n involvement normal sensation dementia a reflexia serum b 1 2 levels fasciculations Shilling test preserved sphincter control treatment with b 1 2 proprioception d ifficu lty

1 6. What are symptoms of ALS? a. s of h and b. a f c. f d . usually preserved s __ _ _

__

_ _ _ _ _

_ _ _ _ _

___ _

c.____

vacuol ization

92.2

92.2

0 ® CD CD 0 CD 0 CD ® CD ® CD CD 92.2

spasticity atrophy of hands and forea rms fasciculations sphincter control

Differential Diagnosis (DDx) - Primarily Spine and Other •

Sciatica 1 7. Complete the following about sciatica: a . T h e sciatic nerve contains roots from L_ to l_ b. The nerve passes out of the pelvis s through the g f c. In the lower third of the thig h , it d ivides i nto the t a n d the c nerves. p d. Most common cause is due to h d, _

L4 t o 5 3

9 2 .3 . 1

g reater sciatic fora men

_ _ _ _ _

_ _ _ _

______

____

1 8.

a. b. c. d. e.

_

_ _ _ _

tibia l ; common peroneal radiculopathy; herniated l u m ba r disc

_

Complete the following about herpes zoster: May rarely cause r Lum bosacra l dermatomas a re involved in _ _% Typical ly, skin lesions fol low pain in __ days. True or Fa lse. Motor weakness ca n occur. True or Fa lse. Urinary retention ca n occur.

Complete the following about piriformis syndrome: a . What are t h e major sym ptoms of pi riformis synd rome?

92.3.2

radiculopathy 1 0-1 5% 3-5 days true true

1 9.

b.

92.3.2

Friedberg test consists of force i of the high and thigh e

92.3.2

pain in the sciatic nerve distri bution with weakness of external rotation and abduction of the hip interna l rotation; extension

___ _

Complete the following about extraspinal tumors causing sciatica: a . What cha racterizes t h e pain? i. i ii. c iii. p iv. position a l vs. non-positional? v. worse in morning or at nig ht? b. About _% wi l l have a previous history of a tum or.

20.

_ ___ __ __ _ _

_ _ _ _ _

21 .

Femoral neuropathy is often mistakenly identified as a radiculopathy at the l_ level.

92.3.3

insidious consta nt prog ressive non-positional night 20% L4

92.3.4

501

E

502

Part 22: Differential Diagnosis

22. Does femoral neuropathy or l4 radiculopathy lead to the following symptoms? a . wea k quadriceps

both femoral neuropathy and L4 radicu lopathy femora l neu ropathy

sensory loss occu rring along the anterior thig h . c . I liopsoas is wea k in

femora l neuropathy

d . Thigh adductors m a y b e wea k in

L4 radicu lopathy

b.

__

23. A peroneal nerve palsy may be mistaken for radiculopathy at what level?

•

92.3.4

LS

92.3.4

Acute Paraplegia or Quadriplegia 24.

a.

Signs of spinal cord compression include: or -p -p

b. u c. s d . possible positive B e. a ltered r

92.4. 1

-plegia or -paresis (parafquadri) u rinary retention sensory level Babinski reflexes (hypo vs. hyper)

25.

Complete the following about para/quadriplegia in infancy: a . Congenita l degeneration o f a nterior horn cells leading to wea kness, a reflexia , tongue fascicu lations, with normal sensation is s m a b. This is also known as f syndrome. b c. If ileus, hypotonia, wea kness, and myd riasis, suspect c bacteria l infection. b

26.

a. b. c. d.

Complete the following about para/ quadriplegia: Classic ascending para lysis is seen with synd rome -B G If post-vira l , paraplegia may be secondary to t m Rapid correction of hyponatremia may lead to c p m a rea may A lesion in t h e p involve both motor strips.

92.4.2

spinal m u scu l a r atrophy (Werd nig-Hoffm a n n d isease is most severe form.) "floppy ba by synd rome" clostrid i u m botu l i n u m

92.4.2

Guillain-Ba rre synd rome tra nsverse myelitis centra l pontine myelinolysis parasag itta l

Differential Diagnosis (DDx) - Primarily Spine and Other •

Hemipa resis or Hemiplegia 27. The most common etiology for pure motor hemiplegia without sensory of loss is a I the contralateral i c 28. What are the different locations in which a lesion can cause hemiplegia? a. c h

c b. i c. b d. c c e. unilatera l s f. While not a lesion, h associated with hemiparesis

•

503

may be

lacu nar infa rct; interna l ca psule

92.5.2

92.5.2

cerebral hemisphere (motor stri p) intern a l ca psule brainstem cervicomed u l l a ry junction spinal cord hypog lycemia

Low Back Pain 29.

a. b. c. d.

Complete the following about back pain: If a patient is writhing in pa i n , consider a or v etiology such as a n a d If consta nt pain at bed rest, consider a s t If noctu rnal back pain relieved by aspiri n , or a consider o 0 benign o Morning back stiffness, h i p pa i n , h i p swelling, no relief with rest, and i mp rovement with exercise is suggestive or e of s a s

30. What are 3 major symptoms of cauda equina syndrome?

Complete the following about cauda equine syndrome: a . What a re 4 treata ble etiolog ies?

92.6.2

abdominal; vascu l a r; aortic dissection spinal tumor osteoid osteom a ; osteoblastoma sacroiliitis; ea rly a n kylosing spondylitis

Perineal (aka saddle) a nesthesia, prog ressive wea kness, u rinary incontinence

31 .

b.

It req u i res (nonemergent or emergent) diag nostic eva l u ation.

92.6.2

92.6.2

Etiolog ies include epid u ra l a bscess, epid u ra l hematoma, tumor (intra d u ra l or extra d u ra l ), massive centra l disc herniatio n . emergent

g

E

504

Part 22: Differential Diagnosis

Complete the following about annular tears: a . Asym ptomatic in _% o f 50-60 yea r old patients. b. Asym ptomatic in _% of 60-70 yea r old patients.

32.

33. Two medications that are associated with acute back pain are: a. s b. p 34.

Disc herniation through the cartilaginous end-plate into the vertebral body is called a S n

92.6.2

40% 75% 92.6.2

stati ns phosphod iesterase in h i bitors such as tadalafil Schmorl's node

92.6.3

---

Complete the following about chronic low back pain: a . After 3 months, a bout _% o f patients with low back pain wi l l have persistent symptoms. A structu ra l diagnosis is fou n d in a bout _% of these patients. b. Erosive changes adjacent to sacroi liac joint and positive H LA-B27 suggests a s

35.

•

92.6.3

5%; 50% a n kylosing spondyl itis

Foot Drop 36. Which exam findings help differentiate common peroneal nerve palsy from l4/l5 radiculopathy? a . strength o f p t with foot i

b.

strength of g with i r of h i p f

m

and

Complete the following about foot drop: a . Due t o wea kness o f a t b. This typica l ly involves cord levels L_ and L_ c. Often accom panied by weak e d I and e h I which a re innervated by the d nerve. p

92.7 . 1

posterior tibia lis; foot inversion (should be i nvolved with radiculopathy but spared in peroneal nerve palsy) g l uteus medius; interna l rotation and flexion (should be i nvolve with radiculopathy but spared in peroneal nerve palsy)

37.

a nterior tibialis L4, L5 extensor digitorum longus; extensor h a l l ucis longus; deep peroneal nerve

•

Neurosurgery Books

92.7 . 1

Differential Diagnosis (DDx) - Primarily Spine and Other "Flail foot" may be caused by s nerve dysfu nction. e. Which division of the sciatic nerve is more sensitive to inj u ry (peroneal vs. tibia l }?

d.

__ _

38. What are the neurologic etiologies for a foot drop? a. p nerve I nJ U ry b. L or L radiculopathy c. I p inj u ry d. nerve inj u ry e. A -M -T f. C g. h m p h. p lesion i. s c inj u ry _

_

__

___

__

__

__

____ _

___

39. What are the muscles and nerve roots that produce the following movements? a. thigh adduction b. knee extension c. i ntern a l rotation at hip d . hip extension e. knee flexion f. foot pla nta r flexion g . foot i nversion h . foot eversion

i.

a n kle dorsiflexion

sciatic nerve peroneal d ivision more sensitive to inj u ry

92.7.3

peroneal (deep vs. com mon) L5; L4 l u m ba r plexus sciatic ALS Charcot-Marie-Tooth heavy meta l poisoning parasag itta l lesion spinal cord

adductors, L2-3 q u a d riceps, L2-4 g l uteus medius, L4-5 , S l g l uteus maximus, L5 , S l -2 biceps femoris, L5, S l -2 gastrocnemius, S l -2 tibia lis posterior, L4-5 peroneus longus and brevis, L5, S l a nterior ti bialis, L4-5

40. Thigh adduction involves: a. muscles b. nerve c. roots

adductors obtu rator L2 ,3

41 . a. b. c.

Knee extension involves: muscles nerve roots

q u a d riceps femoral L2-4

42. a. b. c. d.

Internal rotation of the thigh involves: muscle nerve roots I f weak, means lesion is very p

g l uteus medius su perior g l utea l L4-5 , S l proxi m a l

43. a. b. c. d.

Digging heels into bed involves: m uscle nerve roots I f weak, means lesion is very p

g l uteus maximus inferior g l utea l LS, S l -2 proxi m a l

_ _ _

_ _ _

92.7.2

Fig. 9 2 . 1

Ta ble 9 2 . 3

Fig. 9 2 . 1

Fig. 9 2 . 1

Fig. 9 2 . 1

Fig. 9 2 . 1

505

E

506 44.

Part 22: Differential Diagnosis Fig. 9 2 . 1

Knee flexion with thigh flexed involves: m uscles nerve roots

latera l hamstrings sciatic LS, 5 1 -2

45. a. b. c.

Plantar flexion of foot involves: muscle nerve roots

gastrocnemius sciatic 5 1 -2

46. a. b. c. d.

Foot inversion involves: muscle nerve roots I f strong b u t in the presence o f a foot d rop, it means that the inj u ry is dista l to the take-off of the c p nerve.

a. b. c.

47. Foot eversion involves: a. m uscles b. nerve c. roots d . I f strong b u t in the presence o f a foot d rop, it means that the inj u ry is in the d nerve. p 48. What are the ways to distinguish foot drop from injury to the deep vs. common peroneal nerve? a . Deep peroneal nerve: i. major weakness sym ptom ii. wea k muscle iii. sensory loss b. Common peroneal nerve: i. major weakness sym ptom ii. wea k muscles

iii. sensory loss 49. What distinguishes superficial peroneal nerve injury? a . major wea kness sym ptom b. wea k m u scles c. presence of foot d rop? d. Sensory loss 50. a.

b.

Complete the following: Pai n less foot d rop is likely due to n p Painfu l foot d rop is likely d u e to

Ta ble 9 2 . 3

Ta ble 9 2 . 3

posterior tibial tibial L4-5 common peroneal

Ta ble 9 2 . 3

peroneus longus and brevis superficia l peroneal LS, S 1 deep peroneal

Ta ble 9 2 . 3

foot d rop a nterior tibial web space foot d rop and wea k eversion a nterior tibial and peroneus longus and brevis latera l leg and foot Ta ble 9 2 . 3

foot eversion peroneus longus and brevis no latera l leg and foot 92.7.3

peroneal nerve (palsy) radiculopathy

Differential Diagnosis (DDx) - Primarily Spine and Other c.

Pa in less foot d rop without sensory loss cou l d be due to a p lesion , which wou l d b e associated with a reflex and B (hypo vs. hyperactive) reflexes.

507

parasag itta l ; Babinski; hyperactive

_ _ _ _

•

Weakness/Atrophy of the Hands/UEs Complete the following regarding lesion location and findings in " cruciate paralysis": a. Physical exa m demonstrates bilatera l e wea kness and u a h b. This is due to pressu re on the p d

51 .

