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Neurosurgery

Congenital anomalies
Types & definitions
Encephalocele
Craniosynostosis
Arachnoid cyst

Cystic malformation in which CNS structures in communication with


CSF pathways herniated through a cranial defect

It is the pre-mature fusion of one or more cranial sutures separating


the membranous bones of the skull
Collection of CSF surrounded by a membrane resembling arachnoid
matter

Agenesis of corpus callosum: Complete absence with distortion of ventricles


Cranial

anomalies

Arnold-chiari
malformation

Dandy-walker cyst
Aqueductal
stenosis

Congenital
hydrocephalus

Chronic herniation of hindbrain through foramen magnum (4 types:


Chiari I-IV)

Cystic dilatation of the 4th ventricle with varying degrees of agenesis of


the cerebellar vermis
Narrowing of the aqueduct of Sylvius with dilatation of the
supratentorial ventricular system

Abnormal increase in CSF volume within the brain ventricles resulting


in ventricular dilatation that usually presents after birth with an
enlarged head

Spina bifida
occulta

A posterior bony defect of the vertebra due to incomplete closure of


the laminar arch.

The skin overlying the defect is often marked with a colored nevus
or tuft of hair

This is herniation of a sack of Dura and Arachnoid filled with CSF

Spinal

anomalies

Meningocele

outside the confines of the spinal canal through a localized posterior

Myelomeningo-

This is herniation of dysplastic neural tissue in a dural-lined sac filled

cele

with CSF through a localized posterior spina bifida

Myeloschisis

spina bifida

Complete dehiscence of the neural tube manifesting as gross defect in


neurulation involving neural, osseous and cutaneous structures

This is an epithelium-lined tract in the midline along the spine that

forms a potential communication between the skin-surface and the


Congenital spinal
dermal sinus

deeper tissues

It may be found anywhere from the midsacrum to the cervical area


and may terminate in the subcutaneous tissues on the posterior

elements of the spine, in the epidural or intradural space or the


neural elements

Subcutaneous lipoma that overlies the lumbar or sacral spine, and


Lumbosacral
lipoma

extends through a posterior spina bifida to an extradural or intradural

location to attach to a low-lying conus medullaris, the cauda equine or


the filum terminale

Sacrococcygeal

Congenital tumor that develops from totipotential cells in the area of

teratoma

Hensens node, which migrated caudally to lie within the coccyx

Tethered cord

Abnormally low conus medullaris tethered by one or more forms of

syndrome

intradural abnormality

Partial or complete division of a variable length of spinal cord into


two hemicords of more or less equal caliber

In complete cases, a septum of bone, cartilage or fibrous tissue is


present between the hemi-cords in which case each hemicord is

Diastematomyelia

surrounded by its own dural sheath

In partial forms: no septum is present and a single dural tube


usually surrounds both hemicords

When the split doesnt reunite distally, the condition is referred to


as Diplomyelia

Congenital

syringomyelia

It is tubular dilatation of the central canal within the spinal cord


extending over many segments

Hydrocephalus
Definition

It is a hydrodynamic disorder of the CSF circulation characterized by abnormal increase in


CSF volume within the brain ventricles with or without associated increase of ICP

CSF

CSF is produced by filtration from choroid plexus, in lateral and 4th ventricles
It passes from lateral ventricles through foramina of Monro to 3rd ventricle

Then it passes through the aqueduct of Sylvius to the 4th ventricle

The main volume of CSF then passes through the central foramen of Magendi and lateral

circulation

foramina of Luschka to the sub-arachnoid space

In the sub-arachnoid space it is absorbed through arachnoid villi and granulations into
the superior sagittal sinus

A small volume of CSF exits 4th ventricle to the central canal of the spinal cord
1. Genetic-induced hydrocephalus (Bickers Adams syndrome)

Congenital causes

2. In utero infections/Ischemia
3. Aqueductal stenosis

4. Arnold Chiary syndrome (Type II & III)

Causes

5. Dandy-walker Cyst // Arachnoid cyst


Acquired causes

Post meningitic

Intracerebral , Subarachnoid or intraventricular haemorrhage

Brain tumors

Obstruction
Pathogenesis

Malabsorption

Flow obstruction: due to increased CSF viscosity mainly due to

Agenesis or hypoplasia of arachnoid villi and granulations

Superior sagittal sinus venous thrombosis or obstruction

Choroid plexus hyperplasia or papilloma


Due to atrophy of the periventricular brain mantle thus enlargement of

Exvacu

ventricles

Communicating
classification

Mass obstruction: due to block of ventricles by tumor or hemorrhage


increased proteins as in post hemorrhagic and post infectious

Hyper-secretion

Pathologic

(non-obstructive)
Non-

communicating
(obstructive)

Agenesis or hypoplasia of arachnoid villi and granulations

Choroid plexus hyperplasia or papilloma

Post-meningitic

Post-haemorrhagic

Aqueductal stenosis

Brain tumors

Occurs in infants before closure of the skull sutures manifested by:

Poor suckling & feeding and high pitched cry

Abnormal progressive enlargement of the head i.e. abnormal increase in the


head circumference more than the normal percentile for age. Characterized
by being bilateral, symmetrical and globular with cephalofacial disproportion

Infantile

Separation of skull sutures

Wide, tense, bulging fontanelles, especially the anterior fontanelle

Dilated scalp veins

Loss of upward gaze Parinauds sign which further proceeds to downward


deviation of the eyeballs Sun-set appearance

Clinical
picture

Cranial nerve palsies specially the (VI) nerve

Seizures

Late in the course, there may be UMNL paraparesis which is explained by

stretch and ischemia of the descending periventricular lower limb fibers or


due to associated syringomyelia

Delayed developmental milestones

In children and adults after closure of the skull sutures, manifested by symptoms
Adult

and signs of increased ICP: headache vomiting blurred vision bilateral


papilledema impaired consciousness

Normal
pressure

Elderly patients

Manifested by a triad of (Dementia Gait disturbance Urinary


incontinence)

Diagnosis

Plain skull

Shows large skull with cephalo-facial disproportion and widely-

radiography

separated sutures and fontanels

CT brain & MRI

Show the dilated ventricles and the cause of obstruction in non-

brain

communicating hydrocephalus

Familial hydrocephalus bone disease (rickets) arachnoid cyst

DD of large head

infantile chronic subdural hematoma

Aim

Treatment of the cause

CSF diversion i.e. shunting

a) Elimination of the obstructing lesion

Excision of brain tumor

Evacuation of intracerebral hematoma

b) Placement of shunt device


Treatment

Procedures

(Strictly

surgical)

Ventriculoperitoneal

Ventriculoatrial

Ventriculopleural

Lumboperitoneal shunt

c) Endoscopic procedures

Complication to
shunts

Endoscopic aqueductoplasty

Endoscopic aqueductoplasty

Infection: Ventriculitis Peritonitis Pseudocysts endocarditis

Obstruction

Disconnection: Migration intestinal perforation extrusion

Overdrainage: Subdural hematoma Craniostenosis

Craniosynostosis

Definition

It is the condition in which one or more of the fibrous sutures in an infant skull
prematurely fuses by ossification, thereby changing the growth pattern of the skull

Because the skill cant expand perpendicular to the fused suture, it compensates by
growing more in the direction parallel to the closed sutures

Frontal

(metopic;
Trigonocephaly)
Saggital
Types

(Scaphocephaly)
Unicoronal
(anterior
plagiocephaly)

There is ridging of the metopic suture with bilateral flattening of the


frontal bones and anterior displacement of the coronal suture

There is ridging of the fused saggital suture with frontal and occipital
bossing and flattening of parietal bones

The head is elongated anteroposteriorly

Ridging of half of the coronal sutures and flattening of the ipsilateral


frontal and parietal bones

The orbit is deformed due to elevation of the sphenoid ridge


(commonly called harlequin eye


Bicoronal

There is ridging of the coronal suture and flattening of the caudal


portion of the frontal bones and supraorbital ridges

(brachycephaly)

The skull is broad and short, with expansion in the lateral directions
and bilateral harlequin configuration of the orbit

Could be part of congenital craniofacial syndromes: (Apert/Crouzon


syd)

Lambdoid
(posterior

plagiocephaly)

Ridging of the fused lambdoid suture with flattening of the parietooccipital region ipsilateral to the fused suture

Pansynostosis
(craniostenosis;

Skull assumes a towering shape

oxycephaly)

Cosmotic disfigurement

Neurological: More common when 2 or more sutures undergo premature fusion

Clinical

o Restrained brain growth: this may result in mental retardation, motor impairment and

manifestations

optic atrophy

o Increased ICP: estimated risk: 50% pansynostosis 26% bicoronal 12% unicoronal
8% saggital 6% frontal

DD

Microcephaly

Postnatal positional moulding

Plain skull radiography: shows the suture fusion and the associated cranial and orbital
deformity, if present

Investigations

CT/MRI brain: required in patients with coronal metopic or lambdoid synostosis it may
show associated intracranial anomalies such as hydrocephalus, agenesis of the corpus
callosum

Treatment

Synostectomy: reopening of the prematurely-closed suture

Cranial remodeling & orbital advancement in selected cases

Myelomeningocele

Definition

localized posterior spina bifida

The most common site is lumbosacral

This is the most common form of spinal dysraphism

Clinical
picture

It is a herniation of dysplastic neural tissue in a dural lined sac filled with CSD through a

The protruding sac is usually covered with a translucent membrane of modified


meninges and skin called the placode

The lesion is soft, but the fluid is usually cant be compressed easily from the sac into the
spinal canal owing to the small communication with the subarachnoid space

