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Neurology > Clin Med Neurosurgery > Flashcards

Clin Med Neurosurgery Flashcards

1
Q

Where is cerebrospinal fluid (CSF) produced?

A

choroid plexus tissue in ventricles - mainly in lateral ventricles

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2
Q

CSF circulates…

A

unilaterally through ventricles, then multidirectionally through subarachnoid space

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3
Q

CSF is reabsorbed…

A

through dural venous sinuses through arachnoid granulations

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4
Q

Define hydrocephalus

A

Excessive accumulation of CSF in brain resulting in increased intracranial pressure (ICP)

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5
Q

Define ventriculomegaly

A

Dilation of the ventricles in the brain

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6
Q

Ventriculomegaly & hydrocephalus

A

ventriculomegaly does not equal HCP

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7
Q

Hydrocephalus symptoms

A
  • Headache
  • Recurrent emesis (not related to diarrhea or any other GI symptom)
  • Lethargy
  • Irritability
  • Papilledema
  • Sundowning (commonly seen in children, they physically can’t look up)
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8
Q

Hydrocephalus in infants

A
  • macrocephaly (FOC crossing percentiles)
  • full/firm fontanelle
  • splayed sutures
  • prominent scalp veins
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9
Q

Advanced hydrocephalus

A

Cushing’s triad:

  • increased blood pressure
  • bradycardia
  • irregular breathing
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10
Q

Communicating hydrocephalus

A
  1. Entire ventricular system dilated
  2. Problem with absorption of CSF
    - Post-hemorrhage
    - Post meningitis
  3. Or overproduction
    - Choroid plexus tumors
    - Choroid plexus hyperplasia
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11
Q

Noncommunicating/obstructive

hydrocephalus

A
  • Dilation of ventricular system upstream from block
  • Aqueductal Stenosis
  • Tumors
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12
Q

Ex-vacuo in relation to hydrocephalus

A
  • could be seen in a kid who has had a bad infection or stroke, so the brain is atrophied
  • it looks like hydrocephalus on CT, but the physical exam doesn’t match it
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13
Q

Hydrocephalus dx

A
  • CT is the easiest, but US is good for children with fontanelle
  • can also use MRI
  • consult ophthalmology to evaluate for papilledema
  • intracranial pressure monitor (normal ICP < 20 mm Hg)
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14
Q

What are shunts?

A

used to create an alternate outflow for CSF

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15
Q

Types of shunts

A
  • Ventriculo-peritoneal (VPS)
  • Ventriculo-atrial (VAS)
  • Ventriculo-pleural
  • Subgaleal
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16
Q

Components of shunts

A
  • Ventricular catheter (proximal)
  • Valve/reservoir
  • Distal catheter
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17
Q

Subgaleal shunt

A
  • temporary (lasts about 4 weeks)
  • ends in a subgaleal pocket created during surgery
  • for pts with low body weight <1500 grams
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18
Q

What newborn condition are subgaleal shunts often used for?

A 
Intraventricular Hemorrhage (IVH) of Newborn: high RBCs or protein in CSF
-this basically turns to a sludge and clogs the valves of other shunts
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19
Q

Shunt malfunctions manifest as…

A

hydrocephalus symptoms, because it’s as if you don’t have a shunt at all.

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20
Q

Shunt malfunctions

  • stats
  • reasons why
A
  • 50% of shunts fail in first 2 years of life, then 10% per year
  • no rhyme or reason why they fail but,
  • MC reason is proximal - tissue clogs holes, malpositioned catheter
  • other reasons: valve clogs
  • distal reasons: fractured tubing, infection
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21
Q

Dx of shunt malfunction

A

CT, shunt series, and shunt tap

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22
Q

Shunt infections

A
  • Usually occur at time of surgery with skin flora
  • Occur within first 6 months following placement
  • Typically a distal malfunction
  • Tx: Externalize shunt, IV antibiotics, then replace entire shunt system
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23
Q

External ventricular drains (EVD)

A
  • A short term solution
  • Direct drain from ventricle with usually frontal placed catheter to drainage system
  • Level of chamber acts as valve (low drains more, high drains less)
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24
Q

Endoscopic third ventriculostomy (ETV)

A
  • Creates an alternative pathway within the brain

- Works for cases of obstruction at level of aqueduct

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25
Q

Who does ETV not work well on??

