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Neurosurgery Review for Medical Student

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Neurosurgery Review for Medical Student 17 Febuary 2552 * * * * * * * * * * Tumor DDx for patient with progressive hemiparesis and IICP Supratentorial tumor (Metas ... – PowerPoint PPT presentation

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Title: Neurosurgery Review for Medical Student


1
Neurosurgery Review for Medical Student
  • 17 Febuary 2552

2
  • I ?????/??????????
  • ???????? ???????? ?????????? ??????? ??????
  • ????????????????? ??? ???? ?????? ?? ??? ?????????

3
  • II ???/????/????????????????? (??????????)
  • ????? 1
  • coma
  • convulsion
  • acute increased intracranial pressure
  • Head injury

4
  • III ??????????
  • ????? 3
  • Benign and malignant neoplasm of brain
  • Brain abscess
  • Hydrocephalous
  • Trigeminal neuralgia
  • Head injury and spinal cord injury

5
Stroke
  • ??????????????? 50 ?? ????????????????????
    ????????????????? ???????? ??????? ????? PE
    GCS 13, no motor weakness, stiff neck ve
    ????????????????
  • Pontine hemorrhage
  • Cellebellar hemorrhage
  • Subarchnoid hemorrhage
  • Basal ganglion hemorrhage
  • Intraventricular hemorrhage

???? C
6
Stroke
  • Ischemic VS hemorrhagic
  • Ischemic syndrome ???? ?
  • Hemorrhagic disease
  • Hypertensive hemorrhage
  • Amyloid angiopathy
  • SAH from ruptured aneurysm
  • Ruptured AVM
  • (???? ? bleeding tumor, coagulopathy, parasite,
    vasculitis)

7
Stroke
  • Ischemic VS hemorrhagic
  • Hemorrhagic stroke ????? sign of IICP (??????
    ??????? ?????)
  • Ischemic stroke ????????? sudden neurodeficit
  • Hemiparesis
  • Apasia / apraxia
  • Amaurosis fugax
  • Onset ?????????
  • Clinical ????????? 100 ? need investigation CT

8
Stroke
  • Ischemic stroke
  • MCA Hemiparesis, contralateral hemisensory loss,
    aphasia
  • ACA Paresis and sensory loss of contralateral
    lower extremity
  • PCA Homonymous hemianopia with macular sparing
  • Basilar Cranial nerve signs diplopia, facial
    weakness, vertigo, dysarthria

9
Stroke
  • Hemorrhagic stroke
  • Hypertensive ICH
  • Ruptured cerebral aneurysm
  • Ruptured AVM
  • Amyloid angiopathy
  • Bleeding tumor
  • Coagulopathy

10
Stroke
  • Hypertensive ICH
  • Hypertension gt 90
  • IICP signs and symptoms (headache, vomiting,
    ?consciousness)
  • Common site
  • Basal ganglion Hemiparesis, Aphasia (dominant
    hemisphere)
  • Thalamus hemianesthesia
  • Cerebellar ataxia, cerebellar sign ve
  • Pontine pinpoint pupil

11
Stroke
  • Hypertensive ICH
  • Antihypertensive drugs
  • SBP gt 200 ? IV antihypertensive
  • SBP gt 180 or MAP gt 130
  • IICP suspected ? monitor ICP keep CPP 60-80 mmHg
  • No IICP suspected ? modest ? BP to MAP 110 or
    160/90
  • Surgery VS Medical treatment
  • Recommendation cerebellar hemorrhage gt 3 cm
    (class I)

AHA guideline 2007
12
Stroke
  • Ruptured cerebral aneurysm
  • Worst headache of my life
  • With or without neurodeficit
  • Stiffneck / nuchal rigidity
  • CT Subarachnoid hemorrhage
  • Common sequelae
  • Rebleeding
  • Hydrocephalus
  • Vasospasm

13
Stroke
  • Ruptured cerebral aneurysm
  • Key point of management
  • Refer to neurosurgeon ASAP (for clipping to
    prevent rebleeding)
  • If clinical suspected but negative CT
  • ? LP ?? xanthochromia
  • Investigation of choice 4 vessels angiography
    (alternative CT angiography (CTA), MRA)

14
Stroke
  • Ruptured AVM
  • Young age
  • Lobar hemorrhage
  • Non-hypertension
  • Investigation angiography
  • Risk rebleeding 2-3/y
  • Management
  • Surgery excision
  • Embolization
  • Radiosurgery

15
Stroke
  • Investigation in intracerebral hemorrhage
  • Consider
  • Angiography
  • CT angiography
  • In
  • Young age (lt 45)
  • Non hypertension
  • Uncommon site (Lobar)

16
Stroke
  • Amyloid angiopathy
  • Old age
  • Non-hypertension
  • Lobar hemorrhage
  • No special investigation needed

17
Trauma
  • ?????????????? 50 ?? ??????????????????????
    ????? 10 ???? ?????????????????
    ??????????????????. ????????????????????? ??? 2
    ???????????? GCS E1V2M5, pupils right 3 mm, left
    5 mm SRTL ?????????????????????
  • Epidural hemorrhage
  • Subdural hemorrhage
  • Subarachnoid hemorrhage
  • Intracerebral hemorrhage
  • Diffuse axonal injury

???? a
18
Trauma
  • Initial management
  • Epidural hematoma
  • Subdural hematoma
  • Traumatic intracerebral hematoma
  • Traumatic SAH
  • Skull fracture
  • Sequalae

19
Trauma
  • Initial management
  • ABCDE
  • Dont miss!
  • Collar (primary survey A)
  • ET tube in GCS 8 (primary survey D)
  • Search for other bleeding site in hypotensive
    patient
  • GCS (Must remember!)

