Neurosurgery Review for Medical Student 17 Febuary 2552
<ul><li>I  อาการ / ปัญหาสำคัญ </li></ul><ul><ul><li>ปวดศีรษะ มึนศีรษะ เวียนศีรษะ หน้ามืด เป็นลม </li></ul></ul><ul><ul><li...
<ul><li>II  โรค / ภาวะ / กลุ่มอาการฉุกเฉิน  ( รวมทุกระบบ ) </li></ul><ul><ul><li>กลุ่ม  1 </li></ul></ul><ul><ul><ul><li>c...
<ul><li>III  โรคตามระบบ </li></ul><ul><li>กลุ่ม  3 </li></ul><ul><ul><li>Benign and malignant neoplasm of brain </li></ul>...
Stroke <ul><li>ผู้ป่วยหญิงอายุ  50  ปี ขณะดูโทรทัศน์ที่โซฟา  มีอาการปวดท้ายทอย  อย่างมาก อาเจียน ซึมลง  PE : GCS 13, no mo...
Stroke <ul><li>Ischemic VS hemorrhagic </li></ul><ul><li>Ischemic syndrome  ต่าง ๆ </li></ul><ul><li>Hemorrhagic disease <...
Stroke <ul><li>Ischemic VS hemorrhagic </li></ul><ul><ul><li>Hemorrhagic stroke  มักมี  sign of IICP ( ปวดหัว อาเจียน ซึมล...
Stroke <ul><li>Ischemic stroke </li></ul><ul><ul><li>MCA : Hemiparesis, contralateral hemisensory loss, aphasia </li></ul>...
Stroke <ul><li>Hemorrhagic stroke </li></ul><ul><ul><li>Hypertensive ICH </li></ul></ul><ul><ul><li>Ruptured cerebral aneu...
Stroke <ul><li>Hypertensive ICH </li></ul><ul><ul><li>Hypertension > 90% </li></ul></ul><ul><ul><li>IICP signs and symptom...
Stroke <ul><li>Hypertensive ICH </li></ul><ul><ul><li>Antihypertensive drugs </li></ul></ul><ul><ul><ul><li>SBP > 200    ...
Stroke <ul><li>Ruptured cerebral aneurysm </li></ul><ul><ul><li>“ Worst headache of my life” </li></ul></ul><ul><ul><li>Wi...
Stroke <ul><li>Ruptured cerebral aneurysm </li></ul><ul><ul><li>Key point of management </li></ul></ul><ul><ul><ul><li>Ref...
Stroke <ul><li>Ruptured AVM </li></ul><ul><ul><li>Young age** </li></ul></ul><ul><ul><li>Lobar hemorrhage </li></ul></ul><...
Stroke <ul><li>Investigation in intracerebral hemorrhage </li></ul><ul><li>Consider </li></ul><ul><ul><li>Angiography </li...
Stroke <ul><li>Amyloid angiopathy </li></ul><ul><ul><li>Old age </li></ul></ul><ul><ul><li>Non-hypertension </li></ul></ul...
Trauma <ul><li>ผู้ป่วยชายอายุ  50  ปี  ขับรถยนต์ชนจักรยานยนต์ สลบไป  10  นาที ตื่นมารู้เรื่องดี หน่วยกู้ภัยนำส่งรพ .  ตรวจ...
Trauma <ul><li>Initial management* </li></ul><ul><li>Epidural hematoma* </li></ul><ul><li>Subdural hematoma* </li></ul><ul...
Trauma <ul><li>Initial management </li></ul><ul><ul><li>ABCDE </li></ul></ul><ul><ul><li>Don’t miss! </li></ul></ul><ul><u...
Trauma โจทย์  short essay :  moderate HI in rural hospital Item ตอบถูก % GCS 47 71.21 C-spine protection 14 21.21 O2 17 25...
Trauma <ul><ul><li>Glassow Coma scale </li></ul></ul>Eye Verbal Motor Score ทำตามสั่งได้ 6 ปกติ ปัดที่บริเวณเจ็บได้ 5 ลืมต...
