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High Yield Neurosurgery FRCS Part 2 > Post Chx > Flashcards

Post Chx Flashcards

1
Q

Describe the Frissen grading?

A

Grade II - C shaped halo with temporal gap Grade II - halo becomes circumferential Grade III - loss of major vessels as they leave the disc Grade IV - loss of major vessels on the disc Grade V - criteria of grade IV plus partial or total obscuration of vessels of the disc

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2
Q

What are causes of dural AVF?

A

Trauma Venous sinus thromobosis Craniotomy Meningioma

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3
Q

What size of colloid cyst should be treated?

A

1cm (Pollock Mayo series)

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4
Q

What treatment options are there for colloid cyst?

A

Transcallosal approach (2/3rd in front one front behind) Stereotactic drainage Endoscopic or Open Transventricular

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5
Q

How would you diagnose cushing’s disease?

A

Differential: pituitary adenoma, ectopic ACTH tumour, adrenal tumour Abdominal tumour

Initial screen - early morning cortisol/24hr urinary cortisol

Low dose dexamethasone suppression test - will only suppress cortisol and ACTH in normal person

High dose dexamethasone suppression test - in 80% of pituitary adenomas will suppress cortisol and ACTH but not in ectopic ACTH secreting tumours

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6
Q

What is the risk of hoarse voice after ACDF?

A

approx 10% temporary, approx 5% permanent

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7
Q

What is risk of dysphagia after ACDF?

A

Common immediately but by 6 months only 5% have moderate or severe

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8
Q

Landmarks for Frazier’s burrhole

A

6cm superior to inion and 3cm lateral

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9
Q

What’s the definition of biochemical cure for acromegaly?

A

Not-standardised. Greengerg 1) Normal IGF-1 2) Basal (morning) GH <5ng/ml AND nadir <1ng/ml in OGTT

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10
Q

How do you test for remission in cushing’s post op?

A

Various methods e.g. Early morning cortisol Low dexamethasone suppression test

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11
Q

What classification of Craniopharyngiomas do you know?

A

Paris classification 1-2 depending on hypothalmic involvement (0 not touching, 1 displaced, 2 infiltrated) 0 can be resected 2 can’t be resected

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12
Q

Describe familial cavernoma syndromes?

A

CCM1 (KRIT 1) - hispanics CCM2 (Malcavernin) CCM3 (PDCD10)

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13
Q

What is DBX?

A

Demineralised bone matrix (from cadaveric human donors) - collagen and bone morphogenic proteins

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14
Q

When should you screen for familial cavernoma?

A

2 first degree relatives with cavernoma

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15
Q

What is cell or origin of craniopharyngioma?

A

Nests of odontogenic epithelium in pituitary stalk

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16
Q

How do you decide between DBS targets in parkinsons

A

STN - meds reduction GPi - antidyskinetic effect VIM - tremor control but insufficently addresses other motor feature

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17
Q

What are EMG signs of denervation?

A

Positive sharp waves Insertional activity Fibrillations (later increased duration and polyphasic waves)

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18
Q

What’s significance of EMG signs of denervation in paraspinal muscles?

A

Suggests radiculopathy

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19
Q

What do fall in increased latency, fall in conduction velocity and amplitude indicate respectively?

A

Increased latency or fall in conduction velocity —> demyelination Decreased amplitude –> axonal loss

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20
Q

What screening should you do for VHL?

A

MRI abdomen - renal, pancreas, adrenal Audiology - endolymphatic sac tumour Eyes - retinal haemangioblastomas Neuraxis screening

urine metanephrines

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21
Q

What AED for this patient for focal epilepsy?

A

Levetiracetam (Others for focal seizures are carbamazepine or lamotrigine)

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22
Q

What is the mechanism of action of levetiracetam?

A

It binds SV2A (synaptic vesicle protein) reducing neurotransmitter release

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23
Q

Side effects of levetiracetam?

A

Somnolence Psychosis Depression

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24
Q

Mechanism of action of phenytoin?

A

Voltage-dependent sodium channel blockade

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25
Q

Adverse effects of phenytoin

A

Gingival hyperplasia Rash Bone marrow suppression

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26
Q

What is syndrome of phenytoin toxicity?

