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jK NEURO > Neurosurgery > Flashcards

Neurosurgery Flashcards

1
Q

mild concussion is loc for:

A

30 sec to 5 min
less than 24 hours
gcs of 13-15
ct neg

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2
Q

moderate concussion:

A

6hours or less of loc
7 days or less of amnesia
9-12 on gcs scale
neg or mostly neg on ct

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3
Q

clinical exam is combined with ct if you have:

A 
CT brain if LOC and:
GCS <15
Seizure
Focal neurologic deficit
Alteration in memory
Worsening headache
Vomiting (repeated vomiting in kids)
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4
Q

after possible concussion you can return to playing contact sports when:

A

symptom free for 7 days, problem is that this is very broad: need baseline neuro cognitive testing, step wise working them back up for 7 days

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5
Q

post concussive symptoms:

A

Physical
HA, N/V, dizziness, fatigue, blurred vision, sleep disturbance, loss of appetite, sensitivity to light/noise, balance problems

Cognitive
Impaired attention, concentration, memory, speed of processing, judgment, executive function

Behavioral/emotional
Depression, anxiety, agitation, irritability, impulsivity, aggression

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6
Q 
6 y/o boy fell out of shopping cart
2 minute LOC
No amnesia
Vomited on scene
Complaining of mild headache
Large tender bump in right parietal 
Normal neurologic exam
A

Alert and oriented

Confusion

Agitation FIRST SIGN OF ICP

Lethargy: you can arouse them with voice where as stupor you have to pinch them, etc

Stupor: responsive to vigorous stimulation

Coma: Unarousable to physical stimuli

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7
Q

gcs may not be 100% accurate if :

A

bp is less than 90 (fully recussitated) ox sat at 90%

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8
Q

most important cn to test:

A

2, 3 (extra occular motion) most important pupillary constriction (blown nerve if 3 is out)
6 bc it has the longest course so you can test for hydrocephalus
facial droop: 7,

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9
Q

if you have a _____ you have the ____ of the brain pushing _____ into the _____ and it impinges on the ______

A

subdural hematoma, uncus, down, foramen, cn 3

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10
Q

with subdural hematoma, the brain is pressed down and the midbrain on ct will show ____ because the _______

A

hemorrage of the small vessels off the basilar as they rip off:
Duret haemorrhages are small lineal areas of bleeding in the midbrain and upper pons of the brainstem. They are caused by a traumatic downward displacement of the brainstem.[1]

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11
Q

Bilaterally fixed and dilated

A

Death; hypovolemic shock; drugs (atropine, ecstasy)

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12
Q

Unilaterally fixed and dilated

A

Head injury; stroke

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13
Q

Bilateral pinpoint constriction

A

Opiate overdose

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14
Q

Bilateral constriction

A

Brain stem stroke

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15
Q

Irregular pupil

A

Trauma; previous eye surgery: cateract surgery will give you an irregular pupil

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16
Q

motor exam:

A

0- No muscle activity
1- Muscular contraction without limb movement
2- Can move the limb with gravity eliminated
3- Can move limb against gravity
4- Can move limb against resistance
5- Full strength

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17
Q

note: if a pt has just had an l3 surgery and you ask them to move their iliopsoas:

A

they might not be able to, you may have to hold their leg and let them do the rest

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18
Q

imparied loc on motor exam: if they’ve broken all their extremities and you ask them to move something and they do:

A

they get a 6 because they’ve done everything they can and followed directions

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19
Q

testing with noxious stimuli to check impared loc: testing peripheral is usually done by pushing with a pen on their big toe and having them withdrawl is:

A

triple flexion resonse, and this is just pulling your leg away, NOT A GOOD MOTOR RESPONSE for a test: better to test central!

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20
Q

testing central:

A

pushing on supra orbital, squeezing trapezeus, sternal rub, etc

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21
Q

what is localization for a central noxious stimuli test?

A

I recognize there is a noxious stimuli here and I’m going to try to do something about it

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22
Q

*diff between localization and withdrawl:
if you push above nipple line and patient moves up past nipple line, it is__ if they cannot get past nipple line it is considered_____

A

localization, withdrawl

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23
Q

decortication you have taken away ____ but still have _____

A

cortex input, basil ganglia input, any separation above red nucleus

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24
Q

decerebrate:

A

you have taken the whole brain away

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25
Q

*patients don’t have strength to really posture so you have to put their hands on their hips: if they come up and _____ it is decorticate, if ____ decerebrate

A

flex wrist, bend elbow, straight wrist and lock elbow extended

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26
Q

signs of herniation:

A

bp spikes into 200s (hypothalamus triggers increased heart contractility)
Bradycardia: hr drops (baroreceptors register increased sbp)
apneusis/neurogenic breathing (loss of vagal and pneumotaxic center stimulation)

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27
Q

ICP and CPP

A 
Normal ICP <15mmHg
High >20mmHg sustained for >10min
CPP=MAP-ICP (normal is 70-100 mmHg)
CPP of 70 is needed to provide 
	adequate blood supply to brain
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28
Q

first sign of increased ICP?

