Handbook of neurosurgery 7th

ACA anterior cerebral arteryACAS asymptomatic carotid artery stenosis - 1147 or Asymptomatic Carotid Atherosclerosis Study - 1149 ACDF anterior cervical discectomy & fusion - 462 ACE ang

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Seventh Edition: January 15, 2010

ISBN: 978-1-60406-326-4EISBN: 978-1-60406-327-1

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Important note: Medical knowledge is ever-changing As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy may be required The authors andeditors of the material contained herein have consulted sources believed to be reliable in their efforts

to provide information that is complete and in accord with the standards accepted at the time ofpublication However, in view of the possibility of human error by the authors, editors, or publisher

of the work herein, or changes in medical knowledge, neither the authors, editors, publisher, nor anyother party who has been involved in the preparation of this work, warrants that the informationcontained herein is in every respect accurate or complete, and they are not responsible for any errors

or omissions or for the results obtained from use of such information Readers are encouraged toconfirm the information contained herein with other sources For example, readers are advised tocheck the product information sheet included in the package of each drug they plan to administer to becertain that the information contained in this publication is accurate and that changes have not beenmade in the recommended dose or in the contraindications for administration This recommendation is

of particular importance in connection with new or infrequently used drugs

Some of the product names, patents, and registered designs referred to in this book are in factregistered trademarks or proprietary names even though specific reference to this fact is not alwaysmade in the text Therefore, the appearance of a name without designation as proprietary is not to beconstrued as a representation by the publisher that it is in the public domain

Printed in Canada

Printing: 5 4 3

Naomi A Abel, M.D.

Electrodiagnostics

Siviero Agazzi, M.D., M.B.A.

Management of vestibular schwannomas

Blunt cerebrovascular injury

Amir Ahmadian, M.D.

Cavernous malformations

Norberto Andaluz, M.D.

Carotid stenosis & endarterectomy

Emergency carotid endarterectomy

Totally occluded carotid artery

Update on aneurysms, 6ed

Sarah J Gaskill, M.D., F.A.C.S., F.A.A.P.

Periventricular-intraventricular hemorrhage of the newborn

Asymptomatic carotid stenosis

Ashraf Samy Youssef, M.D., Ph.D.

Treatment algorithm for vasospasm, 6ed

Treatment of pineal region tumors

“Seize the moment of excited curiosity on any subject to solve your doubts; for if you let it pass, the desire may never return, and you may remain in ignorance.” - William Wirt

The seventh edition of the Handbook of Neurosurgery is dedicated to my family To my wonderfulwife, Debbie, who’s loving support has made this book worthwhile; to my father, Louis Greenberg,for everything he has given me; and to my children, Michael, Leah, Alexa and Shaina

The scalpel, and more recently, the vascular introducer sheath, are the keys that open the gate togain access to the nervous system Illustration by the author © 2010

CONVENTIONS

Cross references: the terms “see below” and “see above” are normally used when the referenced

item is on the same page, or at most on the following (or preceding) page When further excursionsare needed, the page number will usually be included

Σ Paragraphs with this symbol summarize or synthesizes information from the associated text.

EVIDENCE BASED MEDICINE

The configuration shown below is used to call attention to evidence-based guidelines developed

by authoritative committees The definitions employed are in accordance with generally acceptedcurrent usage The relevant document will be cited This does not preclude selective deviation fromrecommendations to individualize care for specific and unique circumstances of a particular case Astandard of care is not implied For an upto-date listing of some guidelines, visit

www.guidelines.gov If a Level other than I or A is given, this implies that a higher levelrecommendation could not be made In some instances, the strength of the data will be mentioned e.g

as (Class II) For a listing of evidence-based guidelines contained in this book, see the Index under

practice guideline.

PRACTICE GUIDELINE: DEFINITIONS

S trength of recommendation Description

Le ve l B Single Class I study or consistent Class II evidence or strong Class II evidence especially when

circumstances preclude randomized clinical trials

Le ve l II Moderate

degree of clinical

certainty

Le ve l C Usually derived from Class II evidence (one or more well-designed comparative clinical studies

or less well-designed randomized studies) or a preponderance of Class III evidence

Le ve l III Unclear Generally based on Class III evidence (case series, historical controls, case reports and expert

clinical certainty. Le ve l D opinion) Useful for educational purposes and to guide future research

* as used in the Guidelines for the Management of Severe Traumatic Brain Injury, 3rd edition (Brain Trauma Foundation: Introduction J

Ne urotrauma 24, Suppl 1: S1-2, 2007).

† as used in the Guidelines for the Surgical Management of Cervical Degenerative Disease (Matz P G, et al.: Introduction and

methodology J Neurosurg: Spine 11 (2): 101-3, 2009).

BOOKING THE CASE

These sections appear under certain specific operations to help when scheduling that surgery.Default information appears below, for example, a specific type of anesthesia will only be mentioned

if something other than general anesthesia is typically used A list of operations addressed by this

means can be found in the index under “Booking the case”

Default values: (these details are not repeated in each section).

1 position: (depends on the operation)

2 pre-op:

A NPO after midnight the night before except meds with sips of water

B antithrombotics: discontinue Coumadin® ≥ 3 days prior to surgery, Plavix® 5-7 d pre-op,aspirin 7-10 d pre-op, other NSAIDs 5 d pre-op

3 cardiology/medical clearance as needed

4 anesthesia: default = general anesthesia, unless otherwise specified

5 equipment: special devices such as ultrasonic aspirator, image guidance…

6 instrumentation: standard surgical instrument trays for a specific operation are assumed.Special instrumentation resident in the hospital will be listed

representative/distributor) to provide

8 neuromonitoring: will be listed if typically required

9 post-op: default care is on the ward (ICU is typically needed after craniotomy)

10 blood availability: specified if recommended

11 consent (these items use lay terms for the patient - not all-inclusive):

Disclaimers: informed consent for surgery requires disclosure of risks and benefits that

would substantively affect a normal person’s decision to have the operation It cannot and

should not attempt to include every possibility The items listed in this section are included asmemory joggers for some items for various procedures, but are not meant to be all inclusive.The omission of information from this memory aid is not to be construed as implying that theomitted item is not important or should not be mentioned

