THM_Kranzler Hübner EP GmbH 16/09/30 The Greenberg Rapid Review THM_Kranzler Hübner EP GmbH 16/09/30 THM_Kranzler Hübner EP GmbH 16/09/30 The Greenberg Rapid Review A Companion to the 8th Edition Leonard I. Kranzler, MD, JD, FACS, FAANS Clinical Professor of Surgery (Neurosurgery) University of Chicago Chicago, Illinois Jonathan G. Hobbs, MD Resident Neurosurgeon University of Chicago Chicago, Illinois ERRNVPHGLFRVRUJ Thieme New York • Stuttgart • Delhi • Rio de Janeiro THM_Kranzler Hübner EP GmbH 16/09/30 Executive Editor: Timothy Y. Hiscock Managing Editor: Judith Tomat Director, Editorial Services: Mary Jo Casey Production Editor: Naamah Schwartz International Production Director: Andreas Schabert Vice President, Editorial and E-Product Development: Vera Spillner International Marketing Director: Fiona Henderson International Sales Director: Louisa Turrell Director of Sales, North America: Mike Roseman Senior Vice President and Chief Operating Officer: Sarah Vanderbilt President: Brian D. Scanlan Library of Congress Cataloging-in-Publication Data Names: Kranzler, Leonard I., author. | Hobbs, Jonathan G., author. Title: The Greenberg rapid review: a companion to the 8th edition / Leonard I. Kranzler, MD, JD, RACS, FAANS, Clinical Professor of Surgery (Neurosurgery), University of Chicago, Chicago, Illinois, Jonathan G. Hobbs, MD, Resident Neurosurgeon, University of Chicago, Chicago, Illinois. Description: New York : Thieme, [2017] | A companion to: Handbook of neurosurgery. 8th ed., c2017. | Includes bibliographical references and index. | Description based on print version record and CIP data provided by publisher; resource not viewed. Identifiers: LCCN 2016037898 (print) | LCCN 2016035166 (ebook) | ISBN 9781626232075 | ISBN 9781626232068 (pbk.) Subjects: LCSH: Nervous system–Surgery–Examinations, questions, etc. Classification: LCC RD593 (print) | LCC RD593 .G677 2017 Suppl. (ebook) | DDC 617.4/80076–dc23 LC record available at https://lccn.loc.gov/2016037898 © 2017 Thieme Medical Publishers, Inc. 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Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. THM_Kranzler Hübner EP GmbH 16/09/30 In appreciation for their example of scholarship, tradition, and love of family, this book is dedicated to the memory of: Mr. Morris Kranzler Mr. Louis Weinberg Mr. Max Goldstein Dr. K. Jeffery Kranzler Mr. Charles Kranzler Dr. Gershon Kranzler Rabbi Alex Weisfogel Mr. Nate Blum Mr. Henry Kranzler Mr. Harvey Goldstein Mrs. Luiza Anghelo Mr. Yerachmiel Kranzler Mrs. Ruth Yudkofsky Mr. Ben Teichner Dr. David Kranzler Mr. Alex Angheluta Mr. Milton Saltzman Mr. David Hurwitz Mr. Kurt Loebenberg Mr. Joseph Kranzler Mr. Walter Rosenbush Mr. Steve Rotter Mr. Tobey Friedman Mr. Python Anghelo Mr. Arthur Kranzler In appreciation of my parents, Lillian (obm) and George Kranzler (obm). And to my wife Uliana and children, Jenelle, Justin, and Jared. Leonard I. Kranzler Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Mrs. Eva Teichner Ada Rotter Rina Rosenbush Dina Weinberg Chana Kranzler Rose Hurwitz Ruth Kranzler Helen Goldstein Betty Blum Rosalie Goldstein Eveline Kranzler Miriam Saltzman THM_Kranzler Hübner EP GmbH 16/09/30 No accomplishment would be possible without the unwavering and selfless love of my family, allowing me to pursue my aspirations and dreams without limits. They are the ones who made this possible. My friends and mentors who provide guidance, support, and an often needed voice of reason; I am grateful for all that you do. It is for my family, friends, and the countless others who are yet to be named, that I strive to be a better physician and most importantly, a better person. Thank you all. Jonathan G. Hobbs Below is a quote from Walden, a book that has provided inspiration, fostered self-reflection and a deeper understanding of what my family and friends mean to me, and how I want to approach life. It is my hope that these words will speak to you too, even in some minute way, that may give you hope and reason in those dark times we all face during our journey to become the person we want to be. “I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived. I did not wish to live what was not life, living is so dear; nor did I wish to practice resignation, unless it was quite necessary. I wanted to live deep and suck out all the marrow of life, to live so sturdily and Spartan-like as to put to rout all that was not life, to cut a broad swath and shave close, to drive life into a corner, and reduce it to its lowest terms.” ― Henry David Thoreau, Walden: Or, Life in the Woods THM_Kranzler Hübner EP GmbH 16/09/30 Contents Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Special Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv Part 1: Anatomy and Physiology 1 Gross Anatomy, Cranial, and Spinal.......................................................................... 1 2 Vascular Anatomy ................................................................................................ 12 3 Neurophysiology and Regional Brain Syndromes ..................................................... 18 Part 2: General and Neurology 4 Neuroanesthesia................................................................................................... 28 5 Sodium Homeostasis and Osmolality ..................................................................... 31 6 General Neurocritical Care .................................................................................... 36 7 Sedatives, Paralytics, Analgesics............................................................................. 38 8 Endocrinology ...................................................................................................... 44 9 Hematology......................................................................................................... 48 10 Neurology for Neurosurgeons ............................................................................... 53 11 Neurovascular Disorders and Neurotoxicology ........................................................ 64 Part 3: Imaging and Diagnostics 12 Plain Radiology and Contrast Agents ..................................................................... 68 13 Imaging and Angiography..................................................................................... 73 14 Electrodiagnostics ................................................................................................ 78 Part 4: Developmental Anomalies 15 Primary Intracranial Anomalies .............................................................................. 81 16 Primary Spinal Anomalies...................................................................................... 88 17 Primary Craniospinal Anomalies............................................................................. 95 Part 5: Coma and Brain Death 18 Coma .................................................................................................................102 19 Brain Death and Organ Donation..........................................................................108 Part 6: Infection 20 Bacterial Infections of the Parenchyma and Meninges and Complex Infections.........111 21 Skull, Spine, and Post-Surgical Infections ...............................................................121 22 Other Nonbacterial Infections...............................................................................128 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) 23 Cerebrospinal Fluid..............................................................................................132 24 Hydrocephalus – General Aspects.........................................................................138 25 Treatment of Hydrocephalus ................................................................................146 Part 8: Seizures 26 Seizure Classification and Anti-Convulsant Pharmacology........................................152 27 Special Types of Seizures .....................................................................................160 ERRNVPHGLFRVRUJ THM_Kranzler Hübner EP GmbH 16/09/30 Part 9: Pain 28 Pain ...................................................................................................................166 Part 10: Peripheral Nerves 29 Peripheral Nerves ................................................................................................173 30 Entrapment Neuropathies ....................................................................................185 31 Non-Entrapment Peripheral Neuropathies..............................................................194 Part 11: Neurophthalmology and Neurotology 32 Neurophthalmology.............................................................................................204 33 Neurotology........................................................................................................217 Part 12: Primary Tumors of the Nervous and Related Systems: Tumors of Neuroepithelial Tissue 34 General Information, Classification and Tumor Markers ..........................................223 35 Syndromes Involving Tumors................................................................................230 36 Astrocytomas......................................................................................................234 37 Other Astrocytic Tumors......................................................................................239 38 Oligodendroglial Tumors and Tumors of the Ependyma, Choroid Plexus, and Other Neuroepithelial Tumors ........................................................................243 39 Neuronal and Mixed Neuronal-Glial Tumors...........................................................248 40 Pineal Region and Embryonal Tumors ...................................................................251 41 Tumors of Cranial, Spinal and Peripheral Nerves ....................................................256 42 Meningiomas ......................................................................................................266 43 Other Tumors Related to the Meninges.................................................................271 Part 13: Tumors Involving Non-Neural Origin: Metastases, Lymphomas, Chordomas 44 Lymphomas and Hematopoietic Neoplasms ..........................................................275 45 Pituitary Tumors – General Information and Classification ......................................278 46 Pituitary Adenomas – Evaluation and Nonsurgical Management..............................284 47 Pituitary Adenomas – Surgical Management, Outcome, and Recurrence Management .....................................................................................289 48 Cysts and Tumor-Like Lesions ...............................................................................291 49 Pseudotumor Cerebri and Empty Sella Syndrome...................................................294 50 Tumors and Tumor-Like Lesions of the Skull ..........................................................295 51 Tumors of the Spine and Spinal Cord....................................................................297 52 Cerebral Metastases ............................................................................................299 53 Spinal Epidural Metastases ...................................................................................302 Part 14: Head Trauma 54 General Information, Grading, Initial Management .................................................305 55 Concussion, High Altitude Cerebral Edema, Cerebrovascular Injuries........................308 56 Neuromonitoring.................................................................................................314 57 Skull Fractures ....................................................................................................320 58 Traumatic Hemorrhagic Conditions.......................................................................324 59 Gunshot Wounds and Non-Missile Penetrating Brain Injuries...................................332 60 Pediatric Head Injury ...........................................................................................334 61 Head Injury: Long-Term Management, Complications, Outcome .............................337 Part 15: Spine Trauma 62 General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries ......................................................340 63 Management of Spinal Cord Injury .......................................................................349 64 Occipitoatlantoaxial Injuries (Occiput to C2) ..........................................................354 65 Subaxial (C3 through C7) Injuries / Fractures.........................................................361 66 Thoracic, Lumbar and Sacral Spine Fractures .........................................................366 67 Penetrating Spine Injuries and Long Term Management / Complications .................373 ERRNVPHGLFRVRUJ THM_Kranzler Hübner EP GmbH 16/10/14 Part 16: Spine and Spinal Cord 68 Low Back Pain and Radiculopathy .........................................................................376 69 Lumbar and Thoracic Intervertebral Disk Herniation / Radiculopathy .......................383 70 Cervical Disc Herniation .......................................................................................393 71 Degenerative Cervical Disc Disease and Cervical Myelopathy ..................................397 72 Thoracic and Lumbar Degenerative Disc Disease....................................................400 73 Adult Spinal Deformity and Degenerative Scoliosis.................................................404 74 Special Conditions Affecting the Spine ..................................................................407 75 Other Non-Spine Conditions with Spine Implications ..............................................412 76 Special Conditions Affecting the Spinal Cord .........................................................415 Part 17: SAH and Aneurysms 77 Introduction and General Information, Grading, Medical Management, Special Conditions ...............................................................................................419 78 Critical Care of Aneurysm Patients........................................................................428 79 SAH from Cerebral Aneurysm Rupture ..................................................................432 80 Aneurysm Type by Location .................................................................................438 81 Special Aneurysms and Non-Aneurysmal SAH........................................................444 Part 18: Vascular Malformations 82 Vascular Malformations........................................................................................448 Part 19: Stroke and Occlusive Cerebrovascular Disease 83 General Information and Stroke Physiology ...........................................................454 84 Evaluation and Treatment for Stroke .....................................................................457 85 Special Conditions ...............................................................................................462 86 Cerebral Arterial Dissections.................................................................................468 Part 20: Intracerebral Hemorrhage 87 Intracerebral Hemorrhage ....................................................................................470 Part 21: Outcome Assessment 88 Outcome Assessment ..........................................................................................477 Part 22: Differential Diagnosis 89 Differential Diagnosis by Location or Radiographic Finding – Intracranial .................478 90 Differential Diagnosis by Location or Radiographic Finding – Spine .........................490 91 Differential Diagnosis (DDx) by Signs and Symptoms – Primarily Intracranial............493 92 Differential Diagnosis (DDx) by Signs and Symptoms – Primarily Spine and Other...........................................................................................................498 Part 23: Procedures, Interventions, Operations 93 Procedures, Interventions, Operations: General Information....................................509 94 Specific Craniotomies ..........................................................................................515 95 Spine, Cervical ....................................................................................................522 96 Spine, Thoracic and Lumbar .................................................................................527 97 Miscellaneous Surgical Procedures ........................................................................531 98 Functional Neurosurgery ......................................................................................534 99 Pain Procedures ..................................................................................................542 100 Seizure Surgery ...................................................................................................546 101 Radiation Therapy (XRT).......................................................................................550 102 Endovascular Neurosurgery ..................................................................................555 ERRNVPHGLFRVRUJ THM_Kranzler Hübner EP GmbH 16/09/30 Preface This offering is a study and review aid. It is to be used in conjunction with Handbook of Neurosurgery, Eighth Edition, by Mark S. Greenberg. It permits the user, after reading a page, section, or chapter in Greenberg, to test retention of the details of that portion. Every question is directly referenced to Greenberg’s text, where background information and context is readily available. An effort has been made to highlight the important facts in neurosurgical practice by posing questions to the reader that forces active involvement in the learning and review process. The purpose of this textbook is to make clinicians aware of what they should expect to know using a rapid review format. It will help identify for readers what they already know as well as what is not known and provide a method by which an individual can verify the fact that has been learned. The reader can also have confidence that what has been highlighted as valuable has been identified by peers and by an editor who has been involved in neurosurgical education as coordinator of the Chicago Review Course in Neurological Surgery since 1974. Many questions were contributed by enrollees in the Chicago Review Course in Neurological Surgery as well as by young neurosurgeons and neurologists. In a nutshell, individuals at all levels of neurosurgical and neurological sophistication have contributed to this book. It is expected that the reader will review the material multiple times until success in responding to the questions has been achieved. The question formats take advantage of the established ideas in learning theory: • complex subjects broken into small bits • fill-in-the-gap exercises in sentences and words • progressive withdrawal of cues forcing the user to recall more and more of the details • mnemonics or hints (some material has been arranged in “study charts” to aid mnemonic teaching techniques) • Humor • alternate arrangements of the material (the same facts presented in different formats) • repetition Moreover, this study guide is designed with answers appearing directly after the questions (we recommend that users cover the answers in the outer page margin) so that time is not wasted searching for correct answers at the back of the book. This format should further facilitate rapid review. Please note that literature references and the index are present in the parent volume, Handbook of Neurosurgery, Eighth Edition. ERRNVPHGLFRVRUJ THM_Kranzler xii Hübner EP GmbH 16/09/30 Preface Knowledge of this material demonstrated by correct responses to the questions can give confidence to the reader that much of the current scientific foundation of the specialty of neurosurgery has been mastered. This reassurance of a strong, up-to-date knowledge base should be helpful to the resident, the instructor, the neurosurgeon, and those who are planning to take written, oral, or recertification examinations. Note to the Reader Please call to our attention any mistakes that you identify. Please suggest any additional mnemonic devices that might help others in the field of neurosurgery. Be aware that medical knowledge is ever changing and that some items and opinions conveyed in these pages are controversial. Leonard I. Kranzler Jonathan G. Hobbs Contact the authors at KranzlerMD@gmail.com jonathanhobbs@gmail.com ERRNVPHGLFRVRUJ THM_Kranzler Hübner EP GmbH 16/09/30 Acknowledgments We acknowledge the cooperation and encouragement of Dr. Mark S. Greenberg. Our generation of neurosurgeons is fortunate that Dr. Greenberg has collated the literature of our field and presented it to us in such a concise, authoritative, well-balanced, and wise manner. We also thank our contributors and the team of Thieme who helped us so much. ERRNVPHGLFRVRUJ THM_Kranzler Hübner EP GmbH 16/09/30 Special Acknowledgment It has been a pleasure to work with and have the collective experience of our contributors. They have been insightful in their choice of questions, prompt and efficient, and fully cooperative. We thank each of you. For more details on the specific work of our contributors, please contact jonathanhobbs@gmail.com. Uchenna Ajoku, MD University of Port Harcourt Teaching Hospital Port Harcourt, Nigeria Ryan A. McDermott, MD University of Texas at San Antonio San Antonio, Texas Jason L. Choi, MD University of Chicago Chicago, Illinois Jose M. Morales, MD MSc University of Chicago Chicago, Illinois Bhargav D. Desai, BS University of Illinois-Chicago College of Medicine Chicago, Illinois Ramin A. Morshed, MD University of California, San Francisco San Francisco, California J. Palmer Greene, BA University of Chicago Pritzker School of Medicine Chicago, Illinois Dominic A. Harris, MD University of New Mexico Albuquerque, New Mexico Andrew W. Platt, MD, MBA University of Chicago Chicago, Illinois Sean P. Polster, MD University of Chicago Chicago, Illinois Sophia F. Shakur, MD University of Chicago Chicago, Illinois Jordan Lebovic, BA Harvard Medical School Boston, Massachusetts Yimo Lin, MD Oregon Health and Science University Portland, Oregon Jacob S. Young, BS University of Chicago Pritzker School of Medicine Chicago, Illinois Raisa C. Martinez Martinez, MD University of Chicago Chicago, Illinois ERRNVPHGLFRVRUJ LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 1 1 Gross Anatomy, Cranial, and Spinal Cortical Surface Anatomy 1. Characterize the lateral cortical surface. a. The pre-central sulcus is not______. b. The middle frontal gyrus connects with the ______gyrus via a thin _____. c. The central sulcus is separated from the sylvian fissure ___% of the time. d. The tissue separating them is called the _____ ______. e. The inferior and superior parietal lobules are separated by the ________ sulcus. f. The inferior parietal lobule is composed of i. the __________ _____ ii. and the_____ _____. g. The sylvian fissure i. terminates in the______, ii. which is the Brodmann area #___. h. The superior temporal gyrus i. terminates in the____, ii. which is the Brodmann area #___. 2. Complete the following regarding surface anatomy: a. The middle frontal gyrus often connects with the _____ _____. b. The central sulcus joins the sylvian fissure in only___%. c. A sub-central sulcus is present in___% of patients. d. The sylvian fissure terminates in the _______ _______. e. The superior temporal sulcus is capped by the______ _____. 1.1.1 complete precentral, isthmus 98% subcentral gyrus intraparietal supramarginal gyrus (SMG) angular gyrus SMG 40 AG 39 1.1.1 precentral gyrus 2 98 supramarginal gyrus angular gyrus ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 2 Part 1: Anatomy and Physiology 3. Matching. Match the following Brodmann cortical areas and their functional significance: 1 a. b. c. d. e. f. g. h. Functional significance: ① primary motor cortex; ② Broca’s area (motor speech); ③ Wernicke’s area in the dominant hemisphere; ④ primary auditory area; ⑤ frontal eye fields; ⑥ primary somatosensory area; ⑦ premotor area; ⑧ primary visual cortex Area: (a-h) below Area 3, 1, 2 Area 41, 42 Area 4 Area 6 Area 44 Area 17 Area 40, 39 Area 8 4. Complete the following regarding pars marginalis: a. Is the terminal part of the ____ sulcus. b. Is visible on axial view in___% of CTs and ___% of MRIs. c. Is the____ _______ of the middle paired grooves straddling the midline. d. Extends into the hemispheres. On axial CT it is located just posterior to the widest_____ ________. e. It curves______ in lower slices. f. It curves______ in higher slices. ⑥ ④ ① ⑦ ② ⑧ ③ ⑤ 1.1.3 cingulate 95%, 97% most prominent biparietal diameter posteriorly anteriorly Central Sulcus on Axial Imaging 5. Complete the following regarding central sulcus: a. Is visible in almost___%. b. Does it reach the midline? c. Terminates in the_______ ______. 1.1.2 1.2 95% no paracentral lobule Surface Anatomy of the Cranium 6. True or False. The pterion is a region where each of the following bones comes together: a. frontal b. sphenoid (greater wing) c. parietal d. temporal e. sphenoid (lesser wing) 1.3.1 true true true true false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Gross Anatomy, Cranial, and Spinal 7. Matching. Match the bones/sutures that form the listed craniometric points. Bone/suture: ① lambdoid suture; ② occipitomastoid suture; ③ parietomastoid suture; ④ frontal; ⑤ parietal; ⑥ temporal; ⑦ greater wing sphenoid Craniometric point: a. asterion b. pterion 8. True or False. The name of the junction of lambdoid, occipitomastoid, and parietomastoid sutures is a. pterion b. asterion c. d. e. f. lambda stephanion glabella opisthion 9. The asterion junction overlies the a. ____sinus and the b. ____sinus. 10. Describe the visible landmarks of Taylor-Haughton lines. Bone/suture: ① Frankfurt plane (AKA: baseline); ② posterior ear line; ③ condylar line a. perpendicular to the baseline through mastoid process b. perpendicular to the baseline through mandibular condyle c. inferior margin of orbit →upper margin of the external auditory meatus 11. The external landmark for the Sylvian fissure is a line from the lateral canthus to a spot three quarters of the way posterior along an arc running over the convexity in the midline from the ______ to the _____. 1.3.1 3 1 ①, ②, ③ ④, ⑤, ⑥, ⑦ 1.3.1 false true (Asterion is the junction of the lambdoid, occipitomastoid and parietomastoid suture.) false false false false 1.3.1 transverse sigmoid 1.3.2 ② ③ ① nasion; inion 1.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 4 1 Part 1: Anatomy and Physiology 12. True or False. In relation to external landmarks the angular gyrus is a. one finger’s breadth above the zygomatic arch. b. just above the pinna. c. a thumb’s breadth behind the frontal process of the zygomatic bone. d. at the junction of the lambdoid and sagittal suture. 13. True or False. The motor strip of the motor cortex lies a. at the level of the coronal suture. b. within 2 cm of the coronal suture. c. 3 to 4 cm posterior to the coronal suture. d. 4 to 5.4 cm posterior to the coronal suture. e. 2 cm posterior to the mid-position of the nasion-inion arc. f. 5 cm straight up from the external auditory meatus. 14. True or False. In the nonhydrocephalic adult the lateral ventricles lie a. 2 to 3 cm below the outer skull surface. b. 3 to 4 cm below the outer skull surface. c. 4 to 5 cm below the outer skull surface. d. 5 to 6 cm below the outer skull surface. 15. True or False. In the nonhydrocephalic adult the anterior horns extend a. 1 to 2 cm anterior to the foramen of Monro. b. 2.5 cm anterior to the foramen of Monro. c. 3 to 4 cm anterior to the foramen of Monro. 16. True or False. The fastigium is located at a. the midpoint of the Twining’s line. b. the floor of the fourth ventricle. c. the apex of the fourth ventricle within the cerebellum. d. 1 to 2 cm anterior to the coronal suture. 1.3.2 false true (The angular gyrus is just above the pinna and important as part of Wernicke’s area in the dominant hemisphere.) false false 1.3.2 false false false true true true 1.3.3 false false true false 1.3.3 false true false 1.3.3 false false true (The fastigium is the apex of the fourth ventricle in the cerebellum.) false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Gross Anatomy, Cranial, and Spinal 17. List the surface landmarks of the following cervical levels: a. C3-4_____ _____ b. C4-5_____ _____ c. C5-6_____ _____ d. C6-7_____ _____ Table 1.4 hyoid bone thyroid cartilage cricothyroid membrane cricoid cartilage 18. Matching. Match the following surface landmarks and cervical levels: a. b. c. d. e. f. Surface landmark: ① level of thyroid cartilage; ② cricoid cartilage; ③ angle of mandible; ④ cricothyroid membrane; ⑤ carotid tubercle; ⑥ 1 cm above thyroid cartilage (hyoid bone) Cervical level: (a-f) below C1-2 C3-4 C4-5 C5-6 C6 C6-7 5 1 1.3.3 ③ ⑥ ① ④ ⑤ ② Cranial Foramina and their Contents 19. Matching. Match the foramen with contents (choices may be used more than once). Contents: ① nothing; ② middle meningeal artery; ③ VII facial; ④ V2; ⑤ V3; ⑥ V1; ⑦ IX, X, XI Foramen: (a-h) below a. superior orbital fissure b. inferior orbital fissure c. foramen lacerum d. foramen rotundum e. foramen ovale f. foramen spinosum g. stylomastoid foramen h. jugular foramen 20. List the cranial nerves and the three branches of one found within the superior orbital fissure (SOF). a. o______ b. t______ c. n______ d. f______ e. l______ f. a______ 1.5.1 ⑥ ④ ① ④ ⑤ ② ③ ⑦ 1.5.1 CN III oculomotor IV trochlear nasociliary nerve frontal nerve ophthalmic division: all three branches lacrimal nerve VI abducens nerve ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 6 1 Part 1: Anatomy and Physiology 21. List the other contents of the superior orbital fissure (SOF). a. s_____ o______ v_____. b. r_____ m_____ a_____. c. which arises from the l____ artery. d. o ____ b____ of the m____ m____ a_____. e. s____ p____ of the ICA 1.5.1 superior ophthalmic vein recurrent meningeal artery lacrimal orbital branch of the middle meningeal artery sympathetic plexus of the ICA 22. Another name for the transverse crest is ______ ______. crista falciformis 1.5.2 23. Another name for the vertical crest is ______ ______. Bill’s bar 1.5.2 24. Draw and label the nerves in the right porus acusticus. 1.5.2 a. b. c. d. e. f. Bill’s bar Transverse crest crista falciformis CN VII SV—superior vestibular CN VIII IV—inferior vestibular Fig. 1.1 25. Label the diagram of the right internal auditory canal. 1.5.2 a. b. c. d. e. f. Transverse crest Acoustic portion of CN VIII CN VII in facial canal Superior vestibular nerve Inferior vestibular nerve Bill’s bar—vertical crest Fig. 1.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Gross Anatomy, Cranial, and Spinal 26. Matching. Match the nerves of the IAC with the areas that they serve. Nerves: ① facial n.; ② nervus intermedius; ③ acoustic portion of VIII n.; ④ superior branch of vestibular n.; ⑤ inferior branch of vestibular n. Areas served: (a-h) below a. facial muscles b. hair follicles c. taste buds d. hearing e. utricle f. superior semicircular canal g. lateral semicircular canal h. saccule 1.5.2 7 1 ① ② ② ③ ④ ④ ④ ⑤ Internal Capsule 27. Most internal capsule lesions are caused by ______ or ______. 28. Name the vascular supply for the following components of the internal capsule: a. anterior limb b. posterior limb c. ventral posterior limb d. genu e. optic radiations 29. Name four thalamic peduncles and where their radiations go. a. a____, f____ l____ b. s____, p____ g____ c. p____, o____ & p____ a____ d. i____, a____ a____ thrombosis or hemorrhage 1.6.1 1.6.2 lateral striate branches of MCA lateral striate branches of MCA anterior choroidal direct branches of ICA anterior choroidal 1.6.2 anterior, frontal lobe superior, postcentral gyrus posterior, occipital & parietal areas inferior, auditory area ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 8 1 Part 1: Anatomy and Physiology 30. Draw the internal capsule and label which blood vessel serves which area. Hint: MIMA 1.6.2 Fig. 1.3 31. Matching. Match the area in the internal capsule with its function. 1.6.2 Fig. 1.4 Function: (a-d) below a. b. c. d. Movement of face Movement of foot Vision Hearing C D F G genu posterior limb lateral geniculate medial geniculate ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Gross Anatomy, Cranial, and Spinal Occipitoatlantoaxial-Complex Anatomy 32. Matching. Match the ligaments of the occipito-atlantoaxial complex with the statements below. Ligaments: ① apical; ② alar; ③ cruciate; ④ ascending portion; ⑤ descending portion; ⑥ transverse portion; ⑦ posterior longitudinal; ⑧ tectorial; ⑨ anterior longitudinal; ⑩ anterior atlanto-occipital Statements: (a-k) below a. Attaches the odontoid to the foramen magnum. b. Attaches the odontoid to the occipital condyle. c. Attaches the odontoid to the lateral mass of C1. d. Attaches C1 to the clivus and to C2. e. Attaches odontoid to clivus. f. Attaches C1 to C2. g. Traps the odontoid against the atlas. h. Extends cephalad to become the tectorial. i. Is the cephalad extension of the PLL. j. Extends cephalad to become the anterior atlanto-occipital. k. The cephalad extension of the anterior longitudinal ligament. 33. The most important spinal ligaments in maintaining atlanto-occipital stability are the a. _____ membrane and the b. _____ ligaments. 1.8 9 1 ① ② ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩ 1.8 tectorial alar Spinal Cord Anatomy 34. The dentate ligament a. separates _____ b. from _____ roots in the spinal nerves. 35. Which cranial nerve lies dorsal to the dentate ligament? 36. How is the lateral spinothalamic tract (LST) somatotopically organized? a. Cervical is _____. b. Sacral is _____. 37. Which descending motor tract facilitates a. extensor tone? b. flexor tone? 1.9.1 dorsal ventral CN XI spinal accessory 1.9.1 Fig. 1.13 medial lateral Table 1.7 vestibulospinal tract rubrospinal tract ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 10 1 Part 1: Anatomy and Physiology 38. The very large ascending tract closest to the dentate ligament is the _____ _____ _____. 39. Matching. Match sensory function and anatomy. Sensory function: ① pain and temperature: body; ② fine touch, deep pressure and proprioception: body; ③ light (crude) touch: body Anatomy: (a-i) below a. Receptors i. Free nerve ending ii. Meissner’s and Pacinian corpuscles b. First order neurons i. Small ii. Heavily myelinated iii. Finely myelinated iv. Large c. Soma in dorsal root ganglion d. Enter cord at i. zone of Lissauer ii. ipsilateral posterior columns e. Synapse in i. Rexed layer II ii. Rexed layer III and IV iii. Rexed layer VI and VII f. Second order neurons i. cross obliquely in anterior white commissure ii. form the internal arcuate fibers g. and enter the i. lateral spino-thalamic tract. ii. medial lemniscus. iii. anterior spinothalamic tract. h. Second order neurons synapse on the ventral posterior lateral nucleus of the thalamus. i. Third order neurons pass through IC to postcentral gyrus. 40. List the body area with the appropriate root. a. Nipple, root: ______ b. Umiblicus, root: ______ c. Inguinal crease, root: ______ d. Anterior thigh, root: ______ e. Posterior thigh, root: ______ f. Lateral calf, root: ______ g. Medial calf, root: ______ h. Posterior calf, root: ______ i. Big toe, root: ______ j. Little toe, root: ______ lateral spinothalamic tract (LST) (for pain and temperature from the opposite side of the body) Table 1.9 1.9.2 ① ②-③ ① ②-③ ① ② ①-②-③ ① ②-③ ① ② ③ ①-③ ② ① ② ③ ①-②-③ ①-②-③ Fig. 1.14 T4 T10 T12 L2-L3 S1 L5 L4 S1 L5 S1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Gross Anatomy, Cranial, and Spinal k. l. m. n. o. p. q. Sole of foot, root: ______ Lateral shoulder, root: ______ Lateral forearm, root: ______ Thumb, root: ______ Middle finger, root: ______ Little finger, root: ______ Medial forearm, root: ______ S1 C5 C6 C6 C7 C8 T1 41. Complete the following regarding upper extremity vs. trunk dermatomes. Trunk sensory level is reported at T3 on a trauma patient. a. This is a little _____ the clavicle. b. You must check the _____ dermatomes. c. Dermatomes _____ to _____ are not represented on the trunk. 11 1 Fig. 1.14 below arm C5 to T2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 2 2 Vascular Anatomy Cerebral Vascular Territories 1. Cerebral vascular territories: a. Anterior cerebral artery: frontal lobe and _________. b. Posterior cerebral artery: occipital lobe and _________. c. Anterior choroidal artery: internal capsule, medial globus pallidus, and _________ _________. d. _________ _________ artery supplies the rest. Fig. 2.1 caudate thalamus optic tract Middle cerebral Cerebral Arterial Anatomy 2. Circle of Willis: a. Intact in _________%. b. Hypoplasia of at least one of the posterior communicating arteries occurs in ____ - ____%. c. Absent or hypoplastic A1 occurs in _________%. 3. Segments of the ICA: a. Name the 7 segments of the ICA. (Hint: can Peter laugh can Charlie only clap) i. c_________ ii. p_________ iii. l_________ iv. c_________ v. c_________ vi. o_________ vii. c_________ 2.2.2 18% 22-32% 25% 2.2.3 cervical petrous lacerum cavernous clinoid ophthalmic communicating ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Vascular Anatomy b. Now also name the main branches of each segment. i. C1 c_________, no _________ ii. C2 p_________ iii. C3 l_________ iv. C4 c_________ m_________ t_________ a_________ m_________ a_________ v. C5 c_________ vi. C6 o_________ o________ a________ s________ h_________ a________ p________ c_________ a________ a________ c_________ a________ vii. C7 c_________ a________ divides into A_________ M_________ 4. Name the branches of the meningohypophyseal trunk: (Hint: dit) a. d_________ _________ b. i_________ _________ c. t_________ _________ 13 2.2.4 cervical, branches petrous lacerum cavernous meningohypophyseal trunk anterior meningeal artery 2 clinoidal ophthalmic ophthalmic artery superior hypophyseal artery posterior communicating artery anterior choroidal artery communicating artery ACA MCA 2.2.4 dorsal meningeal inferior hypophyseal tentorial artery (artery of Bernasconi and Cassinari) 5. Complete the following: a. Occlusion of the i_________ h_________ artery results in _________ necrosis. b. This artery supplies the _________. c. It is a branch of the _________ artery. d. Occlusion usually occurs in _________ patients. 6. Complete the following about the ophthalmic artery: a. It arises from the _________ segment of the ICA. b. _________% distal to cavernous segment. c. _________% within cavernous segment. d. Shape on lateral angiogram is _________. 2.2.4 inferior hypophyseal; Sheehan’s posterior lobe of pituitary meningohypophyseal post-partum 2.2.4 6th 89% 8% bayonet-like kink ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 14 2 Part 1: Anatomy and Physiology 7. Complete the following about the anterior choroidal artery: a. Name the 7 structures that it supplies. (Hint: gogoupl) i. g_________ p_________ ii. o_________ t_________ iii. g_________ of i_________ c_________ iv. o_________ r_________ v. u_________ vi. p_________ l_________ of i_________ c_________ vii. l_________ g_________ b_________ b. Occlusion may produce (Hint: 3Hs) _________, _________, and _________. 8. Posterior communicating artery: a. _________ segment enters supracornual recess of the _________ _________ to supply _________ _________. b. Origin is proximal to _________ _________ artery. c. Larger than _________ _________ artery. d. Anterior choroidal artery has hump, or _________ _________, where it passes through _________ _________ to enter the _________. e. Travels between cranial nerves _________ and _________. 9. Carotid siphon: a. Begins at the posterior bend of the _________ ICA and ends at the ICA _________. b. It includes 3 segments: ca_________, op_________, and co_________. 10. External carotid artery: a. It lies _________ and _________ to the ICA. b. Name its branches from proximal to distal. (Hint: salfopsmax) i. s_________ _________ ii. a_________ _________ iii. l_________ iv. f_________ v. o_________ vi. p_________ _________ vii. s_________ _________ viii. i_________m_________ 2.2.4 globus pallidus optic tract genu; internal capsule optic radiations uncus posterior limb; internal capsule lateral geniculate body hemiplegia, hemihypesthesia; homonymous hemianopsia 2.2.4 Plexal; temporal horn; choroid plexus anterior choroidal anterior choroidal plexal point; choroidal fissure; ventricle II, III 2.2.4 cavernous; bifurcation cavernous, ophthalmic; communicating 2.2.4 anterior; lateral superior thyroid ascending pharyngeal lingual facial occipital posterior auricular superficial temporal internal maxillary ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Vascular Anatomy 11. Recurrent artery of Heubner: a. Typically arises in area of _________ junction. b. Supplies h_________ of c_________, p_________, and a_________ i_________ c_________. 12. Posterior circulation: a. _________% of patients have a _________ circulation b. where PCA is supplied via _________ instead of the _________ system. 13. Vertebral artery: a. The first segment enters the _________ foramen transversarium. b. The second ascends _________ within the foramina transversaria. c. The second turns _________ as it exits the axis. d. The third curves _________ and _________. e. The fourth pierces the _________. f. Right and left vertebral arteries join at the level of the l_________ p_________ to form the _________ artery. g. Name its 6 branches. (Hint: A postman puts postcards away) i. a_________ m_________ ii. p_________ m_________ iii. m_________ iv. p_________ s_________ v. p_________ vi. a_________ s_________ 14. PICA: a. It arises _________ mm distal to the point where the vertebral artery becomes intradural. b. Has an extradural origin in ____ - ____%. c. Name the 5 segments. i. a_________ m_________ ii. l_________ m_________ iii. t_________, contains _________ loop iv. t_________, contains _________ loop v. c_________ s_________ d. Name its 3 branches. i. c_________ ii. t_________ iii. i_________ v_________ 15 2.2.4 A1/2 head; caudate; putamen; anterior internal capsule 2 2.2.4 15-35%; fetal p-comm; vertebrobasilar 2.2.4 sixth vertically laterally posteriorly; medially dura lower pons; basilar anterior meningeal posterior meningeal medullary posterior spinal PICA anterior spinal 2.2.4 10 mm 5-8% anterior medullary lateral medullary tonsillomedullary; caudal telovelotonsillary; cranial cortical segments choroidal tonsillohemispheric inferior vermian ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 16 Part 1: Anatomy and Physiology e. The choroidal point on angiography is where the _________ artery enters the _________ _________ to supply the _________ _________. f. The copular point on angiography is where the _________ _________ artery inflects _________. 2 15. Posterior cerebral artery: a. Name the 3 segments. i. P1 p_________ ii. P2 a_________ iii. P3 q_________ b. The medial posterior choroidal artery arises from the _________ or _________ segment. c. The lateral posterior choroidal artery arises from the _________ segment. d. Artery of Percheron is a _________ anatomic variant where a _________ trunk arises from _________ PCA to supply _________ paramedian thalami and rostral midbrain. 16. a. b. c. Persistent fetal anastomoses: There are _________ types. They result from a failure to _________. They include t_________, o_________, h_________, and p_________. d. The most common type is _________. e. The first type to involute is _________. choroidal; 4th ventricle; choroid plexus inferior vermian; inferiorly 2.2.4 peduncular ambient quadrigeminal P1, P2 P2 rare; solitary; one; bilateral 2.2.4 4 involute trigeminal, otic, hypoglossal, proatlantal trigeminal otic Cerebral Venous Anatomy 17. Cerebral venous anatomy: a. Dominance: i. The _________ internal jugular vein is usually dominant. ii. The _________ transverse sinus is usually dominant. iii. The _________ vertebral artery is usually dominant. iv. The _________ vein of Labbé is usually dominant. b. The main contributors to the vein of Galen are p_________ c_________ vein, b_________ vein of R_________, and i_________ c_________ vein. c. The joining of the septal vein and thalamostriate vein with the internal cerebral vein forms an angiographic landmark called the v_________ a_________ at the foramen of _________. 2.3.1 right right left left precentral cerebellar; basal vein of Rosenthal; internal cerebral venous angle; Monro ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Vascular Anatomy 18. Cavernous sinus anatomy: a. The cavernous sinus is a _________ of _________. b. Draw the right and left cavernous sinus coronal view. On your drawing label the following: 1. Oculomotor (III); 2. Trochlear (IV); 3. Parkinson triangle; 4. Ophthalmic (V1); 5. Maxillary (V2); 6. Abducent (VI); 7. Carotid. c. Name 6 major contents of the cavernous sinus. d. Cranial nerve _________ is the only nerve of the cavernous sinus that doesn’t exit skull through _________ _________ _________; it exits through _________ _________. e. Cranial nerve _________ is the only nerve not attached to _________ dural wall. f. Parkinson triangle is bordered superiorly by _________ and _________ and inferiorly by _________ and _________. 17 2.3.1 plexus; veins 2 Fig. 2.1 CN III, CN IV, CN V1, CN V2, CN VI, ICA V2; superior orbital fissure; foramen rotundum VI; lateral CN III and IV; CN V1 and V2 Spinal Cord Vasculature 19. Spinal cord vasculature: a. Supply of the cervical spinal cord comes from v_________ artery, d_________ c_________ artery, and c_________ t_________. b. Artery of _________ supplies spinal cord from T8 to conus. c. Artery of _________ is located on the left in _________% and arises between T9-L2 in _________%. d. _________ region is considered a _________ zone and is thus more _________ to vascular insults. 2.4 vertebral deep cervical; costocervical trunk Adamkiewicz Adamkiewicz; 80%; 85% Midthoracic; watershed; susceptible ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 3 Neurophysiology and Regional Brain Syndromes 3 Neurophysiology 1. Answer the following concerning the blood-brain barrier (BBB): a. What chemical opens the BBB? b. What chemical closes the BBB? c. Which sites have no BBB? (Hint: pppcta) 3.1.1 2. Complete the following statements about cerebral edema: a. Cytotoxic i. occurs with h________ i________ ii. occurs with h________ iii. shape is c________ iv. occurs with C________ v. BBB is c________ b. Vasogenic i. shape is ________ 3.1.1 Mannitol Steroids Pituitary, pineal, preoptic recess, choroid plexus, tuber cinereum, area postrema d. What pathology injures BBB? (Hint: histt) Hepatic encephalopathy, infections, stroke, trauma, tumor ii. iii. iv. v. occurs with t________ occurs with m________ treat with s________ with contrast it ________ and ________ vi. BBB is o________ 3. Matching. Match the type of edema with the characteristics. Type of edema: ① cytotoxic; ② vasogenic Hint: cytotoxic—early letters of alphabet vasogenic—later letters of alphabet Characteristics: (a-l) below a. BB disrupted b. BBB closed c. Head injury head injury hematoma circular CVA closed V-shaped (like fingers of white matter edema) tumors metastasis steroids enhances on CT and MR open 3.1.1 ② ① ① ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophysiology and Regional Brain Syndromes d. e. f. g. h. i. j. k. l. Tumor Enhances Does not enhance Not appropriate to use steroids Appropriate to use steroids Circular shape on MR V-shaped finger like extensions on MR Occurs with hematoma Occurs with CVA 4. a. b. c. d. True or False. Cytotoxic edema has: a disrupted BBB expansion of the extracellular space enhancement when contrast injected no protein extravasation ② ② ① ① ② ① ② ① ① 3.1.1 3.1.1 6. Fill in the blanks to complete the details of the Babinski reflex. (Hint: pcrstlpt) a. lateral ________ stimulation b. originates as a ________ ________ c. and stimulates the ________ d. in the ________ dermatome e. that travel via the ________ ________ f. to the spinal cord segments number ________ (________ limb) g. The efferent limb travels via the ________ nerve h. to the ________ ________ 3.1.2 Summarize the Babinski sign. receptor ________ afferent limb ________ cord ________ efferent limb ________ 3 false false false true 5. Study Sheet. a. Cytotoxic: i. Closed BBB ii. Head injury iii. Hematoma iv. Circular shape v. CVA vi. Cells swell then shrink b. Vasogenic: i. Disrupted BBB ii. Tumors iii. Metastasis iv. Steroids v. Protein extravasates vi. Enhances on CT and MRI vii. Wide extracellular space viii. Stable cells 7. a. b. c. d. 19 plantar cutaneous reflex receptors S1 tibial nerve L4-S2; afferent peroneal toe extensors 3.1.2 S1 dermatome tibial nerve L4-S2 peroneal nerve ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 20 3 Part 1: Anatomy and Physiology 8. Fill in the blanks to complete the details of eliciting the plantar reflex. a. Stimulate the ________ ________ surface b. and the ________ ________ c. in a ________ movement d. that lasts ____ - ___ seconds. e. Response consists of ________ of the ________ ________. f. ________ of the small toes is g. ________ clinically important. 9. True or False. The Chaddock maneuver is described as a. scratching the lateral foot b. pinching the Achilles tendon c. sliding knuckles down shin d. momentarily squeezing lower gastrocnemius 10. Complete the following concerning Hoffman sign: a. H (from Hoffman) is the ________ letter of the alphabet. b. If unilaterally present, Hoffman sign indicates a lesion above ________. 11. Complete the following concerning bladder physiology: a. The primary coordinating center for bladder function is in the i. n________ l________ c________ ii. of the p________. b. This center coordinates i. b________ c________ (d________) with ii. s________ r________ (e________ s________). 12. Voluntary cortical control a. inhibits the p________ c________. b. It originates in the i. a________ f________ l________ ii. and g________ of the c________ c________ and c. travels via the p________ t________ d. to inhibit i. c________ of the ii. d________ and contraction iii. of the e________ s________. 3.1.2 lateral plantar transverse arch single 5 to 6 extension; great toe Fanning not 3.1.2 true false false false 3.1.2 eighth C8 3.1.3 nucleus locus coeruleus pons bladder contraction (detrusor) sphincter relaxation (external sphincter) 3.1.3 pontine center—nucleus locus coeruleus anteromedial frontal lobes genu of the corpus callosum pyramidal tract contraction detrusor external sphincter ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophysiology and Regional Brain Syndromes 13. Immaturity, infarct, or cortical lesions cause a. inability to s________ b. the m________ r________ c. and result in i________. suppress micturition reflex incontinence 14. The efferents to the bladder a. travel in the d________ portion b. of the l________ c________. dorsal lateral columns 15. a. b. c. Parasympathetic control detrusor ________ internal sphincter ________ travels via the p________ s________ nerves 16. a. b. c. Somatic nerve external sphincter ________ maintains c________ travels via p________ nerve 3.1.3 3.1.3 3.1.3 3 contracts relaxes pelvic splanchnic 3.1.3 contracts continence pudendal 17. Sympathetic nerve a. provides bladder neck ________ and b. travels via the i________ h________ plexus. 18. True or False. The detrusor muscle of the bladder contracts and the internal sphincter relaxes under a. PNS stimulation b. somatic nerve stimulation c. sympathetic nervous system stimulation d. all of the above 19. True or False. The following can cause detrusor hyperreflexia: a. stroke b. spinal cord lesion (myelopathy) c. chronic bladder catheterization d. e. f. g. h. 21 multiple sclerosis Parkinson disease hydrocephalus dementia brain tumor 20. True or False. Interruption of the efferents results in a. atonic bladder b. overflow incontinence c. uncontrollable voiding d. reflex bladder emptying e. voiding triggered by critical volume 3.1.3 closure inferior hypogastric 3.1.3 true (parasympathetic nervous system stimulation) false false false 3.1.3 true true false (Detrusor hyperreflexia can result from interruption of efferents anywhere from cortex to sacral cord.) true true true true true 3.1.3 false—root lesion false—root lesion true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 22 Part 1: Anatomy and Physiology f. g. h. i. 3 produced by myelopathy produced by head injury produced by certain drugs produced by diabetes mellitus true true false—detrusor areflexia false—automatic neuropathy 21. Loss of centrally mediated inhibition pontine voiding reflex of the p________ v________ r________ is mediated by supraspinal lesions. 3.1.3 22. The s________ v________ c________ is located in the c________ m________, and results from lesions above the ________ spinal cord level, which correspond to ________ vertebral bodies. sacral voiding center; conus medullaris; S1; T12/L1 3.1.3 23. After acute suprasacral spinal cord injuries, there may be s________ s________, and as a result d________ a________. spinal shock; detrusor areflexia 3.1.3 24. When the spinal shock subsides, most develop ________ ________. detrusor hyperreflexia 3.1.3 25. Match the injury to the etiology. Injury: ① suprasacral; ② infrasacral (below the S2 spinal cord level). Etiologies: (a-d) below a. cauda equina b. conus medullaris injury c. transverse myelitis d. peripheral nerve injuries 3.1.3 ② ①, ② ① ② 26. Interruption of the p________ r________ a________ may produce d________ a________. peripheral reflex arc; detrusor areflexia 3.1.3 27. Spinal stenosis urologic symptoms vary (detrusor hyperactivity or detrusor underactivity) and depend on the spinal level involved and the type of involvement depending on whether there is compression of the i________ r________ t________ or m_______ involving the p________ f________. inhibitory reticulospinal tracts; myelopathy; posterior funiculus 3.1.3 28. Cauda equina syndrome usually produces u________ r________, although o________ i________ may occur. urinary retention; overflow incontinence 3.1.3 29. P________ n________ usually produce impaired detrusor activity. peripheral neuropathies 3.1.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophysiology and Regional Brain Syndromes 30. N________ d________ patients have an areflexic bladder neck. 31. True or False. Patients with multiple sclerosis develop voiding symptoms from demyelination primarily involving the a. posterior and lateral columns of lumbar spinal cord. b. lateral column of cervical spine. c. posterior column of lumbar spine. d. lateral column of lumbar spine. e. posterior and lateral columns of cervical spinal cord. neurospinal dysraphism 23 3.1.3 3.1.3 false 3 false false false true (posterior and lateral columns of cervical spinal cord) 32. True or False. Causes of urinary retention are a. urethral stricture b. prostatic enlargement c. detrusor areflexia d. herpes zoster true true true true 33. Evaluation of bladder function usually combines c________ or v________ with s________ m________. cystometrogram; videourodynamics; sphincter myelography 3.1.3 34. Synthetic anticholinergics block p________s ________ (m________ a________) without blocking skeletal neuromuscular or autonomic ganglia (n________ j________). postganglionic synapses (muscarinic action); nicotinic junctions 3.1.3 35. The most widely prescribed anticholinergic for detrusor hyperreflexia is O________, while T________ is considered less effective. Oxybutynin; Tolterodine 3.1.3 36. B________ is indicated for post-op non-obstructive urinary retention and for neurogenic atony due to spinal cord injury or dysfunction. Bethanecol 3.1.3 37. Following acute cauda equina decompression, patients may start T________ to relieve urinary retention symptoms. Tamsulosin 3.1.3 3.1.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 24 3 Part 1: Anatomy and Physiology Regional Brain Syndromes 38. Matching. Match region with deficit. Region: ① pre-frontal lobes; ② frontal lobe; ③ parietal lobe—dominant; ④ parietal— non dominant; ⑤ occipital lobe; ⑥ cerebellum; ⑦ brain stem; ⑧ pineal; ⑨ olfactory groove Deficit: (a-l) below a. apathy abulia b. disorganized thoughts c. contralateral neglect d. language disorders e. anosognosia f. dressing apraxia g. homonymous hemianopsia h. truncal ataxia i. ipsilateral ataxia j. paralysis of upward gaze k. poor planning l. unilateral anosmia 39. Frontal eye fields for contra lateral gaze are a. located in the ________ frontal lobe. b. in Brodmann area ________. c. With a destructive lesion there, the patient’s eyes look ________ the lesion. d. With an irritative lesion there, the patient’s eyes look ________ ________ the lesion. e. Usually the lesions are ________. 40. True or False. Gerstmann syndrome includes a. agraphia without alexia b. left-right confusion c. digit agnosia d. tactile agnosia e. acalculia 3.2.1 ② ① ③ or ④ ③ ④ ④ ⑤ ⑥ ⑥ ⑧ ① ⑨ 3.2.1 posterior 8 toward (Hint: destructive=toward) away from (Hint: irritative=away) destructive 3.2.1 true true true false true 41. True or False. Gerstmann syndrome patients can read. true 3.2.1 42. True or False. Gerstmann syndrome patients can write. false 3.2.1 43. True or False. Cortical sensory syndrome includes: a. loss of position sense b. inability to localize tactile stimuli c. astereognosis d. loss of pain and temperature sense 3.2.2 true true true false (Pain and temperature as well as vibration sense are preserved.) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophysiology and Regional Brain Syndromes 44. a. b. c. d. True or False. Broca aphasia includes: dysarthria lesion is in area 44 “apraxia” of motor sequencing similar to conduction aphasia 45. True or False. Wernicke’s aphasia includes: a. fluent aphasia b. lesion is in Brodmann areas 41 and 42 c. speech devoid of meaning d. normal intonation 46. a. b. c. d. e. f. g. h. i. j. k. l. Alexia without agraphia means that the patient can ________ but cannot ________. Surprisingly, such patients can usually do what with numbers? Lesion is located in the ________ lobe. On which side? Serves to disconnect ________ ________ and ________ ________ also known as ________ ________ ________. This is contrasted with what syndrome? Where patient can ________ but can’t ________ also known as ________ ________ ________. 47. Matching. Match the numbered syndromes with the lettered phrases. Syndrome: ① Gerstmann; ② pure word blindness Phase: (a-d) below a. alexia without agraphia b. agraphia without alexia c. where patient can’t read d. where patient can’t write 48. True or False. Regarding FosterKennedy syndrome: a. usually from olfactory groove or medial third sphenoid wing tumor b. contralateral anosmia 25 3.2.2 true true true false (Broca is a motor aphasia—faltering dysarthric speech. Conduction aphasia is fluent speech with paraphasias.) 3.2.2 3 true false (The lesion is in Brodmann 39 and 40.) true true 3.2.2 write read read and name them parietooccipital dominant left angular gyrus occipital lobe pure word blindness Gerstmann’s read write agraphia without alexia 3.2.2 ② ① ② ① 3.2.3 true false (Ipsilateral not contralateral anosmia is part of the classic triad.) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 26 Part 1: Anatomy and Physiology c. ipsilateral central scotoma d. contralateral papilledema e. contralateral optic atrophy true true false (ipsilateral optic atrophy) true f. usually from meningioma 3 49. True or False. Regarding Weber syndrome: a. Weber syndrome includes CN III palsy with contralateral hemiparesis. b. Weber syndrome includes CN VII palsy with contralateral hemiparesis. c. Weber syndrome includes CN III palsy with ipsilateral hemiparesis. d. Weber syndrome includes CN VI and VII palsy with contralateral hemiparesis. e. Weber syndrome includes i. CN III palsy ii. contralateral hemiparesis iii. arm hyperkinesis iv. ataxia v. intention tremor 50. True or False. Benedict’s syndrome is due to disruption of a. cerebral peduncle b. issuing fibers of CN III c. red nucleus 51. True or False. Millard-Gubler syndrome is due to disruption of a. nucleus of VII b. nucleus of VI c. corticospinal tract 52. True or False. Regarding Parinaud syndrome: a. Parinaud’s syndrome includes downgaze palsy. b. Parinaud’s syndrome includes lid retraction. c. Parinaud’s syndrome includes nystagmus retractorius. d. When Parinaud’s syndrome is combined with downgaze palsy it is known as the syndrome of the ________ ________. 3.2.4 true false false false true true false false false 3.2.4 true true true 3.2.4 true true true 3.2.5 false true false Sylvian aqueduct ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophysiology and Regional Brain Syndromes 27 Jugular Foramen Syndromes 53. True or False. Regarding jugular foramen syndromes: a. transverse sinus b. CNIX, X, andXI c. CN X, XI, and XII d. sigmoid sinus e. petrosal sinus f. branches from the ascending pharyngeal artery g. branches from the occipital artery 54. Matching. Match the following numbered syndromes with the lettered lesions. Also indicate the nerves involved and the results of the lesion. Syndrome: ① Vernet’s; ② Collet-Sicard; ③ Villaret’s Lesion: (a-c) below a. Which jugular foramen syndrome is most likely due to an intracranial lesion? b. extracranial lesion? c. retropharyngeal lesion? 55. True or False. A jugular foramen syndrome that spares CN IX is a. Vernet’s b. Collet-Sicard c. Villaret’s d. Tapia 3.3.1 false true false true true true 3 true 3.3.2 ① involves CN, IX, X, XI taste, vocal cords and SCM (sternocleido mastoid muscle) ② above plus XII tongue ③ above plus Horner 3.3.2 false false false true (Tapia X, XII vocal cords and tongue ) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 4 Neuroanesthesia 4 General Information 1. Provide general information on neuroanesthesia. a. Name the most potent cerebral vasodilator b. Effect of hyperventilation on: i. PaCO2 ii. CBV iii. CBF iv. Goal is end tidal CO2 of (ETCO2) ____ mmHg. v. Correlates with PaCO2 of ___ - ___ mmHg. c. For every ______ degree Celsius change in temperature, d. there is a change in cerebral metabolic rate of oxygen by ____%. e. Hyperglycemia can _____ ischemic deficits. f. Head of the bed elevation will have the i. arterial blood flow ii. ICP iii. venous blood outflow 4.1 CO2 reduces decreases decreases 25-30 mm Hg 30 to 35 mm Hg 1 7% worsen decrease reduce decrease Drugs Used in Neuroanesthesia 2. Inhaled agents have the following effects on: a. cerebral metabolism b. cerebral vessels c. cerebral blood volume d. ICP e. CO2 reactivity 3. What anesthetic drug may come out of solution and aggravate pneumocephalus? 4.2.1 reduce dilate increase increase increase nitrous oxide 4.2.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Neuroanesthesia 4. To reduce the risk of tension pneumocephalus you would a. fill any space with _____ b. and turn off_____ c. ______ minutes before closing the dura. 5. Complete the following regarding barbiturates: a. They produce dose-dependent EEG ____ b. They cause peripheral vaso____ c. which may result in ______ d. and ____ the CPP. 6. Which barbiturate can decrease seizure threshold? 7. a. b. c. d. True or False. Etomidate has analgesic properties. can produce myoclonic activity. can impair renal function. may produce adrenal insufficiency. 8. Ketamine is a _____ receptor antagonist. 9. a. b. c. d. e. f. 4.2.1 fluid agent 10 4.2.2 suppression dilatation hypotension reduce methohexital 4.2.2 4 4.2.2 false true true true NMDA True or False. Morphine significantly crosses BBB releases histamine which produces hypotension causes vasodilation increases ICP compromises CPP 29 4.2.2 4.2.2 false true true true true true 10. Characterize synthetic narcotics: a. Have the advantage that they don’t cause h_______ r_______. b. An example is f_______. fentanyl 11. Benzodiazepines are _____agonists. GABA 4.2.3 12. Dexmedetomidine (Precedex) is an ________ receptor agonist. alpha-2 adrenergic 4.2.3 4.2.2 histamine release 13. What is the only depolarizing paralytic succinylcholine agent? 4.2.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 30 Part 2: General and Neurology Anesthetic Requirements for Intra-Operative Evoked Potential Monitoring 14. Answer the following questions concerning anesthesia requirements for evoked potential monitoring: a. What technique is preferred? b. Second best is _________. c. Are muscle relaxants permitted? 4 15. How should fentanyl be infused? 4.3 total IV anesthesia nitrous/narcotic yes continuously, not intermittently 4.3 Malignant Hyperthermia 16. Regarding malignant hyperthermia: a. Due to block of _____ re-entry into sarcoplasmic reticulum. b. Earliest possible sign is ______ in endtidal pCO2. c. Treatment with ______ IV is usually effective. d. In patients at risk ______ should be avoided. 4.4.1 calcium 4.4.2 increase dantrolene 4.4.3 succinylcholine 4.4.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 5 Sodium Homeostasis and Osmolality Serum Osmolality and Sodium Concentration 1. A serum osmolality of ______is associated with risk of renal failure. > 320 Table 5.1 135 5.2.1 5 Hyponatremia 2. The diagnosis is hyponatremia if the serum sodium is less than _____mEq/L. 3. Two common etiologies for hyponatremia are a. S_____ b. C_____ 5.2.1 SIADH CSW 4. Minimal work-up for hyponatremia should include: a. serum _____ b. serum _____ c. urine _____ d. assessment of _____ e. urine______ f. T______ 5. The syndrome is SIADH a. if the serum osmolality is less than _____mOsm/L b. and the urine osmolality is more than _____mOsm/L. 6. Pseudohyponatremia occurs when _______ active solutes draw ____from the cells and _____the water fraction of plasma and produce artificially _______values. 5.2.1 [Na+] osmolality osmolality volume status [Na+] TSH 5.2.1 275 100 osmotically; water; reduce; low sodium 5.2.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 32 Part 2: General and Neurology 7. Name osmotically active solutes that may cause pseudohyponatremia. a. g______ b. m______ c. h_______ d. h_______ 8. Complete the equation to calculate serum osmolality Effective serum osmolality = [BUN](mg/dl) measured osmolality — _____ 5 9. Matching. Match the symptoms with severity of hyponatremia. Hyponatremia: ① mild, < 130mEq/L; ② severe, < 125mEq/L Symptoms: (a-i) below a. headache b. cerebral edema c. anorexia d. nausea vomiting e. muscle weakness f. muscle twitching g. seizures h. respiratory arrest i. difficulty concentrating 10. a. b. c. SIADH is the release of _______ without _____ stimuli resulting in i. _____natremia ii. _____volemia iii. with inappropriately _____ urine osmolality. 11. Complete the following regarding treatment of hyponatremia: a. Avoid _____ correction. b. Avoid _____ correction. c. Do not exceed ______mEq/L per hour. d. Do not exceed ______mEq/L per 24 hours. e. Do not exceed ______mEq/L per 48 hours. 5.2.1 glucose mannitol hyperlipidemia hyperproteinemia 5.2.2 2.8 5.2.3 ① ② ① ② ① ② ② ② ① 5.2.5 ADH osmotic hypo hyper high 5.2.5 rapid over 1 8 18 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Sodium Homeostasis and Osmolality 12. Matching. Diagnosis of SIADH depends on three diagnostic criteria. Match the laboratory value with the appropriate test. Hyponatremia: ① serum Na; ② serum K; ③ serum osmolality; ④ urinary osmolality; ⑤ urinary Na; ⑥ urinary K; ⑦ blood urea nitrogen (BUN) creatinine a. low ①, ③ b. high ④, ⑤ c. normal ⑥, ⑦ 5.2.5 13. Give the expected result for each test in the diagnosis of SIADH. a. serum Na ________ b. serum osmol______ c. urinary Na_______ d. urinary Na may be as high as _______ e. serum BUN below _______ f. serum creatinine_______ 5.2.5 < 134 mEq/L < 275 mOsm/L > 18 mEq/L 50-150mEq/L 10 normal 14. a. b. c. osmotic demyelination rapid correction pontine white matter Central pontine myelinolysis (CPM) is aka o______ d______ syndrome due to r_____ c______ of hyponatremia a disorder of p______ w______ m______. d. Its symptoms are i. f______ q_______ ii. m______ s_______ changes iii. c_______ n_______ abnormalities iv. p_______ b_______ appearance 15. Features common in patients who develop CPM are a. r_____ c_______ b. o_____ c_______ c. d_____ in _______ for more than _____ hours. d. increase in Na by more than _____mEq/L within _____hours. 5 5.2.5 flaccid quadriplegia mental status cranial nerve pseudobulbar 5.2.5 rapid correction over correction delay in diagnosis; 48 25; 48 16. Treatment of SIADH includes: a. f______ r_______ b. s______ fluid restriction salt 17. a. b. c. d. renal; Na intracranial hypo decrease Cerebral salt wasting (CSW) is r_____ loss of ______ as a result of i_________ disease producing _____natremia and a ______ in extracellular fluid volume. 33 5.2.5 5.2.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 34 Part 2: General and Neurology 18. List the expected patient laboratory result when comparing SIADH with CSW. a. Water: in SIADH _____, in CSW _______ b. Na (serum): in SIADH _____, in CSW _____ c. osmol (serum): in SIADH ______ , in CSW ______ d. osmol (urine): in SIADH ______, in CSW ______ e. Na (urine): in SIADH _______, in CSW ______ f. Hct: in SIADH ______, in CSW______ 5 19. What is the treatment of CSW? a. Hydrate i. with ___% _____saline ii. at _______cc/hr. b. Use furosemide (yes or no?) c. Avoid ______ correction Table 5.5 SIADH: hypervolemic, CSW: hypovolemic SIADH: low, CSW: low SIADH: low, CSW: high SIADH: high, CSW: high SIADH: high, CSW: high SIADH: low, CSW: high 5.2.6 0.9% normal 100-125 no rapid Hypernatremia 20. In neurosurgical patients hypernatremia is seen in a. d______ i_______ b. Define hypernatremia diabetes insipidus Na > 150 mEq/L 21. a. b. c. d. e. ADH 200 1.005 high high 5.3.1 Characterize diabetes insipidus Due to low level of ______. Urine output is < ______cc/hr. Specific gravity of urine is < _______. Serum osmolarity is normal or _______. Serum sodium is _______. 22. In diabetes insipidus is the following low or high? a. ADH is _____. b. Urine specific gravity is ______. c. Urine output is _______. d. Serum osmolality is ________. e. Serum sodium is _________. 23. The etiology of diabetes insipidus can be a. Neu________ b. Nep________ 5.3.2 5.3.2 low low high high high 5.3.2 neurogenic nephrogenic ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Sodium Homeostasis and Osmolality 24. Diagnosis of diabetes insipidus occurs when a. urine output is above _______. b. urine osmol is below _______. c. specific gravity is below _______. d. adrenal function is _________. 25. Treatment of diabetes insipidus in conscious ambulatory patient is to instruct patient to d______ only when ______. 26. Treatment of diabetes insipidus in comatose patient: a. IV fluid management with _________ at appropriate rate (75-100cc/hr). b. Replace _______ above base IV rate mL for mL with _______. c. If unable to keep up with fluid loss use i. v_________ ii. d_________ 35 5.3.2 250cc/hr 200 mOsm/L 1.003 normal drink; thirsty 5.3.2 5.3.2 D5 1/2NS + 20 mEq/L urine output; 1/2 NS 5 vasopressin desmopressin ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 6 General Neurocritical Care 6 Parenteral Agents for Hypertension 1. a. b. c. True or False. Nicardipine is a calcium channel blocker. does not raise ICP. decreases heart rate. true true false 2. a. b. c. Nitroglycerins can _____ ICP. It is a vaso______ acts on v ______more than a____. which _____ LV filling pressures. raise dilator veins, arteries decrease 6.1 alpha-1; beta 6.1 6.1 3. Labetalol is a selective ____ blocker and non selective ____ blocker. 4. List the effects of labetalol on the following: a. ICP b. pulse c. cardiac output d. coronary ischemia e. renal failure 6.1 no change decrease or no change no change no change no change Hypotension (Shock) 5. What is the first sign of hypovolemic shock? tachycardia 6.2.1 6. Septic shock is most often due to gram _____ sepsis. negative 6.2.1 7. Dopamine is primarily a vaso______. constrictor 6.2.2 8. Characterize the effect of dopamine at these doses a. 0.5-2.0 mcg/kg/min b. 2-10 mcg/kg/min c. > 10 mcg/kg/min Table 6.1 dopaminergic beta-1 alpha, beta, dopaminergic ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Acid Inhibitors 9. a. b. c. True or False. Dobutamine is primarily a vasodilator by beta-1. increases cardiac output by inotropy. may exacerbate myocardial ischemia. 10. Phenylephrine ______ blood pressure by ______ SVR, and causes reflex ______ in parasympathetic tone resulting in _______pulse. 6.2.2 true true true elevates; increasing; increase; decreased 11. For the listed pressors complete the following statements to describe the cautions required. a. Phenylephrine: avoid in s______ c______ spinal cord injury i _____ b. Dopamine: may cause h______. hyperglycemia c. Dobutamine: may cause dysfunction of platelets p______. 6.2.2 6.2.2 6 Acid Inhibitors 12. True or False. Extra CNS risk factor that increase the odds of stress ulcers are the following: a. burns covering >25% of body surface area b. hypotension c. renal failure d. coagulopathies 37 6.3.1 true true true true 13. When is the peak time for acid and pepsin production after head injury? 3-5 days after injury 6.3.1 14. Should prophylactic use of H2 blocker be given when steroids are used? no—usually not warranted 6.3.2 15. Gastric pH > 4 may _____ risk of pneumonia from aspiration. increase 6.3.3 16. Omeprazole may ______ the effectiveness of prednisone and _______ the clearance of warfarin and phenytoin due to ______ of hepatic P450 enzymes. decrease; decrease; inhibition 6.3.5 17. Sucralfate may ______ the incidence of lower pneumonia and mortality more than agents that affect gastric pH. 6.3.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 7 Sedatives, Paralytics, Analgesics Sedatives and Paralytics 1. The Richmond Scale: RASS quantitates ________ and ________ levels. a. Positive numbers for _____ b. Negative numbers for _____ 7 2. True or False. Indicate whether the following statements are true or false: a. Methohexital (Brevital) is more potent and shorter acting than thiopental. b. Remifentanil rapidly crosses BBB. c. Fentanyl causes dose-dependent respiratory depression. d. Propofol has better neuroprotection than barbiturates (during aneurysm surgery). e. Precedex can be used to reduce shivering. 3. True or False. The following sedatives may induce seizure: a. Thiopental b. Methohexital c. Fentanyl d. Propofol e. Precedex 4. T________ may cause necrosis when injected intraarterially. 5. Complete the following statements about propofol infusion syndrome: a. Characterized by i. _____kalemia ii. _____megaly iii. m_____ a_____ iv. r__________ v. r______ f________ vi. m______ f_______ vii. h__________ agitation and sedation 7.1.1 agitation sedation 7.1.2, 7.1.3 true true true false (barbiturates are better) true 7.1.3 false true false false false Thiopental 7.1.3 7.1.3 hyperkalemia hepatomegaly metabolic acidosis rhabdomyolysis renal failure myocardial failure hypertriglyceridemia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Sedatives, Paralytics, Analgesics 6. Complete the following statements about Precedex. a. Mechanism of action b. Acts in i. l_______ c________ and ii. d_______ r_______ g_____ c. Has both ______ and ________ properties. d. Side effects: h_______, b_________ 7. Choose the correct order from longacting to short-acting for the following neuromuscular agents: a. Pancuronium b. Succinylcholine c. Rocuronium d. Vecuronium 7.1.3 alpha-2-adrenoreceptor agonist locus ceruleus dorsal root ganglia sedative and analgesic hypotension, bradycardia Table 7.2 Pancuronium: 60 to 180 minutes Vecuronium: 40 to 60 minutes Rocuronium: 40 to 60 minutes (but shorter onset) Succinylcholine: 20 minutes 7 Paralytics (Neuromuscular Blocking Agents) 8. S_______ is always required in a conscious patient simultaneously with the use of a paralytic agent and as ventilation is being established. 9. a. b. c. True or False. Pancuronium is long acting. Rocuronium is short acting. Succinylcholine is a competitive blocker and is short acting. d. Sedation is required for conscious patients. 10. Which is the only depolarizing ganglionic blocker among the following paralytics: a. Succinylcholine b. Rapacuronium c. Mivacuronium d. Rocuronoium 39 Sedation 7.2.1 Table 7.2 true true false (Succinylcholine is noncompetitive blocker and is considered the only depolarizing ganglionic blocker. It has been linked to malignant hyperthermia) true a. Succinylcholine 7.2.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 40 Part 2: General and Neurology 11. Complete the following regarding possible side effects of succinylcholine a. Increases serum potassium by ______. b. Causes severe hyperkalemia in patients with ____________ pathology. c. It is contraindicated in which acute phase injuries? d. May cause dysrhythmias, especially ______ ______. 7 7.2.1 0.5 mEq/mL neuronal or neuromuscular pathology Major burns, multipletrauma sinus bradycardia 12. Which of the following paralytic is contraindicated in the acute phase of injury because of the risk of hyperkalemia? a. Succinylcholine b. Metocurine c. Doxacurium d. Pancuronium e. Vecuronium a. Succinylcholine 7.2.1 13. Which of these is the shortest acting nondepolarzing blocking agent? a. Mivacurium b. Rocuronium c. Vecuronium d. Metocurine e. Doxacurium c. Vecuronium 7.2.4 14. Which nondepolarzing paralytic does not affect ICP or CPP? a. Vecuronium b. Pancuronium c. Succinylcholine d. Rapacuronium e. Rocuronium a. Vecuronium 7.2.4 15. What is the main difference between d. Cistracurium does not cistracrium and its isomer atracurium? release histamine a. cost b. onset of action c. duration d. Cistracurium does not release histamine. e. none of the above 7.2.4 16. State if pancuronium increases or decreases the following: a. cardiac output b. pulse rate c. ICP 7.2.4 increases increases increases ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Sedatives, Paralytics, Analgesics 17. Complete the following statements about reversal of competitive muscle blockade: a. Reversal is not attempted until patient has at least ____ twitch to ________ stimulus. b. A response of ¼ indicates ____% muscle blockade. c. What medication is used for reversal? d. What medications can be added to prevent bradycardia? i. a______ ii. g______ 41 7.2.5 1 twitch to train of four 90 neostigmine (2.5 mg to 5 mg IV) atropine (0.5 mg for each mg of neostigmine) glycopyrrolate (0.2 mg for each mg of neostigmine) Analgesics 18. Metastatic cancer pain can be desensitized by which of these analgesics? a. steroids b. aspirin c. nonsteroidal anti-inflammatory drugs d. acetaminophen 19. How do NSAIDs work? a. They inhibit _______. b. which thereby interferes with the synthesis of p________ c. and t_______. d. This inhibits the function of _______ e. and prolongs _______ _________ f. They may also cause ___________. 20. Complete the following concerning NSAIDS and platelet function: a. The NSAID that results in irreversible binding is ________. b. Which NSAID results in reversible inhibition of platelet function? c. The NSAID that does not interfere with platelet function is ________. 21. List the doses of the following substances: a. NSAID to use i. Naprosyn loading: ______ then _____ every ______ to _____ hours. ii. Motrin no loading: Start dose ______ to _____ mg then ______ times per day. a, b, c 7.3.3 7 7.3.4 cyclooxygenase prostaglandins thromboxanes platelets bleeding time nephrotoxicity 7.3.4 aspirin most NSAIDS Relafen (nabumetone) Table 7.4 500 mg; then 250 mg; 6 to 8 400 to 800; then 4 times per day ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 42 Part 2: General and Neurology b. Opioid to use (moderate to severe pain) i. Percodan no loading: Start dose _______ to _______ pill(s) every ______ to ______ hours. ii. Vicodin no loading: Start dose _______ pill(s) every ______ hours. Limit to ______ every _______ hours per day. c. Opioids use (mild to moderate pain) i. Codeine loading? Start dose _____ to _____ mg at ______ hours, to ______mg at _______ to ______ hours 22. How much Tylenol is safe? a. Comes in dosages of ______ or ________ mg. b. Safe up to ________ mg/day c. Has a ceiling effect at ________ mg/day d. Has hepatic toxicity above ________mg/day 7 1 to 2 pills; 3 to 4 hours 1 pill; every 6 hours 8 pills every 24 hours no loading; 30 to 60 mg at 3 hours; 60 mg at 3 to 5 hours Table 7.3 650 or 1000 mg 4000 mg/day 1300 mg/day 10,000 mg/day 23. A serious side effect of acetaminophen hepatotoxicity is ___________. Table 7.3 24. Complete the following regarding ketorolac (Toradol). a. Only _______ NSAID approved for use in pain control in the U.S. b. A______ effect is more potent than its ____-_________ effect. c. Half-life is _______ hours 7.3.4 25. True or False. Regarding opioid analgesics: a. They have no ceiling effect. b. With chronic use, tolerance develops. c. Overdose is possible with severe respiratory depression. d. Treatment of overdose includes administration of naloxone. e. Flumanezil helps in treatment of overdose. 26. True or False. Regarding narcotics: a. Some opioids may cause seizures. b. Physical and psychological tolerance develops with chronic use. c. There is a ceiling effect with increasing dosage. d. Overdose can cause respiratory depression. parenteral analgesic; anti-inflammatory 6 7.3.5 true true true true false (Flumanezil is useful on treatment overdose from benzodiazepines.) 7.3.5 true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Sedatives, Paralytics, Analgesics 27. Complete the following mnemonic about opioids: a. o__________ b. p__________ c. i__________ d. o__________ e. i__________ f. d___________ 28. To what type of opioid receptor subtype does tramadol (Ultram) bind? 29. Ultram acts centrally to inhibit reuptake of a. n_________ and b. s_________ 30. True or False. OxyContin tablets should never be taken crushed, divided or chewed. 31. What is the intramuscular:per os (IM:PO) potency ratio for morphine? a. single dose b. chronic dosing 32. Indicate the following adjuvant medications’ characteristic actions: a. Tricyclics b. Tryptophan c. Antihistamines d. Phenothiazine 33. What craniofacial pain syndromes are responsive to carbamazepine? a. t________ n_______ b. g_______ n________ c. p________-_________ n________ 34. Chronic use of tryptophan may cause _________. 43 7.3.5 overdose is possible potential for respiratory depression increase dosage = increase effect – no ceiling effect small pupils – miosis intoxication - treat with Narcan develops tolerance with chronic use μ-opioid receptor 7.3.5 7.3.5 norepinephrine serotonin true Table 7.6 7 Table 7.7 1:6 1:2 to 3 7.3.6 blocks serotonin intake precursor of serotonin anxiolytic tranquilizing 7.3.6 trigeminal neuralgia glossopharyngeal neuralgia post-herpetic neuralgia Vitamin B6 depletion 7.3.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 8 Endocrinology 8 Corticosteroids 1. Cortisol is released by the _____ adrenal glands; ______ and is stimulated by pituitary; adrenocorticotrophic hormone (ACTH) hypothalamus from the ______, which in turn is stimulated by corticotropin releasing hormone (CRH) from the ______. 8.1.1 2. True or False. The following has to be replaced in adrenal failure: a. Mineralocorticoids b. Glucocorticoids 8.1.2 3. True or False. The following has to be replaced in pituitary failure: a. Mineralocorticoids b. Glucocorticoids 4. True or False. The following medications have mineralocorticoid potency: a. Cortisone b. Cortisol c. Solu-Cortef d. Prednisone e. Methylprednisolone f. Dexamethasone 5. Hypothalamic-pituitary-adrenal suppression can occur if a dose a. of 40 mg of prednisone is given for _____ days. b. is given for 7 to 14 days taper over ______. c. After a month of steroids, HPA axis may be depressed for as long as ______. true true 8.1.2 false true Table 8.1 true true true true false false 8.1.3 >7 1-2 weeks 1 year ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Endocrinology 6. When withdrawal problems develop a. conservative steroid taper includes small decrements equivalent to ______ mg of prednisone b. every ______ days. 7. List the possible deleterious effects of steroids in alphabetical order. a. a b. b c. c d. d e. e f. f g. g h. h i. j. k. l. m. i j k l m 45 8.1.3 2.5-5 3-7 8.1.4 alkalosis, amenorrhea, avascular necrosis (hip) bone loss cushingnoid features cataracts, compression fractures, chickenpox reactivation diverticular perforation, diabetes epidural lipomatosis fungal infections, fetal adrenal hypoplasia growth suppression in children, GI bleed, glaucoma hypertension, hypokalemia, hyper coagulopathy, hiccups, hirsutism, hyperlipidemia immunosuppression 8 lipomatosis mental agitation, muscle weakness, myopathy non-ketotic coma, nitrogen metabolism is disturbed obesity progressive multifocal leukoencephalopathy (PML), pseudotumor cerebri, pancreatitis n. n o. o p. p q. q r. r s. s reactivation of TB sodium retention, steroid psychosis tissue plasminogen activator inhibition t. t u. u v. v w. w water retention 8. What is the best way to test for hypocortisolism? 8 a.m. cortisol level 8.1.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 46 Part 2: General and Neurology 9. What are the symptoms of Addisonian crisis? (Hint: CLAW) a. C______ b. L______ c. A_______ d. W______ 10. What are the signs of Addisonian crisis? Start your answers with hypo- or hypera. blood pressure b. glucose c. sodium d. temperature e. potassium 12. a. b. c. d. e. f. Confusion Lethargy Agitation Weakness 8.1.5 hypotension hypoglycemia hyponatremia hyperthermia hyperkalemia Hypothyroidism 11. Levothyroxine is almost pure _____ and contains no T3 because most T3 is produced ______ from T4. 8 8.1.5 Signs of myxedema coma include h________ h________ h________ h________ b________ s________ T4; peripherally 8.2.3 8.2.3 hypotension hyponatremia hypoglycemia hypoventilation bradycardia seizures Pituitary Embryology and Neuroendocrinology 13. The posterior pituitary derives from the downward evagination of _____ _____ ____ from the floor of the_____ _____. neural crest cells; third ventricle 8.3.1 14. The anterior pituitary gland develops from evagination of ______ ______, which is also called _______ ________. epithelial ectoderm Rathke’s pouch 8.3.1 15. The pituitary gland is functionally _______ the blood-brain barrier. outside 8.3.1 16. The pituitary gland releases ____ hormones, _____ from the anterior pituitary and _____ from the posterior pituitary. 8; 6; 2 8.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Endocrinology 17. Match the hormone and the portion of the pituitary where it is produced ① anterior; ② posterior a. Thyrotropin releasing hormone b. Corticotropin releasing hormone c. Oxytocin d. Antidiuretic hormone e. Somatostatin f. Prolactin release inhibitory factor g. Gonadotropin releasing hormone 47 Fig. 8.1 ① ① ② ② ① ① ① 18. Prolactin is the only pituitary hormone inhibitory predominantly under ______ control from the hypothalamus. 8.3.2 19. Describe the side effects of ADH. a. _____ the permeability of the distal tubules. b. _____ reabsorption of water. c. _____ circulating blood. d. Produces ______ urine. 8.3.2 increases increases dilutes concentrated 20. What is the most powerful physiologic serum osmolality stimulus for ADH release? 8.3.2 8 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 9 Hematology Blood Component Therapy 1. For an adult, 1 unit of packed red blood cells (PRBCs) should raise the hematocrit by _____%. 9 2. Complete the following concerning platelets: a. Normal platelet count is ____ to _____. b. Regarding transfusion of platelets: i. Transfuse if surgery is ______ or ii. patient is on _____ or ______ and can’t wait ___ to ___ days. iii. Usual transfusion is ______ of platelets. iv. One unit raises platelets by ______. v. Platelet count can be checked in _____ hours. vi. Retransfusion will be needed in _____ days. 3. Complete the following concerning fresh frozen plasma: a. One bag equals _____ cc. b. Risk of acquired immunodeficiency syndrome (AIDS) or hepatitis is the same as __________. c. Use to reverse Coumadin: i. Prothrombin time (PT) greater than _____. ii. International normalized ratio (INR) greater than _____. iii. Von Willebrand’s disease unresponsive to _____. iv. Multiple coagulation dysfunction such as in: h_______ _______ v _______ ______ ______ D________ 3-4% 9.2.2 9.2.3 150 k-400 k/mm3 urgent ASA or Plavix; 5 to 7 an eight pack (=6-10 U) 10 k 2 3-5 9.2.4 200–250 a unit of blood 18 seconds 1.6 DDAVP hepatic dysfunction; vitamin K deficiency; DIC ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Hematology 4. True or False. Regarding Prothrombin complex concentrate (PCC): a. Contains clotting factors II, VII, IX, X. b. Contains protein C & S. c. Primary indication is to be given for warfarin reversal. d. Requires higher volume than FFP to work. 5. In regard to the use of anticoagulation in a patient who has a. an unruptured aneurysm < 4 mm, anticoagulation is ______. b. a drug eluting cardiac stent – continue ______. c. At onset of SAH, we would _______ anticoagulation. d. Post-operative craniotomy may start ____ to ____ days after surgery. 6. Regarding anticoagulation in preparation for surgery. If a patient has: a. a mechanical heart valve i. stop warfarin _____ days before surgery ii. and begin _____. b. chronic atrial fibrillation i. stop warfarin ____ days before surgery. 9.2.4 true true true false (lower volume) 9.2.5 ok Plavix reverse 3 to 5 9.2.5 3 Lovenox 4 to 5 7. Complete the following regarding anticoagulation: a. May resume anticoagulation ____ days 3 to 5 after craniotomy. b. Annual risk of complications while not anticoagulated for a patient with i. mechanical heart valve is ____% per 6% year. ii. chronic atrial fibrillation is ____% per 4-6% year 9.2.5 8. Complete the following regarding neurosurgical procedures: a. PT should be below _____ seconds. b. INR should not be above _____. c. For emergencies give ______ d. and _____. 9.2.5 9. Both Plavix and ASA inhibit platelet function for how long? 10. Plavix is more dangerous drug than ASA because it remains a. _____ for up to b. ________ after the last dose and c. can inhibit even those ______ ______ given treatment. 49 9 < 13.5 1.4 2 U FFP vitamin K permanently 9.2.5 9.2.5 active several days transfused platelets ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 50 Part 2: General and Neurology 11. Name the commonly used herbal products that may affect platelet aggregation. a. g______ b. g______ c. g______ d. f____ ______ 12. Complete the following concerning warfarin (Coumadin): a. Don’t start Coumadin until a ________ has been achieved on heparin b. to reduce the risk of ______ ________. c. For the first 3 days of Coumadin therapy patients are actually _______; d. therefore patients should be ________ with _______ or ________. 13. a. b. c. 9 14. a. b. c. d. e. f. g. Possible heparin side effects include t______ t______ These side effects are due to i. _______ in heparin induced thrombosis or ii. _______ formed against heparin platelet. Low molecular weight heparins should have fewer ______ complications. have more predictable _____ levels. eliminate the need to ______ biologic activity. have a longer ______ life. require _____ doses per day. have a lower incidence of ________. be more effective in _______ prophylaxis than warfarin. 15. A serious side effect could be spinal ______ ________. 16. Regarding dabigatran (Pradaxa). a. It is a d_____ t_____ i______ b. Can be reversed with _______. 17. a. b. c. Regarding fondaparineux (Arixtra) It _____ factor Xa inhibition without affecting Factor _____. Unlike heparin, it does not cause h____ i_____ t______. 9.2.5 garlic ginkgo ginseng fish oil 9.2.5 therapeutic partial thromboplastin time (PTT) Coumadin necrosis hypercoagulable “bridged”; Lovenox or heparin 9.2.5 thrombosis thrombocytopenia consumption antibodies 9.2.5 hemorrhagic plasma monitor half fewer thrombocytopenia DVT epidural hematoma 9.2.5 9.2.5 direct thrombin inhibitor Idarucizumab 9.2.5 increases Factor IIa (thrombin) heparin-induced thrombocytopenia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Hematology 18. Complete the following concerning coagulopathy: a. To reverse Coumadin anticoagulation in a patient who is at the usual therapeutic level, use ______. b. For severely prolonged coagulation use _______. c. To reverse PT from Coumadin use i. ________ ii. Administered by what route? iii. Administration may be fatal if given _______ iv. Why? h________ a_________ 19. Matching. Use the numbers of the listed terms to complete the following statements. ① prothrombin complex concentrate; ② protamine sulfate; ③ vitamin K; ④ AquaMephyton a. Coumadin is reversed by i. ______ _______ _______ ii. ______ ______ iii. ______________ b. Heparin is reversed by ______ ______ 9.2.5 2 to 3 units FFP 6 units FFP vitamin K aqua mephyton IM IV hypotension; anaphylaxis 9.2.5 ① ③ ④ ② 20. Regarding protamine sulfate. a. 1 mg of protamine reverses _____ of 100 U heparin. b. ____% of Lovenox can be reversed with 1 60%; mg of protamine for every mg of 8 Lovenox within the last ____ hours. 9.2.5 21. Significantly elevated pre-op PTT is commonly due to a. f______ d______ b. l______ a______ 9.2.5 22. Complete the following concerning thromboembolism: a. Risk of embolism from calf-deep-vein thrombosis is ___% b. Extends to proximal deep veins in ______%. c. Embolism from thigh veins is ______%. d. Mortality of DVT in legs is _____%. e. DVTs in neurosurgical patients occur in ______%. 23. Conditions that make neurosurgical patients prone to DVTs are a. c______ _______ b. l____-______ ______ c. o______ ______/d__________ d. t________ _________ 51 9 factor deficiency lupus anticoagulant 9.2.5 1% 30 to 50% 40 to 50% 9 to 50% 19-50% 9.2.5 concomitant sludging long-time immobility operating room/dehydration thromboplastin release ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 52 Part 2: General and Neurology 24. The best prophylaxis against DVT is a. PCB, which is the abbreviation for ___________. b. low ______ ______. 25. Matching. One can diagnose DVT with the following tests. Match the finding with its appropriate diagnostic value. ① gold standard; ② associated with PE and DVT; ③ only 50% accurate; ④ 99% specific a. Hot swollen tender calf with positive Homan sign b. Contrast venography c. Doppler ultrasonography d. D-dimer 26. a. b. c. d. e. f. g. h. i. 9 What is the treatment of DVT? b__________ e______ i______ leg h______ or L_______ c________ Consider G________ f________ a_________ after ______ to ______days wear ______-______ ________ For how long? _________ 27. Regarding pulmonary embolism. a. Generally occurs _____ to ____ ____ following surgery. b. Common findings include i. t_______ ii. t_______ iii. f________ iv. h________ c. Classic EKG finding is d. Test of choice is c______-e______ c_____ C______ 9.2.5 pneumatic compression boots dose heparin (5000 IU subcutaneous every to 8 to 12 hours first postop day) 9.2.5 ③ ① ④ ② 9.2.5 bed rest elevate involved leg heparin; Lovenox Coumadin Greenfield filter ambulate 7 to 10 anti-embolic stockings indefinitely 9.2.5 10 to 14 days tachypnea tachycardia fever hypotension S1Q3T3 contrast-enhanced chest CT Extramedullary Hematopoiesis 28. Extramedullary hematopoiesis can result in a. abnormal skull x-ray called ______ _______ ______ b. spinal cord compression due to ________ ______ ______ 29. Extramedullary hematopoiesis can be treated with a. r_______ and/or b. s________ 9.3.1 hair on end vertebral body thickening 9.3.3 radiotherapy surgery ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 10 Neurology for Neurosurgeons Dementia 1. a. b. c. d. e. f. What is the definition of dementia? Loss of i_____ abilities severe enough to interfere with _______ or o_______ functioning. Cardinal feature is m______ d________ plus at least one additional i_________. Affects __ - ___% of persons over 65. 2. True or False. The following are risk factors for dementia: a. Advanced age b. Family history c. Apolipoprotein E2 3. True or False. Regarding dementia vs. delirium: a. Patients with dementia are at increased risk of developing delirium. b. Fifty percent of patients with delirium die within 2 years. c. Unlike dementia, delirium has acute onset. 10.1 intellectual social occupational memory deficit impairment 3 to 11% 10.1 true true false (apolipoprotein E4) 10.1 true 10 true true Headache 4. Regarding unilateral headache. If it persists a. for > 1 year an ______ ______ is recommended b. because this is _______ for migraine c. and may be a hint of an underlying ________. 10.2.1 MRI scan atypical AVM ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 54 Part 2: General and Neurology 5. Matching. Match symptoms with category of migraine. Symptoms: ① episodic H/A; ② N/V; ③ photophobia; ④ aura; ⑤ focal neurologic deficit; (a) that resolves within 24 hours; (b) slow march-like progression of deficit; (c) that resolves within 30 days; ⑥ no headache; ⑦ mostly seen in children; ⑧ hemiplegia; ⑨ mostly seen in adolescents; ⑩ vertigo, ataxia, dysarthria, severe HA Category of migraine: (a-f) below a. Common migraine b. Classic migraine c. Complicated migraine d. Migraine equivalent e. Hemiplegic migraine f. Basilar artery migraine 6. True or False. Neurological deficits seen in classic migraine typically resolve within a. 1 hour b. 1 day c. 1 week d. 1 month e. They are permanent 10 7. True or False. Regarding cluster headaches: a. May include partial Horner’s syndrome and autonomic (ptosis, miosis, tearing) symptoms, nasal stuffiness. b. Are more common in women. c. Occur almost daily. d. Last 30 to 90 minutes. e. Continue for 6 to 9 month period. 8. Treatment of acute attacks of cluster headache includes: a. o_______ b. e_______ c. s________ d. s________ 9. True or false. Basilar artery migraines are essentially restricted to a. geriatric patients b. postmenopausal women c. adolescents d. men 10. True or False. Patients suffering from basilar artery migraine usually have a family history of migraine. 10.2.2 ①-②-③ ①-②-③-④-⑤-⑤a-⑤b ⑤-⑤c-⑥ ②-⑥-⑦ ①-⑧ ⑨-⑩ 10.2.2 false true false false false 10.2.2 true false (5 men to 1 woman) true true false (1 to 3 months) 10.2.2 oxygen 100% by face mask ergotamine sumatriptan SQ steroids 10.2.2 false false true false true (Family history of migraine is present in 86%.) 10.2.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurology for Neurosurgeons 55 Parkinsonism 11. Matching. Match the symptoms with type of parkinsonism. Symptoms: ① gradual onset of bradykinesia; ② asymmetric tremor; ③ responds well to levodopa; ④ rapid progression of symptoms; ⑤ equivocal response to levodopa; ⑥ early midline symptoms (i.e., ataxia, gait, balance); ⑦ early dementia; ⑧ orthostatic hypotension; ⑨ extraocular movement abnormalities Types of parkinsonism: (a-b) below a. Primary idiopathic paralysis agitans (IPA) b. Secondary parkinsonism 12. In parkinsonism, degeneration of substantia nigra cells (pars compacta) results in a. _______ in D2 dopamine receptors projecting to the globus pallidus interna (GPi) b. _______ in D1 receptors projecting to the globus pallidus externa (GPe) and subthalamic nucleus (STN) 13. The effects noted in question 12 result in increased activity by a. ______ causing b. _______of the thalamus, which then suppresses activity in the c. ________ _________ ________. 14. The effects noted in question 13 increase activity by a. degeneration of pigmented ______ neurons b. of the pars compacta of the __________. c. This reduces the levels of _________ in the d. neostriatum; that is the: i. c_______ ii. p_______ iii. g______ p_______ e. This reduces inhibitory D2 receptors to ________. f. and causes the loss of inhibitory D1 receptors to _______ g. and the s______ n_______. h. The net result is an ________ in activity i. of ________. j. GPi has inhibitory projections to the t_________ k. Inhibiting the thalamus also suppresses the s_______m_______c________. 10.3.2 ①-②-③ ④-⑤-⑥-⑦-⑧-⑨ 10.3.2 decrease increase 10.3.2 GPi inhibition supplemental motor cortex 10.3.2 10 dopaminergic substantia nigra dopamine caudate putamen globus pallidus GPi GPe subthalamic nucleus increase GPi thalamus supplemental motor cortex ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 56 Part 2: General and Neurology 15. A hallmark of Parkinson’s disease a. are ________ _________, b. which are i. e______ i_______ ii. h______ i_______ 16. List secondary parkinsonism examples (Hint: p4 secondary) a. p b. p c. p d. p e. s f. e g. c h. o i. n j. k. l. m. 10 d a r y 17. Multisystem atrophy (i.e., Shy-Drager syndrome) is parkinsonism plus a. _______ ________ ________ dysfunction b. plus ________ hypotension. c. Most don’t respond to _________. 18. List the distinguishing features of the progressive supranuclear palsy triad a. ________ (vertical gaze) b. ________ dystonia c. ________ palsy 19. Characteristics of the early stage of progressive supranuclear palsy (PSP) include: a. Falling due to _______ _______ palsy (can’t see the floor). b. Difficulty eating due to ________ and _____ gaze palsy (can’t see plate). 10.3.2 Lewy bodies eosinophilic intraneuronal hyaline inclusions 10.3.3 phenothiazine antiemetics progressive supranuclear palsy (PSP) poisoning CO, manganese parkinson-dementia complex of Guam strial nigral degeneration, Shy-Drager syndrome post-encephaletic parkinsonism Compazine olivo-ponto-cerebellar degeneration neoplasms near substantia nigra dementia pugilistica anti-psychotic drugs Reglan, Reserpine Huntington’s Disease (young people) 10.3.3 autonomic nervous system orthostatic drug therapy 10.3.3 opthalmoplegia axial pseudobulbar 10.3.3 downward gaze downward and vertical gaze ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurology for Neurosurgeons 20. Regarding surgical treatment for Parkinson’s disease. a. The target site was ______ _______ b. True or False. The surgery worked better for i. bradykinesia ii. tremor c. True or False. The more disabling symptom is i. bradykinesia ii. tremor d. The procedure cannot be done bilaterally because of risk of _____ ______. e. Current treatment site is the p________ ________. 57 10.3.3 ventrolateral nucleus false true true false speech disturbance posteroventral pallidum Multiple Sclerosis 21. Prevalence of multiple sclerosis (MS) per 100,000 is variable. a. Near the equator it is _______ per 100,000. b. In Canada and the northern United States it is _______ per 100,000. 22. a. b. c. Multiple sclerosis. Study chart M U L d. T e. I f. P g. h. i. j. k. L E S C L l. m. n. o. p. E R O S I q. S 23. The most common category is r_______-r_______. 10.4.2 <1 30-80 10.4 (de)myelinating urinary symptoms latitudes (northern latitudes affected) time and space dissemination inter-nuclear ophthalmoplegia (INO) paresthesias, peri-ventricular plaques lymphocytes enhancing lesions on MRI scars of the glia cortico spinal tracts involved la belle indifference (euphoria) equator spared remissions optic atrophy sensory loss inflammatory response, IgG elevated shower test (hot causes exacerbation) relapsing-remitting 10 10.4.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 58 Part 2: General and Neurology 24. Name the clinical categories of MS corresponding to their definition. a. r______-r______ (acute episodes with recovery) b. s______-p_______ (gradual deterioration) c. p______p________ (continuous deterioration) d. p______-r________ (gradual deterioration with superimposed relapses) e. Deficits persist if they remain > _______. 25. Matching. Match the multiple sclerosis signs and symptoms with anatomic location. Symptoms: ① visual acuity; ② diplopia; ③ extremity weakness; ④ quadriplegia; ⑤ spasticity; ⑥ scanning speech; ⑦ loss of proprioception Anatomic location: (a-f) below a. optic nerve b. retro-bulbar region c. MLF d. pyramidal tract e. cerebellum f. posterior columns 10 26. Matching. Match anatomic location with multiple sclerosis signs and symptoms. Anatomic location: ① optic nerve; ② retro-bulbar region; ③ MLF; ④ pyramidal tract; ⑤ cerebellum; ⑥ posterior columns Anatomic location: (a-g) below a. visual acuity b. diplopia c. extremity weakness d. quadriplegia e. spasticity f. scanning speech g. loss of proprioception 27. Provide the frequency of multiple sclerosis signs and symptoms. a. Visual symptoms are among the presenting symptoms of multiple sclerosis in ______% b. and occur in multiple sclerosis patients during the course of illness in approximately _____%. c. In addition, abdominal cutaneous reflexes are lost in _____%. Table 10.2 relapsing-remitting secondary-progressive primary-progressive progressive-relapsing > 6 months 10.4.3 10.4.4 ① ① ② ③-④-⑤ ⑥ ⑦ 10.4.4 ①-② ③ ④ ④ ④ ⑤ ⑥ 10.4.4 15% 50% 70 to 80% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurology for Neurosurgeons 28. A multiple sclerosis plaque in the medial longitudinal fasciculus (MLF) will cause a. _______ ________, which will result in b. _________. c. This is important because _________ rarely occurs in other diseases. 29. Indicate the presence or absence of the following reflexes in MS: a. hyperactive muscle stretch reflexes b. Babinski c. abdominal cutaneous reflexes 10.4.4 internuclear ophthalmoplegia (INO) diplopia INO 10.4.4 present present absent 30. Conditions found in the differential diagnosis of multiple sclerosis include a. _____ _____ _____, generally monophasic and b. CNS _________ acute disseminated encephalomyelitis (ADEM) lymphoma 31. True or False. In multiple sclerosis the more MRI lesions, the higher the likelihood of a MS diagnosis. true (MRI is very specific for MS plaques; specificity is 94%.) 32. a. b. c. d. e. f. enhance 3mm 80% lesions are high signal proton density new enhancing lesion Provide MRI criteria for MS. Gadolinium: acute lesions _______ Size: at least ________ in diameter White matter abnormalities: _______% T2-weighted image: _______ ________ Periventricular lesions best seen on ____ Criterion for dissemination is a ________ _______ _______ g. or a ________ _______ _______ 33. True or False. Focal tumefactive demyelination lesions (TDL) can be mistaken for neoplasms because a. they enhance b. they show perilesional edema c. they can be solitary d. they can be in patients known to have MS e. they can be distinguished from MS f. a biopsy may be necessary g. a biopsy results may be confusing 34. Regarding CSF analysis for MS. a. It should include q______ _______ testing. b. In 90% of MS patients the CSF _______ is high. 59 10.4.5 10.4.6 10.4.6 10 new T2 WI lesion 10.4.6 true true true true false true true 10.4.6 qualitative IgG IgG ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 60 Part 2: General and Neurology Acute Disseminated Encephalomyelitis 35. True or False. Regarding acute disseminated encephalitis. a. Associated with recent history of vaccination. b. May demonstrate oligoclonal bands in CSF. c. Is generally monophasic. d. Has good response to high dose IV corticosteroids. true true true true Motor Neuron Diseases 36. Complete the following regarding amyotrophic lateral sclerosis: a. aka m_______ n_______ disease b. aka L_______ G_______ disease c. a mixed ________ and _________ d. m________ n_________ disease e. degeneration of a_______ h_______ cells and f. c_________ t_____ in the cervical spine and medulla 10 10.5 10.6.2 motor neuron Lou Gehrig upper and lower motor neuron anterior horn corticospinal tracts 37. True or False. Regarding clinical characteristics of ALS. a. There is no cognitive, sensory, or true autonomic dysfunction. b. Spares voluntary eye muscles and urinary true sphincter. c. Presents initially with weakness and true atrophy of hands, spasticity and hyperreflexia. 10.6.2 38. The common condition that must be distinguished from ALS is _______ _______. cervical myelopathy 10.6.2 39. R_______ inhibits presynaptic release of g________, and increases tracheostomy-free survival at ____ and _____ months. Riluzole; glutamate; 9 and 12 months 10.6.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurology for Neurosurgeons 61 Guillain-Barré Syndrome 40. Regarding Guillain-Barré Syndrome (GBS). a. Involves a____ onset of peripheral neuropathy with b. p______ muscle weakness with a________. c. Reaches maximum over ____ days to __ weeks. d. Little or no ______ involvement. 10.7.1 acute progressive; arreflexia 3 days to 3 weeks sensory (but paresthesias are not uncommon) 41. What is albuminocytologic dissociation? Elevated CSF protein without pleocytosis 10.7.1 42. What infectious organism is commonly involved? Campylobacter jejuni 10.7.1 43. Features casting doubt on the diagnosis a. asymmetry of ______ b. dysfunction of ______ c. more than 50 ______ in CSF d. any _______ in CSF e. sharp _______ level 44. Complete the following about MillerFisher variant of GBS: a. Describe the triad i. a______ ii. a______ iii. o______ iv. Serum biomarker: anti-_____ antibodies 45. Complete the following about CIDP: a. Stands for c________ i___________ d__________ p__________. b. Symptoms must be present for more than _______ _______. c. Cranial nerves are usually _______. d. Balance difficulties are _______. e. Electrodiagnostic and nerve biopsy findings are indicative of d__________. f. CSF findings are similar to _________. g. Most respond to ________ and ________. 10.7.1 weakness bladder monocytes PMNs sensory 10.7.3 ataxia arreflexia ophthalmoplegia anti-GQ1b 10 10.7.4 chronic immune demyelinating polyradiculoneuropathy 2 months spared common demyelination GBS prednisone and plasmapharesis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 62 Part 2: General and Neurology Myelitis 46. True or False. Regarding Acute Transverse Myelitis a. The most common sensory level in acute true (68% thoracic sensory transverse myelitis is thoracic. level in ATM) b. ATM progresses rapidly. true (66% reach maximal deficit by 24 hours) c. CSF can be normal in the acute phase. true (38%, remainder can have elevated protein or pleocytosis or both) d. An emergency MRI is the first test of true (if not available a choice myelogram with CT to follow) 10.8.3 47. True or False. Regarding treatment of ATM. a. No treatment has been studied in a randomized controlled trial. b. High dose IV methylprednisolone for 3-5 days can be administered. c. Plasma exchange can be given for those who do not respond to steroids. 