Transillumination produces poor glow

The head circumference may be enlarged due to associated hydrocephalus

Neurological examination shows variable degrees of motor weakness, sensory deficits and

sphincteric disturbances
DD

Meningocele lipomyelomeningocele lumbosacral lipoma sarcococcygeal teratoma


Plain spine XRay

Investigations

Posterior spina bifida

Widened interpedicular diameter of the spinal canal at the level of the


defect

MRI spine

Deformity associated tethered cord or associated syringomyelia

MRI head and


craniocervical
junction
Treatment

Hydrocephalus

Chiari malformation

Prevention through dietary supplementation with folic acid

Excision of the sac, untethering of the cord and repair of the dysrahphic defects

Meningocele

Definition

Clinical picture

Herniation of a sac of dura and arachnoid filled with CSF through a localized posterior
spina bifida

The most common site is the lumbosacral region

The protruding sac is usually covered with normal skin

The lesion is soft, and the fluid is compressed easily from the sac into the spinal canal

Transillumination produces a brilliant glow

The head circumference is usually normal, and the anterior fontanelle is lax because
active hydrocephalus is rare in the immediate neonatal period
Myelomenongocele

Meningocele

Overlying skin

Defective

Intact

Cosistency

Doughy

Soft

Compressibility

Partially compressible

Totally compressible

Transilluminatn

Partially illuminated

Totally illuminated

Associated

Intact

65%

Rare

Neurological
deficits
Hydrocephalus

Head trauma
Epidemiology

Causes

It is considered to be a major cause of death

It occurs at all age groups and in young adults

Males are more affected than females

Road traffic accidents (RTA; most common)

Assault by blunt or sharp object

Falling from a height

Falling of heavy object over the head

Blast injuries

Birth injuries

2 main

Simple: Concussion without scalp, bone or brain injury

groups

Compound: head injury associated with scalp wounds, bone fractures and/or brain injury

Derived from the latin word concutere which means to shake

Concussion

It means transient loss of consciousness after head trauma without evidence of brain
damage

Followed by complete recovery

May be associated with retrograde amnesia for less than 24 hours

Scalp wounds
Types

Cut wounds

Contused, lacerated wounds

Penetrating wounds

Blood collection under the scalp, usually it resolves spontaneously without aspiration or

Scalp

drainage. It may be:

hematoma

o Subcutaneous

hematoma)

o Subglial: moves freely between the subtemporal line, supraorbital and superior nuchal

(Cephal-

o Subperiosteal (Stop at the suture line)


line: the cause of black eye

Skull fractures
Vault fractures

Types

Fissure (linear) fracture

Depressed simple or comminuted fracture

And in the above types, the fracture may be:

Simple: i.e. without an external wound

Compound: i.e. with an external wound and risk for infection

In fissure fractures without complications (i.e. underlying hematoma) no surgical


treatment is required, just close observation not to develop underlying extradural

Treatment

hematoma

Depressed and comminuted fractures: the fracture site is explored and the depressed

fracture must be elevated to its original site. Debridement will be required in compound
fracutres

Depression is > 1 cm

Indications

Gross cosmetic deformity

for elevation

Wound infection or gross wound contamination

of depressed

Frontal sinus involvement

fracture

include

Clinical or radiological evidence (CT) or dural penetration (CSF leak, intradural


pneumocephalus etc)

Presence of significant intracranial hematoma


Skull base fractures

May include cranial nerve injuries and more commonly, injury of the basal dura with CSF fistula formation

Anterior cranial

fossa fracture
Classification

fracture
Posterior cranial
fossa fracture
Treatment

Subconjunctival hemorrhage, Raccons eyes (periorbital


hematoma)

Middle cranial fossa

Epistaxis, CSF rhinorrhea

Olfactory nerve affection

Bleeding per ear

CSF otorrhea

Affection of the 7th and 8th cranial nerve

Battle sign: bluish color behind the ear

Brain stem affection

Atlanto-axial sublaxation

Broad spectrum antibiotic must be given to safe guard against meningitis, especially, in
cases with CSF leak

Cranial nerve repair may be done in some cases as the facial nerve
Growing skull fractures

A fracture associated with post-traumatic meningocele or meningoencephalocele that occur in children

The cyst lies in between the bone edges and by continuous pulsations, the fracture gap grows and widens

Treatment

Repair of the post-traumatic cyst, but if the gap is wide, cranioplasty is indicated either by an
artificial material or bone graft

Pathological processes involved in head trauma


Direct

Occurs in penetrating head injuries; in contrast with blunt trauma which produces

trauma

widespread effect
Definition

Brain edema
Causes

Increase of the interstitial fluid in the brain leading to the increase of ICP

Could be focal or diffuse

Disturbance of the vasomotor tone

Hypoxia, hypercapnia

Electrolyte imbalance

Position: elevation of the head of the bed 30-45 degrees

Properventilation and endotracheal intubation

Treatment

Dehydrating medications: Mannitol infusion (1 gm/kg) + Lasix (40


mg/12hrs)

ICP monitoring: using external ventricular drainage

High dose barbiturate

Surgical: unilateral brain edema can be treated by decompressive


craniectomy and extension duroplasty

Cerebral

A bruise of the brain tissue, which can be associated with multiple microhemorrhages, small

contusion

BV leaks into brain tissue

Cerebral

A similar injury except that the pia-arachnoid membranes are torn over the site of injury in

laceration

laceration and not torn in contusion

Burst lobe

Extensive contusion associated with subdural hematoma

Coup and
countercoup

A group of focal brain injuries

The coup injury occur under the impact point where countercoup injuries occur at areas
distant from the point of impact, as a result of shock waves across the brain causing

injuries

stress/cavitations effects

Despite the absence of any intracranial mass lesion or history of hypoxia, some patients
remain unconscious after a TBI

Diffuse

axonal

injuries (DAI)

The usual cause for persistent impairment of consciousness is the condition referred to as
diffuse axonal injury

It is the result of traumatic shearing forces that occur when the head is rapidly accelerated
or decelerated

It results in injury of the axons at the interface between the grey and the white matter

Non-communicating: due to obstruction of the 4th ventricle by blood clot or cerebellar

Hydrocephalus

swelling

Communicating: due to subarachnoid hemorrhage that will decrease the absorption from
the arachnoid villi

Intracranial hemorrhage

More common in the younger age group as the dura is able to strip more readily from the
overlying bone

Extradural
hematoma

Associated with fissure fractures in 90% of cases

Source of

Arterial: middle meningeal artery

bleeding

Venous: middle meningeal vein venous sinuses Diploic veins

75% in the temporal area (due to middle meningeal vessels)

25% in the frontal/parietal/occipital/posterior fossa areas

Site
Clinical

Slowly

presentation accumulating

Stage of concussion

Stage of lucid interval: interval in which the patient

regains consciousness after concussion and before it


is lost once more in the stage of compression

Rapidly
accumulating

Stage of compression

Patients present with stage of compression directly


Signs of

Severe headache. Vomiting and

increased

deterioration of the level of consciousness

ICP

Due to uncal herniation

Stage of
compression

Signs of

Ipsilateral dilated fixed pupil

Ipsilateral conjugate eye deviation

lateralization

Contralateral hemiparesis

Contralateral exaggerated reflexes


and positive Babiniski

Occurs with any space-occupying lesion


Subfalcine

herniation

No clinical effect
Lateral
tentorial
(uncal)

Brain shift
Tentorial

Central

tentorial

Fixed dilated ipsilateral pupil due to compression


of the 3rd nerve

Deterioration of level of consciousness

Diabetes insipidus

herniation

Bilateral initially constricted then dilated


pupils

More depression of the level of consciousness


Tonsillar

herniation

and cushing triad

Hypertension

Bradycardia

Diagnosis

Cheyne-stoke breathing

CT scan is the best diagnostic tool

It will show hyperdense byconvex hematoma with compression of the


underlying brain and may cause distortion of the lateral ventricle

Considered as a surgical emergency & will result in death if not removed


promptly

Treatment

Urgent evacuation of the EDH is required through craniotomy, stopping of


the source of bleeding using (Bipolar coagulation, gel foam, bone wax and
dural hitch stitches)

Usually presents in the context of a patient with severe head injury whose
neurological state is either failing to improve or deteriorating

Acute

Over 80% have associated fracture of the cranial vault or the skull base

Source

Cortical laceration or focal tear of a cortical artery

Diagnosis

CT brain: white (hyperdense) concave hematoma

Considerable sizes should be evacuated surgically by


craniotomy

Treatment

If associated with severe edema and midline shift,


decompressive craniectomy will be done and extension
duroplasty

Sub-acute

Bad prognosis

4-21 days

CT brain = isodense concave hematoma

hematoma

(Adults)

More than 21 days

Usually in old patients (atrophic mobile brain) on anti-coagulant

Bilateral in 25% of cases

Subdural

Source

Bridging veins

Clinical
Chronic

deficit (contralateral weakness or dysphasia) with history of

presentation

trivial trauma

Diagnosis

Old patients with gradual development of a neurological

However, it may happen without history of trauma

CT brain: hypodense concave hematoma usually large in size


with midline shift

Old hematomas are liquefied, therefore evacuation is done


through burr hole and postoperative adequate hydration

Treatment

(IV fluids)

Good prognosis

Birth trauma

It occurs also in battered children, violent shaking of an infant may be sufficient to


lacerate bridging veins

Subdural

hematoma in
infancy

Site

Bilateral in 85% of cases and usually over the frontoparietal area

Clinical

Usually presents with large sized head (as the sutures are non-fused) and

presentation nonspecific symptoms as irritability and failure to thrive


Diagnosis
Treatment

Sub-arachnoid hemorrhage

CT scan: bilateral concave isodense/hypodense hematomas

Can be done by aspiration, which can be repeated

Refractory subdural collection (hygroma) can be treated by subduroperitoneal shunt

