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Neurosurgery MCQ questions and discussions around high yield topicsOverview of session ● MCQ questions ○ Taken from Passmedicine ○ Covers major themes ● Polls ○ Will show question on screen + polls to answer the questions ○ Will be given around 60 sec to answer the questions ○ I won’t pick anyone out to answer any questions! ● Learning points ○ Once the answer is revealed we will talk through themHeadache ● Another very common presenting ● Systems review complaint ○ Trauma ● SOCRATES ○ Constitutional: fever, weight loss, etc ● What to ask in a systems review? ○ Meningism: light sensitivity, neck stiffness, rash, travel ○ GCA: pain on combing, vision changes, jaw claudication ○ Seizures and LOC ○ Stroke: limb weakness, visual changes, etc ○ SOL: morning headache, worse on coughing, lying down or any valsalva manoeuvreHow do we classify headaches? ● Primary and secondary headaches ● What is the difference? ● Primary headaches have no known underlying cause ● Secondary headaches are associated with an underlying cause or conditionPrimary vs secondary headaches Primary headaches Secondary causes ● Migraine ● SOL ● Tension headache ● Meningitis ● Cluster headache ● Temporal arteritis ● Trigeminal neuralgia ● Haemorrhage ● Acute closure glaucoma ● Acute sinusitis ● Idiopathic intracranial hypertensionBrain anatomy recap https://openbooks.lib.msu.edu/introneuroscience1/chapter/external -brain-anatomy/Meningeal layers What are the three meningeal layers? ● Dura mater ● Arachnoid mater ● Pia mater Image: The Meninges - Dura - Arachnoid - Pia - TeachMeAnatomyVentricles in the brain ● Ventricles in the brain produce and store cerebrospinal fluid ● Epithelial cells in the ventricles called the choroid plexus produces the cerebrospinal fluid and dispenses them into the ventricles ● Arachnoid granulations then drain the CSF which enter the brains venous system (dural venous sinus) https://www.thoughtco.com/ventricular-system-of-the-brain-3901496Question 1Answer 1 Key point: Lucid interval is associated with extradural haematoma What is the phenomena that this patient is experiencing What is diffuse axonal injury? called? ● Injury that commonly occurs in deceleration ● Lucid interval accidents like a car accident ● The sudden deceleration causes mechanical ● Initially loses, briefly regains and then loses again consciousness after a low-impact head injury shearing and tearing of the axons in the brain ● The brief reagin of consciousness is the lucid ● Very severe injury interval ● Why does this happen? ● The initial impact causes the LOC, then after regaining consciousness, the expanding haematoma causes the LOC againQuestion 2Answer 2 Key point: subdural haemorrhages often develop over days, weeks or even months, periods of confusion and heavily associated with falls and other risk factors ● Subdural haemorrhage can present over days What is Wernicke’s and Korsakoff’s? weeks or even months ● Patient has risk factors: age, alcohol excess, and is ● Wernicke’s encephalopathy is a result of thiamine deficiency commonly seen in on warfarin ● Spells of confusion and assessed for frequent falls alcoholics also point towards this ○ won’t typically present with headaches ○ Nystagmus, ataxia, encephalopathy ● I’ll explain why in the following slides ● Korsakoff’s syndrome is a progression of Wernicke’s. If Wernicke untreated, can develop ○ Amnesia (atero or retrograde) ○ ConfabulationQuestion 3 Answer 3 Which side is the haematoma? ● Right side, like looking from the patient's feet Is this acute or chronic? We’ll discuss this in a couple slides ● Acute, because hyperdense, chronic would be hypodense compared to surrounding brain tissue ● Subdural bleed can be acute or chronicQuestion 4Answer 4Question 5Answer 5Extradural haemorrhage aetiology What type of injury commonly causes this? ● Trauma to the side of the head Why is the side of the head vulnerable? ● The pterion is the weakest part of the skull, it is a H-shaped junction for the frontal, sphenoid, parietal and squamous bones Injury to this area causes damage to which vessel? Where is the blood? ● Middle meningeal artery, provides blood to the dura ● Between the skull and the dura mater mater, when ruptured, fills in the extradural spaceSubdural haemorrhage aetiology Subdural haemorrhage is blood in the subdural What causes acute subdural? space, between the dura and arachnoid mater ● High-impact injury What causes the bleeding usually? Risk factors for chronic subdural? ● Rupture of the bridging veins within the subdural space ● Old age, alcohol, anticoagulants, falls history There are two types of subdural haemorrhage: Why is old age a risk factor? ● Acute and chronic ● As you grow old, the brain atrophies, this causes the bridging veins to stretch and become taught, drinking also causes the brain to shrinkExtradural vs subduralEpidural/subdural haemorrhage Investigations: Treatment: ● CT scan ● If found incidentally and no neuro deficit, admit for observations and conservative management in the hopes that the bleeding will be absorbed over time ● Otherwise, a decompressive craniotomy is performedQuestion 6Answer 6Question 7Answer 7 Key point: Non-contrast CT first line investigation for suspected SAH Why do we not use contrast? ● The contrast may obscure the haemorrhage because they are both What is the patient presenting with? hyperdense ● Contrast usually used to look for ● Subarachnoid haemorrhage ● Sudden onset intense headache with signs contrast-enhancing lesions like tumour ● We’ll talk about the lumbar puncture in a of meningism such as neck stiffness and bit photophobia ● First line investigation is