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Focused 2 > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

What are 3 signs on examination of an anterior fossa skull base fracture?

A
  1. CSF rhinorrhoea
  2. periorbital ecchymosis
  3. partial/total loss of smell
  4. eye movement defects
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2
Q

What are 4 signs of middle cranial fossa skull base (petrous temporal bone) fractures?

A
  1. Battle sign (bruising behind ear)
  2. CSF otorrhoea / pain
  3. hearing loss
  4. balance problems
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3
Q

What is the definition of spondylolisthesis?

A

slippage (usually forward) of a vertebra in relation to the vertebra below it

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4
Q

What are 3 causes of spondylolisthesis?

A
  1. congenital anomalies of vertebrae
  2. damage to ligaments or joints secondary to degeneration
  3. inflammation or trauma
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5
Q

What finding of fundoscopy is strongly suggestive of subarachnoid haemorrhage?

A

subhyaloid haemorrhages

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6
Q

How should investigations be performed for suspected subarachnoid haemorrhage?

A
  • 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
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7
Q

What LP findings are expected with SAH if if is performed within 6-12 hours?

A

CSF uniformly blood stained (should ideally wait for 12 hours until performing LP)

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8
Q

What LP findings are expected with SAH if if is performed between 12hours - 2 weeks of symptom onset?

A

supernatant is xanthochromic

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9
Q

What is the aim of initial management of SAH?

A

prevent further bleeding and reduce rate of secondary complications (ischaemia or hydrocephalus)

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10
Q

In what proportion of cases of migraine is the headache bilateral?

A

30%

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11
Q

What are the 7 NICE criteria for CT head within 1 hour for head injury?

A
  1. GCS <13 on initial assessment
  2. GCS <15 2 hours post injury
  3. suspected open or depressed skull fracture
  4. basal skull fracture - haemotympanum, panda eyes, CSF rhinorrhoea/otorrhoea, Battle’s sign
  5. post-traumatic seizure
  6. focal neurological deficit
  7. > 1 episode vomiting
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12
Q

What are 4 NICE criteria for CT head within 8 hours for head injury?

A
  1. age >65y
  2. history of bleeding or clotting disorders including anticoagulants
  3. dangerous mechanism of injury e.g. pedestrial or cyclist struck by car, occupant ejected from motor vehicle, fall from heigh <1m or 5 stairs
  4. > 30min retrograde amnesia of events immediately before head injury
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13
Q

Which vessel is classically involved in extradural haematoma?

A

middle meningeal artery - tear, often following skull fracture

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14
Q

What causes the bleeding in a subdural haematoma?

A

tearing of the bridging veins between the dura mater and arachnoid mater, leading to bleeding in the subdural space

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15
Q

What 2 groups can primary brain injury be divided into?

A
  1. focal: contusion or haematoma
  2. diffse: diffuse axonal injury
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16
Q

What causes diffuse axonal injury?

A

mechanical shearing following deceleration, causing disruption and tearing of axons

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17
Q

What are 2 types of contusions (type of primary TBI)?

A
  1. coup (adjacent to side of impact)
  2. contre-coup (contralateral to side of impact)
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18
Q

What is secondary brain injury?

A
  • 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
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19
Q

What is the Cushing’s reflex in traumatic brain injury?

A

hypertension and bradycardia - occurs late an usually pre-terminal event

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20
Q

What type of injury causes extradural haematoma?

A

acceleration-deceleration trauma or blow to side of head

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21
Q

Which region of the brain do the majority of extradural haematomas occur?

A

temporal region (skull fractures cause rupture of middle meningeal artery here)

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22
Q

Which regions of the brain does a subdural haematoma most commonly occur?

A

frontal and parietal lobes

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23
Q

How does the onset of symptoms of subdural vs extradural haemorrhage vary?

A

slower onset of symptoms with subdural; may be fluctuating confusion/consciousness vs lucid interval in extradural

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24
Q

What are 6 risk factors for an intracerebral haematoma?

