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NEUROSURGERY
SIGNS OF NEUROSURGICAL DISEASE RAISED INTRACRANIAL PRESSURE MENINGEAL IRRITATION BRAIN TUMOURS HEAD INJURY

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SIGNS OF NEUROSURGICAL DISEASE

Frontal /parietal regions speech plus motor function on dominant side Parietal/occipital regions sensory plus spatial orientation Occipital visual field Temporal speech(dominant side) plus visual, epilepsy Cerebellum coordination/balance Cranial nerves IXII

RAISED INTRACRANIAL PRESSURE (ICP)

Normal <200 mmH2O Increased volume of CSF Obstruction of normal flow in ventricles, obstructive hydrocephalus Obstruction of normal flow in subarach space communicating hydrocephalus Excessive CSF production papilloma of choroid plexus Increased cranial contents Space-occupying lesion Tumour Abscess Cyst Haematoma Increased volume of intracranial blood Venous obstruction of intracranial sinuses Vasodilatation in hypercapnia Decreased skull size craniosynostosis

CLINICAL FEATURES OF RAISED ICP

Headache, especially in the morning Vomiting Drowsiness Papilloedema plus retinal haemorrhages Fontanelle bulging in children

LATE SIGNS DUE TO DISTORTION OF BRAIN SHAPE

Tentorial notch pressure Ipsilateral IIIrd nerve dilated pupil Pyramidal tract motor weakness Posterior cerebral art occipital lobe infarction> permanent homonymous hemianopia Downward pressure on brainstem Bilatera VIth nerve Cerebellar tonsillar herniation Neck stiffness Bradycardia, hypertension (Cushing response) Respiratory arrest
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MENINGEAL IRRITATION
Features

Headache Neck stiffness Nausea, vomiting Photophobia

Causes (cf. peritonitis)

Blood subarachnoid haemorrhage Pus Spontaneous Post-head injury (especially damage to paranasal sinuses), pneumococcal meningitis Dermoid fistula (midline lesion over vertex of skull) Malignant cells primary or secondary Chemical Post-LP Cholesterol meningitis leakage of cholesterol via dermoid, epidermoid cyst or craniopharyngioma

Investigations

Skull XR CT scan MRI/MRA scans Angiography Lumbar puncture

BRAIN TUMOURS
PRIMARY OR SECONDARY

Overall incidence 5/100,000 Neuroepithelial 50% Metastatic 15% Menigioma 15% Pituitary 8%

Risk factors

Non-firm genetic or environmental link established Increased incidence of tumours in: Neurofibromatosis glioma, meningioma, acoustic neuroma Tuberous sclerosis astrocytoma Von HippelLindau haemangioblastoma

Extracerebral

Meninges meningiomas, pressure symptoms, good prognosis Nerves neuroma (especially acoustic neuroma), tinnitus, vertigo, facial pain Vascular haemangioblastoma (2%), cerebellum, highly vascular

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Pituitary anterior, adenoma Optic chiasm compression, bitemporal hemianopia Pituitary function decreased, hypothyroid, adrenal, gonad Secreting prolacatin, corticotrophin or growth hormone Bone chordoma <1%, embryo notochord remnant

Intracerebral

Gliomas grade 14 depending on histology, rapid presentation, poor prognosis grade 4 (glioblastoma multiforme) Astrocytoma Oligodendroglioma Ependymoma Medulloblastoma Lymphoma Pineal gland tumour <1% Parinaud syndrome(upward gaze ocular convergence paralyses) Germinoma (8090%), choricarcinoma, endodermal sinus tumour Raised AFP , HCG Papilloma of choroid plexus Metastases

NON-MALIGNANT SPACE-OCCUPYING LESIONS

Abscess Congenital cysts Parasitic cysts Granuloma, e.g. TB Vascular anomalies

Management principles

Establish diagnosis Treat raised ICP Anti-convulsant therapy Preoperative devascularization of tumours, e.g. large meningioma via embolization Surgical tumour biopsy /removal Stereotactic Craniotomy Adjuvant treatment radiotherapy

METASTATIC TUMOURS

Present in 30% of patients with systemic cancer Lesions in distal arterial fields, especially mid cerebral articulation Multiple Approximate primary origin Lung 40% Melanoma 11% Kidney 11% Colon 8%

