1. The document discusses the initial management of traumatic brain injury, including decompressive craniectomy to reduce ICP, hyperosmolar therapy with mannitol or HTS, CSF drainage with EVD, and sedation to control refractory ICP. Early enteral nutrition is recommended if no contraindications.
2. Spinal trauma management involves cervical spine clearance following the Canadian C-spine Rule or Nexus criteria. Imaging includes 3-view c-spine series and thoracolumbar films. Neurological exam uses the ASIA chart.
3. Common neurosurgical emergencies are discussed like raised ICP, stroke, seizures, and brainstem compression from posterior fossa
Brain tumor is an abnormal growth of the tissue in the brain.
The brain tumors can be mainly divided into two primary brain tumors and secondary/metastatic brain tumor
Hyponatremia in neurological patients: cerebral salt wasting versus inappropr...Amit Agrawal
This document discusses hyponatremia in neurological patients, specifically comparing cerebral salt wasting syndrome (CSW) and syndrome of inappropriate antidiuretic hormone secretion (SIADH). It notes that hyponatremia is common in acute neurological patients and can worsen outcomes. The key difference between CSW and SIADH is volume status, which is difficult to assess, though treatment differs with fluid restriction for SIADH and saline replacement for CSW. Correct diagnosis and management of hyponatremia in these patients is important.
This document provides information on tumors located in the fourth ventricle of the brain. It discusses the anatomy of the fourth ventricle and some of the most common tumor types found there, including ependymomas, medulloblastomas, hemangioblastomas, and epidermoid cysts. It also outlines the clinical features of fourth ventricle tumors, common investigations and surgical approaches used to access and resect these tumors, as well as potential complications of surgery.
This document provides a summary of neurosurgery topics including neuroembryology, neural tube defects, posterior fossa malformations, syringomyelia, neuroanatomy, dural venous sinuses, intracranial pressure, CSF physiology, common neurosurgical questions, and raised ICP management. Key points include:
- Neural tube formation begins in the third week of development and involves neural plate elevation and fusion.
- Common neural tube defects include spina bifida, anencephaly, and Chiari malformations.
- Posterior fossa malformations include Chiari I/II malformations and Dandy-Walker syndrome.
- Syringomyelia causes dissociated
The document discusses the radiological anatomy of a normal CT brain scan. It begins by describing the lobes of the brain and surfaces visible on CT. It then discusses the history and technique of CT scanning, describing how different tissues appear in varying shades of gray. Common artifacts are also reviewed. Key features of a normal CT brain include symmetric ventricles and sulci, with intact skull and no masses or fluid collections seen.
The document describes the frontotemporal orbitozygomatic (FTOZ) craniotomy surgical approach. It discusses the key anatomical landmarks and surgical steps involved in the approach. The FTOZ approach provides exposure of the parasellar region, anterior circulation aneurysms, and lesions of the cavernous sinus. It can be performed as a one-piece, two-piece, or three-piece craniotomy. Important tips include protecting the superficial temporal artery and periorbita during dissection and osteotomies.
This document discusses neuro-otological aspects of cerebellopontine angle tumors. It begins by describing the anatomy of the cerebellopontine angle and internal acoustic meatus. It then covers the neurophysiology of hearing and vestibular function, as well as common cerebellopontine angle masses like vestibular schwannoma. The clinical presentation, investigations including tuning fork tests, caloric testing, and imaging are discussed. Specific tests like Rinne's test and auditory brainstem response are also summarized.
Brain stem surgical anatomy and approachesKode Sashanka
This document discusses the surgical anatomy and safe entry zones of the brain stem for tumor removal. It describes the anatomy of the midbrain, pons, and medulla oblongata. Several safe entry zones are outlined for each region, including the anterior mesencephalic zone and intercollicular region for the midbrain, the peritrigeminal and supratrigeminal zones for the pons, and the anterolateral sulcus and posterior median sulcus for the medulla. The document also reviews important tenets of brainstem surgery, such as using the two-point method, lighted bipolar cautery, autolock systems, and careful preservation of venous anatomy.
Brain tumor is an abnormal growth of the tissue in the brain.
The brain tumors can be mainly divided into two primary brain tumors and secondary/metastatic brain tumor
Hyponatremia in neurological patients: cerebral salt wasting versus inappropr...Amit Agrawal
This document discusses hyponatremia in neurological patients, specifically comparing cerebral salt wasting syndrome (CSW) and syndrome of inappropriate antidiuretic hormone secretion (SIADH). It notes that hyponatremia is common in acute neurological patients and can worsen outcomes. The key difference between CSW and SIADH is volume status, which is difficult to assess, though treatment differs with fluid restriction for SIADH and saline replacement for CSW. Correct diagnosis and management of hyponatremia in these patients is important.
This document provides information on tumors located in the fourth ventricle of the brain. It discusses the anatomy of the fourth ventricle and some of the most common tumor types found there, including ependymomas, medulloblastomas, hemangioblastomas, and epidermoid cysts. It also outlines the clinical features of fourth ventricle tumors, common investigations and surgical approaches used to access and resect these tumors, as well as potential complications of surgery.
This document provides a summary of neurosurgery topics including neuroembryology, neural tube defects, posterior fossa malformations, syringomyelia, neuroanatomy, dural venous sinuses, intracranial pressure, CSF physiology, common neurosurgical questions, and raised ICP management. Key points include:
- Neural tube formation begins in the third week of development and involves neural plate elevation and fusion.
- Common neural tube defects include spina bifida, anencephaly, and Chiari malformations.
- Posterior fossa malformations include Chiari I/II malformations and Dandy-Walker syndrome.
- Syringomyelia causes dissociated
The document discusses the radiological anatomy of a normal CT brain scan. It begins by describing the lobes of the brain and surfaces visible on CT. It then discusses the history and technique of CT scanning, describing how different tissues appear in varying shades of gray. Common artifacts are also reviewed. Key features of a normal CT brain include symmetric ventricles and sulci, with intact skull and no masses or fluid collections seen.
The document describes the frontotemporal orbitozygomatic (FTOZ) craniotomy surgical approach. It discusses the key anatomical landmarks and surgical steps involved in the approach. The FTOZ approach provides exposure of the parasellar region, anterior circulation aneurysms, and lesions of the cavernous sinus. It can be performed as a one-piece, two-piece, or three-piece craniotomy. Important tips include protecting the superficial temporal artery and periorbita during dissection and osteotomies.
