Neurosurgery

Joshua Gish

TEST TAKING TIPS

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Test Taking Tips

Make sure that you are familiar with the Glasgow Coma Score prior to the test.

Review the neurosurgery section in the trauma chapter.

What components are present in the cranium?

Brain tissue, cerebrospinal fluid (CSF), blood vessels and blood volume, pathological volume (eg, neoplasm, hematoma, abscess, etc)

What may cause an increase in the brain tissue component (not including neoplasms)?

Edema, inflammatory, perineoplastic, vasogenic

What can be given to decrease swelling due to edema?

Mannitol, hypertonic saline

What can be given to decrease the brain tissue component if swelling is caused by inflammation or perineoplastic syndrome?

Steroids

What can be done to decrease the blood volume component?

Hyperventilation, diuretics, head elevation, remove venous obstruction

What can be done to decrease the CSF component?

Drainage (either external or internal such as a VP shunt), acetazolamide (temporary), steroids (temporary)

What can be done to decrease volume due to a mass lesion?

Evacuation or removal of the cause of the mass lesion

What is the Monro-Kelly doctrine?

The total volume of the cranial vault is fixed and thus an increase in one component must be offset by a decrease in another component.

True or false: CSF production rate is affected by intracranial pressure (ICP)?

False. CSF production rate is constant and is not affected by "back pressure."

What is the site of CSF production?

The arachnoid granulations

What is the name of the process that maintains cerebral blood flow at a constant rate despite changes in systemic blood pressure?

Autoregulation

Define cerebral perfusion pressure:

Mean arterial pressure (MAP) – ICP

Why do older people tend to be more tolerant of mass lesions?

They tend to have larger ventricles, which are more tolerant of compression than brain tissue

What is a raised ICP with no mass lesion termed?

Pseudotumor cerebri or idiopathic intracranial hypertension

What is increased ventricular volume without increased intracranial pressure called?

Normal pressure hydrocephalus

What is a failure of proper capillary formation termed?

Arteriovenous malformation (AVM)

What is the risk of hemorrhage associated with an AVM?

4% per year

What percentage of AVM-associated hemorrhages is classified as severe?

FIGURE 29-1.

Cerebral angiogram demonstrating a frontal arteriovenous malformation filling from the left anterior cerebral artery. (Reproduced from Doherty GM. Current Diagnosis and Treatment: Surgery. 13th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)

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This process is caused by defects in the arterial media and is increased in patients with connective tissue disorders such as Ehlers-Danlos or Marfan syndromes:

Berry aneurysms

What is the risk of hemorrhage with an aneurysm measuring less than 1 cm?

0.05% to 0.5% per year

What is the risk of hemorrhage with an aneurysm measuring more than 1 cm?

1% to 2% per year

If not treated, what is the risk of rebleed within 2 weeks from an aneurysm that has ruptured?

Which cerebrovascular moniker derives from the Japanese term for "puff of smoke?"

Moyamoya—it is characterized by idiopathic narrowing of the major intracrainial vessels with formation of a compensatory collateral circulation.

Which medication is prescribed to reduce swelling related to brain tumors?

Dexamethasone

Which class of tumors accounts for half of all primary brain tumors?

Astrocytomas

What is the term for grade IV astrocytomas?

Glioblastoma multiforme

What is the most common Schwannoma?

Vestibular schwannoma

What brain tumor will tend to cause bitemporal hemianopsia?

Pituitary adenomas

What dopamine agonist is useful in 75% of prolactinomas?

Bromocriptine

What is the most common primary lesion for metastatic tumors of the brain?

Lung (~50%)

What is the second most common primary lesion for metastatic tumors of the brain?

Breast (15%–20%)

Chemotherapy is useful for brain metastatic tumors for which 2 primary lesions?

Small cell lung cancer and seminomas

Up to how many lesions can surgery be indicated for metastatic disease in the brain?

Up to 3 (provided they are accessible)

What is the most common cause of subarachnoid hemorrhage?

Trauma

What is the term for rotational acceleration and deceleration injuries that disrupt the white matter tracts of the brain?

