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neurosurgery inbr > chapter 6 neurosurgery cont'd 2 > Flashcards

chapter 6 neurosurgery cont'd 2 Flashcards

1
Q

QUESTIONS 33-36

Scenario: A 42-year-old male falls 25 feet while at work and arrives at the emergency department with a Glasgow Coma Scale (GGS) score of 5, a dilated and nonreactive right pupil, and a mean arterial blood pressure of 80. After airway management and fluid resuscitation, his GGS improves to 7, but his right hemiparesis and nonreactive pupil remain unchanged. The patient also sustained a pelvic fracture, a left humeral fracture, splenic and liver lacerations, and multiple fractures of the cervical spine.

  1. The CT scan of the brain is depicted below (Figure 6.34Q). Why did this patient develop hemiparesis on the same side as the hematoma?

A. Shift of the brainstem away from the mass producing compression of the contralateral cerebral peduncle against the tentorium
B. The patient likely suffered a Duret hemorrhage
C. There was likely a contusion in the underlying motor cortex on the contralateral side that was not detected on the initial CT scan
D. The patient likely had a left internal carotid artery
dissection that subsequently showered emboli to the
distal vasculature
E. There was an associated fracture of the transverse
foramen on the left, which produced a vertebral artery
dissection and small infarct in the ventral pons

A

B. The patient likely suffered a Duret hemorrhage

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2
Q

QUESTIONS 33-36

Scenario: A 42-year-old male falls 25 feet while at work and arrives at the emergency department with a Glasgow Coma Scale (GGS) score of 5, a dilated and nonreactive right pupil, and a mean arterial blood pressure of 80. After airway management and fluid resuscitation, his GGS improves to 7, but his right hemiparesis and nonreactive pupil remain unchanged. The patient also sustained a pelvic fracture, a left humeral fracture, splenic and liver lacerations, and multiple fractures of the cervical spine.

  1. Which of the following are possible complications of
    mannitol administration?
  2. Aggravation of vasogenic edema
  3. Development of a hyperosmolar nonketotic state
  4. Acute tubular necrosis
  5. Hypotension

A. 1, 2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above

A

A. 1, 2, and 3 are correct

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3
Q

QUESTIONS 33-36

Scenario: A 42-year-old male falls 25 feet while at work and arrives at the emergency department with a Glasgow Coma Scale (GGS) score of 5, a dilated and nonreactive right pupil, and a mean arterial blood pressure of 80. After airway management and fluid resuscitation, his GGS improves to 7, but his right hemiparesis and nonreactive pupil remain unchanged. The patient also sustained a pelvic fracture, a left humeral fracture, splenic and liver lacerations, and multiple fractures of the cervical spine.

  1. After surgery for evacuation of the right subdural
    hematoma, CT angiogram was obtained to rule out a vertebral artery injury because of the multiple fractures of the cervical spine extending through the transverse foramina. The study was inconclusive, and a follow-up angiogram (Figure 6.36Q) was obtained later that evening after hematoma evacuation. What would be the most reasonable treatment strategy at this point for this multisystem trauma patient? Consider that the patient adequately fills the posterior circulation from the right vertebral artery.
  2. Commencement of a heparin infusion with a goal of keeping the PTT approximately two times the normal level
  3. Antiplatelet therapy
  4. Intravenous t-PA
  5. Endovascular sacrifice of the occluded vertebral artery

A. 1, 2, and 3 are correct
B. 1 and 3 are correct
C. 2 and 4 are correct
D. Only 4 is correct
E. All of the above

A

E. All of the above

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4
Q

Scenario: A 45-year-old male presents to an emergency room with fever, nausea, vomiting, and severe headache. CT of the brain is normal. Lumbar puncture reveals slightly elevated red blood cells, but normal protein, glucose, white blood cell count, and no xanthochromia. His angiogram is depicted below.

  1. What is the most likely etiology of the abnormality depicted in the angiogram below (Figure 6.37-6.39Q.)?

A. Head trauma
B. Infection
C. Genetic predisposition
D. Collagen vascular disease
E. Hypertension

A

C. Genetic predisposition

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5
Q

Scenario: A 45-year-old male presents to an emergency room with fever, nausea, vomiting, and severe headache. CT of the brain is normal. Lumbar puncture reveals slightly elevated red blood cells, but normal protein, glucose, white blood cell count, and no xanthochromia. His angiogram is depicted below.

  1. This finding occurs most frequently in what condition?

A. Alcoholism

B. Ehlers-Danlos disease
C. Subacute bacterial endocarditis
D. Marfan’s syndrome
E. Polycystic kidney disease

A

B. Ehlers-Danlos disease

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6
Q

Scenario: A 45-year-old male presents to an emergency room with fever, nausea, vomiting, and severe headache. CT of the brain is normal. Lumbar puncture reveals slightly elevated red blood cells, but normal protein, glucose, white blood cell count, and no xanthochromia. His angiogram is depicted below.