10.8.5 48. True or False. Regarding prognosis of ATM. a. There is 15% mortality. b. 62% of survivors are ambulatory. c. Recovery occurs between 1 month to 2 years d. No improvement occurs after 3 months. 10 true true true 10.8.6 true true false (1 to 3 months) true Neurosarcoidosis 49. Regarding sarcoidosis. Complete the following: a. The most common manifestation is _______ _________. b. Treat with __________. 50. CNS sarcoidosis involves the l___________. a. M______-e_________ may occur as well as b. b______ m_______ c. T_____ ventricle and h________ may also be involved. 10.9.1 diabetes insipidus corticosteroids leptomeninges 10.9.1 meningo-encephalitis basal meningitis Third; hypothalamus ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurology for Neurosurgeons 51. Complete the following statements about neurosarcoidosis a. Microscopically we see features of n_______ g________. b. Clinical findings include i. c________ n______ p_______ ii. p________ n_______ iii. m________ iv. h________ c. Diabetes insipidus from involvement of the _________. 52. Regarding laboratory findings in neurosarcoidosis. a. Serum test that is positive in 83% of cases is _____ b. CSF test that is helpful is ________. c. How frequently is it positive? d. CSF suggests _________. e. ACE stands for ________ ________ _______. 53. List the test performed with the results in sarcoidosis. a. Chest X-ray i. H______ a________ ii. M_______ l_______ n________ b. MRI i. Enhancement of l_________ ii. Enhancement of o______ n______ iii. Best seen on ________ sequence c. Gallium scan (nuclear medicine). Useful in neurosurgery for: i. s________ ii. c________v _______ o________ 63 10.9.2, 10.9.4 non-caseating granulomas cranial nerve palsies peripheral neuropathy myopathy hydrocephalus hypothalamus 10.9.5 ACE ACE 55% meningitis angiotensin converting enzyme 10.9.6 hilar adenopathy mediastinal lymph nodes leptomeninges optic nerve FLAIR sarcoidosis chronic vertebral osteomyelitis 10 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 11 Neurovascular Disorders and Neurotoxicology Posterior Reversible Encephalopathy Syndrome (PRES) 1. PRES: a. PRES stands for _________ _________ _________ _________. b. Characterized by v_________ b_________ e_________ on CT or MRI with some predominance in _________ and _________ regions. c. Associated conditions include h_________, e_________, s_________, a_________ d_________, and t_________. d. Treatment involves control of _________ _________ and of underlying cause. 11 posterior reversible encephalopathy syndrome vasogenic brain edema; parietal; occipital 11.1.1 hypertension, eclampsia, sepsis, autoimmune disease, transplantation 11.1.2 blood pressure 11.1.3 Vasculitis and Vasculopathy 2. Giant cell arteritis: a. Also known as _________ _________. b. Involves branches of the _________ _________ artery. c. Seen almost exclusively in _________ older than _________, with a female:male ratio of _________. d. The most common presenting symptom is _________. e. Most serious consequence is _________, which occurs in _________% and is not _________. f. The warning symptom that precedes permanent visual loss is _________ _________, which occurs in _________%. g. Giant cell arteritis is associated with _________ _________ _________, which is _________ times as likely in this disease. h. ESR > _________ mm/hr is suspicious. 11.3.2 temporal arteritis external carotid caucasians; 50; 2:1 headache blindness; 7%; reversible amaurosis fugax; 44% thoracic aortic aneurysms; 17 times 40 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Neurovascular Disorders and Neurotoxicology i. ESR > _________ mm/hr is highly suggestive. j. ESR may be normal in _________% with giant cell arteritis. k. Diagnosed via _________ _________ biopsy. l. Optimal length of STA biopsy is _________ cm. m. Spare _________ and _________ branch of STA during biopsy. n. Manage with _________ for _________ months. 3. Behcet’s syndrome consists of the following: (Hint: Behcet’s) a. B_________ b. e_________ c. h_________ d. c_________, c_________ e. e_________ f. t_________, t_________ g. s_________, s_________ 4. Fibromuscular dysplasia: a. The most common vessel involved is the r_________ artery, _________%. b. The second most common vessel involved is the c_________ artery. c. The incidence of aneurysms with FMD is _________%. d. Presenting symptoms include: i. H_________ in _________% ii. u_________ iii. can be mistaken for t_________ m_________. iv. S_________ in _________% v. due to involvement of the c_________ s_________. vi. T_________ changes in _________% vii. due to involvement of the c_________ a_________. viii. H_________ syndrome in _________%. ix. T_________ or i_________ in up to _________%. e. Gold standard for diagnosis is _________ where the most common finding is “_________” appearance. f. The recommended treatment is _________. 65 80 22.5% temporal artery 4-6 cm main trunk; parietal steroids; 6-24 months 11.3.6 Behcet eye lesions headache cerebellar signs, CSF pleocytosis erosions of mouth and genitals thrombophlebitis, thrombosis of dural sinuses skin lesions, seizures 11.3.9 renal, 85% carotid 20-50% headache; 78% unilaterally typical migraine 11 syncope; 31% carotid sinus T-wave; 33% coronary arteries Horner’s; 8% TIA; infarction; 50% DSA; “string of pearls” aspirin ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 66 Part 2: General and Neurology 5. CADASIL: a. CADASIL stands for _________ _________ _________ _________ with _________ _________ and _________. b. _________ _________ inheritance pattern mapped to chromosome _________. c. MRI findings similar to multiple subcortical infarcts from hypertension, except there is no evidence of _________. 11 11.3.6 Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy Autosomal dominant; 19 hypertension Neurotoxicology 6. Ethanol toxicity: a. The primary effect of ethanol on the CNS is depression of n_________ e_________, i_________ c_________, and n_________ r_________. b. Mellanby effect: the severity of intoxication is greater when blood alcohol level is _________. c. Blood alcohol level of 25 mg/dL causes _______ _______. d. Blood alcohol level of 100 mg/dL causes _______ _______. e. Blood alcohol level of 500 mg/dL causes _______ _______. f. Legal intoxication in most jurisdictions is a blood alcohol level of _________. g. As alcohol levels fall, _________ may occur as a compensation for the _________ effects of chronic alcohol use. h. Mainstay of treatment for alcohol withdrawal syndrome are _________. i. They reduce a_________ h_________ and may prevent s_________ and or _________ _________. j. For alcohol withdrawal also use _________ for _________ days and _________ for seizures. k. Delirium tremens occurs within _________ days of alcohol withdrawal. l. Symptoms include a_________, c_________, and a_________ i_________. m. Mortality is _________% if untreated. n. Treatment includes _________. o. Classic triad of Wernicke’s encephalopathy is e_________, o_________, and a_________. 11.4.1 neuronal excitability, impulse conduction, neurotransmitter release rising mild intoxication cerebellar dysfunction respiratory depression 100 mg/dL hyperactivity; CNS depressant Benzodiazepines autonomic hyperactivity; seizures; delirium tremens Thiamine; 3 days; Dilantin 4 days agitation, confusion, autonomic instability 5-10% benzodiazepines encephalopathy, ophthalmoplegia, ataxia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Neurovascular Disorders and Neurotoxicology p. q. r. s. Due to _________ deficiency. Eye signs occur in _________%. Gait disturbance occurs in _________. Memory disturbance is called _________ syndrome and occurs in _________%. t. Atrophy of the _________ _________ may be seen on MRI. u. It is a medical emergency and should be treated with _________, _________ mg daily for _________ days. v. Thiamine administration improves _________ _________ but not _________ syndrome. 7. Opioid toxicity: a. Opioids include h_________ and _________ drugs. b. Produce _________ pupils. c. Reversal of toxicity is achieved with _________. 8. Cocaine: a. Prevents reuptake of the neurotransmitter _________. b. Produces _________ pupils. c. Can be associated with _________. 9. Amphetamines: a. Toxicity is similar to _________. b. Their use can result in stroke due to _________. 10. Carbon monoxide poisoning: a. The largest source of death from poisoning in the U.S. is from _________ _________. b. It poisons by binding to _________, thereby displacing _________. c. “_________” color of blood occurs in _________%. d. In severe cases, CT scan may show l_________ a_________ in the g_________ p_________. e. _________% die. f. _________% have persistent sequelae. g. _________% make full recovery. 67 thiamine 96% 87% Korsakoff’s; 80% mammillary bodies thiamine, 100 mg; 5 days eye signs; Korsakoff’s 11.4.2 heroin; prescription small Naloxone 11.4.3 norepinephrine large stroke 11.4.4 cocaine vasculitis 11.4.5 carbon monoxide hemoglobin; oxygen Cherry-red; 6% low attenuation; globus pallidus 11 40% 10-30% 30-40% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 12 Plain Radiology and Contrast Agents C-Spine X-rays 1. A lateral C-spine x-ray has four contour lines: a. along anterior surface of vertebral bodies: a______ m______ l___ b. along the back surface of the vertebral bodies: p______ m______ l___ c. along the posterior margin of the spinal canal: s______ l______ l___ d. along the posterior margin of the spinous process: p______ s______ l___ 2. Complete the following about spine films: a. Cervical spine normal canal diameter is ______ mm. b. Stenosis is present when the anteroposterior diameter is less than _____ mm. 12 3. Complete the following about normal prevertebral soft tissue: a. anterior C1 ______mm b. anterior C2,3,4 _______mm c. anterior C5-C6 ________mm 4. Interspinous distances: a. Are abnormal if it is ______ times the adjacent level on AP film. b. True or false. If present they represent: i. fracture ii. dislocation iii. ligament disruption c. This is called _______ on lateral x-ray. 12.1.1 anterior marginal line posterior marginal line spino-laminar line posterior spinous line 12.1.4 17 +/- 5mm 12 mm 12.1.4 10 7 22 12.1.4 1.5 true true true fanning 5. C1 has how many ossification centers? 3 12.1.5 6. C2 has how many ossification centers? 4 12.1.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Plain Radiology and Contrast Agents Lumbosacral (LS) Spine X-rays 7. Complete the following regarding lumbosacral spine films. a. The disc space with the greatest height is at _________. b. AP view. Look for “owl eyes.” i. These correspond to the _________. ii. Can be eroded in ________ disease. c. Oblique views. Look for the neck of the scotty dog. i. It corresponds to the _______. ii. Discontinuity occurs in a ________. 69 12.2 L4-5 pedicles metastatic pars interarticularis fracture Skull X-rays 8. Matching. Match the following skull film findings with their characteristics: ① enlarged sella; ② J-shaped sella; ③ symmetrical ballooning; ④ erosion of posterior clinoids a. craniopharyngioma b. pituitary adenoma c. optic glioma d. empty sella 9. True or False. On a skull x-ray, erosion of the posterior clinoids would most often be seen in the setting of a. craniopharyngioma b. empty sella syndrome c. pituitary adenoma d. Hurler syndrome e. optic glioma 10. True or False. The most common congenital anomaly of the craniocervical junction is: a. Chiari malformation b. basilar impression c. os odontoideum d. incomplete arch C1 e. C1-C2 subluxation 11. What are the types of basilar invagination? a. Type I: __________ b. Type II:__________ 12.3.1 ④ ① ② ③ 12.3.1 true false false false false 12.3.1 12 false true false false false 12.3.2 BI without Chiari malformation BI with Chiari malformation 12. Regarding basilar invagination: a. In Type I ____% can be reduced with 85% traction. b. In Type II, f______ m________ d_______ foramen magnum is appropriate. decompression 12.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 70 Part 3: Imaging and Diagnostics 13. True or False. In the evaluation of basilar invagination, in the normal patient, no part of the odontoid should be above the McRae line. 14. True or False. A line used in the evaluation of the craniocervical junction is a. McRae line b. Chamberlain line c. Wackenheim line d. Maginot line e. Fischgold line 15. True or False. Basilar invagination is seen in a. hypoparathyroidism b. Paget’s disease c. osteogenesis imperfecta d. osteomalacia e. hyperparathyroidism 12.3.2 12.3.2 true true true false true 12.3.2 false true true true true Contrast Agents in Neuroradiology 16. Characteristics of iodinated contrast agents a. may delay excretion of _________, b. which is an ________ _________ agent c. used in _______ ________ ______ d. and can be associated with l________ a_______ e. and r_______ f_________. f. It should be held for ______ hours before and after administration of contrast agent. 12 true 17. The primary approved agent for intrathecal use is _______, trade name _______. 18. Use Omnipaque cautiously in patients who have a. s_______ h________ b. c______-v______ d______ c. c________ a________ d. m_______ s________ e. and stop _______ medications at least _______ hours before procedure. 12.4.1 metformin oral hypoglycemic diabetes type 2 lactic acidosis renal failure 48 iohexol; Omnipaque 12.4.1 12.4.1 seizure history cardio-vascular disease chronic alcoholism multiple sclerosis neuroleptic; 48 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Plain Radiology and Contrast Agents 19. Complete the following regarding iodinated contrast allergy prep: a. Prednisone i. Pretest timing in hours ii. Dose in mg iii. Route b. Benadryl i. Pretest timing in hours ii. Dose in mg iii. Route c. Cimetidine i. Pretest timing in hours ii. Dose in mg iii. Route 20 to 24 hours, 8 to 12 hours, 2 hours 50 PO 1 300 PO or IV 21. Describe some idiosyncratic reactions to contrast media. a. Anaphylactoid reaction i. h________ ii. t________ b. Vasovagal reaction i. h_________ ii. b_________ c. Facial or laryngeal angioedema i. Treat with _________. 12.4.1 1 50 IM 20. ________ may increase the risk of contrast media reactions a. and may mask manifestations of a______ reaction. ii. 71 If respiratory distress, i_________. Beta blockers 12.4.2 anaphylactoid 12.4.2 hypertension tachycardia hypotension bradycardia epinephrine (0.3 – 0.5 mL of 1:1000 SQ) intubate Radiation Safety for Neurosurgeons 22. Characterize radiation safety. a. Rem is the absorbed dose in rads multiplied by ______. b. Q “is the quality factor”: the Q of x-ray is ________. c. 1 rem causes _______ cases of cancer in every 1 million people. d. Spine x-rays with obliques is _______ rem. e. Cerebral angiogram is _______rem. f. Cerebral embolization is ______ rem. 23. Complete the following regarding occupational radiation exposure: a. It is advised to keep below ______ rem per year, b. averaged over a ______ year period. 12.5.2 Q 12 1 300 12.5.3 5 10 to 20 34 12.5.4 2 5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 72 Part 3: Imaging and Diagnostics 24. Provide the precautions advised. a. Increase the _______ from the radiation source. b. Exposure is proportional to the _______ of the distance. c. Stay at least _______ feet, preferably _______ feet away. d. Double the distance and get _______ of the radiation. e. What is better: lead “doors” or lead aprons? 12.5.4 distance inverse square 6; 10 1/4 doors 12 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 13 Imaging and Angiography CAT Scan (AKA CT Scan) 1. For measurement on a CT scan a. Give Hounsfield units for i. air ii. water iii. bone iv. blood clot v. calcium vi. disc material vii. thecal sac b. Effect of anemia on an acute subdural hematoma (SDH) in a patient with less than 23% HCT will look ________. 13.1.1 1000 0 +1000 75-80 100-300 55-70 20-30 isodense 2. Indications for Non-contrast vs. IV contrast enhanced CT scan (CECT): a. Noncontrast: i. Excels in demonstrating a______ b______, f_____, f_____ b______, p______ and h______ 13.1.2 3. Abnormalities that can be demonstrated by CT perfusion (CTP): a. f____ s____ s_____ i. decreased C__ & C__ ii. increased M__ and T___ 13.1.4 acute blood, fractures, foreign bodies, pneumocephalus and hydrocephalus ii. Weak in demonstrating a____ s____ acute stroke; and has poor signal quality in the posterior fossa p____ f____. b. CECT: Excels in demonstrating n____ neoplasms and vascular and v________ m________ malformations b. s___: after A__ c_____, i. ii. decreased C__ & C__ increased c_____ c_____ t____ & M__ flow significant stenosis decreased CBV & CBF increased MTT (mean transit time) and TTP (time to peak) steal: after ACZ (acetazolamide) challenge decreased CBV & CBF increased corresponding contralateral territory and MTT 13 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 74 Part 3: Imaging and Diagnostics Magnetic Resonance Imaging (MRI) 4. Matching. Match the best completion for each of the following: ① short TE, short TR; ② short TE, long TR; ③ long TE, short TR; ④ long TE, long TR a. T1-weighted MRI has ______, ______ b. T2-weighted image has ______, ______ 5. Complete the following about magnetic resonance imaging (MRI): a. List the four materials that appear white on T1-weighted imaging (T1WI) MRI. b. What color is pathology on T1WI? c. What color is pathology on T2WI? 6. Matching. Match the phrases with the appropriate signal. ① high signal (bright); ② low signal (dark); ③ intermediate signal a. Fat on T1 is ________ b. Fat on T2 is ________ c. 7- to 14-day-old blood on T2-weighted MRI is ________ d. 7- to 14-day-old blood on T1-weighted MRI is ________ 7. Complete the following about MRI: a. The best sequence for CVA is ________, which stands for ________-________ ________ ________. b. Cerebrospinal fluid (CSF) is ________. c. Most lesions appear ________ in this sequence. d. Most lesions are more ________. 13 13.2.1 ① ④ 13.2.2 fat, melanin, and subacute blood (3-14 days), Onyx low signal on T1 (dark) high signal on T2 (white) 13.2.2, 13.2.3 ① ② ① ① On T1 both fat and 7-to14day-old blood are high signal (white). On T2 fat drops out (i.e., is dark); blood remains white. 13.2.5 FLAIR; fluid-attenuated inversion recovery black bright conspicuous 8. The best MRI sequence for a. acute SAH is ________. b. old blood is ________ ________. FLAIR gradient echo 9. a. b. c. d. T2 star grass white myelographic Gradient echo: aka ______ ________ aka ________ CSF and flowing blood appear ________. In cervical spine produces a ________ effect. e. Improves delineation of ________ ________. f. Also shows small old ________. g. It is the most sensitive MRI sequence for i_________ b_____. 13.2.5 13.2.7 13.2.7 bone spurs hemorrhage intraparenchymal blood ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Imaging and Angiography 10. Complete the following about MRI: a. An MRI sequence that summates T1 and T2 signals and causes fat to be suppressed is called the ________ sequence. b. STIR stands for ________ ________ ________ ________. c. Use it to see tissues that ________ in areas of fat. 11. Name two contraindications to MRI. a. Patients who contain ________ or ________ b. A relative contraindication to MRI is ________ 12. Complete the following regarding programmable valves and MRI: a. Can such patients have MRI studies? b. You may need to check the ________ ________ after the MRI. 13. Hemorrhage on MRI. Related to time. T1. Hint: George Washington Bridge a. acute g________ b. subacute w________ c. chronic b________ 14. Hemorrhage on MRI. Related to time. T2. Hint: layers of Oreo cookie a. acute b________ b. subacute w________ c. chronic b________ 15. Hemorrhage on MRI. Related to time. Hint: i - baby, i - di, bi - di, ba - by, da - da a. hyper-acute i. T1: i________ ii. T2: b________ b. acute i. T1: i________ ii. T2: d________ c. subacute early i. T1: b________ ii. T2: d________ 75 13.2.8 STIR short tau inversion recovery (summates T1 and T2 images) enhance 13.2.9 ferro metals or cobalt (i.e., cardiac pacemaker, implanted neurostimulators, cochlear implants, ferromagnetic aneurysm clips, foreign bodies with a large component of iron or cobalt, metallic fragments in the eye, placement of stent, coil, or filter within past 6 weeks) claustrophobia 13.2.9 yes pressure setting 13.2.10 gray white black 13.2.10 black white black 13.2.10 13 isodense bright isodense dark bright dark ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 76 Part 3: Imaging and Diagnostics d. subacute late i. T1: b________ ii. T2: b________ e. chronic i. T1: d________ ii. T2: d________ 16. a. b. c. d. e. bright bright dark dark Age of hemorrhage hyper acute: acute: subacute early: subacute late: chronic: 13.2.10 <24 hours 1 to 3 days 3 to 7 days 7 to 14 days >14 days 17. If MRI contrast is given to patients with severe renal failure, a rare condition called n________ s________ f________ may occur. 18. Complete the following regarding diffusion weighted images (DWI): a. Its primary use is to detect i. ________ ii. and a________ MS p________. b. It first generates on ________ map. c. On DWI, freely diffusible water is ________. d. Restricted diffusion is ________. e. Which is abnormal? 19. Characterize DWI. a. Restricted perfusion usually indicates ________ ________. b. DWI abnormally will be present for ________. c. DWI abnormalities can light up within ________ of ischemia. 20. The most sensitive study for ischemia of the brain is the ________. 13 21. DWI and PWI mismatch identifies penumbra. Hint: DWI death PWI penumbra a. Which modality shows irreversible cell injury (death)? b. Which modality shows reversible cell injury (penumbra)? 22. The important peaks in MRS are: Hint: li-la-Na-crea-chol a. li________ b. la________ c. N a________ d. crea________ e. chol________ nephrogenic systemic fibrosis 13.2.11 13.2.13 ischemia active; plaques ADC dark bright restricted diffusion 13.2.13 cell death 1 month minutes PWI (Perfusion Weighted Imaging) 13.2.13 13.2.13 DWI PWI 13.2.14 lipid lactate N acetyl aspartate creatine choline ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Imaging and Angiography 23. The significance of important peaks in MRS are a. hypoxia b. a couplet peak c. nerve and axons d. a reference for choline e. membrane synthesis f. increased in tumor g. increased in developing brain h. reduced in CVA 24. The test that may help distinguish hemangiopericytoma a. from meningioma is the ________; b. specifically the presence of a large ________ peak. 25. The test that may help a surgeon avoid critical white matter a. tracts during brain surgery is ________, b. which stands for d________ t________ i________. 13.2.14 lactate lactate NAA creatinine choline choline choline choline 13.2.14 MRS inositol 13.2.15 DTI diffusor tensor imaging Myelography 26. True or False. The risk of postlumbar puncture headache is higher with a. water-soluble contrast. b. non-water-soluble contrast. 13.4 false true 27. Matching. Match each of the following two statements with answers ①, ②, ③, or ④. ① 10%; ② 35%; ③ 65%; ④ 90% a. In lumbar disc disease, what percentage ② of free fragments move inferiorly? b. In lumbar disc disease, what percentage ③ of free fragments move superiorly? 77 13.4 Radionuclide Scanning 28. a. b. c. Applications for bone scans include: i_____ t_____ d_____ involving a_____ b_____ m_____ d. c________ e. s_____ or s_____ f_____ f. “l_____ b_____ p_____” 29. Applications for Gallium scan are a. s_____ b. c_____ v_____ o_____ 13.5.1 infection tumor diseases involving abnormal bone metabolism craniosynostosis spine or skull fractures “low back problems” 13 13.5.2 sarcoidosis chronic vertebral osteomyelitis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 14 Electrodiagnostics Electroencephalogram (EEG) 1. True or False. Periodic epileptiform discharges (PLEDs) may be produced by a. herpes simplex encephalitis b. brain abscess c. embolic infarct d. brain tumor e. any acute focal cerebral insult 14 14.1.1 true true true true true 2. Matching. Match the following EEG patterns and their probable diagnostic pathology: ① Creutzfeldt-Jakob disease; ② hepatic encephalopathy, post anoxia and hyponatremia; ③ SSPE-subacute sclerosing panencephalitis a. triphasic waves ② b. body jerks plus high-voltage periodicity ③ with 4-15 second separation; no change with pain c. myoclonic jerks, bilateral sharp waves ① 1.5-2/sec, react to painful stimulation 14.1.1 3. What is the frequency of the following EEG rhythms? a. Delta b. Theta c. Alpha d. Beta Table 14.1 0-3 Hz 4-7 Hz 8-13 Hz >13 Hz Evoked Potentials 4. Complete the following statements about evoked potentials: a. Evoked potentials offer limited usefulness in avoiding ______ intraoperative injury because they are _______. 14.2.3 acute; delayed ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Electrodiagnostics b. Criteria for significance: i. Increased latency of ____%. ii. Decreased amplitude of ____%. 5. Intraoperative SSEP may localize the primary sensory cortex by ______ potential across the central sulcus. phase reversal 14.2.3 Table 14.5 7. Evoked potentials during spine surgery: a. May remain unchanged by injury to the ______ cord b. but are sensitive to injury to the ______ columns of the ______ cord. 14.2.3 9. a. b. c. d. e. f. g. h. i. j. 10% 50% 6. When testing brainstem auditory evoked responses (BAER): a. Prolongation in peak I-III suggests lesion pons and inferior colliculus between p____ and i______ c_______. b. Prolongation in peak III-V suggests lesion lower pons and midbrain between l____ p____ and m_______. 8. True or false. Regarding transcranial (i.e., motor evoked) potentials: a. Too painful to do on the awake patient. b. Feedback is prompt, almost immediate. c. Can’t record continuously because of muscle contractions. d. Useful for cervical spine surgery. e. Useful for thoracic spine surgery. f. Useful for lumbar spine surgery. g. Have more special anesthetic requirements. Provide the SSEP deterioration plan. R_____ R_____ R_____ S_____ S_____ S_____ T_____ A_____ H_____ E_____ anterior posterior, dorsal 14.2.3 true true true true true false true 14.2.4 remove hardware reposition patient release retraction sixty Hz steroids stop surgery temperature anemia hypotension electrode contact 14 NCS/EMG 10. Name the parts of the EMG examination. a. I______ a______ b. S______ a______ c. V______ a______ 79 14.3.2 insertional activity spontaneous activity volitional activity ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 80 Part 3: Imaging and Diagnostics 11. How long following denervation of muscle after nerve injury do you want to see fibrillation potentials on electromyography (EMG)? a. The earliest is _____, but b. reliably not until ________. c. Therefore, don’t order EMG until at least _______weeks after the injury. 12. a. b. c. 14. H reflex: a. Is practical only regarding the _____ root. b. Has similar information to the ____ _____. b. Reliable if positive 17. The earliest possible finding in EMG for radiculopathy is ________ __________ 18. Findings with healing radiculopathy: a. ______ potentials return first. b. If lost, ______ return last or may not return. 14.3.2 14.3.2 prolonged proximal 14.3.2 S1 Ankle jerk True or False. Regarding EMG: Is low yield for radiculopathy. true Best reserved for patients with weakness. true Pain without weakness, EMG has low true yield. 16. True or False. Radiculopathy EMG is: a. Reliable if negative 14 10 days 3 to 4 weeks 4 weeks SNAP: aka______ _______ action potential. sensory nerve Ganglion lies within the ______ _______. neural foramen Herniated disc is preganglion; therefore, not affected SNAP is ______ ______. 13. F wave: a. May be______ in multilevel radiculopathy. b. Most helpful in evaluating _______ root slowing. 15. a. b. c. 14.3.2 14.3.2 14.3.2 false – EMG is not sensitive for radiculopathy true – when positive very specific. reduced recruitment (2-3 days) 14.3.2 14.3.2 Motor Sensory ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 15 Primary Intracranial Anomalies Arachnoid Cysts, Intracranial 1. Characterize intracranial arachnoid cysts. a. Origin: c_________ b. Arise from splitting of a_______ m________. c. Contain fluid identical to _______. d. Incidence per 1000 autopsies: e. More common in male or female? f. Most are a_________. g. If symptomatic, typical symptoms are: i. i______ h_______ ii. s________ 2. True or False. Acute deterioration in patients with known arachnoid cysts usually signifies a. rapid increase in cyst size. b. postictal state. c. rupture into subdural space. d. rupture of bridging veins and cyst bleed. 3. Complete the following about arachnoid cysts: a. The location of the only extradural type of arachnoid cyst is in the _____ cyst. b. A retrocerebellar arachoid cyst might mimic a _______-______ syndrome. c. The most common location for an arachnoid cyst is the _____ ______. d. The next most common location is the _____ ______. e. They are associated with ventriculomegaly in _____%. f. The best treatment is probably c______ s________. 15.1.1 congenital arachnoid membrane CSF 5 male asymptomatic intracranial hypertension seizures 15.1.4 false false false true intrasellar 15.1.3 Dandy-Walker Sylvian fissure Table 15.1 cerebellopontine angle 64% 15.1.5 cyst shunting 15.1.6 15 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 82 Part 4: Developmental Anomalies Craniofacial Development 4. Complete the following about craniofacial development: a. The anterior fontanelle closes by age ______. b. Head size is 90% of adult size at age ______. c. The head stops enlarging by age ______. d. The skull is ______ at birth. e. Diploe appears by the _____ year and f. Reaches a maximum at age ______. g. Diploic veins form at age _______. h. Air cells in the mastoid occur in _______ year. 5. True or False. Craniosynostosis a. has been proven to occur after shunting. b. of one suture does not cause increased ICP. 6. Complete the following about craniofacial development: a. The most common craniosynostosis is _______. b. The male to female ratio is ________. c. The resulting skull shape is ________. d. Surgery should be done within the age range of _______. e. The strip craniectomy should be ______ cm wide. 7. Complete the following regarding coronal synostosis a. Incidence of patients with craniosynostosis who have coronal synostosis is _____%. b. In which is it more common, males or females? 15 8. Complete the following regarding coronal suture synostosis (CSS): a. Plus syndactyly is called ______ syndrome. b. Unilateral CSS is called _______. c. CSS plus hypoplasia of the face is called ______ disease. d. Plagiocephaly i. Forehead on affected side is ______ or ______. ii. Supraorbital ridge has a ______ margin. 15.2.1 2.5 years 1 year 7 years unilaminar 4th 35 35 6th 15.2.2 false false (11% have high ICP) 15.2.2 sagittal 80:20 dolichocephalic/ scaphocephalic/boat shape 3 to 6 months 3 cm 15.2.2 18% females 15.2.2 Apert’s syndrome plagiocephaly Crouzon’s disease flattened; concave higher 9. Regarding harlequin eye sign 15.2.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Intracranial Anomalies a. Occurs in u______ c______ suture closure b. seen on ________ _______ ______. c. The abnormal bony structure is the _____ ______, d. which is ______ than the normal side. 10. Complete the following about craniofacial development: a. What suture is closed to produce trigonocehaly? b. It is usually associated with an abnormality of the _______ chromosome. 11. a. b. c. Characterize lambdoid synostosis. Male to female ratio is ______. Side involved most frequently is ______. The frequency of involvement is ______% right. d. Does it have a ridge or an indentation to palpation? 12. Considering lambdoid synostosis: a. Differentiate from positional flattening by looking at the ears from the ________. b. In lambdoid synostosis you will see the ipsilateral ear _____ _______. c. In positional flattening you will see the ipsilateral ear is _____ ______. 13. Answer the following concerning lambdoid synostosis treatment: a. True or False. All require surgery. b. True or False. Surgery is indicated early (i.e., 3 to 6 months). c. Ideal age for surgery is ______ to _____ months. d. Early surgery is indicated for s________ d_______ and e_______ i_______ p_______. 83 unilateral coronal anteroposterior skull X-ray supraorbital margin higher 15.2.2 metopic 19 p 15.2.2 4:1 right side 70% indentation (Not a ridge like the sagittal or coronal synostosis) 15.2.2 top of the head lags behind pushed forward (If flat side of occipital bone is same side as the posteriorly positioned ear it is a case of lamboid synostosis; if not it is a case of positional flattening) 15.2.2 False (15% won’t respond to repositioning.) False (one can observe for 3 to 6 months for improvement) 6 to 18 severe disfigurement and elevated intracranial pressure 14. Complete the following about encephalocele: a. Incidence of basal form of encephalocele 1.5% is ______%. b. May exit the skull via a defect in 15.2.3 15 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 84 Part 4: Developmental Anomalies i. c______ p________ ii. f_______ c_______ iii. s_______ o_______ f________ Dandy Walker Malformation 15. To differentiate DWM from retrocerebellar arachnoid cyst observe for a. v_______ a________ b. cyst opens into f_______ v______ c. enlarged p_______ f_______ d. elevation of the t_______ h________ vermian agenesis fourth ventricle posterior fossa torcular herophili 16. a. b. c. d. e. dilation of 4th ventricle agenesis of vermis membrane of 4th ventricle dysembryo genesis hydrocephalus What is Dandy-Walker pathogenesis? D A N(m) D Y 17. Complete the following regarding Dandy-Walker malformation (DWM): a. It is caused by a ______ of the f_______ of M______ and L_______. b. Results in i. agenesis of ________ ii. large ______ ______ _______ which communicates with the iii. _____ _______, which becomes ________. 18. What is Dandy-Walker pathogenesis? a. Hydrocephalus is present in _______% b. and _____% of hydrocephalus patients have DWS. c. A common associated abnormality is i. a______ of the c_______ c_______ d. e. f. g. 15 cribriform plate foramen cecum superior orbital fissure h. i. 15.3.2 15.3.3 atresia of the foramina; Magendie and Luschka (old theory) 15.3.5 15.3.3 vermis posterior fossa cyst fourth ventricle; enlarged 70 to 90% 2 to 4% agenesis of the corpus callosum ii. in _______ %. 17% and c_______ a________. cardiac abnormalities If treatment is necessary, you must shunt cyst the ventricle, the cyst, or both? If aqueductal stenosis you should shunt ventricle ________ also. But shunting the lateral ventricle alone i. is _______ contraindicated ii. because it might cause ______ upward herniation _______. To avoid ________ herniation, upward you must not shunt the ______ alone. ventricle 19. What is the prognosis of DWM? 15.3.3 15.3.5 15.3.6 15.3.7 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Intracranial Anomalies a. Seizures occur in _____%. b. Mortality occurs in ______ to ______% c. Normal IQ is _______%. 15% 12 to 50% 50% Aqueductal Stenosis 20. True or False. Aqueductal stenosis is seen only in children. 21. What are the causes of aqueductal stenosis? a. A b. Q c. E(i) d. C e. T f. A g. L 22. Complete the following concerning aqueductal stenosis: a. It is associated with congenital hydrocephalus in ______%. b. MRI may show absence of i. n_______ f_______ v_______ in the ii. a________ of S________ c. MRI with contrast should be used to rule out ______. d. Follow-up should be for at least _______. e. In order to rule out ________. 23. True or False. A patient with aqueductal stenosis of adulthood may have the following symptoms: a. Headache b. Visual disturbances c. Decline of mental function d. Gait disturbance e. Papilledema (sign) f. Ataxia g. Urinary incontinence 24. What are the treatment options for aqueductal stenosis? a. Ventriculoperitoneal ______ _______ b. T_______ ________ _______ _______ c. ETV = ________ ________ ________ 85 False (Adults can present with symptoms as well.) 15.4.1 15.4.2 astrocytoma of brain stem quadrigeminal plate mass inflammation infection congenital atresia tumor arachnoid cyst lipoma 15.4.3 70% 15.4.4 normal flow void aqueduct of Sylvius tumor 2 years tumor 15.4.4 true true true true true true true 15.4.4 CSF shunting Torkildsen shunt in adults endoscopic third ventriculostomy 15 Agenesis of the Corpus Callosum 25. Agenesis of the corpus callosum forms 2 weeks; at age _______ after conception and rostrum to splenium forms from _______ to ______. 15.5.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 86 Part 4: Developmental Anomalies 26. Complete the following concerning the bundles of Probst: a. They are aborted beginnings of the _______ _______ b. bulging into the _______ _______. 15.5.3 corpus callosum lateral ventricles 27. Complete the following regarding agenesis of the corpus callosum: a. Does it always have clinical significance? 15.5.4 No, it may be an incidental finding b. Underlying cause may be an abnormality chromosome of a ________. Absence of the Septum Pellucidum 28. One possible cause of absence of septum pellucidum is a. s_____-o________ d_______ b. aka __________ __________, c. which produces h________ of o_______ n_______ d. and o________ c________ as well as e. p________ i_________. septo-optic dysplasia de Morsier syndrome hypoplasia of optic nerve optic chiasm pituitary infundibulum Intracranial Lipomas 29. Intracranial lipomas a. are usually found in the _______ _______ b. especially in the ______ _______. c. They are frequently associated with ________ d. of the ________ ______. e. They may less frequently involve the i. t_______ c______ ii. and the ______ _______. 15 15.6 30. True or False. Characteristics of intracranial lipomas include a. association with ______ abnormalities b. on CT they have a _______ density. c. Differential diagnosis is i. d_______ c________ ii. t________ iii. g_______ d. On MRI they have a _______ intensity on T1. e. On MRI they have a _______ intensity on T2. 15.7.2 midsagittal plane corpus callosum agenesis corpus callosum tuber cinereum quadrigeminal plate 15.7.3 congenital low dermoid cyst teratoma germinoma high low ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Intracranial Anomalies 31. Intracranial lipomas may present clinically with a. s________ b. h_______ d________ c. h_______ d. m_______ r_______ 87 15.7.4 seizures hypothalamic dysfunction hydrocephalus mental retardation Hypothalamic Hamartomas 32. a. b. c. d. Hypothalamic hamartomas are frequent or rare? are neoplastic or nonneoplastic? consist of a mass of ______ _______ that arises from the i. in________ h_______ or ii. t________ c_______ 33. Hypothalamic hamartomas clinically a. may present with a special type of seizure called _______, which means _______ seizure. b. may also have _______ attacks. c. may also present with p_______ p________ d. due to release of g_________ r________ h________ e. formed within the ________ cells. 15.8.1 rare nonneoplastic neuronal tissues inferior hypothalamus tuber cinereum 15.8.2 gelastic; laughing rage precocious puberty gonadotropin releasing hormone hamartoma 15 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 16 Primary Spinal Anomalies Spinal Dysraphism (Spina Bifida) 1. a. b. c. d. e. f. g. h. i. j. k. l. m. Study sheet. Spinal bifida occulta B I F I D A O C C U L T A 2. Complete the following regarding myelomeningocele (MM): a. The anterior neuropore closes at gestational age day ______. b. The posterior neuropore closes at gestational age day ______. 3. Complete the following regarding myelomeningocele (MM): a. Incidence if no previous child has MM equals ____% or ______ per 1000. b. One previous MM child: ______% or ______ per 1000. c. Two previous MM children: _____% or _____ per 1000. d. Associated hydrocephalus: incidence of _______%. e. Associated Chiari II occurs in _______ children with MM. 16.2.2 bifida incidental foot deformity innocuous diastematomyelia atrophy of leg occurs in 20 to 30% cutaneous stigmata clinical importance nil urinary incontinence lipoma leg weakness tethered cord absent spinous process 16.2.3 25 28 16.2.3 0.2% or 2% 2%, 20 6%, 60 80% most 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Spinal Anomalies 4. Answer the following about myelomeningocele: a. What is the incidence of meningocele or myelomeningocele? b. Does the risk increase in families with one affected child? c. Does the risk increase in families with two affected children? 16.2.3 1 to 2/1000 live births (0.2%) Yes (The risk does increases to 2 to 3% in families with one previous myelomeningocele child.) Yes (It further increases to 6 to 8% in families with two previous affected children.) 5. True or False. All children born with false (Not all, but most, have myelomeningocele have an associated Chiari II.) Chiari II malformation. 16.2.3 6. True or False. Closure of myelomeningocele may result in the need for CSF shunting. true 16.2.3 7. Meningomyelocele patients develop allergy to ________. latex 16.2.3 8. True or False or Uncertain. Intrauterine closure of mm defect reduces a. Chiari II defect b. hydrocephalus c. neurological dysfunction 9. Complete the following concerning myelomeningocele: a. If ruptured, start _______ (n________ and g________). b. Perform surgery within ________ to ______ hours. c. Better functional outcome occurs if children have spontaneous _______ of _____ _________. d. Do multiple anomalies occur in myelomeningocele? 10. Complete the following about myelomeningocele and early closure: a. True or False. Results in improvement of neurological functions. b. True or False. Results in lower infection rate. c. Myelomeningocele should be closed within 12, 24, or 36 hours? 89 16.2.3 true uncertain false 16.2.3 antibiotics (nafcillin and gentamicin) 24 to 36 hours movement of lower extremities Yes (average 2 to 2.5 additional anomalies in myelomeningocele) 16.2.3 false true 24 hours 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 90 Part 4: Developmental Anomalies 11. Considering late problems in myelomeningocele repair. Possible late problems include: a. brain: b. cervicomedullary junction: c. cord: d. cauda: 12. Characterize myelomeningocele outcome without treatment and with treatment. a. Survive infancy without treatment ___ ___%; with treatment ____%. b. Normal IQ without treatment _____%; with treatment _____% c. Ambulatory without treatment ____%; with treatment ____ - ____% d. Continence without treatment ______; with treatment ____ - ____%. 13. For each of the following, what are the facts to know concerning lipomeningocele? a. age for surgery b. band c. conus d. dura e. epidural fat versus ______ f. placode g. neuro exam h. sensory loss i. stigmata j. urologic exam 14. True or False. Lipomyelomeningocele is associated with tethered cord. 15. Study Chart. Lipomeningocele: a. Steps in surgical management (Courtesy of Dr. David Frim): 16.2.3 hydrocephalus – malfunctioning shunt Chiari II compressing medulla Syrinx tethered cord 16.2.3 15 to 30%; 85% 70%; 80% 50%; 40 to 85% rare; 3 to 10% 16.2.4 2 months is appropriate thick fibrovascular band is split is dehiscent lipoma (is distinct from epidural fat) attached to neural placode is normal in 50% most common neurological abnormality cutaneous should be done pre-op true 16.2.4 16.2.4 1. Untether the cord using Xomed CUSA and recording from anal sphincter 2. Free up sides from attachment to dura. 3. Reduce the bulk of fat using CUSA in the midline. 4. Tie dura open to sides. 5. Place bovine pericardial graft as dural substitute. 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Spinal Anomalies 16. True or False. The most common location of a dermal sinus tract is the: a. occipital region b. cervical region c. thoracic region d. lumbosacral region 17. What is the most likely cause of dermal sinus? a. Failure of the _______ ectoderm b. to________ c. from the _______-ectoderm d. at the time of _________ e. of the _______ ________. 18. Dermal sinus facts to know include: a. Most commonly located in the _______ area. b. Results from _______ of _______ of ______ _______ c. from _______ _______. d. Appears as a ________: i. Hair? ii. Midline? iii. Skin stigmata? e. First manifestation is _________. f. Tract always courses _______ from lumbosacral area. 19. True or False. An epidermoid cyst contains hair follicles and sweat glands. 20. What is the major difference between epidermoid cyst and dermoid cyst? a. Epidermoid cyst is i. lined with s______ s_______ e_______ ii. and contains only _______ b. Dermoid cyst is i. lined with ________ ii. and contains _______ _______ such as iii. hair follicles? iv. sebaceous glands? 21. True or False. A dermal sinus tract is a potential pathway for intradural infection such as meningitis or abscess. 22. Radiologic evaluation of dermal sinus. a. If seen at births do ________. b. If first seen later do ______. 91 16.2.5 false false false true 16.2.5 cutaneous separate neuro closure neural groove 16.2.5 lumbosacral failure of separation of cuteanous ectoderm neural ectoderm dimple With or without Close to midline yes bladder dysfunction cephalad false 16.2.5 16.2.5 stratified squamous epithelium keratin dermis skin appendages yes yes true 16.2.5 16.2.5 ultrasound MRI 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 92 Part 4: Developmental Anomalies 23. Given the above, indicate whether the dermal sinus tract should be excised at the given locations. a. lumbar yes b. sacral yes c. coccygeal no 16.2.5 24. Complete the following concerning the cranial dermal sinus: a. The track extends _______ b. If the dermal sinus tract enters the skull it does so _____ to the torcula. 16.2.5 caudally caudal Klippel-Feil Syndrome 25. True or False. Klippel-Feil syndrome results from failure of a. primary neurulation b. secondary neurulation c. dysjunction d. segmentation 26. Klippel-Feil syndrome a. Results from failure of _______ of ______ _______ at gestational age of b. ___ to ___ weeks. c. Clinical triad i. Hairline is ______. ii. Neck is ________. iii. Motion is ________. d. Limitation of range of motion of the neck occurs only if more than _______ segments are fused. e. True or false. Other congenital abnormalities may also be present. f. True or false. Klippel-Feil causes symptoms related to fused vertebrae. 27. True or False. Anomalies seen associated with Klippel-Feil include a. Sprengel deformity b. webbing of the neck c. basilar impression d. unilateral absence of the kidney 28. Possible systemic congenital abnormalities include a. g________ b. c_________ 16.3.1 false false false true 16.3.1 segmentation of cervical somites 3 to 8 weeks 16.3.2 low short limited 3 true false 16.3.2 true true true true 16.3.2 genitourinary – absence of one kidney cardiopulmonary 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Spinal Anomalies 93 Tethered Cord Syndrome 29. List the six presenting signs and symptoms of tethered cord syndrome. a. c________ b. s_________ c. b_________ d. s_______ e. g________ f. p_________ Table 16.2 cutaneous (54%) scoliosis (29%) bladder (40%) sensations (70%) gait (93%) pain (37%) 30. True or False. Regarding tethered cord syndrome. a. Progressive scoliosis is not seen in false conjunction with tethered cord syndrome. b. Early untethering may result in true improvement in scoliosis. 16.4.4 31. True or False. The following is associated with adult tethered cord syndrome: a. Foot deformities b. Pain c. Leg weakness d. Urological symptoms 16.4.5 false true true true 32. True or False. Urological symptoms are not common in the adult tethered cord syndrome. false 16.4.5 33. True or False. A tethered conus lies distal to L2 on radiographic evaluation. true 16.4.5 34. Complete the following concerning tethered cord syndrome: a. Name two criteria. i. Conus below level ______ ii. Thick filum greater than _______ b. A preop test that is strongly recommended is a ________. 35. Indicate the characteristics used to identify the filum. a. The vessel on the surface is _______. b. The color of the filum is ______ ______ than nerve roots 16.4.5 L2 2mm diameter cystometrogram 16.4.6 16.4.6 squiggly more white 36. Complete the following outcome from tethered cord: a. In meningomyelocele it is usually impossible; untether ________ to permanently ________. b. Repeated untethering is advised till growing patient stops _______. 16.4.6 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 94 Part 4: Developmental Anomalies 37. Symptoms of untethering are especially likely during the a_______ g______ s_______. 38. Surgical release in an adult is a. good for _______ _______ and b. poor for return of ______ _______. adolescent growth spurt 16.4.6 16.4.6 pain relief bladder function Split Cord Malformation 39. True or False. Diastematomyelia is false (septum is rigid) associated with nonrigid bony septum that separates two durally unsheathed hemicords. 16.5.2 40. Complete the following concerning diastematomyelia: a. Cutaneous stigmata are h________ tuft or hypertrichosis. b. True or false. There are foot abnormalities, c. specifically n______ h______-a_____ f_______. 16.5.2 hair true neurogenic high-arched foot 16 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 17 17 Primary Craniospinal Anomalies Chiari Malformations 1. Compare Chiari types I and II. a. medulla-caudal dislocation b. into cervical canal c. myelomeningocele d. hydrocephalus e. medullary kink f. cervical nerves g. age at presentation h. symptoms Table 17.1 Chiari I, no; Chiari II, yes Chiari I, tonsils; Chiari II, vermis, medulla, fourth ventricle Chiari I, no; Chiari II, yes Chiari I, no; Chiari II, yes Chiari I, no; Chiari II, 55% Chiari I, normal; Chiari II, upward Chiari I, adult; Chiari II, infant Chiari I, neck pain; Chiari II, hydrocephalus, respiratory distress 2. Complete the following about Chiari malformation: a. Chiari I has how many abnormalities? 1—with many names b. List four names this abnormality has been called. i. t________ h________ tonsillar herniation ii. c________ d________ of c________ caudal displacement of cerebellum iii. p________ e________ of t________ peglike elongation of tonsil iv. c________ e________ cerebellar ectopia 17.1.2 3. Chiari I a. has how many deformities? b. is known by the following names i. e________ ii. e________ iii. d________ iv. h________ 17.1.2 1 ectopia elongation displacement herniation ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 96 17 Part 4: Developmental Anomalies c. symptoms i. o________ h________ ii. c________ p________ occipital headaches cervical pain 4. What is the particular eye sign associated with Chiari I? Downbeat nystagmus is considered a characteristic of this condition in 47%, but it can also occur in Chiari II. 17.1.2 5. What percentage of Chiari I patients have hydrosyringomyelia? 20 to 30% of Chiari I patients have a syrinx. 17.1.2 6. Characterize the location of tonsils and Chiari I. a. Normal range related to foramen magnum i. high ii. low iii. mean b. Chiari I range is i. high ii. low iii. mean c. Symptoms can occur with tonsils at ________ mm below. d. Usual level considered cutoff for diagnosis is ________ mm below. 7. Possible better correlation with symptoms of tonsillar herniation is the degree of brain stem compression a. at the ________ ________ b. as seen on the ________ c. T________ W1 MRI. d. The best results from surgery occur if treated within ________ years of onset of symptoms. 8. Complete the following concerning Chiari I: a. The most common postop complication is ________ ________ in ________ %. b. Occurs within how many days of surgery? c. Occurs mostly at what time of day? d. Death can occur from s________ a________. e. Other risks of surgery include i. c________ f________ l________ ii. injury to p________ i________ c________ a________ iii. h________ of c________ h________ Table 17.4 8 mm above 5 mm below 1 mm above 3 mm below 29 mm below 13 mm below 2 5 17.1.2 foramen magnum axial 2 2 17.1.2 respiratory depression in 15% 5 night sleep apnea cerebrospinal fluid leak posterior inferior cerebellar artery (PICA) herniation of cerebellar hemispheres ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Craniospinal Anomalies 9. Complete the following concerning Chiari I: a. Operative results i. Main benefit may be to a______ p________. ii. Best results in patients with ________ syndrome iii. which consists of t________ a________ l________ a________ n________ d________ b. Which responds better: pain or weakness? 10. Factors that correlate with a worse outcome are a. a________ b. s________ c. symptoms that are lasting more than ________ ________ 17.1.2 arrest progression 97 17 cerebellar truncal ataxia limb ataxia nystagmus dysarthria pain 17.1.2 atrophy scoliosis 2 years 11. Which Chiari malformation is associated with myelomeningocele? Chiari II 17.1.3 12. Study Chart. Chiari II anatomical abnormalities: A to Z. atlas assimilation beaking of tectum, bony abnormalities cerebellar folia poorly myelinated, cervical medullary junction compression, craniolacunia, corpus callosum agenesis degenerated lower CN nuclei enlarged massa intermedia falx hypoplasia, fourth ventricle trapped, fusion of cervical vertebrae gyri miniaturized hydrocephalus, heterotopia, hydromyelia Klippel-Feil deformity low attachment of tentorium massa intermedia enlarged medulla oblongata “z” bend microgyria nuclei of lower CN degenerated platybasia, peg of cerebellar tonsils septum pellucidum absent, syringomyelia tectum beaking, tentorium low attachment Z-shaped bend of medulla 17.1.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 98 Part 4: Developmental Anomalies 13. Finding on presentation of Chiari II. 2 Hint: n chiari two a. n________ b. n________ ________ c. c________ d. h________ e. i________ ________ ________ f. a________ ________, ________ g. r________, ________ ________ 17 h. i________ ________ i. t________ ________ ________ ________ ________ j. w________ ________ k. o________ 14. Complete the following regarding Chiari II. a. The most common cause of mortality is ________ ________. b. The mortality at 6 years follow-up is ________%. c. Range of mortality i. Infants in poor condition (i.e., cardiopulmonary arrest, vocal cord paralysis, and/or arm weakness mortality) is ________%. d. If there is gradual onset of symptoms, mortality is ________%. e. The worst prognostic factor for response to surgery is b________ v________ c________ p________. 17.1.3 nystagmus—down beat nasal regurgitation cyanosis hoarseness impaired ventilatory drive apneic spells, aspiration regurgitation, respiratory arrest inspiratory stridor tenth nerve (vagus) vocal cord paralysis weak arm—weak cry opisthotonus 17.1.3 respiratory arrest 40% 71% 23% bilateral vocal cord paralysis Neural Tube Defects 15. With neural tube defects there are classification systems. Give examples of a. neurulation defects i. a________ ii. m________ b. postneurulation defects i. m________ ii. h________ iii. h________ iv. l________ v. s________ c. spinal defects i. d________ ii. s________ 17.2.1 anencephaly myelomeningocele microcephaly hydranencephaly holoprosencephaly lissencephaly schizencephaly diastematomyelia syringomyelia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Craniospinal Anomalies 16. Complete the following about neural tube defects: a. Failure to fuse the anterior neuropore results in ________. b. Failure to fuse the posterior neuropore results in ________. c. The definition of microcephaly is head circumference ________ ________ ________ below the mean. d. In hydranencephaly the cortex is replaced by ________. e. Failure to cleave can result in ________. 17. Complete the following about neural tube defects: a. Give examples of neurulation defects. i. a________ ii. c________ iii. m________ b. These defects are due to ________ of the neural tube. 18. Complete the following about neural tube defects: a. Name five postneurulation defects. i. h________ ii. l________ iii. h________ iv. a________ of _________ ________ v. d________ b. Which is the most severe? 17.2.1 anencephaly 17 myelomeningocele 2 standard deviations CSF holoprosencephaly 17.2.1 anencephaly craniorachischisis myelomeningocele nonclosure 17.2.1 hydranencephaly lissencephaly (most severe) holoprosencephaly agenesis of corpus callosum diastematomyelia lissencephaly 19. Complete the following regarding lissencephaly: a. It is an example of an abnormality of migration neuronal ________. b. It results in an abnormality of the ______ cortical convolutions _______ c. called _______ agyria 17.2.1 20. Name the key features of schizencephaly. a. ________ which communicates with ________ b. lined with ________ ________ c. Two types are i. o________ l________ ii. c________ l________ 17.2.1 21. Complete the following about neural tube defects: a. In schizencephaly, the cleft wall is lined with cortical ________ ________. b. In porencephaly, the cystic lesion is lined with ________ or ________ tissue. 99 cleft; ventricle gray matter open lipped close lipped 17.2.1 gray matter connective or glial ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 100 17 Part 4: Developmental Anomalies 22. a. b. c. d. Hydranencephaly is a ________ defect. Cranium is filled with ________. Is there a small or large head? Most common etiology is ________ ________ ________. e. Angiography i. of anterior circulation shows ________ ________. ii. of posterior circulation shows ________ ________. 23. Complete the following about neural tube defects: a. What are the three types of holoprosencephaly? Please list in order of decreasing severity. i. a________ ii. s________ iii. l________ b. They occur because of i. failure to ________ ii. of the ________ ________. 24. List the risk factors for neural tube defects. a. B________ i________ b. c________ c. D________ d. f________ a________ i________ e. f________ f. h________ e________ g. o________ h. v________ a________ i. v________ 25. What are the tests for prenatal detection of neural tube defects? a. Serum ________ ________. b. U________, c. which can detect what % of spina bifida cases? d. a________ 17.2.2 post-neurulation CSF large (macrocrania) bilateral ICA infarcts no flow normal flow 17.2.2 alobar (single ventricle, most severe) semilobar lobar (least severe) cleave telencephalic vesicle 17.2.3 B12 insufficiency cocaine—maternal use Depakene—use during pregnancy folic acid insufficiency fever in first trimester heat exposure—maternal hot tub, sauna obesity before and during pregnancy valproic acid use during pregnancy vitamins—prenatal lack of folic acid and B12 17.2.4 alfa fetoprotein (If high at 15 to 20 weeks be suspicious for neural tube defects.) ultrasonography 90% amniocentesis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Primary Craniospinal Anomalies 26. Regarding prenatal detection of neural tube defects. a. Test mother’s serum for ________ ________, b. which has a sensitivity rate for spina bifida ________% and for anencephaly ________%. c. Closed spinal dysraphism ________ ________ ________. d. An overestimate of gestational age will make us think that a high alpha fetoprotein level is ________. e. Real-time imaging through ________. f. Identifies ________% of s ________ b________. g. Obtaining fluid from the womb is called ________. h. It carries a risk of fetal loss of ________%. 17.2.4 alpha fetoprotein 101 17 91%; 100% may be missed normal ultrasonography 90% of spinal bifida amniocentesis 6% Neurenteric Cysts 27. Complete the following about neurenteric cysts: a. A neurenteric cyst is a central nervous system (CNS) cyst lined with ________ b. resembling the ________ or ________ tract. c. Regions affected are usually the ________ or ________ areas. d. Histologically, cyst lined with c________-c________ e________ e. with m________-s________ g________ c________. 17.3.1 endothelium gastrointestinal or respiratory cervical or thoracic cuboidal-columnar epithelium mucin-secreting goblet cells 17.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 18 18 Coma General Information 1. Write out the Glascow Coma Scale (GCS) and indicate the score assigned to each point on the scale. a. Eyes i. e___ ii. y___ iii. e___ iv. s___ b. Verbal i. v___ ii. o___ iii. i___ iv. c___ v. e___ c. Motor i. m___ ii. o___ iii. v___ iv. i___ v. n___ vi. g___ 18.1 4 spontaneous 3 to speech 2 to pain 1 nil 5 oriented 4 confused 3 inappropriate 2 incoherent 1 nil 6 obeys 5 localizes 4 withdrawal 3 decorticate 2 decerebrate 1 nil 2. True or False. A patient with a GCS score E2 V1 M2 (GCS 5) is in a coma. false (Whereas 90% of patients with GCS < 8 are in a coma, coma is defined as the inability to obey commands, speak or open the eyes even to pain.) 18.1 3. Define coma. A GCS less than 8 is a generally accepted operational definition of coma. 18.1 4. List the three locations of brain lesions that produce coma. a. u_____ p____ and m______ upper pons and midbrain b. d_______ diencephalic c. b_____ c_______ h_______ bilateral cerebral hemisphere 18.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Coma Posturing 5. Disinhibition by removal of the corticospinal pathways above the midbrain typically results in _____ (f_____) posturing. decorticate (flexion) 6. Disinhibition by removal of the vestibulospinal tract and pontine reticular formation by removing inhibition of medullary reticular formation typically results in _______ (e_______) posturing. decerebrate (extension) 7. Complete the following about coma in general: a. In a decorticate posturing i. the upper extremities are in ______. ii. the lower extremities are in _______. b. In decerebrate posturing i. the upper extremities are in ______. ii. the lower extremities are in ______. 103 18.2.2 18 18.2.3 18.2.3 flexion extension extension extension Etiologies of Coma 8. A patient is brought to the ER in a coma after being found down. Pupils are equal and reactive. Painful stimulus elicits no movement. No signs of trauma are evident. Studies show Na 130, K 4.9. C 1-100, HCO3 215, BUN 30, Cr 1.2, Glu 440. The likely cause of coma is _______ _______. 9. Indicate the effect of midline shift on level of consciousness. a. 0 to 3 mm: b. 3 to 4 mm: c. 6 to 8.5 mm: d. 8 to 13 mm: 10. The three categories of disorders in the different diagnosis of pseudocoma are: a. l_____-i______ s______ and v______ p______ i_______ b. p_____ d______, c________, and c_________ r________ c. n_________ w_______ and m________ g________, G_______B__________s______ diabetic ketoacidosis 18.3.1 Table 18.3 alert drowsy stuporous comatose 18.3.3 locked-in syndrome; ventral pontine infract psychiatric disorders, catatonia; conversion reaction neuromuscular weakness; myasthenia gravis; GuillainBarré syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 104 Part 5: Coma and Brain Death 11. A patient presents with coma. Your first move is to assess and secure the _______. 18 airway 18.3.4 12. Complete the following about approach to the comatose patient: a. What percentage of patients with 3% Wernicke’s encephalopathy present with coma? b. You would initially treat those patients thiamine with ______. 18.3.4 13. Matching. Match the respiratory pattern with the location of the lesion. ① medullary; ② pontine; ③ bilateral cerebral hemisphere; ④ high medulla or lower pons a. Cheyne-Stokes b. hyperventilation c. cluster breathing d. apneustic e. ataxic 18.3.4 ③ ② ④ ② ① 14. What is the significance of equal, reactive pupils in a comatose patient? Indicates toxic metabolic cause. 18.3.4 15. What is the most useful sign in distinguishing metabolic from structural coma? the light reflex 18.3.4 16. The only metabolic causes of fixed/dilated pupils are a. a______ e_______ b. g______ t_______ c. a______ u_______ 18.3.4 d. b_______ t_______ p________ 17. In a third nerve palsy a. the pupil is _______ b. and the eye looks _____ and ______. 18. True or False. The following ocular finding can be seen in comatose patients with pontine lesions: a. pinpoint pupils b. periodic alternating gaze c. ocular bobbing d. bilateral conjugate deviation to cold caloric anoxic encephalopathy glutethimide toxicity anticholinergic use (i.e., atropine) botulin toxin poisoning 18.3.4 dilated down and out 18.3.4 true false (usually indicates bilateral cerebral dysfunction) true false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Coma 19. In frontal lobe lesions patient looks a. ______ the side of the destructive lesions that is _____from the hemiparesis. b. ______ from the side of the irritative lesions (seizures) that is _____ the jerking side. 20. In a pontine lesion the eyes deviate towards the ______ side. 21. Name three causes of bilateral downward gaze deviation. a. t______ l______ b. m_____ p______ l______ c. b________ 22. Complete the following concerning internuclear opthalmoplegia: a. Is due to a lesion in the ______ _____ _____. b. Fibers are interrupted that go to the ______ ______ ______. c. Results in i. loss of ________ ii. of the ______ eye iii. on _______ _______ _______ iv. or in response to _______ ______. v. and convergence is ____ _______. 18.3.4 toward; away 18 away; toward hemiparetic 18.3.4 18.3.4 thalamic lesion midbrain pretectal lesion barbiturates 18.3.4 medial longitudinal fasciculus contralateral 3rd nerve nucleus adduction ipsilateral spontaneous eye movement reflex movement (doll’s, calorics) not impaired 23. Complete the following regarding oculo-vestibular reflex: a. A comatose patient with an intact tonic; towards brainstem will have _____ conjugate eye deviation _____ the side of the cold stimulus, b. which may be delayed up to _____ 1 minute. c. Will there be nystagmus? No 18.3.4 24. In a normal ciliospinal reflex, the pupil _______ to noxious cutaneous stimulus. 18.3.4 25. True or False. The ciliospinal reflex is indicative of a. parasympathetic pathways b. spinothalamic pathways c. integrity of the periaqueductal gray d. sympathetic pathway 105 dilates 18.3.4 false false false true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 106 18 Part 5: Coma and Brain Death Herniation Syndromes 26. True or False. Subfalcine herniation is of concern because: a. Anterior cerebral artery territory infarcts may occur. b. Transtentorial herniation may occur. c. There is no obvious concern. 18.4.2 true true false 27. True or False. Decreased consciousness occurs early in uncal herniation. false (It occurs late in uncal and early in central herniation.) 18.4.2 28. True or False. Uncal herniation rarely gives rise to decorticate posturing. true 18.4.2 29. Upwards cerebellar herniation a. can occlude the _________, b. resulting in ________ infarction SCA cerebellar 30. Tonsillar herniation a. can compress the _____, b. resulting in _______. medulla respiratory arrest 31. a. b. c. 18.4.3 18.4.3 Central herniation can occlude the _______, resulting in ________. It can shear the basilar artery _______ and cause D ______ hemorrhages. 32. True or False. This stage of central herniation is reversible. a. medullary stage b. diencephalic stage c. lower pons d. upper pons 33. List the distinguishing features of pupils and respiratory rate in the following injuries. a. Injury at the diencephalon: i. Pupils _____ to _____ ii. Respiratory pattern is ______. b. Injury at the midbrain: i. Pupils are in ______. ii. Respiratory pattern is ______. c. Injury at the pons: i. Pupils________. ii. Respiratory pattern is______. d. Injury at the medulla oblongata: i. Pupils are ______. ii. Respiratory pattern is _______. 34. True or False. Internuclear ophthalmoplegia is prominent at the “lower pons” stage of central herniation. 18.4.4 PCA cortical blindness perforators; Duret 18.4.4 false true false false 18.4.4 react to light Cheyne-Stokes midposition hyperventilation pin-point apneustic dilated, fixed ataxic false (at the upper pons stage) 18.4.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Coma 35. Why does injury to the pons result in pinpoint pupils? Sympathetics are lost. 18.4.4 36. Why does injury of midbrain herniation result in moderately dilated, fixed pupils? Sympathetics and parasympathetics are lost. 18.4.4 37. What percentage of patients with central herniation symptoms had: a. good outcome? b. functional outcome? c. died? 18 18.4.4 9% 18% 60% 38. True or False. Regarding uncal herniation: a. The earliest consistent sign is i. impaired consciousness ii. unilateral dilated pupil false true 39. What shape is the suprasellar cistern? pentagonal 40. During uncal herniation, Kernohan’s phenomenon occurs a. when the _______ cerebral peduncle b. is compressed against the ______ ______, c. causing _______ hemiplegia. d. Kernohan’s phenomenon is designated as a _____ localizing sign 107 18.4.4 18.4.4 18.4.4 contralateral tentorial edge ipsilateral false Hypoxic Coma 41. Regarding the most vulnerable cells in anoxic encephalopathy. a. Cortex i. ______ cortical layer ii. ______ horn b. Basal ganglia i. g______ p______ ii. c________ iii. p________ c. Cerebellum i. P_______ cells ii. d_______ nucleus iii. i________ o________ d. What tissue is more sensitive to anoxia, gray or white matter? e. Are steroids useful after cardiac arrest? 18.5 3rd Ammon’s globus pallidus caudate putamen Purkinje dentate inferior olive gray (has greater O2 requirement) no ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 19 Brain Death and Organ Donation 19 Brain Death in Adults 1. True or False. According to the Uniform Determination of Death Act of 1980, an individual is dead if they have sustained a. irreversible cessation of circulatory and respiratory functions. b. irreversible cessation of all functions of the entire brain, including brain stem. 19.1 true true Brain Death Criteria 2. The basic requirements and clinical findings that may be used in determining brain death include: a. Core temperature ______. b. Systolic blood pressure _____. c. Blood alcohol level _____. d. Absence of b_______ r_______. e. No response to d____ c_____ p_____. f. Failed a_____ c_______. 3. When testing oculovestibular reflex you should a. instill ___ - ___ mL of ice water into one ear b. with HOB at ____, c. wait ___ minute for response and d. > ___ minutes before testing the opposite side. 4. The apnea test: a. Assesses f_____ of m_____ b. to be valid test for brain death, the PaCO2 must reach _____ without any respirations. c. This usually takes ____ minutes. Table 19.1 > 36 C (96.8F) > 100 mmHg < 0.08 % brainstem reflexes deep central pain apnea challenge 19.2.3 60-100 30 degrees 1 5 19.2.3 function of medulla > 60 mmHg 6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Brain Death and Organ Donation 5. True or False. The apnea test should be aborted if: a. the patient has chest or abdominal movement. b. SBP < 90 mmHg c. SaO2 drops < 80% for > 30 seconds. 19.2.3 true true true 6. True decerebrate or decorticate posturing or seizures are ______ with the diagnosis of brain death. incompatible 19.2.3 7. Spinal cord mediated reflex movements are ______ with the diagnosis of brain death. compatible 19.2.3 8. Name five complicating conditions that must not be present to declare an adult brain dead. a. h_______ b. i________ c. p________ d. p________ e. s________ 9. Cerebral angiography is compatible with brain death when there is ______ of intracranial flow at the level of the c______ b _______ or the c_____ of W______. 10. True or False. Regarding the use of EEG as an ancillary confirmatory test. a. It is able to detect brainstem activity. b. It does not exclude the possibility of reversible coma. c. It requires electro-cerebral silence. 11. When performing a cerebral radionuclide angiogram for brain death confirmation, the finding of no uptake in brain parenchyma is also called h____ s_____ p_____. 109 19 19.2.3 hypothermia: core temperature < 32.2 (90F) intoxication (i.e. paralytics, barbiturates, benzodiazepines) post-resuscitation (i.e., could be in shock, or atropine may have been used in resuscitation, causing fixed dilated pupils) pentobarbital (> 10 ug/mL) shock (SBP < 90 mmHg) absence; carotid bifurcation; circle of Willis 19.2.5 19.2.5 false true true (no electrical activity > 2mcV) hollow skull phenomenon 19.2.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 110 Part 5: Coma and Brain Death Brain Death in Children 12. Current guidelines for diagnosis of brain death in children are not supported for infants ____ week gestational age due to insufficient data. 19 13. Recommended observation periods to declare brain death in children: a. Term newborn – 30 days of age b. Infants and children < 37 19.3.1 19.3.2 24 hours 12 hours Organ and Tissue Donation 14. Brain death can result in the following physiologic aberration: a. h_____ b. h_____ c. d_____ i_______ 15. True or False. Candidates for organ donation by cardiac death: a. Are ventilator dependent. b. Their family has decided to withdraw support. c. Further treatment would improve outcome. 19.4.3 hypotension hypothermia diabetes insipidus 19.4.5 true true false (it would be futile) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 20 Bacterial Infections of the Parenchyma and Meninges and Complex Infections 20 Meningitis 1. True or false. Regarding meningitis. a. Community acquired meningitis is typically more fulminant than meningitis following a neurosurgical procedure or trauma. b. Focal neurological signs are common in acute meningitis 2. What syndrome describes large petechial hemorrhages in the skin and mucous membranes, fever, septic shock, adrenal failure, and DIC in children with disseminated meningococcal infection? 3. Regarding treatment of meningitis. a. What is empiric antibiotic coverage for post-neurosurgical procedure meningitis? b. If the patient has a severe PCN allergy, what antibiotics can be used instead? c. What are the three phases of antifungal treatment for cryptococcal meningitis? 20.1.1 true false Waterhouse-Friderichsen syndrome 20.1.1 20.1.2 Vancomycin (MRSA coverage), 15mg/kg q 8 – 12 hrs to achieve a trough level of 15 – 20 mg/dl + cefepime 2gm IV q 8 hrs Aztreonam 2gm IV q 6 – 8 hrs or Ciprofloxacin 400 mg IV q 8 hrs Induction therapy: liposomal amphotericin B 3-4 mg/kg IV daily + flucytosine 25 mg/kg PO QID for at least two weeks followed by Consolidation therapy: fluconazole 400mg PO daily for at least 8 weeks followed by Chronic maintenance therapy: fluconazole 200mg PO daily ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 112 Part 6: Infection 4. What are the most common causal organisms in post-neurosurgical procedure meningitis? a. C_______-n_______ S________ b. c. d. e. 20 S______ a_____ E_______________ P____________ sp. P____________ 5. In immunocompromised patients, what additional organisms must be considered in the differential diagnosis? a. C__________ n_________ b. M_________ t________ c. H______ a______ m________ d. L_________ m___________ 6. True or false. Regarding posttraumatic meningitis. a. Most cases will have a basal skull fracture. b. Most patients have obvious CSF rhinorrhea. c. Most infections are from organisms indigenous to the nasal cavity. d. Surgical treatment is preferred to conservative management. e. Ciprofloxacin or Imipenem is the treatment for gram-negative organisms. f. Penicillin is the treatment of choice for gram-positive organisms. g. Antibiotics should be continued for 1 week after CSF is sterilized. 7. Patients with recurrent meningitis must be evaluated for the presence of the following etiologies of an abnormal communication between the environment and the intraspinal/intracranial compartment. a. d_____ s_____ b. C__ f______ c. n_________ c___ 8. Differential diagnosis for chronic meningitis: a. t___________ b. f______ i________ c. n____________ d. s__________ e. m________ c___________ 20.1.2 Coagulase-negative staphylococci S. aureus Enterobacteriaceae Pseudomonas sp. Pneumococci (usually with basilar skull fractures and otorhinologic surgery) 20.1.2 Cryptococcus meningitis Mycobacterium tuberculosis HIV aseptic meningitis Listeria Monocytogenes 20.1.3 true true true false true false true 20.1.4 dermal sinus CSF fistula neuroenteric cyst 20.1.5 tuberculosis fungal infections neurocysticercosis sarcoidosis meningeal carcionmatosis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Bacterial and Complex Infections 9. List the favored antibiotic for each of the following organisms: a. S. pneumonia b. N. meningitidis c. H. influenza d. Group B Strep e. L. monocytogenes f. S. auerus g. aerobic gram negative bacilli h. P. aeruginosa i. Candida spp. 113 20.1.6 PCN G PCN G ampicillin (beta lactamase neg) or ceftriaxone (beta lactamase pos) ampicillin ampicillin ± IV gentamicin oxacillin (MSSA) or vancomycin ± rifampin (MRSA) ceftriaxone ceftazidime or cefepime Liposomal amphotericin B + flucytosine 20 Cerebral Abscess 10. True or false. Regarding brain abscesses. a. Are most commonly polymicrobial. b. Staphylococcus is the most common organism isolated. c. CRP is typically normal. d. Symptoms are similar of other mass lesions by progress rapidly. 11. The incidence of brain abscesses is _____ in developing countries. 12. What are the risk factors for a brain abscess? a. p_________ a___________ b. c________ c________ h______ d_______ c. b___________ e____________ d. p___________ h_____ t_______ e. c______ s_______ f. o_______ m________ g. i_____________________ h____ 13. Complete the following about sources of brain abscesses: a. For what percentage of cerebral abscesses is no source found? b. Where is the most common origin for hematogenous spread? c. Ethmoidal and frontal sinusitis leads to an abscess in which lobe? d. Why are infants less likely to develop a brain abscess following purulent sinusitis? e. After penetrating trauma, open surgical debridement is required to ________. 20.2.1 true false false true higher 20.2.2 20.2.3 pulmonary abnormalities congenital cyanotic heart disease bacterial endocarditis penetrating head trauma chronic sinusitis otitis media immunocompromised host 20.2.4 25% of cases chest frontal lobe Lack of aerated sinuses and air cells. remove foreign matter and devitalized tissue ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 114 20 Part 6: Infection 14. Complete the following about causative pathogens of brain abscesses: a. What percentage of cerebral abscesses fail to grow an organism on culture? b. The most common organism is _________. c. The most common orgamisms in frontalethmoid sinusitis are ______ ______ and ________ ___________. d. The most common organism in traumatic causes is _________ _________. e. The most common organisms in transplant patients are _______ ________. f. The most common organisms following neurosurgical procedures are _______ __________ and ________ _________. g. The most common type of organism in infants is _____ _________. h. The most common organism from a dental source is _________. i. The most common organisms in AIDS patients are ________ ________. 15. The symptoms of a brain abscess in adults are largely the result of? 16. Describe the four stages of a cerebral abscess. a. Stages i. stage 1 e_______ c_______ ii. stage 2 l_______ c_______ iii. stage 3 e_______ c_______ iv. stage 4 l_______ c_______ b. Number of days i. stage 1 ii. stage 2 iii. stage 3 iv. stage 4 c. Histologic characteristics i. stage 1 ii. stage 2 iii. stage 3 iv. stage 4 d. Resistance to needle aspiration i. stage 1 ii. stage 2 iii. stage 3 iv. stage 4 20.2.5 25% Streptococcus Streptococcus milleri and Streptococcus anginosus Streptococcus auerus fungal infections Staphylococcus epidermidis and Staphylococcus aureus gram negative actinomyces toxoplasmosis nocardia Edema surrounding the lesion causing increased ICP (headache, nausea/vomiting, lethargy) and a rapid progression of symptoms 20.2.6 20.2.7 early cerebritis late cerebritis early capsule late capsule 1 to 3 4 to 9 10 to 13 > 14 inflammation developing necrotic center neovascularity, reticular network gliosis around collagen capsule intermediate resistance no resistance no resistance firm resistance ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Bacterial and Complex Infections 17. Indicate the value of the following diagnostic tests in the work up for a brain abscess? a. blood work b. lumbar puncture (LP) c. computed tomography (CT) d. MRI e. MRS f. leukocyte scan g. effect of steroids 18. How long should antibiotics be used for treating brain abscesses? 19. Medical therapy alone is more successful for the treatment of abscesses if: a. it is in the _________ stage. b. the abscess is less than ___ cm in diameter. c. symptom duration is less than ___ wks. 20. What antibiotics are used in AIDS patients with Toxoplasma gondii? 21. General management of brain abscesses includes: a. b______ c_______ b. e______ a_______ c. a____________ d. s______ 115 20.2.8 WBC may be normal or mildly elevated; blood cultures should be obtained but are often negative; ESR may be normal or elevated; CRP is typically elevated very dubious and not routinely done – may cause herniation excellent (sensitivity ≈ 100%) good for staging cerebral abscesses presence of amino acids and either acetate or lactate are diagnostic for abscess excellent although infrequently used tests become less positive may mislead Often IV x 6-8 wks followed by oral x 4-8 wks, although duration should be guided by clinical and radiographic response (note: CT improvement may lag behind clinical improvement (neovascularity remains) so it is okay to d/c antibiotics even if the CT abnormalities persist. 20 20.2.9 20.2.9 cerebritis stage (before complete encapsulation) 3 2 Sulfadiazine + pyrimethamine + leucovorin 20.2.9 20.2.9 blood cultures empiric antibiotics anticonvulsants (optional) steroids (controversial) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 116 20 Part 6: Infection 22. The surgical mainstay of treatment for needle aspiration a brain abscess is _____ _____. 20.2.9 23. Complete the following regarding outcomes for patients with brain abscesses? a. mortality (in the CT era) b. neurologic disability c. late focal or generalized seizures d. hemiparesis e. mortality for transplant patients with fungal abscesses? 20.2.10 0 – 10% 45% 27% 29% approaches 100% Subdural Empyema 24. Why is a subdural empyema (SDE) typically more emergent than a brain abscess? No anatomic barrier to spread of a SDE, no surrounding tissue reaction to contain the infection, and poor antibiotic penetration into the space 20.3.1 25. Where are SDE typically located? 70-80% over the convexity, 10-20% are parafalcine 20.3.2 26. List the most common etiologies of SDE: a. p______ s______ (especially f______) b. o______ (usually c_____ o_____ m______) c. p____ s_________ (neuro or ENT) d. t______ 27. Causative organisms in SDE: a. Associated with sinusitis? a______ and a_______ s____ b. Following trauma or procedures? s____ and g___-n____ c. Sterile cultures are more common following ________. 28. a. b. c. d. e. f. g. h. i. Neurological findings in SDE include: f_____ h_______ m___________ h_________ a______ m_____ s______ s______ s______ t_________ n______/v_________ h_____________ h___________ 20.3.3 paranasal sinusitis (esp. frontal) otitis (usually chronic otitis media) post surgical trauma 20.3.4 aerobic and anaerobic strep staph and gram-negatives previous antibiotic exposure 20.3.5 fever headache meningismus hemiparesis altered mental status seizures (usually occur late) sinus tenderness nausea/vomiting homonymous hemianopsia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Bacterial and Complex Infections 29. True or False. Evaluating SDE with a LP true is potentially hazardous and rarely positive. 20.3.6 30. True or False. Burr holes are more true effective for SDEs early in the course when the pus tends to be more fluid and fewer loculations have developed. 20.3.7 31. Fatal cases of SDE have been venous infarction of the brain associated with v_____ i_______ of the b_____. 20.3.8 117 20 Neurologic Involvement in HIV/AIDS 32. Regarding patients with AIDS. a. What percentage will present initially with a neurological complaint? b. How many patients that die with AIDS have a normal brain at autopsy? 33. The most common conditions producing focal CNS lesions in AIDS are: a. t_____________ b. p______ C__ l_________ c. p_________ m__________ l____________ d. c____________ e. t__________ 34. Infection with HIV itself can have direct neurological involvement such as: a. A____ e_____________ b. A____ d________ c. a______ m_________ d. c______ n__________ e. A____-r_____ m_________ f. p___________ n_______ 35. Complete the following about CNS diseases in AIDS: a. Does CNS toxoplasmosis occur early or late in the course of HIV infection? b. What causes PML? c. What virus is associated with primary CNS lymphoma (PCNSL)? d. How quickly can AIDS patients develop neurosyphilis? 20.4.1 33% 5% 20.4.1 toxoplasmosis primary CNS lymphoma progressive multifocal leukoencephalopathy (PML) cryptococcus tuberculoma (TB) 20.4.1 AIDS encephalopathy (most common) AIDS dementia aseptic meningitis cranial neuropathies (e.g. Bell’s palsy) AIDS-related myelopathy peripheral neuropathy 20.4.1 late (typically CD4 counts < 200 cells/mm3) JC virus EBV as little as 4 months following infection ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 118 Part 6: Infection 36. Complete the following chart by listing the CT and MRI findings in each of the following: a. Toxo i. number ii. enhance iii. location 20 iv. mass effect v. miscellaneous b. PCNSL i. number ii. enhance iii. location iv. mass effect v. miscellaneous c. PML i. number ii. enhance iii. location iv. mass effect v. miscellaneous 20.4.2 > 5 lesions ring basal ganglia and grey-white junction mild-moderate surrounded by edema < 5 lesions homogenous subependymal mild may cross corpus callosum may be multiple none white-matter none-minimal high signal on T2WI, low signal on T1W1 37. Complete the following about the management of AIDS-related intracerebral lesions: a. Treatment for toxoplasmosis i. p__________ ii. s_________ iii. l__________ b. How promptly should we see improvement clinically and radiologically? c. If successful, how long should toxoplasmosis be treated? d. biopsy should be considered if there is no response in ______ _____. e. True or false. Toxo cannot be radiologically distinguished from i. PCNSL. ii. PML. f. For diagnosis, check: i. for toxo ii. for lymphoma 20.4.3 pyrimethamine sulfadiazine leucovorin 2 to 3 weeks Patients need lifetime meds 3 weeks true usually serum toxo titers OP of LP and cytology; PCR amplification of EBV DNA ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Bacterial and Complex Infections 38. Considerations for performing a biopsy of a brain lesion in an HIV+ patient? a. If toxo titers are ________. b. If no response to toxo meds in ________. c. True or false. Biopsy is equally valuable in lesions that enhance or don’t enhance. d. Technique for biopsy: e. What two areas should be sampled? f. Positive biopsy can be expected in _____% 39. Indicate the survival times for AIDS patients with the following conditions: a. CNS toxo ________ b. PML _______ c. lymphoma __________ d. lymphoma in nonimmunosuppressed patients _________ 119 20.4.3 negative 3 weeks false (more valuable in enhancing lesions to differentiate toxo from lymphoma) stereotactic enhancing rim and center 96 20 20.4.4 15 months 15 months 3 months (1 month w/o treatment) 13.5 months Lyme Disease – Neurologic Manifestations 40. Lyme disease is caused by _________ and transmitted by the ______ tick. 41. Regarding clinical findings of Lyme disease. a. classic rash e______ c_______ m_____ b. clinical triad of neurological manifestations i. c____ n______ ii. m_______ iii. r___________ c. neurological findings frequently m________ d. cardiac c______ d_____ and m___________ e. in the late stage: a______ and c____ n________ s_______ 42. True or false. Regarding diagnosis of Lyme disease. a. No test is indicative of active infection. b. Antibodies can be seen on serology immediately after initial infection. c. CSF studies may be compatible with aspectic meningitis or MS. Borrelia spirochetes; Ixodes 20.5.1 20.5.2 erythema chronicum migrans (“bulls-eye” rash) cranial neuritis (bilateral “Bell’s palsy”) meningitis radiculopathy migrate conduction defects; myopericarditis arthritis; chronic neurological syndromes 20.5.3 true false (typically requires 2-3 weeks for antibodies to be detected in untreated patients) true (oligoclonal bands may be seen) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 120 Part 6: Infection Nocardia Brain Abscess 43. Complete the following regarding Nocardia: a. It arises from the ______. b. It is a ______. c. Seen in patients with c______ d_____ i___. 20 44. Nocardia is typically diagnosed with a b____ b_______. 45. The treatment regimen for Nocardia is: a. T___-S___ b. i_______ c. Duration? 20.6.1 soil bacteria (not a fungus) chronic debilitating illness brain biopsy 20.6.2 20.6.3 TMP-SMX imipenem > one year or life-long ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 21 Skull, Spine, and Post-Surgical Infections Shunt Infection 1. a. b. c. Regarding shunt infection. Acceptable infection rate? Risk of early infection after surgery? ___% of Staph infections occur within 2 mos. d. Most common source is _______ ________. 2. Mortality ranges from __ to __% for children after a shunt infection. 3. a. b. c. Risk factors for shunt infection: y______ a___ of p_______ l_____ of p________ o____ n_____ t____ d______ 4. Causal pathogens of shunt infections: a. Early infection i. S____ e_________ (most common) ii. S. a______ iii. g___-n______ b______ iv. in neonates: E____ c___ and S_____ h_____ b. Late infection (> 6 months after procedure) i. risk? ii. most common organism? c. Fungal infections i. most common: C_______ spp. 5. What are the common characteristics of shunt nephritis? a. v_______v_______ shunt b. c______ l___ l_____ infection c. i_______ c________ deposition in g_______ d. p_______ and h________ 21.1.1 < 5 – 7% 7% 70% (> 50% within the first two weeks) patients’ skin 10 to 15% 21 21.1.2 21.1.3 young age of patient length of procedure open neural tube defect 21.1.4 Staph. epidermidis Staph. aureus gram-negative bacilli E. coli and Strep. hemoliticus 2.7 – 31% (typically 6%) Staph. epidermidis Candida 21.1.5 ventriculovascular chronic low level immune complex; glomeruli proteinuria; hematuria ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 122 Part 6: Infection 6. Gram negative bacillus (GNB) shunt infection compared with gram positive bacillus (GPB): a. morbidity b. Following a shunt tap i. Gram stains ii. protein iii. glucose iv. neutrophils 7. True or False. Regarding treatment of shunt infections. a. Remove shunt. b. Treatment with antibiotics without shunt removal is only recommended when patients are terminally ill, is a poor anesthetic risk, or has ventricles that may be difficult to catheterize. c. Place EVD. d. Intraventricular injection of preservativefree antibiotics in addition to IV therapy is never indicated. e. Antibiotics should be continued 7 days after sterilization of the CSF. f. Patients with peritonitis and a VP shunt will often have ascending infection into the CNS. g. VP shunts must be immediately removed following peritonitis. 21 21.1.5 higher in GNB more than 90%+ Gram stain (in contrast to only 50% in GPB) higher in GNB lower in GNB higher in GNB 21.1.5 true true true false false (10-14 days) false false External Ventricular Drain (EVD)-Related Infection 8. The diagnosis of an EVD-related infection is suggested by: a. h____________ b. r______ c____ i______ c. C__ p________ > ____ d. in the presence of p______ C___ c______ 9. What is the formula for cell index? 10. Contamination in the context of EVDinfection is a. P______ CSF c______ and/or g____ s_____. b. No attributable s_______ or s_____. 21.2.1 hypoglycorrhea (CSF glucose/ blood glucose < 0.2) rising cell index CSF pleocytosis > 1000 positive CSF cultures Cell index = CSFleukocytes/CSFerythrocytes Bloodleukocytes/Blooderythrocytes 21.2.2 21.2.2 positive CSF culture and/or gram stain No attributable symptoms or signs ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Skull, Spine, and Post-Surgical Infections 11. a. b. c. d. Risk factors for EVD infections: d______ of EVD s___ l_______ b_____ in CSF (IVH and SAH) i_______ and f________ 12. The usual organisms that cause EVDrelated infections are a. s____ f_____ b. present in the h_______ e_________ c. May form a b_____ that increases antimicrobial resistance. 13. Management of an EVD infection: a. empiric antibiotics: i. v_________ + ii. c_______ or c________ b. r_______ catheter c. add i________ a________ d. by clamping ______ for _____ minutes e. wait at least _____ days after CSF sterilizes to implant new shunt 21.2.3 duration site leakage blood irrigation and flushing 21.2.4 skin flora (coagulase-negative staph, P. acnes) healthcare environment biofilm 21.2.7 vancomycin ceftazidime or cefepime remove (if it is safe to do so) intrathecal antibiotics EVD; 15 – 60 min 7 – 10 days 14. Prevention of EVD infections. a. tunneling _____ away from the burr hole > 5 cm b. a______ c____ c________ antibiotic coated catheters (rifamipin+ minocycline) c. do NOT i. e______ the catheter at day 5 exchange ii. give p_______ a_____ p________ prolonged antibiotic prophylaxis 123 21 21.2.7 Wound Infections 15. Laminectomy superficial wound infection management: Hint: bcdefgh a. b________ b. c______ c. d______ w_____ d. e______ use v______ + c______ e. f_________________ f. g_________________ g. h_________________ 21.3.1 bacitracin (half-strength) followed by normal saline culture debride wound empirically; vancomycin + cefepime fill with iodoform ¼ inch gradually trim 0.5-1 inch of packing with each dressing change change q8 hrs for hospitalized patients, BID for patients at home ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 124 Part 6: Infection 16. Regarding post-operative discitis. a. _______ _________ is the most common pathogen. b. ___% present by 3 weeks post-op c. ____ _____ at the site of the operation is the most common symptom. d. Management includes: i. a______ + m_____ r_______ ii. a________ iii. a______ r________ iv. c______ if radiographs are suspicious 21 80% back pain analgesics + muscle relaxants antibiotics activity restriction culture Osteomyelitis of the Skull 17. Complete the following concerning Pott’s puffy tumor: a. Treatment i. f______ r_______ ii. d________ iii. antibiotics for _____ weeks. ___ for first week iv. wait approx. ____ months for cranioplasty b. Most common organism is ________ __________. 21.3.1 Staph aureus 21.4.4 flap removal debridement 6 to 12; IV 6 Staphlococcus aureus 21.4.2 Spine Infections 18. What are the main categories of spine infections? a. v_______ o__________ b. d______ c. s____ e_______ a_______ d. s____ s______ e_________ e. m__________ f. s______ c_____ a_______ 19. Describe a spinal epidural abscess. a. Most common site for spinal epidural abscess is the ______ ______ at ____% b. The next most common is _____ at _____%, followed by _____ at _____% c. Symptoms include: i. s_____ t________ ii. f_____ iii. b____ p____ d. Co-morbid conditions i. d____ m_______ ii. I_ d____ a_____ iii. a________ iv. c___ r____ f______ v. i______ c_________ 21.5 vertebral osteomyelitis discitis spinal epidural abscess spinal subdural empyema meningitis spinal cord abscess 21.5.1 thoracic level; 50% lumbar; 35%; cervical; 15% spine tenderness fever back pain diabetes mellitus IV drug abuse alcoholism chronic renal failure immune compromised ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Skull, Spine, and Post-Surgical Infections e. ____ ______ is the most common organism cultured. f. ____ is the imaging study of choice. g. Treatment consists of _________ ________ + ________ 20. Describe the pathophysiology of spinal cord dysfunction. a. Compression by i. m_____ of a_____ ii. b____ by c_____ of o_______ v______ b____ b. Infarction by v_____ t___________ c. Direct spread to the cord can cause m_____. 21. Complete the following regarding causes of spinal epidural abscess: a. Hematogenous – most commonly from i. f_______ ii. IV d______ a____ b. d____ e________ c. Spinal procedures i. d_______ ii. n______ d. TB associated with ___ disease: ___% e. multiple organisms: ___% 23. Complete the following regarding spinal epidural abscess (SEA): a. If during a spinal tap you encounter pus, what should you do? b. Empiric antibiotics for SEA i. c________ c. d. e. f. Staph. aureus MRI surgical evacuation + antibiotics 21.5.1 mass of abscess bone by collapse of osteomyelitic vertebral body venous thrombophlebitis myelitis 21.5.1 21 furuncle IV drug abuse direct extension (e.g. psoas abscess) discectomy (incidence of SEA is 0.67%) needles (catheters) 22. Cultures from spinal epidural abscess patients can be expected to show the following: a. Staphlococcus aureus: ___% b. no growth: ___ to ___% c. Streptococcus (frequency) ii. 125 v_______ iii. m___________ iv. ±r__________ The length of time IV antibiotics should be administered for SEA is ____. Mortality is ____% Recovery of severe neurologic deficit is _____ ____. An exception to this rule is ____ - __% improve neurologically. 21.5.1 50 – most common organism 30 to 50% second most common organism Pott’s disease; 25% 10% 21.5.1 Stop advancing the needle and culture the pus. ceftriaxone or cefepime (if pseudomonas is a concern) vancomycin (until MRSA can be ruled out) metronidazole rifampin PO min. 6 weeks with immobilization 4 to 31% very rare Pott’s disease – 50% improve neurologically ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 126 Part 6: Infection 24. Complete the following regarding vertebral osteomyelitis: a. Risk factors i. d_____ ii. d_____ iii. h_____ iv. a_____ b. What condition in renal patients can mimic infection on MRI? c. Sources of infection are never found in ____%. 21 d. Neurologic deficits occur in ____ to ____% of Pott’s disease patients e. How long does it take for plain x-rays to demonstrate changes? f. Best imaging test? 25. True or False. Regarding the treatment of vertebral osteomyelitis. a. Instrumented fusion is contraindicated. b. It is permitted even in pyogenic infections. c. 90% of cases can be successfully managed nonoperatively. d. TLSO brace has no role in nonoperative management. 26. One differentiates spinal destruction from a. infection: i_____ the d____ b. metastases: m______ the d____ 27. What is the MRI triad of infection in discitis? a. a_____ p______ p_____ b. b______ m__________ c. d_____ s________ 28. What is the CT triad of infection in discitis? a. e______ p_______ f_______ b. p_________ s_____________ c. p__________ a______ 29. Complete the following regarding discitis: a. Cultures are positive i. from the disc space in ____%. ii. from the blood in ____%. b. The usual pathogen is _______. c. Special staining is required to detect _____, and should be done in ___ cases. 21.5.2 drug abuse diabetes mellitus hemodialysis advanced age destructive spondyloarthropathy 37% (consider urinary tract infection (UTI; most common source), respiratory tract, teeth) 10 to 47% 2 to 8 weeks MRI with and without contrast 21.5.2 false true true false 21.5.3 involves the disc miss the disc and involve the vertebral body 21.5.3 annulus posterior portion bone marrow disc space 21.5.3 end plate fragmentation paravertebral swelling paravertebral abscess 21.5.3 60% 50% Staphlococcus aureus TB; all ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Skull, Spine, and Post-Surgical Infections 30. Complete the following about discitis: a. In children, discitis manifests itself by the child’s refusal to ____ or _____ or ____. b. Postop discitis is suggested when the i. ESR is raised to ______ and does not come down. ii. CRP is above __ mg/L at ____wks post-op. c. Interval between surgery and radiological changes in discitis: i. plain x-rays: _____ weeks ii. polytomography: ___ weeks 31. a. b. c. Regarding the treatment of discitis. a________ i_________ Approaches for surgery (only needed in 25% of cases) i. a______ in the cervical or thoracic regions ii. p______ l_________ in lumbar region 32. Complete the following concerning psoas abscess: a. Psoas extends from ___ to ___. b. Psoas is the primary hip _____ c. innervated by ______. d. Pain on hip _______. e. CT shows _____ of psoas shadow f. inside the ____ wing. walk or stand or sit 127 21.5.3 21.3.1 20 mm/hr 10; 2 12 (1 to 8 months range) 3 to 8 weeks 21.5.3 antibiotics immobilization 21 anterior posterior laminectomy 21.5.4 T12 VB to L5 VB flexor L2-4 flexion enlargement iliac ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 22 Other Nonbacterial Infections 22 Viral Encephalitis 1. Complete the following regarding herpes simplex: a. HSE stands for ________ ________ _____. b. b. It has a predilection for the t________, o________ l________ and l________ s________. c. Definitive diagnosis requires b________ b________ and v________ i________. d. Treat promptly with ________. 2. HSE has the following characteristics: a. CSF: ________-________ b. EEG: p________ l________ e________ discharges on electroencephalography. c. CT: e________ in t________ l________ d. Hemorrhage on ________ means ________ ________. e. MRI shows t________ s________. f. Significance: If bilateral it is highly suggestive of ________. 3. Transsylvian sign a. indicates temporal lobe e________ b. that extends across the s________ f________. 4. General treatment for intracranial pressure (ICP) elevation involves the following: a. e________ h________ of b________ b. m________ c. h________ 22.1.1 herpes simplex encephalitis temporal, orbitofrontal lobes and limbic system brain biopsy and virus isolation Acyclovir 22.1.1 leukocytosis-monocytes periodic lateralizing epileptiform edema in temporal lobes CT; poorer prognosis transsylvian sign HSE 22.1.1 edema Sylvian fissure 22.1.1 elevate head of bed mannitol hyperventilate ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Other Nonbacterial Infections 5. Complete the following concerning acyclovir treatment: a. The dose is ________ 129 22.1.1 30 mg/kg/day (is divided every 8 hours) b. for a duration of ________ days. 14 to 21 c. If you identify HSE before GCS drops, you limit mortality can l________ m________. 6. Which inclusion body identifies VZV on brain biopsy? a. VZV stands for v________ z_______ v_______ Cowdry type A 22.1.2 varicella zoster virus Creutzfeldt-Jakob Disease 7. Complete the following about Creutzfeldt-Jakob disease: a. CJD stands for ________ ________ ________. b. The prognosis is ________ ________. c. The EEG shows ________. d. Prion stands for ________ _______ ________. e. Classic histologic triad i. n______ l_______ ii. a________ p________ iii. s________ s_________ f. Diagnostic triad i. d________ ii. E________ iii. m_______ 22.2.1 22 Creutzfeldt-Jakob disease invariably fatal characteristic bilateral sharp waves 0.5 to 2.0 per second proteinaceous infectious particles 22.2.8 neuronal loss astrocytic proliferation status spongiosus 22.2.10 dementia EEG myoclonus 8. Detection of protein ______ in the CSF 14-3-3; has _____% sensitivity and specificity 96% for CJD among patients with dementia. 22.2.10 9. What is the biopsy procedure in suspected CJD? a. Use a ________ cranial saw b. to avoid ________ of the infection. c. Avoid cutting the _______ with the saw. d. Clearly ________ containers. e. Fix in ________% phenolized formalin. 22.2.10 manual aerosolization dura label 15% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 130 Part 6: Infection Parasitic Infections of the CNS 10. a. b. c. Regarding cysticercosis. Caused by which organism? At which life cycle stage? The life cycle stages (4) include the following: i. e________ ii. a________ iii. e________ iv. l________ d. The current best test is ________________ ________ ________. 22 11. Complete the following statements about parasitic infections of the CNS: a. Cysticercosis is caused by i. the p________ t______ ii. T________ s________ b. Echinococcus is caused by i. the d________ t______ ii. E________ g________ c. What is hydatid sand? d. Caution is advised during removal not to ________. 12. Describe the life cycle of cysticercosis. a. Pig contains ________ ________ in its flesh. b. Humans eat undercooked ________ with ________ in it. c. Embryo matures to an ________. d. The ________ produces eggs. e. Eggs are released in the ________ of the human. f. The same or a different human _______ the ________. g. Eggs in this host release ________ h. which burrow through the ________ ________ ________ to ________. i. Larva lands and develops a ________ ________ j. and becomes an ________ ________ k. in ________ months. 22.3.2 Taenia solium larval stage embryo adult eggs larva enzyme-linked immunoelectrotransfer blot 22.3.2 pork tapeworm Taenia solium 22.3.3 dog tapeworm Echinococcus granulosa germinating parasitic scoleces rupture the Echinococcus cyst and contaminate adjacent tissues 22.3.2 encysted embryo pork; embryo adult adult feces ingests the eggs (from contaminated fingers, vegetables, or water) larvae small bowel wall to circulation cyst wall encysted embryo 4 13. Answer the following concerning neurocysticercosis a. What is the permanent host for the adult human tapeworm? b. What is the intermediate host? human or animal (pig) 22.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Other Nonbacterial Infections 14. Answer the following concerning neurocysticercosis a. What is the significance of CT scan with i. low-density cysts with eccentric punctate high-density spots in an enhancing ring? ii. above plus edema? iii. intraparenchymal punctate calcifications? b. What may soft tissue x-rays show? c. What might MRI show? 15. Complete the following regarding CT in cysticercosis: a. Ring-enhancing cysts suggest ________ ________. b. Intraparenchymal punctate calcifications suggest ______ __________. c. Ring-enhancing cyst with edema suggests i. r______ d______ or d______ p______ with ii. i_________ r_______ 22.3.2 living cysticerci dying cysticerci dead parasites calcifications in thigh or shoulder intraventricular or cisternal cysts living cysticerci 22.3.2 22 dead parasites recently dead or dying parasite inflammatory reaction Fungal Infections of the CNS 16. What organism can cause a cerebral abscess in an organ transplant patient? Aspergillus fumigatus 17. Name the most common fungal cryptococcosis infection of the CNS diagnosed in the living patient. a. Lumbar puncture usually shows elevated, 75% ________ opening pressure in _____% of patients. b. Serum cryptococcal antigen is ______ elevated with CNS involvement. 131 22.4.1 22.4.2 Amoebic Infections of the CNS 18. Describe amoebic infections of the CNS. a. The only amoeba known to cause infection is ________ ________. b. Infection occurs 5 days after exposure in warm ________. c. The amoeba gains entry to the CNS via o__________ m_________. d. 95% fatal within ________ e. due to ________. f. Treat with ________ ________. 22.5.1 Naegleria fowleri freshwater olfactory mucosa 1 week ↑ICP amphotericin B ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 23 Cerebrospinal Fluid 23 General Information 1. The volume (mL) of cerebrospinal fluid (CSF) in a. a newborn is ________. 5 b. an adult is ________. 150 Table 23.1 2. What is the intracranial:spinal ratio of distribution of CSF in adults? Table 23.1 50:50 Production 3. What percentage of CSF is produced in 80% the lateral ventricles? 23.2.1 4. Where is CSF produced other than in the choroid plexus? a. i________ s________ b. e________ l________ of the v________ 23.2.1 c. d________ of n________ r________ s________ in s________ 5. The amount of CSF volume produced per day for a. adults is ________. b. newborns is ________. 6. What is the rate of CSF formation mL/min in adults? 7. What is the CSF pressure in a patient in lateral decubitus position in the following age groups? a. newborn b. 1 to 10 years old c. young adult d. adult 8. Complete the following concerning CSF: a. What is the rate of CSF production? b. That equals how many mL per day? interstitial space ependymal lining of the ventricles dura of nerve root sleeves in spine 23.2.2 450 to 750 mL/d 25 mL/d 0.3 to 0.5 23.2.2 Table 23.1 9 to 12 cm H2O < 15 < 18 to 20 < 18 (7 to 15) 23.2.2 0.3 to 0.5 mL/min 450 to 750 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Cerebrospinal Fluid c. Normal CSF has i. ________ lymphocytes ii. ________ polymorphonuclear leucocytes (PMN) iii. ________ red blood cells (RBCs) d. White blood cells (WBCs) above ________ is suspicious. e. WBCs above ________ is definitely abnormal. f. Subtract ________ WBC for every ________ RBCs. g. Subtract ________ mg protein for every ________ RBCs. 9. Does intracranial pressure (ICP) have any effect on CSF formation? ii. c________ p________ iii. l________ 0 to 5 0 0 5 to 10 10 WBCs per cubic mm 1; 700 1; 1000 no (The rate of formation is independent of CSF pressure except if the ICP is so high that it causes reduction in cerebral blood flow [CBF].) 23.2.2 Absorption 10. Complete the following concerning CSF: a. True or False. CSF absorption is a pressure-dependent phenomenon. b. Where does it take place? i. a________ v________ 133 23.3 23 true arachnoid villi → dural venous sinuses choroid plexus lymphatics CSF Constituents 11. True or False. The composition of CSF is exactly the same in the ventricles as in the lumbar subarachnoid space. 12. True or False. The following are normally found in CSF: a. lymphocytes b. mononuclear cells c. polymorphonuclear leucocytes d. RBCs 13. True or False. CSF osmolarity and plasma osmolarity are equal, with a ratio 1:1. What is the other constituent that is also equal among the following? a. Na b. K+ c. Cl− d. IgG false (It differs slightly.) 23.4.1 23.4.1 true true false false 23.4.2 true false false false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 134 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) 14. True or False. CSF proteins a. are equal in adults and children. b. in prematures are ~60 mg/dL. c. in newborn are ~40 mg/dL. d. normally rise ~1 mg/dL/yr of age in adults. 15. How do you differentiate true leukocytosis from normal white blood cell count included in the traumatic tap? a. ratio of ________ to ________ b. normal is ________ c. or subtract 1 WBC for every ________ ________ 16. What conditions would affect the WBC:RBC ratio of 1:700? a. a________ b. p________ l________ 23 17. How would you estimate the correct protein in the CSF of a traumatic tap? a. Subtract ________ mg of protein b. for every ________ RBCs/mm3. 