Chapter 74 Neurosurgery

HEAD TRAUMA
What percentage of trauma deaths result from head trauma?
50%

Identify the dermatomes:

What is the Glasgow Coma Scale (GCS)?

GCS is an objective assessment of the level of consciousness after trauma

■ GCS Scoring System

Eyes?

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 Eye Opening (E)
(Think: “4 eyes”)
4—opens spontaneously
3—opens to voice (command)
2—opens to painful stimulus
1—does not open eyes

Motor?
Motor Response (M)
(Think: 6 cylinder motor)
6—obeys commands
5—localizes painful stimulus
4—withdraws from pain
3—decorticate posture
2—decerebrate posture
1—no movement

Verbal?
Verbal Response (V)
(Think: Jackson 5 = verbal 5)
5—appropriate and oriented
4—confused
3—inappropriate words
2—incomprehensible sounds
1—no sounds

What indicates coma by GCS score?

<8 (Think: “less than eight—it may be too late”)

What does unilateral, dilated, nonreactive pupil suggest?

Focal mass lesion with ipsilateral herniation and compression of CN III

What do bilateral fixed and dilated pupils suggest?

Diffusely increased ICP

What are the four signs of basilar skull fracture?

1. Raccoon eyes—periorbital ecchymoses

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2. Battle’s sign—postauricular ecchymoses
3. Hemotympanum
4. CSF rhinorrhea/otorrhea

What is the initial radiographic neuroimaging in trauma?

1. Head CT scan (if LOC or GCS <15)
2. C-spine CT scan
3. T/L spine AP and lateral

Should the trauma head CT scan be with or without IV contrast?

Without!

What is normal ICP?

5 to 15 mm H2O

What is the worrisome ICP?

>20 mm H2O

What determines ICP (Monroe–Kelly hypothesis)?

1. Volume of brain
2. Volume of blood
3. Volume of CSF

What is the CPP?

Cerebral Perfusion Pressure = mean arterial pressure—ICP (normal CPP is >70)

What is Cushing’s reflex?

Physiologic response to increased ICP:
1. Hypertension
2. Bradycardia
3. Decreased RR

What are the three general indications to monitor ICP after trauma?
1. GCS <9
2. Altered level of consciousness or unconsciousness with multiple system
trauma
3. Decreased consciousness with focal neurologic examination abnormality

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 What is Kocher’s point?
Landmark for placement of ICP monitor bolt:

What nonoperative techniques are used to decrease ICP?

1. Elevate head of bed (HOB) 30° (if spine cleared)
2. Diuresis-mannitol (osmotic diuretic), Lasix®, limit fluids
3. Intubation (Pco2 control)
4. Sedation
5. Pharmacologic paralysis
6. Ventriculostomy (CSF drainage)

How does hyperventilation ↓ ICP?

By ↓ Pco2 resulting in cerebral vasoconstriction (and thus less intracranial
volume)

What is the acronym for the treatment of elevated ICP?

“ICP HEAD”:
Intubate
Calm (sedate)
Place drain (ventriculostomy)/Paralysis

Hyperventilate to Pco2 ≈35

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 Elevate head
Adequate blood pressure (CPP >70)
Diuretic (e.g., mannitol)

Can a tight c-collar increase the ICP?

Yes (it blocks venous drainage from brain!)

Why is prolonged hyperventilation dangerous?

It may result in severe vasoconstriction and ischemic brain necrosis!
Use only for very brief periods

What is a Kjellberg? (pronounced “shellberg”)

Decompressive bifrontal craniectomy with removal of frontal bone frozen for
possible later replacement

How does cranial nerve examination localize the injury in a

comatose patient?
CNs proceed caudally in the brainstem as numbered: Presence of corneal reflex
(CN 5 + 7) indicates intact pons; intact gag reflex (CN 9 + 10) shows
functioning upper medulla (Note: CN 6 palsy is often a false localizing sign)

What is acute treatment of seizures after head trauma?

Benzodiazepines (Ativan®)

What is seizure prophylaxis after severe head injury?

Give phenytoin for 7 days

What is the significance of hyponatremia (low sodium level) after

head injury?
SIADH must be ruled out; remember, SIADH = Sodium Is Always Down Here

■ Epidural Hematoma
What is an epidural hematoma?
Collection of blood between the skull and dura

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What causes it?
Usually occurs in association with a skull fracture as bone fragments lacerate
meningeal arteries

Which artery is associated with epidural hematomas?

