neuro surgery lecture 1 - neurology, surgery
TRANSCRIPT
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Neurology, SurgeryPete Gutierrez MD, MMS, PA-C
Miami Dade CollegeJuly 2010
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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
Neurology
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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.
Neurology
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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.
Neurology
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Hydrocephalus:◦ Etiologies:
1. Congenital 2. Hemorrhage 3. Infectious/Inflammatory 4. Obstructive masses 5. Postoperative (Particular in pediatric posterior
fossa procedures).
Neurology
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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.
Neurology
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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.
Neurology
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Complications:1. Obstruction (usually proximal)2. Infection3.Patient growth4. Undershuting kinking5. Overshuting ICP6. Subdural hematomaEvaluation is done with a Shunt series plain film to assess location of ventricular catheterShunt O gram injection of radioisotope into shunt to confirm both proximal catheter patency and distal flow.
Neurology
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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
Neurology
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Treatment:◦ Medical therapy
Aspirin Aspirin plus dipyridamole Clopidogrel Control of Hypertension Control of DM Control of Hyperlipidemia Smoking cessation
Neurology
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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
Neurology
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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
Neurology
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Supratentorial mass:◦ Headache◦ Nausea/vomiting◦ Diplopia◦ Parinaud syndrome◦ Motor weakness◦ Aphasia
Neurology
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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.
Neurology
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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
Neurology
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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.
Neurology
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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
Neurology
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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).
Neurology
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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.
Neurology
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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
Neurology
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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
Neurology
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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
Neurology
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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
Neurology
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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)
Neurology
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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
Neurology
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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%
Neurology
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Metastatic Tumors: More than 50% Common Lung Cancer Breast Cancer Renal Cell carcinoma Colon adenocarcinoma Most occur in the cerebral hemispheres
Neurology
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Management:◦ Biopsy for diagnosis identification purposes◦ Treatment for seizures◦ Palliative◦ Chemotherapy at time beneficial
Neurology
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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!!!!!!!!!!!!!!!!!!!!!!!
Neurology