Chapter 11 - Neurosurgery Flashcards
The timetable and mode of presentation of neurologic disease may provide the first clues as to its nature. ___ problems have sudden onset, without headache when they are ___, and with very severe headache when they are ___.
Vascular; occlusive; hemorrhagic
___ have a timetable of months and produce constant, progressive, severe headache, sometimes worse in the mornings. As ICP increases, what 2 symptoms are added?
Brain tumors; blurred vision and projectile vomiting
Note - if the tumor presses on a specific area of the brain, there may be functional deficits
___ problems have a timetable of days or weeks and often an identifiable source in the history.
Infectoius
___ problems develop rapidly (hours or days) and affect the entire CNS.
Metabolic
___ diseases usually have a timetable of years.
Degenerative
Presentation of TIA?
Sudden, transitory losses of neurologic function that come on without headache and resolve spontaneously leaving no neurologic sequela.
Specific symptoms depend on the area of the brain affected, which is in turn related to the vessels involved
Most common origin of TIA?
High-grade stenosis (70% or above) of the internal carotid, or ulcerated plaque, at the carotid bifurcation
What is the importance of TIAs and how does this affect management?
They are predictors of stroke. Timely elective carotid endarterectomy may prevent or minimize that possibility.
Work-up of suspected TIA?
Non-invasive Duplex studies (high-quality sonogram plus Doppler)
When is surgery (carotid endarterectomy) indicated for TIA?
If the lesions described above are found in the location that explains the neuro symptoms
Note - angioplasty and stent can be done if a filter is first deployed to prevent embolization of debris to the brain
Presentation of ischemic stroke?
Sudden onset without headache. Neuro deficits are present for a longer time, leaving permanent sequelae.
Ischemic strokes that have been present for longer than ___ hours are not amenable to revascularization procedures - why not?
3; if blood supply to the brain is suddenly increased, ischemic infarct may be complicated by a hemorrhagic infarct
Work-up of ischemic stroke?
At the first sign of a sudden-onset neuro deficit, patient is urged to report to the ER.
CT scan to rule out infarcts that are too extensive to be treated and confirm there is no hemorrhage
(Vascular work-up in the future to identify and treat lesions that might produce another stroke)
If at any time the neuro functions spontaneously return, reclassify as TIA and manage accordingly
Treatment of ischemic stroke?
IV infusion of tissue-type plasminogen activator (t-PA) - best within 90 minutes, but can be done up to 3 hours after onset of symptoms
Presentation of hemorrhagic stroke?
Uncontrolled hypertensive who complains of very severe headache of sudden onset, develops severe neuro deficits
Dx and Rx hemorrhagic stroke?
CT scan to evaluate location and extent of hemorrhage; therapy directed at control of HTN and rehabiliation efforts
Presentation of sub-arachnoid bleeding from intracranial aneurysms?
Wide spectrum of severity when it first presents. Some patients are not salvageable.
Extremely severe headache of sudden onset, like no other ever experienced before.
May be no neuro findings at all because the blood is in the subarachnoid space and there is no hematoma pressing on the brain; if not recognized, often re-present ~10 days later with another bleed
May have meningeal irritation and nuchal rigidity
Work-up for suspected subarachnoid hemorrhage?
CT scan looking for blood in the subarachnoid space
Spinal tap can identify old blood or small amounts of current blood but it is never the first test
Rx subarachnoid hemorrhage?
Arteriogram to locate the aneurysm and clip it; endovascular coiling is the radiological alternative
Are most intracranial tumors metastatic or primary?
Metastatic (one of the four favorite destinations of blood-borne malignant cells -> brain, bone, liver, lung)
Common sources of metastatic brain tumors?
50% - lung
Next most common are breast and melanoma
Presentation of intracranial tumor?
Symptoms of space-occupying lesion (progressively increasing headache for several months, worse in the morning)
Eventual signs of increased ICP (blurred vision, papilledema, projectile vomiting)
Extreme -> bradycardia, HTN (due to Cushing reflex)
History of lung, breast, skin cancer
About 50% of primary brain tumors in adults are ___; ___ account for about 20%.
