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Neurosurgery Flashcards

1
Q

Criteria for brain stem death testing:

A
  • deep coma of known aetiology
  • reversible causes excluded
  • no sedation
  • normal electrolytes
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2
Q

Testing for brain death:

A
  • fixed pupils which do not respond to sharp changes of light
  • no corneal reflex
  • absent oculo-vestibular reflexes - no eye movements following slow injection of at least 50ml of ice cold water into each ear in turn (caloric test)
  • no response supraorbital pressure
  • no cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation
  • no observed respiratory effort
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3
Q

How should the brain death test be undertaken?

A
  • two appropriately experienced doctors on two separate occasions
  • both experienced and have at least 5 years post-graduate experience
  • on must be consultant
  • cannot be member of transplant team if organ donation contemplated
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4
Q

Types of brain herniation:

A
  • subfalcine
  • central
  • transtentorial/uncal herniation
  • tonsillar
  • transcalvarial
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5
Q

What is subfalcine herniation?

A

displacement of cingulate gyrus under falx cerebri

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6
Q

What is central herniation?

A

downwards displacement of brain

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7
Q

What is transtentorial/uncal herniation?

A
  • displacement of uncut of temporal lobe under tentorium cerebelli
  • ispilaterl fixed, dilated pupil
  • contalateral paralysis (compression of peduncle)
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8
Q

What is tonsillar herniation?

A
  • cerebellar tonsils through foramen magnum
  • ‘coning’
  • in raised ICP, compression of cardiorespiratory centre
  • chiari malformation
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9
Q

What is transcalvarial herniation?

A
  • when brain is displaced through defect in skull

- fracture or craniotomy site

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10
Q

Where do subdural haematomas most commonly happen and what are the risk factors?

A
  • outermost meningeal layer
  • frontal and parietal lobes
  • old age and alcoholism
  • slower onset than extradural and fluctuating confusion/consciousness
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11
Q

What is diffuse axonal injury?

A
  • mechanical shearing following deceleration

- disruption and tearing of axons

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12
Q

What is secondary brain injury?

A
  • cerebral oedema
  • ischemia
  • infection
  • tonsillar or tentorial herniation
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13
Q

Cushing’s reflex:

A
  • HTN

- bradycardia

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14
Q

Management head injury:

A
  • raised ICP: IV mannitol/furosemide
  • diffuse oedema: decompressive craniotomy
  • Burr holes and craniotomy flap
  • debridement
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15
Q

Who should receive ICP monitoring?

A
  • GCS 3-8 and normal CT

- mandatory if abnormal CT

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16
Q

What is minimum cerebral perfusion pressure in adults and children?

A
  • adults: 70mmHg

- children: 40-70mmHg

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17
Q

What does it mean if the pupil is unilaterally dilated and response is sluggish or fixed?

A

3rd nerve compression secondary to tentorial herniation

18
Q

What does it mean if the pupils are bilaterally dilated and the response is sluggish or fixed?

A
  • poor CNS perfusion

- bilateral 3rd nerve palsy

19
Q

What does it mean if the pupils are unilaterally dilated or equal and the response is cross reactive (Marcus-Gunn)?

A

optic nerve injury

20
Q

What does it mean if the pupils are bilaterally constricted and the response is difficult to assess?

A
  • opiates
  • pontine lesion
  • metabolic encephalopathy
21
Q

What does it mean if the pupils are unilaterally constricted and the response is preserved?

A

sympathetic pathway disruption

22
Q

Criteria for immediate CT head:

A
  • GCS <13 on initial
  • GCS <15 at 2 hours post injury
  • open or depressed fracture
  • any sign basal skull fracture (harm-tympanum, panda eyes, CSF leak, Battle’s sign)
  • seizure
  • focal neuro deficit
  • more than 1 episode vomiting
23
Q

Criteria CT head within 8 hours of injury:

A
  • > =65yo
  • history bleeding or clotting disorders
  • dangerous mechanism of injury
  • more than 30 minutes retrograde amnesia of events immediately before injury
  • warfarin
24
Q

How does an intracerebral haematoma appear on CT?

A

hyperdense bright lesion

25
Risk factors intracerebral heamatoma:
- HTN - vascular lesion - cerebral amyloid angiopathy - trauma - brain tumour or infarct (particularly in stroke patients undergoing thrombolysis)
26
Symptoms hydrocephalus:
- headache (worse in morning, lying down and during valsalva) - n&v - papilloedema - coma
27
Hydrocephalus appearance in children:
- skull sutures not fused - open anterior fontanelle will bulge and become tense - sunsetting gaze due to compression of superior colliculus in midbrain
28
What is obstructive hydrocephalus?
- pathology blocking flow - dilation of ventricles seen superior to site - tumours, acute haemorrhage, development abnormalities
29
What is non-obstructive hydrocephalus?
- imbalance of CSF production and absorption - increased production: choroid plexus tumour) - failure of reabsorption: meningitis, post-hemorrhagic
30
What is normal pressure hydrocephalus?
- non-obstructive - large ventricles but normal pressure - triad: dementia, incontinence, disturbed gait
31
Investigations hydrocephalus:
- CT head - MRI - lumbar puncture diagnostic and therapeutic
32
Treatment hydrocephalus:
- external ventricular drain (EVD) in acute, severe hydrocephalus and inserted into right lateral ventricle and drains into bag - ventriculoperitoneal shunt is long term CSF diversion technique from ventricles to peritoneum - obstructive: surgical
33
When must you not use lumbar puncture in hydrocephalus?
- obstructive | - difference in cranial and spinal pressure will cause brain herniation
34
Causes of spontaneous SAH:
- intracranial aneurysm (85%) - arteriovenous malformation - pituitary apoplexy - arterial dissection - mycotic aneurysms - perimesencephalic (idiopathic venous bleed)
35
Presenting features SAH:
- headache - n&v - meningism - coma - seizures - sudden death - STE on ECG
36
Confirmation of SAH:
- CT: acute blood is hyper dense on CT typically in basal cisterns, sulci in severe cases, ventricular system - CT can be negative - LP: if CT negative, at least 12 hours following onset to allow development of xanthochromia - normal or raised opening pressure in LP - referral to neurosurgery asap when confirmed
37
After spontaneous SAH confirmed, investigations to identify cause:
- CT intracranial angiogram | - digital subtraction angiogram
38
Treatment SAH:
- most treated with coil - minority require craniotomy and clipping - bed rest and well controlled BP - vasospasm prevented with 21 days of nimodipine (calcium channel inhibitor) - treat hydrocephalus
39
Complications SAH:
- re bleeding (10% in first 12 hour) - vasospasm (7-14 days post) - hyponatraemia (SIADH) - seizures - hydrocephalus - death
40
Predictive factors SAH:
- consciousness level - age - amount of blood visible on CT

Surgery (10 decks)

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