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Neurosurgery
| Question | Answer |
|---|---|
| What are the types of head injuries? | 1) Scalp 2) Skull 3) Brain |
| Why do scalp injuries cause hypovolemic shock? | Scalp injuries cause profuse bleeding due to the many blood vessels in the scalp and their poor constrictive ability |
| When encountering hypovolemic shock in children, what are the main causes? | 1) Cephalohematoma 2) Subdural hematoma 3) Scalp injuries |
| What are the types of scalp injuries? | 1) Abrasion 2) Contusion 3) Wounds (cuts or lacerations) 4) Avulsion 5) Subgaleal (Sub-aponeurotic) 6) Subperiosteal (cephalohematoma) |
| How are cuts differentiated from lacerations? | Cut wounds have regular margins, while laceration wounds have irregular margins |
| What are the types of cut wounds? | 1) Incised (length is greater than depth) 2) Punctured 3) Stab (depth greater than length) |
| What wound causes prevent healing by tension? | Infection and ischemia |
| What is Avulsion? | An injury in which a body or structure is forcibly detached from its insertion and may be complete or incomplete |
| Scalp avulsion is mostly found in: | Women with long hair |
| What is the most common cause of subgaleal injury? | Vacuum assisted childbirth |
| What is the pathology behind subgaleal injury? | Bleeding of emissary veins |
| How do you differentiate a subgaleal injury from a subperiosteal injury? | 1) Subgaleal injuries cross the midline, but subperiosteal do not 2) Subgaleal injuries are fluctuating, but subperiosteal are solid 3) Subgaleal injuries have superficial bruising and swelling, 12-72 hours later |
| What are the types of skull injuries? | 1) Open vs closed 2) Penetrating vs blunt |
| What are the types of blunt skull injury? | 1) Linear fractures 2) Depressed fractures 3) Pond |
| What is the most common skull fracture? | Linear |
| What is the cause of linear skull fractures? | Wide blunt skull injury |
| What are the locations of linear skull fractures? | 1) At the vault (hairline) 2) Diastatic (Suture) 3) Basilar (Base) |
| In which group do Diastatic fractures occur? | Children and young adults In adults, it involves the lambdoid suture |
| What are the causes of depressed fractures? | Small blunt skull injury |
| What is the treatment for pond fractures? | None,it will be corrected by the growing brain, as it usually occurs in babies |
| When do you treat a linear skull fracture? | 1) When it's parallel in close proximity 2) Transverse to a suture 3) Involves a venous sinus groove or vascular channel |
| What is the most severe complication of a basilar skull fracture? | CSF leak |
| What are the clinical manifestations of basilar fractures? | 1) Blood in the sinuses 2) Raccoon eyes (subconjunctival hemorrhage, periorbital ecchymosis) 3) Battles sign (retroauricular ecchymosis) and bruising over the mastoid process |
| What are the usual sites of basilar fractures? | 1) Petrous part of temporal bone 2) Orbital part of frontal bone 3) Basiooccipital |
| What are the complications of linear fractures? | A growing fracture due to pulsations forms a leptomeningeal cyst |
| What is a leptomeningeal cyst? | Cystic mass filled with CSF |
| What are the complications of depressed fractures? | High risk of epilepsy Increased ICP and hemorrhage |
| Which depressedskull fractures requires surgical intervention? | 1) All open depressed fractures 2) If closed: A) A fracture greater than the thickness of the skull B) Associated with neurological signs C) Associated with speech problems D) Associated with seizures |
| How do you treat an open fractures based on the time of presentation? | Less than 12 hours: Clean and close immediately More than 12 hours: Do a craniotomy, leave for 6 months, then do a delayed craniotomy |
| How do you treat a comminuted depressed fracture? | Do a craniotomy, followed by immediate cranioplasty |
| What is the most serious complication of an open fracture? | Infections |
| What are the types of brain injuries? | 1) Direct brain injury (open or closed) 2) Accelerating/decelerating injury (Coup-countercoup) 3) Shearing forces |
| What is a coup-countercoup injury? | When the brain is thrust against the skull opposite to the side of the blow |
| What is caused by a coup-countercoup injury? | A subdural hematoma |
| Why is coup-countercoup injury more common in the elderly? | Due to brain atrophy and more space in the skull |
| When do shearing force injuries occur? | When the grey matter slides over the the white matter, leading to diffuse axonal injury (DAI) |
| What is the pathophysiology of shearing force injuries? | The nerve cell body originates in the grey matter, and the axon travels from the grey matter to the white matter. Grey matter sliding over the white matter leads to injury of these axons |
| What are the ICP and CT findings in shearing force injuries? | Normal |
| What are the microscopic findings in shearing forces injuries? | Axonal swellings (spheroids) |
| What is the diagnosis of a patient with a 3/15 score on the Glasgow Coma Scale, but normal ICP and CT? | Diffuse axonal swellings |