52. Atrophy of the first dorsal interosseous muscle is usually due to C_/T_ nerve root or u nerve disease.

92.8 . 1

u pper extrem ity; hand atrophy pyra m idal decussations C8/Tl ; u l n a r nerve

92.8.2

___

•

Radicu lopathy, Upper Extremity (Cervical ) 53.

Myocardial infarction may present with symptoms similar to a radiculopathy at what level and side?

54. Complete the following: a . T h e "em pty ca n " test suggests

b.

Intersca pular pain suggests

55. Match the symptom with the position of the disc most likely to produce it: CD centra l cervical disc; (I) latera l cervical disc Sym ptom: (a-f) below a . pain b. myelopathy c. bilatera l sym ptoms d . u pper extrem ity sym ptoms e. lower extrem ity sym ptoms f. n u m b-cl u m sy hand synd rome

left C6

92.9

92.9

shoulder pathology referred pain with cervical radiculopathy or cholecystitis 9 2 . 9 , 9 2 . 1 0 , 92 . 1 1

Cil CD CD Cil CD CD

508 •

Part 22: Differential Diagnosis

Burning Ha nds/ Feet 56. What are possible etiologies for a patient complaining of burning hands or feet? c s a. c b. b h s, c. n -c h s d. c p s e. p n, f. e __ __

__

___

__ _ _ _

_ __ _

__

__

_ _ _ _

__

_ _ _ _ _

__ _ _

_ __ _ _

g.

•

a

d isease

92 . 1 1

centra l cord synd rome b u rning hands synd rome n u m b-cl umsy hand synd rome complex reg ional pain synd rome peripheral neuropathy erytherma lgia (or eryth romela lg ia) a rterial

Lhermitte's Sig n Complete the following about lhermitte's sign: a . What is t h e major symptom and what provokes it?

57.

b.

Etiolog ies include: i. m s s ii. c c iii. s d iv. tumor of the v. disc herniation in the reg ion vi . C m vii . r m viii. c c s. ____

____ _ _ _ _ _

_ _ _ __

_ ___ _ _ _ _ __

_ _ _ _ _ _ _____

•

92 . 1 3 . 1

92. 1 3.2

__ _ _ _

__

An electrical shock-like sensation radiating down the spine. Usually provoked by neck flexion.

_ _ _ __

mu ltiple sclerosis cervica l spondylosis su bacute combined degeneration cervica l cord cervica l Chiari ma lformation rad iation myelopathy centra l cord synd rome

Swa llowing Difficu lties 58. Although swallowing difficulties are not uncommon after an A this should prompt consideration for a post-op h ___ ,

_ _ _ _ _

ACDF; hematoma

92. 1 4

93 Procedures, Interventions, Operations: General Information

•

I ntraoperative Dyes Complete the following about intraoperative dyes: carries a s m a l l risk o f seizu re a. when administered intratheca l ly. is cytotoxic b. and should not be used at a l l . c. can be used to demonstrate a rteriovenous ma lformation (AVM) vessels intraoperatively and a reas of blood brain ba rrier breakdown (e.g . tumors). d. c a n b e used t o identify cerebrospinal fl uid (CSF) leaks a n d is considered safe. used for e. intraoperative ang iogra m . 1.

•

93.2

Fluorescein Methylene blue Fluorescein

Fluorescein lndigocyanine g reen (ICG)

Operating Room Equipment 2.

a. b.

Complete the following about microscope setup For spine cases t h e eyepiece is usually directly the pri mary s u rgeon. I n contrast, for intracranial work, the observer's eyepiece is placed to the

c. The exceptions to this a re: i. ii.

93.3 . 1

opposite rig ht

tra nsphenoid ial su rgery right posterior fossa cra n iotomy in the latera l oblique position

Neurosurgery Books

g

I!

51 0

Part 23: Procedures, Interventions, Operations

3.

Complete the following on headfixation a . Alternatives t o pin based head fixation include i. ii.

93.3.2

Horse-shoe head rest Dou g h n ut fashioned out of stockinette Prone-view 3

iii. Pin-sta bilization is not recommended for use in children under the age of _. c. These featu res of head-fixation should be considered depending on the type of case: i. radiolucent head holders for vascular cases with angiograms ii. attachment of self-retaining retractor or systems iii. to the Mayfield system . image g u idance systems

b.

4.

Manufacture recommendations for cranial pin placement include: a. Similar to a sweatba nd worn just about and the b. Avoid placing pins in the tem poral bone or the sin uses. for c. The single pin is placed the supine position and on the side as the operation when doing prone posterior fossa cases. d. Ad u lts should be placed in pins that have fin a l resti ng tension between and 80 lbs.

93.3.2

orbits and pinna squamous; fronta l

___

a nteriorly; same 60

___

•

Surgica l Hemostasis 5. Complete the following about surgical hemostasis: a . Bone wax i n h ibits formation. b. True or Fa lse. The fol lowing chemical hem ostatic agents exerts its effect by promoti ng platelet aggregation: i. Gelfoam ii. Oxidized cel l u lose iii. Avitene iv. Throm bin Match the surgical hemostasis substance with its trade name: CD Throm bostat; @ Gelfoa m ; G) Oxycel ; @ S u rgicel ; ® Avitene a. gelatin sponge b. oxidized cel l u lose c. regenerated cel l u lose

bone

93.4. 1 93.4.2

fa lse fa lse true (less so if platelets < 1 OK) fa lse

6.

93.4.2

@ G) @

Procedures, Interventions, Operations: General Information d . microfibri l l a r collagen e. thrombin

•

51 1

® CD

Craniotomy General I nformation 7 . Complete the brain swelling intraoperative checklist. ( H i nt: decompress) a. d b. e ( c. c d. 0 of e. m f. p g. r h. e _ ____ _ _ _

_ _ _ __ _

i. j.

(s) (s)

8.

Complete the following regarding the risks of craniotomy: increased neurological deficit (tu mor case): % postop hemorrhage: % infection: % a nesthetic complications: %

a. b. c. d.

Complete the following regarding anticonvulsants: a . True or Fa lse. Maintain their u s e if cortica l incision is a nticipated . b. Describe the method of load i n g.

93.5.3

d rain CSF elevate head C02 (hyperca rbia) obstruction of jug ul a r veins mannitol hyperventilate remove bone excise bra i n (tem pora l or fronta l lobes)

93.5.4

1 0% 1% 2% 0.2%

9.

1 0.

a. b. c. d. e. f. g. h. 11.

list the possible causes for acute postoperative deterioration h h a c p e v s p a

a.

If postoperative seizures occur, consider the following: (Hint: a bci) a

b.

b

___ __ _

_ _ _

93.5.4

true (use Keppra) 500 mg PO/ IV q 1 2 hours 93.5.5

hematoma acute hyd rocephalus cerebra l infa rction pneumosephalus edema vasospasm seizu re persistent anesthetic

g 93.5.5

a nticonvu lsant level-d raw blood bol us-additional a nticonvu lsa nts

51 2 c.

Part 23: Procedures, Interventions, Operations c

CAT sca n-to identify if a ny cause intubate-to protect a i rway

d. 1 2.

a.

Complete the following regarding postoperative headaches: "Synd rome o f t h e trephined" ca n conti n u e to improve out to yea rs in one series for posterior fossa cra niotomies. It has been described to be similar to synd rome.

93.5.6

2

_

b.

•

post-concussive synd rome

I ntraoperative Cortical Mapping ( Brain Mapping) 1 3. Answer the following questions regarding locating the primary sensory cortex: a . I ntraoperative SSEP m a y local ize the phase reversa l pri mary sensory cortex by potentia ls across the centra l sulcus. perpendicu lar b. This is done with a stri p electrode oriented in the di rection to the antici pated orientation of the centra l sulcus.

93.6.2

1 4. Answer the following questions regarding awake craniotomies: a . Critica lly im porta nt t o understa nd a n d manage the a nesthetic agents which include and para lytics as to not obscure electrica l sti m u lation. b. Pre-operative practice with the patient can be im porta nt to identify necessa ry aids in the OR, such as

93.6.3

c.

I! d.

Loca l a nesthesia should be considered in 4 reg ions: i. s ii. a iii. p iv. 0 is pain I ntracra n i a l , the sensitive while the brain is not.

local and short acti ng

reading glasses

supraorbita l and supratroch lear a u ricu lotem pora l postra u ricu l a r occipita l d u ra

Procedures, Interventions, Operations: General Information •

51 3

Cranioplasty 1 5. Answer the following about cranioplasty a . Indications include and

b.

Material options include the -- ---

'

or

cosmetic, symptomatic relief, and protection patient's own bone, methyl methacrylate, mesh, pre-fa bricated custom flap; split thickness calvaria

Localizing levels in spine surgery. Name pitfalls a. The count can be off if there a re not 1 2; ribs and l u m ba r vertebra . 5 b. The transverse process ca n mimic a ri b at L1 if it is large.

1 6.

93. 7 . 1

93.7.3

93.7.3

__

•

Bone Graft 1 7. Answer the following regarding bone graft: a . Autologous bone or rh B M P i s recommended in the setti ng of an in conjunction with a threaded tita n i u m cage. This is based on level _ evidence.

93. 8 . 1

AUF; 1

___

1 8. Which of the flowing should not be used to assess for fusion? a . static x-rays alone b. Technetium-99 bone sca n c. flexion/extension fi lms

d. The correlation between fusion and clinical outcome is 1 9.

a.

For spine fusions, components of bone graft that are important for fusion:

b. c. d. 20.

a. b. c.

For each of the above graft characteristics which material has a very strong effect in each. osteoinduction osteogensis osteoconduction

93.8.2

do not use do not use do not use in the absence of instru mentation not strong, possibly u n related 93.8.3

osteoinduction (sti m u late cel l s to develop) osteogensis (formation of new bone) osteoconduction (structu re of g raft so new bone can build upon) mechanical sta bil ity

g 93.8.3

BMP ca ncellous a utog raft ca ncellous a utog raft

I!

514

Part 23: Procedures, Interventions, Operations

d.

mechanical sta bil ity

e.

B M P is FDA approved only for use in procedures, other uses a re off label.

21 . a. b. c. d.

Common autograft donor sites include

22. Bone graft procurement a . Anterior i l i a c bone should b e obtained 3, to avoid 4 em latera l to the the b. Posterior iliac crest bone g rafts a re taken from the 6-8 em of the iliac crest to avoid . I nj u ry here can resu lt in a

c. When isolating the fi bula, the nerve is t o b e avoided a t the proxim a l head. At least em should be dista l ly preserved to mainta in a n kle stabil ity.

cortical or vascula rized a utog ra ph AUF

93.8.3

iliac crest ri b fibula bone removed d u ring de com pression 93.8.4

AS IS; latera l femoral cuta neous nerve media l ; su perior cluneal nerves (which cross the posterior iliac crest at 8 em); n u m b buttock or painfu l neuromas peronea l ; 7

__

•

Stereotactic Surgery 23. a. b. c. d. e. f.

Stereotactic surgery indications

g . T h e abil ity t o m a ke a diagnosis i n the setting of a stereotactic biopsy ra nges from to in a large series and was slig htly lower in patients with __

biopsy catheter placement electrode placement lesion generation SRS experimental (laser, transpla ntation, other) 82-99%; AI DS

___

h . T h e yield rate is h i g h e r for lesions that on CT or M RI . i. The most frequent complication is , which was slig htly worse in patients with j. In non-i m m u nocom promised patients, the highest rate of complication occu rred in

enha nce hemorrhage; AIDS m u ltifoca l high g rade g liomas

Neurosurgery Books

93.9.2

93.9.3

94 Specific Craniotomies

•

Posterior Fossa (Suboccipital ) Cra niectomy 1 . True or False. The correct treatment for air embolism sustained during a craniotomy performed with the patient in a sitting position is a . t o fi nd and occl ude site o f entry o r ra pidly pack wound with sopping wet sponges. b. bilatera l or right-sided j u g u l a r venous compression. c. venti lation with 1 00% 02• d. rotati ng the patient rig ht side down .

e . aspirating air from centra l venous pressu re (CVP) catheter. f. avoiding positive end -expi ratory pressure (PEEP), which is ineffective and may worsen the risk of paradoxica l a i r embolism. 2.

a.