This document discusses neuro-otological aspects of cerebellopontine angle tumors. It begins by describing the anatomy of the cerebellopontine angle and internal acoustic meatus. It then covers the neurophysiology of hearing and vestibular function, as well as common cerebellopontine angle masses like vestibular schwannoma. The clinical presentation, investigations including tuning fork tests, caloric testing, and imaging are discussed. Specific tests like Rinne's test and auditory brainstem response are also summarized.
Brain stem surgical anatomy and approachesKode Sashanka
This document discusses the surgical anatomy and safe entry zones of the brain stem for tumor removal. It describes the anatomy of the midbrain, pons, and medulla oblongata. Several safe entry zones are outlined for each region, including the anterior mesencephalic zone and intercollicular region for the midbrain, the peritrigeminal and supratrigeminal zones for the pons, and the anterolateral sulcus and posterior median sulcus for the medulla. The document also reviews important tenets of brainstem surgery, such as using the two-point method, lighted bipolar cautery, autolock systems, and careful preservation of venous anatomy.
Ring-enhancing lesions seen on CT or MRI in patients with HIV/AIDS are most commonly toxoplasmosis, primary CNS lymphoma, or brain abscess. Toxoplasmosis lesions typically appear as multiple ring-enhancing lesions in the basal ganglia and corticomedullary junction. Primary CNS lymphoma lesions can have an irregular or ring enhancement appearance, often in the periventricular regions. Brain abscesses demonstrate central restricted diffusion on DWI with a surrounding zone of vasogenic edema, helping differentiate them from other ring-enhancing lesions.
This document discusses the classification and management of spinal arteriovenous malformations (AVMs). It begins by describing the different types of spinal vascular abnormalities, including AV malformations and fistulas. It then discusses various classification systems for spinal AVMs, highlighting the widely accepted Anson-Spetzler classification system which divides AVMs into 4 main types. The document provides details on types I and II lesions, describing dural arteriovenous fistulas and glomus AVMs respectively. It covers arterial and venous anatomy, clinical presentation, imaging characteristics and management considerations for spinal vascular malformations.
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...Abdellah Nazeer
This document discusses radiological imaging of spinal trauma and spinal cord injuries. It describes the common mechanisms of spinal injury including flexion, extension, axial loading, and rotation injuries. It outlines the aims of the radiologist in evaluating spinal trauma to define the extent and type of injury and guide management. The document then focuses on cervical spine trauma, providing details on imaging modalities, injury patterns, classifications of fractures and dislocations, and specific cervical spine injuries associated with different mechanisms. It also discusses thoracolumbar trauma including force vectors, stability considerations, basic fracture patterns, and specific injuries.
Vein of Galen malformations are rare congenital vascular anomalies that develop between weeks 6-11 of fetal development. They present as an aneurysmally dilated midline deep venous structure fed by abnormal arteriovenous communications. In neonates, they can cause high-output cardiac failure. Older children and adults may present with hydrocephalus, neurological deficits, or seizures. Diagnosis is made through imaging like CT, MRI, and angiography. Treatment involves endovascular embolization of the arteriovenous shunts to reduce cardiac overload and improve neurological outcomes. With advances in interventional neuroradiology, vein of Galen malformations can now be successfully treated with low complication rates.
This document discusses foramen magnum meningiomas, a type of brain tumor. It defines the foramen magnum region and describes the structures that pass through it. Foramen magnum meningiomas present with variable neurological symptoms and are challenging to treat due to their proximity to critical structures. Imaging plays an important role in diagnosis and surgical planning. The surgical approach depends on factors such as tumor location and relationship to the vertebral artery. Complications can include lower cranial nerve deficits, cerebrospinal fluid leakage, and vascular injury. Complete resection remains the goal but must be balanced against risk of morbidity.
This document discusses sphenoid wing meningiomas (SWM), a type of meningioma that originates from arachnoid capcells in the sphenoid bone. It covers the classification, causes, locations, presentation, diagnosis, and surgical treatment of SWM. The standard surgical approach is via a pterional craniotomy for resection of the tumor and involved bone. Complete resection is the goal but recurrence is common long-term due to the invasive nature of SWM. Post-operative complications can include edema, CSF leak, seizures, and infection. Overall short and mid-term outcomes are generally good if a gross total resection is achieved.
This document discusses the microsurgery techniques for treating paraclinoid aneurysms. It begins by defining paraclinoid aneurysms and classifying them based on location and variants. It then describes the osseous, dural, neural, and vascular anatomy relevant to the surgery. Surgical approaches including patient positioning, craniotomy, anterior clinoidectomy, and specific techniques for different aneurysm types are outlined. Potential complications are discussed as well as the importance of preserving vital structures. The goal of the surgery is to eliminate the aneurysm while avoiding injury to nearby cranial nerves and vessels.
Brain arteriovenous malformations (bAVM) are abnormal connections of arteries and veins in the brain, forming a tangled web of vessels instead of a normal capillary network treated with multimodalities including, SRS, embolisation and Microneurosurgery.
This slides updates the management of AVM highlighting the importance of SM grading, Pollock radiation grading etc.
This document discusses the surgical management of middle cerebral artery (MCA) aneurysms. Key points include:
- MCA aneurysms are most commonly located at the MCA bifurcation and trifurcation. They can grow quite large before detection and present challenges for endovascular treatment.
- Surgical preparation involves cerebrospinal fluid drainage and a pterional craniotomy for exposure. The Sylvian fissure is opened to access the aneurysm.
- For clipping, the aneurysm is dissected away from surrounding branches and temporarily clipped before applying definitive clips in parallel to branches to avoid remnants. Complex aneurysms may require multiple clips or fenestrated clips.
- Giant or fusiform
X-rays are commonly used to image the spine. The cervical spine can be imaged using anteroposterior, lateral, open mouth, flexion/extension, and oblique views. Key anatomical structures like the vertebrae and discs can be evaluated. Common fractures include teardrop fractures and hangman's fractures. The thoracolumbar spine is also imaged with AP and lateral views. Unstable injuries like burst fractures involve vertebral body collapse while stable injuries include wedge fractures. Spondylolysis is a stress fracture of the pars interarticularis seen best on oblique views.