23.4.4 false (30 mg/dL in adults and 20 mg/dL in children) false (in prematures 150 mg/dL) false (about 80 mg/dL in newborn) true Table 23.4 RBC to WBC 700:1 700 RBCs Table 23.4 anemia peripheral leukocytosis Table 23.4 1 1000 18. Answer the following about subarachnoid hemorrhage: a. How long does it take for RBC to 2 weeks disappear? b. How long does it take for xanthochromia many weeks to disappear? Table 23.4 Cranial CSF Fistula 19. Rosenmüller’s fossa is located just ________ to the ________ ________. inferior to the cavernous sinus (Rosenmüller’s fossa is located just inferior to the cavernous sinus exposed by drilling the anterior clinoid in a paraclinoid aneurysm. Upper lateral pharyngeal recess. Limited above by the sphenoid and occipital bone communicates with the nasal cavities.) 20. True or False. The following are characteristics of traumatic CSF fistula: a. They occur in 2 to 3% of all patients with true head injury. b. 60% are noted within days of trauma. true c. 95% occur within 3 months of trauma. true 23.5.2 23.5.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Cerebrospinal Fluid d. < 5% of cases of CSF rhinorrhea stop within 1 week. e. Adult:child ratio is 1:10. f. Occurrence is common before age 2 years. g. Anosmia is common. h. Most CSF otorrhea ceases in 5 to 10 days. 21. Complete the following concerning posttraumatic CSF fistula: a. Rhinorrhea stops within ________ week in ________%. b. Otorrhea stops within ____ to ____ days in ____ to ____%. 22. True or False. Regarding CSF fistulas. a. Anosmia is common in traumatic leaks. b. Anosmia is common in spontaneous leaks. 23. Study Chart. a. Regarding spontaneous CSF fistula: (Hint: spontaneous fistula h) 135 false (70% of cases stop within 1 week.) false (adult:child ratio is 10:1) false (occurrence uncommon prior to 2 years of age) true (78% have anosmia.) true 23.5.3 1; 70% 5 to10; 80 to 85% 23.5.3 true (78% in traumatic leaks) false (rare inspontaneous leaks; approximately 5%) 23.5.3 sense of smell preserved pneumocephalus is not common otitis media neck stiffness tumor-pituitary-meningioma allergic rhinitis meningitis empty sella syndrome otitis media may result in CSF leak undeveloped floor of anterior fossa sense of smell preserved cribriform plate agenesis sinusitis (paranasal sinusitis) foot plate of stapes is dehiscent—CSF into eustachian tube facial canal fistula into middle ear insidious, ICP is high intermittent serous effusion transsphenoidal surgery consequence unable to hear due to Mundini dysplasia labyrinthine anomalies adenoma of pituitary hydrocephalus 23 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 136 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) Meningitis in CSF Fistula 24. The infection rate for a. penetrating injuries and CSF fistulas is ________%. b. penetrating injuries without fistula is ________%. 25. Complete the following concerning meningitis in CSF fistula: a. Posttraumatic CSF leak has an incidence of meningitis of ____ to ____%. b. Does CSF leakage after surgery have a higher or lower incidence of meningitis? c. If the leakage site is not identified before surgery, failure to close CSF leaks is ________%. d. The most common pathogen is ________ and its percentage is ________%. 23 23.7 50% 4.6% 23.7 5 to 10% higher 30% (recurrent leak postop) Pneumococcus; 83% Evaluation of the Patient with CSF Fistula 26. What are the characteristics of the fluid suggesting the presence of rhinorrhea or otorrhea resulting from a CSF fistula? a. CSF fluid is ________. b. True or False. Fluid causes excoriation. c. Fluid tastes ________. d. Glucose is greater than ________ mg %. 23.8.1 as clear as water (unless infected or blood present). false (Fluid doesn’t cause excoriation of the nose.) salty (in rhinorrhea). normal CSF glucose > 30 mg %. β2-transferrin (present in CSF) e. It contains a special chemical called ________. f. The special sign when it drops on a sheet ring sign (An old but is called a ________. unreliable sign. Described as a ring of blood surrounded by a larger concentric ring of clear fluid [suggests the presence of CSF] seen when blood-tinged fluid allowed to drip onto linen [sheet or pillowcase].) 27. Name five characteristics of fluid that suggest the presence of CSF fistula. Hint: bcsfg a. B__________ b. c__________ c. s__________ d. f__________ e. g__________ 23.8.1 β2-transferrin clear salty taste fluid does not excoriated glucose ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Cerebrospinal Fluid Treatment for CSF Fistula 28. True or False. The procedure of choice to localize the site of CSF fistula is a. magnetic resonance imaging b. iohexol cisternography c. computed tomography with intravenous contrast d. plain x-ray 137 23.9.2 false true false false Intracranial Hypotension (Spontaneous) 29. Spontaneous intracranial hypotension is characterized by a. o________ h________ b. l_____ c______ p_______ c. d_________ p_________ e_________ 30. Characteristics on imaging that suggest intracranial hypotension (Hint: SEEPS) a. S_________ b_________ b. E_________ c. E_________ v_________ d. P_________ h_________ e. S_________ f_________ 31. True or False. Epidural blood patch provides relief for the majority of patients. 32. Conservative management for intracranial hypotension includes a. b______ r______ b. h__________ c. a_________ d. c_________ e. a_________ b_______ 23.10.1 orthostatic headache low CSF pressure diffuse pachymeningial enhancement 23.10.1 sagging brain enhancement (pachymeningeal) engorged veins pituitary hyperemia subdural fluid true 23 23.10.1 23.10.1 bed rest hydration analgesics caffeine abdominal binder ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 24 Hydrocephalus – General Aspects Etiologies of Hydrocephalus 1. Complete the following statements about hydrocephalus: a. Incidence of congenital hydrocephalus is ________%. b. Due to either ______ CSF resorption or c. CSF _________. 24 2. True or False. Indicate if the following are considered “true” hydrocephalus: a. hydrocephalus ex vacuo b. obstructive hydrocephalus c. communicating hydrocephalus 3. Regarding the characteristics of the etiology of hydrocephalus. a. True or False. There is excess production of CSF. b. True or False. There is impaired absorption of CSF. c. True or False. It is congenital without myelomeningocele. d. Congenital with myelomeningocele usually occurs with________. e. Chiari I, if a cause, has ________ ________ ________ ________. f. Aqueductal stenosis presents symptoms in ________. g. Secondary aqueductal stenosis is due to ______ _________, ________, or ________. h. Atresia of foramina of Luschka and Magendie is called ________-________ ________. 24.3.1 0.2% subnormal overproduction 24.3.1 false true true 24.3.2 true true true Chiari II fourth ventricle outlet obstruction infancy intrauterine infection, hemorrhage, or tumor Dandy-Walker syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Hydrocephalus – General Aspects 4. Complete the following concerning etiologies of hydrocephalus: a. ________% of post-op pediatric postfossa tumor patients develop hydrocephalus and need a shunt. b. This may be delayed for up to ________. c. Dandy-Walker malformation occurs in what percentage of patients with hydrocephalus? 139 24.3.2 20% 1 year 2.4% Signs and Symptoms of HCP 5. List the signs and symptoms of active hydrocephalus in older children/adults with rigid cranial vault. a. h_________ b. n_________ c. v__________ d. changes in g______ and b_____ c_____ e. p__________ f. u________ g_________ p_________ 6. List signs and symptoms of hydrocephalus in young children. (Hint: hydrocephalusss) a. h________ b. y________ c. d________ d. r________ e. o________ f. c________ g. e________ h. p________ i. h________ j. a________ k. l. m. n. o. l________ u________ s________ s________ s________ 7. Occipital frontal circumference (OFC) in the normal child should equal the distance from crown to ________. 24.4.1 headache nausea vomiting gait; bladder control papilledema upward gaze palsy 24.4.2 24 hydrocephalus young (children) diplopia (on lateral gaze; abducens palsy) respiratory pattern (irregular) outward protrusion of fontanelle cracked pot sound of Macewen enlargement of cranium poor head control, Parinaud syndrome hyperactive reflexes apneic spells, abducens nerve palsy large head upward gaze palsy scalp veins prominent setting sun sign splaying of cranial sutures (seen on plain skull x-rays) rump 24.4.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 140 24 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) 8. For the indicated ages give the expected normal head circumference pattern. (Hint: At 33 weeks the circumference is 33 cm. In a child younger than 33 weeks the head circumference is greater in cm than the age of the child in weeks old. After 33 weeks head circumference growth slows so that at 40 weeks of age the head circumference is 36 cm.) a. Premature (ages in weeks) i. 28 ii. 29 iii. 30 iv. 31 v. 32 vi. 33 vii. 34 viii. 35 ix. 36 x. 37 xi. 38 xii. 39 xiii. 40 b. Full term (ages in months) (Hint: Note the pattern; with each month head circumference increases by 1 cm.) i. 1 ii. 2 iii. 3 iv. 4 v. 5 vi. 6 c. What is the upper limit of head circumference for a baby? i. 28 weeks gestational age ii. 33 weeks gestational age iii. 2 months old iv. 3 months old v. 4 months old vi. 6 months old 9. Blindness in hydrocephalus may be due to: (Hint: pop) a. p________ b. o________ c________ c________ c. p________ c________ a________ o________ Fig. 24.1 29 cm 30 cm 31 cm 31.5 cm 32 cm 33 cm 33.5 cm 34 cm 34.5 cm 35 cm 35 cm 35.5 cm 36 cm 40 cm 42 cm 43 cm 44 cm 45 cm 46 cm 29 cm 33 cm 42 cm 43 cm 44 cm 46 cm 24.4.3 papilledema (chronic—optic atrophy―damage to optic disc) optic chiasm compression (due to dilation of third ventricle) posterior cerebral artery occlusion (compressed at tentorial edge due to downward herniation) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Hydrocephalus – General Aspects 10. Types of blindness from hydrocephalus are ________ ________and ________ ________. a. Characteristics for pre__________ b________ i. o________ n________ a________— s________ ii. p________ r________—p________ iii. due to p________, h________, a________ b. Characteristics for post________ b_______ i. o________ n________ a_______— m________ ii. p________ r________—n________ iii. due to ________ or ________ 11. Cortical blindness may be associated with a. Anton’s syndrome = d________ of v________ d______ b. Ridoch’s phenomenon = a________ of m________ o________, but n___ a________ of s________ o________ 24.4.3 pregeniculate blindness optic nerve atrophy—severe pupillary reflexes—poor pressure, hypotension, anemia postgeniculate blindness optic nerve atrophy—minimal pupillary reflexes—normal hypoxia or trauma (macular sparing in PCA occlusion, no macular sparing in trauma to occiput) 24.4.3 denial of visual deficit 24 appreciation of moving objects, but no appreciation of stationary objects CT/MRI Criteria for Hydrocephalus 12. Hydrocephalus-radiologic criteria: a. Temporal horns’ width is >________mm. b. Frontal horns ballooning look like M________ M________. c. Transependymal ________ d. Ratio of frontal horns to internal diameter of brain. e. Anteroposterior (AP) view shows _____________________. f. Third ventricle on AP view shows ________ ________. g. Evans ratio > ______. h. Corpus callosum is ________ i. and shows ________and ________ ________. pregeniculate blindness and postgeniculate blindness 141 24.5.2 2 mm Mickey Mouse edema 50% disproportion of ventricle size and cortical sulci bowing laterally 0.3 thin/atrophic stretching and upward bowing Chronic HCP 13. a. b. c. Characteristics of chronic HCP: Inner table shows ________ _______. Sella shows _______. Corpus callosum shows ______. 24.7 beaten copper cranium erosion atrophy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 142 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) External Hydrocephalus (AKA Benign External Hydrocephalus) 14. Complete the following about external hydrocephalus: a. Malignant or benign? b. Enlarged s________ spaces over the c. f________ poles in the d. f____ year of life. e. Resolves by age ______. 24 24.8.1 benign subarachnoid frontal first 2 years of age 15. External hydrocephalus may be distinguished from subdural hematoma by the presence of c________ v______ s_______. cortical vein sign 24.8.1 16. The cortical vein sign shows _____ extending from the brain to the i____ t_____ of the skull on CT or MRI. veins; inner table 24.8.1 hydrocephalus; inherited 24.9.1 X-linked Hydrocephalus 17. X-linked hydrocephalus a. is a type of h_________ that is ________. b. occurs in ________% of patients with hydrocephalus. c. Gene is located on ________. d. It causes abnormality in m_______ r________ and L______. e. produces classical syndromes (Hint: crash) i. c________ c________ h________ ii. r________ iii. a________ t________ iv. s________ p________ v. h________ 18. Complete the following regarding radiographic finding of L1 syndrome: a. Large i. p________ h________ ii. m________ i________ iii. q________ p________ b. Small (hypoplastic) i. c________ c________ ii. c________ v________ c. Rippled i. v________ w________ d. Which feature is pathognomonic? i. r________ v________ w________ e. Available treatment for retardation? 2% Xq28 membrane receptor and L1CAM 24.9.2 24.9.3 corpus callosum hypoplasia retardation adducted thumbs spastic paralysis hydrocephalus 24.9.3 posterior horn massa intermedia quadrigeminal plate corpus callosum cerebellar vermis ventricular wall rippled ventricular wall none ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Hydrocephalus – General Aspects “Arrested Hydrocephalus” 19. True or False. With regard to “arrested hydrocephalus”: a. It is interchangeable with the term “uncompensated hydrocephalus.” b. Arrested hydrocephalus satisfies the following criteria in the absence of a cerebrospinal fluid (CSF) shunt: i. ventriculomegaly nonprogressive ii. normal head growth curve iii. continued psychomotor development 20. True or False. When deemed “arrested,” no further follow-up is needed. 21. True or False. Shunt dependency is likely in hydrocephalus due to a. aqueductal stenosis b. spina bifida c. communicating hydrocephalus (i.e., secondary to arachnoidal adhesions 24.10.1 false true true true false (deterioration can still occur) 24.10.2 24.10.2 true true false (shunt independence more likely to occur) 22. True or False. With respect to a disconnected or nonfunctioning shunt: a. A disconnected shunt may continue to true function by CSF flow through a subcutaneous fibrous tract. b. If in doubt, better to watch, not shunt. false c. Patients with a nonfunctioning shunt false should not be followed with serial CT scans but possibly with serial neuropsychological evaluations. 143 24.10.3 24 Entrapped Fourth Ventricle 23. Complete the following about entrapped fourth ventricle. a. Usually seen with c_______ s_______ of the l_______ v_______. b. Possibly due to a________. c. Occurs in ___ to ___% of patients with shunts. d. True or False. May be treated with a separate VP shunt or by linking into an existing shunt. chronic shunting of the lateral ventricles adhesions 2 to 3% 24.11.1 true 24.11.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 144 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) Normal Pressure Hydrocephalus (NPH) 24. What are the symptoms of normal pressure hydrocephalus? (Hint: dig) a. d________ b. i________ c. g________ 25. What is the etiology? (Hint: mistapa) a. m________ b. i________ c. s________ d. t________ e. a________ f. p________ g. A________ dementia (wacky) incontinence of urine (wet) gait disturbances (wobbly) 24.12.1 meningitis idiopathic subarachnoid hemorrhage trauma aqueductal stenosis posterior fossa surgery Alzheimer’s disease 26. In clinical triad, which symptom precedes the others? 24 24.12.1 27. Note the clinical features of NPH as expected (+) or not expected (–). a. wide-based gait b. shuffling steps c. unsteadiness on turning d. difficult initiating steps e. feel glued to the floor f. ataxia of limbs g. slowness of thought h. unwitting urinary incontinence i. papilledema j. seizure k. headaches gait disturbance 24.12.3 Table 24.3 + + + + + – + – – – – 28. What is the upper limit opening pressure suggested for the definition of NPH? 24 cm H2O 24.12.5 29. What is the tap test? LP with removal of CSF and assessment of response. 40 to 50 mL of CSF 24.12.5 VP shunt 24.12.8 a. How much CSF is withdrawn? 30. What is the procedure of choice for treatment of NPH? a. Complication rates may be as high as ______%. b. Complications include: i. s_______ h______ or h_______ ii. s_______ i______ iii. i________ h_______ iv. s__________ 35% subdural hematoma or hygroma shunt infection intracerebral hemorrhage seizures ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Hydrocephalus – General Aspects 31. In NPH what is the sequence in which symptoms are likely to improve with shunting? Hint: igd a. i________ b. g________ c. d________ 145 24.12.9 incontinence gait dementia Hydrocephalus and Pregnancy 32. Patients with shunt for hydrocephalus should, prior to conception, a. have up-to-date ________ or ________. b. have assessment of any m________. c. If prospective mother’s hydrocephalus is accompanied by a neural tube defect (NTD), her child could be born with an NTD incidence of ________ to ________%. d. have genetic c________. e. start taking v________. f. avoid excessive h________. 33. If shunt malfunctions during pregnancy, shunt revision is performed a. in the first two trimesters using a ________ b. in the third trimester using a ________________ or a ________-________ shunt. 34. During labor and delivery a. use p________ a________. b. If patient is asymptomatic, ________ delivery is performed. c. If patient is symptomatic, deliver via ________. d. In light of increased cranial pressure avoid ________. 24.13.1 CT or MRI medications 2 to 3% counseling vitamins heat 24.13.3 revised VP shunt 24 ventriculo-atrial or ventriculopleural 24.13.4 prophylactic antibiotics vaginal cesarean epidurals ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 25 Treatment of Hydrocephalus Medical Treatment of Hydrocephalus 1. Answer the following about the treatment of hydrocephalus: a. True or False. Hydrocephalus is a medically treated condition. b. Diuretic therapy can include a________ and f________. c. Be sure to watch for the complication of ________ ________. d. Role of spinal taps in hydrocephalus is to t________. 25 e. Critical protein level of CSF is ________. false (mainly to be treated surgically) acetazolamide and furosemide electrolyte imbalances 25.1 temporize (Hydrocephalus after intraventricular hemorrhage may be only transient, and serial taps [ventricular or lumbar] may temporize until resorption resumes, but lumbar taps can be performed only for communicating hydrocephalus.) 100 mg/dL (If reabsorption does not resume when protein content of CSF is <100 mg/dL, then it is unlikely that spontaneous resorption will occur and a shunt will usually be necessary.) 25.2 25.1.1 Spinal Taps 2. Complete the following concerning spinal taps and hydrocephalus: a. Protein above ________ CSF will not be absorbed. b. Protein below ________ CSF may be absorbed. 25.2 100 mg/dL 100 mg/dL ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Treatment of Hydrocephalus Endoscopic Third Ventriculostomy 3. Complete the following concerning surgery and hydrocephalus: a. Third ventriculostomy when looking into ventricle i. Where is thalamostriate vein? ii. Where is septal vein? iii. Where is choroid plexus? b. Where is puncture of third ventricle to occur? c. Into the ________ d. Watch out for ________. e. Success rate is ________% for a___________ s_________, f. but only 20% for p________ p________. 147 25.4.3 lateral wall medial wall enters foramen of Monro anterior to mammillary bodies interpeduncular cistern basilar artery approximately 56% for aqueductal stenosis preexisting pathology 25.4.5 Shunts 4. Concerning shunts and hydrocephalus, what type of shunts do you know? (Hint: palmt) a. v________p________ b. v________-a________ c. l________ d. m________ s________ e. T________ s________ 5. What is shunt usage priority? a. most often used: ________ ________ b. abdominal abnormality: ________ ________ c. pseudotumor cerebri: ________ ________ d. alternative: ________ ________ e. acquired obstructive hydrocephalus: ________ ________ 25.5.1 ventriculoperitoneal ventriculo-atrial lumboperitoneal miscellaneous shunts– ventriculopleural Torkildsen shunt (ventricle– cisterna magna) 25 25.5.1 ventriculoperitoneal shunt ventriculoatrial shunt; Surgery; peritonitis; morbid obesity lumboperitoneal shunt–small ventricles miscellaneous shunts Torkildsen shunt ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 148 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) 6. Which are the miscellaneous shunts? Hint: gupc a. g________ b. u________ c. p________ d. c________ 7. Name six possible shunt complications. Hint: odesma a. o________ b. d________ c. e________ d. s________ obstruction disconnection of shunt parts erosion through skin seizures–5.5% first year, 1.1% after 3 years metastases of tumor cells allergy to silicone 8. What are ventriculoperitoneal shunt complications? 2 3 Hint: h alo mvps a. h________ b. h________ c. a________ d. l________ e. o________ f. o________ g. o________ h. m________ i. v________ j. p________ k. s________ ventricle to gall bladder shunt ventricle to ureter or bladder shunt ventriculopleural shunt cyst shunt (arachnoid cyst or subdural Hygroma cavity to peritoneum) 25.5.2 e. m________ f. a________ 25 25.5.1 25.5.2 hernia–inguinal 17% hydrocele CSF ascites lengthen catheter with growth (preventable) obstruction by omentum or debris, peritoneal cyst (infection or talc from surgical gloves), severe peritoneal adhesions, malposition of catheter tip, collapsed ventricular wall, choroid obstruction or strangulation of intestine overshunting migration of tip to: scrotum perforation of stomach, bladder, diaphragm volvulus peritonitis subdural hematoma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Treatment of Hydrocephalus 9. What are ventriculoatrial shunt complications? (Hint: liverssh) a. l________ b. i________ c. v________ d. e________ e. r________ f. s________ g. s________ h. h________ 10. What are lumboperitoneal shunt complications? (Hint: Carols) a. C________ b. a________ c. r________ d. o________ e. l________ f. s_______ 25.5.2 lengthening in children infection vascular perforation thrombophlebitis pulmonary microemboli shunt embolus retrograde blood flow superior vena cava obstruction subdural hematoma hypertension (pulmonary) 25.5.2 Chiari I malformation (70% made worse) arachnoiditis and adhesions radiculopathy (from tube hard to control) overshunting (sixth and seventh cranial nerve dysfunction) leakage of CSF scoliosis due to laminectomy (14% in children) 25 Shunt Problems 11. What are the two most common shunt problems? a. u____________ b. i_____________ 12. True or False. a. Radiographic shunt evaluation involves plain x-rays. b. “Shunt series” is used to rule out disconnection or migration of tip. c. “Shunt-o-gram” is used if shunt function cannot be reliably ascertained by other imaging. 13. When do you tap the shunt? a. To study CSF for i. i________ ii. c________ iii. b________ b. To assess function: i. measure p________ ii. instill c________ iii. inject m________ 149 25.6.1 undershunting infection 25.6.3 true (“shunt series”) true true 25.6.3 infection cytology blood pressure contrast medication ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 150 Part 7: Hydrocephalus and Cerebrospinal Fluid (CSF) 14. When tapping a shunt, what is normal less than 15 cm of CSF in CSF pressure measured from the relaxed recumbent position ventricle? Table 25.2 15. What are acute symptoms of undershunting? (Hint: salvadibh) a. s________ b. a________ c. l________ d. v________ e. a________ f. d________ g. i________ h. b________ i. h________ 25.6.3 16. What are signs of acute increase in intracranial pressure? 4 2 (Hint: p b ) a. p________ b. p________ c. p________ d. p________ e. b________ f. b________ 25 17. What are complications of overshunting? (Hint: s4i) a. s________ b. s________ c. s________ d. s________ seizures ataxia lethargy vomiting apnea diplopia irritability bradycardia headache 25.6.3 Parinaud’s syndrome palsy of abducens papilledema prominent scalp veins blindness or field cut bulging fontanelle 25.6.6 slit ventricles 12% subdural hematoma/hygroma sylvian aqueduct occlusion skull changes— craniosynostosis or microcephaly intracranial hypotension e. i________ 18. Regarding intracranial hypotension. a. When patient is erect, column of CSF produces a s________ e________. b. Diagnose by documenting a drop in ICP when patient changes from ________ to ________ position. 25.6.6 siphon effect supine to erect 19. Slit ventricles can be diagnosed by 0.2 frontal-occipital horn ratio of less than ________. 25.6.6 20. Name categories of patients with slit ventricles. (Hint: pahms) a. p________ b. a________ c. h________ d. m________ e. s________ 25.6.6 pseudotumor cerebri asymptomatic slit ventricles intracranial hypotension migraine slit ventricle syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Treatment of Hydrocephalus 21. Complete the following concerning hydrocephalus and subdural hematomas (SDs): a. A cause of SD in patients with shunts is ________ of the brain and ________ ________ ________ ________ _______. b. Risk factors i. b________ a________ ii. l________-s________ h_____ iii. n________ v________ p________ 22. If subdural hematoma develops as a shunt complication the subdural is located on a. the same side as the shunt ________%. b. opposite side of the shunt ________%. c. bilaterally ________%. 23. Treatment for subdural hematoma that occurs due to shunting for hydrocephalus could include (Hint: bcdht) a. b________ b. c________ c. d________ d. h________ e. t________ 151 25.6.8 collapse; tearing of the bridging veins brain atrophy long-standing hydrocephalus negative ventricular pressure 25.6.8 32% 21% 47% 25.6.8 burr holes craniotomy drainage–subdural peritoneal shunt higher pressure shunt tie off shunt 25 Instructions to Patients 24. True or False. In VP shunt and laparoscopic surgery, abdominal insufflation can increase ICP. true 25.9 25. How often does the patient have to pump the shunt? Patient must not touch the pump unless instructed to do so. 25.9 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 26 Seizure Classification and Anti-Convulsant Pharmacology Seizure Classification 1. a. b. c. Seizure may be classified by t_____ e_____ e_____ s______ 26.1.1 type etiology epileptic syndrome 2. List the major types of primarily generalized seizures. a. m________ b. a_________ c. g________ d. c________ e. a________ f. t_________ 26 3. What are the major differences between primarily generalized and partial seizures? a. Primarily generalized i. areas involved ii. percent of seizures iii. consciousness iv. significance b. Partial i. areas involved ii. percent of seizures iii. consciousness iv. significance 26.1.1 myoclonic atonic (drop attacks) generalized (grand-mal) clonic absence (petit-mal) tonic 26.1.1 bilateral and symmetrical 40% of all seizures loss of consciousness at onset does not suggest structural lesion one hemisphere 57% of all seizures no loss of consciousness suggests structural lesion ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Seizure Classification and Anti-Convulsant Pharmacology 4. Matching. Match the type of seizure with its listed characteristic(s). More than one may apply. Characteristics: ① 3% of seizures; ② 40% of seizures; ③ 57% of seizures; ④ consciousness lost from onset; ⑤ tonic-clonic motor activity; ⑥ involves both hemispheres; ⑦ no postictal confusion; ⑧ spike and wave 3/s; ⑨ represents a structural lesion a. generalized b. partial c. unclassified d. absence 5. The main difference is that simple partial seizures have a. ___________ of _______ and complex partial seizures have b. _______ of _______. 6. Briefly describe the following characteristics of absence seizures a. motor involvement b. postictal state c. loss of consciousness d. characteristic eeg pattern e. effect of hyperventilation 7. Briefly describe the following characteristics of uncinate seizures: a. Arise from ______-_______. b. Produce hallucinations of _______. c. Kakosmia is perception of ________ where none exist. 8. Complete the following about seizures: a. What is the most common cause of intractable temporal lobe epilepsy? b. due to ________ c. treated by _________ 9. True or False. Patients with mesial temporal lobe epilepsy have higher incidence of complicated febrile seizures than in other epilepsy types. 153 26.1.1 ②, ④, ⑤, ⑥ ③, ⑨ ① ⑦, ⑧ 26.1.1 no loss of consciousness loss of consciousness 26.1.1 absent absent absent 3/s spike and wave induces seizures 26.1.1 uncus-hippocampus odor bad odor 26 26.1.1 mesial temporal sclerosis cell loss in hippocampus medication until refractory, then surgery true 26.1.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 154 Part 8: Seizures 10. Name factors that reduce seizure threshold. (Hint: seizure history) a. s______ b. e______ c. i_______ d. z_______ e. u_______ f. r_______ g. e_______ h. h_______ i. j. k. l. m. i________ s_______ t_______ o_______ r________ n. y________ 26 26.1.3 stroke elevated temperature, fever infection, intoxication “zzzs” lost (sleep deprivation) uremia repeated seizures (kindling) electrolyte imbalance pH, Mg++, low Na, high Ca++ hyperventilation, hyponatremia, hypoglycemia, hypercalcemia ischemia stimulation (photic) trauma, tumor opioids removal or withdrawal of alcohol or AEDs suddenly youth (birth asphyxia, congenital central nervous system abnormalities) 11. Juvenile myoclonic epilepsy is characterized by _____ seizure types: a. m_____ j______ predominantly after _______ b. g______ t_____-c________ c. a_________ d. Patients with JME are most responsive to _______. 3 12. Infantile spasms in West syndrome usually have a dramatic response to ________ or _______. ACTH or corticosteroids 13. Complete the following about LennoxGastaut syndrome: a. Usually begins in childhood as a_________ s_________. b. Seizures are usually d______ to _____. c. 50% of cases have reduced seizures with ______ ______. d. c_______ c________ may reduce the number of atonic seizures. 14. a. b. c. d. Describe Todd’s paralysis. occurs after _______ causes _______ resolves with _______ another name for it is _______ _______. 26.1.3 myoclonic jerks after waking generalized tonic-clonic absence Depakote 26.1.3 26.1.3 atonic seizures (drop attacks) difficult to treat valproic acid corpus callosotomy 26.1.3 seizure weakness time (1/2 to 36 hours) postictal paralysis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Seizure Classification and Anti-Convulsant Pharmacology 155 Antiepileptic Drugs 15. What % of patients can achieve control of seizures with medical therapy? 16. What AEDs interfere with platelet function and may increase the risk of bleeding complications? a. _________ b. _________ _________ 17. Indicate the drug of choice for each type of seizure a. Generalized tonic-clonic i. ________ _________ ii. ________ b. Absence i. _________ _________ ii. _________ c. Myoclonic _______ d. Tonic or atonic _________ e. Partial i. _______ ii. ________ 75% 26.2.1 26.2.2 phenytoin valproic acid 26.2.3 valproic acid phenytoin valproic acid ethosuximide lorazepam lorazepam carbamazepine phenytoin 18. True or False. Increase a given medication until seizures are controlled or side effects become intolerable, but do not rely soley on therapeutic levels which are only a range in which most patients have seizure control without side effects. true 26.2.4 19. True or False. 80% of epileptics can be controlled on monotherapy. true 26.2.4 20. True or False. Only 10% of epileptics benefit significantly from the addition of a second drug. true 26.2.4 21. True or False. If more than two AEDs are required, consider whether the patient might have nonepileptic seizures. true 26.2.4 22. If a loading dose is not given, it takes _____ half-lives to reach steady state. 5 half-lives 26.2.4 23. Give the characteristics of phenytoin. a. half-life: ________ b. oral loading dose: _______ c. Can we use IM route? 26 26.2.4 24 hours, range 9 to 140 hours 300 PO every 4 hours until 17mg/kg no ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 156 Part 8: Seizures d. rate by IV: _______ e. permitted solution: _______ _______ f. How many days to reach steady state? 24. Side effects of phenytoin a. a b. b c. d. e. f. g. h. i. j. k. l. m. n. 26.2.4 ataxia birth control pills less effective cognitive dysfunction drug intercations, Prozac epidermal necrolysis gingival hyperplasia hirsutism liver granulomas megaloblastic anemia newborn hemorrhage osetomalacia papular rash rickets Steven-Johnson syndrome/SLE teratogenic vitamin D antagonism c d e g h l m n o p r s o. t p. v 26 25. Describe carbamazepine a. Indication i. p_______ s_______ ii. t_______ n_______ b. Therapeutic levels ________ c. Side effects i. a ii. a iii. a iv. b v. c vi. d vii. d viii. D ix. e x. f xi. g xii. i xiii. s xiv. s 26. a. b. c. not more than 50 mg/min normal saline 7 to 21 days 26.2.4 partial seizures trigeminal neuralgia 6 to 12 mcg/mL ataxia aplastic anemia agranulocytosis blood dyscrasia cymetidine drowsiness diplopia Darvon erythromycin fatal hepatitis GI upset isoniazid Steven-Johnson syndrome SIADH Describe carbamazepine. Also known as ________ Test for C_______, p_______, i______ Test according to what schedule i. _______ time(s) per week for ________ ______ ii. ________ time (s) per month for ______ ______ 26.2.4 Tegretol CBC, platelets, iron 1; 3 months 1; 3 years ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Seizure Classification and Anti-Convulsant Pharmacology d. Discontinue drug if the levels of the following blood components fall below what level i. wbc ii. rbc iii. Hct iv. platelets v. reticulocytes vi. iron rises e. Increase dose as follows: _____ pill per ______ per ______. 27. True or False. When used for treatment of trigeminal neuralgia or partial seizures with or without generalization, carbamazepine has a. erratic oral absorption although oral suspension is absorbed more readily. b. dramatic elevation levels with cimetidine, isoniazid, erythromycin, and Darvon drug-drug interaction. 28. True or False. Regarding oxcarbamazepine. a. Unlike carbamazepine, there is no auto induction. b. There is liver toxicity. c. There is no hematologic toxicity. d. Dosing is BID. 29. a. b. c. d. Describe valproate. Also known as _______. Indication Therapeutic level is _____ to ______. Side effects (list at least 5) 157 4,000 3,000,000 32 100,000 0.3% higher than 150 mcg% 1 pill per day per week 26.2.4 true true 26.2.4 true false true true 26.2.4 Depakote generalized tonic-clonic 50 to 100 mcg/mL confusion, drowsiness, hair loss, liver failure, neural tube defects, hyperammonemia, platelet dysfunction, teratogenic, tremor, weight gain 26 30. True or False. Acetylsalicyclic acid displaces valproic acid from serum protein. true 26.2.4 31. True or False. Valproic acid causes neural tube defects in 1 to 2% of patients. true 26.2.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 158 32. a. b. c. d. Part 8: Seizures Describe phenobarbital. Indication Therapeutic level is _____ to ______. Half-life ______, steady state _______ Side effects i. c_______ ii. d_______ iii. p_______ h_______ iv. h_______ in n_______ cognitive impairment drowsiness paradoxical hyperactivity hemorrhage in newborns if mother is on phenobarbital 33. True or False. Indicate whether the following statements about antiepileptic drugs are true or false: a. Phenobarbital is a potent inducer of true hepatic enzymes that metabolize other AEDs. b. Cognitive impairment may be subtle and true may outlast administration of the drug at least by several months. c. They may cause hemorrhage in newborn true if mother is on phenobarbital. 26.2.4 34. Caution is needed when using felbamate due to an unacceptably high rate of _______ ______ as a serious side effect. a. Can it be used as a first-line drug? 26.2.4 35. Describe levetiracetam a. Indication 26 26.2.4 generalized tonic-clonic 15 to 30 mcg/mL 5 days; 30 days aplastic anemia No 26.2.4 myoclonic seizure, tonicclonic, partial onset with secondary generalization none somnolence, dizziness b. Drug-drug interaction? c. Side effects 36. Describe topiramate. a. Indication 26.2.4 b. Side effects c. In children it may cause o________. 37. What is the mechanism of action of lacosamide? a. Enhances slow inactivation of ________. 38. True or False. The following are characteristics of Diamox (acetazolamide): a. It reduces CSF production. b. It may have anti-epileptic effect either due to slight central nervous system acidosis or due to its direct inhibition of CNS carbonic anhydrase. adjunct for refractory partial onset seizures cognitive impairment, weight loss, paresthesias renal stone oligohidrosis 26.2.4 voltage-gated Na channels 26.2.4 true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Seizure Classification and Anti-Convulsant Pharmacology 39. Describe withdrawal of AEDs. a. Taper by ______. b. Role of EEG? c. Relapse rate is ______ %. d. over how long? 40. True or False. These are important factors to predict freedom from recurrence after AED withdrawal: a. longer seizure-free period b. use of only one AED c. tonic-clonic seizure 41. Complete the following about antiepileptic drugs: a. What effect do antiepileptic medications have on birth control pills? b. Why? i. AEDs induce liver _______ _______ _______, ii. which degrades the ______ _____ _______. 26.2.5 1 unit every 2 weeks if EEG shows epileptiform discharges, discourage withdrawal 35% 8 months 26.2.5 true true false (seizures other than tonic-clonic) 26.2.6 They increase the failure rate fourfold microsomal cytochrome P450 birth control medication 42. True or False. Regarding complications during pregnancy. a. Women with epilepsy have more true complications. b. > 90% pregnancies have favorable true outcomes. c. Status epilepticus poses serious risk to true the mother and to the fetus. 26.2.6 43. Considering seizures, AEDs, and birth defects, describe the following: a. Effect of seizure history on incidence of fetal malformations. b. Phenobarbital and malformations 26.2.6 c. Teratogenic properties in i. Phenytoin 159 26 double 4 to 5% the worst, 9.1% - highest rate of malformation fetal hydantoin syndrome, low IQ neural tube defects – rare neural tube defects 1-2% ii. Carbamazepine iii. Valproate d. Therefore, during pregnancy i. first choice is ________ ii. second choice is ________ iii. add______ iv. use ______ carbamazepine (lowest dose possible) valproic acid folate monotherapy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 27 Special Types of Seizures New Onset Seizures 1. Incidence of new-onset seizures per 100,000 person years is ______. 2. Neurologic insults resulting in first time seizure include. a. s_____ b. h_____ t_____ c. c_____ i_____ d. f_____ e. b_____ a______ stroke head trauma CNS infection fever birth asphyxia 3. In patients with stroke, _____% had a seizure within ____ days of a stroke. 4.2%; 14 4. What metabolic disturbances can cause first-time seizure? a. u_______ b. _____natremia c. _____glycemia 27 44 5. In pediatric patients the most common etiology of first-time seizure is ________. 6. In patients with new-onset unprovoked seizure, a. ______% had recurrent seizures during follow-up. b. If seizure-free for 3 years, _____ had recurrence. 7. For new-onset seizure in an adult what should be done? a. s______ w______ b. C_______ c. M_______ d. E_______ i. If all studies negative, you should repeat study at ___________. ii. If two EEGs are normal, the 2 year recurrence rate is _____%. 27.1.1 27.1.2 27.1.2 27.1.2 uremia hypo hypo febrile seizures 27.1.2 27.1.2 27% none 27.1.3 systemic work-up CT MRI EEG 6 and 12 (and possibly 24) months 12% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Special Types of Seizures 161 Posttraumatic Seizures 8. What are the two categories of posttraumatic seizure? a. _______ within _______ days after trauma. b. _______beyond_______days after trauma. 9. True or False. Regarding posttraumatic seizures. a. AEDs may be used to prevent early posttraumatic seizures in high risk patients. b. Prophylactic AEDs reduce the frequency of late posttraumatic seizures. c. AEDs can be discontinued after 1 week. 10. Incidence of seizures in early posttrauma period (1 to 7 days) is a. ______% in severe head injuries b. ______% in mild to moderate head injuries. 27.2.1 Early, within 7 days after trauma Late, beyond 7 days after trauma 27.2.1 true false true 27.2.2 30% 1% 11. Incidence of late seizures (> 7 days) is ___ - ___% over a 2-year period. 10-13% 27.2.3 12. The incidence of posttraumatic seizures is higher in ______ head injuries than with _______ head injuries. a. Occur in _____% of penetrating trauma cases followed for 15 years. penetrating; closed 27.2.4 13. True or False. High risk criteria for posttraumatic seizures include: a. acute SDH, EDH, or ICH b. seizure within 24 hours after injury c. Glasgow coma scale > 10 d. alcohol abuse e. penetrating injury 50% Table 27.1 true true false (GCS < 10) true true 27 14. Phenytoin has adverse _________ ________when given long-term as prophylaxis against posttraumatic seizures. cognitive effects 27.2.5 15. Using AEDs after head trauma can result in _____ % reduction of early posttraumatic seizures. 73% 27.2.5 16. In appropriate patients AEDs should be tapered after _____, except in: a. p______ b______ i_____ b. l_____ p______ s______ c. p_____ s_______ h_______ d. c_______ 1 week 27.2.5 penetrating brain injury late posttraumatic seizure prior seizure history craniotomy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 162 Part 8: Seizures 17. In patients not meeting criteria to discontinue AEDs after 1 week, a. AEDs should be maintained for ___ - ___ months. b. _____ should be done before discontinuing. 6-12 months EEG Alcohol Withdrawal Seizures 18. True or False. Ethanol withdrawal seizures are seen in ____% of habitual drinkers within ___ to ___ ______ of stopping or reducing ethanol intake. 27 27.2.5 33%; 7 to 30 hours 27.3.1 19. Regarding alcohol withdrawal patients. a. What occurs first: delirium tremens or seizures seizures? b. Risk of onset of seizures lasts for ______. 48 hours c. Risk of onset of DTs lasts for ______. 96 hours d. Risk persists for ___ to ___ days. 1 to 3 days e. Are AEDs recommended: i. For prophylaxis? yes ii. For treatement? no, (because seizure is usually brief, and self-limited. AEDs are not indicated once seizures have occurred.) 27.3.1 20. True or False. The following patients should be admitted for observation for additional seizures or DT’s: a. Those with their first EtOH withdrawal seizure b. Those with focal findings c. Those with more than 6 seizures in 6 hours d. Those with evidence of trauma 27.3.2 21. True or False. Patients with ethanol withdrawal seizures should receive long-term antiepileptic drugs if they have: a. A history of prior ethanol withdrawal seizures b. Recurrent seizures c. History of prior seizure disorder unrelated to ethanol d. Risk factors for seizures (e.g., subdural hematoma) true true true true 27.3.3 true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Special Types of Seizures 163 Nonepileptic Seizures 22. Answer the following about nonepileptic seizures a. aka pse_______ b. aka psy_______ c. True or False i. They are real events ii. The may not be under voluntary control iii. They are helped by AEDs 23. What are features suggestive of nonepileptic seizures? a. This feature is 90% specific for NES: a________. b. Another highly specific feature is w______. c. Forced eye _______. d. Bilateral shaking with preserved _______. e. Variable _______ f. Clonic UE or LE movements that are _________. g. Pelvic _______. h. Altered by ______. 24. A feature strongly suggestive of epileptic seizure is l_______ t_______ l_______. 25. True or False. Which serum hormone may be used to confirm a true seizure versus nonepileptic seizures: a. TSH b. ACTH c. Cortisol d. GH e. Prolactin 26. Regarding serum prolactin a. Transient elevations occur in ____% of generalized motor seizures. b. Peak levels are reached in ___ - ___ minutes. 27. Overall accuracy of prolactin levels in predicting true seizures is _____%. 27.4.1 pseudoseizures psychogenic true true false 27.4.2 arching back weeping closure awareness seizure types out of phase thrust distraction lateral tongue laceration 27.4.2 27.4.2 false false false false true 27 27.4.2 80% 15-20 72% 27.4.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 164 Part 8: Seizures Febrile Seizures 28. True or False. The most common type of seizure is a. ethanol withdrawal b. tumor induced c. posttraumatic d. febrile e. epileptic 29. Regarding treatment of febrile seizures. a. Recurrence rate can be _______ by b. administering ________ c. every ___ hours and d. continuing until _____ hours after the fever subsides. false false false true false 27.5.3 reduced diazepam (0.33 mg/kg) 8 24 Status Epilepticus 30. Status epilepticus is defined as a. seizure lasting more than _______, b. or persistent seizure after _______. 27 27.5.2 27.6.1 5 minutes 1st and 2nd line AEDs 31. What is the most common etiology for low AED levels status epilepticus? 27.6.1 32. Complete the following about status epilepticus a. The mean duration is _______ hours. b. The mortality for SE is ______%. c. The mortality from underlying acute event is ___ - ___%. d. Irreversible changes from repetitive electrical discharges begin to appear in neurons as early as _____ minutes. e. Cell death may occur after ______ minutes. 27.6.5 33. For a patient in status epilepticus, the work-up includes the following a. a_______ b. b_______ c. c_______ d. e______ e. i_______ f. l_______ 34. If a lumbar puncture is done after a seizure, a. it may show e_______ w_____ c_____, b. which may be b_____ p______ p_______ c. and should be treated as ________. 1.5 2% 10-12% 20 minutes 60 minutes 27.6.6 airway blood pressure CPR EKG, EEG, electrolytes IV lumbar puncture 27.6.6 elevated white count benign postictal pleocytosis infection (until cultures negative) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Special Types of Seizures 35. What is the first line drug for status? benzodiazepine 27.6.6 36. If seizures persist after first dose of benzodiazepine, load with f_______, or p_______. a. Loading dose for fosphenytoin is _______ at _________. b. Loading dose for phenytoin is ________ at __________. c. If no response to loading dose, an additional ______ can be given after ______ minute. fosphenytoin, phenytoin 27.6.6 15-20 mg/kg at 150 mg/min 15-20 mg/kg at 50 mg/min 10 mg/kg; 20 minutes 37. What medication should be avoided in status epilepticus? a. n_______ narcotics b. p_______ phenothiazines c. n______ b______ a________ neuromuscular blocking agents 27.6.6 38. True or False. The drug of choice for myoclonic status is a. Lorazepam b. Benzodiazepine c. Dilantin d. Phenobarbital e. Diazepam 27.6.8 39. True or False. The drug of choice for absence status is a. Valproic acid b. Benzodiazepine c. Dilantin d. Phenobarbital e. Diazepam 165 true false false false false 27.6.8 true false false false false 27 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 28 Pain General Information 1. Complete the following statements about pain: a. The three types of pain are i. n________ ii. d________ iii. s________ m________ b. Two types of nociceptive pain are: i. s________ ii. v________ 28 nociceptive deafferentation sympathetically mediated somatic visceral Neuropathic Pain Syndromes 2. Answer the following about the use of tricyclics to treat neuropathic pain: a. Use is limited by ________ and ________ effects, and by ________. b. Which is more effective: serotonin reuptake blockers, or norepinephrine reuptake blockers? 28.1 28.2.2 anticholinergic; central; limited pain relief serotonin reuptake blockers Craniofacial Pain Syndromes 3. Complete the following statements about craniofacial pain syndromes: a. Tic convulsif is g________ neuralgia plus h________ spasm. b. Ramsay Hunt syndrome is p________ g________ n________. c. Tolosa-Hunt syndrome is s________ o________ f________ i________. d. Raeder neuralgia is p________ n________. 28.3.1 geniculate; hemifacial postherpetic geniculate neuralgia superior orbital fissure inflammation paratrigeminal neuralgia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pain 4. Characterize the craniofacial pain syndrome known as SUNCT a. s________ ________ b. u________ c. n________ ________ d. c________ ________ e. t________ f. brief—about ________ g. near the ________ h. occurs ________ ________ per day i. affects ________ 28.3.1 short lasting unilateral neuralgiform headache conjunctival injection tearing 2 minutes eye multiple times males 5. Complete the following regarding primary otalgia: a. It may have its origin from which nerves? fifth, seventh, ninth, tenth, and occipital nerves b. Cocainization of the pharynx, producing glossopharyngeal neuralgia pain relief, suggests ________ ________ instead of primary otalgia. c. Treatment includes i. Medicines: T________, D________, Tegretol, Dilantin, and and b________ baclofen ii. Surgical procedures: of m________ microvascular decompression d________ or sectioning the (MVD); n________ i________, the nervus intermedius; ________ CN, and the upper two ninth; fibers of the ________ CN tenth 28.3.2 6. Characterize trigeminal neuralgia (TGN). a. The incidence is ________, but higher (2%) in patients with ________. b. It is pathophysiologically caused by what? 28.3.3 c. Pathogenesis may be due to vascular compression from what arteries? d. The neurologic exam in a patient with trigeminal neuralgia should be _______. 7. Complete the following statements about treatment of trigeminal neuralgia: a. Tegretol provides pain relief in ____%. b. What if Tegretol has no effect? 167 4/100,000; MS ephaptic transmission from large myelinated A fibers to poorly myelinated A delta and C fibers superior cerebellar artery (SCA), persistent primitive trigeminal artery, or dolichoectatic basilar artery entirely normal, or with very mild sensory loss 28 28.3.3 69% The diagnosis of trigeminal neuralgia is suspect. baclofen (Lioresal) c. What is the second drug of choice for trigeminal neuralgia? d. The two special precautions needed with the use of this medication are as follows: i. It may be ________. teratogenic ii. Don’t ________ ________. stop abruptly ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 168 Part 9: Pain 8. Medicines for trigeminal neuralgia include the following: a. a________ (E________®) b. b________ (L________®) c. b________ (B________®) d. c________ (Z________®) e. c________ (T________®) f. c________ (K________®) g. g________ (N________®) h. l________ (L________®) i. p________ (D________®) j. o________ (T________®) 28.3.3 amitriptyline; Elavil® baclofen; Lioresal® botulinum toxin; Botox® capsaicin; Zostrix® carbamazepine; Tegretol® clonazepam; Klonopin® gabapentin; Neurontin® lamotrigine; Lamictal® phenytoin; Dilantin® oxcarbazepine; Trileptal® 9. The basis upon which percutaneous nociceptive fibers (A-delta trigeminal rhizotomy treats trigeminal and C fibers); touch fibers (Aneuralgia is the destruction of alpha and A-beta) ________ fibers and while preserving ______ fibers. 10. When treating trigeminal neuralgia, percutaneous trigeminal rhizotomy (PTR) is recommended for whom? a. Patients with p_____ r____ for general anesthesia. b. Patients who wish to avoid m_____ s______, c. have u__________ i___________ t______, d. have m________ s________, e. have i________ h________ on the other side, f. or have l______ l____ e__________. 28 11. State the considerations when choosing radiofrequency rhizotomy (RFR) versus percutaneous microcompression (PMC) rhizolysis for trigeminal neuralgia. a. Recurrence rates and incidence of dysesthesias are ________ across the various lesioning techniques. b. Occurrences of intraoperative hypertension are ________ with PMC than with radiofrequency. c. Bradycardia occurs regularly with _____. d. ________ requires a patient who can cooperate; ________ can be done with the patient asleep. e. Paralysis of the ipsilateral trigeminal motor root is more common with _____. 12. Answer the following concerning trigeminal neuralgia (TGN) and microvascular decompression (MVD): a. True or False. It is appropriate for patients with <5 years expected survival. 28.3.3 28.3.3 poor risk major surgery unresectable intracranial tumors multiple sclerosis impaired hearing limited life expectancy 28.3.3 comparable less PMC RFR; PMC PMC 28.3.3 false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pain b. True or False. It may produce anesthesia dolorosa. c. It has a mortality rate of ________. d. It has a major neurologic morbidity of ____ to ____%. e. It has a failure rate of ____ to _____%. f. True or False. It is the procedure of choice in MS patients. 13. Complete the following about TGN and the benefits of stereotactic radiosurgery: a. Complete pain relief is achieved in ________%. b. There is significant pain reduction in an additional ____ to ____%. c. Must anticoagulation be reversed to have SRS? 14. List some complications with percutaneous radiofrequency trigeminal rhizotomy. a. a______ d______ b. b_________ c. d__________ d. h_______ l____ e. h_______ s______ f. h___________ g. i__________ b_____ h. k_________ i. l__________ c_______ j. m_________ w________ k. m__________ l. m_________ m. o__________ p______ n. s__________ c_______ 15. Describe microvascular decompression (MVD) complications: a. mortality ____ to ____% b. meningitis: aseptic ___%, bacterial ___% c. deafness ________% d. mild facial sensory loss ________% e. success rate ____ to ____% 16. Complete the following about supraorbital and supratrochlear nerves: a. They arise from the ________ nerve. b. The larger of the two is the ________. c. The supraorbital nerve exits the orbit via the ________ notch, usually located within the ________ third of the orbital roof. d. Which nerve is most medial? 169 false <1% 1 to 10% 20 to 25% false (MS patients do not respond to MVD and should be treated with a PTR.) 28.3.3 65% 15 to 31% (80 to 96% total) No 28.3.3 anesthesia dolorosa bradycardia dysesthesias hearing loss herpes simplex hypotension intracranial bleed keratitis lacrimation changes masseter weakness meningitis mortality oculomotor paresis salivation changes 28.3.3 28 0.22 to 2% aseptic 2%; bacterial 0.9% 1% 25% 75 to 80% 28.3.4 frontal supraorbital supraorbital; medial supratrochlear ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 170 Part 9: Pain 17. Answer the following about differential diagnosis of SON and STN: a. What are typical TGN features lacking in SON? b. If SON is suspected, but associated autonomic activity is present, what conditions should be considered? c. Pain of the medial upper orbit exacerbated by supraduction of the eye and palpation of the trochlea might lead one to suspect ________. 18. Characterize glossopharyngeal neuralgia. a. Pain is located in i. base of t________ and ii. t________ b. Other symptoms besides pain: i. h________ ii. s________ iii. c________ a________ 19. Describe glossopharyngeal neuralgia. a. The incidence is ________ as frequent as trigeminal neuralgia. b. Pain occurs in t________, b________ of t________, e________, n________. c. Treatment includes i. medicine: ________ ii. surgery: ________ ________ iii. nerve division: section of ________ and upper ________ of ________ 28 20. Complete the following concerning geniculate neuralgia: a. Pain is located ________. b. If there are herpetic lesions, this is called R________ H________ s________. c. If combined with hemifacial spasm, it is called t________ c________. d. Treatment i. medicine: mild cases may respond to c________, sometimes in combination with p________ ii. surgery: m________ d________ together with division of ________ ________ iii. What vessel is most often involved? 28.3.4 SON lacks characteristic triggers and electric shocklike pain cluster H/A or SUNCT trochleitis 28.3.5 tongue throat hypotension syncope cardiac arrest 28.3.5 1/70 throat, base of tongue, ear, neck cocainization microvascular decompression ninth and upper third of tenth nerve 28.3.6 deep in the ear, eye, cheek Ramsay Hunt syndrome (RHS) tic convulsif carbamazepine; phenytoin microvascular decompression; nervus intermedius AICA—compressing sensory and motor roots of seventh nerve ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pain Postherpetic Neuralgia 21. Complete the following about herpes zoster: a. The etiologic agent is h________ v________ z________ v________. b. It involves the eye in ________%. c. Pain usually resolves after ____ to ____. d. Postherpetic neuralgia occurs in ________% of HZ cases. e. Vesicles and pain run in the i. distribution of the d________ ii. not the p________ n________. 22. Complete the following about postherpetic neuralgia: a. With an acute attack of herpes zoster, you may treat with e________ or i________ i________. b. For acute treatment use i. a________ ii. v________ or iii. f________ c. Medical treatment of PHN is with i. t________ a________ ii. l________ p________ iii. i________ s________ + l________ iv. g________ v. o________ vi. c________ also may be used as a topical treatment. d. Start treatment with l________ p________, which is better tolerated in the ________. 171 28.4.1 herpes varicella zoster virus 10% 2 to 4 weeks 10% dermatome peripheral nerve epidural; intercostal injection 28.4.5 acyclovir valacyclovir famciclovir Table 28.5 tricyclic antidepressants lidocaine patch intrathecal steroids + lidocaine gabapentin oxycodone capsaicin lidocaine patches; elderly 28.4.5 Complex Regional Pain Syndrome (CRPS) 23. Complete the following statements about complex regional pain syndrome (CRPS): a. Formerly known as ________ b. Triad to diagnose: i. a________ d________ ii. b________ p________ iii. t________ c________ c. What is the cause of CRPS Type II (AKA major causalgia)? causalgia 28 28.5.1 autonomic dysfunction burning pain trophic changes nerve damage due to highvelocity missile injury or other penetrating trauma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 172 Part 9: Pain d. Signs of CRPS: i. tapered ________ ii. v________ c________ 28.5.5 iii. Touching causes pain induced by non-noxious stimulus, known as ________. iv. hands are _____ and ______. 24. Complete the following statements about treatments for CRPS: a. True or False. Medical therapy is usually effective. b. Medical treatment for CRPS uses ________ ________. c. A common agent used for intravenous injection for causalgia is ________. d. Surgical sympathectomy may relieve the pain of causalgia in ________%. fingers vascular changes, either vasodilator or vasoconstrictor allodynia 28.5.4 cold and moist 28.5.7 false tricyclic antidepressants guanethidine 90% 28 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 29 Peripheral Nerves General Information 1. Answer the following about motor and sensory classification of nerves. a. Which sensory and motor classification has the greatest conduction velocity? b. All post-ganglionic autonomic nerve fibers are of what type? c. What types of sensory information are carried by A-delta fibers? d. Where can nerves of type B be found? 29.1.1 A-alpha C fine touch, pressure, pain, and temperature preganglionic autonomic fibers 2. Answer the following about grading muscle strength and muscle reflexes. a. A muscle with flicker or trace contraction 1 would score what on the MRC scale? b. What does an MRC score of 4- mean? active movement against slight resistance c. What is a normal score for muscle 2+ stretch reflex? 29.1.2 3. True or False. Upper motor neuron paralysis includes a. clonus b. hyperactive reflexes c. muscle spasms d. atrophy e. fasciculations 29.1.3 true true true false false (Choices d and e are characteristic of lower motor neuron paralysis.) 29 Muscle Innervation 4. For the 11 muscles of the shoulder, list their nerves, roots, and action. a. trapezius i. nerve, s________ a________ spinal accessory (CN XI) ii. roots, ________ C3,4 iii. action, ________ elevate shoulders, abduct arm >90 degrees Table 29.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 174 Part 10: Peripheral Nerves b. serratus anterior i. nerve, l________ t________ ii. roots, ________ iii. action, ________ c. supraspinatus i. nerve, s________ ii. roots, ________ iii. action, ________ d. infraspinatus i. nerve, s________ ii. roots, ________ iii. action, ________ e. rhomboids i. nerve, d________ s________ ii. roots, ________ iii. action, ________ f. pronator teres i. nerve, m________ ii. roots, ________ iii. action, ________ g. pectoralis major i. nerve, p________ ii. roots, ________ iii. action, ________ 29 h. latissimus dorsi i. nerve, t________ ii. roots, ________ iii. action, ________ i. deltoid i. nerve, a________ ii. roots, ________ iii. action, ________ j. brachialis i. nerve, m________ ii. roots, ________ iii. action, ________ k. biceps brachii i. nerve, m________ ii. roots, ________ iii. action, ________ suprascapular C4,5,6 abduct arm 15-30 degrees suprascapular C5,6 exorotation of humerus (backhand tennis shot) dorsal scapular C4,5 adduct and elevate scapulae median C6,7 forearm pronation lat. anterior thoracic and med. anterior thoracic (aka pectoral nerve) C5,6,7,8 adduct arm and push arm forward thoracodorsal C5,6,7,8 adduct arm (climb ladder) axillary C5,6 abduct arm 30-90 degrees musculocutaneous C5,6 flex forearm musculocutaneous C5,6 flex and supinate forearm 5. The suprascapular nerve innervates which two of the following muscles? a. b. c. d. long thoracic C5,6,7 forward shoulder thrust infraspinatus and supraspinatus (teres major innervated by subscapular nerve; teres minor innervated by axillary nerve) Table 29.5 teres major teres minor infraspinatus supraspinatus ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Peripheral Nerves 6. Describe the latissimus dorsi muscle. a. function: ________ 29.2.1 b. nerve: ________ c. roots: ________ adductor—together with pectoralis thoracodorsal C5,6,7,8 7. a. b. c. d. true false true false (infraspinatus muscle) True or False. The deltoid muscle abducts the arm 30 to 90 degrees. abducts arm >90 degrees. is innervated by the axillary nerve. rotates the arm out. 8. True or False. The abductor pollicis longus a. is innervated by the median nerve. b. is innervated by the posterior interosseous nerve. c. is innervated by the ulnar nerve. d. is innervated by the radial nerve. 9. True or False. The median nerve is responsible for the following movements of the thumb: a. adduction b. abduction c. extension d. flexion e. opposition 10. Complete the following about the movements of the thumb: a. Plane of movement for the thumb i. extension: ________ ii. flexion: ________ iii. adduction: ________ iv. abduction: ________ v. opposition: ________ b. Action of nerves to the thumb i. median nerve, Hint: FAO F—action, f________ muscle, f________ p________ b________ root, ________ A—action, a________ muscle, a________ p________ b________ root, ________ O—action, o________ muscle, o________ p________ root, ________ 175 29.2.1 29.2.1 false true false true (The posterior interosseous nerve is a continuation of the radial nerve in the forearm.) 29.2.2 false (ulnar) true false (radial) true true 29.2.2 plane of palm plane of palm perpendicular to palm perpendicular from palm across the palm flexion; flexor pollicis brevis; C8, T1; abduction; abductor pollicis brevis; 29 C8, T1; opposition; opponens pollicis; C8, T1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 176 Part 10: Peripheral Nerves ii. ulnar nerve action, a________ muscle, a________ p________ root, ________ iii. radial nerve action, e________ muscle, e________ p________ b________ and l________ root, ________ 11. Complete this list of the peripheral nerves of the lower extremities: Hint: fosis pdstp (Follow our sign. It says, “please don’t spoil the plants.”) a. f________ b. o________ c. s________ d. i________ e. s________ f. p_______ g. d________ h. s________ i. t________ j. p________ 12. Now name the nerves of the lower extremities along with the roots that form them a. f________ b. o________ c. s________ d. i________ e. s________ f. d________ g. s________ h. t________ i. p________ 29 13. Finally, name the nerves of the lower extremities along with the muscles and their function. a. nerve, f________ i. muscle, i________, q________ f________, s________ ii. function, ________ b. nerve, o________ i. muscle, a________, g________, o________ e________ ii. function, ________ adduction; adductor pollicis; C8, T1 extension; extensor pollicis brevis and longus; C7, C8 29.2.3 femoral obturator superior gluteal inferior gluteal sciatic (trunk) peroneal (trunk) deep peroneal superficial peroneal tibial pudendal 29.2.3 femoral, L2,3,4 obturator, L2,3,4 superior gluteal, L4,5, S1 inferior gluteal, L5, S1,2 sciatic, L5, S1,2 deep peroneal, L4,5, S1 superficial peroneal, L5, S1 tibial, L4,5, S1,2,3 pudendal, S2,3,4 29.2.3 femoral iliopsoas, quadriceps femoris, sartorius flex hip and leg extension (quadriceps femoris) obturator adductor, gracilis, obturator externus adduct thigh (all), and lateral rotation (obturator externus) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Peripheral Nerves c. nerve, s________ i. muscle, g________ m________, t________ f________ l________, p________ ii. function, ________ d. nerve, i________ i. muscle, g________ m________ ii. function, ________ e. nerve, s________ i. muscle, b________ f________, s________, s________ ii. function, ________ f. nerve, d________ i. muscle, t________ a________, e________ d________ l________, e________ h________ l________, e________ d________ b________ ii. function, ________ g. nerve, s________ i. muscle, p________ l________ and b________ ii. function, ________ h. nerve, t________ i. muscle, p________ t________, g________, p________, s______, f________ h________ l________, f________ d________ l________, f________ d________ b________, f________ h________ b________ ii. function, ________ i. nerve, p________ i. muscle, p________, s________ ii. function, ________ 177 superior gluteal gluteus medius/minimus, tensor fasciae lata, piriformis abduct thigh (gluteus), thigh flexion (tensor fasciae lata), lateral thigh rotation (piriformis) inferior gluteal gluteus maximus thigh abduction sciatic trunk biceps femoris, semitendinosus, semimembranosus leg flexion (and assist thigh extension) deep peroneal tibialis anterior, extensor digitorum longus, extensor hallucis longus, extensor digitorum brevis foot dorsiflexion (all but EDB), foot supination (TA), extension toes 2-5 (EDL, EDB), extension great toe (EHL, EDB) superficial peroneal peroneus longus and brevis plantarflex pronated foot and eversion tibial posterior tibialis, gastrocnemius, plantaris, soleus, flexor hallucis longus, flexor digitorum longus, flexor digitorum brevis, flexor hallucis brevis plantarflex supinated foot (PA, FDL, FHL), plantarflex ankle (gastroc, plantaris, soleus), inversion (PA), flex terminal phalanx toes 2-5 (FDL), flex terminal phalanx great toe (FHL), flex mid phalanx toes 2-5 (FDB), flex proximal phalanx great toe (FHB), knee flexion (gastroc, plantaris) pudendal perineal, sphincters voluntary contraction of pelvic floor 29 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 178 Part 10: Peripheral Nerves 14. True or False. The gluteus maximus muscle a. abducts thigh b. adducts thigh c. medially rotates thigh d. laterally rotates thigh e. is innervated by superior gluteal nerve 15. True or False. The tibialis anterior muscle is responsible for foot a. dorsiflexion b. plantarflexion c. eversion d. supination 16. Complete the following about the function of peripheral nerves: a. The function of extension of the great toe is served by i. muscle, e________ h________ l________ and e________ d________ b________ ii. root, ________ b. The function of foot dorsiflexion is served by i. muscle, t________ a________, e________ d________ l________, and e________ h________ l________ ii. root, ________ c. Which is the best L5 muscle to test clinically? (Hint: E is the 5th letter of the alphabet) 17. True or False. The extensor hallucis longus muscle a. extends great toe b. dorsiflexes foot c. is innervated by the deep peroneal nerve 29 29.2.3 true (abducts thigh in a prone position) false (obturator externus and pectineus) false (gluteus medius and gluteus minimus) false (obturator externus) false (inferior gluteal nerve) 29.2.3 true false (soleus, gastrocnemius) false (peroneus longus and brevis) true 29.2.3 extensor hallucis longus and extensor digitorum brevis L5, S1 tibialis anterior, EDL, and EHL L4,5 (TA); L4,5, S1 (EDL and EHL) extensor hallucis longus 29.2.3 true true true Peripheral Nerve Injury/Surgery 18. Complete the following regarding timing of surgical repair of nerves: a. If the nerve must regenerate a long distance, repair should be done ________. b. After ________ months of denervation, most muscles cannot recover. 29.3.3 early 24 ERRNVPHGLFRVRUJ ReU n LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Peripheral Nerves 19. True or False. The brachial plexus is formed by the dorsal rami of C5-T1. false (It is formed by the ventral rami of C5-T1. The dorsal rami innervate the paraspinal muscles.) 20. Draw a diagram of the brachial plexus. 179 29.3.4 29.3.4 Fig. 29.1 21. On your diagram of the brachial plexus, label the following: ① roots C4-T1; ② organization RTDCN (roots, trunks, divisions, cords, nerves); ③ names of trunks—SMI (superior, middle, inferior); ④ add names of cords—LMP (lateral, medial, posterior) 29.3.4 Fig. 29.2 22. On your outline of the brachial plexus, add the nerves. Hint: Donald says somewhat loudly, “Mickey Mouse, you are right to so sincerely love Minnie Mouse madly.” 29.3.4 29 Fig. 29.3 ERRNVPHGLFRVRUJ LiOb ReU n LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 180 Part 10: Peripheral Nerves 23. Draw the left brachial plexus–outline. 29.3.4 Fig. 29.4 24. Complete the following about the brachial plexus: a. Name the roots (6). b. Name the segments (5). (Hint: Run to do Cindy’s needs.) c. Name the nerves (16). (Hint: Donald says somewhat loudly Mickey Mouse you are right to so sincerely love Minnie Mouse madly) d. Name the trunks (3). e. Name the cords (3). 29 25. Trace, using the brachial plexus diagram, the theoretically possible root contribution to each nerve and then compare with the actual root contribution in each nerve. a. nerve, d______ s______ i. theoretical, _____ ii. actual, _____ b. nerve, s______ i. theoretical, ______ ii. actual, ______ c. nerve, s______ i. theoretical, ______ ii. actual, ______ 29.3.4 C4,5,6,7,8, T1 roots, trunks, divisions, cords, nerves dorsal scapular; suprascapular; subclavius; lateral pectoral; musculocutaneous; median; ulnar; axillary; radial; thoracodorsal; subscapular upper; subscapular lower; long thoracic; medial pectoral; medial brachial cutaneous; medial antebrachial cutaneous superior, middle, inferior lateral, medial, posterior (Without rote memorization, this will give accurate answers 83% of the time. Only 8 of 49 theoretical root contributions are not actualized.) dorsal scapular C4,5 C4,5 subscapular C4,5,6 C4,5,6 subclavius C6 C6 Fig. 29.1 ERRNVPHGLFRVRUJ LiOb ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Peripheral Nerves d. nerve, l_______ i. theoretical, ______ ii. actual, ______ e. nerve, m______ i. theoretical, ______ ii. actual, ______ f. nerve, m______ i. theoretical, ______ ii. actual, ______ g. nerve, u______ i. theoretical, ______ ii. actual, ______ h. nerve, a______ i. theoretical, ______ ii. actual, ______ i. nerve, r______ i. theoretical, ______ ii. actual, ______ j. nerve, t______ i. theoretical, ______ ii. actual, ______ k. nerve, s______ u______ i. theoretical, ______ ii. actual, ______ l. nerve, s______ l______ i. theoretical, ______ ii. actual, ______ m. nerve, l_______ t_____ i. theoretical, ______ ii. actual, ______ n. nerve, m______ t_______ i. theoretical, ______ ii. actual, ______ o. nerve, m______ b______ i. theoretical, ______ ii. actual, ______ p. nerve, m______ a_________ i. theoretical, ______ ii. actual, ______ 181 lateral pectoral C4,5,6,7 C4,5,6,7 musculocutaneous C5,6,7 C5,6,7 median C5,6,7, T1 C5,6,7, T1 ulnar C8, T1 C7,8, T1 axillary C4,5,6,7,8, T1 C4,5,6,7,8, T1 radial C4,5,6,7,8, T1 C4,5,6 thoracodorsal C5,6,7,8, T1 C6,7,8 subscapular upper C5,6,7,8, T1 C5,6,7 subscapular lower C5,6,7,8,T1 C5,6,7 long thoracic C5,6,7 C5,6,7 medial thoracic (pectoral) C8, T1 not listed medial brachial C8, T1 not listed medial antebrachial C8, T1 not listed 26. List the brachial plexus nerves (except for median, ulnar, and radial), the muscles they serve, and the action of the muscles. a. nerve, d________ s________ i. muscle 1, l________ s________ ii. action, ________ iii. muscle 2, r________ iv. action, ________ b. nerve, s________ i. muscle 1, s________ ii. action, ________ iii. muscle 2, i________ iv. action, ________ 29.3.4 dorsal scapular levator scapulae elevate scapulae rhomboids adduct and elevate scapula suprascapular supraspinatus adduct arm 15 to 30 degrees infraspinatus exorotation of humerus 29 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 182 Part 10: Peripheral Nerves c. nerve, m________ i. muscle 1, b________ b________ ii. action, ________ iii. muscle 2, c________ iv. action, ________ v. muscle 3, b________ vi. action, ________ d. nerve, a________ i. muscle 1, d ________ ii. action, ________ iii. muscle 2, t________ m________ iv. action, ________ e. nerve, s________ i. muscle 1, ________ ii. action, ________ iii. muscle 2, ________ iv. action, ________ f. nerve, t________ i. muscle, ________ ii. action, ________ g. nerve, l________ t________ i. muscle, ________ ii. action, ________ 27. List the branches of the radial nerve cascade in proper sequence. (Hint: rest in peace, retbes in peeeeeae) a. r______ b. e______ c. t______ d. b______ e. e______ f. s______ g. i______ h. n______ i. p______ j. e______ k. e______ 29 l. m. n. o. p. e______ e______ e______ a______ e______ 28. a. b. c. d. e. True or False. The radial nerve is formed by C5-8. innervates triceps. innervates supinator. innervates brachioradialis. continues into forearm as posterior interosseous nerve. musculocutaneous biceps brachii flex and supinate forearm coracobrachialis flex humerus at shoulder brachialis flex forearm axillary deltoid abduct arm 30 to 90 degrees teres minor exorotate and adduct humerus subscapular teres major adduct arm subscapularis adduct arm thoracodorsal latissimus dorsi adduct arm long thoracic serratus anterior forward shoulder thrust 29.3.4 radial extensor triceps brachioradialis extensor carpi radialis supinator i n posterior interosseous nerve p extensor carpi ulnaris extensor digitorum communis extensor digiti minimi extensor pollicis brevis extensor pollicis longus abductor pollicis longus extensor indicis 29.3.4 true true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Peripheral Nerves 29. What muscle is innervated by the axillary nerve? 30. List the branches of the median nerve cascade. 3 (Hint: pfpf pfaol) a. p________ t________ b. f________ c________ r________ c. p________ l________ d. f________ d________ s________ e. f_________ d__________ p__________ f. g. h. i. j. k. f_________ p__________ l__________ p________ q________ f________ p________ b________ a________ p________ b________ o________ p________ l________ 31. Now list the function of the muscles of the median nerve cascade: (Hint: pfpf3pfaol) a. pronator teres: function ________ b. flexor carpi radialis: function ________ c. palmaris longus: function ________ d. flexor digitorum superficialis: function ________ e. flexor digitorum profundus: function ________ f. flexor pollicis longus: function ________ g. flexor pollicis brevis: function ________ h. abductor pollicis brevis: function ________ i. opponens pollicis: function ________ j. lumbricals 1 and 2: function ________ 32. Which muscles of the hand are innervated by the median nerve? Hint: loaf a. l________ b. o________ p________ c. a________ p________ b________ d. f________ p________ b________ teres minor, deltoid 183 29.3.4 29.3.4 pronator teres flexor carpi radialis palmaris longus flexor digitorum superficialis flexor digitorum profundus I & II flexor pollicis longus pronator quadratus flexor pollicis brevis abductor pollicis brevis opponens pollicis lumbricals 1 and 2 29.3.4 forearm pronator radial flexion of hand wrist flexion flex middle phalanx fingers 2 to 5, flex wrist flex distal phalanx fingers 2 and 3, flex wrist flex distal phalanx of thumb flexes proximal phalanx of thumb abducts thumb metacarpal and radial wrist extension opposes thumb metacarpal flex proximal phalanx and extend 2 distal phalanges Dig 2-3 29.3.4 lumbricals 1 and 2 opponens pollicis abductor pollicis brevis flexor pollicis brevis 29 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 184 Part 10: Peripheral Nerves 33. List the muscles served by the ulnar nerve cascade in proper order, as well as the function of the muscles. (Hint: "Ffafner I Love Him") a. i. f________ c________ u________ ii. function: ________ b. i. f________ d________ p________ ii. function: ________ 29.3.4 flexor carpi ulnaris ulnar flexion of hand flexor digitorum profundus flex distal phalanx of fingers 4 and 5 c. i. ii. a________ p________ function: ________ adductor pollicis thumb adductor i. deep part of f________ p________ b________ function: ________ flexor pollicis brevis d. ii. flex proximal phalanx thumb e. i. i________ ii. function (dorsal): ________ iii. function (palmar): ________ interossei abducts adducts, flex proximal phalanges at metacarpophalangeal joints i. ii. lumbricals 3 & 4 extends two distal phalanges of fingers 3 and 4 at interphalangeal joints f. l________ function: ________ g. hypothenar muscles i. a________ d________ m________ ii. function: ________ iii. f________ d________ m________ iv. function: ________ v. o________ d________ m________ vi. function: ________ h. p________ b________ 29 34. Complete the following about anatomic variants with Martin-Gruber anastomosis: a. Connections between the ________ and ________ nerves b. in the ________ c. found in ________% of cadavers. abductor digiti minimi abduction of little finger flexor digiti minimi flex little finger opponens digiti minimi opposition digit 5 palmaris brevis 29.3.4 median; ulnar forearm 23 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 30 Entrapment Neuropathies General Information 1. List medical etiologies of entrapment neuropathies. a. d________ m________ b. h________ c. a________ d. a________ e. f. g. h. c________ p________ r________ r________ a________ g________ 30.1 diabetes mellitus hypothyroidism acromegaly amyloidosis (primary or secondary) carcinomatosis polymyalgia rheumatica rheumatoid arthritis gout Mechanism of Injury 2. Does brief compression primarily myelinated affect myelinated fibers, unmyelinated fibers, or both? 30.2 Occipital Nerve Entrapment 3. True or False. Occipital nerve entrapment a. is due to compression of a sensory branch of C3. b. presents pain in the occiput with a trigger point near the superior nuchal line. c. is more common in men. 4. Answer the following about nonsurgical treatment of occipital nerve entrapment: a. Greater occipital nerve block may provide relief lasting ~________. b. Inject at ________. 30.3.1 false (sensory branch of C2) true false 30.3.4 30 1 month trigger point ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 186 Part 10: Peripheral Nerves c. If the case is disabling, and pain doesn’t respond to medication, what else may be tried? d. Is a collar indicated? 5. Answer the following about surgical treatment of occipital nerve entrapment: a. decompression of ________ nerve root b. Occipital neurectomy can consist of avulsion of the greater occipital nerve as it exits between the ________ and the ________ ________ muscle. c. Another option is release of nerve within the ________ muscle. i. relief in ________% ii. improvement in ________% no 30.3.4 C2 transverse process of C2 and inferior oblique muscle trapezius 46 36 Median Nerve Entrapment 6. Name the two most common syndromes of median nerve entrapment. a. c________ t________ s________ b. p________ t________ s________ 7. Complete the following about the course of the median nerve: a. The median nerve passes under the ________ ________ ________. b. The motor branch either goes ________ or ________ the ligament c. and serves the ________ muscles, d. which consist of i. ________ ii. ________ iii. ________ iv. ________ 30 surgery, alcohol neurolysis 8. Complete the following about the median nerve: a. Describe the sensory distribution of the median nerve. i. thumb: ________ aspect ii. fingers: ________, ________ , and half of ________ iii. ________ eminence and adjacent iv. ________ palm b. Palmar cutaneous branch (PCB) crosses ________ transverse carpal ligament. 9. Answer the following about the transverse carpal ligament (TCL): a. The TCL extends how far beyond the distal wrist crease? 30.4.1 carpal tunnel syndrome pronator teres syndrome 30.4.2 transverse carpal ligament under; pierces LOAF lumbricals 1 and 2 opponens pollicis abductor pollicis flexor pollicis brevis 30.4.2 palmar index, middle, and half of ring thenar radial above 30.4.2 3 cm ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Entrapment Neuropathies b. What is the name of the sensory nerve spared in carpal tunnel syndrome? c. This nerve arises ________cm proximal to the wrist, d. passes ________ the transverse carpal ligament e. and serves the ________ ________ sensation. 10. Describe main trunk median nerve compression. a. above elbow due to ________ b. at elbow i. l________ f________ ii. p________ t________ iii. s________ b________ c. Honeymoon paralysis is due to _______. d. Benediction hand is due to weakness in what muscle? 11. Characterize pronator teres syndrome (PTS). a. It compresses the ________ nerve b. where it dives between the two heads of the ________ ________. c. Symptoms: i. Pain in ________ distinguishes it from carpal tunnel syndrome ii. due to the ________ ________ ________ branch exiting before the TCL. iii. Also presents with weakness in the ________ and iv. paresthesias in the ________ and ________. v. Nocturnal exacerbation is ________. 12. What are the key features of anterior interosseous neuropathy? a. Presents with i. loss of f________ ii. of the d________ p________ iii. of the ________ iv. and ________ b. due to i. weakness of the f________ d________ p________ and the ii. f________ p________ l________. c. No loss of ________. d. Patient can’t ________. e. treatment i. e________ m________ ii. s________ e________ 187 palmar cutaneous branch 5.5 above thenar eminence 30.4.3 Struther’s ligament lacertus fibrosus (bicipital aponeurosis) pronator teres sublimis bridge external pressure flexor digitorum profundus I and II 30.4.3 median pronator teres palm median palmar cutaneous grip thumb and index finger absent 30.4.3 flexion distal phalanges thumb index finger flexor digitorum profundus flexor pollicis longus sensation make “OK” sign 30 expectant management 8-12 weeks surgical exploration (if no improvement) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 188 Part 10: Peripheral Nerves 13. Describe carpal tunnel syndrome. a. The ________ ________ median nerve entrapment neuropathy. b. It is due to ________. c. d. e. f. g. h. Where? Usually occurs in what population? Male/female ratio: ________ Bilateral in ________% of cases Worse in ________ Phalen sign performed by ________ of the wrist i. and is positive in ________. 14. Answer the following about carpal tunnel syndrome: a. What is the most sensitive electrodiagnostics test for carpal tunnel syndrome? b. Which should be faster, median sensory conduction velocity or ulnar sensory conduction velocity? c. By how much? 15. Complete the following about carpal tunnel syndrome: a. Describe treatment. i. sp________ ii. st________ iii. su________ b. Incision should be slightly to the ________ side of the interthenar crease c. to avoid i. p________ c________ b________ and/or ii. a________ r________ t________ m________ b________. 30 30.4.4 most common compression of the median nerve distal to wrist crease middle-aged patients 4:1 >50% dominant hand forced flexion 80% of cases 30.4.4 sensory latency nerve conduction velocity (NCV) median sensory conduction velocity 4m/s 30.4.4 splint steroids surgery ulnar palmar cutaneous branch anomalous recurrent thenar motor branch Ulnar Nerve Entrapment 16. Complete the following about the ulnar nerve: a. Name the roots. b. Motor findings of entrapment are: i. wasting of the ________ ii. W________ sign iii. F________ sign iv. ________ deformity of hand c. i. disturbance of sensation in ________ ii. and ________ 30.5.1 C7,8, T1 interossei Wartenberg’s Froment’s claw little finger ulnar half of ring finger ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Entrapment Neuropathies 17. a. b. c. Describe Wartenberg’s sign. It affects the ________, which rests in ________ due to weakness of the t________ p________ i________ m________. d. Which nerve is involved? 18. Describe Froment’s sign. a. Test by having the patient g________ b. using their t________ and i________ f________. c. If the ________ nerve is weak the d. thumb b________ b________ e. because ulnar-innervated ________ ________ is weak; f. therefore, the body substitutes it for the stronger ________ ________ ________, g. which is innervated by the ________ branch of the ________ nerve. 19. Describe injury to the ulnar nerve above the elbow. a. Can be due to injury to the ________ cord of the brachial plexus. b. Kinking may be caused by the a________ of S________, c. which is a thin, flat ________ ________. 20. Answer the following about ulnar nerve entrapment at the elbow: a. May present as t________ u________ p________. b. NCV is less than ________ m/s c. or there is a drop of more than ________ m/s between the AE and BE segments. d. Early symptoms may be purely _______. 21. What are surgical options for treatment of ulnar compression at the elbow? a. nerve d________ without t________ b. nerve d________ with ________ c. m________ e________ d. Sometimes e________ of n________ and possibly j________ g________ may be required. e. transposition may be to _________ _______, within the _______ _______ ________, or a _____________ __________. 189 30.5.1 little finger abduction third palmar interosseous muscle ulnar 30.5.1 grasp a piece of paper thumb and index fingers ulnar bends backwards adductor pollicis flexor pollicis longus anterior interosseous; median 30.5.2 medial arcade of Struthers aponeurotic band 30.5.3 tardy ulnar palsy 50 10 motor 30.5.3 decompression, transposition decompression, transposition medial epicondylectomy excision of neuroma; jump graft subcutaneous tissue, within the flexor carpi ulnaris, or a submuscular position 30 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 190 Part 10: Peripheral Nerves 22. Describe the borders of Guyon’s canal. a. roof i. p________ f________ ii. p________ b________ b. floor i. f________ r________ of the p________ ii. p________ l________ c. Below the floor lies the t________ c________ l________. d. Contains only the _______ _______ and _______ _______. 23. Describe the types of ulnar nerve lesions in Guyon’s canal. a. Type I i. location of compression ii. weakness iii. sensory deficit b. Type II i. location of compression ii. weakness 30 palmar fascia palmaris brevis flexor retinaculum of the palm pisohamate ligament transverse carpal ligament ulnar nerve and ulnar artery 30.5.5 just proximal to or within Guyon’s canal all intrinsic hand muscles innervated by ulnar n. palmar ulnar distribution along deep branch muscles innervated by deep branch none iii. sensory deficit c. Type III i. location of compression ii. weakness iii. sensory deficit 30.5.5 distal end of Guyon’s canal none palmar ulnar distribution Radial Nerve Injuries 24. Complete the following regarding radial nerve injuries: a. Sensation loss in the web space of the thumb indicates injury in the ________. b. Pain at the lateral epicondyle indicates compression of the ________. c. Wrist drop indicates injury to __________ ____, where the nerve is in the ________ ________ of the humerus. d. Triceps plus all distal muscle weakness indicates injury at the ________. e. Weakness of the above, plus the deltoid and latissimus dorsi indicates injury to the ________ _______ . 30.6.3 hand supinator tunnel at the elbow mid-upper arm; spiral groove axilla posterior cord ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Entrapment Neuropathies 25. Describe mid-upper or forearm radial nerve compression. a. Radial nerve compression in mid-upper arm produces i. w________ (w________ d________) ii. w________ n________ iii. because it compresses ________ and ________ _______ ________. b. Injury to the posterior interosseous nerve (PIN) produces ________ of fingers. c. Injury at the supinator tunnel produces ________ but no ________. 26. Complete the following about radial nerve anatomy. a. PIN refers to the ________ ________ ________, b. a continuation of the ________ nerve, c. which serves the i. ________ of the fingers ii. and the a ________ p________ l________. 27. Describe management of radial nerve injury. a. posterior interosseous syndrome i. e________ ii. l________ c________ b. supinator tunnel syndrome c. hand injury i. Clinical finding is _____ _____ of _______ loss at the d_________ w________ s_______ of the thumb ii. often caused by ________. 191 30.6.3 weakness (wrist drop) wrist numbness PIN; superficial radial nerve weakness pain; weakness 30.6.3 posterior interosseous nerve radial extensors abductor pollicis longus 30.6.3 exploration (if case doesn’t respond to 4-8 weeks expectant management) lyse constrictions (including arcade of Frohse) Surgery rarely required, but responds to nerve decompression. small area of sensory loss; dorsal web space of the thumb handcuffs Axillary Nerve Injuries 28. List possible etiologies of axillary nerve neuropathy. a. s________ d________ b. sleeping in the ________ position with arms ______ _____ ___ ______ c. compression from a ________ d. i________ i________ e. entrapment in the ________ ______ 30.7 shoulder dislocation prone; abducted above the head thoracic harness injection injury quadrilateral space 30 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 192 Part 10: Peripheral Nerves Suprascapular Nerve 29. Describe suprascapular nerve injury. a. Nerve formed from roots ________ C5,6 b. Entrapped at s___________ n_________ suprascapular notch beneath beneath the __________ ________ the transverse scapular __________ ligament c. Sensory symptoms: ________ deep, poorly localized (referred) shoulder pain d. Motor symptoms: weakness and atrophy supraspinatus and of ________ and ________ infraspinatus e. May be difficult to distinguish from rotator cuff injury ________ ________ injury. f. Differentiate from C5 cervical rhomboid and deltoid radiculopathy and upper brachial plexus lesion by testing ________ and ________. Meralgia Paresthetica 30. a. b. c. Define meralgia paresthetica. Also known as ________, or ________. Hyperpathia located at the l________ u________ t________. d. Entrapment of the l________ f________ c________ nerve. e. True or False. Involves both motor and sensory fibers. 31. Answer the following regarding differential diagnosis of meralgia paresthetica: a. Femoral neuropathy sensory changes tend to be more ________. b. L2 or L3 radiculopathy: look for ______ ______. c. Nerve compression by abdominal or pelvic tumor suspected if ________. 30 30.8 32. Describe treatment options for meralgia paresthetica. a. Nonsurgical measures achieve relief in ~________% of cases. b. True or False. Centrally acting pain medications are often effective. c. Neurectomy may be ________ (more/less) effective than decompression, but risks ________ ________. d. If neurectomy instead of neurolysis is elected, what should be done prior to sectioning? 30.9.2 Bernhardt-Roth syndrome “swashbuckler’s disease” lateral upper thigh (burning pain) lateral femoral cutaneous false (sensory only) 30.9.4 anteromedial motor weakness (thigh flexion or knee extension) concomitant GI or GU symptoms 30.9.5 91 false more; denervation pain electrical stimulation to rule out a motor component ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Entrapment Neuropathies 193 Common Peroneal Nerve Palsy 33. Complete the following about common peroneal nerve palsy: a. True or False. The peroneal nerve is the most common nerve to develop acute compression palsy. b. At what location? 34. Describe the clinical findings in peroneal nerve palsy. a. True or False. The anterior tibialis is the most commonly involved muscle in peroneal nerve palsy. b. Results in impairment of i. motor function: ________ ii. sensory loss in ________ 30.12.1 true fibular head 30.12.3 false (EHL) foot drop, weak foot eversion dorsum of foot and lateral calf superficial peroneal c. The peroneus longus and brevis are innervated by the ______ ______ branch of the common peroneal nerve. d. The deep peroneal branch innervates the EHL, anterior tibialis, and EDL ________, ________ ________, and (extensor digitorum longus) ________ muscles. 35. If EMG stimulation is absent, both above and below fibular head, prognosis is ________. poor 30.12.4 Tarsal Tunnel 36. True or False. The posterior tibial nerve may be a. found in the tarsal tunnel. b. found posterior and inferior to the medial malleolus. c. trapped at the retinacular ligament. d. classically responsible for nocturnal pain and paresthesia at the heel. 37. Answer the following about clinical findings of posterior tibial nerve entrapment: a. Percussion of the nerve at ________ ________ produces paresthesias that radiate ________. b. Exacerbated by ___________. c. Dorsiflexion-eversion test: Examiner maximally everts and dorsiflexes the ankle while ________ for 5-10 seconds. 30.13.1 true true true false (heel is spared) 30.13.2 medial malleolus; distally maximal inversion and eversion of foot dorsiflexing the toes at MTP joints 30 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 31 Non-Entrapment Peripheral Neuropathies Definitions 1. Define: a. peripheral neuropathy 31.1 diffuse lesions of peripheral nerves producing weakness, sensory disturbance, and/or reflex changes disorder of a single nerve, often due to trauma or entrapment involvement of 2 or more nerves, usually due to a systemic abnormality b. mononeuropathy c. mononeuropathy multiplex 31 Etiologies of Peripheral Neuropathy 2. List the etiologies of non-entrapment peripheral neuropathies. (Hint: Grand Therapist) a. G_________ b. R__________ c. A__________ d. N__________ e. D__________ f. T___________ g. H___________ h. E___________ i. R___________ j. A__________ or A_____ k. P_________ or P________ or P__________ l. I____________ m. S___________ n. T________ 31.2 Guillain-Barré Renal (uremic neuropathy) Alcoholism Nutritional Diabetes Traumatic Hereditary Endocrine or Entrapment Radiation Amyloid or AIDS Psychiatric or Paraneoplastic or Pseudoneuropathy Infectious Sarcoidosis Toxins ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Non-Entrapment Peripheral Neuropathies Classification 3. Complete the following regarding peripheral neuropathy: a. The most common peripheral neuropathy that is an inherited disorder is C______-M_______-T_______. b. Psychogenic somatoform disorders or malingering with symptoms of pains, paresthesias, hyperalgesia, weakness, an even objective changes in temperature are associated with p____________. 31.3 Charcot-Marie-Tooth pseudoneuropathy Clinical 4. Regarding peripheral neuropathy. a. Symptoms of peripheral neuropathies include: i. l_____ of s___________ ii. p______ iii. w_______ iv. i__________ v. d________ a____________ b. Work-up includes: i. H___-A___ ii. T____ iii. E____ iv. V______ B___ v. E____ 195 31.4.1 loss of sensation pain weakness incoordination difficulty ambulating 31.4.2 Hgb-A1C TSH ESR Vitamin B12 EMG Syndromes of Peripheral Neuropathy 5. True or False. Regarding critical illness polyneuropathy (CIP). a. Most often affects proximal muscles. b. Occurs in the presence of sepsis or multiorgan failure. c. Abnormal EMG is seen. d. Serum CPK may be normal. e. Treatment is supportive. f. Complete recovery rarely occurs. 6. Which syndrome is associated with a pure sensory neuropathy? 7. True or False. Alcohol neuropathy includes: a. motor neuropathy b. sensory neuropathy c. absent Achilles reflex d. intense pain 31.5.1 false (distal muscles) true true true true false (occurs in 50% of patients) paraneoplastic syndrome (also associated with pyridoxine therapy) 31.5.2 31.5.3 false true true false 31 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 196 Part 10: Peripheral Nerves 8. Brachial neuritis: a. aka P_________-T_____ syndrome b. aka i_________ brachial plexus neuropathy c. Etiology: __________ d. Prognosis: _________ e. Predominant symptom: _______ f. Followed by: _______ in ____% g. Confined to shoulder girdle in ________% 9. True or False. The most important study in the diagnosis of lumbosacral plexus neuropathy is a. MRI b. CT c. EMG d. ESR 10. EMG in lumbosacral neuropathy shows what in regards to: a. Fibrillation potentials in number _________. b. Motor unit potentials in number _________. c. Motor unit potentials in amplitude _________. d. Motor unit potentials in duration __________. e. Motor unit potentials that are __________. f. Have changes involving at least _________ segments. g. _______ the paraspinal muscles is highly __________. 31 31.5.4 Parsonage-Turner idiopathic unclear good pain weakness in 96% 50% 31.5.5 false false true (EMG in lumbosacral neuropathy – rule out diabetic neuropathy) false 31.5.5 decreased decreased increased increased polyphasic 2 Sparing; diagnostic 11. Complete the following about diabetic neuropathy: a. Diabetic patients show neuropathy or 50% EMG changes __%. b. The first symptom of diabetes may be neuropathy _________. c. Neuropathy might be reduced by control sugar of blood ______. 31.5.6 12. Complete the following about druginduced neuropathy: Hint: CDEF a. C__________ b. D__________ c. E__________ d. F__________ 31.5.7 Chemotherapy drugs Dilantin (Phenytoin) Elavil (Amitriptyline) Flagyl (Metronidazole) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Non-Entrapment Peripheral Neuropathies 13. True or False. Femoral neuropathy includes: a. weakness of the quadriceps and iliopsoas b. patellar reflex – reduced c. femoral stretch – positive d. sensation over lateral calf reduced 14. Answer the following regarding femoral neuropathy: a. Name the muscle responsible for i. knee extension ii. hip flexion b. To distinguish L4 radiculopathy from femoral neuropathy, L4 radiculopathy would not involve the _________. c. Femoral neuropathy is caused by i. d_______ ii. c________ 31.5.8 true true true false (femoral neuropathy includes ↓ sensation over anterior thigh and medial calf.) 31.5.8 quadriceps femoris iliopsoas iliopsoas diabetes compression 15. True or False. The most frequent cause of femoral neuropathy is a. intrabdominal tumor false b. retroperitoneal hematoma false c. diabetes true (All other options can cause femoral neuropathy.) d. entrapment due to inguinal hernia false e. trauma false 31.5.8 16. True or False. Regarding AIDS neuropathy. a. It usually presents as proximal symmetric polyneuropathy. b. HIV+ only patients do not develop it. c. It never includes sensory elements. 31.5.9 d. It has an infectious etiology. e. It may be caused by lymphomatous invasion of the meninges or nerves. f. Drugs used to treat HIV can also cause neuropathies, most commonly NRTIs and protease inhibitors. 197 false (distal, symmetric polyneuropathy) true false (usually includes numbness and tingling) true true true 31 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 198 Part 10: Peripheral Nerves 17. Complete the following about monoclonal gammopathy: a. Included entities such as i. m_________ ii. Waldenstrom _____________ iii. M_____ b. Responsible for _____% of neuropathies. c. Patient risk factors for anesthesia-related ulnar neuropathy include: i. m______ g_____ ii. o________ iii. prolonged post-op b_____ r_______ 18. Complete the following about perioperative ulnar neuropathies: a. Avoid elbow flexion of greater than _____ degrees. b. It tightens the _______ ___________ retinaculum. 19. Complete the following about lower extremity neuropathy: a. i. common peroneal in ______% ii. risk is _____ position b. Femoral neuropathy where there is hemorrhage in the _______ muscle. c. Meralgia paresthetica i. tends to occur ________ ii. in young slender _______ iii. positioned _______ iv. in operations lasting ______ hours v. recovers in approximately ____ ________ 20. What is the management of lower extremity neuropathy? a. Call neurologist if not better in _____ days. b. Do EMG not earlier than ____ weeks. 31 21. Complete the following about amyloid neuropathy and uremic neuropathy: a. Amyloid neuropathy i. Amyloid can be deposited in ________ _______. ii. It produces a __________ neuropathy. iii. It can produce pressure on nerves, i.e., _______ _______. b. Uremic neuropathy i. occurs in ________ _______ _______ patients. ii. symptoms include _______ ______ and ________ ________. iii. can be relieved by _______. 31.5.10 myeloma macroglobulinemia MGUS 10% male gender obesity (BMI > 38) bed rest 31.5.11 110 cubital tunnel 31.5.11 81% lithotomy psoas bilaterally males prone 6 to 10 6 months 31.5.11 5 3 31.5.12 peripheral nerves sensory carpal tunnel chronic renal failure “Charlie horses” and “restless legs” dialysis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Non-Entrapment Peripheral Neuropathies 22. Complete the following about postcardiac catheterization neuropathy: a. It involves the ______ nerve. b. It usually involves __________. 199 31.5.12 femoral hematomas Peripheral Nerve Injuries 23. Describe the anatomy of the peripheral nerve. a. The connective tissue membrane that surrounds individual axons is the _______. b. _________ surrounds groups of axons (i.e. fascicles). c. __________ surrounds groups of fascicles (i.e. nerves). 24. Complete the following regarding injury and regeneration of nerve: a. The regeneration rate = ____________ b. Sunderland system i. first degree: anatomy ii. second degree: axon ______ connective tissue is _________ iii. third-degree: axon and endoneurium d________ 25. Complete the following about peripheral neuropathies: a. Fourth-degree axon injury involves _________ of all the elements but ______ is intact. b. Fifth-degree axon injury: endo-, peri-, and epineurium is completely t__________. c. Sixth-degree axon injury: mixed _______ through ______ degree injuries 26. Describe injury classification of peripheral nerves and regeneration prognosis. a. Axon compressed 31.6.1 endoneurium Perineurium Epineurium 31.6.1 1 mm/day (i.e. 1 inch/month) preserved; conduction block, compression, or ischemia injuried; endo-, peri-, epineurium intact (endoneurium provided tube for regeneration) disrupted (grossly normal appearance, recovery related to the extent of intrafascicular fibrosis) 31.6.1 interruption of all elements but epineurium is intact (nerve is indurated and enlarged) transected first through fourth Two classifications: Seddon and Sunderland First degree = Seddon neuropraxia; conduction block from compression or ischemia, anatomy preserved 31.6.1 31 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 200 Part 10: Peripheral Nerves b. Axon injured c. Axon and endoneurium disrupted d. Axon, endoneurium and perineurium disrupted e. Axon endo-, peri-, and epineurium disrupted 27. What are the etiologies of brachial plexus injuries? Hint: CPT a. C________ b. P________ c. T_________ 28. Complete the following about traction (stretch) injuries of the brachial plexus selectively: a. Spare the i. _________ __________ ii. _________ __________ b. Injure the i. _________ __________ ii. _________ __________ 31 Second-degree = Seddon axonotmesis; injury to axon and Wallerian degeneration; endo-, peri-, epineurium intact; endoneurium provides “tube” to optimize successful reinnervation of target muscle Third degree = axon and endoneurium disrupted; recovery inversely related to interfascicular fibrosis; gross normal appearance Fourth-degree = interruption of axon, endo- and perneurium; gross reveals indurated enlarged nerve Fifth-degree = Seddon neurotmesis; complete transection of axon, endo-, peri-, and epineurium 31.6.2 compression penetration traction 31.6.2 medial cord median nerve posterior cord lateral cord 29. Complete the following about the preand post-ganglionic injuries: a. What nerve injury cannot be repaired? proximal to the dorsal root ganglion (i.e. preganglionic) b. What is the evidence for such an injury? (Hint: prEHms) i. p_________ pain ii. r_________ rhomboids iii. E________ EMG iv. H________ Horner’s syndrome v. m________ meningocele vi. s_________ scapula 31.6.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Non-Entrapment Peripheral Neuropathies 30. Describe upper and lower brachial plexus injury. a. Upper brachial plexus injury i. E___-D_______ palsy ii. C__-C__ iii. f_____ s______ of h______ h_____ from s______ iv. i______ r_______ a___ with e_______ e______ v. Commonly shoulder d_______ or m_______ c______ vi. B________ t_____ b. Lower brachial plexus injury: i. aka K_______ palsy ii. C__-T__ iii. s_____ p____ of a_______ a____ in iv. f____ or P_______ t_____ v. c____ h___ with w____ of s_____ h___ m____ vi. s________ h_____ 31. Complete the following about brachial plexus birth injuries: a. i. most common is _______ ii. consisting of C5-C6 _____% and iii. C5, C6-C7 _____% iv. lower C8-T1 _____% b. Combined is ______% c. Bilateral _______% d. Spontaneous recovery is _____% 32. Characterize upper brachial plexus injury – Erb’s palsy. a. Roots involved: _______ b. Position of upper extremity (Hint: erp) i. e_______ ii. r_______ iii. p______ iv. looks like ______ ______ ________ 201 31.6.2 Erb-Duchenne palsy C5-C6 forceful separation of humeral head from shoulder internally rotated arm with extended elbow dystocia or motorcycle crash Bellhop’s tip, hand not affected Klumpke’s palsy C8-T1 sudden pull of abducted arm fall or Pancoast tumor claw hand with weakness of small hand muscles Simian hand 31.6.2 upper 50% 25% 2% 20% 4% 90% 31.6.2 C5 (ABCDE) fifth letter of alphabet, Erb palsy mainly C5 and also C6, C7 extended rotated pronated Bellhop’s tip position 31 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 202 Part 10: Peripheral Nerves c. Weak muscles and their roots. i. d________ roots, ______ ii. b_________ roots, ______ iii. r_________ roots, ______ iv. b_________ roots, ______ v. s________ roots, ______ vi. i____________ roots, ______ d. Mechanism: _______ _______ e. From: i. b_____ i______ ii. m_______ a_______ deltoid; C5, C6 biceps; C5, C6 rhomboids; C4, C5 brachioradialis; C5, C6 supraspinatus; C4, C5, C6 infraspinatus; C5, C6 shoulder separation birth injuries motorcycle accidents 33. Characterize lower brachial plexus injury – Klumke’s palsy. a. Roots involved: _______ b. Position of upper extremity (Hint: klump) i. kl_______ ii. u_______ iii. m______ iv. p________ c. Weak muscles i. upper extremity: ________ ii. face: _________ d. Mechanism: traction on _______ arm e. From: i. f________ ii. b________ iii. P________ t____ 34. Complete the following regarding birth injury of brachial plexus: a. Incidence is _______ i. upper: ___% ii. upper plus C7: ___% b. mixed c. lower d. bilateral 31 35. True or False. The following are indications for early surgical exploration of the brachial plexus: a. any injury needs repair b. progressive deficit 31.6.2 C7, C8, T1 claw hand (Simian hand) ulnar claw median claw paralysis small muscles of hand Horner’s syndrome if T1 involved abducted falls birth Pancoast tumors 31.6.2 0.3 to 2/1000 births 50% (C5, C6) 25% (C5, C6, C7) 20% 2% C7, C8, T1 4% 31.6.2 false (most injuries will have maximal deficit at onset then improve) true (progressive deficit likely vascular injury, explore immediately) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Non-Entrapment Peripheral Neuropathies 203 c. clean sharp injury true (clean, sharp, fresh lacerating injuries → explore acutely and repair end-toend) d. gunshot wound (GSW) to brachial plexus false (surgery is of little benefit) Missile Injuries of Peripheral Nerves 36. Regarding gunshot wounds: a. Most injuries are the result of s____ and c_______ and not d_____ n_____ t_______. b. Approximately ____% will recover with expectant management. c. However, if there is lack of improvement on EMG, intervention should occur about ___ - ___ months after the injury to avoid further nerve fibrosis and muscle atrophy. 31.7 shock and cavitation; direct nerve transection 70% 5-6 months Thoracic Outlet Syndrome 37. True or False. Clinical presentation of thoracic outlet syndrome may include a. pallor and ischemia of hand and fingers. b. arm swelling and edema. c. brachial plexus lower trunk dysfunction. d. brachial plexus median cord dysfunction. 