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testing123 > 5. Cranial Neurosurgery > Flashcards

5. Cranial Neurosurgery Flashcards

1
Q

What lesion can produce head tilt?

A

Anterior vermis, 4th nerve palsy

In MG - head tilts back

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2
Q

Vermicular movement of face with pontine demyelination?

A

Myokymia

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3
Q

DBS of ventral intermediate thalamic nucleus for what dx?

A

Parkinson

Essential tremor

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4
Q

Dysarthria and clumsy-hand syndrome?

A

Genu of internal capsule

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5
Q

Dilute pilocarpine constrict what type of pupil?

A

Addie’s pupil, but not harm dilated

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6
Q

Consensual light reflex > direct light reflex

A

Afferent pupillary defect

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7
Q

Most common cause of spontaneous diplopia in middle-aged

A

Grave’s

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8
Q

Parkinson with vertical gaze palsy?

A

Progressive supranuclear palsy

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9
Q

one-and-a-half syndrome - which eye movement is preserved?

A

Abduction of unaffected eye

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10
Q

Oculomotor palsy from aneurysm vs diabetic?

A

Diabetes: pain with pupillary sparing

Aneurysm - compress parasympathetic fibers on periphery

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11
Q

Ataxia, myoclonus, positive 14-3-3 protein and bilateral sharp waves on ECG?

A

CJD

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12
Q

Actual vs absence seizure?

A

EEG, prolactin, muscle enzyme

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13
Q

EEG for absence seizure

A

3Hz wave and spike

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14
Q

Diplopia of MG vs compressive lesion?

A

Intermittent vs progressive/constant

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15
Q

Which EOM if horizontal object appears slanted?

A

SO

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16
Q

Test for HTN from pheo vs essential?

A

Clonidine suppression test

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17
Q

%L hemisphere dominant in L handed individuals

A

> 75%

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18
Q

Clinical symptoms of NPH

A

Gait disturbances (usually first, most pronounced)
Memory loss
Urinary incontinence

Enlarged ventricles on CT but normal pressure of CSF by LP

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19
Q

Area involved in cortical inhibition of B&B damaged in NPH

A

Paracentral lobule

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20
Q

R/O other dx before NPH

A 
Vascular dementia
Parkinson
Lewy body dementia
Cervical spondylotic myelopathy
Peripheral neuropathy
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21
Q

Pupillary reflex pathway

A

Optic nerve -> superior colliculus -> Edinger-Westphal nuclei -> (third cranial nerve) ciliary ganglion -> short ciliary nerves

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22
Q

Causes of circumoral paresthesia

A

Hypocalcemia
Hyperventilation
Syringobulbia
Neurotoxin fish poison

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23
Q

Low vs high pitch tinnitus

A

Low: conductive/meniere
High: sensorineural

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24
Q

“Transverse smile”

A

Myasthenic snarl with bulbar involvement in MG

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25
Q

Facial myokymia

A

MG, intrinsic brainstem glioma

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26
Q

What maneuver to elicit nystagmus of benign positional vertigo?

A

Dix-Hallpike maneuver

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27
Q

Lateral medulla nuclei

A 
Inf. vestibular nuclei
Solitary nucleus
Inferior cerebellar peduncle
Descending tract of V
Spinothalamic tract
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28
Q

Benign positional vertigo characteristics

A

Position worsens or alleviates symptoms

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29
Q

Meniere’s disease: clinical findings

A

Tinnitus, bouts of vertigo, hearing loss

Can mimic acoustic neuroma

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30
Q

Lateral medulla infarct (wallenberg)

A 
Vertigo, nausea/vomiting
Ddysphagia
Ipsilateral sensory loss of face pain/temp
Ipsilateral horner
Contralateral pain/temp
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31
Q

Ptosis from 3rd CN palsy vs horner syndrome?

A

Horner disappears with looking up

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32
Q

Causes of partial ptosis from 1st order Horner syndrome

A

Posterolateral hypothalamus to intermediolateral cell column (C8-T2)

Arnold-Chiari, basal skull fracture, wallenberg, demyelinating, intrapontine hemorrhage

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33
Q

Pharm test for 2nd or 3rd order horner syndrome?

