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Cover image adapted from Handbook of Neurosurgery, 7^th Edition, with permission from Mark S. Greenberg, MD

Library of Congress Cataloging-in-Publication Data is available from the publisher.

The Greenberg rapid review / Leonard I. Kranzler ; Justin M. Kranzler, contributing editor.

p. cm.

ISBN 978-1-60406-195-6 (alk. Paper)

Nervous system—Surgery—Examinations, questions, etc. I. Title.

RD593.G677 2006 suppl.

617.4’80076—dc22

2009035811

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ISBN 978-1-60406-366-0

In appreciation for their example of scholarship, tradition and love of family this book is dedicated to the

memory of

Mr. Morris Kranzler

Mr. Ben Teichner

Eva Teichner

Mr. Louis Weinberg

Dr. David Kranzler

Ada Rotter

Mr. Max Goldstein

Mr. Alex Angheluta

Rina Rosenbush

Dr. K. Jeffrey Kranzler

Milton Saltzman

Dina Weinberg

Mr. Charles Kranzler

David Hurwitz

Chana Kranzler

Dr. Gershon Kranzler

Kurt Loebenberg

Rose Hurwitz

Rabbi Alex Weisfogel

Joseph Kranzler

Ruth Kranzler

Mr. Nate Blum

Walter Rosenbush

Helen Goldstein

Mr. Henry Kranzler

Steve Rotter

Betty Blum

In appreciation of my parents Lillian (obm) and George Kranzler (obm). And to my wife, Uliana, and children,

Jenelle, Justin, and Jared

Contents

vii

Preface

Acknowledgments

Neuroanesthesia

Neurocritical Care

General Care

Neurology

Neuroanatomy and Physiology

Neuroradiology

Operations and Procedures

Developmental Anomalies

106

Neuroendovascular Intervention

129

Electrodiagnostics

130

Neurotoxicology

134

Coma

138

Brain Death

145

Cerebrospinal Fluid

146

Hydrocephalus

152

Infections

165

Seizures

179

Spine and Spinal Cord

195

Functional Neurosurgery

230

Pain

239

Tumor

248

Radiation Therapy

325

Stereotactic Surgery

328

Peripheral Nerves

330

Neuro-ophthalmology

366

Neurotology

379

Head Trauma

385

Spine Injuries

426

Stroke

463

SAH and Aneurysms

476

Vascular Malformations

508

Intracerebral Hemorrhage

519

Occlusive Cerebrovascular Disease

529

Outcome Assessment

547

Differential Diagnosis (DDx) by Location

548

Preface

This offering is a study and review aid. It is to

achieved. The question formats take advan-

be used in conjunction with Handbook of

tage of the established ideas in learning

Neurosurgery, 7^th Edition, by Mark S. Green-

theory:

berg. It permits the user, after reading a page,

• complex subjects broken into small bits

section, or chapter in Greenberg, to test

• fill-in-the-gap exercises in sentences and

retention of the details of that portion. Every

words

question is directly referenced to Greenberg’s

• progressive withdrawal of cues forcing the

text where background information and

user to recall more and more of the details

context is readily available. An effort has

• mnemonics or hints (some material has

been made to highlight the important facts in

been arranged in

“study charts” to aid

neurosurgical practice by posing questions to

mnemonic teaching techniques)

the reader that forces active involvement in

• humor

the learning and review process.

• alternate arrangements of the material (the

same facts presented in different formats)

The purpose is to pinpoint for clinicians what

• repetition

they should expect to know using a rapid

review format. It will help identify what the

Each question and answer is referenced to

student already knows, what is not known,

the millimeter from the top of the page in

and provide a method by which an individual

Handbook of Neurosurgery, 7^th Edition by

can verify that fact has been learned. The

Greenberg where confirmation and further

reader can also have confidence that what

information can be found. For example, the

has been highlighted as valuable has been

reference “G7 p.2:145mm” means that the

identified by peers and by an editor who has

answer can be found 145 mm down on

been involved in neurosurgical education as

page 2 of Greenberg, 7^th edition. Please note

coordinator of the Chicago Review Course in

that some references to the 6^th edition of

Neurological Surgery since 1974. Many ques-

Greenberg have been made in order to

tions were contributed by enrollees in the

include additional valuable factual material.

Chicago Review Course in Neurological Sur-

Moreover, this study guide is designed with

gery over a three-year period and therefore

answers appearing directly after the ques-

represent questions from individuals at all

tions (we recommend that users cover the

levels of neurosurgical sophistication similar

answers in the outer page margin with a

to those who might use this book.

piece of paper) so that additional time is not

wasted searching for correct answers in the

It is expected that the reader will review the

back of the book. This format should further

material multiple times until success in

facilitate rapid review.

responding to the questions has been

Preface

Please note that literature references and the

Note to the Reader

index are present in the parent volume

Handbook of Neurosurgery,

7^th Edition.

Please call to my attention any mistakes that

Knowledge of this material demonstrated

you identify. Please suggest any additional

by correct responses to the questions can

mnemonic devices that might help others in

give confidence to the reader that much of

the field of neurosurgery. Be aware that

the current scientific foundation of the

medical knowledge is ever changing and that

specialty of neurosurgery has been mastered.

some items and opinions conveyed in these

This reassurance of a strong, up-to-date

pages are controversial.

knowledge base should be helpful to the

resident, the instructor, the neurosurgeon in

practice, and those who are planning to take

Contact the author at

written, oral, or recertification examinations.

likranzlermd@hotmail.com.

Acknowledgments

I would like to acknowledge with apprecia-

The team at Thieme Publishers has been

tion the cooperation and encouragement of

wonderful to work with. Their efforts

Dr. Mark S. Greenberg. Our generation of

improved this offering greatly. My young

neurosurgeons is fortunate that Dr. Green-

students and colleagues, Dr. Mahua Dey and

berg has collated the literature of our field

Javid Khader Eliyas, proofread and greatly

and presented it to us in such a concise,

added to the manuscript’s accuracy. Thank

authoritative, well-balanced, and wise man-

you all.

ner.

This project could not have been done with-

out the pleasant and efficient efforts of Maria

Peña who typed many iterations of this

manuscript. I also appreciate the support for

this project by my nurse of 33 years, Judith

Borchers, and our chief secretary Lucy Sal-

gado.

Neuroanesthesia



General Information

1. Provide general information on

neuroanesthesia.

a. Name the most potent cerebral vaso

CO₂

G7 p.1: 85mm

dilator.

b. Effect of hyperventilation on

G7 p.1: 85mm

PaCO₂

reduces

ii.

CBV

decreases

iii.

CBF

decreases

iv.

Goal is end tidal CO₂ of (ETCO₂)

25 to 30 mm Hg

________

v. Correlates with a PCO₂ of ________

30 to 35 mm Hg

c. For every ________ degree change in

G7 p.1: 110mm

temperature

d. there is a change in cerebral metabolic

rate of oxygen by ________%.

e. The effect that hyperglycemia has on

worse

G7 p.1: 115mm

ischemic deficits is to make them

________.

f. Elevating the patient’s head will have the

G7 p.1: 127mm

following effect on:

arterial blood flow

decreases

ii.

ICP

reduces

iii.

venous blood outflow

improves

 Drugs Used in Neuroanesthesia

2. Inhalation anesthesia agents have the

G7 p.1: 177mm

following effects:

a. cerebral vessels ________

dilate

b. auto-regulation is ________

disturbed

c. cerebral blood volume is ________

increased

d. CSF volume is ________

increased

e. Reactivity of vessels to CO₂ is ________

increased

3. What anesthetic drug may come out

nitrous oxide

G7 p. 2:45mm

of solution and aggravate

pneumocephalus?

Neuroanesthesia

To reduce the risk of tension

G7 p. 2:52mm

pneumocephalus you would

fill any space with ________

fluid

and turn off ________

agent

________ minutes before closing the

dura.

Complete the following regarding

G7 p.2:147mm

barbiturates:

Most are anticonvulsants but there is an

Brevital

exception that actually lowers the

seizure threshold called B________.

They cause peripheral vaso ________

dilatation

which may cause ________

hypotension

and ________ the CPP.

reduce

True or False. Morphine and Demoral

G7 p.3:42mm

release histamine

true

produce hypotension

true

cause vasodilation

true

increase ICP

true

compromise CPP

true

Demoral can cause seizures.

true

Characterize synthetic narcotics.

G7 p.3:72mm

Have the advantage that they don’t

histamine release

cause h________ r________.

An example is f________.

fentanyl

G7 p.3: 85mm

Benzodiazepines are ________

GABA

G7 p.3:115mm

agonists.

Characterize pancuronium (Pavulon).

G7 p.4:40mm

Potentially, ________ minutes are

necessary for full reversal of

pancuronium (Pavulon).

True or false. Due to its long action it is

false

indicated for intubation.

10.

Answer the following questions

G7 p. 4:177mm

concerning anesthesia requirements

for evoked potential monitoring:

What technique is preferred?

total IV anesthesia

Second best is ________.

nitrous/narcotic

Are muscle relaxants permitted?

yes

How should fentanyl be infused?

continuously as opposed to

intermittent injections

11.

The antiepileptic drugs that do not

G7 p.5:25mm

effect SSEP are

c________

carbamazepine

p________

phenytoin

p________

phenobarbital

Neurocritical Care



Fluids and Electrolytes

The diagnosis is hyponatremia if the

135

G7 p.7:107mm

serum sodium is less than

________mEq/l.

The syndrome is SIADH

G7 p.7:107mm

if the serum osmolality is less than

275

________mOsm/l

and the urine osmolality is more than

100

________mOsm/l.

The syndrome is CSW if the urinary

G7 p.7:123mm

sodium is greater than ________mEq/l.

Severe hyponatremia is considered a

125

G7 p.7:142mm

sodium lower than ________mEq/l.

Hyponatremia is considered

G7 p.7:145mm

mild if sodium is________mEq/l

135

moderate if sodium is________mEq/l

130

severe if sodium is________mEq/l

125

Matching. For Na metabolism, match

G7 p.7:145mm

the conditions with their

characteristics and treatment.

Characteristics and treatment:

① hyponatremia; ② increased

intravascular volume; ③ treat with

volume restriction; ④ volume depletion;

⑤ treat with Na + volume replacement;

⑥ symptoms made worse by fluid

restriction

Conditions:

inappropriate antidiuretic hormone

①, ②, ③

(ADH)

cerebral salt wasting

①, ④, ⑤, ⑥

Complete the equation to calculate

G7 p.8:175mm

serum osmolality.

Effective serum osmolality =

BUN

measured osmolality − [

]mg/dl

2.8

Neurocritical Care

Matching. Match symptoms with

G7 p.9:150mm

severity of hyponatremia.

Hyponatremia:

① mild hyponatremia is less than

130 mEq/l, ② severe hyponatremia is

less than 125 mEq/l

Symptoms:

headache

①

cerebral edema

②

anorexia

①

nausea vomiting

②

muscle weakness

①

muscle twitching

②

seizures

②

respiratory arrest

②

difficulty concentrating

①

List the symptoms of hyponatremia.

G7 p.9:158mm

Hint: c⁶natremia

cep________

cephalgia

cer________ e________

cerebral edema

com________

coma

con________

confusion

conv________

convulsions

c________

cramps

n________

nausea

a________

anorexia

t________

twitching

r________ a________

respiratory arrest

e________

excitability

m________ w________

muscle weakness

i________

irritability

10.

SIADH criteria are

G7 p.10:115mm

NA is ________

low

Urine osmolality is________

high

Volemia is________

high

Due to release of ________

ADH

without ________ stimuli

osmotic

ii.

creates ________hyponatremia

dilutional

The release of ADH without a stimulus is

inappropriate

what makes the release________

11.

One of the major effects of

G7 p.11:155mm

antidiuretic hormone is to

________ the permeability of the

increase

________ renal tubule. This results in

distal

________ ________ of water.

increased reabsorption

Its effects on the circulating blood?

dilutes it

Its effect on urine volume?

reduces urine volume

Its effect on urine concentration?

increases urine concentration

Fluids and Electrolytes

12.

True or False. SIADH stands for

true

G7 p.10:115mm

syndrome of inappropriate

antidiuretic hormone.

13.

SIADH can also stand for s________

sodium is abnormal

G7 p.10:115mm

i________ a________ d________

dilutionally hyponatremic

h________.

14.

Complete the following regarding the

G7 p.10:140mm

treatment of hyponatremia:

Avoid ________ correction.

rapid

Avoid ________ correction.

over

Do not exceed ________ mEq/l per hour.

Do not exceed ________ mEq/l per 24

hours.

Do not exceed ________ mEq/l per 48

hours.

15.

Matching. Diagnosis of SIADH depends

G7 p. 11:28mm

on three diagnostic criteria. Match the

laboratory value with the appropriate

test.

Test:

① serum Na; ② serum K; ③ serum

osmolality; ④ urinary osmolality;

⑤ urinary Na; ⑥ urinary K; ⑦ blood urea

nitrogen (BUN) creatinine

Laboratory value:

low

①

high

④

normal

⑦

16.

Give the expected result for each test

G7 p.11:35mm

in the diagnosis of SIADH.

serum Na ________ ________ ________

low—below 134 mEq/l

serum osmol ________ ________

low—below 280 mOsm/L

________

urinary Na ________ ________

high—above 18 mEq/l

________

urinary Na may be as high as ________

50 to 150 mEq/l

serum BUN below ________

serum creatinine ________

normal

17.

Na at what level is always

120 to 125 mEq/l

G7 p.11:95mm

symptomatic?

18.

Characterize the symptoms of SIADH.

G7 p11:95mm

Symptoms are almost always present at

120 to 125mEq/l

a Na of ________ to ________

May treat if asymptomatic with

fluid

________ restriction

Avoid too rapid ________

correction

Neurocritical Care

19.

Central pontine myelinolysis (CPM) is

G7 p.11:150mm

aka o________ d________ syndrome

osmotic demyelination

due to r________ c________ of

rapid correction

hyponatremia

a disorder of p________ w________

pontine white matter

m________

Its symptoms are

f________ q________

flaccid quadriplegia

ii.

m________s________ changes

mental status

iii.

c________ n________ abnormalities

cranial nerve

iv.

p________ p________ appearance

pseudobulbar palsy

20.

Features common to patients who

G7 p.11:178mm

develop CPM are

Hint: rodi

r________ c________

rapid correction

o________ c________

over correction

d________ in d________ for more than

delay in diagnosis, 48

________ hours

increase in NA by more than

25; 48

________ mEq/l within ________ hours

21.

To treat mild SIADH you could modify

G7 p.13:100mm

the following by:

H₂O ________ ________

restrict fluid

Salt ________ ________

use 3% NaCl (to increase Na)

22.

To treat cerebral salt wasting (CSW)

G7 p.14:65mm

you could modify the following by:

H₂O ________ ________

give fluid

Salt ________ ________

give salt (Hint: CSW—cure

with salt and water.)

23.

What is the treatment of severe

G7 p.12:140mm

hyponatremia?

Correct hyponatremia that is below

125

________ mEq/l.

Start with a ________% correction.

10%

24.

Do not exceed a correction of

G7 p.13:15mm

more than ________ mEq/l/hr

1.3

more than ________ mEq/l/24/hrs

use ________% NaCl

this has ________ Eq/NaCl

513

start with ________ cc/hr

simultaneously administer ________

furosemide

25.

List the expected patient laboratory

G7 p.14:20mm

result when comparing SIADH with

CSW.

water: in SIADH ________, in

SIADH: hypervolemic, CSW:

CSW________

hypovolemic

Na (serum): in SIADH ________, in

SIADH: low, CSW: low

CSW________

osmol (serum): in SIADH ________, in

SIADH: low, CSW: high

CSW________

Fluids and Electrolytes

osmol (urine): in SIADH ________, in

SIADH: high, CSW: high

CSW ________

Na (urine): in SIADH ________, in

SIADH: high, CSW: high

CSW ________

Hct: in SIADH ________, in

SIADH: low, CSW: high

CSW ________

26.

What is the treatment of CSW?

G7 p.14:70mm

Hydrate

with ________% ________ saline

0.9%, normal

ii.

at ________ cc/hr

100 to 125

Use furosemide (yes or no?)

Avoid ________ correction

rapid

27.

In neurosurgical patients

G7 p.14:140mm

hyponatremia is seen in

c________ s________ w________

cerebral salt wasting

and S________.

SIADH

28.

In neurological patients

G7 p.14:144mm

hypernatremia is seen in

d________ i________.

diabetes insipidus

Define hypernatremia.

Na above 150 mEq/l

29.

Characterize diabetes insipidus.

G7 p.15:40mm

Due to low level of ________.

ADH

Urine output is > ________ cc/hr.

200

Specific gravity of urine is < ________.

1.003

Serum osmolarity is normal or ________.

high

Serum sodium is ________.

high

30.

In diabetes insipidus is the following

G7 p.15:40mm

low or high?

ADH is ________.

low

Urine specific gravity is ________.

low

Urine output is ________.

high

Serum osmolality is ________.

high

Serum sodium is ________.

high

31.

Diabetes insipidus features:

G7 p.15:40mm

Urine output is ________.

high

Urine mOsm/l is below ________.

200

Specific gravity is below ________.

1.003

Serum osmol is ________.

high or normal

Normal serum osmol is between

282 and 295 mOsm/l

________ and ________ mOsm/l.

32.

Diabetes insipidus etiology:

G7 p.15:80mm

neu________

neurogenic

nep________

nephrogenic

33.

Diagnosis of diabetes insipidus occurs

G7 p.16:110mm

when

urine output is above ________.

250 cc/hr

urine osmol is below ________.

200 mOsm/l

specific gravity is below ________.

1.003

Neurocritical Care

34. Characterize serum osmolality.

G7 p.19:30mm

a. Normal range is between ________ to

282 to 295

________ mOsm/l

b. Dangerous if below ________ mOsm/l

240

c. Dangerous if above ________ mOsm/l

320

d. Risk of renal failure if above ________

320

mOsm/l

e. Seizures can occur if above ________

400

mOsm/l

 Blood Pressure Management

35.

List the effects of labetalol on the

G7 p.20:50mm

following:

ICP

no change

pulse

no change

cardiac output

no change

coronary ischemia

no change

renal failure

no change

36.

List the plasma expanders that are

G7 p.22:50mm

useful cardiovascular agents for

treating shock.

cr________

crystalloids

co________

colloids

bl________ p________

blood products

37.

Describe the method of dosage for an

G7 p.20:70mm

intravenous (IV) drip of labetalol.

add ________ ml (200 mg)

to ________ ml volume to create a

160

volume

of ________ ml and infuse

200

at ________ ml/min until

________ mg is given or the desired

300

blood pressure (BP) is achieved.

38.

For the listed pressors complete the

following statements to describe the

cautions required.

Neo-Synephrine: avoid in s________

spinal cord injuries

G7 p.22:170mm

c________ i________

Dopamine: may cause h________

hyperglycemia

G7 p.22:100mm

Dobutamine: may cause dysfunction of

platelets

G7 p.22:127mm

p________

 Sedatives and Paralytics

39. The Richmond Scale: Rass quantitates agitation and sedation

G7 p.23:90mm

________ and ________ levels.

Sedatives and Paralytics

40.

True or False. Indicate whether the

G7 p.24:25mm

following statements are true or false:

Methohexital (Brevital) is more potent

true

and shorter acting than thiopental.

Fentanyl causes dose-dependent

true (also causes chest wall

respiratory depression.

rigidity if given rapidly)

Propofol has better neuroprotection

false (barbiturates are better)

than barbiturates (during aneurysm

surgery).

Haldol can cause neuroleptic malignant

true

syndrome.

41.

True or False. The following sedatives

G7 p.24:30mm

may induce seizures:

thiopental

false

methohexital

true

fentanyl

false

propofol

false

haloperidol

false

42.

True or False. The drug that can

G7 p.24:47mm

produce a neuroleptic malignant

syndrome as a secondary effect is

propofol

false

benzodiazepines

false

fentanyl

false

haloperidol

true

thiopental

false

43.

Complete the following statements

G7 p.24:47mm

about the neuroleptic malignant

syndrome:

Characterized by

Hint: neuroleptic

n________

motor, mutism

ii.

e________

elevation of temperature

iii.

u________

unconsciousness

iv.

r________

rigid muscles, rapid heart

rate, respiratory failure

v. o________

opisthotonus

vi. l________

lethargy, leucocytosis

vii. e________

elevated CPK

viii. p________

potentially lethal

ix. t________

trembling

x. i________

imbalance of autonomic

system

xi. c________

coma

Neurocritical Care

44.

True or False. Regarding thiopental:

G7 p.24:86mm

It’s a long-acting barbiturate.

false (Thiopental is a short-

acting barbiturate with

consciousness returning after

20 to 30 minutes.)

It causes dose-related respiratory

true

depression.

It causes myocardial depression.

true

It is an antianalgesic.

true

It causes hypotension in hypovolemic

true

patients.

45.

True or False. The following sedative

G7 p.24:94mm

causes necrosis when injected

intraarterially:

thiopental

true

fentanyl

false

propofol

false

46.

True or False. Choose the correct order

G7 p.24:120mm

from long-acting to short-acting for

the following neuromuscular blocking

agents:

succinylcholine, vecuronium,

false

pancuronium, nocuronium

vecuronium, pancuronium,

false

succinylcholine, rocuronium

pancuronium, vecuronium, rocuronium,

true—pancuronium

succinylcholine

(Pavulon)—60 to 180 minutes

vecuronium (Norcuron)—40

to 60 minutes

rocuronium (Zemuron)—40

to 60 minutes (but shorter

onset)

succinylcholine (Anectine)—

20 minutes

rocuronium, succinylcholine,

false

pancuronium, vecuronium

vecuronium, pancuronium, rocuronium,

false

succinylcholine

47.

True or False. The following is always

G7 p.25:100mm

required in a conscious patient

simultaneously with a paralytic agent

and as ventilation is being established:

arterial line

false

Swan-Ganz catheter

false

sedation

true

intracranial pressure (ICP) monitor

false

all of the above

false

Sedatives and Paralytics

48.

True or False.

G7 p.25:165mm

Pancuronium is a long-acting agent.

true

Rocuronium is a short-acting agent.

true

Succinylcholine is a competitive blocker

false (Succinylcholine is a

and is short acting.

noncompetitive blocker and

is considered the only

depolarizing ganglionic

blocker. It has been linked to

malignant hyperthermia.)

Sedation is required for conscious

true

patients.

49.

True or False. The only depolarizing

G7 p.26:25mm

ganglionic blocker among the

following paralytics is

succinylcholine

true

rapacuronium

false

mivacurium

false

rocuronium

false

50.

True or False. Possible side effects of

G7 p.26:53mm

succinylcholine include

elevated serum K+

true (Succinylcholine can

cause elevated K+, especially

in patients with neuronal

[spinal cord injury,

hemiparesis] or muscular

pathology, causing

hyperkalemia.)

cardiac arrest in adolescents and children

true (Adolescents and

children with undiagnosed

cardiac myopathies may

arrest.)

sinus bradycardia

true (It causes dysrhythmia,

mainly sinus bradycardia.)

malignant hyperthermia

true (It has been linked to

malignant hyperthermia.)

51.

True or False. The following paralytic

G7 p.26:60mm

is contraindicated in the acute phase

of injury because of the risk of

hyperkalemia:

succinylcholine

true

metocurine

false

doxacurium

false

pancuronium

false

vecuronium

false

52.

True or False. The shortest-acting

G7 p.26:162mm

nondepolarizing neuromuscular

blocking agent (NMBA) is

mivacurium

false

rocuronium

false

vecuronium

true

metocurine

false

doxacurium

false

Neurocritical Care

53.

True or False. The nondepolarizing

G7 p.26:168mm

paralytic that does not affect ICP or

CPP is

vecuronium

true

pancuronium

false

succinylcholine

false

rapacuronium

false

rocuronium

false

54.

True or False. The main difference

G7 p.27:40mm

between cisatracrium and its isomer

atracurium is

cost

false

onset of action

false

duration

false

cisatracrium does not release histamine

true

none of the above

false

55.

The complete reversal of Pavulon’s

G7 p.27:55mm

effect takes ________ minutes.

56.

True or False. It is true about

G7 p.27:55mm

pancuronium that

it is not reversible

false (It is reversible with

anticholinesterases.)

it is not a competitive paralytic

false (It is a competitive

paralytic.)

it increases cardiac output, pulse rate,

true

and ICP

it is eliminated through the liver

false (It is eliminated through

the kidneys.)

57.

True or False. Regarding atracurium:

G7 p.27:60mm

It is a nondepolarizing (competitive)

true

blocker.

It can produce hypotension.

true

It is reversible with neostigmine.

true

It is metabolized in the kidneys and liver.

false

Neurogenic Pulmonary Edema

 Neurogenic Pulmonary Edema

58. True or False. Which of the following

G7 p.28:30mm

statements about neurogenic

pulmonary edema are true and which

are false?

a. relatively common condition in the

false

neurosurgical patient

b. caused by intracranial pathologies such

true

as subarachnoid hemorrhage (SAH),

seizure (Sz), head injury

c. mechanism caused in part by slow

false

increase in intracranial pressure (ICP)

d. surge of catecholamine disrupts capillary

true

endothelium with increase in alveolar

permeability

59. True or False. For treatment of

false—low levels of PEEP

G7 p.28:55mm

neurogenic pulmonary edema, you

should use high levels of positive end

expiratory pressure (PEEP) to keep

alveoli distended.

60. True or False. For neurogenic

true—and therefore is better

G7 p.28:67mm

pulmonary edema, dobutamine does

than á or â blockers to treat

not reduce cerebral perfusion.

neurogenic pulmonary

edema

General Care



Endocrinology

True or False. The following has to be

G7 p.31:100mm

replaced in adrenal failure:

mineralocorticoids

true

glucocorticoids

true

True or False. The following has to be

G7 p.31:100mm

replaced in pituitary failure:

mineralocorticoids

false

glucocorticoids

true

Matching.

G7 p.31:100mm

① glucocorticoids;

② mineralocorticoids; ③ none

In primary adrenocortical insufficiency

①

you must replace ________ and

________.

②

In secondary adrenocortical insufficiency

①

you must replace ________ and

________.

③

True or False. The following meds

G7 p.31:165mm

should be used for primary

adrenocortical insufficiency:

cortisone

true

cortisol

true

Solu-Cortef

true

prednisone

true

methylprednisolone

false

dexamethasone

false

True or False. The following meds

G7 p.31:165mm

should be used for secondary

adrenocortical insufficiency:

cortisone

false

cortisol

false

Solu-Cortef

false

prednisone

false

methylprednisolone

true

dexamethasone

true

Endocrinology

If you use mineralocorticoids when

G7 p.31:165mm

they are not needed, you risk

developing the following:

Hint: pawnb

p________ a________

potassium—hypokalemia

altered

w________

water retained—fluid

retention

N________

Na retained—salt retention

b________ p________

blood pressure (BP)

elevated—hypertension

Hypothalamic—pituitary—adrenal

G7 p.32:30mm

suppression can occur if a dose of

40 mg of prednisone is given for

________ days.

10 mg of Decadron is given for ________

days.

If steroids are given for less than 7 days

not needed

taper ________.

If given for 7 to 14 days taper over

1 to 2 weeks

G7 p.32:85mm

________.

You should taper prednisone by reducing

5 (3 to 7)

5 mg every ________ days.

You should taper Decadron by reducing

5 (3 to 7)

0.75 mg every ________ days.

After a month on steroids HPA axis may

1 year

G7 p.32:52mm

be depressed for as long as ________.

HPA = ________ ________ ________

hypothalamic pituitary

axis

adrenal

Stress (supplemental) doses of

G7 p.32:165mm

steroids may be needed

if patient is on steroids

c________ or was on them during

chronically

the

ii.

past ________ years

1 to 2

Study Chart. List the possible

G7 p.33:45mm

deleterious effects of steroids.

alkalosis, amenorrhea,

avascular necrosis (hip)

bone loss

cushingoid features,

cataracts, compression

fractures, reactivation of

chickenpox

diverticular perforation,

diabetes

epidural lipomatosis

fungal infections, fetal

adrenal hypoplasia

growth suppression in

children, gastrointestinal

bleed, gastritis, glaucoma

General Care

hypertension: hypokalemia,

hirsutism, hyperlipidemia,

hypercoagulopathy, hiccups

impaired wound healing,

immunosuppression

lipomatosis, spinal epidural

mental agitation, muscle

weakness, steroid myopathy

nonketotic coma, nitrogen

metabolism is disturbed

obesity, osteoporosis

progressive multifocal

leukoencephalopathy (PML),

pseudotumor cerebri,

pancreatitis

reactivation of tuberculosis

(TB)

sodium retention, steroid

psychosis

tissue plasminogen activator

inhibition

water retention

10.

What are the symptoms of addisonian

G7 p.34:75mm

crisis?

Hint: claw

c________

confusion

l________

lethargy

a________

agitation

w________

weakness

11.

What are the signs of Addisonian

G7 p.34:75 mm

crisis? Choose hypo- or hyper-.

hypotension (shock)

hyponatremia

hyperkalemia

glucose

hypoglycemia

temperature

hyperthermia

Hematology

 Hematology

12.

Complete the following concerning

G7 p.34:165mm

platelets:

Normal platelet count is ________ to

150 k to 400 k/mm³

________.

Delay surgery if platelets are below

50,000/mm³

________.

Transfuse if:

surgery is ________

urgent

ii.

patient is on ________ or ________

Plavix or ASA

and can’t wait ________ days.

5 to 7

Usual transfusion is ________ of

an eight-pack (= 6 to 10 U)

platelets.

One U raises platelets by ________.

10 k

13.

Complete the following regarding

G7 p.35:20mm

platelet therapy:

1 unit of platelets has a volume of

approximately ________ cc.

Platelet count can be checked in

________ hours.

Re-transfusion will be needed in

3 to 5

G7 p.35:120mm

________ days.

14.

Complete the following concerning

G7 p.35:130mm

fresh frozen plasma:

One bag equals ________ cc.

250

Risk of acquired immunodeficiency

a unit of blood

syndrome (AIDS) or hepatitis is the same

as ________.

Use to reverse Coumadin:

prothrombin time (PT) greater than

18 seconds

________

ii.

international normalized ratio (INR)

1.6

greater than ________

iii.

von Willebrand disease unresponsive

DDAVP

to ________

iv. multiple coagulation dysfunction

such as in

h________ ________

hepatic dysfunction

v________ ________ ________

vitamin K deficiency

D________

DIC

15.

In regard to the use of anticoagulation

G7 p.37:60mm

in a patient who has:

An incidental aneurysm < 4mm,

anticoagulation is ________

A drug eluting cardiac stent—continue

Plavix

________

At onset of SAH we should ________

reverse

anticoagulation

Postoperative craniotomy may start on

3 to 5

day ________ to ________ weeks after

surgery

General Care

16.

In regard to anticoagulation in

G7 p.37:145mm

preparation for surgery, if a patient

has:

a mechanical heart valve

stop warfarin ________ days before

surgery

ii.

and use ________

Lovenox

chronic A-fib

stop warfarin ________ days before

4 to 5

surgery

17.

Complete the following concerning

G7 p.37:167mm

anticoagulation:

May resume anticoagulation ________

3 to 5

days after craniotomy

Annual risk of nonanticoagulation for a

patient with

mechanical heart valve is ________%

per year

ii.

chronic atrial fibrillation is

4 to 6%

________% per year

If patient is on Plavix or acetylsalicylic

5 to 7 days

acid (ASA) delay surgery for ________.

18.

Provide coagulation factors for

G7 p.38:20mm

neurosurgery.

PT should be below ________ seconds.

13.5

INR should not be above ________.

1.4

For emergencies give ________

FFP 2

________ units

and ________ ________.

vitamin K

19.

Both Plavix and ASA inhibit platelet

permanently

G7 p.38:90mm

function for how long?

20.

Plavix is a more dangerous drug than

G7 p.38:130mm

ASA because it remains

________ for up to

active

________ after the last dose and

several days

can inhibit even those ________

transfused platelets

________ given as treatment.

21.

Complete the following concerning

G7 p.39:42mm

warfarin (Coumadin):

Don’t start Coumadin until a ________

therapeutic partial

________ ________ ________ has been

thromboplastin time (PTT)

achieved on heparin

to reduce the risk of ________

Coumadin necrosis

________.

For the first 3 days of Coumadin therapy

hypercoagulable

patients are actually ________;

therefore continue ________ for a few

heparin

________.

days

Hematology

22.

Possible heparin side effects include

G7 p.39:95mm

t________

thrombosis

t________

thrombocytopenia

These are due to:

________ in heparin-induced

consumption

thrombosis

ii.

________ formed against a heparin-

antibodies

platelet protein complex

In such cases of heparin-induced

lepirudin (Refludan)

thrombocytopenia, treat with ________.

23.

Low molecular weight heparin should

G7 p.39:135mm

have

fewer ________ complications

hemorrhagic

more predictable ________ levels

plasma

less need to ________ biologic activity

monitor

a longer ________ life

half

need for ________ doses per day

fewer

a lower incidence of ________

thrombocytopenia

more effective in ________ prophylaxis

DVT

than warfarin

24.

A serious side effect could be spinal

epidural hematoma

G7 p.39:170mm

________ ________.

25.

Complete the following concerning

G7 p.40:170mm

coagulopathy:

To reverse Coumadin anticoagulation in

2 to 3 units fresh frozen

a patient who is at the usual therapeutic

plasma

levels use ________.

For severely prolonged coagulation use

6 units fresh frozen plasma

________.

To reverse PT from Coumadin use

________

vitamin K aqua mephyton

ii.

administered by what route?

iii.

Administration may be fatal if given

intravenously

________.

iv. Why?

h________

hypotension

a________

anaphylaxis

26.

Matching. Use the numbers of the

G7 p.41:20mm

listed terms to complete the following

statements.

① prothrombin complex concentrate;

② protamine sulfate; ③ vitamin K;

④ AquaMEPHYTON

Coumadin is reversed by:

p________ c________ c________

①

ii.

v________ k________

③

iii.

A________

④

Heparin is reversed by p________

②

s________

General Care

27.

Complete the following concerning

G7 p.42:35mm

thromboembolism:

Risk of embolism from calf deep-vein

thrombosis (DVT) is ________%.

Extends to proximal deep veins in

30 to 50%

________%.

Embolism from thigh veins is ________.

40 to 50%

Mortality of DVT of legs is ________.

9 to 50%

DVTs in NS (neurosurgical) patients

19 to 50%

occur in ________.

28.

Conditions that make NS patients

G7 p.42:50mm

prone to DVTs are

Hint: clot

c________ ________

concomitant sludging

l________-________ ________

long-time immobility (i.e.,

bed rest, paralysis)

o________ ________/d________

operating room/dehydration

t________ ________

thromboplastin release

29.

The best prophylaxis against DVTs is

G7 p.42:110mm

PCBs is the abbreviation for ________

pneumatic compression

________ ________

boots

low ________ ________

dose heparin (5000 IU

subcutaneous every 8 to 12

hours start first postop day)

30.

Matching. One can diagnose DVT with

G7 p.43:80mm

the following tests. Match the finding

with its appropriate diagnostic value.

Diagnostic value:

① gold standard; ② associated with PE

and DVT; ③ only 50% accurate; ④ 99%

specific

Clinical finding or procedure:

hot swollen tender calf with positive

③

Homan sign

contrast venography

①

Doppler ultrasonography

④

D-dimer

②

31.

What is the treatment of DVT?

G7 p.43:135mm

b________ ________

bed rest

e________ i________ leg

elevate involved leg

h________, L________ or

heparin, Legoparin

L________ plus

Lovenox

C________

Coumadin

Consider G________ f________

Greenfield filter

a________

ambulate

after ________ to ________ days

7 to 10

wear ________-________ ________

anti-embolic stockings

For how long ? ________

indefinitely

Pharmacology

32. Extramedullary hematopoiesis can

G7 p.43:170mm

result in

a. abnormal skull x-ray called ________

hair on end

________ ________

b. spinal cord compression due to

vertebral body thickening

________ ________ ________

33. Extramedullary hematopoiesis can be

G7 p.43:170mm

treated with

a. r________ and/or

radiotherapy

b. s________

surgery

 Pharmacology

34.

True or False. Prostaglandins sensitize

true

G7 p. 44:140mm

A-delta and C fibers.

35.

True or False. Metastatic cancer pain

G7 p.44:140mm

can be desensitized by

steroids

true

aspirin

true

nonsteroidal anti-inflammatory drugs

true

(NSAIDs)

acetaminophen (Tylenol)

false

36.

How do NSAIDs work?

G7 p.44:170mm

They inhibit ________

cyclooxygenase

which thereby interferes with the

prostaglandins

synthesis of p________

and t________.

thromboxanes

This inhibits the function of ________

platelets

and prolongs ________ ________.

bleeding time

They may also injure ________

kidneys (nephrotoxicity)

(________).

37.

Complete the following concerning

G7 p.45:50mm

NSAIDs and platelet function:

The NSAID that results in irreversible

aspirin

binding is ________.

Which NSAID results in reversible

most NSAIDS

inhibition of platelet function?

The NSAID that does not interfere with

Relafen (nabumetone)

platelet function is ________.

General Care

38.

List the dosages for the following

G7 p.45:148mm

substances:

NSAIDs to use

Naprosyn loading: ________ then

500 mg, then 250 mg every

________ every ________ to

6 to 8 hours

________ hours.

ii.

Motrin no loading: Start dose

Start dose 400 to 800 mg,

________ to ________mg then

then 4 times a day

________ times a day.

opioids to use (moderate to severe pain)

Percodan no loading: Start dose

1 to 2 pills every 3 to 4 hours

________ to ________ pill(s) every

________ to ________ hours.

ii.

Vicodin no loading: Start dose

1 pill every 6 hours

________ pill(s) every ________

8 pills every 24 hours

hours. Limit ________to ________

every ________ hours per day.

opioids to use (mild to moderate pain)

codeine loading? Start dose

no loading 30 to 60 mg at

________ to ________ mg at

3 hours

________ hours, to ________ mg at

60 mg at 3 to 5 hours

________ to ________ hours.

39.

How much Tylenol is safe?

G7 p.46:145mm

comes in dosages of ________ or

650 or 1000 mg

________

safe up to ________ mg per day

4000

has a ceiling effect at ________ mg/day

1300

has hepatic toxicity above ________

10,000

mg/day

40.

A serious side effect of Tylenol is

hepatic toxicity

G7 p.46:160mm

________ ________.

41.

True or False. Regarding opioid

G7 p.46:180mm

analgesics:

They are only indicated for the treatment

false

of acute pain.

Tolerance develops with chronic use.

true

Potential for respiratory depression is

false

limited.

Seizures are not a known adverse effect.

false

42.

True or False. Regarding opioid

G7 p.47:18mm

analgesics:

They have no ceiling effect.

true

With chronic use, tolerance develops.

true

Overdose is possible with severe

true

respiratory depression.

Treatment of overdose includes

true

administration of naloxone.

Flumazenil helps in treatment of

false (Flumazenil is useful in

overdose.

treatment of overdose from

benzodiazepines not from

opioids.)

Pharmacology

43.

True or False. Regarding narcotics:

G7 p.47:18mm

Some opioids may cause seizures.

true

Physical and psychological tolerance

true

develops with chronic use.

There is a ceiling effect with increasing

false (There is no ceiling

dosage.

effect with opioids. Increasing

dosage does increase

effectiveness, but side effects

may limit higher doses.)

Overdose can cause respiratory

true

depression.

44.

Complete the following mnemonic

G7 p.47:28mm

about opioids:

o________

overdose is possible

p________

potential for respiratory

depression

i________

increase dosage = increase

effect—no ceiling effect

o________

small pupils—miosis—o

i________

intoxication: treat with

Narcan

d________

develops tolerance with

chronic use

45.

To what type of opioid receptor

μ (MU) opioid receptor

G7 p.47:103mm

subtype does tramadol (Ultram) bind?

46.

Ultram acts centrally to inhibit re-

G7 p.47:105mm

uptake of

n________ and

norepinephrine

s________.

serotonin

47.

True or False. OxyContin tablets

true

G7 p.48:40mm

should never be taken crushed,

divided, or chewed.

48.

What is the intramuscular:per os

G7 p.49:20mm

(IM:PO) potency for morphine?

single dose

1:6

chronic dosing

1:2 to 3

49.

What metabolite of meperidine might

normeperidine

G7 p.49:22mm

cause delirium and seizures?

50.

True or False. When taken with

G7 p.49:30mm

monoamine oxidase inhibitors

(MAOIs), meperidine may cause

severe encephalopathy

true

death

true

51.

Tricyclic antidepressants elevate levels

endorphin

G7 p.548:150mm

of what endogenous analgesic?

General Care

52.

Indicate the following adjuvant

medications’ characteristic actions:

tricyclic

blocks serotonin uptake

G7 p.48:150mm

tryptophan

precursor of serotonin

G7 p.50:40mm

antihistamines

anxiolytic

G7 p.50:50mm

phenothiazine

tranquilizing

G7 p.50:75mm

53.

What craniofacial pain syndromes are

G7 p.50:62 mm

responsive to carbamazepine

(Tegretol)?

t________ n________

trigeminal neuralgia

g________ n________

glossopharyngeal neuralgia

p________-h________ n________

post-herpetic neuralgia

54.

Matching. Match each adjuvant pain

G7 p.50:80mm

medication with each description.

Description:

① increases serotonin by blocking

reuptake; ② increases serotonin by

being a substrate for its production;

③ anxiolytic and hypnotic, helps with

nociceptive pain; ④ tranquilizing, helpful

with other adjuvants in neuropathic pain

Pain medication:

tryptophan

② Amino acid precursor for

serotonin, a potentiator for

analgesic effects of

endorphin. Warning: Daily

use depletes vitamin B₆—use

multivitamins. Give 1.5 to

2.0 mg h.s.

phenothiazines

④ Example is fluphenazine

(Prolixin). Give with tricyclic

for neuropathic (diabetic)

pain. May reduce seizure

threshold.

tricyclic antidepressant

① Elavil (75 mg q.d.),

desipramine (10 to 25 mg

q.d.), or doxepin (75 to

150 mg q.d.), more effective

than norepinephrine reuptake

blockers.

antihistamine

③ Histamine plays a role in

nociception. Hydroxyzine

50 mg every a.m. and 100 mg

every h.s.

Benzodiazepines

55. True or False. Regarding

G7 p.50:110mm

antispasmodics/muscle relaxants:

a. Robaxin (methocarbamol) is

true

contraindicated in patients with peptic

ulcer disease because of its aspirin

content.

b. Parafon Forte (chlorzoxazone) should not

true

be used because of its risk of fatal

hepatotoxicity.

c. All of these act as central nervous system

false (Although they act

sedatives and have proven efficacious

centrally, their efficacy for

with acute low back problems.

acute low back problems is

dubious.)

d. Soma (carisoprodol) may produce

true

euphoria and has abuse potential.

e. Taken for “night cramps,” quinine sulfate

true

is an abortifacient, can cause thrombotic

thrombocytopenic purpura (TTP), and

can also result in cinchonism.



Benzodiazepines

56.

True or False. Regarding

G7 p.51:92mm

benzodiazepines:

Effective for treatment of anxiety and

true

insomnia

Safe in the first trimester of pregnancy

false (Not safe in the first

trimester of pregnancy; BZDs

are contraindicated during

first trimester—teratogenic.)

Shorter-acting agents are more likely to

true

cause rebound depression or withdrawal

symptoms.

Longer-acting agents result in cumulative

true

sedation and impairment of

psychomotor function.

57.

True or False. The following group of

G7 p.51:100mm

benzodiazepines is more prone to

cause rebound depression or

withdrawal syndrome:

long duration

false

intermediate duration

false

short duration

true

all of the above

false

none of the above

false

58.

True or False. A contraindication to

G7 p.51:115mm

the use of benzodiazepines is

second trimester of pregnancy

false

first trimester of pregnancy

true

third trimester of pregnancy

false

alcohol use

false (but adds no sedation)

hypoglycemia

false

General Care

59.

True or False. Regarding midazolam

G7 p.51:140mm

(Versed):

more potent than diazepam (Valium)

true

crosses blood-brain barrier

true

has good amnestic effect

true

has good anticonvulsant effect

true

is associated with respiratory arrest

true

60.

You have been called in consultation

G7 p.51:150mm

to see a head-injured patient who is

intubated, sedated, and paralyzed.

How long must you wait to do your

examination?

if Pavulon has been used ________

about 60 minutes

if Norcuron has been used ________

about 60 minutes

if Versed has been used ________

about 2 hours

61.

True or False. The following

G7 p.51:150mm

benzodiazepine has a greater amnestic

effect:

oxazepam

false

alprazolam

false

midazolam

true

temazepam

false

diazepam

false

62.

True or False. The mechanism of

G7 p.52:80mm

action of flumazenil is to

stimulate adenosine monophosphate

false

(AMP)

inhibit AMP

false

hyperpolarize postganglionic neurons

false

competitively inhibit benzodiazepines at

true

receptor sites

63.

The correct order for the following

G7 p.52:40mm

oral benzodiazepines from long-acting

to short-acting duration of action is:

diazepam, flumazenil, alprazolam

false

flumazenil, alprazolam, diazepam

false

alprazolam, flumazenil, diazepam

false

alprazolam, diazepam, flumazenil

false

diazepam, alprazolam, flumazenil

true (Diazepam [Valium] is

G7 p.52:80mm

long acting. Alprazolam

[Xanax] is intermediate

acting. Flumazenil

[Romazicon] is intermediate

to short acting.)

64.

Complete the following statement

reversing benzodiazepine

G7 p.52:80mm

about the previous answer. Therefore

(BDZ) that had been used for

it is used for ________.

conscious sedation or general

anesthesia

Benzodiazepines

65.

Unusual concerns with flumazenil are

G7 p.52:80mm

c________ in p________

contraindicated in pregnancy

works for only 10 to 60 minutes;

resedation may occur

therefore, r________ may o________

66.

True or False. Regarding flumazenil

G7 p.52:80mm

(Romazicon):

resedation may occur if large amounts of

true

benzodiazepines (BZDs) have been given

reversal of BZD-induced respiratory

true

depression is partial or nil

duration of action is shorter than most

true

BZDs

binds BZDs to stop/inhibit their action

false (Flumazenil

competitively inhibits BZDs at

receptor sites.)

may provoke panic attack

true

67.

True or False. The recommended

G7 p.52:100mm

initial dose of flumazenil to reverse

benzodiazepines used for conscious

sedation or general anesthesia is

5 mg IV over 15 seconds

false

0.5 mg IV over 1 minute

false

2 mg IV over 1 minute

false

0.1 mg IV over 5 minutes

false

0.2 mg IV over 15 seconds

true

68.

True or False. How long before brain

G6 p.37:140mm

magnetic resonance imaging (MRI) is

scheduled do you give chloral hydrate

to a child?

5 minutes

false

12 hours

false

30 to 60 minutes

true

it is not relevant

false

3 hours

false

69.

True or False. The following drugs are

G6 p.37:160mm

used in the “DPT” lytic cocktail:

meperidine, promethazine,

true

chlorpromazine

meperidine (Demerol)

promethazine (Phenergan)

chlorpromazine (Thorazine)

meperidine, atenolol, flumazenil

false

propofol, promethazine, thiopental

false

haloperidol, propofol, methohexital

false

midazolam, atracurium, chlorpromazine

false

70.

True or False. Examples of central

false (Spinal cord injury is a

G7 p.52:137mm

nervous system (CNS) factors that

CNS risk factor for stress ulcer

increase the risk of stress ulcers are

also.)

brain tumors and intracerebral

hemorrhage (ICH) but not spinal cord

injury.

General Care

71.

True or False. Extra CNS factors that

G7 p.52:143mm

increase the odds of stress ulcer are

the following:

burns covering > 25% of body surface

true

area

hypotension

true

renal failure

true

coagulopathies

true

72.

When is the peak time for acid and

3 to 5 days after injury

G7 p.52:155mm

pepsin production after head injury?

73.

There is a medication better than H2

G7 p.52:171mm

antagonists to reduce incidence of

stress ulcer.

It is called ________.

sucralfate

The brand name is ________.

Carafate

74.

Name the histamine (H2) antagonists

G6 p.41:20mm

you can prescribe.

Hint: TAPPZ

T________

Tagamet

A________

Axid

P________

Pepcid

Z________

Zantac

75.

Should prophylactic use of H2 blockers

no—usually not warranted

G7 p.52:175mm

be used if steroids are given?

Neurology



Dementia

1. What is the definition of dementia?

G7 p.56:50mm

a. Loss of i________ abilities

intellectual

b. Severe enough to interfere with

social

________

c. or o________ functioning

occupational

d. Cardinal feature is m________

memory deficit

d________

e. plus at least one additional i________

impairment

f. Affects ________% of persons over 65

3 to 11%

2. Risk factors for dementia include

G7 p.56:70mm

Hint: afA

a. a________ a________

advanced age

b. f________ h________

family history

c. A________ ________ ________

Apoli protein E4 allele

a________

3. True or False. Because delirium is

false (Patients with dementia

G7 p.56:75mm

distinct from dementia, patients with

are at increased risk of

dementia are not at increased risk of

developing delirium.)

developing delirium.

4. True or False. Fifty percent of patients

true

G7 p.56:85mm

with delirium die within 2 years.

 Headache

5. In regard to a unilateral headache, if it

G7 p.57:90mm

persists

a. for > a year an ________ ________ is

MRI scan

recommended

b. because this is ________ for migraine

atypical

c. and may be a hint of an underlying

AVM

________

Neurology

Matching. Match symptoms with

G7 p.57:135mm

category of migraine.

Symptoms:

① Episodic H/A; ② N/V; ③ Photophobia;

④ Aura; ⑤ Focal neurological deficit

(a) that resolves within 24 hrs; (b) slow

march—like progression of deficit; (c)

that resolves within 30 days; ⑥ No

headache; ⑦ Mostly seen in children;

⑧ Hemiplegia; ⑨ Mostly seen in

adolescents; ⑩ Vertigo, ataxia,

dysarthria, severe HA

Category of migraine:

Common migraine

①-②-③

Classic migraine

①-②-③-④-⑤-⑤a-⑤b

Complicated migraine

⑤-⑤c-⑥

Migraine equivalent

②-⑥-⑦

Hemiplegic migraine

①-⑧

Basilar artery migraine

⑨-⑩

True or False. Neurological deficits

G7 p.57:145mm

seen in classic migraine typically

resolve within

1 hour

false

1 day

true

1 week

false

1 month

false

They are permanent.

false

True or False. Regarding cluster

G7 p.58:45mm

headaches:

may include partial Horner and

true (ptosis, miosis, tearing,

autonomic symptoms

nasal stuffiness)

are more common in women

false (5 men to 1 woman)

occur almost daily

true

last 30 to 90 minutes

true

continue for a 6- to 9-month period

false (1 to 3 months)

may have a period of remission for

true

~1 year

List the drugs for treatment of

G5 p.61:30mm

migraine headaches.

M________

Midrin (isometheptane

mucate, methysergide)

I________

Inderal

F________

Fiorinal Fioricet

r________

rizatriptan (Maxalt)

a________

aspirin, amitriptyline (Elavil)

I________

(Imitrex) sumatripan (Inderal)

propranolol

Parkinsonism

n________

nonsteroidal

antiinflammatory drugs,

naproxen (Anaprox)

e________

ergotamine tartrate

(Cafergot)

S________

(Sansert) methysergide,

serotonin antagonists,

steroids

10.

True or False. Basilar artery migraines

G7 p.58:95mm

are essentially restricted to

geriatric patients

false

postmenopausal women

false

adolescents

true

men

false

11.

True or False. Patients suffering basilar

true (86%)

G7 p.58:95mm

artery migraine attacks usually have a

family history of migraine.

12.

Most postlumbar puncture headaches

3 days

G7 p.58:145mm

occur within ________ after the

lumbar puncture.

13.

The incidence of postpuncture

2 to 40%,

G7 p.58:145mm

headaches is ________%.

typically 20%

14.

A treatment for post puncture

epidural blood patch

G7 p.59:55mm

headache that is effective in 90% of

cases is ________ ________ ________.

 Parkinsonism

15. Matching. Match the symptoms with

G7 p.59:150 mm

type of parkinsonism.

Symptoms:

① Gradual onset of bradykinesia;

② Asymmetric tremor; ③ Responds well

to levodopa;④ Rapid progression of

symptoms; ⑤ Equivocal response to

levodopa; ⑥ Early midline symptoms

(i.e., ataxia, gait , balance); ⑦ Early

dementia; ⑧Orthostatic hypotension;

⑨ Extraocular movement abnormalities

Types of parkinsonism:

a. Primary idiopathic paralysis agitans (IPA)

①-②-③

b. Secondary parkinsonism

④-⑤-⑥-⑦-⑧-⑨

Neurology

16.

In parkinsonism, degeneration of

G7 p.59:177mm

substantia nigra cells (pars compacta)

results in

________ D2 dopamine receptors

↓

projecting to the globus pallidus interna

(GPi)

________ D1 receptors projecting to

↑

globus pallidus externa (GPe) and

subthalamic nucleus (STN)

17.

This results in increased activity by

G7 p.60:15mm

________, causing

GPi

________ of the thalamus, which then

inhibition

suppresses activity in the

________ ________ ________.

supplemental motor cortex

18.

Provide parkinsonism

G7 p.59:170mm

pathophysiology.

Degeneration of pigmented ________

dopaminergic

neurons

Of the pars compacta of the ________

substantia nigra

________

This reduces the levels of ________ in

dopamine

the

neostriatum; that is, the:

c________

caudate

ii.

p________

putamen

iii.

g________ p________

globus pallidum

This reduces inhibitory D2 receptors to

GPi

________

and causes the loss of inhibitory D1

GPe

receptors to ________

and the s________ n________.

subthalamic nucleus

The net result is an ________ in activity

increase

of ________.

GPi

GPi has inhibitory projections to the

thalamus

t________.

Inhibiting the thalamus also suppresses

supplemental motor cortex

the s________ m________ c________.

19.

A hallmark of Parkinson disease

G7 p.60:25mm

is ________ ________,

Lewy bodies

which are

e________ i________

eosinophilic intraneuronal

ii.

h________ i________

hyaline inclusions

Parkinsonism

20.

List secondary parkinsonism

G7 p.60:35mm

examples.

Hint: P4 secondary

phenothiazine antiemetics,

Compazine

progressive supra nuclear

palsy

poisoning CO₂, manganese

Parkinson dementia complex

of Guam

strial nigral degeneration,

Shy-Drager

(post)-encephaletic

parkinsonism

Compazine (phenothiazine

antiemetics) carbon

monoxide

olivo-ponto-cerebellar

degeneration

neoplasms near substantia

nigra

dementia pugilistica

(boxing—post traumatic

parkinsonism)

anti psychotic drugs

Reglan reserpine, Riley Day

(familial dysautonomia)

21.

Multisystem atrophy (MSA) (i.e., Shy-

G7 p.60:180mm

Drager syndrome) is parkinsonism

plus

________ ________ ________

autonomic nervous system

dysfunction

(ANS)

plus ________ hypotension.

orthostatic

Most don’t respond to ________

drug therapy

________.

22.

List the distinguishing features of the

G7 p.61:40mm

progressive supranuclear palsy (PSP)

triad.

________ (vertical gaze)

ophthalmoplegia

________ dystonia

axial

________ palsy

pseudobulbar

23.

Characteristics of the early stage of

progressive supranuclear palsy (PSP)

(i.e., Steele-Richardson-Olszewski)

include

falling due to ________ ________ palsy

downward gaze

G7 p.61:87mm

(can’t see floor)

difficulty eating due to ________

downward gaze (supranuclear

G7 p.61:103mm

________ palsy (can’t see plate)

ophthalmoplegia), vertical

gaze

Neurology

24. Fill in the blank to summarize surgical

G7 p.61:122mm

treatment for Parkinson disease.

a. The target site was ________ ________. ventrolateral nucleus

b. True or False. The surgery worked best

for which of the following symptoms:

bradykinesia

false

ii.

tremor

true

c. Which is the more disabling symptom?

bradykinesia

true

ii.

tremor

false

d. The operation cannot be done bilaterally

speech function

because of risk to ________ ________.

e. Current treatment site is the p________ posteroventral pallidum

G7 p.533:168mm

p________.

 Multiple Sclerosis

25.

Study Chart.

G7 p.61:150mm

(de) myelinating

urinary symptoms

latitudes (northern latitudes

affected)

time and space dissemination

inter-nuclear

ophthalmoplegia (INO)

paresthesias, peri-ventricular

plaques

lymphocytes

enhancing lesions on MRI

scars of the glia

cortico spinal tracts involved

la belle indifference

(euphoria)

equator spared

remissions

optic atrophy

sensory loss

inflammatory response, IgG

elevated

shower test (hot causes

exacerbation)

26.

Prevalence of multiple sclerosis (MS)

G7 p.62:45mm

per 100,000 is variable.

Near the equator it is ________ per

100,000.

In Canada and the northern United

30 to 80

States it is ________ per 100,000.

27.

The most common category is

relapsing-remitting (Acute

G7 p.62:80mm

r________-r________.

course with recovery, but 50%

become secondarily

progressive.)

Multiple Sclerosis

28.

Name the clinical categories of MS

G7 p.62:60mm

corresponding to their definition.

r ________-r________ (acute episodes

relapsing-remitting recovery

with recovery)

s________-p________ (gradual

secondary-progressive

deterioration)

p________-p________ (continuous

primary-progressive

deterioration)

p ________-r________ (gradual

progressive-relapsing

deterioration with superimposed

relapses)

Deficits persist if they remain > ________

6 months

G7 p.62:100mm

________

29.

Conditions found in the differential

G7 p.62:115mm

diagnosis for multiple sclerosis include

________, generally monophasic

ADEM (acute disseminated

encephalomyelitis)

CNS ________

lymphoma

30.

Matching. Match multiple sclerosis

G7 p.62:135mm

signs and symptoms with anatomic

location.

Symptoms:

① visual acuity; ② diplopia; ③ extremity

weakness; ④ quadriplegia; ⑤ spasticity;

⑥ scanning speech; ⑦ loss of

proprioception

Anatomic location:

optic nerve

①

retro-bulbar region

①

MLF

②

pyramidal tract

③-④-⑤

cerebellum

⑥

posterior columns

⑦

31.

Matching. Match anatomic location

G7 p.62:137mm

with multiple sclerosis signs and

symptoms.

Anatomic location:

① optic nerve; ② retro bulbar region; ③

MLF; ④ pyramidal tract; ⑤ cerebellum;

⑥ posterior columns

Symptom:

visual acuity

①-②

diplopia

③

extremity weakness

④

quadriplegia

④

spasticity

④

scanning speech

⑤

loss of proprioception

⑥

Neurology

32.

Provide the frequency of multiple

G7 p.62:140mm

sclerosis signs and symptoms.

Visual symptoms are among the

15%

presenting symptoms of multiple

sclerosis in ________%

and occur in multiple sclerosis patients

50%

during their course of illness in

approximately ________%.

In addition, abdominal cutaneous

70 to 80%

reflexes are lost in ________%.

33.

A multiple sclerosis plaque in the

G7 p.62:155mm

medial longitudinal fasciculus (MLF)

will cause

________ ________, which will result in

internuclear ophthalmoplegia

________.

diplopia

This is important because ________

INO

rarely occurs in other diseases.

34.

Indicate the presence or absence of

G7 p.63:27mm

the following reflexes in MS:

hyperactive muscle stretch reflexes

present

Babinski

present

abdominal cutaneous reflexes

absent

35.

True or False. In multiple sclerosis the

true (MRI is very specific for

G7 p.64:60mm

more MRI lesions, the higher the

MS plaques; specificity is

likelihood of the diagnosis of MS.

94%.)

36.

Provide MRI criteria for MS.

G7 p.64:100mm

gadolinium: acute lesions ________

enhance

size: at least ________ in diameter

3 mm

white matter abnormalities: ________%

80%

T2-weighted image ________ ________

lesions are high signal

________ ________

periventricular lesions best seen on

proton density

________ ________ images

criterion for dissemination is a ________

new enhancing lesion

________ ________

or a ________ ________ ________

new T2WI lesion

37.

True or False. Focal tumefactive

G7 p.64:135mm

demyelinating lesions (TDL) can be

mistaken for neoplasms because they

Enhance

true

Show perilesional edema

true

Can be solitary

true

Can be in patients known to have MS

true

Can be distinguished from MS

false

Biopsy may be necessary

true

Biopsy results may be confusing

true

Guillain-Barré Syndrome

38. What is CNS analysis for MS?

G7 p.65:20mm

a. It should include q________ ________

qualitative IgG

testing.

b. In 90% of MS patients the CSF ________ IgG

is high.

 Amyotrophic Lateral Sclerosis

39.

Complete the following regarding

G7 p.65:145mm

amyotrophic lateral sclerosis:

aka m________ n________ disease

motor neuron

aka L________ G________ disease

Lou Gehrig

A mixed ________ and ________

upper and lower

m________ n________ disease

motor neuron

Degeneration of alpha motor neurons in

brain stem

Therefore ________ m________

upper motor

neuron disease

ii.

and in spinal cord, therefore

lower motor

________ m________ neuron

disease

40.

True or False. In ALS, there is no

true

G7 p.65:140mm

cognitive, sensory, or autonomic

dysfunction.

41.

True or False. ALS spares voluntary eye

true

G7 p.66:22mm

muscles and urinary sphincter.

42.

The common condition that must be

cervical myelopathy

G7 p.66:55mm

distinguished from ALS is ________

________.

43.

In ALS, two causes of major disability

G7 p.65:105mm

include

a________

aspiration

s________

spasticity

 Guillain-Barré Syndrome

44. True or False. Guillain-Barré involves

G7 p.66:158mm

areflexia and progressive muscle

weakness

a. proximally

true (more severely)

b. distally

false

45. True or False. Guillain-Barré shows

G7 p.66:177mm

a. albuminocytologic dissociation

true (↑ prot > 55 mg/dL, < 10

cells)

b. little or no sensory involvement

true (but paresthesias are not

G7 p.66:167mm

uncommon)

46. In Guillain-Barré, what infectious

Campylobacter jejuni

G7 p.67:40mm

organism is involved?

Neurology

47.

True or False. In Guillain-Barré, there is

true

G7 p.67:83mm

progressive motor weakness that is

relatively symmetric.

48.

Features casting doubt on the

G7 p.67:160mm

diagnosis

asymmetry of ________

weakness

dysfunction of ________

bladder

more than 50 ________ in CSF

monocytes

any ________ in CSF

PMNs

sharp ________ level

sensory

49.

Complete the following about CIDP:

G7 p.68:95mm

True or False. CIDP is also known as

true

chronic relapsing Guillain-Barré

syndrome.

CIDP stands for c________ i________

chronic immune

d________ p________.

demyelinating

polyradituloneropathy

For CIDP, symptoms must be present for

2 months

more than ________.

CSF findings are similar to ________-

Guillain-Barré

________.

50.

The Miller-Fisher variant of Guillain-

G7 p.68:15mm

Barré syndrome includes

a ________

ataxia

a ________

areflexia

o ________

ophthalmoplegia

51.

True or False. In Guillain-Barré,

true

G7 p.68:165mm

plasmapheresis hastens recovery and

reduces residual deficit.

 Myelitis

52. True or False. In acute transverse

true

G7 p.69:62mm

myelitis (ATM), the animal model is

EAE.

53. Complete the following:

G7 p.69:62mm

a. EAE stands for ________ ________

experimental allergic

________.

encephalomyelitis

b. It requires central or peripheral MBP?

central NS MBP (myelin basic

protein, not peripheral MBP)

54. True or False. The most common

true (68% thoracic sensory

G7 p.70:53mm

sensory level in acute transverse

level in ATM)

myelitis is thoracic.

55. True or False. Acute transverse

true (66% reach maximal

G7 p.70:70mm

myelitis progresses rapidly.

deficit by 24 hours)

Neurosarcoidosis

56.

True or False. In acute transverse

true (no characteristic

G7 p.70:86mm

myelitis, MRI/CT/myelography is often

imaging findings in ATM)

performed to rule out compressive

lesions.

57.

True or False. In acute transverse

G7 p.70:95mm

myelitis, symptoms include

paresthesia

true (paresthesia 100%)

weakness

true (weakness 97%)

sphincter disturbance

true (sphincter disturbance

94%—hesitancy, retention,

overflow)

58.

Characterize myelitis.

G7 p.70:120mm

Diagnose with ________.

MRI

If not available use ________.

myelogram

And treat with ________.

steroids

G7 p.70:140mm

59.

True or False. Regarding acute

G7 p.70:160mm

transverse myelitis:

There is 15% mortality.

true (15% mortality by

4 months)

62% of survivors are ambulatory.

true (62% ambulatory by 3 to

6 months)

Recovery occurs between 1 month to

false (1 to 3 months)

2 years.

No improvement occurs after 3 months.

true

 Neurosarcoidosis

60. The most common neurologic

G7 p.71:38mm

a. manifestation is ________ ________.

diabetes insipidus

b. Treat with ________.

corticosteroids

61. Complete the following statements

G7 p.71:76mm

about neurosarcoidosis:

a. Pathology characteristic: m________-

meningo-encephalitis of the

e________ of the s________

subependymal area of the

a________ of the t________ v________

third ventricle and

and hy________.

hypothalamus

May produce d________ i________.

diabetes insipidus

b. Serum test that is positive in 83% of

ACE

G7 p.71:152mm

cases is ________.

c. Cerebrospinal fluid (CSF) test that is

ACE

helpful is ________.

d. How frequently positive?

55%

e. CSF analysis suggests ________.

meningitis

f. ACE stands for ________ ________

angiotensin converting

________.

enzyme

Neurology

62. Complete the following regarding

G7 p.71:87mm

neurosarcoidosis:

a. Microscopically we see features of

non-caseating granulomas

n________ g________

b. Clinical findings include:

c________ n________ palsies

cranial nerve

ii.

p________ n________

peripheral neuropathy

iii.

m________

myopathy

iv.

h________

hydrocephalus

c. Diabetes insipidus from involvement of

hypothalamus

the ________

63. List the test performed with the

G7 p.72:15mm

results in sarcoidosis.

a. Chest x-ray

h________ a________

hilar adenopathy

ii.

m________ l________ n________

mediastinal lymph nodes

b. MRI

enhancement of l________

leptomeninges

ii.

enhancement of o________

optic nerve

n________

iii.

best seen on ________ sequence

flair

c. Gallium scan (nuclear medicine). Useful

in neurosurgery for:

s________

sarcoidosis

ii.

c________ v________ o________

chronic vertebral

osteomyelitis

 Vascular and Dysautoregulatory Encephalopathy

64. You have been called in consultation

G7 p.73:35mm

to see a 6 days post-partum woman

complaining of headaches, seizures,

and blindness. CT shows occipital

intracerebral hemorrhage and

bilateral vasogenic edema.

a. Diagnosis: ________ stands for

PRES, posterior reversible

p________ r________ e________

encephalopathy syndrome

s________

b. Blood pressure will show ________

hypertension

c. True or False. Other causes beside

pregnancy could be

malignant hypertension

true

ii.

eclampsia

true

iii.

infection

true

iv.

auto-immune disease

true

chemotherapy

true

vi.

transplantation

true

Vascular and Dysautoregulatory Encephalopathy

65.

A patient develops blindness. Imaging

G7 p.73:107mm

studies reveal infarctions of both

occipital lobes. You should consider

the diagnosis of v________ d________

vascular dysauto regulatory

r________ e________.

encephalopathy

The blindness may be ________.

temporary

Treat with ________ ________ pressure

tight blood

control.

Without control of BP ________-

intra-cerebral hemorrhage

________ ________ could occur.

(ICH)

In a non-pregnant patient this syndrome

cyclosporine

could occur due to a drug toxicity with

________.

66.

The treatment of vascular

G7 p.73:650mm

dysautoregulatory encephalopathy is

treat b________ p________,

blood pressure

hold ________ ________, and

immune suppressives

remove the p________.

placenta

67.

Uremic encephalopathy

G7 p.73:180mm

has a site of characteristic edema in the

basal ganglia

b________ g________.

In severe cases, it can develop f________

focal infarcts

i________.

68.

Crossed cerebellar diaschisis

G7 p.74:38mm

is h________ of the cerebellum

hypometabolism

due to a

c________

contralateral

ii.

c________ h________ lesion

cerebral hemisphere

Theory is that this occurs because the

c________-p________-c________

cerebro-ponto-cerebellar

pathway

ii.

becomes ________

disconnected

iii.

resulting in reduced: o________ and

oxygen and glucose

g________ consumption.

iv. Decreased ________ production

CO₂

causes

v. local arterial ________

constriction

vi. and reduced ________ blood flow.

cerebellar

Neurology



Vasculitis and Vasculopathy

69.

Giant cell arteritis (formerly called

G7 p.74:182mm

temporal arteritis)

involves branches of the ________

external carotid artery

________ ________.

Most helpful laboratory study is

ESR

________.

Most serious consequence is ________.

blindness

How frequently?

G7 p.75:133mm

Once it occurs is it reversible?

Which vessels are involved?

o________ a________

ophthalmic artery

ii.

p________ c________ b________

posterior ciliary branches

The warning symptom that precedes

G7 p.75:125mm

permanent visual loss

is ________ ________.

amaurosis fugax

ii.

How frequently? ________% of the

44%

time

GCA is associated with another

G7 p.75:160mm

serious condition: t________

thoracic aortic aneurysms

a________ a________.

ii.

This condition is ________ times as

likely in GCA.

Sed rate above ________ is suspicious.

40 mm/hr

G7 p.76:40mm

Sed rate above ________ is highly

80 mm/hr

suggestive.

ESR is normal in up to ________% of

22.5%

patients with GCA.

Temporal artery palpation is normal in

33%

________%.

70.

True of False. Proper technique for

G7 p.76:105mm

biopsy of the superficial temporal

artery (STA) includes:

Plan to remove the parietal branch of the

false

STA

Spare the main trunk of the STA

true

Make the incision perpendicular to the

false

STA

Optimal length of STA biopsy is 4 to

true

6 cm

71.

Treatment that might prevent

blindness

is the use of ________.

steroids

G7 p.76:148mm

Follow patterns closely for ________.

2 years

G7 p.77:26mm

Vasculitis and Vasculopathy

72.

Behçet syndrome consists of the

G7 p.78:130mm

following:

Hint: Behcets

Behçet

eye lesions

headache

cerebellar signs, CSF

pleocytosis

erosions of mouth and

genitalia

thrombophlebitis, thrombosis

of dural sinuses

skin lesions, seizures, use

steroids

73.

Complete the following statements

G7 p.79:114 mm

about fibromuscular dysplasia:

Most common vessels involved are

r________ a________

renal artery

ii.

c________ a________

carotid artery

What other abnormality of vessels occurs

aneurysms

with FMD?

How frequently?

20 to 50%

The gold standard of diagnosis is

angiography

________.

The recommended treatment is

aspirin

________.

74.

Complete the following regarding

G7 p.80:32mm

presentation of fibromuscular

dysplasia:

h________ in ________%

headache, 78%

ii.

u________

unilaterally

iii.

can be mistaken for t________

typical migraine

m________

s________ in ________%

syncope, 31%

ii.

due to involvement of the

carotid sinus

c________ s________

T________ changes in ________%

T wave, 33%

ii.

Due to involvement of c________

coronary arteries

a________

H________ syndrome in ________%

Horner, 8%

Neuroanatomy and Physiology



Surface Anatomy

Characterize the lateral cortical

G7 p.84:65mm

surface.

The pre-central sulcus is not ________.

complete

The middle frontal gyrus connects with

precentral, isthmus

the ________ gyrus through this

________.

The central sulcus is separated from the

98%

sylvian fissure ________% of the time.

The tissue separating them is called the

sub-central gyrus

________ ________.

The inferior and superior parietal lobules

intra-parietal

are separated by the ________ sulcus.

The inferior parietal lobule is composed

the s________ m________

supra marginal gyrus (SMG)

g________

ii.

and the a________ g________.

angular gyrus

The sylvian fissure

terminates in the ________,

SMG

ii.

which is the Brodmann area

#________.

The superior temporal gyrus

terminates in the ________,

ii.

which is the Brodmann area

#________.

Complete the following regarding

G7 p.84:80mm

surface anatomy:

The middle frontal gyrus often connects

pre-central gyrus

with the ________ ________.

The central sulcus joins the sylvian

fissure in only ________%.

A sub-central sulcus is present in

98%

________% of patients.

The sylvian fissure terminates in the

supra-marginal gyrus

________ ________.

The superior temporal sulcus is capped

angular gyrus

by the ________ ________.

Surface Anatomy

Matching. Match the following

G7 p.84:128mm

Brodmann cortical areas and their

functional significance:

Functional significance:

① primary motor cortex; ② Broca area

(motor speech); ③ Wernicke area

dominant hemisphere; ④ primary

auditory area; ⑤ frontal eye fields;

⑥ primary somatosensory area;

⑦ premotor area; ⑧ primary visual

cortex

Area:

Area 3, 1, 2

⑥

Area 41, 42

④

Area 4

①

Area 6

⑦

Area 44

②

Area 17

⑧

Area 40, 39

③

Area 8

⑤

Complete the following regarding pars

G7 p.85:18mm

marginalis:

is the terminal part of the ________

cingulate

gyrus

is visible on axial view in > ________%

90%

is the ________ ________ of the midline

most prominent

paired grooves

extends ________ into the hemispheres

deeper

on axial CT is located just posterior to

9-3

the line ________ (the widest diameter)

it curves ________ in lower slices

posteriorly

it curves ________ in higher slices

anteriorly

Complete the following regarding

G7 p.85:95mm

central sulcus:

Is visible in almost ________%

95%

Does it reach the midline?

Terminates in the ________ ________

para-central lobule

True or False. The pterion is a region

G7 p.86:110mm

where each of the following bones

comes together:

frontal

true

sphenoid (greater wing)

true

parietal

true

temporal

true

sphenoid (lesser wing)

false

Neuroanatomy and Physiology

Matching. Match the bones/sutures

that form the listed craniometric

points.

Bone/suture:

G7 p.86:125mm

① lambdoid suture; ② occipitomastoid

suture; ③ parietomastoid suture;

④ frontal; ⑤ parietal; ⑥ temporal;

⑦ greater wing sphenoid

Craniometric point:

asterion

①, ②, ③

pterion

④, ⑤, ⑥, ⑦

True or False. The name of the

G7 p.86:140mm

junction of lambdoid, occipitomastoid,

and parietomastoid sutures is

pterion

false

asterion

true (Asterion is the junction

of lambdoid, occipitomastoid

suture, and parietomastoid

suture.)

lambdoid

false

stephanion

false

glabella

false

opisthion

false

The asterion junction overlies the

G7 p.86:160mm

________ sinus and the

transverse

________ sinus.

sigmoid

10.

External landmark for the sylvian

G7 p.87:135mm

fissure is a line from the lateral

canthus to a spot three quarters of the

way posterior along an arc running

over the convexity in the midline from

the

________ to the

nasion

________.

inion

11.

True or False. In relation to external

G7 p.87:145mm

landmarks the angular gyrus is

one finger’s breadth above the

false

zygomatic arch

just above the pinna

true (The angular gyrus is just

above the pinna and

important as part of the

Wernicke area in the

dominant hemisphere.)

a thumb’s breadth behind the frontal

false

process of the zygomatic bone

at the junction of the lambdoid and

false

sagittal suture

Surface Anatomy

12.

True or False. The motor strip of the

G7 p.87:165mm

motor cortex lies

at the level of the coronal suture

false

within 2 cm of the coronal suture

false

3 to 4 cm posterior to the coronal suture

false

4 to 5.4 cm posterior to the coronal

true

suture

2 cm posterior to the mid-position of the

true

inion-nasion arc

5 cm straight up from the external

true

auditory meatus

13.

True or False. In the non-hydrocephalic

G7 p.88:87mm

adult the lateral ventricles lie

2 to 3 cm below the outer skull surface

false

3 to 4 cm below the outer skull surface

false

4 to 5 cm below the outer skull surface

true

5 to 6 cm below the outer skull surface

false

14.

True or False. In the non-hydrocephalic

G7 p.88:108mm

adult the anterior horns extend

1 to 2 cm anterior to the coronal suture

true

2 to 3 cm anterior to the coronal suture

false

3 to 4 cm anterior to the coronal suture

false

15.

True or False. In the non-hydrocephalic

G7 p.88:130mm

adult the anterior horns extend

1 to 2 cm anterior to the foramen of

false

Monro

2.5 cm anterior to the foramen of Monro

true

3 to 4 cm anterior to the foramen of

false

Monro

16.

True or False. The fastigium is located

G7 p.88:145mm

the midpoint of the Twinings line

false

the floor of the fourth ventricle

false

the apex of the fourth ventricle within

true (The fastigium is the

the cerebellum

apex of the fourth ventricle in

the cerebellum.)

1 to 2 cm anterior to the coronal suture

false

17.

List the surface landmarks of the

G7 p.89:35mm

following cervical levels.

Hint: htcc

C3-4 ________ ________

hyoid bone

C4-5 ________ ________

thyroid cartilage

C5-6 ________ ________

cricothyroid membrane

C6-7 ________ ________

cricoid cartilage

Neuroanatomy and Physiology

18. Matching. Match the following surface

G7 p.89:35mm

landmarks and cervical levels:

Surface landmark:

① level of thyroid cartilage; ② cricoid

cartilage; ③ angle of mandible;

④ cricothyroid membrane; ⑤ carotid

tubercle; ⑥ 1 cm above thyroid cartilage

(hyoid bone)

Cervical level:

a. C1-2

③

b. C3-4

⑥

c. C4-5

①

d. C5-6

④

e. C6

⑤

f. C6-7

②

 Cranial Foramina and Their Contents

19.

Matching. Match the foramen with

G7 p.89:75mm

contents (choices may be used more

than once).

Contents:

① nothing; ② middle meningeal artery;

③ VII facial; ④ V2; ⑤ V3; ⑥ V1; ⑦ IX, X

Foramen:

superior orbital fissure

⑥

inferior orbital fissure

④

foramen lacerum

①

foramen rotundum

④

foramen ovale

⑤

foramen spinosum

②

stylomastoid foramen

③

jugular foramen

⑦

20.

List the cranial nerves and the three

G7 p.89:85mm

branches of one found within the

superior orbital fissure (SOF).

o________

CN III oculomotor

t________

IV trochlear

n________

nasociliary nerve

f________

frontal nerve ophthalmic

division: all three branches

l________

lacrimal nerve

a________

VI abducens nerve

21.

Additional structures found in the SOF

G7 p.89:85mm

include the

s________ o________ v ________

superior ophthalmic vein

r________ m________ a ________

recurrent meningeal artery

which arises from the l________ artery

lacrimal

o________ b________ of the

orbital branch of the middle

m________ m________ a________

meningeal artery

s________ p________ of the ICA

sympathetic plexus of the ICA

Cranial Foramina and Their Contents

22. Another name for the transverse crest crista falciformis

G7 p.89:182mm

is ________ ________.

23. Another name for the vertical crest is Bill’s bar

G7 p.89:187mm

________ ________.

24. Draw and label the nerves in the right

G7 p.90:22mm

porus acusticus.

a. Bill’s bar

b. transverse crest crista

falciformis

c. cranial nerve VII

d. SV—superior vestibular

e. VIII

f. IV—inferior vestibular

Fig. 5.1

25. Label the diagram of the right internal

G7 p.90:22mm

auditory canal.

a. transverse crest

b. acoustic portion of CN VIII

c. cranial nerve VII in facial

canal

d. superior vestibular nerve

e. inferior vestibular nerve

f. Bill’s bar—vertical crest

Fig. 5.2

26. Matching. Match the nerves of the IAC

G7 p.90:23mm

with the areas that they serve.

Nerves:

① facial n.; ② nervus intermedius;

③ acoustic portion of VIII n.; ④ superior

branch of vestibular n.; ⑤ inferior branch

of vestibular n.

Areas served:

a. Facial muscles

①

b. Hair follicles

②

c. Taste buds

②

d. Hearing

③

e. Utricle

④

f. Superior semi-circular canal

④

g. Lateral semi-circular canal

④

h. Saccule

⑤

Neuroanatomy and Physiology

 Occipitoatlantoaxial-complex Anatomy

27.

Matching. Match the ligaments of the

G7 p.91:32mm

occipito-atlantoaxial complex with the

statements below.

Ligaments:

① apical; ② alar; ③ cruciate;

④ ascending portion; ⑤ descending

portion; ⑥ transverse portion;

⑦ posterior longitudinal; ⑧ tectorial;

⑨ anterior longitudinal; ⑩ anterior

atlanto occipital

Statements:

Attaches the odontoid to the foramen

①

magnum

Attaches the odontoid to the occipital

②

condyle

Attaches the odontoid to the lateral

②

mass of C1

Attaches C1 to the clivus and to C2

③

Attaches odontoid to clivus

④

Attaches C1 to C2

⑤

Traps the odontoid against the atlas

⑥

Extends cephalad to become the

⑦

tectorial

The cephalad extension of the PLL

⑧

Extends cephalad to become the anterior

⑨

atlanto-occipital

The cephalad extension of the anterior

⑩

longitudinal

28.

The most important spinal ligaments

G7 p.92:95mm

in maintaining atlanto-occipital

stability are the

________ membrane and the

tectorial

________ ligaments.

alar

 Spinal Cord Anatomy

29. The very large ascending tract closest

lateral spinothalamic tract

G7 p.93:120mm

to the dentate ligament is the

(LST) for pain and

________.

temperature from the

opposite side of the body

30. How is the lateral spinothalamic tract

G7 p.93:120mm

(LST) somatotopically organized?

a. Cervical is ________.

medial

b. Sacral is ________.

lateral

31. Which descending motor tract

G7 p.92:158mm

facilitates

a. extensor tone?

vestibulospinal tract

b. flexor tone?

rubrospinal tract

Spinal Cord Anatomy

32.

Matching. Match sensory function and

G7 p.93:175mm

anatomy.

Sensory function:

① pain and temperature: body; ② fine

touch, deep pressure and

proprioception: body; ③ light (crude)

touch: body

Anatomy:

Receptors

Free nerve ending

①

ii.

Meissner and pacinian corpuscles

②-③

First order neurons

Small

①

ii.

Heavily myelinated

②-③

iii.

Finely myelinated

①

iv.

Large

②

Soma in dorsal root ganglion

①-②-③

Enter cord at

Zone of Lissauer

①

ii.

Ipsilateral posterior columns

②-③

Synapse in

Rexed layer II

①

ii.

Rexed layer III and IV

②

iii.

Rexed layer VI and VII

③

Second order neurons

Cross obliquely in anterior white

①-③

commissure

ii.

Form the internal arcuate fibers

②

And enter the

Lateral spino-thalamic tract

①

ii.

Medial lemniscus

②

iii.

Anterior spino-thalamic tract

③

Second order neurons synapse on the

①-②-③

ventral posterior lateral nucleus of the

Thalamus

Third order neurons pass through IC to

①-②-③

post-central gyrus

33.

The major blood supply of the spinal

G7 p.95:60mm

cord vasculature

to the anterior cord arises from

the vertebral artery and enters at

________

ii.

the deep cervical artery and enters

at ________

iii.

the costo cervical trunk and enters

at ________

iv. thoracic levels ________ or

T4 or T5

________

v. and from the a_______ of A_______

artery of Adamkiewicz

to the posterior spinal cord arises from:

10 to 23

________ to ________ radicular

branches

The “watershed zone” is at the ________

T4 or T5

or ________ region

Neuroanatomy and Physiology

34.

List the body area with the

G7 p.95:70mm

appropriate root.

