Pestana Chap 11 - Neurosurgery Flashcards
How does vascular neurologic disease present in terms of timetable and mode of presentation? Brain tumors? What happens if ICP increases in either of these conditions?
1) Vascular problems have sudden onset, without headache when they are occlusive, and with very severe headache when they are hemorrhagic
2) Brain tumors have a timetable of months, and produce constant, progressive, severe headache, sometimes worse in the mornings
3) As ICP increases, blurred vision and projectile vomiting are added
What happens if a brain tumor presses on an area of the brain associated with a particular function?
Deficits of that function may be evident
What is the timetable for an infectious neurological problem? What is noted in the history? What is the timetable for metabolic neurologic problems and what part of the CNS do they effect? What is the timetable for degenerative diseases?
1) Infectious problems have a timetable of days or weeks, and often an identifiable source of infection in the history
2) Metabolic problems develop rapidly (hours or days) and affect the entire CNS
3) Degenerative diseases usually have a timetable of years
What are transient ischemic attacks (TIAs)? What do the specific symptoms depend on?
1) TIAs are sudden, transitory losses of neurologic function that come on without headache and resolve spontaneously leaving no neurologic sequela
2) The specific symptoms depend on the area of the brain affected, which is in turn related to the vessels involved
What is the most common origin of a TIA?
High-grade stenosis (70% or above) of the internal carotid, or ulcerated plaque, at the carotid bifurcation
What is the importance of TIAs and what can be done to prevent or minimize the possibility of this complication?
They are predictors of stroke, and timely elective carotid endarterectomy may prevent or minimize that possibility
How does the workup of TIAs begin? When is surgery indicated? When can angioplasty and stent be done?
1) Workup starts with noninvasive Duplex studies (high-quality sonogram plus Doppler)
2) Surgery (carotid endarterectomy) is indicated if the lesions are found in the location that explains the neurologic symptoms
3) Angioplasty and stent can be done if a filter is first deployed to prevent embolization of debris to the brain
How does ischemic stroke present? When is an ischemic stroke not amenable to revascularization procedures?
1) Ischemic stroke has sudden onset without headache, but the neurologic deficits are present for a longer time, leaving permanent sequellae
2) Ischemic strokes that have been present for longer than 3 hours
What causes an ischemic infarct of the brain to be complicated by a hemorrhagic infarct? What is done for the existing infarct?
1) If blood supply to the brain is suddenly increased
2) Vascular workup will eventually be done to identify lesions that might produce another stroke (and treat them), but for the existing infarct, assessment is by CT scan and therapy is centered on rehabilitation
What has become standard practice for managing a stroke? What must be done at the first sign of a sudden-onset neurological deficit? What imaging must be done and what for? What happens if at any time during this evaluation, the neurological functions spontaneously return?
1) Treatment of an early ongoing stroke has now become standard practice, with one or more hospitals in each major city equipped with the necessary resources and staff and designated as the places to do it
2) At the first sign of a sudden-onset neurological deficit, the patient is urged to report immediately to the emergency room
3) CT scan is done first to rule out infarcts that are too extensive to be treated, and to confirm that there is no hemorrhage
4) The case is reclassified as a TIA and manged accordingly. But if not, no time should be wasted
What is the treatment of an ischemic stroke?
Intravenous infusion of tissue-type plasminogen activator (t-PA) is best if started within 90 minutes, but it can still be done up to 3 hours after the onset of symptoms
In what patient is a hemorrhagic stroke most commonly seen? What is used to evaluate the hemorrhage and what is therapy directed at?
1) Hemorrhagic stroke is seen in the uncontrolled hypertensive who complains of very severe headache of sudden onset and goes on to develop severe neurologic deficits
2) CT scan is used to evaluate location and extent of the hemorrhage, and therapy is directed at control of the hypertension and rehabilitation efforts
How does a patient with subarachnoid bleeding from intracranial aneurysms typically present? Why are patients sometimes unfortunately sent home in the presence of a subarachnoid bleed? How are other patients luckily recognized as having a subarachnoid bleed?
1) Extremely severe headache of sudden onset, like no other ever expeirenced before (a “thunderclap,” a headache that is “sudden, severe, and singular”)
2) Because the blood is in the subarachnoid space (there is no hematoma pressing on the brain), there may be no neurologic findings at all, and the patient is sent home
3) Luckier patients may have meningeal irritation and nuchal rigidity, and be recognized
What happens to patients not recognized with a subarachnoid bleed who are discharged home?
They often return in 10 days with another bleed, perhaps this time a much worse one (the early one is referred to as the “sentinel bleed”)
What does workup begin with and follow with for a subarachnoid bleed?
CT scan looks for blood in the subarachnoid space (spinal tap can identify old blood or small amounts of current blood, but it should never be the first test; always start with the CT) and follows with arteriogram to locate the aneurysm (a little devil off the circle of Willis)
What are the treatments for a subarachnoid bleed?
1) Clipping is the surgical therapy
2) Endovascular coiling is the radiological alternative