38. List the differential diagnosis for thoracic outlet syndrome. a. h_____ ______ _____ b. c____ ____ c. l____ ____ d. t_____ _____ _____ ____ e. c____ ____ ____ f. o_______ g. c_____ _____ _____ syndrome 31.8.1 true true true true 31.8.2 herniated cervical disc cervical arthrosis lung cancer (Pancoast tumor) tardy ulnar nerve palsy carpal tunnel syndrome orthopedic shoulder problems complex regional pain syndrome (CPRS) 39. True of False. Regarding thoracic outlet syndrome, conservative treatment may be as effective as the surgical treatment. true 31.8.3 40. True or False. Scalenus syndrome is a well characterized and accepted cause of thoracic outlet syndrome. false 31.8.4 31 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 32 Neurophthalmology Nystagmus 1. Complete the following about nystagmus: a. What is nystagmus? i_______ r______ o________ of the eyes b. What is the most common form? c. How is it directionality defined? d. What is the abnormal component? e. What is vertical nystagmus indicative of? i. p________ f_______ p__________ ii. s_______ iii. a_________ d________ 32 32.1.1 involuntary rhythmic oscillation jerk nystagmus fast component slow component posterior fossa pathology sedatives antiepileptic drugs 2. Seesaw nystagmus occurs with a lesion in the _____________. diencephalon 32.1.2 3. Nystagmus retractorius occurs with a lesion in the ______ _______ _________; for example p_________. upper midbrain tegmentum; pinealoma 32.1.2 4. Ocular bobbing occurs with a lesion in the ________ _________. pontine tegmentum 32.1.2 5. Matching. Match the form of nystagmus and the location of the lesion. Form: ① seesaw nytagmus; ② convergence nystagmus; ③ nystagmus retractorius; ④ downbeat nystagmus; ⑤ upbeat nystagmus; ⑥ abducting nystagmus; ⑦ ocular bobbing Location: (a-f) below a. diencephalon b. upper midbrain tegmentum c. midbrain tectum d. pons medial longitudinal fasciculus (MLF) e. medulla f. posterior-fossa – cervicomedullary junction 32.1.2 ① ② ③ ⑥, ⑦ ⑤ ④ ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophthalmology 6. Name the location of the lesion for the following forms of nystagmus: a. seesaw nystagmus diencephalon b. nystagmus retractorius upper midbrain tegmentum/pineal region c. downbeat nystagmus cervicomedullary junction (foramen magnum) d. upbeat nystagmus medulla e. ocular bobbing pons 205 32.1.2 Papilledema 7. Complete the following about papilledema: a. What is papilledema caused by? b. How long does it take to develop? c. What is the earliest it is seen? d. Does it cause visual blurring? e. Does it cause visual field distortion? f. Differentiate from optic neuritis. i. funduscopy ________ _______ __________ ii. visual loss more with ________ _______ iii. pain on palpation more with ______ ________ 8. What is the differential diagnosis for unilateral papilledema? (Hint: FIOM) a. F_______-_________ _________ b. I_________ c. O________ _________ d. M__________ _________ 32.2.1 Thought to be caused by axoplasmic stasis. Theory: 1. Increased intracranial pressure (ICP) transmitted to the optic disk via subarachnoid (SA) space. Retinal venous pulsations obliterated. 2. Retinal arterial: venous pressure < 1.5:1. 24 to 48 hours 6 hours no (unless severe and prolonged) no (unless severe and prolonged) may look alike optic neuritis optic neuritis 32.2.2 Foster-Kennedy syndrome Inflammation Optic glioma Multiple Sclerosis 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 206 Part 11: Neurophthalmology and Neurotology Visual Fields 9. Complete the following concerning visual fields: a. Normal visual field extends approximately from: i. ____° nasally in each eye ii. ____° temporally in each eye iii. ____° above and below the horizontal meridian in each eye b. The normal blind spot is due to ____________ and is located to the ________ side of the macular visual area in each eye. c. Macular splitting occurs with lesions ________ or ________ to the lateral geniculate body (LGB). d. Macular sparing tends to occur with lesions _________ to the LGB. 32 35 90 50 absence of light receptors in the optic disc where the retina is penetrated by the optic nerve; temporal anterior or posterior 32.3.2 posterior Visual Field Deficits 10. Regarding visual field deficits: a. Can be tested either at the ________ or with _______ _________. b. Visual field deficits depend on the location of the injury, for example: i. right optic nerve: _________ ________ ______ ii. optic chiasm: ________ _______ iii. right Meyer’s loop: ________ ______ ________ with ____ ________ iv. right occipital (visual cortex): ________ ______ ________ with ____ ________ 32.3.1 32.4 bedside; formal perimetry right monocular blindness biltemporal hemianopsia left superior quadrantanopsia with macular sparing left homonymous hemianopsia with macular sparing Pupillary Diameter 11. Complete the following concerning the pupillodilator nerve fibers: a. First-order sympathetic nerve fibers i. origin: p________ h_______ ii. destination: i_____ cell column (_______ to _______) iii. neurotransmitter: a_________ b. Second-order sympathetic nerve fibers i. origin: i_____ cell column ii. destination: s_______ c______ g________ 32.5.1 posterolateral hypothalamus intermediolateral (C8 to T2) Acetylcholine (ACh) intermediolateral superior cervical ganglion ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophthalmology c. Third-order sympathetic nerve fibers i. origin: s_______ c______ g________ ii. destination: p_____ m_______ of the eye, l_______ g________, M________ m________ iii. neurotransmitter: n_________ 12. How are pupillodilator muscles arranged? 13. Describe the anatomy of sympathetic outflow to the eye. (Hint: hilsc) a. h________ b. i_________ ______ __________ c. l_______ ________ _______ c__________ _________ 14. The pupilloconstrictor (parasympathetic) are muscles arranged c________ as a s___________. 207 superior cervical ganglion pupillodilator muscle (long ciliary nerves); lacrimal gland, Müller’s muscle norepinephrine radially 32.5.1 32.5.1 hypothalamus intermediolateral cell column lateral horn cells; ciliary ganglion Sympathetic summary: first order: posterolateral (a) hypothalamus → descend in midbrain tegmentum uncrossed to pons, medulla, spinal cord (SC) to the (b) intermediolateral cell columns, C8-T2 (ciliospinal center of Budge) → synapse with (c) lateral horn cells acetylcholine and give off second-order neurons (a) (preganglionics). Second order: enter sympathetic chain → (b) superior cervical ganglion. Third order: (a) (postganglionics): go up with common carotid artery (CCA) (b), those that mediate sweat to face go up external carotid artery (ECA), the rest go up internal carotid artery (ICA). Some pass: = (d) V1 → ciliary ganglion → (e) pupillodilator norepinephrine = ICA → (f) ophthalmic artery → (g) lacrimal gland and the Muller muscle. concentric as a sphincter 32.5.2 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 208 Part 11: Neurophthalmology and Neurotology 15. Describe the parasympathetic outflow to the eyes. (Hint: Ect) a. E______-___________ b. c_______ ______ c. t_______ ______ 16. Describe the pupillary light reflex. (Hint: ropEtcs) a. r_________ b. o_________ c. p_________ d. E_________ e. t__________ f. c__________ g. s__________ 32.5.2 Edinger-Westphal ciliary ganglion third nerve Parasympathetics summary: Preganglionics arise in the Edinger-Westphal nucleus at the level of the superior colliculus synapse in the ciliary ganglion. Postganglionics travel on the third nerve to (e) innervate sphincter pupillae and ciliary muscle (thickens lens causing accommodation via relaxation). 32.5.3 retina optic nerve pretectal Edinger-Westphal third nerve ciliary ganglion sphincter light reflex Summary: Mediated by (a) rods and cones of retina. Transmit via axons to (b) optic nerve. Bypass lateral geniculate body (unlike vision) synapse in (c) pretectal nuclear complex. Connect to both (d) EdingerWestphal nuclei. Preganglionics travel in (e) third nerve to (f) ciliary gangion, etc. Postganglionics via third nerve to pupillary sphincter. Ciliary muscles thicken (relax) causing accommodation. 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophthalmology 17. Complete the following about Argyll Roberston pupil: (Hint: ALRP = Argyll Robertson pupil = absent light response pupil) a. Key feature is _______ ________ ________ ________ or ALRP. b. It occurs in ________. c. Light-near dissociation means the pupil constricts when focusing on an object ________ d. but the pupil does not react to _______. 18. Does afferent pupillary defect cause anisocoria? 19. Complete the following about anisocoria: a. unequal pupils with an afferent pupillary defect (Marcus-Gunn) means there are ____ _______ b. Physiologic anisocoria occurs in _____% of people. c. The difference is usually _____ mm. d. Sudden onset of anisocoria is usually due to _________. e. Sympathomimetics cause _____ to _____ mm of dilation and f. i. parasympatholytics cause _____ mm of dilation and the ii. eye _____ ______ react to light. 20. What is the differential diagnosis of anisocoria? Hint: u tAp Hat a. u_________ b. t__________ c. A_________ d. p__________ e. H_________ f. a__________ g. t__________ 209 32.5.4 absent light response pupil syphilis near (i.e. convergence) light no 32.5.5 32.5.5 two lesions 20% 0.4 drugs 1 to 2 8 does not 32.5.5 uncal herniation (also has mental status changes) trauma (traumatic iridoplegia mydriasis or miosis) Adie’s pupil (iris palsy – impaired postganglionic parasympathetics) physiologic (less than 1 mm difference – 20% of population) Horner’s syndrome (impaired sympathetics to pupillodilator muscle) aneurysm (posterior communicating, basilar) third nerve palsy (pupil sparing-diabetes mellitus [DM 1], EtOH, cavernous aneurysm) 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 210 Part 11: Neurophthalmology and Neurotology 21. What is the differential diagnosis for Marcus-Gunn pupil? a. Location of lesion: ________ i. r________ - d_________ i__________ ii. n_______ - n_______ (m______ s______, v____), or t_______ b. In Marcus Gunn is/are the i. third nerve intact? ii. parasympathetic nerves intact? 22. Complete the following about Adie’s pupil: a. Dilated or constricted pupil? b. Due to impaired preganglionic or postganglionic fibers? c. Thought to be caused by a ______ ________ d. of the ______ _________. 23. Complete the following about third nerve compression: a. example is __________ b. most common is ______ c. occasionally _______ ________ aneurysm d. usually ______ _____ ______ the pupil 24. Complete the following about Horner’s syndrome: a. The abnormal pupil is __________. b. Ptosis is on the side of the _______ pupil. 32 32.5.5 ipsilateral to impaired direct reflex anterior to chiasm retina – detachment, infarction nerve – neuritis (multiple sclerosis, viral) or trauma Yes Yes 32.5.5 dilated postganglionic viral infection ciliary ganglion 32.5.5 aneurysm P-comm basilar bifurcation does not spare 32.5.6 smaller small 25. The ptosis is due to paralysis of the ________ and ______ ______ muscles. superior and inferior tarsal 32.5.6 26. Is the ptosis complete or partial? partial 32.5.6 27. Enophthalmos is due to paralysis of M______ muscle, which is or is not involved in Horner’s syndrome? Müller’s muscle; is involved 32.5.6 28. Horner’s syndrome is caused by interruption of sympathetics to the eye and face anywhere along their path. Name specific causes that affect the following: a. first-order neurons (three causes) i. i__________ from v_________ o_________ ii. s__________ iii. i_______ n__________ 32.5.6 infarction from vascular occlusion (usually PICA) syringobulbia intraparenchymal neoplasm ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophthalmology b. second-order neurons (three causes) i. l_______ s________ ii. s______ c______ t_______ iii. a_____ p_______ n_______ (P______ t_____) c. third-order neurons (five causes) i. n_______ t________ ii. c______ v______ d_______ iii. c________ b________ a________ iv. m________ 29. Trace the third-order neuron in the pupillodilation/sympathetic path. a. neurons from the s________ c_______ g_______ b. to the p________ m_______ c. and M_______ m________ 211 lateral sympathectomies significant chest trauma apical pulmonary neoplasms (Pancoast tumors) neck trauma (e.g. carotid dissections) carotid vascular disease cervical bony abnormalities migraine 32.5.6 superior cervical ganglion pupillodilator muscle Müller’s muscle 30. True or False. Answer the following regarding Horner’s syndrome: a. In a patient with Horner’s syndrome and preserved sweating of the face, the lesion is located i. in the first-order neuron ii. in the second-order neuron iii. in the third-order neuron 32.5.6 31. Complete the following about Horner’s syndrome: a. What medication is used if diagnosis of Horner’s syndrome is in doubt? b. How does it work? 32.5.6 false false true (injured fibers on ICA produce Horner, intact sweat fibers to face on ECA). b. this is compatible with a Pancoast tumor. false (Pancoast tumor would affect the sympathetics between the spinal cord and superior cervical ganglion [i.e., second-order neurons]. The fibers to sweat glands would be damaged because they had not yet separated to travel with the ECA.) c. Therefore in Horner’s syndrome the pupil will _______ ________ with _________. d. In a normal patient the pupil will _______ _________. cocaine cocaine blocks norepinephrine (NE) reuptake not dilate with cocaine (no NE release) dilate normally 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 212 Part 11: Neurophthalmology and Neurotology Extraocular Muscle (EOM) System 32. Matching. From the list below identify the cranial nerve that innervates the muscle: Nerve: ① CN III; ② CN IV; ③ CN VI Hint: L6 SO4 Muscle: (a-f) below a. medial rectus b. inferior rectus c. inferior oblique d. superior rectus e. superior oblique f. lateral rectus 33. Complete the following regarding the frontal eye field: a. True or False. It moves eyes laterally to the opposite side. b. It is located in the Brodmann area ______. c. Its fibers go through the _____ of the ______ ________. d. It sends fibers to the ipsilateral _______ ________ ______ _________ nucleus. e. It sends fibers to the ipsilateral ______ nucleus f. and the contralateral ______ nucleus g. via the ______ __________ _____________. h. The right paramedian pontine reticular formation (PPRF) controls lateral eye movements to the _________. 34. Complete the following about the extraocular motor system: a. Injury to the medial longitudinal fasciculus (MLF) is called _________ ____________. b. Convergence is ______ ___________. c. If the right MLF is injured the right eye will not _______ _________. d. The left eye when looking laterally shows i. w_______ on a________ ii. n______ on a______ e. The most common cause of MLF malfunction is ________ ___________. 35. With third nerve palsy, if there is ptosis it will be on the side of the ______ pupil. 32.6.1 ① ① ① ① ② ③ 32.6.1 true 8 genu of the internal capsule paramedian pontine reticular formation (PPRF) sixth third medial longitudinal fasciculus (MLF) right 32.6.2 internuclear ophthalmoplegia (INO) not impaired move medially (adduct) weakness on abduction nystagmus on adduction multiple sclerosis (MS) large 32.6.3 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophthalmology 36. Complete the following about oculomotor neuropathy: a. Example is __________. b. Usually ______ the pupil. c. Usually resolved in _____ _____. 37. Name three causes of non-pupilsparing oculomotor palsy. (Hint: tau) a. t________ b. a________ c. u______ ____________ 38. Name seven causes of pupil-sparing oculomotor palsy. (Hint: mEtDacc) a. m__________ b. E__________ c. t__________ d. D__________ e. a__________ f. c_________ ________ ____________ g. c_________ ________ ____________ 213 32.6.3 diabetes spares 8 weeks 32.6.3 tumor aneurysm (PComm, Basilar tip) uncal herniation 32.6.3 myasthenia gravis EtOH temporal arteritis DM atherosclerosis chronic progressive ophthalmoplegia cavernous sinus lesions 39. Complete the following about trochlear nerve palsy (CN IV): a. i. In relation to the aqueduct the ventral trochlear nucleus lies _______ ii. at the level of the ______ ________. inferior colliculi b. i. The axons pass _______ and dorsally ii. decussate ______. internally c. It innervates the _________ ________ superior oblique muscle d. Superior oblique muscle i. Primarily depresses the _______ adducted eye. ii. In primary gaze it moves the eye down and out ______ and ___. 32.6.4 40. Complete the following about the unique features of the trochlear nerve: a. Nucleus is on the __________ side of the b. muscle it goes to: __________ __________ ________ c. It is the only nerve to decussate _________. d. It is the only nerve to exit _______ to the brainstem. e. True or False. It passes through the annulus of Zinn. f. Palsy results in eye deviation “_____ and ____.” 32.6.4 opposite superior oblique muscle internally posterior false “up and in” 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 214 Part 11: Neurophthalmology and Neurotology g. Head is tilted to the ______ _______ the CN IV palsy. h. Diplopia is exacerbated with looking _____ (i.e., ______). 41. Name the causes of abducens palsy. Hint: abducens a. a________ b. b_________ c. d_________ d. u_________ e. c_________ f. e_________ g. n_________ h. s_________ 42. Matching. Match the syndrome with the nerves involved in multiple extraocular motor involvement disorders. Syndrome: ① cavernous sinus; ② superior orbital fissure; ③ orbital apex Nerves involved: (a-g) below a. II b. III c. IV d. V1 e. V2 f. V3 g. VI down; stairs 32.6.5 arteritis, aneurysms sixth nerve palsy diabetes, Dorello canal (Gradenigo’s syndrome) uncontrolled ICP, pseudotumor, trauma, tumor cavernous sinus lesions, clivus, chordoma, or fracture eye disease, thyroid, myasthenia gravis neoplasms sphenoid sinusitis (Gradenigo’s syndrome) 32.6.6 ③ ①, ②, ③ ①, ②, ③ ①, ②, ③ ① ①, ②, ③ Neurophthalmologic Syndromes 43. Regarding Tolosa-Hunt Syndrome: a. Is the ophthalmoplegia painful or painless? b. Which nerve(s) is/are involved? c. d. e. f. g. h. 32 side opposite The pupil is usually _______. How long do symptoms last? Can there be spontaneous remission? Can there be recurrent attacks? Is there systemic involvement? How is it treated? 32.7.2 painful any nerve traversing the cavernous sinus spared days to weeks yes yes no systemic steroids = 60 to 80 mg of prednisone by mouth daily (slow taper) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurophthalmology i. The disease is thought to be a __________ __________. j. The inflammation is located at the _________ ________ ___________. 44. Complete the following about Raeder’s paratrigeminal neuralgia: a. Name two components. i. u_______ o_______ p________ ii. h________ t________ n_______ i_______ b. The pupil is _______. c. True or False. The pain is continuous. d. The pain is located at the _______. 45. Complete the following regarding Gradenigo’s syndrome: a. What is Gradenigo’s syndrome? b. Involves ________ canal. c. Name the classic triad. i. p_______ of _______ ii. p________ where? _______ iii. d_______ e________ d. Pain is located at the p________ a_______. e. Features (Hint: Gradenigo) i. G__________ ii. r_______ ________ iii. a_______ ________ iv. v. vi. vii. viii. ix. d_______ ________ e_______ ________ n_______ ________ __________ i_______ p________ o_______ p__________ 215 nonspecific inflammation superior orbital fissure 32.7.3 unilateral oculosympathetic paresis (think Horner’s syndrome – anhidrosis ± ptosis) homolateral trigeminal nerve involvement (Horner’s syndrome and tic-like pain) small false (intermittent, tic-like) trigeminal nerve V1 (ophthalmic division) and sympathetics 32.7.4 Apical petrositis Dorello’s canal palsy; abducens pain; retro-orbital draining ear petrous apex Gradenigo retro-orbital pain apical petrositis – abducens palsy draining ear – Dorello’s canal ear draining neuropathy of VI inflammation petrositis orbital pain Miscellaneous Neurophthalmologic Signs 46. Complete the following about ocular bobbing: a. The eyes move __________. b. How many times per minute? c. Ocular bobbing is associated with bilateral paralysis of ________ _______. d. It is seen with destruction of the ______ __________. 32.8 downward 2 to 12 horizontal gaze pontine tegmentum 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 216 Part 11: Neurophthalmology and Neurotology 47. Optic atrophy is due to a _________ lesion. compressive 32.8 48. Opsoclonus is ______, ________, ________, ___-_________ eye movement. rapid, conjugate, irregular, non-rhythmic 32.8 49. Oscillopsia is the visual sensation that stationary objects are __________ or _____________ side-to-side. vibrating or swaying 32.8 32 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 33 33 Neurotology Dizziness and Vertigo 1. The differential diagnosis for dizziness includes: a. n_______ s_______ b. d___________ c. v________ d. l____________ 2. What is the definition of vertigo? a. Sensation of _________ b. from i. i________ e_______ d__________ or ii. v_________ n_______ d_________ 3. True or False. Inner ear dysfunction presenting with vertigo includes the following: a. labyrinthitis b. trauma, i.e. e___________ l____ c. drugs, i.e. a___________ d. acoustic neuroma e. vertebrobasilar insufficiency 4. Complete the following regarding cupulolithiasis: a. What is cupulolithiasis? c_______ c________ in s_________ c______ b. It is also known as b________ p___________ p_________ v_______. c. Symptoms are made manifest by ________ _________. d. Patient is usually in ______. 33.1.1 near syncope disequilibrium vertigo lightheadedness 33.1.1 movement (usually spinning) internal ear dysfunction vestibular nerve dysfunction 33.1.1 true true (i.e. endolymphatic leak) true (i.e. aminoglycosides) false (acoustic neuroma does not cause inner ear dysfunction but may cause vertigo from compression of the vestibular nerve) true (other causes of vertigo include inner causes: Meniere disease, benign/paroxysmal positional vertigo, syphilis) 33.1.1 Calcium concentrations in semicircular canal benign paroxysmal positional vertigo head turning bed ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 218 Part 11: Neurophthalmology and Neurotology e. Is it self-limiting? f. For how long? Is hearing affected? 33 yes usually not for > 1 year no hearing loss 5. Describe indications and complications of selective vestibular neurectomy (SVN). a. Indications i. M________ d__________ ii. p_________ v_______ i_________ b. Rationale? c. Complications i. h________ l_______ ii. o_________ iii. l_________ of b________ in the d_______ with bilateral SVN 33.1.2 Meniere’s disease partial vestibular injury In disabling cases of vertigo, refractory to medical/nondestructive surgical treatment. SVN preserves hearing; is 90% (Meniere disease) and 80% (vertiginous spells) effective. hearing loss (unusual) oscillopsia (Dandy’s syndrome) loss of balance in the dark with bilateral SVN (loss of vestibule-ocular reflex) 6. Answer the following about the vestibular nerve: a. In which half of the eighth nerve superior complex? b. What color relative to the cochlear nerve? more gray c. To preserve hearing what vessel must be artery of the auditory canal preserved? 33.1.2 7. True or False. CN VII can be differentiated from CN VIII at the internal auditory canal (IAC) by all of the following: a. direct stimulation/recording b. lies anterior/superior to VIII c. transverse crest and Bill bar d. darker color c/w CN VIII e. Electromyographic (EMG) monitoring of CN VII during manipulation 33.1.2 true true true false (CN VII is paler/whiter) true Meniere’s Disease 8. Meniere’s disease is also known as e__________ h_______. 9. What is the clinical triad of Meniere’s disease? a. v________ v_______ a_______ b. t________ c. h________ l_____ endolymphatic hydrops 33.2.1 33.2.3 violent vertigo attacks tinnitus “escaping steam” hearing loss (fluctuating, lowfrequency) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurotology 10. Diagnostic studies for patients with Meniere’s disease include: a. E____ with b_______ c_______ s________ b. a___________ c. B______ d. No findings on r_________ i_______ 11. True or False. Treatment of Meniere’s disease includes: a. middle ear perfusion with gentamicin b. bilateral vestibular neurectomy c. salt restriction d. vestibular suppressants (e.g. Valium, meclizine) e. endolymphatic shunting f. diuretics (e.g. Diamox) 33.2.3 ENG with bithermal caloric stimulation audiogram BAER radiographic imaging 219 33 33.2.3 true false (bilateral ablative procedure is to be avoided) true true true true Facial Nerve Palsy 12. Answer the following about supranuclear facial palsy: a. Which part of the face is involved? b. Emotional facial expression (e.g. smiling) is _______. c. The lesion is the lowest part of the ________ _______. d. Part of the face is spared paralysis because the _____ _______ has _______ __________. 13. Complete the following regarding nuclear facial palsy: a. It causes paralysis of all ________ _______ ______ muscles. b. Plus sixth nerve palsy constitutes the ______-_______ syndrome. c. It can be caused by a particular tumor called _________. d. Especially when it ______ the _______ of the _____ ___________. e. True or False. Nuclear facial palsy is due to damage to the motor nucleus at the pontomedullary junction. 14. True or False. Regarding CN VII anatomy: a. Enters superior-anterior portion of IAC. b. External genu is geniculate ganglion. c. GSPN is first branch after the ganglion. d. Exits at stylomastoid foramen. 33.3.2 lower only intact precentral gyrus upper face; bilateral representation 33.3.2 ipsilateral CN VII innervated Millard-Gubler medulloblastoma invades the floor of the fourth ventricle true 33.3.2 true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 220 33 Part 11: Neurophthalmology and Neurotology 15. Complete the following about the seventh nerve: a. It exits the brainstem at the _________ ________. b. It enters the IAC at the ________. c. The geniculate ganglion is located in the _______ bone. d. The first branch is the ______ _________ ________ ______, e. which goes to the _______ __________ f. and innervates the _______ __________ and _____ _______. g. The next branch goes to the ___________ _________. h. The next branch is the _________ _________. i. It then exits the s____________ f________ j. and sends branches to the ______. 33.3.2 pontomedullary junction superoanterior portion temporal greater superficial petrosal nerve pterygopalatine ganglion lacrimal gland and nasal muscosa– dry eye and nasal mucosa if injured stapedius muscle – to ear – hyperacusis chorda tympani – taste stylomastoid foramen face 16. Name the facial nerve branches within the temporal bone and their function. a. g__________ greater superficial petrosal nerve (GSPN) to pterygopalatine ganglion, innervates nasal and palatine mucosa and lacrimal gland b. s__________ branch to stapedius muscle, volume regulation c. c__________ chorda tympani, taste sensation from anterior two thirds of the tongue d. fibers to s________ g______ salivary glands, submandibular, sublingual e. the nerve travels on to _______ facial muscles ________ 33.3.2 17. Name the facial nerve branches to the facial muscles cranial to caudal. a. t________ b. z________ c. b________ d. m________ e. c_________ 33.3.2 18. Name the three most common causes of facial nerve palsy. a. B_________ b. h________ c. t_________ temporal zygomatic buccal mandibular cervical 33.3.3 Bell’s palsy herpes zoster oticus trauma/basal skull fracture ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurotology 19. Provide the differential diagnosis for facial nerve palsy. 20. Describe seventh nerve palsy. a. The most common cause of facial palsy is ______ ________. b. Etiology: ________ c. Probable etiology: v______ i_________ d________ p_______ d. Usually proceeded by a ______ __________. e. It is caused by the ________ ________ virus. f. It progresses _________ to __________. g. Meaning i. first ii. then iii. and then iv. and then h. Percent that recover completely is ____%; partially _______% i. Manage with _______ and __________. S________ d__________ is rarely used. j. If herpetic vesicles are present and VZV antibody titers rise, these patients are diagnosed with h_______ z______ o______ f______ p_______ and there is a higher chance of f_____ n_______ d_________. 21. What are the considerations for facial nerve injury surgical repair? a. If known to be interrupted, __________ _______. b. Options for anastomosis include: i. h________, which creates some t_____ morbidity ii. s________ a________, which sacrifices some s______ m________ c. If known to be in continuity, ________. d. Role of electrical testing? acoustic tumor Bell’s palsy congenital diabetes fracture Guillain-Barré herpes zoster Klippel-Feil lyme disease meningioma neoplasm otitis media parotid surgery sarcoid trauma 33.3.3 221 33 33.3.4 Bell’s palsy unknown viral inflammatory demyelinating polyneuritis viral syndrome herpes simplex distally to proximally facial movements weak loss of taste and salivation hyperacusis decreased tearing 75 to 80%; 10% EMG and steroids; Surgical decompression herpes zoster oticus facial paralysis; facial nerve degeneration 33.3.5 33.3.6 reanastomose early hypoglossal; tongue spinal accessory; shoulder movement several months of observation serial electrical testing after 1 week ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 222 33 Part 11: Neurophthalmology and Neurotology Hearing Loss 22. Describe the following about hearing loss: a. Conductive i. patient speech ii. Rinne iii. Weber lateralizes to ________ ________ side. b. Sensorineural i. patient speech ii. Rinne iii. Weber lateralizes to ________ ________ side. 33.4.1 Normal or low volume voice Air < bone = negative (i.e. abnormal) poor hearing 33.4.2 loud voice Air > bone = positive (i.e. normal) good hearing ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 34 General Information, Classification and Tumor Markers 34 Classification of Nervous System Tumors 1. True or False. The following tumor is considered to be a World Health Organization (WHO) grade IV: a. anaplastic astrocytoma b. gliosarcoma c. fibrillary astrocytoma d. subependymal giant cell astrocytoma Table 34.2 false, anaplastic astrocytoma is grade III true false, fibrillary astrocytoma is grade II false, SEGA is grade II 2. True or False. Tumors of mixed neuronal-glial origin include the following: a. ganglioglioma true b. central neurocytoma true c. primitive neuroectodermal tumor (PNET) false, PNET is listed under embryonal tumors d. desmoplastic infantile ganglioglioma true (DIG) e. pineoblastoma false, listed under pinealocyte tumor Table 34.2 3. Complete the following about medulloblastoma: a. Medulloblastoma is considered to be an _______ type of tumor. b. It is also known as ________. Table 34.2 4. Name the two types of craniopharyngiomas: a. a________ b. p________ embryonal PNET Table 34.2 adamantinomatous papillary 5. The following primary cancers commonly metastasize to the brain: a. l______ (especially s_____ c___) b. b_______ c. m________ d. r______ c____ c_______ e. l____________ f. g_____________ Table 34.2 lung, small cell breast melanoma renal cell carcinoma lymphoma gastrointestinal ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 224 34 Part 12: Primary Tumors of the Nervous and Related Systems Brain Tumors – General Clinical Aspects 6. List the four most common presentations of brain tumors and their frequency. a. p________ n______ d_____: ___% b. h_______: ___% c. m________ w________: ___% d. s________: ___% 34.2.1 progressive neurologic deficit: 68% headache: 54% motor weakness: 45% seizure: 26% 7. When encountering a first-time tumor seizure in a patient older than 20 years of age, think ________ until proven otherwise. 34.2.1 8. Describe the characteristic “syndromes” of the following: a. Frontal lobe: a______, d______, p_________ changes b. Temporal lobe: a_______ or o_______ hallucinations, m________ impairment, c________ s______ q_________________ c. Parietal lobe: contralateral m____ or s______ impairment, h_________ h__________ d. Occipital lobe: contralateral v____ f______ deficits, a______ 34.2.2 9. What are 5 common etiologies of headache in the setting of an intracranial tumor? 10. Complete the following concerning a > 20-year-old patient presenting with a headache: a. The classical headache associated with a brain tumor is characterized by: i. worsening in the ____ (A.M. vs. P.M.) ii. ________ (Increased vs. Decreased) with cough iii. ________ (Increased vs. Decreased) with bending forward iv. associated with n________ and/or v________ abulia, dementia, personality changes auditory or olfactory; memory impairment, contralateral superior quadrantanopsia motor or sensory; homonymous hemianopsia visual field deficits; alexia 1. Increased ICP due to mass effect or hydrocephalus 2. Invasion of pain sensitive structures including dura, blood vessels, or periosteum 3. Secondary to difficulty with vision 4. Hypertension secondary to increased ICP 5. Psychogenic due to stress from loss of functional capacity 34.2.3 34.2.3 AM increased increased nausea; vomiting ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 General Information, Classification and Tumor Markers b. What percentage of patients have these “classic” headaches? 34 11. The _______ _________ is the so-called area postrema vomiting center. 34.2.5 12. Cranial nerve ___ has the longest intracranial course. 34.2.5 13. Match the area of cerebellum/brainstem with symptoms ① cerebeller hemisphere; ② vermis; ③ brainstem Symptoms: (a-g) below a. ataxia of extremities b. broad-based gait c. truncal ataxia d. dysmetria e. intention tremor f. nystagmus g. cranial nerve dysfunction 14. What are the pros and cons of placing a shunt or external ventricular drain (EVD) into a pediatric patient with a posterior fossa tumor and hydrocephalus? a. Pros: i. may possibly lower o________ m________ b. Cons: i. l___-____ shunt ii. s________ of peritoneum iii. u____ ________ herniation iv. i______ of shunt v. d____ in definitive treatment 8% (77% had headache similar to tension headache, 9% were similar to migraine, only 8% showed classic brain tumor headache; two thirds of these had high ICP) CN VI (abducens nerve) 225 34.2.5 ① ② ② ① ① ③ ③ 34.2.5 operative mortality life-long seeding upward transtentorial infection delay Pediatric Brain Tumors 15. Common pediatric brain tumors include: a. g_____ b. p______ tumors c. c____________ d. t________ e. g________ f. P______ tumors including m___________ 34.3.2 gliomas pineal tumors craniopharyngiomas teratomas granulomas PNET; medulloblastoma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 226 Part 12: Primary Tumors of the Nervous and Related Systems 16. Complete the following about infravs. supra-tentorial pediatric tumors: a. Age vs. % Infratentorial: i. 0-6 mos: _____% ii. 6-12 mos: ____% iii. 12-24 mos: ___% iv. 2-16 years: ___% b. __________ are the most common supratentorial tumor in pediatrics as a whole. c. True or False? i. Brain tumors are the second most common cancer in childhood. ii. They are the most common solid tumors in childhood. d. In neonates, 90% of brain tumors are of n_____________ origin with _______ being the most common. 34 17. Common presentations for pediatric tumors include: a. v________ b. a______ of d__________ c. f_______ to t______ d. s__________ Table 34.3 27% 53% 74% 42% Astrocytomas 34.3.3 34.3.1 true true neuroectodermal; teratomas 34.3.4 34.3.4 vomiting arrest of development failure to thrive seizures Medications for Brain Tumors 18. The beneficial effects of steroids are greater for __________ (metastatic vs. primary) tumors. 19. In terms of prophylactic anticonvulsants with brain tumors: a. There is Level ___ evidence that AEDs _________ (should/should not) be used routinely in patients with newly diagnosed brain tumors. b. There is Level ___ evidence that in patients undergoing craniotomy for a brain tumors, prophylactic AEDs _______ (can or cannot) be used. metastatic tumors 34.4.1 34.4.2 Level I; should not Level II; can ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 General Information, Classification and Tumor Markers 227 Chemotherapy for Brain Tumors 20. Match the chemotherapeutic agent with its mechanism of action: ① DNA crosslinking; ② DNA alkylation; ③ Microtubule function inhibitor; ④ Topoisomerase II inhibitor; ⑤ Topoisomerase I inhibitor; ⑥ PKC inhibitor; ⑦ Anti-VEGF antibody a. Bevacizumab: _______ b. Vincristine: _________ c. Irinotecan (CPT-11): _______ d. Temozolomide: ________ e. BCNU: ________ 21. Complete the following about Temozolomide: a. It is an ______ (oral vs. IV) medication that works through DNA _________. b. It functions as a p_______ and undergoes rapid non-enzymatic conversion at physiologic pH to ______. c. MITC alkylation occurs primarily at the __ and ___ positions on ________ but some tumors can repair this damage with _____ that is coded by the ______ gene. 22. The following are tactics that can be used to circumvent the blood-brain barrier (BBB): a. l________ agent b. h___ d______ c. d________ of BBB d. b_______ BBB e. d______ i________ polymers 23. Complete the following about tumor imaging: a. The proper time to obtain post-op imaging to check for bleeding is typically within __ - __ hours. b. The proper time to obtain post-op imaging to check for residual tumor is either within __ - __ days or after about ___ days. c. An exception to this timing rule of thumb is for ________ tumors. Table 34.5 34 ⑦ ③ ⑤ ② ① 34.5.2 oral; alkylation prodrug; MITC (monomethyltriazenoimidazo lecarboxamide) O6; N7; guanine; AGT; MGMT 34.5.4 lipophilic agent higher doses (of medication) disruption of BBB (e.g. with mannitol) bypass BBB (e.g. intrathecal methotrexate for primary lymphoma) directly implantable polymers 34.5.5 6-12 hours 2-3 days; 30 days pituitary ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 228 34 Part 12: Primary Tumors of the Nervous and Related Systems Select Commonly Utilized Stains in Neuropathology 24. True or False. This tumor marker usually indicates astroglial origin. a. glial fibrillary acid protein (GFAP) b. c. d. e. S-100 protein cytokeratin neuron specific enolase (NSE) human chorionic gonadotropin (hCG) 34.7.2, 34.7.3 true (GFAP is rarely found outside the CNS. Thus, the presence of GFAP in a tumor found in the CNS is usually taken as good evidence for glial origin of the tumor) false false false false 25. True or False. This tumor marker may be helpful in differentiating metastatic tumor from primary CNS tumors. a. GFAP true (Indicates astroglial origin; unusual for metastatic lesion to stain positive) b. S-100 protein true (Associated with metastatic melanomas) c. cytokeratin true (Associated with metastatic tumors as it stains epithelial cells) d. NSE true (Associated with metastatic small cell lung cancer) e. hCG true (Associated with cerebral metastases from uterine or testicular choriocarcinoma) f. α-fetoprotein true (Associated with cancers of ovary, stomach, lung, colon, and pancreas) g. carcinoembryonic antigen (CEA) true h. CSF-CEA true (Associated with leptomeningeal spread of several cancer types) 34.7.2, 34.7.3 26. Complete the following about tumor marker MIB-I: a. Detects ____ antigen. b. A high number indicates m_____ a_______. c. It correlates with degree of m________. d. It is used for a________, m________, l________, and e________ tumors 34.7.2 Ki-67 mitotic activity malignancy astrocytomas, meningiomas, lymphomas, and endocrine tumors ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 General Information, Classification and Tumor Markers 27. β-hCG is elevated in the following tumors: a. metastatic u______ or t_______ choriocarcinoma b. primary c___________ or e_______ c______ c_____ of pineal or suprasellar region 28. The tumor marker _______ may rise after head trauma and may be elevated in Creutzfeldt-Jakob disease. 229 34.7.3 uterine, testicular 34 choriocarcinoma, embryonal cell carcinoma S-100 34.7.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 35 Syndromes Involving Tumors 35 Neurocutaneous Tumors 1. Most neurocutaneous disorders demonstrate an __________ ____________ inheritance pattern. 2. True or False. The following are neurocutaneous disorders: a. Sturge-Weber syndrome b. Neurofibromatosis c. Tuberous sclerosis d. Von Hippel-Lindau disease e. Foix-Alajouanine syndrome 3. Schwannomas tend to _________ nerve fibers whereas neurofibromas tend to _______ a nerve of origin. 4. True or False. The following is correct about differences between NF-1 and NF-2: a. Alternate name for NF-1 is von Recklinghausen’s syndrome. b. NF-2 has a greater incidence and prevalence than NF-1. c. d. e. f. g. autosomal dominant 35.1.1 35.1.1 true true true true false (Foix-Alajouanine syndrome, acute or subacute neurologic deterioration in a patient with a spinal arteriovenous malformation without evidence of hemorrhage) displace; encapsulate 35.1.2 Table 35.1 true false (NF-1 represents >90% of cases of neurofibromatosis) The inheritance pattern of both NF-1 and true NF-2 is autosomal dominant. Bilateral vestibular schwannomas are true commonly seen in NF-2 but not NF-1. Lisch nodules are associated with NF-2. false (associated with NF-1) Skeletal anomalies are common with true NF-1. Cataracts are common with NF-2. true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Syndromes Involving Tumors h. Gene product of NF-2 is neurofibromin. i. An increased frequency of malignant tumors are seen in both NF-1 and NF-2. 5. Diagnostic criteria for NF-1 include 2 or more of the following: a. six or more c___ a_ l___ spots b. p__________ n________ c. h_____________ in the axillary or inguinal areas d. o_____ g_____ e. Two or more L_______ n________ f. Distinctive o________ abnormality g. __ first degree relative with NF-1 false (NF-1 gene product is neurofibromin, NF-2 gene product is schwannomin (merlin).) true Table 35.2 café au lait peripheral neurofibromatosis hyperpigmentation 35 optic gliomas Lisch nodules osseous (e.g. sphenoid dysplasia) One 6. Complete the following about genetics of NF-1: a. generally _________ ________ autosomal dominant inheritance pattern b. __ - __% of cases are due to new somatic 30-50% mutations. c. After age 5, it has ________% 100% penetrance. d. It is on chromosome ________. 17q11.2 e. Gene product is ________. neurofibromin 35.1.2 7. Diagnostic criteria for NF-2 include: a. Definite diagnosis if b________ v______ s_______ on imaging b. Definite diagnosis if first degree relative with NF-2 AND either u_______ v_____ s_______ at age less than ____ or any two of the following: i. m_________ ii. s_________ iii. g_____ iv. p_________ s_________ l___ o________ Table 35.3 8. What are clinical features of NF-2? a. multiple i______ s_____ t_____ are common b. Most NF-2 patients will become ________. c. R_______ h_________ d. Pregnancy may ________ the growth of eight nerve tumors. 231 bilateral vestibular schwannomas unilateral vestibular schwannoma; 30 meningioma schwannoma glioma posterior subcapsular lens opacity 35.1.2 intradural spinal tumors deaf retinal hamartomas accelerate ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 232 Part 12: Primary Tumors of the Nervous and Related Systems 9. Complete the following about genetics of NF-2: a. Generally _________ ________ inheritance pattern b. It is on chromosome ________. c. Mutation leads to inactivation of ________. 35 10. List the key clinical features of tuberous sclerosis: a. s___________ b. a________ s__________ c. m________ r__________ d. This triad is seen in less than _____ of cases. 11. Complete the following about tuberous sclerosis: a. Typical CNS finding: s________ n________ b. Common associated neoplasm is a g____ c___ a________. c. CT shows i________ c________. 12. Complete the following about genetics of tuberous sclerosis complex: a. The majority of cases are due to s________ m________. b. The two distinct tumor suppressor genes that may be involved are _____ which codes for h_________ and _______ which codes for t_________. c. If one affected child, __ - __% chance of recurrence. 13. Complete the following about the major diagnostic criteria for tuberous sclerosis: a. Cutaneous manifestations: i. f____ a________ ii. u_____ f________ iii. >3 h_________ m_______ iv. s______ p ______ b. Brain and eye lesions: i. c______ t______ ii. s__________ n________ iii. s_________ g____ c___ a_______ iv. r_____ n________ h_________ c. Tumors in other organs: i. c_______ ii. r____________ iii. l______________________ iv. r____ ____________ 35.1.2 autosomal dominant 22q12.2 schwannomin (merlin), a tumor suppression peptide 35.1.3 seizures adenoma sebaceum mental retardation 1/3 35.1.3 subependymal nodules giant cell astrocytoma intracerebral calcifications 35.1.3 spontaneous mutation TSC1; hamartin; TSC2; tuberlin 1-2% 35.1.3 facial angiofibroma ungual fibroma hypomelanotic macules shagreen patch cortical tubers subependymal nodules subependymal giant cell astrocytoma retinal nodular hamartomas cardiac rhabdomyoma lymphangioleiomyomatosis renal angiomyolipoma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Syndromes Involving Tumors 14. Complete the following about tuberous sclerosis: a. In infants, the earliest findings are a____ l_____ m_______ which can be observed with a w____ l_____ examination. b. M______ found in children is often replaced by s______ in adults. c. F_____ a________ appear by 4 years. d. R_______ h___________ are present in 50% of patients. e. CT demonstrates c___________ in 97% of cases along l_______ v_________ or near f_______ of M______. f. Enhancing subependymal lesions on MRI are usually g_____ c_____ a____________. 15. List the key features of Sturge-Weber syndrome. a. a________ b. b____ m____ c. c________ 16. Complete the following about neurocutaneous melanosis: a. Presence of benign or malignant m________ t_____ of the l___________. b. Sometimes associated with S_____W_____ syndrome and n___________. c. >__% of patients die within 3 years after first neurologic manifestation. 233 35.1.3 ash leaf macules; wood’s lamp Myoclonus; seizures Facial adenomas Retinal hamartomas 35 calcifications; lateral ventricles; foramina of Monro giant cell astrocytomas 35.1.4 atrophy: localized cerebral cortical atrophy and calcification birth mark: ipsilateral portwine facial nevus (usually in distribution of trigeminal nerve) calcification: plain skull films classically show “tram tracking” 35.1.5 melanocytic tumors of the leptomeninges Sturge-Weber syndrome; neurofibromatosis 1 >50% Familial Tumor Syndromes 17. Match the familial syndrome and associated CNS tumor: ① von Hippel-Lindau; ② Tuberous sclerosis; ③ NF-1; ④ NF-2; ⑤ Turcot syndrome; ⑥ Li-Fraumeni; ⑦ Cowden a. Hemangioblastoma b. Bilateral vestibular schwannomas c. Colorectal neoplasms and neuroepithelial tumors of the CNS (e.g. medulloblastoma, pineoblastoma) d. Subependymal giant cell astrocytoma e. Optic glioma Table 35.5 ① ④ ⑤ ② ③ ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 36 Astrocytomas 36 Classification and Grading of Astrocytic Tumors 1. For the following astrocytomas, the respective WHO grading are: a. Anaplastic astrocytoma: _____ b. Glioblastoma: ____ c. Diffuse astrocytoma: ____ d. Juvenile pilocytic astrocytoma: _____ e. Subependymal giant cell astrocytoma: ____ f. Pilomyxoid astrocytoma: ____ g. Gliosarcoma: ___ 2. Complete the following about astrocytoma: a. grade I i. frequency ________% ii. median survival ________ years b. grade II i. frequency ________% ii. median survival ________ years c. grade III i. frequency ________% ii. median survival ________ years d. grade IV i. frequency ________% ii. median survival ________ year 3. Complete the following on low-grade astrocytomas: a. Y_____ a____ is a favorable prognosticator. b. Mean time to dedifferentiation for patients diagnosed <45 years is about ___ months whereas for patients diagnosed ≥45 years it is about ___. c. Once dedifferentiation occurs, median survival is __ - __ years after. 36.2.1 WHO III WHO IV WHO II WHO I WHO I WHO II WHO IV 0.7% 8-10 36.2.2 16% 7-8 36.2.2 17% 2-3 36.2.2 65% <1 36.2.2 Table 36.10 Table 36.10 Table 36.10 Table 36.10 36.2.2 Young age 44.2 months; 7.5 months 2-3 years ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Astrocytomas 4. a. b. c. d. e. f. g. Histologic features of GBM include: c__________ g_______ a__________ m_________ p____________ n___________ areas of n_______ p_____________ 36.2.2 cellular gemistocytic astrocytes mitosis pleomorphism neovascularization necrosis pseudopalisading Molecular Genetics and Epigenetics 5. What are three major genetic pathways in the development of GBM? a. Inactivation of the ____ and ____ tumor p53; Rb suppressor pathways. b. Activation of P____, A_____, and PI3K, AKT; mTOR m_____, an intracellular signaling pathway. c. Amplification and mutational activation EGF, VEGF, and PDGF of RTK genes including _____, ______, and _____. 6. In terms of the genetics underlying GBMs: a. Loss of ________ expression makes alkylating agents such as t____________ more effective. b. Mutant IDH1 and IDH2 demonstrate the capacity to convert _____ into ______________________. c. These mutations are associated with l______-g______, o________________, and s__________ g_________ with better overall survival than glioblastomas that are wild type for both genes. 7. True or False. The following are associated with secondary glioblastomas rather than primary glioblastomas: a. EGFR amplification b. TP53 mutations c. IDH1/IDH2 mutations d. PTEN mutations 8. The four subclassifications of GBM based on gene expression analysis are: a. I - ________________ b. II - ________________ c. III - _____________ d. IV - __________ 235 36.3.1 MGMT; temozolomide 36.3.2 α-KG; 2-hydroxyglutarate 36.3.3 36 lower-grade, oligodendrogliomas, and secondary gliomas 36.3.4 false, associated with primary GBMs true, seen in 60% of secondary GBMs true, seen in the majority of secondary gliomas false, more associated with primary GBMs 36.3.5 Classical Mesenchymal Proneural Neural ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 236 Part 12: Primary Tumors of the Nervous and Related Systems Neuroradiological Grading and Findings. Spread. Multiple Gliomas 9. Describe the following features of low-grade gliomas on imaging: a. Usually are ______________(hypo vs. hyper dense) on CT. b. Most are ___________ (hypo vs. hyper intense) on T1WI MRI but ______________ (hypo vs. hyper intense) on T2WI. c. Most ________ (do vs. do not) enhance on CT or MRI. d. Low-grade astrocytomas usually appear as ____________ (hypo vs. hyper metabolic) areas on fluorodeoxyglucose PET scans. 36 10. Describe the following features of high-grade malignant gliomas: a. About ____% of highly anaplastic astrocytomas do not enhance on CT. b. The non-enhancing center of ring enhancement seen with GBM represents __________ while the rim is c__________ t_______. c. Gliomas can spread by the following mechanisms: T___________ through w________ m_________ or spread through the C____ p__________. d. G___________ c___________ is used to describe a diffuse, infiltrating astrocytoma that invades almost all of the cerebral hemispheres. e. Meningeal gliomatosis occurs in ___% of high-grade gliomas at autopsy. 36.5 hypodense hypointense; hyperintense do not hypometabolic 31% 36.5 necrosis; cellular tumor Track through white matter; CSF pathway 36.6 Gliomatosis cerebri 36.7 20% Treatment 11. Describe what should prompt consideration for surgical resection of a low-grade astrocytoma: a. e_________ a d____________ b. presence of p__________ a__________ c. evidence of h_______________ d. evidence of o__________ C___ f_____ e. prevention of m___________ t___________ 36.8.1 establish a diagnosis pilocytic astrocytoma herniation obstructed CSF flow malignant transformation ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Astrocytomas 12. The standard of care for treatment of high-grade gliomas includes c__________ s_________ followed by e________ b______ r___________ and t_______________. Median survival with this regimen is ____ months. cytoreductive surgery; external beam radiation (60 Gy); temozolomide; 14.6 months 36.8.2 13. Use of 5-ALA for tumor resection leads to _____ (less/equal/more) resection which translates into _______ (decreased/increased/no effect on) 6month progression free survival and _______ (decreased/increased/no effect on) on overall survival. more; increased; no effect on 36.8.2 14. Complete the following regarding stereotactic biopsy: a. It underestimates the occurrence of GBM by ________%. b. Some CNS ________ mimic GBM radiographically. c. Yield of biopsy is highest when the following are sampled: i. low density ________ ii. enhancing______ d. If Karnofsky rating is higher than _____. 15. Complete the following about radiation therapy for malignant gliomas: a. ___ - __Gy b. Is whole brain x-ray treatment (XRT) valuable? 16. Complete the following about pseudoprogression: a. Occurs in up to __ - __% of patients after XRT and temozolomide. b. Typically seen ≤__ months after treatment. c. Histologically resembles r____________ n__________. 17. Complete the following about recurrent GBM: a. B________________ is approved for progressive GBM following prior treatment. b. S_______ is the mainstay of treatment and is usually recommended on for patients with KPS ≥ ___. 237 36 36.8.2 25% lymphomas center rim 70 36.8.4 50-60 Gy No, it does not increase survival 36.8.3 28-60% 3 months radiation necrosis 36.8.4 Bevacizumab Surgery; 70 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 238 Part 12: Primary Tumors of the Nervous and Related Systems Outcome 18. The following are prognostic indicators for malignant astrocytomas: a. a____ 36.9 age, found to be the most significant prognosticator histological features performance status MGMT methylation status b. h__________ features c. p__________ s_______ d. M____ m_________ status 36 19. How does MGMT methylation status affect median overall survival in malignant gliomas? Unmethylated – median OS 12.2 months; Methylated – median OS 18.2 months 36.9 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 37 Other Astrocytic Tumors Pilocytic Astrocytomas 1. Pilocytic astrocytomas can be found in the following locations: a. o_______ n_______ b. h_____________ c. c__________ h_______________ d. b__________ e. c_______________ f. s_________ c______ 2. Characteristic histologic findings in pilocytic astrocytomas are a. R___________ f_______ b. f___________ cells c. m___________ d. e___________ g___________ b______ e. typically grossly w___-d________ 37.1.2 optic nerve hypothamus cerebral hemispheres brainstem cerebellum spinal cord 37.1.3 Rosenthal fibers fibrillated cells microcysts eosinophilic granular bodies well-demarcated 3. Complete the following about the radiographic appearance of PCAs: a. Over 66% are c______ with m_________ n_________. b. ____% enhance with contrast. c. ___% are periventricular. d. Are these tumors typically surrounded by edema? e. Cyst wall enhancement indicates _____. tumor 4. Pilocytic astrocytomas typically occur within the ____ decade of life. 2nd (75% occur before age 20) 5. Complete the following about the treatment of PCAs: a. The main treatment of PCAs is _______. b. In tumors composed of a nodule with a true cyst, excision of the _________ is sufficient c. If the cyst wall enhances, it _______ (should vs. should not) be removed. d. Generally, radiation therapy _______ (is vs. is not) recommended as an additional treatment. 37 37.1.4 cystic with mural nodules 94% 82% no 37.1.5 37.1.5 surgery nodule should is not ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 240 Part 12: Primary Tumors of the Nervous and Related Systems 6. According to Collins’ law, a patient’s tumor is considered cured if it does not recur after a post-op period equal to the patient’s ________ plus ________. 37 7. Complete the following about optic gliomas: a. Gliomas in both optic nerves are usually only seen in ___________. b. Often occur in conjunction with a _________________ glioma. c. P______ p_______ is an early sign of an optic nerve tumor, whereas a tumor of the chiasm may cause p______ d__________ or h____________. 8. Complete the following about the treatments for optic gliomas: a. If the tumor involves a single optic nerve, spares the chiasm, and produces proptosis as well as visual loss, then _________ of the ____ _____ should be performed. b. More posterior lesions with nonspecific visual defects and no proptosis, hypothalamic dysfunction, pituitary dysfunction, or hydrocephalus, it is likely a ________ ________. This usually undergoes b______ and ______. 9. Describe the features of diencephalic syndrome: a. c__________ b. h____________ c. o____-a__________ d. e_____________ e. f________ __ t_____ f. h______________ g. m______________ h. Is usually associated with glioma in __________ ______________. i. Usually affects ___________. 10. Characterize brainstem gliomas: a. Lower-grade tumors tend to occur in the ________ brainstem. b. Higher-grade tumors tend to occur in the ________ brainstem. c. Can present with multiple ________ ________ ________. d. Most ______ (are vs. are not) surgical candidates. age; 9 months 37.1.6 37.1.7 neurofibromatosis hypothalamic Painless proptosis; pituitary dysfunction; hydrocephalus 37.1.7 excision of the optic nerve (from globe back to the chiasm) chiasmal lesion; biopsy; XRT 37.1.8 cachexia hyperactivity over-alertness euphoria failure to thrive hypoglycemia macrocephaly anterior hypothalamus children 37.1.10 upper lower cranial nerve palsies are not ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Other Astrocytic Tumors 11. Upper brainstem gliomas present with: a. _________ signs b. _________ 37.1.10 cerebellar hydrocephalus 12. Lower brainstem gliomas present with a. l________ c________ n____ deficits lower cranial nerve b. l________ t________ signs long tract 37.1.10 13. Characterize four MRI growth patterns of brainstem gliomas: a. Diffuse i. Location: _______, _______, _______ _______ ii. Grade (high vs low): ________ iii. Surgical Resection? _____ b. Cervicomedullary i. Location: ________ ii. Grade (high vs low): ________ 37.1.10 iii. Surgical Resection? _____ c. Focal i. Location: ________ ii. Grade (high vs low): ________ iii. Surgical Resection? _____ d. Dorsally Exophytic i. Location: _______, _______ _______ ii. Grade (high vs low): ________ 14. a. b. c. pons, medulla, spinal cord high (100%) no medulla low (66% are low-grade astrocytomas) yes if exophitic medulla, spinal cord iii. Surgical Resection? _____ On MRI, brainstem gliomas appear: T1: ________, ________ T2: ________, ________ Enhancement? ________ ________ hypointense, homogeneous hyperintense, homogeneous highly variable 16. Complete the following about the prognosis of brainstem gliomas: a. Prognosis of most patients is __ - __ months. b. Subgroup of dorsally exophytic pilocytic astrocytomas have a longer survival of up to ________ years. 37 cervicomedullary low (72% are low-grade astrocytomas) yes if exophitic low (60% are low-grade astrocytomas) yes if accessible 15. Surgery may be indicated in the treatment of brainstem gliomas in the following circumstances: a. tumors with _____ _________ component b. some success with resecting ___-______ astrocytomas c. if s______ needed for h_________ 241 37.1.10 37.1.10 dorsally exophytic non-malignant shunting; hydrocephalus 37.1.10 6 to 12 months 5 years ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 242 Part 12: Primary Tumors of the Nervous and Related Systems 17. These neurological findings are possible with a tectal glioma: a. P________ s_______ b. a________ c. n_______ d. d_______ e. s________ f. More commonly presents with signs of __________. 18. Characterize tectal gliomas: a. Present primarily in _________ with a median age of symptom onset of __ - __ years. b. Pathology is usually ___-_____ _______. 37 c. Diagnostic study of choice is ________. d. Symptoms resolve with treatment of the ________. e. MRI appearance i. mass arising from the q_______ _____ ii. on T1: ________ iii. on T2: ________ iv. with gadolinium: ______% enhance 37.1.11 Parinaud’s syndrome ataxia nystagmus diplopia seizures hydrocephalus 37.1.11 childhood; 6-14 years low-grade glioma (diffuse astrocytoma, pilocytic astrocytoma, ependymoma, etc) MRI hydrocephalus quadrigeminal plate isointense iso- or hyperintense 18% 19. Complete the following about the treatment of tectal gliomas: a. A _____-______ _____ may lead to good ventriculo-peritoneal shunt long-term symptom control. b. An alternative is _____ _____________. endoscopic third ventriculostomy 37.1.11 Pleomorphic Xanthoastrocytoma (PXA) 20. Complete the following about pleomorphic xanthoastrocytomas: a. Grade (low vs. high): _____ b. Location: >90% ________ (supra- vs. infratentorial) and typically s________. Meninges involved in >__% of cases. c. Most have a _____ component. d. Treatment: _______, ______ or ______ usually only considered for grade III. e. 5-year survival with gross or subtotal resection, with or without radiation and chemo is ___%. low (typically WHO II) supratentorial; superficial; 67% cystic surgery (maximal safe resection), XRT or chemo 80% 37.2.1 37.2.8 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 38 Oligodendroglial Tumors and Tumors of the Ependyma, Choroid Plexus, and Other Neuroepithelial Tumors Oligodendroglial Tumors 1. Characterize oligodendrogliomas (ODGs). a. Frequent presenting symptom is ________ in __ - __%. b. >__% are ____________ (supra- vs. infratentorial). c. They have a predilection for which part of the CNS? d. Calcified on __ - __% of skull x-rays and __% of CT scan. e. Oligodendroglioma cells in a tumor suggest what sort of prognosis for the patient? 2. Complete the following about the histologic findings of oligodendrogliomas (ODGs): a. The classic description of the cytoplasm of ODG cells is a ____ ____ appearance. b. A “______ _____” characteristic vascular pattern can be seen. c. The above (a & b) are felt to be unreliable findings. What are more consistent findings? seizure; 50-80% 38.1.3 >90%; supratentorial Table 38.1 frontal lobe 38.1.1 30-60%; 90% 38.1.4 38 a better prognosis 38.1.5 fried egg appearance (perinuclear halos) “chicken-wire” cells with monotonous round nuclei with an eccentric rim of eosinophilic cytoplasm lacking obvious cell processes 3. Which of the following features are associated with low-grade vs. highgrade oligodendrogliomas? (e.g. WHO II (low-grade) vs. WHO III (highgrade)) a. Contrast enhancement: _____ WHO III b. Absence of astrocytic component: WHO II ______ Table 38.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 244 Part 12: Primary Tumors of the Nervous and Related Systems c. Endothelial proliferation on histology: ______ d. Large variability in nuclear and cytoplasmic size and shape: _____ 4. Complete the following about the treatment of oligodendrogliomas: a. Following surgical resection, what general adjuvant therapy is preferred in the treatment of these lesions? b. P_______, C_____, v_______, and t________ are chemotherapy agents used for oligodendrogliomas. c. Indications for surgery include: i. Tumors with significant m_____ e______ regardless of grade. ii. If ____-grade, surgery is recommended for ________ lesions but not at the expense of neurological functions. iii. Benefit of surgery less clear with ____-grade tumors 38 5. Arrange the following from best to worst prognosis: a. mixed oligodendroglioma b. pure astrocytoma c. pure oligodendroglioma 6. Complete the following about the prognosis of oligodendrogliomas (ODGs): a. Chromosomal 1p/19q loss is associated with _________ (shorter vs. longer) survival. b. What is the 10-year survival of tumors that are predominantly ODGs? c. Post-op median survival is __ months. d. Calcification is thought to convey a ______ (better vs. worse) prognosis. WHO III WHO III 38.1.6 chemotherapy PCV (procarbazine, CCNU, vincristine) and temozolomide mass effect low; accessible high 38.1.7 c, a, b 38.1.7 longer 10-30% 35 better Ependymal Tumors 7. Complete the following about ependymomas: a. Arise along the v________ and c_____ c____ of the s______ c____. b. 69% of ependymomas occur in _______ (adults vs. children). c. Account for __% of spinal cord gliomas 38.3.1 ventricles, central canal, spinal cord children 60% (most common primary intramedullary spinal cord glioma below the midthoracic region) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Oligodendroglial, Ependymal, Choroid Plexus, and Other Tumors d. In adults, tend to be _________. In children, frequently found in the _______ _______. e. Have the potential to spread via ______ forming “______ _____” 8. Complete the following about histological findings in ependymomas: a. WHO II grade variants include c_______, p________, c______ c____, and t________. b. Myxopapillary ependymomas are WHO grade ___. c. Subependymomas are WHO grade ___. d. Anaplastic ependymomas are WHO grade ___. e. The m_________ subtype occurs in the filum terminale. 9. Complete the following about ependymomas: a. Incidence among intracranial tumors in adults is __ - __%. b. Incidence among pediatric brain tumors is __%. c. It occurs in children __% of the time. d. Incidence among spinal cord gliomas is __%. e. Drop metastases occur in __% of patients. 10. When evaluating a patient with an intracranial ependymoma: a. Which parts of the neuraxis should be imaged? b. An alternative to MRI for detecting drop mets is ________________. c. Commonly occur in the floor of the ______ _________ so may present with h_______ as well as cranial nerve ___ and ____ palsies. 11. Complete the following about the treatment of ependymomas: a. 2 weeks post-op, should perform a ____ _______ to look for _______ _____. b. Ependymomas ________ (are vs. are not) radiosensitive. c. Role of chemo is ______ (important vs. limited) in the treatment of these lesions. 245 intraspinal, posterior fossa CSF; “drop mets” 38.3.1 cellular, papillary (“classic lesion”), clear cell; tanycytic WHO I WHO I WHO III myxopapillary 38.3.1 38 5-6% 9% 70% 60% 11% 38.3.1 usually MRI of the brain as well as cervical, thoracic, and lumbar spine to check for potential seeding myelography (with watersoluble contrast) fourth ventricle; hydrocephalus; CN VI (involvement of nucleus) & VII (involvement of genu) 38.3.1 lumbar puncture; drop mets are (rank 2nd only to medulloblastomas in radiosensitivity) limited ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 246 Part 12: Primary Tumors of the Nervous and Related Systems d. With surgery and ______, 5-year survival is estimated at ___ - ___% in adults. But in pediatric group, 5-year survival is estimated at ___ - ___%. e. Difficult to surgically resect because they can invade the _____. f. Current operative mortality estimated at __ - __% g. Is mortality higher in adults or in children? 12. If CSF after ependymoma resection demonstrates positive cytology, what should be done? 13. True or False. Regarding medulloblastomas and ependymomas: a. Although uncommon in medulloblastomas, calcifications may be seen ~20% of the time. b. The “banana sign” in the fourth ventricle refers to medulloblastomas rather than to ependymomas. c. Ependymomas rank second only to medulloblastomas in radiosensitivity. d. Medulloblastomas arise from the roof of the fourth ventricle, the fastigium. e. Ependymomas arise from the floor of the fourth ventricle, the obex. f. Ependymomas are the most common glioma of the spinal cord below the midthoracic region 38 XRT; 40-80% (adults); 20-30% (pediatrics) obex 5-8% children Usually provide low dose XRT to entire spinal axis with an increased dose to any visible drop mets. 38.3.1 38.3.1 false (<10%) true true true true true Neuronal and Mixed Glial Tumors 14. Complete the following about central neurocytomas: a. Grade: _____ b. Location: usually within the _________ _________ attached to s______ p________ or within the _________ ___________. c. Histologically, can mimic oligodendrogliomas as cells may have a “_______ ____” appearance. d. Imaging findings: i. On CT, 25-50% show _____________. ii. MRI T1: ___________ iii. MRI T2: ___________ iv. Enhancement? _____ e. Surgery _____ (is vs. is not) potentially curative. 38.4.2 WHO grade II lateral ventricles; septum pellucidum; third ventricle “fried egg” calcifications isointense hyperintense yes is ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Oligodendroglial, Ependymal, Choroid Plexus, and Other Tumors 15. Complete the following about dysembryoplastic neuroepithelial tumors (DNET): a. Most common locations are the ________ and ________ lobes. b. Grade: ________ c. Age: Usually presents in __________ or _________ _________ with s__________. d. Imaging findings: i. Edema? ii. iii. iv. v. On CT: _______ MRI T1: ______ MRI T2: ______ PET: _______ e. What therapy is recommended for this tumor type? 16. Lhermitte-Duclos disease is a g__________ of the c_________. 247 38.4.4 frontal; temporal WHO Grade I children; young adults; seizures typically no surrounding edema hypodense hypointense hyperintense hypometabolic (with 18-FDG and negative 11C-methionine uptake) Surgical resection – adjuvant therapies with XRT or chemo do not benefit these patients. 38 gangliocytoma of the cerebellum 38.4.5 true 38.5.2 false (they may grow rapidly) 38.5.1 false, they can produce drop mets (WHO III grade do so more commonly) true 38.5.2 Choroid Plexus Tumors 17. True or False. Regarding choroid plexus tumors: a. The majority of choroid plexus tumors occur in patients less than 2 years old. b. Choroid plexus tumors do not grow rapidly. c. They do not produce drop mets. d. They are usually located infratentorially in adults. e. They are usually located infratentorially in children. f. Hydrocephalus with choroid plexus tumors may result from overproduction of CSF although tumor removal does not always cure the problem. 18. Imaging findings associated with choroid plexus tumors include: a. Location: ________ b. Enhancement? _____ _____ c. Shape: ______________ d. Usually seen associated with _________. false, usually supratentorially true 38.5.3 38.5.4 intraventricular densely enhancing multi-lobulated with projecting “fronds” hydrocephalus ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 39 Neuronal and Mixed Neuronal-Glial Tumors Ganglioglioma 1. Answer the following about gangliogliomas: a. Peak incidence occurs around ______ years. b. Characterized by ________ growth. c. Have a tendency to c_____________. d. Two major classifications include: _____________ and _________________ e. Most common presenting symptom is s______. 39 11 39.1.2 slow calcify ganglioneuromas and gangliogliomas 39.1.1 seizures 39.1.5 39.1.4 Paraganglioma 2. Provide the name of paragangliomas based on location: a. Carotid bifurcation: __________ ___________ ___________ b. Auricular branch of vagus: ________ ________________ c. Superior vagal ganglion: _________ ________________ d. Inferior vagal ganglion: __________ ________________ e. Adrenal medulla & sympathetic chain: ______________ 3. a. b. c. Paragangliomas may secrete: e________ n________ c________ 4. Familial syndromes associated with pheochromocytomas include: a. v____ H_______-L_________ disease b. M_____ ___ & ____ c. n____________________ Table 39.1 carotid body tumors glomus tympanicum glomus jugulare glomus intravagale pheochromocytoma 39.2.1 epinephrine norepinephrine catecholamines 39.2.2 von Hippel-Lindau disease MEN 2A & 2B neurofibromatosis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Neuronal and Mixed Neuronal-Glial Tumors 5. a. b. c. Resection of carotid body tumor has a: stroke risk of__ - __%. 8-20% cranial nerve injury risk of __ - __ %. 33-44% mortality of __ - __%. 5-13% 6. The most common neoplasm of the middle ear is ______ ___________. 7. Complete the following about glomus jugulare tumors: a. They arise from ________ ________. b. Are they vascular or avascular? c. Receive vascular supply from e______ c______ a_____ branches including: i. a________ p________ ii. p________ a________ iii. o___________ iv. i______ m_________ d. Receives vascular supply from ________ portion of the ________ ________ ________. 8. Characterization of glomus tumors include: a. Female-to-male ratio:______ b. Does it typically occur bilaterally? c. Typical presenting symptoms: i. h________ l________ ii. p________ t________ d. Other clinical exam abnormalities: i. V________ due to CN VIII involvement ii. Loss of t______ of p_________ t_______ of t_________ from CN IX involvement iii. V______ c______ paralysis from CNX involvement iv. T________ and s__________ weakness from CN XI involvement v. Ipsilateral t______ a________ from CN XII involvement 9. True or False. During surgical excision of a paraganglioma, the patient is noted to have abrupt onset of hypotension and respiratory distress. Is this most related to: a. intracranial pressure (ICP) changes b. vasovagal response c. inadvertent compression of airway d. tumor manipulation e. due to r________ of h________ or b________ glomus tympanicum 249 39.2.3 39.2.4 39.2.4 glomus bodies very vascular external carotid artery ascending pharyngeal posterior auricular occipital internal maxillary petrous; internal carotid artery 39.2.4 6:1 no, almost non-existent 39 hearing loss pulsatile tinnitus Vertigo taste of posterior third of tongue Vocal cord Trapezius and sternocleidomastoid tongue atrophy 39.2.4 false false false true release of histamine or bradykinin ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 250 Part 12: Primary Tumors of the Nervous and Related Systems 10. What is the major differential diagnosis for potential glomus tumors at the CPA? 11. Complete the following about glomus jugulare: a. Testing for v_____________ _____ should be done. b. If elevated, indicative of secretion of ________, c. which is similar to ________. d. New clinical marker is ________. 39 12. Complete the following about treatment of glomus jugulare: a. Treat medically with ________ and ________ prior to surgery. b. S___________ can be used to inhibit release of serotonin, bradykinin, and histamines. c. E__________ can lead to tumor swelling, which can compress brainstem or cerebellum but can be used to reduce vascularity. d. Recurrence after surgical resection may be as high as ______ of cases. vestibular schwannoma 39.2.4 39.2.4 vanillyl mandelic acid (VMA) catecholamines pheochromocytoma normetanephrine (NMN) 39.2.4 alpha and beta blockers Somatostatin Embolization 1/3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 40 Pineal Region and Embryonal Tumors Pineal Region Tumors 1. True or False. Regarding pineal region tumors. a. The absence of the BBB in the pineal gland makes this area susceptible to hematogenous metastasis. b. Nongerminomas include: i. embryonal carcinoma ii. choriocarcinoma iii. teratoma iv. medulloblastoma c. Germ cell tumors rarely give rise to tumor markers. d. CSF tumor markers are more useful for following response to treatment than they are for diagnosis. e. Obtaining a tissue diagnosis prior to treatment with a test dose of XRT is a growing trend. 2. True or False. Regarding pineal cysts. a. Pineal cysts are a common incidental finding either on MRI or at autopsy. b. Surgery should be performed for all pineal cysts to obtain a diagnosis. c. Surgery can be performed to relieve symptoms should the cyst lead to hydrocephalus. 3. Pineocytoma and pineoblastoma are both______ tumors that are _______. 4. Complete the following about germ cell tumors. a. In the CNS they arise in the __________. b. In males they are most likely in the _______ region. c. In females they are most likely in the _______ region. 40.1.1 true true true true false false 40 true true 40.1.2 true false true malignant; radiosensitive 40.1.3 40.1.3 midline pineal suprasellar ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 252 Part 12: Primary Tumors of the Nervous and Related Systems d. Are germ cell tumors benign or malignant? e. They spread via the ________. CSF 5. True or False. Regarding germ cell tumors. a. Germ cell tumors and pineal cell tumors true occur primarily in childhood and young adults (< 40 years old). b. Clinical features of pineal region tumors true may include hydrocephalus and Parinaud’s syndrome. c. Optimal management strategy for pineal true region tumors has yet to be determined. 40.1.3 6. True or False. Germinomas are very sensitive to radiation but not to chemotherapy. 40.1.3 7. Complete the following about surgery for pineal tumors: a. i. The most common approach is the ______ ______. ii. This cannot be used if the _______ is steep. b. i. Another common approach is the ______ _______, ii. which is best for lesions ______ at iii. or _______ to the tentorial edge iv. or _______ the vein of Galen. c. Anatomically, i. the base of the pineal gland is the ______ wall of the _____ ventricle. ii. the ______ surrounds both sides of the pineal gland. iii. d_____ c_______ v____ are a major obstacle to operations in this region. 40 malignant false – they are sensitive to both 40.1.3 infratentorial supracerebellar tentorium occipital transtentorial centered superior above posterior; 3rd thalamus deep cerebral veins Embryonal Tumors 8. Complete the following about embryonal tumors: a. PNET stands for _____ __________ ______ b. These tumors include: i. p_____________ ii. n____________ iii. e_____________ iv. r_____________ v. m_____________ c. i. They are ______ indistinguishable ii. but genetically _______. 40.2.1 primitive neuroectodermal tumors pineoblastoma neuroblastoma esthesioneuroblastoma retinoblastoma medulloblastoma histologically distinct ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pineal Region and Embryonal Tumors 9. Regarding embryonal tumors. a. The term primitive neuroectodermal tumor (PNET) is entrenched, but the recommendation is to call them ________ tumors. b. A medulloblastoma (MB) is more than just a PNET of the posterior fossa because mutations such as ____-______ and ____ seen in MB are absent in other PNETs. c. The most common location for an embryonal tumor is the _______ _____ (hint: think about MB). d. Embryonal tumors spread via the ____. e. ______ law for children with treated embryonal tumors states that the period of risk of recurrence is equal to the age at diagnosis plus 9 months. f. Require entire ______ ______ evaluation. g. i. Cranial radiotherapy is avoided before ___ years of age ii. to avoid i________ impairment iii. and growth r_________. 10. Complete the following about supratentorial PNET (sPNETs): a. They occur in children under ______ years of age. b. They occur _____ in adults. c. Histologically, they are ______ to medulloblastoma. d. i. They are ____ aggressive than medullobastomas. ii. Survival is _____ and they iii. respond _____ to therapy. 11. True or False. Regarding medulloblastoma. a. It accounts for 15 to 20% of all intracranial tumors in children. b. It is the most common malignant pediatric brain tumors. c. There is a standardized chemotherapy, including lomulstine (CCNU) and vincristine. d. Patients with residual medulloblastoma post-resection and dissemination are a poor risk, with only a 35 – 40% chance of being disease free at 5 years. e. MB are WHO grade ___. 253 40.2.1 embryonal beta-catenin; APC cerebellar vermis CSF Collins spinal axis 3 intellectual retardation 40.2.1 40 5 rarely identical more worse poorly 40.2.2 true true false (There is no standardized regimen; CCNU and vincristine are usually used for recurrences.) true IV ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 254 Part 12: Primary Tumors of the Nervous and Related Systems 12. Complete the following about medulloblastoma: a. The clinical history is _____, b. typically only ____ to ____ weeks. c. Their location of orgin predisposes patients to __________. d. Patients present with: i. h________ ii. n______ iii. a_____ and iv. seeding of the axis in ____ to ____ % 13. True or False. Radiologically, medulloblastomas are a. cystic b. solid c. enhancing d. on non-contrast CT they are hyperdense 14. Complete the following about medulloblastoma location: a. Most are in the ________. b. Laterally situated tumors are more common in _________. 40 15. Complete the following about drop mets to the spine with medulloblastoma: a. The test that should be is a _____ ____ _______. b. Staging should be done _______ or within ____ to _____ weeks post-op. 16. Regarding the molecular biology of medulloblastoma, in 35 to 40% there is a deletion of _______. 17. Poor prognosticators for patients with MB include: a. y________ a_____ b. m_________ d______ c. i________ to p_______ g____-t_____ r_______ d. histological differentiation along g_____, e________, or n_______ lines 18. Regarding atypical teratoid/rhabdoid tumors: a. Occur primarily in i_______ and c________. b. Most patients die with ____ year of diagnosis. c. Have a deletion or monosomy of chromosome __. 40.2.2 brief 6 to 12 hydrocephalus headache nausea ataxia 10 to 35 40.2.2 false true true true 40.2.2 midline adults 40.2.2 MRI w/ contrast pre-op; 2 to 3 17p 40.2.2 40.2.2 younger age metastatic disease inability to perform grosstotal removal glial, ependymal, or neuronal lines 40.2.4 infants and children 1 22 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pineal Region and Embryonal Tumors 19. Complete the following about esthesioneuroblastoma: a. Are a rare _____ _________. b. Are believed to arise from the ___________ ______ ______. c. The _____ grading system should be used to characterize the disease course. d. Median survival is typically _____ years. e. Primary treatment is controversial but typically involves ___________ and ___________ _______. 255 40.2.5 nasal neoplasm olfactory neural crest Hyams approx. 7 years chemoradiotherapy; craniofacial resection 40 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 41 Tumors of Cranial, Spinal and Peripheral Nerves Vestibular Schwannoma 1. True or False. Vestibular Schwannaoms (VS) usually arise from which nerve? a. facial nerve b. cochlear nerve c. nervus intermedius d. vestibular nerve, inferior division e. vestibular nerve, superior division 41 2. Vestibular schwannomas arise from the junction a. of the _________ and _________ myelin called b. the _______-__________ zone 3. Complete the following about vestibular schwannomas: a. What is the Obersteiner-Redlich zone? b. Where is it located? c. From what cells do acoustic tumors arise? d. On what structure do they arise? e. Therefore, are they schwannomas or neuromas? f. They are the result of a chromosomal defect that leads to i. loss of t__________ s___________ gene on the ii. l_______ arm of c____________ #____. iii. If this defect is inherited the patient has____________ ________ ___. 41.1.1 false false false true true 41.1.1 central and peripheral Obersteiner-Redlich 41.1.1 site of junction of central and peripheral myelin 8 to 12 mm from brain stem the neurilemmal sheath superior division of vestibular nerve schwannomas tumor suppressor long arm of chromosome 22 neurofibromatosis Type 2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Tumors of Cranial, Spinal and Peripheral Nerves 4. Pathologically, what fibers constitute vestibular schwannomas? a. A__________ ___ n________ e___________ b__________ f___________ b. A__________ ___ l________ r___________ f_______ 5. List the common triad of symptoms seen with vestibular schwannomas. a. h________ l_______ - ____% b. t__________ - ____% c. d________________ - ____% 6. A patient with good hearing has an MRI study that shows a cerebellopontine angle mass. a. Is this compatible with a vestibular schwannoma? b. When hearing is involved in VS, what is lost? i. low frequencies? ii. high frequencies? iii. word discrimination? 7. What cranial nerve deficits, other than CN VIII, occur with VS? a. CN ____; o__________, f_______ n_________, and t________ c_________ b. CN ____; f__________ w_______________ c. CN ____,_____,____; h____________ and d____________ 8. Answer the following about VS: a. As tumor increases in size the following occur in what sequence? i. facial weakness ii. facial numbness iii. impaired hearing b. What size of tumor causes CN V and CN VII compression? 257 41.1.3 Antoni A narrow elongated bipolar fibers Antoni B loose reticulated fibers 41.1.4 hearing loss – 98% tinnitus – 70% disequilibrium – 70% (insidious, progressive, 70% have high-frequency loss, word discrimination difficulties) 41.1.4 no (at the time of diagnosis virtually all VS have otological symptoms) no yes (70% have a highfrequency loss pattern) yes (e.g. telephone conversation) 41 41.1.4 CN V; otalgia, facial numbness, and taste changes CN VII, facial weakness CN IX, X, XII; horseness and dysphagia 41.1.4 iii, ii, i (facial numbness occurs earlier than weakness even though CN V is only slightly compressed and CN VII is severely compressed – a paradox because of differential resilience of motor nerves relative to sensory nerves.) > 2 cm ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 258 Part 12: Primary Tumors of the Nervous and Related Systems 9. Complete the following about vestibular schwannomas: a. What percentage have no abnormal physical findings except for hearing loss? b. The Weber test lateralizes to the _______ side. c. Is the Rinne test positive or negative if hearing is preserved? d. What is normal for the Rinne test? 10. Regarding vestibular schwannomas. a. What causes nystagmus? b. Vestibular involvement also causes an abnormal __________ with c__________ s________________ c. What is the growth rate for VS? d. What is the proper follow-up protocol, if no surgery is done? e. Recommend surgery if: i. size changes by ____________ ii. or symptoms __________ 41 41.1.4 66% uninvolved (hearing loss is sensorineural) positive air conduction > bone conduction = positive means normal (Note: An A is better than a B.) 41.1.4 vestibular involvement electronystagmography (ENG); caloric stimulation 1 to 10 mm/year repeat scan at 6 month intervals for 2 years then once each year > 2 mm/year progress 11. Answer the following about the House and Brackmann scale? a. What does the House-Brackmann scale facial nerve function measure? b. What are the categories? normal, mild, moderate, moderate-severe, severe, total paralysis c. Synkinesis is defined as i_________ involuntary movement; m___________ accompanying a voluntary movement v__________ m_________ 41.1.4 12. What is the major differential diagnosis for a CPA lesion? 41.1.4 13. Describe the audiometric findings for “useful” hearing in vestibular schwannomas. a. pure-tone audiogram threshold: _____ b. speech discrimination of: _______ meningioma vs. vestibular schwannoma vs. neuroma of adjacent cranial nerve (e.g. CN V). 41.1.5 < 50 dB ≥ 50% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Tumors of Cranial, Spinal and Peripheral Nerves 14. Complete the following regarding the modified Gardener-Robertson system: a. System is used to grade h_________ p____________. b. It consists of testing patient with _______ ________ of increasing loudness. 259 41.1.5 hearing preservation pure tones (decibels [dB]) (if patient hears dB 0 to 30 – excellent hearing; 31 to 50 dB – serviceable; 50 to 90 dB – nonserviceable; 90 dB maxpoor; not testable – none) c. Evaluating patient ability to understand speech discrimination spoken words is called _________ (understands words spoken _______________. correctly 100 to 80% excellent; 70 to 50% serviceable; 50 to 5% nonserviceable) d. Useful hearing is judged to be present up 50/50–patient can hear at 50 to a cutoff point of _______________. dB or less and understands at least 50% of words spoken to him/her 15. Name the findings for the following tests in vestibular schwannomas: a. pure-tone audiogram b. speech discrimination c. brainstem auditory evoked response (BSAER) or auditory brainstem response (ABR) d. electronystagmography (ENG) e. vestibular evoked myogenic potential (VEMP) f. MRI 16. Complete the following concerning vestibular schwannoma: a. It causes what kind of hearing loss? b. This is the same as the loss from i. o____ a______ ii. l______ n______ e_____________ c. Think tumor if the difference between the ears on audiogram is more than _____ dB. 41.1.5 hearing difference between each ear > 10 to 15 dB 4 to 8% score (normal is 92 to 100%) prolonged I-III and I-V interpeak latencies (not used for diagnostic purposes but good for prognostication) abnormal if there is >20% difference between the two sides (normally, 50% of response is from each ear.) assess inferior vestibular nerve independent of hearing (can be used even with deafness present). diagnostic procedure of choice; round, enhancing tumor centered on IAC 41 41.1.5 sensorineural loss of high tones old age loud noise exposure 10 to 15 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 260 Part 12: Primary Tumors of the Nervous and Related Systems 17. True or False. A 55 year old male is referred for evaluation of a 4.0 cm right cerebellopontine angle (CPA) mass. You conclude it is a vestibular schwannoma. Which of the following is least likely to be a factor in your treatment? Give a rationale for each. a. pure-tone audiogram score of 95 dB b. effacement of the fourth ventricle with modest ventriculomegaly c. stereotactic surgery 2 years previously 41 d. contralateral (left) vestibular schwannoma, 1.0 cm in diameter e. angiogram showing absence of right transverse sinus 18. True or False. Possible treatments for vestibular schwannomas include: a. expectant observation, following symptoms, hearing testing, serial CT or MRI b. radiation therapy, external beam radiation therapy (EBRT) c. radiation therapy, stereotactic radiosurgery (SRS), single dose d. radiation therapy, stereotactic radiotherapy, fractionated (SRT) e. retrosigmoid (suboccipital) resection f. translabyrinthine resection g. extradural subtemporal (middle fossa approach) resection 41.1.6 false – audiogram with hearing threshold < 50 dB may allow consideration of hearing-sparing procedure, but with a score of 95 dB hearing-saving procedure is not an option false – evidence of hydrocephalus warrants CSF diversion – needs a shunt true – stereotactic radiosurgery 2 years previously is long enough for SRS effect to be over. Surgery should be avoided during the interval 6 to 18 months after SRS because this is the time of maximum damage from radiation false – bilateral VS unable to preserve right hearing [95 dB], will need to plan for second procedure to address left-sided lesion. Chance of preserving left hearing is 35 – 71% for a 1 cm tumor false – atretic/obstructed right transverse sinus allows consideration of translabyrinthine and suboccipital approach as a combined procedure 41.1.6 true true true true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Tumors of Cranial, Spinal and Peripheral Nerves 19. Answer the following about vestibular schwannomas: a. What is the growth rate of VSs? b. Do some shrink? c. Can they remain stable? d. Can they grow faster? e. If followed most will show _______ in 3 years. 20. Complete the following about vestibular schwannoma treatment: a. Under 25 mm with perfect hearing can be _______. b. Protocol is to retest at 6, 12, 18, 24, 36, 48, 60, 84, 108, and 168 ________. c. Growth of more than ________ mm between studies deserves treatment. d. Tumors larger than 15 to 20 mm should be _________. e. Tumors with cysts can _______ _____________. 21. Comparing microsurgery and SRS: a. Better outcome for hearing? b. Better outcome for trigeminal neuropathy and tumor control? c. No difference for preservation of f________ n_______ f___________. d. Quicker improvement of vertigo? 22. Classically, vestibular schwannomas push the facial nerve in which direction? 23. Complete the following about vestibular schwannomas: a. Small, laterally located intracanalicular VSs can be removed by what surgical approach? b. A disadvantage is that the seventh nerve may be _____ at the ______ ganglion. c. An advantage is that hearing function may be __________. 24. What is the size vestibular schwannomas should be considered for hearing and CN VII preservation procedures? 261 41.1.6 slow (1 to 10 mm/year) yes (6%) yes yes (2 to 3 cm/year) enlargement 41.1.6 observed months 2 treated grow dramatically 41.1.6 SRS microsurgery facial nerve function microsurgery forward and superiorly in 75% of cases 41.1.7 41 41.1.7 subtemporal extradural (also known an middle fossa approach) injured at the geniculate preserved < 2 to 2.5 cm 41.1.7 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 262 Part 12: Primary Tumors of the Nervous and Related Systems 25. What are the advantages of translabyrinthine approach for resecting vestibular schwannomas? a. early identification of the ______ ______ b. less risk to ______________ and _______ __________ __________ c. patients do not get “ill” from _________ in ________ ________ d. best for VS that are located _____________________ 26. What are the disadvantages of the translabyrinthine approach for resecting vestibular schwannomas? a. Hearing is ____________. b. Exposure is ___________. c. May take ___________. d. CSF leak is ____ ____________. 41 41.1.7 facial nerve cerebellum; lower cranial nerves blood in cisterna magna intra-canalicular 41.1.7 sacrificed limited longer more common 27. Complete the following about vestibular schwannomas: a. what are the disadvantages of suboccipital approach (also known as retrosigmoid) for VSs? i. Higher _______ when compared morbidity (H/A more with the translabyrinthine approach. common) ii. Small tumors are _______________. difficult to remove in lateral recess of internal auditory canal (IAC) iii. Facial nerve is located on blind side deep to the ______________ tumor b. the advantage is the possibility of hearing preservation h________ p___________. 41.1.7 28. Complete the following about localizing the CN VII origin: a. The seventh nerve originates in the ____________ sulcus. b. Is anterior to the eighth nerve by ____ mm. c. It lies just anterior to the foramen of ___________ d. and anterior to a tuft of ___________. e. It originates ______ mm cephalad to the IX nerve. 41.1.7 29. How do you treat posteroperative facial nerve weakness after a vestibular schwannoma resection? a. n__________ t________ b. l_____________ c. t_____________ pontomedullary 1-2 Luschka choroid 4 41.1.7 natural tears (2 drops in each eye every 2 hours as needed) lacrilube (to eye and tape eye at bedtime) tarsorrhaphy within a few days if there is a complete CN VII palsy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Tumors of Cranial, Spinal and Peripheral Nerves d. Anastomose by attaching a portion of the __________ nerve to the ________ nerve. e. When there is no CN VII function and i. nerve is known to be divided, you may anastomose in ________. ii. nerve is known to be intact, you may anastomose in ___________. 30. True or False. The following symptoms of brainstem compression from a vestibular schwannoma if present post-op is not likely to improve a. nausea b. vomiting c. balance difficulties d. ataxia 31. True or False. The routes of CSF leakage after vestibular schwannoma resection can be via the a. apical cells b. vestibule c. perilabyrinthine cells d. mastoid air cells 32. With vestibular schwannoma, postoperative routes for rhinorrhea are: Hint: avpam a. a_________ b. v___________ c. p___________ d. a____________ e. m____________ 263 hypoglossal; facial (facial reanimation) 2 months 1 year 41.1.7 false (resolves with time) false (resolves with time) false (clear rapidly) true (may be permanent) 41.1.7 true (to tympanic cavities or Eustachian tube – most common) true (posterior SCC is usually entered by drilling – via the oval window) true (and tracks to mastoid antrum) true (at craniotomy site) 41 41.1.7 apical cells to tympanic cavity and down the Eustachian tube vestibule of the horizontal SCC posterior SCC (most common area entered with drilling) to antrum of mastoid via the perilabyrinthine cells mastoid air cells at site of craniotomy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 264 Part 12: Primary Tumors of the Nervous and Related Systems 33. What are treatment strategies for CSF leakage after vestibular schwannoma resection? a. What percentage stop spontaneously? b. Do what with the head of the bed? c. Place a drain where? d. if hydrocephalus is present place a ____ ______. e. If leak persists _________ ___________________________. 34. What are common complications of vestibular schwannoma surgery? a. CSF leak in ____ – _____% b. infection in ________% c. stroke in ________% d. CN VII palsy in ____ – _____% e. hearing loss in ___ – ____% f. death in _______% 41 35. Complete the following concerning hearing loss and CN VII weakness after suboccipital removal of VS? a. Tumor < 1 cm i. CN VII preserved, ___ – ___% ii. CN VIII preserved, ______% b. Tumor 1 to 2 cm i. CN VII preserved, ___ – ___% ii. CN VIII preserved, ______% c. Tumor > 2cm i. CN VII preserved, ___ – ___% ii. CN VIII preserved, ______% 41.1.7 25 – 35% elevate lumbar CSF shunt re-explore surgical site to pack with tissue or apply bone wax 41.1.7 4 – 27% 5.7% 0.7% 0 – 50% 34 – 43% 1% 41.1.7 95 – 100% 57% 80 – 92% 33% 50 – 76% 6% 36. Complete the following concerning hearing loss after suboccipital removal of VS: a. hearing preserved ___ – ____% with 35 to 71% tumors < 1.5 cm b. after SRS hearing preserved _____% with 26% tumors < 3 cm 41.1.7 37. Concerning acoustic neuroma, recurrence following microsurgery is a. ___ – ___% after b. ___ – ___ years follow-up c. with a subtotal resection of about _____% 41.1.7 38. Complete the following concerning SRS for vestibular schwannoma: a. Dose recommended is _________. b. Local control achieved is ______%. 7-11% 3-16 20% 41.1.7 14 Gy 94% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Tumors of Cranial, Spinal and Peripheral Nerves 39. For vestibular schwannoma, what are short-term local control rates for? a. microsurgery b. SRS 40. When is the time of maximal damage (possible tumor enlargement) from radiation to vestibular schwannomas? a. from _______ to ______ months b. This is important to know because it can produce a false appearance of tumor __________. 265 41.1.7 97% 94% 41.1.7 6 to 18 months enlargement (Surgery should be avoided during the interval 6 to 18 months after SRS because of damage from radiation and the appearance of tumor enlargement.) Tumors of Peripheral Nerves: Perineurioma 41. Regarding tumors of peripheral nerves: a. Intraneural perineurioma: i. Lesion is usually found in __________ or _______ ________. ii. Mitotic activity is _____. iii. MIB-1 labeling is _____. iv. Treatment is ________. b. Soft tissue perineurioma: i. almost exclusively ________ ii. more common in _______ iii. is ___ encapsulated iv. Treatment is __________. 41.2 adolescents; young adults rare low conservative sampling of lesion (not resection) benign females not gross total resection 41 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 42 Meningiomas General information. Common Locations 1. Characterize meningiomas: a. They arise from what cell of origin? b. What percentage of meningiomas occur at the falx (includes parasagittal)? c. With contralateral foot drop plus hypereflexia, think ________ _________. d. Olfactory groove meningiomas i. can produce what syndrome? ii. Consisting of a_______, i________ o______ a_______, and c_________ p_________ iii. What other syndrome? iv. Consisting of a__________, i___________ 42 2. List the most common locations for adult meningiomas. 3. Abulia a. is l________ o_____ w________. b. is characteristic of damage to f______ l_______. c. can occur with a meningioma of the o_______ g________. Arachnoid cap cells 60 to 70% 42.1 parasagittal meningioma 42.3.3 42.3.1 42.3.4 Foster Kennedy syndrome anosmia, ipsilateral optic atrophy, and contralateral papilledema frontal lobe apathy, incontinence Parasagittal (20.8%) – grouped as either anterior, middle, or posterior; up to 50% invade the superior sagittal sinus (SSS); Convexity (15.8%); Tuberculum sellae (12.8%); Sphenoidal ridge (11.9%) – three basic categories: lateral spenoid wing, middle third, and medial; Olfactory groove (9.8%); Falx (8%); Lateral ventricle (4.2%) Table 42.1 42.3.4 lack of willpower frontal lobes olfactory groove ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Meningiomas 267 Pathology 4. Regarding the pathology of meningiomas. a. List the four histopathological variables. 42.4 Grade, histological subtype, proliferation indices, and brain invasion b. There are _____ WHO grades. 3 (I, II, III) c. As the WHO grade increases, there is recurrence; increased risk of _________ and an proliferative index; increase in the __________ _______ (i.e. Ki-67 K__-6___). 5. The presence of brain invasion increases the likelihood of __________ to levels similar to atypical meningiomas, but it is not an indicator of __________ _______. 6. True or False. Regarding meningiomas. a. They commonly metastasize outside of the CNS. b. The most common site of metastatis is the adrenal gland. recurrence; malignant grade 42.4.1 42.4.2 false false – most common sites include the liver, lung, LNs and heart c. The angioblastic and malignant subtypes true most commonly metastasize. 7. Complete the following regarding meningiomas: a. If you see multiple meningiomas, it suggests ______. b. ______ ______ can mimic menigiomas since they may have a dural tail. c. Massive painless lymphadenopathy with sinus histiocytosis that has MRI signal characteristics similar to a meningioma is typical of ______-_________ _________. 42.4.3 NF2 42 Pleomorphic xanthoastrocytoma (PXA) Rosai-Dorfman disease Presentation 8. Give a description of asymptomatic meningiomas. a. The most common primary intracranial tumor is ________ b. Percent of primary brain tumors that are meningiomas: _____% c. Percent that are stable in size over 2.5 years: _____% d. Percent that increase in size when observed for 2.5 years: ______ 42.5 meningioma 32% 66% 33% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 268 Part 12: Primary Tumors of the Nervous and Related Systems e. What does calcification tell us about rate of growth? f. Operative morbidity in patients under 70 is _____% and g. above 70 it is _____% h. classic histological finding is the p_______ b_____. 3.5% 23% psammoma body Evaluation 9. Complete the following about MRI and meningioma: a. Meningioma on T1W1 and T2W1 may be _________. b. With contrast most will __________. c. Accurately predicts sinus involvement in _________%. d. A common finding is a d_______ t______. 10. What metastatic cancer can mimic meningioma in the bone of MRI? 42 slower 11. Olfactory groove meningiomas tend to be fed by the a. _______ arteries, b. which are branches of the __________ artery; c. compared to other meningiomas, which are supplied by feeders from the ______ ________ _______. d. Classically, meningiomas “______ _______, _______ _______” on angiography. 12. The artery of B_________ and C_________ is enlarged in lesions involving the tentorium (i.e. tentorial meningiomas). 13. True or False. The artery most likely to be enlarged on an angiogram depicting a tentorial meningioma is the a. superificial temporal artery b. artery of Bernasconi and Cassinari c. occipital artery d. posterior inferior cerebellar artery e. anterior choroidal artery 42.6.1 isointense enhance 90% dural tail prostate cancer 42.6.2 42.6.3 ethmoidal ophthalmic external carotid artery “comes early, stays late” Bernasconi and Cassinari (a branch of the meningohypophyseal trunk, the “Italian artery”) 42.6.3 42.6.3 false true false false false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Meningiomas 14. Regarding meningiomas and plain xrays, the plain x-rays may show a. b________ _________ __________ b. c________ _________ __________ c. d________ _________ – __________ d. e_________ ________ ___________ e. f_______ ________ ___________ 269 42.6.4 blistering of bone calcification in tumor 10% density changes – hyperostosis enlarged vascular grooves frontal fossa hyperostosis Treatment 15. Complete the following regarding sinus involvement. a. Occlusion of the middle third of the SSS is _________ b. Morbidity/mortality rate is _____/_____% c. due to v_______ i_________ d. The sinus may be divided safely anterior to the ________ __________. e. Posterior to this site the sinus ______ _______ be divided. f. If tumor is attached, it is best to leave _______ __________. g. True or False. It is safe to occlude the dominant transverse sinus. 42.7.2 treacherous 8/3% venous infarction coronal suture must not residual tumor false 16. Complete the following about removal of meningiomas: a. The Simpson grading system grades the meningiomas degree of removal of _________. b. It is important because it correlates with recurrence rate _________ _______. c. What is the most important factor? extent of tumor removal; in order of complexity, from minimal surgery to complete removal d. Components of the system are i. s________ r_________, b_________ small removal, biopsy ii. p__________ r_________ partial removal iii. c________ r________ complete removal iv. c________ d_______ coagulate dura v. r___________ d_________ and remove dura and bone and b___________ and s_______ sinus e. correlates with grade i. ___________ V ii. ___________ IV iii. ___________ III iv. ___________ II v. ____________ I 42.7.2 42 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 270 Part 12: Primary Tumors of the Nervous and Related Systems 17. True or False. Complete the following about radiation therapy (XRT) for meningiomas: a. XRT is effective as a primary modality for treatment. b. XRT is often used for “benign” lesions. c. XRT can be used for invasive, aggressive, recurrent, or non-resectable meningiomas. d. XRT may be beneficial in preventing recurrence for meningiomas that are partially resected. 42.7.3 false false true true Outcome 18. Five year survival for patients with meningioma is ________%. 91.3% 42.8 19. The most important factor in for preventing recurrence is the _____________________. extent of surgical removal 42.8 42 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 43 Other Tumors Related to the Meninges Mesenchymal, Non-meningothelial Tumors 1. True or False. Complete the following about hemangiopericytoma: a. Sarcoma that arises from _________. b. May mimic ________ on CT or MRI. c. Primary treatment is ______. 43.1.1 pericytes meningioma (MRS demonstrating a high inositol peak may help distinguish) surgery Primary Melanocytic Lesions 2. Where does primary CNS melanoma arise? probably from melanocytes in the leptomeninges 43.2 3. In what decade of life does primary CNS melanoma peak? 4th decade (compared to the 7th decade for primary cutaneous melanoma) 43.2 Hemangioblastoma 4. Characterize hemangioblastoma (HGB). a. i. It can be associated with _____ _________-_____ ii. in ______%. b. Surgically treat it like an ______. 5. Answer the following about hemangioblastoma: a. What is the most common primary intraaxial tumor in the adult posterior fossa? b. Can also be located in the r_______. c. What blood paraneoplastic syndrome is associated? i. p_______ due to ii. e__________ d. Histologically, they are _____ tumors. 43.3.2 43 von Hippel-Landau 20% AVM 43.3.2 hemangioblastoma retina polycythemia erythropoietin benign ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 272 Part 12: Primary Tumors of the Nervous and Related Systems 6. Regarding hemangioblastoma: a. They present with typical p-fossa mass symptoms: i. h_________ ii. n_____/v_______ iii. c________ f_______ b. Cardinal pathological feature? c. Most common cyst pattern seen? d. p-fossa HGB should be evaluated with _________. e. Vertebral angiography usually demonstrates ____ ______. f. Check a ____ to identify polycythemia. 7. Complete the following about surgery on a solitary HGB: a. It may be ______ in sporadic HGB b. but not in _____. c. _________ _______ may help reduce vascularity. 8. Complete the following about surgery on HGB: a. Avoid ______ removal, b. work along the ______ c. and _____ the blood supply d. using the same technique as for an _____. 43 9. Complete the following about von Hippel-Landau (VHL) disease: a. Has hemangioblastoma tumors or cyst in the following sites i. c_________ ii. r_______ iii. b_____ s____ iv. s_______ c____ v. p______________ vi. c____ in the k_______ b. Most common location is the ________. c. Second most common location is the ______. d. Always manifests before age ____. e. Incidence is 1 in every ____ persons. f. The mode of inheritance is ________ __________. g. The VHL gene is on chromosome ___. 10. What is the diagnostic criteria for VHL? a. i. One lesion of VHL is necessary if there is a ______ ______. ii. It will be present in ____%. b. Two lesions of VHL are required to make it a ___ ______ mutation. 43.3.2 headache nausea/vomiting cerebellar findings numerous capillary channels peritumoral cyst alone MRI of entire neuroaxis (possibility of spinal HGB) intense vascularity CBC 43.3.2 curative VHL Pre-op embolization 43.3.2 piecemeal margin devascularize AVM 43.3.3 cerebellum retina brainstem spinal cord phemochromocytoma cysts in the kidney cerebellum retina 60 35,000 autosomal dominant 3 43.3.3 family history 80% de novo ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Other Tumors Related to the Meninges 11. Complete the following about tumors associated with VHL? a. Occur in younger persons if patient has ________. b. True or False. Cysts are associated with HGBs. c. Cerebellar HGBs are located in the i. s________ ii. p________ iii. s________ half of the hemisphere d. _____% of cerebellar HGBs were found in the ______. 12. Complete the following about spinal cord hemangioblastoma: a. ____% are in the cervical and thoracic cord. b. ____% are located in the posterior cord. c. ____% of spinal HGBs are associated with VHL. d. ____% symptoms are associated with syringomyelia. 13. The only disease with bilateral endolympathic sac tumors is ____. 14. Complete the following about VHL: a. Retinal hemangioblastomas occur in ____%. b. Typically located in the ______. c. Frequently there are ______. d. Treat with laser _________. 15. Complete the following about renal cell carcinoma (RCC): a. Which is the most common malignant tumor in VHL? b. Usually it is a _____ _____ __________. c. It is the cause of death in __ to __% of VHL patients. 16. Complete the following about surgical treatment of HGB: a. reserved until _________ b. treatment of choice for _______ _______ HGBs c. True or False. The wall must be removed. d. The _____ ________ must be removed. 273 43.3.3 VHL true superficial posterior superior 7%; vermis 43.3.3 90% 96% 90% 95% VHL 43.3.3 43.3.3 50% periphery multiple photocoagulation 43.3.3 RCC 43 clear cell carcinoma 15 to 50% 43.3.3 symptomatic accessible cystic false mural nodule 17. Regarding renal cysts in VHL: a. True or False. They usually cause false significant renal impairment. b. True or False. They are more problematic false than polycystic kidney disease. 