Diffuse axonal injury

FIGURE 29-2.

Spinal cord injury patterns. a., artery. (Adapted with permission from Hoff J, Boland M. Neurosurgery. In: Principles of Surgery. 7th ed. New York: McGraw-Hill; 1999:1837.)

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Which imaging test is paramount in assessing for brain injury following a trauma?

Head computed tomography (CT)

What Glasgow coma score (GCS) is considered the "cutoff" as an indication for ICP monitoring?

How can one differentiate between CSF and mucus secretions in cases of suspected ethmoid plate disruptions?

CSF will contain glucose

What syndrome results in weakness of the upper extremities with relative sparing of the lower extremities?

Central cord syndrome

Which syndrome results in ipsilateral paralysis and contralateral loss of sensation?

Brown-Sequard or hemitransection of the spinal cord

Which syndrome is characterized by paralysis and sensory loss but preservation of deep sensation and proprioception?

Anterior cord syndrome

What is the most common CNS infection in patients with acquired immunodeficiency syndrome?

Toxoplasma gondii

What are considered the symptoms of a carotid stenosis?

Ipsilateral amaurosis fugax (temporary blindness often described as a window shade caused by ophthalmic artery emboli), ipsilateral transient ischemic attack, or stroke

Table 29-1Spinal Tumor Characteristics

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Table 29-1 Spinal Tumor Characteristics

Compartment

Tumor

Predilection

Treatment Options

Comments

Extradural

Vertebral hemangioma

Thoracic

Preoperative embolization + resection (+ XRT) for progressive symptoms

Honeycomb radiographic appearance

Giant cell tumor

Sacral

Resection (+ XRT)

Aggressive spread, often biopsy for diagnosis before treating

Plasmacytoma

Thoracic

(XRT + steroids + surgical stabilization)

Precursor to multiple myeloma

Osteoid osteoma

Lumbar

Resection of nidus (+ fusion)

Peak incidence in adolescence

Osteoblastoma

Lumbar

En bloc resection (+ XRT)

Similar to osteoid osteoma but >1.5 cm

Osteochondroma

Cervical

Resection (+ fusion) to treat symptoms

Often causes spinal deformity

(nonneoplastic)

Eosinophilic granuloma

Cervical

Spine stabilization

Classic vertebra plana in children

(nonneoplastic)

Aneurysmal bone cyst

Thoracic and lumbar

GTR (+ fusion)

Aggressively expansile, peak incidence in adolescence

(nonneoplastic)

Angiolipoma

Thoracic

Resection to treat symptoms

Onset of symptoms often during pregnancy

Metastasis

XRT + steroids

Extradural

Chordoma

Sacral, cervical

En bloc resection (+ XRT)

Most common primary bone malignancy of the spine

Ewing sarcoma

Sacral

Resection + XRT + chemotherapy

Usually metastatic from another site, HBA-71 Ag

Multiple myeloma

Chemotherapy + XRT (+ steroids + surgical stabilization)

Pathological fractures seen in 50% at presentation

Lymphoma

Chemotherapy

Hodgkin and non-Hodgkin

Chondrosarcoma

Thoracic

En bloc resection

Second-most common primary bone malignancy

Osteosarcoma

Chemotherapy + en bloc resection (+ XRT)

Bimodal age distribution, potentially curable

Paravertebral sarcomas

En bloc resection + XRT + chemotherapy

Often painless, presents with neurological deficits

Intradural-extramedullary

Schwannoma

Thoracic

GTR

Associated with dorsal root origin

Neurofibroma

Thoracic

Resection

Associated with ventral root origin

Meningioma

Thoracic

GTR (+ XRT for recurrence)

Extension common

Metastasis

XRT + steroids

Drop metastases from GBM, AA, ependymoma, and MB

Myxopapillary ependymoma

Conus

Resection + XRT

Dissemination common

Lymphoma

Chemotherapy

Lipoma

Lumbosacral

Resection

Congenital, can cause tethered cord

Paraganglioma

Conus

GTR

Can secrete hyperadrenergic state

Neuroganglioma

Rare nerve sheath tumor

Dermoid and epidermoid

GTR (+ steroids for chemical meningitis)