| What are the types of primary brain injuries? | 1) Concussion 2) Contusion 3) Laction |
| How do you assess head injuries using the Glascow Coma Scale? | Mild: 14-15 Moderate: 9-13 Severe: <9 |
| When do you perform a CT in a patient with a head injury? | 1) Headache 2) Vomiting 3) Seizure 4) Coma 5) GCS deterioration 6) Confusion >2h 7) Anterograde amnesia 8) Age>60y 9) Intoxication 10) Visible trauma above clavicle 11) Depressed fracture |
| What is the criteria for admission in patient with head injury? | 1) LOC 2) Post traumatic amnesia >5min 3) Vomiting 4) Seizure 5) Focal neurological symptoms 6) <2 or >65 7) Multiple trauma 8) CSF leak 9) Abnormal CT |
| Which imaging studies do you perform on a patient with head injury? | 1) Skull and lateral cervical spine X-ray (AP, Lateral, and Towns views) 2) |
| In a stable patient, when do you perform imaging? | 3-6 days later and 10-14 days later |
| How do you divide head injuries into low, moderate, and severe risk using clinical manifestations? | Low risk: Normal CT, asymptomatic or only headache/dizziness Moderate risk: CT-hematoma High risk: LOC, Focal signs, and penetrating injury |
| How do you treat head injuries based on severity? | Mild: Elevation of head, analgesia (codeine sulphate), IV line and drain, and CT w/ deterioration Moderate: Mannitol and close observation Severe: ICU admission, ICP monitoring, and Burr hole |
| What are the early complications of head injury? | 1. Hypoxia 2. Electrolyte imbalance 3. Cerebral edema 4. CSF leak 5. Pyrexia 6. Intracranial bleeding 7. Increased intracranial pressure |
| What are the late complications of head injury? | 1. Chronic subdural hematoma 2. Hydrocephalus 3. Epilepsy 4. Post-concussion syndrome 5. Infection |
| What is the most common and most preventable causes of patient deterioration after primary head injury? | Hypoxia |
| What are the general causes of hypoxia? | Airway obstruction, lung injury, respiratory depression, and ARDS |
| How do you manage hypoxia? | ABC,maintain airway patency, and ventilation |
| What is the most common electrolyte imbalance caused by head injury? | Hyponatremia |
| What are the symptoms of hyponatremia? | Confusion, lethargy, dizziness, nausea, and vomiting If conc. >120 mmol/L will lead to seizures and LOC |
| What are the patterns of cerebral edema which occur after head injury? | 1) Diffuse through the cerebrum and cerebellum 2) Focal around an intracerebral hematoma following contusion. |
| What are the symptoms of cerebral edema? | Decreased consciousness |
| What are the types of cerebral edema? | 1) Vasogenic 2) Cytotoxic 3) Interstitial 4) Osmotic |
| How is cerebral edema treated? | Mannitol, diuretics, and surgical decompression |
| What are the causes of vasogenic edema? | Caused by breakdown of BBB Trauma, tumor, abscess, and ischemia Appears as finger-like projections |
| What are the causes of cytotoxic edema? | Cellular retention of sodium and water Ischemia, stroke, cardiac arrest, and intoxications |
| What are the types and subtypes of herniation? | A) Supratentorial 1-Uncal/transtentorial 2-Central 3-Cingulate/subfalcine 4-Transcalvarial B) Infratentorial 1-Upward 2-Downward/tonsillar |
| What is an uncal/transtentorial herniation? | When the innermost part of the temporal lobe squeezes toward the tentorium and puts pressure on the brainstem |
| What is a central herniation? | When the diencephalon and parts of the temporal lobes of both of the cerebral hemispheres are squeezed through a notch in the tentorium cerebelli |
| What is the cingulate/subfalcine herniation? | The most common type of herniation, in which the innermost part of the frontal lobe is scraped under part of the falx cerebri |
| What is a transcalvarial herniation? | When the brain squeezes through a fracture or surgical site in the skull |
| If a CSF leak does not resolve within a week, what do we do? | Lumbar subarachnoid drain to allow the fistula to close |
| What are the causes of pyrexia? | Most commonly due to infection Phenothiazine or damage in the hypothalmus |
| What is the treatment for pyrexia? | Bromocriptine |
| What are the possible outcomes of intracranial bleeding? | 1) Extradural/epidural hematoma 2) Subdural hematoma 3) Subarachnoid hematoma 4) Intracerebral hematoma |
| How do you differentiate between epidural and subdural hematoma based on the timing? | 1) Epidural hematomas occur in the first 24 hours after trauma 2) Subdural hematomas can be acute (<3 days), subacute (4-21 days), and chronic (>3 weeks) |
| How do you differentiate between an epidural and subdural hematoma based on symptoms? | 1) Epidural (LOC-lucid interval-decline in consciousness) -Vomiting, papilledema, with a fixed dilaed pupil ipsilateral and hemeparesis contralateral 2) Subdural (Headache, restlessness, and neurological deterioration) |
| How do you differentiate between epidural and subdural hematoma based on location? | 1) Epidural hematomas are between the skull and dura (temporal) 2) Subdural hematomas are between the arachnoid and dura |
| How do you differentiate between epidural and subdural hematoma based on source of bleeding? | 1) Epidural hematomas are usually from arterial blood, specifically the middle meningeal artery or dural sinuses 2) Subdural hematomas are usually from venous blood |