Nipple, root:________

Umbilicus, root:________

T10

Inguinal crease, root:________

T12

Anterior thigh, root:________

L2-L3

Posterior thigh, root:________

Lateral calf, root:________

Medial calf, root:________

Posterior calf, root:________

Big toe, root:________

Little toe, root:________

Sole of foot, root:________

Lateral shoulder, root:________

Lateral forearm

Thumb

Middle finger

Little finger

Medial forearm

35.

Complete the following regarding

G7 p.95:70mm

upper extremity vs trunk

dermatomes. Trunk sensory level is

reported at T3 on a trauma patient.

This is a little ________ the clavicle.

below

You must check the ________

arm

dermatomes.

Dermatomes ________ to ________ are

C5 to T2

not represented on the trunk.

36.

Characterize spinal cord vasculature.

G7 p.96:35mm

The artery of Adamkiewicz serves the

spinal cord from

T________ distally and from the

________ side in

left

________% of the population.

80%

37.

The artery of Adamkiewicz is also

G7 p.96:35mm

known as

a________

arteria

r________

radicularis

a________

m________

magna

Which side does it arise from?

L 80%, R 20%

What levels does it arise from 100%

T9 and T12 75%

inclusive?

T9 and L2 85%

T5 and T8 15%

T5 and L2 100%

What is its appearance on angiography?

characteristic hairpin shape

38.

An artery that has a hairpin shape on

artery of Adamkiewicz

G7 p.96:52mm

angiography is named the ________.

Cerebrovascular Anatomy

 Cerebrovascular Anatomy

39.

The artery that feeds a tentorial

G7 p.99:118mm

meningioma is named after

________ and

Bernasconi

________.

Cassinari

40.

The artery that has a bayonet-type

ophthalmic artery

G7 p. 99:118mm

kink is the ________ ________.

41.

Circle of Willis is intact in ________%.

18%

G7 p. 97:55mm

42.

Hypoplasia of at least one of the

22 to 32%

G7 p.97:55mm

posterior communicating arteries

occurs in ________%.

43.

Absent or hypoplastic A1 occurs in

25%

G7 p.97:55mm

________%.

44.

What are the seven segments of the

G7 p.98:20mm

internal carotid artery?

Hint: can Peter laugh can Charlie only

clap

c________

cervical

p________

petrous

l________

lacerum

c________

cavernous

c________

clinoid

o________

ophthalmic

c________

communicating

45.

What portion of the PCA traverses the

G7 p.98:95mm

ambient cistern?

46.

What choroidal artery arises from it?

medial posterior choroidal

G7 p.98:103mm

artery

47.

Which cistern is traversed by the P3

quadrigeminal cistern

G7 p.98:102mm

segment of the PCA?

48.

Name the segments of the carotid

G7 p.99:45mm

artery and their main branches.

C1 c________

cervical-carotid sheath

IJV × PGSN × vagus posterior

medial to external carotid

C2 p________

petrous

C3 l________

lacerum

C4 c________

cavernous

m________ t________

meningohypophyseal trunk

ii.

a________ m________ a________

anterior meningeal artery

C5 c________

clinoidal

C6 o________

ophthalmic

o________

ophthalmic

ii.

s________ h________

superior hypophyseal

iii.

p________ c________

posterior communicating

iv.

a________ c________

anterior choroidal

Neuroanatomy and Physiology

C7 c________ d________ i________

communicating divides into

A________

ACA

ii.

M________

MCA

49.

What are the branches of the

G7 p.99:107mm

meningohypophyseal trunk?

G6p.79:100mm

Hint: dit

d________ m________

dorsal meningeal

i________ h________

inferior hypophyseal

t________ a________

tentorial artery of Bernasconi

and Cassinari

50.

Complete the following concerning

G7 p.99:125mm

anterior circulation:

Occlusion of which artery results in

inferior hypophyseal artery

Sheehan syndrome?

It serves ________ ________ ________

posterior lobe of pituitary

________.

It is a branch of the ________ artery,

meningohypophyseal

which is a branch off the ________

cavernous C4

________segment of carotid.

Occlusion causes pituitary infarct in

postpartum

________ patients.

51.

The ophthalmic artery

G7 p.99:145mm

arises from the ________ segment of the

sixth

ICA.

Is distal or inside cavernous sinus?

distal 89%, intracavernous 8%

Has what shape on lateral angiogram?

a bayonet-type kink

52.

The sixth segment of the carotid artery

G7 p.99:150mm

is known as the ________

ophthalmic

begins at the ________ dural ring

distal

ends just proximal to _______-________

P-comm

has its branches

o________ artery and the

ophthalmic

ii.

s________ h________ artery

superior hypophyseal

53.

What vessel supplies the inferior half

anterior choroidal artery

G7 p.100:23mm

of the posterior limb of the internal

capsule?

54.

Complete the following about the

G7 p.100:30mm

anterior choroidal artery:

The anterior choroidal artery serves six

sites. (Hint: gogoup)

g________ p________

globus pallidus

ii.

o________ t________

optic tract

iii.

g________ of i________ c________

genu of internal capsule

iv.

o________ r________

optic radiations

u________

uncus

vi.

p________ l________

posterior limb of internal

capsule

Cerebrovascular Anatomy

Occlusion may produce:

hemiplegia, hemihypesthesia,

Hint: 3 H

homonymous hemianopsia

________, ________, ________

________

MRI shows infarct in the ________.

posterior limb of the internal

capsule

55.

What artery enters the supracornual

plexal segment of the

G7 p.100:30mm

recess of the temporal horn to supply

anterior choroidal artery

the choroid plexus?

56.

Complete the following regarding

G7 p.100:35mm

P-comm and the anterior choroidal

artery (ACH):

They are ________ mm apart.

The origin of the ________-________ is

P-comm

proximal.

Is the Ach smaller or larger than the P-

smaller

comm?

Which artery has the hump of the plexal

Ach

point?

57.

True or False. The carotid siphon

G7 p.100:53mm

is only that part of the carotid that

false

passes within the cavernous sinus.

If an aneurysm ruptures on the siphon

false

there is no SAH.

58.

The carotid siphon

G7 p.100:53mm

begins at the posterior bend of the

cavernous

________ carotid and

ends at the ICA ________.

bifurcation

It includes the

ca________

cavernous

ii.

op________

ophthalmic

iii.

co________.

communicating

59.

Complete the following about

G7 p.102:168mm

vertebral artery segments:

The first segment enters the ________

sixth

foramen transversarium.

The second ascends ________ within the

vertically

foramina transversaria.

The second turns ________ as it exits the

laterally

axis.

The third curves ________ and

posteriorly and medially

________.

The fourth pierces the ________.

dura

60.

The vertebral artery joins the other

G7 p.103:20mm

side at the level of the

________ ________ to form the

lower pons (pontomedullary

junction)

________ ________.

basilar artery

Neuroanatomy and Physiology

61.

The junction of the vertebral arteries is

vertebral confluens

G7 p.103:20mm

called the ________ ________.

62.

What are the six branches arising from

G7 p.103:105mm

the vertebral artery?

Hint: A postman puts postcards away.

a________ m________

anterior meningeal

p________ m________

posterior meningeal

m________

medullary (bulbar)

p________ s________

posterior spinal

P________

PICA

a________ s________

anterior spinal

63.

Complete the following statements

G7 p.103:120mm

about the PICA:

PICA arises ________ mm distal to the

point where VA becomes intradural.

PICA has an extradural origin in

5 to 8%

________ to ________%.

It includes five segments named

a________ m________

anterior medullary

ii.

l________ m________

lateral medullary

iii.

t________-m________ has

tonsillo-medullary, caudal

________ loop

iv. t________-v________-t________

telo-velo-tonsillar, cranial

has ________ loop

(supratonsillar)

v. c________ s________

cortical segments

and has three branches named

c________

choroidal

ii.

t________-h________

tonsillo-hemispheric

iii.

i________ v________

inferior vermian

64.

The cranial loop on angio of the PICA is

supratonsillar (telo-velo-

G7 p.103:165mm

the ________ artery.

tonsillar)

65.

The choroidal point

G7 p.103:173mm

is the point where the ________ artery

choroidal

arises from the ________ artery

supratonsillar

which is a branch of the ________

PICA

enters into the ________ ________

fourth ventricle

to serve the ________ ________

choroid plexus

66.

The copular point

G7 p.103:65mm

is the point where the ________

inferior vermian

________ artery

arises from the ________.

PICA

67.

Name the three segments of the

G7 p.104:65mm

posterior cerebral artery.

c________

crural (peduncular) segment

(P1)

a________

ambient segment (P2)

q________

quadrigeminal segment (P3)

Cerebrovascular Anatomy

68.

Medial posterior choroidal artery

G7 p.104:84mm

arises from the

________ segment of PCA.

crural

It is also called ________.

69.

Lateral posterior choroidal artery

G7 p.104:92mm

arises from the

________ segment of the PCA.

ambient

It is also called ________.

70.

The third segment of PCA is named

quadrigeminal

G7 p.104:117mm

the ________ segment.

71.

Name the branches of the external

G6 p.104:30mm

carotid from proximal to distal.

Hint: salfops m

s________ ________

superior thyroid

a________ ________

ascending pharyngeal

l________

lingual

f________

facial

o________

occipital

p________ ________

posterior auricular

s________ ________

superficial temporal

m________

maxillary

72.

In relation to ICA, the ECA lies

G6 p.79:45mm

________ and

________ to ICA.

lateral

73.

Which internal jugular vein is usually

the right

G7 p.104:140mm

dominant?

74.

Which transverse sinus is usually

the right

G7 p.104:147mm

dominant?

75.

Which vertebral artery is usually

the left by 60%

G7 p.102:156mm

dominant?

76.

Name the major contributors to the

G7 p.105:25mm

great cerebral vein of Galen.

p________ c________ v________

precentral cerebellar vein

b________ v________ of R________

basal veins of Rosenthal

i________ c________ v________

internal cerebral veins

77.

The joining of the septal vein and the

venous angle

G7 p.105:35mm

thalamostriate vein with the internal

cerebral vein forms an angiographic

landmark called the ________

________ at the foramen of Monro.

78.

True or False. The cavernous sinus is

G7 p.105:140mm

a large venous space with multiple

false

trabeculations

a plexus of veins

true

Neuroanatomy and Physiology

79. Draw the right and left cavernous

G7 p.106:15mm

sinus coronal view. On your drawing,

label the following:

1. oculomotor (III)

2. trochlear (IV)

3. Parkinson triangle

4. ophthalmic (V1)

5. maxillary (V2)

6. abducent (VI)

7. carotid

Fig. 5.3

80.

Name six major contents of the

G7 p.106:15mm

cavernous sinus.

________

CN III

________

CN IV

________

CN V1

________

CN V2

________

CN VI

________

internal carotid artery

81.

Complete the following regarding the

cavernous sinus:

Which nerve in the cavernous sinus does

V2 maxillary division of

G7 p.106:30mm

not also pass through the superior orbital

trigeminal

fissure?

Which foramen of the skull does that

foramen rotundum

G7 p.106:30mm

nerve pass through?

Which nerve is not attached to the wall?

VI is not attached to lateral

G7 p.106:85mm

wall (abducens)

82.

With regard to the cavernous sinus,

G7 p.106:90mm

the triangular space of Parkinson is

bounded by what structures?

on its superior border ________

III and IV

on its inferior border ________

trigeminal V1 and V2

83.

Complete the following regarding

G7 p.107:28mm

persistent fetal anastomosis:

How many are there?

They result from a failure to ________.

involute

Name them.

t________

trigeminal

ii.

o________

otic

iii.

h________

hypoglossal

iv.

p________

proatlantal

84.

The most common persistent fetal

trigeminal

G7 p.107:60mm

anastomosis is the ________.

85.

First to involute in persistent fetal

otic

G7 p.107:125mm

anastomsosis is the ________.

Internal Capsule

 Internal Capsule

86. Name the vascular supply for the

G7 p.107:165mm

following components of the internal

capsule:

a. anterior limb

lateral striate branches of

MCA

b. posterior limb

lateral striate branches of

MCA

c. ventral posterior limb

anterior choroidal

d. genu

direct branches of ICA

e. optic radiations

anterior choroidal

87. Name four thalamic peduncles and

G7 p.108:75mm

where their radiations go.

a. a________, f________ l________

anterior, frontal lobe

b. s________, p________ g________

superior, postcentral gyrus

c. p________, o________ p________

posterior, occipital parietal

a________

areas

d. i________, a________ a________

inferior, auditory area

88. Draw the internal capsule and label

G7 p.108:15mm

which blood vessel serves which area.

Hint: MIMA

Fig. 5.4

Neuroanatomy and Physiology

89. Matching. Match the area in internal

G7 p.108:20mm

capsule with its function.

Area in internal capsule:

Fig. 5.5

Function:

1. Movement of face ________

C—genu

2. Movement of foot ________

D—posterior limb

3. Vision ________

F—lateral geniculate

4. Hearing ________

G—medial geniculate

 Miscellaneous

90. The Obersteiner-Redlich zone is

G7 p.108:130mm

a. also known as the ________ ________

root entry zone

________.

b. It is where the central ________ and

myelin, myelin

peripheral ________ transition.

c. It is the zone where ________ tend to

neoplasms

grow.

d. It is located on CN VIII, ________ from

8 to 12 mm

the brain stem.

91. The dentate ligament

G7 p.108:150mm

a. separates ________

dorsal

b. from ________ roots in the spinal

ventral

nerves.

92. Which cranial nerve lies dorsal to the CN XI spinal accessory

G7 p.108:155mm

dentate ligament?

Neurophysiology

 Neurophysiology

93.

Answer the following concerning the

G7 p.109:60mm

blood-brain barrier (BBB):

What chemical opens the BBB?

mannitol

What chemical closes the BBB?

steroids

Which sites have no BBB?

pituitary

G7 p.109:70mm

Hint: pppcta

pineal

preoptic recess

choroid plexus

tuber cinereum

area postrema

What pathology injures BBB?

hepatic encephalopathy

Hint: histt

infections

stroke

trauma

tumor

94.

Complete the following statements

G7 p.109:75mm

about cerebral edema:

Cytotoxic

occurs with h________ i________

head injury

ii.

occurs with h________

hematoma

iii.

shape is c________

circular

iv.

occurs with C________

CVA

BBB is c________

closed

Vasogenic

shape is ________

V-shaped (like fingers of white

matter edema)

ii.

occurs with t________

tumors

iii.

occurs with m________

metastasis

iv.

treat with s________

steroids

with contrast it ________ and

enhances on CT and MR

________

vi. BBB is o________

open

95.

Matching. Match the type of edema

G7 p.109:80mm

with the characteristics.

Type of edema:

① cytotoxic edema; ② vasogenic edema

Hint: cytotoxic—early letters of alphabet

vasogenic—later letters of alphabet

Characteristics:

BBB open

②

BBB closed

①

Head injury

①

Tumor

②

Enhances

②

Does not enhance

①

Not appropriate to use steroids

①

Appropriate to use steroids

②

Circular shape on MR

①

V-shaped finger like extensions on MR

②

Occurs with hematoma

①

Occurs with CVA

①

Neuroanatomy and Physiology

96.

True or False. Cytotoxic edema has:

G7 p.109:89mm

a disrupted BBB

false

expansion of the extracellular space

false

enhancement when contrast injected

false

no protein extravasation

true

97.

Study Sheet.

G7 p.109:100mm

Cytotoxic:

Closed BBB

Head injury

Hematoma

Circular shape

CVA

Cells swell then shrink

Vasogenic:

Open BBB

Tumors

Metastasis

Steroids

Protein extravasates

Enhances on CT and MRI

Wide extracellular space

Stable cells

98.

In pituitary embryology, posterior

G7 p.109:110mm

pituitary

derives from the ________ evagination

downward

of ________ ________ cells

neural crest

(neuroectoderm)

from the ________

floor

of the ________ ventricle.

third

99.

The anterior pituitary

G7 p.109:120mm

develops from the ________

evagination

of ________ ________

epithelial ectoderm

of the ________,

oropharynx

known as ________ ________.

Rathke’s pouch

100.

Complete the following regarding

G7 p.109:150mm

neuroendocrinology:

The pituitary releases ________

hormones

from the anterior pituitary gland:

________ hormones.

Name them.

Hint: pcpgtg

p________

propriomelanocortin

ii.

c________

corticotropin

iii.

p________

prolactin

iv.

g________ ________

growth hormone

t________

thyrotropin

vi.

g________

gonadotropin

and from the posterior pituitary

a________

antidiuretic

ii.

o________

oxytocin

Regional Brain Syndromes

101. The pituitary hormones that are

G7 p109 :165mm

released from the posterior pituitary

are synthesized

a. in ________

neurons

b. in the ________.

hypothalamus

c. Are these cells glands?

d. The hormones are conveyed by

axons

________

e. within the ________ ________

pituitary stalk

f. to the ________ pituitary gland

posterior

g. where they are________.

released

 Regional Brain Syndromes

102.

Matching. Match region with deficit.

G7 p.112:30mm

Region:

① Pre-frontal lobes; ② frontal lobe;

③ parietal lobe—dominant; ④ parietal—

non dominant; ⑤ occipital lobe;

⑥ cerebellum; ⑦ brain stem; ⑧ pineal;

⑨ olfactory groove

Deficit:

Apathy abulia

②

Disorganized thoughts

①

Contralateral neglect

③ or ④

Language disorders

③

Anosognosia

④

Dressing apraxia

④

Homonymous hemianopsia

⑤

Truncal ataxia

⑥

Ipsilateral ataxia

⑥

Paralysis of upward gaze

⑧

Poor planning

①

Unilateral anosmia

⑨

103.

Frontal eye fields for contra lateral

G7 p.112:55mm

gaze are

located in the ________ frontal lobe

posterior

in Broadmann area ________.

With a destructive lesion there, the

toward

patient’s eyes look ________ the lesion.

Hint: destructive=toward

With an irritative lesion there, the

away from

patient’s eyes look ________ ________

Hint: irrigitative=away

the lesion.

Usually the lesions are ________.

destructive

Neuroanatomy and Physiology

104.

True or False. Regarding Foster-

G7 p.114:125mm

Kennedy syndrome:

usually from olfactory groove or medial

true

third sphenoid wing tumor

contralateral anosmia

false (Ipsilateral not

contralateral anosmia is part

of the classic triad.)

ipsilateral central scotoma

true

contralateral papilledema

true

contralateral optic atrophy

false (ipsilateral optic

atrophy)

usually meningioma

true

105.

True or False. Regarding Weber

G7 p. X:X mm

syndrome:

Weber syndrome includes CN III palsy

true

with contralateral hemiparesis.

Weber syndrome includes CN VII palsy

false

with contralateral hemiparesis.

Weber syndrome includes CN III palsy

false

with ipsilateral hemiparesis.

Weber syndrome includes CN VI and VII

false

palsy with contralateral hemiparesis.

Weber syndrome includes

G7 p.114:105

Cranial nerve III palsy

false

ii.

Contralateral hemiparesis

false

iii.

Arm hyperkinesis

false

iv.

Ataxia

false

Intention tremor

false

106.

True or False. Benedict syndrome is

G7 p.114:115mm

due to disruption of

cerebral peduncle

true

issuing fibers of CN III

true

red nucleus

true

107.

True or False. Millard-Gubler syndrome

G7 p.114:130mm

is due to disruption of

nucleus of VII

true

nucleus of VI

true

cortico spinal tract

true

108.

True or False. Regarding Parinaud

G7 p. 114:135mm

syndrome:

Parinaud syndrome includes downgaze

false

palsy.

Parinaud syndrome includes lid

true

retraction.

Parinaud syndrome includes nystagmus

true

retractorius.

When Parinaud syndrome is combined

sylvian aqueduct

with downgaze palsy it is known as the

syndrome of the ________ ________.

Regional Brain Syndromes

109.

True or False. The following are

G7 p.115:70mm

contents of the jugular foramen:

transverse sinus

false

CN IX, X, and XI

true

CN X, XI, and XII

false

sigmoid sinus

true

petrosal sinus

true

branches from the ascending pharyngeal

true

artery

branches from the occipital artery

true

110.

Matching. Match the following

G7 p.115:110mm

numbered descriptions with the

lettered syndromes. Also indicate the

nerves involved and the results of the

lesion.

Description:

① Vernet; ② Collet-Sicard; ③ Villaret

Syndrome:

Which jugular foramen syndrome is most

① involves CN,IX, X, XI taste,

likely due to an intracranial lesion?

vocal cords and SCM (sterno

cleido mastoid muscle)

Extracranial lesion?

② above plus XII tongue

Retropharyngeal lesion?

③ above plus Horner

111.

True or False. A jugular foramen

G7 p.115:155 mm

syndrome that spares CN IX is

Vernet

false

Collet-Sicard

false

Villaret

false

Tapia

true (Tapia X, XII vocal cords

and tongue)

112.

True or False. The following jugular

G7 p.115:180mm

foramen syndrome also results in a

Horner syndrome:

Vernet

false

Collet-Sicard

false

Jackson

false

Villaret

true

113.

True or False. Gerstmann syndrome

G7 p.113:70mm

includes

agraphia without alexia

true

left-right confusion

true

digit agnosia

true

tactile agnosia

false

acalculia

true

114.

True or False. Gerstmann syndrome

true

G7 p.113:70mm

patients can read.

115.

True or False. Gerstmann syndrome

false

G7 p.113:70mm

patients can write.

Neuroanatomy and Physiology

116.

True or False. Cortical sensory

G7 p.113:110mm

syndrome includes

loss of position sense

true

inability to localize tactile stimuli

true

astereognosis

true

loss of pain and temperature sense

false (Pain and temperature

as well as vibration sense are

preserved.)

117.

True or False. Anton Babinski

G7 p.113:155mm

syndrome includes

anosognosia

true

apathy

true

ipsilateral extinction to double-sided

false (contralateral extinction

stimulation

to double-sided stimulation)

dressing apraxia

true

118.

True or False. Wernicke aphasia

G7 p.114:27mm

includes

fluent aphasia

true

lesion is in Brodmann areas 41 and 42

false (The lesion is in

Brodmann 39 and 40.)

speech devoid of meaning

true

normal intonation

true

119.

True or False. Broca aphasia includes

G7 p.114:40mm

dysarthria

true

lesion is in area 44

true

an “apraxia” of motor sequencing

true

similar to conduction aphasia

false (Broca is a motor

aphasia—faltering dysarthric

speech. Conduction aphasia is

fluent speech with

paraphasias.)

120.

Alexia without agraphia

G7 p.114:78mm

means that the patient can ________

write

but cannot ________.

read

Surprisingly, such patients can usually do

read and name them

what with numbers?

Lesion is located in the ________ lobe.

parietooccipital

On which side?

dominant (left) side

Serves to disconnect ________

angular gyrus

________ and

________ ________

occipital lobes

also known as ________ ________

pure word blindness

________.

This is contrasted with what syndrome?

Gerstmann

Where patient can ________

read

but can’t ________

write

also known as ________ ________

agraphia without alexia

________.

Babinski Sign

121. Matching. Match the numbered

G7 p.114:78mm

syndromes with the lettered phrases.

Syndrome:

① Gerstmann; ② Pure word blindness

Phase:

a. alexia without agraphia

②

b. agraphia without alexia

①

c. where patient can’t read

②

d. where patient can’t write

①

 Babinski Sign

122.

Fill in the blanks to complete the

G7 p.116:35mm

details of the Babinski reflex.

Hint: pcrstlpt

lateral ________ stimulation

plantar

originates as a ________ ________

cutaneous reflex

and stimulates the ________

receptors

in the ________ dermatome

that travel via the ________ ________

tibial nerve

to the spinal cord segments number

L4-S2, afferent

________ (________ limb)

The efferent limb travels via the

peroneal, efferent

________ nerve (________ limb)

to the ________ ________

toe extensors

123.

Summarize the Babinski sign.

G7 p.116:65mm

receptor ________

S1 dermatome

afferent limb ________

tibial nerve

cord ________

L4-S2

efferent limb ________

peroneal nerve

124.

Fill in the blanks to complete the

G7 p.116:92mm

details of eliciting the plantar reflex.

Stimulate the ________ ________

lateral plantar

surface

and the ________ ________

transverse arch

in a ________ movement

single

that lasts ________ seconds.

5 to 6

Response consists of ________ of the

extension of the great toe

________ ________.

________ of the small toes is

Fanning

________ clinically important.

not

125.

True or False. The Chaddock maneuver

G7 p. 116:108mm

is described as

scratching the lateral foot

true

pinching the Achilles tendon

false

sliding knuckles down shin

false

momentarily squeezing lower

false

gastrocnemius

Neuroanatomy and Physiology

126. Complete the following concerning

G7 p.116:128mm

Hoffman sign:

a. H (from Hoffman) is the ________ letter eighth

of the alphabet.

b. If unilaterally present Hoffman sign

indicates a lesion above ________.

 Bladder Neurophysiology

127.

Complete the following concerning

G7 p.116:170mm

bladder physiology:

The primary coordinating center for

bladder function is in the

n________ l________ c________

nucleus locus coeruleus

ii.

of the p________.

pons

This center coordinates

b________ c________ (d________)

bladder contraction

with

(detrusor)

ii.

s________ r________ (e________

sphincter relaxation (external

s________).

sphincter)

128.

Voluntary cortical control

G7 p.116:182mm

inhibits the p________ c________.

pontine center—nucleus locus

coeruleus

It originates in the

a________ f________ l________

anteromedial frontal lobes

ii.

and g________ of the c________

genu of the corpus callosum

c________ and

travels via the p________ t________

pyramidal tract

to inhibit

c________ of the

contraction of the

ii.

d________ and contraction

detrusor and contraction

iii.

of the e________ s________.

external sphincter

129.

Immaturity, infarct, or cortical lesions

G7 p.117:17mm

cause

inability to s________

suppress

the m________ r________

micturition reflex

and results in i________.

incontinence

130.

The efferents to the bladder

G7 p.117:28mm

travel in the ________ portion

dorsal

of the ________ ________.

lateral columns

131.

Parasympathetic control

G7 p.117:48mm

detrusor ________

contracts

internal sphincter ________

relaxes

travels via the p________ s________

pelvic splanchnic

nerves

132.

Somatic nerve

G7 p.117:48mm

external sphincter ________

contracts

maintains c________

continence

travels via p________ nerve

pudendal

Bladder Neurophysiology

133.

Sympathetic nerve

G7 p.117:48mm

provides bladder neck ________ and

closure

travels via the i________ h________

inferior hypogastric

plexus.

134.

True or False. The detrusor muscle of

G7 p.117:53mm

the bladder contracts and the internal

sphincter relaxes under

PNS stimulation

true (parasympathetic

nervous system stimulation)

somatic nerve stimulation

false

sympathetic nervous system stimulation

false

all of the above

false

135.

True or False. The following can cause

G7 p.117:125mm

detrusor hyperreflexia:

CVA

true

spinal cord tumor

true

chronic bladder catheterization

false (Detrusor hyperreflexia

can result from interruption

of efferents anywhere from

cortex to sacral cord.)

multiple sclerosis

true

Parkinson disease

true

136.

True or False. Interruption of the

G7 p.117:142mm

efferents results in

atonic bladder

false—root lesion

overflow incontinence

false —root lesion

uncontrollable voiding

true

reflex bladder empting

true

voiding triggered by critical volume

true

produced by myelopathy

true

produced by head injury

true

produced by certain drugs

false—detrusor areflexia

produced by diabetes mellitus

false—automatic neuropathy

137.

True or False. Patients with multiple

G7 p.118:127mm

sclerosis develop voiding symptoms

from demyelination primarily

involving the

posterior and lateral columns of lumbar

false

spinal cord

lateral column of cervical spine

false

posterior column of lumbar spine

false

lateral column of lumbar spine

false

posterior and lateral columns of cervical

true (posterior and lateral

spinal cord

columns of cervical spinal

cord)

138.

True or False. Causes of urinary

G7 p.118:145mm

retention are

urethral stricture

true

prostatic enlargement

true

detrusor areflexia

true

herpes zoster

true

Neuroradiology



Contrast Agents in Neuroradiology

Characteristics of iodinated contrast

G7 p.122:60mm

agents

may delay excretion of ________,

metformin

which is an ________ ________ agent

oral hypoglycemic

used in ________ ________ ________

diabtes type II

It can produce

l________ a________

lactic acidosis

ii.

and r________ f________.

renal failure

It should be held for ________ hours

before and after administration of

contrast agent.

The primary approved agent for

iohexol, Omnipaque

G7 p. 122:90mm

intrathecal use is ________, trade

name ________.

Use Omnipaque cautiously in patients

G7 p.123:70mm

who have

s________ h________

seizure history

c________-v________ d________

cardio-vascular disease

c________ a________

chronic alcoholism

m________ s________

multiple sclerosis

and stop ________ medications

neuroleptic

G7 p.123:52mm

at least _______ hours before procedure

Complete the following for an

G7 p.124:85mm

iodinated contrast allergy prep:

prednisone

pretest timing in hours

20 to 24 hours, 8 to 12 hours,

2 hours

ii.

dose in mg

iii.

route

Benadryl

pretest timing in hours

ii.

dose in mg

iii.

route

cimetidine

pretest timing in hours

ii.

dose in mg

300

iii.

route

PO or IV

CAT Scan



Radiation Safety for Neurosurgeons

Characterize radiation safety.

G7 p.126:165mm

Rem is the absorbed dose in rads

multiplied by ________.

Q “is the quality factor”; the Q of x-ray is

________.

1 rem causes ________ cases of cancer

300

in every 1 million people.

Spine x-rays with obliques is ________

G7 p.127:18mm

rem.

Cerebral angiogram is ________ rem.

10 to 20

Cerebral embolization is ________ rem.

Complete the following regarding

G7 p.127:80 mm

occupational radiation exposure:

It is advised to keep below ________

rem per year,

averaged over a ________ year period.

Provide the precautions advised.

G7 p.127:110mm

Increase the ________ from the

distance

radiation source.

Exposure is proportional to the ________

inverse square

________ of the distance.

Stay at least ________ feet away,

6,10

preferably ________ feet away.

Double the distance and get ________ of

1/4

the radiation.

What is better: lead “doors” or lead

doors

aprons?

 CAT Scan

8. For measurement on a CT scan

G7 p.128:46mm

a. The eyeball is ________ mm through its

equator.

b. Give Hounsfield units for

air

-1000

ii.

water

iii.

bone

+1000

iv.

blood clot

75-80

calcium

100-300

vi.

disc material

55-70

vii. thecal sac

20-30

c. Effect of anemia on an acute subdural

isodense

hematoma (SDH) in a patient with less

than 23% HCT will look ________.

Neuroradiology

 Sylvian Point

9. True or False. The sylvian point is

G5 p.559:10mm

a. the apex of the insula

true

b. usually 5 to 10 mm from the inner table

false (30 to 43 mm from inner

of the skull

table)

c. at or within 1 cm below the midpoint of

true

a vertical line from the superior inner

table to the orbital apex

d. the point where the anterior choroidal

false (That is called the plexal

artery enters the temporal horn of the

point.)

lateral ventricle

 Cerebral Angiography

10.

Answer the following concerning

G7 p.134:145mm

cerebral angiography:

What is the overall risk, in %, of a

0.1%

complication resulting in a permanent

neurological deficit with angiography?

What is the risk, in %, of neuropathy from

0.2%

femoral angiogram?

11.

Complete the following about

G7 p.134:145mm

angiography (cerebral):

The complication rate in

uncomplicated angiography is

0.1%

approximately ________%.

ii.

asymptomatic carotid stenosis is

1.2%

________%.

The most common of the persistent

persistent primitive

carotid basilar anastomoses is ________

trigeminal artery

________ ________ ________.

This occurs in ________% of angiograms.

0.6%

The sylvian point marks the apex of the

insula

________.

12.

Characterize venous structures.

G7 p.134:160mm

Deep lesions cause changes in ________

venous

structures.

Superficial lesions cause changes in

arterial

________ structures.

Malignant lesion (i.e., GBM) show an

draining vein

early ________ ________.

Meningiomas show draining veins

late

________.

Meningiomas come ________ and stay

early, late

________.

Cerebral Angiography

13.

The recurrent artery of Heubner arises

G7 p.134:145mm

from the

________ segment of the

________ ________ artery (80%)

anterior cerebral

and supplies the:

(Controversial item: Rhoton’s

Anatomy, page 119 column B

45 mm, recurrent branch

most commonly arises from

A²—78%

A¹—14%

A¹—A² junction 8%)

a ________

anterior limb: internal capsule

ii.

p ________

putamen

iii.

c ________

caudate head

14.

What is the name of the artery that is

pericallosal artery

G7 p.101:15mm

the continuation of the anterior

cerebral artery?

15.

Complete the following statements

G7 p.101:70mm

about neuroradiology:

The ________ ________ artery enters

anterior choroidal

the temporal horn via the ________

choroidal

fissure.

This is called the p________ p________.

plexal point

It is ________ mm to ________ mm

18 to 26 mm

from origin of that vessel.

What is unique about this point on the

It makes a distinct kink as

angiogram?

seen on the lateral

angiogram.

16.

True or False. From proximal to distal,

G7 p.101:90mm

the branches of the anterior cerebral

artery are

medial orbitofrontal, frontopolar,

true

callosomarginal, pericallosal

frontopolar, callosomarginal, medial

false

orbitofrontal, pericallosal

frontopolar, medial orbitofrontal,

false

pericallosal, callosomarginal

medial orbitofrontal, frontopolar,

false

pericallosal, callosomarginal

17.

True or False. The sylvian triangle on a

G5 p.560:135mm

lateral ICA angiogram is formed by

superior insular line, angular artery, line

true

between MCA origin, and most anterior

ascending branch

superior insular line, line from bregma to

false

torcula, line between posterior temporal

branch, and lateral orbitofrontal branch

superior insular line, clinoparietal line,

false

limbus sphenoidale

clinoparietal line, angular artery, line

false

from bregma to torcula

Neuroradiology

18.

True or False. The following are MCA

G7 p.101:175mm

branches:

lateral orbitofrontal

true

ascending frontal

true

medial orbitofrontal

false (The medial

orbitofrontal is a branch of

the anterior cerebral artery.)

anterior temporal

true

posterior parietal

true

19.

Complete the following about

G7 p.105:86mm

angiography (cerebral):

The foramen of Monro lies at the

junction of what three veins?

i________ c________

internal cerebral

ii.

t________

thalamostriate

iii.

s________

septal

This site is known as the ________

venous angle

________.

20.

True or False. The following veins will

G7 p.105:130mm

drain into the straight sinus in the

normal venous anatomy:

vein of Galen

true

basal cerebral vein of Rosenthal

true (via the vein of Galen)

inferior sagittal sinus

true

vein of Labbé

false (It empties into the

transverse sinus.)

21.

True or False. In the setting of a brain

G5 p.562:143mm

stem mass seen on a lateral

vertebrobasilar angiogram, the

displacement of the choroidal and

colliculocentral points should be

both displaced anteriorly

false (They would both be

displaced anteriorly by a

cerebellar mass but

posteriorly by a brain stem

mass.)

choroidal anteriorly, colliculocentral

false (They outline the fourth

posteriorly

ventricle and would move

with it.)

choroidal posteriorly, colliculocentral

false (They outline the fourth

anteriorly

ventricle and would move

with it.)

both displaced posteriorly

true (Both would be displaced

posteriorly by a brain stem

mass.)

no displacement

false

Magnetic Resonance Imaging (MRI)

22. Complete the following about cerebral

G5 p.562:135mm

angiography:

a. True or False. On a lateral vertebrobasilar

angiogram, the most sensitive indicator

of the anterior border of the pons is the

pontomesencephalic vein

true

ii.

basilar artery

false (Basilar artery may be off

to one side.)

iii.

choroidal point

false (junction of posterior

medullary loop and

supratonsillar loop)

iv. copular point

false (on the inferior vermian

G5 p.562:130mm

vein)

b. Twinings line runs between

t________

tuberculum

ii.

t________

torcula

 Magnetic Resonance Imaging (MRI)

23.

Matching. Match the best completion

G7 p.129:49mm

for each of the following:

① short TE, short TR; ② short TE, long

TR; ③ long TE, short TR; ④ long TE, long

T1-weighted MRI has:

①

T2-weighted image has:

④

24.

Complete the following about

G7 p.129:110mm

magnetic resonance imaging (MRI):

List the three materials that appear white

fat, melanin, and subacute

on T1-weighted imaging (T1WI) MRI.

blood

What color is pathology on T1WI?

low signal on T1 (dark)

What color is pathology on T2WI?

high signal on T2 (white)

25.

Matching. Match the phrases with the

G7 p.129:145mm

appropriate signal.

① high signal (bright); ② low signal

(dark); ③ intermediate signal

Fat on T1 is ________

①

Fat on T2 is ________

②

7- to 14-day-old blood on T2-weighted

①

MRI is:

7- to 14-day-old blood on T1-weighted

①

MRI is:

On T1 both fat and 7- to 14-

day-old blood are high signal

(white).

On T2 fat drops out (i.e., is

dark); blood remains white.

Neuroradiology

26.

Complete the following about MRI:

G7 p.129:170mm

The best sequence for CVA is ________,

FLAIR

which stands for ________-________

fluid-attenuated inversion

________ ________.

recovery

Cerebrospinal fluid (CSF) is ________.

black

Most lesions appear ________ in this

bright

sequence.

Most lesions are more ________.

conspicuous

27.

The best MRI sequence for

SAH is ________

FLAIR

G7 p.130:15mm

blood is ________ ________

gradient echo

G7 p.130:82mm

28.

Gradient echo

G7 p.130:60mm

aka ________ ________

T2 star

aka ________

grass

CSF and flowing blood appear ________

white

In cervical spine produces a ________

myelographic

effect

Improves delineation of ________

bone spurs

________

Also shows small old ________

hemorrhage

It is the most sensitive MRI sequence for

blood

________.

29.

Complete the following about MRI:

G7 p.130:92mm

True or False. An MRI sequence that

summates T1 and T2 signals and causes

fat to be suppressed is called the

________ sequence.

grass

false

ii.

stir

true

iii.

echo train

false

iv.

spin density

false

STIR stands for ________ ________

short tau inversion recovery

________ ________.

(summates T1 and T2

images)

Use it to ________.

see tissues that enhance in

areas of fat

30.

If a MRI contrast is given to patients

nephrogenic systemic fibrosis

G7 p.130:125mm

with severe renal failure, a rare

condition called n________ s________

f________ may occur.

Magnetic Resonance Imaging (MRI)

31.

Name two contraindications to MRI.

G7 p.131:20mm

patients who contain ________ or

ferro metals or cobalt (i.e.,

________

cardiac pacemaker,

implanted neurostimulators,

cochlear implants,

ferromagnetic aneurysm

clips, foreign bodies with a

large component of iron or

cobalt, metallic fragments in

the eye, placement of stent,

coil, or filter within past

6 weeks)

relative contraindication to MRI is

claustrophobia

________

32.

Complete the following regarding

G7 p.131:80mm

programmable valves and MRI:

Can such patients have MRI studies?

yes

You may need to check the ________

pressure setting

________ after the MRI.

33.

Hemorrhage on MRI. Related to time.

G7 p.132:15mm

Hint: George Washington Bridge

acute g________

gray

subacute w________

white

chronic b________

black

34.

Hemorrhage on MRI. Related to time.

G7 p.132:15mm

Hint: layers of Oreo cookie

acute b________

black

subacute w________

white

chronic

b________

black

35.

Hemorrhage on MRI. Related to time.

G7 p.132:15mm

Hint: i - baby, i - di, bi - di, ba - by, da - da

hyper-acute

T1: i________

isodense

ii.

T2: b________

bright

acute

T1: i________

isodense

ii.

T2: d________

dark

subacute early

T1: b________

bright

ii.

T2: d________

dark

subacute late

T1: b________

bright

ii.

T2: b________

bright

chronic

T1: d________

dark

ii.

T2: d________

dark

Neuroradiology

36.

Age of hemorrhage

G7 p.132:15mm

hyper acute

________

<24 hours

acute

________

1 to 3 days

subacute early

________

3 to 7 days

subacute late

________

7 to 14 days

chronic

________

>14 days

37.

Complete the following regarding

G7 p.132:20mm

hemorrhage and the condition of

hemoglobin:

hyperacute o________

oxy

acute d________

deoxy

subacute early m________

met

subacute late m________

met

chronic h________

hemosiderin

38.

Complete the following regarding

G7 p.132:20mm

hemorrhage and the location of

Also see

hemoglobin:

G7 p.1125:50mm

hyperacute I________

intracellular

acute I________

intracellular

subacute early I________

intracellular

subacute late E________

extracellular

chronic I________

intracellular

39.

Complete the following regarding

G7 p.132:103mm

diffusion weighted images (DWI):

Its primary use is to detect

i________

ischemia

ii.

and a________ p________.

active plaques

It first generates on ________ map.

ADC

On DWI freely diffusible water is

dark

________.

Restricted diffusion is ________.

bright

Which is abnormal?

restricted diffusion

40.

Characterize DWI.

G7 p.132:135mm

Restricted perfusion usually indicates

cell death

________ ________.

DWI abnormally will be present for

1 month

________.

DWI abnormalities can light up within

minutes

________ of ischemia.

41.

The most sensitive study for ischemia

PWI

G7 p.133:13mm

of the brain is the ________.

42.

DWI and PWI mismatch identifies

G7 p.133:42mm

penumbra.

Hint: DWI death PWI

Which modality shows irreversible cell

DWI

injury (death)?

Which modality shows reversible cell

PWI

injury (penumbra)?

Plain Films

43.

The important peaks in MRS are

G7 p.133:105mm

Hint: li-la-Na-crea-chol

li________

lipid

la________

lactate

N a________

N acetyl aspartate

crea________

creatine

chol________

choline

44.

The significance of important peaks in

G7 p.133:105mm

MRS are

hypoxia

lactate

a couplet peak

lactate

nerve and axons

NAA

a reference for choline

creatinine

membrane synthesis

choline

increased in tumor

choline

increased in developing brain

choline

reduced in CVA

choline

45.

The test that may help distinguish

G7 p.134:20mm

hemangiopericytoma

from meningioma is the ________;

MRS

specifically the presence of a large

inositol

________ peak.

46.

The test that may help a surgeon

G7 p.134:118mm

avoid critical white matter

tracts during brain surgery is ________,

DTI

which stands for d________ t________

difffusor tensor imaging

i________.

 Plain Films

47. Complete the following about plain

G7 p.135:115mm

films:

a. The basion is at the tip of the ________. clivus

b. The opisthion is at the anterior lip of the occipital bone

G7 p.135:118mm

________ ________.

48. A lateral C-spine x-ray has four contour

G7 p.135:160mm

lines with two marking the borders of

the spinal canal.

Hint: apsp

a. front of vertebral body called ________

anterior marginal line

________ ________

b. back of vertebral body called ________

posterior marginal line (marks

________ ________

anterior border of spinal

canal)

c. posterior margin of spinal canal called

spinolaminar line

________ ________

d. posterior margin of spinous processes is posterior spinous line

called ________ ________ ________

Neuroradiology

49.

Complete the following about spine

films:

Cervical spine normal diameter is

17 ± 5 mm

G7 p.136:130mm

________ mm.

Stenosis is present when the

12 mm

G7 p.136:140mm

anteroposterior diameter is less than

________ mm.

50.

Complete the following about normal

G7 p.137:15mm

prevertebral soft tissue:

Anterior to C1: ________ mm

Anterior to C2, 3, 4: ________ mm

Anterior to C5-C6: ________ mm

51.

Interspinous distances

G7 p.137:50mm

are abnormal if it is ________ times the

1.5

adjacent levels on AP film

if present it represents: true or false

fracture

true

ii.

dislocation

true

iii.

ligament disruption

true

this is called ________ on lateral x-ray

fanning

52.

C1 has how many ossification centers?

G7 p.137:84mm

53.

C2 has how many ossification centers?

G7 p.137:140 mm

54.

Matching. Match the following skull

G7 p.138:115mm

film findings with their characteristics:

① enlarged sella; ② J-shaped sella;

③ symmetrical ballooning; ④ erosion of

posterior clinoids

craniopharyngioma

④ erosion of posterior

clinoids

pituitary adenoma

① enlarged sella

optic glioma

② J-shaped sella

empty sella

③ symmetrical ballooning

55.

True or False. On a skull x-ray, erosion

G7 p.138:115mm

of the posterior clinoids would most

often be seen in the setting of

craniopharyngioma

true

empty sella syndrome

false

pituitary adenoma

false

Hurler syndrome

false

optic glioma

false

Plain Films

56.

Complete the following regarding

G7 p.138:25mm

lumbosacral spine films:

The disc space with the greatest heigh is

L45

at ________

AP view. Look for “owl eyes.”

These correspond to the ________

pedicles

ii.

Can be eroded in ________ disease

metastatic

Oblique views. Look for the neck of the

scotty dog.

It corresponds to the ________

pars interarticularis

________

ii.

Discontinuity occurs in a ________

fracture

57.

True or False. The percentage of all

G5 p.570:55mm

patients over 20 years old who will

have a calcified pineal gland visible on

plain skull x-ray is

false

10%

false

20%

false

55%

true

90%

false

58.

True or False. The most common

G7 p.139:140mm

congenital anomaly of the

craniocervical junction is

Chiari malformation

false

basilar impression

true

os odontoideum

false

incomplete arch of C1

false

C1-C2 subluxation

false

59.

True or False. Basilar invagination is

G7 p.139:166mm

seen in

hypoparathyroidism

false

Paget disease

true

osteogenesis imperfecta

true

osteomalacia

true

hyperparathyroidism

true

60.

True or False. In the evaluation of

true

G7 p.139:48mm

basilar invagination, in the normal

patient, no part of the odontoid

should be above the McRae line.

61.

True or False. A line used in the

G7 p.139:24mm

evaluation of the craniocervical

junction is

McRae line

true

Chamberlain line

true

Wackenheim line

true

Maginot line

false

G7 p.138:115mm

Fischgold line

true

Neuroradiology

62. True or False. The most common

G6 p.142:150mm

nondisc spinal lesion is:

a. synovial cyst

false

b. Tarlov cyst

false

c. astrocytoma

false

d. chordoma

false

e. metastatic tumor

true

 Myelography

63. True or False. The risk of postlumbar

G5 p.572:55mm

puncture headache is higher with

a. water-soluble contrast

false

b. non-water-soluble contrast

true

64. Matching. Match each of the following

G5 p.571:145mm

two statements with answers 1, 2, 3,

or 4.

① 10%; ② 35%; ③ 65%; ④ 90%

a. In lumbar disc disease, what percentage

②

of free fragments move inferiorly?

b. In lumbar disc disease, what percentage

③

of free fragments move superiorly?

Operations and Procedures

 Intraoperative Dyes

1. Matching. Match the intraoperative

G7 p.144:70mm

dyes with their characteristics.

Dyes:

① indigo carmine; ② methylene blue;

③ fluorescein

Characteristic:

a. carries a small risk of seizures when

③

administered intrathecally

b. is cytotoxic and should not be used at all

②

c. can be used to demonstrate

③

arteriovenous malformation (AVM)

vessels intraoperatively

d. used to identify cerebrospinal fluid (CSF)

①

leaks and is considered safe

 Surgical Hemostasis

2. Bone wax inhibits ________ formation. bone

G7 p.146:82mm

3. True or False. The following chemical

G7 p.146:100mm

hemostatic agent exerts its effect by

promoting platelet aggregation:

a. Gelfoam (gelatin sponge)

false

b. Oxycel (oxidized cellulose)

false

c. Avitene (microfibrillar collagen)

true (Avitene, that is,

microfibrillar collagen,

provides platelet adhesion

and aggregation. It loses its

effectiveness with severe

thrombocytopenia less than

10,000/mL.)

d. thrombin

false

Operations and Procedures

4. Matching. Match the surgical

G7 p.146:100mm

hemostasis substance with its trade

name.

Trade name:

① Thrombostat; ② Gelfoam; ③ Oxycel;

④ Surgicel; ⑤ Avitene

Substance:

a. gelatin sponge

②

b. oxidized cellulose

③

c. regenerated cellulose

④

d. microfibrillar collagen

⑤

e. thrombin

①

5. Complete the following about surgical

G7 p.146:139mm

hemostasis:

a. What may thrombin cause if placed on

significant edema

the brain?

b. If the ________ has been ________.

the pia; disrupted

 Intraoperative Brain Swelling

6. Complete the brain swelling

G7 p.147:25mm

intraoperative checklist.

Hint: decompress

a. d________ ________

drain CSF

b. e________ ________

elevate head

c. c________ (________)

CO₂ (hypercarbia)

d. o________ of ________ ________

obstruction of jugular veins

e. m________

mannitol

f. p________

pyperventilate

g. r________ ________

remove bone

h. e________ ________

excise brain (temporal or

frontal lobes)

(s)

 Craniotomies

7. Complete the following regarding the

G7 p.147:140mm

risks of craniotomy:

a. increased neurological deficit ________%

10%

b. postop hemorrhage ________%

c. infection ________%

d. anesthetic complications ________%

0.2%

8. Complete the following regarding

G7 p.148:117mm

anticonvulsants:

a. True or False. Maintain their use if

true (use Keppra)

cortical incision is anticipated.

b. Describe the method of loading.

500 mg PO or IV q 12 hours

c. For supratentorial craniotomy maintain

2 to 3 months

for ________.

Posterior Fossa Craniotomy

For cortical incision maintain for

2 to 3 months

________.

For aneurysm, AVM, or meningioma

6 to 12 months

maintain for ________.

For head injury (see Head Injury

1 week

guidelines) use for ________.

True or False. The following might be

G7 p.149:48mm

caused by pneumocephalus:

lethargy

true

confusion

true

headache

true

nausea

true

vomiting

true

seizures

true

10.

True or False. Simple pneumocephalus

true

G7 p.149:52mm

(the presence of air in the cranium not

apparently under pressure) can cause

neurologic symptoms postoperatively.

11.

Possible symptoms include l________,

lethargy, confusion, severe

G7 p.149:52mm

c________, h________, n________,

headache, nausea, vomiting,

v________, and s________.

and seizures (Obviously,

other etiologies, including

subclinical seizures, and

metabolic causes should be

ruled out.)

12.

Symptoms usually improve over

1 to 3

G7 p.149:62mm

________ days.

13.

If postoperative seizures occur,

G7 p.149:100mm

consider the following:

Hint: abci

a________ ________

anticonvulsant level—draw

blood

b________

bolus—additional

anticonvulsants

c________ ________

CAT scan—to identify if any

cause

i________

intubate—to protect airway

 Posterior Fossa Craniotomy

14. True or False. The correct treatment

G7 p.153:120mm

for air embolism sustained during a

craniotomy performed with the

patient in a sitting position is

a. to find and occlude site of entry or

true

rapidly pack wound with sopping wet

sponges

b. bilateral or right-sided jugular venous

true

compression

Operations and Procedures

ventilation with 100% O₂

true

rotating the patient right side down

false (Patient should be

turned left side down to trap

air in the right atrium.)

aspirating air from central venous

true

pressure (CVP) catheter

avoiding positive end-expiratory pressure

true

(PEEP), which is ineffective and may

worsen the risk of paradoxical air

embolism

15.

Complete the following about

G7 p.153:130mm

posterior fossa craniectomy and air

embolism:

Effect of air in right atrium is

h________

hypotension due to impaired

venous return

ii.

a________

arrhythmias

Paradoxical air embolism may occur if

p________ f________ o________

patent foramen ovale

ii.

p________ arteriovenous (AV)

pulmonary AV fistula

f________

Incidence in sitting position is

7 to 25%

________%.

Precautions require

D________ ________ ________

Doppler precordial ultrasound

ii.

C________ ________ ________

CVP catheter in right atrium

________ ________

Earliest clue to occurrence is ________.

fall in end tidal pCO₂

16.

How does air embolism cause

G7 p.153:130mm

problems?

Air becomes trapped in the ________

right atrium

________,

impairs ________ ________, and

venous return

produces ________.

hypotension

17.

Outline the intraoperative treatment

G7 p.153:145mm

for air embolism during a craniotomy.

Hint: occlude

o________

occlude entry site

ii.

c________

cover with wet laps

iii.

c________

compress jugular veins

iv.

l________

left side down lower head

u________

ventilate/increase volume

vi.

d________

discontinue nitrous

vii. e________

evacuate air

18.

Earliest clues to occurrence include

G7 p.154:20mm

fall in ________ ________ ________

end tidal pCO₂

sound on Doppler is ________ ________

machinery sound

blood pressure ________

hypotension

Posterior Fossa Craniotomy

19.

True or False. The following approach

G7 p.155:22mm

is most applicable for a vertebral

endarterectomy:

midline suboccipital craniotomy

false

extreme lateral posterior fossa approach

false

paramedian suboccipital craniotomy

true (Paramedian suboccipital

craniotomy gives decent

access to the vertebral artery

and to the posterior inferior

cerebellar artery [PICA] and

the vertebrobasilar junction.)

subtemporal craniotomy

false

20.

Consider the concept of “5-5-5.”

G7 p.155:90mm

This relates to the ________ incision

skin

ii.

for a linear ________ incision

paramedian

iii.

for access to the ________.

CPA

The first number relates to the mm

mastoid notch

medial to the ________ ________.

ii.

The second number relates to the

cm above

________ ________ the notch.

iii.

The third number relates to the

cm below

________ ________ the notch.

21.

Matching. Match the incision with the

G7 p.155:90mm

objective.

Incision:

① 5-6-4, ② 5-5-5, ③ 5-4-6

Objective: approach for

the fifth nerve

①

hemifacial spasm

②

glossopharyngeal neuralgia

③

microvascular trigeminal decompression

①

vestibular schwannoma

②

22.

Location of the inferior margin of the

G7 p.156:20mm

transverse sinus can be estimated

to be ________ f________ ________

two finger breadths

above the

m________ n________.

mastoid notch

23.

Describe the Frazier burr hole.

G7 p.156:90mm

It is used

p________

prophylactically

ii.

to relive p________ swelling

postoperative

iii.

due to h________ or

hydrocephalus

iv.

e________.

edema

It is located

________ to ________ cm from the

3 to 4

midline

ii.

________ to ________ cm above

6 to 7

the inion in adults

iii.

________ to ________ cm above

3 to 4

the inion in children

Operations and Procedures

24.

Complete the following regarding

G7 p.157:120mm

posterior fossa postop complications:

Respiratory: prevent by ________

keeping patient intubated

Hypertension: maintain SBP below

160 with nitroprusside

________ with ________

Acute hydrocephalus: treat with

ventricular tap—external

________ ________

ventricular drain (EVD)

Meningitis: prevent by prompt repair of

cerebrospinal fluid (CSF) leak

any ________ ________ ________

25.

Blood pressure above ________ is

160 mm Hg systolic

G7 p.157:148mm

dangerous for the postoperative

posterior fossa patient.

26.

Complete the following regarding the

G7 p.157:160 mm

posterior fossa:

Posterior fossa increased pressure is

heralded by changes in

b________ p________

blood pressure (increase)

ii.

r________ p________

respiratory pattern

not by

p________ i________

pupillary inequality

ii.

m________ s________

level mental status

iii.

I________ c________

ICP changes

27.

Considerations for postoperative

G7 p.158:20mm

posterior fossa emergency include

clinically

blood pressure (BP) ________

high

ii.

respirations ________

labored

recommended treatment

i________

intubate

ii.

t________ ________

tap ventricle

iii.

o________ ________

open wound

Should you

obtain a computed tomographic

(CT) scan first?

ii.

wait for operating room availability?

28.

Indicate whether increased pressure in

G7 p.158:30mm

the posterior fossa or supratentorial

compartment produces a change in

the following:

pupillary reflexes ________

supratentorial compartment

level of consciousness ________

supratentorial compartment

increase in intracranial pressure (ICP)

supratentorial compartment

________

changes in respiration ________

posterior fossa

rise in blood pressure ________

posterior fossa

Frontal Craniotomy

 Pterional Craniotomy

29. Matching. Match the head position

G7 p.159:70mm

with the location of the aneurysm.

Head position:

① angled 30 degrees, ② angled 45

degrees, ③ angled 60 degrees

Location of aneurysm:

a. ICA P-comm

①

b. carotid terminus

①

c. middle cerebral artery

②

d. basilar bifurcation

①

e. A-comm

③

30. Name the artery(ies) that cross the

none cross

G7 p.161:92mm

sylvian fissure.

 Temporal Craniotomy

31. True or False. A temporal craniotomy

G7 p.162:120mm

can allow access to the following

structures:

a. foramen ovale

true

b. Meckel cave

true

c. labyrinthine and upper tympanic portion

true

of the facial nerve

32. A temporal lobectomy

G7 p.163:115mm

a. can safely resect ________ cm in the

4 to 5 (before injury to

dominant hemisphere

Wernicke area)

b. and ________ cm in the nondominant

6 to 7 (before injury to optic

hemisphere.

radiations)

 Frontal Craniotomy

33. Complete the following regarding the

G7 p.163:170mm

superior sagittal sinus (SSS):

a. The risk in sacrifice of the SSS is

venous infarction

________ ________.

b. True or False. It almost always occurs

with sacrifice of

the posterior third

true

ii.

the middle third

true

iii.

the anterior third

false

Operations and Procedures

 Skull Base Surgery

34. The Dolenc approach is

G6 p.609:95mm

a. designed to remove the ________

anterior clinoid extradurally

________ ________

b. and provide access to the ________

proximal carotid artery

________ ________.

 Decompressive Craniectomy

35. Indications for decompressive

G7 p.165:55mm

craniectomy are

m________ m________ cerebral

malignant middle

artery occlusion

ii.

Primarily for the n________ -

non-dominant

d________ hemisphere

b. p________ i________ hypertension

persistent intracranial

c. True or False. It is necessary to open the

true

G7 p.165:110mm

dura.

d. Skull reimplantation can be considered

6 to 12

G7 p.165:140mm

after ________ to ________ weeks

G7 p.165:147mm

A ________ opening is best

large

ii.

Approximately ________ by

12 by 12

________ cm or larger

 Approaches to the Third Ventricle

36. Study Chart.

G7 p. 168:110mm

a. t________

transcortical

b. t________

transcallosal

a________

ii.

p________

posterior

c. s________

subfrontal

s________

subchiasmatic

ii.

o________

opticocarotid

iii.

l________ t________

lamina terminalis

iv.

t________

transsphenoidal

d. t________

transsphenoidal

e. s________

subtemporal

f. s________

stereotactic

37. What is the risk of postoperative

G7 p.168:125mm

seizures after a transcortical approach

to the anterior third ventricle (e.g., for

a colloid cyst)?

Approaches to the Third Ventricle

38.

What are the principles of tumor

G7 p.168:170mm

removal?

Veins must be preserved at all ________.

costs

First remove the tumor from within the

capsule

G7 p.168:180mm

________.

If adhesions seem unyielding the most

incomplete intracapsular

G7 p.169:15mm

likely cause is i________ i________

evacuation.

39.

Complete the following:

G7 p. 170:180mm

True or False. A disconnection syndrome

(split-brain syndrome) is common with

posterior callosotomy through

true (where more visual

splenium

information crosses)

ii.

anterior callosotomy

false

iii.

callosotomy < 2.5 cm in length from

false

a point 1 to 2 cm behind the tip of

the genu.

Which of the above approaches avoids

callosotomy < 2.5 cm in

the disconnection syndrome best?

length from a point 1 to 2 cm

behind the tip of the genu

40.

Describe the transcallosal approach to

G7 p.169:170mm

the third ventricle.

The superior sagittal sinus (SSS) is often

right

to the ________ of the sagittal suture.

The cranial opening should be

G7 p.170:40mm

________ anterior to the coronal

two third

suture

ii.

and ________ behind it.

one third

The two cingulate gyri may be adherent

corpus callosum

G7 p.170:130mm

in the midline and can be mistaken for

the c________ c________.

The corpus callosum has a distinct

white

________ color.

ii.

It is located beneath the paired

pericallosal

________ arteries.

The opening is usually made between

paired pericallosal

G7 p.170:155mm

the p________ p________ arteries.

The trajectory of dissection is from the

c________ s________

coronal suture

ii.

the e________ a________

external auditory meatus

m________.

iii.

The f________ of M________ lies

foramen of Monro

along this line.

G7 p.170:173mm

It is helpful to fenestrate the

septum pellicidum

s________ p________

ii.

to prevent it from b________ into

bulging

the ventricle

iii.

especially in a case of c________

colloid cyst

c________.

Operations and Procedures

41.

How can you tell which ventricle you

G7 p.171:38mm

are in?

The foramen of Monro is located

medially

m________.

If the choroid plexus goes to the left to

right

enter the foramen of Monro you are in

the ________ ventricle.

If you see no choroid plexus and no veins

cavum septum pellucidum

G7 p.171:80mm

you may be in a c________ s________

p________.

The safe way to enlarge the foramen of

choroid plexus; fornix

G7 p.171:115mm

Monro is posteriorly between the

________ ________ and the ________.

42.

Complete the following about

G7 p.172:145mm

approaches to the third ventricle:

The interhemispheric approach runs risk

bilateral cingulate gyrus

of injury to _______ ________ ________

which may produce ________ ________.

transient mutism

The anterior transcallosal approach runs

bilateral fornices

risk of injury to ________ ________

which may produce problem with

short-term memory and new

G7 p.172:135mm

s________-t________ m________ and

learning

n________ l________.

The transcortical approach is

G7 p.172:98mm

made through the ________

middle frontal

________ gyrus.

ii.

This is about the same spot used for

external ventricular drain

e________ v________ d________.

iii.

called ________ point.

Kocher

43.

Localizing levels in spine surgery. Most

G7 p.173:175mm

patients have ________ presacral

vertebra.

44.

The aortic bifurcation is at the mid-

G7 p.175:90mm

body of ________.

 Transoral Approach to Anterior Craniocervical Junction

45. Complete the following regarding

G7 p.176:125mm

transoral approach to anterior

craniocervical junction:

a. What percent of patients need posterior

75%

fusion after a transoral odontoidectomy?

b. The patient must be able to open the

G7 p.177:115mm

mouth at least ________ mm.

G7 p.177:140mm

The tubercle of the ________

atlas

ii.

can be palpated through the

pharynx

posterior ________

iii.

in order to locate the ________.

midline

d. If C1 sparing is not done the central

3; atlas

G7 p.177:168mm

________ cm of the ________ is

removed.

Surgical Fusion of the Cervical Spine

G7 p.177:175mm

There is about ________ to

20 to 25

________ mm working distance

ii.

between the ________ ________

two vertebral arteries

________ where

iii.

they enter the f________ t________ foramen transversarium

at the inferior aspect of

iv. the lateral masses of ________.

46. Complete the following regarding

G7 p.178:110mm

anterior access:

a. To T3 use a s________ s________

sternal splitting

approach.

b. At T10 the attachment of the ________ diaphragm

G7 p.179:45mm

increases the difficulty of this approach.

c. The location of the bifurcation of the

L4-L5

G7 p.179:90mm

vena cava is from just above to just

below the ________ disc.

 Surgical Fusion of the Cervical Spine

47.

What are the disadvantages of

G7 p.179:140mm

occipitocervical fusion?

r________ range of motion

reduces (movement at the

occipitocervical junction)

________ is higher than ________

nonunion rate; C1-C2 fusion

48.

True or False. The following is an

G7 p.179:150mm

indication for occipitocervical fusion:

congenital absence of C1 arch

true

upward migration of the odontoid into

true

the foramen magnum

congenital anomalies of occipitocervical

true

joints

type II odontoid fracture

false

49.

Complete the following regarding

G7 p.179:145mm

occipitocervical fusion:

Patient will lose about ________% of

30%

neck flexion.

G7 p.180:80mm

Keel plate must be placed at the

thickest

________

ii.

region of the ________ occipital

midline

bone.

iii.

It is advisable to ________ it pre-

measure

operatively.

50.

True or False. After occipito-cervical

G7 p.181:64mm

fusion we use a halo for

severe fractures

true

elderly patients

true

unreliable patients

true

smokers

true

8 to 12 weeks

true

Operations and Procedures

51.

True or False. The C1-C2 complex is

G7 p.181:89mm

responsible for the following

percentage of axial rotation:

10%

false

15%

false

25%

false

50%

true

75%

false

52.

Complete the following regarding

G7 p.181:89mm

anterior odontoid screw fixation:

C1-C2 complex is responsible for

50%

________% of head rotation.

Stability depends on the integrity of the

G7 p.181:101mm

o________ p________ and the

odontoid process

ii.

a________ t________ ligament

atlantoaxial transverse

Indicated in patients who have a type

II, transverse

G7 p.181:130mm

________ odontoid fracture and an

intact ________ ligament

Contraindicated if there is a fracture

G7 p.181:140mm

of the ________ ________

vertebral body

ii.

and if the fracture is less than

G7 p.181:162mm

________ months old

G7 p.183:80mm

The immediate postop strength is

50%

only ________%.

ii.

Therefore a brace is recommended

for ________ weeks.

iii.

If the patient has osteoporosis use a

halo

________.

53.

Complete the following regarding

G7 p.181:101mm

anterior odontoid screw fixation:

The most important structure holding

transverse

the odontoid in position against the

anterior arch of C1 is the ________

ligament,

aka the ________ ligament.

atlantoaxial

It is the horizontal limb of the ________

cruciate

ligament.

54.

True or False. The following condition

G7 p.181:130mm

is an indication for anterior odontoid

screw fixation:

pathologic odontoid fracture

false

type III odontoid fracture where the

false

fracture line is in the caudal portion of

body of C2

type I odontoid fracture that is reducible

false

type II irreducible odontoid fracture

false

type II reducible odontoid fracture

true

age of fracture is less than 6 months

true

Atlantoaxial Fusion (C1-C2 Arthrodesis)

55.

What are indications for odontoid

G7 p.181:131mm

screw?

Fracture must be ________

reducible

Type ________ fracture

Which ligament must be intact?

transverse

56.

True or False. The following are

G7 p.181:140mm

contraindications for anterior

odontoid screw fixation:

disruption of atlantal transverse ligament

true

disruption of apical ligament

false

fracture of C2 vertebral body

true

reducible odontoid type II fracture

false

57.

Indications for odontoid screw fixation

G7 p.181:160mm

include

type of fracture: ________

II odontoid

age of fracture: less than ________

6 months

________ old

ligament: t________ l________

transverse ligament intact

i________

judged by:

________ and

MRI

ii.

________ of ________

rule of Spence

The immediate postop strength is

50%

G7 p.183:80mm

only ________%

ii.

Therefore a brace is recommended

for ________ weeks

iii.

If the patient has osteoporosis, use a

halo

________

58.

Provide fusion rates with age of

G7 p.181:162mm

fracture.

Fusion rates in fractures more than 18

25%

months old: ________%

Fusion rates in fractures less than 6

90%

months old: ________%

 Atlantoaxial Fusion (C1-C2 Arthrodesis)

59. Characterize atlantoaxial fusion (C1-C2

G7 p.183:125mm

arthrodesis).

a. The patient will lose about ________% of

50%

head rotation

b. Transarticular screws

G7 p.184:150mm

Danger is to the v________

vertebral artery

a________

ii.

Provides i________ s________

immediate stabilization

iii.

Requires preop ________ to study

G7 p.184:175mm

vertebral arteries

Operations and Procedures

60.

True or False. The following is an

G7 p.183:140mm

indication for atlantoaxial fusion:

type I odontoid fracture

false

disruption of alar ligament of dens

false

disruption of apical ligament of dens

false

vertebrobasilar insufficiency with head

true (Disruption of alar or

turning

apical ligament of dens does

not render the spine unstable

as long as the transverse

ligament is intact.)

61.

Characterize bow hunter’s sign.

G7 p.183:82mm

What is bow hunter’s sign?

vertebrobasilar insufficiency

with head turning

What is the treatment for bow hunter’s

atlantoaxial fusion

sign?

(C1-C2 arthrodesis)

62.

Characterize a C1-C2 fusion.

G7 p.183:125mm

What mobility is lost?

Also

head rotation ________%

50%

G6 p.623:170mm

ii.

lateral mobility ________%

35%

Which technique produces less loss of

mobility?

Brooks

All are the same in regard to

loss of mobility.

ii.

Gallie

All are the same in regard to

loss of mobility.

iii.

Sonntag

All are the same in regard to

loss of mobility.

63.

Describe the fusion technique and

G7 p.184:75mm

differentiate.

Also

Brooks fusion

G6 p.624:120mm

sublaminar to ________

C1 and C2 sublaminar wiring

ii.

with ________ grafts

two-wedge bone

Gallie fusion

sublaminar to ________

C1 only

ii.

with ________ graft

“H” graft wired into place to

C1 only

Sonntag fusion

sublaminar to ________

C1 only

ii.

with ________ graft

bicortical graft wedged

between C1 and C2

64.

Characterize C1-C2 transarticular facet

G7 p.184:175mm

screw.

Special preop test needed is a thin cut CT

scan from the

________ ________

occipital condyles

ii.

through to C________

iii.

to look for the location of the

vertebral arteries

________ ________.

A fusion rate of up to ________% has

99%

been reported.

Atlantoaxial Fusion (C1-C2 Arthrodesis)

65.

With postoperative immobilization:

G6 p.625:25mm

The use of what apparatus is considered

halo brace

optimal immobilization of the cervical

spine?

It reduces cervical motion by ________%.

95%

It is mandatory for use in

r________ ________

rheumatoid arthritis

ii.

o________

osteopenia

The next best apparatus is the ________-

sternal-occipital-mandibular

_______-________ ________ ________.

immobilizer (SOMI) brace

Use this apparatus for ________ weeks.

12 to 16

Follow with a ________ for ________

hard collar for 4 to 6

weeks.

Use ________-________ ________ to

flexion-extension films

determine if this treatment was

satisfactory.

66.

Give the frequency of osseous fusions

G6 p.625:60mm

for the listed techniques.

Brooks ________%

70 to 85%

Gallie ________%

70 to 85%

Sonntag ________%

97%

67.

True or False. The following is

G6 p.625:80mm

associated with nonunion in

atlantoaxial fusion:

rheumatoid arthritis

true

cigarette smoking

true

osteoporosis

true

nonsteroidal antiinflammatory drugs

true

(NSAIDs)

68.

What are modifying correctible risk

G6 p.625:100mm

factors for a C1-C2 arthrodesis?

c________ s________

cigarette smoking

m________-o________

malnutrition-osteoporosis

N________

stopping suppressive drugs

(NSAID) 1 week before and

2 weeks after surgery

s________

steroids

i________

immunosuppressives

a________ b________

use autologous bone

69.

Complete the following:

G6 p.625:105mm

How does smoking produce nonunion of

interferes with vascularization

fusions?

of healing bone grafts

What is the responsible chemical?

nicotine

Will it help if patients stop smoking by

using nicotine patches?

70.

Complete the following concerning an

G7 p.183:85mm

anterior odontoid screw:

After placement what postop treatment

immobilization in cervical

is recommended?

brace

How long?

6 weeks

If patient has osteoporosis, use _______.

halo

Operations and Procedures

71.

Complete the following concerning a

G7 p.184:140mm

C1-C2 transarticular facet screw:

Indication—used in conjunction with

Sonntag fusion

________ ________

Benefit

provides immediate ________

stabilization

ii.

avoids postoperative ________

external orthosis

________

iii.

A major risk of the procedure is

vertebral artery injury

________ ________ ________.

72.

Characterize atlantoaxial-axial fusion

G7 p.183:125mm

(C1-C2 arthrodesis).

The patient will lose about ________% of

50%

head rotation.

Transarticular screws

G7 p.184:150mm

Danger is to the v________

vertebral artery

a________

ii.

Provides i________ s________

immediate stabilization

iii.

Requires preop ________ to study

G7 p.184:175mm

vertebral arteries

73.

Complete the following regarding

G7 p.191:103mm

surgical fusion of lumbar and

lumbosacral spine:

True or False. A lumbar fusion that

includes L1

Should not be terminated at L1

true

ii.

Should not be terminated at T12

true

Pedicle screws

G7 p.191:145mm

Should be ________ to ________ %

70 to 80%

of pedicle

ii.

Should be greater than ________

5.5

mm in the adult

iii.

The length should be ________ to

70 to 80%

________% of the vertebral body

iv. typically ________ to ________ mm

40 to 50

long

Medial angles for lumbar pedicle screws

G7 p.192:15mm

L1 level—medial angle should be

________ degrees

ii.

L2 level—medial angle should be

________ degrees

iii.

L3 level—medial angle should be

________ degrees

iv. L4 level—medial angle should be

________ degrees

v. L5 level—medial angle should be

________ degrees

vi. S1 level—medial angle should be

________ degrees

vii. S2 level—medial angle should be

________ degrees

Atlantoaxial Fusion (C1-C2 Arthrodesis)

On AP view if screw tip

Crosses the midline there is a

medial

________ breech

ii.

Does not pass medial to the medial

lateral

edge of the pedicle there is likely a

________ breech

Posterior lumbar interbody fusion (Plif

G7 p.193:15mm

and Tlif)

Not appropriate if ________ height

disc

is preserved

ii.

Usually supplemented with

pedicle screws

________ ________

Anterior lumbar interbody fusion

G7 p.195:18mm

has a risk of ________ ________

retrograde ejaculation

ii.

of from ________ to ________%

2 to 45%

74.

True or False or Unreliable. In

G7 p.198:40mm

assessing lumbar fusion the following

tests can suggest success:

static x-rays

false

flexion—extension views

true

technetium 99 bone scan

false

good clinical outcome

unreliable

CT scan

true

75.

Components necessary for bone graft

G7 p.198:100mm

fusion are

Hint: IGC

Osteoinduction is ________ of

recruitment

mesenchymal cells.

Osteogenesis is the process of forming

new bone

________ ________.

Osteoconduction structure adds

new vessels, scaffold

________ ________ and acts as a

________.

Hint:

Induces mesenchymal cells to

transform

Generates bone cells

Constructs bone scaffold

76.

Allograft provides only osteo-

conduction

G7 p.199:92mm

________.

77.

DBM

G7 p.199:92mm

aka as d________ bone m________

demineralized; matrix

has ________ and ________ properties

inductive and conductive

78.

BMP

G7 p.199:145mm

aka bone m________ p________

morphogenic protein

has ________ properties

inductive

may cause e________ b________

ectopic bone

approved by FDA only for ________

Alif

G7 p.199:163mm

100

Operations and Procedures

79.

Complete the following regarding

G7 p.200:73mm

graft procurement:

Anterior iliac bone graft

Obtain ________ to ________ cm

3 to 4

ii.

________ to the anterior superior

lateral

iliac crest

iii.

To avoid the l________ f________

lateral femoral cutaneous

c________ nerve

iv. Also need to avoid injury to the

ilioinguinal and

i________ and i________

iliohypogastric

Posterior iliac crest bone graft

G7 p.200:103mm

Obtain from the ________

medial

ii.

________ to ________ cm of the

6 to 8

iliac crest

iii.

To avoid the s________ c________

superior cluneal

nerves

iv. If injured, they cause b________

buttock numbness or painful

n________ or p________

neuromas

n________

The “dimple of Venus” lies directly

G7 p.200:133mm

above the s________ joint.

sacro iliac

ii.

Incise a little ________ to it.

lateral

iii.

Avoid mistaking the s________

sacrum

iv.

and the i________ s________.

iliac spine

 Lumbar Punctures

80. Complete the following regarding

G7 p.201:175mm

lumbar punctures:

a. For lumbar puncture (LP) the platelet

50,000/mm³

count should be higher than ________.

b. In SAH, LP might increase the ________

transmural

G7 p.202:15mm

pressure and precipitate aneurysmal

rupture.

c. An LP in patients with spinal block may

14%

G7 p.202:25mm

produce deterioration in as many as

________%.

81. The spinal cord ends at the given

G7 p.202:45mm

location for what percentage of

adults?

a. between T12 and L1

30%

b. between L1 and L2 middle thirds

51 to 68%

c. between L2 and L3

10%

d. between T12 and L2

94%

82. The intercristal line

G7 p.202:60mm

a. connects the superior border of the

iliac crests

________ ________

b. occurs in most adults between the

L4 and L5

spinous processes of ________ and

________

Lumbar Punctures

101

83.

Complete the following statements:

G7 p.202:95mm

When an LP is performed, we must

the stylet

always advance the needle with

________ ________ in place.

Otherwise we may introduce ________

epidermal cells

________,

which could produce an iatrogenic

epidermoid tumor

________ ________.

84.

Describe the Queckenstedt test and

G7 p.202:180mm

expected results.

What do you compress?

the jugular vein

One or both?

one then the other, while

measuring ICP

If no block what will happen with

pressure should rise 10 to

compression?

20 cm from baseline

If no block what happens upon release of

return to the original level

compression?

within 10 seconds

If there is a block what will happen?

no rise in pressure from

baseline

85.

Complete the following about lumbar

G7 p.203:85mm

punctures:

Incidence of severe postpuncture

0.1 to 0.5%

headache is ________%.

Severe means ________.

lasting longer than 7 days

86.

Complete the following about lumbar

G7 p.203:155mm

punctures:

Can a sixth nerve (abducens nerve) palsy

yes

occur after lumbar puncture?

If so when?

after 5 to 14 days

If it occurs when does it resolve?

4 to 6 weeks

87.

True or False. Regarding fundus exam

G7 p.204:25mm

for papilledema:

It is a reliable test to assure safety of LP.

false

It is an unreliable test.

true

It takes 6 to 24 hours for papilledema to

true

occur.

A better test of safety would be a

CT scan

C________ s________.

88.

True or False. If you suspect meningitis

G7 p.204:85mm

but cannot promptly get a CT scan

you may do an LP without a CT scan

true (very small risk)

even if there is papilledema

true (risk is still low)

and if there are unequal pupils and/or

false (suggests an

hemiparesis

asymmetrical mass; do not do

LP)

89.

You suspect meningitis but cannot

replace the fluid

G7 p.204:85mm

promptly get a CT scan. If the patient

deteriorates during LP the anecdotal

recommendation is to immediately

________ ________ ________.

102 Operations and Procedures

90. True or False. The following may

G7 p.204:135mm

reduce the frequency of post-LP

headache:

a. Use a small-size needle.

true

b. Orient the bevel longitudinally.

true

c. Position the patient flat in bed.

false (not shown to be truly

beneficial)

d. Remove only a little fluid.

false (not shown to be truly

beneficial)

e. Replace the stylet before removing the

true

needle.

f. Hydrate the patient after the LP.

false (not shown to be truly

beneficial)

 C1-C2 Punctures

91. What condition makes lateral cervical Chiari malformation

G7 p.205:125mm

puncture contraindicated?

 Ventricular Catheterization

92. True or False. Sites that may be used

G7 p.207:80mm

for ventricular catheterization are

a. Keen point

true

b. Dandy point

true (but may injure visual

pathways)

c. occipital-parietal region

true

d. Kocher point

true

93. Keen point

G7 p207:168mm

a. is about ________ cm superior to the

PINNA

b. is about ________ cm posterior to the

PINNA

c. places catheter into the ________

trigone

 Ventriculostomy/ICP Monitors

94. True or False. The site most commonly

G7 p.207:180mm

used for ICP monitoring is

a. occipitoparietal region

false

b. Frazier burr hole

false

c. Keen point

false

d. Dandy point

false

e. Kocher point

true (2 to 3 cm from midline,

approximate midpupil line;

1 cm anterior to coronal

suture; aim toward ipsilateral

inner-canthus and external

auditory canal)

104 Operations and Procedures

 Ventricular Shunts

96.

List the layers to traverse in the

G7 p.210:20mm

placement of peritoneal catheter.

Hint: samp³

s________ ________

subcutaneous fat

a________ ________

anterior sheath

m________

muscle

p________ ________

posterior sheath

p________ ________

preperitoneal fat

p________

peritoneum

97.

Ventriculoatrial shunt should be

G7 p.211:110mm

revised when the catheter tip is above

________.

98.

The needle to use in ommaya reservoir

butterfly 25

G7 p.212:160mm

is a b________ ________ or smaller

gauge.

99.

During third ventriculostomy

G7 p.213:70mm

The opening is made

________ to the mammillary bodies.

ii.

This site is ________ to the basilar

artery.

After puncturing the floor be certain that

membrane of Liliequist

G7 p.213:100mm

the m________ of L________ is also

perforated.

 Sural Nerve Biopsy

100. Nerve biopsy has a role in diagnosing

G7 p.214:125mm

the following:

Hint: aCdHmv

a. a________

amyloidosis

b. C________-M________-T________

Charcot-Marie-Tooth

c. d________ a________

diabetic amyotrophy

d. H________ d________

Hansen disease

e. m________ l________

metachromatic

leukodystrophy

f. v________

vasculitis

101. Sural nerve biopsy

G7 p.214:153mm

a. At the level of the ankle the sural nerve

lies between the ________ tendon

Achilles

ii.

and the ________ malleolus.

lateral

b. A tourniquet distends the ________

lesser saphenous

________ vein.

c. To biopsy only a portion of the fascicles

epineurium

open the ________ and tease out a few

fascicles.

G7 p.215:115mm

Sensory loss is ________

expected

ii.

but may not last more than a

a few weeks

________ ________.

Nerve Blocks

105

 Nerve Blocks

102.

True or False. The following are risks

G7 p.215:170mm

of bilateral stellate ganglion block:

glossopharyngeal nerve injury bilaterally

false

respiratory compromise

true

hypoglossal nerve injury bilaterally

false

bilateral laryngeal nerve injury

true (Glossopharyngeal and

hypoglossal nerves are higher

in the cervical region.)

103.

The palpable landmark at C6 is called

G7 p.216:23mm

C________ t________

Chassaignac’s tubercle

also known as a________ t________ of

anterior tubercle; transverse

t________ p________ of C________

process of C6

also known as ________ ________

carotid tubercle

104.

True or False. The following are signs

G7 p.216:40mm

of a successful stellate ganglion block:

unilateral vocal cord paralysis

false

hoarseness

false

unilateral Horner syndrome

true

upper extremity weakness from brachial

false

plexus effect

increased warmth of ipsilateral hand

true

anhidrosis of the ipsilateral hand

true

105.

Complete the following concerning

G7 p.216:115mm

the intercostal nerve block:

A good site for injection is the

posterior axillary line

p________ a________ l________.

How many nerves need to be blocked to

three

produce some anesthesia?

Why so many?

overlap

Order of structures from top down is

rib, vein, artery, nerve

________ ________ ________

________. (Hint: rvan)

Developmental Anomalies



Arachnoid Cysts

Characterize intracranial arachnoid

G7 p.222:100mm

cysts.

Origin: c________

congenital

C________ ________ ________ produce

cells of lining;

________.

CSF

age: y________ ________

young patients

incidence per 1000 autopsies ________

symptoms of s________, h________

seizures, headache

treatment: s________, d________,

shunt, drain,

f________

fenestrate

path: s________ a________ m________

split arachnoid membrane

True or False. Acute deterioration in

G7 p.223:65mm

patients with known arachnoid cysts

usually signifies

rapid increase in cyst size

false

postictal state

false

rupture into subdural space

false

rupture of bridging veins and cyst bleed

true

Complete the following about

G7 p.222:177mm

arachnoid cysts:

The location of the only extradural type

intra sellar

of arachnoid cyst is in the ________ cyst.

A retrocerebellar arachnoid cyst might

Dandy-Walker

mimic a ________-________ syndrome.

The most common location for an

sylvian fissure

arachnoid cyst is the _______ ________.

The next most common location is the

cerebellopontine angle

________ ________.

They are associated with ventriculo

64%

G7 p.224:45mm

megaly in ________%.

The best treatment is probably ________

shunting of cyst

G7 p.224:170mm

of ________.