A

If intact post-ganglionic fibers (1st or 2nd order) - hydroxyamphetamine would dilate pupil

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34
Q

Bell phenomenon

A

Ask to close eye and show teeth

Eye goes up and out

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35
Q

Nutritional causes of dementia

A

Wernicke-Korsakoff

Vitamin B12/Folate

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36
Q

Heritable disorder - migraine in early life, then TIAs and strokes, then early dementia?

A

CADASIL
(Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
Notch3 gene - affects blood vessels grow/development

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37
Q

How can you tell if patient may improve from shunt for NPH?

A

Improvement after lumbar CSF drainage

Beta waves in ICP monitoring

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38
Q

Most common cause of cardioembolic stroke

A

Afib

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39
Q

Arteries supply to macular vision

A

PCA

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40
Q

Acoustic schwannomas - early manifestations?

A

Depression of corneal reflex (CNVII compression)

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41
Q

What diameter of carotid vessel feels bruit?

A

2.5-3mm

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42
Q

Cushing syndrome

A

Moon face, acne, hirsutism, bladness, buffalo-type obesity, purple striae, muscle wasting, osteoporosis, hypertension, infection, DM

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43
Q

Dx with upgaze palsy

A

Perinaud syndrome (tumor in pineal or quadrigeminal plate)
Hydrocephalus
Hypothyroidism/MG/GBS

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44
Q

Recurrent meningitis with no predisposing conditions

A

Children: basal encephalocele
Adult: CSF fistula

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45
Q

Cupulolithiasis

A

Benign positional vertigo

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46
Q

What causes horizontal vertigo?

A

Paresis of 6th CN

Can occur with pseudotumor cerebri (susceptible to stretch forces with high ICP)

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47
Q

Dx with cherry red spot

A

Tay-sachs
Niemann Picks
Pseudo-Hurler (GM1 ganglioside)

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48
Q

Dx with retinitis pigmentosa

A

Freidrich ataxia
Refsum (polyneuropathy)
Cockayne (premature aging)
Kern-Sayre (oculocraniosomatic neuromuscular)

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49
Q

Cerebellar mutism

A

Mute in children 1-4 days after surgery in vermian lesion resection

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50
Q

Classification for CN7

A

House-Brackman

1: Normal
5: no eye closure
6: paralysis, no tone

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51
Q

Recurrent orofacial edema, recurrent 7th nerve palsy, lingua plicata

A

Melkersson-Rosenthal

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52
Q

Herpes zoster oticus

A

Ramsay-Hunt syndrome

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53
Q

Uveoparotid fever

7th CNS palsy in sarcoidosis

A

Heerfrodt

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54
Q

Bilateral 7th nerve palsy

A

Lyme

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55
Q

Ips CN6/7 palsy and contralateral hemiparesis

A

Millard-Gubler

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56
Q

Ips CN7 hemispasm and contralateral hemiparesis

A

Brissaud-Sicard

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57
Q

Ips CN7/8 with horizontal gaze paralysis with contralateral hemiparesis

A

Foville

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58
Q

Benign occipital lobe epilepsy in children, induced by sleep

A

Panayiotopoulos

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59
Q

diameter in mm of a 12-French suction tip?

A 
3-French = 1mm
12-French = 4mm
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60
Q

Significance of frontozygomatic point?

A

On lateral orbital bone (~ 2.5cm from zygoma attachment, which approximates location of sylvian fissure when connected with 75% point (3/4 distance from nasion to inion)

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61
Q

Incision reaching zygoma > 1.5cm anterior to ear may interrupt which nerve?

A

Facial nerve that reaches frontalis muscle

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62
Q

Approach to superficial temporal artery

A
  1. trace out with doppler to determine branching pattern
  2. sample frontal branch by dissecting artery under microscope
    3-5 cm long
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63
Q

Inferior frontal gyrus of dominant hemisphere

A

Broca

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64
Q

Trautman triangle

A

Superior petrosal sinus
Sigmoid sinus
Posterior auricular canal

Access posterior fossa dura anterior to sigmoid sinus

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65
Q

Following greater superficial petrosal nerve lead to which ganglion?