Occurs either as a result of penetrating injury (missile injury), a depressed fracture or


following a severe head injury
Clinical

presentation
Intracerebral

Diagnosis

Depends upon the site and the size of hematoma


CT scan will show the size and the position of the hematoma

hemorrhage

Depends upon the site and size of the hematoma as well as its clinical
presentation

Treatment

Indications for surgery:


o Large sized superficial hematoma causing mass effect (brain shift and
increase intracranial pressure)

o Posterior fossa hematoma as it is a very tight space


Intra-ventricular hemorrhage

Management of head injuries

ABC: maintenance of adequate airway, breathing and circulation

Accurate neurological assessment

Evaluation of other injuries (spine, chest, fractures)

Urgent transfer to hospital

Glasgow coma scale

Assessment of sings of lateralization (pupils and neurological deficit)

Determine the cause, site and type of traumatic brain injury

Eye opening

Best verbal
Neurological

response

assessment

Best motor
response

Spontaneous

To speech

To pain

None

Oriented

Confused conversation

Inappropriate words

Incomprehensible sounds

None

Obey commands

Localizes pain

Withdrawal (normal flexion)

Abnormal flexion (decorticate)

Extension (Decorticate)

None

Glasgow coma scale

The 15 points GCS is the most commonly used neurologic injury severity scale for adults
because of its high inter-observer reliability and generally good prognostic capabilities

Severity of TBI: it is generally agreed that TBI with GCS of 13 or above is mild, 9-12 is
moderate and 8 or below is severe

Intubation is mandatory if GCS <8 as the patient wont be able to protect his airway

Lab
Investigations

CBC

Blood grouping for expected blood transfusion

Coagulation and bleeding profiles

ABG

Plain X-ray Skull/Cervical spine

Plain X-ray chest and U/S abdomen if needed for associated injuries in

Radiology

major trauma especially in RTA

CT scan brain: gold standard in diagnosis of traumatic brain injury

MRI brain: have some value in diagnosis of diffuse axonal injury

Spinal cord compression

It is a common neurosurgical problem

Compression of the cord can occur at any level from the cervicomedullary junction to the

Overview

conus medullaris at L1

It this condition is not recognized and treated, the eventual outcome will be disabling
paralysis and sphincteric disturbance

The spinal cord can be compressed by


Pathology

Extradural lesions in 80%

Intradural, extramedullary lesions in 15%

Intradural, intramedullary lesions in 5%

Traumatic
Tumors
Causes

(surgical
causes of
back pain)

Infection

Fracture spine Hematoma Traumatic disc

Extradural: e.g. metastasis and lymphoma

Intradural extramedullary e.g. meningioma and neurofibroma

Intradural intramedullary e.g. ependymoma and astrocytoma

Acute: staphylococcal

Chronic: TB which can be extradural or intradural

Disc diseases & spondylosis


Hematoma
Congenital

cystic lesions

All can be extradural, intradural or intramedullary

AVM

Spontaneous

Intradural extramedullary: arachnoid cyst

Intradural intramedullary: syringomyelia

Spondylolithesis

Clinical presentation

Root: severe, sharp, shooting, burning pain radiating into the cutaneous distribution or
muscle group supplied by the root; aggravated by movement, straining or coughing

Pain

Segmental: continuous, deep aching pain radiating into whole leg or one half of the body;
not affected by movement

Bone: continuous dull-aching pain and tenderness over affected area, may or may not be
aggravated by movement

Neurological
deficit

According to
the level of

compression

Cervical

Spastic quadriparesis with manifestations of UMNL in

spine

upper/lower limbs

Dorsal

Spastic paraparesis or paraplegia with manifestations of UMNL

spine

in lower limbs

Paraparesis or paraplegia with mixture of UMNL and LMNL


Conus

medullaris

manifestations in lower limbs

Complete

Loss of all motor, sensory and autonomic functions below the

cord syd

level of injury

Anterior

Anterior corticospinal tract injury motor affection mainly in

Posterior

Dorsal column injury, affection of proprioception and vibration

cord syd

sense

Central

Weakness (UL>LL; Proximal>distal; UL/Proximal fibers are more

cord syd

medial than the LL/distal)

cord syd

According to

the lower limbs

the part of the

o Loss of motor function due to affection of

cord

compressed

At level of lesion:

anterior horn cells (LMNL)

Brown-

o Loss of sensory function due to affection of

Same side

Sequard
syndrome

posterior horn cells

Below the lesion:

o Motor paralysis (corticospinal tract)

(Cord

o Loss of proprioception and vibration sense

hemi

(posterior column)

section)

Contralateral Loss of pain and temptrature sensation below the


side

level of the lesion (lateral spinothalamic tract)

UMNL

LMNL

Below the level of the lesion

At the level of the lesion

Minimal wasting

Maximal wasting

Increased

Decreased

Clonus

Present

Absent

Fasciculation

Absent

Present

Paralysis
Muscle state
Tone

Reflexes
Sphincters

Deep: Hyperreflexia

Deep: Hyporeflexia

Superficial: abdominal: absent,

Superficial: abdominal: present,

plantar: extensor (+ve Babiniski)

plantar: flexor/absent

Urgency and automatic urinary

Retention with overflow hypotonic

bladder (spastic bladder)

bladder (flaccid bladder)

Spinal fracutre

Epidemiology

More common in males

More common in 2nd and 3rd decades

Fracture of the spine is rare in children due to laxity of the ligaments, however, spinal cord
injury can occur

Spinal cord injury without fracture can occur also in old age in the cervical region when
there is pre-existing cervical canal stenosis

Etiology

Road traffic accidents

Falling from height

Sport injuries as dividing injuries, horse riding, cycling injuries etc.

Flexion

e.g. seat belt (dorsal spine injury), diving (cervical spine injury)

Mechanisms

Extension

e.g. road traffic accident

of spinal

Torsion

e.g. sport injuries

Compression

e.g. falling from height while standing or sitting

Distraction

e.g. during handing (distraction and extension)

injury

Pathology

Trauma to the spine can lead to various degrees of injury to the vertebral column and/or the
neural structures

Bony injuries e.g. fracture of the vertebral body, lamina, spinous process, transverse
process etc

Vertebral

Ligamentous injuries or disc injuries

Most common bony injuries

column

o Burst fracture: when there is disruption of upper end plate, the lower end plate or both

injuries

o Wedge fracture: no disruption of the end plates but there is decrease in height of the
anterior border of the vertebral body

Assessment of bony instability: the spine is divided into 3 columns: anterior, middle and
posterior. More than one column affection leads to instability

Cord and

root injuries

Ranging from neuropraxia, edema, compression by bone, contusion, laceration or (complete


cord transection // complete avulsion of the root)

Patients with spinal cord injuries may be hypotensive due to

Vascular

Loss of muscle tone in the lower half of the body will lead to decrease in the
venous return and decrease cardiac output resulting in hypotension

Spinal shock

Blood loss due to associated injuries

Interruption of the sympathetic tone to the heart will result in bradycardia,


and will cause vasodilatation to the blood vessels

Neurologic

Transient loss of neurological functions below the level of the injury

On examination there will be loss of voluntary movements

However, there will be sacral sparing (persistent anal tone, positive


bulboanal reflex, voluntary big toe movements)/

Clinical
picture

Pain especially on movements

Tenderness

Due to

Muscle spasm

trauma

Contusion of the back of the neck

spine

Deformity

The patient may be intact

Different degrees of weakness in the lower limbs (in case of dorsal spinal

Due to

cord injury) or in both upper limbs and lower limbs (in case of cervical

neurological
injury

cord injury)

Sphincteric disturbances

Respiratory difficulty (the higher the lesion the more the respiratory
difficulty)

According to the site of cord injury, the patient will manifest with one of the cord syndromes

Initial

ABC (Airway, breathing and circulation)


Transfer of the patient:

o If there is suspicion of spine fracture e.g. weakness, tenderness, major trauma


o Cervical neck collar

o Dorsal or lumbar: transportation on a hard board

Radiological
investigations

Plain X-ray of the whole spine for a screening purpose (to


diagnose and identify the site of spine fracture)

CT scan: best for identification of bone details

MRI: best for identification of soft tissue details (Disc, ligaments,


spinal cord)

Not an alternative to surgery if surgery is indicated

Medical

In the form of bed rest, analgesics and methyl prednisolone

treatment

Methyl prednisolone should be given in the 1st 6 hours after


trauma

Management

In case of neural compression: surgical decompression in the


form of laminectomy, foraminotomy, excession of a retropulsed
bone fragment from the vertebral body that compress neural
structures

Hospital

In case of vertebral column instability: stabilization by screws


and plates or rods (ant or post. Approach) + the bone yield

during surgery is put in a fashion to do further stabilization


Surgical

treatment

after bone fusion

In case of deformity (reduction): preoperative (cervical traction


only) intraoperative correction of deformity

The surgery should be always directed towards the pathology


e.g. in case of traumatic cervical disc prolapse and instability:
cervical discectomy and fixation is done

In case of complete spinal cord transection: the fixation of


unstable spine is beneficial to allow patient rehabilitation (with
a fixed spine, the patient can sit on a wheel chair) and for
psychological aspect

Degenerative spinal disorders


Cervical disc prolapse
Anatomy

Two cartilaginous end plates

Nucleus pulposus: softer form of cartilage

Annulus fibrosus: concentric layers of fibrous tissue and fibrocartilage

Cervical disc prolapse occurs when the soft nucleus pulposus herniates through teat in the
annulus (peripheral fibrous cartilage)

Patho-

physiology

This may result from a single or from repeated incidence

The cervical spine exhibits a great deal of mobility but little weight bearing function
The intervertebral discs serve as mechanical buffers that absorb axial loading, bending and
shear forces

Site

Cervical disc prolapse more common in C5-C6 and C6-C7 levels

The prolapse is usually posterolateral and causes root compression (radiculopathy)

If the prolapse is central, it will cause cord compression (myelopathy)

In case of root and cord compression (Radiculomyopathy occurs)

Symptoms

Neck pain and stiffness

Pain radiating down the arm and hand (brachialgia) exacerbated by neck
motion (extension)

Paresthesia, tingling and numbness along the affected dermatome

Motor weakness

Sphincteric dysfunction

Clinical

Root

picture

compressed/
Signs of

sensory loss

radiculopathy

deficit

Signs

C4-C5

C5-C6

C6-C7

C7-T1

C4

C5

C6

C7

C8

Diaphragm Deltoid

Reflex lost
Signs of
myelopathy
(cord

compression)

Investig.