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CEREBRAL ABSCESS

75% local spread of infection frontal sinus/middle ear 25% systemic spread, congenital heart lesion Treat with Burr hole aspiration Antibiotics Other management as for tumour

HEAD INJURY
Blunt Penetrating Cause of trauma, e.g. collapse, post-epilepsy Most common cause of death in children High morbidity post-major head injury Damage to: Brain accelerationdeceleration Diffuse brain injury Mild = concussion Severe = dementia, spasticity Pathological neuronal damage due to rotatory shear forces Local brain injury Contracoup damage Localized intracerebral/subarachnoid bleeding and oedema Skull fractures Linear Basal Compound Depressed

Complications of head injury

Intracranial bleed extradural/subdural/subarachnoid/intracerebral Cerebral ischaemia Respiratory failure Circulatory failure Cranial nerve damage II, III, VVIII CSF rhinhorea CSF otorrhoea Brain abscess Meningitis Epilepsy Diabetes insipidus Traumatic fat embolism (in major trauma) Carotico-cavernous fistula (rare)

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NEUROSURGERY

Basic management of head injuries

CT scan indications

Skull fracture plus decreasing GCS/confusion/focal neurology/seizures Persistent confusion/decreased GCS Deteriorating conscious level Depressed skull fracture Penetrating/open skull fracture with CSF Leak Difficult assessment, e.g. alcohol

Skull X-ray indications

Loss of consciousness/amnesia Suspected fracture CSF leak

Admission and observation indications

Confused, decreased conscious level but stable Persistent headache, nausea, vomiting Difficult assessment Poor social support.

INTRACRANIAL BLEEDS
Extradural

Damage to middle meningeal artery or large venous sinus Usually present within 24 h post-injury, occurs after lucid interval History of trauma Swelling +/ skull fracture over site Deteriorating conscious level late signs ipsilateral pupil dilation, contralateral motor weakness Need craniotomy and clot evacuation

Subdural

Acute post-trauma to frontal/temporal lobes, assigned with brain swelling, damage to bridging veins Chronic infantile <6 months or elderly >60 years of age, cerebral atrophy, coagulopathy Decreased conscious level Meningeal irritation Need craniotomy and clot evacuation

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Figure 11.1 Axial CT showing a large right temporal extradural haematoma. The fresh blood is highly dense (white). From: Sports Medicine: Problems and Practical Management (Eds. E. Sherry & D. Bokor); Greenwich Medical Media, 1997: page 81.

Figure 11.2 Axial CT of a subdural haematoma with midline shift. Note the haematoma is characteristically more extensive and crescenteric in shape. From: Sports Medicine: Problems and Practical Management (Eds. E. Sherry & D. Bokor); Greenwich Medical Media, 1997: page 81.

Subarachnoid

Post-traumatic severe head injury Spontaneous Rupture of saccular intracranial aneurysm Present in 3% of individuals, circle of Willis Sudden onset headache Meningism Deteriorating conscious level Focal neurological signs Complications

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Death in massive bleed Irreversible cerebral ischaemic damage Rebleed 4% in 24 h; 19% in 2 weeks Cerebrovascular vasospasm Hydrocephalus Electrolyte disturbance Cardiac arrhythmia

Diagnosis

History Examination CT presence of blood in subarachnoid space LP xanthochromia

Anterior communicating (28%)

Posterior communicating (30%) Basilar (3%) Superior cerebellar (1%)

Posterior inferior cerebellar (1%)

Figure 11.3 Anatomical distribution of cerebral aneurysms (figures denote percentage of total).

MRA Angiography identify possible site of lesion

Treatment Medical

Resuscitation intubate and ventilate if required Anti-hypertensives nimodipine, decreases risk of neurological deficit and death Anti-convulsants phenytoin Raised ICP steroids
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cm 13

3 cm 4 cm 8 cm 4 cm

4 cm 3 cm

Figure 11.4 Sites of burr holes.

Hypervolaemic haemodilution > reduces vasospasm and cerebral ischaemia

Surgical

Venticulostomy in progressive hydrocephalus Lesion identifies and ablated via craniotomy and clipping Alternative technique; endovascular occlusion

CEREBRAL ANEURYSM
Incidental findings

>10 mm high risk of rupture = elective treatment advised <5 mm, or difficult to approach surgically monitor wCT scans

Infectious aneurysm

Subacute endocarditis Antibiotics and monitoring

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