NEUROSURGERY BOARD REVIEW PDF
Neurosurgery board review: questions and answers for self-assessment / Cargill H. . tent areas revealed by the American Board of Neurological Surgery over. NEUROSURGERY BOARD REVIEW. Questions and Answers for Self- Assessment. Second Edition. Thieme. This document was downloaded for personal use. Neurosurgery Oral Board ppti.info - Ebook download as PDF File .pdf), Text File .txt) or read book online.
|Language:||English, Spanish, Indonesian|
|ePub File Size:||20.50 MB|
|PDF File Size:||13.48 MB|
|Distribution:||Free* [*Regsitration Required]|
This essential board prep review mirrors the exam's multiple-choice format and seven sections: neurosurgery, clinical neurology, neuroanatomy, neurobiology. PDF | Neurosurgery Oral Board Review. Second Edition. By Citow Jonathan Stuart and Adamson David Cory. Published by Thieme. Comprehensive Neurosurgery Board Review by Jonathan Stuart Citow, , available at Book Depository with free delivery.
Free delivery worldwide. Bestselling Series.
Harry Potter. Popular Features. New in Comprehensive Neurosurgery Board Review. Notify me. Description Praise for the previous edition: Authored by a team of expert clinicians and neurosurgery trainees who earned top scores on their exams, this edition distills the current knowledge of the neurosciences and essential information for clinical practice. Six chapters provide comprehensive coverage of core concepts in anatomy, physiology, pathology, radiology, neurology, neurosurgery, and critical care.
Features of the second edition: Concise descriptions aid rapid review of key concepts Bullet-point format enhances ease of use and facilitates comprehension Up-to-date coverage of classic symptoms and signs of common neurosurgical diseases Current information related to the genetic basis of neurosurgical conditions high-quality illustrations and images typical of those appearing on exams This superb review is an indispensable resource for neurosurgical residents preparing for the ABNS certification exam.
It is also ideal for clinicians seeking a refresher or for those preparing for recertification exams. Product details Format Paperback pages Dimensions x x Back cover copy Praise for the previous edition: All trauma patients should be immobilized on a board with a cervi- cal collar.
Exam was nor- mal but for low back pain Fig. Exam was normal Fig. Past medical history is significant for bladder cancer. Spine trauma cases are often great for percutaneous or minimally invasive procedures.
Past medical history is significant for alcohol abuse. Case 4 A year-old man presents with acute neck pain after a minor motor vehicle acci- dent when he hit his head on the dash- board. Past medical history significant for prostatic hypertrophy. Lhermitte sign—neck flexion causes caudal electrical shocks. Myelopathy—upper motor neuron weakness. Magnetic resonance imaging MRI 2.
Evaluation 1. C8 and T1 radiculo- pathies may cause a partial Horner syndrome. Radiculopathy—neck and interscapular pain. Spurling sign—pressing the vertex of the head with the head ex- tended and tilted to the symptomatic side reproduces radicular pain C. Plating—probably useful for two. Posterior keyhole laminotomy with partial diskectomy for soft lat- eral disks—avoids the need for a fusion consider with professional singers 7.
Anterior cervical diskectomy and fusion—consider for patients who have significant weakness. Hard cervical collar—often used postop for 6 weeks. Useful medical therapy—oral steroids Medrol dose pack. Neuro- surgery Oral Board Review. Epidural steroids—not of clear benefit 5. Physical therapy for range of motion and traction exercises may be helpful. MRI and computed tomography CT better bony detail. Add lateral mass fusion to posterior decompression if no lordoses. Posterior decompression if more than three levels are symptomatic or the pathology is mainly posterior 4.
Caused by direct neural compression.
Rule out—Amyotrophic lateral sclerosis ALS. There may be a central cord syndrome.
Neurosurgery Oral Board Review.pdf
Avoid these medications if the patient is taking Metformin also stop it 3 days preop. If both anterior and posterior approaches are needed.