Complete the following about posterior fossa craniectomy and air embolism: Effect o f a i r in rig ht atri u m i s i. h

ii. a Paradoxica l air em bolism may occur in the presence of f i. p 0 ii. or p a rteriovenous (AV) f c. I n cidence in sitting position is %. d . Preca utions req u i re: i. D ii. c in e . Earliest clue t o occu rrence i s b.

Ta ble 94. 1

true true true fa lse (Patient should be turned left side down to tra p a i r i n the rig ht atri u m . ) true true

94. 1 . 2

hypotension (due to impaired venous retu rn) a rrhyth mias patent fora men ova le pulmonary AV fistu la 7 to 2 5 % Doppler precordial u ltrasound CVP catheter in rig ht atriu m fa l l in e n d tid a l pC02

D

a

51 6

Part 23: Procedures, Interventions, Operations

How does air embolism cause problems? a . A i r becomes tra pped in t h e

3.

___ _

b. c.

i m pa i rs prod uces

___ ___ ,

and

_ _ _

94. 1 . 2

rig ht atri u m venous retu rn hypotension

4. Outline the intraoperative treatment for air embolism during a craniotomy. ( H int: occl ude) a. o b. c c. c d. I e. u f. d g. e

occlude entry site cover with wet laps com p ress j u g u l a r veins left side down lower head venti late/ increase vol u m e disconti nue nitrous evacuate air

5. Earliest clues to occurrence include: a . fa l l i n b. sou nd on Doppler is c. blood pressu re

end tida l pC02 machinery sound hypotension

_ _ _ _ _ _ _ _ _

_ _ _ _ _ _

___ _

True or False. The following approach is most applicable for a vertebral endarterectomy: a . midline su bocci pita l craniotomy b. extreme latera l posterior fossa a pproach c. paramedian su boccipital craniotomy

Ta ble 94. 1

94. 1 . 2

6.

d.

su btem pora l cra n iotomy

7. a.

Consider the concept of " 5-5-5."

b.

i. This relates to the ii. for a linear iii. for access to the

incision incision

The first n u m ber relates to the m m m e d i a l t o the ii. The second n u m ber relates to the the notch . iii. The third n u m ber relates to the the notch .

i.

94. 1 . 2

fa lse fa lse true (Paramedian su bocci pita l cra n iotomy gives decent access to the vertebral a rtery and to the posterior inferior cerebe l l a r artery ( PICA) and the vertebrobasilar junction . ) fa lse 94. 1 . 3

skin paramed ian CPA mastoid notch em a bove em below

Specific Craniotomies 8.

a. b. c. d. e.

Matching. Match the incision with the objective. I n cision: CD 5-6-4; 0 5-5-5; ® 5-4-6 Objective: approach for (a-e) below t h e fifth nerve hemifacia l spasm g lossopharyngea l neura l g ia microvascular trigeminal decompression vesti b u l a r schwa n noma

Location of the inferior margin of the transverse sinus can be estimated f a . t o be above the n b. m

94. 1 . 3

CD 0 ® CD 0

9.

1 0. a.

b.

11.

a.

Describe the Frazier burr hole. It is used i. p ii. to relieve p swelling or iii. d u e to h iv. e It is located i. to em from the midline. ii. to em above the inion in a d u lts. iii. to em above the i n ion in children. Complete the following regarding posterior fossa post-op complications: Respiratory: prevent by

Hypertension: mainta in SBP below with c. Acute hyd rocephalus: treat with

94. 1 . 3

two finger breadths mastoid notch 94. 1 . 3

prophylactica l ly post-operative hyd rocephalus edema 3 to 4 6 to 7 3 to 4 94. 1 . 7

keeping patient intu bated

b.

1 60 with nitroprusside

d.

ventricular ta p-external ventricu l a r d ra i n (EVD) cerebrospinal fl uid (CSF} leak

Meningitis: prevent b y prom pt repair of any

1 2.

is Blood pressure above dangerous for the post-operative posterior fossa patient.

1 3.

Complete the following regarding the posterior fossa: I ncreased pressure in t h e posterior fossa is heralded by changes in i. b p ii. r p not by i i. p ii. m s c iii. I

a.

b.

51 7

1 60 mm Hg systolic

94. 1 . 7

94. 1 . 7

blood pressure (increase) respiratory pattern pupillary inequality level menta l status ICP changes

D

a

51 8 1 4.

a. b.

c.

Part 23: Procedures, Interventions, Operations Considerations for post-operative posterior fossa emergency include: clinica l ly i. blood pressu re (BP} ii. respirations recommended treatment i. i ii. t iii. 0 Should you i. obtain a com puted tomographic (CT} sca n first? ii. wait for operati ng room availabil ity?

94. 1 . 7

high la bored intu bate ta p ventricle open wound no no

Indicate whether increased pressure in the posterior fossa or supratentorial compartment produces a change in the following: a . pupillary reflexes: supratentorial compartment b. level of consciousness: supratentoria l compartment

1 5.

c.

i ncrease in intracranial pressu re (ICP}:

d. changes in respi ration: e. rise in blood pressu re:

•

supratentoria l compartment posterior fossa posterior fossa

Pterional Craniotomy 1 6.

a. b. c. d. e. 1 7.

•

94. 1 . 7

Matching. Match the head position with the location of the aneurysm. Head position: CD ang led 30 degrees; 0 ang led 45 degrees; ® ang led 60 deg rees Location of aneurysm : ICA P-comm ca rotid term inus middle cerebra l a rtery basi l a r bifu rcation A-com m Name the artery ( ies ) that cross the sylvian fissure.

Fig. 94.5

CD CD 0 CD ® none cross

94. 2 . 2

Tempora l Craniotomy 1 8. True or False. A temporal craniotomy can allow access t o the following structures: a . fora men ova le b. Meckel's cave c. la byri nth ine and u pper tym panic portion of the facial nerve

94.3 . 1

true true true

Specific Craniotomies

1 9. A temporal lobectomy a . c a n safely resect _ - _ em in the dominant hemisphere b. and em in the nondominant hemisphere.

•

Frontal Craniotomy 20. Complete the following regarding the superior sagittal sinus {SSS): a . The risk in sacrifice of the SSS is

b. True or Fa lse. It a l m ost a lways occurs with sacrifice of i. the posterior third ii. the middle third iii. the anterior third

•

94.3.4

4-5 (before inj u ry to Wern icke a rea) 6-7 (before inj u ry to optic radiations)

94.4.2

venous infa rction

true true fa lse

Approaches to the Third Ventricle 21 . Study Chart. a. t b. t i. a ii. p c. s i. s ii. 0 iii. I t iv. t d. t e. s f. s 22.

94. 7 . 1

tra nscortica l tra nsca l losa l anterior posterior su bfronta l s u bchiasmatic opticoca rotid lamina term ina lis transsphenoidal transsphenoid a l su btem pora l stereotactic

What is the risk of post-operative 5% seizures after a transcortical approach to the anterior third ventricle {e.g., for a colloid cyst)?

23. What are the principles of tumor removal? a . Veins must b e preserved at a l l - ---,- --,---b. First remove the tumor from with in the

c.

If ad hesions seem u nyielding, the most l i kely cause is i evacuation. _ _ _

94. 7 . 1

94. 7 . 2

costs ca psule incomplete intraca psu lar

_ _ _

Neurosurgery Books

51 9

a

520

Part 23: Procedures, Interventions, Operations

24. Complete the following: a. True or Fa lse. A disconnection synd rome (split-brain synd rome) is com mon with i. posterior ca l losotomy through splen i u m . ii. a nterior ca l losotomy. iii. ca l losotomy < 2 . 5 em in length from a point 1 to 2 em behind the tip of the genu. b. Which of the above a pproaches avoids the disconnection synd rome best?

94. 7 . 3

true (where more visual information crosses) fa lse fa lse ca l losotomy < 2.5 em in length from a point 1 to 2 em behind the tip of the genu

25.

Describe the transcallosal approach to the third ventricle. a . T h e su perior sag itta l s i n u s {SSS) is often to the of the sagitta l sutu re. b. The cranial opening should be i. a nterior to the coronal sutu re ii. and behind it. c. The two cingu late gyri may be ad herent i n the midline and can be mistaken for the c c d. i. The corpus callosum has a disti nct color. ii. It is located beneath the paired a rteries. e. The open ing is usually made between a rteries. the p p f. The trajectory of dissection is from the s i. c a ii. to the e m l ies iii. The f of M along this line. g. i. It is helpfu l to fenestrate the s p ii. to prevent it from b i nto the ventricle iii. especi ally in a case of c c How can you tell which ventricle you are in? a. The fora men of Monro is located m b. If the choroid plexus goes to the left to enter the fora men of Monro you a re in the ventricle.

94. 7 . 3

rig ht two third one third corpus ca llosum

wh ite perica l losa l paired perica l losal coronal suture external aud itory meatus fora men of Monro septu m pel l u cid u m bulging colloid cyst

26.

94. 7 . 3

medially rig ht

Specific Craniotomies c.

If you see no choroid plexus and no veins cavum septu m pel l u cid u m you m a y be in a c s _ _ _

P· ---

d . T h e safe way t o enlarge the fora men of Monro is posteriorly between the a n d the _ _ _

____ ____

27.

a.

choroid plexus; fornix

Complete the following about approaches to the third ventricle: T h e interhemispheric approach runs risk of inj u ry to which may prod uce The a nterior transca l losal a pproach runs risk of inj u ry to which may prod uce problem with m and s -t n I, The transcortica l approach is i. made through the gyrus. --,---- ----,-ii. This is a bout the same spot used for e v d iii. ca lled point.

bilatera l ci n g u l ate gyrus

94. 7 . 3

_ _ _ _ _ _ _ _ _ _ _

b. c.

_ _ _ _ __

tra nsient m utism bilatera l fornices

_ _ _ _ _ _ _

d.

short-term memory and new learning

_ _ _

e.

_ _ _

94. 7 . 4

middle fronta l external ventricu lar d ra i n

___ _

•

Kocher's point

Decompressive Craniectomy 28.

a.

Indications for decompressive craniectomy: 94. 1 0. 1

i.

m m cerebral a rtery occl usion ii. pri marily for the n, hemisphere d b. p i hypertension c. True or Fa lse. It is necessa ry to open the d u ra . d . Sku l l reimpla ntation c a n b e considered after to weeks. e. i. A opening is best, by ii. approximately em or l a rger. _ _ _ _

___

malignant middle non-dominant persistent intracranial true 6 to 1 2 large 1 2 by 1 2

94. 1 0. 3

521

95 Spine, Cervical

•

Anterior Approaches to the Cervica l Spine Complete the following regarding extrapharyngeal approaches to the cervical spine a. Extra pharyngeal approaches use n intu bation. b. The head is slig htly e and is degrees to the rotated contra latera l side. c. In the medial extra pharyngea l a pproach, the branches of the a rtery, u nerves, and h nerve a re encou ntered. d. I n the latera l retropharyngeal a pproach nerve is the s encou ntered .

1.

•

95.1

nasotracheal extended ; 15 branches of external ca rotid a rtery, upper l a ryngeal nerves, and hypog lossa l nerve spinal accessory nerve

Transoral Approach to Anterior Cra niocervical J u nction 2.

Complete the following regarding the transoral approach to the craniocervical junction: a . Pri marily usefu l for midline e. lesions. b. Approach to intra d u ra l lesions is l i m ited beca use of d ifficu lties obtaining closure and increased risk of w m __ _

95.2 . 1

extra d u ra l watertig ht; meningitis

__ _

Complete the following regarding transoral approach to anterior craniocervical junction: a. % o f patients need posterior fusion after a tra nsora l odontoidectomy. b. The patient must be able to open the mm. mouth at least c . T h e tubercle o f t h e a ca n be pal pated through the posterior pharynx in order to locate the m

3.

