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103 Cards in this Set

  • Front
  • Back
What lies just in front and just behind the central sulcus (sulcus of Rolando)?
• in front lies the primary motor strip
• behind lies the primary sensory strip
What portions of the brain are contained in the supratentorial and infratentorial space?
• supratentorial space is occupied by both cerebral hemispheres
• infratentorial compartment contains the brain stem and cerebellum
What is the opening at the base of the skull that allows the brain stem to connect to the spinal cord?
formamen magnum
Which cranial nerves arise from the midbrain, pons, and medulla?
• Midbrain: CN III, IV
• Pons: CN V, VI, VII, VIII
• Medulla: IX, X, XI, XII
What are the major terminal branches of the external carotid artery?
• superfical temporal artery (just in front of the ear)
• occipital artery (just behind the ear)
Which arteries supplies the largest volume of blood flow to the brain is the most common distribution to receive a vascular embolus?
middle cerebral artery
What is the role of CSF?
• provides structure and cushion
• helps maintain and regulate cerebral and systemic homeostasis
CSF from the lateral ventricles drains to the 3rd ventricle through which structure?
foramen of Monroe
CSF drains from the 3rd to 4th ventricle through which structure?
aqueduct of Sylvius
What are the structures that allow CSF to exit the ventricular system?
• a single medial foramen of Magendie
OR
• laterally via two framina of Luschka
Name and describe the various types of cerebral herniations
• Transtentorial: tissue moving downward from the supratentorial space through the tentorial incisura into the infratentorial space

• tonsillar: tissue moving from the posterior fossa through the foramen magnum

• subfalcine: tissue moving from one side of the supratentorial space to the other under the falx cerebri

• upward central: tissue moving upward from the infratentorial space through the tentorial incisura into the supratentorial space

• herniation of tissue outside the skull through a craniotomy or traumatic skull defect
What are the 5 components of the neurologic examination?
• mental status
• cranial nerves
• cerebellar function
• motor & reflex function
• sensory function
Corneal reflex evaluates which cranial nerve?
trigeminal (CN V)
How do you rate reflexes during physical exam?
scale from 0-4
• O: absent reflex
• 1: weak reflex
• 2: normal reflex
• 3: overly active reflex with up to 1-3 beats of clonus
• 4: reflex associated with more sustained clonus
What is the Hoffman response?
finger flexion response with sudden flexion of the distal interphalangeal joint
What is the most common CNS herniation syndrome?
transtentorial herniation
What are some physical manifestations of transtentorial herniation?
• dilated pupil on the the same side of the lesion (due to downward pressure on the CN III)
• contralateral hemiparesis (due to pressure on the cerebral peduncles)
• unconsciousness (due to pressure and torsion on the midbrain & reticular-activating system)
What are some clinical manifestations of central downward herniation (tonsillar herniation)?
• loss of consciousness
• bradycardia and hypertension (Cushing's reflex) & Cheyne-Stokes respirations due to medullary cardiorespiratory dysfunction
What are physical manifestations of a subfalcine herniation?
• the cingulated gyrus moves underneath the falx cerebri over the corpus callosum putting pressure on the anterior cerebral artery

• causes contralateral lower-extremity monoparesis
What is the most common cause of diabetes insipdus?
iatrogenic disruption of the hypothalamus or pituitary stalk after surgery for hypothalamic or pituitary tumors
At what spinal vertebrae are lumbar punctures often performed?
L4-L5 or L5-S1
What are the diagnostic study of choice of neurosurgical emergencies?
CT scan
What are the diagnostic procedure of choice for neurooncology and stroke neurology?
MRI scan
What are different options for medical treatment of increased intracranial pressure?
• elevation of head
• hyperventilation (PCO2 30-35 mm)
• maintain normal volume
• osmotic diuretics (mannitol)
• renal diuretics (Lasix)
Why is hyperventilation used only on a temporary basis in an acute herniation?
can potentially cause ischemia to an already injured brain
What are two ways to monitor intracranial pressure?
• ventriculostomy
• intraparenchymal fiberoptic pressure probe
Which is the preferred method of monitoring ICP?
ventriculostomy because it is therapeutic at the same time that it provides the necessary ICP data
What does a ventriculostomy consist of?
• a percutaneous Silastic tibe inserted through a burr hole in the skull that courses through brain tissue to the lateral ventricle
• provides a continous column of fluid from the ventricular CSF to an external drainage system
Why should neuronal metabolic demands be minimized in patients with head injury?
• high metabolic demand could lead to supply-demand mismatch of nutrients
• can cause potential neuronly injury in the setting of decreased cerebral blood flow
• phenytoin (by preventing seizures) and barbituate comas can reduce neuronal metabolic demand
What is a concussion?
• a clinical syndrome of temporary global brain dysfunction
• can be inferred from a history of brief loss or period of anterograde or retrograde amnesia
When do closed crainal vault fractures require surgical exploation?
• depression is greater than the crosssectional width of the skull
• occurs in a cosmetically obvious area (ex. forehead)
• associated with an underlying mass lesion that needs to be excised
• associated with an area of intracranial air suggesting dural penetration
What are diastatic fractures?
fractures with a gap between the fracture edges
Subdural hematomas are common in which patients?
• elderly patients: have an accentuated distance between their brain and dura due to cerebral atrophy
• patients taking anticoagulant medications
When does a subdural hematoma not require surgical evacuation?
• when the hematoma is small (< 30 mL volume) and the patient is doing well clinically
• can be treated conservatively with careful follow-up, neurologic examination, and serial CT scanning