A procedure: the typical operation and some possible common contingencies

B alternatives: non-surgical (AKA “conservative”) treatment is almost always an option

C complications:

1 risks of general anesthesia include: heart attack, stroke, pneumonia

2 infection: a risk with any invasive procedure

3 usual craniotomy complications include: bleeding intra-op and postop, seizure, stroke,

coma, death, hydrocephalus, meningitis, neurologic deficit related to the area of surgery

including (for applicable locations) paralysis, language or sensory disturbances,coordination impairment

4 usual spine surgery complications include: injury to nerve or spinal cord with possible

numbness, weakness or paralysis, failure of the operation to achieve the desired result,dural opening which may cause a CSF leak which occasionally needs to be surgicalrepair Hardware complications (when used) include: breakage, pull-out, malposition.Although a rare complication, it is serious enough that it bears mentioning in casespositioned prone with possible significant blood loss (> 2 L): blindness (due to PION -

see page 450)

ACKNOWLEDGMENTS

I would like to acknowledge all the sources used for the material in this book This includes themany people involved in my medical and neurosurgical training Special appreciation is expressed toJohn M Tew, Jr., M.D., under whose guidance I received my neurosurgical training It also includesthose who generously granted permission to use figures and tables previously published

I would also like to thank my colleagues and the residents in the neurosurgery program at theUniversity of South Florida from whom I learn every day Special thanks to our chairman, Dr Harryvan Loveren, for his advice and for inspiring excellence in neurosurgery

Many thanks to Kay Conerly, executive editor at Thieme Publishers, for her unfaltering supportand cheerleading

ACA anterior cerebral artery

ACAS asymptomatic carotid artery stenosis - 1147 or

Asymptomatic Carotid Atherosclerosis Study - 1149

ACDF anterior cervical discectomy & fusion - 462

ACE angiotensin-converting enzyme

ACh acetylcholine (neurotransmitter)

AChA anterior choroidal artery

ACoA anterior communicating artery

ACTH adrenocorticotropic hormone (corticotropin) - 111

AD autosomal dominant

ADH antidiuretic hormone - 111

ADI atlantodental interval - 957

ADPKD autosomal dominant polycystic kidney disease - 1057

ADQ abductor digiti quinti (or minimi)

AED anti-epileptic drug (anticonvulsant)- 407

AFP alpha-fetoprotein - 721

Ag antigen

AHCPR Agency for Health Care Policy and Research (of the U S Public Health Service)

AICA anterior inferior cerebellar artery - 104

AIDP acute inflammatory demyelinating polyra-diculoneuropathy - 67

AIDS acquired immunodeficiency syndrome - 364

AIN anterior interosseous neuropathy - 807

AD autosomal dominant (inheritance)

AFO ankle-foot-orthosis - 821

AKA also known as

ALIF anterior lumbar interbody fusion - 195

ALARA As Low As Reasonably Achievable - 127

A-line arterial line

ALL anterior longitudinal ligament

ALS amyotrophic lateral sclerosis - 65

AMS acute mountain sickness - 916

AN acoustic neuroma - 620

ANA antinuclear antibodies

AOD atlantooccipital dislocation - 951

AOI atlantooccipital interval - 953

AP antero-posterior

APAG antipseudomonal aminoglycoside

APAP acetaminophen - 46

APD afferent pupillary defect - 831

APTT (or PTT) activated partial thromboplastin time ARDS adult respiratory distress syndrome

ASA American Society of Anesthesiologists or

aspirin (acetylsalicylic acid)

ASAP as soon as possible

AT anterior tibialis (tibialis anterior)

AT/RT atypical teratoid/rhabdoid tumor - 688

ASHD atherosclerotic heart disease

AVM arteriovenous malformation - 1098

AVP arginine vasopressin - 111

Ax-LIF axial lumbar interbody fusion - 195

ß-hCG beta-human chorionic gonadotropin - 721

BA basilar artery

BBB blood-brain barrier - 109

BC basal cisterns - 909

BCP birth control pills (oral contraceptives)

BCVI blunt cerebrovascular injury - 982

BG basal ganglia

BI basilar impression/invagination - 138

BMD bone mineral density - 992

BMP bone morphogenic protein - 198

BOB benign osteoblastoma - 736

BP blood pressure

BR bed rest (activity restriction)

BSF basal skull fracture - 887

BSG brainstem glioma - 607

Ca cancer

CA cavernous angioma - 1106

CAA cerebral amyloid angiopathy - 1122

CABG coronary artery bypass graft

CAD coronary artery disease

CAT (or CT) computerized (axial) tomography

CBF cerebral blood flow - 1010

CBV cerebral blood volume

CBZ carbamazepine - 411

CCB calcium-channel blocker

CCF carotid-cavernous (sinus) fistula - 1113

CCHD congenital cyanotic heart disease

CD Cushing’s disease - 638

CEA carotid endarterectomy - 1150 or

carcinoembryonic antigen - 721

CECT contrast enhanced CT

cf (Latin: confer) compare

cGy centi-Gray (1cGy = 1 rad)

CHF congestive heart failure

CI confidence interval (statistics)

CIDP chronic inflammatory demyelinating polyra-diculoneuropathy - 68

CIP critical illness polyneuropathy - 794

CJD Creutzfeldt-Jakob disease - 361

CM cavernous malformation - 1106

CMAP compound motor action potential (EMG)

CMRO2 cerebral metabolic rate of oxygen consumption - 1010

CMT Charcot-Marie-Tooth - 793

CMV cytomegalovirus

CNL chemonucleolysis - 447

CNS central nervous system

cCO continuous cardiac output

CO cardiac output or

carbon monoxide - 277

CPA cerebellopontine angle

CPM central pontine myelinolysis - 11

CPN common peroneal nerve - 820

CPP cerebral perfusion pressure - 866

Cr N cranial nerve(s)