Motor

C3-C4

Biceps and

Spastic quadriparesis

Hyperreflexia below the level of the compression

Clumsiness and ataxia of the extremities

Gait disturbance

Sphincteric disturbance

Loss of lordosis - Narrowing of the disc space - Osteophytes

MRI

Best diagnostic technique

Myelography

Triceps

brachiradialis

Plain Xray
CT scan

Hand

Biceps

muscles

Symptoms relevant to radiculopathy usually respond to conservative measures as


Conservative
Manag.

Bed rest - Avoidance of heavy lifting - Physical therapy Analgesics - Muscle


relaxant - Neck collar
Indications

Surgical
Procedures

Brachialgia not responding to medical treatment

Progressive neurolgocal deficit due to root compression

Manifestations of cord compression i.e. myelopathy

Anterior cervical discectomy

Posterior cervical laminectomy foraminotomy

Cervical spondylosis

Definition

It is a degenerative change including vertebral bodies, neural arches, facet joints, ligaments
and blood vessels, which may or may not cause neurological manifestations

Reduction of the sagittal diameter of spinal canal (less than 12 mm) can be associated with
cord compression leading to myelopathy

Clinical
picture

Radiculopathy, myelopathy or radiculomyelopathy

Spastic weakness of lower limbs with clonus and +ve babiniski sign

Weak hand grip and clumsiness

Invest.

Insidious onset

Hypoaglesia due to spinothalamic tract affection

Plain X-ray cervical spine - CT scan - MRI is the most accurate


Conservative

Manage.

As in cervical disc prolapse if there is no cord compression

Surgical

Posterior laminectomy foraminotomy

Anterior: multilevel discectomy, removal of osteophytes and stabilization by


interbody fusion or instrumentation

Lumbar disc prolapse

Pathophysiology
Site

Lumbar disc prolapse occurs when the soft nucleus pulposus herniates through tear in the
annulus (peripheral fibrous cartilage)

This may result from a single or from repeated incidence

Lumbar disc prolapse is the cause of 90% of sciatica

There is a history of falling or lifting heavy weights preceding the onset of symptoms

The majority of lumbar disc prolapse occurs at L4-L5 and L5-S1 (95%)
The typical patient with acute lumbar disc prolapse is from 30-50 years of age in the most
productive period of his life; and has complained of chronic low back pain for some time prior to
onset of acute disorder

Clinical

Herniation occurs either centrally or lateral

picture

When laterally, it compresses the adjacent nerve root: radiculopathy

When central, it compreses the cauda equina: Cauda equina syndrome)

Symptoms

Back pain

Sciatica (pain in the leg in the distribution of the affected root) aggravated by

coughing and sneezing

Pain relief upon flexion of knee and thigh

Numbness or tingling occurs in the distribution of the affected root

Motor weakness

Bladder symptoms (urgency, frequency, retention)

Back signs

Signs of
radiculopathy
Signs

Restricted spinal movement

Local tenderness

Scoliosis

Paravertebral muscle spasm

Obliteration of lumbar lordosis

Motor weakness

Dermatomal sensory changes

Compressed
root

Motor

Reflex changes
L3-L4

L4-L5

L5-S1

L4 root

L5 root

S1 root

Dorsiflexors of the

Planterflexors of the

foot

foot

Quadriceps

weakness

Medial part of the

Sensory

calf, medial

impairment

malleolus and
medial foot

Reflexes
Clinical
tests
(nerve
root

tension
signs)

Straight leg

Femoral
stretch test
(Reverse
SLRT)

Posterior part of the


calf, lateral

calf and dorsum of

malleolus, lateral

the foot and big toe

Impaired knee jerk

foot and sole


Impaired ankle jerk

Passive elevation of the fully-extended leg is considered positive


if the patient feels sciatica at an angle < 60o

raising test
(SLRT)

Lateral side of the

Positive in lower lumbar disc prolapse (L5 S1 root)

With patient in prone position, extend the hip joint

The patient feels a femoral pain

It is positive in higher disc prolapse (L2, L3 or L4 root irritation)

Neurogenic claudication: occurs in cases of lumbar canal stenosis


Cauda Equina syndrome:

Low back pain and bilateral sciatica

Motor (LMNL): bilateral weakness of dorsal and platar flexion of the foot + weakness of hip
flexors and/or extensors + weakness of knee flexors and/or extensors may also occur

Sensory: hypoesthesia bilaterally accoding to the spinal roots affected and saddle-shaped
hyposthesia

Reflexes: ankle reflex is lost bilaterally and also may be the knee reflex

Autonomic: sexual dysfunction (impotence), sphincteric disturbance (retention or


incontinence of urine, chronic constipation or incontinence of stools, diminished anal tone)

Clinical test: SLRT (Positive bilaterally)

AP and lateral views

Dynamic study (neutral, flexion, extension)

Plain X-ray
Invest.

o Narrowing of the disc space Osteophytes - Obliteration of lumbar lordosis


- Scoliosis

o To exclude other pathologies as metastatic lesions


CT scan
MRI

Detects lumbar canal stenosis; hypertrophied facet joint, and narrow canal
dimension

Best diagnostic method of lumbar disc prolapse

Myelography
Nerve conduction velocity: precise information on root lesion

Conservative

Bed rest for 2-4 days on hard board mattress

Activity modification and avoid lifting heavy weights

Exercise Analgesics - Muscle relaxants

Reduction of body weight

Health education

Failure of non-surgical treatment

Patients who dont want to invest time in a trial of non-surgical


treatment

Indications

Urgent surgery:

o Cauda equine syndrome

Treatment

o Progressive motor deficit


o Severe, unremitting, leg pain not relieved by conservative
measures

Surgical

Transcanal: standard open laminectomy and discectomy


microdiscectomy endoscopic discectomy

Methods

Intradiscal procedures :

o Automated percutaneous lumbar discectomy (nucleotome)


o Percutaneous endoscopic discectomy
o Laser disc decompression
o chemonucleolysis

49 years old female patient know to be diabetic had a history of fall downstairs 2 years ago. Now she has
severe low back pain and bilateral sciatica. She has mild weakness of both dorsi-flexors with numbness of
both feet and hands: The cause Possible signs Investigations Treatment

A 60 years old patient with spinal compression of gradual onset at D7 level. C/P, investigations and
treatment

Brain tumors

Primary brain tumors occur in approximately 6/100,000 per year

Fewer patients with metastatic tumors reach a neurosurgical center, it is estimated that 25% of
patients with a malignancy have a CNS metastasis

About 1 in 12 primary brain tumors occur in children under 15 years of age

Adults
Overview

Children

Commonest tumors are gliomas, metastasis and meningiomas and most of them lie in
the supratentorial compartment
Commonest tumors are medulloblastoma, cerebellar astrocytomas and
craniopharyngiomas

Benign

May have devastating effects if allowed to expand within the rigid confines of
the skull cavity

A benign astrocytoma may invade widely throughout the brain tissue preventing
complete removal or may occupy a functionally-critical site preventing even
partial removal

Malignant

Implies rapid growth, poor differentiation, increased cellularity, mitosis, necrosis and
vascular proliferation, but metastases to extracranial sites rarely occur

WHO classification of CNS tumors

Astrocytoma
Tumors of
neuro-

epithelial
tissue

Arise from astrocytes and represent the most primary intra-axial


brain tumor

Based on histopathological criteria, they could be classified into 4


stages (1=benign 4 = glioblastoma multiforme = malignant)

Oligodendroglioma

Arise from oligodendrocytes that normally form the myelin sheath in


the white matter

Ependymoma

Arise from the ependymal lining of the ventricles

Mixed tumors

As oligoastrocytoma

Choroid plexus tumors

Choroid plexus papilloma

Pineal tumors

Pineocytoma

Enlarged tumors

Primitive neuroectodermal tumors (PNET)

Arise mostly from the arachnoid cap cells

Tumors of

Meningiomas are mostly benign tumors but sporadic cases of aggressive meningiomas may

meninges

the

occur (grade 2 atypical meningomas or grade 3 anaplastic meningioma)

It is considered an extra-axial tumor as they arise from the meninges not from the brain
tissue

Germ cell
tumors

They usually occur in the midline especially in the pineal or the suprasellar region

Include: Germinoma Teratoma Embryonal cell carcinoma

Some of these respond well to radiotherapy

Cysts and tumor like conditions: Not true tumors but they represent space-occupying lesions mimicking the
clinical picture of the brain tumors as: Dermoid cyst - Colloid cyst of the 3rd ventricle

