1 / 34

Neurosurgery Review for Medical Student

Neurosurgery Review for Medical Student. 17 Febuary 2552. Stroke. ผู้ป่วยหญิงอายุ 50 ปี ขณะดูโทรทัศน์ที่โซฟา มีอาการปวดท้ายทอย อย่างมาก อาเจียน ซึมลง PE : GCS 13, no motor weakness, stiff neck +ve จงให้การวินิจฉัย Pontine hemorrhage Cellebellar hemorrhage Subarchnoid hemorrhage

ronalee
Download Presentation

Neurosurgery Review for Medical Student

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Neurosurgery Reviewfor Medical Student 17 Febuary 2552

  2. Stroke • ผู้ป่วยหญิงอายุ 50 ปี ขณะดูโทรทัศน์ที่โซฟา มีอาการปวดท้ายทอย อย่างมาก อาเจียน ซึมลง PE : GCS 13, no motor weakness, stiff neck +ve จงให้การวินิจฉัย • Pontine hemorrhage • Cellebellar hemorrhage • Subarchnoid hemorrhage • Basal ganglion hemorrhage • Intraventricular hemorrhage เฉลย C

  3. Stroke • Ischemic VS hemorrhagic • Ischemic syndrome ต่าง ๆ • Hemorrhagic disease • Hypertensive hemorrhage • Amyloid angiopathy • SAH from ruptured aneurysm • Ruptured AVM • (อื่น ๆ – bleeding tumor, coagulopathy, parasite, vasculitis)

  4. Stroke • Ischemic VS hemorrhagic • Hemorrhagic stroke มักมี sign of IICP (ปวดหัว อาเจียน ซึมลง) • Ischemic stroke มักมาด้วย sudden neurodeficit • Hemiparesis • Apasia / apraxia • Amaurosis fugax • Onset แยกไม่ได้ • Clinical แยกไม่ได้ 100%  need investigation = CT

  5. Stroke • Ischemic stroke • MCA: Hemiparesis, contralateralhemisensory loss, aphasia • ACA: Paresis and sensory loss of contralateral lower extremity • PCA: Homonymous hemianopia with macular sparing • Basilar: Cranial nerve signs – diplopia, facial weakness, vertigo, dysarthria

  6. Stroke • Hemorrhagic stroke • Hypertensive ICH • Ruptured cerebral aneurysm • Ruptured AVM • Amyloid angiopathy • Bleeding tumor • Coagulopathy

  7. Stroke • Hypertensive ICH • Hypertension > 90% • IICP signs and symptoms (headache, vomiting, ↓consciousness) • Common site: • Basal ganglion – Hemiparesis, Aphasia (dominant hemisphere) • Thalamus – hemianesthesia • Cerebellar – ataxia, cerebellar sign +ve • Pontine – pinpoint pupil

  8. Stroke • Hypertensive ICH • Antihypertensive drugs • SBP > 200  IV antihypertensive • SBP > 180 or MAP > 130 • IICP suspected  monitor ICP keep CPP 60-80 mmHg • No IICP suspected  modest ↓ BP to MAP 110 or 160/90 • Surgery VS Medical treatment • Recommendation: cerebellar hemorrhage > 3 cm (class I) AHA guideline 2007

  9. Stroke • Ruptured cerebral aneurysm • “Worst headache of my life” • With or without neurodeficit • Stiffneck / nuchal rigidity • CT: Subarachnoid hemorrhage • Common sequelae: • Rebleeding • Hydrocephalus • Vasospasm

  10. Stroke • Ruptured cerebral aneurysm • Key point of management • Refer to neurosurgeon ASAP (for clipping to prevent rebleeding) • If clinical suspected but negative CT  LP ดู xanthochromia • Investigation of choice: 4 vessels angiography (alternative: CT angiography (CTA), MRA)

  11. Stroke • Ruptured AVM • Young age** • Lobar hemorrhage • Non-hypertension • Investigation: angiography • Risk rebleeding 2-3%/y • Management: • Surgery – excision • Embolization • Radiosurgery

  12. Stroke • Investigation in intracerebral hemorrhage • Consider • Angiography • CT angiography In • Young age (< 45) • Non hypertension • Uncommon site (Lobar)

  13. Stroke • Amyloid angiopathy • Old age • Non-hypertension • Lobar hemorrhage • No special investigation needed

  14. Trauma • ผู้ป่วยชายอายุ 50 ปี ขับรถยนต์ชนจักรยานยนต์ สลบไป 10 นาที ตื่นมารู้เรื่องดี หน่วยกู้ภัยนำส่งรพ. ตรวจร่างกายแรกรับปกติ อีก 2 ชั่วโมงซึมลง GCS E1V2M5, pupils right 3 mm, left 5 mm SRTL คิดถึงภาวะใดมากที่สุด • Epidural hemorrhage • Subdural hemorrhage • Subarachnoid hemorrhage • Intracerebral hemorrhage • Diffuse axonal injury เฉลย a

  15. Trauma • Initial management* • Epidural hematoma* • Subdural hematoma* • Traumatic intracerebral hematoma • Traumatic SAH • Skull fracture • Sequalae

  16. Trauma • Initial management • ABCDE • Don’t miss! • Collar (primary survey = A) • ET tube in GCS ≤ 8 (primary survey = D) • Search for other bleeding site in hypotensive patient • GCS (Must remember!)