_ _ _

95.2.2

75% 25 mm atlas; midline

Spine, Cervical d . I f Cl ring sparing is not done, the centra l is em of the removed. e. There is a bout m m of working dista nce between the two vertebral a rteries where they enter the f t at the inferior aspect of the latera l mass of ___

__ __

atlas 20-2 5 ; fora men tra nsversari u m ; C2

_ _ _

•

Occipitocervical Fusion 4. What are the disadvantages of occipitocervical fusion? a . Decreased r at m 0 the occipitocervica l j u n ction b. is higher than with Cl -C2 fusion alone. 5. True or False. The following is an indication for occipitocervical fusion: a . congenita l a bsence o f com plete Cl a rch b. u pwa rd migration of the odontoid into the fora men magnum c. congen ita l anomal ies of occipitocervica l joi nts d . type I I odontoid fractu re 6.

a. b. c.

Complete the following regarding occipitocervical fusion: % of Patient wi l l lose about neck flexion. Keel plate must be placed at the region of the occi pita l bone. the thickness It is advisa ble to of the occipita l bone pre-operatively.

7. True or False. After occipitocervical fusion, a halo is indicated in the following patients for 8-1 2 weeks; a . patients with severe Cl fractu res b. elderly patients c. u n reliable patients d . smokers

95.3

ra nge of motion non-union rate 95.3

true true true fa lse

30%

95.3

thickest; midline measure

9 5 .3 . 1

95.3.4

true true true true

523

Part 23: Procedures, Interventions, Operations

524 •

Anterior Odontoid Screw Fixation 8.

a.

Complete the following regarding anterior odontoid screw fixation: C1 -C2 complex is responsible for % of head rotation. Sta bil ity of the Cl -2 joint depends on the integ rity of the o p and the a t ligament. I n dicated i n patients who have a type odontoid fractu re and a n i ntact t ligament. Patients with type fractu res a re also indicated when the fractu re line is in the c portion of the body of C2 in an elderly patient who may not fuse as wel l with immobilization as a younger patient. Contra ind ications to a nterior odontoid screw fixation include if there is a fractu re of the v b and if the fractu re is less than months old. Fol l owing fixation the immediate post% of the op strength is only normal od ontoid . Therefore, a cervica l brace is weeks recommended for u n less the patient has significant osteoporosis at which point a brace is recom mended. With fractu res < 6 months old, the u n ion %. rate was Chronic non u n ions > 6 months old have a bony union rate of %, and % rate of presumed fibrous u n ion.

50%

95.4. 1

____

b.

___ _

c. d.

e.

odontoid process; atla nta ! tra nsverse II; tra nsverse

95.4.3

Ill; cephalad

vertebral body; 6

95.4.4

_ _ _ _

_ _ _

f. g.

50 %

95.4.5

6· halo

_ _ _

h. i.

95% 3 1 %; 38%

____

•

Atlantoaxial Fusion (Cl -2 Arthrodesis) 9. Complete the following about atlantoaxial fusion (C1 -C2 arthrodesis). a . T h e patient wil l lose a bout % of 50% head rotation. b. Indications for atla ntoaxia l fusion include atlantoaxial; a dislocation d u e to tra nsverse atlanta ! incom petence of the t a ligament. ___

__ _

Neurosurgery Books

95.5.1

Spine, Cervical

525

c. Atla ntoaxia l fusion is fu rther indicated in I I ; patients with incom petence of the 6mm; Bow hu nter's s i g n odontoid process including i n patients fractu res with with type > m m of displacement or i n patients with B h sign characterized by vertebrobasilar insufficiency with head tu rni n g. Describe t h e wiring a n d fusion technique and differentiate. to a . Brooks fusion involves sublaminar wires with bone g rafts. b . Gal lie fusion involves midline wi re under the a rch of with a n bone g raft. c . Dickman and Son ntag fusion involves wire passed sublaminar to with a single g raft wedged between Cl and C2.

1 0.

11.

a. b. c.

d.

Complete the following about C1 -2 transarticular facet screws: A major risk of the proced u re is a rtery inj u ry. May be used as an adjunct to Dickman and Son ntag tech nique to ach ieve sta bil ization. c Req u i res pre-op t c sca ns from the o c with through sag itta l reconstruction through the Cl -2 facet on both sides to look for the presence of a v a in t h e intended path o f t h e screw. A fusion rate of % has been reported.

95.5.2

Cl t o C 2 ; two wedge Cl ;

"H"

Cl ; bicortical

95.5.3

vertebral a rtery i m m ediate thin cut CT; occipita l condyles; C3 ; vertebral a rtery

99%

Complete the following about C1 -2 lateral mass screws: latera l mass; ped icle a . I nvolves placement of polyaxial mi n i screws i n Cl and C2 with rod fixation. vertebral a rtery b . Decreased risk of inj u ry as com pared to tra nsarticu lar facet screws. subl uxation c . May be used in the presence of Cl -2

1 2.

95.5.3

B

Part 23: Procedures, Interventions, Operations

526 d.

Preoperative sca n is req u i red to assess the thickness of the in case the a rch of a rch needs to be d ril led to facil itate screw placement; as wel l as to determ ine screw and to esti mate angle for screws. When placing C1 screws the m m to the may be as close as ideal exit site of the screw. Post-operatively, a cervica l col l a r (soft or rigid, as preferred ) is used for weeks. _ _ _ _ _ _ _

____

____ ____ ____

____

e. f.

t h i n c u t CT; cra nia-ca u d a l ; posterior; C1 ; length; media-latera l

____

_ _ _

ICA; 1 m m 4-6

_ _ _

____

•

C2 Screws 1 3.

a.

The following are the four types of C2 screws: P screws, which a re d irected

b.

L screws, which a re . These screws a re di rected sized to fa l l short of c. C 1 -2 t screws, associated with more risk of VA i nj u ry d. T screws

_ _ _ _ _ _ _

Complete the following about placement of C3-6 lateral mass screws: a . I n t h e A n method t h e screw is placed ,m m medial to the midpoint in the media-latera l direction and in the midpoint in the crania-ca udal d i rection degrees with a trajectory of degrees cepha lad. latera l and b. I n the Magerl method the screw is placed ,m m medial to the midpoint in the media-latera l direction and ,mm cranial to the mid point in the cra nia-caudal direction with a trajectory of degrees latera l and to the facet joi nt. c. In the Roy-Ca mille method the screw is placed at the mid point i n the med ia­ latera l d i rection and cran ia-caudal d i rection with a trajectory of degrees latera l and degrees cra n ia-ca u d a l .

95.6. 1

Ped icle; medially Latera l mass; latera l ly; fora men tra nsversari u m transarticular Translaminar

1 4.

___

___

___

_ _ _

___

_ _ _

Ta ble 9 5 . 1

1 mm; 30 degrees; 1 5 deg rees

2mm; 2mm; 20-25 degrees; parallel

0-1 0 degrees; 0 deg rees

96 Spine, Thoracic and lumbar

•

Anterior Access to the Cervico-Thoracic J unction/Upper Thoracic Spine. Anterior Access to Mid and Lower Thoracic Spine 1.

a. b.

Complete the following about anterior access to the cervico-thoracic junction, upper thoracic spine and lower thoracic spine: proced u re The s s a l lows access to and occasionally I n accessing the mid thoracic spine with a right sided thoracotomy, the h ,m , a nd b vein do not i m pede access. In accessing the mid thoracic spine with a left sided thoracotomy, the a, is easier to mobilize a n d retract. I n accessing the lower thoracic spine, a sided thoracotomy is preferred as it is easier to mobilize the ___

___

sternal spl itti n g ; T3 ; TS heart, mediasti n u m ; brachiocephalic vein

96 . 1 . 1

96.2.2

___

c.

aorta

___

d.

___

e. At Tl 0, the attachment of the increases the d ifficu lty of the a pproach.

•

left; aorta

96.2.3

diaphragm

Thoracic Pedicle Screws 2.

Complete the following about thoracic pedicle screws: a . Due t o t h e dense bone o f t h e shoulders, Tl t o T4 the thoracic spine is usually difficult to on to image from latera l fl uoroscopy. b. With regards to the cran iocaudal middle (mnemonic: Tl -2-3 direction use the "mid tp") of the tra nsverse process as a n entry point for thoracic levels Tl , T2 , T3 & T1 2 .

96.3 . 1

96.3.3

528

Part 23: Procedures, Interventions, Operations

c. With regards to the cra niocaudal of the d i rection, use the tra nsverse process as a n entry point for thoracic levels T7, T8 T9. d . When freehanding using landmarks, the to the su rface screw is inserted of the su perior a rticular facet while "aiming" at the contra latera l e. Typica l thoracic screw length is mm. f. Screw diameter should be approximately % of the ped icle diameter.

top (m nemonic: T7-8-9 "top of the line") perpendicular, pedicle

____ ,

____

35-40m m

____

80%

____

•

Anterior Access to Thoracolumbar J u nction. Anterior Access to the Lumbar Spine 3 . Complete the following about anterior access to the thoracolumbar junction and lumbar spine: a. A sided approach is preferred beca use the is easier to retract is easier than the liver, and the to mobilize than the inferior vena cava . b. It is im porta nt to flex the ipsilatera l leg muscle, to relax the perm itting safer retraction of the ipsi latera l l u m bosacra l plexus. c. The anterior l u m bar i nterbody fusion (AU F) is relatively contraindicated in males beca use of risk of in 1 -2% (as high as 45% in some reviews). d. The bifu rcation of the g reat vessels occu rs just above t o just below the disc space, thus the AUF is best su ited for access to

e. At LS-5 1 , the of ru ns down the the VB and has to be sacrificed to do a n AUF.

left; spleen; aorta

96.4. 1

psoas

retrograde ejaculation

L4-5 ; LS-51

anterior sacra l a rtery; midline

96 . 5 . 1

Spine, Thoracic and Lumbar •

Instrumentation/ Fusion Pearls for the Lumbar and Lumbosacral Spine. Lum bosacral Pedicle Screws Complete the following regarding surgical fusion of lumbar and lumbosacral spine: a . A l u m ba r fusion that includes L 1 should not be term inated at or

4.

b.

Ped icle screws should be to % of ped icle diameter and have a minor diameter > m m in the a d u lt l u m ba r spine and be long enou g h to penetrate to % of the vertebra l body. c. With open l u m ba r pedicle screw placement, the entry point is at the of the tra nsverse process, at the intersection of the center of the tra nsverse process and the sagitta l plane through the latera l aspect of the ___

L 1 or T1 2 70 to 80%; 5.5; 70 t o 80%

96.6

96.7 . 1

___

base; su perior facet

96.7.3

___

d.

e.

Medial ang les for l u m ba r ped icle screws: i. L 1 level-medial angle should degrees. be ii. L2 level-medial angle should be degrees. iii. L3 level-medial angle should be degrees. iv. L4 level-medial angle should be degrees. v. L5 level-medial angle should be degrees. vi . 5 1 level-medial angle should be degrees. vii . 52 level-medial angle should be degrees latera l ly. Each screw should cross ­ ...,.----,...,. of the vertebra l body. On AP view, if screw tip crosses the breach. midline, there is a Posterior l u m ba r i nterbody fusion (PLIF and TLI F) is relatively contraind icated with well-preserved heig ht; and is usually supplemented with to prevent prog ressive Benefits of TLIF over PLI F include less retraction and avoida nce of in reoperations.

5 deg rees 1 0 degrees 1 5 degrees 20 degrees 25 deg rees (Each angle eq uals the VB level x 5 . ) 2 5 degrees 40-45 deg rees two thirds

---

f. g.

_ _ _ _ _ __

medial disc-space; pedicle screws; spondylol isthesis

___ ___

_ _ _

h.