Hypothalamic Hamartomas

107

4. Complete the following regarding

G7 p.224:70mm

intraspinal cysts:

a. If you find one ventrally think ________

neurenteric cyst

________.

b. If you find one dorsally think ________

arachnoid cyst

________.



Intracranial Lipomas

Intracranial lipomas

G7 p.225:130mm

are usually found in the ________

midsagittal plane

________

especially in the ________ ________.

corpus callosum

They are frequently associated with

agenesis

________

of the ________.

corpus callosum

They may less frequently involve the

________ ________

tuber cinereum

ii.

and the ________ ________.

quadrigeminal plate

True or False. Characteristics of

G7 p.225:145mm

intracranial lipomas include

Association with ________ abnormalities

congenital

On CT they have a ________ density.

low

Differential diagnosis is

d________ c________

dermoid cyst

ii.

t________

teratoma

iii.

g________

geminoma

On MRI they have a ________ intensity

high (like fat)

on T1.

On MRI they have a ________ intensity

low

on T2.

Intracranial lipomas may present

G7 p.225:178mm

clinically with

s________

seizures

h________ d________

hypothalamic dysfunction

h________

hydrocephalus

m________ r________

mental retardation

 Hypothalamic Hamartomas

8. Hypothalamic hamartomas

G7 p.226:50mm

a. are frequent or rare?

rare

b. are neoplastic or nonneoplastic?

nonneoplastic

c. consist of a mass of ________ ________

neuronal tissue

d. that arises from the

in________ h________ or

inferior hypothalamus

ii.

t________ c________

tuber cinereum

9. Hypothalamic hamartomas clinically

G7 p.226:98mm

a. may present with a special type of

gelastic; laughing

seizure called ________, which means

________ seizure

108 Developmental Anomalies

b. may also have ________ attacks

rage

G7 p.226:125mm

may also present with p________

precocious puberty

p________

ii.

due to release of g________

gonadotropin releasing

r________ h________

hormone

iii.

formed within the________ cells

hamartoma

 Neurenteric Cysts

10. Complete the following about

G7 p.227:100mm

neurenteric cysts:

a. A neurenteric cyst is a central nervous

endothelium

system (CNS) cyst lined with ________

b. resembling the ________ or ________

gastrointestinal or respiratory

tract.

c. Regions affected are usually the

cervical or thoracic

G7 p.227:115mm

________ or ________ areas.

d. Histology is a cyst lined with c________- cuboidal-columnar epithelium

c________ e________

e. with m________-s________ g________ mucin-secreting goblet cells

G7 p.228:34mm

c________.

 Craniofacial Development

11.

Complete the following about

G7 p.228:105mm

craniofacial development:

The anterior fontanelle closes by age

2.5 years

________.

Head size is 90% of adult size at age

1 year

________.

The head stops enlarging by age

7 years

G7 p.228:130mm

________.

The skull is ________ at birth.

unilaminar

Diploë appears by the ________ year

fourth

and

reaches a maximum at age ________.

35 years

Diploic veins form at age ________.

35 years

Air cells in the mastoid occur in

sixth

________ year.

12.

True or false. Craniosynostosis

G7 p.228:172mm

has been proven to occur after shunting.

false

of one suture does not cause ↑ICP.

false—11 % have ↑ICP

13.

Complete the following about

G7 p.229:157mm

craniofacial development:

The most common craniosynostosis is

sagittal

________.

The male to female ratio is ________.

80:20

The resulting skull shape is ________.

dolichocephalic/

scaphocephalic/boat shape

Craniofacial Development

109

Surgery should be done within the age

3 to 6 months

range of ________.

The strip craniectomy should be

________ cm wide.

14.

Complete the following regarding

G7 p.230:28mm

coronal synostosis:

Incidence of patients with

18%

craniosynostosis who have coronal

synostosis is ________%.

In which is it more common, males or

females

females?

15.

Coronal suture synostosis (CSS)

G7 p.230:35 mm

plus syndactyly is called ________

Apert

syndrome.

Unilateral CSS is called ________.

plagiocephaly

CSS plus hypoplasia of the face is called

Crouzon

________ disease.

Plagiocephaly has an unusual orbit

harlequin eye sign

appearance on x-ray called the ________

________ ________.

Plagiocephaly

Forehead on affected side is

flattened or concave

________ or ________.

ii.

Supraorbital ridge has a ________

higher

margin.

16.

Harlequin eye sign

G7 p.230:40mm

occurs in u________ c________ suture

unilateral coronal

closure

seen on ________ ________ ________.

anteroposterior skull x-ray

The abnormal bony structure is the

supraorbital margin

________ ________

and is ________ than on the normal side.

higher

17.

Complete the following about

G7 p.230:80mm

craniofacial development:

What suture is closed to produce

metopic

trigonocephaly?

It is usually associated with an

19 p

abnormality of the ________

chromosome.

18.

Characterize lambdoid synostosis.

G7 p.230:100mm

Male to female ratio is ________.

4:1

Side involved most frequently is

right side

________.

The frequency of involvement is

70%

________% right.

Does it have a ridge or an indentation to

not a ridge like the sagittal or

palpation?

coronal synostosis, but it has

an indentation

110 Developmental Anomalies

19. Considering lambdoid synostosis:

G7 p.230:160mm

Fig. 8.1

Illustration by Tony Pazos

a. Differentiate from positional flattening

top of the head

by looking at the ears from the ________

________ ________ ________.

b. In lambdoid synostosis you will see the

lags behind

ipsilateral ear ________ ________.

c. In positional flattening you will see the

pushed forward (If flat side of

ipsilateral ear is ________ ________.

occipital bone is same side as

the posteriorly positioned ear

it is a case of lambdoid

synostosis; if not it is a case of

positional flattening.)

20. Answer the following concerning

G7 p.231:85mm

lambdoid synostosis treatment:

a. True or False. All require surgery.

false (Only 15% won’t

respond to repositioning.)

b. True or False. Surgery is indicated early

false (One can observe for

(i.e., in 3 to 6 months).

3 to 6 months for

improvement.)

c. Ideal age for surgery is ________ to

6 to 18

________ months.

d. Early surgery is indicated for s________

severe disfigurement and

d________ and e________ i________

elevated intracranial pressure

p________.

Chiari Malformation

111

21.

Describe oxycephaly.

G7 p.231:155mm

Definition: ________ ________

tower skull

Occurs if there is fusion of ________

multiple sutures

________

Is there elevated ICP?

yes

What is the status of the sinuses?

underdeveloped sinuses

22.

Complete the following about

G7 p.232:60mm

craniofacial development:

Cranium bifidum is another name for

encephalocele or

________ or ________.

meningocele

What type does not produce a visible

basal encephalocele

soft tissue mass?

Definition: an extension of ________

normal, confines

G7 p.232:75mm

structures outside the normal ________

of the skull

A nasal polypoid mass in a newborn

encephalocele

G7 p.232:75mm

should be considered an ________ until

proven otherwise.

23.

Complete the following about

G7 p.232:130mm

encephalocele:

Incidence of the basal form of

1.5%

encephalocele is ________%.

May exit the skull via a defect in

c________ p________

cribriform plate

ii.

f________ c________

foramen cecum

iii.

s________ o________ f________

superior orbital fissure

Treatment is by a combined i________

intracranial and transnasal

and t________ approach

 Chiari Malformation

24. Compare Chiari types I and II.

G7 p.233:100mm

a. medulla-caudal dislocation

Chiari I, no

Chiari II, yes

b. into cervical canal

Chiari I, tonsils

Chiari II, vermis, medulla,

fourth ventricle

c. myelomeningocele

Chiari I, no

Chiari II, yes

d. hydrocephalus

Chiari I, no

Chiari II, yes

e. medullary kink

Chiari I, no

Chiari II, 55%

f. cervical nerves

Chiari I, normal

Chiari II, upward

g. age at presentation

Chiari I, adult

Chiari II, infant

h. symptoms

Chiari I, neck pain

Chiari II, hydrocephalus,

respiratory distress

112

Developmental Anomalies

25.

Complete the following about Chiari

G7 p.234:25mm

malformation:

Chiari I has how many abnormalities?

1—with many names

List four names this abnormality has

been called.

t________ h________

tonsillar herniation

ii.

c________ d________ of c________

caudal displacement of

cerebellum

iii.

p________ e________ of t________

peglike elongation of tonsil

iv.

c________ e________

cerebellar ectopia

26.

Chiari I

G7 p.234:25mm

has how many deformities?

is known by the following names

e________

ectopia

ii.

e________

elongation

iii.

d________

displacement

iv.

h________

herniation

symptoms

o________ h________

occipital headaches

ii.

c________ p________

cervical pain

27.

What is the particular eye sign

Downbeat nystagmus is

G7 p.235:130mm

associated with Chiari I?

considered a characteristic of

this condition in 47%, but it

can also occur in Chiari II.

28.

What percentage of Chiari I patients

20 to 30% of Chiari I patients

G7 p.236:15mm

have hydrosyringomyelia?

have a syrinx.

29.

Characterize the location of tonsils

G7 p.236:15mm

and Chiari I.

Normal range related to foramen

magnum

high

8 mm above

ii.

low

5 mm below

iii.

mean

1 mm above

Chiari I range is

high

3 mm below

ii.

low

29 mm below

iii.

mean

13 mm below

Symptoms can occur with tonsils at

________ mm below.

Usual level considered cutoff for

diagnosis is ________ mm below.

30.

Possible better correlation with

G7 p.236:100mm

symptoms of tonsillar herniation is the

degree of brain stem compression

at the ________ ________

foramen magnum

as seen on the ________

axial

T________ W1 MRI.

Chiari Malformation

113

31.

The best results from surgery occur if

G7 p.237:160mm

treated within ________ years of onset

of symptoms.

32.

Complete the following concerning

G7 p.237:182 mm

Chiari I:

The most common postop complication

________ ________

respiratory depression

ii.

in ________ %.

15%

Occurs within how many days of

surgery?

Occurs mostly at what time of day?

night

Death can occur from s________

sleep apnea

a________.

Other risks of surgery include

c________ f________ l________

cerebrospinal fluid leak

ii.

injury to ________ ________

posterior inferior cerebellar

________ ________

artery (PICA)

iii.

h________ of c________ h________

herniation of cerebellar

hemispheres

33.

Complete the following concerning

G7 p.238:30mm

Chiari I:

Operative results

Main benefit may be to ________

arrest

progression

ii.

Best results in patients with

cerebellar

________ syndrome

iii.

which consists of

G7 p.238:55mm

t________ a________

truncal ataxia

l________ a________

limb ataxia

n________

nystagmus

d________

dysarthria

Which responds better: pain or

pain

G7 p.238:55mm

weakness?

34.

Factors that correlate with a worse

G7 p.238:63mm

outcome are

a________

atrophy

s________

scoliosis

symptoms that are lasting more than

2 years

________ ________

35.

Which Chiari malformation is

Chiari II

G7 p.238:108mm

associated with myelomeningocele?

114

Developmental Anomalies

36.

Study Chart. Chiari II anatomical

atlas assimilation

G7 p.238:137mm

abnormalities: A to Z.

beaking of tectum

bony abnormalities

cerebellar folia poorly

myelinated

cervical medullary junction

compression

craniolacunia

corpus callosum agenesis

degenerated lower CN nuclei

enlarged massa intermedia

falx hypoplasia

fourth ventricle trapped

fusion of cervical vertebrae

gyri miniaturized

hydrocephalus

heterotopia

hydromyelia

Klippel-Feil deformity

low attachment of tentorium

massa intermedia enlarged

medulla oblongata

“z” bend microgyria

nuclei of lower CN

degenerated

platybasia

peg of cerebellar tonsils

septum pellucidum absent

syringomyelia

tectum beaking (fusion)

tentorium low attachment

Z-shaped bend of medulla

37.

Considering Chiari II, presenting

G7 p.239:15mm

symptoms are due to dysfunction of

b________ s________

brain stem

l________ c________ n________

lower cranial nerves

38.

Finding on presentation of Chiari II

G7 p239 :30mm

Hint: n2 chiari two

n________

nystagmus—down beat

n________ ________

nasal regurgitation

c________

cyanosis

h________

hoarseness

i________ ________ ________

impaired ventilatory drive

a________ ________, ________

apneic spells, aspiration

r________, ________ ________

regurgitation, respiratory

arrest

i________ ________

inspiratory stridor

t________ ________ ________

tenth nerve (vagus) vocal

________ ________

cord paralysis

w________ ________

weak arm—weak cry

o________

opisthotonus

Dandy-Walker Malformation

115

39. Complete the following regarding

G7 p.240:68mm

Chiari II:

a. The most common cause of mortality is respiratory arrest

________ ________.

b. The mortality at 6 years follow-up is

40%

________%.

c. Range of mortality

Infants in poor condition (i.e.,

71%

cardiopulmonary arrest, vocal cord

paralysis, and/or arm weakness

mortality) is ________%.

ii.

There is gradual onset of symptoms

23%

in ________%.

iii.

The worst prognostic factor for

bilateral vocal cord paralysis

response to surgery is b________

v________ c________ p________.

 Dandy-Walker Malformation

40.

Complete the following regarding

G7 p.240:138mm

Dandy-Walker malformation (DWM):

It is caused by a________ of the

atresia of the foramina of

f________ of L________ and

Luschka and Magendie

M________.

(old theory)

Results in

agenesis of ________

vermis

ii.

large ________ ________ ________,

posterior fossa cyst

which communicates with the

iii.

________ ________, which

fourth ventricle

becomes

iv.

________.

enlarged

41.

To differentiate DWM from

G7 p.241:28mm

retrocerebellar arachnoid cyst observe

for

v________ a________

vermian agenesis

cyst opens into f________ v________

fourth ventricle

enlarged p________ f________

posterior fossa

elevation of the t________ H________

torcular Herophili

42.

What is Dandy-Walker pathogenesis?

G7 p.241:50mm

D________

Dilation of fourth ventricle

A________

Agenesis of vermis

N________

Membrane of fourth ventricle

D________

Dysembryo genesis

Y________

Hydrocephalus

43.

DWM patients

G7 p.241:60mm

Hydrocephalus is present in

70 to 90%

________%

ii.

and ________% of hydrocephalus

2 to 4%

patients have DWS.

116 Developmental Anomalies

b. A common associated abnormality is

G7 p.241:92mm

________ of the ________

agenesis of the corpus

________ in

callosum

ii.

________%.

17%

c. and c________ a________.

cardiac abnormalities

d. If treatment is necessary, you must shunt cyst

the ventricle, the cyst, or both?

e. If aqueductal stenosis you should shunt

ventricle

________ also.

f. But shunting the lateral ventricle alone

G7 p.241:122mm

is ________

contraindicated

ii.

because it might cause ________

upward herniation

________.

g. To avoid ________ herniation

upward

G7 p.241:125mm

h. you must not shunt the ________ alone.

ventricle

G7 p.241:125mm

44. What is the prognosis in DWM?

G7 p.241:152mm

a. Seizures occur in ________%.

15%

b. Mortality occurs in ________ to

12 to 50%

________%.

c. Normal IQ is ________%.

50%

 Aqueductal Stenosis

45.

True or False. Aqueductal stenosis is

false (Adults can present with

G7 p.241:179 mm

seen only in children.

symptoms as well.)

46.

What are the causes of aqueductal

G7 p.242:20mm

stenosis?

Hint: aqectal

a________

astrocytoma of brain stem

q________

quadrigeminal plate mass

e________

inflammation, infection

c________

congenital atresia

t________

tumors

a________

arachnoid cysts

l________

lipoma

47.

Complete the following concerning

G7 p.242:45mm

aqueductal stenosis:

It is associated with congenital

70%

hydrocephalus in ________%.

MRI may show absence of

n ________ f________ v ________

normal flow void

in the

ii.

a ________ of S________.

aqueduct of Sylvius

MRI with contrast should be used to rule

tumor

out ________.

Follow-up should be for at least

2 years

________

in order to rule out ________.

tumor

G7 p.243:22mm

Neural Tube Defects

117

48. True or False. A patient with

G7 p.242:100mm

aqueductal stenosis of adulthood may

have the following symptoms:

a. headache

true

b. visual disturbances

true

c. decline of mental function

true

d. gait disturbance

true

e. papilledema (sign)

true

f. ataxia

true

g. urinary incontinence

true

49. What are the treatment options for

G7 p.242:175mm

aqueductal stenosis?

a. ventriculoperitoneal ________ ________ CSF shunting

b. T________ ________ ________

Torkildsen shunt in adults

________

c. ETV = ________ ________ ________

endoscopic third

ventriculostomy

 Neural Tube Defects

50.

With neural tube defects there are

G7 p.243:45 mm

classification systems. Give examples

neurulation defects

a________

anencephaly

ii.

m________

myelomeningocele

postneurulation defects

m________

microcephaly

ii.

h________

hydranencephaly

iii.

h________

holoprosencephaly

iv.

l________

lissencephaly

s________

schizencephaly

spinal defects

d________

diastematomyelia

ii.

s________

syringomyelia

51.

Complete the following about neural

G7 p.243:45mm

tube defects:

Failure to fuse the anterior neuropore

anencephaly

results in ________.

Failure to fuse the posterior neuropore

myelomeningocele

results in ________.

The definition of microcephaly is head

2 standard deviations

circumference ________ ________

________ below the mean.

In hydranencephaly the cortex is

CSF

replaced by ________.

Failure to cleave can result in ________.

holoprosencephaly

118

Developmental Anomalies

52.

Complete the following about neural

G7 p.243:45mm

tube defects:

Give examples of neurulation defects.

a________

anencephaly

ii.

c________

craniorachischisis

iii.

m________

myelomeningocele

These defects are due to ________ of

nonclosure

the neural tube.

53.

Complete the following about neural

G7 p.243:70mm

tube defects:

Name five postneurulation defects.

h________

hydranencephaly

ii.

l________

lissencephaly (most severe)

iii.

h________

holoprosencephaly

iv.

a________ of _________ ________

agenesis of corpus callosum

d________

diastematomyelia

Which is the most severe?

lissencephaly

54.

Complete the following regarding

G7 p.243:120mm

lissencephaly:

It is an example of an abnormality of

migration

neuronal ________.

It results in an abnormality of the

cortical

________ convolutions

called ________.

agyria

55.

Name the key features of

G7 p.243:155mm

schizencephaly.

________ which communicates with

cleft; ventricle

________

lined with ________ ________

gray matter

Two types are

o________ l________

open lipped

ii.

c________ l________

close lipped

56.

Complete the following about neural

G7 p.243:160mm

tube defects:

In schizencephaly, the cleft wall is lined

gray matter

with cortical ________ ________.

In porencephaly, a cystic lesion is lined

connective or glial

with ________ or ________ tissue.

57.

Hydranencephaly

G7 p.244:49mm

is a ________-neurolation defect.

post-

Cranium is filled with ________.

CSF

Is there a small or large head?

macrocrania

Most common etiology is ________

bilateral ICA infarcts

________ ________.

58.

Angiography

G7 p.244:137mm

of anterior circulation shows ________

no flow

________.

of posterior circulation shows ________.

normal

Neural Tube Defects

119

59.

Complete the following about neural

G7 p.244:150mm

tube defects:

What are the three types of

holoprosencephaly? Please list in order

of decreasing severity.

a________

alobar (single ventricle) most

severe

ii.

s________

semilobar

iii.

l________

lobar (least severe)

They occur because of

failure to ________

cleave

ii.

of the ________ ________.

telencephalic vesicle

60.

List the risk factors for neural tube

G7 p.245:120mm

defects.

B________ i________

B₁₂ insufficiency

c________

cocaine—maternal use

D________

Depakene—use during

pregnancy

f________ a________ i________

folic acid insufficiency

f________

fever in first trimester

h________ e________

heat exposure—maternal hot

tub, sauna

o________

obesity before and during

pregnancy

v________ a________

valproic acid use during

pregnancy

v________

vitamins—prenatal up folic

acid and B₁₂

61.

What are the tests for prenatal

G7 p.245:160mm

detection of neural tube defects?

serum ________ ________ (If high at 15

alfa fetoprotein (If high at 15

to 20 weeks be suspicious for neural

to 20 weeks be suspicious for

tube defects.)

neural tube defects.)

u________,

ultrasonography

ii.

which can detect what % of spina

90%

bifida cases?

a________

amniocentesis

62.

For prenatal detection of neural tube

G7 p.245:168mm

defects

test mother’s serum for ________

alpha fetoprotein

________.

Has a success rate for

spina bifida open ________% and

91%

ii.

anencephaly ________%.

100%

iii.

Closed spinal dysraphism ________

may be missed

________ ________.

An overestimate of gestational age will

normal

make us think that a high alpha

fetoprotein level is ________.

Real-time imaging is by ________.

ultrasonography

120

Developmental Anomalies

Identifies ________% of s ________

90% of spinal bifida

b________.

Obtaining fluid from the womb is called

amniocentesis

________.

It carries a risk of fetal loss of ________%.

63.

Characterize agenesis of the corpus

G7 p.246:70mm

callosum.

On computed tomographic scan the

typical appearance is as follows:

Third ventricle is ________.

expanded

ii.

Lateral ventricles are ________.

separated

iii.

Atria and occipital horns are

dilated

________.

Corpus callosum forms at age ________

2 weeks; rostral to caudal

________ after conception and forms

from ________ to ________.

64.

Complete the following concerning

G7 p.246:115mm

the bundles of Probst:

They are aborted beginnings of the

corpus callosum

________ ________

bulging into the ________ ________.

lateral ventricles

65.

Complete the following regarding

G7 p246 :155mm

agenesis of the corpus callosum:

Does it always have clinical significance?

no, it may be an incidental

finding

Underlying cause may be an abnormality

chromosome

of a ________.

66.

List the features of spina bifida

G7 p.247:145mm

occulta.

Hint: bifidaocculta

b________

bifida

i________

incidental

f________

foot deformity

i________

innocuous

d________

diastematomyelia

a________

atrophy of leg

o________

occurs in 20 to 30% of people

c________

cutaneous stigmata

c________

clinical importance often nil

u________

urinary incontinence

l________

lipoma, leg weakness

t________

tethered cord

a________

absent spinous process

67.

Complete the following regarding

G7 p.248:28mm

myelomeningocele:

The anterior neuropore closes at

gestational age day ________.

The posterior neuropore closes at

gestational age day ________.

Neural Tube Defects

121

68.

Complete the following concerning

G7 p.248:40mm

myelomeningocele (MM):

Incidence if no previous child has a MM

0.2%, 2

equals ________% or ________ per

1000.

One previous MM child equals

2%, 20

________% or ________ per 1000.

Two previous MM children equals

6%, 60

________% or________ per 1000.

Associated hydrocephalus equals

80%

incidence of ________%.

Associated Chiari II occurs in ________

most

children with MM.

69.

Answer the following about

G7 p.248:40mm

myelomeningocele:

What is the incidence of meningocele or

1 to 2/1000 live births (0.2%)

myelomeningocele?

Does the risk increase in families with

yes (The risk does increase to

one affected child?

2 to 3% in families with one

previous myelomeningocele

child.)

Does the risk increase in families with

yes (It further increases to

two affected children?

6 to 8% in families with two

previous affected children.)

70.

True or False. All children born with

false (Not all, but most, have

G7 p.248:72mm

myelomeningocele have an associated

Chiari II.)

Chiari II malformation.

71.

True or False. Closure of

true

G7 p.248:77mm

myelomeningocele may result in the

need for CSF shunting.

72.

Meningomyelocele patients develop

latex

G7 p.248:80mm

allergy to ________.

73.

True or False or Uncertain.

G7 p.248:120mm

Intrauterine closure of mm defect

reduces

Chiari II defect

true

hydrocephalus

uncertain

neurological dysfunction

false

74.

Complete the following concerning

G7 p.248:140mm

myelomeningocele:

If ruptured start ________ (n________

antibiotics (nafcillin and

and g________).

gentamicin)

Perform surgery within ________ to

24 to 36 hours

________ hours.

Better functional outcome occurs if

movement of lower

children have spontaneous ________ of

extremities

________ ________.

Do multiple anomalies occur in

yes (average 2 to

myelomeningocele?

2.5 additional anomalies in

myelomeningocele)

122

Developmental Anomalies

75.

Complete the following about

G7 p.248:140mm

myelomeningocele and early closure:

True or False. Results in improvement of

false (Early closure does not

neurological functions.

result in improvement of

neurological function.)

True or False. Results in lower infection

true (It does result in a lower

rate.

infection rate.)

Myelomeningocele should be closed

within 12, 24, or 36 hours?

76.

Considering late problems in

G7 p.250:145 mm

myelomeningocele repair, possible

late problems include

brain ________

hydrocephalus—

malfunctioning shunt

cervicomedullary junction ________

Chiari II compressing medulla

cord ________

syrinx

cauda ________

tethered cord

77.

Characterize myelomeningocele

G7 p.251:25mm

outcome without treatment and with

treatment.

survive infancy without treatment ____%

15 to 30%, 85%

with treatment ____%

normal IQ without treatment ____%

70%, 80%

with treatment ___%

ambulatory without treatment ____%

50%, 40 to 85%

with treatment ____%

continence without treatment ______

rare, 3 to 10%

with treatment ____%

78.

For each of the following what are the

G7 p.251:90mm

facts to know concerning

lipomeningocele?

age for surgery

2 months is appropriate for

surgery

band

thick fibrovascular band

constricts

conus

is split

dura

is dehiscent

epidural fat versus

lipoma is distinct from

epidural fat

placode

lipoma attached to neural

placode

neuro exam

is normal 50%

sensory loss

most common neurological

abnormality

stigmata

cutaneous

urologic exam

should be done preop

79.

True or False. Lipomyelomeningocele

true

G7 p.251:90mm

is associated with tethered cord.

Neural Tube Defects

123

80.

Study Chart.

lipomeningocele

G7 p.251:90mm

steps in surgical treatment:

Courtesy of

untether the cord

Dr. David Frim

Xomed

CUSA (Cavitron Ultrasonic

Surgical Aspirator)

recording from anal sphincter

free up sides from

attachment to dura

reduce bulk of fat using CUSA

in the midline

tie dura open to sides

place bovine pericardial graft

as dural substitute

81.

True or False. The most common

G7 p.252:130mm

location of a dermal sinus tract is the

occipital region

false

cervical region

false

thoracic region

false

lumbosacral region

true

82.

What is the most likely cause of

G7 p.252:115 mm

dermal sinus?

Failure of the ________ ectoderm

cutaneous

to ________

separate

from the ________-ectoderm

neuro

at the time of ________

closure

of the ________ ________.

neural groove

83.

Dermal sinus items to know include

G7 p.252:115mm

Location most common is the ________

lumbosacral

area

Results from ________ of ________ of

failure of separation of

________ ________

cutaneous ectoderm

from ________ ________

neural ectoderm

appears as a________

dimple:

hair?

with or without hairs

ii.

midline?

close to midline

iii.

skin stigmata?

yes

First manifestation is ________

bladder

dysfunction

Tract always courses ________ from

cephalad

lumbosacral area

84.

True or False. An epidermoid cyst

false (An epidermoid cyst

G7 p.252:145mm

contains hair follicles and sweat

contains stratified squamous

glands.

epithelium with keratin from

desquamated epithelium. A

dermoid cyst is lined with

dermis and contains sebum

and hair.)

124

Developmental Anomalies

85.

What is a major difference between

G7 p.251:145 mm

epidermoid cyst and dermoid cyst?

Epidermoid cyst is

lined with s________ s________

stratified squamous

e________

epithelium

ii.

and contains only ________.

keratin (from desquamated

epithelium)

Dermoid cyst is

lined with ________

dermis

ii.

and contains ________ ________

skin appendages

such as

iii.

hair follicles?

yes

iv.

sebaceous glands?

yes

86.

True or False. A dermal sinus tract is a

true

G7 p.251:155mm

potential pathway for intradural

infection such as meningitis or

abscess.

87.

Radiologic evaluation of dermal sinus

G7 p.253:48mm

If seen at births do ________

ultrasound

If first seen later do ________

MRI

88.

Given the above, indicate whether the

G7 p.253:80mm

dermal sinus tract should be excised at

the given locations.

lumbar

yes

sacral

yes, though controversial

coccygeal

89.

Complete the following concerning

G7 p.253:140mm

the cranial dermal sinus:

The track extends ________.

caudally

If the dermal sinus tract enters the skull

caudal

they do so ________ to the torcula.

 Klippel-Feil Syndrome

90. True or False. Klippel-Feil syndrome

G7 p.253:183mm

results from failure of

a. primary neurulation

false

b. secondary neurulation

false

c. dysjunction

false

d. segmentation

true (Klippel-Feil results from

abnormal segmentation of

the cervical somites between

3 and 8 weeks gestation.)

91. Klippel-Feil syndrome

G7 p.253:183mm

a. results from failure of ________ of

segmentation of cervical

________ ________ at gestational age of

somites; 3 to 8 weeks

________.

b. Clinical triad

Hairline is ________.

low

ii.

Neck is ________.

short

iii.

Motion is ________.

limited

Tethered Cord Syndrome

125

c. Limitation of range of motion of the neck

occurs only if more than ________

segments are fused.

d. True or False. Other congenital

true

abnormalities may also be present.

e. True or False. Klippel-Feil causes

false (No symptoms ever

symptoms related to fused vertebrae.

attributed to the fused

vertebrae.)

92. True or False. Anomalies seen in

G7 p.254:45mm

association with Klippel-Feil include

a. Sprengel deformity

true

b. webbing of the neck

true

c. basilar impression

true

d. unilateral absence of the kidney

true

93. Possible systemic congenital

G7 p.254:63mm

abnormalities include (be specific)

a. g ________

genitourinary—absence of

one kidney

b. c ________

cardiopulmonary

 Tethered Cord Syndrome

94. List six presenting signs and

G7 p.254:130mm

symptoms of tethered cord syndrome.

① cutaneous, 54%;

② scoliosis, 29%;

③ bladder, 40%;

④ sensations, 70%;

⑤ gait, 93%;

⑥ (+) pain, 37%

Fig. 8.2

Illustration by Tony Pazos

126

Developmental Anomalies

95.

True or False. In a patient with

false (In a myelomeningocele

G7 p.255:15mm

myelomeningocele with worsening

patient with worsening

scoliosis, spasticity, worsening gait, or

clinical symptoms, shunt

deteriorating urodynamics, shunt

evaluation and confirmation

evaluation is not part of the primary

of normal intracranial

workup.

pressure should be one of the

first modalities of

intervention.)

96.

True or False.

G7 p.255:33mm

Progressive scoliosis is not seen in

false (Progressive scoliosis

conjunction with tethered cord

may be seen in up to 29% of

syndrome.

patients with tethered cord

syndrome.)

Early untethering may result in

true

improvement in scoliosis

97.

True or False. The following is

G7 p.255:78mm

associated with adult tethered cord

syndrome:

foot deformities

false (Foot deformities are

associated with childhood

tethered cord syndrome.)

pain

true

leg weakness

true

urological symptoms

true

98.

True or False. Urological symptoms

false (Urological symptoms

G7 p.255:95mm

are not common in the adult tethered

are common in both pediatric

cord syndrome.

and adult tethered cord

syndrome.)

99.

True or False. A tethered conus lies

true

G7 p.255:130 mm

distal to L2 on radiographic

evaluation.

100.

Complete the following concerning

G7 p.255:132mm

tethered cord syndrome:

Name two criteria.

conus below level ________

ii.

thick filum greater than ________

2 mm diameter

A preop test that is strongly

cystometrogram

recommended is a________.

101.

Indicate the characteristics used to

G7 p.255:180mm

identify the filum.

The vessel on the surface is ________.

squiggly

The color of the filum is ________

more white

________ than nerve roots.

102.

Complete the following outcome from

G7 p.256:30mm

tethered cord:

In meningomyelocele it is usually

impossible

________ to permanently untether.

Repeated untethering is advised till

growing

patient stops ________.

Miscellaneous Developmental Anomalies

127

c. Symptoms of retethering are especially

adolescent growth spurt

likely during the a________ g________

s________.

d. Surgical release in an adult is

good for ________ and

pain

ii.

poor for ________ ________.

bladder function

 Split Cord Malformation

103. True or False. Diastematomyelia is

false (Diastematomyelia is

G7 p.256:84mm

associated with a nonrigid bony

associated with a rigid bony

septum that separates two durally

septum that separates two

ensheathed hemicords.

durally ensheathed

hemicords.)

104. Complete the following concerning

G7 p.247:95mm

diastematomyelia:

a. cutaneous stigmata h_______

tuft of hair hypertrichosis

b. True or false. There are foot

true

abnormalities

c. specifically n________ h________-

neurogenic high-arched foot

a________ f________.

 Miscellaneous Developmental Anomalies

105.

True or False. In holoprosencephaly,

true

G7 p.247:33mm

there is absence of the septum

pellucidum.

106.

Characteristic features of septo-optic

G7 p.247:55mm

dysplasia include

Hint: h³pvoplas³i²a

h________

hypopituitarism

h________

hydrocephalus

h________

hypersecretion of hormones

p________

pituitary infundibulum absent

v________

ventricles enlarged

o________

optic nerves absent (blind)

p________

panhypopituitarism

l________

little-dwarfism-Tiny Tim

a________

anterior midline structures

fail

s________

septum pellucidum absent

s________

schizencephaly

s________

sexual precocity

i________

isolated growth hormone

deficiency

i________

intelligence normal

a________

absence of midline

morphogenesis

Neuroendovascular Intervention



Neuroendovascular Intervention

1. True or False. The following conditions

G7 p.262:50mm

may be amenable to treatment by

endovascular techniques:

a. aneurysms

true

b. AVMs

true

c. carotid cavernous fistulas

true

d. carotid stenosis

true

e. tumor embolization

true

2. The sheath may be removed when

G7 p.263:55mm

a. the aPTT is ________.

normal

b. Normal aPTT is less than ________

seconds.

3. True or False. Stenting is useful for

G7 p.263:145mm

a. coiling of

narrow-necked aneurysms

false

ii.

wide-necked aneurysms

true

iii.

ruptured aneurysms

false

b. cerebroarterial dissections

true

4. Complete the following regarding

G7 p.263:145mm

stenting:

a. After stenting, __________ is prescribed ASA

b. for an ___________ period of time.

indefinite

__________ is prescribed for 6 weeks.

Plavix

Electrodiagnostics



Electroencephalogram (EEG)

What is the frequency of the following

G7 p.266:50mm

EEG rhythms?

Hint: dtab

delta

0 to 3 Hz

theta

4 to 7 Hz

alpha

8 to 13 Hz

beta

>13 Hz

Matching. Match the following EEG

G7 p.266:80mm

patterns and their probable diagnostic

pathology:

Pathology:

① Creutzfeldt-Jakob disease; ② Hepatic

encephalopathy-anoxia -hyponatremia;

③ SSPE—subacute sclerosing pan—

encephalitis

EEG pattern:

triphasic waves

②

body jerks plus high-voltage periodicity

③

with 4 to 15 seconds separation; no

change with pain

myoclonic jerks, bilateral sharp waves

①

react to painful stimulation

True or False. Periodic lateralizing

G7 p.266:85mm

epileptiform discharges (PLEDs) may

be produced by

herpes simplex encephalitis

true

brain abscess

true

embolic infarct

true

brain tumor

true

any acute focal cerebral insult

true

Evoked Potentials

131



Evoked Potentials

Complete the following statements

G7 p.267:72mm

about evoked potentials:

Evoked potentials offer limited

delayed (and therefore less

usefulness because they are ________.

valuable in alerting surgeon

to intraoperative injury)

Criteria for significance

increased latency of ________%

10%

ii.

decreased amplitude of ________%

50%

Intraoperative SSEP may localize the

phase reversal

G7 p.267:82mm

primary sensory cortex by ________

________ potential across the central

sulcus.

Evoked potentials during spine

G7 p.267:82mm

surgery

may remain unchanged by injury to the

________ cord

but are sensitive to injury to the

posterior, dorsal

________ columns of the ________ cord

True or False. Regarding transcranial

G7 p.267:140mm

(i.e., motor evoked) potentials:

Too painful to do on the awake patient

true

Feedback is prompt, almost immediate

true

Can’t record continuously because of

true

muscle contractions

Useful for cervical spine surgery

true

Useful for thoracic spine surgery

true

Useful for lumbar spine surgery

false

Have more special anesthetic

true

requirements

Provide the SSEP deterioration plan.

G7 p.268:28mm

Hint: r³s³tahe

r________

remove hardware

r________

reposition patient

r________

release traction

s________

sixty Hz

s________

steroids

s________

stop surgery

t________

temperature

a________

anemia

h________

hypotension

e________

electrode contact

132 Electrodiagnostics

9. Name the location of the generators

G7 p.268:95mm

for the brain stem auditory evoked

potentials (BSAER) test.

Hint: diplomu (Fig. 10.1)

Fig. 10.1 (Reprinted with permission from

Greenberg MS. Handbook of Neurosurgery, 6th

P¹ d________ e________ n________

distal eighth nerve

P² p________ e________ or c________

proximal eighth or cochlear

n________

nucleus

P³ l________ p________ /s________

lower pons/superior olivary

o________ c________

complex

P⁴ m________-u________ p________

mid-upper pons

P⁵ u________ p________ or i________

upper pons or inferior

c________

colliculus

d¹ ________ e________ n________

distal eighth nerve

p________ e________ n________

proximal eighth nerve

lo________

lower

m________

middle

u________ p________

upper pons

10.

Name the parts of the EMG

G7 p.269:176mm

examination.

i________ a________

insertional activity

s________ a________

spontaneous activity

v________ a________

volitional activity

11.

How long following denervation of

G7 p.270:35mm

muscle after nerve injury do you start

to see fibrillation potentials on

electromyography (EMG)?

The earliest is ________, but

10 days

reliably not until ________.

3 to 4 weeks

Therefore don’t order EMG until at least

________ weeks after injury.

12.

SNAP

G7 p.270:99mm

aka ________ ________ action potential

sensory nerve

ganglion

lies within the ________ ________.

neural foramen

Herniated disc is preganglion; therefore,

not affected

SNAP is ________ ________.

Evoked Potentials

133

13.

H reflex

G7 p.270:127mm

is practical only regarding the ________

root.

has similar information to the ________

ankle jerk

________.

14.

True or False. Regarding EMG:

G7 p.270:160mm

Is low yield for radiculopathy

true

Best reserved for patients with weakness

true

Pain without weakness, EMG has low

true

yield

15.

True or False. Radiculopathy EMG is

G7 p.270:170mm

Reliable if negative

false—EMG is not sensitive for

radiculopathy

Reliable if positive

true—When positive it is very

specific

16.

True or False. Paraspinal mm testing is

G7 p.271:70mm

useful for lumbar disc disease.

Preop

true

Postop

false—muscles cut during

surgery

Neurotoxicology



Ethanol

True or False. Primary effect of ethanol

G7 p.273:120mm

(ETOH) on the central nervous system

(CNS) is

depression in neuronal excitability

true

depression in impulse conduction

true

depression in neurotransmitter release

true

Complete the following concerning

G7 p.273:140mm

neurotoxicology:

Describe the Mellanby effect with

rising

respect to ETOH. The severity of

intoxication is greater when blood

alcohol level is ________.

What is the effect of a blood alcohol level

25 mg/dL?

mild intoxication, impaired

cognition

ii.

100 mg/dL?

vestibular/cerebellar

dysfunction

iii.

500 mg/dL?

usually fatal—respiratory

depression

Legal intoxication is a blood alcohol

100 (80)

G7 p.273:155mm

level of ________ mg/dL.

As ETOH levels fall, hyperactivity may

CNS depressant

G7 p.273:177mm

occur as compensation for the

________ effects of ETOH.

True or False. Regarding delirium

G7 p.274:18mm

tremens:

occurs within 4 days of ETOH withdrawal

true

agitation, confusion, autonomic

true

instability

mortality 5 to 10% if untreated

true

benzodiazepine as first-line drug

true

Ethanol

135

True or False. Delirium tremens can be

G7 p.274:30mm

suppressed by

benzodiazepines

true

resumption of drinking

true

beta-adrenergic antagonists

true

A2 agonists

true

What is the treatment for alcohol

G7 p.274:55mm

withdrawal syndrome?

Mainstay of treatment are the ________.

benzodiazepines

They reduce a ________ h________

autonomic hyperactivity

and may prevent s________

seizures

and/or ________ ________.

delirium tremens

G7 p.274:55mm

Also use ________

100mg/day

ii.

for ________ days

3 to 5

and ________ for seizures.

Dilantin

G7 p.274:172mm

ii.

Load with ________ mg/kg.

True or False. Delirium tremens

G7 p.275:20mm

usually begins within ________ days of

the onset of ETOH withdrawal.

true

false

Complete the following about ethanol:

G7 p.275:50mm

True or False. The classic triad of

Wernicke encephalopathy is

encephalopathy, ophthalmoplegia,

true

and ataxia

ii.

apraxia, ophthalmoplegia, and

false

encephalopathy

iii.

ophthalmoplegia, ataxia, and

false

myelopathy

Eye signs occur in ________%.

96%

Gait disturbance occurs in ________%.

87%

Memory disturbance is called ________

Korsakoff syndrome; 80%

________ and occurs in ________%.

10.

True or False. Wernicke

G7 p.275:62mm

encephalopathy is associated with

thiamine deficiency

true

vitamin B₁₂ deficiency

false

folic acid deficiency

false

vitamin C deficiency

false

136

Neurotoxicology

11.

Complete the following about

G7 p.275:108mm

Wernicke encephalopathy (WE):

Is there a unique MRI picture in WE?

yes

There is a ________ signal

high

ii.

on ________ WI

iii.

in the ________ thalamus

medial

iv.

the ________ of the fourth ventricle

floor

and

v. the p________ gray

periaqueductal

vi. of the ________.

midbrain

What changes occur in the mammillary

atrophy

bodies?

12.

Complete the following about

G7 p.275:127mm

Wernicke encephalopathy (WE):

What common treatment can

IV glucose

precipitate acute WE?

What should be given first: IV glucose or

thiamine

thiamine?

WE eye signs improve within ________.

days

However residue of

K________ s________

Korsakoff syndrome

ii.

occurs in ________% in the form of

80%

iii.

h________ n________

horizontal nystagmus

iv.

and a ________.

amnesia

 Opioids

13. True or False. Reversal of opioid

G7 p.276:20mm

toxicity is achieved with

a. naloxone

true

b. methadone

false

c. Catapres

false

d. Romazicon

false

14. Heroin, an opioid, causes small pupils miosis

G7 p.276:120mm

called ________.

15. Complete the following about

G7 p.277:36mm

amphetamines:

a. Toxicity is similar to ________.

cocaine

b. Their use can result in CVA due to

vasculitis

________.

Opioids

137

16.

What are the features of carbon

G7 p.277:65mm

monoxide?

The largest source of poisoning in the

United States is from ________.

It harms by binding to ________.

It has an affinity for it ________ times

250

that of O_2.

Cells need _______ mL O₂/100mL blood.

Blood normally contains ________ mL

O₂/100mL.

The “cherry red” color of blood occurs in

only ________%.

17.

In severe CO intoxication, CT scan may

G7 p.277:100mm

show

l________ a________ in the

low attenuation

g________ p________.

globus pallidus

18.

True or False. Outcome

G7 p.277:115mm

is more closely correlated with CO Hb

false

levels

is more closely correlated with

true

hypotension

________% die

40%

ii.

________% have persistent sequelae

30 to 40%

iii.

________% make a full recovery

30 to 40%

Coma



General

Write out the Glasgow Coma Scale

G7 p.279:50mm

(GCS) and indicate the score assigned

to each point on the scale.

eyes

e________

4 spontaneous

ii.

y________

3 to speech

iii.

e________

2 to pain

iv.

s________

1 nil

verbal

v________

5 oriented

ii.

o________

4 confused

iii.

i________

3 inappropriate

iv.

c________

2 incoherent

e________

1 nil

motor

m________

6 obeys

ii.

o________

5 localized

iii.

v________

4 withdrawal

iv.

i________

3 decorticate

n________

2 decerebrate

vi.

g________

1 nil

True or False. A patient with a GCS

false (Whereas 90% of

G7 p.279:70mm

score E2 V1 M2 (GCS 5) is in a coma.

patients with GCS ≤ 8 are in a

coma, coma is defined as

inability to obey commands,

speak, or open the eyes even

to pain.)

Define coma.

A GCS less than 8 is a

G7 p.279:105mm

generally accepted

operational definition of

coma.

List the three locations of brain lesions

G7 p.279:155mm

that produce coma.

u________ p________ and m________

upper pons and midbrain

d________

diencephalic

b________ c________ h________

bilateral cerebral hemisphere

General

139

Disinhibition by removal of the

decorticate

G7 p.279:180mm

corticospinal pathways above the

midbrain typically results in ________

posturing.

Complete the following about coma in

G7 p.279:182mm

general:

Decorticate lesion is at ________.

midbrain

Decerebrate lesion is at ________.

intercollicular level between

vestibular nuclei and red

nucleus

Locked-in syndrome lesion is at

ventral pons

________.

Complete the following about coma in

G7 p.280:15 mm

general:

In decorticate posturing

The upper extremities are in

flexion

________.

ii.

The lower extremities are in

extension

________.

In decerebrate posturing

The upper extremities are in

extension

________.

ii.

The lower extremities are in

extension

________.

Decorticate and decerebrate posturing

G7 p.280:20 mm

have what lower extremity

movements in common?

e________

extension

i________ ________

internal rotation

p________ ________

plantar flexion

A patient is brought to the emergency

diabetic ketoacidosis

G7 p.280:62mm

room in a coma after being found

down. Pupils are equal and reactive.

Painful stimulus elicits no movement.

No signs of trauma are evident.

Studies show Na⁺ 130, K⁺ 4.9,

C 1—100, HCO₃ 2—15, BUN 30, Cr 1.2,

Glu 440. The likely cause of coma is

________ ________.

10.

What stroke syndromes can lead to

G7 p.280:110 mm

coma?

b________ c________ i________

bilateral cortical infarcts

b________ d________ i________

bilateral diencephalic infarcts

(i.e., top of basilar)

b________ s________

brain stem

11.

A patient in coma eventually arouses

bilateral diencephalic infarcts

G7 p.280:128mm

with apathy, memory loss, and

vertical gaze paresis. The most likely

etiology for the coma was ________

________ ________.

140 Coma

12. Indicate the effect of midline shift on

G7 p.281:155mm

level of consciousness.

0 to 3 mm ________

alert

3 to 4 mm ________

drowsy

6 to 8.5 mm ________

stuporous

8 to 13 mm ________

comatose

13. The three categories of disorders in

G7 p.281:20 mm

the differential diagnosis of

pseudocoma are

a. l________-i________ s________ and

locked-in syndrome and

v________ p________ i________

ventral pontine infarction

(EEG normal)

b. p________ d________, c________, and psychiatric disorders,

c________ r________

catatonia, and conversion

reaction

c. n________ w________ and m________

neuromuscular weakness and

g________, G________-B________

myasthenia gravis, Guillain-

s________

Barré syndrome

 Approach to the Comatose Patient

14.

A patient presents with coma. Your

airway

G7 p.281:60mm

first move is to assess and secure the

________.

15.

Complete the following about

G7 p.281:103mm

approach to the comatose patient:

What percent of patients with Wernicke

encephalopathy present with coma?

You would initially treat those patients

thiamine

with ________.

16.

True or False. The following breathing

G7 p.282:65mm

pattern is most likely to be observed

in a comatose child with fulminant

hepatic failure after acetylsalicylic acid

(ASA) use during a viral infection:

Cheyne-Stokes

true (Seen with diencephalic

lesions or, as in this case,

bihemispheric dysfunction.

The child has a

toxic/metabolic

encephalopathy as a result of

hepatic failure due to Reyes

syndrome.)

hyperventilation

false

cluster

false

apneustic

false

atoxic

false

17.

What is the significance of equal,

indicates toxic metabolic

G7 p.282:133mm

reactive pupils in a comatose patient?

cause

Approach to the Comatose Patient

141

18.

What is the most useful single sign in

the light reflex (Equal and

G7 p.282:138mm

distinguishing metabolic from

reactive pupils indicate

structural coma?

toxic/metabolic cause with

few exceptions.)

19.

The only metabolic causes of

G7 p.282:141mm

fixed/dilated pupils are

a________ e________

anoxic encephalopathy

g________ t________

glutethimide toxicity

a________ u________

anticholinergic use (i.e.,

atropine)

b________ t________ p________

botulinum toxin poisoning

20.

True or False. The following is a

G7 p.282:141mm

metabolic cause of fixed, dilated

pupils:

atropine

true

glutethimide toxicity

true

hyperammonemia

false

anoxic encephalopathy

true

botulinum toxin poisoning

true

21.

In a third nerve palsy

G7 p.282:165mm

the pupil is ________

dilated

and the eye looks ________ and

down and out

________.

22.

True or False. The following ocular

G7 p.282:176mm

findings can be seen in comatose

patients with pontine lesions:

pinpoint pupils

true

periodic alternating gaze

false (Periodic alternating

gaze usually indicates

bilateral cerebral

dysfunction.)

ocular bobbing

true

bilateral conjugate deviation to cold

false

calorics

23.

In frontal lobe lesions patient looks

G7 p.283:30mm

toward

the ________ side

moving

in destructive lesions that is

away from hemiparesis,

________

toward the moving

extremities

ii.

in irritative lesions (seizures) that is

away from seizure focus,

________

toward the jerking

extremities

lesion is in the f________ c________ for

frontal center for

c________ g________

contralateral gaze

24.

In a pontine lesion the eyes deviate

nonmoving

G7 p.283:30mm

toward the ________ side.

142

Coma

25.

True or False. The eyes “look toward

false (Whereas the above is

G7 p.283:45mm

the side of the destructive lesion” in

true for lesions affecting the

all destructive supratentorial lesions

frontal gaze center, medial

causing bilateral conjugate gaze

thalamic hemorrhage can

deviation.

result in gaze deviation away

from the lesion, “wrong way

gaze,” i.e., toward the

nonmoving side.)

26.

Name three causes of bilateral

G7 p.283:55mm

downward gaze deviation in a

comatose patient.

t________ l________

thalamic lesion

m________ p________ l________

midbrain pretectal lesion

b________

barbiturates

27.

Complete the following concerning

G7 p.283:105mm

internuclear ophthalmoplegia:

Lesion is in the ________ ________

medial longitudinal fasciculus

________.

Fibers are interrupted that go to the

contralateral third nerve

________ ________ ________

nucleus

________.

Results in

loss of ________

adduction

ii.

of the ________ eye

ipsilateral

iii.

on ________ ________ ________

spontaneous eye movement

iv.

or in response to ________

reflex movement (doll’s,

________

calorics)

v. and convergence ________

is not impaired

28.

True or False. The ciliospinal reflex is

G7 p.284:80mm

indicative of

parasympathetic pathways

false

spinothalamic pathways

false

integrity of the periaqueductal gray

false

sympathetic pathways

true

 Herniation Syndromes

29. True or False. Subfalcine herniation is

G7 p.284:137mm

of concern because:

a. Anterior cerebral artery territory infarcts true

may occur.

b. Transtentorial herniation may occur.

true

c. There is no obvious concern.

false

30. True or False. Decreased

false (It occurs late in uncal

G7 p.285:15mm

consciousness occurs early in uncal

herniation, early in central

herniation.

herniation.)

31. True or False. Uncal herniation

true

G7 p.285:20mm

syndrome rarely gives rise to

decorticate posturing.

Herniation Syndromes

143

32.

Upward cerebellar herniation

G7 p.285:95mm

can occlude the ________,

SCAs

resulting in ________ infarction.

cerebellar

33.

Central herniation

G7 p.285:142mm

can occlude the ________,

PCA

resulting in ________ ________.

cortical blindness

It can shear basilar artery ________ and

perforators, Duret

G7 p.285:150mm

cause D________ hemorrhages.

34.

True or False. This stage of central

G7 p.285:170mm

herniation is reversible.

medullary stage

false

diencephalic stage

true

lower pons

false

upper pons

false

35.

List the distinguishing features of the

G7 p.286:15mm

pupils and respiratory pattern for the

following injuries:

injury at the diencephalon

pupils ________

react to light

ii.

respiratory pattern is ________

Cheyne-Stokes

injury at the midbrain

pupils ________

midposition

ii.

respiratory pattern is ________

hyperventilation

injury at the pons

pupils ________-________

pin-point

ii.

respiratory pattern is ________

apneustic

injury at the medulla oblongata

pupils are ________

dilated, fixed (markedly open)

ii.

respiratory pattern is ________

ataxic

36.

True or False. Internuclear

false (at the upper pons

G7 p.286:65mm

ophthalmoplegia is prominent at the

stage)

“lower pons” stage of central

herniation.

37.

Matching. Use the numbered options

G7 p.286:75mm

to complete the following statements:

① Parasympathetics are lost;

② Sympathetics are lost; ③ Both are

lost.

Why does injury to the pons result in pin-

②

point pupils?

Why does injury of herniation result in

③ (i.e., bilateral third nerve

dilated fixed pupils?

palsy)

38.

Matching. Use the numbered options

G7 p.286:128mm

to complete the following questions:

① 3%; ② 9%; ③ 15%; ④ 18%

What percentage of patients who had

symptoms of central herniation had:

good outcome?

②

functional outcome?

④

144 Coma

39. True or False. Regarding uncal

G7 p.286:168mm

herniation:

a. The earliest consistent sign is

impaired consciousness

false

ii.

unilateral dilated pupil

true

40. What shape is the suprasellar cistern? pentagonal

G7 p.287:20 mm

41. True or False. Unilateral dilated pupil

G7 p.287:52mm

in early third nerve stage of uncal

herniation is seen in the following

percentage of patients ipsilateral to

the lesion:

65%

false

75%

false

85%

true

95%

false

 Hypoxic Coma

42. Complete the following statements

G7 p.287:140mm

concerning anoxia. Pathological

lesions seen in

a. cortex

________ cortical layer

third

ii.

________ horn

Ammon

b. basal ganglia

g________ p________

globus pallidus

ii.

c________

caudate

iii.

p________

putamen

c. cerebellum

P________ cells

Purkinje

ii.

d________ nucleus

dentate

iii.

i________ o________

inferior olive

d. What tissue is more sensitive to anoxia— gray (It has a greater

gray or white matter?

requirement of O_2.)

e. Are steroids useful after cardiac arrest?

G7 p.288:170mm

Brain Death



Brain Death in Adults

1. The apnea test

G7 p.289:158mm

a. assesses f________ of m ________.

function of medulla

b. To be a valid test of brain death, PaCO₂

60 mm Hg

must reach ________ mm Hg without

respirations.

c. This usually takes ________ minutes.

2. Name five complicating conditions

G7 p.290:134mm

that must not be present to declare an

adult brain dead.

Hint: hipps

a. h________

hypothermia: core

temperature less than

32.2°C (90°F)

b. i________

intoxication (i.e., paralytics,

barbiturates,

benzodiazepines)

c. p________

postresuscitation (i.e., could

be in shock, or atropine may

have been used in

resuscitating, causing fixed,

dilated pupils)

d. p________

pentobarbital level

> 10 μg/mL

e. s________

shock (SBP less than 90)



Brain Death in Children

3. Are there different age-dependent

yes

G7 p.293:35mm

observation periods to declare brain

death? If so, what are they?

a. newborn to 7 days

observe for 7 days

b. age 7 days to 2 months

observe for 2 days; 2 exams,

2 electroencephalographs

48 hours apart

c. age 2 months to 12 months

observe for a day; 2 exams,

2 electroencephalographs

24 hours apart

d. older than 12 months

12 hours observation

Cerebrospinal Fluid



General Information

The volume (mL) of cerebrospinal fluid

G7 p.297:80 mm

(CSF) in

a newborn is ________

an adult is ________

150

What is the intracranial:spinal ratio of

50:50

G7 p.297:80mm

distribution of CSF in adults?

What percentage of CSF is produced in

80%

G7 p.297:80mm

the lateral ventricles?

The amount of CSF volume produced

G7 p.297:84mm

per day for

adults is ________

450 to 750 mL/d

newborns is ________

25 mL/d

What is the rate of CSF formation

0.3 to 0.5

G7 p.297:84mm

mL/min in adults?

What is the CSF pressure in a patient

G7 p.297:87mm

in lateral decubitus position in the

following age groups?

newborn

9 to 12 cm H₂O

1 to 10 years old

< 15

young adult

< 18 to 20

adult

< 18 (7 to 15)

Where is CSF produced other than in

G7 p.297:95mm

the choroid plexus?

i________ s________

interstitial space

e________ l________ of the v________

ependymal lining of the

ventricles

d________ of n________ r________

dura of nerve root sleeves in

s________ in s________

spine

CSF Constituents

147

Complete the following concerning

G7 p.297:115 mm

CSF general information:

What is the rate of CSF production?

0.3 to 0.5 mL/min

That equals how many mL per day?

450 to 750

Normal CSF has

________ lymphocytes

0 to 5

ii.

________ polymorphonuclear

leucocytes (PMN)

iii.

________ red blood cells (RBCs)

White blood cells (WBCs) above

5 to 10

________ is suspicious.

WBCs above ________ is definitely

10 WBCs per cubic mm

abnormal.

Subtract ________ WBC for every

1; 700

________ RBCs.

Subtract ________ mg protein for every

1; 1000

G7 p.298:65mm

________ RBCs.

Does intracranial pressure (ICP) have

no (The rate of formation is

G7 p.297:120mm

any effect on CSF formation?

independent of CSF pressure

except if the ICP is so high

that it causes reduction in

cerebral blood flow [CBF].)

10.

Complete the following concerning

G7 p.297:130mm

CSF general information:

True or False. CSF absorption is a

true

pressure-dependent phenomenon.

Where does it take place?

a________ v________

arachnoid villi → dural venous

sinuses

ii.

c________ p________

choroid plexus

iii.

l________

lymphatics

 CSF Constituents

11. True or False. The composition of CSF

false (It differs slightly.)

G7 p.297:153mm

is exactly the same in the ventricles as

in the lumbar subarachnoid space.

12. True or False. The following are

G7 p.297:170mm

normally found in CSF:

a. lymphocytes

true

b. mononuclear cells

true

c. polymorphonuclear leucocytes

false

d. RBCs

false

148

Cerebrospinal Fluid

13.

True or False. CSF osmolarity and

G7 p.298:160mm

plasma osmolarity are equal, with a

ratio 1:1. What is the other

constituent that is also equal among

the following?

true

K+

false

Cl⁻

false

IgG

false

14.

True or False. CSF proteins

G7 p.299:110mm

are equal in adults and children

false (30 in adults and 20 in

children)

in prematures are ~60 mg/dL

false (in prematures

150 mg/dL)

in newborn are ~40 mg/dL

false (about 80 in newborn)

normally rise ~1 mg/dL/yr of age in

true

adults

15.

How do you differentiate true

G7 p.298:30mm

leukocytosis from normal white blood

cell count included in the traumatic

tap?

ratio of ________ to ________

RBC to WBC

normal is ________

700:1

or subtract 1 WBC for every ________

700 RBCs

________

16.

What conditions would affect the

G7 p.298:30mm

WBC:RBC ratio of 1:700?

a________

anemia

p________ l________

peripheral leukocytosis

17.

In case of a traumatic tap, how could

use Fishman’s formula WBC

G7 p.298:30mm

you estimate the original count in that

original CSF = WBC CSF -

CSF in a patient who has anemia or

(WBCbld × RBCCSF) RBCbld.

peripheral leukocytosis?

Note: WBC and RBC per mm³

in peripheral blood

18.

How would you estimate the correct

G7 p.298:65mm

protein in the CSF of a traumatic tap?

Subtract ________ mg of protein

for every ________ RBCs/mm³.

1000

19.

Answer the following about

G7 p.300:35mm

subarachnoid hemorrhage:

How long does it take for RBC to

2 weeks

disappear?

How long does it take for xanthochromia

many weeks

to disappear?

CSF Fistula

149

 Artificial CSF

20. True or False. In the use of

G7 p.300:84mm

neuroendoscopy, endogenous CSF and

“artificial CSF” should have which of

the following characteristics in

common?

a. physiological temperature

true

b. membrane active ion concentrations

true

c. osmolarity

true

d. pH

true

 CSF Fistula

21.

The Rosenmüller fossa is located just

inferior to the cavernous

G7 p.301:50mm

________.

sinus (Rosenmüller fossa is

located just inferior to the

cavernous sinus exposed by

drilling the anterior clinoid in

a paraclinoid aneurysm.

Upper lateral pharyngeal

recess. Limited above by the

sphenoid and occipital bone.

Communicates with the nasal

cavities.)

22.

True or False. The following are

G7 p.301:77mm

characteristics of traumatic CSF fistula:

They occur in 2 to 3% of all patients with

true

head injury.

60% are noted within days of trauma.

true

95% occur within 3 months of trauma.

true

< 5% of cases of CSF rhinorrhea stop

false (70% of cases stop

within 1 week.

within 1 week.)

Adult:child ratio is 1:10.

false (adult:child ratio is 10:1)

Occurrence is common before age

false (occurrence uncommon

2 years.

prior to 2 years of age)

Anosmia is common.

true (78% have anosmia.)

Most CSF otorrhea ceases in 5 to 10

true

days.

23.

Complete the following concerning

G7 p.301:78mm

posttraumatic CSF fistula:

Rhinorrhea stops within ________ week

1; 70%

in ________%.

Otorrhea stops within ________ days in

5 to10; 80 to 85%

G7 p.301:93mm

________%.

24.

True or False. Regarding CSF fistulas:

G7 p.301:117mm

Anosmia is common in traumatic leaks.

true (78% in traumatic leaks)

Anosmia is common in spontaneous

false (rare in spontaneous

leaks.

leaks; approximately 5%)

150

Cerebrospinal Fluid

25.

The infection rate for

G7 p.301:96mm

penetrating injuries and CSF fistulas is

50%

________%.

penetrating injuries without fistula is

4.6%

________%.

26.

Study Chart.

G7 p.301:110mm

Regarding spontaneous CSF fistula:

sense of smell preserved

Hint: spontaneous fistula h

pneumocephalus is not

common

otitis media

neck stiffness

tumor-pituitary-meningioma

allergic rhinitis

meningitis

empty sella syndrome

otitis media may result in CSF

leak

undeveloped floor of anterior

fossa

sense of smell preserved

cribriform plate agenesis

sinusitis (paranasal sinusitis)

foot plate of stapes is

dehiscent—CSF into

eustachian tube

facial canal fistula into middle

ear

insidious, ICP is high,

intermittent

serous effusion

transsphenoidal surgery

consequence

unable to hear due to

Mundini dysplasia

labyrinthine anomalies

adenoma of pituitary

hydrocephalus

27.

Complete the following concerning

G7 p.302:45mm

meningitis in CSF fistula:

Posttraumatic CSF leak has an incidence

5 to 10%

of meningitis of ________%.

Does CSF leakage after surgery have a

higher

higher or lower incidence of meningitis?

If the leakage site is not identified before

30% (recurrent leak postop)

surgery failure to close CSF leaks is

________%.

The most common pathogen is

pneumococcus; 83%

________ and its percentage is

________%.

CSF Fistula

151

28.

What are the characteristics of the

G7 p.302:92mm

fluid suggesting the presence of

rhinorrhea or otorrhea resulting from

a CSF fistula?

CSF fluid is ________.

as clear as water (unless

infected or blood present).

True or False. Fluid causes excoriation.

false (Fluid doesn’t cause

excoriation of the nose.)

Fluid tastes ________.

salty (in rhinorrhea).

Glucose is greater than ________ mg %.

normal CSF glucose > 30 mg%

It contains a special chemical called

B2-transferrin (present in CSF)

________.

The special sign when it drops on a sheet

ring sign (An old but

is called a ________.

unreliable sign. Described as

a ring of blood surrounded by

a larger concentric ring of

clear fluid [suggests the

presence of CSF] seen when

blood-tinged fluid allowed to

drip onto linen [sheet or

pillowcase].)

29.

Name five characteristics of fluid that

G7 p.302:100mm

suggest the presence of CSF fistula.

Hint: bcsfg

B2 transferrin

clear

salty taste

fluid does not excoriate

glucose—high > 30 mg % vs.

5 mg % in tears and mucous

30.

True or False. The procedure of choice

G7 p.303:34mm

to localize the site of CSF fistula is

magnetic resonance imaging

false

iohexol cisternography

true

computed tomography with intravenous

false

contrast

plain x-ray

false

Hydrocephalus



Hydrocephalus

Complete the following statements

G7 p.307:42mm

about hydrocephalus:

Incidence of congenital hydrocephalus is

0.2%

________%.

Size of normal temporal horns should be

2 mm

no wider than ________ mm.

Width of brain (internal diameter)

2 times or more

compared with largest width of frontal

horns should normally be ________.

Therefore, a ratio of frontal horns to

> 50%

internal diameter of ________% suggests

hydrocephalus.

True or False. Indicate if the following

G7 p.307:82mm

are considered “true” hydrocephalus:

hydrocephalus ex vacuo

false

obstructive hydrocephalus

true

communicating hydrocephalus

true

True or False. The following are

G7 p.307:115mm

characteristics of hydranencephaly:

preneurulation defect

false

cause may be from infection

true

cause may be from bilateral internal

true

carotid artery (ICA) infarcts

electroencephalography (EEG) shows no

true

cortical activity

transillumination specific and very

false

helpful

Complete the following regarding

G7 p.307:115mm

hydranencephaly:

Hydranencephaly is defined as total or

cerebrum

near total absence of the ________.

It occurs before or after neurulation?

postneurulation

The most common cause is ________

bilateral ICA infarcts

________ ________.

Hydrocephalus

153

Other causes are

n________ h________

neonatal herpes

ii.

i________

infection

iii.

t________

toxoplasmosis

The best way to differentiate

EEG

G7 p.244:98mm

hydranencephaly from maximal

hydrocephalus is to perform an

________.

Other tests include

c________ t________

computed tomography (CT)

ii.

m________ r________ i________

magnetic resonance imaging

(MRI)

iii.

a________

angiography

What are key features regarding

G7 p.307:140mm

benign external hydrocephalus (also

known as external hydrocephalus)?

Subarachnoid spaces are ________.

enlarged over frontal poles in

first year of life

Ventricles are ________.

normal or minimally enlarged

They are distinguished from subdural

cortical vein sign

hematoma by the ________ ________

________.

It usually spontaneously ________ by

resolves; 2 years of age

________.

Complete the following concerning

G7 p.307:160mm

external hydrocephalus:

It occurs in what age group?

infants in first year of life

What is the cortical vein sign?

MRI or CT shows veins

extending from brain to inner

table of skull

The cortical vein sign helps differentiate

benign external

________ from ________.

hydrocephalus from subdural

hematoma

Postulated cause of benign external

defect in CSF reabsorption

hydrocephalus (BEH) is ________.

BEH usually resolves by age ________.

Concern is caused by ________.

large head size

“X” linked hydrocephalus

G7 p.308:60mm

is a type of ________ hydrocephalus that

inherited

occurs in ________% of patients with

hydrocephalus.

Gene is located on ________.

Xq28

It causes abnormality in ________

LICAM

membrane receptor and

produces classical syndromes including

G7 p.308:110mm

c________ c________ h________

corpus callosum hypoplasia

ii.

r________

retardation

iii.

a________ t________

adducted thumbs

iv.

s________ p________

spastic paralysis

h________

hydrocephalus

154 Hydrocephalus

Complete the following regarding

G7 p.308:140mm

radiographic finding of L1 syndrome:

Large

p________ h________

posterior horn

ii.

m________ i________

massa intermedia

iii.

q________ p________

quadrigeminal plate

Small (hypoplastic)

c________ c________

corpus callosum

ii.

c________ v________

cerebellar vermis

Rippled

v________ w________

ventricular wall

Which feature is pathognomonic?

rippled ventricular wall

G7 p.308:160mm

r________ v________ w________

Available treatment for retardation?

none

True or False. Shunt dependency is

G7 p.309:53mm

likely in hydrocephalus due to

aqueductal stenosis

true

spina bifida

true

communicating hydrocephalus (i.e.,

false (shunt independence

secondary to arachnoidal adhesions)

more likely to occur)

10.

True or False. With respect to a

G7 p.309:57mm

disconnected or nonfunctioning shunt:

A disconnected shunt may continue to

true

function by CSF flow through a

subcutaneous fibrous tract.

If in doubt, better to watch, not shunt.

false

Patients with a nonfunctioning shunt

false

should not be followed with serial CT

scans but possibly with serial

neuropsychological evaluations.

11.

True or False. When deemed

false, deterioration can still

G7 p.309:60mm

“arrested” no further follow-up is

occur

needed.

12.

True or False. With regard to “arrested

G7 p.309:115mm

hydrocephalus”:

It is interchangeable with the term

false

“uncompensated hydrocephalus.”

Arrested hydrocephalus satisfies the

false

following criteria in the absence of a

cerebrospinal fluid (CSF) shunt

ventriculomegaly nonprogressive

true

ii.

normal head growth curve

true

iii.

continued psychomotor

true

development

13.

Hydrocephalus-radiologic criteria:

G7 p.310:60mm

skull

inner table shows ________

beaten copper

________ cranium

ii.

sella shows ________

erosion

Hydrocephalus

155

ventricles

Frontal horns ballooning look like

Mickey Mouse

M________ M________.

ii.

Frontal horns’ percent of brain width

50%

is > ________%.

iii.

Temporal horns’ width is

2 mm

>________mm.

iv. Anteroposterior (AP) view shows

disproportion of ventricle size

________.

and cortical sulci

v. Third ventricle on AP view shows

bowing laterally

________ ________.

vi. Third ventricle on lateral view shows

bowing down into sella

________ ________ ________

________.

brain

transependymal ________

edema

ii.

corpus callosum is ________

thin/atrophic

iii.

and shows ________

stretching

iv.

and ________ ________

upward bowing

14.

Regarding the characteristics of the

G7 p.310:140 mm

etiology of hydrocephalus:

True or False. There is excess production

true

of CSF.

True or False. There is impaired

true

absorption of CSF.

True or False. It is congenital without

true

myelomeningocele.

Congenital with myelomeningocele

Chiari II

usually occurs with ________.

Chiari I if a cause has ________

fourth ventricle outlet

________ ________ ________.

obstruction

Aqueductal stenosis presents symptoms

infancy

in ________.

Secondary aqueductal stenosis is due to

intrauterine infection,

________ ________, ________, or

hemorrhage, or tumor

________.

Atresia of foramina of Luschka and

Dandy-Walker syndrome

Magendie is called ________-________

________.

15.

Complete the following concerning

G7 p.311:10mm

etiologies of hydrocephalus:

Chiari II is associated with ________.

myelomeningocele

Aqueductal stenosis usually manifests

infancy

itself in which age group?

Of postop pediatric post-fossa tumor

20%

G7 p.311:117mm

patients, ________% develop

hydrocephalus and need a shunt.

This may be delayed for up to ________.

1 year

Dandy-Walker malformation occurs in

2.4%

what percent of patients with

hydrocephalus?

156

Hydrocephalus

16.

Conditions that may mimic

G7 p.311:130mm

hydrocephalus are

h________

hydranencephaly

ii.

a________

atrophy

iii.

a________ of c________ c________

agenesis of corpus callosum

iv.

s ________ o________ d________

septo optic dysplasia

17.

List signs and symptoms of

G7 p.312:45mm

hydrocephalus in young children.

h________

hydrocephalus

ii.

y________

young children

iii.

d________

diplopia on lateral gaze

(abducens palsy)

iv. r________

respiratory pattern irregular

v. o________

outward protrusion of

fontanelle

vi. c________

cracked pot sound of

Macewen

vii. e________

enlargement of cranium

relative to face

viii. p________

poor head control, Parinaud

syndrome

ix. h________

hyperactive reflexes

x. a________

abducens nerve palsy, apneic

spells

xi. l________

large head

xii. u________

upward gaze palsy

xiii. s________

scalp veins prominent

xiv. s________

setting sun sign

xv. s________

splaying of cranial sutures

(seen on plain skull x-rays)

18.

List the signs and symptoms of active

headache, nausea, vomiting

G7 p.312:45mm

hydrocephalus in older children/adults

changes in gait, and urine

with rigid cranial vault.

control

Hint: hcp

papilledema, upward gaze or

abducens palsy

19.

Occipital frontal circumference (OFC)

rump

G7 p.312:115mm

in the normal child should equal the

distance from crown to ________.

20.

For the indicated ages give the

G7 p.313:15mm

expected normal head circumference

pattern.

Hint: At 33 weeks the circumference is

33 cm. In a child younger than 33 weeks

the head circumference is greater in cm

than the age of the child in weeks old.

After 33 weeks head circumference

growth slows so that at 40 weeks of age

the head circumference is 36 cm.

premature (ages in weeks)

29 cm

ii.

30 cm

Treatment of Hydrocephalus

157

iii.

31 cm

iv.

31.5 cm

32 cm

vi.

33 cm

vii.

33.5 cm

viii.

34 cm

ix.

34.5 cm

35 cm

xi.

35 cm

xii.

35.4 cm

xiii.

36 cm

full term (ages in months)

Hint: Note the pattern; with each month

head circumference increases by 1 cm.

40 cm

ii.

42 cm

iii.

43 cm

iv.

44 cm

45 cm

vi.

46 cm

What is the upper limit of head

circumference for a baby?

28 weeks gestational age

29 cm

ii.

33 weeks gestational age

33 cm

iii.

2 months old

42 cm

iv.

3 months old

43 cm

4 months old

44 cm

vi.

6 months old

46 cm

 Treatment of Hydrocephalus

21. Answer the following about the

G7 p.314:40mm

treatment of hydrocephalus:

a. True or False. Hydrocephalus is a

false (mainly to be treated

medically treated condition.

surgically)

b. Diuretic therapy can include a________ acetazolamide and

G7 p.314:68mm

and f________.

furosemide

c. Be sure to watch for the complication of electrolyte imbalances

G7 p.314:95mm

________ ________.

d. Role of spinal taps in hydrocephalus is to temporize (Hydrocephalus

t________.

after intraventricular

hemorrhage may be only

transient, and serial taps

[ventricular or lumbar] may

temporize until resorption

resumes, but lumbar taps can

be performed only for

communicating

hydrocephalus.)

158

Hydrocephalus

Critical protein level of CSF is ________.

100 mg/dL (If reabsorption

G7 p.314:120mm

does not resume when

protein content of CSF is

< 100 mg/dL, then it is

unlikely that spontaneous

resorption will occur and a

shunt will usually be

necessary.)

22.

Complete the following concerning

G7 p.314:110mm

spinal taps and hydrocephalus:

Protein above ________ will not be

100 mg/dL

absorbed.

Protein below ________ may be

100 mg/dL

absorbed.

23.

Complete the following concerning

G7 p.314:110mm

surgery and hydrocephalus:

Third ventriculostomy when looking into

ventricle

Where is thalamostriate vein?

lateral wall

ii.

Where is septal vein?

medial wall

iii.

Where is choroid plexus?

enters foramen of Monro

Where is puncture of third ventricle to

anterior to mammillary

occur?

bodies

Into the ________ cistern

interpeduncular

Watch out for ________.

basilar artery

Success rate is ________%,

approximately 50% (60 to

G7 p.315:70mm

90% range) for aqueductal

stenosis

but only 20% for ________ ________.

preexisting pathology

24.

Concerning shunts and hydrocephalus,

G7 p.315:140mm

what type of shunts do you know?

Hint: palmt

v________ s________

ventriculoperitoneal shunt

v________ a________

ventriculo-jugular vein-right

cardiac atrial

l________

lumboperitoneal

m________ s________

miscellaneous shunts-

ventriculopleural

T________ s________

Torkildsen shunt (ventricle-

cisterna magna)

25.

What is shunt usage priority?

G7 p.315:145mm

Hint: palmt

most often used ________ ________

ventriculoperitoneal shunt

abdominal abnormality ________

ventriculoatrial shunt

________

surgery

peritonitis

morbid obesity

Treatment of Hydrocephalus

159

pseudotumor cerebri ________

lumboperitoneal shunt-small

________

ventricles

alternative ________ ________

miscellaneous shunts

acquired obstructive hydrocephalus

Torkildsen shunt

________ ________

26.

Which are the miscellaneous shunts?

G7 p.316:22mm

Hint: gupc

g________

ventricle to gall bladder shunt

ii.

u________

ventricle to ureter or bladder

shunt

iii.

p________

ventriculopleural shunt

iv.

c________

cyst shunt (arachnoid cyst or

subdural hygroma cavity to

peritoneum)

27.

Name six possible shunt

G7 p.316:160mm

complications.

Hint: odesma

o________

obstruction

ii.

d________

disconnection of shunt parts

iii.

e________

erosion through skin

iv.

s________

seizures-5.5% first year, 1.1%

after 3 years

v. m________

metastases of tumor cells

vi. a________

allergy to silicone

28.

What are ventriculoperitoneal shunt

G7 p.316:125mm

complications?

Hint: h²alo³mvps

h________

hernia-inguinal 17%

ii.

h________

hydrocele

iii.

a________

CSF ascites

iv.

l________

lengthen catheter with

growth (preventable)

v. o________

obstruction by omentum or

debris

by peritoneal cyst (infection

or talc from surgical gloves)

severe peritoneal adhesions

malposition of catheter tip

collapsed ventricular wall

choroid plexus

vi. o________

obstruction or strangulation

of intestine

vii. o________

overshunting

viii. m________

migration of tip to:

scrotum

perforation of stomach,

bladder, diaphragm

ix. v________

volvulus

x. p________

peritonitis

xi. s________

subdural hematoma

160

Hydrocephalus

29.

What are ventriculoatrial shunt

G7 p.317:55mm

complications?

Hint: liverssh

l________

lengthening in children

ii.

i________

infection

iii.

v________

vascular

perforation

thrombophlebitis

pulmonary microemboli

iv. e________

shunt embolus

v. r________

retrograde blood flow

vi. s________

superior vena cava

obstruction

vii. s________

subdural hematoma

viii. h________

hypertension (pulmonary)

30.

What are lumboperitoneal shunt

G7 p.317:70mm

complications?

Hint: Carols

C________

Chiari I malformation (70%

made worse)

ii.

a________

arachnoiditis and adhesions

iii.

r________

radiculopathy (from tube-

hard to control)

iv. o________

overshunting (sixth and

seventh cranial nerve

dysfunction)

v. l________

leakage of CSF

vi. s________

scoliosis due to laminectomy

(14% in children)

 Shunt Problems

31. When do you tap the shunt?

G7 p.322:65mm

a. to study CSF for

i________

infection

ii.

c________

cytology

iii.

b________

blood

b. or to assess function

measure p________

pressure

ii.

instill c________

contrast

c. inject m________

medication

32. When tapping a shunt, what is normal

less than 15 cm of CSF in

G7 p.322:130mm

CSF pressure as measured from the

relaxed recumbent position

ventricle?

33. How often does the patient have to

Patient must not touch the

G7 p.323:48mm

pump the shunt?

pump unless instructed to do

so.

Shunt Problems

161

34.

What are acute symptoms of

G7 p.323:140mm

undershunting?

Hint: salvadib h

s________

seizures

a________

ataxia

l________

lethargy

v________

vomiting

a________

apnea

d________

diplopia

i________

irritability

b________

bradycardia

h________

headache

35.

What are signs of acute increase in

G7 p.323:165mm

intracranial pressure?

Hint: p⁴b²

p________

Parinaud syndrome

p________

palsy of abducens

p________

papilledema

p________

prominent scalp veins

b________

blindness or field cut

b________

bulging fontanelle

36.

What are complications of

G7 p.325:130 mm

overshunting?

Hint: s⁴i

s________

slit ventricles 12%

s________

subdural hematoma

s________

sylvian aqueduct occlusion

s________

skull changes—

craniosynostosis or

microcephaly

i________

intracranial hypotension

37.

Intracranial hypotension

G7 p.326:23mm

When patient is erect, column of CSF

siphon effect

produces a s________ e________.

Diagnose by documenting a drop in ICP

supine to erect

when patient changes from ________ to

________ position.

38.

Slit ventricles can be diagnosed by

0.2

G7 p.326:50mm

frontal-occipital horn ratio of less than

________.

39.

Name categories of patients with slit

G7 p.326:80mm

ventricles.

Hint: pahms

p________

pseudotumor cerebri

a________

asymptomatic slit ventricles

h________

intracranial hypotension

m________

migraine

s________

slit ventricle syndrome

162

Hydrocephalus

40.

Complete the following concerning

G7 p.327:105mm

hydrocephalus and subdural

hematomas (SDs):

Cause of SD in patients with shunts is

collapse; tearing of the

________ of the brain and ________

bridging veins

________ ________ ________ _______.

Risk factors

b________ a________

brain atrophy

ii.

l________-s________ h________

long-standing hydrocephalus

iii.

n________ v________ p________

negative ventricular pressure

41.

If subdural hematoma develops as a

G7 p.327:140mm

shunt complication the subdural is

located on

the same side as the shunt ________%

32%

opposite side of the shunt ________%

21%

bilaterally ________%

47%

42.

Treatment for subdural hematoma

G7 p.328:25mm

that occurs due to shunting for

hydrocephalus could include

Hint: bcdht

b________

burr holes

c________

craniotomy

d________

drainage-subdural peritoneal

shunt

h________

higher pressure shunt

t________

tie off shunt

43.

True or False. In VP shunt and

true

G7 p.328:145mm

laparoscopic surgery, abdominal

insufflation can increase ICP.

 Normal Pressure Hydrocephalus

44. What are the symptoms of normal

G7 p.329:65mm

pressure hydrocephalus?

Hint: dig

a. d________

dementia (wacky)

b. i________

incontinence of urine (wet)

c. g________

gait disturbances (wobbly)

45. What is the etiology?

G7 p.329:85mm

Hint: mistapa

a. m________

meningitis

b. i________

idiopathic

c. s________

subarachnoid hemorrhage

d. t________

trauma

e. a________

aqueductal stenosis

f. p________

posterior fossa surgery

g. A________

Alzheimer disease

46. In clinical triad, which symptom

gait disturbance

G7 p.329:145mm

precedes the others?

Blindness and Hydrocephalus

163

47.

Note the clinical features of NPH as

G7 p.329:145mm

expected (+) or not expected (-).

Wide-based gait

Shuffling steps

Unsteadiness on turning

Difficult initiating steps

Feel glued to the floor

Ataxia of limbs

Slowness of thought

Unwitting urinary incontinence

Papilledema

Seizure

Headaches

48.

True or False. Concerning

G7 p.333:78mm

cisternography for normal pressure

hydrocephalus (NPH), what finding

predicts a 75% improvement with a

shunt? Radionucleotide in the

ventricle at

24 hours

false

48 hours

false

72 hours

true (late scan 48 to 72

hours)

49.

In NPH what is the sequence in which

G7 p.334:125mm

symptoms are likely to improve with

shunting?

Hint: igd

i________

incontinence

g________

gait

d________

dementia



Blindness and Hydrocephalus

50. Blindness in hydrocephalus may be

G7 p.335:30mm

due to

Hint: pop

a. p________

papilledema—chronic—optic

atrophy

b. o________ ________ ________

optic chiasm compression

dilation of third ventricle

c. p________ ________ ________

posterior cerebral artery

________

occlusion compressed at

tentorial edge

51. Blindness clinical criteria for

pregeniculate blindness and

G7 p.335:70mm

localization are ________ ________

postgeniculate blindness

and ________ ________.

a. Characteristics for pre-________

pregeniculate blindness

o________ n________ a________—

optic nerve atrophy—severe

s________

ii.

p________ r________—p________

pupillary reflexes—poor

iii.

due to p________, h________,

pressure, hypotension,

a________

anemia

164 Hydrocephalus

b. Characteristics for p________

postgeniculate blindness

b________

o________ n________ a________— optic nerve atrophy—minimal

m________

ii.

p________ r________—n________ pupillary reflexes—normal

iii.

due to ________ ________

hypoxia macular sparing in

________

PCA occlusion, no macular

sparing in trauma to occiput

52. Cortical blindness may be associated

G7 p.335:82mm

with

a. Anton syndrome = d________ of

denial of visual deficit

v________ d________

b. Riddoch phenomenon = a________ of

appreciation of moving

m________ o________, but n________

objects, but no appreciation

a________ of s________ o________

of stationary objects



Hydrocephalus and Pregnancy

53.