Myelography—may be helpful. Anterior cervical diskectomy and removal of osteophytes around canal and foramen 2. Less often—full corpectomies 3. B III. Most often occurs in young boys. A Axial computed tomgraphic bone window and B sagittal T2-weighted magnetic resonance imaging demonstrate C2—5 PLL calcification with cord compression. Ankylosing spondylitis 1. Associated with rheumatoid arthritis and HLA-B Decompress with anterior corpectomy followed by fusion b.
Ossified posterior longitudinal ligament OPLL 1. CSF leaks—common and should be treated with fibrin glue and lumbar drainage usually temporary Fig. Postsurgery—use a collar for 3 months c. Frequent cause of lower back pain with sacroiliac erosion B. Occiput—C2 fusion may be needed if C1 laminectomy is required for decompression or if the injury is unstable there are fre- quent C1 arch fractures.
Transverse ligament attachment becomes loose and symptoms are produced by a compressive pannus and instability Fig. Causes synovial proliferation with destruction of bone and ligaments 3. Before removing the halo ring. Down syndrome—patients often develop atlantoaxial dislocation and cervical stenosis.
Joints may be unstable. Many spinal levels may fuse. Dislocation may need to be reduced before surgery. Use a halo until the level is fused. Morquio syndrome—patients often develop atlantoaxial subluxation by hypoplasia of the dens and ligamentous laxity. Rheumatoid arthritis 1. May be necessary to perform a dens resection before or after stabilization g. Performed supine with head in neutral position ii. Basilar invagination—congenital condition with a fusion of C1 to the occiput i.
Remove anterior arch of C1 and dens with a drill and pitu- itary forceps vii. Basilar impression a. Close incision in one layer ix. Palpate anterior tubercle of C1. If reducible—usually no need for anterior decompression e. Degenerative condition with ventral compression of the spinal cord or lower brainstem by skull settling over the dens b. Most patients will require a fusion. Retract pharyngeal tissue as one layer after subperiosteal dissection with Bovie vi.
Clean mouth with Betadine iv. Place the Crockard retractor to move tongue caudally. Treatment—reduction with 7—15 lbs followed by transoral odontoidectomy and then occiput—C2 fusion d. Not reducible with traction. Treatment—transoral odontoidectomy i. Use Woodson elevator to push disk material down into the created trough. Posterolateral transpedicular approach—may be adequate exposure for some thoracic disks. Remove hemilamina above and below disk space as well as the facet joint.
Thoracoscopic approaches are gaining in popularity. MRI—most useful test. Complications—radicular artery injury.
Thoracolumbar junction—use left retroperitoneal approach avoid the liver 5. Middle T-spine—use right thoracotomy avoid the heart 3. Lateral extracavitary approach—allows better view of midline.
Cauda equina syndrome—saddle anesthesia and bladder and bowel incontinence or retention. Lower T-spine—use left thoracotomy Fig.
Transthoracic approach—best view for anterior pathology such as disk disease. Costotransversectomy—allows direct line of vision to extend more medially 1. Complications—pneumothorax and radicular artery injury C. Reverse straight leg raise—performed prone with flexed knees to test upper lumbar roots L2—4 3. Initiate dissection as above.
Upper T-spine—use transsternal approach 2. Straight leg raise Lasegue sign —performed supine with leg straight to test lower lumbar roots L5—S1 2.
Indications for early surgery—significant weakness. Nerve conduction velocity NCV test—needed though rarely to distinguish radiculopathy from neuropathy C. Useful medical therapy—same as for cervical disk disease 3. CT-myelography—reserved for more subtle pathology 5. Gold standard procedure—microdiskectomy. Lumbar epidural steroid injections—may be helpful 5. Physical therapy—to strengthen abdominal and back muscles will help prevent future back problems 4.
Pulmonary embolism 9. Positioning pressure sore 6. Extrafacet approach with dissection over the lateral facets and transverse processes to find the nerve root and disk under the intertransverse ligament c.