Glioma; meningioma
What is the most malignant intracranial tumor? Which are usually benign
Glioblastoma multiforme (type of glioma); meningioma
Rx brain tumors?
Surgery, radiation, chemo for cases where the BBB has already been breached
Dx and Rx brain tumors?
MRI (gives better detail than CT)
While awaiting surgical removal, treat increased ICP with high-dose steroids (dexamethasone)
Presentation of tumors at the base of the frontal lobe?
Inappropriate behavior
Optic nerve atrophy on the side of the tumor
Papilledema on the other side
Ansomia
(Foster-Kennedy syndrome)
Presentation of craniopharyngioma?
Youngsters who are short for their age
Bitemporal hemianopsia
Calcified lesion above the sella on CT scan
Presentation of prolactinomas?
Amenorrhea and galactorrhea
Diagnostic work-up of prolactinomas?
R/o pregnancy
R/o hypothyroidism
Determine Prl level
MRI of sella
Rx prolactinomas?
Bromocriptine or a similar drug is used in most cases
Transnasal, trans-sphenoidal surgical removal is reserved for those who wish to get pregnant or who fail to respond to bromocriptine
Presentation of acromegaly?
Huge hands, feet, tongue, and jaws
HTN, DM, sweaty hands, headache, history of wedding bands or hats that no longer fit
Work-up for suspected acromegaly?
Determination of somatomedin C
Pituitary MRI
Rx acromegaly?
Surgical removal preferred
Radiation is an option
Somatic changes are irreversible
___ occurs when there is bleeding into a pituitary tumor, with subsequent destruction of the pituitary gland.
Pituitary apoplexy
Presentation of pituitary apoplexy?
History with clues to a pituitary tumor (headache, visual loss, endocrine problems)
Severe headache followed by signs of increased compression of nearby structures by the hematoma (deterioration of remaining vision, bilateral pallor of the optic nerve), and pituitary destruction (stupor and hypotension)
Dx/manage/Rx pituitary apoplexy?
Steroid replacement is urgently needed; other hormones will eventually need to be replaced
MRI or CT will show extent of problem
Presentation of tumors of the pineal gland?
Loss of upper gaze, physical finding known as “sunset eyes”
Parinaud syndrome
Brain tumors in children are usually in the ___. ___ is the most common type. ___ is the second most common type.
Posterior fossa; medulloblastoma; ependymoma
Presentation of medulloblastoma?
Classic cerebellar symptoms (stumbling around, truncal ataxia)
Presentation of ependymoma?
These may pivot on a pedicle and children assume the knee-chest position to open the flow of CSF and relieve their headache
Presentation of brain abscess?
Same manifestations of brain tumors, but a shorter timetable (week or two)
Fever, usually an obvious source of nearby infection (otitis media and mastoiditis)
Dx and Rx brain abscess?
CT (more expensive MRI not needed, as they have a very typical appearance on CT)
Actual resection is required
Presentation of trigeminal neuralgia (tic douloureux)?
Extremely severe, sharp shooting pain “like a bolt of lightning” in the face, brought about by touching a specific area and lasting about 60 seconds
Completely normal neuro exam
Only exam finding may be an unshaven area in the face (trigger zone that the patient avoids touching)
Dx and Rx trigeminal neuraliga?
MRI to r/o organic lesions
Rx with anticonvulsants often successful (notably carbamazepine). If not, radiofrequency ablation can be done. Some believe pounding from a nearby vessel may be responsible and they advocate an operation to separate them.
Presentation of reflex sympathetic dystrophy (causalgia)?
Develops several months after a crushing injury
Constant, burning, agonizing pain that does not respond to the usual analgescis
Pain aggravated by the slightest stimulation to the area
Extremity is cold, cyanotic, and moist
Dx and Rx reflex sympathetic dystrophy?
Successful sympathetic block is diagnostic
Surgical sympathectomy is curative