43.3.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 274 Part 12: Primary Tumors of the Nervous and Related Systems 18. Complete the following regarding pancreatic lesions in patients with VHL: a. ____ to ____% of patients with VHL develop a pancreatic endocrine tumor or cyst. b. Pancreatic cysts are often ________ and __________. c. Most neuroendocrine tumors are ______ and only ___% are malignant. 43.3.3 35 to 70% multiple and asymptomatic nonfunctional; 8% 43 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 44 Lymphomas and Hematopoietic Neoplasms CNS Lymphoma 1. Complete the following about CNS lymphoma: a. Associated with an eye condition called ________. b. How frequently does it occur? c. What relationship does CNS lymphoma have with the ventricles? d. What form of radiation therapy is given? 2. Regarding secondary CNS lymphoma. a. It is pathologically _______ to primary CNS lymphoma. b. Systemic lymphoma spread to the cerebral parenchyma occurs in ____% of cases at autopsy. 3. The incidence of primary CNS lymphoma is _______ relative to other brain lesions. 4. The following increase the risk of primary CNS lymphoma: a. c________ v_______ d______ b. i___________ c. E______ B____ v_____ 5. True or False. Regarding primary CNS lymphoma. a. B-cell lymphomas are more common than T-cell. b. Painful skin nodules/plaques occur in approx. 10% of patients. c. Intravascular lymphomatosis rarely involves the CNS. uveitis 44.1.1 1 to 2% of all brain tumors up close to ventricles 44.1.3 whole brain 44.1.9 44.1.5 44.1.2 identical 1 to 7% rising 44.1.3 44.1.4 collagen vascular disease immunosuppression Epstein-Barr virus 44 44.1.5 true true false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 276 Part 13: Tumors Involving Non-Neural Origin 6. Regarding the presentation of CNS lymphoma. a. The two most common manifestations are s_____ c____ c________ and c__________ m______. b. Most patients present with n__-f______ n________ symptoms. 7. Regarding diagnosis of CNS lymphoma. a. CT characteristics i. plain CT tumor is __________ ii. contrast CT tumor _________ iii. reminiscent of ______ _______ ______ b. Reaction to steroids ___________. c. CSF is positive for lymphoma cells in _____%. 8. True or False. A 70-year-old male with a homogenously enhancing lesion in the central gray matter and corpus callosum is suspected of having CNS lymphoma. What would make this diagnosis more likely and how is it properly diagnosed? a. hydrocephalus b. café au lait spots c. uveitis d. proximal muscle weakness 44 9. A 73-year-old male with a history of recently diagnosed CNS lymphoma by biopsy presents to the ER with stupor and progressively deteriorating mental status. CT of the brain reveals the mass but no other abnormalities. a. True or False. i. emergent surgical excision ii. radiation therapy iii. chemotherapy iv. steroids b. followed by ________ 10. Regarding the prognosis of CNS lymphoma: a. With no treatment, median survival is ___ to ___ b. With radiation therapy, median survival is _______. c. With intraventricular methrotrexate, the time to recurrence was ____ months. 44.1.6 spinal cord compression; carcinomatous meningitis non-focal neurological 44.1.8 hyperdense to brain enhances homogenously “fluffy cotton balls” may completely resolve only 10% 44.18 false false true (diagnosed with slit lamp) false 44.1.9 false true (CNS lymphomas are very sensitive to radiation) false false chemotherapy 44.1.10 1.8 to 3.3 months 10 months 41 months ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Lymphomas and Hematopoietic Neoplasms Multiple Myeloma 11. Complete the following about multiple myeloma (MM): a. It is a neoplasm of _____ _____ b. that produces _________. 12. The characteristic presentation for MM includes: a. i________ s________ to i___________ b. c. d. e. a______ h___________ b____ p____ r_____ f______ 13. The evaluation for patients with MM includes: a. s_____ r_______ s_____ b. C__ c. S____ d. A urine test for MM is done to identify i. k_____ B_____-J______ p_______ ii. found in _____% of cases. e. The most definitive test is b____ m______ b_____. 14. The treatment of MM includes: a. ______ b. b___________ c. m________ d. Some lesions may benefit from k_________. e. The median survival for untreated MM is ____ months. 277 44.2.1 plasma cells M-protein (monoclonal IgG or IgA) 44.2.3 increased susceptibility to infection anemia hypercalcemia bone pain renal failure 44.2.4 skeletal radiological survey (for “punched out” lesions) CBC SPEP kappa Bence-Jones protein 75% bone marrow biopsy XRT (MM is very radiosensitive) bisphosphonates mobilization kyphoplasty 44.2.5 6 months 44.2.6 44 Plasmacytoma 15. Regarding plasmacytoma. a. If a single lesion consistent with MM is found, it is called p________. b. In 70 to 80% this will progress to i. m______ m_______ in ii. _____ years. plasmacytoma 44.3.1 multiple myeloma 10 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 45 Pituitary Tumors – General Information and Classification General Tumor Types 1. Most pituitary tumors are benign tumors that arise from the a________. 2. Answer the following about pituitary tumors: a. By definition what is the maximal size of a pituitary microadenoma? b. Larger tumors are called ________. c. 50% of pituitary tumors are less than ________ mm. 3. Complete the following about pituitary carcinoma: a. Occurence is ________. b. They are usually i________. c. They are usually s________. d. The most common hormones are i. A________ ii. P________ e. True or false. They can metastasize. f. Prognosis of 1-year mortality is ________%. 4. Neurohypophyseal tumors are tumors of the _______ pituitary a. Occurrence is _______. 45 adenohypophysis 45.2.1 45.2.1 1 cm macroadenomas 5 mm 45.2.2 rare invasive secretory ACTH PRL True 66% posterior 45.2.3 rare Epidemiology 5. Epidemiology a. Pituitary tumors represent approximately _____% of intracranial tumors. b. They are most common in the ______ decades of life. 45.3 10% 3rd and 4th ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Pituitary Tumors – General Information and Classification c. True or false. The incidence is higher among females. d. Incidence is increased in MEA or MEN, especially type __. i. This has an ________ inheritance with _____ penetrance. ii. Also involves p_______ tumors and h______. iii. True or False. Pituitary tumors in this syndrome are usually nonsecretory. 279 false type I autosomal dominant; high pancreatic islet cell tumors; hyperparathyroidism true Clinical Presentation of Pituitary Tumors 6. Complete the following about clinical presentation of pituitary tumors: a. Hormone hypersecretion i. ________% of adenomas secrete active hormone. ii. prolactin ________% iii. growth hormone ________% iv. ACTH ________% v. thyroid-stimulating hormone (TSH) ________% b. Prolactin can cause ______-_______ syndrome in females and ________ in males. Etiologies for increased prolactin include: i. P___________, which is neoplasia of pituitary ________. ii. S_______ effect, which may reduce _______ control over PRL secretion. iii. With tumors that secrete prolactin, levels are usually > ________. c. Growth hormone i. If elevated it is due to a p________ a________ ii. more than _______% of the time. iii. Causes _______ in adults and ________ in prepubertal children. d. Corticotropin i. aka _______ ii. excess causes _______ _______ iii. Nelson syndrome can develop only in patients who have had _________. e. Thyrotropin (TSH) causes _______ hyperthyroidism. 45.5.2 65% 48% 10% 6% 1% amenorrhea-galactorrhea; impotence prolactinoma; lactotrophs stalk effect; inhibitory 1000 ng/ml pituitary adenoma 95% acromegaly; gigantism ACTH Cushing’s disease adrenalectomy 45 secondary (central) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 280 Part 13: Tumors Involving Non-Neural Origin 7. Complete the following about hormone hyposecretion: a. Due to _______ of the normal pituitary. b. In order of sensitivity to compression (Hint: go look for the adenoma) i. G_________ ii. L_________ iii. F_________ iv. T_________ v. A_________ c. Most common symptoms include o_______ h_______ and e_______ f_______. d. Selective loss of one hormone, consider a_______ h________. e. If diabetes insipidus is seen preoperatively, other etiologies should be sought including i. a______ h________ ii. h______ g________ iii. s________ g________ c_______ t________ 45 8. Complete the following about mass effect: a. The pituitary tumor that gains the greatest size i. is nonsecreting (true or false) ii. of the secreting type is the ________ b. The tumor that is usually the smallest is the _____ tumor. c. Structures commonly compressed: i. Optic chiasm classically causing __________ _________. ii. Third ventricle, which can cause _______ _________ iii. Cavernous sinus with pressure on the cranial nerves ________ causing: p_______. f_______ _______ d_______ 9. Patient presents with sudden onset of headache, visual disturbance, ophthalmoplegia, and reduced mental status. Complete the following: a. Consider diagnosis of p_______ a________. b. This may occur in macroadenomas in as many as _______ % 45.5.2 compression GH LH FSH TSH ACTH orthostatic hypotension; easy fatigability autoimmune hypophysitis autoimmune hypophysitis hypothalamic glioma suprasellar germ cell tumor 45.5.2 true prolactinoma ACTH bitemporal hemianopsia obstructive hydrocephalus III, IV, V1, V2, VI ptosis; facial pain; diplopia 45.5.2 pituitary apoplexy (due to expanding mass in sella turcica resulting from hemorrhage or necrosis) 3 to 17% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Pituitary Tumors – General Information and Classification 10. Complete the following about primary brain tumors: a. What are the indications for rapid decompression after pituitary apoplexy? i. severe constriction of _________ _______ ii. severe deterioration of _________ _______ iii. mental status changes due to ________ b. True or False. It is necessary to remove the entire tumor. c. What else needs to be done? 281 45.5.2 visual fields visual acuity hydrocephalus true treat with corticosteroids Specific Types of Pituitary Tumors 11. Complete the following about the anatomic classification of pituitary adenoma: a. Named the ____ system b. Suprasellar extension i. O: ______ ii. A: expanding into the _______ cistern iii. B: anterior recesses of third ventricle ________ iv. C: ________ of third ventricle ________ c. Floor of sella i. I: intact or ________ ________ ii. II: sella ________ d. Sphenoid extension i. III: localized ________ of sella floor ii. IV: diffuse ________ of sella floor 12. Complete the following about functional pituitary tumors: a. What is the most common functional pituitary tumor? b. What are its most common symptoms? i. In females: ________-________ ii. called the ________-________ syndrome iii. In males: ________ c. It arises from anterior pituitary l________. d. The most common cause of amenorrhea is p________. 45.6.1 Hardy none suprasellar obliterated floor; displaced focally expanded enlarged perforation destruction 45.6.2 prolactinoma amenorrhea-galactorrhea Forbes-Albright syndrome impotence lactotrophs 45 pregnancy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 282 Part 13: Tumors Involving Non-Neural Origin 13. Answer the following about Cushing’s syndrome: a. Which hormone? b. Hypersecretion is called ______ ______. c. Accounts for ___ - ___% of pituitary adenomas. d. Other causes of hypercortisolism are known as________ ________. e. List the clinical findings in Cushing’s syndrome: Hint: steroids i. s_________ ii. t____ _____ iii. e_________ iv. r____ _____ v. o_________ vi. i_______, ______ ______ vii. d_________ viii. s____ ______ 45 14. Complete the following about Nelson Syndrome: a. Follows bilateral a___________ in ___ ___% of cases. b. Classic triad includes i. h______________, ii. increase in _____________ and iii. enlargement of the p____________ tumor. iv. Usually occurs __ to ___ years after adrenalectomy. c. Hyperpigmentation is due to crossreactivity of m______ s________ h_______ and ___________. d. The earliest signs include i. l________ n________ ii. midline pigmentation from the pubis to u________ iii. and hyperpigmentation of s________, g________ and areolae. e. Has an ACTH level greater than ________ Ng/l. The normal being less than ________ Ng/l 15. Answer the following about acromegaly: a. > _____% of cases of excess GH result from pituitary ______ adenoma. b. Ectopic GH secretion may uncommonly occur with: i. c___________ t________ ii. l___________ iii. p__________ i_____-c______ t_________ 45.6.2 ACTH Cushing’s disease 10-12% Cushing’s syndrome striae thin skin ecchymosis reduced libido obesity impotence, increased BP diabetes skin hyperpigmentation 45.6.2 adrenalectomy; 10-30% hyperpigmentation ACTH pituitary 1 to 4 years melanocyte-stimulating hormone; ACTH linea nigra umbilicus scars; gingivae 200 54 45.6.2 95%; somatotroph carcinoid tumor lymphoma pancreatic islet-cell tumor ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Pituitary Tumors – General Information and Classification c. 25% of acromegalics have ________ with normal thyroid studies. d. Hypothalamus produces ________ which causes the pituitary to make _________. e. Excess GH induces _____ secretion from the liver, also known as __________. f. What medication can suppress GH release? g. Mortality rates are _____ to______ times the expected rate due to: i. c____________ ii. c____________ iii. d____________ iv. h____________ v. i_____________ vi. n____________ ______________ 16. Answer the following regarding TSHsecreting adenomas: a. Comprise of __ to __% of pituitary tumors. b. Produces _______ hyperthyroidism c. Elevated _____ and _______ levels with elevated or inappropriately normal _______. d. True or False. Most of these tumors are invasive and large enough to produce mass effect. e. Symptoms of hyperthyroidism include i. a___________ ii. p___________ iii. h___________ i__________ iv. h___________ v. w___________ l________ 17. Answer the following regarding pathology of pituitary tumors: a. Chromophobes are most common. May produce _________, ______, or ______. b. Acidophils produce _________, ________, ___________. c. Basophils produce ___________, ________, _____; ______ disease 18. Complete the following about tumors of the neurohypophysis and infundibulum: a. The most common tumor in the posterior pituitary is __________. b. The most common primary tumor is the _________ _______ _______ with a predilection for the _______. c. If this tumor is suspected, operative approach is ________ preferred over _________. 283 thyromegaly GHRH; GH IGF-1; somatomedin-C somatostatin 2 to 3 times cancer cardiomyopathy diabetes hypertension infection neural entrapment 45.6.2 0.5 to 1% central (secondary) T3 and T4; TSH true anxiety palpitations (due to a-fib) heat intolerance hyperhidrosis weight loss 45.6.2 prolactin, GH, or TSH prolactin, TSH, GH gonadotropins, β-lipotropin, ACTH; Cushing’s disease 45.6.3 45 metastatic granular cell tumor (GCT) stalk transcranial preferred over transphenoidal ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 46 Pituitary Adenomas – Evaluation and Nonsurgical Management Evaluation 1. Answer the following regarding visual field deficit patterns: a. The chiasm is located i. above the sella in ______% ii. posterior to the sella in ____% iii. anterior to the sella in ____ % b. Classic visual field deficit is b_______ h_______. c. Optic nerve compression is more likely with a p_______ chiasm. i. Loss of vision in _______ eye. ii. There is usually a _________ _________ in the ______ eye resulting from compression of the ___________. d. Compression of the optic tract may occur with ______ chiasm, producing _________ _________. 46 2. Answer the following regarding adrenal axis screening: a. Cortisol levels normally peak between __ - __ AM. b. ____ AM cortisol better for detecting ________. c. Levels < _____ suggestive of adrenal insufficiency. d. Levels between ___ and ____ are nondiagnostic. 46.1.2 79% 4% (postfixed chiasm) 5% (prefixed chiasm) bitemporal hemianopsia postfixed ipsilateral superior (temporal) quadrantanopsia; contralateral; anterior knee of Wilbrand. prefixed; homonymous hemianopsia 46.1.2 7-8 AM 8 AM; hypocortisolism 6 mcg/100 ml 6 and 14 mcg/100 ml ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pituitary Adenomas – Evaluation and Nonsurgical Management e. ________ is more accurate for _______ f. Normally, ____ dose dexamethasone suppresses release of _______ through negative feedback. i. 8 AM cortisol < _____ rules out Cushing’s syndrome in most patients. ii. Cushing’s syndrome is probably present with cortisol > ____. iii. _____ tumors and most cases of ectopic ACTH production will not suppress even with ____ dose dexamethasone. 3. Thyroid axis: a. Check ____ (total or free) and _____. b. Thyrotropin-releasing hormone (TRH) stimulation test is indicated if _______ or borderline. c. Chronic ______ ______ may produce secondary pituitary hyperplasia indistinguishable from adenoma. d. This is due to loss of ______ feedback from ______ ______ causing increase in release of _____ from the ______. e. Reduced response to TRH stimulation test indicates ______ ______. f. Etiologies for primary hyperthyroidism include i. localized hyperactive ______ ii. circulating ____ that stimulate the thyroid iii. _______ ______ ______ (AKA ophthalmic hyperthyroidism) 4. Hormone evaluation in acromegaly: a. _____ is the recommended initial test. b. Checking a single random ____ may not be a reliable indicator and is therefore not recommended. c. Normal basal fasting GH level is < ____ d. Oral glucose suppression test (OGST): i. Give ___ oral glucose load and measure _____. ii. If ____ nadir is not < _____, the patient has acromegaly. iii. GH suppression may be absent with _____________________. 285 24 hr urine free cortisol; hypercortisolism low dose; ACTH 1.8 mcg/dl 10 mcg/dl Adrenal; high dose 46.1.2 T4; TSH T4 primary hypothyroidism negative; thyroid hormone; TRH; hypothalamus secondary (pituitary) hypothyroidism thyroid nodule antibodies diffuse thyroid hyperplasia 46.1.2 IGF-1 GH 5 ng/ml 75 gm; GH GH; 1 ng/ml liver disease, uncontrolled DM, and renal failure 46 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 286 Part 13: Tumors Involving Non-Neural Origin 5. Inferior petrosal sinus sampling uses a microcatheter to measure ______ levels at baseline then at 2, 5, and 10 minutes after stimulation with IV ____. a. Baseline IPS ACTH to peripheral ACTH ratio ____ is consistent with primary Cushing’s disease. b. Post CRH ratio > ____ is also consistent with primary Cushing’s disease. c. Complication rate is ____ % including puncture of sinus wall. 6. A potent ACTH analogue ______ can be used to assess cortisol reserve. a. Give _______ and check cortisol levels at 60 mins. Normal response is peak level > ___ AND an increment > ____ or peak >_____ regardless of increment. b. Subnormal response indicates _______ _______. c. Response may be normal in mild cases of _______ _______ _______ or early after _______ ______ where ______ _______ has not occurred. 7. Complete the following about the insulin tolerance test: a. Insulin IV will promptly lower ________. b. Hypoglycemia is a ________. c. In response, the body produces c________. d. An increment in baseline more than ________ to a peak of ________ mg/dL is normal. e. Peak cortisol = _______: Steroids needed only for stress f. Peak cortisol < ___: Glucocorticoid replacement is needed. g. Cushing’s syndrome: Increment < _____ 46 ACTH; CRH 46.1.2 1.4:1 3 1-2% cosyntropin 46.1.2 cosyntropin; 18 mcg/dl; 7 mcg/dl; 20 mcg/dl adrenal insufficiency reduced pituitary ACTH; pituitary surgery; adrenal atrophy 46.1.2 blood glucose stressor cortisol 6 mg/dl; 20 mg/dl 16-20 mg/dl 16 mg/dl 6 mg/dl 8. Characterize the neurohypophysis on MRI. a. Normally on T1WI is ________ ________ high signal b. possibly because it contains p________. phospholipids c. Absence of this sign suggests d________ diabetes insipidus i_______. 46.1.2 9. For pituitary tumors, what is the benefit of coronal CT slices? a. sphenoid series ______ 46.1.2 b. sella floor _________ midline (can be identified by anatomy of sphenoid sinus septa) erosion (indicate presence of tumor on one side) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Pituitary Adenomas – Evaluation and Nonsurgical Management 287 Management/Treatment Recommendations 10. What is the medical treatment for the following? a. growth hormone-secreting tumors b. ACTH-secreting tumors c. prolactin-secreting tumors d. TSH-secreting tumors 11. Complete the following about nonsecreting pituitary adenomas: a. Usual treatment is ________ or ________. b. Bromocriptine may reduce tumor size in only ____% of patients c. Poor results are due to the paucity of ________ receptors. d. Octreotide reduces the tumor size in ________%. e. Follow-up by MRI at _______, ________, ________, and ________ years. 12. Complete the following on management of prolactinomas: a. Prolactin level < ____ in tumors not extensively invasive. Levels may be normalized with surgery. b. Prolactin level > _____: Chances of normalizing with surgery are very low. c. Medical management with _______. d. These drugs work by binding ______ receptors inhibiting synthesis and secretion of ______. e. Bromocriptine affects both _____ and _____ receptors. f. __________ is a selective ________ agonist. g. If response is satisfactory, it is recommended to treat for ___ to ___ years for microadenomas and check ______ yearly. h. If prolactin level remains > ___, consider surgery. 13. Management of acromegaly: a. ______ is currently the best initial therapy. b. _____ are used for initial medical therapy. c. _______ which is a GH antagonist may be used. octreotide ketoconazole bromocriptine octreotide 46.2.5 46.2.6 46.2.4 46.2.7 46.2.3 surgery or radiation 20% dopaminergic 10% 0.5, 1, 2, and 5 years 46.2.4 500 ng/ml 500 ng/ml dopamine agonists dopamine; prolactin D1 and D2 Cabergoline; D2 1 to 4 years; prolactin 50 ng/ml 46.2.5 Surgery 46 Somatostatin analogues Pegvisomant ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 288 Part 13: Tumors Involving Non-Neural Origin 14. Management of Cushing’s desease: a. __________ _________ is the treatment choice for most. b. Cure rates are ___ for microadenomas but lower for larger tumors. c. For medical therapy, _______ is an ______ that blocks adrenal steroid synthesis. d. What are the indications for total bilateral adrenalectomy? (4) e. Follow-up after bilateral adrenalectomy to rule out ____________ syndrome. 15. Management of TSH-secreting adenomas: a. First-line treatment is ________ ________. b. The tumor may be difficult to remove and ________. c. Medical treatment is with the same agent as for ________ namely, ________. 46.2.6 Transphenoidal surgery ~85% ketoconazole; antifungal agent non-resectable pituitary adenoma; failure of medical therapy/surgery; lifethreatening Cushing’s disease; Cushing’s disease with no evidence of pituitary tumor. Nelson’s syndrome 46.2.7 transphenoidal surgery fibrous acromegaly; octreotide Radiation Therapy for Pituitary Adenomas 16. True or False. Radiation therapy should be routinely used following surgical removal. false 46.3.3 46 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 47 Pituitary Adenomas – Surgical Management, Outcome, and Recurrence Management Surgical Treatment for Pituitary Adenomas 1. What is the medical preparation for surgery? a. Steroids _________ dose b. Hypothyroid patients ideally to be treated before surgery for ______ weeks. c. However, do not replace _____ ________ until the _____ _______ is assessed. Doing so may precipitate _______ ________. 2. Intraoperative disasters during transphenoidal surgery are usually related to ______ of ______. a. This may include injury of c______ _______ typically injured in lateral aspect of opening. b. Opening through the c_____ may cause erroneous biopsy of the p_____. c. Opening through floor of ______ _______ may cause injury to _____ _______ with entry into ______ _____ _____. d. The incidence of CSF rhinorrhea (fistula) is ___% 3. Answer the following regarding postoperative management: a. Avoid ______ _______, which can cause negative pressure on sphenoid sinus and aggravate ____ ____. b. What are diagnostic criteria for diabetes insipidus? c. Transient DI typically lasts ___ to ___ post-op then normalizes. 47.1.1 stress 4 weeks thyroid hormone; adrenal axis; adrenal crisis loss of landmarks carotid artery 47.1.3 clivus; pons frontal fossa; olfactory nerves; inferior frontal lobes 3.5% 47.1.4 47.1.6 incentive spirometry; CSF leak urine output > 250 for 1-2 hrs and SG < 1.005 ~12 to 36 hours 47 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 290 Part 13: Tumors Involving Non-Neural Origin d. Triphasic response involves the following three stages: i. _____ due to injury to _____ pituitary ii. ______ or _____ due to release of ____ from neuron endings from hypothalamus iii. ______ e. Taper and stop hydrocortisone ___ - ___ hrs post-op. Then check ____ AM cortisol. f. Cortisol level < _____ suggests ____ deficient. g. Cortisol level > ______ is normal. DI (short duration); posterior Normalization or SIADH; ADH DI (long-term) 24-48 hours; 6 AM 3 mcg/dl; ACTH 9 mcg/dl Outcome Following Transsphenoidal Surgery 4. Characterize the good outcomes of transphenoidal surgery: a. Vision is ________ ________. b. Cure attained in ___% of prolactinomas. c. Overall, ____% of all acromegalics had a biochemical cure. d. Cure rate among Cushing’s disease with microadenomas is ____%. e. Recurrence incidence is ____% with most recurring __ - __ years post-op. significantly improved 25% 50% 47.2.2 47.2.3 85% 12%; 4 to 8 years 47 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 48 Cysts and Tumor-Like Lesions Rathke’s Cleft Cyst 1. Describe Rathke’s cleft cyst (RCC) a. Where are the lesions located? b. How common are they? c. Do you find RCC together with pituitary adenomas? d. Why? e. Appearance on CT i. cystic? ii. density? iii. enhancement? f. Cell lining is described as s_____ l_____ c______ e_______ g. Cyst wall is _______. h. What is the surgical treatment? 48.1 intrasellar-pars intermedia incidental finding in 13-23% of autopsies no RCCs have a similar lineage to pituitary adenomas and are rarely found together. yes low density may have capsular enhancement single layer cuboidal epithelium thin partial excision and drainage Colloid Cyst 2. Complete the following regarding Colloid cyst: a. Usual age of diagnosis is ___ - ___ years. b. Most commonly found in ______ ______ in the region of _______ of ________. c. Pathognomonic hydrocephalus involving only ________ ventricles. d. On MRI, usually ____________ on T1 and __________ on T2. e. Symptomatic patients may be more likely to display T2 ________ cysts, indicating high ________ content, which may reflect a propensity for cyst expansion. f. LPs are _________ prior to the placement of shunt due to risks of ________. 20-50 years third ventricle; foramen of Monro lateral 48.2.1 hyperintense; hypointense hyperintense; water 48.2.4 contraindicated; herniation 48.2.2 48 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 292 Part 13: Tumors Involving Non-Neural Origin 3. Treatment for Colloid cysts: a. The nature of the obstruction requires b_______ ventricular shunting. Alternatively, one can use u__________ shunt with f__________ of the s_______ p_________. b. Transcallosal approach has higher incidence of v_________ infarction or f__________ injury. c. True or False. Transcallosal approach depends on dilated ventricles. d. Transcortical approach has higher incidence of p_________ s________. e. What are features of colloid cysts that correlate with unsuccessful stereotactic aspiration? i. high ____________ which correlates with ____________ on CT. ii. d____________ of the cyst from tip of aspirating needed due to ________ _____ 48 48.2.5 bilateral; unilateral; fenestration; septum pellucidum venous; forniceal false post-op seizures viscosity; hyperdensity deflection; small size Epidermoid and Dermoid Tumors 4. Complete the following regarding epidermoid and dermoid cysts: a. Both are d_____, b_____ tumors that may arise when retained _____ implants are trapped by two fusing ________ surfaces. b. Growth rate is l______ rather than e______ as with neoplastic tumors. c. Most common intracranial sites include i. s_________, which commonly produces b________ _______ and o________ a________. ii. S______ f_______, which may present with ___________. iii. C___________, which can produce _________ _______ especially in _______ patients. iv. b_________-p_____ ______, which can produce l_______ c_____ n_____ findings or _________ _______. v. Within the ________ system, particularly the ________. d. Within the spinal canal, most arise in the following locations: i. ____________ ii. ____________ 48.3.1 developmental, benign; ectodermal; ectodermal linear; exponential Suprasellar; bitemporal hemianopsia; optic atrophy Sylvian fissure; seizures CPA (Cerebellopontine angle); trigeminal neuralgia; young basilar-posterior fossa; lower cranial nerve; cerebellar dysfunction ventricular; 4th ventricle thoracic spine upper lumbar spine ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Cysts and Tumor-Like Lesions e. Epidermoids may occur iatrogenically following _________ _________. f. Dermoids of the spinal canal are usually associated with a d_______ s_______ t______, which can produce recurrent bouts of spinal __________. 5. Complete the following regarding epidermoid cysts: a. Usually arise from e_______ trapped within the _______. b. Also known as c__________, which is most often used to describe the lesion in _______ _____ where entrapped epithelium arises from chronic m_______ e_____ i____. c. Epidermoids are lined by _________ _______ epithelium and contain: i. ___________ ii. ___________ iii. ___________ d. Epidermoid cysts are sometimes mistaken for c_________ g________, which usually occur following c_________ i________. e. Rupture of cyst contents may cause recurrent episodes of _______ ________, which may also lead to __________. f. M__________ __________ is a rare variant of _________ which includes the finding of _______ ______ in the CSF. 293 lumbar puncture dermal sinus tract; meningitis 48.3.3 ectoderm; CNS cholesteatoma; middle ear; middle ear infections stratified squamous keratin cellular debris cholesterol cholesterol granulomas; chronic inflammation aseptic meningitis; hydrocephalus Mollaret’s meningitis; meningitis; large cells Craniopharyngioma 6. Complete the following regarding craniopharyngiomas: a. Usually develop from residual cells of _______ ______ and tend to arise from _______ _____ margin of the p__________. b. Some may arise primarily within the ______ ventricle. c. Fluid in the cysts usually contain c_______ c______. d. Peak incidence occurs during age ___ ____. 48.4.1 Rathke’s pouch; anterior superior; pituitary third cholesterol crystals 5 to 10 years 48 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 49 49 Pseudotumor Cerebri and Empty Sella Syndrome Pseudotumor Cerebri 1. Complete the following regarding pseudotumor cerebri: a. Diagnostic criteria: i. CSF pressure above ii. CSF composition iii. Symptoms and signs iv. Radiologic studies b. Severe visual defects occur in __ to ___% c. Best test to follow vision is _________. 2. Describe pseudotumor cerebri treatment. a. Withdraw patient from __________. b. Medications for treatment include: i. D________ ii. L________ iii. D________ c. Procedures to consider include i. serial L__________ ii. l__________ __________ iii. o______ _______ _________ 49.1.1 20 to 25 cm H2O normal protein, glucose, and cell count increased pressure normal CT and MRI 4 to 12% perimetry 49.1.9 OCPs (oral contraception pills) Diamox Lasix Dexamethasone LPs lumbo-peritoneal shunt optic sheath fenestration Empty Sella Syndrome 3. Complete the following regarding empty sella syndrome: a. Herniation of the _______ ______ into the _______ ________ can act as a mass, probably as a result for repeated ________ _______. b. Female:male ratio is _______. c. Associated with _______ and ________. d. Surgical treatment is usually _______ except in cases of ___________. e. Secondary causes include: i. t____________ ii. r______ of p_______ t_______ iii. increased i_________ _______ arachnoid membrane; sella turcica; CSF pulsation 49.2.2 5:1 obesity and hypertension not indicated; (CSF) rhinorrhea 49.2.3 trauma removal of pituitary tumor intracranial pressure ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 50 50 Tumors and Tumor-Like Lesions of the Skull Skull Tumors 1. The most common primary bone tumor of the calvaria a. is the o_________. b. It usually involves only the o______ t______. c. Lesions within ______ ______ may present with recurrent ________. d. The triad of Gardner’s syndrome: i. __________ ii. __________ iii. __________ 2. Complete the following regarding hemangiomas: a. They comprise ______% of skull tumors. b. The two types are c_______ (most common) and c________ (rare) c. Accessible lesions may be cured by e___ b____ e_____ or c________. 3. Complete the following regarding Langerhans cell histiocytosis: a. Most common presenting symptom is _______, ______ _______ _______. b. Most common site is the _______ bone. c. True or False. Involves both inner and outer tables. d. Can differentiate from hemangioma by abscess of _______ appearance. 4. Complete the following on chordomas: a. Chordomas are ______ tumors usually arising from c_______ or s_________. b. Derived from remnants of the p________ n_______ which normally differentiates into the ________ _______of i_________ d__________. 50.1.2 osteoma outer table air sinuses; sinusitis multiple cranial osteomas colonic polyposis soft-tissue tumors 50.1.3 7% cavernous; capillary en bloc excision; curettage 50.1.5 tender, enlarging skull mass parietal true sunburst 50.1.6 malignant; clivus or sacrum primitive notochord; nucleus pulposus; intervertebral disks ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 296 Part 13: Tumors Involving Non-Neural Origin c. Peak age of cranial chordomas is ____ to ____ years. d. Differential diagnosis of foramen magnum region tumors include: i. ____________ ii. ____________ 50 50 to 60 years chondrosarcomas chondromas Non-neoplastic Skull Lesions 5. Complete the following regarding hyperostosis frontalis interna: a. It’s a benign irregular nodular thickening of the _______ _______ of the ______ ______ that is almost always ____________. b. Associated with Morgagni’s syndrome which includes: i. h____________ ii. o____________ iii. v____________ iv. n____________ c. Endocrinologic abnormalities include: i. a____________ ii. h____________ d. Metabolic abnormalities include: i. h____________ ii. o____________ 6. Complete the following regarding fibrous dysplasia: a. It is a benign condition in which normal bone is replaced by ________ _______ _______. b. Most lesions occur in ________ or craniofacial bones, especially the _________. c. Can be part of ______-_______ syndrome. 50.2.2 inner table; frontal bone; bilateral headache obesity virilism neuropsychiatric disorders acromegaly hyperprolactinemia hyperphosphatemia obesity 50.2.3 fibrous connective tissue ribs; maxilla McCune-Albright syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 51 Tumors of the Spine and Spinal Cord 51 Compartmental Locations of Spinal Tumors 1. Compartment locations of spinal tumors and their incidence are a. extradural in ______% b. intradural extramedullary in ______% c. intramedullary in ______% d. Most metastases are __________. 55% 40% 5% extradural 51.5.3 Differential Diagnosis: Spine and Spinal Cord Tumors 2. Complete the following regarding extradural spinal cord tumors: a. Arise in ______ _______ or _______ tissue. b. Osteoblastic tumors indicate _______ _______ in men and ______ ______ ______ in women. 3. Aneurysmal bone cyst is a. an _________ lesion consisting of a highly vascular honeycomb of bloodfilled cavities separated by _________ _____ septa and surrounded by thin _________ _____ which may expand. 4. Most common intradural extramedullary tumors: a. m__________ b. n___________ 51.2 51.3.2 vertebral body; epidural prostate metastases; breast cancer metastases 51.3.2 osteolytic; connective tissue; cortical bone 51.3.4 meningiomas neurofibromas Intradural Extramedullary Spinal Cord Tumors 5. a. b. c. Characterize spinal meningiomas. Peak age is ___ - ___ years. The female:male ratio is ________. Main symptom is ___________. 51.4.1 40-70 years 4:1 local or radicular pain ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 298 6. a. b. c. 51 Part 13: Tumors Involving Non-Neural Origin Characterize spinal schwannomas. _________, _______ tumors. 75% arise from __________. Early symptoms are ________. Intramedullary Spinal Cord Tumors 7. The most common glioma of the lower cord, conus, and filum is __________. a. These tumors of the conus and filum are usually of the __________ subtype. 51.4.2 Slow-growing, benign dorsal rootlets radicular ependymoma 51.5.3 myxopapillary Primary Bone Tumors of the Spine 8. True or False. Regarding osteoid osteomas: a. They are benign lesions presenting less than 1 cm in size. b. Osteoid osteomas often degenerate into osteoblastomas. c. Osteoid osteomas occur more commonly in the pedicle than osteoblastomas. d. They are expansile destructive lesions. 9. The most common primary bone cancer is _________. a. More common in ________. b. In the spine, usually occurs in ______ region in males in their ________. c. Biopsy needle tract _________ the area. d. Survival is ________ months. 10. a. b. c. d. True or False. Vertebral hemangiomas are rare tumors. May be malignant. are often symptomatic. are radiosensitive. e. X-rays show v_________ s__________ f. or h__________ appearance. 11. Giant cell tumors of bone a. arise from __________. a. in the same category as ________ ______ _____. b. Almost always b______ with p__________ behavior. c. Radiation is controversial because of possibility of m________ d_________. 51.6.2 true false false false (Osteoblastomas are expansile destructive lesions.) osteosarcoma 51.6.3 children lumbosacral; 40s contaminates 10 51.6.4 false (occurs in 9-12%) false false true (used for the uncommon painful lesion that can’t be treated by excision or vertebroplasty) vertical striations honeycomb 51.6.5 osteoclasts aneurysmal bone cysts benign; pseudomalignant malignant degeneration ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 52 Cerebral Metastases Metastases to the Brain 1. Complete the following about cerebral metastases: a. The most common brain tumor is ________ _________. b. It will be multiple in _______% on MRI. c. In patients with no cancer history, cerebral metastases are the presenting symptom in ____% d. The route of metastatic spread to the brain is usually h_________ although l_______ e_______ can occur. e. The highest incidence of parenchymal metastases is _______ to the Sylvian fissure, likely due to embolic spread to terminal _____ branches. 52 52.2 cerebral metastases 70% 15% hematogenous; local extension posterior; MCA 52.4 Metastases of Primary CNS Tumors. Location of Cerebral Metastases: Clinical Presentation 2. Complete the following about brain tumors: a. Which primary CNS tumors spread via the CSF? i. g____________ ii. e____________ iii. P____________ iv. p____________ b. The most common primary brain tumor responsible for extraneural spread is m___________. c. Solitary brain metastases are the most common p_______ f_______ tumor in adults. 52.3.1 glioma ependymoma PNET pineal tumors medulloblastoma 52.3.2 posterior fossa 52.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 300 Part 13: Tumors Involving Non-Neural Origin d. Spread to this location may be via _________ _______ plexus and v_________ v________. e. Hemorrhage occurs in i. m_________ ii. c__________ iii. r__________ 52 epidural venous plexus (Batson’s plexus); vertebral veins 52.6 melanoma choriocarcinoma renal cell carcinoma Primary Cancers in Patients with Cerebral Metastases 3. a. b. c. Sources of cerebral mets in children: n____________ r_____________ W____________ 4. Where do brain metastases come from? a. l__________ b. b__________ c. r__________ d. i__________ t________ e. m_________ 5. Complete the following about small cell lung cancer: a. aka o________ c________ cancer b. Strongly associated with ________. c. Reaction to radiation is very __________. d. The most common type of non-small cell lung cancer is __________. 6. Complete the following about metastatic melanoma: a. Longevity after detected in the brain is ______ days. b. Unless it is a single melanoma metastasis, then patient may live _____ years. c. True or False. Melanoma is responsive to chemotherapy and radiation. d. With chemotherapy for melanoma, the gold standard is d_______. e. Immunotherapy that is as effective as chemotherapy is a vaccine: M_______ f. Patients with Karnofsky performance scale (KPS) score < ______ are likely to be poor surgical candidates. 52.5.1 neuroblastoma rhabdomyosarcoma Wilm’s tumor 52.5.1 lung (44%) breast (10%) renal (7%) intestinal tract (6%) melanoma (3%) 52.5.2 oat cell smoking (tobacco) sensitive adenocarcinoma 52.5.3 113 3 years false dacarbazine Melacine 70 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Cerebral Metastases Management 7. Highly radiosensitive brain metastases include: a. s_________ _________ _____ b. g__________ _________ c. l___________ d. l___________ e. m__________ 8. Metastatic tumors highly resistant to radiation therapy include: a. t_________ b. r_________ _________ c. m________ d. s_________ e. a_________ 9. Complete the following regarding radiation therapy for cerebral metastases: a. The standard dose is i. ______ Gy in ii. ______ fractions over iii. ______ weeks. b. After the usual dose of radiation therapy, what percentage of patients develop dementia at i. 1 year: ______% ii. 2 years: _____% 301 52.8.5 small-cell lung Ca germ-cell tumors lymphoma leukemia multiple myeloma 52.8.5 thyroid renal cell melanoma sarcoma adenocarcinoma 52 52.8.5 30 10 2 11% 50% Carcinomatous Meningitis 10. Complete the following about carcinomatous meningitis: a. Symptoms include ______ and _________ ________ dysfunction. b. CSF is eventually abnormal in _____%. c. What size sample of CSF is needed? d. Survival is ______ months without treatment and ___ to ___ months with treatment. e. Always include l___________ m__________ in the differential diagnosis. headache; cranial nerve 95% at least 10 cc of CSF 2 months; 5 to 8 months 52.10.2 lymphomatous meningitis 52.10.1 52.10.3 52.10.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 53 Spinal Epidural Metastases 53 General Information 1. Complete the following regarding spinal epidural metastasis (SEM): a. It occurs in ______% of all cancer patients. b. It most commonly arises from i. l______ ii. b________ iii. p_____________ iv. m__________ v. l________________ c. One route of metastasis to the spine is by B________ p_______. d. The site of metastasis is p_________ to the length of the segment of spine. e. First symptom is usually i. p______ which is ii. worse in r__________. 53.1 10% lung breast prostate myeloma lymphoma Batson’s plexus (spinal epidural veins) proportional pain recumbency Evaluation and Management of Epidural Spinal Metastases 2. Complete the following regarding conus medullaris SEM and cauda equina lesions: a. Conus medullaris lesions i. spontaneous pain ii. sensory deficit iii. motor loss iv. autonomic symptoms v. reflexes vi. onset b. Cauda equina lesions i. spontaneous pain ii. sensory deficit iii. motor loss iv. autonomic symptoms v. reflexes vi. onset Table 53.2 rare saddle, bilateral symmetric prominent early only ankle jerk absent sudden and bilateral severe, radicular saddle, may be unilateral asymmetric late ankle and knee jerk may be absent gradual and unilateral ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Spinal Epidural Metastases 3. Complete the following regarding SEM: a. Outcome depends on p__________ n___________ s_______. b. Grade i. mild ii. moderate iii. severe iv. complete c. Treatment for patient with new symptoms consists of i. d_________ ii. s_________ iii. r_________ 4. Complete the following about MRI scans in SEM: a. They detect multiple sites of cord compression in ____%. b. They are _____ on T1WI. c. They are ______on T2WI. 5. True or False. Regarding diagnostic imaging: a. MRI i. is the diagnostic test of choice. ii. Tumor extension into the spinal canal is common when the patient presents with local back pain. b. Plain x-ray i. Most spinal mets are osteolytic. ii. Plain x-rays are abnormal as soon as there is bone erosion. c. CT-myelo i. can obtain CSF. ii. is invasive. iii. will demonstrate paraspinal lesions. iv. may require C1-C2 puncture. 6. Regarding the management of SEM: a. Group I i. Signs/symptoms? ii. When do you evaluate? b. Group II i. Signs/symptoms? ii. When do you evaluate? presenting neurological status 303 53.4.2 Table 53.3 patient can walk can move legs, but not antigravity slight residual motor and sensory function no motor, sensory, or sphincter function below level of lesion 53.4.4 53 decadron surgery radiation 53.4.3 20% hypointense hyperintense 53.4.3 true false true false true true false true 53.4.4 rapid progression or severe deficit immediately mild and stable admit and evaluate within 24 hrs ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 304 Part 13: Tumors Involving Non-Neural Origin c. Group III i. Signs/symptoms? ii. 53 pain without neurologic involvement as an outpatient over several days When do you evaluate? 7. What is the treatment for SEM? a. Chemotherapy is _________. b. Vertebroplasty/kyphoplasty reduces pain by _____%. c. radiation treatment i. How soon after diagnosis? ii. After surgery? d. pre-op embolization i. appropriate for _______ ___________ tumors ii. such as r_____ c____ iii. t_______ iv. h____________ 8. Regarding surgery for SEM: a. relative contraindications: i. r___________ t_______ ii. t______ p__________ > __ hours iii. expected survival: < ___ - ___ m_________ iv. m_________ l________ at m_______ l__________ b. indication for surgery: i. greater than ________% block ii. r_____ p__________ c. other indications: i. u________ p_________ ii. r______-r________ t______ 9. a. b. c. d. Characterize surgical treatment: Laminectomy is a _____ treatment because it ________ the spine. it is better to do surgery _____________ and add ______________. 53.4.5 ineffective 84% within 24 hours within 2 weeks highly vascular renal cell thyroid hepatocellular 53.4.5 radiosensitive tumors total paralysis > 8 hours <3-4 months multiple lesions at multiple levels 80% rapid progression unknown primary radio-resistant tumors 53.4.5 poor destabilizes anteriorly instrumentation ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 54 General Information, Grading, Initial Management General Information 1. In GCS <8, surgical lesions make up ___. With significant head injury, be weary of ___ spine fractures. 25%; C1-C3 54.1.1 2. With significant head injury, delayed deterioration occurs in ___ %. 75% of these will have an i______ h_______. 15%; intracranial hematoma 54.1.2 Grading 3. a. b. c. d. e. f. 54 Match with mild-moderate-severe GCS 14 Focal Neurological defect GCS 15 + Impaired Alertness or memory GCS 5-8 LOC > 5min GCS 15 + Brief LOC 54.2 mild moderate mild severe moderate mild Management in E/R SBP <90 mm Hg; 4. Hypotension (defined as ____) and hypoxia (defined as apnea, cyanosis or PaO2 <60 mm Hg; PaO2 ____), can ____ the risk of bad triple outcome. 54.4.1 5. Decerebrate or decorticate posturing will usually be _____ to the blown pupil. contralateral Table 54.2 6. Sedatives and paralytics should be used for i____ h____, i____, t____. intracranial hypertension, intubation, transport 54.4.1 7. Trauma intubation practice guidelines GCS ___. GCS<8 54.4.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 306 Part 14: Head Trauma 8. True or False. a. Peri-procedural antibiotics reduce risk of pneumonia and decreases length of stay or mortality. b. Hyperventilation should be used prophylactically for severe head trauma patients. 9. Ideal PaCO2 should be ____. 10. Hyperventilation can cause ______ (increase or decrease) protein binding of calcium and develop _____ (hyper or hypo) calcemia with tetany. 54 11. Regarding mannitol use. a. Contraindication to mannitol is h_____ or h_____. b. In patients with CHF, consider pretreating with ____ due to transient ______ (increase or decrease) of intravascular volume. 12. True or False. a. AEDs are effective in decreasing early and late post-traumatic seizures. 13. True or False. The following conditions have an increased risk of posttraumatic seizures (PTS): a. penetrating brain injuries b. intracranial bleeding c. GCS >13 d. alcohol abuse e. subgaleal bleed 14. Name the condition associated with the following signs: a. postauricular ecchymosis: b____ s____ f_____ b. bruit over globe of eye: c____ c______ f____ c. instability of the zygomatic arch: f____ f____ d. bruit over carotid artery: c_____ d_____ 54.4.1 false (does not alter length of stay or mortality) false 30-35mm Hg 54.4.1 increase; hypocalcemia 54.4.1 54.4.1 hypotension or hypovolemia furosemide; increase 54.4.1 false (only early) Table 54.3 true true false (GCS < 10) true false 54.4.2 basal skull fracture carotid cavernous fistula facial fracture (LeFort) carotid dissection 15. CN ___ palsy occurs with increased ICP VI (Abducens) and clival fractures. 54.4.2 16. Which has higher risk of intracranial injury? a. frontal or occipital fractures? b. upper or lower facial fractures? 54.4.3 occipital upper ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 General Information, Grading, Initial Management Radiographic Evaluation 17. CT findings a. Subdurals are usually ____ in shape, and ____ (do or do not) cross suture lines. b. Pneumocephalus indicates likely underlying s____ ____. c. Traumatic SAH has blood thickest in ______ (circle of Willis/Convexity) and aneurysmal has blood thickest in ______ (circle of Willis/convexity) 54.5.1 crescentic; do not skull fracture Convexity; Circle of Willis Patients with Associated Severe Systemic Injuries 18. Patients with multi-system injuries should receive ____ ____ ____ or ____ ____ before receiving a CT scan of the head. 19. a. b. c. Fat embolism clinicial triad: a____ r____ f_____ g____ n___ d_____ p____ r____ diagnostic peritoneal lavage or FAST scan 54.7.1 54 54.7.2 acute respiratory failure global neurologic dysfunction petechial rash 20. What are the four segments of the optic nerve and their relative length (in mm)? a. i_____________, ___ mm b. i_____________, ___ - ___ mm c. i_____________, ___ mm d. i_____________, ___ mm 21. Which is optic nerve segment is most commonly damaged? 307 54.7.3 intraocular, 1 mm intraorbital, 25-30 mm intracanalicular, 10 mm intracranial, 10 mm intracanalicular 54.7.3 ipsilateral 54.8.1 Exploratory Burr Holes 22. Placement of an emergency burr hole should be ________ (ipsilateral or contralateral) to the blown pupil. ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 55 Concussion, High Altitude Cerebral Edema, Cerebrovascular Injuries Concussion 1. By definition, a concussion typically has _____ imaging studies. 55 2. True or False. The determination of concussion requires a. loss of consciousness from closed head injury. b. brain swelling on computed tomography (CT) of the head. c. altered consciousness as a result of a closed head injury. d. nausea and vomiting after being hit in the head. 3. fMRI may be useful in mTBI, by showing dysfunction in f____ l____ compared to control patients. 4. Complete the following about concussion: a. In concussion, what brain chemical changes in concentration? b. Does it go up or down? c. What mechanism becomes impaired? d. It may predispose to m________ c________ e________ e. and make the patient susceptible to s________ i________ s________. normal 55.1.4 55.1.7 false false true false frontal lobe 55.1.8 55.1.9 glutamate up cerebral autoregulation malignant cerebral edema second impact syndrome 5. Impaired metabolic state from a concussion can last __ - __ days after injury. 7-10 days 55.1.9 6. Post concussive syndrome occurs in ___ - ___% of cases, and often occurs within ___ weeks of injury, and remains ____ after onset of symptoms. 10-15% 4 >1 month 55.1.10 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Concussion, High Altitude Cerebral Edema, Cerebrovascular Injuries 7. True or False. When should a player return to the game after a mild concussion? a. the same day b. only after resolution of symptoms c. only after CT shows no injury d. only after being able to walk or run without difficulty e. Steroids should be the primary pharmacologic treatment in PCS. 8. True or False. The second impact syndrome (SIS) a. is rare. b. requires two head injuries. c. results from cerebral edema. d. is responsible for the policy that “no symptomatic player plays.” e. can have severe consequences. 9. Complete the following regarding SIS a. SIS has a mortality of ___ to ____%. b. What treatment is effective for SIS? 309 55.1.12 false true false false (A symptomatic patient should not return to competition.) false 55.1.13 true true true true true 55.1.13 50 to 100% (Second impact syndrome [SIS] mortality occurs in athletes who sustain a second head injury while still symptomatic from an earlier injury. They usually walk off the field, then deteriorate into a coma within minutes.) none—condition may be refractory to all treatment 55 Other TBI Definitions 10. Regarding contusion. a. Low attenuation areas in a TBI in contusions represent e____. b. High attenuation areas represent h______. 11. In posttraumatic brain swelling, increased cerebral blood volume occurs from loss of c___ v___ a___, and has a mortality rate near ____%. 12. Match symptoms mild-moderatesevere for diffuse axonal injury (DAI). a. Coma 2 hours b. Coma 30 hours c. flexor and extensor posturing with coma for months d. coma with dysautonomia 55.2.1 edema hemorrhage cerebral vascular autoregulation; 100% 55.2.3 Table 55.6 none moderate severe severe ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 310 55 Part 14: Head Trauma High-Altitude Cerebral Edema 13. In your last trip to Machu Picchu in the high Andes you notice that the passenger sitting beside you in the train starts gasping for air and complains of severe headaches. Within minutes he becomes confused and minutes later becomes paralyzed. You suspect high altitude pulmonary edema (HAPE) with or without cerebral edema (HACE). a. You pull out your handy ophthalmoscope and find in the fundus: i. p________ ii. r________ h________ iii. nerve fiber layer i________ iv. vitreous h________ b. This is compatible with the diagnosis of h________ a________ c________ e________. c. Prevention i. g_______ a________ ii. Avoiding E_______ + h_______ d. Treating cerebral edema i. i______ d____ ii. o________ iii. s________ 14. At the upcoming neurosurgical meeting in the Rockies, one of your colleagues presents with acute onset of inappropriate behavior, hallucinations, ataxia, and reduced mental status. If the breathalyzer is negative, what diagnosis should you consider? a. At 7000 ft you would be correct ________% of the time. b. At 15,000 ft you would be correct ________% of the time. 55.3 papilledema retinal hemorrhages infarction hemorrhage HACE—high altitude cerebral edema (A milder case of acute high altitude sickness [AHAS] that presents without ocular findings is called HAPE.) gradual ascent ETOH + hypnotics immediate descent 6-12 L/min O2 steroids may be of use High altitude cerebral edema 55.3 25% 50% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Concussion, High Altitude Cerebral Edema, Cerebrovascular Injuries 311 Traumatic Cervical Artery Dissections 15. Your family medicine colleague called you after his visit to the chiropractor, and he complains of expanding neck, a whooshing sound in the neck, and some left hemiparesis. a. What are you concerned about? c___ cervical artery dissection a___ d___ b. How did this occur? t___ s___ m___ therapeutic spinal manipulation c. What test should you order and within CT Angiogram, within 12 what time frame? hours (if presence of BCVI would alter therapy, and no contraindication to heparin) d. Which test is technically the gold catheter angiogram standard? 16. Complete the following about blunt cerebrovascular injuries (BCVI): a. The usual injury is ________. b. It occurs in ___ - ___% of BCVI patients. c. Mortality occurs in ________%. d. Which is a better test: MRI or CTA? e. Treatment is with h________ or occasionally with e________ techniques. 17. Traumatic fractures for blunt cerebrovascular injury (BCVI): a. L__ f____ b. b___ s___ f___ c. cervical fractures involving ___ dissection 1-2% 13% CTA heparin; endovascular 55.4.1 55.4.1 55.4.2 55.4.1 55.4.5 55.4.6 Table 55.7 Leforte fracture II or III basilar skull fracture C1-C3 18. Carotid artery dissection occurs in __% 1-2%; of blunt trauma patients, and has a 13%; 1/3 __% mortality rate, and about _____ are untreatable. 55.4.2 19. Denver grading scale for BCVI. Match description with appropriate grade. a. pseudoaneurysm b. transection with free extravasation c. luminal irregularity with <25% stenosis d. intraluminal thrombus or raised intimal flap, >25% luminal stenosis e. occlusion Table 55.9 20. a. b. c. Match the treatment with the grade. endovascular occlusion ASA or Heparin Heparin and repeat MDCTA or catheter angiogram in __ - __ days d. urgent surgical repair if accessible 55 III V I II IV 55.4.6 IV I or II III, 7-10 days V ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 312 Part 14: Head Trauma 21. In grade V BCVI dissections, if lesion is inaccessible, treatment should be a. for complete transections: _____ or ______ e________ b. for incomplete transection s________ 55 55.4.6 ligate or occlude endovascularly stenting (possible endovascular stenting with concurrent antithrombotics) 22. Post-injury CTA for grade III was assessed, and the lesion was found to be healed. What is the next step? discontinue anticoagulation 55.4.6 23. If a post-injury CTA shows incomplete lesion, consider ___ (continuing heparin or transitioning to ASA) and do a repeat imaging in ___ months. transitioning to ASA; 3 months 55.4.6 24. PTT goal for heparinization should be ___ - ___ seconds. After trauma, contraindications to anticoagulation are a. i____ h____ b. l___ and s____ injuries c. p____ f_____ 40-50 seconds 55.4.6 intracerebral hemorrhage liver and spleen injuries pelvic fractures 25. Carotid artery dissections occur most commonly in _____, and the mechanism involves both h_____ and l____ r____ of the neck. MVA (motor vehicle accidents); hyperextension; lateral rotation 26. True or False. Regarding carotid dissections. a. Most carotid dissections occur at the ICA/ECA origin. b. Internal bleeding is the most common symptom. c. Pseudoaneurysm tends to be more favorable than an incomplete stenosis in patients with ICA dissection. 27. What is the odds ratio for vertebral artery dissection caused by spinal manipulation? 28. Fractures/injuries often associated with blunt vertebral artery injuries are a. f_____ t______ fractures b. fractures-dislocation of the _____ c. v______ s______ d. any type of c____ s____ injury 55.4.7 55.4.7 false: often 2cm distal to the ICA origin false: ischemic symptoms are the most common false: pseudoaneurysm stroke risk is 44% and most will persist despite heparin therapy 6.62R 55.4.7 55.4.8 foramen transversarium facet vertebral subluxation cervical spine ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Concussion, High Altitude Cerebral Edema, Cerebrovascular Injuries 29. Complete the following regarding blunt vertebral artery injury: a. Most common etiology is ________. b. Treatment to strongly consider is ________ c. because strokes were ________ in those patients not treated. d. Incidence is ____ - ____% but e. increases to ________% if cervical fracture or ligament injury. f. Is there a warning “TIA”? g. Can occur from ________ hours to ________ days. h. Is any cervical fracture pattern a predictor of blunt vertebral injury? i. Overall mortality was ________% j. Bilateral VA dissection is highly ________. 313 55.4.8 motor vehicle accident heparin more frequent 0.5-0.7% 6% no 8 hours to 12 days no 16% fatal 30. Vertebral artery dissection time from injury to stroke ranges from __ hours to __ days. 8 hours to 12 days 55.4.8 31. Treat all blunt vertebral injuries with ___, and restudy chronic occlusion in __ months. ASA; 3 months 55.4.8 55 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 56 Neuromonitoring Intracranial Pressure (ICP) 1. The critical parameter for brain function is adequate c___ b___ f____ to meet C___ demands. 2. CPP formula is CPP = _________ 56 cerebral blood flow; CMRO2 demands 56.2.2 56.2.2 CPP = MAP – ICP 3. Normal CPP is _____ and would have to drop below _____ in a normal brain before CBF is impaired. >50mm Hg <40mm Hg 56.2.2 4. If your computer does not give you mean arterial pressure (MAP) how can you calculate it? (Hint: dds/3) *MAP = [systolic + (diastolic x 2)] / 3 56.2.2 5. If CPP is kept in good range, is ICP above 20 mm Hg well tolerated? No, it is detrimental 56.2.2 6. Complete the following: a. The modified ________ hypothesis states that b. the sum of the intracranial volumes of ________, ________, and ________ c. and other components is ________. d. An increase in any one must be ________ e. by an equal ________ in another f. or else ________ will rise. g. Pressure is ________ ________ throughout the intracranial cavity. 7. Increased muscle tone and valsalva lead to an a. ______ (increase or decrease) in ICP, by b. ______ (increased or decreased) intrathoracic pressure, leading to c. ______ (increased or decreased) jugular venous pressure, leading to d. ______ (increased or decreased) venous outflow from head. 56.2.3 Monroe-Kellie blood, brain, and CSF constant offset decrease pressure distributed evenly 56.2.5 increase increased increased decreased ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neuromonitoring 8. Complete the following regarding intracranial hypertension: a. What is Cushing’s triad? i. h______ ii. b______ iii. r_____ i______ b. Risk factors for IC-HTN with a normal CT: i. age ____ ii. SBP ____ iii. motor exam shows _____________. c. Neurologic Indications for ICP monitoring: GCS of ___ and _____ or ________________. Table 56.2 hypertension bradycardia respiratory irregularity Table 56.3 age >40 SBP <90 decerebrate or decorticate posturing GCS < 8 and abnormal CTH or > risk factors for IC-HTN 56.2.6 9. An important non-traumatic indication for some centers to choose to monitor ICP is a____ f____ l____ f____ with INR ____ and Grade III of IV coma. acute fulminant liver failure; INR > 1.5 56.2.6 10. These patients frequently require ______ prior to administration of subarachnoid bolt. Bolt placement should occur no more than ____ hours after administration. factor VII 40 mcg/kg IV over 1-2 min; 2 hours 56.2.6 11. A criterion for discontinuing ICP monitoring is normal ICP for ________ to ________ hours. 48 to 72 hours 56.2.6 12. Delayed onset IC-HTN may often start on day ___ with a second peak at days ___ - ___. day 2-3; day 9-11 – especially in peds 56.2.6 13. True or False. In regard to ICP monitoring, it is permissible to a. use antibiotics b. not use antibiotics c. place monitor in ICU d. place monitor in OR e. Percentage of patients who develop hemorrhage while ICP is being placed is 1.4%. 14. True or False. a. EVDs should be changed every 5 days to reduce rate of infection. b. Subarachnoid bolts are more accurate with higher pressures. 315 56 56.2.6 true true true true true 56.2.6 false – Does not reduce infection rate false – Surface of brain may occlude lumen, which often show lower than actual ICP, and possible normal waveform. ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 316 Part 14: Head Trauma 15. Complete the following regarding conversion of mm Hg and cm H2O: a. Can only work if the AF is concave with the infant upright, and convex when head is flat. b. Requires the patient to be in supine position. c. When the anterior fontanelle is flat, the ICP equals atmospheric pressure. d. The ICP can be estimated in mmHg as the distance from the AF to the point where venous pressure is 0. 16. Complete the following regarding conversion of mm Hg and cm H2O: a. 1 mm Hg equals ________ cm of H2O b. 1 cm H2O equals ________ mm of Hg c. External auditory canal correlates with what intracranial structure? 17. Maximum output from a ventriculostomy would be ___ - ___ml per day, where none of the CSF is absorbed. 56 18. True or False. If an external ventricular catheter no longer functions, the following can be performed safely: a. lower drip nozzle b. verify clamps are open and air filter is dry c. flush distal tubing with saline d. flush IVC with up to 5 mL of saline under gentle pressure 19. True or False. Possible causes of an ICP wave form that is dampened include the following: a. occlusion of the catheter proximal to the transducer b. catheter pulled out of ventricle c. collapsed ventricle d. air in the system e. intracranial hypertension 20. ICP waveform in a patient with a decompressive craniectomy should appear _____. 56.2.6 true true true false (cm H2O) 56.2.6 1.36 cm .735mm foramen of Monro 450-700ml 56.2.6 56.2.6 true true true false (up to 1.5ml of preservative-free saline can be used) 56.2.6 true true true false false dampened 56.2.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neuromonitoring 21. Regarding normal ICP waveforms. a. Blood Pressure variations i. Large (1-2mm Hg) peak corresponds to the a____ s___ p___ w___ with smaller and less distinct peaks ii. followed by a peak corresponding to the c____ v___ a____ from the right atrium. b. Respiratory variations i. During expiration, pressure in superior vena cava _____ (increases or decreases), which _______ (increases or decreases) venous outflow. 56.2.6 arterial systolic pressure wave central venous "A" wave increases; decreases (Expiration causes an increase in SVC pressure which decreases venous outflow leading to increased ICP.) 22. a. b. c. Lundberg A waves are defined by ICP of ________ duration of ________ plus ________ >50mm Hg 5-20 min increase in MAP 23. a. b. c. Lundberg B waves are defined by ICP of ________ duration of ________ plus ________ 10-20mm Hg 30 secs to 2 minutes periodic respiration 56.2.6 56.2.6 56 Adjuncts to ICP Monitoring 24. An indication for jugular venous oxygen (SjVO2) or brain tissue oxygen tension monitoring (pBtO2) is ______. hyperventilation (pCO2 = 2025) 56.3.1 25. Jugular venous pressure is representative of g____ oxygen content and is insensitive to f____ pathology. global; focal 56.3.1 26. Normal jugular venous oxygen saturation (SjVO2) is _____ and desaturations to ____ suggest ischemia. > 60%; < 50% 56.3.1 27. Brain tissue oxygen tension monitoring shows death increases with sustained pBtO2 of _____ or brief drop to ___ mmHg. pBtO2 <15mm Hg; pBtO2 <6mm Hg 56.3.2 28. Goal is to maintain pBtO2 above ___. pBtO2 >25mm Hg 56.3.2 29. pBtO2 probe placement. Name the correct diagnosis for the following techniques: a. frontal (2-3cm off midline) b. c. d. e. near the site of hemorrhage least injured side 3cm lateral to midline 4.5-5.5 cm off midline 317 56.3.2 ACA or A-comm aneurysm (near the vasospasm risk) ICH TBI ACA-MCA watershed MCA ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 318 Part 14: Head Trauma 30. Treatment tier based on low pBtO2 a. Tier 1 i. keep body temp ____ C ii. increase CPP to ___ mmHg b. Tier 2 i. increase FIO2 to ____ % ii. increase PaCO2 to _____ mmHg iii. transfuse RBC until Hgb ____ g/dl c. Tier 3 i. increase FIO2 to ____ % ii. decrease ICP to ___ mmHg iii. consider increase in___ if FIO2 @ 100% 31. Bedside monitoring of regional CBF can be limited if patient has a f_____. 56 56.3.2 temp <37.5 C increase CPP to >60mm Hg FIO2 to 60% PaCO2 45-50mm Hg Hgb >10g/dl FIO2 100% ICP <10 mm Hg PEEP fever 56.3.3 Treatment Measures for Elevated ICP 32. a. b. c. d. e. Acute ICP crisis - Measures a __ b___ c___ e________ h________ of b________ n____ m_____ d___ C___ if IVC present m________ 1g/kg bolus or ____ 1020ml f. h________ g. sedation with p____ or t____ Table 56.6 airway breathing circulation elevate head of bed neck midline drain CSF mannitol or 23% saline hyperventilate pentobarbital or thiopental 33. Patients with hemorrhagic contusion with progressive deterioration may benefit from s______ e_____. surgical excision 56.4.4 34. Cushing ulcers are caused by s___ h___ i____ and increased I___. severe head injury; increased ICP 56.4.4 35. Fluid volume goal is e________, even with mannitol. euvolemic 56.4.4 36. If ICP remains refractory to mannitol consider h___________ s_________. hypertonic saline 56.4.4 37. Avoid aggressive hyperventilation, with goal PaCO2 at___, and avoid in the first ____ hours after injury if possible. PaCO2 goal 30-35; 24 hours 56.4.4 38. Before proceeding with "second tier" therapy, consider repeating a H____, and possible E____ to rule out s_________ s_________ e_________. repeat head CT; EEG to rule out subclinical status epilepticus 56.4.4 39. Decompressive craniectomy should have a flap at least __cm in diameter, and d____ is mandatory. 12 cm; duraplasty 56.4.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neuromonitoring 40. PEEP of < ___ does not cause clinically significant increases in ICP. If needed for oxygenation, consider increasing the f_____ of ventilation. <10 cm H2O; frequency 56.4.4 41. Prophylactic hypothermia. If used, 32-35C; target temperature is ___ - ____ C, and mortality; a non-significant decrease in m_____ if >48 hours maintained ___ hours. 56.4.4 42. In the first 24 hours of head injury, CBF (cerebral blood flow); C____ is already about h___ of normal. half 56.4.4 43. Hyperventilation a. Avoid use in the first ___ days, and at least in the first __ hours. b. Do not use HPV p________. c. If used in IC-HTN, your PaCO2 goal should be ___ - ___. d. If prolonged HPV deemed necessary, consider monitoring of S___, A___, and o/r C___ is recommended. e. Do not reduce below ____. 56.4.4 44. Mannitol a. First reduces IC HTN by r______, by reducing h____ and b____ v____ then by its o____ e_____. b. When dosing mannitol, it’s important to use the s____ e_____ d_____ as it reduces effectiveness of subsequent doses. c. Mannitol can be enhanced using f_____ as it may reduce c____ e_____ and slow p_____ of C____. 45. Hypertonic saline a. Can be given as a ____ continuous infusion or ___ - ___ bolus through a central line. b. Hold if serum osmolarity is _____. 46. Steroids a. Not effective in c_____ edema seen in trauma, but reduces v____ edema seen in brain tumors. 47. Barbiturate therapy is recommended only if IC-HTN is refractory to maximal m___ and s___ ICP lowering therapy. a. Main limiting factor is h_________. b. True barbiturate coma requires b____ s________ on E___. 319 5 days, and at least in the first 24 hours prophylactically 30-35 SjVO2, AVdO2, CBF < 25cc 56.4.4 rheology; hematocrit and blood viscosity; osmotic effect smallest effective dose 56 furosemide; cerebral edema; slow production of CSF 56.4.4 3%; 7.5-23.4% >320 mOSm/L 56.4.4 cytotoxic edema; vasogenic edema medical and surgical 56.4.4 hypotension burst suppression on EEG ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 57 Skull Fractures Depressed Skull Fractures 1. Indications for surgery in open skull fractures: a. Depressed skull fracture that causes a n_______ d_____. b. c____ s____ f___ l____ c. i______ p_____ d. if depression is greater than __ cm or is greater than the ___________________ e. Involvement of the f_____ s___. f. c______ d______ 2. Indications for surgery in depressed skull fractures: a. Depression greater than ___ cm or greater than the t____ of c____ b. i_____ or g_____ c_____ 57 57.3.1 neurological deficit cerebral spinal fluid leak intradural pneumocephalus 1cm; thickness of the calvarium frontal sinus cosmetic deformity 57.3.2 1 cm; thickness of calvaria infection or gross contamination 3. For contaminated fractures, when excision of depressed bone is necessary, it is recommended to soak fragment in p____ i___. povidone iodine 57.3.2 4. The superior sagittal sinus is often to the ____ of the sagittal suture. right 57.3.2 Basal Skull Fractures 5. Temporal bone fracture considerations: a. More common temporal bone fracture is the l___________ fracture, through the p_____-s____ suture and parallel to and through the EAC. b. Peripheral facial nerve palsy may be associated with t_____ p____ fracture due to stretching of the g_______ g______ 57.4.2 longitudinal fracture; petrosquamosal suture transverse petrous fracture; geniculate ganglion ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Skull Fractures c. Which fracture damages hearing? transverse fracture (horizontal) 6. Facial EMG’s after posttraumatic unilateral peripheral facial nerve palsy often takes ____ hours to become abnormal. 72 hours 57.4.2 7. True or False. Glucocorticoids have false been proven to improve the functional outcome of traumatic facial nerve palsy. 57.4.2 8. Clival fracture considerations: a. T_____ a____ can occur with basal skull fractures involving the clivus. b. A____ c____ vessels may be affected in _____ ________. c. Cranial nerve deficits ___ through ___ and b_______ h_______ d. Pituitary shear damage associated with d______ i______ e. C____ l______ f. b_________ i__________ 57.4.2 9. Most sensitive test for detecting skull base fractures is ____. 10. Complete the following regarding basal skull fractures: a. True or False. Pneumocephalus may be seen on plain skull x-rays. b. Postauricular ecchymosis is called ________. c. True or False. Anosmia can be associated with temporal bone fractures. d. Sixth nerve palsy can occur with ________ fracture. 11. True or False. The following are clinical signs of basal skull fracture: a. CSF otorrhea or rhinorrhea b. hemotympanum c. depressed level of consciousness d. Battle’s sign e. injury to cranial nerve VII 321 Traumatic aneurysms Anterior circulation, transverse fractures CN III through VI; bitemporal hemianopsia diabetes insipidus CSF leak brainstem infarctions CT scan 57.4.3 true 57.4.3 Battle’s sign 57.4.4 57 false (with frontal bone fracture) clival 57.4.4 true true false true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 322 Part 14: Head Trauma 12. Management considerations: a. Do NOT place n___ t___, which can be fatal in ____% of cases if passed intracranially. b. Surgery should be considered for i. t_____ a___ ii. posttraumatic c____ c____ f_____ iii. CSF f_____ iv. c______ d______ v. posttraumatic f___ p___ 14. Matching. Match the type of LeFort fracture with the structures involved. Type of fracture: ① LeFort I; ② LeFort II; ③ LeFort III Structures involved: (a-g) below a. maxilla b. inferior orbital rim c. orbital floor d. nasofrontal suture e. zygomatic arches f. zygomaticofrontal suture g. pterygoid plates traumatic aneurysms posttraumatic cavernous carotid fistula CSF fistula cosmetic deformities posttraumatic facial palsy Craniofacial Fractures 13. Frontal sinus fractures a. Anesthesia of the forehead may be due to s______ and/or s________ nerve involvement. b. Mucocele formation is due to obstruction of the f_______ d____ or chronic inflammation. c. Only packing the sinus increases the risk of i_____ or m_______ formation 57 57.4.5 nasogastric tube; 64% 57.5.1 supratrochlear and/or supraorbital nerve frontonasal duct infection or mucocele formation 57.5.2 ① ② ②, ③ ②, ③ ③ ③ ③ Pneumocephalus 15. Compartments where pneumocephalus can be located in: a. e_____ b. s____ c. s_____ d. i_____ e. i____ 57.6.2 epidural subdural subarachnoid intraparenchymal intraventricular 16. Craniotomy: risk is higher when sitting patient is operated with surgery in the s_____ position. 57.6.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Skull Fractures 17. Congenital skull defects may result in pneumocephalus especially if the defect includes the t_____ t____. 18. Tension pneumocephalus might occur if a. n________ o________ anesthetic is used. b. c________ air is trapped. c. b________ v________ opening occurs. d. g________-p________ organisms are present. 19. True or False. The presence of intracranial air may produce a characteristic sign known as a. empty delta sign b. Mt. Hashimoto sign c. Dawson sign d. Mt. Fuji sign e. gas gap 20. Treatment of pneumocephalus. a. ____% O____ for significant or symptomatic post-op pneumocephalus b. e_____ of tension pneumocephalus tegmen tympani 323 57.6.2 57.6.5 nitrous oxide cool ball valve gas-producing 57.6.6 false false false true false 57.6.7 100% O2 evacuation 57 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 58 Traumatic Hemorrhagic Conditions Posttraumatic Parenchymal Injuries 1. Bifrontal decompressive craniectomy within ____ hours of injury is a treatment option with diffuse, medically refractory posttraumatic cerebral edema and associated ICHTN. 58.1.1 Hemorrhagic Contusion 2. a. b. c. 58 48 hours Surgical evacuation indications: m _____ r_____ IC-HTN or mass effect TICH volume _____ ml GCS ____, with f____ or t____ contusions with ___ mm MLS and or c______ b______ c______. 3. True or False. Regarding delayed traumatic intracerebral hemorrhage (DTICH). a. The patient typically has GCS ≤ 8. b. Incidence is ≈ 10%. c. Most DTICHs occur within 72 hours of trauma. d. Some patients initially appear well and then deteriorate. e. Coagulopathy contributes to DTICH. 4. The following factors contribute to formation of delayed traumatic intracerebral hemorrhage: a. systemic ________ b. hemorrhage into an area of n_____ b____ c. coalescence of extravasated m______ 58.2.2 medically refractory 50ml 6-8; frontal or temporal; > 5; compressed basal cisterns 58.2.3 true true true true true 58.2.3 coagulopathy necrotic brain microhematomas ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Traumatic Hemorrhagic Conditions 325 Epidural Hematoma 5. Complete the following: a. Incidence of epidural hematoma is ________% of all head injuries. b. Incidence of subdural hematoma is ________% of all head injuries. c. Epidural hematoma male to female ratio is ________. d. Epidural hematoma arise from arterial bleeding in ________%. e. Epidural hematoma patients develop a dilated pupil in ________%. f. ________% are ipsilateral. g. ________% had no loss of consciousness. h. ________% had no lucid internal. i. Mortality of epidural hematoma is ____ ____. 6. True or False. Regarding epidural hematomas (EDHs). a. The source of bleeding is arterial 99% of the time. b. Women are more commonly affected. c. EDHs are rare before age 2. d. The anterior meningeal artery is the most common cause of the bleeding. e. Patients with epidural hematomas can present with an ipsilateral hemiparesis. 7. What is Kernohan notch phenomenon? a. Compression of the ________ b. cerebral peduncle on the ________ c. which can produce _______ ________ hemiparesis to the intracranial mass lesion. 8. True or False. Concerning epidural hematomas. a. A dilated pupil is not a good localizing sign as to the hematoma location. b. It occurs in more than 15% of head trauma admissions. c. No initial loss of consciousness occurs in 60%. d. No lucid interval occurs in 20%. e. In pediatric head trauma, EDH should be suspected if there is a 10% drop in hematocrit after admission. 58.3.1 1% 2% 4:1 85% 60% 85% 60% 20% 20-55% 58.3.2 false (85% of the time) false (Men are more commonly affected—4:1.) true (EDHs are rare before years or greater than 60 years.) false (middle meningeal artery) true 58.3.2 58 contralateral tentorial notch ipsilateral hemiparesis false (It is a good sign.) 58.3.2 false 1% 58.3.1 true 58.3.2 true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 326 Part 14: Head Trauma 9. True or False. A 5-year-old girl presents to the emergency room (ER) with a chief complaint of brief posttraumatic loss of consciousness after several hours of playing with her siblings. While she is being worked up in the ER, you get a call from your frantic intern who reports that the patient is now obtunded. You would expect the following signs and symptoms and would include the following statistics in your presumed diagnosis: a. early bradycardia b. Kernohan’s notch phenomenon c. 85% occurrence of associated ipsilateral pupillary dilation d. a crescent-shaped high density lesion on CT 10. What is the mortality rate of EDH? 58 11. Nonsurgical treatment: a. is possible if size is less than ________ and b. patient’s symptoms are ________. c. What may happen between days 5 and16? d. An epidural hematoma thicker than ________ cm should have surgery. e. To document resolution repeat CT in ___ to ___ months. f. A volume of less than ________ cc. 12. Complete the following about delayed epidural traumatic hematoma (DEPTH): a. It may occur in as many as ___ - ____% of epidural hematomas. b. It may be related to increasing the patient’s ________ c. or reducing the patients ________, d. especially following surgical removal of another ________. e. ________ is another predisposing factor. 58.3.2 false (Early bradycardia is included in the differential diagnosis of posttraumatic disorder described by DennyBrown. Late bradycardia may be seen in your presumed diagnosis, epidural hematoma.) true (Ipsilateral hemiparesis has been described in EDH.) true (60% of patients with EDH have a dilated pupil and 85% will be ipsilateral to the hematoma.) true 58.3.4 20 to 55% 58.3.5 58.3.6 1 cm mild increase in size of the hematoma 1cm 1 to 3 30 58.3.7 9-10% BP ICP epidural Coagulopathy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Traumatic Hemorrhagic Conditions 13. True or False. Regarding posterior fossa epidural hematoma. a. Nearly 85% will have an occipital skull fracture in adults. b. Dural sinus tears are common. c. Abnormal cerebellar signs are common. d. Overall mortality is over 25%. e. They represent ~5% of EDH. 327 58.3.7 true true false true true Acute Subdural Hematoma 14. Regarding acute subdural hematomas (ASDH). a. There is more likely to be an underlying brain injury with an ASDH than with an EDH. b. On CT, an ASDH typically appears crescentic in shape. c. One cause of ASDH is the accumulation of blood around a parenchymal laceration. d. A “lucid interval” may be present. 15. Complete the following about acute subdural hematomas: a. Patient on anticoagulation therapy has a greater chance of ASDH i. if the patient is male: ____ fold ii. if the patient is female: ____ fold iii. How many days until the subdural membrane begins to form? 16. a. b. c. d. CT scan in ASDH and time frame acute: ~ ___ - ___ days subacute: ~___ days to ___ - ___ wks chronic: ____ wks to ___ - ___ months lenticular shaped: ___ - ___ months 17. SDH Treatment a. Surgical indications i. ASDH thickness ___ mm or MLS ___ ii. Do a c_____ not a b___ h___ b. Surgical indications for smaller ASDH i. GCS drops by _____ ii. and/or pupils are _____ or fixed and dilated. iii. ICP is _____ c. Timing of Surgery i. Ideally should be operated on within ____ hours. 58.4.1 true true true true 58.4.2 7 26 4 Table 58.1 58 1-3 days 4 days to 2-3 weeks >3 weeks and <3-4 months 1-2 months 58.4.3 > 10mm or >5 craniotomy not a burr hole 2 points asymmetric > 20 4 hours ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 328 Part 14: Head Trauma 18. True or False. Regarding mortality from ASDH. a. Mortality from an acute subdural hematoma (ASDH) ranges from 50 to 90%. b. Mortality is from the ________ ________ ________. c. Mortality is higher in young people. d. Medication that increases mortality is ________. 19. Interhemispheric subdural hematomas a. In children, consider c_____ a____. b. In adults, usually due to t_____ and can also occur with r_____ a______. c. What is falx syndrome? d. What symptoms can it manifest? (Hint: psadlo) i. p________ ii. s________ iii. a________ iv. d________ v. l________ difficulties vi. o________ palsies 58 58.4.4 true underlying brain injury (and not from the extraaxial bleed) false (Mortality thought to be higher in elderly patients.) anticoagulants 58.4.5 child abuse trauma; ruptured aneurysms paresis or focal seizures contralateral to the hematoma paresis seizures ataxia dementia language oculomotor 20. True or False. Regarding infantile acute subdural hematoma. a. Often involves loss of consciousness with false initial injury. b. Skull fractures are often seen. false c. Often presents with g____ s____ after generalized seizure injury. 58.4.5 21. Treatment of IASDH a. For minimimally symptomatic cases, you can consider p______ s____ t____. 58.4.5 percutaneous subdural tap Chronic Subdural Hematoma 22. What are the risk factors for chronic SDH? (Hint: catss falls) a. c________ b. a________ c. t________ d. s________ e. s________ f. f________ 58.5.1 coagulopathies alcohol abuse trauma shunts seizures falls ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Traumatic Hemorrhagic Conditions 23. Techniques that promote continued drainage after immediate procedure and prevent re-accumulation: a. Lay the patient f____. b. Place generous burr hole under the t____ m_____. c. Use of a s_____ d_____. d. Possible l_____ s_______ i_____ . 24. For twist drill craniotomies for chronic subdurals, a. a ventricular catheter is placed into the s_____ space. b. ventriculostomy bag is placed ____ below the ______ ______. c. Catheter is removed when at least _____ of collection is drained and when patient shows signs of improvement which occurs within _____ days. 25. Complete the following regarding chronic subdurals: a. Repeat surgery is needed in ________%. b. Is the use of a drain recommended? c. With a drain the need to repeat surgery is reduced to ________%. 26. Complete the following about chronic subdural hematoma outcomes: a. Persistent fluid at 10 days: ________% b. Persistent fluid at 40 days: ________% c. How long till full resolution? d. One operation is successful in ________% of patients e. Two operations are successful in ________% of patients. 27. What are the complications of surgical treatment of chronic SDH? (Hint: hherps) a. h________ b. h________ c. e________ d. r________ e. p________ f. s________ 329 58.5.4 flat temporalis muscle subdural drain lumbar subarachnoid infusion 58.5.4 subdural 20 cm; craniotomy site ~20%; 1-7 days 58.5.4 19% Yes 10% 58.5.5 78% 15% May take 6 months 80% 58 90% 58.5.5 hemorrhage hyperemia empyema reexpansion failure pneumocephalus seizures ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 330 Part 14: Head Trauma Spontaneous Subdural Hematoma 28. What are the risk factors for spontaneous subdural hematomas? a. h______ b. v_____ m______ c. n______ d. i_______ e. s______ a_______ f. h_______ g. C_______ h. i_____ h_______ 29. In spontaneous SDH, bleeding sites were often a____, often involving c_____ branch of ___. hypertension vascular malformations neoplasms infection substance abuse hypovitaminosis coagulopathies intracranial hypotension arterial; cortical branch of MCA 58.6.3 yes yes; 39% no CSF 58.7.1 Traumatic Subdural Hygroma 30. Complete the following regarding formation of subdural hygromas: a. Are they associated with trauma? b. Do skull fractures occur? ________ c. Do they have membranes? d. Fluid on CT is similar to ________. e. They are created by i. a____ t_____ and ii. b_____ v_____ f_____ f. Can be associated post-meningitis often by ______ (species). g. Recurrent subdural hygromas may benefit from a s____ p____ s_____. 58 58.6.1 58.7.4 58.7.2 arachnoid tear ball valve flap haemophilus influenzae meningitis effusion subdural-peritoneal shunt 58.7.5 Extraaxial Fluid Collections in Children 31. List the differential diagnosis of extraaxial fluid collections in children. a. a________ s________ b. b________ s________ c. c________ s________ d. c________ a________ e. c________ d________ f. e________ h________ 32. What is the mean age of presentation of extraaxial fluid collections of infancy? 58.8.1 acute SDH in a child with low Hct benign subdural (extraaxial) collections of infancy chronic symptomatic extraaxial fluid collections cerebral atrophy external hydrocephalus (EH) craniocerebral disproportion external hydrocephalus 4 months 58.8.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Traumatic Hemorrhagic Conditions 33. What is the treatment of benign extraaxial fluid collections of infancy? a. o________ b. p________ p______ e________ c. h________ c________ d. Most will ________ e. by ________. 34. What are the treatment options for symptomatic chronic extra-axial fluid collections in children? (Hint: otb sp) a. o________ b. t________ c. b________ d. s________ p________ s________ 331 58.8.2 observation (Most cases resolve spontaneously within 8 to 9 months and require no treatment.) periodic physical examination (Repeat physical exam to identify development of symptoms.) head circumference every 3 to 6 months (Orbital-frontal head circumference [OFC] should be done at 3- to 6month intervals to monitor head growth that should parallel normal growth and approach normal at 1 to 2 years. resolve 1-2 years 58.8.3 observation with serial orbital frontal head circumferences, ultrasound at least one percutaneous tap should be done to rule out infection burr-hole drainage ± external drainage subdural to peritoneal shunt (unilateral with extremely low pressure valve) 58 Traumatic Posterior Fossa Mass Lesions 35. Complete the following about traumatic posterior fossa mass lesions: a. Head injury that involves the posterior fossa is less than ________%. b. The majority are e________ h________. c. Parenchymal hemorrhages can be managed nonsurgically if they are less than ________ cm in diameter. d. Posterior fossa lesions meeting surgical criteria should be evacuated ______. 58.9 3% epidural hematoma 3 asap ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 59 Gunshot Wounds and Non-Missile Penetrating Brain Injuries Gunshot Wounds to the Head 1. True or False. Regarding gunshot wounds (GSWs). a. GSWs represent 35% of all deaths from brain injury in the older population (> 45). b. GSWs are the most lethal type of head injury; one fourth die at the scene. c. 90% of victims die. 59 59.1.1 false (35% under 45 die) false (2/3 die) true 2. For GSWs to the head, the mechanisms of injury include (Hint: Capone gang shootings land in the East River) a. c________ b. g________ c. s________ d. l________ e. i________ f. e________ g. r________ cavitation, coup-contrecoup gas shock waves low pressure impact explosive ricochet 3. Cerebral abscess from penetrating wounds can occur from r____ c____ m_____ and p____ c____ with n____ s______. retained contaminated material, persistent communications with nasal sinuses 4. General initial management in penetrating head injuries a. C____ b. evaluation for a_____ i____ c. s_____ i_____ p_____ d. f____ r_____ 5. Patients with little CNS function in absence of s_____ are unlikely to benefit from craniotomy. 59.1.2 59.1.4 59.1.6 CPR additional injuries spine injury precautions fluid resuscitation shock 59.1.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Gunshot Wounds and Non-Missile Penetrating Brain Injuries 6. If surgical intervention is necessitated, a. devitalized tissue around entry and exit wound should be e_____. b. air sinuses should have mucosa e_______. c. ensure tight d_____ c_____. d. cranioplasty should be delayed ___ - ___ months. 333 59.1.6 excised exenterated dural closure 6-12 months Non-Missile Penetrating Trauma 7. True or False. a. It is appropriate to remove the protruding foreign body as soon as possible. b. Consider pre-op angiography if object passes near a large named artery or the dural sinuses. c. They have a higher risk of contamination than missile injuries. d. Prophylactic antibiotics are recommended. e. Post-operative arteriograms are recommended. 59.2.3 false (stabilize object and only consider removal in the OR) true true true true (to rule out traumatic aneurysm) 59 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 60 Pediatric Head Injury General Information 1. Complete the following regarding children hospitalized for trauma: a. What percentage have head injury? 75% b. The overall mortality is ___ - ___%. 10-13% c. If presenting with decerebrate posturing, 71% mortality is ________%. Home Observation 2. A child with a GCS 14, who is neurologically stable with a negative CT, may be appropriate for h_____ o_____. 60 60.1 home observation 60.2.2 Cephalhematoma 3. Indicate if cephalohematoma is more consistent with subgaleal hematoma or subperiosteal hematoma. a. Bleeding is limited by sutures. b. Do not calcify. c. May lead to significant loss of circulating blood volume. d. More commonly seen in a newborn, associated with parturition. 60.4.1 subperiosteal hematoma subgaleal hematoma subgaleal hematoma subperiosteal hematoma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Pediatric Head Injury 4. True or False. A mother brings a 5-dayold baby, born via vaginal delivery, with a large, right-sided, soft scalp swelling that stops at the suture. You should a. percutaneously aspirate the lesion. false (Cephalohematoma is most commonly seen associated with parturition. 80% resorb usually within 2 to 3 weeks. Avoid the temptation of puncturing the lesions because the risk of infection exceeds cosmetic benefits.) b. tell the mother that 50% of these calcify. false c. tell the mother that the baby may develop jaundice as late as age 10 days. d. surgically excise the lesion. e. consider child abuse. f. treat this differently if the soft area crosses sutures. 335 60.4.1 true (Infants may develop hyperbilirubinemia and jaundice as blood is resorbed from this cephalohematoma [subperiosteal hematoma] as late as 10 days after onset.) false (Surgery is considered only after 6 weeks if a CT demonstrates calcifications.) true (Child abuse needs to be considered always.) false (called subgaleal hematoma) Skull Fractures in Pediatric Patients 5. Complete the following regarding growing skull fracture: a. Leptomeningeal cysts result from a combination of two injuries: i. s________ f________ ii. d________ t________ b. Why does it grow? c. If early growth of a fracture line with no subgaleal mass, do _____ in ___ - ___ months to rule out p_______ f_______. d. What is a treatment for true PTLMC? 6. What are the surgical indications for pediatric simple depressed skull fracture? a. d_____ p____ b. c_____ d______ c. f_____ n______ d______ 60.5.2 skull fracture dural tear intact arachnoid pulsates and eventually expands X-ray; 1-2 months; pseudo-growing fracture 60 surgery 60.5.3 dural penetration cosmetic defect focal neurologic deficit consistent with the site of fracture ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 336 Part 14: Head Trauma 7. Fill in the blank regarding ping pong ball fractures a. Usually seen in _____. newborns b. Often no treatment necessary in absence temporoparietal region of underlying brain injury when it occurs in the t________ region 60.5.3 Nonaccidental Trauma (NAT) 8. Answer the following regarding child abuse: a. True or False. There are pathognomonic findings in child abuse. b. Suspicious findings are i. r________ h________ ii. b________ c________ s________ h________ iii. s________ f________ 9. Retinal hemorrhage differential diagnosis: a. c___ a____ b. b_________ s_________ e________ in i_________ c. a_____ h____ a____ s____ d. a_____ increase in I_____ e. P_____ r______ 10. In skull fractures, the most common bone affected is the p_____ bone, and can be missed in clinical exam due to o_____ h______. 60.6.1 false retinal hemorrhage bilateral chronic subdural hematomas skull fractures 60.6.3 child abuse benign subdural effusion in infants acute high altitude sickness acute increase in ICP Purtscher’s retinopathy parietal bone; overlying hematoma 60.6.4 60 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 61 Head Injury: Long-Term Management, Complications, Outcome Airway Management 1. Early tracheostomy can reduce the days of m_______ v_______ but does not reduce m_______. 61.1 Deep-Vein Thrombosis (DVT) Prophylaxis 2. The risk of developing DVT in untreated severe TBI is ____%. mechanical ventilation; mortality 20% 61.2 Nutrition in the Head-Injured Patient 3. Nutritional replacement should begin within ____ hours of post-trauma patients with full caloric replacement by ______. 72 hours; by day 7 61.3.1 4. IV nutrition has increased risk of h_______ and i_______ compared to enteral nutrition. hyperglycemia and infection 61.3.3 5. What is the incidence of clinically symptomatic hydrocephalus after traumatic SAH? 12% 61.4.1 6. Hydrocephalus ex vacuo is v______ e______ due to atrophy secondary to _____ ______ _____ in TBI patients. ventricular enlargement; diffuse axonal injury 61.4.2 Posttraumatic Hydrocephalus 61 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 338 Part 14: Head Trauma 7. When should a shunt be considered in posttraumatic hydrocephalus? a. e_____ p____ on 1 or more LPs b. p______ c. t______ a______ elevated pressure papilledema transependymal absorption Outcome from Head Trauma 8. The basal cisterns is evaluated on axial midbrain; quadrigeminal CT scan at the level of the m______, cistern, 2 lateral limbs and 3 limbs, which are ______. (posterior portion of the ambient cisterns) 61.5.2 9. Compression of the basal cisterns is associated with a ____ fold risk of _______ ______. 61.5.2 3 fold risk; increased ICP 10. Midline shift measurements are done foramen of Monro at the level of the f______ of M______. 61.5.2 11. Complete the following: a. What is the genotype associated with head injury? b. It is also a risk factor for A_____ d_____. 61.5.2 apolipoprotein E4 allele Alzheimer’s disease Late Complications from Traumatic Brain Injury 12. The three most common symptoms associated with postconcussive syndrome are: a. h______ b. d_____ c. m_____ d____ 13. Treatment for postconcussive syndrome is generally s_____. 61 61.4.3 14. Neuropathology in chronic traumatic encephalopathy shows a. n________ t________ and b. a________ a________. c. These changes are similar to A________ disease, however the n_______ t______ are more s_______ in CTE. 61.6.2 headache dizziness memory difficulty supportive 61.6.2 61.6.3 neurofibrillary tangles amyloid angiopathy Alzheimer’s disease; neurofibrillary tangles; superficial ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Head Injury: Long-Term Management, Complications, Outcome 15. True or False. Chronic traumatic encephalopathy is more likely in boxers who a. have more than 20 fights. b. fight for more than 10 years. c. have the apolipoprotein E4 allele d. have cerebral atrophy. e. have cavum septum pellucidum. f. It is also known as d________ p________. 339 61.6.3 true true true true true (13%, may be acquired condition) dementia pugilistica 61 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 62 General Information, Neurologic Assessment, Whiplash and Sports-Related Injuries, Pediatric Spine Injuries Introduction 1. Complete the following: a. What must you look for in a patient with a major spinal injury? b. It occurs in ________%. 20% Terminology 2. Complete the following: a. In spinal cord injury, any residual motor or sensory function more than three segments below the level of injury represents an ________ lesion. b. Signs of this being the case include i. s________ ii. v________ m________ s________ s________ 62 62.1 a second spinal injury c. Types of this lesion include these syndromes: i. c________ c________ ii. B________-S________ iii. a________ c________ iv. p________ c________ 62.2.3 incomplete sensation (include position sense) voluntary movement in the lower extremities; sacral sparing (Preserved sacral reflexes alone do not qualify as incomplete injury. Also requires preserved sensation around the anus or voluntary rectal sphincter contraction, or voluntary toe flexion.) central cord syndrome Brown-Séquard syndrome anterior cord syndrome posterior cord syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 341 3. A complete spinal cord lesion a. is defined as no i. m________ or ii. s________ function iii. t________ levels below lesion. b. What percentage of patients with no function on initial exam will develop some recovery within 24 hours? c. A complete spinal cord injury that persists for 72 hours indicates what? 4. Complete the following regarding spinal shock: a. hypotension: i. interruption of s________ a________ ii. loss of v________ t________ iii. implies injury above which level? b. bradycardia: unopposed p________ activity c. relative hypovolemia: i. loss of ________ ii. resulting in ________ ________ d. true hypovolemia: loss of ________ e. neurogenic spinal shock is: i. transient loss of _____ ii. resulting in _________ iii. loss of ______ reflex 62.2.3 motor sensory three 3% No distal recovery will occur. 62.2.3 sympathetic activity vascular tone T1 parasympathetic muscle skeletal tone below injury venous pooling blood neurological function flaccid paralysis, loss of reflexes bulbocavernosus Whiplash-Associated Disorders 5. What is the most common nonfatal automobile injury? 6. Describe the five grades of whiplashassociated disorders and clinical evaluation of each. a. Grade 0 i. clinical ii. radiological studies iii. treatment b. Grade 1 i. clinical ii. radiological studies iii. treatment c. Grade 2 i. clinical ii. radiological studies iii. treatment whiplash 62.3.1 Table 62.1, Table 62.2, Table 62.3. no complaint none required none neck pain no x-rays optional collar/rest (not more than 72 hours) 62 reduced ROM/point tenderness flexion-extension x-rays optional collar/rest (not more than 96 hours) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 342 Part 15: Spine Trauma d. Grade 3 i. clinical ii. radiological studies iii. treatment e. Grade 4 i. clinical ii. radiological studies iii. treatment f. What percentage of whiplash injuries recover within 1 year? neurological deficits CT/MR treatment as SCI fracture/dislocation CT/MR treatment as SCI 76% Pediatric Spine Injuries 7. Complete the following about pediatric spine injuries: a. Due to ligamentous laxity together with ligamentous immaturity of paraspinal muscles and underdeveloped uncinate processes, pediatric spinal injury tends to involve ________ injuries. b. In the age group ≤ 9 years, the________ cervical spine is the most vulnerable segment. c. Of all cervical spine injuries in the upper 3 pediatric population, 67% occur in the ________ segments of the cervical spine. 8. Complete the following about pediatric spine injuries: a. “Pseudospread of the atlas” is a phenomenon occurring in children – but it could be confused with what kind of fracture? b. Normal total offset of the total overlap of 2 C1 lateral masses on C2 on AP open mouth view is i. ____mm at 1 year of age ii. ____mm at 2 years of age iii. ____mm at 3 years of age iv. and should never be more than ____mm 62 Table 62.4 9. Answer the following about Jefferson fractures: a. True or False. Jefferson fractures are common in pediatric cervical spine injury. b. They are more common during the ________ years. 62.4.1 62.4.3 62.4.3 Jefferson fracture 2 4 6 8 62.4.3 false teenage ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 343 Sports-Related Cervical Spine Injuries 10. Complete the following about football-related cervical spine injuries: a. stinger i. involves ________ ii. represents ________ b. burning hands i. involves ________ ii. represents ________ c. neuropraxia i. involves ________ ii. represents ________ iii. must rule out ________ iv. by performing an ________ 11. Complete the following: a. A football player who uses his helmet as a battering ram is called a ________. b. What evidence may be present on his spine x-rays? i. loss of ________ ii. evidence of ________ iii. presence of ________ c. When may the athlete resume play? 12. True or False. Contact sports are permitted in a. Klippel-Feil with symptoms b. Klippel-Feil without symptoms c. spina bifida d. status post-anterior cervical discectomy and fusion (ACDF) 1 level e. status post-ACDF 2 levels f. status post-ACDF 3 levels 62.7.2 one extremity compression of root bilateral upper extremities mild central cord syndrome all four extremities cervical cord injury cervical stensosis MRI 62.7.2 spear tackler lordosis prior trauma cervical spinal stenosis when lordosis returns Table 62.7 false true true true false false Neurological Assessment 13. Complete the following: a. Cervical nerves exit ________ their likenumbered vertebra. b. Thoracic and lumbar nerves exit ________ their like-numbered vertebra. c. For a segment of cord that lies under a given vertebra, T2 to T10 add ________ ________ ________. d. Under T11, T12, L1 lie the ________ ___ ________ _______. e. The conus lies at ________. 62.8.1 above below two cord levels lowest 11 spinal segments 62 L1-2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 344 Part 15: Spine Trauma 14. Give the location of the key sensory landmarks. a. occipital protuberance b. supraclavicular fossa c. shoulders d. lateral side of antecubital fossa e. thumb f. middle finger g. little finger h. medial side of antecubital fossa i. nipples j. xyphoid k. umbilicus l. inguinal ligament m. medial femoral condyle n. medial maleolus o. great toe p. lateral maleolus q. popliteal fossa in midline r. ischial tuberosity s. perianal area 15. Write out the American Spinal Injury Association (ASIA) motor scoring system—upper extremity—for the indicated root, muscle, and action to test. a. root C5 i. muscle: d________ or b________ ii. action: s________ a________ or e________ f________ b. root C6 i. muscle: w________ e________ ii. action: e________ w________ c. root C7 i. muscle: t________ ii. action: e________ e________ d. root C8 i. muscle: f________ d________ p________ ii. action: s________ h________ e. root T1 i. muscle: h________ i________ ii. action: a________ l________ f________ Table 62.11 C2 C3 C4 C5 C6 C7 C8 T1 T4 T6 T10 T12 L3 L4 L5 S1 S2 S3 S4-5 Table 62.10 deltoid or biceps shoulder abduction; elbow flexion wrist extension extend wrist triceps extend elbow flexor digitorum profundus squeeze hand hand intrinsics abduct little finger 62 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 345 16. Write out the American Spinal Injury Association (ASIA) motor scoring system—lower extremity—for the indicated root, muscle, and action to test. a. root L2 i. muscle: i________ ii. action: f________ h________ b. root L3 i. muscle: q________ ii. action: s________ k________ c. root L4 i. muscle: t________ a________ ii. action: d________ f________ d. root L5 i. muscle: e________ h________ l________ ii. action: d________ g________ t________ e. root S1 i. muscle: g________ ii. action: p________ f________ f________ 17. Name the main nerve root responsible for the following motor action: a. great toe extension b. ankle dorsiflexion c. knee extension d. ankle plantar flexion 18. Complete the following regarding Beevor’s sign: a. It tests the level of spinal cord injury at about T________. b. It is performed by i. flexing the ________. ii. Note that the ________ moves cephalad. 19. Complete the following regarding the abdominal cutaneous reflex: a. What is it? b. The upper quadrant is served by ________. c. The lower quadrant is served by ________. d. Its presence indicates (at least some) function of the ________ ________. Table 62.10 iliopsoas flex hip quadriceps straight knee tibalis anterior dorsiflexion extensor hallucis longus dorsiflex great toe gastrocnemius plantar flex foot Table 62.10 L5 L4 L3 S1 Table 62.10 T9 neck – patient activates rectus abdominus umbilicus Table 62.10 Stroking quadrants of abdomen causes abdominal muscle contraction, umbilicus deviation towards quadrant of stimulus T8-9 62 T10-12 spinal cord ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 346 Part 15: Spine Trauma e. There is ________ ________ spinal cord injury f. because the reflex ________ to the ________ and then ________to the abdominal muscles. 20. There is a sensory region that is not represented on the trunk. a. It jumps from C________ to T________. b. These levels are distributed exclusively on the u________ e________. no complete ascends to the cortex and descends 62.8.3 C4 to T2 upper extremity 21. Give the motor and sensory descriptions for each class in the ASIA impairment scale as modified from the Frankel neurologic performance scale. a. class A Complete cord injury: no motor or sensory function preserved b. class B Incomplete cord injury: sensory but no motor function preserved below the neurological level (includes sacral segments S4-5) c. class C Incomplete cord injury: motor function preserved below the neurologic level (more than half of key muscles below the neurologic level have a muscle strength grade <3) d. class D Incomplete cord injury: motor function preserved below the neurologic level (more than half of key muscles below the neurologic level have a muscle strength grade ≥ 3) e. class E Normal: sensory and motor function normal 62 Table 62.13 Spinal Cord Injuries 22. True or False. Regarding central cord injuries. a. They usually result from a hyperflexion injury. b. Motor deficit is greater in the arms than legs. c. Hyperpathia is uncommonly seen. d. It’s the most common type of incomplete spinal injury. e. The cord’s centermost region is a watershed zone. 62.9.3 false (hyperextension) true false (hyperpathia is common) true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Neurologic Assessment, Whiplash, Sports-Related Injuries, Pediatrics 347 f. Somatotopic organization places fibers to lower extremities more medial. g. BP must be maintained at an MAP of 85 to 90 for at least 1 week. h. Prompt surgery for decompression is advised. 