* majority of subdural hematomas will naturally resorb
What is carotid-cavernous fistula?
• when arterial blood epmties directly into the cavernous sinus venous spaces

• can be caused by interal carotid artery damage in the cavernous sinus

• can cause injection & chemosis of the conjunctiva, pulsating exophthalmos w/ a bruit, elevated intraocular pressure from venous congestion, and cranial nerve dysfunction
What are the two types of incracerebral hemorrhage?
• spontaneous intraparenchymal hemorrhage
• subarachnoid hemorrhage
Most TIAs result from either artery-to-artery emboli or cardiac origin emboli. What is the most common source of artery-to-artery emboli?
athersclerotic plaque at the carotid bufurcation
What are causes of intraparenchymal hemorrhage?
• amyloid angiopathy
• AVM rupture
• cerebral infection
• coagulopathy
• drug abuse
• hemorrhage into a brain tumor
• hypertensive arteriolar disease
• vasculitis
What are characteristics of amyloid angiopathy?
• fragile cerebral arteries due to amyloid protein deposition in the vessel wall
• tend to be subcortical and lobar in location
• most commonly occurs in the parietal lobe (at the parietal-occipital junction)
What are potential curative treatment options for AVMs?
• high dose radiation (stereotactic radiosurgery)
• microsurgical excision
• endovascular embolization (rare)
Name the 2 types of cerebral edema
• Vasogenic edema
• Cytotoxic edema
Describe vasogenic edema
• occurs from an impaired function of the blood-brain barrier
• water and protein are transferred from the vasculature to the interstitial space
• manifests as focal neurologic deficits, disturbances in consciousness, & severe intracranial hypertension
Describe cytotoxic edema
• involves the actual swelling of brain cells due to increased intracellular fluid
• can be caused by hypoosmotic states, impairment of Na+/K+ pump
What is the most common histiology of metastatic brain tumor to present with a single lesion? with multiple lesions?
• single cell » renal cell carcinoma
• multiple cell » melanoma
What is the most common cranial nerve schwannoma?
vestibular schwannomas
Bilateral verstibular schwannomas are diagnostic for what genetic disease?
neurofibromatosis (type 2)
How do patients with vestibular schwannomas present initially and present as the tumor grows?
• patient usually has a history of unilateral tinnitus with vertigo that disappears as the vestibular nerve is destroyed
• tumor grows and puts pressure on the auditory nerve causing deafness
• can eventually involve the CN V causing facial numbness and loss of corneal reflex
• ultimately can cause cerebelar deficits and CN IX and X deficits
What are different ways to classify pituitary adenomas?
• functional (secretes hormones) vs. nonsecretory
• microadenomas (< 1 cm diameter) vs. macroadenomas (> 1cm diameter)
What are treatment options for secretory pituitary tumors?
• treat medically
- bromocriptine for prolactinoma
- somatastain for acromegaly
- ketoconazole for Cushing's disease

• treat surgically
- microsurgery
- endoscopoic trans-sphenoidal surgery
What is the most common pediatric brain during during the first 9 years? between ages 9-19?
• medulloblastoma is the most common tumor during the first 9 years
• pilocytic astrocytoma is the msot common from ages 9-19
What are some sources of cerebral abscesses?
• cardiac source (valvular or congenital heart disease)
• dental infection
• head trauma
• mastoiditis
• previous surgery
• sinusitis
What are the classic symptoms of a brain abscess?
• headache (most common ~ 70%)
• fever (less than 50%)
• focal neurologic deficits