Pituitary adenoma arises primarily from the anterior pituitary gland

They are classified according to the size into microadenoma (<1cm) or macroadenoma
(>1cm)

Pituitary
tumors

Or according to endocrinal function into hormone secreting or non-secreting adenomas

Pituitary adenomas usually grows upward, compressing the optic chiasm causing
bitemporal hemianopia

If the tumor grows further upward, it can compress the 3rd ventricle and hypothalamus
causing obstructive hydrocephalus and hypothalamic manifestations

Less commonly, pituitary adenoma can grow laterally into the cavernous sinus leading to

compression of the 3rd, 4th and 6th cranial nerves and cause strabismus or ophthalmoplegia

Hormone secreting: GH (macro/gigantism or acromegaly) Prolactinoma (macro) ACTH

(Micro/cushing) TSH (2ry thyrotoxicosis) rarely the tumor may secrete several hormones
at the same time

Cranio-

It is a benign tumor, which usually contains cysts and areas of calcification

Similar to pituitary adenoma, craniopharyngioma exerts sometimes mechanical


compression on the visual pathway and the 3rd ventricle

pharyngio
ma

It arises from embryonic remnants of Rathkes cleft present in the pituitary stalk

Pituitary hypofunction and diabetes insipidus are commonly associated due to pituitary stalk
compression

Craniopharyngioma is commonly found in children and young adolescents

One of the primitive neuroectodermal tumors (PNET)

Medullo-

It is the most common malignant pediatric brain tumor and the most common PNET

blastoma

It usually arises from the roof of the 4th ventricle producing obstructive hydrocephalus
10-35% of cases develop spinal metastasis (drop metastasis) via CSF

Clinical picture of brain tumors

Manifestations of increased intracranial pressure (ICP): headache, blurring of vision,


nausea, projectile vomiting and seizures

General

Regional manifestations:

Contralateral face, arm or leg weakness

Frontal lobe

Expressive dysphasia (dominant hemisphere)

tumor

Personality changes: antisocial behavior loss of inhibitions intellectual

manifestatn

impairment profound dementia esp. if corpus cullosum is involved

Disturbed cortical sensation: tactile localization two point discrimination


astereognosis sensory inattention

Parietal lobe

Visual field defect: lower homonymous hemianopia

tumors

In dominant hemisphere: right/left confusion finger agnosia acalculia


agraphia

Non dominant hemisphere: sensory or motor hemineglect syndrome

Temporal
lobe tumors

Psychomotor epilepsy

Receptive dysphasia (dominant hemisphere)

Visual defect (upper homonymous quadrantanopia)

Occipital lobe

Visual field defect (homonymous hemianopia), visual hallucination and

tumors

cortical blindness

Supra-sellar

As pituitary adenoma and craniopharyngioma: bitemproal hemianopia,

Tumors of

Inter-hemispheric disconnection syndrome

corpus

tumors

hormonal dysfunction, and hypothalamic manifestations


Left side apraxia

callosum

Pure word blindness or alexia without agraphia

Posterior

Obstructive hydrocephalus due to obstruction of the 4th ventricle and

fossa tumors

cerebellar manifestations as tremors, ataxia, dysmetria and nystagmus


As acoustic shwannoma; cerebellar manifestations and cranial nerve
dysfunction:

Cerebello-

Trigeminal: facial hypothesia, neuralgia, loss of corneal reflex

pontine angle

Facial: facial palsy

tumors

Vestibulocochlear: tinnitus and sensory neural hearning loss

Lower cranial nerves: difficult swallowing, loss of gag reflex and frequent
aspiration

The golden diagnostic tool as it defines clearly the tumor


extension and its relation to the surrounding structures: it
shows: site mass effect lesion multiplicity

Axial, coronal and sagittal scanning provide valuable

MRI brain

information about the exact anatomical relationship of the

gadolinium

tentorium cerebelli

with

tumor to the sulci and gyri, the ventricles, the falx and

IV gadolinium provides a paramagnetic enhancement that


increases sensitivity of detection and clarifies the site of

Investigatns

origin i.e. intrinsic or extrinsic, and may delineate the

Radiological

border between tumor and surrounding edema

investigatns
CT brain

with contrast
Angiography

Plain X-ray

Superior to MRI in the delineation of bony structures and/or


tumor calcification as in oligodendroglioma,
craniopharyngeoma and calcified meningioma
Study the vascularity of the tumor and relation with important
vascular structures

Calcification as in oligodendroglioma, craniopharyngeoma

Osteolytinc lesions in 1ry or 2ry bone tumors, chondromas

Erosion of the posterior clinoids from local pressure as in


craniopharyngeoma

SPECT and
PET scan

Ballooning of the sella in large pituitary adenoma

Pineal shift: seen if the gland is calcified

Help identify high grade activity within a tumor

Useful to exclude if proposing conservative management


or in planning stereotactic biopsy

Routine

Hormonal assay for pituitary adenoma

Lab

Tumor markers for germ cell tumors

investigatns

CSF analysis: lumbar puncture is contraindicated if the clinician suspects

an intracranial tumor if obtained by ventricular drainage, tumor cells


may appear in cytology

Surgical

excision

Considered the cornerstone in the treatment of brain tumors, especially in


large-sized tumors

Usually performed through a craniotomy flap but in certain cases other


routes could be attempted as trans-sphenoidal approach for pituitary
tumors

Biopsy
Conventional
radiotherapy
Treatment

Used sometimes to establish diagnosis in controversial cases

Biopsy can be done using standard microsurgical techniques (through a

small craniotomy flap) or by stereotaxy especially in deeply seated lesions


Used either as a substitute for surgery in medially unfit patients and in some
inoperable tumors or as an adjuvant treatment after surgery in case of
malignant tumors or in the presence of residual tumor

Stereotactic

Multiple converging beams from a linear accelerator, gamma knife or

radiosurgery

cyberknife, are focused on a selected target in a single treatment

Proton beam

Allows delivery of high doses of radiation to a very localized region adjacent to

Chemo-

Temozolomide, oral alkylating agent: anaplastic astrocytoma and newly

therapy

diagnosed Glioblastoma multiforme

therapy

vital structures as skull base

Medical dehydrating measures can be used before or during surgery to


decrease the intracranial pressure

Medical
treatment

Steroid therapy: dramatically reduce edema surrounding intracranial


tumors. It doesnt affect the tumor growth

Anti-epileptic drugs are also needed to prevent epileptic fits in patients


with brain tumors

Medical treatment is of utmost importance in management of


prolactinomas: bromocriptine or cabergoline

Cerebrovascular disorders
I. Stroke

Clinical symptoms of focal and/or global disturbance of cerebral function lasting more
than 24 hours or leading to death, with no apparent cause other than vascular

Stroke is one of the leading causes of permanent disability and is the 3rd largest cause of
death in western countries

Definition

The etiology of stroke includes


o Cerebral hemorrhage originating for example from cerebral aneurysm or brain AVM

o Ischemic cerebral infarction results from occlusive disease of the extracranial or major
intracranial arteries (AS lesions) and the majority of these strokes (around 85%) are of
ischemic origin

Ischemic stroke
Classification
(according to
source of

embolism)

Cardiac (e.g. atrial fibrillation)

Large artery strokes (lesions in the aortic arch, extracranial vessels or the major
intracranial branches)

Small vessel disease/lacunar infarctions (occlusion of minor intracranial branches)


Others (e.g. carotid dissection or sinus thrombosis)

TIA (transient ischemic attacks)

Clinical

presentation

Episode which is sudden in onset, resolve within 24 hours or less


Leaves no residual deficit

RIND (Reversible ischemic neurological deficit): It lasts more than 24 hours but resolve within
one week
Complete
stroke

Typically, it results in profound multimodal neurologic deficit such as:


hemiplegia, hemosensory effect and hemi-anopia

Carotid

territory

Reduction in cerebral perfusion leading to hemiparesis, hemianaesthesia


Binocular visual disturbance, diplopia and nystagmus

Vertebro-

Vertigo, ataxia, deafness and tinnitus

basilar

Bilateral weakness and may be loss of consciousness

territory

In this type, there is transient ischemia of the brain stem, occipital lobes,

Imaging

(Amourosis Fugax)
and dysphasia

Site of
affection

Reduction in retinal perfusion leading to transient monocular blindness

medial temporal lobes and the upper spinal cord

Extracranial, intracranial carotid or middle cerebral artery stenosis can be diagnosed and
measured using different imaging modalities

The golden standard used in the majority of large RCTs is digital substraction angiography
(DSA)

Other non-invasive modalities: MRA and CTAngio


Treatment

Stroke prevention is primarily based on medical treatment, but in some situations, surgical
or endovascular treatment becomes the method of choice

Medical treatment to reduce the overall risk includes: antiplatelet medications, statins, and
anticoagulation for AF, smoke cessation, control of HTN, and metabolic control in diabetic
patients

Management
for acute
ischemic
stroke

Management

ABCs

Lab: CBC platelet coagulation profile blood glucose level, lipid profile

ECG, Cardiac monitor

Establish IV access

Baseline vitals, most important = BP, SBP must be less than 185/110 for the acute
intervention

