Nervous system surg Flashcards
An epidural hepatoma causes what type of herniation? How may it present?
How does uncal herniation present?
What about tonsilar herniation?
Subfalcine - ipsilateral anterior cerebral artery compression so contralateral leg weakness. No pupillary symptoms
Uncal - ipsilateral fixed and dilated pupil due to compression of oculomotor nerve. (Signs of brain stem compression so irregular respirations, unconsciousness and pupillary changes). contralateral leg weakness.
Tonsilar - mid position FIXED pupils. Signs of brain stem compression so irregular respirations, unconsciousness and pupillary changes)
What are the indications for imaging when cervical spine injury is suspected?
What imaging is carried out?
Management if imaging not indicated?
- High energy mechanism of injury
- Neurologic deficit
- Spinal tenderness
- AMS!!
- Intoxication!!
- Distracting injury
Non contrast CT scan!!! Of cervical spine (Picks up fractures)
Neurological exam if not indicated
Acute spinal cord injury starts with HTN and tachycardia but then the reverse quickly takes over. Patient develops neurogenic shock.
Thus is immediately after injury ie spinal shock
Years later = autonomic dysreflexia can develop = when a stimuli below the injury eg urinary retention, constipation, pressure ulcer can cause severe hypertension and bradycardia. Management is remove stimuli and treat htn
Lower extremity tingling and numbness, difficulty walking at night. Gastric bypass surgery 5 years ago and has been taking zinc . Gait ataxia with loss of vibration and position sense in feet. Positive Romberg, skin depigmentation
Labs reveal microcytic anemia and leukopenia. Most likely deficiency?
Copper!!
Risk factors = bariatric surgery, zinc ingestion, chronic malabsorption eg IBD
Manifestation = neuropathy similar to B12, anemia, skin depigmentation, hepatospleenomegly, edema, osteoporosis.
NOT B12 or folate deficiency as these would cause megaloblastic anemia
Mineral deficiencies and presentation
Chromium -impaired glucose control in diabetes
Selenium - thyroid dysfunction, cardiomyopathy, immune dysfunction
Zinc Alopecia, pustular rash in perioral region and extremities, hypogonadism, impaired wound healing, impaired taste, immune dysfunction.
Patient with a history of traumatic brain injury. Now having fevers and diaphoresis. High BPs, tachycardia, tachypnea. Most likely cause of abnormal vital signs?
Paroxysmal sympathetic activity!!
Due to damage to areas inhibiting sympathetic activity.
Not uncontrolled pain as can cause signs to less extreme level and no fevers.
Not sepsis as there would by hypotension
Describe the medical management of an HEMORRHAGIC stroke
Blood pressure control =IV nifedipine, IV labetalol
Anticoagulant reversal = vitamin k if warfarin, protamine sulfate for heparin
ICP regulation = mannitol!! Hypertonic saline!!!, head of bed elevation
headaches and vertigo and positive head ct finding for cerebellar Hemorrhage.
Vertigo or dizziness!! Is common!! Patient presented with this and also headaches, Other cerebellar signs depending on location eg ipsilateral ataxia, r Dysarthria, nystagmus, cranial neuropathy
Question was how do you manage this type of hemorrhage
Medical management of stroke + SURGERY!!- answer they were after
Surgical, decompression indicated if
1. Signs of neurological deterioration = progressive lethargy!! (Patient had this), obtundation, coma
2. Radiological evidence of bleed >3cm, brain stem compression or obstructive hydrocephalus.
patient with end stage renal disease that has bilateral tingling, burning and numbness in his hands. symptoms worsen during hemodyalisis and are more severe in the hand with vascular access. most likely diagnosis?
carpal tunnel syndrome
dialysis related amyloidosis depositing in carpal tunnel + increased venous pressure during hemodialysis
CT spinal cord trauma. burst fracture. patient is alert. first step in management?
bladder catheterisation!! due to acute urinary retention risk and injury
bilateral extremity lower weakness and difficulty walking in 65 year old woman. constant dull headache and occasional urinary incontinence. spastic gait and babinskis sign present bilaterally and hyperreflexia. most likely diagnosis?
parasagittal meningioma!! - constant headache and lack of sensory finding point to lesion in brain
not ALS as presents with mixed upper and lower motor neurone signs and no headache
not mononeuritis multiplex as this is a neuropathy of at least 2 non contiguous peripheral nerves.
