Ebook Neurosurgery rounds: Part 1

(BQ) Part 1 book “Neurosurgery rounds - Questions and answers” has contents: Basic neurosciences, neuroanatomy, neurophysiology, spine and peripheral nerve, anesthetics, analgesics, and antiinflammatories, intensive care - vasogenic and hematologic,… and other contents.

Neurosurgery Rounds Questions and Answers

Neurosurgery Rounds Questions and Answers

Mark R Shaya, MD, FACS

Chief Executive OfficerNeurosurgical Institute of FloridaUniversity of Miami HospitalMiami, Florida

Remi Nader, MD, CM, FRCSC, FACS, FAANS

Chief, Neurosurgery SectionDirector, Neuroscience Clinical Effectiveness ProgramMemorial Hospital at Gulfport

Affiliate Assistant Professor of NeurosurgeryUniversity of Mississippi Medical CenterAttending Neurosurgeon

Gulf Coast Brain and Spine InstituteGulfport, Mississippi

Jonathan S Citow, MD

Lake County NeurosurgeryChief of Neurosurgery, Condell Medical Center Libertyville, Illinois

Associate Clinical ProfessorRosalind Franklin UniversityNorth Chicago, Illinois

Hamad I Farhat, MD

Section HeadNeurovascular and Neuroendovascular SurgeryNorthShore Medical Group, NeurosurgeryEvanston Hospital

Evanston, IllinoisAssistant Clinical ProfessorUniversity of ChicagoChicago, Illinois

Abdulrahman J Sabbagh, MD, FRCSC

Deputy Chairman, Department of NeurosurgeryDirector, Neurosurgery Residency ProgramNeurosciences Center

King Fahd Medical City—Ministry of HealthRiyadh, Saudi Arabia

ThiemeNew York • Stuttgart

Thieme Medical Publishers, Inc.

333 Seventh Ave.

New York, NY 10001 Executive Editor: Kay D Conerly Managing Editor: Lauren Henry Editorial Director: Michael Wachinger Production Editor: Marcy Ross International Production Director: Andreas Schabert Vice President, International Marketing and Sales: Cornelia Schulze Chief Financial Officer: James W Mitos

President: Brian D Scanlan Compositor: MPS Limited, a Macmillan Company Printer: Sheridan Press

Library of Congress Cataloging-in-Publication Data: Available from the

publisher upon request.

Copyright © 2011 by Thieme Medical Publishers, Inc This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing

or duplication of any kind, translating, preparation of microfilms, and tronic data processing and storage

elec-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 and editors of the material 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 of publication However, in view of the possibility of human error

by the authors, editors, or publisher of the work herein or changes in cal knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work, warrants that the information contained 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 to confirm the information contained herein with other sources For example, readers are advised to check the product information sheet included in the package

medi-of each drug they plan to administer to be certain that the information tained in this publication is accurate and that changes have not been made

con-in the recommended dose or con-in the contracon-indications for admcon-inistration

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 fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text There- fore, the appearance of a name without designation as proprietary is not

to be construed as a representation by the publisher that it is in the public domain.