Middle meningeal artery

What is the most common sign of an epidural hematoma?

>50% have ipsilateral blown pupil

What is the classic history with an epidural hematoma?

LOC followed by a “lucid interval” followed by neurologic deterioration

What are the classic CT scan findings with an epidural hematoma?

Lenticular (lens)-shaped hematoma (Think: Epidural = LEnticular)

What is the surgical treatment for an epidural hematoma?

Surgical evacuation

■ Subdural Hematoma
What is it?
Blood collection under the dura

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 What causes it?
Tearing of “bridging” veins that pass through the space between the cortical
surface and the dural venous sinuses or injury to the brain surface with resultant
bleeding from cortical vessels

What are the three types of subdurals?

1. Acute—symptoms within 48 hours of injury
2. Subacute—symptoms within 3 to 14 days
3. Chronic—symptoms after 2 weeks or longer

What is the treatment of epidural and subdural hematomas?

Mass effect (pressure) must be reduced; craniotomy with clot evacuation is
usually required

What classic findings appear on head CT scan for a subdural

hematoma?
Curved, crescent-shaped hematoma (Think: sUbdural = cUrved)

■ Traumatic Subarachnoid Hemorrhage

What is it?
Head trauma resulting in blood below the arachnoid membrane and above the
pia

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 What is the treatment?
Anticonvulsants and observation

■ Cerebral Contusion
What is it?
Hemorrhagic contusion of brain parenchyma

What are coup and contrecoup injuries?

Coup—injury at the site of impact
Contrecoup—injury at the site opposite the point of impact

What is DAI?
Diffuse Axonal Injury (shear injury to brain parenchyma) from rapid
deceleration injury

What is the best diagnostic test for DAI?

MRI

What can present after blunt trauma with neurologic deficits and a
normal brain CT scan?
DAI, carotid artery injury

■ Skull Fracture
What is a depressed skull fracture?
Fracture in which one or more fragments of the skull are forced below the inner
table of the skull

What are the indications for surgery?

1. Contaminated wound requiring cleaning and débridement
2. Severe deformity
3. Impingement on cortex
4. Open fracture

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5. CSF leak

What is the treatment for open skull fractures?

1. Antibiotics
2. Seizure prophylaxis
3. Surgical therapy

SPINAL CORD TRAUMA

What are the two general types of injury?
1. Complete—no motor/sensory function below the level of injury
2. Incomplete—residual function below the level of injury

What is “spinal shock”?

Loss of all reflexes and motor function

What is “sacral sparing”?

Sparing of sacral nerve level: anal sphincter intact, toe flexion, perianal
sensation

What are the diagnostic studies?

CT scan, MRI

What are the indications for emergent surgery with spinal cord
injury?
Unstable vertebral fracture
Incomplete injury with extrinsic compression
Spinal epidural or subdural hematoma

Describe the following conditions:

Anterior cord syndrome

Affects corticospinal and lateral spinothalamic tracts, paraplegia, loss of
pain/temperature sensation, preserved touch/vibration/proprioception

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 Central cord syndrome
Preservation of some lower extremity motor and sensory ability with upper
extremity weakness

Brown–Séquard syndrome
Hemisection of cord resulting in ipsilateral motor touch/proprioception loss
with contralateral pain/temperature loss

Posterior cord syndrome

Injury to posterior spinal cord with loss of proprioception distally

How can the findings associated with Brown–Séquard syndrome be

remembered?
Think: CAPTAIN Brown–Séquard = “CPT”:
Contralateral
Pain
Temperature loss

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Define the following terms:

Jefferson’s fracture
Fracture through C1 arches from axial loading (unstable fracture)

Hangman’s fracture
Fracture through the pedicles of C2 from hyperextension; usually stable
Think: A hangman (C2) is below stature of President T. Jefferson (C1)

Odontoid fracture
Fracture of the odontoid process of C2 (view with open-mouth odontoid x-
ray)

Priapism
Penile erection seen with spinal cord injury

Chance fracture
Transverse vertebral fracture

Clay shoveler’s fracture

Fracture of spinous process of C7

Odontoid fractures

A: Type I—fracture through tip of dens

B: Type II—fracture through base of dens
C: Type III—fracture through body of C2

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 TUMORS

■ General
What is the incidence of CNS tumors?
≈1% of all cancers; third leading cause of cancer deaths in people 15 to 34 years
of age; second leading cause of cancer deaths in children

What is the usual location of primary tumors in adults/children?