20
Trauma
????? short essay moderate HI in rural hospital
Item ??????
GCS 47 71.21
C-spine protection 14 21.21
O2 17 25.76
IV 47 71.21
Refer or CT brain 50 75.76
Suture/dressing 37 56.06
Dilantin 11 16.67
Foley or NG 20 30.30
21
Trauma
  • Glassow Coma scale

Eye Verbal Motor Score
???????????? 6
???? ??????????????????? 5
???????? ????????????? ???????? Withdraws 4
?????????????? ??????????????????? Decorticate 3
??????????????? ????????????? Decerebrate 2
???????? ?????????? ?????????????????? 1
22
?????????????? Head Injury
ABCDEs, C spine protection Resuscitation
??????? GCS
GCS lt 9 Severe HI
GCS 9-12 Moderate HI
GCS 13-15 Mild HI
??????? O2 mask c bag IV fluid
??????? Endotracheal tube Hyperventilation
Mannitol/osmolar Rx
  • ??????? risk Mild HI
  • D/C
  • Admit observe
  • CT

Refer
23
Trauma Risk factors for Intracranial lesion for
Mild HI
  • Clinical findings
  • GCS lt 15 ???? 1-2 ???????
  • Amnesia
  • ????????
  • ???????
  • ???????????????
  • ?? Sign ???????????? (skull Fx (Skull Base/Valve)
  • ??????????????????????????????
  • Risk factors
  • ???? gt 60
  • Coagulopathy (Warfarin, Hemophilia,etc)
  • ???
  • ????????/????????????
  • ????????????????????????? ???? ?????????????????

24
Trauma
  • Epidural Hematoma (EDH)
  • Associated with skull fracture
  • Classic Middle meningeal artery tear
  • Lens shape/biconvex
  • Lucid interval
  • Rapidly fatal
  • Good prognosis if proper management

25
Trauma
  • Subdural hematoma (SDH)
  • Venous tear/ brain laceration
  • High morbidity/mortality due to underlying brain
    injury
  • Crescent concaved shape
  • Counter coup

26
Trauma
  • Chronic Subdural hematoma (CSDH)
  • Elderly, alcohol abuse, coagulopathy
  • Motor oil fluid, no clot
  • Minimal or no Hx of injury
  • Insidious onset
  • Minor symptoms ? hemiplegia/seizure

27
Trauma
  • Skull Fracture
  • Skull Fx ? ? risk of intracranial bleeding 5
    times
  • Skull base fracture
  • CSF rhinorrhea, otorrhea
  • Battles sign, Raccoons eye (anterior skull
    base)
  • Facial weakness (petrous part of temporal bone)

28
Trauma
  • Sequelae of head injury
  • Increased intracranial pressure (gt 20 mmHg)
  • General sedation, analgesia, elevate head, avoid
    hypoxia
  • Ventricular drainage
  • Mannitol
  • Hyperventilation
  • 2nd tier
  • Phenobarb coma
  • Decompressive craniectomy

29
Trauma
  • Sequelae of head injury
  • Electrolyte imbalance hyponatremia
  • Seizure
  • Antiepileptic drug - ? early seizure
  • Prophylaxis 7 days
  • I/C GCS10, intracranial lesion, penetrating
    injury, depressed skull fracture
  • Carotid-cavernous fistula
  • Posttrauma 2-3 mo
  • Unilateral chemosis, proptosis
  • Bruit/thrill at the orbit
  • Ix angiography
  • Management balloon embolizaion

30
Herniation syndrome
  • Central
  • Diencephalon ? tentorial
  • Chronic
  • Pupils SRTL? Fixed
  • Uncal
  • Uncus and hippocampal gyrus over tentorium
  • CN III compression ? unilateral pupil ?,
    hemiparesis
  • Consciousness preserved in early stages
  • Classic for EDH

31
Herniation syndrome
  • Cingulate (subfalcine H)
  • asymptomatic except ACA kink, warning of
    impending transtentorial H.
  • Upward
  • posterior fossa mass ventriculostomy
  • Tonsillar
  • Posterior fossa mass LP

32
Tumor
  • Supratentorial
  • Gliomas
  • Astrocytoma
  • Oligodendrogliomas
  • Ependymomas
  • Meningiomas
  • Sellar and suprasellar
  • Pituitary adenomas
  • craniopharyngiomas
  • Infratentorial
  • Medulloblastoma (Ped)
  • Cerebellar astrocytoma
  • Brainstem gliomas
  • CP angle tumor
  • Vestibular schwannoma (acoustic neuromas)
  • Meningiomas
  • Meningiomas

33
Tumor
  • Most common brain tumor
  • Metastasis
  • Most common primary brain tumor
  • Astrocytoma
  • Most common primary brain tumor in children
  • Medulloblastoma
  • Glioblastoma multiforme
  • Grade IV of astrocytoma
  • Poor prognosis. 2 yr survival 11 mo for total
    resection

34
Tumor
  • DDx for patient with progressive hemiparesis and
    IICP
  • Supratentorial tumor (Metas, gliomas, meningioma,
    etc)
  • Brain abscess (ped. With rt to lt shunt eg TOF)
  • DDx for patient with bitemporal hemianopia
  • gt sellar and suprasellar tumor
  • Pituitary adenoma
  • Craniopharyngioma
  • Meningioma

35
Hydrocephalous
  • Mechanism
  • Obstruction at CSF pathway
  • Obstructive hydrocephalous
  • CSF pathway tumor, blood, etc
  • Obstruction at arachnoid granulation
  • Communicating hydrocephalous
  • Overproduction choroid plexus papilloma
  • Treatment
  • Remove etiology
  • Drainage
  • Ventriculostomy (temporary)
  • Shunting
  • VP shunt
  • VA shunt
  • Ventriculo-pleural shunt

36
(No Transcript)
37
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