A

agitation (20-25 mmHg)

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29
Q

agitation____ lethargy _____ coma_____

A

20-25, 25-30, 40s

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30
Q

decrease icp?

A 
Positioning
Hyperventilation
Hypertonic therapy  (steroids not useful except in tumor swelling)
CSF drainage
Decrease brain metabolism
Surgical decompression
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31
Q

locations of hemmorhage:

A 
subgaleal
epidural
subdural
subarachnoic
intracerebral
intraventricular
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32
Q

SUBGALEAL HEMATOMA

A 
DDX: Caput succedaneum
Potential complications
Anemia/shock due to small circulating volume in infants
Potential calcification- cosmesis
Management: goes away on its own
Nonoperative
Cosmesis concerns usually resolve
Monitor CBC
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33
Q 
54 y/o man hit a tree while skiing
Transient loss of consciousness
Amnestic
Worsening headache
Normal neurologic exam
what is it's a 1 inch lens? what about huge lens?
A

watch for 3-4 hr intervals if only 1 inch, if huge, operate asap, they end up fine

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34
Q

epidural hematoma:

A

Etiology
Skull fracture with laceration of middle meningeal artery
Skull fracture with dural venous sinus laceration
High suspicion for early imaging
Lucent period prior to deterioration
Without associated injuries, 100% good outcome with prompt care
Any mortality is a system failure or delay in care
True neurosurgical emergency

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35
Q 
65 y/o male who fell backward off the back of a golf cart while drinking
On ASA for CAD
PE: Confused and combative, yelling
Opens eyes to voice 
Follows commands all extremities
what about his GCS?
A

opens eyes to voice: 3
confused: 4
follows commands all extremities: 6

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36
Q

how do sub dural surgeries turn out?

A

not nearly as well, ripped off bridging veins, confusion

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37
Q

in ____ the dura peels off of the skull and in _____ the dura is stuck to the skull

A

epidural hematoma, subdural hematoma

38
Q

subdural hematoma:

A

Associated with underlying brain injury
Worse prognosis
If asymptomatic, may watch if <1cm in diameter
Treatment
Acute- Hyperintense- craniotomy
Subacute- Isointense- bur holes
Chronic- Hypointense- SEPS (twist drill/suction)

39
Q 
83 y/o man s/p drug eluting coronary stent
On Plavix and ASA
Tripped in the driveway 4 weeks ago (No LOC)
Now with HA and difficulty walking
PE: Awake with mild STM deficit
         PERRLA, EOMI
	5/5 all extremities, left drift
what do they have?
A

chronic or sub acute subdural which is common with people on BLOOD THINNER MEDS and OLD (rip bridging veins and it’ll build up)

40
Q

on ct acute blood looks ____ while chronic blood looks _____

A

white, dark subacute in the middle looks gray

41
Q

24 y/o male fell off bike
Seizure at the scene
Normal neurologic exam
on arrival

A

subarachnoid space (fills up all the sulci and gyri- esecially on the sides)

42
Q 
45 y/o male pedestrian hit by car
\+LOC
PE: PERRLA
Moaning
No eye opening
Withdrawing
A

contusion:
coup and contracoup
especially frontal lobe, and sections across from each other,
anterior fossa and middle fossa have lots of little ridges

43
Q

contusions

A 
Parenchymal damage from the bony ridges at base of the skull
Associated with edema
Worse prognosis
Potential for “blossoming”
Repeat CT within 4-6 hours
44
Q

of the herniation types: ____ is not as bad, and ____ is BAD

A

Subfalcine- not that dangerous

Transtentorial
Foramen magnum
patient dies

Risk with GCS <8
Place ICP monitor

45
Q

treatment of ICP

A

Elevate head of bed to 30 degrees
Maintain head and neck in straight alignment
Prevent compression of jugular veins by circumferential ETT tape, trach ties or cervical collar
Minimize ETT suction and gagging

46
Q

*Hyperventilation

A

Mechanism:
CO2 is a vasodialator, so when you blow off co2, it causes vasoconstriction
this causes decrease the blood volume of the brain
*Maintain CO2 30-35 for <24 hrs to prevent ischemia
Never drop CO2 below 30

47
Q

ideally the CO2 level can be kept approximately around:

A

30-35

48
Q

*what is normal na level?