  1. How should this problem be treated?

A. Observation followed by repeat angiography in 6 months
B. Antibiotics followed by repeat angiography
C. Emergent surgery
D. Stent/coiling followed by blood pressure control
E. Steroids

A

C. Emergent surgery

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7
Q

QUESTIONS 40-43

Scenario: A 15-month-old girl was brought to the emergency department for lethargy, nausea, and vomiting and was found to have aqueductal stenosis on brain MRI.

  1. What is the best treatment strategy for this patient?

A. Observation
B. Placement of a subgaleal shunt
C. Placement of a ventriculoperitoneal shunt followed
by endoscopic third ventriculostomy if shunting fails
D. Endoscopic third ventriculostomy
E. Endoscopic third ventriculostomy followed by sep-
tostomy

A

B. Placement of a subgaleal shunt

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8
Q

QUESTIONS 40-43

Scenario: A 15-month-old girl was brought to the emergency department for lethargy, nausea, and vomiting and was found to have aqueductal stenosis on brain MRI.

  1. All of the following are advantages of endoscopic third ventriculostomy (ETV) over shunting EXCEPT?

A. Lower rate of subdural hematoma formation with ETV
B. Higher rate of craniosynostosis with ETV
C. Lower infection rate with ETV
D. Physiologic CSF diversion with ETV
E. Higher chance of overdrainage with shunt placement

A

D. Physiologic CSF diversion with ETV

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9
Q

QUESTIONS 40-43

Scenario: A 15-month-old girl was brought to the emergency department for lethargy, nausea, and vomiting and was found to have aqueductal stenosis on brain MRI.

  1. All of the following are true about preoperative planning for ETV EXCEPT?

A. It is relatively straightforward to accurately determine the future function of the subarachnoid pathways and patency of the ETV as long as a high resolution MR cisternogram is obtained preoperatively that identifies the level of the block
B. MRI can accurately delineate the anatomy of the for-
amen of Monro, third ventricle, and massa intermedia
C. The position of the basilar artery and the thickness
of the third ventricular floor can be verified on most
preoperative MRIs
D. A prior history of CSF infection may decrease the
success rate of ETV
E. A prior history of a shunt is not an absolute contra-
indication for ETV

A
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10
Q

QUESTIONS 40-43

Scenario: A 15-month-old girl was brought to the emergency department for lethargy, nausea, and vomiting and was found to have aqueductal stenosis on brain MRI.

  1. What is the optimal site for fenestrating the floor of the third ventricle during ETV?

A. Posterior to the mammillary bodies
B. Anterior to the infundibular recess, posterior to the
prechiasmatic space
C. In the most translucent area of the floor of the third
ventricle
D. Anterior to the mammillary bodies, posterior to the
infundibular recess
E. Anterior to the pulsations of the basilar artery

A

B. Anterior to the infundibular recess, posterior to the
prechiasmatic space

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11
Q
  1. The underlying cause of lateral recess stenosis is osteophyte formation originating from what structure?

A. Inferior articular process
B. Pedicle
C. Superior articular process
D. Ligamentum flavum hypertrophy
E. Vertebral body

A

D. Ligamentum flavum hypertrophy

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12
Q
  1. Although quite similar to the symptoms of radiculopathy secondary to discogenic disease, lateral recess stenosis can be differentiated from discogenic disease by which of the following?
    A. Pain in the lateral recess syndrome is exacerbated by
    walking or standing
    B. Failure of coughing or sneezing to aggravate pain in
    discogenic disease
    C. Positive straight leg raising in lateral recess syndrome
    D. Pain in lateral recess syndrome is relieved by postures
    accentuating lumbar lordosis
    E. There is a slightly higher incidence of bladder inconti-
    nence with lateral recess stenosis
A

C. Positive straight leg raising in lateral recess syndrome

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13
Q
  1. What is the best surgical strategy for patients with lateral recess stenosis?

A. Laminectomy
B. Laminectomy with resection of the medial third of the
hypertrophied facet (medial facetectomy)
C. Microdiscectomy
D. Laminectomy and fusion
E. None of the above

A

C. Microdiscectomy

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14
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. Dysarthria and cognitive decline
A

A. Cordotomy

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15
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. Hemiparesis, homonymous hemianopia
A

B. Periaqueductal gray stimulation

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16
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. “Ondine’s curse”
A

E. Bilateral thalamotomy

17
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. Eye movement disorder, pupillary dilation, feeling of fear
A

F. Pallidotomy

18
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. Horner’s syndrome
A

A. Cordotomy

19
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. Anesthesia dolorosa
A

B. Periaqueductal gray stimulation

20
Q

QUESTIONS 48-54

Directions: Match each of the following procedures with the potential complication using each answer once, more than once, or not at all.

  1. Leg weakness, dysesthesias, bladder dysfunction
A

D. Sympathectomy

21
Q
  1. All of the following are established procedures for the treatment of trigeminal neuralgia EXCEPT?

A. Glycerol rhizolysis
B. Balloon decompression
C. Radiofrequency thermocoagulation
D. Microvascular decompression
E. Peripheral alcohol injection

A

C. Radiofrequency thermocoagulation

22
Q

QUESTIONS 56-58

Scenario: A 58-year-old male with rheumatoid arthritis pre¬sents to the emergency department with intolerable neck pain and cervical myelopathy. On MRI, he is found to have superior migration of the odontoid (SMO) process through the foramen magnum (cranial settling) and compression of the brainstem by the odontoid process itself.