In adults, ≈66% of tumors are supratentorial, ≈33% are infratentorial; the reverse
is true in children (i.e., ≈66% infratentorial)

What is the differential diagnosis of a ring-enhancing brain lesion?

Metastatic carcinoma, abscess, GBM, lymphoma

What are the signs/symptoms of brain tumors?

1. Neurologic deficit (66%)
2. Headache (50%)
3. Seizures (25%)
4. Vomiting (classically in the morning)

How is the diagnosis made?

CT scan or MRI is the standard diagnostic study

What are the surgical indications?

1. Establishing a tissue diagnosis
2. Relief of increased ICP
3. Relief of neurologic dysfunction caused by tissue compression
4. Attempt to cure in the setting of localized tumor

What are the most common intracranial tumors in adults?

Metastatic neoplasms are most common; among primaries, gliomas are #1 (50%)
and meningiomas are #2 (25%)

What are the three most common in children?

1. Medulloblastomas (33%)

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2. Astrocytomas (33%)
3. Ependymomas (10%)

■ Gliomas
What is a glioma?
General name for several tumors of neuroglial origin (e.g., astrocytes,
ependymal, oligodendrocytes)

What are the characteristics of a LOW-grade astrocytoma?

Nuclear atypia, high mitotic rate, high signal on T2-weighted images,
nonenhancing with contrast CT scan

What is the most common primary brain tumor in adults?

Glioblastoma multiforme (GBM) (Think: GBM = Greatest Brain Malignancy)

What are its characteristics?

Poorly defined, highly aggressive tumors occurring in the white matter of the
cerebral hemispheres; spread extremely rapidly

What is the average age of onset?

Fifth decade

What is the treatment?

Surgical debulking followed by radiation

What is the prognosis?

Without treatment, >90% of patients die within 3 months of diagnosis; with
treatment, 90% die within 2 years

■ Meningiomas
What is the layer of origination?
Arachnoid cap cells

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What are the risk factors?
Radiation exposure
Neurofibromatosis type 2
Female gender

What are the associated histologic findings?

Psammoma bodies (concentric calcifications), whorl formations (“onion skin”
pattern)

What is the histologic malignancy determination?

Brain parenchymal invasion

What is the peak age of occurrence?

40 to 50 years

What is the gender ratio?

Females predominate almost 2:1

What is the clinical presentation?

Variable depending on location; lateral cerebral convexity tumors can cause
focal deficits or headache; sphenoid tumors can present with seizures; posterior
fossa tumors with CN deficits; olfactory groove tumors with anosmia

What is the treatment?

± Preoperative embolization and surgical resection

■ Cerebellar Astrocytomas
What is the peak age of occurrence?
5 to 9 years

What is the usual location?

Usually in the cerebellar hemispheres; less frequently in the vermis

What are the signs/symptoms?

Usually lateral cerebellar signs occur: ipsilateral incoordination or dysmetria

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(patient tends to fall to side of tumor) as well as nystagmus and ataxia; CN
deficits are also frequently present, especially in CNs VI and VII

■ Medulloblastoma
What is the peak age of occurrence?
First decade (3 to 7 years)

What is the most common location?

Cerebellar vermis in children; cerebellar hemispheres of adolescents and adults

■ Pituitary Tumors
What is the most common pituitary tumor?
Prolactinoma

What is the most common presentation of a prolactinoma?

Bitemporal hemianopsia (lateral visual fields blind)

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What are the blood prolactin levels with a prolactinoma?
>300 mg/L is diagnostic for prolactinoma (>100 mg/L is abnormal)

Medical treatment of a prolactinoma?

Bromocriptine

Surgical treatment for a prolactinoma?