A

140

you would want to get it up to 150-155

49
Q

why is it a challenge to get young people to increase their na level to 150s?

A

kidneys are still working well and ridding body of na

50
Q

never increase the na concentration too fast bc:

A

chance of central pontine myelinolisis (common in patients who are hyponeutremic and/or alcoholics)

51
Q

hyponeutrimic alcoholics never get icp bc:

A

atrophy

52
Q

it can be necessary to ____ in healthy people, but:

A

increase na rapidly; hypotonic fluid (1/2ns or d5w) it is easy to accidentally kill them

53
Q

you want to avoid _____ because when _____ it ______

A

dextrose, it is in fluids, decrases glutamate production (it can be neurotoxic)

54
Q

to decrease cerebral metabolic rate, you want to:

A

Sedation (propofol or precedex for continual neuro assessment)
Paralytics
Barbituate coma
Control Seizures, Fever, Restlessness, Pain
Normothermia

this is to fix icp

55
Q

with _____ no one will be completely normal afterwards:

A

DAI

56
Q

with DAI, you have :

A

Deceleration injury- usually high speed MVA
Shear-strain forces on the axons during rotation/deceleration of head
rips the blood supply at the base of the skull
Poor prognosis
35% of all TBI deaths
Most common cause of coma
and severe disability
ct has all microhemorrhages

57
Q

Skull Fractures include:

A

Linear: do nothing!
Depressed- Surgical elevation if cortical compression or cosmetic deformity
Open– Surgical Debridement have to be careful of osetomyelitis
Frontal Sinus- Surgery if through inner and outer tables with pneumocephalus
Skull Base
Temporal Bone- CN7 palsy
Carotid Canal- Vascular Injury
CSF Leak

58
Q

if your kid is hit in the head and you don’t want to go to ed?

A

check on them for 4 hours

59
Q

tbi outcomes:

A

EDH: 5-43% mortality depending on location, age, pupils, ICP, LOC
Acute SDH
Mortality: 20% <40 yrs, 65% over 40 yrs
Timing of operation: 60% lower mortality if OR within 4 hours
DAI: 51% mortality rate, 14% severely disabled, 8% vegetative, 26% good recovery
GSW– 70 % die at scene, 25% favorable outcome (GCS 13-15)

60
Q

58 yo woman
Lifelong smoker, HTN, DM
Sudden onset of right sided weakness and word finding difficulty
it is a central white spot by thalamus so it is:
what do you do?

A

hemorrhage, central, so hypertensive hemorrhage
most found with people that have HTN
monitor to see if patient changes and becomes more lathargic
if less than 30 cc, no way to operate

61
Q

location is important in considering surgery because:

A

if you are lateral to internal capsule, should be fine
if medial to internal capsule, the patient will remain hemipalegic
in this case you would insert a catheter, use tpa and let the clot dissolve and drip out

62
Q

*Why is a cerebellar hematoma different than any other type of hematoma?

A

if you take out a cerebellar hematoma, your patient will be fine, maybe will have ataxia but that will improve with time, and most important is that the mass effect will press on the brainstem and kill you

63
Q

cerebellar hemorrhage also will kill you bc:

A

mass effect wiil push on brainstem area and eventually close off 4th ventrical and cause a hydrocephalus

64
Q

*cerebellar hemorrhage:
1st thing to go:
then:
bc:

A

potential space, causes hydrocephalus
patient gets aggitated
they start hyperventillating to blow off co2

65
Q

*cerebellar hemorrhage is also dangerous because it pushes and closes off 4th ventrical and at the base of the 4th ventrical is:

A

6 and 7, so patient first gets aggitated and then develops a 6th and 7th nerve palsey simultaneously, usually on 1 side, and at that point you have 30 min to get to or

66
Q

*why are temporal hemorrhages dangerous?

A

they cause uncal herniation, so there is no rise in icp, no lethargy, no change or decline in patient, just fine then dead

67
Q 
43 y/o woman
Sudden onset of severe headache during intercourse last night
PMH: Smoker, HTN
FH: Mother died of “stroke”
PE: Drowsy but arousable
PERRLA
5/5 strength, no drift
right around basal ganglia and circle of willis
star of death
A

aneurysmal subarrachnoid hemorrhage= star of death

traumatic subarrachnoid hemorrhage: slightly detectable blood on side of brain

68
Q

*cereberal aneurysms

A 
Prevalence – 5%
Ruptured: Unruptured
Ratio 1:1
SAH Morbidity/Mortality
33% functional
33% dependent
33% mortality
when small, very little chance of rupture, larger=more likely
69
Q

arterial bp____ venous bp ____

A

120-80, 0-5

70
Q

aneurysm management:

A 
Prevent rerupture
Surgical clipping
Endovascular coiling/remodeling
Observation
Manage complications
Hydrocephalus
Vasospasm
71
Q

avm:

A

Arteriovenous shunts without intervening capillary bed
Congenital
Risk of hemorrhage: 2- 4%/year
– 25% morbidity and mortality after hemorrhage

Increased Risk
Flow related aneurysm: 10-15%
Intranidal aneurysm: 50%
Venous outflow obstruction/stenosis
Vascular steal
72
Q

what do you do with avm?

