surgery - NEURO neurovasuclar disease

Question 1

what is a brain arteriovenous malformation?

Answer 1

The abnormal blood vessels result from feeding arteries directly connecting to a venous drainage system, in the absence of a true capillary bed.

Question 2

pathophysiology of AVM?

Answer 2

thought to be congenital in pathophysiology, involving dysregulation of vascular endothelium growth factor.

Question 3

classification of AVM

Answer 3

Spetzler-Martin grading

Question 4

RF of AVM

Answer 4

inherited disorders, such as Osler-Weber-Rendu syndrome, Sturge-Weber disease, neurofibromatosis, and von Hippel-Lindau syndrome

Question 5

features of AVM

Answer 5

asymptomatic
haemorrhage
seizures
persistent headaches
focal neurology

Question 6

ix for AVM?

Answer 6

Digital subtraction angiography
CT and MR angiography
transcranial Doppler imaging

Question 7

mx of AVM

Answer 7

Microsurgery
Stereotactic radiosurgery
Endovascular embolisation

Question 8

what is intracerebral haemorrhage?

Answer 8

bleed which occurs within the brain parenchyma

Question 9

classification of intracerebral haemorrhage?

Answer 9

primary or secondary

Primary ICH occurs spontaneously, whilst secondary ICH results from underlying lesions;

Question 10

causes of primary ICH?

Answer 10

Hypertension
Cerebral amyloid angiopathy

Question 11

causes of secondary ICH?

Answer 11

Trauma
Primary and secondary brain tumours
Arteriovenous malformation (AVM)
Intracranial aneurysms
Coagulation or clotting disorders
Haemorrhagic conversion of ischaemic infarcts

Question 12

RF for ICH?

Answer 12

increasing age, male sex, Asian ethnicity, excessive alcohol consumption, smoking, illicit drug use (such as cocaine, amphetamines), and anti-coagulation or anti-platelet drug therapy.

Question 13

features of ICH?

Answer 13

nausea and vomiting, loss of sensory or motor function, severe headache, and alterations in level of consciousness.

basal ganglia = contralateral hemiparesis/ hemiplegia
thalamic haemorrhage = contralateral hemisensory loss
cerebellar haemorrhage = cerebellar signs
lobar haemorrhages = focal signs and symptoms

Question 14

ix of ICH?

Answer 14

urgent non-contrast CT head
MRI head imaging
cerebral angiography

Question 15

mx of ICH?

Answer 15

BP control
reverse coagulopathy
if seizures give anti-epileptics
supratentorial = haematoma evacuation
cerebellar = posterior fossa decompression

craniotomy or craniotomy + evacuation of haematoma

Question 16

where do aneurysms occur in the brain?

Answer 16

form at sites where blood vessels bifurcate or merge, and as such the majority form around the Circle of Willis (

Question 17

causes of intracranial aneurysms

Answer 17

hereditary
hypertension smoking
trauma
connective tissue diseases

Question 18

types of intracranial aneurysms

Answer 18

saccular
fusiform

can be classified by size, with <10mm = small, 10-24mm = large, >24mm = giant.

Question 19

Answer 19

Question 20

RF for intracranial aneurysms?

Answer 20

female gender, family history, hypertension, and smoking

Autosomal dominant polycystic kidney disease (ADPKD) and connective tissue disorders (e.g. Marfans)

Question 21

RF for intracranial aneurysm rupture

Answer 21

posterior circulation

Question 22

features of intracranial aneurysms?

Answer 22

incidentally found on MRI
headaches or nausea
focal neurological deficits, seizures, or isolated cranial nerve palsies
intracranial haemorrhage - SAH

Question 23

ix for intracranial aneurysm?

Answer 23

CT angiogram
Magnetic Resonance Angiography

Question 24

mx of intracranial aneurysm

Answer 24

surgical clipping or endovascular coiling

Surgical clipping is seen more suitable in aneurysms that have branching arteries or are wide-necked, and often has lower reported rates or recurrence and rebleeding
Endovascular coiling is usually more favourable in posterior circulation aneurysms or co-morbid or older patients

Question 25

what are intracranial infections?

Answer 25

infections of the CNS that can be caused by bacteria, viruses, or fungi.

Question 26

who should you suspect intracranial infection in?

Answer 26

rapidly progressive neurological illness or systemic manifestation of sepsis with an unclear source.

Question 27

types of intracranial infections?

Answer 27

meningitis, extradural abscess, subdural empyema, and cerebral infections (cerebral abscess, encephalitis, or ventriculitis); surgical intervention can be required in extradural abscess, subdural empyema, and cerebral abscess

Question 28

routes of spread of intracranial infection?

Answer 28

(1) haematogenous spread via the choroid plexus (2) direct extension from adjacent tissues (3) inoculation from interventional procedures or surgery

Question 29

Within the cerebral vasculature, what restricts infiltration of peripheral immune cells?

Answer 29

BBB

Question 30

what is extradural abscess?

Answer 30

typically develops following neurotrauma, surgery (such as following a craniotomy), or direct spread from sinusitis or mastoiditis

Question 31

symptoms of extradural abscess?

Answer 31

localised pain over the affected region and can present concurrently with osteomyelitis of the cranial vault

Question 32

causative bacteria of extradural abscess?

Answer 32

Streptococci and S. aureus

Question 33

what is subdural empyema?

Answer 33

typically develops as direct spread from sinusitis (particularly frontal sinusitis) or from chronic otitis media, extending to the subdural space via the emissary veins or as a result of retrograde thrombophlebitis.

Question 34

what is a cerebral abscess?

Answer 34

can occur due to direct spread from sinusitis, haematogenous spread from a septic focus*, or following a penetrating wound to the head or following neurosurgical procedures.

Question 35

causative organisms of cerebral abscess?

Answer 35

S. pneumoniae and S. aureus.

Question 36

cerebral abscess on imaging?

Answer 36

discrete lesions with an enhancing rim

Question 37

what is ventriculitis?

Answer 37

inflammation of the ependymal cells which lines the cerebral ventricles secondary to pre-existing infections

Question 38

features of intracranial infection/

Answer 38

new-onset confusion or reduced level of consciousness, headache, or clinical features of sepsis.

Question 39

RF of intracranial infection?

Answer 39

extremes of age, recent neurosurgical procedure, intravenous drug use, the presence of any long-term intracranial devices, or immunosuppresion.

Question 40

ix for intracranial infection?

Answer 40

FBC, U&Es, CRP, and a clotting screen, and blood cultures CSF samples CT head with IV contrast MRI head with contrast

Question 41

mx of intracranial infection?

Answer 41

iv abx + fluids high dose long term abx antiviral or anti fungal therapy mannitol or hypertonic saline anti-epileptics

Question 42

surgical mx of intracranial infection?

Answer 42

cerebral abscess = burr hole or craniotomy to drain epidural abscess + subdural empyema = craniotomy

Question 43

surgical mx of subarachnoid haemorrhage?

Answer 43

coiling