The document discusses various surgical approaches to the temporal bone, including:
1. The anterior, posterior, superior, and inferior boundaries of the temporal bone.
2. Ten triangles of the temporal bone - four in the cavernous sinus and six in the middle fossa.
3. The Kawase vs modified Dolenc-Kawase approach - which differs in the drilling sequence and angle of approach.
4. Several cranial fossa approaches - simple middle cranial fossa, anterior petrosectomy, extended middle fossa, presigmoid, and various modifications.
5. Anatomic landmarks and surgical techniques for the postauricular transtemporal, combined presigmoid
4 th ventricle- Anatomical and surgical perspectivesuresh Bishokarma
4th ventricle connects the entire ventricular system of brain. Its connection with cisterns magna and cerebella pontine cistern via foramen of magenta and Luschka. CSF absorbs into the arachnoid granulation.
The adult brain is composed of the cerebral hemispheres, brain stem, and cerebellum, which are covered by meninges and float in cerebrospinal fluid within the ventricular system. The ventricular system includes the lateral ventricles within the cerebral hemispheres, the third ventricle, aqueduct of Sylvius in the brain stem, and fourth ventricle in the pons and medulla oblongata. The choroid plexus produces cerebrospinal fluid and is composed of a network of blood vessels. The cerebral hemispheres contain gray matter in the cortex and basal ganglia, as well as white matter.
Summary and illustrations of various traumatic brain injury including primary and secondary lesions as well as limited information on indications of brain imaging in trauma
This document provides a summary of the history, indications, types, efficacy, complications and conclusions regarding decompressive craniectomy. Some key points:
- Decompressive craniectomy relieves increased intracranial pressure by removing a portion of skull bone and opening the dura, allowing swollen brain tissue to herniate out rather than compress the brainstem.
- Indications for decompressive craniectomy include severe traumatic brain injury, malignant middle cerebral artery infarction, aneurysmal subarachnoid hemorrhage, and other conditions causing refractory elevated intracranial pressure.
- Complications occur in 50-55% of cases and include CSF absorption disorders, expanding hematomas, syndrome
This document discusses classification and pathophysiology of traumatic brain injury (TBI). It defines TBI and provides epidemiological data on incidence and causes. It describes several classification systems that categorize TBI based on mechanism, location, severity and other factors. It then explains the primary and secondary pathophysiological changes that occur following TBI, including disruption of autoregulation, increased intracranial pressure, blood-brain barrier breakdown, cellular metabolic changes, free radical production and more. Potential therapeutic strategies are also briefly mentioned.
Cerebral herniation occurs when brain tissue shifts from its normal position inside the skull due to swelling. This is usually caused by head injury, stroke, bleeding or tumors. There are several types of herniation including subfalcine, transtentorial, uncal, and cerebellar tonsillar herniation. Management involves reducing intracranial pressure through surgical removal of mass lesions, ventricular drainage, medical therapies like hyperventilation, hyperosmotic agents, induced hypertension, barbiturate coma or hypothermia, and in severe cases decompressive craniectomy. The condition progresses through stages as herniation worsens and involves specific neurological exam findings at each stage.
Craniocerebral trauma is a leading cause of death and disability in children, most commonly resulting from road traffic accidents, falls, or assaults. Head injuries can cause skull fractures, hemorrhages such as epidural or subdural hematomas, and diffuse axonal injuries that may require neurosurgical intervention. Secondary injuries like increased intracranial pressure, edema, or hypotension can further damage the brain if not properly managed.
1. The document discusses traumatic brain injuries and CNS infections, outlining their assessment, management, and surgical treatment.
2. Key points include evaluating patients using the Glasgow Coma Scale, identifying different types of intracranial hemorrhages on imaging and their presentations, and treating brain abscesses medically with antibiotics and surgically via burr hole aspiration or craniotomy for excision.
3. Surgical management of conditions like epidural hematomas and brain abscesses aims to decrease intracranial pressure and obtain samples for culture.
Ring-enhancing lesions seen on CT or MRI in patients with HIV/AIDS are most commonly toxoplasmosis, primary CNS lymphoma, or brain abscess. Toxoplasmosis lesions typically appear as multiple ring-enhancing lesions in the basal ganglia and corticomedullary junction. Primary CNS lymphoma lesions can have an irregular or ring enhancement appearance, often in the periventricular regions. Brain abscesses demonstrate central restricted diffusion on DWI with a surrounding zone of vasogenic edema, helping differentiate them from other ring-enhancing lesions.
This document discusses the classification and management of spinal arteriovenous malformations (AVMs). It begins by describing the different types of spinal vascular abnormalities, including AV malformations and fistulas. It then discusses various classification systems for spinal AVMs, highlighting the widely accepted Anson-Spetzler classification system which divides AVMs into 4 main types. The document provides details on types I and II lesions, describing dural arteriovenous fistulas and glomus AVMs respectively. It covers arterial and venous anatomy, clinical presentation, imaging characteristics and management considerations for spinal vascular malformations.
Presentation1.pptx, radiological imaging of spinal trauma and spinal cord inj...Abdellah Nazeer
This document discusses radiological imaging of spinal trauma and spinal cord injuries. It describes the common mechanisms of spinal injury including flexion, extension, axial loading, and rotation injuries. It outlines the aims of the radiologist in evaluating spinal trauma to define the extent and type of injury and guide management. The document then focuses on cervical spine trauma, providing details on imaging modalities, injury patterns, classifications of fractures and dislocations, and specific cervical spine injuries associated with different mechanisms. It also discusses thoracolumbar trauma including force vectors, stability considerations, basic fracture patterns, and specific injuries.
Vein of Galen malformations are rare congenital vascular anomalies that develop between weeks 6-11 of fetal development. They present as an aneurysmally dilated midline deep venous structure fed by abnormal arteriovenous communications. In neonates, they can cause high-output cardiac failure. Older children and adults may present with hydrocephalus, neurological deficits, or seizures. Diagnosis is made through imaging like CT, MRI, and angiography. Treatment involves endovascular embolization of the arteriovenous shunts to reduce cardiac overload and improve neurological outcomes. With advances in interventional neuroradiology, vein of Galen malformations can now be successfully treated with low complication rates.
This document discusses foramen magnum meningiomas, a type of brain tumor. It defines the foramen magnum region and describes the structures that pass through it. Foramen magnum meningiomas present with variable neurological symptoms and are challenging to treat due to their proximity to critical structures. Imaging plays an important role in diagnosis and surgical planning. The surgical approach depends on factors such as tumor location and relationship to the vertebral artery. Complications can include lower cranial nerve deficits, cerebrospinal fluid leakage, and vascular injury. Complete resection remains the goal but must be balanced against risk of morbidity.