Exam/NIHSS

Rule out hypoglycemia, seizures

Rule out hemorrhage or massive infarction by CT and CTA if available

IV-tPA if no contraindication

Or endovascular treatment if IV-tPA is contraindicated

Strategies for revascularization in patients with intracranial carotid or middle cerebral

for

artery stenosis include surgical bypass, percutaneous transluminal angioplasty (PTA)

extracranial,

alone, and percutaneous transluminal angioplasty and stenting (PTAS)

intracranial

middle

carotid or

Revascularization by means of extracranial-intracranial bypass surgery in stenotic


intracranial arteries was shown to be inferior as compared to medical therapy

Percutaneous balloon angioplasty has been reported in several retrospective case series to

cerebral

be useful and safe for the treatment of stenotic intracranial arteries, but still holds a risk of

stenosis

the small caliber of the vessel

artery

vascular dissection, elastic recoil vasospasm, and high grade residual stenosis because of

Hemorrhagic stroke
Hypertension

The most frequent sites of hypertensive intracerebral hemorrhage are the

common)

cerebellum or the pons

(most

Due to rupture of vessel within the brain parenchyma

Etiology

Clinical
picture

basal ganglia and thalamus and less commonly may involve the

Systemic coagulation disorders

Lobar

Amyloid deposits

hematoma

Vasculitis

Secular aneurysm

Vascular malformations

Abrupt severe headache and vomiting followed by

Rapid decrease of level of consciousness up to coma

Specific neurological symptoms develop and are dependent on the location

o Cerebrum: hemiparesis, hemisensory loss, 3rd nerve palsy tentorial herniation and
coma

o Cerebellum: ataxia, nystagmus, obstructive hydrocephalus


o Pontine: sudden loss of consciousness, quadriplegia, pin point pupils
Investigations

Routine, coagulation profile work up

CT scan (best for intracranial hemorrhage) and MRI: site, size, mass effect, extent,
associated pathologies

Angiography (DSA, CTA, MRA) for diagnosis of aneurysm and AVM

Hospitalization

ABC

IV fluids

Medical: Control hypertension control ICP anticonvulsant

Surgical:

o Craniotomy with evacuation of clot under direct vision + hemostasis

Treatment

o Resection source of bleeding (AVM)


o Supratentorial

Surgical evacuation if sizable, superficial, clinically acceptable patient


Conservative management if small, deep

o Cerebellar: urgent evacuation: life-saving as it relieves brainstem compression


o Pontine: high mortality: conservative management

II. Aneurysms

Aneurysm may be defined as an abnormal blood-filled dilatation of a blood vessel


resulting from a disease of the vessel wall

Definition

Intracranial aneurysms are common acquired lesions commonly located at the branching
points of the major intracranial arteries coursing through the subarachnoid space at the
base of the brain

Prevalence

1-6% of the population

The typical presentation of aneurysmal subarachnoid hemorrhage is


sudden onset of severe headache, which may be associated with nausea,
vomiting and meningeal irritation signs

Subarachnoid
Clinical

hemorrhage

The patient may lose consciousness

These meningeal irritation signs include neck stiffness, which usually


develops several hours after the hemorrhage, severe lower back pain and

presentation

bilateral radicular leg pain due to the subsequent circulation of blood CSF
down the spinal axis

Mass effect

The most common clinical presentation due to mass effect of intracranial


aneurysms is 3rd nerve palsy associated with carotid-posterior
communicating aneurysms

Some intracranial aneurysms often of the large or giant types present


with visual field defects, trigeminal pain, ophthalmoplegia, seizures and
hypothalamic-pituitary dysfunction

Stroke may be the presenting clinical manifestation of an unruptured


intracranial aneurysm

Cerebral

ischemia

Such ischemia is usually due to the detachment of an embolus from an


intra-aneurysmal thrombus, and it should be differentiated from

intracranial arterial dissection with the 2ry formation of an aneurysm


Asymptomatic
unruptured

intracranial

With the widespread use of helical (spiral) CT angio and MRA, many
unruptured asymotomatic intracranial aneurysms can now be detected

aneurysms

CT scanning

Detects subarachnoid hemorrhage

Very sensitive in detecting any associated intracerebral hemorrhage or


hydrocephalus

the CT scan is normal, a lumbar puncture should be performed to

Diagnostic
imaging

If there is a strong clinical suspicion of a subarachnoid hemorrhage but


exclude the presence of xanthochromia in the CSF

Conventional

Conventional angiography and 3D angiography remain the gold standard


for detecting an intracranial aneurysm and determining its anatomical

angiography

characteristics

MRA

Carries no risk as it doesnt require the IV administration of contrast

CT angio.

The detection rate is similar to MRA

Complete anatomical exclusion of the aneurysmal sac from the intracranial circulation
with parent artery preservation is the main treatment goal to prevent future rupture or

Treatment

re-rupture with its devastating consequences

This aim can be achieved either by open microneurosurgical clipping or endovascular


embolization

III.

Definition

Brain arteriovenous malformations (AVMs)

Brain AVMs are composed of a network of blood channels (nidus) supplied by cerebral

arterial feeders, drained by veins emptying into the venous sinuses, and surrounded with
gliotic non-functioning brain parenchyma

Natural
history

The risk of hemorrhage from a brain AVM has an average 2-4% yearly risk of hemorrhage
from brain AVM

Clinical

presentation

Intracranial

hemorrhage

The most common clinical presentation of brain AVM is intracranial


hemorrhage

Bleeding from brain AVMs can give rise to subarachnoid hemorrhage,


intracerebral hematoma and/or intraventricular bleeding

Epilepsy

Could be the presenting symptom in 30% of patients

In majority of cases, seizures are partial or partial complex and sometimes


with 2ry generalization type seizures

Cortical AVMs cause seizures more often than deep AVM

Headache

30% of cases

Focal

neurologic

deficits
CT scan

Progressive neurologic deficit may be the result of steal phenomenon,


venous hypertension or mass effect

CT scan mainly to rule out hemorrhage and if hyperdose serpiginous

structures are visible on contrast injection CT scan, AVM is suspected

CT angio

May be progressive, stable or reversible

3D CT angiography provides good anatomic information on nidus and


draining veins

Small AVMs and small AVM feeders can be misdiagnosed by this


technique

The brain AVM anatomical characteristics such as the size, location of the
nidus and the proximity of the AVM nidus to eloquent brain regions are
best defined by MRI

Diagnostic
imaging

In addition, MRI data clearly demonstrate the status of the brain


parenchyma surrounding the AVM

MRI

It clearly defines areas of encephalomalacia or hemorrhage (recent or


remote) around the nidus, these data are very important for clinical
correlation

Functional MRI is very helpful in detecting functional areas of the brain


particularly sensorimotor, visual and language cortex and their relation
to the AVM

Selective and
superselective
cerebral

Assess the detailed anatomic characteristics of the AVM

Give an anatomical base for understanding the nidal vascular

angiography

Treatment

compartmental angio-architecture essential for embolization planning

Treatment should be done after a careful consideration of clinical data & AVM anatomy

Potential risks must be carefully balanced against the benefits in each patient

The treatment options available at present are:


o Surgical resection
o Radiosurgery

o Endovascular embolization

Peripheral Nerve disorders


Entrapment pathology
Carpal tunnel syndrome

It occurs as a result of compression of the median nerve beneath the carpal transverse
ligament, affects 1% of the population and more frequent in females

Definition

The carpal tunnel syndrome should be considered when there is any unexplained pain or
sensory disturbance (e.g. intermittent numbness and pain of the hand that is worse at

night) and weakness of abductor pollicis brevis, the lateral two lumbricals, the opponens
pollicis and the flexor pollicis brevis muscles)
Contributing
factors

Physical tests

Ligamentous or synovial thickening; trauma, obesity, diabetes, thyroid disease, amyloidosis,


gout, acromegaly, Pagets disease, mucopolysaccharidoses
Median nerve

Positive when tapping the area over the median nerve at the wrist

percussion test

produces paresthesia in the median nerve distribution (Tinels test)

Carpal tunnel

Positive when the patients sensory symptoms are duplicated after

Phalen wrist

Positive when full flexion of the wrist for 60 seconds produces the

flexion test

patients symptoms

compression test

pressure is applied over the carpal tunnel for 30 seconds

Electrodiagnostic
tests

Most sensitive

Cervical radiculopathy (C6, C7)

Brachial plexopathy (upper and lower plexus paralysis; also thoracic outlet syndrome)

DD

Sensory conducation studies and electromyography

Pronator teres syndrome: compression of median nerve between the 2 heads of the
pronator teres

Anterior interosseous syndrome: loss of flexion of the terminal phalanx of the thumb and
the index (pinch sign), and no sensory loss

Management

Treatment of the systemic disease

Reduction of the hand usage

NSAID

Division of carpal transverse ligament in severe cases

Ulnar entrapment at the elbow (Cubital tunnel syndrome)

Results from entrapment of ulnar nerve as it enters the forearm through the narrow opening
(the cubital tunnel) formed by medial humeral epicondyle, medial collateral ligament of the
joint & the firm aponeurotic band, to which flexor carpi ulnaris is attached

Overview

Elbow flexion reduces the size of the opening under the apneurotic band, while extension
widens it

Symptoms include paresthesia, numbness or pain in the 4th and 5th fingers, occasionally
provoked by prolonged elbow flexion, associated with decreased vibratory perception and
abnormal 2-point-discrimination

Weakness affects the 1st dorsal interosseous muscle first and most severely

Weakness and wasting of the hypothenar and intrinsic hand muscles result in the loss of
power

The sensory symptoms usually precede weakness

Tinels sign may be present

Electrodiagnostic tests: Motor nerve conduction velocity


Management: Neurolysis and decompression with or without ulnar nerve transposition

Cervical radiculopathy (C8-T1)

Thoracic outlet syndrome, lower brachial plexopathy

Syringomyelia: dissociated sensory loss is characteristic, there are often associated long track
findings in the legs, and the MRI is diagnostic

DD

Motor neuron disease: there is weakness and wasting of intrinsic hand muscles. Thenar
muscles as well as the hypothenar muscles are often affected

Ulnar nerve entrapment at the wrist or hand (Guyons canal)

o Includes sensory loss in the medial 4th and 5th fingers

o The palmar and dorsal surfaces of the hand are spared due to sensory nerve had branched
proximal to the wrist level

o Weakness is predominantly affecting ulnar-innervated thenar muscle relative to the


hypothenar muscles

Meralgia Paresthetica

The lateral cutaneous nerve of the thigh


o Is a purely sensory branch arising from the lumbar plexus (L2-L3)

o It passes obliquely across the iliac muscle, and enters the thigh under the lateral part of the
inguinal ligament

Overview

o It supplies the skin over the anterolateral aspect of the thigh

Numbness is the earliest and most common symptom

Patients also complain of pain, paresthesias (tingling and burning) and often touch-paintemprature hypestheasia over the anterolateral aspect of the thigh

Could be

Obese individuals who wear constricting garments (e.g. belts, tight jeans, corsets)

also due

Abdominal distension (ascites, pregnancy, tumor)

to

Removal of an iliac crest bone graft if it is taken too close (2 cm) from ASIS

Weight reduction + NSAID

Manage.

