MEDI7302 Study Guide - Final Guide: Bradycardia, Tinnitus, Craniotomy

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School
Department
Course
Professor
Neurosurgery
Learning
objectives
Display ability to assess Glasgow Coma Score (GCS) and perform a full neurological
examination
Describe the basic anatomy of the brain including ventricular system and spine.
List potential consequences of traumatic brain injury
List the types of intracranial hemorrhage, usual source of bleeding and prognosis.
Explain coup and contra-coup injuries.
Describe presentation, investigation and causes of subarachnoid hemorrhage and
options for management.
Discuss presentation of brain tumours – benign and malignant.
List pathophysiology, clinical features and causes of raised intracranial pressure
(including Monro-Kelly doctrine).
List the types of hydrocephalus, common causes and management options.
List symptoms of spinal injury and acute spinal cord compression
Head layers Skin, periosteum - highly vascular
Meninges - dura mater (periosteal, sinus space, meningeal), subdural space,
arachnoid mater (villi, intracranial vessels), subarachnoid space, pia mater
GCS score GCS assessment
Eye opening Verbal response Motor response
6 Obeys commands
5 Orientated Localizes to pain
(move toward painful stimuli eg grasp
arm applying pressure)
4Spontaneous Confused Withdrawal to pain
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(responds to questions
coherently, but some
disorientation)
(move away from painful stimuli)
3To voice Inappropriate words
(random speech, no proper
conversational exchange)
Decorticate response (flexion to pain)
Adduct arm, internal rotation shoulder,
pronate forearm, flex wrist
2To pain Incomprehensible noises
(moaning, no words)
Decerebrate response (extension to
pain)
Abduct arm, external rotation shoulder,
supinate forearm, extend wrist
1None None None
GCS scoring
15 point score = 4 eye response + 5 verbal response + 6 motor response
Generally <7-8 points corresponds to 'unconscious or comatosed' patient
Lowest score is 3
GCS classification of TBI/ head injury
Mild 80% (GCS 13-15)
Moderate 10% (GCS 9-12) - everyone gets CT, frequent neurologic exam,
repeat CT scan next day
Severe 10% (GCS < 9) - primary and secondary survey (intubate early)
If patient is drunk, still treat according to whatever GCS they are
Traumatic brain
injury
Clinical features - base of skull fracture
Mastoid ecchymoses (battle sign)
Periorbital ecchymoses (racoon eyes)
CSF rhinorrhoea and otorrhoea
Haematotympanum
Clinical sequelae
Traumatic intracranial hemorrhage - EDH, SDH, SAH (laceration of
superficial microvessels in subarachnoid space), ICH, intraventricular hemorrhage
Skull fracture
Auditory/ temporal dysfunction (impact of temporal region)
Contusions
Concussion (deformity of deep brain structures leading to widespread
neurological dysfunction that can result in impaired consciousness or coma)
Diffuse axonal injury
Secondary injuries via further cellular damage (develops later) -> raised
ICP, cerebral oedema, hydrocephalus, brain herniation, CTE
Coup contra-
coup injury
Coup and contra-coup injuries are due to vascular and tissue damage
Coup - an injury at site of direct impact to skull via creation of negative pressure
when skull (distorted at site of impact) returns to its normal shape
Contra-coup - an injury located opposite to site of direct impact via skull and dura
mater starting to accelerate before the brain on initial impact
Brain tumours Brain tumors manifest with particular sx/signs via local invasion, compression of
adjacent structures and increased ICP
Types
Benign - meningioma, pituitary adenomas
Malignant - glioma, CNS lymphoma, brain mets
Symptom progression
High grade glioma or mets -> days to weeks
Low grade gliomas or other indolent tumors -> months to years
Low grade tumors and small lesions without surrounding oedema ->
asypmtomatic
Clinical sx/ signs
Asymptomatic OR generalised and/or focal features
Headache 50% patient's first presenting symptom
Bifrontal, usually dull and constant (sometimes
throbbing), progressive
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Classical 'early morning' brain tumor headache
is uncommon
Worse at night & certain positions that raise
ICP, severe if raised ICP or meningeal irritation
Associated N&V, abnormal neuro exam
Seizures Usually low-grade > high-grade tumors
Dependent on tumor location
Focal deficits Dependent on tumor location
Weakness
Sensory loss
Aphasia
Visual spatial dysfunction
Gait abnormalities
Cognitive
dysfunction
Increased ICP Large mass or obstruction -> hydrocephalus
Headache, nausea, papilloedema
Raised ICP Intra-cranial volume
Intra-
cranial volume ~1500mL
CSF
(100mL) - 50mL basal
cisterns (subarachnoid
space) + 50mL ventricles
Blood
(100mL) - 80-90mL in venous
system, predominantly dural
sinuses
Brain
ECF (100mL)
Brain
cell mass (1.2L) - 700mL glia,
500mL neurones
Monro-Kellie doctrine
Pressure-volume relationship
to keep dynamic equilibrium amongst essential
non-compressible components inside compact skull
ICP is a function of volume
and compliance of the intracranial compartment
Total sum of intracranial
volumes of blood, brain matter and CSF is
constant
An increase in one
component must be offset by equal decrease in
another
Hence, any addition
of new volume (hematoma, tumour) in
cranial compartment has to be
compensated by shrinkage of the other
physiological compartments, otherwise rise
in ICP
Compensatory volumes
Brain - volume of
brain is relatively constant and won't
change for compensation (otherwise
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Document Summary

Display ability to assess glasgow coma score (gcs) and perform a full neurological. Describe the basic anatomy of the brain including ventricular system and spine. List the types of intracranial hemorrhage, usual source of bleeding and prognosis. Describe presentation, investigation and causes of subarachnoid hemorrhage and. Discuss presentation of brain tumours benign and malignant. List pathophysiology, clinical features and causes of raised intracranial pressure options for management. (including monro-kelly doctrine). List the types of hydrocephalus, common causes and management options. List symptoms of spinal injury and acute spinal cord compression. Meninges - dura mater (periosteal, sinus space, meningeal), subdural space, arachnoid mater (villi, intracranial vessels), subarachnoid space, pia mater. Localizes to pain (move toward painful stimuli eg grasp arm applying pressure) Withdrawal to pain (responds to questions coherently, but some disorientation) Inappropriate words (random speech, no proper conversational exchange) Adduct arm, internal rotation shoulder, pronate forearm, flex wrist. Abduct arm, external rotation shoulder, supinate forearm, extend wrist.