This document discusses sphenoid wing meningiomas (SWM), a type of meningioma that originates from arachnoid capcells in the sphenoid bone. It covers the classification, causes, locations, presentation, diagnosis, and surgical treatment of SWM. The standard surgical approach is via a pterional craniotomy for resection of the tumor and involved bone. Complete resection is the goal but recurrence is common long-term due to the invasive nature of SWM. Post-operative complications can include edema, CSF leak, seizures, and infection. Overall short and mid-term outcomes are generally good if a gross total resection is achieved.
This document discusses the microsurgery techniques for treating paraclinoid aneurysms. It begins by defining paraclinoid aneurysms and classifying them based on location and variants. It then describes the osseous, dural, neural, and vascular anatomy relevant to the surgery. Surgical approaches including patient positioning, craniotomy, anterior clinoidectomy, and specific techniques for different aneurysm types are outlined. Potential complications are discussed as well as the importance of preserving vital structures. The goal of the surgery is to eliminate the aneurysm while avoiding injury to nearby cranial nerves and vessels.
Brain arteriovenous malformations (bAVM) are abnormal connections of arteries and veins in the brain, forming a tangled web of vessels instead of a normal capillary network treated with multimodalities including, SRS, embolisation and Microneurosurgery.
This slides updates the management of AVM highlighting the importance of SM grading, Pollock radiation grading etc.
This document discusses the surgical management of middle cerebral artery (MCA) aneurysms. Key points include:
- MCA aneurysms are most commonly located at the MCA bifurcation and trifurcation. They can grow quite large before detection and present challenges for endovascular treatment.
- Surgical preparation involves cerebrospinal fluid drainage and a pterional craniotomy for exposure. The Sylvian fissure is opened to access the aneurysm.
- For clipping, the aneurysm is dissected away from surrounding branches and temporarily clipped before applying definitive clips in parallel to branches to avoid remnants. Complex aneurysms may require multiple clips or fenestrated clips.
- Giant or fusiform
X-rays are commonly used to image the spine. The cervical spine can be imaged using anteroposterior, lateral, open mouth, flexion/extension, and oblique views. Key anatomical structures like the vertebrae and discs can be evaluated. Common fractures include teardrop fractures and hangman's fractures. The thoracolumbar spine is also imaged with AP and lateral views. Unstable injuries like burst fractures involve vertebral body collapse while stable injuries include wedge fractures. Spondylolysis is a stress fracture of the pars interarticularis seen best on oblique views.
The document discusses various surgical approaches to the temporal bone, including:
1. The anterior, posterior, superior, and inferior boundaries of the temporal bone.
2. Ten triangles of the temporal bone - four in the cavernous sinus and six in the middle fossa.
3. The Kawase vs modified Dolenc-Kawase approach - which differs in the drilling sequence and angle of approach.
4. Several cranial fossa approaches - simple middle cranial fossa, anterior petrosectomy, extended middle fossa, presigmoid, and various modifications.
5. Anatomic landmarks and surgical techniques for the postauricular transtemporal, combined presigmoid
4 th ventricle- Anatomical and surgical perspectivesuresh Bishokarma
4th ventricle connects the entire ventricular system of brain. Its connection with cisterns magna and cerebella pontine cistern via foramen of magenta and Luschka. CSF absorbs into the arachnoid granulation.
The adult brain is composed of the cerebral hemispheres, brain stem, and cerebellum, which are covered by meninges and float in cerebrospinal fluid within the ventricular system. The ventricular system includes the lateral ventricles within the cerebral hemispheres, the third ventricle, aqueduct of Sylvius in the brain stem, and fourth ventricle in the pons and medulla oblongata. The choroid plexus produces cerebrospinal fluid and is composed of a network of blood vessels. The cerebral hemispheres contain gray matter in the cortex and basal ganglia, as well as white matter.
Summary and illustrations of various traumatic brain injury including primary and secondary lesions as well as limited information on indications of brain imaging in trauma
This document provides a summary of the history, indications, types, efficacy, complications and conclusions regarding decompressive craniectomy. Some key points:
- Decompressive craniectomy relieves increased intracranial pressure by removing a portion of skull bone and opening the dura, allowing swollen brain tissue to herniate out rather than compress the brainstem.
- Indications for decompressive craniectomy include severe traumatic brain injury, malignant middle cerebral artery infarction, aneurysmal subarachnoid hemorrhage, and other conditions causing refractory elevated intracranial pressure.
- Complications occur in 50-55% of cases and include CSF absorption disorders, expanding hematomas, syndrome
This document discusses classification and pathophysiology of traumatic brain injury (TBI). It defines TBI and provides epidemiological data on incidence and causes. It describes several classification systems that categorize TBI based on mechanism, location, severity and other factors. It then explains the primary and secondary pathophysiological changes that occur following TBI, including disruption of autoregulation, increased intracranial pressure, blood-brain barrier breakdown, cellular metabolic changes, free radical production and more. Potential therapeutic strategies are also briefly mentioned.
Cerebral herniation occurs when brain tissue shifts from its normal position inside the skull due to swelling. This is usually caused by head injury, stroke, bleeding or tumors. There are several types of herniation including subfalcine, transtentorial, uncal, and cerebellar tonsillar herniation. Management involves reducing intracranial pressure through surgical removal of mass lesions, ventricular drainage, medical therapies like hyperventilation, hyperosmotic agents, induced hypertension, barbiturate coma or hypothermia, and in severe cases decompressive craniectomy. The condition progresses through stages as herniation worsens and involves specific neurological exam findings at each stage.
Craniocerebral trauma is a leading cause of death and disability in children, most commonly resulting from road traffic accidents, falls, or assaults. Head injuries can cause skull fractures, hemorrhages such as epidural or subdural hematomas, and diffuse axonal injuries that may require neurosurgical intervention. Secondary injuries like increased intracranial pressure, edema, or hypotension can further damage the brain if not properly managed.
1. The document discusses traumatic brain injuries and CNS infections, outlining their assessment, management, and surgical treatment.
2. Key points include evaluating patients using the Glasgow Coma Scale, identifying different types of intracranial hemorrhages on imaging and their presentations, and treating brain abscesses medically with antibiotics and surgically via burr hole aspiration or craniotomy for excision.