| Which groups of people do epidural and subdural hematomas occur in? | 1) Epidural hematomas occur in children and young adults 2) Subdural hematomas usually occur in the elderly especially if they're on anticoagulants |
| How do you differentiate between epidural and subdural hematomas based on their appearance on a CT scan without contrast? | 1) Epidural hematomas appear in a hyper dense biconvex shape 2) Subdural hematomas apear in a cresent shape |
| What are the mortality rates of epidural and subdural hematomas? | 1) Epidural hematomas have a mortality rate of about 30% 2) Subdural hematomas have a mortality rate of about 50% |
| How do you treat epidural and subdural hematomas? | Emergency surgical evacuation by either a burr hole or flap craniotomy |
| What are the indications for surgery in epidural and subdural hematomas? | 1) Thickness greater than the skull 2) Pediatrics 3) Symptomatic |
| How do you differentiate between the epidural and subdural hematoma based on its location relative to the suture? | Epidural hematomas cant cross the suture, while subdural hematomas do |
| What is a subarachnoid hemorrhage? | When blood accumulates in the subarachnoid space around the brain due to trauma |
| What is a intracerebral hematoma? | Hemorrhage into the brain parenchyma due to areas of traumatic contusion |
| How does brain tissue aggravate an intracerebral hematoma? | By releasing thromboplastin |
| If the lesion of an intracerebral hematoma is large and expanding, how do you treat it? | Evacuation |
| How does an intracerebal hematoma appear on CT scan? | As a hyperdense area with midline shift |
| How long after trauma does raised ICP occur? | 3-10 days |
| In which ways can a hydrocephalus occur after trauma? | 1) Acutely due to intraventricular hemorrhage and block CSF flow 2) Insidiously |
| What are the manifestations of a hydrocephalus? | 1) Ventriculomegaly with raised ICP (vomiting, headache, and visual disturbances) 2) Normal pressure hydrocephalus (memory problems, gait ataxia, and urinary incontinence) |
| How long after surgical intervention of a chronic subdural hematoma do you follow up with a CT scan? | 1 month |
| At what time intervals can epilepsy occur after head trauma? | Acute (24 hours) Intermediate (1-7 days) Late(>7 days) |
| When does epilepsy occur after trauma? | Mostly with penetrating injury Mostly in young adults |
| What is the pathophysiology of epilepsy after trauma? | After trauma, the neural icrcuit becomes hyperexcitable, so epilepsy will increase brain metabolism. Increased brain flow will lead to a raised ICP |
| What are the risk factors of epilepsy after trauma? | 1) GSC <10 2) History of alcohol 3) Hematoma 4) Post traumatic amnesia (>24 hours) |
| Prophylactic anticonvulsants after trauma prevent which types of epilepsy? | Early and intermediate epilepsy |
| What are the symptoms of post concussion syndrome? | 1) Headache, dizziness, hearing, and visual difficulty 2) Impaired memory and concentration 3) Emotional instability, personality change, insomnia, and loss of lipido |
| What percentage of strokes are due to SAH? | 10% |
| What are the mean ages of normal and aneurysmal SAH? | 1) 55 years old 2) 40-60 years old |
| Which gender is more likely to get a SAH? | Females |
| In which trimester of pregnancy is there an increased risk of SAH? | 3rd |
| What are the risk factors of a SAH? | Smoking, hypertension, antithrombotic therapy, statins, alcohol, estrogen deficiency, family history, and advanced age |
| What is the most common cause of SAH? | Trauma |
| What are the non-traumatic causes of SAH? | 1) Rupture of a berry aneurysm (70%) 2) Rupture of AV malformation (10%) 3) 15% are of an unknown cause 4) Less common causes are mycotic aneurysm, infection, neoplasm, and vasculitis |
| What are the most common locations of a cerebral aneurysm? | 1) Anterior communicating artery 2) Posterior communicating artery 3) Middle meningeal artery *80% are in the anterior circulation and 20% are in the posterior circulation |
| What are the types of cerebral anuerysms? | 1) Saccular 2) Fusiform 3) Mycotic(Staph) |
| What aneurysmal size is correlated with a greater risk of rupture? | >7mm |
| What location is correlated witha greater risk of aneurysmal rupture? | 1) Posterior circulation 2) Anterior circulation 3) Cavernous (lowest risk) |
| What is the clinical presentation of SAH? | 1) Headache (sudden, severe headache(thunderclap)) 2) Decreased LOC 3) Meningism 4) Focal neurological signs 5) Mild papilledema, hemorrhage of the fundi and retina on fundoscopy 6) Oribital pain or diplopa |
| How do we identify meningism? | Neck stiffness, photophobia, fever, and headache |
| What is a sentinel headache? | An acute headache which occurs a few hours before a ruptured aneurysm and is due to minor SAH leak |
| What signs present before a SAH? | 1) Sensory or motor disturbances 2) Seizures 3) Ptosis 4) Bruits |
| What are the 2 clinical scales used to asses a SAH? | 1) Hunt and Hess grading system 2) WFNS grading system |