Printed in the United States of America

5 4 3 2 1 ISBN 978-1-58890-499-7

Preface vii

Contributors ix

I BASIC NeuRoSCIeNCeS 1 Neuroanatomy 1

Cranial .2

Spine and Peripheral Nerve 42

Cases 55

2 Neurophysiology 63

General 64

Cases 90

3 Neuropathology 97

Congenital 98

Trauma 102

Epilepsy 104

Neoplastic 110

Degenerative 123

4 Neuropharmacology 127

Neurotransmitters 128

Epilepsy 133

Anesthetics, Analgesics, and Antiinflammatories 135

Antimicrobials 142

Intensive Care: Vasogenic and Hematologic 145

Toxicology 149

II CLINICAL NeuRoSCIeNCeS 5 Cranial Neurosurgery 153

General 154

Trauma and Emergencies 175

Neoplasms 187

Endocrine 207

Radiation Therapy 213

Infections 215

Vascular 218

Congenital and Pediatric 240

Pain and Functional 252

Cases 255

6 Spine 281

Spinal Anatomy and Surgical Technique 282

Trauma 305

Degenerative 324

Neoplastic, Infectious, Vascular 332

Congenital and Pediatric 342

Cases 346

7 Peripheral Nerves 357

General 358

Upper Extremity 370

Lower Extremity 379

Cases 385

8 Neurology 391

General 392

Emergencies and Epilepsy 394

Infectious and Inflammatory 397

Congenital and Pediatric 404

Functional and Pain 411

Cases 413

9 Neuroradiology 423

Cranial 424

Spinal 433

Index 443

vi Contents

The front cover of this text shows neurosurgical pioneer

Dr Harvey Cushing on rounds almost a century ago with residents, students, and nurses examining a patient after

a craniotomy It is truly extraordinary to see this patient without all the bedside machines, monitors, and tubes we are used to seeing today Although the science and techno-logic armamentarium have progressed over the years, the true didactics of neurosurgery remain essentially as they were at the time this picture was taken

The amount of information required to complete rosurgery residency training can be very intimidating and broad The diagnosis and management of neurosurgical diseases is an ever-advancing field that remains challeng-ing for both the trainees and mentors

neu-The purpose of this book is to provide diversified age of the multiple disciplines that are involved and inter-twined in the understanding, care, and treatment of neu-rosurgical patients Although its primary use will be for review purposes by the trainee, resident, or medical stu-dent prior to being “pimped” by their mentor about topics

cover-in neurosurgery, the book also provides a handy reference guide that the reader can fall back upon in reviewing spe-cific topics as they relate to simple and complex neurosur-gery and neuroscience issues

The book is divided into two sections including basic and clinical neurosciences The sections are further composed

of four to five subsections including neuroanatomy, physiology, neuropathology, neuropharmacology, cranial neurosurgery, spine, peripheral nerves, neurology, and neuroradiology By providing this organization we have attempted to cover all categories involved in the practice and understanding of neurosurgical diseases, both from

neuro-a bneuro-asic science neuro-and clinicneuro-al stneuro-andpoint With 23 neuro-authors, contributors, and collaborators from four countries, in-cluding not only neurosurgeons but also specialists in neuropathology, neuroradiology, orthopedic surgery, an-esthesiology, and neurology, we have attempted to cover

as broadly as possible—yet in a concise manner—specific topics that will come up in the day-to-day evaluation and treatment of neurosurgical patients

This book was edited as a combined effort from the

experts in the now new field of neurosurgical review to

bring to the reader the optimal didactic experience We

have attempted to present material in a way to best tate the retention and understanding of complex concepts and rare diseases by breaking them down to their bare essentials.

facili-We hope that you enjoy reading this book as much as we did putting it together

Mark Shaya, MD Remi Nader, MD

viii Preface

Nazek Ahmad, MD (Cranial Neurosurgery–Pediatric)

Neurosurgery ResidentDepartment of NeurosurgeryNeurosciences Center King Fahd Medical CityRiyadh, Saudi Arabia

Mohammd Alfawareh, MD (Spine)

Subspecialty Consultant Spine Surgeon, Pediatric Spine Surgeon, Musculoskeletal Oncology SurgeonSpine Surgery Department

Neurosciences CenterPart-time Orthopedic Surgery Section, Department of Surgery

King Fahd Medical CityRiyadh, Saudi Arabia

Aisha Nassr Al-Hajjaj, MD (Neuroradiology)

Subspecialty Consultant Neurosurgeon, Neuro-endovascular InterventionistDepartment of NeurosurgeryNeurosciences CenterKing Fahd Medical CityRiyadh, Saudi Arabia

Tamer Altay, MD (Neuroradiology)

Assistant Professor Department of NeurosurgeryUniversity of Arkansas for Medical SciencesLittle Rock, Arkansas

