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Surgery > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

history

A

-is there neurologic disease causing systemic issues or systemic issues causing neurological disease
-can the pt withstand anesthesia
-where is the lesion, what caused it, how do we treat it

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2
Q

cerebral lesions

A

-cause contralateral deficits in extremities
-mostly require a bilateral lesion for it to be apparent tho
-olfactory CN1- doesnt cross so unilateral lesion results in ipsilateral anosmia
-optic CN2, oculomotor CN3, trochlear CN4, abducens CN6- both eyes cant MOVE to contralateral side of lesion (look towards lesion), both eyes cant SEE contralaterally, pupillary light reflex is consensual bc its mediated by the brainstem
-trigeminal CN5- contralateral loss of facial sensation
-facial CN7- contralateral lower half of face paralysis // if facial nerve itself is damaged (bells palsy) -> total ipsilateral hemifacial paralysis
-vestibulocochlear CN8- needs to be bilateral for hearing loss, can cause vertigo
-glossopharyngeal CN9, vagus CN10, accessory (CN11)- needs to be bilateral usually
-hypoglossal CN12- contralateral weakness of the tongue, more pronounced with direct lesions

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3
Q

right optic nerve damage and light shined into right eye

A

-no response
-if light shined in left eye -> both pupils constrict

-right oculomotor nerve damage and light shined in right eye -> only left pupil constricts
-right oculomotor nerve damaged and light shined in left eye -> only left pupil constricts

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4
Q

CNS vs PNS lesions

A

-PNS
-follow dermatomes or glove and stocking
-sensory loss with pain

-CNS
-defects in extremity
-loss of sensation with no pain

-exception- thalamic pain syndrome- causes diffuse pain

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5
Q

thalamic syndrome

A

-usually caused by occlusion of thalamogeniculate branches of PCA supplying posterior thalamus
-contralateral hemianesthesia, ataxia, excruciating neurogenic pain
-unresponsive to analgesics
-symptoms vary
-CNS exception

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6
Q

upper motor neuron vs lower motor neuron defect

A

-UPPER
-spastic weakness
-no significant muscle atrophy
-no fasciculations and fibrillations
-hyperreflexia
-babinski reflex may be present

-LOWER
-flaccid weakness
-significant atrophy
-fasciculations and fibrillations
-hyporeflexia
-no babinski reflex

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7
Q

spinal cord defect

A

-UMN signs with spinal dermatome defect
-loss of pain-temperature in one leg and loss of proprioception in the other leg

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8
Q

brain stem lesion

A

-cranial nerve deficit with contralateral extremity hemiparesis (right facial paralysis and left hemiplegia)
-you can rule out cerebral cortex lesions bc it would be confine to contralateral deficit (left facial paralysis and left hemiplegia)

-CN2- loss of vision in one eye
-CN3,4, or 6- pupillary inequality or difficulty moving one eye
-CN5- unilateral weakness of masseter muscle
-CN7- total unilateral facial paralysis
-CN8- unilateral hearing loss
-CN9/and or 10- difficulty swallowing
-CN10- hoarseness
-CN11- difficulty raising shoulder or turning head

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9
Q

cerebellar or basal ganglia lesions

A

-awkward movement
-not weak
-intended movement awkwardness- tremor, ataxia -> cerebellar
-involuntary awkwardness- resting tremor, chorea, athetosis, hemiballismus -> basal ganglia lesions

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10
Q

parts of brain and function

A

-brocas- expressing language
-wernickes- understanding language
-temporal- memory, recognizing faces, emotions, language
-parietal- perception, spatial awareness, manipulating objects, spelling

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11
Q

corpus callosum

A

-connects brain left and right
-coordinate

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12
Q

brown sequard syndrome

A

-hemisection of the spinal cord
-ipsilateral loss of all sensory modalities at level of the lesion
-ipsilateral flaccid paralysis at level of lesion
-ipsilateral spastic paraparesis below the lesion
-ipsilateral loss of vibration and position sense below the lesion
-contralateral loss of pain and temperature below the lesion

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13
Q

posterior column- medial lemniscus pathway of CNS

A

-proprioception, vibration, discriminative touch, weight discrimination and stereognosis
-signals travel up spinal cord in posterior column
-fibers cross over in medulla -> become the medial lemniscus pathway ending in thalamus
-thalamic fibers reach cortex

