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Back to Basics for Surgery Neurosurgery

Back to Basics for Surgery Neurosurgery. R. Moulton. Principles of Neurological Diagnosis. Questions. What is the lesion Where is the lesion. History Physical (Neurological) Examination Special Tests. Presentation of Neurosurgical Illness. Raised ICP Headache, vomiting papilloedema

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Back to Basics for Surgery Neurosurgery

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  1. Back to Basics for SurgeryNeurosurgery R. Moulton

  2. Principles of Neurological Diagnosis

  3. Questions • What is the lesion • Where is the lesion

  4. History • Physical (Neurological) Examination • Special Tests

  5. Presentation of Neurosurgical Illness • Raised ICP • Headache, vomiting • papilloedema • Neurological Dysfunction • General – level of consciousness • Focal – sensory or motor loss • Seizures • Pain

  6. What is the lesion – history • Where is the lesion – neurological exam

  7. History (What is the lesion?) • Symptoms • Mode of onset • Speed of onset • Prior relevant illness • Progression/regression of symptoms

  8. Neurological Examination (Where is the Lesion?) • Level of Consciousness – GCS • Mental status – orientation, memory, concentration, abstraction, calculation • Cranial Nerves • Motor examination • Upper vs. lower motor neuron • Cerebellar function • Gait • Sensory examination • light touch, pain & temp, joint position sense • Cortical sensory modalities

  9. Cranial Nerves • I Olfactory • II Optic • III Oculomotor • IV Trochlear • V Trigeminal • VI Abducens • VII Facial • VIII Acoustic • IX Glossopharyngeal • X Vagus • XI Accessory • XII Hypoglossal

  10. Motor Examination • Upper Motor Neuron • Weakness (distal > proximal) antigravity muscles preserved • Increased reflexes and tone (spasticity) • Disuse atrophy • Loss of coordination (ataxia) • Apraxia • Upgoing plantar response

  11. Lower Motor Neuron • Weakness • Decreased tone • Decreased reflexes • Denervation atrophy • Coordination usually intact

  12. Sensory Examination • Special senses – cranial nerves • Basic Modalities • Light touch, pain & temp, vibration & proprioception • Dermatomes, peripheral nerve distribution • Cortical Modalities • Graphaesthesia, stereognosis, simultaneous appreciation of tactile stimuli, somatotopognosis, agnosagnosia, neglect

  13. Special Tests • Biochemical, hematological, microbiology • Blood • CSF • Imaging • Plain x-rays • CT • MRI • Angiography • Electrophysiology • EMG, nerve conduction, EEG etc.

  14. Neurological Examination of the Comatose Patient • Level of Consciousness • Glasgow Coma Score • Brainstem Integrity • Pupillary Reaction • Ocular Movement • Corneal reflexes • Gag/breathing

  15. Eye Opening spontaneous 4 to voice 3 to pain 2 none 1 • Verbal Response oriented 5 confused - sentences 4 words only 3 sounds 2 none 1 • Movement obeys 6 localises 5 flexion withdrawal 4 abnormal flexion 3 extension 2 none 1

  16. Rostral-Caudal Deterioration • Midbrain • Bilateral pupillary abnormalities • Oculomotor abnormalities • Pons • Loss of corneal reflexes • Medulla • Loss of gag reflexes • Respiratory and vasomotor collapse

  17. Brain Tumour Classification • Intra-axial (frequently malignant) • Primary • Glial • Choroid plexus • Neuronal or mixed glial-neuronal • PNET/medulloblastoma • CNS lymphoma • Pineal region • hemangioblastoma • Metastatic

  18. Brain Tumour Classification • Extra-axial (usually benign) • Meninges • Cranial nerves (Schwannoma) • Pituitary • skull

  19. Glial Tumours • Astrocytoma (gliobastoma multiforme) • Oligodendroglioma • Ependymoma • Mixed tumours • Gr. I - IV

  20. Treatment • Supportive • Specific • Corticosteroids (dexamethasone) • Surgical • Biopsy • Excision • Internal decompression

  21. Treatment contd. • Radiotherapy • Conventional • Stereotactic focused • Chemotherapy • Temazolamide (malignant glial tumours) • Lymphoma protocols • Specific to tissue of origin for metastases • Observation

  22. No Contrast With Contrast

  23. Stroke: Classification and Management

  24. Stroke Definition • Sudden onset of a neurological deficit due to disease or injury of the blood supply of the brain.

  25. Stroke Classification • Ischemic • Bland • Hemorrhagic transformation • Hemorrhagic (hemorrhage is 10 event) • Hypertension • Amyloid angiopathy • Aneurysmal • AVM • Other

  26. Ischemic Stroke (Infarction) • Thrombotic (local vessel disease) • Embolic • Artery to artery (usually carotid) • Heart to artery (atrial fibrillation) • Paradoxical (vein to artery) • Other (air, foreign body, iatrogenic)

  27. Intracerebral Hemorrhage • Hypertensive • Occurs in long narrow perforating arteries (basal ganglia, thalamus, pons, cerebellar nuclei) • Charcot-Bouchard aneurysms • Related primarily to duration of hypertension

  28. Intracerebral Hemorrhage • Amyloid angiopathy • Age related change in cerebral vessels • Lobar hemorrhage • Most commonly in posterior part of cerebral hemispheres

  29. Intracerebral Hemorrhage • AVM • Berry aneurysm • Subarachnoid hemorrhage • Usually exclusively subarachnoid • May have intracerebral component • Occasionally exclusively intracerebral

  30. Management • Diagnosis • History • Physical Examination • Special tests (imaging) • Treatment

  31. Stroke Diagnosis • History • Rapid onset fixed deficit – ischemic • Rapid onset progressive deficit – hemorrhage • Sudden severe headache, nausea/vomiting/photophobia +/- neurological deficit - SAH

  32. Stroke Physical Examination • Focal deficits • Most often ischemic stroke or ICH • Much less common in SAH • Alteration in level of consciousness • SAH • ICH • Delayed swelling from large infarcts

  33. Stroke Investigation • CT scan • First line imaging to distinguish infarct from hemorrhage • 1st choice for confirming SAH, LP if negative • Other • Cerebral angiography, doppler for carotids • MRI in special circumstances

  34. Acute Stroke Treatment • Supportive • Airway • Blood pressure • Definitive • Thrombolysis • Hematoma evacuation (limited circumstances)

  35. Prevention Risk factor modification Hypertension, smoking, diabetes, lipids/cholesterol Antiplatelet agents (artery-artery embolism, local occlusive disease) Anticoagulation (heart to artery emboli) Surgical prevention Carotid endarterectomy, stenting Aneurysm obliteration AVM excision Stroke Treatment

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