Transsphenoidal resection of the pituitary tumor (in cases refractory to
bromocriptine)

What is the treatment of a recurrent prolactinoma after surgical

resection?
Radiation therapy

VASCULAR NEUROSURGERY

■ Subarachnoid Hemorrhage (SAH)

What are the usual causes?
Most cases are due to trauma; of nontraumatic SAH, the leading cause is
ruptured berry aneurysm, followed by arteriovenous malformations

What is a berry aneurysm?

Saccular outpouching of vessels in the circle of Willis, usually at bifurcations

What is the usual location of a berry aneurysm?

Anterior communicating artery is #1 (30%), followed by posterior
communicating artery and middle cerebral artery

What medical diseases increase the risk of berry aneurysms?

Polycystic kidney disease and connective tissue disorders (e.g., Marfan’s
syndrome)

What are the signs/symptoms of SAH?

Classic symptom is “the worst headache of my life”; meningismus is
documented by neck pain and positive Kernig’s and Brudzinski’s signs;

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 occasionally LOC, vomiting, nausea, photophobia

What comprises the workup of SAH?

If SAH is suspected, head CT scan should be the first test ordered

What are the possible complications of SAH?

1. Brain edema leading to increased ICP
2. Rebleeding (most common in the first 24 to 48 hours post-hemorrhage)
3. Vasospasm (most common cause of morbidity and mortality)

What is the treatment for vasospasm?

Nimodipine (calcium channel blocker)

What is the treatment of aneurysms?

Surgical treatment by placing a metal clip on the aneurysm is the mainstay of
therapy; alternatives include balloon occlusion or coil embolization

What is the treatment of arteriovenous malformations (AVMs)?

Many are on the brain surface and accessible operatively; preoperative
embolization can reduce the size of the AVM; for surgically inaccessible lesions,
radiosurgery (gamma knife) has been effective in treating AVMs <3 cm in
diameter

SPINE

■ Lumbar Disc Herniation

What is it?

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 Extrusion of the inner portion of the intervertebral disc (nucleus pulposus)
through the outer annulus fibrosis, causing impingement on nerve roots exiting
the spinal canal

Which nerve is affected?

Nerve exiting at the level below (e.g., an L4–L5 disc impinges on the L5 nerve
exiting between L5 and S1)

What are the most common sites?

L5–S1 (45%)
L4–L5 (40%)

What is the treatment?

Conservative—bed rest and analgesics
Surgical—partial hemilaminectomy and discectomy (removal of herniated disc)

What are the indications for emergent surgery?

1. Cauda equina syndrome
2. Progressive motor deficits

What is cauda equina syndrome?

Herniated disc compressing multiple S1, S2, S3, S4 nerve roots, resulting in
bowel/bladder incontinence, “saddle anesthesia” over buttocks/perineum, low
back pain, sciatica

■ Cervical Disc Disease

What are the most common sites?
C6–C7 (70%)
C5–C6 (20%)

What is Spurling’s sign?

Reproduction of radicular pain by having the patient turn his head to the affected
side and applying axial pressure to the top of the head

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■ Spinal Epidural Abscess
What is the etiology?
Hematogenous spread from skin infections is most common; also, distant
abscesses/infections, UTIs, postoperative infections, spinal surgery, epidural
anesthesia

What is the most common organism?

Staphylococcus aureus

What are the signs/symptoms?

Fever; severe pain over affected area and with flexion/extension of spine;
weakness can develop, ultimately leading to paraplegia; 15% of patients have a
back furuncle

What is the treatment?

Surgical drainage and appropriate antibiotic coverage

What is the prognosis?

Depends on preop condition; severe neurologic deficits (e.g., paraplegia) show
little recovery; 15% to 20% of cases are fatal

PEDIATRIC NEUROSURGERY

■ Hydrocephalus
What is it?
Abnormal condition consisting of an increased volume of CSF along with
distension of CSF spaces

What are the signs/symptoms?

Signs of increased ICP: HA, nausea, vomiting, ataxia, increasing head
circumference exceeding norms for age

What is the treatment?

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1. Remove obvious offenders
2. Perform bypass obstruction with ventriculoperitoneal shunt or ventriculoatrial
shunt

What is a “shunt series”?

Series of x-rays covering the entire shunt length—looking for shunt
disruption/kinking to explain malfunction of shunt

■ Spinal Dysraphism/Neural Tube Defects

What is spina bifida occulta?
Defect in the development of the posterior portion of the vertebrae

What is the treatment?