A

Ataxia Nystagmus Slurred Speech Confusion

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27
Q

Describe course of the facial nerve?

A

Nuclei - motor nucleus, sensory (nucleus solitary tract), Superior salivatory nucleus Leaves pons at level of middle cerebellar peduncle Enters internal auditory canal (7 up coke down) Then there’s the genu of facial canal with geniculate ganglion Branch 1 Gives of GSPN - runs on floor of temporal fossa, enters foramen lacerum and joins lesser petrosal (sympathetics from carotid) to form vidian nerve - pterygopalatine ganglion Branch 2 nerve to stapedius Branch 3 chorda tympani Then leaves through stylomastoid foramen

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28
Q

What is facial colliculus?

A

Fibres of VII looping over nucleus of VI

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29
Q

What are the segments of PCA?

A

1 - precommunicationg 2 - ambient 3 - quadigeminal 4 - calcarine

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30
Q

Draw the floor of the fourth ventricle

A
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31
Q

What are three groups of thalamic nuclei?

A

Anterior

Lateral

Medial

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32
Q

When is gastrulation?

Pimary neurulation?

Secondary neurulation?

A

Days’s 14-17

weeks 3-4

weeks 5-6

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33
Q

Pathognomic Path

Pilocytic

Schwannoma

Ependymoma

Chordoma

A

Pilocytic - Rosenthal fibres

Schwannoma - Antoni A and B fibres, verocay bodies

Ependymoma - pseudorosettres

Chordoma - chords and nests, physallipherous

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34
Q

What are four GBM criteria histology?

A

Anaplasia

Mitotic Activity

Necrosis

Endothelial/microvascular proliferation

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35
Q

What is marker for ATRT

A

INI-1 loss

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36
Q

What is significance of ATRX loss?

A

Defines a subgroup of WHO II tumour with better prognosis

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37
Q

What’s significnace of TP53 mutation

A

Marker of astrocytoma and GBM

Suggestive not oligodendroglioma

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38
Q

What types of (extra-neural) tumours occur in VHL and TS?

A

VHL - retinal haemangioblastomas, endolymphatic sac tumours, renal carcinoma, pancreatic carcinoma, (also cysts of both), phaeochromocytoma

TS - cardiac rhabdomyomas, renal angiomyolipoma

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39
Q

How much facet can you take in c spine?

A

medial 25%

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40
Q

How does gamma knife work?

A

201 cobalt-60 sources with a collimator

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41
Q

What are four feautres of parinaud’s syndrome?

A

Collier’s lid retration sign

Lid near dissociation

Convergence nystagmus

Upgaze palsy

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42
Q

What are the muscles overlying posterior fossa?

A

Superficially

Semispinalis capitis (lateral)

Splenius capitis (medial)

Deeper

Rectus Capitis (medially)

Obliquus Capitis (laterally)

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43
Q

What are differentials for trigeminal neuralgia?

A

Migraine - Aura, vomiting, photophobia

trigemianal Autonomic cephalgia -

Cluster headache - eye watering, nasal congestion

short-lasting unilateral neuralgiform headache attacks - conjunctival injection tearing

SUNA - short lasting neuralgiform headache (like sunt less prominnent conj injection and tearing)

MS

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44
Q

What are outcomes with RF of gasserian ganglion?

A

60% patients off meds

80% have numbness

Reduced corneal reflex 7%

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45
Q

What is NICE criteria for decompressive hemicraniectomy in stroke?

A

A score of 1 of more on alertness component of NIHSS

Signs of infarct on CT of at least 50% MCA territory

(infarct volume greater than 145cm3) on DWI

(ACA and PCA additionally is not a contraindication in NICE)

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46
Q

How do you look left?

A

Left Parapontine reticular formation stimultates left VIth

and crosses over to right MLF to stimulate right III’d

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47
Q

What was outcome of destingy/decimal/hamlet?

A

Mortality reduced (71-22%) - extra survivors evenly spread between MRS 2,3 and 4

48
Q

What were outcome of rescue ICP?