A
  1. hypertension
  2. vascular lesion e.g. aneurysm / AVM
  3. cerebral amyloid angiopathy
  4. trauma
  5. brain tumour
  6. infarct
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25
Q

What is the appearance of extradural and subdural haematoma on CT?

A

extradural - lentiform, subdural: crescenteric

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26
Q

What is the most common cause of subarachnoid haemorrhage?

A

head injury - traumatic SAH

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27
Q

What proportion of cases of spontaneous subarachnoid haemorrhage is due to saccular berry aneurysms?

A

85%

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28
Q

What are 4 diseases associated with berry aneurysms?

A
  1. hypertension
  2. adult polycystic kidney disease
  3. Ehlers-Danlos syndrome
  4. coarctation of the aorta
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29
Q

What ECG changes may be seen in subarachnoid haemorrhage?

A

ST elevation (may be secondary to autonomic neural stimulation from hypothalamus or elevated levels of circulating catecholamines)

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30
Q

What are 3 aspects of management of a confirmed aneurysmal SAH?

A
  • supportive: bed rest, analgesia, VTE prophylaxis, discontinuation of antithrombotics
  • oral nimodipine - prevent vasospasm
  • coil by interventional neuroradiologists (/ craniotomy + clipping by NSx)
31
Q

What is the purpose of coil / clipping of subarachnoid haemorrhages that are aneurysmal?

A

preventing rebleeding

32
Q

What are 5 complications of subarachnoid haemorrhage?

A
  1. rebleeding
  2. hydrocephalus
  3. vasospasm - delayed cerebral ischaemia
  4. hyponatraemia - usually due to SIADH
  5. seizures
33
Q

What proportion of cases of SAH rebleed?

34
Q

When does rebleeding of SAH most commonly occur?

A

first 12 hours

35
Q

How is hydrocephalus secondary to SAH treated?

A

temporarily with an external ventricular drain (CSF diverted into bag at bedside), or long-term ventriculoperitoneal shunt if required

36
Q

When does vasospasm typically occur as a complication of SAH?

A

7-14 days after onset

37
Q

What is the treatment of vasospasm following SAH?

A

ensure euvolaemia, consider vasopressure if symptoms persist

38
Q

What are 3 important predictive factors in SAH?

A
  1. conscious level on admission
  2. age
  3. amount of blood visible on CTH
39
Q

What distinguishes acute vs subacute vs chronic subdural haemorrhage?

A
  • acute: symptoms develop within 48h of injury, rapid deterioration
  • subacute: symptoms days to weeks post-injury, more gradual progression
  • chronic: common in elderly - develops over weeks to months
40
Q

What pattern of consciousness is typical in chronic SDH?

A

lucid interval followed by gradual decline in consciousness

41
Q

Why might a unilateral dilated pupil be seen in subdural haematoma?

A

haematoma compressing third cranial nerve

42
Q

What is Cushing’s triad?

A

seen due to increased intracranial pressure - bradycardia, hypertension, respiratory irregularities

43
Q

What is usually the aetiology of an acute subdural haematoma?

A

high-impact trauma (often other underlying brain injuries)

44
Q

What will be seen on CT in subdural haematoma?

A

crescenteric collection, not limited by suture lines (mass effect may be seen with midline shift / herniation)

45
Q

What are the management options for acute subdural haematoma?

A
  • small / incidental: observe, conservative
  • surgical options: monitoring of ICP, decompressive craniectomy
46
Q

Which vessels lead to a subdural haematoma?

A

rupture of small bridging veins within subdural space

47
Q

What will differ in acute vs chronic subdural haematomas on imaging?

A

will be dark (hypodense) in chronic rather than bridge (hyperdense)

48
Q

What are the management options for chronic subdural haematoma?

A
  • incidental / small, no neuro deficit: conservative
  • confused / neuro deficit / severe findings: surgical decompression with burr holes
49
Q

What is the guidance for a patient on warfarin with a head injury with no other indications for CT head?

A

do CT head within 8 hours of injury

50
Q

What are 4 features of L3 nerve root compression due to a prolapsed disc?