A

Geniculate ganglion

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66
Q

What part of the internal capsule lies ver close to the foramen of monro?

A

Genu

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67
Q

What thalamic nucleus may be damaged while opening the body of the choroidal fissure?

A

dorsomedial nucleus

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68
Q

What areas of bone may be needed to be removed to clip a low-lying basilar artery aneurysm?

A

Posterior clinoid

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69
Q

When would you approach an acomm artery aneurysm from left?

A

Dominant left A1, dome pointing to the right, another left-sided aneurysm

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70
Q

Craniotomy - why linear incision?

A

Increases blood supply to wound

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71
Q

Craniotomy - why “lazy S incision”?

A

prevent incision line in dura from lying directly underneath incision in skin

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72
Q

Craniotomy - why flap incision?

A

scalp blood flow is not compromised

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73
Q

Craniotomy - why zigzag incision?

A

minimize visibility of scalp alopecia

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74
Q

Technique for placing ventriculoatrial shunt?

A
  1. Incision at anterior border of sternomastoid muscle to identify jugular vein
  2. Tie off vein distally
  3. Small opening to pass shunt down juvular vein into right atrium (biphasic P wave)
  4. intraop fluoroscopy to confirm catheter is at T6 level
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75
Q

Technique for placing ventriculopleural shunt?

A
  1. Incision between second and third rib lateral to midclavicular plane
  2. insert tube after puncture of parietal pleura
76
Q

What bones form the hard palate?

A

Maximall anteriorly

Palatine posteriorly

77
Q

What veins connected at the torcula?

A 
(Confluence of sinus)
Superior sagittal
Transverse sinus
Straight sinus
Occipital sinus
78
Q

What bones form the zygomatic arch?

A

Anterior (Zygoma)

Posterior (Temporal - squamosal part)

79
Q

What bones form the nasal septum?

A

Ethmoid (perpendicular plate) and vomer

80
Q

What bones form the clivus?

A

Sphenoid and occipital bone

81
Q

What nerve carries parasympathetic innervation to parotid gland?

A

Auriculotemporal nerve (part of mandibular nerve)

82
Q

Which cerebellar peduncle carries only afferent fibers?

A

Middle cerebellar peduncle

83
Q

Which thalamic vein join the thalamostriate vein?

A

None!

Thalamostriate joins the internal cerebral vein of galen

84
Q

Superior orbital fissure provides communication between which 2 areas?

A

Orbit and middle fossa

85
Q

Lamina terminalis extends upward from optic chiasm and blends into what?

A

Rostrum of corpus callosum

86
Q

What cistern is contained in posterior incisural space?

A

Quadrigeminal cistern

87
Q

Lateral and medial posterior choroidal arteries are branches of which circle of willis artery?

A

PCA

88
Q

How is CSF secreted from choroid plexus enters subarachnoid space?

A

Ventricular foramina of Magendie and Luschka

89
Q

Rate of CSF formation

A

0.5L per day (0.33mL per minute)

90
Q

Normal diameter of supraclinoid ICA

A

4-5mm

91
Q

Where does basal vein originate and through which cistern does it pass?

A

Anterior perforated substance -> crural and ambient cisterns -> quadrigeminal cistern -> internal cerebral vein

92
Q

Most medial structure in cavernous sinus?

A

ICA

93
Q

Most common side effect of mannitol

A

Renal failure

94
Q

When do majority of perioperative MI occur

A

POD3 and 5

95
Q

Best method to assess cerebral metabolism

A

PET

96
Q

Why are inhalational anesthetics called “uncoupling” agents?

A

Decrease cerebral metabolism but increase cerebral flow through vasodilation.

97
Q

When should you reconsider use of nimodipine in vasospasm?

A

Diminished cardiac contractility (negative inotrope)

98
Q

Elective craniotomy for meningioma who is hyponatremic and hypotension - what should you consider?