การดูแลผู้ป่วย  Head Injury ABCDEs, C spine protection Resuscitation ประเมิน  GCS GCS < 9 Severe HI GCS 9-12 Moderate HI G...
Trauma Risk factors for Intracranial lesion for Mild HI <ul><li>Clinical findings </li></ul><ul><ul><li>GCS < 15  หลัง  1-...
Trauma <ul><li>Epidural Hematoma (EDH) </li></ul><ul><ul><li>Associated with skull fracture </li></ul></ul><ul><ul><li>Cla...
Trauma <ul><li>Subdural hematoma (SDH) </li></ul><ul><ul><li>Venous tear/ brain laceration </li></ul></ul><ul><ul><li>High...
Trauma <ul><li>Chronic Subdural hematoma (CSDH) </li></ul><ul><ul><li>Elderly, alcohol abuse, coagulopathy </li></ul></ul>...
Trauma <ul><li>Skull Fracture </li></ul><ul><ul><li>Skull Fx    ↑ risk of intracranial bleeding 5 times </li></ul></ul><u...
Trauma <ul><li>Sequelae of head injury </li></ul><ul><ul><li>Increased intracranial pressure ( > 20 mmHg) </li></ul></ul><...
Trauma <ul><li>Sequelae of head injury </li></ul><ul><ul><li>Electrolyte imbalance – hyponatremia </li></ul></ul><ul><ul><...
Herniation syndrome <ul><li>Central </li></ul><ul><ul><li>Diencephalon    tentorial </li></ul></ul><ul><ul><li>Chronic </...
Herniation syndrome <ul><li>Cingulate (subfalcine H):  </li></ul><ul><ul><li>asymptomatic except ACA kink, warning of impe...
Tumor <ul><li>Supratentorial </li></ul><ul><li>Gliomas </li></ul><ul><ul><li>Astrocytoma </li></ul></ul><ul><ul><li>Oligod...
Tumor <ul><li>Most common brain tumor </li></ul><ul><ul><li>Metastasis </li></ul></ul><ul><li>Most common primary brain tu...
Tumor <ul><li>DDx for patient with progressive hemiparesis and IICP </li></ul><ul><ul><li>Supratentorial tumor (Metas, gli...
Hydrocephalous <ul><li>Mechanism </li></ul><ul><ul><li>Obstruction at CSF pathway:  </li></ul></ul><ul><ul><ul><li>Obstruc...
 
 
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  1. 1. Neurosurgery Review for Medical Student 17 Febuary 2552
  2. 2. <ul><li>I อาการ / ปัญหาสำคัญ </li></ul><ul><ul><li>ปวดศีรษะ มึนศีรษะ เวียนศีรษะ หน้ามืด เป็นลม </li></ul></ul><ul><ul><li>กล้ามเนื้ออ่อนแรง ชัก สั่น กระตุก ชา ซึม ไม่รู้สติ </li></ul></ul>
  3. 3. <ul><li>II โรค / ภาวะ / กลุ่มอาการฉุกเฉิน ( รวมทุกระบบ ) </li></ul><ul><ul><li>กลุ่ม 1 </li></ul></ul><ul><ul><ul><li>coma </li></ul></ul></ul><ul><ul><ul><li>convulsion </li></ul></ul></ul><ul><ul><ul><li>acute increased intracranial pressure </li></ul></ul></ul><ul><ul><ul><li>Head injury </li></ul></ul></ul>
  4. 4. <ul><li>III โรคตามระบบ </li></ul><ul><li>กลุ่ม 3 </li></ul><ul><ul><li>Benign and malignant neoplasm of brain </li></ul></ul><ul><ul><li>Brain abscess </li></ul></ul><ul><ul><li>Hydrocephalous </li></ul></ul><ul><ul><li>Trigeminal neuralgia </li></ul></ul><ul><ul><li>Head injury and spinal cord injury </li></ul></ul>