CRH corticotropin-releasing hormone - 111

CRP C-reactive protein

CRPS complex regional pain syndrome - 576

CSM cervical spondylotic myelopathy - 486

CSO craniosynostosis - 228

CSW cerebral salt wasting - 13

CTA CT angiogram - 128

CTP CT perfusion - 128

CTS carpal tunnel syndrome - 808

CVA cerebrovascular accident (stroke) - 1010

CVP central venous pressure

CVVT cerebrovascular venous thrombosis - 1166

CVR cerebrovascular resistance - 1010

CVS cerebral vasospasm - 1045

CXR chest x-ray

DACA distal anterior cerebral artery

DAI diffuse axonal injury - 853

DBM demineralized bone matrix - 199

DIND delayed ischemic neurologic deficit - 1045

DIG desmoplastic infantile astrocytoma and ganglioglioma - 612

DISH diffuse idiopathic skeletal hyperostosis - 506

DKA diabetic keto-acidosis

DLC disco-ligamentous complex - 968

DLIF direct lateral lumbar interbody fusion - 194

DOC drug of choice

DM diabetes mellitus

DMZ dexamethasone

DNT (or DNET) dysembryoplastic neuroepithelial tumors - 591

DOE dyspnea on exertion

DOMS delayed onset muscle soreness - 478

DPL diagnostic peritoneal lavage

DREZ dorsal root entry zone lesion - 575

DSA digital subtraction angiogram

DWI (or DWMRI) diffusion-weighted imaging (MRI) - 132

EAC external auditory canal

EAM external auditory meatus

EAST Eastern Association for the Surgery of Trauma EBRT external beam radiation therapy

EBV Epstein-Barr Virus

ECM erythema chronicum migrans - 368

EDC electrolytically detachable coils - 1059

EDH epidural hematoma - 894

EHL extensor hallicus longus

ELISA enzyme-linked immunosorbent assay

ELST endolymphatic sac tumors - 668

EM electron microscope (microscopy)

ENG electronystagmography - 624

ENT ear, nose and throat (otolaryngology)

EOM extra-ocular muscles - 834

EOO external oculomotor ophthalmoplegia

ESR erythrocyte sedimentation rate

EST endodermal sinus tumor - 692

EtOH ethyl alcohol (ethanol)

ET tube endotracheal tube

ETV endoscopic third ventriculostomy - 315

EVD external ventricular drain (ventriculostomy)

FCU flexor carpi ulnaris

FDP flexor digitorum profundus]

FIM Functional Independence Measure - 1184

FLAIR fluid-attenuated inversion recovery (on MRI) - 129

FM face mask

FMD fibromuscular dysplasia - 79

FSH follicle stimulating hormone - 111

F/U follow-up

FUO fever of unknown origin

GABA gamma-aminobutyric acid

GBM glioblastoma (multiforme) - 596

GBS Guillain-Barré syndrome - 66

GCA giant cell arteritis - 74

GCS Glasgow coma scale - 279

GCT granular cell tumor - 641 or

germ cell tumor - 692

GD Graves’ disease

GFAP glial fibrillary acidic protein - 720

GGT gamma glutamyl transpeptidase

GH growth hormone - 111

GH-RH growth hormone releasing hormone - 111

GMH germinal matrix hemorrhage - 1131

GNR gram negative rods

GnRH gonadotropin-releasing hormone - 111

GSW gunshot wound

GTC generalized tonic-clonic (seizure)

H/A headache - 57

H&H Hunt and Hess (SAH grade) - 1039

H&P history and physical exam

HBsAg hepatitis B surface antigen

HCD herniated cervical disc - 461

hCG human chorionic gonadotropin - 721

HCP hydrocephalus - 307

HDT hyperdynamic therapy - 1052

HGB hemangioblastoma - 667

Hgb-A1C hemoglobin A1C

hGH human growth hormone

HH hypothalamic hamartomas - 226 or

homonymous hemianopsia

HHT hereditary hemorrhagic telangiectasia - 1106

HIV human immunodeficiency virus

HLD herniated lumber disc - 442

HLA human leukocyte antigen

H.O house officer

HNP herniated nucleus pulposus (herniated disc) - 442

HNPP hereditary neuropathy with liability to pressure palsies - 793

HOB head of bed

HPA hypothalamic-pituitary-adrenal axis

HSE herpes simplex encephalitis - 358

HTN hypertension

IAC internal auditory canal

IASDH infantile acute subdural hematoma - 899

ICA internal carotid artery

ICG indocyanine green

ICH intracerebral hemorrhage - 1118

IC-HTN intracranial hypertension (increased ICP)

ICP intracranial pressure - 866

ICU intensive care unit

IDDM insulindependent diabetes mellitus

IDET intradiscal endothermal therapy - 448

IEP immune electrophoresis

IG image guidance (intraoperative)

IGF-1 insulin-like growth factor-1 (AKA somatomedin-C) - 111

IIH idiopathic intracranial hypertension (pseudotumor cerebri) - 713

IIHWOP idiopathic intracranial hypertension without papilledema - 714

IJV internal jugular vein

IMRT intensity modulated radiation therapy

INO internuclear ophthalmoplegia - 834

INR international normalized ratio - 39

IPS inferior petrosal sinus

IPA idiopathic paralysis agitans (Parkinson’s disease) - 59

ISAT International Subarachnoid Hemorrhage Aneurysm Trial - 1059

IT intrathecal

ITB intrathecal baclofen - 539

IVC intraventricular catheter or

inferior vena cava

IVH intraventricular hemorrhage - 1228

IVP intravenous push (medication route) or

intravenous pyelogram (x-ray study)

JPS joint position sense

LBP low back pain - 428

LDD Lhermitte-Duclos disease - 593

LE lower extremity

LFTs liver function tests

LGG low-grade glioma - 590

LH leuteinizing hormone - 111

LH-RH leuteinizing hormone releasing hormone - 111

LMD low molecular weight dextran

LMN lower motor neuron - 786

LMW low-molecular-weight (e.g heparins)