Gmaan Alzahrani, MD (Cranial Neurosurgery–Pediatric)

Neurosurgery ResidentDepartment of NeurosurgeryNeurosciences Center King Fahd Medical CityRiyadh, Saudi Arabia

Walid I Attia, MD, MSc, PhD (Spine)

Subspecialty Consultant Neurosurgery Department, Spine Surgery DepartmentDirector, Spine Fellowship Program

Neurosciences Center King Fahd Medical CityRiyadh, Saudi Arabia

eman Bakhsh, MD (Neuroradiology)

Subspecialty Consultant NeuroradiologistDiagnostic Neuroradiology SectionDepartment of Radiology

King Fahd Medical CityRiyadh, Saudi Arabia

Leonardo Rangel Castillia, MD (Neuropharmacology)

Neurosurgery ResidentThe Methodist Neurological InstituteHouston, Texas

Cristian Gragnaniello, MD (General)

NeurosurgeronDepartment of NeurosurgeryAustralian School of Advanced MedicineMacquarie University

Sydney, Australia

Nazer Qureshi, MD (Cranium)

Chief, Division of NeurosurgeryBaptist North Little Rock HospitalNorth Little Rock, Arkansas

Ali Raja, MD (Cranium)

Assistant Professor Department of NeurosurgeryUniversity of Arkansas for Medical SciencesLittle Rock, Arkansas

Bahauddin I Sallout, MD (Cranial Neurosurgery—

Pediatric)

Chairman, Department of Maternal-Fetal MedicineConsultant, Obstetrician and GynecologistSubspecialty Consultant Maternal-Fetal MedicineWomen’s Specialized Hospital

King Fahd Medical CityRiyadh, Saudi Arabia

Michael Zwillman, MD (Neuropharmacology)

Assistant Professor Department of Anesthesiology and Neuro Critical CareThe Methodist Neurological Institute, Houston, TX

 Contributors

Neurosciences CenterKing Fahd Medical CityRiyadh, Saudi Arabia

Khaled N Almusrea, MBBS, FRCSC

Chairman, Spine Surgery DepartmentSubspecialty Consultant Neurosurgeon, Spine SurgeonDepartment of Spine, Department of NeurosurgeryNeurosciences Center

King Fahd Medical CityRiyadh, Saudi Arabia

Neuropathology

Manuel B Graeber, MD (Neurology)

Professor of NeuropathologyDivision of NeuropathologyDepartment of Pathology and Clinical Laboratory Medicine

Neurosciences CenterKing Fahd Medical CityRiyadh, Saudi ArabiaThe Brain and Mind Research InstituteUniversity of Sydney

Sydney, Australia

Referencing

Irish L Matlock, RN (Neurology)

Department of NeurologyUniversity of Arkansas for Medical SciencesLittle Rock, Arkansas

Spine

Milan G Mody, MD

Orthopedic Spine SurgeonWillis Knighton Spine InstituteShreveport, Louisiana

Contributors i

Content ReviewerJaime Gasco, MD

Chief Resident PGY-6UTMB Division of NeurosurgeryThe University of Texas Medical BranchGalveston, Texas

ii Contributors

2 What are the major branches of the ECA?

The  mnemonic  SALFOPSI  is  very  useful  in  remembering the branches of the ECA in ascending order (proximal to 

Facial artery

Posteriorauricular arteryOccipital artery

Fig. 1.1  External carotid artery and branches.  (From THIEME  Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2007, Illustration 

by Karl Wesker 2 )

5 What classical clinical findings occur in an occlusion

of the anterior choroidal artery?