A

Adrenal insufficiency

99
Q

What types of coagulopathies are not detected by PT/PTT/INR and platelet counts?

A

Dysfibrinogenemia, vWF disease, Factor XIII deficiency, ASA/Plavix use

100
Q

Disorders with platelet sequestration

A

Hypersplenism with cirrhosis
Gaucher
Sarcoidosis

101
Q

Who has increased risk of GI hemorrhage with steroid use?

A

Preexisting ulcer disease

102
Q

O2 transport is maximal in what hematocrit range?

A

30-32%

103
Q

What on CT is predictive for success of 3rd ventriculostomy for hydrocephalus

A

Triventricular hydrocephalus (obstructive) from aqueductal stenosis or blockage of 3rd ventricular outflow

104
Q

Morphology of cerebral aneurysms

A

Saccular, dissecting and fusiform. Influences surgical and endovascular treatment

105
Q

Most common cause of SAH

A

Head trauma

106
Q

Most common cause of CSF leakage

A 
Head trauma (skull fracture doubles risk)
Leaks to nose (rhinorrhea), ear (otorrhea), or orbit (mimics tears)
107
Q

CSF nasal drainage vs secretion?

A

Glucose level (in CSF but not nasal drainage)
Double-ring “halo” sign on bed sheets or clothing
Confirm with beta-2 transferrin test

108
Q

Best initial treatment for CSF leak

A

Bed rest and head elevation.

If persists for 3 days, lumbar drainage

109
Q

Major cause of spontaneous intracranial hypotension

A

Spontaneous CSF leaks

Look for diffuse pachymeningeal enhancement on MIR

110
Q

Areas most prone to DAI after head trauma

A

Corpus callosum and superior cerebellar peduncle

111
Q

Microscopic hallmark of DAI

A

Axonal retraction balls (eosinophilic globular swellings at proximal/distal sites of disrupted axons)

112
Q

Bullet wound: entrance or exit wound larger?

A

Entrance typically smaller

113
Q

What radiologic view to fully appreciate occipital bone fracture

A

Towne view (mandible)

114
Q

Which allele predisposes one to greater risk of Alzheimer after head injury

A

Apo E4

115
Q

Area of intracranial facial nerve most commonly damaged by blunt trauma

A

Facial nerve around geniculate ganglion

116
Q

Schirmer test

A 
Distinguish facial nerve injury proximal/distal to geniculate ganglion.
Assess lacrimation (proximal = dry eye; distal = not interfere)
117
Q

What type of temporal bone fractures most frequently results in external manifestations (otorrhea, tympanic membrane rupture)?

A

Longitudinal fractures

Transverse spares middle ear, tympanic membrane and external auditory canal (fewer signs)

118
Q

Why EEG ordered in lowered levels of consciousness posttrauma?

A

R/O subclinical status epilepticus

119
Q

Range of cerebral perfusion pressure accommodated by cerebral autoregulation

A

60-160mmHg

120
Q

Calculation for cerebral perfusion pressure?

A

Mean arterial pressure - intracranial pressure

121
Q

CPP should be maintained above what after severe head injury?

A

70 mmHg

122
Q

Calculating MAP?

A

1/3SBP+2/3DBP

123
Q

At what blood flow rate does electrical activity of cerebral cortex fail?

A

20 mL/100g /min

124
Q

Brainstem reflexes mandatory to test in brain death evaluation

A

Pupils, corneal, oculovestibular, oculocephalic, gag.
Response to deep central pain and apnea test
No evidence of drug or metabolic intoxication

125
Q

Auditory evoked potentials in evaluating brain death, what weight is necessary for the test to be valid?

A

Wave I, at least on one side

126
Q

Neuroprotective medications

A

Corticosteroids, calcium channel blockers, glutamate antagonist, Manitoba, barbiturates

127
Q

Trauma patient with broken leg deteriorates after manipulation of broken leg on hospital day five. Most likely cause?

A

Fat emboli syndrome

128
Q

Why bifrontal exposure for persistent rhinorrhea after trauma?

A

Fracture of anterior fossa often extends across midline

129
Q

Prophylactic antibiotics for CSF leaks after traumatic brain injury?