A

Does not work well on infants or communicating hydrocephalus

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26
Q

Choroid plexectomy

A
  • Coagulate or remove choroid plexus
  • Decreases CSF production enough to control head growth
  • Works for patient with little or no cerebral cortex
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27
Q

Intraventricular hemorrhages (IVH)

A
  • Arises from germinal matrix
  • Graded I-IV
  • May cause communicating hydrocephalus
  • Dx by head US
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28
Q

What population is at risk for IVH?

A

Infants born more than 10 weeks premature are at greatest risk

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29
Q

What is often confused as hydrochephalus?

A

Benign extra-axial fluid of infancy

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30
Q

Benign extra-axial fluid of infancy characteristics

A
  • Normal variant
  • Enlarged subarachnoid spaces over frontal poles with normal ventricular size
  • Macrocephalic with flat fontanelle
  • Asymptomatic
  • May be familial macrocephaly
  • Usually resolves spontaneously by 2 years old
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31
Q

Define spina bifida

A

Neural tube fails to develop or close properly causing defects in spinal cord and vertebrae

  • 1-2/1500 live births
  • genetic and environmental factors
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32
Q

2 types of spina bifida

A

Open (myelomeningocele or meningocele) v. Closed (lipomyelomeningocele) neural tube defect

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33
Q

What 3 factors are most strongly correlated to spina bifida?

A

Carbamazepine, Valproic acid, and low folate most strongly related

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34
Q

Spina bifida level of defect

A

*determines physical findings

L2 - Hip flexors
L3 - Knee extensors
L4 - Knee flexors, ankle dorsiflexors 
L5 - Long toe extensors
S1 - Ankle plantar flexors
S2-4 - Bowel/bladder sphincter

The higher the defect, the less the patient is able to do.

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35
Q

Tx of spinda bifida

A
  • Keep patient flat/prone with sterile saline soaked gauze and IV antibiotics for open defects
  • Close open defects within first 48-72 hours of life
  • Closed defects can be repaired around 6 months of life
  • Layered repair closure – bring the layers of the spinal cord as close together as possible, then layer muscle, then skin
  • In utero fetal closure
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36
Q

Spina bifida late problems

A
  • Neurologic - 80-90% of patients have HCP and require shunting (Higher lesion = higher risk of hydrocephalus)
  • Chiari malformation
  • syrinx
  • tethered cord
  • Often need orthopedics for scoliosis, clubfoot, etc.
  • 100% have neurogenic bladder
  • latex allergy
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37
Q

Tethered Cord

occult spina bifida

A
  • Tissue attachments limit the movement of spinal cord within the spinal column
  • Causes abnormal stretching of spinal cord
  • Low conus or fatty filum terminals
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38
Q

Signs of tethered cord

A

Cutaneous lesions:

  • Tuft of hair
  • Hemangioma or nevus
  • Dermal sinus
  • Dimple
  • Asymmetric gluteal cleft
  • Subcutaneous lipoma
  • Tail
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39
Q

Symptoms of tethered cord

A
  • changes in lower extremity strength/sensation
  • gait abnormality – walk on outsides of feet
  • back/leg pain
  • bowel/bladder issues (incontinence/retention)
  • may cause scoliosis
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40
Q

Dx of tethered cord

A

***MRI is gold standard

Lumbar spinal ultrasound in newborn - 6 months old

Lumbar MRI if ultrasound abnormal or > 6mo

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41
Q

Surgery for tethered cord

A
  • lumbar laminectomy with microscopic sectioning of filum
  • early surgery (even if asymptomatic) is recommended, because over time they’ll eventually get symptoms
  • incontinence is often the first symptom and regain continence in only 50%
42
Q

Encephalocele

A
  • neural tube defect resulting in extension of intracranial structures outside normal confines of skull
  • 1 in 12,000 births
  • most often occipital or frontal
43
Q

Chiari malformation

A
  • cerebellar tonsils extend through the foramen magnum > 5mm, resulting in compression of cerebellum and brainstem and possible alteration of CSF flow (associated hydrocephalus)
  • typically asymptomatic and an incidental finding
44
Q

Types of chari malformation

A

Classified as 3 types: I, II (Arnold-Chiari) & III

45
Q

Which type of chiari malformation is associated with spina bifida?