* this triad is found in fewer than 50% of patients
What does a brain abscess look like on CT or MRI?
a uniform thin, enhancing wall surrounding a low-density core
What complication can lumbar puncture cause in patients with a mass lesion?
it decreases the pressure beneath a mass lesion and encourages transtentorial herniation
What is the treatment of choice for brain abscess?
stereotactic aspiration
What are the most common causes for viral encephalitis?
• primary HIV CNS infection
• primary CNS repetic encephalitis
• rabies
What is Klüver-Bucy syndrome?
• herpetic encephalitis characterized by bilateral temporal lobe involvement
• can lead to dramatic limbic system and behavioral symptoms
What are organisms commonly involves in fungal CNS infections?
• Actinomyces
• Aspergillus
• Blastomyces
• Candida
• Coccidioides
• Cryptococcus
• Histoplasma
• Mucormuces
• Nocardia
Which fungal infection is know for producing hemorrhagic encephalitis and areas of hemorrhagic infarction?
asergillosis
Which fungus produces a devastating, rapidly progressive, and usually fatal disease and involves the CNS by direct extention of sinus disease in patients with diabetes and poorly controlled blood sugar?
Mucormyces (ie. Mucormycosis)
List some parsitic infections of the CNS
• cysticercosis (acquired from eating poorly cooked, infested pork)
• echinococcosis (endemic in sheep-raising communities)
• toxoplasmosis (associated with HIV/AIDS)
What is a Collier's sign?
• aka sunset sign
• tonic conjugate downgaze caused by CN III interference from hydrocephalus
What are encephaloceles?
• herniations of malformed brain through defects in the skull
• most common are occipital and cerebellar emcephaloceles
List examples of primary epilepsy surgeries
• cortical ressections
• functional hemispherectomy
• partial corpus callosotomy
• standard temporal lobectomy
• selective amygdalohippocampectomy
• subcortical disconnections
What is HFS and what is its surgical treatment?
• hemifacial spasm is a progressive disorder of the facial nerve that leads to unilateral rhythmic facial twitching of the facial musculature

• surgical treament: posterior fossa cerebellopontine angle exploration with microvascular decompression of the centrally myelinated portion of the facial nerve
What are surgical treatment options for Parkinson's disease once medical treatment has become refractory?
• stereotactic lesioning of select areas of the globus pallidus (pallidotomy)
• stereotactic lesioning of select areas of the thalamus (thalamotomy)
• selective thalamic stimulation after stereotactic insertion of stimulator electrodes
What is normal pressure hydrocephalus?
• a clinical condition in which there is symmetric ventricular enlargement on CT or MR scan with normal iCP
• associated with a triad of symptoms (gait disturbance, incontinence, and dementia)
• improves or resolves with CSF diversion by VP shunting
Normal pressure hydrocephalus must be distinguished from what condition to avoid complications such as subdural hygromas and hematomas?
• ex vacuo ventriculomeagly resulting from gradual brain loss
• can be caused by multiple ischemic insults, previous traumatic injuries, primary neurodegernerative disorders)
What is currently the gold standard for assessing patients for normal pressure hydrocephalus?
• placement of a lumbar drain and setting it to withdraw CSF at VP shunt rates
• meanwhile, the patient is evaluated for gait by a physical therapist and cognitive function by a speech therapist
Which vertebrae are lordotic?
cervical and lumbar vertebrae
Which vertebrae are kyphotic?
thoracic and sacral vertebrae
The lemniscal sensory pathway is located in which portion of the spinal column and provide awareness of which sensations?
• runs dorsally in the dorsal columns
• provides vibration and joint position sense
Where are the pyramidal tracts located in the spinal column?
laterally
Where are the spinothalamic tracts located and what sensations does it relay?
• run anterolaterally on either side
• conveys pain and temperature sense
What is anterior spinal cord syndrome?
• leads to bilateral dysfunction of the spinothalamic pathways and pyramidal tracts with sparing of the lemniscal pathways

• leads to upper motor neuron findings and pinnsensation reduction or loss bilaterally below the level of the lesion

• spares joint vibration and position sense bilaterally
What is posterior spinal cord syndrome?
• leads to bilateral dysfunction of the lemniscal sensory pathways and pyramidal tracts

• spares the spinothalamic pathwyas

• leads to upper motor neuron finds and vibration and joint position sense reduction or loss bilaterally below the level of the lesion with sparing of pin sharpness appreciation bilaterally
What is Brown-Sequard Syndrome?
• aka lateral spinal cord syndrome

