Neurosurgery Review

for Medical Student

17 Febuary 2552
 Stroke
50

PE : GCS 13, no motor weakness,
stiff neck +ve
a) Pontine hemorrhage
b) Cellebellar hemorrhage
c) Subarchnoid hemorrhage
d) Basal ganglion hemorrhage
e) Intraventricular hemorrhage
C
 Stroke
Ischemic VS hemorrhagic
Ischemic syndrome
Hemorrhagic disease
Hypertensive hemorrhage
Amyloid angiopathy
SAH from ruptured aneurysm
Ruptured AVM
( bleeding tumor, coagulopathy,
parasite, vasculitis)
 Stroke
Ischemic VS hemorrhagic
Hemorrhagic stroke sign of IICP (
)
Ischemic stroke sudden neurodeficit
Hemiparesis
Apasia / apraxia
Amaurosis fugax
Onset
Clinical 100% need investigation
= CT
 Stroke

Ischemic stroke
MCA: Hemiparesis, contralateral hemisensory loss,
aphasia
ACA: Paresis and sensory loss of contralateral lower
extremity
PCA: Homonymous hemianopia with macular
sparing
Basilar: Cranial nerve signs diplopia, facial
weakness, vertigo, dysarthria
 Stroke
Hemorrhagic stroke
Hypertensive ICH
Ruptured cerebral aneurysm
Ruptured AVM
Amyloid angiopathy
Bleeding tumor
Coagulopathy
 Stroke
Hypertensive ICH
Hypertension > 90%
IICP signs and symptoms (headache,
vomiting, consciousness)
Common site:
Basal ganglion Hemiparesis, Aphasia
(dominant hemisphere)
Thalamus hemianesthesia
Cerebellar ataxia, cerebellar sign +ve
Pontine pinpoint pupil
 Stroke
Hypertensive ICH
Antihypertensive drugs
SBP > 200 IV antihypertensive
SBP > 180 or MAP > 130
IICP suspected monitor ICP keep CPP 60-80
mmHg
No IICP suspected modest BP to MAP 110 or
160/90
Surgery VS Medical treatment
Recommendation: cerebellar hemorrhage > 3
cm (class I)
AHA guideline 2007
 Stroke
Ruptured cerebral aneurysm
Worst headache of my life
With or without neurodeficit
Stiffneck / nuchal rigidity
CT: Subarachnoid hemorrhage
Common sequelae:
Rebleeding
Hydrocephalus
Vasospasm
 Stroke
Ruptured cerebral aneurysm
Key point of management
Refer to neurosurgeon ASAP (for clipping to
prevent rebleeding)
If clinical suspected but negative CT
LP xanthochromia
Investigation of choice: 4 vessels
angiography (alternative: CT angiography
(CTA), MRA)
 Stroke
Ruptured AVM
Young age**
Lobar hemorrhage
Non-hypertension
Investigation: angiography
Risk rebleeding 2-3%/y
Management:
Surgery excision
Embolization
Radiosurgery
 Stroke
Investigation in intracerebral
hemorrhage
Consider
Angiography
CT angiography
In
Young age (< 45)
Non hypertension
Uncommon site (Lobar)
 Stroke
Amyloid angiopathy
Old age
Non-hypertension
Lobar hemorrhage
No special investigation needed
 Trauma
50
10
.
2 GCS E1V2M5, pupils right
3 mm, left 5 mm SRTL
a) Epidural hemorrhage
b) Subdural hemorrhage
c) Subarachnoid hemorrhage
d) Intracerebral hemorrhage
e) Diffuse axonal injury

a
 Trauma
Initial management*
Epidural hematoma*
Subdural hematoma*
Traumatic intracerebral hematoma
Traumatic SAH
Skull fracture
Sequalae
 Trauma
Initial management
ABCDE
Dont miss!
Collar (primary survey = A)
ET tube in GCS 8 (primary survey = D)
Search for other bleeding site in hypotensive
patient
GCS (Must remember!)
 Trauma
short essay:
moderate HI in rural hospital
Item %
GCS 47 71.21
C-spine protection 14 21.21
O2 17 25.76
IV 47 71.21
Refer or CT brain 50 75.76
Suture/dressing 37 56.06
Dilantin 11 16.67
Foley or NG 20 30.30
 Trauma
Glassow Coma scale