___ ___

nerve root; scar tissue

Neurosurgery Books

96.7.8

529

530 •

Part 23: Procedures, Interventions, Operations

Minimally I nvasive Lateral Retroperitonea l Transpsoas l nterbody Fusion 5. Complete the following regarding minimally invasive lateral retroperitoneal transpsoas interbody fusion: a . Access is best from however, a similar retropleura l approach can be employed in the thoracic spine up to b. With thoracic latera l interbody fusions one ca n n ot the contra latera l ___

_ _ __

L1 -L5; T4

96 . 8 . 1

_ __

penetrate; anulus

LLIF is particula rly usefu l in cases of a s f beca use it obviates dealing with or from previous su rgery which red uces the risk of d . LLI F, when combined with release o f the a I I , ca n be used to correct a n d to l u m ba r lordosis. e. LLI F is contraindicated i n cases req u i ring d d , disc space height > m m , or in cases with pathology at the space secondary to interference from the

adjacent segment fai l u re; sca r tissue; hardwa re; d u rotomy

f. A standalone cage should not be placed , pre-operative in patients with o , or if the i ligament is disru pted d u ring placement. g. Common transient compl ications include thigh n u m b ness in % of cases due to inj u ry to the nerve and thigh flexion weakness dye to inj u ry to the muscle. h. Fusion rates fol l owing LLI F ra nge from %.

osteoporosis; insta bility; anterior longitudinal

c.

___

96.8.2

_ __

__ _

___

___ __ _

_ __

___

a nterior longitudinal ligament; scoliosis; increase direct decom pression; 1 2mm; L5-S 1 ; ilium

1 0- 1 2%; genitofemora l ; psoas

96.8.3

96.8.5

96.8.6

___

_ __

___ ___

9 1 - 1 00%

96.8.8

97 Miscellaneous Surgical Procedures

•

Lumbar Puncture. Cl -2 Puncture and Cisternal Ta p 1.

a.

b. c. d.

e.

f.

g.

h. i.

Complete the following about spinal punctures: Contra ind ications t o l u m ba r punctu res i n c l u d e patients with platelet count < or patients with n hyd rocepha l u s . I n patients with SAH , a LP can increase the t pressu re and precipitate aneurysm a l rupture. A LP in patients with spinal block may prod uce deterioration i n as many as _%. T h e conus med u l l a ris is located between T1 2 and L 1 i n _% of patients, between %, and between L2 L 1 and L2 in and L3 i n _% of patients. The intercrista l line connects the su perior border of the i and occu rs in most a d u lts c between the spinous processes of and When performing a LP the needle is in a lways adva nced with the place in order t o prevent introd uction of cel l s which cou l d prod uce an iatrogenic e t T h e Queckenstedt is a test for block in which the j v is com pressed , fi rst on o n e side then o n both while measu ring ICP; if there is no block, the pressure wi l l rise to __ em of fl uid, and wil l d rop to the origi n a l level with in seconds of release. I n non-anemic patients there should be RBCs. _-_ WBCs for every that changes A RBC count > little as CSF d rains and an elevated ratio of to distin g u ished SAH from

50,000; non-co m m u nicating

97.3 . 1

tra n s m u ra l 1 4% 30%; 5 1 -68%; 1 0%

97.3.2

iliac crests; L4 and L5

stylet; epiderm a l ; epidermoid tumor subarachnoid ; j u g u l a r vei n ; 1 0-20; 10

1 -2 ; 1 000 1 00,000; WBC to RBC; tra u m atic ta p

97.3.4

Part 23: Procedures, Interventions, Operations

532

E

I n cidence of severe postpunctu re headache (lasting longer than days) is %. k. A CN palsy can occur delayed days post-LP and usually recovers after weeks. I. Epid u ra l b is a p treatment for refractory post LP headache. m. The C1 -2 punctu re is contraindicated in m due patients with C t o risk o f l o w lying c t and med u l l a ry k j.

•

7; 0 . 1 t o 0.5%, CN VI (usually u n i latera l ) ; 5 - 1 4 days; 4-6 weeks blood patch Chiari ma lformation; cerebellar tonsils; kin k

97 . 5 . 1

Lumbar Catheter CSF Drainage 2 . Complete the following about lumbar catheter CSF drainage: a . Ind ications for d rainage include red ucing CSF pressu re on a site of CSF , red ucing ,/ intracranial pressure in cases of hyd rocepha l u s or red ucing CSF pressure to attem pt to increase - perfusion of the -----,- .,-b. If the catheter does not thread into the spinal ca n a l , the catheter must be with the need le to withd rawn off the catheter tip. prevent ___

lea k/fistu la; com m u nicati n g ; s p i n a l cord

97.4.2

___

•

together; shearing

97.4.4

CSF Diversionary Procedures. Ventricular Access Device Complete the following regarding ventricular catheterization: a . Kocher's point is used as an entry point to place a catheter into the of the latera l ventricle a n d can be found em from midline and em a nterior to coronal suture which is approximately em u p from the nasion; the trajectory is to surface of bra i n , which ca n be approximated by aiming towa rds m c of ipsilatera l eye and the E b. Keen 's point is a bout em su perior to and posterior to the pinna and results in catheter placement into the em from c. Da ndy's point is em a bove inion. midline, and

3.

97.6. 1

fronta l horn; 2-3cm (mid pupillary line); 1 ern ; 1 1 em; perpendicu lar; medial canth us; EAM

2 . 5-3 em; trigone 2 em ; 3 cm

Miscellaneous Surgical Procedures d.

Occi pita l-parieta l approach is freq uently used for s h u nti n g ; a common entry point is em above and posterior to the top of the pinna; the catheter is to sku l l base initia lly inserted of the forehead or towa rds the ipsi latera l

3 cm , para l l e l ; middle; m e d i a l canth us

_ _ _ _ ____

Complete the following about ventricular shunts: a . List t h e layers t o traverse in open placement of the peritoneal catheter. ( H int: sa m p3 ) i. s ii. a, iii. m iv. p v. p vi . p b. If a connector must be used near the the clavicle to clavicle, place it decrease the risk of ---,---,c. A ventricu loatrial s h u nt should be revised when the catheter tip is a bove d. D u ring third ventriculostomy the open ing is made to the m a m m i l l a ry bodies which is to the tip of the basi lar a rtery; after puncturing the floor be certa in that the is a lso perforated. of e. The needle to be used in a n ommaya reservoir puncture is a gauge or smaller need le.

4.

__ _ ___

_ _ _ _ _ _ _ _ __ _ _

97.6.3

su bcuta neous fat anterior rectus sheath muscle posterior rectus sheath preperitoneal fat peritoneum a bove; disconnection T4

___

a nterior; a nterior; mem brane of Liliequ ist

97.6.4

____

•

25; butterfly

97.7.4

Sural Nerve Biopsy 5.

a.

Complete the following about sural nerve biopsies: T h e fol l owing a re ind ications for s u ra l nerve biopsy: i. a, ii. C -M -T a iii. d iv. H d. I v. m vi . v - --,- ,......., At the level of the a n kle the sura l nerve lies between the tendon and mal leolus. the A tou rniq uet is used to distend the I s vei n . loss is expected b u t does not persist for more than weeks. _ _ _ _

____

___

___ _

_ _ _ _

b. c. d.

_ _ _ _

97.8.2

a myloidosis Charcot-M a rie-Tooth dia betic a myotrophy Ha nsen 's disease metachromatic leu kodystrophy vascu litis achil les; latera l

97.8.4

lesser saphenous

97.8.5

Sensory; severa l

97.8.3

533

a

��nal •

Neurosurgery

Deep Brain Stimu lation 1 . Characterize Parkinson's disease. a . Best target is the b. It has similar efficacy to c. with fewer d . Ablative surgery is giving way t o

__

98. 1

.

2. Match the following conditions with their stimulation target sites. Conditions: CD Tou rette's synd rome; 0 obsessive com p u lsive disorder; ® depression a. a nterior ca psule b. thalamic c. STN d . subgenual e. ci n g l u ate gyrus f. pa llidal

•

s u bthalamic nucleus levodopa side effects DBS (deep brain sti m u lators) 98. 1

0. ® CD 0 ® ® CD

Surgica l Treatment of Parkinson's Disease 3.

a. b. c. d. e.

Matching. Regarding surgical ablative treatment of Parkinson's disease and its historical background, match the listed procedures with the appropriate phrase(s) and benefits. Aba ndoned beca use: CD u n p redicta ble resu lts; 0 tremor did not i mp rove; ® bradykinesia did not i mp rove; @ rigid ity did not i mprove ; ® ipsilatera l tremor persists; ® side effects/ resista nce; (j) only modest benefits Proced u re: (a-e) below a nterior choroidal a rtery ligation anterodorsal pallidotomy ventrolatera l thalamotomy L-dopa transpla ntation

CD 0. ® ® . @. ® ® (j)

Neurosurgery Books

98.3 . 1

98.3.2

Functional Neurosurgery 4. True or False. The following symptoms improve after anterodorsal pallidotomy: fa lse a . tremor ipsilatera l b. rig idity true fa lse c. bradyki nesia d. ataxia fa lse e. tremor contra latera l fa lse

98.3 . 1

5. Ventrolateral thalamotomy can improve tremor; i t cannot be performed bilaterally because bilateral thalamotomy causes a. d dysa rth ria and b. g d gait distu rba nce

98.3 . 1

Complete the following about surgical treatment of Parkinson's disease: a . T h e target today is the

98.3.2

6.

b.

specifica l ly the which blocks the in put from the

7. a. b. c.

How might pallidotomy work? direct destruction of the fibers interrupt d i m inish in put from the

8. Answer the following about surgical treatment of Parkinson's disease: a . What was a n ea rly procedure for the treatment of Parkinson disease? b. What a re the mechanisms by which pa llidotomy may work? i. destroy ii. interru pt p p iii. red uce input into m p c. What is the ta rget for the tremor treatment? d . True or Fa lse. Pa llidotomy is pri marily focused on the treatment of motor symptoms. e. What are the most common com p lications of pa llidotomy? Hint: vhid i. v ii. h iii. i h iv. d

g

a nterodorsal pallidum G Pi-intern a l segment of the globus pallidus; STNs u bthalamic nucleus 98.3.2

G Pi pa l l idofugal s u bthalamic nucleus 98.3.2

l igation of the a nterior choroidal a rtery GPi pa l l idofugal pathways medial pallidum ventra l is intermedius nucleus (VI M ) of the tha l a m u s true

visual field deficit hemiparesis intracerebral hemorrhage dysa rth ria

535

536

Part 23: Procedures, Interventions, Operations

9. True or False. Indications for pallidotomy in parkinsonism include a. refractory to d rug thera py b. d rug-induced dyskinesia c. rigidity d . tremor e. dementia

a

1 0.

Ipsilateral hemianopsia is a contraindication to ventral pallidotomy because one of the side effects of the procedure could be i t 0 and would cause the patient to be

11.

Bilateral pallidotomies carry an increased risk of and s d d c

a. b.

1 2. True or False. What are the benefits for the patient from posteroventral pallidotomy as done currently? a . motor sym ptoms b. dyskinesia c. rigidity d . bradyki nesia e. tremor 1 3. a.

b. c. d.

1 4. a.

b.

•

98.3.2

true true true fa lse fa lse optic tract inj u ry; blind (Visual field defects cou l d occur in 2 . 5 % of patients; blind ness could resu lt.)

98.3.2

speech d ifficu lties cog nitive decl ine 98.3.2

true true true true true

Characterize thalamic lesions. Lesioning in the thalamic n ucleus red uces parkinsonian H owever, it does not improve

tremor dyskinesia

and may worsen s i. g ii. s p

gait sym ptoms speech problems

and

Characterize subthalamatomy. Lesions i n the STN classica l ly prod uced

Selective lesions may give relief on a par with

98.3.2

98.3.2

intermedius

98.3.2

hemiballism pallidotomy

Dystonia 1 5. a.