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14
Q

MCA stroke

A

-middle cerebral artery
-contralateral hemiparesis (usually upper)
-contralateral hypesthesia
-ipsilateral hemianopsia (vision loss)
-gaze goes towards the side of lesion
-agnosia- cant recognize
-receptive or expressive aphasia
-weakness in arms and face
-aphasia

-ex. left MCA stroke -> right face/arm > leg numbess and weakness, APHASIA, left gaze preference
-ex. right MCA stroke -> left face/arm > leg numbness and weakness, LEFT HEMISPATIAL NEGLECT, right gaze preference, agraphesthesia/asteroagnosia

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15
Q

PCA stroke

A

-posterior cerebral artery
-cortical blindness
-visual agnosia
-altered mental status
-impaired memory
-hemiparesis
-hemianopsia
-ataxia
-dizziness

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16
Q

VBA stroke

A

-veterbrobasilar artery
-vertigo
-nystagmus
-diplopia
-ipsilateral cranial nerve deficit with contralateral motor deficits
-dysphagia
-syncope
-ataxia

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17
Q

ACA stroke

A

-anterior cerebral artery
-frontal lobe function affected
-disinhibition
-primitive reflexes- grasping, sucking
-AMS
-impaired judgement
-gait apraxia
-urinary incontinence
-hemiparesis, especially inferior limbs!

-EX. left ACA stroke -> right leg numbness/weakness, transcortical motor aphasia, ideomotor apraxia
-ex. right ACA stroke -> left leg numbness/weakness, motor neglect, possible ideomotor apraxia

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18
Q

internal carotid artery stroke

A

-ACA + MCA
-ipsilateral monocular visual loss (amurosis) secondary to central retinal arterial occlusion (CRAO)
-hemiparesis
-aphasia
-hemianopsia

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19
Q

basilar artery stroke

A

-before PCA
-breathing difficulties
-sensory or balance disorders
-ataxia
-nystagmus
-opisthotonus- possessed looking
-tremors and vomiting

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20
Q

cerebellar artery

A

-sensory difficulties
-headaches
-fever
-vomiting
-cerebellar signs

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21
Q

wallenberg (lateral medullary syndrome)

A

-vertebral artery or PICA occlusion
-stroke of the brain stem
-lateral medulla ischemia
-ipsilateral palate weakness
-impaired coordination
-contralateral sensory disturbances of trunk and extremities -> impaired gait and falls.
-Horner syndrome- decreased pupil size, drooping eyelid, decreased sweating on one side
-dizziness, double vision, pain or loss of pain on one side of the face, loss of taste on one side of the tongue, difficulty swallowing, slurred speech, and hoarseness

22
Q

lacunar strokes

A

-5 kinds- motor, motor and sensory, sensory, ataxic hemiparesis, dysarthria-clumsy hand syndrome

23
Q

glasgow coma scale

A

-intubated cant have verbal score done -> mark score with a T if intubated
-max score- 10T and minimum is 2T when intubated

-severe- <= 8 -> MUST intubate, monitor ICP with a bolt
-moderate- 9-12
-minor- >= 13

24
Q

subdural hematoma

A

-rupture of the bridging VEINS
-high CSF pressure can cause a pt to be prone to rupture
-may cause herniation of brain
-shaken baby syndrome -> also affects older pts
-mass effect
-can be chronic or subacute (non urgent)
-banana

-tx- airway management -> if stable be conservative and repeat CT
-blood is self enhancing -> no dye
-if midline shift > 5mm, OR size of hematoma > 10mm, OR chronic (gray) -> surgery
-surgery if unstable

25
Q

epidural hematoma

A

-trauma, infection, coagulopathy…
-life threatening
-middle meningeal artery
-usually occurs with skull fracture
-loss of consciousness/coma- lucid interval
-urgent surgery in acute EDH, volume > 30ml regardless of GCS, or < 9 GCS with pupillary abnormalities like anisocoria
-craniotomy and evacuation -> trephination if not possible
-football- lentiform
-MC from temporal skull fracture
-try to lift head to decrease ICP, recumbent