23. A 45-year-old alcoholic male trips and falls, briefly losing consciousness. He was unable to move for 15 minutes, but currently complains only of weakness of both hands. He has an abrasion of his forehead. Computed tomographic (CT) scan of his head was negative. X-ray of C-spine reveals only spondylosis. True or False. Regarding this lesion. a. It has the best prognosis of all incomplete spinal cord injuries. b. There may be sparing of sensation around the anus with an intact voluntary anal sphincter. c. Immediate surgery is recommended even for patients without spinal instability. d. Urinary catheterization is recommended for patients in spinal shock. false (more lateral) true false 62.9.3 false (Brown-Séquard is the best) true false true 24. Complete the following about surgical intervention in patients who have had a central spinal cord injury: a. Indications for surgical intervention are i. spine ________ instability ii. continued spinal cord compression improve; progressively in a patient who fails to ________ or worsens ________ b. What surgery should be done? decompressive laminectomy + fusion 62.9.3 25. What is the prognosis in patients with central cord injury? a. ________% will recover enough to ambulate. b. Bowel and bladder function ________. c. Upper extremities (do/don’t) ________ recover well. d. Elderly patients (do/don’t) ________ recover well. 62.9.3 50% recover don’t don’t 62 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 348 Part 15: Spine Trauma 26. Answer the following about anterior cord syndrome: a. True or False. Motor findings are those of false (paraplegia) hemiplegia below the lesion. b. True or False. There is loss of pain true sensation, with preservation of deep pressure sensation. c. It may result from ________________. occlusion of anterior spinal artery d. Sensory pattern is termed “dissociated” because there is loss of i. ________ ________ ________ and spinal thalamic tract preservation of ii. ________ ________. dorsal columns 62.9.3 27. Answer the following about a BrownSéquard syndrome: a. True or False. There is contralateral pain loss beginning 1 to 2 levels above the lesion. b. True or False. Contralateral position sense is preserved. c. Prognosis compared with all other incomplete cord lesions is ________________. d. What % will eventually walk? 62.9.3 false (1-2 levels below lesion) true best of all incomplete cord injuries 90% 62 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 63 Management of Spinal Cord Injury General Information 1. Complete the following: a. The major causes of death in spinal cord injury are i. ________ and ________. b. Associated findings suggestive of spinal cord injury include i. ________ breathing and ii. ________. aspiration and shock abdominal priapism (autonomic dysfunction) Management in the Field 2. True or False. In caring for an injured false athlete, prompt removal of the helmet is recommended. 63.2 3. Complete the following: a. In spinal cord injury with hypotension in the field, the agent of choice is ________. b. Avoid ________. 63.2 4. In evaluating spinal cord injury in the field, hypopnea may be related to three conditions: a. paralyzed i________ m________ b. paralyzed d________ c. depressed ________ 63.1 dopamine phenylephrine – noninotropic, possible reflex bradycardia 63.2 intercostal muscles diaphragm LOC Management in the Hospital 5. Complete the following: a. True or False. Spinal cord injury can cause loss of temperature regulation. b. This is called p________ c. and is caused by v________ p________. 63.3.1 true 63 poikilothermy vasomotor paralysis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 350 Part 15: Spine Trauma 6. Complete the following about initial management of spinal cord injuries: a. True or False. Spinal cord injury can cause electrolyte disturbances b. due to what changes to blood pressure and volume? c. which cause an increase in what plasma hormone? d. which leads to what electrolyte changes? 63 true hypotension & hypovolemia aldosterone hypokalemia 7. Should methylprednisolone be given for the treatment of acute SCI? no 63.3.3 8. Should GM-1 ganglioside (sygen) be given for the treatment of acute SCI? no 63.3.3 9. True or False. Methylprednisolone protocol has been shown to be useful for patients with a. cauda equina syndrome b. gunshot wounds to the spine c. children d. pregnant women 63.3.1 63.3.3 false false false false 10. True or False. Regarding deep vein thrombosis (DVT) in spinal cord injury (SCI): a. Heparin 5000 U subcutaneous (SQ) twice false — better to titrate to a day is more effective than SQ heparin 1.5x PTT to titrate partial thromboplastin time (PTT) to 1.5 times normal. b. Pneumatic boots should be used initially. true 63.3.5 11. Complete the following about spinal cord injury and deep vein thrombosis: a. incidence: ________% b. mortality: ________% c. What medication can cause thrombocytopenia and osteoporosis? 63.3.5 100% 9% heparin Radiographic Evaluation and Initial C-Spine Immobilization 12. Matching. In assessing C-spine in these categories of trauma patient, perform the following tests: ① none needed; ② CT from occiput to T1; ③ plain C-spine x-rays; ④ flexionextension; ⑤ MRI Category of trauma patient: (a-e) below a. alert, denies neck pain b. alert, complains of neck pain c. obtunded or inebriated d. abnormal CT e. neurological deficit 63.4.3 ① ② ② ⑤ ② and ⑤ ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Management of Spinal Cord Injury 13. When do we do plain 3-view C-spine x-ray? a. If ________ is not available. b. Flexion extension views i. in an ________ patient ii. who complains of ________ ________ iii. and in whom ________ is normal iv. and ________ is not available. 63.4.3 CT awake neck pain CT MRI 14. Factors associated with increased risk of failing to recognize spinal injuries during radiographic evaluation include a. decreased ________ of ________ level of consciousness b. multiple ________ injuries 63.4.3 15. Radiographic signs of C-spine trauma include a. retropharyngeal space > ________ mm b. retrotracheal space > ________ mm in adult c. or > ________ mm in pediatrics d. atlantodental interval (ADI) > ________ mm in adult e. > ________ mm in pediatrics f. In the neurologically intact patient, subluxation up to ________ mm may be normal. g. To prove it is normal do ________. Table 63.2 7mm 14 mm 22 mm 3mm 4mm 3.5 mm flexion-extension views 16. When should we order anteroposterior (AP) and lateral views of the thoracic and lumbosacral spine? a. clinical symptoms? back pain b. mechanism of injury? high grade: MVA, fall > 6 feet, LOC 63.4.3 17. Complete the following: a. How can we tell an old injury from an acute one? b. We should test between ________ and ________ days. c. Test will remain abnormal for ________. 63.4.3 18. During evaluation of occult cervical spine trauma, what are the contraindications for flexion-extension cervical spine x-rays? a. patient who is not ________ b. patient who has ________ impairment c. subluxation of ________mm or more d. neurologic deficit of ________ 351 bone scan 2 and 21 1 year 63.4.3 cooperative/awake cognitive 3.5 any degree 63 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 352 Part 15: Spine Trauma 19. True or False. A normal flexiontrue extension of the cervical spine x-ray may demonstrate slight anterior subluxation distributed over all cervical levels with preservation of the normal contour lines. 63.4.3 20. Complete the following: a. Lumbar puncture (for myleogram) is dangerous in complete spinal block and may cause deterioration in ________%. b. Avoid this with a ________ ________ ________ or ________. 63.4.3 21. Indications for emergent myelogram or magnetic resonance imaging (MRI) in spinal cord injury includes neurologic deficit a. that is not ________. b. after closed ________. c. after ________ surgery. 22. Complete the following about MRI in spine: a. It is appropriate when i. CT of spine is ________, ii. patient has neurological ________. b. It should be done within ____ - _____ hours. c. Most useful sequences are i. ________ and ii. ________. lateral cervical puncture or MRI 63.4.3 explained reduction spinal 63.4.3 inconclusive deficits 48-72 T2 STIR Traction/Reduction of Cervical Spine Injuries 23. Contraindications to traction/reduction of cervical spine injuries include a. atlanto-occipital ________. b. types of axis fractures called ________ or ________. c. a defect in the ________ d. the patient is less than ____ years of age. 63 14% 24. Complete the following: a. After placing the patient in tongs we must obtain a ________ b. and measure the distance between the ________ and the ________, i. which should be less than ________ mm in adults ii. and less than ________ mm in children. 63.5.1 disassociation type IIA or III hangman’s fractures skull at pin site 3 63.5.2 lateral c-spine x-ray basion; odontoid Table 64.1 12mm 10mm (unreliable <13 yrs because of variable ossification/fusion of odontoid tip) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Management of Spinal Cord Injury 25. What is considered proper pin care? a. Clean with ________________________. half strength hydrogen peroxide b. Apply ________. povidone-iodine c. This may reduce the incidence of osteomyelitis ________. 63.5.2 26. Complete the following: a. Closed reduction of cervical dislocations may be associated with neurologic deterioration, and this may be due to a r________ c________ d________. b. If neurologic deterioration occurs after closed reduction what tests must you do immediately? 63.5.2 353 retropulsed cervical disc MRI Indications for Emergency Decompressive Surgery 27. Complete the following: a. True or False. Patient with recent onset of loss of function due to spinal cord injury should have a decompressive laminectomy. b. If surgery is done, it is usually combined with ________ ________. 28. Contraindications to emergent operation for acute spinal cord injury include: a. complete ________ ________ ________ for more than 24 hours without evidence of ______ ______ b. unstable ________ c. central ________ ________ 63.6.1 false (May worsen injury.) stabilization procedure 63.6.1 spinal cord injury; spinal shock medically cord syndrome (controversial) 63 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 64 Occipitoatlantoaxial Injuries (Occiput to C2) Atlanto-Occipital Dislocation 1. Complete the following: a. Incidence in spinal injury is approximately ____%. b. Are they more common in pediatrics or in adults? c. Mortality results from ________ ________. d. They may demonstrate what type of paralysis? 2. Complete the following about the three types of atlanto-occipital dislocation: a. Type I: occiput in relation to atlas is dislocated ____ b. Type II: occiput in relation to atlas is dislocated ____ c. Type III: occiput in relation to atlas is dislocated ____ 3. Name the ligaments at the following sites: a. atlas to occiput i. a________ a________-o________ m________ ii. p________ a________-o________ m________ iii. a________ b________ (of c_____ l______) b. axis to occiput (via dens) i. t________ m________ ii. a________ l________ iii. a________l________ c. atlas to axis i. t________ l________ 64 ii. a________ l________ iii. d________ b________ (of c______ l______) 64.1.1 1% pediatrics respiratory arrest (bulbar cervical disassociation) cruciate 64.1.1 anteriorly superiorly posteriorly 1.8 anterior atlanto-occipital membrane (ALL) posterior atlanto-occipital membrane ascending band (cruciate ligament) tectorial membrane alar ligaments apical ligament transverse ligament (part of cruciate) alar ligament descending band (cruciate ligament) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Occipitoatlantoaxial Injuries (Occiput to C2) 4. Complete the following: a. What structure is the cephalad extension of the i. anterior longitudinal ligament? anterior atlanto-occipital membrane ii. posterior longitudinal ligament? tectorial membrane b. Which structures are most important in maintaining atlanto-occipital stability? i. t________ m________ tectorial membrane ii. a________ l________ alar ligaments 1.8 5. Complete the following: a. Name the horizontal component of the cruciate ligament. b. What does it hold together? c. What is the strongest ligament in the spine? 1.8 6. Complete the following: a. What is the best method by which to measure AOD? b. It is considered normal if each is less than _____ mm. c. Another method is called the ________ ________. d. Traction may be used but ________% of patients deteriorate. 7. Complete the following: a. A measurement used in evaluating atlanto-occipital dislocation (AOD) is called ________ ________. i. divide distance from basion to ________ ii. by distance from opisthion to ________ b. It is considered normal if below _______. c. It is definitely abnormal if above ________. 8. Power’s ratio greater than ________ is diagnostic of atlanto-occipital dislocation. 9. AOD is suspected if a. the atlanto-occipital interval is greater than ________ mm and/or b. there is blood in the _______ _______. 355 transverse ligament odontoid and atlas transverse ligament BAI-BDI 64.1.3 12 Powers’ ratio 64.1.4 10% 64.1.5 Power’s ratio 64.1.4 posterior arch of the atlas anterior arch of the atlas 0.9 1 Table 64.2 1 Table 64.2 2 mm Table 64.1 basilar cistern 64.1.3 64 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 356 Part 15: Spine Trauma Occipital Condyle Fractures 10. Complete the following: a. Can they involve the hypoglossal nerve? b. List the types. i. I is a ________ fracture. ii. II has a ________fracture. iii. III has an ________ fracture. c. Treatment is with ________. d. What are the indications for halo or fusion? e. Incidence in trauma patients is ________%. 64.2.1 Table 64.4 comminuted (axial loading) linear (extension of basilar skull fracture) avulsion (traction) collar craniocervical misalignment, occiput-C1 interval > 2mm 0.4% 64.2.1 Atlantoaxial Subluxation/Dislocation 11. Answer the following about atlantoaxial dislocation: a. True or False. It has less morbidity and mortality than atlanto-occipital dislocation. b. Name and describe the three types. i. rotatory atlanto-axial dislocation type I transverse ligament ________ facet capsule ________ ________ treatment ________ ________ type II transverse ligament ________ facet capsule ________ ________ treatment ________, ________ type III transverse ligament ________ facet capsule ________ ________ treatment ________, ________ ii. anterior atlanto-axial dislocation o________ f________ c________ h________ d________ of t________ l________ 12. Complete the following regarding atlanto-axial rotatory subluxation: a. Name four causes. Hint: stur i. s________ ii. t________ iii. u________ 64 yes iv. r________ b. Competence of the ________ ________ must be assessed. true 64.3.1 rotatory, anterior, posterior Table 64.5 intact bilateral injured soft collar injured unilateral injury fusion, halo injured bilateral injury fusion, halo odontoid fracture congenital hypoplasia disruption of transverse ligament 64.3.2 spontaneous trauma upper respiratory tract infection (Grisel syndrome) rheumatoid arthritis transverse ligament ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Occipitoatlantoaxial Injuries (Occiput to C2) c. What is the characteristic head position? d. Patients are usually ________. e. It can occlude the ________ arteries. 13. Complete the following regarding the rule of Spence: a. It is designed to determine if the transverse ligament ________ ________ b. If disrupted what effect does it have on treatment? c. It is performed by studying what view? d. To assess what structures? e. The critical reference number is ___mm sum of both sides. “cock robin” (20 degrees lateral tilt, 20 degrees rotation opposite, slight flexion) young vertebral 64.3.3 is disrupted requires immobilization (surgical, halo, or collar, based on type of disruption) open-mouthed AP lateral masses of C1-C2 overhang 7mm Atlas (C1) Fractures 14. a. b. c. d. Complete the following: isolated fracture: ________% combined with C2 fracture: ________% additional spine fracture: ________% combined with head injury: ________% 15. True or False. Regarding a Jefferson fracture: a. It involves a single fracture through the ring of C1. b. It is generally a stable fracture. c. “Rule of Spence” assesses displacement. d. Treatment is generally surgical (fusion). 357 64.4.1 56% 44% 9% 21% 64.4.3 false (at least 2 fracture sites) false (But without neurologic deficit.) false false (usually collar/halo) Axis (C2) Fractures 16. Complete the following about acute fractures of the axis: a. Represent ________% of cervical fractures. b. Neurologic deficit occurs in ________%. 64.5.1 20% 10% 64 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 358 Part 15: Spine Trauma 17. Complete the following: a. True or False. Regarding hangman’s fracture: i. In contrast to judicial hanging, modern-day hangman’s fractures result from hyperextension and distraction. ii. This is usually a stable fracture. b. There is a common occurrence of nonunion, hence the need for surgery. c. Hangman’s fracture results in a fracture through the ________. It is also known as ________________________. 64.5.3 false – hyperflexion, axial loading true false (usually heal with collar) pars of C2; traumatic spondylolisthesis of the axis 18. Complete the following regarding hangman’s fracture: a. Subluxation of C2 on C3 by more than 3; disc ______ mm indicates ________ disruption. b. This is a marker for ________ and usually instability; surgery requires ________. 64.5.3 19. Classify hangman’s fractures a. Type I: i. subluxation: ________ ii. angulation: ________ iii. treatment b. Type IA: i. subluxation: ________ ii. angulation: ________ iii. treatment c. Type II: Table 64.7 vertical pars fractures <3mm 0 collar nonparallel fractures 2-3 mm 0 collar vertical fracture through pars with disruption of C2/3 disc and PLL >3mm significant traction/halo vs surgery type II with oblique fractures >3mm >15 deg NO TRACTION. Halo. type II + bilat C2-3 facets disrupted yes facets locked NO TRACTION. Surgery traction i. subluxation: ________ ii. angulation: ________ iii. treatment d. Type IIA: i. subluxation: ________ ii. angulation: ________ iii. treatment e. Type III: i. subluxation: ________ ii. angulation: ________ iii. treatment f. A special caution for Type IIA and III fractures is to avoid the use of ________. g. What is the name of the classification Effendi system? 64 20. Most hangman’s fracture patients a. present neurologically ________ and b. need MRI to assess ________ disc. 64.5.3 intact C2-3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Occipitoatlantoaxial Injuries (Occiput to C2) c. It can be treated with ________ for _____ weeks. d. Average time to heal is ________ weeks 21. Describe the radiologic criteria of good fusion. a. Across the fracture site we should see ________. b. Flexion-extension radiographs should show no _______. 22. Complete the following about odontoid fractures: a. Odontoid fractures represent approximately ____ - ____% of all cervical spine fractures. b. Mechanism of injury is usually ________. c. They are fatal in about ____ - ____%. d. Major deficits in type II is ________%. e. In Type III it is ________ to have neurologic deficit. f. A displacement i. of ________ mm ii. results in a nonunion rate of ________%. iii. Therefore, the treatment advised is ________. 23. True or False. Regarding odontoid fractures: a. They are a hyperflexion injury in most instances. b. Most patients have presenting neurological deficit. c. Neck pain is infrequent. 24. Complete the following: a. Regarding odontoid fractures: i. Type I is fracture through the _____ _____. ii. Type II is fracture through the _____ of _____. iii. Type III is fracture through the _____ of _____. b. True or False. The spinal cord occupies 50% of the canal at C1. c. True or False. The ossiculum terminale results from posttraumatic fracture of the apical dens. 359 immobilization; 12 11.5 64.5.3 trabeculations movement 64.5.4 10-15% flexion 25-40% 10% rare 6mm 70% surgical 64.5.4 true false false Table 64.9 apical dens base of dens body of C2 false (1/3) 64.5.4 false – from nonunion 64 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 360 Part 15: Spine Trauma 25. Complete the following: a. List indications for surgical treatment of Type II odontoid fractures. i. displacement of dens more than ________ mm ii. despite halo there is ________ iii. despite immobilization there is ________ iv. patient is older than ________ v. disruption of the ________ ________ b. True or False. Most odontoid type III fractures should be treated surgically due to low union rate by rigid external immobilization (halo). 26. a. b. c. d. e. The appearance of os odontoideum is a ________ bone with ________ borders near a ________ odontoid peg. It may fuse with the ________. It may mimic a ________ fracture. 27. Complete the following about os odontoideum: a. Postulated etiologies i. c________ ii. a________ b. Does treatment depend on the etiology? c. Myelopathy correlates with an AP canal diameter of less than ________mm. d. Will immobilization result in fusion? e. Treatment i. p________ w________ ii. t________ s________ f. Do we need a halo with each of these procedures? 64.5.4 5mm instability nonunion 50 transverse ligament false – 90% heal 64.5.4 separate smooth short clivus type II odontoid 64.5.4 congenital avulsion of alar ligament no 13 mm no posterior wiring transarticular screw Not with transarticular screws Combination C1–2 Injuries 28. Complete the following about combined C1 and C2 fractures: a. Treatment is decided based on type of ________ fracture. b. An odontoid fracture type II that is displaced more than ________ mm is considered ________. c. Treatment is ________ ________. C2 64.6.2 5mm; unstable Table 64.13 posterior fusion 64 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 65 65 Subaxial (C3 through C7) Injuries / Fractures Classification Systems 1. Matching. For the following conditions, choose the most appropriate mechanism producing the cervical fracture. Mechanism: ① hyperextension; ② vertical compression; ③ hyperflexion; ④ flexion plus rotation a. burst fracture b. unilateral locked facet c. bilateral locked facet d. laminar fracture 2. Guidelines for determining clinical instability include: a. Compromise of the anterior elements produces more instability in ________. b. Compromise of the posterior elements produces more instability in ________. 3. Give radiographic criteria for clinical instability. a. a sagittal plane displacement of ________ mm and b. relative sagittal plane angulation of ________ degrees(on neutral position lateral C-spine films) Table 65.3 ② ④ ③ ① 65.1.4 extension flexion Table 65.4 >3.5mm >11 Clay Shoveler’s Fracture 4. Clay shoveler’s fracture usually involves the spinous process of ________. C7 65.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 362 65 Part 15: Spine Trauma Flexion Injuries of the Subaxial Cervical Spine 5. True or False. The following is true of teardrop fractures: a. They usually result from i. hyperflexion injuries ii. compression flexion injury iii. hyperextension injury b. They are stable fractures. c. The fractured vertebra is usually displaced posteriorly into the spinal canal. d. They are often associated with a fracture through the sagittal plane of the vertebral body. e. The patient is often quadriplegic. f. A “teardrop” chip of bone is at the anterior-superior edge of the vertebral body. 6. Complete the following: a. A teardrop fracture must be distinguished from an ________ ________. i. ______ _______ is unstable and requires ________, ii. ________ ________ is stable. b. How can we distinguish them? A teardrop will have: i. size of fracture ii. alignment iii. neurological ______ iv. soft tissue v. fracture vi. height of disc vii. height of vertebral body c. If in doubt, perform ___________ views. d. If negative, repeat __________ in ___ ___ days. e. The fractured vertebra is displaced ________. f. True teardrop fractures should be treated with c_______ a________ and p________ f________. 7. Quadrangular fractures have four features. a. Feature 1: an ________ fracture i. from ________-________ ii. to ________ ________ b. Feature 2: subluxation of superior vertebral body (VB) on the inferior VB ________ c. Feature 3: with angular ________ 65.4.3 true true false false true true true false – anterior-inferior 65.4.3 avulsion fracture Teardrop fracture; surgery avulsion fracture small chip displaced deficits swelling through vertebra reduced reduced/wedged flexion-extension flexion-extension; 4-7 days posteriorly combined anterior and posterior fusions. 65.4.5 oblique anterior-superior inferior endplate posteriorly kyphosis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Subaxial (C3 through C7) Injuries / Fractures d. Feature 4: disruption of i. ________ ii. ________ iii. ________ e. Treat with ______ ______ ______ ______ ______. 363 65 disc ALL PLL combined anterior and posterior fusions. Distraction Flexion Injuries 8. Describe distraction flexion injuries. a. Flexion injuries include __________, __________, _________ ________. b. Which ligament is injured early? c. X-rays demonstrate this by showing ________________________. d. We may need to test by performing ________________________. e. If symptoms persist 1 to 2 weeks we should ________. f. Ligamentous instability is confirmed if there is a i. subluxation of ________ mm or angulation of ii. ________ degrees. 9. Describe locked (aka jumped) facets. a. Normally the inferior facet of the level above is ________ to the superior facet of the level below. b. In locked facets there is ________ of the facet ________. c. Flexion and rotation produces ________ ________ ________. d. Hyperflexion produces ________ ________ ________. e. Neurological injury is ________ for cord and/or root injury. f. In patients with locked facets the inferior facet of the level above is ________ to the superior facet of the level below. 10. Describe evidence of locked facets on x-ray. a. In unilateral locked facets the spinous process is rotated to the side of the ________ ________. b. Facets look like a ________. c. Interspinous space is ________. d. Neural foramen is ________. e. Articular surfaces of the facets are ________________. strain, subluxation, locked facets posterior ligamentous complex widening of interspinous distance flexion-extension views or MRI repeat flexion-extension views 65.5.1 65.5.2 65.5.3 3.5 11 65.5.4 posterior disruption; capsule unilateral locked facets bilateral locked facets frequent anterior 65.5.4 locked facet bow tie widened blocked on the wrong side ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 364 Part 15: Spine Trauma 11. Complete the following regarding locked facets: a. When the articulating surfaces of the facets are on the wrong side, this is called the “______ ______ sign.” b. In bilateral locked facets traumatic disc herniation is found in ________%. c. Attempt at closed reduction of locked facets by traction must not exceed ____ lb per vertebral level. d. Disc space height must not exceed ____mm. e. If neurologic worsening occurs, you should suspect _______ ________ and plan for ________. f. Closed reduction is ________ until MRI assesses for _______ ________. 65 12. Answer the following about locked facets: a. True or False. Stabilization is more likely to be successful in halo if there are i. multiple fractures of the facets. ii. no fractures of the facets. b. Halo alone is successful for good anatomical result in ________%. c. Failure of good anatomical result occurs in ___%. d. True or False. Surgical fusion is therefore clearly indicated in cases without facet fracture fragments. 65.5.4 naked facet 80% 10 10 disc hernation; surgery contraindicated; disc hernation 65.5.4 true false 23% 77% true Extension Injuries of the Subaxial Cervical Spine 13. Complete the following about subaxial (C3 - C7) injuries/fractures: a. Extension injuries can produce i. ________ ________ ________ in adults and ii. ________ in children. b. The ligament that is most often injured in extension injuries is the ________. c. Is disc injury possible? d. What vascular injury can occur? 65.6.1 central cord syndrome SCIWORA ALL yes carotid artery dissection ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Subaxial (C3 through C7) Injuries / Fractures Treatment of Subaxial Cervical Spine Fractures 14. Complete the following: a. When combined anterior and posterior anterior cervical fusion is needed which should be done first? b. When the mechanism of injury is flexion posterior fusion what is the procedure of choice? c. When the mechanism of injury is extension what is the procedure of choice for i. teardrop fracture combined anterior/posterior fusion ii. burst fracture combined anterior/posterior fusion 65.7.3 15. Complete the following about cervical corpectomy: a. Decompression of the cord usually requires corpectomy that is at least ________ mm wide. b. It is advised to note position of _______. 65.7.3 365 65 16mm vertebral arteries Spinal Cord Injury Without Radiographic Abnormality (SCIWORA) 16. True or False. Answer the following about SCIWORA (spinal cord injury without radiographic abnormality): a. There is a higher incidence in age ≤ 9 years. b. There is a risk of SCIWORA among young children with asymptomatic Chiari I. c. Dynamic flexion/extension films are normal. d. 54% of children have a delay between injury and the onset of objective sensorimotor dysfunction. 65.8.1 true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-14 66 66 Thoracic, Lumbar and Sacral Spine Fractures Assessment and Management of Thoracolumbar Fractures 1. Matching. Match the following structures with the appropriate Denis column: ① anterior; ② middle; ③ posterior a. anterior half of disc b. posterior half of disc c. posterior arch d. anterior half of vertebral body e. posterior half of vertebral body f. facet joints and capsule g. anterior anulus fibrosus h. posterior anulus fibrosus i. interspinous ligament j. supraspinous ligament k. anterior longitudinal ligament l. posterior longitudinal ligament m. ligamentum flavum 2. True or False. The following are considered minor fractures of the lumbar spine: a. fracture of transverse process b. fracture of spinous process c. fracture of superior articular process d. fracture of inferior articular process e. fracture of superior end plate of vertebral body 3. True or False. Major injuries of the spine include: a. compression fracture b. burst fracture c. seat belt fracture d. fracture of articular process e. fracture dislocation 66.1.2 ① ② ③ ① ② ③ ① ② ③ ③ ① ② ③ 66.1.2 true true true true false 66.1.2 true true true false true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Thoracic, Lumbar and Sacral Spine Fractures 4. True or False. Subtypes of burst fracture include the following: a. fracture of both end plates b. fracture of superior end plate c. fracture of inferior end plate d. fracture of pars interarticularis e. burst rotation 5. True or False. Regarding burst fracture. a. It occurs mainly at thoracolumbar junction. b. Mechanism—axial load c. Mechanism—flexion and compression d. It is a consequence of fracture of the anterior and middle column. e. The most common subtype is fracture of the superior end plate. 6. True or False. Radiographic evaluation of burst fracture might show the following: a. lateral x-ray—cortical fracture of posterior vertebral wall b. AP x-ray—increase in interpedicular distance c. lateral x-ray—loss of posterior vertebral height d. CT—fracture posterior wall with retropulsed bone e. myelogram—large central defect 7. True or False. Seat belt fracture has all of the following subtypes: a. chance fracture, one-level through bone b. one-level through ligaments c. two-level, bone in middle column, ligaments in anterior and posterior columns d. pedicle fracture e. two-level through ligaments in all three columns 8. State which of the following are stable or unstable fractures of the spine: a. three or more consecutive compression fractures b. a single compression fracture with loss of > 50% of height with angulation c. kyphotic angulation > 40 degrees at one level or > 25% d. progressive kyphosis 367 66.1.2 true true true false true 66 66.1.2 true true false – usually pure axial load true true 66.1.2 true true true true true 66.1.2 true true true false true 66.1.2 unstable unstable unstable unstable ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 368 66 Part 15: Spine Trauma 9. State whether the following are stable or unstable fractures of the spine: a. middle column fracture above T8 below stable T1 if ribs and sternum intact b. middle column fracture below L4 if stable posterior column is intact c. posterior column fracture stable acutely, as long as middle column intact d. compression fracture in three unstable consecutive segments 10. True or False. Regarding burst fractures. a. Surgical treatment is recommended if angular deformity > 20 degrees. b. Surgical treatment is recommended for patients with neurologic deficit. c. Surgical treatment is recommended for anterior body height reduction ≥ 50% compared with the posterior body height. d. Surgery is recommended for canal reduction ≥ 50%. e. The anterior approach is recommended if a dural tear is present. 11. a. b. c. d. Burst fractures are unstable if K—Kyphosis is more than ________. I—Interpendicular distance is ________. P—Progressive ________ occurs. H—Height of anterior body is less than________% posteriorly. e. D—Deficit in n________ status. 12. True or False. Regarding L5 burst fractures. a. They are very common. b. It is difficult for instrumentation to maintain alignment at this level. c. Patients will lose ~15 degrees of lordosis between L4 and S1 even with instrumentation. d. If treatment is nonsurgical, a thoracolumbar-sacral orthosis (TLSO) brace is recommended for 4 to 6 months. e. If treatment is surgical a posterior approach with fusion and fixation L5-S1 is recommended. f. If “ligamentotaxis” is expected, distraction should be done within ________ hours. 66.1.2 66.1.2 true true true true false – posterior recommended 66.1.2 20% increased kyphosis 50% neurological false true 66.1.2 true true true 48 66.2.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Thoracic, Lumbar and Sacral Spine Fractures Surgical Treatment 13. Complete the following about postspinal fusion wound infections: a. They are usually due to ___________. b. They may respond to ________ alone. c. Rarely ________ may be necessary. d. Only occasionally must instrumentation be ________. 369 66.2.5 66 staph aureus antibiotics debridement removed Osteoporotic Spine Fractures 14. Complete the following regarding demographics of osteoporotic spine fractures: a. True or False. There are ~700,000 osteoporotic fractures per year in the United States. b. True or False. Risk factors include weight. c. There is a risk with the use of which anticonvulsant? d. There is a risk with the use of which anticoagulant? e. There is a risk with consumption of which beverage? f. There is a risk with the use of c________. g. There is a risk with the use of which antiinflammatory drug? 15. Complete the following regarding osteoporotic spine fractures: a. The most likely population is ________. b. Can these fractures occur in premenopausal women? c. The lifetime risk for women is _____%. d. The lifetime risk for men is ________%. e. The best predictor of fractures is ______ ________ ________ test measured at the ______. 16. True or False. Regarding bone mineral density (BMD). a. It is not the correct predictor of bone fragility. b. It is measured by DEXA Scan at the proximal femur. c. The AP view of the lumbosacral spine underestimates BMD. d. The T-score of BMD compares to normal subjects. e. The Z-score defines osteoporosis compared with subjects of the same age and sex. true 66.3.1 true – weight < 58kg phenytoin 66.3.2 warfarin alcohol cigarettes steroids elderly white and Asian females yes 16 5 bone mineral density; femur 66.3.1 66.3.3 66.3.3 false true false- overestimates true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 370 66 Part 15: Spine Trauma 17. True or False. Regarding sodium fluoride. a. 75 mg/d increases bone mass. b. 75 mg/d decreases fracture rate. c. 25 mg PO BID (slow fluoride) increases the fragility of the bone. d. Fluoride increases the demand for Ca. e. If you use fluoride also use Ca and vitamin D. 66.3.4 true false true true true 18. True or False. The following drugs reduce bone resorption: a. estrogen b. calcium c. vitamin D d. calcitonin true true true true 19. Calcitonin is derived from ________. salmon 20. How do the bisphosphonates work? a. They inhibit ________ b. by destroying ________. bone resorption osteoclasts 21. True or False. The following are bisphosphonates that inhibit bone resorption: a. etidronate (Didronel) b. alendronate (Fosamax) c. risedronate (Actonel) 22. True or False. Recommended treatment for osteoporotic vertebral body fracture: a. sufficient pain medications b. bed rest for 3 to 4 weeks c. DVT prophylaxis is contraindicated. d. Start physical therapy in 7 to 10 days. e. lumbar brace for pain control and comfort 23. True or False. Regarding PVP. a. PVP stands for percutaneous vertebroplasty. b. It involves injection of polymethylmethacrylate (PMMA) into compressed bone. c. Goals include prevention of progression of kyphosis. d. Goals include correction of kyphosis. e. Goals include shortened duration of pain. f. PMMA injection is FDA approved for treatment of compression fractures due to tumor, osteoporosis and trauma. 66.3.4 66.3.4 66.3.4 66.3.4 true true true 66.3.4 true false (7 to 10 days only) false true true 66.3.4 true true true false true false – not for trauma, PMMA may inhibit healing ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Thoracic, Lumbar and Sacral Spine Fractures 24. True or False. Indications for PVP include the following: a. severe pain that interferes with activity b. painful osteoporotic compression fracture with < 10% of height reduction c. failure to control pain with pain medications d. progressive vertebral hemangioma e. pedicle screw salvage 25. True or False. Vertebroplasty contraindications include a. coagulopathy b. chronic injury c. active infection d. burst fracture 66.3.4 true false 66 true true true 66.3.4 true true true true – concern for PMMA leakage 26. Matching. Match the complications of PVP with the order in which they are more likely to occur. ① highest; ② second highest; ③ least Complications: (a-c) below a. vertebral hemangiomas b. pathologic fractures c. osteoporotic compression fractures 27. True or False. Complications of PVP include a. PMMA leak b. pedicle fracture c. transverse process fracture d. spinous process fracture e. rib fracture 28. True or False. Post-PVP recommendations include the following: a. discharge home the same day b. c. d. e. 371 watch for chest pain watch for fever watch for neurologic deficit gradual mobilization after 2 hours 66.3.4 ② ① ③ 66.3.4 true true true false true 66.3.4 false – usually admitted overnight true true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 372 66 Part 15: Spine Trauma Sacral Fractures 29. Complete the following: a. Look for in patients who have ________ fractures i. because ________% will also have sacral fractures b. accompanied in ________% by neurologic deficits. c. Sacral fractures are divided into ________ zones. i. I involves ________ ________ ii. II involves ________ ________ iii. III involves ________ ________ d. The fractures that involve neurologic deficits are those involving zones ____ and ____ e. Which fracture can cause bowel and bladder incontinence? f. Which fracture can cause L5 root injury? pelvic 66.4.1 17% 20-60 3 Table 66.6 ala only sacral foramina neural canal II and III 66.4.3 III I ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 67 Penetrating Spine Injuries and Long Term Management / Complications Gunshot Wounds to the Spine 1. True or False. Indications for surgery in gunshot wounds to the spine include the following: a. injury to cauda equina if root compression is demonstrated b. to remove copper-jacketed bullets from the spine c. CSF leak d. compression of nerve root e. vascular injury f. to improve spinal cord function g. spinal instability 67 67.1.2 true true – cause local reaction true true true false true Penetrating Trauma to the Neck 2. True or False. Regarding vascular injuries of the neck: a. Venous injuries occur in ≈ 30% of penetrating neck trauma. b. Arterial injuries occur in ≈ 12% of penetrating neck trauma. c. 72% of vertebral artery injuries had no neurological deficits on exam. d. Common carotid artery injury is the most common vascular injury. 3. Matching. Penetrating wounds of the neck are divided into three zones by anatomical boundaries. Zone: ① zone I; ② zone II; ③ zone III Anatomical boundaries: (a-e) below a. clavicle b. angle of mandible c. head of clavicle d. thoracic outlet e. base of skull 67.2.2 false – 18% true true true 67.2.3 ② ②-③ ① ① ③ ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 374 Part 15: Spine Trauma 4. True or False. Treatment of penetrating trauma to the neck includes the following: a. immediate prophylactic intubation to protect airway b. cricothyroidotomy if apparent mechanical instability of the neck c. Surgical exploration is recommended for all wounds piercing the platysma and entering the anterior triangle of the neck. d. Patients in coma are poor candidates for surgical vascular reconstruction. 67 5. Complete the following regarding vertebral artery (VA) trauma: a. It is more common to treat by ________ than by direct repair. i. What must you know about other vessels before you decide on treatment of VA injury? ii. Which vessels? b. What minimally invasive treatment is available? c. Is arterial bypass ever indicated? false true true true – high mortality 67.2.5 ligation patency contralateral VA, PICA covered stent placement no Delayed Cervical Instability 6. Delayed cervical instability is defined as instability identified after ___ days. 67.2.5 20 67.3.1 Chronic Management Issues with Spinal Cord Injuries 7. True or False. Syndromes associated with spinal cord injuries include all of the following: a. autonomic hyporeflexia b. DVT c. syringomyelia d. spasticity e. osteoporosis f. shoulder-hand syndrome 8. True or False. In autonomic hyperreflexia the following is found: a. exaggerated autonomic response to stimuli b. only in patients with lesion above T6 c. complaints of headache, flushing, and diaphoresis d. extreme hypertension e. epinephrine is released causing this syndrome 67.5.1 false – hyperreflexia true true true true true 67.5.3 true true true true false – norepinephrine ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Penetrating Spine Injuries and Long Term Management / Complications 375 9. True or False. Regarding autonomic hyperreflexia in SCI. a. It occurs only in patients with SCI below T6. b. Patients complain of pounding headache. c. It can be life threatening. d. It occurs in ≈ 30% of quadriplegic patients. e. There is a lag time of 3 to 4 months. 10. True or False. Regarding autonomic dysreflexia in SCI. a. It often occurs in the first 3 to 4 months after SCI. b. Bladder distension may cause onset. c. Colorectal distension may cause onset. d. DVT may cause onset. 11. True or False. Presentation of autonomic hyperreflexia in SCI includes a. paroxysmal hypertension b. anxiety c. miosis d. penile erection e. Horner’s syndrome 12. Complete the following about autonomic hyperreflexia: a. What is the triad of presenting symptoms? i. h________ ii. s________ iii. facial f________ b. It could be confused with ________. 67.5.3 false – above T6 true true true 67 true 67.5.3 false – occurs after first 3-4 mos. true true true 67.5.3 true true false – mydriasis true true 67.5.3 headache sweating facial flushing pheochromocytoma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 68 Low Back Pain and Radiculopathy 68 General Information 1. Complete the following about low back pain and radiculopathy: a. True or False. Bed rest beyond 4 days is more helpful than harmful for patients with low back pain. b. True or False. 60% of patients with low back pain will improve clinically within 1 month even without treatment. c. Pure radicular symptoms will include upper motor neuron (UMN) signs or lower motor neuron (LMN) signs? 2. True or False. The percentage of lowrisk back pain patients who will improve without treatment in 1 month’s time is a. 10% b. 20% c. 90% d. 0% 68.1 false (Bed rest beyond 4 days may be more harmful than helpful.) false (89-90% will improve within 1 month without treatment, including patients with sciatica from disc herniation.) LMN signs (Radiculopathy will/may show associated decreased reflexes, weakness, and atrophy.) 68.1 false false true (Most low back patients will resolve and no specific diagnosis can be made in 85% despite aggressive workup.) false Intervertebral Disc 3. The nucleus pulposus is a remnant of the embryonic __________. notocord 68.2.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Low Back Pain and Radiculopathy Nomenclature for Disc Pathology 4. True or False. The following may be considered a non-pathological condition: a. degenerated disc b. annular fissure c. bulging disc generalized > 50% d. focal herniation e. protruding disc 5. True or False. Gas in the disc usually is a sign of a. disc infection b. disc degeneration c. AKA v______ d_______ 68.3 false false true (Bulging disc is a circumferential symmetrical extension of the disc beyond the endplates. Incidence increases with age.) false false 68 Table 68.1 false true vacuum disc 6. An extruded disc where the free sequestered fragment is contained by the posterior longitudinal ligament is called a ______ disc. Table 68.1 7. Give the definition of a sequestered disc. a. ______ disc b. loss of ______ with its disc of ______ c. also known as a ______ ______ Table 68.1 extruded continuity; origin free fragment Vertebral Body Marrow Changes 8. Provide the Modic’s classification of vertebral body marrow changes: a. Type 1: T1WI ___, T2WI ___ b. Type 2: T1WI ______, T2WI ______ c. Type 3: T1WI ______, T2WI ______ 377 Table 68.2 ↓↑ (bone marrow edema associated with acute or subacute inflammation) ↑↑ (chronic change- bone marrow replaced by fat) ↓↑ (chronic- reactive osteosclerosis) Disability, Pain and Outcome Determinations 9. Oswestry disability index a. Is a scale used for ____ ____. b. A score of ______% is essentially totally disabled. c. A functional score is below ______%. Table 68.3 back pain 45% 20% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 378 Part 16: Spine and Spinal Cord Initial Assessment of the Patient with Back Pain 10. True or False. Cauda equina syndrome may include the following: a. bladder dysfunction (incontinence or retention) b. Faber sign or Patrick-Faber sign (flexion abduction external rotation) 68 c. saddle anesthesia d. unilateral/bilateral leg weakness or pain e. fecal incontinence 11. Name the associated nerve root for each of the following: a. great toe strength b. dorsal foot sensation c. lateral foot sensation d. medial foot sensation e. plantar foot sensation f. achilles reflex 12. For patients with low back pain, red flags for a serious underlying pathology would include signs consistent with what conditions? (Hint: CISC) a. C ______ b. I ______ c. S______ d. C______ 13. Signs of cauda equina syndrome include a. ______ b. ______ c. ______ d. ______ e. ______ 68.8.2 true false (Positive in hip joint disease and does not exacerbate true nerve root compression.) true true true 68.8.3 L5 and some L4 L5 S1 L4 S1 S1 68.8.4 cauda equina syndrome infection spinal fracture cancer Table 68.5 saddle anesthesia bladder overflow incontinence or retention fecal incontinence or loss of anal sphincter tone leg pain (unilateral/bilateral) leg weakness (unilateral/bilateral) 14. Electromyography (EMG) is not helpful 3 to 4 (results are variable to evaluate for myelopathy, before this time) myopathy, or nerve root dysfunction unless the symptoms have been present for at least ___ - ___ weeks. 68.8.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Low Back Pain and Radiculopathy 379 Radiographic Evaluation 15. True or False. Regarding plain lumbosacral spine x-rays. a. Are recommended for routine evaluation of back pain. b. When indicated, AP and Lateral views are usually adequate. c. Unexpected findings occur frequently. d. Gonadal radiation is insignificant. e. Appropriate in patients who have “red flags.” 16. a. b. c. d. e. f. True or False. Red flags include patients under age 20 patients over age 50 drug users diabetics post-op urinary tract patients persistent pain for more than 1 week 17. Complete the following about low back pain and radiculopathy: a. Signs on MRI that indicate disc degeneration include i. increase or decrease of signal intensity on T2-weighted imaging (T2WI)? ii. increase or decrease of disc height? b. Signs on computed tomography (CT) that indicate disc herniation include i. increase or decrease of the normal epidural fat ii. ______ of the thecal sac c. CT will show loss of ________ (concavity/convexity) of the thecal sac? 18. Other useful tests include the following: a. Myelogram-CT: Identifies contribution to cause of pressure by ______. b. In terms of discography i. reliability? ii. interpretation? iii. false positives? iv. May help in cases of multiple discs when? 68.9.2 false true false false true 68.9.2 68 true false (>70) true true true false (>4 weeks) 68.9.3 decrease decrease decrease indentation convexity 68.9.4 68.9.5 bone controversial equivocal high one produces pain ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 380 Part 16: Spine and Spinal Cord Psychosocial Factors 19. List five signs of psychosocial distress in back pain, remembering that inappropriate response to any three suggests psychological distress is present. (Hint: PIAMP) a. P* b. I* 68 c. A* d. M e. P 68.13 physical exam over reaction inconsistent performance (straight leg test changes from sitting to standing, etc.) axial loading produces pain motor/sensory exam inconsistent with anatomy pain on superficial palpation Treatment 20. Clear indications for urgent lumbar surgery include a. c_____ e_____ b. p_____ n_____ d_____ c. p_____ w_____ 21. True or False. The following conservative therapy treatments have proven beneficial for patients with back pain: a. epidural steroids b. transcutaneous electrical nerve stimulation (TENS) c. traction d. oral steroids e. spinal manipulation f. muscle relaxants 68.14.1 cauda equina syndrome progressive neurological deficit profound weakness (motor) 68.14.2 false false false false false false 22. Is there a risk to the use of Parafon Forte? If so, what is the risk? yes; fatal hepatotoxicity 68.14.2 23. Is lumbar fusion for LBP without stenosis or spondylolisthesis ever recommended? yes, for patients with LBP due to 1 or 2 level DDD for ≥ 2 years who failed medical therapy, with disease at L4-L5 and/or L5-S1 68.14.3 24. When is lumbar spinal fusion indicated according to current practice guidelines? a. fracture/dislocation b. instability due to tumor or infection c. following disc excision for HLD or 1st time recurrence 68.14.3 yes yes no ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Low Back Pain and Radiculopathy d. as potential adjunct to discectomy in HLD with preoperative deformity or instability e. Pain associated with Modic type 1 changes? Modic type 2 or 3? 25. True or False. Standard discectomy and microdiscectomy are of similar efficacy. yes; no true Table 68.6 Table 68.7 68 50% 20% < 5% Coccydynia 27. True or False. Coccydynia is related to the following: a. Is worse when standing. b. Is most common in females. c. Differential involves local trauma, neoplasms, and prostatitis. d. Needs nuclear bone scan for workup. yes Chronic Low Back Pain 26. The patient’s chances of returning to work if off for a. 6 months is ______% b. 1 year is ______% c. 2 years is ______% 381 false (worse when sitting or rising from sitting) true true 68.16.1 false (CT for bony pathology, and MRI for detecting soft tissue masses) 68.16.3 68.16.2 Failed Back Surgery Syndrome 28. Failure rate for lumbar discectomy to provide long-term pain relief is ___ ___% 29. Common etiologies of failed back surgery syndrome include but are not limited to: a. incorrect initial diagnosis b. continued nerve root compression 8-25% 68.17.1 68.17.2 true (clinical findings not correlating with imaging abnormality, imaging consistent but actually symptomatic from other diagnosis (e.g. trochanteric bursitis, diabetic amyotrophy, etc.)) true (residual compression, recurrent pathology, adjacent pathology, peridural scar, epidural hematoma, etc.) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 382 Part 16: Spine and Spinal Cord c. temporary nerve root injury 68 false (associated with permanent injury from original compression) 30. Discitis usually produces back pain ___ 2-4 - ___ weeks post-op. 68.17.2 31. Arachnoiditis: a. Also known as ______ arachnoiditis. b. Inflammatory fibrosis of which meningeal layers? c. Increased risk associated with which of the following: i. spinal anesthesia ii. spinal meningitis iii. autoimmune diseases iv. trauma 68.17.3 32. MRI findings in arachnoiditis typically are in 3 patterns: a. c_____ a_____ separating nerve roots into 1 or 2 chords b. e_____ t_____ s_____: only CSF signal visible intrathecally adhesive pia, arachnoid, dura true true false true 68.17.3 Central adhesion Empty thecal sac- roots adhere to meninges around periphery c. thecal sac filled with i________ t_______ inflammatory tissue; no CSF signal, candle-dripping appearance 33. At 6-month follow up, ___% of patients will have extensive peridural scar, but ___% of the time, these are asymptomatic. 43%; 84% 68.17.4 34. Peridural scar is best evaluated by what imaging modality? a. True or False. Unenhanced MRI shows scar that becomes more enhanced from T1WI to T2WI. b. True or False. Enhanced MRI shows enhancement of scar. MRI with and without IV gadolinium false (Becomes less intense whereas HLD becomes more intense with this transition.) true (Enhances inhomogeneously, whereas disc does not enhance at all.) 68.17.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 69 Lumbar and Thoracic Intervertebral Disk Herniation / Radiculopathy 69 Lumbar Disc Herniation and Lumbar Radiculopathy 1. Radiculopathy typically presents with ____________________________. pain and/or subjective sensory changes (numbness, tingling) in nerve root dermatome 69.1.1 2. True or False. Radiculopathy causes hyperreflexia. false (sometimes accompanied by weakness and decreased reflex changes) 69.1.1 3. Typical disc herniation compresses the below nerve exiting the neural foramen at the level ______. 69.1.1 4. True or False. Surgical indications include a. cauda equine syndrome b. numbness of foot c. progressive symptoms d. abnormal MRI e. neurologic deficits f. abnormal discogram g. failed conservative treatment h. pain when coughing i. severe radicular pain for 2 weeks j. severe back pain 69.1.1 5. Why do disc herniations tend to occur slightly off midline posteriorly to one side within the central canal? true false true false true false true false false (6 weeks) false Posterior longitudinal ligament is strongest in midline, and posterolateral annulus bears disproportionate load from above. 69.1.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 384 Part 16: Spine and Spinal Cord 6. Complete the following regarding lumbar disc herniation: a. Occurrence of voiding dysfunction in lumbar disc herniation varies from ___ to ___%. b. Concerning bladder symptoms, what is the sequence of events from the earliest findings? i. d_____ b_____ s_____ ii. u_____ u_____ iii. i_____ f_____ iv. e_____ and i_____ 69 c. Urinary retention with overflow incontinence is suggestive of what diagnosis? 7. What is the most sensitive sign of herniated lumbar disc? 8. Regarding the significance of a positive crossed straight-leg raising sign. a. Specificity for nerve root compression of ___%. b. It suggests a more ______ HNP. c. It may correlate with a disc fragment within the ______ of the contralateral root. d. Lasègue specificity for root compression is ___% e. For crossed Lasègue, the percentage increases to ___% 9. Describe a positive Lasègue’s sign: a. patient positioned ________ b. raise leg by the ankle until ___________ c. pain occurs below ___ degrees d. positive in ___% herniated nucleus pulposus (HNP) 69.1.5 1 to 18% decreased bladder sensation urinary urgency increased frequency (due to increased postvoid residual) enuresis (bed wetting) and incontinence are rare cauda equina compression Lasègue’s sign 69.1.6 90% Table 69.1 central axilla 69.1.6 83% 90% 69.1.6 supine pain elicited, specifically in leg (paresthesias or pain). Back pain alone is negative SLR. 60 83% (most likely to be positive in patients under 30) 10. Describe the following techniques to elicit indications of nerve root tension: a. Lasègue’s sign straight leg raising by ankle b. Cram test extend knee with leg already raised c. Fajersztajn’s sign crossed SLR (central disc). 97% HNP had this be positive d. Femoral stretch test prone, knee maximally flexed = L2, L3, L4 root lesions 69.1.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Lumbar and Thoracic Intervertebral Disk Herniation / Radiculopathy e. Bowstring sign 385 flex knee after SLR: Hip pain persists but sciatic pain ceases sitting SLR f. Sitting knee extension 11. Describe the FABER test a. also known as ________ _____ b. performed by ___________________ ____________ 69.1.6 12. Complete the following regarding the Trendelenburg sign: a. The affected hip ______ when the patient is walking, b. which indicates the contralateral thigh adductors are ______. c. This causes the contralateral pelvis to ______, d. which is caused by a lesion of the ______ root. 69.1.6 Patrick's test flexion abduction, external rotation; lateral malleolus on contralateral knee, with downward pressure on flexed knee c. positive sign indicative of ____ ________ hip pathology 13. Complete the following about crossed adductors sign: a. Crossed adductors sign is positive when knee jerk is elicited and the contralateral thigh ______ ______. b. If knee jerk is i. hyperactive, it suggests ____ ______ ii. hypoactive, it suggests ____________ ______ 14. Complete the following about Hoover’s sign: a. It is a test to learn if patient’s leg weakness is ______. b. Examiner places hand under patient’s normal ______. c. When asked to lift the weak leg, lack of effort to move the ______ leg ______ is indication that weakness is functional. 15. For the listed lumbar disc level, what is the frequency of herniated disc syndrome? a. L5-S1: ___ - ___% b. L4-5: ___ - ___% c. L3-4: ___ - ___% 69 dips weak tilt L5 (Affected hip dips when walking to indicate weakness of contralateral thigh adductors, or while standing on leg with weak adductors causes pelvis to tilt contralateral to weakness.) 69.1.6 adductors contract UMN lesion pathological spread due to nerve root irritation 69.1.6 functional (vs. organic) heel normal; down Table 69.3 45-50% 40-45% 3-10% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 386 69 Part 16: Spine and Spinal Cord 16. Name physical findings associated with a L5-S1 disc herniation and where pain radiates. a. Reflex: absent a______ r______ achilles reflex b. Motor: ______ weakness gastrocnemius (plantar flexion) c. Sensory: decreased at l_____ m_____ lateral malleolus and lateral and l_____ f_____ foot d. Pain: posterior aspect of ____ and _____ calf and ankle Table 69.3 17. Name three indicators for emergency lumbar surgery. (hint: ces, pmd, ip) a. ces 69.1.9 b. pmd c. ip 18. List potential findings for cauda equina syndrome. (Hint: cauda-s) a. C b. A c. U d. D e. A f. S 19. True or False. The following is classically recognized as a cause of the cauda equina syndrome: a. tumor b. epidural spinal hematoma c. free fat graft following discectomy d. trauma/fracture e. lumbar stenosis 20. True or False. In cauda equina syndrome, surgery should be performed a. stat b. within 24 hours c. within 48 hours d. within 72 hours e. within a week cauda equina syndrome (urinary retention and/or overflow incontinence, saddle anesthesia) progressive motor deficit (i.e. foot drop) intolerable pain (urgent) 69.1.9 Can’t function sexually (sexual dysfunction) Ankle jerk absent Urinary retention/incontinence (most consistent finding) Diminished sphincter tone Anesthesia of saddle area (most common sensory deficit) Strength decreased 69.1.9 true true true true false (more chronic process/ would not classically give an acute/subacute presentation of CES) 69.1.9 false false true false false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Lumbar and Thoracic Intervertebral Disk Herniation / Radiculopathy 21. True or False. Comparing microdiscectomy to standard discectomy for lumbar disc herniation, which of the following are true? a. shorter incision b. shorter hospital stay c. less blood loss d. better efficacy e. may be more difficult to retrieve large fragments 69.1.9 true true true false (Efficacy has been shown to be equivalent between the two techniques.) true 22. Success rate at 1 year for surgical discectomy is ___%. 85% 69.1.9 23. True or False. Intradiscal procedures such as chemonucleolysis are used more than discectomy. false 69.1.9 24. Complete the following about intradiscal procedures: a. What percentage of lumbar disc patients 10-15% considered for surgery could be candidates for intradiscal procedures? b. What is the success rate of intradiscal 37-75% procedures (pain free and return to work)? 69.1.9 25. True or False. Following discectomy: a. Epidural steroids prior to closure have no true benefit. b. Systemic steroids and bupivacaine may true reduce hospital stay and postop narcotic requirements. 69.1.9 26. True or False. Regarding epidural free fat graft. a. It can cause nerve root compression. b. It is believed to reduce epidural scar formation. c. Some believe it may increase epidural scar. d. It increases the incidence of postoperative infection. e. It may cause cauda equina syndrome. 69.1.9 27. Characterize complications of lumbar disc surgery. a. Mortality: ___% b. Superficial infection: __ - __% with ______ organism c. Deep infection: ___% d. Discitis: ___% e. Motor deficit: __ - __% 387 69 true mixed (opinions vary) true false true but rare 69.1.9 0.06% (1/1800 patients) 0.9-1%, S. aureus <1% (discitis, spinal epidural abscess) 0.5% 1-8% (some transient) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 388 f. g. h. i. j. Part 16: Spine and Spinal Cord Durotomy: __ - __% Durotomy after redo: ___% Surgical repair: ___ Pseudomeningocele: __ - __% Recurrent disc: ___% 0.3-13% 18% 1/1000 patients 0.7-2% 4% (with 10 year follow-up) 28. Complete the following about durotomy: a. What is the incidence of incidental durotomy in lumbar laminectomy? b. Give four possible complications related to incidental durotomies. i. C__________________________ ii. p__________________________ iii. h__________________________ iv. i__________________________ 69 29. What is the incidence of recurrent herniated lumbar disc? a. same level either side in first 10 years ___% b. any level over 10 years c. first year same level either side ___% d. any different incidence depending on level e. same level recurrence ___% f. different level recurrence ___% 30. Complete the following regarding the anterior longitudinal ligament: a. Asymptomatic perforations occur in ___% of discectomies. b. Depth of disc space is ___. c. Vascular injury produces bleeding into operative field only ___% of the time. d. Great vessel injury mortality is ___%. 31. Enumerate five complications related to positioning for lumbar discectomies. Hint: tecup a. t________ b. c. d. e. e________ c________ u________ p________ 69.1.9 0.3-13% (increases to 18% on redos) CSF fistula-requiring repair in 10/10,000 patients pseudomeningocele 0.7-2% herniation of nerve roots increased epidural bleeding 69.1.9 ~4% 3-19% 1.5% 2x more common at L4-5 74% 26% 69.1.9 12% 3.3 cm 50% 37-67% 69.1.9 tibialis anterior compartment syndrome eyes pressure cervical spine injury ulnar nerve compression peroneal nerve compression ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Lumbar and Thoracic Intervertebral Disk Herniation / Radiculopathy 32. True or False. Regarding unintended durotomy. a. Normal ambulation is not considered a cause for failure of dural repair. b. Risk of a cerebrospinal fluid (CSF) leak is increased in i. revision surgery ii. removal of ossification of the posterior longitudinal ligament (OPLL) iii. high-speed drills c. It is not considered an act of malpractice. d. The use of fibrin glue to close is advantageous. e. It can be due to thinned dura by longstanding stenosis. 33. Enumerate four signs of postoperative cauda equina syndrome (i.e., from epidural hematoma). Hint: pain a. p________ b. a________ c. i________ d. n________ 34. True or False. Regarding the outcome of surgical treatment of lumbar herniated disc. a. 5% will be classified as having failed back syndrome. b. At 1 year the surgical group had a better outcome than with conservative treatment. c. The benefit persisted at 10 years. 389 69.1.9 true true true true true true true 69 69.1.9 pain out of the ordinary anesthesia of saddle area inability to void numerous muscle groups weak 69.1.9 true true false (Surgery group had better outcome at 1 year but benefit was no longer statistically significant at 4year follow-up. At 10 years neither surgical nor conservative treatment group complained of sciatica or back pain.) d. 63% had complete relief of back pain at 1 true year post-op. e. At 5- to 10-year follow-up 86% felt true improved. ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 390 Part 16: Spine and Spinal Cord 35. True or False. The percentage of patients with L3-4 disc herniation having a past history of L4-5 or L5-S1 disc herniation is a. < 10% b. approximately 25% c. approximately 50% d. 60 to 80% e. almost 90% 69 36. Characterize a herniated upper lumbar disc. a. What is the incidence? i. L1-2: ________% ii. L2-3: ________% iii. L3-4: ________% b. Most common muscle involved? c. Femoral stretch test ____________. d. Knee jerk ______________. 37. Characterize extreme lateral lumbar disc herniations. a. What is the incidence? b. What level is most commonly involved? i. L4-5: ________% ii. L3-4: ________% iii. L5-S1: ________% c. Enumerate four differences compared with other common disc herniations. i. Straight leg raising (SLR) is negative in ___ - ___%. ii. Pain is increased by lateral bending in ________%. iii. Pain is more ________. iv. Extruded fragments are _____ _______. 38. Distinguishing features concerning far lateral disc herniation include the following: a. The root involved is the root ________ ________ ________ ________. b. SLR is ________. c. Lateral bending is _________________. d. Severity of pain is ________ because ________ ________ ________ is compressed. e. Most common levels are ________ and ________. f. Best surgical approach is ________ ___________. 69.1.10 false true false false false 69.1.10 0.28% 1.3% 3.6% quadriceps femoris may be positive reduced in 50% 69.1.11 3 to 10% 60% 24% 7% 85 to 90% 75% severe more frequent 69.1.11 exiting at that level negative likely to produce pain greater; dorsal root ganglion L4-5 and L3-4 standard hemilaminectomy (and follow nerve laterally; perform medial facetectomy) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Lumbar and Thoracic Intervertebral Disk Herniation / Radiculopathy 39. Zones in which disc herniation can occur are: a. c________ b. s________ c. f________ d. e________ 69.1.11 central subarticular foraminal extraforaminal 40. True or False. One third of extreme lateral lumbar disc herniations are missed on initial radiologic exams. true 69.1.11 41. To test for far lateral disc, what is the value of post-discography CT scan? may be the most sensitive test—94% 69.1.11 42. Give the incidence of surgery for herniated discs in pediatric patients. a. under 20 years of age: ________% b. under 17 years of age: ________% 43. Characterize intradural disc herniation. a. What is the incidence? b. Can it be diagnosed preoperatively? c. It is suspected at surgery because of a n________ e________. d. Does it require a surgical dural opening? 391 69.1.12 less than 1% less than 1/2 of 1% 69 69.1.13 0.04 to 1.1% rarely negative exploration rarely 44. Regarding intravertebral disc herniations, answer the following: a. It is also known as _________ _______. b. Herniation occurs through what structure? 69.1.14 Schmorl’s nodes through the cartilaginous end plate into cancellous bone of the vertebral body c. True or False. Presentation is similar to false - Presents with low back typical herniated disk with radiculopathy. pain aggravated by axial weight load bearing. d. Radiographically on MRI i. Symptomatic (acute) lesions present low; high as ______ on T1WI and ______ on T2WI. ii. Asymptomatic (chronic) lesions high; low present as ______ on T1WI and ______ on T2WI. e. Treatment? conservative therapy with NSAIDs. Symptoms generally improve within 3-4 months. 45. a. b. c. Characterize recurrent herniated disc. second herniation: ___ - ____% 10 years same level: ________% 1 year same level: ________% 69.1.15 3 to 19% 4% 1.5% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 392 Part 16: Spine and Spinal Cord 46. Does it take a larger or smaller disc herniation to cause symptoms in recurrent disc? Why? Because s_______ t_______ prevents the nerve from moving away. 69 smaller; scar tissue 69.1.15 Thoracic Disc Herniation 47. Characterize thoracic disc herniation. a. It usually occurs below the level of________. b. Because many are calcified it is wise to get a ________ ________. c. The incidence is ____ to ____% of all disc herniations. d. ________% occur between ages 30 and 50. e. History of trauma is ________%. 48. Characterize access to the thoracic spine. a. upper: ________ b. mid: ________ c. lower: ________ d. thoracolumbar: ________ e. lumbar: ________ 49. Complete the following concerning the thoracic spine and spinal cord anterior access to: a. lower thoracic spine i. use ________ side thoracotomy ii. avoid ________ ________ iii. easier to mobilize ________ b. thoracolumbar spine i. use ________ side retroperitoneal approach ii. thereby avoiding ________ 69.2.1 T8 CT scan 0.25 to 0.75% 80% 25% sternal splitting right thoracotomy (heart not in way) left–easier to mobilize aorta than vena cava right to avoid liver unless pathology is far on left side transabdominal 96.1.1 96.2.2 96.2.3 96.4.1 96.5.1 96.2.3 left vena cava aorta 96.4.1 right liver ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 70 Cervical Disc Herniation General Information 1. Where does the cervical root exit in relation to the pedicle? in close relation to the undersurface of the pedicle 70.1 Cervical Nerve Root Syndromes (Cervical Radiculopathy) 2. Complete the following table concerning cervical disc syndromes: Table 70.1 (incomplete) 70 Table 70.1 Table 70.1 (complete) (Reprinted with permission from Greenberg MS, th Handbook of Neurosurgery. 8 ed. New York: Thieme; 2016.) 3. Complete the following about intervertebral disc herniation: a. C6-7 disc causes a C________ radiculopathy. b. C5-6 disc causes a C________ radiculopathy. c. It may simulate a ________. C7 70.2.1 C6 70.2.2 myocardial infarction 4. A left C6 radiculopathy can simulate an ________ ________ ________. acute myocardial infarction 70.2.2 5. C8 or T1 nerve root involvement (i.e., a C7-T1 or T1-T2 disc) may produce a partial ________ syndrome. a partial Horner syndrome 70.2.2 6. The most common scenario for patients with herniated cervical discs is that the symptoms were first noticed upon ____________________. awakening in the morning (without identifiable trauma and stress) 70.2.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 394 Part 16: Spine and Spinal Cord 7. Complete the following about intervertebral disc herniation: a. C4-5 disc compresses C ________ root________. b. C7-T1 disc compresses C ________ root 9. Complete the following about the Spurling’s sign: a. Performed by i. examiner exerting pressure on the________ ii. while patient tilts head toward the________ ________ iii. with neck ________. b. Reproduces ________ ________. c. analogous to ________ C8 root Spurling’s sign 70.5.2 70.5.2 vertex symptomatic side extended radicular pain SLR for lumbar disc—a mechanical sign Radiologic Evaluation 10. Give the accuracy of radiological workups. a. MRI is ____ to ____%. b. CT myelogram is ________%. C5 root Physical Exam for Cervical Disc Herniation 8. Narrowing the cervical foramen mechanically is called ________ ________. 70 Table 70.1 85 to 90% 98% 70.6.1 70.6.2 Cervical Myelopathy and SCI due to Cervical Disc Herniation 11. a. b. c. d. e. f. g. h. i. j. True or False. Regarding fusion. a plate reduces pseudoarthrosis. a plate reduces graft problems. a plate maintains lordosis. improves clinical outcome. improves arm pain. provides more rapid relief of arm pain. maintains foraminal height. maintains disc space height. reduces post-op kyphosis. improves fusion rate. 12. What is the incidence of vocal cord paresis due to injury of the recurrent laryngeal nerve (RLN)? a. Temporary: ________ % b. Permanent: ________ % 70.7.3 true true true false true true false false true true 70.7.3 11% 4% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Cervical Disc Herniation 13. True or False. A good way to treat vertebral artery injury is by a. packing b. direct suture c. endovascular trapping 70.7.3 false true true 14. The rare complication of sleep-induced C3-4 apnea can occur with anterior cervical discectomy and fusion (ACDF) at the level of ________. 70.7.3 15. Characterize dysphagia following ACDF. a. Incidence early is ________%, b. at 6 months only ________%. c. Most serious cause is ________. d. Permanent recurrent laryngeal nerve injury occurs in ________%. 70.7.3 16. Characterize pseudoarthrosis following ACDF. On flexion extension cervical spine x-rays: a. movement of more than ________ mm b. between the ________ ________ c. lack of ________ across the fusion d. l________ around the screws e. t________ of the screws on flexion extension films f. n________ uniformly associated with symptoms 17. For patients in certain professions we prefer to do posterior cervical surgery instead of anterior. a. Which two professions? b. The reason is that there is a ________% incidence of ________ ________ after anterior cervical surgery. 18. Indications for posterior keyhole laminotomy are a. s________ l________ d________ b. occupation of s________ or s________ c. l______- or u______-l______ d______ 395 60% 5% hematoma 1.3% 70.7.3 70 2 spinous processes trabeculation lucency toggling not 70.7.3 speaker and singer 4%; voice change 70.7.3 soft lateral disc singer or speaker lower- or upper-level disc ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 396 Part 16: Spine and Spinal Cord 19. Matching. Match the recommended sequence of bone removal with the recommended sequence for posterior keyhole laminotomy. Sequence of bone removal recommended: ① superior facet of the vertebra below; ② inferior facet of the vertebra above; ③ lateral aspect of lamina above Recommended sequence: (a-c) below a. 1st area of bone removal b. 2nd area of bone removal c. 3rd area of bone removal 20. The success rate of posterior keyhole laminectomy is in the range of ________ to ________ %. 70.7.3 ③ ② ① 90 to 96% 70.7.3 70 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 71 Degenerative Cervical Disc Disease and Cervical Myelopathy General Information 1. Cervical degenerative disc disease is generally discussed in terms of “________ ________,” a term which is sometimes used synonymously with “cervical spinal stenosis.” cervical spondylosis 71.1 71 Clinical 2. Cervical spondylosis is the most common cause of myelopathy in patients >___ yrs of age. 3. Characterize the frequency of symptoms for the following reflexes a. hyperreflexia: ___% b. Babinski: ___% c. Hoffman: ___% 4. Complete the following about degenerative disc/spine disease: a. What reflex test is said to be pathognomonic of cervical spinal myelopathy? b. Elicited by performing the ____________ ________ c. and obtaining a response of f________ of the f________. 5. Complete the following regarding hyperactive jaw jerk: a. Significant is that it indicates an u________ m________ n________ l________ b. located a________ t________ m________. 55 71.3.1 Table 71.1 87% 54% 12% 71.3.4 inverted radial reflex brachioradialis reflex flexion of the fingers 71.3.4 upper motor neuron lesion above the midpons (It distinguishes this from UMN lesions due to lower-level causes, i.e., cervical myelopathy.) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 398 Part 16: Spine and Spinal Cord Differential Diagnosis 6. Complete the following table to differentiate amyotrophic lateral sclerosis (ALS) from cervical myelopathy: Table 71.1 (complete) Table 71.1 (incomplete) 7. True or False. Concerning ALS: a. Jaw jerk is present. b. Tongue fasciculations are present. 71 71.4.2 71.4.2 true (may be first clue) true (as seen on EMG or visible fasciculations) Evaluation 8. Complete the following about degenerative disc/spine disease: a. cervical spine myelopathy, spinal canal diameter i. myelopathic at ________ mm or less ii. symptomatic at ________ mm iii. increased risk at ________ mm b. not symptomatic at ________ mm or more 71.5.1 10 mm or less 11.8 mm 14.0 mm 14 mm 9. True or False. Regarding MRI abnormalities that correlate with poor prognosis in cervical spondylitic myelopathy. a. T2W1 hyperintensity within the cord true b. A “banana” shaped cord on axial images false has no correlation with the presence of CSM. c. “snake eyes” on axial T2W1 true 10. True or False. Preop SSEP testing can aid in decision making. true 71.5.2 71.5.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Degenerative Cervical Disc Disease and Cervical Myelopathy 399 Treatment 11. Contraindications to posterior decompression are a. kyphotic angulation, also known as ________ ________. b. subluxation of greater than ________ mm c. or rotation in the sagittal plane of more than ________ degrees. 12. Characterize cervical spondylitic myelopathy. a. Post-op palsy after anterior or posterior decompression occurs in ____ to ____%. b. It involves the d________ or b________ muscles c. and C5 region, which provides sensation to the ______ area. d. It usually occurs within ________ ________ of surgery. e. Prognosis for recovery is ________. 71.6.2 swan neck 3.5 mm 20 degrees 71.6.2 3 to 5% deltoid, biceps shoulder 1 week good 71 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 72 Thoracic and Lumbar Degenerative Disc Disease General Information about Degenerative Disc Disease (DDD) 1. Since structures outside of the disc are degenerative disc disease usually also involved, the term degenerative spine disease (DSD) may be preferable to ________ ________ ________. 72 72.1 Anatomic Substrate 2. Enumerate the changes that occur in the intervertebral disc with increasing age. (Hint: ddddisc) a. d_____ b. d_____ c. d. e. f. g. d_____ d_____ i_____ s_____ c_____ 3. What level is most commonly the site of lumbar stenosis? 4. a. b. c. d. Characterize lateral recess stenosis. Is the pain unilateral or bilateral? It is due to ________ of the ________ ________ facet. The most common level is at ________. 72.2.1 decrease disc height decrease in proteoglycan content desiccation (loss of hydration) degeneration of mucoid ingrowth of fibrous tissue susceptibility to injury circumferential tears of the annulus L4-5 and then L3-4 72.2.2 72.2.4 can be either hypertrophy superior articular L4-5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Thoracic and Lumbar Degenerative Disc Disease 5. Complete the following about degenerative disc/spine disease: a. Spondylolisthesis or anterior subluxation of one vertebral body on another is graded according to the percent of ________. b. List the % for the following grades. i. I ________% ii. II ___ to ____% iii. III ___ to ____% iv. IV ________% 6. What posture may elicit pain in lumbar stenosis in adolescents and teens? 7. Complete the following about degenerative disc/spine disease: a. True or False. It is common for listhesis to cause root compression. b. If it does do so it compresses the nerve root that ________ at that level c. below the ________ above d. compressed by the ________ ________ ________ e. being displaced ________. 8. a. b. c. What is a pseudo disc? It is the appearance on ________ in a patient with ________. It is more common to see a herniated disc at the level ________ the listhesis 401 72.2.5 subluxation < 25% 25 to 50% 50 to 75% 75% to complete hyperextension 72.2.5 72.2.5 false exits pedicle superior articular facet upward 72.2.5 72 MRI listhesis above Associated Conditions 9. What two congenital conditions are associated with spinal stenosis? 10. Paget’s disease and ankylosing spondylitis are examples of ________ conditions that are associated with spinal stenosis? achondroplasia and congenitally narrowed canal 72.4 acquired 72.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 402 Part 16: Spine and Spinal Cord Clinical Presentation. Differential Diagnosis 11. Matching. Match the condition with the appropriate clinical feature(s). Clinical feature: ① pain is dermatomal; ② sensory loss stocking; ③ sensory loss is dermatomal; ④ pain with exercise; ⑤ pain with standing; ⑥ rest relieves pain promptly; ⑦ rest relieves pain slowly; ⑧ relief with standing; ⑨ relief only with stooping or sitting; ⑩ achiness over thigh; ⑪ pain on pressure over hip; ⑫ Faber sign positive Condition: (a-c) below a. neurogenic claudication ①, ③, ④, ⑤, ⑦, ⑨ b. vascular claudication ②, ④, ⑥, ⑧ c. trochanteric bursitis ⑩, ⑪, ⑫ 13. State the AP diameter of the normal lumbar spine canal on plain films. a. lower limits of normal: ________mm b. severe lumbar stenosis: ________mm c. average: ________mm 14. Give the dimensions of lateral recess on CT. a. lateral recess height: ________ mm b. suggestive of lateral recess syndrome: ________ mm c. diagnostic of lateral recess syndrome: ________ mm 72.6.1 Diagnostic Evaluation 12. Give the normal lumbar spine CT measurements for each of the following: a. anteroposterior (AP) diameter ________mm b. ligamentum flavum thickness ________mm c. height of lateral recess ________mm 72 72.5.2 72.7.1 > 11.5 mm < 4 to 5 mm > 3 mm 72.7.1 15 mm less than 11 mm 22–25mm 72.7.1 3 to 4 mm < 3 mm < 2mm Treatment 15. Is treatment for asymptomatic moderate stenosis at adjacent levels appropriate? yes (They have a likelihood of progressing to become symptomatic.) 72.8.4 16. True or False. Patients who undergo decompressive laminectomies are likely to develop lumbar instability? false - Less than 1% 72.8.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Thoracic and Lumbar Degenerative Disc Disease 17. Complete the following: a. Stability is thought to be maintained if ____ - ____% of the facets are preserved during surgery b. and the ________ space is not violated. c. Younger or more active patients are at ________ risk of subluxing. 72.8.4 >50-60% disc higher 18. Matching. Following decompression in a patient, which procedures are appropriate? ① no fusion; ② posterolateral fusion; ③ adding pedicle screw instrumentation a. no instability preop ① b. instability preop ② c. spondylolisthesis preop ②, ③ 403 72.8.4 Outcome 19. Give the lumbar spinal stenosis outcomes. a. mortality: ________% b. superficial infection: ________% c. deep infection: ________% d. deep vein thrombosis (DVT): ________% e. postural pain relief: ________% f. recurrence after 5 years: ________% g. long-term success at 1 year and 5 years: ________% 20. a. b. c. Non-union risk factors include s________ number of ________ fused use of ________ type medications .32% 2.3% 5.9% 2.8% 96% 27% 70% 72.9.1 72.9.3 72 72.9.2 smoking levels NSAIDs ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 73 Adult Spinal Deformity and Degenerative Scoliosis General Information 1. Adult degenerative scoliosis: a. Spinal deformity with a Cobb angle > ___ 10 degrees degrees. b. Causes include asymmetric d_____ asymmetric disc d_____, h_____ p_____, o_____ degeneration, hip pathology, osteoporosis Epidemiology 2. Adult degenerative scoliosis is more prevalent in patients over ___ years old, and incidence of asymptomatic burden is over ___ % in the same age group. 73 73.1 60 years; 68% 73.2 Clinical Evaluation. Diagnostic Testing 3. Evaluation of ADS includes: a. Unlike lumbar spinal stenosis in the absence of scoliosis, spinal stenosis secondary to adult deformity is usually ______ by flexion, b. True or False. Diagnostic testing includes all of the following. i. CT ii. MRI iii. myelogram iv. DEXA scan v. standing x-rays not improved 73.3 73.4 true true false true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Adult Spinal Deformity and Degenerative Scoliosis 405 Pertinent Spine Measurements 4. Scoliosis nomenclature a. What are end vertebrae? 73.5.2 b. What does the Cobb angle measure? c. Which side of curve determines naming properties? d. What is the difference between a structural and non-structural curve? e. Major vs. fractional curve? Defined as top and bottom of scoliotic curve on AP x-ray. Angle made between a horizontal line through the superior endplate of the superior end vertebrae, and another line through inferior end plate of inferior vertebra. Convex side (convex to right=dextroscoliosis, convex to left=levoscoliosis) Non-structural curve can correct on side bending. Major is the largest structural curve. Fractional is curve below major curve. 5. Spino-pelvic parameters are important to understand ADS correction. Regarding the following measurements: a. Sagittal vertical alignment (SVA) i. Define it. horizontal distance from posterior edge of S1 endplate to plumb line (from mid C7 vertebrae) ii. What is normal? <5cm iii. Is this susceptible to error? yes, depending on patient pain level and accommodation b. Pelvic Tilt (PT) i. Define it. angle between vertical reference line (midpoint of femoral head) to midpoint of S1 endplate ii. What is normal? 10-25 degrees (goal is <20 degrees) c. Pelvic incidence (PI) i. Define it. angle between line perpendicular to S1 endplate, and line from midpoint of femoral head to middle of S1 endplate ii. What is normal? approximately 50 degrees iii. Does this change? no, not once skeletal maturity is reached d. Sacral Slope (SS) i. Define it. angle between the horizontal reference line and S1 endplate ii. What is normal? 36-42 degrees iii. SS = ___ - ___ PI - PT 73.5.3 73 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 406 Part 16: Spine and Spinal Cord e. Lumbar lordosis (LL) i. Define it. angle between top of S1 and top of L1 20-40 degrees LL = PI ± 9 degrees ii. What is normal? iii. What is the goal? f. Thoracic kyphosis (TK) i. Define it. ii. angle between top of T4 and bottom of T12 41 degrees, ± 12 degrees What is normal? SRS-Schwab Classification of Adult Spinal Deformity 6. What is the SRS-Schwab classification? Scoliosis classification based on regional radiographic features as well as spinopelvic parameters as it relates to quality of life. Treatment/Management 7. Indications for surgery? 73 73.6 8. a. b. c. axial back pain ± neuropathic symptoms deleterious to ADLs Summary of spino-pelvic objectives: LL: _________ degrees PT: ______ degrees SVA: ______cm 9. What is generally considered an appropriate goal for sagittal correction of lumbar lordosis, given retroverting the pelvis for compensation? 73.7.2 73.7.2 LL= PI ± 9 degrees <20 degrees <5cm Increase in LL needed is approximately equal to (PI – LL – 9 degrees) + (PT – 20 degrees) 73.7.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 74 Special Conditions Affecting the Spine Paget’s Disease of the Spine 1. a. b. c. d. Characterize Paget’s disease. Also known as o________ d________. Disorder of o________. Results in r________ of bone. Reactive osteoblasts o________produce bone. e. This results in sclerotic, radiodense, brittle bone called i________ b_______. 74.1.1 osteitis deformans osteoclasts resorption over ivory bone 2. Which spinal nerve is most commonly compressed as it exits through its bony foramina? CN VIII 74.1.5 3. Most common symptom of Paget’s disease is? bone pain 74.1.6 4. Typical presentation to a neurosurgeon includes: a. Neural compression due to i. expansion of w_____ b_____, ii. o_____ t_____, iii. pagetic extension into l_____ f_____ and e_____ f_____. b. Typically present for longer than ______. c. If symptoms progress over a timeframe < 6 months, then what is differential? i. m_________ ii. p_______ f_______ iii. compromise of n_______ s_______ 5. Recommended laboratory tests include: a. a________ ph________ b. ur________ hy________ c. bone scan ________ ________ areas of abnormality 74.1.6 74 woven bone osteoid tissue ligamentum flavum; epidural fat 12 months malignancy (sarcomatous) pathological fracture neurovascular supply (compression or pagetic vascular steal) 74.1.7 alkaline phosphatase urinary hydroxyproline lights up (localized enlargement of bone, cortical thickening, sclerotic changes, and osteolytic areas) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 408 Part 16: Spine and Spinal Cord d. Spinal Paget’s disease involves s_____ c_____ l_____ e. Treatment with c________ and b______ may reverse neurologic deficit in 50% of cases. 6. What are the neurosurgical indications in Paget’s disease of the spine? a. spinal ________ b. uncertain ________ c. failure of ________ ________ 74 several contiguous levels (pedicles/lamina thickened, vertebral bodies dense, discs replaced by bone) calcitonin; bisphosphonates 74.1.8 74.1.8 instability diagnosis medical management Ankylosing Spondylitis 7. Characterize ankylosing spondylitis. a. It is also known as M________S________ d________. b. Locus of involvement at the e________ c. Replacement of ________ with ________. d. Bone is very o________. e. On x-ray it is called b________ s________. f. To differentiate from rheumatoid arthritis (RA), serum is n________ for r________ f________. g. Fracture may occur with ________ ________. h. Screws for fusion may ________ ________. i. Enthesis i. is the ________ _______ ii. of ligaments, tendons or capsules on ________. 8. True or False. Ankylosing spondylitis usually presents as: a. radiating low back pain b. evening back stiffness exacerbated by inactivity and improved by exercise c. Patrick’s test is performed by compressing the pelvis with patient in lateral decubitus position. 9. What are radiologic considerations in ankylosing spondylosis? a. Rotary s________ may occur in high cervical area. b. Last area to stay mobile is the o________-a________ 74.2.1 Marie-Strümpell disease entheses ligaments with bone osteoporotic bamboo spine negative for rheumatoid factor minimal trauma not hold attachment point bones 74.2.3 false (non-radiating low back pain) false (Morning back stiffness. Everything else is accurate) true (Positive test will elicit pain.) 74.2.5 subluxation occipito-atlanto ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Conditions Affecting the Spine c. and a________ joints. d. Minor trauma may result in spine ________. e. Vertebral fractures occur through the ________ ________. f. An early site of involvement is the ________ joint. g. If suspicious, x-ray the ________ ________. 409 atlantoaxial fracture ossified disc SI joint (This is the sine qua non for definite diagnosis.) entire spine Ossification of the Posterior Longitudinal Ligament (OPLL) 10. Insert a term starting with the indicated letter to characterize the pathologic process of ossification of the posterior longitudinal ligament (OPLL). a. c________ b. d________ c. e________ d. f________ e. g________ f. h________ g. p________ h. o_______ 11. True or False. OPLL progresses in the following order: ① ossification; ② fibrosis; ③ calcification a. ①, ③, ② b. ②, ①, ③ c. ③, ①, ② d. ②, ③, ① 12. OPLL grows at a rate of a. ________ mm in the anterior posterior (AP) direction and b. ________ mm longitudinally per year. 74.3.2 calcification dura evolves from C3-4 fibrosis grows 0.6 mm/year in the AP direction and 4.1 mm/year in the longitudinal direction hypervascular periosteal ossification 74.3.2 74 false false false true 74.3.2 0.6 mm 4.1 mm 13. Provide the pathologic classification. a. Confined to space behind vertebral body segmental is called__________. b. Extends from body to body spanning continuous disc is called ________. c. Combines both of the above and has skip mixed areas is called ________. 74.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 410 Part 16: Spine and Spinal Cord 14. Describe the evaluation of OPLL. a. Plain x-rays ________ ________ to demonstrate OPLL. b. MRI: i. OPLL is difficult to appreciate until it is ________ mm thick. ii. T2W1 may be very ________. c. CT, especially with 3D reconstruction, is the ________ method. 15. List the clinical grading of OPLL. a. Class I b. Class II c. Class IIIA d. Class IIIB 16. Complete the following regarding Nurick grades of cervical spondylosis: a. Assess the extent of ________. b. Surgery showed no benefit for Nurick grades ________ and ________. c. Surgery was valuable for Nurick grades ________ and ________. d. Surgery was ineffective for Nurick grade ________. 74 74.3.6 often fail 5mm helpful best 74.3.7 x-ray only—radiographically evident; no symptoms or signs minimal—myelopathy A/O radiculopathy minimal or stable deficit myelopathy—moderate to severe myelopathy quadriplegia—moderate to severe quadriplegia 74.3.7 disability 1 and 2 3 and 4 5 Diffuse Idiopathic Skeletal Hyperostosis (DISH) 17. Characterize diffuse idiopathic skeletal hyperostosis (DISH). a. The following areas of the spine are affected in what percentage of cases? i. thoracic: ________% ii. lumbar: ________% iii. cervical: ________% iv. all three segments: ________% b. Area spared? c. Is the area spared in ankylosing spondylitis? 74.5 97% 90% 78% 70% sacroiliac joints no ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Conditions Affecting the Spine Scheuermann’s Kyphosis 18. Complete the following regarding Scheuermann’s kyphosis: a. It is defined as i. ________ wedging ii. of at least ________ degrees iii. of ________ or more ________ iv. ________ vertebral bodies. b. Which age group does it affect? 411 74.6.1 anterior 5 3; adjacent thoracic adolescents 74.6.2 Spinal Epidural Hematoma 19. What is the most common cause of spinal epidural hematoma? a. ________ plus b. h________ b________ t________ 74.7.1 trauma - almost exclusively in patients with higher bleeding tendency (anticoagulated, bleeding diathesis, etc.) 20. Complete the following about spinal epidural hematoma: a. The most common area of occurrence is ________. b. Is it anterior or posterior? thoracic 21. What is the usual presentation of spinal epidural hematoma? severe back pain (with radicular component) 74.7.1 often posterior (which facilitates removal) c. The most common category of patient is anticoagulated ________. 74.7.3 74 Spinal Subdural Hematoma 22. Complete the following regarding spinal subdural hematoma: a. They occur ________. b. They are often related to ________. c. Patients are usually on ________ medication. d. It may sometimes be managed ________. 74.8 rarely trauma anticoagulant conservatively ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 75 Other Non-Spine Conditions with Spine Implications Rheumatoid Arthritis 1. Name four upper cervical spine abnormalities associated with rheumatoid arthritis. a. b________ i________ b. a________ s________ c. s________ s________ d. v________ a________ i________ 75 2. What are the three stages in pathophysiology that lead to atlantoaxial subluxation in rheumatoid arthritis? (Hint: iel) a. infl________ at a________ s________ j________ b. ero________ c________ in o________ c. loo________ of the t________ l________ 75.1.2 basilar impression atlantoaxial subluxation subaxial subluxation (less common) vertebral artery insufficiency—due to changes at the craniocervical junction (less common) 75.1.3 inflammation at atlantoaxial synovial joints erosive changes in odontoid loosening of the transverse ligament 3. What percentage of rheumatoid Atlantoaxial subluxation arthritis patients develop subluxation? occurs in 25% of patients with rheumatoid arthritis. 4. Complete the following regarding atlantoaxial subluxation in rheumatoid arthritis: a. The odontoid C1 interval is normal when less than ________ mm. b. The asymptomatic patient needs surgery if distance is greater than ________ mm. c. To do transoral odontoidectomy, the mouth needs to open at least ________ mm. d. Mortality of C1-C2 wiring is ___ to ____%. 4 mm 75.1.3 75.1.3 8 mm 25 mm 5 to 15% 75.1.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Other Non-Spine Conditions with Spine Implications 5. Characterize posterior atlantodental interval (PADI). a. Correlates with the presence of _______. b. Predicts neurologic recovery following ________. c. No recovery occurs if the PADI is less than ________ mm. d. An indication for surgery is a PADI less than ________ mm. 75.1.3 paralysis surgery 10 14 6. What degree of atlantodental interval is a generally accepted surgical indication in asymptomatic patients? 8 mm (6 to 10 mm is the range) 75.1.3 7. What is the percentage of nonfusion for C1-C2 fusions in rheumatoid arthritis? 18 - 50% 75.1.4 8. Characterize basilar impression in rheumatoid arthritis. a. Changes in lateral masses are called e________. b. Permitting relationship of C1-C2 to change is called t________. c. Position of dens moves u________ i. causes compression of p________ and m________ ii. contributes to b________ compression 9. Matching. List the most common symptoms and signs of basilar impression of patients with rheumatoid arthritis and match with their order of frequency. ① 100%; ② 80%; ③ 71%; ④ 30%; ⑤ 22% a. limb paresthesias b. Babinski, hyperreflexia c. bladder incontinence/retention d. cranial nerve dysfunction e. headache f. ambulatory problems 10. Characterize basilar impression in rheumatoid arthritis. a. Pain may be a result of c________ of C1 and C2 nerves. b. Cranial nerve dysfunction results from compression of the m________. 413 75.1.6 erosive telescoping upward pons and medulla brainstem Table 75.3 75 ③ 71% ② 80% ④ 30% ⑤ 22% ① 100% ② 80% 75.1.6 compression medulla ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 414 Part 16: Spine and Spinal Cord 11. What is the treatment for basilar impression? a. if reducible with t________ i. C1 d________ l________ followed by ii. o________-c________ f________ b. in nonreducible patients i. t________ o________ r________ followed by ii. o________-c________ f________ 75.1.6 traction decompressive laminectomy occipital-cervical fusion transoral odontoid resection occipital-cervical fusion Down Syndrome 12. Down syndrome is associated with l________ l________ of the spine. ligamentous laxity 75.2.1 13. Incidence of AAS in Down syndrome is ________% 20% 75.2.2 75 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 76 Special Conditions Affecting the Spinal Cord Spinal Vascular Malformations 1. Characterize spinal AVM classification. a. Type I i. known as d________ A________ ii. IA: has a s________ arterial feeder iii. IB: has ________ or ________ arterial feeders iv. formed at the d________ r________ sleeve b. Intradural AVMs i. flow is ________ ii. ________% with acute symptoms c. Type II i. aka spinal g________ AVM ii. located i________ iii. true A________ of the cord iv. has a c________ n________ v. prognosis is ________ than dural AVM d. Type III i. aka ________ spinal AVM ii. essentially on enlarged ________ iii. occupies the e________ cross section e. Type IV i. aka ________ spinal AVM ii. aka ________ fistula iii. presents with ________ hemorrhage 2. What is the most common type of spinal AVM? a. type ________ b. dural ________ c. fed by a r________ a________ d. and draining into a s________ v________ e. on the ________ aspect of the cord f. ________ % are males 76.1.2 dural AVM single 2 or more dural root high 75% glomus intramedullary AVM compact nidus worse juvenile glomus entire 76 perimedullary arteriovenous catastrophic 76.1.2 type 1 AVM radicular artery spinal vein posterior 90% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 416 Part 16: Spine and Spinal Cord 3. What is the most common presentation of a spinal AVM? a. onset of ________ pain b. progressive lower extremity ________ and ________ ______ 4. Spinal AVM with pain may have this syndrome. a. Onset of subarachnoid hemorrhage (SAH), and sudden excruciating back pain is also called c________ d________ p________ of Michon. b. This is considered clinical evidence of ______ _______. 5. a. b. c. d. e. What is Foix-Alajouanine syndrome? Acute or subacute ________ ________ in a patient with ________ ________ without evidence of ________ caused by ________ ________ with secondary ________ back pain weakness and sensory loss— acute onset of back pain associated with progressive LE weakness and sensory loss (may be over months to years) 76.1.3 Coup de Poignard of Michon spinal AVM 76.1.3 neurologic deterioration spinal AVM hemorrhage venous hypertension ischemia Spinal Meningeal Cysts 6. What is a Tarlov’s cyst? spinal meningeal cyst 7. What are the different types of spinal meningeal cyst, and which compartment are they located in? a. Type I b. Type II 76 76.1.3 c. Type III 8. Complete the following statements about spinal meningeal cyst: a. Type II spinal meningeal cyst is also known as ________ ________. b. It occurs on the ________ roots. 9. What are the treatment options for spinal meningeal cyst? a. e_________________ b. o_________________ c. m_________________ 76.2.1 76.2.1 superficial compartment extradural without root fibers middle compartment extradural with spinal root fibers—diverticulum central compartment intradural arachnoid cyst 76.2.1 Tarlov’s cyst dorsal 76.2.4 excise the cyst obliterate the ostium between cyst and subarachnoid space marsupialize if excision is not possible ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Conditions Affecting the Spinal Cord 417 Syringomyelia 10. Complete the following about syringomyelia: a. ________ cavitation of the spinal cord b. associated with Chiari I in ________% c. Affects upper or lower extremities first? d. More rapid neurologic progression is predicted by a cavity more than ________mm in diameter and with associated cord ________. 11. Rostral extension into brainstem is called ________. 12. Communicating syringomyelia is commonly associated with what congenital conditions? (Hint: bCDe) a. b________ b. C________ c. D________ d. e________ 13. What are the main presenting symptoms and signs of a syrinx? (Hint: accC) a. a________ w________ b. c ________ s________ l________ c. c ________/o________ p________ d. C ________ j________ (p________ a________) 14. Distinguish from similar entities. a. Tumor cyst i. Most e________. ii. Fluid is p________. iii. Syrinx fluid has MRI characteristics of C________. b. Residual spinal canal i. Central canal usually ________. ii. Is not more than ________ to ________ mm wide. iii. Is perfectly ________ on cross section. iv. Is perfectly in the ________ on axial MRI. 15. Dilatation of central canal with ependymal cell lining is called ________. 76.4.1 cystic 70% upper 5 mm; edema syringobulbia 76.4.1 76.4.2 basilar impression Chiari malformation Dandy-Walker syndrome ectopia of cerebellum 76.4.6 arm/hand weakness sensory loss with suspended “cape” dissociated sensory loss (loss of pain and temperature with preserved joint position sense) cervical/occipital pain Charcot’s joints—painless arthropathies 76.4.8 76 enhance proteinaceous CSF involutes 2 to 4 round center hydromyelia 76.4.8 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 418 Part 16: Spine and Spinal Cord Posttraumatic Syringomyelia 16. True or False. The level of spinal injury that has the highest incidence of posttraumatic syringomyelia is a. cervical b. thoracic c. lumbar 17. Characterize posttraumatic syringomyelia. a. Most common symptom is ________. b. Most common sign is ________ ________ ________. 18. What may be the only feature of descending syringomyelia in patients with complete cord lesions? 19. Complete the following statements about traumatic syringomyelia: a. Incidence is ________. b. Latency is ________. c. What should raise the index of suspicion for a syrinx in a patient who is paraplegic from trauma? i. The ________ development ii. in a ________ iii. of ________ ________ weakness. 76 76.5.2 false true false Table 76.6 pain - not relieved by analgesics ascending sensory level hyperhidrosis 76.5.3 3.2% average 9 years after injury 76.5.2 76.5.3 late paraplegic patient upper extremity Spinal Epidural Lipomatosis (SEL) 20. Characterize spinal epidural lipomatosis (SEL). a. due to h________ of epidural fat b. due to i. o________ and/or ii. exogenous s________ c. Symptoms i. first is ________ ________ ii. progressive ________ ________ ________ iii. and ________ changes. d. Most occur in the ________ spine. e. Diagnose by using _______ or _______. f. Should be at least ________ mm thick to be SEL. g. Treatment i. Reduce the use of ________ or ii. lose ________. iii. Remove ________. h. Complication rate is ________. hypertrophy 76.7.1 obesity steroids back pain lower extremity weakness sensory thoracic CT or MRI 7 76.7.2 76.7.3 steroids weight surgically high 76.7.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 77 Introduction and General Information, Grading, Medical Management, Special Conditions Definition 1. Complete the following about aneurysmal SAH: a. What percentage of patients die before reaching the hospital? b. What is the risk of rebleeding within 2 weeks? c. What is the risk of death from vasospasm? d. What is the risk of severe deficit from vasospasm? e. What is the 30-day mortality rate? f. What is the strongest prognostic indicator? 10-15% 15-20% 7% 7% about 50% severity of clinical presentation Etiologies of SAH 2. True or False. Etiologies of subarachnoid hemorrhage (SAH) include the following: a. arteriovenous malformation (AVM) rupture b. vasculitis c. encephalitis d. drug use e. coagulopathy f. dural sinus thrombosis 77.1.3 77.2 true true false true true true 77 Incidence 3. What is the incidence of aneurysmal SAH? 9.7-14.5 per 100,000 77.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 420 Part 17: SAH and Aneurysms Risk Factors for SAH 4. True or False. Risk factors for SAH include the following: a. hypertension b. genetic syndromes c. cigarette smoking d. pregnancy true true true false Clinical Features 5. True or False. SAH may present as any of the following: a. meningismus b. photophobia c. hearing loss d. low back pain e. ptosis 6. True or False. Formal angiography is indicated in a. sentinel hemorrhage b. crash migraine (thunderclap headache) c. benign orgasmic cephalgia 7. The incidence of sentinel hemorrhage is ____ - ____%. 8. True or False. Regarding benign thunderclap headache. a. Can be distinguished from SAH. b. Reaches maximal intensity in one minute. c. Is accompanied by vomiting. d. Never recurs. e. Is related to vascular cause. f. CT and LP show no blood. g. Require angiography. 77 77.4 9. Complete the following about reversible cerebral vasoconstrictive syndrome: a. Has a s________ onset. b. Associated with n________ deficit. c. Angiography shows ________ appearance, d. which clears within ________ months. e. Associated with v________ drugs. f. May occur p________. 10. Complete the following about benign orgasmic headache: a. Occurs just before or at time of o________. b. Workup is the same as for t________ headache. 77.5.1 true true false true true 77.5.2 true false false 30-60% 77.5.2 77.5.2 false true true false true true false 77.5.2 sudden neurological string of beads 1-3 months vasoconstrictive post-partum 77.5.2 orgasm thunderclap ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 General Information, Grading, Medical Management, Special Conditions 421 11. Complete the following about meningismus: a. aka n________ r________ b. Signs i. Bend neck and hip flexes called ________ sign ii. Knee bent then straightened causes ______ pain and is called _____ sign 12. True or False. Coma in SAH may be due to the following: a. seizure b. increased intracranial pressure (ICP) c. intraparenchymal hemorrhage d. hydrocephalus e. low blood flow 13. What percentage of patients with subarachnoid hemorrhage have funduscopic abnormalities? 14. Matching. Match the type of ocular hemorrhage with the associated characteristic(s). Ocular hemorrhage: ① subhyaloid; ② retinal; ③ vitreous Characteristic: (a-e) below a. bright red blood near optic disc b. vitreous opacity c. blood obscures the retinal vessels d. surrounds the fovea e. may result in retinal detachment 15. True or False. The following are characteristics of SAH: a. Subhyaloid hemorrhage from SAH occurs near the optic disc. b. Retinal hemorrhage occurs near the fovea. c. The prognosis for vision recovery in Terson syndrome is poor. d. Vitreous hemorrhage may occur with nonaneurysmal causes for increased ICP. e. Ocular hemorrhage from SAH may be associated with retinal detachment. 77.5.3 nuchal rigidity Brudzinski’s sign hamstring; Kernig’s sign 77.5.3 true true true true true 20-40% 77.5.3 77.5.3 ① ③ ① ② ③ 77.5.3 true true false true 77 true Work-Up of Suspected SAH 16. Complete the following: a. A good-quality computed tomographic (CT) scan will detect SAH in what percentage of patients? b. If scanned within how many hours? c. Ventriculomegaly (hydrocephalus) occurs acutely in ________%. 77.6.2 ≥95% 48 hours 21% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 422 Part 17: SAH and Aneurysms 17. True or False. Regarding head CT for SAH. a. Ventricular size needs to be assessed because hydrocephalus can occur acutely. b. There may be intracranial hemorrhage requiring urgent craniotomy. c. The amount of SAH correlates with vasospasm risk. d. If there are multiple aneurysms, the distribution of SAH may reveal which aneurysm ruptured. e. Head CT is a poor predictor of aneurysm location. 