a non-contrast CT ● CT angiogram can be used to look for an aneurysm as a cause after SAH had been head confirmed on CTSubarachnoid haemorrhage (SAH) Blood in the subarachnoid space, in between the arachnoid mater and pia mater. Around the sulci and gyri of the brainSAH symptoms What are the symptoms? ● headache ○ usually of sudden-onset (‘thunderclap’ or ‘hit with a baseball bat’) ○ severe (‘worst of my life’) ○ occipital ○ typically peaking in intensity within 1 to 5 minutes ○ there may be a history of a less-severe 'sentinel' headache in the weeks prior to presentation ● nausea and vomiting ● meningism (photophobia, neck stiffness) ● coma ● seizuresQuestion 8Answer 8 SAH causes Most common cause is trauma - traumatic SAH There is also another type called a spontaneous SAH What are the causes of spontaneous SAH? ● intracranial aneurysm - berry aneurysms (5% of cases) ○ hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome increase risk of berry aneurysm ● arteriovenous malformation ● pituitary apoplexy Berry aneurysm commonly affect the circle of Willis (anastomosis of the major vessels at brain base)Question 9Answer 9● If CT is done within 6 hours, and there is no evidence of SAH, guidelines recommend considering an alternative diagnosis ● Only if CT is done after 6 hours AND it shows no evidence of SAH should you do a lumbar puncture ● When would you do the lumbar puncture if it is indicated? ○ 12 hours after the onset of headache ● Previous guidelines used to recommend lumbar puncture if no SAH regardless of when CT was done but not the case anymore ● CT angiogram after SAH confirmed on CT to look for aneurysm ● DSA if CT angiogram can’t find aneurysmSAH investigations ● CT head non-contrast ● If shows evidence of SAH ○ Proceed to CT angiogram to look for aneurysm If a lumbar puncture was done, what would we be ● If CT done within 6 hours of symptom onset and looking for? no evidence of SAH ● Xanthocromia ○ Consider alternative diagnosis ● If CT done after 6 hours of symptom onset and no evidence of SAH What is xanthocromia? ○ Perform lumbar puncture 12 hours after ● Yellow discolouration of CSF due to breakdown of symptom onset haemoglobin to bilirubin ● That’s also why we wait 12 hours, to allow the haemoglobin time to breakdownQuestion 10Answer 10Key point: nimodipine is used to control vasospasm in patients with SAH One of the complications of SAH is vasospasm which can cause further ischaemia of brain tissue if not managed, so Nimodipine (NOT NIFEDIPINE) is used. Nimodipine and nifedipine are both non-dihydropyridine CCB but Nimodipine targets brain vasculatureQuestion 11Answer 11 Coiling ● Endovascular coiling is also usually carried out under general anaesthetic. ● The procedure involves inserting a thin tube called a catheter into an artery in your leg or groin. ● The tube is guided through the network of blood vessels, up into your head and finally into the aneurysm. ● Tiny platinum coils are then passed through the tube into the aneurysm. ● Once the aneurysm is full of coils, blood cannot enter it. This means the aneurysm is sealed off from the main artery, which prevents it growing or rupturing. ● Usually done by neuroradiologistsSAH treatment ● Supportive: bed rest, observation, analgesia ● Nimodipine: for vasospasm ● Coil insertion: to reduce risk of rebleeding ● Craniotomy of clipping: if coil not possibleQuestion 12 Key point: SIADH is a common complication of SAH, always suspect this if patient with history of SAH has hyponatraemia Answer 12 Complications of SAH: ● Re-bleeding ● Hydrocephalus ● Vasospasm ● Hyponatraemia (SIADH) ● Seizures Intracranial bleeds summary Condition Symptoms Causes/risk Investigation Management Extradural LOC followed by brief regain of Trauma to the side of the CT head: convex shaped Craniotomy if severe haemorrhage consciousness (lucid interval) followed head, damaging the pterion haematoma Conservative if incidental LOC again due to expanding and the middle meningeal haematoma artery, bleeding into epidural space Subdural Usually in elderly, history of fall, Damage to the bridging CT head: concave shaped Craniotomy if severe haemorrhage anticoagulants, alcohol history veins in the subdural space, haematoma Conservative if incidental Days to months history of progressive age and alcohol causes headache, confusion and neurological brain atrophy which deficit stretches bridging veins Subarachnoid Sudden ‘thunderclap’ headache, severe Trauma or spontaneous CT head: hyperdense basal Coiling haemorrhage and intense pain, meningism (neck Spontaneous commonly cisterns and sylvian fissures Nimodipine stiffness and photophobia), nausea and caused by berry aneurysms Bed rest and observation vomiting in the circle of WillisQuestion 13Answer 13What were the 2 signs of basal skull fracture in this patient? ● Post-auricular bruising (Battle’s sign) ● Periorbital bruising (Racoon eyes) What are other signs of basal skull fracture? ● CSF leak from ear or nose ● Haemotympanum (blood behind eardrum)Question 14Answer 14Brain death ● Fixed pupils which do not respond to sharp changes in the intensity of incident light ● No corneal reflex ● Absent oculo-vestibular reflexes - no eye movements after injection of ice-cold water into each ear ● No response to supraorbital pressure ● No cough reflex to bronchial stimulation or gagging response to pharyngeal stimulation ● No observed respiratory effort in response to disconnection of the ventilator for long enough (typically 5 minutes)Thank you! Any questions → joshua.williams@student.manchester.ac.uk luqman.aizan@student.manchester.ac.uk Please fill out the feedback form! Next session is next Tuesday on Ophthalmology