LOC loss of consciousness

LOH loss of heterozygosity

LP lumbar puncture - 201

LSO lumbo-sacral orthosis

MAC mycobacterium avian complex - 381

MAOI monoamine oxidase inhibitor

MAP mean arterial pressure

MAST® military anti-shock trousers

MB medulloblastoma - 686

MBEN medulloblastoma with extensive nodularity - 686

MBI modified Barthel index - 1183

MIB-1 monoclonal anti-Ki-67 antibody - 720

MIC minimum inhibitory concentration (for antibiotics) MID multi-infarct dementia

MISS minimally invasive spine surgery

mJOA modified Japanese Orthopedic Association scale - 487

MLF medial longitudinal fasciculus

MMPI Minnesota Multiphasic Personality Inventory

MTT mean transit time (on CT perfusion) - 128

MUAP motor unit action potential - 270

MVA motor vehicle accident

MVD microvascular decompression - 559

MW molecular weight

n nerve (nn = nerves)

Na (or Na+) sodium

N2O nitrous oxide - 2

NAA N-acetyl aspartate - 133

NAP nerve action potential - 789

NASCET North American Symptomatic Carotid Endarterectomy Trial - 1150

NB (Latin: nota bene) note well

NC nasal cannula

NCCN National Comprehensive Cancer Network

NCD neurocutaneous disorders - 722

NCV nerve conduction velocity

NEC neurenteric cyst - 227 or

NG tube nasogastric tube

NGGCT non-germinomatous germ cell tumors - 692

NIHSS NIH Stroke Scale - 1014

NMBA neuromuscular blocking agent - 25

NMO neuromyelitis optica (Devic disease) - 1187

NPH normal pressure hydrocephalus - 329

NPS neuropathic pain syndrome - 564

NS normal saline

NSAID non-steroidal anti-inflammatory drug - 44

NSCLC non-small-cell cancer of the lung - 704

NSF nephrogenic systemic fibrosis - 130

NSM neurogenic stunned myocardium - 1054

NTP nitroprusside - 19

N/V nausea and vomiting

NVB neurovascular bundle

OAD occipital atlantal dislocation, see atlantooccipital dislocation - 951

OALL ossification of the anterior longitudinal ligament - 506

OC occipital condyle

OCB oligoclonal bands (in CSF) - 65

OCF occipital condyle fracture - 954

ODG oligodendroglioma - 609

OEF oxygen extraction fraction

OFC occipital-frontal (head) circumference

OGST oral glucose suppression test (for growth hormone) - 648

OMO open-mouth odontoid (C-spine x-ray view)

OMP oculomotor (third nerve) palsy

ONSF optic nerve sheath fenestration - 718

OP opening pressure (on LP) - 202

OPLL ossification of the posterior longitudinal ligament - 504

ORIF open reduction/internal fixation

OS overall survival

OTC over the counter (i.e without prescription)

PACU post-anesthesia care unit (AKA recovery room, PAR)

PADI posterior atlantodental interval - 495 ]

PAN poly- (or peri-) arteritis nodosa - 77

PBPP perinatal brachial plexus palsy - 802

pBtO2 brain tissue oxygen tension - 874

PC pineal cyst- 691

PCA pilocytic astrocytoma - 603 or

posterior cerebral artery

PCB pneumatic compression boot

PCC prothrombin complex concentrate - 41

PCI prophylactic cranial irradiation

PCN penicillin

PCNSL primary CNS lymphoma - 672

P-comm posterior communicating artery

PCV procarbazine, CCNU, & vincristine (chemotherapy)

PCWP pulmonary capillary wedge pressure

PDA patent ductus arteriosus

PDN painful diabetic neuropathy - 548

PDR Physicians Desk Reference®

peds pediatrics (infants & children)

PEEK poly-ether-ether-ketone (graft material)

PET positron emission tomography (scan)

p-fossa posterior fossa

PFS progression-free survival

PFT pulmonary function test

PHN postherpetic neuralgia - 564

PHT phenytoin (Dilantin®) - 409

PICA posterior inferior cerebellar artery - 103

PIF prolactin release inhibitory factor - 111

PIN posterior interosseous neuropathy - 817

PION posterior ischemic optic neuropathy - 450

PIVH periventricular-intraventricular hemorrhage - 1131

PLAP placental alkaline phosphatase - 693

PLEDs periodic lateralizing epileptiform discharges

PLIF posterior lumbar interbody fusion

PM pars marginalis - 85

PMA progressive muscular atrophy - 65 or

pilomyxoid astrocytoma - 606

PMH pure motor hemiparesis

PML progressive multifocal leukoencephalopathy - 364

PMMA polymethylmethacrylate (methylmethacrylate)

PMR polymyalgia rheumatica - 77

PMV pontomesencephalic vein

PNET primitive neuroectodermal tumor - 686

POD post-operative day

PPV positive predictive value: in unselected patients who test positive, PPV is the probability that the patient has the disease

PR per rectum

PRES posterior reversible encephalopathy syndrome - 73

PRF prolactin releasing factor - 111

PRIF prolactin (releasing) inhibitory factor - 111

PRN as needed

PRSP penicillinase resistant synthetic PCN

PSNP progressive supra-nuclear palsy - 61

PSR percutaneous stereotactic rhizotomy (for trigeminal neuralgia) - 553

PSW positive sharp waves (on EMG) - 270

pt patient

PT physical therapy or prothrombin time

PTC pituicytoma - 641

PTR percutaneous trigeminal rhizotomy

PTT (or APTT) partial thromboplastin time

PUD peptic ulcer disease

PVP percutaneous vertebroplasty - 994

PWI perfusion-weighted imaging (MRI) - 132

PXA pleomorphic xanthoastrocytoma - 592

q (Latin: quaque) every (medication dosing)