A

Inclusion Criteria ICP over 25 for 1 hour despite step 1 and step 2 therapy

Mortality reduced(50%–>25%) however increased survivors spread between upper severe, lower severe and vegetative at 6 months

49
Q

Drugs in status

A

Lorazepam 4mg/Diazepam 10mg

Phenytoin 20mg/kg

+/-pabrinex +/-dextrose 50ml/50%

50
Q

How does dexamethasone work?

A

Downregulates vegf

51
Q

What drugs can you give for IIH?

A

Acetazolamide

Topiramate

52
Q

What electrolytes disturbance to you see from thiopentone?

A

Hypernatreamia

Hypokalaemia

53
Q

What is the hierarchy of evidence?

A

Level 1 - Metanalysis or good RCT

Level 2 - poor rct or Cohort Studies

3 - Case control studies

4 - Case series

5 - expert opinion

54
Q

What are phases of clinical trials?

A

Phase 0 - first trials in people

Phase 1 - dosing

Phase 2 - safety and efficacy

Phase 3 - compared to standard of care drug

Phase 4 - post introduction surveillance (report to MHRA via yellow card scheme)

55
Q

What is the likelihood ratio?

A

Likelihood ratio = Sensitivity/(1-Specificity)

56
Q
A
57
Q

What is type I error vs type II error?

A

Type I is falsely positive trial

58
Q

What drugs can you give in cushings?

A

metyrapone

(or ketokonazole)

59
Q

How can you treat SIADH?

A

Fluid restriction

PO Na, Hypertonic saline

Demeclocycline

60
Q

What’s the natural history of lumbar disc herniation?

A

1/3rd recover at 2 weeks

75% at 3 months

(Vroomen Dutch population study)

61
Q

What’s the hardy classification?

A

pituitary adenoma

62
Q

What is normal vs serviceable hearing?

A

normal is 20 decibels, 50 decibels is cut off for serviceable

[=right ear, bone conduction

63
Q

How does 5-ALA work?

A

5-ALA is absorbed by lots of cells and converted to fluorescent protopophyrin IX. HGG are unable to absorb this.

64
Q

Draw a neuronal action potential depolarising?

A

Starts -70mV -

Depolarises to +40mV - influx of sodium

Repolarises to -90mv with refractory period - (voltage gated potassium channels)

65
Q

What are settings for 5-ALA and ICG?

A

For 5-ALA use a light source at 400nm and for ICG digital camera sensitive at 800nm

66
Q

What’s incidence of crouzon

A

1:65,000

67
Q

What are the craniosynostosis syndromes, genes, key features?

A

Crouzon - midface hypoplasia, FGFR2 or FGFR3

Pfeiffer - broad short thumbs or big goes FGFR 1 FGFR 2

Apert - FGFR 2 - syndactyly - looked like had glabella pushed in

Also

Saethre-Chotzen - TWIST1

Muenke - coronal synostosis FGFR 3

68
Q

Describe the papile grading?

A

Grade 1 - germinal matrix

Grade 2 - intraventricular

Grade 3 - intraventricular + hydro

Grade 4 - intraventricular + intraparenchymal

69
Q

What’s the ventricular index treatment line?

A

97th centile+4

70
Q

What weight for VPS?

A

2kg

71
Q

Draw the brachial plexus

A

5 roots

Upper Middle Inferior Trunks

Each gives ant and post division

Posterior divisisons form posterio cord

Lateral cord from upper two

Medial cord from lower two

72
Q

How much radiotherapy in Stupp protocol?

A

60Gy in 30 fractions

73
Q

What is chance of AVM obliteration with gamma knife?

A

75% at 4 years

74
Q

What are hounsfield units for air, water, blood, calcium?

A

Hounsfield units - water=0 air=-1000. Blood=50-70 hounsfield units, calcium>150

75
Q

What are the RANO (response assessment in neuro-oncology) criteria?

A

Complete Response (CR) - disappearance of all enhancing disease, clinically stable or improved

Partial Response (PR) - 50% decrease in measureable enhancing disease, clinically stable

Progression - 25% increase in enhancing lesions or any new lesions with clinical deterioration

Stable - None of the above

76
Q

How would you distinguish true tumour progression from pseudoprogression?