Patients with shunt for hydrocephalus

G7 p.336:65mm

should prior to conception

have up-to-date ________ or ________

CT or MRI

have assessment of any m________

medications

if prospective mother’s hydrocephalus is

2 to 3%

accompanied by a neural tube defect

(NTD), her child could be born with an

NTD incidence of ________ to

________%

have genetic c________

counseling

start v________

vitamins

avoid excessive h________

heat

54.

If shunt malfunctions during

G7 p.336:100mm

pregnancy, you may

in the first two trimesters ________ the

revise

VP shunt

in the third trimester use a ________-

ventriculo-atrial,

________ or a ________-________ shunt

ventriculo-pleural

55.

During labor and delivery

G7 p.336:175mm

Use p________ a________.

prophylactic antibiotics

If patient is asymptomatic deliver via

vagina

________.

If patient is symptomatic deliver via

cesarean

________.

In light of increased cranial pressure

epidurals

avoid ________.

Infections



General Information

1. Complete the following regarding

G7 p.342:127mm

antibiotics:

a. An antibiotic good for neurosurgical

Ancef (cefazolin)

prophylaxis is ________.

b. An antibiotic good for shunt surgery

Ancef (cefazolin)

prophylaxis is ________.

c. The above are ________ cephalosporins.

first-generation

d. A third-generation cephalosporin good

Rocephin (ceftriaxone)

G7 p.343:33mm

for treatment of Lyme disease is

________.



Prophylactic Antibiotics

2. Describe the administration of

G7 p.342:127mm

prophylactic antibiotics.

a. Ancef—also known as ________

cefazolin

b. dose and route

1 to 2 g IV

c. when? ________ before surgery

60 minutes

d. and repeat every ________ hours for

6; 24

________ hours

e. if allergic to ________ use ________

penicillin; vancomycin

f. dose and route ________

1 g IV

g. and repeat every ________ hours for

8; 24

________ hours

 Meningitis

3. List the differential diagnosis of

G5 p.213:40 mm

chronic meningitis.

Hint: msfict

a. m________ c ________

meningeal carcinomatosis

b. s________

sarcoidosis

c. f________

fungal

d. i________

infection

e. c________

cysticercosis

f. t________

tuberculosis

166 Infections

4. Describe the treatment for

G7 p.344:60mm

posttraumatic meningitis.

a. for gram-negative

imipenem or cipro

b. for gram-positive

vancomycin

c. continue until ________

1 week after CSF sterilization

d. Surgery may be needed to ________

repair fistula

________.



Shunt Infection

What are the characteristics of shunt

G7 p.345:97mm

infection?

Risk of early infection is ________%.

7% overall

Risk of mortality is ________%.

10 to 15%

Risk of late is ________% within

2.7 to 31% (typically 6%)

G7 p.345:179mm

6 months.

Organism is ________ ________.

Staphylococcus epidermidis

What are the characteristics of shunt

G7 p.346:88mm

nephritis?

v________ s________

ventriculovascular shunt

c________ l________-l________

chronic low-level infection

i________

i________ c________ d________ in

immune complex deposit in

g________

glomeruli

p________ and h________

proteinuria and hematuria

Gram-negative bacillus (GNB) shunt

G7 p.346:165mm

infection compared with gram-

positive bacillus (GPB)

morbidity

higher in GNB

Gram stain

more than 90% + Gram stain

(in contrast to GPB only 50%)

protein

↑ protein

glucose

↓ glucose

neutrophils

↑ neutrophils

The reason we must identify GNB

infection is because

treatment ________ ________ than

is different

for staph and

ii.

there is a higher ________ for GNB.

morbidity

What is the treatment for shunt

G7 p.347:60mm

infection?

Remove ________.

shunt

Insert ________ ________ ________.

external ventricular drain

(EVD)

Administer antibiotics of ________ plus

vancomycin plus rifampin

G7 p.347:105mm

________

(change to nafcillin if

possible)

for ________ days.

14—with CSF sterilization

Add i________ a________

intrathecal antibiotics

by clamping ________ for ________

EVD for 30

minutes.

Cerebral Abscess

167

 Wound Infections

9. Describe laminectomy wound

G7 p.349:15mm

infection treatment.

a. B________

Betadine—if purulent—half

strength follow with normal

saline

b. c________

culture

c. d________

debride wound

d. e________

empirically vancomycin plus

third generation

cephalosporin (ceftazidime)

e. f________

fill (pack) with iodoform ¼

inch

f. g________

gradually reduce packing trim

by 1 inch each day

g. h________

hospital—change pack every

8 hours

h. h________

home—change pack twice a

day

 Osteomyelitis of the Skull

10. Complete the following concerning

G7 p.349:130mm

Pott puffy tumor:

a. Treatment

f________ r________

flap removal

ii.

d________

debridement

iii.

antibiotics for ________ weeks. For

6 to 12; IV

first week use ________

iv. c________

cranioplasty after 6 months

b. Most common organism is ________

Staphylococcus aureus

________.

 Cerebral Abscess

11. What are the risk factors for cerebral

G7 p.350:85mm

abscess?

Hint: Abcdefghi

A________

AIDS

ii.

b________

bacterial sepsis

iii.

c________

cyanotic heart disease

iv.

d________

dental abscess

e________

endocarditis

vi.

f________

fistula (arteriovenous)

vii. g________

gastrointestinal infection

viii. h________

hematogenous spread

ix. i________

infection pulmonary

168

Infections

12.

Complete the following about cerebral

G7 p.351:75mm

abscess:

What percentage of cerebral abscesses

25%

fail to grow organism on culture?

The most common organism is

Streptococcus, 30 to 50%

________.

The most common organisms in frontal-

Streptococcus milleri and

ethmoid sinusitis are ________

Streptococcus anginosus

________ and ________ ________.

The most common organism in

Staphylococcus aureus

traumatic causes is ________ ________.

The most common organism in

Aspergillus fumigatus

transplant patients is ________

________.

The most common organism in infants is

gram negative

________ ________.

The most common organisms in AIDS

toxoplasmosis and Nocardia

patients are ________ and ________.

The most common dental source is

actinomyces

________.

The most common organisms following

Staphylococcus epidermidis

neurosurgical procedures are ________

and aureus

________ and ________.

13.

Indicate the value of the following

G7 p.352:40mm

diagnostic tests or treatment for brain

abscess:

lumbar puncture (LP)

dubious value—may herniate

computed tomography (CT)

excellent

leukocyte scan

excellent

effect of steroids

tests become less positive—

can mislead

14.

Describe the four stages of cerebral

G7 p.352:120mm

abscess.

stages

stage 1 e________ c________

early cerebritis

ii.

stage 2 l________ c________

late cerebritis

iii.

stage 3 e________ c________

early capsule

iv.

stage 4 l________ c________

late capsule

number of days

stage 1

1 to 3

ii.

stage 2

4 to 9

iii.

stage 3

10 to13

iv.

stage 4

histologic characteristics

stage 1

inflammation

ii.

stage 2

developing necrotic center

iii.

stage 3

neovascularity reticular

network, necrotic center

iv. stage 4

collagen capsule

necrotic center

gliosis around capsule

Viral Encephalitis

169

15.

Conservative management of cerebral

G7 p.353:130mm

abscess is appropriate

if the abscess is less than ________ cm in

diameter

or it is in the ________ ________ phase.

early cerebritis (where

surgery would not be

appropriate)

16.

List the empiric antibiotics used for

G7 p.354:60mm

cerebral abscess.

Hint: vcmc or r

v________

vancomycin

c________

cefotoxime

m________ or

metronidazole (Flagyl)

c________ or

chloramphenicol

r________

rifampin

17.

For how long should IV antibiotics be

6 weeks

G7 p.354:135mm

used in cerebral abscess?

18.

Complete the following regarding

G7 p.356:40mm

Nocardia:

It arises from the ________.

soil

What is the duration of treatment?

many months

Is it a fungus?

no, it is a bacterium

 Subdural Empyema

19. Complete the following regarding

G7 p.357:20mm

subdural empyema:

a. It spreads as a result of ________

direct extension

________.

b. The leading cause was previously

chronic otitis media

c________ o________ m________.

c. The leading cause now is ________.

frontal sinusitis, 65 to 75%

d. Is LP used for diagnosis?

no, rarely positive and it is

hazardous

e. Fatal cases are associated with

venous infarction of the brain

v________ i________ of the b________.

 Viral Encephalitis

20. Complete the following regarding

G7 p.358:150mm

herpes simplex:

a. HSE stands for ________ ________

herpes simplex encephalitis

________.

b. It has a predilection for the t________,

temporal, orbitofrontal lobes

o________ l________ and l________

and limbic system

s________.

c. Definitive diagnosis requires b________ brain biopsy and virus

b________ and v________ i________.

isolation

d. Treat promptly with ________.

acyclovir

170

Infections

21.

HSE has the following characteristic:

G7 p.359:70mm

CSF: ________-________

leukocytosis-monocytes

EEG: p________ l________ e________

periodic lateralizing

d________ on electroencephalography

epileptiform discharges

CT e________ in t________ l________

edema in temporal lobes

Hemorrhage on ________ means

CT; poorer prognosis

________ ________.

MRI shows t________ s________.

transsylvian sign

Significance: if bilateral it is highly

HSE

suggestive of ________.

22.

Transsylvian sign

G7 p.359:105 mm

indicates temporal lobe e________

edema

that extends across the s________

sylvian fissure

f________.

23.

General treatment for intracranial

G7 p.360:60mm

pressure (ICP) elevation involves the

following:

e________ h________ of b________

elevate head of bed

m________

mannitol

h________

hyperventilate

24.

Complete the following concerning

G7 p.360:85mm

acyclovir treatment:

The dose is ________

30 mg/kg/day is divided every

8 hours

for a duration of ________ days.

14 to21

If you identify HSE before GCS drops you

limit mortality

can l________ m________.

 Creutzfeldt-Jakob Disease

25. Complete the following about

G7 p.361:30mm

Creutzfeldt-Jakob disease:

a. CJD stands for ________ ________

Creutzfeldt-Jakob disease

________.

b. The prognosis is ________ ________.

invariably fatal

c. The EEG shows ________.

characteristic bilateral sharp

G7 p.361:43mm

waves 0.5 to 2.0 per second

d. Prion stands for ________ ________

proteinaceous infectious

________.

particles

e. Diagnostic triad

G7 p.362:160mm

Hint: dEm

d________

dementia

ii.

E________

EEG

iii.

m________

myoclonus

26. What is the biopsy procedure in

G7 p.363:150mm

suspected CJD?

a. Use a ________ cranial saw

manual

b. to avoid ________ of the infection.

aerosolization

c. Avoid cutting the _______ with the saw.

dura

d. Clearly ________ containers .

label

e. Fix is ________% phenolized formalin.

15%

Neurologic Manifestations of AIDS

171

 Neurologic Manifestations of AIDS

27.

Name four conditions in AIDS

G7 p.364:75mm

producing focal CNS lesions.

t________

toxoplasmosis

l________

lymphoma

p________ m ________ l ________

progressive multifocal

leukoencephalopathy (PML)

C________

Cryptococcus

28.

Complete the following about the

G7 p.364:95mm

neurologic manifestations of AIDS:

What is the most common lesion causing

toxoplasmosis

mass effect in AIDS patients?

Does this occur early or late in the course

late

of HIV infection?

Central nervous system (CNS) lymphoma

Epstein-Barr virus

is associated with what virus?

PML is associated with what virus?

polyoma or J-C virus (not to

be confused with Creutzfeldt-

Jakob)

29.

An imaging characteristic of

G7 p.365:170mm

toxoplasmosis in AIDS patients is

number

multiple

density

low

located

basal ganglia

enhancement

ring—“multiple enhancing

lesions in the basal ganglia”

30.

Complete the chart by listing the CT

G7 p. 365:171mm

and MRI findings in each of the

following:

toxoplasmosis

number

more than 5

ii.

enhance

ring

iii.

location

basal ganglia

iv.

mass effect

moderate

miscellaneous

edema

lymphoma

number

less than 5

ii.

enhance

homogeneous

iii.

location

subependymal

iv.

mass effect

mild

miscellaneous

may cross corpus callosum

PML

number

multiple

ii.

enhance

iii.

location

white matter

iv.

mass effect

none

miscellaneous

high on T2 and low on T1

172

Infections

31.

Complete the following about the

G7 p. 366:135mm

neurologic manifestations of AIDS:

treatment for toxoplasmosis

p________

pyrimethamine

ii.

s________

sulfadiazine

How promptly should we see

2 to 3 weeks

G7 p. 367:68mm

improvement clinically and

radiologically?

If successful how long should

for patient’s lifetime if meds

toxoplasmosis be controlled?

are continued

Biopsy should be considered if there is

3 weeks (some say 7 to 10

G7 p. 367:82mm

no response in ________ ________.

days)

32.

Complete the following about the

G7 p.366:160mm

neurologic manifestations of AIDS:

Can toxoplasmosis be radiologically

distinguished from

lymphoma?

ii.

PML?

usually

Therefore check

for toxo ________ ________

serum toxo titers

________

ii.

for lymphoma ________ study for

LP (if no mass effect);

c________, PCR a________ of

cytology; amplification of

v________ D________

viral DNA

33.

Considerations for performing a

G7 p.367:15mm

biopsy of a brain lesion in a HIV+

patient

if toxo titers are ________

negative

if no response to toxo meds in ________

3 weeks

True or False. Biopsy is equally valuable

false (more valuable in

G7 p.367:113mm

in lesions that enhance or don’t enhance.

enhancing lesions to

differentiate toxoplasmosis

from lymphoma)

technique for biopsy ________

stereotactic

What two areas should be sampled?

enhancing rim and the center

Positive biopsy can be expected in

96%

G7 p.367:120mm

________%.

34.

Indicate the survival times for AIDS

G7 p.367:160mm

patients with the following

conditions:

CNS toxo ________

15 months

PML ________

15 months

lymphoma ________

3 months versus 1 month

without treatment

lymphoma in nonimmunosuppressed

13.5 months

patient ________

Parasitic Infections of the Central Nervous System

173

 Lyme Disease—Neurologic Manifestations

35.

Complete the following regarding

G7 p.368:30mm

Lyme disease:

It is caused by a ________.

spirochete transmitted by a

tick

The hallmark skin lesion is called

erythema chronicum migrans

e________ c________ m________.

The clinical triad consists of

c________ n________

cranial neuritis

ii.

m________

meningitis

iii.

r________

radiculopathy

On clinical exam, don’t be misled into

Bell palsy (The seventh nerve

diagnosing ________ ________.

weakness in Lyme disease is

common.)

On CSF exam, don’t be misled into

multiple sclerosis (MS) (from

diagnosing ________ ________.

the oligoclonal bands that

also occur in Lyme disease)

What is the most common cause of

Lyme disease cranial neuritis

G7 p.368:110mm

bilateral Bell palsy?

36.

Complete the following about Lyme

G7 p.369:100mm

disease neurologic manifestations:

What two conditions share an

MS (multiple sclerosis) and

uncommon CSF finding?

Lyme disease

The CSF component they share is

oligoclonal bands

________ ________.

 Parasitic Infections of the Central Nervous System

37. Cysticercosis is a disease caused by

G7 p.370:60mm

a. Which organism?

Taenia solium

b. At which life cycle stage?

larval stage

c. The life cycle stages (4) include the

following:

Hint: eael

e________

embryo

ii.

a________

adult

iii.

e________

eggs

iv.

l________

larva

d. The current best test is ________-

enzyme-linked

________ ________ ________.

immunoelectrotransfer blot

38. Complete the following statements

G7 p.370:65mm

about parasitic infections of the CNS:

a. Cysticercosis is caused by

the p________ t________

pork tapeworm

ii.

T________ s________

Taenia solium

b. Echinococcus is caused by

the d________ t________

dog tapeworm

ii.

E________ g________

Echinococcus granulosa

G7 p.373:80mm

c. What is hydatid sand?

germinating parasitic

G7 p.373:120mm

scoleces

174

Infections

Caution is advised during removal not to

rupture the Echinococcus cyst

G7 p.373:135mm

________.

and contaminate adjacent

tissues

39.

Describe the life cycle of cysticercosis.

G7 p.370:85mm

Pig contains ________ ________ in its

encysted embryo

flesh.

Humans eat undercooked ________ with

pork with embryo

________ in it.

Embryo matures to an ________.

adult

The ________ produces eggs.

adult

Eggs are released in the ________ of the

feces

human.

The same or a different human ________

ingests the eggs (from

the ________.

contaminated fingers,

vegetables, or water)

Eggs in this host release ________

larvae

which burrow through the ________

small bowel wall to

________ ________ to ________.

circulation

Larva lands and develops a ________

cyst wall

________

and becomes an ________ ________

encysted embryo

in ________ months.

40.

Answer the following concerning

G7 p.371:107mm

neurocysticercosis:

What is the permanent host for the adult

human

tapeworm?

What is the intermediate host?

human or animal (pig)

41.

Answer the following concerning

G7 p.371:175mm

neurocysticercosis:

What is the significance of CT scan with

low-density cysts with eccentric

living cysticerci

punctate high-density spots in an

enhancing ring?

ii.

above plus edema?

dying cysticerci

iii.

intraparenchymal punctate

dead parasites

calcifications?

What may soft tissue x-rays show?

calcifications in thigh or

shoulder

What might MRI show?

intraventricular or cisternal

cysts

42.

Complete the following regarding CT

G7 p.372:20mm

in cysticercosis:

Ring-enhancing cysts suggest ________

living cysticerci

________.

Intraparenchymal punctate calcifications

dead parasites

suggest ________ ________.

Ring-enhancing cyst with edema

suggests

________ with

recently dead or dying

parasite

ii.

________

inflammatory reaction

Spine Infections

175

 Fungal Infections of the CNS

43. What organism can cause a cerebral

Aspergillus fumigatus

G7 p.374:80mm

abscess in an organ transplant

patient?

44. Name the most common fungal

cryptococcosis

G7 p.374:100mm

infection of the CNS diagnosed in the

living patient.

 Amoebic Infections of CNS

45. Describe amoebic infections of the

G7 p.375:120mm

CNS.

a. The only amoeba known to cause

Naegleria fowleri

infection is ________ ________.

b. Infection occurs 5 days after exposure in freshwater

warm ________.

c. The amoeba gains entry to the CNS via

olfactory mucosa

the ________ ________.

95% die within ________ ________

1 week

due to ________.

↑ICP

Prescribe with ________ ________.

amphotericin B

 Spine Infections

46. Describe spinal epidural abscess.

G7 p.367:140mm

a. Most common site for spinal epidural

thoracic level at 50%

abscess is the ________ at ________%.

b. The next most common is

________ at ________%

lumbar at 35%

ii.

________ at ________%

cervical at 15%

c. Symptoms of epidural abscess are

s ________ p________

severe pain over the area

ii.

p________ upon p________

pain upon percussion

iii.

f________

fever

47. What is the pathophysiology of cord

G7 p.377:45mm

in spinal epidural abscess?

a. compression by

m________ of a________

mass of abscess

ii.

b________ by c________ of

bone by collapse of

o________ v________ b________

osteomyelitic vertebral body

b. infarction by v________ t________

venous thrombophlebitis

c. direct spread to cord can cause

myelitis

________

176 Infections

48.

Complete the following regarding

G7 p.377:100mm

causes of spinal epidural abscess:

hematogenous—most commonly from

f________

furuncle

ii.

IV ________ ________

drug abuse

direct extension from a p________

psoas abscess

a________

spinal procedures

d________

discectomy (incidence of SEA

0.67%)

ii.

n________

needles (catheters)

Underlying causes are

Hint: idIra

i________ c________

immune compromised

ii.

d________

diabetes

iii.

IV d________ a________

IV drug abuse

iv.

r________ f________

renal failure

a________

alcoholism

49.

Complete the following concerning

G7 p.377:160mm

psoas abscess:

Muscle extends from T________ to

T12 to L5

L________

Psoas is the primary hip________

flexor

Innervated by ________

L2, L3

Proximity to sources of ________

infection

Pain on ________ flexion

hip

CT shows ________ of psoas shadow

enlargement

G7 p.378:80mm

Inside the ________ wing

iliac

50.

Cultures from spinal epidural abscess

G7 p.378:100mm

patients can be expected to show the

following:

Staphylococcus aureus ________%

50%— the main organism

no growth ________%

30 to 50%

Streptococcus (frequency)

second-most-common

organism

tuberculosis (TB) associated with

Potts disease; 25%

________ disease ________%

multiple organisms ________%

10%

51.

Complete the following regarding

G7 p.378:175mm

spinal epidural abscess (SEA):

If during the spinal tap you encounter

stop advancing needle and

pus, what should you do?

send pus for culture

The best test if you suspect SEA is

MRI

________.

Treatment includes

Hint: eabc

e________

evaluation

ii.

a________

antibiotics

iii.

b________

bracing—immobilization

iv.

c________

compression relief if present

Vertebral Osteomyelitis

177

d. If no organism is known, start empiric

antibiotics of

Hint: cvr

c________

cephalosporin third-

generation (cefotaxime)

ii.

v________

vancomycin

iii.

r________

rifampin

52. Complete the following regarding

G7 p.380:35mm

spinal infections:

a. The length of time IV antibiotics should

3 to 4 weeks

be administered for spinal epidural

abscess is ________.

b. The length of time IV antibiotics should

6 to 8 weeks

be administered for vertebral

osteomyelitis is ________.

c. Follow with ________.

serial sedimentation (ESR)

rates

d. Mortality is ________%.

4 to 31%

e. Recovery of neurologic deficit is

very rare

________ ________.

f. An exception to the rule is ________

Potts disease—50% improve

________—________% improve.

neurologically



Vertebral Osteomyelitis

53.

Complete the following regarding

G7 p.380:85mm

spine infections:

vertebral osteomyelitis risk factors

Hint: d³e

d________

drug abusers

ii.

d________

dialysis patients

iii.

d________

diabetes

iv.

e________

elderly

What condition in renal patients can

destructive

G7 p.1233:30mm

mimic infection on MRI?

spondyloarthropathy

Sources of infection are never found in

37% (consider urinary tract

________%.

infection [UTI], respiratory

tract, teeth)

Neurologic deficits occur in ________%

10 to 47%

of Pott’s disease patients.

54.

Answer the following about spine

G7 p.382:105mm

infections:

How long does it take for plain x-rays to

2 to 8 weeks

demonstrate changes in osteomyelitis?

What % of cases can be successfully

90%

managed nonoperatively?

55.

True or False. Regarding treatment of

G7 p.383:73mm

vertebral osteomyelitis:

Instrumented fusion is contraindicated.

false

It is permitted even in pyogenic

true

infections.

178 Infections



Discitis

56.

One differentiates spine destruction

G7 p.384:45mm

from

infection: i________ d________

involves the disc

metastases: m________ d________

miss the disc and involve the

vertebral body

57.

What is the MRI triad of infection?

G7 p.384:120mm

Enhancement of

a________ p________ p________

annulus posterior portion

b________ m________

bone marrow

d________ s________

disc space

58.

What is the CT triad of infection?

G7 p.384:160mm

e________ p________ f________

end plate fragmentation

p________ s________

paravertebral swelling

p________ a________

paravertebral abscess

59.

Complete the following regarding

G7 p.385:70mm

discitis:

Cultures are positive

from disc space in ________%.

60%

ii.

from blood in ________%.

50%

The usual pathogen is ________.

Staphylococcus aureus

Special staining is required to detect

TB in all cases

________.

60.

Complete the following about discitis:

G7 p.386:100mm

In children discitis manifests itself by the

walk or stand or sit

child refusing to ________ or ________

or ________.

Postop discitis is suggested when the

G7 p.387:90mm

Erythrocyte sedimentation rate

20 mm/hour

(ESR) is raised in infection to above

________ and does not come down.

ii.

CRP reactive protein above

10; 2

________ mg/L at ________ weeks

postop.

Interval between surgery and

G7 p.387:135mm

radiological changes in discitis

plain x-rays ________ weeks

12 (1 to 8 months range)

ii.

polytomography ________ weeks

3 to 8

61.

The empiric antibiotic treatment for

G7 p.388:30mm

postop discitis is

v________

vancomycin

r________

rifampin

C________

Ceftizox

Seizures



Seizures

Name the two major categories of

G7 p.394:60mm

seizures.

g________

generalized

p________

partial

List the six major types of primary

G7 p.394:60mm

generalized seizures.

Hint: magcat

m________

myoclonic

a________

atonic (drop attacks)

g________

generalized (grand mal)

c________

clonic

a________

absence (petit mal)

t________

tonic

What are the major differences

G7 p.394:60mm

between primary generalized and

partial seizures?

primary generalized

areas involved

bilateral and symmetrical

ii.

percent of seizures

40% of all seizures

iii.

consciousness

loss of consciousness at onset

iv.

significance

does not suggest structural

lesion

partial

areas involved

one hemisphere

ii.

percent of seizures

57% of all seizures

iii.

consciousness

no loss of consciousness at

onset

iv. significance

suggests structural lesion

180

Seizures

Matching. Match the type of seizure

G7 p.394:70mm

with its listed characteristic(s). More

than one may apply.

Characteristic:

① 3% of seizures; ② 40% of seizures;

③ 57% of seizures; ④ consciousness lost

from onset; ⑤ tonic clonic motor

activity; ⑥ involves both hemispheres;

⑦ no postictal confusion; ⑧ spike and

wave exactly 3/s; ⑨ represents a

structural lesion

Seizure:

generalized

②, ④, ⑤, ⑥

partial

③, ⑨

unclassified

①

absence

⑦, ⑧

The main difference is that simple

G7 p.394:120mm

partial seizures have

________ ________ of ________

no loss of consciousness

and complex partial seizures have

________ of ________.

loss of consciousness

Briefly describe the following

G7 p.395:70mm

characteristics of absence seizures:

motor involvement ________

absent

postictal state ________

absent

loss of consciousness ________

absent

characteristic electroencephalography

abnormal EEG 3/s spike and

(EEG) of ________

wave

effect of hyperventilation ________

induces seizures

Briefly describe the following

G7 p.395:100mm

characteristics of uncinate seizures:

arise from ________-________

uncus-hippocampus

produce hallucinations of ________

odor

kakosmia is perception of ________

bad odors

where none exist

Complete the following about

G7 p.395:120mm

seizures:

What is the most common cause of

mesial temporal sclerosis

intractable temporal lobe epilepsy?

due to ________

loss of cells in hippocampus

treated by ________

medication till refractory then

surgery

Name the rare syndrome with the

Lennox-Gastaut syndrome

G7 p.396:45mm

following features: childhood onset,

drop attacks, treatment by valproic

acid, and surgery by corpus

callosotomy.

Special Types of Seizures

181

10.

Describe Todd paralysis.

G7 p.396:60mm

occurs after ________

seizure

causes ________

weakness

resolves with ________

time

another name for it is ________

postictal paralysis

11.

Name factors that lower seizure

G7 p.396:90mm

threshold.

Hint: seizure history

s________

stroke

ii.

e________

elevated temperature, fever

iii.

i________

infection, intoxication

iv.

z________

“zzzzs” lost (sleep

deprivation, fatigue)

v. u________

uremia

vi. r________

repeated seizures (kindling)

vii. e________

electrolyte imbalance pH,

Mg++, low NA, high Ca++

viii. h________

hyperventilation,

hyponatremia, hypoglycemia,

hypercalcemia

ix. i________

ischemia

x. s________

stimulation (photic)

xi. t________

trauma, tumor

xii. o________

opioids

xiii. r________

removal or withdrawal of

alcohol or antiseizure meds

suddenly

xiv. y________

youth (birth asphysia,

congenital central nervous

system [CNS] abnormalities)

 Special Types of Seizures

12. Complete the following about special

G7 p.396:150mm

types of seizures:

a. Incidence of new-onset seizures per

44 per 100,000

100,000 person years is ________.

% that recur

27%

If all studies are normal can you release

the patient from your care?

d. What should you do?

repeat CT or MRI

e. For how long?

6 months and again in 1 or

G7 p.397:140mm

2 years

13. What are the two categories of

G7 p.398:48mm

posttraumatic seizures?

________ within ________ days

early within 7 days after

trauma

________ beyond ________ days

late beyond 7 days after

trauma

182

Seizures

14.

Complete the following about special

G7 p.398:55mm

types of seizures:

True or False. Anticonvulsants prevent

false (Anticonvulsants have

early posttraumatic seizures and reduce

been shown to reduce the

the frequency of late posttraumatic

risk of early posttraumatic

seizures.

seizures, up to 1 week, but

they do not reduce the

frequency of late

posttraumatic seizures.)

Therefore, you should stop antiepileptic

1 week

drugs (AEDs) after ________.

15.

Incidence of seizures in early

G7 p.398:70mm

posttrauma period (1 to 7 days) is

________% in severe head injuries

30%

________% in mild to moderate head

injuries

16.

Incidence of late seizures (greater than

10 to 13%

G7 p.398:90mm

7 days) is ________% over a 2-year

period.

17.

True or False. The incidence of

false (The incidence is higher

G7 p.398:120mm

posttraumatic seizures is higher with

with penetrating head

closed head injuries than with

injuries; occurs in 50% of

penetrating head injuries.

cases followed 15 years.)

18.

Answer the following concerning

G7 p.398:140mm

posttraumatic seizures:

Is there any treatment that reduces the

frequency of late posttraumatic

seizures?

ii.

frequency of early posttraumatic

yes

seizures?

iii.

by how much?

75%

What may reduce the frequency?

antiseizure medication

To be used for how long?

1 week

ii.

Are there any exceptions to that

yes

length of time?

iii.

What are they?

penetrating wound,

craniotomy, prior seizures

What do we mean when we say late

1 week after the trauma

posttraumatic seizure (PTS)?

19.

What occurs with long-term Dilantin

adverse cognitive effects

G7 p.398:150mm

use?

20.

True or False. Antiepileptic drugs have

G7 p.398:160mm

been shown to

impede epileptogenesis

false

reduce the incidence of late

false

posttraumatic seizures

improve outcome by reducing

false

posttraumatic seizures

reduce seizure recurrence after epilepsy

true

has developed

all of the above

false

Special Types of Seizures

183

21.

True or False. Indications for AEDs

G7 p.399:15mm

after trauma include

alcohol abuse

true

computed tomographic (CT) scan shows

true

blood in brain

Glasgow Coma Scale (GCS) score below

true

seizure after injury

true

22.

Using AEDs after head trauma can

reduction

G7 p.399:15mm

result in ________ in early

posttraumatic seizures.

23.

True or False. In appropriate patients,

G7 p.399:50mm

antiepileptic drugs should be tapered

off after

24 hours

false

48 hours

false

7 days

true

14 days

false

6 months

false

24.

True or False. Physicians should

G7 p.399:55mm

continue antiepileptic drugs longer

than 1 week in patients with

penetrating brain injury

true

development of late posttraumatic

true

seizures

prior seizure history

true

undergoing craniotomy

true

25.

True or False. Ethanol withdrawal

G7 p.399:95mm

seizures are seen in 33% of habitual

drinkers within ________ of stopping

or reducing ethanol intake.

1 to 2 hours

false

3 to 5 days

false

7 to 30 hours

true

1 to 2 weeks

false

26.

Answer the following about alcohol

G7 p.399:105mm

withdrawal patients:

What occurs first: delirium tremens (DTs)

seizures

or seizures?

Risk of onset of seizures lasts for

48 hours (2 days)

________.

Risk of onset of DTs lasts for ________.

96 hours (4 days)

G7 p.274:30mm

Risk persists for ________ days.

1 to 3 days

G7 p.275:20mm

Are AEDs recommended?

for prophylaxis?

yes, as prophylaxis only

ii.

for treatment?

no (Because seizure is usually

single, brief, and self-limited,

AEDs are not indicated once

seizure has occurred.)

184 Seizures

27. True or False. Patients with ethanol

G7 p.399:175mm

withdrawal seizures should receive

long-term antiepileptic drugs if they

have

a. history of prior ethanol withdrawal

true

seizures

b. recurrent seizures

true

c. history of prior seizure disorder

true

unrelated to ethanol

d. risk factors for seizures (e.g., subdural

true

hematoma)

 Nonepileptic Seizures

28.

Answer the following about

G7 p.400:32mm

nonepileptic seizures (NES):

aka pse________

pseudoseizures

aka psy________

psychogenic

True or False

They are real events.

true

ii.

They may not be under voluntary

true

control.

iii.

They are helped by AEDs.

false

iv.

Up to 50% of these patients also

true

have legitimate seizures at times.

29.

What are the features suggestive of

G7 p.401:75mm

nonepileptic seizures (NES)?

This feature is 90% specific for NES:

arching; back

________ of the ________

Another feature that is very specific is

weeping

w________

Forced eye ________

closing

Bilateral shaking with preserved

awareness

________

Variable ________ ________

seizure types

Clonic UE or LE movements that are

out of phase

________ ________ ________

Pelvic ________

thrust

Altered by ________

distraction

30.

A feature strongly suggestive of

lateral tongue laceration

G7 p.401:160mm

epileptic seizure is l________

t________ l________.

Status Epilepticus

185

31.

True or False. Nonepileptic seizures

G7 p.401:135mm

(NES) can be detected with the

following:

out of phase (arrhythmic) motor activity

true

lack of vocalization at start of seizure

true

lack of postictal confusion or lethargy

true

absence of urinary incontinence

false (Absence of urinary

incontinence may be the case

in both epileptic seizures and

NES and therefore can’t be

used to differentiate.)

suggestible or inducible seizures

true

32.

True or False. Which serum hormone

G7 p.401:165mm

may be used to confirm a true seizure

versus nonepileptic seizures

(psychogenic seizures)?

TSH

false

ACTH

false

Cortisol

false

prolactin

true

33.

To use this test, blood must be drawn

20 minutes

G7 p.401:165mm

promptly because peak levels of the

hormone are reached in ________.

34.

True or False. The most common type

G7 p.402:85mm

of seizure is

ethanol withdrawal

false

tumor induced

false

posttraumatic

false

febrile

true

epileptic

false

35.

True or False. Antiepileptic drugs that

G7 p.402:115mm

prevent afebrile seizures after a febrile

seizure include

phenobarbital

false

phenytoin

false

valproic acid

false

carbamazepine

false

none of the above

true (Diazepam may be

helpful during period of

fever.)

 Status Epilepticus

36. True or False. Status epilepticus is

G7 p.402:178mm

defined as more than 5 minutes of

a. continuous seizures

true

b. multiple seizures without fully recovering

true

consciousness

c. persistent seizure despite 1st and 2nd

true

line AED

186

Seizures

37.

Complete the following about status

G7 p.403:170mm

epilepticus (SE):

The mean duration of status is ________

1.5

hours.

The mortality from SE is ________ %.

1 to 2%

The mortality from underlying acute

10 to 12%

event is ________ %.

Irreversible changes from repetitive

electrical discharges begin to appear in

neurons as early as ________ minutes.

Cell death may occur after ________

minutes.

38.

For a patient in status epilepticus, the

G7 p.404:70mm

workup includes the following:

Hint: abceIl

a________

airway

b________

blood pressure

c________

CPR

e________

EKG, EEG, electrolytes

I________

l________

lumbar puncture

39.

Complete the following regarding

G7 p.404:105mm

lumbar puncture (LP) after a seizure:

LP after a seizure may show ________.

elevated white count

This may be b________ p________

benign postictal pleocytosis

p________.

Treat as ________.

infection with antibiotics until

cultures return

40.

Medications for patients in status

G7 p.404:115mm

epilepticus and their amount are

Hint: bAnd DIpt

b________

bicarbonate—2 ampules IV

A________

Ativan—4 mg slowly IV

n________

naloxone—0.4 mg IV

d________

dextrose—25 to 50 mL of a

50% solution

D________

Dilantin—20 mg/kg slowly IV

normal saline (NS)

I________

IV NS

p________

phenobarbital—20 mg/kg IV

t________

thiamine—50 to 100 mg IV

41.

True or False. The following

G7 p.405:35mm

medications are used in treating

status epilepticus:

lorazepam

true

phenytoin

true

phenobarbital

true

general anesthesia

true

all of the above

true

Antiepileptic Drugs

187

42.

What is the safe rate?

G7 p.405:35mm

For Dilantin ________ mg/minute

50 mg/minute

For phenobarbital ________ mg/minute

100 mg/minute

43.

What IV fluid must be used for giving

normal saline to avoid

G7 p.406:18mm

Dilantin and why?

precipitation

44.

Complete the following about

G7 p.406:135mm

diazepam:

name (proprietary)

Valium

stops seizures in ________

80% in 5 minutes

preferred drug

no (stored in fat)

seizures recur in ________

in 20 minutes

aborts seizures %

68%

depresses respiration

dose

10 mg

45.

Complete the following about

G7 p.406:145mm

lorazepam:

name (proprietary)

Ativan

preferred drug

yes

aborts seizures %

97%

depresses respiration

less

dose

4 mg

46.

True or False. The drug of choice for

G7 p.407:40mm

myoclonic status epilepticus is

lorazepam

true

benzodiazepine

false

Dilantin

false

phenobarbital

false

diazepam

false

47.

True or False. The drug of choice for

G7 p.407:55mm

absence status epilepticus is

valproic acid

true

benzodiazepine

false

dilantin

false

phenobarbital

false

diazepam

false

 Antiepileptic Drugs

48. What % of patients can achieve

75 to 80%

G7 p.407:80mm

control of seizures with medical

therapy?

49. Indicate the drug of choice for each

G7 p.407:145mm

type of seizure.

a. generalized tonic-clonic

________

valproic acid

ii.

________

Dilantin

b. absence ________

valproic acid

c. myloclonic ________

lorazepam

188

Seizures

tonic or atonic ________

lorazepam

partial

________

Tegretol

ii.

________

Dilantin

50.

True or False. Increase a given

true

G7 p.409:35mm

medication until seizures are

controlled or side effects become

intolerable, but do not rely solely on

therapeutic levels, which are only a

range in which most patients have

seizure control without side effects.

51.

True or False. 75 to 80% of epileptics

true

G7 p.409:35mm

can be controlled on monotherapy.

52.

True or False. Only 10% of epileptics

true

G7 p.409:52 mm

benefit significantly from the addition

of a second drug.

53.

True or False. If more than two AEDs

true

G7 p.409:52mm

are required, consider whether the

patient might have nonepileptic

seizures.

54.

Give the characteristics of Dilantin.

G7 p.409:155mm

half-life ________

24 hours, range 9 to 140

hours

oral loading dose ________

300 PO every 4 hours until

17 mg/kg given

Can we use IM route?

rate by IV ________

not more than 50 mg/min

permitted solution ________ ________

normal saline

How many half-lives until you reach a

5; therefore, 7 to 21 days

steady state?

55.

Complete the following about

G7 p.409:155mm

Dilantin:

How long does it take for Dilantin to

7 to 21 days

reach a steady state?

Dilantin can be safely withdrawn over a

4-week

________ period gradually.

What is the safe rate at which Dilantin

50 mg/minute

may be given IV?

56.

True or False. Fosphenytoin Na (Fos)

G7 p.411:40mm

injection has the following advantages

over conventional IV phenytoin:

The maximum administration rate is

true

three times as fast (i.e., 150 mg/minute).

Fos is water soluble and therefore may

true

be infused with saline or dextrose.

There is less venous irritation due to

true

lower pH of 8.6 to 9 compared with 12

for Dilantin.

Antiepileptic Drugs

189

57.

Study Chart.

G7 p.411:85mm

Side effects of Dilantin

a________

ataxia

ii.

b________

birth control pills less

effective

iii.

c________

cognitive dysfunction,

cerebellar degeneration

iv. d________

drug interactions, Prozac

v. e________

epidermal necrolysis

vi. g________

gingival hyperplasia

vii. h________

hirsutism

viii. l________

liver granulomas, Lupus

ix. m________

megaloblastic anemia

x. n________

newborn hemorrhage

xi. o________

osteomalacia

xii. p________

papular rash

xiii. r________

rickets

xiv. s________

Stevens-Johnson

syndrome/systemic lupus

erythematosus (SLE)-like

syndrome

xv. t________

teratogenic

xvi. v________

vitamin D antagonism

58.

Describe Tegretol.

G7 p.411:135mm

indication

p________ s________

partial seizures

ii.

t________ n________

trigeminal neuralgia

therapeutic level ________ mcg/ml

6 to 12 mcg/ml

side effects

a________

ataxia

ii.

a________

aplastic anemia

iii.

a________

agranulocytosis

iv.

b________

blood dyscrasia

c________

cymetidine

vi.

d________

drowsiness

vii. d________

diplopia

viii. D________

Darvon

ix. e________

erythromycin

x. f________

fatal hepatitis

xi. g________

gastrointestinal upset

xii. i________

isoniazid

xiii. S________

Stevens-Johnson syndrome

xiv. S________

SIADH

190

Seizures

59.

Describe carbamazepine.

G7 p.411:136 mm

also known as ________

Tegretol

test for C________, p________,

CBC, platelets, iron

i________

test according to what schedule

________ time(s) per week for

1; 3 months

________ ________

ii.

________ time(s) per month for

1; 3 years

________ ________

discontinue drug if levels fall below

WBC ________

4,000

ii.

RBC ________

3,000,000

iii.

HCT ________

iv.

platelets ________

100,000

reticulocytes ________

0.3%

vi.

iron rises to ________

higher than 150 microgram%

increase dose as follows: ________ pill

1 pill per day per week

per ________ per ________

60.

True or False. When used for

G7 p.412:17mm

treatment of trigeminal neuralgia or

partial seizures with or without

generalization, carbamazepine

(Tegretol) has both

erratic oral absorption although oral

true

G7 p.412:75mm

suspension is absorbed more readily

dramatic elevation of CBZ levels with

true

cimetidine, isoniazid, erythromycin, and

propoxyphene (Darvon) drug-drug

interaction

61.

Describe valproate.

G7 p.412:155mm

also known as ________

Depakote

indication ________

generalized tonic clonic

therapeutic level ________ to ________

50 to 100 mcg/ml

mcg/ml

side effects (list at least five)

confusion

drowsy

hyperammonemia

hair loss

liver failure

neural tube defects

platelet dysfunction

teratogenic, tremor

weight gain

62.

True or False. Acetylsalicylic acid

true

G7 p.413:44mm

displaces valproic acid from serum

protein.

63.

True or False. Valproic acid causes

true

G7 p.413:72mm

neural tube defects in 1 to 2% of

patients.

Antiepileptic Drugs

191

64.

Describe phenobarbital.

G7 p.413:95mm

indication ________ ________ ________

generalized tonic clonic

therapeutic level ________ mcg/ml

15 to 30 mcg/ml

half-life ________, steady state

5 days; 30 days

________

side effects

c________

cognitive

ii.

d________

drowsiness

iii.

p________ h________

paradoxical hyperactivity

iv.

h________ in n________

hemorrhage in newborns if

mother is on phenobarbital

65.

True or False. Indicate whether the

G7 p.413:145mm

following statements about

antiepileptic drugs are true or false:

Phenobarbital is a potent inducer of

true

hepatic enzymes that metabolize other

AEDs.

Cognitive impairment may be subtle and

true

may outlast administration of the drug

by at least several months.

They may cause hemorrhage in newborn

true

if mother is on phenobarbital.

66.

True or False. The following are

G7 p.416:70mm

characteristics of Diamox

(acetazolamide):

It reduces cerebrospinal fluid (CSF)

true

production.

It may have antiepileptic effect either

true

due to slight central nervous system

(CNS) acidosis or due to its direct

inhibition of CNS carbonic anhydrase.

67.

Describe withdrawal of AEDs.

G7 p.418:160mm

taper by ________

1 unit every 2 weeks

role of EEG ________

if EEG shows epileptiform

discharge, discourage AED

withdrawal

relapse rate________%

35%

over how long? ________ ________

8 months

68.

Complete the following about

G7 p.419:104mm

antiepileptic drugs:

What effect do antiepileptic medications

failure rate fourfold

have on birth control pills? They increase

the ________ ________ ________.

Why?

AEDs induce liver ________

microsomal cytochrome P450

________ ________ ________,

enzymes

ii.

which degrades the ________

birth control medication

________ ________.

192

Seizures

What is the effect of an isolated seizure

little—usually cause no

on pregnancy?

problem

The effect of status epilepticus on

mother and child

pregnancy is serious to ________ and

________.

69.

Considering seizures, AEDs, and birth

G7 p.419:165mm

defects, describe the following:

effect of seizure history on incidence of

double 4 to 5%

fetal malformations

phenobarbital and malformations

the worst 9.1%—highest rate

of malformations

teratogenic properties in

Dilantin

fetal hydantoin syndrome

lower IQ

ii.

Tegretol

neural tube defects—rare

iii.

valproate

neural tube defects 1 to 2%

therefore, during pregnancy

first choice is ________

carbamazepine—lowest dose

possible (Tegretol)

ii.

second choice is ________

valproic acid

iii.

add ________

folate

iv.

use ________

monotherapy

 Seizure Surgery

70. What percent of patients are not

20%

G7 p.420:85mm

controlled with medication?

71. Surgery is for refractory seizures.

G7 p.420:102mm

a. nature of seizures

severe disabling

b. length of treatment

at least 1 year

c. How many trials?

three (two mono- and one

polytherapy)

72. Name the seizure types for which

G7 p.420:115mm

surgery is appropriate.

Hint: teLi

a. t________

temporal

b. e________

extratemporal

c. L________-G________

Lennox-Gastaut

d. i________ h________ s________

infantile hemiplegia

syndrome

Seizure Surgery

193

73.

Complete the following about seizure

G7 p.420:175mm

surgery:

Can you see a seizure on diagnostic

yes

images?

Give examples.

CT with IV contrast ________

focus may enhance

________ ________

ii.

positron emission tomography (PET)

hypometabolism; 70%

________ in ________%

iii.

single-photon emission computed

increased blood flow during a

tomography (SPECT) ________

seizure

________ ________

Best test for hippocampal asymmetry for

MTS, which produces CPS is m________

mesial temporal sclerosis

t________ s________ c________

complex partial seizures in

p________ s________ in ________.

MRI

74.

Complete the following about the

G7 p.421:70mm

Wada test:

The purpose is to localize ________

dominant hemisphere (side of

________.

language)

You can be misled by

a ________ m________

arteriovenous malformation

(AVM)

ii.

p________ t________ a________

persistent trigeminal artery

iii.

h________s________ by

hippocampus supplied by

p________c________

posterior circulation

75.

Surgical disconnection operations

G7 p.422:60mm

available are

c________

callosotomy

h________

hemispherectomy

m________ s________ t________

multiple subpial transections

76.

Complete the following regarding

G7 p.423:100mm

temporal lobectomy limits:

on dominant side permitted

________

4 to 5 cm

ii.

too much ________

injures speech

on nondominant side permitted

________

6 to 7 cm

ii.

too much ________

contralateral partial upper

quadrant homonymous

hemianopsia (Hint: clpuqhh)

greater resection of

________ will cause

8 to 9 cm

ii.

________ ________

contralateral complete upper

quadrant homonymous

hemianopsia (Hint: clcuqhh)

194

Seizures

77.

Complete the following about corpus

G7 p.422:180mm

callosotomy (CC):

Indication for corpus callosotomy

d________ a________—a________

drop attacks—atonic seizures

s________

ii.

i________ h________ s________

infantile hemiplegia

syndrome

How much of the CC is resected?

anterior two thirds

Complication is ________.

akinetic mutism or reduced

verbalization temporary

Must the anterior commissure also be

no—less likely to get

sectioned?

disconnection syndrome if

spared

Contraindication

crossed dominance

Exclude by ________ ________ on all

Wada test on all left-handed

________ ________.

persons

78.

Answer the following about corpus

G7 p.423:58mm

callosotomy:

What test should be done

Wada

preoperatively?

In which group of patients?

left-handed

Why? To identify those with ________

crossed dominance

________.

79.

Answer the following about

G7 p.423:70mm

disconnection syndrome in a left-

dominant person (i.e., right-handed):

usually lasts ________

2 to 3 months

effect on

left hand ________

tactile anomia

ii.

vision ________

pseudohemianopsia

iii.

smell ________

anomia for smell

iv.

copying figures (i.e., spatial

poor with right hand

synthesis) ________ ________

________ ________

v. speech ________

reduced spontaneity

vi. urinary ________

incontinence

vii. left-sided ________ (resembles

dyspraxia (resembles

________)

hemiparesis)

occurs with ________

large lesions of corpus-

callosum

less likely to occur if ________

anterior commissure is spared

80.

Describe seizure surgery outcome

G7 p.424:125mm

expectations.

incidence of being seizure free

50%

________%

seizures reduced by at least 50% in

80%

________%

Spine and Spinal Cord



Low Back Pain and Radiculopathy

Complete the following about low

G7 p.428:70mm

back pain and radiculopathy:

True or False. Bed rest beyond 4 days

true

may be more harmful than helpful for

patients with low back pain.

True or False. 60% of patients with low

false (89 to 90% will improve

back pain will improve clinically within

in 1 month even without

1 month even without treatment.

treatment)

Pure radicular symptoms will include

LMN signs (Radiculopathy

upper motor neuron (UMN) signs or

will/may show associated

lower motor neuron (LMN) signs?

decreased reflexes, weakness,

and atrophy.)

True or False. The percentage of low-

G7 p.428:78mm

risk back pain patients who will

improve without treatment in

1 month’s time is

10%

false

20%

false

90%

true (Most low back patients

will resolve and no specific

diagnosis can be made in 85%

despite aggressive workup.)

none

false

The nucleus pulposus is a remnant of

notocord

G7 p.428:160mm

the embryonic ________.

True or False. The following may be

G7 p.429:37mm

considered a nonpathological

condition:

degenerated disc

false

protruded disc

false

bulging disc generalized > 50%

true (Bulging disc is

circumferential symmetrical

extension of the disc beyond

the end plates. Incidence

increases with age.)

herniated disc

false

focal bulging disc

false

196

Spine and Spinal Cord

True of False. Gas in the disc usually is

G7 p.429:37mm

a sign of

disc infection

false

disc generation

true

aka v________ d________

vacuum disc

An extruded disc where the free

sequestered

G7 p.429:95mm

fragment is contained by the posterior

longitudinal ligament is called a

________ disc.

Give the definition of a sequestered

G7 p.429:95mm

disc.

________ disc

extruded

that has lost ________

continuity

with its disc of ________

origin

also known as a ________ ________

free fragment

Provide the Modic classification.

G7 p.430:20mm

Type 1 T1W1________

↓↑

T2W1________

Type 2 T1W1________

↑↓

T2W1________

Type 3 T1W1________

↓↓

T2W1________

Kyphosis

G7 p.430:35mm

is measured by the ________ angle.

Cobb

Drawn with a line parallel to the

superior end plate of the body

above

________ and the

ii.

inferior end plate of the body

below

________.

10.

Scoliosis

G7 p.430:60mm

is a measure of ________ of the

convexity

curvature.

Drawn with a line parallel to the superior

uppermost

end plate of the ________ body and the

inferior end plate of the ________ body

lowermost

involved.

Draw ________ to these lines

perpendicular

and measure the ________.

angle

11.

Oswestry disability index

G7 p.430:105mm

is a scale used for ________ ________.

back pain

A score of ________% is essentially

45%

totally disabled.

A functional score is in the ________.

teens

12.

Signs of cauda equina syndrome

G7 p.431:110mm

include

a________

anesthesia (saddle)

b________

bladder incontinence

c________

continence of stool impaired

Low Back Pain and Radiculopathy

197

d________

dolor leg pain

(unilateral/bilateral)

l________

leg weakness

(unilateral/bilateral)

13.

True or False. Cauda equina syndrome

G7 p.431:110mm

may include the following:

bladder dysfunction (incontinence or

true

retention)

Faber sign or Patrick-Faber sign (flexion

false (Positive in hip joint

abduction external rotation)

disease and does not

exacerbate true nerve root

compression.)

saddle anesthesia

true

unilateral/bilateral leg weakness/pain

true

fecal incontinence

true

14.

Name the associated nerve root for

G7 p.432:28mm

each of the following:

great toe strength

L5 and some L4

dorsal foot sensation

lateral foot sensation

medial foot sensation

plantar foot sensation

Achilles reflex

15.

For patients with low back pain, red

G7 p.432:65mm

flags for a serious underlying

pathology would include signs

consistent with what conditions?

Hint: cisc

c________

cauda equina syndrome

i________

infection

s________

spinal fracture

c________

cancer

16.

Electromyography (EMG) is not helpful

3 to 4 (Results are variable

G7 p.432:65mm

to evaluate for myelopathy,

before this time.)

myopathy, or nerve root dysfunction

unless the symptoms have been

present for at least ________ weeks.

17.

True or False. Regarding plain

G7 p.434:70mm

lumbosacral spine x-rays:

Are recommended for routine evaluation

false

of back pain

When indicated AP and lateral views are

true

usually adequate

Unexpected findings occur frequently

false

Gonadal radiation is insignificant

false

Appropriate in patients who have “red

true

flags”

198

Spine and Spinal Cord

18.

True or False. Red flags include

G7 p.434:105mm

patients under age 20

true

patients over age 50

false (> 70)

drug users

true

diabetics

true

postop urinary tract patients

true

persistent pain for more than 1 week

false (> 4 weeks)

19.

Complete the following about low

G7 p.435:60mm

back pain and radiculopathy:

Signs on MRI that indicate disc

degeneration include

increase or decrease of signal

decrease

intensity on T2-weighted imaging

(T2WI)?

ii.

increase or decrease of disc height?

decrease

Signs on computed tomography (CT)

that indicate disc herniation include

increase or decrease of the normal

decrease

epidural fat?

ii.

________ of the thecal sac

indentation

Will CT show loss of concavity, or

convexity

G7 p.435:96mm

convexity, of the thecal sac?

20.

Other useful tests include the

G7 p.435:155mm

following:

myelogram-CT. Identifies contribution to

bone

cause of pressure by ________.

discography

reliability ________

controversial

ii.

interpretation ________

equivocal

iii.

false positives ________

high

iv.

may help in cases of ________

multiple discs

________ if one

v. produces ________

pain

21.

List five signs of psychosocial distress

G7 p.436:138mm

in back pain, remembering that

inappropriate response to any three

suggests distress is present.

Hint: ppaim

p________

physical exam over reaction

p________

pain on superficial palpation

a________

axial loading produces pain

i________

inconsistent SLR

m________

motor or sensory exam

inconsistent

22.

Clear indications for urgent lumbar

G7 p.436:175mm

surgery include

c________ e________ s________

cauda equina syndrome

p________ n________ d________

progressive neurological

deficit

p________ w________

profound weakness (motor)

Intervertebral Disc Herniation

199

23.

True or False. The following

G7 p.437:40mm

conservative therapy treatments have

shown proven benefit for patients

with back pain:

epidural steroids

false

transcutaneous electrical nerve

false

stimulation (TENS)

traction

false

oral steroids

false

spinal manipulation

false

muscle relaxants

false

G7 p.438:50mm

24.

Is there a risk to the use of Parafon

yes; fatal hepatotoxicity

G7 p.438:62mm

Forte? If so what is the risk?

25.

True or False. Standard discectomy

true

G7 p.440:25mm

and microdiscectomy are of similar

efficacy.

26.

Injection of chymopapain into

anaphylaxis

G7 p.440:40mm

herniated discs for treatment carries a

significant risk of ________.

27.

The patient’s chances of returning to

G7 p.440:145mm

work if off for

6 months is ________%

50%

1 year is ________%

20%

2 years is ________%

< 5%

 Intervertebral Disc Herniation

28. Enumerate the changes that occur in

G6 p.323:80mm

the intervertebral disc with increasing

G5 p.295:120mm

age.

Hint: ddddisc

a. d________

decrease disc height

b. d________

decrease in proteoglycan

content

c. d________

desiccation (loss of hydration)

d. d________

degeneration of mucoid

e. i________

ingrowth of fibrous tissue

f. s________

susceptibility to injury

g. c________

circumferential tears of the

annulus

29. Complete the following concerning

G5 p.295:121mm

the aging of a disc:

a. What decreases?

________

proteoglycan content

ii.

________

water

b. What increases?

________

mucoid degeneration

ii.

________

fibrous tissue ingrowth

c. This results in

________

annular tears

ii.

________

nucleus herniation

200

Spine and Spinal Cord

30.

Complete the following about sagittal

G7 p.441:130mm

balance:

Assessment requires a

s________

standing

ii.

l________ and

lateral

iii.

f________ spine x-ray.

full

A plumb line is drawn

from the center of ________

ii.

to the disc space of ________.

L5S1

iii.

Within ________

3.2 cm ±

iv.

behind the s________ p________ is

sacral promontory

normal.

31.

Typical disc herniation compresses the

below

G7 p.442:100mm

nerve exiting ________.

32.

True or False. Surgical indications

G7 p.442:115mm

include

cauda equina syndrome

true

numbness of foot

false

progressive symptoms

true

abnormal MRI

false

neurologic deficits

true

abnormal discogram

false

failed conservative treatment

true

pain when coughing

false

severe radicular pain for 2 weeks

false (6 weeks)

severe back pain

false

33.

The posterior longitudinal ligament

G7 p.442:160mm

is strongest in the ________.

midline

Therefore, most disc herniations occur

one side

off to ________ ________.

34.

Complete the following regarding

G7 p.443:35mm

lumbar disc herniation:

The occurrence of voiding dysfunction in

1 to 18%

lumbar disc herniation varies from

________ to ________%.

Concerning bladder symptoms, what is

the sequence from the earliest findings?

d________ b________ s________

decreased bladder sensation

ii.

u________ u________

urinary urgency

iii.

i________ f________

increased frequency due to

increased postvoiding

residual

iv. e________ and i________

enuresis (bed wetting) and

incontinence are rare

Urinary retention with overflow

cauda equina compression

incontinence is suggestive of what

diagnosis?

35.

What is the most sensitive sign of

the Lasègue sign

G7 p.443:132mm

herniated lumbar disc?

Intervertebral Disc Herniation

201

36.

The significance of a positive crossed

G7 p.443:132mm

straight-leg raising sign is

specificity for nerve root compression of

90%

________%

It suggests a more ________ HNP.

central

It may correlate with a disc ________

fragment within the axilla

________ ________ ________ of the

contralateral root.

Lasègue specificity for root compression

83%

is ________%.

For crossed Lasègue it is ________%.

90%

37.

Describe a positive Lasègue sign.

G7 p.443:155mm

Patient’s position is ________.

supine

Raise leg by the ankle until ________

pain elicited

________.

Pain occurs below ________ degrees.

It is positive in ________% herniated

83%

nucleus pulposus (HNP).

38.

Describe the following techniques to

G7 p.443:155mm

elicit indications of nerve root tension:

Lasègue sign ________ ________

straight leg raising (SLR)

________

Cram test ________ ________ with

extend knee with leg raised

________ ________

Fajersztajn sign ________ ________

crossed SLR (central

disc)= 97% HNP (crossed

Lasègue test)

femoral stretch test ________

prone, knee maximally

flexed = L2, L3, L4 root lesions

bowstring sign ________ ________

flex knee after SLR, hip pain

________ ________

persists but sciatic pain

ceases

sitting knee extension ________

sitting SLR

________

39.

Describe the Faber test.

G7 p.444:90mm

another name?

Patrick sign

perform by?

flexion abduction external

rotation

positive in?

hip pathology

40.

Complete the following regarding the

G7 p.444:110mm

Trendelenburg sign:

The affected hip ________ when the

dips

patient is walking,

which indicates the contralateral thigh

weak

adductors are ________.

202

Spine and Spinal Cord

This causes the contralateral pelvis to

tilt

________,

which is caused by a lesion of the

L5 (Affected hip dips when

________ root.

walking to indicate weakness

of contralateral thigh

adductors, or while standing

on leg with weak adductors

causes pelvis to tilt

contralateral to weakness

[L5 lesion].)

41.

Complete the following about crossed

G7 p.444:120mm

adductors sign:

Crossed adductors sign is positive when

adductors contract

knee jerk is elicited and the contralateral

thigh ________ ________.

If knee jerk is

hyperactive it suggests ________.

UMN lesion

ii.

hypoactive it suggests ________.

pathological spread due to

nerve root irritation

42.

Complete the following about

G7 p.444:133mm

Hoover’s sign:

It is a test to learn if patient’s leg

functional

weakness is ________.

Examiner places hands under patients

heels

________.

Patient is asked to lift each leg from the

bed

________.

If when lifting the normal leg the weak

down

heel pushes ________,

we know the leg has ________

strength

and the alleged weakness is ________.

functional

43.

For the listed lumbar disc level, what

G7 p.444:133mm

is the frequency of herniated disc

syndrome?

L5-S1 ________%

45 to 50%

L4-5 ________%

40 to 45%

L3-4 ________%

3 to 10%

44.

Name physical findings associated

G7 p.445:50mm

with an L5-S1 disc herniation and

where pain radiates.

reflex, a________ A________

absent Achilles tendon

reflexes

motor, g________ w________

gastrocnemius weakness

(plantar flexion)

sensory, decreased at l________

lateral malleolus and lateral

m________ and l________ f________

foot

pain, p________ c________

posterior aspect of calf to the

ankle

45.

How many vertebrae (presacral) are

G7 p.173:175mm

there in the typical human?

Intervertebral Disc Herniation

203

46.

Name three indicators for emergency

G7 p.445:160mm

lumbar surgery.

Hint: ces, pmd, ip

ces ________

cauda equina syndrome—

urinary retention or overflow

incontinence, saddle

anesthesia

pmd ________

progressive motor deficit—

“foot drop”

ip ________

intolerable pain (urgent)

47.

List potential findings for cauda

G7 p.446:30mm

equina syndrome.

Hint: cauda s

c________

can’t function sexually—

sexual dysfunction

a________

ankle jerks absent

u________

urinary

retention/incontinence

d________

diminished sphincter tone

a________

anesthesia of saddle area

s________

strength is decreased

48.

True or False. The following is

G7 p.446:90mm

classically recognized as a cause of the

cauda equina syndrome:

tumor

true

epidural spinal hematoma

true

free fat graft following discectomy

true

trauma/fracture

true

lumbar stenosis

false (Lumbar stenosis is a

more chronic process and

therefore would not

classically give an

acute/subacute presentation

of cauda equina syndrome.)

49.

True or False. In cauda equina

G7 p.447:35mm

syndrome, surgery should be

performed

stat

false

within 24 hours

false

within 48 hours

true

within 72 hours

false

within a week

false

204

Spine and Spinal Cord

50.

True or False. Comparing

G7 p.447:114mm

microdiscectomy to standard

discectomy for lumbar disc herniation,

which of the following are true?

shorter incision

true

shorter hospital stay

true

less blood loss

true

better efficacy

false (Efficacy has been

shown to be equivalent

between the two techniques.)

may be more difficult to retrieve large

true

fragments

51.

Success rate at 1 year for surgical

85%

G7 p.447:143mm

discectomy is ________%.

52.

Success rate at 1 year for

44 to 63%

G7 p.447:146mm

chemonucleolysis (CNL) is ________%.

53.

The percentage of patients of

approximately 56% at

G7 p.447:152mm

chemonucleolysis who eventually

6 months

undergo surgery for unresolved

symptoms is ________%.

54.

Complete the following about

G7 p.448:23mm

intradiscal procedures:

What percent of lumbar disc patients

10 to 15%

considered for surgery could be

candidates for intradiscal procedures?

What is the success rate of intradiscal

37 to 75%

G7 p.448:60mm

procedures?

55.

True or False. Following discectomy:

G7 p.448:140mm

epidural steroids prior to closure have no

true

benefit.

systemic steroids and bupivacaine may

true

reduce hospital stay and postop narcotic

requirements.

56.

True or False. Regarding epidural free

G7 p.448:168mm

fat graft:

It can cause nerve root compression.

true

It is believed to reduce epidural scar

Opinions on whether it

formation.

reduces scar formation are

mixed.

Some believe it may increase epidural

true

scar.

It increases the incidence of

false

postoperative infection.

It may cause cauda equina syndrome.

true, rarely

Intervertebral Disc Herniation

205

57.

Characterize complications of lumbar

G7 p.449:25mm

disc surgery.

mortality ________%

0.06% (1/1800 pts)

superficial infection ________% usual

1 to 5%; Staphylococcus aureus

organism ________%

deep infection ________%

< 1%

discitis ________%

0.5%

motor deficit ________%

1 to 8%

durotomy ________%

0.3 to 13%

after redo ________%

18%

surgical repair ________

1/1000 pts

pseudomeningocele ________%

0.7 to 2%

recurrent disc ________%

4% (1.5% first year) 10-year

follow-up

58.

Complete the following about

G7 p.449:60mm

durotomy:

What is the incidence of incidental

incidence is 0.3 to 13%

durotomy in lumbar laminectomy?

(increases up to 18% in

reoperations)

Give four possible complications related

to incidental durotomies

C________

CSF fistula-requiring repair in

~10 per 10,000

ii.

p________

pseudomeningocele

0.7 to 2%

iii.

h________

herniation of nerve roots

iv.

i________

increased epidural bleeding

59.

What is the incidence of recurrent

G7 p.449:80mm

herniated lumbar disc?

same level either side in first 10 years

~ 4%

________%

any level over 10 years ________%

3 to 19%

first year same level either side

1.5%

________%

any different incidence depending on

two times more common at

level

L4-5

same level recurrence ________%

74%

different level recurrence ________%

26% had herniated disc at

another level

60.

Complete the following regarding the

G7 p.449:103mm

anterior longitudinal ligament:

Asymptomatic perforations occur in

12%

________% of discectomies.

Depth of disc space is ________.

3.3 cm

Vascular injury produces bleeding into

50%

operative field only ________% of the

time.

Great vessel injury mortality is

37 to 67%

________%.

206

Spine and Spinal Cord

61.

Enumerate five complications related

G7 p.450:90mm

to positioning for lumbar

discectomies.

Hint: tecup

t________

tibialis anterior compartment

syndrome

e________

eyes pressure

c________

cervical spine injury

u________

ulnar nerve compression

p________

peroneal nerve compression

62.

True or False. Regarding unintended

durotomy:

Normal ambulation is not considered a

true

G7 p.451:135mm

cause for failure of dural repair.

Risk of a cerebrospinal fluid (CSF) leak is

increased in

revision surgery

true

ii.

removal of ossification of the

true

posterior longitudinal ligament

(OPLL)

iii.

high-speed drills

true

It is not considered an act of malpractice.

true

The use of fibrin glue to close is

true

advantageous.

It can be due to thinned dura by long-

true

standing stenosis.

63.

Enumerate four signs of postoperative

G7 p.452:78mm

cauda equina syndrome (i.e., from

epidural hematoma).

Hint: pain

p________

pain out of the ordinary

a________

anesthesia of saddle area

i________

inability to void

n________

numerous muscle groups

weak

64.

True or False. Regarding the outcome

G7 p.452:127mm

of surgical treatment of lumbar

herniated disc:

5% will be classified as having failed back

true

syndrome.

At 1 year the surgical group had a better

true

outcome than with conservative

treatment.

Intervertebral Disc Herniation

207

The benefit persisted at 10 years.

false (Surgery group had

better outcome at 1 year but

benefit was no longer

statistically significant at 4-

year follow-up. At 10 years

neither surgical nor

conservative treatment group

complained of sciatica or

back pain.)

63% had complete relief of back pain at

true

1 year postop.

At 5- to 10-year follow-up 86% felt

true

improved.

65.

True or False. The percentage of

G7 p.453:28mm

patients with L3-4 disc herniation

having a past history of L4-5 or

L5-S1 disc herniation is

< 10%

false

approximately 25%

true

approximately 50%

false

60 to 80%

false

almost 90%

false

66.

Characterize a herniated upper lumbar

G7 p.453:33mm

disc.

What is the incidence?

L1-2 ________%

0.28%

ii.

L2-3 ________%

1.3%

iii.

L3-4 ________%

3.6%

Most common muscle involved?

quadriceps femoris

Femoral stretch test ________

may be positive

Knee jerk ________

reduced in 50%

67.

Characterize extreme lateral lumbar

G7 p.453:105mm

disc herniations.

What is the incidence?

3 to 10%

What level is most commonly involved?

L4-5 ________%

60%

ii.

L3-4 ________%

24%

iii.

L5-S1 ________%

Enumerate four differences compared

with other common disc herniations

Straight leg raising (SLR) is negative

85 to 90%

in ________%.

ii.

Pain is increased by lateral bending

75%

in ________%.

iii.

Pain is more ________.

severe

iv.

Extruded fragments are ________.

more frequent

208

Spine and Spinal Cord

68.

Distinguishing features concerning far

G7 p.453:118mm

lateral disc herniation include the

following:

The root involved is the root ________

exiting at that level

________ ________ ________.

SLR is ________.

negative

Lateral bending is ________.

likely to produce pain

Severity of pain is ________ because

greater; dorsal root ganglion

________ ________ ________ is

compressed.

Most common levels are ________ and

L4-5 and L3-4

________.

Best surgical approach is ________

standard hemilaminectomy

________.

(and follow nerve laterally;

perform medial facetectomy)

69.

Zones in which disc herniation can

G7 p.453:128mm

occur are

c________

central

s________

subarticular

f________

foraminal

e________

extraforaminal

70.

True or False. One third of extreme

true

G7 p.454:70mm

lateral lumbar disc herniations are

missed on initial radiologic exams.

71.

To test for far lateral disc what is the

may be a most sensitive test—

G7 p.454:94mm

value of postdiscography CT scan?

94%

72.

Give the incidence of surgery for

G7 p.455:65mm

herniated discs in pediatric patients.

under 20 years of age ________%

less than 1%

under 17 years of age ________%

less than ½ of 1%

73.

Characterize intradural disc

G7 p.455:100mm

herniation.

What is the incidence?

0.04 to 1.1%

Can it be diagnosed preoperatively?

rarely

It is suspected at surgery because of a

negative exploration

________ ________.

Does it require a surgical dural opening?

rarely

74.

Characterize juxta facet cysts (JFCs).

G7 p.456:50mm

What are the types?

s________

synovial

ii.

g________

ganglion

What is the incidence?

rare (1/500 spinal CTs)

Key to diagnosis on myelography or

posterolateral filling defect

post-myelogram cat scan PMCT is a

p________ f________ d________.

Is it uni- or bilateral?

may be bilateral

Does juxta facet cysts suggest stability or

check for stability—may serve

G7 p.457:5mm

instability to the spine?

as a marker of instability

Intervertebral Disc Herniation

209

75.

Regarding failed back syndrome, the

8 to 25%

G7 p.457:120mm

failure rate for lumbar discectomy is

________%.

76.

True or False. Regarding failed back

G7 p.459:45mm

syndrome, the following is the best

test for detecting residual or recurrent

disc herniation:

myelography with postmyelogram CT

false

scan

CT scan with infusion

false

MRI without and with IV gadolinium

true

unenhanced MRI

false

77.

Answer the following about

G7 p.459:55mm

arachnoiditis:

What test is used to differentiate residual

MRI without and with IV

or recurrent disc herniation from scar

gadolinium

tissue and adhesive arachnoiditis?

Why is it so important to differentiate?

poor results for scar tissue or

Because surgical treatment for scar has

adhesive arachnoiditis

________.

78.

Characterize recurrent herniated disc.

G7 p.460:90mm

second herniation ________%

3 to 19%

10 years same level ________%

1 year same level ________%

1.5%

second recurrence ________%

79.

Does it take a larger or smaller disc

smaller; scar tissue

G7 p.460:110mm

herniation to cause symptoms in

recurrent disc? Why? Because

________ ________ prevents the nerve

from moving away.

80.

Where does the cervical root exit in

in close relation to the

G7 p.461:42mm

relation to the pedicle?

undersurface of the pedicle

81.

Complete the following table

G7 p.461:60mm

concerning cervical disc syndromes:

C4-5

C5-6

C6-7

C7-T1

C4-5

C5-6

C6-7

C7-T1

% of cervical

2 %

19 %

69 %

10 %

discs

Compressed

C 5

C 6

C 7

C 8

root

Reflex

Deltoid

Biceps

Triceps

Finger

Reflex

diminished

and

jerk

diminished

Pectoral

Brachio-

radialis

Motor weakness

Deltoid

Forearm

Hand

Flexion

Extensio

Intrinsic

Motor weakness

n Wrist

drop

Paresthesias +

Shoulde

Upper

Fingers

Hypesthesias

arm

2 and 3

4 and 5

Paresthesias +

Thumb

Hypesthesias

Radial

Forearm

Table 18.1

Reprinted with permission from Greenberg MS, Handbook of

Neurosurgery. 7th ed. New York: Thieme; 2006:318, Table 18.

210

Spine and Spinal Cord

82.

Complete the following about

G7 p.461:70mm

intervertebral disc herniation:

C6-7 disc causes a C________

radiculopathy.

C5-6 disc causes a C________

radiculopathy.

It may simulate a ________.

myocardial infarction

G7 p.461:110mm

83.

A left C6 radiculopathy can simulate

acute myocardial infarction

G7 p.461:110mm

an ________ ________ ________.

84.

C8 or T1 nerve root involvement (i.e.,

a partial Horner syndrome

G7 p.461:115mm

a C7-T1 or T1-T2 disc) may produce

________.

85.

The most common scenario for

awakening in the morning

G7 p.461:120mm

patients with herniated cervical discs

(without identifiable trauma

is that the symptoms were first

and stress)

noticed upon ________.

86.

Complete the following about

G7 p.461:60

intervertebral disc herniation:

Table 18.18

C 4-5 disc compresses C ________ root

C5 root exiting

________.

L 4-5 disc compresses L ________ root

L5 root passing

________.

87.

Narrowing the cervical foramen

Spurling sign

G7 p.461:180mm

mechanically is called ________

________.

88.

Complete the following about the

G7 p.461:181mm

Spurling sign:

performed by

examiner exerting pressure on the

vertex

________

ii.

while patient tilts head toward the

symptomatic side

________ ________

iii.

with neck ________

extended

reproduces ________ ________

radicular pain

analogous to ________

SLR for lumbar disc—

a mechanical sign

89.

Give the accuracy of radiological

G7 p.462:58mm

workups.

MRI is ________%.

85 to 90%

CT myelogram is ________%.

98%

G7 p.462:83mm

90.

True or False. To fuse or not to fuse.

G7 p.464:15mm

Fusion is beneficial to

a plate reduces pseudoarthrosis

true

a plate reduces graft problems

true

a plate maintains lordosis

true

improve clinical outcome

false

improve arm pain

true

provide more rapid relief of arm pain

true

Intervertebral Disc Herniation

211

maintain foraminal height

false

maintain disc space height

false

reduce post op kyphosis

true

improve fusion rate

true

91.

What is the incidence of vocal cord

G7 p.465:45mm

paresis due to injury of the recurrent

laryngeal nerve (RLN)?

Temporary ________ %

11%

Permanent ________ %

92.

True or False. A good way to treat

G7 p.465:70mm

vertebral artery injury is by

packing

false

direct suture

true

endovascular trapping

true

93.

The rare complication of sleep-induced

C3-4

G7 p.465:140mm

apnea can occur with anterior cervical

discectomy and fusion (ACDF) at the

level of ________.

94.

Characterize dysphagia following

G7 p.466:80mm

ACDF.

Incidence early is ________ %

60%

At 6 months only ________%

Most serious cause is ________

hematoma

Permanent recurrent laryngeal nerve

1.3%

injury ________%

95.

Characterize pseudoarthrosis

G7 p.467:60mm

following ACDF. On flexion extension

cervical spine x-rays

movement of more than ________ mm

between the ________ ________

spinous processes

lack of ________ across the fusion

trabeculation

l________ around the screws

lucency

t________ of the screws on flexion

toggling

extension films

n________ uniformly associated with

not

symptoms

96.

For patients in certain professions we

G7 p.468:125mm

prefer to do posterior cervical surgery

instead of anterior.

Which two professions?

speaker and singer

The reason is there is a ________%

incidence of ________ ________ after

voice change

anterior cervical surgery.

97.

Indications for posterior keyhole

G7 p.469:95mm

laminotomy are

s________ l________ d________

soft lateral disc

occupation of s________ or s________

singer or speaker

l________- or u________-l________

lower- or upper-level disc

d________

212

Spine and Spinal Cord

98.

Matching. Match the recommended

G7 p.470:20mm

sequence of bone removal with the

More posterior lesions with nonspecific

chiasmal lesion

visual defects, no proptosis,

hypothalamic dysfunction, pituitary

dysfunction, hydrocephalus, it is likely a

________ ________.

Treatment should be b________

biopsy

and

ii.

X________.

XRT

42.

Diencephalic syndrome consists of

G7 p.606:135mm

Hint: diencephalic

d________ s________

diencephalic syndrome

ii.

i________ a________ r________

intraventricular appearance

radiographically

iii.

e________ e________

excessively energetic

iv.

n________

macrocephaly

c________

cachexia

vi.

e________

euphoria

vii. p________

failure to thrive

viii. h________

hypoglycemia

ix. a________ h________

anterior hypothalamus

x. l________ of s________ f________

loss of subcutaneous fat

xi. i________

infiltrating

xii. c________ u________

children usually

43.

Characterize brain stem glioma.

G7 p.607:28mm

Lower-grade tumors tend to occur in the

higher

________ brain stem.

Higher-grade tumors tend to occur in the

lower

________ brain stem.

They present with ________ ________

multiple cranial nerve palsies

________ ________.

True or False. Most are surgical

false

candidates.

44.

How do upper brain stem gliomas

G7 p.607:65mm

present?

c________ f________

cerebellar findings

h________

hydrocephalus

Primary Brain Tumors

257

45.

How do lower brain stem gliomas

G7 p.607:65mm

present?

l________ c________ n________

lower cranial nerves

l________ t________ f________

long tract findings

46.

Characterize four categories of brain

G7 p.607:120mm

stem gliomas.

diffuse

location _______, _______, _______

pons, medulla, cord

ii.

glioma grade ________

malignant

iii.

percent ________%

100%

iv.

treatment ________ ________

no surgery

cervicomedullary

location ________

cervicomedullary

ii.

glioma grade ________

low

iii.

percent ________%

72%

iv.

treatment ________ ________

surgery if exophitic

________

focal

location ________

medulla

ii.

glioma grade ________

low

iii.

percent ________%

66%

iv.

treatment ________ ________

surgery if exophitic

________

exophytic

location _______, _______ _______

medulla, spinal cord

ii.

glioma grade ________

low

iii.

percent ________%

60%

iv.

treatment ________ ________

surgery is okay

________

47.

How do brain stem gliomas appear on

G7 p.607:175mm

MRI?

T1 ________

hypointense

T2 ________

increased signal

gad ________

gadolinium highly variable

48.

Complete the following about brain

G7 p.608:140mm

stem gliomas:

Prognosis of most patients is ________

6 to 12

months.

Subgroup of dorsally exophytic pilocytic

G7 p.608:150mm

astrocytomas have a longer survival of

up to ________ years.

49.

Characterize tectal gliomas.

G7 p.608:165mm

Pathology is usually ________-________

low-grade astrocytoma

________ that

presents with ________.

hydrocephalus

Diagnostic study of choice is ________.

MRI

Symptoms resolve with treatment of the

hydrocephalus

________.

258

Tumor

MRI appearance

mass arising from the q________

quadrigeminal plate

p________

ii.

on T1 ________

isointense

iii.

on T2 ________

iso- or hyperintense

iv.

gadolinium ________% ________

18% enhance

Treatment

s________ or

shunt

ii.

t________ v________

third ventriculostomy

50.

Characterize oligodendroglioma.

G7 p.609:120mm

Presenting symptom is ________ in

seizure in 50 to 80%

________%.

Calcified on

________% of skull x-rays

30 to 60%

ii.

________% of CT scan

90%

Oligodendroglioma cells in a tumor

a better prognosis

suggests what for the patient?

51.

Characterize oligodendrogliomas.

G7 p.609:155mm

They have a predilection for the

frontal lobes

f________ l________.

A classic description of cytoplasm is

fried egg

f________ e________.

The role of chemotherapy is the

primary treatment

p________ t________

after s________ r________.

surgical resection

52.

What are the chemotherapy agents

G7 p.611:30mm

used for oligodendrogliomas?

Hint: Cvpt

C________

CCNU

v________

vincristine

p________

procarbazine

t________

temozolomide

53.

Prognosis: best, middle, worst. Relate.

G7 p.611:130mm

Pure oligodendroglioma

best

Mixed oligodendroglioma

middle

Pure astrocytoma

worst

54.

Complete the following regarding

G7 p.611:130mm

prognosis:

An oligodendroglial component conveys

better

a ________ prognosis.

Pure oligo 10-year survival is ________%.

10 to 30%

Postop survival is ________ to ________

35 to 52

months.

Calcification in an oligodendrogliioma

better

(ODG) conveys a ________ prognosis.

Loss of chromosome 1p conveys a

better

________ prognosis.

Loss of chromosome 1p and 19q conveys

better

a ________ prognosis.

Primary Brain Tumors

259

55.

Describe central neurocytoma.

G7 p.612:105mm

It is located in the l________ v________

lateral ventricles

or in the s________ p________.

septum pellucidum

It tends to affect y________ a________

young adults

and is curable by t________ r________.

total resection

56.

Characterize meningiomas.

They arise from what cell of origin?

arachnoid cap cell

G7 p.613:90mm

What percentage of meningiomas occur

60 to 70%

G7 p.613:155mm

at the falx? (includes parasagittal)

With foot drop plus hypereflexia, think

parasagittal meningioma

G7 p.614:50mm

________ ________.

Olfactory groove meningiomas

G7 p.614:68mm

can produce what syndrome?

Foster Kennedy

ii.

consisting of a________, i________

anosmia, ipsilateral optic

o________ a________, and

atrophy, and contralateral

c________ p________

papilledema

iii.

What other syndrome?

frontal lobe

iv.

consisting of a________, i________

apathy, incontinence

57.

Abulia is

G7 p.614:85mm

l________ o________ w________.

lack of willpower

characteristic of damage to f________

frontal lobes

l________.

can occur with a meningioma of the

olfactory groove

o________ g________.

58.

Give a description of asymptomatic

G7 p.615:30mm

meningiomas.

The most common primary intracranial

meningioma

tumor is ________.

Percent of primary brain tumors that are

32%

meningiomas ________%

Percent that are stable in size over 2½

66%

years ________%

Percent that increase in size when

33%

observed for 2½ years ________%

What does calcification tell us about rate

slower

of growth?

Operative morbidity in patients under 70

3.5%

________%

Above 70 ________%

23%

Classic histological finding is the

psammoma body

p________ b________.

59.

Complete the following about MRI and

G7 p.616:175mm

meningioma:

Meningioma on T1W1 and T2W1 may be

isodense

________.

With contrast most will ________.

enhance

Accurately predicts sinus involvement in

90%

________%.

A common finding is a d________

dural tail

t________.

260

Tumor

60.

What metastatic cancer can mimic

prostate

G7 p.617:40mm

meningioma in the bone on MRI?

61.

Olfactory groove meningiomas tend

G7 p.617:52mm

to be fed by the

________ arteries

ethmoidal

which are branches of the ________

ophthalmic

artery.

62.

The artery of B________ and

Bernasconi and Cassinari

G7 p.617:65mm

C________ is enlarged in lesions

(a branch of the

involving the tentorium (i.e., tentorial

meningohypophyseal trunk)

meningiomas).

63.

True or False. The artery most likely to

G7 p.617:65mm

be enlarged on an angiogram

depicting a tentorial meningioma is

the

superficial temporal artery

false

artery of Bernasconi and Cassinari

true

occipital artery

false

posterior inferior cerebellar artery

false

anterior choroidal artery

false

64.