3. Surgical management of conditions like epidural hematomas and brain abscesses aims to decrease intracranial pressure and obtain samples for culture.
BMS2-K13 Pemeriksaan Radiologi pada Sistem Saraf.pptxssuser144901
CT and MRI are commonly used imaging modalities to evaluate the brain and spine. CT can clearly image bone structures and is useful for detecting fractures, while MRI provides excellent soft tissue contrast and is more sensitive for abnormalities within the brain and spinal cord. Some key applications discussed include using CT to identify intracranial hemorrhages such as epidural, subdural, subarachnoid, and intraventricular bleeds. CT is also used to diagnose strokes, brain tumors, hydrocephalus, and traumatic injuries. MRI is superior for evaluating many conditions like brain infarctions, demyelinating diseases, and spinal disc herniations. Both modalities have advantages and can be complementary in the evaluation of many neurological
Intracranial bleeding encompasses all bleeds that may occur within the cranial cavity including Epidural, Subdural, Sub arachnoid, intraparenchymal and Intraventricular haemorrhages. all are discussed in these slides and relevant references are provided for detailed information.
It is important to note that medicine is not learnt online but through series of organised events under specialised supervision in recognised institutions of learning.
This document provides an overview of the management of head injuries. It defines head injury as damage to the head from impact and classifies injuries as closed or open, diffuse or focal. The pathophysiology section explains how small increases in intracranial volume can raise pressure dramatically. Presentation may include altered consciousness, bleeding, seizures or vomiting. Investigations include CT scans to detect fractures or bleeds. Treatment focuses on preventing secondary injuries like hypoxia, controlling pressure, and maintaining perfusion and nutrition. Follow-up is needed as some patients with mild injuries may later develop complications.
lucid interval and its importance in trauma and mental healthsreya paul
1) A 38-year old cricket player was hit on the temple by a cricket ball while fielding without a helmet. He initially seemed fine but later lost consciousness and was found to have a brain hemorrhage.
2) The document discusses lucid intervals which is a period of temporary consciousness that can occur between initial unconsciousness from head trauma and delayed worsening of symptoms from a brain injury like an epidural hematoma.
3) Recognizing lucid intervals is important to prevent delays in treating expanding brain injuries. The cricket player discussed experienced a lucid interval but ultimately died after surgery failed to control his brain hemorrhage.
This document provides an outline and introduction to the management of head injuries. It discusses the relevant anatomy of the head, definitions of head and brain injuries, epidemiology, causes, classifications based on severity, location and type of injury. It also covers the pathogenesis of head injuries and specific entities like skull fractures, concussions, hemorrhages. The assessment and treatment of head injured patients is outlined along with conclusions.
This document provides an overview of head injury management in the emergency department. It begins with an introduction on the importance of not neglecting or giving up on head injuries. It then describes a case of a 25-year-old man brought to the ED unconscious after a bike accident while intoxicated. The document reviews head injury classification, mechanisms of injury, diagnostic imaging, medical and surgical management strategies, and goals of preventing secondary brain injury. Key points covered include initial resuscitation, indications for observation versus admission, guidelines for mild, moderate and severe injuries, and timing of surgical interventions.
The clot is on the right side of the brain. The labeling at the top of the image indicates "R" for right. It's important to always verify the left/right labeling when interpreting images to avoid potential mistakes from flipped or differently labeled images.
1. The document discusses various types of head injuries including concussions, contusions, epidural hematomas, subdural hematomas, penetrating injuries, and blunt trauma injuries.
2. It provides definitions and descriptions of these injuries, their causes, signs and symptoms, diagnostic methods including CT and MRI scans, treatment approaches including surgery, and considerations in the emergency department.
3. The document is a reference for emergency medicine that covers classification, pathophysiology, clinical findings, radiographic findings, and management of different types of head injuries.
This document discusses traumatic head injuries, including causes, risk factors, pathophysiology, assessment, complications, and nursing management. It describes different types of brain injuries such as concussions, hematomas, herniations, and diffuse axonal injury. Key points include identifying high risk groups for TBI, assessing neurological status using the Glasgow Coma Scale, monitoring for increased intracranial pressure, and treating complications like diabetes insipidus and SIADH. Nursing focuses on maintaining cerebral perfusion, minimizing stimuli, and addressing psychosocial needs through education and support.
hydrocephalus, clinical features in various age groups, investigations, treatment options to create a basic understanding of the underlying pathology and management
Initial Management of the Trauma Patient II.pptxHadi Munib
The document provides information on performing a secondary assessment on a trauma patient. It focuses on assessing injuries to the head and skull, as well as the chest. For the head, it describes examining for lacerations, fractures, neurological changes, and signs of increased intracranial pressure. CT scans are useful for diagnosing brain injuries and hemorrhages. Chest injuries can involve fractures, lung issues, and mediastinal injuries. Vital signs, respiratory status, and neurological functions should be monitored for changes.
This document provides an overview of neuroradiology with a focus on cerebral ischemia. It discusses the pathophysiology and evolution of ischemic stroke seen on imaging techniques like CT and MRI. Key points covered include the appearance of acute ischemic stroke on non-contrast CT and differences seen on DWI, T1, T2 and FLAIR MRI sequences over time. It also addresses hemorrhagic transformation, evaluation of infarct size using ASPECTS scoring on CT, and the role of CT angiography and perfusion in assessing salvageable brain tissue. Cerebral venous infarction and classification of hemorrhagic transformations are briefly outlined.
Non accidental head injury - how to improve outcomeTeik Beng Khoo
This document discusses non-accidental head injury in children. It notes that 1/3 of children with non-accidental head injury die, 1/3 have permanent neurological damage, and 1/3 have no long-term effects. It provides details on different types of brain injuries that can occur from head trauma like subdural hematomas, epidural hematomas, cerebral contusions, and diffuse axonal injury. The document emphasizes the importance of oxygenation, cerebral perfusion, intracranial pressure monitoring and control in managing traumatic brain injury in children. It outlines factors that can help predict outcomes like Glasgow Coma Scale, presence of seizures, and signs of increased intracranial pressure.
The document discusses head injuries and traumatic brain injuries (TBI). It covers causes of TBI like falls and motor vehicle accidents. It then discusses the primary and secondary injuries that can occur from a TBI. It explains increased intracranial pressure and outlines treatments to control pressure like osmotic diuretics, CSF drainage, and fluid restriction. The document also covers assessing and diagnosing different types of brain injuries through imaging and examinations.