  5. 5. Stroke <ul><li>ผู้ป่วยหญิงอายุ 50 ปี ขณะดูโทรทัศน์ที่โซฟา มีอาการปวดท้ายทอย อย่างมาก อาเจียน ซึมลง PE : GCS 13, no motor weakness, stiff neck +ve จงให้การวินิจฉัย </li></ul><ul><ul><li>Pontine hemorrhage </li></ul></ul><ul><ul><li>Cellebellar hemorrhage </li></ul></ul><ul><ul><li>Subarchnoid hemorrhage </li></ul></ul><ul><ul><li>Basal ganglion hemorrhage </li></ul></ul><ul><ul><li>Intraventricular hemorrhage </li></ul></ul>เฉลย C
  6. 6. Stroke <ul><li>Ischemic VS hemorrhagic </li></ul><ul><li>Ischemic syndrome ต่าง ๆ </li></ul><ul><li>Hemorrhagic disease </li></ul><ul><ul><li>Hypertensive hemorrhage </li></ul></ul><ul><ul><li>Amyloid angiopathy </li></ul></ul><ul><ul><li>SAH from ruptured aneurysm </li></ul></ul><ul><ul><li>Ruptured AVM </li></ul></ul><ul><ul><li>( อื่น ๆ – bleeding tumor, coagulopathy, parasite, vasculitis) </li></ul></ul>
  7. 7. Stroke <ul><li>Ischemic VS hemorrhagic </li></ul><ul><ul><li>Hemorrhagic stroke มักมี sign of IICP ( ปวดหัว อาเจียน ซึมลง ) </li></ul></ul><ul><ul><li>Ischemic stroke มักมาด้วย sudden neurodeficit </li></ul></ul><ul><ul><ul><li>Hemiparesis </li></ul></ul></ul><ul><ul><ul><li>Apasia / apraxia </li></ul></ul></ul><ul><ul><ul><li>Amaurosis fugax </li></ul></ul></ul><ul><ul><li>Onset แยกไม่ได้ </li></ul></ul><ul><ul><li>Clinical แยกไม่ได้ 100%  need investigation = CT </li></ul></ul>
  8. 8. Stroke <ul><li>Ischemic stroke </li></ul><ul><ul><li>MCA : Hemiparesis, contralateral hemisensory loss, aphasia </li></ul></ul><ul><ul><li>ACA : Paresis and sensory loss of contralateral lower extremity </li></ul></ul><ul><ul><li>PCA : Homonymous hemianopia with macular sparing </li></ul></ul><ul><ul><li>Basilar : Cranial nerve signs – diplopia, facial weakness, vertigo, dysarthria </li></ul></ul>
  9. 9. Stroke <ul><li>Hemorrhagic stroke </li></ul><ul><ul><li>Hypertensive ICH </li></ul></ul><ul><ul><li>Ruptured cerebral aneurysm </li></ul></ul><ul><ul><li>Ruptured AVM </li></ul></ul><ul><ul><li>Amyloid angiopathy </li></ul></ul><ul><ul><li>Bleeding tumor </li></ul></ul><ul><ul><li>Coagulopathy </li></ul></ul>
  10. 10. Stroke <ul><li>Hypertensive ICH </li></ul><ul><ul><li>Hypertension > 90% </li></ul></ul><ul><ul><li>IICP signs and symptoms (headache, vomiting, ↓consciousness) </li></ul></ul><ul><ul><li>Common site: </li></ul></ul><ul><ul><ul><li>Basal ganglion – Hemiparesis, Aphasia (dominant hemisphere) </li></ul></ul></ul><ul><ul><ul><li>Thalamus – hemianesthesia </li></ul></ul></ul><ul><ul><ul><li>Cerebellar – ataxia, cerebellar sign +ve </li></ul></ul></ul><ul><ul><ul><li>Pontine – pinpoint pupil </li></ul></ul></ul>