Regarding meningiomas and plain x-

G7 p.617:110mm

rays, the plain x-rays may show

b________ ________ ________

blistering of bone

c________ ________ ________

calcification in tumor 10%

d________ ________—________

density changes—

hyperostosis

e________ ________ ________

enlarged vascular grooves

f________ ________ ________

frontal fossa hyperostosis

65.

Complete the following regarding

G7 p.618:20mm

sinus involvement:

Occlusion of middle third of the SSS is

treacherous

________.

Morbidity/mortality is ________ /

8/3%

________%,

due to v________ i________.

venous infarction

66.

Complete the following regarding

G7 p.618:60mm

sinus involvement:

The sinus may be divided safely anterior

coronal suture

to the ________ ________.

Posterior to this site the sinus ________

must not

________ be divided.

If tumor is attached, it is best to leave

residual tumor

G7 p.618:82mm

________ ________.

True or False. It is safe to occlude the

false

G7 p.618:92mm

dominant transverse sinus.

Vestibular Schwannoma

261

67.

Complete the following about the

G7 p.619:140mm

removal of meningiomas:

The Simpson grading system grades the

meningiomas

degree of removal of ________.

It is important because it correlates with

recurrence rate

________ ________.

Components of the system are

In order of complexity, from

minimal surgery to complete

removal:

s________ r________, b________

small removal, biopsy

ii.

p________ r________

partial removal

iii.

c________ r________

complete removal

iv.

c________ d________

coagulate dura

r________ d________ and

remove dura and bone and

b________ and s________

sinus

Correlates with grade

________

ii.

________

iii.

________

III

iv.

________

What is the most important factor

extent of tumor removal

regarding recurrence?

68.

Five year survival for patients with

91.3%

G7 p.619:150mm

menigioma is ________%.

 Vestibular Schwannoma

69. True or False. Vestibular

G7 p.620:145mm

schwannomas (VS) usually arise from

which nerve?

a. facial nerve

false

b. cochlear nerve

false

c. nervus intermedius

false

d. vestibular nerve, inferior division

false

e. vestibular nerve, superior division

true

70. Vestibular schwannomas arise from

central and peripheral;

G6 p.429:170mm

the junction of the ________ and

Obersteiner-Redlich

________ myelin called the

________-________ zone.

71. Complete the following about primary

G6 p.429:175mm

brain tumors:

a. What is the Obersteiner-Redlich zone?

site of junction of central and

peripheral myelin

b. Where is it located?

8 to 12 mm from brain stem

c. From what cells do acoustic tumors

from the neurilemmal sheath

arise?

d. On what structure do they arise?

the superior division of the

vestibular nerve

e. Therefore, are they schwannomas or

schwannomas

neuromas?

262

Tumor

They are the result of a chromosomal

defect that leads to

loss of a t________ s________ gene

tumor suppressor

G7 p.620:148mm

on the

ii.

l________ arm of c________

long arm of chromosome 22

#________.

72.

True or False. What is the most

G7 p.620:150mm

common chromosomal defect in

vestibular schwannomas?

P53 mutation

false

gain of function mutation on Ch 3

false

loss of tumor suppressor gene on Ch 22

true

loss of tumor suppressor gene on Ch 17

false

loss of heterozygosity on Ch 10

false

73.

List the common triad of symptoms

G7 p.621:40mm

seen with vestibular schwannomas.

h________—________%

hearing loss—98%

t________—________%

tinnitus—70%

d________—________%

dysequilibrium—67%

(insidious, progressive, 70%

have high-frequency loss,

word discrimination

difficulties)

74.

A patient with good hearing has an

G7 p.621:65mm

MRI study that shows a

cerebellopontine angle mass.

Is this compatible with a vestibular

no (At the time of diagnosis

schwannoma?

virtually all VS have otologic

symptoms.)

When hearing is involved in VS, what is

lost?

low frequencies?

ii.

high frequencies?

yes (70% have a high-

frequency loss pattern.)

iii.

word discrimination?

yes (Most have impaired word

discrimination, e.g.,

telephone conversation.)

75.

What cranial nerve deficits, other than

G7 p.621:125mm

CN VIII, occur with vestibular

schwannomas?

CN ________; o________, f________

CN V; otalgia, facial

n________, and t________ c________

numbness, and taste changes

CN ________; f________ w________

CN VII; facial weakness

CN ________; h________ and

CN IX, X, XII; hoarseness and

d________

dysphagia

Vestibular Schwannoma

263

76.

Answer the following about vestibular

G7 p.621:135mm

schwannoma:

As tumor increases in size the following

C, B, A (Facial numbness

occur in what sequence?

occurs earlier than facial

A. facial weakness

weakness even though CN V

B. facial numbness

is only slightly compressed,

C. impaired hearing

whereas CN VII is severely

distorted early—a paradox.

Why? Differential resilience of

motor nerves relative to

sensory nerves.)

What size tumor causes fifth and seventh

larger than 2 cm

nerve compression?

77.

Complete the following about

G7 p.621:170mm

vestibular schwannomas:

What percentage of patients have no

66%

abnormal physical findings except for

hearing loss?

The Weber test lateralizes to the

uninvolved (Hearing loss is

________ side.

sensorineural.)

Is the Rinne test positive or negative if

positive

hearing is preserved?

What is normal for the Rinne test?

air conduction > bone

conduction = positive means

normal. (Note: An A is better

than a B.)

78.

Complete the following about primary

G7 p.622:75mm

brain tumors:

In VS what causes nystagmus?

vestibular involvement

What fibers constitute VS?

A________ ________ n________

Antoni A narrow elongated

e________ b________ f________

bipolar fibers

ii.

A________ ________ l________

Antoni B loose reticulated

r________ f________

fibers

What is the growth rate for VS?

1 to 10 mm/year

What is the proper follow-up protocol, if

repeat scan at 6-month

no surgery is done?

intervals for 2 years then once

each year

Recommend surgery if what occurs?

size changes by ________

> 2 mm/year

ii.

or symptoms ________

progress

264

Tumor

79.

Answer the following about the House

G7 p.622:15mm

and Brackmann scale:

What does the House-Brackmann scale

clinical measurement of facial

measure?

nerve function

What are the categories?

normal

mild

moderate

moderate-severe

severe

no movement

Synkinesis is defined as i________

involuntary movement

m________ accompanying a v________

accompanying a voluntary

m________.

movement

80.

Answer the following about vestibular

G7 p.625:30mm

schwannomas:

and

G6 p.431:110mm

What is the growth rate of vestibular

slow (1 to 10 mm/year)

schwannomas?

Do some shrink?

yes (6%)

Can they remain stable?

yes

Can they grow faster?

yes (2 to 3 cm/year)

If followed most will show ________ in

enlargement

3 years.

81.

Describe the audiometric findings for

50/50 rule

G7 p.623:90mm

“useful” hearing in vestibular

schwannomas.

pure-tone audiogram threshold of

≤ 50%

________

speech discrimination of ________

≥ 50%

82.

Complete the following regarding the

G7 p.623:108mm

Gardener-Robertson system:

The Gardener-Robertson system is used

hearing preservation

to grade h________ p________.

It consists of

testing patient with ________

pure tones (decibels [db]) (If

________ of increasing loudness.

patient hears dB 0 to 30—

excellent hearing; 30 to

50 dB—serviceable; 50 to

90 dB—nonserviceable;

90 dB max—poor; not

testable—none)

ii.

Evaluating patient ability to

speech discrimination

understand spoken words is called

(understands words spoken

________ ________.

to him or her correct 100 to

70%—excellent; 70 to 50%—

serviceable; 50 to 5%—

nonserviceable)

Useful hearing is judged to be present up

50/50 patient can hear at

to a cutoff point of ________.

50 dB or less and understands

at least 50% of words spoken

to him or her

Vestibular Schwannoma

265

83.

Name the findings for the following

G7 p.622:175mm

tests in vestibular schwannomas:

pure-tone audiogram

hearing difference between

each ear > 10 to 15 dB

speech discrimination

4 to 8% score (normal is 92 to

G7 p.623:45mm

100%)

brain stem auditory evoked response

prolonged I-III and I-V

G7 p.624:45mm

(BSAER)

interpeak latencies

electronystagmography (ENG)

abnormal if one ear has ≤ 35%

G7 p.624:20mm

of total (Normally, 50% of

response is from each ear.)

84.

Complete the following concerning

G7 p.623:20mm

vestibular schwannoma:

It causes what kind of hearing loss?

sensorineural loss of high

tones

This is the same as the loss from

________

old age

ii.

________

loud noise exposure

Think tumor if the difference between

10 to 15

the ears on audiogram is more than

________ dB.

85.

True or False. A 55-year-old male is

G7 p.624:65mm

referred for evaluation of a 4.0 cm

right cerebellopontine angle (CPA)

mass. You conclude it is a vestibular

schwannoma. The following is least

likely to be a factor in your treatment.

Give rationale for each.

pure-tone audiogram score of 95 dB

false (Audiogram with

G7 p.622:175mm

hearing threshold < 50 dB

may allow consideration of

hearing—sparing procedure,

but with a score of 95 dB

hearing—saving procedure is

not an option.)

effacement of the fourth ventricle with

false (Evidence of

G7 p.621:170mm

modest ventriculomegaly

hydrocephalus warrants CSF

diversion—needs a shunt.)

stereotactic surgery 2 years previously

true (Stereotactic

radiosurgery 2 years

previously is long enough for

SRS effect to be over. Surgery

should be avoided during the

interval 6 to 18 months after

SRS because this is the time

of maximum damage from

the radiation.)

266

Tumor

contralateral (left) vestibular

false (Bilateral VS unable to

schwannoma, 1.0 cm in diameter

preserve right hearing

[95 dB], will need to plan for

second procedure to address

the left-sided lesion. Chance

of preserving left hearing—

35 to 71% for a 1 cm tumor.)

angiogram showing absence of right

false (Atretic/obstructed right

transverse sinus

transverse sinus allows

consideration of

translabyrinthine and

suboccipital approach as a

combined procedure.)

86.

True or False. Possible treatments for

G7 p.624:120mm

vestibular schwannomas include

expectant observation, following

true

symptoms, hearing testing, serial CT, or

MRI

radiation therapy, external beam

true

radiation therapy (EBRT)

radiation therapy, stereotactic

true

radiosurgery (SRS)

retrosigmoid (suboccipital) resection

true

translabyrinthine resection

true

extradural subtemporal (middle fossa

true

approach) resection

87.

Complete the following about

G7 p.625:115mm

vestibular schwannoma treatment:

Under 20 mm can be ________,

observed

Protocol is to retest at 6, 12, 18, 24, 36,

months

48, 60, 84, 108, and 168 ________.

Growth of more than ________ mm

between studies deserves treatment.

Tumors larger than 15 to 20 mm should

treated

be ________.

Tumors with cysts can ____ ____.

grow dramatically

G7 p.625:103mm

88.

Matching. Match outcome with

G7 p.625:170mm

technique with microsurgery and SRS.

Outcome:

① hearing, ② facial nerve function, ③

trigeminal neuropathy, ④ tumor control

Technique:

microsurgery

③, ④

stereotactic radiosurgery

①

equal

②

89.

Classically, vestibular schwannomas

forward and superiorly in 75%

G7 p.627:92mm

push the facial nerve in which

direction? Pushed ________ and

________ in ________% of cases.

Vestibular Schwannoma

267

90.

Complete the following about

G7 p.627:145mm

vestibular schwannomas:

Small, laterally located intracanalicular

subtemporal extradural (also

vestibular schwannomas can be removed

known as middle fossa

by what surgical approach?

approach)

A disadvantage is that the seventh nerve

injured at the geniculate

may be ________ at the ________

ganglion.

An advantage is that hearing function

preserved

may be ________.

91.

What is the size vestibular

< 2 to 2.5 cm

G7 p.627:80mm

schwannomas should be considered

for hearing and CN VII preservation

procedures?

92.

What are the advantages of

G7 p.628:65mm

translabyrinthine approach for

resecting vestibular schwannomas?

early identification of the ________

facial nerve

less risk to ________ and ________

cerebellum and lower cranial

________ ________

nerves

best for VS that are located ________

intracanalicular

93.

What are the disadvantages of a

G7 p.628:65mm

translabyrinthine approach for

resecting vestibular schwannomas?

Hearing is ________.

sacrificed

Exposure is ________.

limited

CSF leak is ________.

more common

94.

Complete the following about

G7 p.628:135mm

vestibular schwannomas:

and also

G6 p.434:122mm

What are the disadvantages of

suboccipital approach (also known as

retrosigmoid) for vestibular

schwannomas?

higher ________ when compared

morbidity

with the translabyrinthine approach

ii.

small tumors ________

difficult to remove in lateral

recess of internal auditory

canal (IAC)

iii.

facial nerve is located ________

on blind side deep to the

tumor

The advantage is the possibility of

hearing preservation

h________ p________.

268

Tumor

95.

Complete the following about

G7 p.629:145mm

localizing the VII nerve origin:

The seventh nerve originates in the

pontomedullary

________ sulcus,

anterior to the eighth nerve by

________ mm.

It lies just anterior to the foramen of

Lushka

________

and anterior to a tuft of ________.

choroid

It originates ________ mm cephalad to

the ninth nerve.

96.

How do you treat postoperative facial

G7 p.630:130mm

nerve weakness after vestibular

schwannoma resection?

N________ T________

Natural Tears (2 drops to eye

every 2 hours as needed)

L________

Lacrilube (to eye and tape eye

at bedtime)

t________

tarsorrhaphy within a few

days if there is a complete CN

VII palsy

Anastomose by attaching a portion of

the ________ nerve to the ________

hypoglossal

nerve

facial

When there is no CN VII function and

nerve is known to be divided you

2 months

may anastomose in ________

ii.

nerve is known to be intact you may

1 year

anastomose in ________

97.

True or False. The following symptoms

G7 p.630:155mm

of brain stem compression from a

vestibular schwannoma if present

postop is not likely to improve:

nausea

false (Nausea resolves with

time.)

vomiting

false (Vomiting resolves with

time.)

balance difficulties

false (Balance difficulties clear

rapidly.)

ataxia

true (Ataxia from brain stem

dysfunction may be

permanent.)

Vestibular Schwannoma

269

98.

True or False. The routes of CSF

G7 p.631:20mm

leakage after vestibular schwannoma

resection can be via the

apical cells

true (to tympanic cavities or

eustachian tube—most

common)

vestibule

true (Posterior SCC is usually

entered by drilling—via the

oral window.)

perilabyrinthine cells

true (and tracks to mastoid

antrum)

mastoid air cells

true (at craniotomy site)

99.

True or False. The following is the

G7 p.631:20mm

most likely source of a postoperative

CSF fistula after resection of a

vestibular schwannoma:

mastoid air cells via craniotomy site

false

through the vestibule of the bony

false

labyrinth via the oval window

perilabyrinthine cells to the mastoid

false

antrum

apical cells to the tympanic cavity or

true (All are potential routes

eustachian tube

but this is the most frequent.)

100.

With vestibular schwannoma,

G7 p.631:20mm

postoperative routes for rhinorrhea

are

Hint: avam

a________

apical cells to tympanic cavity

and down the eustachian

tube

v________

vestibule after drilling the ICA

into the semicircular canal via

oval window

a________

to antrum of mastoid via the

perilabyrinthine cells

m________

mastoid air cells at site of

craniotomy

101.

What are treatment strategies for CSF

G7 p.631:92mm

leakage after vestibular schwannoma

resection?

What percent stop spontaneously?

25 to 35%

Do what with the head of the bed?

elevate

Place a drain where?

lumbar

If hydrocephalus is present place a

CSF shunt

________.

If leak persists ________.

reexplore surgical site to pack

with tissue or apply bone wax

270

Tumor

102.

What are common complications of

G7 p.631:175 mm

vestibular schwannoma surgery?

CSF leak in ________%

4 to 27%

infection in ________%

5.7% meningitis

stroke in ________%

0.7% cerebrovascular

accident (CVA)

CN VII palsy in ________%

0 to 50%

hearing loss in ________%

34 to 43%

death in ________%

103.

Complete the following concerning

G7 p.632:25mm

hearing loss and CN VII weakness after

suboccipital removal of VS:

Tumor < 1 cm

CN VII preserved, ________%

95 to 100%

ii.

CN VIII preserved, ________%

57%

Tumor 1 to 2 cm

CN VII preserved, ________%

80 to 92%

ii.

CN VIII preserved, ________%

33%

Tumor > 2 cm

CN VII preserved, ________%

50 to 76%

ii.

CN VIII preserved, ________%

104.

Complete the following concerning

G7 p.632:25mm

hearing loss after suboccipital removal

of VS:

Hearing preserved ________% with

14 to 48%

tumors < 1.5 cm

After SRS hearing preserved ________%

26%

with tumors < 3 cm

105.

Concerning acoustic neuroma (i.e.,

G7 p.633:18mm

vestibular schwannoma), recurrence

following microsurgery is

________% after

________ years follow-up.

106.

Complete the following concerning

G7 p.633:47mm

SRS for vestibular schwannoma:

Dose recommended is ________.

14 Gy

Local control achieved is ________%.

94%

107.

For vestibular schwannoma, what are

G7 p.633:60mm

local control rates for?

microsurgery

97%

SRS

94%

108.

When is the time of maximal damage

G7 p.633:75mm

(possible tumor enlargement) from

radiation to vestibular schwannomas?

from ________ to ________ months

6 to 18

This is important to know because it can

enlargement (Surgery should

produce a false appearance of tumor

be avoided during the interval

________.

of 6 to 18 months after SRS

because of damage from

radiation and the appearance

of tumor enlargement.)

Vestibular Schwannoma

271

109.

Most pituitary tumors are benign

adenohypophysis

G7 p.634:25 mm

tumors that arise from the ________.

110.

Answer the following about pituitary

G7 p.634:37mm

tumors:

By definition what is the maximal size of

1 cm

a pituitary microadenoma?

Larger tumors are called ________.

macroadenomas

50% of pituitary tumors are less than

5 mm

________ mm.

111.

Complete the following about

G7 p.634:48mm

pituitary carcinoma:

Occurence is ________.

rare

They are usually i________.

invasive

They are usually s________.

secretory

The most common hormones are

a________

adrenocorticotropic hormone

(ACTH)

ii.

P________

PRL

True or false. They can metastasize.

true

Prognosis of 1-year mortality is

66%

________%.

112.

True or False. Regarding pituitary

G7 p.634:67mm

tumors:

10% of intracranial tumors

true

most common in third to fourth decades

true

affect females more often

false (Pituitary tumors affect

both sexes equally.)

higher incidence in MEN or MEA

true

syndrome

usually present due to endocrine

true

disturbance or mass effect

113.

Complete the following about

G7 p.634:70mm

pituitary tumors:

MEN stands for ________ ________

multiple endocrine

________.

neoplasms

MEA stands for ________ ________

multiple endocrine

________.

adenomatosis

Incidence of pituitary tumors in MEN is

increased

________.

114.

Complete the following about clinical

G7 p.634:125mm

presentation of pituitary tumors:

Hormone hypersecretion

________% of adenomas secrete

65%

active hormone

ii.

prolactin ________%

48%

iii.

growth hormone ________%

10%

iv.

ACTH ________%

thyroid-stimulating hormone (TSH)

________%

272

Tumor

Growth hormone

If elevated it is due to a ________

pituitary adenoma

________

ii.

More than ________% of the time.

95%

Corticotropin

aka ________

ACTH

ii.

Excess causes ________ ________

Cushing disease

iii.

Nelson syndrome can develop only

adrenalectomy

in patients who have had an

________.

115.

Complete the following about

G7 p.634:180mm

hormone hyposecretion:

Due to ________ of the normal pituitary

compression

In order of sensitivity to compression

Hint: go look for the adenoma

G________

ii.

L________

iii.

F________

FSH

iv.

T________

TSH

A________

ACTH

Most common symptom

G7 p.635:52mm

o________ h________

orthostatic hypotension

ii.

e________ f________

easy fatigability

selective loss of one hormone consider

hypophysitis

________

A________

ACTH

ii.

A________

ADH

True or False. Diabetes insipidus is seen

false

with preop pituitary tumors.

116.

Complete the following about mass

G7 p.635:95mm

effect:

The pituitary tumor that gains the

greatest size is

non-secreting. (True or False)

true

ii.

of the secreting type is the

prolactinoma

________

The tumor that is usually the smallest is

ACTH

the ________ tumor.

117.

Patient presents with sudden onset of

G7 p.635:155mm

headache, visual disturbance,

ophthalmoplegia, and reduced mental

status.

Consider diagnosis of p________

pituitary apoplexy (due to

a________.

expanding mass in sella

turcica resulting from

hemorrhage or necrosis)

This may occur in macroadenomas in as

3 to 17%

G7 p.636:110mm

many as ________%.

Vestibular Schwannoma

273

118.

Complete the following about primary

G7 p.636:150mm

brain tumors:

What are the indications for rapid

decompression after pituitary apoplexy?

s________ c________

sudden constriction of visual

field (VF)

ii.

s________

severe deterioration of acuity

iii.

mental status changes due to

hydrocephalus (complete

h________

tumor removal usually not

necessary)

What else needs to be done?

treat with corticosteroids

119.

Complete the following about the

G7 p.637:15mm

anatomic classification of pituitary

adenoma:

Named the ________ system

Hardy

Suprasellar extension

none

ii.

A expanding into the ________

suprasellar

cistern

iii.

B anterior recesses of third

obliterated

ventricle ________

iv. C

________ of third ventricle

floor; displaced

________

Floor of sella

Intact or ________ ________

focally expanded

ii.

Sella ________

enlarged

Sphenoid extension

Localized ________ of sella floor

perforation

ii.

Diffuse ________ of sella floor

destruction

120.

Complete the following about

G7 p.637:135mm

functional pituitary tumors:

What is the most common functional

prolactinoma

pituitary tumor?

What are its most common symptoms?

In females, ________-________

amenorrhea-galactorrhea

ii.

called the syndrome of ________-

Forbes-Albright

________

iii.

causes ________ in males

impotency

It arises from anterior pituitary

lactotrophs

l________.

The most common cause of amenorrhea

pregnancy

is p________.

121.

Answer the following about Cushing

G7 p.638:25mm

syndrome:

Which hormone?

ACTH

It is produced by a ________ tumor.

pituitary

It is called Cushing ________.

disease (if tumor is in the

pituitary hypercorticalism, it

is called Cushing disease)

274

Tumor

122.

Complete the following about

G7 p.638:25mm

pituitary adenoma:

Adrenocorticotropic hormone (ACTH)—

Cushing disease

secreting pituitary adenoma is known as

________ ________.

Other causes of hypercortisolism are

Cushing syndrome

known as ________ ________.

Nelson disease manifests by

hyper-________ due to

hyperpigmentation

G7 p.639:30mm

ii.

cross reactivity of m________-

melanocyte-stimulating

s_______ h_______ with _______.

hormone (MSH) with ACTH

123.

Complete the following about Nelson

G7 p.639:30mm

syndrome:

Follows bilateral ________

adrenalectomy

In only ________ to ________% of cases

10 to 30%

Classic triad of

h________

hyperpigmentation

ii.

↑ in ________

ACTH

iii.

Enlargement of the ________

pituitary tumor

________

iv. Usually occurs ________ to

1 to 40 years

________ years after adrenalectomy

G7 p.639:90mm

The earliest sign is the ________

linea negra

________

ii.

Midline pigmentation from the pubis

umbilicus

to ________

iii.

And hyperpigmentation of

scars, gingivae

________ ________ and areolae

Have an ACTH level greater than

200

G7 p.639:130mm

________ Ng/L

The normal being less than ________

Ng/l

124.

Complete the following about

G7 p.638:25mm

pituitary adenoma (Cushing

syndrome):

caused by ________

hypercortisolism—from any

source

exogenous source ________

ingestion of steroids

endogenous sources

p________ t________, ________%

pituitary tumor, 60 to 80%

ii.

a________ t________, ________%

adrenal tumor, 10 to 20%,

15 to 25%

iii.

e________ t________, ________%

ectopic tumor, 1 to 10%,

5 to 10%

125.

Characterize the typical Nelson

G7 p.639:53mm

syndrome scenario.

patient who had ________ ________

Cushing syndrome

had a surgical procedure ________

adrenalectomy

develops ________

hyperpigmentation

occurs in ________% of such patients

10 to 30%

due to ________-________ of ________

cross-reactivity of ACTH and

and ________

MSH

Vestibular Schwannoma

275

126.

To remember Cushing syndrome

G7 p.638:36mm

versus disease:

syndrome due to ________

steroids from any source

Hint: syndrome = steroids

disease due to ________

pituitary only

127.

List the findings in Cushing syndrome.

G7 p.638:115mm

Hint: steroids

s________

striae

t________

thin skin

e________

ecchymosis

r________

reduced libido

o________

obesity

i________

impotence, increased blood

pressure

d________

diabetes

s________

skin hyperpigmentation

128.

List the findings in Cushing syndrome.

G7 p.639:15mm

Hint: Ectopic sources of acth secretions

Hint: (a) c³ t² h

(a)

c________

carcinoma small cell lung

c________

carcinoid

c________

(pheo) chromocytoma

t________

thymoma

t________

thyroid carcinoma

h________

islet cell pancreas

129.

Characterize pituitary adenoma in

G7 p.638:36mm

Cushing disease.

secretion of ________

ACTH

most are small < ________ mm

5 mm

only ________% are large enough to

10%

produce mass effect

cells produce ________

proopiomelanocortin (POMC)

which contains the precursors for:

A________

ACTH

ii.

a________

alpha-MSH

iii.

b________

beta-lipotropin

iv.

b________

beta-endorphin

e________

met-enkephalin

130.

Criteria for biochemical cure is IGF-1

G7 p.639:180mm

level less than ________ Ng/mL.

276

Tumor

131.

Chart. List the effects of excess growth

G7 p.640:50mm

hormone alphabetically.

arthropathy

acromegaly

bone

cartilage

cardiomyopathy

diabetes

entrapment of nerve

syndromes

frontal bossing

fatigue

glucose intolerance

gigantism

hyperhydrosis

hypertension

headaches

infection

increased hand and foot size

joint pain

macroglossia

malignancies

neoplasia

neuropathy

oily skin

polyps

paresthesias

prognathism

palmar hyperhydrosis

respiratory obstruction

rings no longer fit

shoe size enlarges

sleep apnea

skeletal changes

soft tissue swelling

thickened heel pad

thyromegaly with normal

thyroid studies

132.

Describe the hypothalamic pituitary

G6 p.441:55mm

axis dysfunction in acromegaly.

Hypothalamus produces ________.

GHRH

________ causes the pituitary to make

GHRH; GH

________.

________ affects the liver, which

GH, somatomedin-C, IGF--

produces ________ also known as

1 (hypothalamic GHRH

________.

stimulates pituitary GH

secretion. Excess GH induces

IGF-1 secretion from liver.)

What medication can suppress GH

somatostatin (Acromegaly

release?

findings are due to IGF-1, also

known as somatomedin-C.)

Vestibular Schwannoma

277

133.

Complete the following about

G6 p.441:56mm

acromegaly growth hormone

releasing hormone (GHRH):

produced in the ________

hypothalamus

causes

sy________

synthesis of growth hormone

ii.

se________

secretion

iii.

re________

release

somatomedin-C

produced in the ________

liver

ii.

due to stimulus of ________

iii.

produces ________ ________

systemic effects

iv.

also known as ________ ________

insulin-like growth factor (IGF-

________

1, also known as

somatomedin-C)

134.

True or False. Regarding acromegaly,

G6 p.441:60mm

somatostatin suppresses growth

hormone by interfering with

synthesis

false

secretion

false

release of the hormone

true

135.

Answer the following about

G7 p.640:18mm

acromegaly:

Is there any possible ectopic source of

yes

growth hormone?

If so, what?

carcinoid tumor

136.

Answer the following about

G7 p.640:135mm

acromegaly:

What effect on mortality does elevated

2 to 3 times

GH levels have? Mortality rates are

________ to ________ times normal

due to

c________

cancer

ii.

c________

cardiomyopathy

iii.

d________

diabetes

iv.

h________

hypertension

i________

infection

vi.

n________ ________

neural entrapment

137.

Concerning growth hormone, what

G7 p.640:136 mm

effects does GH have on the

following?

mortality rates

↑

blood pressure

↑

diabetes

↑

infections

↑

cancer

↑

cardiomyopathy

↑

closure of epiphyseal plates in children

delays closure

138.

Which pituitary tumor is

G7 p.638:90mm

least likely to cause mass effect?

ACTH-producing tumor

most likely to cause mass effect?

prolactin-producing tumor

278

Tumor

139.

Describe the mass effects of pituitary

G7 p.637:80 mm

tumors.

What are the structures compressed?

Hint: cop

c________ s________

cavernous sinus

ii.

o________ c________

optic chiasm

iii.

p________

pituitary

What are the mass effects usually seen in

nonfunctioning pituitary tumors?

p________, f________ p________,

ptosis, facial pain, diplopia

d________

ii.

b________ h________

bitemporal hemianopsia

iii.

h________

hypopituitarism

140.

Describe the Hardy system of pituitary

G7 p.637:14mm

adenoma classification.

suprasellar extension of tumor

________

no suprasellar extension

ii.

________

fills suprasellar cistern

iii.

________

anterior recess of III ventricle

iv.

________

displaces floor of III ventricle

________

intracranial (intradural)

vi.

________

intracavernous sinus

(extradural)

invasion

I s________ n________

sella normal

ii.

II s________ e________

sella enlarged

iii.

III l________ p________ of

localized perforation of sella

s________ f________

floor

iv. IV d________ d________ of

diffuse destruction of sella

s________ f________

floor

v. V s________ via C________

spread via CSF

141.

What percentage of pituitary

G7 p.637:15mm

adenomas become locally invasive?

142.

Cavernous sinus invasion

G7 p.637:60mm

can be suspected if medial wall of sinus is

pushed laterally

________ ________.

can be diagnosed if carotid artery is

encased

________.

143.

What is the most definite sign of

carotid artery encasement

G7 p.637:70mm

cavernous sinus invasion?

144.

Matching. Match the light microscopic

G7 p.641:60mm

appearance of each of the following

pituitary tumors with its most

common secretory product.

Secretory product:

① growth hormone; ② ACTH;

③ prolactin; ④ TSH; ⑤ nonsecretory

Appearance:

chromophobe

⑤

acidophil

①

basophil

②

Vestibular Schwannoma

279

145.

What percentage of pituitary tumors

G7 p.641:30mm

are

endocrine-secretorily active?

70%

endocrine-secretorily inactive?

30%

146.

Complete the following about tumors

G7 p.641:105mm

of the neurohypophysis and

infundibulum:

Most common tumor in the posterior

metastasis

pituitary is ________.

Most common primary tumor is the

granular cell tumor (GCT)

________ ________ ________.

If this tumor is suspected, operative

transcranial

approach is ________.

MRI appearance is identical to ________.

adenoma

147.

True or False. Baseline endocrinologic

G7 p.642:80mm

evaluation of patients presenting with

pituitary tumors includes the

following among others:

8 a.m. cortisol (24 hours is better)

true

serum prolactin level

true

somatomedin-C

true

serum thyroid-stimulating hormone

true

(TSH)

serum T3

false

148.

List the baseline pituitary function

G7 p.642:81mm

tests.

Hint: pqrsTT

p________

prolactin serum level

q________

Q-cortisol 24 hour

r________

rest FSH LH FBS (rest means

the rest of the endocrine

studies) (reproductive)

s________

somatomedin C

T________

TSH serum level

T________

T4 serum level

149.

What is the chiasm location in

G7 p.642:80mm

relationship to the sella and the

resulting visual field defect?

prefixed ________%

5%, homonymous

hemianopsia

above ________%

80%, bitemporal hemianopsia

postfixed ________%

5%, ipsilateral loss of vision,

junctional scotoma

contralaterally, so-called “pie

in the sky,” due to

compression of the anterior

knee of Willebrand

280

Tumor

150.

Visual fields is tested using a small red

chiasmal

G7 p.642:170mm

stimulus because desaturation of color

is an early sign of ________

compression.

151.

Answer the following about pituitary

G7 p.643:24mm

adenoma:

What is the classic finding when a tumor

bitemporal hemianopsia

compresses the optic chiasm?

What occurs in patients with a postfixed

chiasm?

s________ o________ q________

superior outer (temporal)

quadrantanopsia

ii.

j________ s________

junctional scotoma

due to compression of the k________ of

knee of von Willebrand

v________ W________

What occurs in patients with a prefixed

homonymous hemianopsia

chiasm?

(complete or incomplete)

due to compression of ________ or

one or both

________ optic tracts

152.

Characterize the pattern of

G7 p.643:24mm

progressive visual field defect caused

by pituitary tumor.

Fig. 21.1

a. first

superior temporal field

b. second

inferior temporal field

c. third

inferior nasal field

d. fourth

superior nasal field

e. clockwise in the ________ field

right

f. counterclockwise in the ________ field

left

Vestibular Schwannoma

281

153.

Describe baseline pituitary evaluation

G7 p643:70mm

before surgery. (*Note: Results not

listed here are also not listed in the

Greenberg 6^th edition because results

vary with age, gender, and menstrual

cycle.)

Hint: P₈R³st²

p________

prolactin

normal

< 30

measured in

ng/mL

maybe abnormal

25 to 150

abnormal value

> 150

ii.

(sounds like q) c________

cortisol 8 a.m.

normal

6 to 18

measured in

μg/100 mL

maybe abnormal

5 to 10

abnormal value

> 10

iii.

*(r rest) f________-s________

follicle-stimulating hormone

________

(FSH)

normal

measured in

maybe abnormal

abnormal

iv.

*(r rest) l________

luteinizing hormone

normal

measured in

maybe abnormal

abnormal

(r rest) f________ b________

fasting blood sugar

s________

normal

65 to 99

measured in

mg/dL

maybe abnormal

abnormal

vi.

*s________

somatomedin-C

normal

0.31 to 1.4

measured in

U/mL

maybe abnormal

abnormal

vii.

*T________

TSH

G7 p.445:15mm

normal

0.4 to 5.5 mg

measured in

μg

maybe abnormal

peak 2x normal

abnormal

if TSH stimulation test causes

peak 2x normal

viii.

*T________

TH thyroid hormone

normal

0.8 to 15

measured in

free T4 index

maybe abnormal

abnormal

282

Tumor

Also include diagnostic studies of

f________ v________ f________

formal visual fields

ii.

M________ w________ and

MRI with and without

w________ e________

enhancement

iii.

C________-c________ v________

CT-coronal views (11 tests in

all)

154.

Thickening of the pituitary stalk and

lymphocytic hypophysitis

G7 p.643:83mm

loss of a single pituitary hormone is

also see

strongly suggestive of l________

G7 p.1217:55mm

h________.

155.

True or False. Regarding lymphocytic

G7 p.643:83mm

hypophysitis:

also see

G7 p.1217:55mm

more common in men than women

false (more common in

women; only 5 cases reported

in men)

associated with postpartum state

true

affects multiple pituitary hormones

false (affects single hormone)

rarely causes diabetes insipidus

false (often causes diabetes

insipidus)

156.

Characterize screening for Cushing

G7 p.643:92mm

syndrome.

8 a.m. cortisol level: normal value is

6 to 18 μg/100 mL

________

24-hour urine-free cortisol ________

more accurate—almost 100%

sensitive and specific

157.

True or False. Findings of primary

G7 p.645:45mm

hypothyroidism with secondary

pituitary hyperplasia include the

following:

prolonged and elevated TSH response to

true

TRH stimulation

low T4

true

hypoglycemia

false (Hypoglycemia is not

part of the syndrome.)

elevated TSH

true

elevated prolactin

true (Enlarged pituitary

causes stalk effect and

prolactin increases.)

pituitary enlarges because of

thyrotropin releasing

hypertrophy of the ________ producing

hormone (TRH)

cells

pituitary enlargement occurs because of

negative feedback from

the loss of ________ ________ from

thyroid hormones

________ ________

Vestibular Schwannoma

283

158.

Considering pituitary tumors,

G7 p.644:35mm

prolactin is under:

inhibitory control of the ________ and

hypothalamus

the infundibular stalk.

Therefore, injury to the hypothalamus or

prolactin inhibitory factor

injury to the pituitary stalk causes loss of

(PRIF)

the inhibitory chemical ________.

Does this lead to an increase or decrease

increase

in prolactin in the patient?

159.

After surgery for prolactin-secreting

G7 p.644:33mm

tumor, what should you think if

prolactin is still elevated

but less than 90 ng/mL ________?

injury to stalk and/or

hypothalamus due to loss of

prolactin inhibitory factor

(PRIF), which is present in the

intact stalk and hypothalamus

but more than 150 ng/mL ________?

persistent tumor

160.

Answer the following about large

G7 p.644:160 mm

adenomas with normal prolactin:

What should you instruct the laboratory

perform several dilutions and

to do?

rerun the PRL (This may be a

false negative.)

This false negative is called the ________

hook

effect.

161.

True or False. Extremely high prolactin

true (hook effect)

G7 p.644:160mm

levels may produce false negatives

due to the tendency for large numbers

of PRL molecules to prevent formation

of PRL-antibody-signal complexes in

assays.

162.

Complete the following about cortisol

G7 p.647:115mm

reserve insulin tolerance test:

Insulin IV will promptly lower ________

blood sugar

________.

Hypoglycemia is a ________.

stressor

In response the body produces

cortisol

________.

An increment in baseline more than

________ mg/dL

ii.

to a peak of ________ mg/dL is

normal.

An increment of less than ________

mg/dL

ii.

to a peak less than ________ mg/dL

iii.

indicates a need for g________

glucocorticoid replacement

r________.

163.

The most useful test for acromegaly is

IGF-1

G7 p.647:170mm

an ________ level.

284

Tumor

164.

Complete the following about

G7 p.647:170mm

acromegaly and somatomedin-C:

also known as ________

IGF-1

normal fasting level ________

0.67 U/mL (range 0.31 to

1.4 U/mL)

in acromegalics level is ________

6.8 U/mL (range 2.6 to

21.7 U/mL)

165.

Some growth hormone-secreting

prolactin

G7 p.653:20mm

pituitary tumors also secrete

also

________.

G6 p.447:115mm

166.

Complete the following about growth

G7 p.648:15mm

hormone:

Normal basal fasting level is ________.

less than 5 ng/mL

Acromegalic patients have levels

greater than 10 ng/mL

________ than ________.

Due to pulsatile secretion of GH sporadic

50 ng/mL

peaks up to ________ can occur.

Is this a reliable test?

167.

Complete the following about the size

G7 p.648:115mm

of the pituitary gland:

Size of pituitary gland

in men up to ________ mm

ii.

in women up to ________ mm

9, 11

child-bearing age up to

________ mm

iii.

in adolescent girls up to

________ mm

size of stalk is same size as b________

basilar artery

differential diagnosis of large stalk

l ________

lymphoma

ii.

l________ h________

lymphocytic hypophysitis

iii.

g________ d________

granulomatous disease

iv.

h________ g________

hypothalamic glioma

168.

Findings compatible with pituitary

G7 p.648:145mm

microadenoma on MRI include the

following:

True or False. Lack of early (< 5 minute)

true

gadolinium enhancement

True or False. Pituitary stalk deviation

true

True or False. Thickened pituitary stalk

false (A thickened pituitary

stalk is not compatible with

adenoma.)

True or False. Late (after 30 minute)

true

gadolinium enhancement

True or False. Timing of scan after

true (In early scanning, under

gadolinium infusion is important.

5 minutes, tumor will not

enhance but gland will. In late

scanning, after 30 minutes,

tumor will enhance as well

and may not be seen because

the gland is also enhanced.)

Vestibular Schwannoma

285

The best time to scan for pituitary tumor

is ________ minutes after infusion.

At that time what enhances?

normal pituitary tissue

Microadenoma is seen since it does

not enhance

________ ________.

169.

Characterize the neurohypophysis.

G7 p.648:160 mm

normally on T1WI is ________ ________

high signal

possibly because it contains ________

phospholipids

absence of this sign suggests ________

diabetes insipidus

________

170.

For pituitary tumors, what is the

G7 p.649:42mm

benefit of coronal CT slices?

sphenoid series ________

midline (can be identified by

the anatomy of sphenoid

sinus septa)

sella floor ________

erosion (of the sella floor to

indicate presence of the

tumor on one side)

171.

What is the medical treatment for the

following?

growth hormone-secreting tumors

octreotide

G7 p.653:45mm

________

ACTH-secreting tumors ________

ketoconazole

G7 p.654:148mm

prolactin-secreting tumors ________

bromocriptine

G7 p.651:60mm

172.

Complete the following about

G7 p.649:100mm

nonsecreting pituitary adenomas:

Usual treatment is with ________ or

Sx or XRT

________

Medication (bromocriptine) may

20%

reduce tumor size by ________%

ii.

Due to the paucity of ________

dopaminergic

receptors

Octreotide reduces the tumor by

10%

________%

Follow-up by MRI at: _______, ________,

0.5, 1, 2, and 5

________, and ________ years

173.

Surgical indications are v________

visual field defects

G7 p.649:165mm

f________ d________.

174.

Tumors secreting GH or ACTH

G7 p.650:70mm

warrant ________ treatment

surgical

because the secretion is ________

harmful

and there is no effective ________

medical treatment

________.

175.

Complete the following about

G7 p.650:125mm

hormone replacement therapy:

corticosteroids

am replacement dose is _______ mg

and

ii.

pm replacement dose is ______ mg

286

Tumor

thyroid hormone

Do not replace if patient has

adrenal insufficiency

________ ________

ii.

Synthroid ________ μg/d

125

176.

Complete the following about primary

G7 p.651:24mm

brain tumors:

Above what level of prolactin is surgery

above 500 ng/mL

unlikely to normalize the prolactin?

In such a case what should your

medication—dopamine

treatment be?

agonists bromocriptine—not

surgery

177.

Complete the following about

G7 p.651:40mm

prolactinoma as treatment with

bromocriptine:

Response should be evident in ________

4 to 6

to ________ weeks.

________% will not respond.

18%

________% will continue to enlarge on

bromocriptine.

Upon discontinuation tumor may

rapidly enlarge

________ ________.

178.

What does bromocriptine do?

G7 p.651:80 mm

binds to r________

receptors

inhibits s________ and s________ of

synthesis and secretion of PRL

________

lowers prolactin to about ________% of

~10%

its elevated amount

reduces tumor size by ________% in

75% in 6 to 8 weeks

________

restores ________

fertility

harms patient by ________

producing fibrosis

This reduces good surgical results by

50%

________%.

Therefore, decide about surgery within

6 months

________ ________ of starting

bromocriptine.

Prolactinomas may ________ ________

enlarge rapidly

upon discontinuation of the drug.

179.

If response to dopamine agonists is

G7 p.652:90mm

satisfactory

continue to treat for ________ to

1 to 4

________ years and

check prolactin every ________.

year

If tumor not visible on MRI may

discontinue

________.

Recurrence rate is highest in the

first year

________ ________.

180.

True or False. Surgery is not indicated

true

G7 p.652:125mm

in elderly asymptomatic patients with

GH-secreting pituitary tumors.

Vestibular Schwannoma

287

181.

Answer the following about pituitary

G7 p.652:130mm

tumors:

best treatment for prolactinoma PRL <

transsphenoidal surgery

500

best treatment for prolactinoma PRL >

surgery not recommended if

500

PRL > 500

best treatment if prolactin is < 500 try

medical treatment

________ first

meds will fail in ________%

18%

treat the failures with ________

transsphenoidal surgery

acromegaly best treatment is ________

transsphenoidal surgery

(Surgery is not recommended

for elderly; instead use

bromocriptine and/or

octreotide.)

cure for microadenoma ________%

85%

cure for macroadenoma ________%

30%

Cushing disease best treatment is

transsphenoidal surgery

________.

182.

In acromegaly, IGF-1 stabilizes after

months

G7 p.652:185mm

surgery in ________.

183.

Complete the following about

G7 p.652:98mm

acromegaly and octreotide:

suppresses ________ ________

growth hormone

reduces ________, ________% to

GH in 71%, 50 to 66% become

________% become ________

normal

reduces ________ in ________%,

GF-1 in 93%, 66% become

________% become ________

normal

requires injection ________

3 times per day

side effects can be ________

cholelithiasis (10 to 25% of

patients)

may also be useful in ________

thyrotropic (TSH)-secreting

tumors

184.

True or False. Common side effects of

G7 p.653:120mm

octreotide include the following:

decreased GI motility

true

sweating

false

diarrhea

true

steatorrhea

true

bradycardia

true

cholelithiasis

true

185.

Complete the following about Cushing

G7 p.654:148mm

disease and ketoconazole:

blocks ________ ________ synthesis

adrenal steroid

normalizes ________% of patients

75%

normalizes ________ ________ cortisol

urinary free

normalizes ________ steroids

hydroxycortico

may cause

adrenal ________

insufficiency

ii.

hepato-________

hepatotoxicity

288

Tumor

186.

True or False. Regarding bilateral total

G7 p.654:90mm

adrenalectomy:

It is better tolerated than

false

transsphenoidal pituitary surgery.

Lifelong glucocorticoid replacement is

true

required.

Lifelong mineralocorticoid replacement

false

G7 p.654:94mm

is not required.

Development of Nelson syndrome is

false (Not rare; it occurs in

rare.

30%.)

187.

Complete the following about

G7 p.655:85mm

thyrotropin-secreting adenomas:

First-line treatment is ________

transsphenoidal surgery

________.

The tumor may be difficult to remove

fibrous

and ________.

Medical treatment is with the same

acromegaly

agent as for ________

ii.

namely, ________.

octreotide

188.

Complete the following about

G7 p.655:147mm

pituitary tumors and radiation therapy

side effects on:

cognition

m________ d________

memory disturbances

ii.

l________

lethargy

vision

o________ n________ and

optic nerve and chiasm injury

c________ i________

ii.

b________

blindness

endocrine

h________

hypocorticalism

ii.

h________

hypothyroidism

tumor

n________

necrosis

ii.

a________

apoplexy

189.

Radiation therapy should be routinely

G7 p.655:160mm

used:

True or False. Following surgical removal

false

of pituitary adenomas

True or False. If recurrence occurs

false (Repeat surgery is

recommended.)

Radiation is appropriate in the following

circumstances

if recurrence ________ ________

can't be removed

________

ii.

if recurrence ________ ________

mass continues to grow

________ ________

Vestibular Schwannoma

289

190.

Answer the following about radiation

G7 p.656:35mm

for acromegaly:

True or False. It is the preferred

false

treatment.

90% of patients reach normal growth

hormone levels in ________ years.

During this time they are exposed to

unacceptable

________ levels of GH

and are also exposed to the risks of

radiation

________.

191.

True or False. Indications for pituitary

G7 p.649:164mm

surgery include

also

G6 p.452:140mm

prolactinomas with levels greater than

true (Medical treatment will

500 ng/mL not controlled with surgery

not suffice; both are needed

in 18%.)

Cushing disease

true (Medical therapy is not

adequate.)

acromegaly

true

macroadenoma

true (if not PRL secreting)

visual field defect

true

sudden visual loss

true

to obtain tissue for diagnosis

true

hypopituitarism

false

Nelson syndrome

true

192.

What is the medical preparation for

G7 p656 :90mm

surgery?

Steroids ________ ________

stress doses

Hypothyroid patients ideally to be

4 weeks

treated before surgery for ________

________

193.

Regarding pituitary tumors, what

the sphenopalatine artery—a

G7 p. 656:117mm

artery might you encounter laterally

branch of the maxillary artery,

as you open the Hardy speculum and

which is the eighth branch of

expose the keel of the sphenoid bone?

the external carotid artery

194.

Concerning the sublabial approach for

G7 p.656:118mm

pituitary adenoma, what structures

can be injured?

artery g________ p________

greater palatine artery

branches (AKA) descending

palatal arteries (They enter

the incisive foramina and

incisive canals.)

nerve n________

nasopalatine nerves (Branch

of maxillary nerve [V2] serves

roof of mouth, upper lip, and

teeth.)

195.

True or False. Regarding pituitary

G7 p.656:150mm

tumors:

Minimal enlargement of the sella and a

true

large suprasellar mass indicate a

transcranial approach.

290

Tumor

The subtemporal approach provides

false (The subfrontal

good visualization of the optic nerves,

approach is better to see this

chiasm, and carotid arteries.

anatomy.)

The subfrontal approach may be more

true

difficult with prefixed chiasm.

The transsphenoidal approach is

true

preferred for microadenomas.

196.

Conditions indicating transsphenoidal

G7 p.656:151mm

approach that may not be appropriate

for this pituitary tumor include:

sella not ________

enlarged

large ________ mass

suprasellar

e________ tumor

extrasellar

sphenoid ________

sinusitis

197.

Complete the following about

G7 p.657:185mm

transspehenoidal surgery:

Open the sella exactly in the ________.

midline

Use the ________ ________ as your

nasal septum

landmark.

Is the sphenoid sinus septum also

no, it is unreliable

reliable?

198.

Complete the following about

G7 p.659:100mm

intraoperative disaster:

Profuse arterial bleeding suggests

carotid injury

________ ________.

It can usually be controlled by ________.

packing

The operation should ________

be stopped

________

ii.

and ________ be done.

angiography

If ________ is found

pseudoaneurysm

ii.

the patient is at risk for ________

lethal rupture

________.

It must be eliminated by ________

endovascular techniques

________

ii.

or surgical ________.

trapping

199.

True or False. Common complications

G7 p.659:135mm

of transsphenoidal pituitary surgery

include

transient diabetes insipidus

true (common but lasts less

than 3 months)

basilar artery injury

false (Basilar artery injury is

rare.)

cerebrospinal fluid leakage

true (Cerebrospinal fluid

leakage is common, 3.5%.)

carotid artery rupture

false (Carotid artery rupture is

rare.)

Vestibular Schwannoma

291

200.

True or False. Treatment for diabetes

G7 p.661:125mm

insipidus includes the following:

desmopressin 2 to 4 mg daily

true

(subcutaneous)

vasopressin 5 U (IV) every 6 hours

true

desmopressin 10 to 40 mg twice a day

true

clofibrate 500 mg four times a day by

true

mouth

201.

Complete the following regarding

G7 p.661:26mm

postoperative pituitary surgery:

diabetes insipidus

can be diagnosed if urine output is

250 cc

more than ________ cc

ii.

for ________

1 to 2 hours

ACTH (corticotropin) reserve

take patient off steroids for

24 hours

________ hours

ii.

check ________ a.m. cortisol level

6 a.m.

iii.

normal cortisol level at 6 a.m. is

above 9 μg/dL

________

iv. suspect low cortisol is ________

3 to 9 μg/dL

v. definitely low cortisol is ________

below 3 μg/dL

To assess for residual tumor don’t do CT

4 months

G7 p.661:40mm

until ________ ________ postoperative.

202.

Characterize the good outcomes of

G7 p.662:60mm

transsphenoidal surgery.

vision ________ ________

much improved

prolactin secreting tumors in ________%

25%

growth hormone secreting tumors in

20%

________%

Cushing disease—microadenomas in

85%

________%

acromegaly

microadenoma in ________%

85%

ii.

macroadenoma in ________%

30%

iii.

all acromegalics in ________%

50%

recurrence ________%

12%

203.

Regarding acromegaly, cure requires:

G7 p.662:130mm

basal (morning) serum GH of less than

5 ng/mL

________

suppression after ingesting glucose less

2 ng/mL

than ________

somatomedin-C (I-GF-1) of normal

normal range—0.31 to

________ acromegalics ________

1.4 ng/mL; acromegalics

2.6 to 21.7 ng/mL

204.

Characterize biochemical outcome

G7 p.662:120mm

acromegaly.

Recommended is a ________ serum GH

morning

level.

Cure is considered GH level of less than

________ ng/ml.

292

Tumor

In tumors less than 10 mm this is

85%

achieved in ________%.

In all acrogmegalics cure is achieved in

50%

________%.

Macroadenomas cure is achieved in

30%

________%.

These patients should be seen for follow-

6 to 12

up every ________ to ________ months.

205.

Answer the following about

G7 p.663:130mm

craniopharyngiomas:

Craniopharyngiomas are lined with what

stratified squamous

types of cells?

epithelium

They arise from ________ ________

anterior superior margin

________ of the pituitary.

Show calcification

on histology in ________%

50%

ii.

on plain x-ray in children in

85%

________%

iii.

on plain x-ray in adults in ________%

40%

Do they contain cysts?

yes

Do they contain solid components also?

yes

Do they undergo malignant

degeneration?

206.

The pituitary stalk can be recognized

G7 p.664:95mm

by its pattern

of l________ s________

longitudinal striations

which are the long ________ ________.

portal veins

207.

Describe the Rathke cleft cyst (RCC).

G7 p.665:25mm

Where are they located?

intrasellar—pars intermedia

How common are they?

incidental finding in 20% of

autopsies

Do you find RCC together with pituitary

adenomas?

Why?

They arise from the same

tissue, which goes one way or

the other but not both.

appearance on CT

cystic?

yes

ii.

density?

low density

iii.

enhancement?

may have capsular

enhancement

208.

True or False. Rathke cleft cysts arise

G7 p.665:35mm

in/at the:

anterior superior margin of pituitary

false

neurohypophysis

false

pars intermedia

true

none of the above

false

Vestibular Schwannoma

293

209.

Answer the following about Rathke

G7 p.665:35mm

cleft cyst:

Where is a Rathke cleft cyst located?

in the pars intermedia of

pituitary

From what does Rathke cleft cyst

remnant of Rathke pouch—

originate?

stomodeum

210.

True or False. A 14-year-old patient is

G7 p.665:45mm

found to have a 3 cm low-density

lesion in the sella turcica. Surgical

excision reveals a single-layer cuboidal

epithelium. The most likely diagnosis is

mucocele

false

epidermoid

false

craniopharyngioma

false

Rathke cleft cyst

true

211.

With a colloid cyst, hydrocephalus

lateral ventricles

G7 p.665:90mm

involves only the ________ ________.

212.

Complete the following about primary

G7 p.665:120mm

brain tumors:

True or False. A 40-year-old male

complains of intermittent headaches and

gait difficulty. CT scan of head shows a

cystic mass in the third ventricle. The

most likely diagnosis is

neurocystercercosis

false

ii.

meningioma

false

iii.

choroid plexus papilloma

false

iv.

colloid cyst

true

the site of origin of this cystic mass is the

d________ e________ of the recess

diencephalic ependyma

of the postvelar arch called

ii.

the p________

paraphysis (that is, an

evagination of the roof of the

third ventricle)

213.

True or False. A 27-year-old male with

G7 p.110:110mm

a history of a colloid cyst who

underwent a right frontal

ventriculoperitoneal shunt 3 days ago

returns to the emergency room (ER)

with recurrence of severe headaches

and gait difficulty. Treatment at this

time could be

removal of ventriculoperitoneal shunt

false

externalization of shunt

false

placement of left frontal ventricular

true (Colloid cysts can

drainage

obstruct both foramina of

Monro; thus, bilateral

ventricular drainage is

needed.)

medical management and reassurance

false

fenestration of the septum pellucidum

true

removal of colloid cyst

true

294

Tumor

214.

Complete the following about colloid

G7 p. X:111mm

cyst:

shunt

r________ b________ s________

requires bilateral shunts

ii.

or f________ of s________

fenestration of septum

p_______ plus o_______ s_______

pellucidum plus one shunt

transcallosal approach complications

v________ i________

venous infarction

ii.

f________ i________

fornix injury

transcortical approach complications

s________ ________%

seizures 5%

stereotactic aspiration

f________—r________

failure—recurrence

ventriculoscopy

f________—r________

failure—recurrence

215.

Answer the following about

G7 p.667:80mm

hemangioblastoma:

What is the most common primary

hemangioblastoma

intraaxial tumor in the adult posterior

fossa?

It can occur sporadically or as part of

von Hippel-Lindau

v________ ________-________ disease.

What blood problem is associated?

P________ also known as

polycythemia

ii.

e________ due to

erythropoietin

iii.

e________.

erythropoitin

Incidence of brain tumors ________%

1 to 2%

Characteristic appearance c________

cystic cerebellar mass with

c________ m________ w________

mural nodule

m________ n________

Should you remove the cyst wall?

216.

True or False. A 42-year-old male

G7 p.667:80mm

presents with headache, nausea,

vomiting, and right-sided dysmetria.

Laboratory studies revealed a

hemoglobin of 17. The likely diagnosis

metastatic lesion

false

renal cell carcinoma

false

hemangioblastoma

true (headache, nausea,

vomiting-hydrocephalus-

dysmetria-cerebellum high

hemoglobin-polycythemia)

high-grade astrocytoma

false

217.

Complete the following about the

G7 p.667:80mm

posterior fossa hemangioblastoma:

May be associated with

p________, e________

polycythemia, erythrocytosis

ii.

v________ H________-L________

von Hippel-Lindau disease

d________

Vestibular Schwannoma

295

218.

Complete the following about von

G7 p.667:130mm

Hippel-Lindau disease (VHL):

Has hemangioblastomas tumors or cysts

in the following sites:

c________

cerebellum

r________

retina

b________

brain stem

s________

spinal cord

p________

pheochromocytomas

c________

cysts in kidneys

219.

Complete the following about von

G7 p.667:135mm

Hippel-Lindau disease (VHL):

Most common in the ________

cerebellum

Second most common in the ________

retina

Always manifests before age ________

Incidence is 1 in every ______ persons

35,000

220.

True or False. The mode of inheritance

G7 p.667:175mm

of von Hippel-Lindau disease is:

autosomal recessive

false

autosomal dominant

true

sex linked

false

multifactorial

false

221.

What is the diagnostic criteria for VHL?

G7 p.668:60mm

One sign of VHL is needed if there is

family history

a ________ ________

ii.

It will be present in ________%

80%

Two signs of VHL if it is a ________

de novo

________ mutation

222.

Complete the following about tumors

G7 p.668:105mm

associated with VHL:

Occur in younger persons if patient has

VHL

________

True or False. Cysts are associated with

true

HGBs.

Cerebellar HGBs are located in the

s________

superficial

ii.

p________

posterior

iii.

s________ half of the hemisphere

superior

________% of cerebellar HGBs were

7%, vermis

found in the ________

223.

Complete the following about spinal

G7 p.668:145mm

cord hemangioblastoma:

________% are in the cervical and

90%

thoracic cord.

________% are located in the posterior

96%

cord.

________% of spinal HGBs are associated

90%

with VHL.

________% symptoms are associated

95%

with syringomyelia.

296

Tumor

224.

The only disease with bilateral

VHL

G7 p.668:180mm

endolymphatic sac tumors is

________.

225.

Complete the following about VHL:

G7 p. : mm

Retinal hemangioblastomas occur in

50%

________%

Typically located in the ________

periphery

Frequently ________

multiple

Treat with laser ________

photocoagulation

226.

Complete the following about renal

G7 p.669:130mm

cell carcinoma (RCC):

Which is the most common malignant

RCC

tumor in VHL?

Usually it is a ________ ________

clear cell carcinoma (CCC)

________.

It is the cause of death in ________ to

15 to 50%

________% of VHL patients.

227.

Complete the following about surgical

G7 p. : mm

treatment of HGB:

Reserved until ________

symptomatic

Treatment of choice for ________

accessible cystic

________ HGBs

True or False. The wall must be removed.

false

The ________ ________ must be

mural nodule

removed.

228.

Answer the following about

G7 p.671:17mm

hemangioblastoma (HGB):

True or False. Starts at an earlier age in

von Hippel-Lindau disease

true

ii.

sporadic cases

false

In sporadic cases

Most originate in the ________

cerebellum

ii.

Next most common is the

spinal cord

s________ c________

iii.

________% of patients with

30%

cerebellar HGB have VHL

Erythropoitin liberated by the tumor may

erythrocytosis

G7 p.671:53mm

be responsible for the ________

If one HGB is suspected we should do an

G7 p.671:140mm

MRI scan of the ________ ________.

entire neuraxis

ii.

Vertebral angiography usually

intense vascularity

demonstrates ________ ________.

iii.

CBC reveals ________.

polycythemia

229.

Complete the following about surgery

G7 p.672:22mm

on a solitary HGB:

It may be ________ in sporadic HGB

curative

but not in ________.

VHL

Preoperative ________ may be helpful.

embolization

CNS Lymphoma

297

230. Complete the following about surgery

G7 p.672:40mm

on HGB:

a. They should be removed using ________ AVM

technique.

b. Avoid ________ removal.

piecemeal

c. Work along the ________

margin

d. and ________ the blood supply.

devascularize

 CNS Lymphoma

231.

Complete the following about CNS

G7 p.672:95mm

lymphoma:

Associated with an eye condition called

uveitis

________

How frequently does it occur?

1 to 2% of all brain tumors

What relationship does CNS lymphoma

up close to ventricles

have with the ventricles?

CT characteristics

plain CT tumor is ________

hyperdense to brain

ii.

contrast CT tumor ________

enhances homogeneously

iii.

reminiscent of ________ ________

“fluffy cotton balls”

________

reaction to steroids ________

tumor may completely

resolve

CSF is positive for lymphoma cells in

only 10%

________%.

What form of radiation therapy is given?

whole brain

232.

True or False. A 70-year-old male with

G7 p.672:107mm

a homogeneously enhancing lesion in

the central gray matter and corpus

callosum is suspected of having CNS

lymphoma. What would make this

diagnosis more likely and how is it

properly diagnosed?

hydrocephalus

false

café au lait spots

false

uveitis

true (diagnosed with slit

lamp)

proximal muscle weakness

false

233.

A 73-year-old male with a history of

G7 p.675:55mm

recently diagnosed CNS lymphoma by

biopsy presents to the ER with stupor

and progressively deteriorating

mental status. CT of the brain reveals

the mass but no other abnormalities.

True or False.

emergent surgical excision

false

ii.

radiation therapy

true (CNS lymphomas are

very sensitive to radiation.)

iii.

chemotherapy

false

iv.

steroids

false

followed by ________

chemotherapy

298 Tumor

 Chordoma

234. Complete the following about

G7 p.675:165mm

chordoma:

a. It has a characteristic cell type called

physaliphorous

________.

b. It occurs in the clivus in ________%.

35%

c. It occurs in the sacrococcygeal area in

55%

________%.

d. The recurrence rate after surgery is

85%

________%.

e. X-rays show ________ lesions with

lytic lesions with calcifications

________.

f. Is there any gender predominance?

yes, male predominance for

sacral chordomas

g. What are the risks to bladder and bowel

control

from a sacrectomy between S1 and

most will be impaired

S2?

ii.

from a sacrectomy between S2 and

50% will be impaired

S3?

 Ganglioglioma

235. True or False. Physaliphorous cells are

G7 p.675:165mm

distinctive features of

a. schwannomas

false

b. pinealoblastomas

false

c. gangliogliomas

false

d. chordomas

true

236. Answer the following about

G7 p.677:165mm

gangliogliomas:

a. True or False. Peak age of occurrence for

gangliogliomas is

children

true (Peak age is 11.)

ii.

elderly

false

iii.

no age predilection

false

iv.

unknown

false

b. presenting symptom is ________

seizure

 Paraganglioma

237. Complete the following about

G7 p.678:175mm

paraganglioma:

a. used to be called ________

chemodectomas

b. now also called what if at

carotid bifurcation: c________

carotid body tumor

b________ t________

ii.

jugular foramen: g________

glomus jugulare

j________

iii.

adrenal medulla: p________

pheochromocytoma

Paraganglioma

299

may secrete

e________

epinephrine

ii.

n________

norepinephrine

iii.

c________

catecholamines

Resection of carotid body tumor has a

morbidity of up to ________%

50%

ii.

mortality of ________%

5 to 13%

238.

Complete the following about

G7 p.679:80mm

pheochromocytoma:

We used to study ________

catecholamines

Better test now is

f________

fractioned

ii.

p________

plasma

iii.

m________

metanephrines

Imaging is ________ with ________

MRI; contrast

239.

Carotid body tumor

G7 p.679:140mm

and ________ are the most common

pheochromocytoma

paraganglioma.

occur bilaterally in ________%.

240.

True or False. A 40-year-old female

G7 p.679:160mm

complains of a painless mass in her

right upper neck and has deviation of

the tongue to the right. The following

is the most likely source of her mass:

carotid bifurcation

true (Paragangliomas present

with mass in neck and CN XI

and CN XII nerve palsy.)

superior vagal ganglion

false

inferior vagal ganglion

false

hypoglossal nerve neuroma

false

auricular branch of vagus

false

241.

Regarding carotid body tumors,

high

G7 p.680:25 mm

treatment carries a ________

complication rate.

242.

Complete the following about glomus

G7 p.680:50mm

jugulare tumors:

They arise from ________ ________.

glomus bodies

Are they vascular or avascular?

vascular

Receives branches from the ________

external carotid artery

________ ________

a________ p________

ascending pharyngeal

ii.

p________ a________

posterior auricular

iii.

o________

occipital

iv.

i ________ m________

internal maxillary

________ portion of the ________

petrous portion of the

________ ________

internal carotid artery

300

Tumor

243.

Characterize glomus jugulare tumors.

G7 p.680:88mm

female to male ratio

6:1

Does it occur bilaterally?

presenting symptoms

h________ l________

hearing loss

ii.

p________ t________

pulsatile tinnitus

clinical exam abnormalities

h________ l________ and

hearing loss and vertigo CN

v________

VIII

ii.

t________ p________ t________

loss of taste posterior third of

tongue CN IX

iii.

v________ c________ p________

vocal cord paralysis CN X

iv.

t ________ and SCM w________

trapezius and

sternocleidomastoid (SCM)

CN XI weakness

v. t________ a________ and CN

tongue atrophy CN XII and

________ i________ to mass and

ipsilateral to mass and side

s________ of the hearing loss

244.

During surgical excision of a

G7 p.680:170mm

paraganglioma the patient is noted to

have abrupt onset of hypotension and

respiratory distress. This is most likely

related to

intracranial pressure (ICP) changes

vasovagal response

inadvertent compression of airway

tumor manipulation

yes

due to r________ of h________ or

release of histamine or

b________

bradykinin

245.

Describe glomus jugulare differential

G7 p.681:15 mm

diagnosis.

Distinguish from ________ ________ in

vestibular schwannoma

the CPA

True or False. By CT enhancement

false (Both enhance.)

True or False. By presence of cystic

true (VS may have cystic

component

component.)

True or False. By angiography

true (GJ [glomus jugulare] is

very vascular.)

What else will be learned by

whether the transverse sinus

angiography?

is occluded

246.

Complete the following about glomus

G7 p.681:120mm

jugulare:

What chemical should be tested for?

vanillylmandelic acid (VMA)

If elevated, indicative of secretion of

catecholamines

________

similar to ________

pheochromocytoma

Treat medically with ________ and

alpha and β blockers

________

New clinical marker is ________ (NMN)

normetanephrine

G7 p.679:90mm

Ependymoma

301

 Ependymoma

247.

Complete the following about

G7 p.682:165mm

ependymoma:

Incidence among intracranial tumors in

5 to 6%

adults is ________%.

Incidence among pediatric brain tumors

is ________%.

It occurs in children ________%.

70%

Incidence among spinal cord gliomas is

60%

________%.

Drop metastases occur in ________% of

11%

patients.

What is the pathology of the distinctive

myxopapillary

G7 p.683:190mm

type that occurs in the filum terminale?

248.

Characterize intracranial

G7 p.683:160mm

ependymomas.

usually occur in the ________ ________

fourth ventricle

dangerous to remove because they

floor of the fourth ventricle

invade the ________

specifically they invade the ________

obex

current operative mortality ________%

5 to 8%

Is mortality higher in adults or in

children

children?

249.

Answer the following about postop

G7 p.684:123mm

ependymoma:

What must we do?

When? ________ weeks postop

What should be sent to lab?

10cc CSF

If positive follow with ________

radiation

G7 p.684:140mm

True or False. Ependymoma is sensitive

true

to radiation.

Name the tumor that is more sensitive.

medulloblastoma

250.

True or False. Regarding primary brain

G6 p.471:180mm

tumors:

Calcifications, although uncommon in

false (< 10%)

medulloblastomas, may be seen ~20% of

the time.

The “banana sign” in the fourth ventricle

true

refers to the medulloblastoma rather

than to ependymomas.

Ependymomas rank second only to

true

medulloblastomas in radiosensitivity.

Medulloblastomas arise from the roof of

true

the fourth ventricle, the fastigium.

Ependymomas arise from the floor of the

true

fourth ventricle, the obex.

251.

What is the most common glioma of

ependymoma

G7 p.685:100mm

the spinal cord below the midthoracic

region?

302 Tumor

 Embryonal Tumors

252.

Complete the following about

G7 p.685:135mm

embryonal tumors:

PNET stands for

P________

Primitive

ii.

N________

Neuro

iii.

E________

Ectodermal

iv.

T________

Tumors

These tumors include

P________

Pineoblastoma

ii.

N________

Neuroblastoma

iii.

E________

Esthesioneuroblastoma

iv.

R________

Retinoblastoma

M________

Medulloblastoma

They are ________ indistinguishable

histologically

ii.

but genetically ________.

distinct

Medulloblastomas are different. They

G7 p.685:140mm

contain

Beta ________

catenin

ii.

APC ________

mutations

iii.

And some originate from the

external granular

________ ________

iv. layer of the ________.

cerebellum

253.

Embryonal tumors

G7 p.685:178mm

require entire ________ ________

spinal axis

evaluation.

Cranial radiotherapy is avoided

before ________ years of age

ii.

to avoid i________ impairment

intellectual

iii.

and growth r________.

retardation

254.

Complete the following about

G7 p.686:25mm

supratentorial PNET (sPNETs):

They occur in children under ________

years of age.

They occur ________ in adults.

rarely

Histologically, they are ________ to

identical

medulloblastoma.

They are ________ aggressive than

medulloblastomas.

ii.

Survival is ________ and they

shorter

iii.

respond to therapy ________.

poorly

Embryonal Tumors

303

255.

True or False. Regarding

G7 p.686:55mm

medulloblastoma:

It accounts for 15 to 20% of all

true

intracranial tumors in children.

It is the most common malignant

true

pediatric brain tumor.

There is a standardized chemotherapy,

false (There is no

G7 p.687:115mm

including lomustine (CCNU) and

standardized regimen; CCNU

vincristine.

and vincristine are usually

reserved for recurrences.)

Patients with residual medulloblastoma

true

postresection and dissemination are a

poor risk, with only a 35 to 50% chance

of being disease free at 5 years.

256.

Complete the following about

G7 p.686:95mm

medulloblastoma:

The clinical history is ________,

brief

typically only ________ to ________

6 to 12

weeks.

Their location of origin predisoses to

hydrocephalus

________.

They present with

h________

headache

ii.

n________

nausea

iii.

a________ and

ataxia

iv.

seeding of the axis has occurred in

10 to 35%

________ to ________ %.

257.

True or false. Radiologically

G7 p.686:135mm

medulloblastomas are

cystic

false

solid

true

enhancing

true

on non-contrast CT they are hyperdense

true

258.

Complete the following about

G7 p.686:157mm

medulloblastoma location:

Most are in the ________.

midline

Laterally situated tumors are more

adults

common in ________.

259.

Complete the following about drop

G7 p.686:157mm

mets to the spine with

medulloblastoma:

The test that should be done is ________

MRI with contrast

________ ________.

This study should be done ________

preop

ii.

or within ________ to ________

2 to 3

weeks postop.

260.

Regarding the molecular biology of

17p

G7 p.687:40mm

medulloblastoma, in 35 to 40% there

is deletion of ________.

304

Tumor

261.

True or False. Regarding epidermoid

G7 p.688:143mm

and dermoid brain tumors:

Epidermoid tumors tend to occur

true

laterally, whereas dermoid tumors are

more common near the midline.

Epidermoid tumors are associated with

false (Dermoid tumors are

other congenital anomalies in up to 50%

associated with other

of cases.

congenital anomalies in over

50%.)

Epidermoid cysts, also known as

true

G7 p.689:62mm

cholesteatomas, are often confused with

cholesterol granuloma.

262.

True or False. Regarding primary brain

G7 p.690:50mm

tumors:

Cholesterol granulomas usually involve

true

vestibular or cochlear dysfunction.

Both epidermoid cysts and cholesterol

false (Cholesterol granulomas

granulomas have a pearly white gross

are brown.)

appearance.

Mollaret meningitis is a rare variant of

true

G7 p.690:85mm

aseptic meningitis that may be seen in

some patients with epidermoid cysts.

263.

Complete the following about imaging

G7 p.690:122mm

of epidermoids:

On T1W1 they mimic ________.

CSF

On T2W1 they are ________ ________.

high signal

With contrast they ________ ________.

don’t enhance

They pass from the ________

posterior fossa

________

ii.

through the ________

incisura

iii.

into the ________ ________.

middle fossa

The best test to differentiate them

DWI

from CSF is ________

ii.

where they show _______ _______

intense signal

iii.

because of ________ ________.

restricted diffusion

 Pineal Region Tumors

264. True or False. Regarding pineal region

G7 p.691:130mm

tumors:

a. The absence of the BBB in the pineal

true

gland makes this area a susceptible site

for hematogenous metastasis.

b. Nongerminomas include

embryonal carcinoma

true

ii.

choriocarcinoma

true

iii.

teratoma

true

iv.

medulloblastomas

false

c. Germ cell tumors rarely give rise to

false

tumor markers.

Choroid Plexus Tumors

305

265.

Complete the following about germ

G7 p.692:50mm

cell tumors:

In the CNS they arise in the ________.

midline

In males they are most likely in the

pineal

________ region.

In females they are most likely in the

suprasellar

________ region.

Are germ cell tumors benign or

malignant

malignant?

They spread via the ________.

CSF

266.

True or False. Regarding germ cell

G7 p.693:90mm

tumors:

Germ cell tumors and pineal cell tumors

true

occur primarily in childhood and young

adults (< 40 years old).

Clinical features of pineal region tumors

true

may include hydrocephalus and Parinaud

syndrome.

Optimal management strategy for pineal

true

region tumors has yet to be determined.

267.

True or False. Germinomas are very

false (They are sensitive to

G7 p.694:165mm

sensitive to radiation but not to

both.)

chemotherapy.

268.

Complete the following about surgery

G7 p.695:78mm

for pineal tumors:

The most common approach is the

infratentorial supracerebellar

________ ________.

ii.

This cannot be used if the ________

tentorium

is steep.

Another common approach is the

occipital transtentorial

________

ii.

which is best for lesions ________ at

centered

iii.

or ________ to the tentorial edge

superior

iv.

or ________ the vein of Galen.

above

 Choroid Plexus Tumors

269. True or False. Regarding brain tumors:

G7 p.696:22mm

a. Choroid plexus tumors largely occur in

true

patients less than 2 years old.

b. Choroid plexus tumors do not grow with false (They sometimes grow

any particular rapidity.

rapidly.)

306

Tumor

270.

True or False. Regarding choroid

plexus tumors:

They are usually located in:

G7 p.696:30mm

adults ________

infratentorially

ii.

children ________

supratentorially

Hydrocephalus with choroid plexus

true

G7 p.696:60mm

tumors may result from overproduction

of CSF, although tumor removal does

not always cure the problem.

271.

CT or MRI usually demonstrates a

G7 p.696:75mm

mass

located ________

intraventricularly

which is contrast ________.

enhancing

It has a ________ shape

multi-lobulated

with projecting ________

fronds

and commonly h________.

hydrocephalus

272.

True or False. Regarding primary CNS

G7 p. 697:45mm

melanomas:

Primary CNS melanoma does not arise

false

from melanocytes in the leptomeninges.

The peak age for primary CNS melanoma

true

is in the fourth decade.

 Pediatric Brain Tumors

273.

Complete the following about

G7 p.696:77mm

pediatric brain tumors:

What is the second most common

brain tumor

childhood cancer?

What is the first?

leukemia

Brain tumor incidence in children is

2 to 5 cases/100,000

________.

274.

Of all brain tumors in the age group

42%

G7 p.697:102mm

2 to 16, ________% are infratentorial.

275.

True or False. The most common

G7 p.697:137mm

supratentorial tumors in children are

astrocytoma

true

pinealoma, teratoma, choroid plexus

true

tumors, craniopharyngioma

medulloblastoma

false

276.

True or False. Regarding pediatric

G7 p.697:170mm

brain tumors:

50% of brain tumors in neonates are of

false (90%)

neuroectodermal origin

Many of the brain tumors in infants

true

< 1 year old escape diagnosis until they

are quite large due to the plasticity of

the infant’s skull.

Astrocytomas are the most common

true

supratentorial tumors in pediatrics as in

adulthood.

Skull Tumors

307

277. What are the most common

G7 p. 698:20mm

symptoms of intracranial tumor in

children?

Hint: tumors

a. t ________

throwing

b. u________

c. m________

macrocrania

d. o________

oral intake poor

e. r________

regression in milestones

f. s________

seizures

 Skull Tumors

278.

The most common primary bone

G7 p.698:117mm

tumor of the calvarium

is the ________.

osteoma

It usually involves only the ________

outer table

G7 p.698:172mm

________.

At surgery you can leave the inner table

intact

________.

279.

True or False. Regarding skull tumors:

G7 p.699:22mm

Hemangiomas comprise 15% of skull

false (7%)

tumors.

50% of hemangiomas on skull x-ray show

true

a circular lucency with a honeycomb or

trabecular pattern.

280.

Characterize skull tumor x-rays.

G7 p.699:90mm

The margin of an epidermoid is

edges distinct

________.

(epidermoid = ED well

defined—sclerotic)

The margin of an eosinophilic granuloma

edges graded (eosinophilic

is ________.

granuloma = EG

nonsclerotic—beveled edges)

281.

Complete the following about skull

G7 p.699:150mm

tumors:

True or False. Eosinophilic granuloma is

true

generally a condition of youth.

True or False. Eosinophilic granulomas

false

cause a usually nontender enlarging skull

mass.

True or False. The CT appearance of

true

eosinophilic granulomas includes a soft

mass within an area of bone destruction

having a central density.

On skull x-ray of eosinophilic granuloma

graded (beveled) = EG

the edges are ________.

308 Tumor

282. True or False. Regarding skull tumors:

G7 p.700:115mm

a. Hyperostosis frontalis interna (HFI) is a

false (It is almost always

benign, irregular thickening of the inner

bilateral.)

table of the frontal bone that is rarely

expressed bilaterally.

b. HFI has also been called a metabolic

true

craniopathy.

c. HFI has been associated with Morgagni

true

syndrome.

283. Answer the following about fibrous

G7 p.701:89 mm

dysplasia:

a. True or False. It is benign.

true

b. True or False. It is inheritable.

false

c. True or False. It can cause cranial nerve

true (especially hearing)

deficits.

d. True or False. It may be tender to touch. true

e. True or False. Alkaline phosphatase is

false (only in 33% of patients)

invariably elevated.

f. Appearance on x-ray is that of ________ ground glass

G7 p.701:187 mm

________.

g. It can be treated with ________.

calcitonin

G7 p.270:823mm

 Cerebral Metastases

284.

Complete the following about cerebral

G7 p.702:48mm

metastases:

The most common brain tumor is the

metastasis

________.

It will be multiple in ________% on MRI.

70%

Need biopsy for solitary lesion because

11%

________% will not be a metastasis.

285.

Complete the following about brain

G7 p.702:72mm

tumors:

Metastatic brain tumors represent

50%

________% of all brain tumors that

occur.

How often is the brain metastases the

only site of spread?

Which primary CNS tumors spread via

the CSF?

g________

glioma

ii.

e________

ependymoma

iii.

P________

PNET

iv.

p________

pineal tumors

Where do metastases occur?

g ________-w________ j________

gray-white junction

ii.

t________ p________ and

temporal parietal and

o________ l________ junction.

occipital lobe junction

iii.

c________ ________%

cerebellum 16%

Cerebral Metastases

309

286.

Regarding a metastatic tumor at the

G7 p.702:105mm

time of neurological diagnosis, how

many of the cerebral metastases are

considered solitary as studied by

CT? ________%

50% seem to be solitary

MR? ________%

only 30% seem to be solitary

(The rest are multiple

because MR is more sensitive

and identifies more than one

metastasis.)

287.

Complete the following about cerebral

G7 p.703:65mm

metastases:

Where do brain metastases come from?

Hint: lubrim

lu________

lung

ii.

b________

breast

iii.

r________

renal

iv.

i________

intestinal tract

m________

melanoma

Percent from each of the above primary

sites

________%

44%

ii.

________%

10%

iii.

________%

iv.

________%

At autopsy what percent of these tumors

has metastasized to the brain?

lung ________%

21%

ii.

breast ________%

iii.

renal ________%

11%

iv.

GI ________%

melanoma ________%

40%

Which tumor is most likely to be found

small cell lung cancer (SCLC)

as a metastasis to the brain?

288.

Complete the following about small

G7 p.703:175mm

cell lung cancer (SCLC):

aka ________ ________ cancer

oat cell

Strongly associated with ________

cigarette smoking

________

Reaction to radiation is ________

very sensitive

G7 p.704:40mm

________

289.

Most common type of nonsmall cell

adenocarcinoma

G7 p.704:80mm

lung cancer is ________.

310

Tumor

290.

True or False. Protocol for newly

G7 p.704:125mm

diagnosed lung lesion plus single brain

lesion. You should

remove the solitary brain lesion

false

biopsy the brain lesion

false

biopsy the lung lesion

true

because if it is ________

SCLC

ii.

you will treat with ________

radiation

291.

The most common source of cerebral

lungs (SCLC)

G7 p.703:160mm

metastatic disease comes from the

________.

292.

Complete the following about

G7 p.704:160mm

metastatic melanoma:

Longevity after detected in the brain is

113 days

________ days.

Unless it is a single melanoma

3 years

metastasis, then patient may live

________ years.

True or False. Melanoma is responsive to

false (very poor response)

chemotherapy and radiation.

293.

Complete the following about

G7 p.705:85mm

melanoma treatment:

With chemotherapy for melanoma, the

dacarbazine

gold standard is ________.

Immunotherapy for melanoma that is as

Melacine

G7 p.705:115mm

effective as chemotherapy is a vaccine:

________.

Prognosis

G7 p.705:165mm

Median survival is ________ months

ii.

5 year survival is ________%

20%

294.

True or False. Regarding cerebral

metastases:

The primary site for a brain metastasis

false (never identified in 14%

G7 p.704:150mm

can always be identified.

of patients)

Renal cell carcinoma frequently presents

false (It has usually spread

G7 p.705:183mm

as isolated cerebral metastases.

widely before invading the

CNS.)

295.

Characterize metastatic brain tumor

G7 p.706:52mm

presentation.

headache in ________%

50%

seizures ________%

15%

hemorrhage occurs in

G7 p.706:80mm

m________ m________

metastatic melanoma

ii.

c________

choriocarcinoma

iii.

r________ c________ c________

renal cell carcinoma

Cerebral Metastases

311

296.

Answer the following about the

G7 p.706:128mm

workup of a solitary brain lesion:

In a patient who has no history of cancer,

negative chest x-ray, and negative

intravenous pyelogram (IVP), what

percent will be

metastases

ii.

primary brain tumors

87%

iii.

nonneoplastic

If the patient has a history of cancer,

93%

what percent will be metastatic?

Most commonly ________

adenocarcinoma

G7 p.707:61mm

But the primary may remain occult in

88%

________%

297.

Complete the following about cerebral

G7 p.707:90mm

metastases:

True or False. A patient with known

false (7 to 11% of patients

cancer of the breast 2 years earlier

with a history of cancer and

develops a seizure and MRI shows a brain

an abnormal CT or MRI scan

lesion. You may consider this a

will not have a metastasis.)

metastasis from the breast and treat her

with radiation and chemotherapy.

What should be advised?

biopsy (You should do a

biopsy to identify

glioblastoma, low-grade

glioma, abscess, etc.)

