Neurosurgery Flashcards
Nonfluent aphasias, presentations
Brocas - poor speech output, pt aware
Fluent aphasias, presentations, causes
Wernickes - comprehension and repetition impaired, normal melody of speech but incorrect words
Anomic - repetition and comprehension intact, poor naming, d/t ICP/Alzheimer’s/drugs
Conduction - comprehension good, but repetition poor, d/t arcuate fasciculus lesion
Global aphasia presentation, cause
nonfluent speech, impaired comprehension and repetition
- MCA stroke
Glasgow coma scale (GCS) measures degree of ________. It takes into account ___+____+____
- head trauma
- eye movements, verbal commands, motor response
Explain the scoring for eye movements on GCS
4 - spontaneous
3 - to voice
2 - to pain
1 - not at all
Explain the scoring for verbal commands on GCS
5 - oriented to person, place, time 4 - confused 3 - inappropriate words 2 - incomprehensible sound 1 - none
Explain the scoring for motor movements on GCS
6 - obeys commands 5 - localizes pain 4 - nonpurposeful response to pain 3 - flexion in response to pain 2 - extension in response to pain 1 - no pain response
What GCS scores indicate mild, moderate, and severe head injury?
Mild - 13-15
Moderate - 9-12
Severe - <8
Indications for CT in context of head injury (3)
- LOC >5 min
- GCS <13
- symptomatic
Management for moderate head injury per GCS
CT + q1h checks in ICU
Management for severe head injury per GCS
CT + thorough w/u
Decorticate posture
flexed UE, extended LE
Decerebrate posture
extended UE and LE
Intracranial hematoma/mass would produce ____ _____ posturing
contralateral decerebrate
dilated pupil (unilateral) indicates ______
unilateral uncal herniation
b/l dilated pupils _______
b/l uncal herniation
b/l constricted pupils
pontine hemorrhage
Cheyne-Stokes respiration
deep cerebral hemisphere injury
Resuscitation for head injury? If focal injury? If unilateral posturing? If >5-10 mm shift?
IVF, +/- dexamethasone
if focal injury - phenytoin
if unilateral posturing - mannitol
if >5-10 mm shift - surgery
Uncal herniation s/sx
- ipsilateral pupil dilatation (PSNS lost first)
- 3rd nerve palsy
- contralateral weakness/posturing (pyramidal compression
Nb. pupillary dilatation more representative of the side of herniation (as opposed to which side has the hemiparesis)
Tx for uncal herniation (5)
Intubation, hyperventilation, mannitol, furosemide, surgery
Foramen magnum herniation s/sx
- Early - posterior h/a, neck stiffness, vomiting, gait disturbance)
- drowsiness
- possible cushing response (HTN, bradycardia, resp arrest)
Tx for foramen magnum herniation
emergency surgery for decompression
Anterior SCI s/sx
Movement - lost b/l
Posterior column fxn intact
Central SCI s/sx (4)
- Weakness
- hypoesthesia of UE
- gait disturbance
- incontinence
Tx of SCI
alignment, Methylprednisolone, foley
+/- CP resuscitation
Workup of SCI (6)
- assess neck
- document ext sensation/movement
- neuro assessment
- ABG
- CMP
- typing
Cervical SCI tx
traction ?probably a c-spine collar
spinal shock s/sx (2)
- hypotension
- warm extremities d/t autonomic dysfxn
Para/quadriplegia causes? w/u (2)?
causes - acute disc herniation, epidural tumor
w/u - spine films, MRI* or myelography
When you see ataxia think _____
cerebellar mass
cerebellar mass s/sx (3)
- h/a
- N/V
- weakness of conjugate gaze to side of lesion
cerebellar mass w/u?