With open myelomeningoceles, patients are operated on immediately to prevent
infection

Which vitamin is thought to lower the rate of neural tube defects in

utero?
Folic acid

■ Craniosynostosis
What is it?
Premature closure of one or more of the sutures between the skull plates

What is the timing of surgery?

Usually 3 to 4 months of age; earlier surgery increases the risk of anesthesia;
later surgeries are more difficult because of the worsening deformities and
decreasing malleability of the skull

■ Miscellaneous

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What is syringomyelia?
Central pathologic cavitations of the spinal cord

RAPID FIRE REVIEW

Name the most likely diagnosis:

What is the GCS for an 18-year-old woman s/p MVC in a

“coma”?
=8

What is the GCS for a 40-year-old man brought in dead after an

MVC by the rescue paramedics?
3: eyes = 1, motor = 1, verbal = 1

What is the GCS for 20-year-old woman s/p motorcycle collision

with open eyes, grunting only, and withdrawals to pain?
10 = eyes: 4, motor = 4, verbal = 2

What is the GCS for a 29-year-old woman s/p skiing accident

into a tree who is intubated; eyes closed even to pain,
decorticate posturing only?
5T: eyes = 1, intubated = IT, motor = 3

28-year-old man involved in high-speed MVC with lower back

spine fracture, bladder/bowel incontinence, decreased lower
extremity sensation, and decreased lower extremity strength
Cauda equina syndrome

24-year-old woman with spine fracture; paraplegia but with

touch and proprioception intact
Anterior spinal cord syndrome

29-year-old man s/p 45-foot fall with left-sided loss of

temperature and pain sensation; right-sided paresis and loss of

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right-sided proprioception
Brown–Séquard syndrome

18-year-old woman with a cervical spinal fracture after diving

into a shallow pool; intact perianal sensation and decreased
lower extremity sensation and movement
Central cord syndrome

50-year-old woman with painless proptosis and a brain tumor

stuck to the dura
Meningioma

19-year-old woman involved in a high-speed MVC and was

thrown unrestrained into the windshield; she has a GCS of 15 at
the scene and initially upon admission to the ER; she then
becomes comatose with a GCS of 3
Epidural hematoma and “lucid interval”

Patient with head trauma and a peripheral “crescent”-shaped

hematoma on CT scan
Subdural hematoma

Patient with head trauma and a peripheral “lenticular” (lens-like)

hematoma on CT scan
Epidural hematoma

Hypoxia after brain injury without lung injury, no fractures, no

DVTs
Neurogenic pulmonary edema

Coagulopathy after isolated brain injury

Brain thromboplastin

40-year-old s/p fall from a balcony, GCS of 3, heart rate 40, SBP
of 190/90, blown right pupil
Elevated ICP with brain herniation

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 22-year-old female s/p MVC, GCS of 3, nl brain CT scan, nl brain
MRI, nl EEG
Cervical vascular injury (e.g., carotid artery dissection with thrombosis)

21-year-old male s/p MVC with hypotension, bradycardia, nl

CXR, nl FAST exam, nl pelvic x-ray
Spinal cord injury with neurologic shock

39-year-old woman lifting weights has onset of lower back pain,

cannot urinate, and is passing flatus that she cannot control; on
exam, the bladder is distended, poor rectal tone, and perineal
skin numbness (anesthesia)
Cauda equina syndrome

29-year-old diabetic with chronic bacterial sinusitis, new-onset

seizures, fever, and right-sided weakness
Brain abscess

40-year-old male with chronic low back pain lifts a refrigerator

and experiences severe pain shooting down his right leg out his
right big toe
Herniated disc at L4–L5

Name the diagnostic modality:

18-year-old female with fall from horse with loss of

consciousness
Brain CT scan without contrast

39-year-old female librarian with acute loss of hearing in her left

ear
MRI to rule out acoustic nerve neuroma

What is the treatment?

28-year-old male s/p motorcycle collision, presents with eyes

closed, not making any verbal sounds, decorticate posturing to

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 painful stimuli
GCS of 5 and in a “coma”; must be intubated

34-year-old female with small prolactinoma

Bromocriptine (transsphenoidal resection if refractory)

Name the radiographic test for localizing the following:

Pituitary adenoma?
Gadolinium-enhanced MRI

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