Characterize dystonia. Sti m u lation o f the is the pri mary surgical treatment for the dystonia. b. Resu lts a re better for dyski nesia. c. The most common target is

98.4

pallidum ta rd ive G Pi

Functional Neurosurgery 1 6. True or False. Stimulation has attracted increasing interest in patients with Parkinson's disease who are refractory to medical drug treatment. The deep brain stimulator (the electrode) is placed in which of the following locations? (There are three true answers.) a. zona i ncerta b. posterior ventra l pallidum (PV} c. su bsta ntia nigra (SN} d. Forel's field ( H ) e. s u bthalamic nucleus (STN} f. globus pallidus intern us (GPi} g . ped unculoponti ne nucleus

•

98.4

g fa lse fa lse fa lse fa lse true true true

Spasticity 1 7. True or False. A spastic bladder will a. have high capacity and em pty sponta neously. b. have high capacity and em pty with difficu lty. c. have low capacity and em pty sponta neously.

d.

have low capacity and em pty with difficu lty.

1 8. True or False. The onset of a spastic bladder after spinal cord injury is a . im med iate b. delayed

c.

ca n occur at any time

1 9. True or False. The Ashworth score can grade severity of spasticity. The highest score in this system is given when there is a . no increase in tone (fu l l movement) b. rigidity in all flexors c. rigid ity i n all extensors d. rigid ity in flexion and extension 20. The Ashworth score is the clinical of grading of the

537

98.5.2

fa lse fa lse true ( Low capacity a n d spontaneous em ptyi ng a re the h a l l m a rks of the spastic bladder.) fa lse 98.5.2

fa lse true (Delayed onset is typica l beca use the acute phase of spinal shock is hyporeflexic and hypotonic.) fa lse Ta ble 9 8 . 2

fa lse fa lse fa lse true severity of spasticity

98.5.2

538

Part 23: Procedures, Interventions, Operations

21 . What are the medications used in the treatment of spasticity? a. b b. d c. d d. p

a

22. What are the nonablative procedures used for the treatment of spasticity? a. b m b. i e c. e s 23. True or False. Fibers that are more sensitive to radiofrequency rhizotomy are a . s m a l l u n myel i nated sensory fi bers. b. large myeli nated alpha motor fibers. 24. What are the ablative procedures with preservation of ambulation used for the treatment of spasticity? Name one.

98.5.3

baclofen diazepam da ntrolene prog a bide 98.5.3

i ntratheca l baclofen intrathecal morph ine epid u ra l electrical sti m u l ation 98.5.3

true fa lse motor point block; phenol nerve block; selective neu rectomy; percuta neous radiofrequency foramina! rhizotomy; Bischof's myelotomy; selective dorsal rhizotomy; stereotactic thalamotomy; dentatotomy

25. What are the ablative procedures with intratheca l injection of sacrifice of ambulation used for the phenol; selective anterior treatment of spasticity? Name one. rhizotomy; neu rectomy; intra m uscu l a r neurolysis; cordectomy; cordotomy 26. True or False. Spasticity can be treated with intrathecal baclofen pumps. Complications are mainly fa lse a. p u m p u n der-infusion fa lse b. wou n d com p l ications c. catheter compl ications true (Catheter com p l ications may have a freq uency of up to 30% in baclofen p u m ps.) fa lse d. d rug resista nce

•

98.5.3

98.5.3

98.5.3

Torticol lis 27. What is another name for torticollis?

wry neck

98.6. 1

28. What muscle is usually affected in spasmodic torticollis?

sternocleidomastoid

98.6.2

Functional Neurosurgery 29. What are the surgical procedures used for the treatment of spasmodic torticollis? a . sti m u late dorsal cord botu l i n u m toxi n b. inject rh izotomy Forel's H l c. cut d . coa g u late vertebra l a rtery 30. What artery is most commonly implicated in the torticollis of the eleventh nerve origin?

•

vertebra l a rtery

98.6.3

g 98.6.6

Neu rovascular Compression Syndromes 31 . a.

Characterize root entry zone. Synd romes d u e t o com pression of i. ii. at the

98. 7 . 1

cranial nerves root entry zone

b. This site, also known as the zone, c. is the point where the centra l myelin from the cel l s d . changes t o t h e periphera l myelin o f the cells.

Obersteiner-Red lich

32. True or False. Hemifacial spasm ( HFS ) starts from the lower half of the face and spreads to the upper half of the face.

fa lse (sta rts with the orbicu l a ris ocu li)

33.

a. b. c. d. e.

Complete the following about neurovascular compression syndromes: On what side is H FS more com mon? What is the age and gender pred ilection? What is the most commonly involved a rtery? True or Fa lse. Ca rba mazepine and phenytoin a re genera l ly effective treatment. What is the material used as a cushion in the microvascu lar decompression (MVD)?

34. What is the only other involuntary movement disorder besides HFS that persists during sleep?

oligodendrog lia! Schwa n n cel l s 98.7.2

98.7.2

left women, after the teen ages AICA fa lse lvalon, polyvinyl formyl alcohol foam palata l myoclonus

Neurosurgery Books

539

98.7.2

a

Part 23: Procedures, Interventions, Operations

540

35. What distinguishes HFS from facial myokymia {FM)? a . Hemifacia l spasm ( H FS) i s b. Facial myokymia (FM) is 36. True or False. The vessel most commonly associated with hemifacial spasm is a . posterior inferior cerebel lar a rtery (PICA) b. su perior cerebel l a r a rtery (SCA) c. a nterior inferior cerebel lar a rtery (AICA) d . posterior cerebral artery (PCA) e. vertebra l a rtery f. basilar a rtery 37. a.

Hemifacial spasm is ca used by com pression at the

b. of the c. by the d . This does not cause conduction but e. prod uces and 38. a.

b. 39.

a. b. c. d. e. f. 40.

a. b. c. d. e. f. g. h.

Synkinesis is a phenomenon where of sti m u lation of the facia l nerve resu lts i n thro u gh True or False. Postoperatively after microvascular decompression for hemifacial spasm, the patient can expect im med iate cessation o f facia l spasms. red uction sta rti ng 2 to 3 days later. better resu lts the longer the patient has had H FS. better resu lts t h e o l d e r t h e patient is. com plete resol ution of spasms eventua l ly. possible rela pse even if free of spasms for a fu l l 2 years. Complications of hemifacial spasm { H FS) surgery include the following: H i nt: hemifacial s h e m i f a c ___

98.7.2

u n i l atera l bilatera l 98.7.2

fa lse fa lse true fa lse fa lse fa lse 98.7.2

root entry zone facia l nerve AICA ephaptic ki n d l in g , syn kinesis 98.7.2

one branch delayed discharges; another branch 98.7.2

fa lse true fa lse fa lse true (in 81 to 93% of patients) fa lse (relapse after 2 yea rs only 1 %) 98.7.2

hoa rseness elderly do less wel l meningitis (aseptic) ipsilatera l hearing loss facial weakness ataxia CSF rhinorrhea incomplete relief of sym ptoms

Functional Neurosurgery i. j. k.

•

a I s

aseptic meningitis lip (periora l) herpes swa l lowing (dysphagia)

_ _ _ _ _ _ __

_ _ _ _ _ ___ _ _ _ _ _ _ __

Hyperhid rosis Complete the following statements about hyperhidrosis: a . I t is d u e t o overactivity o f t h e gla nds. b. These glands are under control of the

41 .

_ _ _ _

eccrine sweat

98. 8 . 1

____

c. The neu rotra nsm itter is end organs a re d . Most

_ _ _ _

e.

•

Some cases wa rra nt

_ _ _ _

sym pathetic nervous system acetylcholine sym pathetic; adrenergic surgical sym pathectomy

98.8.2

from stel late ganglion

98. 1 0. 1

Sympathectomy 42. Complete the following statements about sympathectomy: a . What is t h e level for ca rdiac sym pathectomy? b. What is the level for U E sym pathectomy? c. What is the level for l u m ba r sympathectomy? d . What is t h e most com monly used a pproach for l u m ba r sym pathectomy? 43.

a. b. c. d. e. 44.

a. b. c. d.

Name five indications for upper extremity (UE) sympathectomy. H i nt: "crash" the sym pathetic ganglia c R a s h What are the complications of UE sympathectomy? p i n c s H s

second thoracic ganglia T2 L2 and L3 sym pathetic ganglia retroperitoneal

98. 1 0. 2 98. 1 0.4

Ta ble 9 8 . 6

ca usalgia major prim a ry Raynaud disease intracta ble angina shoulder-hand synd rome hyperhidrosis 98. 1 0. 2

pneumothorax intercosta l neuralgia spinal cord i nj u ry Horner's synd rome

541

99 Pain Procedures

•

General I nformation 1.

Usual oral narcotic dose tolerated is c M ___ ,

•

MS contin (up to 300 to 400 mgfday)

99. 1

Types of Pain Procedures Name intracranial ablative procedures to treat the following pains: t a . cancer pa i n : m m b. head, neck, face pai n : s

2.

__

_ __

__

3.

a. b. c. d. e. f. g. h.

__

Matching. Match the procedure and its application (some have more than one). Applications for pain fro m : CD s p i n a l cord inj u ries; 0 post­ laminectomy pai n ; ® pelvic pain with incontinence; @ at or below CS; ® head , face, neck, u pper extrem ity; ® bilatera l below the diaphra g m ; (j) ca usalgia; ® bilatera l below thoracic dermatomes; ® avu lsion inju ries; @) not for cancer pain Proced u re: (a-h) below stereotactic mesencephalotomy cordotomy spinal i ntrathecal sacra l cordotomy sym pathectomy com m issura l myelotomy dorsal entry zone (DREZ) spinal cord sti m u l ator

99.3

medial thalamotomy stereotactic mesencephalon 99.3

® @ ® ® (j) ®

CD. ®. @ 0. @

Pain Procedures •

Cordotomy 4. Complete the following concerning cordotomy: a . You r objective is t o interru pt t h e fi bers of the I s t t on the side thalamic tract c to the pai n . b . Cordotomy is t h e procedure o f choice pain below the c for u dermatome. c. Two ways to perform cordotomy: i. o ii. p d . Loss o f a utomatic breath ing can occur after b c and is ca l led o c e. What is the cutoff percentage on pul monary fu nction test before patients can undergo cordotomy? __

__

__

_ _ _

__ _ __ _

___

___

___

99.4. 1

u n i latera l ;

cs

open percuta neously bilatera l cordotomy; Ondine's cu rse

__

5. Answer the following about pain procedures: a . What kind o f patients a re ca ndidates for cordotomy? b. On which side should the cordotomy be performed? c. What happens to i m pedance as the needle penetrates the cord? d. What response should stop cordotomy from being performed? e. If you look at the patient's eyes, what will you learn?

f. What percentage wi l l have pain rel ief?

•

latera l spinal tha lamic tract; contra latera l

50%

99.4.2

99.4.3

term inally ill patients contra latera l to pain j u m ps from 300 to 500 ohms to 1 200 to 1 500 ohms muscle teta ny u pon sti m u l ation If a n ipsilatera l Horner's synd rome occurs, the procedure is satisfactory. 94%

Commissu ral Myelotomy 6. Answer the following concerning commissural myelotomy: a. What is the ind ication for com m issura l myelotomy? b. What is the rate of complete pain rel ief after com m issural? c. What is the special req u i rement for i ntrathecal morphi ne?

bilatera l or midline pain

99.5.2

60%

99.5.4

preservative-free 0.9% saline

99 . 7 . 1

543

544 •

Part 23: Procedures, Interventions, Operations

CNS Narcotic Administration 7. Answer the following regarding central nervous (CNS) narcotic administration: a . Req u i rement for implantation o f a morphine p u m p is p t d i ca n shorten the delay b. B time for a morphine p u m p to fu nction; otherwise the rel ief may not occur for d c. Is meningitis common after pump placement? d . Is respi ratory fai l u re common after p u m p placement? ___

E •

pre-operative testi ng dose

___

--

___

99.7 . 1

___

Bolus infusion; days no no

Spinal Cord Stimulation (SCS) Complete the following regarding spinal cord stimulation: a . Site o f spinal cord sti m u l ation is the c d i. The most common ind ication is s p p ii. It is not usually ind icated for c p . b. Two ki nds of electrodes: -li ke i. p ii. w -like

8.