Scor
Eye Verbal Motor
e
6

5

Withdraws 4

Decorticate 3

Decerebrate 2

ABCDEs, C spine
protection Resuscitation
Head
Injury GCS

GCS 13-15 GCS 9-12 GCS < 9

Mild HI Moderate HI Severe HI

Endotracheal tube
O2 mask c bag Hyperventilation **
IV fluid Mannitol/osmolar Rx
**

risk Mild HI
1. D/C
2. Admit observe Refer
3. CT
 Trauma
Risk factors for Intracranial lesion for
Mild HI
Clinical findings Risk factors
GCS < 15 1-2 > 60
*
Coagulopathy
Amnesia
(Warfarin,

Hemophilia,etc)

*

Sign
/
(skull Fx (Skull
Base/Valve)

*
 Trauma
Epidural Hematoma
(EDH)
Associated with skull
fracture
Classic: Middle meningeal
artery tear
Lens shape/biconvex
Lucid interval*
Rapidly fatal
Good prognosis if proper
management
Trauma

Subdural hematoma
(SDH)
Venous tear/ brain
laceration
High morbidity/mortality
due to underlying brain
injury
Crescent concaved
shape
Counter coup
Trauma
Chronic Subdural
hematoma (CSDH)
Elderly, alcohol abuse,
coagulopathy
Motor oil fluid, no clot
Minimal or no Hx of injury
Insidious onset
Minor symptoms
hemiplegia/seizure
 Trauma
Skull Fracture
Skull Fx risk of intracranial bleeding
5 times
Skull base fracture
CSF rhinorrhea, otorrhea
Battles sign, Raccoons eye (anterior skull
base)
Facial weakness (petrous part of temporal
bone)
 Trauma
Sequelae of head injury
Increased intracranial pressure (> 20
mmHg)
General: sedation, analgesia, elevate head,
avoid hypoxia
Ventricular drainage
Mannitol
Hyperventilation
2nd tier
Phenobarb coma
Decompressive craniectomy
 Trauma
Sequelae of head injury
Electrolyte imbalance hyponatremia
Seizure
Antiepileptic drug - early seizure
Prophylaxis 7 days
I/C: GCS10, intracranial lesion, penetrating
injury, depressed skull fracture
Carotid-cavernous fistula
Posttrauma 2-3 mo
Unilateral chemosis, proptosis
Bruit/thrill at the orbit
Ix: angiography
Management: balloon embolizaion
 Herniation syndrome
Central
Diencephalon tentorial
Chronic
Pupils: SRTL Fixed
Uncal**
Uncus and hippocampal
gyrus over tentorium
CN III compression
unilateral pupil ,
hemiparesis
Consciousness preserved
in early stages
Classic for EDH
 Herniation syndrome
Cingulate (subfalcine
H):
asymptomatic except
ACA kink, warning of
impending transtentorial
H.
Upward
posterior fossa mass +
ventriculostomy
Tonsillar
Posterior fossa mass + LP
 Tumor
Supratentorial Infratentorial
Gliomas Medulloblastoma (Ped)
Astrocytoma Cerebellar
Oligodendrogliomas astrocytoma
Ependymomas Brainstem gliomas
Meningiomas CP angle tumor
Vestibular schwannoma
Sellar and (acoustic neuromas)
suprasellar Meningiomas
Pituitary adenomas Meningiomas
craniopharyngiomas
 Tumor
Most common brain tumor
Metastasis
Most common primary brain tumor
Astrocytoma
Most common primary brain tumor in children
Medulloblastoma

Glioblastoma multiforme
Grade IV of astrocytoma
Poor prognosis. 2 yr survival 11 mo for total resection
 Tumor
DDx for patient with progressive
hemiparesis and IICP
Supratentorial tumor (Metas, gliomas,
meningioma, etc)
Brain abscess (ped. With rt to lt shunt eg TOF)
DDx for patient with bitemporal
hemianopia
=> sellar and suprasellar tumor
Pituitary adenoma
Craniopharyngioma
Meningioma
 Hydrocephalous
Mechanism Treatment
Obstruction at CSF Remove etiology
pathway:
Drainage
Obstructive
hydrocephalous Ventriculostomy
CSF pathway: tumor, (temporary)
blood, etc Shunting
Obstruction at VP shunt
arachnoid granulation VA shunt
Communicating Ventriculo-pleural
hydrocephalous shunt
Overproduction:
choroid plexus
papilloma