| What are the first 3 grades of the Hunt and Hess grading system? | 1 --> Asymptomatic or minimal headache and slight nuchal rigidity 2 --> Moderate to severe headache, nuchal rigidity, no neurological defect except cranial nerve palsy 3 --> Drowsiness, confusion, or mild focal deficit |
| What are the last 2 grades of the Hunt and Hess grading system? | 4 --> Stupor, moderate to severe hemiparesis, and severe focal deficit 5--> Deep coma,decerebrate rigidity and moribund |
| What are the mortalities based on the grading of the Hunt and Hess grading system? | 1-->30% 2 -->40% 3--->50% 4 --> 80% 5 --> 90% |
| What is the WFNS grading system ? | 1 --> GCS 15 and no deficit 2 --> 13-14 and no deficit 3 -->13-14 and deficit 4 --> 7-12 with or without deficit 5 -->3-6 and coma |
| What is the Fischer scale points system? | 0--> Unruptured 1 -->No blood detected 2-->Diffuse or vertical layers <1mm thick 3-->Clot and/or vertical layers >1 mm thick 4--> Intracerebral or intraventricular clot |
| What are the investigations used to diagnose SAH? | 1) CT without contrast 2) Lumbar puncture (blood in the subarachnoid space) --> sensitive after 12 hours of bleed 3) Angiography(MRI)--> to know the source of hemorrhage 4) Lab investigations --> CBC, PTT, cardiac enzymes, ABG |
| What are the complications of SAH? | 1) Rebleeding ->occurs within 24 h, 78% mortality 2) Cerebral vasospasm -->in 70% of SAH --> 4-14 days after symptoms 3) Hydrocephalus 4) Seizures 5) Hyponatremia |
| What medication is given as a prophylactic for seizures? | Phenytoin |
| What is cerebral vasospasm? | Delayed narrowing of large capacitance vessels at the base of the brain |
| What are the consequences of cerebral vasospasm? | 1) Decreased consciousness 2) Focal neurological deficit 3) |
| What arteries are involved in cerebral vasospasm? | 1) Terminal internal carotid artery 2) Anterior cerebral artery 3) Middle cerebral artery |
| How are patients with SAH managed? | 1) Stabilization (ABC, intubation) 2) Intubation, hyperventilation, osmotic agents/mannitol, loop diuretics, and IV steroids (For increased ICP and herniation) |
| How do you treat rebleeding in SAH? | Bedrest Analgesia Stool softeners Antifibrinolytics |
| How do you treat vasospam? | Oral nimodipine (CCB) Subarachnoid clot removal HT, hypervolemic, and hemodilutional therapy (HHH) Transluminal balloon angioplasty Papaverine |
| How do you treat hydrocephalus? | Eexternal ventricular drainage |
| How do you treat hyponatremia? | Hypertonic sodium chloride |
| What are the surgical interventions used to treat SAH? | 1) Direct aneurysmal clipping 2) Guglielmi detachable coil (GDC) 3) Balloon embolixation 4) Proximal ligation of the paent artery 5) Wrapping or coating of aneurysms |
| What is direct aneurysmal clipping? | The aneurysmal neck is obliterated via application of a clip that occludes blood flow to the aneurysmal dome without compromising flow to the parent. |
| What is the Guglielmi detachable coil? | It is a form of embolization where the aneurysm is filled with coils of decreasing size until densely packed artery |
| What are the advantages of EARLY surgical intervention? | Decreased risk of rebleeding |
| What are the disadvantages of EARLY surgical intervention? | Edematous brain tissue or intraoperative aneurysmal rupture may be a consequence |
| What are the advantages of LATE surgical intervention? | Less edema and aneurysmal rupture |
| What are the disadvantages of LATE surgical intervention? | Increased risk of rebleeding |
| Which Hunt and Hess/WFNS grade patients are recommended to undergo surgical treatment? | Grades 1-3 |
| What are the complications of surgical clipping? | 1) Hemmorhage 2) Ischemia 3) Damage to the parent or perforating arteries 4) Acute or delayed neurologic deficits 5) Meningitis 6) Cellulitis and wound infection |
| What are the complication of endovascular therapy? | 1) Aneurysmal rupture 2) Thromboembolism 3) Balloon rupture or deflation |
| What are the etiologies of Spina Bifida? | 1) Genetic 2) Teratogenic 3) Nutritional |
| What is spina bifida? | A birth defect resulting from incomplete closure of the embryonic neural tube |
| What are the types of spina bifida? | Aperta, Occulta, and Ventralis |
| What are the subtypes of Spina Bifida Aperta? | 1) Myelomeningocele 2) Meningocele 3) Lipomeningocele |
| What is Spina Bifida Occulta? | When the bony vertebra is open, but the spine is within the spinal canal |
| How does Spina Bifida Occulta present? | 1) Swelling 2) Tuft of hair 3) Redness 4) Skin discoloration (Mongolian spot --> dark blue discoloration on the back of the baby) |
| What is a lipomeningocele? | Lipoma located over the lumbosacral spine associated with bowel or bladder dysfunction |
| What is a meningocele? | A fluid filled sac, which involves the meninges The neural tissue is not affected |
| What is a myelomeningocele? | Protruding part of the meninges and part o all of the spinal cord protrudes through the open vetebrae |
| What are the symptoms of Spina Bifida? | 1) Pain, weakness, paralysis 2) Bowel/Bladder symptoms 3) Skin ulceration |