A

Type II (Arnold-Chiari)

*typically asymptomatic

46
Q

Dx of chiari malformation

A

C-spine CT or MRI

47
Q

Symptoms of chiari malformation

A
  • Occipital headache with exertion, coughing, sneezing or straining
  • Balance problems, dizziness
  • Muscle weakness or numbness
  • Trouble speaking or swallowing
  • Problems with hand coordination, fine motor skills

*often asymptomatic, symptoms may not develop until adolescence or adulthood

48
Q

Chiari malformation may be associated with…

A

syringomyelia

-may also have associated hydrocephalus

49
Q

Define syrinx

A
  • tubular cyst within central canal of spinal cord which results in pain, weakness, and stiffness in the back, shoulders, arms, or legs
  • if severe, may have loss of pain or temperature sensation
50
Q

When to operate for chiari malformation

A
  • severe headaches or presence of a syrinx
  • surgery involves removing portion of posterior fossa skull and lamina of C1/C2 aka “Posterior fossa decompression (PFD)”
51
Q

GFS scale for head trauma

A
  • Minor head injury 15-13
  • Moderate head injury 13-9
  • Severe head injury <= 8
  • Even if you are dead you have a score of at least 3
52
Q

In a patient with head trauma you assess…

A
  • assess motor strength and sensation in all extremities
  • assess reflexes
  • cranial nerve exam (check EOM, make them stick out their tongue, make them smile)
53
Q

Skull fracture

A
  • Very common
  • May have associated intracranial injuries
  • In infants/children: make sure mechanism of injury fits to rule out NAT (non-accidental trauma aka child abuse)
54
Q

Skull fracture symptoms

A

-Headache
-emesis
-lethargy
+/- LOC
-overlying scalp edema
-bleeding from nostrils/ears

55
Q

Dx of skull fracture

A

noncontrast CT

56
Q

Skull fracture types

A
  • simple, linear, non-displaced

- depressed

57
Q

Simple skull fracture

A
  • Nonsurgical
  • 24 hours observation
  • if through sinus/mastoid, may have pneumocephalus or CSF leak
58
Q

Depressed skull fracture

A
  • more significant trauma

- clinical judgement about surgery

59
Q

Growing skull fracture

A
  • involves a dural tear
  • usually involves severe underlying brain injury
  • delayed repair necessary
60
Q

Epidural hematoma (EDH)

A
  • Accumulation of blood between skull and dura
  • Brief LOC followed by lucid interval, then obtundation
  • Deterioration typically over a few hours
61
Q

EDH is usually a disruption of what artery?

A

Middle meningeal A

62
Q

EDH on CT

A

Crescent shape

-represents space-occupying lesion to brain and can lead to herniation

63
Q

Tx of EDG

A

Evacuate blood with craniotomy

64
Q

Subdural hematoma (SDH)

A
  • Blood between dura and arachnoid

- Can be acute, chronic or acute on chronic

65
Q

Vessels involved in SDH

A

Tearing or bridging veins of brain

66
Q

SDH on CT

A

follows contours of brain

67
Q

Tx of SDH

A

depends on size and growth

68
Q

Subarachnoid hemorrhage (SAH)

A
  • Bleeding between arachnoid membrane and pia matter

- Often minor head trauma or due to ruptured cerebral aneurysm

69
Q

Symptoms of SAH

A

“thunderclap” headache, neck stiffness

70
Q

SAH on CT

A

within arachnoid folds

71
Q

Tx of SAH

A

Angiogram/embolization if indicated

72
Q

Why is SAH called chemical meningitis?