A

MRS

77
Q

What are the borders of Kambin’s triangle?

A

NB - variable description of this

Medially - superior articular process/inferior facet

Inferiorly - transverse process

Superiorolaterally - nerve root

78
Q

What evidence to you know for early decompression in spinal cord injury?

A

STASCIS study compares 6 month outcome for cervical SCI with early and late surgery. 3x chance of 2 grade improvement with early surgery.

79
Q

How do you assess for craniocervical dissociation?

A

Powers ratio < 1

(Basion–>posterior C1) / (opisthion–>ant C1)

80
Q

Where do spinal cord schwannomas typically occur?

A

Posterolateral (sensory root) in obsteinerredlich zone

81
Q
A
82
Q

What is differential for primary bony tumours of spine?

A
83
Q
A
84
Q

What primary bone tumours of spine could occcur?

A

Osteogenic - e.g. osteoblastoma, osteosarcoma

Chondrogenic - e.g. osteochondroma, chondrosarcoma

Vascular e.g hamangioma (?ABC)

Haemotopoeetic e.g myeloma, lymphoma, histiocystosis

Notochordal - chordoma

85
Q

What are the boundaries of kawases triangle?

A

Manbidular division one side

GSPN other side

Back is line between geniculate ganglion and V3 drawn along petrous apex

86
Q

What is the grading for Moya Moya?

A

Angiographic stages (Suzuki grade)

  1. Stenosis of distal intracranial ICAs
  2. Formation of moyamoya collateral vessels at the base of the brain
  3. Further prominence of moyamoya vessels as stenosis of the anterior circulation progresses
  4. Severe stenosis or occlusion of the entire circle of willis
  5. Enlgagement of extracranial collateral vessels
  6. Occlusion of distal ICAs, disappearance of basal moya moya vessels and cerebral vasculariation from extracranial sources only
87
Q

Describe the neuronal migration abnormalities?

A

Lissencephaly - maldevelopment of cerebral convolusions. Agyria (completely flat), pachygyria, polymicrogyria (small gyri)

Schizencephaly - grey matter lined cleft (distinguishing it from porencephaly) between surface and ventricle. Open lipped or closed lipped (walls fused)

Heterotopia - abnormal grey matter (anywhere from subcortical grey matter to the subependymal lining of the ventricles

Focal cortical dysplasia - local migratiln failure

88
Q

When does infantile germinal matrix persist until?

A

35 weeks

Haemorrhage typically 32 weeks or earlier

89
Q

Things to warn the surgeon about in SSEP/MEP

A

SSEP - 50% decrease in peak signal amplitude from baseline

Increase in peak latency >10%

Complete loss of a waveform

TCMEP - sustained 50% decrease in signal amplitude

DEP - decrease in signal of > 60%

90
Q

Intevention for SSEP/MEP changes (Vitale checklist)

A
  1. Verify change in real (rule out interference from other equipment - OR table, C-arm, microscope…anything with. a plug). Check connections. Verify that stimulating electrodes and recording leads are making good contact.
  2. Place OR on alert status

Announce intraoperative pause and stop the case. Eliminate possible distractions. Inform anaesthetist, experienced colleague in

  1. Anaeshtic metabolic - optimise MAP, check haematocrit, optimize blood pH, normalise patient body temperature, check anaesthetic technical factors, consider Stagnara wake up test
  2. Surgical considerations - visually check position, remove traction if used, decrease distraction or other corretive forces, remove rods, remove screw that could correlate with change and re-probe for breach, check for spinal cord compression, check for nerve root compression at osteotomy sites, obtain intraoperative imaging (CT or O-arm if available), consider staging operation if practical
  3. Stagnara (if feasible) - lighten anaesthetic and ask patient to wiggle toes
  4. Consider IV steroids
91
Q

What windows are there for TCDs?

A

Almost all TCD is via the transtemporal window (MCA, ACA, PCA, terminal ICA)

[otherwindows exist - transorbital (ophthalmic), occipital (verts and basilar), submandibular (distal extracranial ICA)]

Lindegard ratio >3 is pathological (ratio ICA to MCA)

92
Q

Where are EEG leads?

