Neurology #5

Question 1

A subarachnoid hemorrhage is MC due to

Answer 1

A ruptured berry aneurysm at the anterior communicating artery

Question 2

Risk factors for a subarachnoid hemorrhage

Answer 2

• Smoking
• Hypertension
• PKD, CAD, smoking, alcohol, marfan Syndrome, family history

Question 3

Symptoms of a subarachnoid hemorrhage

Answer 3

• Sudden, intense thunderclap headache
• Worst headache of my life
• Nausea, vomiting, meningeal symptoms (neck stiffness, fever, photophobia)
• May have LOC initially

Question 4

Diagnostics for a subarachnoid hemorrhage

Answer 4

• CT scan without contrast: initial

- LP: xanthrochromia (yellow-pink color of CSF due to breakdown of RBCs)

Question 5

What diagnostic is done AFTER confirmed subarachnoid hemorrhage to identify source of bleeding and other aneurysms?

Answer 5

4-vessel angiography

Question 6

Treatment for a subarachnoid hemorrhage

Answer 6

-Supportive: bed rest, stool softeners, lower intracranial pressure (Nimodipine)

Question 7

How to prevent a rebreeding of a SAH

Answer 7

-Endovascular coiling or surgical clipping of aneurysm or AVM

Question 8

Lowering the BP may reduce the risk of rebleeding in a SAH. What medications are preferred?

Answer 8

Labetolol, Nicardipine, Enalapril

Question 9

What medications are given to reduce increased intracranial pressure, in an intracerebral hemorrhage?

Answer 9

IV mannitol

Question 10

Physical exam signs of a basilar skull fracture

Answer 10

• Periorbital ecchymosis (Raccoon eyes)
• Mastoid ecchymosis (Battle Sign)
• Hemotympanum (blood behind TM)
• Rhinorrhea (CSF leak)

Question 11

True or False: most basilar skull fractures are nonoperative without underlying brain injury?

Answer 11

True

Question 12

What is a Jefferson (Burst) Fracture?

Answer 12

Fracture of the Atlas (C1)

-Bilateral fractures of both anterior and posterior arches of the atlas

Question 13

Stability of the Burst/Jefferson Fracture is determined by what?

Answer 13

Involvement of the transverse ligament

Question 14

Mechanism of injury for a Burst/Jefferson Fracture

Answer 14

-Axial load on the back of the head or hyperextension of the neck (diving)

Question 15

What two views of XR are ordered with a Burst Fracture?

Answer 15

• Lateral radiographs: increase in predental space between C1 and odontoid (Dens)
• Odontoid views: step off of lateral masses of atlas

Question 16

Management, both nonoperative and operative, for a Burst Fracture

Answer 16

• Nonoperative: external immobilization for 6-12 weeks for stable fractures
• Operative: C1-C2 fusion if unstable

Question 17

An odontoid fracture (fracture of dens/odontoid process of the axis/C2) is from what?

Answer 17

Head placed in forced flexion or extension in anterior-posterior orientation (forward fall onto the forehead)

Question 18

With a hangman’s fracture (C2/axis pedicle) fracture, what is one complication that can occur?

Answer 18

Spondylolisthesis between C2 and C3 (anterior dislocation of C2)

Question 19

MOA of a Hangman’s Fracture

Answer 19

-Extreme hyperextension (MVA, chin hitting the steering wheel)

Question 20

What is the difference between a nonoperative and an operative Hangman’s Fracture?

Answer 20

Nonoperative (Type I): < 3 mm horizontal displacement = right cervical collar for 4-6 weeks. (Type II) 3-5 mm displacement = closed reduction and immobilization 8-12 weeks

Operative (Type II): > 5 mm displacement with angulation

Question 21

What is a Clay-Shoveler’s Fracture?

Answer 21

Spinous process avulsion fracture (C6-T3)

Question 22

Where does a Clay Shoveler’s Fracture MC occur?

Answer 22

C7 MC

Question 23

MOA of a Clay Shoveler’s Fracture

Answer 23

Forced neck flexion after sudden deceleration injuries (MVA)

-Usually a stable injury

Question 24

Treatment for a Clay Shoveler’s Injury?

Answer 24

Nonoperative: NSAIDs, rest, immobilization for support

Surgical excision only needed if persistent pain or nonunion

Question 25

What is subclavian steal syndrome?

Answer 25

Signs and symptoms due to retrograde blood flow from vertebral artery to ipsilateral arm as a result of decreased flow into the subclavian artery

Question 26

MC etiology of subclavian steal syndrome

Answer 26

Atherosclerosis of subclavian artery

-Others: dissecting aortic aneurysm, thoracic outlet syndrome

Question 27

Symptoms of subclavian steal syndrome

Answer 27

• Arm arterial insufficiency: arm claudication with exercise, paresthesias
• Vertebrobasilar insufficiency: syncope, neuro deficits, vertigo, weakness

Question 28

What is seen on physical exam of a patient with subclavian steal syndrome?

Answer 28

Blood pressure difference between the arms ( > 15 mmHg) compared to unaffected arm
-Radial pulse diminishes with arm elevation or exercise

Question 29

Treatment for subclavian steal syndrome

Answer 29

-Revascularization or percutaneous transluminal angioplasty

Question 30

Deficits of an anterior cord injury

Answer 30

• Motor deficit: lower extremity > upper extremity
• Sensory deficit: pain, temperature, light touch
• May develop bladder dysfunction

-Preserved: vibration pressure, proprioception, light touch

Question 31

Deficits of a central cord injury

Answer 31

• Motor: upper extremity > lower extremity
• Sensory: pain, temperature (in upper > lower) = shawl distribution
• Preserved: proprioception, vibration, pressure

Question 32

Deficits of a posterior cord injury

Answer 32

• Motor: NONE
• Sensory: loss of proprioception and vibratory sense only
• Preserved: pain, light touch, no MOTOR DEFICITS

Question 33

What is Brown-Sequard Syndrome?

Answer 33

• Ipsilateral deficits
• -Motor
• -Vibration and proprioception
• Contralateral Deficits
• -pain and temperature