  17. Trauma โจทย์ short essay: moderate HI in rural hospital

  18. Trauma Glassow Coma scale

  19. การดูแลผู้ป่วย Head Injury ABCDEs, C spine protection Resuscitation ประเมิน GCS GCS 13-15 Mild HI GCS 9-12 Moderate HI GCS < 9 Severe HI พิจารณา O2 mask c bag IV fluid พิจารณา Endotracheal tube Hyperventilation ** Mannitol/osmolar Rx ** • ประเมิน risk Mild HI • D/C • Admit observe • CT Refer

  20. TraumaRisk factors for Intracranial lesion for Mild HI • Clinical findings • GCS < 15 หลัง 1-2 ชั่วโมง* • Amnesia • ปวดศีรษะ • อาเจียน • มีประวัติหมดสติ • มี Sign ของกะโหลกแตก (skull Fx (Skull Base/Valve) • ตรวจพบความผิดปกติทางระบบประสาท* • Risk factors • อายุ > 60 • Coagulopathy (Warfarin, Hemophilia,etc) • ชัก* • ดื่มสุรา/ใช้สารเสพติด • มีกลไกการบาดเจ็บที่รุนแรง เช่น โดนรถชนขณะเดินถนน

  21. Trauma • Epidural Hematoma (EDH) • Associated with skull fracture • Classic: Middle meningeal artery tear • Lens shape/biconvex • Lucid interval* • Rapidly fatal • Good prognosis if proper management

  22. Trauma • Subdural hematoma (SDH) • Venous tear/ brain laceration • High morbidity/mortality due to underlying brain injury • Crescent – concaved shape • Counter coup

  23. Trauma • Chronic Subdural hematoma (CSDH) • Elderly, alcohol abuse, coagulopathy • Motor oil fluid, no clot • Minimal or no Hx of injury • Insidious onset • Minor symptoms  hemiplegia/seizure

  24. Trauma • Skull Fracture • Skull Fx  ↑ risk of intracranial bleeding 5 times • Skull base fracture • CSF rhinorrhea, otorrhea • Battle’s sign, Raccoon’s eye (anterior skull base) • Facial weakness (petrous part of temporal bone)

  25. Trauma Sequelae of head injury • Increased intracranial pressure (> 20 mmHg) • General: sedation, analgesia, elevate head, avoid hypoxia • Ventricular drainage • Mannitol • Hyperventilation • 2nd tier • Phenobarb coma • Decompressive craniectomy

  26. Trauma Sequelae of head injury • Electrolyte imbalance – hyponatremia • Seizure • Antiepileptic drug - ↓ early seizure • Prophylaxis 7 days • I/C: GCS≤10, intracranial lesion, penetrating injury, depressed skull fracture • Carotid-cavernous fistula • Posttrauma 2-3 mo • Unilateral chemosis, proptosis • Bruit/thrill at the orbit • Ix: angiography • Management: balloon embolizaion

  27. Herniation syndrome • Central • Diencephalon  tentorial • Chronic • Pupils: SRTL Fixed • Uncal** • Uncus and hippocampal gyrus over tentorium • CN III compression  unilateral pupil ↑, hemiparesis • Consciousness preserved in early stages • Classic for EDH

  28. Herniation syndrome • Cingulate (subfalcine H): • asymptomatic except ACA kink, warning of impending transtentorial H. • Upward • posterior fossa mass + ventriculostomy • Tonsillar • Posterior fossa mass + LP

  29. Tumor Supratentorial • Gliomas • Astrocytoma • Oligodendrogliomas • Ependymomas • Meningiomas • Sellar and suprasellar • Pituitary adenomas • craniopharyngiomas Infratentorial • Medulloblastoma (Ped) • Cerebellar astrocytoma • Brainstem gliomas • CP angle tumor • Vestibular schwannoma (acoustic neuromas) • Meningiomas • Meningiomas

  30. Tumor • Most common brain tumor • Metastasis • Most common primary brain tumor • Astrocytoma • Most common primary brain tumor in children • Medulloblastoma Glioblastomamultiforme • Grade IV of astrocytoma • Poor prognosis. 2 yr survival 11 mo for total resection

  31. Tumor • DDx for patient with progressive hemiparesis and IICP • Supratentorial tumor (Metas, gliomas, meningioma, etc) • Brain abscess (ped. With rt to lt shunt eg TOF) • DDx for patient with bitemporalhemianopia => sellar and suprasellar tumor • Pituitary adenoma • Craniopharyngioma • Meningioma

  32. Hydrocephalous • Mechanism • Obstruction at CSF pathway: • Obstructive hydrocephalous • CSF pathway: tumor, blood, etc • Obstruction at arachnoid granulation • Communicating hydrocephalous • Overproduction: choroid plexus papilloma • Treatment • Remove etiology • Drainage • Ventriculostomy (temporary) • Shunting • VP shunt • VA shunt • Ventriculo-pleural shunt

  33. ขอให้โชคดีในการสอบ

More Related