Facial artery

Posteriorauricular artery

Occipital artery

Fig. 1.1  External carotid artery and branches.  (From THIEME 

Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2007, Illustration 

by Karl Wesker 2 )

11 Which large anastomotic vein joins the veins of the sylvian fissure with the transverse sinus?

Inferioranastomoticvein (of Labbé)

Superioranastomotic vein(of Trolard)

Fig.  1.  Superficial  venous  anatomy  of  the  brain. (From  THIEME Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2007, Il- lustration by Markus Voll 2 )

8 What are Virchow-Robin spaces?

The spaces between the blood vessels and the arachnoid and pia layers within the brain and spinal cord

9 Which sinus courses within the attachment of the tentorium to the petrous ridge?

  I  Basic Neurosciences 

13 What is the most constant branch of the hypophyseal trunk?

meningo-The tentorial artery. It passes forward to the roof of the cavernous sinus and then posterolaterally along the free edge of the tentorium. It sends branches to cranial nerves (CNs)  III  and  IV.  Bernasconi  and  Cassinari  first  reported 

14 Which branch of the intracavernous carotid artery passes between CN VI and the ophthalmic division of the trigeminal nerve?

15 What is the venous angle as seen on a lateral view of

a cerebral angiogram?

The angle is formed by the junction of the thalamostriate vein and the internal cerebral veins at the thalamic tubercle. 

Petrouspart

Cerebralpart

Inferior hypophysealartery

Marginal tentorial branchBasal tentorial branch

b

Fig.  1.  Internal  carotid  artery  and  branches. (From  THIEME  Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2007, Illustration 

by Karl Wesker 2 )

1  Neuroanatomy: Cranial  

Inferior vestibular nucleus

Inferior cerebellar peduncleNucleus ambiguusCochlear nucleusSpinal nucleus of the trigeminal nerve

Lateral spinothalamic tract

Fig 1.5 Cross-section  of  the  medulla  with  outlined  blood 

 Mumenthaler and Matte 9 )

17 What is the most likely clinical symptom in a tient with a large unruptured cavernous sinus carotid aneurysm?

pa-Ipsilateral  sixth  nerve  palsy.  The  cavernous  sinus  contains 

18 Which artery is the most common cause of lateral medullary syndrome?

Also known as Wallenberg syndrome, it is most commonly due  to  occlusion  of  the  vertebral  artery  on  the  ipsilateral side. This syndrome results from infarct in the region sup-plied by the posterior inferior cerebellar artery (PICA), which 

  I  Basic Neurosciences 

Branches tothalamic nucleiPosteromedialcentral arteriesPosterior cerebral artery

Lenticulostriate arteriesMiddle cerebral arteryAnteriorchoroidal artery

23 What is the most common artery involved in sopharyngeal neuralgia?

19 What is the arterial supply of the thalamus?

Branches of the posterior communicating arteries and the perimesencephalic portion of the posterior cerebral arter-

1  Neuroanatomy: Cranial  11

24 What is the main arterial supply of the internal sule?

cap-striate branches from the middle carotid artery (MCA), the medial striate artery from the ACA, and the direct branches from the ICA. The anterior choroidal artery comes off the 

28 What external landmark on the skull marks the eral margin of the sphenoid ridge and sylvian fissure?

Fig. 1.10 

Craniometric points and sutures. Named bones ap-pear in all upper case letters. Abbreviations: GWS 5 greater wing of sphenoid bone, NAS 5 nasal bone, stl 5 superior tem-poral line, zyG 5 zygomatic. Sutures: cs 5 coronal, ls 5 lamb-doid, oms 5 occipitomastoid, pms 5 parietomastoid, sms 5 

31 Which cranial fossa is the largest?

The  posterior  cranial  fossa.  It  is  also  the  deepest  of  the 

three cranial fossas (Fig 1.11).