A

Not recommended according to Lancet 1994 article. Encourage resistance and late attacks of meningitis

130
Q

Use of hyperventilation and head injury?

A

No good random my studies to support for use. May decrease cerebral perfusion pressure and delivery of oxygen and glucose.

131
Q

Young adult with family history of migraines present with head trauma and blindness

A

Trauma triggered migraine with transient cortical blindness

132
Q

How can acute SDH appear ice so intense to brain in multi-trauma patient?

A

Hematocrit less than 23

Coagulopathy

133
Q

Why EDH more common in younger adults?

A

Dura is thinner and more adherent to the skull in elderly

134
Q

EDH in children versus adults

A

Children: caused by venous bleeding more
Adult: middle meningeal artery

135
Q

Common drug to suppress cerebral metabolism in setting of major cerebral trauma

A

Barbiturates

136
Q

Typical dosage of pentobarbital for suppression of cerebral metabolism and setting of major cerebral trauma

A

Loading dose of 10 mg/kg over 30 minutes, then 5 mg/kg per hour over three hours

137
Q

Where on carotid artery is the most common location for a traumatic aneurysm?

A

Between proximal and distal dural rings. Pseudoaneurysms that may project medially into sphenoid sinus.

138
Q

Shortcomings of GCS

A

Eye-opening in periorbital trauma, verbal response and intubated patient, brainstem functions or reflexes

139
Q

Association between mean your skull fracture on radiograph and risk of intracranial hematoma

A

Increase risk by 400 fold

140
Q

Early versus late posttraumatic seizure

A

Early: first seven days. Prophylactic phenytoin therapy to prevent early posttraumatic seizures
Late: after seven days. No proven advantage to prevent late seizures

141
Q

Preferred method of intubation in patients with basal skull fracture

A

Orotracheal intubation. Possibility of entering cranium through cribriform plate with nasotracheal intubation.

142
Q

Prerequisites for growing skull fracture

A
  1. Fracture occurs in infancy or early childhood
  2. Dural tear at time of fracture
  3. Brain injury at time of fracture with displacement up leptomeninges
  4. Subsequent enlargement of fracture to form cranial defect
143
Q

Fall in end tital CO2 could be the only clue to what?

A

Air embolus

144
Q

Treatment of air embolism

A

Lower patients head, rotate patients left side downward, aspirate from venous line in right atrium, and eventually patient while maintaining blood pressure and heart rate

145
Q

Cases where hyperemia of brain occurs?

A

Head trauma, after carotid endarterectomy/stenting, excision of AVM

146
Q

How to confirm diagnosis of DIC?

A

Low platelet count, prolonged PT, elevated fibrin degradation products, reduced fibrinogen levels

147
Q

Treatment of cluster headaches

A

Oxygen, sumatriptan

148
Q

Best drug for immediate control of seizures and status epilepticus

A

Lorazepam, better than diazepam are phenytoin

149
Q

Signs and symptoms of myxedema coma

A

Emergency of hypothyroidism: hypotension, bradycardia, hyponatremia, hypoglycemia, hypothermia, hypoventilation

150
Q

Treatment of myxedema coma

A

IV fluids, intubation if necessary, IV glucose

400 MG hydrocortisone IV over 24 hours, 0.5 MG levothyroxine IV followed by 0.05 levothyroxine per day

151
Q

Three places a shunt maybe occluded

A
  1. Entry point (proximal occlusion)
  2. Valve system (valve obstruction)
  3. Distal and (distal catheter occlusion)

CT head, shunt series, palpation about

152
Q

Patient with history of pituitary trauma presents with sudden onset headache and rapid visual failure with extra ocular nerve palsy. Most likely diagnosis

A

Pituitary apoplexy, can mimic SAH. Treatment is urgent steroids

153
Q

Management of life-threatening cerebellar swelling from infarction

A

Reception up cerebellar infarction maybe needed

Ventriculostomy as temporizing measure in anticipation of surgery

154
Q

Drugs used in NMS

A

Bromocriptine and dantrolene

155
Q

Most common cerebrovascular comp patient during pregnancy

A

SAH
Risk of rupture parallels hemodynamic changes with blood volume change; most prone to rupture during seventh and eight months of pregnancy

156
Q

Most common site of hypertensive cerebral hemorrhage?