18. Regarding prediction of aneurysm location. a. Blood in the ventricles suggests ________ ________ aneurysm. b. Anterior interhemispheric fissure suggests an ________ aneurysm. c. Sylvian fissure is compatible with a i. ________ or a ii. ________ aneurysm 19. Complete the following: a. The most sensitive test for SAH is ________ ________. b. Lowering the cerebrospinal fluid (CSF) pressure might precipitate rebleeding because it causes an ________ ________ ________ ________. c. Therefore, as a precaution i. use only a ________-________ ________ and ii. remove only a ________ ________ of ________. 77 20. True or False. The following CSF findings are expected with SAH: a. elevated opening pressure b. nonclotting bloody fluid c. xanthrochromia d. red blood cells (RBCs) > 100,000 e. elevated glucose 21. Complete the following about xanthochromia: a. Used to differentiate SAH from ________. b. Does not show up until ________ hours after bleeding. c. Is present in 100% of patients by ________ hours. d. Lingers for up to ________ weeks. 77.6.2 true true true true false 77.6.2 posterior fossa A-Comm P-Comm MCA 77.6.2 lumbar puncture increase in transmural pressure small-gauge needle small amount of fluid 77.6.2 true true true true false 77.6.2 traumatic tap 2-4 12 4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 General Information, Grading, Medical Management, Special Conditions 423 22. Complete the following about MRI: a. Most sensitive sequence for detecting blood in the subarachnoid space is the ________ sequence. b. It is most reliable for detecting SAH after ___ - ___ days. 23. Complete the following about MRA: a. Can detect aneurysm larger than ________ mm with approximately ________% accuracy. 4-7 days 77.6.2 3; 90 24. CTA has an accuracy of ________% and 97; shows a ________-dimensional image. three 77.6.2 25. Complete the following: a. Angiography demonstrates the source of SAH in ___ - ___%. b. To call an angiogram negative for aneurysm you must see what two areas? i. Take off both ________ and ii. ________ c. What percentage of aneurysms occur at the posterior inferior cerebellar artery (PICA) origin? 77.6.2 26. Complete the following about the infundibulum: a. The three criteria are i. ________ shape ii. size of mouth less than ________ mm iii. ________ at apex b. The most common site is at the ________. 77.6.2 FLAIR 80-85 PICAs A-Comm 1-2% 77.6.2 triangular 3 vessel P-Comm 27. Infundibula are found in approximately what percentage of normal angiograms? 10 77.6.2 28. If infundibulum is located near SAH, ________ is advisable. exploration 77.6.2 77 Grading SAH 29. Matching. Match the hemorrhage grade with when to operate. ① manage till patient improves; ② immediately; ③ promptly within 24 hours a. Hunt and Hess grade 1 b. Hunt and Hess grade 2 c. Hunt and Hess grade 3, 4, or 5 d. Patient with large hematoma e. Patient with multiple bleeds 77.7.2 ③ ③ ① ② ② ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 424 Part 17: SAH and Aneurysms 30. What is the Hunt and Hess grade in a patient who has a headache and SAH seen on CT scan a. and a third nerve palsy? b. and mild one-sided weakness and confusion? c. deep coma and decerebrate rigidity? 31. Complete the World Federation of Neurologic Surgeons (WFNS) grading scale for SAH grade. a. Grade 0: ________ b. Grade 1 Glasgow Coma Scale (GCS): ________ c. Grade 2 GCS: ________ d. Grade 3 GCS: ________ e. Grade 4 GCS: ________ f. Grade 5 GCS: ________ Hunt and Hess grade 2 Hunt and Hess grade 3 Hunt and Hess grade 5 Table 77.4 unruptured GCS 15 GCS 13 to 14 GCS 13 to 14 and major focal deficit GCS 7 to 12 GCS 3 to 6 Initial Management of SAH 32. List nine potential complications of SAH. (Hint: veraNdsah) a. v________ b. e________ c. r________ d. a________ e. f. g. h. i. N________ d________ s________ a________ h________ 33. Complete the orders for SAH patient. a. intravenous (IV) fluids? 77 Table 77.2 b. c. d. e. rate? blood pressure parameters? calcium channel blocker? dose? 77.8.1 vasospasm embolus—pulmonary rebleed arachnoid granulation blockage Na metabolism deep vein thrombosis seizures acute hydrocephalus hyponatremia 77.8.3 normal saline (NS) and 20 milliequivalents (mEq) KCl 2 mL/kg/hour SBP 120-160 yes-Nimodipine 60 mg PO/NG every 4 hours ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 General Information, Grading, Medical Management, Special Conditions 425 34. True or False. During the post-SAH period, with the aneurysm unclipped, phenothiazines should be avoided because a. they may be overly sedating and obscure neurological assessment. b. they may lower seizure threshold. c. they cause elevation of systolic blood pressure. d. their metabolites may hasten vasospasm, e. instead use ________. 35. True or False. The following is the most reliable parameter to differentiate syndrome of inappropriate diuretic hormone (SIADH) from cerebral salt wasting syndrome: a. serum atrial natriuretic factor (ANF) and brain natriuretic factor (BNF) b. urine Na+ and osmolarity c. serum Na+ and osmolarity d. extracellular fluid volume e. 24-hour urine output 36. Complete the following: a. True or False. Cerebral salt wasting (CSW) is best differentiated from SIADH by measuring the: i. serum sodium ii. intravascular volume iii. urine osmolarity iv. extracellular fluid volume b. Keeping serum Na levels normal is important because hyponatremic patients have three times the rate of d________ c________ i________ as do normal natremic patients. 37. a. b. c. 77.8.3 false true false false Zofran 77.8.5 false false false true false 77.8.5 false false false true delayed cerebral infarction Cerebral salt wasting is more common after SAH than ________. SIADH Treat with ________ ________. normal saline Use caution regarding the rate of central pontine myelinolysis treatment because you risk producing ________ ________ ________. 77.8.5 77 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 426 Part 17: SAH and Aneurysms Rebleeding 38. True or False. Regarding rebleeding. a. The maximum frequency of rebleeding from SAH is on day 7. b. Approximately 50% of ruptured aneurysms will rebleed within 6 months. c. Epsilon-aminocaproic acid may decrease the risk of rebleeding. 39. Complete the following: a. Maximum frequency of rebleeding is on the ________ day b. at a rate of ________% c. then at ________% d. for ________ days. e. Total of rebleed in 2 weeks = ________% f. ________% in 6 months g. Thereafter rebleed rate is ___% per year. h. Time period of the highest risk of rebleeding is the ________. true true 77.9.1 first 4% 1.5% 13 15 to 20% 50% 3% first 6 hours Pregnancy and Intracranial Hemorrhage 40. True or False. Intracranial hemorrhage during pregnancy is more commonly caused by: a. AVM b. aneurysms 41. True or False. The following is a correct recommendation for pregnant patients with SAH: a. Do not perform CT or angiogram. b. Mannitol, Nipride, and nimodipine can be used as usual. c. Delay surgery until pregnancy has come to term. 77 77.9.1 false (4% on day 1) d. Deliver by C-section. e. f. g. h. MRI is safe in pregnancy. Gadolinium is safe in pregnancy. Angiographic contrast is safe. Treatment recommendation is surgical clipping. 77.10.1 false, 23% true, 77% 77.10.2 false (They are okay if the fetus is shielded.) false (They are not to be used in pregnancy.) false (Clipping is recommended in the pregnant patient.) false (There is no different fetal or maternal outcome by C-section or vaginal delivery.) true not yet studied true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 General Information, Grading, Medical Management, Special Conditions 427 Hydrocephalus after SAH 42. Complete the following about acute post-SAH hydrocephalus: a. Frequency of hydrocephalus in SAH is ___ - ___%. b. Hydrocephalus is more frequently associated with aneurysms in what location? c. What aneurysm has a low incidence of hydrocephalus? d. The proper treatment is placement of a ________ ________. e. It is recommended to keep the ICP in the range of ___ - ___ mm Hg. f. This reduces the tendency to ________. 43. Complete the following about chronic post-SAH hydrocephalus: a. Approximately ________% of patients with acute post-SAH hydrocephalus need permanent cerebrospinal fluid diversion. b. ________ ________ and ________ ________ are associated with shunt dependency. c. There was ________ difference in the rate of shunt placement between patients who underwent rapid versus gradual weaning of the ventriculostomy drain. 77.11.2 15-20 posterior circulation aneurysms MCA aneurysms ventriculostomy drain 15-25 rebleed 77.11.3 50 Intraventricular blood; Fisher grade no 77 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 78 Critical Care of Aneurysm Patients Neurogenic Stress Cardiomyopathy (NSC) 1. Neurogenic stress cardiomyopathy: a. Is impaired cardiac function not attributable to ________. b. May be ________. c. Is distinguished from acute myocardial ischemia by ________ ________ ________ cardiac enzymes. d. Is treated by increasing ________ using these two medications: ________ or ________. 2. EKG changes that can occur after SAH: a. T waves may be i________. b. QT may be p________. c. i. ST segments may be e________ ii. or d________. 3. The mechanism for the EKG changes is thought to be due to a. h________ i________, b. which causes increased ________ tone, c. which releases a surge of c________, d. which produces s________ ischemia, e. or c________ a________ vasospasm. 78 4. Complete the following about cardiac problems and SAH: a. EKG changes occur in ________%. b. The mechanism is (Hint: hics) i. h________ i________ ii. i________ s________ t________ iii. c________ s________ iv. s________ i________ 78.1.1 coronary artery disease reversible lower than expected cardiac output; Milrinone; Dobutamine 78.1.2 inverted prolonged elevated depressed 78.1.3 hypothalamic ischemia sympathetic tone catecholamines subendocardial coronary artery 50 78.1.2 78.1.3 hypothalamic ischemia increased sympathetic tone catecholamine surge subendocardial ischemia ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Critical Care of Aneurysm Patients 429 Vasospasm 5. Complete the following about vasospasm: a. also known as ________ ________ ________ ________ b. True or False. Higher incidence occurs in: i. ACA distribution ii. MCA distribution 6. Complete the following regarding cerebral vasospasms: a. The incidence of radiographic cerebral vasospasm is ____ - ____% b. as measured on day ________. c. The incidence of symptomatic cerebral vasospasm is ________%. d. Produces infarction in ________%. e. Produces mortality in ________%. f. Onset almost never before day _______. g. Resolved by day ________. h. Radiographically resolves over ___ - ___ weeks 7. Complete the following: a. Spasmogenic region on ACA and MCA is the ________. b. True or False. There is more vasospasm with: i. cigarette smoking ii. lower Hunt and Hess grade iii. amount of blood on CT iv. advancing age of patient v. presence of intraventricular hemorrhage vi. presence of intraparenchymal hemorrhage 8. Complete the following about Fisher grade: a. Describe the Fisher grading system. i. Grade 1 ii. Grade 2 iii. Grade 3 iv. Grade 4 b. Clinical vasospasm is essentially limited to Fisher grade ________. 9. What chemicals have been identified as critical mediators of vasospasm? a. decreased production of ________ and ________ b. overproduction of ________ delayed ischemic neurologic deficit 78.3.2 78.3.3 true false 78.3.3 20-100 7 30 60 7 3 12 3-4 78.3.3 proximal 9 cm true false true true false false Table 78.2 no blood slight—less than 1 mm localized clot—more than 1 mm intracerebral or intraventricular clot 3 78 78.3.4 nitrous oxide; prostacyclins endothelin-1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 430 Part 17: SAH and Aneurysms 10. What transcranial Doppler (TCD) values are consistent with vasospasm? a. Velocity at MCA of more than ________. b. ________ ratio of more than ________ between c. the ________ and the ________ indicates vasospasm. d. Velocity < than ________ and ratio <________ is normal. e. Velocity between ________ and ________ is mild vasospasm. f. Velocity above ________ is severe vasospasm. g. Ratio between ________ and ________ is mild vasospasm. h. Ratio above ________ is severe vasospasm. 11. Complete the following: a. Describe the treatment for vasospasm i. avoid h________, a________, and h________ ii. surgery? iii. remove c________ iv. drug? Table 78.5 120 cm/sec Lindegaard, 3 MCA, ICA 120, 3 120, 200 200 3 and 6 6 78.3.6 hypovolemia, anemia, and hypotension do early clots calcium channel blockernimodipine dilatation bloody CSF 30-35 60-80 v. catheter? vi. drain? vii. obtain hematocrit of ____ - ____% b. Angioplasty produces clinical improvement in ____ - ____%. c. Intra-arterial drugs i. The primary drug used is ________ Verapamil; hypotension but watch for ________. ii. N________ restores vessel diameter Nicardipine; 60 to at least ________%. iii. Other drugs used include P________ Papaverine and Nitroglycerin and N________. 78 12. Complete the following: a. What is “triple H” therapy? i. h________v________ ii. h________ t________ iii. h________ d________ b. The fluid to use is ________ ________. c. Maximum systolic blood pressure for an untreated aneurysm is ________. d. Maximum systolic blood pressure for a treated aneurysm is ________. e. What do you do if triple H does not work? f. Hemodilution is used to lower hematocrit to ____ - ____ 78.3.7 hypervolemia hypertension hemodilution normal saline 160mm Hg 220mm Hg endovascular techniques 30-35% 13. Triple H therapy may cause pulmonary 17 edema in ________% of patients. 78.3.7 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Critical Care of Aneurysm Patients 431 Post-Op Orders for Aneurysm Clipping 14. Complete the following about dose for calcium channel blocker: a. What is the name of antivasospasm medication/drug? b. dose: ________ mg every ________ hours c. route: ________ d. duration: ________ e. unless ________ 78.4 nimodipine 60 mg every 4 hours by mouth or nasogastric tube 21 days patient going home intact—if so, may stop the calcium channel blocker 78 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 79 SAH from Cerebral Aneurysm Rupture Etiology of Cerebral Aneurysms 1. Matching. What are ideas regarding the etiology of aneurysms? Match the lettered term with the numbered description. Description: ① less elastic; ② less muscle; ③ more prominent; ④ less supportive connective tissue Term: (a-d) below a. tunica media b. adventitia c. internal elastic lamina d. location—occur 79 ② ① ③ ④ Location of Cerebral Aneurysms 2. Give the % incidence of cerebral aneurysm for each of the following: a. A-comm b. P-comm c. MCA d. posterior circulation e. basilar f. multiple 79.2 79.3 30% 25% 20% 15% 10% 20 to 30% Presentation of Cerebral Aneurysms 3. Complete the following about intraventricular hemorrhage: a. General i. True or False. It does not affect morbidity-mortality. ii. It has a mortality of ________%. b. A-comm aneurysms rupture into the ventricle through the ________ ________. 79.4.2 false 64% lamina terminalis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 SAH from Cerebral Aneurysm Rupture c. Distal basilar artery aneurysms rupture through the ________ of the ________ ________. d. PICA aneurysm may rupture through the i. ________ of ________ ii. and into the ________ ________. foramen of Luschka fourth ventricle 4. a. b. c. aneurysm diabetes pupils Third nerve palsy can occur with ________ or ________. One can differentiate by examining the ________. i. Pupil dilated in ________. ii. Pupil not dilated in ________. d. The mnemonic is “______________” from the third nerve palsy syndrome. e. Aneurysms ________ the pupil. f. NPSTN means ________ palsy. 433 floor of the third ventricle 79.4.3 aneurysm diabetic “diabetes deletes the pupil” include non-pupil-sparing third nerve Conditions Associated with Aneurysms 5. True or False. All of the following conditions may be associated with SAH: a. hypertension b. Osler-Weber-Rendu syndrome c. diabetes mellitus d. renal fibromuscular dysplasia e. Ehlers-Danlos type IV 79.5.1 true true false (Diabetes insipidus can be associated.) true true 6. The following conditions are associated with an increased incidence of aneurysm: a. a________ d________ p________ autosomal dominant k________ d________ polycystic kidney disease— 15% b. a________ m________ arteriorvenous malformation c. a ________ atherosclerosis d. b________ e________ bacterial endocarditis e. c________ of the a________ coarctation of the aorta f. c________ t________ d________ connective tissue disorders g. Eh________-Da________ Ehlers-Danlos type IV h. fib________ d________ r________ fibromuscular dysplasia renal d________ disease—7% i. f________ o________ familial occurrences j. M________ s________ Marfan syndrome k. m________ d________ moyamoya disease l. O________-W________-R________ Osler-Weber-Rendu s________ syndrome m. p________ e________ pseudoxanthoma elasticum 79.5.1 79 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 434 Part 17: SAH and Aneurysms 7. Complete the following about aneurysms and polycystic kidney disease: a. ADPKD stands for ________ ________ ________ ________. b. Incidence is 1 in ________ autopsies. c. Prevalence of aneurysms in patients with ADPKD is ____ - ____%. d. Risk of SAH in a person with ADPKD is ___ to ___ times the general population. e. Screening protocol in a patient with ADPKD with a prior aneurysm or a kindred with aneurysm is to perform ________ every ___ to ___ years. adult polycystic kidney disease 500 10 to 30%—15% a reasonable estimate 10 to 20 times MRA every 2 to 3 Treatment Options for Aneurysms 8. Complete the following: a. In trapping an aneurysm is it better to tie off the common carotid artery or the internal carotid artery? b. It reduces the incidence of ________ ________. 9. True or False. Regarding treatment options for aneurysms. a. The following procedures offer protection if the aneurysm can’t be clipped or coiled: i. wrapping with muscle ii. wrapping with cotton iii. wrapping with muslin iv. coating with plastic resin v. coating with polymer vi. coating with Teflon vii. coating with fibrin glue b. In such cases you could consider trapping or bypass or carotid ligation. 10. a. b. c. d. 79 79.5.2 True or False. Coils are not ideal for very small aneurysms very large aneurysms aneurysms with wide necks If after coiling residual filling is noted you should “recoil.” 11. Data for Guglielmi detachable coils indicate a. morbidity: ________% b. mortality: ________% c. complete obliteration of aneurysm: ________% d. subsequently required open surgical repair: ________% 79.6.3 common carotid occlusion is better thromboembolic phenomenon 79.6.3 false false false false false false false true 79.6.5 true true true false (Proceed with surgery.) 79.6.5 4% 1% 40% 20% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 SAH from Cerebral Aneurysm Rupture Timing of Aneurysm Surgery 12. Complete the following about timing for aneurysm surgery: a. The definition of early surgery is less than ________ to ________ hours. b. Late surgery is after ____ to ____ days. c. More likely to delay surgery when ________________________________. d. Avoid doing surgery between days ________ and ________ because that is considered a ________ ________. 13. Complete the following regarding vasospasm treatment: a. It peaks in incidence between ________ and ________ days. b. It never occurs before day ________. c. Vasospastic interval during which surgery should be avoided is days ________ to ________. 435 79.7.1 48 to 96 hours 10 to 14 days treating a basilar artery aneurysm because you want a lax brain during the surgical approach 4 and 10; vasospastic interval 79.7.1 6 and 8 days 3 4 to 10 General Technical Considerations of Aneurysm Surgery 14. Complete the following regarding aneurysmal rest. a. What is an aneurysmal rest? b. c. d. e. f. Why are they dangerous? What is the incidence of rebleeding? There is a risk per year of ____ to ____%. How should they be handled? If they increase in size, treat with ________ or ________ ________. 15. Answer the following about CSF drainage during craniotomy: a. True or False. CSF should be drained before opening the dura. b. True or False. CSF should be drained after opening the dura. c. What is the rate of rebleeding with CSF drainage? 79.8.2 residual unclipped part of aneurysm they may bleed 3.7% 0.4 to 0.8% serial angiography surgery or endovascular coiling 79.8.3 false (This is associated with an increased incidence of rebleeding.) true 0.3% 16. Complete the following regarding cerebral protection during surgery: a. O2 consumption by the neuron is for two functions: i. to maintain ________ ________ cell integrity ii. for conduction of ________ electrical impulse 79.8.3 79 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 436 Part 17: SAH and Aneurysms b. If there is occlusion of a vessel it produces ________ c. due to ________ ________. d. This precludes i. a________ g________ and ii. o________ p________ e. What happens to adenosine triphosphate (ATP) production? f. What happens to the cell? 17. What can be done to protect against ischemia? a. Tactics to reduce injury by ischemia include i. n________ ii. b________ ischemia oxygen deficiency aerobic glycolysis oxidative phosphorylation it declines cell death occurs 79.8.3 nimodipine—calcium channel blockers barbiturates—free radical scavengers mannitol iii. m________ b. Tactics to reduce the cerebral metabolic rate of oxygen consumption (CMRO2) required include i. reducing electrical activity of the barbiturates-etomidate neuron with ________. ii. reducing maintenance energy of the hypothermia neuron with ________. 18. Answer the following about temporary clipping during aneurysm surgery: a. True or False. Under 5 minutes occlusion is well tolerated. b. If occluded 10 to 15 minutes, must add ________________________. c. If occluded more than 20 minutes, ____ ________. 19. Answer the following about post-op angiography after aneurysm or AVM surgery: a. True or False. It is not needed. b. ________% showed unexpected findings. c. True or False. It is the standard of care. d. True or False. It is recommended. 79 79.8.3 true dose and drip titrated to burst suppression not tolerated 79.8.4 false 19% false true 20. Complete the following regarding drugs useful in aneurysm surgery: a. What special medications should be used etomidate or propofol during temporary clipping of an aneurysm? b. What do they do? suppress neuronal activity by reducing neuronal metabolism c. By how much? 50% 79.8.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 SAH from Cerebral Aneurysm Rupture d. What is the side effect of etomidate? e. Guard against this side effect by ________________________. 21. Complete the following about intraoperative aneurysm rupture (IAR): a. True or False. Intraoperative aneurysm rupture increases the morbidity and mortality of surgery threefold. b. True or False. Techniques to decrease the probability of intraoperative rupture include i. preventing hypertension ii. minimizing brain retraction iii. sharp vs. blunt dissection iv. radical removal of sphenoid wing c. List the three general stages of aneurysm surgery during which intraoperative rupture is most likely to occur. d. During which of these three stages is intraoperative rupture most likely to occur? 22. True or False. During intraoperative rupture by clip application, bleeding reduces as clip blades approximate. 23. Complete the following about aneurysm recurrence after treatment: a. Can an incompletely clipped aneurysm bleed? b. Can an incompletely coiled aneurysm bleed? c. Can an aneurysm that has been completely obliterated recur and bleed? 437 lowers seizure threshold using preoperative antiepileptic drugs 79.8.6 true true true true true stage 1 = initial exposure, stage 2 = dissection of the aneurysm, and stage 3 = clip application dissection of aneurysm (stage 2) false 79.8.6 79.8.7 yes—0.4 to 0.8% per year yes—0.16% per year yes—0.37% per year 79 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 80 Aneurysm Type by Location Anterior Communicating Artery Aneurysms 1. Complete the following: a. The most common site of ruptured aneurysms is ________. b. Diabetes insipidus and/or hypothalamic dysfunction can be the presenting symptoms of an aneurysm of the ________. 2. Complete the following about aneurysm type by location: a. The single most common site for an aneurysm is ________. b. Subarachnoid hemorrhage from an Acomm aneurysm rupture is associated with an intracerebral hematoma in what percentage of cases? c. The most common site for subarachnoid blood on a CT associated with A-comm aneurysm rupture is ________ ________ ________. d. In what percentage of cases? 3. Complete the following: a. Vasospasm from A-comm aneurysm rupture can cause bilateral ACA infarcts in the frontal lobes and result in the symptoms of ________ and ________. b. Frontal lobe infarcts occur in ________% of cases of A-comm aneurysm rupture. c. This results in a virtual ________-like lobotomy. 80 4. True or False. Regarding A-comm aneurysms: a. It is unnecessary to assess the side from which an A-comm aneurysm fills by angiography because all A-comm aneurysms should be approached from the right side. 80.1.1 A-commA A-commA 80.1.2 A-commA 63% anterior interhemispheric fissure virtually 100% 80.1.2 apathy and abulia 20% prefrontal 80.1.4 false ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Aneurysm Type by Location b. Surgical approaches to an A-comm aneurysm include i. pterional approach ii. anterior interhemispheric approach iii. transcallosal approach iv. subfrontal approach c. The two most common sites for distal ACA aneurysms are i. terminal pericallosal artery ii. terminal callosomarginal artery iii. frontopolar artery origin iv. bifurcation of pericallosal and callosomarginal arteries above the splenium of the corpus callosum 5. There are three indications for left pterional craniotomy for A-comm aneurysm. a. pointing to ________ b. feeder from ________ c. multiple ________ 439 true true true true false false true true 80.1.4 the right the left ACA additional left-sided aneurysm(s) Distal Anterior Cerebral Artery Aneurysms 6. Pericallosal aneurysms are anatomically close to which part of the corpus callosum? 7. True or False. Regarding ACA and AcommA aneurysms and approaches. a. i. The more distally located ACA aneurysms are generally due to posttraumatic, infectious, or embolic etiologies. ii. Aneurysms up to 1 cm from the AcommA may be approached through a standard pterional craniotomy. iii. Aneurysms > 1 cm distal to the AcommA may also be easily approached through a pterional craniotomy with partial gyrus rectus resection. iv. ACA aneurysms distal to the genu of the corpus callosum may be approached via an interhemispheric route. b. Prolonged retraction of the cingulate gyrus during an interhemispheric approach may result in a foot drop that is usually temporary. genu 80.2.1 true 80.2.1 true 80.2.2 false true false 80 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 440 Part 17: SAH and Aneurysms 8. Which approach should be used for aneurysms > 1 cm distal to A-comm? 10. True or False. Regarding P-comm aneurysms. a. Third nerve palsies associated with Pcomm aneurysms are not pupil sparing in 99% of cases. b. P-comm aneurysms most commonly occur at the junction of the P-comm with the PCA. c. Before clipping a P-comm aneurysm, the origin of the anterior choroidal artery must be identified and excluded from the clip. d. Most P-comm aneurysms project laterally, inferiorly, and posteriorly. 11. What congenital anomaly must be discovered on angiogram prior to surgery for P-comm aneurysm? 80.3.1 posterior communicating artery dilated “down and out” not spared surface spared deeper; vasa nervorum 80.3.1 true false true true fetal origin of the PCA 80.3.2 Supraclinoid Aneurysms 12. What is the name of the dural constriction around the carotid artery a. as it exits the cavernous sinus? b. as it enters the subarachnoid space? 80 80.2.2 Posterior Communicating Artery Aneurysms 9. Complete the following: a. Which aneurysm presents with a third nerve palsy? b. What is the status of the pupil? c. What position does the eye have at rest? d. If due to P-comm, the pupil is ________ e. because pupillary fibers run on the ________ of the third nerve. f. If due to diabetes, the pupil is ________ g. because motor fibers run in the ________ part of the third nerve and are affected by pathology of the ______ ________. basal frontal interhemispheric approach, right side preferred 13. List the supraclinoid branches of the ICA. (Hint: ospa) a. o________ b. s________ h________ c. p________ c________ d. a________ c________ 80.6.1 proximal carotid ring distal carotid ring or clinoidal ring 80.6.1 ophthalmic superior hypophyseal posterior communicating anterior choroidal ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Aneurysm Type by Location 14. Ophthalmic artery aneurysms a. arise just distal to the origin of the ________ _______ and b. project ________. 15. Name two major presentations of ophthalmic artery aneurysms. a. S________ b. v________ ________ ________ i. True or False. A superior nasal homonymous quadrantanopsia usually means impingement on the lateral portion of the optic nerve. ii. True or False. An ipsilateral monocular inferior nasal field cut may result from compression of the optic nerve against the falciform ligament. 16. Complete the following: a. List the two variants of superior hypophyseal artery aneurysms. i. p________ ii. s________ b. Which variant of superior hypophyseal artery aneurysm can mimic pituitary tumor clinically and on CT? c. Under what circumstances? d. It may present clinically with ________ e. and visual symptoms of ________ ________. 17. Complete the following: a. On angiogram, a notch in a giant ophthalmic artery aneurysm is due to the ________ ________. b. The notch, if present, is located in the ________-________-________ aspect. 18. Complete the following: a. What happens if you occlude the ophthalmic artery? b. True or False. A contralateral ophthalmic aneurysm is rare. c. If present, can both be clipped at the same surgery? 19. Answer the following: a. Can you sacrifice a superior hypophyseal artery? b. Can you clip a contralateral superior hypophyseal aneurysm? 441 80.6.2 ophthalmic artery dorsomedially 80.6.2 SAH (45%) visual field defect (45%) false true 80.6.2 paraclinoid suprasellar suprasellar variant when it is a giant aneurysm hypopituitarism bitemporal hemianopsia 80.6.2 optic nerve anterior-superior-medial 80.6.3 It is tolerated without loss of vision in most patients. false yes 80.6.3 Yes, the pituitary receives bilateral blood supply. No, this is not technically feasible. 80 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 442 Part 17: SAH and Aneurysms Posterior Circulation Aneurysms 20. Matching. Match the frequency of posterior circulation aneurysms compared with anterior circulation aneurysms to the lettered conditions. ① same frequency; ② posterior is more frequent a. clinical syndrome of SAH b. respiratory arrest c. neurogenic pulmonary edema d. midbrain syndrome from vasospasm e. hydrocephalus 21. True or False. 20% of patients with a posterior fossa SAH will require permanent ventricular shunting. 22. Regarding vertebral artery aneurysms. a. The preoperative angiogram should assess the patency of the ________ ________ ________ in the event that trapping is necessary. b. The Allcock test involves vertebral angiography with ________ ________ to assess the patency of the circle of Willis. c. Vertebral artery (VA) aneurysms most commonly occur at the junction of the ________ with the ________. d. True or False. Nontraumatic VA aneurysms are more common than dissecting, traumatic VA aneurysms. 23. Complete the following regarding PICA aneurysms: a. They represent ________% of cerebral aneurysms. b. The most common site is at ________ junction. c. Aneurysms far more distal on PICA tend to be ________ and therefore should be treated ________. d. Blood from rupture is predominantly in the ________ ________. 24. Complete the following: a. The most common site for a posterior circulation aneurysm is the ________ ________. ① ② ② ② ② 80.7.1 true 80.7.2 80.7.2 80.7.3 contralateral vertebral artery carotid compression VA; PICA false 80.7.3 3% VA-PICA fragile; promptly fourth ventricle 80.7.6 basilar tip 80 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Aneurysm Type by Location b. True or False. Regarding basilar tip aneurysms. i. Surgical treatment is associated with a 5% overall mortality rate. ii. Surgical approaches include pterional and supracerebellar infratentorial routes. iii. Because of the technical difficulties associated with clipping basilar aneurysms many still recommend waiting up to 1 week prior to surgery. iv. The morbidity rate of 12% is mostly due to perforating vessel injury. 25. On angiography the following characteristics should be noted about basilar artery aneurysms: a. Direction dome points? b. P-comm characteristics i. P-comm ________ ii. may need ________ ________. c. Bifurcation characteristics: i. Assess position of ________ ii. in relation to ________. iii. If high, use ________ ________ ______. iv. If low, use ________ ________. 26. Matching. Match the numbered approaches to the conditions for the basilar artery aneurysm surgical approach. Approach: ① subtemporal approach; ② pterional approach Conditions: (a-h) below a. bifurcation is high b. aneurysm projects posteriorly/posteriorly inferiorly c. low bifurcation d. concomitant anterior circulation aneurysms e. for better visualization of P1 and thalamoperforating vessels f. for less temporal lobe retraction g. for shorter distance (by 1 cm) h. produces a risk to third nerve (mild and temporary) 443 true false true true 80.7.6 usually superiorly flow Allcock test bifurcation dorsum sella pterional transsylvian approach subtemporal approach 80.7.6 ② ① ① ② ② ② ① ② 27. What is the % risk of oculomotor palsy 30% by the pterional approach? 80.7.6 28. Complete the following about basilar artery aneurysms: a. Mortality is ________%. b. Morbidity is ________%. 80.7.6 5% 12% 80 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 81 81 Special Aneurysms and Non-Aneurysmal SAH Unruptured Aneurysms 1. Complete the following about unruptured aneurysms: a. Estimated prevalence of incidental aneurysms is ___ - ___% of the population. b. Annual risk of rupture of aneurysms <10 mm estimated by ISUIA is _________, but other studies suggest the risk is closer to _________. 2. Complete the following about surgical management of unruptured aneurysms: a. Surgical morbidity is estimated to be _________% and mortality _________%. b. 3 factors used to determine whether to treat are s________, p______ a_______, and l________. c. Treatment should also be recommended for patients with h_____ of a________ S_____, s_____ f______ h______, s_______ a_______, and e________ or c_______ in a_______ c_______. 3. Cavernous carotid artery aneurysms: a. Most develop on the h________ segment of the artery. b. Usually present with h________ or c_________ s_________ s_________. c. Cavernous sinus syndrome produces d________ and t_______ n_______ p________ that is pupil-s________. d. When these aneurysms rupture, they usually produce a c____-c______ f____. 5-10% 81.1.1 0.05%/year; 1%/year 81.1.3 81.1.4 2%; 6% size, patient age; location history of aneurysmal SAH, strong family history, symptomatic aneurysms; enlargement or change in aneurysm configuration 81.1.4 horizontal headache; cavernous sinus syndrome diplopia; third nerve palsy; sparing a carotid-cavernous fistula 4. Indications for treatment of cavernous carotid artery aneurysms: (Hint: gees) a. g__________ giant aneurysm b. e__________ enlarging aneurysm 81.1.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Aneurysms and Non-Aneurysmal SAH c. e__________ d. s__________ before endarterectomy symptomatic 5. Treatment options for cavernous carotid artery aneurysms: a. Preferred treatment technique is e________. b. o_______ s_______ t________ is rarely appropriate. 81 endovascular open surgical treatment Multiple Aneurysms 6. Complete the following about multiple aneurysms: a. Present in ___ - ______% of SAH cases. b. When a patient presents with SAH and is found to have multiple aneurysms, the following clues can be used to determine the source of SAH: (Hint: evil) i. e_________ ii. v_________ iii. i_________ iv. l_________ 81.1.4 445 81.2 15-33.5% epicenter of blood vasospasm on angiogram irregularities in shape largest aneurysm Familial Aneurysms 7. Complete the following about familial aneurysms: a. In patients with SAH, _________% have a 1st-degree relative with SAH or aneurysm and _________% have a 2nddegree relative. b. Most common relative to also have an aneurysm is a s________. c. Aneurysms in siblings occur at i________ or m_______ i_______ location. d. Familial aneurysms tend to rupture at a s________ size and at a y________ age. 8. Screening recommendations for familial aneurysms: a. Recommended for f_______-d________ relatives of affected family members when _________ or more family members have an aneurysm or history of SAH. b. Also recommended in patients with c________ of the a_______ or with A________. c. Screen using M________ or C________ scans. d. To confirm findings, use D________. 81.3.1 9.4%; 14% sibling identical; mirror image smaller; younger 81.3.3 first-degree; 2 coarctation of the aorta; ADPKD MRA; CTA DSA ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 446 81 Part 17: SAH and Aneurysms Traumatic Aneurysms 9. Complete the following about traumatic aneurysms: a. Represent _________% of aneurysms. b. They are not really aneurysms but are p_________. c. Mechanisms of injury resulting in traumatic aneurysms include p_________ t________, c_________ h________ i________, and i_________. <1% pseudoaneurysms penetrating trauma, closed head injury; iatrogenic Mycotic Aneurysms 10. Complete the following about mycotic aneurysms: a. The etiology for these aneurysms is i________. b. Represent _________% of aneurysms. c. Most common location is d_______ M_______ b________. d. Often associated with subacute bacterial e________. e. Infectious work-up includes b_______ c________, l_______ p________, and e________. f. F________ morphology makes surgical treatment difficult and/or risky, and so treated acutely with ____ - ____ weeks of antibiotics. g. Delayed clipping indicated in patients with S________ and with f________ response to antibiotics. 81.4.1 infectious 81.5.1 4% distal MCA branches 81.5.2 endocarditis blood cultures, lumbar puncture; echo 81.5.3 Fusiform; 4-6 weeks 81.5.4 SAH; failed Giant Aneurysms 11. Complete the following about giant aneurysms: a. Defined as an aneurysm >_________ cm. b. Represent ____ - ____% of aneurysms. c. Present with h_________, T_________, or m_________ e________. d. DSA often u________ size of aneurysm due to t________ parts that do not fill with contrast. e. Direct surgical clipping is possible in only _________% of cases. f. Other surgical treatment options include b_________ followed by c_________, t_________, l_________, or w_________. 2.5 3-5% hemorrhage, TIA; mass effect underestimates; thrombosed 81.6.1 50% 81.6.3 81.6.2 bypass; clipping, trapping, ligation; wrapping ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Aneurysms and Non-Aneurysmal SAH SAH of Unknown Etiology 12. SAH of unknown etiology: a. “Angiogram-negative SAH” occurs in ___ - ___% of cases. b. Causes i. i________ angiography. Must see both P________ origins and A________. ii. Aneurysm obscured by h________. iii. t________ of aneurysm. iv. Aneurysms too s________ to be seen. v. Lack of filling due to v________ of parent vessel. vi. Repeat angiogram is recommended after ___ - ___ days. vii. If the first 2 angiograms are negative, a third angiogram is recommended after ___ - ___ months and has a _________% chance of revealing a source of SAH. 447 81 7-10% 81.8.1 inadequate; PICA; AComm hemorrhage thrombosis small vasospasm 10-14 81.8.3 3-6; 1% Pretruncal Nonaneurysmal SAH (PNSAH) 13. SAH of unknown etiology: a. Also known as p_______ S_______, which is a misnomer since b. hemorrhage is located in front of the b________ centered in front of the p________. c. Perimesencephalic cisterns include: (Hint: Iraq) i. i_________ ii. r_________ iii. a_________ iv. q_________ d. Considered to be a b________ condition with g________ outcome, l________ risk of rebleeding, and l________ risk of v________ compared to patients with SAH of unknown etiology. e. Represent ____ - ____% of angiogramnegative SAH. f. Repeat angiography is n________ indicated. g. Management does not include h_________ t_________ or c_________ c_________ b_________ given low risk of vasospasm. h. Hydrocephalus requiring shunting occurs in _________%. perimesencephalic SAH 81.9.1 brainstem; pons interpenduncular crural ambient quadrigeminal benign; good; less; less; vasospasm 20-68% 81.9.3 not 81.9.6 hyperdynamic therapy; calcium channel blockers 81.9.7 1% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 82 82 Vascular Malformations General Information and Classification 1. Complete the following about vascular malformations: a. 4 classic types include A_________, c_________, c_________, D_________. b. A________ is the most prevalent type, accounting for ___ - ___% of vascular malformations. c. A direct fistula is also known as A________ and includes V_______ of G______ m_______, d_______ A_______, and C_________. 82.1 AVM, cavernoma, capillary telangiectasia, DVA AVM; 44-60% AVF; Vein of Galen malformation, dural AVF; CCF Arteriovenous Malformation (AVM) 2. Complete the following about AVMs: a. Arterial blood flows directly from a________ to v________ without normal interposed c_______ b________ but with n________ instead. b. C________ rather than acquired. c. Associated with the hereditary syndrome O_________-W_________-R_________, also known as h_________ h_________ t_________. 3. AVM presentation: a. Average age of patients diagnosed with AVMs is _________. b. AVMs most commonly present with h________. c. Another common presentation is s________. 4. a. b. c. AVMs and hemorrhage Peak age for hemorrhage is ___ - ___. Mortality for each bleed is _________%. Morbidity for each bleed is ___ - ___%. 82.2.1 arteries; veins; capillary beds; nidus Congenital Osler-Weber-Rendu; hereditary hemorrhagic telangiectasia 33 years-old 82.2.4 hemorrhage 82.2.5 seizures 82.2.5 15-20 years-old 10% 30-50% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Vascular Malformations d. Most common site for hemorrhage is i________, present in _________% of cases. e. Other sites include I________, S________, and s_______ h_________. 5. Risk factors related to AVM rupture: a. Small AVMs present more often as h________, whereas large AVMs present with s________. b. D________ venous drainage and prior h________ are also associated with AVM rupture. intraparenchymal; 82% IVH, SAH; subdural hematoma 82.2.5 Deep; hemorrhage 82.2.5 7. AVMs and aneurysms: a. _________% of patients with AVMs have aneurysms. b. Aneurysms associated with AVMs usually arise from a f________ artery. c. If it is not clear which bled, the AVM or the aneurysm, it is usually the a________. d. Do aneurysms regress after AVM removal? 82.2.5 9. Spetzler-Martin grading of AVMs: a. Grade ranges from _________ to _________. b. Graded features of an AVM include s_________, e_________ of _________, and p_________ of _______ _________. c. The Spetzler-Martin grade of a 4 cm AVM that drains into the vein of Galen and is located in the visual cortex is _________. d. This AVM has a major surgical morbidity of _________% and a minor surgical morbidity of _________%. 82 hemorrhage; seizures 6. Risk of AVM rupture: a. Average risk of hemorrhage from an 2-4% AVM is ___ - ___% per year. b. What is the risk of bleeding (at least 73% once) from an AVM during the lifetime of a 35 year-old healthy male, assuming a 3% annual bleeding risk? 8. MRI characteristics of AVMs: a. F________ v________ on T1- or T2weighted imaging. b. Presence of e________ can help differentiate AVM from t________. c. A complete hemosiderin ring suggests AVM over t________. d. What sequence best shows hemosiderin? 449 7% feeder aneurysm yes (66%) 82.2.6 Flow voids edema; tumor tumor gradient echo 82.2.7 1 to 5 size, eloquence of adjacent brain; pattern of venous drainage 4 7%; 20% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 450 Part 18: Vascular Malformations 10. Complete the following about AVM treatment: a. The treatment of choice for AVMs is s________. b. Surgery eliminates the risk of bleeding almost i________. c. Conventional radiation is effective in less than _________% of cases. d. SRS takes ___ - ___ years to work. e. Endovascular embolization: i. Does not permanently o________ AVMs. ii. Does f________ surgery. iii. Induces acute h________ changes. iv. May require m________ procedures. f. What pretreatment can be used to reduce the incidence of normal perfusion pressure breakthrough? 82 immediately 20% 1-3 obliterate facilitate hemodynamic multiple propranolol 20 mg four times a day for 3 days developmental venous anomaly (DVA) starburst rare rare Low; low no treatment needed 82.3.1 82.3.3 Angiographically Occult Vascular Malformations 12. Angiographically occult vascular malformation (AOVM) presentation: a. The incidence of angiographically occult vascular malformations is _________%. b. They most often present with s________ or h________, rather than h________. c. The most common angiographically occult vascular malformation is A_____. surgery Venous Angiomas 11. Complete the following about venous angiomas: a. Also known as d_________ v_________ a_________. b. Demonstrable on angiography as a s________ pattern. c. Seizures are r________. d. Hemorrhage is r________. e. L______-flow, l______-pressure lesions. f. What is the treatment of choice? 82.2.8 10% 82.4.2 seizures or headache; hemorrhage AVM 82.4.3 Osler-Weber-Rendu Syndrome 13. Capillary telangiectasias: a. Usually found i________ without c________ significance. b. Usually s_______ but may be m_______ when seen as part of a syndrome. 82.5.1 incidentally; clinical solitary; multiple ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Vascular Malformations c. Syndromes include O______-W_______- Osler-Weber-Rendu (aka R______, L______-B_______, M______- hereditary hemorrhagic M_______, S________-W_________ telangiectasia), Louis-Barr (aka ataxia telangiectasia), Myburn-Mason, SturgeWeber 451 82 Cavernous Malformation 14. a. b. c. Cavernous malformations: Most often present with s________. They are angiographically o________. Account for ___ - ___% of all CNS vascular malformations. d. Present with i. s_________ in 60%. ii. p_________ n________ deficit in 50%. iii. h_________ in 20%. iv. i_________ finding in 50%. 15. Cavernous malformation genetics: a. Cavernous malformations can occur s________ or in a h________ form. b. M________ lesions are more common in the h________ form. c. There are _________ genetic subtypes. d. CCM1 subtype is more common in H________. e. Genetic subtypes are inherited in an a________ d________ pattern with v________ expressivity. f. DVA may be seen adjacent to s________ cavernous malformations. g. F_______-d_______ relatives of patients with more than one family member having a cavernous malformation should have MRI s________ and appropriate g_______ counseling. 16. Cavernous malformation bleeding risk: a. Risk of significant bleeding is ___ - ___% per year. b. Bleeding risk is higher in f________. c. P_______ h________, p________, and p________ are not clearly risk factors for hemorrhage. (Hint: 3Ps) seizures occult 5-13% 82.6.1 82.6.3 82.6.5 seizures progressive neurological hemorrhage incidental 82.6.4 sporadically; hereditary Multiple; hereditary 3 Hispanics autosomal dominant; variable solitary First-degree; screening; genetic 82.6.5 2-3% females Prior hemorrhage, pregnancy; parturition ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 452 Part 18: Vascular Malformations 17. Radiographic evaluation of cavernous malformations: a. The most sensitive test is M________. b. The most sensitive sequence is G_______-e_______ T________. c. Display a pathognomonic p________ pattern. 82 18. Management of cavernous malformations: a. Three treatment options include o________, s________, or S________. b. New onset seizures may be an indication for s________ because removal before k________ may reduce future seizures. c. S________ should not be considered as an alternative to s________. MRI Gradient-echo T2WI popcorn 82.6.7 observation, surgery; SRS surgery; kindling SRS; surgery Dural Arteriovenous Fistulae (DAVF) 19. Complete the following about dural arteriovenous fistulae: a. Arteriovenous shunt is contained within the d________. b. Most common location is t________/s________ ________. c. Considered to be a________ rather than c________ lesions. d. Primary etiology is v_______ s_______ t_______. e. Most common presenting symptom is p_________ t_________. f. C_______ v_______ d_______ with v_______ h_______ is the most common cause of morbidity and mortality, and thus is the strongest indication for t________. g. D________ is required to establish the diagnosis. 82.6.6 dura 82.7.1 transverse/sigmoid sinus acquired; congenital venous sinus thrombosis 82.7.2 pulsatile tinnitus 82.7.4 Cortical venous drainage with venous hypertension; treatment DSA 82.7.5 choroidal arteries 82.8.1 medial vein of the prosencephalon hydrocephalus; congestive heart failure 60-100% 82.8.2 Vein of Galen Malformation 20. Vein of Galen malformation: a. Feeders are primarily from c_______ a_______. b. Drainage is into the m_________ v_________ of the p_________. c. Trigger symptoms by causing h________ and c_______ h_______ f________. d. If untreated mortality is ___ - ___%. 82.8.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Vascular Malformations 453 Carotid-Cavernous Fistula 21. Complete the following about carotidcavernous fistulae: a. Classified as d________ and i________ types. b. Type A: h________-flow shunt between I________ and c_______ s________. c. Type B: l_____-flow shunt with feeders from m_______ b_______ of I_____. d. Type C: l________-flow shunt with feeders from m_______ b_______ of E_______. e. Type D: l________-flow shunt with feeders from b_______ of I_______ and E________. f. Direct CCF occurs in _________% of head trauma patients. g. ___ - ___% of low-flow CCF spontaneously t________. h. U_______ t_______ is usually indicated for h________-flow CCF. i. Preservation of v________ is another critical indication for treatment. j. E_______ e________ is the treatment of choice. direct; indirect high; ICA; cavernous sinus low; meningeal branches of ICA low; meningeal branches of ECA 82.9.1 82 low; branches of ICA and ECA 0.2% 20-50%; thrombose Urgent treatment; high vision 82.9.4 Endovascular embolization ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 83 General Information and Stroke Physiology 83 Definitions 1. Types of cerebral infarction: a. TIA = t_______ neuronal dysfunction without p________ acute infarction. b. Ischemic infarction = p________ death of neurons caused by inadequate p________. c. Watershed infarct = infarction located in two b________ arterial distributions. bordering Cerebrovascular Hemodynamics 2. Cerebrovascular hemodynamics: a. Cerebral blood flow _________ is associated with i________ and if prolonged will produce c____ d______. b. Types of responses of cerebral blood flow to vasodilator challenge with a________: i. Type 1 = n_______ baseline CBF with ___ - ___% i________. ii. Type 2 = d_______ baseline CBF with _________% i________. iii. Type 3 = d________ baseline CBF with d________, suggesting s________ phenomenon. 83.1 transient; permanent permanent; perfusion <20; ischemia; cell death acetazolamide 83.2.1 83.2.4 normal; 30-60% increase decreased; <10% increase decreased; decrease; steal Collateral Circulation 3. Collateral circulation: a. Flow through C________ of W________ b. via a________ c________ artery and p________ c________ artery. c. Also r________ flow through o________ artery. d. Also d________-l________ anastomoses. 83.3.1 Circle of Willis anterior communicating; posterior communicating retrograde; ophthalmic dural-leptomeningeal ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 General Information and Stroke Physiology “Occlusion” Syndromes 4. “Occlusion” syndromes a. Overall annual ischemic stroke risk in symptomatic ICA occlusion is _____%. b. A_________ syndrome and B_________ syndrome are caused by occlusion of p_______ c_______ a_______. c. Bilateral thalamic and mesencephalic infarctions are caused by occlusion of artery of P________. d. Eponym for lateral medullary syndrome is W_______ s________. e. This syndrome is classically attributed to P________ occlusion but in ___ - ___% of cases involves the v_______ a________. f. This syndrome also produces only s________ loss and no m________ function loss. g. Small infarcts in deep cerebrum or brainstem are called l________ strokes. h. Pure sensory loss indicates lacunar stroke in p________ t________. i. Pure hemiparesis indicates lacunar stroke in p________ l________ of i________ c________. 83.4.1 7% Anton; Balint; posterior cerebral artery 83 Percheron Wallenberg’s syndrome PICA; 80-85%; vertebral artery sensory; motor lacunar posteroventral thalamus posterior limb; internal capsule Stroke in Young Adults 5. Stroke in young adults: a. Only _________% of ischemic strokes occur in patients who are _________ years-old. b. Most common cause is t________, _________%. c. Other causes include a_________, e_________, v_________, h______ s_______, and p_________. 455 3%; <40 years-old 83.5.1 trauma, 22% 83.5.2 atherosclerosis, embolism, vasculopathy, hypercoagulable state; peripartum Atherosclerotic Carotid Artery Disease 6. Atherosclerotic carotid artery disease: a. Carotid artery lesions are considered symptomatic if there is o________ or m________ ischemic episodes in the d________ of the vessel. b. They are considered asymptomatic if the patient only has non-specific v______ complaints, d_______, or s_____ not associated with TIA or stroke. one; more; distribution 83.6.2 visual; dizziness; syncope ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 456 83 Part 19: Stroke and Occlusive Cerebrovascular Disease c. ____% of atherosclerotic carotid strokes occur without warning symptoms. d. Asymptomatic carotid stenosis is usually discovered as a c_______ b________. e. Accuracy of a bruit predicting carotid stenosis is ___ - ___%. f. Screening for carotid stenosis may be considered for patients who are o_______ than ________ years old and have multiple c________ risk factors. g. The gold standard test to evaluate carotid stenosis is D________. h. Percent stenosis by NASCET criteria is _________ (formula), where N is measured at maximal n________ and D is measured d________ to the c________ b________. i. Percent stenosis by ECST criteria is _________ (formula), where N is measured at maximal n________ and B is measured at the c________ b________. j. Doppler ultrasound sensitivity _________% and specificity _________%. k. MRA sensitivity _________% and specificity _________%. l. CTA sensitivity _________% and specificity _________%. 7. Medical treatment for carotid stenosis: a. Includes anti-p_______, anti-h_______, anti-c_______, anti-l_________, antid_________, and anti-s_________. b. Aspirin irreversibly inhibits c________. c. Optimal dose of Aspirin for cerebrovascular ischemia is d________. d. Aspirin reduces risk of stroke following TIA by ___ - ___%. e. Daily doses of 81 or 325 mg were b________ than higher doses. f. Plavix inhibits A________-induced platelet fibrinogen binding 8. a. b. c. Asymptomatic carotid stenosis: Stroke rate is ____% per year. ___% of these strokes are not d_______. Carotid endarterectomy may be better than medical management if stenosis _________%. d. 2 main studies comparing surgical vs. medical management of asymptomatic carotid stenosis are A_________ and A_________. 80% carotid bruit 50-83% older than 55 years old; cardiovascular 83.6.3 DSA [1-(N/D)]x100%; narrowing; distal; carotid bulb [1-(N/B)]x100%; narrowing; carotid bulb 88%; 76% 91%; 88% 85%; 93% 83.6.4 anti-platelet, -hypertensive, -coagulation, -lipid, -diabetic, -smoking cyclooxygenase debated 25-30% better ADP 83.6.4 2% 50%; disabling >60% ACST, ACAS ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 84 Evaluation and Treatment for Stroke Rationale for Acute Stroke Treatment 1. Penumbra: a. Tissue at r________ that retains v________ for a period of t________ through suboptimal perfusion from c________ is called the p________. b. The goal of stroke treatments is p________ of this s________ neuronal injury. 84 84.1.1 risk; viability; time; collaterals; penumbra prevention; secondary Evaluation 2. Key components of history: a. Time last seen n________. b. N_________ s_________ s_________ s_________. 3. Role of CT scan: a. Used mainly to rule-out h________. b. H________ a________ sign can be seen on CT _________ hours after stroke, but it has low s________. c. At 24 hours, stroke identified as l________ density on CT. d. M________ effect reaches a maximum ___ - ___ days after the stroke. e. CT enhancement in stroke: (Hint: rule of 2’s) _________% enhance at _________ days, _________% enhance at _________ months. 4. Other imaging studies: a. CTA is used to identify location and extent of v________ o________. b. CT perfusion identifies salvageable p________. c. Infarcted core has d________ CBF within region of d________ CBV. 84.2.1 normal NIH Stroke Scale score 84.2.2 hemorrhage Hyperdense artery; <6 hours; sensitivity low Mass; 2-4 days 2%; 2; 2%; 2 vascular occlusion 84.2.3 penumbra 84.2.4 decreased; decreased ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 458 Part 19: Stroke and Occlusive Cerebrovascular Disease d. Penumbra has d________ CBV w________ d________ CBF; m________ between CBF and CBV. e. MRI is more s________ than CT, particularly in first _________ hours after stroke. 5. NIH stroke scale score: a. Higher score correlates with more p________ vessel occlusion. b. Complete hemianopia adds _________ points. c. Severe aphasia adds _________ points. d. Performance of all commands adds _________ points. 84 decreased; without decreased; mismatch sensitive; 24 hours 84.2.1 84.2.8 proximal 2 2 0 Management of TIA or Stroke 6. Management of ischemic stroke a. Within 4.5 hours of symptom onset, patient may be a candidate for I_______ t________. b. 4.5-6 hours after onset, may use I_______t________ or m_______ t________. c. 6-8 hours after onset, may perform m_______ t________ after checking p________ scan. d. P________ circulation strokes may be treated more a________. 7. Tissue plasminogen activator: a. Alteplase = t________. b. IV tPA contraindications include: i. i_________ ii. known _______ or _____ iii. active _________ iv. anti_________ v. platelet count _________ vi. h_______ t________, s________, or b_______ s________ within past _________ months vii. SBP > _________ c. After administering tPA, anticoagulation and antiplatelets are held for _________ hours. d. There is increased risk for s________ i________ h________ with use of tPA, but no increased risk of m________. 84.3.1 IV tPA IA tPA; mechanical thrombectomy mechanical thrombectomy; perfusion Posterior; aggressively 84.3.2 tPA intracerebral hemorrhage aneurysm or AVM internal bleeding anticoagulation <100K head trauma, stroke, brain surgery; 3 months 185 mmHg 24 hours symptomatic intracerebral hemorrhage; mortality ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Evaluation and Treatment for Stroke 8. Blood pressure guidelines: a. If no prior history of hypertension, do not lower SBP below ___ - ___ and DBP below ___ - ___. b. If prior history of hypertension, do not lower SBP below ___ - ___ and DBP below ___ - ___. 9. Anticoagulation in ischemic stroke: a. American Heart Association recommended the use of heparin remains a matter of p________ by the treating physician. b. Effectiveness of heparin is unproven except with c________ stroke. c. Stop warfarin after _________ months. d. A________ should be administered to most patients. 459 84.3.4 160-170; 95-105 180-185; 105-110 84.3.4 preference 84 cardioembolic 6 Aspirin 325 mg Carotid Endarterectomy 10. Symptomatic carotid stenosis: a. NASCET stands for N_______ A_______ S________ C_______ E_______ T________. b. Carotid endarterectomy (CEA) for symptomatic carotid stenosis _________% reduces strokes by _________% at 18 months and reduces death by _________% at 18 months. c. Only need to wait _________ days after acute stroke to perform CEA. 11. CEA surgery complications: a. _________ days before surgery patient should be started on a________, which should be c________ the day of surgery. b. Aspirin should be h_______ 24-48 hours postop. c. Morbidity absolute upper limit is _________%. d. In-hospital mortality is _________%. e. List postop complications: (Hint: ch4arm2s2) i. c_______ n_______ i_______ ii. h_________ iii. h_________ iv. h_________ v. h_________ vi. a_________ d_______ vii. r_________ viii. m_________ ix. m_________ x. s_________ xi. s_________ North American Symptomatic Carotid Endarterectomy Trial 84.4.1 >70%; 17%; 7% 7 days 84.4.2 84.4.4 5; aspirin 325 mg; continued held 3% 1% cranial nerve injury headache hoarseness hyperperfusion hypertension arteriotomy disruption restenosis morbidity mortality seizures stroke ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 460 84 Part 19: Stroke and Occlusive Cerebrovascular Disease f. Incidence of hypoglossal nerve injury is _________%. g. Tongue deviates t_______ the i_______. h. Hoarseness is most commonly caused by e________ and not n_______ i________. i. Unilateral vocal cord paralysis is due to v________ or r_______ l________ nerve injury. j. Lip asymmetry is due to m_______ b_______ of f_______ nerve injury. k. Hypertension may occur as a result of loss of the c_________ s_________ b_________ reflex. l. Intracerebral hemorrhage occurs in _________% and is related to c________ h________. m. Incidence of post-op ischemic stroke is _________%. n. Post-op TIAs are usually due to c_______ o________ but may also be due to m________. o. Late restenosis occurs in ___% at ______; within 2 years postop it is due to f_______ h________ and after 2 years it is due to a________. p. If TIAs occur in recovery room, then obtain C________. q. If fixed deficit occurs in recovery room, then d_______ n________ obtain CT; instead r________ indicated. r. If arteriotomy closure is disrupted, then o_______ w________ first to e________ clot, then have anesthesia i________ patient, and finally revise endarterectomy in O________. 12. CEA surgery technique: a. There is n_______ d________ between the use of l________ and g________ anesthesia. b. Use a shunt if there is h_________ i_________ to clamping or if s________ pressure is _________. c. C_______ f_______ vein crosses over the carotid bifurcation. d. H________ nerve is in vicinity of f_______ v________. e. S_______ t________ artery is first branch of E________ and helps differentiate E________ from I________. f. Place temporary clip on s_______ t_______ a________. g. Order of occlusion of vessels is I_______ C_______ E_______ (Hint: ICE). 1% towards the injury edema; nerve injury vagus; recurrent laryngeal mandibular branch of facial carotid sinus baroreceptor 0.6%; cerebral hyperperfusion 5% carotid occlusion; microemboli 25% at 1 year; fibrous hyperplasia; atherosclerosis CT do not; reexploration open wound; evacuate; intubate; OR 84.4.5 no difference; local; general hemodynamic intolerance; stump; <25 mmHg Common facial Hypoglossal; facial vein Superior thyroid artery; ECA; ECA; ICA superior thyroid artery ICA, CCA, ECA ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Evaluation and Treatment for Stroke h. P_______ g________ may reduce risk of perioperative occlusion and restenosis. i. Order of releasing the vessels is E_______ C_______ I________. 461 Patch graft ECA, CCA, ICA Carotid Angioplasty/Stenting 13. Carotid angioplasty/stenting: a. Should be considered instead of CEA in patients with severe c________ disease. b. Also in patients with: i. contralateral c________ ii. l_______ n_______ p________ to neck iii. previous CEA with r_______ t________, r_______ iv. h________ carotid bifurcation v. s_______ t_______ lesions vi. age _________ 84.5.2 cardiovascular comorbidities laryngeal nerve palsy 84 radiation treatment, restenosis high severe tandem >80 years-old ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 85 Special Conditions 85 Totally Occluded Internal Carotid Artery 1. Totally occluded internal carotid artery: a. ___ - ___% of patients with carotid territory stroke or TIA have ipsilateral carotid occlusion. b. Patients with mild deficit have stroke rate of ___ - ___% per year related to the occluded carotid. c. ___ - ___% of patients with acute occlusion and profound deficit make a good recovery. d. C________-occluded carotid has p________ patency rate and l________ gain from re-opening. e. R________ filling of ICA to pretrous or cavernous segment from ECA or from contralateral ICA is a g________ sign of operability. 10-15% 85.1.1 3-5% 85.1.3 2-12% Chronically; poor; little 85.1.5 Retrograde; good Cerebellar Infarction 2. Cerebellar infarction: a. _________% of patients developing signs of b________ c________ will die within hours to days. b. Symptoms generally increase within ___ - ___ hours following onset. c. Operation of choice is s________ d________. d. Avoid using v________ d________ alone as this may cause u________ h________ and does not relieve b________ c________. 80%; brainstem compression 85.2.1 12-96 hours suboccipital decompression 85.2.3 ventricular drainage; upward herniation; brainstem compression 85.2.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Conditions Malignant Middle Cerebral Artery Territory Infarction 3. Malignant middle cerebral artery territory infarction: a. Occurs in up to _________% of stroke patients. b. Carries a mortality of up to _________%. c. T________ herniation occurs within _________ days of stroke. d. H________ can reduce mortality to _________% among all comers. e. Better results if surgery performed b________ any signs of herniation. f. 3 r_________ c_________ t_________ found that hemicraniectomy with _________ hours of stroke onset decreased m________ and increased favorable f________ o________. 10% 80% Transtentorial; 2-4 days Hemicraniectomy; 37% before 85.3.1 85.3.2 randomized controlled trials; 48 hours; mortality; functional outcome 85 Cardiogenic Brain Embolism 4. Cardiogenic brain embolism: a. _________ stroke in _________ is cardioembolic. b. _________% of patients will have a stroke within ___ - ___ weeks of an acute MI, and the risk is higher with a________ wall MI. c. Patients with A-fib have a _________% rate of stroke per year without treatment. d. Ischemic stroke rate per year for patients with mechanical heart valves who are on anticoagulation is _________% per year for mitral and _________% per year for aortic valves. e. P________ embolism can occur with a p_________ f_________ o_________, which is present in ___ - ___% of the general population. 463 1 in 6 85.4.1 2.5%; 1-2; anterior 85.4.2 4.5% 85.4.3 3% per year; 1.5% per year 85.4.4 Paradoxical; patent foramen ovale; 10-18% 85.4.5 Vertebrobasilar Insufficiency 5. Vertebrobasilar insufficiency: a. Six of the symptoms of VBI begin with the letter “d.” They are: i. dr_________ _________ ii. di_________ iii. dy_________ iv. de_________ _________ _________ v. diz_________ vi. de_________ b_________ 85.5.2 drop attack diplopia dysarthria defect in vision dizziness deficit bilaterally ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 464 Part 19: Stroke and Occlusive Cerebrovascular Disease b. Clinical diagnosis of VBI requires _________ or more of the symptoms listed above. c. The most common cause of VBI is h_________ i_________. d. S_________ s_________ causes r________ flow in the v________ artery due to p________ stenosis of the s________ artery. e. Stroke rate is ___ - ___% per year. f. A________ is the mainstay of medical management. 85 hemodynamic insufficiency 85.5.3 Subclavian steal; reversed; vertebral; proximal; subclavian 4.5-7% Anticoagulation 85.5.4 vertebral; head rotation 85.6.1 85.5.6 Bow Hunter’s Stroke 6. Bow hunter’s stroke: a. Bow hunter’s stroke is caused by occlusion of the v________ artery resulting from h________ r________. b. The vessel occluded is c________ to the direction of head rotation. c. It is more likely in patients with incompetent p________ c________ arteries. d. An appropriate test for this condition is d________ c________ a________. e. The treatment of choice is d________ of the v________ artery at C________. f. If symptoms persist, then perform C_______ f________. 2 contralateral posterior communicating dynamic cerebral angiography decompression; vertebral; C1-2 C1-2 fusion 85.6.3 85.6.4 Cerebrovascular Venous Thrombosis 7. Cerebrovascular venous thrombosis: a. Hypercoagulable states include: (Hint: a2p4rs) i. a_________ III deficiency ii. a_________ antibodies iii. p_________ C deficiency iv. p_________ S deficiency v. p_________ n________ hemoglobinuria vi. p_________ deficiency vii. r_________ to activated protein C viii. s_________ lupus erythematosis b. Occurs in mothers with incidence of _________, and the highest risk is f_______ ________ weeks post-partum. c. Frequency of dural sinus involvement: i. _________% superior sagittal sinus ii. _________% left transverse sinus iii. _________% multiple sinuses 85.7.2 antithrombin antiphospholipid protein protein paroxysmal nocturnal plasminogen resistance systemic 1/10,000 births; first 2 weeks 85.7.3 70% 70% 71% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Conditions d. Clinical symptoms associated with superior sagittal sinus thrombosis: i. Anterior 1/3 n_______ s________ ii. m________ 1/3 increased muscle tone iii. p________ 1/3 cortical blindness or edema/death e. Jugular bulb thrombosis may produce the following symptoms: (Hint: bash) i. b_________ ii. a_________ iii. s_________ d_______ iv. h_________ f. The best way to diagnose venous sinus thrombosis is by M________ or D________. g. CT findings: i. May be normal in ___ - ___%. ii. H________ sinuses and veins, dubbed the c________ sign, is pathognomonic. iii. Petechial “flame” h_______. iv. Small ventricles in _________%. v. E_________ d_________ sign seen on CT scan with c________. vi. White matter e________. vii. Above findings occur b________. h. H________ is the treatment of choice for venous sinus thrombosis, even when associated with i_______ h________. i. Must not treat with s________ because they reduce f________ and thereby increase t________. j. Should also correct u________ a________ and control h________. k. Continue anticoagulation for ___ - ___ months. l. If medical management fails, can perform d_________ c_________, d_________ s_________ t_________, or e_________ c_________ r_________. m. Mortality is approximately _________%. n. Poor prognosticators are e_________ o_________ a_________, c_________, r_________ n_________ d_________, and d_________ v_________ involvement. 465 85.7.5 no symptoms middle posterior breathlessness aphonia swallowing difficulty hoarseness MRI; DSA 85 85.7.6 10-20% Hyperdense; cord hemorrhages 50% Empty delta; contrast edema bilaterally Heparin; intracerebral hemorrhage 85.7.7 steroids; fibrinolysis; thrombosis underlying abnormality; hypertension 3-6 months decompressive craniectomy, direct surgical treatment; endovascular clot retrieval 30% extremes of age, coma, rapid neurological deterioration; deep venous 85.7.8 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 466 85 Part 19: Stroke and Occlusive Cerebrovascular Disease Moyamoya Disease 8. Moyamoya disease: a. Characterized by p________ s________ occlusion of o________ or usually b________ ICAs and their major b________, with secondary formation of collaterals that have a p_________ o_________ s_________ appearance. b. The 2 types are p________ or s________. c. Primary moyamoya is neither a________ nor i________ in origin. d. Can be associated with a________ in 3 locations (C_______ of W________, c________, M_______ v________), and with increased frequency of v________ aneurysms. e. 2 age peaks: j________ or a________, _________ decades. f. Presentation in children is with i________ attacks and in adults with h________. g. Prognosis is p________ with _________% rate of major deficit or death within _________ years of diagnosis. h. Diagnose with M________ and D________. i. Medical treatment has n________ proven benefit. j. Surgical treatment includes d________ or i________ revascularization. k. The direct revascularization treatment of choice is S_______-M_______ b_______. l. Indirect revascularization is reserved for y________ patients and include EMS (_________), EDAS (_________), and OPT (_________). m. With surgical treatment, the prognosis is g________ in 58%. n. Guidelines for management of asymptomatic moyamoya have n________ been established. progressive spontaneous; one; both; branches; puff of smoke primary; secondary atherosclerotic; inflammatory aneurysms; Circle of Willis, choroidals, Moyamoya vessels; vertebrobasilar 85.8.1 85.8.2 juvenile; adult, 3rd/4th decades ischemic; hemorrhage 85.8.3 poor; 73%; 2 years 85.8.5 MRI/A; DSA no 85.8.6 direct; indirect STA-MCA bypass 85.8.7 85.8.4 younger; encephalomyosynangiosis; encephaloduroarteriosynangiosis; omental pedicle transposition good not ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Special Conditions 467 Extracranial-Intracranial (EC/IC) Bypass 9. EC/IC bypass: a. EC/IC bypass study was published in _________. b. Study critics highlight study’s failure to distinguish between h________ vs. t________ causes of stroke. c. Imaging technologies introduced since the study can now identify f_________d_________ ischemia. d. Misery perfusion = o_________ e_________ f_________ increases when a_________ unable to maintain adequate c_________ b_________ f_________ to meet m_________ d_________. e. Current indications for EC/IC bypass include patients with m________ p________, certain a________, t_______, and m________ disease. f. Bypass grafts: i. Pedicled arterial grafts include: S________ and o________ arteries that are considered l________ flow. ii. R________ artery graft that is m_______ to h________ flow. iii. S________ vein graft that is h________ flow and associated with l________ graft patency rates. 85.9.1 1985 hemodynamic; thromboembolic flow-dependent oxygen extraction fraction; autoregulation; cerebral blood flow; metabolic demands 85 misery perfusion; aneurysms, tumors; moyamoya STA; occipital; low Radial; moderate to high Saphenous; high; lowest ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 86 Cerebral Arterial Dissections General Information 1. Key concepts: a. Hemorrhage between i________ and m________ layers of vessel wall. b. Can present with p_________, H_________, T_________, or S_________. c. Causes include s_________, t_________, or i_________. d. Extracranial dissections usually treated m________. e. Intracranial dissections with S________ are treated with s________. 86 SAH; surgery Sites of Dissection 2. Sites of dissection: a. Most common site is v_______ a________, _________%. b. Basilar/ICA/MCA _________%. c. ACA/PCA/PICA _________%. 86.1 intima; media pain, Horner’s syndrome, TIA/stroke; SAH spontaneous, trauma; iatrogenic medically 86.5 vertebral artery, 60% 30% 10% Evaluation 3. Imaging: a. CTA may obviate need for D________. b. D________ is the definitive diagnostic study. c. Pathognomonic sign on DSA is d_______ l_______ s________. d. Most helpful MRI sequence is T_______ with f_______ s________. 86.7 DSA DSA double lumen sign T1WI with fat suppression ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Cerebral Arterial Dissections Overall Outcome 4. a. b. c. 469 Outcomes: Overall mortality is _________%. _________% have a favorable outcome. Mortality is higher in I________ lesions (_________%) than in v________ lesions (_________%). 86.8 26% 70% ICA (49%); vertebral (22%) Vessel Specific Information 5. Complete the following about carotid dissections: a. Most commonly caused by t________. b. The most common initial symptom is i_______ h________. c. May also present with H________ syndrome. 86.9.1 trauma ipsilateral headache 86 Horner’s 6. Complete the following about vertebral dissections: a. Most commonly caused by t________, trauma; and so most commonly located within extracranial e________ portion of vertebral artery. b. Intracranial dissection can present with SAH S________. c. Treatment is generally medical with anticoagulation a________. d. A________ are equally effective. Antiplatelets e. E________ or s_______ treatment is Endovascular; surgical; recommended for i________ intracranial dissections. f. Endovascular treatment is indicated medical therapy; when m_______ t________ is contraindicated; ineffective, medical therapy is symptomatic flow-limiting c________, or when there is s_________ stenosis f_________-l_________ s_________. 86.9.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 87 Intracerebral Hemorrhage Intracerebral Hemorrhage in Adults 1. Intracerebral hemorrhage key concepts: a. Accounts for ___ - ___% of strokes. b. Presentation differs from ischemic infarct because it includes h_________, v_________, and a_________. c. Hematoma v________ correlates with morbidity and mortality. d. Hematoma enlarges in at least _________% of cases within first _________ hours of onset. e. Angiography is recommended except in patients older than _________ years old with preexisting h________ and hematoma in t_________, p_________, or p________ f_______. 87 87.2 15-30% headache, vomiting; altered consciousness volume 33%; 3 45; hypertension; thalamus, putamen; posterior fossa Epidemiology 2. Risk factors: a. Incidence increases significantly after age _________ and d________ with each decade of age until age 80. b. Preventable risk factors include a_______ c_______, c_________, d_________. 87.3.2 55; doubles alcohol consumption, cigarettes, drugs ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Intracerebral Hemorrhage Locations of Hemorrhage within the Brain 3. Locations of intracerebral hemorrhage: a. Hypertensive hemorrhage sites of predilection are: i. b_________ g_________; _________% ii. t_________; _________% iii. p_________; ___ - ___% iv. c_________; _________% v. c_________ w_________ m_________; ___ - ___% vi. b_________; ___ - ___% b. Most common location for deep hematoma is p________ and is due to rupture of l_______ a________. c. Incidence of lobar hemorrhages is ___ ___% d. Compared with deep hemorrhages, lobar hemorrhages have a b________ prognosis. 471 87.4.1 basal ganglia; 50% thalamus; 15% pons; 10-15% cerebellum; 10% cerebral white matter; 1020% brainstem; 1-6% putamen; lenticulostriate arteries 10-30% 87.4.2 better 87 Etiologies 4. List the causes of lobar hemorrhage: (Hint: teach it) a. t_________ b. e_________ of d_______ I_______ c. a_________ a_______ d. c_________ m_______ e. h_________ c_______ f. i_________ g. t_________ 5. Hemorrhagic transformation of an ischemic infarct: a. Estimated to occur in _________% b. within the first m________ c. and may occur within _________ hours. 6. Coagulation disorders and intracerebral hemorrhage: a. Incidence of symptomatic ICH within 36 hours of treatment with rtPA is ___ ___%. b. Aspirin is associated with increased risk of ICH at a rate of l_______ than _________% per year. 87.5.2 tumor extension of deep ICH amyloid angiopathy cerebrovascular malformation hemorrhagic conversion idiopathic trauma 87.5.2 43% month 24 87.5.2 2-4% less than 1% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 472 Part 20: Intracerebral Hemorrhage 7. Infection and intracerebral hemorrhage: a. 3 types of infection that predispose to ICH: i. f_________ ii. g_________ iii. h_________ s_______ 8. Hypertension and intracerebral hemorrhage: a. Hypertension is a risk factor for hemorrhage in what 2 locations? b. It is not a risk factor for at least _________% of basal ganglia hemorrhages. c. C_________-B_________ a_________ are the source of some hypertensive hemorrhages. 87 9. Amyloid angiopathy: a. Present in _________% of patients over _________ years old, but most do not h________. b. Accounts for _________% of ICH cases. c. Should be suspected in patients with r________ hemorrhages in the l________ location. d. Associated with deposition of b_______ a________ that appears on polarized light as b_______ a_______ g________. e. Genetic link is a_______ E. f. Is not associated with s_______ a________. 10. Hemorrhagic brain tumors: a. Primary brain tumors associated with ICH include g_______ m_______ and l_________. b. Metastatic tumors associated with ICH include l_________, c_________, m_________, and r________ c_______. 11. Anticoagulation and intracerebral hemorrhage: a. Incidence of bleeding complications in patients on anticoagulation is _________% per year. b. Incidence of intracerebral hemorrhage is ___ - ___% per year. c. Mortality in the intracerebral hemorrhage group is _________%. 87.5.2 fungal granulomas herpes simplex pons; cerebellum 87.5.4 35% Charcot-Bouchard aneurysms 87.5.5 87.5.6 50%; 70; hemorrhage 10% recurrent; lobar beta amyloid; birefringent apple green Apolipoprotein E systemic amyloidosis 87.5.7 glioblastoma multiforme; lymphoma lung, choriocarcinoma, melanoma; renal cell 87.5.8 10% 0.3-1.8% 65% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Intracerebral Hemorrhage Clinical 12. Clinical presentation of intracerebral hemorrhage: a. Unlike embolic/ischemic stroke, the neurological deficit with ICH has p________ onset over m________ to h________. b. Thalamic ICH is usually associated with h________ loss, m________ loss if i_________ c_________ is compressed, and e________ signs with upper b________ extension. c. Thalamic ICH >_________ cm has high mortality. d. Cerebellar ICH produces c________ before h________ due to b________ compression. 13. Rebleeding: a. Rebleeding is more common with b_______ g________ ICH than l________ ICH. b. Incidence d________ with time. c. ___ - ___% in first 1-3 hours. d. _________% in 3-6 hours. e. S________ sign on CTA correlated with increased risk of ICH expansion. f. Incidence of late rebleeding is ___ ___%. 14. Edema and intracerebral hemorrhage: a. Edema can cause delayed d________ after ICH. b. The component that is released by clot and presumed to be the most likely cause of surrounding delayed edema is t________. 473 progressive; minutes; hours 87.6.1 hemisensory; motor; internal capsule; eye; brainstem 87.6.3 3.3 coma; hemiparesis; brainstem 87.6.4 basal ganglia; lobar 87 decreases 33-38% 16% Spot 1.8-5.3% 87.6.4 deterioration thrombinin Evaluation 15. Evaluation of intracerebral hemorrhage: a. ICH volume is approximated by the e________ method. b. Formula is _________. c. On average, clot size decreases _________mm/day d. Density decreases _________ Hounsfield units/day ellipsoid 87.7.1 (AP x LAT x HT)/2 0.75 2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 474 Part 20: Intracerebral Hemorrhage e. With l________ change for the first _________ weeks. f. List the sequence of hemoglobin evolution after ICH: (Hint: On days my mom’s home) i. o_________ 0 to 1 day ii. d_________ 1 to 3 days iii. m_________ 3 to 7 days iv. m_________ 7 to 14 days v. h_________ 14 plus days 16. ICH score: a. Give the number of points for the following factors: i. GCS 3-4: _________ points ii. GCS 5-12: _________ points iii. GCS 13-15: _________ points iv. Age > 80: _________ points v. Age < 80: _________ points vi. Infratentorial location: _________ points vii. Supratentorial location: _________ points viii. Volume > 30 cc: _________ points ix. Volume < 30 cc: _________ points x. IVH present: _________ points b. Give the 30-day mortality based on ICH score: i. 0 points _________% ii. 1 points _________% iii. 2 points _________% iv. 3 points _________% v. 4 points _________% vi. 5 points _________% vii. 6 points _________% 87 little; 2 Table 87.4 oxyhemoglobin deoxyhemoglobin methemoglobin methemoglobin hemosiderin Table 87.5 2 1 0 1 0 1 0 1 0 1 Table 87.6 0% 13% 26% 72% 97% 100% 100% Initial Management of ICH 17. Medical management: a. Reduce MAP to pre-morbid level if known or by _________% if unknown. b. Suggested target BP is _________. c. Platelet goal is >_________. d. Most studies suggest that resumption of anticoagulation after ICH is s________. e. Probability of ischemic stroke 30 days following cessation of warfarin for 10 days: i. _________% for those treated for prosthetic heart valve ii. _________% for AFibb iii. _________% for cardioembolic stroke 20% 87.8.1 140/90 100K safe 87.8.2 87.8.4 2.9% 2.6% 4.8% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Intracerebral Hemorrhage Surgical Treatment 18. Surgical management: a. Indications for surgery: i. ICH with significant m_________ e_________ ii. ICH with s_________ iii. ICH volume _________ iv. l_________ and c_________ locations v. y________ age b. Surgery is recommended for cerebellar ICH if GCS is _________, size is _________ and h________ present. 87.9.2 mass effect symptoms 10-30 cc lobar, cerebellar young 13 or less; 4 cm or more, hydrocephalus ICH in Young Adults 19. Name the top 5 causes of nontraumatic ICH in young adults (other than “undetermined” which accounts for ~1/4): Hint: AHadt a. A_________, _________% b. H_________, _________% c. a_________, _________% d. d_________, _________% e. t_________, _________% 475 Table 87.7 87 AVM, 30% HTN, 15% aneurysm, 10% drugs, 7% tumor, 4% Intracerebral Hemorrhage in the Newborn 20. ICH in the newborn: a. G_________ m_________ progressively i_________ until _________ weeks gestational age. b. Matrix may persist in p________ infants and cause hemorrhage. c. Site of hemorrhage depends on a________. d. Between 24-28 weeks, ICH located in b_______ of c________. e. 29 weeks or more, ICH located in h_______ of c________. f. List the risk factors: (Hint: vespacc) i. v_________ e_______ ii. E_________ iii. s_________ iv. p_________ v. a_________ vi. c_________ h_______ d_______ vii. c_________ a_______ by m_______ Germinal matrix; involutes; 36 87.12.2 premature age body of caudate head of caudate 87.12.4 volume expansion ECMO seizures pneumothorax asphyxia cyanotic heart disease cocaine abuse by mother ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 476 87 Part 20: Intracerebral Hemorrhage g. Grading system of P________. i. Grade I = s________. ii. Grade II = I________ without v_______ d_________. iii. Grade III = I________ with v_______ d_________. iv. Grade IV = I________ with p_______ I________. h. Hydrocephalus develops in ___ - ___% about ___ - ___ weeks after ICH. i. Diagnosed using u________ imaging. j. Medical treatments are n________ effective. k. Surgical options include serial l_________ p_________, v_________ t_________, t_________ v_________ a_________ d_________, s_________. l. Prerequisites before shunt insertion include infant weight of _________ and CSF protein of _________. m. Outcomes: i. Mortality ___ - ___% with severe ICH. ii. Hydrocephalus ___ - ___% with severe ICH. iii. _________% ambulatory with grade II ICH. iv. _________% IQ normal range with grade II ICH. Papile subependymal IVH; ventricle dilation Table 87.8 IVH; ventricle dilation IVH; parenchymal ICH 20-50%; 1-3 weeks ultrasound not 87.12.7 87.12.9 87.12.10 lumbar puncture, ventricular tap, temporary ventricular access device, shunt 2000 grams or more; less than 100 mg/dl 50-65% Table 87.9 65-100% 100% 87.12.11 75% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 88 Outcome Assessment Cancer. Head Injury. Cerebrovascular Events. Spinal Cord Injury 1. Matching. Match the following outcome scores with the condition they are designed to assess. Outcome scores: ① Karnofsky; ② Rancho Los Amigos; ③ Glasgow Outcome; ④ Modified Rankin; ⑤ Barthel; ⑥ Functional Independence Measure; ⑦ WHO performance score a. cerebrovascular b. spinal cord c. cancer d. head injury ④, ⑤ ⑥ ①, ⑦ ②, ③ 88.3.1 2. True or False. A higher number indicates better function. a. Karnofsky scale b. WHO Performance Scale c. Rancho Los Amigos scale d. Glasgow Outcome scale e. Modified Rankin scale f. Barthel scale g. Functional Independence Measure true false true true false true true 88.1 d. 70%. There are no 75 or 85 scores. 70 cares for self, unable to carry on normal activity or work; 50 requires considerable care; and 40 is disabled. Table 88.1 3. On the Karnofsky scale, which score represents the transition from being able to engage in normal activity to only caring for self? a. b. c. d. 88.4 88.1 88 88.2 88.2 88.3 88.4 80% 85% 75% 70% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 89 Differential Diagnosis by Location or Radiographic Finding – Intracranial 89 Posterior Fossa Lesions 1. If a solitary intraparenchymal lesion in the p-fossa in an adult is seen, a m_______ must be ruled out. metastasis (from an extracranial primary malignancy) 89.2.1 2. The most common primary intra-axial p-fossa tumor in adults is h__________________. hemangioblastoma 89.2.1 3. Complete the following about hemangioblastomas: a. Account for ___-___% of p-fossa tumors. 7-12% b. Usually see s________ v_______ on MRI. signal voids (serpentine appearance) 89.2.1 4. Besides embolism and thrombosis of a plaque, 2 other etiologies for a cerebellar stroke are: a. v__________ a_________ vertebral artery dissection d_____________ b. v_________________ h______________ vertebrobasilar hypoplasia 89.2.1 5. Multiple lesions in the cerebellum can be suggestive of: a. m___________ b. h__________________ associated with V____ c. a_____________ d. c__________ m_____________ 89.2.1 6. As a group, a____________ are the most common pediatric brain tumors in the p-fossa. metastases hemangioblastomas; VHL abscesses cavernous malformations astrocytomas 89.2.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Intracranial 479 7. The following 3 types of tumors account for the majority of infratentorial tumors in patients less than 18 years of age: a. P______ including m__________________: ___% (of infratentorial tumors) b. a_____________ including p__________ a_____________: ___% c. b__________ g_________: ___% 8. The following facts help differentiate medulloblastomas and ependymomas: a. “Banana sign” is seen with ___________. b. Grow from anterior aspect of 4th ventricle ___________. c. Tend to grow from floor of 4th ventricle. d. Tend to be inhomogeneous on T1WI MRI. e. Calcification is common. 9. Complete the following about CPA lesions: a. Acoustic neuromas are more accurately known as v__________ s___________ and occur in ___ to ___% of CPA lesions. b. Meningioma occurs in ___ to ___% of CPA lesions. c. Epidermoid occurs in ___ to ___% of CPA lesions. 10. Match the tumor with the characteristic finding: ① vestibular schwannoma; ② meningioma Characteristic: (a-f) below a. Hearing loss occurs early. b. Facial weakness occurs early. c. Internal auditory canal is enlarged. d. Calcifications seen more commonly. e. Represents 90% of CPA tumors. f. Homogeneous signal and enhancement. 11. Match the cystic lesions of the CPA which its characteristic findings: ① arachnoid cyst; ② epidermoid cyst; ③ dermoid cyst; ④ cholesterol granuloma Characteristic: (a-d) below a. High signal on T1WI and high signal on T2WI and associated with bone destruction. b. Cystic component has same intensity as CSF. 89.2.1 PNET; medulloblastoma: 27% astrocytomas; pilocytic astrocytoma: 27% brainstem gliomas: 28% 89.2.1 medulloblastoma medulloblastoma ependymomas ependymomas ependymomas 89.2.2 vestibular schwannomas; 80-90% 5-10% 5-7% 89 89.2.2 ① ② ① ② ① ② 89.2.2 ④ ① ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 480 Part 22: Differential Diagnosis c. High signal on DWMRI differentiates this from arachnoid cyst. d. T1WI intensity similar to fat and usually midline. 12. What are some differentiating features that distinguish neuromas of the V, VII, and VIII cranial nerves? a. Neuromas of CN ___ can pass through the tentorial hiatus medially. b. Neuromas of CN ___ can cross into the middle fossa via the petrous apex. c. Neuromas of CN ___ can cross the midpetrosal bone. 13. Complete the following about foramen magnum lesions: a. Most are ___________ (extra-axial vs. intra-axial.) b. A mass behind the dens compressing the spinal cord is a c_________ until proven otherwise. c. The second most common site of origin of posterior fossa meningiomas is the a_______ l___ of the foramen magnum d. C_____________ p_____ is usually an early symptoms of lesions in this location. 89 ② ③ 89.2.2 CN VIII CN V CN VII 89.2.4 extra-axial chordoma anterior lip Craniocervical pain Multiple Intracranial Lesions on CT or MRI 14. Infectious causes of multiple intracranial lesions on imaging include: a. t_____________ b. fungal etiologies including: i. a_____________ ii. c______________ iii. c__________________ iv. c_______________ c. Parasitic etiologies including: i. e______________ ii. s_______________ iii. p______________ 15. Complete the following about multiple intracranial lesions on imaging: a. What percentage of gliomas are multicentric? b. HSV usually occurs in the t________ lobe. c. MS lesions are located in the p___________ area. 89.3 toxoplasmosis aspergillosis coccidiomycosis cryptococcus candidiasis echinococcus schistosomiasis paragonimiasis 89.3 6% temporal periventricular ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Intracranial 481 d. Dural sinus thrombosis can cause multiple v________ i__________ e. Multiple “hypertensive” hemorrhages is likely due to a________ a____________ 89.4.3 Metastases Abscess GBM Infarction Contusion Demyelination Radiation Lymphoma (primary vs. metastatic) White Matter Lesions 17. List conditions that can affect the corpus callosum: a. m_________ ____________ b. G_______ c. l_____________ d. l________ e. d________ a_______ i_________ amyloid angiopathy Ring-Enhancing Lesions on CT/MRI 16. What are the classic etiologies for ring-enhancing lesions on imaging? (hint: MAGIC DR. L) a. M_____________ b. A___________ c. G_____ d. I___________ e. C___________ f. D_____________ g. R___________ h. L_________ venous infarcts 89.5.2 multiple sclerosis GBM lymphoma lipoma diffuse axonal injury 89 Sellar, Suprasellar and Parasellar Lesions 18. The most common enhancing pituitary lesion in adults is a p_____________ a_________. pituitary adenoma 89.6.1 19. The most common sellar and parasellar lesions in children are c_____________________ and g______________. craniopharyngiomas and germinomas 89.6.1 20. Regarding pituitary tumors. a. Adenohypophyseal tumors include pituitary a____________ and c_____________. b. Neurohypophyseal tumors include m__________, p____________, and a_____________ c. What is the most common tumor found in the posterior pituitary? 89.6.2 adenomas, carcinomas metastases, pituicytomas, and astrocytomas metastases (most common primaries are lung and breast) ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 482 Part 22: Differential Diagnosis 21. The pituitary gland can normally be slightly enlarged in w___________ of c_________________ age. 22. Complete the following about pituitary hyperplasia: a. Thyrotroph hyperplasia is most likely due to ______ ________. b. Gonadotroph hyperplasia is most likely due to ______ _______. c. Somatotroph hyperplasia is most likely due to _____ ___-___ _______. d. Lactotroph hyperplasia is most likely due to ________. 23. Suprasellar germ cell tumors are: a. more common in _______ (men vs. women) b. triad of d_________ i__________, p______________________, and v_________ d____________ 89 women of childbearing age 89.6.2 primary hypothyroidism primary hypogonadism ectopic GH-RH secretion pregnancy 89.6.2 women (pineal region more common in men) diabetes insipidus, panhypopituitarism; visual deficits 24. Complete the following about juxtasellar masses: a. Craniopharyngiomas account for ___% of 20%; 54% tumors in this region in adults and ___% in children. b. To differentiate meningiomas from gadolinium pituitary adenomas, use g__________. c. On imaging, meningiomas demonstrate: i. Enhancement? bright homogenous enhancement ii. Epicenter is s_________. suprasellar iii. May see d_______ t____. dural tail iv. Is sellar enlarged or not enlarged? Usually not enlarged v. Tend to encase _______ ________. carotid arteries 25. Pituitary hypophysitis and adenomas can be distinguished by the following: (hypophysitis vs. adenoma) a. Symmetric enlargement is most often seen with _______. b. Sellar floor may be eroded with ______. c. Enhancement more intense with ______. d. Pituitary stalk thickened with _______. e. Associated with pregnancy 26. True or False regarding lymphocytic hypophysitis: a. May cause hypopituitarism. b. Most cases are seen in men. c. Requires surgery for treatment. d. May produce diabetes insipidus. 89.6.2 89.6.2 hypophysitis Table 89.2 adenoma hypophysitis hypophysitis hypophysitis 89.6.4 89.6.6 true false - in women in late pregnancy or early postpartum period false - treatment with steroids true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Intracranial 483 Intracranial Cysts 27. Complete the following about arachnoid cyst: a. aka l_______ c_______ b. Due to a d________ of the a________. c. Reach maximum size in __ month(s). d. Need surgery in about ___% of cases. 28. Complete the following about cavum septum pellucidum: a. Present in all p___________ b________ and 97% of n____________. b. Present in ___% of adults. c. What is it? d. Seen in _________ suffering from c______ t_________ e_________________ 29. Cavum vergae is located posterior to and communicates with c__________ s_________ p_____________. 30. Complete the following about cavum velum interpositum: a. Due to separation of the c______ of the f__________ b. between the t________ and the t_______ v_________. c. Present in ___% of children less than 1 year of age. d. Present in ____% of children between 1 and 10 years old 89.7.1 leptomeningeal cyst duplication; arachnoid 1 month 30% premature babies; newborns 10% Variable slit-like fluid-filled space between the leaflets of the left and right septum pellucidum. boxers; chronic traumatic encephalopathy Table 89.3 cavum septum pellucidum (CSP) Table 89.3 89.7.3 Table 89.3 crura; fornix thalami; third ventricle 60% 89 30% Orbital Lesions 31. The most common benign primary cavernous hemangioma; intraorbital neoplasm is melanoma c_____________ h_________. The most common primary intraocular malignancy in adults is m___________. 89.8.2 32. Complete the following about orbital and ocular lesions: a. The most common orbital lesion in children is a d________ c______ b. The most common malignant tumor of the orbit in this age group is r____________________. c. The most common primary intraocular malignancy in children is r___________. 89.8.3 dermoid cyst rhabdomyosarcoma retinoblastoma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 484 Part 22: Differential Diagnosis 33. Match the orbital lesions with their characteristics. (multiple answers may be correct for a given characteristic) ① capillary hemangioma; ② lymphangioma; ③ lymphoma; ④ thyroid ophthalmoplegia Characteristic: (a-e) below a. infantile proptosis b. regress spontaneously c. do not regress d. painless proptosis e. bilateral 80% of the time 89 89.8.2 ①, ② ① ② ③, ④ ④ Skull Lesions 34. Complete the following about skull lesions: a. The most common benign tumors of the osteomas, hemangiomas skull are o________ and h___________. b. The most common malignancy of the osteogenic sarcoma skull is o______________ s___________. 89.10.1 35. Complete the following about characteristics of skull lesions: a. Multiplicity suggests m___________. b. Expansion of diploe suggests a b_______ lesion. c. Peripheral sclerosis suggests a b_______ lesion. d. Full-thickness lesions suggest m____________. e. Multiple sharply demarcated and punched-out defects suggest m_______ m________. f. Presence of peripheral vascular channels is highly suggestive of ________ lesions. 89.10.1 36. Complete the following: a. Which skull lesion demonstrates a i. trabecular pattern? ii. sunburst pattern? iii. islands of bone pattern? iv. tenderness to palpation? b. Eosinophilic granuloma is the mildest form of L______________ c_____ h____________. 37. The following can cause diffuse demineralization or destruction of the skull: a. h______________________ b. m______________ c. m___________ m____________ d. o______________ malignancy benign benign malignancy multiple myeloma benign 89.10.1 hemangioma hemangioma fibrous dysplasia Langerhans cell histiocytosis lesion Langerhans cell histiocytosis 89.10.3 hyperparathyroidism metastases multiple myeloma osteoporosis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Intracranial 485 38. The following can cause diffuse or generalized increased skull density: a. a______ b. f_________ d________ c. h__________ i__________ g____________ d. o_____________ m_____________ e. P_______ d____________ 39. A pneumocele is an enlargement of an a____ s________ that ________ (has vs. does not have) bone erosion. Pneumosinus dilatans is an enlargement of an a___ s________ that ________ (has vs. does not have) bone erosion. air sinus; has; air sinus; does not have 89.10.9 Typically, no. However, a fungating malignant glioma may do this. 89.11 Intracranial Hyperdensities 41. What can cause an intra-axial structure to appear hyperdense with respect to normal brain tissue on a non-contrast CT? a. a_______ b________ b. c__________ c. l____ f_____ v________ d. m____________ anemia fibrous dysplasia hyperostosis interna generalisata osteoblastic metastases (prostate and breast) Paget’s disease Combined Intracranial/Extracranial Lesions 40. Can intra-axial lesions grow out of the skull? 89.10.5 89.12 89 acute blood calcium low flow vessels melanoma (melanin can appear hyperdense) Intracranial Calcifications 42. The following are physiologic causes of localized intracranial calcifications: a. c________ p______ b. a____________ g__________ c. d__________ s_______ d. d_____ e. p________ g_______ 43. Choroid plexus calcifications have the following features: a. ___% of patients by 5th decade of life demonstrate calcifications. b. Calcifications are rare under age ___. 89.13.1 choroid plexus arachnoid granulation diaphragma sellae dura pineal gland 89.13.2 75% age 3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 486 Part 22: Differential Diagnosis c. If calcifications present under age 10, consider c_________ p________ p_________. d. If calcified, choroid plexus in the temporal horn, then consider n____________. 44. Complete the following about basal ganglia calcifications: a. Common in e________ b. Causes include: i. h_______________ ii. a____________ use iii. F______ disease c. Correlated with psychiatric diseases if > ____ cm. 45. Fahr’s disease involves progressive idiopathic c____________ of the b________ g_______, s_______ d________ of cerebral cortex, and d________ n_________. 89 choroid plexus papilloma neurofibromatosis 89.13.2 elderly hyperparathyroidism anticonvulsant use Fahr’s disease 0.5 cm calcification; basal ganglia (medial portions), sulcal depths; dentate nuclei 89.13.2 Intraventricular Lesions 46. Complete the following about intraventricular lesions: a. What is the most common lesion? b. Lesion at the foramen of Monro? c. 3rd ventricle lesion with punctate calcifications? d. Fills the 4th ventricle with “banana sign”? e. Most common low density 4th ventricle lesion? f. Free-floating fat in ventricles? g. Has fat and calcifications? h. At the septum pellucidum? i. Densely enhancing with calcifications? 47. Intraventricular meningiomas are: a. Usually arterial supply from a__________ c____________ artery b. Less common arterial supply from m___________ p__________ c_________ artery and l__________ p__________ c__________ artery. c. Tumor thought to arise from ______________ _____ cells. 89.14.2 astrocytoma colloid cyst craniopharyngioma medulloblastoma epidermoid dermoid with cyst rupture teratoma central neurocytoma meningioma 89.14.2 anterior choroidal artery medial posterior choroidal artery, lateral posterior choroidal artery arachnoid cap cells ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Intracranial 487 48. Match the tumor that is found most often in the following ventricles: ① astrocytoma; ② medulloblastoma; ③ meningioma; ④ ependymoma; ⑤ colloid cyst; ⑥ epidermoid; ⑦ dermoid; ⑧ teratoma Ventricle: (a-e) below a. 3rd ventricle b. 4th ventricle c. atrium of lateral ventricle d. frontal horn of lateral ventricle e. body of lateral ventricle 49. The following are lesions that can be found in the posterior of the 3rd ventricle: a. p_____________ b. m______________ c. a_____________ c_______ d. a___________ of v_____ of G________ 50. Which masses within the lateral ventricles do not enhance? a. c______ b. d__________ c. e_____________ d. s_____________________ Table 89.4 ⑤ ② ③ ① ④ 89.14.3 pinealoma meningioma arachnoid cyst aneurysm of vein of Galen 89.14.3 cysts dermoids epidermoids subependymomas 89 Periventricular Lesions 51. What is the differential for a periventricular solid enhancing lesion? a. l___________ b. e____________ c. m____________ d. m_____________ in child e. p__________ t________ f. G_____ 52. What are some etiologies of lowdensity periventricular lesions? a. t____________ e_______ b. m__________ s_________ c. s________ a_____________ e______________ d. l__________ 89.15.1 lymphoma ependymoma metastases medulloblastoma pineal tumor GBM 89.15.2 transependymal edema multiple sclerosis subacute arteriosclerotic encephalopathy (aka Binswanger’s disease) leukoaraiosis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 488 Part 22: Differential Diagnosis Ependymal and Subependymal Enhancement 53. What is the differential for ependymal and subependymal enhancement? (Hint: some overlap with periventricular lesions) a. v____________ b. c___________ m_______________ c. m__________ s____________ d. t__________ s____________ 54. In immunocompromised patients, what do the following patterns suggest? a. thin linear enhancement b. nodular enhancement ventriculitis carcinomatous meningitis (would see meningeal enhancement as well) multiple sclerosis tuberous sclerosis (supependymal hamartomas) 89.17 viral infection (CMV, varicellazoster) CNS lymphoma Intraventricular Hemorrhage 55. Complete the following about intraventricular hemorrhage: a. Most occur as a result of _______________ of ______________ ________________. i. In the adult, this may originate in the t___________ or p___________. ii. In a newborn, this may originate in the s________________. b. Aneurysms account for about ___% of IVH in adults. c. What are the typical locations of an involved aneurysm? 89 89.17 89.18 extension of intraparenchymal hemorrhage thalamus, putamen subependymal region 25% a-comm, distal basilar artery, carotid terminus, vertebral artery, distal PICA Medial Temporal Lobe Lesions 56. The most common medial temporal lobe lesions are: a. h_____________ b. m________ t___________ s___________ c. g_______ 89.19 hamartoma mesial temporal sclerosis glioma ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Intracranial 489 Intranasal/Intracranial Lesions 57. Complete the following about intranasal/intracranial lesions: a. M____________ is a fungal infection seen primarily in diabetics or immunocompromised patients. b. Nasopharyngeal carcinomas are associated with _____ infection. c. A s_________ u__________ c_______________ (aka ________) is an aggressive carcinoma that may invade into the frontal fossa and cavernous sinus. d. E_________________ arises from crest cells of the nasal vault and often demonstrates intracranial invasion. Typically presents with e_______ or n_______ o____________. e. A nasal polypoid mass in a newborn should be considered an e________________ until proven otherwise. It can be distinguished by a nasal glioma because it is often p___________ and s______ with the Valsalva maneuver. 89.22 Mucormycosis EBV sinonasal undifferentiated carcinoma; SNUC Esthesioneuroblastoma; epistaxis; nasal obstruction encephalocele; pulsatile; swells 89 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 90 Differential Diagnosis by Location or Radiographic Finding – Spine Atlantoaxial Subluxation 1. What are the disease processes causing atlantoaxial subluxation? a. incompetence of the __________ ____________ ligament i. r_________ a_____________ ii. t________ iii. c________ l__________ 90 iv. chronic ________ use v. chronic ______________ infections b. incompetence of the ___________ ________________ i. f___________ ii. o_ o_____________ iii. r_________ a_____________ iv. erosion by t_______ v. M______ syndrome vi. c_________ d__________ vii. i_________ 2. Complete the following about atlantoaxial subluxation: a. Incompetence of the ________ ________ ligament b. results in increased ________ interval. 3. Complete the following regarding differential diagnosis by location: a. Morquio syndrome is hypoplasia of the ________ b. due to a m__________________. c. It may result in ________ subluxation. 90.2 transverse atlantal ligament rheumatoid arthritis trauma congenital laxity (esp. with Down syndrome) steroid retropharyngeal odontoid process fracture os odontoideum rheumatoid arthritis tumor Morquio syndrome (hypoplasia of dens) congenital dysplasia infection 90.2 transverse atlantal atlantodental 90.2 dens mucopolysaccharidosis atlantoaxial ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis by Location or Radiographic Finding – Spine Abnormalities in Vertebral Bodies 4. What are 8 malignancies that have a tendency to metastasize to the vertebral bodies? 