Surgical neurolysis and decompression of the nerve where it passes through its canal within
the inguinal ligament

Tarsal tunnel syndrome

Overview

Involves compression of the posterior tibial nerve at the ankle behind the medial malleolus,
where the laciniate ligament connecting the distal tibia to the calcaneous covers it

It is usually related to local fractures, tumors, and vascular abnormalities

The entrapment results in hypoesthesia in the sole of the foot, a positive Tinels sign with
percussion, or pressure over the flexor retinaculum below the medial malleolus

Manage.

NSAID with the conservative measures such as external ankle support (e.g. shoe orthoses) to
improve foot mechanics

Surgical release of the entrapment is not rewarding as often as in carpal tunnel syndrome

Thoracic outlet syndrome

(Cervicobrachial neurovascular compression syndrome)

The thoracic outlet syndrome may be purely vascular, purely neuropathic or rarely mixed

The true neurogenic thoracic outlet syndrome occurs more frequently in young women and
affecting the lower trunk of the brachial plexus

Intermittent pain is the most common symptom, referred to the medial arm, forearm and the
ulnar border of the hand

Overview

Paesthesias and sensory losses involve the same distribution

The motor and reflex findings are essentially those of lower brachial plexus palsy, with

particular involvement of the C8 root causing weakness and wasting of the thenar muscles
similar to carpal tunnel syndrome

However, in contrast to the latter, in the thoracic outlet syndrome wasting and paresis also
tend to involve the hypothenar muscles

Electrodiagnostic studies show evidence of lower trunk brachial plexus dysfunction

Plain X-ray: may show cervical rib

Manage.

Angiography: may show vascular anomalies

Removal of the cervical rib or sectioning of the fibrous band of the anterior scalene muscle

Traumatic lesions
Concussion

(Neuropraxia)

Pathology
(types)

Contusion

It is a transient neuronal physiological dysfunction, its function returns


within 24-48 hours.

It may occur with blunt injuries

The epineuria and perineurium are totally intact

Alteration of the endoneurium (containing axons) occurs

All conductivity is lost in the distal segments

The axon distal to the site of injury degenerates (Wallerian degeneration)

Such injuries occur after blunt trauma or penetrating trauma in the nerve

(Axonotenesis)

vicinity

Spontaneous regeneration may take place and the prognosis is good

Regeneration sometimes cant occur due to disruption of the fascicular


anatomy, but the nerve remains in gross continuity leading to the
formation of neuroma in continuity

Complete

disruption

There is no possibility of regeneration without operative repair

It occurs in cut and gunshot injuries and with fracture of long bones

(Neurotemesis)
Cutting
injuries

Most common cause of nerve injury, usually by sharp instruments

Traction injuries
Electric

High voltage current may cause disruption of the nerve all the way back to the

traumatic

trauma

anterior horn cell

agents

Ischemic

Severe and prolonged compression may undergo severe degeneration e.g.

Types of

damage

plaster cast

Gunshot injury Causes severe laceration of the nerve and difficulty in approximation
Chemical injury

Upper limb nerve injuries

a) Brachial plexus injury (birth injuries)


The muscles supplied by the C5 and C6 roots are paretic and atrophic (i.e. the deltoid, biceps,

Upper

brachioradialis, radialis and occasionally, the supraspinatus, infraspinatus and subscapularis

plexus
(trunk)

muscles)

Produces a characteristic limb position known as the Policemans tip position (internal

paralysis

rotation and adduction of the arm, extension and pronation of the forearm, and with the

Duchenne)

The biceps and brachioradialis reflexes are depressed or absent

(Erb

palm facing out and backward)

There may be some sensory loss over the deltoid muscle area

The muscles supplied by C8 and T1 roots are paretic and possibly atrophic (weak wrist and

Lower
plexus
(trunk)

finger flexion and weakness of the small hand muscles), producing a claw hand deformity

paralysis

The finger flexor reflex is depressed or absent

(Dejerine

Sensation may be intact or lost over the medial arm, forearm and ulnar aspect of the hand

Klumpke

There is an ipsilateral Horner syndrome (with injury of the T1 root)

type)

b) Injuries in the axilla


Musculocutaneous n.

Weakness of the biceps and brachialis muscles and sensory deficit in the lateral forearm

Radial n.

Median n.
Ulnar n.

Affects all extensors of the elbow, wrist and fingers

Deformity: wrist and finger drop

Sensory loss: in the dorsum of the hand and the base of the thumb

Triceps reflex is lost

Weakness of flexors of the fingers and opposition of the thumb

Ape hand deformity

Sensory loss in lateral 2/3 of the palm and the lateral 3 fingers

Weak flexion of the little finger, palmar and dorsal interossei

This results in weak abduction and adduction of the fingers, and weak adduction of the
thumb

Deformity: partial claw hand deformity

Sensory loss: of the palmar and dorsal aspect of the medial 1/3 of the hand; and medial 1
fingers

c) Arm and forearm


Radial nerve in spiral groove (lateral injury)

There is wrist and finger drop with preservation of the elbow extensors

Sensory: loss of the dorsolateral aspect of the hand

Posterior

Motor: paralysis of all extensors of fingers and most of the extensors of the wrist

interosseus

Deformity: finger drop only

in forearm

Sensory: no sensory loss

Pointing index deformity: due to paralysis of the flexor digitorum superficialis


and the lateral half of the flexor digitorum profundus

throwing of the 1st metacarpus due to paralysis of opponens pollicis muscles

Deformity

Median

and over-action of abductor pollicis longus abduct the thumb

Ulnar deviation of the hand

Atrophy of the flexor muscles, tips of the index and thumb, with or without
skin atrophic changes

nerve injury
(Medial
injury)

Ape-hand deformity: due to atrophy of the thenar muscles. Backward

Special
motor
tests

Sensory
system

Pointing index test: ask the patient to grasp his hands

Radial grip of the hand is weak

Pencil test (thumb abduction test): abducting the thumb 90o from the plane of
the palm to test for the action of abductor pollicis brevis

Weak pronation of the arm

Opposition of the thumb across the palm fails

Sensory distribution = lateral 3 fingers of palmar aspect and dorsum of


terminal phalanges

Buttoning test fails with closure of the eyes due to loss of deep sensation

Partial claw hand: due to affection of the little and ring fingers only flexion
of the interphalangeal joint, hyperextension of metacarpophalangeal joints of
the medial 2 fingers especially the little finger

Ulnar nerve
injury

(medial
injury)

Deformity

Radial deviation of the hand: due to paralysis of the flexor carpi ulnaris muscle

Trophic changes: maximal on the tip of the little finger

Atrophic changes

o Sunken interossei spaces on dorsum of the hand esp. 1st space (most imp.)
o Atrophy of the hypothenar muscles and the tip of little finger
o Wasting of the muscles of the medial side of the forearm

Weak ulnar grip

Card board test: abduction (dorsal interossei) and adduction (palmar

interossei) of fingers fails; the patient is unable to hold a card between two

Specific
motor
tests

Ulnar

paradox

fingers

Paper test (Fromants sign): for the thumb to test for the action of the adductor
pollicis: the patient will hold the paper by flexing the terminal phalanx

Flexion of wrist shows radial deviation

Abduction of little finger fails

The higher the lesion of the ulnar nerve, the lesser the claw hand, because the
flexor digitorum profundus is completely paralyzed and no flexion of
interphalangeal joint takes place

Lesions above 5 cm from the wrist: palmar and dorsal surfaces of the medial
1 fingers and the medial 1/3 of the palm

Sensory

system

Lesions below 5 cm from the wrist: only the palmar surface is affected because
the dorsal branch arises above that level

Lesions below the wrist: have no sensory changes, because the superficial
branch escapes

d) Wrist and hand injuries

Median
nerve injury

Motor paralysis: of the thenar muscles and firs and 2nd lumbricals

Deformity: ape hand

Trophic changes: on the tip of index finger

Atrophic changes: of the thenar muscles

Tests for abductor pollicis brevis: pencil test is used

Sensory changes: loss of sensation on the lateral 3 fingers, dorsal nail beds and lateral
half of the palm

Ulnar nerve
injury

Same motor affection as injury in the forearm, with the exception that the partial claw
hand is more severe (ulnar paradox)

No sensory affection

e) Lower extremities injuries

Femoral n.