-if brain herniates -> ipsilateral CN3 palsy and contralateral hemiparesis

26
Q

subarachnoid hemorrhage

A

-MC is due to TRAUMA
-spontaneous- most 2ndary to aneurysm rupture
-sudden, severe headache
-nuchal rigidity, photophobia
-CN 3 and/or CN6 palsy
-hypophosphatemia
-changes in EKG
-CTA, Digital Subtraction Angiography (DSA), MRA, LP
-1. CT -> if neg -> 2. LP 6 hrs after to assess xanthochromia -> 3. CTA
-LP is gold standard
-coiling or clipping
-hydrocephalus -> drain
-vasospasm -> osmotic diuretics
-higher risk -> airway management, arterial line to monitor BP, urinary catheter, seizure prophylaxis

27
Q

pathophysiology of delayed cerebral ischemia after SAH

A

-neuroinflammation
-perfusion mismatch
-vasospasm
-cortical spreading depolarization (CSD)
-microthrombosis
-BBB breakdown
-brain edema
-oxidative stress

28
Q

SAH treatment

A

-pharm management:
-blood pressure control
-tranexamic acid (antifibrinolytic) and factor 7
-antioxidants

-surgical management:
-craniopuncture
-craniotomy
-hematoma aspiration and thrombolysis
-neuroendoscopy and evacuation
-novel method

29
Q

most common aneurysms

A

-anterior cerebral artery + anterior communicating artery -> 40%
-Posterior communicating artery -> 20%
-middle cerebral artery -> 34%
-posterior cerebral artery + basilar artery -> 4%

29
Q

SAH concern

A

-vasospasm- often within 3-7 days
-can occur at any time within the 21 day window following the initial hemorrhage
-surveillance is key!

30
Q

other causes of SAH

A

Central amyloid angiopathy
AVM
Septic aneurysm
Cocaine use
Moya-Moya Disease
Sickle Cell Disease
Vertebral Artery Dissection
Carotid Artery Dissection

31
Q

gliomas

A

-persistent headache, seizures!!, nausea, vomiting, focal neurological deficits
-AMS, hydrocephalus
-CT, MRI
-tx- surgery

32
Q

pituitary adenomas

A

-tumor of anterior pituitary
-micro- <10mm
-macro >10mm- bitemporal defect, headache
-usually benign
-transsphenoidal resection for macroadenomas or visual deficit, pituitary apoplexy, loss of endocrine function, significant growth
-prolactinoma- meds first -> if resistant -> resect
-GH secreting- resect
-ATCH adenoma -> resection

33
Q

craniopharyngiomas

A

-benign tumor
-headache, nausea, vomiting, visual deficits, endocrine disturbance
-stick to surfaces around it and reoccur often
-bimodal
-sellar/suprasellar region -> pituitary
-CT /MRI
-tx- replace hormones, transsphenoidal or transcranial surgery, radiotherapy
-adamantinomatous craniopharnygioma- kids
-papillary craniopharyngioma- adults

34
Q

blood flow

A

-internal carotids -> MCA, ACA, PCoA
-vertebral artery (PiCA branch to cerebellum) -> basilar artery -> PCA

35
Q

basilar skull fracture

A

-racoon eyes-Associated with orbital fractures
-halo sign
-battle sign-Retroauricular ecchymosis
-Associated with fracture of auditory canal and lower areas of skull
-if dura tear -> CSF drains from nose or ear
-sinus leak -> bacteria in the nose -> antibiotics

36
Q

brain injury: management

A

-requires significant nutrition to heal
-get CT
-put pt on antiepileptic (Keppra) for 7 days -> prevents seizures and convulsions
-NO anticoagulation for 48 hrs -> if stable then start DVT prophylaxis??- from high yield
-treat coagulopathies
-monitoring
-dx studies
-prevent secondary injuries- anemia, acidosis, shock, pt positioning
-flexible approach to care
-prophylaxis
-make sure temperature is okay -> brain does not like temp

37
Q

head trauma: glucose

A

-want glucose to be <200-> 140-160
-bc pt cant verbalize symptoms and CC you want them to be a little higher than normal
->100 for surgery

38
Q

primary vs secondary head injuries

A

-primary
-occurs when it happens
-mechanical fall

-secondary- injuries evolve days after primary
-giving too much fluid, hypoxic, not monitoring head position, hyponatremia, hypotension, poor control of glucose, increase ICP, hypovolemia
-we must prevent this