  1. All of the following information is important to gather preoperatively in patients with craniocervical junction (GCJ) abnormalities EXCEPT?

A. The evaluation of craniocervical stability
B. EMG and nerve conduction studies (NCS) to identify
the extent of peripheral nerve damage
C. Whether there is an associated syrinx
D. The extent of ventral compression
E. Presence of abnormal ossification centers and epi-
physeal growth plates in children, as this may alter
treatment strategies

A

C. Whether there is an associated syrinx

23
Q

QUESTIONS 56-58

Scenario: A 58-year-old male with rheumatoid arthritis pre¬sents to the emergency department with intolerable neck pain and cervical myelopathy. On MRI, he is found to have superior migration of the odontoid (SMO) process through the foramen magnum (cranial settling) and compression of the brainstem by the odontoid process itself.

  1. Dynamic imaging studies of the craniocervical junction reveal instability. The neurosurgeon elects to employ gentle cervical traction for 3 days with good success in reducing the abnormality. After 3 days of traction, the patient’s neck pain significantly improves, and MRI reveals minimal brainstem
    compression in the reduced position. What should be the next course of management?
    A. Posterior cervical laminectomy
    B. Posterior cervical laminectomy, suboccipital craniectomy, and fusion
    C. Cervical traction for another week to attempt to fur-
    ther reduce the abnormality before embarking on any
    surgical procedure
    D. Immobilization alone with posterior cervical fusion
    without a decompression
    E. Transoral odontectomy followed by posterior cervical decompression, suboccipital craniectomy, and fusion
A

B. Posterior cervical laminectomy, suboccipital craniectomy, and fusion

24
Q

QUESTIONS 56-58

Scenario: A 58-year-old male with rheumatoid arthritis pre¬sents to the emergency department with intolerable neck pain and cervical myelopathy. On MRI, he is found to have superior migration of the odontoid (SMO) process through the foramen magnum (cranial settling) and compression of the brainstem by the odontoid process itself.

  1. One year later the patient experiences progressive
    weakness in his legs, ataxia, and bladder incontinence. His strength in the upper extremities is preserved, and he has no evidence of cranial nerve abnormalities. Plain films and CT scan of the craniocervical junction are unremarkable. What should be the next diagnostic test employed?

A. CT of the brain to look for hydrocephalus
B. EMG and NCS to identify the extent of peripheral
nerve damage
C. Screening MRI of the spine
D. Bladder urodynamic testing
E. Dynamic films of the cervical spine to evaluate for
pseudoarthrosis and instability

A

B. EMG and NCS to identify the extent of peripheral
nerve damage

25
Q
  1. A surgeon utilizes an infratemporal fossa approach to remove a large infiltrating tumor of the cranial base. He comes across the shaded structure depicted by the arrow below (Figure 6.59-6.61Q). How many muscles attach to this structure?

A. 2
B. 3
C. 4
D. 5
E. 6

A

D. 5

26
Q
  1. Which cranial nerves innervate these muscles?

A. VII, IX
B. VII, IX, XII
C. IX, X, XII
D. V, VII, IX
E. X,XII

A

C. IX, X, XII

27
Q
  1. How many ligaments attach to this structure?

A. 1
B. 2
C. 3
D. 4
E. 5

A

B. 2

28
Q

QUESTIONS 62-69

Directions: Match each of the following questions with the most likely fracture pattern (letterhead) depicted in Figure 6.62-6.69Q, using each answer once, more than once, or not at all.

  1. Most likely to cause weakness of the extensor muscles of the wrist and hand; extension of forearm typically not affected; sensation of dorsal hand affected
A

B

29
Q

QUESTIONS 62-69

Directions: Match each of the following questions with the most likely fracture pattern (letterhead) depicted in Figure 6.62-6.69Q, using each answer once, more than once, or not at all.

  1. May result in teres minor weakness
A
30
Q

QUESTIONS 62-69

Directions: Match each of the following questions with the most likely fracture pattern (letterhead) depicted in Figure 6.62-6.69Q, using each answer once, more than once, or not at all.

  1. Weakness of flexion and adduction of wrist, paralysis of hypothenar muscles and most deep muscles of the hand, some weakness in thenar muscles
A

B

31
Q

QUESTIONS 62-69

Directions: Match each of the following questions with the most likely fracture pattern (letterhead) depicted in Figure 6.62-6.69Q, using each answer once, more than once, or not at all.

  1. Shoulder abduction weakness
A

B

32
Q

QUESTIONS 62-69

Directions: Match each of the following questions with the most likely fracture pattern (letterhead) depicted in Figure 6.62-6.69Q, using each answer once, more than once, or not at all.

  1. High likelihood of ulnar nerve injury only
A

A

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