In wounds of the inguinal region

There is weakness of the quadriceps and knee extension muscles

Knee jerk is lost

Sciatic nerve injury


Common

It is damaged by trauma to the fibular neck

perineal

Weakness of the dorsiflexors and evertors of the foot foot drop

injury

Sensory loss: over the dorsum of the foot

The tibial

Weakness of the plantar flexors

nerve

Weak ankle jerk

The sciatic

Occurs in case of faulty IM injections and hip dislocation

nerve

Deformity: flail foot

Management of traumatic nerve injuries

In cases of neuropraxia or axonotemesis nerve regeneration is possible, so operative repair is not required;
It occurs usually after blunt trauma

Neurotemesis is an indication for surgery

Clean wounds can be repaired immediately (primary sutures)

Crushed and contaminated wounds, nerve repair should be delayed for 3-6 weeks (2ry sutures)

Advantages of 2ry sutures


o Controlling infection

o Proper evaluation of the extent of injry


o Presence of an expert neurosurgeon and good operative room
o Have a thickened neuroliemmal sheath that can withstand sutures
o Maximum state of regeneration is after 3 weeks 1 ml/day

Neurorolysis is decided at the time of surgery

Surgical microscope for nerve suturing is a must

Strategies for management of nerve gaps include: neurolysis, transposition, flexion of the limb and
autologous nerve graft (sural nerve)

Results of surgery depend on:

o Age: children give better results than adults


o Duration: more than 3 months after injury have bad prognosis

o Distance: between the site of injury and peripheral nerve (terminal branches)
o Regeneration: 1-2 mm/day
o Type of nerve: pure motor/sensory do better than mixed nerves

o Care of the injured extremities is also important. And the joint should be held in functional position
o Physical therapy is needed postoperatively

Qs:

In fracture spine: paraplegia with sensory level will occur below the dorsal lesion

In radial nerve injury at the posterior interosseous branch: finger drop

Brain tumors that may commonly show calcification: All (Meningioma craniopharyngioma
oligodendroglioma)

Functional pituitary micro-adinomas: produce clinical manifestations by: hormonal disturbances

Non-functional pituitary adenoma usually present with: visual field defect

In complete cauda equina syndrome: All (flaccid paralysis of ankles sphincteric impairment saddle
shaped hypoesthesia)

Medulloblastoma: intra-axial tumor common in children

Paraparesis with sensory level is diagnostic of spinal cord compression

Cervical disc prolapse there may be: All (radiculopathy myelopathy radiculomyelopathy)

In extradural hematoma all are wrong: hypotension and tachycardia are cardinal signs of brain
compression surgery can be planned at a later date (not an emergency) there must be a lucid interval
in order to diagnose - CT has no value in diagnosis

Glasgow coma: severe = 3-7

Subdural hematoma: bridging veins

Diffuse axonal injury: in the deep regions of the brain, this impairment of the white matter, corpus
callosum and subcortical structures (nerves in interface between grey and white matter)

Surgical indication in lumbar disc prolapse (complete): sphincteric disturbance

Congenital hydrocephalus is diagnosed by: progressively enlarging head circumference sunset


appearance of the eye open anterior fontanel and suture diastasis thin scalp skin and dilated veins
ventricular dilatation on CT scan BUT NOT severe neurological deficits

Infantile large head: All (Familial rickets hydrocephalus chronic infantile subdural hematoma
cephalhematoma)

A patient with frontal lobe tumor may present with: All (epilepsy hemiparesis mental changes
dysphasia)

A patient with stable fracture spine and cord contusion should have: corticosteroids in high doses during
the 1st 24 hours

Ulnar nerve injury there will be: claw hand deformity

A patient with deteriorating consciousness because of large acute traumatic extradural hematoma on CT
scan must have: urgent surgical evacuation and decompression

Clinical picture of cerebellopontine angle: cerebellar manifestations (ataxia, nystagmus, imbalance)


vestibulocochlear nerve defect (hearing and equilibrium disturbances) long tract manifestations
(hemiparesis and/or sensory hypoesthesia) BUT NOT paraplegia

Posterior fossa tumors may commonly present with: All (ataxia frequent chocking and nasal tone 6th
nerve palsy hemiparesis)

A patient with cauda equine syndrome due to lumbar disc prolapse will have: hemiplegia and hemianesthesia

In a dorsal spinal tumor at D10 segment: spastic paraparesis extensor plantar response sensory level at
D10 BUT NOT spastic quadriparesis

Astrocytoma is common in: pediatric age group

Main cause of spontaneous subarachnoid hemorrhage is: bleeding from cerebral aneurysm

Transient loss of consciousness after head injury is called: concussion

Aqueductal stenosis is one of the causes of : obstructive (non-communicating) hydrocephalus

Weakness of the dorsal flexors of the foot is one of the cardinal signs of compression of nerve root: L5

Sphincteric disturbance is one of the cardinal symptoms of: cauda equina syndrome

Wasting of thenar eminence is characteristic of: median nerve injury

Transnasal transsphenoidal surgery : small pituitary adenoma

Extradural hematoma is usually associated with: fissure fracture of the skull

Quadriparesis following head injury: cervical cord injury

Wrist drop: radial nerve injury

Lumbosacral meningeomyelocele: paraparesis

Meningioma: adults

Revision Dr. Anwar


-

Ankle reflex is absent in S1 syndrome

Causes of SC compression or low back pain

Mention 5 neurosurgical emergencies


1. Cauda equina syndrome
2. Fracture spine
3. Subdural hematoma

4. Extradural hematoma
5. Subarachonoid hemorrhage
6. Rupture meningeocele
7. Hydrocephalus
-

Hydrocephalus: definition and C/P

o Congenital hydrocephalus: sunset eye appearance dt pressure on the tectum of the midbrain -->
upward gaze of the eyes + squint dt 6th nerve palsy dt large IC course

Diastomatomyelia (split cord malformation)


Tetherd cord

1. Hypertrophied filum terminal


2. Lipomyelomeningeocele

3. Myelomeningeocele
4. Meningeiocele

5. Sarcococcygeal teratoma
6. Diastomatomyelia
7. Arachnoid cyst mcq: not spina bifida occulta

Craniosynostosis: sagittal --> scaphocephaly "most common"

D.D large head (arranged)


1. Subdural hematoma
2. Hydrocephalus
3. Rickets

4. Familial
-

Extradural --> middle meningeal a.

Subdural --> bridging

Subarachnoid --> rupture aneurysm: anterior communication - commonest cause of spontaneous


intracerebral hemorrhage --> HTN

Spinal tumors are extra or subdural

Medical treatment used in neurosurgery are:

Complications of ventriculo-peritoneal shunt: (Arranged) infection, obstruction, over drainage


o diuretics --> furasemide- mannitol
o CCs --> decrease edema
o nemostidine --> dec vasospasm produced in ICH

o methylprednisolone --> fracture spine in the 1st 6 hrs "mcq"


-

brain tumors:

Most common CerebelloPontine Angle : acoustic neuroma

Most common supratentorial tumor in children : craniopharyngeoma

Most common tumors in pediatrics : craniopharyngeoma- medulloblastoma- astrocytoma and


ededymoma all are infratentorial except craniopharyngeoma

Most common tumor in adult : metastasis

Calcifications : meningeoma- oligodendroglioma- cracniopharyngeoma

C/P

1. left frontal lobe: increased ICP epilepsy according to the site : speech- behavior- contralateral
weakness no sensory loss "mcq"

2. Temporal : inc ICP epilepsy speech visual field no sensory loss


3. Intratentorial : no epilepsy except if inc ICP
4. CPA : inc ICP cerebellar brain stem : contralateral weakness and sensory loss 5,6,7 nerves affection
no epilepsy

Pit. adenoma: mico --> inc secretion macro --> ICP and compression manifestations like bitemporal
hemianopia

gdwal el lumber disc prolapse

indications of surgery in lumber prolapse

Claudicationg sciatica --> lumber canal stenosis "mcq"

Cervical disc may be radiculopathy "may be medical" or myelopathy "only surgical"

Single disc compressing the cord --> anterior cervical discectomy not llaminectomy "only in cervical

Thoracic outlet syndrome --> compression of brachial plexus

Best inv. in all is MRI except fracture spine CT

canal stenosis"

Causes of complete claw hand --> 1. brachial 2. ulnar + median 3. non neurologic : volkman ischemic
cord

Entrapment neuropathy: carpal tunnel --> median tarsal --> post medial cubital tunnel --> ulnar

* extradural hematoma --> middle meningeal - diploid- venous sinus c/p: slow- rapid "

head trauma: depressed fracture

concussion"transient loss of con <24 hr" - lucid- compression --> spastic not flaccid paralysis"

* subdural : acute --> middle meningeal - hyperdense at CT chronic --> bridging veins- better

prognosis- surgical ttt - hypodense at CT


-

skull fracture:

o loss of smell --> ant


o facial --> middle

o battle sign --> post


-

Glasgow coma scale : lowest = 3 highest = 15 no 1 "mcq" <7 has bad prognosis extension to pain = 2
spontaneous eye movement = 4

Define Brown Sequard syndrome (compression - ipsi- contralatral )


foster kennedy syndrome : tumor or lesion compressing the optic n. on one side --> atrophy & increased
ICP on the opposite side --> papilledema + anosmia mostly bilateral

Adam Hakim's syndrome --> dementia- ataxia - urinary incontinence

cauda equina --> saddle shaped- foot drop- sphincters

Anterior Compression /Posterior Compression syndrome

radial --> wrist and finger drop while post interosseous --> finger drop only - Ape --> median - claw -> ulnar