Vessel injury rarely —aorta and vena cava bifurcate into iliac ves- sels at L4 Arachnoiditis—central adhesive nerve root cords or roots adherent to the dura seen on MRI 7. Deep infection—usually requires debridement with closure over a drain a. For an extraforaminal lateral lumbar disk. Superficial infection—treat with antibiotics Evaluate the infection with complete blood count CBC.
Deep vein thrombosis DVT 8. Iliac crest may need to be drilled down to reach the extruded disk D. Hemilaminotomy to identify the nerve root followed by a com- plete facetectomy until the disk is identified consider fusion if taking entire facet b. Complications 1. Conservative management as with disk disease. Vertically aligned facets—more likely to become unstable 4. Posterior lumbar interbody fusion PLIF cages—may be placed to augment a posterior fusion with a tall disk space.
Similar to lumbar disk disease symptoms but usually with a more insidious onset 2. Lumbar fusion—best performed with pedicle screws augmenting a bony lateral fusion over decorticated transverse processes 6.
Thigh pain—can be caused by trochanteric bursitis or hip arthritis. Dysplastic 3. ALIF is typically reserved for discogenic back pain confirmed by discogram. May Have a Pars Defect A. Pedicle screws—usually 5. Isthmic—little degenerative changes. Evaluation—same as lumbar stenosis with flexion—extension x-rays to rule out instability and oblique films to evaluate pars.
Incision for ALIF placement is at the lateral edge of the rectus abdominis with a retroperitoneal dissection and great vessel mobilization. Pathologic C. Spondylolysis refers to the defect without subluxation.
Traumatic 5. Spondylolisthesis varieties 1. Complications—same as lumbar disk disease complications 1. Should be aimed 20 degrees medial at L5. Spinal cord tumor. Treatment—as with lumbar stenosis with the addition of pedicle screws though some reports suggest fusion not needed because most cases of degenerative spondylolisthesis do not slip more after decompression Fig.
Symptomatic spondylolysis back pain 1. Spinal cord compression—disk. Evaluation—MRI C. Evaluation—dynamic studies and local injections into the pars to determine if this is indeed the pain source 2. Treatment—consider repairing the pars directly with a screw avoid- ing a fusion or performing the traditional fusion most common treatment VIII. Refractory cases may be treated with radiofrequency facet dener- vation. Evaluation—MRI rule out tumor or infection and dynamic x-ray rule out instability and may be tender to palpation over facets C.
Tibial nerve L5. L4 radiculopathy should have sensory loss from knee to medial malleo- lus not anterior thigh. Superficial peroneal nerve L4. Spinal cord cerebrovascular accident CVA —aortic dissection F. Transverse myelitis E. S1 —foot inversion and plantar flexion with sensation to the sole of the foot D.
Sciatic nerve injury proximal to the peroneal division produces flail foot no plantar. L5 proximal branches—gluteus medius L4. Deep peroneal nerve L4. Syphilis—tabes dorsalis G. ALS—tongue fasciculations. Thigh adductors—not weak with a femoral neuropathy. Case 7 A year-old man presents with progressive low back pain LBP after a fall 2 days ago.
Exam found intact. Postop leg pain should prompt search for DVT. Past medi- cal history is significant for cer- vical fracture 2 years prior.
Neurosurgery Oral Board Review.pdf
There are various interspinous devices on the market for treating lumbar stenosis and instability. Be careful operating on ankylosing spondylitis—prepare for poor bone quality and significant bleeding. Most degenerative spine disorders improve with medical therapy first! Exam was negative Fig. Legs get weak after walking and improve with leaning forward. Past medical history is significant for obesity. Past medical his- tory is significant for obesity.
T1-weighted magnetic resonance image demonstrates enhancing nodular mass filling the distal spinal cord. Neurosurgery Oral Board Re- view. Sagittal- Infused. Lesions of the cauda equina—section the upper filum first to pre- vent retraction Fig.