| What are the complications of Spina Bifida? | 1) Club foot 2) Spinal curvature abnormality 3) Osteoporosis 4) Hydrocephalus |
| How is Spina Bifida detected? | Triple screening (Maternal alpha fetoprotein, amniocentesis, and bone US) MRI to locate hydrocephalus |
| How is Spina Bifida treated? | 1) Antibiotics 2) Surgery 3) Observation 4) Physical Therapy |
| What are the types of surgery used to treat Spina Bifida? | 1) Within 48 hours of delivery (cover t hespinal cord with skin) 2) In Uterosurgery |
| What are the benefits of surgery? | 1) Mother being able to handle her child 2) Cosmetic 3) Reduced rupture and infection |
| What is spina bifida ventralis? | Protrusion of the defect into the retroperitoneal space, affecting the retroperitoneal organs (kidneys, dueodenum, adrenal glands) and vessels (aorta and IVC) |
| What are the causes for pressure on spinal cord or nerve root? | 1) Disc displacement 2) Disc herniation 3) Spinal stenosis 4) Osteoarthritis 5) Cartilage breakdown |
| What are the stages of the prolapsed disc? | 1) Bulge 2) Protrusion 3) Herniation |
| Which substances decrease with age? | 1) Proteoglycans 2) Water 3) Non-collagenous protein |
| What are the types of cervical disc disorders? | 1) Herniated nucleus pulposus 2) Degenerative disc disease 3) Internal disc disruption |
| When does herniation occur in the cervical disc? | Secondary to posterolateral annular stress |
| What are the types of herniation in the cervical disc? | 1) Focal 35% 2) Broad 25% to 50% |
| What are the risk factors of cervical disc herniation? | 1) Age 2) Lifestyle 3) Genetics 4) Smoking 5) Nutrition 6) Physical activity |
| Whats the first site of degeneration in case of the cervical disc? | Nucleus pulposus |
| Once injury or degeneration occurs, which site causes pain generation? | Annulus fibrosis |
| What are the most common sites of cervical herniation? | 1) C6/C7 2) C5/C6 3) C4/C5 4) C7/T1 |
| What are the areas of herniation and their symptoms? | 1) Nerve root --> radiculopathy 2) Anterior spinal artery or vein -->Myelopathy 3) C5/C6 prolapse -->weak elbow extension, numb middle/index finger, and depressed supinator reflex 4) C6/7 --> weak elbow extens. numb middle/index, and absence triceps |
| What are the consequences of C7/T1 prolapse? | Weakness may involve long flexor muscles, triceps, finger extension or small hand muscles Decreased sensation in ring and middle finger and medial side of the hand and forearm Reflex: triceps jerk may be depressed |
| How do you examine the cervical spine? | By the Spurling maneuver shoulder abduction and neck distraction |
| How is Spurling Maneuver done? | Patient’s neck is extended, laterally bend toward site of pain in seated position will produce radiculopathy |
| How does shoulder abduction aid in examination? | Active abduction of symptomatic armplacing the patient’s hand on head in seated position decreases pain and symptoms |
| In which cases of cervical disc disease do we go for surgery? | Significant weakness Evidence of central disc prolapse Pain not resolving with conservative treatment for more than 10 days or chroming/ relapsing pain |
| What surgeries are done in cervical degenerative disease? | Anterior cervical discectomy with fusion Poster cervical fusion (cervical spondylotic myelopathy) |
| What is sciatica? | Neuralgia along the course of the sciatic nerve (L4 to S3) |
| Causes of lumbar herniation include: | Trauma 80% and degeneration 20% |
| What is the most common direction of herniation? | Posterolateral The PLL prevents the disc from herniating posteriorly |
| What are the consequences of C5/C6 prolapse (C6 nerve root)? | Motor: mild weakness of elbow extension Sensory: numbness in the thumb or index finger Reflex: depressed supinator reflex |
| What are the consequences of C6/C7 prolapse (C7 nerve root)? | Motor: weakness of elbow extension Sensory: numbness in the middle or index finger Reflex: absence triceps jerk |
| What are the consequences of L3/L4 (L4 root) herniation? | Motor: weakness of quadriceps Sensory: decrease sensation over anterior thigh and medial aspect of lower leg Reflex: decreased or absent knee jerk |
| What are the consequences of L4/L5 (L5 root) herniation? | Motor: weak dorsiflexion Sensory: parasthesia on dorsum of the root and great toe Reflex: decreased or absent medial hamstring reflex |
| What are the consequences of L5/S1 (S1 root) herniation? | Motor: weak plantar flexion 2015/2016 Page 27 Sensory: parasthesia in lateral root Reflex absent ankle jerk |
| What is Cauda Equina Syndrome? | Compression of lumbosacral nerve roots below conus medularis (below L2) |
| What are the clinical manifestations of Cauda Equina syndrome? | Low back pain bowel and bladder dysfunction numbness in saddle area parasthesia weakness sexual dysfunction foot drop and absent ankle jerks on both sides |
| What does the physical examination for Cauda Equina consist of? | 1) Straight leg raising 2) Femoral Stretch 3) Nafzigger test |
| What are the proper investigations for Cauda Equina? | MRI Xray and CT |