  11. 11. Stroke <ul><li>Hypertensive ICH </li></ul><ul><ul><li>Antihypertensive drugs </li></ul></ul><ul><ul><ul><li>SBP > 200  IV antihypertensive </li></ul></ul></ul><ul><ul><ul><li>SBP > 180 or MAP > 130 </li></ul></ul></ul><ul><ul><ul><ul><li>IICP suspected  monitor ICP keep CPP 60-80 mmHg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No IICP suspected  modest ↓ BP to MAP 110 or 160/90 </li></ul></ul></ul></ul><ul><ul><li>Surgery VS Medical treatment </li></ul></ul><ul><ul><ul><li>Recommendation: cerebellar hemorrhage > 3 cm (class I) </li></ul></ul></ul>AHA guideline 2007
  12. 12. Stroke <ul><li>Ruptured cerebral aneurysm </li></ul><ul><ul><li>“ Worst headache of my life” </li></ul></ul><ul><ul><li>With or without neurodeficit </li></ul></ul><ul><ul><li>Stiffneck / nuchal rigidity </li></ul></ul><ul><ul><li>CT: Subarachnoid hemorrhage </li></ul></ul><ul><ul><li>Common sequelae: </li></ul></ul><ul><ul><ul><li>Rebleeding </li></ul></ul></ul><ul><ul><ul><li>Hydrocephalus </li></ul></ul></ul><ul><ul><ul><li>Vasospasm </li></ul></ul></ul>
  13. 13. Stroke <ul><li>Ruptured cerebral aneurysm </li></ul><ul><ul><li>Key point of management </li></ul></ul><ul><ul><ul><li>Refer to neurosurgeon ASAP (for clipping to prevent rebleeding) </li></ul></ul></ul><ul><ul><ul><li>If clinical suspected but negative CT </li></ul></ul></ul><ul><ul><ul><li> LP ดู xanthochromia </li></ul></ul></ul><ul><ul><ul><li>Investigation of choice: 4 vessels angiography (alternative: CT angiography (CTA), MRA) </li></ul></ul></ul>
  14. 14. Stroke <ul><li>Ruptured AVM </li></ul><ul><ul><li>Young age** </li></ul></ul><ul><ul><li>Lobar hemorrhage </li></ul></ul><ul><ul><li>Non-hypertension </li></ul></ul><ul><ul><li>Investigation: angiography </li></ul></ul><ul><ul><li>Risk rebleeding 2-3%/y </li></ul></ul><ul><ul><li>Management: </li></ul></ul><ul><ul><ul><li>Surgery – excision </li></ul></ul></ul><ul><ul><ul><li>Embolization </li></ul></ul></ul><ul><ul><ul><li>Radiosurgery </li></ul></ul></ul>
  15. 15. Stroke <ul><li>Investigation in intracerebral hemorrhage </li></ul><ul><li>Consider </li></ul><ul><ul><li>Angiography </li></ul></ul><ul><ul><li>CT angiography </li></ul></ul><ul><ul><li>In </li></ul></ul><ul><ul><li>Young age (< 45) </li></ul></ul><ul><ul><li>Non hypertension </li></ul></ul><ul><ul><li>Uncommon site (Lobar) </li></ul></ul>
  16. 16. Stroke <ul><li>Amyloid angiopathy </li></ul><ul><ul><li>Old age </li></ul></ul><ul><ul><li>Non-hypertension </li></ul></ul><ul><ul><li>Lobar hemorrhage </li></ul></ul><ul><ul><li>No special investigation needed </li></ul></ul>
  17. 17. Trauma <ul><li>ผู้ป่วยชายอายุ 50 ปี ขับรถยนต์ชนจักรยานยนต์ สลบไป 10 นาที ตื่นมารู้เรื่องดี หน่วยกู้ภัยนำส่งรพ . ตรวจร่างกายแรกรับปกติ อีก 2 ชั่วโมงซึมลง GCS E1V2M5, pupils right 3 mm, left 5 mm SRTL คิดถึงภาวะใดมากที่สุด </li></ul><ul><ul><li>Epidural hemorrhage </li></ul></ul><ul><ul><li>Subdural hemorrhage </li></ul></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><ul><li>Intracerebral hemorrhage </li></ul></ul><ul><ul><li>Diffuse axonal injury </li></ul></ul>เฉลย a
