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Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
Neuro Surgery Lecture 1 - Neurology, Surgery
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Neuro Surgery Lecture 1 - Neurology, Surgery

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  • 1. Pete Gutierrez MD, MMS, PA-C Miami Dade College July 2010
  • 2.  Internal Carotid Artery Major branches visible on Angiography: ◦ 1. Meningohypophysial ◦ 2.Inferolateral ◦ 3.Ophtalmic ◦ 4. Posterior Communicating ◦ 5. Anterior choroidal ◦ 6. Middle cerebral ◦ 7. Anterior cerebral
  • 3.  Circle of willis: ◦ Is form by the:  1.Anterior communicating Artery  2. Internal Carotid Artery  3. Basilar Artery  4. Posterior Cerebral Artery  Surgical Interventions mostly malformations.
  • 4.  Hydrocephalus: ◦ General  1. 1% prevalence ; 1/1000 congenital incidence  Divided into three general categories:  Communicating: All ventricles affected, defect in absorption at the arachnoid granulations  No communicating (Obstructive): Block in CSF flow proximal to arachnoid granulations. This may not affect all ventricle depending on the location of the block (e.g. aqueductal stenosis spares the fourth ventricle.  Ex Vacuo: Atrophic parenchymal tissue loss results in dilated ventricles. Not pathologic Hydrocephalus.
  • 5.  Hydrocephalus: ◦ Etiologies:  1. Congenital  2. Hemorrhage  3. Infectious/Inflammatory  4. Obstructive masses  5. Postoperative (Particular in pediatric posterior fossa procedures).
  • 6.  Clinical Presentation: ◦ 1. ICP Headaches, nausea/vomiting, ataxia, adbucens palsy. ◦ 2. In children check for bulging anterior fontanels, increase in head circumference, irritability, poor feeding, and engorged scalp veins.
  • 7.  Treatment: ◦ Acetazolamide to reduce CSF production and furosemide to promote diuresis. ( This is only temporizing). ◦ Shunt placement:  Most common a ventriculoperitoneal shunt is placed alternatives include ventriculoatrial and ventriculopleural shunts.  Shunts are placed similar to an extra ventricular drain except that the catheter is subcutaneously tunneled behind the ear where a valve is attached and placed in the subgaleal space.
  • 8.  Complications: 1. Obstruction (usually proximal) 2. Infection 3.Patient growth 4. Undershuting kinking 5. Overshuting ICP 6. Subdural hematoma Evaluation is done with a Shunt series plain film to assess location of ventricular catheter Shunt O gram injection of radioisotope into shunt to confirm both proximal catheter patency and distal flow.
  • 9.  Carotid Artery Stenosis:  Symptomatic or Asymptomatic  Syncope is not consider symptomatic because unilateral carotid occlusion rarely results in impairment of consciousness.  Evaluation:  Dopplex Ultrasound.  MR Angiogram  Carotid Angiogram
  • 10.  Treatment: ◦ Medical therapy  Aspirin  Aspirin plus dipyridamole  Clopidogrel  Control of Hypertension  Control of DM  Control of Hyperlipidemia  Smoking cessation
  • 11.  Surgical ◦ Carotid endarectomy ◦ Over medical treatment in men with asymptomatic disease but over 60% occlusion complication rate 3%. ◦ Procedure can be done 4-6 weeks after CVA. ◦ Risk complications:  Hoarseness (recurrent laryngeal nerve injury)  Horner syndrome  Partial tongue paresis  Hematoma causing airway complications
  • 12.  Central Nervous system tumors: ◦ General tumors present with progressive neurologic deficit, motor weakness headache and seizure. ◦ Posterior Fossa mass:  Headache  Nausea/vomiting  Ataxia  Diplopia  Parinaud syndrome  Cranial nerve paresis  Vertical nystagmus
  • 13.  Supratentorial mass: ◦ Headache ◦ Nausea/vomiting ◦ Diplopia ◦ Parinaud syndrome ◦ Motor weakness ◦ Aphasia
  • 14.  Low grade Astrocytoma: ◦ Approximately 12% of primary brain tumors ◦ Mostly on children ◦ Located in cerebral hemispheres, cerebellum  Treatment:  Resected for cure  Surgery not curative for most low grade gliomas.  Radiotherapy for most postoperatively.