Commonly in children

Teratoma

Sacral

GTR

Can be in any compartment

Intramedullary

Ependymoma

Cervical

GTR

Strongly enhancing, well-circumscribed

Astrocytoma

Cervical

Biopsy ± resection + XRT

Infiltrative, common in children

Lipoma

Cervical and thoracic

Debulking

Hemangioblastoma

Thoracic and cervical

GTR

Cystic with mural nodule, associated with von Hippel-Lindau syndrome

Metastasis

Cervical and conus

XRT + steroids

Most commonly small-cell lung cancer

Ganglioglioma

Thoracic

GTR + XRT

Commonly in children

Oligodendroglioma

Thoracic

GTR + XRT

Spinal deformity, syrinx common

Neuroblastoma

Cervical

GTR

AA, anaplastic astrocytoma; GBM, glioblastoma multiforme; GTR, gross total resection; MB, medulloblastoma; XRT, radiation therapy.

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TEST TAKING TIPS

What components are present in the cranium?

What may cause an increase in the brain tissue component (not including neoplasms)?

What can be given to decrease swelling due to edema?

What can be given to decrease the brain tissue component if swelling is caused by inflammation or perineoplastic syndrome?

What can be done to decrease the blood volume component?

What can be done to decrease the CSF component?

What can be done to decrease volume due to a mass lesion?

What is the Monro-Kelly doctrine?

True or false: CSF production rate is affected by intracranial pressure (ICP)?

What is the site of CSF production?

What is the name of the process that maintains cerebral blood flow at a constant rate despite changes in systemic blood pressure?

Define cerebral perfusion pressure:

Why do older people tend to be more tolerant of mass lesions?

What is a raised ICP with no mass lesion termed?

What is increased ventricular volume without increased intracranial pressure called?

What is a failure of proper capillary formation termed?

What is the risk of hemorrhage associated with an AVM?

What percentage of AVM-associated hemorrhages is classified as severe?

FIGURE 29-1.

This process is caused by defects in the arterial media and is increased in patients with connective tissue disorders such as Ehlers-Danlos or Marfan syndromes:

What is the risk of hemorrhage with an aneurysm measuring less than 1 cm?

What is the risk of hemorrhage with an aneurysm measuring more than 1 cm?

If not treated, what is the risk of rebleed within 2 weeks from an aneurysm that has ruptured?

Which cerebrovascular moniker derives from the Japanese term for "puff of smoke?"

Which medication is prescribed to reduce swelling related to brain tumors?

Which class of tumors accounts for half of all primary brain tumors?

What is the term for grade IV astrocytomas?

What is the most common Schwannoma?

What brain tumor will tend to cause bitemporal hemianopsia?

What dopamine agonist is useful in 75% of prolactinomas?

What is the most common primary lesion for metastatic tumors of the brain?

What is the second most common primary lesion for metastatic tumors of the brain?

Chemotherapy is useful for brain metastatic tumors for which 2 primary lesions?

Up to how many lesions can surgery be indicated for metastatic disease in the brain?

What is the most common cause of subarachnoid hemorrhage?

What is the term for rotational acceleration and deceleration injuries that disrupt the white matter tracts of the brain?

FIGURE 29-2.

Which imaging test is paramount in assessing for brain injury following a trauma?

What Glasgow coma score (GCS) is considered the "cutoff" as an indication for ICP monitoring?

How can one differentiate between CSF and mucus secretions in cases of suspected ethmoid plate disruptions?

What syndrome results in weakness of the upper extremities with relative sparing of the lower extremities?

Which syndrome results in ipsilateral paralysis and contralateral loss of sensation?

Which syndrome is characterized by paralysis and sensory loss but preservation of deep sensation and proprioception?

What is the most common CNS infection in patients with acquired immunodeficiency syndrome?

What are considered the symptoms of a carotid stenosis?

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