Treatment—surgical resection. Ependymoma—the most frequent tumor in the lower spinal cord 1. Multiple myeloma an isolated lesion is called a plasmacytoma 1. Treatment—surgical resection D. Neuro- pathology and Neuroradiology: Astrocytoma—more common in children and in the upper spinal cord.
Vertebral hemangioma 1. Evaluation—urinalysis Bence Jones protein. B Intramedullary juvenile pilocytic astrocytoma. Hemangioblastoma—usually cystic with a vascular mural nodule and located near the cord surface 1.
Treatment only if symptomatic —XRT. Treatment—XRT and chemotherapy. T1-weighted magnetic resonance images demonstrate the enhancing tumor with the associated syrinx extending into the brainstem. A Sagittal. Exam was positive for bi- lateral L1 sensory loss Fig. Embolize large metastatic tumors preop. Steroids and XRT—30 Gy over 10 days. Metastatic tumors 1. Neuromonitor all cases with SSEPs. Extramedullary tumors are typically benign.
Surgery—indicated for unknown diagnosis. Previous medical history is unremarkable. Intramedullary ependymomas typically have a good resection plane. Exam revealed a T5 sensory level. Previous medical history is significant for obesity. Previous medical history is significant for hyper- tension. Causes progressive myelopathy 4. Foix-Alajouanine syndrome—subacute necrotizing myelitis due to venous hypertension B.
Type I—dural artery to a spinal vein in a foramina 1. Evaluation—magnetic resonance imaging MRI and angiography 1. Frequently hemorrhages E. Usually occurs in older men 3.
Treatment—endovascular embolization of feeding vessel or open coag- ulation and division of feeding vessels. Occurs in younger patients 2. Carries a worse prognosis D. Noncommunicating—trauma or tumor C. Charcot joint. Rarely develops into a sarcoma C. Evaluation—increased serum alkaline phosphatase. Other types of syrinxes—treat by local decompression if possible or syringoperitoneal shunting midline or dorsal root entry zone incision with gauge tubing 2.
Type I AVMs—radicular artery can be divided or clipped on the foramen. Occurs in the skull. Communicating—central canal is patent i.
Syringosubarachnoid shunting—less successful III. Chiari malformation. Cause—increased resorption of bone and replacement with irregular weak bone B. Treatment—antibiotics and immobilization Fig. Risk increased in the obese.
Telusuri video lainnya
Causes—usually due to staph rather than strep. Treatment—antibiotics and immobilization. Closing over a drain or packing 4. Surgical debridement 3. Culture-guided antibiotics—14 days for superficial infection 2.
Plastic surgery closure—consider for infection extending down to the bone V. Causes—staph and strep B. Causes—usually staph. Cause—usually S. Previous medical his- tory is significant for uncomplicated lum- bar diskectomy 2 months before presen- tation and diabetes mellitus.
Exam revealed new right foot drop Fig. T2-weighted magnetic reso- nance image of the thoracic spine demonstrating Pott disease with diskitis and osteomyelitis at T7 and 8. For infection. Case 13 A year-old presents with progressively worsening back pain. Neuropa- thology and Neuroradiology: Helpful Hint 1. Consider repeating biopsies. Exam revealed cape-like loss of pain temperature from T1 to T9. Exam was remarkable for increased reflexes in his legs.
Previous medical history is significant for a motor vehi- cle accident 10 years ago with tempo- rary leg weakness. There is no previous medical history. Located two fingerbreadths above the zygomatic arch and two finger- widths behind the frontal process of zygoma Fig. Located over the transverse—sigmoid junction Fig. Hand- book of Neurosurgery. Junction of frontal.
Junction of lambdoid. The Wernicke receptive speech area also includes the supramarginal gyrus that caps the sylvian fissure. Junction of coronal—sagittal suture IV. Expressive speech center located in inferior frontal gyrus pars opercu- laris behind the pars orbitalis and triangularis. Located just above the pinna. From inferior orbit to top of external acoustic meatus EAM V.