RA rheumatoid arthritis

RAPD relative afferent pupillary defect - 831

RASS Richmond agitation-sedation scale - 23

RCVS reversible cerebral vasoconstrictive syndrome - 1035

rem roentgen-equivalent man

REZ root entry zone

RFR radiofrequency rhizotomy - 553

rFVIIa recombinant (activated) factor VII

RH recurrent artery of Heubner

rhBMP recombinant human BMP - 199

R/O rule out

ROM range of motion

RPA recursive partitioning analysis

RPDB randomized prospective double-blind

RPLS reversible posterior leukoencephalopathy syndrome (see posterior reversible encephalopathy syndrome - 73) RPNB randomized prospective non-blinded

RTOG Radiation Therapy Oncology Group

RTP return to play (sports) - 851

rt-PA recombinant tissue plasminogen activator (AKA tissue plasminogen activator)

RTX (or XRT) radiation therapy - 770

S/S signs and symptoms

SAH subarachnoid hemorrhage - 1034

SBE subacute bacterial endocarditis

SBO spina bifida occulta - 247

SBP systolic blood pressure

SCA superior cerebellar artery

SCLC small-cell lung cancer - 703

SCD sequential compression device

SCI spinal cord injury - 930

SCM sternocleidomastoid (muscle)

SD standard deviation

SDE subdural empyema - 356

SDH subdural hematoma - 896

SE status epilepticus (for seizures) - 402 )

SEA spinal epidural abscess - 376

SEP (or SSEP) somatosensory evoked potential

SG specific gravity

SIAD syndrome of inappropriate antidiuresis - 10

SIADH syndrome of inappropriate antidiuretic hormone (ADH) secretion - 10

SIDS sudden infant death syndrome

SIH spontaneous intracranial hypotension - 305

SIRS septic inflammatory response syndrome

SjVO2 jugular venous oxygen saturation - 874

SLAD surgical laser aiming device

SLE systemic lupus erythematosus

SLIC subaxial injury classification - 968

SMC spinal meningeal cyst - 509

SMT spinal manipulation therapy - 438

SNAP sensory nerve action potential (EMG) - 270

SNUC sinonasal undifferentiated carcinoma - 1230

SOMI sternal-occipital-mandibular immobilizer - 979

SON supraorbital neuralgia - 562

S/P status-post

SPAM subacute progressive ascending myelopathy - 1000

SPECT single positron emission computed tomography (scan)

SPEP serum protein electrophoresis

sPNET supratentorial primitive neuroectodermal tumor - 686

SQ subcutaneous injection

SRS stereotactic radiosurgery - 773

SRT stereotactic radiotherapy - 775

SSEP (or SEP) somatosensory evoked potential

SSPE subacute sclerosing panencephalitis - 266

SSRI selective serotonin reuptake inhibitors

SSS superior sagittal sinus

STA superficial temporal artery

STICH Surgical Trial in Intracerebral Haemorrhage - 1129

STIR short tau inversion recover (MRI image)

STN subthalamic nucleus

STSG Spine Trauma Study Group

SUNCT short-lasting unilateral neuralgiform H/A with conjunctival injection and tearing - 549

SVC superior vena cava

SVM spinal vascular malformations - 507

SVR systemic venous resistance

SVT supraventricular tachycardia

Sz seizure - 394

T1WI T1 weighted image (on MRI) - 129

T2WI T2 weighted image (on MRI) - 129

TAL transverse atlantal ligament - 92

TBA total bilateral adrenalectomy - 850

TBI traumatic brain injury - 654

TCA tricyclic antidepressants

TCD transcranial doppler - 1048

TDL tumefactive demyelinating lesions - 64

TE time to echo (on MRI) - 129

TEE transesophageal echocardiogram

TEN toxic epidermal necrolysis

TENS transcutaneous electrical nerve stimulation

TGN trigeminal neuralgia - 551

T-H lines Taylor-Haughton lines - 87

TIA transient ischemic attack - 1010

TICH traumatic intracerebral hemorrhage (hemorrhagic contusion) - 893

TIVA total intravenous anesthesia

TLIF transforaminal lumbar interbody fusion - 193

TLISS thoracolumbar injury severity score - 990

TLJ thoracolumbar junction - 986

TLSO thoracolumbar-sacral orthosis

TM tympanic membrane

TMB transient monocular blindness (amaurosis fugax) - 1144

t-PA tissue plasminogen activator

TR time to repetition (on MRI) - 129

TRH thyrotropin releasing hormone; AKA TSH-RH - 111

TS transverse sinus

TSC tuberous sclerosis complex - 725

TSH thyroid-stimulating hormone (thyrotropin) - 111

TSV thalamostriate vein

TTP thrombotic thrombocytopenic purpura

TVO transient visual obscurations - 715

Tx treatment

UBOs unidentified bright objects (on MRI)

UE upper extremity

UMN upper motor neuron - 786

UTI urinary tract infection

URI upper respiratory tract infection

U/S ultrasound

VA vertebral artery or ventriculoatrial

VB vertebral body

VBI v]ertebrobasilar insufficiency - 1158

VEMP vestibular evoked myogenic potential = 624

VHL von Hippel-Lindau (disease) - 667

VMA vanillylmandelic acid

VP ventriculoperitoneal

VS vestibular schwannoma - 620

VZV (herpes) varicella zoster virus

WBC white blood cell (count)

WBXRT whole brain radiation therapy - 770

WFNS World Federation of Neurosurgical Societies (grading SAH) - 1040

WHO World Health Organization For tumor grading, e.g WHO II indicates WHO grade II wks weeks

WNL within normal limits

w/o without

WRS word recognition score - 623

W/U work-up (evaluation)