CT cervical spine shows fracture. what additional study do you need?
CT thoracic and lumbar spine
full workup now needed
tingling and numbness of thumb and index finger. weakness of elbow flexion. biceps reflex decreased. all on left side. most likely diagnosis?
spinal nerve root compression!!! (cervical radiculopathy) - can cause neck pain as well. lateral flexion and rotation of neck worsens compression and thus symptoms
findings arent limited or attributed to a single peripheral nerve eg ulnar or median but rather follow the dermatomal and myotomal pattern of C6 consistent with radiculopathy
scalp claceration injury. patient becomes unresponsive after lucid interval -> likely epidural hematoma from injury to the middle meningeal artery.
cushings triad seen (HTN, brdycardia, bradypnea) and this is consistent with increased ICP
patient reports progressive weakness on right side. which head and neck nerve is most likely to be compromised?
occculomotor nerve!!! (weakness in keeping with uncal herniation)
patient with history of hodgkins lymphoma treated with chemo and radiation. presents with neurological symptoms and MRI reveals homogenous mass compressing spinal cord at C2 level.
what is this? and greatest risk factor?
cervical spine meningioma!!
radiation!!!!!!
not hodgkins increases risk of secondary malignancies NOT meningioma
mild cervical radiculopathy treated with nsaids and activity avoidance. get a general idea of C5, C6, C7, C8 T1 findings
if a patient previously had norrmal medical evelauation and now presents with high BP. doesnt actually mean the patient has htn!!
so ICH in a young patient, most common culprit?
AVM!!
Symptoms and progression of spinal epidural abscess?
Rf?
Management?
Fever and malaise -> Back pain -> motor weakness and sensory changes - bowel and bladder dysregulation - paralysis!!!
Distant infection eg cellulitis, injection drug use, spinal procedure eg epidural catheter which is most common!!! And immunosuppression, trauma eg fight
Urgent MRI spine!!!! And then treat with urgent decompression including laminectomy!! and drainage !!! and antibiotics
Expansion of abscess in to retropharyngeal space can cause sore throat
SAH can cause normal pressure hydrocephalus characterised by ventriculomegaly, classic symptoms and normal opening pressure. Only gait dysfunction and imaging required for diagnosis
SAH can also cause aqueductal stenosis also characterised by ventriculomegaly!, but also signs of raised ICP = headache, nausea
How to diagnose NPH? Management
High volume lumbar puncture !!! Causing improvement of gait with fluid removal
Shunt!!
78 year old woman Clumsiness and weakness of hands
Trouble buttoning shirts
Stiffness in neck and legs
Stigf growths in distal and proximal interphalangealh joints
Wasting of intrinsic hand muscles
Neck flexion elicits shock like sensation
Most likely diagnosis ?
Cervical spinal cord compression!!
Patient has cervical myelopathy causing both
Cord compression = UMN signs below lesion so hyperreflexia, stiffness
Compression of cervical spinal nerve roots = atrophy, hyper reflexia, pain in dermatomal/myotomal pattern
Llermittee sign may occur
Hoffman sign = flicking the nail of middle finger cause flexion and adduction of the thumb
Patient with history of injection heroin use. Ptosis of both eyes, pupils are dilated and ptosis present (bilateral CN palsy), acute hypoxemic respiratory failure, unable to hold head up due to muscle weakness. Puncture wound abscesses on thigh. Most likely diagnosis and treatment
Equine botulinum antitoxin!
Clostridium botulinum infection
CENTRAL! cord syndrome, an incomplete spinal cord injury! is common after whiplash injuries in older adults with underlying cervical spondylosis. Presentation?
Upper extremity = weakness, sensory loss, triceps reflex loss
Bilateral upper extremity weakness with decreased pain and temp sensation specifically!!! . Whiplash cervical spine injury 1 year ago. Most likely diagnosis?
Syringomelia = fluid filled cavity in spinal cord
MRI visualises this
Chiari type 1 also risk factor
Surgical intervention eg shunt
Tranexamic acid can improve outcomes for patients with TBI