Midmastoid up rostrally perpendicular to baseline Frankfort plane VI. Top is 2 cm behind nasion—inion line 3—4 cm behind coronal suture. Superior orbital vein D. Pterygopalatine branch of the maxillary nerve D. Structures passing above it include the lacrimal nerve. Zygomatic nerve C. V1 all three branches: Infraorbital artery and vein E. CN V2 B. Orbital branch of the middle meningeal artery E. Recurrent meningeal branch of the lacrimal artery XII.
Inferior ophthalmic vein XIII. Sympathetic fibers from the internal carotid artery ICA plexus C. Skin incision may be horseshoe anterior and posterior to the ear. Distal to the C1 foramina transversarium. Enters the foramen transversarium at C6 B. Consider a lateral or supine patient position b. Temporal lobe lesions 1. Comprehensive Neurosurgical Board Review. Key Points a. Be careful with the uncus preserve medial arachnoidal plane near tentorium to avoid CN3 and PCA and middle cerebral ar- tery MCA branches in the sylvian fissure stay in a subpial plane B.
Enter through the inferior or middle temporal gyrus and spare the superior temporal gyrus d. We prefer a linear incision to a horseshoe incision in this and most procedures.
Lateral ventricle atrium trigone —patient in lateral position. Body of lateral ventricle—patient in supine position.
Third ventricle—patient in supine position. Frontal horn of lateral ventricle—patient in supine position. Be careful with superior sagittal sinus retraction. Disconnection syndrome more likely with posterior incision through the splenium 5.
Jonathan Stuart Citow, MD
Anterior fossa skull base—for olfactory groove meningiomas. Patient in supine position Fig. Incise only 2. Fenestrate the lateral ventricle and then proceed into the third ventricle via an interforniceal approach or extend the foramen of Monro posteriorly by opening the choroidal fissure.
Dissection over the temporalis muscles should be in the interfascial plane or below the fascia when the fat pads are reached to avoid injuring the frontalis branch of the facial nerve. The scalp flap should be dissected forward above the pericranium to provide a vascularized flap for closure.
Bicoronal incision is made connecting the two zygomatic arches Soutor incision allows easier skin closure. Frontal sinus should be cranialized by removing the posterior wall and removing the mucosa.
Frontal ostium should be plugged with muscle. Blood supply is usually under the lesion. Burr holes are placed at the keyholes and around the anterior su- perior sagittal sinus. Horseshoe incision is fashioned from the base of the mastoid. Transpetrosal approach—used to expose anterior or lateral lesions from the midbrain to the lower pons i.
Patient positioned with falx parallel to floor usually lateral. At closure. Cerebrospinal fluid leak CSF should be treated with a lumbar drain and intermittent skull x-rays to watch for pneumocephalus. Outer dura should then be closed in a water-tight fashion. Transverse sinus is usually under the superior nuchal line. Close with a fat graft. The exposure will not reach lesions below the jugular foramen. Remove the boomerang-shaped bone flap 9. Do not dissect across the sinus with a Penfield 3.
Burr holes are placed on both sides of the transverse and sigmoid sinuses. Maximize bony removal to minimize brain retraction With permis- sion from Citow JS. Open the presigmoid dura and divide the superior petrosal sinus Locate the trochlear nerve under the tentorium Locate the asterion junction of the parietomastoid.
Greater occipital nerve may be identified under sternocleiodo- mastoid muscle and followed down to the C2 nerve root. Perforate methylmethacrylate if used as a skull replacement to decrease the fluid accumulation under the bone flap. Intraoperative brain swelling—consider edema. Vertebral artery is identified at the superior C1 transverse arch as it pierces the dura to move up the foramen magnum.