XLIF extreme lateral lumbar interbody fusion - 194

XRT (or RTX) radiation therapy - 770

⇒ vascular supply

a branch of the preceding nerve crucial point

post-op check item

✖ caution; possible danger; negative factor…

Σ summary

therefore www.net an internet URL address

Medical pearls

Instrumentation: the following short-hand allows rapid identification of metrics for spinal

instrumentation

ENTRY screw entry site

TRAJ screw trajectory

TARGET object to aim for

SCREWS typical screw specifications

Contributors

Evidence based medicine

Booking the case

Abbreviations

1 Neuroanesthesia

1.1 General information

1.2 Drugs used in neuroanesthesia

1.3 Anesthetic requirements for intraoperative evoked potential monitoring1.4 Malignant hyperthermia

1.5 References

2 Neurocritical care

2.1 Fluids and Electrolytes

2.2 Blood pressure management

2.3 Sedatives & paralytics

2.4 Neurogenic pulmonary edema

4.9 Vascular dysautoregulatory encephalopathy

4.10 Vasculitis and vasculopathy

4.11 References

5 Neuroanatomy and physiology

5.1 Surface anatomy

5.2 Cranial foramina & their contents

5.3 Cerebellopontine angle anatomy

5.9 Neurophysiology

5.10 References

6 Neuroradiology

6.1 Contrast agents in neuroradiology

6.2 Radiation safety for neurosurgeons

6.3 CAT scan or CT scan

6.4 Magnetic resonance imaging (MRI)

7.6 Localizing levels in spine surgery

7.7 Anterior approaches to the spine

7.8 Surgical fusion of the cervical spine

7.9 Surgical fusion of the thoracic spine

7.10 Surgical fusion of the lumbar and lumbosacral spine7.11 Bone graft

7.12 Percutaneous access to the CSF

8.9 Neural tube defects

8.10 Absence of the septum pellucidum

8.11 Klippel-Feil syndrome

8.12 Tethered cord syndrome

8.13 Split cord malformation

8.14 Lumbosacral nerve root anomalies

8.15 References

13.1 Brain death in adults

13.2 Brain death in children

13.3 Organ and tissue donation

16.5 Osteomyelitis of the skull

16.6 Cerebral abscess

16.7 Subdural empyema

16.8 Viral encephalitis

16.9 Creutzfeldt-Jakob disease

16.10 Neurologic manifestations of AIDS

16.11 Lyme disease - neurologic manifestations

16.12 Parasitic infections of the CNS

16.13 Fungal infections of the CNS

18 Spine & spinal cord

18.1 Low back pain and radiculopathy

18.2 Sagittal balance

18.3 Intervertebral disc herniation

18.4 Degenerative disc/spine disease

18.5 Craniocervical junction and upper cervical spine abnormalities18.6 Rheumatoid arthritis

18.7 Atlantoaxial subluxation (AAS) in Down syndrome

18.14 Spinal vascular malformations

18.15 Spinal meningeal cysts

18.16 Syringomyelia

18.17 Spinal cord herniation (idiopathic)

18.18 Spinal epidural hematoma

18.19 Spinal subdural hematoma

18.20 Spinal epidural lipomatosis (SEL)

18.21 Coccydynia

18.22 References

19 Functional neurosurgery

19.1 Deep brain stimulation

19.2 Surgical treatment of Parkinson’s disease

20.1 Neuropathic pain syndromes

20.2 Craniofacial pain syndromes

21.2 Primary brain tumors

21.3 Pediatric brain tumors

21.4 Skull tumors

21.5 Cerebral metastases

21.6 Carcinomatous meningitis

21.7 Foramen magnum tumors

21.8 Idiopathic intracranial hypertension (IIH)

21.9 Empty sella syndrome

22.1 Conventional external beam radiation

22.2 Stereotactic radiosurgery & radiotherapy

24.4 Thoracic outlet syndrome

24.5 Miscellaneous peripheral nerve

24.6 References

25 Neurophthalmology

25.1 Nystagmus

25.2 Papilledema

25.3 Visual fields

25.4 Pupillary diameter

25.5 Extraocular muscle (EOM) system

25.6 Miscellaneous neurophthalmologic signs

27.10 Aspects of general care in severe TBI

27.11 Outcome from head trauma

27.12 Gunshot wounds to the head

27.13 Non-missile penetrating trauma

27.14 High altitude cerebral edema

27.15 Pediatric head injury

27.16 References

28 Spine injuries

28.1 Whiplash-associated disorders

28.2 Pediatric spine injuries

28.3 Initial management of spinal cord injury

28.4 Neurological assessment

28.5 Spinal cord injuries

28.6 Cervical spine fractures

28.7 Blunt cerebrovascular injuries

28.8 Thoracic & lumbar spine fractures

28.9 Osteoporotic spine fractures

28.10 Sacral fractures

28.11 Gunshot wounds to the spine

28.12 Penetrating trauma to the neck

28.13 Delayed deterioration following spinal cord injuries28.14 Chronic management issues with spinal cord injuries

28.15 References

29 Stroke

29.1 Cerebrovascular hemodynamics

29.2 Strokes: general information

29.3 Stroke in young adults

30.6 Treatment options for aneurysms

30.7 Timing of aneurysm surgery

30.8 General technical considerations of aneurysm surgery30.9 Aneurysm recurrence after treatment

30.10 Aneurysm type by location

30.11 Post-op orders for aneurysm clipping

32.1 Intracerebral hemorrhage in adults

32.2 ICH in young adults

32.3 Intracerebral hemorrhage in the newborn

32.4 References

33 Occlusive cerebro-vascular disease

33.1 Atherosclerotic cerebrovascular disease

33.2 Cerebral arterial dissections

33.3 Extracranial-intracranial (EC/IC) bypass

33.4 Cerebrovascular venous thrombosis

1 Neuroanesthesia

1.1 General information

For issues related to intracranial pressure (ICP), cerebral perfusion pressure (CPP), intracranial

constituents, etc., s e e page 867 For cerebral blood flow (CBF) and cerebral metabolic rate of

oxygen consumption (CMRO2), see page 1010

Parameters of primary relevance to neurological surgery that can be modulated by theanesthesiologist:

1 blood pressure: one of the factors that determines CPP May need to be manipulated (e.g.reduced when working on an aneurysm, or increased to enhance collateral circulation duringcross clamping) Measurement by arterial line is most accurate and depending on the patient’spresentation and the planned procedure, often should be placed prior to induction of anesthesia.For intracranial procedures, the arterial line should be calibrated at the external auditorymeatus to most closely reflect intracranial blood pressure