| What are the surgical considerations of lumbar degenerative disease? | Cauda equina Progressive neurological deficit during a period of observation Persistent bothersome sciatica Pain despite conservative management or a period of 6-12 weeks |
| What s the surgical teatment of a lumbar disk herniation? | Micro sequestrectomy |
| What are the components of lumbar spondylosis? | Degenerative arthritis and osteophyte formation |
| What is the difference between spondylosis or spondylolisthesis? | Spondylolysis: defect in pars interarticularis Spondylosthesis: when spondylolysis is accompanied with forward translation of one vertebrae relative to another |
| What is the classification of lumbar spondylosis or spondylolisthesis? | I: congenital: sacral-facet dysplasia II: isthmic: stress fracture of the pars inter-articularis III: degenerative: intersegmental instability (produced by facet arthropathy) IV: traumatic: acute stress V: pathologic --bone disease |
| What is the grading scale of lumbar spondylosis or spondylolisthesis? | I: 1-25% II: 26-50% III: 51-75% IV: 76-100% V: >100% |
| What is the surgical therapy of lumbar spondylosis or spondylolisthesis? | Lumbar spine fusion surgery |
| When do you treat lumbar spondylosis or spondylolisthesis? | Accompanying neuro deficits Persistent back pain after conservative treatment Slippage > Grade II (50%) Traumatic spondylolysis |
| What are the clinical manifestations of lumbar stenosis? | 1) Neurogenic claudication 2) Lower back pain, radiating leg pain |
| What are the components of lumbar canal stenosis? | 1) Osteophyte formation 2) Facet hypertrophy 3) Ligamentum flavum hypertrophy 4) Diffuse bulging disc |
| What are the two main divisions of spinal cord tumors? | 1) Extradural (55%) 2) Intradural (45%) |
| What are the subdivisions of extradural spinal cord tumors? | 1) Primary 2) Secondary (metastasis) |
| What are the subdivisions of intradural spinal cord tumors? | 1) Extramedullary 2) Intramedullary |
| What are the clinical manifestations of spinal cord tumors? | Mainly pain (at night, due to decreased cortisol and CO2 retention) Other localizing symptoms |
| How does a spinal cord tumor appear on a plain X-ray? | 1) General signs of bone destruction, deformity (scoliosis) 2)Mass 3) Increase intervertebral foramen size (dumbbell (like in shwannoma) 4) Increase inerpedicular distance (normal 22-25 mm) 5) Scalloping of the vertebrae |
| Why do we perform a CT scan on a spinal cord tumor? | To differentiate between an intramedullary and extramedullary tumor |
| What tumor appears as a CT enhancement lesion? | Hemangioblastoma |
| What are the types of extramedullary tumors? | 1) Schwannoma 2) Meningioma |
| What are the types of intramedullary tumors? | 1) Astrocytoma 2) Ependymoma 3) Hemangioblastoma |
| What is the most important type of imaging required in spinal cord tumors? | MRI |
| Why can a lumbar puncture aid in diagnosis of a spinal cord tumor? | There is a raise in protein in 95% of intramedullary tumors (especially ependymoma) |
| Which type of intramedullary tumor is more common in the spine? Which is more common in the brain? | Ependymoma Astrocytoma |
| In what age group does astrocytoma occur? | 2nd to 5th decade |
| Which gender is more likely to get spinal astrocytoma? | Male |
| What is the most common intramedullary spinal tumor in pediatrics? | Astrocytoma |
| In which segment of the spinal cord is astrocytoma more likely to occur? | Thoracic>cervical |
| What are the types of astrocytoma? | 1) Pilocytic 2) Diffuse (Well-differentiated, Anaplastic, Glioblastoma/Multiform) |
| What percentage of astrocytoma is malignant? | 1/3rd |
| What is the most common primary intramedullary tumor? | Ependymoma |
| What are the types of spinal ependymoma? | 1) Myxopapillary 2) Anaplastic |
| What is the age and gender predilection for spinal ependymoma? | 30-40 years old Male |
| What about spinal ependymoma allows complete resection? | Separated from the spinal cord by a plane of cleavage |
| What syndrome is associated with 5% of hemangioblastomas? | VHL syndrome |
| What blood changes are associated with hemangioblastomas? | Polycythemia |
| What is the age and gender predilection for spinal meningioma? | 30-50 years old Female |
| What is a spinal meningioma? | Chronic slowly growing tumor eroding the bone and compressing the SC |
| In what segment of the spinal cord is most commonly affected in spinal meningioma? | Thoracic spine (80%)--> Upper cervical -->Foramen magnum |
| What is the typical presentation of a spinal meningioma? | An elderly lady with dorsal pain over years associated with weakness progressing over months |
| How does a spinal meningioma appear on MRI? | Adherent to spinal dura --> base attached to the dura give the appearance of dural tail |
| What syndrome is a spinal meningioma associated with? | Neurofibromatosis |
| How does a spinal meningioma appear on Xray? | Bone erosion of the pedicles and NO hyperostosis |
| In which segment are Schwannomas and Neurofibromas (Neural Sheath tumors) most common? | Low thoracic and upper lumbar |
| What is the age predilection for Neurofibromas? | 20-50 years old |