A

the blood inside their head is really irritating and it hurts like meningitis

73
Q

Intraparenchymal Hemorrhage (IPH)

A
  • Usually moderate to severe trauma

- Essentially bruise of brain near bony prominence

74
Q

IPH on CT

A

rounded white spot

75
Q

Diffuse axonal injury (DAI)

A
  • sloshing of brain in skull shears axons
  • cellular level damage
  • may not even have increased ICP despite poor neurological exam
76
Q

DAI on CT

A

little to no CT findings

77
Q

Non-accidental trauma

A
  • Story is often not consistent
  • Common story: baby found not breathing or scalp swollen with no known cause of injury
  • Any level of injury: simple fracture to DAI
78
Q

What is the “incredibly shrinking brain”?

A

Significant anoxic injury and stroke – then the brain dies off

79
Q

Cranial sutures

A
  • Allow passage through birth canal, growth of skull and absorb mechanical forces during childhood
  • Metopic typically closes between 3-9 months
  • Coronal, sagittal and lambdoid sutures close between 22-39 months
80
Q

Define Plagiocephaly

A

Benign positional molding

“Parallelogram skull”

81
Q

Characteristics of plagiocephaly

A
  • Ear forward on side of flattening with frontal bossing
  • No pressure on brain
  • No imaging needed
  • Improves with repositioning and time
  • No neurosurgical intervention/helmets indicated
82
Q

Craniosynostosis

A
  • Fusion of suture present at birth
  • Worsens with time
  • No movement across suture and ridging on palpation
  • requires surgical correction
83
Q

Dx of craniosynostosis

A

3D head CT is definitive study

84
Q

Metopic synostosis

A
  • Trigonocephaly
  • Narrow bitemporal width
  • Lateral orbital rims retracted
  • May only result in metopic ridging on the forehead
85
Q

Coronal synostosis

A
  • Asymmetry of forehead - flat forehead on ipsilateral side
  • Harlequin eye
  • Trapezoid shape
  • Ear forward on flat side
86
Q

Sagittal synostosis

A
  • Most common
  • Scaphocephaly with parietal narrowing
  • Frontal and occipital bossing
87
Q

Lambdoid synostosis

A
  • Unilateral occipital flattening
  • Ear posterior
  • Forehead not protruded
  • Trapezoid
  • Often confused with plagiocephaly
88
Q

Which synostosis is the most common?

A

Sagittal

89
Q

Lambdoid synostosis is often confused for…

A

plagiocephaly

90
Q

Craniosynostis surgery

A
  • Cranial vault remodeling (CVR)
  • Synostectomy: removal of affected suture
  • May involve both neurosurgery and plastic surgery
91
Q

Plagio vs. cranio

A

review slide 65

92
Q

Small anterior fontanelle

A
  • Normal variant
  • Fontanelle closes between 1-24 months
  • Check growth curve
  • Development
  • Shape of head
93
Q

Most pediatric brain tumors are…

A

primary tumors

94
Q

Location of brain tumors

A

60% located in posterior fossa, 40% in cerebral hemispheres

95
Q

Types of brain tumors

A
  • medulloblastoma
  • juvenile pilocytic astrocytoma (JPA)
  • ependymoma, diffuse internsic pontine glioma (DIPG)
  • craniopharyngioma
96
Q

Symptoms of brain tumor

A
  • headache (worse in morning or awakens pt at night)
  • vomiting
  • ataxia
  • vision changes
  • memory changes
  • seizures
97
Q

Dx of brain tumor

A

MRI with and without contrast

-also obtain MRI of C/T/L spine with and without contrast to look for metastasis

98
Q

Brain tumor surgery

A

biopsy, tumor debulking

99
Q

Tx of brain tumor

A

Further treatment including chemo, proton therapy or radiation therapy as indicated by heme/onc

100
Q

Arachnoid cyst

A
  • Congenital
  • Typically asymptomatic and incidental finding
  • Most common in middle cranial fossa
  • Surgery if causing localized headaches or pressure on surrounding brain

Neurology (11 decks)

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