With optimal treatment what is the

26 to 32 weeks

prognosis for patients with brain

metastases?

298.

True or False. Most important factor in

G7 p.707:130mm

prognosis is:

tumor type

false

time since diagnosis

false

Karnofsky performance score

true

better prognosis with a score > ________

G7 p.707:140mm

299.

Tumors considered radioresistant are

G7 p.707:140mm

Hint: last m(a)rc

l________ ________

(NSCLC) nonsmall cell lung

cancer

a________

adenocarcinoma

s________

sarcoma

t________

thyroid

m________

malignant melanoma

(a)

r________ ________

renal cell

c________

colon

312

Tumor

300.

Tumors considered radiosensitive are

G7 p.708:115mm

Hint: gllemmS

g________ c________ t________

germ cell tumors

l________

lymphoma

le________

leukemia

m________ m________

multiple myeloma

S________

SCLC

301.

Complete the following about cerebral

G7 p.708:132mm

metastases:

After the usual dose of radiation therapy

for cerebral metastases what percent of

patients develop dementia at

1 year ________%

11%

ii.

2 years ________%

50%

The standard dose is

________ Gy in

ii.

________ fractions over

iii.

________ weeks

302.

True or False. The results of operating

true

G7 p.709:100mm

on multiple metastases are similar to

the results of operating on a single

metastasis, if all of the lesions are

resected completely.

303.

Characterize outcomes of treatment

G7 p.710:60mm

for cerebral metastases survival.

untreated patients ________

1 month

steroids ________

2 months

steroids plus radiation ________

3 to 6 months

steroids plus radiation plus surgery

8 months

________

if systemic disease ________

20% live 1 year

if no systemic disease ________

80% live 1 year

304.

Which patient lives longer: one who

control rates are similar

G7 p.710:155mm

has a metastasis and is treated with

radiosurgery plus whole brain

radiation or one who has a metastases

and is treated with surgery plus whole

brain radiation?

305.

Which patient lives longer: one who

survival is similar

G7 p.710:155mm

has multiple metastases that were

totally removed or one who has a

single metastases that was totally

removed?

Idiopathic Intracranial Hypertension

313

 Carcinomatous Meningitis

306. Complete the following about

G7 p.711:45 mm

carcinomatous meningitis:

a. Symptoms

h________

headache

ii.

m________ c________ n________

multiple cranial nerve

d________

dysfunction

b. CSF is eventually abnormal in ________%

95%

of patients.

c. What size sample of CSF is needed?

at least 10 cc of CSF

d. Survival

without treatment is ________

2 months

ii.

with treatment is ________

5 to 8 months

 Foramen Magnum Tumors

307. Foramen magnum tumors present

G7 p.712:45mm

with

a. n________ p________

neck pain

b. w________

weakness

which begins in the ________

ipsilateral

hand/arm

ii.

then progresses to the ________

ipsilateral

lower extremity

iii.

then progresses to the ________ LE

contralateral

iv.

and finally to the ________ hand

contralateral

and arm

c. this is called ________ ________

rotating paralysis

G7 p.712:60mm

d. sensory loss if present is ________ to the

contralateral to the mass

________

e. eyes may show d________-b________

down-beat nystagmus

n________

 Idiopathic Intracranial Hypertension

308. Complete the following about

G7 p.713:73mm

idiopathic intracranial hypertension:

a. Also known as p________ c________

pseudotumor cerebri

b. Diagnostic criteria

CSF pressure above ________

above 20 to 25 cm H₂O

ii.

CSF composition

normal protein, glucose, and

cell count

iii.

symptoms and signs

of increased pressure

iv.

radiologic studies

normal CT and MRI

c. Severe visual defects occur in

4 to 12%

________%.

d. Best test to follow vision is ________.

perimetry

314

Tumor

309.

Characterize pseudotumor cerebri.

G7 p.713:100mm

gender preponderance ________

female 2 to 8:1

size of patient ________

more frequent with obesity

childbearing years ________

more frequent

Can this condition recur?

yes

What is the most serious consequence of

visual loss

this condition?

How long does it take for visual changes

occurs in 4 to 12% unrelated

to occur?

to duration of symptoms

How should the vision be followed?

by perimetry

310.

List pseudotumor cerebri diagnostic

G7 p.714:13mm

criteria.

Hint: rinc

Radiology studies are ________.

normal

Intracranial pressure is ________.

high

Neurological exam is ________.

normal

Composition of CSF is ________.

normal

311.

Describe pseudotumor cerebri

G7 p.717:90mm

treatment.

Withdraw patient from o________

oral contraceptives and other

c________ and o________ m________.

medications

Use medications such as

D________

Diamox

ii.

L________

Lasix

iii.

d________

dexamethasone

Procedures to consider include

s ________ L________

serial LPs

ii.

l_____-p_____ s______

lumbo-peritoneal shunt

iii.

o________ s________ f________

optic sheath fenestration

312.

True or False. Regarding pseudotumor

G7 p.718:28mm

cerebri, the following are frequently

used methods in the surgical

treatment of pseudotumor cerebri:

lumbar puncture

true

lumboperitoneal shunt

true

ventriculoperitoneal shunt

true

decompression of optic sheath

true

 Empty Sella Syndrome

313. Matching. Match the type of empty

G7 p.719:95mm

sella origin with its clinical

characteristics/features.

Characteristic:

① visual deterioration; ② obese women;

③ treat surgically; ④ headache,

dizziness, seizures; ⑤ surgery not

indicated; ⑥ postsurgical

Origin:

a. primary origin (idiopathic)

②, ④, ⑤

b. secondary origin (post surgical)

①, ③, ⑥

Tumor Markers

315

314. Complete the following about empty

G7 p.719:125mm

sella syndrome:

a. True or False. May have elevated

true

prolactin.

b. If so how can you differentiate from

TRH stimulation

prolactinoma by endocrine testing?

c. if prolactinoma

no PRL rise

d. if empty sella

normal PRL rise

 Tumor Markers

315.

True or False. This tumor marker

G7 p.720:38mm

usually indicates astroglial origin.

glial fibrillary acid protein (GFAP)

true (GFAP is rarely found

outside the CNS. Thus the

presence of GFAP in a tumor

found in the CNS is usually

taken as good evidence for

glial origin of the tumor.)

S-100 protein

false

cytokeratin

false

neuron specific enolase (NSE)

false

human chorionic gonadotropin (HCG)

false

316.

True or False. This tumor marker may

G7 p.720:85mm

be helpful in differentiating metastatic

tumor from primary CNS tumors.

GFAP

true (indicates astroglial

origin)

S-100 protein

true (similar to GFAP, may

arise from Schwann cells and

be positive in melanomas,

head trauma, and Creutzfeldt-

Jakob)

cytokeratin

true (may help distinguish

metastatic tumors, stains

epithelial cells)

NSE

true (metastatic small cell

tumors to the brain staining

positive due to lung)

HCG

true (high levels indicate

cerebral metastases from

uterine or testicular

choriocarcinoma)

α-fetoprotein

true (cancer of ovary,

stomach, lung, colon,

pancreas)

carcinoembryonic antigen (CEA)

true

CSF-CEA

true, (leptomeningeal spread

of lung cancer, breast,

bladder cancer, malignant

melanoma)

316 Tumor

317. Complete the following about tumor

G7 p.720:100mm

marker MIB-I:

a. A high number indicates ________

mitotic activity

________.

b. It correlates with degree of ________.

malignancy

c. It is used for

a________

astrocytoma

ii.

m________

meningioma

iii.

b________ c________

breast cancer

iv.

l________

lymphoma

318. True or False. Which tumor marker do

G7 p.721:175mm

you also use in head trauma?

a. GFAP

false

b. S-100 protein

true (S-100 protein levels rise

after head trauma.)

c. CEA

false

d. HCG

false

e. cytokeratin

false

 Neurocutaneous Disorders

319.

True or False. The following are

G7 p.722:45mm

neurocutaneous disorders:

Sturge-Weber syndrome

true

neurofibromatosis

true

tuberous sclerosis

true

von Hippel-Lindau disease

true

Foix-Alajouanine syndrome

false (Foix-Alajouanine

syndrome, acute or subacute

neurologic deterioration in a

patient with a spinal

arteriovenous malformation

without evidence of

hemorrhage)

320.

True or False. Features for

G7 p.723:35mm

neurofibromatosis 1 include

more than six café au lait spots

true

peripheral neurofibromatosis (NF)

true

gene is on chromosome 17q 11.2

true

optic glioma

true

bilateral acoustic neuroma

false (almost never bilateral;

bilateral are the hallmark of

neurofibromatosis 2)

321.

Complete the following about

G7 p.723:145mm

genetics of NF-1:

It is a________ d________.

autosomal dominant

After age 5 it has ________%

100%

penetrance.

It is on chromosome ________

17q11.2

which codes for ________.

neurofibromin

Tuberous Sclerosis

317

322.

True or False. When comparing NF1

G7 p.724:70mm

with NF2, the following is in both:

Antigenetic nerve growth factor is

false (Antigenetic nerve

increased.

growth factor does not occur

with NF1 only with NF2.)

Skin nodules, dermal neurofibromas

true

Multiple intradural spinal tumors are

true

common.

Autosomal dominant inheritance

true

G7 p.724:140mm

Malignant tumors that have increased

true

frequency

323.

Complete the following about

G7 p.724:110mm

neurofibromatosis 2:

Despite its name it has no ________.

neurofibromas

NF2 is due to a ________

mutation

ii.

on chromosome ________

22q 12.2

iii.

which results in inactivation of

Schwannomin

s________.

It is associated with bilateral (2)

vestibular schwannoma

G7 p.724:110mm

v________ s________.

Most NF2 patients will become

deaf

________.

Pregnancy may ________ the growth of

accelerate

eight nerve tumors.

 Tuberous Sclerosis

324. Complete the following about

G7 p.725:28mm

tuberous sclerosis:

a. List the key clinical features of tuberous

sclerosis.

Hint: sam

s________

seizures

ii.

a________ s________

adenoma sebaceum

iii.

m________ r________

mental retardation

b. CNS finding is typically a s________

subependymal nodule—

n________—a h________.

a hamartoma

c. Common neoplasm is a s________

subependymal giant cell

g________ c________ a________.

astrocytoma

d. CT shows i________ s________

intracerebral subependymal

c________.

calcifications (usually

subependymal)

325. True or False. The clinical triad of

G7 p.725:28mm

tuberous sclerosis includes

a. seizures

true

b. mental retardation

true

c. sebaceous adenomas

true

d. port-wine facial nevus

false

318

Tumor

326.

True or False. Regarding tuberous

G7 p.725:140mm

sclerosis:

In infants the earliest finding is of ash leaf

true

macules.

Myoclonus found in children is often

true

replaced by partial complex seizures in

adults.

Facial adenomas are present at birth.

false (Facial adenomas are

not present at birth but occur

by age 4 years in 91% of

patients.)

Retinal hamartomas are present.

true in ~50% of patients

327.

List the key features of Sturge-Weber

G7 p.726:85mm

syndrome.

Hint: abc

a________

atrophy: localized cerebral

cortical atrophy and

calcification

b________ ________

birth mark: ipsilateral port-

wine facial nevus (usually in

distribution of trigeminal

nerve)

c________

calcification: plain skull films

classically show “tram

tracking”

328.

True or False. The port-wine facial

G7 p.726:118 mm

nevus associated with Sturge-Weber

syndrome is

ipsilateral to the seizures

false (It is contralateral.)

in the distribution of the third division of

false (in distribution of the

the trigeminal nerve

first division)

contralateral to the “tram tracking” on

false (Nevus is ipsilateral to

plain x-rays

“tram tracks.”)

rarely bilateral

true

 Spine and Spinal Cord Tumors

329. Compartment locations of spinal

G7 p.728:57mm

tumors and their incidence are

a. extradural ________%

tumor (55%)

b. intradural ________%

extramedullary (40%)

c. intramedullary ________%

spinal cord tumor (5%)

330. Osteoblastic tumors indicate

G7 p.728:107mm

a. in men likely ________

prostate metastasis

b. in women likely ________

breast cancer metastasis

331. One cause of vertebra plana is

eosinophlic granuloma

G7 p.729:28mm

e________ g________.

Spine and Spinal Cord Tumors

319

332.

True or False. The most common

G7 p.729:28mm

extradural spinal tumor causing

vertebral osteolytic defect on x-ray is

giant cell tumors

false

aneurysmal bone cyst

false

osteoblastoma

false

eosinophilic granuloma

true

333.

True or False. The following spinal

G7 p.729:45mm

tumors are usually primary in the

spine:

Ewing sarcoma

false (Aggressive malignant

tumor with a peak incidence

during second decade of life.

Spine metastases are more

common.)

chordoma

true

chondrosarcoma

true

vertebral hemangioma

true

osteogenic sarcoma

true

334.

Characterize spinal meningiomas.

G7 p.729:155mm

Peak age is ________.

40s

The female:male ratio is _______ :

4:1

_______.

Main symptom is ________.

pain

Main sign preop is d________

difficulty walking

w________.

335.

Characterize spinal lymphoma.

G7 p730 :65mm

It occurs in patients who have ________-

non-Hodgkins

________ lymphoma.

Incidence in these patients is from 1 to

10%

________%.

336.

True or False. The two most common

G7 p.730:122mm

intramedullary spinal cord tumors are

teratoma

false

astrocytoma

true

ependymoma

true

dermoid

false

malignant glioblastoma

false

337.

True or False. The following is an

G7 p.730:122mm

intramedullary spinal cord tumor:

dermoid

true

teratoma

true

lipoma

true

320

Tumor

neuroma

true (very rarely

intramedullary)

meningioma

false (Meningiomas are

usually intradural but may be

partially or wholly extradural

and are always

extramedullary. 15% of spinal

meningiomas are extradural.

The other examples are

miscellaneous intramedullary

tumors.)

338.

Considering epidermoid tumors, they

G7 p.731:80mm

are

most common in ________ or ________

conus or filum

usually m________

myxopapillary

must image the ________ ________

entire neuraxis

most are e________

encapsulated

treatment is ________ ________

total excision

ii.

by dividing the ________

filum

339.

Characterize astrocytoma of the cord.

G7 p.731:160mm

It occurs at all ________.

levels

Most common is ________.

thoracic

________% are cystic.

38%

Fluid has high ________.

protein

340.

Lipoma is usually associated with

dysraphism

G7 p.732:15mm

________.

341.

Characterize hemangioblastoma.

G7 p.732:50mm

It is usually associated with

von Hippel-Lindau

________ ________-________

ii.

in ________%.

33%

Surgically treat it like an ________.

AVM

342.

True or False. The tumor least

G7 p.732:70mm

common as an intramedullary spinal

cord tumor is

astrocytoma

false

ependymoma

false

dermoid

false

lipoma

false

metastatic tumor

true (Most spinal metastases

are extradural; only a few

hundred case reports of

intramedullary spinal cord

tumor metastases exist,

accounting for only 3.4% of

symptomatic metastatic

spinal cord lesions.)

Spine and Spinal Cord Tumors

321

343.

Complete the following about

G7 p.732:70mm

metastases intraparenchymal:

Rare—only a few ________ cases

hundred

Primarily from

S________

SCLC

ii.

b________

breast

iii.

m________ ________

malignant melanoma

iv.

l________

lymphoma

c________

colon

344.

Complete the following about

G7 p.732:100mm

intramedullary spinal cord tumors:

The pain pattern suggestive of spinal

upon recumbency

cord tumor is pain ________ ________.

Children present most commonly with

gait disturbance

G7 p.732:117mm

________ ________.

345.

Complete the following about spine

G7 p.733:65mm

and spinal cord tumors:

Spinal fluid that clots is called ________

Froin syndrome

________.

Clotting is due to ________.

fibrinogen

346.

True or False. With intraoperative

G7 p.734:15mm

spinal cord monitoring, a proof of

improved outcome has been

established for

SSEP

false

MEP

false

347.

Complete the following about

G7 p.734:115mm

prognosis of spinal cord tumors:

Better results in patients with ________

lesser deficits

________

Ependymoma

Improved outcome with ________

total removal

________

ii.

Myxopapillary tumors do ________

better

iii.

If symptoms less than ________

years

Astrocytoma

True or False. There is a cleavage

false

plane.

ii.

Functional results ________ than

poorer

ependymoma

iii.

Recurrence rate at 5 years is

50%

________%

322

Tumor

348.

Complete the following about spinal

G7 p.734:165mm

schwannomas:

Slow growing ________ tumors

benign

75% arise from the ________ roots

dorsal (sensory)

Early symptoms are often ________

radicular

Most are ________

intradural

G7 p.735:165mm

Dumbbell

Have a ________

waist

ii.

Usually at the ________

dura

iii.

Sometimes these are classified as

type ________

iv. Sometimes at the ________

foramen

v. These are classified as type

________

Nerve sacrifice is usually ________

not required

G7 p.736:13mm

________ because the involved fascicles

are often ________ ________

349.

Complete the following about bone

G7 p.736:50mm

tumors of the spine:

Osteolytic metastases (Hint: bl²emp²):

b________

breast

ii.

l________

lung

iii.

l________

lymphoma

iv.

e________

eosinophilic granuloma

m________

multiple myeloma

vi.

p________

prostate

vii. p________

plasmacytoma

Osteolytic metastases

G7 p.736:75mm

b________

breast

ii.

p________

prostate

350.

True or False. Regarding osteoid

G7 p.737:15mm

osteomas:

They are benign lesions presenting less

true

than 1 cm in size.

Osteoid osteomas often degenerate into

false

osteoblastomas.

Osteoid osteomas occur more

false

commonly in the pedicle than

osteoblastomas.

They are expansile destructive lesions.

false (Osteoblastomas are

expansile destructive lesions)

351.

Osteoid osteoma. The diagnosis is

G7 p.737:35mm

osteoid osteoma if it is less than

1 cm

________ ________ in size.

osteoblastoma if it is more than

1 cm

________ ________ in size.

They are histologically ________.

identical

Spine and Spinal Cord Tumors

323

352.

True or False. The distributions of

G7 p. 737:50mm

benign osteoblastomas in the spine

are

10% cervical, 50% thoracic, 40% lumbar

false

25% cervical, 35% thoracic, 35% lumbar

true

50% cervical, 10% thoracic, 40% lumbar

false

35% cervical, 25% thoracic, 35% lumbar

false

353.

Benign osteoblastoma and osteoid

G7 p.737:125mm

osteoma usually

have the symptom of n________

night pain

p________

which is relieved by a________.

aspirin

354.

The most common primary

G7 p.738:20mm

bone cancer is ________.

osteosarcoma

Spinal form occurs in the ________

lumbosacral

region

ii.

in males in their ________.

40s

Biopsy needle tract ________ the area.

contaminates

Survival is ________ months.

355.

True or False. Vertebral hemangiomas

G7 p.738:75mm

are rare tumors

false (occurs in 9 to 12% of

the population)

may be malignant

false (never found to be

malignant)

are often symptomatic

false (rarely symptomatic)

are radiosensitive

true (used for the uncommon

painful lesion that can’t be

treated by excision or

vertebroplasty)

x-rays show ________ ________

vertical striations

G7 p.738:170mm

or ________ appearance

honeycomb

356.

Complete the following about

G7 p. 740:40mm

multiple myeloma (MM):

If a single lesion is found it is called

plasmacytoma

p________.

In 70 to 80% this will progress to

G7 p. 742:15mm

m________ m________ in

multiple myeloma

ii.

________ years.

A urine test for MM is done to identify

G7 p. 741:30mm

________ ________ ________

kappa Bence-Jones protein

ii.

found in ________% of cases.

75%

The most definitive test is b________

bone marrow biopsy

G7 p. 741:90mm

m________ b________.

357.

Giant cell tumors

G7 p. 742:38mm

are considered in the same category as

aneurysmal bone cysts

a________ b________ c________.

The recommended treatment is

intratumoral curettage

i________ c________.

Consider preop e________.

embolization

324

Tumor

358.

Complete the following regarding

G7 p.742:110mm

spinal epidural metastasis:

It occurs in ________% of all cancer

10%

patients.

It most commonly arises from

l________ b________ g________

lung breast gastrointestinal

and

ii.

p________ m________ l________.

prostate myeloma lymphoma

It is thought to reach the spine by the

Batson plexus

B________ p________.

The site of metastasis is p________ to

proportional

the length of the segment of spine.

First symptom is usually

p________ which is

pain

ii.

worse in r________.

recumbency

359.

Complete the following regarding

G7 p.743:114mm

spinal epidural metastasis:

Outcome depends on p________

presenting neurologic status

n________ s________.

Treatment for patient with new

symptoms consists of

d________

decadron

ii.

s________

surgery

iii.

r________

radiation

Indication for surgery is

greater than ________% block

80%

ii.

r________ p________

rapid progression

360.

Complete the following about MRI

scans in spinal epidural metastasis:

They detect multiple sites of cord

20%

G7 p.744:130mm

compression in ________%.

They are ________ on T1.

hypointense

G7 p.744:150mm

They are ________ on T2.

hyperintense

361.

What is the treatment for SEM?

G7 p. 747:65mm

Chemotherapy is ________.

ineffective

Vertebroplasty/kyphoplasty reduces pain

84%

G7 p. 747:150mm

by ________%.

Radiation treatment

G7 p. 748:28mm

How soon after diagnosis?

within 24 hours

ii.

After surgery?

within 2 weeks

Preop embolization

G7 p. 748:60mm

Appropriate for ________ ________

highly vascular

tumors

ii.

such as r________ ________

renal cell

iii.

t________

thyroid

iv.

h________

hepatocellular

362.

Characterize surgical treatment.

G7 p.748:78mm

Laminectomy is a ________ treatment

poor

because it ________ the spine.

destabilizes

It is better to do surgery ________

anteriorly

and add ________.

instrumentation

Radiation Therapy



Conventional External Beam Radiation

What are the four “R’s” of external

G7 p.770:105mm

beam radiation?

rep________

repair

reo________

reoxygenation

repop________

repopulation

red________

redistribution

Complete the following about cranial

G7 p.770:177mm

radiation:

After surgery most surgerons wait

7 to 10

________ to ________ days.

Tumors that melt away with XRT are

l________

lymphomas

ii.

g________ c________

germ cell

True or False. Regarding radiation

G7 p.771:20mm

necrosis (RN):

RN is easy to differentiate from tumor

false

recurrence.

Best test to differentiate is

G7 p.771:150mm

MR spectroscopy if mass is pure

true

tumor

ii.

MR spectroscopy if mass is pure

true

necrosis

iii.

MR spectroscopy if mass is mixed

false (unreliable)

iv.

SPECT (poor man’s pet scan)

true

G7 p.772:30mm

Treatment

G7 p.772:45mm

Most RN will respond to steroids.

true

ii.

Mass effect dictates advisability of

true

surgery whether RN or recurrent

tumor.

Spinal radiation

G7 p.722:115mm

can produce ________.

myelopathy

can increase risk of developing spinal

cavernous malformation

________ ________.

326 Radiation Therapy

5. Complete the following about

G7 p.772:180mm

radiation myelopathy (RM):

a. Most important factor is rate of radiation application

________.

b. Second is total ________ ________.

radiation dose

6. Is stereotactic radiosurgery (SRS)

G7 p.774:135mm

useful for:

a. venous angiomas?

b. cavernous angiomas?



Stereotactic Radiosurgery

Complete the following about

G7 p.775:17mm

stereotactic radiosurgery:

For most cases what is the optimal

surgery

treatment for vestibular schwannoma?

What alternative is available?

SRS

When would the alternative for the

patient be considered?

p________ m________ c________

poor medical condition

ii.

o________ a________ g________

older age group

Answer the following about

G7 p.776:157mm

stereotactic radiosurgery:

Accuracy is never better than ________.

0.6 mm

If embolization is used what precaution

wait 30 days between

is advised before SRS?

procedures

What dose is optimal for an

10 to 15 Gy to periphery of

arteriovenous malformation (AVM)?

AVM

What dose is optimal for tumors?

10 to 15 Gy with tumor in the

80% isodose line

What dose is optimal for metastatic

15 Gy to center of tumor in

tumors?

the 80% isodose line

Complete the following regarding the

G7 p.777:110mm

results, in percent, of SRS obliteration

of:

AVM

AVM at 1 year ________

46 to 61%

ii.

AVM at 2 years ________

86%

iii.

under 2 cm ________

94%

iv.

over 2.5 cm ________

50%

acoustic tumor

decreased in size ________

44%

ii.

stabilized in size ________

42%

iii.

increased in size ________

14%

local metastatic control ________

88%

10.

What is advised if, after SRS, an AVM

may re-treat with SRS

G7 p.777:160mm

persists after 2 to 3 years?

Interstitial Brachytherapy

327

11. Is there any difference in outcome

G7 p.778:45mm

with SRS by radio-resistant versus

radio-sensitive tumors?

12. Which has a better response, supra- or supratentorial

G7 p.778:60mm

infratentorial metastases?

13. Which premedication is given before steroids and phenobarbital

G7 p.778:100mm

SRS?

14. During the latency period is there a

no, approximately 3 to 4% per

G7 p.778:118mm

higher incidence of hemorrhage from

year

AVM?

 Interstitial Brachytherapy

15. Answer the following about interstitial

G7 p.779:60mm

brachytherapy:

a. How much radiation is given?

60 Gy

b. To what area?

a volume that extends 1 cm

beyond the contrast-

enhancing tumor

c. At what rate?

40 to 50 c Gy/h

d. For how many days?

e. What is the radiation amount that will

30 c Gy/h

cause tumor growth to stop?

f. With this protocol what percent of

40%

patients develop symptomatic radiation

necrosis?

Stereotactic Surgery



Stereotactic Surgery

True or False. Indications for

G7 p.782:125mm

stereotactic surgery include

biopsy of multiple lesions

true

brachytherapy implants

true (catheter placement for

brachytherapy)

treatment of chronic pain

true (electrode placement for

pain, seizures)

gamma knife radiosurgery

true (lesion generation for

trigeminal pain)

biopsy of a deep cerebral lesion

true

hematoma evacuation

true (evacuation of

intracerebral hemorrhage,

cystic fluid)

localization of lesion for open

true

craniotomy

True or False. Stereotactic biopsy

G7 p.783:65mm

contraindications include

coagulopathy

true

multiple lesions

false (Multiple lesions are an

indication for stereotactic

biopsy.)

brain stem lesions

false (A brain stem lesion is an

indication for stereotactic

biopsy.)

inability to tolerate general anesthesia

false (can usually tolerate

local anesthesia)

thrombocytopenia

true (Platelets below 50,000

are an absolute

contraindication to biopsy.)

inability to cooperate for biopsy

false (may do stereotactic

biopsy under general

anesthesia)

Stereotactic Surgery

329

True or False. The yield rate for

G7 p.783:90mm

stereotactic biopsy is

higher for enhancing lesions than for

true

nonenhancing

lower for enhancing lesions than

false

nonenhancing

enhancing and nonenhancing lesions

false

have equal yield rates

yield rates range from 82 to 99%

true

True or False. The most common

G7 p.783:107mm

complication of stereotactic surgery is

hemorrhage

true (Most are too small to be

clinically significant. The

hemorrhage rate is higher in

AIDS and in central nervous

system lymphoma.)

infection

false

inability to localize lesion

false

inability to provide sufficient tissue

false

quality/quantity for biopsy

Answer the following regarding

G7 p.783:113mm

stereotactic biopsy:

True or False. The risk for major

false

complication due to stereotactic biopsy

is higher in patients with multifocal high-

grade gliomas than in patients with

AIDS.

Relative risk for patients that are

immune compromised ________ to

0 to 12%

________%

ii.

nonimmune compromised

0 to 3%

________ to ________%

iii.

or have glioma ________%

Peripheral Nerves



Peripheral Nerves

True or False. The peripheral nervous

G7 p.786:35 mm

system includes

spinal nerves

true

all cranial nerves

false

cranial nerves III-XII

true

cervical, brachial, lumbosacral plexus

true

True or False. Upper motor neuron

G7 p.786:135mm

paralysis includes

clonus

true

hyperactive reflexes

true

muscle spasms

true

atrophy

false

fasciculations

false

(Choices d and e are

characteristic of lower motor

neuron paralysis.)

List the 11 muscles of the shoulder

G7 p.787:40mm

and their nerves and roots.

Hint: pqrst (tssrppldbb)

muscle, t________

trapezius

nerve, s________ a________

CN X1 spinal accessory

ii.

roots, ________

C3,4

muscle, s________ a________

serratus anterior

nerve, l________ t________

long thoracic

ii.

roots, ________

C5,6,7

muscle, s________

supraspinatus

nerve, s________

suprascapular

ii.

roots,________

C4,5,6

muscle, i________

infraspinatus

nerve, s________

suprascapular

ii.

roots, ________

C5,6

muscle, r________

rhomboids

nerve, d________ s________

dorsal scapular

ii.

roots, ________

C4,5

Peripheral Nerves

331

muscle, p________ m________

pectoralis minor

nerve, a________ t________

anterior thoracic (med) aka

pectoral nerve

ii.

roots, ________

C7,8

muscle, p________ m________

pectoralis major (lat.

nerve, a________ t________

anterior thoracic anterior

thoracic med) aka pectoral

nerve

ii.

roots, ________

C4,5,6,7,8

muscle, l________ d________

latissimus dorsi

nerve, t________

thoracodorsal

ii.

roots, ________

C5,6,7,8

muscle, d________

deltoid

nerve, a________

axillary

ii.

roots, ________

C5,6

muscle, b________

brachialis

nerve, m________

musculocutaneous

ii.

roots, ________

C5,6

muscle, b________

biceps

nerve, m________

musculocutaneous

ii.

roots, ________

C5,6

List 11 muscles of the shoulder and

G7 p.787:40mm

arm, their nerve, and their action.

muscle, t________

trapezius

nerve, ________

CNX1

ii.

action, ________ ________

shrug shoulders

muscle, s________ ________

serratus anterior

nerve, ________ ________

long thoracic

ii.

action, ________ ________

forward shoulder thrust

________

muscle, s________

supraspinatus

nerve, ________

suprascapsular

ii.

action, ________ ________

abduct arm 90 degrees

________

muscle, ________

infraspinatus

nerve, ________

suprascapsular

ii.

action, ________ ________

backhand tennis shot

________

muscle, r________

rhomboids

nerve, ________ ________

dorsal scapular

ii.

action, ________ ________

abduct scapulae

muscle, p________ m________

pectoralis minor

nerve, ________ ________

pectoral nerve medial

________

ii.

action, ________ ________

adduction arm

muscle, p________ m________

pectoralis major

nerve, ________ ________

pectoral nerve lateral and

________ ________ ________

medial

ii.

action, ________ ________

adduction arm and push arm

________ ________ ________

forward

________

332

Peripheral Nerves

muscle, l________ d________

latissimus dorsi

nerve, ________

thoracodorsal

ii.

action, ________ ________,

adduct arm, ladder climb,

________ ________, ________

cough

muscle, d________

deltoid

nerve, ________

axillary

ii.

action, ________ _______ ________

abduct arm > 90 degrees

muscle, b________

brachialis

nerve, ________

musculocutaneous

ii.

action, ________ ________

flex forearm

muscle, b________

biceps

nerve, ________

musculocutaneous

ii.

action, ________ and ________

flex and supinate forearm

________

True or False. The suprascapular nerve

G7 p.787:75mm

innervates which of the following?

teres major

false—subscapular nerve

(C5-C7)

teres minor

false—axillary nerve (C4-C5)

infraspinatus

true

supraspinatus

true

The suprascapular nerve contains

C4, C5, C6

G7 p.787:75mm

roots from ________, ________, and

________.

Describe the latissimus dorsi muscle.

G7 p.787:82mm

function

l________ ________

ladder climbing

ii.

c________

cough

iii.

a________

adductor—together with

pectoralis

nerve

thoracodorsal nerve

cord

posterior cord

roots

C6,7,8

True or False. The deltoid muscle

G7 p.787:90mm

abducts arm 0 to 90 degrees

false (The arm is abducted

0 to 90 degrees by the

supraspinatous muscle.)

abduct arm > 90 degrees

true

is innervated by the axillary nerve

true

rotates the arm out

false (Arm is rotated out by

the infraspinatus muscle.)

True or False. The abductor pollicis

G7 p.788:60mm

longus

is innervated by the median nerve

false

is innervated by the radial nerve

true

is innervated by the ulnar nerve

false

is innervated by the posterior

true (The posterior

interosseous nerve

interosseus nerve is a

continuation of the radial

nerve in the forearm.)

Peripheral Nerves

333

10.

True or False. The median nerve is

G7 p.788:110mm

responsible for the following

movements of the thumb:

adduction

false (served by ulnar nerve)

abduction

true

extension

false (served by radial nerve)

flexion

true

opposition

true

11.

Complete the following about the

G7 p.788:110mm

movements of the thumb:

Actions of nerves to the thumb

median nerve, Hint: FAO

F—action, f________

flexion

muscle, f________ p________

flexor pollicis brevis and

b________ and l________

longus

root, ________

C8, T1, median

A—action, a________

abduction

muscle, a________ p________

abductor pollicis brevis

b________

root, ________

C8, T1, median

O—action, o________

opposition

muscle, o________ p________

opponens pollicis

root, ________

C8, T1

ii.

ulnar nerve

action, a________

adduction

muscle, a________ p________

adductor pollicis

root, ________ ________

C8, T1

iii.

radial nerve

action, e________

extension

muscle, e________ p________

extensor pollicis brevis and

b________ and l________

longus

root, C________ and C________

C7, C8

Plane of movement for the thumb

extension is ________

plane of palm

ii.

flexion is ________

plane of palm

iii.

adduction is ________

perpendicular to palm

iv.

abduction is ________

perpendicular from palm

opposition is ________

across the palm

12.

Complete the following about

G7 p.788:145mm

peripheral nerves of the leg:

Hint: fosis pdstp (follow our sign. it says

“please don't spoil the plants”)

f________

femoral

o________

obturator

s________

superior gluteal

i________

inferior gluteal

s________

sciatic (trunk)

p________

peroneal (trunk)

d________

deep peroneal

s________

superficial peroneal

t________

tibial

p________

pudendal

334

Peripheral Nerves

13.

Name the nerves of the lower

G7 p.788:145mm

extremities and the roots that form

them.

f________

femoral, 1,2,3

o________

obturator, 2,3

s________

superior gluteal, 4, 5, S1

i________

inferior gluteal, 5, S1, S2

s________

sciatic, 5, S1, S2

p________

peroneal, 4, 5, S1

d________

deep peroneal, 4, 5

s________

superficial peroneal, 5, S1

t________

tibial, 4, 5, S1, S2, S3

p________

pudendal, S2, S3, S4

14.

Name the nerves of the lower

G7 p.788:155mm

extremities and the muscles and

function of the muscles they serve.

nerve, f________

femoral

muscle, i________, q________

iliopsoas, quadriceps femoris,

f________, s________

sartorius

ii.

function, f________ h________

flex hip

nerve, o________

obturator

muscle, a________

adductor

ii.

function, a________ t________

adduct thigh

nerve, s________ g________

superior gluteal

muscle, g________ m________

gluteus medius

ii.

function, a________ t________

abduct thigh

nerve, i________ g________

inferior gluteal

muscle, g________ m________

gluteus maximus

ii.

function, f________ l________

flex leg

nerve, s________ t________

sciatic trunk

muscle, b________ s________

biceps femoris, semi

s________

tendenosis, semi

membranosis

ii.

function, e________ t________

extend thigh

nerve, d________ p________

deep peroneal

muscle, t________ a________,

tibialis anterior, extensor

e________ h________ l________

hallucis longus (EHL)

ii.

function, g________ t________

great toe extension, foot

e________, f________ d________

dorsiflexion

nerve, s________ p________

superficial peroneal

muscle, p________ l________

peroneus longus

ii.

function, p________ f________

plantar flexion foot and toes

f________ and t________

nerve, t________

tibial

muscle, p________ t________,

posterior tibial,

g________, s________, f________

gastrocnemius, soleus, flexor

h________ l________

hallucis longus (FHL)

ii.

function, p________ f________

plantar flex foot and toes

f________ and t________

nerve, p________

pudendal

muscle, p________, s________

perineal, sphincters

ii.

function, v________ c________ of

voluntary contraction of

p________ f________

pelvic floor

Peripheral Nerves

335

15.

True or False. The gluteus maximus

G7 p.789:37mm

muscle

abducts thigh

true (The gluteus maximus

abducts thigh in a prone

position.)

adducts thigh

false (thigh—adduction — the

obturator externus muscle

and pectineus muscle)

medially rotates thigh

false (thigh—medial rotation

— the gluteus medius and

minimus muscle)

externally rotates thigh

false (thigh—external rotation

— the obturator externus

muscle)

is innervated by superior gluteal nerve

false (The gluteus maximus is

innervated by the inferior

gluteal nerve.)

16.

True or False. The tibialis anterior

G7 p.789:60mm

muscle is responsible for foot

dorsiflexion

true

plantar flexion

false (plantar flexion—soleus

muscle, gastrocnemius

muscle)

eversion

false (eversion—peroneus

longus and brevis muscles)

inversion

false (inversion—posterior

tibialis muscle)

17.

Complete the following about the

G7 p.789:65mm

function of peripheral nerves:

The function of extension of the great

toe is served by

muscle, ________ ________

extensor hallucis longus

________

ii.

root, ________

The function of foot dorsiflexion is

served by

muscle, ________ ________

tibialis anterior

ii.

root, ________

Which is the best L5 muscle? (Hint: The

extensor hallucis longus

G7 p.789:140mm

letter E is the fifth letter in the alphabet.)

18.

True or False. The extensor hallucis

G7 p.789:65mm

longus muscle

is the best L5 muscle

true

extends great toe

true

dorsiflexes foot

true

is innervated by the deep peroneal nerve

true

19.

Complete the following regarding

G7 p.790:55mm

timing of surgical repair of nerves:

If the nerve must regenerate a long

early

distance, repair should be done _______.

After ________ months most muscles

cannot recover.

Brachial Plexus

339

Name the nerves (16). (Hint: Donald says

dorsal scapular

somewhat loudly, “Mickey Mouse, you

suprascapular

are right to so sincerely love Minnie

subclavius

Mouse madly.”)

lateral pectoral

musculocutaneous

median

ulnar

axillary

radial

thoracodorsal

subscapular upper

subscapular lower

long thoracic

medial pectoral

medial brachial cutaneous

medial antebrachial

cutaneous

Name the trunks (3).

superior, middle, inferior,

Name the cords (3).

lateral, medial, posterior

28.

Trace, using the brachial plexus

G7 p.790:100mm

diagram, the theoretically possible

Fig. 24-1

root contribution to each nerve and

then compare with the actual root

contribution in each nerve.

nerve, d ________ s________

dorsal scapular

theoretical, ________

C4,5

ii.

actual, ________

C4,5

nerve, s________

suprascapular

theoretical, ________

C4,5,6

ii.

actual, ________

C4,5,6

nerve, s________

subclavius

theoretical, ________

ii.

actual, ________

nerve, l________ p________

lateral pectoral

theoretical, ________

C4,5,6,7

ii.

actual, ________

C4,5,6,7

nerve, m________

musculocutaneous

theoretical, ________

C5,6,7

ii.

actual, ________

C5,6,7

nerve, m________

median

theoretical, ________

C5,6,7, T1

ii.

actual, ________

C5,6,7, T1

nerve, u________

ulnar

theoretical, ________

C8, T1

ii.

actual, ________

C7,8, T1

nerve, a________

axillary

theoretical, ________

C4,5,6,7,8, T1

ii.

actual, ________

C4,5,6,7,8, T1

nerve, r________

radial

theoretical, ________

C4,5,6,7,8, T1

ii.

actual, ________

C4,5,6

nerve, t________

thoracodorsal

theoretical, ________

C5,6,7,8, T1

ii.

actual, ________

C6,7,8

340

Peripheral Nerves

nerve, s________ u________

subscapular upper

theoretical, ________

C5,6,7,8, T1

ii.

actual, ________

C5,6,7

nerve, s________ l________

subscapular lower

theoretical, ________

C5,6,7,8, T1

ii.

actual, ________

C5,6,7

nerve, l________ t________

long thoracic

theoretical, ________

C5,6,7

ii.

actual, ________

C5,6,7

nerve, m________ t________

medial thoracic (pectoral)

theoretical, ________

C8, T1

ii.

actual, ________

not listed

nerve, m________ b________

medial brachial

theoretical, ________

C8, T1

ii.

actual, ________

not listed

nerve, m________ a________

medial antebrachial

theoretical, ________

C8, T1

ii.

actual, ________

not listed

29.

List the brachial plexus nerves (except

G7 p.790:100mm

for median ulnar and radial), the

Table 24-4

muscles they serve, the roots that are

in that nerve, and the action of the

muscles.

nerve, d________ s________

dorsal scapular

muscle,________ ________

levator scapulae

ii.

root, ________

C3,4,5

iii.

action, ________ ________

elevate scapulae

nerve, d________ s________

dorsal scapular

muscle, ________

rhomboids

ii.

root, ________

C4,5

iii.

action, ________ ________

adduct and elevate scapula

________ ________

nerve, s________

suprascapular

muscle, ________

supraspinatus

ii.

root, ________

C4,5,6

iii.

action, ________ ________

adduct arm 0 to 90 degrees

________ ________ ________

nerve, s________

supraspinatus

muscle, ________

infraspinatus

ii.

root, ________

C5,6

iii.

action, ________ _______ ________

rotate arm out

nerve, m________

musculocutaneous

muscle, ________ ________

biceps brachii

ii.

root, ________

C5,6

iii.

action, ________ ________

flex and supinate forearm

________ ________

nerve, m________

musculocutaneous

muscle, ________

coracobrachialis

ii.

root, ________

C5,6,7

iii.

action, ________ ________

flex and adduct forearm

________ ________

Brachial Plexus

341

nerve, m________

musculocutaneous

muscle, ________

brachialis

ii.

root, ________

C5,6

iii.

action, ________ ________

flex forearm

nerve, a________

axillary

muscle, ________

deltoid

ii.

root, ________

C5,6

iii.

action, ________ ________ _______

abduct arm > 90 degrees

nerve, s________

subscapularis

muscle, ________ ________

teres major

ii.

root, ________

C5,6,7

iii.

action, ________ ________

adduct arm

nerve, t________

thoracodorsal

muscle, ________ ________

latissimus dorsi

ii.

root, ________

C5,6,7,8

iii.

action, ________ ________,

adduct arm, ladder, cough

________, ________

nerve, a________

axillary

muscle, ________ ________

teres minor

ii.

root, ________

C4,5

iii.

action, ________ ________

rotation lateral

nerve, l________ t________

long thoracic

muscle, ________ ________

serratus anterior

ii.

root, ________

C5,6,7

iii.

action, ________ _______

forward shoulder thrust

_________

30.

Considering the brachial plexus and

G7 p.791:30mm

radial nerve, list the branches of the

radial nerve cascade in proper

sequence and the function of the

muscles.

Hint: rest in peace, retbes in peeeeeae

r________

radial

e________

extensor

t________

triceps

b________

brachioradialis

e________

extensor carpi radialis

s________

supinator

i________

n________

n posterior interosseus nerve

p________

e________

extensor carpi ulnaris

e________

extensor digitorum

communis

e________

extensor digiti minimi

e________

extensor pollicis brevis

e________

extensor pollicis longus

a________

abductor pollicis longus

e________

extensor indicis

342

Peripheral Nerves

31.

True or False. The radial nerve is

G7 p.791:29mm

formed by

C5-T1

false

C5-C8

true

C6-T1

false

C5-C7

false

32.

True or False. Regarding the radial

G7 p.791:29mm

nerve, it

is formed by C5-C8

true

innervates triceps

true

innervates supinator

true

innervates brachioradialis

true

continues into forearm as posterior

true

interosseus nerve

33.

What is innervated by the axillary

G7 p.791:105mm

nerve?

t________ m________

teres minor

d________

deltoid

34.

Regarding the brachial plexus and

G7 p.791:120mm

median nerve, list the 11 branches of

the median nerve cascade in proper

sequence.

p________

pronator teres

f________

flexor carpi radialis

p________

palmaris longus

f________

flexor digitorum superficialis

f________

flexor digitorum profundus

f________

flexor pollicis longus

p________

pronator quadratus

f________

flexor pollicis brevis

a________

abductor pollicis brevis

o________

opponens pollicis

l________

lumbricales 1 and 2

35.

Regarding the brachial plexus and

G7 p.791:120mm

median nerve, list the 11 branches of

the median nerve cascade and the

function of the muscles.

p________ t________

pronator teres

ii.

function: f________ p________

forearm pronator

f________ ________ ________

flexor carpi radialis

ii.

function: r________ f________ of

radial flexion of hand

h________

p________ ________

palmaris longus

ii.

function: h________ f________

hand flexion

f________ ________ ________

flexor digitorum superficialis

ii.

function: f________ m________

flex middle phalanx, fingers 2

p________, fingers ________ to

to 5

________

Brachial Plexus

343

f________ ________ ________

flexor digitorum profundus

ii.

function: f________ d________

flex distal phalanx, fingers 2

p________, fingers ________ to

to 3

________

f________ p________ l________

flexor pollicis longus

ii.

function: f________ d________

flex distal phalanx of thumb

p________ of t________

p________ ________

pronator quadratus

ii.

function: p________ f________

pronates forearm

f________ p________ b________

flexor pollicis brevis

ii.

function: f________ p________

flexes procimal phalanx of

p________ of t________

thumb

a________ ________ ________

abductor pollicis brevis

ii.

function: a________ t________

abducts thumb metacarpal

m________

o________ ________

opponens pollicis

ii.

function: op________ t________

opposes thumb metacarpal

m________

l________ 1 and 2

lumbricales

ii.

function: e________ 2 d________

extend 2 distal phalanges of

p________ of ________ 2 and 3

fingers 4 and 5

36.

Which muscles in the hand are

G7 p.791:150mm

innervated by the median nerve?

Hint: loaf

l________

lumbricals 1 and 2

o________

opponens pollicis

a________

abductor pollicis brevis

f________

flexor pollicis brevis

37.

Which muscles are served by the

G7 p.791 :170mm

anterior interosseous nerve?

f________ d________ p________

flexor digitorum profundus

f________ p________ l________

flexor pollicis longus

p________ q________

pronator quadratus

38.

Regarding the brachial plexus and

G7 p.792:25mm

ulnar nerve, list the muscles served by

the ulnar nerve cascade in proper

order and the function of the muscles.

Hint: “Ffafner I Love Him”

f________ c________ u________

flexor carpis ulnaris

ii.

function: u________ f________ of

ulnar flexion of hand

h________

344 Peripheral Nerves

f________ ________ ________

flexor digitorum profundus

ii.

function: f________ d________

flex distal phalanx of fingers 4

p________ of f________ ________

and 5

and ________

a________ p________

adductor pollicis

ii.

function: t________ a________

thumb adductor

f________ ________ ________

flexor pollicis brevis

ii.

function: f________ p________

flex proximal phalanx of

p________ of t________

thumb

i________

interossei

ii.

function: dorsal a________

abducts

iii.

function: palmar a________

abducts flex proximal

f________ p________ p________ at

phalanges at metacarpo

m________ joints

phalangeal joints

l________

lumbricales

ii.

function: e________ t________

extends two distal phalanges

d________ p________ of ________

of 3 and 4 at interphalangeal

________ and ________ at

joints

i________ j________

h________

hypothenar abductor digiti

minimi, flexor digiti minimi

opponens

function: a________ l________

abduction little finger

f________

ii.

function: f________ l________

flex little finger

f________

39.

Study Chart.

G7 p.791:20mm

Radial

Ulnar

Median

Radial

Ulnar

Median

RETBES in PE5AE

FFAF ILH

PFPF3PFAOL

radial

flexor carpi ulnaris

pronator teres

RETBES in

extensor

PEEEEEAE

triceps

flexor digitorum

flexor carpi radialis

brachioradialis

profundus

almaris longus

extensor carpi radialis

adductor pollicis

flexor digitorum superficialis

}

supinator

flexor pollicis brevis

flexor digitorum profundus

interossei

flexor pollicis longus AIN

lumbricales

pronator quadratus

} PIN

hypothenar

flexor pollicis brevis

extensor carpi ulnaris

abductor pollicis brevis

extensor digitorum

opponens pollicis

extensor digiti minimi

lumbricales

extensor pollicis brevis

extensor pollicis longus

abductor pollicis longus

extensor indicis

40. Which muscles in the arm are

none

G7 p.792:30mm

innervated by the ulnar nerve?

Peripheral Neuropathies

345

41.

Regarding the following additional (2)

G7 p.792:60mm

nerves of the brachial plexus, number

also

the roots and name the muscles and

G7 p.792:110mm

their actions:

nerve, musculocutaneous

roots, ________

C5,6,7

ii.

muscles, ① b________,

① biceps,

② c________, ③ b________

② coracobrachialis,

③ brachialis

iii.

action, ① f________ f________ and

① flex forearm and supinates

s________

iv.

② f________ f________ and

② flex forearm and adducts

a________

③ f________ f________

③ flex forearm

nerve, axillary

roots, ________

C4,5,6

ii.

muscles, ① d________,

① deltoid, ② teres minor

② t________ m________

iii.

action, ① a________ a________

① abduct arm 30 to 90

________ to ________ degrees

degrees

iv.

② l________ a________ r________

② lateral arm rotation

42.

Complete the following about

G7 p.792:135mm

anatomic variants with Martin-Gruber

anastomosis:

Connections between the ________ and

median; ulnar

________ nerves

In the ________

forearm

Found in ________% of cadavers

23%

 Peripheral Neuropathies

43. List the etiology.

G7 p.793:65mm

Hint: dang the rapist

a. d________

diabetes

b. a________

alcohol

c. n________

nutritional, B₁₂

d. g________

Guillain-Barré

e. t________

traumatic

f. h________

hereditary

g. e________

entrapment

h. r________

renal, radiation

a________

amyloid

p________

porphyria, paraneoplastic

k. i________

infectious, Hanson

s________

sarcoidosis

m. t________

toxins, heavy metals

346

Peripheral Nerves

44.

Complete the following regarding

G7 p.793:130mm

peripheral neuropathy:

The most common peripheral

Charcot-Marie-Tooth

neuropathy that is an inherited disorder

syndrome

is C________-M________-T________

s________.

The percent of patients with diabetes

50%

mellitus who develop diabetic

neuropathy is ________%.

45.

Which syndrome is associated with

paraneoplastic syndrome

G7 p.794:75mm

pure sensory neuropathy?

(also seen with pyridoxine

therapy)

46.

True or False. Alcohol neuropathy

G7 p.794:100mm

includes

motor neuropathy

false

sensory neuropathy

true

absent Achilles reflex

true

intense pain

false

47.

Brachial neuritis

G7 p.794:78mm

aka P________ t________ syndrome

Parsonage tumor

aka i________ brachial plexus

idiopathic

neuropathy

Etiology: ________

unclear

Prognosis: ________

good

Predominant symptom: ________

pain

Followed by: ________ in ________%

weakness, 96%

Confined to shoulder girdle in

50%

________%

48.

True or False. The most important

G7 p.796:45mm

study in the diagnosis of lumbosacral

plexus neuropathy is

magnetic resonance imaging (MRI)

false

computed tomography (CT)

false

electromyography (EMG)

true (EMG in lumbosacral

neuropathy—rule out diabetic

neuropathy!)

erythrocyte sedimentation rate (ESR)

false

49.

EMG in lumbosacral neuropathy shows

G7 p.796:45mm

what in regards to:

fibrillation potentials ________

increased

motor unit potentials in number

decreased

________

motor unit potentials in amplitude

increased

________

motor unit potentials in duration

increased

________

motor unit potentials that are ________

polyphasic

have changes involving at least

________ segments

________ the paraspinal muscles is

sparing

highly ________

diagnostic

Peripheral Neuropathies

347

50.

Complete the following about diabetic

G7 p.796:65mm

neuropathy:

Diabetic patients show neuropathy or

EMG changes ________%.

The first symptom of diabetes may be

neuropathy

________.

Neuropathy might be reduced by control

sugar

of blood ________.

51.

Complete the following about drug-

G7 p.797:145mm

induced neuropathy:

Hint: CDEF

C________

Chemotherapy drugs

D________

Dilantin

E________

Elavil

F________

Flagyl

52.

True or False. Femoral neuropathy

G7 p.798:25mm

includes

weakness of quadriceps and iliopsoas

true

patellar reflex—reduced

true

femoral stretch—positive

true

sensation over lateral calf reduced

false (Femoral neuropathy

includes ↓ sensation over

anterior thigh and medial

calf.)

53.

Answer the following regarding

G7 p.798:35mm

femoral neuropathy:

Name the muscle responsible for

knee extension

quadriceps femoris

ii.

hip flexion

iliopsoas

To distinguish L4 radiculopathy from

iliopsoas

femoral neuropathy, L4 radiculopathy

would not involve the ________.

Femoral neuropathy is caused by

d________

diabetes

ii.

c________

compression

54.

True or False. The most frequent cause

G7 p.798:75mm

of femoral neuropathy is

intraabdominal tumor

false

retroperitoneal hematoma

false

diabetes

true (Diabetes is the most

frequent cause. All options

can cause femoral

neuropathy.)

entrapment due to inguinal hernia

false

trauma

false

348

Peripheral Nerves

55.

True or False. Regarding AIDS

G7 p.798:110mm

neuropathy:

It usually presents as proximal symmetric

false (It is a distal symmetric

polyneuropathy.

polyneuropathy.)

Only HIV+ patients do not develop it.

true

It never includes sensory elements.

false (usually includes

numbness and tingling)

It has infectious etiology.

true

It may be caused by lymphomatous

true

invasion of the meninges or nerves.

56.

Complete the following about

G7 p.799:28mm

monoclonal gammopathy:

Include entities such as

m________

myeloma

ii.

Waldenström ________

macroglobulinemia

Responsible for ________% of

10%

neuropathies

57.

Complete the following about

G7 p.799:126mm

perioperative neuropathies ulnar:

Avoid elbow flexion of greater than

110

________ degrees.

It tightens the ________ ________

cubital tunnel

retinaculum.

58.

Complete the following about lower

G7 p.799:172mm

extremity neuropathy:

Common peroneal in ________%

81%

ii.

risk is ________ position

lithotomy

femoral neuropathy where there is

psoas

G7 p.800:27mm

hemorrhage in the ________ muscle

meralgia paresthetica

G7 p.800:40mm

tends to occur ________

bilaterally

ii.

in young slender ________

males

iii.

positioned ________

prone

iv.

in operations lasting ________ hours

6 to 10

recovers in approximately ________

6 months

________

59.

What is the management of lower

G7 p.800:53mm

extremity neuropathy?

Call neurologist if not better in ________

days.

Do EMG not earlier than ________

weeks.

60.

Complete the following about amyloid

G7 p.800:82mm

neuropathy:

Amyloid can be deposited in ________

peripheral nerves

________.

It produces a ________ neuropathy.

Sensory

It can produce pressure on nerves, i.e.,

carpal tunnel

________ ________.

Peripheral Neuropathies

349

61.

Complete the following about post-

G7 p.800:145mm

cardiac catheterization neuropathy:

It involves the ________ nerve.

femoral

It usually involves ________.

hematomas

62.

Describe the anatomy of the

G7 p.801:53mm

peripheral nerve.

Which connective tissue membrane

endoneurium surrounds

surrounds individual axons?

individual axons

Which surrounds groups of axons (i.e.,

perineurium bundles axons

fascicles)?

(covered by endoneurium)

into fascicles

Which surrounds groups of fascicles (i.e.,

epineurium groups fascicles

nerves)?

(covered by perineurium) into

nerve trunk

63.

Complete the following regarding

G7 p.801:75mm

injury and regeneration of nerve:

The regeneration rate = ________

1 mm/day (i.e., 1 inch per

month)

Sunderland system

first-degree anatomy ________

preserved; conduction block,

compression, or ischemia

ii.

second-degree axon ________

injured; endo-, peri-,

connective tissue is ________

epineurium intact

(endoneurium provided tube

for regeneration)

iii.

third-degree axon and endoneurium

axon and endoneurium

d________

disrupted (grossly normal

appearance, recovery related

to extent of intrafascicular

fibrosis)

64.

Complete the following about the

G7 p.801:75 mm

peripheral neuropathies:

fourth-degree axon endoperi ________

interruption of all elements

G7 p. 802:82mm

but epineurium is intact,

nerve is indurated and

enlarged

fifth-degree axon endoperi and

completely transected

epineurium is completely t________

sixth-degree mixed ________ through

mixed first through fourth

G7 p.802:105mm

________ degree injuries

65.

Complete the following about the

G7 p.801:110mm

peripheral neuropathies:

Nerve regeneration occurs at the rate of

1 mm/day

G7 p.802:62mm

________ mm/day.

Nerve regeneration occurs at the rate of

1 inch/month

________ inch(es)/month.

350

Peripheral Nerves

Describe injury classification of

two classifications: Seddon

peripheral nerves and regeneration

and Sunderland

prognosis.

axon compressed

first-degree = Seddon

neuropraxia; conduction

block from compression or

ischemia; anatomy preserved

ii.

axon injured

second-degree = Seddon

axonotmesis; injury to axon

with Wallerian degeneration;

endoneurium/perineurium/ep

ineurium intact; endoneurium

provides “tube” to optimize

successful reinnervation of

target muscle

iii.

axon and endoneurium disrupted

third-degree = axon and

endoneurium disrupted;

recovery inversely related to

interfascicular fibrosis; gross

normal appearance

iv. axon, endoneurium and perineurium

fourth-degree = interruption

disrupted

axon, endoneurium,

perineurium; gross reveals

indurated enlarged nerve

v. axon endo-, peri-, and epineurium

fifth-degree = Seddon

disrupted

neurotmesis; complete

transection of axon, endo-,

peri-, epineurium

66.

What are etiologies of brachial plexus

G7 p.801:130 mm

injuries?

Hint: cpt

c________

compression

p________

penetration

t________

traction

67.

Complete the following about traction

G7 p.801:138mm

(stretch) injuries of the brachial plexus

selectively:

spare the

________ ________

medial cord

ii.

________ ________

median nerve

injure the

________ ________

posterior cord

ii.

________ ________

lateral cord

Peripheral Neuropathies

351

68.

Complete the following about the

G7 p.801:150 mm

peripheral neuropathies:

What nerve injury cannot be repaired?

proximal to dorsal root

ganglion (i.e., preganglionic)

What is the evidence for such an injury?

Hint: prEHms

pain

rhomboids

EMG

Horner

meningocele

scapula

69.

List the characteristics of Erb and

G7 p.802:130mm

Klumpke brachial plexus injury.

e________

extended

r________

rotated

p(b)________

pronated

k(cl)________

claw

l________

lower roots C8 T1

u________

ulnar type claw plus

m________

median type claw

p________

palsy

70.

Describe upper and lower brachial

G7 p.802:135mm

plexus injury.

upper brachial plexus injury

D________-E________ palsy

Duchenne-Erb palsy

ii.

u________ p________ C________,

upper plexus C5, C6

C________

iii.

f________ s________ h________

forceful separation humeral

h________ from s________

head from shoulder

iv. d________ or m________

commonly dystocia or

c________

motorcycle crash

v. i________ r________ a________

internally rotated arm with

with e________ e________

extended elbow

vi. b________ t________

bellhop’s tip, hand not

affected

lower brachial plexus injury

K________ p________

Klumpke palsy

ii.

l________ p________ C________,

lower plexus C8, T1

T________

iii.

s________ p________ of a________

sudden pull of abducted arm

a________ i________

iv. f________ or P________ t________

fall or Pancoast tumor

s________

syndrome

v. c________ h________ with

claw hand with

w________/w________ of

weakness/wasting of small

s________ h________ m________

hand muscles

vi. s________ h________

simian hand

352

Peripheral Nerves

71.

Complete the following about brachial

G7 p.802:135mm

plexus birth injuries:

most common is ________

upper

ii.

consisting of C5-C6________% and

50%

iii.

C5, C6-C7 ________%

25%

iv.

lower C8-T1 ________%

combined is ________%

20%

bilateral ________%

spontaneous recovery is ________%

90%

72.

Characterize upper brachial plexus

G7 p.802:140mm

injury—Erb palsy.

roots involved ________

C5 (ABCDE) fifth letter of

alphabet, Erb palsy mainly

C5 and also C6, C7

position of upper extremity (Hint: erp)

e________

extended

ii.

r________

rotated

iii.

p________

pronated

iv.

looks like ________ ________

bellhop’s tip position

________

Weak muscles and their roots

d________

deltoid

roots, ________

C5, C6

ii.

b________

biceps

roots, ________

C5, C6

iii.

r________

rhomboids

roots, ________

C4, C5

iv. b________

brachioradialis

roots, ________

C5, C6

v. s________

supraspinatus

roots, ________

C4, C5, C6

vi. i________

infraspinatus

roots, ________

C5, C6

mechanism ________ ________

shoulder separation

from:

b________ i________

birth injuries

ii.

m________ a________

motorcycle accidents

73.

Characterize lower brachial plexus

G7 p.802:155mm

injury—Klumpke palsy.

roots involved

C7, C8, T1

position of upper extremity (Hint: klump)

kl________

claw hand (Simian hand)

ii.

u________

ulnar claw

iii.

m________

plus median claw

iv.

p________

paralysis

weak muscles

upper extremity ________

small muscles of hand

ii.

face ________

Horner if T1 involved

mechanism: traction on ________ arm

abducted

from

f________

falls

ii.

b________

birth

iii.

P________

Pancoast tumors

Peripheral Neuropathies

353

74.

Complete the following regarding

G7 p.802:175mm

birth injury of brachial plexus:

incidence is ________

0.3 to 2/1000 births

upper

50% C5, C6

ii.

upper plus C7

25% C5, C6, C7

mixed

20%

lower

2% C7, T1

bilateral

75.

True or False. The following are

G7 p.803:105mm

indications for early surgical

exploration of the brachial plexus:

any injury needs repair

false (most injuries maximal

deficit at onset then improve)

progressive deficit

true (progressive deficit likely

vascular injury, explore

immediately)

clean sharp injury

true (clean, sharp, fresh

lacerating injuries → explore

acutely and repair end-to-end

tension-free within 72 hours)

gunshot wound (GSW) to brachial plexus

false (surgery is of little

benefit)

76.

List medical etiologies of entrapment

G7 p.804:85mm

neuropathies.

a________

arthritis rheumatoid

a________

acromegaly

a________

amyloidosis

p________

polymyalgia rheumatica

c________

carcinomatosis

d________

diabetes

g________

gout

h________

hypothyroidism

77.

Name the two most common

G7 p.806:60mm

syndromes of median nerve

entrapment.

c________ t________ s________

carpal tunnel syndrome

p________ t________ s________

pronator teres syndrome

78.

Describe carpal tunnel syndrome (CTS)

G7 p.806:72mm

anatomy.

The median nerve passes under the

transverse carpal ligament

________ ________ ________.

The motor branch either goes

________ or

under

ii.

________ the ligament

pierces

and serves the ________ muscles,

loaf

which are

l________

limbricales 1 and 2

ii.

o________

opponens pollicis

iii.

a________

abductor pollicis

iv.

f________

flexor pollicis brevis

354

Peripheral Nerves

79.

Answer the following about carpal

G7 p.806:150mm

tunnel syndrome:

The transverse carpal ligament extends

3 cm

how far beyond the distal wrist crease?

What is the name of the sensory nerve?

palmar cutaneous branch

G7 p.806:160mm

It arises ________ cm proximal to the

5.5 cm

wrist.

It passes ________ the transverse carpal

above

G7 p.806:172mm

ligament

and serves the ________ ________

thenar eminence

sensation.

80.

Complete the following about the

G7 p.806:177mm

median nerve:

Describe the sensory distribution of the

median nerve.

thumb: ________ aspect

palmar

ii.

fingers: ________, ________ and

index, middle, and half of ring

half of ________

iii.

________ eminence and adjacent

thenar

iv.

________ palm

radial

crosses ________ transverse carpal

above

ligament

81.

Describe main trunk median nerve

G7 p.807:17mm

compression.

above elbow due to ________ ________

Struthers ligament →

supracondylar to medial

epicondyle, mostly

asymptomatic

at elbow

b________ a________

bicipital aponeurosis

ii.

p________ t________

pronator teres

iii.

s________ b________

sublimis bridge

Honeymoon paralysis is due to ________

direct compression

________.

Benediction hand is due to weakness of

flexor digitorum profundus

G7 p.807:30mm

________ ________ ________ I and II.

82.

Characterize pronator teres syndrome

G7 p.807:60mm

(PTS).

It compresses the ________ nerve

median

where it dives between the two heads of

pronator teres

the ________ ________.

Symptoms are

pain in the ________

palm

ii.

weakness in the ________

grip

iii.

paresthesias in the ________ and

thumb and index finger

________.

iv. It differs from CTS in that there is no

nocturnal pain in pronator

________,

teres syndrome

v. but there is ________ in PTS

pain in the palm

vi. because the ________ branch is

median palmar cutaneous

compressed in PTS.

Peripheral Neuropathies

355

83.

Describe pronator teres syndrome.

G7 p.807:60mm

caused by repeated ________

pronation

ii.

with a ________ ________

tight fist

due to ________ ________ where it

nerve entrapment

dives between

ii.

two heads of the ________

pronator teres

________.

Symptoms are

a________

ache

ii.

p________ in p________

pain in palm

iii.

w________ g________

weak grip

Distinguished from carpal tunnel

syndrome by

no n________ e________

nocturnal exacerbation

84.

What are the key features of anterior

G7 p.807:95mm

interosseous neuropathy?

loss of f________

flexion

ii.

of the d________ p________

distal phalanges

iii.

of the t________

thumb

iv.

and i________ f________

index finger

due to

weakness of the f________

flexor digitorum profundus

d________ p________ and the

ii.

f________ p________ l________

flexor pollicis longus

no loss of ________

sensation (anterior

interosseous is pure motor)

patient can’t ________

make “OK” sign

treatment

e________

no identifiable cause—

expectant; management 8 to

12 weeks

ii.

e________

if no improvement or if

progression proceed with

surgical exploration

85.

Answer the following about the

G7 p.807:100mm

anterior interosseous nerve:

If injured a person can’t do what with the

make an “O”

thumb and index finger?

There is weakness of the

f________ d________ p________

flexor digitorum profundus

and

ii.

f________ p________ l________

flexor pollicis longus

Is part of what nerve?

median

Syndrome may be caused by ________

constricting

ligament.

Is there any sensory loss?

no sensory loss

356

Peripheral Nerves

86.

Describe the epidemiology of carpal

G7 p.808:78mm

tunnel syndrome.

What is the most common median nerve

carpal tunnel syndrome

entrapment neuropathy?

It is due to ________.

compression of the median

nerve

Where?

distal to wrist crease

Age ________

middle-aged patient

Male/female ratio ________

4:1

Bilateral ________%

bilateral > 50%

Worse in ________

dominant hand

Phalen sign is performed by ________ of

forced flexion

G7 p.808:85mm

the wrist

and is positive in ________%.

80%

87.

What is double-crush syndrome?

G7 p.809:130mm

It involves two sites.

________

cervical radiculopathy

ii.

________

median/ulnar neuropathy

It is exacerbated by ________.

neck movement

Pathophysiology

postulated that ________

cervical

compression

ii.

compromises ________ ________

axoplasmic flow

iii.

predisposing ________ ________

nerve to distal

________ injury

88.

Answer the following about carpal

G7 p.810:25mm

tunnel syndrome:

What is the most sensitive

sensory latency nerve

electrodiagnostic test for carpal tunnel

conduction velocity (NCV)

syndrome?

Which should be faster, median sensory

median

conduction velocity or ulnar sensory

conduction velocity?

By how much?

4 m/s faster

89.

Complete the following about carpal

G7 p.810:165mm

tunnel syndrome:

Describe treatment.

sp________

splint

ii.

st________

steroids

iii.

su________

surgery

Incision should be slightly to the

ulnar

________ side of the interthenar crease

to avoid

p________ c________ b________

palmar cutaneous branch

G7 p.812:43mm

and/or

ii.

a________ r________ t________

anomalous recurrent thenar

G7 p.812:70mm

m________ b________.

motor branch

Peripheral Neuropathies

357

90.

Complete the following about the

G7 p.812:155mm

ulnar nerve:

Name the roots.

ulnar components C7, C8, T1

Motor findings of entrapment?

G7 p.813:17mm

(Hint: abcWF)

a________

interossei wasting; atrophy,

particularly thumb web space

ii.

b________

benediction hand

iii.

c________

claw deformity

iv.

W________

Wartenberg sign: abducted

G7 p.813:22mm

little finger

v. F________

Froment thumb sign

G7 p.813:27mm

pain and tingling in ________

little finger

________

ii.

and ________ ________ ________

ulnar half ring finger

________

91.

Answer the following about ulnar

G7 p.813:17mm

nerve entrapment:

What occurs to interossei?

atrophy

Little finger weak on

________ is called

adduction

ii.

W________ s________.

Wartenberg sign (little finger

held in abduction)

Holding a piece of paper requires

modification because of a weak

________ ________ and is called

adductor pollicis

ii.

________ ________ ________

Froment prehensile thumb

________.

sign

Waving goodbye demonstrates a

claw deformity of the hand

c________ d________

also known as m________ en

main en griffe

G7 p.813:40mm

g________

ii.

also known as b________

benediction hand

h________.

What other nerve injury can produce

benediction hand?

median

ii.

upon what attempted action?

making a fist

92.

Describe Wartenberg sign.

G7 p.813:22mm

It affects the ________.

little finger

What occurs to the ________?

little finger

It rests in ________

abduction

due to weakness of the t________

third palmar interosseous

p________ i________ m________.

muscle

Which nerve is involved?

ulnar

93.

Describe Froment sign.

G7 p.813:27mm

Test by having the patient g________

grasp a piece of paper

using his t________ and i________

thumb and index fingers

f________.

If the ________ nerve is weak what

ulnar

happens?

358

Peripheral Nerves

Thumb b________ b________

bends backward (i.e., flexing

the distal phalanx or

extending proximal phalanx

of the thumb)

Because ulnar innervated ________

adductor pollicis

________ is weak

Therefore the body substitutes for it the

stronger flexor pollicis longus

________ ________ ________

________,

which is innervated by the ________

anterior interosseous nerve,

________ ________ of the ________

median

nerve.

94.

Describe ulnar nerve entrapment.

G7 p.813:70mm

Injury above elbow due to

i________ to m________

injury to medial cord

c________

ii.

kinking at the a________ of

arcade of Struthers

S________

aponeurotic band

Entrapment at the e________

elbow

G7 p.813:90 mm

aka t________ u________

“tardy ulnar palsy” (delayed

p________

presentation—initial case 12

years > from injury to elbow—

elbow dislocation/lateral

condyle fracture; nerve is

superficial, fixed and crosses

joint)

ii.

NCV is less than ________ m/s

48 m/s

iii.

or a difference between the 2 slides

10 m/s

of greater than ________ m/s

Entrapment in the f________

forearm

Entrapment in the

wrist/hand

w________/h________

95.

What are surgical treatment options

G7 p.814:150mm

for ulnar compression at the elbow?

de________ without ________

simple nerve decompression

without transposition

de________ with ________

nerve decompression with

transposition

medial ________

epicondylectomy

Results in %

G7 p.815:125mm

excellent ________%

60%

ii.

fair ________%

25%

iii.

poor ________%

15%

True or False. What responds better?

pain and sensory loss

true

ii.

weakness and atrophy

false

96.

Answer the following about

G7 p.815:155mm

entrapement in the forearm—cubital

tunnel syndrome:

Involves which nerve?

ulnar

Due to which muscle?

flexor carpi ulnaris

Peripheral Neuropathies

359

The mechanism is compression between

(Just distal to the elbow, the

the

ulnar nerve passes from the

groove between the)

m ________ e________ and the

medial epicondyle and the

ii.

o ________ p________

olecranon process to enter

the two heads of the flexor

carpi ulnaris under the fascial

band connecting the two

heads (the cubital tunnel)

results in a ________ W________,

atrophy of the interrossei,

F________, c________

Wartenberg sign, Froment

prehensile thumb sign, claw

deformity of the hand (main

en griffe)

97.

Characteristics of the cubital tunnel

G7 p.815:155mm

syndrome are

c________

claw deformity

c________

(flexor) carpi ulnaris

u________

ulnar nerve

b________

band is tight

i________

interossei atrophied

t________

thumb sign Froment

prehensile

t________

two heads of flexor carpi

ulnaris

a________

atrophy of interossei

l(el)________ e________

elbow epicondyle

98.

Describe the borders of the Guyon

G7 p.816:25mm

canal.

roof

p ________ f________

palmar fascia

ii.

p ________ b________ m________

palmar brevis muscle

floor

f________ r________ of the

flexor retinaculum of the

p________

palm

ii.

p________ l________

pisohamate ligament

Below the floor is the t________

transverse carpal ligament

c________ l________.

It contains only the ________ nerve and

ulnar (At the middle of the

artery.

canal the nerve divides into

deep and superficial

branches. Superficial branch

is mostly sensory [except for

the branch to palmar brevis]

and supplies hypothenar

eminence and ulnar half of

ring finger. The deep

[muscular] branch innervates

hypothenar muscles,

lumbricals 3, 4, and

interossei.)

360

Peripheral Nerves

99.

Describe the types of ulnar nerve

G7 p.816:70mm

lesions in Guyon canal type—location

of compression—weakness-sensory

deficit.

type I

location of compression

just proximal to or within

Guyon canal

ii.

weakness

all intrinsic muscles

innervated by ulnar nerve

iii.

sensory deficit

palmar ulnar distribution

(palmar ulnar distribution: the

hypothenar eminence and

ulnar half of ring finger both

on the palmar surface only)

type, II

location of compression

along deep branch

ii.

weakness

muscles innervated by deep

branch (depending on

location may spare

hypothenar muscles)

iii.

sensory deficit

none

type III

location of compression

distal end of Guyon canal

ii.

weakness

none

iii.

sensory deficit

palmar ulnar distribution (the

hypothenar eminence and

ulnar half of ring finger both

on the palmar surface only)

100.

Complete the following regarding

G7 p.816:145mm

radial nerve injuries:

Sensation loss in the web space of the

hand

thumb indicates injury in the ________.

Pain at the lateral epicondyle indicates

supinator tunnel at the elbow

compression of the ________ ________

________ ________ ________.

Finger drop indicates injury to the

________

ii.

resulting from entrapment at the

arcade of Frohse

a________ of F________.

Wrist drop indicates injury to

mid-upper arm

________-________ ________

ii.

where the nerve is in the ________

spiral groove

________.

Triceps plus all distal muscle weakness

axilla

indicates injury at the ________

above plus weakness of the deltoid and

posterior cord

latissimus dorsi indicates injury to the

________

above plus winging of the scapula on the

roots

forward shoulder thrust indicates injury

to the ________.

Peripheral Neuropathies

361

101.

Differentiate radial nerve injury from

G7 p.816:145mm

brachial plexus posterior cord injury.

Check the function of the ________ and

deltoid

________ muscles.

latissimus dorsi radial nerve

arises from posterior divisions

of the three trunks of the

brachial plexus to form the

posterior cord. Sparing of

deltoid (axillary) and

latissimus dorsi

(thoracodorsal) localizes

injury to radial nerve and not

the more proximal portion of

the posterior cord.

102.

Differentiate axilla and mid-upper arm

G7 p.816:175mm

radial nerve compression.

Check the function of the ________

triceps

muscle.

Wrist drop plus weak triceps implicates

axilla; crutch misuse, weak

injury at ________.

triceps and distal, radial

innervated muscles

Wrist drop but normal triceps implicates

mid-upper arm; sites:

injury at ________.

spiral groove, intermuscular

septum; improper arm

positioning with; intoxication

“Saturday night palsy”;

iatrogenic surgical

positioning; callus old

humeral fracture; wrist drop-

normal triceps; DDX (lead

poisoning)

103.

Describe mid-upper or forearm radial

G7 p.817:38mm

nerve compression.

Radial nerve compression mid-upper arm

produces

w________ (w________ d________)

weakness (wrist drop)

and

ii.

________ ________

wrist numbness

iii.

because it compresses ________

PIN and superficial (sensory)

and ________ ________ ________.

radial nerve (finger drop)

Injury to the posterior interosseous nerve

G7 p.817:75mm

(PIN) produces

________ of fingers

weakness

ii.

but no weakness of ________

numbness

iii.

because it compresses ________

PIN (motor) and not the

and not the s________ r________

superficial radial nerve

n________.

(sensory)

Injury at the supinator tunnel produces

G7 p.817:105mm

________ but no

pain

ii.

________ and no

weakness

iii.

________.

numbness

362

Peripheral Nerves

104.

Complete the following about

G7 p.817:80mm

peripheral neuropathies:

PIN refers to the ________ ________

posterior interosseous nerve

________

a continuation of the ________ nerve,

radial

which serves the

e________ of the f________ and the

extensors of the fingers

ii.

a________ p________ l________

abductor pollicis longus

105.

Complete the following about the

G7 p.817:55mm

radial nerve and wrist weakness:

Failure of wrist extension (wrist drop)

proximal

indicates ________ radial nerve injury.

Failure of finger extension (finger drop)

indicates ________ injury.

106.

Describe forearm/hand radial nerve

G7 p.817:95mm

compression management.

posterior interosseous syndrome

Surgical exploration if no

________ ________ and ________

improvement after 4 to

________ ________

8 weeks expectant

management. Lyse

constrictions and arcade of

Frohse.

supinator tunnel syndrome ________

Responds to nerve

________ and ________ ________

decompression. Lyse

________

constrictions and extensor

carpi radialis brevis.

hand injury

Clinically you find ________

small area of sensory loss

________ ________ ________

dorsal

ii.

at the ________ ________ of

web space of thumb

________

iii.

often caused by ________.

handcuffs

iv.

Symptoms are mild so ________

no surgery is needed

________ ________ ________.

107.

Describe the suprascapular nerve.

G7 p.818:35mm

Formed from roots ________

C5, C6

Entrapped at ________ ________

transverse scapular ligament

________

(TSL) (History: antecedent

frozen shoulder or trauma)

Sensory symptoms ________ ________

referred, poorly localized

________ ________ ________

shoulder pain. Nerve

innervates joint capsule, no

cutaneous representation.

Motor symptoms

atrophy of ________ and ________

infraspinatus and

supraspinatus

ii.

weakness of a ________ ________

supraspinatus upper

________ ________ from 0 to

extremity abduction; 30

________ degrees

iii.

weak ________ tennis shot

backhand

Is EMG helpful?

yes, to distinguish from

rotation cuff injury

Peripheral Neuropathies

363

Treatment ________

surgery; if fails to improve cut

TSL

Differentiate from C5 cervical

rhomboid and deltoid (will

radiculopathy and upper brachial plexus

show weakness in

lesion by testing ________ and

C5 radiculopathy)

________.

108.

Define meralgia paresthetica.

G7 p.818:150 mm

hyperpathia located at the l ________

lateral upper thigh (burning

u________ t ________

pain with hyperpathia)

entrapment of the l ________ f________

lateral femoral cutaneous

c________ nerve

True or False. It contains motor and

false (pure sensory L2, L3)

sensory fibers.

109.

Complete the following about

G7 p.820:95mm

peripheral neuropathies:

Which is the most common nerve to

the common peroneal nerve

develop acute compression palsy?

At what location?

fibular head

It results in impairment of

motor function: ________ ________

foot drop

ii.

sensory loss: ________ of ________

dorsum of foot

110.

Matching. Match the following:

G7 p.820:114mm

Nerve also known as:

① musculocutaneous

② medial popliteal

③ lateral popliteal

④ anterior tibial

tibial L4-5, S2-3

②

common peroneal L4-5, S1

③

deep peroneal L4-5, S1

④

superficial peroneal L5, S1

①

111.

Matching. Match the nerve with the

G7 p.820:114mm

function it serves.

Nerve functions:

① plantar flexors and inversion

② origin of deep and superficial peroneal

③ dorsiflexors superation toe extensors

④ plantar flexors and eversion

tibial

①

common peroneal

②

deep peroneal

③

superficial peroneal

④

112.

Matching. Match the following nerve

G7 p.820:114 mm

and its area of isolated sensory loss:

Nerve area of isolated sensory loss:

① lateral aspect of calf and dorsum of

foot

② space between great and second top

deep peroneal

②

superficial peroneal

①

364

Peripheral Nerves

113.

Matching. Match the nerve with its

G7 p.820:119mm

characteristics.

Characteristic:

① passes behind the fibular head; ② is

the most common nerve to develop

acute compression palsy; ③ serves the

foot extensors; ④ serves the foot

evertors; ⑤ space between great toe

and second toe; ⑥ dorsum of foot

Nerve:

common peroneal

①, ②

deep peroneal

③, ⑤

superficial peroneal

④, ⑥

114.

True or False. Loss of pinprick

G7 p.820:134mm

sensation to the web space between

the great toe and first toe can occur

with

superficial peroneal nerve compression

false (sensory loss lateral leg

and dorsum of foot)

deep peroneal compression

true

S1 nerve root compression

false (sensory loss to lateral

foot and little toe)

none of the above

false

115.

True or False. Entrapment of the

G7 p.785:107mm

common peroneal nerve at the fibular

head may result in:

weak soleus muscle

false (innervated by the tibial

nerve)

foot drop

true

weak biceps femoris muscle

false (biceps femoris

G7 p.1195:70mm

innervated by sciatic proximal

to take off of common

peroneal)

sensory impairment in the lateral calf

true (foot drop and sensory

and dorsum of foot

impairment in lateral calf and

dorsum foot)

116.

True or False. A foot drop may result

G7 p.821:27mm

from

parasagittal meningioma

true

G7 p.1196:60mm

deep peroneal nerve palsy

true

G7 p.1195:180mm

L5 radiculopathy (occasionally L4)

true (L5 is more commonly

G7 p.1195:180mm

the cause of foot drop.)

superficial peroneal nerve palsy

false (There is weakness of

G7 p.820:140mm

foot eversion but not foot

drop.)

common peroneal nerve palsy

true

G7 p.821:16mm

117.

True or False. Peroneal nerve palsy

G7 p.821:55mm

may result from

diabetes mellitus

true

clipping injury in a football player

true

venous thrombosis

true

leprosy (Hansen disease)

true

Thoracic Outlet Syndrome

365

118.

True or False. The posterior tibial

G7 p.822:62mm

nerve may be

found in the tarsal tunnel

true

found posterior and inferior to the

true

medial malleolus

trapped at the retinacular ligament

true

classically responsible for nocturnal pain

false (Heel is spared.

and paresthesia at the heel

Paresthesias are in the toes

and sole of the foot.)

119.

Matching. Match the following nerves

G7 p.820:114mm

with their functions and alternate

names:

Function and alternate name:

① also known as musculocutaneous;

② also known as medial popliteal;

③ also known as lateral popliteal; ④ also

known as anterior tibial; ⑤ serves

plantar flexors of foot plus inversion;

⑥ origin of deep plus sup P; ⑦ foot

dorsiflexors supination and toe

extensors; ⑧ foot plantar flex and

eversion; ⑨ space between great and

second toe; ⑩ lateral aspect of the calf

and dorsum of foot

Nerve:

tibial L4, 5, S2, S3

②, ⑤

common peroneal

③, ⑥

deep peroneal L4, 5, S1

④, ⑦ ,⑨

superficial peroneal L5, S1

①, ⑧ ,⑩

 Thoracic Outlet Syndrome

120. True or False. Clinical presentation of

G7 p.822:155mm

the thoracic outlet syndrome may

include

a. pallor and ischemia of hand and fingers

true

b. arm swelling and edema

true

c. brachial plexus lower trunk dysfunction

true

d. brachial plexus medial cord dysfunction

true

121. True or False. Regarding the thoracic

true

G7 p.823:130mm

outlet syndrome, conservative

treatment may be as effective as the

surgical treatment.