---

__

__

__

dorsal col u m n s postlaminectomy pain synd rome ca ncer pain

99.8 . 1

99.8.2

__

___

9.

a. b.

Complete the following statements about complex regional pain syndrome (CRPS)? I t is a c pain condition characterized by intense a or b pa i n . ___

1 0. What is the difference between Type I and Type I I chronic regional pain syndrome?

plate wire 99.8.6

chronic ach i n g ; burning Type I has no nerve inj u ry and Type II fol l ows a nerve inj u ry.

1 1 . True or False. Regarding spinal cord stimulation: a . I m p roves p a i n control over physica l true therapy or medical ma nagement alone in patients with failed back surgery. b. It helps with pain d u e to inoperable l i m b true ischemia. c. Red uces angina pain and i mproves true exercise capacity.

Neurosurgery Books

99.8.6

99.8.6

Pain Procedures •

Deep Brain Stimu lation ( DBS) 1 2.

a.

Complete the following regarding deep brain stimulation: Deafferentiation pain synd romes may benefit from sti m u lation of the

99.9

sensory thalamus

DBS for chronic neuropathic pain 40-50%; prod uces a red u ction of _-_% in pain 2 5-60% in a bout _-_% of patients. periaq ued ucta l g ray matter c. Nociceptive pain synd romes benefit from sti m u lation of

b.

_ _ _ _

d.

•

Cluster headaches m a y benefit from

hypothalamic sti m u l ation

Dorsa l Root Entry Zone (DREZ) Lesions 1 3.

a. b. c. d.

Complete the following about dorsal root entry zone {DREZ) lesions: They a re usefu l for d pa i n . They result from nerve root a . They most com monly occur from accidents. m For such a n inj u ry, pain relief c a n be %. expected in __

__

deafferentiation avu lsion motorcycle 80 to 90%

99 . 1 0. 1

99. 1 0. 5

545

1 00 Seizure Surgery

•

General I nformation, Indications 1 . What percent of patients are not controlled with medication? 2.

a. b.

Characteristics of refractory seizures considered for surgery. Nature o f seizu res? Length of treatment?

20%

1 00 . 1

1 00 . 1

severe disabling at least 1 yea r

Complete the following regarding medically refractory seizures. a . Medica l ly refractory is usually considered two attem pts of high dose monothera py two distinct AEDs, and b. with attem pt at polytherapy. one c.

3.

1 00 . 1

__

__

__

•

Pre-surgica l Eva luation 4. True or False. Regarding pre-surgical evaluation. a . A l l patients should u ndergo high resol ution M RI as part of pre-su rgical eva l u ation. b. It is the best test to demonstrate hippocampal asym metry. 5.

a.

Complete the following about noninvasive seizure evaluation techniques. Video-EEG monitoring is used t o identify f the s I n a CT with IV contrast the focus may e in l ntericta l PET sca n shows h % of patients with refractory CPS. D u ring a seizu re a SPECT wi l l demonstrate b f d u ring a s

true

1 00 . 2 . 1

true

1 00 . 2 . 2

1 00 . 2 . 2

seizure focus

__

b. c.

---

enhance hypometabolism ; 70%

__

d.

___

___

blood flow d u ring a seizu re

Seizure Surgery Complete the following about the WADA test: a . T h e pu rpose is t o loca lize d, h b. You ca n be misled by i. A ii. p a t. iii. h by s iv. p c.

6.

_ _ _

__ _

____

__ _

_ _ _ _

7. When there is lack of lateralizing or localizing physiology in pre-operative evaluation, there are two surgical options for better definition of seizure focus: a. d e b. s g or s _ _ _

___

•

_ _ _

dominant hemisphere AVM persistent trigeminal a rtery hi ppoca mpus su ppl ied by posterior circu lation 1 00 . 2 . 4

depth electrode surgical g rids or strips

Surgica l Techniques 8.

a. b. c.

•

___

1 00 . 2 . 3

Surgical disconnection operations available are: c.____

h m

___ _ ____

s

____

t.

_ _ _ _

1 00 . 3 . 1

ca llosotomy hemispherectomy m u ltiple su bpial tra nsections

Surgica l Procedu res 9.

a.

Complete the following about corpus callosotomy (CC): Indication for corpus callosotomy i. d a -a s s h ii.

1 00.4. 1

d rop attacks - atonic seizu res

___

____

____

___

b. c.

How much of the CC is resected? Com p l ication is a m

d.

M u st the anterior com m issure also be sectioned?

e. f.

Contra ind ication? Exclude by W t I h persons.

__ _ _

___

___

on a l l

infa ntile hemi plegia synd rome a nterior two-thirds akinetic m utism (or red uced tem porary verba l ization) no - less likely to get disconnection synd rome if spared crossed dominance Wada test on a l l left-handed persons

547

548

Part 23: Procedures, Interventions, Operations

1 0. Answer the following about disconnection syndrome in a left­ dominant person (i.e., right-handed): months. a . Usually lasts b. Effect: i. left hand t a ii. vision p iii. smel l : a iv. copyi ng fig u res (i.e., spatial synthesis): p with r h v. speech: r s vi . u ri n ary i vii . left-sided d c. Occu rs with I of c c d . Less likely t o occur i f a c is s. _ _ _

__

1 00.4. 1

2 to 3 months tacti le anomia pseudohemia nopsia anosmia poor with right hand

__

_ _ _

__ _

__

_ _ _

_ __

red u ced spontaneity incontinence dyspraxia l a rge lesions of corpus ca llosum a nterior com missure is spared

_ _ _

11.

Complete the following regarding temporal lobectomy limits: a . On dominant side permitted i. ii. too much i s b. On nondominant side perm itted i. ii. too much c p u h c. G reater resection of wil l cause i. c ii. c u h __

__

___ ___

___

_ _ _

_ _ _

•

1 00 . 4 . 2

4 to 5 em inj u res speech 6 to 7 em contra latera l partial u pper hemia nopsia 8 to 9 em contra latera l complete u pper hemia nopsia

M RI Guided Laser I nterstitial Thermal Thera py ( M RGLITT) 1 2. a.

Complete the following. M RG LITT sta nds for M g l i t t.___ b. It is performed with s i m u lta neous M RI g s c. It is considered I invasive than microsu rgery. d . What is t h e main advantage? e. Preliminary seizu re control is _ to _%. __

__

__

__

1 00 . 6

M RI g u ided laser interstitia l therm a l thera py stereotactic g u ida nce

_ _ _

less shorter post-op recovery 60 to 70%

Seizure Surgery •

Post-operative Management for Seizure Surgery (Epilepsy Surgery) 1 3. True or False. Regarding post­ operative management for epilepsy surgery. a . Req u i res I C U observation for 24 hou rs. b. Not necessa ry to treat one brief general ized seizure. c. Ad m i nister 1 0 mg dexamethasone IV before s u rgery followed by q8 hours dosing as necessa ry. d . Anti-convu lsa nts ca n b e discontin ued immediately after su rgery.

e.

•

549

1 00 . 7

true true true fa lse (need to be contin ued for 1 -2 yea rs even if no post­ op seizu res occur) true

Neu ropsych iatric eva l uation 6- 1 2 months after surgery.

Outcome Describe seizure surgery outcome expectations. a . T h e g reatest effect o f surgery is r s f . b. Incidence of being seizu re free is %. c. Seizu res red u ced by at least 50% in %.

1 4.

__

__

__

1 00 . 8 . 1

of

red uction of seizu re frequency 50%

__

80%

__

1 5. What is the main risk of surgery during vagus nerve stimulation?

voca l cord para lysis

Neurosurgery Books

1 00 . 8 . 3

1 01 Radiation Therapy {XRT)

•

Conventional External Bea m Radiation 1.

a. b. c.

Radiation injury to tissue is a function of: d e a

2. What are the four " R's" of radiobiology? a. R b. R

c.

R

d.

R

3. What is the linear-quadratic equation ( LQ-model)?

Complete the following about cranial radiation: a. After surgery most s u rgeons wait _ to _ days before irradiati n g . b . Tumors that a re very responsive t o XRT include: i. I ii. g_ c_ t

1 01 .2.1

dose exposu re time a rea 1 01 .2.1

Repair of sublethal damage Reoxygenation of previously hypoxic tumor cells Repopu lation of tumor cel l s fol lowing treatment Red istri bution of cel l s within the cel l cycle Biolog ica lly effective dose (Gy) = n x d x [1 + d / (a/�)] ; where n = # of doses, d = dose per fraction, and a/� ratio = description of cel l response t o radiation with higher va l u es corresponding to earlier-responding tissue such as tumor cells.

4.

___

5. What are the two normal CNS cell types most vulnerable to radiation necrosis? a. v b. 0 --

1 01 .2.2

1 01 .2.3

7 to 1 0

lym phomas germ cel l tumors 1 01 .2.3

vascu l a r endothelium oligodendrog lia! cel l s

Radiation Therapy (XRT) 6. Seven major side effects of radiation: a. d c b. r n c. o_ p inj u ry d. h e. p h f. formation of new _ __

___

__ _

_ ___ __

_ _ _ _

_ _ _ _

g. 7. Two major treatments of radiation necrosis are: a. s b. s _ __

__

8.

What is the estimated dose of XRT that can be tolerated by normal brain tissue?

9. True or False. Regarding the following imaging studies to detect radiation necrosis: a . M R spectroscopy is usefu l i f mass is pure tumor. b. MR spectroscopy is usefu l if mass is pure necrosis. c. MR spectroscopy is usefu l if mass is a m ix of tumor and necrosis. d. RN wi l l lead to decreased radionuclide u pta ke on SPECT imaging. e. RN wil l lead to increased reg ional g l u cose meta bolism on PET imaging.

1 01 .2.3

decreased cog nition radiation necrosis optic pathway inj u ry hypopitu ita rism pri m a ry hypothyroidism formation of new tumors g l iomas, meningiomas, nerve sheath tumors leukoencephalopathy 1 01 .2.3

steroids su rgery (if deterioration from mass effect) About 65-75 Gy g iven as 5 fractions/week over 6. 5-8 wks. Radiation necrosis wil l occur in about 5% o f patients after 60 Gy g iven as 5 fractions/week over wks.

1 01 .2.3

true true fa lse true fa lse (wil l be decreased) No definitive proof of prolonged s u rviva l . Often used for pain relief and preservation of fu nction.

1 0.

Has radiation of spinal metastases been shown to prolong survival?

11. a. b. c. d.

Side effects of spinal radiation include: m myelopathy or neuropathy or n nausea, vomiti ng, dia rrhea n ,v .d b m s bone ma rrow s u ppression in children g r g rowth reta rdation in children development of c cavernous ma lformations m

e.

___ _

_ _ _ _

__ __

___

___

___

___

____

1 01 .2.3

1 01 .2.4

1 01 .2.4

551

552

Part 23: Procedures, Interventions, Operations

1 2. What are important factors relating to the occurrence of radiation myelopathy? a. r b. t r d s c. extent of c d. i s e. a m ount of t r f. v s to the reg ion radiated g. s of r __

__

__

__

_ _ _

_ _ _ _

__

__

__

__

__

__ _

a.

Describe the 4 types of radiation myelopathy. Type 1

b.

Type 2

c.

Type 3

1 3.

d . Type 4

1 4. What radiation doses are associated with negligible risk of radiation myelopathy?