  18. 18. Trauma <ul><li>Initial management* </li></ul><ul><li>Epidural hematoma* </li></ul><ul><li>Subdural hematoma* </li></ul><ul><li>Traumatic intracerebral hematoma </li></ul><ul><li>Traumatic SAH </li></ul><ul><li>Skull fracture </li></ul><ul><li>Sequalae </li></ul>
  19. 19. Trauma <ul><li>Initial management </li></ul><ul><ul><li>ABCDE </li></ul></ul><ul><ul><li>Don’t miss! </li></ul></ul><ul><ul><ul><li>Collar (primary survey = A) </li></ul></ul></ul><ul><ul><ul><li>ET tube in GCS ≤ 8 (primary survey = D) </li></ul></ul></ul><ul><ul><ul><li>Search for other bleeding site in hypotensive patient </li></ul></ul></ul><ul><ul><li>GCS (Must remember!) </li></ul></ul>
  20. 20. Trauma โจทย์ short essay : moderate HI in rural hospital Item ตอบถูก % GCS 47 71.21 C-spine protection 14 21.21 O2 17 25.76 IV 47 71.21 Refer or CT brain 50 75.76 Suture/dressing 37 56.06 Dilantin 11 16.67 Foley or NG 20 30.30
  21. 21. Trauma <ul><ul><li>Glassow Coma scale </li></ul></ul>Eye Verbal Motor Score ทำตามสั่งได้ 6 ปกติ ปัดที่บริเวณเจ็บได้ 5 ลืมตาเอง พูดเป็นประโยค แต่สับสน Withdraws 4 ลืมตาเมื่อเจ็บ พูดเป็นคำมีความหมาย Decorticate 3 ลืมตาเมื่อเรียก ส่งเสียงอืออา Decerebrate 2 ไม่ลืมตา ไม่มีเสียง ไม่มีการเคลื่อนไหว 1
  22. 22. การดูแลผู้ป่วย Head Injury ABCDEs, C spine protection Resuscitation ประเมิน GCS GCS < 9 Severe HI GCS 9-12 Moderate HI GCS 13-15 Mild HI <ul><li>ประเมิน risk Mild HI </li></ul><ul><ul><li>D/C </li></ul></ul><ul><ul><li>Admit observe </li></ul></ul><ul><ul><li>CT </li></ul></ul>พิจารณา O2 mask c bag IV fluid Refer พิจารณา Endotracheal tube Hyperventilation ** Mannitol/osmolar Rx **
  23. 23. Trauma Risk factors for Intracranial lesion for Mild HI <ul><li>Clinical findings </li></ul><ul><ul><li>GCS < 15 หลัง 1-2 ชั่วโมง * </li></ul></ul><ul><ul><li>Amnesia </li></ul></ul><ul><ul><li>ปวดศีรษะ </li></ul></ul><ul><ul><li>อาเจียน </li></ul></ul><ul><ul><li>มีประวัติหมดสติ </li></ul></ul><ul><ul><li>มี Sign ของกะโหลกแตก ( skull Fx (Skull Base/Valve) </li></ul></ul><ul><ul><li>ตรวจพบความผิดปกติทางระบบประสาท * </li></ul></ul><ul><li>Risk factors </li></ul><ul><ul><li>อายุ > 60 </li></ul></ul><ul><ul><li>Coagulopathy (Warfarin, Hemophilia,etc) </li></ul></ul><ul><ul><li>ชัก * </li></ul></ul><ul><ul><li>ดื่มสุรา / ใช้สารเสพติด </li></ul></ul><ul><ul><li>มีกลไกการบาดเจ็บที่รุนแรง เช่น โดนรถชนขณะเดินถนน </li></ul></ul>
  24. 24. Trauma <ul><li>Epidural Hematoma (EDH) </li></ul><ul><ul><li>Associated with skull fracture </li></ul></ul><ul><ul><li>Classic: Middle meningeal artery tear </li></ul></ul><ul><ul><li>Lens shape/biconvex </li></ul></ul><ul><ul><li>Lucid interval* </li></ul></ul><ul><ul><li>Rapidly fatal </li></ul></ul><ul><ul><li>Good prognosis if proper management </li></ul></ul>