- CT diagnostic
- MRI for more thorough eval
coma + stiff neck = ___ or ____ or ____
meningitis
SAH
encephalitis
Causes of a coma (12)
Mnemonic: 2I'd (eye'd) HAMMSSTTEEr Infection Infarction Hematoma Abscess Metabolic Meningitis SAH Seizure Trauma Tumor Encephalopathy Encephalitis
W/u for coma (5)
- CT
- LP (if no mass)
- Vitals
- EKG
- CXR
Tx for coma (5)
- ABC
- IVF
- foley, NGT
- Thiamine/D50W/naloxone
- Cspine
Status epilepticus tx (4)
- ABC
- thiamine/D50W
- Phenytoin (50 mg/min to 1000 mg, i.e., for 20 min)
- Ativan 2 mg IV
Meningitis w/u (4)
- CT
- LP w/gram stain
- India ink stain
- cultures
____ strokes most common
ischemic (80%)
Symptomatic tight stenosis, >65% occlusion of vessels, or complex ulcer should get ____
endarterectomy
noncomplex ulcer of bvs tx’ed w/______
anticoagulation
thrombotic strokes tend to be 2/2 ____ and sx resolve in _____hr
- HTN
- 48
Vertebrobasilar strokes usually 2/2 ______ which can cause ____ and ____, or can be 2/2 ______
atherosclerosis
subclavian steal
basilar artery stenosis
cervical osteophytes
Subclavian steal
pre/syncope 2/2 collateral blood flow from the vertebral arteries to the arm
Locked in syndrome can be caused by
basilar artery stenosis
If hypotensive stroke you would also expect to see?
anteriorly - shoulder/anterior thigh weakness
posteriorly - visual difficulties, memory difficulties
RFs for hemorrhagic stroke
AVM, aneurysm, HTN, anticoagulation
Indications for surgical correction of hemorrhagic stroke (4)
- cerebellar stroke
- lobar (esp temporal)
- caudate
- putamen (non-dominant side)
h/a, gaze paresis towards lesion and ataxia are sx of ___ stroke
cerebellar
midline shift, drowsiness are sx of ____ stroke
lobar
behavioral disturbances is a sx of ___ stroke
caudate
hemipelgia and gaze paresis towards the lesion are sx of ____
non-dominant putamen stroke
nonsurgical strokes (4)
- thalamic
- pontine
- tegmental
- putamen (dominant side)
sensory dysfxn, poorly reactive pupils are sx of ____ stroke
thalamic
coma, qudriplegia, pinpoint pupils are sx of ___ stroke
pontine
ipsilateral horner’s, ataxia, hemisensory loss, abnormal eye movements are sx of _____ stroke
tegmental
SAH causes (4)
- trauma
- aneurysms
- AVM
- HTN
Causes of aneurysms (7)
Mnemonic - "Make SAH" Marfan's Aortic coarctation Kidney disease (polycystic AD) Ehlers-Danlos SSA Atherosclerosis Hx (FMHx)
S/sx of SAH
- Worst h/a of my life
- vision changes (compression of aneurysm if around PCA/superior cerebellar artery)
- mydriasis
- LOC
- Meningeal irritation (neck stiffness, photophobia, N/V)
- Sentinel bleed (d/w earlier, marked by abrupt onset of h/a, n/v, transient diplopia that resolved in min/hrs)
- hydrocephalus (presents as drowsiness; 2/2 increased absorption of blood into CSF sinuses causing communicating hydrocephalus)
Tx of SAH
- prevent rebleeding - SBP < 150 using Hydralazine or Nitroprusside
- head elevation (to decrease ICP)
- hyperventilation (decreases CO2 which decreases blood flow to the brain)
- Nimodipine (CCB) to decrease vasospasm
- Seizure ppx (phenytoin)
- +/- ventricular drain (if hydrocephalus)
- +/- surgery
Which requires early surgery and which requires non-emergent surgery of the following: Berry aneurysm, AVM
- Berry - ASAP surgery for clipping/intravascular coiling
- AVM - non-emergent excision
______ is the most common vascular dz of the SC
Dural AV fistula (nidus w/in the dura)
Dx modality of vascular dz of SC _____
MRI
What vascular dz do you never see in the SC?
aneurysms
Tx of vascular dz of SC
hemilaminectomy w/coagulation of intradural draining vessel (for fistula)
Cervical disk disease in young patients presents as _________
severe neck and arm pain
Cervical disk disease in old patients presents as _____
chronic course w/recurrent episodes of arm and neck pain (spondylosis)
Etiology of cervical disk disease in old patients?