A
  1. sensory loss over anterior thigh
  2. weak hip flexion, knee extension and hip adduction
  3. reduced knee reflex
  4. positive femoral stretch test
51
Q

What are 4 features of L4 nerve root compression due to a prolapsed disc?

A
  1. Sensory loss anterior aspect of knee and medial malleolus
  2. Weak knee extension and hip adduction
  3. Reduced knee reflex
  4. Positive femoral stretch test
52
Q

What are 4 features of L5 nerve root compression due to a prolapsed disc?

A
  1. sensory loss dorsum of foot
  2. weakness in foot and big toe dorsiflexion
  3. reflexes intact
  4. positive sciatic nerve stretch test
53
Q

What are 4 features of S1 nerve root compression due to a prolapsed disc?

A
  1. sensory loss posterolateral aspect of leg and lateral aspect of foot
  2. weakness in plantar flexion of foot
  3. reduced ankle reflex
  4. positive sciatic nerve stretch test
54
Q

What is the approach to management for sciatica due to prolapsed disc?

A
  • NSAIDS +- PPI
  • physisotherapy / exercises
  • if symptoms persist after 4-6 weeks - refer for consideration MRI
55
Q

What are the classic features of lumbar spinal stenosis?

A
  • back pain / neuropathic pain
  • claudication like symptoms
  • sitting better than standing (relieved leaning forwards/crouching)
  • easier to walk uphill rather than downhill
56
Q

What is the investigation of choice in lumbar spinal stenosis?

57
Q

What is the treatment of lumbar spinal stenosis?

A

laminectomy

58
Q

What level of metastatic spinal cord compression causes upper motor neuron signs in the legs vs lower motor neuron signs? What other features are seen?

A
  • Above L1: UMN signs in legs, sensory level
  • Below L1: LMN signs, perianal numbness
59
Q

What happens to tendon reflexes in metastatic spinal cord compression?

A
  • increased below level of lesion
  • absent at level of lesion
60
Q

What is the management of metastatic spinal cord compression?

A
  • high-dose oral dexamethasone
  • urgent oncological assessment - consideration of radiotherapy or surgery
61
Q

What should be done if there is life-threatening rising ICP e.g. extradural haematoma whilst theatre is prepared / transfer arranged?

A

may require use of IV mannitol / furosemide

62
Q

What may be the required treatment for diffuse cerebral oedema due to head injury?

A

decompressive craniotomy

63
Q

What is the only situation where exploratory Burr holes may be required in clinical practice?

A

little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap

64
Q

What is the management of depressed skull fractures that are open?

A

formal surgical reduction and debridement

65
Q

What is the management of closed depressed skull fractures?

A

may be managed non-operatively if minimal displacement

66
Q

When should ICP monitoring be performed after traumatic head injury?

A
  • appropriate if GCS 3-8 and normal CT head
  • GCS 3-8 and abnormal CT head - mandatory
67
Q

What is the minimum cerebral perfusion pressure in adults after TBI?

68
Q

What is the minimum cerebral target perfusion pressure in children?

A

between 40 and 70 mmHg

69
Q

What does a unilaterally dilated pupil indicated after TBI?

A

3rd nerve compression secondary to tentorial herniation

70
Q

What do bilaterally dilated pupils after TBI Suggest?

A

poor CNS perfusion / bilateral 3rd nerve palsy

71
Q

What are 3 causes of bilaterally constricted pupils?

A
  1. opiates
  2. pontine lesions
  3. metabolic encephalopathy
72
Q

What are 3 things that elicit pain in lower back pain due to facet joint pathology?

A
  1. pain worse in morning
  2. pain worse on standing
  3. worse on extension of back
73
Q

What is the commonest cause of recurrent symptoms after degenerative cervical myelopathy surgery with cervical laminectomy?

A

recurrent disease in adjacent spinal levels not treated by initial decompressive surgery (adjacent segment disease) - patients require ongoing follow-up after surgery

Focused 2 (27 decks)

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