Neurosurgery

Question 1

list the radiological abnormalities

Answer 1

LIST NEGATIVES
1. extensive SAH
2. intraventricular haemorrhage
3. no midline shift
4. no hydrocephalus
5. evidence of cerebral oedema

Question 2

What are the immediate management priorities with ICH?

Include end points

Answer 2

Three:

Neuroprotective measures/Prevent raised ICP

• normothermia - Warm fluids v cooling/anti pyrextics
• normoglycamia (BSL 6-10 - insulin and dextrose as needed)
• mild hyperventilation maintain co2 30-35 to manage ICP
• head up and 30 degress - prevent raised ICP
• po2 over 80
• adequate sedation or paralysis - intubate - stops agitation and coughing/gagging to stop raised ICP. Use high dose fent and roc to blunt sympathetic tomeblunt sympathetic tone
• best intubator - prevent stimulation
• dont tie cord around head - prevent ICP

Treat hypertension

• invasive BP monitoring aim 160 (MAP 70-85) with GTN infusion/metoprolol boluses V 500ml boluses or vasopressors aith MAP 70-80mmhg
• IDC - avoid hypertension from bladder extendiob*

**Manage potential ICP/Cerebral complications*

• prevent vasospasm eg nimidopine infusion
• osmotherapies
  — mannitol 0.25-1g/kg Q3hrly
  — hypertonic saline (3%) 3 mL/kg over 10 min or 10-20 mL 20% saline

Supportive care

• electrolyte management

** Involve Neurosurg**

Question 3

what can be used to prognosticate in SAH?

Answer 3

1.** fisher criteria**
* Age
* GCS
* motor deficit

2 hunt and hess criteria

Question 4

what are some complications post SAH that can case reduced GCS

Answer 4

• seizure
• re-bleed
• vasospasm
• hydrocephalus

Question 5

main findings
Differentials

Answer 5

Findings
* ring enhancing lesion
* loss of grey white differentiaion
* vasogenic oedema
* mild mass effect
*
**
Differentials**
* Infective - toxoplasmosis
Cerebral TB

• Maligancy
  cerebral lymphoma
  GBM
  Cerebral mets
  cerebral abscess

Question 6

What is the ED management when finding brain lesion?

Answer 6

• Analgesia - fent/morp
• IV dex 8mg
• seizure prophylaxis - IV kepra 500mg (20mg/kg)
• consult neurosurgery
• social support to patient and family

Question 7

risk factors for SAH?

Answer 7

smoking
hypertension
known aneurysm
trauma
FH

Question 8

four relevant findings
four investigations and why (on dig)

Answer 8

bilateal acute on chronic subdural haematoma
compression of the ventricles - RAISED ICP
no midline shift

Investigations
* INR - ?reversal of warfarin
* ECG - bradycardia eg on dig
* renal function - ?AKi on dig
* dig level
* CT neck as ?trauma

Question 9

post large ICH there isa DNA so patient is not for surgery
what do you need to address?

Answer 9

• analgesia
• family expectations
• seizure prophylaxis
• ceilings of care on the ward
• electrolytes and flud status
• end of life plan
• documentation
• adequte communication with family/GP/cae home at discharge

Question 10

where may a VP shunt drain?

Answer 10

peritoneal cavity
right atrium
ureter
gall bladder

Question 11

what are the causes of VP shunt obstruction?

Answer 11

infection
clot
catheter tip migration
kinking

Question 12

what is the most common organism in VP shunt infection?
Is an LP useful?

Answer 12

staph epidermis
no

Question 13

diagnosis?

Answer 13

slit ventricle syndrome

Question 14

what are the differentials/investigation for headache post VP shunt revision?

Answer 14

• blocked shunt - CT
• fractured shunt - shunt series x ray
• meningioencephalitis - LP
• wound infection - Swab

Question 15

diagnosis and supportive findngs

Answer 15

right SDH

Extra-axial collection
Crossing suture lines
Sulcal Effacement
Midline Shift
Subfalcine Herniation

Question 16

SDH
list four further investigstions and why

Answer 16

INR - reversal or retrieval
electrolytes - ?low na
FBC ?thrombocytopenia
Group and hold - ?transfusion
ECG - assess AF control given confusion

Question 17

how do you reverse warfarin and whats the aim

Answer 17

• Vit K 2.5-5mg IV
• prothrombin complex concentrate 50u/kg

Targert - INR under 1.1

Question 18

what are the two major vessels involved in blunt cerebrovascular injury?

What are the risk factors?

Answer 18

ICA and vetebral artery

Risk factors
Trauma:
* cervical fracture
* severe facial trauma
* near hanging with anoxic brain injury

• Connective tissue disease
• Cervical manipulation

Question 19

ICA v Vertebral artery blunt injury clinical features

Answer 19

ICA
* Unilateral frontal headache
* anterior neck pain
* Cranial nerve palsies
* partial horners - ptosis and miosis

Vertbral Artery
* occipital headache
* posterior neck pain
* facial parasthesias
* lateral medullary syndrome - brain stem dysfunction

Question 20

what is a screening tool for blunt CVA injury

Answer 20

Denver screening criteria - do you need CTA?

Question 21

exam findngs and CT findings of blunt CVA

Answer 21

CT:
* infarct on CT and inconsistent neurology

Exam findings:
* focal neuro deficit
* thrill or bruit
* expanding neck haematomy