Neuro-ophthalmology



Nystagmus

Complete the following about

G7 p.828:50mm

nystagmus:

What is nystagmus? i________

involuntary rhythmic

r________ o________ of the eyes

oscillation

What is the most common form?

jerk nystagmus

How is its directionality defined?

fast component

What is the abnormal component?

slow component

What is vertical nystagmus indicative of?

p________ f________ p________

posterior fossa pathology

ii.

s________

sedatives

iii.

a________ d________

antiepileptic drugs

Seesaw nystagmus occurs with a

diencephalon

G7 p.828:68mm

lesion in the ________.

Nystagmus retractorius occurs with a

upper midbrain tegmentum;

G7 p.828:83mm

lesion in the ________ ________

pinealoma

________; for example p________.

Ocular bobbing occurs with a lesion in

pontine tegmentum

G7 p.828:135mm

the ________ ________.

Matching. Match the form of

G7 p.828:70mm

nystagmus and the location of the

lesion.

Form:

① seesaw nystagmus; ② convergence

nystagmus; ③ nystagmus retractorius;

④ downbeat nystagmus; ⑤ upbeat

nystagmus; ⑥ abducting nystagmus;

⑦ ocular bobbing

Location:

diencephalon

①

upper midbrain tegmentum

②

midbrain tectum

③

pons medial longitudinal fasciculus (MLF)

⑥, ⑦

medulla

⑤

post-fossa—cervicomedullary junction

④

Papilledema

367

6. Name the location of the lesion in

G7 p.828:70mm

nystagmus.

a. seesaw nystagmus

diencephalon

b. nystagmus retractorius

upper midbrain

tegmentum/pineal region

c. downbeat nystagmus

cervicomedullary junction

(foramen magnum)

d. upbeat nystagmus

medulla

e. ocular bobbing

pons



Papilledema

Complete the following about

G7 p.828:165mm

papilledema:

What is papilledema caused by?

Thought to be caused by

axoplasmic stasis. Theory:

① Increase intracranial

pressure (ICP) transmitted to

the optic disk via

subarachnoid (SA) space.

Retinal venous pulsations

obliterated. ② Retinal

arterial: venous pressure ratio

< 1.5:1.

How long does it take to develop?

24 to 48 hours

What is the earliest it is seen?

6 hours

Does it cause visual blurring?

no (unless severe and

prolonged)

Does it cause visual field distortion?

no (unless severe and

prolonged)

Differentiate from optic neuritis.

funduscopy ________ ________

may look alike

________

ii.

visual lost more with ________

optic neuritis

________

iii.

pain on palpation more with

optic neuritis

________ ________

What is the differential diagnosis for

G7 p.829:30mm

unilateral papilledema?

Hint: Fiom

F________-________

Foster-Kennedy

i________

inflammation

o________ ________

optic glioma

m________ ________

multiple sclerosis

368 Neuro-ophthalmology

 Pupillary Diameter

Complete the following concerning

G7 p.829:180mm

the pupillodilator nerve fibers:

first-order sympathetic nerve fibers

origin, p________ h________

posterolateral hypothalamus

ii.

destination, i________ cell column

intermediolateral

(________ to ________)

(C8 to T2)

iii.

neurotransmitter, a________

acetylcholine (ACh)

second-order sympathetic nerve fibers

origin, i________ cell column

intermediolateral

ii.

destination, s________ c________

superior cervical ganglion

g________

third-order sympathetic nerve fibers

origin, s________ c________

superior cervical ganglion

g________

ii.

destination, p________ m________

pupillodilator muscle (long

of the eye, l________ g________,

ciliary nerves), lacrimal gland,

M________ m________

Müller muscle

iii.

neurotransmitter, n________

norepinephrine

10.

How are pupillodilator muscles

radially

G7 p.829:180mm

arranged?

11.

Describe the anatomy of sympathetic

G7 p.829:180mm

outflow to the eye.

Hint: hilsc

h________

hypothalamus

i________ ________ ________

intermediolateral cell column

l________ ________ ________

lateral horn cells

Pupillary Diameter

369

c________ ________

ciliary ganglion

Sympathetic summary: first

order: posterolateral (a)

hypothalamus → descend in

midbrain tegmentum

uncrossed to pons, medulla,

spinal cord (SC) to the (b)

intermediolateral cell

columns, C8-T2 (ciliospinal

center of Budge). → synapse

with (c) lateral horn cells

acetylcholine (ACh) and give

off second-order neurons (a)

(preganglionics). Second

order: enter sympathetic

chain → (b) superior cervical

ganglion. Third order: (a)

(postganglionics): go up with

common (b) carotid artery

(CCA) those that mediate

sweat to face go up external

carotid artery (ECA), the rest

go up internal carotid artery

(ICA). Some pass: = (d) V1 →

ciliary ganglion → (e)

pupillodilator norepinephrine

(NE)= ICA → (f) ophthalmic

artery → (g) lacrimal gland

and the Müller muscle.

12.

The pupilloconstrictor

concentric as a sphincter

G7 p.830:55mm

(parasympathetic) are muscles

arranged c________ as a s________.

13.

Describe the parasympathetic outflow

G7 p.830:75mm

to the eyes.

Hint: Ect

E________

Edinger-Westphal

c________

ciliary ganglion

t________

third nerve

Parasympathetics

summary: Preganglionics

arise in the Edinger-Westphal

nucleus at the level of the

superior colliculus synapse in

the ciliary ganglion.

Postganglionics travel on the

third nerve to (e) innervate

sphincter pupillae and ciliary

muscle (thickens lens causing

accommodation via

relaxation).

370

Neuro-ophthalmology

14.

Describe the pupillary light reflex.

G7 p.830-:75mm

Hint: ropEtcs

r________

retina

o________

optic nerve

p________

pretectal

E________

Edinger-Westphal

t________

third nerve

c________

ciliary ganglion

s________

sphincter light reflex

Summary: Mediated by (a)

rods and cones of retina.

Transmit via axons to (b)

optic nerve (ON). Bypass

lateral geniculate body

(unlike vision) synapse in (c)

pretectal nuclear complex.

Connect to both (d) Edinger-

Westphal nuclei.

Preganglionics travel in (e)

third nerve to (f) ciliary

ganglion, etc. Cornea rods

and cones (retina) axons optic

nerve bypass lateral

geniculate body pretectal

nuclear complex Edinger-

Westphal nuclei (both

preganglionics) to ciliary

ganglion. Postganglionics via

third nerve to pupillary

sphincter. Ciliary muscles

thicken (relax) causing

accommodation.

15.

Complete the following about Argyll

G7 p.830:140mm

Robertson pupil:

Hint: ALRP = Argyll Robertson

pupil = absent light response pupil

Key feature is ________ ________

absent light response pupil

________ ________ or ALRP.

It occurs in ________.

syphilis

Near light dissociation means the pupil

near

constricts when focusing on an object

________

but the pupil does not react to

light

________.

16.

In which condition do you have light-

syphilis

G7 p.830:140mm

near dissociation, that is, an Argyll

Robertson pupil?

Alterations in Pupillary Diameter

371

17. Complete the following about Argyll

G7 p.830:135mm

Robertson pupil:

a. Light-near dissociation refers to pupillary constriction

________

b. on convergence and ________ of

absence

papillary constriction to shining of the

light into the eye

c. classically described in ________

syphilis

d. also known as ________ ________

Argyll Robertson pupil

________

Hint: prostitutes principle, “They

accommodate but don’t react.”

 Alterations in Pupillary Diameter

18.

Does afferent pupillary defect cause

G7 p.831:25mm

anisocoria?

19.

Complete the following about

G7 p.831 :25mm

anisocoria:

Unequal pupils with an affarent pupillary

two lesions

defect (Marcus-Gunn) means there are

________ ________.

Physiologic anisocoria occurs in

20%

________% of people.

The difference is usually ________ mm.

0.4

Sudden onset of anisocoria is usually due

drugs

to ________.

Sympathomimetics cause ________ to

1 to 2

________ mm of dilation and

parasympatholytics cause ________

mm of dilation and the

ii.

eye ________ ________ react to

does not

light.

20.

Complete the following about Horner

G7 p.831:100mm

syndrome:

The abnormal pupil is ________.

smaller

Ptosis is on the side of the ________

small

pupil.

21.

With third nerve palsy, if there is

large

G7 p.831:110mm

ptosis it will be on the side of the

________ pupil.

22.

Complete the following about

G7 p.831:116mm

oculomotor neuropathy:

Example is ________

diabetes

Usually ________ the pupil

spares

Usually resolves in ________ ________

8 weeks

372

Neuro-ophthalmology

23.

Complete the following about third

G7 p.831:121mm

nerve compression:

Example is ________

aneurysm

Most common is ________

P-comm

Occasionally ________ ________

basilar bifurcation

aneurysm

Usually ________ ________ ________

does not spare

the pupil

24.

What is the differential diagnosis of

G7 p.831:38mm

anisocoria?

Hint: u tAp Hat

u________

uncal herniation (also has

mental status changes)

t________

trauma (traumatic iridoplegia

mydriasis or miosis)

A________

Adie pupil (iris palsy—

impaired postganglionic

parasympathetics)

p________

physiologic (less than 1 mm

difference—20% of

population)

H________

Horner syndrome (impaired

sympathetics to pupillodilator

muscle)

a________

aneurysm (posterior

communicating, basilar)

t________

third nerve palsy (pupil

sparing-diabetes mellitus

[DM 1], ETOH, cavernous

aneurysm)

25.

What is the differential diagnosis for

G7 p.831:170mm

Marcus-Gunn pupil?

Location of lesion ________

ipsilateral to impaired direct

reflex anterior to chiasm

r________—d________ i________

retina—detachment,

infarction

ii.

n________—m________ s________,

nerve—neuritis, multiple

v________, or t________

sclerosis (MS, viral)—trauma

In Marcus Gunn is/are the

third nerve intact?

yes

ii.

parasympathetic nerves intact?

yes

26.

Complete the following about Adie

G7 p.832:40mm

pupil:

An Adie pupil is an ________ palsy

iris

resulting

in a ________ pupil, due to

dilated

impaired ________ ________.

postganglionic

parasympathetics

Clinically, patients exhibit ________-

light-near dissociation

________ ________.

Typically it occurs in a ________ in her

woman; twenties

________.

Horner Syndrome

373

27. The patient with an Adie pupil has a

G7 p.832:45mm

a. dilated or constricted pupil?

dilated

b. due to impaired preganglionic fibers or

postganglionic

postganglionic fibers?

c. thought to be caused by a ________

viral infection

________

d. of the ________ ________

ciliary ganglion

 Horner Syndrome

28.

Horner syndrome is caused by

G7 p.833:80mm

interruption of sympathetics to the

eye and face anywhere along their

path. Name specific causes that affect

the following:

first-order neurons (three causes)

i ________

infarction from vascular

occlusion (usually posterior

inferior cerebellar artery)

ii.

s________

syringobulbia

iii.

i ________ n________

intraparenchymal neoplasm

second-order neurons (three causes)

l________ s________

lateral sympathectomies

ii.

s________ c________ t________

significant chest trauma,

iii.

a________ p________ n________

apical pulmonary neoplasms

(P________ t________)

(Pancoast tumor)

third-order neurons (five causes)

n________ t________

neck trauma (e.g., carotid

dissections)

ii.

c________ v________ d________

carotid vascular disease

iii.

c________ b________ a________

cervical bony abnormalities

iv.

m ________

migraine

sk________-b________ n________

skull-base neoplasms

29.

The ptosis is due to paralysis of the

superior and inferior tarsal

G7 p.833:80mm

________ and ________ ________

muscles.

30.

Is the ptosis complete or partial?

partial

G7 p.833:80mm

31.

Enophthalmos is due to paralysis of

Müller muscle; is involved

G7 p.833:89mm

M________ muscle, which is or is not

involved in Horner syndrome?

32.

Trace the third-order neuron in the

G7 p.833:125mm

pupillodilation/sympathetic path.

Neurons from the s________

superior cervical ganglion to

c________ g________ to the

the pupillodilator muscle and

p________ m________ and M________

Müller muscle

m________.

374

Neuro-ophthalmology

33.

True or False. Answer the following

G7 p.833:125mm

regarding Horner syndrome:

In a patient with Horner syndrome and

preserved sweating of the face, the

lesion is located

in the first-order neuron

false

ii.

in the second-order neuron

false

iii.

in the third-order neuron

true (Injured fibers on ICA

produce Horner, intact sweat

fibers to face on ECA.)

This is compatible with a Pancoast

false (Pancoast tumor would

tumor.

affect the sympathetics

between the spinal cord and

superior cervical ganglion

[i. e., second-order neurons].

The fibers to sweat glands

would be damaged because

they had not yet separated to

travel with the ECA.)

34.

Complete the following about Horner

G7 p.833:160mm

syndrome:

What medication is used if diagnosis of

cocaine

Horner syndrome is in doubt?

How does it work?

cocaine blocks

norepinephrine (NE) reuptake

Therefore in Horner syndrome the pupil

not dilate with cocaine (there

will ________.

is no NE release)

In a normal patient the pupil will

dilate normally

________.

 Extraocular Motor System

35. Matching. From the list below identify

G7 p.834:45mm

the cranial nerve that innervates the

muscle.

Nerve:

① III; ② IV; ③ VI Hint: L6 SO4

Muscle:

a. medial rectus

①

b. inferior rectus

①

c. inferior oblique

①

d. superior rectus

①

e. superior oblique

②

f. lateral rectus

③

36. Complete the following regarding the

G7 p.834:52mm

frontal eye field:

a. True or False. It moves eyes laterally to

true

the opposite side.

b. It is located in the Brodmann area

________.

c. Its fibers go through the ________ of the

genu of the internal capsule

________ ________.

Extraocular Motor System

375

It sends fibers to the ipsilateral ________

paramedian pontine reticular

________ ________ ________ nucleus.

formation (PPRF)

It sends fibers to the ipsilateral ________

sixth

nucleus

and the contralateral ________ nucleus

third

via the ________ ________ ________.

medial longitudinal fasciculus

(MLF)

The right paramedian pontine reticular

right

formation (PPRF) controls lateral eye

movements to the ________.

37.

Complete the following about the

G7 p.834:90mm

extraocular motor system:

Injury to the medial longitudinal

internuclear ophthalmoplegia

fasciculus (MLF) is called ________.

(INO)

Convergence is ________ ________.

not impaired

If the right MLF is injured the right eye

move medially (adduct)

will not ________ ________.

The left eye on looking laterally shows

w________ ________ a________

weakness on abduction

ii.

n________ or adduction.

nystagmus

The most common cause of MLF

multiple sclerosis (MS)

malfunction is ________ ________.

38.

Name three causes of non-pupil-

G7 p.835:40mm

sparing oculomotor palsy.

Hint: tau

t________

tumor

a________

aneurysm (posterior

communicating artery, basilar

tip)

u________

uncal herniation

39.

Name seven causes of pupil-sparing

G7 p.835:100mm

oculomotor palsy.

Hint: mEtDacc

m________

myasthenia gravis

E________

ETOH

t________

temporal arteritis

D________

a________

atherosclerosis

c________ ________ ________

chronic progressive

ophthalmoplegia

c________ ________ ________

cavernous sinus lesions

40.

Complete the following about

G7 p.835:160mm

trochlear nerve palsy (IV):

In relation to the aqueduct the

ventral

trochlear nucleus lies ________

ii.

At the level of the _______ _______

inferior colliculi

The axons pass ________

dorsally

ii.

Decussate ________

internally

It innervates the ________ ________

superior oblique

muscle

376

Neuro-ophthalmology

The superior oblique muscle

Which primarily depresses the

adducted

________ eye?

ii.

In primary gaze it moves the eye

down and out

________ and ________.

41.

Complete the following about the

G7 p.835:172mm

unique features of the trochlear nerve:

Nucleus is on the ________ side of the

opposite

muscle it goes to: ________ ________

superior oblique muscle

________.

It is the only nerve to decussate

internally

________.

It is the only nerve to exit ________ to

posterior

the brain stem.

True or false. It passes through the

false

annulus of Zinn.

Palsy results in eye deviation ________

up and in

G7 p.836:18mm

and ________.

Head is tilted to the ________ ________

side opposite

the IV palsy.

Diplopia is exacerbated when looking

down; stairs

________ (i.e., ________).

42.

Name the causes of abducens palsy.

G7 p.836:45mm

Hint: abducens

a________

arteritis, aneurysms

b________

sixth nerve palsy

d________

diabetes, Dorello canal

(Gradenigo syndrome)

u________

uncontrolled ICP,

pseudotumor, trauma, tumor

c________

cavernous sinus lesions,

clivus, chordoma, or fracture

e________

eye disease, thyroid,

myasthenia gravis

n________

neoplasms

s________

sphenoid sinusitis (Gradenigo

syndrome)

43.

Matching. Match the syndrome with

G7 p.836:125mm

the nerves involved in multiple

extraocular motor involvement.

Syndrome:

① cavernous sinus; ② superior orbital

fissure; ③ orbital apex

Nerves involved:

③

III

①, ②, ③

V¹

①, ②, ③

V²

①

V³

①, ②, ③

Tolosa-Hunt Syndrome

377

 Tolosa-Hunt Syndrome

44.

Is the ophthalmoplegia painful or

painful

G7 p.837:175mm

painless?

45.

Which nerve(s) is/are involved?

any nerve traversing the

G7 p.837:175mm

cavernous sinus

46.

The pupil is usually ________.

spared

G7 p.837:175mm

47.

How long do symptoms last?

days to weeks

G7 p.837:175mm

48.

Can there be spontaneous remission?

yes

G7 p.837:175mm

49.

Can there be recurrent attacks?

yes

G7 p.837:175mm

50.

Is there systemic involvement?

G7 p.837:175mm

51.

How is it treated?

systemic steroids = 60 to

G7 p.837:175mm

80 mg prednisone by mouth

daily (slow taper)

52.

The disease is thought to be a

nonspecific inflammation

G7 p.837:175mm

________ ________.

53.

The inflammation is located at the

superior orbital fissure

G7 p.837:175mm

________ ________ ________.

54.

Complete the following about Raeder

G7 p.838:50mm

paratrigeminal neuralgia:

Name two components.

u________ o________ p________

unilateral oculosympathetic

paresis (think Horner

syndrome—anhidrosis

± ptosis)

ii.

h________ t________ n________

homolateral trigeminal nerve

i________

involvement (Horner

syndrome and tic-like pain)

The pupil is ________.

small

True or False. The pain is continuous.

false (intermittent, tic-like)

The pain is located at the________.

trigeminal nerve V¹

(ophthalmic division) and

sympathetics

55.

Complete the following regarding

G7 p.838:85mm

Gradenigo syndrome:

Name the classic triad.

p________ of________

palsy; abducens

ii.

p________ where? ________

pain; retro-orbital

iii.

d________ e________

draining ear

Pain is located at the p________

petrous apex

a________.

378 Neuro-ophthalmology

56. Complete the following about

G7 p.838:85mm

Gradenigo syndrome:

a. What is Gradenigo syndrome?

apical petrositis

b. Involves ________ canal

Dorello

c. Features

G________

Gradenigo

ii.

r________ ________

retro-orbital pain

iii.

a________ ________

apical petrositis—abducens

palsy

iv. d________ ________

draining ear—Dorello canal

v. e________ ________

ear draining

vi. n________ ________ ________

neuropathy of VI

vii. i________

inflammation

viii. p________

petrositis

ix. o________ p________

orbital pain

 Miscellaneous Neuro-ophthalmologic Signs

57. Complete the following about ocular

G7 p.838:165mm

bobbing:

a. The eyes move ________.

downward

b. How many times per minute?

2 to 12

c. Ocular bobbing is associated with

horizontal gaze

bilateral paralysis of ________ ________.

d. It is seen with destruction of the

pontine tegmentum

________ ________.

58. Optic atrophy is due to a ________

compressive

G7 p.839:45mm

lesion.

Neurotology



Dizziness and Vertigo

What is the definition of vertigo?

G7 p.840:78mm

sensation of ________

movement (usually spinning)

from

i________ e________ d________ or

inner ear dysfunction or

ii.

v________ n________ d________

vestibular nerve dysfunction

True or False. Inner ear dysfunction

G7 p.840:82mm

presenting with vertigo includes the

following:

labyrinthitis

true

trauma, i.e., e________ l________

true (i.e., endolymphatic leak)

drugs, i.e., a________

true (i.e., aminoglycosides)

acoustic neuroma

false (Acoustic neuroma does

not cause inner ear

dysfunction but may cause

vertigo from compression of

the vestibular nerve.)

vertebrobasilar insufficiency

true (Other causes of vertigo

include inner ear causes:

Meniere disease,

benign/paroxysmal positional

vertigo, syphilis.)

Complete the following regarding

G7 p.840:90mm

cupulolithiasis:

What is cupulolithiasis? c________

calcium concretions in

c________ in s________ c________

semicircular canal

It is also known as b________

benign (paroxysmal)

p________ v________.

positional vertigo

Symptoms are made manifest by

head turning

________ ________.

Patient is usually in ________.

bed

Is it self-limiting?

yes

For how long?

usually not for > 1 year

Is hearing affected?

no hearing loss

380

Neurotology

Describe indications and

G7 p.841:40mm

complications of selective vestibular

neurectomy (SVN).

Indications

M________ d________

Meniere disease

ii.

p________ v________ i________

partial vestibular injury

Rationale?

In disabling cases of vertigo,

refractory to

medical/nondestructive

surgical treatment. SVN

preserves hearing; is 90%

(Meniere disease) and 80%

(vertiginous spells) effective.

Complications

h________ l________

hearing loss (unusual)

ii.

o________

oscillopsia (Dandy syndrome)

iii.

l________ of b________ in the

loss of balance in the dark

d________

with bilateral SVN

Answer the following about the

G7 p.841:117mm

vestibular nerve:

In which half of the eighth nerve

superior

complex?

What color relative to the cochlear

more gray

nerve?

To preserve hearing what vessel must be

artery of the auditory canal

preserved?

True or False. CN VII can be

G7 p.841:122mm

differentiated from CN VIII at the

internal auditory canal (IAC) by all of

the following:

direct stimulation/recording

true

lies anterior/superior to VIII

true

transverse crest and Bill bar

true

darker color c/w CN VIII

false (CN VII is paler/whiter

than CN VIII)

electromyographic (EMG) monitoring of

true

CN VII during manipulation

 Meniere Disease

7. What is the clinical triad of Meniere

G7 p.842:33mm

disease?

a. v________ v________ a________

violent vertigo attacks

b. t________

tinnitus “escaping steam”

c. h________ l________

fluctuating low-frequency

hearing loss

8. Meniere disease is also known as

endolymphatic hydrops

G7 p.842:46mm

e________ h________.

Facial Nerve Palsy

381

9. True or False. Treatment of Meniere

G7 p.843:23mm

disease includes

a. middle ear perfusion with gentamicin

true

b. bilateral vestibular neurectomy

false (Bilateral ablative

procedure is to be avoided.)

c. salt restriction

true

d. vestibular suppressants (e.g., Valium)

true

e. endolymphatic shunting

true

 Facial Nerve Palsy

10.

Segments of the facial nerve include

G7 p.844:30mm

Hint: see my little tin man

c________

cisternal

m________

meatal

l________

labyrinthine

t________

tympanic

m________

mastoid

11.

Answer the following about

G7 p.844:55mm

supranuclear facial palsy:

Which part of the face is involved?

lower only

Emotional facial expression is ________.

intact

The lesion is in the lowest part of the

precentral gyrus

________ ________.

Part of the face is spared paralysis

upper face; bilateral

because the ________ ________ has

representation

________ ________.

12.

True or False. The following is correct

G7 p.844:55mm

regarding central facial palsy

(supranuclear facial palsy):

confined to lower face

true

spares emotional facial expression

true

lesion in most inferior opercular portion

true

of precentral gyrus

upper face has bilateral representation

true

13.

Complete the following regarding

G7 p.844:80mm

nuclear facial palsy:

It causes paralysis of all ________

ipsilateral CN VII innervated

________ ________ muscles.

It plus sixth nerve palsy constitutes the

Millard-Gubler

________-________ syndrome.

It can be caused by a particular tumor

medulloblastoma

called ________

especially when it ________ the

invades the floor of the fourth

________ of the ________ ________.

ventricular

True or False. Nuclear facial palsy is due

true

to damage to the motor nucleus at the

pontomedullary junction.

382

Neurotology

14.

True or False. Regarding CN VII

G7 p.844:100mm

anatomy:

enters superior-anterior portion of IAC

true

external genu is geniculate ganglion

true

GSPN first branch after the ganglion

true

exits at stylomastoid foramen

true

15.

Complete the following about the

G7 p.844:100mm

seventh nerve:

It exits the brain stem at the ________

pontomedullary junction

________.

It enters the internal auditory canal at

superoanterior portion

the ________ ________.

The geniculate ganglion is located in the

temporal

________ bone.

The first branch is the ________

greater superficial petrosal

________ ________ ________

nerve

which goes to the ________ ________

pterygopalatine ganglion

and innervates the ________ ________.

lacrimal gland—dry eye and

nasal mucosa if injured

The next branch goes to the ________.

stapedius muscle—to ear—

hyperacusis

The next branch is the ________

chorda tympani—taste

________.

It then exits the s________ f________

stylomastoid foramen

and sends branches to the ________.

face

16.

Name the facial nerve branches within

G7 p.844:115mm

the temporal bone and their function.

g________

greater superficial petrosal

nerve (GSPN) to

pterygopalatine ganglion,

innervates nasal and palatine

mucosa and lacrimal gland

s________

branch to stapedius muscle,

volume regulation

c________

chorda tympani, taste

sensation from anterior two

thirds of tongue

fibers to s________ g________

salivary glands,

submandibular, sublingual

The nerve travels on to ________

facial muscles

_______.

17.

Name the facial nerve branches to the

G7 p.844:135mm

facial muscles cranial to caudal.

t________

temporal

z________

zygomatic

b________

buccal

m________

mandibular

c________

cervical

Facial Nerve Palsy

383

18.

Name the three most common causes

G7 p.844:155mm

of facial nerve palsy.

B________

Bell palsy

h________

herpes zoster oticus

t________

trauma/basal skull fracture

19.

Study Chart. Provide the differential

G7 p.844:155mm

diagnosis for facial nerve palsy.

facial nerve palsy

acoustic tumor

Bell—birth

congenital

diabetes

fracture

Guillain-Barré

herpes zoster

Klippel-Feil

Lyme disease

meningioma

neoplasm

otitis media

parotid surgery

sarcoid

trauma

20.

Describe seventh nerve palsy.

G7 p.845:80mm

The most common cause of facial palsy

Bell palsy

is ________ ________.

Etiology: ________

unknown

Probable etiology: v________ i________

viral inflammatory

d________ p________

demyelinating polyneuritis

It is caused by the ________ ________

herpes simplex

virus.

It progresses ________ ________

distally to proximally

________.

Meaning

first

facial movements weak

ii.

then

loss of taste and salivation

iii.

and then

hyperacusis

iv.

and then

decreased tearing

Percent that recover completely is

75 to 80%; 10%

________%; partially ________%.

Manage with ________ and ________.

EMG and steroids

21.

Answer the following regarding Bell

G7 p.845115mm

palsy:

What often precedes Bell palsy?

a viral syndrome

What is the usual sequence of clinical

findings? List in order:

① decreased tearing; ② hyperacusis;

③, ④, ②, ①

③ facial muscle weakness; ④ loss of

taste

What treatment is recommended?

steroids

384 Neurotology

22. What are the considerations for facial

G7 p.846:180mm

nerve injury surgical repair?

a. if known to be interrupted ________

reanastomose early

b. if known to be in continuity ________

several months of

observation

c. role of electrical testing ________

serial electrical testing after

1 week

 Hearing Loss

23. Describe the following about hearing

G7 p.848:40mm

loss:

a. conductive

speech

normal or low volume

ii.

Rinne

air less than bone = negative

(i.e., abnormal)

iii.

Weber lateralizes to ________

poor hearing

________ side

b. sensorineural

speech

loud

ii.

Rinne

air more than bone = positive

(i.e., normal)

iii.

Weber lateralizes to ________

good hearing

________ side

Head Trauma



Concussion

True or False. The determination of

G7 p.850:42mm

concussion requires

loss of consciousness from closed head

false

injury

brain swelling on computed tomography

false

(CT) of the head

altered consciousness as a result of a

true (The definition of

closed head injury

concussion only requires

altered consciousness after

closed head injury. The other

findings may be associated

but are not definitive.)

nausea and vomiting after being hit in

false

the head

Complete the following about second

G7 p.850:103mm

impact syndrome:

List the known biochemical

derangements caused by brain trauma-

concussion. (Hint: acdefghi)

a________

ATP:ADP ratio

ii.

c________

calcium overloading

iii.

d________

dysfunction of mitochondria

iv.

e________

energy disturbances

f________

fluxes of ions

vi.

g________

glutamate release

vii. h________

hyperglycolysis

viii. i________

impaired oxidative

metabolism

can assess by measuring ________

NAA: N-glutamate

restores after approximately ________

7 to 10

days

386

Head Trauma

Complete the following about

G7 p.850:103mm

concussion:

In concussion what brain chemical

glutamate

changes in concentration?

Does it go up or down?

What mechanism becomes impaired?

cerebral autoregulation

It may predispose to m________

malignant cerebral edema

c________ e________

and make the patient susceptible to

second impact syndrome

s________ i________ s________.

(SIS)

True or False. The hyperglycolytic,

G7 p.850:108mm

hypermetabolic state associated with

concussion can last for

0 hours (it doesn’t occur)

false

2 to 4 hours

false

24 to 48 hours

false

5 to 7 days

false

7 to 10 days

true

Complete the following for each grade

G7 p.850:175mm

of head injury as classified by the

American Academy of Neurology

(AAN) System:

mild

loss of consciousness (LOC)

ii.

symptoms last for

less than 15 minutes

moderate

LOC

ii.

symptoms last for

greater than 15 minutes

severe

LOC

any

ii.

symptoms last for

even briefly

True or False. The second impact

G7 p.851:15mm

syndrome (SIS)

is rare

true

requires two head injuries

true

results from cerebral edema

true

is responsible for the policy that “no

true

symptomatic player plays”

can have severe consequences

true

Complete the following regarding SIS:

G7 p.851:140mm

SIS has a mortality of ________%.

50 to 100% (Second impact

syndrome [SIS] mortality

occurs in athletes who sustain

a second head injury while

still symptomatic from an

earlier injury. They usually

walk off the field, then

deteriorate into a coma

within minutes.)

What treatment is effective for SIS?

none—condition may be

refractory to all treatment

Neuroimaging

387

True or False. When should a player

G7 p.851:88mm

return to the game after a mild

concussion?

never (The player should leave the

false

game.)

only after resolution of symptoms

true

only after CT shows no injury

false

only after being able to walk or run

false (A symptomatic patient

without difficulty

should not return to

competition.)

With the indicated number and type

G7 p.852:56mm

of multiple concussions, when is a

return to competition recommended?

2 mild ________

1 week

2 moderate ________

1 month and CT

3 mild ________

consider season ending and

3 moderate ________

season ending

2 severe ________

season ending

10.

Answer the following about multiple

G7 p.852:10mm

sports related mild concussions:

How many mild concussions before an

athlete should be told to discontinue for

the season?

What else should be done?

CT or MRI is recommended as

well after 3 mild concussions

 Neuroimaging

11. Answer the following about head

G7 p.853:155mm

injury:

a. What percentage of patients with

4 to 5%

significant head injury (GCS ≤ 8) has

spine injury?

b. Most injuries occur at levels ________.

C1-C3

12. The criteria for diffuse head injury

G7 p.854:15mm

grades are the following:

a. Grade I

cisterns

open

ii.

shift

iii.

hemorrhage

iv.

mortality

10%

b. Grade II

cisterns

open

ii.

shift

0 to 5 mm

iii.

hemorrhage

5 cc

iv.

mortality

14%

c. Grade III

cisterns

compressed/absent

ii.

shift

0 to 5 mm

iii.

hemorrhage

> 25 cc

iv.

mortality

34%

388

Head Trauma

Grade IV

cisterns

compressed/absent

ii.

shift

> 5 mm

iii.

hemorrhage

> 25 cc

iv.

mortality

56%

13.

True or False. Hypotension is rarely

G7 p.854:55mm

attributable to head injury except in

the following circumstances:

in extremis

true (terminal stages;

dysfunction of the medulla)

in infants

true (in infancy, where

enough blood can be lost

intracranially or into the

subgaleal space to cause

shock)

massive scalp wounds

true (when enough blood has

been lost from the scalp

wounds to cause

hypovolemia and

hypotension)

head injury and pelvic fracture

false (The head injury is

incidental to the hypotension.

Each fracture in the pelvis can

be responsible for 1 L blood

loss.)

14.

Complete the following:

G7 p.854:55mm

Delayed deterioration after head trauma

15%

(i.e., talk and die) occurs in what percent

of patients?

List the usual causes.

i________ h________

intracranial hematoma (75%

[epidural hematoma,

subdural hematoma,

traumatic contusions])

ii.

e________

edema

iii.

s________

seizures

iv.

h________

hydrocephalus

15.

What are the two types of

G7 p.852:165mm

posttraumatic brain swelling?

H________

hyperemia

Blood volume is ________.

increased

ii.

Autoregulation is ________.

lost

iii.

It is also known as ________.

malignant cerebral edema

iv.

Mortality is close to ________%.

100%

T________ c________e________

true cerebral edema

At autopsy ________ ________

brain seeps fluid

________.

ii.

It combines both ________ plus

vasogenic plus cytotoxic

________ ________.

edema

Neurosurgical Exam in Trauma

389

16. Complete the following about diffuse

G7 p853 :35mm

axonal injury (DAI):

a. Due to r________

rotational

acceleration/deceleration head injury

b. Hemorrhagic foci occur in the

c________ c________

corpus callosum

ii.

d________ r________ brain stem

dorsolateral rostral

Consider if CT is essentially

normal

________

ii.

And loss of consciousness lasts more

than ________ hours

iii.

Following h________ i________

head injury

 Transfer of Trauma Patients

17. Pretransfer assessments include

G7 p.855:17mm

a. A________

ABG

b. B________

c. c________

circulation Hgb Hct

d. D________

Dilantin levels

e. e________

electrolytes

f. f________

fever

________

spine x-rays

 Neurosurgical Exam in Trauma

18. Complete the following:

G7 p.855:175mm

a. Children who receive trauma to the back

transient blindness

of their head can develop ________

________,

b. which can last ________.

1 to 2 days

19. Complete the following about

G7 p.856:115mm

examining a flaccid limb:

a. Preserved reflexes indicates ________.

central nervous system injury

b. Absent reflexes indicates ________.

root or nerve injury

20. Complete the following:

G7 p.857:140mm

a. The percentage of patients with minor

8 to 46%

head injury who have findings on CT is

________%.

b. The most common finding is ________ hemorrhagic contusion

________.

21. A patient has a deteriorating

ipsilateral to a blown pupil

G7 p.858:32mm

neurological exam with a dilated

(This will be on the correct

pupil. The CT scanner is unavailable.

side in > 85% of epidurals and

The operating room (OR) is ready

other extraaxial mass lesions.)

now. You decide to place a burr hole.

On which side do you place the burr

hole?

390 Head Trauma

22. Complete the following:

G7 p.858:65mm

a. Comparing frontal and occipital skull

occipital

fracture which is associated with a higher

risk of intracranial injury?

b. Why?

Facial bones and ________ absorb

sinuses

frontal impact.

ii.

Contrecoup against ________

frontotemporal bones

________ is more harmful.

iii.

Arms ________.

can’t protect oneself with

outstretched arms as when

falling forward

 Radiographic Evaluation

23.

Extraaxial hematoma evacuation

greater than 1 cm thick

G7 p.858:115mm

(i.e., subdural or epidural) is indicated

when blood collection is ________.

24.

True or False. The most common cause

G7 p.858:135mm

of subarachnoid hemorrhage is

aneurysm

false

trauma

true

dural arteriovenous fistulas

false

spontaneous

false

25.

Intraventricular hemorrhage (IVH) is

G7 p.858:156mm

present in what percentage of severe

head injuries?

percent

10%

correlates with

poor outcome

26.

Complete the following:

G7 p.859:20mm

The term diastasis means ________.

separation

If diastasis of a suture occurs is it

yes

considered a fracture?

27.

Matching. After a head injury which

G7 p.859:40mm

test is appropriate for the following

Also

conditions?

G7 p.859:4135mm

Also

G7 p.860:18mm

Test:

① skull x-ray; ② CT scan; ③ MRI

Conditions:

GCS below 14

②

CT unavailable

①

search for DAI

③

amnesia for injury

②

signs of basal skull fracture

②

inebriation

②

ER Management Specifics

391

 ER Management Specifics

28.

Complete the following:

G7 p.860:105mm

What antiemetic is appropriate for the

Tigan

G7 p.860:118mm

head injury patient?

IV fluid consists of ________.

normal saline and 20 mEq KCl

The rate is ________.

100 cc/hr

Do we run the patient dry?

no, that is obsolete

29.

True or False. Routine usage of

G7 p.860:170 mm

paralytics in trauma patients may

cause Guillain-Barré syndrome

false

lead to higher incidence of pneumonia

true

and sepsis

cause syndrome of inappropriate

false

antidiuretic hormone secretion (SIADH)

cause increased intensive care unit (ICU)

true

stay

30.

Complete the following regarding

G7 p.861:105mm

hyperventilation:

It may exacerbate cerebral ________.

ischemia

True or False. It may be used

false

prophylactically.

PCO₂ must never go below ________

30 mm Hg

mm Hg.

Hyperventilation reduces ________.

cerebral blood flow

It does not necessarily reduce ________.

when PCO₂ < 30 mmHg

Hyperventilation may cause ________,

alkalosis

which increases protein binding of

calcium

________,

which can result in hypo________

calcemia

and show up clinically as ________.

tetany

31.

What conditions are associated with

G7 p.862:125mm

increased risk of posttraumatic

seizures?

Hint: a to i

a________

alcohol abuse

b________

brain injury

c________

cortical contusion

d________

depressed skull fracture

e________

epidural hematoma

f________

fracture of skull

G________

Glasgow coma scale < 10

h________

hematoma

i________

injured brain

392 Head Trauma

32. True or False. The following conditions

G7 p.862:126mm

are associated with increased risk of

posttraumatic seizures:

a. acute subdural, epidural, or intracerebral true

hematoma

b. open depressed skull fracture with

true

parenchymal injury

c. seizure within 24 hours after injury

true

d. GCS < 10

true

e. penetrating brain injury

true

f. history of significant alcohol abuse

true

g. cortical (hemorrhagic) contusion on CT

true

 Head-Injured Patients with Associated Severe Systemic

Injuries

33.

What is considered hypotension or

G7 p.863:20mm

hypoxia?

blood pressure (BP) below ________

90 mm Hg

PCO₂ below ________

60 mm Hg

34.

What chemical in the brain

thromboplastin

G7 p.863:60mm

predisposes the head injury patient to

disseminated intravascular

coagulopathy (DIC)?

35.

Complete the following:

G7 p.863:125mm

Visual system injury occurs in ________%

of head injury patients.

Can hypopituitarism occur with head

yes

injury?

36.

The optic nerve can be divided into

G7 p.863:135mm

four segments.

Give the names and the length of each

segment.

segment 1 name ________, length

intraocular, 1 mm

________

ii.

segment 2 name ________, length

intraorbital, 25 to 30 mm

________

iii.

segment 3 name ________, length

intracanalicular, 10 mm

________

iv. segment 4 name ________, length

intracranial, 10 mm

________

Which segment is most commonly

intracanalicular segment

damaged with closed head injury?

Intracranial Pressure and Head Trauma

393

 Exploratory Burr Holes

37. A unilateral blown pupil is on the

> 85%

G7 p.865:20mm

same side of an epidural hematoma or

other extraaxial mass lesion what

percent of the time?

38. Complete the following regarding burr

G7 p.865:135mm

hole placement for dilated pupil:

a. In cases where no CT scan can be done,

list the placement for

burr hole #1

temporal ipsilateral

ii.

burr hole #2

temporal contralateral

iii.

burr hole #3

frontal ipsilateral

iv.

burr hole #4

parietal

burr hole #5

posterior fossa

b. How often were these positive?

56%

c. When positive the first burr hole was

86%

positive in ________%.

 Intracranial Pressure and Head Trauma

39.

What is the relation between the

G7 p.866:140mm

intracranial pressure (ICP) and the

cerebral perfusion pressure (CPP)?

Formula

CPP = MAP* - ICP (cerebral

perfusion pressure is the

mean arterial pressure minus

the intracranial pressure)

If your computer does not give you

*MAP = 1 systolic plus

mean arterial pressure (MAP) how can

2 diastolic divided by 3

you calculate it? (Hint: dds/3)

40.

Answer the following:

G7 p.866:167mm

What is the normal CPP in adults?

> 50 mm Hg

What is the recommended CPP in head

> 60 mm Hg

trauma?

If CPP is kept in good range is ICP above

no, it is detrimental

20 mm Hg well tolerated?

41.

Complete the following:

G7 p.867:15mm

The modified ________ hypothesis

Monro-Kellie

states that

the sum of the intracranial volumes of

blood, brain, and CSF

________, ________, and ________

and other components is ________.

constant

An increase in any one must be

offset

________

by an equal ________ in another

decrease

or else ________ will rise.

pressure

Pressure is ________ ________

distributed evenly

throughout the intracranial cavity.

394

Head Trauma

42.

Complete the following:

G7 p.868:50mm

At what level of ICP do we treat

20 or greater

intracranial (IC) hypertension (HTN)?

What is the mortality rate for those

20%

whose ICP is kept below 20 mm Hg?

If ICP is higher mortality is ________.

also much higher

43.

What is considered a “deadly” ICP

above 25 to 30 mm Hg

G7 p.868:80mm

(i.e., likely to be fatal if not

controlled)?

44.

CT finding may be correlated with a

G7 p.868:84mm

risk of intracranial hypertension.

After a closed head injury, what % of

60%

patients with abnormal CT will have

intracranial hypertension?

What % of patients with normal CT will

13%

have intracranial hypertension?

Give three risk factors for intracranial

hypertension for patients with normal

CT.

age above ________

40 years

ii.

blood pressure below ________

90 mm Hg

iii.

neurological status

decerebration/decortication

With normal CT plus two risk factors

60%

________% will have ICP elevation.

With normal CT plus only one risk factor

________% will have ICP elevation.

 ICP Monitoring

45. Complete the following about ICP

G7 p.868:130mm

monitoring:

a. One of the criteria for placement of an

ICP monitor is a Glasgow coma scale

(GCS) score below ________

b. and a CT that is ________, or two of the

abnormal

following:

age above ________

ii.

systolic blood pressure (SBP) below

________

iii.

motor exam shows ________ or

decerebrate or decorticate

________ ________

posturing

c. may discontinue monitor when ICP is

48 to 72 hours

normal for ________ to ________ hours

46. Complete the following about ICP

G7 p.869:75mm

monitoring:

a. A criterion for discontinuing ICP

48 to 72 hours

monitoring is normal ICP for ________ to

________ hours.

b. Risk of hemorrhage from ICP monitor

placement is

________% requiring surgery and

0.5 to 2.5

G7 p.869:105mm

ii.

________% incidental finding

1.4

ICP Monitoring

395

47.

True or False. In regard to ICP

G7 p.869:145mm

monitoring, it is permissible to

use antibiotics

true

not use antibiotics

true

place monitor in ICU

true

place monitor in OR

true

Patients who develop hemorrhage while

true

ICP is being placed is 1.4%.

48.

Complete the following:

G7 p.869:175mm

Is the prophylactic change of external

ventricular drain 5 days or less after

insertion associated with a significant

reduction in infection rates?

Do we need to change the site every

5 days?

49.

Complete the following regarding

G7 p.870:160mm

conversion of mm Hg and cm H₂O:

1 mm Hg equals ________ cm of H₂O

1.36 cm

1 cm H₂O equals ________ mm of Hg

0.735 mm

External auditory canal correlates with

foramen of Monro

G7 p.871:50mm

what intracranial structure?

50.

Lundberg A waves are defined by

G7 p.872:130mm

ICP of ________

> 50 mm Hg

duration of ________

5 to 20 minutes

plus ________

increase in MAP

51.

Lundberg B waves are defined by

G7 p.872:150mm

ICP of ________

10 to 20 mm Hg

duration of ________

30 seconds to 2 minutes

varies with ________

periodic respiration

52.

Regarding IVC problems, when open

not meaningful

G7 p.873:150mm

to drain, pressure reading from

transducer is ________ ________.

53.

True or False. If an external ventricular

G7 p.874:30mm

catheter no longer functions, all of the

following can be performed safely:

lower drip nozzle

true

verify clamps are open and air filter is dry

true

flush distal tubing with saline

true

flush IVC with up to 5 mL of saline under

false (Up to 1.5 mL of

gentle pressure

preservative-free saline can

be used.)

54.

True or False. Possible causes of an ICP

G7 p.874:65mm

wave form that is dampened include

all of the following:

occlusion of the catheter proximal to the

true

transducer

catheter pulled out of ventricle

true

collapsed ventricle

true

air in the system

true

intracranial hypertension

false

396

Head Trauma

55.

What should happen to the ICP wave

It should be dampened.

G7 p.874:88mm

form in a patient with a

decompressive craniectomy?

56.

Answer the following about

G7 p.874:145mm

arteriojugular venous oxygen content

differences:

True or False. In head trauma the

following arteriojugular venous

difference in oxygen content (AVDO₂)

difference indicates global cerebral

ischemia and cerebral hyperemia,

respectively:

> 9 mL/dL, < 4 mL/dL

true (With ischemia, the brain

is oxygen starved, so more

oxygen is extracted and the

difference in O₂ between the

arterial and venous blood is

greater. The opposite is true

in hyperemia.)

ii.

< 4 mL/dL, > 9 mL/dL

false

iii.

> 12 mL/dL, < 6 mL/dL

false

iv.

< 6 mL/dL, > 12 mL/dL

false

Another term for cerebral hyperemia is

luxury perfusion

________ ________.

57.

Complete the following about brain

G7 p.874:165mm

tissue oxygen tension (pBtO₂):

Treatment threshold is pBtO₂ less than

________ mmHg.

Death occurs with brief drop below

________ mm Hg.

Level of less than ________ mm Hg

ii.

For more than ________ minutes

increases the risk of bad outcome

A probe should be placed in a patient

G7 p.874:182mm

with

traumatic brain injury on the

least injured

________ ________ side

ii.

subarachnoid hemorrhage near

vasospasm

________

iii.

intracerebral hemorrhage near the

hematoma

________

ICP Treatment Measures

397

 ICP Treatment Measures

58.

True or False. All of the following are

G7 p.877:18mm

general goals of ICP management:

keep ICP < 20 mm Hg

true

G7 p.877:62mm

keep CPP > 60 mm Hg (used to be

true

G7 p.877:125mm

> 70 mm Hg)

avoid SBP < 90 mm Hg

true

avoid PO₂ < 60 mm Hg

true

keep PCO₂ < 30 mm Hg

false (PCO₂ should be

brought down below 30 mm

Hg only in an acute ICP crisis

and then only briefly.)

59.

True or False. The contraindications

G7 p.877:100mm

for administration of mannitol are the

following:

hypovolemia

true

hypotension

true

serum osmol > 320

true

cerebral infarction

false

ICP < 20 mm Hg

true

60.

Complete the following about ICP

G7 p.878:90mm

treatment measures:

Which antacid should be avoided if the

cimetidine

patient is receiving phenytoin?

Why?

drug—drug interaction

What occurs?

dramatic elevation of drug

concentration

Due to?

inhibition of hepatic

cytochrome oxidase

The best choice may be ________.

sucralfate (Carafate)

61.

True or False. Fever should be

true

G7 p.878:100mm

controlled aggressively in the setting

of elevated ICP.

62.

True or False. In traumatic brain

G7 p.878:120mm

injury, the following statements are

correct:

Pressors (e.g., dopamine) should be

false (The blood pressure

avoided because there is increased risk

should be maintained with

of hemorrhage.

pressors, if necessary.)

The IV fluid of choice is isotonic saline +

true

20 mEq KCl/L.

If mannitol is required the patient should

false (Hypovolemia decreases

be kept slightly hypovolemic to allow the

cerebral blood flow and may

serum osmolality to rise.

elevate ICP through

autoregulatory cerebral

vasodilation.)

The patient’s temperature is not

false

important.

398

Head Trauma

63.

Answer the following:

G7 p.878:118mm

Is it okay to use lactated Ringer solution

for head injury patients?

Why or why not?

it is hypotonic

64.

True or False. IV fluids in the head-

G7 p.878:130mm

injured patient

should be sufficient to avoid

true

hypotension.

should be limited to “run the patient

false

dry.”

Euvolemia should be maintained even if

true

mannitol is required.

65.

True or False. The following can

G7 p.879:14mm

exacerbate intracranial hypertension:

hyperglycemia

true (makes edema worse)

hyperventilation

false

hyperparathyroidism

false

cholestasis

false

66.

Complete the following about the use

G7 p.879:98mm

of mannitol:

Useful for intracranial

hypertension

Usual dose advised is

0.25 to 1

________ gm/kg

ii.

Infused as a ________

bolus

iii.

Over ________ minutes

This is followed by ________ gm/kg

0.25

ii.

Infused over ________ minutes

If ICP remains over ________

Must cease use if serum osmolarity rises

320

above ________ mOsm/L

67.

True or False. Second-tier therapy for

G7 p.880:15mm

persistent intracranial hypertension

includes all of the following:

high-dose barbiturate therapy

true

hyperventilation

true

hypothermia

true

decompressive craniectomy

true

68.

True or False. Hypothermia as a

G7 p.880:25mm

“second tier” therapy for persistent IC

HTN may be associated with all of the

following:

decreased cardiac index

true

thrombocytopenia

true

elevated creatinine clearance

true

seizures

false (Seizures are more apt

to occur with fever, not

hypothermia.)

pancreatitis

true

ICP Treatment Measures

399

69.

To treat refractory increased ICP a

G7 p.880:35mm

decompressive craniectomy

must be at least ________ cm in

12 cm

diameter

should include a ________

duraplasty

70.

Complete the following:

G7 p.880:65mm

True or False. In decompressive surgery

for head injury, the following set of

values describes the appropriate limits of

temporal tip resection for the dominant

and nondominant temporal lobes,

respectively:

1 to 2 cm, 3 to 4 cm

false

ii.

2 to 4 cm, 8 to 10 cm

false

iii.

4 to 5 cm, 6 to 7 cm

true

iv.

6 to 8 cm, 10 to 12 cm

false

0 cm, 4 to 5 cm

false

What other lobectomy may be

frontal lobectomy

performed?

Are these very helpful?

they have shown no great

therapeutic promise

71.

Complete the following about PCO₂:

G7 p.881:82mm

Normocarbia is between ________ and

35 to 40

________ mm Hg.

Usual hyperventilation range is between

30 to 35

________ and ________ mm Hg.

This will reduce ICP by ________ to

25 to 30%

________%

ii.

in about ________ seconds

iii.

and will last for ________ minutes.

5 to 20

A level of PCO₂ below ________ mm Hg

risks ischemia.

72.

Complete the following about PCO₂ in

G7 p.881:95mm

the head-injured patient:

Normocarbia is considered to be

35 to 40 mm Hg—use

________ mm Hg.

routinely

Hyperventilation to PCO₂ of

30 to 35 mm Hg—brief use

________ mm Hg.

only

73.

True or False. When using mannitol it

G7 p.882:23mm

is best to

use intermittent bolus

true

use continuous infusion

false

use doses of 3g/kg

false

avoid hypotension below 90 systolic

true

maintain euvolemia

true

monitor serum osmolality

true

limit serum osmolality to below

true

320mOsm/L

400

Head Trauma

74.

True or False. Mannitol lowers the ICP

G7 p.882:47mm

within a few minutes of

administration by

decreasing the production of

false

cerebrospinal fluid (CSF)

reducing the hematocrit and blood

true (The rapid effect of

viscosity

mannitol is not explained by

an osmotic effect. Instead,

mannitol increases the

intravascular volume and

lowers the hematocrit, thus

lowering the blood viscosity.

The brain responds to the

increased blood flow through

autoregulatory

vasoconstriction, decreasing

the volume of the

intravascular blood

compartment in the brain

and lowering the ICP.)

causing an immediate diuresis and

false

decrease in the intravascular volume

raising the serum osmolarity to establish

false (Osmotic effect takes 15

an osmotic gradient between the blood

to 30 minutes.)

and brain

75.

Mannitol works by two mechanisms.

G7 p.882:69mm

Mechanism I

This is a rapid mechanism that

increases plasma volume by

________ ________ ________ by

dilution

________,

ii.

which improves ________

rheology

iii.

thereby improving ________ and

CBF and O₂

________ delivery,

iv. which produces ________.

vasoconstriction

Mechanism II

This is a slower ________ ________.

osmotic effect

ii.

Hypertonic plasma draws in

edema fluid

________ ________

iii.

from the ________,

brain

iv.

which takes ________ to ________

15 to 30

minutes to begin.

76.

The protocol for mannitol

G7 p.882:100mm

administration is

bolus

dose ________ per kilogram

1 gram

ii.

infuse over ________ minutes

30 (rapidly)

iii.

onset ________ minutes

1 to 5

iv.

peaks ________ minutes

20 to 60

long term

dose ________ per kilogram

0.25 to 0.50 gram

ii.

infuse over ________ minutes

30 to 60

High-Dose Barbiturate Therapy

401

77.

True or False.

G7 p.882:115mm

Administer mannitol best as a bolus.

true

Administer mannitol best as a

false

continuous drip.

A continuous drip aggravates vasogenic

true

edema.

It is better to stop mannitol by tapering

true

the dose.

It is better to stop mannitol when it is no

false

longer needed.

Taper prevents rebound.

true

G7 p.882:128mm

78.

Three drugs used in the same patient

G7 p.882:130mm

can produce a fatal syndrome.

Name the three medications.

(Hint: Dms)

D________

Dilantin

ii.

m________

mannitol

iii.

s________

steroids

Name the syndrome: h________

hyperosmolar nonketotic

n________ s________

state

79.

What is the mechanism of renal injury

acute tubular necrosis

G7 p.882:143mm

associated with mannitol therapy for

high ICP (serum Osm > 320 mOsm/L)?

80.

True or False. Glucocorticoids have

true (at least not at the doses

G7 p.883:97mm

little impact on cytotoxic cerebral

that have been tried)

edema due to head trauma.

81.

True or False. Steroids are not

G7 p.883:107mm

recommended to treat patients with

traumatic brain injury because

they work on vasogenic edema of

true

tumors.

they do not work on cytotoxic edema of

true

traumatic brain injury (TBI).

they have significant side effects.

true

they increase the incidence of

coagulopathies

true

ii.

hyperglycemia

true

iii.

infection

true

iv.

hypotension

false

 High-Dose Barbiturate Therapy

82. True or False. Theoretical benefits of

G7 p.883:158mm

barbiturates in head injury include the

following:

a. vasoconstriction in normal areas

true

b. decreased metabolic demand

true

c. free radical scavenging

true

d. reduced intracellular calcium

true

e. reduced extracellular calcium

false

f. stabilized lysosomal activity

true

402

Head Trauma

83.

True or False.

G7 p.883:180mm

When using pentobarbital for ICP

false (Hypotension due to

control, the limiting factor is systemic

reduction of sympathetic

hypertension.

tone is the limiting factor.)

In those patients who respond mortality

true (Mortality in those who

is lower.

respond is 33%; mortality in

those who do not respond is

75%.)

84.

Complete the following about

G7 p.884:25mm

barbiturate coma:

The goal is

to reduce the cerebral metabolic

CMRO₂

rate of ________

ii.

and cerebral b________ f________.

blood flow

The protocol is pentobarbital IV

A loading dose of ________ mg/kg

ii.

Over ________ minutes

iii.

Then ________ mg/hr for 3 doses

iv.

Then ________ mg/hr

85.

The goals of barbiturate therapy are

G7 p.885:30mm

electroencephalogram (EEG) showing

burst suppression

________ ________.

serum level of ________% pentobarbital.

3 to 5 mg%

86.

Complete the following:

G7 p.885:30mm

If a patient is treated with pentobarbital

2 days

coma how long does it take for baseline

neurofunction to return?

What decreased level of pentobarbital in

less than 10 μg/mL

the blood will permit a valid brain death

assessment?

87.

Complete the following:

G7 p.885:50mm

The loading dose of thiopental is

5 mg/kg over 10 minutes

________ mg/kg over ________,

followed with ________ mg/kg for

5 mg/kg for 24 hours

________.

88.

Complete the following:

G7 p.885:87mm

Also

G7 p.25:25mm

The most commonly reported side effect

hypotension—due to

of propofol is ________.

myocardial depression (rarely

causes pancreatitis)

It is used for neuroprotection in

aneurysm surgery

________.

Skull Fractures

403

 Skull Fractures

89.

True or False. All of the following are

G7 p.885:165mm

indications for elevating a depressed

skull fracture:

fracture depressed full thickness of skull

true

deficit relating to underlying brain injury

true

open fracture

false (Depressed bone

compressing sinus is not an

indication for elevating that

depressed fracture.)

dural laceration

true

depressed bone compressing sinus

false

90.

True or False. Regarding skull fracture:

G7 p.886:95mm

There is no evidence that elevating a

true

depressed skull fracture will reduce the

subsequent development of seizure.

CN VI palsy can occur after a clivus

true

fracture.

Antibiotics should incontrovertibly be

false (Giving antibiotics with

given in the case of basal skull fracture,

skull fracture, even CSF leak,

especially with CSF fistula.

is controversial. Very limited

data may suggest that the

incidence of meningitis is not

reduced and that resistant

organisms may be selected

by routine use of antibiotics.)

Intracranial passage of a nasogastric

true

(NG) tube carries 64% mortality.

Recall that the SSS is often to the

right

G7 p.887:128mm

________ of the sagittal suture.

Bone fragments that may have lacerated

last

G7 p.887:146mm

a sinus should be removed.

91.

True or False. CT is very sensitive in

false (Plain x-ray and clinical

G7 p.887:180mm

the detection of basal skull fractures.

exam are more sensitive.)

92.

Complete the following regarding

G7 p.888:20mm

basal skull fractures:

True or False. Pneumocephalus may be

true

seen on plain skull x-rays.

Postauricular ecchymosis is called

Battle sign

________.

True or False. Anosmia can be associated

false (with frontal bone

with temporal bone fractures.

fracture)

Sixth nerve palsy can occur with

clival

________ fracture.

93.

True or False. The following are clinical

G7 p.888:30mm

signs of basal skull fracture:

CSF otorrhea or rhinorrhea

true

hemotympanum

true

depressed level of consciousness

false

Battle sign

true

injury to cranial nerve VII

true

404

Head Trauma

94.

True or False. The following cranial

G7 p.888:50mm

nerves can be injured in basal skull

fractures:

CN I

true

CN II

true

CN III

true

CN IV

true

CN V

true

CN VI

true

CN VII

true

CN VIII

true

CN IX

true

CN X

true

CN XI

true

CN XII

true

95.

True or False. Complications seen with

G7 p.888:115mm

basal skull fractures include

traumatic aneurysms

true

carotid cavernous fistula

true

meningitis

true

facial palsy

true

CSF fistula

true

96.

True or False. Otorrhea and rhinorrhea

false (Only persistent CSF

G7 p.888:120mm

are clinical indications for emergent

leaks from basal skull

treatment of basal skull fractures.

fractures warrant

investigation and treatment.)

97.

Complete the following regarding

G7 p.888:163mm

basilar skull fracture involving the

petrous part of the temporal bone:

longitudinal fracture

incidence is ________%

70 to 90%

ii.

complication ________

leak of CSF

horizontal (transverse) fracture

incidence is ________%

10 to 30%

ii.

complication ________

hearing loss = VII and VIII

nerve injury

98.

True or False. Regarding temporal

G7 p.888:165mm

bone fractures:

The longitudinal fracture is more

true

common.

Transverse fractures spare the seventh

false

and eighth nerves.

Longitudinal fractures can disrupt the

true

ossicular chain.

Transverse fractures lie perpendicular to

true

the external auditory canal (EAC).

Longitudinal fractures can often be

true

diagnosed on otoscopic examination.

Longitudinal fractures can result in CSF

true

leakage.

Craniofacial Fractures

405

99.

Complete the following:

G7 p.888:166mm

What are the two types of temporal

bone fractures?

l________

longitudinal

ii.

t________

transverse (horizontal)

Which is more common?

longitudinal fracture

By what %?

90%

Which damages hearing?

transverse fracture

(horizontal)

Which may injure the facial nerve?

transverse fracture

CSF leak may occur with ________.

longitudinal fracture

Mnemonic to recall these facts

Transverse ________

T = Gacial seventh

ii.

Horizontal ________

H = Hearing

iii.

Longitudinal ________

L = Leakage

100.

True or False. Glucocorticoids have

false

G7 p.889:35mm

been proven to improve the functional

outcome of traumatic facial nerve

palsy.

101.

Complete the following about

G7 p.889:43mm

temporal bone fractures:

True or False. They may result in

true

immediate facial nerve palsy.

How long until electromyography (EMG)

at least 72 hours

reliably confirms nerve injury?

Usually requires ________

surgery

True or False. They may result in delayed

true

facial nerve palsy.

True or False. Delayed facial palsy is less

true

likely to need surgery.

 Clival Fractures

102. Complete the following about

G7 p.889:70mm

fractures of the clivus:

a. True or False. They can produce

cranial nerve injuries

true

ii.

vascular injuries

true

iii.

CSF leakage

true

iv.

brain stem infarction

true

traumatic aneurysms

true

vi.

diabetes insipidus

true

b. The nerves that may be injured are

III; IV

________ through ________.

 Craniofacial Fractures

103. True or False. Indication for surgery

G7 p.889:172mm

for frontal sinus fractures are

a. anterior wall linear fracture

false

b. posterior wall displaced fracture

true

406

Head Trauma

104.

Matching. Match the type of LeFort

G7 p.890:90mm

fracture and structures involved.

Type of fracture:

① LeFort I; ② LeFort II; ③ LeFort III

Structures involved:

maxilla

①

inferior orbital rim

②

orbital floor

②, ③

nasofrontal suture

②, ③

zygomatic arches

③

zygomaticofrontal suture

③

pterygoid plates

③

105.

True or False. The fracture producing

G7 p.890:90mm

craniofacial dislocation is known as:

LeFort I

false

LeFort II

false

LeFort III

true

depressed fracture

false

Salter fracture

false

106.

True or False. Congenital skull defects

true (especially if the defect

G7 p.891:40mm

may result in pneumocephalus.

includes the tegmen

tympani)

107.

Tension pneumocephalus might occur

G7 p.891:90mm

n________ o________ anesthetic is used

nitrous oxide

c________ air is trapped

cool

b________ v________ opening occurs

ball valve

g________-p________ organisms are

gas-producing

present

108.

True or False. The presence of

G7 p.891:134mm

intracranial air may produce a

characteristic sign known as

empty delta sign

false

Mt. Hashimoto sign

false

Dawson sign

false

Mt. Fuji sign

true

gas gap

false

109.

What is the Mt. Fuji sign?

pneumocephalus—the frontal

G7 p.891:134mm

poles surrounded by air

110.

True or False. Pneumocephalus due to

true (Appropriate antibiotic

G7 p.891:177mm

a gas-producing organism can be

therapy should be started.

treated with antibiotics and the

Tension pneumocephalus

patient followed. The gas will be

must be drained.)

absorbed.

Hemorrhagic Contusions

407

111.

Complete the following regarding

G7 p. 892:65mm

growing skull fracture:

It is called ________ ________

posttraumatic

________.

leptomeningeal cyst

It results from a combination of two

injuries:

s________ f________

skull fracture

ii.

d________ t________

dural tear

Why does it grow?

intact arachnoid pulsates

112.

Complete the following about

G7 p.892:75mm

pediatric skull fractures:

The development of a posttraumatic

dural tear

leptomeningeal cyst requires a widely

separated skull fracture and a ________.

The incidence in skull fracture is

0.05 to 0.6%

________%.

The mean age at injury is ________ and

< 1 year; 3

high index of suspicion up to age

________.

It presents as a ________.

scalp mass

Treatment is mandatory ________.

dural closure

113.

Answer the following about a growing

G7 p.892:80mm

skull fracture:

It is also known as ________ ________.

leptomeningeal cyst

True or False. It is commonly seen within

false

2 weeks of injury.

90% occur before age ________.

It may present as a ________.

scalp mass

It requires surgical repair of the

dura

________.

It occurs within ________ months of

injury.

Screen linear fractures below age

________

by follow-up x-ray in ________ months.

2 to 4

 Hemorrhagic Contusions

114. True or False. Regarding delayed

G7 p.893:148mm

traumatic intracerebral hemorrhage

(DTICH):

a. The patient typically has GCS ≤ 8.

true

b. Incidence is ≈ 10%.

true

c. Most DTICHs occur within 72 hours of

true

trauma.

d. Some patients initially appear well and

true

then deteriorate.

e. Coagulopathy contributes to DTICH.

true

408 Head Trauma

115. These factors contribute to formation

G7 p.893:160mm

of delayed traumatic intracerebral

hemorrhage.

a. systemic ________

coagulopathy

b. hemorrhage into an area of ________

necrotic brain

________

c. coalescence of extravasated ________

microhematomas

 Epidural Hematoma

116.

Complete the following:

G7 p.894:23mm

Incidence of epidural hematoma is

________% of all head injuries.

Incidence of subdural hematoma is

________% of all head injuries.

Epidural hematoma male to female ratio

4:1

is ________.

Epidural hematoma arise from arterial

85%

bleeding in ________%.

Epidural hematoma patients develop a

60%

dilated pupil in ________%.

________% are ipsilateral.

85%

________% had no loss of consciousness.

60%

________% had no lucid internal.

20%

Mortality of epidural hematoma is

20 to 55%

________.

117.

True or False. Regarding epidural

G7 p.894:23mm

hematomas (EDHs):

The source of bleeding is arterial 99% of

false (The source of bleeding

the time.

is arterial 85% of the time and

most commonly from the

middle meningeal artery.)

Women are more commonly affected.

false (Men are more

commonly affected—4:1—

than women.)

EDHs are rare before age 2.

true (EDHs are rare before

age 2 years or greater than 60

years.)

The anterior meningeal artery is the

false (middle meningeal

most common cause of the bleeding.

artery)

118.

True or False. Patients with epidural

true (There can be shift of the

G7 p.894:102mm

hematomas can present with an

brainstem away from the

ipsilateral hemiparesis.

mass causing compression of

the opposite cerebral

peduncle causing ipsilateral

hemiparesis, also known as

Kernohan notch

phenomenon.)

Epidural Hematoma

409

119.

What is Kernohan notch

G7 p.894:102mm

phenomenon?

compression of the ________

opposite

cerebral peduncle on the ________

tentorial notch

which can produce ipsilateral ________

hemiparesis to the

intracranial mass lesion

120.

True or False. Concerning epidural

G7 p.894:110mm

hematomas:

A dilated pupil is not a good localizing

false (It is a good sign.)

sign as to the hematoma location.

It occurs in more than 15% of head

false (1%)

trauma admissions.

No initial loss of consciousness occurs in

true

60%.

No lucid interval occurs in 20%.

true

In pediatric head trauma, EDH should be

true

suspected if there is a 10% drop in

hematocrit after admission.

121.

True or False. A 5-year-old girl presents

G7 p.894:120mm

to the emergency room (ER) with a

chief complaint of brief posttraumatic

loss of consciousness after several

hours of playing with her siblings.

While she is being worked up in the

ER, you get a call from your frantic

intern who reports that the patient is

now obtunded. You would expect the

following signs and symptoms and

would include the following statistics

in your presumed diagnosis.

early bradycardia

false (Early bradycardia is

included in the differential

diagnosis of posttraumatic

disorder described by Denny-

Brown. Late bradycardia may

be seen in your presumed

diagnosis, epidural

hematoma.)

Kernohan notch phenomenon

true (Ipsilateral hemiparesis

has been described in EDH.)

85% occurrence of associated ipsilateral

true (60% of patients with

pupillary dilation

EDH have a dilated pupil and

85% will be ipsilateral to the

hematoma.)

a crescent-shaped high density lesion on

true (An EDH may resemble

an SDH on CT; however, 84%

of EDH cases have the

“classic” CT appearance of a

high-density biconvex lens-

shaped mass.)

122.

What is the mortality rate of EDH?

20 to 55%

G7 p.894:180mm

410

Head Trauma

123.

Nonsurgical treatment is possible if

G7 p.895:57mm

size is less than ________ and

1 cm

patient’s symptoms are ________.

mild

What may happen between days 5 and

increase in size of the

16?

hematoma

An epidural hematoma thicker than

1 cm

________ cm should have surgery.

To document resolution repeat CT in

1 to 3

________ to ________ months.

A volume of less than ________ cc

G7 p.895:117mm

124.

Complete the following about delayed

G7 p.896:60mm

epidural traumatic hematoma

(DEPTH):

It may occur in as many as ________% of

9 to 10%

epidural hematomas.

It may be related to increasing the

patient’s ________

or reducing the patients ________,

ICP

especially following surgical removal of

epidural

another ________.

________ is another predisposing factor.

Coagulopathy

125.

True or False. Regarding posterior

G7 p.896:115mm

fossa epidural hematoma:

Nearly 85% will have an occipital skull

true

fracture in adults.

Dural sinus tears are common.

true

Abnormal cerebellar signs are common.

false

Overall mortality is over 25%.

true

They represent ~5% of EDH.

true

 Subdural Hematomas

126. True or False. Regarding acute

G7 p.896:160mm

subdural hematoma (ASDH):

a. There is more likely to be an underlying

true

brain injury with an ASDH than with an

EDH.

b. On CT an ASDH typically appears

true

crescentic in shape.

c. One cause of the ASDH is the

true

accumulation of blood around a

parenchymal laceration.

d. A “lucid interval” may be present.

true

127. Complete the following about acute

G7 p.897:25mm

subdural hematomas:

a. A patient on anticoagulation therapy has

a greater chance of ASDH

if the patient is a male ________-

fold.

ii.

if the patient is a female ________-

fold.

Subdural Hematomas

411

How many days until the subdural

membrane begins to form?

How long until acute blood on CT

2 weeks

becomes isodense?

If CT after trauma is normal can we have

not entirely; delayed

a sense of security regarding that

hematomas can occur

patient?

DEPTH ________%

epidural 10%

G7 p.896:60mm

ii.

DASDH ________%

subdural 0.5%

G7 p.899:50 mm

128.

Concerning treatment of acute

G7 p.897:90mm

subdural hematoma, you evacuate if

the blood clot is

________ thick in adults

1 cm

________ thick in pediatric patients

0.5 cm

by performing a ________

craniotomy

not a ________ ________

burr hole

129.

Complete the following about

G7 p.898:40mm

subdural hematomas:

True or False. Mortality from an acute

true

subdural hematoma (ASDH) ranges from

50 to 90%.

Mortality is from the ________ ________

underlying brain injury and

________.

not from the extraaxial bleed

True or False. Mortality is higher in young

false (Mortality thought to be

G7 p.898:47mm

people.

higher in aged patients.)

Medication that increases mortality is

anticoagulants

________.

130.

Complete the following about

G7 p.898:55mm

subdural hematomas:

Is there a preferred time for SDH

yes

surgery?

If so, when is it?

before 4 hours (patients

operated within 4 hours of an

acute SDH had a 30%

mortality rate compared with

90% mortality if surgery was

delayed > 4 hours.) Hint: 30 -

4 - 90 - more. Known as the

“4-hour rule.”

131.

Give the statistics for acute subdural

G7 p.898:96mm

hematomas for the following:

rate of seizures

mortality in unhelmeted motorcyclists

100%

mortality in helmeted motorcyclists

33%

132.

True or False. Acute subdural

G7 p.898:96mm

hematoma outcomes relate to the

following factors:

seizures

false

surgery later than 4 hours after injury

true

Glasgow coma scale

true (Lower number poor

outcome.)

412

Head Trauma

mechanism of injury

true (Motorcycle accidents

are the worst.)

age

true (above 65 year olds 85%

mortality)

postoperative ICP

true

if under 20 mm Hg 40% mortality

true

if above 45 mm Hg 100% mortality

true

133.

Complete the following about

G7 p.898:170mm

interhemispheric subdural hematoma:

It is usually related to h________

head trauma

t________.

It may be due to a________.

aneurysm

If symptomatic the falx syndrome

consists of

Hint: psadlo

p________

paresis

ii.

s________

seizures

iii.

a________

ataxia

iv.

d________

dementia

l________ difficulties

language

vi.

o________ palsies

oculomotor

134.

For delayed acute subdural hematoma

0.50%

G7 p.899:50mm

(DASDH) the incidence is ________% in

operatively treated acute subdural

hematomas.

135.

What are the risk factors for chronic

G7 p.899:155mm

SDH?

Hint: catss falls

c________

coagulopathies

a________

alcohol abuse

t________

trauma

s________

shunts

s________

seizures

f________

falls

136.

For treatment of chronic subdural

G7 p.901:75mm

hematoma, the following are

recommended:

Surgery type is ________.

large craniectomy at least

2.5 cm

Membrane treatment is ________.

coagulate outer membrane

Drain until ________.

drainage negligible 24 to 48

hours

Postoperative position of patient is

flat in bed

________.

During treatment if you notice that it has

a membrane it is at least ________ days

old.

During treatment if the CT scan shows it

is isodense it is ________ weeks old.

Subdural Hematomas

413

137.

Complete the following regarding

G7 p.901:105mm

chronic subdural hematomas:

Repeat surgery is needed in ________%.

19%

Is the use of a drain recommended?

yes

With a drain the need to repeat surgery

10%

is reduced to ________%.

138.

Complete the following about chronic

G7 p.901:167mm

subdural hematoma outcomes:

Persistent fluid at 10 days ________%

78%

Persistent fluid at 40 days ________%

15%

How long till full resolution?

may take 6 months

One operation is successful in

80%

________% of patients.

Two operations are successful in

90%

________% of patients.

139.

What are the complications of surgical

G7 p.902:25mm

treatment of chronic SDH?

Hint: hherps

h ________

hemorrhage

h ________

hyperemia

e ________

empyema

r ________

reexpansion failure

p ________

pneumocephalus

s ________

seizures

140.

Complete the following regarding

G7 p.902:60mm

chronic subdural hematomas:

complication associated with rapid

hyperemia

decompression ________

age group ________

elderly (over age 75)

overall mortality of CSDH ________%

4 to 8%

141.

Answer the following about subdural

G7 p.902:80mm

hematoma:

True or false. They are invariably caused

false

by trauma.

There is an entity called ________

spontaneous

subdural hematoma.

Possible etiologies are

a________

aneurysms

ii.

a________-v________

arterio-venous

malformations

iii.

c________

coagulopathies

iv.

i________ h________

Intracranial hypotension

414

Head Trauma

142.

Complete the following regarding

G7 p.903:68mm

formation of subdural hygromas:

Are they associated with trauma?

yes

Do skull fractures occur? ________%

yes; 39%

Do they have membranes?

Fluid on CT is similar to ________.

CSF

They are created by

________ and

arachnoid tear

ii.

________.

ball valve flap

Another mechanism is ________

after Haemophilus influenzae

________.

meningitis effusion

143.

Complete the following regarding

G7 p.903:115mm

traumatic subdural hygromas:

What chemical is found in hygroma fluid

prealbumin

that helps in diagnosis?

Is this found in CSF?

yes

Is this found in subdural hematomas?

This suggests that hygroma originates

arachnoid tears

from ________ ________.

If surgery is needed what may reduce

leave a drain

recurrences?

144.

When extraaxial fluid looks dark on CT

fluid from hygroma and CSF

G7 p.903:120mm

how can we differentiate

contains prealbumin not

CSF/hygroma from chronic subdural

found in subdural hematoma

hygroma?

Test for ________.

prealbumin

CSF/hygroma will ________ ________.

have prealbumin

Subdural hygroma will ________

not contain prealbumin

________ ________.

145.

True or False. The following is a

G7 p.903:115mm

common clinical finding in traumatic

subdural hygroma:

spontaneous eye opening

true

disorientation or stupor

true

mental status changes without focal

true

signs

seizures (usually generalized)

true

hemiparesis

true

146.

Matching. What is the treatment of

G7 p.903:180mm

choice for subdural hygroma? Choose

one or more:

① subdural to peritoneal shunt; ② no

treatment; ③ burr hole drainage;

④ external subdural drain; ⑤ repeat burr

hole drainage

asymptomatic

②

symptomatic

③ or ④

recurrent

⑤ or ①

Subdural Hematomas

415

147.

List the differential diagnosis of

G7 p.904:50mm

extraaxial fluid collections in children.

a________ s________

acute SDH in a child with low

Hct

b________ s________

benign subdural (extraaxial)

collections of infancy

c________ s________

chronic symptomatic

extraaxial fluid collections

c________ a________

cerebral atrophy external

hydrocephalus (EH)

c________ d________

craniocerebral disproportion

e________ h________

external hydrocephalus

148.

What is the mean age of presentation

4 months

G7 p.904:130mm

of benign subdural (extraaxial) fluid

collections of infancy?

149.

What is the treatment of benign

G7 p.904:155mm

extraaxial fluid collections of infancy?

o________

observation (Most cases

resolve spontaneously within

8 to 9 months and require no

treatment.)

p________ e________

physical examination

periodically (Repeat physical

exam to identify

development of symptoms.)

h________ c________

head circumference every 3

to 6 months (Orbital-frontal

head circumference [OFC]

should be done at 3- to 6-

month intervals to monitor

head growth that should

parallel normal growth and

approach normal at 1 to

2 years.)

Most will ________

resolve

by ________.

1 to 2 years

150.

Name seven frequent etiologies of

G7 p.905:35mm

symptomatic chronic extraaxial fluid

collections in children.

Hint: subtact

s________

shunt (18%)

u________

unknown (16%)

b________

bacterial meningitis (22%)

t________

trauma (36%)

a________

asphyxia

c________

coagulopathy (vitamin K

deficiency)

t________

tumors

416 Head Trauma

151. What are the treatment options for

G7 p.905:90mm

symptomatic chronic extra-axial fluid

collections in children?

Hint: otb sp

a. o________

observation with serial orbital

frontal head circumferences,

ultrasound

b. t________

at least one percutaneous tap

should be done to rule out

infection

c. b________

burr-hole drainage ± external

drainage

d. s________ p________ s________

subdural collection to

peritoneal shunt (unilateral

with extremely low pressure

valve)

 Traumatic Posterior Fossa Mass Lesions

152. Complete the following about

G7 p.905 :155mm

traumatic posterior fossa mass lesions:

a. Head injury that involves the posterior

fossa is less than ________%.

b. The majority are e________ h________. epidural hematomas

c. Parenchymal hemorrhages can be

managed nonsurgically if they are less

than ________ cm in diameter.

 Posttraumatic Hydrocephalus

153. Complete the following about

G7 p.906:80mm

posttraumatic hydrocephalus:

It can occur in up to ________% of

40%

patients

ii.

who have GCS below ________.

b. It can develop up to ________ weeks

post-trauma.

c. It occurs in ________% of patients with

12%

G7 p.906:150mm

traumatic subarachnoidal hemorrhage.

d. There is an increased incidence with

a________

age

ii.

i________ hemorrhage

intraventricular

iii.

blood thickness greater than

________ mm

iv. d________ distribution of blood

diffuse

Nutrition in the Head-Injured Patient

417

 Aspects of General Care in Severe TBI

154. Complete the following about deep

G7 p.907:75mm

vein thrombosis:

a. Risk after severe TBI is ________%.

20%

b. Prophylactic measures advised are

c________ b________ and

compression boots

ii.

l________-d________ h________.

low-dose heparin

 Nutrition in the Head-Injured Patient

155.

What is the basal energy expenditure

G7 p.907:144mm

(BEE) of the head-injured patient?

nonparalyzed ________% of BEE

140%

paralyzed ________% of BEE

100%

What % of replacement should be in the

provide ≥ 15% calories as

form of protein?

protein

156.

Complete the following regarding

G7 p.907:155mm

head trauma:

When should nutritional

within 72 hours

supplementation begin?

When should full caloric replacement be

by 7 days

achieved?

Rested comatose patients have

140%

G7 p.907:180mm

metabolic expenditure that is ________%

of normal

157.

What is the formula for estimation of

G7 p.908:55mm

the BEE?

The name of the equation is the

Harris-Benedict equation

________.

males ________

BEE = 66.5 + 13.8 × W(kg) +

5 × H(cm) - 6.8 × age

females ________

BEE = 65.5 + 9.6 × W(kg) +

1.9 × H(cm) - 4.7 × age

infants ________

BEE = 22.1 + 31.1 × W(kg) +

1.2 × H(cm)

takes into account ________, ________,

weight in kg, height in cm,

and ________

and age in years

418 Head Trauma

 Outcomes from Head Trauma

158.

A 40-year-old male and his 8-year-old

G7 p.909:13mm

daughter were involved in a head-on

collision. You examine them in the

emergency room. The child is flaccid

with both pupils fixed and dilated. The

father's pupils are also fixed and

dilated. He has decerebrate posture.

True or False. The following parts of

the history or physical determine

which patient will have the worse

prognosis:

mechanism of trauma

false

fixed dilated pupils

false

flaccid posture

false

decerebrate posture

false

age

true (In general, the degree of

recovery from closed head

injury is better in infants and

young children than in adults.

In most cases

decerebrate/flaccid posture

and loss of pupillary reflex are

associated with poor

outcome in adults, but these

findings are not as ominous in

the pediatric age group.)

159.

Head injury factors to consider for

G7 p.909:35mm

predictors of poor outcome include

Hint: bih macs

b________

blood pressure

i________

intracranial pressure

h________

hydrocephalus

m________

mass lesion

a________

age

c________

cisterns

s________

shift of midline

160.

True or False. With head injury

G7 p.909 :44mm

outcomes an important predictor for

poor outcome is

mass lesion requiring surgical removal

true (Mass lesions requiring

surgical removal are one of

the most important

predictors of outcome.)

hydrocephalus

true

obliteration of basal cisterns

true

persistent ICP > 20

true

increased age

true

hypotension SBP < 90

true

midline shift greater than 15 mm

true

Outcomes from Head Trauma

419

161.

Complete the following about closed

G7 p.909:44mm

head injury:

Predictors of poor outcome are

Hint: a²mc-sh³Ip

a________

age

ii.

a________

anemia

iii.

m________ l________

mass lesion

iv.

c________

cisterns

s________ of m________

shift of midline

vi.

h________ SBP below

hypotension/90

________ mm Hg

vii. h________

hypercarbia

viii. h________

hypoxemia

ix. I________ elevated above ________

ICP; 20

x. p________ responses

pupillary

High ICP during the ________ hours is

first 24

especially bad.

162.

Complete the following about midline

G7 p.909:75mm

shift:

Midline is measured at the level of the

foramen of Monro

________ of ________.

A shift of ________ mm is well

tolerated.

ii.

A shift of ________ mm correlates

with drowsiness.

iii.

A shift of ________ mm correlates

with stuporousness.

iv. A shift of ________ mm correlates

with coma.

v. A shift of ________ mm correlates

G7 p.909:168mm

with death.

163.

Complete the following about the

G7 p.909:119mm

status of basal cisterns:

It is measured at the ________ level.

midbrain

Study three limbs.

2 ________ cisterns

ambient

G7 p.909:142mm

ii.