1. An epidural haematoma (EDH) is a collection of blood between the skull and the dura mater that is usually caused by an injury to the middle meningeal artery from a head trauma.
2. Symptoms of an EDH can include confusion, loss of consciousness, headaches, vomiting and neurological deficits. Patients may experience an initial lucid interval followed by deterioration in their mental status.
3. A CT scan is the primary method used to diagnose an EDH, which appears as a hyperdense, biconvex lesion between the skull and dura. Surgical evacuation is usually required for symptomatic EDHs, while small, asymptomatic EDHs may be monitored conservatively.
This patient is a 24-year-old male who was in a high-speed motor vehicle collision and suffered a closed head injury with a Glasgow Coma Scale of 7/15. He has a fractured femur but no other obvious injuries. The document outlines the steps to manage this severe traumatic brain injury case, beginning with stabilizing the airway, breathing, and circulation. It then discusses assessing the severity of the head injury using CT scans and the Glasgow Coma Scale. The subsequent steps involve monitoring intracranial pressure, treating increased ICP to maintain adequate cerebral perfusion pressure, and managing potential complications.
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2. “To the age of the hearer, in which men had heard and heard only, had
succeeded the age of the eye in which men had seen and been content
only to see. But at last came the age of the hand – the thinking,
devising, planning hand, the hand as an instrument of the mind, now
reintroduced into the world in a modest little monograph from which
we may date the beginning of experimental medicine” – Sir William
Osler
12. MCQs
9. Most common primary metastasis to the Brain come from…
A. Melanoma
B. Kidney
C. GI
D. Lung
13. MCQs
10. Temporal lesions most commonly cause which of the following
forms of brain herniation?
A. Subfalcine herniation
B. Uncal herniation
C. Central transtentorial herniation
D. Tonsillar herniation
16. Neurologic Examination
• Glasgow Coma Scale
• Mental Status – awake, lethargic, stuporous, comatose.
• Cranial Nerves – pupil reactivity, eye movement, facial symmetry and
gag.
• Motor testing – maximal effort of major muscle groups
• Sensory testing – Light touch, proprioception, temperature and pain
17. Table 42-2. Schwartz, S.I, & Brunicardi, F.C. (2015). Schwartz’s principles of surgery (10th
ed.). Pg 1712
18. Diagnostic Studies
• Xrays – fractures, osteoblastic or osteolytic lesions, pneumocephaly.
Not used as much
• CT Scan
• Non contrast CT useful in new onset neuro deficits, trauma or decreased
mental status. High sensitivity of acute hemorrhage.
• Contrast CT – neoplastic or infectious processes
• Thin slice CT angiography – vascular lesions
• MRI
• T1 – useful for detecting neoplastic and infectious processes
• T2 – facilitate assessment of lesion associated edema and neural compression
in the spine by presence or absence of bright T2 CSF signals
19. Diagnostic Studies
• Invasive Monitoring
• External ventricular drain – perforated plastic catheter passed into frontal
horn of lateral ventricle, fluid column allows transduction of ICP.
• Intraparenchymal fiber-optic pressure transducer (bolt)– less invasive
compared to EVD
• Brain tissue oxygen sensors – similar to bolt, but can assess pressure, oxygen
and temperature.
• Electromyography/Nerve Conduction Studies
21. Raised ICP
• Normal ICP 4-14mmHg
• Monro-Kellie doctrine – cranial vault is a rigid structure and thus total
volume of contents determines ICP. (Brain tissue, CSF and Blood).
• The pressure-volume curve demonstrates a compensated region with
a small ΔP/ΔV, and an uncompensated region with large ΔP/ΔV.
• In the compensated region, increased volume is offset by decreased
volume of CSF and blood.
• Increased ICP can lead to shifts and herniation.
22. Table 42-3. Schwartz, S.I, & Brunicardi, F.C. (2015). Schwartz’s principles of surgery (10th
ed.). Pg 1714
23. Raised ICP
• Uncal Herniation – temporal lesions push uncus medially and
compress the midbrain, PCA passes between uncus and midbrain, can
be occluded leading to occipital infarcts.
• Subfalcine herniation – Cingulate gyrus pushed under the falx cerebri.
ACA branches pass along the medial surface of the cingulate gyrus,
occlusion leads to medial frontal and parietal infarcts.
• Diffuse increases in cerebral hemisphere pressure can cause central,
transtentorial herniation.
• Pressure in posterior fossa –upward central herniation or downward
tonsillar herniation.
24. Table 42-4. Schwartz, S.I, & Brunicardi, F.C.
(2015). Schwartz’s principles of surgery
(10th ed.). Pg 1714
25. ICP
• Presentation
• headache, nausea, vomiting, progressive mental status decline, hemiparesis
may be present if there is a focal mass lesion. Cushing’s triad – hypertension,
bradycardia and irregular respirations.
• Management
• Airway protection
• bolus of mannitol 1g/kg
• Ventriculostomy or craniectomy
• Obtunded patients have a decreased respiratory drive, causing PaCO2 to
increase and vasodilation of cerebral vessels worsening ICP.
26. Brain Stem Compression
• Posterior fossa lesions like tumors, hemorrhage or stroke can cause
mass effect rapidly killing the patient in two ways;
• Occlusion of the 4th ventricle can lead to acute obstructive hydrocephalus,
raised ICP, herniation and death.
• Direct brainstem compression – hypertension, agitation, progressive
obtundation leading to death.
• Management – immediate ventriculostomy, suboccipital craniectomy
27. Stroke
• Ischaemic or Hemorrhagic
• Hemorrhagic – can be seen early in stroke via CT scan.
• Ischaemic – may take up to 24 hours for changes to appear on CT
scan.
• Thrombolysis can be done if within 3 hours of onset of symptoms.
28. Seizure
• Uncontrolled electrical activity
• New onset seizure often signifies an irritative mass lesion in the brain
especially in adults.
• Patients with traumatic intracranial hemorrhage are at risk of
seizures.
• New onset seizures warrant imaging.
30. Skull fractures
• Open fractures require debridement and repair of the scalp.
• Indications for craniotomy – depression greater than cranial
thickness, intracranial hematoma and frontal sinus involvement.