Incision is made over the spinous processes of C1—C3 and curved laterally over the mastoid bone. Patient positioned supine. Complications—injury to the CNs. Vertebral artery is mobilized from the C2 arch to the foramen mag- num and retracted medially Fig. Anterior foramen magnum lesions—consider transoral approach see Rheumatoid Arthritis section. C1 hemilaminectomy is performed and the foramen magnum is opened. Consider what neural structures should be monitored or localized.
Always consider placement of an occipital Frazier burr hole with posterior fossa surgery Helpful Hints 1. Consider how to neuronavigate 4. Thieme Medical Pub- lishers. Evaluation—intraoperative ultrasound 2. Standard craniotomy preop: Plan dural closure for skull base approaches e. Past medical history is significant for poste- rior fossa tumor resection 5 years earlier. Past medical history and exam were unre- markable Fig.
Case 16 A year-old woman presents with a mild. Past medical history is signifi- cant for smoking history. Exam re- vealed bitemporal heteronymous hemianopsia Fig. Eye opening—none 1. Cerebrospinal fluid CSF drainage.
Motor function—none 1. Verbal output—none 1. Insert Swan-Ganz catheter and nasogastric NG tube for hyper- alimentation 6. Carafate or Pepcid C.
Produces hypotension by decreasing sympathetic tone and causing myocardial depression 4. Tube feeds after 3 days. Fever control—cooling blanket and rectal Tylenol B. Decreases free radicals 3. Sedation and paralytics D. Pentobarbital coma 1. Avoid mannitol with congestive heart failure or renal failure C. Increase dose until burst suppression achieved on electroencepha- logram EEG 5.
Maintain euvolemia and normokalemia 3. Have blood available XI. Use anti-epileptic e. Use question mark or linear incision but be sure to expose low enough to reach foramen spinosum middle meningeal artery C. Consider placement of ICP monitor if there is also cerebral edema D.
Consider an angiogram to rule out vessel injury for lesions crossing the sylvian fissure or interhemispheric fissure E. Shave around the wound. Monitor ABCs airway. B2-transferrin—found only in CSF. Otorrhea—CSF leak requires perforated tympanic membrane C. May calcify 4. Rhinorrhea—CSF may travel from middle ear through eustachian tube to nasopharynx or directly through cribriform plate to nasopharynx B.
Surgical evacuation for cosmesis is performed after 6 weeks. For management guidelines for sports-related concussions. Subgaleal hematoma—does not calcify. Subperiosteal hematoma 1. Occurs mainly in newborns and is limited by sutures 2. Transient confusion B. Symptomatic neurologic or pain-producing abnormalities about the foramen magnum e.. No LOC C.
Permanent CNS sequelae from head injury e. Persistent postconcussion symptoms B. American Academy of Neurology. Chiari malformation Abbreviations: Hydrocephalus D. No LOC B. Spontaneous SAH from any cause E. Consider ending all par- ticipation in contact sports. Disallow return that day C. Ambulance transport from field to ER if still unconscious or for concerning signs C-spine precautions if indicated B.
Return to play in any contact sports in the future should be seriously discouraged. Examine on-site frequently for signs of evolving intracranial pathology D. May return to contest if symptoms clear within 15 min 2 Moderate A. Prolonged unconsciousness. Reexamination the next day by a trained individual E.
Admit to hospital for any signs of pathology or for continued abnormal mental status E. Remove from contest B. Emergent neuro exam. Assess neuro status daily until all symptoms have stabilized or resolved F. May go home with head-injury instructions if normal findings at time of initial neuro exam D. Leak site—localize with coronal thin-cut CT of anterior fossa to sella or with CT cisternography with iohexol lumbar puncture LP injec- tion followed by Trendelenburg position prone D.
Be aggressive with temporal prepare for middle meningeal artery bleeding and posterior fossa hematomas prepare for sinus in- volvement. Bed rest. Rule out nonsurgical causes of depressed consciousness.
