Neurosurgery

Question 1

Timetable and mode of presentation

Answer 1

First clues to its nature. Vascular = sudden! No h/a when occlusive, severe h/a when hemorraghic. Brain tumors take months, constant, progressive, severe h/a, worse in morning. ICP goes up, then blurred vision and projectile vom. If tumor presses on certain area, functional deficit. Infectious = days or weeks, and identifable infection source in hx. Mets problems are fast (hours/days), hit whole CNS. Degen disease takes years

Question 2

TIA (Trans ichemic attack)

Answer 2

Sudden, transitory loss of neuro fn w/ h/a, resolve spontaneously. Sx dep on part of brain affected, most common = high-grade stenosis (70% or more) in internal carotid or ucerated plaque @ carotid bifuc. TIA predicts stroke, timely elective carotid enarterectomy (remove plaque) to prevent. W/u w/ Duplex study (sonogram + doppler), then arteriogram if no dx. Surgery if lesions are found in location explaining the neuro sx

Question 3

Ischemic stroke

Answer 3

Sudden onset w/out h/a, neuro def present for more than 24 hrs, permanent sequela. Few exceptions, but ischemic stroke can’t really be revascularized. Can be complicated by hemorrhagic infarct if you suddenly increase blood supply. Eventually do vascualr w/u to find lesions, but for infarct, asses w/ CT scan, center on rehab. New- Docs trying to recog very early stroeks and treat quick w/ clot busters after CT scan rles out extensive infarct of hemorraghe. IV t-PA if started within 90 min-3 hrs after sx onset

Question 4

Hemorraghic stroke

Answer 4

Seen w/ uncontrolled HTN w/ severe h/a of sudden onset, develops neuro deficits. CT scan to see location/extent of hemorrhage, txx to control HTN and rehab

Question 5

Subarach bleed from intracranial aneurysm

Answer 5

Wide spec of severity, some pts not salvageable, but high index of suspicision + timely dx can be lifesaving. Pt comes w/ extremely severe thunderclap h/a, blood in SA space, no hematoma pressing on brain, no neuro findings, might get sent home (sentinel bleed). Or pt as meningeal sx, and recog. Not recog, come back in 10 days, and way worse. W/u with CT scan lookin for blood, spinal tap can identify old blood but do it second), then arteriogram to find aneurysm off circle of willis. Do surgical clipping

Question 6

Brain tumors

Answer 6

Dont give any clues if in silent area of brain, just increasing h/a , worse in mornings, then increased ICP blurry vision, papilledema, projectile vom, then brady and HTN and irregular breathingif really bad b/c Cushing reflex). Can see on CT, but MRI gives better detail (preferred). While awaiting surg, tx ICP with high-dose steroids (dexamethasone)

Question 7

Clinical localization of brain tumors

Answer 7

Can do it by virtue of neuro deficits or sx patterns. Motor strip/speech centers hit if tumor is on lateral side of brain, makes sx on opposite side of body. People speak w/ side of brain controlling dom hand!

Question 8

Tumors at base of frontal lobe

Answer 8

Inappropriate behavior, optic nerve atrophy on tumor side, papilledema on other side, and anosmia (foster-Kennedy syndrome)

Question 9

Craniopharyngioma

Answer 9

In kids who are short for age, bitemporal hemianopsia and calcified lesion above sella on x-ray

Question 10

Prolactinomas

Answer 10

Amenorrhea, galactorrhea in young women. Dx workup rule out pregnancy, hypothyroid, det prolactin level, and MRI sella. Tx w/ bromocriptine most often. Can do transnasal/sphenoidal surg removal in those who want to get pregnant or don’t respond

Question 11

Acromegaly

Answer 11

Huge hands, huge feet, tongue, jaws, w/ HTN, diabetes, sweaty hands, h/a, and wedding bands that don’t fit anymore. DO w/u of somatomedin C, and pituitary MRI. Surgery better, but radiation is an option

Question 12

Pituitary apoplexy

Answer 12

Bleeding into pit tumor, w/ destruction of gland. Clues = long-standing present of tumor (h/a, visual loss, endocrine problems), and acute = severe h/a, and then compression by hematoma => deterioration of vision, bilateral pallor of optic nerves, stupor and hypotension from pit destroy. Steroid replace urgent, and then replace other hormones. MRI/CT to know extent

Question 13

Pineal gland tumors

Answer 13

Loss of upper gaze, and sunset eyes (Parinauds syndrome)

Question 14

Brain tumors in kids

Answer 14

Posterior fossa most often. Give cerebellar sx (stumble around, truncal ataxia), and kids sit in knee-chest position to relieve h/a

Question 15

Brain abscess

Answer 15

Seems like brain tumor (SOL), but much shorter time table + fever, obvious infection source like otitis media or mastoiditis. Typical look on CT, so no MRI needed. Gotta resect

Question 16

Spinal cord tumors

Answer 16

Mets and extradural, often primary tumor was dx and treated before back pain starts. If undx, can compress cord or fracture spine. Do MRI dx, and try neurosurg decompression

Question 17

Neurogenic claudication

Answer 17

Old ppl w/ pain by walking, relieved by rest, problem is position dependent, can walk w/out pain if hunched over. Pain relief requires sitting down or bending over for relief. Pulses normal, dx = spinal stenosis, do MRi and pain control specialists, block affected nerves under radiologic guidance

Question 18

Trigeminal neuralgia

Answer 18

Tic douloureux- extremely severe sharp bolt of lighting pain down the face if you touch a certain area, lasts 1 min. pts in 60, normal neuro exam, touch the trigger zone not shaved). Do MRi to rule out organic lesions, then tx w/ anticonvulsants, or do radiofreq ablation

Question 19

Reflex sympathetic dystrophy (casualgia)

Answer 19

Mos after crushing injury, constant, burn agonizing pain not responding to analgesis, aggravated by slight stim. Extremity = cold, cyanotic and moist. Do sympathetic block to dx, then surgical sympathectomy for cure