A

10:20 rule

Odd left, Even right

FP - frontopolaer

F - frontal

C - coronal

P - Parietal

O - occipital

T.- temporal

A - auricular

93
Q

What are contradindications to MEPs?

A

History of epilepsy/seizures

Past surgical skull defects

Metal in head or neck

Special care with implanted electronic devices

94
Q

What was result of cooling?

A

Cooling in eurotherm trial (2nd line after sedation) 32-35 degrees was harmful

95
Q

What dose TXA is recommended in CRASH-3?

A

1g over 10min then 1g over 8 hour

96
Q

Whats the size of a cranial perforator?

A

14mm and 11mm

97
Q

What are brain trauma foundation indications for ICP monitoring?

A

GCS 3-8 + abnormal head scan

OR GCS 3-8 with normal scan if age >40, unilateral or bilateral motor posturing, of SBP <90mmHg

98
Q

What is brain trauma foundation target ICP?

A

ICP <23

99
Q

What are the relevant tumour volumes in radiotherapy planning?

A

GTV - gross tumour volume (enhancing in GBM, flair in LGG)

Clinical target volume

Planning target volume (accounts for terrors)

100
Q

Describe biochemical differences between SIADH and CSW?

A

Both low sodium

Both low serum osmolality (normal 285-295)

Both Urine osmolality > plasma osmo

Both relatively elevated urine sodium (>50 CSW, 20-40 SIADH)

Treatment CSW - fluid replacement and salt replacement, no diuretics, fludrocortisone

101
Q

What are ligaments of occipitocervical junction?

C1 to occiput

C2 to occiput

C2 to atlas

A

C1 to occiput - anterior alanto-occipital membrane, posterior atlanto-occipital membrane, ascending band of cruciate ligament

C2 to occiput - tectorial membrane, alar ligaments, apical ligament (occipoalar)

C2 to atlas C1 - transverse ligament, descending band of cruciate ligament, apical ligament (atlanto-alar)

102
Q

Describe the engel classification

A

1 - seizure free

2 - rare seizures

3 - substanital improvement

4 - no improvement

103
Q

What are safe doses of local anaesthetic?

A

Lignocaine 3mg/kg

7mg/kg with adrenaline

Bupivacaine 2mg/kg

104
Q

Local anaesthetic toxicity?

A

Coma

Seizures

Hypotension

AV block

105
Q

What’s MAC 1?

A

Mean alveolar concentration

Level required to prevent motor response to pain in 50% of subjects

106
Q

What’s the blood supply of the optic chiasm?

A

Superior hypophyseal and perforators

107
Q

How do ICP monitors work?

A

Strain gauge - Transistor that changes resistance depending upon pressure it’s under

Fibreoptic - using mirror with deformation

108
Q

Which way do you look in seizure related to frontal eye fields?

A

Away from seizure focus

109
Q

What are borders of Kambin’s triangle?

A

Root superolaterally

Endplate inferiorly

Theca medially

110
Q

What drugs would you give for TN?

A

Carbamzepine 100mg BD (increasing to 400mg TDS if required)

Oxycarbazepine

Baclofen

Gabapentin

Phenytoin

Amitryptaline

Lamotrigine

111
Q

How do you interpret lumbar infusion studies

A

Infuse until you reach plateau

Resistance to outflow = (pressure divided by flow in steady state)

If resistance to outflow is >18cmH20/ml/min then this predicts shunt responsiveness

112
Q

Describe MRS score?

A

0 - no symptoms

1 - no significant

2 slight disability

3 moderate - can walk

4 modereate severe disability - can’t walk

5 severe disability (bedridden

6 - death

113
Q

Describe extended GOS

A

8 components

Dead/vegetative

Severe upper/lower

Moderate upper/lower

Good recovery upper/lower

114
Q

Where would you place a Paine’s point EVD?

A

2.5cm superior to anterior fossa floor, 2.5cm anterior to sylvian fissure

115
Q

SG in D.I.

A

<1.005

High Yield Neurosurgery FRCS Part 2 (18 decks)

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