ABCs first 2. Make sure spine is evaluated 3. Prophylactic antibiotics—not proven helpful 3. Past medical history is significant for bipolar disorder. Past medical history is signifi- cant for cocaine abuse. Past medical his- tory is unremarkable. PCV chemotherapy. Cytoreductive surgery—image-guided surgery suggested 2.
Gliadel carmustine [BCNU] wafers—increase survival by 8 weeks 5. External beam radiation—typically 60 Gy at 2 Gy fractions 5 days a week. Karnofsky score. Temodar—an oral alkylating agent that increases median survival— from 12 to 14 months when given concurrently with radiation therapy 4. Prognosis—depends on age younger is better. Avastin—an anti-VEGF agent may increase survival minimally 6. Radiation dose. Usually with surgery alone curative if juvenile pilocytic astro- cytoma 2.
Surgery 2. Treatment—surgery only. Surgery—avoid if tumor is bilateral. Per grade—1 10 years. Survival 1. Average—17 weeks with biopsy. XRT—50 Gy to the tumor bed. Survival—tumor is usually very radiosensitive. Evaluate for drop mets with all varieties 2. If tumor resection does not relieve hydrocephalus—place ventriculo- peritoneal VP shunt or perform third ventriculostomy penetrate floor of third ventricle anterior to mamillary bodies.
Tumor varieties a. Chemotherapy—CCNU and vincristine 4.
XRT—radiate craniospinal axis after resection. BHCG—choriocarcinoma and germinoma B. Surgical resection for medulloblastoma a. Germ cell—most common.
Treatment—surgery alone VIII. Usually safe to divide the precentral cerebellar vein c. Avoid performing a stereotactic biopsy due to the hazard of adjacent vessels unless you are comfortable with third ventricular biopsy 3. Germinoma may be treated with biopsy followed by radiation and chemotherapy. Not as easy with a steep tentorium b. Risk of visual loss. Operative approaches 1. Operative window—between the two basal veins of Rosenthal Fig.
Transcallosal—minimalize to avoid disconnection syndrome 4. Best for tumors above the tentorial edge and vein of Galen Fig.
Operative window—between internal cerebral vein and basal vein of Rosenthal 3. Not an emergency if asymptomatic 4. Transventricular—through the nondominant superior temporal gyrus IX. One third of prolactin-secreting adenomas will hemorrhage. Incise the tentorium 1 cm lateral to the straight sinus d.
Peripheral neuropathy. Decreased GH—dwarfism f. Bitemporal hemianopsia 2. Cavernous sinus invasion—impaired cranial nerves CNs. May also be seen with hepatic or renal disease. Increased growth hormone GH i. Decreased thyroid stimulating hormone TSH —cold intolerance. Increased somatomedin C—synthesized in the liver and produces IGF-1 ii. Decreased ACTH—orthostatic hypotension and fatigue d. Somatostatin decreases GH release. Acromegaly—coarse facial features. Increased adrenocorticotropic hormone ACTH —increased serum and urine cortisol.
Low dose of 1 mg—normally decreases ACTH b. May be caused by primary hypothyroidism elevated TSH. May be caused by pregnancy also with amenorrhea and increased prolactin ii. There is no suppression with an ectopic tumor 6.
Morning cortisol. Dexamethasone suppression test a. ACTH—decreased with adrenal tumor. Decreased antidiuretic hormone ADH —diabetes insipidus very rare with a sellar mass C. Rapid-sequence infused MRI—may demonstrate location of a small adenoma D. MRI a. Petrosal sinus sampling—has been used to evaluate the location of an ACTH-secreting tumor. Enlarged pituitary gland on MRI i. Endocrine history as above. Starting dose—2.
Dostinex is another medical option. Postop steroid withdrawal is a good sign. Lifelong therapy needed to control tumor growth c. Surgical resection—best option b. If tumor enlarges during pregnancy. Acromegaly a. IGF-1 levels usually drop 4 weeks after surgery. Surgical resection—best option. Consider transsphenoidal or subfrontal resection if medical ther- apy fails. Cushing disease a. Safe to take oral contraceptives OCP with bromocriptine and safe to take bromocriptine while pregnant g.