  • 15.  Malignant Glioma: ◦ Anaplastic astrocytoma ◦ Glioblastoma multiforme ◦ Approximately 40% of primary brain tumors ◦ Most commonly in the erderly ◦ Treatment is palliative, not for cure.  Surgical excision  Post operative radiotherapy  Post operative chemotherapy
  • 16.  Meningioma: ◦ 12% of all primary brain tumors ◦ 1.8:1 female to male ratio ◦ Arise from arachnoid cells ◦ Slow progresive growth ◦ Treatment:  Observe if asymptomatic  Surgical excision if symptomatic  External beam radiotherapy/knife  Outcome five year survival rate.
  • 17.  Pituitary Adenoma: ◦ 10% of brain tumors ◦ Male=Female incidence ◦ Associated with multiple endocrine neoplasia (MEN) syndrome. ◦ Located Silla Turca ◦ Treatment:  Perform preoperative visual field testing  Pre op endocrinological evaluation
  • 18.  Medical treatment for: ◦ Prolactinomas:  Dopamine agonists  Surgical excision  Acromegaly:  Surgical resection 50% cure rate  Avoid surgery in asymptomatic elderly patients as there is no survival benefit.  Medical therapy with octreotide (somatostatin analogue).
  • 19.  Cushing syndrome, surgery is the treatment of choice. 85% cure rate.  Thyroid stimulating hormone (TSH) adenomas Medical treatment with octreotide.  Nonfunctional adenomas observe if asymptomatic and surgical resection otherwise.
  • 20.  Neuroma: ◦ 8-10% of primary brain tumors: ◦ 1 in 100.000 incidence ◦ Most common affected is the CNS VIII nerve, but any cranial nerve can be involved. ◦ Usually unilateral ◦ Treatment:  Perform pretreatment audiometric and vestibular testing  Surgical resection  Conversional Radiotherapy
  • 21.  Ependymona: ◦ 6% of primary brain tumors ◦ Location 4th ventricle most common ◦ Mostly occur in children ◦ Treatment surgical resection ◦ Radiation if located in the fourth ventricle or spinal cord ◦ Chemotherapy of little benefit ◦ Outcome 80% 5 year adult with surgical and radiation ◦ 30% 5 years survival in children
  • 22.  Oligodendroglioma: ◦ 4% of primary brain tumors ◦ Male >female(3:2) ◦ Mostly occur in middle age adults ◦ Slow progressive present with a seizure ◦ Treatment:  Surgery  Radiotherapy  Chemotherapy  Survival 30-75% survival rate
  • 23.  Pineal tumors: ◦ One to two % of primary brain tumors ◦ Most frequent in children's ◦ Germinomas and teratomas have a male preponderance ◦ Location pineal region and third ventricle ◦ Surgery only if well encapsulated ◦ No evidence of metastases
  • 24.  CNS Lymphoma: ◦ 1% of primary brain tumors ◦ May be primary of secondary ◦ Associated with  AIDS  Connective tissue disease  Chronic Immunosuppression  Epstein-Barr virus infection  Male>Female (1.5:1)
  • 25.  This tumors tend to melt away with an initial round of steroids treatment.  Radiation therapy is the mainstay of treatment  The main role of surgery is diagnosis biopsy  Surgery does not improve survival
  • 26.  Other non common tumors of the brain: ◦ Epidermoid and Dermoid tumors ◦ Primitive Neuroectodermal tumors ◦ Choroid Plexus tumors ◦ Glomus tumors ◦ Chordoma tumors  1% of brain tumors  Surgical treatment  Chemotherapy and Radiation  Survival 70-85%
  • 27.  Metastatic Tumors:  More than 50%  Common Lung Cancer  Breast Cancer  Renal Cell carcinoma  Colon adenocarcinoma  Most occur in the cerebral hemispheres
  • 28.  Management: ◦ Biopsy for diagnosis identification purposes ◦ Treatment for seizures ◦ Palliative ◦ Chemotherapy at time beneficial
  • 29.  May the Force be with you?  Break a leg?  Enjoy Vacation!!!!!  To be or not to Be that is the QUESTION!!!!!!!  GO FORTH AND CONQUER!! CONGRAT’S!!!!!!!!!!!!!!!!!!!!!!!

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