2 jugular venous pressure: one of the factors that influences ICP

3 arterial CO2 tension (PaCO2): CO2 is the most potent cerebral vasodilator Hyperventilationreduces PaCO2 (hypocapnea) which decreases CBV but also CBF Goal is generally end tidal

CO2 (ETCO2) of 25-30 mm Hg with a correlating PaCO2 of 30-35 Use with care forstereotactic procedures to minimize shift of intracranial contents when using this method tocontrol ICP1

7 blood glucose level: hyperglycemia exacerbates ischemic deficits2

8 CMRO2: reduced with certain neuro-protective agents and by hypothermia (see above) which

helps protect against ischemic injury

9 in cases where a lumbar drain or a ventricular drain has been placed: CSF output

10 elevation of the head of the patient: lowering the head increases arterial blood flow, but alsoincreases ICP by impairing venous outflow

11 intravascular volume: hypovolemia can impair blood flow in for neurovascular cases In

surgery in the prone position, excessive fluids may contribute to facial edema which is one of

the risk factors for PION (see page 450)

12 positioning injuries: during the procedure, the patient’s position may change and be unnoticeddue to draping Careful and frequent examination of the patient’s position may prevent injuriesassociated with prolonged malpositioning

13 post operative nausea and vomiting (PONV): may adversely affect ICP and may negativelyimpact recent cervical surgical procedures Avoidance of anesthetic agents known to causePONV or pretreatment to prevent PONV may be prudent

1.2 Drugs used in neuroanesthesia

INHALATIONAL AGENTS

Most reduce cerebral metabolism (except nitrous oxide, see below) by suppressing neuronal

activity These agents disturb cerebral autoregulation and cause cerebral vasodilatation which

increases cerebral blood volume (CBV) and can increase ICP With administration > 2 hrs they

increase CSF volume which can also potentially contribute to increased ICP Most agents increase the

CO2 reactivity of cerebral blood vessels These agents affect intraoperative EP monitoring (see page

4)

nitrous oxide (N 2 O) DRUG INFO

A potent vasodilator that markedly increases CBF and minimally increases cerebral

metabolism Contributes to post-op N/V

Nitrous oxide, pneumocephalus and air embolism: The solubility of nitrous oxide (N 2 O) is ≈ 34

times that of nitrogen3 When N2O comes out of solution in an airtight space it can increase thepressure which may convert pneumocephalus to “tension pneumocephalus” It may also aggravate airembolism Thus caution must be used especially in the sitting position where significant post-oppneumocephalus and air embolism are common The risk of tension pneumocephalus may be reduced

by filling the cavity with fluid in conjunction with turning off N2O about 10 minutes prior to

completion of dural closure See Pneumocephalus on page 890

Halogenated agents:

Agents in primary usage today are shown below All suppress EEG activity and may providesome degree of cerebral protection

isoflurane (Forane®) DRUG INFO

Can produce isoelectric EEG without metabolic toxicity Improves neurologic out-come incases of incomplete global ischemia (although in experimental studies on rats, the amount of tissueinjury was greater than with thiopental4)

desflurane (Suprane®) DRUG INFO

A cerebral vasodilator, increases CBF and ICP Decreases CMRO2 which tends to cause acompensatory vasoconstriction.

sevoflurane (Ultane®) DRUG INFO

Mildly increases CBP and ICP, and reduces CMRO2 Mild negative inotrope, cardiac outputnot as well maintained as with isoflurane or desflurane

INTRAVENOUS AGENTS

INDUCTION

Agents generally used for induction:

1 propofol: exact mechanism of action unknown Short half life with no active metabolites May

be used for induction ans as a continuous infusion during total intravenous anesthesia (TIVA).

Causes dose dependent decrease in mean arterial blood pressure (MAP) and ICP For

information other than use in induction see page 3) Is more rapidly cleared than, and haslargely replaced, thiopental

2 barbiturates: produce significant reduction in CMRO2 and scavenge free radicals among other

effects (see page 1063) Produce dose-dependent EEG suppression which can be taken all theway to isoelectric Minimally affect EPs Most are anticonvulsant, but methohexital

(Brevital®) can lower the seizure threshold (s e e page 24) Myocardial suppression andperipheral vasodilatation from barbiturates may cause hypotension and compromise CPP,especially in hypovolemic patients

sodium thiopental (Pentothal®): the most common agent Rapid onset, short acting Minimaleffect on ICP, CBF and CMRO2

3 etomidate (Amidate®): a carboxylated imidazole derivative Anesthetic and amnestic, but noanalgesic properties Sometimes produces myoclonic activity which may be confused withseizures Impairs renal function and should be avoided in patient’s with known renal disease

May produce adrenal insufficiency For information other than use in induction, see page 3

4 ketamine: NMDA receptor antagonist Produces a dissociative anesthesia Maintains cardiacoutput May slightly increase both heart rate and blood pressure

NARCOTICS IN ANESTHESIA

Increase CSF absorption and minimally reduce cerebral metabolism They slow the EEG but willnot produce an isoelectric tracing ✖ All narcotics cause dose-dependent respiratory depressionwhich can result in hypercarbia and concomitant increased ICP in non-ventilated patients Oftencontribute to post-op N/V

Morphine: does not significantly cross the BBB.

✖ Disadvantages in neuro patients:

1 causes histamine release which

A may produce hypotension

B may cause cerebrovascular vasodilation → increased ICP5 (p 1593)

C the above together may compromise CPP

2 in renal or hepatic insufficiency, the metabolite morphine-6-glucuronide can accumulate whichmay cause confusion

Meperidine (Demerol®): has negative inotropic effects, and its neuroexcitatory metabolite

nor-meperidine can cause hyperactivity or seizures (see footnote, page 49) Also causes histaminerelease, increased ICP and tachycardia

Synthetic narcotics

These do not cause histamine release, unlike morphine and meperidine

Remifentanil (Ultiva®): (see page 24 for details) reduces CMRO2, CBV and ICP Large doses

may be neurotoxic to limbic system and associated areas May be used for awake craniotomy (see

page 151)

Fentanyl: crosses the BBB Reduces CMRO2, CBV and ICP May be given as bolus and/or as acontinuous infusion

Sufentanil: more potent then fentanyl Does not increase CBF ✖ Raises ICP and is thus often not

appropriate for neurosurgical cases

Alfentanil: the most rapid onset and the shortest duration of the narcotics ✖ NB: raises ICP.