  25. 25. Trauma <ul><li>Subdural hematoma (SDH) </li></ul><ul><ul><li>Venous tear/ brain laceration </li></ul></ul><ul><ul><li>High morbidity/mortality due to underlying brain injury </li></ul></ul><ul><ul><li>Crescent – concaved shape </li></ul></ul><ul><ul><li>Counter coup </li></ul></ul>
  26. 26. Trauma <ul><li>Chronic Subdural hematoma (CSDH) </li></ul><ul><ul><li>Elderly, alcohol abuse, coagulopathy </li></ul></ul><ul><ul><li>Motor oil fluid, no clot </li></ul></ul><ul><ul><li>Minimal or no Hx of injury </li></ul></ul><ul><ul><li>Insidious onset </li></ul></ul><ul><ul><ul><li>Minor symptoms  hemiplegia/seizure </li></ul></ul></ul>
  27. 27. Trauma <ul><li>Skull Fracture </li></ul><ul><ul><li>Skull Fx  ↑ risk of intracranial bleeding 5 times </li></ul></ul><ul><ul><li>Skull base fracture </li></ul></ul><ul><ul><ul><li>CSF rhinorrhea, otorrhea </li></ul></ul></ul><ul><ul><ul><li>Battle’s sign, Raccoon’s eye (anterior skull base) </li></ul></ul></ul><ul><ul><ul><li>Facial weakness (petrous part of temporal bone) </li></ul></ul></ul>
  28. 28. Trauma <ul><li>Sequelae of head injury </li></ul><ul><ul><li>Increased intracranial pressure ( > 20 mmHg) </li></ul></ul><ul><ul><ul><li>General: sedation, analgesia, elevate head, avoid hypoxia </li></ul></ul></ul><ul><ul><ul><li>Ventricular drainage </li></ul></ul></ul><ul><ul><ul><li>Mannitol </li></ul></ul></ul><ul><ul><ul><li>Hyperventilation </li></ul></ul></ul><ul><ul><ul><li>2 nd tier </li></ul></ul></ul><ul><ul><ul><ul><li>Phenobarb coma </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Decompressive craniectomy </li></ul></ul></ul></ul>
  29. 29. Trauma <ul><li>Sequelae of head injury </li></ul><ul><ul><li>Electrolyte imbalance – hyponatremia </li></ul></ul><ul><ul><li>Seizure </li></ul></ul><ul><ul><ul><li>Antiepileptic drug - ↓ early seizure </li></ul></ul></ul><ul><ul><ul><li>Prophylaxis 7 days </li></ul></ul></ul><ul><ul><ul><li>I/C: GCS≤10, intracranial lesion, penetrating injury, depressed skull fracture </li></ul></ul></ul><ul><ul><li>Carotid-cavernous fistula </li></ul></ul><ul><ul><ul><li>Posttrauma 2-3 mo </li></ul></ul></ul><ul><ul><ul><li>Unilateral chemosis, proptosis </li></ul></ul></ul><ul><ul><ul><li>Bruit/thrill at the orbit </li></ul></ul></ul><ul><ul><ul><li>Ix: angiography </li></ul></ul></ul><ul><ul><ul><li>Management: balloon embolizaion </li></ul></ul></ul>
  30. 30. Herniation syndrome <ul><li>Central </li></ul><ul><ul><li>Diencephalon  tentorial </li></ul></ul><ul><ul><li>Chronic </li></ul></ul><ul><ul><li>Pupils: SRTL  Fixed </li></ul></ul><ul><li>Uncal** </li></ul><ul><ul><li>Uncus and hippocampal gyrus over tentorium </li></ul></ul><ul><ul><li>CN III compression  unilateral pupil ↑, hemiparesis </li></ul></ul><ul><ul><li>Consciousness preserved in early stages </li></ul></ul><ul><ul><li>Classic for EDH </li></ul></ul>