| How do you differentiate between Neurofibromas and Schwannomas? | 1) Neurofibromas -->extends into nerve sheath, infiltrate, with NF 1, and multiple 2) Schwannomas -->surrounds the nerve sheath without internal extension, with NF II, solitary |
| How do you differentiate between Meningiomas and NSTs? | Meningiomas compress the cord --> myelopathy NSTs compress the nerve root -->radiculopathy (may progress to myeloradiculopathy) |
| What is the age and gender predilection of Filum terminale tumor? | 30-40 years old Males |
| What is the most common extradural tumor? | Metastasis to the thoracic spine |
| What are the most common sources of metastasis to the spine? | Lung > Breast/Prostate >Kidney >Lymphoma >Thyroid |
| What is the most common mode of metastasis to the spine? | Hematogenous |
| What is the watershed area of the spinal cord? | T4 area Anterior and posterior vertebral arteries |
| What is the most common type of primary brain tumors? | Gliomas |
| Which cells have the ability to form medullablastomas? | Neuronal cells |
| What is the most common benign primary brain tumor in children? | Pilocytic astrocytoma |
| What is the most common primary brain tumor in adults? | Glioblastoma Multiform |
| Which type of tumors increase ICP and hydrocephalus? | Upper cervical tumors |
| What are the CMs of pain in the filum terminale? | Increase with recumbency, neck flexion, movement, and relieved by paracetemol |
| All of the primary spinal tumors are treated by: | Laminectomy +excision vs debulking |
| If the vertebrae is involved: | Vertebrectomy and fusion |
| What part of the spine resists metastasis? | Disc and dura |
| Which cancer can not be treated with radiotherapy? | Schwannoma |
| Astrocytomas make up which percentage of brain tumors? | 45% |
| What are the grades of astrocytoma based on histopathology? | Grade 1 --> Pilocytic (high cellularity) Grade 2--> Low grade (pleomorphic) Grade 3 --> Anaplastic (mitosis) Grade 4--> Glioblastoma Multiforme (necrosis and hemmorhage) |
| How does GBM appear on CT? | Palisaded necrosis |
| How does an astrocytoma appear on CT? | Low grade: Hypodense, edema, calcification, and intact BBB High grade: Larger, marked edema, enhancement, and BBB distorted |
| What is the life expectancy in grade 4 astrocytoma? | Less than a year |
| What's the benefit of chemotherapy in brain tumors? | It does not cross the BBB |
| What is the most common brain tumor to present with seizure? | Oligodendroglioma |
| What is the most common calcifying primary brain tumor? | Oligodendroglioma |
| What is the most common site of ependymoma in children and in adults? | Children --> 4th ventricle Adult --> Lateral ventricle |
| What are the two categories of Ependymoma? | 1) Anaplastic 2) Non-anaplastic --> papillary, myxopapillary, and subependymoma |
| Where do medulloblastomas occur? | Midline, in the vermis |
| Which primary brain tumor is highly radio and chemo therapy sensitive? | Medullablastoma |
| Which primary brain tumors have a female predominance? | Meningiomas, acoustic schwannoma, and pituitary adenoma |
| What are the risk factors for meningiomas? | Radiation, trauma, Neurofibromatosis 2, and sex hormones |
| What are the possible locations for meningiomas? | 1) Parasagittal 2) Suprasellar 3) Olfactory groove 4) Cavernous sinus 5) In sphenoidal ridge --> Foster Kennedy syndrome |
| What is the surgical aim of resection of meningiomas? | Total resecion with meninges according to Simspon grade |
| What is the Simspon grade and percentage of recurrence within 10 years? | Grade 0--> 3 cm margin (0%) Grade 1--> resection of bone and dura (9%) Grade 2--> Removal and coagulation of dura (19%) Grade 3--> Complete removal w/o resection of dura (29%) Grade 4-->Substotal (44%) Grade 5--> Simple decompression (100%) |
| What is the most common pituitary adenoma? | Prolactinoma |
| Which types of primary brain tumors can cause drop metastasis/ intramedullary spinal cord metastasis? | 1) Ependymoma 2) Medullablastoma 3) Glioblastoma |
| What are the most common brain tumors? | Metastasis |
| What is the normal value of CSF pressure? | 200 cmH2O |
| What is the daily production of CSF? | 500 ml/day |
| What amount of CSF is in the brain at all times? | 150 ml |
| What components found inside the skull determine the ICP? | CSF, Blood, and Brain tissue |
| After reaching the point of discrimination on the intracranial volume/pressure curve, what happens to the line? | There is an exponential rise in ICP with every rise in volume |
| What are the phases of the intracranial volume/pressure curve? | Phase A : compensating, compliant Phase B: non-compensating, non-compliant, elasticity Beyond point of discrimination: derranged cerebrovascular reactivity |
| What are the equations for cerebral perfusion pressure and cerebral blood flow? | CPP (60-120) =MAP - ICP CBF = CPP/CVR |
| What are the symptoms of increased intracranial pressure? | Headache, papilledema, and vomiting |
| What are the causes of headache in increased ICP? | Traction of blood vessels and compression of dura at the base of the cranium Caused by hypoventilation and cortisol levels |
| What is the Cushing Triad caused by tonsillar herniation? | 1_ Increased BP 2) Bradycardia 3) Cheynne Stokes breathing |