Ketoconazole may be used to temporarily lower cortisol levels. Bilateral adrenalectomy—last resort patient may develop Nel- son syndrome 4.
Hyperthyroidism—surgical resection favored over octreotide 5. Watch for low estrogen—may cause osteoporosis f.
Follow patient with visual field examinations i. Postop MRI should be done at 3 months. Visual loss may occur. Surgery—subfrontal or transsphenoidal a. Transnasal transsphenoidal—most common approach i. In a submucosal plane. Consider only if unable to reoperate 6. Insert the Cushing speculum and finally the Hardy specu- lum. A newer approach is to insert the speculum directly to the floor of the sphenoid sinus.
A lumbar drain may be inserted and air injected to help push the tumor down during resection. Insert a throat pack. Diabetes insipidus DI. Antibiotics—use until the packs are removed at 3 days chloram- phenicol and ampicillin as well as a hydrocortisone stress dose fol- lowed by a replacement dose mg intravenously every 8 hours.
CSF leak—treat initially with a lumbar drain and if this is unsuc- cessful, consider exploration and packing.
Carotid injury with pulsatile bleeding—should be treated with packing followed by an angiogram to determine if bypass or endo- vascular treatment occlusion, stenting, etc. Subtotal resection—appears to be the best treatment unless com- plete removal can be safely achieved , followed by XRT. Surgical management—stereotactic aspiration or open transcallosal resection remember to fenestrate the septum pellucidum.
Surgical pitfalls—damage to anterior cerebral artery, cingulate gyrus, fornix, internal cerebral veins; enter wrong ventricle; intra- ventrical hemorrhage.
Preop—remember to consider dural patch material autograft or synthetic , dural sinus patency, and possibility of emboliza- tion may cause distant strokes. Treatment—if asymptomatic, consider following with MRI evaluation every 6 months Fig. Middle fossa approach—for small intracanalicular tumors distal in the canal. Use intraop 8th brainstem auditory evoked response [BAER] , 7th, and 5th nerve monitoring.
C D Fig. D Vestibular schwannoma exposure via suboccipital—retrosigmoid craniotomy. Thieme Medical Publishers; Place the patient semiprone 45 degrees or lateral with the falx parallel to the floor.
Incision is the length of the pinna and located 2 cm posterior to the mastoid notch. A burr hole is made at the asterion and a small craniotomy fash- ioned after eggshelling edge of transverse and sigmoid sinuses. Dura is opened with triangular flaps based on the transverse and sigmoid sinuses.
Cerebellum is gently and slowly retracted medially to expose the CNs. Facial palsy—if unable to close eyes, use natural tears q2h, Lacri-Lube, and tape eyes shut qHs.Winn HR.
Evaluation—same as lumbar stenosis with flexion—extension x-rays to rule out instability and oblique films to evaluate pars. Being comfortable with the rela- tively fast format will greatly help you. Key Points a. XRT—radiate craniospinal axis after resection.
Admit to hospital for any signs of pathology or for continued abnormal mental status E. Surgery—subfrontal or transsphenoidal a. Lumbar epidural steroid injections—may be helpful 5.
- BIHAR BOARD 10TH RESULT 2013 PDF
- PHARMACOLOGY EXAMINATION AND BOARD REVIEW PDF
- BOARD BOOK BANGLADESH
- GAME OF THRONES BOARD GAME PDF
- CIVIL SERVICE EXAM REVIEWER PDF
- PHILIPPINE CIVIL SERVICE EXAM REVIEWER PDF
- ROBBINS AND COTRAN REVIEW OF PATHOLOGY 4TH EDITION PDF
- CLINICAL REVIEW OF ORAL AND MAXILLOFACIAL SURGERY PDF
- GUYTON AND HALL PHYSIOLOGY REVIEW PDF