1  Neuroanatomy: Cranial  1

32 What are the boundaries of the suboccipital triangle?17The suboccipital triangle is a region bounded by the fol-lowing three muscles:

34 What sutures make up the asterion?

The  lambdoid,  parietomastoid,  and  occipitomastoid  tures.  It  is  an  important  landmark  to  define  the  lower half of the junction of the transverse and sigmoid sinuses 

35 Which bones make up the osseous nasal septum?

The  perpendicular  plate  of  the  ethmoid  and  the  vomer 

Hypoglossalcanal

Foramenlacerum

ForamenovaleForamenspinosum

Internalacoustic meatusJugular foramenPosterior fossa

Fig. 1.11  Interior view of the skull base. (From THIEME Atlas of  Anatomy, Head and Neuroanatomy, © Thieme 2007, Illustration by Karl  Wesker 2 )

1  I  Basic Neurosciences 

36 What are the compartments of the jugular foramen?

Pars venosa (posterolateral), which contains the sigmoid sinus, jugular bulb, and CNs X and XI

Pars  nervosa  (anteromedial),  which  contains  CN  IX  and 

37 What structure does the abducens nerve go through

to enter the cavernous sinus?

Vome

Fig. 1.1  Nasal septum innervation. (From THIEME Atlas of Anatomy,  Head and Neuroanatomy, © Thieme 2007, Illustration by Karl Wesker 2 )

1  Neuroanatomy: Cranial  1

Inferior petrosal sinusPosterior meningeal arteryAccessory nerve

Glossopharyn nerveVagus nerveInternal jugular vein

Jugular Foramen

Internal jugular vein

Jugular Foramen

geal nerveVagus nerve

Glossopharyn-Accessory nerveInferior petrosal sinusPosterior meningeal artery

Internal Acoustic Meatus

Labyrinthine artery and veinVestibulocochlear nerveFacial nerve

Fig. 1.1  Foramina of the skull base with exiting structures. 

(From  THIEME  Atlas  of  Anatomy,  Head  and  Neuroanatomy,  ©  Thieme 

2007, Illustration by Karl Wesker 2 )

1  I  Basic Neurosciences 

Fig. 1.1  Lateral ventricle and choroid plexus location. (From  THIEME  Atlas  of  Anatomy,  Head  and  Neuroanatomy,  ©  Thieme  2007,   Illustration by Markus Voll 2 )

Collateral atrium Anterior horn of

lateral ventricle Posterior horn

of lateral ventricle

52 What are the circumventricular organs?

These  are  areas  where  the  blood–brain  barrier  is  absent. 

Seven different such areas have been identified (Fig 1.17):

1.  Pineal gland

2.  Subforniceal organ

3.  Organum vasculosum of the lamina terminalis

4.  Median eminence of the hypothalamus

56 Two pairs of small swellings can be seen in the floor

of the 4th ventricle, the lateral and medial ridges What

do these structures represent?

The  lateral  ridges  constitute  the  vagal  trigone  and  cate the location of the underlying dorsal motor nucleus 

indi-of the vagus. The medial ridges constitute the hypoglossal 

0  I  Basic Neurosciences 

Fig.  1.1  Brainstem  schematic  anatomy,  posterior  view. 

AqD,  Aqueduct  of  Sylvius;  N,  nucleus;  IC,  inferior  colliculus; 

MS, median sulcus; Vm, mesencephalic N. of the 5th cranial nerve  (V);  Vcs,  chief  (sensory)  N.  of  V;  Vms,  motor  (masti-cation)  N.  of  V;  MLF,  medial  longitudinal  fascicle;  FC,  facial colliculus;  IV,  trochlear  N.;  CTT,  central  tegmental  tract;  SL, sulcus limitans; SLI, sulcus limitans incisure; HT, hypoglossal triangle; SM, striae medullaries; SCP, MCP, and SCP, superior, middle and inferior cerebellar peduncle; VT, vagal triangle; AP, area postrema; Obx, obex; VI, abducent N.; VII, facial N. and fiber tracks and nerve; VIII, vestibular N.; XII, hypoglossal N.; 

Xd, dorsal vagal N.; Am, N. ambiguus of 9th and 10th cranial nerves with parasympathetics on its medial border; Ss and Si, superior and inferior salivatory Nn.; ST, spinal trigeminal tract; 

STT, spinothalamic tract; ML, medial lemniscus; ION, inferior olivary N.; P, pyramid; TB, trapezoid body; Pn TPF, pontine N. 