A

Putamen

157
Q

Addisonian crisis: signs and symptoms

A

Atrial insufficiency emergency: mental status changes, muscle weakness, postural hypotension, shock, hyponatremia, hyperkalemia, hypoglycemia, hyperthermia

158
Q

Addisonian crisis: treatment

A

100 MG IV hydrocortisone immediately and then 50 MG IV Q6 hours

159
Q

Central pontine myelinolysis

A

Rapid correction of hyponatremia causing disorder of punching white matter; insidious flaccid quadriplegia and mental status changes.

Sodium should not be corrected faster than 10 mEq per liter/24h

160
Q

Neurogenic pulmonary edema

A

Associated with SAH, head trauma, seizure

Increased capillary permeability and lungs associated with increased sympathetic discharge.

161
Q

Neurogenic pulmonary edema: treatment

A

Reduce ICP, maintain positive pressure ventilation, supportive care

162
Q

Treatment of acute migraine attack

A

Compazine/prochlorperazine 10 MG IV

163
Q

What potential emergency can occur intracranial late if nitrous oxide anesthesia is not discontinued prior to closure of director in surgery?

A

Tension pneumocephalus

164
Q

Most common complication of trans oral operative route?

A

CSF leakage and infection

165
Q

Cystic tumor of suprasellar region that arises from neuroectodermal remnants of Rathke pouch

A

Craniopharyngioma

166
Q

Preop medications to lessen risk of patients with growth hormone secreting tumor

A

Somatostatin analog

167
Q

Lesion with calcification in cellar area and erode through posterior clinoid

A

Craniopharyngioma. Erosion of posterior clinoid may also occur from chronic increase in ICP

168
Q

Tumor that can erode internal acoustic meatus

A

Acoustic schwannoma

169
Q

Tumor that can erode petrous apex

A

Trigeminal schwannoma

170
Q

Tumor that can erode clivus

A

Chordoma

171
Q

Tumor that can erode sellar floor

A

Large pituitary tumor

172
Q

Tumor that can erode orbital foramen

A

Optic nerve glioma

173
Q

Tumor that can erode jugular foramen (the bone)

A

Glomus jugulare

174
Q

What disease may produce generalizable erosion? and hyperostosis?

A

Multiple myeloma, paget disease

Meningioma results in focal hyperostosis

175
Q

Most common extradural neoplasm involving the clivus

A

Chordoma (typical, and chondroid - better prognosis)

176
Q

IHC of chordoma versus chordosarcoma

A

Chordoma always things positive for keratin with S 100.

Chordosarcoma lacks epithelial markers but always positive for S 100

177
Q

Malignant potential of chordoma

A

Critical location, locally aggressive nature, hybrid of recurrence, occasional tendency to metastasize
Histologically benign

178
Q

Most common site of origin of chordoma

A

Sacrum

179
Q

Second most common site of chordoma

A

Clivus

180
Q

Prophylactic cranial irradiation may be considered for what patients

A

Small cell lung cancer

181
Q

What lesion most commonly removed by endoscopic methods

A

Colloid cyst

182
Q

Where are colloid cyst found?

A

Anterior roof of third ventricle

183
Q

How do colloid cyst cause death?

A

Obstructive hydrocephalus

184
Q

Most common in intraorbital tumor in adults

A

Cavernous hemangioma: benign, slow-growing vascular lesion

Painless, progressively proptotic eye

185
Q

Second most common type of intracranial schwannoma

A

Trigeminal schwannoma

Vestibular type most common

186
Q

Most common presentation of choroid plexus tumor?

A

Intracranial hypertension

187
Q

Location of choroid plexus papilloma between adults and children

A

Children: left lateral ventricle
Adults: fourth ventricles
Rare benign tumors of CMS, male predominance

testing123 (11 decks)

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