Neurosurgery

Question 1

list the radiological abnormalities

Answer 1

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 significant SAH?

Answer 2

Neuroprotective measures
* normothermia
* normoglycamia
* mild hyperventilationmaintain co2 30-35
* head up
* po2 over 80

adequate sedation or paralysis - intubate
* blunt sympathetic tone - high dose fent and roc
* best intubator
* dont tie cord around head

Treat hypertension
invasive BP monitoring aim 160
GTN infusion v metoprolol boluses

Involve neurosurgery immediately
* 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
IDC
electrolyte management

Question 3

what can be used to prognosticate in SAH?

Answer 3

1. fisher criteria
   * Age
   * GCS
   * motor deficit

2hunt and hess criteria

Question 4

what are some complications post SAH that can case reduced GCS

Answer 4

seizure
re-bleed
vasospasm
hydrocephalus

also reduce GCS

Question 5

main findings
Differentials

Answer 5

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

aim 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 dissection
vetebral artery dissection

Risk factors
* connective tissue disease
* cervical fracture
* severe facial trauma
* cervical manipulation
* near hanging with anoxic brain injury

Question 19

what are the clinical features of blunt cerebrovascular injury to the ICA

Answer 19

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

Question 20

what are the clinical features of blunt cerebrovascular injury to the vertebral artery?

Answer 20

• occipital headache
• posterior neck pain
• facial parasthesias
• lateral medullary syndrome

Question 21

what is a screening tool for blunt CVA injury

Answer 21

Denver screening criteria

Question 22

what are the signs of symptoms of a blunt CVA injury

Answer 22

infarct on CT
focal neuro deficit
thrill or bruit
expanding neck haematomy
neuro findings inconsistent with CT