39
Q

diffuse axonal injury

A

-Due to stretching forces placed on axons.
-Pathology distributed throughout brain
-Types:
-Concussion- mild
-Moderate diffuse axonal injury- classic concussion
-Severe diffuse axonal injury
-sheering of axons on brain
-scan- no grey white differentiation*

40
Q

cushing reflex

A

-response to increase ICP
-cushing triad:
-increase BP- to perfuse the brain -> increase ICP
-irregular breathing- cheyne stokes
-bradycardia

41
Q

compression/herniation of brainstem

A

-Upper brainstem- Vomiting, Altered mental status, Pupillary dilation, decorticate posture
-Medulla oblongata- Respiratory, Cardiovascular, Blood pressure disturbances

42
Q

brain herniations

A

-transcalvarial

-uncal- uncinate process of the temporal lobe herniates into the anterior part of the opening of the tentorium cerebelli

-cingulate (subfalcine)- displacement of cingulate gyrus under the falx and across the midline

-central (trans-tentorial)
-upward cerebellar / transtentorial
-downward cerebellar (tonsillar)

43
Q

glioblastoma

A

-26% frontal
-19% temporal
-parietal lobe 12%

44
Q

glioblastoma multiforme (GBM) on imaging

A

-Large mass with necrosis
-Prominent edema
-Mass effect
-Strong heterogeneous contrast enhancement

-tx-
-Surgery: De bulking
-Radiation: 10 – 30 external radiation beam treatments. 1x/day; 5 days/week.
-Chemotherapy: Temozolamide (Temodal); every day during radiation therapy and then for six cycles after radiation during the maintenance phase. Each cycle lasts for 28 days, with temozolomide given the first five days of each cycle, followed by 23 days of rest.

45
Q

intraparenchymal

A

-contusion

46
Q

interventricular hemorrhage

A

-blocks flow of CSF
-increase ICP
-hydrocephalus

47
Q

brain injury on arrival

A

-EKG
-TED
-CT of chest, neck, abdomen, pelvis -> PAN scan -> fractures, perforations
-CT with no contrast for head
-give reversal agents for anticoagulants if bleeding -> Andexanet alfa (Andexxa) for apixaban
-propofol, diuretics, hyperventilate them, pain management, to lower BP if ICP is high
-elevate the head to decrease ICP with cervical collar
-Vitamin K and prothrombin complex concentrate (PCCs)
-heparin- Protamine sulfate
-warfarin- Vitamin K and prothrombin complex concentrate (PCCs)
-2 large bore needles to
-anti-epileptics - levetiracetam keppra for 7 days
-cefazolin- for pts with drains to prevent infection

48
Q

TBI

A

-MC in >75yo
-can happen with no impact (accel and decel)
-shearing
-cerebral contusions
-extra-axial lesions: epidural, subdural, SAH, intraventricular hemorrhage

-severe- GCS <9
-moderate- 9-13
-mild- 14/15, no pathology on imaging, low risk for deterioration

49
Q

TBI tx

A

-decompressive craniectomy
-prophylactic hypothermia - prevent secondary brain injury
-osmotherapy- mannitol (for herniating pts)
-draining CSF- continuous (not intermittent) -> drain for first 12 hrs from pts with GCS <6
-ventilation- avoid hyperventilation (especially in first 12 hrs) -> use jugular venous saturation monitoring to ensure brain is getting enough O2
-sedation- propofol for ICP control, barbiturate coma is for super-refractory ICP
-steroids- ??
-nutrition- aim for goal nutrition by 5-7 days
-prophylactic antibiotics- use routine protocol to prevent VAP -> no need for prophylactic
-DVT prophylaxis- TED stockings and heparin or enoxaparin (lovenox)
-seizure prophylaxis- 7 days of phenytoin or levetiracetam (keppra)

50
Q

TBI ICP monitoring

A

-indicated for GCS 3-8 and abnormal CT
-if GCS 3-8 and CT normal -> monitor ICP if they have 2 of following: >40yo, motor posturing, hypotension (SBP <90)
-ICP of 22mmHg is threshold for tx
-CPP monitoring- aim for 60-70

51
Q

TBI systolic BP targets

A

-110 for young (18-49)
-110 for elderly (>70)
-100 for 50-69
-keep BP <160!!!!

Surgery (10 decks)

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