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
