Pestana Neurosurgery

Question 1

Neurovascular problems can present these different ways if they are hemorrhagic vs occlusive.

Answer 1

hemorrhagic - sudden onset of very severe HA with subsequent development of severe neurological deficits

occlusive - sudden onset of neurological deficits, but without HA

Question 2

How quickly do brain tumors occur and how do they usually present? What are some unusual presentations of ICP

Answer 2

months - usually presents with a constant, progressive and severe HA that is sometimes worse in the AM. May present with blurred vision, papilledema, and projectile vomiting at later stages due to increased ICP.

Bradycardia + HTN (due to Cushing reflex) may also occur

Question 3

How quickly do infectious problems of the CNS present?

Answer 3

days - weeks, often presents with an identifiable source of infection in the history

Question 4

How quickly do metabolic problems of the CNS present?

Answer 4

rapidly - on the order of hours - days

Question 5

How quickly do degenerative problems of the CNS present?

Answer 5

years

Question 6

common etiology of TIAs 2

Answer 6

stenotic ICA
- or -
ulcerated plaque at the carotid bifurcation

Question 7

How do you work up a TIA?

Answer 7

non-invasive Duplex study (sonogram + doppler)

Question 8

How is a TIA managed?

Answer 8

carotid endarterectomy (remember that most TIAs are due to stenotic ICA - or - ulcerated plaque at the carotid bifurcation) with angioplasty + stent if a filter can be placed to prevent further embolization of debris to the brain

Question 9

complications of ischemic infarct

Answer 9

hemorrhage

Question 10

Patient rolls into the ED with suspected ischemic stroke. What is the FIRST step in management?

Answer 10

get a CT scan to determine extent of infarct or the presence of hemorrhage

Question 11

hemorrhagic strokes are often seen in this patient population.

Answer 11

patients with uncontrolled HTN

Question 12

Patient rolls into the ED with suspected hemorrhagic stroke. What is the FIRST step in management?

Answer 12

CT to evaluate location and extent of hemorrhage

Question 13

treatment of hemorrhagic stroke 2

Answer 13

control HTN

rehab

Question 14

thunderclap headache without neurologic deficits

Answer 14

subarachnoid hemorrhage - absence of neurologic findings may be because the blood is in the subarachnoid space, some patients have nuchal rigidity secondary meningeal irritation

Question 15

thunderclap headache with nuchal rigidity

Answer 15

subarachnoid hemorrhage - absence of neurologic findings may be because the blood is in the subarachnoid space, some patients have nuchal rigidity secondary meningeal irritation

Question 16

management and treatment of patient with extremely headache of sudden onset

Answer 16

workup with

• CT to look for blood in the subarachnoid space
• arteriogram to locate the aneurysm

treatment

• clipping or
• endovascular coiling

Question 17

preferred imaging for brain tumors

Answer 17

MRIs - better details compared to CT

Question 18

management of increased ICP while awaiting surgical resection of brain tumor

Answer 18

high dose dexamethasone (decadron)

Question 19

locate this tumor: inappropriate behavior with ipsilateral optic nerve atrophy and contralateral papilledema and anosmia

Answer 19

at base of frontal lobe

Question 20

identify and locate this tumor: youngsters short for their age with bitemporal hemianopsia

Answer 20

craniopharyngioma - usually calcified lesion above sella is observed on CT

Question 21

identify this tumor: amenorrhea + galactorrhea in young women

Answer 21

prolactinoma

Question 22

w/u of a young women who presents with amenorrhea + galactorrhea

Answer 22

pregnancy test
TSH (r/o hypothyroidism)
prolactin levels
MRI (of sella)

Question 23

treatment of prolactinoma 2

Answer 23

Bromocriptine

transnasal surgical resection (alternative is trans-sphenoidal approach for those who wish to get pregnant or those who fail to respond to medical therapy)

Question 24

patient with HTN, DM, sweaty hands, HA complains that his wedding band no longer fits. Physical exam shows large hands, feet, tongue, and jaw

Answer 24

acromeagly

Question 25

w/u of someone with suspected acromeagly 2

Answer 25

measure somatomedin C

pituitary MRI

Question 26

w/u of someone with confirmed acromeagly

Answer 26

surgical removal (radiation is also an option)

Question 27

patient complains of an acute severe headache with deterioration of vision. History is noted for a chronic headache with bitemoral hemianopsia. Rapidly becomes hypotensive and stuporous.

Answer 27

pituitary apoplexy

Question 28

management 2 and treatment 2 of patients with suspected pituitary apoplexy

Answer 28

management: MRI or CT

urgent replacement of steroid + hormones

Question 29

locate this tumor: loss of upper gaze + sunset eyes

Answer 29

pineal gland tumor

Question 30

locate this tumor: mother complains that her child has truncal ataxia and has been stumbling around

Answer 30

posterior fossa tumor (cerebellar symptoms)

Question 31

common etiologies of brain abscesses

Answer 31

otitis media and mastoiditis

Question 32

management and treatment of patients with brain abscesses

Answer 32

CT (MRI not needed because brain abscess has a very typical appearance on CT)
Resection

Question 33

patient complains of extremely severe sharp shooting pain in the face that lasts for ~1 minute, brought about touching a specific area.

Answer 33

trigeminal neuralgia (tic douloureux)

Question 34

management and treatment of trigeminal neuralgia (tic douloureux)

Answer 34

MRI to r/o organic lesions

carbamazepine or radiofreuency ablation

Question 35

what is causalgia? what causes it and how does it usually present?

Answer 35

aka “reflex sympathetic dystrophy”
etiologies: trauma/crushing injury or surgery that result in partial peripheral nerve injuries, commonly brachial plexus injuries
Symptoms: burning pain prominent in the hand or foot within 24H of injury; any sensory stimulation worsens the pain; often worsens over time. Does not respond to analgesics!

Question 36

diagnosis and treatment for causalgia

Answer 36

diagnosis: sympathetic block (series of localized anesthetic injections to block signals from the sympathetic nervous system)
treatment: sympathectomy