| What are the clinical manifestations of uncal/transtentorial herniation? | 1) Loss of consciousness (compression of RAS) 2) Ipsilateral and CL mydriasis (CN3) 3) CL and ipsilateal homonymous hemianopia (PCA) 4) CL and ipsilateral hemiparesis (ipsilateral crus cerebri) |
| In which case of ICP is lumbar puncture contraindicated? | In the presence of an intracranial mass |
| What is Froin syndrome? | Yellowish CSF caused by increased protein content (more than 40 mg) and it usually indicates obstruction |
| What is the golden standard for diagnosing increased ICP? | Intraventricular measuring at the level of the foramen of Monro |
| What are the 3 Lundberg waves of the ICP waveform? | Percussion(P1- highest), tidal(P2), and dicrotic(P3-lowest). |
| What are the potential changes on brain xray in increased ICP? | 1. Widened sutures ( children) 2. Thumb impressions – Beaten copper/silver (gyrus impressions on the skull due to pulsations) 3. Decrease in the post-clinoid processes 4. Increase in the sella turcica |
| What are the potential changes on brain CT in increased ICP? | 1) A lesion 2) Small, shifted ventricles 3) Effacement |
| What are the types of hydrocephalus? | 1) Increased CSF production 2) Decreased CSF absorption 3) Obstruction |
| What is the most common cause of increased CSF production? | Choroid plexus papilloma |
| What are the causes of decreased absorption of CSF? | Infection or hemorrhage |
| Any obstruction beyond the 4th ventricle is called: | The communicating hydrocephalus |
| Any obstruction before of in the ventricular system is called: | A non-communicating hydrocephalus |
| Most common cause of pediatric hydrocephalus is | Aqueductal stenosis |
| Most common cause of adult hydrocephalus | Idiopathic |
| What are the clinical manifestations of hydrocephalus? | Increased ICP (triad of headache, vomiting and papilledema) , mass symptoms, ataxia/urine incontinence/dementia, increased head circumference and most importantly failure to thrive |
| What are the treatments for hydrocephalus? | 1) Removing the tumor 2) Shunts 3) Ventriculostomy |
| What is a third ventriculosternostomy? | Surgical creation of a communication between the 3rd ventricle and the interpeduncular cistern, for drainage of CSF in hydrocephalus |
| What structures can be injured during a third ventriculostomy? | Basilary artery and mammary bodies |
| What are the advantages and disadvantages of a third ventriculostomy over shunts? | Advantages over shunts include: 1. No foreign body used 2. Once obstruction is gone everything goes back to normal Disadvantages over shunts include: 1. High failure rates 2. Fast closure 3. It is only a temporary solution |
| What are the types of shunts? | 1) Ventriculoperitoneal 2) Ventriculoatrial 3) Ventriculopleural |
| What are the complications of shunts? | 1) Proximal obstruction 2) Distal obstruction 3) Shunt infection 4) Skin infection 5) Hemorrhage 6) Valve malfunction 7) Shunt fracture 8) Migration or disconnection |
| What do you do in case of shunt infection? | a) Use an external ventricular drain b) Calculate the amount of CSF from the drain c) Perform a CSF culture d) Monitor ICP e) Give antibiotics (gentamycin, vancomycin) |
| Following up a hydrocephalus patient with a valve include performing a: | 1. Shunt survey/series : which is a series of x-rays covering the entire shunt length 2. CT scan : to check for hydrocephalus |
| What are the CMS of normal pressure hydrocephalus? | 1) Abnormal gait 2) Urinary incontinence 3) Dementia |
| When is a patient considered refractory to epilepsy medication? | Epilepsy that doesn't respond to medical management by at least 2 conventional and 1 newer epilepsy drug, for at least 6 months in adults, and ASAP in newborns |
| What percentage of epilepsy patients are refractory to medicine? | 30% |
| Who are the typical patients with refractory epilepsy? | 50% less than 25 y/o |
| What percentage of patients of patients can be managed with epilepsy medication? | 1 drug --> 50% 2 drugs --> 62% 3 drugs -->65% |
| How do we evaluate a patient with refractory epilepsy? | MRI to rule out organic lesions, congenital anaomly, and temporal sclerosis Standard EEG --> abnormal electrical actvitiy Video EEG --> Localizing focus SPECT --> Blood flow (hypoperfusion in the focus of epilepsy) PET -->Metabolism |
| What is the most common location for refractory seizures? | Temporal lobe |
| What are the surgical options for epilepsy? | 1) Temporal lobectomy 2) Amygdalohippocampectomy 3) Lesionectomy / Hemispherectomy 3) Callostomy 4) Vagal Nerve stimulation |
| What are the complications of temporal lobectomy? | 15% upper quadrant quadrantanopia |
| When can lesionectomy be performed? | Hemimegaloencephaly Sturge-Weber Disease Rasmussen Disease |
| At what age can lesionectomy be performed? | Ideally <5 y/o |
| What are the transient complications of vagus nerve stimulation? | • Dysphonia (temporary on insertion of electrodes) • Dyspnea • Pain • Sensation of abnormal respiration. |
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Ulaisl
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