Chapter 52. Principle of Neurosurgery

Question 1

Question 52-1: 
A patient presents with clinical symptoms and signs of bacterial meningitis. Emergent CT has already been done by the emergency physician and is normal. Lumbar puncture is performed which shows purulent fluid. Shortly after the procedure, the patient becomes comatose and loses eye movements. Which is the most likely diagnosis? 
A.  Brain abscess 
B.  Basilar thrombosis 
C.  Herniation 
D.  Venous thrombosis

Answer 1

Answer 52-1: D.
Herniation is uncommon, but can occasionally
occur after LP in patients with bacterial
meningitis and in patients with tuberculosis
and sarcoidosis. A good-quality CT is unlikely
to miss a brain abscess. Basilar thrombosis
from secondary vasculopathy from the
meningitis is possible, but this acute
deterioration would not be the most likely
clinical presentation. (P964)

Question 2

Question 52-2: 
A 56-year-old man presents with acute onset of headache in the occipital region, nausea, and vomiting. Exam shows severe truncal and appendicular ataxia. Which is the most likely diagnosis? 
A.  Brainstem infarction 
B.  Cerebellar hemorrhage 
C.  Basilar migraine 
D.  Vertebral dissection

Answer 2

Answer 52-2: B.
292
Cerebellar hemorrhage is the most likely
diagnosis in a patient who presents with
cerebellar ataxia in the absence of other
brainstem signs, especially when associated
with headache, nausea, and vomiting.
Brainstem infarction would be expected to
produce other signs of brainstem dysfunction.
Basilar migraine is not expected to start at this
age. Vertebral dissection~an produce some of
these symptoms, but again the pattern of
ataxia would be different. (P965)

Question 3

Question 52-3:
A 70-year-old female presents with acute onset of headache and left hemiparesis and is found to have hemorrhage in the left frontal lobe with a maximum diameter of 4.5 cm. There is a small amount of midline shift, although there is no rupture into the ventricles. Which is the most appropriate management?
A. Prophylactic ventriculostomy
B. Surgical evacuation of the hematoma
C. Stereotactic aspiration of the hematoma
D. Medical management

Answer 3

Answer 52-3: D..
Medical management is indicated for this
patient. Surgery for intraparenchymal
hematoma is reserved for patients who require
intervention for life-threatening deterioration.
(p965)

Question 4

Question 52-4:
The patient described in the above question deteriorates through the evening. Repeat CT shows slight increase in the size of the intraparenchymal hematoma, but it has ruptured into the lateral ventricle, and there is now dilation of the blood-containing ventricles. Which is the most appropriate next step in management?
A. Ventriculostomy
B. Surgical evacuation of the hematoma
C. Stereotactic aspiration of the hematoma
D. Medical management

Answer 4

Answer 52-4: A.
Ventriculostomy is the most appropriate to
i.mmediately save the life of the patient.
Medical management would be a possibility if
the family has decided on a non-aggressive
approach. Surgical evacuation of the
hematoma could be performed as well,
although there is significant morbidity from
this procedure, and the patient can be left
devastated ifhe survives. (p965)

Question 5

Question 52-5:
A 42-year-old man presents with acute onset of headache and ataxia and is found to have extensive cerebellar infarction. While in the emergency department, his mental status deteriotates. Repeat CT shows increased mass effect of the cerebellar infarct. Which is the most appropriate management?
A. Suboccipital decompression
B. Intubation, hyperventilation, and mannitol administration
C. Conservative medical management

Answer 5

Answer 52-5: A.
Suboccipital decompression is performed in
patients with cerebellar hemorrhage and
infarction, especially when any sign of
neurologic deterioration is observed.
(P965)

Question 6

Question 52-6:
What is the prognosis for survival and recovery for the patient described in the previous question?
A. High mortality and poor quality of recovery
B. High mortality, but good recovery if he does survive
C. Relatively good prognosis for survival but most likely poor neurologic function
D. Relatively good survival and good prognosis for good functional status

Answer 6

Answer 52-6: D.
Functional recovery from cerebellar infarction
is good with urgent decompression, even if the
patient is comatose. The survival and degree
of recovery deteriorates significantly if there
is delay in evacuation. (P965)

Question 7

Question 52-7:
A 26-year-old female presents with explosive onset of headache and diplopia. CT confirms the clinical suspicion of subarachnoid hemonbage. She is admitted to the neurological ICU and placed on appropriate medical therapy. Which of the following is the most appropriate statement about riming of angiography and surgery?
A. Angiography is performed within the first day with an eye toward early surgery if anewysm is identified
B. Angiography is perfomedwithin the first day, with anticipated surgery after 1-2 weeks
C. Angiography is performed after one week, with surgery to follow
D. Angiography is performed after the patient has completely recovered, with surgery to follow, if needed

Answer 7

Answer 52-7: A.
This patient would be classified as grade 2,
where there is headache but only minor
cranial nerve deficit. Angiography should be
performed early with an eye towards early
surgery. Since vasospasm does not occur
immediately, surgery can allow for some of
the treatments for vasospasm which would be
risky with a persistent aneurysm. (p968)

Question 8

Question 52-8:
Which of the following statements is true regarding cavernomas?
1.Cavernomas are frequently asymptomatic
2. Cavernomas can hemorrhage to the point of requiring treatment
3. Cavernomas are common in the pons
4. Radiosurgery is the most effective approach to these lesions
Select: A = 1,2,3. B = 1.3. C = 1. 4. D = 4 only. E = All

Answer 8

Answer 52-8: A.
Cavernomas are particularly insensitive to
radiosurgery, although this technique has been
tried whi!n the lesion is not amenable to
conventional surgery and there is deficit from
repeated hemorrhages. (p973)

Question 9

Question 52-9: 
A 47•year-old man presents with mild left hemiparesis and is found on angiography to have dissection of  the right  internal carotid artery extending from just distal to the bifurcation to the skull base. Which is the most appropriate management: 
A.  Urgent carotid surgery 
B.  Anticoagulation 
C.  Stent placement 
D  Angioplasty

Answer 9

Answer 52-9: B.
Most patients with carotid dissections respond
well to anticoagulation. Interventions are used
for patients who have persistent symptoms
despite anticoagulation. Unfortunately,
conventional surgery is usually not possible
because of the length of the Iesion.
Angioplasry with stem placem~t is
occasionally performed (p979)

Question 10

Question 52-10:
A 78-year-old man presents with progcessive dementia for the past three years. On examination he has some mild gait ataxia, and slightly stooped posture but no other significant abnormalities. MRI shows increased ventricular size out of proportion to cortical atrophy with periventricular white matter changes. Which would be the best next step?
A. Ventriculoperitoneal shunt placement
B. Radionuc1eotide cisternography
C. Treatment with acetylcholinesterase inhibitor
D. Serial scans to follow ventricular size

Answer 10

Answer 52-10: B.
The clinical presentation is of a degenerative
dementia but the scan raises the concern over
normal pressure hydrocephalus. With
dementia being the only prominent
presentation of the NPH triad, the patient is
not likely to benefit from shunting.
Cistemography can help to determine who
will respond to treatment, although even this
test is not definitive. (p981)