MISCELLANEOUS DRUGS IN NEUROANESTHESIA

Benzodiazepines: These drugs are GABA agonists and decrease CMRO2 They also provideanticonvulsant action and produce amnesia See page 51 for agents and reversal

Etomidate: Used primarily for induction (see page 2) Initial hopes for use as a cerebral protectantwere abandoned based on experimental studies6 and a drop in pBtO2 with temporary MCA clipping7

A cerebrovasoconstrictor, it reduces CBF and ICP Does not suppress brainstem activity Suppressescortisol production with prolonged administration, and may induce seizures

Propofol: A sedative hypnotic Useful for induction (see page 2) Reduces cerebral metabolism, CBF

and ICP Has been described for cerebral protection ( see page 1064 ) and for sedation (see page 24)

Short half life permits rapid awakening which may be useful for awake craniotomy (see page 151).Not analgesic

Lidocaine: Given IV, suppresses laryngeal reflexes which may help blunt ICP elevations that

normally follow endotracheal intubation or suctioning Anticonvulsant at low doses, may provokeseizures at high concentrations

Esmolol: Selective beta-1 adrenergic antagonist, blunts the sympathetic response to laryngoscopy and

intubation Less sedating than equipotent doses of lidocaine or fentanyl used for the same purpose

Half life: 9 minutes For dosing, etc., see page 20

Dexmedetomidine (Precedex®): Alpha 2 adrenergic receptor agonist, used for control of

hypertension post operatively as well as, for it’s sedating qualities during awake craniotomy either

alone or in conjunction with propofol (see page 151) Also used to help patients tolerate endotrachealtube without sedatives/narcotics to facilitate extubation

PARALYTICS FOR INTUBATION

Paralytics (neuromuscular blocking agents (NMBA)): administered to facilitate tracheal

intubation and to improve surgical conditions when indicated Administration of paralytics ideally

should always be guided by neuromuscular twitch monitoring Also see Sedatives & paralytics, page

23 In addition to paralytics, all conscious patients should also receive a sedative to blunt awareness.Paralytics should not be given until it has been determined that patient can be ventilated manually,unless treating laryngospasm (may be tested with thiopental) Use with caution in non-fixated patientswith unstable C-spine

Due to long action, pancuronium (Pavulon®) is not indicated as the primary paralytic forintubation, but may be useful once patient is intubated or in low dose as an adjunct to succinylcholine

(see below).

succinylcholine (Anectine®) DRUG INFO

The only depolarizing agent May be used to secure airway for emergency intubation, but due to

possible side effects (see page 26), should not be used acutely following injury or in adolescents

or children (a short acting nondepolarizing blocker is preferred) May transiently increase ICP.Prior dosing with 10% of the ED95 dose of a non-depolarizing muscle relaxant reduces musclefasciculations

Rx Intubating dose: 1-1.5 mg/kg (supplied as 20 mg/ml → 3.5-5 cc for a 70 kg patient), onset

60-90 sec, duration 3-10 min, may repeat same dose x 1.

rocuronium (Zemuron®) DRUG INFO

Intermediate acting, aminosteroid, non-depolarizing muscle relaxant The only nondepolarizingneuromuscular blocking agent approved for rapid sequence intubation Duration of action and onset

are dose dependent Rx see page 26

vecuronium (Norcuron®) DRUG INFO

Aminosteroid with activity similar to that of rocuronium, however, does not cause histamine

release and is not approved for rapid sequence intubation Rx see page 26

cisatracurium (Nimbex®) DRUG INFO

Metabolized by Hoffman degradation (temperature dependent), intermediate acting, no

significant increases in histamine Rx see page 4

1.3 Anesthetic requirements for intraoperative evoked potential monitoring

For details of intraoperative evoked potential (EP) monitoring itself, see page 267

All volatile anesthetics produce dose-dependent reduction in SSEP peak amplitude and anincrease in peak latency Adding nitrous oxide increases this sensitivity to anesthetic agents

Anesthesia issues related to intraoperative evoked potential (EPs) monitoring:

1 induction: minimize pentothal dose (produces ≈ 30 minutes of suppression of EPs), or useetomidate (which increases both SSEP amplitude and latency8)

2 total intravenous anesthesia (TIVA) is ideal

3 nitrous/narcotic technique is a second choice

4 if inhalational anesthetic agents are required:

A use < 1 MAC (minimum alveolar concentration), ideally < 0.5 MAC

B avoid older agents such as Halothane

5 nondepolarizing muscle relaxants have little effect on EP (in monkeys9)

6 propofol has a mild effect on EP: total anesthesia with propofol causes less EP depression thaninhalational agents at the same depth of anesthesia10

7 benzodiazepines have a mild-to-moderate depressant effect on EPs

8 continuous infusion of anesthetic drugs is preferred over intermittent boluses

9 SSEPs can be affected by hyper- or hypothermia, and changes in BP

10 hypocapnia (down to end tidal CO2 = 21) causes minimal reduction in peak latencies11

11 antiepileptic drugs: phenytoin, carbamazepine and phenobarbital do not affect SSEP12

1.4 Malignant hyperthermia

Malignant hyperthermia (MH) is a hypermetabolic state of skeletal muscle due to idiopathic block

of Ca++ reentry into sarcoplasmic reticulum Transmitted by a multifactorial genetic predisposition.Total body O2 consumption increases x 2-3.

Incidence: 1 in 15,000 anesthetic administrations in peds 1 in 40,000 adults 50% had previousanesthesia without MH Frequently associated with administration of halogenated inhalational agentsand the use of succinylcholine (fulminant form: muscle rigidity almost immediately aftersuccinylcholine, may involve masseters → difficulty intubating) Initial attack and recrudescence mayalso occur post-op 30% mortality13