  31. 31. Herniation syndrome <ul><li>Cingulate (subfalcine H): </li></ul><ul><ul><li>asymptomatic except ACA kink, warning of impending transtentorial H. </li></ul></ul><ul><li>Upward </li></ul><ul><ul><li>posterior fossa mass + ventriculostomy </li></ul></ul><ul><li>Tonsillar </li></ul><ul><ul><li>Posterior fossa mass + LP </li></ul></ul>
  32. 32. Tumor <ul><li>Supratentorial </li></ul><ul><li>Gliomas </li></ul><ul><ul><li>Astrocytoma </li></ul></ul><ul><ul><li>Oligodendrogliomas </li></ul></ul><ul><ul><li>Ependymomas </li></ul></ul><ul><li>Meningiomas </li></ul><ul><li>Sellar and suprasellar </li></ul><ul><ul><li>Pituitary adenomas </li></ul></ul><ul><ul><li>craniopharyngiomas </li></ul></ul><ul><li>Infratentorial </li></ul><ul><li>Medulloblastoma (Ped) </li></ul><ul><li>Cerebellar astrocytoma </li></ul><ul><li>Brainstem gliomas </li></ul><ul><li>CP angle tumor </li></ul><ul><ul><li>Vestibular schwannoma (acoustic neuromas) </li></ul></ul><ul><ul><li>Meningiomas </li></ul></ul><ul><li>Meningiomas </li></ul>
  33. 33. Tumor <ul><li>Most common brain tumor </li></ul><ul><ul><li>Metastasis </li></ul></ul><ul><li>Most common primary brain tumor </li></ul><ul><ul><li>Astrocytoma </li></ul></ul><ul><li>Most common primary brain tumor in children </li></ul><ul><ul><li>Medulloblastoma </li></ul></ul><ul><li>Glioblastoma multiforme </li></ul><ul><li>Grade IV of astrocytoma </li></ul><ul><li>Poor prognosis. 2 yr survival 11 mo for total resection </li></ul>
  34. 34. Tumor <ul><li>DDx for patient with progressive hemiparesis and IICP </li></ul><ul><ul><li>Supratentorial tumor (Metas, gliomas, meningioma, etc) </li></ul></ul><ul><ul><li>Brain abscess (ped. With rt to lt shunt eg TOF) </li></ul></ul><ul><li>DDx for patient with bitemporal hemianopia </li></ul><ul><ul><li>=> sellar and suprasellar tumor </li></ul></ul><ul><ul><li>Pituitary adenoma </li></ul></ul><ul><ul><li>Craniopharyngioma </li></ul></ul><ul><ul><li>Meningioma </li></ul></ul>
  35. 35. Hydrocephalous <ul><li>Mechanism </li></ul><ul><ul><li>Obstruction at CSF pathway: </li></ul></ul><ul><ul><ul><li>Obstructive hydrocephalous </li></ul></ul></ul><ul><ul><ul><li>CSF pathway: tumor, blood, etc </li></ul></ul></ul><ul><ul><li>Obstruction at arachnoid granulation </li></ul></ul><ul><ul><ul><li>Communicating hydrocephalous </li></ul></ul></ul><ul><ul><li>Overproduction: choroid plexus papilloma </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Remove etiology </li></ul></ul><ul><ul><li>Drainage </li></ul></ul><ul><ul><ul><li>Ventriculostomy (temporary) </li></ul></ul></ul><ul><ul><ul><li>Shunting </li></ul></ul></ul><ul><ul><ul><ul><li>VP shunt </li></ul></ul></ul></ul><ul><ul><ul><ul><li>VA shunt </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ventriculo-pleural shunt </li></ul></ul></ul></ul>

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