However fractures overlying the dural sinuses require restraint,
exploration can lead to life threatening hemorrhage.
• Base of skull fractures if asymptomatic require no treatment.
However if associated with cranial nerve deficit or persistent CSF leak,
may warrant intervention.
31. Closed Head Injury
• Primary vs. Secondary Injury – hypoxia, hypotension, hydrocephalus,
ICP, thrombosis and hemorrhage.
• Assessment involves the ATLS protocol. Assess ABCDE with C-collar,
Secondary Survey.
• Why C-collar? C spine injuries among head injured patients range
between 4-8%
32. • In the setting of an isolated mandible,
nasal, orbital floor, malar/maxilla, or
frontal/parietal bone fracture, cervical
spine injury ranged from 4.9 to 8.0 %,
head injury ranged from 28.7 to 79.9
%, and concomitant cervical spine and
head injury was present in 2.8 to 5.8
%.
• In the setting of two or more facial
fractures, the prevalence of cervical
spine injury ranged from 7.0 to 10.8
%. The prevalence of head injury
ranged from 65.5 to 88.7 %, and the
prevalence of concomitant cervical
spine and head injury ranged from 5.8
to 10.1 %.
33. Glasgow Coma Scale
• Scored out of 15.
• Special circumstances:
• Swollen or damaged eyelids – 1C
• Dysphasic patient – 1D
• Intubated patient – 1T
• Pain
• Nail bed pressure – peripheral stimulus
• Sternal rub – central stimulus
• Supraclavicular (trapezius) pinch– central stimulus
• Superior orbital ridge – central stimulus
34. Types of Closed Head Injuries
Concussion
Observed or documented disorientation or confusion immediately after
an event.
• Impaired balance within 1 day after injury
• Slower reaction time within 2 days from injury
• Impaired verbal learning memory within 2 days from injury
Colorado grading – grade 1 – confusion, grade 2 – amnesia, grade 3 –
LOC
Normal Imaging.
35. Types of Closed Head Injuries
Contusion
• Bruise on the brain, with breakdown of small vessels and
extravasation of blood into brain. Contused areas appear bright on CT
scan.
• By themselves contusions may not cause mass effect but perilesional
edema may. Contusions may enlarge and progress to frank hematoma
esp in first 24 hrs.
• Contre-coup injury?
36. Types of Closed Head Injuries
Diffuse Axonal Injury
• Damage to axons throughout the brain due to acceleration,
deceleration.
• On CT scan – characteristic hemorrhages at grey-white matter
junction.
• On MRI – increased signal intensity at grey-white matter junction,
particularly at the corpus callosum and dorsolateral midbrain.
37. Intracranial Hematomas
Epidural Hematoma
• Blood between skull and dura
• Vessels
• Temporoparietal locus – middle meningeal artery
• Frontal locus – anterior ethmoidal artery
• Occipital locus – transverse or sigmoid sinus
• Vertex locus – superior sagittal sinus
• Symptoms – lucid interval “talks and dies”, uncal herniation from EDH
causes contralateral hemiparesis and ipsilateral CN3 palsy (eyeball
position is down and outward- SO,LR, pupil dilation and ptosis)
38. Intracranial Hematomas
Epidural Hematoma
• Imaging – biconvex bright clot never crossing suture lines.
• Open craniectomy
• Non-operative:
• Clot volume <30cc
• Max thickness <1.5cm
• GCS>8
• Prognosis after evacuation better for EDH vs. SDH as lower energy
involved in EDH.
39. Intracranial Hematomas
Acute Subdural Hematoma
• Blood between Dura and arachnoid
• Vessels – bridging veins
• Symptoms – intractable headache, confusion, may present with
localizing signs
• CT Scan - bright crescent shaped clot
• Craniotomy if thickness>1cm, MDS>5mm, GCS drop>2pts
40. Intracranial Hematomas
Chronic Subdural Hematoma
• Chronic? Collection atleast 2-3 weeks old.
• Imaging – iso/hypodense, a true chronic SDH is as dark as CSF.
• Vascularised membranes may form within the clot as it matures and
become focus for further bleeding (acute on chronic).
• Elderly, Alcoholics and Pts on anticoag at highest risk from minor
head trauma.
• SDH >1cm or with symptoms should be drained. Usually Burrhole.
41. Spinal Trauma
• Need to actively search for signs of spinal injury in all trauma patients.
• Starts with on-site care, transportation and ATLS protocol: C-collar, in-
line stabilization and log rolling.
• ASIA chart allows an accurate and reproducible record or neurological
deficits – sensory deficits in all dermatomes, power in major
myotomes, reflexes and perianal sensation and anal sphincter tone.
• C spine xrays are part of Trauma series. 3 views – lateral, AP and
odontoid.
• Xrays of thoracic and lumbar spine can provided a rapid initial
assessment of bony injuries
42. Spinal Trauma
Clearance of C Spine
• Conscious patient
• Fully alert and oriented
• No associated head injury
• Free of sedatives or alcohol
• No distracting injury
• Complete Normal Neuro-exam
• No post neck tenderness
• Able to turn 45 degrees side to
side
Canadian C spine Rule vs. Nexus C spine Rule
• CCR more sensitive than Nexus (99.4 % vs 90.7%)
and more specific (45.1% vs 36.8%) p<0.001
43. Spinal Trauma
Clearance of C Spine
• Unconscious patient
• Imaging is key
• Adequacy – Occiput to T1
• Five lines of alignment
• Ant soft tissue shadow – C1-C4 shadow ≤50% of body width, C5-C7 ≤100%
• Ant vertebral line – steps or breaks – unstable injury
• Post vertebral line – represents the anterior border of spinal canal)
• Base of spinous process line (spinolaminar line) – posterior border of spinal canal
• Tips of spinous process line – check for avulsion #
• Atlanto-dens interval - <3mm adults, <5mm in child. – larger interval means subluxation
• Space available for the cord >14mm
• Odontoid view – No overhang of lateral mass of C1 over C2. interval between odontoid peg
and C1 lateral masses should be equal.
• AP view – alignment of spinous processes and lateral edges
45. Initial Management of Neurotrauma – Brain
Injury -
1. Decompressive Craniectomy – reduces ICP and ICU days however does not
improve neuro outcomes as measured by GOS score at 6 months post injury in
severe TBI. Primary decompression when high ICP is anticipated or ICP
uncontrolled after maximal medical management in salvageable patient.
