Neurosurgery Flashcards
How do vascular neurologic problems present?
- Sudden onset
- w/o headache when they are occlusive
- w headache when they are hemorrhagic
How do brain tumors present?
- Constant, progressive and severe headache, sometimes worse in the morning
- Timetable of months
- As intracranial pressure increases, blurred vision and projectile vomiting occur
- Functional deficits are seen when tumor presses on an area assoc. w a particular function
How do infectious neurological problems present?
- timetable of days/weeks
- An identifiable source of infection is commonly found in the pt’s hx
- -Metabolic problems develop w/in hrs or days and affect the whole CNS
How long do degenerative diseases take before presenting sx?
-They have a timetable of years
What is an Transient Ischemic Attack (TIA)?
- Sudden, transitory losses of neurologic function, w or w/o headache, that resolve spontaneously leaving no sequela
- Specific sx depend on area affected, which is related to the vessels involved
What s the most common origin of a TIA?
->= 70% stenosis of internal carotid, or ulcerated plaque at carotid bifurcation
What is the significance of TIA’s?
-They predict strokes, which can be prevented with timely elective carotid endarterectomy
What is the work up of TIA’s?
- Duplex studies
- Surgery indicated if the lesions are found at the locations that explain the neurologic symptoms
What alternative tx can be used for TIA’s?
-Angioplasty and stent can be done if a filter is first deployed to prevent embolization of debris
How does an Ischemic stroke present?
-Sudden onset w/o headache but w neurologic sx present for >24 hrs, leaving permanent sequela. Not amenable to revascularization (except for very early strokes)
What is a hemorrhagic infarct?
-It can be a complication of an ischemic infarct when blood supply to that area of the brain is suddenly increased.
How are ischemic strokes managed?
- Vascular studies are done to identify lesions that might produce another stroke and prevent it.
- For existing infarcts, the only management available is assessment with CT and rehabilitation
How are early strokes treated?
- CT scan to r/o existing infarcts or presence of hemorrhage
- t-PA IV within 90 min and up to 3 hrs after onset of sx
In what patient is a hemorrhagic stroke commonly seen?
-Uncontrolled hypertensive with sudden onset of headache and goes son to develop neurologic sx
How is a hemorrhagic stroke managed?
- CT scan to evaluate location and extent
- Tx to control hnt and focused on rhabilitation
A patient c/o extremely severe headache of sudden onset like no other ever experienced before (Thunderclap: sudden, severe, singular) is suspicious for…?
- Subarachnoid bleeding from intracranial aneurysms
- In many cases the pt is not salvageable
- Patient may be sent home by mistake bc there is likely no neurologic findings (Blood in the subarachnoid space, so there’ snot hematoma pressing on the brain)
What are two red flag sx of subarachnoid aneurysm bleeding?
-Meningeal irritation and nuchal rigidity
What happens to patients who are not recognized to have a bleeding subarachnoid aneurysm?
-IF they survive, they may return in 10 days with a subsequent (and likely more severe) bleed.
What is the workup for subarachnoid aneurysm bleed?
- CT scan to look for bleeding
- Arteriogram to locate aneurysm
- Surgical clipping or endovascular coiling may be performed
- NOTE: Spinal tap looking for blood may be done, but should never be the first test. Always do CT first
What is the presenting history of Brain tumors?
- Progressively increasing headache for several months, worse in the mornings
- Eventually: accompanied by signs of increased intracranial pressure
What are sx of increased intracranial pressure?
- Blurred vision
- Papilledema
- Projectile vomiting
- Bradycardia (extreme d/t Cushing reflex)
- Hypertension (Extreme d/t Cushing reflex)
Which is the preferred study to visualize brain tumors?
-MRI bc it gives better details
How is increased intracranial pressure treated?
-High-dose steroids like dexamethasone (Decadron) while awaiting for surgical removal
What is a “silent area”?
An area of the brain where brain tumors can grow without providing any clue as to their location (no neurological sx)
How can brain tumors be localized?
Some tumors can be localized by specific neurological effects depending on which area of the brain they affect
How do tumors pressing on the lateral side of the brain present?
-Motor strip and speech center may be affected producing sx in the opposite side of the body
How do tumors at the base of the frontal lobe present?
-They can cause inappropriate behaviors, optic nerve atrophy on the side of the tumor, papilledema on the other side and anosmia (Foster-Kennedy Syndrome)
How do Craniopharyngioma present?
-In youngsters who are short for their age, w bitemporal hemianopsia, and calcified lesion above the sella on x-rays
how do prolactinomas present?
-Amenorrhea and galactorrhea in young women
What is the work up for prlactinomas?
- r/o pregnancy
- r/o hypothyroidism
- determine prolactine level
- MRI of sella
What is the treatment of prolactinomas?
- Bromocriptine
- Transnasal or trans-sphenoidal surgical removal for those wishing to get pregnant or who fail medication
What are sx of acromegaly?
- Huge tongue, hands, feet and jaws
- hypertension, diabetes, sweaty hands, headache and a hx of wedding bands of hasts that no longer fit
What is pituitary apoplexy?
-Bleeding into a pituitary tumor, destroying the pituitary gland
What are the sx of pituitary apoplexy?
- Starts w sx of pituitary tumor: headache, visual loss, endocrine problems
- Then the acute bleeding episode: severe headache, deterioration of remaining vision w bilateral pallor of the optic nerves d/t compression by hematoma, and stupor w hypotension d/t destruction of the pituitary gland
What is the management of pituitary apoplexy?
- Urgent steroid replacement as well as other hormones
- MRI or CT can show extent of the problem
What causes loss of upper gaze and “sunset eyes” sign?
-Tumors of the pineal gland
-Sunset eyes: The sclera are visible between the upper eyelid and the iris-
Part of Parinaud syndrome
Where are brain tumors in children commonly located?
-The posterior fossa
What sx can be seen in brain tumors in children?
- Cerebellar sx: stumbling around, central ataxia
- -Severe headache relieved by assuming the knee-chest position
What can cause similar sx to brain tumors, but in a much shorter timetable?
- Brain abscesses (they are a space-occupying lesion)
- They develop sx in a week or two
What are the sx of brain abscesses? How are they managed?
- Fever, obvious source of infection nearby (usually)
- Typical appearance on CT, so MRI is not needed
- They require resection
How do brain abscesses look on CT? (Not from Pestana’s, but I figured it might be useful)
-Ring of iso / hyperdense tissue, typically of uniform thickness
-Central low attenuation (fluid / pus)
surrounding low density (vasogenic oedema)
-Ventriculitis may be present, seen as enhancement of the ependyma
-Obstructive hydrocephalus will commonly be seen when intraventricular spread has occurred
What does a patient with severe sharp shooting pain “like a bolt of lightning” after touching a specific area and lasting about 60 seconds have?
-Trigeminal neuralgia (tic douloureux)
How do patients with trigeminal neuralgia present?
- Normal neurologic exam
- Unshaven area in the face (trigger zone)
How is trigeminal neuralgia managed?
- MRI to r/o organic lesions
- Anticonvulsants
- Radiofrequency ablation can be done if medication fails
Constant, burning, agonizing pain that does not respond to usual analgesics and develops several months after a crushing injury:
- Reflex sympathetic dystrophy (causalgia)
- Pain aggravated by slightest stimulation of the area
- Extremity is cold, cyanotic and moist
How is causalgia treated?
- Dx with successful sympathetic block
- Cured with surgical sympathectomy
What are the 3 signs of cushings reflex? When does cushings reflex occur?
- htn, bradycardia, respiratory depression
- sign of increased intracranial pressure
