Neurosurgery Flashcards
What are 3 signs on examination of an anterior fossa skull base fracture?
- CSF rhinorrhoea
- periorbital ecchymosis
- partial/total loss of smell
- eye movement defects
What are 4 signs of middle cranial fossa skull base (petrous temporal bone) fractures?
- Battle sign (bruising behind ear)
- CSF otorrhoea / pain
- hearing loss
- balance problems
What is the definition of spondylolisthesis?
slippage (usually forward) of a vertebra in relation to the vertebra below it
What are 3 causes of spondylolisthesis?
- congenital anomalies of vertebrae
- damage to ligaments or joints secondary to degeneration
- inflammation or trauma
What finding of fundoscopy is strongly suggestive of subarachnoid haemorrhage?
subhyaloid haemorrhages
How should investigations be performed for suspected subarachnoid haemorrhage?
- CT - CT non contrast first line but angiography if possible - ideally within 6h of sx onset
- if CT negative - MRI or LP - CONSIDER LP IF CTH NEGATIVE AND DONE >6H AFTER SYMPTOM ONSET
- LP must not be performed if raised ICP
What LP findings are expected with SAH if if is performed within 6-12 hours?
CSF uniformly blood stained (should ideally wait for 12 hours until performing LP)
What LP findings are expected with SAH if if is performed between 12hours - 2 weeks of symptom onset?
supernatant is xanthochromic
What is the aim of initial management of SAH?
prevent further bleeding and reduce rate of secondary complications (ischaemia or hydrocephalus)
In what proportion of cases of migraine is the headache bilateral?
30%
What are the 7 NICE criteria for CT head within 1 hour for head injury?
- GCS <13 on initial assessment
- GCS <15 2 hours post injury
- suspected open or depressed skull fracture
- basal skull fracture - haemotympanum, panda eyes, CSF rhinorrhoea/otorrhoea, Battle’s sign
- post-traumatic seizure
- focal neurological deficit
- > 1 episode vomiting
What are 4 NICE criteria for CT head within 8 hours for head injury?
- age >65y
- history of bleeding or clotting disorders including anticoagulants
- dangerous mechanism of injury e.g. pedestrial or cyclist struck by car, occupant ejected from motor vehicle, fall from heigh <1m or 5 stairs
- > 30min retrograde amnesia of events immediately before head injury
Which vessel is classically involved in extradural haematoma?
middle meningeal artery - tear, often following skull fracture
What causes the bleeding in a subdural haematoma?
tearing of the bridging veins between the dura mater and arachnoid mater, leading to bleeding in the subdural space
What 2 groups can primary brain injury be divided into?
- focal: contusion or haematoma
- diffse: diffuse axonal injury
What causes diffuse axonal injury?
mechanical shearing following deceleration, causing disruption and tearing of axons
What are 2 types of contusions (type of primary TBI)?
- coup (adjacent to side of impact)
- contre-coup (contralateral to side of impact)
What is secondary brain injury?
- occurs when cerebral oedema, ischaemia, infection, tonsillar or tenotrial herniation exacerbates the original injury
- normal cerebral auto-regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
What is the Cushing’s reflex in traumatic brain injury?
hypertension and bradycardia - occurs late an usually pre-terminal event
What type of injury causes extradural haematoma?
acceleration-deceleration trauma or blow to side of head
Which region of the brain do the majority of extradural haematomas occur?
temporal region (skull fractures cause rupture of middle meningeal artery here)
Which regions of the brain does a subdural haematoma most commonly occur?
frontal and parietal lobes
How does the onset of symptoms of subdural vs extradural haemorrhage vary?
slower onset of symptoms with subdural; may be fluctuating confusion/consciousness vs lucid interval in extradural
What are 6 risk factors for an intracerebral haematoma?
- hypertension
- vascular lesion e.g. aneurysm / AVM
- cerebral amyloid angiopathy
- trauma
- brain tumour
- infarct
What is the appearance of extradural and subdural haematoma on CT?
extradural - lentiform, subdural: crescenteric
What is the most common cause of subarachnoid haemorrhage?
head injury - traumatic SAH
What proportion of cases of spontaneous subarachnoid haemorrhage is due to saccular berry aneurysms?
85%
What are 4 diseases associated with berry aneurysms?
- hypertension
- adult polycystic kidney disease
- Ehlers-Danlos syndrome
- coarctation of the aorta
What ECG changes may be seen in subarachnoid haemorrhage?
ST elevation (may be secondary to autonomic neural stimulation from hypothalamus or elevated levels of circulating catecholamines)