2. Prophylactic hypothermia – Not recommended. Not recommended
3. Hyperosmolar therapy – Mannitol 0.25-1g/kg, avoid SBP <90mmHg. Restrict
Mannitol use to patients with signs of herniation or progressive neurological
deterioration. HTS – shown to be more effective at lowering ICP but no
mortality benefit. Risk of rebound ICP with mannitol (HTS preferred)
4. CSF drainage (EVD) – Use of CSF drainage to lower ICP in patients with GCS<6
during the first 12 hours should be considered. EVD used in reducing ICP in
trauma patients
46. Initial Management of Neurotrauma – Brain
Injury -
5. Ventilation therapies – hyperventilation can be used as a temporizing
measure to lower ICP, should be avoided in the first 24 hours after injury
when cerebral blood flow is often reduced. (Rarely used as means of
lowering ICP)
6. Analgesics and Sedatives – barbiturates not recommended for
prophylaxis against raised ICP, but are recommended for treatment of ICP
refractory to standard surgical and medical therapies. Hemodynamic
stability is essential before and after administration. (Sedation with
sedation off intervals to assess neuro-function ideal)
7. Steroids – contraindicated – associated with increased mortality
(Contraindicated)
8. Nutrition – Early enteral feeding recommended – no mortality benefit
shown. (if no contraindication to feeding, then as early as possible)
47. Initial Management of Neuro-trauma – Brain
Injury -
9. Infection Prophylaxis – Open skull fractures (No Abx for BOS#)
10. DVT prophylaxis – LMWH or low dose unfractionated heparin can be used –
associated with increased risk of expansion of intracranial hemorrhage.
Pneumatic compression stockings been shown to be comparable to LMWH
however compression stocking inferior to LMWH. (Wait 12 days to begin
Enoxaparin)
11. Seizure Prophylaxis – In pts with ICH or depressed skull #, phenytoin 17mg/kg
loading dose and 300-400mg/d maintenance shown to reduce early
posttraumatic seizures. (Can use phenytoin prophylactically upto 7 days)
12. GI prophylaxis – H2RA vs. PPI. H2RA- undergo tachyphylaxis, thus unpredictable
acid suppression, also do not block vagal stimulated gastric secretion. PPI
superior to H2RA in regard to acid suppression. Omeprazole interacts with
CYP450, can interact with phenytoin. Pantoprazole less CYP interaction.
48. Initial Management of Neuro-trauma – Spinal
Injury -
1. Steroids – Contentious, Schwartz recommends decision to be based
on local practice patterns for legal liability issues.
2. Orthotic devices – C-Collar, Thoracolumbar Orthosis
3. Surgical Decompression and Stabilisation
49. CNS Tumors
• Intracranial Tumors
• Cause brain injury from mass effect, dysfunction or destruction of adjacent
neural structures, swelling or abnormal electrical activity.
• Supratentorial tumors commonly present with focal neurological deficits such
as contralateral limb weakness, visual deficits or seizures.
• Infratentorial tumors often cause increased ICP due to hydrocephalus from
compression of the 4th ventricle, causing headache, nausea and diplopia
• Cerebellar hemisphere or brain stem dysfunction can result in ataxia,
nystagmus, cranial nerve palsies. Infratentorial tumors rarely cause seizures.
• MRI ± gadolinium contrast is recommended
• Initial Mx – Dexamethasone for reduction of vasogenic edema and phenytoin
for patients who have seized.
50. CNS Tumors
• Metastatic tumors
• Lung, breast, kidney, GI tract and melanoma. (Lung and breast >50%)
• Mets tend to seed at the grey-white matter junction and also cerebellum and
meninges (leptomeningeal carcinomatosis).
• Well circumscribed, round and multiple lesions should prompt metastatic work up
(CT chest, abdomen, pelvis and bone scan).
• Management depends on the primary, overall tumor burden, patient’s medical
condition, location and number of metastasis.
• Single lesion – Craniotomy + Whole brain Radiotherapy or stereotactic radiosurgery
beneficial than WBRT alone.
• Post-op radio – reduces original lesion recurrence but no survival benefit.
• Craniotomy for multiple lesions not recommended unless all lesions can be resected.
52. Spinal Tumors
• Majority of spinal tumors are benign.
• Effects usually involve either destruction of the bones and ligaments
causes spinal instability leading to deformities, subluxation.
• Tumor growth within the canal can cause direct compression of the
cord or roots leading to pain and loss of function.
54. Cerebrovascular Disease
• Ischemic Stroke -85%
• Thrombotic disease – carotid most affected, diagnosis via angiography.
Treatment – carotid endarterectomy
• Embolic disease – occlusion tends to favor the anterior circulation
• ACA stroke – medial, frontal and parietal lobes incl motor cortex – contralat leg
weakness
• MCA stroke – lateral frontal and parietal lobes. Contralat face and arm weakness.
Language deficits if dominant hemisphere. Prox MCA stroke with wide area of ischemia
can lead to mass effect
• PCA stroke – supplies occipital lobe – contralateral homonymous hemianopsia
• PICA stroke – supplies lateral medulla and inferior half of the cerebellar hemispheres –
nausea, vomiting, nystagmus, dysphagia, ipsilateral Horner’s syndrome, ipsilateral limb
ataxia (lateral medullary or Wallenberg’s syndrome)
• Mx – revascularization with tPA within 3 hrs
61. MCQs
5. Standard treatment for Asymptomatic SDH >2cm is
A. Craniectomy
B. Burrhole drainage
C. Observation and Serial CT
D. Bedside ventriculostomy
62. MCQs
6. Is not part of Cushings triad
A. Hypertension
B. Pinpoint pupils
C. Bradycardia
D. Irregular respirations
63. MCQs
7. Best Treatment Option is
A. Burrhole surgery
B. In hospital Non-op care
C. Craniectomy
D. Discharge home to come to
Neuroclinic
64. MCQs
8. Name the Cervical Collar (each ½ mark)
B – Miami J Collar
A – Philadelphia Collar
65. MCQs
9. Most common primary metastasis to the Brain come from…
A. Melanoma
B. Kidney
C. GI
D. Lung
66. MCQs
10. Temporal lesions most commonly cause which of the following
forms of brain herniation?
A. Subfalcine herniation
B. Uncal herniation
C. Central transtentorial herniation
D. Tonsillar herniation