5. General differential for vertebral body lesions: a. n_________ b. i__________ c. f_____ i________ d. d_____________ changes e. m_____________ diseases including P________ disease, o_____________, and a___________ s_____________ prostate, breast, lung, renal cell, thyroid, lymphoma, melanoma, and multiple myeloma 90.3 90.3 neoplasm (metastatic vs. primary) infection (osteomyelitis vs. discitis) fatty infiltration degenerative changes metabolic; Paget’s disease, osteoporosis, ankylosing spondylitis Pathologic Fractures of the Spine 6. What are the 6 criteria for vertebra plana? What are 3 etiologies that may lead to this phenomenon? a. Criteria: b. Etiologies: 491 90.5.3 1. uniform collapse of vertebral body into flat thin disc 2. increased density of vertebra 3. spares neural arches 4. normal disc and intervertebral disc space 5. intervertebral vacuum cleft sign (pathognomonic) 6. no kyphosis 1. Langerhans cell histiocytosis 2. Calve-Kummel-Verneuil disease (avascular necrosis of the vertebral body) 3. hemangioma 90 Destructive Lesions of the Spine 7. If vertebral body destruction is infection (often involves at associated with destruction of the disc least two adjacent vertebral space, what general etiology is this levels) suggestive of? 90.7.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 492 Part 22: Differential Diagnosis Vertebral Hyperostosis 8. What is the differential diagnosis of vertebral body hyperostosis? a. P_______ ___________ b. m____________ including l__________ as well as p________ c_______ in men and b_________ c________ in women 90.9 caudal regression syndrome 16-20%, diabetic mothers spinal Enhancing Nerve Roots 10. What is the differential for an enhancing nerve root? a. t______ such as m_________ c____________ or l__________ b. i_________ especially if patient has _____ c. i___________ including ______________ or ____________ 90 Paget’s disease Metastases (osteoblastic); lymphoma; prostate cancer; breast cancer Sacral Lesions 9. Complete the following about sacral agenesis: a. Sacral agenesis is also known as ______ ___________ ____________. b. __-__% have _________ mothers. c. Increased incidence of ________ abnormalities. 90.8 90.10 tumor; meningeal carcinomatosis; lymphoma infection; AIDS (consider CMV) inflammatory; Guillain-Barré, sarcoidosis Intraspinal Cysts 11. What is the differential for an intraspinal cyst? a. s______ m________ c______ b. c______ n___________ c. e____________ d. s_______________ e. dilated c________ c______ 90.12 spinal meningeal cysts cystic neurofibroma ependymoma syringomyelia dilated central canal ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 91 Differential Diagnosis (DDx) by Signs and Symptoms – Primarily Intracranial Syncope and Apoplexy 1. Complete the following about the causes of syncope: a. Prevalence of syncope is about ___% and is higher in the e_______. b. In about ___% of cases, no cause can be diagnosed. c. Cerebrovascular causes include: i. s_______________ h______________ ii. b_________ infarction iii. v________________ i_____________ iv. p____________ a____________ d. Disorder of AV node conduction leading to syncope with bradycardia is called ____________________. e. Syncope while wearing a tight collar or while shaving may be due to _______ _______ ______. f. Micturition or cough causing syncope is called t________ syncope and is usually associated with elevation in i______________ pressure. g. Orthostatic hypotension is defined as a drop in systolic BP of at least ______ mm Hg or diastolic BP of at least ______ mm Hg on standing. 2. When are neurodiagnostic tests (EEG, CT scan, MRI, carotid Doppler) warranted in the setting of syncope? 50%; elderly 40% 91.3.1 91.3.2 subarachnoid hemorrhage (most commonly aneurysmal) brainstem infarction vertebrobasilar insufficiency pituitary apoplexy Stokes-Adams syndrome carotid sinus syncope 91 triggered; intrathoracic 20; 10 seizures, altered mental status, Todd’s paralysis, known history of cerebrovascular compromise, new focal deficits, new language deficits 91.3.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 494 Part 22: Differential Diagnosis Transient Neurologic Deficit 3. Complete the following about transient neurological deficits (TIA): a. By definition, lasts less than ___ hours. b. Symptoms will usually subside within ___ ___________ (minutes vs. hours) c. They are a result of i________. d. Differential for a transient neurologic deficit includes: i. t________ i________ a__________ ii. m____________ iii. s______________ followed by _______ ______________ iv. c_______ s_______ h____________ e. TIA-like symptoms from cerebral amyloid angiopathy require avoidance of a________ or a__________ medications. 91 91.4 24 20 minutes ischemia transient ischemic attack migraine seizure; Todd’s paralysis chronic subdural hematoma antiplatelet; anticoagulant Diplopia 4. Complete the following regarding the etiology of diplopia secondary to VI nerve palsy: a. i________ i___________ p_____________ b. s__________ s_____________ c. t________ increased intracranial pressure sphenoid sinusitis tumor 5. a. b. c. d. e. f. g. cranial nerve palsies intraorbital mass Graves’ disease myasthenia gravis giant cell arteritis botulism trauma The differential for diplopia includes: c_______ n_________ p_________ i_____________ m________ G_________ disease m____________ g________ g______ c____ a____________ b_____________ secondary to t________ 91.6 91.6 Anosmia 6. Complete the following about anosmia: a. Most common cause is a severe u______ r__________ i_________. b. Second most common cause is h_______ t___________ with a __-__% occurrence in severe cases. c. Intracranial neoplasms such as o_____________ g___________ m___________ can be a cause. d. Congenital anosmia is also known as K_____________ syndrome. 91.7 upper respiratory infection head trauma; 7-15% olfactory groove meningiomas Kallmann syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Differential Diagnosis (DDx) by Signs and Symptoms – Primarily Intracranial 495 Multiple Cranial Nerve Palsies (Cranial Neuropathies) 7. Complete the following about cranial neuropathies: a. Congenital facial diplegia is also known as M_______ s_______. b. It affects which half of the face more? c. Which other cranial nerves may be involved? d. Lyme disease can cause CN________ palsy. e. Affects which half of the face? f. True or False. It may also involve other cranial nerves. g. Tuberculous meningitis usually involves which cranial nerve first and most frequently? h. Weber’s syndrome involves CN ___ and c_____________ h__________________. i. Millard-Gubler syndrome involves CN ___ and CN ____ as well as c____________ h______________. j. A mass in the ____ ventricle may compress the f_______ c__________ causing facial diplegia. 8. Complete the following about cavernous sinus syndrome: a. Which cranial nerves can be involved with a lesion in the cavernous sinus? b. Clinical symptoms include d________ due to o_________________. c. With CN ___ palsy in cavernous sinus syndrome, the pupil ______ (will vs. will not) be dilated. 9. Complete the following about osteopetrosis: a. Also known as m________ b______. b. It is a g_________ disorder involving defective o______________ resorption of bone. c. Patients will have ___________ (increased vs. decreased) bone density. d. Most common neurologic manifestation is b_____________. e. Treatment consists of bilateral o________ n_________ decompression. Möbius syndrome 91.8.1 upper half CN VI, III, or XII CN VII (unilateral or bilateral) lower half False CN VI CN III and contralateral hemiparesis CN VI and VII; contralateral hemiparesis 4th ventricle; facial colliculus 91.8.2 91.8.2 CN III, IV, V1, V2, and VI diplopia; opthalmoplegia CN III; will not 91.8.2 91 marble bone genetic; osteoclastic increased blindness optic nerve ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 496 Part 22: Differential Diagnosis Binocular Blindness 10. What is the differential diagnosis for new onset binocular blindness? a. bilateral o__________ l________ dysfunction secondary to either t________ or i_________ b. s_________ c. m________ d. p__________ i_______ o_____ n_____________ e. bilateral v________ h___________ f. f___________ such as ____________ disorder 91 occipital lobe; trauma; ischemia seizures (Epileptic blindness) migraines posterior ischemic optic neuropathy vitreous hemorrhage functional; conversion Monocular Blindness 11. Complete the following about temporal arteritis: a. Also known as g________ c_______ a__________ b. Usually due to ischemia of the: i. o_________ n________ ii. o________ t________ iii. c_______ r_________ a__________ (less likely) 91.9 91.10 giant cell arteritis optic nerve optic tract central retinal artery Exophthalmos 12. Complete the following about exophthalmos: a. Also known as p________. b. If history of trauma, differential should include c______ c________ f_________. c. If following frontal-orbital surgery, differential should include o________ r_________ defect. proptosis carotid cavernous fistula 91.11.1 91.11.2 orbital roof defect 13. What is the differential of pulsatile exophthalmos? a. c___________ c__________ f_________ carotid cavernous fistula b. o_________ r_______ d_________ with orbital roof defect transmitted intracranial pulsations c. v____________ t_________ vascular tumor 91.11.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Differential Diagnosis (DDx) by Signs and Symptoms – Primarily Intracranial 497 Ptosis 14. What is the differential diagnosis for etiologies causing ptosis? a. c__________ b. t________ to eyelid c. CN _____ palsy or seen in H__________ syndrome d. m_________ g_____ e. b_______ f. mechanical obstruction secondary to t_________ or extension of m________ from frontal sinus g. d_____ induced congenital (often autosomal dominant inheritance) trauma CN III; Horner’s syndrome myasthenia gravis botulism tumor; mucocele drug (alcohol, opium, etc.) Tinnitus 15. Complete the following about pulsatile tinnitus: a. Most cases of pulsatile tinnitus are due to v__________ lesions. b. Workup includes: M______ and a__________. 16. What is the differential for nonpulsatile tinnitus? a. occlusion of e__________ e____ b. o________ m________ c. M__________ d___________ d. l______________ e. e____________ _____ tumors f. Drugs such as s______________, q________, and a__________________ 91.12 91.15.2 vascular MRI (with and without enhancement); angiogram 91.15.3 external ear otitis media Meniere’s disease labyrinthitis endolymphatic sac salicylates, quinine; aminoglycosides 91 Language Disturbance 17. Complete the following about language disturbances: a. Wernicke’s aphasia is a f________ aphasia. b. Conduction aphasia is associated with f_______ speech and p______________. Patients _______ (are vs. are not) aware of their deficits. c. Bilateral frontal lobe dysfunction is associated with a________ m_________. 91.17 fluent fluent; paraphasias; are not akinetic mutism ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 92 Differential Diagnosis (DDx) by Signs and Symptoms – Primarily Spine and Other Myelopathy 1. True or False. The following are potential causes of myelopathy: a. cervical or thoracic spinal stenosis b. chronic anemia c. Cushing’s disease d. Lyme disease e. acquired immunodeficiency syndrome (AIDS) 2. How does anemia produce myelopathy? a. Chronic anemia can lead to b_________ m___________ hypertrophy and c_______ c______________. b. Pernicious anemia can lead to s________ c____________ d_____________. 3. E___________ l__________ is seen in Cushing’s disease and can produce myelopathy. 92 92.2 true true true true true 92.2 bone marrow; cord compression subacute combined degeneration Epidural lipomatosis 92.2 4. Order the following location of neoplastic masses causing myelopathy in order of most common to least common: a. intramedullary extradural, b. extradural intradural extramedullary, c. intradural extramedullary intramedullary 92.2 5. What are the frequencies of spinal cord tumors in the following locations? a. extradural: __% b. intradural extramedullary: __% c. intradural intramedullary: __% 92.2 55% 40% 5% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis (DDx) – Primarily Spine and Other 6. Complete the following about spinal cord infarction: a. Although uncommon, spinal cord infarction most often occurs in the territory of the a________ s__________ artery and most commonly at the level of ____. b. This occurs because this region is a w__________ area. c. This spares the p__________ c_______. d. Causes of infarction include: i. h___________ ii. a______________ iii. e_____________ iv. a_____ d_____________ v. s_______ s____________ 7. Necrotizing myelopathy associated with spontaneous thrombosis of a spinal cord AVM that presents as spastic to flaccid paraplegia with ascending sensory level is called F_____-A____________. 8. Regarding acute (idiopathic) transverse myelitis: a. True or False. Clinical onset is indistinguishable from acute spinal cord compression. b. ________ (Abnormal vs. Normal) imaging is expected on CT, myelogram and MRI. c. Cerebrospinal fluid (CSF) analysis shows p____________ and h_______________. d. The t_______ region is the most common level. e. True or False. The most common onset is 20 to 40 years of age. f. True or False. Usually results in a diagnosis of multiple sclerosis. 9. Abdominal cutaneous reflexes are almost always absent in m_______ s___________. 10. Regarding Devic’s syndrome: a. Characterized by acute bilateral o______ n_________ and m__________. b. True or False. The transverse myelitis can be a cause of complete block on myelography. c. True or False. More common in Asia than in the United States. d. True or False. It is a variant of multiple sclerosis. 499 92.2 anterior spinal artery; T4 watershed posterior columns hypotension atherosclerosis embolization aortic dissection spinal stenosis Foix-Alajouanine disease 92.2 92.2 true Normal pleocytosis and hyperproteinemia thoracic false - most common during first 2 decades of life false - MS is diagnosed in only 7% multiple sclerosis 92.2 92 92.2 optic neuritis; myelopathy true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 500 Part 22: Differential Diagnosis 11. N___________ o_______ is another name for Devic’s syndrome. 12. The following are part of the mechanism responsible for pernicious anemia: a. malabsorption of B12 in the d____________ i________ b. lack of secretion of intrinsic factor by g_____ p_________ c_____ 13. Complete the following about viral causes of myelopathy: a. Herpes varicella-zoster can rarely cause n____________ m_____________. b. HSV type 2 may cause a__________ m_____________. c. CMV may cause t_____________ m_____________. 14. AIDS can produce myelopathy via v__________________ of the spinal cord. 92 15. Match the disease with the important feature: ① pernicious anemia; ② Guillain-Barré; ③ ALS Features: (a-m) below a. ascending weakness b. atrophic weakness of hands c. symmetrical paresthesias d. posterior column involvement e. normal sensation f. dementia g. areflexia h. serum b12 levels i. fasciculations j. Shilling test k. preserved sphincter control l. treatment with b12 m. proprioception difficulty 16. What are symptoms of ALS? a. s_________ b. a________ of h______ and f____________ c. f____________ d. usually preserved s_________ c________ Neuromyelitis optica 92.2 92.2 distal ileum gastric parietal cells 92.2 necrotizing myelopathy ascending myelitis transverse myelitis vacuolization 92.2 92.2 ② ③ ① ① ② ① ② ① ③ ① ③ ① ① 92.2 spasticity atrophy of hands and forearms fasciculations sphincter control ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis (DDx) – Primarily Spine and Other 501 Sciatica 17. Complete the following about sciatica: a. The sciatic nerve contains roots from L___ to L___. b. The nerve passes out of the pelvis through the g________ s___________ f_________. c. In the lower third of the thigh, it divides into the t_________ and the c___________ p__________ nerves. d. Most common cause is r_______________ due to h_________ l__________ d________ 18. Complete the following about herpes zoster: a. May rarely cause r_________________. b. Lumbosacral dermatomas are involved in ___-___% c. Typically, skin lesions follow pain in ______ days. d. True or False. Motor weakness can occur. e. True or False. Urinary retention can occur. 19. Complete the following about piriformis syndrome: a. What are the major symptoms of piriformis syndrome? b. Friedberg test consists of force i__________ r__________ of the high and thigh e_________. 20. Complete the following about extraspinal tumors causing sciatica: a. What characterizes the pain? i. i__________ ii. c_________ iii. p___________ iv. positional vs. non-positional? v. worse in morning or at night? b. About ___% will have a previous history of a tumor. 21. Femoral neuropathy is often mistakenly identified as a radiculopathy at the L___ level. L4 to S3 92.3.1 greater sciatic foramen tibial; common peroneal radiculopathy; herniated lumbar disc 92.3.2 92.3.2 radiculopathy 10-15% 3-5 days true true 92.3.2 pain in the sciatic nerve distribution with weakness of external rotation and abduction of the hip internal rotation; extension 92.3.3 92 insidious constant progressive non-positional night 20% L4 92.3.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 502 Part 22: Differential Diagnosis 22. Does femoral neuropathy or L4 radiculopathy lead to the following symptoms? a. weak quadriceps b. sensory loss occurring along the anterior thigh. c. Iliopsoas is weak in______________ _____________. d. Thigh adductors may be weak in____ ______________. 23. A peroneal nerve palsy may be mistaken for radiculopathy at what level? both femoral neuropathy and L4 radiculopathy femoral neuropathy femoral neuropathy L4 radiculopathy L5 92.3.4 Acute Paraplegia or Quadriplegia 24. Signs of spinal cord compression include: a. -p________ or -p_________ b. c. d. e. 92 92.3.4 u________ _____________ s________ l__________ possible positive B_________ altered r__________ 25. Complete the following about para/quadriplegia in infancy: a. Congenital degeneration of anterior horn cells leading to weakness, areflexia, tongue fasciculations, with normal sensation is s________ m___________ a____________. b. This is also known as f_________ b_________ syndrome. c. If ileus, hypotonia, weakness, and mydriasis, suspect c____________ b_____________ bacterial infection. 26. Complete the following about para/quadriplegia: a. Classic ascending paralysis is seen with G____________-B________ syndrome b. If post-viral, paraplegia may be secondary to t_____________ m__________. c. Rapid correction of hyponatremia may lead to c_________ p____________ m______________. d. A lesion in the p____________ area may involve both motor strips. 92.4.1 -plegia or -paresis (para/quadri) urinary retention sensory level Babinski reflexes (hypo vs. hyper) 92.4.2 spinal muscular atrophy (Werdnig-Hoffmann disease is most severe form.) “floppy baby syndrome” clostridium botulinum 92.4.2 Guillain-Barré syndrome transverse myelitis central pontine myelinolysis parasagittal ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis (DDx) – Primarily Spine and Other Hemiparesis or Hemiplegia 27. The most common etiology for pure motor hemiplegia without sensory loss is a l_________ i_____________ of the contralateral i___________ c_____________. 28. What are the different locations in which a lesion can cause hemiplegia? a. c_______ h____________ b. c. d. e. f. 503 i_________ c__________ b____________ c__________________ j___________ unilateral s_______ c______ While not a lesion, h__________ may be associated with hemiparesis lacunar infarct; internal capsule 92.5.2 92.5.2 cerebral hemisphere (motor strip) internal capsule brainstem cervicomedullary junction spinal cord hypoglycemia Low Back Pain 29. Complete the following about back pain: a. If a patient is writhing in pain, consider a__________ or v___________ etiology such as an a________ d___________. b. If constant pain at bed rest, consider a s__________ t__________ c. If nocturnal back pain relieved by aspirin, consider o_________ o_________ or a benign o_____________. d. Morning back stiffness, hip pain, hip swelling, no relief with rest, and improvement with exercise is suggestive of s_________ or e_______ a__________ s__________. 30. What are 3 major symptoms of cauda equina syndrome? 31. Complete the following about cauda equine syndrome: a. What are 4 treatable etiologies? b. It requires _______________ (nonemergent or emergent) diagnostic evaluation. 92.6.2 abdominal; vascular; aortic dissection spinal tumor osteoid osteoma; osteoblastoma sacroiliitis; early ankylosing spondylitis Perineal (aka saddle) anesthesia, progressive weakness, urinary incontinence 92.6.2 92 92.6.2 Etiologies include epidural abscess, epidural hematoma, tumor (intradural or extradural), massive central disc herniation. emergent ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 504 Part 22: Differential Diagnosis 32. Complete the following about annular tears: a. Asymptomatic in ___% of 50-60 year old patients. b. Asymptomatic in ___% of 60-70 year old patients. 33. Two medications that are associated with acute back pain are: a. s_________ b. p________________ i____________ 34. Disc herniation through the cartilaginous end-plate into the vertebral body is called a S________ n______. 35. Complete the following about chronic low back pain: a. After 3 months, about ___% of patients with low back pain will have persistent symptoms. A structural diagnosis is found in about ___% of these patients. b. Erosive changes adjacent to sacroiliac joint and positive HLA-B27 suggests a__________ s_________. 40% 75% 92.6.2 statins phosphodiesterase inhibitors such as tadalafil Schmorl’s node 92.6.3 92.6.3 5%; 50% ankylosing spondylitis Foot Drop 36. Which exam findings help differentiate common peroneal nerve palsy from L4/L5 radiculopathy? a. strength of p_________ t__________ with foot i__________ 92 92.6.2 b. strength of g________ m_________ with i_________ r_________ and f________ of hip 37. Complete the following about foot drop: a. Due to weakness of a__________ t__________. b. This typically involves cord levels L___ and L___. c. Often accompanied by weak e__________ d__________ l_______ and e__________ h__________ l_______, which are innervated by the d_________ p___________ nerve. 92.7.1 posterior tibialis; foot inversion (should be involved with radiculopathy but spared in peroneal nerve palsy) gluteus medius; internal rotation and flexion (should be involve with radiculopathy but spared in peroneal nerve palsy) anterior tibialis 92.7.1 L4, L5 extensor digitorum longus; extensor hallucis longus; deep peroneal nerve ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis (DDx) – Primarily Spine and Other d. “Flail foot” may be caused by s________ nerve dysfunction. e. Which division of the sciatic nerve is more sensitive to injury (peroneal vs. tibial)? 38. What are the neurologic etiologies for a foot drop? a. p_______ nerve injury b. L___ or L___ radiculopathy c. l________ p_______ injury d. ________ nerve injury e. A____ f. C_______-M______-T_____ g. h_______ m______ p____________ h. p_________ lesion i. s______ c_______ injury 39. What are the muscles and nerve roots that produce the following movements? a. thigh adduction b. knee extension c. internal rotation at hip d. hip extension e. knee flexion f. foot plantar flexion g. foot inversion h. foot eversion i. ankle dorsiflexion sciatic nerve 505 92.7.2 peroneal division more sensitive to injury 92.7.3 peroneal (deep vs. common) L5; L4 lumbar plexus sciatic ALS Charcot-Marie-Tooth heavy metal poisoning parasagittal lesion spinal cord adductors, L2-3 quadriceps, L2-4 gluteus medius, L4-5, S1 gluteus maximus, L5, S1-2 biceps femoris, L5, S1-2 gastrocnemius, S1-2 tibialis posterior, L4-5 peroneus longus and brevis, L5, S1 anterior tibialis, L4-5 40. a. b. c. Thigh adduction involves: muscles nerve roots adductors obturator L2,3 41. a. b. c. Knee extension involves: muscles nerve roots quadriceps femoral L2-4 42. a. b. c. d. Internal rotation of the thigh involves: muscle nerve roots If weak, means lesion is very p_______ gluteus medius superior gluteal L4-5, S1 proximal 43. a. b. c. d. Digging heels into bed involves: muscle nerve roots If weak, means lesion is very p_______. gluteus maximus inferior gluteal L5, S1-2 proximal Fig. 92.1 Table 92.3 Fig. 92.1 Fig. 92.1 92 Fig. 92.1 Fig. 92.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 506 Part 22: Differential Diagnosis 44. Knee flexion with thigh flexed involves: a. muscles b. nerve c. roots lateral hamstrings sciatic L5, S1-2 45. a. b. c. Plantar flexion of foot involves: muscle nerve roots gastrocnemius sciatic S1-2 46. a. b. c. d. Foot inversion involves: muscle nerve roots If strong but in the presence of a foot drop, it means that the injury is distal to the take-off of the c_______ p____________ nerve. 47. a. b. c. d. Foot eversion involves: muscles nerve roots If strong but in the presence of a foot drop, it means that the injury is in the d_______ p____________ nerve. 48. What are the ways to distinguish foot drop from injury to the deep vs. common peroneal nerve? a. Deep peroneal nerve: i. major weakness symptom ii. weak muscle iii. sensory loss b. Common peroneal nerve: i. major weakness symptom ii. weak muscles 92 iii. sensory loss 49. What distinguishes superficial peroneal nerve injury? a. major weakness symptom b. weak muscles c. presence of foot drop? d. Sensory loss 50. Complete the following: a. Painless foot drop is likely due to p__________ n_______. b. Painful foot drop is likely due to r________________. Fig. 92.1 Table 92.3 Table 92.3 posterior tibial tibial L4-5 common peroneal Table 92.3 peroneus longus and brevis superficial peroneal L5, S1 deep peroneal Table 92.3 foot drop anterior tibial web space foot drop and weak eversion anterior tibial and peroneus longus and brevis lateral leg and foot Table 92.3 foot eversion peroneus longus and brevis no lateral leg and foot 92.7.3 peroneal nerve (palsy) radiculopathy ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Differential Diagnosis (DDx) – Primarily Spine and Other c. Painless foot drop without sensory loss could be due to a p___________ lesion, which would be associated with a B__________ reflex and _________ (hypo vs. hyperactive) reflexes. parasagittal; Babinski; hyperactive Weakness/Atrophy of the Hands/UEs 51. Complete the following regarding lesion location and findings in “cruciate paralysis”: a. Physical exam demonstrates bilateral u______ e________ weakness and h_______ a___________. b. This is due to pressure on the p___________ d___________. 52. Atrophy of the first dorsal interosseous muscle is usually due to C__/T__ nerve root or u______ nerve disease. 507 92.8.1 upper extremity; hand atrophy pyramidal decussations C8/T1; ulnar nerve 92.8.2 Radiculopathy, Upper Extremity (Cervical) 53. Myocardial infarction may present with symptoms similar to a radiculopathy at what level and side? 54. Complete the following: a. The “empty can” test suggests __________ _________. b. Interscapular pain suggests _________________________________ _______________________________. 55. Match the symptom with the position of the disc most likely to produce it: ① central cervical disc; ② lateral cervical disc Symptom: (a-f) below a. pain b. myelopathy c. bilateral symptoms d. upper extremity symptoms e. lower extremity symptoms f. numb-clumsy hand syndrome left C6 92.9 92.9 shoulder pathology referred pain with cervical radiculopathy or cholecystitis 92.9, 92.10, 92.11 92 ② ① ① ② ① ① ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 508 Part 22: Differential Diagnosis Burning Hands/Feet 56. What are possible etiologies for a patient complaining of burning hands or feet? a. c_______ c______ s___________ b. b_______ h_____ s___________ c. n____-c______ h______ s__________ d. c______ r________ p_____ s___________ e. p_________ n__________ f. e____________ g. a__________ disease b. Etiologies include: i. m_________ s___________ ii. c________ s_____________ iii. s_________ c__________ d_____________ iv. tumor of the __________ ________ v. disc herniation in the ________ region vi. C_______ m_______________ vii. r_________ m___________ viii. c_______ c_____ s___________ 92 central cord syndrome burning hands syndrome numb-clumsy hand syndrome complex regional pain syndrome peripheral neuropathy erythermalgia (or erythromelalgia) arterial Lhermitte’s Sign 57. Complete the following about Lhermitte’s sign: a. What is the major symptom and what provokes it? 92.11 An electrical shock-like sensation radiating down the spine. Usually provoked by neck flexion. 92.13.1 92.13.2 multiple sclerosis cervical spondylosis subacute combined degeneration cervical cord cervical Chiari malformation radiation myelopathy central cord syndrome Swallowing Difficulties 58. Although swallowing difficulties are not uncommon after an A______, this should prompt consideration for a post-op h____________. ACDF; hematoma 92.14 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 93 Procedures, Interventions, Operations: General Information Intraoperative Dyes 1. Complete the following about intraoperative dyes: a. ________ carries a small risk of seizure when administered intrathecally. b. ______________ _________ is cytotoxic and should not be used at all. c. ________ can be used to demonstrate arteriovenous malformation (AVM) vessels intraoperatively and areas of blood brain barrier breakdown (e.g . tumors). d. ________ can be used to identify cerebrospinal fluid (CSF) leaks and is considered safe. e. ________ ________ used for intraoperative angiogram. 93.2 Fluorescein Methylene blue Fluorescein Fluorescein Indigocyanine green (ICG) Operating Room Equipment 2. Complete the following about microscope setup a. For spine cases the eyepiece is usually directly ________ the primary surgeon. b. In contrast, for intracranial work, the observer’s eyepiece is placed to the _______. c. The exceptions to this are: i. _________ ii. _____________________________. 93.3.1 opposite right transphenoidial surgery right posterior fossa craniotomy in the lateral oblique position 93 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 510 Part 23: Procedures, Interventions, Operations 3. Complete the following on headfixation a. Alternatives to pinbased head fixation include i. _________ ii. _________ iii. _________ b. Pin-stabilization is not recommended for use in children under the age of ___. c. These features of head-fixation should be considered depending on the type of case: i. radiolucent head holders for __________________ ii. attachment of _________ _________ _________ or iii. _________ to the Mayfield system. 4. Manufacture recommendations for cranial pin placement include: a. Similar to a sweatband worn just about the ________ and ________. b. Avoid placing pins in the _________temporal bone or the ______ sinuses. c. The single pin is placed _________ for the supine position and on the ________ side as the operation when doing prone posterior fossa cases. d. Adults should be placed in pins that have final resting tension between ______ and 80 lbs. 93 93.3.2 Horse-shoe head rest Doughnut fashioned out of stockinette Prone-view 3 vascular cases with angiograms self-retaining retractor systems image guidance systems 93.3.2 orbits and pinna squamous; frontal anteriorly; same 60 Surgical Hemostasis 5. Complete the following about surgical hemostasis: a. Bone wax inhibits ________ formation. b. True or False. The following chemical hemostatic agents exerts its effect by promoting platelet aggregation: i. Gelfoam ii. Oxidized cellulose iii. Avitene iv. Thrombin 6. Match the surgical hemostasis substance with its trade name: ① Thrombostat; ② Gelfoam; ③ Oxycel; ④ Surgicel; ⑤ Avitene a. gelatin sponge b. oxidized cellulose c. regenerated cellulose bone 93.4.1 93.4.2 false false true (less so if platelets <10K) false 93.4.2 ② ③ ④ ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Procedures, Interventions, Operations: General Information d. microfibrillar collagen e. thrombin 511 ⑤ ① Craniotomy General Information 7. Complete the brain swelling intraoperative checklist. (Hint: decompress) a. d________ ________ b. e________ ________ c. c________ (________) d. o________ of ________ ________ e. m________ f. p________ g. r________ ________ h. e________ ________ 93.5.3 drain CSF elevate head CO2 (hypercarbia) obstruction of jugular veins mannitol hyperventilate remove bone excise brain (temporal or frontal lobes) i. (s) j. (s) 8. Complete the following regarding the risks of craniotomy: a. increased neurological deficit (tumor case): ________% b. postop hemorrhage: ________% c. infection: ________% d. anesthetic complications: ________% 9. Complete the following regarding anticonvulsants: a. True or False. Maintain their use if cortical incision is anticipated. b. Describe the method of loading. 10. List the possible causes for acute postoperative deterioration a. h__________ b. a__________ h__________ c. c__________ i___________ d. p___________ e. e__________ f. v__________ g. s__________ h. p__________ a__________ 11. If postoperative seizures occur, consider the following: (Hint: abci) a. a________ ________ b. b________ 93.5.4 10% 1% 2% 0.2% 93.5.4 true (use Keppra) 500 mg PO/IV q12 hours 93.5.5 hematoma acute hydrocephalus cerebral infarction pneumosephalus edema vasospasm seizure persistent anesthetic 93 93.5.5 anticonvulsant level—draw blood bolus—additional anticonvulsants ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 512 Part 23: Procedures, Interventions, Operations c. C________ ________ CAT scan—to identify if any cause intubate—to protect airway d. i________ 12. Complete the following regarding postoperative headaches: a. “Syndrome of the trephined” can continue to improve out to ___ years in one series for posterior fossa craniotomies. b. It has been described to be similar to _______-___________ syndrome. 93 93.5.6 2 post-concussive syndrome Intraoperative Cortical Mapping (Brain Mapping) 13. Answer the following questions regarding locating the primary sensory cortex: a. Intraoperative SSEP may localize the phase reversal primary sensory cortex by ________ ________ potentials across the central sulcus. b. This is done with a strip electrode perpendicular oriented in the ________ direction to the anticipated orientation of the central sulcus. 93.6.2 14. Answer the following questions regarding awake craniotomies: a. Critically important to understand and manage the anesthetic agents which include _________ and _______________ paralytics as to not obscure electrical stimulation. b. Pre-operative practice with the patient can be important to identify necessary aids in the OR, such as _________ _________. c. Local anesthesia should be considered in 4 regions: i. s___________ 93.6.3 ii. a__________ iii. p___________ iv. o___________ d. Intracranial, the ________ is pain sensitive while the brain is not. local and short acting reading glasses supraorbital and supratrochlear auriculotemporal postrauricular occipital dura ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Procedures, Interventions, Operations: General Information Cranioplasty 15. Answer the following about cranioplasty a. Indications include ___________, ___________ ___________ and ___________. b. Material options include the _________ _____ ______, ____________, _______, ___________ _____ or ____________. cosmetic, symptomatic relief, and protection 93.7.1 patient’s own bone, methylmethacrylate, mesh, pre-fabricated custom flap; split thickness calvaria 93.7.3 16. Localizing levels in spine surgery. Name pitfalls a. The count can be off if there are not ___ 12; ribs and ___ lumbar vertebra. 5 b. The transverse process can mimic a rib at L1 ____ if it is large. 513 93.7.3 Bone Graft 17. Answer the following regarding bone graft: a. Autologous bone or rhBMP is recommended in the setting of an ______ in conjunction with a threaded titanium cage. This is based on level __ evidence. 18. Which of the flowing should not be used to assess for fusion? a. static x-rays alone b. Technetium-99 bone scan c. flexion/extension films d. The correlation between fusion and clinical outcome is _________. 93.8.1 ALIF; 1 93.8.2 do not use do not use do not use in the absence of instrumentation not strong, possibly unrelated 19. For spine fusions, components of bone graft that are important for fusion: a. ____________ osteoinduction (stimulate cells to develop) b. ____________ osteogensis (formation of new bone) c. ____________ osteoconduction (structure of graft so new bone can build upon) d. ____________ ____________ mechanical stability 93.8.3 20. For each of the above graft characteristics which material has a very strong effect in each. a. osteoinduction b. osteogensis c. osteoconduction 93.8.3 93 BMP cancellous autograft cancellous autograft ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 514 Part 23: Procedures, Interventions, Operations d. mechanical stability e. BMP is FDA approved only for use in _______ procedures, other uses are off label. 21. a. b. c. d. Common autograft donor sites include _____ _______ ____________ ____________ _________________________________ 22. Bone graft procurement a. Anterior iliac bone should be obtained 34 cm lateral to the _________, to avoid the ___________. b. Posterior iliac crest bone grafts are taken from the _______ 6-8 cm of the iliac crest to avoid __________. Injury here can result in a ________. c. When isolating the fibula, the _______ nerve is to be avoided at the proximal head. At least ____ cm should be distally preserved to maintain ankle stability. 93.8.3 iliac crest rib fibula bone removed during decompression 93.8.4 ASIS; lateral femoral cutaneous nerve medial; superior cluneal nerves (which cross the posterior iliac crest at 8 cm); numb buttock or painful neuromas peroneal; 7 Stereotactic Surgery 23. a. b. c. d. e. f. 93 cortical or vascularized autograph ALIF Stereotactic surgery indications _________ ________ ________ ________ ________ ________ ________ _________ _________ g. The ability to make a diagnosis in the setting of a stereotactic biopsy ranges from _____ to ______ in a large series and was slightly lower in patients with _______. h. The yield rate is higher for lesions that _________ on CT or MRI. i. The most frequent complication is ________, which was slightly worse in patients with _________. j. In non-immunocompromised patients, the highest rate of complication occurred in ________ ________ ________ _______. biopsy catheter placement electrode placement lesion generation SRS experimental (laser, transplantation, other) 82-99%; AIDS 93.9.2 93.9.3 enhance hemorrhage; AIDS multifocal high grade gliomas ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 94 Specific Craniotomies Posterior Fossa (Suboccipital) Craniectomy 1. True or False. The correct treatment for air embolism sustained during a craniotomy performed with the patient in a sitting position is a. to find and occlude site of entry or rapidly pack wound with sopping wet sponges. b. bilateral or right-sided jugular venous compression. c. ventilation with 100% O2. d. rotating the patient right side down. e. aspirating air from central venous pressure (CVP) catheter. f. avoiding positive end-expiratory pressure (PEEP), which is ineffective and may worsen the risk of paradoxical air embolism. 2. Complete the following about posterior fossa craniectomy and air embolism: a. Effect of air in right atrium is i. h________ ii. a________ b. Paradoxical air embolism may occur in the presence of i. p________ f________ o________ ii. or p________ arteriovenous (AV) f________. c. Incidence in sitting position is ________%. d. Precautions require: i. D________ ________ ________ ii. C________ in ________ ________ e. Earliest clue to occurrence is ________________________. Table 94.1 true true true false (Patient should be turned left side down to trap air in the right atrium.) true true 94.1.2 hypotension (due to impaired venous return) arrhythmias patent foramen ovale pulmonary AV fistula 7 to 25% 94 Doppler precordial ultrasound CVP catheter in right atrium fall in end tidal pCO2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 516 Part 23: Procedures, Interventions, Operations 3. How does air embolism cause problems? a. Air becomes trapped in the ________ ________, b. impairs ________ ________, and c. produces ________. right atrium venous return hypotension 4. Outline the intraoperative treatment for air embolism during a craniotomy. (Hint: occlude) a. o________ b. c________ c. c________ d. l________ e. u________ f. d________ g. e________ occlude entry site cover with wet laps compress jugular veins left side down lower head ventilate/increase volume discontinue nitrous evacuate air 5. a. b. c. end tidal pCO2 machinery sound hypotension Earliest clues to occurrence include: fall in ________ ________ ________ sound on Doppler is ________ ________ blood pressure ________ 6. True or False. The following approach is most applicable for a vertebral endarterectomy: a. midline suboccipital craniotomy b. extreme lateral posterior fossa approach c. paramedian suboccipital craniotomy d. subtemporal craniotomy 94 94.1.2 7. Consider the concept of “5-5-5.” a. i. This relates to the ________ incision ii. for a linear ________ incision iii. for access to the ________. b. i. The first number relates to the mm medial to the ________ ________. ii. The second number relates to the ________ ________ the notch. iii. The third number relates to the ________ ________ the notch. Table 94.1 94.1.2 94.1.2 false false true (Paramedian suboccipital craniotomy gives decent access to the vertebral artery and to the posterior inferior cerebellar artery [PICA] and the vertebrobasilar junction.) false 94.1.3 skin paramedian CPA mastoid notch cm above cm below ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Specific Craniotomies 8. Matching. Match the incision with the objective. Incision: ① 5-6-4; ② 5-5-5; ③ 5-4-6 Objective: approach for (a-e) below a. the fifth nerve b. hemifacial spasm c. glossopharyngeal neuralgia d. microvascular trigeminal decompression e. vestibular schwannoma 9. Location of the inferior margin of the transverse sinus can be estimated a. to be ________ f________ ________ above the b. m________ n________. 10. Describe the Frazier burr hole. a. It is used i. p________ ii. to relieve p________ swelling iii. due to h________ or iv. e________. b. It is located i. ________ to ________ cm from the midline. ii. ________ to ________ cm above the inion in adults. iii. ________ to ________ cm above the inion in children. 11. Complete the following regarding posterior fossa post-op complications: a. Respiratory: prevent by ________ ________ ________. b. Hypertension: maintain SBP below ________ with ________. c. Acute hydrocephalus: treat with ________ ________. d. Meningitis: prevent by prompt repair of any ________ ________ ________. 12. Blood pressure above ________ is dangerous for the post-operative posterior fossa patient. 13. Complete the following regarding the posterior fossa: a. Increased pressure in the posterior fossa is heralded by changes in i. b________ p________ ii. r________ p________ b. not by i. p________ i________ ii. m________ s________ iii. I________ c________ 517 94.1.3 ① ② ③ ① ② 94.1.3 two finger breadths mastoid notch 94.1.3 prophylactically post-operative hydrocephalus edema 3 to 4 6 to 7 3 to 4 94.1.7 keeping patient intubated 160 with nitroprusside ventricular tap—external ventricular drain (EVD) cerebrospinal fluid (CSF) leak 160 mm Hg systolic 94.1.7 94.1.7 94 blood pressure (increase) respiratory pattern pupillary inequality level mental status ICP changes ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 518 Part 23: Procedures, Interventions, Operations 14. Considerations for post-operative posterior fossa emergency include: a. clinically i. blood pressure (BP) ________ ii. respirations ________ b. recommended treatment i. i________ ii. t________ ________ iii. o________ ________ c. Should you i. obtain a computed tomographic (CT) scan first? ii. wait for operating room availability? 15. Indicate whether increased pressure in the posterior fossa or supratentorial compartment produces a change in the following: a. pupillary reflexes: ________ ________ b. level of consciousness: ________ ________ c. increase in intracranial pressure (ICP): ________ ________ d. changes in respiration: ________ ______ e. rise in blood pressure: ________ ______ 17. Name the artery(ies) that cross the sylvian fissure. 94 high labored intubate tap ventricle open wound no no 94.1.7 supratentorial compartment supratentorial compartment supratentorial compartment posterior fossa posterior fossa Pterional Craniotomy 16. Matching. Match the head position with the location of the aneurysm. Head position: ① angled 30 degrees; ② angled 45 degrees; ③ angled 60 degrees Location of aneurysm: a. ICA P-comm b. carotid terminus c. middle cerebral artery d. basilar bifurcation e. A-comm 94.1.7 Fig. 94.5 ① ① ② ① ③ none cross 94.2.2 Temporal Craniotomy 18. True or False. A temporal craniotomy can allow access to the following structures: a. foramen ovale b. Meckel’s cave c. labyrinthine and upper tympanic portion of the facial nerve 94.3.1 true true true ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Specific Craniotomies 19. A temporal lobectomy a. can safely resect ___ - ___ cm in the dominant hemisphere b. and ___ - ___ cm in the nondominant hemisphere. 94.3.4 4—5 (before injury to Wernicke area) 6—7 (before injury to optic radiations) Frontal Craniotomy 20. Complete the following regarding the superior sagittal sinus (SSS): a. The risk in sacrifice of the SSS is ________ ________. b. True or False. It almost always occurs with sacrifice of i. the posterior third ii. the middle third iii. the anterior third 519 94.4.2 venous infarction true true false Approaches to the Third Ventricle 21. Study Chart. a. t________ b. t________ i. a________ ii. p________ c. s________ i. s________ ii. o________ iii. l________ t________ iv. t________ d. t________ e. s________ f. s________ 94.7.1 transcortical transcallosal anterior posterior subfrontal subchiasmatic opticocarotid lamina terminalis transsphenoidal transsphenoidal subtemporal stereotactic 22. What is the risk of post-operative 5% seizures after a transcortical approach to the anterior third ventricle (e.g., for a colloid cyst)? 94.7.1 23. What are the principles of tumor removal? a. Veins must be preserved at all ________. costs b. First remove the tumor from within the capsule ________. c. If adhesions seem unyielding, the most incomplete intracapsular likely cause is i________ i________ evacuation. 94.7.2 94 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 520 Part 23: Procedures, Interventions, Operations 24. Complete the following: a. True or False. A disconnection syndrome (split-brain syndrome) is common with i. posterior callosotomy through splenium. ii. anterior callosotomy. iii. callosotomy < 2.5 cm in length from a point 1 to 2 cm behind the tip of the genu. b. Which of the above approaches avoids the disconnection syndrome best? 25. Describe the transcallosal approach to the third ventricle. a. The superior sagittal sinus (SSS) is often to the ________ of the sagittal suture. b. The cranial opening should be i. ________ anterior to the coronal suture ii. and ________ behind it. c. The two cingulate gyri may be adherent in the midline and can be mistaken for the c________ c________. d. i. The corpus callosum has a distinct ________ color. ii. It is located beneath the paired ________ arteries. e. The opening is usually made between the p________ p________ arteries. f. The trajectory of dissection is from the i. c________ s________ ii. to the e________ a________ m________. iii. The f________ of M________ lies along this line. g. i. It is helpful to fenestrate the s________ p________ ii. to prevent it from b________ into the ventricle iii. especially in a case of c________ c________. 94 26. How can you tell which ventricle you are in? a. The foramen of Monro is located m________. b. If the choroid plexus goes to the left to enter the foramen of Monro you are in the ________ ventricle. 94.7.3 true (where more visual information crosses) false false callosotomy < 2.5 cm in length from a point 1 to 2 cm behind the tip of the genu 94.7.3 right two third one third corpus callosum white pericallosal paired pericallosal coronal suture external auditory meatus foramen of Monro septum pellucidum bulging colloid cyst 94.7.3 medially right ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-30 Specific Craniotomies 521 c. If you see no choroid plexus and no veins cavum septum pellucidum you may be in a c________ s________ p________. d. The safe way to enlarge the foramen of choroid plexus; fornix Monro is posteriorly between the ________ ________ and the ________. 27. Complete the following about approaches to the third ventricle: a. The interhemispheric approach runs risk of injury to _______ ________ ________ b. which may produce ________ ________. c. The anterior transcallosal approach runs risk of injury to ________ ________ d. which may produce problem with s________-t________ m________ and n________ l________. e. The transcortical approach is i. made through the ________ ________ gyrus. ii. This is about the same spot used for e________ v________ d________, iii. called ________ point. bilateral cingulate gyrus 94.7.3 transient mutism bilateral fornices short-term memory and new learning 94.7.4 middle frontal external ventricular drain Kocher’s point Decompressive Craniectomy 28. Indications for decompressive craniectomy: a. i. m________ m________ cerebral artery occlusion ii. primarily for the n________d________ hemisphere b. p________ i________ hypertension c. True or False. It is necessary to open the dura. d. Skull reimplantation can be considered after ________ to ________ weeks. e. i. A ________ opening is best, ii. approximately ________ by ________ cm or larger. 94.10.1 malignant middle non-dominant persistent intracranial true 94.10.3 6 to 12 large 12 by 12 94 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 95 Spine, Cervical Anterior Approaches to the Cervical Spine 1. Complete the following regarding extrapharyngeal approaches to the cervical spine a. Extrapharyngeal approaches use n________ intubation. b. The head is slightly e________ and is rotated ________ degrees to the contralateral side. c. In the medial extrapharyngeal approach, the branches of the ________ artery, u________ nerves, and h________ nerve are encountered. d. In the lateral retropharyngeal approach the s________ ________ nerve is encountered. nasotracheal extended; 15 branches of external carotid artery, upper laryngeal nerves, and hypoglossal nerve spinal accessory nerve Transoral Approach to Anterior Craniocervical Junction 2. Complete the following regarding the transoral approach to the craniocervical junction: a. Primarily useful for midline e________ lesions. b. Approach to intradural lesions is limited because of difficulties obtaining w________ closure and increased risk of m________. 95 95.1 3. Complete the following regarding transoral approach to anterior craniocervical junction: a. ________% of patients need posterior fusion after a transoral odontoidectomy. b. The patient must be able to open the mouth at least ________ mm. c. The tubercle of the a________ can be palpated through the posterior pharynx in order to locate the m________. 95.2.1 extradural watertight; meningitis 95.2.2 75% 25 mm atlas; midline ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Spine, Cervical d. If C1 ring sparing is not done, the central________ cm of the ________ is removed. e. There is about ____-____ mm of working distance between the two vertebral arteries where they enter the f________ t________ at the inferior aspect of the lateral mass of ________. 523 3; atlas 20-25; foramen transversarium; C2 Occipitocervical Fusion 4. What are the disadvantages of occipitocervical fusion? a. Decreased r________ o___ m_______ at range of motion the occipitocervical junction b. ________ ________ is higher than with non-union rate C1-C2 fusion alone. 95.3 5. True or False. The following is an indication for occipitocervical fusion: a. congenital absence of complete C1 arch b. upward migration of the odontoid into the foramen magnum c. congenital anomalies of occipitocervical joints d. type II odontoid fracture 95.3 6. Complete the following regarding occipitocervical fusion: a. Patient will lose about ________% of neck flexion. b. Keel plate must be placed at the ________ region of the ________ occipital bone. c. It is advisable to ________ the thickness of the occipital bone pre-operatively. 7. True or False. After occipitocervical fusion, a halo is indicated in the following patients for 8-12 weeks; a. patients with severe C1 fractures b. elderly patients c. unreliable patients d. smokers true true true false 30% 95.3 thickest; midline measure 95.3.1 95.3.4 true true true true 95 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 524 Part 23: Procedures, Interventions, Operations Anterior Odontoid Screw Fixation 8. Complete the following regarding anterior odontoid screw fixation: a. C1-C2 complex is responsible for ________% of head rotation. b. Stability of the C1-2 joint depends on the integrity of the o________ p________ and the a________ t________ ligament. c. Indicated in patients who have a type________ odontoid fracture and an intact t________ ligament. d. Patients with type ________ fractures are also indicated when the fracture line is in the c________ portion of the body of C2 in an elderly patient who may not fuse as well with immobilization as a younger patient. e. Contraindications to anterior odontoid screw fixation include if there is a fracture of the v________ b________ and if the fracture is less than ________ months old. f. Following fixation the immediate postop strength is only ________% of the normal odontoid. g. Therefore, a cervical brace is recommended for ________ weeks unless the patient has significant osteoporosis at which point a ________ brace is recommended. h. With fractures < 6 months old, the union rate was ________ %. i. Chronic nonunions > 6 months old have a bony union rate of ________ %, and ________ % rate of presumed fibrous union. 95 50% 95.4.1 odontoid process; atlantal transverse II; transverse 95.4.3 III; cephalad vertebral body; 6 95.4.4 50 % 95.4.5 6; halo 95% 31%; 38% Atlantoaxial Fusion (C1–2 Arthrodesis) 9. Complete the following about atlantoaxial fusion (C1-C2 arthrodesis). a. The patient will lose about ________% of 50% head rotation. b. Indications for atlantoaxial fusion include atlantoaxial; a________ dislocation due to transverse atlantal incompetence of the t________ a________ ligament. 95.5.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Spine, Cervical 525 c. Atlantoaxial fusion is further indicated in II; patients with incompetence of the 6mm; odontoid process including in patients Bow hunter’s sign with type ________ fractures with > ________ mm of displacement or in patients with B________ h________ sign characterized by vertebrobasilar insufficiency with head turning. 10. Describe the wiring and fusion technique and differentiate. a. Brooks fusion involves ________ to ________ sublaminar wires with ________ ________ bone grafts. b. Gallie fusion involves midline wire under the arch of ________ with an ________ bone graft. c. Dickman and Sonntag fusion involves wire passed sublaminar to ________ with a single ________ graft wedged between C1 and C2. 11. Complete the following about C1-2 transarticular facet screws: a. A major risk of the procedure is ________ artery injury. b. May be used as an adjunct to Dickman and Sonntag technique to achieve ________ stabilization. c. Requires pre-op t________ c________ C________ scans from the o________ c________ through ________ with sagittal reconstruction through the C1–2 facet on both sides to look for the presence of a v________ a________ in the intended path of the screw. d. A fusion rate of ________% has been reported. 95.5.2 C1 to C2; two wedge C1; “H” C1; bicortical 95.5.3 vertebral artery immediate thin cut CT; occipital condyles; C3; vertebral artery 99% 12. Complete the following about C1-2 lateral mass screws: a. Involves placement of polyaxial mini lateral mass; pedicle screws in C1 ________ ________ and C2 ________ with rod fixation. b. Decreased risk of ________ ________ vertebral artery injury as compared to transarticular facet screws. c. May be used in the presence of C1-2 subluxation ________. 95.5.3 95 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 526 Part 23: Procedures, Interventions, Operations d. Preoperative ________ ________ ________ scan is required to assess the ________-________ thickness of the ________ arch of ________ in case the arch needs to be drilled to facilitate screw placement; as well as to determine screw ________ and to estimate ________-________ angle for screws. e. When placing C1 screws the ________ may be as close as ________mm to the ideal exit site of the screw. f. Post-operatively, a cervical collar (soft or rigid, as preferred) is used for ________________ weeks. ICA; 1mm 4-6 C2 Screws 13. The following are the four types of C2 screws: a. P________ screws, which are directed ________. b. L________ ________ screws, which are directed ________. These screws are sized to fall short of ________ ________. c. C1–2 t________ screws, associated with more risk of VA injury d. T________ screws 95 thin cut CT; cranio-caudal; posterior; C1; length; medio-lateral 14. Complete the following about placement of C3-6 lateral mass screws: a. In the An method the screw is placed _______mm medial to the midpoint in the medio-lateral direction and in the midpoint in the cranio-caudal direction with a trajectory of _______ degrees lateral and _______ degrees cephalad. b. In the Magerl method the screw is placed _______mm medial to the midpoint in the medio-lateral direction and _______mm cranial to the midpoint in the cranio-caudal direction with a trajectory of _______-_______ degrees lateral and _______ to the facet joint. c. In the Roy-Camille method the screw is placed at the midpoint in the mediolateral direction and cranio-caudal direction with a trajectory of ______________ degrees lateral and _______ degrees cranio-caudal. 95.6.1 Pedicle; medially Lateral mass; laterally; foramen transversarium transarticular Translaminar Table 95.1 1mm; 30 degrees; 15 degrees 2mm; 2mm; 20-25 degrees; parallel 0-10 degrees; 0 degrees ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 96 Spine, Thoracic and Lumbar Anterior Access to the Cervico-Thoracic Junction/Upper Thoracic Spine. Anterior Access to Mid and Lower Thoracic Spine 1. Complete the following about anterior access to the cervico-thoracic junction, upper thoracic spine and lower thoracic spine: a. The s________ s________ procedure allows access to ________ and occasionally ________. b. In accessing the mid thoracic spine with a right sided thoracotomy, the h________, m________, and b________ vein do not impede access. c. In accessing the mid thoracic spine with a left sided thoracotomy, the a________ is easier to mobilize and retract. d. In accessing the lower thoracic spine, a ________ sided thoracotomy is preferred as it is easier to mobilize the ________. e. At T10, the attachment of the ________ increases the difficulty of the approach. sternal splitting; T3; T5 heart, mediastinum; brachiocephalic vein 96.1.1 96.2.2 aorta left; aorta 96.2.3 diaphragm Thoracic Pedicle Screws 2. Complete the following about thoracic pedicle screws: a. Due to the dense bone of the shoulders, T1 to T4 the thoracic spine is usually difficult to image from ________ to ________ on lateral fluoroscopy. b. With regards to the craniocaudal middle (mnemonic: T1–2-3 direction use the ________ of the “mid tp”) transverse process as an entry point for thoracic levels T1, T2, T3 & T12. 96.3.1 96.3.3 96 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 528 Part 23: Procedures, Interventions, Operations c. With regards to the craniocaudal direction, use the ________ of the transverse process as an entry point for thoracic levels T7, T8 T9. d. When freehanding using landmarks, the screw is inserted ________ to the surface of the superior articular facet while “aiming” at the contralateral ________. e. Typical thoracic screw length is ________–________ mm. f. Screw diameter should be approximately ________% of the pedicle diameter. top (mnemonic: T7–8-9 “top of the line”) perpendicular, pedicle 35-40mm 80% Anterior Access to Thoracolumbar Junction. Anterior Access to the Lumbar Spine 3. Complete the following about anterior access to the thoracolumbar junction and lumbar spine: a. A ________ sided approach is preferred because the ________ is easier to retract than the liver, and the ________ is easier to mobilize than the inferior vena cava. b. It is important to flex the ipsilateral leg to relax the ________ muscle, permitting safer retraction of the ipsilateral lumbosacral plexus. c. The anterior lumbar interbody fusion (ALIF) is relatively contraindicated in males because of risk of ________ ________ in 1–2% (as high as 45% in some reviews). d. The bifurcation of the great vessels occurs just above to just below the ________ –________ disc space, thus the ALIF is best suited for access to ________ –________. e. At L5-S1, the ________ ________ ________ runs down the ________ of the VB and has to be sacrificed to do an ALIF. left; spleen; aorta 96.4.1 psoas retrograde ejaculation 96.5.1 L4-5; L5-S1 anterior sacral artery; midline 96 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Spine, Thoracic and Lumbar 529 Instrumentation/Fusion Pearls for the Lumbar and Lumbosacral Spine. Lumbosacral Pedicle Screws 4. Complete the following regarding surgical fusion of lumbar and lumbosacral spine: a. A lumbar fusion that includes L1 should not be terminated at ________ or ________. b. Pedicle screws should be ________ to ________ % of pedicle diameter and have a minor diameter ≥________mm in the adult lumbar spine and be long enough to penetrate ________ to ________ % of the vertebral body. c. With open lumbar pedicle screw placement, the entry point is at the ________ of the transverse process, at the intersection of the center of the transverse process and the sagittal plane through the lateral aspect of the ________ ________. d. Medial angles for lumbar pedicle screws: i. L1 level—medial angle should be________ degrees. ii. L2 level—medial angle should be________ degrees. iii. L3 level—medial angle should be________ degrees. iv. L4 level—medial angle should be________ degrees. v. L5 level—medial angle should be________ degrees. vi. S1 level—medial angle should be________ degrees. vii. S2 level—medial angle should be________-________ degrees laterally. e. Each screw should cross ________ ________ of the vertebral body. f. On AP view, if screw tip crosses the midline, there is a________ breach. g. Posterior lumbar interbody fusion (PLIF and TLIF) is relatively contraindicated with well-preserved _______-________ height; and is usually supplemented with _______ ________ to prevent progressive _______. h. Benefits of TLIF over PLIF include less _______ _______ retraction and avoidance of _______ _______ in reoperations. L1 or T12 96.6 70 to 80%; 5.5; 70 to 80% 96.7.1 base; superior facet 96.7.3 5 degrees 10 degrees 15 degrees 20 degrees 25 degrees (Each angle equals the VB level x 5.) 25 degrees 40-45 degrees two thirds medial disc-space; pedicle screws; spondylolisthesis 96.7.8 nerve root; scar tissue 96 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 530 Part 23: Procedures, Interventions, Operations Minimally Invasive Lateral Retroperitoneal Transpsoas Interbody Fusion 5. Complete the following regarding minimally invasive lateral retroperitoneal transpsoas interbody fusion: a. Access is best from _______-________; however, a similar retropleural approach can be employed in the thoracic spine up to _______. b. With thoracic lateral interbody fusions one cannot _______the contralateral _______. c. LLIF is particularly useful in cases of a_______ s_______ f_______ because it obviates dealing with _______ or _______ from previous surgery which reduces the risk of _______. d. LLIF, when combined with release of the a_______ l_______ l_______, can be used to correct _______ and to _______ lumbar lordosis. e. LLIF is contraindicated in cases requiring d_______ d_______, disc space height > _______mm, or in cases with pathology at the _______-_______ space secondary to interference from the _______. f. A standalone cage should not be placed in patients with o_______, pre-operative i_______, or if the _______ _______ ligament is disrupted during placement. g. Common transient complications include thigh numbness in ______________% of cases due to injury to the _______ nerve and thigh flexion weakness dye to injury to the _______ muscle. h. Fusion rates following LLIF range from _______-_______%. L1-L5; T4 96.8.1 penetrate; anulus adjacent segment failure; scar tissue; hardware; durotomy anterior longitudinal ligament; scoliosis; increase direct decompression; 12mm; L5-S1; ilium 96.8.2 96.8.3 osteoporosis; instability; anterior longitudinal 96.8.5 10-12%; genitofemoral; psoas 96.8.6 91-100% 96.8.8 96 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 97 97 Miscellaneous Surgical Procedures Lumbar Puncture. C1–2 Puncture and Cisternal Tap 1. Complete the following about spinal punctures: a. Contraindications to lumbar punctures include patients with platelet count <________ or patients with n________ hydrocephalus . b. In patients with SAH, a LP can increase the t________ pressure and precipitate aneurysmal rupture. c. A LP in patients with spinal block may produce deterioration in as many as __%. d. The conus medullaris is located between T12 and L1 in ___% of patients, between L1 and L2 in ________%, and between L2 and L3 in ___% of patients. e. The intercristal line connects the superior border of the i________ c________ and occurs in most adults between the spinous processes of ________ and________. f. When performing a LP the needle is always advanced with the ________ in place in order to prevent introduction of ________ cells which could produce an iatrogenic e________ t________. g. The Queckenstedt is a test for ________ block in which the j________ v________ is compressed, first on one side then on both while measuring ICP; if there is no block, the pressure will rise to ______ cm of fluid, and will drop to the original level within ________ seconds of release. h. In non-anemic patients there should be ___-___ WBCs for every _______ RBCs. i. A RBC count > ________ that changes little as CSF drains and an elevated ratio of ________ to ________ distinguished SAH from ________ ________. 50,000; non-communicating 97.3.1 transmural 14% 30%; 51-68%; 10% 97.3.2 iliac crests; L4 and L5 stylet; epidermal; epidermoid tumor subarachnoid; jugular vein; 10-20; 10 1-2; 1000 100,000; WBC to RBC; traumatic tap 97.3.4 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 532 Part 23: Procedures, Interventions, Operations j. Incidence of severe postpuncture headache (lasting longer than ________ days) is ________%. k. A CN ________ palsy can occur delayed ________-________days post-LP and usually recovers after ________________weeks. l. Epidural b________ p________ is a treatment for refractory post LP headache. m. The C1-2 puncture is contraindicated in patients with C________ m________due to risk of low lying c________ t________ and medullary k________. 97 CN VI (usually unilateral); 5-14 days; 4-6 weeks blood patch Chiari malformation; cerebellar tonsils; kink 97.5.1 Lumbar Catheter CSF Drainage 2. Complete the following about lumbar catheter CSF drainage: a. Indications for drainage include reducing CSF pressure on a site of CSF ________/________, reducing intracranial pressure in cases of ________ hydrocephalus or reducing CSF pressure to attempt to increase perfusion of the ________ ________. b. If the catheter does not thread into the spinal canal, the catheter must be withdrawn ________ with the needle to prevent ________ off the catheter tip. 7; 0.1 to 0.5%, leak/fistula; communicating; spinal cord 97.4.2 together; shearing 97.4.4 CSF Diversionary Procedures. Ventricular Access Device 3. Complete the following regarding ventricular catheterization: a. Kocher’s point is used as an entry point to place a catheter into the ________ ________ of the lateral ventricle and can be found ________- ________cm from midline and ________cm anterior to coronal suture which is approximately ________cm up from the nasion; the trajectory is ________ to surface of brain, which can be approximated by aiming towards m________ c________ of ipsilateral eye and the E________. b. Keen’s point is about ________________cm superior to and posterior to the pinna and results in catheter placement into the________. c. Dandy’s point is ________cm from midline, and ________cm above inion. 97.6.1 frontal horn; 2-3cm (mid pupillary line); 1 cm; 11 cm; perpendicular; medial canthus; EAM 2.5-3 cm; trigone 2 cm; 3 cm ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Miscellaneous Surgical Procedures d. Occipital-parietal approach is frequently used for shunting; a common entry point is ________cm above and posterior to the top of the pinna; the catheter is initially inserted ________ to skull base towards the ________ of the forehead or ipsilateral ________ ________ 4. Complete the following about ventricular shunts: a. List the layers to traverse in open placement of the peritoneal catheter. (Hint: samp3) i. s________ ________ ii. a________ ________ ________ iii. m________ iv. p________ ________ ________ v. p________ ________ vi. p________ b. If a connector must be used near the clavicle, place it ________ the clavicle to decrease the risk of ________. c. A ventriculoatrial shunt should be revised when the catheter tip is above________. d. During third ventriculostomy the opening is made________ to the mammillary bodies which is ________ to the tip of the basilar artery; after puncturing the floor be certain that the ________ of ________ is also perforated. e. The needle to be used in an ommaya reservoir puncture is a ________ gauge or smaller ________ needle. 3 cm, parallel; middle; medial canthus 533 97 97.6.3 subcutaneous fat anterior rectus sheath muscle posterior rectus sheath preperitoneal fat peritoneum above; disconnection T4 anterior; anterior; membrane of Liliequist 97.6.4 25; butterfly 97.7.4 Sural Nerve Biopsy 5. Complete the following about sural nerve biopsies: a. The following are indications for sural nerve biopsy: i. a________ ii. C________-M________-T________ iii. d________ a________ iv. H________ d________ v. m________ l________ vi. v________ b. At the level of the ankle the sural nerve lies between the ________ tendon and the ________ malleolus. c. A tourniquet is used to distend the l________ s________ vein. d. ________ loss is expected but does not persist for more than ________ weeks. 97.8.2 amyloidosis Charcot-Marie-Tooth diabetic amyotrophy Hansen’s disease metachromatic leukodystrophy vasculitis achilles; lateral 97.8.4 lesser saphenous 97.8.5 Sensory; several 97.8.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-14 98 98 Functional Neurosurgery Deep Brain Stimulation 1. a. b. c. d. Characterize Parkinson’s disease. Best target is the _________ _________ It has similar efficacy to _________ with fewer _________ _________. Ablative surgery is giving way to ______. 2. Match the following conditions with their stimulation target sites. Conditions: ① Tourette’s syndrome; ② obsessive compulsive disorder; ③ depression a. anterior capsule b. thalamic c. STN d. subgenual e. cingluate gyrus f. pallidal 98.1 subthalamic nucleus levodopa side effects DBS (deep brain stimulators) 98.1 ②, ③ ① ② ③ ③ ① Surgical Treatment of Parkinson’s Disease 3. Matching. Regarding surgical ablative treatment of Parkinson’s disease and its historical background, match the listed procedures with the appropriate phrase(s) and benefits. Abandoned because: ① unpredictable results; ② tremor did not improve; ③ bradykinesia did not improve; ④ rigidity did not improve; ⑤ ipsilateral tremor persists; ⑥ side effects/resistance; ⑦ only modest benefits Procedure: (a-e) below a. anterior choroidal artery ligation b. anterodorsal pallidotomy c. ventrolateral thalamotomy d. L-dopa e. transplantation ① ②, ③ ③, ④, ⑤ ⑥ ⑦ 98.3.1 98.3.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Functional Neurosurgery 4. True or False. The following symptoms improve after anterodorsal pallidotomy: a. tremor ipsilateral b. rigidity c. bradykinesia d. ataxia e. tremor contralateral 98.3.1 false true false false false 98 5. Ventrolateral thalamotomy can improve tremor; it cannot be performed bilaterally because bilateral thalamotomy causes a. d_________ and dysarthria b. g_________ d_________. gait disturbance 98.3.1 6. Complete the following about surgical treatment of Parkinson’s disease: a. The target today is the _________ _________ b. specifically the __________________ which blocks the input from the _____________ _________. 98.3.2 7. a. b. c. How might pallidotomy work? direct destruction of the _________ interrupt _________ fibers diminish input from the _________ ________ 8. Answer the following about surgical treatment of Parkinson’s disease: a. What was an early procedure for the treatment of Parkinson disease? b. What are the mechanisms by which pallidotomy may work? i. destroy _________ ii. interrupt p_________ p_________ iii. reduce input into m_________ p_________ c. What is the target for the tremor treatment? d. True or False. Pallidotomy is primarily focused on the treatment of motor symptoms. e. What are the most common complications of pallidotomy? Hint: vhid i. v_________ ii. h_________ iii. i_________ h_________ iv. d________ 535 anterodorsal pallidum GPi–internal segment of the globus pallidus; STN– subthalamic nucleus 98.3.2 GPi pallidofugal subthalamic nucleus 98.3.2 ligation of the anterior choroidal artery GPi pallidofugal pathways medial pallidum ventralis intermedius nucleus (VIM) of the thalamus true visual field deficit hemiparesis intracerebral hemorrhage dysarthria ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 536 Part 23: Procedures, Interventions, Operations 9. True or False. Indications for pallidotomy in parkinsonism include a. refractory to drug therapy b. drug-induced dyskinesia c. rigidity d. tremor e. dementia 98 10. Ipsilateral hemianopsia is a contraindication to ventral pallidotomy because one of the side effects of the procedure could be o_________ t_________ i_________ and would cause the patient to be _________. 11. Bilateral pallidotomies carry an increased risk of a. s_________ d_________ and b. c_________ d_________. 12. True or False. What are the benefits for the patient from posteroventral pallidotomy as done currently? a. motor symptoms b. dyskinesia c. rigidity d. bradykinesia e. tremor 13. Characterize thalamic lesions. a. Lesioning in the thalamic _________ nucleus b. reduces parkinsonian _________, c. However, it does not improve _________ d. and may worsen i. g_________ s_________ and ii. s_________ p_________. 14. Characterize subthalamatomy. a. Lesions in the STN classically produced _________. b. Selective lesions may give relief on a par with _________. 98.3.2 true true true false false optic tract injury; blind (Visual field defects could occur in 2.5% of patients; blindness could result.) 98.3.2 98.3.2 speech difficulties cognitive decline 98.3.2 true true true true true 98.3.2 intermedius tremor dyskinesia gait symptoms speech problems 98.3.2 hemiballism pallidotomy Dystonia 15. Characterize dystonia. a. Stimulation of the _________ is the primary surgical treatment for the dystonia. b. Results are better for _________ dyskinesia. c. The most common target is _________. 98.4 pallidum tardive GPi ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Functional Neurosurgery 16. True or False. Stimulation has attracted increasing interest in patients with Parkinson’s disease who are refractory to medical drug treatment. The deep brain stimulator (the electrode) is placed in which of the following locations? (There are three true answers.) a. zona incerta b. posterior ventral pallidum (PV) c. substantia nigra (SN) d. Forel’s field (H) e. subthalamic nucleus (STN) f. globus pallidus internus (GPi) g. pedunculopontine nucleus 537 98.4 98 false false false false true true true Spasticity 17. True or False. A spastic bladder will a. have high capacity and empty spontaneously. b. have high capacity and empty with difficulty. c. have low capacity and empty spontaneously. d. have low capacity and empty with difficulty. 18. True or False. The onset of a spastic bladder after spinal cord injury is a. immediate b. delayed c. can occur at any time 19. True or False. The Ashworth score can grade severity of spasticity. The highest score in this system is given when there is a. no increase in tone (full movement) b. rigidity in all flexors c. rigidity in all extensors d. rigidity in flexion and extension 98.5.2 false false true (Low capacity and spontaneous emptying are the hallmarks of the spastic bladder.) false 98.5.2 false true (Delayed onset is typical because the acute phase of spinal shock is hyporeflexic and hypotonic.) false Table 98.2 false false false true 20. The Ashworth score is the clinical severity of spasticity grading of the _________ of_________. 98.5.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 538 Part 23: Procedures, Interventions, Operations 21. What are the medications used in the treatment of spasticity? a. b_________ b. d_________ c. d_________ d. p_________ 98 22. What are the nonablative procedures used for the treatment of spasticity? a. i_________ b_________ b. i_________ m_________ c. e_________ e_________ s_________ 23. True or False. Fibers that are more sensitive to radiofrequency rhizotomy are a. small unmyelinated sensory fibers. b. large myelinated alpha motor fibers. 24. What are the ablative procedures with preservation of ambulation used for the treatment of spasticity? Name one. 98.5.3 baclofen diazepam dantrolene progabide 98.5.3 intrathecal baclofen intrathecal morphine epidural electrical stimulation 98.5.3 true false motor point block; phenol nerve block; selective neurectomy; percutaneous radiofrequency foraminal rhizotomy; Bischof’s myelotomy; selective dorsal rhizotomy; stereotactic thalamotomy; dentatotomy 98.5.3 25. What are the ablative procedures with intrathecal injection of sacrifice of ambulation used for the phenol; selective anterior treatment of spasticity? Name one. rhizotomy; neurectomy; intramuscular neurolysis; cordectomy; cordotomy 98.5.3 26. True or False. Spasticity can be treated with intrathecal baclofen pumps. Complications are mainly a. pump under-infusion false b. wound complications false c. catheter complications true (Catheter complications may have a frequency of up to 30% in baclofen pumps.) d. drug resistance false 98.5.3 Torticollis 27. What is another name for torticollis? wry neck 98.6.1 28. What muscle is usually affected in spasmodic torticollis? sternocleidomastoid 98.6.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Functional Neurosurgery 29. What are the surgical procedures used for the treatment of spasmodic torticollis? a. stimulate _________ _________ b. inject _________ _________ c. cut _________ d. coagulate _________ ________ 30. What artery is most commonly implicated in the torticollis of the eleventh nerve origin? 539 98.6.3 dorsal cord botulinum toxin rhizotomy Forel’s H1 vertebral artery vertebral artery 98 98.6.6 Neurovascular Compression Syndromes 31. Characterize root entry zone. a. Syndromes due to compression of i. _________ _________ ii. at the _________ _________ _________. b. This site, also known as the __________________ zone, c. is the point where the central myelin from the _________ cells d. changes to the peripheral myelin of the _________ cells. 32. True or False. Hemifacial spasm (HFS) starts from the lower half of the face and spreads to the upper half of the face. 33. Complete the following about neurovascular compression syndromes: a. On what side is HFS more common? b. What is the age and gender predilection? c. What is the most commonly involved artery? d. True or False. Carbamazepine and phenytoin are generally effective treatment. e. What is the material used as a cushion in the microvascular decompression (MVD)? 34. What is the only other involuntary movement disorder besides HFS that persists during sleep? 98.7.1 cranial nerves root entry zone Obersteiner-Redlich oligodendroglial Schwann cells false (starts with the orbicularis oculi) 98.7.2 98.7.2 left women, after the teen ages AICA false Ivalon, polyvinyl formyl alcohol foam palatal myoclonus 98.7.2 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 540 98 Part 23: Procedures, Interventions, Operations 35. What distinguishes HFS from facial myokymia (FM)? a. Hemifacial spasm (HFS) is _________. b. Facial myokymia (FM) is _________. 36. True or False. The vessel most commonly associated with hemifacial spasm is a. posterior inferior cerebellar artery (PICA) b. superior cerebellar artery (SCA) c. anterior inferior cerebellar artery (AICA) d. posterior cerebral artery (PCA) e. vertebral artery f. basilar artery 37. Hemifacial spasm a. is caused by compression at the _________ _________ _________ b. of the _________ _________ c. by the _________. d. This does not cause _________ conduction but e. produces _________and _________. 98.7.2 unilateral bilateral 98.7.2 false false true false false false 98.7.2 root entry zone facial nerve AICA ephaptic kindling, synkinesis 38. Synkinesis is a phenomenon where a. stimulation of _________ _________ of one branch the facial nerve b. results in _________ _________ through delayed discharges; _________ _________. another branch 98.7.2 39. True or False. Postoperatively after microvascular decompression for hemifacial spasm, the patient can expect a. immediate cessation of facial spasms. b. reduction starting 2 to 3 days later. c. better results the longer the patient has had HFS. d. better results the older the patient is. e. complete resolution of spasms eventually. f. possible relapse even if free of spasms for a full 2 years. 98.7.2 40. Complications of hemifacial spasm (HFS) surgery include the following: Hint: hemifacial s a. h_________ b. e__________________ c. m_________ d. i_________ _________ _________ e. f_________ _________ f. a_________ g. c_________ h. i_________ _________ false true false false true (in 81 to 93% of patients) false (relapse after 2 years only 1%) 98.7.2 hoarseness elderly do less well meningitis (aseptic) ipsilateral hearing loss facial weakness ataxia CSF rhinorrhea incomplete relief of symptoms ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-09-27 Functional Neurosurgery i. a_________ _________ j. l_________ _________ k. s_________ _________ aseptic meningitis lip (perioral) herpes swallowing (dysphagia) 98 Hyperhidrosis 41. Complete the following statements about hyperhidrosis: a. It is due to overactivity of the _________ _________ glands. b. These glands are under control of the _________ _________ _________. c. The neurotransmitter is _________. d. Most _________ end organs are _________. e. Some cases warrant _________ _________. 541 eccrine sweat 98.8.1 sympathetic nervous system acetylcholine sympathetic; adrenergic surgical sympathectomy 98.8.2 from stellate ganglion 98.10.1 second thoracic ganglia T2 L2 and L3 sympathetic ganglia retroperitoneal 98.10.2 Sympathectomy 42. Complete the following statements about sympathectomy: a. What is the level for cardiac sympathectomy? b. What is the level for UE sympathectomy? c. What is the level for lumbar sympathectomy? d. What is the most commonly used approach for lumbar sympathectomy? 43. Name five indications for upper extremity (UE) sympathectomy. Hint: “crash” the sympathetic ganglia a. c_________ _________ _________ b. R_________ _________ c. a_________ _________ d. s_________-_________ _________ e. h_________ 44. What are the complications of UE sympathectomy? a. p_________ b. i_________ n_________ c. s_________ c_________ i_________ d. H_________ s_________ 98.10.4 Table 98.6 causalgia major primary Raynaud disease intractable angina shoulder-hand syndrome hyperhidrosis 98.10.2 pneumothorax intercostal neuralgia spinal cord injury Horner’s syndrome ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-14 99 Pain Procedures 99 General Information 1. Usual oral narcotic dose tolerated is M_______ c_______. MS contin (up to 300 to 400 mg/day) 99.1 Types of Pain Procedures 2. Name intracranial ablative procedures to treat the following pains: a. cancer pain: m______ t_______ b. head, neck, face pain: s_____ m______ 3. Matching. Match the procedure and its application (some have more than one). Applications for pain from: ① spinal cord injuries; ② postlaminectomy pain; ③ pelvic pain with incontinence; ④ at or below C5; ⑤ head, face, neck, upper extremity; ⑥ bilateral below the diaphragm; ⑦ causalgia; ⑧ bilateral below thoracic dermatomes; ⑨ avulsion injuries; ⑩ not for cancer pain Procedure: (a-h) below a. stereotactic mesencephalotomy b. cordotomy c. spinal intrathecal d. sacral cordotomy e. sympathectomy f. commissural myelotomy g. dorsal entry zone (DREZ) h. spinal cord stimulator 99.3 medial thalamotomy stereotactic mesencephalon 99.3 ⑤ ④ ⑥ ③ ⑦ ⑧ ①, ⑨, ⑩ ②, ⑩ ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-14 Pain Procedures Cordotomy 4. Complete the following concerning cordotomy: a. Your objective is to interrupt the fibers of the l______ s_______ t______ t______ on the side thalamic tract c_______ to the pain. b. Cordotomy is the procedure of choice for u_______ pain below the C_______ dermatome. c. Two ways to perform cordotomy: i. o_______ ii. p_______ d. Loss of automatic breathing can occur after b______ c______ and is called O______ c_____. e. What is the cutoff percentage on pulmonary function test before patients can undergo cordotomy? 5. Answer the following about pain procedures: a. What kind of patients are candidates for cordotomy? b. On which side should the cordotomy be performed? c. What happens to impedance as the needle penetrates the cord? d. What response should stop cordotomy from being performed? e. If you look at the patient’s eyes, what will you learn? f. What percentage will have pain relief? 543 lateral spinal thalamic tract; contralateral 99.4.1 99 unilateral; C5 open percutaneously bilateral cordotomy; Ondine’s curse 50% 99.4.2 99.4.3 terminally ill patients contralateral to pain jumps from 300 to 500 ohms to 1200 to 1500 ohms muscle tetany upon stimulation If an ipsilateral Horner’s syndrome occurs, the procedure is satisfactory. 94% Commissural Myelotomy 6. Answer the following concerning commissural myelotomy: a. What is the indication for commissural myelotomy? b. What is the rate of complete pain relief after commissural? c. What is the special requirement for intrathecal morphine? bilateral or midline pain 99.5.2 60% 99.5.4 preservative-free 0.9% saline 99.7.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-14 544 Part 23: Procedures, Interventions, Operations CNS Narcotic Administration 7. Answer the following regarding central nervous (CNS) narcotic administration: a. Requirement for implantation of a morphine pump is p______ t______ d_____. b. B______ i______ can shorten the delay time for a morphine pump to function; otherwise the relief may not occur for d_______. c. Is meningitis common after pump placement? d. Is respiratory failure common after pump placement? 99 99.7.1 pre-operative testing dose Bolus infusion; days no no Spinal Cord Stimulation (SCS) 8. Complete the following regarding spinal cord stimulation: a. Site of spinal cord stimulation is the d_______ c______. i. The most common indication is p______ p______ s________. ii. It is not usually indicated for c_____ p______. b. Two kinds of electrodes: i. p_______-like ii. w______-like 9. Complete the following statements about complex regional pain syndrome (CRPS)? a. It is a c______ pain condition characterized by b. intense a_______ or b_______ pain. 10. What is the difference between Type I and Type II chronic regional pain syndrome? dorsal columns 99.8.1 postlaminectomy pain syndrome cancer pain 99.8.2 plate wire 99.8.6 chronic aching; burning Type I has no nerve injury and Type II follows a nerve injury. 11. True or False. Regarding spinal cord stimulation: a. Improves pain control over physical true therapy or medical management alone in patients with failed back surgery. b. It helps with pain due to inoperable limb true ischemia. c. Reduces angina pain and improves true exercise capacity. 99.8.6 99.8.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-14 Pain Procedures Deep Brain Stimulation (DBS) 12. Complete the following regarding deep brain stimulation: a. Deafferentiation pain syndromes may benefit from stimulation of the ______ _______. b. DBS for chronic neuropathic pain produces a reduction of ___-___% in pain in about ___-___% of patients. c. Nociceptive pain syndromes benefit from stimulation of __________ ____ _______. d. Cluster headaches may benefit from _________ __________. 545 99.9 sensory thalamus 99 40-50%; 25-60% periaqueductal gray matter hypothalamic stimulation Dorsal Root Entry Zone (DREZ) Lesions 13. Complete the following about dorsal root entry zone (DREZ) lesions: a. They are useful for d______ pain. b. They result from nerve root a______. c. They most commonly occur from m_______ accidents. d. For such an injury, pain relief can be expected in ________%. deafferentiation avulsion motorcycle 99.10.1 80 to 90% 99.10.5 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 100 Seizure Surgery 100 General Information, Indications 1. What percent of patients are not controlled with medication? 2. Characteristics of refractory seizures considered for surgery. a. Nature of seizures? b. Length of treatment? 20% 100.1 severe disabling at least 1 year 3. Complete the following regarding medically refractory seizures. a. Medically refractory is usually considered two _____ attempts of high dose monotherapy b. with _____ distinct AEDs, and two c. _____ attempt at polytherapy. one 100.1 100.1 Pre-surgical Evaluation 4. True or False. Regarding pre-surgical evaluation. a. All patients should undergo high resolution MRI as part of pre-surgical evaluation. b. It is the best test to demonstrate hippocampal asymmetry. 5. Complete the following about noninvasive seizure evaluation techniques. a. Video-EEG monitoring is used to identify the s_______ f______. b. In a CT with IV contrast the focus may e______. c. Interictal PET scan shows h_________ in ____% of patients with refractory CPS. d. During a seizure a SPECT will demonstrate b______ f______ during a s_______. true 100.2.1 true 100.2.2 100.2.2 seizure focus enhance hypometabolism; 70% blood flow during a seizure ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 Seizure Surgery 6. Complete the following about the WADA test: a. The purpose is to localize d_______ h______. b. You can be misled by i. A______ ii. p_______ t________ a_______ iii. h_______ s_______ by iv. p________ c________ 7. When there is lack of lateralizing or localizing physiology in pre-operative evaluation, there are two surgical options for better definition of seizure focus: a. d______ e_______ b. s_______ g______ or s_______ 100.2.3 dominant hemisphere AVM persistent trigeminal artery hippocampus supplied by posterior circulation 100.2.4 100 depth electrode surgical grids or strips Surgical Techniques 8. Surgical disconnection operations available are: a. c__________ b. h__________ c. m________ s________ t________ 547 100.3.1 callosotomy hemispherectomy multiple subpial transections Surgical Procedures 9. Complete the following about corpus callosotomy (CC): a. Indication for corpus callosotomy i. d____ a______ – a________ s________ ii. i_________ h_________ s________ b. How much of the CC is resected? c. Complication is a_______ m_________. d. Must the anterior commissure also be sectioned? e. Contraindication? f. Exclude by W_______ t_______ on all l______ h______ persons. 100.4.1 drop attacks – atonic seizures infantile hemiplegia syndrome anterior two-thirds akinetic mutism (or reduced temporary verbalization) no – less likely to get disconnection syndrome if spared crossed dominance Wada test on all left-handed persons ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 548 Part 23: Procedures, Interventions, Operations 10. Answer the following about disconnection syndrome in a leftdominant person (i.e., right-handed): a. Usually lasts _______ months. b. Effect: i. left hand t_______ a______ ii. vision p______ iii. smell: a______ iv. copying figures (i.e., spatial synthesis): p_____ with r_____ h_____ v. speech: r_______ s_______ vi. urinary i______ vii. left-sided d_____ c. Occurs with l_______ l_______ of c_______ c______. d. Less likely to occur if a_______ c_______ is s_______. 100 11. Complete the following regarding temporal lobectomy limits: a. On dominant side permitted i. _______ ii. too much i_______ s______ b. On nondominant side permitted i. ________ ii. too much c_______p_____ u_______ h______ c. Greater resection of i. _______ will cause ii. c______ c_______ u_______ h_______ 100.4.1 2 to 3 months tactile anomia pseudohemianopsia anosmia poor with right hand reduced spontaneity incontinence dyspraxia large lesions of corpus callosum anterior commissure is spared 100.4.2 4 to 5 cm injures speech 6 to 7 cm contralateral partial upper hemianopsia 8 to 9 cm contralateral complete upper hemianopsia MRI Guided Laser Interstitial Thermal Therapy (MRGLITT) 12. Complete the following. a. MRGLITT stands for M____ g______ l______ i______ t_______ t________. b. It is performed with simultaneous MRI s_______ g_______. c. It is considered l_____ invasive than microsurgery. d. What is the main advantage? e. Preliminary seizure control is ___ to ___%. 100.6 MRI guided laser interstitial thermal therapy stereotactic guidance less shorter post-op recovery 60 to 70% ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 Seizure Surgery Post-operative Management for Seizure Surgery (Epilepsy Surgery) 13. True or False. Regarding postoperative management for epilepsy surgery. a. Requires ICU observation for 24 hours. b. Not necessary to treat one brief generalized seizure. c. Administer 10 mg dexamethasone IV before surgery followed by q8 hours dosing as necessary. d. Anti-convulsants can be discontinued immediately after surgery. e. Neuropsychiatric evaluation 6-12 months after surgery. 549 100.7 true true true 100 false (need to be continued for 1-2 years even if no postop seizures occur) true Outcome 14. Describe seizure surgery outcome expectations. a. The greatest effect of surgery is r____ of s____ f____. b. Incidence of being seizure free is ______%. c. Seizures reduced by at least 50% in _____%. 15. What is the main risk of surgery during vagus nerve stimulation? 100.8.1 reduction of seizure frequency 50% 80% vocal cord paralysis 100.8.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 101 Radiation Therapy (XRT) 101 Conventional External Beam Radiation 1. Radiation injury to tissue is a function of: a. d____ b. e_______ ____ c. a____ 2. What are the four “R’s” of radiobiology? a. R________ b. R________ 101.2.1 dose exposure time area 101.2.1 Repair of sublethal damage Reoxygenation of previously hypoxic tumor cells Repopulation of tumor cells following treatment Redistribution of cells within the cell cycle c. R________ d. R________ 3. What is the linear-quadratic equation (LQ-model)? 4. Complete the following about cranial radiation: a. After surgery most surgeons wait __ to __ days before irradiating. b. Tumors that are very responsive to XRT include: i. l_________ ii. g___ c___ t______ 5. What are the two normal CNS cell types most vulnerable to radiation necrosis? a. v______ ________ b. o_________ _____ Biologically effective dose (Gy) = n x d x [1 + d / (α/β)]; where n = # of doses, d = dose per fraction, and α/β ratio = description of cell response to radiation with higher values corresponding to earlier-responding tissue such as tumor cells. 101.2.2 101.2.3 7 to 10 lymphomas germ cell tumors 101.2.3 vascular endothelium oligodendroglial cells ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 Radiation Therapy (XRT) 6. a. b. c. d. e. f. Seven major side effects of radiation: d______ c_______ r______ n_______ o___ p________ injury h_________ p_____ h_________ formation of new _________ g. l_________ 7. Two major treatments of radiation necrosis are: a. s______ b. s______ 8. What is the estimated dose of XRT that can be tolerated by normal brain tissue? 9. True or False. Regarding the following imaging studies to detect radiation necrosis: a. MR spectroscopy is useful if mass is pure tumor. b. MR spectroscopy is useful if mass is pure necrosis. c. MR spectroscopy is useful if mass is a mix of tumor and necrosis. d. RN will lead to decreased radionuclide uptake on SPECT imaging. e. RN will lead to increased regional glucose metabolism on PET imaging. 10. Has radiation of spinal metastases been shown to prolong survival? 11. a. b. c. d. Side effects of spinal radiation include: m_______ or n_________ n______, v________, d__________ b_____ m______ s______ g______ r__________ in children e. development of c_______ m________ 551 101.2.3 decreased cognition radiation necrosis optic pathway injury hypopituitarism primary hypothyroidism formation of new tumors – gliomas, meningiomas, nerve sheath tumors leukoencephalopathy 101.2.3 steroids surgery (if deterioration from mass effect) About 65-75 Gy given as 5 fractions/week over 6.5-8 wks. Radiation necrosis will occur in about 5% of patients after 60 Gy given as 5 fractions/week over wks. 101.2.3 101 101.2.3 true true false true false (will be decreased) No definitive proof of prolonged survival. Often used for pain relief and preservation of function. 101.2.4 101.2.4 myelopathy or neuropathy nausea, vomiting, diarrhea bone marrow suppression growth retardation in children cavernous malformations ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 552 Part 23: Procedures, Interventions, Operations 12. What are important factors relating to the occurrence of radiation myelopathy? a. r____ b. t_____ r________ d____ c. extent of c____ s______ d. i_________ s________ e. amount of t_____ r_____ f. v_____ s_____ to the region radiated g. s____ of r________ 13. Describe the 4 types of radiation myelopathy. a. Type 1 101 b. Type 2 c. Type 3 d. Type 4 14. What radiation doses are associated with negligible risk of radiation myelopathy? 101.2.4 rate of application total radiation dose extent of cord shielding individual susceptibility amount of tissue radiated vascular supply source of radiation Table 101.1 Benign form, mild sensory symptoms/Lhermitte’s sign, occurs several months following XRT but usually resolves within several months. Lower motor neuron signs in upper or lower extremities due to injury to anterior horn cells. Complete cord lesion within hours due to blood vessel injury. Most common, chronic progressive myelopathy with initial paresthesias/Lhermitte’s sign and eventual spastic weakness with hyperreflexia. Dependent on field size. Large field: negligible risk with ≤ 3.3 Gy over 6 weeks (0.55 Gy/wk). Small field: negligible risk with ≤ 4.3 Gy over 6 weeks (0.717 Gy/wk). 101.2.4 Stereotactic Radiosurgery and Radiotherapy 15. The three main categories for delivery of SRS/SRT are: a. G_______ K_______ b. l_______ a_______ c. h_______ c_______ p_________ r___________ 101.3.1 Gamma Knife (gamma ray) linear accelerator (x-ray) heavy charged particle radiosurgery 16. The main source of gamma decay used Cobalt-60 in Gamma Knife is __________. 101.3.1 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 Radiation Therapy (XRT) 17. In general, lesions less than ______ in diameter are amenable to treatment with SRS. 18. What is the maximum recommended radiation dose to the following organs? a. eye lens: ___ Gy b. optic nerve: ___ Gy c. skin in beam: ___ Gy d. thyroid: ___ Gy 19. a. b. c. Is SRS useful for venous angiomas? an AVM with a compact nidus? dural AVF with cortical drainage? < 3 cm 101.3.2 101.3.4 1 Gy 1 Gy 0.5 Gy 0.1 Gy 101.3.5 no yes no – high risk of hemorrhage with cortical drainage 101 20. The V__________ R_________ A____ scale and P_______-F________ score are useful scales to predict favorable outcome with AVM radiosurgery. Virginia Radiosurgery AVM Scale; Pollock-Flickinger score 101.3.5 21. The gold standard (Level 1) recommendation for a single brain metastasis in an accessible region is s________ r_______ plus W_____. surgical resection; WBRT 101.3.5 22. True or False. Based on prospective randomized study data involving patients with a single brain metastasis: a. Survival between SRS vs. surgery + WBRT true is equal. b. There was a higher incidence of distant true recurrence in the SRS arm. 101.3.5 23. In pituitary adenomas treated with SRS, is the percentage of tumor growth control rate or endocrine remission rate higher? 101.3.5 24. Immediate adverse reactions to SRS include: a. p______________ h_____________ b. n________ and v__________ c. s___________ d. Adverse events have been reduced by pre-medicating with m___________ and p__________________. 553 Overall tumor control rate has been reported as 90% vs. endocrine remission rates ranging from 26 – 54% depending on the hormone being over-secreted. Typically a higher dose of radiation is required for secretory tumors. 101.3.5 post-procedural headaches nausea and vomiting seizures methylprednisolone; phenobarbital ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 554 25. a. b. c. d. 101 Part 23: Procedures, Interventions, Operations Complications from SRS include: v_______________ c__________ n___________ deficits radiation-induced t________ radiation-induced i________ c________ 101.3.5 vasculopathy cranial nerve deficits radiation-induced tumors radiation-induced imaging changes Interstitial Brachytherapy 26. What are three techniques for brachytherapy? a. insertion of i__-______ p_________ b. insertion of c____________ containing radioactive source c. administration of r___________ l________ 101.4.2 Iodine-125 pellets catheters radioactive liquids ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 102 Endovascular Neurosurgery General Information 1. Contraindications to catheter angiography: a. uncorrected b________ disorders b. poor r________ function due to i________ dye load 102.1.3 bleeding renal; iodine 102 Pharmacologic Agents 2. Pharmacologic agents: a. Brand name of abciximab is R________. ReoPro; b. Mechanism of action is that it prevents fibrinogen; binding of f________ to p________ GP platelet; IIb/IIIa r________. receptors c. Aspirin works by irreversibly inactivating cyclo-oxygenase c________. d. Uncoated aspirin achieves peak plasma 30-40 minutes; concentrations in ___ - ___ minutes, 6 hours whereas enteric-coated aspirin reaches peak in _________ hours. e. Up to _________% of patients are 30% resistant to aspirin 325 mg/day. f. Brand name of clopidogrel is P________. Plavix g. It is a platelet A________ receptor ADP antagonist. h. Start _________ days before procedure 5 days; because it takes ___ - ___ days to reach 3-7 days full therapeutic effect. i. Use _________ mg loading dose it there 300 mg is no time to reach therapeutic effect over a few days. j. Brand name of eptifibatide is I________. Integrilin k. It is a r________ inhibitor of p________ reversible; platelet aggregation. l. ACT goal for embolization of an 300-350 seconds aneurysm or AVM is ____ - ____ seconds. m. ACT goal for angioplasty with/without 250-300 seconds stenting is ____ - ____ seconds. 102.2.2 102.2.3 102.2.4 102.2.5 102.2.6 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 556 Part 23: Procedures, Interventions, Operations n. Agent used to reverse heparin is p_______ s________. o. Agent used during Wada test is s_______ a________. p. _________ mg is injected through catheter for Wada test with additional boluses of _________ mg if needed. q. tPA converts p________ to p________. r. Can be administered i________ or i________. s. tPA can be reversed using F________. t. Verapamil is a c________ c________ blocker that enables v________. sodium amytal 102.2.9 100 mg; 25 mg plasminogen; plasmin intravenously; intraarterially FFP calcium channel; vasodilation 102.2.10 102.2.11 Neuroendovascular Procedure Basics 3. Neuroendovascular procedure basics: a. Vascular access can be obtained via f________ artery, r________ artery, b________ artery, or c_______ artery. b. Arteriotomy closure options include m_______ pressure or percutaneous c________ devices. 102 protamine sulfate femoral; radial; brachial; carotid manual; closure 102.3.1 102.3.3 Disease-Specific Intervention 4. Endovascular treatment of aneurysms: a. Endovascular treatment has emerged as a f________ l________ therapy for most aneurysms, but surgery still remains a strong option for M________ and P________ aneurysms. b. Wide necked aneurysms were previously thought better suited for c________ but the availability of s________ increased the spectrum of aneurysms amenable to endovascular treatment. c. Small aneurysms ____ ____ ____ mm are less favorable for c________. d. Another endovascular option for wide necked aneurysms is b________-assisted coiling. e. Most coils are made from b________ p________. f. The p________ e________ device prevents b________ e________ into aneurysm and therefore encourages s________. 102.5.1 first line; MCA; PICA clipping; stents less than 4 mm; coiling balloon bare platinum pipeline embolization; blood entry; stasis ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 Endovascular Neurosurgery g. _________ month follow-up angiogram usually reveals complete o________ of aneurysm. h. Treatment of aneurysm rupture during coiling: i. lower b_______ p________ ii. inflate b________ if being used iii. reverse a________ iv. continue c________ v. insert E________ 5. Management of vasospasm: a. Endovascular options include c________ spasmolysis and a________. b. Drug of first choice for spasmolysis is v________. c. R________ treatments may be considered. 6. AVM embolization: a. Indications: i. Most common indication is p________ embolization. ii. Embolization of associated aneurysms located on f________ or in n_______. iii. Curative AVM embolization is r________ and limited to s________ AVMs with s________ angioarchitecture. b. 2 most common embolic agents include o________ and N________. c. Radiopaque component of Onyx is t________. d. Onyx requires priming microcatheter with D________ to prevent Onyx s________ within microcatheter. e. NBCA is an embolic agent that is a g________. 7. Dural arteriovenous fistula (DAVF): a. DAVF with a________ features are always considered for treatment. b. These features include c_________ v_________ r_________, h_________, f_________ n_________ d_________, d_________, p_________, and i_________ i_________ p_________. c. T________ approach is preferred. d. Embolic materials that can be used include c________, o________, and N________. 557 6 month; obliteration blood pressure balloon anticoagulation coiling EVD 102.5.2 chemical; angioplasty verapamil Repeat 102.5.3 102 pre-operative feeders; nidus rare; small; simple onyx; NBCA tantalum DMSO; solidification glue aggressive cortical venous reflux, hemorrhage, focal neurological deficit, dementia, papilledema; increased intraocular pressure Transvenous coils, onyx; NBCA 102.5.4 102.5.3 ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 558 Part 23: Procedures, Interventions, Operations 8. Carotid cavernous fistula (CCF): a. Direct fistula requires t________ because they do not resolve s________. b. Endovascular routes used to treat CCF are t________, t________, and via s________ o________ v________. c. Route and technique of choice is t________ c________ embolization. d. Detachable balloons are n________ l_______ a________ in the U.S. 102 9. Vertebrojugular fistula: a. 3 main etiologies are i_________, t_________, or v_________. b. 2 main endovascular treatments are c_________ s_________ or c_________ o_________ if there is adequate blood flow through contralateral vertebral artery. 10. Carotid dissection: a. The most common angiographic feature is l_______ s________ (_________%). b. Indications for endovascular intervention are persistent i________ symptoms despite a________ or f________-limiting lesion with h________ compromise. c. Endovascular treatment consists of s________ with either c________ or u________ stent. 11. Subclavian artery stenosis: a. Only _________% of patients with subclavian artery stenosis have flow r________ in the vertebral artery. b. Indication for endovascular intervention is stenosis resulting in s_________ s_________ s_________. c. Intervention consists of a________ and s________. 12. Mechanical thrombectomy for ischemic stroke: a. May be performed within _________ hours of symptom onset. b. May be performed for posterior circulation strokes up to _________ hours after symptom onset. c. Current device of choice is the s________ r________. d. Recanalization rate with this device is ____ - ____ %. e. An older device used is p________ a________. 102.5.5 treatment; spontaneously transarterial, transvenous; superior ophthalmic vein transarterial coil no longer available 102.5.6 iatrogenic, trauma; vasculitis covered stent; coil occlusion 102.5.7 luminal stenosis (65%) ischemic; anticoagulation; flowlimiting; hemodynamic stenting; covered or uncovered 102.5.8 2.5%; reversal subclavian steal syndrome angioplasty; stenting 102.5.9 6 hours 24 hours stent retriever 88-100% penumbra aspiration ERRNVPHGLFRVRUJ ReU n LiOb LiOb ReO b THM_Kranzler Hübner EP GmbH 2016-10-10 Endovascular Neurosurgery 559 f. Has a recanalization rate of _________%. 80% g. Recanalization with the older device longer takes l________ to achieve. 13. Tumor embolization: a. Purpose is preoperative d________ of v________ tumors, such as m________. b. Embolization with P________ particles is not d________ and so surgery should be performed within a f________ days of embolization. 14. The PVA particle size that is typically used to treat epistaxis is ____ - ____ mcgm. 102.5.11 devascularization; vascular; meningiomas PVA; durable; few 250-300 mcgm 102.5.13 102 ERRNVPHGLFRVRUJ ReU n ERRNVPHGLFRVRUJ