A 
Surgery
Grade 1-2: 2% complication rate
Immediate results
Embolization
Cure is rare, only 10-15%
Radiosurgery
80% occluded at 3 years
73
Q

every 30 min that passes with no blood flow to the brain you have ____

A

10% less chance of having a functional outcome

74
Q

back pain, we get concerned with?

A 
Weakness
Radicular numbness/pain
Bowel or Bladder changes 
Urinary retention, 
NOT incontinence
Saddle anesthesia/erectile dysfunction
Rectal exam- Volitional tone
Severe, localized midline pain
Night time pain (tumor
75
Q

severe localized midline pain that gets worse at night, can be made better with aspirin, sit up in a chair:

A

tumor

76
Q

dermatomes:

A

t1 medial arm (from armpit)

l3 inner thigh, l4 inner calf, l5 outer calf

77
Q

dermatome testing:

A 
C5	Deltoid
C6	Biceps is a waste of time, just check Wrist extension
C7	Triceps
C8	IO
don't test grip, it's a waste of time
L3   Iliopsoas
L4	Quadriceps, patellar reflex
L5	EHL
S1	Plantar flexion, achilles
78
Q

disk dessication is ____ and is characerized by:

A

arthritis:
Loss of water in the disks
Loss of disk height
disk bulge

79
Q

*disk bulge is caused by:

A

Loss of water leads to bulging against the annulus
TEARING ANNuLUS HURTS!
Car tire analogy
Rarely surgical
the water is now in the bone and shows white on t2 image
disk not doing its job so you go to physical therapy

80
Q

treatment for disk herniation:

A

Good explanation of the musculoskeletal basis of their disease, what to expect, and how to control it
Paraspinal muscle conditioning
Physical therapy
Daily home exercise, Pilates, Water aerobics, Water therapy, Biofeedback
NSAIDs
Smoking Cessation
Weight loss

81
Q

disk herniation has to correspond to the _____ or else :

A

dermatome location, surgery won’t help

If active participation in conservative measures for 6-12 weeks fail, then consider surgical intervention

Interventional Pain 
Decompression
Fusion
Disk replacement
Spinal cord stimulation
82
Q

the explanation of arthritis spinal pain includes:

A

there are 4 columns of muscles around the spine and if they stop doing their job and atrophy and start spasming, then it hurts like crazy, it’s more muscle problem from muscles spasing

83
Q

surgical treatment for spinal surgery disk herniation procedures

A

If active participation in conservative measures for 6-12 weeks fail, then consider surgical intervention

Interventional Pain 
Decompression
Fusion
Disk replacement
Spinal cord stimulation
84
Q

*Lumbar stenosis
neurogenic claudication presents as:
vascular claudication presents in:
how to tell the difference?

A

crampy end organ pain associated with stenosis
the feet
in neurogenic claudication, leaning forward will open up the pinched area and relieve pain, vascular it won’t help
not associated with incontinence, bowel problems

85
Q

a problem associated with osteoperosis:

A 
compression fractures
Treat conservatively if <50% height loss, <11 degrees of angulation
Semi-rigid brace
Analgesia
Begin PT at 6 wks
Consider Kyphoplasty/Vertebroplasty 
at 6 wks if still with unresponsive pain
86
Q

*cervical stenosis:

A 
Same progression as lumbar, with bigger neurologic consequences
Myelopathy
Hyperreflexia
Proprioceptive loss
Wide based gait
\+Hoffmans/Babinskiif
87
Q

if problem coming from lumbar to nerve roots, you will be:

from spinal cord:

A

hyporeflexic

hyperreflexic

88
Q

hoffmans sign:

A

is a finding elicited by a reflex test which verifies the presence or absence of problems in the corticospinal tract
if thumb flicks IN, not normal

89
Q

what are you testing with romberg?

A

vision, vestibular, proprioception

vestibular there to keep you balanced, vision is there in case vestibular is not working,

90
Q

important things to ask about for stenosis:

A

bladder retention in women, ed in men

jK NEURO (35 decks)

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