1  Neuroanatomy: Cranial  1

57 What is the outlet of the 4th ventricle?

There  are  two  laterally  located  foramina  of  Luschka  and 

Cortex Hypothalamus

3 rd

order neuron

Ophthalmic

Long ciliary nerves

ganglion

2 nd division of

Pupillary dilator

Superior orbital fissure

order neuron

Sweat fibers

Internal and external carotid Sympathetic Chain

T1 Intermedio lateral gray A.J.Sabbagh MD 2006

Fig.  1.1  Schematic  representation  of  Horner  syndrome. 

(Reprinted with permission from Nader and Sabbagh 21 )

64 What type of nerve fibers does the vidian nerve carry?

sal nerve and sympathetic fibers from the deep petrosal nerve around the ICA. The nerve passes in the pterygoid canal with the vidian artery

Parasympathetic fibers from the greater superficial petro-65 What kind of fibers does the intermediate nerve (nervus intermedius) carry?

This  is  the  sensory  and  parasympathetic  division  of  the facial nerve. The intermediate nerve carries preganglionic parasympathetic fibers from the superior salivary nucleus that  synapse  in  the  pterygopalatine  and  submandibular ganglia.  It  also  carries  taste  sensation  from  the  anterior 

1  Neuroanatomy: Cranial  

66 What provides the parasympathetics of the parotid glands?

The glossopharyngeal nerve. These parasympathetic fibers originate  from  the  inferior  salivatory  nucleus  and  travel via CN IX. These fibers synapse in the otic ganglion before 

Facial nerve

Superior salivatory nucleus

Submandibularganglion

palatineganglion

Pterygo-Fig. 1.0  Parasympathetic visceral innervation of the facial 

Thieme 2007, Illustration by Karl Wesker 2 )

Glossopharyngealnerve

Parotidgland

Oticganglion

Lesser petrosalnerve

Tympanicplexus

Fig.  1.1 

(From THIEME Atlas of Anatomy, Head and Neu-roanatomy, © Thieme 2007, Illustration by Karl Wesker 2 )

  I  Basic Neurosciences 

The Meninges

67 What are the leptomeninges?

The arachnoid and pia mater. The pia and arachnoid layers have a common embryologic origin (ectoderm), whereas 

CortexPia

ArachnoidDura

Tightjunctions

Fig.  1.  Meningeal  cross-sectional  anatomy. (From  THIEME  Atlas of Anatomy, Head and Neuroanatomy, © Thieme 2007, Illustration 

by Karl Wesker 2 )

1  Neuroanatomy: Cranial  

69 What separates the interpeduncular cistern from the chiasmatic cistern?

The Liliequist membrane. The Liliequist membrane is an arachnoidal sheet extending from the dorsum sellae to the 

7

8 9 10 1112

18 17 19 37 20 28 38 34 25

23 30

6 8 9

44 45 11

4

7 40

1817 37

21

41

20 38

Central sulcus

ParietooccipitalsulcusCalcarinesulcus

72 What is the indusium griseum?

sal surface of the corpus callosum (the supracallosal gyrus). It contains two longitudinally directed strands of fibers termed 

DentategyrusFornix

Fig. 1.  Fornix, corpus callosum, and septum pellucidum. 

(From  THIEME  Atlas  of  Anatomy,  Head  and  Neuroanatomy,  ©  Thieme 

2007, Illustration by Markus Voll 2 )

77 What deficit would result from a lesion of the right Meyer’s loop?

78 What clinical finding is seen when there is a lesion

of the posterior part of the middle frontal gyrus?

Conjugate eye deviation toward the ipsilateral side. This is area 8, the cortical lateral conjugate gaze center. Stimula-tion of this area results in eye deviation toward the con-tralateral side

79 The hypothalamus receives fibers from the dala via which bundle?