1 ________ cisterns

quadrigeminal

Obliteration of cistern correlates with

G7 p.910:14mm

mortality

All limbs open: mortality is

22%

________%.

ii.

One or two limbs closed: mortality is

39%

________%.

iii.

All 3 absent: mortality is ________%.

77%

420

Head Trauma

164.

Complete the following:

G7 p.910:15mm

You obtain a head CT in both father and

daughter. The child’s CT demonstrates

diffuse edema with open cisterns and no

hydrocephalus. The father’s CT

demonstrates complete obliteration of

the basal cisterns. True or False. The

most probable Glasgow outcome score

in this adult patient is

GOS1

true (GOS 1 mortality)

ii.

GOS2

false

iii.

GOS3

false

iv.

GOS4

false

GOS5

false

An adult with obliterated cisterns has a

77%

mortality of ________%.

165.

Complete the following:

G7 p.910:18mm

What is the genotype associated with

apolipoprotein E4 allele

head injury?

It is also a risk factor for ________.

Alzheimer disease

166.

True or False. Long-term complications

G7 p.910:70mm

from head injury (HI) include the

following:

posttraumatic seizures

true (early: severe HI 30%,

mild HI 1%; Late: LOC > 2 min

10 to 13%)

Alzheimer disease

true (HI promotes amyloid

deposits.)

hypogonadotropic hypogonadism

true (but rare)

visual disturbances

true (5% of head-injured

patients injure visual system.)

communicating hydrocephalus

true (severe HI: 3.9%)

167.

A 28-year-old male sustained a minor

G7 p.911:70mm

head injury at Macy’s with a small

forehead laceration but without loss

of consciousness. He comes to your

office 4 months later after being

offered only supportive treatment by

other clinicians. He presents with

headache, dizziness, anosmia,

difficulty concentrating, and loss of

libido. There are no positive findings

on your physical examination. At this

time do you:

tell the patient (and the lawyer) that

psychiatric evaluation is warranted?

Outcomes from Head Trauma

421

implement a neurophysiological battery

yes (The patient has

of tests including magnetic resonance

persistent symptoms,

imaging (MRI), EEG, brain stem auditory

> 3 months, that include

evoked response (BSAER), and head CT?

somatic, cognitive, and

psychosocial manifestations.

Alves and Jane perform a full

battery of testing before

proceeding with any plan or

venturing any prognosis.)

send the patient home with Tylenol?

168.

Complete the following:

G7 p.911:75mm

The above patient returns after 1 week.

You notice in his records that all the tests

are normal. At this time do you

tell the patient (and the lawyer) that

yes (“If all studies are

psychiatric evaluation is warranted?

negative,” the authors, Alves

and Jane, tell the patient and

the lawyer to seek psychiatric

evaluation.)

ii.

schedule more testing?

iii.

send the patient home with Tylenol?

iv.

reassure the patient that symptoms

will resolve?

and if the tests are abnormal? (Choose:

iv. (Noncorrectable

i., ii., iii., or iv. from above)

abnormalities prompt

reassurance that significant

symptoms should subside by

1 year.)

169.

Neuropathology in chronic traumatic

G7 p.911:170mm

encephalopathy shows

n________ t________ and

neurofibrillary tangles

a________ a________.

amyloid angiopathy

These changes are similar to A________

Alzheimer

disease.

170.

True or False. Chronic traumatic

G7 p.912:20mm

encephalopathy is more likely in

boxers who

have more than 20 fights

true

fight for more than 10 years

true

have the apolipoprotein E4 allele

true

have cerebral atrophy

true

have cavum septum pellucidum

true (13%)

also known as d________ p________

dementia pugilistica

422 Head Trauma

 Gunshot Wounds to the Head

171.

True or False. Regarding gunshot

G7 p.912:140mm

wounds (GSWs):

GSWs represent 35% of all deaths from

false (GSWs represent 35% of

brain injury in the older population

deaths by head injury in the

(> 45).

population aged < 45.)

GSWs are the most lethal type of head

false (It is lethal and two

injury; one fourth die at the scene.

thirds of patients die at the

scene.)

90% of victims die.

true (Ultimately 90% of

patients will die directly or

from complications related to

GSW regardless of their

expression of APO E4 allele.)

Poor outcome in GSWs is related to APO

false (APO E4 allele relates

E4 allele.

well to the poor closed head

injury outcome and

Alzheimer disease but not to

GSW.)

172.

For GSWs to the head the mechanisms

G7 p.912:155mm

of injury include

Hint: Capone gang shootings land in the

East River

c________

cavitation, coup-contrecoup

g________

gas

s________

shock waves

l________

low pressure

i________

impact

e________

explosive

r________

ricochet

173.

Complete the following:

G7 p.913:84mm

Higher impact velocity is correlated with

higher

ICP that is ________.

The size of the entrance wound is

smaller

________ compared with the exit

wound.

Edges of entrance wound show a

inner

beveled ________ table.

Edges of exit wound show a beveled

outer

________ table.

174.

Angiography in penetrating injury to

G7 p.914:160mm

the brain should be considered if there

a trajectory near major ________ or

arteries

________ and

sinuses

a large ________.

hematoma

High-Altitude Cerebral Edema

423

175. Complete the following:

G7 p.915:135mm

a. What is the most important prognostic

level of consciousness on

factor after a gunshot wound to the head

admission

(GSWH)?

b. What is the mortality/morbidity in GSWH

94% of patients comatose on

if the patient is unconscious?

admission die; 3% are severely

disabled

c. The prognosis is worse if the path of the

bullet

c________ the m________

crosses the midline

ii.

passes through the g________

geographic center of the

c________

brain

iii.

t________ the v________

traverses the ventricle

iv.

passes through m_______ l_______

multiple lobes

 Non-missile Penetrating Trauma

176. Complete the following:

G7 p.916:45mm

a. Because of low velocity only l________

local debridement

d________ is needed.

b. These are more or less contaminated

G7 p.916:133mm

than gunshot wounds?

c. Prophylactic antibiotics are or are not

are

advised?

Would you consider an angiogram? yes

ii.

If so why? To rule out a t________

traumatic aneurysm

a________

 High-Altitude Cerebral Edema

177. In your last trip to Machu Picchu in the

G7 p.916:150mm

high Andes you notice that the

passenger sitting beside you in the

train starts gasping for air and

complains of severe headaches.

Within minutes he becomes confused

and minutes later becomes paralyzed.

You suspect high altitude pulmonary

edema (HAPE) with or without

cerebral edema (HACE).

a. You pull out your handy

ophthalmoscope and find in the fundus:

p________

papilledema

ii.

r________ h________

retinal hemorrhages

iii.

nerve fiber layer i________

infarction

iv.

vitreous h________

hemorrhage

424

Head Trauma

This is compatible with the diagnosis of

HACE—high altitude cerebral

h________ a________ c________

edema (A milder case of

e________.

acute high altitude sickness

[AHAS] that presents without

ocular findings is called

HAPE.)

Prevent fundus deterioration by

g________ d________ and

gradual descent

ii.

avoiding ________.

ETOH

Treat with

o________

6 to 12 L/min O₂

ii.

s________

steroids may be of use

178.

Complete the following:

G7 p.916:163mm

At the upcoming neurosurgical meeting

in the Rockies, one of your colleagues

presents with acute onset of

inappropriate behavior, hallucinations,

ataxia, and reduced mental status.

If the breathalyzer is negative, what

high altitude cerebral edema

diagnosis should you consider?

(HACE)

ii.

At 7000 ft you would be correct

25%

________% of the time.

iii.

At 15,000 ft you would be correct

50%

________% of the time.

What else might you see with this

condition?

r________ h________

retinal hemorrhage

ii.

p________

papilledema

iii.

v________ h________

vitreous hemorrhage

iv.

s________ h________

severe headache

What treatment should be initiated in a

severe case?

location: i________ d________

immediate descent

ii.

breathe: o________

oxygen (6 to 12 L/min by NC

or FM)

iii.

medication: d________

dexamethasone 8 mg/PO/IV

followed by 4 mg in 96 hours

 Pediatric Head Injury

179. Complete the following regarding

G7 p.917:54mm

children hospitalized for trauma:

a. What percent have head injury?

75%

b. The mortality overall is ________%.

10 to 13%

c. If presenting with decerebrate posturing

71%

mortality is ________%.

Pediatric Head Injury

425

180.

True or False. A mother brings a 5-day-

G7 p.918:100mm

old baby born via vaginal delivery with

a large, right-sided, soft scalp swelling

that stops at the suture. You should

percutaneously aspirate the lesion

false (Cephalohematoma is

most commonly seen

associated with parturition.

80% resorb usually within 2 to

3 weeks. Avoid the

temptation of puncturing the

lesions because the risk of

infection exceeds cosmetic

benefits.)

tell the mother that 50% of these calcify

false—occasionally only

tell the mother that the baby may

true (Infants may develop

develop jaundice as late as age 10 days

hyperbilirubinemia and

jaundice as blood is resorbed

from this cephalohematoma

[subperiosteal hematoma] as

late as 10 days after onset.)

surgically excise the lesion

false (Surgery is considered

only after 6 weeks if a CT

demonstrates calcifications.)

consider child abuse

true (Child abuse needs to be

excluded always.)

treat this differently if the soft area

false (called subgaleal

crosses sutures

hematoma)

181.

If a child is in the ER under age 10 with

G7 p.918:130mm

trauma

one must think ________, which will be

child abuse

true in

________% of cases.

10%

Examine ________ for ________.

retina; hemorrhages

182.

Answer the following regarding child

G7 p.918:142mm

abuse:

True or false. There are pathognomonic

false

findings in child abuse.

Suspicious findings are

r________ h________

retinal hemorrhage

ii.

b________ c________ s________

bilateral chronic subdural

h________

hematomas

iii.

s________ f________

skull fractures

183.

Retinal hemorrhage in a baby is

shaken/impact baby

G7 p.919:40mm

pathognomonic of

syndrome

s________/i________ b________

s________.

Spine Injuries



Spine Injuries

Complete the following:

G7 p.930:35mm

What must you look for in a patient with

a second spinal injury

a major spinal injury?

It occurs in ________%.

20%

Complete the following:

G7 p.930:105mm

In spinal cord injury, any residual motor

incomplete

or sensory function more than three

segments below the level of injury

represents an ________ lesion.

Signs of this being the case include

s________

sensation (include position

sense)

ii.

v________ m________

voluntary movement in the

lower extremities

iii.

s________ s________

sacral sparing (Preserved

sacral reflexes alone do not

qualify as incomplete injury.

Also requires preserved

sensation around the anus.)

Types of this lesion include these

syndromes:

c________ c________

central cord

ii.

B________-S________

Brown-Séquard

iii.

a________ c________

anterior cord

iv.

p________ c________

posterior cord

A complete spinal cord lesion

G7 p.930:144mm

is defined as no

m________ or

motor

ii.

s________ function

sensory

iii.

t________ levels below lesion.

three

What percent of patients with no

G7 p.930:147mm

function on initial exam will develop

some recovery within 24 hours?

A complete spinal cord injury that

no distal recovery will occur

persists for 72 hours indicates that

________ ________ ________ ________

________.

Whiplash-Associated Disorders

427

4. Complete the following regarding

G7 p.930:160mm

spinal shock:

a. hypotension:

interruption of ________ ________ sympathetic activity

ii.

loss of ________ ________

vascular tone

b. bradycardia: unopposed ________

parasympathetic

activity

c. relative hypovolemia:

loss of ________

muscle tone due to skeletal

muscle paralysis below level

of injury

ii.

resulting in ________ ________

venous pooling

d. true hypovolemia: loss of ________

blood from associated

wounds



Whiplash-Associated Disorders

What is the most common nonfatal

whiplash

G7 p.931:57mm

automobile injury?

Describe the five grades of whiplash-

G7 p.931:80mm

associated disorders and clinical

evaluation of each.

grade 0

clinical

no complaint

ii.

radiological studies

none required

grade 1

clinical

neck pain

ii.

radiological studies

no x-rays needed

grade 2

clinical

reduced ROM/point

tenderness

ii.

radiological studies

CS x-ray flexion/extension

(F/E) views

grade 3

clinical

weakness, sensory deficit,

deep tendon reflexes (DTR)

abnormality

ii.

radiological studies

CT, MR, treatment as SCI

grade 4

clinical

fracture or dislocation

ii.

radiological studies

CT, MR, treat as spinal cord

injury

428 Spine Injuries



Pediatric Spine Injuries

Complete the following:

G7 p.932:80mm

Due to ligamentous laxity together with

ligamentous

immaturity of paraspinal muscles and

underdeveloped uncinate processes,

pediatric spinal injury tends to involve

________ types of injury.

In the age group ≤ 9 years, the________

cervical

spine is the most vulnerable segment.

In cervical spine injuries in the pediatric

upper 3 (occiput-C2)

population, 67% occur in the ________

segments of the cervical spine.

Complete the following about

G7 p.933:50mm

pediatric spine injuries:

“Pseudospread of the atlas” is a

children

phenomenon occurring in ________.

It could be confused with ________

Jefferson fracture

________.

Answer the following about Jefferson

G7 p.933:70mm

fractures:

True or False. Jefferson fractures are

false

common in pediatric cervical spine

injury.

They are more common during the

teenage

________ years.

 Initial Management of Spinal Cord Injuries

10. Complete the following:

G7 p.933:135mm

a. The major causes of death in spinal cord

injury are

________ and

aspiration

ii.

________.

shock

b. Associated findings suggestive of spinal

cord injury include

________ ________ and

abdominal breathing

ii.

________.

priapism (autonomic

dysfunction)

11. True or False. In caring for an injured

false (Do not remove the

G7 p.934:90mm

athlete, prompt removal of the helmet

helmet in the field—National

is recommended.

Athletic Trainers Association

[NATA] guidelines.)

12. Complete the following:

G7 p.934:125mm

a. In spinal cord injury with hypotension in

dopamine

the field, the agent of choice is

________.

b. Avoid ________.

phenylephrine—noninotropic,

and possible reflex increase in

vagal tone with bradycardia

Initial Management of Spinal Cord Injuries

429

13.

In evaluating spinal cord injury in the

G7 p.934:175mm

field, hypopnea may be related to

three conditions:

paralyzed i________ m________

intercostal muscles

paralyzed d________

diaphragm (phrenic

nerve = C3, C4, C5)

depressed ________

LOC

14.

Complete the following:

G7 p.936:26mm

True or False. Spinal cord injury can

true

cause loss of temperature regulation.

This is called p________

poikilothermy

and is caused by v________ p________.

vasomotor paralysis

15.

Complete the following about initial

G7 p936:32mm

management of spinal cord injuries:

True or False. Spinal cord injury can

true

cause electrolyte disturbances

due to

________ and

hypotension

ii.

________,

hypovolemia

which cause an increase in ________

plasma aldosterone

________,

which leads to ________.

hypokalemia

16.

Complete the following: (Note:

G7 p.936:165mm

Practice parameter caution regarding

use of steroids.)

In adhering to the spinal cord injury

steroid protocol, methylprednisolone

needs to be administered within

________ hours of injury to improve

outcome.

What may occur if given later?

worse outcome at 1 year

17.

True or False. Methylprednisolone

G7 p.936:177mm

protocol has been shown to be useful

for patients with

cauda equina syndrome

false

gunshot wounds to the spine

false

children

false

pregnant women

false

18.

Discuss administration of

G7 p.937:35mm

methylprednisolone protocol in spinal

cord injury.

Initial bolus is ________ mg/kg IV.

Over how long a period of time?

15 minutes

Followed by a ________.

45-minute pause

Follow with maintenance infusion of

5.4 mg/kg/hr IV

________.

Over how long a period of time?

G7 p.937:73mm

If started within 3 hours of injury,

________ hours.

ii.

If started between 3 and 8 hours,

________ hours.

430

Spine Injuries

19.

True or False. Regarding deep vein

G7 p.937:130mm;

thrombosis (DVT) in spinal cord injury

(SCI):

Heparin 5000 U subcutaneous (SQ) twice

false (Better to titrate SQ

a day is more effective than SQ heparin

heparin to PTT 1.5 times

to titrate partial thromboplastin time

control.)

(PTT) to 1.5 times normal.

Pneumatic boots should be used initially.

true

20.

Complete the following about spinal

G7 p.637:132mm

cord injury and deep vein thrombosis:

incidence ________%

100%

mortality ________%

prevent with ________ ________ boots

pneumatic compression

and subcutaneous ________

heparin

preferably titrated to a partial

1.5 times control

thromboplastin time (PTT) of ________

What medication can cause

heparin

thrombocytopenia and osteoporosis?

21.

Matching. In assessing C-spine in these

G7 p.938:73mm

categories of trauma patient, perform

the following tests:

Test to perform:

① none needed; ② CT from occiput to

T1; ③ plain C-spine x-rays; ④ flexion-

extension; ⑤ MRI

Category of trauma patient:

Alert, denies neck pain

①

Alert, complains of neck pain

②

Obtunded or inebriated

②

Abnormal CT

⑤

Neurological deficit

② and ⑤

22.

When do we do

G7 p.938:148mm

Plain C-spine x-ray? If ________ is not

available

Flexion extension views

in an ________ patient

alert

ii.

who complains of ________

neck pain

________

iii.

and in whom ________ is normal

iv.

and ________ is not available

MRI

23.

Factors associated with increased risk

G7 p.939:49mm

of failing to recognize spinal injuries

during radiographic evaluation include

decreased ________ of ________

level of consciousness

multiple ________

injuries

inadequate ________

x-rays (technically)

Initial Management of Spinal Cord Injuries

431

24.

Radiographic signs of C-spine trauma

G7 p.939:80mm

include

retropharyngeal space > ________ mm

7 mm

retrotracheal space > ________ mm in

14 mm

adult

or > ________ mm in pediatrics

22 mm

atlantodental interval (ADI) > ________

3 mm

mm in adult

> ________ mm in pediatrics

4 mm

In the neurologically intact patient,

3.5 mm

subluxation up to ________ mm may be

normal.

To prove it is normal do ________.

flexion-extension views

25.

When should we order

G7 p.940:90mm

anteroposterior (AP) and lateral views

of the thoracic and lumbosacral spine?

Hint: btuf

b________

back pain complaints

t________

thrown from a vehicle

u________

unconscious

f________

fell more than 6 feet

26.

Complete the following:

G7 p.940:115mm

How can we tell an old injury from an

bone scan

acute one?

We should test between ________ and

2 and 21 days

________ days.

Test will remain abnormal for ________

1 year

________.

27.

During evaluation of occult cervical

G7 p.940:58mm

spine trauma, what are the

contraindications for flexion-extension

cervical spine x-rays?

patient who is not ________

cooperative

patient who has ________ impairment

mental

subluxation of ________ or more

3.5 mm

neurologic deficit of ________

any degree

28.

True or False. A normal flexion-

true

G7 p.941:35mm

extension study of the cervical spine x-

ray may demonstrate slight anterior

subluxation distributed over all

cervical levels with preservation of the

normal contour lines.

29.

Complete the following:

G7 p.941:77mm

Lumbar puncture is dangerous in

14%

complete spinal block and may cause

deterioration in ________%.

Avoid this with a ________ or ________.

lateral cervical puncture or

MRI

432

Spine Injuries

30.

Indications for emergent myelogram

G7 p.941:98mm

or magnetic resonance imaging (MRI)

in spinal cord injury includes

neurologic deficit

that is not ________

explained

after closed ________

reduction

after ________ surgery

spinal

31.

Complete the following about MRI in

G7 p.941:147mm

spine:

It is appropriate when

CT of spine is ________,

inconclusive

ii.

patient has neurological ________.

deficits

It should be done within ________

48 to 72

hours.

Most useful sequences are

________ and

T2W1

ii.

F________.

FLAIR

32.

Contraindications to

G7 p.942:95mm

traction/reduction of cervical spine

injuries include

atlanto-occipital ________

dislocation

types of axis fractures called ________ or

type II A, or III hangman’s

________

fracture

a defect in the ________

skull at an anticipated pin site

the patient is less than ________ years of

age

33.

Complete the following:

G7 p.943:90mm

After placing the patient in tongs we

lateral cervical spine x-ray

must obtain a ________

and measure the distance between the

________ and the

basion

ii.

________,

odontoid

which should be less than ________ mm

2 mm

in adults

and less than ________ mm in children.

10 mm

34.

What is considered proper pin care?

G7 p.943:117mm

Clean with ________.

half-strength hydrogen

peroxide

Apply ________.

povidone-iodine

This may reduce the incidence of

osteomyelitis

________.

35.

Complete the following:

G7 p.943:75mm

Closed reduction of cervical dislocations

retropulsed cervical disc

may be associated with neurologic

deterioration, and this may be due to a

r________ c________ d________.

If neurologic deterioration occurs after

closed reduction what tests must you do

immediately?

l________ c________ p________

lateral cervical puncture

followed by myelogram/CT

ii.

________

MRI

Neurological Assessment

433

36. Complete the following:

G7 p.944:50mm

a. True or False. Patient with recent onset

false (Recent acute injury is

of loss of function due to spinal cord

not the time for surgery; it

injury should have a decompressive

may be associated with

laminectomy.

neurologic deterioration.)

b. If surgery is done it is usually combined

a stabilization procedure

with ________.

37. Contraindications to emergent

G7 p.944:140mm

operation for acute spinal cord injury

include

a. complete ________ ________ ________ spinal cord injury

for more than 24 hours

b. unstable ________

medically

c. central ________ ________

cord syndrome

 Neurological Assessment

38.

Complete the following:

G7 p.944:180mm

Cervical nerves exit ________ their like-

above

numbered vertebra.

Thoracic and lumbar nerves exit

below

________ their like-numbered vertebra.

For a segment of cord that lies under a

two cord levels

G7 p.945:30mm

given vertebra T2 to T10 add ________

________ ________.

Under T11, T12, L1 lie the ________.

lowest 11 spinal segments

The conus lies behind ________.

L1 or L2

39.

Give the location of the key sensory

G7 p.945:55mm

landmarks.

occipital protuberance

supraclavicular fossa

shoulders

lateral side of antecubital fossa

thumb

middle finger

little finger

medial side of antecubital fossa

nipples

xyphoid

umbilicus

T10

inguinal ligament

T12

medial femoral condyle

medial maleolus

great toe

lateral maleolus

popliteal fossa in midline

ischial tuberosity

perianal area

S4-5

434

Spine Injuries

40.

Write out the American Spinal Injury

G7 p.945:55mm

Association (ASIA) motor scoring

system—upper extremity—for the

indicated root, muscle, and action to

test.

root C5

muscle: d________ or b________

deltoid or biceps

ii.

action: s________ a________ or

shoulder abduction or elbow

e________ f________

flexion

root C6

muscle: w________ e________

wrist extensors

ii.

action: e________ w________

extend wrist

root C7

muscle: t________

triceps

ii.

action: e________ e________

extend elbow

root C8

muscle: f________ d________

flexor digitorum profundus

p________

ii.

action: s________ h________

squeeze hand

root T1

muscle: h________ i________

hand intrinsics

ii.

action: a________ l________

abduct little finger

f________

41.

Write out the ASIA motor scoring

G7 p.945:56mm

system—lower extremity—for the

indicated root, muscle, and action to

test.

root L2

muscle: i________

iliopsoas

ii.

action: f________ h________

flex hip

root L3

muscle: q________

quadriceps

ii.

action: s________ k________

straight knee

root L4

muscle: t________ a________

tibialis anterior

ii.

action: d________ f________

dorsiflex foot

root L5

muscle: e________ h________

extensor hallucis longus (EHL)

l________

ii.

action: d________ g________

dorsiflex great toe

t________

root S1

muscle: g________

gastrocnemius

ii.

action: p________ f________

plantar flex foot

f________

Neurological Assessment

435

42.

Matching. Match the main nerve root

G7 p.946:45mm

responsible for the following motor

action:

Nerve root:

① L3; ② L4; ③ L5; ④ S1

Motor action:

great toe extension

③ (+S1)

ankle dorsiflexion

② (+L5)

knee extension

① (+L4)

ankle plantar flexion

④ (+S2)

43.

Complete the following regarding

G7 p.946:75mm

Beevor sign:

It tests the level of spinal cord injury at

about T________.

It is performed by

flexing the ________.

neck

ii.

Note that the ________ moves

umbilicus

cephalad.

44.

Complete the following regarding the

G7 p.946:83mm

abdominal cutaneous reflex:

The upper quadrant is served by

T8-9

________.

The lower quadrant is served by

T10-11-12

________.

Its presence indicates (at least some)

spinal cord

function of the ________ ________.

There is ________ ________ spinal cord

no complete

injury

because the reflex ________ to the

ascends to the cortex and

________ and then ________to the

then descends

abdominal muscles.

45.

Complete the following about

G7 p.946:108mm

priapism:

After spinal cord trauma it indicates

sympathetic

injury to the ________ tone

and a dominance of ________ tone.

parasympathetic

Priapism indicates ________ prognosis

poor

for spinal cord recovery of function.

46.

There is a sensory region that is not

G7 p.946:148mm

represented on the trunk.

It jumps from C________ to T________.

C4 to T2

These levels are distributed exclusively

upper extremities

on the u________ e________.

436

Spine Injuries

47.

Give the motor and sensory

G7 p.947:120mm

descriptions for each class in the ASIA

impairment scale as modified from the

Frankel neurologic performance scale.

class A

motor

no motor

ii.

sensory

no sensory, (class

A = complete motor and

sensory paralysis below

lesion)

class B

motor

no motor

ii.

sensory

some sensory, (class

B = complete motor paralysis,

some residual sensory

perception below lesion)

class C

motor

useless motor

ii.

sensory

good sensory, (class

C = residual motor function

but no practical use)

class D

motor

some motor

ii.

sensory

good sensory, (class

D = useful but subnormal

motor function below lesion)

class E

motor

good motor

ii.

sensory

good sensory (class

E = normal)

 Spinal Cord Injuries

48. True or False. Regarding central cord

G7 p.948:85mm

injuries:

a. They usually result from a hyperflexion

false (hyperextension)

injury.

b. Motor deficit is greater in the arms than true

legs.

c. Hyperpathia is uncommonly seen.

false (Hyperpathia is

commonly seen.)

d. It is the most common type of

true

G7 p.948:140mm

incomplete spinal injury.

e. The cord’s centermost region is a

true

watershed zone.

f. Somatotopic organization places fibers

false (more lateral)

to lower extremities more medial.

g. BP must be maintained at an MAP of

true

G7 p.949:107mm

85 to 90 for at least 1 week.

h. Prompt surgery for decompression is

false

advised.

Spinal Cord Injuries

437

49.

A 45-year-old alcoholic male trips and

G7 p.949:140mm

falls, briefly losing consciousness. He

was unable to move for 15 minutes,

but currently complains only of

weakness of both hands. He has an

abrasion of his forehead. Computed

tomographic (CT) scan of his head was

negative. X-ray of C-spine reveals only

spondylosis. True or False. Regarding

this lesion:

It has the best prognosis of all

false (Brown-Séquard has the

incomplete spinal cord injuries.

best prognosis.)

There may be sparing of sensation

true

around the anus with an intact voluntary

anal sphincter.

Immediate surgery is recommended

false

even for patients without spinal

instability.

Urinary catheterization is recommended

true

for patients in spinal shock.

50.

Complete the following about surgical

G7 p.949:140mm

intervention in patients who have had

a central spinal cord injury:

Indications for surgical intervention are

spine ________

instability

ii.

continued spinal cord compression

improve or deteriorates

in a patient who fails to ________ or

________

What surgery should be done?

decompressive laminectomy

and lateral mass or pedicle

screw fixation and fusion

51.

What is the prognosis in patients with

G7 p.950:82mm

central cord injury?

________% will recover enough to

50%

ambulate.

Bowel and bladder function ________.

recovers

Upper extremities (do/don’t) ________

don’t

recover well.

Elderly patients (do/don’t) ________

don’t

recover well.

52.

Answer the following about anterior

G7 p.950:105mm

cord syndrome:

True or False. Motor findings are of

false (paraplegia)

hemiplegia below the lesion.

True or False. There is loss of pain

true (deep pressure sensation

sensation, with preservation of deep

is via posterior columns)

pressure sensation.

It may result from ________.

occlusion of anterior spinal

artery

438 Spine Injuries

d. Sensory pattern is termed “dissociated”

because there is loss of

________ ________ and

spinothalamic tract

preservation of

ii.

________ ________ ________.

posterior column function

53. Answer the following about a Brown-

G7 p.950:116mm

Séquard syndrome:

a. True or False. There is contralateral pain

false (Pain loss is 1 to 2 levels

loss beginning 1 to 2 levels above the

below the lesion.)

lesion.

b. True or False. Contralateral position

true

sense is preserved.

c. Prognosis compared with all other

best of all the incomplete

incomplete cord lesions is ________.

cord lesion types

d. What% will eventually walk?

90%

 Cervical Spine Fractures

Atlanto-occipital Dislocation

54.

Complete the following:

G7 p.951:156mm

Incidence in spinal injury is

approximately ________%.

Are they more common in pediatrics or

pediatrics (twice as common)

in adults?

Mortality results from ________

respiratory arrest causing

________ ________ ________.

anoxia

55.

Complete the following about the

G7 p.952:17mm

three types of atlanto-occipital

dislocation:

Type I: occiput in relation to atlas is

anteriorly

dislocated ________.

Type II: occiput in relation to atlas is

longitudinally distracted

dislocated ________.

Type III: occiput in relation to atlas is

posteriorly

dislocated ________.

56.

Name the ligaments at the following

G6 p.718:15mm

sites:

atlas to occiput

a________ a________-o________

anterior atlanto-occipital

m________

membrane (continuation of

the ALL)

ii.

p________ a________-o________

posterior atlanto-occipital

m________

membrane

iii.

a________ b________ (of

ascending band (of cruciate

c________ l________)

ligament)

axis to occiput (via dens)

t________ m________

tectorial membrane

(continuation of the PLL)

ii.

a________ l________

alar ligaments (occipital-alar

portion)

iii.

a________l________

apical ligament

Cervical Spine Fractures

439

atlas to axis

t________ l________

transverse ligament

(horizontal part of cruciate)

ii.

a________ l________

alar ligaments (atlanto-alar

portion)

iii.

d________ b________ (of

descending band (of cruciate

c________ l________)

ligament)

57.

Complete the following:

G6 p.718:100mm

What structure is the cephalad extension

of the

anterior longitudinal ligament?

anterior atlanto-occipital

membrane

ii.

posterior longitudinal ligament?

tectorial membrane

Which structures are most important in

maintaining atlanto-occipital stability?

t________ m________

tectorial membrane

ii.

a________ l________

alar ligaments

58.

Complete the following:

G6 p.719:60mm

Name the horizontal component of the

transverse ligament

cruciate ligament.

What does it hold together?

odontoid and atlas

What is the strongest ligament in the

transverse ligament

spine?

59.

Complete the following:

G7 p.952:55mm

The best method by which to measure is

BAI-BDI (basion axial interal-

the ________.

basion dental interval)

It is considered normal if each is less than

________ mm.

Another method is called the ________

Powers ratio

________.

Traction may be used but ________% of

10%

patients deteriorate.

60.

Complete the following:

G7 p.952:145mm

A measurement used in evaluating

Powers ratio

atlanto-occipital dislocation (AOD) is

called ________ ________.

divide distance from basion to

post prior arch of atlas

________ ________ ________ of

________

ii.

by distance from opisthion to

anterior arch of atlas

________ ________ of ________

It is considered normal if below _______.

0.9, > 0.9 and < 1 = gray zone

It is definitely abnormal if above

1 = AOD (assumes an intact

________.

atlas and foramen magnum)

61.

Powers ratio greater than ________ is

1.0

G7 p.952:145mm

diagnostic of atlanto-occipital

dislocation.

62.

AOD is suspected if

G7 p.953:70mm

the atlanto-occipital interval is greater

than ________ mm and/or

there is blood in the _______ _______.

basal cisterns

G7 p.954:45mm

440 Spine Injuries

 Occipital Condyle Fractures

63. Complete the following:

G7 p.954:130mm

a. Can they involve the hypoglossal nerve? yes

b. List the types.

I is a ________ fracture.

comminuted

ii.

II has a ________fracture.

linear

iii.

III has an ________ fracture.

avulsion

c. Treatment is with ________ or

collar or halo

________.

d. Incidence in trauma patients is

0.4%

G7 p.955:35mm

________%.

 Atlanto-axial Dislocation

64.

Answer the following about atlanto-

G7 p.955:120mm

axial dislocation:

True or False. It has less morbidity and

true

mortality than atlanto-occipital

dislocation.

Name and describe the three types.

rotatory subluxation

ii.

atlanto-axial dislocation

type I

transverse ligament ________

intact

facet capsule ________

bilateral injury

treatment ________

soft collar

type II

transverse ligament ________

injured

facet capsule ________

unilateral injury

treatment ________

Philadelphia collar or SOMI

type III

transverse ligament ________

injured

facet capsule ________

bilateral injury

treatment ________

halo

iii.

anterior atlanto-axial dislocation

o________ f________

odontoid fracture

c________ h________

congenital hypoplasia

d________ of t________ l________

disruption of transverse

ligament

65.

Complete the following regarding

G7 p.956:40mm

atlanto-axial rotatory subluxation:

Name four causes.

Hint: stur

s________

spontaneous

ii.

t________

trauma

iii.

u________

upper respiratory tract

infection (Grisel syndrome)

iv. r________

rheumatoid arthritis

Competence of the ________ ________

transverse ligament

must be assessed.

Atlas (C2) Fractures

441

c. What is the characteristic head position?

“cock robin” (20 degrees

lateral tilt, 20 degrees

rotation opposite, slight

flexion)

d. Patients are usually ________.

young

G7 p.956:70mm

e. It can occlude the ________ arteries.

vertebral

66. Complete the following regarding the

G7 p.957:120mm

rule of Spence:

a. It is designed to determine if the

transverse ligament

________ ________ is disrupted.

b. If disrupted what effect does it have on

halo versus collar

treatment?

c. It is performed by studying what view on open-mouthed AP odontoid

x-ray?

view

d. To assess what structures?

lateral masses of

C1-C2 overhang

e. The critical reference number is

7 mm—sum of both sides

________.

 Atlas (C1) Fractures

67. Complete the following:

G7 p.957:165mm

a. isolated fracture ________%

56%

b. combined with C2 fracture ________%

44%

c. additional spine fracture ________%

d. combined with head injury ________%

21%

68. True or False. Regarding a Jefferson

G7 p. 958:35mm

fracture:

a. It involves a single fracture through the

false (At least 2 fracture

arch of C1.

sites—it’s a ring!)

b. It is generally a stable fracture.

false (But without neurologic

deficit.)

“Rule of Spence” assesses displacement

false (Rule of Spence assesses

of the dens on a lateral C-spine x-ray.

the lateral movement of the

C1 lateral masses; if sum of

overhang of both sides

> 7 mm, halo will be

necessary for treatment;

assessed on AP C-spine x-ray.)

d. Treatment is generally surgical (fusion).

false (Treatment is generally

with external

immobilization—soft collar or

rigid external device.)

 Atlas (C2) Fractures

69. Complete the following about acute

G7 p.959:35mm

fractures of the axis:

a. Represent ________% of cervical

20%

fractures

b. Neurologic deficit occurs in ________%.

10%

442

Spine Injuries

70.

Complete the following:

G7 p.960:13mm

True or False. Regarding hangman’s

fracture:

In contrast to judicial hanging,

false (hyperextension and

modern-day hangman’s fractures

axial loading)

result from hyperextension and

distraction.

ii.

This is usually a stable fracture.

true

iii.

There is a common occurrence of

false (usually heal with

nonunion, hence the need for

external immobilization)

surgery.

Hangman’s fracture results in a fracture

pars interarticularis bilaterally

through the ________.

It is also known as ________.

traumatic spondylolisthesis of

the axis

71.

Complete the following regarding

G7 p.960:58mm

hangman’s fracture:

Subluxation of C2 and C3 by more

than ________ mm

ii.

indicates ________ disruption.

disc

G7 p.961:106mm

This is a marker for ________

instability

ii.

and usually requires ________.

stabilization

72.

Classify hangman’s fractures and give

G7 p.960:70mm

the subluxation, angulation, and

neurologic deficit.

Type I

subluxation: ________

< 3 mm

ii.

angulation: ________

iii.

neurologic deficit: ________

Type IA

subluxation: ________

2 to 3 mm

ii.

angulation: ________

iii.

neurologic deficit: ________%

33%

Type II

subluxation: ________

> 3 mm

ii.

angulation: ________

not specified

G7 p.960:150mm

iii.

neurologic deficit: ________

rare

Type IIA

subluxation: ________

< 3 mm

ii.

angulation: ________

> 15 degrees

iii.

neurologic deficit: ________%

10%

Type III

subluxation: ________

yes

ii.

angulation: ________

facets locked

iii.

neurologic deficit: ________

deficit: ± fatal: occasionally

A special caution for fractures IIA and III

traction

it is best to avoid the use of ________.

Whose classification is this?

Effendi

Atlas (C2) Fractures

443

73.

Describe radiologic abnormalities of

G7 p.960:82mm

hangman’s fractures.

Type I

vertical pars fracture

yes

ii.

disruption

none

Type IA

vertical pars fracture

yes, nonparallel

ii.

disruption

none

Type II

vertical pars fracture

yes

ii.

disruption

C2-3 disc

Type IIA

vertical pars fracture

yes, oblique

ii.

disruption

none

Type III

vertical pars fracture

yes

ii.

disruption

facets of C2/C3 subluxed or

locked

74.

Classify hangman’s fractures.

G7 p.960::90mm

Type I

subluxation less than ________ mm

3 mm

ii.

angulation ________

none

Type IA

C2 appearance

elongated

ii.

canal

narrowed

iii.

typical?

atypical

iv.

paralysis?

33%

Type II

subluxation more than

3 mm

________ mm

ii.

angulation more than ________

11 degrees (indicates

disruption of C2-3 disc and

PLL)

Type IIA

subluxation is ________

< 3 mm

ii.

angulation ________

more angulation than type II

Type III

facets are ________ and

C2-3 facets disrupted

(conceptually similar to

bilateral jumped facets)

ii.

________ with traction

nonreducible

75.

Most hangman’s fracture patients

G7 p.961:60mm

present neurologically ________ and

intact

need MRI to assess ________ disc.

C2-C3

G7 p.962:26mm

It can be treated with ________

immobilization

ii.

for ________ weeks.

Average time to heal is ________ weeks,

11.5

444

Spine Injuries

76.

Describe treatment of Effendi

G7 p.963:110mm

classification fractures

Type I: c________

collar

Type IA: c________

collar

Type II: Less than 5 mm sublux and less

than 10 degrees angulation

t________

traction

ii.

h________

halo

Type IIA: More than 5 mm sublux or

surgical fusion

more than 10 degrees angulation

________

no t________

traction

ii.

h________

halo

Type III:

M________

MRI

ii.

s________

surgery (ORIF)

77.

Describe the radiologic criteria of

G7 p.963:110mm

good fusion.

Across the fracture site we should see

trabeculations

________.

Flexion-extension radiographs should

movement

show no ________.

 Odontoid Fractures

78. Complete the following about

G7 p.963:160mm

odontoid fractures:

a. Odontoid fractures represent

10 to 15%

approximately ________% of all cervical

spine fractures.

b. Mechanism of injury is usually ________.

flexion

c. They are fatal in about ________%.

25 to 40%

d. Major deficits in type II is ________%.

10%

e. In Type III it is ________ to have

rare

neurologic deficit.

f. A displacement

of ________ mm

6 mm

ii.

results in a nonunion rate of

70%

________%

iii.

therefore the treatment advised is

surgical

________

79. True or False. Regarding odontoid

G7 p.963:170mm

fractures:

a. They are a hyperflexion injury in most

true

instances.

b. Most patients have presenting

false

neurological deficit.

c. Neck pain is infrequent.

false

Os Odontoideum

445

80.

Complete the following:

G7 p.964:50mm

Regarding odontoid fractures:

Type I is fracture through the

apical dens (rare)

________.

ii.

Type II is fracture through the

base of the dens

________.

iii.

Type III is fracture through the

body of C2

________.

True or False. The spinal cord occupies

false (Steele’s rule of thirds:

50% of the canal at C1.

dens, space, spinal cord.)

True or False. The ossiculum terminale

false (Os

results from posttraumatic fracture of

odontoideum = fracture of

the apical dens.

apical dens or avulsion of alar

ligament. Ossiculum

terminale = nonunion of

secondary ossification

center.)

81.

Complete the following:

G7 p.965:75mm

List indications for surgical treatment of

Type II odontoid fractures.

displacement of dens more than

5 mm (4 to 5 or 6 mm used

________ mm

by some)

ii.

despite halo there is ________

instability

iii.

despite immobilization there is

nonunion

________

iv. patient is older than ________

v. disruption of the ________

transverse ligament

________

True or False. Most odontoid type III

false (Most [90%] heal with

fractures should be treated surgically

external immobilization.)

due to low union rate by rigid external

immobilization (halo).

 Os Odontoideum

82. The appearance of os odontoideum is

G7 p.966:135mm

a. a ________ bone

separate

b. with ________ borders

smooth

c. near a ________ odontoid peg.

short

d. It may fuse with the ________.

clivus

e. It may mimic an ________ fracture.

odontoid

83. Complete the following about os

G7 p.966:142mm

odontoideum:

a. Postulated etiologies

c________

congenital

ii.

a________

acquired—avulsion of alar

ligament

b. Does treatment depend on the etiology? no

c. Myelopathy correlates with an AP canal

13 mm

diameter of less than ________.

d. Will immobilization result in fusion?

446 Spine Injuries

e. Treatment

p________ w________

posterior wiring C1-C2

ii.

t________ s________

transarticular screw

f. Do we need a halo with each of these

not with transarticular screws

procedures?

 Combined C1 and C2 Fractures

84. Complete the following about

G7 p.967:123mm

combined C1 and C2 fractures:

a. Treatment is decided based on type of

________ fracture.

b. An odontoid fracture type II that is

displaced more than

________ mm is considered

5 mm

ii.

________.

unstable

c. Treatment is with ________ ________

posterior surgical fusion

________.

 Subaxial (C3 through C7) Injuries/Fractures

85.

Answer the following about SCIWORA:

G7 p.975:20mm

True or False.

There is a higher incidence in age

true

≤ 9 years.

ii.

There is a risk of SCIWORA among

true

young children with asymptomatic

Chiari I.

iii.

Dynamic flexion/extension (F/E)

true

films are normal.

iv.

54% of children have a delay

true

between injury and the onset of

objective sensorimotor dysfunction.

SCIWORA stands for ________.

spinal cord injury without

radiological abnormality

86.

Matching. For the following

G7 p.968:100mm

conditions, choose the most

appropriate mechanism producing the

cervical fracture.

Mechanism:

① hyperextension; ② vertical

compression; ③ hyperflexion; ④ flexion

plus rotation

Condition:

burst fracture

②

unilateral locked facet

④

bilateral locked facet

③

laminar fracture

①

87.

Clay shoveler’s fracture usually

G7 p.969:160mm

involves the spinous process of

________.

Subaxial (C3 through C7) Injuries/Fractures

447

88.

Guidelines for determining clinical

G7 p.970:20mm

instability include

compromise of the anterior elements

extension

produces more instability in ________.

compromise of the posterior elements

flexion

produces more instability in ________.

extension will demonstrate more

instability if the ________ elements are

injured.

flexion will demonstrate more instability

posterior

if the ________ elements are injured.

89.

Give radiographic criteria for clinical

G7 p.970:60mm

instability.

A sagittal plane displacement of

> 3.5 mm

________ mm and

relative sagittal plane angulation of

> 11 degrees

________ degrees (on neutral position

lateral C-spine films) are associated with

instability.

90.

True or False. The following is true of

G7 p.970:135mm

teardrop fractures:

They usually result from

hyperflexion injuries

true

ii.

compression flexion injury

true

iii.

hyperextension injury

false

They are stable fractures.

false (Teardrop fractures are

unstable due to complete

disruption of the ALL, PLL,

and facet joints.)

The fractured vertebra is usually

true

displaced posteriorly into the spinal

canal.

They are often associated with a fracture

true

through the sagittal plane of the

vertebral body.

The patient is often quadriplegic.

true

A “teardrop” chip of bone is at the

false (Teardrop is at the

anterior-superior edge of the vertebral

anterior-inferior edge of the

body.

vertebral body.)

91.

Complete the following:

G7 p.971:37mm

A teardrop fracture must be

avulsion fracture

distinguished from an ________

________.

________ is unstable and requires

Teardrop; surgery

________, and

ii.

________ is stable.

avulsion

448

Spine Injuries

How can we distinguish them? Serious

teardrop will have:

Hint: sansfhh

size of fracture ________

small chip

ii.

alignment ________

displaced

iii.

neurological ________

injured

iv.

soft tissue ________

swelling

fracture ________

through vertebra

vi.

height of disc ________

reduced

vii. height of vertebral body ________

reduced or wedged

If in doubt perform ________ views.

flexion-extension views

If negative repeat ________ ________ in

flexion-extension views in 4 to

________ to ________ days.

7 days

The fractured vertebra is displaced

posteriorly

________.

True teardrop fractures should be

combined anterior and

treated with c________ a________ and

posterior fusions

p________ f________.

92.

Quadrangular fractures have four

G7 p.971:140mm

features.

feature 1: an ________ fracture

oblique

from ________-________

anterior-superior

ii.

to ________ ________ ________

inferior end plate

feature 2: subluxation of superior

posteriorly

vertebral body (VB) on the inferior VB

________

feature 3: with angular ________

kyphosis

feature 4: disruption of

________

disc

ii.

________

ALL

iii.

________

PLL

Treat with ________ ________

combined anterior and

________ ________ ________.

posterior fusion

93.

Describe distraction flexion injuries.

G7 p.971:165mm

Flexion injuries include ________.

strain, subluxation, locked

facets

Which ligament is injured early?

posterior ligamentous

complex

X-rays demonstrate this by showing

widening of the interspinous

________.

distance

We may need to test by performing

flexion-extension views (or

________.

MRI)

If symptoms persist 1 to 2 weeks we

repeat the flexion-extension

should ________.

views

Ligamentous instability is confirmed if

there is a

subluxation of ________ mm or

3.5 mm

angulation of

ii.

________ degrees.

Subaxial (C3 through C7) Injuries/Fractures

449

94.

Describe locked facets.

G7 p.972:85mm

Normally the inferior facet of the level

posterior

above is ________ to the superior facet

of the level below.

In locked facets there is ________

disruption

of the facet ________.

capsule

Flexion and rotation produces ________

unilateral locked facet

________ ________.

Hyperflexion produces ________

bilateral locked facets

________ ________.

Neurological injury is ________ for cord

frequent

and/or root injury.

In patients with locked facets the inferior

facet of the level above is ________ to

the superior facet of the level below.

95.

Describe evidence of locked facets on

G7 p.973:25mm

x-ray.

In unilateral locked facets the spinous

unilateral locked facet

process is rotated to the side of the

________ ________ ________.

Facets look like a ________ ________.

bow tie

Interspinous space is ________.

widened

Neural foramen is ________.

blocked

Articular surfaces of the facets are

on the wrong side

________ ________ ________

________.

96.

Complete the following regarding

G7 p.973:60mm

locked facets:

When the articulating surfaces of the

naked facet

facets are on the wrong side, this is

called the “________ ________ sign.”

In bilateral locked facets traumatic disc

80%

herniation is found in ________%.

Attempt at closed reduction of locked

facets by traction must not exceed

________ lb per vertebral level.

Disc space height must not exceed

________ mm.

If neurologic worsening occurs you

disc herniation

should suspect ________ ________

and plan for ________ ________.

prompt surgery

G7 p.973:120mm

Closed reduction is c________

contraindicated

ii.

until MRI assesses for t________

traumatic herniated disc

h________ d________.

450

Spine Injuries

97.

Answer the following about locked

G7 p.974:60mm

facets:

True or False. Stabilization is more likely

to be successful in halo if there are

multiple fractures of the facets

true

ii.

no fractures of the facets

false

Halo alone is successful for good

23%

anatomical result in ________%.

Failure of good anatomical result occurs

77%

in ________%.

True or False: Surgical fusion is therefore

true

more or less clearly indicated in cases

without facet fracture fragments.

98.

Complete the following about subaxial

G7 p.974:155mm

(C3 through C7) injuries/fractures:

Extension injuries can produce

________ in adults and

central cord syndrome

ii.

________ in children.

SCIWORA

The ligament that is most often injured

ALL

in extension injuries is the ________.

Is disc injury possible?

yes

What vascular injury can occur?

carotid artery dissection

99.

Complete the following:

G7 p.978:25mm

When combined anterior and posterior

cervical fusion is needed which should be

done first?

When the mechanism of injury is flexion

posterior fusion

what is the procedure of choice?

When the mechanism of injury is

extension what is the procedure of

choice for

teardrop fracture is c________

combined anterior and

a________ and p________ fusion

posterior

ii.

burst fracture is c________

combined anterior and

a________ and p________ fusion

posterior

100.

Complete the following about cervical

G7 p.978:110mm

corpectomy:

Decompression of the cord usually

16 mm

requires corpectomy that is at least

________ mm wide.

It is advised to note position of ________

vertebral arteries

________.

101.

Complete the following about

G7 p.980:85mm

football-related cervical spine injuries:

stinger

involves ________

one extremity

ii.

represents ________

compression of a root

burning hands

involves ________

both arms

ii.

represents ________

mild central cord syndrome

Subaxial (C3 through C7) Injuries/Fractures

451

neuropraxia

involves ________

four extremities

ii.

represents ________

cervical cord injury

must rule out ________

cervical stenosis

by performing an ________

MRI

102.

Complete the following:

G7 p.980:140mm

A football player who uses his helmet as

spear tackler

a battering ram is called a ________.

What evidence may be present on his

spine x-rays?

loss of ________

lordosis

ii.

evidence of ________ ________

prior trauma

iii.

presence of ________ ________

cervical spinal stenosis

________

When may the athlete resume play?

when lordosis returns

103.

True or False. Contact sports are

G7 p.981:45mm

permitted in

Klippel-Feil with symptoms

false

Klippel-Feil without symptoms

true

spina bifida

true

status post-anterior cervical discectomy

true

and fusion (ACDF) 1 level

status post-ACDF 2 levels

false

status post-ACDF 3 levels

false

104.

Delayed cervical instability is defined

G7 p.982:35mm

as instability identified after ________

days.

105.

Complete the following about blunt

G7 p.982:115mm

cerebrovascular injuries (BCVI):

The usual injury is ________.

dissection

It occurs in ________% of BCVI patients.

1 to 2%

Mortality occurs in ________%.

Which is a better test: MRI or CTA?

CTA

G7 p.984:52mm

Treatment is with h________

heparin

ii.

or occasionally with e________

endovascular

techniques.

106.

Complete the following regarding

G7 p.985:55mm

blunt vertebral artery injury:

most common etiology ________

motor vehicular accidents

treatment to strongly consider is

IV heparin

________ ________

because strokes were ________

more frequent

________ in those patients not treated

incidence is ________% but

0.5 to 0.7%

G7 p.985:85mm

increases to ________% if cervical

fracture or ligament injury

Is there a warning “TIA”?

G7 p.985:130mm

Can occur from ________ hours to

8; 12

________ days

452 Spine Injuries

h. Is any cervical fracture pattern a

G7 p.985:145mm

predictor of blunt vertebral injury?

Overall mortality was ________%

16%

G7 p.986:17mm

Bilateral VA dissection is highly

fatal

________.

 Thoracolumbar Spine Fractures

107.

Complete the following about thoracic

G7 p.986:48mm

and lumbar spine fractures:

Percent of spinal fractures that occur at

64%

T11, T12, L1 is ________%.

Percent that have neurological deficits is

30%

________%.

108.

Matching. Match the following

G7 p.986:100mm

structures with the appropriate Denis

column:

① anterior; ② middle; ③ posterior

anterior half of disc

①

posterior half of disc

②

posterior arch

③

anterior half of vertebral body

①

posterior half of vertebral body

②

facet joints and capsule

③

anterior anulus fibrosus

①

posterior anulus fibrosus

②

interspinous ligament

③

supraspinous ligament

③

anterior longitudinal ligament

①

posterior longitudinal ligament

②

ligamentum flavum

③

109.

True or False. The following are

G7 p.986:165mm

considered minor fractures of the

lumbar spine:

fracture of transverse process

true

fracture of spinous process

true

fracture of superior articular process

true

fracture of inferior articular process

true

fracture of superior end plate of

false (Fracture of the superior

vertebral body

end plate of the vertebral

body is not considered a

minor fracture.)

110.

True or False. Major injuries of the

G7 p.987:110mm

spine include:

compression fracture

true

burst fracture

true

seat belt fracture

true

fracture of articular process

false (Fracture of the articular

process is a minor fracture.)

fracture dislocation

true

Thoracolumbar Spine Fractures

453

111.

True or False. Subtypes of burst

G7 p.987:75mm

fracture include the following:

fracture of both end plates

true

fracture of superior end plate

true

fracture of inferior end plate

true

fracture of pars interarticularis

false (Fracture of the pars

interarticularis is not a burst

fracture.)

burst rotation

true

112.

True or False. Regarding burst

G7 p.987:78mm

fracture:

It occurs mainly at thoracolumbar

true

junction

Mechanism—axial load

true

Mechanism—flexion and compression

false (Mechanism is not

flexion and compression but

pure axial loading and in

some subtypes added

flexion.)

It is a consequence of fracture of the

true

anterior and middle column.

The most common subtype is fracture of

true

the superior end plate.

113.

True or False. Radiographic evaluation

G7 p.987:100mm

of burst fracture might show the

following on

lateral x-ray—cortical fracture of posterior

true

vertebral wall

AP x-ray—increase in interpedicular

true

distance

lateral x-ray—loss of posterior vertebral

true

height

CT—fracture posterior wall with

true

retropulsed bone

myelogram—large central defect

true

114.

True or False. Seat belt fracture has all

G7 p.987:145mm

of the following subtypes:

chance fracture, one-level through bone

true

one-level through ligaments

true

two-level, bone in middle column

true

ligaments in anterior and posterior

columns

pedicle fracture

false (A pedicle fracture is not

one of the subtypes of seat

belt fracture.)

two-level through ligaments in all three

true

columns

454

Spine Injuries

115.

State which of the following are stable

G7 p.988:160mm

or unstable fractures of the spine:

three or more consecutive compression

unstable

fractures

a single compression fracture with loss of

unstable

> 50% of height with angulation

kyphotic angulation > 40 degrees at one

unstable

level or > 25%

Chance fracture

stable

progressive kyphosis

unstable

116.

State whether the following are stable

G7 p.989:60mm

or unstable fractures of the spine:

middle column fracture above T8 below

stable

T1 if ribs and sternum intact is ________

middle column fracture below l4 if

stable

posterior column is intact is ________

posterior column fracture is ________

stable

compression fracture in three

unstable

consecutive segments is ________

117.

True or False. Regarding burst

G7 p.989:153mm

fractures:

Surgical treatment is recommended if

true

angular deformity > 20 degrees.

Surgical treatment is recommended for

true

patients with neurologic deficit.

Surgical treatment is recommended for

true

anterior body height reduction ≥ 50%

compared with the posterior body

height.

Surgery is recommended for canal

true

reduction ≥ 50%.

The anterior approach is recommended

false (A posterior approach is

if a dural tear is present.

recommended if there is a

dural tear.)

118.

Burst fractures are unstable if

G7 p.989:154mm

Hint: KIPHD

K—Kyphosis is more than ________

I—Interpendicular distance is ________

Increased

P—Progressive ________ occurs

Kyphosis

H—Height of anterior body is less than

50; posterior

________% ________

D—Deficit in n________ status

neurological

119.

True or False. Regarding L5 burst

G7 p.990:40mm

fractures:

They are very common.

false

It is difficult for instrumentation to

true

maintain alignment at this level.

Patients will lose ~15 degrees of lordosis

true

between L4 and S1 even with

instrumentation.

Thoracolumbar Spine Fractures

455

If treatment is nonsurgical a

true

thoracolumbar-sacral orthosis (TLSO)

brace is recommended for 4 to

6 months.

If treatment is surgical a posterior

true

approach with fusion and fixation

L5-S1 is recommended.

If “ligamentotaxis” is expected,

G7 p.990:165mm

distraction should be done within

________ hours.

120.

Complete the following about post-

G7 p.991:155mm

spinal fusion wound infections:

They are usually due to ________

Staph aureus

________.

They may respond to ________ alone.

antibiotics

Rarely ________ may be necessary.

debridement

Only occasionally must instruments be

removed

________.

121.

Complete the following regarding

G7 p.992:28mm

demographics of osteoporotic spine

fractures:

True or False. There are ~700,000

true

osteoporotic fractures per year in the

United States.

True or False. Risk factors include weight

false (Risk factors include

> 58 kg (127 lb).

weight below 58 kg [127 lb].)

There is a risk with the use of which

phenytoin

anticonvulsant?

There is a risk with the use of which

warfarin

anticoagulant?

There is a risk with consumption of

ETOH

which beverage?

There is a risk with the use of c________.

cigarettes

There is a risk with the use of which anti-

steroids

inflammatory drug?

122.

Complete the following regarding

G7 p.992:35mm

osteoporotic spine fractures:

The most likely population is ________

elderly white females

________ ________.

Can these fractures occur in

yes

premenopausal women?

The lifetime risk for women is

16%

________%.

The lifetime risk for men is ________%.

The best predictor of fractures is

the ________ ________ ________

bone mineral density

test

ii.

measured at the ________

proximal femur

________.

456

Spine Injuries

123.

True or False. Regarding bone mineral

G7 p.992:110mm

density (BMD):

It is not the correct predictor of bone

false

fragility.

It is measured by Dexa Scan at the

true

proximal femur.

The AP view of the lumbosacral spine

false (It overestimates BMD.)

underestimates BMD.

The T-score of BMD compares to normal

true

subjects.

The Z-score defines osteoporosis

true

compared with subjects of the same age

and sex.

124.

True or False. Regarding sodium

G7 p.993:59mm

fluoride:

75 mg/d increases bone mass.

true

75 mg/d decreases fracture rate.

false (It increases bone mass

but did not reduce the

fracture rate.)

25 mg by mouth twice a day (slow

true

fluoride) decreases the fracture rate.

25 mg PO BID (slow fluoride) increases

true

the fragility of the bone.

Fluoride increases the demand for Ca.

true

If you use fluoride also use Ca and

true

vitamin D.

125.

True or False. The following drugs

G7 p.993:80mm

reduce bone resorption:

estrogen

true

calcium

true

vitamin D

true

calcitonin

true

126.

Calcitonin is derived from s________.

salmon

G7 p.993:150mm

127.

How do the bisphosphonates work?

G7 p.993:170mm

They inhibit ________ ________

bone resorption

by destroying ________.

osteoclasts (They are carbon-

substituted analogues of

pyrophosphate.)

128.

True or False. The following are

G7 p.993:183mm

bisphosphonates that inhibit bone

resorption:

etidronate (Didronel)

true

alendronate (Fosamax)

true

risedronate (Actonel)

true

Thoracolumbar Spine Fractures

457

129.

True or False. Recommended

G7 p.994:92mm

treatment for osteoporotic vertebral

body fracture includes

sufficient pain medications

true

bed rest for 3 to 4 weeks

false (7 to 10 days)

DVT prophylaxis is contraindicated.

false

Start physical therapy in 7 to 10 days.

true

lumbar brace for pain control and

true

comfort

130.

True or False. Regarding PVP:

G7 p.994:140mm

PVP stands for percutaneous

true

vertebroplasty.

It involves injection of

true

polymethylmethacrylate (PMMA) into

compressed bone.

Goals include prevention of progression

true

of kyphosis.

Goals include correction of kyphosis.

false

Goals include shortened duration of pain.

true

131.

True or False. Indications for PVP

G7 p.995:45mm

include the following:

severe pain that interferes with activity

true

painful osteoporotic compression

false (We do not treat for less

fracture with < 10% of height reduction

than 10% reduction in

height.)

failure to control pain with pain

true

medications

progressive vertebral hemangioma

true

pedicle screw salvage

true

132.

True or False. Vertebroplasty

G7 p.995:100mm

contraindications include

international normalized ratio (INR) of

true

3.4

because patient has ________

coagulopathy

injury occurred > 8 months ago

true

because patient has ________

completely healed

________

fever, chills, elevated WBCs

true

because patient has ________

active infection

________

burst fracture

true

because of concern for ________

leakage of PMMA

________

458

Spine Injuries

133.

Matching. Match the complications of

G7 p.995:140mm

PVP with the order in which they are

more likely to occur with.

Occurrence:

① highest; ② second highest; ③ least

complications

Complications:

vertebral hemangiomas

②

pathologic fractures

①

osteoporotic compression fractures

③

134.

True or False. Complications of PVP

G7 p.995:145mm

include

PMMA leak

true

pedicle fracture

true

transverse process fracture

true

spinous process fracture

false

rib fracture

true

135.

True or False. Post-PVP

G7 p.997:25mm

recommendations include the

following:

discharge home the same day

false (Patients are usually

admitted overnight.)

watch for chest pain

true

watch for fever

true

watch for neurologic deficit

true

gradual mobilization after 2 hours

true

 Sacral Fractures

136. Complete the following:

G7 p.997:65mm

a. Look for in patients who have ________ pelvic

fractures

because ________% will also have

17%

sacral fractures

b. accompanied in ________% by

20 to 60%

neurologic deficits.

c. Sacral fractures are divided into

three

________ zones.

I involves ________ ________.

ala only

ii.

II involves ________ ________.

sacral foramina

iii.

III involves ________ ________.

sacral canal

d. The fractures that involve neurologic

II and III

deficits are those involving zone

________ and zone ________.

e. Which fracture can cause bowel and

zone III (bilateral nerve injury)

bladder incontinence?

f. Which fracture can cause L5 root injury? zone I

G7 p.997:132mm

Penetrating Trauma to the Neck

459

 Gunshot Wounds to the Spine

137.

Name the surgical indications for

G7 p.998:60mm

gunshot wounds (GSW) to the spine.

Hint: rinds

remove ________-jacketed bullet

copper (local reaction)

________ is more of a concern in

infection; military; civilian

________ than ________ GSW

neurologic

cauda e________ i________

equina injury

ii.

root ________ c________

nerve root compression

iii.

leak ________

CSF leak

iv.

hema ________

spinal hematoma/vascular

injury

delayed complications

migrating ________

bullet

ii.

plumbism means ________

lead toxicity

________

sp________ inst________

spinal instability (rare)

138.

True or False. Indications for surgery

G7 p.998:60mm

in gunshot wounds to the spine

include the following:

injury to cauda equina if root

true

compression is demonstrated

to remove copper-jacketed bullets from

true

the spine

CSF leak

true

compression of nerve root

true

vascular injury

true

to improve spinal cord function

false (Surgery will not

improve spinal cord function.)

 Penetrating Trauma to the Neck

139. Matching. Penetrating wounds of the

G7 p.998:145mm

neck are divided into three zones by

anatomical boundaries.

Zone:

① zone I; ② zone II; ③ zone III

Anatomical boundaries:

a. clavicle

②

b. angle of mandible

②-③

c. head of clavicle

①

d. thoracic outlet

①

e. base of skull

③

460

Spine Injuries

140.

True or False. Regarding vascular

G7 p.998:168mm

injuries of the neck:

Venous injuries occur in ≈ 30% of

false (Venous injury

penetrating neck trauma.

represents 18%.)

Arterial injuries occur in ≈ 12% of

true

penetrating neck trauma.

72% of vertebral artery injuries had no

true

neurological deficits on exam.

Common carotid artery injury is the most

true

common vascular injury.

141.

True or False. Treatment of

G7 p.999:89mm

penetrating trauma to the neck

includes all of the following:

Immediate prophylactic intubation to

false (Intubation is not

protect airway

needed in stable patients.)

Cricothyroidotomy if apparent

true

mechanical instability of the neck

Surgical exploration is recommended for

true

all wounds piercing the platysma and

entering the anterior triangle of the

neck.

Patients in coma are poor candidates for

true

surgical vascular reconstruction.

142.

Complete the following regarding

G7 p.999:148mm

vertebral artery (VA) trauma:

It is more common to treat by ________

ligation

than by direct repair.

What must you know about other

their patency

vessels before you decide on

treatment of VA injury?

ii.

Which vessels?

contralateral VA and posterior

inferior cerebellar artery

(PICA)

What minimally invasive treatment is

endovascular occlusion

available?

Is arterial bypass ever indicated?

yes

 Chronic Management of Spinal Cord Injuries

143. True or False. Syndromes associated

G7 p.1000:98mm

with spinal cord injuries include all of

the following:

a. autonomic hyporeflexia

false (Autonomic

hyperreflexia is associated

with spinal cord injury.)

b. DVT

true

c. syringomyelia

true

d. spasticity

true

e. osteoporosis

true

f. shoulder-hand syndrome

true

Chronic Management of Spinal Cord Injuries

461

144.

True or False. In autonomic

G7 p.1000:145mm

hyperreflexia the following is found:

exaggerated autonomic response to

true

stimuli

only in patients with lesion above T6

true

complaints of headache, flushing, and

true

diaphoresis

extreme hypertension

true

epinephrine is released causing this

false (Norepinephrine is

syndrome

released but not

epinephrine.)

145.

True or False. Regarding autonomic

G7 p.1000:170mm

hyperreflexia in SCI:

It occurs only in patients with SCI below

false (It occurs only in

T6.

patients with SCI above T6.)

Patients complain of pounding

true

headache.

It can be life threatening.

true

It occurs in ≈ 30% of quadriplegic

true

patients.

There is a lag time of 3 to 4 months.

true

146.

True or False. Regarding autonomic

G7 p.1001:22mm

dysreflexia in SCI:

It often occurs in the first 3 to 4 months

false (It occurs after the first

after SCI.

12 to 16 weeks.)

Bladder distension may cause onset.

true

Colorectal distension may cause onset.

true

DVT may cause onset.

true

147.

True or False. Presentation of

G7 p.1001:45mm

autonomic hyperreflexia in SCI

includes

paroxysmal hypertension

true

anxiety

true

miosis

false (Mydriasis occurs

[dilated pupil].)

penile erection

true

Horner syndrome

true

148.

Complete the following about

G7 p.1001:46mm

autonomic hyperreflexia:

What is the triad of presenting

symptoms?

h________

headache—cephalgia

ii.

s________

sweating—hyperhydrosis

iii.

f________ f________

facial flushing—cutaneous

vasodilation

It could be confused with ________.

pheochromocytoma

Stroke



Cerebrovascular Hemodynamics

Complete the following:

G7 p.1010:100mm

Cerebral blood flow (CBF) less than

20 mL

________ mL per 100 g of tissue per

minute is associated with ischemia.

If prolonged, it will result in ________.

cell death

Electroencephalography (EEG)

16 to 18

G7 p.1010:150mm

becomes flat line at CBF of ________

mL/100 g/min.

Complete the following about strokes

G7 p.1010:163mm

in general:

What is the range of cerebral perfusion

50 to 150 mm Hg

pressure in which cerebral blood flow is

maintained constant despite changes in

cerebrovascular resistance?

This is called ________.

autoregulation

Complete the following about strokes

G7 p.1010:175mm

in general:

CMRO₂ stands for ________ and

cerebral metabolic rate of

oxygen consumption

averages ________.

3.0 to 3.8 mL/100 g of tissue

per minute

Complete the following regarding

G7 p.1011:60mm

abrupt onset of new focal deficit

caused by:

tumor/seizure ________%

ischemic infarct ________%

85%

hemorrhagic infarct ________%

15%

mortality ________%

25%

nursing home ________%

25%

home ________%

50%

464

Stroke

True or False. The following is a cause

G7 p.1011:75mm

of ischemic infarcts:

lacune

true

large artery embolism

true

cardiogenic embolism

true

aortic arch plaques

true

Modifiable risk factors for stroke

G7 p.1011:120mm

include

c________

cigarettes

a________

alcohol

h________

hypertension

l________

lipids

a________

antiplatelets

Computed tomographic (CT) scan

G7 p.1012:110mm

signs of early ischemia include

i________

insular ribbon lost

s________

shift of midline day 1 to 25

c________

calcification almost never 1 to

h________

hyperdense artery sign

e________

effacement of cerebral sulci

m________

mass effect

i________

interface of gray-white lost

c________

contrast CT should be

included on at least one

occasion

True or False. The following can be

G7 p.1012:125mm

early CT findings of ischemic strokes:

midline shift

true

loss of gray-white interface

true

hyperdensity of lentiform nucleus

false (Attenuation of the

lentiform nucleus may be

seen.)

enhancement of ischemic area

true (One third of ischemic

strokes may enhance early.)

normal CT

true

hyperdense artery sign

true (usually MCA)

G7 p.1013:40mm

10.

Is there CT enhancement with

no (As a rule of thumb there

G7 p.1013:55mm

intravenous (IV) contrast in

should not be.)

cerebrovascular accidents (CVAs) in

the presence of mass effect?

11.

MRI sequences in stroke are

G7 p.1013:160mm

________ represents dead tissue.

DWI

________ represents penumbra.

PWI

Penumbra is potentially s________

salvageable

tissue.

Cerebrovascular Hemodynamics

465

12.

Components of luxury perfusion are

G7 p.1014:35mm

Hint: ischemia

i________

ischemia

“s”________

“s” idosis (acidosis)

c________

CO₂ rises

h________

hyperemia

e________

enlargement (dilation) of

vessels

m________

mechanism of luxury

perfusion

i________

increase blood flow

a________

accelerated circulation

adjacent to an infarct

13.

Explain the mechanism of luxury

G7 p.1014:40mm

perfusion.

Ischemia produces ________,

acidosis

which causes an ________ in PCO₂.

increase

What does this do to regulation?

loss of autoregulation

It results in ________ vessels

dilated

and blood flow ________ called

excess; hyperemia

________.

What happens to blood flow adjacent to

it becomes accelerated

an infarct?

14.

t-PA works by

G7 p.1016:145mm

converting p________

plasminogen

to the fibrinolytic compound ________.

plasmin

The primary agent is a ________.

alteplase

15.

Complete the following regarding the

G7 p.1016:175mm

use of recombinant tissue

plasminogen activator (rt-PA)

compared with control groups:

reduction in stroke ________%

30%

recurrent stroke rate ________%

5%—same in both groups

mortality ________ vs ________%

17 vs 21%

hemorrhage (NINDS study) ________ vs

6.4 vs 0.6%

________%

hemorrhage ECASSII study ________ vs

8.8 vs 3.4%

________%

benefit at 90 days in mortality ________

no difference

________

466

Stroke

16.

Facts learned from the ECASS-3 study

G7 p.1017:16mm

of t-PA include

Extended the window of IV treatment to

4.5

________ hours

Improved outcome at 90 days by

7.2%

________%

Incidence of hemorrhage

7.9%

________%

ii.

And ________% for placebo

3.5%

Yet no increase in death rate t-PA

7.7%

________%

ii.

Placebo ________%

8.4%

For every 100 patients treated with t-PA

________ will benefit

ii.

________ will be harmed

17.

True or False. The following would

G7 p.1017:70mm

exclude a patient with ischemic stroke

from treatment with tissue

plasminogen activator (t-PA):

systolic blood pressure (SBP) 180 mm Hg

false (SBP above 185

disqualifies.)

gastrointestinal (GI) bleed 6 months ago

false (GI bleed within 21 days

requiring transfusion

disqualifies.)

platelet count 120,000/mm³

false (Below 100,000

disqualifies.)

hip arthroplasty 10 days ago

true (Major surgery within 14

days of an ischemic stroke is a

contraindication for t-PA

treatment.)

blood glucose 250 mg%

false (Above 400 mg%

disqualifies.)

18.

Complete the following about the

G7 p.1018:15mm

management of post-t-PA

intracerebral hemorrhage:

Stop ________.

t-PA

Obtain stat ________.

Send labs for PT, PTT, platelet and

fibrinogen

________.

Prepare to administer

6 to 8 units of c________

cryoprecipitate

ii.

6 to 8 units of p________

platelets

Consider use of ________ ________.

factor VII

19.

Intra-arterial t-PA may be used up to

G7 p.1018:48mm

________ hours after stroke onset.

20.

Merci retriever

G7 p.1018:48mm

stands for mechanical embolus removal

cerebral ischemia

in ________.

It can be used for up to ________ hours.

It has a recanalization rate of ________%.

48%

Cerebrovascular Hemodynamics

467

21.

Complete the following about strokes

G7 p.1018:165mm

in general:

After a stroke you must monitor

electrocardiography (EKG) because

________% have EKG changes

5 to 10%

ii.

________% have myocardial

2 to 3%

infarction (MI)

You must avoid hyperglycemia because

hyperglycemia

________ the ischemia zone, also

extends

known as the

ii.

________.

penumbra

22.

Complete the following regarding

G7 p.1019:120mm

hypertension treatment:

If diastolic blood pressure (DBP) is above

140 mm Hg

________ it is called malignant

hypertension.

Decreasing by ________% to DBP of

20 to 30% (112 to 98 mm Hg)

________ is desirable.

If SBP is above 230 or DBP is above 120

180; 110

decrease to SBP of ________ or DBP of

________.

For SBP of 180 to 230 or DBP of 105 to

not needed emergently

120 decrease n________ n________

e________.

For SBP of less than ________or DBP of

180; 105

less than ________ antihypertensive

treatment is not needed.

Approximately ________ / ________ is

180/100

acceptable.

Add ________ if there is a history of

hypertension.

23.

Complete the following:

G7 p.1020:40mm

Incidence of recurrent ischemic strokes

2.2%

in the week following a CVA is

________%.

Is it any less if you use heparin?

except in ________

cardiogenic emboli

Complication rate of heparin

symptomatic intracerebral

1 to 8%

hemorrhage (ICH) occurs in

________%

ii.

conversion of pale to hemorrhagic

2 to 5%

CVA ________%

iii.

other bleeding complications

3 to 12%

________%

On balance is it justified to use heparin

after an ischemic CVA?

The American Heart Association

doctor

states that the ________ decides.

468 Stroke

24.

Complete the following regarding the

G7 p.1020:40mm

use of anticoagulants (heparin or

warfarin):

True or False. They are effective in the

true

prevention of embolic strokes caused by

cardiogenic embolism.

True or False. They are effective in

false

ischemic strokes.

They have a risk of hemorrhage of

1 to 8%

________% per year.

They will convert pale to hemorrhagic

2 to 5%

CVA in ________%.

25.

CVA and anticoagulation are generally

G7 p.1020:115mm

used for

c________ e________.

cardiogenic emboli

c________ d________.

carotid dissection

Complications are worse if the patient

hypertension

has ________.

How do you start the drugs?

simultaneously

(heparin/warfarin)

Why? Because of initial ________.

hypercoagulability

Stop warfarin after ________.

6 months

Why?

reduced benefits, increased

risks

26.

True or False. Regarding cerebellar

G7 p.1021:30mm

infarction:

Hydrocephalus may occur.

true

Surgery is appropriate even if patient is

true (Patient may respond

in coma.

even if in deep coma.)

Steroids should be used.

true (Steroids are suggested

G7 p.1020:145mm

for cerebellar stroke.)

Ventricular drainage should be used.

false (Is to be avoided; it

might cause upward

herniation.)

Incidence of cerebellar infarction is less

true (It is seen on 0.6% of all

than 1%.

CT scans.)

27.

Cerebellar infarction of the

G7 p1021 :30mm

tonsil implicates the ________

PICA

inferior vermis implicates the ________

PICA

superior hemisphere implicates the

SCA

________

superior vermis implicates the ________

SCA

28.

True or False. The following may be a

G7 p.1021:105mm

late finding in patients with cerebellar

infarctions that may prompt surgical

decompression:

sixth nerve palsy

true

seventh nerve palsy

true

worsening headache

true

Cerebrovascular Hemodynamics

469

Horner syndrome

false (The late findings in a

cerebellar infarction are from

hydrocephalus or brain stem

compression. Horner

syndrome is typically seen

with lateral medullary

syndrome and is due to an

intrinsic brain stem lesion and

is not an indication for

surgery.)

decreased level of consciousness

true

29.

Surgical decompression is appropriate

G7 p.1021:105mm

if patient develops:

True or False. Coma

true

True or False. Ataxic respiration

true

Loss of lateral gaze implicates ________

sixth

nerve.

Paresis of face implicates ________

facial colliculus

________.

Confusion and somnolence implicates

hydrocephalus

________ ________.

30.

With MCA infarction, consider

G7 p.1022:85mm

hemicraniectomy if

distribution of infarct is in the ________

middle cerebral artery (MCA)

territory

age of the patient is ________

under age 70

if CVA is on the ________ side

right (nondominant)

it may reduce mortality from ________

80 to 30%

to ________%

31.

Demographics of cardiogenic stroke

G7 p.1022:140mm

include

incidence of ________

1 in every 6 strokes (i.e.,

~17%)

after MI ________% in 2 weeks

2.5%

anterior wall ________%

inferior wall ________%

atrial fibrillation ________% per year

4.5%

without treatment

especially if patient has ________

left

ventriculomegaly

due to ________ ________

atrial thrombosis

G7 p.1022:165mm

heart valve prostheses with

anticoagulation

mitral ________% per year

ii.

aortic ________%

1.5%

iii.

without anticoagulation ________%

2 to 4%

per year

470 Stroke

32.

Complete the following about

G7 p.1023:55mm

paradoxical embolus:

Population incidence of patent foramen

10 to 18%

ovale is ________%.

In patients with unexplained CVA, the

56%

incidence is ________%.

33.

Complete the following about a

G7 p.1023:100mm

cardiogenic brain embolism:

Transformation from bland to

2 days (48 hours)

hemorrhagic infarct may occur within

________.

Based on what three-step mechanism?

i________

ischemia

ii.

c ________ l________

clot lysis

iii.

r________

reperfusion of the infarcted

brain

If transformation occurs you can surmise

cardiac cause

that indeed this large infarction can be

attributed to a ________ ________.

34.

Complete the following:

G7 p.1023:145mm

What is the only stroke for which

cardiogenic brain embolism

anticoagulation is beneficial?

What does anticoagulation accomplish

reduces the incidence

regarding further CVAs?

The natural risk without treatment is

12%

________%.

If used, when should anticoagulation be

not before 48 hours

instituted?

The size of the infarct should be

not a large one

________.

Aim for an international normalized ratio

2 to 3

(INR) of ________.

Coumadin reduces stroke risk in atrial

66 to 86%

fibrillation by ________%.

35.

True or False. Anticoagulation should

false (After 48 hours is the

G7 p.1023:165mm

be initiated immediately after

proper time. Hemorrhagic

detection of stroke caused by

conversion is more likely to

cardiogenic embolism.

occur with cardiogenic

embolic strokes and is most

likely to occur within 48 hours

of the stroke. A CT scan

should be obtained 48 hours

after the stroke and before

the initiation of

anticoagulation.)

Lacunar Strokes

471

 Strokes in Young Adults

36.

Complete the following about strokes

G7 p.1024:45mm

in young adults:

Incidence of all strokes

Under age 40: ________%

ii.

Under age 55: ________%

Etiologies

Hint: mA³pc³le²hv

m________

migraine

ii.

al________

alcohol

iii.

AP________

APLAS

iv.

ar________

arteriosclerosis

p________

peripartum

vi.

coa________

coagulopathy

vii. coc________

cocaine

viii. con________

contraceptives

ix. l________

lupus

x. ec________

ecstasy

xi. em________

embolism

xii. h________

homocystinuria

xiii. v________

vasculitis

Incidence of main etiologies

arterio-sclerosis ________%

20%

ii.

embolism ________%

20%

iii.

vasculitis ________%

10%

iv.

coagulopathy ________%

 Lacunar Strokes

37. Complete the following about lacunar

G7 p.1026:50mm

infarcts:

a. size of infarct ________

3 to 20 mm

b. size of artery involved ________

less than 200 μm in diameter

c. due to ________

lipohyalinosis

d. related to ________

hypertension

e. L’etat Lacunaire is ________ ________.

multiple lacunae

f. Small-step gait is called ________

marche á petits pas

________ ________ ________.

38. What is Dejerine-Roussy syndrome?

G7 p.1026:105mm

a. The patient complains of ________.

pain

b. The area of the brain involved is

thalamus

________,

c. specifically the ________ ________

posteroventral nucleus

d. due to a ________ infarct.

lacunar (Rare thalamic pain

syndrome develops long after

a lacunar infarct in the

posteroventral [sensory]

thalamus.)

472

Stroke

39.

Name the lacunar syndrome sites.

G7 p.1026:115mm

pure sensory ________

posterior ventral thalamus

pure motor ________

posterior limb of internal

capsule

ataxia hemiparesis ________

basis pontis

top of the basilar ________

mesencephalothalamic

Weber ________

third-nerve palsy and

contralateral hemiparesis

(cerebral peduncle and

issuing fibers of third nerve)

hemiballismus ________

subthalamic nucleus of Luys

Wallenberg ________

posterior inferior cerebellar

artery (PICA)—vertebral artery

40.

Concerning lacunar infarcts, give the

G7 p.1026:120mm

symptoms, anatomic site, and

distinguishing comment for the listed

syndromes.

pure sensory

symptom: f ________, a________,

face, arm, leg numbness

l________ n________

ii.

anatomic site: PVT

PV thalamus

iii.

comment: (first)

most common lacuna

pure motor

symptom: f________, a________,

face, arm, leg

l________

ii.

anatomic site: PL-IC

posterior limb of IC

iii.

comment: (second)

second most common

ataxia hemiparesis

symptom: a________

ataxia

ii.

anatomic site: PL-IC

basis pontis (midbrain)

iii.

comment: (lips)

numb lips

top of the basilar

(mesencephalothalamic)

symptoms: t________ n________

third nerve palsy, Parinaud,

p________, P________, a________

abulia

ii.

anatomic site: b________

basis pontis (midbrain)

p________

iii.

comment: b________ s________

butterfly shape

Weber

symptoms: t________ n________

third nerve palsy, motor

p________, m________ w________

weakness

ii.

anatomic site: i________ a________

interpeduncular arteries to

to the m________

the midbrain

iii.

comment: b________ a________

basilar aneurysm

Miscellaneous CVA

473

41.

True or False. The following is part of

G7 p.1026:160mm

the “top of the basilar” syndrome:

third nerve palsy

true

amnesia

true

light-near dissociation

true

vertical gaze impairment

true

dysarthria, clumsy hand

false (Dysarthria—clumsy

hand syndrome—occurs with

lacunar infarction of the basis

pontis or genu of the internal

capsule.)

42.

Matchin. Match the following

G7 p.1028:25mm

regarding MCA occlusion and

symptoms.

Area of MCA occlusion:

① complete MI; ② superior division;

③ inferior division

Symptoms:

homonymous hemianopsia

①, ③

aphasia

①, ③

paresis

①, ②

hemi-sensory loss

①, ②

43.

True or False. Complete the following

G7 p.1028:25mm

regarding inferior division MCA

occlusion:

Patient’s visual fields will be normal.

false

Patient’s speech will be normal.

false

Patient will have hemiparesis.

false

Patient will have sensory deficit.

false

 Miscellaneous CVA

44. Complete the following about the

G7 p.1028:121mm

Huebner artery:

a. also known as the r________ a________ recurrent artery

b. also known as m________ s________

medial striate artery

a________

arises from A2 in ________% of

78%

patients

ii.

arises from A1 in ________% of

14%

patients

iii.

arises from anterior communicating

artery (A-comm) in ________% of

patients

iv. arises within ________ mm of the

5 mm

A-comm junction

c. diameter is ________ mm: mean range

1 mm: mean range 0.2 to

________ to ________

2.9 mm

d. diameter compared with diameter of A1 one third

is ________

474

Stroke

may be confused at surgery with the

orbitofrontal artery (second

________ artery

branch of A2—arises 5 mm or