• leads to unilateral dysfunction of the lemniscal and spinothalmic sensory pathways as well as the ipsilateral pyramidal tract

• leads to ipsilaterael vibration and proprioception loss and contralateral loss of pain sensation below the level of the lesion
What is a Jefferson fracture?
• an axial load and compression fracture of the anterior and posterior arches of C1
• open-mouth c-spine views shows lateral spreading of the lateral masses of C1
Describe the 3 types of odontoid fractures
• Type 1: avulsion fractures of the odontoid tip
• Type 2: fractures occur right at the base of the odontoid
• Type 3: fracture goes down into the base of the body of C2
Describe a Hangman's fracture
• a bilateral pedicle fracture of C2
• usually from acute hyperextension injury
What is the most common mid-thoracic traumatic fracture?
vertebral body compression fracture
What are potential sequelae of spinal cord injry?
• decubitus ulcers
• DVTs
• pneumonia
• pulmonary emboli
• septicemia
• urinary infection
• urinary reflux
What are examples of degenerative diseases of the spine?
• disc herniation
• spinal osteoarthritis & stenosis
• spondylolisthesis
What causes degeneration of the intervertebral disc?
• the nucleus pulposus becomes desiccated due to age or recurrent trauma
• detected as a "black disc" on T2-weighted MRI
What is the treatment for disc herniation?
• conservative treatment:
- rest
- analgesics
- anti-inflammatory agents
- muscle relaxants

• surgical treatment:
- microscopic or endoscopic excision
What are causes of lumbar stenosis?
• progressive encroachment of the spinal canal from the ventral aspect (ex. disc degeneration, disc bulge, and reactive osteophyte formation

• from the posterior lateral direction (ex. facetal hypetrophy and arthropathy)
What are examples of vascular spine disease?
• AVMs
• dural A-V fistula
• epidural hematomas
• ischemic infarctions
What are some causes of spinal cord stroke?
• embolic occlusion of the anterior spinal artery
• flow-related ischemia due to significant systemic hypotension
• loss of a major segmental feeding artery (ex. artery of Adamkiewicz)
At what vertebral level is the spinal cord most susceptible to flow-related ischemia?
T4-T5 level
Name and describe the 3 groups of spinal tumors
• extradural tumors: arise from the osseous element of the spinal column

• intradural extramedullary tumors: arise from the dural shealth around the spinal cord OR from the Schwann cell sheath around the spinal roots

• Intramedullary tumors: arise from the glial element of the spinal cord OR from trapped ectodermal elements
What is the most common spinal tumor?
extradural tumors (usually metastatic)
What is the treatment for spinal cord compression from a metastatic tumor?
• immediate: high-dose IV steroids

• radiotherapy (if the patient is in good shape and the tumor is radiosensitive)

• surgical decompression (reserved for evidence of neurological deterioration)
What are examples of primary spine tumors?
• intradural extramedullary tumors
• intradural intramedullary tumors
What is the most common intradural extramedullary tumor?
• neurofibromas

* multiple tumors are found in patients with neurofibromatosis
What is a myxopapillary ependymoma?
• a benign ependymoma that is prone to develop in the filum terminale within the cauda equina

* the filum terminale within the cauda equina contains a continuation of the ependymal lining of the central spinal canal
What is the most common intramedullary tumor in adults?
ependymoma
What type of spinal cord tumor is assoicated with von Hippel-Lindau syndrome?
hemangioblastomas

* Von Hippel-Lindau disease (VHL) is a rare inherited genetic condition involving the abnormal growth of tumors in parts of the body which are particularly rich in blood supply
What are examples of infections of the spine?
• discitis
• epidural abscess
• osteomyelitis
What is the most common cause of fungal osteomyelitis?
coccidioidomycosis
What is spina bifida?
• inadequate closure of the neural tube, vertebral column, and overlying soft tissues
• usually lumbar or lumbosacral
• most common form is spina bifida occulta
What is the difference between meningocele and myelomeningocele?
• Meningocele: occurs when most of the elements dorsal to the spinal canal do not close; does not cause neural malformation

• Myelomeningocele: when neural tube closure is incomplete and malformed neural elements protrude posteriorly through a defect in the dura and vertebral lamina
What are some specific pain syndromes that can be successfully treatment with neurosurgery?
• Trigeminal neuralgia
• Glossopharyngeal neuralgagia
What is the treatment of trigeminal neuralagia?
• intially: anticonvulsant meds (ex. Carbamazepine, Oxcarbazepine)
• microvascular decompression of the trigeminal nerve