- osteophytes, hypertrophy of facet joints
- C5-T1 affected
S/Sx of degenerative disk disease (5)
- pain
- parasthesia
- weakness
- h/a
- radiculopathy
Radiculopathy from C6 sx
- parasthesias of thumb + index finger
- weakness of biceps
Radiculopathy from C7 sx
- parasthesias of middle finger
- weakness of triceps
Radiculopathy from C8 sx
- parasthesias of ring and pinky fingers
- weakness in intrinsic hand muscles
Tx of degenernative disk dz
- Anti-inflammatories
- Muscle relaxants
- moderate cervical traction
What is the utility of surgery in context of degenerative disk dz?
- not helpful for chronic pain, but may reduce radiculopathy or myelopathy
- indicated for severe pain 2/2 acute soft disk rupture
- usually posterior laminectomy performed
4 syndromes of lumbar disk dz
- recurrent lower back pain
- acute monoradiculopathy
- cauda equina
- “failed back”
Recurrent lower back pain
a/w back spasms, limited motion
acute monoradiculopathy
pain radiates to foot/leg, worse with sneezing or coughing
cauda equina syndrome
saddle anesthesia, bowel/bladder incontinence, pain in legs
Failed back
back pain following back surgeries
Radiculopathy vs. myelopathy
- radiculopathy - damage/compression of nerve roots (peripheral NS), non-emergent
- myelopathy - damage/compression of SC, emergent
Positive straight leg raise test indicates
HNP
Tx for HNPs
most resolve spontaneously over 12 wks (if greater = chronic), but can use epidural corticosteroid injections, NSAIDs/narcotics, PT/OT. If it’s refractory can do surgical laminectomy/discectomy
Lumbar stenosis differs from HNP in that _____
HNP - unilateral leg pain (can be b/l but usually worse on one side)
LS - b/l leg pain
Etiology of LS
- degeneration of intervertebral disks causing increased stress on facet joints, causing hypertrophy of the ligamentum flavum and then compression of the nerve roots/spinal cord
disk degeneration to <9 mm indicates _____
- always pathologic
- stenosis
S/sx of LS (5)
- worse w/walking/standing, and takes a while for the pain to abate when sitting
- a/w numbness
- a/w spasticity
- NEGATIVE straight leg raise test
- neurogenic claudication, proximal first, shopping cart sign
DDx for LS
- vascular claudication (pain decreases rapidly when movement stops)
- Cauda Equina syndrome (saddle anesthesia, bowel/bladder dysfxn, impotence)
- Hematoma
- AVN
- tumors
- Pagets
- Ankylosing spodylitis
Tx for LS
- Medical pain management first (heat, analgesics, antispasmodics)
- Laminectomy for more advanced disease
In the setting of increased ICP, steroids (i.e., ____) are ONLY used for ____ and _____
- decadron (dexamethasone)
- decreasing cerebral edema 2/2 abscess
- decreasing cerebral edema 2/2 tumor
When an adult has a brain tumor, think ___, ___, or ___
- mets
- GBM
- meningioma
When an child has a brain tumor, think ___, or ___
- medulloblastoma
- pilocytic astrocytoma
Most common brain mets (first 5)
lungs > breast > kidney > GI > melanoma
Tx for brain tumors
- chemo/XRT
- decadron (dexamethasone ) for vasogenic edema
- anti-epileptics (AEDs)
- surgery (debulking)
(T/F) Most brain abscesses are 1 microbe
False - most are polymicrobial
Leading organisms (7)
- anaerobic (bacteroides)
- staph, strep, gram (-)’s
- Fungal - aspergillus, candida
- Toxo
S/Sx of brain abscess
Triad: - H/a - Focal neurologic deficit - FEVER Increased ICP can cause CN III and VI deficits
Dx of brain abscesses
- CT scan for ring enhancing lesions
- ESR
- CRP
- NO LP!
ophthalmoplegia (EOM paralysis) + severe H/a + visual field defect = _______
Pituitary apoplexy (hemorrhage into pre-existing tumor d/t vasculature of pit tumor)
Syringomyelia S/Sx (4)
- b/l pain and temp loss in upper extremities
- UE weakness
- sensory loss in cape distribution
- leg spasticity
Causes of syringomyelia
- trauma
- Potts (TB of vertebrae)
- ependymomas
- Chiari type I
- arachnoiditis (causes scar formation/adhesions forming syrinx and hydrocephalus)
Dx of syringomyelia
MRI of c spine
treatment of syringomyelia (4)
- decompression
- dural grafting
- peritoneal shunting
- ventricular shunting