•

1 01 .2.4

rate of appl ication tota l radiation dose extent of cord shielding individ ual suscepti bil ity amount of tissue radiated vascu lar su pply sou rce of rad iation Ta ble 1 0 1 . 1

Benign form , mild sensory symptoms/ Lherm itte's sig n , occurs severa l months following XRT but usually resolves within severa l months. Lower motor neuron signs in u pper or lower extrem ities due to inj u ry to a nterior horn cells. Complete cord lesion with in hours due to blood vessel inj u ry. Most com mon, chronic prog ressive myelopathy with initial pa resthesiasf Lherm itte's sign and eventual spastic wea kness with hyperreflexia . Dependent on field size. Large fiel d : neg ligible risk with � 3.3 Gy over 6 weeks (0.55 Gyfwk). Small field: negligible risk with � 4.3 Gy over 6 weeks (0. 7 1 7 Gyfwk).

1 01 .2.4

Stereotactic Radiosurgery and Radiotherapy 1 5.

a. b. c. 1 6.

The three main categories for delivery of SRS/SRT are: G K I a h c p _ __

_ _ _

___ _

1 01 .3.1

Gamma Kn ife (gamma ray) linear accelerator (x-ray) heavy charged particle radiosu rgery

The main source of gamma decay used Coba lt-60 in Gamma Knife is ___ _

1 01 .3.1

Radiation Therapy (XRT) 1 7.

In general, lesions less than in diameter are amenable to treatment with SRS. ___

1 8. What is the maximum recommended radiation dose to the following organs? a . eye lens: Gy Gy b. optic nerve: Gy c. skin in bea m : d. thyroid: Gy _

_

_

_

1 9. Is SRS useful for a . venous an giomas? b. an AVM with a compact nidus? c. d u ra l AVF with cortical d rainag e?

< 3 cm

1 0 1 .3.2

1 0 1 .3.4

1 Gy 1 Gy 0 . 5 Gy 0 . 1 Gy 1 0 1 .3.5

no yes no - high risk of hemorrhage with cortica l d rainage

20.

The V R A scale and P -F score are useful scales to predict favorable outcome with AVM radiosurgery.

Virginia Radiosu rgery AVM Scale; Pollock-Fiickinger score

21 .

The gold standard ( Level l ) recommendation for a single brain metastasis in an accessible region is s r plus w .

surgical resection ; WBRT

__

1 0 1 .3.5

1 0 1 .3.5

__

22. True or False. Based on prospective randomized study data involving patients with a single brain metastasis: a . S u rviva l between SRS vs. su rgery + WBRT true is equal. true b. There was a higher incidence of d ista nt recu rrence i n the SRS arm. 23.

In pituitary adenomas treated with SRS, is the percentage of tumor growth control rate or endocrine remission rate higher?

Immediate adverse reactions to SRS include: h a. p and v b. n c. s d . Adverse events have been red uced by pre-medicating with m and

Overa l l tumor control rate has been reported as 90% vs. endocrine rem ission rates ra nging from 26 - 54% depending on the hormone being over-secreted. Typica lly a higher dose of radiation is req u i red for secretory tumors.

24.

_ _____

_ _ _ _

_ ____

P· -------

1 01 .3.5

1 01 .3.5

1 01 .3.5

post-proced u ra l headaches nausea and vomiting seizu res methyl pred nisolone; phenoba rbita l

553

554

Part 23: Procedures, Interventions, Operations

25. Complications from SRS include: a. v deficits n b. c c. radiation-ind uced t d . radiation-induced i c __ __ __ __ __ ___

_______

__ _

_ _ _

•

1 01 .3.5

vasculopathy cranial nerve deficits radiation-i nduced tumors radiation-i nduced imaging changes

I nterstitial Brachytherapy 26. What are three techniques for brachytherapy? a . insertion o f i_p b. insertion of c containing radioactive sou rce c. admin istration of r I _____

_ _ _ _

__ _ _ __

1 0 1 .4.2

lodine- 1 2 5 pellets catheters radioactive liquids

_ _ _

Neurosurgery Books

1 02 Endovascular Neurosurgery

•

General I nformation 1.

a. b.

•

Contraindications to catheter angiography: disorders u ncorrected b poor r fu nction d u e to dye load

1 02 . 1 . 3

ml

bleeding rena l ; iodine

Pharmacologic Agents 2. a. b.

c. d.

e. f. g. h. i. j. k. I.

Pharmacologic agents: Brand n a m e o f abcixi m a b is R Mecha nism of action is that it prevents binding of f to p GP lib/lila r Aspirin works by irreversibly inactivati ng c U n coated aspirin achieves p e a k plasma concentrations in _ - _ min utes, whereas enteric-coated aspirin reaches peak in hours. % of patients a re U p to resista nt to aspirin 325 mgfday. Brand name of clopidogrel is P It is a platelet A receptor a ntagonist. days before procedure Sta rt beca use it takes _ - _ days to reach fu l l therapeutic effect. Use mg load ing dose it there is no tim e to reach therapeutic effect over a few days. Brand name of eptifi batide is I i n h i bitor of p It is a r aggregation. ACT g o a l for embolization o f a n aneurysm or AVM is seconds. ACT goal for angioplasty with/without seconds. stenting is __

m.

__

__

Reo Pro; fi brinogen; platelet; receptors cyclo-oxygenase

1 02 . 2 . 2

1 02 . 2 . 3

30-40 min utes; 6 hours 30% Plavix ADP

1 02 . 2 . 4

5 days; 3-7 days 300 mg l nteg ri l i n reversible; platelet 300-350 seconds

__

2 50-300 seconds

1 02 . 2 . 5

1 02 . 2 . 6

Part 23: Procedures, Interventions, Operations

556

n . Ag ent used t o reverse heparin i s p s o. Agent used d u ring Wada test is a s mg is injected through p. catheter for Wada test with additional mg if needed. bol uses of q . tPA converts p to p r. Can be administered i or i s. tPA can be reversed using F t. Verapamil is a c c blocker that enables v _ _ _ _

prota mine su lfate sod i u m a myta l

1 02 . 2 . 9

_ _ _

_ _ _

_ _ _ _

_ _ _

_ _ _ _

__ _

•

E

plasminogen; plasmin intravenously; i ntraarteria l ly FFP ca lcium channel; vasod ilation

1 02 . 2 . 1 0

1 02 . 2 . 1 1

Neu roendovascular Procedure Basics 3. Neuroendovascular procedure basics: a . Vascular access c a n b e obtained via f a rtery, r a rtery, a rtery, or c a rtery. b b. Arteriotomy clos u re options include m pressure or percuta neous devices. c

•

1 00 m g ; 25 mg

femora l ; rad i a l ; brachial; ca rotid manual; clos u re

1 02 . 3 . 1

1 02 . 3 . 3

Disease-Specific I ntervention 4. a.

b.

c. d. e. f.

Endovascular treatment of aneurysms: Endovascu lar treatment h a s emerged a s af I thera py for most aneurysms, but su rgery stil l remains a strong option for M and p aneurysms. Wide necked aneurysms were previously thought better su ited for c but increased the availability of s the spectru m of aneurysms a menable to endovascu lar treatment. S m a l l aneurysms mm a re less favora ble for c Another endovascu lar option for wide necked aneurysms is b -assisted coi ling. Most coils a re made from b p The p device e e into prevents b aneurysm and therefore encourages s __ __ __

1 02 . 5 . 1

fi rst line; MCA; PICA clipping; stents

less than 4 m m ; coi ling ba l l oon bare plati n u m pipeline embolization; blood entry; stasis

Endovascular Neurosurgery month fol low-up ang iogram of usually reveals complete o aneurysm . h . Treatment o f aneurysm ru ptu re d u ring coi ling: p i. lower b if being used ii. inflate b iii. reverse a iv. contin u e c v. insert E.

g.

___

___ _

__ _

___ _

_ _ _ _

5. a.

Management of vasospasm: Endovascu lar options include c. spasmolysis and a Drug of fi rst choice for spasmolysis is v R treatments may be considered .

_ _ _ _

_ _ _ _

b.

6 month; obl iteration

blood pressu re bal loon a nticoa g u lation coi ling EVD 1 02 . 5 . 2

chemica l ; a n g ioplasty verapamil

_ _ _

c.

6. AVM embolization: a . Ind ications: i. Most common indication is p embolization. ii. Embol ization of associated or aneurysms located on f in n iii. Cu rative AVM embolization is r and l i m ited to s AVMs with s a ngioarchitecture. b. 2 most common embolic agents include o and N c. Radiopaque component of Onyx is t d . Onyx req u i res priming microcatheter with D to prevent Onyx s within microcatheter. e. N B CA is an embolic agent that is a g

Repeat 1 02 . 5 . 3

pre-operative feeders; nidus

___

_ _ _

__ _

___ _

__ _

_ __ _

ra re; sma l l ; simple onyx; N BCA ta nta l u m DMSO; solid ification glue

_ _ _

7. a.

Dural arteriovenous fistula (DAVF): featu res a re DAVF with a a lways considered for treatment. b. These features include c ,h v f n d d , a nd ,p i i P· a pproach is preferred . c. T d . Embolic materia ls that c a n b e used ,o include c , and N _ ___

___ _

_ ___

----

__ _

agg ressive cortica l venous refl ux, hemorrhage, focal neurological deficit, dementia, papilledema; increased intraocular pressu re Tra nsvenous coi ls, onyx; N BCA

1 02 . 5 .4

1 02 . 5 . 3

557

E

558

Part 23: Procedures, Interventions, Operations

Carotid cavernous fistula (CCF): Di rect fistula req u i res t beca use they do not resolve s b. Endovascu l a r routes used to treat CCF , and via are t t ' v s 0 c. Route and tech nique of choice is em bolization. c t d. Detachable ba l l oons a re n I a in the U.S.

8. a.

9. Vertebrojugular fistula: a. 3 main etiologies a re i , or v t b. 2 main endovascular treatments are or e s c if there is adequate blood 0 flow through contra latera l vertebral artery. 1 0. Carotid dissection: a. The most common ang iographic featu re ( is I s %). b. Ind ications for endovascular intervention are persistent i sym ptoms or f despite a -limiting lesion with h com promise. c. Endovascu lar treatment consists of or s with either c stent. u 11. a.

b. c. 1 2.

a. b. c. d. e.

Subclavian artery stenosis: % of patients with Only su bclavian a rtery stenosis have flow r in the vertebral a rtery. Ind ication for endovascular intervention is stenosis resu lti ng in s s s and I ntervention consists of a s Mechanical thrombectomy for ischemic stroke: M a y b e performed withi n hours of symptom onset. May be performed for posterior circu lation strokes u p to hours after symptom onset. Cu rrent device of choice is the s r Recanal ization rate with this device i s %. An older device used is p a

--

--

1 02 . 5 . 5

treatment; spontaneously transarteria l , tra nsvenous; su perior ophtha lmic vei n transarterial coil no longer available 1 02 . 5 . 6

iatrogen ic, tra u m a ; vascu litis covered stent; coil occlusion

1 02 . 5 . 7

l u m i n a l stenosis (65%) ischemic; a nticoa g u lation; flowl i m iting; hemodynamic stenti n g ; covered or u ncovered 1 02 . 5 . 8

2 . 5%; reversa l su bclavian steal synd rome a n g ioplasty; stenti ng 1 02 . 5 . 9

6 hours 24 hours stent retriever 88-1 00% pen u m bra aspiration

Endovascular Neurosurgery f. g.

Has a reca nal ization rate of Reca nal ization with the older device takes I to achieve.

____

%.

80% longer

1 3. Tumor embolization: of a . Pu rpose is preoperative d v tu mors, such as m b. Embolization with P particles is and so surgery should be not d performed with in a f days of em bol ization.

devascu larization; vascu lar; meningiomas PVA; d u rable; few

1 4.

2 50-300 mcgm

_ _ _ _

The PVA particle size that is typically used to treat epistaxis is mcgm.

1 02 . 5 . 1 1

__ - __

Neurosurgery Books

1 02 . 5 . 1 3

559